Caval tumor thrombus volume influences outcomes in renal cell carcinoma with venous extension

Introduction: Surgery for renal cell carcinoma with tumor thrombus has a high potential morbidity rate, and the current clasification system based on proximal tumor thrombus level (TTL) has not been shown to consistently predict outcomes. Aim: To assess the prognostic value of inferior vena cava tumor thrombus volume (IVC-TV) for determining the perioperative complications as well as with survival end points. Methods: From June 2001 to June 2012, we identified 147 patients who underwent radical nephrectomy with venous thrombi. In total, 66 patients had IVC involvement and available imaging for review. IVC-TV was measured by cross-sectional area and height measurement for each axial slice. Linear, logistic models and Cox proportional hazard was used for analysis. Results: Median IVC-TV was 16.5 cm(3), and 18 patients had TTI >= III. In total, 57 Clavien I V complications were documented in 32 patients including 3 deaths. On multivariate analysis, age >65 years, American Society of Anesthesiologists >3, and IVC-TV > 15 cm(3) were independent predictors for perioperative complications. Disease progression (PoD) occurred in 78% of patients, and metastatic disease (hazard ratio [HR] = 333, P < 0.01) and non -clear cell histology (HR = 2.98, P = 0.02) were independent predictors of PoD. Median time to death was 16 months (interquartile range: 5.2-42.9), On Cox regression analysis, metastatic disease, non clear cell histology, IVC-TV > 15 cm(3), and TTI III/IV were significantly associated with overall survival. As a preoperative variable, IVC-TV > 15 cm(3) was shown to be an independent predictor of PoD (HR = 2.3, P = 0.01) and overall survival (HR = 2.21, P = 0.03). Conclusion: IVC-TV has value as a prognostic indicator, which is superior to TTL in the setting of renal cell carcinoma with IVC venous thrombus. (C) 2015 Elsevier Inc. All rights reserved.