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Mata M, Tabbara MM, Alvarez A, González J, Ciancio G. Renal cell carcinoma with an "uncoiling" tumor thrombus: intraoperative shift from level III to level IV. World J Surg Oncol 2024; 22:76. [PMID: 38454471 PMCID: PMC10918875 DOI: 10.1186/s12957-024-03355-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 02/26/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND The gold standard treatment for renal cell carcinoma (RCC) with tumor thrombus (TT) is complete surgical excision. The surgery is complex and challenging to the surgeon, especially with large tumor thrombus extending into the inferior vena cava (IVC) and right atrium. Traditionally, these difficult cases required the use of cardiopulmonary bypass (CPB) with or without deep hypothermic cardiac arrest, but in recent years, different surgical techniques derived from the field of liver transplantation have been used in efforts to avoid CPB. CASE PRESENTATION We present a case of RCC with TT level IIIc (extending above major hepatic veins) that "uncoiled" intraoperatively into the right atrium after division of the IVC ligament, transforming into a level IV TT. Despite the new TT extension, the surgery was successfully completed exclusively through an abdominal approach without CPB and while using intraoperative transesophageal echocardiography (TEE) monitoring and a cardiothoracic team standby. CONCLUSIONS This case highlights the need for a multidisciplinary approach and the utility of intraoperative continous TEE monitoring which helped to visualize the change of the TT venous extension, allowing the surgical teamto modify their surgical approach as needed avoiding a catastrophic event.
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Affiliation(s)
- Marina Mata
- Department of Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
- Unidad de Cirugia Renal, Trasplante e Investigación, Hospital Ramón y Cajal, Madrid, Spain
| | - Marina M Tabbara
- Department of Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - Angel Alvarez
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - Javier González
- Servicio de Urología, Unidad de Trasplante Renal, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Gaetano Ciancio
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA.
- Department of Surgery and Urology, University of Miami Miller School of Medicine, 1801 NW 9th Ave, 7th Floor, Miami, FL, 33136, USA.
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Current Approaches in Surgical and Immunotherapy-Based Management of Renal Cell Carcinoma with Tumor Thrombus. Biomedicines 2023; 11:biomedicines11010204. [PMID: 36672712 PMCID: PMC9855836 DOI: 10.3390/biomedicines11010204] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/06/2023] [Accepted: 01/10/2023] [Indexed: 01/15/2023] Open
Abstract
Renal cell carcinoma (RCC) accounts for 2-3% of all malignant disease in adults, with 30% of RCC diagnosed at locally advanced or metastatic stages of disease. A form of locally advanced disease is the tumor thrombus (TT), which commonly grows from the intrarenal veins, through the main renal vein, and up the inferior vena cava (IVC), and rarely, into the right cardiac chambers. Advances in all areas of medicine have allowed increased understanding of the underlying biology of these tumors and improved preoperative staging. Although the development of several novel system agents, including several clinical trials utilizing immune checkpoint inhibitors and combination therapies, has been shown to lower perioperative morbidity and increase post-operative recurrence-free and progression-free survival, surgery remains the mainstay of therapy to achieve a cure. In this review, we provide a description of specific surgical approaches and techniques used to minimize intra- and post-operative complications during radical nephrectomy and tumor thrombectomy of RCC with TT extension of various levels. Additionally, we provide an in-depth review of the major developments in neoadjuvant and adjuvant immunotherapy-based treatment and the impact of ongoing and recently completed clinical trials on the surgical treatment of advanced RCC.
