Negative impact of papillary histological subtype in patients with renal cell carcinoma extending into the inferior vena cava: Single-center experience

The Impact of Histological Variants on Oncological Outcomes After Surgical Resection of a Nonmetastatic Renal Cell Carcinoma with Tumor Thrombus: A Multi-institutional Study

Background

There is no definitive evidence of the prognosis impact of histological variants (HVs) in patients who undergo surgical resection of a nonmetastatic renal cell carcinoma (nm-RCC) with venous tumor thrombus (TT).

Objective

To investigate the impact of HVs on the prognosis of patients with nm-RCC with TT after radical surgery.

Design setting and participants

Patients who underwent radical nephrectomy with the removal of the venous TT for an nm-RCC were included in a retrospective study.

Outcome measurements and statistical analysis

Three groups were identified: clear cell (ccRCC), papillary (pRCC), and chromophobe (chRCC) RCC. The primary outcome measures (disease-free and overall survival [OS]) were assessed using the Kaplan-Meier method and compared using the log-rank test. Univariate and multivariate Cox proportional hazard models were used to study the impact of HVs on survival.

Results and limitations

A total of 873 patients were included. The histological subtypes were distributed as follows: ccRCC in 780 cases, pRCC in 58 cases, and chRCC in 35 cases. At the time of data analysis, 612 patients were recurrence free and 228 had died. A survival analysis revealed significant differences in both OS and recurrence-free survival across histological subtypes, with the poorest outcomes observed in pRCC patients (p < 0.05). In a multivariable analysis, pRCC was independently associated with worse disease-free survival and OS (hazard ratio [HR]: 1.71; p = 0.01 and HR: 1.24; p = 0.04), while chRCC was associated with more favorable outcomes than ccRCC (HR: 0.05; p < 0.001 and HR: 0.02; p < 0.001). A limitation of the study is its retrospective nature.

Conclusions

In this multicentric series, HVs appeared to impact the medium-term oncological prognosis of kidney cancer with TT.

Patient summary

This study investigated the differences in oncological outcomes among histological variants (clear cell, papillary, and chromophobe) in a cohort of nonmetastatic renal cell carcinoma patients with venous tumor thrombus extension. We observed that these histological variants within this specific subgroup exhibit distinct outcomes, with papillary renal cell carcinoma being associated with the worst prognosis.

Oncological outcomes of papillary versus clear cell renal cell carcinoma in pT1 and pT2 stage: Results from a contemporary Turkish patient cohort

OBJECTIVES

To compare overall survival (OS), recurrence free survival (RFS), and cancer-specific survival (CSS) in the long-term follow-up of T1 and T2 clear-cell-Renal Cell Carcinoma (ccRCC) and papillary Renal Cell Carcinoma (pRCC) patients, as well as to determine the risk factors for recurrence and overall mortality.

MATERIAL AND METHOD

Data of patients with kidney tumors obtained from the Urologic Cancer Database - Kidney (UroCaD-K) of Turkish Urooncology Association (TUOA) were evaluated retrospectively. Out of them, patients who had pathological T1-T2 ccRCC and pRCC were included in the study. According to the two histological subtype, recurrence and mortality status, RFS, OS and CSS data were analyzed.

RESULTS

RFS, OS and CSS of pRCC and ccRCC were found to be similar. Radiological local invasion was shown to be a risk factor for recurrence in pRCC, and age was the only independent factor affecting overall mortality.

CONCLUSIONS

There were no differences in survivals (RFS, OS and CSS) of patients with localized papillary and clear cell RCC. While age was the only factor affecting overall mortality, radiological local invasion was a risk factor for recurrence in papillary RCC.

Identification of Prognostic Markers of DNA Damage and Oxidative Stress in Diagnosing Papillary Renal Cell Carcinoma Based on High-Throughput Bioinformatics Screening

Purpose

Papillary renal cell carcinoma (pRCC) is the second most common histological subtype of adult kidney tumors, with a poor prognosis due to limited understanding of the disease mechanism. Herein, we have performed high-throughput bioinformatic screening to explore and identify potential biomarkers of DNA damage and oxidative stress for pRCC.

