Skip to main content

Renal Cell Carcinoma Involving the Inferior Vena Cava

  • Chapter
  • First Online:
Surgery of the Inferior Vena Cava

Abstract

Renal cell carcinoma (RCC) accounts for 2–3 % of all malignant diseases in adults, representing the third most frequent and the most lethal genitourinary cancer [1, 2]. An estimated 61,560 new cases of renal cancer are expected in 2015, with an estimated 14,080 deaths from this entity in the same period [3].

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Gupta K, Miller JD, Li JZ et al (2008) Epidemiologic and socioeconomic burden of metastatic renal cell carcinoma (mRCC): a literature review. Cancer Treat Rev 34:193–205

    Article  PubMed  Google Scholar 

  2. Kim HL, Zisman A, Han KR et al (2004) Prognostic significance of venous thrombus in renal cell carcinoma. Are renal vein and inferior vena cava different? J Urol 171:588–591

    Article  PubMed  Google Scholar 

  3. Siegel RL, Miller KD, Jemal A (2015) Cancer statistics, 2015. CA Cancer J Clin 65:5–29

    Article  PubMed  Google Scholar 

  4. Pouliot F et al (2010) Contemporary management of renal tumors with venous tumor thrombus. J Urol 184:833–841

    Article  PubMed  Google Scholar 

  5. Boorjian SA, Blute ML (2009) Surgery for vena caval tumor extension in renal cancer. Curr Opin Urol 19:473–477

    Article  PubMed  Google Scholar 

  6. Abreu SC, Gill IS (2003) Renal cell carcinoma: modern surgical approach. Curr Opin Urol 13:439–444

    Article  PubMed  Google Scholar 

  7. Martínez-Salamanca JI, Huang WC, Millán I et al (2011) Prognostic impact of the 2009 UICC/AJCC TNM staging system for renal cell carcinoma with venous extension. Eur Urol 59:120–127

    Article  PubMed  Google Scholar 

  8. Boorjian SA, Sengupta S, Blute ML (2007) Renal cell carcinoma: vena caval involvement. BJU Int 99:1239–1244

    Article  PubMed  Google Scholar 

  9. Kaag MG, Toyen C, Russo P et al (2011) Radical nephrectomy with vena caval thrombectomy: a contemporary experience. BJU Int 107:1386–1393

    Article  PubMed  Google Scholar 

  10. Klatte T, Pantuck AJ, Riggs SB et al (2007) Prognostic factors for renal cell carcinoma with tumor thrombus extension. J Urol 178:1189–1195

    Article  PubMed  Google Scholar 

  11. Lambert EH, Pierorazio PM, Shabsiqh A et al (2007) Prognostic risk stratification and clinical outcomes in patients undergoing surgical treatment for renal cell carcinoma with vascular tumor thrombus. Urology 69:1054–1058

    Article  PubMed  Google Scholar 

  12. Sweeney P, Wood CG, Pisters LL et al (2003) Surgical management of renal cell carcinoma associated with complex inferior vena caval thrombi. Urol Oncol 21:327–333

    Article  PubMed  Google Scholar 

  13. Zisman A, Pantuck AJ, Chao DH et al (2002) Renal cell carcinoma with tumor thrombus: is cytoreductive nephrectomy for advance disease associated with an increased complication rate? J Urol 168:962–967

    Article  PubMed  Google Scholar 

  14. Ciancio G, Soloway M (2001) Renal cell carcinoma invading the hepatic veins. Cancer 92:1836–1842

    Article  CAS  PubMed  Google Scholar 

  15. Shirodkar S, Soloway MS, Ciancio G (2011) Budd-Chiari syndrome in urology: impact on nephrectomy for advanced renal cell carcinoma. Indian J Urol 27:351–356

    Article  PubMed  PubMed Central  Google Scholar 

  16. Parekh DJ, Cookson MS, Chapman W et al (2005) Renal cell carcinoma with renal vein and inferior vena cava involvement: clinicopathological features, surgical techniques and outcomes. J Urol 173:1897–1902

