Surgical Management of Inferior Vena Cava Tumor Thrombus in Patients with Renal Cell Carcinoma

Background: The incidence of venous extension to the renal vein and inferior vena cava (IVC) in renal cell carcinoma (RCC) due to the least resistance to invasive growth is markedly increased compared to other tumors. Their length can reach up to 20 cm and reach the heart chambers. Tumor thrombus originates from the tumor in the kidney parenchyma and floats at different levels in the lumen of the IVC.

Methods: A total of 91 kidney cancer patients with IVC tumor thrombus were recruited in a prospective study in the period from 2014 to 2022. Of them, 68 (74.7%) were men and 23 (25.3%) were women. The mean age of the patients was 60.9 ± 9.1 years. TNM staging: рТ1а—3bN0-2M0–1 G1–3. IVC block symptoms were detected in 54 (59.3%) patients. The upper border of the tumor thrombus head was limited by the renal vein (RV) in 24 (26.4%) patients. 21 (23.1%) patients suffered from tumor thrombus extended less than 2 cm above RV. 16 (17.6%) patients had IVC tumor thrombus of more than 2 cm above RV, but below the hepatic veins. Tumor thrombus did not reach the main hepatic veins in 15 (16.5%) patients. The head of tumor thrombus was located between the mouths of the main hepatic veins and the diaphragm in 7 (7.7%) patients, and 1 (1.1%) patient had tumor thrombus head between the pericardium and the diaphragm. One (1.1%) patient had tumor thrombus head at the level of the diaphragm, four (4.4%) patients –in the intrapericardial segment, above the diaphragm, and two (2.2%) patients – at the right atrium. At the time of the index surgery, 47 (51.6%) patients had distant metastases.

Results: The duration of surgery ranged from 105 to 715 minutes (the mean time of 294±111.5 min). The mean blood loss was 1178±2165.4 mL. Intraoperative complications occured in one (1.1%) patient. The total number of postoperative complications according to Clavien-Dindo was 13 (14.3%). Grade 1-2 complications were detected in 9 (9.9%) patients, grade 3-4 – in 4 (4.4 %). The follow-up ranged from 3 to 86 months (58.7±19.1). Tumor progression was reported in one (1.1%) patient.

Conclusion: Nephrectomy with IVC thrombectomy is the gold standard for treating patients with RCC and IVC tumor thrombosis. This surgical treatment remains challenging and requires a multidisciplinary approach to improve patient survival.

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