Thrombus Level Research Articles

Neoadjuvant toripalimab plus axitinib for clear cell renal cell carcinoma with inferior vena cava tumor thrombus: NEOTAX, a phase 2 study

The potential benefit of neoadjuvant toripalimab plus axitinib in cases with clear cell renal cell carcinoma (ccRCC) and inferior vena cava tumor thrombus (IVC-TT) remains unclear. NEOTAX was a phase 2 study to investigate the efficacy and safety of neoadjuvant toripalimab plus axitinib in patients with ccRCC and IVC-TT (ChiCTR2000030405). The primary endpoint was the down-staging rate of IVC-TT level. Secondary endpoints included change in TT length, response rate, percentage change in surgical approach, surgical morbidity, progression-free survival (PFS), safety, and biomarker analyses. In all, 25 patients received study treatment, 44.0% (11/25) patients had a reduction in thrombus level, and none experienced an increase in Mayo level. The median change in tumor thrombus length was −2.3 cm (range: −7.1 to 1.1 cm). Overall, 61.9% (13/21) patients experienced changes in surgical strategy compared with planned surgery, three patients experienced major complications. The median PFS was 25.3 months (95% CI: 17.0-NE). The 1-year PFS was 89.1% (95% CI: 62.7–97.2). No any of grade 4 or 5 treatment-related adverse event was identified. Biopsy samples of non-responders exhibited increased T cytotoxic cell infiltration, but these cells were predominantly PD-1 positive. Biopsy samples of responders exhibited lower T helper cells, however, their subtype, regulatory T cells remained unchanged. In surgical samples of the TT, non-responders exhibited increased CD8T_01_GZMK_CXCR4 subset T cells. NEOTAX met preset endpoints proving that toripalimab in combination with axitinib downstages IVC-TT in a significant proportion of patients leading to simplification in the procedure of surgery.

Renal cell carcinoma with inferior vena cava thrombus: Survival and prognostic factors in surgically treated patients

Introduction: Renal cell carcinoma (RCC) often develops a tumor thrombus extending into the inferior vena cava (IVC). Radical nephrectomy with IVC thrombectomy is the standard treatment, although prognostic factors are yet to be properly established. Objectives: The objectives of this study were to review the clinicopathological features of surgically treated patients with RCC and IVC thrombus and to investigate potential prognostic factors. Materials and Methods: This retrospective analysis covered patients with RCC and IVC thrombus who underwent surgical treatment at a tertiary center over 12 years. Results: Of the 32 patients included, 56% and 41% had nodal (N1) and metastatic (M1) diseases, respectively. Thrombus level was 1 in 25% and 4 in 21.9% of cases, according to the Mayo classification. The median follow-up was 17.0 months. The median overall survival (OS) was 20.0 months, with a median OS of 36.0 months in M0 patients and 10.0 months in M1 patients (log-rank P = 0.029). Stage IV disease (T4 and/or M1 status) (hazard ratio [HR]: 2.85, P = 0.021), fat invasion (HR: 2.52, P = 0.044), positive margins (HR: 2.54, P = 0.037), American Society of Anesthesiologists score (HR: 2.59, P = 0.033), tumor size >100 mm (HR: 2.538, P = 0.033), and higher neutrophil-to-lymphocyte ratio (r 2 = 0.304, P = 0.001) were significantly associated with worse OS in univariate analysis. Thrombus level did not impact prognosis. Conclusions: Certain clinicopathological factors, but not thrombus level, appear to influence prognosis. Prospective multicentric randomized studies are needed to better stratify patient risk, improve prognostic prediction, and evaluate systemic therapy responses.

Renal Cell Carcinoma With Tumor Thrombus Extending Into the Inferior Vena Cava and the Right Atrium Demonstrated by 68 Ga-DOTATATE PET/CT.

Approximately 10% of all renal cell carcinoma (RCC) patients develop a venous tumor thrombus, a major negative prognostic factor. Surgical excision is commonly required for RCC patients with tumor thrombus. Accurate preoperative diagnosis and assessment of tumor thrombus level is vital because the level of thrombus may influence treatment decisions. MRI, contrast-enhanced CT, 18 F-FDG PET/CT, and 68 Ga-PSMA PET/CT have been used to diagnose and evaluate the extent of tumor thrombus in RCC. However, no case of RCC with inferior vena cava tumor thrombus showing 68 Ga-DOTATATE uptake has been reported yet. Herein, we report a case of metastatic RCC with tumor thrombus in the inferior vena cava on 68 Ga-DOTATATE PET/CT.

