Adam Lorentz

Renal cell carcinoma with inferior vena cava involvement: Prognostic effect of tumor thrombus consistency on cancer specific survival

Renal cell carcinoma forming a venous tumor thrombus (VTT) in the inferior vena cava (IVC) has a poor prognosis. Recent investigations have been focused on prognostic markers of survival. Thrombus consistency (TC) has been proposed to be of significant value but yet there are conflicting data. The aim of this study is to test the effect of IVC VTT consistency on cancer specific survival (CSS) in a multi‐institutional cohort.

Renal cell carcinoma with vena caval involvement: a contemporary clinicopathologic analysis of 53 cases

A clinicopathologic analysis of patients with renal cell carcinoma (RCC) and vena caval involvement diagnosed at our institution was performed. Multiple clinicopathologic parameters were examined. Fifty-three cases were identified. Mean patient age was 62 years (range, 40-82 years). The cohort comprised 36 of 53 (68%) men and 17 of 53 (32%) women. Mean primary tumor size was 10.4 cm (range, 3.1-21.0 cm). The breakdown of tumor stage was as follows: 37 of 53 (70%) were pT3b, 14 of 53 (26%) were pT3c, and 2 of 53 (4%) were pT4. Most of the tumors were clear cell RCC (45/53, 84.6%), although other variants were also represented. All cases were Fuhrman nuclear grade 3 (34/53, 64%) or 4 (19/53, 36%). Tumor necrosis was present in 41 of 53 (77%) cases. At the time of the initial tumor resection, 11 of 53 (21%) cases were staged pM1. Of the 42 patients staged as pMX at the time of primary tumor resection, 12 of 42 (29%) later developed metastasis, most commonly to the lungs. Of all 53 cases with these very advanced tumors, only 6 of 53 (11.3%) had positive surgical margins: 4 of 53 (7.5%) had positive vascular resection margins, and 2 of 53 (3.8%) had focally positive perinephric fat margins. The mean 5-year survival in our cohort was 50%. Our findings suggest that a select group of patients with RCC with vena caval involvement may benefit from radical nephrectomy, although some tumors may have positive vascular and/or nonvascular surgical resection margins even in the best surgical hands. Multi-institutional studies are needed to further characterize these advanced tumors from the molecular standpoint.

Impact of lymph node dissection at the time of radical nephrectomy with tumor thrombectomy on oncological outcomes: Results from the International Renal Cell Carcinoma-Venous Thrombus Consortium (IRCC-VTC)

OBJECTIVES To study the effect of lymph node dissection (LND) at the time of nephrectomy and tumor thrombectomy on oncological outcomes in patients with renal cell carcinoma (RCC) and tumor thrombus. PATIENTS AND METHODS The records of 1,978 patients with RCC and tumor thrombus who underwent radical nephrectomy and tumor thrombectomy from 1985 to 2014 at 24 centers were analyzed. None of the patients had distant metastases. Extent and pathologic results of LND were compared with respect to cancer-specific survival (CSS). Multivariable Cox regression models were used to quantify the effect of multiple covariates. RESULTS LND was performed in 1,026 patients. In multivariable analysis, the presence of LN metastasis, the number of positive LNs, and LN density were independently associated with cancer-specific mortality (CSM). Clinical node-negative (cN-) disease was documented in 573 patients, 447 of them underwent LND with 43 cN- patients (9.6%) revealing positive LNs at pathology. LN positive cN- patients showed significantly better CSS when compared to LN positive cN+ patients. In multivariable analysis, positive cN status in LN positive patients was a significant predictor of CSM (HR, 2.923; P = 0.015). CONCLUSIONS The number of positive nodes harvested during LND and LN density was strong prognostic indicators of CSS, while number of removed LNs did not have a significant effect on CSS. The rate of pN1 patients among clinically node-negative patients was relatively high, and LND in these patients suggested a survival benefit. However, only a randomized trial can determine the absolute benefit of LND in this setting.

