title: Renal cell carcinoma with thrombus extending to the hepatic veins or right atrium: operative strategies based on 41 consecutive patients.
abstract: OBJECTIVE
  The natural history of renal cell carcinoma (RCC) with tumour thrombus extending at or above the hepatic veins is dismal. Different surgical approaches have been described including cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest. We here report our experience in terms of surgical techniques and outcomes on 41 consecutive patients presenting an RCC extending to the hepatic veins or the right atrium. A surgical decision-making algorithm is discussed.
  
  
  METHODS
  Retrospective review of 41 patients operated for RCC extending in the retrohepatic vena cava (extent level III-IV) between 2000 and 2015. Patients were operated by a dedicated urology/cardiac surgery team.
  
  
  RESULTS
  The mean age was 62.6 ± 10.4 years; 39% were female. Surgery was emergent in 7.3% of patients, 2.4% of patients had preoperative dialysis, 4.9% required a redo sternotomy and 19.5% had coronary artery disease. Tumour thrombus extended above the diaphragm in 23 patients (level IV) and to the level of hepatic veins (level III) in 18 patients. CPB was used in 38 patients. Arterial cannulation was in the aorta or femoral artery in 14 patients during the initial experience. In the current era, the axillary artery and the innominate artery were used in 12 patients each. Mean CPB, cross-clamp and circulatory arrest times were, respectively, 96.5 ± 42.9, 21.1 ± 16.4 and 10.2 ± 8.2 min (mean temperature of 25.7 ± 4.9°C). Hepatic exclusion without the use of CPB was performed to excise the thrombus in 3 patients. A right nephrectomy was performed in 25 patients, a left in 15 patients and a bilateral nephrectomy in 1 patient. Five patients had a partial inferior vena cava (IVC) resection, with 4 patients requiring a patch reconstruction of the IVC. Three patients had an infrarenal IVC ligation. One patient suffered a cerebrovascular accident in the postoperative period. One in-hospital death occurred (in-hospital mortality 2.4%). The mean follow-up was 1.9 ± 2.0 years. Twenty-three patients died during follow-up; 21 were disease-related. Three-year survival rate was 37.1%.
  
  
  CONCLUSIONS
  High-level RCC tumour thrombus is a rare clinical entity, the treatment of which is complex and requires dedicated operative teams. The operative technique should be tailored according to the level of extension and the extent of vena cava obstruction/occlusion of the tumour thrombus. Contemporary operative techniques may be conducted with excellent results. Mid-term survival is limited, supporting the necessity to pursue research efforts towards establishing effective adjunct therapies.
authors.affiliation: Department of Cardiovascular Surgery, Quebec Heart and Lung Institute, Laval University, Sainte-Foy, Canada.
authors.forename: Maude
authors.initials: M
authors.lastname: Gagné-Loranger
authors.affiliation: Department of Urology, Hôtel-Dieu de Québec, Centre Hospitalier Universitaire de Québec, Laval University, Québec, Canada.
authors.forename: Louis
authors.initials: L
authors.lastname: Lacombe
authors.affiliation: Department of Urology, Hôtel-Dieu de Québec, Centre Hospitalier Universitaire de Québec, Laval University, Québec, Canada.
authors.forename: Frédéric
authors.initials: F
authors.lastname: Pouliot
authors.affiliation: Department of Urology, Hôtel-Dieu de Québec, Centre Hospitalier Universitaire de Québec, Laval University, Québec, Canada.
authors.forename: Vincent
authors.initials: V
authors.lastname: Fradet
authors.affiliation: Department of Cardiovascular Surgery, Quebec Heart and Lung Institute, Laval University, Sainte-Foy, Canada francois.dagenais@chg.ulaval.ca.
authors.forename: François
authors.initials: F
authors.lastname: Dagenais
mesh_terms: D000465:Algorithms; D002292:Carcinoma, Renal Cell / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D006348:Cardiac Surgical Procedures; D003657:Decision Making; D005260:Female; D006325:Heart Atria; D006331:Heart Diseases / Q000209:etiology* / Q000401:mortality / Q000601:surgery; D006503:Hepatic Veins; D006801:Humans; D007680:Kidney Neoplasms / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009392:Nephrectomy / Q000379:methods; D017410:Practice Guidelines as Topic; D011792:Quebec / Q000453:epidemiology; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D017131:Thrombectomy / Q000379:methods*; D013927:Thrombosis / Q000209:etiology* / Q000401:mortality / Q000601:surgery
keywords: Aorta; Aortitis; Surgery