Renal cell carcinoma with extension into the inferior vena cava: problems in diagnosis, staging and treatment

Management of renal cell carcinoma with extension into the vena cava is one of the highest challenges in urology. The delineation of the upper level of the endocaval thrombus, its possible extension into the hepatic veins and possible involvement of the caval wall are crucial points and dictate the operative strategy. From 1978 to 1989, at the Department of Urology of the University of Padua, 29 patients with renal cell carcinoma and caval extension were submitted to surgery. Seventeen patients were staged V2 according to the UICC TNM Staging System 1983, 2 patients V3 and 10 V4. The median patient age was 57 years and the male:female ratio was 1.9:1. A complete thrombus removal was accomplished in all patients. In 2 patients, a caval resection was necessary. Five patients died during the perioperative period. The patient survival rate was comparable to that of T3N0M0-staged cases. Survival rates at 1 and 4 years were, respectively, 96.8 and 40% for V2 cases, 100 and 100% for V3, 85.7 and 40% for V4. It seems, therefore, that in patients with locoregional disease and satisfactory conditions, the presence of vascular invasion did not lead to a worst prognosis. By itself, the extent of the caval thrombus seems not to influence the prognosis.