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Filizzola R, Romero D, Mendez S, Brunstein D, Benitez A. Results of Radical Nephrectomy and Inferior Vena Cava Thrombectomy. Curr Urol Rep 2024; 25:339-342. [PMID: 39138814 DOI: 10.1007/s11934-024-01228-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2024] [Indexed: 08/15/2024]
Abstract
PURPOSE OF REVIEW Renal Cell Carcinoma (RCC) with invasion into the inferior vena cava (IVC) is a rare and mortal condition. Patients with RCC have an average life expectancy of no more than six months, thus requiring an aggressive surgical approach. We analyze the outcomes of patients that underwent surgery at a single medical institution. RECENT FINDINGS The analysis of recent series of successful treatment with radical nephrectomy and IVC thrombectomy shows a 5 year survival from 45 to 69%. We found in the analyzed series that the success of the treatment in these patients depends on the resection of the renal tumor and venous thrombectomy. We found that at our medical institution nephrectomy and IVC thrombectomy with primary repair have no intraoperative mortality and no pulmonary embolism. Nephrectomy and thrombectomy of IVC is a reliable approach for patients with advance RCC.
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Affiliation(s)
- Roberto Filizzola
- Department of Vascular Surgery, Hospital Central Instituto de Prevision Social, Asunción, 001519, Paraguay.
| | - Daniel Romero
- Department of Urology, Hospital Central Instituto de Previsión Social, Asunción, 001519, Paraguay
| | - Samuel Mendez
- Department of Urology, Hospital Central Instituto de Previsión Social, Asunción, 001519, Paraguay
| | - David Brunstein
- Department of Vascular Surgery, Hospital Central Instituto de Prevision Social, Asunción, 001519, Paraguay
| | - Alejandro Benitez
- Department of Vascular Surgery, Hospital Central Instituto de Prevision Social, Asunción, 001519, Paraguay
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2
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Filizoglu N, Ozguven S. Renal Cell Carcinoma With Tumor Thrombus Extending Into the Inferior Vena Cava and the Right Atrium Demonstrated by 68Ga-DOTATATE PET/CT. Clin Nucl Med 2024:00003072-990000000-01302. [PMID: 39354686 DOI: 10.1097/rlu.0000000000005487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2024]
Abstract
ABSTRACT Approximately 10% of all renal cell carcinoma (RCC) patients develop a venous tumor thrombus, a major negative prognostic factor. Surgical excision is commonly required for RCC patients with tumor thrombus. Accurate preoperative diagnosis and assessment of tumor thrombus level is vital because the level of thrombus may influence treatment decisions. MRI, contrast-enhanced CT, 18F-FDG PET/CT, and 68Ga-PSMA PET/CT have been used to diagnose and evaluate the extent of tumor thrombus in RCC. However, no case of RCC with inferior vena cava tumor thrombus showing 68Ga-DOTATATE uptake has been reported yet. Herein, we report a case of metastatic RCC with tumor thrombus in the inferior vena cava on 68Ga-DOTATATE PET/CT.
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Affiliation(s)
- Nuh Filizoglu
- From the Department of Nuclear Medicine, University of Health Sciences, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Salih Ozguven
- Department of Nuclear Medicine, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
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Goronzy IN, Yearwood A, Drews E, Brundage T, Ranade M, Moriarty JM. Endovascular thrombectomy provides durable, symptomatic relief in iliocaval tumor thrombosis. Clin Radiol 2024; 79:e1268-e1278. [PMID: 39084932 DOI: 10.1016/j.crad.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 07/04/2024] [Accepted: 07/06/2024] [Indexed: 08/02/2024]
Abstract
AIMS Iliocaval venous tumor thrombus is a morbid condition associated with chronic venous stasis, lower extremity edema/pain, extensive thrombus burden and high mortality secondary to critical flow obstruction, intracardiac thrombus extension and tumor embolization. Typically resistant to medical therapy, management is primarily surgical, presenting challenges for medically complex patients with widespread or end-stage disease. Mechanical or aspiration thrombectomy represents an appealing treatment strategy but data are lacking. MATERIALS AND METHODS We performed a single-center, 10-year, retrospective review of patients with pathology-confirmed, iliocaval tumor thrombus who underwent thrombectomy. 14 patients met inclusion criteria and were managed by 18 procedures over this period. RESULTS The most common malignancy was renal-cell carcinoma (n=7; 50%); other types included germ cell (n=2; 14%), other genitourinary (n=2; 14%), neuroendocrine (n=1; 7%), soft tissue (n=1; 7%), and skin cell malignancies (n=1; 7%). All patients had thrombus involving the distal inferior venous cava (IVC), 50% had bilateral iliac involvement and 29% atrial involvement. Common indications were venous obstruction symptoms (n=11; 65%) and evidence of embolism (n=6; 35%). All patients tolerated the procedures without acute complication. The technical success rate was 94%, with marked improvement of flow and reduction in thrombus burden, and 79% had subjective symptomatic improvement. All patients survived for >2 weeks and 50% had long-term survival of >1 year, with 86% of these patients having renal-cell carcinoma (RCC). Three patients underwent multiple thrombectomies within days to weeks, with ultimate symptomatic improvement. CONCLUSIONS Overall, our study results suggest mechanical or aspiration thrombectomy as a safe and efficacious treatment for patients with iliocaval tumor thrombus.
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Affiliation(s)
- I N Goronzy
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - A Yearwood
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; Department of Radiology, Los Angeles, CA 90095, USA
| | - E Drews
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; Department of Radiology, Los Angeles, CA 90095, USA
| | - T Brundage
- Rosalind Franklin University of Medicine and Science, North Chicago, IL 60064, USA
| | - M Ranade
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; Department of Radiology, Los Angeles, CA 90095, USA
| | - J M Moriarty
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; Department of Radiology, Los Angeles, CA 90095, USA.
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Sandberg M, Namugosa M, Ritts R, Costa CM, Temple D, Hayes M, Whitman W, Ye E, Refugia J, Ben-David R, Alerasool P, Eilender B, Zanotti RR, Mourão TC, Kim JK, Marchiñena PG, Byun SS, Abreu D, Mehrazin R, Spiess P, de Cassio Zequi S, Rodriguez A. The role of preoperative immune cell metrics in renal cell carcinoma with a tumor thrombus. Urologia 2024; 91:477-485. [PMID: 38661082 DOI: 10.1177/03915603241248020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
INTRODUCTION The objective of this study was to stratify preoperative immune cell counts by cancer specific outcomes in patients with renal cell carcinoma (RCC) and a tumor thrombus after radical nephrectomy with tumor thrombectomy. METHODS Patients with a diagnosis of RCC with tumor thrombus that underwent radical nephrectomy with thrombectomy across an international consortium of seven institutions were included. Patients who were metastatic at diagnosis and those who received preoperative medical treatment were also included. Retrospective chart review was performed to collect demographic information, past medical history, preoperative lab work, surgical pathology, and follow up data. Neutrophil counts, lymphocyte counts, monocyte counts, neutrophil to lymphocyte ratios (NLR), lymphocyte to monocyte ratios (LMR), and neutrophil to monocyte ratios (NMR) were compared against cancer-specific outcomes using independent samples t-test, Pearson's bivariate correlation, and analysis of variance. RESULTS One hundred forty-four patients were included in the study, including nine patients who were metastatic at the time of surgery. Absolute lymphocyte count preoperatively was greater in patients who died from RCC compared to those who did not (2 vs 1.4; p < 0.001). Patients with tumor pathology showing perirenal fat invasion had a greater neutrophil count compared to those who did not (7.5 vs 5.5; p = 0.010). Patients with metastatic RCC had a lower LMR compared to those without metastases after surgery (2.5 vs 3.2; p = 0.041). Tumor size, both preoperatively and on gross specimen, had an interaction with multiple immune cell metrics (p < 0.05). CONCLUSIONS Preoperative immune metrics have clinical utility in predicting cancer-specific outcomes for patients with RCC and a tumor thrombus. Additional study is needed to determine the added value of preoperative serum immune cell data to established prognostic risk calculators for this patient population.
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Affiliation(s)
- Maxwell Sandberg
- Department of Urology, Atrium Health Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | - Mary Namugosa
- Department of Urology, Atrium Health Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | - Rory Ritts
- Department of Urology, Atrium Health Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | | | - Davis Temple
- Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Mitchell Hayes
- Department of Urology, Moffitt Cancer Center, Tampa Bay, FL, USA
| | - Wyatt Whitman
- Department of Urology, Atrium Health Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | - Emily Ye
- Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Justin Refugia
- Department of Urology, Atrium Health Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | - Reuben Ben-David
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Parissa Alerasool
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Benjamin Eilender
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Jung Kwon Kim
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | | | - Seok-Soo Byun
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Diego Abreu
- Urology Service, Pasteur Hospital, Montevideo, Uruguay
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Philippe Spiess
- Department of Urology, Moffitt Cancer Center, Tampa Bay, FL, USA
| | | | - Alejandro Rodriguez
- Department of Urology, Atrium Health Wake Forest Baptist Medical Center, Winston Salem, NC, USA
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Feng T, Wang Y, Zhang W, Cai T, Tian X, Su J, Zhang Z, Zheng S, Ye S, Dai B, Wang Z, Zhu Y, Zhang H, Chang K, Ye D. Machine Learning-based Framework Develops a Tumor Thrombus Coagulation Signature in Multicenter Cohorts for Renal Cancer. Int J Biol Sci 2024; 20:3590-3620. [PMID: 38993563 PMCID: PMC11234220 DOI: 10.7150/ijbs.94555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/17/2024] [Indexed: 07/13/2024] Open
Abstract
Background: Renal cell carcinoma (RCC) is frequently accompanied by tumor thrombus in the venous system with an extremely dismal prognosis. The current Tumor Node Metastasis (TNM) stage and Mayo clinical classification do not appropriately identify preference-sensitive treatment. Therefore, there is an urgent need to develop a better ideal model for precision medicine. Methods: In this study, we developed a coagulation tumor thrombus signature for RCC with 10 machine-learning algorithms (101 combinations) based on a novel computational framework using multiple independent cohorts. Results: The established tumor thrombus coagulation-related risk stratification (TTCRRS) signature comprises 10 prognostic coagulation-related genes (CRGs). This signature could predict survival outcomes in public and in-house protein cohorts and showed high performance compared to 129 published signatures. Additionally, the TTCRRS signature was significantly related to some immune landscapes, immunotherapy response, and chemotherapy. Furthermore, we also screened out hub genes, transcription factors, and small compounds based on the TTCRRS signature. Meanwhile, CYP51A1 can regulate the proliferation and migration properties of RCC. Conclusions: The TTCRRS signature can complement the traditional anatomic TNM staging system and Mayo clinical stratification and provide clinicians with more therapeutic options.
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Affiliation(s)
- Tao Feng
- Qingdao Institute, School of Life Medicine, Department of Urology, Fudan University Shanghai Cancer Center, Fudan University, Qingdao, 266500, China
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Yue Wang
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Wei Zhang
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Tingting Cai
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Xi Tian
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Jiaqi Su
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Zihao Zhang
- Qingdao Institute, School of Life Medicine, Department of Urology, Fudan University Shanghai Cancer Center, Fudan University, Qingdao, 266500, China
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Shengfeng Zheng
- Qingdao Institute, School of Life Medicine, Department of Urology, Fudan University Shanghai Cancer Center, Fudan University, Qingdao, 266500, China
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Shiqi Ye
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Bo Dai
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Ziliang Wang
- Central Laboratory, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, 274 Middle Zhijiang Road, Shanghai 200071, China
| | - Yiping Zhu
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Hailiang Zhang
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Kun Chang
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Dingwei Ye
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
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Bernaschina-Rivera SA, Alayón-Rosario G, Dieppa-Barnés G, Encarnación J, Ortiz-Sánchez C, Santini-Domínguez R, Martínez-Trabal JL, Ruiz-Deyá G. Renal Cell Carcinoma With Tumor Thrombus: A Case Series in Puerto Rico. Cureus 2024; 16:e58113. [PMID: 38738111 PMCID: PMC11088801 DOI: 10.7759/cureus.58113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/11/2024] [Indexed: 05/14/2024] Open
Abstract
INTRODUCTION Renal cell carcinoma (RCC) is one of the most common types of kidney cancer. While RCC tends to present as a localized tumor, a notable proportion may present with distant metastasis. In some instances, RCC may also present with intravascular tumor extension, often called tumor thrombus (TT). Its presence confers a worse prognosis and has important implications for the tumor's staging and treatment. Despite extensive documentation of RCC TT in the US, limited data exists regarding its presentation, management, and outcomes in Puerto Rico (PR). This study aims to broaden the available information on RCC TT, emphasizing surgical management and outcomes. We also provide descriptive data on patient demographics and clinical presentation to improve decision-making among clinicians caring for Puerto Rican men and women. METHODS In this single-center, retrospective study, we evaluated patients who underwent partial or total nephrectomy at Saint Luke's Episcopal Medical Center between 2018 and 2022. Data was abstracted from electronic health records (EHR). Patients without documented evidence of TT during the peri-operative period were excluded from the study. A total of 220 patient records were evaluated, of which 12 met the inclusion criteria for the study. Cases were categorized using the latest RCC TT guidelines. Central tendency measurements were used to describe the sample distribution. The mean was considered to make assumptions regarding the prevalent observations, and the median was considered to rule out possible outliers. Categorical data were evaluated using proportion analyses, including TT extension level and BMI variables. Fisher's exact test evaluated the association between the World Health Organization/International Society of Urological Pathology (WHO/ISUP) grade and TT extension level. RESULTS Most patients lacked TT-related symptoms. The most severe presenting symptom was a pulmonary embolism (8.3%). Hypertension (83.3%), BMI greater than 25 at the time of diagnosis (75%), and type 2 diabetes mellitus (66.7%) were the most common comorbid conditions within our cohort. Nearly 75% of patients underwent laparoscopic radical nephrectomy with TT resection. One left-sided level III case was managed by laparoscopic-assisted open radical nephrectomy with a right subcostal incision. There were zero intraoperative complications and two postoperative complications. The histopathological reports of all cases were consistent with clear cell carcinoma, and half of the cases (n=6) were WHO/ISUP G4. All patients are alive and free of disease. CONCLUSION RCC is a common renal neoplasm in PR that can present with intravascular tumor extension. Our findings do not establish a definitive association between BMI, tumor size, WHO/ISUP grading, and TT extension level. Our study shows that laparoscopic removal of RCC TT is a safe and effective approach. However, the generalizability of our findings is limited by the study's design and sample size. Future research should focus on identifying predictive markers, establishing effective screening protocols, and determining if our hybrid approach has comparable outcomes to the standard open approach.
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Affiliation(s)
| | | | - Gabriel Dieppa-Barnés
- General Surgery, St Luke's Episcopal Medical Center, Ponce, PRI
- Surgery, Ponce Health Sciences University, Ponce, PRI
| | | | | | - Rafael Santini-Domínguez
- General Surgery, St Luke's Episcopal Medical Center, Ponce, PRI
- Surgery, Ponce Health Sciences University, Ponce, PRI
| | - Jorge L Martínez-Trabal
- General Surgery, St Luke's Episcopal Medical Center, Ponce, PRI
- Surgery, Ponce Health Sciences University, Ponce, PRI
| | - Gilberto Ruiz-Deyá
- Urology, St Luke's Episcopal Medical Center, Ponce, PRI
- Surgery, Ponce Health Sciences University, Ponce, PRI
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KC M, Bhattarai HB, Subedi P, Kashyap A, Wadhwa M, Kaur D, Koirala S, Gautam S. Renal vein thrombosis in a patient secondary to high-grade rhabdoid renal cell carcinoma: a case report and review of literature. Ann Med Surg (Lond) 2024; 86:2194-2199. [PMID: 38576908 PMCID: PMC10990342 DOI: 10.1097/ms9.0000000000001923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/25/2024] [Indexed: 04/06/2024] Open
Abstract
Introduction Renal cell carcinoma, a common kidney tumour which is often incidentally discovered on imaging, can manifest with atypical symptoms. Renal cell carcinoma with rhabdoid features is a rare occurrence and even rarer in case of adults. Renal cell carcinoma has the tendency to form thrombus that can migrate to renal vein, inferior vena cava and even right atrium. Case presentation The authors report a case of an 81-year-old male with rhabdoid renal cell carcinoma presenting with persistent cough for 6-7 months. with tumour thrombus extending into the renal vein and hepatic inferior vena cava. The patient was found feeble for the surgery and hence was treated on anticancer drugs pembrolizumab and axitinib. Conclusion Renal cell carcinoma has the tendency to form tumour thrombus in renal vein and inferior vena cava. Prognosis without surgical intervention in these conditions is very poor.
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Affiliation(s)
- Manish KC
- North Alabama Medical Center, Florence, AL
| | | | - Pratik Subedi
- Nepalese Army Institute of Health Sciences, Tribhuvan University, Sanobharyang
| | - Ashutosh Kashyap
- Maharajgunj Medical Campus, Tribhuvan University, Institute of Medicine, Maharajgunj
| | | | - Dania Kaur
- North Alabama Medical Center, Florence, AL
| | - Sabina Koirala
- Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal
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8
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Al-Rusan OM, Patil D, Master VA, Osunkoya AO. A Contemporary Clinicopathologic Analysis of Patients With Renal Cell Carcinoma and Vena Cava Involvement. Int J Surg Pathol 2024; 32:279-285. [PMID: 37306114 DOI: 10.1177/10668969231177264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Renal cell carcinoma (RCC) is occasionally associated with vena cava involvement. Despite recent advances in therapeutic modalities, the 5-year survival in this population continues to be poor. Therefore, further studies are required to better characterize this patient population, especially from the clinicopathologic standpoint. A comprehensive review of patients with RCC and vena cava involvement managed at our institution from 2014 to 2022 was performed. Multiple clinicopathologic parameters including follow-up were obtained. A total of 114 patients were identified. The mean patient age was 63 years (range: 30-84 years). The cohort consisted of 78/114 (68%) males and 36/114 (32%) females. The mean primary tumor size (excluding tumor thrombus) was 11 cm. The majority of tumors (104/114, 91%) were unifocal. Tumor stages were categorized as follows: pT3b (51/114, 44%), pT3c (52/114, 46%), and pT4 (11/114, 10%). Most of the tumors were clear cell RCC 89/114 (78%), although other more aggressive RCC subtypes were also present. Most tumors were WHO/ISUP grade 3 (44/114, 39%) or 4 (67/114, 59%) with sarcomatoid differentiation present in 39/67 (58%). Necrosis was present in 94/114 (82%) tumors. Twenty-three of 114 (20%) tumors were categorized as pM1 and the ipsilateral adrenal gland was the most common site of metastasis. Of the 91 patients categorized as pM, not applicable at nephrectomy, 42/91 (46%) subsequently developed metastasis, most frequently to the lung. Of all patients, only 16/114 (14%) had positive vascular margins and 7/114 (6%) had positive soft tissue margins despite having very advanced disease and a subset considered inoperable at other centers.
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Affiliation(s)
- Omar M Al-Rusan
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - Dattatraya Patil
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Viraj A Master
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
- Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Adeboye O Osunkoya
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, USA
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
- Winship Cancer Institute of Emory University, Atlanta, GA, USA
- Department of Pathology, Veterans Affairs Medical Center, Decatur, GA, USA
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9
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Leyderman M, McElree IM, Nepple KG, Zakharia Y, Ghodoussipour S, Packiam VT. Management of Renal Cell Carcinoma With Supradiaphragmatic Inferior Vena Cava Thrombus Diagnosed During Acute COVID-19 Infection. Cureus 2024; 16:e55565. [PMID: 38576641 PMCID: PMC10993925 DOI: 10.7759/cureus.55565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 04/06/2024] Open
Abstract
Renal cell carcinoma (RCC) tends to undergo intravascular tumor growth along the renal vein, forming tumor thrombi that may extend into the inferior vena cava (IVC) or even the right atrium (Level IV). Managing such cases requires a multidisciplinary approach, especially in patients with acute coronavirus disease 2019 (COVID-19) infection, who face increased risks from surgical interventions. We present a case of RCC with Level IV thrombus and concurrent COVID-19 managed with systemic therapy. We also summarize current literature on treating RCC with IVC thrombus and COVID-19's impact on prognosis. The patient was a 70-year-old female with incidental detection of a 9-cm right heterogeneous renal mass with a supradiaphragmatic tumor thrombus during COVID-19 infection. Due to ongoing pulmonary symptoms, systemic therapy with a combination of ipilimumab and nivolumab was initiated. After an excellent initial response, the patient continued systemic therapy, maintaining a necrotic response in the renal mass and tumor thrombus. The patient continues to tolerate systemic therapy well. We report a rare case of RCC with Level IV tumor thrombus and synchronous acute COVID-19 infection. Our report depicts successful management utilizing systemic therapy with a combination of ipilimumab and nivolumab. The management of such cases necessitates a comprehensive, multidisciplinary approach, considering the risks associated with surgery in the context of recent COVID-19 infection. The case presentation and ensuing literature discussion of the dynamic landscape of RCC management highlights the need for more research to improve treatment plans and guide clinicians in handling such complex situations.
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Affiliation(s)
- Michael Leyderman
- Urology, Norton College of Medicine, SUNY Upstate Medical University, Syracuse, USA
| | - Ian M McElree
- Urology, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Kenneth G Nepple
- Urology, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Yousef Zakharia
- Internal Medicine - Hematology/Oncology, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Saum Ghodoussipour
- Division of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, USA
| | - Vignesh T Packiam
- Division of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, USA
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Chen R, Mei Z, Chen J. Scrutinizing VTE risk factors in complex renal tumor patients: a comprehensive look at the VTE-RT-IVCTT study. Int J Surg 2024; 110:1813-1814. [PMID: 38051929 PMCID: PMC10942190 DOI: 10.1097/js9.0000000000000969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 12/07/2023]
Affiliation(s)
- Ru Chen
- Department of Urology, Fujian Medical University Union Hospital, Gulou District, Fuzhou City, Fujian Province
| | - Zubing Mei
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine
- Anorectal Disease Institute of Shuguang Hospital, Shanghai, People’s Republic of China
| | - Jianhui Chen
- Department of Urology, Fujian Medical University Union Hospital, Gulou District, Fuzhou City, Fujian Province
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11
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Shah MS, Wang KR, Shah YB, Ragam R, Simhal RK, Ghodoussipour S, Djaladat H, Mark JR, Lallas CD, Chandrasekar T. A Narrative Review on Robotic Surgery as Treatment for Renal Cell Carcinoma with Inferior Vena Cava Thrombus. J Clin Med 2024; 13:1308. [PMID: 38592152 PMCID: PMC10932232 DOI: 10.3390/jcm13051308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/13/2024] [Accepted: 02/21/2024] [Indexed: 04/10/2024] Open
Abstract
Renal cell carcinoma (RCC) is a common diagnosis, of which a notable portion of patients present with an extension into the venous circulation causing an inferior vena cava (IVC) tumor thrombus. Venous extension has significant implications for staging and subsequent treatment planning, with recommendations for more aggressive surgical removal, although associated surgical morbidity and mortality is relatively increased. The methods for surgical removal of RCC with IVC thrombus remain complex, particularly surrounding the use of robot-assisted surgery. Robot assistance for radical nephrectomy in this context is recently emerging. Thrombus level has important implications for surgical technique and prognosis. Other preoperative considerations may include location, laterality, size, and wall invasion. The urology literature on treatment of such tumors is largely limited to case series and institutional studies that describe the feasibility of various surgical options for these complex tumors. Further understanding of the outcomes and patient-specific risk factors would shed increased light on the optimal treatment for such cases. This narrative review provides a thorough overview on the previously reported use of robot-assisted nephrectomy in RCC with IVC thrombus to inform further studies which may optimize outcomes and guide shared decision-making.
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Affiliation(s)
- Mihir S. Shah
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA; (M.S.S.)
| | - Kerith R. Wang
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA; (M.S.S.)
| | - Yash B. Shah
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA; (M.S.S.)
| | - Radhika Ragam
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA; (M.S.S.)
| | | | - Saum Ghodoussipour
- Division of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
| | - Houman Djaladat
- Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90007, USA
| | - James R. Mark
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA; (M.S.S.)
| | - Costas D. Lallas
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA; (M.S.S.)
