Vein invasion in renal cell carcinoma: impact on metastatic behavior and survival

A 10-year Australian experience of rare intraabdominal venous thrombosis with comparison to deep vein thrombosis and pulmonary embolism

OBJECTIVE

Intra-abdominal venous thromboembolism is rare with heterogeneous management. We aim to evaluate these thrombosis and compare them to deep vein thrombosis and/or pulmonary embolism.

METHOD

A 10-year retrospective evaluation of consecutive venous thromboembolism presentations (January 2011-December 2020) at Northern Health, Australia, was conducted. A subanalysis of intraabdominal venous thrombosis involving splanchnic, renal and ovarian veins was performed.

RESULTS

There were 3343 episodes including 113 cases of intraabdominal venous thrombosis (3.4%) - 99 splanchnic vein thrombosis, 10 renal vein thrombosis and 4 ovarian vein thrombosis. Of the splanchnic vein thrombosis presentations, 34 patients (35 cases) had known cirrhosis. Patients with cirrhosis were numerically less likely to be anticoagulated compared to noncirrhotic patients (21/35 vs. 47/64, P  = 0.17). Noncirrhotic patients ( n  = 64) were more likely to have malignancy compared to those with deep vein thrombosis and/or pulmonary embolism (24/64 vs. 543/3230, P  < 0.001), including 10 patients diagnosed at time of splanchnic vein thrombosis presentation. Cirrhotic patients reported more recurrent thrombosis/clot progression (6/34) compared to noncirrhotic patients (3/64) (15.6 vs. 2.3 events/100-person-years; hazard ratio 4.7 (95% confidence interval 1.2-18.9), P  = 0.030) and other venous thromboembolism patients (2.6/100-person-years; hazard ratio 4.7, 95% confidence interval 2.1-10.7; P  < 0.001) with comparable major bleeding rates. All renal vein thrombosis were provoked including five malignant-related cases while three ovarian vein thrombosis occurred postpartum. No recurrent thrombotic or bleeding complications were reported in renal vein thrombosis and ovarian vein thrombosis.

CONCLUSION

These rare intraabdominal venous thromboses are often provoked. Splanchnic vein thrombosis (SVT) patients with cirrhosis have a higher rate of thrombotic complications, while SVT without cirrhosis was associated with more malignancy. Given the concurrent comorbidities, careful assessment and individualized anticoagulation decision is needed.

Critical Evaluation of a microRNA-Based Risk Classifier Predicting Cancer-Specific Survival in Renal Cell Carcinoma with Tumor Thrombus of the Inferior Vena Cava

(1) Background: Clear cell renal cell carcinoma extending into the inferior vena cava (ccRCCIVC) represents a clinical high-risk setting. However, there is substantial heterogeneity within this patient subgroup regarding survival outcomes. Previously, members of our group developed a microRNA(miR)-based risk classifier—containing miR-21-5p, miR-126-3p and miR-221-3p expression—which significantly predicted the cancer-specific survival (CSS) of ccRCCIVC patients. (2) Methods: Examining a single-center cohort of tumor tissue from n = 56 patients with ccRCCIVC, we measured the expression levels of miR-21, miR-126, and miR-221 using qRT-PCR. The prognostic impact of clinicopathological parameters and miR expression were investigated via single-variable and multivariable Cox regression. Referring to the previously established risk classifier, we performed Kaplan–Meier analyses for single miR expression levels and the combined risk classifier. Cut-off values and weights within the risk classifier were taken from the previous study. (3) Results: miR-21 and miR-126 expression were significantly associated with lymphonodal status at the time of surgery, the development of metastasis during follow-up, and cancer-related death. In Kaplan–Meier analyses, miR-21 and miR-126 significantly impacted CSS in our cohort. Moreover, applying the miR-based risk classifier significantly stratified ccRCCIVC according to CSS. (4) Conclusions: In our retrospective analysis, we successfully validated the miR-based risk classifier within an independent ccRCCIVC cohort.

Histological features suggestive of survival in patients with renal cell carcinoma and tumor thrombus: A single-center experience

Purpose

To evaluate the impact of histological subtype on the survival of patients with renal cell carcinoma (RCC) and tumor thrombus (TT).

Patients and methods

We retrospectively analyzed 350 patients with RCC and TT admitted to Chinese People’s Liberation Army General Hospital between January 2006 and June 2021. The patients underwent radical nephrectomy and thrombectomy using robot-assisted laparoscopic, laparoscopic, or open surgery. The clinical and pathological parameters of the patients were taken from their medical records. Survival was calculated with the Kaplan–Meier method. Univariate and multivariate Cox regression analyses were performed to evaluate the prognostic significance of variables on overall survival (OS) and progression-free survival (PFS).

Results

TT levels 0–IV were observed in 132 (37.71%), 43 (12.29%), 134 (38.29%), 20 (5.71) and 21 (6.00%) patients, respectively. Papillary (pRCC), clear cell, and other histological subtypes of RCC were detected in 28 (8.00%), 286 (81.71%), and 36 (10.29%) patients, respectively. Compared to the clear cell cohort, collecting systemic invasion (46.43 vs. 25.17%; p = 0.030) and lymph node metastasis (39.29 vs. 11.54%; p < 0.01) were more common in the pRCC cohort. Kaplan–Meier analyses showed that patients with pRCC and other subtypes had significantly worse OS and PFS compared to patients with the clear cell subtype (p < 0.05). Multivariate analyses revealed that histology was independently associated with reduced OS and PFS, including among patients without lymph node and distant metastasis (N0M0).

Conclusion

Papillary or other subtypes have a considerably shorter OS and PFS compared to clear cell subtype in RCC patients with TT. Strict follow-up and surveillance should be performed for papillary or other subtypes RCC with TT.

Radical Nephrectomy in Renal Cell Carcinoma with Venous Tumoral Thrombus: Long-term Outcomes and Overall Survival

Objective To describe the five-year overall survival (OS) and perioperative morbidity of patients with renal cell carcinoma (RCC) with venous tumor thrombus (VTT) treated through radical nephrectomy and thrombectomy.

Materials and Methods We evaluated a cohort of 530 patients with a diagnosis of RCC from January 2009 to December 2019, and found VTT in 42 of them; these 42 patients composed the study sample. The patients were stratified according to the Neves Thrombus Classification (NTC). The baseline and perioperative characteristics, as well as the follow-up, were described. The Kaplan-Meier curve and its respective Cox regression were applied to present the 5-year OS and the OS stratified by the NTC.