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Zhu AH, Hou XY, Tian S, Zhang WF. Diagnostic value of 18F-FDG PET/CT versus contrast-enhanced MRI for venous tumour thrombus and venous bland thrombus in renal cell carcinoma. Sci Rep 2022; 12:587. [PMID: 35022440 PMCID: PMC8755813 DOI: 10.1038/s41598-021-04541-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/20/2021] [Indexed: 11/09/2022] Open
Abstract
The purpose of this study was to compare the ability of 18F-FDG PET/CT and contrast-enhanced MRI (CEMRI) to detect and grade venous tumour thrombus (VTT) and venous bland thrombus (VBT) in RCC and assess invasion of the venous wall by VTT. The PET/CT and CEMRI data of 41 patients with RCC were retrieved. The difference in maximum standardized uptake value (SUVmax) between VTT and VBT was analysed. According to their pathological diagnosis, the patients were divided into those with and without venous wall invasion. The PET/CT and CEMRI features, including the SUVmax of the primary lesion and VTT, maximum venous diameter, complete occlusion of the vein by VTT, and VTT morphology, were compared between the two groups. All 41 patients had VTT, and eleven of the 41 patients had VBT. The mean SUVmax of the VTT (6.33 ± 4. 68, n = 41) was significantly higher than that of the VBT (1.37 ± 0.26, n = 11; P < 0.001). Ten of the 11 cases of VBT were correctly diagnosed by 18F-FDG PET/CT, and all 11 were diagnosed by CEMRI. Both 18F-FDG PET/CT and CEMRI can effectively detect VTT and distinguish VTT from VBT. 18F-FDG PET/CT is less effective in grading VTT than CEMRI. Complete venous occlusion by VTT indicates venous wall invasion.
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Affiliation(s)
- An-Hui Zhu
- Department of Nuclear Medicine, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China
| | - Xiao-Yan Hou
- Department of Nuclear Medicine, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China
| | - Shuai Tian
- Department of Radiology, Peking University Third Hospital, Beijing, 100191, China
| | - Wei-Fang Zhang
- Department of Nuclear Medicine, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China.
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Chaud F, Tucci S, Bassetto S, Reis RBD, Rodrigues AJ, Vicente WVDA, Evora PRB. Right Atrium Tumor Extension Through the Inferior Vena Cava. Considerations About Nine Cases Operated Under Cardiopulmonary Bypass. Braz J Cardiovasc Surg 2019; 34:723-728. [PMID: 31545579 PMCID: PMC6894024 DOI: 10.21470/1678-9741-2019-0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Adrenocortical and renal cell carcinomas rarely invade the right atrium (RA). These neoplasms need surgical treatment, are very aggressive and have poor prognostic and surgical outcomes. Case series We present a retrospective cohort of nine cases of RA invasion through the inferior vena cava (four adrenocortical carcinomas and five renal cell carcinomas). Over 13 years (2002-2014), nine patients were operated in collaboration with the team of urologists. Surgery was possible in all patients with different degrees of technical difficulty. All patients were operated considering the imaging examinations with the aid of CPB. In all reported cases (renal or suprarenal), the decision to use CPB with deep hypothermic circulatory arrest (DHCA) on surgical strategy was decided by the team of urological and cardiac surgeons. Conclusion Data retrospectively collected from patients of public hospitals reaffirm: 1) Low incidence with small published series; 2) The selected cases did not represent the whole historical casuistry of the hospital, since they were selected after the adoption of electronic documentation; 3) Demographic data and references reported in the literature were presented as tables to avoid wordiness; 4) The series highlights the propensity to invade the venous system; 5) Possible surgical treatment with the aid of CPB in collaboration with the urology team; 6) CPB with DHCA is a safe and reliable option; 7) Poor prognosis with disappointing late results, even considering the adverse effects of CPB on cancer prognosis are expected but not confirmed.