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12
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Chen W, Zhao X, Lu Y, Wang H, Wang X, Wang Y, Liang C, Jia Z, Ma W. Clinical significance, molecular characterization, and immune microenvironment analysis of coagulation-related genes in clear cell renal cell carcinoma. CANCER INNOVATION 2024; 3:e105. [PMID: 38948537 PMCID: PMC11212306 DOI: 10.1002/cai2.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/17/2023] [Accepted: 09/30/2023] [Indexed: 07/02/2024]
Abstract
Background Numerous studies have revealed a tight connection between tumor development and the coagulation system. However, the effects of coagulation on the prognosis and tumor microenvironment (TME) of clear cell renal cell carcinoma (ccRCC) remain poorly understood. Methods We employed the consensus clustering method to characterize distinct molecular subtypes associated with coagulation patterns. Subsequently, we examined variations in the overall survival (OS), genomic profiles, and TME characteristics between these subtypes. To develop a prognostic coagulation-related risk score (CRRS) model, we utilized the least absolute shrinkage and selection operator Cox regression and stepwise multivariate Cox regression analyses. We also created a nomogram to aid in the clinical application of the risk score, evaluating the relationships between the CRRS and the immune microenvironment, responsiveness to immunotherapy, and targeted treatment. The clinical significance of PLAUR and its biological function in ccRCC were also further analyzed. Results There were significant differences in clinical features, prognostic stratification, genomic variation, and TME characteristics between the two coagulation-related subtypes. We established and validated a CRRS using six coagulation-related genes that can be employed as an effective indicator of risk stratification and prognosis estimation for ccRCC patients. Significant variations in survival outcomes were observed between the high- and low-risk groups. The nomogram was proficient in predicting the 1-, 3-, and 5-year OS. Additionally, the CRRS emerged as a novel tool for evaluating the clinical effectiveness of immunotherapy and targeted treatments in ccRCC. Moreover, we confirmed upregulated PLAUR expression in ccRCC samples that was significantly correlated with poor patient prognosis. PLAUR knockdown notably inhibited ccRCC cell proliferation and migration. Conclusion Our data suggested that CRRS may be employed as a reliable predictive biomarker that can provide therapeutic benefits for immunotherapy and targeted therapy in ccRCC.
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Affiliation(s)
- Weihao Chen
- Department of UrologyThe Third Medical Center of PLA General HospitalBeijingChina
| | - Xupeng Zhao
- School of MedicineNankai UniversityTianjinChina
| | - Yongliang Lu
- Department of UrologyThe Third Medical Center of PLA General HospitalBeijingChina
| | - Hanfeng Wang
- Department of UrologyThe Third Medical Center of PLA General HospitalBeijingChina
| | - Xiyou Wang
- Department of UrologyThe Third Medical Center of PLA General HospitalBeijingChina
| | - Yi Wang
- Department of UrologyThe Third Medical Center of PLA General HospitalBeijingChina
| | - Chen Liang
- Medical Service DepartmentThe PLA General HospitalBeijingChina
| | - Zhuomin Jia
- Department of UrologyThe Third Medical Center of PLA General HospitalBeijingChina
| | - Wei Ma
- Senior Department of Otolaryngology‐Head & Neck SurgeryThe Sixth Medical Center of PLA General HospitalBeijingChina
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13
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Yang DX, Kwon YS, Timmerman R, Hannan R. Stereotactic ablative radiotherapy for primary renal cell carcinoma. Clin Transl Radiat Oncol 2024; 44:100705. [PMID: 38073715 PMCID: PMC10698523 DOI: 10.1016/j.ctro.2023.100705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 11/25/2023] [Indexed: 05/19/2024] Open
Abstract
Stereotactic ablative radiotherapy (SAbR) is an emerging non-invasive definitive treatment option for primary renal cell carcinoma (RCC), particularly when surgery is not ideal. Employing ablative doses, SAbR delivered in one to five fractions to the primary tumor has been shown to achieve high local control rates with favorable toxicity profile in multiple retrospective and prospective series, and has dispelled previous notions of RCC radio-resistance. Moreover, emerging evidence suggests possible immunomodulatory effects, leading to clinical investigations of SAbR in combination with systemic and surgical management in patients with metastatic disease. In this review, we summarize key evidence supporting SAbR delivered to the primary tumor including preclinical rationale, dose escalation studies, recent prospective trials, and outcomes from ongoing multi-institutional registries. We also discuss areas of active clinical investigation including the use of primary SAbR in combination with systemic therapies in patients with metastatic disease. The accumulated body of evidence supports SAbR as promising indication being increasingly incorporated into the multi-disciplinary management of primary RCC.
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Affiliation(s)
- Daniel X. Yang
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Young Suk Kwon
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Robert Timmerman
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Raquibul Hannan
- University of Texas Southwestern Medical Center, Dallas, TX, United States
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14
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Williams CM, Myint ZW. The Role of Anticoagulation in Tumor Thrombus Associated with Renal Cell Carcinoma: A Literature Review. Cancers (Basel) 2023; 15:5382. [PMID: 38001642 PMCID: PMC10670835 DOI: 10.3390/cancers15225382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/10/2023] [Accepted: 11/11/2023] [Indexed: 11/26/2023] Open
Abstract
Tumor thrombus (TT) is a complication of renal cell carcinoma (RCC) for which favorable medical management remains undefined. While radical nephrectomy has been shown to increase overall survival in RCC patients, surgical interventions such as cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) utilized to perform TT resection carry high mortality rates. While it has been documented that RCC with TT is associated with venous thromboembolism (VTE) development, anticoagulation use in these patients remains controversial in clinical practice. Whether anticoagulation is associated with improved survival outcomes remains unclear. Furthermore, if anticoagulation is initiated, there is limited evidence for whether direct oral anticoagulants (DOACs), heparin, or warfarin serve as the most advantageous choice. While the combination of immunotherapy and tyrosine kinase inhibitors (TKIs) has been shown to improve the outcomes of RCC, the clinical benefits of this combination are not well studied prospectively in cases with TT. In this literature review, we explore the challenges of treating RCC-associated TT with special attention to anticoagulation. We provide a comprehensive overview of current surgical and medical approaches and summarize recent studies investigating anticoagulation in RCC patients undergoing surgery, targeted therapy, and/or immunotherapy. Our goal is to provide clinicians with updated clinical insight into anticoagulation for RCC-associated TT patients.
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Affiliation(s)
- Chelsey M. Williams
- Department of Internal Medicine, University of Kentucky, Lexington, KY 40536, USA;
| | - Zin W. Myint
- Division of Medical Oncology, Department of Internal Medicine, University of Kentucky, Lexington, KY 40536, USA
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15
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Gwon JG, Cho YP, Han Y, Suh J, Min SK. Technical Tips for Performing Suprahepatic Vena Cava Tumor Thrombectomy in Renal Cell Carcinoma without Using Cardiopulmonary Bypass. Vasc Specialist Int 2023; 39:23. [PMID: 37667821 PMCID: PMC10480049 DOI: 10.5758/vsi.230056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/27/2023] [Accepted: 08/02/2023] [Indexed: 09/06/2023] Open
Abstract
Radical nephrectomy with tumor thrombectomy for advanced renal cell carcinoma is an oncologically relevant approach that can achieve long-term survival even in the presence of distant metastases. However, the surgical techniques pose significant challenges. The objective of this clinical review was to present technical recommendations for tumor thrombectomy in the vena cava to facilitate surgical treatment. Transesophageal echocardiography is required to prepare for this procedure. Cardiopulmonary bypass should be considered when the tumor thrombus has invaded the cardiac chamber and clamping is not feasible because of the inability to milk the intracardiac chamber thrombus in the caudal direction. Prior to performing a cavotomy, it is crucial to clamp the contralateral renal vein and infrarenal and suprahepatic inferior vena cava (IVC). If the suprahepatic IVC is separated from the surrounding tissue, it can be gently pulled down toward the patient's leg until the lower margin of the atrium becomes visible. Subsequently, the tumor thrombus should be carefully pulled downward to a position where it can be clamped. Implementing the Pringle maneuver to reduce blood flow from the hepatic veins to the IVC during IVC cavotomy is simpler than clamping the hepatic veins. Sequential clamping is a two-stage method of dividing thrombectomy by clamping the IVC twice, first suprahepatically and then midretrohepatically. This sequential clamping technique helps minimize hypotension status and the Pringle maneuver time compared to single clamping. Additionally, a spiral cavotomy can decrease the degree of primary closure narrowing. The oncological prognoses of patients can be improved by incorporating these technical recommendations.
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Affiliation(s)
- Jun Gyo Gwon
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Pil Cho
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
| | - Youngjin Han
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
| | - Jungyo Suh
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Kee Min
- Division of Vascular Surgery, Department of Surgery, Seoul National University Hospital, Seoul, Korea
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16
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He W, Cong Z, Liu Y, Yao Z, Cheng F, Zhang Y, Niu Z. A novel technique for avoidance of sternotomy, diaphragmic incision and cardiopulmonary bypass during cavoatrial tumor thrombectomy for renal cell carcinoma with intraatrial tumor thrombus: a case series at a single center. BMC Surg 2023; 23:252. [PMID: 37620830 PMCID: PMC10463378 DOI: 10.1186/s12893-023-02156-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Radical nephrectomy with thrombectomy in patients with renal cell carcinoma (RCC) and level IV thrombus extending to the right atrium (RA) offers improved survival. However, this procedure is associated with significant perioperative morbidity and mortality. In this report, we describe a novel milking technique for patients with RA tumor thrombus using abdominal access, which does not require diaphragmic incision, sternotomy, right atriotomy, or cardiopulmonary bypass (CPB). METHODS Between January 2019 and January 2022, four patients underwent resection of renal cell carcinoma extending into RA by a milking technique developed to avoid diaphragmic incision, sternotomy, or CPB. Patient characteristics, perioperative data, pathological features, and survival were evaluated. RESULTS Complete resection was successful through pure transabdominal access without diaphragmic incision, sternotomy, or CPB in all patients. CONCLUSION We conclude that radical nephrectomy and thrombectomy in optimized cases with renal cell carcinoma extending into RA can be safely and effectively performed without diaphragmic incision, sternotomy, or CPB, avoiding serious perioperative complications while providing acceptable oncological outcomes.
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Affiliation(s)
- Wei He
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324, Jingwu Road, Huaiying District, Jinan, 250021, Shandong, China
| | - Zixiang Cong
- Department of Urology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong province, China
| | - Yaqing Liu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Zhongshun Yao
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324, Jingwu Road, Huaiying District, Jinan, 250021, Shandong, China
| | - Fajuan Cheng
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Yiming Zhang
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324, Jingwu Road, Huaiying District, Jinan, 250021, Shandong, China
| | - Zhihong Niu
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324, Jingwu Road, Huaiying District, Jinan, 250021, Shandong, China.
- Department of Urology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong province, China.
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17
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Li H, Sahu KK, Brundage J, Benson M, Swami U, Boucher KM, Gupta S, Hawks J, Sirohi D, Agarwal N, Maughan BL. Phase I Trial of Combination Therapy With Avelumab and Cabozantinib in Patients With Newly Diagnosed Metastatic Clear Cell Renal Cell Carcinoma. Oncologist 2023; 28:737-e693. [PMID: 36952231 PMCID: PMC10400129 DOI: 10.1093/oncolo/oyad019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 01/03/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Combination immunotherapy is now considered the standard first-line therapy for patients with metastatic clear cell renal cell carcinoma (mccRCC) after multiple clinical trials demonstrated improved overall survival compared with single-agent tyrosine kinase inhibitors. Cabozantinib modulates critical components of the immune system, such as decreasing regulatory T cells and increasing T-effector cell populations, and is approved for the treatment of mRCC. Avelumab is a human IgG1 monoclonal antibody that binds to programmed death-ligand 1 protein and inhibits the interaction with PD-1. This phase I trial assessed the safety and clinical activity of avelumab and cabozantinib combination therapy in mccRCC. METHODS This study was a phase I, 3+3 dose escalation clinical trial. The primary endpoint was the safety and identification of the recommended phase II dose (RP2D). Secondary endpoints included objective response rate (ORR) and radiographic progression-free survival (rPFS). There were 3 dose cohorts: cabozantinib 20, 40, and 60 mg/day, each combined with avelumab (10 mg/kg intravenously every 2 weeks). An additional 3 patients were included in the final dose cohort as a confirmation of the RP2D. No dose modifications were allowed for avelumab, but dose delays were permitted. Both dose reductions and holds were allowed for cabozantinib. Response Evaluation Criteria in Solid Tumors (RECIST), version 1.1, was used to determine ORR, and treatment beyond progression was allowed. RESULTS Twelve patients with newly diagnosed mccRCC were enrolled from July 2018 until March 2020. Three patients were enrolled in the 20 and 40 mg cohorts each, and 6 were enrolled in the 60 mg cohort. The International Metastatic RCC Database Consortium (IMDC) risk categories for these patients were: 4 patients (favorable risk), 6 patients (intermediate risk), and 2 patients (poor risk). No dose-limiting toxicities (DLTs) were observed in any cohort. Six patients developed serious adverse events related to study treatment after the DLT window period. Immune-related adverse events (iRAEs) were reported in 11 patients; fatigue and diarrhea were the most common (each with n = 4, 33.3%), followed by maculopapular rash and hand-foot syndrome (each with n = 3, 25%). Dose reductions were required in 5 of 6 patients in the cabozantinib 60 mg cohort after the DLT period. One patient discontinued avelumab due to irAE (nephritis), while none discontinued cabozantinib due to toxicity. The ORR was 50%, with one complete response (CR) and 5 partial responses (PR). The disease control rate (CR + PR + stable disease) was noted in 92% of the patients. Radiological PFS survival rate at 6 and 12 months was reported in 67.7% and 33.5% of patients, respectively. CONCLUSION Combination therapy with avelumab and cabozantinib is safe and showed preliminary clinical activity in mccRCC. Even though the DLT was not met in any of the 3 cohorts, the recommended RP2D dose for the combination is cabozantinib 40 mg/day due to a high incidence of grade 2 toxicity for cabozantinib 60 mg/day after the DLT period. (ClinicalTrials.gov Identifier: NCT03200587).
