title: Cytoreductive Nephrectomy for Renal Cell Carcinoma with Venous Tumor Thrombus.
abstract: Careful selection is critical to identify those with metastatic renal cell carcinoma who are most likely to benefit from cytoreductive nephrectomy. Surgery in patients who have metastatic renal cell carcinoma with tumor thrombus is complex and may not benefit some patients with poor overall survival. We evaluated whether preoperative variables or risk stratification systems could predict overall survival following cytoreductive nephrectomy.
  
  
  
  Prognostic factors for overall survival after surgery were evaluated in patients who had metastatic renal cell carcinoma with venous tumor thrombus at 5 institutions from 2000 to 2014. Prognostic variables, including metastatic renal cell carcinoma risk models, were evaluated for associations with overall survival. Multivariable analysis was used to determine independent associations of preoperative variables with overall survival.
  
  
  
  A total of 427 patients with metastatic renal cell carcinoma were identified with tumor thrombus. Patients with inferior vena cava thrombus above the diaphragm had shorter median overall survival vs those with renal vein only thrombus (9.2 months, IQR 4.2-30.8, vs 21.7, IQR 7.7-42.8, p = 0.0165). Individual risk factors from prognostic models were evaluated among other preoperative characteristics for associations with overall survival in 122 patients (32%) who died within 270 days of surgery. Independent predictors of overall survival included lactate dehydrogenase greater than the upper limit of normal (p = 0.003), systemic symptoms (p = 0.003), inferior vena cava thrombus above the diaphragm (p = 0.02) and sarcomatoid features (p = 0.005).
  
  
  
  Poor overall survival following cytoreductive nephrectomy in patients with metastatic renal cell carcinoma with tumor thrombus is associated with inferior vena cava thrombus above the diaphragm, poor risk group, systemic symptoms or sarcomatoid dedifferentiation. Patients with expected poor overall survival should be considered for preoperative systemic therapy clinical trials.
authors.affiliation: Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. Electronic address: abel@urology.wisc.edu.
authors.forename: E Jason
authors.initials: EJ
authors.lastname: Abel
authors.affiliation: Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida.
authors.forename: Philippe E
authors.initials: PE
authors.lastname: Spiess
authors.affiliation: Department of Urology, University of Texas Southwest Medical Center, Dallas, Texas.
authors.forename: Vitaly
authors.initials: V
authors.lastname: Margulis
authors.affiliation: Department of Urology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Viraj A
authors.initials: VA
authors.lastname: Master
authors.affiliation: Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
authors.forename: Michael
authors.initials: M
authors.lastname: Mann
authors.affiliation: Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida.
authors.forename: Kamran
authors.initials: K
authors.lastname: Zargar-Shoshtari
authors.affiliation: Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, Texas.
authors.forename: Leonardo D
authors.initials: LD
authors.lastname: Borregales
authors.affiliation: Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida.
authors.forename: Wade J
authors.initials: WJ
authors.lastname: Sexton
authors.affiliation: Department of Urology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Datta
authors.initials: D
authors.lastname: Patil
authors.affiliation: Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, Texas.
authors.forename: Surena F
authors.initials: SF
authors.lastname: Matin
authors.affiliation: Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, Texas.
authors.forename: Christopher G
authors.initials: CG
authors.lastname: Wood
authors.affiliation: Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, Texas.
authors.forename: Jose A
authors.initials: JA
authors.lastname: Karam
mesh_terms: D000368:Aged; D002292:Carcinoma, Renal Cell / Q000097:blood / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D065426:Cytoreduction Surgical Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D007668:Kidney / Q000098:blood supply / Q000000981:diagnostic imaging / Q000473:pathology; D007680:Kidney Neoplasms / Q000097:blood / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D007770:L-Lactate Dehydrogenase / Q000097:blood; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness / Q000473:pathology; D009392:Nephrectomy / Q000379:methods*; D018579:Patient Selection; D057234:Preoperative Period; D011379:Prognosis; D012082:Renal Veins / Q000000981:diagnostic imaging / Q000601:surgery; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D017131:Thrombectomy / Q000379:methods*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014682:Vena Cava, Inferior / Q000000981:diagnostic imaging / Q000601:surgery; D020246:Venous Thrombosis / Q000097:blood / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*
chemical_list: D007770:L-Lactate Dehydrogenase
keywords: carcinoma; inferior; mortality; neoplasm metastasis; renal cell; thrombosis; vena cava