AUA 2022: Outcomes of Nephrectomy for Renal Cell Carcinoma with Venous Thrombus Following Immune Checkpoint Inhibitor Therapy: A Multicenter Collaborative Study

(UroToday.com) The 2022 American Urological Association (AUA) Annual Meeting included a session on advanced kidney cancer and a presentation by Dr. Alireza Ghoreifi discussing a multicenter collaborative assessment of outcomes of nephrectomy for renal cell carcinoma (RCC) with venous thrombus following immune checkpoint inhibitor therapy. Nephrectomy and venous thrombectomy is a challenging procedure with potential morbidity and mortality. Despite the increasing use of immune checkpoint inhibitors in the management of advanced RCC, data regarding the outcomes of venous thrombectomy following immune checkpoint inhibitors is limited. This study presented by Dr. Ghoreifi evaluated the feasibility and perioperative outcomes of nephrectomy and venous thrombectomy following immune checkpoint inhibitors.


Patients with locally advanced or metastatic RCC with venous thrombus undergoing nephrectomy following immune checkpoint inhibitor therapy were evaluated in 5 high-volume US academic centers between June 2017 and June 2021. For this study, clinical data, perioperative outcomes, and 90-day complications were recorded.

Among 113 patients who received post-immune checkpoint inhibitor nephrectomy, 33 had venous thrombus. The median age was 64 (IQR 56-70) years, 85% of patients were male, 55% were MSKCC favorable risk, 36% intermediate risk, and 9% high risk. post-immune checkpoint inhibitor nephrectomy, included nivolumab ± ipilimumab (n=25, 76%), and pembrolizumab ± axitinib (n=8, 24%). Venous thrombi levels were as follows:

  • Level 0: n=8, 24.5%
  • Level 1: n=11, 33.5%
  • Level 2: n=6, 18%
  • Level 3: n=3, 9%
  • Level 4: n=5, 15%

Among all patients, 32 (97%) underwent radical and 1 (3%) patient underwent partial nephrectomy. There were 15 (44.5%) open, 14 (42.5%) robotic, and 4 (12%) laparoscopic operations, including one robotic and one laparoscopic case that were converted electively to open. Vascular procedures included renal vein thrombectomy (n=8), IVC thrombectomy and primary repair (n=23), IVC patch repair (n=1), and suprarenal cavectomy (n=1). As follows are the pre-and post-operative CT images of the patient with right RCC and level III IVC thrombus who underwent an open radical nephrectomy and suprarenal cavectomy following 3 doses of nivolumab + ipilimumab:

RCC-0.jpg

No intraoperative complications were reported; the following table highlights the perioperative findings:

RCC-1.jpg

A summary of the pathologic findings is as follows:

RCC-2.jpg

Overall, the 90-day complication rate was 27% (n=9), with 8 patients (24%) requiring readmission, and only one death was reported within 90 days due to COVID-19 infection.

Dr. Ghoreifi concluded this presentation by discussing a multicenter collaborative assessment of outcomes of nephrectomy for RCC with venous thrombus following immune checkpoint inhibitor therapy with the following take-home messages:

  • Nephrectomy and venous thrombectomy following systemic immune checkpoint inhibitor therapy is feasible
  • One third of patients show no viable tumor in the thrombus
  • Larger studies are needed to predict pathological response

Presented by: Alireza Ghoreifi, MD, University of Southern California, Los Angeles, CA 

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2022 American Urological Association (AUA) Annual Meeting, New Orleans, LA, Fri, May 13 – Mon, May 16, 2022.

email news signup