Renal cell carcinoma extending into inferior vena cava

Liver Harvesting Surgical Technique for the Treatment of Retro-Hepatic Caval Thrombosis Concomitant to Renal Cell Carcinoma: Perioperative and Long-Term Results in 15 Patients without Mortality

OBJECTIVE

Radical surgical treatment improves the prognosis of patients affected by Inferior Vena Cava (IVC) thrombosis concomitant to renal carcinoma. However, thrombus extension above the infrahepatic IVC represents a major technical topic for surgeons because of the possible occurrence of uncontrollable haemorrhages and tumor fragmentation. We report the results of an innovative surgical approach to caval thrombosis including the isolation of the IVC from the liver as routinely performed during liver harvesting. In the presence of retro-hepatic IVC thrombosis, this technique improves vascular control and allows to perform a large cavotomy with an en-bloc removal of the thrombus and the tumor.

METHODS

From January 1995 through June 2003, 15 patients with renal cancer and caval thrombosis were treated at our Institution. Four, ten and one patients were respectively affected by an infrahepatic (Level I), retro-hepatic (Level II) and atrial (Level III) IVC thrombosis.

RESULTS

All patients underwent radical surgical treatment. In presence of Level II caval thrombosis, the patients underwent the above reported surgical technique. Perioperative mortality was absent; major morbidity occurred in one patient (6.7%). The thrombus was radically removed in all cases. After a mean follow-up of 53.9 months (5-100 months) all patients but one are still alive. One patient died 9 months after surgery with multiple bilateral pulmonary metastases.

CONCLUSIONS

Isolation of the retro-hepatic IVC is a safe and effective manoeuvre to significantly reduce perioperative mortality and morbidity in patients affected by Level II caval thrombosis concomitant to renal carcinoma.

Risk and prognosis in renal neoplasms. A pathologist's prospective

The incidence of renal carcinoma has increased in the United States over the last two decades. An increased rate of detection of incidental tumors and a variety of exogenous risk factors may be responsible for this increase. Pathologic stage and nuclear grade remain the most important and practical prognostic features, however, the specific tumor type has emerged as important as the cytogenetic validation of recent renal carcinoma classification. Proliferation markers, DNA ploidy, and morphometry have powerful predictive value but are handicapped by cost and complexity. The search continues for molecules of diagnostic and prognostic utility that may also impact invasive and metastatic capability for this group of neoplasms whose course is principally determined by the completeness of the original resection.

Surgical treatment of renal cell carcinoma extending into the vena cava

BACKGROUND

Renal cell carcinoma has a tendency to invade the vasculature and the prognostic implications of intravena caval tumor thrombectomy remains controversial. We reviewed our clinical experience with RCC patients who underwent tumor thrombectomy and radical nephrectomy.

METHODS

Surgery was carried out in 13 renal cell carcinoma patients with inferior vena cava extension over the past seven years. Diagnosis of intracaval tumor extension and thrombus formation was made by imaging techniques including ultrasonography and computed tomography. Cavography and magnetic resonance imaging were also performed in some cases.

RESULTS

The level of the tumor thrombus was infrahepatic (V2a) in nine cases and retrohepatic (V2b) in four. Ultrasound and magnetic resonance imaging were extremely useful in defining the extent of the thrombus in addition to detecting its presence. The caval thrombi were reached simply by ligation and division of the short hepatic veins in the V2a cases, but liver mobilization was required in the V2b cases. There were no operative deaths. Two patients who had metastases on surgery died of the disease eight and 13 months after surgery. Four of the 11 patients in whom no evidence of metastasis was found on surgery also died of the disease between nine and 16 months postoperatively. The remaining seven patients are still alive at periods of 6-74 months after surgery, with or without residual tumors. The nature of the intracaval tumor thrombi seems to affect the overall prognosis for survival. Elevated levels of acute phase reactants and immunosuppressive acidic protein were associated with short survival times.

CONCLUSIONS

Our experience suggests that aggressive surgery should be considered in selected patients with non-metastatic renal cell carcinoma extending into the vena cava.

