Abstract

Objectives: Intracaval thrombus may be seen 4-10% in renal cell carcinoma (RCC), which is such entity that influences prognosis poorly. In this study, we evaluated patients with intracaval thrombus who have introduced us with RCC between 1998 and 2000.

Material and Methods: Between 1998 and 2000, 73 cases diagnosed as RCC, of these patients 11(15.7%) had intracaval thrombus, which have been evaluated with abdominal thomography, color Doppler ultrasongraphy, MRI and cavography when needed. Mean age of the patients was 60±3 years (45-71 years). Extracorporeal circulation conditions provided for 7 patients and 4 patients operated in normal conditions.

Results: At the time of diagnosis, 7 patients had only flank pain, 3 had flank pain and hematuria and one patient had palpable abdominal mass with severe nausea and vomiting. Tumor was at the right side in 8 (72.7%) and left side in 3 (27.3%) patients. The level of caval thrombus was supradiaphragmatic in 2 (18.2%) cases and infradiaphragmatic in 9 (81.8%) cases. There was not distant metastasis in all cases. Of 4 patient who had been operated in normal conditions, 2 (50%) had died intraoperatively because of pulmoner embolus. In these cases, thrombus was in the infradiaphragmtic vena cava and embolus was realized before the control of vena caval segment that cranial of the thrombus. Standard radical nephrectomy and intracaval thrombectomy were performed to 6 patients and in 1 patient inferior vena cava invasion was seen peroperatively and considered as inoperable. In this group no patients has been lost peroperatively.

Of 7 patients who have been operated in extracorporeal conditions, one patient who was considered as inoperable died in the first month after surgery. Six patients have taken into the immunotherapy protocol and 4 (66.7%) of them died in the first year. The other two patients died 18th and 20th month after surgery respectively. Two patients who have been operated in normal conditions have taken into the immunotherapy protocol and they died 16th and 18th month of operation respectively.

Conclusion: Aggressive surgical approach for RCC with isolated intracaval thrombus is significantly remaining survival rates. In view of the high perioperative mortality decisions about radical surgery (hemorrahage, pulmoner embolus), radical surgical approaches must be made carefully in selected patients. We think that if caval thrombectomy will be performed to the patients having RCC with intracaval thrombus, vena caval segment that cranial of the thrombus should be clemped and controlled absolutely before the manipulation of renal vein, also operation should be performed in extracorporeal circulation conditions.