ELSEVIER ADULT UROLOGY NEPHRECTOMY AND VENA CAVAL THROMBECTOMY IN PATIENTS WITH METASTATIC RENAL CELL CARCINOMA JOEL W. SLATON, M. DERYA BALBAY, DAVID A. LEVY, LOUIS L. PISTERS, JONATHAN C. NESBITT, DAVID A. SWANSON, AND COLIN P. N. DINNEY ABSTRACT Objectives. To report our experience with performing nephrectomy and vena caval thombectomy in patients with metastatic renal cell carcinoma. Methods. A retrospective review was performed of 15 patients who underwent surgical excision of the primary tumor and a caval thrombus and treatment of concurrent metastases between 1989 and 1995. The sites of metastases included lungs (n = 8), bone (n = 3), bulky retroperitoneal or mediastinal lymph nodes (n = 2). liver (n = 1 ), and contralateral adrenal (n = 1). The level of caval involvement was suprahepatic in 3 cases, retrohepatic in 2 cases, and infrahepatic in 10 cases. Three patients had an Eastern Cooperative Oncology Group performance score of 0, 1 1 had a score of 1, and 1 had a score of 2. Median follow-up was 17 months. Results. Median operative time was 6.5 hours and median hospitalization was 10 days. Two patients required re-exploration for postoperative hemorrhage. There were no perioperative deaths. Four patients underwent surgery for resection of solitary metastases (1 lung, 2 spine, and 1 humerus); 2 of the 4 received adjuvant radiotherapy. Two patients received biologic therapy preoperatively, 3 received it both preoperatively and postoperatively, and 6 received it only postoperatively. The median time to initiation of postoperative biologic therapy was 48 days (range 25 to 1 10). Eleven patients are currently alive, 7 with no evidence of disease at a median follow-up of 17 months [range 6 to 66) and 4 with stable metastases at 14 months (range 4 to 22). Ten of the 13 symptomatic patients had improved performance scores after surgery. Four patients have died from metastatic disease: 2 from rapid progression at 2 and 5 months after surgery and the other 2 at 17 and 42 months. Conclusions. Nephrectomy and vena caval thrombectomy can be safely performed in selected patients with metastatic disease. Furthermore, in patients receiving biologic therapy, nephrectomy may enable a better quality of life and prolonged survival. UROLOGY 50: 673-677, 1997. 0 1997, Elsevier Science Inc. All rights reserved. T he vena cava is involved in 4% to 25% of pa- tients with renal cell carcinoma (RCC).lm4 The presence of a tumor thrombus associated with RCC has not been proven to have a detrimental impact on survival.3,5-9 In patients who are ac- ceptable surgical candidates, radical nephrectomy with vena cavotomy and resection of the caval thrombus provides effective palliation and long- term survival rates as high as 68% at 5 years.’ From the Departments of Urology and Thoracic and Cardiovas- cular Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas Reprint requests: Cohn P. N. Dinney, M.D., Department of Urology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 110, Houston, TX 77030 Submitted: March 19, 1997, accepted (with revisionsI:June 3, 1997 0 1997, ELSEVIER SCIENCE INC ALL RIGHTS RESERVED One third of patients with a vena caval thrombus will also have one or more metastatic lesions.‘ou The role of surgery in the management of these pa- tients remains controversial. Several reports stress that the presence of metastases is a contraindication to vena caval thombectomy.3’7’9’12-16 On the other hand, a number of authors espouse the benefit of surgical resection of the primary tumor in patients with or without caval thrombus when performed be- fore or after immunotherapy or in conjunction with resection of solitary metastases.17-22 We report our experience with nephrectomy and vena caval throm- bectomy in patients with metastatic RCC to help de- fine their role in the delivery of aggressive therapy. MATERIAL AND METHODS Between January 1989 and October 1996, 44 patients un- derwent nephrectomy and resection of a vena caval thrombus 0090.4295/97/$17.00 PI1 SOO90-4295(97)00329-4 673