Results The average age of the sample was of 63.19 ± 10.7 years, and there were no differences regarding gender. In total, VTT was present in 7.9% of the patients. According to the NTC, 30.9% of the cases corresponded to level I, 21.4%, to level II, 26.1%, to level III, and 21.4%, to level IV. The 5-year OS was of 88%. For level-I and level-II patients, the 5-year OS was of 100%, and of only 38% among level-IV patients. Complications, mostly minor, occurred in 57% of the cases.

Conclusions Radical nephrectomy with thrombectomy is a morbid procedure; however, most complications are minor, and the five-year mortality is null for patients in NTC levels I and II, and low for levels III and IV, and it may be even lower in level-III patients when standardizing transesophageal echocardiogram intraoperatively and routinary extracorporeal bypass. Thus, we recommend considering this surgery as the first-line management in patients with RCC and VTT.

Large left moiety renal tumor with renal vein thrombus in a horseshoe kidney

Background

Management of large renal tumors in a horseshoe kidney has received little attention due to the highly infrequent occurrence. Surgical management for tumors in horseshoe kidney is challenging due to complex aberrant vascular anatomy, relative fixity of the renal moieties and other associated conditions such as ectopia and malrotation. An added component of a renal vein thrombus in this scenario often adds to the surgical conundrum. Inadequate peri-operative management may cause devastating complications and increased morbidity and mortality. Careful pre-operative planning and meticulous intra-operative dissection limits blood loss and thereby complications.

Case presentation

We present the peri-operative management of a large renal tumor with a renal vein thrombus in a horseshoe kidney moiety as a case report with literature review focusing on the intra-operative surgical approach that may be adopted for these tumors. A 12 cm × 10 cm left renal moiety mass with renal vein thrombus with no distant metastasis was diagnosed. After confirmation of thrombus extent with CT as well as MRI Abdomen, the patient underwent left moiety radical nephrectomy with renal vein thrombectomy. Careful intra-operative dissection and division of the vascular supply of the left renal moiety was performed. Vessel stapler was used for division of isthmus that resulted in minimal blood loss, complete oncologic clearance and minimal post operative morbidity.

Conclusions

Large renal tumor with renal vein thrombus in horseshoe kidneys is an uncommon condition. Pre operative cross-sectional imaging and intra-operative use of vessel sealants like Ligasure, harmonic scalpel and vessel staplers contribute to minimizing blood loss and thereby result in excellent patient outcomes. We report a case of a large left renal moiety tumor with renal vein thrombus successfully managed with open radical left moiety nephrectomy and isthmectomy with tumor thrombectomy.

Prognostic Factors for Localized Clear Cell Renal Cell Carcinoma and Their Application in Adjuvant Therapy

Simple Summary

Approximately one fifth of patients with newly diagnosed renal cell carcinoma (RCC) present with metastatic disease and over one third of the remaining patients with localized RCC will eventually have metastases spread to distant sites after complete resection of the primary tumor in the kidney. Usually, disease recurrence is observed within the first five years of follow-up, but late recurrences after five years are seen in up to 10% of patients. Despite novel biomarkers, simple histopathological factors, such as tumor size, tumor grade, and tumor extension into the blood vessels or beyond the kidney, are still valid features in predicting the risk of disease recurrence after surgery. The optimal set of prognostic factors remains unclear. The results from ongoing placebo-controlled adjuvant therapy trials may elucidate prognostic features that help to define high-risk patients for disease recurrence.

Abstract

Approximately 20% of patients with renal cell carcinoma (RCC) present with primarily metastatic disease and over 30% of patients with localized RCC will develop distant metastases later, after complete resection of the primary tumor. Accurate postoperative prognostic models are essential for designing personalized surveillance programs, as well as for designing adjuvant therapy and trials. Several clinical and histopathological prognostic factors have been identified and adopted into prognostic algorithms to assess the individual risk for disease recurrence after radical or partial nephrectomy. However, the prediction accuracy of current prognostic models has been studied in retrospective patient cohorts and the optimal set of prognostic features remains unclear. In addition to traditional histopathological prognostic factors, novel biomarkers, such as gene expression profiles and circulating tumor DNA, are extensively studied to supplement existing prognostic algorithms to improve their prediction accuracy. Here, we aim to give an overview of existing prognostic features and prediction models for localized postoperative clear cell RCC and discuss their role in the adjuvant therapy trials. The results of ongoing placebo-controlled adjuvant therapy trials may elucidate prognostic factors and biomarkers that help to define patients at high risk for disease recurrence.

Experience with management of renal cell carcinoma with inferior vena cava/right atrial tumor thrombus

Introduction:

We aimed to present our experience in managing renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus.

Methods:

Records of all patients aged 18 years and older, with a diagnosis of primary renal masses with IVC thrombus, presenting to our institute from January 2012 to August 2020 were retrospectively reviewed. Patients with tumor thrombus limited only to renal vein were excluded from the analysis. Their hospital course and outcomes were recorded and evaluated for predictors of survival.

Results:

During the study period, we treated 61 patients with a renal mass and concurrent IVC thrombus and 56 of these underwent surgery. 7 of them had level III and 6 had level IV thrombus. A total of six patients received neoadjuvant tyrosine kinase inhibitor (TKI) therapy and all of them showed a decrease in size and level of tumor thrombus and cardiopulmonary bypass was safely avoided. Fourteen patients had distant metastasis and underwent cytoreductive surgery and of these 12 patients received TKI therapy after surgery with a mean survival of 26.8 months. The overall survival at 2 and 5 years of nonmetastatic group was 81.1% and 47.5% respectively and in metastatic group was 35.1% and 0%, respectively. Poor performance status, distant metastasis, higher T stage, higher thrombus levels, and positive surgical margins were all predictors of decreased survival.

Conclusions:

Complete surgical resection in both nonmetastatic and metastatic RCC with IVC thrombus has long-term survival benefits. Neoadjuvant TKI therapy, with adequate preoperative planning, helps in decreasing the size of the thrombus and in safely avoiding bypass in level III and IV IVC thrombi.

