Prognostic benefit of surgical management in renal cell carcinoma patients with thrombus extending to the renal vein and inferior vena cava: 17-year experience at a single center

Shingo Hatakeyama, Takahiro Yoneyama, Itsuto Hamano, Hiromi Murasawa, Takuma Narita, Masaaki Oikawa, Kazuhisa Hagiwara, Daisuke Noro, Toshikazu Tanaka, Yoshimi Tanaka, Yasuhiro Hashimoto, Takuya Koie, Chikara Ohyama, Shingo Hatakeyama, Takahiro Yoneyama, Itsuto Hamano, Hiromi Murasawa, Takuma Narita, Masaaki Oikawa, Kazuhisa Hagiwara, Daisuke Noro, Toshikazu Tanaka, Yoshimi Tanaka, Yasuhiro Hashimoto, Takuya Koie, Chikara Ohyama

Abstract

Background: Management of renal cell carcinoma (RCC) with tumor thrombus extending to the renal vein and inferior vena cava (IVC) is challenging. The aim of this study was to evaluate the benefit of surgical management in such patients.

Methods: From February 1995 to February 2013, 520 patients were treated for RCC at Hirosaki University Hospital, Hirosaki, Japan. The RCC patients with tumor thrombus extending to the renal vein (n = 42) and IVC (n = 43) were included in this study. The records of these 85 patients were retrospectively reviewed to assess the relevant clinical and pathological variables and survival. Prognostic factors were identified by multivariate analysis. The benefit of surgical management was evaluated using propensity score matching to compare overall survival between patients who received surgical management and those who did not.

Results: RCC was confirmed by pathological examination of surgical or biopsy specimens in 74 of the 85 patients (87%). Sixty-five patients (76%) received surgical management (radical nephrectomy with thrombectomy). Distant metastasis was identified in 45 patients (53%). The proportion of patients with tumor thrombus level 0 (renal vein only), I, II, III, and IV was 49%, 13%, 18%, 14%, and 5%, respectively. The estimated 5-year overall survival rate was 70% in patients with thrombus extending to the renal vein and 23% in patients with thrombus extending to the IVC. Multivariate analysis identified thrombus extending to the IVC, presence of distant metastasis, surgical management, serum albumin concentration, serum choline esterase concentration, neutrophil-lymphocyte ratio, and Carlson comorbidity index as independent prognostic factors. In propensity score-matched patients, overall survival was significantly longer in those who received surgical management than those who did not.

Conclusions: Surgical management may improve the prognosis of RCC patients with thrombus extending to the renal vein and IVC.

Figures

Figure 1
Figure 1
Classification of tumor thrombus level according to the Mayo staging system. Level 0, thrombus extending to the renal vein; level I, thrombus extending into the IVC to no more than 2 cm above the renal vein; level II, thrombus extending into the IVC to more than 2 cm above the renal vein but not to the hepatic vein; level III, thrombus extending into the IVC to above the hepatic vein but not to the diaphragm; and level IV, thrombus extending into the supradiaphragmatic IVC or right atrium.
Figure 2
Figure 2
Management of enrolled patients. A total of 85 patients were enrolled in this study, including 42 in the RV group and 43 in the IVC group. Sixty-five patients underwent radical nephrectomy with thrombectomy and 20 did not undergo surgery.
Figure 3
Figure 3
Survival in the RV and IVC thrombus groups, according to surgical management and distant metastasis. (A) Overall survival in the RV thrombus and IVC thrombus groups. (B) In the RV thrombus group, survival was significantly longer in patients who received surgical management than those who did not. (C) In the RV thrombus group, distant metastasis was a powerful prognostic factor. (D) In the IVC thrombus group, thrombus level was not significantly correlated with overall survival. (E) In the IVC thrombus group, survival was significantly longer in patients who received surgical management than those who did not. (F) In the IVC thrombus group, distant metastasis was not a significant prognostic factor.
Figure 4
Figure 4
Overall survival curves, estimated median survival times, and estimated 5-year survival rates in pair-matched patients. Comparison of the 15 pairs of propensity score-matched patients suggests that surgical management may improve survival.

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