Bland thrombus association with tumour thrombus in renal cell carcinoma: analysis of surgical significance and role of inferior vena caval interruption

• Published in: BJU international 2012-12, Vol.110 (11b), p.E449-E455
• Main Authors: Ayyathurai, Rajinikanth, Garcia‐Roig, Michael, Gorin, Michael A., González, Javier, Manoharan, Murugesan, Kava, Bruce R., Soloway, Mark S., Ciancio, Gaetano
• Format: Article
• Language: English
• Subjects: Adult; Aged; Aged, 80 and over; bland thrombus emboli; Blood clots; Carcinoma, Renal Cell - complications; Carcinoma, Renal Cell - pathology; Carcinoma, Renal Cell - surgery; Confidence intervals; Diagnosis, Differential; Female; Follow-Up Studies; Humans; inferior vena cava filter; Kidney Neoplasms - complications; Kidney Neoplasms - pathology; Kidney Neoplasms - surgery; Magnetic Resonance Imaging; Male; Middle Aged; Mortality; Multivariate analysis; Neoplastic Cells, Circulating - pathology; Nephrectomy - methods; pulmonary emboli; renal tumour; Retrospective Studies; Thrombectomy - methods; Thrombosis - diagnosis; Thrombosis - etiology; Thrombosis - therapy; Tomography, X-Ray Computed; tumour thrombus; tumour thrombus emboli; Vena Cava Filters; Vena Cava, Inferior
• ISSN: 1464-4096; 1464-410X
• DOI: 10.1111/j.1464-410X.2012.11128.x

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The surgical implications of renal cell carcinoma with coexisting bland and tumour thrombi of the inferior vena cava is not well described. In this study we review our experience managing these tumours. On multivariate analysis, we found that the presence of bland thrombus was associated with an increased need for surgical interruption of the inferior vena cava. OBJECTIVE •  To study the role of interruption of the inferior vena cava (IVC) in patients with renal cell carcinoma (RCC) and associated bland and tumour thrombi. METHODS •  We reviewed 129 consecutive patients with the preoperative diagnosis of RCC with tumour thrombus who underwent radical nephrectomy and tumour thrombectomy in one academic institution between May 1997 and February 2011. RESULTS •  Percentages of patients with levels I, II, III and IV tumour thrombus were 29%, 13%, 48% and 9%, respectively. •  The perioperative mortality rate was 2.3%. There were 29 (22%) perioperative complications recorded. •  In all, 19 patients underwent surgical interruption of the IVC by ligation or segmental resection, including one level II, 14 level III and four level IV thrombi. •  A total of 15 patients (12%) had bland thrombus associated with the tumour thrombus; four of these underwent intraoperative IVC filter placement and eight underwent surgical IVC interruption. •  Advanced level of tumour thrombus was the only significant factor predicting association of bland thrombus (odds ratio [OR]= 2.09, 95% confidence interval [CI]: 1.082–4.037, P= 0.028). •  On multivariate analysis, level of thrombus (OR = 3.1, 95% CI: 1.30–7.74, P= 0.011) and association of bland thrombus (OR = 9.07, 95% CI: 2.42–34.01, P= 0.001) were significant factors for IVC interruption. CONCLUSIONS •  Surgical interruption of the IVC is a feasible option in selected patients with chronic IVC obstruction. Association of bland thrombus with tumour thrombus should alert the surgical team to the potential for a challenging surgery. •  Precise preoperative imaging to assess the degree of venous obstruction and to help with differentiation between bland and tumour thrombus is key to achieving a surgical outcome with minimal morbidity.