Metastatic renal cell carcinoma with concurrent inferior vena caval invasion: Long-term survival after combination therapy with radical nephrectomy, vena caval thrombectomy and postoperative immunotherapy

Purpose: We report our experience using aggressive multimodal therapy in a high risk group of patients with metastatic renal cell carcinoma and concur rent inferior vena caval extension. Materials and Methods: We retrospectively reviewed the records of all patie nts in our kidney cancer database who had metastatic renal cell carcinoma a nd tumor thrombus extension into the inferior vena cava at the initial diag nosis. Patients were included in the study if they underwent radical nephre ctomy and inferior venal caval thombectomy, and immunotherapy was planned f or the postoperative period. Tumor size and grade, metastatic sites, level of vena caval extension, surgical complications and overall survival were o btained from the medical records. The primary end point analyzed was overal l survival. Results: We identified 31 cases of metastatic renal cell cancer with, exten sive disease and vena caval extension. Of the patients 23% had an isolated lung metastasis, and 53% had metastasis in the lung and at other sites. The remaining patients had involvement primarily at nonpulmonary metastatic si tes, including lymph node in 38%, soft tissue in 13%, liver in 29% and bone in 10%. Average blood loss during nephrectomy was 3,200 cc (median 2,100) and the rate of major complications was 12%. Of the patients 80% underwent the full course of surgery and postoperative immunotherapy. At a mean follo wup of 18 months (34 for survivors) 26% of the patients are alive. Actuaria l overall 5-year survival. of the group was 17%. Tumor thrombus level did n ot correlate with overall survival, while immunotherapy, tumor grade, and m etastatic site provided significant prognostic information. In patients wit h an isolated pulmonary metastasis the 5-year survival rate was 43%, while in those with low grade tumors it was 52%. Conclusions: In contrast to the poor results of surgery only in patients wi th renal cell carcinoma and concurrent inferior venal caval invasion, reaso nable 5-year survival may be achieved after combined aggressive surgery and immunotherapy. Patients in whom metastasis was limited to the lungs and th ose with grade 1 to 2 tumors had a better prognosis. With careful planning and experienced immunotherapists therapy may be completed in the majority o f this high risk group of patients.