Surgical treatment of renal cell
carcinoma with caval thrombus
Oliver Hakenberg
Urologische Klinik und Poliklinik
Universitätsklinikum Rostock
Tumor stage
90%
5-year survival
70%
35%
15%
after surgery
Cava tumour extension
Mayo Clinic classification
Classification
50%
40%
Level I
Level II
renal or < 2cm IVC
infrahepatic
Level III
Level IV
retrohepatic
atrial
TNM
10%
T3b
below diaphragm
T3c
above diaphragm
Neves & Zincke, Brit J Urol 1987
Caval thrombus
TEE
transesophageal ultrasound
MRI
Duplex venous sonography
cavography not necessary
Caval thrombus
Renal vein
vena cava
kidney
Removal of suprahepatic caval thrombus
cavotomy
Specimen after nephrectomy and resection of caval
thrombus
Rim of renal vein
Presentation
 Up to 10% of patients with RCC (1990s)
 majority right-sided (85%)
 majority have symptoms
–
–
–
–
–
IVC syndrome
edema
cardiac dysfunction
abdominal pain
hematuria
Surgical technique
 Exposure
– Chevron bilateral subcostal
– Median laparotomy with sternotomy
 Standard
–
–
–
–
isolation of vena cava
extended hepatic mobilization
PRINGLE maneuver
Primary or patch closure of vena cava
 Alternative
– Endoluminal occlusion
– Resection of vena cava
 Cardiac bypass
 Resection of vena cava/prosthetic interposition
Endoluminal caval occlusion
 Through inferior vena cava
– blind
– transesophageal echography-guided
 Through jugular vein
– preoperatively
Surgical technique: endoluminal occlusion

Through inferior vena cava
–
–

blind
transesophageal echography-guided
through jugular vein
–
preoperatively
n=31
Follow-up
level II or III
22.1 months
2000-2005
n= 13
1 splenectomy
1 thrombosis IVC
Avoids suprahepatic approach
No complications due to endoluminal occlusion
No air embolism
Zini et al, BJU Int, 2006
n=7 M+
Intraatrial thrombectomy
 Standard
– Cardiopulmonary bypass with hypothermia
 Alternative
– mild hypothermia, cardiopulmonary bypass
– beating, perfused heart
– n= 6, no mortality (Chowdury et al, 2006)
– venous cardiac bypass (superior vena cava + infrarenal vena
cava)
– endoluminal occlusion via cavotomy at renal vein level
– N= 6, 1 postoperative death (Modine et al, 2007)
Chowdhury et al, Ann Thorac Surg 2007
Modine et al, Int J Surg 2007
Interruption of vena cava
 n=40 patients with vena cava interruption at surgery
 Postoperative venous disability score
–
–
–
–
None class 3
12/40 (30%) class 2
12/40 (30%) class 1
16/40 (40%) no disability
Blute et al, J Urol 2007
Perioperative mortality 3-16%
n=
Bissada et al, 2003
75
Perioperative
mortality
n= 48 without M+
2% (1)
n= 26 with M+
7% (2)
Kaplan et al, 2002
11
9.1% (1)
Zini et al, 2005
10
10% (1)
Galluci et al, 2004
15
0%
Bastian et al, 2005
27
Parekh et al, 2005
49
Bissada et al, Urology 2003
Kaplan et al, Am J Surg 2002
Parekh et al, J Urol 2005
Bastian et al, Eur J Surg Oncol 2005
n=8 with N+
8% (4)
Surgical series
n= 63
5-yr-disease-free
survival
1993-2003
infrahepatic
35
48.5%
Retrohepatic
20
50.6%
Suprahepatic
5
66.6%
Atrial
3
40%
operative
mortality 3%
complications
34% (conservative)
Perinephric fat invasion
yes
31%
no
68%
p<0.01
positive
30%
p<0.05
negative
60.9%
pN
Kulkarni et al, Indian J Cancer 2007
Prognosis with treatment
N+
M1
n= 107
RCC with renal vein or
vena cava thrombus
26%
54%
n= 100
12%
31%
N0M0
N0M0
2-yearsurvival
5-year survival
Vena cava
83%
72%
Renal vein
90%
68%
93%
81%
RCC without
Prognostic factors:
capsular penetration
collecting system invasion
extension into hepatic veins
Zisman et al, J Urol 2003
Prognosis of surgery in non-metastatic RCC
n
3-year cancerspecific survival
5-yr overall
survival
Skinner, 1989
43
57%
Glazer, 1996
18
57%
Moinzadeh, 2004 153
Kim, 2004
81
66% (renal vein)
renal vein 36%
IVC
35%
T3c
Lubahn, 2006
44
Ciancio, 2007
56
10-year overall
survival
12%
56%
53%
Skinner et al, Ann Surg 1989; Glazer et al, J Urol 1996;
Moinzadeh et al, J Urol 2004; Kim et al, J Urol 2004;
Lubahn et al, J Thora Cardiovasc Surg 2006; Ciancio et al, Eur Urol 2007
Impact of level of thrombus on survival?
