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Journal of Peking University (Health Sciences) ›› 2021, Vol. 53 ›› Issue (4): 665-670. doi: 10.19723/j.issn.1671-167X.2021.04.007

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Influence of deep invasive tumor thrombus on the surgical treatment and prognosis of patients with non-metastatic renal cell carcinoma complicated with venous tumor thrombus

ZHAO Xun,YAN Ye,HUANG Xiao-juan,DONG Jing-han,LIU Zhuo,ZHANG Hong-xian,LIU Cheng(),MA Lu-lin()   

  1. Department of Urology, Peking University Third Hospital, Beijing 100191, China
  • Received:2021-03-16 Online:2021-08-18 Published:2021-08-25
  • Contact: Cheng LIU,Lu-lin MA E-mail:chengliu@bjmu.edu.cn;malulinpku@163.com
  • Supported by:
    National Natural Science Foundation of China(82070778)

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Abstract:

Objective: To evaluate the impact of deep invasive tumor thrombus on the surgical complexity and prognosis of patients with renal cell carcinoma complicated with inferior vena cava tumor thrombus. Methods: We retrospectively reviewed the clinical data of 94 patients with non-metastatic renal cell carcinoma complicated with inferior vena cava tumor thrombus, who underwent surgical treatment in Peking University Third Hospital from January 2017 to June 2020. The patient’s general condition, clinicopathological characteristics, surgery and survival information were collected. The patients were divided into two groups based on the intra-operative findings of tumor thrombus adhesion to the venous wall, of which 64 cases were in the deep invasive tumor thrombus (DITT) group and 30 cases were in the non-invasive tumor thrombus (NITT) group. Chi-square, t test and Mann-Whitney U test were used for categorical and continuous variables respectively. Kaplan-Meier plots and multivariable Cox regressions were performed to evaluate the influence of DITT on the prognosis of the patients with renal cell carcinoma with inferior vena cava tumor thrombus. Results: DITT significantly increase the difficulty of surgery for the patients with renal cell carcinoma with venous tumor thrombus, which was mainly reflected in the longer operation time (362.5 vs. 307.5 min, P=0.010), more surgical bleeding (1 200 vs. 450 mL, P=0.006), more surgical blood transfusion (800 vs. 0 mL, P=0.021), more plasma transfusion (200 vs. 0 mL, P=0.001), a higher proportion of open surgery (70.3% vs. 36.7%, P=0.002), a longer post-operative hospital stay (9.5 vs. 8 days, P=0.036), and a higher proportion of post-operative complications (46.9% vs. 13.8%, P=0.002). DITT was associated with worse overall survival of the patients with renal cell carcinoma with inferior vena cava tumor thrombus (P=0.022). Even in the multivariate analysis, DITT was still a poor prognostic factor for the overall survival of these patients [HR: 4.635 (1.017-21.116), P=0.047]. Conclusion: For patients with non-metastatic renal cell carcinoma with inferior vena cava tumor thrombus, DITT will significantly increase the difficulty of surgery, and may lead to poor prognosis.

Key words: Renal cell carcinoma, Inferior vena cava, Tumor thrombus, Prognosis

CLC Number: 

  • R737.11

Figure 1

Typical CT image appearance of DITT group and NITT group DITT, deep invasive tumor thrombus; NITT, non-invasive tumor thrombus."

Table 1

Comparison of clinical and pathologic features between DITT group and NITT group"

