Large sarcomatoid chromophobe renal cell carcinoma with tumor thrombus extending into the inferior vena cava: a case report on the challenges and lessons from a fatal outcome.

Background: Renal cell carcinoma (RCC) affects around 400,000 people annually and remains a major cause of cancer-related mortality. Tumor thrombus (TT) is a rare manifestation of disease that occurs in 4-10% of RCC cases and is one that poses significant surgical risk. Despite recent advancements in immunotherapy for metastatic RCC disease, cytoreductive nephrectomy (CN) continues to be the preferred surgical treatment for resectable disease. Case Description: A 63-year-old male presented with several months of progressive anemia, weight loss, and abdominal pain in which he had not undergone prior workup. Imaging revealed a large left renal mass with level II inferior vena cava (IVC) TT, liver metastases, and invasion into multiple adjacent organs. The patient underwent CN with IVC thrombectomy and multivisceral resection with pathology demonstrating a mixed sarcomatoid and chromophobe RCC with lymphovascular invasion. Although the surgery was initially well-tolerated, the postoperative course was complicated by pulmonary embolism, sepsis, and multiorgan failure, resulting in death on postoperative day 15. Conclusions: Our experience highlights the complex technical demands and ethical considerations of pursuing CN in advanced RCC with IVC thrombus. While tumor resection may be feasible, the associated risks and complications can be considerable. Nevertheless, multidisciplinary collaboration and transparent communication with patients and their families are essential in guiding decision-making and ultimately pursuing the avenue of care that best reflects the patient's values, goals, and quality of life.