MP16-03 UTILITY OF INFLAMMATORY MARKERS IN PROGNOSIS FOR PATIENTS WITH RENAL CELL CARCINOMA AND VENA CAVA TUMOR THROMBUS

INTRODUCTION AND OBJECTIVES: Nephrectomy and inferior vena cava (IVC) thrombectomy for renal cell carcinoma (RCC) with IVC involvement is associated with significant morbidity and mortality, making accurate prognosis valuable. Systemic inflammatory markers have shown to be prognostic in malignancy. We assess preoperative Creactive protein (CRP), albumin, and the modified Glasgow Prognostic Score (mGPS), which combines both assays, for prognostic utility in RCC with IVC thrombus. METHODS: From 2006-2016, one surgeon performed 149 cases of radical nephrectomy and IVC tumor thrombectomy. Only those with clear cell RCC and available laboratory data were included. Patients were assigned an mGPS score 0-2 based on preoperative lab values (01⁄4CRP 10 mg/L, 11⁄4CRP > 10 mg/L, and 21⁄4CRP > 10 mg/L and albumin < 3.5 g/dL). Other factors included in the analysis were age, gender, race, body mass index, 2009 AJCC pathologic T and M stages, necrosis, and nuclear grade. Also examined were well-established prognostic scoring systems, the University of California Los Angeles Integrated Staging System and the Mayo Clinic Stage, Size, Grade, and Necrosis scoring system. Log-rank and multivariable regression analysis examined overall survival (OS). RESULTS: Of 117 clear cell RCC patients with IVC thrombus, the mortality rate was 38.4% over a median follow-up period of 12.6 months (interquartile range 4.8-32.4 months). Patients with albumin < 3.5 g/dL represented 62.7% of the population and those with CRP > 10 mg/L represented 67.7%. Those with mGPS scores 0, 1, and 2 represented 32.3%, 14.4%, and 53.54%, respectively. CRP > 10 mg/L (HR 4.94, 95% 1.7-14.2, p<0.001), albumin < 3.5 g/dL (HR 2.16, 95% 1.14.3, p1⁄40.024), and mGPS1⁄42 (HR 5.56, 95% 1.9-16.1, p1⁄40.002) correlated with OS. After adjusting for other factors, only mGPS1⁄42 (HR 4.25, 95% 1.4-13.3; p1⁄40.01) was an independent predictor of OS. A secondary analysis of only non-metastatic patients maintained significance. CONCLUSIONS: For patients with RCC and IVC involvement, elevated CRP and low albumin correlate with OS. Combining albumin with CRP in the modified Glasgow Prognostic Score independently predicts OS. The mGPS could serve as a useful clinical adjunct with regard to follow-up counseling and clinical trial design. Source of Funding: None

MP57-12 CANCER-SPECIFIC SURVIVAL AND PREDICTORS IN PATIENTS WITH CT3B KIDNEY CANCER: DATA OF THE IRCVT RCC VENOUS THROMBUS CONSORTIUM

(P 1⁄4 0.180) or when adjusting for thrombus level, age, sex, T stage, N stage, presence of metastasis, and time under surgery (P 1⁄4 0.734). Median cancer-specific survival was 29.1 months (95% CI [21.2, 48.3]) in non-CPB patients and 39.4 months in CPB patients (95% CI [29.3, 80.0]). Cancer-specific survival did not differ significantly based on CPB, either in the univariate analysis (P 1⁄4 0.704) or in the multivariate analysis (P 1⁄4 0.888). In univariate analysis, length of stay (LOS) was estimated to be 26% higher in CPB patients (P 1⁄4 0.002) and the complication rate was marginally lower in CPB patients (P 1⁄4 0.053). However, in multivariable analysis, no significant difference was seen in hospital LOS (P 1⁄4 0.439) or complication rate with the use of CPB (P 1⁄4 0.457). CONCLUSIONS: In our multi-institutional analysis, the use of cardiopulmonary by-pass did not significantly impact cancer specific survival or overall survival in patients undergoing nephrectomy and level III or IV tumor thrombectomy. Higher surgical complications or longer hospital stay were not independently associated with the used of CPB.