title: Renal cell carcinoma with IVC and atrial thrombus: a single centre's 10 year surgical experience.
abstract: Renal cell carcinoma (RCC) propagates into the IVC in 4% of cases with 1% extending into the right atrium. Radical surgical resection remains the definitive curative/palliative treatment in those without significant metastases. The aim was to review our experience in patients with different levels of IVC involvement, cardiopulmonary bypass (CPB) and perioperative/long term outcomes.
  
  
  METHODS
  From 2001 to 2012, 24 radical nephrectomies with IVC thrombectomy were performed. A retrospective chart review was undertaken to record demographics, presenting symptoms, duration of surgery, peri-operative transfusion, CPB and peri-operative complications, tumour grade/stage, and patient survival.
  
  
  RESULTS
  We identified 24 patients (18 male, Age median 59 range 35-78). The commonest presenting symptoms were weight loss, pain and haematuria. The majority of tumours were right sided (n = 17) with 8 having lung metastases at presentation. Thrombus level was 16 (infradiaphragmatic), 2 (supradiaphragmatic), 6 (intra-atrial). 15 patients required sternotomy for vascular control and 9 required CPB both with a significantly longer operative time compared (6.1 ± 3.5 vs. 7.2 ± 1.2 vs. 3.5 ± 1.1 h, respectively). Peri-operative complications (n = 21) included cardiopulmonary, renal, gastrointestinal and septic problems. There were 2 peri-operative deaths. Blood transfusion was significantly less in those not requiring sternotomy or CPB using the "Cell Saver" device. The majority were Fuhrman grade 3 (n = 16) and clear cell type (n = 14). Overall 3-year survival was 100% (Laparotomy only), 40% (sternotomy + cross-clamp), and 20% (CPB).
  
  
  CONCLUSIONS
  IVC thrombectomy has significant morbidity and requires careful patient selection and a multi-disciplinary approach to optimise patient outcomes. In this series, the level of IVC thrombus and requirement for CPB directly affects patient morbidity and outcome.
authors.affiliation: Department of Urology, St. James's Hospital, Dublin 8, Ireland. Electronic address: rowan.casey@colchesterhospital.nhs.uk.
authors.forename: R G
authors.initials: RG
authors.lastname: Casey
authors.forename: O A
authors.initials: OA
authors.lastname: Raheem
authors.forename: E
authors.initials: E
authors.lastname: Elmusharaf
authors.forename: P
authors.initials: P
authors.lastname: Madhavan
authors.forename: M
authors.initials: M
authors.lastname: Tolan
authors.forename: T H
authors.initials: TH
authors.lastname: Lynch
mesh_terms: D000328:Adult; D000368:Aged; D002292:Carcinoma, Renal Cell / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D002315:Cardiopulmonary Bypass / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D005544:Forecasting; D006325:Heart Atria; D006331:Heart Diseases / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D006801:Humans; D007680:Kidney Neoplasms / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009360:Neoplastic Cells, Circulating / Q000473:pathology; D009392:Nephrectomy; D018579:Patient Selection; D012189:Retrospective Studies; D017131:Thrombectomy / Q000379:methods*; D013927:Thrombosis / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D016896:Treatment Outcome; D014682:Vena Cava, Inferior
keywords: Cancer; Inferior; Renal; Thrombectomy; Vena