Role of cytoreductive nephrectomy in renal cell cancer (RCC) with venous tumor thrombus.

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496 Background: RCC with tumor thrombus may require complex surgery to remove the primary tumor. Some patients with tumor venous thrombus and metastatic RCC are unlikely to benefit from cytoreductive nephrectomy. The purpose of this study was to identify risk factors for poor overall survival in metastatic RCC patients with tumor thrombus. Methods: Patient data was collected from 4 centers for patients with mRCC and venous thrombus at presentation treated surgically from 2000-2014. Kaplan Meier analysis was used to estimate OS using two prognostic classification systems (MSKCC, IMDC) assessed at time of surgery. MDACC criteria (Cancer 2010) were calculated to estimate potential benefit from cytoreductive nephrectomy. Univariate and multivariate Cox proportional hazard models were used to evaluate the association of individual variables with OS. Results: A total of 293 patients were evaluated and median OS (IQR) was 17.2 (6.4-41.0) months for the entire cohort. Venous thrombus level (Neves classification) was 0,1,2,3, and 4 for 77, 38, 104, 45, and 29 patients respectively. Median OS (IQR) was worse (p = 0.03) for patients with IVC thrombus above the diaphragm 6.8 (2.2-19.1) months compared to renal vein only thrombus 18.8(8.1-37.8) months or IVC thrombus below the diaphragm 18.9 (6.7-44.5) months. Using MSKCC criteria, patients were classified as favorable (21), intermediate (213) or poor risk (59). MSKCC risk grouping was not predictive of OS (p = 0.14). Using IMDC criteria, patients were classified as favorable (24), intermediate (176) or poor risk (93). IMDC risk grouping was not predictive of OS (p = 0.99). Using MDACC criteria, patients were divided into favorable (258) and unfavorable (35) groups. Median OS was higher (p = 0.008) in favorable risk patients, 18.8 (7.2-43.7) vs. 8.2 (2.3-28.2) months. Preoperative variables that were independent predictors of OS included: body mass index, IVC thrombus above diaphragm, lactate dehydrogenase > ULN, and retroperitoneal lymphadenopathy. Conclusions: Metastatic RCC patients with IVC thrombus above the diaphragm or patients classified as unfavorable using MDACC criteria have poor OS and may not benefit from cytoreductive nephrectomy in the presence of venous tumor thrombus.