Agung Adhitya Indra

 Characteristic RCC intraluminally growth

IVC  vein tumor thrombus
 extreme cases of tumor thrombus growth
cephalad aligned right atrium
 No metastatic  many patients of IVC tumor
thrombus  nteresting aspects
 Good high risk of
prognosis recurrence

Restricted extends into

kidney perinephric
tumor fat

extends the
trombus
lymph
nonadherent
nodes

IVC wall
invasion
 4% -10%  RCC
 45 -70 %  trombus tumor vena  nefrectomy
& thrombectomy
 Trombus below the vena hepatica  easy to
control  removal of thrombus tumor
 Trombus  above the hepatic vein  requires
dissection extension  venovenous bypass or
cardiopulmonary bypass with circulatory
arrest
 large tumor radiographic suspicion of invasion of
adjacent structures or organs (CT4)  complete
excision with en -bloc resection  only hope
 Big limfadenopathy  poor prognosis  similiar
metastatic  Surgical resection is considered:
 location
 border
 Patient ages
 comorbidity
 high quality imaging preoperative(CT or MRI)
 shortly before surgery  intraoperative
success
 RCC local advanced primary disease surgery
 Systemic adjuvant therapy  certain
patients  better prognosis
 suspected venous tumor thrombus. RCC :
 lower extremity edema
 varicocele right side and remains visible when you
lie down
 superficial abdominal vein dilatation
 proteinuria
 Pulmonary embolism
 Right atrial mass
 No function of the invloved kidney
 I: closed with ostium
 II: lower border of
hepatic
 III: intrahepatic of IVC
 IV: above diaphragm
 significance  stage trombus IVC 
prognostic  controversy
 Reseach  development of locoregional or
systemic higher  stage III-IV IVC trombus
 reduce survival rate
 Factors that affect the survival rate:
 expansion limfonode
 metastatic
 tumor grade
 Many patients  gr. IV IVC trombus  cured
 surgical resection  restricted no adverse
abnormality
 7th edition TNM  tumor classification :
 thrombus above the diaphragm (T3c)
 hrombus below the diaphragm (T3b)
 thrombus in renal vein or branched(T3a)
 MRI  non invasive & accurate  appearance
& level of tumor thrombus extension 
diagnostic in many centers
 gadolinium  ct angiography  distinguish
tumor thrombus from bland thrombus
 CT multiplanar  caput & caudal of trombus
 important  preoperative imaging  closely
surgery date  the development of tumor
thrombus changed  intraoperative
management
 invasive imaging contrast  backup:
 MRI & CT equivocal findings
 MRI & CT is contraindicated
 Inferior venacavography  inj. contrast
antegrade and / or retrograde  accurate
diagnostic  IVC involvment invasive  not
necessary in modern era
 Renal arteriography additional preoperative
studies  RCC invloving IVC  clear
vascularization of thrombus tumor  35% -
40% cases (Gambar. 49-27)
 Preoperative renal artery embolization 
helping surgical procedures
 Research  Renal artery embolization  no
benefit:
 reduce blood loss
 complications of tumor nephrectomy with
thrombectomy
 225 patients  Renal artery embolization 
multivariable analysis:
 increased risk of perioperative mortality
 increased of blood transfusion
 Thrombus tumor  supradiaphragmatic vein
 cardiopulmonary bypass with deep
hypothermic circulatory arrest  coroner
angiography  preoperative
 Significant troumbus coronary obstruction 
repaired together  cardiopulmonary bypass
 If needed  transesophageal echocardiography
 invasive imaging  intraoperative
diagnostic modalities  monitoring
supradiaphragmatic thrombus
Grade I
Thrombus
• Renal
mobilization
• ligation
• transection
arterial blood
supply
• vascular control
in IVC involved
• isolated by
Satinsky clamp
and remove
grade II
thrombus
• sequential
clamping of the
caudal IVC
• contralateral renal
blood vessels
• relevant segments
IVC
• lumbar vein
occlusion
• Renal ostium
opened
• thrombus removed
(bloodless area)
 thrombus tumor  vena cava wall 
aggressive resection  achievement of
negative surgical margins  minimize the risk
of recurrence
 Bland trombus  distal of IVC or iliac vein 
let it in situ  IVC ligation/clip at cephalad 
prevent pulmonary embolism
 Vascular control  Gr. III & IV thrombus:
 More dissection
 venovenous bypass / cardiopulmonary bypass
 hypothermic circulatory arrest
Grade III
thrombus
• Hepar
mobilization
• Exposure of IVC
intrahepatic
• Mobilization of
caudal thrombus
at hepatic vein
• vein isolation as
thrombus grade II
 not possible pringle maneuver  interrupt
A.Hepatica & V.Porta
 grade IV thrombus  cardiopulmonary bypass
dan hypothermic circulatory arrest  still uses
 complex cases
 Many centers avoiding hypothermic
circulatory arrest  hypocoagulable state 
increased risk cerebrovascular event & infark
myocardial
 Morbidity risk  important  thrombus Gr.
IV  mortality associated radical nephrectomy
& thrombectomy  5% - 10%
 patient selection and surgical planning  good
general status of patients non substantially
lymphadenopathy or metastatic
 palliative surgery:
 metastases with severe disabilities of the edema
 ascites
 cardiac dysfunction
 Local symptoms such as abdominal pain and
hematuria
 nephrectomy and thrombectomy metastasis
expected slowing after cytoreduction Gr. I,
II atau III trombus wich easy to control
 algorithm  the risk of metastatic RCC
 morbidity  aggressive surgery avoid 
patients with limited life expectancy
 location is isolated& RCC trend RCC
aggressive 
 large primary tumors  invade adjacent
structures
 T4  < 2%  reclassification RCC extends the
adrenal glands  percentage increase
 locally advanced RCC  pain due to invasion
 posterior abdominal wall
 nerve roots
 muscle paraspinous
 Large tumor capsule  compress the hepatic
parenchyma  rarely extensions directly to the
liver
 Margulis and colleagues (2007)  suspect
invasion of adjacent organs  histopatological
 40%
 The duodenum and pancreas invasion  poor
prognostic
 evaluation of patients with invasive upper
quadrant abdominal large mass  differential
diagnosis  except locally invasive RCC
 adrenocortical carcinoma
 infiltrative transitional cell carcinoma
 sarcoma
 lymphoma
 Margulis and colleagues(2007)  aggressive
surgery  10 of 12 patients (T4)  median
recurrence 2 months after surgery
 negative surgical margins  (34) 63% from
(38) 90% patients dies  median 12 months
after surgery
 complete excision of larger pimary tumor
12% life  1st year
 < 5%  extensions to the borders with viscera
(Pt4)  survive 5 years after surgery
 The main indication resection of locally
advanced RCC curative or palliative
 research  preoperative radiotherapy
increases survival rate
 van der Werf-Messing (1973)  comparison
radiotherapy before surgery with control  no
difference in survival rate at 5 years
 Postoperative radiotherapy  dangerous
because of the small intestine adjacentl 
radiosensitive
 currently  systemic chemotheraphy 
residual or locally recurrent.