Renal cell carcinoma (RCC) accounts for approximately 3% of all adult malignancies [1]. A characteristic feature of RCC is its propensity to grow within the venous system, extending from the renal vein into the inferior vena cava (IVC) and, in a small proportion of cases, as far as the right atrium [2,3]. A macroscopic venous tumour thrombus is identified in roughly 4–10% of patients with RCC [3,4].

The presence of venous extension does not, in itself, preclude cure. Whereas patients with distant metastatic disease carry an unfavourable prognosis, those with venous tumour thrombus but no metastasis retain a comparatively optimistic outlook, with reported five-year cancer-specific survival of approximately 60% following complete surgical resection [3,4]. Consequently, an aggressive surgical strategy—radical nephrectomy combined with tumour thrombectomy—is widely regarded as the standard of care and the only potentially curative intervention for these patients [2,5].

The technical demands of surgery increase substantially with the cranial extent of the thrombus. The Neves–Zincke (Mayo) classification stratifies thrombi from level I (renal vein/perirenal IVC) through level IV (supradiaphragmatic or intra-atrial) and guides operative planning, the need for vascular reconstruction, and the involvement of cardiothoracic and vascular teams with cardiopulmonary bypass capability [5,6]. High-level thrombi in particular demand meticulous multidisciplinary coordination and are best managed in high-volume centres [2,5].

We present our institutional experience with the surgical management of nine patients with RCC and tumour thrombus spanning the full spectrum of venous involvement, from the renal vein to the right atrium, with the aim of describing our operative approach, perioperative outcomes, and lessons for practice.

This was a retrospective, single-centre study conducted at Narayana Health, Bengaluru. We reviewed the records of all patients who underwent surgical resection of RCC with an associated tumour thrombus involving the renal vein, IVC, or right atrium between January 2011 and February 2018. Nine consecutive patients met the inclusion criteria and were analysed.

All patients underwent preoperative staging and operative planning with contrast-enhanced computed tomography (CT) of the abdomen and pelvis, magnetic resonance imaging (MRI) to delineate the cranial extent and wall adherence of the thrombus, and renal angiography where indicated. The extent of the tumour thrombus was documented using the Neves–Zincke (Mayo) classification: level I (thrombus confined to the renal vein or extending ≤2 cm into the IVC), level II (infrahepatic IVC), level III (retrohepatic IVC, at or above the hepatic veins but below the diaphragm), and level IV (supradiaphragmatic or intra-atrial extension) [5,6].

In our cohort the thrombus was renal-vein/level I in four patients, infrahepatic/level II in three, retrohepatic with hepatic-vein involvement/level III in one, and intra-atrial/level IV in one. Radical nephrectomy with tumour thrombectomy was performed in every case. The surgical approach was individualised to thrombus level: an open transperitoneal approach was used for the majority, while a laparoscopic radical nephrectomy with thrombectomy was undertaken in one selected level-I case. For IVC thrombi, vascular control was obtained above and below the thrombus and, where the thrombus was adherent to the caval wall, partial resection of the IVC wall with reconstruction was performed. For the intra-atrial thrombus, a combined approach with the cardiac and vascular teams was used, employing median sternotomy and cardiopulmonary bypass with right-atrial access for thrombus extraction.

Data collected included age, sex, laterality, presenting symptoms, thrombus level, operative procedure, intraoperative and postoperative complications, mortality, and histopathological diagnosis. Given the retrospective, descriptive nature of the series, data are reported using descriptive statistics.

Nine patients were treated during the study period; the demographic, clinical, operative, and pathological details are summarised in Table 1. Eight patients were male and one was female, with most patients in the sixth and seventh decades of life (age range 36–76 years). Presentations ranged from incidental radiological detection to painless haematuria, flank pain, lower-limb swelling, and syncope.

Table 1. Clinical, operative, and pathological characteristics of the nine patients.

