OBJECTIVE: To evaluate clinical and radiographic predictors of need for partial or circumferential resection of the inferior vena cava (IVC-R) requiring complex vascular reconstruction during venous tumor thrombectomy for renal cell carcinoma (RCC).
PATIENTS AND METHODS: Data were collected regarding 172 patients with RCC and IVC (level I-IV) venous tumor thrombus who underwent radical nephrectomy with tumor thrombectomy at the Mayo Clinic between 2000 and 2010. Preoperative imaging was re-reviewed by one of two radiologists blinded to details of the patient's surgical procedure. Univariable and multivariable associations of clinical and radiographic features with IVC-R were evaluated by logistic regression. Secondary analysis assessed the ability of the model to predict histologic invasion of the IVC by the tumor thrombus.
RESULTS: Of the 172 patients, 38 (22%) underwent IVC-R procedures during nephrectomy. Optimal radiographic cut-points determined to predict need for IVC-R based on preoperative imaging included a renal vein (RV) diameter at the RV ostium (RVo) of 15.5 mm, maximal AP diameter of the IVC of 34.0 mm and AP and coronal diameters of the IVC at the RVo of 24 mm and 19 mm respectively. On multivariable analysis, the presence of a right-sided tumor (OR 3.3; p=0.017), AP diameter of the IVC at the RVo ≥ 24.0 mm (OR 4.4; p=0.017), and radiographic identification of complete occlusion of the IVC at the RVo (OR 4.9; p< 0.001) were associated with a significantly increased risk of IVC-R. The c-index for the model was 0.81.
CONCLUSIONS: We present a multivariable model of radiographic features associated with the need for IVC-R during tumor thrombectomy. Pending external validation, this model may be used for preoperative planning, patient counseling, and planned involvement of vascular surgical colleagues in anticipation of need for complex vascular repair.
Psutka SP, Boorjian SA, Thompson RH, Schmit GD, Schmitz JJ, Bower TC, Stewart SB, Lohse CM, Cheville JC, Leibovich BC. Are you the author?
Department of Urology, Mayo Clinic, Rochester, Minnesota.
Reference: BJU Int. 2014 Nov 28. Epub ahead of print.