    Article  PubMed  Google Scholar 

  17. Rini BI, Campbell SC, Escudier B (2009) Renal cell carcinoma. Lancet 373:1119–1132

    Article  CAS  PubMed  Google Scholar 

  18. Lam JS, Klatte T, Kim HL et al (2008) Prognostic factors and selection for clinical studies of patients with kidney cancer. Crit Rev Oncol Hematol 65:235–262

    Article  PubMed  Google Scholar 

  19. Haferkamp A, Bastian PJ, Jakobi H et al (2007) Renal cell carcinoma with tumor thrombus extension into the vena cava: prospective long-term follow up. J Urol 177:1703–1708

    Article  PubMed  Google Scholar 

  20. Ficarra V, Novara G, Iafrate M et al (2007) Proposal for reclassification of the TNM staging system in patients with locally advanced (pT3-4) renal cell carcinoma according to the cancer related outcome. Eur Urol 51:722–729

    Article  PubMed  Google Scholar 

  21. Margulis V, Tamboli P, Matin SF et al (2007) Redefining pT3 renal cell carcinoma in the modern era: a proposal for a revision of the TNM primary tumor classification system. Cancer 109:2439–2444

    Article  PubMed  Google Scholar 

  22. Hallscheidt PJ, Fink C, Haferkamp A et al (2005) Preoperative staging of renal cell carcinoma with inferior vena cava thrombus using multidetector CT and MRI: prospective study with histopathological correlation. J Comput Assist Tomogr 29:64–68

    Article  PubMed  Google Scholar 

  23. Kallman DA, King BF, Hattery RR et al (1992) Renal vein and inferior vena cava tumor thrombus in renal cell carcinoma: CT, US, MRI and venacavography. J Comput Assist Tomogr 16:240–247

    Article  CAS  PubMed  Google Scholar 

  24. Guzzo TJ, Pierorazio PM, Schaeffer EM et al (2009) The accuracy of multidetector computerized tomography for evaluating tumor thrombus in patients with renal cell carcinoma. J Urol 181:486–490

    Article  PubMed  Google Scholar 

  25. Zini L, Destrieux-Garnier L, Leroy X et al (2008) Renal vein ostium wall invasion of renal cell carcinoma with an inferior vena cava thrombus: prediction by renal and vena caval vein diameters and prognostic significance. J Urol 179:450–454

    Article  PubMed  Google Scholar 

  26. Thompson RH, Hartmann RP, Lowe VJ, Kawashima A, Leibowich BC (2004) Application of positron emission tomography imaging, intraoperative ultrasound, magnetic resonance imaging and angiography in the evaluation of renal masses. Curr Urol Rep 5:30–34

    Article  PubMed  Google Scholar 

  27. Woodruff DY, Van Veldhuizen P, Meuhlebach G et al (2013) The perioperative management of an inferior vena caval tumor thrombus in patients with renal cell carcinoma. Urol Oncol 31:517–521

    Article  PubMed  Google Scholar 

  28. Blute ML, Leibovich BC, Lohse CM et al (2004) The Mayo Clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumor thrombus. BJU Int 94:33–41

    Article  PubMed  Google Scholar 

  29. Thompson RH, Cheville JC, Lohse CM et al (2005) Reclassification of patients with pT3 and pT4 renal cell carcinoma improves prognostic accuracy. Cancer 104:53–60

    Article  PubMed  Google Scholar 

  30. Moch H, Artibani W, Delahunt B et al (2009) Reassessing the current UICC/AJCC TNM staging for renal cell carcinoma. Eur Urol 56:636–643

    Article  PubMed  Google Scholar 

  31. Wagner B, Patard JJ, Mejean A et al (2009) Prognostic value of renal vein and inferior vena cava involvement in renal cell carcinoma. Eur Urol 55:452–459

    Article  PubMed  Google Scholar 

  32. Sobin LH, Gospodariwicz M, Wittekind C (eds) (2009) TNM classification of malignant tumors. UICC international union against cancer, 7th edn. Wiley Blackwell, pp 255–257

