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Oliver Hakenberg Urologische Klinik und Poliklinik Universitätsklinikum Rostock Surgical treatment of renal cell carcinoma with caval thrombus.

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Presentation on theme: "Oliver Hakenberg Urologische Klinik und Poliklinik Universitätsklinikum Rostock Surgical treatment of renal cell carcinoma with caval thrombus."— Presentation transcript:

1 Oliver Hakenberg Urologische Klinik und Poliklinik Universitätsklinikum Rostock Surgical treatment of renal cell carcinoma with caval thrombus

2 Tumor stage 90% 70% 35% 15% 5-year survival after surgery

3 Cava tumour extension

4 Mayo Clinic classification Classification Level Irenal or < 2cm IVC Level IIinfrahepatic Level IIIretrohepatic Level IVatrial Neves & Zincke, Brit J Urol % 10%40% TNM T3bbelow diaphragm T3cabove diaphragm

5 Caval thrombus TEE transesophageal ultrasound MRI Duplex venous sonography cavography not necessary

6 Caval thrombus Renal vein vena cava kidney

7 Removal of suprahepatic caval thrombus cavotomy

8 Specimen after nephrectomy and resection of caval thrombus Rim of renal vein

9 Presentation  Up to 10% of patients with RCC (1990s)  majority right-sided (85%)  majority have symptoms –IVC syndrome –edema –cardiac dysfunction –abdominal pain –hematuria

10 Surgical technique  Exposure –Chevron bilateral subcostal –Median laparotomy with sternotomy  Standard –isolation of vena cava –extended hepatic mobilization –PRINGLE maneuver –Primary or patch closure of vena cava  Alternative –Endoluminal occlusion –Resection of vena cava  Cardiac bypass  Resection of vena cava/prosthetic interposition

11 Endoluminal caval occlusion  Through inferior vena cava –blind –transesophageal echography-guided  Through jugular vein –preoperatively

12 Surgical technique: endoluminal occlusion n=31 level II or III Follow-up 22.1 months n= 131 splenectomy 1 thrombosis IVC n=7 M+ Avoids suprahepatic approach No complications due to endoluminal occlusion No air embolism Zini et al, BJU Int, 2006  Through inferior vena cava –blind –transesophageal echography-guided  through jugular vein –preoperatively

13 Intraatrial thrombectomy  Standard –Cardiopulmonary bypass with hypothermia  Alternative –mild hypothermia, cardiopulmonary bypass –beating, perfused heart –n= 6, no mortality (Chowdury et al, 2006) –venous cardiac bypass (superior vena cava + infrarenal vena cava) –endoluminal occlusion via cavotomy at renal vein level –N= 6, 1 postoperative death (Modine et al, 2007) Chowdhury et al, Ann Thorac Surg 2007 Modine et al, Int J Surg 2007

14 Interruption of vena cava  n=40 patients with vena cava interruption at surgery  Postoperative venous disability score –None class 3 –12/40 (30%) class 2 –12/40 (30%) class 1 – 16/40 (40%) no disability Blute et al, J Urol 2007

15 Perioperative mortality 3-16% n =Perioperative mortality Bissada et al, n= 48 without M+2% (1) n= 26 with M+7% (2) Kaplan et al, % (1) Zini et al, % (1) Galluci et al, % Bastian et al, n=8 with N+ Parekh et al, % (4) Bissada et al, Urology 2003 Kaplan et al, Am J Surg 2002 Parekh et al, J Urol 2005 Bastian et al, Eur J Surg Oncol 2005

16 Surgical series n= yr-disease-free survival infrahepatic 35 Retrohepatic 20 Suprahepatic 5 Atrial % 50.6% 66.6% 40% operative mortality 3% complications 34% (conservative) Perinephric fat invasion yes no 31% 68%p<0.01 pN positive negative 30% 60.9% p<0.05 Kulkarni et al, Indian J Cancer 2007

17 Prognosis with treatment N+M1N0M0 2-year- survival N0M0 5-year survival n= 107 RCC with renal vein or vena cava thrombus 26%54% Vena cava83%72% Renal vein90%68% n= 100 RCC without 12%31%93%81% Prognostic factors: capsular penetration collecting system invasion extension into hepatic veins Zisman et al, J Urol 2003

18 Prognosis of surgery in non-metastatic RCC n3-year cancer- specific survival 5-yr overall survival 10-year overall survival Skinner, % Glazer, % Moinzadeh, % (renal vein) Kim, renal vein 36% IVC 35% T3c 12% Lubahn, % Ciancio, % Skinner et al, Ann Surg 1989; Glazer et al, J Urol 1996; Moinzadeh et al, J Urol 2004; Kim et al, J Urol 2004; Lubahn et al, J Thora Cardiovasc Surg 2006; Ciancio et al, Eur Urol 2007

19 Impact of level of thrombus on survival? n5-yr overall survival 10-year overall survival Impact on survival Skinner, Level I 35% Level II 18% Level III 0% yes Glazer, Level III 60% Level IV 57% no Moinzadeh, Level not associated with local stage Level 1 66% Level II-IV 29% ? Kim, Level IV much worse than Level I/II yes Skinner et al, Ann Surg 1989; Glazer et al, J Urol 1996; Moinzadeh et al, J Urol 2004; Kim et al, J Urol 2004;

20 Prognosis with cytoreductive treatment in M1 disease M1 patients2-year- survival 5-year survival Nephrectomy + immunotherapy 52%41% nephrectomy45%32% immunotherapy13%0% No treatment0% Zisman et al, J Urol 2003

21 Impact of thrombus removal in metastatic RCC  30% of patients with IVC thrombus have M+ disease  patients are symptomatic  surgery is palliative: quality of life  cytoreductive surgery improves response to immunotherapy  impact of targeted therapies?

22 Outcome n= 134 FU 16.4 months median nMedian survival (months) Radical nephrectomy with thrombectomy N0M0: 51.7 NxM1: 6.9 ImmunoRx With 13.5 Without 5.1 Embolization + immunotherapy Prognostic factors: localized tumour stage N0M0 vs N+M0, NxM1 Fuhrmann grades1 and 2 vs 3 and 4 thrombus levelI and II vs III and IV Haferkamp et al, J Urol 2007

23 Outcome nn (M+)Follow-up (months) DODAlive with M+Alive and NED Bissada et al, (41%)22 (47%) Kaplan et al, % estimated survival at 10 years Zini et al, Galluci et al, Bastian et al, (7%)11 (40%) Parekh et al, (16%)29% (14)21 (43%) Bissada et al, Urology 2003 Kaplan et al, Am J Surg 2002 Galluci et al, Eur Urol 2004 Parekh et al, J Urol 2005 Bastian et al, Eur J Surg Oncol 2005

24 Conclusions  thrombus carries worse prognosis because local prognostic indicators are worse  overall survival with R0 resection is > 50%  Level of thrombus –increases difficulties of surgery –probably correlates with reduced survival –increases the risk of recurrence  Surgery in non-metastatic disease improves survival  Surgery in metastatic disease –improves survival –is palliative –cytoreduction improves results of adjuvant therapy


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