Management of Locally Advanced Renal Cell Carcinoma
Abstract
Renal cell carcinoma (RCC) has a natural tendency to invade the venous system with formation of a venous tumor
thrombus in the renal vein, which can extend proximally into the inferior vena cava (IVC) and in some cases into
the right atrium. The presence of venous involvement significantly worsens prognosis. Despite recent advances in
systemic therapies, surgery remains the most effective method of treatment and in the case of complete removal
of all tumor, it provides satisfactory long-term survival and must be attempted whenever possible. Several surgical
techniques have been proposed, but all are associated with a high rate of perioperative complications and mortality.
Minimally invasive approaches are mainly applicable for less extended IVC thrombi, while open surgery remains the
gold standard for this category of patients. Most IVC thrombi can be managed without use of circulatory support
by using different methods of IVC control depending on the thrombus level. However, use of cardiac bypass with or
without deep hypothermic cardiac arrest is indicated in some patients with bulky intraatrial tumor thombi. In select
patients presenting with IVC tumor thrombus and synchronous distant metastases, cytoreductive nephrectomy with
IVC tumor thrombectomy may be considered with or without neoadjuvant systemic therapy. Surgery for RCC with
venous thrombus is complex and requires experienced multidisciplinary surgical, anesthesia, and critical care teams
at high-volume centers to achieve the best outcomes.
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