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array:24 [ "pii" => "S2173578621000330" "issn" => "21735786" "doi" => "10.1016/j.acuroe.2021.03.001" "estado" => "S300" "fechaPublicacion" => "2021-05-01" "aid" => "1321" "copyright" => "AEU" "copyrightAnyo" => "2020" "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Actas Urol Esp. 2021;45:257-63" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0210480620302217" "issn" => "02104806" "doi" => "10.1016/j.acuro.2020.09.009" "estado" => "S300" "fechaPublicacion" => "2021-05-01" "aid" => "1321" "copyright" => "AEU" "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Actas Urol Esp. 2021;45:257-63" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">ARTÍCULO DE REVISIÓN</span>" "titulo" => "Controversias en el diagnóstico del carcinoma de células renales con trombosis venosa asociada" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "257" "paginaFinal" => "263" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Controversies in the diagnosis of renal cell carcinoma with tumor thrombus" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1001 "Ancho" => 1255 "Tamanyo" => 132155 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Reconstrucción tridimensional cáncer renal con trombo en VCI mediante tecnología CADD a partir de TC.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. 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Ruiz Guerrero, M.J. Ledo Cepero, A. Ojeda Claro, M. Soto Delgado, J.L. Álvarez-Ossorio Fernández" "autores" => array:5 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Ruiz Guerrero" ] 1 => array:2 [ "nombre" => "M.J." "apellidos" => "Ledo Cepero" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Ojeda Claro" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Soto Delgado" ] 4 => array:2 [ "nombre" => "J.L." "apellidos" => "Álvarez-Ossorio Fernández" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210480620302588" "doi" => "10.1016/j.acuro.2020.11.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210480620302588?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578621000457?idApp=UINPBA00004N" "url" => "/21735786/0000004500000004/v1_202105020845/S2173578621000457/v1_202105020845/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2173578621000342" "issn" => "21735786" "doi" => "10.1016/j.acuroe.2020.10.011" "estado" => "S300" "fechaPublicacion" => "2021-05-01" "aid" => "1325" "copyright" => "AEU" "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Actas Urol Esp. 2021;45:247-56" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review article</span>" "titulo" => "Urinary tract infection as the main cause of admission in cystectomized patients" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "247" "paginaFinal" => "256" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La infección del tracto urinario como causa principal de ingreso en pacientes cistectomizados" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Gayarre Abril, J. Subirá Ríos, L. Muñiz Suárez, C. Murillo Pérez, M. Ramírez Fabián, J.I. Hijazo Conejos, P. Medrano Llorente, J. García-Magariño Alonso, F.X. Elizalde Benito, G. Aleson Hornos, B. Blasco Beltrán, P. Carrera Lasfuentes" "autores" => array:12 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Gayarre Abril" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Subirá Ríos" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Muñiz Suárez" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Murillo Pérez" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Ramírez Fabián" ] 5 => array:2 [ "nombre" => "J.I." "apellidos" => "Hijazo Conejos" ] 6 => array:2 [ "nombre" => "P." "apellidos" => "Medrano Llorente" ] 7 => array:2 [ "nombre" => "J." "apellidos" => "García-Magariño Alonso" ] 8 => array:2 [ "nombre" => "F.X." "apellidos" => "Elizalde Benito" ] 9 => array:2 [ "nombre" => "G." "apellidos" => "Aleson Hornos" ] 10 => array:2 [ "nombre" => "B." "apellidos" => "Blasco Beltrán" ] 11 => array:2 [ "nombre" => "P." "apellidos" => "Carrera Lasfuentes" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578621000342?idApp=UINPBA00004N" "url" => "/21735786/0000004500000004/v1_202105020845/S2173578621000342/v1_202105020845/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review article</span>" "titulo" => "Controversies in the diagnosis of renal cell carcinoma with tumor thrombus" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "257" "paginaFinal" => "263" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Caño Velasco, L. Polanco Pujol, J. Hernandez Cavieres, F.J. González García, F. Herranz Amo, G. Ciancio, C. Hernández Fernández" "autores" => array:7 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Caño Velasco" "email" => array:1 [ 0 => "jorcavel@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L." "apellidos" => "Polanco Pujol" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Hernandez Cavieres" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "F.J." "apellidos" => "González García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "F." "apellidos" => "Herranz Amo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "G." "apellidos" => "Ciancio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "C." "apellidos" => "Hernández Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Tumores Renales con Afectación Venosa (TRAV), Servicio de Urología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Urology, Miami Transplant Institute and Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, United States" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Controversias en el diagnóstico del carcinoma de células renales con trombosis venosa asociada" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 487 "Ancho" => 1255 "Tamanyo" => 85006 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) Right acute pulmonary thromboembolism secondary to (B) right lower pole renal tumor with venous thrombus in infrahepatic cava (cT3b) and PTE in the base of the right lung.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Tumor thrombus invasion into the inferior vena cava (IVC) occurs in 4%–10%<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> of patients with locally advanced renal cell carcinoma (RCC). Extension into the right atrium is infrequent (1%).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Preoperative determination of the thrombus level,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a> as well as the approach to the anatomopathological diagnosis, are fundamental for treatment planning and perioperative anesthetic management.