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Long-Term Followup After Surgical Treatment for Renal Cell Carcinoma Extending into the Right Atrium
LONG-TERM FOLLOWUP AFTER SURGICAL TREATMENT FOR RENAL CELL CARCINOMA EXTENDING INTO THE RIGHT ATRIUM
ABSTRACT
P u r p o s e : Renal cell c a r c i n o m a extends i n t o the i n f e r i o r v e n a c a v a i n 4 t o 1 0 % of p a t i e n t s and i t i s believed t h a t the c e p h a l a d e x t e n t of inferior v e n a c a v a l i n v o l v e m e n t i s i n v e r s e l y c o r r e l a t e d w i t h survival. We evaluated this i s s u e f u r t h e r . M a t e r i a l s and M e t h o d s : F r o m June 1984 to August 1 9 9 3 , 18 p a t i e n t s underwent s u r g i c a l t r e a t m e n t for localized renal cell c a r c i n o m a and an i n f e r i o r v e n a c a v a l thrombus e x t e n d i n g i n t o the r i g h t atrium. One p a t i e n t had a c o n t r a l a t e r a l adrenal m e t a s t a s i s at o p e r a t i o n . All patients underwent complete t u m o r excision w i t h r a d i c a l n e p h r e c t o m y and i n f e r i o r vena c a v a l t h r o m b e c t o m y u s i n g a d j u n c t i v e c a r d i o p u l m o n a r y b y p a s s and d e e p h y p o t h e r m i c c i r c u l a t o r y a r r e s t . P a t h o logical s t u d y i n d i c a t e d n o renal c a p s u l a r p e n e t r a t i o n of r e n a l cell c a r c i n o m a in 10 p a t i e n t s and p e r i n e p h r i c fat i n v o l v e m e n t i n 8. Results: The overall and cancer-specific 5-year s u r v i v a l rates were 56.6% and 60.2%, r e s p e c tively. E i g h t p a t i e n t s (45%) w e r e free of m a l i g n a n c y at a mean of 71.6 months. One p a t i e n t w a s a l i v e w i t h m e t a s t a t i c d i s e a s e 15 months postoperatively. There w a s 1 o p e r a t i v e d e a t h , w h i l e 8 p a t i e n t s died of metastatic renal cell c a r c i n o m a at a mean of 18.8months postoperatively. Mean p o s t o p e r a t i v e s u r v i v a l w a s significantly i m p r o v e d i n p a t i e n t s w i t h no renal c a p s u l a r p e n e t r a t i o n by tumor compared t o t h o s e with perinephric fat involvement (58.1 versus 19.7 m o n t h s , p = 0.035). Conclusions: Long-term survival after surgical treatment is possible in p a t i e n t s w i t h localized renal cell c a r c i n o m a extending i n t o the right a t r i u m . In p a t i e n t s w i t h localized renal cell c a r c i n o m a and an i n f e r i o r v e n a c a v a l tumor thrombus the cephalad extent of inferior vena caval i n v o l v e m e n t d o e s not a p p e a r to be prognostically i m p o r t a n t . K h Y WORDS.carcinoma, renal cell; kidney neoplasms; vena cava, inferior, heart atrium Renal cell carcinoma extends into the inferior vena cava in 4 t o 10% of all patients.' The 5-year survival rates of 47 to 6Wir have been reported following complete surgical excision of localized renal cell carcinoma in this setting.2-4 However, the presence of lymph node or distant metastasis significantly diminishes t h e prospect for extended survival. The prognostic significance of the cephalad extent of a n inferior vena caval tumor thrombus associated with renal cell carcinoma is controversial. I t h a s been suggested t h a t survival following surgical treatment is diminished in patients with supradiaphragmatic inferior vena caval involvement, even when there is no apparent metastatic disease a t operation5 To address this issue further we reviewed the longterm outcome in 18 patients who underwent complete surgical excision of localized renal cell carcinoma and a n inferior vena caval thrombus extending into the right atrium. MATERIALS A N D METHODS
From J u n e 1984 to August 1993,9 men and 9 women 42 to 75 years old (mean age 62.8) underwent surgical treatment for nonmetastatic renal cell carcinoma and a n intra-atrial inferior vena caval thrombus. Renal cell carcinoma involved the right and left kidneys in 11 and 7 patients, respectively. Patients with inferior vena caval tumor thrombi t h a t did not extend into the right atrium were excluded from this study. All patients underwent a preoperative chest x-ray, bone scan and computerized tomography of the abdomen to verify absence of gross lymph node involvement or metastatic disease. One patient had a contralateral 4 cm. adrenal mass of uncertain etiology. Contrast enhanced venacavography was done in 16 Accepted for publication August 18. 1995. * Requests for reprints: Department of Urology, Cleveland Clinic Foundation, 9.500 Euclid Ave.. Clcveland, Ohio 44195.