*Thrombus level per the Neves–Zincke (Mayo) classification. RCC, renal cell carcinoma; IVC, inferior vena cava; LUTS, lower-urinary-tract symptoms; PTFE, polytetrafluoroethylene; CABG, coronary artery bypass grafting; CPB, cardiopulmonary bypass.

Four patients with thrombus confined to the renal vein (level I) underwent radical nephrectomy and thrombectomy; one of these was completed laparoscopically, with an excellent postoperative recovery. Three patients with infrahepatic IVC thrombus (level II) underwent radical nephrectomy with IVC thrombectomy; in one, the thrombus was adherent to the caval wall and was managed by partial resection of the IVC wall with reconstruction using a polytetrafluoroethylene (PTFE) patch. One patient had a level-III thrombus involving the hepatic vein.

One patient had tumour thrombus extending into the right atrium (level IV). The cardiac and vascular teams were involved, and thrombus removal was undertaken via median sternotomy with cardiopulmonary bypass and right-atrial access; concurrent coronary artery bypass grafting was performed. In the postoperative period, one patient developed duodenal obstruction at the level of D2, which was managed conservatively. There was one mortality, in the patient with intra-atrial (level IV) tumour thrombus. Postoperative recovery was satisfactory in all other patients. Histopathology demonstrated clear-cell RCC in five patients, papillary RCC in two, eosinophilic RCC in one, and unclassified RCC in one.

Venous tumour thrombus is an uncommon but well-recognised manifestation of RCC, occurring in 4–10% of cases, and its cranial extent dictates operative complexity [3,4]. Our series, spanning the full spectrum from renal-vein to intra-atrial involvement, illustrates that complete surgical extirpation is technically feasible across all thrombus levels when supported by appropriate imaging and a multidisciplinary team. This aligns with the established principle that, in the absence of metastatic disease, radical nephrectomy with thrombectomy offers the only realistic prospect of cure and can yield five-year cancer-specific survival approaching 60% [3,4].

Accurate preoperative delineation of the thrombus is critical. We routinely employed contrast-enhanced CT and MRI, with MRI being particularly valuable for defining the cranial limit of the thrombus and detecting caval-wall invasion, which in turn determines whether simple thrombectomy will suffice or whether caval resection and reconstruction are required [5]. In one level-II patient, wall adherence mandated partial IVC-wall excision with PTFE-patch reconstruction—an approach consistent with published technical series describing tailored caval management to achieve negative margins while preserving venous return [5].

Management of high-level (III–IV) thrombi is considerably more demanding. Our single intra-atrial case required median sternotomy and cardiopulmonary bypass with right-atrial access, undertaken jointly with cardiothoracic and vascular colleagues, mirroring reported one-stage combined cardiac and urological strategies for level-IV disease [2]. The solitary mortality in our series occurred in this highest-risk group, underscoring that operative risk escalates sharply with thrombus level and that such surgery should be concentrated in high-volume centres with bypass capability and invasive intraoperative monitoring [2,5]. The laparoscopic resection of a level-I tumour, by contrast, demonstrates that minimally invasive approaches can be appropriate for carefully selected low-level thrombi [7].

Reported outcomes indicate that 40–70% of patients with RCC and venous thrombus can be cured by nephrectomy and thrombectomy, and while thrombus level influences perioperative morbidity, tumour grade, histological subtype, and the presence of metastasis remain the dominant determinants of long-term survival [3,4]. The limitations of the present study are those inherent to a small, retrospective, single-centre case series without long-term survival follow-up; nonetheless, it adds to the collective experience guiding the surgical management of this challenging condition.

An aggressive surgical approach—radical nephrectomy with tumour thrombectomy—remains the only curative option for RCC with tumour thrombus in the IVC and can provide acceptable long-term survival and quality of life. The level of thrombus principally reflects operative complexity and perioperative risk rather than being the sole determinant of survival. Operative management of patients with high-level caval thrombi should be undertaken in high-volume centres by surgical teams that include cardiothoracic and vascular surgeons, with the capacity for cardiopulmonary bypass and invasive intraoperative monitoring.

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