Oncologic outcomes following surgical resection of renal cell carcinoma with inferior vena caval thrombus extending above the hepatic veins: a contemporary multicenter cohort.
OBJECTIVE
Suprahepatic inferior vena caval tumor thrombus in renal cell carcinoma cases has historically portended a poor prognosis. With advances in perioperative treatment of patients with high level thrombus contemporary outcomes are hypothesized to be improved. We evaluated long-term oncologic outcomes of contemporary surgical treatment of patients with renal cell carcinoma in whom level III-IV inferior vena caval thrombus was managed at high volume centers.


METHODS
We examined clinical and pathological data on patients with renal cell carcinoma and level III-IV thrombus treated with surgery from January 2000 to June 2013 at 4 tertiary referral centers. Survival outcomes and associated prognostic variables were assessed by Kaplan-Meier and multivariate Cox regression analyses.


RESULTS
We identified 166 patients, including 69 with level III and 97 with level IV thrombus. Median postoperative followup was 27.8 months. Patients with no evidence of nodal or distant metastasis (pN0/X, M0) had 5-year 49.0% cancer specific survival and 42.2% overall survival. There was no difference in survival based on tumor thrombus level or pathological tumor stage. Variables associated with an increased risk of death from kidney cancer on multivariate analysis were regional nodal metastases (HR 3.94, p <0.0001), systemic metastases (HR 2.39, p = 0.01), tumor grade 4 (HR 2.25, p = 0.02), histological tissue necrosis (HR 3.11, p = 0.004) and increased preoperative serum alkaline phosphatase (HR 2.30, p = 0.006).


CONCLUSIONS
Contemporary surgical management achieves almost 50% 5-year survival in patients without metastasis who have renal cell carcinoma thrombus above the hepatic veins. Factors associated with increased mortality included nodal/distant metastases, advanced grade, histological necrosis and increased preoperative serum alkaline phosphatase. These findings support an aggressive surgical approach to the treatment of patients with renal cell carcinoma who have advanced tumor thrombus.
Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas.
Ahmed Q
AQ
Haddad
Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, Texas.
Christopher G
CG
Wood
Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
E Jason
EJ
Abel
Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Urology, University of Muenster Medical Center, Muenster, Germany.
Laura-Maria
LM
Krabbe
Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas.
Oussama M
OM
Darwish
Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, Minnesota.
R Houston
RH
Thompson
Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
Jennifer E
JE
Heckman
Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, Texas.
Megan M
MM
Merril
Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas.
Bishoy A
BA
Gayed
Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas.
Arthur I
AI
Sagalowsky
Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, Minnesota.
Stephen A
SA
Boorjian
Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas. Electronic address: vitaly.margulis@utsouthwestern.edu.
Vitaly
V
Margulis
Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, Minnesota.
Bradley C
BC
Leibovich
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002292:Carcinoma, Renal Cell / Q000150:complications / Q000401:mortality / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007680:Kidney Neoplasms / Q000150:complications / Q000401:mortality / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009360:Neoplastic Cells, Circulating; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D017131:Thrombectomy; D013997:Time Factors; D014481:United States / Q000453:epidemiology; D014682:Vena Cava, Inferior; D020246:Venous Thrombosis / Q000209:etiology* / Q000401:mortality / Q000601:surgery; D055815:Young Adult
carcinoma; inferior; kidney; mortality; renal cell; thrombosis; vena cava