Surgical management of Renal Cell Carcinoma with tumor thrombosis of renal vein and inferior vena cava

Purpose: we reviewed the outcome of surgical treatment of 165 patients with renal cell carcinoma (RCC) invading venous system.

Materials and methods: 3187 patients with RCC were seen at our institution between 1971 and 2004. The vascular extension (stages T3b-T3c) was present in 299 (9,3%) cases. Of 299 patients 82(27,5%) were not considered for surgery, 52(17,3%) underwent palliative nephrectomy and 165(55,2%) underwent radical surgery including radical nephrectomy with thrombectomy. The latter group was retrospectively analyzed. Of 165 cases the tumor thrombus was confined to the renal vein in 58 (35,2%). In patients with IVC involvement 28 (17%) had perirenal, 39(23,6%) subhepatic, 16(9,7%) retrohepatic and 24 (14,5%) — suprahepatic types of tumor thrombi. The surgical technique varied according to the level of tumor thrombus.

Results: The complete removal of primary tumor and venous thrombus was possible in 147 of 165 cases. The histology showed organ-confined tumor in 93 (56,4%) cases. The perirenal fat invasion was present in 66 (40%) and was not assessed in 6 cases. Histology report confirmed the diagnosis of renal cell carcinoma in all patients. The tumor grade occurred to be G1 in 5(3%), G2 — in 52(31,5%), G3 — in 53 (32,1%) and was not mentioned in the histology report in 55 (33,3%) cases. Regional lymph-nodes were positive (pN+) in 29 (17,6%), clear in 131 (79,4%) and not assessed in 5(3%) cases. Distant metastasis were found in 21(12,7%) and were not properly assessed in 5 (3%) patients. Major intra and postoperative complications occurred in 16,3% of cases with the mortality rate of 3,6% (6 patients). Overall 3, 5 and 10 year survival of 165 patients was 58,5%, 46%, and 25% respectively with a median survival of 52 months. Five factors including perinephric fat invasion, presence of lymph node and distant metastasis, poor tumour differentiation and not radical surgery proved to significantly worsen the survival in univariable analysis. Moreover, overall 3,5 and 10 year survival of the patients who did not have these adverse factors, was found to be significantly better — 72%, 62% and 31% respectively. In multivariable regression (Cox stepwise) analysis only 2 factors — the presence of lymph node metastasis and completeness of the surgery influenced the survival.

Conclusions: Although the presence of venous invasion worsens the prognosis of patients with RCC radical surgery gives the chance for cure and long-term survival. With new drug development stratification of patients according to their prognosis could be beneficial.