Outcomes in Renal Cell Carcinoma With IVC Thrombectomy: A Multiteam Analysis Between an NCI-Designated Cancer Center and a Quaternary Care Teaching Hospital

Renal cell carcinoma with inferior vena cava thrombus: did we make progress in oncologic outcomes and complications?

PURPOSE OF REVIEW

Surgery for renal cell carcinoma (RCC) with inferior vena cava tumor thrombus (TT) remains one of the most complex surgeries performed with high rates of associated complications and perioperative mortality. Surgical techniques and neoadjuvant therapies have an important role to play in improving outcomes. This review provides a narrative analysis of recent literature on patients with RCC and TT.

RECENT FINDINGS

Several imaging techniques are emerging that may improve diagnostic staging of tumor thrombus level. Robotic approaches to surgical resection for all thrombi levels is feasible and safe, while longer term outcomes for higher level thrombi continues to mature. Early data on neoadjuvant immunotherapy and radiotherapy have shown improvements in complication rates and intermediate term oncologic outcomes.

SUMMARY

Data suggests that neoadjuvant therapies and minimally invasive techniques may improve outcomes in patients undergoing surgical resection for RCC with tumor thrombus. Larger multiinstitutional series are needed to confirm the benefit of these techniques as well as the durable long term oncologic outcomes.

Predictors of Survival in Patients Undergoing Surgery for Renal Cell Carcinoma and Inferior Vena Cava Tumor Thrombus

INTRODUCTION

Surgical resection of renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus is a complex procedure with significant morbidity. Patient selection is critical to determining whether the benefits of the procedure outweigh the risks. In this study, we identified and stratified the risk factors that were associated with overall survival (OS) and recurrence-free survival (RFS) in patients undergoing surgical resection of RCC with IVC thrombus.

METHODS

We identified all patients with RCC with IVC tumor thrombus (stages cT3b and cT3c) who had undergone radical nephrectomy with tumor thrombectomy between December 1, 1993 and June 30, 2009. Kaplan-Meier method was used to estimate OS and RFS. Cox proportional hazards models were used to determine the association between risk factors and OS. Patients were stratified into 3 groups based on the number of risk factors present at diagnosis.

RESULTS

Two hundred twenty-four patients were included in the study. A total of 45.3% of patients had metastasis at presentation, 84.5% had cT3b, and 90.2% had clear cell RCC. cT3c, cN1, and cM1 were significantly associated with the risk of death. Group 1 patients (0 risk factors) had a median OS duration of 77.6 months (95% CI 50.5-90.4), group 2 (1 risk factor) 26.0 months (95% CI 19.5-35.2), and group 3 (≥2 risk factors) 8.9 months (95% CI 5.2-12.9; P < .001).

CONCLUSIONS

Stratification of patients with RCC and IVC thrombus by risk factors allowed us to predict survival duration. In patients with ≥2 risk factors, new treatment strategies with preoperative systemic therapy may improve survival.

Prevalence and risk factors of myocardial and acute kidney injury following radical nephrectomy with vena cava thrombectomy: a retrospective cohort study

BACKGROUND

Radical nephrectomy with thrombectomy is the mainstay treatment for patients with renal cell carcinoma with vena cava thrombus. But the procedure is full of challenge, with high incidence of major complications and mortality. Herein, we investigated the incidence and predictors of myocardial injury and acute kidney injury (AKI) in patients following radical nephrectomy with inferior vena cava thrombectomy.

METHODS

Patients who underwent nephrectomy with thrombectomy between January 2012 and June 2020 were retrospectively reviewed. Myocardial injury was diagnosed when peak cardiac troponin I was higher than 0.03 ng/ml. AKI was diagnosed according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression models were used to identify predictors of myocardial injury or AKI after surgery.

RESULTS

A total of 143 patients were included in the final analysis. Myocardial injury and AKI occurred in 37.8 and 42.7% of patients after this surgery, respectively. Male sex (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.10-0.71; P = 0.008) was associated with a lower risk, whereas high level Mayo classification (compared with Mayo level I + II, Mayo level III + IV: OR 4.21, 95% CI 1.42-12.4; P = 0.009), acute normovolemic hemodilution before surgery (OR 2.66, 95% CI 1.10-6.41; P = 0.029), long duration of intraoperative tachycardia (per 20 min: OR 1.49, 95% CI 1.10-2.16; P = 0.036), and long duration of surgery (per 1 h, OR 1.48, 95% CI 1.03-2.16, P = 0.009) were associated with a higher risk of myocardial injury. High body mass index (OR 1.18, 95% CI 1.06-1.33; P = 0.004) and long duration of intraoperative hypotension (per 20 min: OR 1.30, 95% CI 1.04-1.64; P = 0.024) were associated with a higher risk, whereas selective renal artery embolism before surgery (OR 0.20, 95% CI 0.07-0.59, P = 0.004) was associated with a lower risk of AKI.

CONCLUSION

Myocardial injury and AKI were common in patients recovering from radical nephrectomy with inferior vena cava thrombectomy. Whether interventions targeting the above modifiable factors can improve outcomes require further studies.