Surgery for vena caval tumor extension in renal cancer

PURPOSE OF REVIEW: We review recent efforts designed to improve the preoperative assessment, minimize the surgical morbidity, and develop multimodal treatments for patient with renal cell carcinoma and venous tumor thrombus. RECENT FINDINGS: The ability of computerized tomography to classify venous thrombus has improved with recent advancements in multidetector/three- dimensional technology. The utility of preoperative imaging to predict vascular wall invasion, which carries adverse prognostic significance, has also been demonstrated. Minimally invasive approaches to low-level thrombus cases have been explored, whereas techniques to minimize the morbidity associated with the use of cardiopulmonary bypass and circulatory arrest in patients with a retrohepatic or supradiaphragmatic thrombus, including antegrade cerebral perfusion, the use of cardiopulmonary bypass with mild hypothermia, and the increased application of veno-venous bypass, have improved perioperative outcomes. Meanwhile, results from several case reports suggest a potential role for neoadjuvant systemic therapy with tyrosine kinase inhibitors prior to resection. SUMMARY: Improvements in perioperative assessment and surgical technique have decreased the morbidity and improved the outcomes for patients with renal cell carcinoma and venous tumor thrombus. Further investigations of the role for targeted therapies in the management of these complex patients are needed to define the optimal multimodal approach.