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Affiliation(s)
- Haoran Li
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Kamal Kant Sahu
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - James Brundage
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Mallory Benson
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Umang Swami
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Kenneth M Boucher
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Sumati Gupta
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Josiah Hawks
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Deepika Sirohi
- Department of Pathology, ARUP Institute for Clinical and Experimental Pathology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Neeraj Agarwal
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Benjamin L Maughan
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
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Du T, Wu Z, Wu Y, Liu Y, Song Y, Ma L. CD44 Is Associated with Poor Prognosis of ccRCC and Facilitates ccRCC Cell Migration and Invasion through HAS1/MMP9. Biomedicines 2023; 11:2077. [PMID: 37509716 PMCID: PMC10377257 DOI: 10.3390/biomedicines11072077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/13/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND In many solid tumors, CD44 has been identified as a cancer stem cell marker as well as an important molecular in cancer progression and metastasis, making it attractive for potential therapeutic applications. However, our knowledge of the biological function and mechanism of CD44 in clear cell renal cell carcinoma (ccRCC) is limited. METHODS In this study, the expression, prognostic values and functional enrichment analysis of CD44 in ccRCC were analyzed using public databases. Quantitative real-time PCR (qRT-PCR), Western blotting, and immunohistochemical (IHC) assays were taken to detect CD44 expression in ccRCC tissues. The effects of CD44 on the proliferation, migration and invasion of ccRCC cells were investigated by gain-of-function and loss-of-function experiments. Subcutaneous models further confirmed the role of CD44 in tumor growth. The relationship between CD44, HAS1 and MMP9 was investigated to uncover the regulatory mechanism of CD44 in ccRCC. RESULTS CD44 was significantly upregulated in ccRCC and associated with poor overall survival (OS). Based on the functional enrichment analysis and PPI network, we found that CD44 had associations with ECM interaction and focal adhesion pathway. Clinical ccRCC sample validation revealed that CD44 mRNA and protein expression were significantly increased in ccRCC tissues, and strong CD44 staining was observed in four metastatic ccRCC cases. In vitro experiments showed that CD44 overexpression promoted cell proliferation, migration and invasion. In vivo experiments also demonstrated that CD44 overexpression accelerated tumor formation in mice. Finally, we found that CD44 regulates the expression of HAS1 in ccRCC, which is essential for the secretion of MMP9 and cell migratory ability. CONCLUSION The upregulation of CD44 mRNA and protein expressions in ccRCC is indicative of unfavorable clinical prognoses. The CD44/HAS1/MMP9 axis is believed to exert a significant influence on the regulation of ECM degradation and ccRCC metastasis.
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Affiliation(s)
- Tan Du
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - Zonglong Wu
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - Yaqian Wu
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - Yunchong Liu
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - Yimeng Song
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
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Acuña Pais B, Casais R, Lugo J, Piñón MÁ, Legarra JJ. Surgical management of tumor thrombus into the right atrium. J Cardiovasc Thorac Res 2023; 15:121-126. [PMID: 37654816 PMCID: PMC10466468 DOI: 10.34172/jcvtr.2023.31597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 03/27/2023] [Indexed: 09/02/2023] Open
Abstract
Renal cell carcinoma represents 3% of solid tumors. In 4-10% of patients, venous tumor thrombosis is present, and 1% reaches the right atrium. Other tumors can be associated with tumor thrombosis. The natural history of venous tumor thrombosis implies a mean survival of 5 months. Between 2001 and 2021, 4 patients underwent resection of tumor thrombi into the right atrium, requiring cardiopulmonary bypass. None of the patients died within 30 days postoperatively. Mean follow-up time was 30.9 months (2.4- 96.1). Two patients are still alive and two died due to disease progression. Died patient's follow-up was 7.5 and 17.4 months, surpassing life expectancy of those without surgery. We present a series of patients who underwent lumpectomy and IVC thrombectomy. IVC tumor thrombosis has an ominous prognosis, however surgical treatment has an important role by improving the survival of these patients. The multidisciplinary approach is necessary to obtain good postoperative results.
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Affiliation(s)
- Beatriz Acuña Pais
- Cardiovascular Surgery Service, Álvaro Cunqueiro Hospital, Carretera de Clara Campoamor, Vigo, Spain
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20
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Pei X, Lu M, Liu Z, Liu B, Deng Y, Yuan H, Ma L. The value of enhanced multiparameteric MRI diagnostic model for preoperatively predicting surgical methods of inferior vena cava in patients with renal tumors and inferior vena cava tumor thrombus. BMC Med Imaging 2023; 23:86. [PMID: 37355601 PMCID: PMC10290788 DOI: 10.1186/s12880-023-01043-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 06/05/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND Inferior vena cava tumor thrombus (IVCTT) invading the IVC wall majorly affects the surgical method choice and prognosis in renal tumors. Enhanced multiparameteric MRI plays an important role in preoperative evaluation. In this work, an MRI-based diagnostic model for IVCTT was established so as to guide the preoperative decisions. METHODS Preoperative MR images of 165 cases of renal tumors with IVCTT were retrospectively analyzed, and imaging indicators were analyzed, including IVCTT morphology and Mayo grade, IVCTT diameter measurements, bland thrombosis, primary MRI-based diagnosis of renal tumor, and involvement of contralateral renal vein. The indicators were analyzed based on intraoperative performance and resection scope of the IVC wall. Multivariate logistic regression analysis was used to establish the diagnostic model. RESULTS The morphological classification of the IVCTT, primary MRI-based diagnosis of renal tumors, maximum transverse diameter of IVCTT, and length of the bland thrombus were the main indexes predicting IVC wall invasion. The MRI-based diagnostic model established according to these indexes had good diagnostic efficiency. The prediction probability of 0.61 was set as the cutoff value. The area under the curve of the test set was 0.88, sensitivity was 0.79, specificity was 0.85, and prediction accuracy was 0.79 under the optimal cutoff value. CONCLUSION The preoperative MRI-based diagnostic model could reliably predict IVC wall invasion, which is helpful for better prediction of IVC-associated surgical operations.
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Affiliation(s)
- Xinlong Pei
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Min Lu
- Department of Pathology, Peking University Third Hospital, Beijing, China
| | - Zhuo Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Baohua Liu
- School of Public Health, Peking University, Beijing, China
| | - Yuhan Deng
- School of Public Health, Peking University, Beijing, China
| | - Huishu Yuan
- Department of Radiology, Peking University Third Hospital, Beijing, China.
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing, China.
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Shi X, Pang Q, Nian X, Jiang A, Shi H, Liu W, Gan X, Gao Y, Yang Y, Ji J, Tan X, Xiao C, Zhang W. Integrative transcriptome and proteome analyses of clear cell renal cell carcinoma develop a prognostic classifier associated with thrombus. Sci Rep 2023; 13:9778. [PMID: 37328520 PMCID: PMC10276054 DOI: 10.1038/s41598-023-36978-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 06/13/2023] [Indexed: 06/18/2023] Open
Abstract
Clear cell renal cell carcinoma (ccRCC) with venous tumor thrombus (VTT) is associated with poor prognosis. Our integrative analyses of transcriptome and proteome reveal distinctive molecular features of ccRCC with VTT, and yield the development of a prognostic classifier to facilitate ccRCC molecular subtyping and treatment. The RNA sequencing and mass spectrometry were performed in normal-tumor-thrombus tissue triples of five ccRCC patients. Statistical analysis, GO and KEGG enrichment analysis, and protein-protein interaction network construction were used to interpret the transcriptomic and proteomic data. A six-gene-based classifier was developed to predict patients' survival using Cox regression, which was validated in an independent cohort. Transcriptomic analysis identified 1131 tumorigenesis-associated differentially expressed genes (DEGs) and 856 invasion-associated DEGs. Overexpression of transcription factor EGR2 in VTT indicated its important role in tumor invasion. Furthermore, proteomic analysis showed 597 tumorigenesis-associated differentially expressed proteins (DEPs) and 452 invasion-associated DEPs. The invasion-associated DEPs showed unique enrichment in DNA replication, lysine degradation, and PPAR signaling pathway. Integration of transcriptome and proteome reveals 142 tumorigenesis-associated proteins and 84 invasion-associated proteins displaying changes consistent with corresponding genes in transcriptomic profiling. Based on their different expression patterns among normal-tumor-thrombus triples, RAB25 and GGT5 were supposed to play a consistent role in both tumorigenesis and invasion processes, while SHMT2 and CADM4 might play the opposite roles in tumorigenesis and thrombus invasion. A prognostic classifier consisting of six DEGs (DEPTOR, DPEP1, NAT8, PLOD2, SLC7A5, SUSD2) performed satisfactorily in predicting survival of ccRCC patients (HR = 4.41, P < 0.001), which was further validated in an independent cohort of 40 cases (HR = 5.52, P = 0.026). Our study revealed the transcriptomic and proteomic profiles of ccRCC patients with VTT, and identified the distinctive molecular features associated with VTT. The six-gene-based prognostic classifier developed by integrative analyses may facilitate ccRCC molecular subtyping and treatment.
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Affiliation(s)
- Xiaolei Shi
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Qingyang Pang
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Xinwen Nian
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Aimin Jiang
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Haoqing Shi
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Wenqiang Liu
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Xinxin Gan
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Yisha Gao
- Department of Pathology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Yiren Yang
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Jin Ji
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Xiaojie Tan
- Department of Epidemiology, Naval Medical University, 800 Xiangyin Rd, Shanghai, 200433, China
| | - Chengwu Xiao
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China.
| | - Wei Zhang
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China.
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22
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Almatari AL, Sathe A, Wideman L, Dewan CA, Vaughan JP, Bennie IC, Buscarini M. Renal cell carcinoma with tumor thrombus: A review of relevant anatomy and surgical techniques for the general urologist. Urol Oncol 2023; 41:153-165. [PMID: 36804205 DOI: 10.1016/j.urolonc.2022.11.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 02/19/2023]
Abstract
Renal cell carcinoma (RCC) is estimated to account for 4.1% of all new cancer diagnoses and 2.4% of all cancer deaths in 2020 according to the National Cancer Institute SEER database. This will likely total 73,000 new cases and 15,000 deaths. RCC is one of the most lethal of the common cancers urologists will encounter with a 5-year relative survival of 75.2%. Renal cell carcinoma is one of a small subset of malignancies that are associated with tumor thrombus formation, which is tumor extension into a blood vessel. An estimated 4% to 10% of patients with RCC will have some degree of tumor thrombus extending into the renal vein or inferior vena cava at the time of diagnosis. Tumor thrombi change the staging of RCC and therefore are an important part of initial patient workup. It is known that such tumors are more aggressive with higher Fuhrman grades, N+ or M+ at time of surgery and have higher probability of recurrence with lower cancer-specific survival. Aggressive surgical intervention with radical nephrectomy and thrombectomy can be performed with survival benefits. Classifying the level of the tumor thrombus becomes vitally important in surgical planning as it will dictate the surgical approach. Level 0 thrombi may be amenable to simple renal vein ligation while level 4 can require thoracotomy and possible open-heart surgery with coordination of many surgical teams. Here we will review the anatomy associated with each level of tumor thrombus and attempt to construct an outline for surgical techniques that may be used. We aim to give a concise overview so that general urologists may use it to understand these potentially complicated cases.
