title: Long-term survival after radical surgery for renal cell carcinoma with tumour thrombus extension into the right atrium.
abstract: What's known on the subject? and What does the study add? Surgical treatment of renal cell carcinoma (RCC) with tumour thrombus extending into the right atrium remains, despite its complexity and specific technical aspects, the only radical therapeutic option. This single-centre study, unique in size for this rare condition, reports early and late results over a period of 18 years. All patients were operated on using a standardised protocol with use of cardiopulmonary bypass and deep hypothermic circulatory arrest. Overall and cancer-specific cumulative survival was better than in other reports.
  
  
  OBJECTIVE
  To evaluate the long-term results of radical surgical management of renal cell carcinoma (RCC) with tumour thrombus extension (TTE) level IV into the right atrium (RCC/TTE IV) in a large single-institution series.
  
  
  METHODS
  Radical complex urological and cardio-surgical procedure was performed over a period of 18 years (1993-2010) on 21 patients with RCC/TTE IV. A radical nephrectomy was performed followed by sternotomy, institution of cardiopulmonary bypass and extraction of the intracardiac tumour thrombus under direct visual control during deep hypothermic circulatory arrest (DHCA). Perioperative and postoperative variables, and long-term overall and cancer-specific survival using the Kaplan-Meier method were analysed.
  
  
  RESULTS
  In all patients, precise removal of tumour thrombus was accomplished in a bloodless field during DHCA. The mean (sd) duration of circulatory arrest was 16 (6) min at a mean hypothermia of 20 (3) °C. In-hospital mortality was 9.5% (two patients). The median survival (including in-hospital mortality) was 25 months. In Kaplan-Meier analysis, 2- and 5-year overall cumulative survival rate was 57 (95% confidence interval, CI 36-78)% and 37 (95% CI 15-58)%, respectively. Cancer-specific cumulative survival was 68 (95% CI 49-89)% at 2 years and 51 (95% CI 28-74)% at 5 years.
  
  
  CONCLUSIONS
  Late outcome after radical surgical treatment in patients with RCC and TTE reaching up to the right atrium justifies this extensive procedure. Cardiopulmonary bypass with DHCA allows safe and precise extirpation of all intracaval and intracardiac tumour mass.
authors.affiliation: Department of Cardiac Surgery, Charles University in Prague, Faculty of Medicine and Faculty Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
authors.forename: Jan
authors.initials: J
authors.lastname: Dominik
authors.forename: Petr
authors.initials: P
authors.lastname: Moravek
authors.forename: Pavel
authors.initials: P
authors.lastname: Zacek
authors.forename: Jan
authors.initials: J
authors.lastname: Vojacek
authors.forename: Miroslav
authors.initials: M
authors.lastname: Brtko
authors.forename: Miroslav
authors.initials: M
authors.lastname: Podhola
authors.forename: Jaroslav
authors.initials: J
authors.lastname: Pacovsky
authors.forename: Jan
authors.initials: J
authors.lastname: Harrer
mesh_terms: D000328:Adult; D000368:Aged; D002292:Carcinoma, Renal Cell / Q000401:mortality* / Q000556:secondary / Q000601:surgery*; D005260:Female; D006325:Heart Atria; D006338:Heart Neoplasms / Q000401:mortality* / Q000556:secondary / Q000601:surgery*; D006801:Humans; D007680:Kidney Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009360:Neoplastic Cells, Circulating; D009392:Nephrectomy / Q000379:methods; D015996:Survival Rate; D013997:Time Factors