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Taweemonkongsap T, Suk-Ouichai C, Jitpraphai S, Woranisarakul V, Hansomwong T, Chotikawanich E. Survival benefits after radical nephrectomy and IVC thrombectomy of renal cell carcinoma patients with inferior vena cava thrombus. Heliyon 2024; 10:e25835. [PMID: 38390094 PMCID: PMC10881333 DOI: 10.1016/j.heliyon.2024.e25835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/15/2023] [Accepted: 02/02/2024] [Indexed: 02/24/2024] Open
Abstract
Objective The role of tumor thrombus as a predictor of survival in patients with renal cell carcinoma (RCC) is controversial. This study aims to evaluate surgical and oncological outcomes after surgery in RCC with inferior vena cava (IVC) tumor thrombus patients. Materials and methods A total of 58 patients (2002-2019) underwent radical nephrectomy and IVC thrombectomy at our institute, were retrospectively reviewed. Kaplan-Meier analysis was utilized to compare survival benefits between cohorts and Cox-regression to evaluate potential predictors of patient survival. Results There were 5(8.6%), 21(36.2%), 23(39.7%) and 9 (15.5%) patients with tumor thrombus level I, II, III and IV respectively. The major complications (Clavien 3-5) were observed in 15 patients (25.8%) and 12 patients (80%) were patients with high thrombus level (III-IV). There was 9%mortality (5patients): 2 intraoperatively and 3 postoperatively. Median follow-up was 15 months (IQR:5-41). Two-year overall survival (OS) was 80% and 75% in all patients and pN0M0 cohort, respectively. There was significant difference in OS among each IVC thrombus level cohort (p < 0.02). Two-year OS of metastatic RCC patients was 67% and not significantly different when compared to non-metastatic cohort (p = 0.12). On multivariate analysis, only sarcomatoid dedifferentiation was associated with OS(p = 0.04). Disease-free survival was not significantly different among thrombus-level cohorts (p = 0.65). Conclusions Our study suggested that surgical treatment for RCC with IVC thrombus provided substantial OS outcomes. Although survival was significantly reduced with higher IVC thrombus level cohort, the level of thrombus itself was not an independent factor. Only sarcomatoid dedifferentiation was a predictor for reduced OS after radical nephrectomy and tumor thrombectomy. Meticulous patient selection and prompt counselling are substantial step for the operation.
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Affiliation(s)
- Tawatchai Taweemonkongsap
- Division of Urology, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chalairat Suk-Ouichai
- Division of Urology, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Siros Jitpraphai
- Division of Urology, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Varat Woranisarakul
- Division of Urology, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thitipat Hansomwong
- Division of Urology, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ekkarin Chotikawanich
- Division of Urology, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Lewis KC, Werneburg GT, Dewitt-Foy ME, Lundy SD, Eltemamy M, Murthy PB, Przybycin CG, Campbell SC, Weight C, Krishnamurthi V. Surgical Management and Oncologic Outcomes of Renal Cell Carcinoma and Inferior Vena Caval Thrombi With Aggressive Histologic Variants. Urology 2024; 184:128-134. [PMID: 37925024 DOI: 10.1016/j.urology.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/02/2023] [Accepted: 10/18/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE To characterize the surgical management, perioperative, and cancer-specific outcomes, and the influence of aggressive histologic variants (AHV) on operative management among patients with renal cell carcinoma (RCC) and inferior vena cava (IVC) thrombus. RCC with rhabdoid and/or sarcomatoid differentiation, which we defined as AHV, portends a worse prognosis. AHV can be associated with a desmoplastic reaction which may complicate resection. METHODS We reviewed patients undergoing radical nephrectomy and IVC thrombectomy between 1990 and 2020. Comparative statistics were employed as appropriate. Survival analysis was performed according to the Kaplan-Meier method, and intergroup analysis performed with log-rank statistics. Multivariable cox proportional hazards regression was used to assess the effect of AHV, age, thrombus level, vena cavectomy, metastases, and medical comorbidities on recurrence and overall survival (OS). RESULTS Ninety-four of 403 (23.3%) patients had AHV, including 43 (46%) rhabdoid, 39 (41%) sarcomatoid, and 12 (13%) with both. AHV were more likely to present with advanced disease; however, increased perioperative complications or decreased OS were not observed. Median (IQR) survival was 16.7 (4.8-47) months without AHV and 12.6 (4-29) months with AHV (P = .157). Sarcomatoid differentiation was independently associated with worse OS (HR = 2.016, CI 1.38-2.95, P <.001), whereas rhabdoid alone or with sarcomatoid demonstrated similar OS (P = 0.063). CONCLUSION RCC and IVC thrombus with AHV are more likely to present with metastatic disease, and sarcomatoid differentiation is associated with a worse OS. Resection of tumors with and without AHV have similar perioperative complications, suggesting that surgery can be safely accomplished in patients with RCC and IVC thrombus with AHV.
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Affiliation(s)
- Kevin C Lewis
- Cleveland Clinic Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH.
| | - Glenn T Werneburg
- Cleveland Clinic Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
| | - Molly E Dewitt-Foy
- Cleveland Clinic Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
| | - Scott D Lundy
- Cleveland Clinic Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
| | - Mohamed Eltemamy
- Cleveland Clinic Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
| | - Prithvi B Murthy
- Cleveland Clinic Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
| | | | - Steven C Campbell
- Cleveland Clinic Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
| | - Christopher Weight
- Cleveland Clinic Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
| | - Venkatesh Krishnamurthi
- Cleveland Clinic Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
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Barashi NS, Friedman D, Shiang A, Pickersgill N, Vetter J, Suresh T, Ippolito JE, Smith ZL. Growth kinetics of venous tumor thrombus in patients with renal cell carcinoma. Urol Oncol 2024; 42:31.e17-31.e23. [PMID: 38160126 DOI: 10.1016/j.urolonc.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/11/2023] [Accepted: 12/02/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Some patients with renal cell carcinoma (RCC) present with venous tumor thrombus (VTT). The extent of the VTT is related to survival, so prompt surgical care is recommended. However, studies evaluating the natural history of VTT in patients with RCC are rare. We sought to evaluate the growth kinetics of VTT in patients with RCC using preoperative cross-sectional images. MATERIALS AND METHODS We identified patients who underwent radical nephrectomy and venous tumor thrombectomy at our institution from 01/2009 to 02/2022. We included those with a minimum of 2 adequate preoperative imaging studies (contrast-enhanced Computerized Tomography (CT), noncontrast Magnetic resonance imaging (MRI), or contrast-enhanced MRI), at least 14 days apart. We measured VTT in each study to calculate growth rate, and evaluated predictors of faster growth (demographics, histology, laterality, tumor diameter, and staging). To assess the relation between clinical variables and VTT growth, we used the Wilcoxon Rank-Sum, Kruskal-Wallis, and Spearman correlation tests. RESULTS A total of 30 patients were included in the analysis. The median time interval between studies was 33 days. Patients were mostly Caucasian and Males (90% and 70%, respectively). Most patients underwent a CT scan as their initial imaging study (66%), followed with an MRI as second study (73%). The mean venous tumor thrombus growth rate was 0.3 mm/d (standard deviation of 0.5mm), and only rhabdoid/sarcomatoid differentiation showed an association with tumor thrombus growth rate (0.3 vs. 0.63 mm/d, P = 0.038). CONCLUSIONS To the best of our knowledge, this is the first study evaluating the natural growth rate of venous tumor thrombus in patients with renal cell carcinoma. We found that tumor thrombi grew an average of 0.3 mm/d (1.0 cm/month) and that those with sarcomatoid and/or rhabdoid differentiation grew faster (0.63 mm/d). Further studies are needed to validate these results and provide a better understanding of tumor thrombus kinetics.
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Affiliation(s)
- Nimrod S Barashi
- Division of Urologic Surgery, Department of Surgery, Washington University in St. Louis, MO.
| | - Daniel Friedman
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO
| | - Alex Shiang
- Washington University in St. Louis School of medicine. St. Louis, MO
| | - Nicholas Pickersgill
- Division of Urologic Surgery, Department of Surgery, Washington University in St. Louis, MO
| | - Joel Vetter
- Division of Urologic Surgery, Department of Surgery, Washington University in St. Louis, MO
| | - Tara Suresh
- Washington University in St. Louis School of medicine. St. Louis, MO
| | - Joseph E Ippolito
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO
| | - Zachary L Smith
- Division of Urologic Surgery, Department of Surgery, Washington University in St. Louis, MO
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Gwon JG, Cho YP, Han Y, Suh J, Min SK. Technical Tips for Performing Suprahepatic Vena Cava Tumor Thrombectomy in Renal Cell Carcinoma without Using Cardiopulmonary Bypass. Vasc Specialist Int 2023; 39:23. [PMID: 37667821 PMCID: PMC10480049 DOI: 10.5758/vsi.230056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/27/2023] [Accepted: 08/02/2023] [Indexed: 09/06/2023] Open
Abstract
Radical nephrectomy with tumor thrombectomy for advanced renal cell carcinoma is an oncologically relevant approach that can achieve long-term survival even in the presence of distant metastases. However, the surgical techniques pose significant challenges. The objective of this clinical review was to present technical recommendations for tumor thrombectomy in the vena cava to facilitate surgical treatment. Transesophageal echocardiography is required to prepare for this procedure. Cardiopulmonary bypass should be considered when the tumor thrombus has invaded the cardiac chamber and clamping is not feasible because of the inability to milk the intracardiac chamber thrombus in the caudal direction. Prior to performing a cavotomy, it is crucial to clamp the contralateral renal vein and infrarenal and suprahepatic inferior vena cava (IVC). If the suprahepatic IVC is separated from the surrounding tissue, it can be gently pulled down toward the patient's leg until the lower margin of the atrium becomes visible. Subsequently, the tumor thrombus should be carefully pulled downward to a position where it can be clamped. Implementing the Pringle maneuver to reduce blood flow from the hepatic veins to the IVC during IVC cavotomy is simpler than clamping the hepatic veins. Sequential clamping is a two-stage method of dividing thrombectomy by clamping the IVC twice, first suprahepatically and then midretrohepatically. This sequential clamping technique helps minimize hypotension status and the Pringle maneuver time compared to single clamping. Additionally, a spiral cavotomy can decrease the degree of primary closure narrowing. The oncological prognoses of patients can be improved by incorporating these technical recommendations.
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Affiliation(s)
- Jun Gyo Gwon
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Pil Cho
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
| | - Youngjin Han
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
| | - Jungyo Suh
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Kee Min
- Division of Vascular Surgery, Department of Surgery, Seoul National University Hospital, Seoul, Korea
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Komarov RN, Rapoport LM, Belov YV, Germagenova EK, Chernyavskii SV, Ismailbaev AM, Tlisov BM, Zhong B, Zavaruev AV, Tsarichenko DG, Korolev DO. Surgical treatment of renal cell carcinoma with tumor thrombosis of the inferior vena cava and the right heart: How we do it. Urologia 2023:3915603221143566. [PMID: 36803097 DOI: 10.1177/03915603221143566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
OBJECTIVE Renal cell carcinoma with inferior vena cava thrombosis is a rare disease with a poor prognosis without surgical treatment. We report our 11-year experience in the surgical treatment of renal cell carcinoma with extension of the inferior vena cava. METHODS We conducted a retrospective analysis of patients undergoing surgical treatment for renal cell carcinoma with invasion of the inferior vena cava in two hospitals from May 2010 to March 2021. To assess the spread of the tumor process invasion, we used the Neves and Zincke classification. RESULTS A total of 25 people underwent surgical treatment. Sixteen patients were men, nine were women. Thirteen patients underwent cardiopulmonary bypass (CBP) surgery. The following postoperative complications were recorded: two cases of disseminate intravascular coagulation (DIC), two cases of acute myocardial infarction (MI) and one case of coma of unknown reason, Takotsubo syndrome and postoperative wound dehiscence. Three patients deceased (16.7%) of DIC syndrome and AMI. After discharge, one of the patients had a recurrence of tumor thrombosis 9 months after surgery, and another patient had the same 16 months later, presumably due to the neoplastic tissue in the adrenal gland on the contralateral side. CONCLUSION We believe that this problem should be dealt with by an experienced surgeon with a multidisciplinary team in the clinic. The use of CPB provides benefits and reduces blood loss.
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Affiliation(s)
| | | | - Yuri V Belov
- Institute of Clinical Medicine, Chair of department Hospital Surgery, Sechenov University, Moscow, Russia
| | - Ekaterina K Germagenova
- Institute of Clinical Medicine, Chair of department Hospital Surgery, Sechenov University, Moscow, Russia
| | | | | | - Boris M Tlisov
- Departament of Cardiovascular Surgery, Sechenov University, Moscow, Russia
| | - Baojun Zhong
- Departament of Cardiovascular Surgery, Sechenov University, Moscow, Russia
| | - Artem V Zavaruev
- Institute of Clinical Medicine, Department of Faculty Surgery, Sechenov University, Moscow, Russia
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Garg H, Nayak B, Kumar A, Singh P, Nayyar R, Kaul A, Seth A. Survival analysis and predictors of long-term outcomes following radical nephrectomy with inferior vena cava (IVC) thrombectomy in renal cell carcinoma. Indian J Cancer 2022; 0:348195. [PMID: 36861688 DOI: 10.4103/ijc.ijc_5_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background Renal cell carcinoma (RCC) presents with inferior vena cava (IVC) thrombus in 10%-30% cases and surgical management forms the mainstay of the treatment. The objective of this study is to assess the outcomes of the patients undergoing radical nephrectomy with IVC thrombectomy. Methods A retrospective analysis of patients undergoing open radical nephrectomy with IVC thrombectomy between 2006 till 2018 was done. Results A total of 56 patients were included. The mean (±standard deviation) age was 57.1 (±12.2) years. The number of patients with levels I, II, III, and IV thrombus were 4, 29,10, and 13, respectively. The mean blood loss was 1851.8 mL, and the mean operative time was 303.3 minutes. Overall, the complication rate was 51.7%, while the perioperative mortality rate was 8.9%. The mean duration of hospital stay was 10.6 ± 6.4 days. The majority of the patients had clear cell carcinoma (87.5%). There was a significant association between grade and stage of thrombus (P = 0.011). Using Kaplan-Meier survival analysis, the median overall survival (OS) was 75 (95% confidence interval [CI] = 43.5-106.5) months, and the median recurrence-free survival (RFS) was 48 (95% CI = 33.1-62.3) months. Age (P = 0.03), presence of systemic symptoms (P = 0.01), radiological size (P = 0.04), histopathological grade (P = 0.01), level of thrombus (P = 0.04), and invasion of thrombus into IVC wall (P = 0.01) were found to be significant predictors of OS. Conclusion The management of RCC with IVC thrombus poses a major surgical challenge. Experience of a center along with high-volume and multidisciplinary facility particularly cardiothoracic facility provides better perioperative outcome. Though surgically challenging, it offers good overall-survival and recurrence-free survival.
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Affiliation(s)
- Harshit Garg
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
| | - Brusabhanu Nayak
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Kumar
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
| | - Prabhjot Singh
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
| | - Rishi Nayyar
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
| | - Aashir Kaul
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
| | - Amlesh Seth
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
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Yang L, Fu B. Nomograms for Predicting Overall Survival and Cancer-Specific Survival of Patients With Renal Cell Carcinoma and Venous Tumor Thrombus: A Population-Based Study. Front Surg 2022; 9:929885. [PMID: 36034346 PMCID: PMC9411105 DOI: 10.3389/fsurg.2022.929885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background To provide better prognostic information for patients with renal cell carcinoma (RCC) combined with venous tumor thrombus (VTT). In turn, guide patients’ families and doctors to formulate plans for follow-up treatment and follow-up. We developed nomograms to predict cancer-specific survival (CSS) and overall survival (OS). Methods A total of 2961 cases were included in this study. Through univariate and multivariate Cox proportional hazard regression analysis, independent risk factors affecting CSS and OS were screened out, and then a nomogram was drawn based on the screened variables. Results Independent risk factors affecting CSS include: tumor size (HR = 1.05), histology (HR = 1.75), grade (HR = 1.94), N staging (HR = 2.06), and M staging (HR = 2.87). The median survival time for CSS was 106 months. Independent risk factors for OS include age (HR = 1.60), tumor size (HR = 1.04), histology (HR = 1.60), grade (HR = 1.68), N staging (HR-1.99), M staging (HR = 2.45). The median survival time for OS is 67 months. Conclusions The nomogram based on independent risk factors affecting CSS and OS can well predict the prognosis of renal cell carcinoma with venous tumor thrombus.
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Tariq A, McGeorge S, Pearce A, Rhee H, Wood S, Kyle S, Marsh P, Raveenthiran S, Wong D, McBean R, Westera J, Dunglison N, Esler R, Navaratnam A, Yaxley J, Thomas P, Pattison DA, Roberts MJ. Characterization of tumor thrombus in renal cell carcinoma with prostate specific membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT). Urol Oncol 2022; 40:276.e1-276.e9. [DOI: 10.1016/j.urolonc.2022.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/06/2022] [Accepted: 03/12/2022] [Indexed: 02/04/2023]
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Predictors of Survival in Patients Undergoing Surgery for Renal Cell Carcinoma and Inferior Vena Cava Tumor Thrombus. Clin Genitourin Cancer 2022; 20:e330-e338. [PMID: 35279419 PMCID: PMC9486579 DOI: 10.1016/j.clgc.2022.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 01/27/2022] [Accepted: 02/05/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Surgical resection of renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus is a complex procedure with significant morbidity. Patient selection is critical to determining whether the benefits of the procedure outweigh the risks. In this study, we identified and stratified the risk factors that were associated with overall survival (OS) and recurrence-free survival (RFS) in patients undergoing surgical resection of RCC with IVC thrombus. METHODS We identified all patients with RCC with IVC tumor thrombus (stages cT3b and cT3c) who had undergone radical nephrectomy with tumor thrombectomy between December 1, 1993 and June 30, 2009. Kaplan-Meier method was used to estimate OS and RFS. Cox proportional hazards models were used to determine the association between risk factors and OS. Patients were stratified into 3 groups based on the number of risk factors present at diagnosis. RESULTS Two hundred twenty-four patients were included in the study. A total of 45.3% of patients had metastasis at presentation, 84.5% had cT3b, and 90.2% had clear cell RCC. cT3c, cN1, and cM1 were significantly associated with the risk of death. Group 1 patients (0 risk factors) had a median OS duration of 77.6 months (95% CI 50.5-90.4), group 2 (1 risk factor) 26.0 months (95% CI 19.5-35.2), and group 3 (≥2 risk factors) 8.9 months (95% CI 5.2-12.9; P < .001). CONCLUSIONS Stratification of patients with RCC and IVC thrombus by risk factors allowed us to predict survival duration. In patients with ≥2 risk factors, new treatment strategies with preoperative systemic therapy may improve survival.
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Asencio JM, González J, Herranz-Amo F, Hernández-Fernández C. Retrohepatic inferior vena cava control through an anterior approach in cases of renal cell carcinoma with level IIIa tumor thrombus: Step-by-step description. Actas Urol Esp 2021; 45:587-596. [PMID: 34697007 DOI: 10.1016/j.acuroe.2021.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 04/18/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the safety and efficacy of the retrohepatic inferior vena cava control through an anterior approach (RIVCA) technique in renal cell carcinoma (RCC) with level IIIa tumor thrombus. PATIENTS AND METHODS Initial series of 6 cases presenting RCC and level IIIa tumor thrombus who underwent radical nephrectomy and tumor thrombectomy using the RIVCA technique between 2018-2019. RIVCA technique aims to gain complete control of the retrohepatic inferior vena cava above the cranial end of the tumor thrombus, but excluding the major hepatic veins in order to preserve the natural hepato-caval shunt. A step-by-step description of the procedure is provided. Disease features, operative characteristics, and surgical outcomes were registered prospectively. RESULTS Radical nephrectomy and tumor thrombectomy were completed in all cases. RIVCA technique did not increase operative time significantly (range: 14-22 min). Mean estimated blood loss was 325 cc (range: 250-400). Blood transfusion was not required intraoperatively in any of the cases. Mean postoperative transfusion rate was 1.3 red blood cells packed units (range: 0-2). There were no cases of intraoperative pulmonary embolism or major complications (Clavien-Dindo III-V) in the period of 30 days postoperatively. Median postoperative length of stay was 8 days (range: 5-11). CONCLUSIONS The RIVCA technique applied to cases of RCC and level IIIa tumor thrombus provides complete control of the retrohepatic inferior vena cava above the tumor thrombus cranial end, while prevents intraoperative hemodynamic instability by maintaining cardiac preload through the porto-caval shunt. This technique may limit operative morbidity (intraoperative pulmonary embolism and massive hemorrhage), thus becoming a helpful adjunct to be used in cases of RCC with level IIIa tumor thrombus.
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Affiliation(s)
- J M Asencio
- Sección de Cirugía Hepato-Bilio-Pancreática, Unidad de Trasplante Hepático, Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain.
| | - J González
- Servicio de Urología, Hospital Universitario Gregorio Marañón, Madrid, Spain; Unidad de Trasplante Renal, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - F Herranz-Amo
- Servicio de Urología, Hospital Universitario Gregorio Marañón, Madrid, Spain; Unidad de Trasplante Renal, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - C Hernández-Fernández
- Universidad Complutense de Madrid, Madrid, Spain; Servicio de Urología, Hospital Universitario Gregorio Marañón, Madrid, Spain
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Asencio JM, González J, Herranz-Amo F, Hernández-Fernández C. Retrohepatic inferior vena cava control through an anterior approach in cases of renal cell carcinoma with level iiia tumor thrombus: Step-by-step description. Actas Urol Esp 2021; 45:S0210-4806(21)00101-7. [PMID: 34334240 DOI: 10.1016/j.acuro.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 04/18/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the safety and efficacy of the retrohepatic inferior vena cava control through an anterior approach (RIVCA) technique in renal cell carcinoma (RCC) with level iiia tumor thrombus. PATIENTS AND METHODS Initial series of 6 cases presenting RCC and level iiia tumor thrombus who underwent radical nephrectomy and tumor thrombectomy using the RIVCA technique between 2018-2019. RIVCA technique aims to gain complete control of the retrohepatic inferior vena cava above the cranial end of the tumor thrombus, but excluding the major hepatic veins in order to preserve the natural hepato-caval shunt. A step-by-step description of the procedure is provided. Disease features, operative characteristics, and surgical outcomes were registered prospectively. RESULTS Radical nephrectomy and tumor thrombectomy were completed in all cases. RIVCA technique did not increase operative time significantly (range: 14-22min). Mean estimated blood loss was 325cc (range: 250-400). Blood transfusion was not required intraoperatively in any of the cases. Mean postoperative transfusion rate was 1.3 red blood cells packed units (range: 0-2). There were no cases of intraoperative pulmonary embolism or major complications (Clavien-Dindo III-V) in the period of 30 days postoperatively. Median postoperative length of stay was 8 days (range: 5-11). CONCLUSIONS The RIVCA technique applied to cases of RCC and level iiia tumor thrombus provides complete control of the retrohepatic inferior vena cava above the tumor thrombus cranial end, while prevents intraoperative hemodynamic instability by maintaining cardiac preload through the porto-caval shunt. This technique may limit operative morbidity (intraoperative pulmonary embolism and massive hemorrhage), thus becoming a helpful adjunct to be used in cases of RCC with level iiia tumor thrombus.
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Affiliation(s)
- J M Asencio
- Sección de Cirugía Hepato-Bilio-Pancreática, Unidad de Trasplante Hepático, Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario Gregorio Marañón, Madrid, España; Universidad Complutense de Madrid, Madrid, España.
| | - J González
- Servicio de Urología, Hospital Universitario Gregorio Marañón, Madrid, España; Unidad de Trasplante Renal, Hospital Universitario Gregorio Marañón, Madrid, España
| | - F Herranz-Amo
- Servicio de Urología, Hospital Universitario Gregorio Marañón, Madrid, España; Unidad de Trasplante Renal, Hospital Universitario Gregorio Marañón, Madrid, España
| | - C Hernández-Fernández
- Universidad Complutense de Madrid, Madrid, España; Servicio de Urología, Hospital Universitario Gregorio Marañón, Madrid, España
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Chen Z, Yang F, Ge L, Qiu M, Liu Z, Liu C, Tian X, Zhang S, Ma L. Outcomes of renal cell carcinoma with associated venous tumor thrombus: experience from a large cohort and short time span in a single center. BMC Cancer 2021; 21:766. [PMID: 34215223 PMCID: PMC8254310 DOI: 10.1186/s12885-021-08508-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 06/14/2021] [Indexed: 11/10/2022] Open
Abstract
Background The surgical management and outcomes of renal cell carcinoma (RCC) with venous tumor thrombus (VTT) have been reported in limited sample size, and there remain discrepancies over the factors that influence oncologic outcomes after radical nephrectomy with thrombectomy (RNTE). The aim of the study was to analyze the outcomes of the patients with RCC with VTT in our institution and identify the independent prognostic factors. Methods Patients with RCC with VTT were enrolled for the study from February 2015 to December 2018. All patients underwent RNTE. Clinical data were compared using Mann-Whitney U test and the chi-square test for continuous and categorical variables respectively. Survival analysis was estimated using the Kaplan-Meier method. Univariable and multivariable survival analyses were performed using Cox regression model. Results 121 patients (91 men & 30 women) were identified with a median age of 60 years. VTT level was 0 in 25 patients, I in 20, II in 50, III in 12 and IV in 14. The median follow-up time was 24 months. During the follow-up period, 51 (42%) patients died and 69 (57%) patients experienced recurrence or metastasis. The 3-year and 5-year over-all survival (OS) were 58 and 39%. Among the several factors examined, positive lymph node (P = 0.016), metastasis at surgery (P = 0.034), tumor necrosis (P = 0.023) and sarcomatoid differentiation (P < 0.001) were demonstrated as independent significant risk factors on multivariable analysis. Conclusion The OS was poor for patients with RCC with VTT. Rather than VTT level, positive lymph node, metastasis at surgery, tumor necrosis and sarcomatoid differentiation were independent prognostic predictors.
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Affiliation(s)
- Zhigang Chen
- Peking University Health Science Centre, No.49 North Garden Road, Haidian District, Beijing, P. R. China.,Department of Urology, Peking University Third Hospital, Beijing, 100191, China
| | - Feilong Yang
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China.,Department of Urology, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Liyuan Ge
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China
| | - Min Qiu
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China
| | - Zhuo Liu
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China
| | - Cheng Liu
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China
| | - Xiaojun Tian
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China
| | - Shudong Zhang
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China.
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China.
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Gritsch D, Abdallah A, Taylor AM, Mesbah Z, Demaerschalk BM. Acute Ischemic Stroke as a Result of Paradoxical Embolus in a Patient with Renal Cell Carcinoma, Intravenous Tumor Thrombus Extension, and Patent Foramen Ovale. Neurologist 2021; 25:137-140. [PMID: 32925485 DOI: 10.1097/nrl.0000000000000276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Patent foramen ovale is a common congenital cardiac abnormality. An association with acute ischemic stroke is well described. Extension of renal cell carcinoma (RCC) into the adjacent veins is common. Surgical resection is felt to be an effective approach to treatment, even in the setting of extensive venous involvement. CASE REPORT A 55-year-old woman with recently diagnosed right renal mass and cavoatrial tumor thrombus was transferred to our facility for surgical resection. She subsequently underwent open radical right nephrectomy, regional lymph node dissection, inferior vena cava and right atrial tumor thrombectomy, and resection of the infrahepatic vena cava. An intraoperative transesophageal echocardiogram confirmed the absence of tumor thrombus from the inferior vena cava and right atrium and also identified a patent foramen ovale (PFO). Upon weaning sedation, she was noted to be agitated and have left hemiplegia. Her National Institutes of Health Stroke Scale (NIHSS) was 30 and Glasgow Coma Scale (GCS) 6. The computerized tomography scan of head revealed extensive hypoattenuation right in the middle and left posterior cerebral artery territories. There was associated cerebral edema and 5-mm midline shift. In the setting of devastating neurological injury, her family elected to transition to comfort care and the patient died on the postoperative day 7. CONCLUSIONS This is the first reported case of intraoperative paradoxical embolism in the setting of RCC with cavoatrial extension and PFO. The presence of PFO may be a risk factor for severe cerebrovascular complications in the surgical management of RCC with venous involvement.
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Triple Retroaortic Renal Vein With Tumor Thrombus. Urology 2021; 154:e17-e18. [PMID: 33891926 DOI: 10.1016/j.urology.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/04/2021] [Accepted: 04/06/2021] [Indexed: 11/20/2022]
Abstract
A case report of a 51-year-old man with left renal tumor and level II vena cava tumor thrombus (thrombus extending >2 cm above the renal vein, but below the hepatic veins) in a rare anatomical variant of renal vein. In nonmetastatic patients, aggressive surgical resection is widely accepted as the standard management option, but some doubts about the best practice in these patients are relevant. Surgical approach on those patients is a challenge for the surgeons, and anatomical variants make the procedure even more difficulty. These patients should be referring to a tertiary center because of the potential perioperative complexity.
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Ghoreifi A, Djaladat H. Surgical Tips for Inferior Vena Cava Thrombectomy. Curr Urol Rep 2020; 21:51. [PMID: 33090290 DOI: 10.1007/s11934-020-01007-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to describe the preoperative evaluation, surgical techniques, and postoperative management of patients with renal cell carcinoma (RCC) undergoing radical nephrectomy (RN) and inferior vena cava (IVC) thrombectomy. RECENT FINDINGS RN and IVC thrombectomy remains the standard management option in non-metastatic RCC patients with IVC thrombus. A comprehensive preoperative workup, including high-quality imaging, blood works, and appropriate consultations are required for all patients. The aim of the surgery is complete resection of all tumor burden, which requires a skillful surgical team for such a challenging procedure and is inherently associated with a high rate of perioperative morbidity and mortality. Preoperative CT or MRI is essential for surgical planning. The surgical approach is mainly determined by the level of the tumor thrombus. The open approach has been the standard, though minimally invasive and robotic techniques are emerging in selected cases by experienced surgeons.
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Affiliation(s)
- Alireza Ghoreifi
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Ave. Suite 7416, Los Angeles, CA, 90089, USA
| | - Hooman Djaladat
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Ave. Suite 7416, Los Angeles, CA, 90089, USA.
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Przydacz M, Golabek T, Okon K, Dudek P, Chlosta P. Prognostic effect of renal collecting system invasion on survival of patients with renal cell carcinoma and tumor thrombus. Cent European J Urol 2020; 73:280-286. [PMID: 33133654 PMCID: PMC7587485 DOI: 10.5173/ceju.2020.0172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/30/2020] [Accepted: 08/30/2020] [Indexed: 11/22/2022] Open
Abstract
Introduction Urinary collecting system invasion (UCSI) has been found to have significant prognostic value for patients with renal cell carcinoma (RCC). However, for RCC patients with venous tumor thrombus (VTT), only contradictory data exist regarding the prognostic efficacy of UCSI. Therefore, the aim of this study is to assess the prognostic relevance of UCSI in survival of patients with RCC and VTT. Material and methods Medical records in a prospectively maintained institutional database were analyzed for RCC-VTT patients who had undergone nephrectomy with thrombectomy. Then, the effect of UCSI on overall survival was analyzed. Results The study examined data for 114 patients, including patients with VTT present in the renal vein (35 patients, 31%), infrahepatic inferior vena cava (28 patients, 24%), and suprahepatic inferior vena cava (51 patients, 45%). Nineteen percent of patients had UCSI. The median overall survival of patients with UCSI was 9 months, whereas median overall survival was 10 months for patients without collecting system invasion. Survival and regression analyses rejected UCSI as a prognostic marker for overall survival. Conclusions UCSI has no effect on survival in our cohort of RCC-VTT patients. Therefore, it should not be considered in risk stratification models or in treatment decision-making for this patient group.
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Affiliation(s)
- Mikolaj Przydacz
- Department of Urology, Jagiellonian University Medical College, Cracow, Poland
| | - Tomasz Golabek
- Department of Urology, Jagiellonian University Medical College, Cracow, Poland
| | - Krzysztof Okon
- Department of Pathology, Jagiellonian University Medical College, Cracow, Poland
| | - Przemyslaw Dudek
- Department of Urology, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Chlosta
- Department of Urology, Jagiellonian University Medical College, Cracow, Poland
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González J, Gaynor JJ, Martínez-Salamanca JI, Capitanio U, Tilki D, Carballido JA, Chantada V, Daneshmand S, Evans CP, Gasch C, Gontero P, Haferkamp A, Huang WC, Espinós EL, Master VA, McKiernan JM, Montorsi F, Pahernik S, Palou J, Pruthi RS, Rodriguez-Faba O, Russo P, Scherr DS, Shariat SF, Spahn M, Terrone C, Vera-Donoso C, Zigeuner R, Hohenfellner M, Libertino JA, Ciancio G. Association of an organ transplant-based approach with a dramatic reduction in postoperative complications following radical nephrectomy and tumor thrombectomy in renal cell carcinoma. Eur J Surg Oncol 2019; 45:1983-1992. [PMID: 31155470 DOI: 10.1016/j.ejso.2019.05.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/06/2019] [Accepted: 05/08/2019] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Our aim was to determine whether using an organ transplant-based(TB) approach reduces postoperative complications(PCs) following radical nephrectomy(RN) and tumor thrombectomy(TT) in renal cell carcinoma(RCC) patients with level II-IV thrombi. METHODS A total of 390(292 non-TB/98 TB) IRCC-VT Consortium patients who received no preoperative embolization/IVC filter were included. Stepwise linear/logistic regression analyses were performed to determine significant multivariable predictors of intraoperative estimated blood loss(IEBL), number blood transfusions received, and overall/major PC development within 30days following surgery. Propensity to receive the TB approach was controlled. RESULTS The TB approach was clearly superior in limiting IEBL, blood transfusions, and PC development, even after controlling for other significant prognosticators/propensity score(P < .000001 in each case). Median IEBL for non-TB/TB approaches was 1000 cc/300 cc and 1500 cc/500 cc for tumor thrombus Level II-III patients, respectively, with no notable differences for Level IV patients(2000 cc each). In comparing PC outcomes between non-TB/TB patients with a non-Right-Atrium Cranial Limit, the observed percentage developing a: i) PC was 65.8%(133/202) vs. 4.3%(3/69) for ECOG Performance Status(ECOG-PS) 0-1, and 84.8%(28/33) vs. 25.0%(4/16) for ECOG-PS 2-4, and ii) major PC was 16.8%(34/202) vs. 1.4%(1/69) for ECOG-PS 0-1, and 27.3%(9/33) vs. 12.5%(2/16) for ECOG-PS 2-4. Major study limitation was the fact that all TB patients were treated by a single, experienced, high volume surgeon from one center (non-TB patients were treated by various surgeons at 13 other centers). CONCLUSIONS Despite this major study limitation, the observed dramatic differences in PC outcomes suggest that the TB approach offers a major breakthrough in limiting operative morbidity in RCC patients receiving RN and TT.
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Affiliation(s)
- Javier González
- Department of Urolorgy, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Jeffrey J Gaynor
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | | | - Umberto Capitanio
- Department of Urology, Hospital San Raffaele, University Vita-Salute, Milano, Italy.
| | - Derya Tilki
- Department of Urology, University of California, Davis, School of Medicine, Sacramento, CA, USA.
| | - Joaquín A Carballido
- Servicio de Urología, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain.
| | - Venancio Chantada
- Servicio de Urología, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | | | - Christopher P Evans
- Department of Urology, University of California, Davis, School of Medicine, Sacramento, CA, USA.
| | - Claudia Gasch
- Department of Urology, University of Heidelberg, Heidelberg, Germany.
| | - Paolo Gontero
- Department of Urology, A.O.U. San Giovanni Battista, University of Turin, Turin, Italy.
| | - Axel Haferkamp
- Department of Urology and Pediatric Urology, Mainz University Medical Center, Mainz, Germany.
| | - William C Huang
- Department of Urology, New York University Langone School of Medicine, New York, USA.
| | | | - Viraj A Master
- Department of Urology, Emory University, Atlanta, GA, USA.
| | - James M McKiernan
- Department of Urology, Columbia University College of Physicians and Surgeons, New York, USA.
| | - Francesco Montorsi
- Department of Urology, Hospital San Raffaele, University Vita-Salute, Milano, Italy.
| | - Sascha Pahernik
- Department of Urology, Paracelsus University Hospital (PMU), Nürnberg, Germany.
| | - Juan Palou
- Department of Urology, Fundació Puigvert, Barcelona, Spain.
| | - Raj S Pruthi
- Department of Urology, UNC at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Paul Russo
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Douglas S Scherr
- Department of Urology, Weill Cornell Medical Center, New York, USA.
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria.
| | - Martin Spahn
- Department of Urology, Center of Urology/Prostate Cancer Center Hirslanden, Zürich, Switzerland.
| | - Carlo Terrone
- Division of Urology, Maggiore della Carita Hospital, University of Eastern Piedmont, Novara, Italy.
| | | | - Richard Zigeuner
- Department of Urology, Medical University of Graz, Graz, Austria.
| | | | - John A Libertino
- Department of Urology, Emerson Hospital-MGH Cancer Center, Boston, MA, USA.
| | - Gaetano Ciancio
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
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Thoracic Manifestations of Genitourinary Neoplasms and Treatment-related Complications. J Thorac Imaging 2019; 34:W36-W48. [PMID: 31009398 DOI: 10.1097/rti.0000000000000382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Genitourinary (GU) malignancies are a diverse group of common and uncommon neoplasms that may be associated with significant mortality. Metastases from GU neoplasms are frequently encountered in the chest, and virtually all thoracic structures can be involved. Although the most common imaging manifestations include hematogenous dissemination manifesting with peripheral predominant bilateral pulmonary nodules and lymphatic metastases manifesting with mediastinal and hilar lymphadenopathy, some GU malignancies exhibit unique features. We review the general patterns, pathways, and thoracic imaging features of renal, adrenal, urothelial, prostatic, and testicular metastatic neoplasms, as well as provide a discussion of treatment-related complications that might manifest in the chest. Detailed reporting of these patterns will allow the imager to assist the referring clinicians and surgeons in accurate determination of the stage, prognosis, and treatment options available for the patient. Awareness of specific treatment-related complications further allows the imager to enhance patient safety through accurate and timely reporting of potentially life-threatening consequences of therapies.
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Barbas Bernardos G, Herranz Amo F, Caño Velasco J, Cancho Gil M, Mayor de Castro J, Aragón Chamizo J, Polanco Pujol L, Hernández Fernández C. Influence of venous tumour extension on local and remote recurrence of stage pT3a pN0 cM0 kidney tumours. Actas Urol Esp 2019; 43:77-83. [PMID: 30268687 DOI: 10.1016/j.acuro.2018.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 06/10/2018] [Accepted: 06/11/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION AND OBJECTIVE One of the inherent features of kidney tumours is the capacity to spread inside the venous system as tumour thrombi. The aim of this study was to assess in patients with stage pT3apN0cM0 kidney cancer whether venous tumour involvement influenced tumour recurrence. MATERIALS AND METHODS A retrospective analysis of patients with stage pT3apN0cM0 kidney cancer treated with radical nephrectomy between 1990-2015. Univariate and multivariate Cox regression analysis to identify predictive variables and independent predictive variables relating to recurrence. RESULTS The results of 153 patients were studied. The median follow-up was 82 (IQR 36-117) months. Recurrence-free survival at 5 years was 58.9% with a median of 97 (95% CI 49.9-144.1) months. Seventy-seven (50.3%) patients recurred. Seventy cases 70 (90.9%) had distant metastases, 17 (14.2%) of these patients had local recurrence in the bed of nephrectomy. Tumour necrosis (p=.0001), and microvascular invasion (p=.001) were identified as independent predictors of tumour recurrence in the multivariable analysis. CONCLUSIONS In our series, after multivariable analysis, venous tumour extension was not related to recurrence. Tumour necrosis and microvascular infiltration did behave as independent predictive factors of tumour recurrence.
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20
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Phung MC, Lee BR. Recent advancements of robotic surgery for kidney cancer. Asian J Endosc Surg 2018; 11:300-307. [PMID: 30168283 DOI: 10.1111/ases.12635] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 06/27/2018] [Accepted: 07/03/2018] [Indexed: 01/20/2023]
Abstract
Surgical management of renal cell carcinoma has undergone a transformation in recent decades, especially with the dissemination of the robotic platform. Increasingly, larger and more complex renal lesions are now being treated in a minimally invasive fashion. The purpose of this article is to review advances in the use of the robotic approach for treatment of renal cell carcinoma, including nephron-sparing surgery, radical nephrectomy, and cytoreductive nephrectomy.
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Affiliation(s)
- Michael C Phung
- Division of Urology, Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Benjamin R Lee
- Division of Urology, Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
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Calderone CE, Tuck BC, Gray SH, Porter KK, Rais-Bahrami S. The role of transesophageal echocardiography in the management of renal cell carcinoma with venous tumor thrombus. Echocardiography 2018; 35:2047-2055. [DOI: 10.1111/echo.14187] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 10/04/2018] [Accepted: 10/05/2018] [Indexed: 01/08/2023] Open
Affiliation(s)
- Carli E. Calderone
- Department of Urology; University of Alabama at Birmingham; Birmingham Alabama
| | - Benjamin C. Tuck
- Department of Anesthesiology; University of Alabama at Birmingham; Birmingham Alabama
| | - Stephen H. Gray
- Department of Surgery; University of Alabama at Birmingham; Birmingham Alabama
| | - Kristin K. Porter
- Department of Radiology; University of Alabama at Birmingham; Birmingham Alabama
| | - Soroush Rais-Bahrami
- Department of Urology; University of Alabama at Birmingham; Birmingham Alabama
- Department of Radiology; University of Alabama at Birmingham; Birmingham Alabama
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Master VA, Ethun CG, Kooby DA, Staley CA, Maithel SK. The value of a cross-discipline team-based approach for resection of renal cell carcinoma with IVC tumor thrombus: A report of a large, contemporary, single-institution experience. J Surg Oncol 2018; 118:1219-1226. [PMID: 30332513 DOI: 10.1002/jso.25271] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 09/18/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION We report the evolution of the largest, contemporary, single-institution experience with this complex procedure to highlight the value of a cross-discipline, team-based approach. METHODS Patients from a prospectively maintained database who underwent resection of renal cell carcinoma (RCC) with inferior vena cava (IVC) tumor thrombus from 2005 to 2016 at a single-institution were included for analysis. RESULTS Of 140 patients, 102 (73%) had tumor thrombus below the level of the hepatic vein confluence, and 96 (69%) were performed for curative-intent, while 43 (31%) were cytoreductive procedures for clinical trial consideration. Median overall survival (OS) of the entire cohort was 43.8 months (5-year OS:43%), and 73.6 months (5-year OS:59%) for those without metastatic disease. Fifty-one patients underwent resection from 2005 to 2010 and 89 from 2011 to 2016. All procedures since 2011 were performed by the same cross-discipline dedicated team of two surgeons, composed of a surgical and urological oncologist. When comparing the two time-periods, the team-approach after 2011 had shorter operative-times (5.3 vs 6.7 hours; P = 0.009), decreased ICU-utilization (25% vs 72%; P < 0.001), and decreased ICU length-of-stay (0.4 vs 2.2 days; P = 0.001). This group also trended towards less blood loss (1.2 vs 1.8 L), shorter average hospital length-of-stay (10 vs 11 days), and decreased 90-day mortality (6% vs 10%). CONCLUSION Resection of RCC with IVC tumor thrombus yields long-term survival. A dedicated, cross-discipline, and team-based approach optimizes patient outcomes and may improve value of care by reducing utilization of expensive hospital resources.
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Affiliation(s)
- Viraj A Master
- Department of Urology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Charles A Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Postsurgical complications in patients with renal tumours with venous thrombosis treated with surgery. Actas Urol Esp 2018; 42:531-537. [PMID: 29631912 DOI: 10.1016/j.acuro.2018.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 02/26/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Surgery on renal tumours with venous thrombosis suffers a high rate of complications and non-negligible perioperative mortality. Our objective was to analyse the postoperative complications, their relationship with the level of the thrombus and its potential predisposing factors. MATERIALS AND METHODS A retrospective analysis was conducted of 101 patients with renal tumours with venous thrombosis operated on between 1988 and 2017. Two patients were excluded because of intraoperative pulmonary thromboembolism and exitus (2%). The postsurgical complications were classified according to Clavien-Dindo. To compare the qualitative variables, we employed the chi-squared test. We performed a multivariate analysis using binary logistic regression to identify the independent predictors. RESULTS Some type of postsurgical complication occurred in 34 (34.3%) patients, 11 (11.1%) of which were severe (Clavien III-V). There were significant differences in the total complications (P=.003) and severe complications (Clavien≥III; P=.03) depending on the level of the tumour thrombus.
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Haidar GM, Hicks TD, El-Sayed HF, Davies MG. Treatment options and outcomes for caval thrombectomy and resection for renal cell carcinoma. J Vasc Surg Venous Lymphat Disord 2018; 5:430-436. [PMID: 28411712 DOI: 10.1016/j.jvsv.2016.12.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/13/2016] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Advanced renal cell carcinoma (RCC) has a significant predisposition to vascular invasion. Tumor vascular invasion and thrombus are found in the renal vein and the inferior vena cava (IVC) in up to 10% to 25% of patients. This study reviewed the current status of radical nephrectomy with IVC thrombectomy for advanced RCC. METHODS A two-level search strategy of the literature (MEDLINE, PubMed, The Cochrane Library, and Google Scholar) for relevant articles listed between January 2000 and December 2015 was performed. The review was confined to patients with primary RCC associated with vascular invasion. RESULTS Untreated RCC with intravascular thrombus has a median survival of 5 months. Surgical exposure and intervention are tailored to the level of tumor thrombus. The 30-day mortality for radical nephrectomy with IVC thrombectomy is low (1.5%-10%), and the complication rates have been reported to be 18%, 20%, 26%, and 47% for IVC tumor thrombus level I, II, III, and IV disease, respectively. Disease-specific survival ranges from 40% to 60% at 5 years after nephrectomy and removal of the intravascular tumor. CONCLUSIONS Radical nephrectomy with IVC thrombectomy is an effective cancer control operation that can be safely performed with acceptable mortality and morbidity. Preoperative imaging coupled with perioperative surgical management of the IVC is critical to procedural success and patient outcomes.
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Affiliation(s)
- Georges M Haidar
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, University Hospital System, San Antonio, Tex
| | - Taylor D Hicks
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, University Hospital System, San Antonio, Tex
| | - Hosam F El-Sayed
- Division of Vascular Diseases and Surgery, Department of Surgery, Wexner Medical Center, Ohio State University, Columbus, Ohio
| | - Mark G Davies
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, University Hospital System, San Antonio, Tex.
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Marra G, Gontero P, Brattoli M, Filippini C, Capitanio U, Montorsi F, Daneshmand S, Huang WC, Linares Espinós E, Martínez-Salamanca JI, McKiernan JM, Zigeuner R, Libertino JA. Is imperative partial nephrectomy feasible for kidney cancer with venous thrombus involvement? Outcomes of 42 cases and matched pair analysis with a large radical nephrectomy cohort. Urol Oncol 2018; 36:339.e1-339.e8. [PMID: 29801993 DOI: 10.1016/j.urolonc.2018.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 02/23/2018] [Accepted: 04/16/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Radical nephrectomy (RN) with/without (±) thrombus excision (ThE) is the undisputed standard treatment for kidney cancer (KC) with renal or caval thrombus (Th). However, partial nephrectomy (PN) ± ThE may be considered in rare cases due to imperative (I) indications. OBJECTIVE To evaluate the efficacy of IPN ± ThE and to compare it with RN ± ThE for KC with Th. DESIGN, SETTING, AND PARTICIPANTS Records of 2,549 patients undergoing surgery for KC with Th at 24 institutions between 1971 and 2014 were retrospectively reviewed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary outcomes were overall survival (OS) and cancer specific survival (CSS), renal function variation after surgery and complications. Secondary outcomes were predictors of OS and CSS for IPN cases. To reduce bias IPN group was matched with RN using a propensity score with greedy algorithm on the basis of age, gender, tumor size, TNM, and histology. RESULTS AND LIMITATIONS Forty-two patients underwent IPN ± Th. All thrombi were ≥level I; 5 patients experienced Clavien ≥ 3 complications with 2 complications-related deaths. At 27.3 (interquartile range: 7.1-47.7) months OS and CSS were 54.8% and 78.6%, respectively whereas at 9.7 (interquartile range: 1.4-43.7) months eGFR change was -17.3 ± 27.0ml/min. On univariate analysis tumour size, preoperative eGFR, transfusions, hospital stay, high serum creatinine, operating time, complications, lymphadenectomy, and metastases related to an increased risk of death. After matching (n = 38 per arm) no significant differences were present except for tumor necrosis (IPN = 39.5%; 15.8%; P = 0.01), thrombus level (P = 0.02), so as for operating time (P = 0.27), perioperative transfusions (P = 0.74) and complications (P = 0.35). A 5-year OS and CSS for IPN were 57.9% and 73.7%, respectively with no significant differences with RN (OS = 63.2, P = 0.611; CSS = 68.4, P>0.99). After 14.9 months creatinine and eGFR changes were (+0.4 ± 0.6mg/dl and -23.2 ± 37.3ml/min; P = 0.2879). CONCLUSIONS In selected cases due to imperative indications PN ± ThE is a complex procedure and may be an alternative to RN ± ThE for KC with Th yielding noninferior oncological outcomes, functional outcomes, and complications. Further studies are needed to determine the role of PN ± ThE for KC with Th.
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Affiliation(s)
- Giancarlo Marra
- Department of Urology, San Giovanni Battista Hospital, Città della Salute e della Scienza, University of Turin, Turin, Italy.
| | - Paolo Gontero
- Department of Urology, San Giovanni Battista Hospital, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Michele Brattoli
- Department of Urology, San Giovanni Battista Hospital, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Claudia Filippini
- Department of Urology, San Giovanni Battista Hospital, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Umberto Capitanio
- Department of Urology, Hospital San Raffaele, University Vita-Salute, Milano, Italy
| | - Francesco Montorsi
- Department of Urology, Hospital San Raffaele, University Vita-Salute, Milano, Italy
| | - Siamak Daneshmand
- Department of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA
| | - William C Huang
- Department of Urology, New York University School of Medicine, New York, NY
| | | | - Juan I Martínez-Salamanca
- Department of Urology, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid, Madrid, Spain
| | - James M McKiernan
- Department of Urology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Richard Zigeuner
- Department of Urology, Medical University of Graz, Graz, Austria
| | - John A Libertino
- Department of Urology, Emerson Hospital MGH Cancer Center, Tufts University School of Medicine, Boston, MA
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Genomic features of renal cell carcinoma with venous tumor thrombus. Sci Rep 2018; 8:7477. [PMID: 29748622 PMCID: PMC5945671 DOI: 10.1038/s41598-018-25544-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 04/25/2018] [Indexed: 12/17/2022] Open
Abstract
A venous tumor thrombus (VTT) is a potentially lethal complication of renal cell carcinoma (RCC) but virtually nothing is known about the underlying natural history. Based on our observation that venous thrombi contain significant numbers of viable tumor cells, we applied multiregion whole exome sequencing to a total of 37 primary tumor and VTT samples including normal tissue specimens from five consecutive patients. Our findings demonstrate mutational heterogeneity between primary tumor and VTT with 106 of 483 genes (22%) harboring functional SNVs and/or indels altered in either primary tumor or thrombus. Reconstruction of the clonal phylogeny showed clustering of tumor samples and VTT samples, respectively, in the majority of tumors. However, no new subclones were detected suggesting that pre-existing subclones of the primary tumor drive VTT formation. Importantly, we found several lines of evidence for “BRCAness” in a subset of tumors. These included mutations in genes that confer “BRCAness”, a mutational signature and an increase of small indels. Re-analysis of SNV calls from the TCGA KIRC-US cohort confirmed a high frequency of the “BRCAness” mutational signature AC3 in clear cell RCC. Our findings warrant further pre-clinical experiments and may lead to novel personalized therapies for RCC patients.
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Shah PH, Thompson RH, Boorjian SA, Lohse CM, Lyon TD, Shields RC, Froehling D, Leibovich BC, Viers BR. Symptomatic Venous Thromboembolism is Associated with Inferior Survival among Patients Undergoing Nephrectomy with Inferior Vena Cava Tumor Thrombectomy for Renal Cell Carcinoma. J Urol 2018; 200:520-527. [PMID: 29709665 DOI: 10.1016/j.juro.2018.04.069] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE We investigated the incidence and survival impact of symptomatic venous thromboembolism after nephrectomy with inferior vena cava tumor thrombectomy. MATERIALS AND METHODS We retrospectively reviewed the records of 183 patients who underwent nephrectomy with inferior vena cava tumor thrombectomy (level I-IV) for renal cell carcinoma between 2000 and 2010. Postoperative venous thromboembolism was defined as symptomatic bland thrombus or embolism confirmed on imaging. The cumulative incidence of venous thromboembolism was estimated by the Kaplan-Meier method. Associations of clinicopathological features with time to thromboembolism after surgery and all cause mortality were evaluated on multivariable analysis with Cox models. RESULTS Symptomatic venous thromboembolism developed in 55 patients a median of 23 days (IQR 5-142) postoperatively, including pulmonary thrombosis in 24, deep venous thrombosis in 17, bland inferior vena cava thrombosis in 13 and portal vein thrombosis in 1. The cumulative incidence of thromboembolism 30, 90 and 365 days following surgery was 17%, 22% and 27%, respectively. A history of smoking (HR 2.15, 95% CI 1.09-4.24, p = 0.028), ECOG (Eastern Cooperative Oncology Group) performance status 1 or greater (HR 2.15, 95% CI 1.17-3.93, p = 0.013), hypercoagulability disorder (HR 5.12, 95% CI 1.93-13.59, p = 0.001) and bulky lymphadenopathy at surgery (HR 4.84, 95% CI 1.87-12.51, p = 0.001) was significantly associated with an increased risk of venous thromboembolism on multivariable analysis. Postoperative venous thromboembolism was significantly associated with an increased risk of all cause mortality (HR 1.53, 95% CI 1.04-2.23, p = 0.029). CONCLUSIONS Venous thromboembolism after nephrectomy and tumor thrombectomy is common within 90 days of surgery. Symptomatic venous thromboembolism in this population is independently associated with a greater risk of mortality.
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Affiliation(s)
- Paras H Shah
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Christine M Lohse
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Timothy D Lyon
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | - Raymond C Shields
- Division of Vascular Medicine, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - David Froehling
- Division of Vascular Medicine, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Boyd R Viers
- Department of Urology, Mayo Clinic, Rochester, Minnesota.
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Lee L, Huned D, Carsen J, Huang H. The incremental benefit of upfront surgery in renal cell carcinoma with venous tumor thrombus of the inferior venae cavae. UROLOGICAL SCIENCE 2018. [DOI: 10.4103/uros.uros_31_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Quencer KB, Friedman T, Sheth R, Oklu R. Tumor thrombus: incidence, imaging, prognosis and treatment. Cardiovasc Diagn Ther 2017; 7:S165-S177. [PMID: 29399520 PMCID: PMC5778532 DOI: 10.21037/cdt.2017.09.16] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 09/12/2017] [Indexed: 12/11/2022]
Abstract
Intravascular tumor extension, also known as tumor thrombus, can occur in many different types of cancer. Those with the highest proclivity include Wilm's tumor, renal cell carcinoma (RCC), adrenal cortical carcinoma (ACC) and hepatocellular carcinoma (HCC). The presence of tumor thrombus markedly worsens prognosis and impacts treatment approach. Imaging plays a key role in its diagnosis. Endovascular methods also play a large role in treatment.
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Affiliation(s)
| | - Tamir Friedman
- Division of Interventional Radiology, Department of Radiology, Cornell University, New York, NY, USA
| | - Rahul Sheth
- Division of Interventional Radiology, Department of Radiology, MD Anderson Cancer, Houston, TX, USA
| | - Rahmi Oklu
- Division of Interventional Radiology, Department of Radiology, Mayo Clinic-Arizona, Phoenix, AZ, USA
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Tilki D, Chandrasekar T, Capitanio U, Ciancio G, Daneshmand S, Gontero P, Gonzalez J, Haferkamp A, Hohenfellner M, Huang WC, Linares Espinós E, Lorentz A, Martinez-Salamanca JI, Master VA, McKiernan JM, Montorsi F, Novara G, Pahernik S, Palou J, Pruthi RS, Rodriguez-Faba O, Russo P, Scherr DS, Shariat SF, Spahn M, Terrone C, Vera-Donoso C, Zigeuner R, Libertino JA, Evans CP. Impact of lymph node dissection at the time of radical nephrectomy with tumor thrombectomy on oncological outcomes: Results from the International Renal Cell Carcinoma-Venous Thrombus Consortium (IRCC-VTC). Urol Oncol 2017; 36:79.e11-79.e17. [PMID: 29129353 DOI: 10.1016/j.urolonc.2017.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 09/11/2017] [Accepted: 10/09/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To study the effect of lymph node dissection (LND) at the time of nephrectomy and tumor thrombectomy on oncological outcomes in patients with renal cell carcinoma (RCC) and tumor thrombus. PATIENTS AND METHODS The records of 1,978 patients with RCC and tumor thrombus who underwent radical nephrectomy and tumor thrombectomy from 1985 to 2014 at 24 centers were analyzed. None of the patients had distant metastases. Extent and pathologic results of LND were compared with respect to cancer-specific survival (CSS). Multivariable Cox regression models were used to quantify the effect of multiple covariates. RESULTS LND was performed in 1,026 patients. In multivariable analysis, the presence of LN metastasis, the number of positive LNs, and LN density were independently associated with cancer-specific mortality (CSM). Clinical node-negative (cN-) disease was documented in 573 patients, 447 of them underwent LND with 43 cN- patients (9.6%) revealing positive LNs at pathology. LN positive cN- patients showed significantly better CSS when compared to LN positive cN+ patients. In multivariable analysis, positive cN status in LN positive patients was a significant predictor of CSM (HR, 2.923; P = 0.015). CONCLUSIONS The number of positive nodes harvested during LND and LN density was strong prognostic indicators of CSS, while number of removed LNs did not have a significant effect on CSS. The rate of pN1 patients among clinically node-negative patients was relatively high, and LND in these patients suggested a survival benefit. However, only a randomized trial can determine the absolute benefit of LND in this setting.
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Affiliation(s)
- Derya Tilki
- Department of Urology, University of California, Davis School of Medicine, Sacramento, CA
| | - Thenappan Chandrasekar
- Department of Urology, University of California, Davis School of Medicine, Sacramento, CA
| | - Umberto Capitanio
- Department of Urology, Hospital San Raffaele, University Vita-Salute, Milano, Italy
| | - Gaetano Ciancio
- Department of Urology, Miami Transplant Institute, University of Miami, Miami, FL
| | - Siamak Daneshmand
- Department of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Paolo Gontero
- Department of Urology, A.O.U. San Giovanni Battista, University of Turin, Turin, Italy
| | - Javier Gonzalez
- Department of Urology, Hospital Central de la Cruz Roja San José y Santa Adela, Madrid, Spain
| | - Axel Haferkamp
- Department of Urology, University of Frankfurt, Frankfurt, Germany
| | | | - William C Huang
- Department of Urology, New York University School of Medicine, New York City, NY
| | | | - Adam Lorentz
- Department of Urology, Emory University, Atlanta, GA
| | - Juan I Martinez-Salamanca
- Department of Urology, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - James M McKiernan
- Department of Urology, Columbia University College of Physicians and Surgeons, New York City, NY
| | - Francesco Montorsi
- Department of Urology, Hospital San Raffaele, University Vita-Salute, Milano, Italy
| | - Giacomo Novara
- Department of Urology, University of Padua, Padua, Italy
| | - Sascha Pahernik
- Department of Urology, University of Heidelberg, Heidelberg, Germany
| | - Juan Palou
- Department of Urology, Fundació Puigvert, Barcelona, Spain
| | - Raj S Pruthi
- Department of Urology, UNC at Chappel Hill, Chapel Hill, NC
| | | | - Paul Russo
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Douglas S Scherr
- Department of Urology, Weill Cornell Medical Center, New York City, NY
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Martin Spahn
- Department of Urology, University of Würzburg, Würzburg, Germany; Department of Urology, University Hospital Bern, Bern, Switzerland
| | - Carlo Terrone
- Division of Urology, Maggiore della Carita Hospital, University of Eastern Piedmont, Novara, Italy
| | - Cesar Vera-Donoso
- Department of Urology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Richard Zigeuner
- Department of Urology, Medical University of Graz, Graz, Austria
| | | | - Christopher P Evans
- Department of Urology, University of California, Davis School of Medicine, Sacramento, CA.
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Gologorsky E, Fukazawa K, Ciancio G. Perioperative management of patients with renal cell carcinoma with high level of IVC tumor thrombus invasion revisited. J Clin Anesth 2017; 39:23-24. [PMID: 28494899 DOI: 10.1016/j.jclinane.2017.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Edward Gologorsky
- Temple University School of Medicine, Department of Anesthesiology, CVT and Liver Transplant Divisions, Allegheny General Hospital, Pittsburgh, PA, United States.
| | - Kyota Fukazawa
- Dept. of Anesthesiology and Pain Medicine, Univ. of Washington School of Medicine, Seattle, WA, United States
| | - Gaetano Ciancio
- Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
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Mansukhani NA, Havelka GE, Helenowski IB, Rodriguez HE, Hoel AW, Eskandari MK. The enduring patency of primary inferior vena cava repair. Surgery 2017; 161:1414-1422. [PMID: 28011005 PMCID: PMC5404996 DOI: 10.1016/j.surg.2016.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/19/2016] [Accepted: 11/05/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Inferior vena cava repair after planned and unplanned venotomy is performed by either interposition bypass, patch venopasty, or lateral venorrhaphy and primary repair. Primary repair of the inferior vena cava avoids the use of foreign material and allows an all-autologous repair in an expeditious fashion. The purpose of this study was to demonstrate the utility of inferior vena cava repair, determine the degree of inferior vena cava stenosis, and examine clinical outcomes after primary repair. METHODS We conducted a single-center retrospective review of patients who underwent primary inferior vena cava repairs between January 2002 and January 2014 at a tertiary care center. Primary repair followed lateral venorrhaphy for tumor extraction or for repair of an iatrogenic inferior vena cava injury. Patient demographics, cross-sectional vena cava dimensions, and patient outcomes were tabulated. RESULTS In total, 47 (30 men and 17 women) patients underwent primary inferior vena cava repair (median age 58 years, range 31-83 years). Twenty-six patients (15 men and 11 women) underwent en bloc radical nephrectomy, inferior vena cava tumor thrombus extraction, and primary lateral venorrhaphy (median age 61 years, range 39-83 years). The majority, 92% of these patients, had renal cell carcinoma on final pathology, with a median follow-up period of 39 months (range 1-108 months). Twenty-one patients (15 men and 6 women) underwent primary repair for iatrogenic inferior vena cava injury (median age 54 years, range 31-82 years). The median follow-up period was 18.5 months (3-110 months). Clinic follow-up with postoperative imaging was obtained in 76.9% of those undergoing tumor thrombus extraction (n = 20) and 76.2% of those undergoing repair of an iatrogenic injury (n = 16). Overall, there was a 13% infrarenal inferior vena cava diameter loss, 17% inferior vena cava diameter loss at the level of the renal veins, and 10% suprarenal inferior vena cava diameter loss when comparing postoperative with preoperative imaging. All patients remained asymptomatic; therefore, inferior vena cava narrowing associated with primary repair was clinically insignificant. CONCLUSION Primary inferior vena cava repair is associated with less than 20% inferior vena cava diameter loss and does not compromise venous outflow from the extremities. Primary inferior vena cava repair is a safe and expeditious technique that provides excellent clinical outcomes and long-term patency.
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Affiliation(s)
- Neel A Mansukhani
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - George E Havelka
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Irene B Helenowski
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Heron E Rodriguez
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Andrew W Hoel
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mark K Eskandari
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
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Rodríguez-Cabello MA, Laso-García I, Donis-Canet F, Gómez-Dos-Santos V, Varona-Crespo C, Burgos-Revilla FJ. Renal cell carcinoma with vascular invasion: Mortality and prognostic factors. Actas Urol Esp 2017; 41:132-138. [PMID: 27461850 DOI: 10.1016/j.acuro.2016.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/05/2016] [Accepted: 06/06/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Analysis of the results of patients who had been operated of renal cell carcinoma with vascular invasion in our institution, evaluation of prognostic factors and complications. METHODS Retrospective observational study of 37 patients diagnosed of renal cell carcinoma with vascular invasion operated between May 1999 and July 2013. We used the method of Kaplan-Meier survival analysis and the Mantel-Haenszel's test (log rank) and the Cox's proportional hazards analysis test to analyse the risk factors of mortality. RESULTS The median age was 60 years. Mean follow-up period was 42.1 months. The median overall survival and disease-free survival were 53.8and 36.3 months, respectively. There was statistical association between overall survival and ASA (p=0.047), tumor stage (p=0.003), lymph node involvement (p=0.024), presence of metastases (p=0.013), level of tumor thrombus (p=0, 05) and histological type (p=0.001). 14 patients had grade IIIb complications or higher according to the Clavien Dindo classification, the most frequent was bleeding. CONCLUSIONS Renal cell carcinoma with vascular invasion is a disease with high rate of mortality. Surgery is a therapeutic option that can be curative. The number of complications is important. Survival is conditioned by the ASA, tumor stage, the level of tumor thrombus, lymph node involvement, metastasis and histological type.
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Affiliation(s)
| | - I Laso-García
- Servicios de Urología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - F Donis-Canet
- Servicios de Urología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - V Gómez-Dos-Santos
- Servicios de Urología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - C Varona-Crespo
- Servicios de Anatomía Patológica, Hospital Universitario Ramón y Cajal, Madrid, España
| | - F J Burgos-Revilla
- Servicios de Urología, Hospital Universitario Ramón y Cajal, Madrid, España
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Spelde A, Steinberg T, Patel PA, Garcia H, Kukafka JD, MacKay E, Gutsche JT, Frogel J, Fabbro M, Raiten JM, Augoustides JGT. Successful Team-Based Management of Renal Cell Carcinoma With Caval Extension of Tumor Thrombus Above the Diaphragm. J Cardiothorac Vasc Anesth 2017; 31:1883-1893. [PMID: 28502456 DOI: 10.1053/j.jvca.2017.02.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Indexed: 12/24/2022]
Affiliation(s)
- Audrey Spelde
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Toby Steinberg
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Harry Garcia
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jeremy D Kukafka
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Emily MacKay
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan Frogel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael Fabbro
- Cardiothoracic Anesthesiology, Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Jessie M Raiten
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Gerstein NS, Zhang R, Davis MS, Ram H. Lessons Still Being Learned: Acute Pulmonary Tumor Embolus During Renal Cell Carcinoma Resection. ACTA ACUST UNITED AC 2017; 7:172-176. [PMID: 27552241 DOI: 10.1213/xaa.0000000000000378] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Renal cell carcinoma (RCC) is the most common primary renal neoplasm and is associated with the intraluminal growth into the venous system with possible extension into the inferior vena cava or even right heart. Intraoperative pulmonary embolism is a complication of resection of RCC, which may be mitigated by the use of the cardiopulmonary bypass with or without deep hypothermic circulatory arrest. We present a case of unexpected pulmonary embolism diagnosed during RCC surgery. The case highlights the central importance of intraoperative transesophageal echocardiography use and the need for proper preoperative planning for the use of cardiopulmonary bypass.
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Affiliation(s)
- Neal S Gerstein
- From the *Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico; and †Division of Urology, Department of Surgery, University of New Mexico, Albuquerque, New Mexico
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Palmer DA, Humphrey JE, Fredrick A, Piemonte TC, Libertino JA. Endovascular Removal of Intracardiac Thrombus Prior to Radical Nephrectomy and Inferior Vena Cava Thrombectomy. Urology 2016; 96:85-86. [DOI: 10.1016/j.urology.2016.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 07/02/2016] [Accepted: 07/15/2016] [Indexed: 10/21/2022]
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Tornberg SV, Nisen H, Visapää H, Kilpeläinen TP, Järvinen R, Mirtti T, Kantonen I, Simpanen J, Bono P, Taari K, Järvinen P. Outcome of surgery for patients with renal cell carcinoma and tumour thrombus in the era of modern targeted therapy. Scand J Urol 2016; 50:380-6. [DOI: 10.1080/21681805.2016.1217558] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Mager R, Daneshmand S, Evans CP, Palou J, Martínez-Salamanca JI, Master VA, McKiernan JM, Libertino JA, Haferkamp A, Haferkamp A, Capitanio U, Carballido JA, Chantada V, Chromecki T, Ciancio G, Daneshmand S, Evans CP, Gontero P, González J, Hohenfellner M, Huang WC, Koppie TM, Libertino JA, Espinós EL, Lorentz A, Martínez-Salamanca JI, Master VA, McKiernan JM, Montorsi F, Novara G, O'Malley P, Pahernik S, Palou J, Moreno JLP, Pruthi RS, Faba OR, Russo P, Scherr DS, Shariat SF, Spahn M, Terrone C, Tilki D, Vázquez-Martul D, Donoso CV, Vergho D, Wallen EM, Zigeuner R. Renal cell carcinoma with inferior vena cava involvement: Prognostic effect of tumor thrombus consistency on cancer specific survival. J Surg Oncol 2016; 114:764-768. [PMID: 27562252 DOI: 10.1002/jso.24395] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 07/18/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Renal cell carcinoma forming a venous tumor thrombus (VTT) in the inferior vena cava (IVC) has a poor prognosis. Recent investigations have been focused on prognostic markers of survival. Thrombus consistency (TC) has been proposed to be of significant value but yet there are conflicting data. The aim of this study is to test the effect of IVC VTT consistency on cancer specific survival (CSS) in a multi-institutional cohort. METHODS The records of 413 patients collected by the International Renal Cell Carcinoma-Venous Thrombus Consortium were retrospectively analyzed. All patients underwent radical nephrectomy and tumor thrombectomy. Kaplan-Meier estimate and Cox regression analyses investigated the impact of TC on CSS in addition to established clinicopathological predictors. RESULTS VTT was solid in 225 patients and friable in 188 patients. Median CSS was 50 months in solid and 45 months in friable VTT. TC showed no significant association with metastatic spread, pT stage, perinephric fat invasion, and higher Fuhrman grade. Survival analysis and Cox regression rejected TC as prognostic marker for CSS. CONCLUSIONS In the largest cohort published so far, TC seems not to be independently associated with survival in RCC patients and should therefore not be included in risk stratification models. J. Surg. Oncol. 2016;114:764-768. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Rene Mager
- Department of Urology and Pediatric Urology, University Medical Center Mainz, Mainz, Germany.
| | | | | | - Joan Palou
- Department of Urology, Fundació Puigvert, Barcelona, Spain
| | - Juan I Martínez-Salamanca
- Department of Urology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain
| | - Viraj A Master
- Department of Urology, Emory University, Atlanta, Georgia
| | - James M McKiernan
- Department of Urology, Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Axel Haferkamp
- Department of Urology and Pediatric Urology, University Medical Center Mainz, Mainz, Germany
| | | | - Axel Haferkamp
- Department of Urology and Pediatric Urology, University Medical Center Mainz, Mainz, Germany
| | - Umberto Capitanio
- Department of Urology, Hospital San Raffaele, University Vita-Salute, Milano, Italy
| | - Joaquín A Carballido
- Department of Urology, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid, Madrid, Spain
| | - Venancio Chantada
- Department of Urology, Complejo Hospitalario Universitario A Coruña, Coruña, Spain
| | - Thomas Chromecki
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Gaetano Ciancio
- Miami Transplant Institute, University of Miami, Miami, Florida
| | | | | | - Paolo Gontero
- Department of Urology, A.O.U. San Giovanni Battista, University of Turin, Turin, Italy
| | - Javier González
- Department of Urology, Hospital Central de la Cruz Roja San José y Santa Adela, Madrid, Spain
| | | | - William C Huang
- Department of Urology, New York University School of Medicine, New York, New York
| | - Theresa M Koppie
- Department of Urology, Oregon Health and Science University, Portland, Oregon
| | | | | | - Adam Lorentz
- Department of Urology, Emory University, Atlanta, Georgia
| | - Juan I Martínez-Salamanca
- Department of Urology, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid, Madrid, Spain
| | - Viraj A Master
- Department of Urology, Emory University, Atlanta, Georgia
| | - James M McKiernan
- Department of Urology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Francesco Montorsi
- Department of Urology, Hospital San Raffaele, University Vita-Salute, Milano, Italy
| | - Giacomo Novara
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Padraic O'Malley
- Department of Urology, Weill Cornell Medical Center, New York, New York
| | - Sascha Pahernik
- Department of Urology, University of Heidelberg, Heidelberg, Germany
| | - Joan Palou
- Department of Urology, Fundació Puigvert, Barcelona, Spain
| | | | - Raj S Pruthi
- Department of Urology, UNC at Chapel Hill, Chapel Hill, North Carolina
| | | | - Paul Russo
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Douglas S Scherr
- Department of Urology, Weill Cornell Medical Center, New York, New York
| | | | - Martin Spahn
- Department of Urology, University of Würzburg, Würzburg, Germany
| | - Carlo Terrone
- Division of Urology, Maggiore della Carita Hospital, University of Eastern Piedmont, Novara, Italy
| | - Derya Tilki
- Department of Urology, UC Davis Medical Center, Sacramento, California
| | - Dario Vázquez-Martul
- Department of Urology, Complejo Hospitalario Universitario A Coruña, Coruña, Spain
| | | | - Daniel Vergho
- Department of Urology, University of Würzburg, Würzburg, Germany
| | - Eric M Wallen
- Department of Urology, UNC at Chapel Hill, Chapel Hill, North Carolina
| | - Richard Zigeuner
- Department of Urology, Medical University of Graz, Graz, Austria
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Salerno TA, Ciancio G. Invited Commentary. Ann Thorac Surg 2016; 102:842. [PMID: 27549521 DOI: 10.1016/j.athoracsur.2016.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 03/10/2016] [Accepted: 03/14/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Tomas A Salerno
- Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1611 NW 12th Ave, East Tower 3072 (R-114), Miami, FL 33136.
| | - Gaetano Ciancio
- Department of Surgery (Division of Transplantation) and Urology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
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Gagné-Loranger M, Lacombe L, Pouliot F, Fradet V, Dagenais F. Renal cell carcinoma with thrombus extending to the hepatic veins or right atrium: operative strategies based on 41 consecutive patients. Eur J Cardiothorac Surg 2016; 50:317-21. [PMID: 27016196 DOI: 10.1093/ejcts/ezw023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/12/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The natural history of renal cell carcinoma (RCC) with tumour thrombus extending at or above the hepatic veins is dismal. Different surgical approaches have been described including cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest. We here report our experience in terms of surgical techniques and outcomes on 41 consecutive patients presenting an RCC extending to the hepatic veins or the right atrium. A surgical decision-making algorithm is discussed. METHODS Retrospective review of 41 patients operated for RCC extending in the retrohepatic vena cava (extent level III-IV) between 2000 and 2015. Patients were operated by a dedicated urology/cardiac surgery team. RESULTS The mean age was 62.6 ± 10.4 years; 39% were female. Surgery was emergent in 7.3% of patients, 2.4% of patients had preoperative dialysis, 4.9% required a redo sternotomy and 19.5% had coronary artery disease. Tumour thrombus extended above the diaphragm in 23 patients (level IV) and to the level of hepatic veins (level III) in 18 patients. CPB was used in 38 patients. Arterial cannulation was in the aorta or femoral artery in 14 patients during the initial experience. In the current era, the axillary artery and the innominate artery were used in 12 patients each. Mean CPB, cross-clamp and circulatory arrest times were, respectively, 96.5 ± 42.9, 21.1 ± 16.4 and 10.2 ± 8.2 min (mean temperature of 25.7 ± 4.9°C). Hepatic exclusion without the use of CPB was performed to excise the thrombus in 3 patients. A right nephrectomy was performed in 25 patients, a left in 15 patients and a bilateral nephrectomy in 1 patient. Five patients had a partial inferior vena cava (IVC) resection, with 4 patients requiring a patch reconstruction of the IVC. Three patients had an infrarenal IVC ligation. One patient suffered a cerebrovascular accident in the postoperative period. One in-hospital death occurred (in-hospital mortality 2.4%). The mean follow-up was 1.9 ± 2.0 years. Twenty-three patients died during follow-up; 21 were disease-related. Three-year survival rate was 37.1%. CONCLUSION High-level RCC tumour thrombus is a rare clinical entity, the treatment of which is complex and requires dedicated operative teams. The operative technique should be tailored according to the level of extension and the extent of vena cava obstruction/occlusion of the tumour thrombus. Contemporary operative techniques may be conducted with excellent results. Mid-term survival is limited, supporting the necessity to pursue research efforts towards establishing effective adjunct therapies.
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Affiliation(s)
- Maude Gagné-Loranger
- Department of Cardiovascular Surgery, Quebec Heart and Lung Institute, Laval University, Sainte-Foy, Canada
| | - Louis Lacombe
- Department of Urology, Hôtel-Dieu de Québec, Centre Hospitalier Universitaire de Québec, Laval University, Québec, Canada
| | - Frédéric Pouliot
- Department of Urology, Hôtel-Dieu de Québec, Centre Hospitalier Universitaire de Québec, Laval University, Québec, Canada
| | - Vincent Fradet
- Department of Urology, Hôtel-Dieu de Québec, Centre Hospitalier Universitaire de Québec, Laval University, Québec, Canada
| | - François Dagenais
- Department of Cardiovascular Surgery, Quebec Heart and Lung Institute, Laval University, Sainte-Foy, Canada
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41
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Hevia V, Ciancio G, Gómez V, Álvarez S, Díez-Nicolás V, Burgos FJ. Surgical technique for the treatment of renal cell carcinoma with inferior vena cava tumor thrombus: tips, tricks and oncological results. SPRINGERPLUS 2016; 5:132. [PMID: 26933631 PMCID: PMC4761352 DOI: 10.1186/s40064-016-1825-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 02/15/2016] [Indexed: 11/15/2022]
Abstract
Renal cell carcinoma represents 3 % of all cancers. Around 4–10 % of cases present with inferior vena cava involvement, generally with tumor thrombus. Clinical and preoperative stage will be classified depending of the thrombus extension. A high quality preoperative workup is essential to properly plan surgical approach. Complete surgical resection of the tumor is potentially the only curative treatment, although it supposes a real challenge due to operative difficulty, potential for massive bleeding or tumor pulmonary thromboembolism. Surgery includes techniques derived from transplantation surgery and, in some cases, cardiovascular intervention with cardiopulmonary bypass. Long-term oncological outcomes after complete removal of the entire tumor burden are acceptable. In this report we describe step-by-step surgical maneuvers depending on the thrombus lever, and focusing in complete abdominal approach for the complete excision of the tumor. Moreover, a recent literature review about oncological results is reported.
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Affiliation(s)
- Vital Hevia
- Urology Department, Renal Surgery and Kidney Transplant Section, Hospital Universitario Ramón y Cajal, Ctra Colmenar km 9,100, 28034 Madrid, Spain
| | - Gaetano Ciancio
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami, FL USA
| | - Victoria Gómez
- Urology Department, Renal Surgery and Kidney Transplant Section, Hospital Universitario Ramón y Cajal, Ctra Colmenar km 9,100, 28034 Madrid, Spain
| | - Sara Álvarez
- Urology Department, Renal Surgery and Kidney Transplant Section, Hospital Universitario Ramón y Cajal, Ctra Colmenar km 9,100, 28034 Madrid, Spain
| | - Víctor Díez-Nicolás
- Urology Department, Renal Surgery and Kidney Transplant Section, Hospital Universitario Ramón y Cajal, Ctra Colmenar km 9,100, 28034 Madrid, Spain
| | - Francisco Javier Burgos
- Urology Department, Renal Surgery and Kidney Transplant Section, Hospital Universitario Ramón y Cajal, Ctra Colmenar km 9,100, 28034 Madrid, Spain
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Lardas M, Stewart F, Scrimgeour D, Hofmann F, Marconi L, Dabestani S, Bex A, Volpe A, Canfield SE, Staehler M, Hora M, Powles T, Merseburger AS, Kuczyk MA, Bensalah K, Mulders PFA, Ljungberg B, Lam TBL. Systematic Review of Surgical Management of Nonmetastatic Renal Cell Carcinoma with Vena Caval Thrombus. Eur Urol 2015; 70:265-80. [PMID: 26707869 DOI: 10.1016/j.eururo.2015.11.034] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 11/30/2015] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Michael Lardas
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Fiona Stewart
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | | | - Fabian Hofmann
- Department of Urology, Sunderby Hospital, Sunderby, Sweden
| | - Lorenzo Marconi
- Department of Urology, Coimbra University Hospital, Coimbra, Portugal
| | - Saeed Dabestani
- Department of Urology, Skåne University Hospital, Malmö, Sweden
| | - Axel Bex
- Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Alessandro Volpe
- Division of Urology, Maggiore della Carita' Hospital, University of Eastern Piedmont, Novara, Italy
| | - Steven E Canfield
- Division of Urology, University of Texas Medical School at Houston, Houston, TX, USA
| | - Michael Staehler
- Department of Urology, Ludwig-Maximilians University, Munich, Germany
| | - Milan Hora
- Department of Urology, Faculty Hospital and Faculty of Medicine in Pilsen, Charles University in Prague, Prague, Czech Republic
| | - Thomas Powles
- The Royal Free NHS Trust and Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Axel S Merseburger
- Department of Urology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Markus A Kuczyk
- Department of Urology and Urologic Oncology, Hannover Medical School, Hannover, Germany
| | - Karim Bensalah
- Department of Urology, University of Rennes, Rennes, France
| | - Peter F A Mulders
- Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Börje Ljungberg
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | - Thomas B L Lam
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK; Academic Urology Unit, University of Aberdeen, Aberdeen, UK.
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43
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Psutka SP, Leibovich BC. Management of inferior vena cava tumor thrombus in locally advanced renal cell carcinoma. Ther Adv Urol 2015; 7:216-29. [PMID: 26445601 PMCID: PMC4580091 DOI: 10.1177/1756287215576443] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The diagnosis of renal cell carcinoma is accompanied by intravascular tumor thrombus in up to 10% of cases, of which nearly one-third of patients also have concurrent metastatic disease. Surgical resection in the form of radical nephrectomy and caval thrombectomy represents the only option to obtain local control of the disease and is associated with durable oncologic control in approximately half of these patients. The objective of this clinical review is to outline the preoperative evaluation for, and operative management of patients with locally advanced renal cell carcinoma with venous tumor thrombi involving the inferior vena cava. Cornerstones of the management of these complex patients include obtaining high-quality imaging to characterize the renal mass and tumor thrombus preoperatively, with further intraoperative real-time evaluation using transesophageal echocardiography, careful surgical planning, and a multidisciplinary approach. Operative management of patients with high-level caval thrombi should be undertaken in high-volume centers by surgical teams with capacity for bypass and invasive intraoperative monitoring. In patients with metastatic disease at presentation, cytoreductive nephrectomy and tumor thrombectomy may be safely performed with simultaneous metastasectomy if possible. In the absence of level one evidence, neoadjuvant targeted therapy should continue to be viewed as experimental and should be employed under the auspices of a clinical trial. However, in patients with significant risk factors for postoperative complications and mortality, and especially in those with metastatic disease, consultation with medical oncology and frontline targeted therapy may be considered.
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Affiliation(s)
| | - Bradley C Leibovich
- Department of Urology, Mayo Clinic, 200 First Street SW, Gonda 7, Rochester, MN 55905, USA
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44
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Haddad AQ, Leibovich BC, Abel EJ, Luo JH, Krabbe LM, Thompson RH, Heckman JE, Merrill MM, Gayed BA, Sagalowsky AI, Boorjian SA, Wood CG, Margulis V. Preoperative multivariable prognostic models for prediction of survival and major complications following surgical resection of renal cell carcinoma with suprahepatic caval tumor thrombus. Urol Oncol 2015; 33:388.e1-9. [PMID: 26004163 DOI: 10.1016/j.urolonc.2015.04.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 03/24/2015] [Accepted: 04/19/2015] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Ahmed Q Haddad
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Bradley C Leibovich
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX; Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, MN
| | - Edwin Jason Abel
- Department of Urology, University of Wisconsin School of Medicine, Madison WI
| | - Jun-Hang Luo
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Laura-Maria Krabbe
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX; University of Muenster Medical Center, Muenster, Germany
| | | | - Jennifer E Heckman
- Department of Urology, University of Wisconsin School of Medicine, Madison WI
| | - Megan M Merrill
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Bishoy A Gayed
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Arthur I Sagalowsky
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Stephen A Boorjian
- Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, MN
| | - Christopher G Wood
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Vitaly Margulis
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX.
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45
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Nguyen HG, Tilki D, Dall'Era MA, Durbin-Johnson B, Carballido JA, Chandrasekar T, Chromecki T, Ciancio G, Daneshmand S, Gontero P, Gonzalez J, Haferkamp A, Hohenfellner M, Huang WC, Espinós EL, Mandel P, Martinez-Salamanca JI, Master VA, McKiernan JM, Montorsi F, Novara G, Pahernik S, Palou J, Pruthi RS, Rodriguez-Faba O, Russo P, Scherr DS, Shariat SF, Spahn M, Terrone C, Vergho D, Wallen EM, Xylinas E, Zigeuner R, Libertino JA, Evans CP. Cardiopulmonary Bypass has No Significant Impact on Survival in Patients Undergoing Nephrectomy and Level III-IV Inferior Vena Cava Thrombectomy: Multi-Institutional Analysis. J Urol 2015; 194:304-308. [PMID: 25797392 DOI: 10.1016/j.juro.2015.02.2948] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The impact of cardiopulmonary bypass in level III-IV tumor thrombectomy on surgical and oncologic outcomes is unknown. We determine the impact of cardiopulmonary bypass on overall and cancer specific survival, as well as surgical complication rates and immediate outcomes in patients undergoing nephrectomy and level III-IV tumor thrombectomy with or without cardiopulmonary bypass. MATERIALS AND METHODS We retrospectively analyzed 362 patients with renal cell cancer and with level III or IV tumor thrombus from 1992 to 2012 at 22 U.S. and European centers. Cox proportional hazards models were used to compare overall and cancer specific survival between patients with and without cardiopulmonary bypass. Perioperative mortality and complication rates were assessed using logistic regression analyses. RESULTS Median overall survival was 24.6 months in noncardiopulmonary bypass cases and 26.6 months in cardiopulmonary bypass cases. Overall survival and cancer specific survival did not differ significantly in both groups on univariate analysis or when adjusting for known risk factors. On multivariate analysis no significant differences were seen in hospital length of stay, Clavien 1-4 complication rate, intraoperative or 30-day mortality and cancer specific survival. Limitations include the retrospective nature of the study. CONCLUSIONS In our multi-institutional analysis the use of cardiopulmonary bypass did not significantly impact cancer specific survival or overall survival in patients undergoing nephrectomy and level III or IV tumor thrombectomy. Neither approach was independently associated with increased mortality on multivariate analysis. Greater surgical complications were not independently associated with the use of cardiopulmonary bypass.
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Affiliation(s)
- Hao G Nguyen
- Department of Urology, UC Davis Medical Center, Sacramento, California, USA
| | - Derya Tilki
- Department of Urology, UC Davis Medical Center, Sacramento, California, USA
| | - Marc A Dall'Era
- Department of Urology, UC Davis Medical Center, Sacramento, California, USA
| | | | - Joaquín A Carballido
- Department of Urology, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Thomas Chromecki
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Gaetano Ciancio
- Miami Transplant Institute, University of Miami, Miami, FL, USA
| | - Siamak Daneshmand
- USC/Norris Comprehensive Cancer Center, Los Angeles, California, USA
| | - Paolo Gontero
- Department of Urology, A.O.U. San Giovanni Battista, University of Turin, Turin, Italy
| | - Javier Gonzalez
- Department of Urology, Hospital Central de la Cruz Roja San José y Santa Adela, Madrid, Spain
| | - Axel Haferkamp
- Department of Urology, University of Frankfurt, Frankfurt, Germany
| | | | - William C Huang
- Department of Urology, New York University School of Medicine, New York, USA
| | - Estefania Linares Espinós
- Department of Urology, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid, Madrid, Spain
| | - Philipp Mandel
- Institute of of Empirical Economic Research, University of Leipzig, Leipzig, Germany
| | - Juan I Martinez-Salamanca
- Department of Urology, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid, Madrid, Spain
| | - Viraj A Master
- Department of Urology, Emory University, Atlanta, Georgia, USA
| | - James M McKiernan
- Department of Urology, Columbia University College of Physicians and Surgeons, New York, USA
| | - Francesco Montorsi
- Department of Urology, Hospital San Raffaele, University Vita-Salute, Milano, Italy
| | | | - Sascha Pahernik
- Department of Urology, University of Heidelberg, Heidelberg, Germany
| | - Juan Palou
- Department of Urology, Fundació Puigvert, Barcelona, Spain
| | - Raj S Pruthi
- Department of Urology, UNC at Chappel Hill, Chapel Hill, North Carolina, USA
| | | | - Paul Russo
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Douglas S Scherr
- Department of Urology, Weill Cornell Medical Center, New York, USA
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | | | - Carlo Terrone
- Division of Urology, Maggiore della Carita Hospital, University of Eastern Piedmont, Novara, Italy
| | | | - Eric M Wallen
- Department of Urology, UNC at Chappel Hill, Chapel Hill, North Carolina, USA
| | - Evanguelos Xylinas
- Department of Urology, Weill Cornell Medical Center, New York, USA.,Department of Urology, Cochin Hospital, APHP, Paris Descartes University, Paris, France
| | - Richard Zigeuner
- Department of Urology, Medical University of Graz, Graz, Austria
| | - John A Libertino
- Department of Urology, Lahey Clinic, Burlington, Massachusetts, USA
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