A Concise Review of the Multimodality Imaging Features of Renal Cell Carcinoma

The evaluation of renal cell carcinoma (RCC) is routinely performed using the multimodality imaging approach, including ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). Ultrasonography is the most frequently used imaging modality for the initial diagnosis of renal masses. The modality of choice for the characterization of the renal mass is multiphasic CT. Recent advances in CT technology have led to its widespread use as a powerful tool for preoperative planning, reducing the need for catheter angiography for the evaluation of vascular invasion. CT is also the standard imaging modality for staging and follow-up. MRI serves as a problem-solving tool in selected cases of undefined renal lesions. Newer MRI techniques, such as arterial spin labeling and diffusion-weighted imaging, have the potential to characterize renal lesions without contrast media, but these techniques warrant further investigation. PET may be a useful tool for evaluating patients with suspected metastatic disease, but it has modest sensitivity in the diagnosis and staging of RCC. The newer radiotracers may increase the accuracy of PET for RCC diagnosis and staging. In summary, the main imaging modality used for the characterization, staging, and surveillance of RCC is multiphasic CT. Other imaging modalities, such as MRI and PET, are used for selected indications.

Renal cell carcinoma: Associations between tumor imaging features and epidemiological risk factors

PURPOSE

To investigate associations between imaging features of tumors and age, gender and body mass index (BMI) in patients with renal cell carcinoma.

METHOD

This IRB-approved, HIPAA-compliant study included 1348 patients with histopathologically confirmed renal cell carcinoma of the clear cell subtype (ccRCC, n = 904) or non-clear cell subtype (n = 444), who underwent pre-treatment CT imaging less than 180 days before nephrectomy between 1999 and 2011. Two radiologists independently, retrospectively analyzed all imaging studies and identified features (necrosis, renal vein invasion, contact with renal sinus fat, multicystic appearance and nodular enhancement), which were then correlated with patient age, gender and BMI at time of surgery.

RESULTS

Inter-reader agreement on imaging features ranged from substantial to excellent (kappa: 0.688 to 0.982). In the ccRCC group, multicystic tumor appearance was significantly associated with lower patient age (p < 0.05) and lower BMI (p < 0.05); the presence of renal vein invasion was significantly associated with lower BMI in males (p < 0.05); and both tumor contact with the renal sinus and nodular enhancement were significantly associated with greater patient age (p < 0.05). In the non-clear cell RCC group, necrosis was associated with lower BMI for females (p < 0.05).

CONCLUSIONS

This study demonstrated significant associations between imaging features of RCC and patient age and BMI, hinting an influence of these factors on tumor biology and genomic make-up. These findings could aid future studies in selecting patients while investigating genomic, molecular and metabolic variables in RCC and might potentially impact on future stratification and therapy of patients.

Perioperative and oncologic outcome in patients treated for renal cell carcinoma with an extended inferior vena cava tumour thrombus level II-IV

PURPOSE

 Surgical treatment of patients with renal cell carcinoma (RCC) and an extended tumour thrombus (TT) in the inferior vena cava (IVC) is challenging and often requires a multidisciplinary approach. The aim of this study was to analyse results in the real-world management of RCC patients with an extended IVC TT (level II-IV according to the Mayo classification of macroscopic venous invasion in RCC) in terms of pre-, peri- and postoperative outcome, complications and oncologic outcome.

METHODS

 We investigated 61 patients with evidence of RCC and an extended TT in the IVC undergoing radical nephrectomy and tumour thrombectomy at our tertiary referral centre. Patients and operative characteristics were recorded and complications were analysed using the Clavien-Dindo classification. Follow-up data were retrieved by contacting the treating outpatient urologists, general practitioners and patients.

RESULTS

 The TT level was II in 36, III in 8 and IV in 17 patients. Complications grade IIIb and higher according to the Clavien-Dindo classification occurred in n = 3 (8.4 %), n = 2 (25.0 %) and n = 5 (29.5 %) patients with level II, III and IV TT, respectively. The overall survival of patients with TT level II, III and IV at 24 months (60 months) was 66.9 % (41.6 %), 83.3 % (83.3 %) and 64.1 % (51.3 %). Presence of primary metastatic disease was the only significant independent predictor for OS.  CONCLUSIONS:  Radical nephrectomy with tumour thrombectomy appears to be a feasible and effective treatment option in the management of patients with RCC and an extended IVC TT.

Surgical Interventions for Renal Cell Carcinoma with Thrombus Extending into the Inferior Vena Cava: A Multidisciplinary Approach

Objective: To assess surgical strategies and the impact of a multidisciplinary approach on patients undergoing inferior vena caval thrombectomy for renal cell carcinoma and to evaluate perioperative morbidity and mortality associated with these procedures.

Methodology: A retrospective audit for all adults who underwent nephrectomy and inferior vena caval thrombectomy from January 2008 till November 2018 at a University hospital. Patients with incomplete records were excluded from the study.

Results: During the study period, 21 patients underwent inferior vena caval thrombectomy as a completion of radical nephrectomy. Most were males (19 : 2) with a mean age of 54±11.3 years. The most common surgical approach was the 11th rib flank approach (n=8) followed by midline abdominal (n=6) and Mercedes-Benz (n=5). Eight patients had level 1, 10 patients had level 2, and three patients had level 3 tumour thrombus. The cavotomy was closed primarily in 20 patients; one required inferior vena cava (IVC) reconstruction with a pericardial patch. The proximal clamp was applied below the hepatic veins for most patients. Two patients required suprahepatic clamping before thrombectomy. There was no intraoperative mortality. Five patients (24%) developed complications: two required cardiopulmonary resuscitation due to severe hypotension and were revived; one developed acute renal failure; and one patient required a damage control laparotomy for excessive oozing. There was no thirty-day mortality.

Conclusion: The IVC thrombectomy, along with radical nephrectomy for renal cell carcinoma for 1–3 level thrombus, can be performed with acceptable morbidity in a multidisciplinary team approach.

Novel Use of Capturex Device and Reliant Balloon for Inferior Vena Cava Tumor Thrombectomy: A Case Report and Review of Literature

Introduction:

Most common tumor extending into the inferior vena cava (IVC) are renal carcinomas, such extension have been noted in nearly one-fifth of tumors. Tumor thrombectomy improves the prognosis of patients including those with extension of tumor as far as supra hepatic vena cava. In contrast, if radical nephrectomy is performed as the sole procedure, the prognosis is reduced drastically.

