AUA 2017: Impact of Renal Vein Invasion on the Outcome in Patient with Renal Cell Carcinoma and Caval Thrombus
The study included 257 patients who presented with level II-IV caval thrombus and no evidence of metastatic disease. All patients with grossly positive margins were excluded from the study. The median age of the cohort was 64 years. A total of 45% had renal artery embolization prior to nephrectomy. On pre-operative imaging the tumor thrombus level was noted to be level 2 in 42%, level 3 in 35% and level 4 in 20%. A total of 35% experienced recurrence with a median time of recurrence of 15 months. At median follow-up of 21 months, 53% of the patients remained alive. Vascular invasion was noted in 145 patients, the majority presenting with renal vein invasion.
On regression analysis microscopic renal vein invasion was not significantly associated with an increased risk of recurrence or death. Invasion of IVC wall was associated with increased risk of recurrence (HR: 1.9, p<0.05) but was not significantly associated with an increased risk of death. In regards to survival, pre-operative anemia, need for cardio-pulmonary bypass, need for blood transfusion, older age and longer operative times were associated with poor survival.
In conclusion, microvascular invasion of the renal vein is not associated with risk of RCC recurrence or death. Invasion of the IVC is associated with risk of local recurrence but not death. The fact that invasion to the IVC is at higher risk of local recurrence than renal vein invasion is a function of surgical technique as efforts are made to decrease the amount of cava resected at the time of thrombectomy to facilitate reconstruction. The panel asks if it would be wise to send intra-operative frozen sections; however, time is of the essence during this part of the procedure and time wasted in waiting for frozen section results may affect overall outcomes. Sadly, this study just adds to the confusion in regards to the prognostic value of vascular wall invasion. It’s probably team to combine all this series to generate a uniform recommendation.
Presented By: Sudhir Isharwal, MBBS, Cleveland Clinic Foundation (CCF)
Written By: Andres F. Correa, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia, PA
at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA