Cytoreductive Nephrectomy Renal Cell Carcinoma Patients with Venous Tumor Thrombus

Careful selection is critical to identify metastatic renal cell carcinoma (mRCC) patients who are most likely to benefit from cytoreductive nephrectomy (CN). Surgery for mRCC patients with tumor thrombus is complex and may not benefit some patients with very poor overall survival (OS). The objective of this study was to evaluate whether preoperative variables or risk stratification systems could predict OS following CN.

Prognostic factors for overall OS following surgery were evaluated in mRCC patients with venous tumor thrombus at 5 institutions from 2000-2014. Prognostic variables including mRCC risk models were evaluated for associations with overall survival (OS). Multivariable analysis was used to determine independent associations of preoperative variables with OS.

A total of 427 mRCC patients were identified with tumor thrombus. Patients with IVC thrombus above the diaphragm had shorter median OS vs. renal vein only thrombus 9.2 (IQR 4.2-30.8) vs. 21.7(7.7-42.8) months, p=0.0165. Individual risk factors from prognostic models were evaluated among other preoperative characteristics for associations with OS in 122 (32%) patients who died within 270 days of surgery. Independent predictors of OS included lactate dehydrogenase >ULN (p=0.003), the presence of systemic symptoms (p=0.003), IVC thrombus above the diaphragm (p=0.02), and the presence of sarcomatoid features (p=0.005).

Poor OS following cytoreductive nephrectomy in mRCC patients with tumor thrombus is associated with IVC thrombus above the diaphragm, poor risk grouping, systemic symptoms, or sarcomatoid de-differentiation. Patients with expected poor OS should be considered for pre-surgical systemic therapy clinical trials.

The Journal of urology. 2017 Mar 04 [Epub ahead of print]

E Jason Abel, Philippe E Spiess, Vitaly Margulis, Viraj A Master, Michael Mann, Kamran Zargar, Leonardo D Borregales, Wade J Sexton, Datta Patil, Surena F Matin, Christopher G Wood, Jose A Karam

Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison WI. Electronic address: ., Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL., Department of Urology, The University of Texas Southwest Medical Center, Dallas, TX., Department of Urology, Emory University School of Medicine., Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison WI., Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas.

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