Introduction

Upwards of 15% of cases of renal cell carcinoma (RCC) have vascular involvement at diagnosis. While tumor thrombus is often limited to the ipsilateral renal vein, about 1% extend though the IVC into the right atrium. Complete surgical resection is the mainstay of treatment, but few centers have experience with such advanced disease. We examine our experience with resection of level IV tumor thrombus using cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA).

Methods

Twenty two consecutive patients who underwent resection of RCC with cavoatrial thrombectomy using DHCA at a single tertiary center from 2000-2016 were analyzed. Complications within 30 and 90 days were captured and classified using the Clavien-Dindo system. Overall survival (OS), cancer-specific survival (CSS), and recurrence free survival (RFS) estimates were generated using Kaplan-Meier analysis.

Results

Median age was 63 years (IQR 54.5-66.5) and 13 (59%) patients were male. Median tumor size was 8.75 cm (6.25-11.75) and 14 (64%) were right sided. Surgical pathology revealed 4 tumors (18%) were pT4, while the remainder were pT3c. 77% of tumors were clear cell, while the remainder were papillary. Of the 12 patients who underwent regional lymphadenectomy, 33% had LN+ disease. Five patients (23%) had ipsilateral adrenal involvement, while 4 (18%) had non adrenal metastatic involvement, most commonly the liver (50%). Positive surgical margin was present in 77% of cases, most commonly involving the renal vein. Patients received a median 6 units of PRBC intra-op, with a CPB time of 136 (120.5-148.75) minutes. Median length of stay was 13 days (8-14). Two patients (9%) experienced peri-operative mortality, while 31.8% and 36.4% of patients experienced major complications, respectively. Most commonly encountered major complications were pulmonary (9%), re-exploration for bleeding (9%) and renal failure requiring dialysis 3 (13.6%). Kaplan-Meier analysis revealed OS, CSS, and RFS estimates at 22 mo (95% CI 0.79.7), 41 mo (95% CI 0-92), and 16 mo (95% CI 0.1-31.9) respectively.

Conclusions

Surgical resection for patients with level IV tumor thrombus using CPB and DHCA can be accomplished with acceptable morbidity and mortality. Overall prognosis remains poor, but improvement in surgical morbidity by experienced multi-disciplinary teams paves the way for the possibility of multi-modal treatments combining surgery with newer targeted and/or immunotherapy agents.

Funding

None