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Affiliation(s)
- Abraham L Almatari
- Department of Urology, The University of Tennessee Health Science Center, Memphis, TN
| | - Aditya Sathe
- Department of Urology, The University of Tennessee Health Science Center, Memphis, TN
| | - Lauren Wideman
- Department of Urology, The University of Tennessee Health Science Center, Memphis, TN
| | - Christian A Dewan
- Department of Urology, The University of Tennessee Health Science Center, Memphis, TN
| | - Joseph P Vaughan
- Department of Urology, The University of Tennessee Health Science Center, Memphis, TN
| | - Ian C Bennie
- Department of Urology, The University of Tennessee Health Science Center, Memphis, TN
| | - Maurizio Buscarini
- Department of Urology, The University of Tennessee Health Science Center, Memphis, TN.
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23
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Garg H, Whalen P, Marji H, Cooper R, Dursun F, Bhandari M, Khanna L, Jayakumar L, Liss MA, Svatek RS, Rodriguez R, Kaushik D, Pruthi DK. Patency outcomes of primary inferior vena cava repair in radical nephrectomy and tumor thrombectomy. J Vasc Surg Venous Lymphat Disord 2023; 11:595-604.e2. [PMID: 36736700 DOI: 10.1016/j.jvsv.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/15/2022] [Accepted: 01/04/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The reconstruction of inferior vena cava (IVC) during radical nephrectomy and venous tumor thrombectomy (RN-VTT) is mostly performed with primary repair or with a patch/graft. We sought to systematically evaluate the outcomes of IVC patency over short- to intermediate-term follow-up for patients undergoing primary repair of IVC and to assess the association with survival. METHODS A retrospective review of patients undergoing RN-VTT between January 2013 and August 2018 was conducted. Patients were followed until death, last available follow-up, or March 2022. The patency outcomes and IVC diameters were studied using follow-up cross-sectional imaging. The χ2 test, Student t test, and Kaplan-Meier survival analysis were used. RESULTS Seventy-seven patients were included. The mean age was 59.2 ± 12.2 years and 45.4% had Mayo classification level III thrombus or higher. At a median follow-up of 36.5 months (13.3-60.7 months), the 3-year overall survival (OS) was 64%. Sixty patients underwent primary repair of the IVC and 48 of these patients were assessed for IVC patency. Ten patients (20.8%) developed caval occlusion, either from recurrent tumor (8.3%), new-onset bland thrombus (8.3%), or stenosis (4.2). The IVC patency seemed to be a significant predictor of OS (hazard ratio, 2.85; P = .021). Although the IVC diameters decreased significantly at the 3-month postoperative scan at the infrarenal (P = .019), renal (P < .001), and suprarenal (P < .001) levels, they did not decrease further on long-term follow-up imaging. CONCLUSIONS IVC reconstruction with primary repair results in an overall patency rate of 80.2% with only a 4.0% rate of stenosis. Recurrence of tumor thrombus (8.3%) or bland thrombus (8.3%) are the predominant reasons for IVC occlusion after RN-VTT, and this outcome is associated with poor OS.
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Affiliation(s)
- Harshit Garg
- Department of Urology, University of Texas Health, San Antonio, TX
| | - Philip Whalen
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio, TX
| | - Haneen Marji
- Department of Radiodiagnosis, University of Texas Health, San Antonio, TX
| | - Robert Cooper
- Department of Urology, University of Texas Health, San Antonio, TX
| | - Furkan Dursun
- Department of Urology, University of Texas Health, San Antonio, TX
| | - Mukund Bhandari
- Department of Population Health Science, University of Texas Health, San Antonio, TX
| | - Lokesh Khanna
- Department of Radiodiagnosis, University of Texas Health, San Antonio, TX
| | | | - Michael A Liss
- Department of Urology, University of Texas Health, San Antonio, TX
| | - Robert S Svatek
- Department of Urology, University of Texas Health, San Antonio, TX
| | - Ronald Rodriguez
- Department of Urology, University of Texas Health, San Antonio, TX
| | - Dharam Kaushik
- Department of Urology, University of Texas Health, San Antonio, TX
| | - Deepak K Pruthi
- Department of Urology, University of Texas Health, San Antonio, TX.
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24
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Tabbara MM, González J, Martucci M, Ciancio G. Current Approaches in Surgical and Immunotherapy-Based Management of Renal Cell Carcinoma with Tumor Thrombus. Biomedicines 2023; 11:204. [PMID: 36672712 PMCID: PMC9855836 DOI: 10.3390/biomedicines11010204] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/06/2023] [Accepted: 01/10/2023] [Indexed: 01/15/2023] Open
Abstract
Renal cell carcinoma (RCC) accounts for 2-3% of all malignant disease in adults, with 30% of RCC diagnosed at locally advanced or metastatic stages of disease. A form of locally advanced disease is the tumor thrombus (TT), which commonly grows from the intrarenal veins, through the main renal vein, and up the inferior vena cava (IVC), and rarely, into the right cardiac chambers. Advances in all areas of medicine have allowed increased understanding of the underlying biology of these tumors and improved preoperative staging. Although the development of several novel system agents, including several clinical trials utilizing immune checkpoint inhibitors and combination therapies, has been shown to lower perioperative morbidity and increase post-operative recurrence-free and progression-free survival, surgery remains the mainstay of therapy to achieve a cure. In this review, we provide a description of specific surgical approaches and techniques used to minimize intra- and post-operative complications during radical nephrectomy and tumor thrombectomy of RCC with TT extension of various levels. Additionally, we provide an in-depth review of the major developments in neoadjuvant and adjuvant immunotherapy-based treatment and the impact of ongoing and recently completed clinical trials on the surgical treatment of advanced RCC.
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Affiliation(s)
- Marina M. Tabbara
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
| | - Javier González
- Servicio de Urología, Unidad de Transplante Renal, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
| | - Melanie Martucci
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
| | - Gaetano Ciancio
- Department of Surgery and Urology, Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
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25
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Baia M, Naumann DN, Wong CS, Mahmood F, Parente A, Bissacco D, Almond M, Ford SJ, Tirotta F, Desai A. Dealing with malignancy involving the inferior vena cava in the 21st century. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:664-673. [PMID: 36239927 DOI: 10.23736/s0021-9509.22.12408-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
INTRODUCTION Malignancies involving the inferior vena cava (IVC) have historically been considered not amendable to surgery. More recently, involvement of the IVC by neoplastic processes in the kidney, liver or in the retroperitoneum can be managed successfully. EVIDENCE ACQUISITION In this systematic review we summarize the current evidence regarding the surgical management of the IVC in cases of involvement in neoplastic processes. Current literature was searched, and studies selected on the base of the PRISMA guidelines. Evidence was synthesized in narrative form due to heterogeneity of studies. EVIDENCE SYNTHESIS Renal cell carcinoma accounts for the greatest proportion of studied patients and can be managed with partial or complete vascular exclusion of the IVC, thrombectomy and direct closure or patch repair with good oncological prognosis. Hepatic malignancies or metastases may involve the IVC, and the joint expertise of hepatobiliary and vascular surgeons has developed various strategies, according to the location of tumor and the need to perform a complete vascular exclusion above the hepatic veins. In retroperitoneal lymph node dissection, the IVC can be excised en-block to guarantee better oncological margins. Also, in retroperitoneal sarcomas not arising from the IVC a vascular substitution may be required to improve the overall survival by clearing all the neoplastic cells in the retroperitoneum. Leiomyoma can have a challenging presentation with involvement of the IVC requiring either thrombectomy, partial or complete substitution, with good oncological outcomes. CONCLUSIONS A multidisciplinary approach with specialist expertise is required when dealing with IVC involvement in surgical oncology. Multiple techniques and strategies are required to deliver the most efficient care and achieve the best possible overall survival. The main aim of these procedures must be the complete clearance of all neoplastic cells and achievement of a safe margin according to the perioperative treatment strategy.
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Affiliation(s)
- Marco Baia
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK -
- Sarcoma Service, Department of Surgery, IRCCS Istituto Nazionale Tumori Foundation, Milan, Italy -
| | - David N Naumann
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Chee S Wong
- Department of General Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Fahad Mahmood
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Alessandro Parente
- Unit OF HPB and Transplant, Department of Surgical Science, Tor Vergata University, Rome, Italy
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Daniele Bissacco
- Unit of Vascular Surgery, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Max Almond
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Samuel J Ford
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Fabio Tirotta
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Anant Desai
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK
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26
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Chen S, Zhao Y, Tang Q, Wu C, Wang A, Ma L, Zhang X, Chen J, Gao Y, Liao X, Feng N, Fan Y, Zhang J, Li X, Liu M. Diagnostic performance and prognostic value of preoperative 18F-FDG PET/CT in renal cell carcinoma patients with venous tumor thrombus. Cancer Imaging 2022; 22:65. [DOI: 10.1186/s40644-022-00502-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 11/03/2022] [Indexed: 11/28/2022] Open
Abstract
Abstract
Background
To observe the diagnostic efficacy of preoperative fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) upon venous tumor thrombus (VTT) in patients with renal cell carcinoma (RCC), and investigate the prognostic value of imaging parameters integrated with clinicopathological characteristics in patients with VTT after nephrectomy with tumor thrombectomy.
Methods
Patients with newly diagnosed RCC who underwent 18F-FDG PET/CT were reviewed retrospectively. The diagnostic efficacy of 18F-FDG PET/CT in VTT was analyzed. Logistic regression analysis was carried out to identify the clinical variables and PET/CT variables (including maximum standardized uptake value (SUVmax) of primary tumor, VTT SUVmax and primary tumor size) for differentiating early VTT (Mayo 0-II) from advanced VTT (Mayo III-IV). Cox proportional hazard analyses were used to evaluate clinicopathological factors and PET/CT factors (including distant metastasis, primary tumor SUVmax, VTT SUVmax and primary tumor size) for disease-free survival (DFS) in patients with VTT after operation.
Results
A total of 174 eligible patients were included in this study, including 114 men (65.5%) and 60 women (34.5%), with a median age of 58 years (range, 16–81 years). The distribution of pathological tumor stage (T stage) was 56 (T1), 17 (T2), 95 (T3), and 6 cases (T4), respectively. According to WHO/ISUP grade, except for 4 cases of chromophobe cell RCC, there were 14 patients (8.0%) of grade 1, 59 patients (33.9%) of grade 2, 74 patients (42.5%) of grade 3 and 23 patients (13.2%) of grade 4. The median maximum diameter of the primary tumor on PET/CT was 7.3 cm (5.0–9.5 cm). The distal metastasis was observed in 46 patients (26.4%). Sixty-one cases (35.1%) were confirmed with VTT by pathology. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 18F-FDG PET/CT imaging were 96.7, 99.1, 98.3, 98.3, and 98.2%, in detecting VTT, respectively, and 70.0, 100.0, 94.9, 100.0, and 94.2%, in evaluating the level of VTT, respectively. Elevated VTT SUVmax (≥5.20) could significantly distinguish the early VTT group and advanced VTT group (P = 0.010). In the prognosis analysis, elevated VTT SUVmax (≥4.30) (P = 0.018, HR 3.123, 95% CI 1.212–8.044) and distant metastasis (P = 0.013, HR 3.344, 95% CI 1.293–8.649) were significantly independent predictors for DFS.
Conclusion
Preoperative 18F-FDG PET/CT has a high diagnostic efficacy in detecting VTT and evaluating its level in RCC patients. Those patients with elevated VTT SUVmax should be carefully monitored to detect the possibility of disease progression after operation.
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27
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Master VA, Schmeusser BN, Osunkoya AO, Palacios AR, Midenberg E, Yantorni L, Ogan K, Bilen MA. Neoadjuvant Nivolumab and Ipilimumab for Nonmetastatic Renal Cell Carcinoma with Tumor Thrombus. JOURNAL OF IMMUNOTHERAPY AND PRECISION ONCOLOGY 2022; 6:50-55. [PMID: 36751655 PMCID: PMC9888517 DOI: 10.36401/jipo-22-16] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 11/09/2022]
Abstract
Renal cell carcinoma with level IV tumor thrombus is a condition necessitating aggressive surgical management. Many solid organ malignancies often benefit from neoadjuvant treatments for tumor debulking and improvement of surgical outcomes. However, neoadjuvant treatments for renal cell carcinoma have been limited by its resistance to traditional chemotherapy and radiation. Emerging treatment modalities, such as immunotherapies, are exciting new options that may be therapeutically effective. The combination of nivolumab and ipilimumab has exhibited success in managing metastatic renal cell carcinoma. Limited data exist for its use in nonmetastatic renal cell carcinoma with tumor thrombus. This case illustrates the use of nivolumab and ipilimumab combination therapy in delaying tumor growth, producing observable tumor thrombus histologic and radiologic treatment changes, and, most importantly, facilitating a less invasive surgical approach of a level IV renal cell carcinoma tumor thrombus.