Renal cell carcinoma extending to the renal vein and inferior vena cava: results of surgical treatment and prognostic factors

Forty-seven patients with renal cell carcinoma with tumor thrombus extension to the renal vein or inferior vena cava (IVC) were treated surgically over a 10-year period. There were 41 males and 6 females with a mean age of 45.7 years. Thirty-three patients had right-sided and 14 had left-sided tumors. Patients with renal vein or infrahepatic IVC thrombus were treated with radical nephrectomy with tumor thrombus excision after achieving conventional vascular control over the IVC and the opposite renal vein. Four patients with retrohepatic IVC thrombus were treated with venacavotomy and thrombectomy after achieving vascular control above the thrombus but below the hepatic veins while two other patients with retrohepatic and one with suprahepatic thrombus required a bifemoroatrial partial venous bypass prior to tumor thrombectomy. There was one postoperative death due to pulmonary embolism. The actuarial 5-year survival for all patients with venous extension was 50% and the median survival was 4.35 years. Perinephric spread and lymph node metastases were significant prognostic factors affecting survival. This suggests that it is the locoregional spread of renal cell carcinoma rather than the level of the thrombus which governs the prognosis of patients with tumor thrombus extension to the renal vein or IVC.

Renal cell carcinoma extending into the vena cava: surgical approach, technique and results

OBJECTIVE

To describe the technique and results of a thoraco-abdominal approach to removing the caval thombi in patients with renal cell carcinoma extending into the vena cava.

PATIENTS AND METHODS

Between 1970 and 1990 35 patients presenting with renal cell carcinoma extending into the vena cava were treated at the Department of Urology, Innsbruck. Twenty-three of these patients underwent radical tumour nephrectomy including cavotomy and thrombectomy or caval resection. A transabdominal approach had been used in this department for radical tumour nephrectomy including cavotomy and thrombectomy or caval resection until 1987. Since 1988, a thoraco-abdominal approach has been employed. In group I patients the approach was via the seventh intercostal space, whereas in group II and III patients the thoraco-abdominal incision was made through the fifth intercostal space. In the present study the anatomy of the thoraco-abdominal approach is described.

RESULTS

Tumour staging and grading yielded stage T3b in 15 patients (grade I, 1; grade II, 6; grade III, 8); another eight patients with stage T3b were found to have metastatic disease (N1, 6; N2, 2; M1, 3). On the basis of the extension of the caval thrombus the patients were classified as follows: group I, 16; group II, 3; group III, 4. In T3b N0 M0 patients the 5-year-survival rate was 62.5%, while in patients with positive lymph nodes the mean survival rate was 15.5 months.

CONCLUSION

Our results suggest that the thoracoa-abdominal approach is the method of choice for the safe removal of renal cell carcinomas associated with caval thombi. If resection of the caval tumour is complete, prognosis is dependent on known factors, such as tumour invasion, nodal involvement and distant metastases rather than the extension of the tumour thrombus. An aggressive approach is not warranted in patients with nodal involvement and/or distant metastases, as it does not improve survival.

Radical nephrectomy in patients with renal cell carcinoma with venous, vena caval, and atrial extension

BACKGROUND

From July 31, 1968, through August 31, 1992, 100 patients with renal cell carcinoma extending into the renal vein, vena cava, and right atrium were treated and evaluated at our institution. Each patient underwent radical nephrectomy with vena cavotomy and atriotomy as considered to be appropriate for each individual patient's tumor thrombus.

METHODS

The charts were retrospectively analyzed, and surveys were sent to survivors or nearest of kin.

RESULTS

The median age was 61 years, and two thirds of the tumors occurred in men (67 cases). Of the 100 patients with renal cell carcinoma resected, 13 patients (13%) had atrial extension; 75 patients (75%) had vena caval extension; and 12 patients (12%) had extension only into the renal vein. Seventy-two patients (72%) had no evidence of metastatic disease at the time of surgery and have a median survival of 21.1 years. Five-year survival is 64%, and 10-year survival is 57%. Twenty-eight patients (28%) had evidence of metastatic intraoperative and/or pathologically proven metastatic disease and have a median survival of 2.5 years with a 5-year survival of 20% and no patient living beyond 7.8 years.

CONCLUSION

We believe that an extended operation for renal cell cancer with involvement of the renal vein, vena cava, and right atrium is warranted in properly selected patients and ensures reasonable long-term survival.

