Prognostic factors of renal cell carcinoma with extension into inferior vena cava

Objective:   To evaluate the prognosis of our series of patients with renal cell carcinoma (RCC) and tumor thrombus involving inferior vena cava (IVC) treated with nephrectomy and thrombectomy.
Methods:   In 46 patients with unilateral RCC extending into IVC who underwent nephrectomy and thrombectomy (T3b in 38 patients, T3c in 6, T4 in 2, N+ in 15, M1 in 21), overall and cancer-specific survival rates were estimated, and the univariable and multivariable analysis were carried out to determine the prognostic factors among age, gender, performance status, fever, inflammatory laboratory parameters, nodal and distant metastasis, tumor thrombus level, pathological parameters and postoperative interferon-α administration.
Results:   The median age was 66.5 (range 35–79) years. The median follow-up was 18.0 (mean 36.7 ± 38.7) months. The overall and cancer-specific 5-year survival rates were 32.9% and 40.0%, respectively. The univariate analysis revealed that fever (hazard ratio: HR 4.03), C-reactive protein (HR 4.89), grade of tumor cell (HR 3.83), and lymph node metastasis (HR 5.99) were independent prognostic factors of cause-specific survival in all patients. The multivariate analysis demonstrated that lymph node metastasis (HR 4.13) was the only independent prognostic factor of cause-specific survival. The extension level or postoperative interferon-α administration did not influence the prognosis of patients with tumor thrombus involving IVC.
Conclusions:   Aggressive surgery should be considered first in RCC patients with any levels of tumor thrombus. However, patients with both IVC involvement and nodal metastasis showed significantly poor prognosis, and development of novel intensive multidisciplinary therapies will be needed.     

Surgical strategy for treating renal cell carcinoma with thrombus extending into the inferior vena cava

OBJECTIVE: A surgical strategy for treating malignant renal tumors with thrombus extending into the inferior vena cava (IVC) was assessed. METHODS: We retrospectively reviewed the records for all patients with renal cell carcinoma (RCC; n=30) or Wilms tumor (n=1) with tumor thrombus extending into the IVC who underwent surgical intervention at our institution between January 1980 and December 2001. Tumors were classified preoperatively according to the cephalad extension of thrombus, and intraoperative procedures were selected on the basis of degree of extension. Patients with RCC underwent radical nephrectomy and removal of thrombus with (n=11) or without (n=19) IVC resection. Partial normothermic cardiopulmonary bypass without cardiac arrest was used in 4 patients. The Pringle maneuver was performed in 8 patients. Infrarenal abdominal aortic cross-clamping was used in 8 patients to maintain systemic blood pressure. IVC cross-clamping and the Pringle maneuver were performed in 5 patients with suprahepatic thrombus extension. Temporary placement of a filter in the IVC or plication of the IVC above the hepatic vein was performed before hepatic mobilization, to decrease the risk for pulmonary embolism. RESULTS: One patient died intraoperatively of pulmonary embolism. Postoperative complications occurred in 11 patients; all resolved with conservative therapy. The postoperative duration of survival in patients with RCC was 37 +/- 44 months (range, 4-180 months); the 5-year survival rate was 42%. CONCLUSION: Aortic cross-clamping during IVC occlusion prevented hypotension and maintained hemodynamic stability that has required bypass in other series. This surgical treatment with the less extensive approach could result in long-term survival of patients with RCC in whom tumor thrombus extends into the IVC. We recommend that radical nephrectomy and tumor thrombectomy, with or without caval resection, be performed in these patients, with less invasive additional maneuvers.     

Renal cell carcinoma with caval involvement: Contemporary strategies of surgical treatment

