Inferior Vena Cava Tumor Thrombosis Research Articles

Comparative analysis of dual immune checkpoint inhibitor combination therapy versus immune checkpoint inhibitor plus tyrosine kinase inhibitor combination therapy for renal cell carcinoma with inferior vena cava tumor thrombosis.

Whether immune checkpoint inhibitor (ICI) plus ICI combination therapy or ICI plus tyrosine kinase inhibitor (TKI) combination therapy is useful for renal cell carcinoma (RCC) with inferior vena cava tumor thrombosis (IVCTT) remains unclear. We retrospectively evaluated the therapeutic effects and incidence of treatment-related adverse events (TRAEs) associated with ICI-based combination therapy in 36 patients with advanced RCC with IVCTT. The median age at initiation of treatment was 71years; the IVCTT stages were cT3b in 22 patients and cT3c in 14. The ICI-ICI and ICI-TKI groups comprised 15 and 21 patients, respectively. Median tumor shrinkage at the best response showed that the primary tumor diameter decreased by 1.8cm (22%), and the IVCTT height decreased by 1.5cm (26%). A higher proportion of patients in the ICI-TKI group experienced tumor shrinkage than those in the ICI-ICI group (primary tumor, p = 0.0325; IVCTT, p = 0.0112). Approximately 27% of patients experienced an increase in the IVCTT height with ICI-ICI combination therapy. No significant difference was observed in the relative tumor shrinkage of IVCTT, primary or level-down staging of IVCTT, other treatment effects, incidence of TRAEs, surgical outcomes, or prognosis between the groups. ICI-based combination therapy is effective against IVCTT and primary RCC. Although ICI-ICI is associated with a higher probability of tumor growth compared with ICI-TKI in the frequency of tumor regression, both therapies may be almost equally effective against primary RCC with IVCTT.

Efficacy of TACE Combined with Lenvatinib Plus Sintilimab for Hepatocellular Carcinoma with Tumor Thrombus in the Inferior Vena Cava and/or Right Atrium.

To validate the safety and effectiveness of transarterial chemoembolization (TACE) combination with lenvatinib and sintilimab in treating hepatocellular carcinoma (HCC) patients with inferior vena cava (IVC) and/or right atrium (RA) tumor thrombosis (TT). This study retrospectively analyzed HCC patients with IVC and/or RA TT treated with TACE combined with lenvatinib plus sintilimab. Overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and disease control rate (DCR) were calculated to evaluate the anti-tumor efficacy. Treatment-related adverse events (TRAEs) were analyzed to assess the safety profiles. A total of 58 patients were screened for eligibility between March 2019 and May 2022. At the time of data collection, 48.2% of patients were still receiving treatment. The median follow-up was 23.5 months. The ORR was 48.3%, the DCR was 91.4%, the median OS was 17.3 months, and the median PFS was 13.0 months. The ORR for IVC/RA TT was 62.1%, DCR was 94.9%, and the median PFS was 14.3 months. 56.9% of patients experienced ≥ grade 3 TRAEs, such as hypertension (10.3%) and elevated liver enzymes (13.8%). No new safety signals were identified. Participants with low levels of serum PCT value had satisfactory prognoses. TACE combination with lenvatinib plus sintilimab is effective in treating HCC with IVC and/or RA TT. The toxicities were manageable, with no unexpected safety signals. The baseline levels of serum PCT might be the predictive biomarkers for the triple combination therapy.

Response and Survival in Patients of BCLC Stage C Hepatocellular Carcinoma Receiving SBRT and Immunotherapy

<h3>Purpose/Objective(s)</h3> Immune checkpoint inhibitors (ICI) demonstrated antitumor activity has been increasingly used as first-line or second-line treatments for patients with advanced hepatocellular carcinoma (HCC). In the meanwhile, radiotherapy is turning into a crucial component of multidisciplinary treatment for HCC. Mounting evidence suggests local radiotherapy including SBRT might promote immunogenic tumor cell death and could enhance immunotherapeutic effects in several cancers. However, evidence on advanced HCC is few. Here we report the efficacy and safety of combined SBRT and immunotherapy in patients of BCLC stage C HCC in our center. <h3>Materials/Methods</h3> This is a retrospective analysis of twenty-nine patients with advanced HCC, previously treated with sorafenib or lenvatinib, who received SBRT and anti-PD1 antibody concomitantly or sequentially. Here we report their treatment responses both in-field and outside the radiation field according to RECIST1.1 criteria, progression-free survival (PFS), overall survival (OS), and toxicities. <h3>Results</h3> The median age was 55.1 years (range, 25-75), 90% of patients were male, eighty percent had hepatitis B virus and all patients' Child-Pugh score ≤ B7. Among these patients, twenty-one (70%) had portal vein tumor thrombosis (PVTT), four (13.3%) had inferior vena cava tumor thrombosis and nineteen (63.3%) had extrahepatic metastasis. Eight patients had both extrahepatic metastases and PVTT. 86.2% of patients were also treated with second-line targeted therapy. Tumors treated with SBRT located in liver (52.7%), lung (33.3%), bone (11.2%) and retroperitoneal lymph nodes (2.8%). SBRT administration was a median of 40Gy (range, 25-60) and 5 fractions (range, 3-6). The median follow-up was 16.5 months (range, 6-58). The in-field ORRs were 82.8% and the DCR were 100% (CR 20.7%, PR 62.1%, four bone lesions and one lymph nodes were SD). The out-field ORRs were 27.6% and the DCR were 86.2%. The median PFS was 7 months (95% CI, 1-24 months). Six months PFS rate was 53.3% and 1-year PFS rate was 32.6%. At the time of data cutoff, the median duration of OS has not reached. 1-year OS rate was 62.1% and 2-years OS rate was 50.5%. The prognosis of patients with PVTT was worse than those patients without PVTT (2-years OS rate 35.07% vs 88.89%; p=0.04). Treatment-related AEs consisted of platelet count decrease in four patients, alanine/aspartate aminotransferase increase in five patients and myocarditis in one patient. No SBRT-related grade 3 or higher adverse events occurred. <h3>Conclusion</h3> Our experience suggests that combined SBRT and second line ICI with or without targeted drug can be a safe and effective therapy for BCLC stage C HCC. Further prospective trials are warranted.

Етапність хірургічних маніпуляцій при раку лівої нирки з імплантаційним венозним тромбом

Introduction. Defeat of the left kidney by cancer and left-sided tumor venous invasion are diagnosed almost half as often as the right one. Only radical treatment for renal cancer (RC) complicated by a tumor thrombus of the inferior vena cava (IVC) is considered to be surgical. The use of aggressive surgery, which involves the implementation of radical nephrectomy and thrombectomy with IVC, leads to a number of complications that can be prevented by improving surgical techniques. Insufficiently covered issues of surgical tactics in left kidney cancer with implantation venous thrombus lead to their detailed discussion. Objective. To improve the results of surgical treatment of left renal cancer complicated by implantation thrombus of IVC by developing a differentiated approach to access and stages of surgical procedures. Materials and methods. The study included 147 patients with RC complicated by IVC tumor thrombosis, of which 96 (65.3%) – with right renal cancer, 51 (34.7%) – with left renal cancer. All patients underwent surgical treatment at the Transcarpathian Regional Clinical Hospital named after Andriy Novak or the Transcarpathian Antitumor Center in the period from 2005 to 2020. The level of spreading of tumor thrombus by IVC was determined according to the classification of the Mayo clinic. At defeat of the left kidney by a tumor 0 the level of a thrombus was diagnosed in 17 (33,3%) patients, I level – in 17 (33,3%), II level – in 10 (19,6%), III level – in 5 (9,8%), IV level – in 2 (3,4%). In 6 (11,8%) cases, the implantation thrombus of the IVC was combined with retrograde spread to the left adrenal and left gonadal veins, and in 12 (23,5%) – with descending phlebothrombosis of the IVC and the common iliac vein. All patients underwent surgery with a «chevron» or «mercedes» transabdominal approach using the en block organ mobilization technique in the right and left abdominal and retroperitoneal regions. Results. The average time of the operation was 196 minutes, the average volume of blood loss was 400 ml. The spleen was injured during surgery in 2 (3.9%) patients. Tumor IVC thrombus was removed in all (100%) cases. Postoperative complications of I-II degrees according to the Clavien-Dindo classification were recorded in 12 (23,5%) cases. Overall 1, 3, 5 year survival was 98,0%; 70,6%; 47,1% respectively. The use of the presented stages in the surgical treatment of left kidney tumors with implantation IVC thrombus made it possible to perform radical intervention in all cases: cavatrombectomy and nephrectomy, without episodes of pulmonary embolism, without significant bleeding and without repeated thrombosis. Conclusion. Transabdominal «chevron» or «mercedes» access with the use of the «en block» organ mobilization technique in the right and left sides of the abdominal cavity and retroperitoneal space, priority complete control of IVC and renal veins with priority performance of the venous stage of the operation and transfer of the stump of the left renal vein through the mesenteric window of the small intestine to the left provide successful radical surgical treatment of patients with left renal cancer with implantation venous thrombus.

