Urologic Oncology: Seminars and Original Investigations
Original articleClinical—kidneyNatural history of untreated renal cell carcinoma with venous tumor thrombus
Introduction
For decades, radical nephrectomy has served as the mainstay of treatment for patients with renal cell carcinoma (RCC). Although originally reserved for patients with localized disease, refinements of surgical technique in the 1970s allowed for the safe resection of disease with venous tumor thrombus (VTT) extending into the renal vein, inferior vena cava, and even the right atrium [1]. More recent data confirming the survival benefits of cytoreductive nephrectomy have further expanded the indications for surgical intervention to include those patients with metastatic disease [2]. Thus, surgical excision serves as the primary intervention for the majority of contemporary patients with RCC.
However, a recent publication suggests that nearly 20% of patients with RCC and concomitant VTT are managed nonoperatively [3]. The natural history of disease in these unresected patients with VTT is poorly characterized, as the published literature contains only a few single-institution case series describing the outcomes of nonoperative management in this patient group [4], [5], [6], [7]. While prognosis appears to be poor for the majority of these conservatively managed patients, survival as long as 18 months has been reported [7]. Furthermore, given the paucity of published data, prognostic factors for untreated patients with VTT remain unknown. Although prior studies have identified prognostic variables for patients undergoing surgery, [8], [9], [10], [11], [12], [13], [14], [15], it is unclear whether these same factors are associated with outcome in patients managed nonoperatively.
In this study, we analyzed a large, population-based data set to characterize the natural history of patients with RCC and VTT. Additionally, we sought to identify prognostic factors associated with cancer-specific mortality in this patient group.
Section snippets
Study population
The study cohort was derived from the Surveillance Epidemiology and End Results (SEER) database, a population-based United States national cancer registry. Eighteen individual registries contribute data to SEER, accounting for approximately 26% of the U.S. population, and mirroring its demographics. An exemption from the University of California San Francisco Committee on Human Research was obtained in lieu of Institutional Review Board approval.
Patients with RCC and VTT who were diagnosed
Results
We identified a total of 2,265 patients with RCC and VTT. Of these individuals, 391 (17%) were managed nonoperatively and form the study population. Median follow-up in this group was 3 months (IQR 1–7); 278 (71%) patients died during follow-up; of these, 243 deaths (87%) were due to RCC.
Patient demographic and disease-specific data are shown in Table 1. Mean patient age was 69 (SD ± 12) years. The majority of patients were male (60%), White (68%), and married (55%). Mean tumor size was 9.6 (SD
Discussion
The published literature investigating outcomes in patients with RCC and concomitant VTT has focused almost exclusively on patients managed with nephrectomy [8], [9], [10], [11], [12], [13], [14], [15]. However, recent data suggest that nearly 20% of such patients pursue nonoperative management [3]. In this population-based study from the SEER registry, we describe the natural history of disease in the only multi-institutional series of patients with untreated RCC and VTT, and the largest
Conclusions
The current study is the only published series investigating the natural history and prognostic factors for a population-based cohort of patients with untreated RCC and VTT. Unfortunately, when left untreated, prognosis is quite poor for the majority of patients with this disease. This information is important when counseling patients as to the risk and benefits of surgical vs. conservative management of RCC and VTT.
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