n
5-yr overall
survival
Skinner, 1989
56
Level I 35%
Level II 18%
Level III 0%
yes
Glazer, 1996
18
Level III 60%
Level IV 57%
no
Moinzadeh, 2004 153 Level not
associated with
local stage
Kim, 2004
10-year overall
survival
Impact on
survival
Level 1
66% ?
Level II-IV 29%
221 Level IV much
worse than Level
I/II
Skinner et al, Ann Surg 1989; Glazer et al, J Urol 1996;
Moinzadeh et al, J Urol 2004; Kim et al, J Urol 2004;
yes
Prognosis with cytoreductive treatment in M1 disease
M1 patients
2-yearsurvival
5-year
survival
Nephrectomy +
immunotherapy
52%
41%
nephrectomy
45%
32%
immunotherapy
13%
0%
No treatment
0%
Zisman et al, J Urol 2003
Impact of thrombus removal in metastatic RCC
 30% of patients with IVC thrombus have M+ disease
 patients are symptomatic
 surgery is palliative: quality of life
 cytoreductive surgery improves response to
immunotherapy
 impact of targeted therapies?
Outcome
n= 134
FU 16.4 months
median
n
Median survival
(months)
Radical
nephrectomy
with
thrombectomy
111
19.8
N0M0: 51.7
NxM1: 6.9
Embolization +
immunotherapy
23
6.9
Prognostic factors:
ImmunoRx
With
13.5
Without 5.1
localized tumour stage N0M0 vs N+M0, NxM1
Fuhrmann grades 1 and 2 vs 3 and 4
thrombus level
Haferkamp et al, J Urol 2007
I and II vs III and IV
Outcome
n
n (M+)
Follow-up
(months)
DOD
Bissada et al,
2003
75
26
Kaplan et al,
2002
11
Zini et al, 2005
10
10
2
Galluci et al,
2004
15
53
1
Bastian et al,
2005
27
Parekh et al,
2005
49
Alive with M+
Alive and NED
24 (41%)
22 (47%)
71.4% estimated survival at 10 years
8
15
Bissada et al, Urology 2003
Kaplan et al, Am J Surg 2002
Galluci et al, Eur Urol 2004
Parekh et al, J Urol 2005
Bastian et al, Eur J Surg Oncol 2005
11
2 (7%)
11 (40%)
8 (16%)
29% (14)
21 (43%)
Conclusions
 thrombus carries worse prognosis because local
prognostic indicators are worse
 overall survival with R0 resection is > 50%
 Level of thrombus
– increases difficulties of surgery
– probably correlates with reduced survival
– increases the risk of recurrence
 Surgery in non-metastatic disease improves survival
 Surgery in metastatic disease
– improves survival
– is palliative
– cytoreduction improves results of adjuvant therapy