PRESENTATIONS AND OUTCOMES OF AORTOFEMORAL BYPASS GRAFTING

Objectives: The aim of the study is to study presentations and clinical outcomes in patients undergoing Aortofemoral Bypass Grafting Surgery (AFB). Design: This was a Hospital based prospective study. Materials And Methods: During 18 months period , 20 patients (mean age = 56 years) underwent AFB. Indications comprised of occlusive disease with Intermittent Claudication (IC) (n=10), Critical Limb Ischaemia (CLI)(n=4), Resting Pain (RP) (n=4) and Tissue Loss (TL) (n=2). Results: From Jan 2023 to June 2024, AFB was performed more frequently for IC (50%) vs rest of other indications. 30 day observations / follow up showed infection in 5%, Graft occlusion in 5% for which patient underwent emergency graft thrombectomy, Amputation in 10% due to gangrenous changes and 15% mortality. Graft patency was found to be triphasic in 90% cases. Hypertension was leading risk factor (85%) followed by Diabetes Mellitus(70%) and smoking (65%). Predictors of morbidity included CKD (25%), CAD (25%), COPD (20%), CVA (20%).90% Patients were operated via thoracotomy approach and 10% were operated via abdominal approach depending on level of aortic thrombus. 20% of patients had previous history of endovascular interventions followed by stent occlusion. Conclusion: In era of endovascular intervention, Aortofemoral Bypass Surgery is more likely to be performed for Intermittent Claudication and graft patency has a better outcome.

Thrombectomy under deep hypothermic circulatory arrest (DHCA) for renal cell carcinoma with atrio-caval thrombus

Renal cell carcinoma accounts for 85–90 % of all primary renal neoplasms and has the propensity to expand and directly invade contiguous structures such as the inferior vena cava predisposing to thrombus formation in approximately 10 % of cases. Overall, 70 % of patients survive for 5 years. While several classifications have been published to characterize the level of thrombus involvement and subsequently define the appropriate surgical treatment, the prognosis of such remains to be ascertained. Furthermore, controversies exist as to the most appropriate surgical approach particularly for atrial thrombus (Level IV). Although traditionally such thrombus level is addressed using cardiopulmonary bypass with or without deep hypothermic arrest, there have been recent reports of a less invasive maneuver using a transdiaphragmatic approach, essentially milking the thrombus down, avoiding sternotomy. We present our initial case of a 59-year-old male having a right renal mass with extensive thrombus from the inferior vena cava up to the right atrium managed with radical nephrectomy and thrombectomy under cardiopulmonary bypass with deep hypothermic circulatory arrest. Patient remains tumor-free after 1 year of follow-up.

Outcomes after radical nephrectomy with vena cava thrombectomy using multidisciplinary approach: A single center experience

IntroductionTo describe the perioperative outcomes in patients treated with radical nephrectomy with cava thrombectomy at all thrombi levels using a multidisciplinary approach, with or without extracorporeal circulation (ECC), and to identify factors associated with perioperative morbidity. MethodsWe retrospectively identified 42 patients who were diagnosed with renal cell carcinoma (RCC) and a vena cava thrombus and treated with radical nephrectomy and cava thrombectomy by a double surgical team at Lyon University Hospital from 2008 through 2021. The surgeons operated in the cardiothoracic operating theater to proceed with median sternotomy or ECC, if necessary. The primary endpoint of this study was perioperative morbidity and mortality assessed using the Clavien-Dindo scale. Complications were recorded until 90 days after surgery, and those classified as grade IIIa or higher were considered high-grade complications. ResultsOverall, 32 (76%) patients required ECC. No intraoperative mortality occurred; however, two patients (5%) died within 30 days. Complications occurred within 30 days in 30 patients (72%), with severe complications observed in 10 patients (24%). No further complications occurred between 30 and 90 days. Multivariate analysis revealed that age, thrombus level, ECC, American Society of Anesthesiologists physical status, symptoms, and metastasis at presentation were not significantly associated with high-grade complications (P>0.05). ConclusionsMultidisciplinary approach is essential and frequent use of ECC, when achieved by a trained team, may facilitate surgery, and is associated with low perioperative morbidity, especially for patients with high-level thrombi. Level of evidenceIV.

