Director Emerson Urology Associates; Senior VP Emerson Hospital Tufts University School of Medicine
Introduction: The objective of surgical management of RCC with IVC tumor thrombus is complete resection of all tumor burden. In addition to radical nephrectomy and tumor thrombectomy, this may also involve resection of the vena cava with or without vascular reconstruction, and retroperitoneal lymphadenectomy. The successful excision requires careful preoperative planning and remains a complex technical challenge. Our purpose is to determine which risk factors are associated with overall survival in patients with T3b or T3c renal carcinoma using both the AJCC (8th edition) and the Mayo Clinic thrombus classification level III & IV, to assess this difficult high risk patient population.
Methods: A retrospective analysis was performed on 347 patients who underwent a radical nephrectomy with venous invasion at Lahey Clinic Medical Center from 1971-2014; of which 182 patients had a diagnosis of pathologic T3b or T3c renal cell carcinoma. Twenty-one potential risk factors were examined and analyzed using Cox Proportional Hazard Survival models. Additional factors examined in this cohort included rate of complications, tumor recurrence, intra-operative death rate, and 30-day mortality rate.
Results: 182 patients with stage T3b or T3c renal cell carcinoma met inclusion criteria with a median follow-up of 18.5 months. Of these, 124 (68%) were stage T3b and 58 (32%) were stage T3c. 106 patients ( 53%) experienced surgical complications. The intra-operative death rate was 1.1% (2 patients), and the 30-day mortality rate was 7.1% (13patients). The 5-year disease-specific survival was 40% and the 5-year overall survival was 32%. Of the 21 risk factors analyzed: clear cell histology, positive lymph nodes, and peri-nephric fat involvement were all significant at the p < 0.05 level using unadjusted modeling. On multivariable analysis, fully adjusting for all three significant variables, only positive lymph nodes and peri-nephric fat involvement remained significant.
We have also separately investigated the same cohort of patients and analyzed 93 patients with a level III & IV thrombus, using the Mayo Clinic thrombus classification; with special reference to patients undergoing: CPB & DHCA, Langenbeck-Pringle maneuver, and a new technique of minimally invasive endovascular down staging. This novel technique will be described in detail.
Conclusions: In patients with T3b or T3c renal cell carcinoma overall survival is associated with lymph node positivity and peri-nephric fat involvement and not tumor thrombus level. The surgical management of high level III & IV thrombi are described in detail, as is the new technique of minimally invasive endovascular down staging. This new procedure and approach has the potential to dramatically reduce surgical morbidity and mortality for these very high risk surgical procedures.
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