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

Long-term functional outcomes in patients undergoing radical nephrectomy for renal cell carcinoma and tumor thrombus

BACKGROUND

Up to 15% of patients with locally advanced renal cell carcinoma (RCC) harbors tumor thrombus (TT). In those cases, radical nephrectomy (RN) and thrombectomy represents the standard of care. We assessed the impact of TT on long-term functional and oncological outcomes in a large contemporary cohort.

METHODS

Within a prospective maintained database, 1207 patients undergoing RN for non-metastatic RCC between 2000 and 2021 at a single tertiary centre were identified. Of these, 172 (14%) harbored TT. Multivariable logistic regression analyses evaluated the impact of TT on the risk of postoperative acute kidney injury (AKI). Multivariable Poisson regression analyses estimated the risk of long-term chronic kidney disease (CKD). Kaplan Meier plots estimated disease-free survival and cancer specific survival. Multivariable Cox regression models assessed the main predictors of clinical progression (CP) and cancer specific mortality (CSM).

RESULTS

Patients with TT showed lower BMI (24 vs. 26 kg/m2) and preoperative Hb (11 vs. 14 g/mL; all-p < 0.05). Clinical tumor size was higher in patients with TT (9.6 vs. 6.5 cm; p < 0.001). After adjusting for potential confounders, the presence of TT was significantly associated with a higher risk of postoperative AKI (OR 2.03, 95% CI 1.49-3.6; p < 0.001) and long-term CKD (OR: 1.32, 95% CI 1.10-1.58; p < 0.01). Notably, patients with TT showed worse long-term oncological outcomes and TT was a predictor for CP (2.02, CI 95% 1.49-2.73, p < 0.001) and CSM (HR 1.61, CI 95% 1.04-2.49, p < 0.03).

CONCLUSIONS

The presence of TT in RCC patients represents a key risk factor for worse perioperative, as well as long-term renal function. Specifically, patients with TT harbor a significant and early estimated glomerular filtration rate (eGFR) decrease. However, despite TT patients show a greater eGFR decline after surgery, they retain acceptable renal function, which remains stable over time.

Survival benefits after radical nephrectomy and IVC thrombectomy of renal cell carcinoma patients with inferior vena cava thrombus

Objective

The role of tumor thrombus as a predictor of survival in patients with renal cell carcinoma (RCC) is controversial. This study aims to evaluate surgical and oncological outcomes after surgery in RCC with inferior vena cava (IVC) tumor thrombus patients.

Materials and methods

A total of 58 patients (2002-2019) underwent radical nephrectomy and IVC thrombectomy at our institute, were retrospectively reviewed. Kaplan-Meier analysis was utilized to compare survival benefits between cohorts and Cox-regression to evaluate potential predictors of patient survival.

Results

There were 5(8.6%), 21(36.2%), 23(39.7%) and 9 (15.5%) patients with tumor thrombus level I, II, III and IV respectively. The major complications (Clavien 3-5) were observed in 15 patients (25.8%) and 12 patients (80%) were patients with high thrombus level (III-IV). There was 9%mortality (5patients): 2 intraoperatively and 3 postoperatively. Median follow-up was 15 months (IQR:5-41). Two-year overall survival (OS) was 80% and 75% in all patients and pN0M0 cohort, respectively. There was significant difference in OS among each IVC thrombus level cohort (p < 0.02). Two-year OS of metastatic RCC patients was 67% and not significantly different when compared to non-metastatic cohort (p = 0.12). On multivariate analysis, only sarcomatoid dedifferentiation was associated with OS(p = 0.04). Disease-free survival was not significantly different among thrombus-level cohorts (p = 0.65).

Conclusions

Our study suggested that surgical treatment for RCC with IVC thrombus provided substantial OS outcomes. Although survival was significantly reduced with higher IVC thrombus level cohort, the level of thrombus itself was not an independent factor. Only sarcomatoid dedifferentiation was a predictor for reduced OS after radical nephrectomy and tumor thrombectomy. Meticulous patient selection and prompt counselling are substantial step for the operation.

