EURURO Vol. 72 No. 6

1024 1030

evidence that the five-tier grading system is helpful to better
predict prognosis in patients with prostate cancer, without
completely omitting the familiar and well-established Gleason
scoring system.
Conflicts of interest: The [8_TD$DIFF]author [9_TD$DIFF]has nothing to disclose.
References
[1]
.
[2]
.
[3]
.
Thomas Gasse
Department of Urology, Urologic Clinics of the University of Basel, Liestal,
Switzerland
*Department of Urology, Urologic Clinics of the University of Basel,
Kantonsspital Baselland, Rheinstrasse 26, 4410 Liestal, Switzerland[1_TD$DIFF].
E-mail address:
© 2017 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
Re: Cytoreductive Nephrectomy for Renal Cell Carcino-
ma with Venous Tumor Thrombus
Abel EJ, Spiess PE, Margulis V, et al
J Urol 2017;198:281–8
Experts’ summary:
The role of cytoreductive nephrectomy (CN) in metastatic
renal cell carcinoma (mRCC) in the era of targeted therapy
and novel immunotherapeutic approaches has not been clear-
ly defined yet. The presence of inferior vena cava (IVC) in-
volvement increases the complexity and morbidity of surgery,
making the risk-to-benefit ratio even higher for CN. The
authors of this retrospective analysis of 427 mRCC patients
with different levels of IVC thrombosis undergoing CN at five
institutions between 2000 and 2014 defined preoperative
variables that could predict overall survival (OS) and help in
patient selection for CN. Independent adverse predictors of OS
included poor risk according to Memorial Sloan Kettering
Cancer Center, International Metastatic Renal-Cell Carcinoma
Database Consortium, and M.D. Anderson Cancer Center strat-
ification systems; level 4 IVC thrombus; systemic symptoms;
and sarcomatoid dedifferentiation.
Experts’ comments:
One of the important results of this study is the conclusion
that OS in mRCC with venous thrombus is similar to the
survival of patients in non-thrombectomy CN series, suggest-
ing that the presence of venous involvement by itself should
not exclude mRCC patients from consideration for cytoreduc-
tive surgery. Poor risk grouping and sarcomatoid features are
well-established negative predictors of survival and are stated
as contraindications for CN in guidelines, while the influence
of the height of tumor thrombus on survival is controversial.
The level of tumor thrombus did not significantly affect OS in
patients with RCC in the largest European multicenter study
[1]. RCC with IVC tumor thrombus comprises very heteroge-
neous group of patients who require different surgical
approaches, depending more on factors other than thrombus
level, such as IVC wall invasion, tumor thrombus consistency,
degree of IVC occlusion, occlusion of the main hepatic veins,
associated infrarenal IVC thrombosis, and the size and side of
the primary tumor. The latter factors are unfortunately rarely
assessed in retrospective studies, but may significantly affect
surgical complexity, complication rates, early mortality, and
OS, while cancer-specific survival is more influenced by dis-
tant metastasis and the efficacy of postoperative systemic
therapy.
Patients with level 4 thrombi are at risk of dying from
specific complications such as pulmonary embolism and
renal, liver, and heart failure if left without surgery. The
complexity of the surgery and associated morbidity can be
decreased by avoiding the use of cardiopulmonary bypass in
selected patients [2]. The decision to perform CN in mRCC
patients with venous thrombus should be considered on an
individual basis, taking into account prognostic scores,
tumor histology, risk of surgery, and tumor progression.
Conflicts of interest: The authors have nothing to disclose.
References
[1]
.
[2]
.
Vsevolod B. Matvee
Department of Urology, N.N. Blokhin Cancer Research Center,
Moscow, Russia
*Corresponding author. Department of Urology, N.N. Blokhin Cancer
Research Center, Kashirskoe Shosse 24, Moscow 115478, Russian
Federation.
E-mail addresses: ,
(V.B. Matveev).
© 2017 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
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