Safety and Feasibility of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy With Calcium-Containing Solutions: A Randomized Controlled Trial.

Calcium-free (Ca-free) solutions are theoretically the most ideal for regional citrate anticoagulation (RCA) in continuous renal replacement therapy (CRRT). However, the majority of medical centers in China had to make a compromise of using commercially available calcium-containing (Ca-containing) solutions instead of Ca-free ones due to their scarcity. This study was designed to probe into the potential of Ca-containing solution as a secure and efficient substitution for Ca-free solutions. In this prospective, randomized single-center trial, 99 patients scheduled for CRRT were randomly assigned in a 1:1:1 ratio to one of three treatment groups: continuous veno-venous hemodialysis Ca-free dialysate (CVVHD Ca-free) group, continuous veno-venous hemodiafiltration calcium-free dialysate (CVVHDF Ca-free) group, and continuous veno-venous hemodiafiltration Ca-containing dialysate (CVVHDF Ca-containing) group at cardiac intensive care unit (CICU). The primary endpoint was the incidence of metabolic complications. The secondary endpoints included premature termination of treatment, thrombus of filter, and bubble trap after the process. The incidence of citrate accumulation (18.2% vs. 12.1% vs. 21.2%) and metabolic alkalosis (12.1% vs. 0% vs. 9.1%) did not significantly differ among three groups (p > 0.05 for both). The incidence of premature termination was comparable among the groups (18.2% vs. 9.1% vs. 9.1%, p = 0.582). The thrombus level of the filter and bubble trap was similar in the three groups (p > 0.05 for all). In RCA-CRRT for CICU population, RCA-CVVHDF with Ca-containing solutions and traditional RCA with Ca-free solutions had a comparable safety and feasibility. ChiCTR2100048238 in the Chinese Clinical Trial Registry.

A Narrative Review on Robotic Surgery as Treatment for Renal Cell Carcinoma with Inferior Vena Cava Thrombus.

Renal cell carcinoma (RCC) is a common diagnosis, of which a notable portion of patients present with an extension into the venous circulation causing an inferior vena cava (IVC) tumor thrombus. Venous extension has significant implications for staging and subsequent treatment planning, with recommendations for more aggressive surgical removal, although associated surgical morbidity and mortality is relatively increased. The methods for surgical removal of RCC with IVC thrombus remain complex, particularly surrounding the use of robot-assisted surgery. Robot assistance for radical nephrectomy in this context is recently emerging. Thrombus level has important implications for surgical technique and prognosis. Other preoperative considerations may include location, laterality, size, and wall invasion. The urology literature on treatment of such tumors is largely limited to case series and institutional studies that describe the feasibility of various surgical options for these complex tumors. Further understanding of the outcomes and patient-specific risk factors would shed increased light on the optimal treatment for such cases. This narrative review provides a thorough overview on the previously reported use of robot-assisted nephrectomy in RCC with IVC thrombus to inform further studies which may optimize outcomes and guide shared decision-making.

Surgical Management and Oncologic Outcomes of Renal Cell Carcinoma and Inferior Vena Caval Thrombi With Aggressive Histologic Variants