Prognostic value of renal venous involvement in renal carcinoma

A series of 108 renal tumour nephrectomies carried out between 1975 and 1984 was studied to determine the prognostic statistical significance of the relationship between venous involvement and various pathological features. Tumour size, spread, histological grade and lymph node involvement were compared between V0 tumours (58%), V1 (32%) and V2 tumours (10%). Actuarial 5-year survival rates revealed a poor prognosis with venous involvement (V0 66%, V1 27%, V2 33%). Tumours larger than 10 cm with perirenal spread and of higher histological grade were significantly related to venous involvement. Survival between renal vein involvement and inferior vena caval extension was statistically similar, but it was influenced by tumour size and higher grade. Perirenal spread and nodal involvement were poor indicators.

Extension incision for renal carcinoma including invaded vena cava and right lobe of liver

We report on a thirty-five-year-old woman with renal cell carcinoma who successfully underwent right radical nephrectomy and extended right hepatic lobectomy with resection and reconstruction of inferior vena cava (IVC). A temporary bypass was placed between the infrarenal IVC and right atrium using a heparin-coated synthetic tube. The tumor was resected en bloc including right kidney, adrenal gland, hepatic lobe, and IVC. The IVC was reconstructed using an expanded polytetrafluoroethylene (EPTFE) graft. Her postoperative course was uneventful with no signs of recurrence four years after surgery.

Surgical management and prognosis of renal cell carcinoma invading the vena cava

A total of 44 patients with renal cell carcinoma and vena caval tumor thrombus underwent surgical resection. Of these patients 27 had primary tumor confined within Gerota's fascia, negative lymph nodes and no distant metastases (stage T3cN0M0). Patients who underwent extraction of a mobile tumor thrombus from the vena cava had a 69% 5-year survival rate (median 9.9 years) but patients with tumor thrombus directly invading the vena cava had a 26% 5-year survival rate (median 1.2 years), which improved to 57% (median 5.3 years) if the involved vena caval side wall was resected successfully. Of these patients 17 had renal cell carcinoma with vena caval thrombus as well as extrafascial extension, regional lymphadenopathy or distant metastases, and the 5-year survival rate was less than 18% in all groups (median survival less than 0.9 years). Prognosis was determined by the pathological stage of the renal cell carcinoma and by the presence or absence of vena caval side wall invasion but not by the level of tumor thrombus extension. Patients with incomplete resection of localized renal cell carcinoma with tumor thrombus do not survive any longer than those with extensive cancer, positive lymph nodes or distant metastases. However, when partial venacavectomy establishes negative surgical margins then survival markedly improves.

Renal cell carcinoma. A clinicopathologic and DNA flow cytometric analysis of 103 cases

Renal cell carcinoma is unpredictable in outcome, although the best predictor is tumor stage, followed by histologic grade. The authors retrospectively assessed the clinicopathologic features and DNA ploidy of 103 cases of renal cell carcinoma, the latter determined by flow cytometry of formalin-fixed, paraffin-embedded tissue. The study group comprised 63 men and 40 women (age, 28-80 years; mean, 57 years). Robson stage at diagnosis was Stage I in 52 patients, Stage II in 21, and Stage III in 30. Statistically significant variables in predicting outcome were Robson stage (P less than 0.0001), DNA ploidy (P = 0.0008), mitotic rate (MR, P less than 0.0001), worst nuclear grade (WNG, P = 0.00009), predominant nuclear grade (P = 0.019), and sex (P = 0.044). Tumor size, cell type, and architectural pattern were also assessed but did not prove to be significant. Statistically significant associations occurred between DNA ploidy and WNG (P less than 0.0001), stage (P = 0.0037), and MR (P = 0.015); between WNG and MR (P less than 0.0001) and stage (P = 0.0007); and between stage and MR (P = 0.002). Cox proportional hazards regression analysis of all significant variables showed Robson stage, tumor ploidy, and MR to be independent, significant predictors of outcome. If ploidy data had not been available, WNG would have been independently significant. The authors conclude that DNA ploidy analysis provides significant predictive information on renal cell carcinoma.