Case Presentation:

We present a case of a 42-year-old male who presented to us with renal cell carcinoma with tumor thrombus extending to IVC. We performed a hybrid endovascular and open procedure using novel surgical techniques to obtain proximal vena caval control and to remove the tumor thrombus—Capturex filter which was placed endovascularly 1 cm above the thrombus via the right internal jugular vein and reliant balloon was placed above the capturex below the hepatic veins. At this position, when the reliant balloon was inflated, it acted as a retro hepatic IVC control. Following vascular control, we proceeded to tumor thrombectomy and radical nephrectomy using transperitoneal approach. Patient made an uneventful recovery and was subsequently referred for medical oncology service for consideration of targeted therapy. Detailed description of the procedure is followed by the discussion of the literature.

Evaluation of microvascular invasion as a prognostic factor in the progression of non-metastatic renal cancer

Introduction

The aim of this study was to describe the prognostic impact of microvascular invasion (MVI) in patients with non-metastatic renal cell cancer.

Material and methods

We carried out a retrospective, descriptive and analytical study of patients with non-metastatic renal cell carcinoma who had undergone a radical or partial nephrectomy. Patients were divided according to the presence of MVI. In each group, clinical and pathological characteristics were evaluated. Metastasis-free and cancer-specific survival was evaluated by the Kaplan Meier method. The multivariate analysis was performed with Cox proportional method in order to predict risk factors of metastasis and cancer-specific mortality.

Results

A total of 221 patients with a median of 40-month long follow-up were evaluated. Patients with MVI+ were 40 (18%) while those with MVI – were 181 (82%). In the univariate analysis, the presence of MVI had a strong correlation with symptomatic tumors (OR 3.56; p 0.0003), tumor size (OR 12.08; p <0.0001), nuclear grade (OR 6.99; p <0.0001), pathological stage (OR 35.8; p <0.0001), distance metastasis (OR 4.16; p 0.0001), and death by cancer (OR 4.7; p 0.0004). However, in the multivariate analysis it is not presented as an independent predictor of metastasis (HR 0.45; p 0.11) or cancer-specific mortality (HR 0.93; p 0.91).

Conclusions

In our series, MVI is associated with unfavorable tumors characteristics. In spite of this, it does not seem to be an independent predictor for metastasis and death by non-metastatic renal cancer.

Selective Upper-Body Perfusion Technique for Removal of Renal Cell Carcinoma Extending into the Inferior Vena Cava and Right Atrium

Invasion of a renal cell carcinoma thrombus into the inferior vena cava and right atrium is infrequent. Reaching and completely excising a tumor from the inferior vena cava is particularly challenging because the liver covers the surgical field. We report the case of a 61-year-old man who underwent surgery for a renal cell carcinoma of the right kidney that extended into the inferior vena cava and right atrium. During dissection of the liver to expose the inferior vena cava, transesophageal echocardiograms revealed right atrial mass migration into the tricuspid valve. On emergency sternotomy, the tumor embolized into the main pulmonary artery. We used a selective upper-body perfusion technique involving moderately hypothermic cardiopulmonary bypass, cardioplegic arrest, and clamping of the descending aorta, which provided a bloodless surgical field for precise removal of the mass and resulted in minimal blood loss. Our technique might be useful in other patients with tumor thrombus extending into the right atrium because it reduces the need for transfusion and avoids the deleterious effects of deep hypothermic circulatory arrest. Our case also illustrates the importance of continuous transesophageal echocardiographic monitoring to detect thrombus embolization.

Massive renal urothelial carcinoma with renal vein tumor thrombus, pancreatic infiltration and adrenal metastasis: A case report

A 49-year-old female patient presented with a massive left renal tumor, recurrent left flank pain and gross hematuria. The tumor was accompanied by a renal vein tumor thrombus, pancreatic infiltration and a solitary adrenal metastasis. Radical nephrectomy, distal pancreatectomy, ipsilateral adrenalectomy and splenectomy were performed. Histopathological examination suggested high-grade urothelial carcinoma (UC); however, tumor recurrence and multiple metastases were detected only 3 months after the surgery, and the patient succumbed during follow-up 1 month later. To the best of our knowledge, this is the first case of renal UC of such advanced stage with renal vein tumor thrombus, pancreatic infiltration and a solitary adrenal metastasis.

Clear Cell Renal Cell Carcinoma: Associations Between CT Features and Patient Survival

OBJECTIVE

The objective of this study was to investigate associations between CT features and survival in patients with clear cell renal cell carcinoma (ccRCC).

MATERIALS AND METHODS

The study included 763 patients with histopathologically confirmed ccRCC who underwent preoperative contrast-enhanced CT between 1999 and 2011. Imaging features, both qualitative (cystic tumor, necrosis, tumor contact with renal sinus, renal vein invasion, peritumoral stranding, and peritumoral neovascularity) and quantitative (maximal tumor diameter and distance from the tumor to the renal sinus), were evaluated. Univariate and multivariable Cox regressions were used to assess associations of imaging features with disease-specific survival (DSS) and disease-specific progression-free survival (PFS).

RESULTS

Greater tumor size and the presence of renal vein invasion on CT were associated with decreased DSS and disease-specific PFS (p < 0.05), and the presence of extensive necrosis (more than two-thirds of the tumor volume) was associated with decreased disease-specific PFS (p < 0.05); this association remained statistically significant when we controlled for pathologic tumor stage. In contrast, no disease-specific death or progression was seen in patients with purely cystic tumors. Greater distance between the tumor and the renal sinus was not statistically significantly associated with longer survival.

CONCLUSION

In patients with ccRCC, observation of extensive necrosis on CT was statistically significantly associated with decreased disease-specific PFS, whereas greater tumor size and the presence of renal vein invasion on CT were statistically significantly associated with decreased DSS and disease-specific PFS. No disease progression was observed in tumors with a cystic appearance. Therefore, selected CT features could potentially aid in risk assessment for and counseling of patients with ccRCC and could provide prognostic information beyond the established tumor staging system.

