title: The surgical management and prognosis of renal cell cancer with IVC tumor thrombus: 15-years of experience using a multi-specialty approach at a single UK referral center.
abstract: OBJECTIVE
  Surgical management of renal cell carcinoma (RCC) invading the inferior vena cava (IVC) remains a technical challenge. However, radical surgery is the only potentially curative treatment. We set out to review our experience of using a multi-specialty approach to these patients over the last 15 years.
  
  
  METHODS
  Fifty patients with RCC and IVC invasion underwent surgery at our institution (mean age: 59 years). Tumor thrombus was infrahepatic/levels I and II: n = 24, intrahepatic/level III: N = 14, or suprahepatic/level IV: n = 12. Infra- and intrahepatic caval tumors were resected using an abdominal approach and liver transplant techniques without cardiopulmonary bypass (CPB). CPB was used only with level IV thrombus.
  
  
  RESULTS
  There were no intraoperative deaths. Median operating time was 6 hours and blood loss 3.5 liters (l). Staging was T3b: n = 34, T3c: n = 10 and T4: n = 6. Median time spent in HDU and hospital were 2 and 12.5 days, respectively. Perioperative mortality was 4%. Metastatic disease (P < 0.001) and level IV thrombus (P < 0.05) were significant negative prognostic factors. Forty of the 50 patients did not have metastasis. With mean follow-up of 38 months, the non-metastatic group had 2-year estimated Kaplan-Meier survival of 82.0% falling to 62.4% at 5 years. Conversely, in the metastatic group, estimated 2-year survival was 26.6% falling to 0% by 5 years.
  
  
  CONCLUSIONS
  Surgical treatment of RCC involving the IVC is possible with acceptable morbidity and mortality. Long-term survival can be expected in over 60% of non-metastatic patients at 5 years. These cases benefit from a multidisciplinary surgical approach. Level III thrombus can be successfully managed without CPB.
authors.affiliation: Department of Urology, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
authors.forename: Ased S M
authors.initials: AS
authors.lastname: Ali
authors.forename: Nikhil
authors.initials: N
authors.lastname: Vasdev
authors.forename: Selvaraj
authors.initials: S
authors.lastname: Shanmuganathan
authors.forename: Edgar
authors.initials: E
authors.lastname: Paez
authors.forename: John H
authors.initials: JH
authors.lastname: Dark
authors.forename: Derek
authors.initials: D
authors.lastname: Manas
authors.forename: David J
authors.initials: DJ
authors.lastname: Thomas
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002292:Carcinoma, Renal Cell / Q000473:pathology / Q000601:surgery*; D002315:Cardiopulmonary Bypass; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D033183:Interdisciplinary Communication; D053208:Kaplan-Meier Estimate; D007680:Kidney Neoplasms / Q000473:pathology / Q000601:surgery*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D009360:Neoplastic Cells, Circulating / Q000473:pathology; D009392:Nephrectomy / Q000379:methods; D011379:Prognosis; D012017:Referral and Consultation; D013927:Thrombosis / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome; D006113:United Kingdom; D014682:Vena Cava, Inferior / Q000473:pathology / Q000601:surgery*; D055815:Young Adult