Robotic Radical Nephrectomy with Vena Cava Thrombus Extraction (RRN-VCTE) for Renal Cell Carcinoma: A Meta-Analysis of Surgical Technique and Outcomes

Renal cell carcinoma (RCC) with vena cava tumor thrombus is a challenging condition, which requires complex surgical management. Robotic radical nephrectomy with vena cava thrombus extraction (RRN-VCTE) has emerged as a promising and minimally invasive technique. This meta-analysis aims to review the surgical technique and outcomes of RRN-VCTE in patients with RCC and vena cava tumor thrombus. A comprehensive literature search was conducted using databases, including PubMed, Embase, and Cochrane Library. Studies published in English till October 2021 were included. Keywords used for the search included "robotic radical nephrectomy," "vena cava tumor thrombus," "surgical technique," and "outcomes." Studies that reported on patient outcomes and surgical techniques of RRN-VCTE were included. Statistical analysis was performed to assess the pooled outcomes. The meta-analysis included 16 studies comprising 298 patients who underwent RRN-VCTE. The majority of patients were males (62.4%) with a median age of 58.9 years. The median tumor size was 7.2 cm, and 93.9% of patients had level 3 or 4 vena cava thrombus. The mean operating time was 328 min, with a range of 248-423 min. Blood loss ranged from 100 to 1500 mL. The overall complication rate was 26.5%, with no reported deaths. The average hospital stay was 9.5 days. The 2-year and 5-year survival rates were 77.5 and 53.1%, respectively. RRN-VCTE is a promising and minimally invasive surgical technique for RCC with vena cava tumor thrombus, whch is associated with low complication rates and acceptable oncological outcomes. Further research is needed to confirm the long-term survival rates and compare RRN-VCTE outcomes with conventional surgical techniques. Nonetheless, RRN-VCTE appears to be a valuable option for patients with RCC and vena cava tumor thrombus.

Construction of the prognostic model in non-metastatic renal cancer patients with venous tumor thrombus

Background

Venous system invasion is a prominent characteristic of local progression in renal cancer and treatment-naïve renal cancer patients with venous tumor thrombus (VTT) gained short natural course and poor prognosis. This study aimed to investigate the efficacy of the surgery and prognostic factors in non-metastatic renal cancer patients with VTT and to construct a nomogram prognostic model.

Methods

Clinical data of 114 non-metastatic renal cancer patients with VTT who underwent surgical treatment from January 2011 to September 2022 were retrospectively analyzed. In order to find independent risk factors of prognosis, survival analysis was performed via univariate and multivariate Cox regression models and Kaplan-Meier method. Nomogram prognostic model was established to calculate patients' risk scores. Receiver operating characteristic curve and decision curve analysis were conducted to evaluate the efficacy of the prognostic model.

Results

A total of 114 patients were included in this study and there were 48, 12, 25, 23, and 6 cases of grade 0-IV VTT. No perioperative death occurred. The 3-year probabilities of overall survival (OS) and 5-year probabilities of OS were 67% and 43.8%, respectively. Multivariate Cox regression analysis revealed that kidney tumor diameter, preoperative lactate dehydrogenase (LDH), and preoperative neutrophils were independent risk factors. Nomogram was constructed to predict prognosis in renal cancer patients with VTT based on above indicators and Mayo VTT grading. The area under the ROC curve of 1-, 2-, 3-, and 5-year OS of the patients were 0.82, 0.67, 0.57, and 0.55 respectively.

Conclusions

Surgical treatment enables renal cancer patients with VTT to gain a better prognosis. Kidney tumor diameter, preoperative LDH, and preoperative neutrophils were independent risk factors. The nomogram perfects the Mayo grading, and provides a reliable reference for evaluation of prognosis of renal cancer patients with VTT.

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

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.

Diagnostic performance and prognostic value of preoperative 18F-FDG PET/CT in renal cell carcinoma patients with venous tumor thrombus

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.

Analysis of surgical outcomes in 102 patients with renal cell carcinoma with venous tumor thrombus: A retrospective observational single-center study

