Renal cell carcinoma with extension of tumor thrombus into the vena cava: Surgical strategy and prognosis

Purpose: The outcome of patients who underwent radical resection of renal c ell carcinoma extending into the vena cava was retrospectively analyzed, an d risk factors for long-term survival were investigated. Methods: From 1983 to 1999, 33 patients who had renal cell carcinoma with i nferior vena caval tumor extension underwent 34 surgical procedures. There were 27 men and six women with an average age of 60.1 years. Twenty-two cas es (64.7%) were classified as stage III (T1-2 N1 M0 or T3 N0-1 M0), and 12 cases (35.3%) as stage IV (T4 or N2-3 or M1). Coexistent lung metastasis wa s found in seven cases (20.6%). The tumor thrombi invaded into the inferior vena cava below the hepatic hilum in 19 cases, below the orifice of hepati c veins in 12, and above the diaphragm in 3. Cardiopulmonary bypass graft w as applied in 13 cases (38.2%). Inferior vena cava was reconstructed by dir ect suture (n = 19), polytetrafluoroethylene patch angioplasty (n = 13), or graft replacement (n = 2). Results: Two patients died during the early postoperative period because of retrohepatic caval injury and intraoperative pulmonary embolism. Late deat h occurred in 16 patients; the causes of death were tumor recurrence in 15 and acute pulmonary embolism as a result of graft thrombosis in 1. Overall 1-, 5-, and 10-year survival rates were 70%, 44%, and 26.4%, respectively. One- and 5-year survival rates were 81.3% and 52.9% for stage III and 50% a nd 31.2% for stage IV; a statistically significant correlation was found be tween surgical staging and survival (P = .049). Patients without lymph node metastasis had a significant survival advantage over those with lymph node metastasis (P = .022). There was no significant difference in survival on the basis of the presence or absence of synchronous lung metastasis (P = .2 91). The degree of local extension of the tumor or the level of tumor throm bus did not tend to influence survival. Conclusions: Surgical prognosis in patients with renal cell carcinoma exten ding into the vena cava was determined by the staging of the tumor, especia lly lymph node status, and not by the level of tumor thrombus or the presen ce of concurrent lung metastasis. The use of cardiopulmonary bypass graft i s recommended for the resection of tumor thrombus extending over the diaphr agm.