Management of acute intra-operative thromboembolism in renal cell carcinoma

Renal cell carcinoma (RCC) is the most common malignant tumor of the kidney and has got association with inferior vena cava (IVC) extension in 5-10% of the patients. In this case report, we present a case of a 22-year- young female who was posted for radical nephrectomy and tumor thrombectomy to remove the thrombus extending up to IVC- right atrium junction. The surgical procedure was complicated by intraoperative thromboembolism during tumour manipulation. Continual Trans esophageal monitoring helps in early diagnosis of thromembolic event. Immediate diagnosis and awareness of clinical management in such circumstances contribute to a decrease in the associated morbidity and mortality.

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

Emergency cardiopulmonary bypass for massive pulmonary embolism occurring during nephrectomy

We report a case of cardiac arrest secondary to pulmonary tumor embolization occurring in a patient undergoing nephrectomy for renal cell carcinoma with a tumor thrombus invading the inferior vena cava infrahepatically. Tumor embolization in such cases is very rare (1.5%), but if it occurs, mortality is 75%. In our case, resources were rapidly mobilized, and cardiopulmonary bypass was initiated for pulmonary embolectomy within 34 minutes of the cardiac arrest. The patient's trachea was extubated on postoperative day 1, and he was discharged home 9 days later neurologically intact. Excellent preoperative and intraoperative communication among all involved health care providers, as well as rapid mobilization of the available resources, played important roles in the patient's positive outcome.

Surgical resection of recurrent inferior vena cava tumor following radical nephrectomy for renal cell carcinoma: A case report

Late recurrence is a known characteristic of the biological behavior of renal cell carcinoma (RCC) following radical nephrectomy. However, the development of recurrent inferior vena cava (IVC) tumors following radical nephrectomy for RCC is a rare event, and surgical resection of recurrent IVC tumors is a challenge for urologists. The present study reports the case of a patient with a local recurrent tumor in the IVC following a right radical nephrectomy 4 years previously for RCC. The patient was referred to the Department of Urology, First Affiliated Hospital of Anhui Medical University, due to bilateral lower extremity edema, and magnetic resonance imaging showed an intraluminal tumor thrombus in the IVC. Therefore, a thrombectomy and partial IVC resection with defect reconstruction were performed successfully. The results of follow-up for 72 months showed that there were no signs of recurrence as local or distant metastasis. This case of local recurrence in the IVC highlights that active long-term surveillance for RCC patients of all stages is important for the early diagnosis of tumor recurrence, which improves the potential resectability.

Adult Wilms tumor: Case report

Wilms tumor (WT) occurs infrequently in adults. Even rarer is adult WT with extension by direct intravascular spread into the right side of the heart. The present report describes a WT with intracaval and intracardiac extension in a 38-year-young man. In addition, thrombus extension above the infrahepatic IVC represents a major technical topic for surgeons because of the possible occurrence of uncontrollable hemorrhages and tumor fragmentation. We report the results of a surgical approach to caval thrombosis including the isolation of the IVC from the liver as routinely performed during liver harvesting. The morphologic and immune-histochemical findings confirmed the diagnosis.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

[Place of beating heart bypass surgery in kidney cancers with supradiaphragmatic invasion: about seven cases]

Ce travail vise à analyser les résultats de la néphrectomie avec thrombectomie atrio-cave sous circulation extracorporelle (CEC) chez sept patients ayant un cancer du rein avec envahissement cave supra-diaphragmatique et de discuter les indications opératoires. Sept patients, six hommes et une femme dont l’âge varie entre 46ans et 65ans, ont été opérés d'un cancer du rein avec extension atrio-cave. L’écho-doppler a toujours permis la mise en évidence de l'extension veineuse mais la limite supérieure du thrombus était formellement identifiée par l'examen tomodensitométrique quatre fois, et par la résonance magnétique nucléaire dans tous les cas. Tous les patients ont été opérés sous CEC à cœur battant en normothermie. Un seul décès postopératoire est survenu. La durée du séjour en réanimation a été de 4,5 jours. Cinq patients ont eu à distance une dissémination métastatique. Cinq malades ont eu une médiane de survie de 11,5 mois (de 7 à16). Un malade a subi une métastasectomie pulmonaire 6 mois après la néphrectomie. L'exérèse des thrombi atrio-caves a été facilitée par la CEC avec une mortalité et une morbidité postopératoires acceptables mais les résultats à distance ont été décevants. Cette intervention ne peut être proposée qu'aux patients n'ayant aucune extension locorégionale et générale décelable, ce qui souligne l'importance des examens morphologiques préopératoires.

Prognostic benefit of surgical management in renal cell carcinoma patients with thrombus extending to the renal vein and inferior vena cava: 17-year experience at a single center

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVE

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

DESIGN, SETTINGS, AND PARTICIPANTS

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

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

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

RESULTS AND LIMITATIONS

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

CONCLUSIONS

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

Evaluating hemorrhage in renal cell carcinoma using susceptibility weighted imaging

Background

Intratumoral hemorrhage is a frequent occurrence in renal cell carcinoma and is an indicator of tumor subtype. We hypothesize that susceptibility weighted imaging (SWI) is sensitive to hemorrhage in renal cell carcinoma and can give a more diagnostic image when compared to conventional imaging techniques.

Materials and Methods

A retrospective review of 32 patients with clear cell renal cell carcinoma was evaluated. All patients underwent magnetic resonance imaging (MRI) and 22 out of 32 patients also underwent a computed tomography (CT) scan. Hemorrhage was classified into 3 different categories according to shape and distribution. Histopathology was obtained from all masses by radical nephrectomy. The ability to detect the presence of hemorrhage using CT, non-contrast conventional MRI and SWI was evaluated, and the patterns of hemorrhage were compared.

Results

Using pathologic results as the gold standard, the sensitivities of non-contrast conventional MRI, SWI and CT in detecting hemorrhage in clear cell renal cell carcinoma were 65.6%, 100% and 22.7%, respectively. Accuracy of non-contrast conventional MRI and SWI in evaluating hemorrhagic patterns were 31.3% and 100%, respectively.

Conclusion

These results demonstrate that SWI can better reveal hemorrhage and characterize the pattern more accurately than either non-contrast conventional MRI or CT. This suggests that SWI is the technique of choice for detecting hemorrhagic lesions in patients with renal cancer.