    Google Scholar 

  33. Edge SB, Byrd DR, Compton CC et al (2010) AJCC cancer staging manual, 7th edn. Springer, New York, pp 479–489

    Google Scholar 

  34. Neves RJ, Zincke H (1987) Surgical treatment of renal cancer with vena cava extension. Br J Urol 59:390–395

    Article  CAS  PubMed  Google Scholar 

  35. Ciancio G, Vaidya A, Savoie M et al (2002) Management of renal cell carcinoma with level III thrombus in the inferior vena cava. J Urol 168:1374–1377

    Article  PubMed  Google Scholar 

  36. Berg AA (1913) Malignant hypernephroma of the kidney, its clinical course and diagnosis, with a description of the author’s method of radical operative cure. Surg Gynecol Obstet 17:463–471

    Google Scholar 

  37. Marshall VF, Middleton RG, Holswade GR et al (1970) Surgery for renal cell carcinoma in the vena cava. J Urol 103:414–420

    CAS  PubMed  Google Scholar 

  38. Hatakeyama S, Yoneyama T, Hamano I et al (2013) Prognostic benefit of surgical management in renal cell carcinoma patients with thrombus extending to the renal vein and inferior vena cava: 17-year experience at a single center. BMC Urol 13:47

    Article  PubMed  PubMed Central  Google Scholar 

  39. Skinner DG, Pritchett TR, Lieskovsky G, Boyd SD, Stiles QR (1989) Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 210:387–394

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Golimbu M, Joshi P, Sperber A, Tessier A et al (1986) Renal cell carcinoma -survival and prognostic factors. J Urol 27:291–301

    Article  CAS  Google Scholar 

  41. Hatcher PA, Anderson EE, Paulson DF, Carson CC, Robertson JE (1991) Surgical management and prognosis of renal cell carcinoma invading the vena cava. J Urol 145:20–24

    CAS  PubMed  Google Scholar 

  42. Nesbitt JC, Soltero ER, Dinney CP (1997) Surgical management of renal cell carcinoma with IVC tumor thrombus. Ann Thorac Surg 63:1592–1600

    Article  CAS  PubMed  Google Scholar 

  43. Sosa RE, Muecke EC, Vaughan ED Jr (1984) Renal carcinoma extending into the inferior vena cava: the prognostic significance of the level of vena caval involvement. J Urol 132:1097–1100

    CAS  PubMed  Google Scholar 

  44. Kirkali Z, van Poppel H (2007) A critical analysis of surgery for kidney cancer with vena cava invasion. Eur Urol 52:658–662

    Article  PubMed  Google Scholar 

  45. Tilki D, Nguyen HG, Dall'era MA et al (2014) Impact of histologic subtype on cancer-specific survival in patients with renal cell carcinoma and tumor thrombus. Eur Urol 66:577–583

    Article  PubMed  Google Scholar 

  46. Krajewski KM, Giardino AA, Zukotynski K, Van den Abbeele AD, Pedrosa I (2011) Imaging in renal cell carcinoma. Hematol Oncol Clin N Am 25:687–715

    Article  Google Scholar 

  47. Kulkarni J, Jadhav Y, Valsangkar RS (2012) IVC thrombectomy in renal cell carcinoma- analysis of outcome data of 100 patients and review of literature. Indian J Surg Oncol 3:103–107

    Article  Google Scholar 

  48. Shuch B, Larochelle JC, Onyia T et al (2009) Intraoperative thrombus embolization during nephrectomy and tumor thrombectomy: critical analysis of the University of California-Los Angeles experience. J Urol 181:492–498, discussion 498-9

    Article  PubMed  Google Scholar 

  49. Abel EJ, Wood CG, Eickstaedt N et al (2013) Preoperative pulmonary embolism does not predict poor postoperative outcomes in patients with renal cell carcinoma and venous thrombus. J Urol 190:452–457

