Modern management of locally advanced renal cancers with inferior vena cava thrombus

Renal cell carcinoma (RCC) with inferior vena cava (IVC) tumour thrombus is an uncommon but highly complex presentation associated with substantial surgical morbidity and poor natural history. This review summarises contemporary evidence on diagnostic evaluation, multidisciplinary management and operative strategies, with novel contributions on evolving minimally invasive and robotic surgical approaches, the emerging role of neoadjuvant immune checkpoint inhibition as a thrombus downstaging strategy and the inclusion of stereotactic ablative radiotherapy (SABR) in the multidisciplinary treatment pathway.

A narrative review of the literature was performed, incorporating large institutional series, registry data, systematic reviews, and recent prospective and retrospective clinical studies. Evidence relating to imaging, perioperative optimisation, surgical techniques by thrombus level, decision making for cardiopulmonary bypass, neoadjuvant therapies and SABR was utilised.

Radical nephrectomy with IVC thrombectomy remains the standard treatment and confers a significant survival benefit compared with non-operative management, despite perioperative mortality rates of 2-10%. Outcomes are strongly associated with tumour biology, metastatic status, and treatment at high volume centres. MRI is central for preoperative staging and prediction of operative complexity. Surgical strategy varies according to thrombus level, ranging from conventional vascular control to liver mobilisation and cardiopulmonary bypass in advanced disease. Minimally invasive approaches are increasingly becoming feasible. Neoadjuvant systemic therapy and stereotactic ablative radiotherapy show potential for thrombus downstaging yet remain investigational.

Management requires specialised multidisciplinary care and centralisation to experienced centres. Surgery remains the cornerstone of treatment, while evolving multimodal strategies, including neoadjuvant systemic therapy and SABR, alongside improved risk stratification may further refine patient selection and outcomes.