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> It often requires management by a multidisciplinary team, especially for levels III and IV.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,9</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Surgery for renal tumors with associated venous thrombosis suffers a high percentage of complications that increase according to the level of the tumor thrombus: level I: 12; II: 18; III: 26 and IV: 47% and with perioperative mortality ranging from 0.8% in level I to 40% for level IV.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> Timing, referring to the time elapsed between diagnosis and surgical intervention, is a determining factor.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Delayed treatment can increase the risk of complications, including fatal ones such as perioperative pulmonary embolism (PE).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This manuscript presents a review of the current literature and exposes the current controversies on the diagnosis of renal cancer with associated venous tumor thrombosis.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Diagnostic imaging</span><p id="par0020" class="elsevierStylePara elsevierViewall">Preoperative determination of the thrombus level is essential for planning and optimizing surgical exposure.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleBold">Computed tomography (CT)</span> with and without intravenous contrast (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) is the most widely used technique in the diagnosis of renal masses and their extension study, given its high availability and relatively low cost. The <span class="elsevierStyleItalic">late venous phase</span> is preferable to the routine <span class="elsevierStyleItalic">portal venous phase</span> for the determination of tumor thrombus, since it provides a more uniform enhancement of the IVC and avoids interference with renal venous return.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Vascular reconstruction during the arterial phase complements the study for surgical planning.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnostic approach for a specific <span class="elsevierStyleItalic">histological subtype and grade</span> through imaging can provide useful clinical information, as clear cell RCC tends to grow more rapidly than papillary RCC.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The former usually show significant enhancement in the corticomedullary phase of CT with washout in nephrogenic phase, whereas papillary RCCs show gradual and progressive enhancement.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The latter may not enhance (<10 HU), given their hypovascularity.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">However, <span class="elsevierStyleBold">magnetic resonance imaging (MRI)</span> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) can provide additional information on venous involvement if the extent of the tumor thrombus is poorly defined on CT,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> given the better characterization of soft tissues. The most sensitive and specific method for this is three-dimensional T1-weighted MRI with patients holding breath (3 D breath-hold T1-weighted MRI) after gadolinium administration.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The identification of the <span class="elsevierStyleItalic">bland</span> thrombus is of great utility in surgical planning, showing no enhancement in CT and MRI with contrast, unlike tumor thrombus.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> In those cases in which contrast cannot be administered (e.g., allergy to intravenous iodinated contrast or renal insufficiency) non-contrast MRI shows greater sensitivity and specificity than non-contrast CT.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnostic approach to histological subtype by MRI has been proposed by several authors<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22–24</span></a>; however, in daily clinical practice, its determination is infrequent.</p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Echocardiography</span> allows evaluation of the cavoatrial junction, IVC and hepatic veins, with better characterization of the cranial extension,<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,26</span></a> providing complementary information on the consistency, fragility, adherence and mobility of the thrombus.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> No significant difference has been established between the transthoracic (TTE) or transesophageal (TEE) approach; however, only TEE can be performed in the operating room allowing modifications of the surgical strategy and approach in case of disagreement with preoperative imaging tests.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Three-dimensional reconstructions can provide dynamic clinical information.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The high growth rate and rapid cranial extension of the thrombus may alter surgical management. Kostibas et al.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> report percentages of strategy changes already at the operating room if the level of thrombus is higher when determined by <span class="elsevierStyleBold">real-time TEE</span> (II: 16%; III: 21% and IV: 100%). In addition, TEE allows better evaluation of posterior cardiac structures<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>; provides information on possible pre-existing cardiac disease,<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> ventricular function, valve and cardiac anatomy; optimizes the location of vascular clamping<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29,31</span></a>; is a complementary imaging method in case cardiopulmonary bypass or the milking maneuver (mobilization of the proximal end of the thrombus to a level below the major hepatic veins)<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> are required; allows verification of complete or incomplete resection of the thrombus. The measurement of peri thrombotic blood flow, thanks to <span class="elsevierStyleBold">color Doppler</span>, allows us to estimate the degree of hemodynamic compromise of the preload.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> It must be performed by specialists, generally qualified anesthesiologists, as it requires meticulous handling/interpretation and is not an ancillary test devoid of possible adverse side effects (laryngospasm, pulmonary aspiration, laryngeal bleeding, among others).<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Contrast-enhanced ultrasound (CEUS)</span> allows precise categorization of complex cystic renal lesions, differentiation of solid masses from indeterminate cystic lesions identified incidentally in cross-sectional imaging studies, as well as monitoring of small renal masses during active surveillance,<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,33</span></a> thanks to the exquisite evaluation of renal microvascularization, which may not be detected with color Doppler.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Moreover, it has shown remarkable utility in the differentiation of <span class="elsevierStyleItalic">bland</span> and <span class="elsevierStyleItalic">tumor</span> thrombus, as early enhancement of thrombus within the lumen is indicative of <span class="elsevierStyleItalic">tumor</span> thrombus as opposed to the absence of enhancement that characterizes <span class="elsevierStyleItalic">soft</span> thrombus.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Furthermore, synchronous tumor thrombus and vascular wall enhancement correlates with tumor invasion of the latter with high sensitivity and specificity.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Several studies attempt to correlate CEUS findings with <span class="elsevierStyleItalic">histological subtype</span>: a hyperenhancement of the lesion compared to the renal cortex, together with a fast intensity acquisition curve have been associated with clear cell RCC, versus the hypoenhancement/slow curve associated with papillary RCC.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Surgical planning with three-dimensional printing</span><p id="par0060" class="elsevierStylePara elsevierViewall">Obtaining three-dimensional biomodels with reconstructions generated from imaging tests (CT or MRI), thanks to computer-aided design and drafting (CADD), makes it possible to replicate anatomical structures of the patient in plastic materials. Its use is complementary to the surgeon’s surgical planning and training in a detailed way, and it optimizes communication with the patient. Its use in urology is limited,<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> with isolated bibliographic references on reconstructions in renal cancer with venous thrombosis.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39,40</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">A multicenter phase I clinical trial (NCT03738488)<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> is currently underway to evaluate the efficacy and efficiency of 3D models versus classic imaging tests (CT) in surgery for renal cell carcinoma with venous thrombosis.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In our experience, as a CSUR (Centers, Services and Units of Reference of the National Health System) center in renal cancer with venous thrombosis, 3-D printing is an improvement factor in surgical preparation thanks to the tactile and visual aspects; it is also a valuable teaching tool. Its reproducibility and rapid acquisition make these models a useful evolving instrument in selected patients (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Access to this technology and its costs can be limiting factors for its implementation<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a>; however, the progressive development of the technique is reducing the costs of materials.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Importance of diagnostic-therapeutic timing</span><p id="par0075" class="elsevierStylePara elsevierViewall">Given the rapid growth and propagation of tumor thrombi, some authors agree on the greater importance of <span class="elsevierStyleBold">timing</span> or delay between diagnosis and surgical treatment (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>), over the imaging modality (CT or MRI).<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,43–47</span></a> Thus, Woodruff et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> establish <span class="elsevierStyleItalic">14 days</span> from diagnosis as the optimal time for surgical planning, with a maximum interval of <span class="elsevierStyleItalic">30 days</span>. Fukazawa et al.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> establish a maximum treatment time of <span class="elsevierStyleItalic">21 days</span> after diagnosis for level I and II tumors<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and <span class="elsevierStyleItalic">7 days</span> for level III tumors. This time delay predicts the absence of tumor progression with a sensitivity of 100% in both groups and a specificity of 32–38 and 10%, respectively. However, they do not provide information on timing in level IV tumors, probably because of the small sample size. Gershman et al. (Mayo Clinic recommendation)<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> recommend MRI within a maximum of <span class="elsevierStyleItalic">one week</span> prior to surgery. The need for urgent surgical intervention is exceptional in the case of an imminent risk of death due to thrombus progression from the right atrium to the right ventricle. However, all these recommendations are based on short series, retrospective analyses and expert opinion.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Likewise, timing is crucial in the development of <span class="elsevierStyleBold">perioperative PTE</span> (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>) with an estimated incidence between 0%–4% and mortality rates between 60%–75%.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12,20,48</span></a> There are two patterns of clinical presentation: (a) acute circulatory collapse; or (b) subclinical presentation, probably determined by the site of differential embolization, the central pulmonary arteries or the distal subsegmental territory (CTEPH), respectively.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,48,50</span></a> However, there is no clear correlation between the level of the tumor thrombus and the development of perioperative embolic events; thus, in different series, intraoperative PTE is more frequently described in tumors at the level of the infrahepatic IVC.