NEPHRECTOMY AND VENA-CAVAL THROMBECTOMY IN PATIENTS WITH METASTATIC RENAL-CELL CARCINOMA

Objectives. To report our experience with performing nephrectomy and v ena caval thombectomy in patients with metastatic renal cell carcinoma . Methods. A retrospective review was performed of 15 patients who und erwent surgical excision of the primary tumor and a caval thrombus and treatment of concurrent metastases between 1989 and 1995. The sites o f metastases included lungs (n = 8), bone (n = 3), bulky retroperitone al or mediastinal lymph nodes (n = 2), liver (n = 1), and contralatera l adrenal (n = 1). The level of caval involvement was suprahepatic in 3 cases, retrohepatic in 2 cases, and infrahepatic in 10 cases. Three patients had an Eastern Cooperative Oncology Group performance score o f 0, 11 had a score of 1, and 1 had a score of 2. Median follow-up was 17 months. Results. Median operative time was 6.5 hours and median ho spitalization was 10 days. Two patients required re-exploration for po stoperative hemorrhage. There were no perioperative deaths. Four patie nts underwent surgery for resection of solitary metastases (1 lung, 2 spine, and 1 humerus); 2 of the 4 received adjuvant radiotherapy. Two patients received biologic therapy preoperatively, 3 received it both preoperatively and postoperatively, and 6 received it only postoperati vely. The median time to initiation of postoperative biologic therapy was 48 days (range 25 to 110). Eleven patients are currently alive, 7 with no evidence of disease at a median follow-up of 17 months (range 6 to 66) and 4 with stable metastases at 14 months (range 4 to 22). Te n of the 13 symptomatic patients had improved performance scores after surgery. Four patients have died from metastatic disease: 2 from rapi d progression at 2 and 5 months after surgery and the other 2 at 17 an d 42 months. Conclusions. Nephrectomy and vena caval thrombectomy can be safely performed in selected patients with metastatic disease. Furt hermore, in patients receiving biologic therapy, nephrectomy may enabl e a better quality of life and prolonged survival. (C) 1997, Elsevier Science Inc. All rights reserved.