The aim of the study was to assess short- and long-term results following radical nephrectomy with renal vein and inferior vena cava thrombectomy in patients with renal cell cancer with venous thrombus and to investigate impact of various demographical, clinical and histological factors on overall survival (OS). The medical records of 102 adult patients with renal cell cancer with venous thrombus admitted for surgery in Department of General, Vascular and Transplant Surgery from 2012 to 2019 were retrospectively analyzed. The tumor was more frequently located on the right side compared to the left one (55 vs. 47). According to Neves Zincke classification, the levels of venous thrombus were as follows: 1 to 48 (47%), 2 to 47 (46%), 3 to 6 (6%), and 4 to 1 (1%). Postoperative complications were noted in 16 (15.7%) patients. One (3%) patient (Neves Zincke 2) died of intraoperative pulmonary embolism during hospitalization. Clear cell carcinoma was the most common pathological type reported in 92 (90.2%) patients. Thirty nine (38.2%) patients were alive at the time of last follow-up. The median OS was 21.50 (0-101.17) months. The 1-year OS was 75.5%. Significantly better OS (median 38.03 months) was noted in patients with RCC Neves Zincke 1 compared to OS (median 14.79 months) in patients with Neves Zincke 2-4 VT (P = .008). Higher tumor staging (T3 vs. T4) (P = .038), nodal staging (N0 vs. N1) (P = .0008), Fuhrman histological grading (G1-2 vs. G3-4) (P = .033) were associated with a shorter OS. Patients with renal cell cancer with venous thrombus, with an acceptable perioperative risk, should be treated surgically, because radical nephrectomy with thrombectomy performed in a high volume surgical center is a safe procedure. Neves Zincke 2-4 venous thrombus, higher tumor and nodal staging, as well higher Fuhrman histological grading are associated with a shorter OS.

Nomograms for Predicting Overall Survival and Cancer-Specific Survival of Patients With Renal Cell Carcinoma and Venous Tumor Thrombus: A Population-Based Study

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.

Preoperative systemic inflammation response index indicates poor prognosis in patients treated with resection of renal cell carcinoma with inferior vena cava tumor thrombus

OBJECTIVES

To evaluate the prognostic value of systemic Inflammation Response Index (SIRI) in patients with renal cell carcinoma and inferior vena cava tumor thrombus (RCC-IVCTT) treated with radical nephrectomy and IVCTT thrombectomy.

METHODS

We retrospectively reviewed the clinical data of 144 consecutive patients with RCC-IVCTT who received radical nephrectomy and IVCTT thrombectomy at our center from January 2008 to August 2018. Receiver operating characteristic curve analysis was performed to calculate the optimal cutoff value of preoperative SIRI. Kaplan-Meier analysis was used to compare progression-free survival (PFS) and overall survival (OS). Univariable and multivariable Cox proportional hazard models were constructed to identify the independent prognostic factor for OS and PFS. The Harrell concordance index (C-index) was used to assess whether preoperative SIRI could improve the predictive accuracy of the existent prognostic models including Tumor, Node, Metastasis (TNM) stage model, University of California at Los Angeles Integrated Staging System (UISS) model and Stage, Size, Grade and Necrosis (SSIGN) model.

RESULTS

Elevated preoperative SIRI was significantly correlated with clinicopathologic features that are associated with tumor progression. Patients were divided into a high or low SIRI group by the optimal cutoff value of SIRI. Patients in the high SIRI group had longer postoperative hospital stays and lost more blood during surgery. Kaplan Meier curve showed that high SIRI was correlated with decreased OS (P = 0.036) and PFS (P = 0.039) for patients with RCC-IVCTT after surgery. Increased preoperative SIRI was an independently risk factor for decreased OS (P = 0.038) and PFS (P = 0.021). To evaluate PFS, integrating SIRI to each model led to an increased predictive accuracy of 13.2% for TNM staging model (P = 0.007), 14.4% for UISS model (P = 0.000), 12.9% for SSIGN model (P = 0.003). To evaluate OS, integrating SIRI to each model led to an increased predictive accuracy of 13.2% for TNM staging model (P = 0.006), 12.8% for UISS model (P = 0.004), 12.4% for SSIGN model (P = 0.008).

CONCLUSIONS

Preoperative SIRI serves as an independent predictor of prognosis for patients with RCC-IVCTT after surgery. Adding preoperative SIRI to the established prognostic models enhance their predictive accuracy.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Low Lymphocyte-to-Monocyte Ratio Is the Potential Indicator of Worse Overall Survival in Patients with Renal Cell Carcinoma and Venous Tumor Thrombus

