Urologic Oncology: Seminars and Original Investigations
Original articlesA contemporary evaluation of cytoreductive nephrectomy with tumor thrombus: Morbidity and long-term survival
Introduction
Kidney and renal pelvic tumors will be diagnosed in 35,710 patients this year in the United States [1]. At presentation, approximately 20% of the patients with renal cell carcinoma (RCC) will have metastatic disease diagnosed with routine preoperative radiography [2]. Metastatic renal cell cancer remains a therapeutic challenge as the disease is extremely resistant to various chemotherapeutic regimens because of the expression of the multiple drug resistance (MDR) gene in many cells [3]. Recently, however, two randomized multi-center trials showed a significant survival advantage for patients with metastatic RCC who underwent nephrectomy before treatment with interferon-alfa as compared to patients who received interferon alone [2], [4]. In select patients with good performance status, these studies show that cytoreductive surgery before the administration of systemic immunotherapy improves survival, does not delay the administration of adjuvant therapy, and can be performed with minimal complications.
Metastatic RCC is also an aggressive entity that has a high likelihood of invading the venous system. In patients with metastatic RCC, approximately 50% of patients will present with gross tumor thrombus, either extending to the renal vein or to the inferior vena cava (IVC) [5]. Patients with evidence of tumor thrombus are classified as T3b and T3c under the 1997 TNM (Tumor, Node, Metastasis) classification system [6]. With the steady improvement in surgical techniques, particularly for patients who present with IVC involvement, and perioperative care, patients with tumor thrombus can be effectively treated with minimal morbidity and mortality [7]. To date, there have been few studies that have evaluated the survival and complication rate in those patients undergoing cytoreductive nephrectomy with tumor thrombus [5], [8]. We evaluated our institution’s experience over the past decade with cytoreductive nephrectomy with particular emphasis on the survival and complication rate of patients with concurrent tumor thrombus.
Section snippets
Methods
A total of 730 patients were surgically treated for a renal cortical mass at our institution between January 1989 and January 2003. Of these, we identified 56 patients (8%) from our database who presented with a primary renal tumor in place and documented metastasis (M+) found after routine preoperative radiography. These 56 patients had surgery performed at our institution between July 1991 and January 2003 (Table 1). Patients with retroperitoneal lymphadenopathy as noted on an abdominal
Results
Of the 56 patients who underwent surgery at our institution with preoperative radiographic evidence of metastatic disease, 39 (70%) were male and 17 (30%) were female. Median age at the time of surgery was 58 years (37–77). There were 27 patients (48%) who had right-sided tumors and 29 (52%) had left-sided tumors. At the time of diagnosis, no patients presented with bilateral disease. There were 19 patients (34%) who had their tumors discovered incidentally, 22 patients (39%) presented with
Discussion
The decision to perform cytoreductive surgery for metastatic RCC has recently been supported by two randomized clinical trials that showed a statistically significant survival advantage in patients who received systemic immunotherapy after nephrectomy compared to patients who received immunotherapy alone [2], [4]. Frequently, patients with metastatic RCC also have a concurrent tumor thrombus extending either to the renal vein alone or to the IVC. Patients with tumor thrombus are categorized
Conclusions
This retrospective series describes our 11-year institutional experience with cytoreductive nephrectomy. The majority of our patients presented with a tumor thrombus in either the renal vein or the inferior vena cava. Although patients with a tumor thrombus had a higher rate of complication as compared to patients without a thrombus, the long-term survival was not statistically different in the two groups. In patients with thrombus, the long-term survival was not statistically different after
Acknowledgements
M.A. Goetzl was supported by a Clinical Research Fellowship award from the Doris Duke Charitable Foundation. There is no financial relationship between any of the authors and the subject matter in this manuscript.
References (20)
- et al.
Radical nephrectomy plus interferon-alfa-based immunotherapy compared with interferon alfa alone in metastatic renal cell carcinomaa randomized trial
Lancet
(2001) - et al.
Renal cell carcinoma with tumor thrombusis cytoreductive nephrectomy for advanced disease associated with an increased complication rate?
J Urol
(2002) - et al.
