Impact of imaging and thrombus level in management of renal cell carcinoma extending to veins

OBJECTIVES: To evaluate the role of newer imaging modalities in the diagnosis and evaluation of management according to extent of renal vein (RV) or inferior vena cava (IVC) thrombi in patients with renal cell carcinoma. MATERIAL AND METHODS: Fifty-nine patients with renal cell carcinoma and tumor thrombus extension into the RV or IVC were studied. Diagnosis was based on contrast-enhanced CT, magnetic resonance imaging or color-Doppler ultrasonography. Surgical treatment was contemplated in 42 suitable patients and complete resection could be done in all but 3 cases. RESULTS: There were 48 males and 11 females with mean age of 51.8 years. Isolated RV involvement was seen in 27 cases whereas IVC extension was present in 32 cases. The thrombus extent was infrahepatic in 62.5% (20/32) patients with IVC extension. With the newer imaging modalities like contrast-enhanced CT, color-Doppler ultrasound and/or magnetic resonance imaging, correct diagnosis of the extent of the thrombus was possible in 95% of the patients. The accuracy of color-Doppler ultrasound was same as magnetic resonance imaging in the evaluation of the extent of the thrombus. In the present series a median follow-up of 4 years revealed a high incidence of local and distant recurrences and decreased survival in patients presenting with advanced disease, who had venous wall invasion. CONCLUSIONS: The extent of RV or IVC thrombi can be accurately diagnosed with contrast-enhanced CT scan and in case of doubt color-Doppler ultrasound is a good alternative to magnetic resonance imaging. Management can be planned according to the level of the tumor thrombus. Invasion of the venous wall was found to be a bad prognostic factor affecting survival.