The purpose of the study was to determine the influence of lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio (NLR) values on the prognosis in patients with renal cell carcinoma (RCC) and venous tumor thrombus. The respective data of 91 patients treated with radical surgery in the years 2012-2021 in 2 tertiary referral urological centers were retrieved from local medical databases. Mean calculated 3-year overall survival (OS) reached 70% (mean follow-up 35.3 months). The association between lower LMR and the presence of tumor necrosis (p = 0.0004) was observed. Amongst systemic inflammatory markers, only LMR was selected as the sensitive marker predicting death with a calculated cut-off value of 2.53. OS was decreased in patients presenting with low LMR when compared to the high LMR group (39% vs. 82%, p = 0.0011). Neither NLR nor PLR were associated with survival rates. In multivariate analysis, LMR was identified as the independent prognostic factor (HR = 0.20, 95% CI 0.07-0.55, p = 0.001). Low values of LMR (<2.53) are independently connected with poorer OS in patients with RCC and coexisting tumor thrombus. The incorporation of the hematological variables into the prognostic model greatly increased its accuracy in predicting survival in the distinctive subpopulation of patients with RCC.

The inferior vena cava: anatomical variants and acquired pathologies

The inferior vena cava (IVC) is the largest vein in the body, draining blood from the abdomen, pelvis and lower extremities. This pictorial review summarises normal anatomy and embryological development of the IVC. In addition, we highlight a wide range of anatomical variants, acquired pathologies and a common pitfall in imaging of the IVC. This information is essential for clinical decision making and to reduce misdiagnosis.

Analysis of Clinicopathological Factors Influencing Survival in Patients with Renal Cell Carcinoma and Venous Tumor Thrombus

This study aimed to define patients with renal cell cancer and coexisting tumor thrombus in order to address concerns regarding survival and prognostic factors after radical surgery. Several prognostic factors for overall survival (OS) were assessed in patients treated surgically at five institutions from 2012 to 2018. Univariate and multivariate analyses were used to determine the independent risk factors of OS. A total of 142 patients were eligible for further analysis (mean age of 64.75 years, 56% males). Most patients presented with clear cell carcinoma (95%). The Mayo stage was predominantly 0–1 (88%). Distant visceral metastases at the time of diagnosis were present in 36 patients (25%), whereas nodal metastases were present in 24 patients (16.9%). During the follow-up period (mean of 32.5 months), the 3-year OS rate reached 68.2%. The majority of patients received no adjuvant treatment (n = 107). In a multivariable model predicting OS, regional lymph node status (p < 0.001), distant metastases (p = 0.009), tumor grade (p = 0.002), duration of hospitalization (p = 0.016), and Clavien–Dindo grade (p = 0.047) were identified as independent prognostic factors. A subgroup of patients with specific clinicopathological factors may benefit most from the radical surgery, including patients without regional lymph node or distant metastases and with low tumor grades, whereas short hospitalization and low Clavien–Dindo grades represent additional independent prognostic factors.

Outcomes of renal cell carcinoma with associated venous tumor thrombus: experience from a large cohort and short time span in a single center

Background

The surgical management and outcomes of renal cell carcinoma (RCC) with venous tumor thrombus (VTT) have been reported in limited sample size, and there remain discrepancies over the factors that influence oncologic outcomes after radical nephrectomy with thrombectomy (RNTE). The aim of the study was to analyze the outcomes of the patients with RCC with VTT in our institution and identify the independent prognostic factors.

Methods

Patients with RCC with VTT were enrolled for the study from February 2015 to December 2018. All patients underwent RNTE. Clinical data were compared using Mann-Whitney U test and the chi-square test for continuous and categorical variables respectively. Survival analysis was estimated using the Kaplan-Meier method. Univariable and multivariable survival analyses were performed using Cox regression model.

Results

121 patients (91 men & 30 women) were identified with a median age of 60 years. VTT level was 0 in 25 patients, I in 20, II in 50, III in 12 and IV in 14. The median follow-up time was 24 months. During the follow-up period, 51 (42%) patients died and 69 (57%) patients experienced recurrence or metastasis. The 3-year and 5-year over-all survival (OS) were 58 and 39%. Among the several factors examined, positive lymph node (P = 0.016), metastasis at surgery (P = 0.034), tumor necrosis (P = 0.023) and sarcomatoid differentiation (P < 0.001) were demonstrated as independent significant risk factors on multivariable analysis.

Conclusion

The OS was poor for patients with RCC with VTT. Rather than VTT level, positive lymph node, metastasis at surgery, tumor necrosis and sarcomatoid differentiation were independent prognostic predictors.

Prognostic role of bland thrombus in patients treated with resection of renal cell carcinoma with inferior vena cava tumor thrombus

OBJECTIVES

To assess the impact of the presence of bland thrombus (BT) on prognosis of patients treated with resection of renal cell carcinoma (RCC) with inferior vena cava tumor thrombus (IVCTT).

