Surgical Outcomes After Cytoreductive Nephrectomy With Inferior Vena Cava Thrombectomy

En-Bloc Resection of Renal Cell Carcinoma With Tumor Thrombus Propagating Into the Intrapericardial Inferior Vena Cava: Efficacy and Safety of Transabdominal Approach

BACKGROUND

Renal cell carcinoma (RCC) is the most common primary kidney cancer. In up to 4-10% of patients, the tumor is complicated with a malignant thrombus extending to the inferior vena cava (IVC). Complete surgical excision of the RCC and the neoplastic thrombus can be curative. We aim to present a safe and feasible alternative transabdominal operative technique with the omission of thoracotomy, as applied in six patients diagnosed with RCC and IVC thrombus extending over the diaphragm.

METHODS

This case series study was conducted in a tertiary university hospital in Athens, Greece. All six patients, who were operated on for RCC and a malignant thrombus exceeding in the intrapericardial IVC in our department from January 2009 until March 2020, were screened. Intraoperatively, the infrarenal and intrapericardial IVC were clamped simultaneously with the renal and liver blood inflow. Access to the intrapericardial IVC was obtained via the central tendon of the diaphragm. Intrathoracic extension of the tumor was confirmed by transesophageal or intraoperative ultrasonography. The intrathoracic IVC was exposed to direct vision and two finger palpation was applied to secure the clamping of the IVC above the tip of the thrombus. The tumor was resected through a longitudinal venotomy and the operation was completed on a standard radical nephrectomy.

RESULTS

During the study period six patients presented with RCC and intrapericardial IVC thrombus. All patients, five female and one male, underwent radical nephrectomy combined with IVC thrombectomy, without the need for a thoracotomy. The mean age was 66 years old and the mean operative time was 122.5 minutes. Mean blood loss was 338 ml and only four of the patients were transfused with two units of RBC. Operative and hospital mortality was 0%. The hospital stay was seven (six to nine) days. Only one patient required readmission and reoperation 30 days later, due to intrapericardial herniation.

CONCLUSIONS

The proposed surgical technique may be curative in patients with advanced intracaval thrombus and helps reduce the associated morbidity, mortality, and the overall cost of more extended operations.

Long-term outcomes after cytoreductive nephrectomy and thrombectomy of patients with metastatic renal cell carcinoma with venous tumor thrombus: a retrospective study from a large Chinese center

BACKGROUND

Targeted therapy combined with immunotherapy is the current first-line treatment for metastatic renal cell carcinoma (mRCC), but patients with tumor thrombus (TT) may suffer from lower limb edema or even sudden cardiac death, so the purpose of this study is to investigate the efficacy and safety of surgical treatment in patients with mRCC and TT and explore worse factors to affect the prognosis in this series of patients.

PATIENTS AND METHODS

A total of 85 mRCC patients with TT who received cytoreductive nephrectomy and thrombectomy at our medical center from 2014 to 2023 are included. All patients received postoperative systemic therapy. Overall survival (OS) is defined as the time from surgery to death due to any reason or the last follow-up. Kaplan-Meier analysis was performed to evaluate OS and differences among groups were tested by log-rank. Multivariable Cox proportional hazards analysis was performed to ascertain independent relationships between clinicopathological factors and OS.

RESULTS

The median age of patients was 58 years old. Eleven patients (12.9%) had no symptoms, 39 patients (45.9%) had local symptoms, 15 patients (17.6%) had systemic symptoms, and 20 patients (23.5%) had both. Mayo grade of TT was 0, 1, 2, 3, and 4 for 12, 27, 31, 7, and 8 patients respectively. Fifty-five patients had lung metastasis, 23 had bone metastasis, 16 had liver metastasis, 13 had adrenal metastasis, and 9 had lymph node metastasis. Of all patients, 17 patients had multiple metastases. The median operation time is 289 min and the median intraoperative hemorrhage is 800 ml. Twenty-eight patients experienced postoperative complications, 8 of which were serious complications of modified Clavien grade III or higher. The median OS of all patients was 33 months and median follow up time was 26 months. In multivariate analysis, systemic symptom (p = 0.00753), pathological type (p = 0.0166), sarcomatous degeneration (p = 0.0334), and perirenal fat infiltration (p = 0.0202) are independent predictors of OS.

