Preoperative metastatic status, level of thrombus and body mass index predict overall survival in patients undergoing nephrectomy and inferior vena cava thrombectomy.

Departments of Genitourinary Oncology Biostatistics, Moffitt Cancer Center, Tampa, FL, USA.
BJU International (Impact Factor: 3.13). 04/2012; DOI: 10.1111/j.1464-410X.2012.11155.x
Source: PubMed

ABSTRACT Study Type - Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Little is known about the prognostic impact of body mass index (BMI) and obesity on patients with locally advanced kidney cancer. Previous studies suggest that clinical/pathological stage, the proximal extent of the tumour thrombus, direct vascular wall invasion, and preoperative performance status may all constitute important prognostic factors within this patient population. The present study shows that a patient's metastatic status, higher level of tumour thrombus, and lower BMI all constitute adverse predictors of overall survival in patients who have RCC with inferior vena cava tumour thrombus. OBJECTIVE: •  To determine which clinical variables, including body mass index (BMI), predict overall survival (OS) after nephrectomy with inferior vena cava (IVC) thrombectomy for renal cell carcinoma (RCC) with tumour thrombus. PATIENTS AND METHODS: •  After institutional review board approval, a retrospective analysis of all patients (N= 100) undergoing nephrectomy and IVC thrombectomy for RCC from 1989 to 2010 were reviewed. One patient was excluded owing to missing clinical information leaving 99 patients in the study cohort. •  Patients were placed into one of two subgroups, based on their preoperative BMI (BMI ≤30 kg/m(2) or BMI >30 kg/m(2) ). •  Complications, blood loss, level of tumour thrombus, side of tumour and follow-up data were tabulated. RESULTS: •  Fifty-six patients had a BMI ≤30 kg/m(2) and 43 patients had a BMI >30 kg/m(2) . Intraoperative complications occurred in 14% of those with BMI >30 kg/m(2) and 5.4% of those with a BMI ≤30 kg/m(2) (P= 0.171). •  On multivariate analysis, a higher thrombus level (III/IV vs I/II) and the presence of metastatic disease at time of diagnosis was associated with a worse OS (P= 0.041 and P < 0.001, respectively). •  The subgroup with a higher preoperative BMI had a significantly better OS (hazard ratio 0.42; 95% confidence interval 0.22-0.80, P= 0.009). •  Similarly, our Kaplan-Meier survival analysis showed an improved OS in the patient cohort with a BMI >30 kg/m(2) (P= 0.016). CONCLUSION: •  Important predictors of outcome in patients undergoing nephrectomy with IVC thrombectomy for RCC with tumour thrombus include preoperative BMI, level of IVC tumour thrombus, and metastatic status at time of surgery.

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    ABSTRACT: Background and Objectives To evaluate the impact of surgery on the prognosis of metastatic renal cell carcinoma (mRCC) with inferior vena cava (IVC) thrombus.Methods In this retrospective study, the medical records of 45 patients who presented with synchronous mRCC with IVC thrombus, between 2005 and 2012, were reviewed. Twenty-eight patients underwent radical nephrectomy with IVC thrombectomy followed by targeted therapy (group 1) and 17 received targeted therapy alone (group 2). Cox proportional hazards regression models served to estimate the prognostic significance of variables.ResultsThe median progression-free survival of group 1 and group 2 was 4.1 and 3.5 months, respectively (P = 0.672). Their median overall survival was 17.3 and 19.7 months, respectively (P = 0.353). Multivariate analysis revealed that non-clear cell type RCC (HR = 3.46, P = 0.007) and lymph node metastasis (HR = 2.31, P = 0.003) independently predicted progression-free survival, and Karnofsky performance status (HR = 3.82, P = 0.013) and non-clear cell type RCC (HR = 4.01, P = 0.003) independently predicted overall survival. Surgical resection of the primary renal mass with IVC thrombus did not affect the probability of progression or overall mortality.Conclusions Our limited data set would suggest a limited role for surgery in this patient population and that a prospective study in this group may define the role of surgery. J. Surg. Oncol. © 2014 Wiley Periodicals, Inc.
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    ABSTRACT: Supra-hepatic IVC tumor thrombus in RCC has historically portended a poor prognosis. With advances in perioperative management of patients with high level thrombi, contemporary outcomes are hypothesized to be improved. We evaluated long-term oncologic outcomes of contemporary surgical management of RCC patients with level III-IV IVC thrombi treated at high volume centers. Clinical and pathologic data of RCC patients with level III-IV thrombus who had surgery from January 2000-June 2013 at 4 tertiary referral centers was examined. Survival outcomes and associated prognostic variables were assessed with Kaplan-Meier and multivariable Cox-regression analyses. 166 patients were identified (69 with level III, and 97 with level IV thrombus). Median post-operative follow-up was 27.8 months. Patients with no evidence of nodal or distant metastases (pN0/X,M0) had 5-yr CSS and OS of 49.0% and 42.2% respectively. There were no differences in survival based on the level of tumor thrombus or pathologic tumor stage. Variables associated with increased risk of death from kidney cancer on multivariable 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), histologic tissue necrosis (HR 3.11,p=0.004), and elevated pre-operative serum alkaline phosphatase level (HR 2.30, p=0.006). Contemporary surgical management achieves nearly 50% 5-year survival in non-metastatic patients with RCC tumor thrombus above the hepatic veins. Factors associated with increased mortality included nodal/distant metastases, advanced grade, histologic necrosis and elevated pre-operative serum alkaline phosphatase. These findings support an aggressive surgical approach to the management of RCC patients with advanced tumor thrombi.
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    ABSTRACT: Inferior vena cava tumor thrombectomy requires experienced surgical teams due to complex hemodynamic considerations, often utilizing vascular bypass techniques that introduce additional risk. Control of the IVC within the pericardium obviates the need for cardiopulmonary bypass (CPB). We reviewed our experience with intrapericardial control during IVC tumor thrombectomy to evaluate perioperative outcomes and determine factors associated with overall survival. We completed a retrospective review of 87 patients who underwent nephrectomy with IVC tumor thrombectomy using intrapericardial IVC control from 1978-2012. This technique was performed in all cases of intrahepatic (n=43) and supradiaphragmatic (n=35) thrombi, and select cases of intra-atrial (n=9) thrombi. Patient demographics, operative variables, and post-operative outcomes were examined. Multivariate regression analysis was used to determine associations between clinical variables and overall survival. Perioperative mortality (30-day) was 9.2% and incidence of high-grade complications was 19.5%. Median survival was 3.1 years and 2.5 years for pT3bN0 and pT3cN0 patients, respectively. Extended regional lymphadenectomy, performed in all cases revealed nodal metastasis in 36% of patients. On multivariate analysis, ECOG >2 and pT3c stage were associated with worse survival. Histologic grade, perinephric fat invasion and presence of lymph node involvement were not associated with worse survival. Intrapericardial control of the IVC allows a single surgical team to safely perform tumor thrombectomy for intrahepatic and supradiaphragmatic thrombi, eliminating risk and morbidity related to CPB. Though supradiaphragmatic extent and ECOG >2 are associated with worse survival, complete resection with lymphadenectomy can allow long-term survival in patients with locally advanced disease.
    The Journal of urology 04/2014; · 3.75 Impact Factor

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