Long-term survival in patients undergoing radical nephrectomy and inferior vena cava thrombectomy: single-center experience

Abstract

Background: Renal cell carcinoma (RCC) with a tumor thrombus extension into the inferior vena cava (IVC) demands aggressive surgical management.

Objective: To evaluate the long-term survival in patients undergoing radical nephrectomy and IVC thrombectomy.

Design, setting, and participants: We performed a retrospective analysis of 87 patients undergoing surgery between 1997 and 2008. The patients were grouped according to the extent of tumor thrombus, with level I involving the IVC at the level of the renal vein, level II being infrahepatic IVC, level III being intrahepatic IVC, and level IV being suprahepatic IVC or right atrium. Relevant clinical and pathologic data were analyzed.

Measurements: Disease-free survival (DFS) and disease-specific survival (DSS) were studied.

Results and limitations: The median follow-up was 22 mo, and 19, 14, 40, and 14 patients had level I, II, III, and IV IVC thrombus, respectively. Among patients with M0 disease, 22 developed metastases. The 5-yr DFS was 64% for all levels and 74%, 69.5%, 59.5%, and 58% for levels I, II, III, and IV, respectively. Of the level I group, 16% of patients died of disease compared to 57% of the level IV group. The 5-yr DSS for all levels was 46% and 71%, 48%, 40%, and 35% for levels I, II, III, and IV, respectively. Patients with level IV thrombus had a significantly lower 5-yr DSS compared to level I (p=0.03). However, when analyzed in two groups-supradiaphragmatic and infradiaphragmatic-there was no significant difference in DSS (P=0.14). On univariate analysis, metastasis at presentation, non-clear-cell histology, lymph node metastases, and higher nuclear grade were statistically significant prognostic factors influencing DSS. Only higher nuclear grade (p=0.03), metastasis at presentation (p<0.01), and non-clear-cell histology (p=0.03) were independent prognostic factors on multivariate analysis.

Conclusions: Radical nephrectomy and IVC thrombectomy offer reasonable long-term survival. The level of tumor thrombus is not an independent prognostic factor. Distant metastasis at presentation, higher nuclear grade, and non-clear-clear cell histology are significant prognostic factors influencing DSS.