patients and magnetic resonance imaging was done in 9 to determine the cephalad extent of the inferior vena caval tumor thrombus. An echocardiogram was performed in 11 patients to confirm the presence of thrombus in the right atrium. All patients were studied with renal arteriography to evaluate tumor thrombus vascularity. In 9 patients with a n arterialized inferior vena caval thrombus, percutaneous renal artery embolization was performed 2 to 3 days preoperatively as described previously.6 Other than occasional ensuing mild flank discomfort, preoperative renal artery embolization was well tolerated in all patients with no associated perioperative morbidity. Complete tumor excision was done in all patients with radical nephrectomy and inferior vena caval thrombectomy using adjunctive cardiopulmonary bypass a n d deep hypothermic circulatory arrest. Regional lymphadenectomy was performed i n patients with enlarged or suspicious lymph nodes. The involved adrenal gland was removed in t h e patient with t h e contralateral adrenal mass of uncertain etiology. All patients were studied with a complete blood count, serum chemistry panel, chest x-ray and abdominal CT a t 6 to 12-month intervals postoperatively. A bone scan was also obtained in some patients. All hospital charts were reviewed and followup information was obtained by contacting the patient or local physician directly. Complete followup data were available for all patients. Cancer-free s t a t u s was determined by negative findings on the aforementioned followup studies. Survival analysis was calculated by t h e KaplanMeier method, with statistical comparisons by the log rank test. Mean survival reflected t h e interval to last followup for patients still alive or to death. R b:S U LTS
Patholoecal study of each surgical specimen confirmed renal cell carcinoma with a n inferior vena caval tumor
448
SURGICAL TREATMENT FOR RENAL CELL CANCER EXTENDING INTO RIGHT ATRIUM
thrombus. Further histopathological study revealed no renal capsular penetration of the tumor in 10 patients (group 1) and perinephric fat involvement in 8 (group 2). There were no other significant differences between groups 1and 2 in terms of patient age, sex, tumor size or focality, or the number of patients undergoing preoperative renal artery embolization. Four patients underwent regional lymphadenectomy to remove enlarged lymph nodes and in all cases the nodes were negative for renal cell carcinoma. The excised adrenal gland in the patient with the contralateral adrenal mass contained metastatic renal cell carcinoma. This patient had no renal capsular penetration by the primary tumor and no other evidence of metastasis. The overall 5-year survival rate for the entire series was 56.6%, with a cancer-specific 5-year survival rate of 60.2% (see figure). Currently, 8 patients (45%) are free of malignancy (mean followup 71.6 months). One patient was alive 15 months postoperatively and currently is receiving immunotherapy for suspected metastatic disease. One patient died of myocardial failure 14 days postoperatively and 8 died of metastatic r e n d cell carcinoma at a mean of 18.8 months postoperatively. Mean postoperative survival in group 1was 58.1 months, including the single intraoperative death and the patient with a contralateral adrenal metastasis who died of metastatic disease 49 months postoperatively. Currently, 6 patients (60%)from group l are free of malignancy (followup54 to 123 months, mean 86.3).There was 1 operative death and 3 patients died of metastatic disease at 5 to 49 months postoperatively (mean 20.6). Mean postoperative survival in group 2 was 19.7 months, which is significantly less than that in group 1(p = 0.035). Two patients (20%) were free of malignancy at 13 and 42 months postoperatively, respectively, 1was receiving treatment for metastatic disease a t 15 months and 1 died of metastatic disease at 61 months. The remaining 4 patients died of metastatic disease within 1 year postoperatively (mean survival 6.8 months).
