Renal cell carcinoma with IVC and atrial thrombus: A single centre's 10 year surgical experience

Renal cell carcinoma (RCC) propagates into the IVC in 4% of cases with 1% extending into the right atrium. Radical surgical resection remains the definitive curative/palliative treatment in those without significant metastases. The aim was to review our experience in patients with different levels of IVC involvement, cardiopulmonary bypass (CPB) and perioperative/long term outcomes. Patients and methods: From 2001 to 2012, 24 radical nephrectomies with IVC thrombectomy were performed. A retrospective chart review was undertaken to record demographics, presenting symptoms, duration of surgery, pen-operative transfusion, CPB and peri-operative complications, tumour grade/stage, and patient survival. Results: We identified 24 patients (18 male, Age median 59 range 35-78). The commonest presenting symptoms were weight loss, pain and haematuria. The majority of tumours were right sided (n = 17) with 8 having lung metastases at presentation. Thrombus level Was 16 (infradiaphragmatic), 2 (supradiaphragmatic), 6 (intra-atrial). 15 patients required sternotomy for vascular control and 9 required CPB both with a significantly longer operative time compared (6.1 +/- 3.5 vs. 7.2 +/- 1.2 vs. 3.5 +/- 1.1 h, respectively). Pen-operative complications (n = 21) included cardiopulmonary, renal, gastrointestinal and septic problems. There were 2 peri-operative deaths. Blood transfusion was significantly less in those not requiring sternotomy or CPB using the "Cell Saver" device. The majority were Fuhrman grade 3 (n = 16) and clear cell type (n = 14). Overall 3-year survival was 100% (Laparotomy only), 40% (sternotomy + cross-clamp), and 20% (CPB). Conclusions: IVC thrombectomy has significant morbidity and requires careful patient selection and a multi-disciplinary approach to optimise patient outcomes. In this series, the level of IVC thrombus and requirement for CPB directly affects patient morbidity and outcome. (C) 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.