Cytoreductive Nephrectomy for Renal Cell Carcinoma with Venous Tumor Thrombus.

Careful selection is critical to identify those with metastatic renal cell carcinoma who are most likely to benefit from cytoreductive nephrectomy. Surgery in patients who have metastatic renal cell carcinoma with tumor thrombus is complex and may not benefit some patients with poor overall survival. We evaluated whether preoperative variables or risk stratification systems could predict overall survival following cytoreductive nephrectomy. Prognostic factors for overall survival after surgery were evaluated in patients who had metastatic renal cell carcinoma with venous tumor thrombus at 5 institutions from 2000 to 2014. Prognostic variables, including metastatic renal cell carcinoma risk models, were evaluated for associations with overall survival. Multivariable analysis was used to determine independent associations of preoperative variables with overall survival. A total of 427 patients with metastatic renal cell carcinoma were identified with tumor thrombus. Patients with inferior vena cava thrombus above the diaphragm had shorter median overall survival vs those with renal vein only thrombus (9.2 months, IQR 4.2-30.8, vs 21.7, IQR 7.7-42.8, p = 0.0165). Individual risk factors from prognostic models were evaluated among other preoperative characteristics for associations with overall survival in 122 patients (32%) who died within 270 days of surgery. Independent predictors of overall survival included lactate dehydrogenase greater than the upper limit of normal (p = 0.003), systemic symptoms (p = 0.003), inferior vena cava thrombus above the diaphragm (p = 0.02) and sarcomatoid features (p = 0.005). Poor overall survival following cytoreductive nephrectomy in patients with metastatic renal cell carcinoma with tumor thrombus is associated with inferior vena cava thrombus above the diaphragm, poor risk group, systemic symptoms or sarcomatoid dedifferentiation. Patients with expected poor overall survival should be considered for preoperative systemic therapy clinical trials.

Abel EJ ，Spiess PE ，Margulis V ，Master VA ，Mann M ，Zargar-Shoshtari K ，Borregales LD ，Sexton WJ ，Patil D ，Matin SF ，Wood CG ，Karam JA ... -  《-》

Surgical treatment of renal cell carcinoma: Can morphological features of inferior vena cava tumor thrombus on computed tomography or magnetic resonance imaging be a prognostic factor?

To evaluate the impact of morphological features of inferior vena cava thrombus on the overall survival and cancer-specific survival (cancer-specific survival of patients with renal cell carcinoma). We retrospectively analyzed the records of 156 renal cell carcinoma patients with inferior vena cava thrombus who underwent radical nephrectomy and thrombectomy from 1998 to 2013 at five tertiary centers. Inferior vena cava thrombi were classified as spherical (type I) and spiculated (type II) according to morphological features on computed tomography or magnetic resonance imaging. Multivariate cox regression models were used to quantify the impact of prognostic factors on overall survival and cancer-specific survival. Type I was found in 29 patients (18.6%), and type II in 127 patients (81.4%). Median follow up was 38.2 months (interquartile range 12-57). Demographic characteristics were not significantly different, except for the cranial thrombus height (P = 0.003). On multivariate analysis, Eastern Cooperative Oncology Group performance score, clinical tumor size, distant metastasis, histologic subtype, thrombus morphology and remnant venous thrombus significantly affected overall survival in pNany Many patients (all P < 0.05). Among the pNO /X MO patients, clinical tumor size, histologic subtype, thrombus morphology and remnant venous thrombus significantly affected overall survival (all P < 0.05). In terms of cancer-specific survival, Eastern Cooperative Oncology Group performance score, clinical tumor size, distant metastasis, histologic subtype and thrombus morphology significantly affected cancer-specific survival in pNany Many patients (all P < 0.05). In patients with pNO /X MO , body mass index, clinical tumor size, histological subtype, thrombus morphology and remnant venous thrombus significantly affected cancer-specific survival (all P < 0.05). Clinical tumor size, histological subtype, and thrombus morphology are independent predictors of overall survival and cancer-specific survival in renal cell carcinoma patients with inferior vena cava thrombus. These factors might be helpful for the surgeon's determination to improve therapeutic efficacy.

Choi DK ，Jeon HG ，Jeong CW ，Kwak C ，Song C ，Chung J ，Hong SK ，Hong SH ，Seo SI ，Korean Renal Cancer Study Group ... -  《-》

Oncological outcomes after cytoreductive nephrectomy for patients with metastatic renal cell carcinoma with inferior vena caval tumor thrombus.

Miyake H ，Sugiyama T ，Aki R ，Matsushita Y ，Tamura K ，Motoyama D ，Ito T ，Otsuka A ... -  《-》

Prognostic risk stratification and clinical outcomes in patients undergoing surgical treatment for renal cell carcinoma with vascular tumor thrombus.

Lambert EH ，Pierorazio PM ，Shabsigh A ，Olsson CA ，Benson MC ，McKiernan JM ... -  《-》

Preoperative metastatic status, level of thrombus and body mass index predict overall survival in patients undergoing nephrectomy and inferior vena cava thrombectomy.

Study Type - Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Little is known about the prognostic impact of body mass index (BMI) and obesity on patients with locally advanced kidney cancer. Previous studies suggest that clinical/pathological stage, the proximal extent of the tumour thrombus, direct vascular wall invasion, and preoperative performance status may all constitute important prognostic factors within this patient population. The present study shows that a patient's metastatic status, higher level of tumour thrombus, and lower BMI all constitute adverse predictors of overall survival in patients who have RCC with inferior vena cava tumour thrombus. •  To determine which clinical variables, including body mass index (BMI), predict overall survival (OS) after nephrectomy with inferior vena cava (IVC) thrombectomy for renal cell carcinoma (RCC) with tumour thrombus. •  After institutional review board approval, a retrospective analysis of all patients (N= 100) undergoing nephrectomy and IVC thrombectomy for RCC from 1989 to 2010 were reviewed. One patient was excluded owing to missing clinical information leaving 99 patients in the study cohort. •  Patients were placed into one of two subgroups, based on their preoperative BMI (BMI ≤30 kg/m(2) or BMI >30 kg/m(2) ). •  Complications, blood loss, level of tumour thrombus, side of tumour and follow-up data were tabulated. •  Fifty-six patients had a BMI ≤30 kg/m(2) and 43 patients had a BMI >30 kg/m(2) . Intraoperative complications occurred in 14% of those with BMI >30 kg/m(2) and 5.4% of those with a BMI ≤30 kg/m(2) (P= 0.171). •  On multivariate analysis, a higher thrombus level (III/IV vs I/II) and the presence of metastatic disease at time of diagnosis was associated with a worse OS (P= 0.041 and P < 0.001, respectively). •  The subgroup with a higher preoperative BMI had a significantly better OS (hazard ratio 0.42; 95% confidence interval 0.22-0.80, P= 0.009). •  Similarly, our Kaplan-Meier survival analysis showed an improved OS in the patient cohort with a BMI >30 kg/m(2) (P= 0.016). •  Important predictors of outcome in patients undergoing nephrectomy with IVC thrombectomy for RCC with tumour thrombus include preoperative BMI, level of IVC tumour thrombus, and metastatic status at time of surgery.

Spiess PE ，Kurian T ，Lin HY ，Rawal B ，Kim T ，Sexton WJ ，Pow-Sang JM ... -  《-》