Outcomes of Nephrectomy and Caval Thrombectomy Using Extracorporeal Circulation and Deep Hypothermic Circulatory Arrest for Renal Cell Carcinoma Invading the Supradiaphragmatic Inferior Vena Cava and/or Right Atrium: Beyond the Abstract

In patients with renal cell carcinoma (RCC) with tumor thrombus involving the inferior vena cava (IVC), at the level of or above the hepatic veins or extending above the diaphragm (Mayo level III and IV), the standard of care remains radical nephrectomy (RN) with caval thrombectomy (CT). Among those patients, several surgical strategies have been described to achieve supradiaphragmatic IVC control: cardiopulmonary bypass (CBP) with or without deep hypothermic arrest (DHCA), liver transplantation and intrapericardial control of IVC through thoraco-abdominal incision. 

In this specific scenario, clinical presentation is often characterized by acute cardiovascular failure or major systemic symptoms due to the concomitant presence of locally advanced bulky tumour, caval involvement, and/or distant metastases. Although prognosis is usually poor, selected patients with RCC and supradiaphragmatic vena cava invasion may benefit from surgical treatment in the context of a multimodal management. Surgery is usually challenging with significant postoperative morbidity and mortality

Therefore, the objective of our study was to evaluate intraoperative and perioperative morbidities, as well as oncologic outcomes of patients undergoing RN and CT with CBP and DHCA.  Surgery was performed between 1990 and 2013 by a team of two urologists and a cardiac surgeon. Preoperative management and staging; surgical, CBP and cardiac arrest time, intraoperative blood loss, postoperative complications and their management, pathologic features, length of hospital stay, 30-d and 90-d mortality were reported. Kaplan Meier curves were used to assess overall survival (OS) and cancer specific mortality (CSM)-free survival rates. 

We found that 72% of patients did not require any additional interventional or surgical treatment, in addition to routine Intensive Care Unit support. Thirty-day and 90-d mortality were 11% (5/46) and 15% (7/46). The 1-yr, 2-yr, and 3-yr CSM-free survival rates were 77%, 62%, and 56%, respectively. After stratification, according to metastatic status at diagnosis, CSM-free survival rates were significantly lower for cM1 patients compared with cM0 patients (1-yr 46% vs 93%, 2-yr 23% vs 81%, 3-yr 23% vs 73%, p<0.01). Presence of solid tumour thrombus consistency, nodal positive status and metastatic disease represented independent predictors of CSM (all p <0.01).

Our study represents a single high-volume academic institution’s experience over two decades. Therefore, the results are limited by the retrospective and non-comparative nature of the study. However, this study represents the largest study on patients with RCC with high-level thrombi treated with RN and CT, using ECC and DHCA at a single tertiary care referral center. Pending confirmation from other centers series, multidisciplinary dedicated team can provide adequate midterm cancer control in patient with an acute life-threatening condition if distant metastases are not evident at diagnosis. Specifically, it is possible that even a longer survival of the patients could be expected nowadays with the implementation in daily clinical practice of tyrosine kinase inhibitors and checkpoint inhibitors. This is especially important in the setting of adjuvant therapy since the patients included in the current series could not be faced with an upfront systemic therapy due to the presence of short-term life-threatening conditions (as the case of atrial or supradiaphragmatic caval throumbus). 

Written by: Nini Alessandro1,2, Capitanio Umberto1,2 and Bertini Roberto1,2

Read the Abstract


Unit of Urology, University Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy 
Division of Oncology, URI, Urological Research Institute, Renal cancer Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy