Diagnosis And Treatment Of Renal Cell Carcinoma Involved Inferior Vena Cava (With A Report Of 21 Cases)

Propagation of renal cell carcinoma into the inferior vena cava is rare, accounting for 4% to 10% of all renal carcinomas. Sometimes the thrombus can even reach the right atrium. Most patients abandon the operations because of the high risk. Nowdays, with the improvement of the techniques in the operations, the 5-year survival rate of the patients who undergo radical nephrectomy and thrombus extraction is 25% to 57%.Material and Methods21 cases of renal cell carcinoma involving the inferior vena cava were analysed retrospectively. The patients consisted of 13 males and 8 females .Patient age ranged from 29 to 80 years(mean 50). The tumor was right sided in 13 patients and left sided in 8 patients. Most patients complained of flank pain and hematuria . The history of disease was 1 week to 8 years.Of them , 1 case complained of lower extremity edema; 8 cases had got a fever; 7 cases had a palpable mass in the flank. Theclassic triad of hematuria, pain and lump was present in 3 cases. The diagnoses were confirmed by ultrasound, Doppler ultrasonography, CT and MRL Tumor thrombus was in level I in 3 cases , level II in 10, level III in 6, level IV in 2(all of which reached the right atrium). 18 cases were categorized as stage III, and 3 cases were categorized as stage IV (Robson staging system). 19 cases were categorized as stage T3b, and 2 cases were categorized as stage T3c (1997 TMN staging system).Chest radiography showed 1 case of metastasis in the lung. ECT showed 2 cases of metastases in the bone. Radical nephrectomy with extraction of the thrombus was carried out for 15 patients,and 4 patients were treated by radical nephrectomy and sectional venacavorectomy.The other two patients abandoned operation.ResultsAll operations were successful, and no tumoral embolism happened. The operation time ranged from 2 hours to 6 hours. The mean occlusion time was 23 minutes(range 11 to 39 minutes).The total bleeding were 350 ml to 4800 ml. All cases had been followed-up for 3 to 57 months. 8 patients died 3 to 13 months after the operation. 11 patients who were still alive had been followed-up for 4 to 57 months to date, and 3 cases relapsed. The 2 patients who abandoned operation died 3 and 5 months later respectively.Conclusion1. Doppler ultrasonography is more useful in diagnosis and category than B ultrasound. CT scan is able to show the level of the thrombus, but whether it is pure thrombus or tumor thrombus is difficult to descide. However MRI can defines the thrombus level easily .It is also a sensitive technique for detecting vessel wall invasion and lymph nodes metastasis, which provides important preoperation information for surgical planning.2. Radical nephrectomy with extraction of the thrombus is the most effective outlet to cure renal cell carcinoma with inferior vena cava tumor thrombus up to now, which is more necessary in patients without lymph nodes involvement and distant metastasis. The diagnosis of vessel wall invasion and the level of tumoral thrombus extension are important determinants when planning the surgical approach. To avoid tumoral embolism, vascular control of vena cava distal and proximal to the thrombus should be established, and tumor thrombus should be extracted completely.3. Besides postoperative bleeding and acute renal failure, pulmonary embolus, pancreatitis, sepsis, bowel obstruction, DIC and multi-organ deficiency are the most common complications.