Introduction:

For metastatic renal cell carcinoma with a tumor thrombus (mRCC-TT), prognosis is often considered poor, but the gold standard of treatment in most instances remains cytoreductive nephrectomy with tumor thrombectomy (CN-TT). Operative techniques, training, and resources vary significantly across the globe. Prior research has either focused on CN-TT outcomes or radical nephrectomy with tumor thrombectomy (RN-TT) outcomes, without emphasis on surgical approach. The purpose of this analysis was to compare survival outcomes between patients who underwent CN-TT via an open (OCN-TT) approach, laparoscopic (LOCN-TT), or robotic (RCN-TT) approach from the Intercontinental Collaboration on Renal Cell Carcinoma (ICORCC) database.

Methods:

This was a retrospective analysis of all patients with a diagnosis of mRCC-TT who underwent CN-TT from the ICORCC database from 1999-2024. ICORCC is a multi-institutional and multi-continental database that focuses its research on RCC-TT and pulls patients from North America, Central/South America, Spain, and South Korea. All patients in this study required radiographic confirmation of mRCC-TT through either magnetic resonance imaging (MRI) or computerized tomography (CT). All patients underwent CN-TT through either an open, laparoscopic, or robotic approach. Systemic symptoms were defined as fever, weight loss, night sweats, or paraneoplastic syndromes. Preoperative demographic variables as well as peri- and postoperative outcomes were collected. Metastatic locations were qualified as either lung, bone, brain, liver, retroperitoneum, adrenal, periaortic nodes, or “other nodes.” Progression was defined as radiographic evidence of recurrence or metastasis not seen on MRI or CT scan done prior to CN-TT. Progression locations were all metastatic locales previously noted plus the nephrectomy bed. Overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS) were calculated. Comparisons were performed between OCN-TT, LCN-TT, and RCN-TT using analysis of variance and chi-squared test. Kaplan-Meier survival analysis with log-rank test was also performed to compare OS, CSS, and PFS by approach to CN-TT.

Results:

 A total of 131 patients were included in the analysis (97 OCN-TT, 25 LCN-TT, and 9 RRN-TT; Table 1). Gender did not differ by operative approach (p>0.05). Race was significantly different, and LCN-TT patients had a greater proportion of Hispanic/Latino patients (84%; p<0.001) relative to OCN-TT (5%) and RCN-TT (22%). Body mass index and Charlson Comorbidity Index were not significantly different between OCN-TT, LCN-TT, and RCN-TT (p>0.05). Presence of systemic symptoms did not differ by approach (p>0.05). TT level was also not different (p>0.05) nor laterality of the procedure (p>0.05). Neoadjuvant systemic therapy was not different by approach (p>0.05). Tumor stage, tumor grade, proportion of sarcomatoid features, and proportion of rhabdoid features were equivalent by approach (p>0.05). Tumor necrosis was more common in LCN-TT (60%) and OCN-TT (74%) compared to RCN-TT (44%; p=0.027). Tumor subtype and postoperative tumor size were equivalent between the three surgical approaches. Proportion of lymph node (LN) dissections, LN yield, and LN positivity were equivalent between OCN-TT, LCN-TT, and RCN-TT (p>0.05). Both renal vein margin positivity and soft tissue margin positivity were equivalent (p>0.05). There was a greater proportion of retroperitoneal metastasis in LCN-TT (48%; p=0.026) patients compared to OCN-TT (20%) and RCN-TT (11%) patients. International Metastatic Disease Consortium (IMDC) scores did not differ significantly by approach (p>0.05). Rates of progression were equivalent as were all the locations of progression in the study (p>0.05). Proportion of both death and cancer-specific death was equivalent in the analysis (p>0.05).

Median OS was 1.6 years in OCN-TT, 1.5 years in LCN-TT, and 2.5 years in RCN-TT (p=0.42; Figure 1a). Median CSS was 2.1 years in OCN-TT, 3 years in LCN-TT, and 2.5 years in RCN-TT (p=0.86; Figure 1b). PFS was 0.8 years in OCN-TT, 1.2 years in LCN-TT, and 1.2 years in RNC-TT (p=0.76; Figure 1c).

Conclusion:

In this series, we present one of the largest reports of CN-TT in the literature to date, coming from the ICORCC database. For the most part, operative approach does not appear to affect outcomes for CN-TT. Importantly, OS, CSS, and PFS were not different. This is critical as we demonstrate that minimally invasive approaches do not appear to compromise survival or progression. Concurrently, for countries that lack access to surgical robots, an open approach to CN-TT also provides adequate surgical outcomes. Surgical approaches to CN-TT are adequate via an open, laparoscopic, or robotic choice, and surgeon comfort and patient preference should weigh heavily in the decision-making.

Funding: N/A