    Article  PubMed  Google Scholar 

  50. Ayyathurai R, Garcia-Roig M, Gorin MA et al (2012) Bland thrombus association with tumor thrombus: analysis of surgical significance and role of inferior vena cava interruption. BJU Int 110:E449–E455

    Article  PubMed  Google Scholar 

  51. Wotkowicz C, Wszolek MF, Libertino JA et al (2008) Resection of renal tumors invading the vena cava. Urol Clin North Am 35:657–671

    Article  PubMed  Google Scholar 

  52. Loffroy R, Rao P, Ota S, Geschwind JF (2010) Renal artery embolisation prior to radical nephrectomy for renal cell carcinoma: when, how and why? Br J Radiol 83:630, author reply 631–632

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  53. Subramanian VS, Stephenson AJ, Goldfarb DA, Fergany AF, Novick AC, Krishnamurthi V (2009) Utility of preoperative renal artery embolization for management of renal tumors with inferior vena caval thrombi. Urology 74:154–159

    Article  PubMed  Google Scholar 

  54. Margulis V, Master VA, Cost NG et al (2011) International consultation on urologic diseases and the European association of urology on locally advanced renal cell carcinoma. Eur Urol 60:673–683

    Article  PubMed  Google Scholar 

  55. Wellons E, Rosenthal D, Schoborg T, Shuler F, Levitt A (2004) Renal cell carcinoma invading the inferior vena cava: use of a “temporary” vena cava filter to prevent tumor emboli during nephrectomy. Urology 63:380–382

    Article  PubMed  Google Scholar 

  56. Kappa SF, Morgan TM, Keegan KA, Cookson MS (2012) Inferior vena cava filter strut perforation discovered during right robotic-assisted laparoscopic partial nephrectomy. Urology 79:e49–e50

    Article  PubMed  Google Scholar 

  57. Chandra PA, Nwokolo C, Chuprun D, Chandra AB (2008) Cardiac tamponade caused by fracture and migration of inferior vena cava filter. South Med J 101:1163–1164

    Article  PubMed  Google Scholar 

  58. Motzer RJ, Hutson TE, Tomczak P et al (2007) Sunitinib versus interferon alfa in metastatic renal-cell carcinoma. N Engl J Med 356:115–124

    Article  CAS  PubMed  Google Scholar 

  59. Motzer RJ, Rini BI, Bukowsky RM et al (2006) Sunitinib in patients with patients with metastatic renal cell carcinoma. JAMA 295:2516–2524

    Article  CAS  PubMed  Google Scholar 

  60. Escudier B, Eisen T, Stadler WM et al (2007) Sorafenib in advanced clear-cell renal cell carcinoma. New Eng J Med 356:125–134

    Article  CAS  PubMed  Google Scholar 

  61. González J, Andrés G, Martínez-Salamanca JI, Ciancio G (2013) Improving surgical outcomes in renal cell carcinoma involving the inferior vena cava. Expert Rev Anticancer Ther 13:1373–1387

    Article  PubMed  Google Scholar 

  62. Abaza R (2011) Robotic surgery and minimally invasive management of renal tumors with vena caval extension. Curr Op Urol 21:104–109

    Article  Google Scholar 

  63. Skinner E (2012) Surgical approaches for open renal surgery. In: Smith JA, Howards SS, Preminger GM (eds) Hinman’s atlas of urologic surgery, 3rd edn. Elsevier-Saunders, Philadelphia, pp 799–832

    Google Scholar 

  64. Brown SR, Goodfellow PB (2005) Transverse versus midline incisions for abdominal surgery. Cochrane Database Syst Rev 4, CD005199

    Google Scholar 

  65. Ciancio G, Vaidya A, Soloway M (2003) Early ligation of the renal artery using the posterior approach: a basic surgical concept reinforced during resection of large hypervascular renal cell carcinoma with or without inferior vena cava thrombus. BJU Int 92:488–489

    Article  CAS  PubMed  Google Scholar 

  66. Grantcharov TP, Rosenberg J (2001) Vertical compared with transverse incisions in abdominal surgery. Eur J Surg 167:260–267