Methods

RNA sequencing data related to pRCC were downloaded from the TCGA database, and differentially expressed genes (DEG) were identified by a wide variety of clustering and classification algorithms, including self-organized maps (SOM), artificial neural networks (ANN), support vector machines (SVM), fuzzy logic, and hyphenated techniques such as neuro-fuzzy networks. Then DAVID and STRING online biological information tools were used to analyze functional enrichment of the regulatory networks of DEG and construct a protein-protein interaction (PPI) network, and then the Cytoscape software was used to identify hub genes. The importance of key genes was assessed by the analysis of the Kaplan-Meier survival curves using the R software. Lastly, we have analyzed the expression of hub genes of DNA damage and oxidative stress (BDKRB1, NMUR2, PMCH, and SAA1) in pRCC tissues and adjacent normal tissues, as well as the relationship between the expression of hub genes in pRCC tissues and pathological characteristics and prognosis of pRCC patients.

Results

A total of 1,992 DEGs for pRCC were identified, with 1,142 upregulated ones and 850 downregulated ones. The DEGs were significantly enriched in activities including DNA damage and oxidative stress, chemical synaptic transmission, an integral component of the membrane, calcium ion binding, and neuroactive ligand-receptor interaction. cytoHubba in the Cytoscape software was used to determine the top 10 hub genes in the PPI network as BDKRB2, NMUR2, NMU, BDKRB1, LPAR5, KNG1, LPAR3, SAA1, MCHR1, PMCH, and NCAPH. Furthermore, the expression level of hub genes BDKRB1, NMUR2, PMCH, and SAA1 in pRCC tissues was significantly higher than that in the adjacent normal tissues. Meanwhile, the expression level of hub genes BDKRB1, NMUR2, PMCH, and SAA1 in pRCC tissues was significantly positively correlated with tumor stage, lymph node metastasis, and the histopathology grade of pRCC. In addition, high expression levels of hub genes BDKRB1, NMUR2, PMCH, and SAA1 were associated with a poor prognosis for patients with pRCC. Univariate and multivariate analyses showed that the expression of hub genes BDKRB1, NMUR2, PMCH, and SAA1 were independent risk factors for the prognosis of patients with pRCC.

Conclusion

The results of this analysis suggested that BDKRB1, NMUR2, PMCH, and SAA1 might be potential prognostic biomarkers and novel therapeutic targets for pRCC.

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.

Bioinformatics Study Identified EGF as a Crucial Gene in Papillary Renal Cell Cancer

Background

Due to a lack of knowledge of the disease process, papillary renal cell carcinoma (PRCC) has a dismal outlook. This research was aimed at uncovering the possible biomarkers and the underlying principles in PRCC using a bioinformatics method.

Methods

We searched the Gene Expression Omnibus (GEO) datasets to obtain the GSE11151 and GSE15641 gene expression profiles of PRCC. We used the R package limma to identify the differentially expressed genes (DEGs). The online tool DAVID and ClusterProfiler package in R software were used to analyze Gene Ontology and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway dominance, respectively. The STRING database was utilized to construct the PPI network of DEGs. Using the Cytoscape technology, a protein-protein interaction (PPI) network that associated with DEGs was created, and the hub genes were identified using the Cytoscape plug-in CytoHubba. The hub genes were subjected to a Kaplan-Meier analysis to identify their correlations with survival rates.

Results

From the selected datasets, a total of 240 common DEGs were identified in the PRCC, including 50 upregulated genes and 190 downregulated regulated genes. Renal growth, external exosome, binding of heparin, and metabolic processes were all substantially associated with DEGs. The CytoHubba plug-in-based analysis identified the 10 hub genes (ALB, KNG1, C3, CXCL12, EGF, TIMP1, VCAN, PLG, LAMC1, and CASR) from the original PPI network. The higher expression group of EGF was associated with poor outcome in patients with PRCC.

Conclusions

We revealed important genes and proposed biological pathways that may be implicated in the formation of PRCC. EGF might be a predictive biomarker for PRCC and therefore should be investigated as a novel treatment strategy.

Clinicopathological Features of Papillary Renal Cell Carcinoma With Venous Tumor Thrombus: Case Series from a Large Chinese Center

Background:

Few studies have reported the influence of the histological classification of type-2 papillary renal cell carcinoma (PRCC), which may differ from that of clear cell renal carcinoma (ccRCC), on the prognosis of renal cell carcinoma with tumor thrombus. We investigated the clinicopathological features and prognosis of type-2 PRCC associated with venous tumor thrombi (PRCC-TT).

