Prediction of Perioperative Death Following Surgery for Renal Cell Carcinoma with Vein Involvement: A Retrospective Study.
BACKGROUND
Advanced renal cell carcinoma (RCC) shows a propensity for extending into the tributaries of the renal veins, which poses a notable surgical challenge. In this study we addressed the question as to whether patients with RCC and vein involvement can be identified as having a significant risk of immediate death associated with surgery preoperatively.


METHODS
A total of 118 patients with RCC and vein involvement from February 1999 until November 2012 were evaluated. The association of early mortality within 60 days after the intervention was tested with various covariates including: age, body mass index (BMI), preoperative serum C-reactive protein, preoperative serum creatinine, preoperative hemoglobin level, tumor diameter, suspicion of metastasis on prior computed tomography, documented cardiac insufficiency, extent of vein invasion, prior myocardial infarction, TNM stage, American Society of Anesthesiologists score, New York Heart Association classification and Karnofsky index. A multiple logistic regression model was used to test all risk factors including the combination of an elevated BMI with an impaired Karnofsky index with all covariates.


RESULTS
A total of 17 patients died within 60 days after the operation with most patients dying from cardio-embolic complications during the first two quartiles of the observation, while later deaths were mostly attributable to sequelae of surgical complications. None of the tested risk factors were significantly associated with early mortality in the logistic regression model. The presence of an elevated BMI (≥30 kg/m(2)) in combination with a Karnofsky index ≤70% predicted early death in univariate (p = 0.006) and multivariate analysis (p = 0.023). Death rates for patients with BMI <30 kg/m(2) and Karnofsky index >70%, BMI ≥ 30 kg/m(2) or Karnofsky index ≤70%, BMI ≥30 kg/m(2) and Karnofsky index ≤70% were 5%, 14.8% and 37.5%, respectively.


CONCLUSIONS
The risk of early death is dramatically elevated to more than one-third of cases with elevated BMI and unfavorable Karnofsky index in patients with RCC and vein involvement. Patients need to be counseled in this regard especially when planning cytoreductive treatment without curative intent.
Department of Urology and Urological Oncology, Hannover University Medical School, Hannover, Germany. Akkoyun.Meryem@mh-hannover.de.
Meryem
M
Akkoyun
Department of Urology, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany. axel.merseburger@uksh.de.
Axel S
AS
Merseburger
Department of Urology and Urological Oncology, Hannover University Medical School, Hannover, Germany.
Mario W
MW
Kramer
Department of Urology and Urological Oncology, Hannover University Medical School, Hannover, Germany.
Thomas R
TR
Herrmann
Department of Urology and Urological Oncology, Hannover University Medical School, Hannover, Germany.
Markus A
MA
Kuczyk
Department of Urology and Urological Oncology, Hannover University Medical School, Hannover, Germany.
Christoph A
CA
von Klot
D000328:Adult; D000368:Aged; D015992:Body Mass Index; D002097:C-Reactive Protein / Q000032:analysis; D002292:Carcinoma, Renal Cell / Q000097:blood / Q000401:mortality / Q000473:pathology / Q000601:surgery; D015897:Comorbidity; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D007680:Kidney Neoplasms / Q000097:blood / Q000401:mortality / Q000473:pathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D009392:Nephrectomy / Q000009:adverse effects / Q000379:methods / Q000401:mortality; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality*; D012082:Renal Veins / Q000473:pathology*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D014057:Tomography, X-Ray Computed / Q000379:methods; D047368:Tumor Burden
D002097:C-Reactive Protein
Advanced renal cancer; Mortality; Radical nephrectomy; Risk factors; Tumor thrombus