Renal cell carcinoma with tumor thrombus extension into the vena cava: prospective long-term followup

Multi-disciplinary surgical approach to the management of patients with renal cell carcinoma with venous tumor thrombus: 15 year experience and lessons learned

BACKGROUND

The management of patients with renal cell carcinoma (RCC) with venous tumor thrombus (VTT) is challenging. We report our 15 year experience in the management of patients with RCC with VTT utilizing a multidisciplinary team approach, highlighting improved total and specifically Clavien III-V complication rates.

METHODS

We reviewed the records of 146 consecutive patients who underwent radical nephrectomy with venous thrombectomy between 1998 and 2012. Data on patient history, staging, surgical techniques, morbidity, and survival were analyzed. Additionally, complication rates between two surgical eras, 1998-2006 and 2006-2012, were assessed.

RESULTS

The study included 146 patients, 97 males (66 %), and a median age of 61 years (range, 24-83). Overall complications rate was 53 %, high grade complications (Clavien III -V) occurred in 10 % of patients. Most importantly, there was a lower incidence of overall and high grade complications (45 % and 8 %, respectively) in the last 6 years compared to the earlier surgeries included in the study (67 % and 13 % respectively) [p = .008 and .03, respectively). 30 day postoperative mortality was 2.7 %. 5 year overall survival (5Y- OS) and 5 year cancer specific survival (5Y- CSS) were 51 % and 40 %, respectively. Metastasis was the only independent predictor factor for CSS (HR 3.8, CI 1.9-7.6 and p < .001) and OS (HR 2.6, CI 1.5-4.7 and p = .001) in all patients.

CONCLUSIONS

Our data suggest that patients with RCC and VTT can be treated safely utilizing a multidisciplinary team approach leading to a decrease in complication rates.

Renal cancer

The diagnosis and management of renal cell carcinoma have changed remarkably rapidly. Although the incidence of renal cell carcinoma has been increasing, survival has improved substantially. As incidental diagnosis of small indolent cancers has become more frequent, active surveillance, robot-assisted nephron-sparing surgical techniques, and minimally invasive procedures, such as thermal ablation, have gained popularity. Despite progression in cancer control and survival, locally advanced disease and distant metastases are still diagnosed in a notable proportion of patients. An integrated management strategy that includes surgical debulking and systemic treatment with well established targeted biological drugs has improved the care of patients. Nevertheless, uncertainties, controversies, and research questions remain. Further advances are expected from translational and clinical studies.

Robotic Level III IVC Tumor Thrombectomy: Duplicating the Open Approach

OBJECTIVES

To describe our surgical technique for robotic radical nephrectomy and thrombectomy for renal cell carcinoma and associated level III inferior vena cava (IVC) thrombus with retroperitoneal lymph node dissection.

METHODS

The patient is a 75-year-old Caucasian man with a 10-cm right renal neoplasm and associated level III tumor thrombus. After preoperative imaging was reviewed, a robotic approach was planned. Real-time intraoperative transesophageal ultrasonography was performed to assess the cranial extent of tumor thrombus. The major steps of our technique include early inter-aortocaval control of the right renal artery, circumferential mobilization of the IVC, contralateral renal vein control, cavotomy, thrombectomy, and reconstruction of the IVC.

RESULTS

Operative time was 5 hours and 53 minutes (353 minutes) with 150 mL estimated blood loss. The patient was allowed to have a clear liquid diet immediately after surgery and was discharged home on postoperative day 3. Final pathology demonstrated a 9.8-cm clear cell renal cell carcinoma, nuclear grade 3 with a pT3bN1 stage.

CONCLUSIONS

With adequate team experience and preparation, robotic radical nephrectomy and IVC tumor thrombectomy for level III tumor thrombus is challenging but feasible in select patients. Herein we describe our robotic technique which duplicates the open approach. This minimally invasive approach may offer lower estimated blood loss, improved pain control, and expedited recovery.

Systematic Review of Surgical Management of Nonmetastatic Renal Cell Carcinoma with Vena Caval Thrombus

CONTEXT

Overall, 4-10% of patients with renal cell carcinoma (RCC) present with venous tumour thrombus. It is uncertain which surgical technique is best for these patients. Appraisal of outcomes with differing techniques would guide practice.

OBJECTIVE

To systematically review relevant literature comparing the outcomes of different surgical therapies and approaches in treating vena caval thrombus (VCT) from nonmetastatic RCC.

EVIDENCE ACQUISITION

Relevant databases (Medline, Embase, and the Cochrane Library) were searched to identify relevant comparative studies. Risk of bias and confounding assessments were performed. A narrative synthesis of the evidence was presented.

EVIDENCE SYNTHESIS

The literature search identified 824 articles. Fourteen studies reporting on 2262 patients were included. No distinct surgical method was superior for the excision of VCT, although the method appeared to be dependent on tumour thrombus level. Minimal access techniques appeared to have better perioperative and recovery outcomes than traditional median sternotomy, but the impact on oncologic outcomes is unknown. Preoperative renal artery embolisation did not offer any oncologic benefits and instead resulted in significantly worse perioperative and recovery outcomes, including possibly higher perioperative mortality. The comparison of cardiopulmonary bypass versus no cardiopulmonary bypass showed no differences in oncologic outcomes. Overall, there were high risks of bias and confounding.

CONCLUSIONS

The evidence base, although derived from retrospective case series and complemented by expert opinion, suggests that patients with nonmetastatic RCC and VCT and acceptable performance status should be considered for surgical intervention. Despite a robust review, the findings were associated with uncertainty due to the poor quality of primary studies available. The most efficacious surgical technique remains unclear.

PATIENT SUMMARY

We examined the literature on the benefits of surgery to remove kidney cancers that have spread to neighbouring veins. The results suggest such surgery, although challenging and associated with high risk of complications, appears to be feasible and effective and should be contemplated for suitable patients if possible; however, many uncertainties remain due to the poor quality of the data.

Precise control of caval and hepatic vessels: Surgical technique to treat level III caval thrombus concomitant to renal cell carcinoma

INTRODUCTION

We investigated the surgical techniques, safety, and prevention of complications of nephrectomy and removal of tumour thrombus for treating level III inferior vena cava (IVC) concomitant to renal cell carcinoma (RCC). We did this by precise controlling IVC and hepatic vessels without a vascular bypass.

METHODS

In this series, we included 5 patients with level III IVC tumour thrombus below the hepatic vein concomitant to RCC. After precisely controlling the IVC and hepatic vessels, we then removed the thrombus en bloc with the renal vein. Blood loss volume, IVC clamping time, hypotension time, resuscitation, cardiocerebrovascular complications, and postoperative organ dysfunction were observed.

RESULTS

Surgery was successfully performed without perioperative death. Blood loss volume was 900 to 1500 mL, operation time was 165 to 250 minutes, vascular clamping time was 8 to 12 minutes, and intraoperative hypotension time was 9 to 12 minutes. Serious perioperative complications were not observed. Local recurrence was not observed during the 9 to 24 months of follow-up. One patient exhibited disease-free survival, 3 developed lung or liver metastasis, and 1 died 11 months after surgery.