Combined resection of a tumor and the inferior vena cava: report of two cases

Tumor resection and caval tumor thrombectomy, with or without cavotomy and inferior vena cava (IVC) replacement are sometimes performed in patients with renal cell carcinoma (RCC) extending into the IVC or liver tumors invading the IVC. Two such cases were treated. Case 1: a 68-year-old female was transferred with a diagnosis of right RCC with tumor thrombus extending into the IVC. A plication was performed to prevent extension into the right atrium before the nephrectomy and cavotomy with removal of the tumor thrombus was accomplished, because the IVC was almost completely obstructed and the hemodynamics were stable during cross-clamping of the IVC. Case 2: a 37-year-old female was transferred with a diagnosis of a giant metastatic liver tumor. A trisegmentectomy with resection of the invaded IVC and IVC replacement was performed while the abdominal aorta was cross-clamped to maintain the hemodynamics. Therefore, abdominal aortic cross-clamping was convenient to maintain the hemodynamics when the IVC replacement was performed during IVC cross-clamping.

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

Background

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

Methods

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

Results

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

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

Conclusions

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

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Staging of renal cell carcinoma: Current concepts

The most important and widely utilized system for providing prognostic information following surgical management for renal cell carcinoma (RCC) is currently the tumor, nodes, and metastasis (TNM) staging system. An accurate and clinically useful staging system is an essential tool used to provide patients with counseling regarding prognosis, select treatment modalities, and determining eligibility for clinical trials. Data published over the last few years has led to significant controversies as to whether further revisions are needed and whether improvements can be made with the introduction of new, more accurate predictive prognostic factors. Staging systems have also evolved with an increase in the understanding of RCC tumor biology. Molecular tumor biomarkers are expected to revolutionize the staging of RCC by providing more effective prognostic ability over traditional clinical variables alone. This review will examine the components of the TNM staging system, current staging modalities including comprehensive integrated staging systems, and predictive nomograms, and introduce the concept of molecular staging for RCC.

Prognostic impact of the 2009 UICC/AJCC TNM staging system for renal cell carcinoma with venous extension

BACKGROUND

The prognostic significance of venous involvement and tumour thrombus level in renal cell carcinoma (RCC) remains highly controversial. In 2010, the American Joint Committee on Cancer (AJCC) and the Union International Centre le Cancer (UICC) revised the RCC staging system (7th edition) based on tumour thrombus level, differentiating the T stage of tumours limited to renal-vein-only involvement.

OBJECTIVE

We aimed to evaluate the impact of tumour thrombus extension in a multi-institutional cohort of patients.

DESIGN, SETTING, AND PARTICIPANTS

An international consortium of 11 institutions was established to retrospectively review a combined cohort of 1215 patients undergoing radical nephrectomy and tumour thrombectomy for RCC, including 585 patients with inferior vena cava (IVC) involvement or higher.

MEASUREMENTS

Predictive factors of survival, including histology, tumour thrombus level, nodal status, Fuhrman grade, and tumour size, were analysed.

RESULTS AND LIMITATIONS

A total of 1122 patients with complete data were reviewed. The median follow-up for all patients was 24.7 mo, with a median survival of 33.8 mo. The 5-yr survival was 43.2% (renal vein involvement), 37% (IVC below the diaphragm), and 22% with caval involvement above the diaphragm. On multivariate analysis, tumour size (hazard ratio [HR]: 1.64 [range: 1.03-2.59]; p=0.036), Fuhrman grade (HR: 2.26 [range: 1.65-3.1]; p=0.000), nodal metastasis (HR: 1.32 [range: 1.09-1.67]; p=0.005), and tumour thrombus level (HR: 2.10 [range: 1.53-3.0]; p=0.00) correlated independently with survival.

CONCLUSIONS

Based on analysis of the largest known cohort of patients with RCC along with IVC and atrial thrombus involvement, tumour thrombus level is an independent predictor of survival. Our findings support the changes to the latest AJCC/UICC staging system.

Prognostic factors for renal cell carcinoma: Trakya University experience from Turkey

The purpose of the present study is to evaluate the prognostic factors of patients with renal cell carcinoma. The treatment results such as distant metastasis-free survival and overall survival of 59 previously untreated patients were retrospectively analysed. Median follow-up was 17.5 months (3.8-88.5 months). Overall survival was 22.4 months (3-87 months). Distant metastasis developed in 35 (59%) patients. The Eastern Cooperative Oncology Group (ECOG) performance status (P=0.022), tumour size (P=0.025) and lymphatic invasion (P<0.0001) were significantly effective prognostic factors for distant metastasis-free survival on multivariate analysis. Related to overall survival, gender (P=0.025), ECOG performance status (P=0.027), nuclear grade (P=0.002), tumour size (P=0.029), T stage (P=0.044), nodal involvement (P=0.003), surgical margin (P=0.046), renal sinus invasion (P<0.0001), perineural growth (P=0.001) and lymphatic invasion (P<0.0001) were significant prognostic factors on univariate analysis. Gender (P=0.008), ECOG performance status (P=0.027), tumour size (P=0.025) and lymphatic invasion (P<0.0001) retained their significance on multivariate analysis. We concluded that the most important prognostic factors for patients with renal cell carcinomas are ECOG performance status, tumour size and lymphatic invasion.

Long-term survival in patients undergoing radical nephrectomy and inferior vena cava thrombectomy: single-center experience

BACKGROUND

Renal cell carcinoma (RCC) with a tumor thrombus extension into the inferior vena cava (IVC) demands aggressive surgical management.

OBJECTIVE

To evaluate the long-term survival in patients undergoing radical nephrectomy and IVC thrombectomy.

DESIGN, SETTING, AND PARTICIPANTS

We performed a retrospective analysis of 87 patients undergoing surgery between 1997 and 2008. The patients were grouped according to the extent of tumor thrombus, with level I involving the IVC at the level of the renal vein, level II being infrahepatic IVC, level III being intrahepatic IVC, and level IV being suprahepatic IVC or right atrium. Relevant clinical and pathologic data were analyzed.

MEASUREMENTS

Disease-free survival (DFS) and disease-specific survival (DSS) were studied.

