Resection of inferior vena cava tumor thrombi from renal cell carcinoma

Renal cell carcinoma is an unusual cancer with the propensity to invade not only the renal vein but to propagate into the inferior vena cava (IVC) as a tumor thrombus. Experience has recently confirmed that MRI will be valuable in evaluating the extent of the tumor thrombus. The surgical techniques used to remove the thrombus are dependent on the extent of the cancer. For lesions involving the infrahepatic IVC, only proximal and distal control of the IVC are necessary. For a thrombus involving the intrahepatic IVC, isolation of the suprahepatic IVC, hepatic circulation, and infrahepatic IVC or cardiopulmonary bypass can be used. For the large thrombus in the supradiaphragmatic IVC or atrium, cardiopulmonary bypass either with or without deep hypothermic circulatory arrest is appropriate. In a review of 48 cases with renal cell carcinoma with IVC tumor thrombi, the tumor thrombus was removed intact in 58 per cent and in multiple fragments ("piece-meal") in 42 per cent of the patients. Cardiac bypass has been used in 26 cases with 22 undergoing deep hypothermic circulatory arrest. The postoperative mortality of 48 cases between 1965 and 1987 was 4 per cent. Removal of the most complicated and extensive renal cell carcinoma tumor thrombi is now technically feasible. In patients with large tumor thrombi, however, the ultimate outlook remains poor in the absence of effective systemic adjuvant therapy.