449
node or distant metastasis is known to diminish survival significantly in these cases. However, there is controversy concerning the prognostic significance of the level of the inferior vena caval tumor thrombus. Some studies have suggested that the risk of metastasis and early death is increased with a more cephalad extent of inferior vena caval thrombi. Sosa et al reported a 2-year survival rate of 80% in patients with intrahepatic inferior vena caval thrombi compared to only 21% in those with suprahepatic thrombi, and patients in the latter category were also more likely to have perinephric fat and regional lymph node involvement.6 Subsequently Skinner et al indicated a 5-year survival rate of 35% following surgical treatment for patients with renal cell carcinoma and a subhepatic inferior vena caval thrombus, and 5-year survival rates for patients with intrahepatic or atrial tumor thrombi were 18% and O%, respectively.4 Other reports in the literature have suggeated that the level of an inferior vena caval thrombus in renal cell carcinoma may not be of prognostic signiiicance. Cheme et al analyzed 27 patients with renal cell carcinoma and inferior vena caval involvement, and observed that capsular invasion, nodal disease and distant metastasis had an adverse effect on patient survival.7 Eight patients had supradiaphragmatic inferior vena caval tumor thrombi and the level of the thrombus had no statistically significant impact on survival. More recently, Hatcher et al reviewed 44 patients with renal cell carcinoma and inferior vena caval tumor thrombi, and found that the presence of inferior vena caval wall invasion was prognostically signiscantbut that the level of inferior vena caval tumor thrombus involvement was not.8 A major limitation of previous studies relevant to this issue has been few patients with supradiaphragmatic inferior vena caval involvement and the relatively short followup in most cases. There are 2 important issues to address when evaluating the possible prognostic signiticance of the cephalad extent of inferior vena caval involvement in patients with renal cell carcinoma: 1)is there a greater incidence of lymph DISCUSSION node or distant metastasis at the initial presentation in such Inferior vena caval extension of renal cell carcinoma occurs cases, and 2) is the risk of early metastasis and death inin 4 to 10% of the patients. In patients with nonmetastatic creased following surgical treatment in patients who present renal cell carcinoma and inferior vena caval involvement with nonmetastatic renal cell carcinoma and an inferior vena 5-year survival rates of 47 to 68% have been reported follow- caval thrombus extending into the right atrium. We ading complete surgical resection.2-4 The presence of lymph dressed issue 1 in a previous review of 39 patients with renal cell carcinoma and inferior vena caval thrombi, and found no difference in the incidence of lymph node or distant metastasis at the initial presentation between patients with an atrial thrombus compared to those with lower levels of inferior vena caval involvement.6 The present study was done to evaluate specifically issue 2. We reviewed the long-term outcome in 18 patients who underwent complete surgical excision for localized renal cell carcinoma and an intra-atrial tumor thrombus. These patients underwent radical nephrectomy and inferior vena caval thrombedomy with adjunctive cardiopulmonary bypass and deep hypothermic circulatory arrest. We previously reported on the safety and efficacy of this approach in such cases.6 We continue to perform preoperative renal arteriogk? 40 raphy, and renal arterial embolization of hypervascular Cancer Specific thrombi to facilitate operative extraction as described previOverall ously.6 The latter surgical adjunct has proved useful with no 20 significant associated morbidity. Our results indicate overall and cancer-specific5-year survival rates of 56.6% and 60.2%, respectively. Of the 18 pa0' I I I I I I I I tients 8 (45%) are currently free of malignancy (mean fol0 1 2 3 4 5 6 7 8 lowup approximately 6 years), including 3 who were tumorYears Post-operatlvely free at 7.3,9.0 and 10.3 years postoperatively. Our findings Overall and cancer-specificsurvival rate8 following surgicaltreat- also indicate that the presence or abmnce of perinephrie fat involvement is an important prognostic factor in such cases. ment for renal cell carcinoma extending into right atrium.
