Surgery promising for non-metastatic RCC with thrombus

Almost half of patients with non-metastatic renal cell carcinoma (RCC) who have tumour thrombus above the hepatic veins will survive for 5 years after surgery, indicate study results published in The Journal of Urology.

The finding emerges from an analysis of 166 RCC patients who underwent nephrectomy and caval thrombectomy, and “strongly advocates for aggressive surgical intervention” in those with a non-metastatic tumour-thrombi profile, remark the researchers, led by Vitaly Margulis (The University of Texas Southwestern Medical Center, Dallas, USA).

The team also recommends that the role of extirpative surgery in patients with metastatic disease – who therefore have a poorer post-surgery prognosis – is further investigated, since their long-term survival is “likely to improve further” with the increased use of targeted therapies.

The study participants, aged a median 62 years, had a median tumour size of 10.5 cm, with tumour thrombus extending above the diaphragm in 97 (58.4%) cases (level IV) and above the hepatic veins but below the diaphragm in 69 (41.6%) cases (level III).

While overall there was no significant difference in cancer-specific survival (CSS) between patients with level III and those with level IV thrombi, those without nodal disease had significantly better CSS than their counterparts with nodal metastasis, remark Margulis et al.

Furthermore, 42.2% of the 111 patients without nodal or distant metastatic disease survived and 32.1% remained cancer free for 5 years after surgery.

Multivariate analysis revealed several variables that significantly increased the risk of all-cause mortality during the median 27.8-month study follow-up. Specifically, the presence of regional nodal metastasis, histological tissue necrosis, having a grade 4 tumour or having elevated preoperative serum alkaline phosphatase (>131 IU/L) increased the risk 2.72-, 2.98-, 2.01- and 2.58-fold, respectively.

However, when the analysis included only patients without nodal disease or metastasis, only histological grade 4 RCC and neoadjuvant therapy were significantly independently associated with death from any cause, with respective hazard ratios (HR) of 2.08 and 6.90.

A similar pattern surfaced for the risk of death from RCC in the 5 years after surgery, with only grade 4 tumour and neoadjuvant therapy showing significant associations in patients without metastasis, with HRs of 2.31 and 11.0, respectively.

However, Margulis and colleagues point out that “[t]he association of neoadjuvant targeted therapy with worse CSS and [overall survival] is likely due to selection bias, with more advanced cases being selected for neoadjuvant therapy.”

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