ObjectivesWe retrospectively evaluated the outcome of the surgical treatment of patients with renal cell carcinoma (RCC) and extensive inferior vena cava (IVC) involvement. Our aim was to investigate if a particular surgical technique could reduce morbidity and complications associated with this condition.Materials and methodsFrom 1996 to 2007, 22 patients with RCC and extensive IVC involvement underwent radical surgical treatment with the intention to avoid, whenever possible, sternotomy and cardiopulmonary bypass. The level of the tumor thrombus was I (<2 cm above the renal vein) in 2 patients, II (below the intrahepatic vena cava) in 9 patients, III (intrahepatic vena cava below the diaphragm) in 7 patients, and IV (atrial) in 4 patients. Extracorporeal vascular bypass was used for 4 patients with level IV and for 2 patients with level III tumor thrombi, with hypothermic circulatory arrest in 2 patients. Extensive liver mobilization techniques were adopted in 16 patients. Overall and cancer-specific survival (CSS) were analyzed based on tumor extent (N0M0, N+M+), pathologic stage (pT3b, pT3c, pT4), thrombus level, and caval wall infiltration.ResultsTwo patients died within 1 month of surgery and the remaining 20 patients have a mean follow-up of 32.2 months (range 6–90): 8 are alive (overall survival 40%), but 2 with disease (CSS 30%). A total of 10 severe complications developed in 8 patients (36%). Both overall and CSS were significantly associated with tumor stage (Log-rank P = 0.0237 and 0.0465), presence of nodal or systemic metastases (Log-rank P = 0.0835 and 0.0669; Wilcoxon's test P = 0.0407 and 0.0411), and caval wall infiltration (Log-rank P = 0.0200 and 0.0418).ConclusionsDespite the low overall survival, related to the high percentage of nodal and systemic metastases, aggressive surgical management with resection of synchronous metastatic disease for symptom palliation and cytoreduction, followed by immunotherapy is justified in this setting. A transabdominal approach to RCC and IVC involvement, even in patients with level III thrombus, can provide the surgeon with an exposure similar to thoracoabdominal incisions without the complications associated with thoracotomy.     

Renal cell carcinoma with inferior vena cava thrombus: The Hacettepe experience

ObjectivesWe evaluated the clinical outcome and factors affecting survival in patients with renal cell carcinoma (RCC) and tumor thrombus involving inferior vena cava (IVC).MethodsBetween 1990 and 2007, 28 patients with RCC and tumor thrombus extending into IVC underwent radical nephrectomy and thrombectomy. Patient data were reviewed retrospectively to evaluate the demographics, clinical presentation, surgical approach, pathological features, clinical outcomes, and survival.ResultsTwenty-eight patients with a mean age of 52.7 years were operated. Thrombus level was infrahepatic in 15 patients (54%), intrahepatic in 3 patients (10%), suprahepatic in 3 patients (10%), supradiaphragmatic in 2 patients (8%), and intracardiac in 5 patients (18%). All patients with intracardiac thrombi underwent cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). The mean tumor size was 98.21 mm. Four patients had distant metastases and 3 patients had lymph node involvement. Pathological examination revealed RCC of clear cell type in 26 patients, papillary in 1 and chromophobe in 1 patient. At a mean follow-up of 36.4 months, 16 patients were still alive while 8 patients died due to disease progression and 2 patients died of other causes. Two patients died of pulmonary emboli in the early postoperative period. Lymph node involvement, distant metastases, hypercalcemia, and sarcomatoid component were found to be factors affecting overall survival significantly. Level of tumor thrombus and Fuhrman grade did not affect survival.ConclusionsRadical nephrectomy and tumor thrombectomy is currently known to be the most effective method in patients with RCC and tumor thrombus extending into IVC. Factors affecting survival are the ones related to tumor biology. Tumor thrombus level does not affect the prognosis.     

经皮球囊导管阻断技术在下腔静脉瘤栓切除术中的应用

目的 探讨经皮球囊导管阻断技术在下腔静脉瘤栓切除术中的应用价值. 方法 经CT、MRI及彩色多普勒超声等检查确诊为肾或肾上腺肿瘤合并肝后型或肝下型下腔静脉瘤栓患者12例.男7例,女5例.年龄20～76岁,平均51岁.右侧肿瘤11例,左侧1例.肾肿瘤11例,肾上腺肿瘤1例.12例均于术前经皮穿刺右侧颈内静脉,于瘤栓近心端下腔静脉内预置一球囊导管,术中经导管充盈球囊阻断下腔静脉后,再行下腔静脉瘤栓切除术. 结果 12例肿瘤合并下腔静脉瘤栓的根治性切除术全部完成.手术时间210～670 min,平均324 min.术中出血量600～7960 ml,平均2563 ml.无手术或围手术期死亡.术后患者恢复良好,肝肾功能正常,无并发症发生.术后平均12(9～15)d出院.术后病理报告:肾细胞癌9例,转移性肝细胞癌1例,良性血管平滑肌脂肪瘤1例,肾上腺平滑肌肉瘤1例.肾癌术后TNM分期:T3b N0M08例,T3bNxM11例.术后平均随访(21±10)个月,中位随访时间24个月.4例分别于术后6、9、15、22个月死于肺转移、肝转移及肝癌复发,其余8例术后已存活6～35个月,平均26个月.9例肾癌患者术后1、3年肿瘤特异生存率分别为78%和67%. 结论 经皮球囊导管阻断技术在低位肝后型或肝下型下腔静脉瘤栓的根治性切除术中是一种安全、简便、有效的方法,具有重要的临床应用价值.     