Methods:

We retrospectively analyzed 163 patients with renal cell carcinoma with venous tumor thrombus (RCC-TT) admitted to Peking University Third Hospital between June 2016 and June 2020. Twenty-five patients had type-2 PRCC-TT and 138 had ccRCC combined with tumor thrombus; there were 125 males and 38 females. All the included patients underwent radical nephrectomy and thrombectomy under either complete laparoscopic surgery or open surgery. Univariate and multivariate Cox regression analysis were performed to evaluate the prognostic significance of each variable on cancer-specific survival (CSS). Cancer-specific survival was calculated from the date of surgery to death or the last follow-up using the Kaplan–Meier method.

Results:

The blood vessels of type-2 PRCC-TT presented on CT images were not as abundant as those of ccRCC-TT. Slight enhancement was observed in the corticomedullary phase. While wash-out symptoms were observed, contrast agent extinction was not obvious in the nephrographic and excretory phases. We compared the macroscopic and microscopic appearances of the 2 cohorts. Compared to the ccRCC-TT cohort, lymph node invasion was more prevalent in the PRCC-TT cohort (88.0% vs. 60.9%, P = .009). Multivariate analysis revealed that sarcomatoid differentiation, distant metastasis, and pathological type were the independent predictors of poor CSS. The Kaplan–Meier analysis showed that the CSS of type-2 PRCC-TT and ccRCC-TT were 23.5 and 38.4 months, respectively, with statistical significance (P = .002).

Conclusion:

Type-2 PRCC-TT varies with common ccRCC-TT in imaging manifestation and pathological characteristics. The prognosis of type-2 PRCC-TT patients was worse than that of ccRCC-TT patients.

Prognostic value of CDCA3 in kidney renal papillary cell carcinoma

Kidney renal papillary cell carcinoma (KIRP) is a type of low-grade malignant renal cell carcinoma. Huge challenges remain in the treatment of KIRP. Cell division cycle associated 3 (CDCA3) participates in human physiological and pathological processes. However, its role in KIRP has not been established. Here, we evaluated the prognostic value of CDCA3 in KIRP using a comprehensive bioinformatics approach. Data for CDCA3 expression in KIRP were obtained from online database. Different expression genes between high and low CDCA3 expression groups were identified and evaluated by performing Gene ontology and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses. A gene set enrichment analysis was performed to elucidate the function and pathway differences between the different. Differences in immune cell infiltration between low and high CDCA3 expression groups were analyzed by a single-sample GSEA method for immune cells. A protein-protein interaction network was generated and hub genes were identified. UALCAN was used to analyze associations between the mRNA expression levels of CDCA3 in KIRP tissues with clinicopathologic parameters. The diagnostic efficacy of CDCA3 for KIRP was analyzed by ROC analysis. Logistic regression was used to analyze relationships between the clinicopathological characteristics and CDCA3 expression. Our results indicated that high CDCA3 mRNA expression is significantly associated with some clinicopathologic parameters in KIRP patients High CDCA3 mRNA expression associated with a shorter overall survival, progression-free interval, and disease-special survival. Taken together, CDCA3 is a potential target for the development of anti-KIRP therapeutics and is an efficient prognostic marker.

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.

Imaging and implications of tumor thrombus in abdominal malignancies: reviewing the basics

Extension of tumor tissue within a vein is a recognized prognostic factor in abdominal malignancy because of its influence on tumor staging and selection of therapeutic management. With the advent of newer surgical techniques, and variable treatment strategies, imaging plays a crucial role in categorizing patients according to the tumor resectability and vascular reconstruction techniques during surgery. Understanding the clinical impact of tumor thrombus increases the awareness of the radiologist about the key findings in tumor staging and decision-making of surgical approach. Ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) can be used individually and in combination to accurately assess the tumor thrombus. In our pictorial review, we will discuss the imaging findings and clinical consequences of tumor thrombosis in abdominal malignancies, including hepatocellular carcinoma, pancreatic neuroendocrine tumor, renal cancer, and adrenal cortical carcinoma.