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Affiliation(s)
- Fernando Chaud
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto Department of Pathology Ribeirão Preto SP Brazil Department of Pathology, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Silvio Tucci
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto Department of Surgery and Anatomy Ribeirão Preto SP Brazil Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Solange Bassetto
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto Department of Surgery and Anatomy Ribeirão Preto SP Brazil Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Rodolfo Borges Dos Reis
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto Department of Surgery and Anatomy Ribeirão Preto SP Brazil Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Alfredo José Rodrigues
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto Department of Surgery and Anatomy Ribeirão Preto SP Brazil Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Walter Vilella de Andrade Vicente
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto Department of Surgery and Anatomy Ribeirão Preto SP Brazil Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Paulo Roberto Barbosa Evora
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto Department of Surgery and Anatomy Ribeirão Preto SP Brazil Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
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Xiao X, Zhang L, Chen X, Cui L, Zhu H, Pang D, Yang Y, Wang Q, Wang M, Gao C. Surgical Management of Renal Cell Carcinoma Extending Into Venous System: A 20-Year Experience. Scand J Surg 2017; 107:158-165. [PMID: 29141518 DOI: 10.1177/1457496917738922] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS The purpose of this study is to report our 20-year experience with the surgical management of renal cell carcinoma extending into the inferior vena cava using a novel classification system. MATERIALS AND METHODS We retrospectively reviewed the data of 103 patients (69 males, 34 females, mean age: 52.9 ± 12.6 years) with renal cell carcinoma involving the venous system treated between 1993 and 2014. The inferior vena cava tumor thrombus was classified into five levels: 0 (renal vein, n = 12), 1 (infrahepatic, n = 33), 2a (low retrohepatic, n = 26), 2b (high retrohepatic, n = 19), and 3 (supradiaphragmatic, n = 13). Clinical data were summarized, and overall survival, cancer-specific survival, and disease-free survival were examined by Cox regression analysis. RESULTS All patients underwent radical surgery. Complete resections of the renal tumor and thrombus were achieved in 101 patients (98.1%). Two intraoperative and one postoperative in-hospital deaths (2.9%) occurred. In total, 19 patients (18.8%) had a total of 29 postoperative complications. Mean follow-up time was 46 months (range, 1-239 months). The 5- and 10-year overall survival rates were 62.9% and 56.0%, respectively. Metastasis, rather than thrombus level, was a significant risk factor associated with overall survival (hazard ratio = 4.89, 95% confidence interval: 2.24-10.67, p < 0.001). CONCLUSION Our novel classification system can be used to select the optimal surgical approach and method for patients with renal cell carcinoma and venous thrombus. Its use is associated with prolonged survival and relatively few complications. Metastasis is an independent risk factor of overall survival.
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Affiliation(s)
- X Xiao
- 1 Department of Urology, General Hospital of Chinese People's Armed Police Forces, Beijing, China.,2 Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - L Zhang
- 2 Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - X Chen
- 1 Department of Urology, General Hospital of Chinese People's Armed Police Forces, Beijing, China
| | - L Cui
- 3 Department of Urology, General Hospital of Civil Aviation Administration of China, Beijing, China
| | - H Zhu
- 1 Department of Urology, General Hospital of Chinese People's Armed Police Forces, Beijing, China
| | - D Pang
- 1 Department of Urology, General Hospital of Chinese People's Armed Police Forces, Beijing, China
| | - Y Yang
- 2 Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Q Wang
- 4 Department of Cardiac Surgery, General Hospital of Chinese People's Armed Police Forces, Beijing, China
| | - M Wang
- 5 Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, China
| | - C Gao
- 6 Department of Cardiac Surgery, Chinese PLA General Hospital, Beijing, China
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Fukushima S, Uemura M, Gotoh K, Ujike T, Wada H, Miyagawa S, Toda K, Sawa Y. Xeno-pericardial patch repair of the inferior vena cava for radical resection of renal cell carcinoma with tumor thrombus. J Surg Oncol 2017; 116:775-782. [PMID: 28608432 PMCID: PMC5724493 DOI: 10.1002/jso.24709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 05/13/2017] [Indexed: 01/24/2023]
Abstract
Background and Objectives For tumor thrombus in the inferior vena cava (IVC) complicated with kidney cancer, we built a surgical team to achieve (1) en bloc tumor resection; (2) xeno‐pericardial patch IVC repair; and (3) minimum organ damages. We reviewed outcome of the case series to verify rationale of this approach. Methods A consecutive series of 12 patients having the IVC tumor thrombus by renal cell carcinoma in the last 3 years was enrolled. Minimum kidney ischemia was induced in five cases (Procedure I), whereas liver and kidney ischemia was induced in five cases (Procedure II). Mild hypothermic extracorporeal circulation was used in two cases (Procedure III). Results There was no mortality or severe morbidities related to the surgery. Postoperative recovery was most prompt by the Procedure I. Liver and kidney ischemic time was longer in the Procedure III than the Procedure II, whereas organ function was not substantially impaired in either series. The resected IVC margin was free from the cancer in all cases, while local recurrence was not seen in any cases. Conclusions En bloc resection with xeno‐pericardial patch repair of the IVC was successfully performed in the tumor thrombus complicated with kidney cancer with minimum organ damage.
