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Nephron-sparing surgery for pathological stage T3b renal cell carcinoma confined to the renal vein
Surendra B Kolla1, Cesar Ercole, Philippe E Spiess
1Genitourinary Oncology Program, Moffitt Cancer Center, Tampa, FL 33612-9416, USA.
Objective:
To report the functional and oncological outcome of nephron-sparing surgery (NSS) for pathological stage pT3bNxMx (2002 Tumour-Node-Metastasis staging) renal cell carcinoma (RCC) with tumour thrombus confined to the renal vein.
Patients And Methods:
Of the 305 patients who underwent NSS at our institute from October 2004 to July 2009, seven (2%) were found to have stage T3bNxMx RCC on final pathology. Their charts were reviewed to identify demographic, operative and pathology details of these patients, in addition to obtaining functional and oncological outcome data.
Results:
All seven patients had centrally located endophytic tumours. There were absolute indications for NSS in six patients (solitary kidney in five, renal insufficiency in one). The clinical stage was T1a in five and T3b in two patients; in those with cT1a, thrombus was first identified with intraoperative ultrasonography in two and by palpation of the renal vein or during the NSS in the remaining three. Renal surface hypothermia was applied in four cases (mean 77 min) and warm ischaemia in three (mean 38 min). The mean (range) tumour size was 3.9 (2.5-6) cm and all the tumours were clear cell RCC on histology, and all had negative surgical margins. The mean estimated glomerular filtration rate (eGFR) decreased by 24% after surgery. One patient developed new-onset renal failure (eGFR < 30 mL/min/1.73 m(2) ). Postoperative urine leak occurred in one patient successfully managed with a JJ stent. One patient developed a local recurrence with level III inferior vena caval (IVC) tumour thrombus 9 months after NSS and was managed with radical excision and IVC thrombectomy followed by postoperative dialysis. Six other patients were free of recurrence with no need for dialysis at a mean follow-up of 30 months.
Conclusions:
In selected patients with pathological stage T3b RCC and tumour thrombus confined to the renal vein, NSS is a feasible treatment option with acceptable oncological and renal functional outcomes.
Insights
Nephron-sparing surgery (NSS) is a viable option for selected renal cell carcinoma (RCC) patients with tumor thrombus in the renal vein. This approach offers acceptable oncological and renal functional outcomes, preserving kidney function in most cases.
Area of Science:
- Urology
- Nephrology
- Oncology
Background:
- Renal cell carcinoma (RCC) with tumor thrombus extending into the renal vein presents a surgical challenge.
- Nephron-sparing surgery (NSS) is increasingly considered for localized RCC.
- The role of NSS in advanced RCC stages, specifically pT3b with venous thrombus, requires further investigation.
Purpose of the Study:
- To evaluate the functional and oncological outcomes of NSS for pathological stage pT3bNxMx RCC with tumor thrombus confined to the renal vein.
- To assess the feasibility and safety of NSS in this specific patient cohort.
Main Methods:
- Retrospective review of seven patients who underwent NSS for pT3bNxMx RCC with renal vein thrombus between October 2004 and July 2009.
- Data collected included patient demographics, operative details, pathology, and postoperative functional and oncological outcomes.
- Surgical techniques involved hypothermia or warm ischemia, with detailed analysis of complications and recurrence rates.
Main Results:
- All seven patients had centrally located endophytic clear cell RCC with negative surgical margins.
- Five patients had a solitary kidney, and one had renal insufficiency, indicating strong indications for NSS.
- Mean estimated glomerular filtration rate (eGFR) decreased by 24% post-surgery, with one patient developing new-onset renal failure. One recurrence was noted and successfully managed.
Conclusions:
- NSS is a feasible treatment for selected patients with pT3b RCC and renal vein tumor thrombus.
- The procedure demonstrates acceptable oncological control and preserves renal function in the majority of cases.
- Careful patient selection is crucial for optimizing outcomes in NSS for advanced RCC with venous involvement.
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