Surgical techniques for treating a renal neoplasm invading the inferior vena cava
J Urol
(2003) - et al.
Metastatic renal cell carcinoma with concurrent inferior vena caval invasionlong-term survival after combination therapy with radical nephrectomy, vena caval thrombectomy and postoperative immunotherapy
J Urol
(1999) - et al.
Renal cell carcinoma with tumor thrombus extensionbiology, role of nephrectomy and response to immunotherapy
J Urol
(2003) - et al.
Prognostic factors in renal cancer
Urol Clin North Am
(1993) - et al.
Surgical management and prognosis of renal cell carcinoma invading the vena cava
J Urol
(1991) - et al.
Complete radical nephrectomy and vena caval thrombectomy during circulatory arrest
J Urol
(2000) - et al.
The use of liver transplant techniques to aid in the surgical management of urological tumors
J Urol
(2000) - et al.
Vein invasion in renal cell carcinomaimpact on metastatic behavior and survival
J Urol
(1995)
Cited by (25)
Effect of Inferior Vena Cava Tumor Thrombus on Overall Survival in Metastatic Renal Cell Carcinoma Patients Treated with Cytoreductive Nephrectomy
2022, European Urology Open ScienceCitation Excerpt :In the current study, more than twice that number (n = 86) was identified [2]. Even though the presence of tumor thrombus varied within other more historical, smaller-scale, single-institution case series (range: 23–59%), the results of the current study clearly indicate that a large proportion of CN patients harbor vascular tumor thrombus [6,7,16]. In consequence, additional large-scale, epidemiological data regarding this important subgroup of CN patients are clearly needed to address the important knowledge gap regarding eligibility for CN and cancer control outcomes after CN.
Cytoreductive nephrectomy in patients with metastatic renal cell carcinoma and venous thrombus—Trends and effect on overall survival
2019, Urologic Oncology: Seminars and Original InvestigationsCitation Excerpt :Additionally, use of CN has decreased in the era of targeted therapy, though because targeted therapy generally has little effect on tumor thrombi, CN likely will remain an important treatment modality for this subset of patients with mRCC [7]. Several small, contemporary studies have examined oncologic outcomes of CN in mRCC patients with tumor thrombus, but with conflicting results [6,8–12]. These series have mainly evaluated feasibility, survival with respect to the level of tumor thrombus, and complications.
Cytoreductive Nephrectomy for Renal Cell Carcinoma with Venous Tumor Thrombus
2017, Journal of UrologyCitation Excerpt :However, the 32% rate of early mortality (within 9 months) in this series was greater than the 18% to 22% early mortality rates reported in other large CN studies.4,5 In patients who have mRCC with thrombus other groups have also reported poor OS (median 8.3 to 15 months),21–23 although the largest prior series was done in only 76 patients and included those treated during several decades.21 The median OS in all patients in the current study was 18.9 months, similar to the OS of 19 to 20 months reported in contemporary series of patients treated with CN and targeted therapies.2,5
Treatment of caval vein thrombosis associated with renal tumors
2017, Cirugia EspanolaSurgical outcomes after cytoreductive nephrectomy with inferior vena cava thrombectomy
2014, UrologyCitation Excerpt :The Mayo Clinic group reported on 142 pM1 patients but the number of patients with level II or higher IVCTs, in contrast to renal vein thrombi, is not clear.17 Additionally, the proportion of patients requiring CPB in our study, theoretically a more complex patient group, was considerably higher than that reported in previous studies.6,7,14 Notwithstanding these differences in patient characteristics, our major perioperative complication rate of 8% is lower than that seen in prior reports and is likely the result of several factors.
Contemporary management of renal tumors with venous tumor thrombus
2010, Journal of UrologyCitation Excerpt :Similarly Haferkamp et al reported that receiving immunotherapy was a good prognostic factor in metastatic RCC with IVTT when nephrectomy was performed (median survival 13.5 vs 5.1 months with surgery alone).8 Finally, Goetzl et al reported that patients undergoing cytoreductive nephrectomy for RCC with IVTT had the same survival as those without IVTT.16 In the current era of targeted cancer therapy most candidates for cytoreductive nephrectomy are treated with tyrosine kinase inhibitors.