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Affiliation(s)
- Viraj A. Master
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Adeboye O. Osunkoya
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
,Department of Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - Arnold R. Palacios
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Eric Midenberg
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Lauren Yantorni
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kenneth Ogan
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Mehmet A. Bilen
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
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28
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Characterizing Tumor Thrombus Arising from Non–Clear Cell Renal Cell Carcinoma. EUR UROL SUPPL 2022; 43:28-34. [PMID: 36353070 PMCID: PMC9638762 DOI: 10.1016/j.euros.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2022] [Indexed: 12/02/2022] Open
Abstract
Background Renal cell carcinoma (RCC) can exhibit a unique vascular tropism that enables tumor thrombus extension into the inferior vena cava (IVC). While most RCC subtypes that form tumor thrombi are of clear cell (cc) histology, non–clear cell (ncc) subtypes can also exhibit this unique growth pattern. Objective To characterize clinicopathologic differences and survival outcomes among patients with IVC tumor thrombus arising from ccRCC versus nccRCC. Design, setting, and participants Patients diagnosed with IVC tumor thrombus secondary to RCC in our institutional experience from 2003 to 2021 were identified. Outcome measurements and statistical analysis Clinicopathologic characteristics were compared by histology. Perioperative and oncologic outcomes including recurrence-free (RFS), overall (OS), and cancer-specific (CSS) survival were assessed using multivariable Cox regression analyses. Results and limitations The analyzed cohort included 103 patients (82 ccRCC and 21 nccRCC). There were no significant differences in baseline demographic parameters. Patients with nccRCC were more likely to have regional lymph node involvement (42.9% vs 20.7%, p = 0.037). No differences in perioperative outcomes, IVC resection, or IVC reconstruction were observed between groups. The median follow-up time was 30 mo. The median RFS was 30 (nccRCC) versus 53 (ccRCC) mo (p = 0.1). There was no significant difference in OS or CSS. This study was limited by its small sample size. Conclusions Patients with IVC tumor thrombus arising from ccRCC and nccRCC exhibit similar perioperative and oncologic outcomes. While surgical appropriateness was not impacted by histologic subtype, multimodal strategies are needed to improve outcomes for patients with tumor thrombus. Patient summary Renal cell carcinoma (RCC) can uniquely invade vasculature and form a tumor thrombus. This study examined the difference in outcomes of patients with tumor thrombus based on RCC subtype (clear cell vs non–clear cell). We found that patients exhibited similar surgical and survival outcomes regardless of RCC type.
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29
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Cheong I. Multiple organ dysfunction due to inferior vena cava thrombosis diagnosed by point-of-care ultrasound in the intensive care unit. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:940-941. [PMID: 35584041 DOI: 10.1002/jcu.23235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/25/2022] [Accepted: 05/10/2022] [Indexed: 06/15/2023]
Abstract
We describe the case of a 75-years-old woman with history of left renal cell carcinoma that presented multiple organ dysfunction due to IVCT diagnosed by point-of-care ultrasound (POCUS) in the intensive care unit (ICU).
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Affiliation(s)
- Issac Cheong
- Department of Critical Care Medicine, Sanatorio De los Arcos, Buenos Aires, Argentina
- Argentinian Critical Care Ultrasonography Association (ASARUC), Buenos Aires, Argentina
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30
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Aimanan K, Koay KL, Hayati F, Tajri HM. Single-stage inferior vena caval intravenous leiomyomatosis excision. BMJ Case Rep 2022; 15:e250261. [PMID: 35953149 PMCID: PMC9379474 DOI: 10.1136/bcr-2022-250261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2022] [Indexed: 11/04/2022] Open
Abstract
Intravascular tumour extension can occur in many different types of cancer. Those with the highest tendency include renal cell carcinoma, adrenal cortical carcinoma and hepatocellular carcinoma. Inferior vena cava (IVC) tumour thrombus in gynaecological malignancy is rarely reported. We present a report on a female patient with extensive IVC tumour thrombus (intravenous leiomyomatosis) with concurrent intrauterine leiomyomatosis. She underwent a single-stage procedure, involving laparotomy and a sternotomy to remove her pelvic tumour, as well as the intracaval and intracardiac thrombus. The clinical presentation and management of this rare tumour will be detailed in this case report.
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Affiliation(s)
- Karthigesu Aimanan
- Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
- Department of Surgery, Hospital Serdang, Kajang, Selangor, Malaysia
| | - Kean Leong Koay
- Department of Surgery, Hospital Serdang, Kajang, Selangor, Malaysia
| | - Firdaus Hayati
- Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
- Department of Surgery, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
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31
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Author's Reply to Şener and Begijanashvili: "Thromboembolism in Patients with Metastatic Renal Cell Carcinoma Treated with Immunotherapy". Target Oncol 2022; 17:495-496. [PMID: 35819564 DOI: 10.1007/s11523-022-00895-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 10/17/2022]
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32
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Tabbara MM, González J, Ciancio G. Renal Cell Carcinoma with Supradiaphragmatic Tumor Thrombus: Avoiding Sternotomy and Cardiopulmonary Bypass. MEDICAL RESEARCH ARCHIVES 2022; 10:10.18103/mra.v10i7.2913. [PMID: 36714035 PMCID: PMC9879345 DOI: 10.18103/mra.v10i7.2913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Renal cell carcinoma (RCC) accounts for 2-3% of all malignant disease in adults and has a propensity to infiltrate the surrounding adjacent structures with a biologic predisposition for vascular invasion. This tropism for the venous system facilitates propagation into the renal vein and inferior vena cava (IVC) in up to 25% of patients with RCC. Surgical resection remains the mainstay treatment for RCC with venous tumor thrombus (TT) extension and the only hope for a potential cure. Higher thrombus levels correlate with more advanced stages of disease and thus poorer survival rates. Although CPB with circulatory arrest has been successfully performed during resection of these tumors, its use remains controversial due to the risk of coagulopathy, platelet dysfunction, and central nervous system complications. Complete intraabdominal surgical excision of level III thrombi can be achieved without sternotomy and CPB by utilizing hepatic mobilization maneuvers. The purpose of this review is to provide an update on the surgical management of these difficult cases of RCC with supradiaphragmatic tumor thrombi, including a description of transplant-based techniques that avoid sternotomy and cardiopulmonary bypass (CPB), minimizing intra- and post-operative complications.
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Affiliation(s)
- Marina M. Tabbara
- Department of Surgery, University of Miami Miller School of Medicine; Miami, Florida,Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital; Miami, Florida
| | - Javier González
- Servicio de Urología, Unidad de Trasplante Renal, Hospital General Universitario Gregorio Marañón; Madrid, Spain
| | - Gaetano Ciancio
- Department of Surgery, University of Miami Miller School of Medicine; Miami, Florida,Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital; Miami, Florida,Department of Urology, University of Miami Miller School of Medicine; Miami, Florida,
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Yang L, Fu B. Nomograms for Predicting Overall Survival and Cancer-Specific Survival of Patients With Renal Cell Carcinoma and Venous Tumor Thrombus: A Population-Based Study. Front Surg 2022; 9:929885. [PMID: 36034346 PMCID: PMC9411105 DOI: 10.3389/fsurg.2022.929885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background To provide better prognostic information for patients with renal cell carcinoma (RCC) combined with venous tumor thrombus (VTT). In turn, guide patients’ families and doctors to formulate plans for follow-up treatment and follow-up. We developed nomograms to predict cancer-specific survival (CSS) and overall survival (OS). Methods A total of 2961 cases were included in this study. Through univariate and multivariate Cox proportional hazard regression analysis, independent risk factors affecting CSS and OS were screened out, and then a nomogram was drawn based on the screened variables. Results Independent risk factors affecting CSS include: tumor size (HR = 1.05), histology (HR = 1.75), grade (HR = 1.94), N staging (HR = 2.06), and M staging (HR = 2.87). The median survival time for CSS was 106 months. Independent risk factors for OS include age (HR = 1.60), tumor size (HR = 1.04), histology (HR = 1.60), grade (HR = 1.68), N staging (HR-1.99), M staging (HR = 2.45). The median survival time for OS is 67 months. Conclusions The nomogram based on independent risk factors affecting CSS and OS can well predict the prognosis of renal cell carcinoma with venous tumor thrombus.
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Wallace A, Porten SP, Lo AA, Oreper D, Lounsbury N, Havnar C, Pechuan-Jorge X, Zill OA, Meng MV. Origins and Timing of Emerging Lesions in Advanced Renal Cell Carcinoma. Mol Cancer Res 2022; 20:909-922. [PMID: 35297992 PMCID: PMC9381131 DOI: 10.1158/1541-7786.mcr-21-0590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 01/05/2022] [Accepted: 03/10/2022] [Indexed: 01/07/2023]
Abstract
Renal cell carcinoma (RCC) with venous tumor thrombus (VTT) arising from the primary tumor occurs in approximately 10% of cases and is thought to represent more advanced disease. The intravascular nature of VTT suggests that it may serve as a source for hematogenous metastases. RCC with VTT and distant metastasis provides unique opportunities to examine the origins and emergence timing of these distinct tumor lesions, and to identify molecular correlates with disease state. We performed multi-region exome and RNA-sequencing analysis of 16 patients with RCC with VTT, with eight patients also having sequenced metastasis, to identify genomic alterations, biological pathways, and evolutionary processes contributing to VTT and metastasis, and to ask whether metastasis arises directly from or independent of VTT. No specific genomic alterations were associated with VTT. Hallmark copy-number alterations (deletions of 14q, 8p, and 4q) were associated with metastasis and disease recurrence, and secondary driver alterations tended to accumulate in metastatic lineages. Mismatch repair mutational signatures co-occurred across most tumors, suggesting a role for intracellular DNA damage in RCC. Robust phylogenetic timing analysis indicated that metastasis typically emerged before VTT, rather than deriving from it, with the earliest metastases predicted to emerge years before diagnosis. As a result, VTT in metastatic cases frequently derived from a metastatic lineage. Relative to the primary tumor, VTT upregulated immediate-early genes and transcriptional targets of the TNFα/NF-κB pathway, whereas metastases upregulated MTOR and transcriptional targets downstream of mTORC1 activation. IMPLICATIONS These results suggest that VTT and metastasis formation occur independently, VTT presence alone does not necessarily imply more advanced disease with inevitably poor prognosis.
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Affiliation(s)
- Andrew Wallace
- Department of Oncology Bioinformatics, Genentech, Inc., San Francisco, California
- Corresponding Authors: Oliver A. Zill, Oncology Bioinformatics, Genentech, 501 DNA Way, South San Francisco, CA 94080. Phone: (650) 225-1000; E-mail: ; Maxwell V. Meng, ; and Andrew Wallace,
| | - Sima P. Porten
- Department of Urology, University of California, San Francisco, California
| | - Amy A. Lo
- Department of Research Pathology, Genentech, Inc., San Francisco, California
| | - Daniel Oreper
- Department of Oncology Bioinformatics, Genentech, Inc., San Francisco, California
| | - Nicolas Lounsbury
- Department of Oncology Bioinformatics, Genentech, Inc., San Francisco, California
| | - Charles Havnar
- Department of Research Pathology, Genentech, Inc., San Francisco, California
| | - Ximo Pechuan-Jorge
- Department of Cancer Immunology, Genentech, Inc., San Francisco, California
| | - Oliver A. Zill
- Department of Oncology Bioinformatics, Genentech, Inc., San Francisco, California
- Corresponding Authors: Oliver A. Zill, Oncology Bioinformatics, Genentech, 501 DNA Way, South San Francisco, CA 94080. Phone: (650) 225-1000; E-mail: ; Maxwell V. Meng, ; and Andrew Wallace,
| | - Maxwell V. Meng
- Department of Urology, University of California, San Francisco, California
- Corresponding Authors: Oliver A. Zill, Oncology Bioinformatics, Genentech, 501 DNA Way, South San Francisco, CA 94080. Phone: (650) 225-1000; E-mail: ; Maxwell V. Meng, ; and Andrew Wallace,
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Shi Y, Zhang Q, Bi H, Lu M, Tan Y, Zou D, Ge L, Chen Z, Liu C, Ci W, Ma L. Decoding the multicellular ecosystem of vena caval tumor thrombus in clear cell renal cell carcinoma by single-cell RNA sequencing. Genome Biol 2022; 23:87. [PMID: 35361264 PMCID: PMC8969307 DOI: 10.1186/s13059-022-02651-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 03/09/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Vascular invasion with tumor thrombus frequently occurs in advanced renal cell carcinoma (RCC). Thrombectomy is one of the most challenging surgeries with high rate of perioperative morbidity and mortality. However, the mechanisms driving tumor thrombus formation are poorly understood which is required for designing effective therapy for eliminating tumor thrombus. RESULTS We perform single-cell RNA sequencing analysis of 19 surgical tissue specimens from 8 clear cell renal cell carcinoma (ccRCC) patients with tumor thrombus. We observe tumor thrombus has increased tissue resident CD8+ T cells with a progenitor exhausted phenotype compared with the matched primary tumors. Remarkably, macrophages, malignant cells, endothelial cells and myofibroblasts from TTs exhibit enhanced remodeling of the extracellular matrix. The macrophages and malignant cells from primary tumors represent proinflammatory states, but also increase the expression of immunosuppressive markers compared to tumor thrombus. Finally, differential gene expression and interaction analyses reveal that tumor-stroma interplay reshapes the extracellular matrix in tumor thrombus associated with poor survival. CONCLUSIONS Our comprehensive picture of the ecosystem of ccRCC with tumor thrombus provides deeper insights into the mechanisms of tumor thrombus formation, which may aid in the design of effective neoadjuvant therapy to promote downstaging of tumor thrombus and decrease the perioperative morbidity and mortality of thrombectomy.
