RENAL CELL CARCINOMA EXTENDING INTO THE INFERIOR VENA CAVA

Abstract

Among 109 cases of renal cell carcinoma which received treatment at Jikei University Hospital during the 26 years from 1953 to 1978, clinical observation was carried out in 10 cases (9.2%) diagnosed as having tumor thrombus of the inferior vena cava.
Out of these 10 patients, 7 were males and 3 were females. Their age ranged from 22 to 69 years, with an average of 50 years. The affected side was right in 8 cases and left in 2 cases, with a prevalence of the right side.
As the triad, apart from gross hematuria observed in 8 of 10 cases the renal mass could be palpated in as many as 7 cases (70%). Extrarenal symptoms were noted in 9 cases, especially fever was seen in a high percentage of patients (7 cases or 70%).
Clinical findings of inferior vena caval obstruction revealed varicocele in the right side in 2 cases and edema of lower extremities in 2 cases. However, proteinuria was found in 7 cases (70%).
Laboratory findings showed an elevation of α₂-globulin levels in 9 cases, and positive CRP in 5 of 7 cases tested. Liver dysfunction was noted in only 2 cases.
The excretory urography demonstrated no visualization in 3 cases (30%). In 6 of 7 cases in which selective renal arteriography was performed, striated vascular pattern was seen. In addition, in 3 cases collateral veins were visualized, which suggested the possible presence of tumor thrombus from the renal vein to the inferior vena cava. The inferior vena cavography carried out in 8 cases revealed a filling defect in all of the cases tested, being consistent with the presence of tumor thrombus. Therefore, the inferior vena cavography was considered to be most valuable as an aid for diagnosing this disease. In 2 cases, in which the inferior vena cava was found to be obstructed completely, extensive collateral veins chiefly consisting of vertebral and lumber veins were observed.
Among these 10 cases, metastasis was found at the initial examination in 6 cases (60%). The remaining 4 cases (40%) showed no metastasis.
In 6 cases operation was carried out. Except one case which was diagnosed as having unresectable lesion, nephrectomy was performed in 5 cases, in 3 of which venacavotomy and thrombectomy were performed at the same time.
As to the clinical courses of 10 cases, in 5 of 6 cases with metastatic lesion death occurred within one year from the start of treatment, with only one case surviving these 7 months after nephrectomy. On the contrary to this, 2 of 3 cases without metastatic lesion who received nephrectomy have survived till now, for 8 years and 5 months and one year and 2 months, respectively. Therefore, even in the presence of tumor thrombus in the inferior vena cava, unless there is metastatic lesion, a prolonged survival period can be expected if the tumor thrombus can be resected successfully. Consequently, aggressive surgical approach is recommended in these cases.