Venous Tumor Thrombosis and Pulmonary Metastases in a Case of Adrenal Neuroblastoma—Occurrence of Two Rare Manifestations in a Single Patient: Case Report and Review of Literature

AbstractUnlike other pediatric extra cranial solid neoplasms, neuroblastomas have very low incidence of pulmonary metastases. Neuroblastomas also tend to encase rather than infiltrate the major vessels with very low incidence of tumor thrombus. Even in cases with inferior vena cava tumor thrombosis, pulmonary metastases are a rare occurrence. These patients usually show widespread disseminated disease at presentation. We present a rare case of adrenal neuroblastoma with tumor thrombus and bilateral pulmonary metastases at presentation. This presentation can be confused with adrenocortical carcinoma and differentiating between the two is essential for further management.

Long-term survival after anterior approach right hepatectomy combined with inferior vena cava thrombectomy using trans-diaphragmatic intrapericardial inferior vena cava occlusion: a case report and review of the literature

BackgroundPresence of inferior vena cava tumor thrombosis (IVCTT) is an unfavorable factor to prognosis for patients with hepatocellular carcinoma (HCC).Case presentationHerein we report a case of HCC with IVC tumor thrombosis extending from the right hepatic vein (RHV) to the IVC, but it had not infiltrated the right atrium. Anterior approach right hepatectomy combined with IVC thrombectomy using trans-diaphragmatic IVC occlusion was performed for this patient. The patient is alive with disease-free at 32 months after treatment. A literature review was also performed. This case was demonstrated with the details and concepts of surgery.ConclusionThis case suggested that surgical resection of HCC involving the IVC, but still outside the right atrium (RA), could offer satisfactory surgical outcomes in selected patients.

The loss of BAP1 protein expression predicts poor prognosis in patients with nonmetastatic clear cell renal cell carcinoma with inferior vena cava tumor thrombosis

ObjectivesRenal cell carcinoma (RCC) is characterized by a propensity for extension into the renal vein and inferior vena cava (IVC) and is associated with poor prognosis. BAP1 mutation, which occurs in about 15% of patients with clear cell RCC (ccRCC), also predicts poor prognosis. The aim of this study was to elucidate the association between BAP1 protein expression and clinicopathological outcomes in patients with nonmetastatic ccRCC with an IVC tumor thrombus (IVCTT). Material and methodsThirty-five patients with nonmetastatic ccRCC with an IVCTT who underwent radical nephrectomy and tumor thrombectomy at our institution from 1999 to 2010 were retrospectively evaluated. Immunohistochemical (IHC) analyses were performed for the expression of BAP1 protein, and the associations between the expression of BAP1 and clinical outcomes were assessed. Survival analyses were performed using the Kaplan-Meier method and log-rank test. Multivariate analyses of the associations between disease-free survival (DFS) and clinical variables including BAP1 protein expression, tumor size, Karnofsky performance status (KPS) score, and the extension level of the tumor thrombus were performed using a Cox proportional hazard model. ResultsThe median follow-up time was 58.8 months (range: 2–130 months). The median age was 68 years (range: 37–80 years). The median size of the primary tumor was 9.6cm (range: 3.0–15.0cm). The IVCTT extended above and below the diaphragm in 10 (28.6%) and 25 (71.4%) patients, respectively. The KPS score was>80 in 23 patients (65.7%). BAP1 protein expression on IHC was positive in 24 cases (68.8%) and negative in 11 cases (31.2%). The median overall survival in cases with BAP1-negative and -positive tumor on IHC staining were 44.7 and 81.5 months, respectively (P = 0.052). BAP1-negative tumor on IHC staining was associated with a significantly shorter DFS than BAP1-positive tumor (median DFS = 10.0 vs. 26.0 months, respectively; P = 0.011). Multivariate analysis showed that only BAP1-negative tumor on IHC staining was significantly associated with shorter DFS (P = 0.004). ConclusionsPatients whose tumors had loss of BAP1 protein expression were significantly associated with poor prognosis in patients with ccRCC with an IVCTT who underwent radical nephrectomy and tumor thrombectomy.

