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

Renal cell carcinoma (RCC) with a tumor thrombus extension into the inferior vena cava (IVC) demands aggressive surgical management. To evaluate the long-term survival in patients undergoing radical nephrectomy and IVC thrombectomy. We performed a retrospective analysis of 87 patients undergoing surgery between 1997 and 2008. The patients were grouped according to the extent of tumor thrombus, with level I involving the IVC at the level of the renal vein, level II being infrahepatic IVC, level III being intrahepatic IVC, and level IV being suprahepatic IVC or right atrium. Relevant clinical and pathologic data were analyzed. Disease-free survival (DFS) and disease-specific survival (DSS) were studied. The median follow-up was 22 mo, and 19, 14, 40, and 14 patients had level I, II, III, and IV IVC thrombus, respectively. Among patients with M0 disease, 22 developed metastases. The 5-yr DFS was 64% for all levels and 74%, 69.5%, 59.5%, and 58% for levels I, II, III, and IV, respectively. Of the level I group, 16% of patients died of disease compared to 57% of the level IV group. The 5-yr DSS for all levels was 46% and 71%, 48%, 40%, and 35% for levels I, II, III, and IV, respectively. Patients with level IV thrombus had a significantly lower 5-yr DSS compared to level I (p=0.03). However, when analyzed in two groups-supradiaphragmatic and infradiaphragmatic-there was no significant difference in DSS (P=0.14). On univariate analysis, metastasis at presentation, non-clear-cell histology, lymph node metastases, and higher nuclear grade were statistically significant prognostic factors influencing DSS. Only higher nuclear grade (p=0.03), metastasis at presentation (p<0.01), and non-clear-cell histology (p=0.03) were independent prognostic factors on multivariate analysis. Radical nephrectomy and IVC thrombectomy offer reasonable long-term survival. The level of tumor thrombus is not an independent prognostic factor. Distant metastasis at presentation, higher nuclear grade, and non-clear-clear cell histology are significant prognostic factors influencing DSS.

Ciancio G ，Manoharan M ，Katkoori D ，De Los Santos R ，Soloway MS ... -  《-》

Impact of venous tumour thrombus consistency (solid vs friable) on cancer-specific survival in patients with renal cell carcinoma.

To our knowledge, the impact of venous tumour thrombus (VTT) consistency in patients affected by renal cell carcinoma (RCC) has never been addressed. To analyse the effect of VTT consistency on cancer-specific survival (CSS). We retrospectively analysed 174 consecutive patients with RCC and renal vein or inferior vena cava (IVC) VTT who underwent surgical treatment between 1989 and 2007 at our institute. All patients underwent radical nephrectomy and thrombectomy. Pathologic specimens were reviewed by a single uropathologist. In addition to traditional pathologic features, the morphologic aspect of the tumour thrombus was evaluated to distinguish solid from friable patterns. The prognostic role of thrombus consistency (solid vs friable) on CSS was assessed by means of Cox regression models. The VTT was solid in 107 patients (61.5%) and friable in 67 patients (38.5%). The presence of a friable VTT increased the risk of having synchronous nodal or distant metastases, higher tumour grade, higher pathologic stage, and simultaneous perinephric fat invasion (all p < 0.05). The median follow-up was 24 mo. The median CSS was 33 mo; the median CSS was 8 mo in patients with a friable VTT and 55 mo in patients with a solid VTT (p < 0.001). On multivariable analyses, the presence of a friable VTT was an independent predictor of CSS (p = 0.02). The power of our conclusion may be somewhat limited by the relatively small study population and the retrospective nature of the study. In patients with RCC and VTT, the presence of a friable thrombus is an independent predictor of CSS. If our finding is confirmed by further studies, the consistency of the tumour thrombus should be introduced into routine pathologic reports to provide better patient risk stratification.

Bertini R ，Roscigno M ，Freschi M ，Strada E ，Angiolilli D ，Petralia G ，Matloob R ，Sozzi F ，Capitanio U ，Da Pozzo LF ，Colombo R ，Guazzoni G ，Cremonini A ，Montorsi F ，Rigatti P ... -  《-》