To characterize the surgical management, perioperative, and cancer-specific outcomes, and the influence of aggressive histologic variants (AHV) on operative management among patients with renal cell carcinoma (RCC) and inferior vena cava (IVC) thrombus. RCC with rhabdoid and/or sarcomatoid differentiation, which we defined as AHV, portends a worse prognosis. AHV can be associated with a desmoplastic reaction which may complicate resection. We reviewed patients undergoing radical nephrectomy and IVC thrombectomy between 1990 and 2020. Comparative statistics were employed as appropriate. Survival analysis was performed according to the Kaplan-Meier method, and intergroup analysis performed with log-rank statistics. Multivariable cox proportional hazards regression was used to assess the effect of AHV, age, thrombus level, vena cavectomy, metastases, and medical comorbidities on recurrence and overall survival (OS). Ninety-four of 403 (23.3%) patients had AHV, including 43 (46%) rhabdoid, 39 (41%) sarcomatoid, and 12 (13%) with both. AHV were more likely to present with advanced disease; however, increased perioperative complications or decreased OS were not observed. Median (IQR) survival was 16.7 (4.8-47) months without AHV and 12.6 (4-29) months with AHV (P=.157). Sarcomatoid differentiation was independently associated with worse OS (HR=2.016, CI 1.38-2.95, P<.001), whereas rhabdoid alone or with sarcomatoid demonstrated similar OS (P=0.063). RCC and IVC thrombus with AHV are more likely to present with metastatic disease, and sarcomatoid differentiation is associated with a worse OS. Resection of tumors with and without AHV have similar perioperative complications, suggesting that surgery can be safely accomplished in patients with RCC and IVC thrombus with AHV.

Clinical Outcome of Surgical Resection for Renal Cell Carcinoma with Inferior Vena Cava Tumor Thrombus

We analyzed 45 patients who were diagnosed with renal cell carcinoma with inferior vena cava tumor thrombus (IVC) and underwent surgical resection at Nagasaki University Hospital during the 17 years from March 2003 to November 2020. The median overall survival (OS) was 68.5, 53.5, 45.7, and 20.4 months, respectively, according to the tumor thrombus level (Lv) of I, II, III and IV, with a median level of (P＝0.025). In multivariate analysis, pathological sarcomatoid changes were associated with risk of tumor recurrence in the postoperative complete remission group, and IVC thrombus level above Lv III was associated with poor prognosis in the postoperative incomplete remission group. On postoperative systemic treatment for the postoperative recurrence group and the incomplete remission group, overall survival was significantly prolonged in cases using immune checkpoint inhibitors. The results of surgical treatment of renal cell carcinoma with IVC tumor embolization were analyzed. Patients who underwent surgical resection and achieved postoperative complete remission had a relatively long prognosis with a median OS of more than 6 years. In contrast, patients with metastases, especially those with postoperative incomplete remission group, had a poor prognosis despite surgical resection, depending on the patient's situation.

Management and Outcomes of Wilms Tumor With Suprarenal Intravascular Extension: A Pediatric Surgical Oncology Research Collaborative Study.

The purpose of this study was to describe management and outcomes from a contemporary cohort of children with Wilms tumor complicated by inferior vena caval thrombus. The largest series of these patients was published almost 2 decades ago. Since then, neoadjuvant chemotherapy has been commonly used to manage these patients, and outcomes have not been reported. Retrospective review of 19 North American centers between 2009 and 2019. Patient and disease characteristics, management, and outcomes were investigated and analyzed. Of 124 patients, 81% had favorable histology (FH), and 52% were stage IV. IVC thrombus level was infrahepatic in 53 (43%), intrahepatic in 32 (26%), suprahepatic in 14 (11%), and cardiac in 24 (19%). Neoadjuvant chemotherapy using a 3-drug regimen was administered in 82% and postresection radiation in 90%. Thrombus level regression was 45% overall, with suprahepatic level showing the best response (62%). Cardiopulmonary bypass (CPB) was potentially avoided in 67%. The perioperative complication rate was significantly lower after neoadjuvant chemotherapy [(25%) vs upfront surgery (55%); P =0.005]. CPB was not associated with higher complications [CPB (50%) vs no CPB (27%); P =0.08]. Two-year event-free survival was 93% and overall survival was 96%, higher in FH cases (FH 98% vs unfavorable histology/anaplastic 82%; P =0.73). Neither incomplete resection nor viable thrombus cells affected event-free survival or overall survival. Multimodal therapy resulted in excellent outcomes, even with advanced-stage disease and cardiac extension. Neoadjuvant chemotherapy decreased the need for CPB to facilitate resection. Complete thrombectomy may not always be necessary.

Renal Cell Carcinoma with Venous Extension: Safety of Laparoscopic Surgery for Thrombus Levels I-IIIa.

Background: Novel studies are helping to consider minimally invasive surgery for treating patients with renal cell carcinoma and venous tumor thrombus. Evidence regarding its feasibility and safety is still sparse and does not include a subclassification for level III thrombi. We aim to compare the safety of laparoscopic vs open surgery in patients with levels I-IIIa thrombus. Materials and Methods: This is a cross-sectional comparative study using single-institutional data on adult patients treated surgically between June 2008 and June 2022. Participants were categorized into open and laparoscopic surgery groups. Primary outcome was difference in the incidence of 30-day major postoperative complications (Clavien-Dindo III-V) between groups. Secondary outcomes were differences in operative time, length of hospital stay, intraoperative blood transfusions, delta hemoglobin level, 30-day minor complications (Clavien-Dindo I-II), estimated overall survival, and progression-free survival between groups. A logistic regression model was performed including adjustment for confounding variables. Results: Overall, 15 patients in the laparoscopic group and 25 patients in the open group were included. Major complications occurred in 24.0% of patients within the open group and 6.7% of patients were treated laparoscopically (p = 0.120). Minor complications arose in 32.0% of patients treated with open surgery and in 13.3% of patients treated in the laparoscopic group (p = 0.162). Although not significant, there was a higher perioperative death rate within open surgery cases. The laparoscopic approach presented a crude odds ratio for major complications of 0.22 (95% confidence interval 0.02-2.1, p = 0.191) compared with open surgery. No differences were found between groups regarding oncologic outcomes. Conclusion: Laparoscopic approach for patients with venous thrombus levels I-IIIa seems to be as safe as open surgery.

Renal cell carcinoma with tumor thrombus: A review of relevant anatomy and surgical techniques for the general urologist.

Renal cell carcinoma (RCC) is estimated to account for 4.1% of all new cancer diagnoses and 2.4% of all cancer deaths in 2020 according to the National Cancer Institute SEER database. This will likely total 73,000 new cases and 15,000 deaths. RCC is one of the most lethal of the common cancers urologists will encounter with a 5-year relative survival of 75.2%. Renal cell carcinoma is one of a small subset of malignancies that are associated with tumor thrombus formation, which is tumor extension into a blood vessel. An estimated 4% to 10% of patients with RCC will have some degree of tumor thrombus extending into the renal vein or inferior vena cava at the time of diagnosis. Tumor thrombi change the staging of RCC and therefore are an important part of initial patient workup. It is known that such tumors are more aggressive with higher Fuhrman grades, N+ or M+ at time of surgery and have higher probability of recurrence with lower cancer-specific survival. Aggressive surgical intervention with radical nephrectomy and thrombectomy can be performed with survival benefits. Classifying the level of the tumor thrombus becomes vitally important in surgical planning as it will dictate the surgical approach. Level 0 thrombi may be amenable to simple renal vein ligation while level 4 can require thoracotomy and possible open-heart surgery with coordination of many surgical teams. Here we will review the anatomy associated with each level of tumor thrombus and attempt to construct an outline for surgical techniques that may be used. We aim to give a concise overview so that general urologists may use it to understand these potentially complicated cases.

PD08-09 INTERIM ANALYSIS OF A NATIONAL RETROSPECTIVE STUDY OF cT3b+ RENAL CELL CARCINOMA PATIENTS’ PULMONARY EMBOLISM RISK AND THROMBOPROPHYLAXIS MANAGEMENT

