A case of renal cell carcinoma with tumor thrombus extension into the right atrium

Over the last half-century, mortality from renal cell carcinoma (RCC) has seen a dramatic reduction, while 5-year survival rates have reached an all-time high (34% to 75%).

A 77-year-old female with Stage 4 RCC (cT3c, cN1, cM1) presented with acute onset chest and back pain. Imaging revealed interval enlargement of a left renal mass with propagation of tumor thrombus (TT) throughout the left renal vein, intrahepatic and suprahepatic inferior vena cava (IVC) with extension into the right atrium (RA). The patient successfully underwent a high-risk open left nephrectomy with caval thrombectomy, retroperitoneal lymph node dissection, and atrial thrombectomy.

Approximately, 1% of RCC cases involve the right atrium, and radical nephrectomy with vena caval thrombectomy remains the most effective treatment for cavoatrial TT, with 5-year survival rates between 30% and 72%. While patients with renal vein involvement have better survival rates than those with IVC involvement, advanced TT cases (Types III and IV) often require extracorporeal circulation. Though the patient understood the prognosis of her RCC, discussing the risks of a complex procedure versus not intervening was challenging. Despite a typical median survival of 12 months for level IV tumor thrombus (TT), she remains stable 28 months post-surgery.

Although the 5-year survival rate for renal cell carcinoma (RCC) has increased from 34% to 75%, the disease still adversely affects patients' quality of life. A multidisciplinary approach is essential when managing metastatic RCC, particularly involving the heart. Despite the associated risks, surgical intervention is more effective in prolonging life by preventing sudden cardiac death due to embolic events.