Long-term survival after radical nephrectomy with intrahepatic or supradiaphragmatic intracaval thrombectomy for renal cell carcinoma

Purpose: Four to ten percent of patients with renal cell carcinoma have direct extension of tumor into the inferior vena cava. Although many patients, particularly those with locally confined lesions and small intracaval tumor extensions, may be surgical cured, long-term survival data following radical surgery for RCC involving significant vena caval tumor extension is lacking. We report the long-term follow-up of 34 patients undergoing radical nephrectomy with intrahepatic or supradiaphragmatic intracaval thrombectomy for RCC. Materials and Methods: From October 1982 through January 1993, 34 patients (24 men and 10 women) with a mean ago of 60 years (range, 33-79 years) underwent surgical treatment of clinical stage T3 RCC with intrahepatic (41%) or supradiaphragmatic (59%) intracaval neoplastic extension. Patients underwent nephrectomy with intrahepatic caval thrombectomy (13 patients or 38%) or supradiaphragmatic caval thrombectomy using cardiac bypass with hypothermia (21 patients or 62%). There were 24 right-sided tumors and 10 lefl-sided tumors with an overall mean diameter of 9.5 +/- 4.0 cm (range, 4-18 cm). In all, 24 of 33 (73%) patients had capsular penetration and 22 of 3 3 (67%) had perinephric extension. Metastatic disease was identified in 7 patients (21%). Mean follow-up was 30 months (range, 1-182 months). Results: Using Kaplan-Meier actuarial analysis, the likelihood of survival was 68 +/- 8% at 1 year, 32 +/- 8% at 2 years, 14 +- 6% at 5 years and 9 +/- 6% at 10 years. Although capsular penetration did not significantly affect survival, patients with perinephric extension had significantly worse survival (p=0.025). There was no statistically significant difference in survival between patients with intrahepatic extension compared to those with tumor extension to the heart (p=0.4). Survival was not significantly different between patients undergoing cardiac bypass compared to intrahepatic caval thrombectomy (p=10). Two patients are alive without disease at 76 and 172 months and a third patient is alive with metastases 70 months postoperatively. Conclusions: Given the extensive disease burden, survival following radical surgery for significant intracaval neoplastic extension of RCC appears limited. However, select patients will endure long-term survival following radical nephrectomy with intrahepatic or supradiaphragmatic intracaval thrombectomy.