Original articles
A contemporary evaluation of cytoreductive nephrectomy with tumor thrombus: Morbidity and long-term survival

https://doi.org/10.1016/j.urolonc.2004.02.001Get rights and content

Abstract

Background: Metastatic renal cell carcinoma (RCC) is an aggressive entity that frequently invades the venous system. We evaluated the morbidity and survival of patients with tumor thrombus who undergo cytoreductive nephrectomy. Materials and methods: We identified 56 patients from our institution’s database who had a primary renal tumor in place and documented metastases at the time of surgery. We reviewed demographic and pathologic characteristics from these patients as well as complications and overall survival. Results: Median age was 58 (37–77). There were 33 patients (59%) who had tumor thrombus with 21 (64%) involving the renal vein, 10 (30%) involving the infradiaphragmatic inferior vena cava (IVC), and 2 (6%) involving the supradiaphragmatic IVC. Median tumor size for thrombus patients was 12 cm (5–29). There were 8 (14.2%) who had complications, including 1 death. Thrombus patients were significantly more likely to have a complication (P = 0.008). Median survival for all patients was 10.7 months (0.3–61). There was no significant difference in overall survival between patients with and without thrombus (P = 0.76). Conclusions: Patients who undergo cytoreductive nephrectomy with a tumor thrombus have a higher rate of complications as compared to patients undergoing cytoreductive nephrectomy without tumor thrombus. The long-term survival, however, was not statistically different and thus aggressive surgery for select metastatic RCC patients is warranted.

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.

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    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.

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