Adult Wilms tumor with inferior vena cava thrombus and distal deep vein thrombosis \u2013 a case report and literature review

BackgroundAdult Wilms tumor (WT, nephroblastoma) is a rare, but well-described renal neoplasm. Although inferior vena cava tumor thrombosis is present in up to 10% of Wilms tumors in childhood, only few cases of this clinical manifestation in adults have been reported. To the best of our knowledge, this is the first case of adult WT infiltrating into inferior vena cava (IVC) with concomitant distal deep vein thrombosis.Case presentationA 28-year-old male patient with gross hematuria and right flank pain was diagnosed with right kidney tumor penetrating to IVC. Preoperatively, acute distal thrombosis in inferior vena cava and lower extremities veins occurred. Right radical nephrectomy with tumor thrombectomy via cavotomy was performed. In order to prevent pulmonary embolism, IVC was ligated below left renal vein level. Histopathological examination revealed a triphasic nephroblastoma without anaplastic features. Postoperatively, patient was diagnosed with metastatic liver disease, which was treated with two lines of chemotherapy followed by radiotherapy with achievement of complete response.ConclusionsAdult WT occurs usually in young patients, under 40 years of age. Neoadjuvant chemotherapy proved to be effective in children, resulting with tumor shrinkage and venous tumor thrombus regression. Therefore, percutaneous biopsy should be always considered in young patients presenting with renal tumor invading venous system. IVC ligation is a safe treatment option in the event of complete inferior vena cava occlusion due to distal thrombosis concomitant to tumor thrombus, provided collateral venous pathways are well-developed.

P100 - Our experience of laparoscopic surgery of inferior vena cava tumor thrombosis in patients with renal cell carcinoma

P100 - Our experience of laparoscopic surgery of inferior vena cava tumor thrombosis in patients with renal cell carcinoma

Efficacy of Proton Beam Therapy for Hepatocellular Carcinoma With Portal Vein or Inferior Vena Cava Tumor Thrombosis

Vascular invasion, such as portal vein tumor thrombosis (PVTT) and inferior vena cava tumor thrombosis (IVCTT), is a common condition in advanced hepatocellular carcinoma (HCC). HCC patients with PVTT or IVCTT have an extremely poor prognosis. In order to clarify the clinical outcome of proton beam therapy (PBT) for HCC with PVTT or IVCTT, this prospective study was performed. This was a clinical study for HCC with PVTT or IVCTT using PBT based on protocols determined at Nagoya Proton Therapy Center. The primary and secondary endpoints were overall survival (OS) and complication rates, respectively. The number of patients required for this study was estimated to be 31 using the chi-square test (type 1 error=0.05, power=0.8, P0=0.3, P1=0.6). Response after PBT was evaluated using modified RECIST. OS rates were calculated using the Kaplan-Meier method and were compared using the log-rank test. Toxicities were graded according to the common terminology criteria for adverse events (v4.03). Between September 2013 and January 2017, 34 patients (27 males and 7 females) were enrolled, assuming dropout of a few patients. The median follow-up period was 8.4 months (interquartile range (IQR), 4.7-19.1). Median patient age was 68 years (IQR, 61-73). Twenty patients had Child-Pugh A liver function, 12 had Child-Pugh B, and 2 had Child-Pugh C. Etiology of HCC was hepatitis B (7), hepatitis C (18), alcoholism (5), autoimmune hepatitis (1), and nonalcoholic steatohepatitis (1). Median alpha-fetoprotein and PIVKA-II levels were 171.2 ng/mL (IQR, 28.9-5241.3) and 2620 mAU/ml (IQR, 135-12800), respectively. Median gross tumor volume was 220.0 ml (IQR, 87.6-620.6). The median biologically effective dose 10 (BED10) was 81.3 GyE (IQR, 75-96.6). Twenty-one (62%) lesions achieved a complete (15%) or partial response (47%). Stable and progressive diseases were observed in 12 (35%) and 1 (3%), respectively. Tumor thrombosis was present in the portal vein trunk (15), portal vein branch (18), or inferior vena cava (8). The 1-year OS rate was 55%. Eighteen patients in whom all tumors could be included in the irradiation field had good prognoses (P<0.05). The prognoses of 16 patients whose tumor thrombosis shrank after irradiation were good (P<0.05). One patient had grade 3 acute dermatitis. Grade 3 liver enzyme elevation was observed in 2 patients at 3 months after radiotherapy. However, no severe radiation-induced liver disease was observed. No late gastrointestinal symptoms with grade 3 or higher toxicity, such as ulceration, bleeding, perforation, and ileus were recorded. PBT for advanced HCC with PVTT or IVCTT is a safe and effective treatment without severe complications. When all the tumors can be included in the irradiation field, PBT may be effective even for large HCC.

