Aggressive surgical resection is indicated in RCC with VTT as nephrectomy alone is associated with dismal prognosis [10]. Through an experienced team, consisting of a urologic oncology surgeon, cardiothoracic surgeon, cardiac anesthesiologist, and cardiac scrub team we were able to achieve satisfactory surgical and oncological outcomes and decrease the incidence of complications.
We noticed a significant reduction in the rate of overall and high grade complications (45 % and 8 %, respectively) in the last 6 years compared to the earlier surgeries included in the study (67 % and 13 % respectively) [p = .008 and .03, respectively]. We believe this reduction may be due to our multidisciplinary team approach, which provides uniform and consistent management of patients with VTT. The team approach further supports meticulous perioperative and postoperative planning and delivery of care, refinement of surgical technique, and improved anesthesia.
In terms of oncological outcomes, metastasis was found to be the strongest independent predictor of survival. Patients with M+ had a 3.8 times risk of cancer specific mortality compared to M0 patients (p < .001). While M0 patients had 5-Y CSS of 68 % and median survival that was not reached yet, M+ patients had a 17 % 5-Y CSS and 11 months median survival. Our survival rates were superior to those reported in the literature for M0 patients [3–5, 11–24] but they were similarly poor in M+ patients who were reported to have 4-30 % 5Y-CSS and 11–20 months median survival [3–5, 11–18, 21]. In this study, 29 % of patients had metastasis at presentation. This incidence was even higher in other series [14, 16]. Surgery might be indicated not only to improve oncological outcomes but also to relieve symptoms and provide better quality of life. However, performance status and associated comorbidities should be considered [10].
Overall, LN+ showed a trend toward poor CSS (HR 1.9, CI and p = .06) and achieved prognostic significance only in M+ patients (HR 2.3 and p = .03). Perhaps, statistical significance, in the analysis involving all patients, would be reached if the sample size was larger and/or follow up was longer. The independent prognostic role of LN+ was reported in other RN and IVCT series [12, 14, 21, 24]. Previous studies support the role of aggressive debulking of regional nodal disease at the time of cytoreductive RN for metastatic RCC [2, 25, 26].
There has been wide variation in reporting different prognostic factors and the prognostic value of VTT level has been debated. Our prognostic factors were similar to those reported in the largest European study that included 1192 patients from 13 European centers [12] and the US based analysis including 1875 patients with RCC and VTT from the SEER database [27]. In both studies, metastasis was the most important independent predictor of worse survival.
Interestingly, analysis of data for all patients showed that metastasis was the only independent predictor of oncological outcomes. However, in M0 patients, features associated with aggressive tumor behavior (high level VTT, large tumor size, and sarcomatoid differentiation) had an independent prognostic role. The size of the tumor has been implicated in staging of RCC. Large tumor size was among the strongest predictors of worse survival in the international RCC-VTT consortium that included 1215 RN and IVCT from 11 American and European institutions [21] as well as in a population based analysis including 1875 patients with RCC and VTT from the SEER database [27]. Sarcomatoid differentiation was reported with an incidence of 9 % and was among the independent predictors of worse survival in RN and IVCT series [3, 14, 20]. We found sarcomatoid differentiation in 13 % of tumors and it did not correlate with higher VTT levels, as 95 % of tumors with sarcomatoid differentiation had level I or II VTT.
We acknowledge several limitations in this review. First, is the retrospective design with its inherited bias. Second, while our multidisciplinary approach has lead to a decrease in the rate of complications, other factors may have also lead to improved outcomes. Improvement in surgical technique, enhanced understanding of the biology of the disease, and improved delivery of medical care throughout the course of the study may have also lead to improved patient outcomes. Lastly, the impact of venous wall invasion by thrombus could not be evaluated, as it was not reported by consistent pathologic criteria over the period under review.