CONCLUSION

Precise control of IVC and hepatic pedicle vessels, without vascular bypass, is a safe and effective surgical treatment for level III tumor thrombus below the hepatic vein concomitant to RCC. The procedure was conducted without increased risks of intraoperative hypotensive shock, difficult resuscitation, pulmonary embolism, and multiple organ dysfunctions.

Successful removal of uterine leiomyosarcoma tumour thrombus propagating to the right atrium

Although intravenous leiomyomatosis is widely documented, intravenous extension of leiomyosarcoma into the inferior vena cava (IVC) and subsequently into the right atrium is extremely rare. Less than five such cases have been reported in the literature worldwide. Uterine leiomyosarcoma is an aggressive smooth muscle tumour occurring with an incidence of 1% in all female genital tract cancers and comprises about 3-7% of uterine cancers. It carries a generally poor prognosis with 5-year survival rates ranging from 18.8% to 65% across all stages. We report a case of primary uterine leiomyosarcoma with intravascular tumour propagation extending to the renal vein, IVC and right atrium of the heart, which was successfully resected in a one stage operation by a multidisciplinary team. This case demonstrates the importance of preoperative radiological staging and multidisciplinary planning.

A new classification of inferior vena cava thrombus in renal cell carcinoma could define the need for cardiopulmonary or venovenous bypass

INTRODUCTION

Although the level of inferior vena cava (IVC) thrombus governs the type of surgical approach, there is no consistency in reporting the levels of IVC thrombus in the literature. This prospective study illustrates a simple three-level classification based on the need for clamping hepatoduodenal ligament and venovenous or cardiopulmonary bypass.

MATERIALS AND METHODS

Between January 2010 and June 2014, 30 patients of renal mass with renal vein and/or IVC thrombus were treated after classifying the IVC thrombus into three levels on the basis of need for clamping the hepatoduodenal ligament. After excluding renal vein thrombi, level I was described as thrombus located caudal to the hepatic vein. Level II included all retrohepatic, suprahepatic infradiaphragmatic or supradiaphragmatic thrombi reaching till the right atrium. Atrial thrombi were categorized as level III. Level I and II thrombi were managed without venovenous or cardiopulmonary bypass. Level III thrombus required cardiopulmonary bypass.

RESULTS

Of 26 patients with thrombus, 13 had level I thrombus. Of eight cases with level II thrombus, three were retrohepatic, three were suprahepatic infradiaphragmatic and two were supradiaphragmatic. All were removed successfully. Of five patients with level III thrombus, three were operated with cardiopulmonary bypass while the remaining two patients were too sick to be taken up for surgery. The median hepatoduodenal ligament clamp time was 10 min. One patient with level II thrombus had transient liver enzyme elevation.

CONCLUSION

Renal vein thrombus should not be categorized as level I thrombus. Level II thrombus, irrespective of its relation to the diaphragm, could be managed without venovenous or cardiopulmonary bypass.

Multi-Institutional Experience with Robotic Nephrectomy with Inferior Vena Cava Tumor Thrombectomy

PURPOSE

Since the first report of robotic management of renal tumors with inferior vena cava tumor thrombi, few additional cases have been reported in the literature. We report our combined experience with this procedure, to our knowledge the first multi-institutional and largest series reported to date.

MATERIALS AND METHODS

A retrospective, multi-institutional review of robotic nephrectomy with inferior vena cava tumor thrombectomy was performed with institutional review board approval.

RESULTS

A total of 32 cases were performed among 9 surgeons at 9 institutions since the first known procedure in 2008. Of these cases 30 were level II and 2 were level III thrombi with no level I thrombi (renal vein only) included in the analysis. Each surgeon performed between 1 and 10 procedures. Mean patient age was 63 years (range 43 to 81) with a mean body mass index of 30 kg/m(2) (range 17 to 43) and mean maximal tumor diameter of 9.6 cm (range 5.4 to 20). The length of inferior vena cava tumor thrombi ranged from 1 to 11 cm (median 4.2) on preoperative imaging. The inferior vena cava required cross-clamping in 24 cases. One patient had 2 renal veins with 2 caval thrombi and 1 patient required synthetic patch cavoplasty. Mean operative time was 292 minutes (range 180 to 411) with a mean blood loss of 399 cc (range 25 to 2,000). There were no conversions to open surgery or aborted procedures and there were 3 transfusions of 1 to 3 units. All but 2 patients ambulated by postoperative day 1 and mean hospital stay was 3.2 days (range 1 to 7). Lymphadenectomy in 24 patients yielded a mean of 11 nodes and 8 patients had node positive disease. There were 7 patients who experienced distant recurrence at a mean followup of 15.4 months, including 4 who had node positive disease on postoperative pathological examination.

CONCLUSIONS

Robotic nephrectomy in the setting of inferior vena cava tumor thrombus is feasible and was performed safely in selected patients. Despite the complex and critical nature of these procedures, our series demonstrates favorable outcomes and reproducibility with adequate robotic experience.

Nephrectomy and inferior vena cava thrombectomy for renal cell carcinoma among patients with impaired renal function: defining predictors of outcomes

BACKGROUND

Management of renal cell carcinoma (RCC) with inferior vena cava thrombus (IVCT) is associated with high morbidity. Chronic kidney disease (CKD) is a known risk factor for perioperative complications in many surgical procedures. The objective of this study was to review the association between preoperative CKD (eGFR < 60 mL/min) and post-operative outcomes in patients with RCC and IVCT undergoing radical nephrectomy (RN) and tumour thrombectomy (TT).

METHODS

A retrospective review of patients with RCC and IVCT treated with RN and TT was carried out. Complications were recorded according to the Clavien-Dindo classification. Multivariable models were fitted using logistic regression analyses for high-grade complications and salvage therapies and linear-regression for intraoperative blood loss (IBL).

RESULTS

One hundred and one patients with RCC and IVCT, treated with RN and TT, were identified. Forty per cent of patients had preoperative CKD. Median IBL was higher in CKD arm (2.5 versus 1.6 L, P = 0.04). In a multivariate linear regression analysis, CKD (beta 1.34, P = 0.01) remained an independent predictor of IBL. High-grade complications were more frequent in the CKD group (34% versus 16%, P = 0.09) and in logistic regression analysis, CKD was an independent predictor of high-grade complications (OR 3.33, 95% CI 1.01-10.9). Furthermore, CKD patients were less likely to be considered for salvage therapies (62% versus 38%, P = 0.02).

CONCLUSIONS

In patients treated with RN and TT, CKD is an independent predictor of perioperative morbidity. This clinical variable should be considered when selecting patients and subsequent efforts should be made to optimize other competing risk factors in order to reduce the incidence of perioperative adverse events in this patient population.

