BERKELEY, CA (UroToday.com) - Renal cell carcinoma is well known to have a particular angiotropism, with up to 10% of tumors presenting with neoplastic tumoral thrombosis. Surgical treatment of renal cell carcinoma with venous neoplastic thrombosis is one of the most challenging procedures in urology, requiring optimal surgical skills and a multidisciplinary approach, and involving other specialists such as radiologists, cardiothoracic surgeons, and oncologists to assess the best treatment for each case. While the literature has described a minimally-invasive endoscopic approach for this type of intervention, the gold standard remains open surgery.
In this work, we presented cases between 2002 and 2012, involving 67 patients who underwent surgery for this pathology. We classified tumor thrombus extension using Neves and Zincke criteria, assessing the kind of surgical approach for each case. To prevent pulmonary embolism during surgery, a preoperative caval filter was positioned in 26.8% of cases. The indication for this procedure is not clear in the literature, and the risk of thrombus detachment during caval mobilization is very low. We didn’t perform extended lymphadenectomy, removing only large size or palpable nodes in 6 cases (9% of total).
Tumor staging and histological findings were the most important prognostic factors in predicting survival. Three-year survival for patients with pathological N0M0 disease was 70%, while for N1M1, it was 20%. Our data confirm that non-metastatic RCC with extension into the vena cava, without venous wall infiltration, is potentially curable and that this intervention is safe and feasible for a highly experienced center.
There is no significant difference in outcome, by thrombus level, among patients with IVC venous neoplastic thrombosis without distant metastasis and infiltration of the caval wall. Patients with more extensive thrombus propagation tend to have tumors of a higher grade and a of a more advanced local stage. Survival was better in patients without renal capsular extension compared to those with perinephric fat penetration.
Cytoreductive surgery is also feasible for patients with metastatic disease or venous wall infiltration because it allows for better response to adjuvant immunotherapy and it provides palliation of neoplastic symptoms like local flank pain or hematuria, that occur with progressive neoplastic enlargement. However, it would have to be evaluated for each patient to assess a good balance between risks and benefits of the outcome as in our study we didn’t assess the long-term survival in those cases.
Giacomo Maria Pirola, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Urology Unit, Ospedale di Circolo e Fondazione Macchi, Varese, Italy