A comparison of the prognosis of papillary and clear cell renal cell carcinoma: Evidence from a meta-analysis

OBJECTIVE

To compare the prognosis of papillary and clear cell renal cell carcinoma (RCC) in order to determine the optimal follow-up and therapy for patients with RCC.

METHODS

A systematic search of Web of Science, EMBASE, Cochrane Library, and PubMed databases was conducted for articles published through July 30, 2018, reporting on a comparison of the prognosis of papillary RCC and clear cell RCC using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

RESULTS

Of 1896 studies, 11 were considered for the evidence synthesis. A total of 35,832 patients were included. Of these patients, 6907 patients were diagnosed with papillary renal cell carcinoma, and 28,925 patients were diagnosed with clear cell renal cell carcinoma. The prognosis of papillary RCC was better than that of clear cell RCC (hazard ratio (HR) = 0.50; 95% confidence interval (CI) 0.45 to 0.56; P < .001; I = 91.9%). A subgroup analysis indicated that papillary RCC was associated with better outcomes (HR = 0.76, 95% CI 0.50-1.16), and a trend toward a higher risk of mortality was observed in patients with metastatic RCC presenting with papillary histology, but the difference was not statistically significant (HR = 1.12, 95% CI 0.71-1.76, P = .085). Pooled data suggested a lack of a significant difference between papillary RCC (p-RCC) type 1 and clear cell RCC (cc-RCC) (HR = 0.30, 95% CI 0.12-0.73, P = .085). The pooled HR for the prognosis of p-RCC type 2 compared to cc-RCC was 1.69 (95% CI 0.93-3.08; P = .032).

CONCLUSION

Papillary RCC is associated with better outcomes than clear cell RCC in patients without metastases, but not in patients with metastases. Optimal follow-up or therapy for patients with RCC should be assigned according to the tumor stage and subtype.

The prognostic value and clinicopathological features of sarcomatoid differentiation in patients with renal cell carcinoma: a systematic review and meta-analysis

Background and purpose

Numerous studies have demonstrated that sarcomatoid differentiation is linked to the risk of renal cell carcinoma (RCC). However, its actual clinicopathological impact remains inconclusive. Therefore, we undertook a meta-analysis to evaluate the pathologic and prognostic impacts of sarcomatoid differentiation in patients with RCC by assessing cancer-specific survival, overall survival, recurrence-free survival, progression-free survival, and cancer-specific mortality.

Materials and methods

In accordance with the preferred reporting items for systematic reviews and meta-analysis statement, relevant studies were collected systematically from PubMed, Embase, and Web of Science to identify relevant studies published prior to January 2018. The pooled effects (hazard ratios, odds ratios, and standard mean differences) and 95% confidence intervals were calculated to investigate the association of sarcomatoid differentiation with cancer prognosis and clinicopathological features.

Results

Thirty-five studies (N=11,261 patients [n=59-1,437 per study]) on RCC were included in this meta-analysis. Overall, the pooled analysis suggested that sarcomatoid differentiation was significantly associated with unfavorable cancer-specific survival (HR=1.46, 95% CI: 1.26-1.70, p<0.001), overall survival (HR=1.59, 95% CI: 1.42-1.78, p<0.001), progression-free survival (HR=1.61, 95% CI: 1.35-1.91, p<0.001), recurrence-free survival (HR=1.60, 95% CI: 1.29-1.99, p<0.001), and cancer-specific mortality (HR=2.36, 95% CI: 1.64-3.41, p<0.001) in patients with RCC. Moreover, sarcomatoid differentiation was closely correlated with TNM stage (III/IV vs I/II: OR=1.84, 95% CI: 1.12-3.03, p=0.017), Fuhrman grade (III/IV vs I/II: OR=8.37, 95% CI: 2.92-24.00, p<0.001), lymph node involvement (N1 vs N0: OR=1.88, 95% CI: 1.08-3.28, p=0.026), and pathological types (clear cell RCC-only vs mixed type: OR=0.48, 95% CI: 0.29-0.80, p=0.005), but was not related to gender (male vs female, OR=0.86, 95% CI: 0.58-1.28, p=0.464) and average age (SMD=-0.02, 95% CI: -0.20-0.17, p=0.868).