Prognostic Outcomes and Risk Factors for Patients with Renal Cell Carcinoma and Venous Tumor Thrombus after Radical Nephrectomy and Thrombectomy: The Prognostic Significance of Venous Tumor Thrombus Level

Introduction. To evaluate the prognostic outcomes and risk factors for renal cell carcinoma (RCC) patients with venous tumor thrombus in China. Materials and Methods. We reviewed the clinical information of 169 patients who underwent radical nephrectomy and thrombectomy. Overall and cancer-specific survival rates were analyzed. Univariate and multivariate analyses were used to investigate the potential prognostic factors. Results. The median survival time was 63 months. The five-year overall survival and cancer-specific survival rate were 53.6% and 54.4% for all patients. For all patients, significant survival difference was only observed between early (below hepatic vein) and advanced (above hepatic vein) tumor thrombus. However, significant differences existed between both RV/IVC and early/advanced tumor thrombus groups in N0M0 patients. Multivariate analysis demonstrated that higher tumor thrombus level (p = 0.016, RR = 1.58), N (p = 0.013, RR = 2.60), and M (p < 0.001, RR = 4.14) stages and adrenal gland invasion (p = 0.001, RR = 4.91) were the most significant negative prognostic predictors. Conclusions. In this study, we reported most cases of RCC patients with venous extension in China. We proved that patients with RCC and venous tumor thrombus may have relative promising long-term survival rate, especially those with early tumor thrombus.

Prediction of Perioperative Death Following Surgery for Renal Cell Carcinoma with Vein Involvement: A Retrospective Study

INTRODUCTION

Advanced renal cell carcinoma (RCC) shows a propensity for extending into the tributaries of the renal veins, which poses a notable surgical challenge. In this study we addressed the question as to whether patients with RCC and vein involvement can be identified as having a significant risk of immediate death associated with surgery preoperatively.

MATERIALS AND METHODS

A total of 118 patients with RCC and vein involvement from February 1999 until November 2012 were evaluated. The association of early mortality within 60 days after the intervention was tested with various covariates including: age, body mass index (BMI), preoperative serum C-reactive protein, preoperative serum creatinine, preoperative hemoglobin level, tumor diameter, suspicion of metastasis on prior computed tomography, documented cardiac insufficiency, extent of vein invasion, prior myocardial infarction, TNM stage, American Society of Anesthesiologists score, New York Heart Association classification and Karnofsky index. A multiple logistic regression model was used to test all risk factors including the combination of an elevated BMI with an impaired Karnofsky index with all covariates.

RESULTS

A total of 17 patients died within 60 days after the operation with most patients dying from cardio-embolic complications during the first two quartiles of the observation, while later deaths were mostly attributable to sequelae of surgical complications. None of the tested risk factors were significantly associated with early mortality in the logistic regression model. The presence of an elevated BMI (≥30 kg/m(2)) in combination with a Karnofsky index ≤70% predicted early death in univariate (p = 0.006) and multivariate analysis (p = 0.023). Death rates for patients with BMI <30 kg/m(2) and Karnofsky index >70%, BMI ≥ 30 kg/m(2) or Karnofsky index ≤70%, BMI ≥30 kg/m(2) and Karnofsky index ≤70% were 5%, 14.8% and 37.5%, respectively.

CONCLUSION

The risk of early death is dramatically elevated to more than one-third of cases with elevated BMI and unfavorable Karnofsky index in patients with RCC and vein involvement. Patients need to be counseled in this regard especially when planning cytoreductive treatment without curative intent.

Preoperative multivariable prognostic models for prediction of survival and major complications following surgical resection of renal cell carcinoma with suprahepatic caval tumor thrombus

OBJECTIVE

Surgical resection for renal cell carcinoma (RCC) with suprahepatic inferior vena cava tumor thrombus is associated with significant morbidity, yet there are currently no tools for preoperative prognostic evaluation. Our goal was to develop a preoperative multivariable model for prediction of survival and risk of major complications in patients with suprahepatic thrombi.

METHODS

We identified patients who underwent surgery for RCC with suprahepatic tumor thrombus extension from 2000 to 2013 at 4 tertiary centers. A Cox proportional hazard model was used for analysis of overall survival (OS) and logistic regression was used for major complications within 90 days of surgery (Clavien ≥ 3A). Nomograms were internally calibrated by bootstrap resampling method.

RESULTS

A total of 49 patients with level III thrombus and 83 patients with level IV thrombus were identified. During median follow-up of 24.5 months, 80 patients (60.6%) died and 46 patients (34.8%) experienced major complication. Independent prognostic factors for OS included distant metastases at presentation (hazard ratio = 2.52, P = 0.002) and Eastern Cooperative Oncology Group (ECOG) performance status (hazard ratio = 1.84, P<0.0001). Variables associated with increased risk of major complications on univariate analysis included preoperative systemic symptoms, level IV thrombus, and elevated preoperative alkaline phosphatase and aspartate transaminase levels; however, only systemic symptoms (odds ratio = 8.45, P<0.0001) was an independent prognostic factor. Preoperative nomograms achieved a concordance index of 0.72 for OS and 0.83 for major complications.

CONCLUSIONS

We have developed and internally validated multivariable preoperative models for the prediction of survival and major complications in patients with RCC who have a suprahepatic inferior vena cava thrombus. If externally validated, these tools may aid in patient selection for surgical intervention.

Palliative iliac vein-to-right atrium bypass in a patient with a prior vena cava ligation for invasive renal cell carcinoma

Renal cell carcinoma can involve the inferior vena cava and extend into the right atrium. Cure is rarely achieved in patients with concomitant metastases, but cytoreductive nephrectomy and eradication of the entire tumor thrombus can extend survival and prevent symptoms of venous congestion; however, the invasive nature of the tumor thrombus can make resection with negative margins difficult. We present a patient with aggressive renal cell carcinoma that demanded an iliac vein-to-right atrium bypass after inferior vena cava ligation during a previous attempt at curative resection with nephrectomy and caval thrombectomy.

Renal cell carcinoma and tumour thrombus in the inferior vena cava: clinical outcome of 98 consecutive patients and the prognostic value of preoperative parameters

OBJECTIVES

To evaluate the outcome of patients after nephrectomy and removal of tumour thrombus and to assess the prognostic value of preoperative parameters.

PATIENTS AND METHODS

Ninety-eight patients who were surgically treated between 2002 and 2011 were included. Patients' charts were reviewed, and patients with renal cell carcinoma (RCC) and concomitant tumour thrombus in the renal vein (RV) were compared with those with extended inferior vena cava (IVC) thrombus. Wilcoxon rank-sum test, Kaplan-Meier analysis and uni- and multivariate Cox regression analysis were used for statistical evaluation.

RESULTS

Follow-up was 36 months (20-122 months), and 5-year disease-specific survival (DSS) and overall survival were 68.4 and 54.1 %, respectively. Patients with extended thrombus (levels 2-4) had higher intraoperative transfusion rates of concentrated red cells (CRC) and fresh-frozen plasma (FFP) compared with patients with thrombus confined to the RV (CRC: 5.8 vs. 1.5, p < 0.0001; FFP: 2.3 vs. 0.4, p = 0.0032). Surgery time (190 vs. 107 min, p < 0.0001), duration of hospitalisation (16 vs. 11 days, p = 0.0269), serum phosphate (3.64 vs. 3.29 mmol/l, p = 0.0369) and CRP levels (6.7 vs. 4.4 mg/dl, p = 0.0194) as well as aPTT were increased (33.7 vs. 29.6 s, p = 0.0059) in extended thrombus disease. In multivariate analysis, the presence of distant metastasis (p = 0.03) and lymphovascular invasion (p = 0.001), high platelet counts (p = 0.001) and high serum potassium levels (p = 0.032) proved to be independent prognostic factors.

CONCLUSION

The surgical treatment of RCC with tumour thrombus in the RV or IVC has favourable results. Extended thrombus disease requires multidisciplinary approach. High serum potassium levels and platelet counts are associated with reduced DSS.

Impact of miR-21, miR-126 and miR-221 as prognostic factors of clear cell renal cell carcinoma with tumor thrombus of the inferior vena cava

Clear cell renal cell carcinoma (ccRCC) characterized by a tumor thrombus (TT) extending into the inferior vena cava (IVC) generally indicates poor prognosis. Nevertheless, the risk for tumor recurrence after nephrectomy and thrombectomy varies. An applicable and accurate prediction system to select ccRCC patients with TT of the IVC (ccRCC/TT) at high risk after nephrectomy is urgently needed, but has not been established up to now. To our knowledge, a possible role of microRNAs (miRs) for the development of ccRCC/TT or their impact as prognostic markers in ccRCC/TT has not been explored yet. Therefore, we analyzed the expression of the previously described onco-miRs miR-200c, miR-210, miR-126, miR-221, let-7b, miR-21, miR-143 and miR-141 in a study collective of 74 ccRCC patients. Using the expression profiles of these eight miRs we developed classification systems that accurately differentiate ccRCC from non-cancerous renal tissue and ccRCC/TT from tumors without TT. In the subgroup of 37 ccRCC/TT cases we found that miR-21, miR-126, and miR-221 predicted cancer related death (CRD) accurately and independently from other clinico-pathological features. Furthermore, a combined risk score based on the expression of miR-21, miR-126 and miR-221 was developed and showed high sensitivity and specificity to predict cancer specific survival (CSS) in ccRCC/TT. Using the combined risk score we were able to classify ccRCC/TT patients correctly into high and low risk cases. The risk stratification by the combined risk score (CRS) will benefit from further cohort validation and might have potential for clinical application as a molecular prediction system to identify high- risk ccRCC/TT patients.

Recurrent intravenous leiomyosarcoma of the uterus in the retrohepatic vena cava

Although intravenous extension of uterine leiomyosarcomas has been described, extension into the inferior vena cava (IVC) and right atrium, so-called ‘intravenous leiomyosarcomatosis (IVLS)’, is rare. To our knowledge only a few cases have been described in the literature. We describe a case of recurrent uterine leiomyosarcoma to the retrohepatic IVC. The patient was initially treated with total abdominal hysterectomy. Follow-up computed tomography a year later showed an extensive intravascular and intracardiac soft tissue mass treated with tumor extraction using cardiac bypass. Five years later she presented to our institution with a new retrohepatic caval mass treated with surgical resection and caval grafting. IVLS is a rare disease that is best treated with surgical resection even in the recurrent setting. The role of adjuvant therapy remains unclear.

Landmarks in the diagnosis and treatment of renal cell carcinoma

The most common renal cancer is renal cell carcinoma (RCC), which arises from the renal parenchyma. The global incidence of RCC has increased over the past two decades by 2% per year. RCC is the most lethal of the common urological cancers: despite diagnostic advances, 20-30% of patients present with metastatic disease. A clearer understanding of the genetic basis of RCC has led to immune-based and targeted treatments for this chemoresistant cancer. Despite promising results in advanced disease, overall response rates and durable complete responses are rare. Surgery remains the main treatment modality, especially for organ-confined disease, with a selective role in advanced and metastatic disease. Smaller tumours are increasingly managed with biopsy, minimally invasive interventions and surveillance. The future promises multimodal, integrated and personalized care, with further understanding of the disease leading to new treatment options.

Cardiopulmonary bypass with brain perfusion for renal cell carcinoma with caval thrombosis

AIM: To compare a modified technique preserving brain circulation during cardiopulmonary by-pass (CPB) for radical nephrectomy and caval thrombectomy, to the standard technique.

METHODS: Retrospective evaluation of an institutional database that collects the data of patients submitted to nephrectomy and removal of caval thrombosis with CPB since 1998. In period between 1998 and 2007, CPB followed a standard technique (group sCPB); then, since 2008, a variation in the perfusional technique was introduced, allowing the anterograde perfusion of brain circulation during circulatory arrest (group CPB + BP) with the aim to reduce the risk of ischemic damage to the brain and also the need of deeper hypothermia. Patients (age, gender, comorbidity) and tumor characteristics (side, histology, staging, level of thrombosis), as well as parameters of CPB (times of CPB, aortic clamping and circulatory arrest, minimum temperature reached during hypothermia), intra- and perioperative morbidity (complications in general, bleeding, renal and hepatic failure) and mortality were analyzed and compared between 2 groups (sCPB vs CPB + BP)

RESULTS: The data of 24 patients, respectively 9 in sCPB group and 15 in CPB + BP group, have been reviewed. No differences in the characteristics of patients and tumors were observed. Only 1 (11.1%) and 4 (26.0%) of sCPB and CPB + BP patients, respectively, didn’t experience any event of complication. In sCPB group were observed 15 events of complication (5 of which Clavien ≥ 3, 33% of the events), for a mean of 1.66 events/patient; 29 events (10 Clavien ≥ 3, 30.3%), in the CPB + BP group, for a mean of 2.1 events/patient. 1 (11.1%) and 2 (14.2%) deaths occurred, respectively. For patients submitted to CPB + BP, the minimum temperature reached was significantly higher (29.9 °C vs 26.4 °C, P = 0.001), the time of circulatory arrest was longer (17.4 min vs 13.7 min, NS), but the overall time of CPB shorter (76.1 min vs 92.5 min, NS), albeit these latter differences were not statistically significant. No differences in terms of bleeding, impairment of renal function (post-operative Cr > 2.0 mg/dL respectively in 44.4% vs 35.7% of cases, in the two groups, NS) or hepatic insufficiency (post-operative GOT or GPT > 50 U/L respectively in 44.4% and 66.7% of patients, NS) were noted. Average follow-up was 51 mo in patients undergoing a sCPB and 12 mo in the CPB + BP group of patients; at the last follow-up, 7 patients had died of progression of the condition (4 in the first group and 3 in the second group, respectively), 7 were alive in progression and 10 had no evidence of the disease.

CONCLUSION: The perfusional technique that maintains brain perfusion during circulatory arrest limits hypothermia and lowers time of CPB, without rising the risk of renal and hepatic injury.

Surgical management of renal cell carcinoma

Surgical resection of renal cell carcinoma (RCC) is the benchmark for long-term cure of the disease. Although open or laparoscopic radical nephrectomy is considered the gold standard for stage T1b-T4 tumors, nephron-sparing surgery is the preferred operative modality for small renal masses demonstrating equivalent oncologic efficacy and improved renal function outcomes compared with complete nephrectomy. With the advance of minimally invasive surgery, nephron-sparing procedures can safely be conducted laparoscopically with or without robotic assistance. RCC with intravenous tumor thrombus presents a surgical challenge, but multidisciplinary surgical approaches can provide long-term benefit in these patients. The role of cytoreductive nephrectomy and metastasectomy in patients with metastatic RCC (mRCC) is controversial, but seems to be beneficial for patients in the era of targeted therapy.

Pre-operative risk stratification for cancer-specific survival in patients with renal cell carcinoma with venous involvement who underwent nephrectomy

OBJECTIVE

The aim of this study is to identify the pre-operative prognostic factors and create a risk stratification model for patients with renal cell carcinoma with extension into the renal vein or inferior vena cava.

METHODS

The study cohort included 61 patients with renal cell carcinoma extending into the renal vein or inferior vena cava that underwent operations between 1993 and 2012. Cancer-specific survival rates were estimated, and univariate and multivariate analyses were carried out to determine the prognostic factors. A simple risk stratification model was developed for these patients.

RESULTS

The median follow-up period of the current patient cohort was 33.7 months. Their 1, 3 and 5-year cancer-specific survival were 89, 70 and 65%, respectively. On multivariate analysis, the level of tumor thrombus extension (extension into the supradiaphragm), presence of distant metastasis and elevation of lactate dehydrogenase and C-reactive protein were independent negative prognostic factors for cancer-specific survival. Cancer-specific survival rates were clearly discriminated by the stratification according to the scoring model (P < 0.001). The concordance index of the new model was 0.80.

CONCLUSIONS

We demonstrated a simple risk stratification model with four pre-operative independent prognostic factors for patients with renal cell carcinoma with venous involvement. This may be a useful decision-making model in the management of such patients.

Oncologic outcomes following surgical resection of renal cell carcinoma with inferior vena caval thrombus extending above the hepatic veins: a contemporary multicenter cohort

PURPOSE

Suprahepatic inferior vena caval tumor thrombus in renal cell carcinoma cases has historically portended a poor prognosis. With advances in perioperative treatment of patients with high level thrombus contemporary outcomes are hypothesized to be improved. We evaluated long-term oncologic outcomes of contemporary surgical treatment of patients with renal cell carcinoma in whom level III-IV inferior vena caval thrombus was managed at high volume centers.

MATERIALS AND METHODS

We examined clinical and pathological data on patients with renal cell carcinoma and level III-IV thrombus treated with surgery from January 2000 to June 2013 at 4 tertiary referral centers. Survival outcomes and associated prognostic variables were assessed by Kaplan-Meier and multivariate Cox regression analyses.

RESULTS

We identified 166 patients, including 69 with level III and 97 with level IV thrombus. Median postoperative followup was 27.8 months. Patients with no evidence of nodal or distant metastasis (pN0/X, M0) had 5-year 49.0% cancer specific survival and 42.2% overall survival. There was no difference in survival based on tumor thrombus level or pathological tumor stage. Variables associated with an increased risk of death from kidney cancer on multivariate analysis were regional nodal metastases (HR 3.94, p <0.0001), systemic metastases (HR 2.39, p = 0.01), tumor grade 4 (HR 2.25, p = 0.02), histological tissue necrosis (HR 3.11, p = 0.004) and increased preoperative serum alkaline phosphatase (HR 2.30, p = 0.006).

CONCLUSIONS

Contemporary surgical management achieves almost 50% 5-year survival in patients without metastasis who have renal cell carcinoma thrombus above the hepatic veins. Factors associated with increased mortality included nodal/distant metastases, advanced grade, histological necrosis and increased preoperative serum alkaline phosphatase. These findings support an aggressive surgical approach to the treatment of patients with renal cell carcinoma who have advanced tumor thrombus.

Prognostic factor for Korean patients with renal cell carcinoma and venous tumor thrombus extension: application of the new 2009 TNM staging system

PURPOSE

To study the surgical outcomes of radical nephrectomy with thrombectomy and to determine prognostic factors for survival of Korean patients with renal cell carcinoma (RCC) and venous tumor thrombus.

MATERIALS AND METHODS

A total of 124 patients with RCC and venous tumor thrombus who underwent radical nephrectomy and thrombectomy were included in this retrospective study. Cancer-specific survival (CSS) and recurrence-free survival (RFS) rates were analyzed retrospectively according to various prognostic factors.

RESULTS

The median overall follow-up period for all patients was 29.0 months; the median survival period was 50.0 months. The 2-, 5- and 10-year CSS rates for all patients were 64.2%, 47.1% and 31.7%, respectively. Those for 76 patients (pN0/xM0) without metastasis at presentation were 80.9%, 64.5% and 44.9%, respectively. For all patients, lower body mass index (BMI), higher Fuhrman grade, presence of symptoms, perinephric fat invasion, invasion of inferior vena cava (IVC) wall, lymph node (LN) involvement and distant metastasis at presentation were independent predictors for decreased CSS on multivariate analysis, while thrombus level was not. For non-metastatic patients, lower BMI, presence of symptoms and tumor size were independently associated with decreased CSS. In terms of RFS, lower BMI, presence of perinephric fat invasion were prognostic factors for recurrence.

CONCLUSIONS

Our data suggest that obesity is independently associated with better survival or lower risk of tumor recurrence in Korean patients undergoing radical nephrectomy with tumor thrombectomy. Also, our results indicate that Fuhrman grade, presence of symptoms, perinephric fat invasion and invasion of IVC wall, LN involvement and distant metastasis at presentation are independent predictors for survival.

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

BACKGROUND

Management of renal cell carcinoma (RCC) with tumor thrombus extending to the renal vein and inferior vena cava (IVC) is challenging. The aim of this study was to evaluate the benefit of surgical management in such patients.

METHODS

From February 1995 to February 2013, 520 patients were treated for RCC at Hirosaki University Hospital, Hirosaki, Japan. The RCC patients with tumor thrombus extending to the renal vein (n = 42) and IVC (n = 43) were included in this study. The records of these 85 patients were retrospectively reviewed to assess the relevant clinical and pathological variables and survival. Prognostic factors were identified by multivariate analysis. The benefit of surgical management was evaluated using propensity score matching to compare overall survival between patients who received surgical management and those who did not.

RESULTS

RCC was confirmed by pathological examination of surgical or biopsy specimens in 74 of the 85 patients (87%). Sixty-five patients (76%) received surgical management (radical nephrectomy with thrombectomy). Distant metastasis was identified in 45 patients (53%). The proportion of patients with tumor thrombus level 0 (renal vein only), I, II, III, and IV was 49%, 13%, 18%, 14%, and 5%, respectively. The estimated 5-year overall survival rate was 70% in patients with thrombus extending to the renal vein and 23% in patients with thrombus extending to the IVC. Multivariate analysis identified thrombus extending to the IVC, presence of distant metastasis, surgical management, serum albumin concentration, serum choline esterase concentration, neutrophil-lymphocyte ratio, and Carlson comorbidity index as independent prognostic factors. In propensity score-matched patients, overall survival was significantly longer in those who received surgical management than those who did not.

CONCLUSIONS

Surgical management may improve the prognosis of RCC patients with thrombus extending to the renal vein and IVC.

Impacts of clinicopathologic and operative factors on short-term and long-term survival in renal cell carcinoma with venous tumor thrombus extension: a multi-institutional retrospective study in Japan

BACKGROUND

Although the percentage of patients with renal cell carcinoma (RCC) extending into venous systems is unexpectedly high, the prognostic impact and independency of venous tumor thrombus-related factors on overall survival (OS) remain controversial. Furthermore, the prognostic impact of various clinicopathologic factors including tumor thrombus-related factors on OS may change with elapsed years after the intervention and also with follow-up duration of participants. The aim of the study is to explore independent and universal predictive preoperative and intraoperative clinicopathologic factors on OS in patients with RCC extending into venous systems using subgroup analysis in terms of restricted follow-up duration and yearly-based survivors.

METHODS

Between 1980 and 2009, 292 patients diagnosed with RCC with venous tumor thrombus were retrospectively registered for this study. The prognostic impacts of various clinicopathologic and surgical treatment factors including levels of venous thrombus, venous wall invasion status and likelihood of aggressive cytoreductive operation, were investigated using Kaplan-Meier method and following multivariate Cox proportional hazards model for all patients and those still alive at 1, 2, and 3 years of follow-up. To investigate the impact of follow-up duration on the statistical analyses, multivariate logistic regression analyses were used to explore prognostic factors using restricted data until 1, 2, and 3 years of follow-up.

RESULTS

The median follow-up duration was 40.4 months. The 5-year OS was 47.6%. Several independent predictive factors were identified in each subgroup analysis in terms of yearly-based survival and restricted follow-up duration. The presence of tumor thrombus invading to venous wall was independently related to OS in the full-range follow-up data and in survivors at 2 and 3 years of follow-up. Using restricted follow-up data until 1, 2, and 3 years of follow-up, many independent predictive factors changed with follow-up duration, but surgical category could be universal and independent predictive factors.

CONCLUSION

The most universal factors affecting improvement both in short-term and long-term survivals could be cytoreductive surgery and absence of venous wall invasion. It may mean that feasible aggressive cytoreductive operation following more reliable preoperative imaging for predicting venous wall invasion status would improve OS for patients with RCC extending into venous systems.

Impact of histologic subtype on cancer-specific survival in patients with renal cell carcinoma and tumor thrombus

BACKGROUND

Although different prognostic factors for patients with renal cell carcinoma (RCC) and vena cava tumor thrombus (TT) have been studied, the prognostic value of histologic subtype in these patients remains unclear.

OBJECTIVE

We analyzed the impact of histologic subtype on cancer-specific survival (CSS).

DESIGN, SETTINGS, AND PARTICIPANTS

We retrospectively analyzed the records of 1774 patients with RCC and TT who underwent radical nephrectomy and tumor thrombectomy from 1971 to 2012 at 22 US and European centers.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Multivariable ordered logistic and Cox regression models were used to quantify the impact of tumor histology on CSS.

RESULTS AND LIMITATIONS

Overall 5-yr CSS was 53.4% (confidence interval [CI], 50.5-56.2) in the entire group. TT level (according to the Mayo classification of macroscopic venous invasion in RCC) was I in 38.5% of patients, II in 30.6%, III in 17.3%, and IV in 13.5%. Histologic subtypes were clear cell renal cell carcinoma (cRCC) in 89.9% of patients, papillary renal cell carcinoma (pRCC) in 8.5%, and chromophobe RCC in 1.6%. In univariable analysis, pRCC was associated with a significantly worse CSS (p<0.001) compared with cRCC. In multivariable analysis, the presence of pRCC was independently associated with CSS (hazard ratio: 1.62; CI, 1.01-2.61; p<0.05). Higher TT level, positive lymph node status, distant metastasis, and fat invasion were also independently associated with CSS.

CONCLUSIONS

In our multi-institutional series, we found that patients with pRCC and vena cava TT who underwent radical nephrectomy and tumor thrombectomy had significantly worse cancer-specific outcomes when compared with patients with other histologic subtypes of RCC. We confirmed that higher TT level and fat invasion were independently associated with reduced CSS.

Renal mass with caval thrombus as atypical presentation of xantogranulomatous pyelonephritis. A case report and literature review

INTRODUCTION

Xantogranulomatous pyelonephritis is a rare, severe, chronic renal infection typically resulting in diffuse renal destruction. Enlarged kidney is typical radiological finding. In this work we describe an extremely rare case in which a clinically classified cT3b Tumor (level II IVC thrombus) was detected; at specimen analysis to be xantogranulomatous pyelonephritis with IVC extension.

MATERIAL AND METHOD

U.V., female, 86 years old, we diagnosed with right renal mass, with extension to IVC. By pathological analysis, it was found that renal mass and the thrombus was not due to RCC, but by xantogranulomatous pyelonephritis.

DISCUSSION

Xantogranulomatous pyelonephritis with IVC thrombus is exceptional and has been described in 4 cases. Such a diagnosis could have anesthesiologic importance, in particular related to antimicrobial treatment. Xantogranulomatous pyelonephritis has its own classification, based on extension and organ involvement, but this case fall out of current classification.

CONCLUSION

This possibility could be suspected and updating of disease's classification could be suggested.

Renal cell carcinoma with tumor-thrombus extension into the right ventricle

Renal cell carcinoma is a tumor with the distinct feature that it can invade through the renal vein into the inferior vena cava, and can grow intravascularly, sometimes extending into right cardiac chambers. Surgical resection provides the only reasonable chance for a cure, and cardiopulmonary bypass with hypothermic circulatory arrest is used to resect an intracardiac extension of the tumor because the tumor-thrombus adhered strongly to the hepatic vein and to the endocardium of the right atrium (RA). We present 2 patients, with renal cell carcinoma extending into the right ventricle, who have lived for more than five years after the operation.

Management of locally advanced renal cell carcinoma with invasion of the duodenum

Renal cell carcinoma (RCC) is rare but aggressive, with greater than 20% of patients presenting with stage III or IV, disease. Surgical resection of the primary tumor regardless of stage is the treatment of choice, and en bloc resection of involved organs provides the only potential chance for cure. This case report describes a patient with metastatic right-sided RCC with invasion of the inferior vena cava and duodenum managed by en block resection and pancreaticoduodenectomy. This report will review the workup and treatment of locally advanced RCC, as well as the role of cytoreductive nephrectomy in the setting of metastatic disease.

Neoadjuvant targeted therapy in a primary metastasized renal cell cancer patient leads to down-staging of inferior vena cava thrombus (IVC) enabling a cardiopulmonary bypass-free tumor nephrectomy: a case report

BACKGROUND

We report on a 62-year-old gentleman presenting at our urological department with an advanced renal cell cancer of the right kidney (10 cm in diameter), with an extensive caval vein thrombus (level IV) and bilateral pulmonary metastases. Another suspicious lesion at the left hemithorax was radiologically described.

METHOD

A presurgical, neoadjuvant systemic therapy with sunitinib, a tyrosine kinase inhibitor, was initiated for 4 cycles in total (50 mg/day; 4 weeks on/2 weeks off). The cytoreductive nephrectomy was performed following the fourth cycle of sunitinib and after a 14-day break. Transesophageal echocardiography was used for intraoperative monitoring of the caval vein thrombus. Systemic treatment with sunitinib was continued 4 weeks after surgery.

RESULTS

A significant reduction in tumor size, metastatic sites and down-staging of IVC from level IV to level III according to Novick classification was achieved.

CONCLUSION

Significant down-staging of the tumor caval vein thrombus which initially reached the right atrium enabled us to perform surgery limited to the abdominal cavity without extracorporeal circulation nor hypothermia.

Type II papillary histology predicts poor outcome in patients with renal cell carcinoma and vena cava thrombus

What's known on the subject? and What does the study add? In patients with pRCC, the presence of venous tumour thrombus is known to be a predictor of poorer outcomes. However, a paucity of data is available regarding the prognostic significance of histology in patients with RCC and IVC thrombus. In our series, we found that patients with type II pRCC had significantly poorer outcomes when compared to those with cRCC. Although the lack of effective treatment for patients with metastatic pRCC may have contributed to these adverse outcomes, type II papillary histology was independent predictor not only of CSS but also of RFS.

OBJECTIVE

• To analyze the prognostic impact of papillary histology on oncological outcomes in patients with renal cell carcinoma (RCC) and inferior vena cava (IVC) thrombus.

PATIENTS AND METHODS

• We reviewed the medical records of 74 patients who underwent radical nephrectomy and IVC thrombectomy between 1990 and 2010 for clear cell or papillary RCC. • We compared the clinicopathological features and clinical outcomes of 62 patients with clear cell RCC (cRCC) and 12 with papillary RCC (pRCC). • All cases of pRCC were subdivided into type I or type II. • The prognostic role of papillary histology on recurrence-free survival (RFS) and cancer-specific survival (CSS) was estimated using Cox's regression models.

RESULTS

• Upon reclassification of the pRCC subtype, all 12 patients with pRCC had type II tumours. • Patients with type II pRCC were significantly younger (P=0.028) and were more probably women (P=0.025) than those with cRCC • The 2- and 5-year CSS rates were 81.1% and 53.6% in cRCC patients, and 28.1% and 0% in type II pRCC patients, respectively. All eight patients with non-metastatic type II pRCC developed disease recurrence at a median interval of 6 months after surgery, whereas 25 of 44 (56.8%) patients with non-metastatic cRCC experienced such recurrence at a median interval of 10 months after surgery. • Patients with type II pRCC showed significantly lower CSS (P<0.001) and RFS (P=0.002) than those with cRCC. • On multivariate analysis, type II papillary histology was an independent predictor of CSS (hazard ratio, 3.73; P=0.003) and RFS (hazard ratio, 3.15; P=0.015).

CONCLUSIONS

• Type II papillary histology appears to be predominant in cases of pRCC with IVC thrombus. •  Patients with type II pRCC who presented with IVC thrombus had significantly worse outcomes than those with cRCC, and histology is an important prognostic factor in patients with RCC and IVC thrombus.

Tumor thrombus of inferior vena cava in patients with renal cell carcinoma - clinical and oncological outcome of 50 patients after surgery

Background

To evaluate oncological and clinical outcome in patients with renal cell carcinoma (RCC) and tumor thrombus involving inferior vena cava (IVC) treated with nephrectomy and thrombectomy.

Methods

We identified 50 patients with a median age of 65 years, who underwent radical surgical treatment for RCC and tumor thrombus of the IVC between 1997 and 2010. The charts were reviewed for pathological and surgical parameters, as well as complications and oncological outcome.

Results

The median follow-up was 26 months. In 21 patients (42%) distant metastases were already present at the time of surgery. All patients underwent radical nephrectomy, thrombectomy and lymph node dissection through a flank (15 patients/30%), thoracoabdominal (14 patients/28%) or midline abdominal approach (21 patients/42%), depending upon surgeon preference and upon the characteristics of tumor and associated thrombus. Extracorporal circulation with cardiopulmonary bypass (CPB) was performed in 10 patients (20%) with supradiaphragmal thrombus of IVC. Cancer-specific survival for the whole cohort at 5 years was 33.1%. Survival for the patients without distant metastasis at 5 years was 50.7%, whereas survival rate in the metastatic group at 5 years was 7.4%. Median survival of patients with metastatic disease was 16.4 months.

On multivariate analysis lymph node invasion, distant metastasis and grading were independent prognostic factors. There was no statistically significant influence of level of the tumor thrombus on survival rate. Indeed, patients with supradiaphragmal tumor thrombus (n = 10) even had a better outcome (overall survival at 5 years of 58.33%) than the entire cohort.

Conclusions

An aggressive surgical approach is the most effective therapeutic option in patients with RCC and any level of tumor thrombus and offers a reasonable longterm survival. Due to good clinical and oncological outcome we prefer the use of CPB with extracorporal circulation in patients with supradiaphragmal tumor thrombus. Cytoreductive surgery appears to be beneficial for patients with metastatic disease, especially when consecutive therapy is performed. Although sample size of our study cohort is limited consistent with some other studies lymph node invasion, distant metastasis and grading seem to have prognostic value.

Preoperative metastatic status, level of thrombus and body mass index predict overall survival in patients undergoing nephrectomy and inferior vena cava thrombectomy

Study Type - Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Little is known about the prognostic impact of body mass index (BMI) and obesity on patients with locally advanced kidney cancer. Previous studies suggest that clinical/pathological stage, the proximal extent of the tumour thrombus, direct vascular wall invasion, and preoperative performance status may all constitute important prognostic factors within this patient population. The present study shows that a patient's metastatic status, higher level of tumour thrombus, and lower BMI all constitute adverse predictors of overall survival in patients who have RCC with inferior vena cava tumour thrombus.