Items DITT (n=64) NITT (n=30) t/U/χ2 P value
Age/years 60.4±8.9 59.4±10.9 0.453 0.652
Gender 3.548 0.060
Male 52 (81.3%) 19 (63.3%)
Female 12 (18.8%) 11 (36.7%)
Side 0.121 0.728
Left 17 (26.6%) 9 (30.0%)
Right 47 (73.4%) 21 (70.0%)
Clinical symptoms 1.294 0.523
No clinical symptoms 13 (20.3%) 7 (23.3%)
Local symptoms 36 (56.3%) 19 (63.3%)
Systemic symptoms 15 (23.4%) 4 (13.3%)
BMI/(kg/m2) 24.7±3.5 24.0±2.8 0.893 0.374
Tumor diameter/cm 8.1±2.9 9.1±2.8 1.684 0.096
Hb/(g/L) 120.3±20.4 130.3±20.7 2.203 0.030
Neu/(×109/L) 4.8±1.7 4.2±1.1 1.784 0.078
Plt/(×109/L) 255.0±118.6 262.7±77.8 0.325 0.746
ALP/(U/L) 91.6±37.6 85.6±22.5 0.802 0.424
Alb/(g/L) 39.1±5.1 40.5±4.4 1.257 0.212
Ca/(mg/L) 2.3±0.2 2.2±0.1 0.552 0.583
SCr/(μmol/L) 100.2±25.3 90.8±20.4 1.766 0.081
SCr after surgery/(μmol/L) 116.5±54.2 101.9±37.7 1.259 0.211
ASA score 5.876 0.053
1 3 (4.7%) 2 (6.7%)
2 50 (78.1%) 28 (93.3%)
3 11 (17.2%) 0 (0)
pN stage 4.099 0.052
N0 56 (87.5%) 30 (100.0%)
N1 8 (12.5%) 0 (0)
Mayo classification 8.755 0.033
Ⅰ 11 (17.2%) 12 (40.0%)
Ⅱ 40 (62.5%) 15 (50.0%)
Ⅲ 8 (12.5%) 0 (0)
Ⅳ 5 (7.8%) 3 (10.0%)
Pathology type 0.424 0.769
Clear cell carcinoma 52 (81.3%) 26 (86.7%)
Non clear cell carcinoma 12 (18.7%) 4 (13.3%)
Fuhrman grade 0.419 0.518
Ⅰ-Ⅱ 27 (42.9%) 15 (50.0%)
Ⅲ-Ⅳ 36 (57.1%) 15 (50.0%)
Surgical approach 9.601 0.002
Laparoscopic surgery 19 (29.7%) 19 (63.3%)
Open surgery 45 (70.3%) 11 (36.7%)
IVC resection 13.464 <0.001
No 42 (65.6%) 30 (100.0%)
Yes 22 (34.4%) 0 (0)
Operative time/min 362.5 (305.3, 429.8) 307.5 (254.5, 374.0) 644.0 0.010
Surgical bleeding volume/mL 1 200 (325, 2 500) 450 (200, 800) 621.0 0.006
Surgical blood transfusion volume/mL 800 (0, 1 600) 0 (0, 600) 689.0 0.021
Plasma transfusion volume/mL 200 (0, 750) 0 (0, 0) 598.0 0.001
Post-operative hospital stay/d 9.5 (7.0, 13.0) 8.0 (6.0, 9.3) 702.5 0.036
Post-operative adjuvant targeted therapy 2.546 0.111
No 23 (35.9%) 16 (53.3%)
Yes 41 (64.1%) 14 (46.7%)
Post-operative complications 9.417 0.002
No 34 (53.1%) 25 (86.2%)
Yes 30 (46.9%) 4 (13.8%)

Table 2

Comparison of surgical features between DITT group and NITT group in Mayo Ⅱ level tumor thrombus subgroup"

Items DITT (n=40) NITT (n=15) U/χ2 P value
Operative time/min 368.5 (306.5, 525.0) 302.0 (258.0, 355.0) 139 0.002
Surgical bleeding volume/mL 1 450 (525, 2 925) 400 (200, 800) 152.5 0.005
Surgical blood transfusion volume/mL 800 (0, 1 600) 0 (0, 400) 202 0.054
Plasma transfusion volume/mL 400 (0, 800) 0 (0, 0) 155 0.003
Post-operative hospital stay/d 11.0 (7.0, 13.0) 8.0 (6.0, 9.0) 190 0.036
Open surgery 30 (75.0%) 4 (26.7%) 10.8 0.001
Post-operative complications 22 (55.0%) 2 (13.3%) 7.7 0.006

Figure 2

Overall survival time between DITT group and NITT group DITT, deep invasive tumor thrombus; NITT, non-invasive tumor thrombus."

Table 3

Multivariate Cox regression analysis of prognosis risk factors for patients with non-metastatic renal cell carcinoma and inferior vena cava tumor thrombus"

Items HR 95%CI P value
DITT 4.635 1.017-21.116 0.047
Mayo classification 2.046 1.161-3.604 0.013
Hb - - 0.484
Non-clear cell carcinoma 4.275 1.495-12.229 0.007
Fuhrman grade (Ⅲ-Ⅳ vs. Ⅰ-Ⅱ) - - 0.719
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