CONCLUSION

Cytoreductive nephrectomy and thrombectomy is relatively safe and effective for patients with mRCC accompanied by TT. In this series of patients, the worse prognosis is associated with systemic symptoms, non-clear cell carcinoma, sarcomatous degeneration and perirenal fat infiltration.

Effect of Inferior Vena Cava Tumor Thrombus on Overall Survival in Metastatic Renal Cell Carcinoma Patients Treated with Cytoreductive Nephrectomy

Background

Survival data regarding cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) patients according to the type and extent of tumor-associated vascular thrombus are scarce.

Objective

To test for survival differences in mRCC patients treated with CN according to the type and extent of tumor-associated vascular thrombus.

Design, setting, and participants

Within Surveillance, Epidemiology, and End Results Research Plus (2004–2017), we identified CN mRCC patients with renal vein (pT3a-TT) versus infradiaphragmatic inferior vena cava (IVC; pT3b) versus supradiaphragmatic IVC tumor thrombus/IVC invasion (pT3c).

Outcome measurements and statistical analysis

Overall survival (OS) was addressed in Kaplan-Meier and Cox regression analyses, in addition to 3-mo landmark analyses.

Results and limitations

Of 2170 mRCC patients, 1880 (87%), 204 (9%), and 86 (4%) harbored pT3a-TT, pT3b, and pT3c, respectively. The respective median OS periods were 21, 23, and 12 mo (p < 0.001). In multivariable Cox regression models, pT3c stage, but not pT3b stage, was an independent predictor of higher overall mortality (hazard ratio [HR]: 1.37; 95% confidence interval [CI]: 1.09–1.73; p = 0.007), as well as in 6-mo landmark analyses (HR: 1.36; 95% CI: 1.02–1.80; p = 0.04). In the sensitivity analysis, relying on all pT3a patients, the predictor status of pT3c stage remained unchanged (HR: 1.37; 95% CI: 1.09–1.71; p = 0.007). Limitations have to be addressed regarding the sample size and the retrospective design of the current study.

Conclusions

Although overall mortality is significantly higher in pT3c mRCC patients than in their pT3b and pT3a-TT counterparts, these individuals may still expect 12-mo or better OS after CN versus virtually 2-yr OS in their pT3a and pT3b counterparts.

Patient summary

In this study, we looked at the survival outcomes of metastatic renal cell carcinoma patients who presented with tumor thrombus at cytoreductive nephrectomy. Even though these patients with most advanced tumor thrombus stage demonstrated lower survival rates, the median overall survival was still 1 yr.

Application of 18F Prostate-Specific Membrane Antigen Positron Emission Tomography/Computed Tomography in Monitoring Gastric Metastasis and Cancer Thrombi from Renal Cell Carcinoma

Background. Renal cell carcinoma (RCC) with gastric metastasis is rare, particularly accompanied by multiple cancer thrombi. Methods. We reported a 66-year-old man with a history of a right radical nephrectomy because of RCC. The patient underwent 18F prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) scanning after 6 months of targeted therapy because of gastric metastasis and cancer thrombi. We conducted a systematic review of the literature and identified 73 cases of RCC with gastric metastasis. We analyzed the clinicopathological characteristics, therapies, and outcomes of patients. Results. 18F-PSMA PET/CT showed a large mass in the gastric fundus and cancer thrombi in the right atrium, inferior vena cava, and splenic vein with intense tracer uptake. Other metastases with increased tracer uptake included multiple bones and abdominal lymph nodes. The majority of gastric metastasis of RCC were men (53/73, 72.6%), with a median age at presentation of 67 (from 48 to 87) years. Gastric metastasis of RCC was mainly metachronous, and presented with small polyps or mass appearance and often accompanied by multiple-site metastases and gastrointestinal symptoms. An overall median interval between nephrectomy and diagnosis of gastric metastasis was 6 (from 0.1 to 23) years, and an overall median survival time was 14 (from 0.25 to 72) months. The median interval time of solitary gastric metastasis was longer than gastric metastasis with multiple-site metastases (7 vs.5 years; $P=0.034$ ). Patients with gastric and multiple-site metastases had higher mortality than patients with solitary metastasis (17 vs.1; $P=0.028$ ). The patients with synchronous gastric metastasis had a shorter survival time than metachronous gastric metastasis (6 vs.17 months; $P=0.018$ ). Conclusions. Postoperative follow-up of multiple imaging modalities to monitor recurrence and metastasis is necessary and important. PSMA PET/CT can improve the detection sensitivity of RCC, especially in metastatic clear cell renal cell carcinoma (ccRCC), and could provide a basis for disease staging, restaging, and therapeutic efficacy evaluation.

Surgical treatment of renal cell carcinoma with inferior vena cava tumor thrombus

PURPOSE

The present report discusses the indications of cardiopulmonary bypass (CPB) in open nephrectomy and surgical outcomes of conventional and minimally invasive surgical techniques for treating advanced renal cell carcinoma with inferior vena cava tumor thrombus.

METHODS

The present study involved a comprehensive retrieval of pertinent literature from the most recent two decades.

RESULTS

Comparisons between radical nephrectomy procedures in terms of open, laparoscopic and robotic-assisted surgeries revealed that open surgery had more blood loss, a longer operation time and higher mortality rates than laparoscopic and robotic-assisted surgeries. Furthermore, surgery with CPB was associated with more blood loss than non-CPB surgery. Rates of early and late deaths were much higher in patients with CPB than in those without CPB.

CONCLUSIONS

Different surgical techniques had different indications in terms of levels of inferior vena cava tumor thrombus. The laparoscopic, robotic-assisted, open surgical techniques and CPB with deep hypothermic circulatory arrest were indicated for Levels I, II, III and III-IV inferior vena cava tumor thrombus, respectively. Laparoscopic and robotic-assisted surgeries cause less trauma than open surgery but require more complicated equipments to support the procedure. CPB should be avoided in radical nephrectomy whenever possible. The increased application of laparoscopic and robotic techniques in the future is anticipated.

Radical nephrectomy and vena caval thrombectomy with the use of cardiopulmonary bypass and hypothermic circulatory arrest: Experience at a large tertiary institution

Objective:

This study aimed to review the experience at a large regional tertiary centre of open radical nephrectomy (RN) with vena caval thrombectomy with cardiopulmonary bypass (CPB) and hypothermic circulatory arrest (HCA) for the management of renal masses.

Method:

Data on patients with renal masses who had undergone RN and vena caval thrombectomy with CPB and HCA had been prospectively collected at two centres over a 19-year period (2000–2019). Twenty-three consecutive patients were identified and retrospectively analysed for operative and tumour characteristics and for postoperative outcome. Kaplan–Meier survival analysis was performed to compare patient outcomes based on tumour characteristics.

Results:

Median operating time was 358 minutes (interquartile range (IQR)=94 minutes), median bypass time was 117 minutes (IQR=28.5 minutes) and median circulation arrest time was 25 minutes (IQR=18.5 minutes). The median hospital length of stay was 11 days (IQR=5.3 days). Total complication rate was 52% ( n=12), consisting of four minor and eight major complications (Clavien–Dindo score >IIIa), including one intraoperative death. The overall five-year survival rate was 73% (11/15), with a median follow-up time of 53.1 months. Eleven (48%) patients were surgically cured, with a median follow-up time of 60.1 months (IQR=71.8 months). Disease recurrence was seen in eight (35%) patients, of whom four died. Patients who died survived for a median of 46.5 months. Median survival after the diagnosis of metastatic disease was seven months.