MATERIALS AND METHODS

The medical records of a total of 145 consecutive postsurgical RCC patients with level I-IV IVCTT were reviewed from January 2008 to August 2018. Associations of BT with clinicopathological variables were estimated by chi-square test or Student's t-test. Kaplan-Meier method and multivariate Cox proportional hazard model were used. The eighth TNM staging system, "Spiess PE" model, University of California at Los Angeles Integrated Staging System and Stage, Size, Grade, and Necrosis (SSIGN) score were selected to assess whether BT could improve their predictive abilities.

RESULTS

BT was observed in 34 (23.4%) patients and was significantly associated with increased levels of IVCTT (P = 0.004) and invasion of IVC wall (P = 0.030). Multivariable Cox analyses revealed that tumor grade, T stage, M stage, tumor thrombus consistency and BT were independent risk factors for both progression-free survival and overall survival. The concordance indexes ranged from a low of 0.652 in TNM to a high of 0.731 in SSIGN, and integrating BT into each base model led to an increased predictive accuracies of 6.2% for TNM (P = 0.025), 4.0% for "Spiess PE" model (P = 0.069), 2.1% for University of California at Los Angeles Integrated Staging System (P = 0.149) and 1.2% for SSIGN (P = 0.290), respectively.

CONCLUSIONS

Presence of BT was independently associated with survival in postsurgical patients with RCC-IVCTT. Routine consideration of BT as an adjunct to TNM staging system may be suggested.

Prognostic effect of renal collecting system invasion on survival of patients with renal cell carcinoma and tumor thrombus

Introduction

Urinary collecting system invasion (UCSI) has been found to have significant prognostic value for patients with renal cell carcinoma (RCC). However, for RCC patients with venous tumor thrombus (VTT), only contradictory data exist regarding the prognostic efficacy of UCSI. Therefore, the aim of this study is to assess the prognostic relevance of UCSI in survival of patients with RCC and VTT.

Material and methods

Medical records in a prospectively maintained institutional database were analyzed for RCC-VTT patients who had undergone nephrectomy with thrombectomy. Then, the effect of UCSI on overall survival was analyzed.

Results

The study examined data for 114 patients, including patients with VTT present in the renal vein (35 patients, 31%), infrahepatic inferior vena cava (28 patients, 24%), and suprahepatic inferior vena cava (51 patients, 45%). Nineteen percent of patients had UCSI. The median overall survival of patients with UCSI was 9 months, whereas median overall survival was 10 months for patients without collecting system invasion. Survival and regression analyses rejected UCSI as a prognostic marker for overall survival.

Conclusions

UCSI has no effect on survival in our cohort of RCC-VTT patients. Therefore, it should not be considered in risk stratification models or in treatment decision-making for this patient group.

Imaging predictors for assessment of inferior vena cava wall invasion in patients with renal cell carcinoma and inferior vena cava tumor thrombus: a retrospective study

Background

Renal cell carcinoma (RCC) has the propensity to lead to venous tumor thrombus (VTT). Nephrectomy with tumor thrombectomy is an effective treatment option but is a technically challenging surgical procedure that is accompanied by a high rate of complications. The aims of this study were to investigate pre-operative imaging parameters for the assessment of inferior vena cava (IVC) wall invasion due to a tumor thrombus in patients with RCC and to identify predictors from the intra-operative findings.

Methods

Clinical and imaging data were collected from 110 patients who underwent nephrectomy with IVC tumor thrombectomy (levels I–IV) for RCC and IVC tumor thrombus at the Peking University Third Hospital between May 2015 and March 2018. Univariable and multivariable logistic regression and receiver operating characteristic curves were used to assess the correlations between pre-operative imaging features and intra-operative macroscopic invasions of the IVC wall by tumor thrombus.