Venous invasion in renal cell carcinoma: a correlative clinical and radiologic study

Angiography, cavography, ultrasound (US), computed tomography (CT), and low-field magnetic resonance imaging (MRI) were used to explore venous tumor invasion in 86 patients with renal cell carcinoma. The findings confirm previous experience that ultrasound and dynamic CT are reliable methods for the evaluation of venous invasion. Low-field magnetic resonance imaging does not improve tumor staging. In case of equivocal findings, vena cavography should be used as a complementary examination.

Surgical management of renal cell carcinoma with intracaval neoplastic extension above the hepatic veins

Cardiopulmonary bypass, hypothermia, temporary cardiac arrest and exsanguination represent the next logical step in the evolutionary management of intracaval neoplastic extension with renal cell carcinoma. This method of management provides control of the circulation of the entire body and allows for careful dissection in a bloodless field with less risk of embolization. From 1981 to 1986, 15 patients were treated with intracaval neoplastic extension of renal cell carcinoma above the level of the most inferior hepatic veins. In 6 patients mobilization of the vena cava with division of the hepatic veins to the caudate lobe allowed excision of the tumor and tumor thrombus without cardiopulmonary bypass (group 1). The remaining 9 patients underwent cardiopulmonary bypass and hypothermia (group 2). There was 1 postoperative mortality in the entire group. Most patients had advanced regional disease but the feasibility of this technique has been demonstrated. Survival appeared to be less in the bypass group. Although some of the patients have had metastatic disease, the quality of life and survival have been prolonged in many of these acutely ill patients.

Renal cell carcinoma. Prognostic significance of morphologic parameters in 121 cases

Morphologic parameters were correlated with survival in 121 renal cortical neoplasms including 116 carcinomas and five oncocytomas. An increasing nuclear grade was generally correlated with a significant decrease in disease-free survival although no statistical difference was found between nuclear Grade 1 and 2 tumors. Similarly, a higher stage at diagnosis predicted a shorter disease-free survival. Renal vein invasion adversely affected prognosis only for high nuclear grade carcinomas. Papillary and spindled carcinomas, independent of nuclear grade, were associated with a significant decrease in disease-free survival compared to tumors with a solid pattern. Patients with large neoplasms (greater than 10 cm) had a significantly worse disease-free survival than patients with tumors 10 cm or less. The prognostic significance of tumor cell type is less clear. Patients with oncocytomas had the best disease-free survival compared with patients with tumors of other cell types. However, the difference in survival was not statistically significant for low-grade tumors, suggesting that nuclear grade rather than cell type may be the more important determinant.

Surgical approach to inferior vena caval extension of renal carcinoma

Between 1979 and 1985, 10 patients were treated for renal carcinoma with extension into the inferior vena cava but without evidence of disseminated disease. Two of these had tumour thrombus extension up to the level of the hepatic veins and in four the extension was above the level of the diaphragm, two of which entered the atrium. Thrombus was removed en bloc at radical nephrectomy. Six patients are still alive, with a mean survival of 22 months. There was no correlation between the level of tumour thrombus and perinephric extension or indeed any correlation between tumour thrombus level and overall survival. It is suggested that tumour thrombus in the inferior vena cava, in the absence of metastatic disease, should be managed by radical surgery.

Caval extension of renal cell carcinoma. Results of surgical treatment

Twenty-eight patients with renal cell carcinoma extending to the vena cava underwent surgical treatment consisting of radical nephrectomy and removal of tumor thrombus, which was at the level of the renal veins in 23 cases, the hepatic veins in 4, and extending above the diaphragm in 1 case. In 7 patients lymph nodes were invaded, and 8 had both positive nodes and extrarenal tumor diffusion discovered at surgery. The mean survival was 41.7 months for patients with only venous extension of the tumor, 16 months for patients with positive nodes, and 10.2 months for those with both nodal and extrarenal tumor diffusion.

Long-term effects of initial therapy

The long term effects of initial therapy are a combined consequence of the effects of treatment on the cancer and on the host. Local tumor control, whatever its impact on the occurrence of metastasis, is an achievable and worthwhile goal of therapy and the methods for attaining it may have significantly different effects on quality of life. These considerations are grossly illustrated for renal cell, bladder and prostatic cancers.

