Compared to other cancers, renal cell carcinoma has a higher rate of venous invasion, affecting the renal vein or inferior vena cava in up to 10% of cases. Due to the invasion of the tumor into the heart, treating venous tumors requires a high level of surgical expertise from skilled oncologists and heart surgeons with a team approach. “Duke has well-established and experienced cardiothoracic and urologic oncology surgery programs, which have come together as one of the only centers in the region performing nephrectomy with tumor thrombectomy,” says Michael Abern, MD, urologic oncologist and co-chair of the Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers. 

Cardiothoracic surgeon Adam Williams, MD, partners with Abern to perform this complex surgery. “Venous tumors grow like a beanstalk up into the heart. While they are typically resectable and curable, these tumors require a specialized team, which we’ve assembled at Duke,” says Abern. The procedure is often time-sensitive and requires coordination with multiple specialties, including oncology, urology, cardiology, and surgical teams.
Williams adds, “We’re seeing very positive outcomes and developing our own approach to these surgeries.” Williams and his colleagues have a clinical pathway to expedite thorough pre-surgical evaluations. “Additional workup includes a left heart cardiac catheterization to rule out coronary artery disease (CAD) and confirm the patient is fit to undergo this extensive procedure,” he adds.

For the surgical planning, Abern and Williams leverage Duke’s access to advanced ultrasound that allows special echo visualization of the tumor’s location in the heart with MRI-like images. “These images help us plan the surgical approach with precision,” says Williams. 

Abern and Williams perform the surgery together, with Abern focused on abdominal incisions to perform the nephrectomy, and Williams on the thoracic cavity to access the right atrium and remove the tumor invading the inferior vena cava. “We are a high-volume center for this procedure that we’ve been doing for a decade, and we’re performing up to 10 cases per year,” says Williams.

Abern and Williams are leveraging technology and surgical innovation to refine a technique that minimizes the surgical impact on patients and maximizes their recovery. “This is a major surgery,” says Abern. “But we’re committed to achieving the best possible outcomes for patients.” 

Abern and Williams are retrospectively studying patients who undergo the procedure and examining outcome correlates. “We want to understand predictors of the best outcomes and recovery so we can evolve our care to the highest standards,” says Abern. 

“One of the factors we’ve recognized early is obesity,” Abern adds. Data suggest that obesity, a risk factor for kidney cancer, may also complicate outcomes of patients who undergo tumor thrombus surgery. “We want to find ways to modify these risk factors and improve outcomes for more patients.”

Williams explains, “We are unique in that we use cardiopulmonary bypass during surgery for hemodynamic management, so we avoid having to put the patient under circulatory arrest. Our goal is to maintain patients’ normal thermal dynamics.”

Williams adds that he and Abern are currently studying outcomes related to this approach, thus far finding no additional complication rates associated with cardiopulmonary bypass for an upper-level thrombectomy procedure.

“We’d like referring physicians to know that we are trusted partners for patients needing treatment for renal cell carcinoma with upper-level tumor thrombus,” says Abern. “We can consult on cases, provide second opinions, and work with patients’ primary medical teams when they are not local to the surrounding Wake County area.”

As one of the few tertiary medical centers performing this level of care for complex renal carcinoma, “many patients travel to us for the procedure,” says Williams. “We are committed to providing a very high level of care for our patients, and continuing to advance our approaches with evolving research.”