SURGICAL-MANAGEMENT OF RENAL-CELL CARCINOMA WITH INFERIOR VENA-CAVA TUMOR THROMBUS

Background. The optimal management of patients with renal cell carcino ma with inferior vena cava tumor thrombus remains unresolved. Traditio nal approaches have included resection with or without the use of card iopulmonary bypass. Chemotherapy has played a minor role except for bi otherapeutic agents used for metastatic disease. Methods. From January 1989 to January 1996, 37 patients with renal cell carcinoma and infer ior vena cava tumor thrombus underwent surgical resection. The 27 men and 10 women had a median age of 57 years (range, 29 to 78 years). Thi rty-six patients presented with symptoms; 21 had hematuria. Distant me tastases were present in 12 patients. Tumor thrombi extended to the in frahepatic inferior vena cava (n = 16), the intrahepatic inferior vena cava (n = 16), the suprahepatic inferior vena cava (n = 3), and into the right atrium (n = 2). All tumors were resected by inferior vena ca va isolation and, when necessary, extended hepatic mobilization and Pr ingle maneuver, with primary or patch closure of the vena cavotomy. Ca rdiopulmonary bypass was necessary in only 2 patients with intraatrial thrombus. Results. Complications occurred in 11 patients, and 1 patie nt died in 2 days postoperatively of a myocardial infarction (mortalit y, 2.7%). Twenty patients are alive; overall 2- and 5-year survival ra tes were 61.7% and 33.6%, respectively. For patients without lymph nod e or distant metastases (stage IIIa), 2- and 5-year survival rates wer e 74% and 45%, respectively. The presence of distant metastatic diseas e (stage IV) at the time of operation did not have a significant adver se effect on survival, as reflected by 2- and 5-year survival rates of 62.5% and 31.3%, respectively. Lymph node metastases (stage IIIc) adv ersely affected survival as there was no long-term survivors. Conclusi ons. Resection of an intracaval tumor thrombus arising from renal cell carcinoma can be performed safely and can result in prolonged surviva l even in the presence of metastic disease. In our experience, extraco rporeal circulatory support was required only when the tumor thrombus extended into the heart. (C) 1997 by The Society of Thoracic Surgeons.