Renal Cell Carcinoma Associated with Xp11.2 Translocation/TFE3 Gene Fusions: Clinical Features, Treatments and Prognosis.

To investigate the clinical characteristics, treatments and prognosis of renal cell carcinoma associated with Xp11.2 translocation/TFE3 gene fusions (Xp11.2 tRCC), the epidemiological features and treatment results of 34 cases of Xp11.2 tRCC, which were diagnosed by immunohistochemistry staining of TFE3 and fluorescence in situ hybridization at our center, were retrospectively reviewed. The 34 patients included 21 females and 13 males aged 3 to 64 years (median age: 27 years). Four patients were children or adolescents (<18 years of age), and 26 patients were young or middle-aged adults (18–45 years). Radical nephrectomy was performed on 25 patients. Laparoscopic nephron-sparing surgery was performed on 9 patients who presented with an isolated mass with a small diameter (<7 cm) and well-defined boundary on computed tomography imaging. Postoperative staging showed that 25 cases (73.53%) were at stage I/II, while 9 cases (26.47%) were at stage III/IV. All stage I/II patients received a favorable prognosis with a three-year overall survival rate of 100%, including the patients who underwent laparoscopic nephron-sparing surgery. With the exception of 2 children, the other 7 stage III/IV patients died or developed recurrence with a median follow-up of 29 months. On univariate analysis, maximum diameter, adjuvant treatment, TNM stage, lymph node metastasis, inferior vena cava tumor thrombosis and tumor boundary were identified as statistically significant factors impacting survival (P<0.05). Multivariate analysis indicated that TNM stage and inferior vena cava tumor thrombosis were independent prognostic factors (P<0.05). In conclusion, Xp11.2 tRCC is a rare subtype of renal cell carcinoma that mainly occurs in young females. Nephron-sparing surgery was confirmed effective preliminarily in the treatment of small Xp11.2 tRCCs with clear rims. Advanced TNM stage and inferior vena cava tumor thrombosis were associated with poor prognosis.

Long-term physiologic and oncologic outcomes of inferior vena cava thrombosis in pediatric malignant abdominal tumors

BackgroundThe long-term physiologic and oncologic outcomes of treatment for inferior vena cava (IVC) thrombosis in children with malignant abdominal tumors are unclear. MethodsWe conducted a retrospective review of children with malignant IVC tumor thrombosis treated at our institution between January 1996 and December 2011. Extent of tumor thrombus was classified using the Hinman system. Disease stage, management, and oncologic and physiologic outcomes and complications were evaluated. ResultsWe identified 15 patients (median age, 4.7years): 12 with Wilms tumor, 2 with hepatoblastoma, and 1 with adrenocortical carcinoma. Neoadjuvant chemotherapy changed Hinman levels in 2 (13%) patients. IVC thrombus resection was complete in 6 (40%) patients, partial in 7 (47%) patients, and not performed in 1 (6.7%) patient. On follow-up imaging, 8 (53%) patients' IVCs were patent, 6 (40%) had residual thrombus, and 1 (6.7%) was surgically interrupted. Three (20%) patients had perioperative complications, and 2 (13%) experienced transient effects related to IVC occlusion. ConclusionsSurgical management of tumor thrombus in the vena cava of children with solid abdominal tumors is challenging. Evidence on which to base strong treatment recommendations is lacking. Few long-term physiologic complications were observed.

