e u r o p e a n u r o l o g y 5 5 ( 2 0 0 9 ) 4 5 2 – 4 6 0 459

[29] Ciancio G, Livingstone AS, Soloway M. Surgical manage-

ment of renal cell carcinoma with tumor thrombus in the

renal and inferior vena cava: the University of Miami

experience in using liver transplantation techniques.

Eur Urol 2007;51:988–95.

Editorial Comment on: Prognosis Value of RenalVein and Inferior Vena Cava Involvement inRenal Cell CarcinomaPaul RussoMemorial Sloan Kettering Cancer Center,1275 York Avenue, New York, New York 10021,United StatesRussoP@MSKCC.org

The authors present data from 13 centers and1192 patients accumulated over a 21-yr period todefine the prognosis of renal tumors invading therenal vein and inferior vena cava (IVC) [1]. Mostpatients had a renal vein thrombus (78.3%), 16.4%had subdiaphragmatic IVC thrombus, and 5.3% hada supradiaphragmatic IVC thrombus. Despite thelarge number of patients in this study, 47% of thepatients already had evidence of poor prognosticsystemic disease in the form of metastatic nodes(n = 235, 19.7%) and distant metastases (n = 326,27.3%), and even a highly successful operation onthe renal tumor and its thrombus would not affectthe poor outcome for those patients. When theauthors analyzed their data in the N0 M0 patients,only tumor size predicted vascular invasion andoverall survival. For patients with N+ and M+disease, resection of the kidney tumor and itsthrombus should be considered either a cytore-ductive nephrectomy and/or a tumor metastasec-tomy [2] with patient survival ultimatelydependent upon the presence of associated riskfactors [3] and response to systemic agents.

This large surgical series is notable for aperioperative mortality of 3% for tumors involvingthe renal vein and 9.6% for tumors involving theIVC, which is most consistent with the contem-porary literature and again reminds us that theseare a very challenging group of surgical patients.Elements of the individual tumor (size, tumorgrade, perinephric fat extension, regional anddistant metastases) have the greatest bearing onsurvival.

[30] Zisman A, Pantuck AJ, Chao DH, et al. Renal cell carci-

noma with tumor thrombus: is cytoreductive nephrec-

tomy for advanced disease associated with an increased

complication rate? J Urol 2002;168:926–67.

There is a reason for optimism for futurepatients with locally advanced, massive renaltumors with or without renal vein and IVCextension. Our new understanding of the molecu-lar biology of renal cell carcinoma has led to thedevelopment and the US Food and Drug Adminis-tration approval of new systemic chemotherapyagents, including the multitargeted tyrosine kinase(TKI) inhibitors (sunitinib, sorafenib) and mamma-lian target of rapamycin (mTOR) kinase inhibitors(temsirolimus, RAD001). These agents have beeneffective in inducing partial remissions andprolonging survival in metastatic renal cancerand previously treated metastatic renal cancerpatients [4,5] and are more effective than cytokineswhen compared in randomized trials. For thesedifficult, poor prognostic surgical patients, numer-ous neoadjuvant and adjuvant clinical trials utiliz-ing these agents have been launched in the UnitedStates and Europe in hopes of improving prognosis.

References

[1] Wagner B, Patard J-J, Mejean A, et al. Prognostic value of

renal vein and inferior vena cava involvement in renal

cell carcinoma. Eur Urol 2009;55:452–60.

[2] Russo P, Snyder M, Vickers A, Kondagunta V, Motzer R.

Cytoreductive nephrectomy and nephrectomy/com-

plete metastasectomy for metastatic renal cancer.

TSW Urology 2007;2:42–52.

[3] Eggener SE, Yossepowitch O, Pettus JA, Snyder ME,

Motzer RJ, Russo P. Renal cell carcinoma recurrence

after nephrectomy for localized disease. Predicting

survival from time of recurrence. J Clin Oncol 2006;24:

3101–31.

[4] Bukowski RM, Wood LS. Renal cell carcinoma: state of

the art diagnosis and treatment. Clin Oncol 2008;11:9–21.

[5] O’Brien F, Motzer R, Russo P. Sunitinib therapy in renal

cell carcinoma. BJU Int 2008;101:1339–42.

DOI: 10.1016/j.eururo.2008.07.054

DOI of original article: 10.1016/j.eururo.2008.07.053