MP70-15 INCREASING COMPLEXITY OF TUMOR THROMBI IN RENAL CELL CARCINOMA OVER 40 YEARS OF EXPERIENCE (2015)

You have accessJournal of UrologyKidney Cancer: Surgical Therapy V1 Apr 2015MP70-15 INCREASING COMPLEXITY OF TUMOR THROMBI IN RENAL CELL CARCINOMA OVER 40 YEARS OF EXPERIENCE Sarah Psutka, R. Houston Thompson, Stephen Boorjian, Christine Lohse, Suzanne Stewart, John Cheville, and Bradley Leibovich Sarah PsutkaSarah Psutka More articles by this author , R. Houston ThompsonR. Houston Thompson More articles by this author , Stephen BoorjianStephen Boorjian More articles by this author , Christine LohseChristine Lohse More articles by this author , Suzanne StewartSuzanne Stewart More articles by this author , John ChevilleJohn Cheville More articles by this author , and Bradley LeibovichBradley Leibovich More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2540AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Our objective was to report determinants of oncologic outcome and temporal changes in presentation of patients treated with surgical intervention for renal cell carcinoma (RCC) with venous tumor thrombus (VTT). METHODS We identified 845 patients with RCC and VTT treated with nephrectomy and tumor thrombectomy from 1970-2009. Perioperative complications and mortality were assessed in early (1970-89), mid (1990-99), and late (2000-09) time periods. Following pathological re-review, clinicopathologic features and outcomes were compared. Cancer-specific survival (CSS) was estimated using the Kaplan-Meier method and Cox proportional multivariate modeling was used to determine factors prognostic of cancer specific mortality (CSM). Median follow-up was 7.9 years. RESULTS There were 510 (60%), 91 (11%), 139 (16%), 57 (7%), and 48 (6%) patients with levels 0, I, II, III, and IV VTT, respectively. The proportion of level III-IV VTT increased between 1970-89 (5.5%), 1990-99 (14.6%), and 2000-09, (18.9%, p<0.001). In total, 717 patients died, of whom 550 died from RCC. Although 30-day Clavien III-IV complications (overall n=47, 5.6%) have increased over time (early: 4.6% to late: 8.7%, p = 0.03), 30-day perioperative mortality (overall n = 25, 3%) decreased from 4.6% (early) to 1.9% (late, p = 0.04). Median CSS for patients with levels 0-IV VTT occurred at 4.9, 2.2, 2.4, 2.0, and 1.7 years (p<0.001). Patients with levels I-IV VTT had increased CSM compared to level 0 VTT (HR 1.59, p<0.001); however, no incremental risk in CSS was noted within levels I-IV (p=0.81). Median CSS by pNM status occurred at 7.4, 1.9, 1.2, and 0.8 years in pNx/0M0, pN1M0, pNx/0M1, and pN1M1 disease (p<0.001). Independent predictors of CSM (table) include increasing tumor thrombus level (Level II – IV, HR 1.4 – 1.55, p < 0.05), surgery in 2000-09 (HR 0.5, p < 0.001), fat invasion (HR 1.5, p < 0.001), pN1 (HR 1.7, p < 0.001) or M1 disease (HR 2.7, p < 0.001), coagulative tumor necrosis (HR 1.7, p < 0.001), and sarcomatoid differentiation (HR 1.7, p = 0.003). CONCLUSIONS CSS is inferior in patients with IVC VTT compared to renal vein VTT alone and in those with simultaneous nodal and metastatic disease at presentation. Despite increasing rates of level III-IV VTT in recent years, perioperative mortality and cancer-specific mortality has declined. Multivariate Cox proportional hazards model evaluating predictors of cancer-specific mortality among patients with tumor thrombus treated with radical nephrectomy and tumor thrombectomy (n = 845, treated 1970 - 2009). Feature HR (95%CI) P-value Level 0 tumor thrombus 1.0 (reference) Level 1 tumor thrombus 1.22 (0.92 - 1.62) 0.18 Level 2 tumor thrombus 1.40 (1.10 - 1.80) 0.007 Level 3 tumor thrombus 1.55 (1.09 - 2.21) 0.016 Level 4 tumor thrombus 1.50 (1.02 - 2.21) 0.042 Surgery (1970 - 1989) 1.0 (reference) Surgery (1990 - 1999) 0.80 (0.63 - 1.01) 0.055 Surgery (2000 - 2009) 0.51 (0.40 - 0.64) < 0.001 Negative surgical margins 1.0 (reference) Positive surgical margins 1.31 (0.94 - 1.84) 0.11 Nonaggressive RCC histologic subtype 1.0 (reference) Aggressive RCC histologic subtype 1.12 (0.74 - 1.71) < 0.001 No fat invasion present 1.0 (reference) Fat invasion present 1.49 (1.21 - 1.83) < 0.001 pNx 1.0 (reference) pN0 1.07 (0.86 - 1.33) 0.52 pN1 1.70 (1.33 - 2.19) < 0.001 M0 1.0 (reference) M1 2.72 (2.26 - 3.28) < 0.001 Nuclear grade 1 1.0 (reference) Nuclear grade 2 0.92 (0.44 - 1.94) 0.83 Nuclear grade 3 1.30 (0.63 - 2.67) 0.48 Nuclear grade 4 1.67 (0.78 - 3.61) 0.19 Coagulative tumor necrosis absent 1.0 (reference) Coagulative tumor necrosis present 1.67 (1.35 - 2.06) < 0.001 Sarcomatoid differentiation absent 1.0 (reference) Sarcomatoid differentiation present 1.69 (1.20 - 2.37) 0.003 Aggressive RCC histologic subtypes include: non-cystic clear cell, collecting duct, and RCC (not otherwise specified). © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e881 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sarah Psutka More articles by this author R. Houston Thompson More articles by this author Stephen Boorjian More articles by this author Christine Lohse More articles by this author Suzanne Stewart More articles by this author John Cheville More articles by this author Bradley Leibovich More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...