Surgical treatment of hepatocellular carcinoma combined with inferior vena cava tumor thrombosis

Hepatocellular carcinoma (HCC) combined with inferior vena cava (IVC) tumor thrombosis is regarded unresectable.Most of the patients received non-surgical treatment or gave up treatment,and the prognosis of these patients is poor.As the development of surgical treatment,the success rate of surgical treatment for HCC combined with IVC tumor thrombosis is increasing yearly.In May of 2012,one patient with HCC combined with IVC tumor thrombosis received hepatic Ⅴ,Ⅶ and Ⅷ segmentectomy + tumor thrombosis removal from the IVC at the Second Affiliated Hospital of Harbin Medical University.Preoperative computed tomography showed space-occupying lesions in the segments Ⅴ,Ⅶ and Ⅷ,and the IVC was filled with tumor thrombi.The volume of the left liver was 489 cm3,which was under the limit for survival.In order to preserve the remnant liver,right hepatectomy with reservation of hepatic segment Ⅵ,and the tumor thrombi in the IVC were removed with total hepatic vascular exclusion.The patient was recovered with no tumor recurrence or metastasis at postoperative month 18. Key words: Liver neoplasms; Inferior vena cava tumor thrombosis ; Liver resection; Surgical technique

Effectiveness of Stereotactic Body Radiotherapy for Hepatocellular Carcinoma with Portal Vein and/or Inferior Vena Cava Tumor Thrombosis

BackgroundTo report the feasibility, efficacy, and toxicity of stereotactic body radiotherapy (SBRT) for the treatment of portal vein tumor thrombosis (PVTT) and/or inferior vena cava tumor thrombosis (IVCTT) in patients with advanced hepatocellular carcinoma (HCC).Materials and methodsForty-one patients treated with SBRT using volumetric modulated arc therapy (VMAT) for HCC with PVTT/IVCTT between July 2010 and May 2012 were analyzed. Of these, 33 had PVTT and 8 had IVCTT. SBRT was designed to target the tumor thrombosis and deliver a median total dose of 36 Gy (range, 30–48 Gy) in six fractions during two weeks.ResultsThe median follow-up was 10.0 months. At the time of analysis, 15 (36.6%) achieved complete response, 16 (39.0%) achieved partial response, 7 (17.1%) patients were stable, and three (7.3%) patients showed progressive disease. No treatment-related Grade 4/5 toxicity was seen within three months after SBRT. One patient had Grade 3 elevation of bilirubin. The one-year overall survival rate was 50.3%, with a median survival of 13.0 months. The only independent predictive factor associated with better survival was response to radiotherapy.ConclusionsVMAT-based SBRT is a safe and effective treatment option for PVTT/IVCTT in HCC. Prospective randomized controlled trials are warranted to validate the role of SBRT in these patients.

Three-Dimensional Conformal Radiotherapy for Hepatocellular Carcinoma in Patients Unfit for Resection, Ablation, or Chemotherapy: A Retrospective Study

Purpose. The purpose is to evaluate the feasibility, efficacy, and the toxicity of three-dimensional conformal radiotherapy (3DCRT) in patients with advanced hepatocelluar carcinoma (HCC) and inferior vena cava tumor thrombosis (IVCTT). Methods. Between 2007 and 2012, in a retrospective way, 9 patients (median age 69 years) with advanced HCC and IVCTT unfit for surgery, radiofrequency ablation, embolization, or chemotherapy were treated with three-dimensional conformal radiotherapy (3DCRT). The radiotherapy volume included both primary tumor and IVTT. The radiotherapy schedule was 50–52 Gy in 2 Gy fractions. Overall survival (OS), response to radiotherapy, visual analogue scale (VAS), and toxicity were assessed. Results. All patients demonstrated a response rate up to 60%. During radiotherapy, 3 patients experienced grade 1 nausea/vomit toxicity. All patients demonstrated an elevation of the liver enzymes (3 patients with grade 1 and 6 patients with grade 2). The mean VAS-score was decreased from 6.11 to 3.11, while the median overall survival was 24 months. Conclusion. 3DCRT achieves a very high local control rate and is suitable for patients with HCC and IVTT, while the documented radiation induced toxicity is moderate. It can be recommended for palliation in patients unable to undergo curative therapies.

Influence of Tumor Thrombus Location on the Outcome of External-beam Radiation Therapy in Advanced Hepatocellular Carcinoma With Macrovascular Invasion

The present study evaluates the influence of portal vein (PV) vs. inferior vena cava (IVC) tumor thrombosis sites on the effectiveness of external-beam radiation therapy (EBRT) in advanced hepatocellular carcinoma (HCC) with macrovascular invasion. We retrospectively reviewed 181 HCC patients with PV and/or IVC tumor thrombi who were referred for EBRT at our institution between 2000 and 2009. EBRT was designed to focus on the tumor thrombi with or without primary intrahepatic tumors to deliver a median total conventional dose of 50 Gy (range, 30-60 Gy). Predictors of survival were identified using univariate and multivariate analyses. The median survival was 10.2, 7.4, 17.4, and 8.5 months for patients with PV branch, PV trunk, IVC, and PV plus IVC tumor thrombosis, respectively. Unfavorable pretreatment predictors were associated by multivariate analysis with lower albumin and higher α-fetoprotein levels, poorer Child-Pugh liver function classification, multiple intrahepatic foci, lymph node metastases, thrombus location, less chance to receive post-EBRT transarterial chemoembolization (TACE) and the two-dimensional EBRT technique. In comparison to patients with PV tumor thrombosis, patients with IVC thrombi had a higher occurrence of solitary intrahepatic lesions (p = 0.027), well-controlled intrahepatic tumors (p < 0.001), and a better response to EBRT (p < 0.001), and they were more likely to receive post-EBRT TACE (p = 0.033). In HCC, patients with IVC thrombus treated with EBRT had a better response rate and longer survival than those with PV thrombus.

Nephron-sparing procedures in 11 patients with Wilms' tumor.

In unilateral Wilms' tumor (WT), tumor nephrectomy is the standard surgical approach, whereas partial nephrectomy (PN) is controversially discussed. The aim of our retrospective study was to show that in selected cases of unilateral WT kidney-sparing operations could be a reasonable alternative to nephrectomy and to discuss the results of patients with bilateral WT treated by tumor enucleation. From 1981 to 1998, seven patients with unilateral nephroblastoma (four stage I, one stage III and two stage IV) had tumor resection by PN (five right side, two left side), which was planned when the tumor volume was reduced after 4 to 6 weeks of chemotherapy by at least 50%, when the tumor occupied one pole or was easily resectable, when 50% or more of the kidney tissue remained and when paraaortic lymph nodes were free by intraoperative histological examination. In four patients with bilateral WT (stage V) bilateral tumor enucleation was carried out-except in one patient in whom the contralateral kidney had to been removed because of extension of the tumor via the inferior vena cava to the right atrium. All patients ( n = 11) received pre- and postoperative chemotherapy followed by radiotherapy in four patients. All patients with unilateral WT ( n = 7) are still alive and disease free (follow-up time: mean 6.6 years, range: 28 months to 11 years) with normal renal function, although two patients with secondary nephrectomy revealed creatinine clearance levels at the lower range. In six patients primary PN was performed successfully. In a stage III tumor patient (intraperitoneal metastasis, free lymph nodes), secondary nephrectomy was necessary due to renal arterial thrombosis 2 days after PN. In one stage IV tumor patient (lung metastasis, free lymph nodes), the primary resection was not far enough away from the tumor margin so that an additional slice of tissue with then tumor-free margins had to be resected. This patient evolved a local relapse 19 months after PN and had to be nephrectomised thereafter. In the group of bilateral WT patients ( n = 4), one child died 2 months after surgery during chemotherapy because of central venous line sepsis. One patient who additionally suffered from inferior vena cava tumor thrombosis extending to the right atrium making nephrectomy of the right kidney necessary developed chronic renal failure 4.7 years postoperatively. The other two stage V tumor patients have creatinine clearance levels within the normal range. Kidney-sparing procedures remain the operative approach of choice in patients with bilateral WT, but bear the risk of chronic renal failure when one kidney has to be removed. PN in children with unilateral WT, carried out by an experienced surgeon, is a reasonable alternative to nephrectomy if strict guidelines such as excellent tumor response to preoperative chemotherapy and easy resectability far away from the tumor margins through healthy kidney tissue are followed. Paraaortic lymph nodes must be free of tumor invasion in order to avoid local radiotherapy. PN prevents the patient from having to have dialysis in cases of contralateral nephrectomy resulting from metachronous WT or subsequent renal trauma.