    Article  CAS  PubMed  Google Scholar 

  67. Ciancio G, Gonzalez J, Shirodkar SP, Angulo JC, Soloway MS (2011) Liver transplantation techniques for the surgical management of renal cell carcinoma with tumor thrombus in the inferior vena cava: step-by-step description. Eur Urol 59:401–406

    Article  PubMed  Google Scholar 

  68. González J, Angulo J, Ciancio G (2011) Surgical management of renal cell cancer with tumor thrombus through an exclusive transabdominal approach. Arch Esp Urol 64:297–309

    PubMed  Google Scholar 

  69. González J, Shirodkar SP, Ciancio G (2011) Multivisceral organ procurement for transplantation derived mobilization manoeuvres: very helpful auxiliary techniques in the excision of large retroperitoneal masses. Arch Esp Urol 64:257–266

    PubMed  Google Scholar 

  70. Gorin MA, Garcia-Roig M, Shirodkar SP, Gonzalez J, Ciancio G (2012) Modified surgical technique for the management of renal cell carcinoma with level I or II tumor thrombus. Urology 79:478–481

    Article  PubMed  Google Scholar 

  71. Ciancio G, Vaidya A, Shirodkar S, Manoharan M, Hakky T, Soloway M (2009) En bloc mobilization of the pancreas and spleen to facilitate resection of large tumors, primarily renal and adrenal, in the left upper quadrant of the abdomen: techniques derived from multivisceral transplantation. Eur Urol 55:1106–1111

    Article  PubMed  Google Scholar 

  72. Gorin MA, González J, Garcia-Roig M, Ciancio G (2014) Transplantation techniques for the resection of renal cell carcinoma with tumor thrombus: a technical description and review. Urol Oncol 32:34.e19–34.e26

    Article  Google Scholar 

  73. Langenbuch C (1894) Chirurgie der leben und gallenblase. F. Enke Verlag, Stuttgart

    Google Scholar 

  74. Tzakis A, Todo S, Starzl TE (1989) Orthotopic liver transplantation with preservation of the inferior vena cava. Ann Surg 210:649–652

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  75. Wotkowicz C, Libertino JA, Sorcini A, Mourtzinos A (2006) Management of renal cell carcinoma with vena cava and atrial thrombus: minimal access vs median sternotomy with circulatory arrest. BJU Int 98:289–297

    Article  PubMed  Google Scholar 

  76. González J (2012) Update in the surgical management of renal cell carcinoma with venous extension. Curr Urol Rep 13:8–15

    Article  PubMed  Google Scholar 

  77. González J, Ciancio G (2014) Caval thrombus in conjunction with renal tumors: indication for surgery and technical details. Curr Urol Rep 15:451–459

    Article  PubMed  Google Scholar 

  78. Novick AC, Kaye MC, Cosgrove DM et al (1990) Experience with cardiopulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi. Ann Surg 212:472–476

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  79. Marshall FF, Reitz BA, Diamond DA (1984) A new technique for management of renal cell carcinoma involving the right atrium. Hypothermia and cardiac arrest. J Urol 131:103–107

    CAS  PubMed  Google Scholar 

  80. Vaislic C, Puel P, Grondin P et al (1986) Cancer of the kidney invading the vena cava and heart. Results after 11 years of treatment. J Thorac Cardiovasc Surg 91:604–609

    CAS  PubMed  Google Scholar 

  81. Murphy GJ, Angelini GD (2004) Side effects of cardiopulmonary bypass: what is the reality? J Card Surg 19:481–843

    Article  CAS  PubMed  Google Scholar 

  82. Shirodkar SP, Ciancio G (2010) Cardiopulmonary bypass and renal cell carcinoma with level IV tumour thrombus: can deep hypothermic circulatory arrest limit perioperative mortality? BJU Int 106:879

    Article  PubMed  Google Scholar 

  83. Granberg CF, Boorjian SA, Schaff HV et al (2008) Surgical management, complications and outcome of radical nephrectomy with inferior vena cava tumor thrombectomy facilitated by vascular by-pass. Urology 72:148–152