Conclusion

This study suggests that sarcomatoid differentiation in histopathology is associated with poor clinical outcome and advanced clinicopathological features in RCC and could serve as a poor prognostic factor for RCC patients.

A systematic review and meta-analysis of clinicopathologic factors linked to oncologic outcomes for renal cell carcinoma with tumor thrombus treated by radical nephrectomy with thrombectomy

BACKGROUND

There remain discrepancies over the factors that influence oncologic outcomes after radical nephrectomy with thrombectomy (RNTE). To assess significant predictors of oncologic outcomes after RNTE from a systematic review and meta-analysis.

METHODS

A comprehensive search of PubMed, Embase, Cochrane Library and Web of Science was performed to identify eligible studies. The endpoints included cancer-specific survival (CSS), overall survival (OS), and recurrence-free survival (RFS). A formal meta-analysis was performed for studies containing non-metastatic and metastatic tumors. Additionally, a sensitivity analysis including the subgroup of studies containing non-metastatic tumors only was conducted. Cumulative analyses of hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs) were conducted.

RESULTS

Overall, 35 retrospective studies of low to moderate risk of bias including 11,929 patients were included. The results indicated that large tumor size, high Fuhrman grade, tumor necrosis, positive lymph node, and metastasis at surgery were adverse significant predictors for both CSS and OS. Also, IVC tumor thrombus, sarcomatoid differentiation, perinephretic fat invasion, and adrenal gland invasion were associated with poor CSS. In the subset of non-metastatic patients, the significant predictors were clinical symptom, thrombus level, Fuhrman grade and adrenal gland invasion for CSS; thrombus consistency, Fuhrman grade and tumor necrosis for OS; tumor size, Fuhrman grade and perinephretic fat invasion for RFS.

CONCLUSIONS

A meta-analysis of available data identified significant prognostic factors of CSS, OS and RFS that should be systematically evaluated to propose a risk-adapted approach to postoperative patient counseling, risk stratification, and therapy selection.

Loss of PD-L1 (SP-142) expression characterizes renal vein tumor thrombus microenvironment in clear cell renal cell carcinoma

Immunotherapy is a promising tool in the treatment of patients with advancer renal cancer, in particular the blockage of immune checkpoint inhibitors. Clear cell renal cell carcinoma is an example of heterogeneous neoplasm and this particular characteristic is responsible of many therapeutic failures so far. Since variations in the local microenvironment across a tumor may conditionate the effect of this new therapy, a deeper knowledge of this issue seems advisable for any treatment success. We have analyzed the PD-L1 (SP142) expression in three different areas in the tumor and in two areas in the renal vein/caval thrombi in 39 advanced clear cell renal cell carcinomas to determine the extent and potential clinical significance of this regional variability. A statistically significant decrease in PD-L1 expression has been detected between the main tumor and its thrombus faction (p < 0.0001). Also, we have observed a high variability in the PD-L1 positivity across the three different areas of the main tumor tested, with only three cases being uniformly positive in all tested areas. In conclusion, PD-L1 expression display a highly variable distribution in clear cell renal cell carcinomas and this particularity should be kept in mind when selecting the tumor samples to be tested for immunotherapy.

The radiologist's role in the management of papillary renal cell carcinoma

Papillary carcinoma is the second most common renal cell carcinoma. It has a better prognosis than the more frequent clear cell carcinoma, although this does not hold true for advanced cases, because no specific treatment exists. It presents as a circumscribed peripheral tumor (small and homogeneously solid or larger and cystic/hemorrhagic) or as an infiltrating lesion that invades the veins, which has a worse prognosis. Due to their low vascular density, papillary renal cell carcinomas enhance less than other renal tumors, and this facilitates their characterization. On computed tomography, they might not enhance conclusively, and in these cases they are impossible to distinguish from hyperattenuating cysts. Contrast-enhanced ultrasonography and magnetic resonance imaging are more sensitive for detecting vascularization. Other characteristics include a specific vascular pattern, hypointensity on T2-weighted images, restricted water diffusion, and increased signal intensity in opposed phase images. We discuss the genetic, histologic, clinical, and radiological aspects of these tumors in which radiologists play a fundamental role in management.

