Surgical treatment of renal cell carcinoma with tumor venous thrombosis in patients without distant metastases
Abstract Aim – to analyze results of surgical treatment of renal cell carcinoma (RCC) with tumor venous thrombosis in patients without distant metastases.
Material and methods. Medical data of 318 consecutive patients with RCC and tumor venous thrombosis without distant metastases who undergone nephrectomy with tumor thrombectomy at N.N. Blokhin Cancer Center from 1990 to 2012 were analyzed. Median age was 57 years, a male- to female ratio – 2.3:1. Tumor venous thrombus level I (perirenal) was diagnosed in 36.8%, level II (subhepatic) – in 27.7%, level III (intrahepatic) – in 16.4%, level IV (supradiaphragmatic) – in 19.1% (intrapericardial – 9.4%, intraatrial – 9.4%, intraventricular – 0.3%) patients. Nephrectomy, thrombectomy, extended retroperitoneal lymphadenectomy was performed in all cases. Complete removal of all tumor masses was achieved in 309 (97.2%) patients. Method of thrombectomy depended on the level of thrombi. Median follow-up was – 45.5 (1–244) months.
Results. The rate of intraoperative and postoperative complications was 23.9% (76/318) and 21.7% (68/314) respectively, relaparotomy was demanded in 5.1% (16/314) of cases, hospital mortality was 5.7% (18/318). Pathologically clear-cell RCC was verified in 94.1% (299/318) of specimens, lymph node metastases were diagnosed in 56 (17.6%) cases [pN1 – 19 (6.0%), pN2 – 37 (11.6%)]. RCC relapses appeared in 89 (30.5%) of 291 patients after complete tumor removal [local recurrence – 1 (0.3%), distant metastases – 83 (28.4%), local and distant relapses – 5 (1.8%)]. 5- and 10-years overall, cancer-specific, and recurrence-free survival were 58.8 and 43.4%, 66.1 and 58.0%, 51.7 and 36.3% respectively. A sinus fat invasion, ascites, and tumor invasion of ostia of major hepatic veins showed independent impact on overall survival in the regression analysis.
Conclusion. Nephrectomy, thrombectomy is the only effective method of the treatment in RCC with tumor venous thrombosis, providing satisfactory long-term results. Nephrectomy, thrombectomy is associated with high operative risk and has to be performed only in referring surgical centers.
Keywords:renal cell carcinoma with tumor venous thrombosis, nephrectomy, thrombectomy
Clin. Experiment. Surg. Petrovsky J. 2015. № 4. Р. 18–27.
1. Alyaev U.G. Extended, combined, and organ-preserving surgery in kidney cancer: Autoabstract of diss.Moscow, 1989. (in Russian)
2. Davydov M.I., Matveev V.B., Matveev B.P. Surgical treatment of renal cell carcinoma complicated with venous invasion (manual for physicians). Moscow, 2003: 24 р. (in Russian)
3. Davydov M.I., Akchurin R.S., Gerasimov S.S. Cardiovascular section of the thoracoabdominal oncosurgery. Kardiologiya [Cardiology]. 2005; Vol. 3: 45. (in Russian)
4. Davydov M.I., Matveev V.B., Volkov M.I. Predictors of immediate results of thrombectomy in patients with renal cell carcinoma with tumor venous thrombosis. Onkourologiya [Oncourology]. 2014; Vol. 3: 36–44. (in Russian)
5. Kaag Matthew G., Christien Toyen, Paul Russo, et al. Radical nephrectomy with vena caval thrombectomy: a contemporary experience. BJU Int. 2011; Vol. 107, Issue 9: 1386–93.
6. Blute M.L., Boorjian S.A., Leibovich B.C., et al. Results of inferior vena caval interruption by greenfield filter, ligation or resection during radical nephrectomy and tumor thrombectomy. J Urol. 2007; Vol. 178: 440–5.
7. Abel E.J., Thompson R.H., Margulis V., et al. Perioperative Outcomes Following Surgical Resection of Renal Cell Carcinoma with Inferior Vena Cava Thrombus Extending Above the Hepatic Veins: A Contemporary Multicenter Experience. Eur Urol. Available online 6 November 2013.
8. Jibiki M., Iwai T., Inoue Y., Sugano N., et al. Surgical strategy for treating renal cell carcinoma with thrombus extending into the inferior vena cava. J Vasc Surg. 2004; Vol. 39, N 4. P. 829–35.
9. Kirkali Z., Van Poppel H. A Critical Analysis of Surgery for Kidney Cancer with Vena Cava Invasion. Eur Urol. 2007; Vol. 52, Issue 3: 658–62.
10. Pouliot F., Shuch B., Larochelle J.C., Pantuck A., et al. Contemporary management of renal tumors with venous tumor thrombus. J Urol. 2010; Vol. 184: 833–41.
11. Delis S., Dervenis C., Lytras D., Avgerinos C., et al. Liver transplantation techniques with preservation of the natural veno- venous bypass: effect on surgical resection of renal cell carcinoma invading the inferior vena cava. World J Surg. 2004; Vol. 28, N 6: 614–9.
12. Ciancio G., Vaidya A., Savoie M., Solowy M. Management of renal cell carcinoma with level III thrombus in the IVC. J Urol. 2002; Vol. 168: 1374–7.
13. Patil M.B., Montez J., Loh-Doyle J., et al. Level III–IV In- ferior Vena Caval Thrombectomy without Cardiopulmonary Bypass: Long-Term Experience with Intrapericardial Control. J Urol. 2014; Vol. 192: 682–9.
14. Gaetano C., Shirodkar S.P., Soloway M.S., et al. Techniques for avoidance of sternotomy and cardiopulmonary bypass during resection of extensive renal cell carcinoma with vena caval tumor thrombus extension above the diaphragm. J Card Surg. 2009; Vol. 24, Issue 6: 657–60.
15. Novick A.C., Kaye M.C., Cosgrove D.M., Angermeier K., et al. Experience with cardiopulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi. Ann Surg. 1990; Vol. 212 (4): 472–6; discussion 476–7.
16. Shuch B., Crispen P.L., Leibovich B.C., et al. Cardiopulmo- nary bypass and renal cell carcinoma with level IV tumour thrombus: can deep hypothermic circulatory arrest limit perioperative mortal- ity? BJU Int. 2011; Vol. 107: 724–8.
17. Modine T., Haulon S., Zini L., Fayad G., et al. Surgical treatment of renal cell carcinoma with right atrial thrombus: early experience and description of a simplified technique. Int J Surg. 2007; Vol. 5, N 5: 305–10.
18. Wang G.J., Carpenter J.P., Fairman R.M., et al. Single-center experience of caval thrombectomy in patients with renal cell carcinoma with tumor thrombus extension into the inferior vena cava. Vasc Endovasc Surg. 2008; Vol. 42: 335–40.
19. Tsuji Y., Goto A., Hara I., Ataka K., et al. Renal cell carcinoma with extension of tumor thrombus into the vena cava: Surgical strategy and prognosis. J Vasc Surg. 2001; Vol. 33: 789–96.
20. Calligaro K.D., Savarese R.P., McCombs P.R., DeLaurentis D.A. Division of the left renal vein during aortic surgery. Am J Surg. 1990; Vol. 160: 192–6.
21. Skinner D.G., Pritchett T.R., Lieskovsky G., Boyd S.D., et al. Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg. 1989; Vol. 210 (N 3): 387–92; discussion 392–34.
22. Kaplan S., Ekici S., Dogan R., Demircin M., et al. Surgical management of renal cell carcinoma with IVC tumor thrombus. Am J Surg. 2002; Vol. 183: 292–9.
23. Pertia A., Chkhotua A., Managadze L. Surgical management of renal cell carcinoma invading the inferior vena cava. Georgian Med News. 2006; Vol. 136: 21–7.
24. Wagner B., Patard J.J., Mejean A., et al. Prognostic value of renal vein (RV) and inferior vena cava (IVC) involvement in renal cell carcinoma (RCC). Eur Urol Suppl. 2007; Vol. 6: 159 (abstract no. 546).