Surgical treatment of renal cancer with vena cava extension

Fifty-four patients with renal cancer and vena cava tumour thrombus underwent radical nephrectomy and removal of the thrombus; the operative mortality rate was 9.3% (5 patients). The extent of the vena cava thrombus did not affect survival. Of 36 patients with no known pre-operative metastases and complete (29 patients) and incomplete (7 patients) removal of the vena cava tumour thrombus, the 5-year survival rate was 68 and 17%, respectively (P = 0.01). Thirteen patients (45%) who underwent complete removal of the vena cava tumour thrombus are alive and free of disease, with a mean follow-up of 51.2 months (range 4-144); three died without disease 110, 31 and 23 months after operation. The 2-year and 5-year survival rates of 18 patients with known pre-operative metastases was 37.5 and 12.5% respectively; 14 died between 1 and 27 months post-operatively (mean 11.6) of metastatic disease. Two of these 18 patients experienced long-term remission: one died of unrelated causes 151 months after operation; the other was lost to follow-up 219 months after operation, with no evidence of disease. Of 14 patients with positive regional nodes, the mean survival in those with metastases compared with those without metastases was 7.5 versus 15 months, respectively; only one patient survived at 14 months. Operative intervention in patients without metastatic disease (systemic or regional) and complete removal of the vena cava thrombus achieved a 5-year survival rate of 68%. Variables which significantly decreased survival and may be considered contraindications for operation were systemic metastasis, regional lymph node involvement and incomplete removal of the vena cava thrombus.

Renal cell carcinoma: survival and prognostic factors

Three hundred twenty-six patients treated at New York University from 1970 to 1982 were studied for survival in relationship to surgical stage, type of therapy, and pathologic characterization of the primary tumor. At the time of diagnosis 25.5 per cent of tumors were Stage I, 15 per cent Stage II, 28.5 per cent Stage III, and 31 per cent Stage IV. The retrospective study showed that patients with tumor confined within the capsule achieved the highest five- and ten-year survivals of 88 per cent and 66 per cent, respectively. Survivals decreased as tumor invaded perirenal fat (67% and 35%) or regional lymph nodes (17% and 5%). Tumor invasion into the renal vein alone did not significantly change five-year survival (84%) but lowered ten-year survival to 45 per cent. Patients with metastases at the time of nephrectomy did poorly regardless of site of metastases or kind of adjuvant therapy, except for those managed by surgical extirpation of the secondary lesion. Certain tumor characteristics were associated with a better prognosis, e.g., size below 5 cm in diameter, lack of invasion of collecting system, perirenal fat or regional lymph nodes, and predominance of clear or granular cells growing into a recognizable histologic pattern.

Surgical management of renal cell carcinoma with inferior vena caval and right atrial involvement

A 52-year old man underwent successful surgical removal of renal cell carcinoma with inferior vena caval and right atrial involvement, under cardio-pulmonary bypass. The postoperative progress was uneventful and at this writing he is doing well, with no evidence of metastasis.

Renal cell carcinoma invading the inferior vena cava: the use of the Greenfield filter to prevent tumor emboli during nephrectomy

Renal cell carcinoma with tumor thrombus extension into the inferior vena cava occurs in approximately 5 per cent of the cases. Despite invasion of the inferior vena cava an aggressive surgical approach for these neoplasms is recommended but prevention of a tumor thrombus pulmonary embolus during operation is necessary. Placement of a suprarenal Greenfield filter, with its ease of insertion, excellent late patency rates and minimal morbidity, has made it the procedure of choice today. Preoperative venacavography with radiopaque marking of the tumor thrombus will prevent filter displacement, malpositioning and the awkward use of intraoperative venography, while shortening operative time and minimizing patient risk.

Surgery of renal cancer with extensive caval invasion. Suggestion for a new approach

Radical surgery for renal cancer with invasion of the inferior vena cava can improve the patient's quality of life and, in some cases, offer longer survival or even cure. With a carefully planned surgical approach it is possible to remove renal tumours with thrombotic extension to the most proximal part of the inferior vena cava without necessity for cardiopulmonary bypass and without undue risk to the patient. In the operative procedure, good access and visual control of the proximal vena cava and all the contributing veins seem to be crucially important.