Results

Among the 110 patients, 41 underwent partial or segmental resection of IVC. There were univariate associations of pre-operative imaging parameters that could be used to predict the need for IVC resection, including those of the Mayo classification, maximum anterior-posterior (AP) diameter of the renal vein at the renal vein ostium (RVo), maximum AP diameter of the VTT at the RVo and IVC occlusion. For the multivariable analysis, the AP diameter of the VTT at the RVo and IVC occlusion were associated with a significantly increased risk of invasion of the IVC wall by tumor thrombus. The optimum imaging thresholds included an AP diameter of the VTT at the RVo larger than 17.0 mm and the presence of IVC occlusion, with which we predicted invasions of the IVC wall requiring IVC resection. The probabilities of intra-operative IVC resection for patients without both independent factors, with an AP diameter of the VTT at the RVo larger than 17.0 mm, with IVC occlusion, and with both concurrent factors were 5%, 23%, 56%, and 66%, respectively.

Conclusion

An increase in the AP VTT diameter at the RVo and the presence of complete occlusion of the IVC are independent risk factors for a high probability of IVC wall invasion by tumor thrombus.

[Evaluating inferior vena cava wall invasion in renal cell carcinoma tumor thrombus with MRI]

OBJECTIVE

To evaluate the diagnostic performance of MRI for the assessment of inferior vena cava (IVC) wall invasion by IVC thrombus in patients with renal cell carcinoma (RCC).

METHODS

We retrospectively collected patients who underwent radical nephrectomy and thrombectomy for RCC between 2010 and 2018 at Peking University First Hospital. All the patients underwent imaging on a 1.5 Tesla or 3.0 Tesla MRI scanner. Fifty-six patients met the inclusion criteria. Preoperative imaging was reviewed by two radiologists blinded to details of the patient's surgical procedure and histopathology. Two radiologists measured the maximum anterior-posterior diameter and coronal diameters of the IVC and renal vein, and the craniocaudal extent of tumor thrombus, and evaluated the MRI features of IVC thrombus, including occlusion of the IVC lumen, the margin of the tumor thrombus (smooth vs. irregular), contact of the IVC thrombus and IVC wall, and altered signal of the IVC wall. Univariable and multivariable associations of clinical and radiographic features with IVC wall invasion were evaluated by Logistic regression.

RESULTS

Of the 56 patients [male: 43, female: 13, mean age: (55.64±0.43) years], 17 (30.36%) were detected with IVC wall invasion, and most were clear cell carcinoma. Tumor thrombus with IVC wall invasion showed an increase in length of IVC thrombus [(7.91±3.59) cm vs. (5.94±3.57) cm, P=0.049], and more features of complete occlusion of the IVC lumen (P=0.002), irregular margin of the IVC thrombs (P=0.005), contact of the IVC thrombus and IVC wall (P=0.001), and altered signal of the low-intensity vessel wall (P<0.001), with a sensitivity of 94.12% and a specificity of 79.49%.

CONCLUSION

The present study indicates that MRI could be a means of evaluating RCC with IVC wall invasion, and the combination of tumor thrombus length and subjective impression of IVC wall invasion achieved a high sensitivity and specificity for diagnosis.

Long-term survival and prognostic factors for locally advanced renal cell carcinoma with renal vein tumor thrombus

BACKGROUND

Previous related studies have mainly focused on renal cell carcinoma (RCC) with venous tumor thrombus, specifically inferior vena cava tumor thrombus with renal vein tumor thrombus (RVTT). However, only a few studies have focused on postoperative long-term survival of RCC patients exclusively with RVTT. Our aim was to investigate the independent prognostic factors for locally advanced RCC with RVTT in China.

METHODS

Patients with locally advanced RCC with RVTT were enrolled for the study from January 2000 to December 2015. All patients underwent radical nephrectomy. Survival analysis was estimated using Kaplan-Meier. Univariable and multivariable survival analyses were performed using COX. Patients were divided into high-risk, middle-risk, and low-risk groups based on independent prognostic factors and then analyzed for survival.

RESULTS

One hundred twenty-eight consecutive patients (103 men & 25 women) were enrolled with a median age of 61 years. Thrombi were all graded 0 using the Mayo system, of which 23 were friable. None of the thrombi detached during surgery. 121 patients were successfully followed up, with a median follow-up period of 47 months. Median overall survival was 127 months (95%CI: 101-153). The 5-year and 10-year cancer-specific survival (CSS) rate was 67.9 and 57.0%. 59 patients had recurrence with median time of 40 months. Friable thrombus, paraneoplastic syndrome (PNS), modified Fuhrman grade 3/4 and perirenal fat invasion were independent prognostic factors (p < 0.05). The 5-year CSS for the Low-risk group (no factors) was 100%, Middle-risk group (1-2 factors) was 68.6%, while the High-risk group (3-4 factors) was 0%.