CANCER SPECIFIC SURVIVAL FOR PATIENTS WITH pT3 RENAL CELL CARCINOMA—CAN THE 2002 PRIMARY TUMOR CLASSIFICATION BE IMPROVED?

PURPOSE: The 2002 primary tumor classification for renal cell carcinoma (RCC) does not distinguish between patients with tumor thrombus involving the renal vein only and those with inferior vena cava tumor thrombus below the diaphragm. We evaluated the association of tumor thrombus level and fat invasion with outcome to determine if further subclassification would improve the prognostic accuracy of the current classification. MATERIALS AND METHODS: We studied 675 patients treated with radical nephrectomy or nephron sparing surgery for pT3a (206, 30.5%), pT3b (422, 62.5%), pT3c (19, 2.8%) or pT4 (28, 4.2%) RCC at the Mayo Clinic between 1970 and 2000. Associations with outcome were evaluated using Cox proportional hazards regression. RESULTS: There were 531 deaths from RCC at a median of 1.5 years following nephrectomy. Patients with pT3b RCC and level I, II or III tumor thrombus were significantly more likely to die of RCC compared to patients with pT3b RCC and level 0 tumor thrombus (risk ratio 1.62, p <0.001). Patients with peripheral perinephric or renal sinus fat invasion were also more likely to die of RCC compared to patients without fat invasion (risk ratio 1.87, p <0.001). Therefore, patients with pT3 RCC were reclassified into 4 groups as thrombus level 0 without fat invasion, fat invasion only, thrombus level 0 with fat invasion or thrombus level I, II or III without fat invasion, and thrombus level I, II or III with fat invasion or thrombus level IV. This reclassification significantly improved prediction of death from RCC compared with the current classification (c indexes of 0.61 versus 0.55, respectively). CONCLUSIONS: Further subclassification of the primary tumor classification for patients with pT3 RCC improved prognostic accuracy.     

Carcinoma de células renales con extensión a vena cava: puesta al día y revisión de nuestra casuística

ObjectiveTo assess current management of renal cell carcinoma (RCC) extending into the inferior vena cava (IVC): staging, diagnosis, surgical approach, adjuvant therapy, prognostic factors and survival rate.Materials and methodsNineteen cases of RCC extending into the IVC undergoing surgical resection from January 1988 to August 2008 were reviewed. TNM staging and Neves-Zincke grading of the tumor were also assessed. Surgical approach depended on thrombus level.ResultsWith a perioperative mortality rate of 10.5% and a mean follow-up of 22.65 months (range 2-79), 5 patients are still alive, while 11 patients died from the disease, 1 from an unrelated cause, and 2 were lost to follow-up. Patients with metastatic disease received adjuvant treatment with immunotherapy or kinase inhibitors. Mean survival was 15.1 months. Significant differences were found in 3- and 5-year survival rates in patients staged as n0m0 as compared to all other stages (n+m0, n0m+, n+m+). no differences were found depending on thrombus level.ConclusionsRCC with thrombus in the IVC is a tumor with a high mortality rate. Surgery continues to be the best option, and requires adequate preoperative evaluation and the support of an experienced and well trained multidisciplinary team. Survival depends on disease extension.     

Determinants of outcomes after resection of renal cell carcinoma with venous involvement

Purpose

To determine the outcomes and to identify prognostic variables determining mortality and recurrence after surgery for renal cell cancer (RCC) with venous involvement.

Methods

Retrospective evaluation of the medical records of 132 patients with RCC and tumor thrombi treated at Johns Hopkins Hospital (1997?C2008) was done. Kaplan?CMeier analysis was used to determine survivals. Uni- and multivariate Cox proportional analysis was done to identify predictors for recurrence, all-cause mortality (ACM) and cancer-specific mortality (CSM).