RESULTS AND LIMITATIONS

The median follow-up was 22 mo, and 19, 14, 40, and 14 patients had level I, II, III, and IV IVC thrombus, respectively. Among patients with M0 disease, 22 developed metastases. The 5-yr DFS was 64% for all levels and 74%, 69.5%, 59.5%, and 58% for levels I, II, III, and IV, respectively. Of the level I group, 16% of patients died of disease compared to 57% of the level IV group. The 5-yr DSS for all levels was 46% and 71%, 48%, 40%, and 35% for levels I, II, III, and IV, respectively. Patients with level IV thrombus had a significantly lower 5-yr DSS compared to level I (p=0.03). However, when analyzed in two groups-supradiaphragmatic and infradiaphragmatic-there was no significant difference in DSS (P=0.14). On univariate analysis, metastasis at presentation, non-clear-cell histology, lymph node metastases, and higher nuclear grade were statistically significant prognostic factors influencing DSS. Only higher nuclear grade (p=0.03), metastasis at presentation (p<0.01), and non-clear-cell histology (p=0.03) were independent prognostic factors on multivariate analysis.

CONCLUSIONS

Radical nephrectomy and IVC thrombectomy offer reasonable long-term survival. The level of tumor thrombus is not an independent prognostic factor. Distant metastasis at presentation, higher nuclear grade, and non-clear-clear cell histology are significant prognostic factors influencing DSS.

Concomitant surgery for renal neoplasm with pulmonary tumor embolism

OBJECTIVE

Gross tumor pulmonary embolism from renal carcinoma is rarely diagnosed preoperatively. Individual cases of intraoperative embolization of tumor during radical resection of the kidney have been reported. We report on 9 patients who underwent pulmonary arterial tumor removal concomitant with nephrectomy.

METHODS

Between 2000 and 2008, 9 patients underwent simultaneous nephrectomy and removal of gross embolic tumor from the pulmonary arteries. In 7 of these patients the diagnosis was made preoperatively by either computed tomography or magnetic resonance imaging. Cardiopulmonary bypass was used in all cases. Bilateral removal of pulmonary artery tumor was required in 7 patients and unilateral in 2.

RESULTS

All patients survived to hospital discharge after a median stay of 8.8 days (mean, 6-17 days). Two patients are currently alive 4 and 56 months after the operation. Six patients died of distant metastasis or local recurrence of disease after 6, 9, 12, 17, 25, and 29 months. Actuarial survival at 6 months, 1, 2, and 3 years was 100%, 75%, 50%, and 25%, respectively.

CONCLUSIONS

Pulmonary artery embolic tumor removal concomitant with nephrectomy for renal carcinoma can be performed safely. Survival of patients with combined surgery is comparable with that of patients with the same stage of renal neoplasm without pulmonary tumor embolism. The pulmonary tumor embolism in patients with renal carcinoma should be considered as extension of vena caval tumor but not as a distant metastasis. Pulmonary tumor removal provides symptomatic relief and may provide a survival benefit in these patients.

The prognostic relevance of interactions between venous invasion, lymph node involvement and distant metastases in renal cell carcinoma after radical nephrectomy

BACKGROUND

To investigate a possible prognostic significance of interactions between lymph node invasion (LNI), synchronous distant metastases (SDM), and venous invasion (VI) adjusted for mode of detection, Eastern Cooperative Oncology Group performance status (ECOG PS), erythrocyte sedimentation rate (ESR) and tumour size (TS) in 196 patients with renal cell carcinoma treated with radical nephrectomy.

METHODS

Median follow-up was 5.5 years (mean 6.9 years; range 0.01-19.4). The mode of detection, ECOG PS, ESR and TS were obtained from the patients' records. Vena cava invasion and distant metastases were detected by preoperative imaging. The surgical specimens were examined for pathological stage, LNI and VI.

RESULTS

The univariate analyses showed significant impact of VI, LNI, SDM, ESR and TS (p < 0.001), as well as mode of detection (p = 0.003) and ECOG PS (p = 0.002) on cancer specific survival. In multivariate analyses LNI was significantly associated with survival only in patients without SDM or VI (p < 0.001) with a hazard ratio of 9.0. LNI lost its prognostic significance when SDM or VI was present.

CONCLUSION

Our findings underline the prognostic importance of the status of the lymph nodes. LNI, SDM, ESR, and VI were independently associated with cancer specific survival after radical nephrectomy. LNI provided the strongest prognostic information for patients without SDM or VI whereas SDM and VI had strongest impact on survival when there was no nodal involvement.

Single-Center Experience of Caval Thrombectomy in Patients With Renal Cell Carcinoma With Tumor Thrombus Extension Into the Inferior Vena Cava

The objective of this study is to describe a single-center experience of caval thrombectomy in patients with renal cell carcinoma (RCC) and tumor thrombus extension into the inferior vena cava (IVC). We retrospectively reviewed 23 patients undergoing radical nephrectomy with caval thrombectomy. Follow-up included an office visit and computed tomography scan. Statistical comparisons were made using 2-sample t tests. Patients' ages ranged from 32 to 83 years (mean, 62 years; 18 male, 5 female). Tumor size ranged from 3 to 21 cm (mean, 8.6 cm). Tumor thrombus staging was based on the Nevus classification: level I (2/23), II (6/23), III (13/26), IV (2/23). Tumor thrombi were removed by means of digital extraction (20), Fogarty embolectomy (2), or endarterectomy (1-caval wall invasion). Lateral venorrhaphy was used for IVC repair in all cases. Hepatic mobilization and suprahepatic clamping were necessary in 14 patients. Clamp times were significantly different between the suprahepatic (SH) and infrahepatic (IH) groups (15 vs 9.4 minutes, P < .012). Mean blood loss was also significantly different (3.2 L vs 2 L, P < .045). In the SH group, 2 patients developed postoperative atrial fibrillation and 2 patients died (respiratory failure; missed enterotomy). The IH group had no perioperative morbidity or mortality. Median followup was 15 months (range, 1—54 months). Follow-up imaging was available for 19/23 patients. Ninety-five percent of patients had a patent IVC (18). One SH patient developed an IVC stenosis/thrombosis 12 months postoperatively with successful thrombolysis and stenting. There was a 16% (3/19) recurrence rate in follow-up, with all patients demonstrating renal vascular invasion and high Fuhrman grade upon final pathologic evaluation. Caval thrombectomy can be performed safely during radical nephrectomy for RCC with tumor thrombus extension. The need for suprahepatic clamping is associated with longer clamp times, increased blood loss, and increased morbidity and mortality. Lateral venorrhaphy with primary repair avoids complicated caval reconstructions and results in high patency rates, despite a not insignificant recurrence rate.

