Editing Management of Localized and Locally Advanced Disease (section)

=== IVC involvement (cT3b-cN0M0) ===
*Primary and secondary malignant neoplasms can involve the IVC and often have similar imaging features[https://pubmed.ncbi.nlm.nih.gov/25763740/]
**Primary IVC involvement[https://pubmed.ncbi.nlm.nih.gov/16144273/]
***Extremely rare
***Leiomyosarcoma (most common cause, accounts for >75% of tumours arising from large veins)
***Leiomyoma (accounts for 15% of tumours arising from large veins)
**Secondary IVC involvement
***Children (4):
***#Wilms tumor
***#Neuroblastoma
***#Adrenocortical carcinoma
***#Clear cell sarcoma of the kidney
***'''Adults (7):'''
***#'''Renal cell carcinoma (most common cause,''' 18% of all secondary tumours associated with IVC thrombi''')''' 
***#'''Urothelial carcinoma of the renal pelvis'''
***#'''Lymphoma'''
***#'''Retroperitoneal sarcoma'''
***#'''Adrenocortical carcinoma'''
***#'''Pheochromocytoma'''
***#'''Angiomyolipoma'''
*Incidence of kidney cancer with associated venous thrombus varies by series
**Earlier series from 1969 - 1980[https://pubmed.ncbi.nlm.nih.gov/6628471/] described that 77% of cases were associated with vein invasion, compared to 9% in series from 2000 - 2007[https://pubmed.ncbi.nlm.nih.gov/21795070/]
***Contemporary incidence likely lower given that most kidney cancers are diagnosed incidentally on imaging
*'''IVC thrombi can consist of 2 components:'''
*#'''Tumor thrombus (intraluminal growth of RCC into the venous circulation)'''
*#'''Bland thrombus (blood coagulum without tumor cells)'''
*#*'''Venous drainage is hampered by thrombus encouraging further formation of bland thrombus'''
*#*'''Distinction between these two forms of venous thrombus is critical and forms the basis of operative management for IVC thrombi.'''
*'''RCC with venous thrombus associated with aggressive disease'''[https://pubmed.ncbi.nlm.nih.gov/19100567/][https://pubmed.ncbi.nlm.nih.gov/21795070/][https://pubmed.ncbi.nlm.nih.gov/15217427/]
**≈15% have associated positive regional lymph nodes
**≈20-25% have associated metastases
**≈90% are clear cell histology
*'''<span style="color:#ff0000">Diagnosis and evaluation</span>'''
**'''<span style="color:#ff0000">IVC tumour thrombus should be suspected in patients with a renal tumour and (7):</span>'''
**#'''Lower extremity edema'''
**#'''Isolated right-sided varicocele or one that does not collapse with recumbency'''
**#'''Dilated superficial abdominal veins'''
**#'''Proteinuria'''
**#'''Pulmonary embolism'''
**#'''Right atrial mass'''
**#'''Non-function of the involved kidney'''
**'''<span style="color:#ff0000">Imaging</span>'''
***'''<span style="color:#ff0000">M</span><span style="color:#ff0000">RI is the preferred imaging to characterize the extent of the thrombus, though CT may be adequate</span>'''
****Although MRI has been recommended as the test of choice at most centers, several studies have demonstrated that CT also provides sufficient information for surgical planning, and has become the preferred diagnostic study at many centers
****Historically, venacavography was the 'gold standard' imaging test to evaluate thrombus level[https://pubmed.ncbi.nlm.nih.gov/3694754/]
***'''Imaging should be obtained as close as possible to the date of surgery''' because progression of the tumor thrombus may mandate important changes in intraoperative management
***'''<span style="color:#ff0000">Classification of IVC thrombi</span>'''
{| class="wikitable" style="margin: auto;"
|'''<span style="color:#ff0000">Thrombus level</span>'''
|'''<span style="color:#ff0000">Cranial extent of thrombus</span>'''
|Incidence rate in RCC
|Proportion of thrombi
|-
| '''<span style="color:#ff0000">0</span>'''
|'''<span style="color:#ff0000">Confined to renal vein</span>'''
|12%
|65%
|-
|'''<span style="color:#ff0000">I</span>'''
|'''<span style="color:#ff0000">Within 2 cm of renal vein ostium</span>'''
|2%
|10%
|-
|'''<span style="color:#ff0000">II</span>''' 
|'''<span style="color:#ff0000">Subhepatic (below hepatic veins)</span>'''
|3%
|15%
|-
|'''<span style="color:#ff0000">III</span>'''
|'''<span style="color:#ff0000">Intrahepatic (between hepatic veins and diaphragm)</span>'''
|1% 
|5%
|-
| '''<span style="color:#ff0000">IV</span>'''
|'''<span style="color:#ff0000">Suprahepatic (above diaphragm)</span>'''
|1% 
|5%
|}
**'''Prognosis'''
***'''45-70% of patients with RCC and IVC thrombus can be cured with an aggressive surgical approach including RN and IVC thrombectomy'''
***Prognostic significance of IVC thrombus level has been controversial. Even patients with level IV IVC thrombi can be cured with surgical resection
**'''Management'''
***'''See [[Open Kidney Surgery]] Chapter Notes'''