Perioperative and oncologic outcome in patients treated for renal cell carcinoma with an extended inferior vena cava tumour thrombus level II-IV

Abstract

Purpose Surgical treatment of patients with renal cell carcinoma (RCC) and an extended tumour thrombus (TT) in the inferior vena cava (IVC) is challenging and often requires a multidisciplinary approach. The aim of this study was to analyse results in the real-world management of RCC patients with an extended IVC TT (level II-IV according to the Mayo classification of macroscopic venous invasion in RCC) in terms of pre-, peri- and postoperative outcome, complications and oncologic outcome.

Methods We investigated 61 patients with evidence of RCC and an extended TT in the IVC undergoing radical nephrectomy and tumour thrombectomy at our tertiary referral centre. Patients and operative characteristics were recorded and complications were analysed using the Clavien-Dindo classification. Follow-up data were retrieved by contacting the treating outpatient urologists, general practitioners and patients.

Results The TT level was II in 36, III in 8 and IV in 17 patients. Complications grade IIIb and higher according to the Clavien-Dindo classification occurred in n = 3 (8.4 %), n = 2 (25.0 %) and n = 5 (29.5 %) patients with level II, III and IV TT, respectively. The overall survival of patients with TT level II, III and IV at 24 months (60 months) was 66.9 % (41.6 %), 83.3 % (83.3 %) and 64.1 % (51.3 %). Presence of primary metastatic disease was the only significant independent predictor for OS. 

Conclusions Radical nephrectomy with tumour thrombectomy appears to be a feasible and effective treatment option in the management of patients with RCC and an extended IVC TT.

Zusammenfassung

Einleitung Die Behandlung von Patienten mit Nierenzellkarzinom (NZK) und extendiertem Tumorthrombus (TT) der Vena cava inferior (VCI) stellt eine Herausforderung dar und erfordert häufig ein multidisziplinäres Vorgehen. Das Ziel dieser Studie war es, die Behandlung von Patienten mit NZK und extendiertem VCI-TT (Level II–IV, gemäß der Mayo-Klassifikation) im Hinblick auf prä-, peri- und postoperative Ergebnisse, Komplikationen und onkologischem Ergebnis zu analysieren.

Methoden In einer retrospektiven Studie wurden 61 Patienten mit bildmorphologischem Nachweis eines NZK und TT (Level II-IV) in der VCI, die an unserem Zentrum einer radikalen Nephrektomie und Tumorthrombektomie unterzogen wurden, eingeschlossen. Prä-, peri-, und postoperative Parameter wurden erhoben und Komplikationen anhand der Clavien-Dindo-Klassifikation analysiert. Das Follow-up der Patienten wurde durch Kontaktaufnahme mit den behandelnden Urologen, Allgemeinärzten und Patienten durchgeführt.

Ergebnisse Das TT-Level betrug II bei 36, III bei 8 und IV bei 17 Patienten. Grad IIIb und höhere Komplikationen gemäß der Clavien-Dindo-Klassifikation traten bei 3 (8,4 %) mit TT Level II, 2 (25,0 %) mit TT Level III und 5 (29,5 %) Patienten mit TT Level IV auf. Das Gesamtüberleben für Patienten mit TT-Level II, III und IV nach 24 Monaten (60 Monaten) betrug 66,9 % (41,6 %), 83,3 % (83,3 %) und 64,1 % (51,3 %). Das Vorliegen einer primären metastasierten Erkrankung war der einzige signifikante unabhängige Prädiktor für das Gesamtüberleben.

Schlussfolgerung Die radikale Nephrektomie mit Tumorthrombektomie scheint eine praktikable und wirksame Behandlungsoption bei der Behandlung von Patienten mit NZK und extendiertem VCI-TT zu sein.