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,48,51</span></a> In addition to the delay time, other related factors are: invasion/degree of compression of the IVC,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,48</span></a> presence of <span class="elsevierStyleItalic">bland</span> thrombus, history of smoking, ECOG (Eastern Cooperative Oncology Group) performance status ≥1, hypercoagulability,<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> bulky lymphadenopathy at surgery,<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> liver mobilization or intraoperative transfusion.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Early detection of thromboembolic events and adequate preoperative anticoagulation therapy can improve morbidity and mortality,<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> despite the increased risk of metastatic disease.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> In contrast, intraoperative thrombus detachment dramatically increases mortality.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Intraoperative TEE allows intraoperative recognition of the right atrium and ventricle, as well as the pulmonary artery, which provides a highly useful tool for the diagnosis of intraoperative embolic events.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29,56</span></a> Likewise, the development of postoperative thromboembolic events significantly increases the risk of mortality. Prophylactic anticoagulant treatment plays a fundamental role, especially in high-risk patients, so it is imperative to seek a risk-benefit balance in the face of possible hemorrhagic events.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0090" class="elsevierStylePara elsevierViewall">The progressing technological development has improved the diagnosis of RCC associated with venous thrombosis. Regardless of the imaging technique used for its detection (CT, MRI, TEE, contrast-enhanced ultrasound [CEUS]), the time from diagnosis to treatment is of vital importance to reduce the risk of complications, some of them fatal, such as pulmonary thromboembolism. A multidisciplinary team with extensive surgical experience is essential to achieve the best oncologic outcomes and reduce potential postoperative complications.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that they have not received external funding for the research.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1505945" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1366608" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1505946" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1366609" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Diagnostic imaging" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical planning with three-dimensional printing" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Importance of diagnostic-therapeutic timing" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-09-18" "fechaAceptado" => "2020-09-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1366608" "palabras" => array:4 [ 0 => "Renal carcinoma" 1 => "Venousthrombosis" 2 => "Diagnosis" 3 => "Time" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1366609" "palabras" => array:4 [ 0 => "Carcinoma renal" 1 => "Trombosis venosa" 2 => "Diagnóstico" 3 => "Tiempo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">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.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El diagnóstico y tratamiento del carcinoma de células renales asociado con trombosis venosa tumoral sigue suponiendo un reto en la actualidad, requiriendo de equipos multidisciplinares, fundamentalmente en niveles del trombo III y IV. Nuestro objetivo es la exposición de las distintas técnicas diagnósticas empleadas y de las controversias asociadas. Para ello se ha llevado a cabo una revisión de los artículos relacionados más relevantes entre enero del 2000 y agosto de 2020 en PubMed, EMBASE y Scielo. El continuo desarrollo tecnológico, ha permitido avanzar en su detección, en la aproximación del subtipo histológico y en la determinación del nivel del trombo tumoral. Independientemente de la técnica de imagen utilizada para su diagnóstico (TC, RMN, ETE, ecografía con contraste), es de vital importancia el tiempo transcurrido hasta su tratamiento con el fin de disminuir el riesgo de complicaciones, algunas de ellas fatales como el tromboembolismo pulmonar.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Caño Velasco J, Polanco Pujol L, Hernandez Cavieres J, González García FJ, Herranz Amo F, Ciancio G, et al. Controversias en el diagnóstico del carcinoma de células renales con trombosis venosa asociada. Actas Urol Esp. 2021;45:257–263.</p>" ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 658 "Ancho" => 1674 "Tamanyo" => 114399 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Renal tumor in right lower pole with infradiaphragmatic vena cava thrombosis (cT3b).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 714 "Ancho" => 755 "Tamanyo" => 63732 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Right renal tumor with infradiaphragmatic cava thrombosis (cT3b).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1001 "Ancho" => 1255 "Tamanyo" => 132155 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Three-dimensional reconstructed CADD model from CT of renal cancer with IVC thrombosis.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1234 "Ancho" => 905 "Tamanyo" => 142280 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Timing. (A) CT: level cT3b tumor thrombus infrahepatic IVC; (B) MRI seven days later: level cT3b tumor thrombus subdiaphragmatic IVC; (C) Intraoperative TEE 17 days after initial CT: right atrial tumor thrombus (cT4).</p>" ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 487 "Ancho" => 1255 "Tamanyo" => 85006 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) Right acute pulmonary thromboembolism secondary to (B) right lower pole renal tumor with venous thrombus in infrahepatic cava (cT3b) and PTE in the base of the right lung.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:56 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systematic review of surgical management of nonmetastatic renal cell carcinoma with vena caval thrombus" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. 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