Management of Venous Involvement in Locally Advanced Renal Cell Carcinoma

 Management of Venous Involvement in Locally Advanced Renal Cell Carcinoma

MDACC 2018: Management of Venous Involvement in Locally Advanced Renal Cell Carcinoma
November 10, 2018
Houston, TX (UroToday.com) Christopher G. Wood, MD discussed how to manage patients with locally advanced renal cancer with venous involvement.  Radical cystectomy with IVC thrombectomy is a technically challenging surgery associated with significant morbidity and mortality.  However, there are select patients that would benefit from surgery. Patients should be considered for nephrectomy and IVC thrombectomy if there is no evidence of metastases, nodal disease, sarcomatoid de-differentiation, or invasion into the perinephric fat or wall of the vein, all which predict poor prognosis. In patients that will undergo surgery, there are several considerations that should be taken for the best possible outcome.
Is there a role for preoperative systemic therapy or angioembolization?  In the MD Anderson experience, prior systemic therapy in efforts to shrink tumor thrombus in 25 patients did not have any effect1 with other studies reporting the progression of tumor thrombus.  Pre-operative embolization for intracardiac or cavoatrial thrombi is rarely used as it can lead to increased blood loss, complications and mortality2 . 
Dr. Wood emphasized the importance of obtaining a contrast-enhanced MRI, which is the gold standard for evaluating these patients.   MRIS have 100% sensitivity in detecting tumor thrombus, are able to distinguish between bland versus tumor thrombus and provide a detailed map of venous collaterals.   As thrombi can progress rapidly, it is imperative for patients to have recent imaging.  If pulmonary emboli are discovered on chest imaging, the concern is whether this represents tumor thrombi or bland thrombi.  A retrospective review from MD Anderson reported that patients with pulmonary emboli had the same cancer-free survival and recurrence-free survival as those that did not(3).  This suggests that the pulmonary emboli are likely bland thrombus and that these patients should not be excluded from surgery.
An intraoperative transesophageal echocardiogram is imperative as it allows assessment of tumor thrombus level and can identify the dreaded complication of thrombus migration.  General surgical technique recommendations included a midline or chevron approach, obtaining early arterial control as it is key to reducing blood loss (“it’s a vascular surgery before a cancer surgery”), and use of a LigaSure™ for collateralizing vessels.   Dr. Wood also stated that there is no indication for an IVC filter prior to surgery, patients should be anticoagulated for bland thrombus and that sternotomy is for selected level III and IV patients as these cases can often be done transdiaphragmatic from the abdomen. 
In the MD Anderson experience in patients from 1993-2009, median EBL was 900mL, median operative time was 186 minutes.  Factors predictive of major complications included age >60 and preoperative embolization.  Independent predictors of survival included clear cell subtype, Furhman grade IV, sarcomatoid de-differentiation, peri-nephric fat invasion, lymph node metastasis and distant metastasis.  For patients presenting with Budd-Chiari syndrome, there was an 80% in-hospital mortality.  Therefore, in this scenario, patients undergo angioembolization followed by interval resection 3-6 months after angioembolization. Finally, in the era of minimally invasive surgery, is this approach possible for nephrectomy and IVC thrombectomy?  While it is described in the literature, Dr. Wood states that it should be reserved for only very select patients and in his personal opinion, would not recommend it at this time.
Presented by: Christopher G. Wood, MD, Professor and Deputy Chairman of Urologic Oncology at MD Anderson Cancer Center in Houston, TX
Written by Dr. Amy H. Lim, MD, Ph.D., Urologic Oncology Fellow with Dr. Ashish M. Kamat, MD, (@UroAshDoc), Professor, Department of Urology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX at the 13th Update on the Management of Genitourinary Malignancies, The University of Texas (MDACC - MD Anderson Cancer Center) November 9-10, 2018, Dan L. Duncan Building, Houston, TX
References:
2. Subramanian VS, Stephenson AJ, Goldfarb DA, Fergany AF, Novick AC, Krishnamurthi V. Utility of preoperative renal artery embolization for management of renal tumors with inferior vena caval thrombi. Urology. 2009;74(1):154-9.
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