Clinical and radiographic predictors of the need for resection of the inferior vena cava during nephrectomy for patients with renal cell carcinoma and caval tumor thrombus

Objective

To evaluate clinical and radiographic predictors of need for resection of the inferior vena cava (IVC-R) requiring complex vascular reconstruction during venous tumor thrombectomy at the time of nephrectomy for renal cell carcinoma (RCC).

Methods

We performed a retrospective review of 172 patients treated for RCC with IVC (level I-IV) venous tumor thrombus at the Mayo Clinic between 2000 and 2010. Preoperative imaging was re-reviewed by two radiologists blinded to the patient’s surgical procedure. Univariable and multivariable associations of clinical and radiographic features with IVC-R were evaluated by logistic regression. Secondary analysis assessed the ability of the model to predict histologic invasion of the IVC by the tumor thrombus.

Results Obtained

Of the 172 patients, 38 (22%) underwent IVC-R procedures during nephrectomy. Optimal radiographic cut-points determined to predict need for IVC-R based on preoperative imaging included a renal vein (RV) diameter at the RV ostium (RVo) of 15.5 mm, maximal AP diameter of the IVC of 34.0 mm and AP and coronal diameters of the IVC at the RVo of 24 mm and 19 mm respectively. On multivariable analysis, the presence of a right-sided tumor (OR 3.3; P = 0.017), a measured AP diameter of the IVC at the Rvo ≥ 24.0 mm (OR 4.4; P = 0.017), and radiographic identification of complete occlusion of the IVC at the RVo (OR 4.9; P < 0.001) were associated with a significantly increased risk of IVC-R. The c-index for the model predicting IVC-R was 0.8. The AP diameter of the IVC at the RVo ≥ 24 mm was also independently associated histologic invasion of the IVC wall by the tumor thrombus (OR 5.04, P < 0.001; c-index 0.7).

Conclusions

We present a multivariable model detailing radiographic features associated with the need for IVC-R during tumor thrombectomy that may be used for preoperative planning, patient counseling, and planned involvement of vascular surgical colleagues in anticipation of need for complex vascular repair.