title: Clinical management of renal cell carcinoma with venous tumor thrombus.
abstract: OBJECTIVE
  Venous invasion is common in advanced renal cell carcinoma (RCC) due to the unique biology of this cancer. The presence of a tumor thrombus often makes clinical management challenging. In this review, we detail specific preoperative, perioperative, and surgical strategies involving the care of the complex kidney cancer patient with venous tumor involvement.
  
  
  METHODS
  We performed a comprehensive review of selected peer-reviewed publications regarding RCC tumor thrombus biology, medical and surgical management techniques, and immediate and long-term outcomes.
  
  
  RESULTS
  The perioperative management may require special imaging techniques, preoperative testing, very recent imaging, and consultation with other surgical services. There are various approaches to these patients as the clinical presentation, stage of disease, primary tumor size, level of thrombus, degree of venous occlusion, presence of bland thrombus, and primary tumor laterality influence management. Select patients with metastatic disease can do well with cytoreductive nephrectomy and thrombectomy. Those with localized disease have a high risk of recurrence; however, some patients can exhibit durable survival with surgery alone. The evolving surgical and medical treatments are discussed.
  
  
  CONCLUSIONS
  Even when these surgeries are performed in high volume centers, significant perioperative complications are common and greater complications are seen with higher thrombus extent. If surgery is attempted, it is important for urologic oncologists to follow strict attention to specific surgical principles. These general principles include complete vascular control, avoidance of thrombus embolization, close hemodynamic monitoring, and institutional resources for caval resection/replacement and venous bypass if necessary.
authors.affiliation: Department of Urology, Yale School of Medicine, 310 Cedar Street 238A, New Haven, CT, 06510, USA.
authors.forename: Nnenaya
authors.initials: N
authors.lastname: Agochukwu
authors.forename: Brian
authors.initials: B
authors.lastname: Shuch
mesh_terms: D002292:Carcinoma, Renal Cell / Q000150:complications / Q000175:diagnosis / Q000628:therapy; D003952:Diagnostic Imaging / Q000379:methods; D019468:Disease Management; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D007680:Kidney Neoplasms / Q000150:complications / Q000175:diagnosis / Q000628:therapy; D009367:Neoplasm Staging; D009392:Nephrectomy / Q000379:methods*; D017131:Thrombectomy / Q000379:methods*; D020246:Venous Thrombosis / Q000175:diagnosis / Q000209:etiology / Q000628:therapy
chemical_list: D005343:Fibrinolytic Agents
references.citation: BJU Int. 2004 Jul;94(1):33-41
references.pmid: 15217427
references.citation: J Comput Assist Tomogr. 2005 Jan-Feb;29(1):64-8
references.pmid: 15665685
references.citation: J Urol. 2003 Mar;169(3):909-16
references.pmid: 12576811
references.citation: World J Urol. 2014 Feb;32(1):109-14
references.pmid: 23624719
references.citation: Ann Surg. 2012 Feb;255(2):270-80
references.pmid: 21975322
references.citation: Urol Clin North Am. 2008 Nov;35(4):657-71; viii
references.pmid: 18992619
references.citation: Urol Oncol. 2004 May-Jun;22(3):182-7
references.pmid: 15271312
references.citation: J Urol. 2007 Aug;178(2):440-5; discussion 444
references.pmid: 17561151
references.citation: Eur Urol. 2008 Apr;53(4):845-8
references.pmid: 18053636
references.citation: Eur Urol. 2011 Mar;59(3):401-6
references.pmid: 20724064
references.citation: J Urol. 2002 Oct;168(4 Pt 1):1374-7
references.pmid: 12352396
references.citation: BJU Int. 2005 Aug;96(3):291-5
references.pmid: 16042716
references.citation: Ann Surg. 1989 Sep;210(3):387-92; discussion 392-4
references.pmid: 2774709
references.citation: Urology. 2009 Jul;74(1):154-9
references.pmid: 19428069
references.citation: Urol Oncol. 2013 Jul;31(5):517-21
references.pmid: 21514183
references.citation: Curr Opin Urol. 2011 Mar;21(2):104-9
references.pmid: 21200324
references.citation: BJU Int. 2011 Mar;107(5):724-728
references.pmid: 20626391
references.citation: BJU Int. 2008 Sep;102(6):692-6
references.pmid: 18410444
references.citation: Eur Urol. 2014 Sep;66(3):584-92
references.pmid: 24262104
references.citation: J Urol. 2009 Feb;181(2):492-8; discussion 498-9
references.pmid: 19110280
references.citation: Cancer. 2008 Sep 15;113(6):1324-31
references.pmid: 18661529
references.citation: J Urol. 2013 Aug;190(2):452-7
references.pmid: 23434945
references.citation: Eur Urol. 2011 Jun;59(6):912-8
references.pmid: 21367518
references.citation: J Urol. 2009 Feb;181(2):486-90; discussion 491
references.pmid: 19100567
references.citation: Cancer. 2007 Jun 15;109(12):2439-44
references.pmid: 17487856
references.citation: Anesth Analg. 2004 Aug;99(2):357-9, table of contents
references.pmid: 15271705
references.citation: Urology. 2011 Oct;78(4):838-43
references.pmid: 21821277
references.citation: J Urol. 2010 Sep;184(3):833-41; quiz 1235
references.pmid: 20643450
references.citation: Br J Urol. 1987 May;59(5):390-5
references.pmid: 3594097
references.citation: J Urol. 2007 Oct;178(4 Pt 1):1189-95; discussion 1195
references.pmid: 17698087
references.citation: J Urol. 2008 Feb;179(2):450-4; discussion 454
references.pmid: 18076946
references.citation: Ann Surg. 1990 Oct;212(4):472-6; discussion 476-7
references.pmid: 2222013
references.citation: World J Urol. 2014 Feb;32(1):245-8
references.pmid: 23053210
references.citation: Ann Surg. 1984 Oct;200(4):524-34
references.pmid: 6385876
references.citation: CA Cancer J Clin. 2013 Jan;63(1):11-30
references.pmid: 23335087