t
450
SURGICAL TREATMENT FOR RENAL CELL CANCER EXTENDING INTO RIGHT ATRIUM
We noted significantly improved extended survival among patients with no renal capsular penetration by tumor compared to those with perinephric fat involvement (p = 0.035). CONCLUSIONS
Our results indicate that extended cancer-free survival is possible following surgical treatment of localized renal cell carcinoma with intra-atrial tumor extension. The survival results presented are not significantly different from those reported for patients with renal cell carcinoma and idrahepatic or intrahepatic inferior vena caval thrombi. In patients with localized renal cell carcinoma and an inferior vena caval tumor thrombus the cephalad extent of inferior vena caval involvement does not appear to be prognostically important. REFERENCES
1. Marshall, V. F., Middleton. R. G., Hotswade, G. R. and Goldsmith, E. I.: Surgery for renal cell carcinoma in the vena cava. J. Urol., 103:414, 1970. 2. Libertino, J. A., Zinman, L. and Watkins, E., Jr.: Long-term results of resection of renal cell cancer with extension into
inferior vena cava. J. Urol., 137:21,1987. 3. Neves, R. J. and Zincke, H.: Surgical treatment of renal cancer with vena cava extension. Brit. J. Urol., 69:390, 1987. 4. Skinner, D.G., Pritchett, T. R., Lieskovsky, G., Boyd, S. D. and Stiles, Q. R.: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann. Surg., 210 387, 1989. 5. Sosa, R. E., Muecke, E. C., Vaughan, E. D., Jr. and McCarron, J. P., Jr.: Renal cell carcinoma extending into the inferior vena cava: the prognostic significance of the level of vena cava involvement. J. Urol., 132 1097,1984. 6. Novick, A. C., Kaye, M. C., Cosgrove, D. M., Angermeier, K., Pontes, J. E., Montie. J. E., Streem, S. B., Klein, E., Stewart, R. and Goormastic, M.: Experience with cardiopulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi. Ann. Surg., 212 472, 1990. 7. Cherrie, R. J.,Goldman, D. G., Lindner, A. and deKernion, J. B.: Prognostic implications of vena caval extension of renal cell carcinoma. J. Urol., 128:910,1982. 8. Hatcher, P. A.,Anderson, E. E., Paulson, D. F., Carson, C. C. and Robertson, J. E.: Surgical management and prognosis of renal cell carcinoma invading the vena cava. J. Urol., 145:20,1991.
ABSTRACT
P u r p o s e : Renal cell c a r c i n o m a extends i n t o the i n f e r i o r v e n a c a v a i n 4 t o 1 0 % of p a t i e n t s and i t i s believed t h a t the c e p h a l a d e x t e n t of inferior v e n a c a v a l i n v o l v e m e n t i s i n v e r s e l y c o r r e l a t e d w i t h survival. We evaluated this i s s u e f u r t h e r . M a t e r i a l s and M e t h o d s : F r o m June 1984 to August 1 9 9 3 , 18 p a t i e n t s underwent s u r g i c a l t r e a t m e n t for localized renal cell c a r c i n o m a and an i n f e r i o r v e n a c a v a l thrombus e x t e n d i n g i n t o the r i g h t atrium. One p a t i e n t had a c o n t r a l a t e r a l adrenal m e t a s t a s i s at o p e r a t i o n . All patients underwent complete t u m o r excision w i t h r a d i c a l n e p h r e c t o m y and i n f e r i o r vena c a v a l t h r o m b e c t o m y u s i n g a d j u n c t i v e c a r d i o p u l m o n a r y b y p a s s and d e e p h y p o t h e r m i c c i r c u l a t o r y a r r e s t . P a t h o logical s t u d y i n d i c a t e d n o renal c a p s u l a r p e n e t r a t i o n of r e n a l cell c a r c i n o m a in 10 p a t i e n t s and p e r i n e p h r i c fat i n v o l v e m e n t i n 8. Results: The overall and cancer-specific 5-year s u r v i v a l rates were 56.6% and 60.2%, r e s p e c tively. E i g h t p a t i e n t s (45%) w e r e free of m a l i g n a n c y at a mean of 71.6 months. One p a t i e n t w a s a l i v e w i t h m e t a s t a t i c d i s e a s e 15 months postoperatively. There w a s 1 o p e r a t i v e d e a t h , w h i l e 8 p a t i e n t s died of metastatic renal cell c a r c i n o m a at a mean of 18.8months postoperatively. Mean p o s t o p e r a t i v e s u r v i v a l w a s significantly i m p r o v e d i n p a t i e n t s w i t h no renal c a p s u l a r p e n e t r a t i o n by tumor compared t o t h o s e with perinephric fat involvement (58.1 versus 19.7 m o n t h s , p = 0.035). Conclusions: Long-term survival after surgical treatment is possible in p a t i e n t s w i t h