title: Caval tumor thrombus volume influences outcomes in renal cell carcinoma with venous extension.
abstract: BACKGROUND
  Surgery for renal cell carcinoma with tumor thrombus has a high potential morbidity rate, and the current classification system based on proximal tumor thrombus level (TTL) has not been shown to consistently predict outcomes.
  
  
  OBJECTIVE
  To assess the prognostic value of inferior vena cava tumor thrombus volume (IVC-TV) for determining the perioperative complications as well as with survival end points.
  
  
  METHODS
  From June 2001 to June 2012, we identified 147 patients who underwent radical nephrectomy with venous thrombi. In total, 66 patients had IVC involvement and available imaging for review. IVC-TV was measured by cross-sectional area and height measurement for each axial slice. Linear, logistic models and Cox proportional hazard was used for analysis.
  
  
  RESULTS
  Median IVC-TV was 16.5 cm(3), and 18 patients had TTL≥III. In total, 57 Clavien I-V complications were documented in 32 patients including 3 deaths. On multivariate analysis, age>65 years, American Society of Anesthesiologists>3, and IVC-TV>15 cm(3) were independent predictors for perioperative complications. Disease progression (PoD) occurred in 78% of patients, and metastatic disease (hazard ratio [HR] = 3.33, P<0.01) and non-clear cell histology (HR = 2.98, P = 0.02) were independent predictors of PoD. Median time to death was 16 months (interquartile range: 5.2-42.9). On Cox regression analysis, metastatic disease, non-clear cell histology, IVC-TV>15 cm(3), and TTL III/IV were significantly associated with overall survival. As a preoperative variable, IVC-TV>15 cm(3) was shown to be an independent predictor of PoD (HR = 2.3, P = 0.01) and overall survival (HR = 2.21, P = 0.03).
  
  
  CONCLUSIONS
  IVC-TV has value as a prognostic indicator, which is superior to TTL in the setting of renal cell carcinoma with IVC venous thrombus.
authors.affiliation: Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL.
authors.forename: Kamran
authors.initials: K
authors.lastname: Zargar-Shoshtari
authors.affiliation: Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL.
authors.forename: Pranav
authors.initials: P
authors.lastname: Sharma
authors.affiliation: Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL.
authors.forename: Patrick
authors.initials: P
authors.lastname: Espiritu
authors.affiliation: Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL.
authors.forename: Tony
authors.initials: T
authors.lastname: Kurian
authors.affiliation: Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL.
authors.forename: Julio M
authors.initials: JM
authors.lastname: Pow-Sang
authors.affiliation: Anesthesiology, Tampa General Hospital, Tampa, FL.
authors.forename: Devanand
authors.initials: D
authors.lastname: Mangar
authors.affiliation: Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL.
authors.forename: Wade J
authors.initials: WJ
authors.lastname: Sexton
authors.affiliation: Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL. Electronic address: philippe.spiess@moffitt.org.
authors.forename: Philippe E
authors.initials: PE
authors.lastname: Spiess
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002292:Carcinoma, Renal Cell / Q000098:blood supply* / Q000473:pathology*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000098:blood supply* / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy; D011379:Prognosis; D016016:Proportional Hazards Models; D012372:ROC Curve; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D017131:Thrombectomy; D013927:Thrombosis / Q000175:diagnosis*; D016896:Treatment Outcome; D014682:Vena Cava, Inferior / Q000473:pathology
keywords: Complications; Inferior vena cava; Renal cell carcinoma; Survival; Thrombectomy