Kidney Tumors with Vascular Invasion

Renal cell carcinoma is a rare cancer that can invade nearby blood vessels.  Kidney tumors can invade the renal vein (that drains the kidney) and even extend into the inferior vena cava – the largest vein in the body that drains the body beneath the chest.  This extension is called a “tumor thrombus” and can even reach as high as the heart. 

For select patients with vena cava involvement, surgery could be life-saving.  These cancers are typically aggressive and can spread (metastasize) if not treated promptly.  In addition, they can occlude the inferior vena cava and cause swelling and pain in the legs.  Surgery is often recommended as it can often be curative (if cancer has not spread) and improve or prevent symptoms related to inferior vena cava obstruction. 

This type of surgery is very rare and is best approached at centers of excellence (watch video clips) like Johns Hopkins.  At Hopkins, we take a multi-disciplinary surgical approach to these cases.  Depending on the extent of the tumor, a team is assembled that may consist of a general surgeon, vascular surgeon, cardiothoracic surgeon, and a specialized anesthesiologist.  

The inferior vena cava must always be opened to safely remove these tumors.  Depending on the extent of the tumor thrombus, a patient may require any number of intraoperative and reconstructive options discussed below:

  • Primary repair: the inferior vena cava is opened to remove the tumor thrombus and closed with water-tight suturing.  (See inset Figure 1 below)
  • Patch or tube grafting: the inferior vena cava is opened, but would be narrowed to severely by a primary repair.  Therefore, material in either the shape of a patch or tube can be used to repair the defect. (See inset Figures 2 and 3 below)
  • Venous bypass: when the tumor thrombus is extensive and bleeding can be hard to control, the blood supply to the vena cava can be "bypassed" by using vascular clamps and cannulas (similar to large IV catheters most patients are familiar with).  This is performed in conjunction with the vascular surgeons.
  • Cardiopulmonary bypass: if the tumor thrombus is reaching the heart, the entire blood circulation may need to be temporarily stopped to safely excise the cancer.  This is the equivalent of having “open heart surgery” and is performed in conjunction with the cardiovascular surgeons. 

When Kidney Cancer Hits the Vena Cava  

Video Clips of Nephrectomy with Tumor Thrombectomy (watch video clips)

Figure 1.  Primary Repair.  A kidney tumor extending into the renal vein but NOT the vena cava.  The tumor is extracted and the vena cava is closed.  Courtesy of Dr. James Black, MD.

vena cava kidney tumor

Figure 2.  Patch Graft.  A kidney tumor is extending into the vena cava.  The tumor is extracted with the wall of the vena cava to ensure complete removal.  A patch is then sewn onto the vena cava to close it properly. Courtesy of Dr. James Black, MD.

vena cava kidney tumor

Figure 3.  Tube Graft.  The tumor is extending and invading into the vena cava wall.  A large portion of the vena cava is excised with the kidney and the vena cava is replaced with a graft as shown. Courtesy of Dr. James Black, MD.

vena cava kidney tumor