Conservative management of inferior vena cava thrombus during nephrectomy for renal cell carcinoma

To assess the impact on survival outcomes of positive vascular margins (PVM) after nephrectomy, open thrombectomy and renal vein ostium resection without inferior vena cava (IVC) segmental resection for nonmetastatic clear cell renal cell carcinoma (ccRCC).

Medical records of patients undergoing nephrectomy and open thrombectomy for ccRCC in 1 center were retrospectively reviewed. Baseline characteristics, pathological features and surgery parameters were collected. A Cox uni- and multivariate regression model was used to evaluate the association between common prognosis factors including PVM and survival outcomes.

Thirty-nine patients were included. Median age was 65 (55-74) years, mean tumor size was 101±35.7mm, 35/39 (89%) had an infra-diaphragmatic IVC thrombus, and on pathological examination 19 (49%) and 17 (44%) patients had a Fuhrman/ISUP grade 3 and grade 4 ccRCC, respectively, and 23 (59%) had PVM. The median overall survival (OS), cancer specific survival (CSS) and disease-free survival (DFS) were 66, 116 and 28 months, respectively. In the univariate analysis, OS was significantly shorter in case of PVM (HR 4.21, P = 0.01), but there was no significative impact on CSS, local recurrence and DFS. In the multivariate analysis, PVM had no impact on OSS, CSS, local recurrence and DFS, but metastatic lymph nodes were associated with a higher risk of death (HR 4.37, P = 0.015), local recurrence (HR 9.98, P = 0.004) and disease progression (HR 6.09, P = 0.002) and a supra-diaphragmatic thrombus was associated with a higher risk of local recurrence (HR 13.83, P = 0.007) and disease progression (HR 7.77, P = 0.003).

In a population with a high rate of positive vascular margins, inferior vena cava wall invasion had a minimal impact on survival outcomes. This must be considered regarding the invasiveness of the surgery used for these patients.