Renal cell carcinoma (RCC) with level IV inferior vena cava (IVC) thrombus and without metastases is a T3c cancer and a resectable disease. It requires interdisciplinary cooperation and delicate surgical technique.

Herein, we report a case of a 71-year-old man, who came to our urological clinic for management of weight loss of 10 kg and poor appetite in 1 year. Computed Tomography scan (CT) disclosed a right renal tumor about 3.7 cm with IVC thrombus extending to right atrium. CT guided biopsy proved clear cell RCC. Surgery was performed for salvage treatment. Transesophageal echocardiography was first introduced by anesthesiologist and V-V ECMO was inserted by cardiovascular surgeons. Right open radical nephrectomy was performed by genitourinary surgeons. General surgeon was than consulted for Pringle maneuver and liver mobilization to expose subhepatic and subdiaphragmatic IVC. V-V ECMO was shifted to heart lung machine and cardiovascular surgeons performed sternotomy and right atrial thrombectomy. Consequently, immediate heart repair was conducted and V-V ECMO was returned. We clamped distal IVC, left renal vein and proximal IVC in order and completed IVC thrombectomy and IVC repair. The surgery was smooth and the patient recovered well postoperatively. The final pathology confirmed clear cell renal cell carcinoma, pT3c and free surgical margin. Follow up image showed no tumor recurrence and stable condition.

Discussion

        According to NCCN guideline Version 3.2024, the optimal treatment for T3c RCC is surgical resection, either radical or partial nephrectomy if indicated. The objective of the surgery is total resection of all tumor burden. The open approach could be performed via a midline, chevron, subcostal incision or mixture. For level III or above IVC thrombus, mobilization of liver is important. Pringle maneuver is performed for temporary portal venous return occlusion to prevents hepatic congestion and subsequent hemorrhage or capsule fracture. Another emphasis for level III or IV IVC thrombectomy is the cardiopulmonary bypass performed by cardiovascular surgeons to maintain hemodynamics. However,

V-V ECMO may be an alternative for thrombus beneath the diaphragm. For caval wall tumor excision, resection of IVC is sometimes indicated for tumor eradication, because cancer had higher risk of recurrence if the surgical margin is not free in these cases.

Conclusion

        Back to our cases, we followed the surgical principles for IVC thrombectomy and went through a tough and delicate multidisciplinary operation. We achieved fair results and the patient had no tumor recurrence to date. It seems that the successful operation provides acceptable long-term outcomes and disease free survival time, compared with those without treatment. Although surgery remains the mainstay treatment for the disease, further adjuvant therapy should be discussed with oncologist and constructed a team work.