localized renal cell c a r c i n o m a extending i n t o the right a t r i u m . In p a t i e n t s w i t h localized renal cell c a r c i n o m a and an i n f e r i o r v e n a c a v a l tumor thrombus the cephalad extent of inferior vena caval i n v o l v e m e n t d o e s not a p p e a r to be prognostically i m p o r t a n t . K h Y WORDS.carcinoma, renal cell; kidney neoplasms; vena cava, inferior, heart atrium Renal cell carcinoma extends into the inferior vena cava in 4 t o 10% of all patients.' The 5-year survival rates of 47 to 6Wir have been reported following complete surgical excision of localized renal cell carcinoma in this setting.2-4 However, the presence of lymph node or distant metastasis significantly diminishes t h e prospect for extended survival. The prognostic significance of the cephalad extent of a n inferior vena caval tumor thrombus associated with renal cell carcinoma is controversial. I t h a s been suggested t h a t survival following surgical treatment is diminished in patients with supradiaphragmatic inferior vena caval involvement, even when there is no apparent metastatic disease a t operation5 To address this issue further we reviewed the longterm outcome in 18 patients who underwent complete surgical excision of localized renal cell carcinoma and a n inferior vena caval thrombus extending into the right atrium. MATERIALS A N D METHODS
From J u n e 1984 to August 1993,9 men and 9 women 42 to 75 years old (mean age 62.8) underwent surgical treatment for nonmetastatic renal cell carcinoma and a n intra-atrial inferior vena caval thrombus. Renal cell carcinoma involved the right and left kidneys in 11 and 7 patients, respectively. Patients with inferior vena caval tumor thrombi t h a t did not extend into the right atrium were excluded from this study. All patients underwent a preoperative chest x-ray, bone scan and computerized tomography of the abdomen to verify absence of gross lymph node involvement or metastatic disease. One patient had a contralateral 4 cm. adrenal mass of uncertain etiology. Contrast enhanced venacavography was done in 16 Accepted for publication August 18. 1995. * Requests for reprints: Department of Urology, Cleveland Clinic Foundation, 9.500 Euclid Ave.. Clcveland, Ohio 44195.
patients and magnetic resonance imaging was done in 9 to determine the cephalad extent of the inferior vena caval tumor thrombus. An echocardiogram was performed in 11 patients to confirm the presence of thrombus in the right atrium. All patients were studied with renal arteriography to evaluate tumor thrombus vascularity. In 9 patients with a n arterialized inferior vena caval thrombus, percutaneous renal artery embolization was performed 2 to 3 days preoperatively as described previously.6 Other than occasional ensuing mild flank discomfort, preoperative renal artery embolization was well tolerated in all patients with no associated perioperative morbidity. Complete tumor excision was done in all patients with radical nephrectomy and inferior vena caval thrombectomy using adjunctive cardiopulmonary bypass a n d deep hypothermic circulatory arrest. Regional lymphadenectomy was performed i n patients with enlarged or suspicious lymph nodes. The involved adrenal gland was removed in t h e patient with t h e contralateral adrenal mass of uncertain etiology. All patients were studied with a complete blood count, serum chemistry panel, chest x-ray and abdominal CT a t 6 to 12-month intervals postoperatively. A bone scan was also obtained in some patients. All hospital charts were reviewed and followup information was obtained by contacting the patient or local physician directly. Complete followup data were available for all patients. Cancer-free s t a t u s was determined by negative findings on the aforementioned followup studies. Survival analysis was calculated by t h e KaplanMeier method, with statistical comparisons by the log rank test. Mean survival reflected t h e interval to last followup for patients still alive or to death. R b:S U LTS
Patholoecal study of each surgical specimen confirmed renal cell carcinoma with a n inferior vena caval tumor
448
SURGICAL TREATMENT FOR RENAL CELL CANCER EXTENDING INTO RIGHT ATRIUM