Results

Mean follow-up was 30.3 (0.03?C159.5) months. Sixty-four (48.5?%) patients had renal vein thrombus (Group 1), 55 (41.7?%) had subdiaphragmatic inferior vena cava (IVC) tumor thrombus (Group 2), while 13 (9.8?%) had involvement of IVC above diaphragm or atrial extension (Group 3). IVC thrombus was more common from the right-sided tumors. Patients with higher thrombus levels had more blood loss and complicated and longer hospital stay. Thrombus level was not found to be a predictor of recurrence, ACM and CSM. One- and three-year recurrence-free survivals for non-metastatic patients were 69 and 53?%. Tumor size (p?=?0.015), grade (p?=?0.007) and venous wall invasion (p?=?0.027) were predictors for recurrence. Five-year overall survival was 48, 35 and 13?% for 3 groups, respectively. Presence of distant metastasis (p?=?0.032), size (p?=?0.002), histology (p?=?0.020) and grade (p?=?0.013) were predictors of ACM. Five-year cancer-specific survival was 65, 43 and 36 for 3 groups, respectively. Tumor size (p?=?0.001) and distant metastasis at presentation (p?=?0.025) were the predictors of CSM.

Conclusions

Tumor thrombus level does not predict recurrence or mortality in RCC with venous involvement. Survival is determined by inherent aggressiveness of the cancer manifested by tumor size, grade and distant metastasis at presentation.     

Positron emission tomography enhancing tumor thrombus in patient with renal cell carcinoma

A 65-year-old man underwent computed tomography (CT) of the abdomen during evaluation for anemia which showed a 10 cm right renal mass and inferior vena cava (IVC) thrombus. Positron emission tomography (PET)/CT revealed uptake of flurorodeoxyglucose (FDG) within only the tumor mass and thrombus. Right radical nephrectomy and IVC thrombectomy with IVC patch graft reconstruction were performed. Final pathology showed pT3bNxMx renal cell carcinoma (RCC) with IVC thrombus composed of poorly differentiated RCC. There is no evidence of recurrence at one year follow-up. We discuss the role of PET in RCC.     

Vascular endothelial growth factor as prognostic factor in renal cell carcinoma

PURPOSE: Vascular endothelial growth factor (VEGF) has been recognized as an important constituent of vascularization and growth of solid tumors. Serum VEGF levels were evaluated and correlated to clinicopathologic findings and clinical outcome in patients with renal cell carcinoma (RCC). MATERIALS AND METHODS: Serum samples were collected before surgery in 164 patients with RCC. Levels of VEGF165 protein in sera were measured using a quantitative ELISA. Univariate and multivariate analyses were performed. RESULTS: The VEGF165 level in serum was significantly increased (p = 0.0001) in patients with RCC (median 343.4 pg./ml.) compared with the control patients (median 103.8 pg./ml.). The level of VEGF165 in serum correlated to clinical stage and histopathological grade. Patients with VEGF165 levels below median value had significantly longer survival time than patients with higher levels (p = 0.0001). This was also shown when VEGF165 was analyzed in univariate Cox regression (p = 0.0001). The impact of VEGF165 on survival was especially shown in patients having tumors with vein invasion (pT3b-c N0 M0) and in patients with clinical stages I - III (p = 0.0240 and p = 0.0023, respectively). When using multivariate analysis, only tumor stage and grade remained as independent prognostic variables. CONCLUSIONS: In RCC, serum VEGF165 level was significantly correlated to tumor stage and grade. Increased levels were correlated to adverse survival. Although, VEGF did not remain as an independent prognostic factor in multivariate analysis the levels of VEGF165 in serum was found useful for the identification of patients with potentially progressive disease especially for those with vein invasion.     

