"The findings of this study and of previous studies [3,8-10,17,18,23] suggest that the upper limit of the 5-year survival rate in RCC patients with venous thrombus who receive surgical management may be 50–60%. Because these patients have a high rate of metastasis at presentation, optimal systemic therapy, such as neoadjuvant therapy using molecular-targeting agents, is important. "
[Show abstract][Hide abstract] ABSTRACT: Management of renal cell carcinoma (RCC) with tumor thrombus extending to the renal vein and inferior vena cava (IVC) is challenging. The aim of this study was to evaluate the benefit of surgical management in such patients.
From February 1995 to February 2013, 520 patients were treated for RCC at Hirosaki University Hospital, Hirosaki, Japan. The RCC patients with tumor thrombus extending to the renal vein (n = 42) and IVC (n = 43) were included in this study. The records of these 85 patients were retrospectively reviewed to assess the relevant clinical and pathological variables and survival. Prognostic factors were identified by multivariate analysis. The benefit of surgical management was evaluated using propensity score matching to compare overall survival between patients who received surgical management and those who did not.
RCC was confirmed by pathological examination of surgical or biopsy specimens in 74 of the 85 patients (87%). Sixty-five patients (76%) received surgical management (radical nephrectomy with thrombectomy). Distant metastasis was identified in 45 patients (53%). The proportion of patients with tumor thrombus level 0 (renal vein only), I, II, III, and IV was 49%, 13%, 18%, 14%, and 5%, respectively. The estimated 5-year overall survival rate was 70% in patients with thrombus extending to the renal vein and 23% in patients with thrombus extending to the IVC. Multivariate analysis identified thrombus extending to the IVC, presence of distant metastasis, surgical management, serum albumin concentration, serum choline esterase concentration, neutrophil-lymphocyte ratio, and Carlson comorbidity index as independent prognostic factors. In propensity score-matched patients, overall survival was significantly longer in those who received surgical management than those who did not.
Surgical management may improve the prognosis of RCC patients with thrombus extending to the renal vein and IVC.
"In retrospective series on 168 primary metastatic tumors an increase by >30% has been observed in 1.19% and increases >11% in 4.76% . Individual cases have been reported of new onset caval vein thrombi leading to more extensive surgery . Of even bigger concern may be the onset of metastasis in the pretreatment period. "
[Show abstract][Hide abstract] ABSTRACT: With an increasing number of small renal masses being diagnosed organ-preserving treatment strategies such as nephron-sparing surgery (NSS) or radiofrequency and cryoablation are gaining importance. There is evidence that preserving renal function reduces the risk of death of any cause, cardiovascular events, and hospitalization. Some patients have unfavourable tumor locations or large tumors unsuitable for NSS or ablation which is a clinical problem especially in those with imperative indications to preserve renal function. These patients may benefit from downsizing primary tumors by targeted therapy. This paper provides an overview of the current evidence, safety, controversies, and ongoing trials.
"It is acknowledged that the aim of the present study was not to investigate whether surgery would be rendered easier by downsizing. However, it is probably true to say that only cases with level 3 and 4 thrombus would benefit from pretreatment downsizing, thus justifying delaying surgery, with the established danger of further progression and exposure to adverse events . It is possible that higher level caval tumour thrombus is more susceptible to downsizing by reduction of cranial extension. "
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