Renal cell carcinoma with tumor thrombus extension to inferior vena cava: SGPGIMS experience

Vishwajeet Singh; Wahid Zaman; Anant Kumar; Rakesh Kapoor; Aneesh Srivastava

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RESEARCH ARTICLE

Year : 2004 \| Volume : 20 \| Issue : 2 \| Page : 90-94

Renal cell carcinoma with tumor thrombus extension to inferior vena cava: SGPGIMS experience

Vishwajeet Singh, Wahid Zaman, Anant Kumar, Rakesh Kapoor, Aneesh Srivastava
Department of Urology & Renal Transplantation, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, India

Correspondence Address:
Aneesh Srivastava
Department of Urology & Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow - 226 014
India

Source of Support: None, Conflict of Interest: None

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Abstract

Objectives : Renal cell carcinoma with tumor thrombus extension to inferior vena cava is found in 4-10% of patients. We evaluated the surgical techniques of thrombectomy for different levels of the tumor thrombus in inferior vena cava and overall surgical outcome in these patients.
Methods : We retrospectively reviewed the records of 17 patients operated between 1994 and 2001. Eleven patients had Infrahepatic (level I) thrombus, retrohepatic (level II) thrombus in two patients and four had supradiaphragmatic (level III) thrombus without intra-a trial extension. All patients underwent radical nephrectomy and vena caval thrombectomy. The retrohepatic and supradiaphragmatic thrombectomies were done under venovenous bypass.
Results : The patients with infrahepatic and retrohepatic thrombectomies recovered without any major post operative complication. Two patients with supradiaphragmatic thrombectomy died in postoperative period. The overall 2-year and 5-year survivals were 64.9% and 29.5% respectively.
Conclusions: Radical nephrectomy and vena caval thrombectomy is the best treatment option in renal call carcinoma with tumor thrombus extending to inferior vena cava. The retrohepatic and supradiaphragmatic thrombectomies can be done with the help of venovenous bypass in select group of patients.

Keywords: Renal cell carcinoma, thrombus, venovenous bypass.

How to cite this article:
Singh V, Zaman W, Kumar A, Kapoor R, Srivastava A. Renal cell carcinoma with tumor thrombus extension to inferior vena cava: SGPGIMS experience. Indian J Urol 2004;20:90-4

How to cite this URL:
Singh V, Zaman W, Kumar A, Kapoor R, Srivastava A. Renal cell carcinoma with tumor thrombus extension to inferior vena cava: SGPGIMS experience. Indian J Urol [serial online] 2004 [cited 2023 Mar 28];20:90-4. Available from: https://www.indianjurol.com/text.asp?2004/20/2/90/21519

Introduction

Renal cell carcinoma has an unique feature of intracaval extension of tumor thrombus without involvement of vena cava wall in majority of the cases.^{[1],[2],[3],[4],[5]} The vena caval extension of thrombus is seen in 4 to 10 per cent of cases.^{[1],[2],[3],[4],[5],[6]} It is a locoregional disease and has no bearing on distant spread or survival.^[6],[8] In the absence of alternative effective treatment, radical nephrectomy and vena caval thrombectomy is the only hope for a potential cure in patients who do not have metastasis.^[9],[10]

The distal end of the tumor thrombus is the basis of classification for the level of thrombus.^{[1],[2],[3],[4],[5],[8],[10]} The level I thrombus is defined as when the distal end of thrombus lying below the liver (infrahepatic), level II thrombus are those lying behind the liver (retrohepatic) and level III thrombus are supradiaphragmatic with or without extension to the right atrium.^{[1],[2],[3],[4],[5],[6],[11],[12]} Preoperative determination of the cephalad extension of the tumor thrombus is essential because the surgical techniques for thrombectomy is determined by the distal end of thrombus which may affect the immediate surgical outcome.^{[7],[11],[12],[13]} This study presents the clinical utility of preoperative determination of the distal end of thrombus, its impact on surgical techniques for thrombectomy and overall surgical outcome in these patients.

Patients and Methods

Between 1994 and 2001, 17 patients of renal cell carcinoma with vena cava extension of tumor thrombus were seen at our centre. All were male patients and mean age was 55 years.The tumor was seen on right side in 11 patients and left side in 6 patients.The painless hematuria was the commonest presentation seen in 10 patients, flank pain in 8 cases, renal lump in 7 cases, anorexia and weight loss in 3 patients and varicocele on the tumor side in 2 patients.The triad of pain, hematuria and lump was seen in 3 patients. All patients had routine hemogram, renal function tests, urinalysis, urine culture, liver function tests, chest X-ray and ultrasound abdomen.The diagnosis of renal tumor with tumor thrombus in IVC was accomplished by CECT scan in all patients. The cephalad extension of thrombus was clearly delineated by CT scan in 9 patients [Figure - 1]. In 6 patients MRI abdomen and thorax was needed to confirm the distal end of tumor thrombus [Figure - 2]. In two patients apart from CT scan and MRI, color doppler ultrasound was required to determine exactly the distal end of tumor thrombus as well as to confirm the patency of the hepatic veins.Both these cases had retrohepatic tumor thrombus.The cephalad extension of the tumor thrombus was infrahepatic in 11 patients, retrohepatic in 2 patients (in both cases the thrombus extended up to the hepatic veins) and supradiaphragmatic thrombus in 4 patients. All patients had negative preoperative metastatic work-up.

Surgical Techniques of Thrombectomy

Infrahepatic Thrombectomy (n=11). The primary tumor mass was approached either by chevron or midline incision. Thrombectomy in these cases need no complex manuevers.The IVC was isolated and conventional vascular controls taken both above and below the thrombus and of the opposite renal vein. After extraction of tumor thrombus the cavotomy was repaired by 4/0 polypropylene.

Retrohepatic Thrombectomy (n=2). The surgical approach in these patients was right thoracoabdominal incision.The right lobe of the liver was mobilised and lifted anteriorly after incising the right triangular and coronary ligaments to expose the retrohepatic IVC. The caudate lobe vein was ligated and cut. The porta hepatis was mobilised and control was taken over porta hepatis. The distal and proximal controls were taken by mobilising the intrapericardial IVC and the infrarenal vena cava. The venovenous bypass was instituted at this stage to divert the blood from infrarenal vena cava to the right atrium. The porta hepatis was clamped to stop the return from IVC and hepatic veins. Now the vena cava was opened and tumor thrombus was removed. In one case who had right renal tumor, the left renal vein and porta hepatis were not clamped and the hepatic venous backflow and venous blood from left renal vein were drained separately by two sump suction drain and was returned to right atrium after the filtration.

Supradiaphragmatic Thrombectomy (n=4). These cases were done by instituting venovenous bypass, thus diverting blood from infrarenal IVC to right atrium. The porta hepatis was clamped for 10 to 15 minutes in all cases during cavotomy and thrombectomy. The surgical approach was thoracoabdominal in two cases and median sternotomy in another two cases. None of the patients had intra-atrial thrombus extension. However the cardiovascular surgeons were involved in all these cases with the readiness to go for total cardipulmonary bypass and circulatory arrest. The IVC reconstruction by longitudinal pericardial patch was done in 2 cases where tumor was adherent to the vena caval wall.

The survivals were calculated from the time of surgery to the last follow-up and subsequently analysed by Kaplan-Meier method [Figure - 3]

Results

Eleven patients had infrahepatic (level I) thrombus, retrohepatic (level II) thrombus in two cases and four patients had supradiaphragmatic (level III) thrombus. None of the level III thrombus had intra-atrial extension.The thrombectomy was done successfully in all cases. There was no operative mortality, intraoperative tumor embolism or major exsanguination.The average blood loss was 600 ml (400 -2000 ml). Six patients required blood transfusion and mean transfusion requirement was 4 units.The mean operative time was 210 minutes (150 - 300 minutes). The IVC reconstruction by longitudinal pericardial patch was done in 2 cases where tumor was adherent to the vena caval wall. There was no evidence of microscopic invasion of the vena caval wall by tumor on histopathological examination. Two patients with level III thrombectomy died in postoperative period. One patient developed severe jaundice and hepatic encephalopathy due to hemolytic reaction and died on tenth postoperative day. Other patient who had solitary kidney with renal failure was on maintenance hemodialysis. He had severe hematemesis on 12th postoperative day and died within hours inspite of intensive resuscitation. The survivals were calculated from the time of surgery to the last follow-up and subsequently analysed by Kaplan-Meier survival curve [Figure 3].The mean follow-up of the patient is 48 months. Two patients with supradiaphragmatic thrombectomy died in post operative period.The patients who were lost to follow-up after recurrences and did not respond to our letters were considered as dead. Three patients with infrahepatic thrombectomy and one patient with retrohepatic thrombectomy died in follow-up.The survival of the patients are shown in the table. The overall 2-year and 5-year survivals are 64.9% and 29.5% respectively [Table - 1].

