Prevalence, Treatment, and Prognosis of Tumor Thrombi in Renal Cell Carcinoma

Fleur H J Kaptein; Tom van der Hulle; Sander J E Braken; Erik J van Gennep; Jeroen T Buijs; Mark C Burgmans; Suzanne C Cannegieter; Emma M E du Chatinier; Menno V Huisman; Els L van Persijn van Meerten; Henri H Versteeg; Rob C M Pelger; Frederikus A Klok

doi:10.1016/j.jaccao.2022.07.011

Prevalence, Treatment, and Prognosis of Tumor Thrombi in Renal Cell Carcinoma

JACC CardioOncol. 2022 Nov 15;4(4):522-531. doi: 10.1016/j.jaccao.2022.07.011. eCollection 2022 Nov.

Affiliations

¹ Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
² Department of Medicine-Oncology, Leiden University Medical Center, Leiden, the Netherlands.
³ Department of Urology, Leiden University Medical Center, Leiden, the Netherlands.
⁴ Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.
⁵ Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.

Abstract

Background: Renal cell carcinoma (RCC) can be complicated by a venous tumor thrombus (TT), of which the optimal management is unknown.

Objectives: This study sought to assess the prevalence of TT in RCC, its current management, and its association with venous thromboembolism (VTE), arterial thromboembolism (ATE), major bleeding (MB), and mortality.

Methods: Patients diagnosed with RCC between 2010 and 2019 in our hospital were included and followed from RCC diagnosis until 2 years after, or until an outcome of interest (VTE, ATE, and MB) or death occurred, depending on the analysis. Cumulative incidences were estimated with death as a competing risk. Cause-specific hazard models were used to identify predictors and the prognostic impact.

Results: Of the 647 patients, 86 had a TT (prevalence 13.3%) at RCC diagnosis, of which 34 were limited to the renal vein, 37 were limited to the inferior vena cava below the diaphragm, and 15 extended above the diaphragm; 20 patients started therapeutic anticoagulation and 45 underwent thrombectomy with/without anticoagulation. During follow-up (median 24.0 [IQR: 7.0-24.0] months), 17 TT patients developed a VTE, 0 developed an ATE, and 11 developed MB. TT patients were more often diagnosed with VTE (adjusted HR: 6.61; 95% CI: 3.18-13.73) than non-TT patients, with increasing VTE risks in more proximal TT levels. TT patients receiving anticoagulation still developed VTE (HR: 0.56; 95% CI: 0.13-2.48), at the cost of more MB events (HR: 3.44; 95% CI: 0.95-12.42) compared with those without anticoagulation.

Conclusions: Patients with RCC-associated TT were at high risk of developing VTE. Future studies should establish which of these patients benefit from anticoagulation therapy.

Keywords: ATE, arterial thromboembolism; CT, computed tomography; DVT, deep vein thrombosis; IVC, inferior vena cava; LMWH, low-molecular-weight heparin; MB, major bleeding; PE, pulmonary embolism; RCC, renal cell carcinoma; TT, tumor thrombus; VKA, vitamin K antagonist; VTE, venous thromboembolism; aHR, adjusted HR; anticoagulants; hemorrhage; inferior vena cava; prognosis; renal cell carcinoma; venous thrombosis.