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

Abstract

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. OBJECTIVE 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. PATIENTS AND METHODS 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/m2 or BMI >30 kg/m2). Complications, blood loss, level of tumour thrombus, side of tumour and follow‐up data were tabulated. RESULTS Fifty‐six patients had a BMI ≤30 kg/m2 and 43 patients had a BMI >30 kg/m2. Intraoperative complications occurred in 14% of those with BMI >30 kg/m2 and 5.4% of those with a BMI ≤30 kg/m2 (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/m2 (P= 0.016). CONCLUSION 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.

Risk factors for recurrence after surgery in non‐metastatic RCC with thrombus: a contemporary multicentre analysis

“…Interestingly, higher BMI was associated with lower cancer mortality in several studies . It is important to note that the trend for better outcomes in patients with higher BMI is also evident in the present study, despite the technical challenges of nephrectomy with thrombectomy in patients with higher BMI. Preoperative haemoglobin level is also known to predict survival in patients with RCC after surgery or after diagnosis of metastatic disease , but anaemia has not been identified in previous studies evaluating RCC with venous invasion.…”

A proposal of post‐operative nomogram for overall survival in patients with renal cell carcinoma and venous tumor thrombus

“…The predictive role of level of tumor thrombus for oncologic outcomes is controversial. Previous published studies have reported adverse oncologic outcomes for patients with high‐level tumor thrombus, though there are also significant data proposing that IVC thrombus level is not a predictor of oncologic outcomes . The level of tumor thrombus is short of predictive significance in the present cohort.…”

“…Previous published studies have confirmed that patients with RCC accompanying tumor thrombus and metastases at surgery experience remarkably poor OS when compared to those with non‐metastatic disease. Presence of distant metastasis was also demonstrated to be an independent prognostic factor in multivariate analysis . Tumor Fuhrman grade and maximum width were also common prognosis predictors in patients with RCC and VTT .…”

Negative impact of papillary histological subtype in patients with renal cell carcinoma extending into the inferior vena cava: Single‐center experience

“…The median survival of the patients with papillary subtype was 5.2 months when those patients were positive for node or distant metastases. In general, node or distant metastases have been reported to be predictive factors for the poor prognosis . In addition, this extensive surgery is associated with a high mortality or morbidity rate.…”