Conclusions:

We report the largest Australian cohort of RN with vena caval thrombectomy with CPB and HCA. We demonstrate outcomes comparable to major overseas centres, with an overall five-year survival rate of 73%. This suggests that even patients with extensive venal caval thrombus from renal masses can experience long-term survival benefit from RN and venal caval thrombectomy.

Level of evidence:

Level 3.

Impact of sarcopenia on post-operative outcomes following nephrectomy and tumor thrombectomy for renal cell carcinoma with inferior vena cava thrombus

OBJECTIVE

Sarcopenia is associated with oncological outcomes in various types of cancer. However, the impact of sarcopenia in renal cell carcinoma with inferior vena cava thrombus remains unclear. We herein evaluated the prognostic significance of sarcopenia for renal cell carcinoma with inferior vena cava thrombus following nephrectomy and thrombectomy.

METHODS

Patients who underwent nephrectomy and thrombectomy for renal cell carcinoma with inferior vena cava thrombus at our department between 2004 and 2019 were retrospectively evaluated. Their sarcopenic status, determined by sex, body mass index and skeletal muscle index, was calculated using pre-surgical radiographic imaging. We compared the post-operative cancer-specific survival and overall survival, surgical data and duration of post-operative hospitalization of sarcopenic and non-sarcopenic patients.

RESULTS

Out of 83 patients, 54 (65%) were sarcopenic. Sarcopenic patients had significantly shorter cancer-specific survival (median: 33.3 months vs. not reached, P = 0.0323) and overall survival (32.0 months vs. not reached, P = 0.0173) than non-sarcopenic patients. Furthermore, multivariate analyses showed that sarcopenia was an independent factor for cancer-specific survival (hazard ratio: 2.76, P = 0.0212) and overall survival (hazard ratio: 2.93, P = 0.014). The incidence rate of surgical complications (any grade: 35.2% vs. 27.6%, P = 0.482; grades ≥ 3: 7.4% vs. 10.3%, P = 0.648) or duration of post-operative hospitalization (median: 11 vs. 10 days, P = 0.148) was not significantly different between sarcopenic and non-sarcopenic patients.

CONCLUSIONS

In conclusion, this study showed that sarcopenia was an independent prognostic factor for renal cell carcinoma with inferior vena cava thrombus after nephrectomy and tumor thrombectomy. Thus, sarcopenia evaluation can be utilized as an effective prognosticator of post-operative survival.

Surgery for high-risk locally advanced (pT3c) renal tumours: oncological outcomes and prognostic significance of a modified International Metastatic Renal Cell Cancer Database Consortium (IMDC) score

OBJECTIVES

To evaluate contemporary oncological outcomes and long-term survival in patients undergoing surgery for urological tumours involving the peridiaphragmatic inferior vena cava up to the level of the right atrium. To apply prognostic factors developed for metastatic renal cancer to patients with very-high-risk but apparently localized tumours, and develop a scoring system.

PATIENTS AND METHODS

A retrospective cohort study of 54 patients referred between December 2007 and April 2018 to a single surgical and oncological team was conducted. Electronic patient records were used to obtain peri-operative data and oncological follow-up. For operated patients lost to follow-up, survival data were obtained from primary care physicians. We used Kaplan-Meier curves to estimate overall survival (OS) and disease-free survival. For the subgroup undergoing curative surgery (n = 32) the prognostic value of a renal cancer score developed at Guy's Hospital using five of the six criteria in the International Metastatic Renal Cell Carcinoma Database Consortium prognostic model (one point for each of anaemia, neutrophilia, thrombophilia, hypercalcaemia and Karnofsky performance status <80), in order to be relevant for M0 disease, was assessed using the log-rank test.

RESULTS

The median (interquartile range [IQR]) OS of the whole cohort was 29 (11-57) months. The median (IQR) survival of the curative subgroup (n = 32) was 32 (16-57) months, vs 11 (4-upper limit not reached) months for the cytoreductive subgroup (n = 13; P = 0.14). The median (IQR) follow-up time was 14 (1-65) months for patients alive at analysis. Disease-free survival in the curative subgroup was 10 (6-30) months. The median (IQR) OS by risk category for curative cases, as defined by the Guy's renal cancer score, was not reached in the favourable risk group (score = 0 points) because there were no patient deaths, 43 (30-61) months in the intermediate-risk group (score = 1 point), and 18 months (11-32) months in the poor-risk group (score ≥ 2 points; P = 0.005).