Discussion

An aggressive approach is needed in RCC with thrombus extension to IVC without distant metastatis^[1],[2],[5] . The prognosis of patients with resectable IVC extension without unresectable vena caval wall invasion or lymph node metastasis approaches that of stage I disease ^[2],[6],[6] . The Spiral CT scan can diagnose the tumor thrombus in the IVC.^{[1],[2],[3],[4],[6]} Sosa and colleagues reported no survivors at the end of one year leaving the tumor thrombus in the IVC after nephrectomy.^[9] The distal end of tumor thrombus in IVC is^, important because the surgical techniques for thrombectomy is determined by the distal end of thrombus.^{[1],[2],[3],[4],[7],[10]} The preoperative determination of the distal end of thrombus can be done traditionally by vena cavography^[7] but transesophageal echocardiography^[7] and color doppler ultrasound^[11] can diagnose it also. However, MRI is the best technique for the exact determination of the distal end of thrombus.^[12],[13] Thrombectomy for infrahepatic thrombus do not require any complex maneuvers.^{[1],[2],[5],[8]} For retrohepatic thrombectomy, venovenous bypass and occlusion of porta hepatis and opposite renal vein are required to achieve the bloodless operative field.^{[8],[15],[16]} In the present study, one retrohepatic thrombectomy was done without putting clamps on the porta hepatis and the opposite renal vein.^[18] Level III thrombus extending in to the right atrium requires full cardiopulmonary bypass, hypothermia and circulatory arrest.^{[10],[14],[16]} However, if the thrombus is lying just below the right atrium, thrombectomy can be done on venovenous bypass^[14],[16] and temporary occlusion of porta hepatis.^{[14],[15],[16]} Cardiopulmonary bypass and circulatory arrest is ideal for level III thrombectomy as the entire surgery is done in a bloodless field without much mobilization of IVC.^[14],[16] The major problem in using cardiopulmonary bypass with hypothermia and circulatory arrest is bleeding diathesis^{[8],[14],[15],[16]} seen in 5% cases which can be profuse and secondary to the heparinization and hyperfibrinosis leading to platelet dysfunction.^[20] The advantage of venovenous bypass is that full heparinization is not always needed.^{[14],[15],[16],[17]} In the present study full heparinization was done in all the venovenous bypass. Burt et al has strongly recommended the use of blood retrieval system because by retrieving, filtering, washing and returning the autologous blood, the volume of transfused banked blood will be reduced.^[14] The disadvantage of this procedure is the possibility of disseminating tumor emboli from the operated site.^[16],[18] However, literature suggests that there is no increase in metastasis with autotransfusion.^[19] Venovenous bypass is simple to institute and uses less priming fluid resulting in much less hemodilution.^[16] The extended access to IVC with a greately reduced blood loss, minimal or no heparinization and prevention from hypotension are the distinct advantages of venovenous bypass.^{[14],[15],[16],[18]} In the present study all level II and level III thrombectomies were done on venovenous bypass because of our limitations to use cardiopulmonary bypass, circulatory arrest and hypothermia. The authors strongly feel that in a select group of patients without atrial thrombus extension, venovenous bypass can be a resonable alternative to total cardiopulmonary bypass and hypothermia. If we compare the expenditure of consumables and post operative intensive care monitoring of the patients who have had cardiopulmonary bypass, circulatory arrest and hypothermia then it would be rupees fifty thousand more than in venovenous bypass. Thus venovenous bypass is cost-saving in the context of Indian scenario. In the present study all 4 patients with level III thrombus had tumor thrombus lying below the right atrium which were diagnosed accurately preoperatively. These cases were operated successfully on venovenous bypass without major blood loss and intraoperative tumor embolism. Our 2 patients with level III thrombectomy died in postoperative period but the cause of death was not related to the surgical technique and the type of bypass.

Conclusions

In renal cell carcinoma with vena caval thrombus, radical nephrectomy and vena caval thrombectomy provides satisfactory surgical outcome in select groups of patients. Prior knowledge of cephalad extension of the tumor thrombus helps in deciding the technique for thrombectomy. The venovenous bypass is a reasonable alternative for cardiopulmonary bypass and circulatory arrest for the supradiaphragmatic thrombus without right atrial extension. One or more imaging modalities should be considered preoperatively to know accurately the cephalad extension of tumor thrombus. With improvement in operative technique and perioperative care, we advocate an aggressive, optimistic approach for those patients with clinically confined tumor with isolated caval thrombus extension.

References

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