Carcinoma de células renales con extensión a vena cava: puesta al día y revisión de nuestra casuística

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Abstract

Objetivo:Valorar la situación actual en el tratamiento del carcinoma renal con extensión a vena cava inferior (VCI): Clasificación, diagnóstico, abordaje quirúrgico, terapia adyuvante, factores de pronóstico y supervivencia. Materiales y Métodos: Se revisan 19 casos de carcinomas renales con extensión a VCI intervenidos entre enero de 1988 y agosto de 2008. Se valoran la edad, el sexo, lateralidad y función renal de los pacientes. Con respecto al tumor se valoran: estadio según TNM y la clasificación de Neves-Zincke. Se describe el abordaje quirúrgico según el nivel del trombo. Resultados: Con una tasa de mortalidad perioperatoria del 10.5% y una media de seguimiento de 22,65 meses (rango 2-79), sobreviven 5 pacientes; 11 han fallecido por la enfermedad; uno por otra causa y 2 se han perdido. Los pacientes metastásicos han recibido tratamiento adyuvante con Inmunoterapia o inhibidores de las kinasas. La supervivencia media es de 15,1 meses. Existen diferencias significativas a tres y cinco años en la supervivencia de los pacientes estadiados como N0M0 vs resto (N+M0, N0M+, N+M+). No hay diferencias en función del nivel del trombo. Conclusiones: El carcinoma renal con trombo en VCI es un tumor con alta mortalidad. El abordaje quirúrgico del mismo es la opción más valida y precisa una correcta valoración prequirúrgica y el apoyo de un equipo multidisciplinar preparado y con experiencia. La supervivencia depende de la extensión de la enfermedad.

Translated abstract

Objective: To assess current management of renal cell carcinoma (RCC) extending into the inferior vena cava (IVC): staging, diagnosis, surgical approach, adjuvant therapy, prognostic factors and survival rate. Materials and Methods: Nineteen cases of RCC extending into the IVC undergoing surgical resection from January 1988 to August 2008 were reviewed. TNM staging and Neves-Zincke grading of the tumor were also assessed. Surgical approach depended on thrombus level. Results: With a perioperative mortality rate of 10.5% and a mean follow-up of 22.65 months (range 2-79), 5 patients are still alive, while 11 patients died from the disease, 1 from an unrelated cause, and 2 were lost to follow-up. Patients with metastatic disease received adjuvant treatment with immunotherapy or kinase inhibitors. Mean survival was 15.1 months. Significant differences were found in 3- and 5-year survival rates in patients staged as N0M0 as compared to all other stages (N+M0, N0M+, N+M+). No differences were found depending on thrombus level. Conclusions: RCC with thrombus in the IVC is a tumor with a high mortality rate. Surgery continues to be the best option, and requires adequate preoperative evaluation and the support of an experienced and well trained multidisciplinary team. Survival depends on disease extension.

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Most cited references 71

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Surgical treatment of renal cancer with vena cava extension.

Horst Zincke, R. Neves (1987)

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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Renal cell carcinoma guideline.

Jean-Jacques Patard, Axel S. Merseburger, … (2007)

The European Association of Urology (EAU) Guideline Group for renal cell carcinoma (RCC) prepared this guideline to help urologists assess the evidence-based management of RCC and to incorporate the guideline recommendations into their clinical practice. The recommendations provided in the current guideline are based on a systematic literature search using MedLine, the Cochrane Central Register of Controlled Trials, and publications and review articles. A limited number of prospective randomised studies are available with high-level evidence. Most publications concerning RCC are based on retrospective analyses, including some larger multicentre validation studies and well-designed controlled studies. It must be stressed that the current guideline contains information for the treatment of an individual patient according to a standardised general approach. Updated recommendations concerning diagnosis, treatment, and follow-up can improve the clinical handling of patients with RCC.