CONCLUSION

A median survival of 29 months appears to justify this type of surgery. A prognostic model, the Guy's renal cancer score, using five readily available clinical measures, appears promising in patients with very-high-risk locally advanced tumours.

Cytoreductive nephrectomy in patients with metastatic renal cell carcinoma and venous thrombus-Trends and effect on overall survival

PURPOSE

Patients with metastatic renal cell carcinoma (mRCC) commonly present with tumor thrombi in the renal vein and inferior vena cava (IVC). The benefit of cytoreductive nephrectomy (CN) in this population is unclear and the effect on overall survival (OS) has been incompletely evaluated.

MATERIALS AND METHODS

We queried the National Cancer Database from 2010 to 2013 for patients diagnosed with mRCC and tumor thrombi, which was defined as renal vein, infradiaphragmatic IVC, or supradiaphragmatic IVC. Descriptive statistics were performed and associations between clinicopathologic variables and utilization of CN were analyzed. Patients were matched on the receipt of CN and Kaplan-Meier analyses and multivariable Cox proportional hazards models were used to estimate survival.

RESULTS

In total, 8,629 patients were found to have mRCC during the study period. Approximately 27% (n = 2,376) had tumor thrombus. Tumor thrombus was associated with increased rates of CN utilization, however rates decreased as thrombus level increased. In a matched Kaplan-Meier analysis, CN was associated with improved OS in patients without thrombus, and with renal vein or infradiaphragmatic thrombus (all P < 0.01). Patients with supradiaphragmatic thrombus did not benefit from CN (P = 0.46). This effect was confirmed in a Cox proportional hazards model.

CONCLUSIONS

Tumor thrombus is common in patients with mRCC. OS is poor, and patient and tumor specific factors influence the use of CN. Despite discrepancies in utilization, CN is associated with improved OS, although this effect appears to be limited to those with mRCC and tumor thrombus limited to the renal vein and infradiaphragmatic IVC.

Surgical management of renal cell carcinoma with associated tumor thrombus extending into the inferior vena cava: A 10-year single-center experience

OBJECTIVE

Renal cell carcinoma (RCC) is a tumor that has a tendency of vascular invasion by extending to the inferior vena cava (IVC) after the renal vein. The total resection of the renal tumor and tumor thrombus is considered the optimal treatment. In our study, we aimed to present the results related to 34 consecutive cases of RCC with tumor thrombus.

MATERIAL AND METHODS

Of the 442 patients diagnosed with renal tumors between January 2008 and January 2018, 34 (7.6%) had tumor thrombus over the renal vein extending to the IVC. The data of the 34 patients with tumor thrombus were retrospectively reviewed and included in the study. All the 34 patients underwent radical nephrectomy with tumor thrombectomy. The presence of thrombus was evaluated using contrast-enhanced abdominal tomography, magnetic resonance imaging, or color Doppler ultrasonography. The level of thrombus was classified using the Mayo Clinic tumor thrombus classification. Surgery was performed transperitoneally through a modified Chevron incision and mostly in collaboration with other clinics. Complications were classified according to the Clavien system.

RESULTS

Of the 34 patients, 22 were males and 12 were females. The mean follow-up period was 36±27.2 months in patients who had a mean age of 61±10.9 years. The mean tumor size was 10.5±3.3 cm. The number of patients according to the thrombus levels I, II, and III were 20, 9, and 5, respectively. The average blood loss was 744±285.4 mL. Radical surgery for all patients who had direct invasion to the vena cava wall and/or level II and III was performed by gastrointestinal and cardiothoracic surgeons. Cardiopulmonary bypass was not performed in any patient. Minor complications (Clavien grades 1-2) were seen in 8 (23.5%) patients, while 2 (5.8%) patients had major complications (Clavien grades 3-5). The mean follow-up period was 36 months (range, 6-72 months). The overall 5-year survival rate was 85.2%.

