Reassessing prognosis in renal cell carcinoma with venous tumor thrombus: Prospective data from 46 cases

ABSTRACT Objectives: To evaluate perioperative and oncologic outcomes after radical nephrectomy with inferior vena cava (IVC) thrombectomy for renal cell carcinoma (RCC) with venous tumor thrombus, and to assess whether survival relates more to thrombus extent or tumor biology. Materials and Methods: This prospective cohort study enrolled 46 patients with RCC and IVC tumor thrombus treated between 2019 and 2022; the last follow-up was March 2025. The primary endpoints were overall survival (OS) and cancer-specific survival (CSS), estimated using Kaplan–Meier analysis and exploratory univariate Cox regression. Results: Median age was 59.5 years; 36 of 46 were male. Thrombus level was Mayo I in 17, II in 20, III in 7, and IV in 2; 8 had pM1, and 7 had pN1 disease. Median follow-up was 24 months; 26 patients were alive, 18 had died, and 2 were lost to follow-up. 1- and 3-year OS were 78% and 50% (extrapolated); 3-year CSS was approximately 60%. Median OS was 36 months in non-metastatic (n = 38) versus 10 months in metastatic patients (n = 8) (P < 0.001). Nodal involvement (Hazard Ratio [HR] 2.8, P = 0.03) and metastasis (HR 5.1, P = 0.001) predicted poor survival; thrombus level was not associated with OS or CSS (P = 0.65). R0 resection was achieved in 44 of 46 patients. Complications occurred in 7 patients (1 major), with 2 perioperative deaths. Conclusion: In this small prospective cohort, metastatic and nodal status, rather than thrombus extent, were associated with survival, though limited sample size precludes definitive conclusions. Thrombus level affected surgical complexity but not OS or CSS.