Clinical outcomes after vena cava thrombectomy for renal cell carcinoma with venous extension – institutional experience

Abstract

INTRODUCTION: Renal cell carcinoma (RCC) frequently progress to involve the inferior vena cava (IVC) and even the right atrium (RA). Nephrectomy and eradication of the tumour thrombus, can extend survival and prevent symptoms of venous congestion. The authors evaluated the institutional experience of a tertiary center in the surgical management of RCC patients with tumour thrombi invading the IVC.

METHODS: Retrospective analysis of a single-center consecutive serie of patients with RCC and IVC tumor thrombi treated with surgery in our department between 2012 and 2021 was carried out. Demographic data, diagnostic and procedural characteristics, clinical outcomes and survival analysis were examined.

RESULTS: Of the included 18 patients, 33% (n=6) had smoking history, 78% (n=14) hypertension, 33% (n=6) diabetes and dyslipidaemia. Mean tumour size was 8.78±2.47cm (3-12cm), and 67% (n=12) of the cases were renal clear cell adenocarcinoma. On the basis of the Neves classification for IVC thrombus extension, 39% (n=7) of the patients had level I; 28% (n=5) level II; 17% (n=3) level III and 17% (n=3) level IV. The majority underwent radical nephrectomy, with cavotomy and vena cava thrombus removal followed by lateral venorrhaphy of the vena cava (89%,n=16). In one patient an infra-renal IVC ligation was performed and, in another patient, an IVC interposition with PTFE and a protesic-renal bypass were performed. In level IV, combined open sternotomy and cardiac bypass for RA thrombus control were necessary.

Mean total operative time was 3h4min±1h19min and median intraoperative blood loss was 600ml requiring a median blood cells transfusion of 3.5units (0,16) during the hospital stay. Median ICU days was 2 days (0,14) and median hospital stay was 8 days (4,61). The mean preoperative serum creatinine was 1.23+0.38 mg/dL. After surgery, there was a mean decrease of serum creatinine of 0.001 mg/dL (p=.991) (paired T test), confirming the absence of renal impairment. Only one patient required reintervention in the post-operative course for splenectomy. Post- operative complications included one case of pulmonary embolism, pneumonia, acute coronary syndrome and two cases of temporary acute renal lesion. There was no 30-day mortality. Five patients underwent adjuvant chemotherapy. Median follow-up time was 19.5 months (6-46.2 months). The four-year overall survival rate was of 52.4% (figure 1).

CONCLUSION: For advanced RCC with tumour thrombus extension into the IVC, despite the expected poor prognosis, nephrectomy and eradication of the entire tumour thrombus, has low morbidity and can prolong patient survival, in line with the presented results.