Long-term Survival in Patients Undergoing Radical Nephrectomy and Inferior Vena Cava Thrombectomy: Single-Center Experience.
Ciancio G, Manoharan M, Katkoori D, De Los Santos R, Soloway MS.

Department of Urology, Miller School of Medicine, University of Miami, Miami, FL, USA.

BACKGROUND: Renal cell carcinoma (RCC) with a tumor thrombus extension into the inferior vena cava (IVC) demands aggressive surgical management. OBJECTIVE: To evaluate the long-term survival in patients undergoing radical nephrectomy and IVC thrombectomy. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective analysis of 87 patients undergoing surgery between 1997 and 2008. The patients were grouped according to the extent of tumor thrombus, with level I involving the IVC at the level of the renal vein, level II being infrahepatic IVC, level III being intrahepatic IVC, and level IV being suprahepatic IVC or right atrium. Relevant clinical and pathologic data were analyzed. MEASUREMENTS: Disease-free survival (DFS) and disease-specific survival (DSS) were studied. RESULTS AND LIMITATIONS: The median follow-up was 22 mo, and 19, 14, 40, and 14 patients had level I, II, III, and IV IVC thrombus, respectively. Among patients with M0 disease, 22 developed metastases. The 5-yr DFS (disease free survival) was 64% for all levels and 74%, 69.5%, 59.5%, and 58% for levels I, II, III, and IV, respectively.
Patients with level IV thrombus had a significantly lower 5-yr DSS compared to level I (p=0.03). However, when analyzed in two groups-supradiaphragmatic and infradiaphragmatic-there was no significant difference in DSS (P=0.14). On univariate analysis, metastasis at presentation, non-clear-cell histology, lymph node metastases, and higher nuclear grade were statistically significant prognostic factors influencing DSS. Only higher nuclear grade (p=0.03), metastasis at presentation (p<0.01), and non-clear-cell histology (p=0.03) were independent prognostic factors on multivariate analysis. CONCLUSIONS: Radical nephrectomy and IVC thrombectomy offer reasonable long-term survival. The level of tumor thrombus is not an independent prognostic factor. Distant metastasis at presentation, higher nuclear grade, and non-clear-clear cell histology are significant prognostic factors influencing DSS

ie ALL still alive at 5 years after the op, irrespective of how far up the vena cava the tumour was growing! Even if its right up, 53% of you will be disease free in 5 years with the op! They just haven't got the equipment in every area to do this before a bit of the tumour shoots off and causes a pulmonary embolism! And even if you have an embolism – hey , in the states, thats no problem either, as they just fish it out at the same time they do the kidney!
The lies we were told about 'no treatment being available apart from chemo and palliative care!

NICE/European Urological Guidelines say you are entitled to surgery for this – PUBMED has literally dozens of highly successful ops for this now, and excellent chances of still being alive and disease free in 10 years, REGARDLESS OF AGE – so why are so few stage iv patients told in an undertakers voice ‘sorry theres nothing we can do’? ANSWER – the op requires a brief stint on cardiopulmonary bypass equipment – and there are only 13 hospitals in the entire UK with this – their waiting lists are full of their own cardiac patients, so we can go away and die! Stuff that – insist on nhs choose and book referral to guys and st thomas’ (which has this equipment) or go to America and live!