Keywords

RCC - renal cell carcinoma - IVC - inferior vena cava - tumour thrombus

Schlüsselwörter

Nierenzellkarzinom - Cavazapfen - Operative Therapie

^* contributed equally

Publication History

Article published online:
04 June 2019

• References

• 1 Ljungberg B, Bensalah K, Canfield S. et al. EAU guidelines on renal cell carcinoma: 2014 update. Eur Urol 2015; 67: 913-924
• 2 Hatcher PA, Anderson EE, Paulson DF. et al. Surgical management and prognosis of renal cell carcinoma invading the vena cava. J Urol 1991; 145: 20-23
• 3 Neves RJ, Zincke H. Surgical treatment of renal cancer with vena cava extension. Br J Urol 1987; 59: 390-395
• 4 Klatte T, Pantuck AJ, Riggs SB. et al. Prognostic factors for renal cell carcinoma with tumor thrombus extension. J Urol 2007; 178: 1189-1195
• 5 Wagner B, Patard JJ, Mejean A. et al. Prognostic value of renal vein and inferior vena cava involvement in renal cell carcinoma. Eur Urol 2009; 55: 452-459
• 6 Nesbitt JC, Soltero ER, Dinney CP. et al. Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus. Ann Thorac Surg 1997; 63: 1592-1600
• 7 Skinner DG, Pritchett TR, Lieskovsky G. et al. Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 1989; 210: 387-392
• 8 Kaplan S, Ekici S, Dogan R. et al. Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus. Am J Surg 2002; 183: 292-299
• 9 Bissada NK, Yakout HH, Babanouri A. et al. Long-term experience with management of renal cell carcinoma involving the inferior vena cava. Urology 2003; 61: 89-92
• 10 Moinzadeh A, Libertino JA. Prognostic significance of tumor thrombus level in patients with renal cell carcinoma and venous tumor thrombus extension. Is all T3b the same?. J Urol 2004; 171: 598-601
• 11 Kirkali Z, Van Poppel H. A critical analysis of surgery for kidney cancer with vena cava invasion. Eur Urol 2007; 52: 658-662
• 12 Haferkamp A, Bastian PJ, Jakobi H. et al. Renal cell carcinoma with tumor thrombus extension into the vena cava: prospective long-term followup. J Urol 2007; 177: 1703-1708
• 13 Zisman A, Wieder JA, Pantuck AJ. et al. Renal cell carcinoma with tumor thrombus extension: biology, role of nephrectomy and response to immunotherapy. J Urol 2003; 169: 909-916
• 14 Rigaud J, Hetet JF, Braud G. et al. Surgical care, morbidity, mortality and follow-up after nephrectomy for renal cancer with extension of tumor thrombus into the inferior vena cava: retrospective study since 1990s. Eur Urol 2006; 50: 302-310
• 15 Yap SA, Horovitz D, Alibhai SM. et al. Predictors of early mortality after radical nephrectomy with renal vein or inferior vena cava thrombectomy - a population-based study. BJU Int 2012; 110: 1283-1288
• 16 Dellaportas D, Arkadopoulos N, Tzanoglou I. et al. Technical Intraoperative Maneuvers for the Management of Inferior Vena Cava Thrombus in Renal Cell Carcinoma. Front Surg 2017; 4: 48
• 17 Facciuto ME, Singh MK, Rocca JP. et al. Benefits of liver transplantation surgical techniques in the management of extensive retroperitoneal tumors. World J Surg 2008; 32: 2403-2407
• 18 Ciancio G, Livingstone AS, Soloway M. Surgical management of renal cell carcinoma with tumor thrombus in the renal and inferior vena cava: the University of Miami experience in using liver transplantation techniques. Eur Urol 2007; 51: 988-994 ; discussion 994-985
• 19 Novick AC, Kaye MC, Cosgrove DM. et al. Experience with cardiopulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi. Ann Surg 1990; 212: 472-476
• 20 Peters I, Winkler M, Juttner B. et al. Neoadjuvant targeted therapy in a primary metastasized renal cell cancer patient leads to down-staging of inferior vena cava thrombus (IVC) enabling a cardiopulmonary bypass-free tumor nephrectomy: a case report. World J Urol 2014; 32: 245-248
• 21 Bigot P, Fardoun T, Bernhard JC. et al. Neoadjuvant targeted molecular therapies in patients undergoing nephrectomy and inferior vena cava thrombectomy: is it useful?. World J Urol 2014; 32: 109-114
• 22 Mejean A, Ravaud A, Thezenas S. et al. Sunitinib Alone or after Nephrectomy in Metastatic Renal-Cell Carcinoma. N Engl J Med 2018; 379: 417-427
• 23 Bex A, Albiges L, Ljungberg B. et al. Updated European Association of Urology Guidelines for Cytoreductive Nephrectomy in Patients with Synchronous Metastatic Clear-cell Renal Cell Carcinoma. Eur Urol 2018; 74: 805-809
• 24 Massari F, Di Nunno V, Gatto L. et al. Should CARMENA Really Change our Attitude Towards Cytoreductive Nephrectomy in Metastatic Renal Cell Carcinoma? A Systematic Review and Meta-Analysis Evaluating Cytoreductive Nephrectomy in the Era of Targeted Therapy. Target Oncol 2018;
• 25 Lardas M, Stewart F, Scrimgeour D. et al. Systematic Review of Surgical Management of Nonmetastatic Renal Cell Carcinoma with Vena Caval Thrombus. Eur Urol 2016; 70: 265-280
• 26 Blute ML, Leibovich BC, Lohse CM. et al. The Mayo Clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumour thrombus. BJU Int 2004; 94: 33-41
• 27 Orihashi K, Sueda T, Usui T. et al. Deep hypothermic circulatory arrest for resection of renal tumor in the inferior vena cava: beneficial or deleterious?. Circ J 2008; 72: 1175-1177
• 28 Tilki D, Nguyen HG, Dall'Era MA. et al. Impact of histologic subtype on cancer-specific survival in patients with renal cell carcinoma and tumor thrombus. Eur Urol 2014; 66: 577-583
• 29 Leibovich BC, Cheville JC, Lohse CM. et al. Cancer specific survival for patients with pT3 renal cell carcinoma-can the 2002 primary tumor classification be improved?. J Urol 2005; 173: 716-719
• 30 Martinez-Salamanca JI, Huang WC, Millan I. et al. Prognostic impact of the 2009 UICC/AJCC TNM staging system for renal cell carcinoma with venous extension. Eur Urol 2011; 59: 120-127
• 31 Ciancio G, Manoharan M, Katkoori D. et al. Long-term survival in patients undergoing radical nephrectomy and inferior vena cava thrombectomy: single-center experience. Eur Urol 2010; 57: 667-672
• 32 Ljungberg B, Stenling R, Osterdahl B. et al. Vein invasion in renal cell carcinoma: impact on metastatic behavior and survival. J Urol 1995; 154: 1681-1684