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Affiliation(s)
- Yue Shi
- Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, and China National Center for Bioinformation, Chinese Academy of Sciences, Beijing, 100101, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Qi Zhang
- Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, and China National Center for Bioinformation, Chinese Academy of Sciences, Beijing, 100101, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Hai Bi
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China
| | - Min Lu
- Department of Pathology, School of Basic Medical Sciences, Peking University Third Hospital, Peking University Health Science Center, Beijing, 100191, China
| | - Yezhen Tan
- Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, and China National Center for Bioinformation, Chinese Academy of Sciences, Beijing, 100101, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Daojia Zou
- Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, and China National Center for Bioinformation, Chinese Academy of Sciences, Beijing, 100101, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Liyuan Ge
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China
| | - Zhigang Chen
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China
| | - Cheng Liu
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China.
| | - Weimin Ci
- Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, and China National Center for Bioinformation, Chinese Academy of Sciences, Beijing, 100101, China.
- University of Chinese Academy of Sciences, Beijing, 100049, China.
- Institute for Stem cell and Regeneration, Chinese Academy of Sciences, Beijing, China.
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China.
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Gudapati P, Abouamara M. Clear cell renal cell carcinoma with stage IV cavoatrial tumour thrombus extension and rapid metastatic reoccurrence postsurgical treatment with review of current treatment strategies. BMJ Case Rep 2022; 15:e248156. [PMID: 35296494 PMCID: PMC8928259 DOI: 10.1136/bcr-2021-248156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 01/20/2023] Open
Abstract
Renal cell carcinoma (RCC) is the most aggressive urological malignancy, with a high recurrence rate. Despite the rapid evolution of the treatment of RCC from non-specific cytotoxic therapies to specific novel combination therapies, the general prognosis for advanced RCC remains poor because patients' responses to these therapies vary. Herein, we present the case of a male in early forties who was diagnosed with a right lower pole renal mass with a level IV tumour thrombus, which was later confirmed as stage IIIc clear cell RCC. About 19 months after radical nephrectomy (curative surgery), the patient was diagnosed with a biopsy-proven metastatic disease, which was not responsive to first-line treatment owing to insufficient data on the best treatment regimen. Herein, we also present a literature review on the pathological impact of genomic alterations in tumour suppressors and highlight emerging paradigm shifts in the treatment of RCC.
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Affiliation(s)
- Prathyusha Gudapati
- Internal Medicine, UNC Health Southeastern, Lumberton, North Carolina, USA
- Internal Medicine, Campbell University Jerry M Wallace School of Osteopathic Medicine, Buies Creek, North Carolina, USA
| | - Mouna Abouamara
- Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Liu Z, Li Y, Zhang Y, Zhao X, Ge L, Tang S, Hong P, Zhang S, Tian X, Wang S, Liu C, Zhang H, Ma L. PUTH Grading System for Urinary Tumor With Supradiaphragmatic Tumor Thrombus: Different Surgical Techniques for Different Tumor Characteristics. Front Oncol 2022; 11:735145. [PMID: 35070959 PMCID: PMC8770268 DOI: 10.3389/fonc.2021.735145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/09/2021] [Indexed: 01/11/2023] Open
Abstract
Purpose To explore the different treatment strategies for urinary tumors with Mayo IV thrombus. Materials and Methods We retrospectively analyzed the patients with Mayo IV thrombus in Peking University Third Hospital from January 2014 to April 2021. We used the Peking University Third Hospital (PUTH) grading system to classify urinary tumors with supradiaphragmatic thrombus. PUTH-A referred to the filled thrombus whose tip just reached above the diaphragm, or the thrombus entering the right atrium (< 2cm). PUTH-B referred to the filled thrombus entering the right atrium (> 2cm), or the thrombus invading the wall of the inferior pericardial vena cava. Detailed techniques were described for various scenarios. Clinicopathological data and perioperative outcomes were reported. Group difference statistical analysis was performed. Results A total of 26 cases of urinary tumors with supradiaphragmatic IVC thrombus (Mayo grade IV) underwent treatment were enrolled in this study. 19 patients in the PUTH-A group received the open approach without sternotomy and cardiopulmonary bypass. Seven patients in the PUTH-B group received open thoracotomy assisted by cardiopulmonary bypass. No intraoperative death occurred. After 56 months of follow-up, 46.2% (12 of 26) patients died of all causes. Estimated 1-year, 2-year, and 3-year overall survival were 72.0% (95% CI, 54.4%-89.6%), 58.2% (95% CI, 38.0%-78.4%), and 52.4% (95% CI, 31.2%-73.6%), respectively. Conclusions We introduced the PUTH grading system for the characteristics of urinary tumors with supradiaphragmatic tumor thrombus, and selected different surgical techniques according to different classifications. This grading system was relatively feasible and effective.
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Affiliation(s)
- Zhuo Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Yuxuan Li
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Yu Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Xun Zhao
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Liyuan Ge
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Shiying Tang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Peng Hong
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Shudong Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Xiaojun Tian
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Shumin Wang
- Department of Ultrasound, Peking University Third Hospital, Beijing, China
| | - Cheng Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Hongxian Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing, China
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Optimizing Perioperative Treatment for Kidney Cancer. Urol Oncol 2022. [DOI: 10.1007/978-3-030-89891-5_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Multidisciplinary surgical treatment under cardiopulmonary bypass for non-metastatic renal cell carcinoma with Mayo level 4 inferior vena cava thrombus extending into right atrium. UROLOGY VIDEO JOURNAL 2022. [DOI: 10.1016/j.urolvj.2022.100134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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40
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Keranmu A, Wang M, Li Y, Yang F, Wahafu W, Chen D, Liang J, Guan K, Xing N. Feasibility of single position laparoscopic radical nephrectomy and tumor thrombectomy for left renal cell carcinoma with high-risk Mayo grade 0 and 1 tumor thrombus. BMC Urol 2021; 21:181. [PMID: 34937546 PMCID: PMC8693484 DOI: 10.1186/s12894-021-00924-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background To explore the feasibility of single-position laparoscopic radical nephrectomy (LRN) and tumor thrombectomy for left renal cell carcinoma with high-risk Mayo 0 and 1 tumor thrombus (TT). Methods All patients with left renal cell carcinoma and venous TT (high-risk Mayo grade 0 and 1) who were performed single-position LRN and tumor thrombectomy were involved. After the renal artery was controlled by Hem-o-lok, the left renal vein was dissected through descending colon mesentery. The left renal vein was divided by EndoGIA for high-risk Mayo grade 0 TT. For Mayo grade 1 TT, part of the inferior vena cava was blocked by a bulldog clamp after milking the TT into the left renal vein and the inferior vena cava was sutured after complete excision of the TT. Results 3 patients were involved and operations were performed successfully without conversion to open surgery. The mean operation time was 136 min and the mean estimated blood loss was 60 mL. No postoperative complications occurred. Conclusions It is feasible to control left renal vein and partial inferior vena cava through descending colon mesentery in a single position during LRN and tumor thrombectomy for the treatment of high-risk Mayo grade 0 and 1 TT.
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Ciancio G, Tabbara MM, Martucci M, Gaynor JJ, Morsi M, Gonzalez J. Surgical Management of Upper Urinary Tract Urothelial Cell Carcinoma with Venous Tumor Thrombus: A Liver Transplant-Based Approach. J Clin Med 2021; 10:jcm10245964. [PMID: 34945260 PMCID: PMC8704680 DOI: 10.3390/jcm10245964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/25/2021] [Accepted: 12/16/2021] [Indexed: 11/23/2022] Open
Abstract
Upper urinary tract urothelial cell carcinoma (UTUC) with venous tumor thrombus (TT) that extends into the renal vein (RV) and inferior vena cava (IVC) is a rare entity and its management is a surgical challenge. We report the largest single experience of surgical management of UTUC and accompanying venous TT with radical nephroureterectomy and tumor thrombectomy (RNATT) using transplant-based (TB) surgical techniques. From September 2003 to June 2021, nine patients with UTUC and venous TT underwent RNATT. Demographics, disease characteristics, surgical details, 30-day postoperative complications, and overall survival (OS) were analyzed. All nine patients had extension of the TT into the RV. Of those, seven had additional extension of the TT into the IVC. Venous TT level was categorized as 0 (n = 2), I (n = 2), II (n = 4), and IIIa (n = 1). Median tumor size was 12 cm (range 3–20 cm). Median estimated blood loss was 300 (range 150–1000) cc. One patient was still alive at last follow-up (4 months), and in total, eight patients have died with a median time-to-death of 12 months (range 10 days–24 months). RNATT using TB maneuvers like liver mobilization and pancreas-spleen en bloc mobilization provide excellent exposure to the retroperitoneal space and enable the safe removal of UTUC with venous TT.
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Affiliation(s)
- Gaetano Ciancio
- Department of Surgery and Urology, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Correspondence: ; Tel.: +1-305-335-5803
| | - Marina M. Tabbara
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (M.M.T.); (M.M.); (J.J.G.); (M.M.)
| | - Melanie Martucci
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (M.M.T.); (M.M.); (J.J.G.); (M.M.)
| | - Jeffrey J. Gaynor
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (M.M.T.); (M.M.); (J.J.G.); (M.M.)
| | - Mahmoud Morsi
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (M.M.T.); (M.M.); (J.J.G.); (M.M.)
| | - Javier Gonzalez
- Department of Urology, Hospital General Universitario Gregoria Marañón, 28007 Madrid, Spain;
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Otsuka H, Masui K, Hosomi T, Makino Y, Shibasaki N, Shichiri Y. Preoperative ipilimumab/nivolumab combination therapy reduced operation risk by downstaging the inferior vena cava tumor thrombus extending to the right atrium in a metastatic renal cell carcinoma: A case report. Urol Case Rep 2021; 40:101912. [PMID: 34777999 PMCID: PMC8577410 DOI: 10.1016/j.eucr.2021.101912] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 10/22/2021] [Indexed: 12/04/2022] Open
Abstract
The success of immune checkpoint inhibitors in metastatic renal cell carcinoma (RCC) has renewed interest in studying these agents in preoperative settings. Here, we present a case of metastatic RCC with an inferior vena cava (IVC) tumor thrombus extending to the right atrium. Preoperative systemic therapy with ipilimumab/nivolumab was initiated for four cycles. The IVC tumor thrombus level was significantly downstaged from IV to I according to the Mayo classification, which enabled us to perform cytoreductive nephrectomy and IVC thrombectomy without extracorporeal circulation. Preoperative ipilimumab/nivolumab may lead to significant downstaging of caval tumor thrombus in metastatic RCC.
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Affiliation(s)
| | | | | | - Yuki Makino
- Department of Urology, Otsu City Hospital, Japan
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Determinants of renal cell carcinoma invasion and metastatic competence. Nat Commun 2021; 12:5760. [PMID: 34608135 PMCID: PMC8490399 DOI: 10.1038/s41467-021-25918-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 08/30/2021] [Indexed: 01/06/2023] Open
Abstract
Metastasis is the principal cause of cancer related deaths. Tumor invasion is essential for metastatic spread. However, determinants of invasion are poorly understood. We addressed this knowledge gap by leveraging a unique attribute of kidney cancer. Renal tumors invade into large vessels forming tumor thrombi (TT) that migrate extending sometimes into the heart. Over a decade, we prospectively enrolled 83 ethnically-diverse patients undergoing surgical resection for grossly invasive tumors at UT Southwestern Kidney Cancer Program. In this study, we perform comprehensive histological analyses, integrate multi-region genomic studies, generate in vivo models, and execute functional studies to define tumor invasion and metastatic competence. We find that invasion is not always associated with the most aggressive clone. Driven by immediate early genes, invasion appears to be an opportunistic trait attained by subclones with diverse oncogenomic status in geospatial proximity to vasculature. We show that not all invasive tumors metastasize and identify determinants of metastatic competency. TT associated with metastases are characterized by higher grade, mTOR activation and a particular immune contexture. Moreover, TT grade is a better predictor of metastasis than overall tumor grade, which may have implications for clinical practice.