Prognostic Factors for Renal Cell Carcinoma With Tumor Thrombus Extension

PURPOSE

We identified prognostic factors for renal cell carcinoma with tumor thrombus extension and assessed whether the current T3 classification could be improved.

MATERIALS AND METHODS

We studied clinicopathological parameters in 321 consecutive patients who were surgically treated for renal cell carcinoma with tumor thrombus extension. Disease specific survival was evaluated with univariate and multivariate analysis. Harrell's C-index was used to assess the prognostic accuracy of prognostic models.

RESULTS

Tumor thrombus extended into the renal vein in 166 patients, the inferior vena cava in 137 and the atrium in 18. Metastatic renal cell carcinoma was found in 198 patients (62%). The thrombus level had no impact on clinicopathological parameters or survival but perioperative morbidity and mortality increased with cranial extension of the thrombus. Mean followup was 49 months. Five and 10-year disease specific survival rates were 36% and 24%, respectively. On multivariate analysis Eastern Cooperative Oncology Group performance status, lymph node and distant metastases, sarcomatoid features and perinephric fat invasion were independent prognostic factors. Weight loss, anemia, collecting system invasion, incomplete surgical resection, nuclear grade and T classification were also significant prognosticators on univariate analysis. For patients with advanced disease the number of metastatic sites and the disease-free interval further predicted prognosis. The overall immunotherapy response rate was 19%, which decreased with cranial extension of the thrombus. Redefinition of the T3 classification with the incorporation of fat invasion improved prognostic accuracy, as shown by an increase in the C-index.

CONCLUSIONS

Eastern Cooperative Oncology Group performance status, metastatic status, sarcomatoid features and concomitant perinephric fat invasion are the most powerful prognostic factors of survival in renal cell carcinoma with tumor thrombus extension. Our data indicate that a redefinition of the current T3 classification may improve its predictive accuracy. We propose that T3 renal cell carcinoma with fat invasion or thrombus extension alone should be classified as T3a, while that with thrombus extension plus fat invasion should be classified as T3b.

Prognostic Impact of Perirenal Fat or Adrenal Gland Involvement in Patients with pT3b Renal Cell Carcinoma

OBJECTIVES

To analyze the prognostic impact of the pT3a factors, perirenal fat or adrenal gland involvement, in patients with pT3b renal cell carcinoma (RCC).

METHODS

A total of 43 patients with pT3b RCC who underwent radical nephrectomy, with complete resection of tumor thrombus, at our institution from March 1972 to September 2005 were enrolled in this study. The presence of pT3a factors was reviewed, and the disease-specific survival was compared according to the reclassification as pT3b only or pT3b with pT3a.

RESULTS

After review by a single pathologist, 23 patients (53.5%) were identified as having pT3b only and 20 patients (46.5%) as having pT3b with pT3a. The mean disease-specific survival time in those with pT3b only was significantly longer at 70.9 +/- 9.1 (SE) months compared with 25.0 +/- 4.4 (SE) months in those with pT3b with pT3a (P = 0.0032). On univariate analyses, the presence of pT3a factors (P = 0.0065), preoperative metastasis (P = 0.0025), surgical specimens positive for lymph node metastasis (P = 0.0183), and spindle cell factor (P = 0.0233) were recognized as predictors of a poor prognosis.

CONCLUSIONS

The presence of perirenal fat or adrenal gland involvement in patients with pT3b RCC renders the prognosis significantly worse. Careful postoperative examination should be required, along with reclassification for Stage pT3b with pT3a in RCC.

Microvascular Tumor Invasion: Prognostic Significance in Low-Stage Renal Cell Carcinoma

OBJECTIVES

To evaluate the role of microvascular tumor invasion (MVI) in clinical behavior and prognosis of low-stage renal cell carcinoma.

METHODS

We retrospectively reviewed the records of patients who had undergone radical nephrectomy from 1990 to 2004 for clinically confined kidney tumors (Stage T1-T2N0M0) with a minimal follow-up period of 1 year. The pathology slides were reviewed regarding tumor diameter, pathologic tumor stage, histologic cell type, nuclear grade, macroscopic or MVI, perirenal fat invasion, and neoplastic lymph node involvement.

RESULTS

A total of 48 patients, 22 men and 26 women (mean +/- SD age 50.73 +/- 13.03 years, range 20-80) were included in the study. The patients were followed up for a mean +/- SD of 37.65 +/- 18.19 months (range 12-60). MVI was encountered in 8 patients (16.7%); 50% developed treatment failure in the form of distant metastases. Of the 40 patients without MVI, only 2 (5%) had treatment failure. MVI had a statistically significant association with sex (P = 0.017) and stage (P = 0.039). On comparing treatment failure with different patient and histologic parameters, a statistically significant association was noted with sex (P = 0.006) and MVI (P = 0.005). The 5-year disease-free survival rate was estimated at 45% and 90% when MVI was and was not present. Only MVI showed an independent statistically significant impact (P = 0.007) on multivariate analysis considering the impact of MVI, stage, grade, cell type, perirenal fat invasion, tumor size, and patient age on disease-free survival.

CONCLUSIONS

The results of our study have shown that MVI is an independent and relevant prognostic parameter for clinically low-stage renal cell carcinoma.

Evolving principles of surgical management and prognostic factors for outcome in renal cell carcinoma

The generally accepted principles for the surgical management of renal cell carcinoma (RCC) were first described more than 30 years ago. Since then, much has changed in the understanding of the basic biology and genetics of kidney cancer. Improvements in cross-sectional imaging has allowed for more accurate preoperative clinical staging of renal tumors, and the necessity of completing all the components of the radical nephrectomy have been questioned. Surgical techniques have also evolved, and technology has advanced to make possible new methods of managing renal tumors. The TNM staging system is currently the most extensively used system to provide prognostic information for RCC. However, data published in the last few years has led to significant controversies as to whether further revisions are needed and whether improvements can be made with the introduction of new, more accurate and predictive prognostic factors. Furthermore, the recent discovery of molecular tumor markers are expected to revolutionize the staging of RCC and lead to the development of new therapies based on molecular targeting. This review will examine the evolving principles in the surgical management of RCC as well as provide an update on current staging modalities and prognostic factors.