A contemporary evaluation of cytoreductive nephrectomy with tumor thrombus: Morbidity and long-term survival

BACKGROUND: Metastatic renal cell carcinoma (RCC) is an aggressive entity that frequently invades the venous system. We evaluated the morbidity and survival of patients with tumor thrombus who undergo cytoreductive nephrectomy. MATERIALS AND METHODS: We identified 56 patients from our institution's database who had a primary renal tumor in place and documented metastases at the time of surgery. We reviewed demographic and pathologic characteristics from these patients as well as complications and overall survival. RESULTS: Median age was 58 (37-77). There were 33 patients (59%) who had tumor thrombus with 21 (64%) involving the renal vein, 10 (30%) involving the infradiaphragmatic inferior vena cava (IVC), and 2 (6%) involving the supradiaphragmatic IVC. Median tumor size for thrombus patients was 12 cm (5-29). There were 8 (14.2%) who had complications, including 1 death. Thrombus patients were significantly more likely to have a complication (P = 0.008). Median survival for all patients was 10.7 months (0.3-61). There was no significant difference in overall survival between patients with and without thrombus (P = 0.76). CONCLUSIONS: Patients who undergo cytoreductive nephrectomy with a tumor thrombus have a higher rate of complications as compared to patients undergoing cytoreductive nephrectomy without tumor thrombus. The long-term survival, however, was not statistically different and thus aggressive surgery for select metastatic RCC patients is warranted.     

Renal cell carcinoma in adults 40 years old or less: young age is an independent prognostic factor for cancer-specific survival

OBJECTIVES: Renal cell carcinoma (RCC) is uncommon in young adults. Based on the few studies published to date, it is difficult to determine whether this tumour has a particular progression pattern. This retrospective, multicentre study analysed RCC in young patients, defined as 相似文献   

Clinicopathological factors predicting recurrence of N0M0 renal cell carcinoma: A case series analysis of one facility

BACKGROUND: Although many factors have been reported as predictors of the recurrence of renal cell carcinoma (RCC), none of the factors are consistent among different studies. In the study presented here, the potential clinicopathological predictors of the recurrence of N0M0 RCC were examined. METHODS: A total of 201 patients who underwent nephrectomy for N0M0 RCC were examined to determine the pathological tumor stage (pT stage), pathological tumor grade of malignancy (tumor grade), symptoms, and tumor size. RESULTS: RCC recurred in 29 patients (14.4%), 50% of whom developed new tumors within 24 months after nephrectomy. The disease-free 3- and 10-year survival rates declined as the pT stage and tumor grade increased: these rates were, respectively, 98.6% and 86.5% for pT1a; 93.7% and 87.9% for pT1b; 100% and 100% for pT2; 78.6% and 58.0% for pT3a; and 88.9% and 16.7% for pT3b. Significant differences in the recurrence rate were noted between pT3 and pT1 or pT2, as well as between grade 3 disease and grade 1 or grade 2 tumors. Multivariate analysis showed that a combination of the pT stage, grade, and presence of symptoms was useful for predicting the recurrence of RCC. CONCLUSION: The present study showed that patients undergoing nephrectomy for N0M0 RCC should be followed-up carefully for 2 years postoperatively with special attention to high pT stage, high grade, and the development of symptoms.     

P53 mutations and other prognostic factors of renal cell carcinoma

OBJECTIVE: Tumor stage, histological pattern, cell type, diameter and cell ploidy are the factor that have been proposed for predicting the prognosis of renal cell carcinoma (RCC). There is a wide variation in the reported incidence of p53 mutation in RCC, and its prognostic significance for this tumor is unknown. We investigated the prognostic value of p53 mutations among other prognostic factors. PATIENTS AND METHOD: We evaluated the stages, tumor diameters, histological grades, cellular patterns and the presence of mutant p53 protein in 50 cases of RCC. The survival function of each parameter was estimated by Kaplan-Meier and log-rank tests, and the significance of each parameter on survival was evaluated by logistic regression analysis. RESULTS: The p53 mutation incidence was 20% in the RCC cases included in the study (n = 50). The survival rates of stages pT(2), pT(3) and pT(2-3)N+ were 87.8, 61.0 and 0%, respectively (p = 0.0462). The survival analysis of grade 1-2 and grade 3-4 tumors revealed 92.3 and 51.5% survival rates, respectively (p = 0.002). The survival rates of mutant p53+ and mutant p53- cases were 33.3 and 84.2%, respectively (p = 0.0027). The logistic regression test analysis demonstrated that tumor grade, tumor stage and mutant p53 positivity status were the most significant prognostic factors (p < 0.03). The survival rates of mutant p53+ and p53- cases at stages pT(2), pT(3) and pT(2-3)N+ were 66.67 versus 91.48%, 33.3 versus 71.43% and 0 versus 100%, respectively (p = 0.0392). A similar finding was present at each stage for cellular grades (p = 0.0093). The survival rates of mutant p53+ and p53- cases for grades 3 and 4 were 33.33 and 74.48%, respectively (p = 0.2731). CONCLUSION: Our results suggested that many parameters can affect survival of RCC cases, but among these, tumor grade, tumor stage and p53 mutation status are the most important prognostic factors, but p53 mutation status and cellular grade can afford additional prognostic information at each stage.     