thrombus. Further histopathological study revealed no renal capsular penetration of the tumor in 10 patients (group 1) and perinephric fat involvement in 8 (group 2). There were no other significant differences between groups 1and 2 in terms of patient age, sex, tumor size or focality, or the number of patients undergoing preoperative renal artery embolization. Four patients underwent regional lymphadenectomy to remove enlarged lymph nodes and in all cases the nodes were negative for renal cell carcinoma. The excised adrenal gland in the patient with the contralateral adrenal mass contained metastatic renal cell carcinoma. This patient had no renal capsular penetration by the primary tumor and no other evidence of metastasis. The overall 5-year survival rate for the entire series was 56.6%, with a cancer-specific 5-year survival rate of 60.2% (see figure). Currently, 8 patients (45%) are free of malignancy (mean followup 71.6 months). One patient was alive 15 months postoperatively and currently is receiving immunotherapy for suspected metastatic disease. One patient died of myocardial failure 14 days postoperatively and 8 died of metastatic r e n d cell carcinoma at a mean of 18.8 months postoperatively. Mean postoperative survival in group 1was 58.1 months, including the single intraoperative death and the patient with a contralateral adrenal metastasis who died of metastatic disease 49 months postoperatively. Currently, 6 patients (60%)from group l are free of malignancy (followup54 to 123 months, mean 86.3).There was 1 operative death and 3 patients died of metastatic disease at 5 to 49 months postoperatively (mean 20.6). Mean postoperative survival in group 2 was 19.7 months, which is significantly less than that in group 1(p = 0.035). Two patients (20%) were free of malignancy at 13 and 42 months postoperatively, respectively, 1was receiving treatment for metastatic disease a t 15 months and 1 died of metastatic disease at 61 months. The remaining 4 patients died of metastatic disease within 1 year postoperatively (mean survival 6.8 months).
449
node or distant metastasis is known to diminish survival significantly in these cases. However, there is controversy concerning the prognostic significance of the level of the inferior vena caval tumor thrombus. Some studies have suggested that the risk of metastasis and early death is increased with a more cephalad extent of inferior vena caval thrombi. Sosa et al reported a 2-year survival rate of 80% in patients with intrahepatic inferior vena caval thrombi compared to only 21% in those with suprahepatic thrombi, and patients in the latter category were also more likely to have perinephric fat and regional lymph node involvement.6 Subsequently Skinner et al indicated a 5-year survival rate of 35% following surgical treatment for patients with renal cell carcinoma and a subhepatic inferior vena caval thrombus, and 5-year survival rates for patients with intrahepatic or atrial tumor thrombi were 18% and O%, respectively.4 Other reports in the literature have suggeated that the level of an inferior vena caval thrombus in renal cell carcinoma may not be of prognostic signiiicance. Cheme et al analyzed 27 patients with renal cell carcinoma and inferior vena caval involvement, and observed that capsular invasion, nodal disease and distant metastasis had an adverse effect on patient survival.7 Eight patients had supradiaphragmatic inferior vena caval tumor thrombi and the level of the thrombus had no statistically significant impact on survival. More recently, Hatcher et al reviewed 44 patients with renal cell carcinoma and inferior vena caval tumor thrombi, and found that the presence of inferior vena caval wall invasion was prognostically signiscantbut that the level of inferior vena caval tumor thrombus involvement was not.8 A major limitation of previous studies relevant to this issue has been few patients with supradiaphragmatic inferior vena caval involvement and the relatively short followup in most cases. There are 2 important issues to address when evaluating the possible prognostic signiticance of the cephalad extent of inferior vena caval involvement in patients with renal cell carcinoma: 1)is there a greater incidence of lymph DISCUSSION node or distant metastasis at the initial presentation in such Inferior vena caval extension of renal cell carcinoma occurs cases, and 2) is the risk of early metastasis and death inin 4 to 10% of