1991 Volume 82 Issue 1 Pages 130-138
Twenty-eight patients with a tumor thrombus 914 in the inferior vena cava and 14 in the renal vein), among a series of 170 renal cell carcinoma patients receiving hospital treatment at the Gunma University during the period from 1961 to 1989, were explored for clinical features, with the results leading to the following conclusions:
1) There were 19 male and 9 female with respective mean ages of 62.1 and 54.4 years.
2) The disease was right-sided in 16 patients and left-sided in the other 12, but there were no striking left-to-right difference in tumor location.
3) The most frequent chief complaint was symptoms arising from the urinary tract. Among symptoms and sings occulusion of the inferior vena cava or renal vein, proteinuria was most frequent, being present in 56% of patients with clinical evidence of occlusion, followed by tortuosity of veins of the abdominal wall and edema in the lower extremities noted in 3 patients.
4) Selective renal arteriography demonstrated tumor hypervascularity in all 22 patients (except for one with a hypovascular tumor mass) and A-V shunt at a high percentage. Profuse striated vascular pattern representing arterialization of an extensive tumor thrombus was also noted, particularly with intracaval involvement. Venacavography demonstrated neoplastic thrombi in the inferior vena cava as filling defects, thus proving the diannosis. CT also provided diagnostic evidence of a tumor thrombus in all cases except for one in which it failed to detect a tumor thrombus in the renal vein preoperatively, with an accurate diagnosis rate of 100% for intracaval tumor thrombi and 83% for tumor thrombi in the renal vein.
5) The extent of tumor thrombosis was graded in the entire 28 patients as well as in 22 patients operated upon and correlated with prognosis. The results indicate that the extent of tumor thrombosis had no bearing upon the pathologic stage of disease. Stage IIIc or more advanced cases had a poor prognosis irrespective of the extent of tumor thrombosis; 6 patients not undergoing operation all died of cancer within 12 months of onset, while patients operated upon all had a fatal outcome within 20 months excepting for one with stage IVB disease and extention of intracardiac type who has been surviving for 11 months. Stage IIIA disease patients had a survival time of 10 to 98 months even in the presence of recurrence, thus generally having favorable prognosis regardless of the degree of extention of a tumor thrombus.
6) With the exception of 1 patient treated by transabdominal simple nephrectomy and 3 by translumbar simple nephrectomy, all patients underwent a transabdominal or thoracoabdominal radical nephrectomy, either of these approaches being neccessary for successful performance of an intravenous thombectomy.
7) The operative procedure of choice may vary depending upon the extent of tumor thrombosis. We consider, therefore, that a key for successful operation is to accurately determine the extent of a tumor thrombus by preoperative diagnosistic imaging.