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

The prognostic significance of venous involvement and tumour thrombus level in renal cell carcinoma (RCC) remains highly controversial. In 2010, the American Joint Committee on Cancer (AJCC) and the Union International Centre le Cancer (UICC) revised the RCC staging system (7th edition) based on tumour thrombus level, differentiating the T stage of tumours limited to renal-vein-only involvement. We aimed to evaluate the impact of tumour thrombus extension in a multi-institutional cohort of patients. An international consortium of 11 institutions was established to retrospectively review a combined cohort of 1215 patients undergoing radical nephrectomy and tumour thrombectomy for RCC, including 585 patients with inferior vena cava (IVC) involvement or higher. Predictive factors of survival, including histology, tumour thrombus level, nodal status, Fuhrman grade, and tumour size, were analysed. A total of 1122 patients with complete data were reviewed. The median follow-up for all patients was 24.7 mo, with a median survival of 33.8 mo. The 5-yr survival was 43.2% (renal vein involvement), 37% (IVC below the diaphragm), and 22% with caval involvement above the diaphragm. On multivariate analysis, tumour size (hazard ratio [HR]: 1.64 [range: 1.03-2.59]; p=0.036), Fuhrman grade (HR: 2.26 [range: 1.65-3.1]; p=0.000), nodal metastasis (HR: 1.32 [range: 1.09-1.67]; p=0.005), and tumour thrombus level (HR: 2.10 [range: 1.53-3.0]; p=0.00) correlated independently with survival. Based on analysis of the largest known cohort of patients with RCC along with IVC and atrial thrombus involvement, tumour thrombus level is an independent predictor of survival. Our findings support the changes to the latest AJCC/UICC staging system.

Martínez-Salamanca JI ，Huang WC ，Millán I ，Bertini R ，Bianco FJ ，Carballido JA ，Ciancio G ，Hernández C ，Herranz F ，Haferkamp A ，Hohenfellner M ，Hu B ，Koppie T ，Martínez-Ballesteros C ，Montorsi F ，Palou J ，Pontes JE ，Russo P ，Terrone C ，Villavicencio H ，Volpe A ，Libertino JA ，International Renal Cell Carcinoma-Venous Thrombus Consortium ... -  《-》

Management of renal cell carcinoma with tumor thrombus in renal vein and the inferior vena cava.

The article aims to sum up experience in the treatment of renal cell carcinoma complicated with tumor thrombus in renal vein and inferior vena cava. A retrospective review was made on the diagnosis, treatment, and prognosis of 15 cases of renal carcinoma complicated with venous tumor thrombus from July 1994 to July 2006. The diagnosis of 93% (14/15) cases was confirmed by preoperative computed tomography or magnetic resonance imaging. Of the 15 cases, two had simple renal vein tumor thrombus of left kidney and 13 had inferior vena cava tumor thrombus; of the latter, nine were type I (pararenal type), three type II (subhepatic type), and one type III (intrahepatic type). Of the 12 patients who received surgical treatment, 11 had the renal tumors completely resected, the venous tumor thrombus removed, and lymph nodes cleared. Palliative excision was performed in one patient with a left kidney tumor because of adjacent adhesion. All the three patients who did not receive surgical treatment died, with a mean survival period of 7 months. Of the 12 surgical patients who received surgical treatment, three were lost during follow-up, and the other nine were followed up for 4-72 months; of these 9 patients, three (25%) survived tumor-free for more than 5 years, three for 1-3 years, and the other three died of metastasis within 1 year. Computerized tomography and magnetic resonance imaging are the best choice for noninvasive diagnosis of renal cell carcinoma complicated with inferior vena cava tumor thrombus. For patients without metastasis, radical resection of both the tumor and the thrombus often offers a relatively satisfactory outcome.

Qi J ，Gu Z ，Chen F ，Shen H ，Chen J ，Zhang L ，Wang W ... -  《-》

Oncological outcomes in patients undergoing radical nephrectomy and vena cava thrombectomy for renal cell carcinoma with venous extension: a single-centre experience.

To report on the effectiveness of the surgical management of renal cell carcinoma (RCC) in patients with a neoplastic thrombus of the vena cava. We examined pre- and post-operative clinical data for all patients who had received a nephrectomy for the management of RCC with a neoplastic thrombus of the vena cava between spanning 10 years. The procedure depended on the exact location and size of the thrombus according to the Mayo Clinic and the 2009 TNM classifications. A total of 32 patients underwent surgery. Eight of these patients had stage I, nine had stage II, six had stage III and nine had stage IV thrombi according to the Mayo Clinic staging, and twenty were T3b, eight were T3c and four were T4 according to the 2009 TNM classifications. An open abdominal approach was performed in patients with stage I and II thrombi, whereas five of the stage III patients and all of the stage IV patients required combined sternotomies. Five patients whose thrombi extended to the right atrium were treated with a cardiac bypass. The complication rate was 53% and the peri-operative mortality rate was 12.5%. The median follow-up interval was 64 months. The overall and cancer-specific five-year survival rates for all stages combined were 47% and 52%, respectively. Surgical resection remains the first-line treatment for patients with RCC infiltrating the vena cava, but surgical morbidity is prevalent and survival is poor.

Parra J ，Drouin SJ ，Hupertan V ，Comperat E ，Bitker MO ，Rouprêt M ... -  《-》