Renal Cell Carcinoma with IVC Thrombi; Current Concepts and Future Perspectives

Abstract

Abstract:The incidence of venous extension to the inferior vena cava (IVC) in renal cell carcinoma (RCC) is markedly increased recently mostly due to the advances in diagnostic modalities. Such vascular invasion implies a heightened biologic behavior and a surgical challenge during the course of treatment. In this study, we reviewed the classifi cation guidelines, recent diagnostic tools and up-to-date therapeutic modalities for RCC with IVC tumor thrombi added to the prognostic signifi cance regarding the pathologic nature of vascular invasion; cephalad extent of thrombi and any associated distant metastasis. Also, we are providing our suggestion regarding the use of angioscopy for removal of IVC thrombi in a relatively bloodless fi eld without aggressive surgical manipulations or shunt techniques for maintenance of hemodynamic stability.

Perioperative Management of Adrenalectomy and Inferior Vena Cava Reconstruction in a Patient With a Large, Malignant Pheochromocytoma With Vena Caval Extension

“…The role of VVB is well documented for resection of tumors complicated with IVC thrombus. 81,82 The advantages of VVB in this setting include avoiding significant decreases in preload during IVC clamping, reduction of blood loss, and improved surgical exposure. 81 The indication for possible VVB in this case conference was that the caval spread of tumor had reached the liver.…”

“…The caval spread of tumor thrombi traditionally has been classified into 4 levels. 81 This classification is important to understand because it provides a platform for understanding the surgical approach to resection and the roles of ECC. Level I is defined as tumor thrombus that is confined to the renal vein.…”

“…Level II is defined as tumor thrombus that is confined to the infrahepatic IVC. 81 Levels I and II tumor thrombi typically are resected via a cavotomy without ECC. 81 Level III is defined as tumor thrombus that has reached the retrohepatic IVC or the suprahepatic IVC without reaching the right atrium.…”

“…81 Levels I and II tumor thrombi typically are resected via a cavotomy without ECC. 81 Level III is defined as tumor thrombus that has reached the retrohepatic IVC or the suprahepatic IVC without reaching the right atrium. 81 Level III tumor thrombi are further subdivided into 4 types.…”

“…81 Level III is defined as tumor thrombus that has reached the retrohepatic IVC or the suprahepatic IVC without reaching the right atrium. 81 Level III tumor thrombi are further subdivided into 4 types. Level IIIa (intrahepatic) thrombus, as in this patient, extends into the retrohepatic IVC but terminates below the major hepatic veins.…”