    Article  PubMed  Google Scholar 

  84. Chowdhry UK, Mishra AK, Seth A et al (2007) Novel techniques for tumor thrombectomy for renal cell carcinoma with intraatrial tumor thrombus. Ann Thorac Surg 83:1731–1736

    Article  Google Scholar 

  85. Bertini R, Roscigno M, Lapenna E et al (2008) Radical nephrocapsulectomy and caval thrombectomy with extracorporeal circulation and deep hypothermic circulatory arrest in right anterior minithoracotomy: a minimally invasive approach. Urology 71:957–961

    Article  PubMed  Google Scholar 

  86. Mazzola A, Gregorini R, Villani C et al (2007) Cavoatrial tumor thrombectomy with systemic circulatory arrest and antegrade cerebral perfusion. Ann Thorac Surg 83:1564–1565

    Article  PubMed  Google Scholar 

  87. González J, Gorin MA, Garcia-Roig M, Ciancio G (2014) Inferior vena cava resection and reconstruction: technical considerations in the surgical management of renal cell carcinoma with tumor thrombus. Urol Oncol 32:34.e.19–34.e.26

    Article  Google Scholar 

  88. Vincent C, Moorthy K, Sarker SK, Chang A, Darzi AW (2004) Systems approaches for surgical quality and safety: from concept to measurement. Ann Surg 239:475–482

    Article  PubMed  PubMed Central  Google Scholar 

  89. Rigaud J, Hetet JF, Braud G et al (2006) Surgical care, morbidity, mortality and follow-up after nephrectomy for renal cancer with extension of tumor thrombus into the inferior vena cava: retrospective study since 1990s. Eur Urol 50:302–310

    Article  PubMed  Google Scholar 

  90. Lubahn JG, Sagalowsky AI, Rosenbaum DH et al (2006) Contemporary techniques and safety of cardiovascular procedures in the surgical management of renal cell carcinoma with tumor thrombus. J Thorac Cardiovasc Surg 131:1289–1295

    Article  PubMed  Google Scholar 

  91. Karnes RJ, Blute ML (2008) Surgery insight: management of renal cell carcinoma with associated inferior vena cava thrombus. Nat Clin Pract Urol 5:329–339

    PubMed  Google Scholar 

  92. Moinzadeh A, Libertino JA (2004) Prognostic significance of tumor thrombus level in patients with renal cell carcinoma and venous tumor thrombus extension. Is all T3b the same? J Urol 171:598–601

    Article  PubMed  Google Scholar 

  93. Reese AC, Whitson JM, Meng MV (2013) Natural history of untreated renal cell carcinoma with venous tumor thrombus. Urol Oncol 31:1305–1309

    Article  PubMed  Google Scholar 

  94. Ciancio G, Manoharan M, Katkoori D et al (2010) Long-term survival in patients undergoing radical nephrectomy and inferior vena cava thrombectomy: single-center experience. Eur Urol 57:667–672

    Article  PubMed  Google Scholar 

  95. Goetzl MA, Goluboff ET, Murphy AM et al (2004) A contemporary evaluation of cytoreductive nephrectomy with tumor thrombus: morbidity and long-term survival. Urol Oncol 22:182–187

    Article  PubMed  Google Scholar 

  96. Shuch B, Crispen PL, Leibovich BC et al (2011) Cardiopulmonary bypass and renal cell carcinoma with level IV tumour thrombus: can deep hypothermic circulatory arrest limit perioperative mortality? BJU Int 107:724–728

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Gaetano Ciancio .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer International Publishing Switzerland

About this chapter

Cite this chapter

González, J., Ciancio, G. (2017). Renal Cell Carcinoma Involving the Inferior Vena Cava. In: Azoulay, D., Lim, C., Salloum, C. (eds) Surgery of the Inferior Vena Cava. Springer, Cham. https://doi.org/10.1007/978-3-319-25565-1_5

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-25565-1_5

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-25563-7

  • Online ISBN: 978-3-319-25565-1

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics