Radical nephrectomy with en bloc resection of liver, diaphragm, and lung for locally invasive sarcomatoid renal cell carcinoma

Morbidity and mortality of multivisceral resection with radical nephrectomy for locally advanced renal cell carcinoma: An analysis of the National Surgical Quality Improvement Program (NSQIP) database

INTRODUCTION

Locally advanced renal cell carcinoma (RCC) can rarely invade into adjacent abdominal viscera without clinical evidence of distant metastases. The role of multivisceral resection (MVR) of involved adjacent organs at the time of radical nephrectomy (RN) remains poorly described and quantified. Using a national database, we aimed to evaluate the association between RN+MVR and 30-day postoperative complications.

METHODS AND MATERIALS

We conducted a retrospective cohort study of adult patients undergoing RN for RCC with and without MVR between 2005 and 2020 using the ACS-NSQIP database. The primary outcome was a composite of any of the following 30-day major postoperative complications: mortality, reoperation, cardiac event, and neurologic event. Secondary outcomes included individual components of the composite primary outcome, as well as infectious and venous thromboembolic complications, unplanned intubation and ventilation, transfusion, readmission, and prolonged length of stay (LOS). Groups were balanced using propensity score matching. Likelihood of complications was assessed by conditional logistic regression adjusted for unbalanced total operation time. Postoperative complications were compared by Fisher's exact test among subtypes of resection.

RESULTS

A total of 12,417 patients were identified: 12,193 (98.2%) undergoing RN alone and 224 (1.8%) undergoing RN+MVR. Patients undergoing RN+MVR were more likely to experience major complications (odds ratio [OR] 2.46; 95% confidence interval [CI] 1.28-4.74). However, there was no significant association between RN+MVR and postoperative mortality (OR 2.49; 95% CI 0.89-7.01). RN+MVR was associated with higher rates of reoperation (OR 7.85; 95% CI 2.38-25.8), sepsis (OR 5.45; 95% CI 1.83-16.2), surgical site infection (OR 4.41; 95% CI 2.14-9.07), blood transfusion (OR 2.24; 95% CI 1.55-3.22), readmission (OR 1.78; 95% CI 1.11-2.84), infectious complications (OR 2.62; 95% CI 1.62-4.24), and longer hospital stay (5 days [IQR 3-8] vs. 4 days [IQR 3-7]; OR 2.31 [95% CI 2.13-3.03]).  There was no heterogeneity in the association between subtype of MVR and major complication rate.

CONCLUSION

Undergoing RN+MVR is associated with an increased risk of 30-day postoperative morbidity, including infectious complications, reoperation, blood transfusion, prolonged LOS, and readmission.

3D reconstruction of CT scans aid in preoperative planning for sarcomatoid renal cancer: A case report and mini-review

Contrast-enhanced multi-slice computed tomography (MSCT) is commonly used in the diagnosis of complex malignant tumours. This technology provides comprehensive and accurate information about tumour size and shape in relation to solid tumours and the affected adjacent organs and tissues. This case report demonstrates the benefit of using MSCT 3D imaging for preoperative planning in a patient with late-stage (T4) sarcomatoid renal cell carcinoma, a rare renal malignant tumour. The surgical margin on the liver was negative, and no metastases to veins, lungs or other organs were detected by abdominal and chest contrast-enhanced CT. Although sarcomatoid histology is considered to be a poor prognostic factor, the patient is alive and well 17 months after surgery. The MSCT imaging modality enables 3D rendering of an area of interest, which assists surgical decision-making in cases of advanced renal tumours. In this case, as a result of MSCT 3D reconstruction, the patient received justified surgical treatment without compromising oncological principles.

A safe combined nephrectomy and right lobectomy using the liver hanging maneuver for huge renal cell carcinoma directly invading the right lobe of the liver: report of a case

We herein discuss a patient who underwent simultaneous combined right nephrectomy and right lobectomy of the liver. A 64-year-old male was diagnosed with a huge right renal cell carcinoma (RCC), 13 cm in diameter, which was invading directly into the right hepatic lobe. This type of RCC has been rarely reported, and an anterior approach using the liver hanging maneuver was extremely useful during hepatic parenchymal dissection. The liver parenchymal dissection was performed prior to mobilization of the liver, because the mobilization of the right lobe of the liver was impossible. During the hepatic parenchymal resection, the liver was suspended with the tape and transected, and thereafter, retroperitoneal dissection, nephrectomy and right lobectomy of the liver were completed. The patient was discharged from the hospital on the 12th postoperative day with an uneventful clinical course. The anterior approach using the liver hanging maneuver during hepatic parenchymal resection can be safe and feasible for huge RCC invading the right hepatic lobe.

MRI findings of sarcomatoid renal cell carcinoma in nine cases

PURPOSE

To assess the magnetic resonance imaging (MRI) features of a series of 9 cases of pathologically proven sarcomatoid renal cell carcinoma (SRCC).

METHODS

Two radiologists in consensus retrospectively reviewed a spectrum of MRI features of nine cases of SRCC imaged at our institution between 2003 and 2009.

RESULTS

SRCC had a mean diameter of 9.9 cm. All cases had an irregular or infiltrative morphology and demonstrated heterogeneous T2 signal intensity and enhancement. Internal necrosis was present in all cases, with four cases demonstrating >50% necrosis. Evidence of aggressive local behavior and/or distant spread was frequently observed.

CONCLUSIONS

We have presented the largest case series to our knowledge of the MRI appearance of SRCC, with the lesions tending to appear as large heterogeneous masses with internal necrosis and evidence of aggressive local or distant behavior. However, these imaging features are non-specific, and histology remains necessary to establish the diagnosis.

Combined nephrectomy and major hepatectomy: indications, outcomes, and recommendations

BACKGROUND

Simultaneous nephrectomy with major hepatectomy (NMH) is uncommon. We reviewed our experience with NMH.

STUDY DESIGN

Records of patients who underwent NMH at Emory Hospital between January 1995 and May 2008 were examined. Patients undergoing resection of three or more liver segments at the same setting as a total nephrectomy were included. Indications and outcomes were assessed.

RESULTS

Twenty patients underwent NMH. Mean (+/- SD) age was 59.9+/-12.8 years, 6 (30%) were women, and 15 (75%) presented with comorbidities. Most kidney neoplasms were renal cell carcinomas of the right kidney (n=16, 80%) with a mean diameter of 10.0+/-6.1 cm. Eight patients (40%) also underwent thrombectomy for inferior vena cava tumor thrombus. The most common indications for hepatectomy were direct liver invasion in eight patients (40%) and distant hepatic metastases in nine (45%); liver tumors were 4.2+/-3.3 cm (mean +/- SD) in diameter. Mean (+/- SD) operative time was 8.3+/-2.6 hours. Liver resections included 15 (75%) right hepatectomies and 5 (25%) left hepatectomies. In all cases, tumor negative hepatic margins were achieved. Median operative blood loss was 1,700 mL (range 200 to 8,000 mL). Ten patients (50%) suffered complications in the postoperative period; three of these suffered major complications, resulting in one perioperative death (5%). Mean hospital stay was 12+/-8.8 days. Overall survival was 25 months (range 0 to 34 months).

CONCLUSIONS

In this large series of nephrectomy with simultaneous major hepatectomy, morbidity and mortality were acceptable. In specialized centers NMH may be considered in properly selected patients for combined resection for synchronous neoplasms of the kidney and liver.

Tumor renal con invasión hepática: aportación de un nuevo caso y revisión de la literatura

Locally advanced renal cell carcinoma (RCC) with involvement to adjacent organs is uncommon and the prognosis is poor. Radical surgery remains the only effective treatment. We report the case of a woman with RCC and direct liver extension who was surgically treated. A literature review is made.