The Incremental Benefit of Upfront Surgery in Renal Cell Carcinoma with Venous Tumor Thrombus of the Inferior Venae Cavae

摘要

Background: Surgical extirpation for renal cell carcinoma (RCC) with inferior venae cavae (IVC) thrombi is the standard of care. The incremental impact of upfront surgery has not been well described. Objective: We aim to quantify the overall survival (OS) benefit of upfront surgery in RCC with IVC thrombi when compared to a conservative approach and also analyze perioperative outcomes. Materials and Methods: Patients with RCC with IVC thrombus between January 1, 2001, and December 31, 2014, in a single institution were identified, and data reviewed for demographics, performance status, and tumor thrombus levels. Pathological and operative outcomes were analyzed in the surgical cohort (Sx). Survival outcomes were computed with Kaplan-Meier analysis. Prognostic factors were determined using univariate and multivariate analyses. Statistical significance was defined as P < 0.1. Results: There were 51 patients identified, comprising 31 and 20 in the Sx and nonsurgical (NSx) cohorts. For the Sx cohort, 5-year OS and recurrence-free survival were 48% and 45%, respectively, with a median OS of 51.7 months. Nodal involvement was an independent predictor for OS (P < 0.1) on multivariate analysis. In the NSx cohort, 75% (15/20) had distant metastasis at diagnosis, with a 5-year OS of 13.4 months. Patients with better baseline ECOG statuses had better survival outcomes (P < 0.1). The mean OS of patients (n = 5) with M0 disease was 18.8 months. The advantage conferred by surgery was a 38.2-month longer median OS (P < 0.0001). In the Sx cohort, 87% had no or minor perioperative complications. Conclusion: Nephrectomy and IVC thrombectomy have an OS survival advantage of 38.2 months with acceptable perioperative morbidity. Therefore, it is preferred over an initial nonsurgical approach where possible.