Presurgical treatment for inferior vena cava tumor thrombus in patients with renal cell carcinoma: A scoping review.

Abstract

602 Background: To date, there is no evidence-based standard of care for the management of patients with tumor-related thrombus (TT) in the inferior vena cava (IVC) associated with renal cell carcinoma (RCC).The aim of our study is to analyze published papers on presurgical treatment and their effect on reducing the TT length, level and deintensification of surgical approach. Methods: MEDLINE, Embase, and Cochrane Central were systematically searched using PRISM-Scr checklist for studies evaluating presurgical therapies intended to decrease the TT length, and level in RCC patients as well as surgical outcome. Patient were reviewed to have the following outcomes: clinically significant (>20%) reduction in TT length, reduction in TT level by Mayo classification and deintensification of planned surgical intervention. Results: After comprehensive review of 1175 studies by PRISMA-Scr protocol, 21 studies fulfilled prespecified criteria that included 1 phase II clinical trial, 3 case series and 16 retrospective cohort studies. Among 216 patients reviewed, 178 (82.4%) had clear cell RCC, 106 (49.07%) had stage T3b and 53 (24.53%) had nodal involvement. Presurgical regimes included Thyrosine Kinase Inhibitors (TKI) (81%), TKI-Immune check point inhibitor (ICI) combination (6%), ICI monotherapy (3%), Stereotactic radiation (4%) and others (6%). Significant decrease in length in TT was reported in 40.29%, 42.86% and 84.62% of patients treated with TKI, ICI and TKI-ICI combination, respectively. Levels of TT were decreased in 30.32%, 46.15% and 14.29% patients treated with TKI, ICI and TKI-ICI combination, respectively. Among the patients reported to have less invasive surgical approach following presurgical treatment (n=34), 29.41% avoided cardiac bypass. Conclusions: Published studies have reported benefits of presurgical treatment in reducing length and level of TT as well as improving surgical outcome. However, significant heterogeneity exists and prospective studies are required to draw a meaningful conclusion.