Renal cell carcinoma invading the inferior vena cava (IVC) with supradiaphragmatic thrombus but no distant metastases (T3cN0M0) requires which surgical approach?

• A Cytoreductive nephrectomy followed by sunitinib; IVC thrombus not surgically removed
• B Radical nephrectomy with IVC thrombectomy via thoracoabdominal incision with cardiopulmonary bypass for supradiaphragmatic thrombus ✓
• C IVC filter placement followed by radical nephrectomy without thrombus removal
• D Neoadjuvant sunitinib to reduce thrombus level below the hepatic veins, then standard nephrectomy

Explanation

T3c RCC defines supradiaphragmatic IVC thrombus (above the diaphragm but below the right atrium), or intra-atrial extension. Surgical removal requires radical nephrectomy with IVC thrombectomy; supradiaphragmatic extension necessitates thoracoabdominal incision and cardiopulmonary bypass (or veno-venous bypass) with cardiac surgical support to extract the thrombus under cardiac arrest. Despite the technical complexity, 5-year survival after R0 resection of level III-IV thrombus can reach 50-60%, making aggressive surgical resection appropriate in fit patients without metastases.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.