4 – 10 % of patients with RCC may have venous tumour thrombus.
Only roughly 30 % of patients with tumour thrombus have metastatic disease – meaning cure is possible with aggressive surgery in 40 – 70 % of patients even with caval thrombus.
Prognosis:
- Median survival 5 months for IVC thrombus if no surgery, 1 year cancer specific survival 30 %
- Improved to cancer specific survival 40 – 65 % at 5 years with surgery
Suspect venous involvement if:
- New irreducible or right sided varicocele
- Lower limb oedema
- Dilated superficial abdominal veins
- Atrial mass on imaging
- Non functioning involved kidney
Old Mayo classification of IVC thrombus:
- Level 0 – renal vein only
- Level 1 – < 2 cm above renal vein
- Level 2 – > 2 cm above renal vein, below hepatics
- Level 3 – at or above the hepatic vein
- Level 4 – above the diaphragm
Updated classification 2020 – level 1 below caudate, level 2 above caudate and below main hepatics
Recall TNM staging
- T3a – into renal vein
- T3b – into IVC, below diaphragm
- T3c – into IVC, above diaphragm, or into caval wall
Pre-operative work up:
- Must have recent imaging before proceeding to surgery – within a couple of weeks.
- Have blood products available, group and hold, appropriate teams available (HPB, cardiac, vascular)
- MRI and CT are complementary and can both be useful – MRI “gold standard” with 100 % sensitivity in detecting IVC thrombus
- Consider pre-operative and intra-operative TOE
- Tumour thrombus will enhance on contrast imaging; bland thrombus will not
- Cardiology/cardiothoracic consult prior for level 4 thrombus – consider pre-operative angiography +/- need for CABG during procedure.
Pre-operative renal artery embolisation:
- No strong evidence supporting its use (not routinely done locally)
- Advantages – may induce thrombus regression, can allow venous ligation before arterial intra-op, ? reduces blood loss but not proven
- Disadvantages – likelihood of post embolisation syndrome, unproven benefit
- Can be used in palliation for bleeding / haematuria etc