Surgical strategy in late-stage renal cell cancer with intracaval extension

During the past two years several reports have substantially contributed to the surgical stratification of patients with late-stage renal cell cancer and simultaneously occurring intracaval neoplastic extension, and our knowledge about the clinical prognosis of the patients after nephrectomy with complete removal of the tumour thrombosis has been extended. Recognizing the importance of a tolerable perioperative and postoperative morbidity and mortality, it is now well documented in the literature that a multidisciplinary approach involving the combined use of deep hypothermia, cardiac arrest and cardiopulmonary bypass has dramatically improved the feasibility of surgical treatment of the venous extension above the hepatic veins. Furthermore, the diagnostic approach for patients with intracaval thrombosis, aiming at the reliable delineation of the cranial margin of venous extension, has been rationalized without compromising important diagnostic information required for the surgical stratification. This review assesses the current opinion of the surgical stratification of patients with renal cell cancer and intracaval neoplastic extension, the most reliable and least invasive diagnostic approach for the preoperative staging and, finally, the independent prognostic value of neoplastic venous extension for the clinical course of the disease.