Long‐term survival after radical surgery for renal cell carcinoma with tumour thrombus extension into the right atrium

Abstract

E 5 9What ' s known on the subject? and What does the study add? Surgical treatment of renal cell carcinoma (RCC) with tumour thrombus extending into the right atrium remains, despite its complexity and specifi c technical aspects, the only radical therapeutic option.This single-centre study, unique in size for this rare condition, reports early and late results over a period of 18 years. All patients were operated on using a standardised protocol with use of cardiopulmonary bypass and deep hypothermic circulatory arrest. Overall and cancer-specifi c cumulative survival was better than in other reports. OBJECTIVE• To evaluate the long-term results of radical surgical management of renal cell carcinoma (RCC) with tumour thrombus extension (TTE) level IV into the right atrium (RCC/TTE IV) in a large singleinstitution series. PATIENTS AND METHODS• Radical complex urological and cardio-surgical procedure was performed over a period of 18 years (1993 -2010) on 21 patients with RCC/TTE IV. A radical nephrectomy was performed followed by sternotomy, institution of cardiopulmonary bypass and extraction of the intracardiac tumour thrombus under direct visual control during deep hypothermic circulatory arrest (DHCA).• Perioperative and postoperative variables, and long-term overall and cancer-specifi c survival using the Kaplan -Meier method were analysed. RESULTS• In all patients, precise removal of tumour thrombus was accomplished in a bloodless fi eld during DHCA.• The mean ( SD ) duration of circulatory arrest was 16 (6) min at a mean hypothermia of 20 (3) ° C. In-hospital mortality was 9.5% (two patients).• The median survival (including in-hospital mortality) was 25 months.• In Kaplan -Meier analysis, 2-and 5-year overall cumulative survival rate was 57 (95% confi dence interval, CI 36 -78)% and 37 (95% CI 15 -58)%, respectively.• Cancer-specifi c cumulative survival was 68 (95% CI 49 -89)% at 2 years and 51 (95% CI 28 -74)% at 5 years. CONCLUSIONS• Late outcome after radical surgical treatment in patients with RCC and TTE reaching up to the right atrium justifi es this extensive procedure.• Cardiopulmonary bypass with DHCA allows safe and precise extirpation of all intracaval and intracardiac tumour mass.

Raised preoperative international normalised ratio (INR) identifies patients at high risk of perioperative death after simultaneous renal and cardiac surgery for tumours involving the peri‐diaphragmatic inferior vena cava and right atrium

“…This report is not considering the long‐term oncological outcomes in this group of patients, but it is known that most patients with locally advanced renal cancer of this type will develop systemic relapse . The advent of multiple new medications for the control of metastatic disease does, however, offer hope to patients if their heavily symptomatic loco‐regional disease can be controlled .…”

An uncommon and insidious presentation of renal cell carcinoma with tumor extending into the inferior vena cava and right atrium: a case report

“…The radical surgical strategy may include extracorporeal circulation with cardiopulmonary bypass (CPB) and sometimes deep hypothermic circulatory arrest (DHCA) [ 3 ]. Long-term survival is possible and the operative approach has been described earlier [ 4 , 9 ]. For our patient, care was taken perioperatively since the surgical approach was complex and our patient had a past history of CABG.…”

How to proceed in the case of a tumour thrombus in the inferior vena cava with renal cell carcinoma

“…Přestože je karcinom ledviny s nádorovým trombem dle klasifi kace TNM zařazen až do stadia T3, několik studií prokázalo pětileté přežívání až v 60 % případů, pokud nebyly prokázány vzdálené metastázy. Výsledky tohoto radikálního přístupu jsou srovnatelné jako u nádoru ve stadiu T1 a T2, tedy omezeného pouze na ledvinu [1][2][3][4][5][6][7].…”