OBJECTIVE

•  To determine which clinical variables, including body mass index (BMI), predict overall survival (OS) after nephrectomy with inferior vena cava (IVC) thrombectomy for renal cell carcinoma (RCC) with tumour thrombus.

PATIENTS AND METHODS

•  After institutional review board approval, a retrospective analysis of all patients (N= 100) undergoing nephrectomy and IVC thrombectomy for RCC from 1989 to 2010 were reviewed. One patient was excluded owing to missing clinical information leaving 99 patients in the study cohort. •  Patients were placed into one of two subgroups, based on their preoperative BMI (BMI ≤30 kg/m(2) or BMI >30 kg/m(2) ). •  Complications, blood loss, level of tumour thrombus, side of tumour and follow-up data were tabulated.

RESULTS

•  Fifty-six patients had a BMI ≤30 kg/m(2) and 43 patients had a BMI >30 kg/m(2) . Intraoperative complications occurred in 14% of those with BMI >30 kg/m(2) and 5.4% of those with a BMI ≤30 kg/m(2) (P= 0.171). •  On multivariate analysis, a higher thrombus level (III/IV vs I/II) and the presence of metastatic disease at time of diagnosis was associated with a worse OS (P= 0.041 and P < 0.001, respectively). •  The subgroup with a higher preoperative BMI had a significantly better OS (hazard ratio 0.42; 95% confidence interval 0.22-0.80, P= 0.009). •  Similarly, our Kaplan-Meier survival analysis showed an improved OS in the patient cohort with a BMI >30 kg/m(2) (P= 0.016).

CONCLUSION

•  Important predictors of outcome in patients undergoing nephrectomy with IVC thrombectomy for RCC with tumour thrombus include preoperative BMI, level of IVC tumour thrombus, and metastatic status at time of surgery.

Recurrence pattern in patients with locally advanced renal cell carcinoma: The implications of clinicopathological variables

Objectives

Recurrence rates for patients with locally advanced renal cell carcinoma (LARCC) remain high. To date the predictors of recurrence in those patients remain controversial. The aim of the present study was to assess the relapse pattern in those patients and identify predictors for recurrence.

Patients and methods

We evaluated retrospectively 112 consecutive patients who underwent surgery for LARCC (T3–T4N0M0) between January 2000 and December 2010. Clinical and pathological data were collected from hospital medical records and compiled into a computerized database. Studied variables were age, mode of presentation, Tumour-Node-Metastasis (TNM) stage, Fuhrman nuclear grade, histological subtype, tumour size, venous thrombus level, collecting-system invasion and sarcomatoid differentiation. Recurrence-free survival (RFS) was estimated using the Kaplan–Meier method. Univariate and multivariate analyses were conducted.

Results

Patients were followed for a mean and median follow-up of 33 and 24 months, respectively, after surgery. During the follow-up, recurrences (distant and/or local) were recorded in 58 patients, representing 52% of the cohort. The mean and median times to recurrence were 25 and 13 months, respectively. Sites of recurrence were multiple in 36 patients (62%), lung only in 14 (24%), and local in eight (14%). RFS rates at 1, 2, and 5 years were 50%, 43% and 34%, respectively, while the median RFS was 23.7 months. Using univariate analysis, RFS after nephrectomy was significantly shorter in patients aged <70 years, symptomatic at presentation, with larger tumours, higher nuclear grade, collecting-system invasion, and/or sarcomatoid differentiation. After multivariate analysis, T-stage, nuclear grade and sarcomatoid differentiation retained their power as independent predictors of RFS (P = 0.032, <0.001 and 0.003, respectively).

Conclusions

For patients with LARCC, T-stage, grade and sarcomatoid differentiation independently dictate the risk of tumour recurrence. Considering these variables in the postoperative surveillance protocols and in the need for a multimodal therapeutic approach is highly recommended.

[Prognostic value of venous tumor thrombus in renal cell carcinoma]

OBJECTIVE

To evaluate the prognostic value of venous tumor thrombus in renal cell carcinoma.

MATERIAL AND METHODS

A retrospective study of 167 patients with renal cell carcinoma and stage pT3 who underwent radical nephrectomy and extended lymphadenectomy from July 1969 to May 2008 was conducted. Patients with any kind of venous involvement were selected for the analysis (73 patients; 43.7%). The Kaplan Meier survival curves and log-rank test for comparisons were used for the survival analysis. Multivariate analysis was done by Cox regression.

RESULTS

Lymph node involvement was present in 30 patients (41.1%) and metastatic disease in 9 patients (12.3%). The most frequent histologic renal cell carcinoma subtype was 50 (68.5%) conventional carcinoma, followed by nondifferentiated in 11 (15.5%), and chromophobe in 9 (12.3%). High grade tumors (Furhman 3-4) were present in 57% of the cases. Venous thrombus level extended to renal vein in 61 patients (83.6%), to inferior vena cava in 9 patients (12.3%) and to the cardiac right atrium in 3 cases (4.1%). The survival analysis showed worse survival in those patients with venous tumor thrombosis (p=.001) and with vein wall invasion (p=.0042), but not in function on the level of the thrombus (p=.12). The multivariate analysis identified the Furhman grade and venous tumor thrombosis as independent survival prognostic factors.

CONCLUSIONS

In our series, venous tumor thrombosis, together with the Furhman nuclear grade, is an independent survival prognostic factor. However, neither cephalic extension of the thrombus nor the invasion of the vein wall showed independent prognostic value.

International consultation on urologic diseases and the European Association of Urology international consultation on locally advanced renal cell carcinoma

CONTEXT

Although an ever-increasing number of patients are being incidentally diagnosed with small renal masses, there is still a sizable portion of patients with renal cell carcinoma (RCC) who present with locally advanced or metastatic disease. Those with locally advanced disease present a challenge because they may be difficult to distinguish from those with organ-confined disease at the time of diagnosis. However, this distinction is important because they may require a different management strategy. These advanced RCC patients include those with venous tumour thrombi, extracapsular tumour extension, adjacent organ involvement, as well as nodal disease.

EVIDENCE ACQUISITION

A thorough literature search of the following terms was undertaken: advanced renal cell carcinoma, renal cell carcinoma venous tumour thrombi, renal cell carcinoma extra-capsular extension, renal cell carcinoma nodal metastasis, and locally recurrent renal cell carcinoma. An international expert panel convened by the International Consultation on Urologic Diseases and the European Association of Urology reviewed these articles.

EVIDENCE SYNTHESIS

Review of the available literature allowed for assessment of the level of evidence for the diagnosis, management, and therapy of locally advanced RCC with the ultimate goal of providing a synthesis of this information with a consensus statement from leaders in the field.

CONCLUSIONS

Despite the advances in prognostic markers and targeted molecular therapies for RCC, currently the only curative treatment for locally advanced RCC is aggressive surgical resection.