You have accessJournal of UrologyCME1 Apr 2023PD08-09 INTERIM ANALYSIS OF A NATIONAL RETROSPECTIVE STUDY OF cT3b+ RENAL CELL CARCINOMA PATIENTS’ PULMONARY EMBOLISM RISK AND THROMBOPROPHYLAXIS MANAGEMENT Osman El-Koubani, James Blackmur, Flora Rodgers, Gianluca Maresca, Lucy Drummond, Caroline Bradley, Siobhan Duffy, Satchi Swami, Khalid Janjua, Steve Leung, Ross Clark, Gavin Lamb, Alex Chapman, James Donaldson, Grenville Oades, and Alexander Laird Osman El-KoubaniOsman El-Koubani More articles by this author , James BlackmurJames Blackmur More articles by this author , Flora RodgersFlora Rodgers More articles by this author , Gianluca MarescaGianluca Maresca More articles by this author , Lucy DrummondLucy Drummond More articles by this author , Caroline BradleyCaroline Bradley More articles by this author , Siobhan DuffySiobhan Duffy More articles by this author , Satchi SwamiSatchi Swami More articles by this author , Khalid JanjuaKhalid Janjua More articles by this author , Steve LeungSteve Leung More articles by this author , Ross ClarkRoss Clark More articles by this author , Gavin LambGavin Lamb More articles by this author , Alex ChapmanAlex Chapman More articles by this author , James DonaldsonJames Donaldson More articles by this author , Grenville OadesGrenville Oades More articles by this author , and Alexander LairdAlexander Laird More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003239.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Up to 10% of patients with renal cell carcinoma (RCC) have venous tumour thrombus at diagnosis. The incidence of PE in patients with RCC invading the venous system is unknown. The role of anticoagulation to prevent PE in such patients is also unknown and there is currently no guidance on whether patients should receive anticoagulation at diagnosis. We aimed to determine the incidence of PE is patients with RCC invading the inferior vena cava, understand the pattern of prophylactic anticoagulation prescribing in such patients and assess the effect of anticoagulation of PE risk. METHODS: We performed a retrospective review of records for all consecutive patients with cT3b, cT3c or cT4 with associated IVC thrombus (T3b+) RCC from 9 centres across a nation between Jan 2017 and Dec 2020. Patient demographics, comorbidities, anticoagulation prescription and outcomes were recorded. RESULTS: Data from 6 of 9 units was available for analysis, including 162 patients with RCC and IVC thrombus. 94(58%) patients were male and the median age was 68yrs (range: 31-93yrs). 112 (69.1%) patients died during follow-up.42(25.9%) patients developed a PE during the study period. PE was more common with larger venous tumour thrombus (10/64 patients [15.5%] level 1, 32/98 patients [32.7%] level 2+; p=0.17). 27(16.7%) patients had a PE at initial RCC diagnosis while 15 (11.1%) of the remaining 135 patients subsequently developed a PE during their management. Of the 135 patients, 11 (8.1%) patients, 27(20%) patients, and 97(71.9%) patients were commenced on prophylactic dose, treatment dose or no anticoagulation respectively. While not significant, there was a trend for higher rate of PE in the non-anticoagulated group, compared with those receiving prophylactic anticoagulation and treatment dose anticoagulation after diagnosis of T3b+ RCC (13[13.4%], 1[9.0%] and 1[3.7%] respectively, p=0.357). There was a higher rate of post-diagnosis haematuria in the anticoagulated group compared to the non-anticoagulated group (15.4% and 7.7%, p=0.122). CONCLUSIONS: In this interim analysis, we demonstrate a significant risk of concurrent or subsequent diagnosis of PE in those patients with cT3b+ RCC, which is related to venous tumour thrombus level. There is heterogeneity in the approach to prescribing anticoagulant prophylaxis in these patients. However, there is a trend for a reduction in the diagnosis of PE in those patients who receive anticoagulation following diagnosis of cT3b+ RCC, although this may result in higher rates of haematuria. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e236 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Osman El-Koubani More articles by this author James Blackmur More articles by this author Flora Rodgers More articles by this author Gianluca Maresca More articles by this author Lucy Drummond More articles by this author Caroline Bradley More articles by this author Siobhan Duffy More articles by this author Satchi Swami More articles by this author Khalid Janjua More articles by this author Steve Leung More articles by this author Ross Clark More articles by this author Gavin Lamb More articles by this author Alex Chapman More articles by this author James Donaldson More articles by this author Grenville Oades More articles by this author Alexander Laird More articles by this author Expand All Advertisement PDF downloadLoading ...

Survival analysis and predictors of long-term outcomes following radical nephrectomy with inferior vena cava (IVC) thrombectomy in renal cell carcinoma.

Renal cell carcinoma (RCC) presents with inferior vena cava (IVC) thrombus in 10%-30% cases and surgical management forms the mainstay of the treatment. The objective of this study is to assess the outcomes of the patients undergoing radical nephrectomy with IVC thrombectomy. A retrospective analysis of patients undergoing open radical nephrectomy with IVC thrombectomy between 2006 till 2018 was done. A total of 56 patients were included. The mean (±standard deviation) age was 57.1 (±12.2) years. The number of patients with levels I, II, III, and IV thrombus were 4, 29,10, and 13, respectively. The mean blood loss was 1851.8 mL, and the mean operative time was 303.3 minutes. Overall, the complication rate was 51.7%, while the perioperative mortality rate was 8.9%. The mean duration of hospital stay was 10.6 ± 6.4 days. The majority of the patients had clear cell carcinoma (87.5%). There was a significant association between grade and stage of thrombus (P = 0.011). Using Kaplan-Meier survival analysis, the median overall survival (OS) was 75 (95% confidence interval [CI] = 43.5-106.5) months, and the median recurrence-free survival (RFS) was 48 (95% CI = 33.1-62.3) months. Age (P = 0.03), presence of systemic symptoms (P = 0.01), radiological size (P = 0.04), histopathological grade (P = 0.01), level of thrombus (P = 0.04), and invasion of thrombus into IVC wall (P = 0.01) were found to be significant predictors of OS. The management of RCC with IVC thrombus poses a major surgical challenge. Experience of a center along with high-volume and multidisciplinary facility particularly cardiothoracic facility provides better perioperative outcome. Though surgically challenging, it offers good overall-survival and recurrence-free survival.

Evaluation of the relationship between monocyte to high-density lipoprotein cholesterol ratio and thrombus burden in patients with deep vein thrombosis

The purpose of this study was to evaluate monocyte count and high-density lipoprotein cholesterol levels and their ratio (monocyte/high-density lipoprotein ratio) in patients with deep venous thrombosis as well as to determine whether this ratio at the time of diagnosis can be an indicator of thrombus burden in terms of thrombus location in deep venous thrombosis. We retrospectively analyzed the patient's diagnosis of deep venous thrombosis confirmed with venous Doppler ultrasound, using a database query for outpatients between 2018 and 2022. Of 378 patients included, blood count results at the time of diagnosis were available for 356. We recruited 300 age- and sex-matched patients with appropriate blood counts, without a diagnosis of deep venous thrombosis, as the control group, by querying the outpatient clinic database. The monocyte/high-density lipoprotein ratio was computed from the ratio of monocyte count to high-density lipoprotein-C. Patients were categorized based on the level of thrombus and the number of vein segments involved as evidenced by Doppler ultrasound findings. The serum level of monocyte/high-density lipoprotein ratio was significantly higher in the patient group compared to the control group (p<0.01). Patients with proximal deep venous thrombosis had a higher mean monocyte/high-density lipoprotein ratio (19.6±5.1 vs. 17.1±5.5; p<0.01) than patients with distal deep venous thrombosis. Monocyte/high-density lipoprotein ratio increased with the number of vein segments involved (p<0.01). Monocyte/high-density lipoprotein ratio is significantly elevated in patients with deep venous thrombosis when compared to the control group. Monocyte/high-density lipoprotein ratio levels were correlated with disease burden reflected by thrombus location and the number of vein segments involved in deep venous thrombosis patients.

Up, Up, and Above—Tumor Thrombus in RCC

AbstractIntravascular tumor thrombosis is most commonly encountered in renal cell carcinoma (RCC), which alters the staging and prognosis of malignancies, indicating an advanced stage of malignancy, which can be surgically challenging during treatment course. Imaging plays a vital role in the detection of tumor thrombus and in differentiating it from bland thrombus. The Mayo Clinic thrombus classification is widely used to describe levels of inferior vena cava tumor thrombus (IVC-TT) in patients with locally advanced RCC. In this article, we review the classification, guidelines, and recent diagnostic tools for RCC with IVC tumor thrombi, and mention about the various surgical approaches for each stage of tumor thrombi.

Хирургия опухолевых тромбов нижней полой вены.