Combined resection of a tumor and the inferior vena cava: report of two cases

Tumor resection and caval tumor thrombectomy, with or without cavotomy and inferior vena cava (IVC) replacement are sometimes performed in patients with renal cell carcinoma (RCC) extending into the IVC or liver tumors invading the IVC. Two such cases were treated. Case 1: a 68-year-old female was transferred with a diagnosis of right RCC with tumor thrombus extending into the IVC. A plication was performed to prevent extension into the right atrium before the nephrectomy and cavotomy with removal of the tumor thrombus was accomplished, because the IVC was almost completely obstructed and the hemodynamics were stable during cross-clamping of the IVC. Case 2: a 37-year-old female was transferred with a diagnosis of a giant metastatic liver tumor. A trisegmentectomy with resection of the invaded IVC and IVC replacement was performed while the abdominal aorta was cross-clamped to maintain the hemodynamics. Therefore, abdominal aortic cross-clamping was convenient to maintain the hemodynamics when the IVC replacement was performed during IVC cross-clamping.     

The Mayo Clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumour thrombus

OBJECTIVE: To report the surgical management, complications and outcomes over three decades by tumour thrombus level for patients with renal cell carcinoma (RCC) and renal venous extension, as surgery is the most effective treatment. PATIENTS AND METHODS: We assessed 540 patients who underwent surgical resection for RCC with renal venous extension between 1970 and 2000. Early and late surgical complications, including operative mortality, were compared with tumour thrombus level using the chi-square, Fisher's exact and Wilcoxon rank-sum tests. Cancer-specific survival was estimated using the Kaplan-Meier method and compared across tumour thrombus levels using log-rank tests. RESULTS: There were 349 (64.6%) patients with level 0 thrombus and 191 (35.4%) with inferior vena cava thrombus, including 66 (12.2%) with level I, 77 (14.3%) with level II, 28 (5.2%) with level III, and 20 (3.7%) with level IV thrombus. Patients with a higher thrombus level had more early surgical complications (respectively for level 0 to IV, 8.6%, 15.2%, 14.1%, 17.9% and 30.0%, P < 0.001). However, there was no statistically significant difference in the incidence of late complications by thrombus level (P = 0.445). The incidence of any early surgical complication decreased from 13.4% for patients treated in 1970-1989 to 8.1% for those treated in 1990-2000 (P = 0.064); the respective operative mortality decreased from 3.8% to 2.0% (P = 0.260), and in patients with inferior vena cava thrombus, from 8.1% to 3.8% (P = 0.227). The respective duration of hospitalization decreased from a median of 8 to 7 days (P < 0.001) but the incidence of late complications increased significantly over time (P < 0.001.) Among patients with clear cell RCC, the respective estimated 5-year cancer-specific survival rates (Se, number still at risk) for patients with level 0 to IV thrombus were 49.1 (3.0)% (125), 31.7 (6.4)% (14), 26.3 (6.1)% (11), 39.4 (10.7)% (7) and 37.0 (12.9)% (5), (P = 0.028). There was a statistically significant difference in outcome for patients with level 0 vs those with level >0 thrombus (P = 0.002), but there was no significant difference in outcome by thrombus level among patients with inferior vena cava tumour thrombus (P = 0.868). CONCLUSIONS: The surgical management of RCC with renal venous extension continues to develop. The incidence of early surgical complications and operative death have decreased in recent times with the introduction of improved imaging, surgical monitoring and vascular bypass techniques. There is significantly better cancer-specific survival for patients with renal vein involvement only than those with inferior vena cava involvement.     

