[Renal carcinoma with tumor thrombus in the vena cava and auricle. Experience and review].

OBJECTIVES

To report on our experience in the treatment of renal cell carcinoma with vena caval or right atrial extension, with special reference to the level of involvement and the surgical technique indicated for each case.

METHODS

From early 1975 to April, 1997, 212 patients underwent surgery for renal cell carcinoma. Of these, 15 patients (11 male, 4 female), aged 27 to 73 years, had a tumor thrombus extending to the inferior vena cava. The tumor was located in the right kidney in 11 patients and in the left kidney in 4 patients. The tumor thrombus was infrahepatic in 10 cases, it extended beyond the suprahepatic veins in 3 cases, and 2 cases showed right atrial extension. The 10 patients with infrahepatic caval thrombus underwent radical nephrectomy with cavotomy and thrombus removal. In the remaining 5 patients with suprahepatic or atrial extension, thrombus removal was performed via cardiopulmonary by-pass with hypothermic circulatory arrest, with the assistance of a team of cardiac surgeons.

RESULTS

Pathological staging showed 2 T3cNoMo, 1 T3bNoMo and 2 T3bN1Mo in the patients who underwent cardiopulmonary bypass. There were 5 T3bNoMo, 2 T3bN2Mo, 1 T3bN2M1, 1 T4NoMo and 1 T4N1M1 in the group of patients with infrahepatic thrombus. There were two postoperative deaths. The overall survival rate was poor. Six patients are alive at 3-26 months' follow-up and 9 have died from disease progression. Patients with lymph node involvement or metastasis at the time of diagnosis had a worse survival rate.

CONCLUSIONS

Surgical treatment of renal cancer with vena caval extension is specially difficult depending on the level of involvement, which must therefore be determined with precision. MRI is an effective and noninvasive technique. Tumors with thrombus below the suprahepatic veins can be managed by the direct approach with cavotomy. The use of cardiopulmonary bypass is advocated for tumors with suprahepatic caval or atrial extension. Tumors with caval-atrial extension have a negative influence on survival.