Prognostic Benefit of Surgical Management of Renal Cell Carcinoma Invading the Inferior Vena Cava

Renal cell carcinoma (RCC) accounts for approximately 3 % of adult malignancies and 90-95 % of neoplasms arising from the kidney. One of the unique features of RCC is the tumor thrombus formation that migrates into the venous system including renal vein (RV) and inferior vena cava (IVC). Only 10 % of patients with RCC present with the classic triad of flank pain, hematuria and defined mass, while 25-30 % of affected patients are asymptomatic. Signs of para-neoplastic syndrome such as hypercalcemia, hypertension, anemia, cachexia and increased erythrocyte sedimentation rate (ESR) are often apparent. Extension of tumor thrombus into the venous system is depicted by radiological examinations, such as contrast enhanced Computed Tomography (CT), Magnetic Resonance Imaging (MRI) and vena cavography. The level of the thrombus is mostly determined according to the Mayo classification. Despite recent research on the therapeutic strategies against advanced RCC, surgical resection appears the only potentially curative approach. Aggressive surgical management including nephrectomy with thrombectomy is currently the standard therapeutic approach for RCC patients with tumor thrombus extending to the RV or the IVC. Pre-surgical down-staging with the use of molecular targeted therapy has also been proposed. Alternative therapies, such as radio- and chemotherapy proved insufficient. The aim of this review is to evaluate the results of surgical treatment for RCC invading IVC with special reference to the extent of its histological spread. Review of recent world literature was accomplished to provide an update on the current concepts of surgical management of the disease.

The safety and validity of surgical resection for hemodialysis-dependent patients with renal cell carcinomas involving the inferior vena cava

Perioperative morbidity and mortality increase during renal cell carcinoma resection with inferior vena cava involvement in hemodialysis-dependent end-stage renal disease patients. We evaluated the safety and validity of surgical management for renal cell carcinoma with inferior vena cava thrombi in such patients undergoing radical nephrectomies and tumor thrombectomies. There were three patients with tumor thrombus level II, and one each with tumor thrombus level III and IV. We evaluated median operative time (337 min), median estimated blood loss (1300 mL), and median postoperative hospitalization (15 days). Postoperative complications included surgical site dehiscence and pulmonary thromboembolism. One patient with preoperatively identified lung metastases developed a pulmonary thromboembolism on day 3 and died on day 15. The other four patients had long postoperative survival (19-104 months). Successful surgical management of renal cell carcinoma involving the inferior vena cava requires preoperative evaluation of the patient's condition to improve survival for hemodialysis-dependent end-stage renal disease patients.

Clinical and oncological outcomes in Chinese patients with renal cell carcinoma and venous tumor thrombus extension: single-center experience

BACKGROUND

To evaluate the clinical and oncological outcomes and to identify prognostic factors for survival in Chinese patients with renal cell carcinoma (RCC) and venous tumor thrombus (VTT).

METHODS

A total of 86 patients who underwent nephrectomy and tumor thrombectomy for RCC and venous tumor thrombus extension from 2003 to 2013 were included in this retrospective study. The records of these patients were reviewed. Kaplan-Meier analysis was used to determine cancer-specific survival (CSS). Prognostic factors for CSS were identified by univariate and multivariate analyses using the Cox proportional hazards regression mode.

RESULTS

All patients in this cohort received radical nephrectomy and tumor thrombectomy. Median follow-up period was 27.0 months (range 3-111). No patients died intraoperatively, and the complication rate was 36.0%. The 1-, 3-, and 5-year CSS rates for all patients were 93.0%, 70.9%, and 58.1%, respectively, and those for patients without distant metastasis at presentation were 95.3%, 82.6%, and 68.6%, respectively. Multivariate Cox regression analysis showed that lymph node invasion, distant metastasis at presentation, and invasion of the inferior vena cava (IVC) wall were the independent prognostic factors for CSS in all patients. For patients without distant metastasis, tumor grade, lymph node invasion, and perinephric fat invasion were significantly associated with CSS on multivariate analysis.

CONCLUSIONS

Survival rates for patients with RCC and VTT were still poor. Our results indicated that lymph node invasion, distant metastasis at presentation, and invasion of the IVC wall were independent negative prognostic factors.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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