the patients. In patients with nonmetastatic creased following surgical treatment in patients who present renal cell carcinoma and inferior vena caval involvement with nonmetastatic renal cell carcinoma and an inferior vena 5-year survival rates of 47 to 68% have been reported follow- caval thrombus extending into the right atrium. We ading complete surgical resection.2-4 The presence of lymph dressed issue 1 in a previous review of 39 patients with renal cell carcinoma and inferior vena caval thrombi, and found no difference in the incidence of lymph node or distant metastasis at the initial presentation between patients with an atrial thrombus compared to those with lower levels of inferior vena caval involvement.6 The present study was done to evaluate specifically issue 2. We reviewed the long-term outcome in 18 patients who underwent complete surgical excision for localized renal cell carcinoma and an intra-atrial tumor thrombus. These patients underwent radical nephrectomy and inferior vena caval thrombedomy with adjunctive cardiopulmonary bypass and deep hypothermic circulatory arrest. We previously reported on the safety and efficacy of this approach in such cases.6 We continue to perform preoperative renal arteriogk? 40 raphy, and renal arterial embolization of hypervascular Cancer Specific thrombi to facilitate operative extraction as described previOverall ously.6 The latter surgical adjunct has proved useful with no 20 significant associated morbidity. Our results indicate overall and cancer-specific5-year survival rates of 56.6% and 60.2%, respectively. Of the 18 pa0' I I I I I I I I tients 8 (45%) are currently free of malignancy (mean fol0 1 2 3 4 5 6 7 8 lowup approximately 6 years), including 3 who were tumorYears Post-operatlvely free at 7.3,9.0 and 10.3 years postoperatively. Our findings Overall and cancer-specificsurvival rate8 following surgicaltreat- also indicate that the presence or abmnce of perinephrie fat involvement is an important prognostic factor in such cases. ment for renal cell carcinoma extending into right atrium.
t
450
SURGICAL TREATMENT FOR RENAL CELL CANCER EXTENDING INTO RIGHT ATRIUM
We noted significantly improved extended survival among patients with no renal capsular penetration by tumor compared to those with perinephric fat involvement (p = 0.035). CONCLUSIONS
Our results indicate that extended cancer-free survival is possible following surgical treatment of localized renal cell carcinoma with intra-atrial tumor extension. The survival results presented are not significantly different from those reported for patients with renal cell carcinoma and idrahepatic or intrahepatic inferior vena caval thrombi. In patients with localized renal cell carcinoma and an inferior vena caval tumor thrombus the cephalad extent of inferior vena caval involvement does not appear to be prognostically important. REFERENCES
1. Marshall, V. F., Middleton. R. G., Hotswade, G. R. and Goldsmith, E. I.: Surgery for renal cell carcinoma in the vena cava. J. Urol., 103:414, 1970. 2. Libertino, J. A., Zinman, L. and Watkins, E., Jr.: Long-term results of resection of renal cell cancer with extension into
inferior vena cava. J. Urol., 137:21,1987. 3. Neves, R. J. and Zincke, H.: Surgical treatment of renal cancer with vena cava extension. Brit. J. Urol., 69:390, 1987. 4. Skinner, D.G., Pritchett, T. R., Lieskovsky, G., Boyd, S. D. and Stiles, Q. R.: Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann. Surg., 210 387, 1989. 5. Sosa, R. E., Muecke, E. C., Vaughan, E. D., Jr. and McCarron, J. P., Jr.: Renal cell carcinoma extending into the inferior vena cava: the prognostic significance of the level of vena cava involvement. J. Urol., 132 1097,1984. 6. Novick, A. C., Kaye, M. C., Cosgrove, D. M., Angermeier, K., Pontes, J. E., Montie. J. E., Streem, S. B., Klein, E., Stewart, R. and Goormastic, M.: Experience with cardiopulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi. Ann. Surg., 212 472, 1990. 7. Cherrie, R. J.,Goldman, D. G., Lindner, A. and deKernion, J. B.: Prognostic implications of vena caval extension of renal cell carcinoma. J. Urol., 128:910,1982. 8. Hatcher, P. A.,Anderson, E. E., Paulson, D. F., Carson, C. C. and Robertson, J. E.: Surgical management and prognosis of renal cell carcinoma invading the vena cava. J. Urol., 145:20,1991.