Review article
The perioperative management of an inferior vena caval tumor thrombus in patients with renal cell carcinoma

https://doi.org/10.1016/j.urolonc.2011.03.006Get rights and content

Abstract

Objectives

Inferior vena caval tumor thrombus (IVC-TT) occurs in 10% of patients diagnosed with renal cell carcinoma (RCC). The perioperative management of these patients remains challenging. Despite multiple publications outlining surgical approaches and outcomes there have been few studies detailing the best peri-operative management of patients with IVC-TT. Our goal was to define the optimal management of patients with RCC and IVC-TT.

Materials and methods

A review of all published literature regarding the management of RCC with IVC-TT was performed utilizing Pub Med and the Cochrane Database. Reviews were also made of all relevant literature regarding the need for cardiopulmonary bypass and recommendations regarding thrombus in any location in patients with malignancy. Specific items critically examined included: need for preoperative heart catheterization, need for anticoagulation and type of anticoagulation, need for additional studies such as lower extremity duplex or venogram, and indications for vena caval filter placement. The results were then presented to a multidisciplinary group made up of experts in the fields of Urology, Hematology, Oncology, Cardiothoracic Surgery, Interventional Radiology, and Pulmonary/Critical Care. Based on the available literature a best practice guidelines regarding the management of RCC with IVC-TT was established at our institution.

Results

Our institutional recommendations include (1) preoperative cardiac catheterization in all patients believed to require cardiopulmonary bypass for removal of the thrombus but only cardiac clearance for those who bypass is unlikely, (2) preoperative anticoagulation using a low molecular weight heparin such as enoxaparin unless contraindicated due to bleeding from the tumor or other contraindication, (3) avoidance of vena caval filters whenever possible is recommended due the potential for caval thrombosis and the difficulties they present during surgical resection.

Conclusion

This study identified the available literature on the management of IVC-TT in association with RCC and was carefully reviewed by a multidisciplinary team. As a result, we have established a set of practice guidelines at our institution to help optimally manage patients with renal cell carcinoma and an inferior venal caval thrombus.

Introduction

Renal cell carcinoma (RCC) has a unique propensity to develop local extension via tumor thrombus (TT) into the venous system in 10% of patients with extension into the right atrium in 1% [1]. Fortunately, less than 6% of patients with inferior vena cava (IVC) TT experience perioperative pulmonary embolism (PE), which carries a mortality rate of 60%–75% [2]. With recent improvements in treatment of patients with advanced RCC, the scenario of operative intervention in patients with TT is becoming more common. Despite multiple publications outlining surgical approaches and outcomes [3], [4], [5], [6], there have been few studies that evaluate perioperative management of a patient with inferior vena cava tumor thrombus (IVC TT). Therefore, we have attempted to create a clinical pathway for perioperative management of patients with RCC and IVC TT, based on recommendations from a multispecialty panel combined with supporting literature when available. The results presented in this paper are a “best practice guidelines” based on consensus of panel members and evidence-based recommendations found in the literature.

Section snippets

Materials and methods

Our panel consisted of experts from the fields of Urology, Hematology/Oncology, Interventional Radiology, Cardiothoracic Surgery, and Pulmonary Critical Care. An extensive literature review was carried out utilizing PubMed and the Cochrane Database. Search terms included “inferior vena cava,” “tumor thrombus,” “renal mass,” “renal cell carcinoma,” “venous thromboembolism,” “vena cava filter,” “renal embolization,” “renal imaging,” “computed tomography,” and “magnetic resonance imaging,” alone

Results

Guidelines were organized as follows:

Discussion

Patients with RCC and associated IVC TT represent a challenging set of management issues. Due to the nature of the problem, they are high risk for perioperative complications. Historically, these patients have had a 30% perioperative mortality rate either due to bleeding or intraoperative embolization of the thrombus. More recent series suggest mortality rates on the order of 2%–10.5% [1], [8], [9], [10], mainly due to improvements in technique, instrumentation, and recognition of high risk and

Conclusion

Patients with RCC and TT remain complex patients with high risk of perioperative morbidity and potential mortality. We recognize other institutions and practitioners vary in their practice and may disagree with the guidelines we have presented. Lack of prospective research has led to a great deal of variability in perioperative management of these patients. Thus, development of guidelines based on currently available literature and multispecialty expert opinion is a first step in

References (32)

  • B. Shuch et al.

    Intraoperative thrombus embolization during nephrectomy and tumor thrombectomy: Critical analysis of the University of California-Los Angeles experience

    J Urol

    (2009)
  • T. Kwon et al.

    Surgical treatment of inferior vena cava tumor thrombus with renal cell carcinoma

    J Korean Med Sci

    (2010)
  • M.J. Schwartz et al.

    Renal artery embolization: Clinical indications and experience from over 100 cases

    BJU Int

    (2006)
  • G.J. Wang et al.

    Single-center experience of caval thrombectomy in patients with renal cell carcinoma with tumor thrombus extension into the inferior vena cava

    Vasc Endovascular Surg

    (2008)
  • S.A. Boorjian et al.

    Surgery for vena caval tumor extension in renal cancer

    Curr Opin Urol

    (2009)
  • F.M. Muggia et al.

    National Cancer Institute Levels of evidence for adult and pediatric cancer treatment studies

  • Cited by (74)

    • Single-stage resection with intraoperative filter placement for right renal carcinoma with vena cava extension

      2021, Journal of Vascular Surgery Cases, Innovations and Techniques
      Citation Excerpt :

      Patients with tumor thrombus involving the IVC without metastatic disease secondary to RCC have a 5-year survival of 34% to 72%, which makes surgical resection a viable treatment option.4 Extensive thrombus can make the decision regarding the timing of anticoagulation therapy postoperatively challenging owing to the 30% risk of perioperative mortality secondary to bleeding or intraoperative embolization associated with no IVC filter used.6 We believe that surgeons should make a multidisciplinary care plan to determine the anticoagulation therapy and how to best prevent embolic events.

    View all citing articles on Scopus
    View full text