BERKELEY, CA (UroToday.com) - The surgical management of renal cell carcinoma with intravascular venous tumor thrombus requires the commitment of a multidisciplinary surgical team, particularly for higher tumor thrombus extending into the intrahepatic or cardiac segments.
Preoperative imaging is a vital component of the surgical planning and management in such cases. Although magnetic resonance imaging with intravenous contrast is currently the imaging modality of choice for assessment of the presence and level of a tumor thrombus, high-resolution computerized tomography remains an equally effective diagnostic modality.
Current recommendations do not support the preoperative placement of an inferior vena cava (IVC) filter in patients with tumor thrombus or use of neoadjuvant systemic therapy in an attempt to improve treatment outcomes. The surgical approach should be tailored to the individual patient case as well as to the level of the IVC tumor thrombus. An extended subcostal abdominal incision with or without sternal extension provides excellent surgical exposure and has been our traditional approach for such cases. Patient education and counseling is essential prior to surgery, recognizing the complexity of such surgical procedures, particularly when dealing with higher-level tumor thrombus.
Lastly, the role of minimally invasive surgical approaches (including robotics) remains, for the most part, limited, and should be considered only in highly selected cases -- typically lower-level tumor thrombus not extending into the intrahepatic IVC. Adherence to some of our clinical pearls may likely optimize the surgical outcomes imparted to patients.
Written by:
Philippe E. Spiess, MD, MSc, FACS, FRCS(C) as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Associate Member
Department of Genitourinary Oncology
Moffitt Cancer Center
Tampa, FL USA
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