The Mayo Clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumour thrombus

The Mayo clinic experience with renal carcinoma and venous tumour thrombus is presented in this section. The authors show that the surgical management of these patients continues to develop, and that complications and mortality are decreasing. They also show that cancer‐specific survival is better with renal vein involvement only, as compared with vena caval involvement. Authors from Dallas examined whether Gleason 3+4 tumours behaved differently to 4+3, and found that that the latter pattern is more aggressive. They propose that the Gleason 4 pattern deserves further molecular study. Several authors from the USA and Austria compared the performance of complexed PSA with that of total PSA and percentage free PSA; complexed PSA provided better specificity than the other two tests and reduced the number of unnecessary biopsies in patients with a total PSA of 2.6–4.0 ng/mL. OBJECTIVE To report the surgical management, complications and outcomes over three decades by tumour thrombus level for patients with renal cell carcinoma (RCC) and renal venous extension, as surgery is the most effective treatment. PATIENTS AND METHODS We assessed 540 patients who underwent surgical resection for RCC with renal venous extension between 1970 and 2000. Early and late surgical complications, including operative mortality, were compared with tumour thrombus level using the chi‐square, Fisher's exact and Wilcoxon rank‐sum tests. Cancer‐specific survival was estimated using the Kaplan‐Meier method and compared across tumour thrombus levels using log‐rank tests. RESULTS There were 349 (64.6%) patients with level 0 thrombus and 191 (35.4%) with inferior vena cava thrombus, including 66 (12.2%) with level I, 77 (14.3%) with level II, 28 (5.2%) with level III, and 20 (3.7%) with level IV thrombus. Patients with a higher thrombus level had more early surgical complications (respectively for level 0 to IV, 8.6%, 15.2%, 14.1%, 17.9% and 30.0%, P < 0.001). However, there was no statistically significant difference in the incidence of late complications by thrombus level ( P = 0.445). The incidence of any early surgical complication decreased from 13.4% for patients treated in 1970–1989 to 8.1% for those treated in 1990–2000 ( P = 0.064); the respective operative mortality decreased from 3.8% to 2.0% ( P = 0.260), and in patients with inferior vena cava thrombus, from 8.1% to 3.8% ( P = 0.227). The respective duration of hospitalization decreased from a median of 8 to 7 days ( P < 0.001) but the incidence of late complications increased significantly over time ( P < 0.001.) Among patients with clear cell RCC, the respective estimated 5‐year cancer‐specific survival rates ( Se , number still at risk) for patients with level 0 to IV thrombus were 49.1 (3.0)% (125), 31.7 (6.4)% (14), 26.3 (6.1)% (11), 39.4 (10.7)% (7) and 37.0 (12.9)% (5), ( P = 0.028). There was a statistically significant difference in outcome for patients with level 0 vs those with level >0 thrombus ( P = 0.002), but there was no significant difference in outcome by thrombus level among patients with inferior vena cava tumour thrombus ( P = 0.868). CONCLUSIONS The surgical management of RCC with renal venous extension continues to develop. The incidence of early surgical complications and operative death have decreased in recent times with the introduction of improved imaging, surgical monitoring and vascular bypass techniques. There is significantly better cancer‐specific survival for patients with renal vein involvement only than those with inferior vena cava involvement.