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
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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
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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
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[Prognostic value of venous tumor thrombus in renal cell carcinoma].
To evaluate the prognostic value of venous tumor thrombus in renal cell carcinoma.
A retrospective study of 167 patients with renal cell carcinoma and stage pT3 who underwent radical nephrectomy and extended lymphadenectomy from July 1969 to May 2008 was conducted. Patients with any kind of venous involvement were selected for the analysis (73 patients; 43.7%). The Kaplan Meier survival curves and log-rank test for comparisons were used for the survival analysis. Multivariate analysis was done by Cox regression.
Lymph node involvement was present in 30 patients (41.1%) and metastatic disease in 9 patients (12.3%). The most frequent histologic renal cell carcinoma subtype was 50 (68.5%) conventional carcinoma, followed by nondifferentiated in 11 (15.5%), and chromophobe in 9 (12.3%). High grade tumors (Furhman 3-4) were present in 57% of the cases. Venous thrombus level extended to renal vein in 61 patients (83.6%), to inferior vena cava in 9 patients (12.3%) and to the cardiac right atrium in 3 cases (4.1%). The survival analysis showed worse survival in those patients with venous tumor thrombosis (p=.001) and with vein wall invasion (p=.0042), but not in function on the level of the thrombus (p=.12). The multivariate analysis identified the Furhman grade and venous tumor thrombosis as independent survival prognostic factors.
In our series, venous tumor thrombosis, together with the Furhman nuclear grade, is an independent survival prognostic factor. However, neither cephalic extension of the thrombus nor the invasion of the vein wall showed independent prognostic value.
García-Fadrique G
，Budía-Alba A
，Ruiz-Cerdá JL
，Morales-Solchaga G
，Pontones JL
，Jiménez-Cruz JF
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