CONCLUSION

We think that radical nephrectomy and caval thrombectomy is a safe and effective method in patients with RCC without tumor exceeding the diaphragmatic level. We believe that the surgical success rate can be increased using a multidisciplinary approach in selected cases.

[Limits of surgery in uro-oncology]

The limits of cancer surgery in uro-oncology are characterized by a carefully weighed risk of surgical feasibility and oncological necessity. The limits of uro-oncological cancer surgery do not represent fixed dogmas but ideally these more or less cognitive boundaries move based on new scientific findings, improved imaging modalities, optimized surgical techniques and perioperative care. The limits of cancer surgery are defined by patient-specific parameters, the biological aggressiveness of the tumor itself, the skills and expertise of the surgeon, and adequate perioperative care of the patient. Dependent on the origin of the cancers of the upper and lower urogenital tract, the specific particularities of each individual cancer in terms of prognosis need to be known, taking into consideration the newest molecular insights and modern multimodality treatment regimes. Only the consideration of the above mentioned basics will allow the best decision to be made with the patient concerning the optimal individual treatment. The current article highlights general parameters of the patient, tumor and surgeon which might define the limits of cancer surgery in uro-oncology. In addition, specific clinical scenarios are discussed with regard to surgery limits in cancer of the kidney, the prostate and the testis.

Indications, complications, and outcomes following surgical management of locally advanced and metastatic renal cell carcinoma

INTRODUCTION

Surgery may set the basis for a potential cure or would provide the best achievable quality of life in locally advanced or metastatic renal cell carcinoma (mRCC). However, survival extension with this approach would be scarce and not exempt from adverse events, thus preventing its recommendation in an already frail patient. An evidence based analysis on the role of surgery in each of the possible clinical scenarios involved under this heading may provide a clear picture on this issue and would be of value in the decision making process. Areas covered: Current literature was queried in PubMed/Medline in a systematic fashion. Manuscripts included were selected according to the quality of the data provided. A narrative review strategy was adopted to summarize the evidence acquired. Expert commentary: A surgery-based multimodal treatment approach should be strongly considered after adequate counseling in locally advanced and mRCC, since it may provide for additional benefits in terms of survival. However, a critical reevaluation of its adequacy, optimal timing, and selection of ideal candidates is currently ongoing.

Surgical Management of Renal Cell Carcinoma Extending Into Venous System: A 20-Year Experience

BACKGROUND AND AIMS

The purpose of this study is to report our 20-year experience with the surgical management of renal cell carcinoma extending into the inferior vena cava using a novel classification system.

MATERIALS AND METHODS

We retrospectively reviewed the data of 103 patients (69 males, 34 females, mean age: 52.9 ± 12.6 years) with renal cell carcinoma involving the venous system treated between 1993 and 2014. The inferior vena cava tumor thrombus was classified into five levels: 0 (renal vein, n = 12), 1 (infrahepatic, n = 33), 2a (low retrohepatic, n = 26), 2b (high retrohepatic, n = 19), and 3 (supradiaphragmatic, n = 13). Clinical data were summarized, and overall survival, cancer-specific survival, and disease-free survival were examined by Cox regression analysis.

RESULTS

All patients underwent radical surgery. Complete resections of the renal tumor and thrombus were achieved in 101 patients (98.1%). Two intraoperative and one postoperative in-hospital deaths (2.9%) occurred. In total, 19 patients (18.8%) had a total of 29 postoperative complications. Mean follow-up time was 46 months (range, 1-239 months). The 5- and 10-year overall survival rates were 62.9% and 56.0%, respectively. Metastasis, rather than thrombus level, was a significant risk factor associated with overall survival (hazard ratio = 4.89, 95% confidence interval: 2.24-10.67, p < 0.001).

CONCLUSION

Our novel classification system can be used to select the optimal surgical approach and method for patients with renal cell carcinoma and venous thrombus. Its use is associated with prolonged survival and relatively few complications. Metastasis is an independent risk factor of overall survival.