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Abstract
A new cancer diagnosis is expected to affect approximately 1.9 million people in the United States in 2021. A small percentage of these patients will experience an emergent cancer-related complication. Oncologic emergencies may be encountered in emergency departments or require intensive care management. Patients newly diagnosed with cancer are more likely to present with emergencies related to the underlying malignancies. Oncologic emergencies can have various manifestations, ranging from mechanical obstruction due to tumor growth to metabolic derangements due to abnormal secretions from the tumor. Therefore, early identification and treatment of life-threatening oncologic events is critical. Although there are several different types of oncologic emergencies, this article focuses on metabolic emergencies (tumor lysis syndrome and cytoreductive hyperthermic intraperitoneal chemotherapy) and structural emergencies (increased intracranial pressure and vena cava thrombus). The purpose of this article is to provide acute care clinicians with an overview of selected oncologic emergencies and their evidence-based management.
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Affiliation(s)
- Ninotchka Brydges
- Ninotchka Brydges is Manager and Advanced Practice Provider, Department of Critical Care Medicine, Division of Anesthesia, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston TX 77030
| | - Garry J Brydges
- Garry J. Brydges is Director, Anesthesia Safety and Quality, Department of Anesthesiology, Division of Anesthesia, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Jain A, Nalavenkata S, Nahm C, Yuen L, Di Mascio D, Kim L. A diagnostic and management conundrum in a rare case of a small renal mass UTUC with IVC and bilateral renal vein tumour thrombus. Urol Case Rep 2021; 39:101817. [PMID: 34485085 PMCID: PMC8399384 DOI: 10.1016/j.eucr.2021.101817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 11/25/2022] Open
Abstract
Upper Tract Urothelial Carcinomas (UTUC) are generally uncommon, accounting for approximately 5% of all urinary tract tumours. This report describes a unique Case of a 52-year-old-male with no known risk factors or symptoms of UTUC, who presented with bilateral sub-massive pulmonary embolus (PE). Subsequent computed tomography (CT) demonstrated a small (<2cm) right cortical based mass a discordant venous tumour thrombus (VTT) extending in the IVC, up to the level of the hepatic vein and bilateral renal veins. The patient had surgical excision in the form of right radical nephroureterectomy, IVC resection with bovine pericardial graft reconstruction and left renal autotransplant.
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Affiliation(s)
- Anika Jain
- Cnr Hawkesbury Road and, Darcy Rd, Westmead, NSW, 2145, Australia
| | | | - Chris Nahm
- Cnr Hawkesbury Road and, Darcy Rd, Westmead, NSW, 2145, Australia
| | - Lawrence Yuen
- Cnr Hawkesbury Road and, Darcy Rd, Westmead, NSW, 2145, Australia
| | | | - Lawrence Kim
- Cnr Hawkesbury Road and, Darcy Rd, Westmead, NSW, 2145, Australia
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Niu S, Liu K, Xu Y, Peng C, Yu Y, Huang Q, Wu S, Cui B, Huang Y, Ma X, Zhang X, Wang B. Genomic Landscape of Chinese Clear Cell Renal Cell Carcinoma Patients With Venous Tumor Thrombus Identifies Chromosome 9 and 14 Deletions and Related Immunosuppressive Microenvironment. Front Oncol 2021; 11:646338. [PMID: 34249685 PMCID: PMC8260842 DOI: 10.3389/fonc.2021.646338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 05/18/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Clear cell renal cell carcinoma (ccRCC) with venous tumor thrombus (VTT) is associated with a poor clinical outcome. Although several studies have examined the genomic features of ccRCC, the genetic profile of VTT along with its matched primary tumor has not been fully elucidated. MATERIALS AND METHODS Samples of VTT tissues and matched primary tumor tissues from ccRCC patients (n = 25), as well as primary tumor tissues from patients without VTT (n = 25) were collected and analyzed using whole-exome sequencing. Four additional ccRCC patients who were unfit for surgery were treated with an anti-programmed death receptor-1 (PD-1) monoclonal antibody (Toripalimab, 240 mg, Q3W, IV). RESULTS By comparing the primary kidney tumors from ccRCC patients with or without VTT, a relatively higher prevalence of BAP1 and KDM5C alterations were found in ccRCC patients with VTT, and these alterations were associated with worse overall survival in the kidney renal clear cell carcinoma (KIRC) database. Based on subclone analysis, VTT was predicted to primarily originate directly from the primary renal mass. A significantly higher prevalence of CELSR2 and TET2 alterations were identified in the VTTs compared with the matched primary tumors. An increased prevalence of DNA damage repair genes, especially those involved in homologous recombination repair and non-homologous end joining, was found in ccRCC patients with VTT. Notably, VTT was characterized by the increase incidence of copy number loss in the whole exome (p < 0.05), particularly in the chromosome 9 and 14 regions. Deletion of chromosome 9 and 14 was associated with worse survival, unfavorable clinical features, and the presence of an immunosuppressive microenvironment, which was characterized by higher infiltration of regulatory T cells, follicular helper T cells, and resting mast cells, but lower counts of resting CD4 memory T cells and CD8 positive T cells. A significantly lower count of CD4+ and CD8+ tumor-infiltrated lymphocytes was identified in the VTT samples comparing with matched primary tumor. Of note, three out of the four ccRCC patients with VTT in our cohort who were treated with the anti-PD-1 therapy exhibited remarkable remission in the renal mass but no notable shrinkage in the VTT mass. CONCLUSION Our study revealed the genetic profile of Chinese ccRCC patients with VTT, and identified multiple features associated with known poor outcomes, including gene alterations and copy number loss. The deletions in chromosomes 9 and 14, and the associated immunosuppressive microenvironment may indicate limited sensitivity to anti-PD-1/PD-L1 monotherapy in VTT.
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Affiliation(s)
- Shaoxi Niu
- Department of Urology, The Third Medical Centre, Chinese PLA (People’s Liberation Army) General Hospital, Beijing, China
| | - Kan Liu
- Department of Urology, The Third Medical Centre, Chinese PLA (People’s Liberation Army) General Hospital, Beijing, China
| | - Yong Xu
- Department of Urology, The Third Medical Centre, Chinese PLA (People’s Liberation Army) General Hospital, Beijing, China
| | - Cheng Peng
- Department of Urology, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yao Yu
- Department of Urology, The Third Medical Centre, Chinese PLA (People’s Liberation Army) General Hospital, Beijing, China
| | - Qingbo Huang
- Department of Urology, The Third Medical Centre, Chinese PLA (People’s Liberation Army) General Hospital, Beijing, China
| | - Shengpan Wu
- Department of Urology, The Third Medical Centre, Chinese PLA (People’s Liberation Army) General Hospital, Beijing, China
| | - Bo Cui
- Department of Urology, The Third Medical Centre, Chinese PLA (People’s Liberation Army) General Hospital, Beijing, China
| | - Yan Huang
- Department of Urology, The Third Medical Centre, Chinese PLA (People’s Liberation Army) General Hospital, Beijing, China
| | - Xin Ma
- Department of Urology, The Third Medical Centre, Chinese PLA (People’s Liberation Army) General Hospital, Beijing, China
| | - Xu Zhang
- Department of Urology, The Third Medical Centre, Chinese PLA (People’s Liberation Army) General Hospital, Beijing, China
| | - Baojun Wang
- Department of Urology, The Third Medical Centre, Chinese PLA (People’s Liberation Army) General Hospital, Beijing, China
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47
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A 25 year perspective on the evolution and advances in an understanding of the biology, evaluation and treatment of kidney cancer. Urol Oncol 2021; 39:548-560. [PMID: 34092483 DOI: 10.1016/j.urolonc.2021.04.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/20/2021] [Accepted: 04/25/2021] [Indexed: 01/20/2023]
Abstract
The diagnosis, evaluation and management of patients with renal cell carcinoma has transformed in the 21st century. Utilizing biological discoveries and technological advances, the field has moved from blunt surgical and largely ineffective medical treatments, to nuanced and fine-tuned approaches based on biology, extent of disease and patient preferences. In this review we will summarize the last 25 years of progress in kidney cancer.
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48
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Comparison of PD-L1 Scores in Primary Kidney Tumors Versus Accompanying Venous Tumor Thrombi: Retrospective, Comparative, Monocentric Study in Treatment-Naive Patients. Adv Ther 2021; 38:3373-3388. [PMID: 34021481 PMCID: PMC8189971 DOI: 10.1007/s12325-021-01737-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/01/2021] [Indexed: 11/12/2022]
Abstract
Introduction Renal cell carcinoma (RCC), an immunogenic tumor, is the most common form of kidney cancer worldwide. Immune checkpoint inhibitors (ICIs) play an important role in the treatment of metastatic RCC. Programmed death-ligand (PD-L1) has already been proposed as a possible prognosticator for ICIs effectiveness. To elucidate the feasible role of ICIs in neoadjuvant settings, we have assessed the most common PD-L1 expression modalities [tumor proportion score (TPS), combined positivity score (CPS) and inflammatory cell (IC) score] in primary tumors (PTs) and venous tumor thrombi (VTT) in first diagnosed, previously untreated RCC patients with accompanying VTT.
Methods Between January 1999 and December 2016, 71 patients with a first diagnosed, untreated, locally advanced RCC (aRCC) (≥ pT3a) underwent surgery in Hanover Medical School (MHH). PD-L1 expression was examined separately in PTs and VTT using the CPS, IC score and TPS. We also considered the age at the time of the initial surgery and gender as probable influencing factors. By using a cutoff value of 1 (1%), PD-L1 expression levels in PTs and VTT were assessed to enable the determination of any frequency differences. Results Positive scores for PTs were shown by 54 (CPS), 53 (IC score) and 34 (TPS) patients, whereas in VTT, positive scores were evaluated for a total of 50 (CPS), 47 (IC-score) and 36 (TPS) patients. No statistically significant differences were obtained between the PD-L1 expression immunoscores for PTs and VTT. The covariates age at the time of the initial surgery and gender could not be statistically proven to influence the differences in PD-L1 expression between the VTT and PTs. Conclusion To the best of our knowledge, this research is the largest study to investigate PD-L1 expression in PTs and VTT in 71 cases. It could have relevance for the future development of neoadjuvant immunotherapy options, particularly in aRCC with VTT.
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Caño Velasco J, Polanco Pujol L, Hernandez Cavieres J, González García F, Herranz Amo F, Ciancio G, Hernández Fernández C. Controversies in the diagnosis of renal cell carcinoma with tumor thrombus. Actas Urol Esp 2021; 45:257-263. [PMID: 33139067 DOI: 10.1016/j.acuro.2020.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
Diagnosis and treatment of renal cell carcinoma with venous tumor thrombosis remains a challenge today, requiring multidisciplinary teams, mainly in tumor thrombus levels III-IV. Our objective is to present the various diagnostic techniques used and its controversies. A review of the most relevant related articles between January 2000 and August 2020 has been carried out in PubMed, EMBASE and Scielo. Continuous technological development has allowed progress in its detection, in the approximation of the histological subtype, and in the determination of tumor thrombus level. Regardless of the imaging technique used for its diagnosis (CT, MRI, TEE, ultrasound with contrast), the time elapsed until treatment is vitally important to reduce the risk of complications, some of them fatal, such as pulmonary thromboembolism.
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50
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Triple Retroaortic Renal Vein With Tumor Thrombus. Urology 2021; 154:e17-e18. [PMID: 33891926 DOI: 10.1016/j.urology.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/04/2021] [Accepted: 04/06/2021] [Indexed: 11/20/2022]
Abstract
A case report of a 51-year-old man with left renal tumor and level II vena cava tumor thrombus (thrombus extending >2 cm above the renal vein, but below the hepatic veins) in a rare anatomical variant of renal vein. In nonmetastatic patients, aggressive surgical resection is widely accepted as the standard management option, but some doubts about the best practice in these patients are relevant. Surgical approach on those patients is a challenge for the surgeons, and anatomical variants make the procedure even more difficulty. These patients should be referring to a tertiary center because of the potential perioperative complexity.
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