Introduction. Venous invasion and tumor thrombus formation are rare, but life-threatening complications of renal cell carcinoma (RCC), especially in combination with metastases, are considered significant adverse prognostic factors. Aim. To systematize the existing knowledge and summarize the clinical experience of surgical treatment (open and robot-assisted surgery) of RCC with inferior vena cava (IVC) tumor thrombus. Materials and methods. A literature search in the period 2000-2022 was performed in core databases MEDLINE, Scopus, Clinicaltrials.gov, Google Scholar and Web of Science. The PICO framework (Population-Intervention-Comparison-Outcome) was used to develop a literature search strategy. The following keywords were used to search databases: «renal cell carcinoma», «venous invasion», «inferior vena cava tumor thrombus», «surgical treatment», «robot-assisted», «clinical outcomes». Results. A total of 65 publications were identified. Various classifications of tumor thrombus level are considered, their inferiority and superiority in terms of selecting optimal surgical treatment, both open or robot-assisted surgeries, are discussed. Independent predictors of severe perioperative complications are determined. Optimal surgical treatment of RCC with tumor thrombus is highlighted. Functional and oncological outcomes of patients with RCC with IVC tumor thrombus, who underwent open surgical intervention and robot-assisted ones, are presented. Conclusion. Open surgery in patients with RCC and IVC tumor thrombus above the hepatic veins is associated with prolonged surgery duration, higher intraoperative blood loss, and prolonged in-hospital stay. Prolonged in-hospital stay, the need for blood transfusion, metastasis, sarcomatoid differentiation, and Clavien-Dindo grade 3-5 postoperative complications are predictors of poor outcomes.

Management of Locally Advanced Renal Cell Carcinoma

Renal cell carcinoma (RCC) has a natural tendency to invade the venous system with formation of a venous tumor thrombus in the renal vein, which can extend proximally into the inferior vena cava (IVC) and in some cases into the right atrium. The presence of venous involvement significantly worsens prognosis. Despite recent advances in systemic therapies, surgery remains the most effective method of treatment and in the case of complete removal of all tumor, it provides satisfactory long-term survival and must be attempted whenever possible. Several surgical techniques have been proposed, but all are associated with a high rate of perioperative complications and mortality. Minimally invasive approaches are mainly applicable for less extended IVC thrombi, while open surgery remains the gold standard for this category of patients. Most IVC thrombi can be managed without use of circulatory support by using different methods of IVC control depending on the thrombus level. However, use of cardiac bypass with or without deep hypothermic cardiac arrest is indicated in some patients with bulky intraatrial tumor thombi. In select patients presenting with IVC tumor thrombus and synchronous distant metastases, cytoreductive nephrectomy with IVC tumor thrombectomy may be considered with or without neoadjuvant systemic therapy. Surgery for RCC with venous thrombus is complex and requires experienced multidisciplinary surgical, anesthesia, and critical care teams at high-volume centers to achieve the best outcomes.

Analysis of surgical outcomes in 102 patients with renal cell carcinoma with venous tumor thrombus: A retrospective observational single-center study.

The aim of the study was to assess short- and long-term results following radical nephrectomy with renal vein and inferior vena cava thrombectomy in patients with renal cell cancer with venous thrombus and to investigate impact of various demographical, clinical and histological factors on overall survival (OS). The medical records of 102 adult patients with renal cell cancer with venous thrombus admitted for surgery in Department of General, Vascular and Transplant Surgery from 2012 to 2019 were retrospectively analyzed. The tumor was more frequently located on the right side compared to the left one (55 vs. 47). According to Neves Zincke classification, the levels of venous thrombus were as follows: 1 to 48 (47%), 2 to 47 (46%), 3 to 6 (6%), and 4 to 1 (1%). Postoperative complications were noted in 16 (15.7%) patients. One (3%) patient (Neves Zincke 2) died of intraoperative pulmonary embolism during hospitalization. Clear cell carcinoma was the most common pathological type reported in 92 (90.2%) patients. Thirty nine (38.2%) patients were alive at the time of last follow-up. The median OS was 21.50 (0–101.17) months. The 1-year OS was 75.5%. Significantly better OS (median 38.03 months) was noted in patients with RCC Neves Zincke 1 compared to OS (median 14.79 months) in patients with Neves Zincke 2-4 VT (P = .008). Higher tumor staging (T3 vs. T4) (P = .038), nodal staging (N0 vs. N1) (P = .0008), Fuhrman histological grading (G1-2 vs. G3-4) (P = .033) were associated with a shorter OS. Patients with renal cell cancer with venous thrombus, with an acceptable perioperative risk, should be treated surgically, because radical nephrectomy with thrombectomy performed in a high volume surgical center is a safe procedure. Neves Zincke 2-4 venous thrombus, higher tumor and nodal staging, as well higher Fuhrman histological grading are associated with a shorter OS.