Surgical complexity and prognostic outcome of small volume renal cell carcinoma with high-level venous tumor thrombus and large volume renal cell carcinoma with low-level thrombus

Abstract

Background:Radical nephrectomy with thrombectomy is one of the most difficult and complicated urological operations. But the roles of renal tumor volume and thrombus level in surgical complexity and prognostic outcome are not clear. This study aimed to evaluate the surgical complexity and prognostic outcome between the volume of renal cell carcinoma (RCC) and the level of venous tumor thrombus.Methods:The clinical data of 67 RCC cases with renal vein or inferior vena cava (IVC) tumor thrombus from January 2015 to May 2018 were retrospectively analyzed. Among these 67 cases, 21 (31.3%) were small tumors with high-level thrombus (tumor ≤7 cm in diameter and thrombus Neves Level II–IV), while 46 (68.7%) were large tumors with low-level thrombus group (tumor >7 cm in diameter and thrombus Level 0–I). Clinical features, operation details, and pathology data were collected. Univariable and multivariable logistic regression analyses were applied to evaluate the risk factors for small tumor with high-level thrombus.Results:Patients with small tumors and high-level thrombus were more likely to have longer operative time (421.9 ± 135.1 min vs. 282.2 ± 101.9 min, t = 4.685, P < 0.001), more surgical bleeding volume (1200 [325, 2900] mL vs. 500 [180, 1000] mL, U = 270.000, P = 0.004), more surgical blood transfusion volume (800 [0, 1400] mL vs. 0 [0, 800] mL, U = 287.500, P = 0.004), more plasma transfusion volume (0 [0, 800] mL vs. 0 [0, 0] mL, U = 319.000, P = 0.004), higher percentage of open operative approach (76.2% vs. 32.6%, χ2 = 11.015, P = 0.001), higher percentage of IVC resection (33.3% vs. 0%, χ2 = 17.122, P < 0.001), and higher percentage of post-operative complications (52.4% vs. 19.6%, χ2 = 7.415, P = 0.010) than patients with large tumors and low-level thrombus. In multivariate analysis, decreased hemoglobin (Hb) (odds ratio [OR]: 0.956, 95% confidence interval [CI]: 0.926–0.986, P = 0.005) and non-sarcomatoid differentiation (OR: 0.050, 95% CI: 0.004–0.664, P = 0.023) were more likely to form small tumors with high-level tumor thrombus rather than large tumor with small tumor thrombus. The estimated mean cancer-specific survival times of small tumor with high-level thrombus and large tumor with low-level thrombus were 31.6 ± 3.8 months and 32.5 ± 2.9 months, without statistical significance (P = 0.955). After univariate and multivariate Cox proportional hazard survival regression analyses, only distant metastasis (hazard ratio [HR]: 3.839, P = 0.002), sarcomatoid differentiation (HR: 7.923, P < 0.001), alkaline phosphatase (HR: 2.661, P = 0.025), and severe post-operative complications (HR: 10.326, P = 0.001) were independent predictors of prognosis.Conclusions:The level of the tumor thrombus was more important than the diameter of the primary kidney tumor in affecting the complexity of surgery. In the same T3 stage, neither the renal tumor diameter nor the tumor thrombus level was an independent risk factor for prognosis.

The Important Role of Tumor Volume In Surgical Approach Choice, Surgical Complexity, and Post-Operative Complications In Renal Cell Carcinoma With Venous Tumor Thrombus From A Large Chinese Center Experience

“…The latest version introduces nearly 1000 enhancements and bug xes for better performance and stability. This software has been used and cited in more than 443 publications and more than 36 pulmonary-speci c articles 14 . And to the best of our knowledge, the present study is the rst to perform a 3D volume measurement for patients with inferior vena cava tumor thrombus in locally advanced renal cell carcinoma.…”

Imaging predictors for assessment of inferior vena cava wall invasion in patients with renal cell carcinoma and inferior vena cava tumor thrombus: a retrospective study

“…[ 16 ] In light of the potential for major intra-operative complications, it is essential that more accurate pre-operative predictive models for megascopic invasion of the IVC wall requiring IVC resection are established to help surgeons overcome the challenges and select the best treatment strategies. [ 17 ] In this context, in the present study, imaging features of the VTT at the RVo and IVC were identified and measured by pre-operative imaging, and the features were used to predict whether IVC needed to be performed at the time of tumor thrombectomy for patients with a level I–IV thrombus. Specifically, an AP diameter of the VTT at the RVo of >17.0 mm and the presence of complete occlusion of the IVC were independently associated with a higher probability of IVC resection.…”

Laparoscopic conversion to open surgery in radical nephrectomy and tumor thrombectomy: causal analysis, clinical characteristics, and treatment strategies

“…4) Patients with right adrenal metastasis or tumor invasion underwent ipsilateral adrenalectomy. The operative procedures for the different tumor thrombus levels were as follows [10]: For Mayo level I, the IVC was exposed and partially occluded using Satinsky forceps. For Mayo level II, the distal end and proximal end of the IVC and the contralateral renal vein were exposed and occluded in sequence.…”