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      Renal cell carcinoma with venous extension: prediction of inferior vena cava wall invasion by MRI

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          Abstract

          Background

          Renal cell carcinoma (RCC) are accompanied by inferior vena cava (IVC) thrombus in up to 10% of the cases, with surgical resection remaining the only curative option. In case of IVC wall invasion, the operative procedure is more challenging and may even require IVC resection. This study aims to determine the diagnostic performance of contrast-enhanced magnetic resonance imaging (MRI) for the assessment of wall invasion by IVC thrombus in patients with RCC, validated with intraoperative findings.

          Methods

          Data were collected on 81 patients with RCC and IVC thrombus, who received a radical nephrectomy and vena cava thrombectomy between February 2008 and November 2017. Forty eight patients met the inclusion criteria. Sensitivity and specificity as well as the positive and negative predictive values were calculated for preoperative MRI, based on the assessments of the two readers for visual wall invasion. Furthermore, a logistic regression model was used to determine if there was an association between intraoperative wall adherence and IVC diameter.

          Results

          Complete occlusion of the IVC lumen or vessel breach could reliably assess IVC wall invasion with a sensitivity of 92.3% (95%-CI: 0.75–0.99) and a specificity of 86.4% (95%-CI: 0.65–0.97) (Fisher-test: p-value< 0.001). The positive predictive value (PPV) was 88.9% (95%-CI: 0.71–0.98) and the negative predictive value reached 90.5% (95%-CI: 0.70–0.99). There was an excellent interobserver agreement for determining IVC wall invasion with a kappa coefficient of 0.90 (95%CI: 0.79–1.00).

          Conclusions

          The present study indicates that standard preoperative MR imaging can be used to reliably assess IVC wall invasion, evaluating morphologic features such as the complete occlusion of the IVC lumen or vessel breach. Increases in IVC diameter are associated with a higher probability of IVC wall invasion.

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          Most cited references26

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          Surgical treatment of renal cancer with vena cava extension.

          Fifty-four patients with renal cancer and vena cava tumour thrombus underwent radical nephrectomy and removal of the thrombus; the operative mortality rate was 9.3% (5 patients). The extent of the vena cava thrombus did not affect survival. Of 36 patients with no known pre-operative metastases and complete (29 patients) and incomplete (7 patients) removal of the vena cava tumour thrombus, the 5-year survival rate was 68 and 17%, respectively (P = 0.01). Thirteen patients (45%) who underwent complete removal of the vena cava tumour thrombus are alive and free of disease, with a mean follow-up of 51.2 months (range 4-144); three died without disease 110, 31 and 23 months after operation. The 2-year and 5-year survival rates of 18 patients with known pre-operative metastases was 37.5 and 12.5% respectively; 14 died between 1 and 27 months post-operatively (mean 11.6) of metastatic disease. Two of these 18 patients experienced long-term remission: one died of unrelated causes 151 months after operation; the other was lost to follow-up 219 months after operation, with no evidence of disease. Of 14 patients with positive regional nodes, the mean survival in those with metastases compared with those without metastases was 7.5 versus 15 months, respectively; only one patient survived at 14 months. Operative intervention in patients without metastatic disease (systemic or regional) and complete removal of the vena cava thrombus achieved a 5-year survival rate of 68%. Variables which significantly decreased survival and may be considered contraindications for operation were systemic metastasis, regional lymph node involvement and incomplete removal of the vena cava thrombus.
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            Prognostic value of renal vein and inferior vena cava involvement in renal cell carcinoma.