Cytoreductive nephrectomy with thrombectomy before targeted therapy improves survival for metastatic renal cell carcinoma with venous tumor thrombus: a single-center experience

Background

The aim of the study is to evaluate the role of cytoreductive nephrectomy (CN) with thrombectomy before targeted molecular therapy (TMT) on survival in metastatic renal cell carcinoma (mRCC) with venous tumor thrombus.

Methods

We performed a retrospective analysis of 47 patients treated in our center from April 2008 to October 2014. In the study, 20 patients underwent CN with thrombectomy followed by targeted therapy (group 1); 15 patients received targeted therapy alone (group 2); and 12 patients underwent CN with thrombectomy alone (group 3). The overall survival (OS) and cancer-specific survival (CSS) were calculated according to the Kaplan-Meier survival curve method, and prognostic variables were assessed by Cox regression analyses.

Results

The median follow-up times of group 1, group 2, and group 3 were 24.5, 12, and 6.5 months, respectively. During follow-up, in both group 1 and group 3, 12 patients died. In group 2, 14 patients died. The median OS of group 1, group 2, and group 3 was 22, 12, and 6 months, respectively (P < 0.001). Compared with surgery alone and targeted therapy alone, patients with cytoreductive surgery before targeted therapy had statistically better survival benefits (P < 0.001, P = 0.009, respectively). On univariate analysis, the number of metastatic sites (P = 0.004) was a statistically significant prognostic factor influencing OS.

Conclusions

Our single-center experience showed that CN with thrombectomy before targeted therapy improved the survival of patients with mRCC with venous tumor thrombus. The number of metastatic sites was an independent prognostic factor influencing OS.

Raised preoperative international normalised ratio (INR) identifies patients at high risk of perioperative death after simultaneous renal and cardiac surgery for tumours involving the peri-diaphragmatic inferior vena cava and right atrium

OBJECTIVE

To identify preoperative factors that predict 30-day mortality in patients undergoing simultaneous cardiac and renal surgery for urological tumours involving the peri-diaphragmatic vena cava and right atrium- The ability to predict mortality and therefore avoid surgery in those patients likely to die would be valuable.

PATIENTS AND METHODS

We retrospectively reviewed perioperative outcomes in patients managed between December 2007 and January 2016 by a single team. The relationships of outcome measurements were analysed using Fisher's exact and Mann-Whitney U-tests.

RESULTS

Of the 46 patients identified, 41 (89%) underwent surgery (20 males and 21 females). The median (range) age was 65 (17-95) years. Histology confirmed 37 renal cell cancers, one adrenal cancer, two primitive neuroectodermal tumours, and one leiomyosarcoma. The overall 30-day mortality rate was 7% (three of 41 patients). The international normalised ratio (INR), age, and estimated glomerular filtration rate (eGFR) correlated significantly with 30-day mortality. The mortality rate was high in patients with an INR ≥1.5 and <1.5 (with three of the five patients dying) compared to those with an INR <1.5 (0/36 patients died; 30 day mortality 0%). The INR correlated with serious complications (≥Clavien-Dindo Grade III), which occurred in all five patients with an INR ≥1.5 and <1.5 vs 12/36 (33%) with an INR <1.5 (P < 0.002). The median (range) eGFR in those that died was 36 (26-37) mL/min/1.73 m² compared to 52 (24-154) mL/min/1.73 m² in those that survived (P = 0.018).

CONCLUSIONS

In patients undergoing combined cardiac and renal tumour surgery raised preoperative INR is associated with a high risk of 30-day mortality when the patient is elderly (>70 years) and of significant post-operative complications in younger patients (<70 years). Surgery in patients with a normal INR is challenging but much safer.

Renal cell carcinoma with thrombus extending to the hepatic veins or right atrium: operative strategies based on 41 consecutive patients

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.

Management of inferior vena cava tumor thrombus in locally advanced renal cell carcinoma

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.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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