CONCLUSIONS

After radical surgery, RCC patients with RVTT had a relatively fair prognosis except for patients with friable thrombus, PNS, higher modified Fuhrman grade and perirenal fat invasion.

Postsurgical complications in patients with renal tumours with venous thrombosis treated with surgery

BACKGROUND AND OBJECTIVE

Surgery on renal tumours with venous thrombosis suffers a high rate of complications and non-negligible perioperative mortality. Our objective was to analyse the postoperative complications, their relationship with the level of the thrombus and its potential predisposing factors.

MATERIALS AND METHODS

A retrospective analysis was conducted of 101 patients with renal tumours with venous thrombosis operated on between 1988 and 2017. Two patients were excluded because of intraoperative pulmonary thromboembolism and exitus (2%). The postsurgical complications were classified according to Clavien-Dindo. To compare the qualitative variables, we employed the chi-squared test. We performed a multivariate analysis using binary logistic regression to identify the independent predictors.

RESULTS

Some type of postsurgical complication occurred in 34 (34.3%) patients, 11 (11.1%) of which were severe (Clavien III-V). There were significant differences in the total complications (P=.003) and severe complications (Clavien≥III; P=.03) depending on the level of the tumour thrombus.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Renal cell carcinoma with venous extension: prediction of inferior vena cava wall invasion by MRI

BACKGROUND

Renal cell carcinoma (RCC) are accompanied by inferior vena cava (IVC) thrombus in up to 10% of the cases, with surgical resection remaining the only curative option. In case of IVC wall invasion, the operative procedure is more challenging and may even require IVC resection. This study aims to determine the diagnostic performance of contrast-enhanced magnetic resonance imaging (MRI) for the assessment of wall invasion by IVC thrombus in patients with RCC, validated with intraoperative findings.

METHODS

Data were collected on 81 patients with RCC and IVC thrombus, who received a radical nephrectomy and vena cava thrombectomy between February 2008 and November 2017. Forty eight patients met the inclusion criteria. Sensitivity and specificity as well as the positive and negative predictive values were calculated for preoperative MRI, based on the assessments of the two readers for visual wall invasion. Furthermore, a logistic regression model was used to determine if there was an association between intraoperative wall adherence and IVC diameter.

RESULTS

Complete occlusion of the IVC lumen or vessel breach could reliably assess IVC wall invasion with a sensitivity of 92.3% (95%-CI: 0.75-0.99) and a specificity of 86.4% (95%-CI: 0.65-0.97) (Fisher-test: p-value< 0.001). The positive predictive value (PPV) was 88.9% (95%-CI: 0.71-0.98) and the negative predictive value reached 90.5% (95%-CI: 0.70-0.99). There was an excellent interobserver agreement for determining IVC wall invasion with a kappa coefficient of 0.90 (95%CI: 0.79-1.00).

CONCLUSIONS

The present study indicates that standard preoperative MR imaging can be used to reliably assess IVC wall invasion, evaluating morphologic features such as the complete occlusion of the IVC lumen or vessel breach. Increases in IVC diameter are associated with a higher probability of IVC wall invasion.

Sonography and Transthoracic Echocardiography for Diagnosis of Systemic Cardiovascular Metastatic Tumor Thrombi

Sonography and transthoracic echocardiography (TTE) are seldom used for assessment of metastatic tumor thrombi in the cardiovascular system in routine clinical practice. We performed this retrospective study to evaluate the combination of sonography with TTE for diagnosis of metastatic tumor thrombi in heart and systemic vessels. Vascular, abdominal, pelvic, and small-part sonography was applied in 18 patients, and TTE was conducted simultaneously in 14 patients. Tumor thrombi invaded into the inferior vena cava system in 12 patients, superior vena cava system in 5 patients, and aorta in 1 patient; they extended to the right cardiac chambers in 11 patients. Six patients had diagnoses by pathologic examination. The primary neoplasms were identified by conventional imaging in 17 patients. The morphologic and echogenic characteristics of the tumor thrombi were diverse and depended on their original tumors. The thrombi were either contiguous or discrete from the original tumors. The neoplastic vascularity of the thrombi and the invasive extension were the primary characteristics that distinguished them from bland thrombi. Simultaneous application of sonography and TTE is a feasible way to comprehensively evaluate cardiovascular metastatic tumor thrombi in most patients.