            The prognostic significance of venous tumor thrombus extension in patients with renal cell carcinoma (RCC) is a matter of many controversies in the current literature. To evaluate the prognostic role of inferior vena cava (IVC) involvement in a large series of pT3b and pT3c RCCs. A total of 1192 patients from 13 European institutions underwent a radical nephrectomy for pT3b and pT3c RCC between 1982 and 2003. The patients were evaluated in a retrospective manner. Age, gender, clinical symptoms, Eastern Cooperative Oncology Group (ECOG) performance status, TNM stage, tumor size, adrenal invasion, perinephric fat invasion, histological type, and Fuhrman grade were reviewed. The log-rank and Cox uni- and multivariate regression analyses were used to evaluate prognostic factors for overall survival. Overall survival and prognostic factors for overall survival in patients with RCC extending to the renal vein (RV) or to the IVC. The median follow-up was 61.4 mo (56.3-66.5 mo). The mean age was 63.2 yr. The mean tumor size was 8.9 cm. Group 1 (Gr 1) included 933 patients with a renal vein tumor thrombus (78.3%), Group 2 (Gr 2) included 196 patients with a subdiaphragmatic IVC tumor thrombus (16.4%), and Group 3 (Gr 3) included 63 patients with a supradiaphragmatic IVC tumor thrombus (5.3%). Median survival was 52 mo for Gr 1, 25.8 mo for Gr 2, and 18 mo for Gr 3. In univariate analysis, Gr 1 had a significantly better overall survival than Gr 2 (p<0.001) and Gr 3 (p
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              Imaging the inferior vena cava: a road less traveled.

              A broad spectrum of congenital anomalies and pathologic conditions can affect the inferior vena cava (IVC). Most congenital anomalies are asymptomatic; consequently, an awareness of their existence and imaging appearances is necessary to avoid misinterpretation. Imaging also plays a central role in the diagnosis of Budd-Chiari syndrome secondary to membranous obstruction of the intrahepatic IVC. Primary malignancy of the IVC is far less common than intracaval extension of malignant tumors arising in adjacent organs, and imaging can accurately help determine the presence and extent of tumor thrombus, information that is crucial for surgical planning. However, the radiologist should be aware that artifactual filling defects at computed tomography and magnetic resonance imaging can mimic true thrombus in the IVC and must be able to differentiate true from pseudo filling defects. Other imaging findings such as flat IVC and early enhancement of the IVC are useful in limiting the differential diagnosis. Familiarity with the imaging features of the various congenital and pathologic entities that can affect the IVC is paramount for early diagnosis and management. Copyright RSNA, 2008.
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                Author and article information

                Contributors
                +49 30 450 627 376 , Lisa.adams@charite.de
                Berhard.ralla@charite.de
                Yi-na.bender@charite.de
                Keno-kyrill.bressem@charite.de
                Bernd.hamm@charite.de
                Jonas.busch@charite.de
                Florian.fuller@charite.de
                Marcus.makowski@charite.de
                Journal
                Cancer Imaging
                Cancer Imaging
                Cancer Imaging
                BioMed Central (London )
                1740-5025
                1470-7330
                3 May 2018
                3 May 2018
                2018
                : 18
                : 17
                Affiliations
                [1 ]ISNI 0000 0001 2218 4662, GRID grid.6363.0, Department of Radiology, Charité, ; Charitéplatz 1, 10117 Berlin, Germany
                [2 ]ISNI 0000 0001 2218 4662, GRID grid.6363.0, Department of Urology, Charité, ; Charitéplatz 1, 10117 Berlin, Germany
                [3 ]ISNI 0000 0001 2218 4662, GRID grid.6363.0, Department of Urology, Charité, ; Hindenburgdamm 30, 12200 Berlin, Germany
                Author information
                http://orcid.org/0000-0001-5836-4542
                Article
                150
                10.1186/s40644-018-0150-z
                5934829
                29724245
                6efba29c-8fad-4eab-918b-efa7e04a7441
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 30 January 2018
                : 25 April 2018
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100001659, Deutsche Forschungsgemeinschaft;
                Award ID: 5943/31/41/91
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2018

                renal cell carcinoma,inferior vena cava thrombus,magnetic resonance imaging,preoperative planning,sensitivity and specificity

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