title: Outcomes after inferior vena cava thrombectomy and reconstruction for advanced renal cell carcinoma with tumor thrombus.
abstract: BACKGROUND
  This report details the experience of a multidisciplinary surgical team in the management of stage III and stage IV renal cell carcinoma (RCC) with concomitant inferior vena cava (IVC) tumor thrombus.
  
  
  METHODS
  A retrospective inquiry of our vascular database from 2003 to 2012 identified 55 surgical cases of stage III (n = 40) and stage IV (n = 15) RCC presenting with IVC tumor thrombus. Tumor characteristics and IVC tumor thrombus were evaluated by clinical staging and postoperative pathology staging. Patient demographics and surgical reconstruction are detailed. Cancer-specific outcomes consisted of oncologic surveillance with computed tomography or magnetic resonance imaging. A Clavien-Dindo classification of early (<30 days) complications and mortality was recorded, including a review of secondary surgical interventions.
  
  
  RESULTS
  According to the Novick classification of IVC tumor thrombus, there were 10 supradiaphragmatic (level IV), 20 intrahepatic (level III), and 25 infrahepatic (level II or I) tumor thrombi. Vena cava reconstruction was completed in 54 patients (98%), with one patient deemed unresectable. Vena cava control required cardiac bypass (n = 10), venovenous bypass (n = 4), or infrahepatic IVC control (n = 40). Reconstruction of the IVC was completed with two prosthetic interposition grafts for one stage IV thrombus and one stage III thrombus; two patch repairs were done for stage III thrombus, and there were 50 primary IVC repairs. All other IVC reconstructions were patent at a mean follow-up of 23 months. A single asymptomatic patient with primary IVC repair had estimated 30% IVC narrowing but no other measurable stenosis as detected by postoperative imaging. Three patients required reoperation (two for surgical site bleeding, one for small bowel fistula). Early surgical complications included Clavien-Dindo grades I (n = 3), II (n = 6), IIIa (n = 2), IIIb (n = 3), and V (n = 2). Regional retroperitoneal or distant recurrent RCC occurred in 26 patients (48%); a single patient demonstrating recurrent IVC tumor thrombus at 8 months required secondary IVC thrombectomy. All patients with tumor invasion of the IVC wall developed recurrent RCC, and no patient survived beyond 5 years. Early mortality was 3.6% (n = 2), with 27 patients (49%) dying within 24 months, resulting in an overall mortality for the cohort of 80% (n = 44) as established on routine regular postoperative surveillance.
  
  
  CONCLUSIONS
  A multidisciplinary approach for the management of advanced RCC and IVC tumor thrombus helps optimize outcomes. Primary IVC repairs are possible in most patients, and IVC patency is good. Recurrent tumor thrombus rates are low; however, RCC tumor recurrence and mortality are high, especially among patients with advanced cancer with IVC wall invasion.
authors.affiliation: Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, Fla. Electronic address: parmstro@health.usf.edu.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Armstrong
authors.affiliation: Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, Fla.
authors.forename: Martin R
authors.initials: MR
authors.lastname: Back
authors.affiliation: Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, Fla.
authors.forename: Murray L
authors.initials: ML
authors.lastname: Shames
authors.affiliation: Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, Fla.
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Bailey
authors.affiliation: Department of Urology, University of South Florida, Tampa, Fla.
authors.forename: Timothy
authors.initials: T
authors.lastname: Kim
authors.affiliation: Department of Urology, University of South Florida, Tampa, Fla.
authors.forename: Samuel M
authors.initials: SM
authors.lastname: Lawindy
authors.affiliation: Department of Urology, University of South Florida, Tampa, Fla; Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Fla.
authors.forename: Wade J
authors.initials: WJ
authors.lastname: Sexton
authors.affiliation: Department of Urology, University of South Florida, Tampa, Fla; Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Fla.
authors.forename: Philippe E
authors.initials: PE
authors.lastname: Spiess