Partial nephrectomy in two patients with known T3a tumours involving the renal vein

Abstract

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Although nephron‐sparing surgery (NSS) has became accepted therapy for T1 tumours, radical nephrectony is considered the best therapy for T3a tumours involving the renal vein. NSS can be considered in T3a or greater tumours if imperative indications exist, such as bilateral disease or solitary kidney. However, there is little published data on the characteristics of these patients, the impact of surgery on their renal function, and long‐term oncologic outcomes. This study profiles single‐institution experience with nephron‐sparing surgery for known T3a tumours involving the renal vein, including patient characteristics, tumour characteristics, preoperative and follow‐up imaging, preoperative and follow‐up estimated glomerular filtration rate, length of temporary postoperative haemodialysis, and oncologic outcome. Additionally, we compare this to other published data on nephron‐sparing surgery for similar tumors. OBJECTIVE To present two patients with T3a tumours involving the renal vein who underwent nephron‐sparing surgery (NSS) for imperative reasons. PATIENTS AND METHODS Retrospective chart review of patients who underwent NSS for renal cell carcinoma (RCC) with known renal vein tumour thrombus (RVTT). Both patients underwent open partial nephrectomy and renal vein thrombectomy of a solitary kidney. Primary outcomes of the study include radiographic evidence of recurrence, haemodialysis requirement and estimated glomerular filtration rate (eGFR) before and after surgery. RESULTS Patient 1 is 24 months from NSS and has no evidence of recurrence based on CT scan. His final pathology revealed a 9‐cm, T3a, clear cell, Fuhrman grade II carcinoma. He spent 42 days on haemodialysis and is now off all dialysis. His preoperative and most recent eGFR are 48 and 23 mL/min/1.73 m2 based on the Modification of Diet in Renal Disease (MDRD) equation and 69.4 and 29.8 mL/min by the Cockcroft–Gault equation. Patient 2 is 9 months from NSS and has no evidence of recurrence based on CT scan. Her final pathology revealed a 6‐cm, T3a, clear cell, Fuhrman grade II–III carcinoma. She spent 30 days on haemodialysis and is now off all dialysis. Her preoperative and most recent eGFR are 58 and 30 mL/min/1.73 m2 based on the MDRD equation and 62.2 and 32.8 mL/min by the Cockcroft–Gault equation. CONCLUSION Based on our review, preservation of renal function and favourable oncological outcome can be accomplished with NSS in patients with known stage T3a RCC with RVTT and should be considered in carefully selected patients.

Nephron-Sparing Surgery for Renal Cell Carcinoma with Tumor Thrombus

“…We acknowledge that this experience is rather small, but these cases of imperative partial nephrectomy in conjunction with tumor thrombectomy are extremely rare. In fact, with the exception of a single multi-institutional cohort including a total of 42 patients from 9 different institutions [10], most of the remaining published series comes from single referral centers reporting on the experience obtained from the management of a few cases (Table 1) [19][20][21][22][23]. All these series agree in the technical feasibility of different parenchymal-preserving surgical procedures for cases of intraparenchymal venous branches or main renal vein involvement by the TT.…”

Nephron Sparing Surgery for Renal Angiomyolipoma with Inferior Vena Cava Thrombus in Tuberous Sclerosis

“…Cases of nephron sparing surgery for T3a or T3b renal cell carcinoma, whether for imperative indications (solitary kidney or renal failure) or intraoperative discovery of the thrombus, showed outcomes that seem acceptable compared to nonconserving surgery [58–60]. …”

Nephron-sparing surgery for tumors in a solitary kidney

“…Long et al [43] reported OPN in seven solitary kidneys in their series of 49 tumors of at least 7 cm. OPN in patients with a solitary kidney involving renal vein and inferior vena cava has also been reported [44,45]. Liu et al [46] reported on the outcome of patients with a solitary kidney who underwent repeat partial nephrectomy because of recurrence after previous NSS.…”