546 PROGNOSIS VALUE OF RENAL VEIN (RV) AND INFERIOR VENA CAVA (IVC) INVOLVEMENT IN RENAL CELL CARCINOMA (RCC)

IVC Thrombectomy in Renal Cell Carcinoma-Analysis of Out Come Data of 100 Patients and Review of Literature

To review our experience of RCC with IVC thrombus in terms of clinical presentation, principles of surgical management in contemporary era, also an impact of clinico-pathological factors on prognosis. Total 100 patients who underwent radical nephrectomy and IVC thrombectomy between 1991-2008 were included in this retrospective analysis. Data was analysed in terms of clinical pathological factors, survivals and compared with contemporary literature. The extent tumour thrombus was infrahepatic in 58 retro hepatic in 28 and suprahepatic in 14 patients including 6 with right atrial thrombus. The immediate postoperative mortality was 2% and incidence of major postoperative non fatal complications was 38%, which were managed conservatively. The overall and disease free 5 year survival was 63% and 55%. Further amongst the histological types, patients with clear cell tumours had the best (DFS- 71.42%), and those with papillary had the poor (DFS- 30.76%) outcome. Grade II tumors had better survivals as compared to grade IV (DFS 75.39% vs 23.52%, p < 0.05). Loco- regional extent wise 74% patients without perinephric fat invasion were free from disease at 5 years as compared to 30% of those who had perinephric fat invasion (p < 0.01). Similarly 5 year DFS was 76.11% in patients with negative nodes as compared to 12% in positive nodes (p < 0.01). In conclusion radical nephrectomy with IVC thrombectomy still remains the most effective therapeutic option in management in this clinical setting. Although this is complicated surgery success with multi disciplinary approach excellent survival outcome can be obtained. Further pathological factors, such as loco-regional spread and grade of tumor, rather than clinical factors influence long term survival.

Analysis of renal cell carcinoma with subdiaphragmatic macroscopic venous invasion (T3b)

OBJECTIVE

To review our institutional experience of surgery for renal cell carcinoma (RCC) with subdiaphragmatic macroscopic venous invasion (T3b) and to assess variables associated with cancer-specific survival (CSS), as the stratification of RCC with venous involvement (T3b and T3c) is subject to debate.

PATIENTS AND METHODS

We retrospectively reviewed the hospital records of patients who underwent a radical nephrectomy with resection of subdiaphragmatic tumour thrombus (T T) between October 1990 and May 2006. The log-rank and Cox uni- and multivariate regression analysis were used to evaluate predictive factors for CSS.

RESULTS

In all, 101 cases were identified. In the N0M0 group, univariate Cox regression analysis confirmed that ipsilateral adrenal gland invasion, Mayo Clinic level of T T, histological subtype and fat invasion were significantly associated with worse CSS. In multivariate Cox regression analysis, only Mayo Clinic level of T T was an independent predictor for CSS. In the subgroup with renal vein involvement only, the median CSS was not reached. In the subgroups with level I, II and III T T involvement, the median CSS was 69, 26 and 21 months, respectively. In the N+ and/or M+ group, only tumour size and type were independent predictors of CSS, while the level of T T was not. Radical nephrectomy yielded poor results with a median CSS of 13 months.

CONCLUSION

The Mayo Clinic level of T T is an independent prognostic predictor for CSS in non-metastatic T3b RCC. We strongly support the need for re-classification of the currently applied 2002 Tumour-Node-Metastasis staging system, which in its present form does not discriminate between levels of subdiaphragmatic venous invasion.

A critical analysis of surgery for kidney cancer with vena cava invasion

OBJECTIVE

Patients with kidney cancer with venous system involvement are at high risk of cancer recurrence even after the tumor thrombus is successfully removed. This review analyzes the impact on prognosis of the level of involvement of the inferior vena cava (IVC) in renal cell carcinoma (RCC).

METHODS

A literature search was done and relevant papers were reviewed. Relatively recent papers as well as large series or papers from expert centers are included in the reference list.

RESULTS

Venous invasion in RCC is a major challenge for urologists and patients with venous involvement have a worse prognosis. Although successful removal of a tumor thrombus in the renal vein and IVC may result in improved long-term survival in more than half of the affected patients, a higher level of thrombus appears to be a bad prognosticator for cancer recurrence. A complete IVC thrombectomy, even in the metastatic setting, provides a better quality of life and may prolong survival.

CONCLUSIONS

Because surgery still remains the most effective therapeutic option in patients wtih RCC, every attempt should be made to completely remove the IVC thrombus. New targeted agents could be promising as adjuvant therapy in this subset of patients.