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Affiliation(s)
- Satsuki Fukushima
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Motohide Uemura
- Department of Urology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kunihito Gotoh
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takeshi Ujike
- Department of Urology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hiroshi Wada
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Spelde A, Steinberg T, Patel PA, Garcia H, Kukafka JD, MacKay E, Gutsche JT, Frogel J, Fabbro M, Raiten JM, Augoustides JGT. Successful Team-Based Management of Renal Cell Carcinoma With Caval Extension of Tumor Thrombus Above the Diaphragm. J Cardiothorac Vasc Anesth 2017; 31:1883-1893. [PMID: 28502456 DOI: 10.1053/j.jvca.2017.02.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Indexed: 12/24/2022]
Affiliation(s)
- Audrey Spelde
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Toby Steinberg
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Harry Garcia
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jeremy D Kukafka
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Emily MacKay
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan Frogel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael Fabbro
- Cardiothoracic Anesthesiology, Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Jessie M Raiten
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Gerstein NS, Zhang R, Davis MS, Ram H. Lessons Still Being Learned: Acute Pulmonary Tumor Embolus During Renal Cell Carcinoma Resection. ACTA ACUST UNITED AC 2017; 7:172-176. [PMID: 27552241 DOI: 10.1213/xaa.0000000000000378] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Renal cell carcinoma (RCC) is the most common primary renal neoplasm and is associated with the intraluminal growth into the venous system with possible extension into the inferior vena cava or even right heart. Intraoperative pulmonary embolism is a complication of resection of RCC, which may be mitigated by the use of the cardiopulmonary bypass with or without deep hypothermic circulatory arrest. We present a case of unexpected pulmonary embolism diagnosed during RCC surgery. The case highlights the central importance of intraoperative transesophageal echocardiography use and the need for proper preoperative planning for the use of cardiopulmonary bypass.
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Affiliation(s)
- Neal S Gerstein
- From the *Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico; and †Division of Urology, Department of Surgery, University of New Mexico, Albuquerque, New Mexico
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Psutka SP, Leibovich BC. Management of inferior vena cava tumor thrombus in locally advanced renal cell carcinoma. Ther Adv Urol 2015; 7:216-29. [PMID: 26445601 PMCID: PMC4580091 DOI: 10.1177/1756287215576443] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The diagnosis of renal cell carcinoma is accompanied by intravascular tumor thrombus in up to 10% of cases, of which nearly one-third of patients also have concurrent metastatic disease. Surgical resection in the form of radical nephrectomy and caval thrombectomy represents the only option to obtain local control of the disease and is associated with durable oncologic control in approximately half of these patients. The objective of this clinical review is to outline the preoperative evaluation for, and operative management of patients with locally advanced renal cell carcinoma with venous tumor thrombi involving the inferior vena cava. Cornerstones of the management of these complex patients include obtaining high-quality imaging to characterize the renal mass and tumor thrombus preoperatively, with further intraoperative real-time evaluation using transesophageal echocardiography, careful surgical planning, and a multidisciplinary approach. Operative management of patients with high-level caval thrombi should be undertaken in high-volume centers by surgical teams with capacity for bypass and invasive intraoperative monitoring. In patients with metastatic disease at presentation, cytoreductive nephrectomy and tumor thrombectomy may be safely performed with simultaneous metastasectomy if possible. In the absence of level one evidence, neoadjuvant targeted therapy should continue to be viewed as experimental and should be employed under the auspices of a clinical trial. However, in patients with significant risk factors for postoperative complications and mortality, and especially in those with metastatic disease, consultation with medical oncology and frontline targeted therapy may be considered.
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Affiliation(s)
| | - Bradley C Leibovich
- Department of Urology, Mayo Clinic, 200 First Street SW, Gonda 7, Rochester, MN 55905, USA
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