Loss of uroplakin III expression is associated with a poor prognosis in patients with urothelial carcinoma of the upper urinary tract

OBJECTIVE: To investigate the association between the expression of uroplakin III (UPIII) and the prognosis of patients with urothelial carcinoma of the upper urinary tract, as uroplakins are urothelium-specific markers of terminal urothelial differentiation. PATIENTS AND METHODS: Clinicopathological and follow-up data from 71 patients who had undergone radical nephroureterectomy and lymph node dissection or sampling for urothelial carcinoma of the upper urinary tract were reviewed. The expression of UPIII was evaluated immunohistochemically in surgical specimens. Cancer-specific survival was calculated using Kaplan-Meier plots. Prognostic values of clinicopathological variables including UPIII expression status, tumour stage and grade were evaluated by univariate analyses, followed by multivariate analysis using the Cox proportional-hazard model. RESULTS: In all specimens there was intense UPIII immunoreactivity of umbrella cells of normal urothelium. In tumour samples, UPIII expression was positive in 75% of < or = pT1 tumours and 40% of > or = pT2 (P = 0.02), and in 65% of grade 1-2 tumours and 33% of grade 3 (P = 0.009). Of the 71 patients, 21 died from the disease during the median follow-up of 61 months. The cancer-specific survival of patients with negative UPIII expression was significantly worse than that of those with positive UPIII expression (5-year cancer-specific survival, 100% vs 46%, P < 0.001). Neither patient age at diagnosis, histological grade, sex, or multiplicity of the tumour had significant prognostic value. Multivariate analysis revealed that UPIII expression was the most powerful prognostic indicator (P < 0.001) followed by tumour stage (P = 0.04) and lymph node metastasis (P = 0.05). CONCLUSION: The present data suggest that UPIII expression is a powerful prognostic factor in patients with upper urinary tract urothelial carcinoma.     

Surgical management of renal cell carcinoma with tumor thrombus in the renal and inferior vena cava: the University of Miami experience in using liver transplantation techniques

OBJECTIVES: Renal cell carcinoma (RCC) with tumor thrombus in the inferior vena cava (IVC) poses a challenge to the surgeon due to the potential for massive hemorrhage and tumor thromboemboli. We developed a technique for safe resection of these tumors through a transabdominal approach, without recourse to cardiopulmonary bypass (CPB). MATERIALS AND METHODS: From August 1997 to February 2005, 66 patients underwent resection of a RCC with tumor thrombus in the IVC. The extent of the tumor thrombus was renal in 13, infrahepatic in 7; retrohepatic in 38; and intra-atrial in 8 patients. RESULTS: Mean operative time was 6.16+/-0.32 hours. The estimated blood loss ranged from 200 cc to 16,000 cc, with a mean of transfusions being 3.56+/-0.94 U. CBP was required in only 3 patients. Three patients (4.5%) died in the immediate postoperative period. Median follow-up among the 56 survivors was 7.1 months. Six patients died due to metastasis and 1 died of a cause unrelated to the cancer. The estimated actuarial survival at 36 months was 66%. CONCLUSIONS: An aggressive surgical approach is the only hope for curing patients having RCC with a tumor thrombus in the IVC. The extent of dissection is predicated on the extent and level of tumor thrombus. Our surgical approach uses liver transplant techniques to mobilize the liver off the IVC and to separate the IVC from the posterior abdominal wall. This maneuver provides excellent exposure and enables safe vascular control of the IVC.     

A critical analysis of surgery for kidney cancer with vena cava invasion

OBJECTIVE: Patients with kidney cancer with venous system involvement are at high risk of cancer recurrence even after the tumor thrombus is successfully removed. This review analyzes the impact on prognosis of the level of involvement of the inferior vena cava (IVC) in renal cell carcinoma (RCC). METHODS: A literature search was done and relevant papers were reviewed. Relatively recent papers as well as large series or papers from expert centers are included in the reference list. RESULTS: Venous invasion in RCC is a major challenge for urologists and patients with venous involvement have a worse prognosis. Although successful removal of a tumor thrombus in the renal vein and IVC may result in improved long-term survival in more than half of the affected patients, a higher level of thrombus appears to be a bad prognosticator for cancer recurrence. A complete IVC thrombectomy, even in the metastatic setting, provides a better quality of life and may prolong survival. CONCLUSIONS: Because surgery still remains the most effective therapeutic option in patients wtih RCC, every attempt should be made to completely remove the IVC thrombus. New targeted agents could be promising as adjuvant therapy in this subset of patients.