Outcomes of Resection for Renal Cell Carcinoma with Extensive Inferior Vena Caval Thrombus
Hallie Baer, MD, Taylor Hicks, MD, Matthew Sideman, MD, Lori Pounds, MD, Ronald Rodriguez, MD, Dharam Kaushik, MD, Mark Davies, MD, PhD, MBA, Georges Haidar, MD.
UTHSCSA, San Antonio, TX, USA.
Background: Renal cell carcinoma has a propensity for vascular invasion with the presence of intravascular tumor thrombus. Tumor thrombus invades along the renal vein to the IVC and ultimately atrium with a worsening prognosis associated with caudal progression. Radical nephrectomy and caval thrombectomy represent the only method of local disease and durable oncologic control. The aim of this study is to examine the outcomes in the setting of a multidisciplinary team. Methods: We reviewed a prospectively maintained database of patients with tumor thrombus. Patients were evaluated pre-operatively with a standardized protocol to assess for extent of disease, specifically presence and level of tumor thrombus. A multidisciplinary surgical approach was taken involving Urology, Cardiothoracic, and Vascular surgery. Intraoperative Doppler ultrasound and trans-esophageal echocardiography were performed to aid in confirming the level of thrombus and identify lumbar and hepatic veins insertion into the vena cava. Results: A total of 57 patients underwent radical nephrectomy with tumor thrombectomy over the course of 28 months. Patients were predominantly Hispanic (61%), male (63%), overweight (median BMI 29), and middle aged (median age 58 with a history of hypertension (68%), tobacco use (56%), and diabetes (40%)). Almost all patients were symptomatic at presentation: hematuria (53%), flank pain (37%), weight loss (26%). Thrombus level for L0, L1, L2, L3, and L4 disease was 23%, 11%, 32%, 25%, and 11%, respectively. Use of intraoperative US correlated with an average EBL of 3.2L (vs. 3.5L without). Bypass was required in 35% of cases (veno-veno 25%, cardiopulmonary 11%) and IVC reconstruction with patch only occurred twice (3.5%). Median length of stay was 12 days with a 30-day re-admission rate of 17.5%. Mortality at 30 and 90 days for all patients was 5.7% and 9.4%, respectively.
| HISPANIC | L0 | L1 | L2 | L3 | L4 | TOTAL |
| Thrombus Level | 23% (8) | 11% (4) | 37% (13) | 20% (7) | 9% (3) | - |
| 30 Day Mortality | 0 | 0 | 0 | 6.3% (2) | 3.1% (1) | 9.4% |
| 90 Day Mortality | 0 | 0 | 3.1% (1) | 6.3% (2) | 3.1% (1) | 12.5% |
| NON-HISPANIC | ||||||
| Thrombus Level | 23% (5) | 10% (2) | 23% (5) | 32% (7) | 14% (3) | - |
| 30 Day Mortality | 0 | 0 | 0 | 0 | 0 | 0.0%* |
| 90 Day Mortality | 0 | 0 | 0 | 0 | 4.7% (1) | 4.7%* |
*P<0.05 compared to Hispanic patientsConclusions: Renal call carcinoma with extensive inferior vena caval thrombus remains a high risk surgery that requires a multidisciplinary approach, but is associated with acceptable mortality and morbidity. Our results demonstrate Hispanic patients present with less invasive disease, but a higher overall mortality. Additionally, intraoperative ultrasound aids in limiting blood loss and caval preservation based on EBL and low graft rate.
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