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Case Reports
. 2024 Sep 30;13(9):5141-5148.
doi: 10.21037/tcr-23-1547. Epub 2024 Sep 27.

A case report of robot-assisted radical nephrectomy and inferior vena cava thrombectomy in a patient with renal cell carcinoma after pembrolizumab and axitinib combination therapy

Ryo Shiode  1 , Terutaka Noda  1 , Shota Nobumori  1 , Naoya Sugihara  1 , Maki Yamakawa  1 , Kaori Saiki  1 , Takatora Sawada  1 , Reina Kono  1 , Toshio Kakuda  1 , Kenichi Nishimura  1 , Tetsuya Fukumoto  1 , Noriyoshi Miura  1 , Yuki Miyauchi  1 , Tadahiko Kikugawa  1 , Takashi Saika  1
Affiliations
Case Reports

A case report of robot-assisted radical nephrectomy and inferior vena cava thrombectomy in a patient with renal cell carcinoma after pembrolizumab and axitinib combination therapy

Ryo Shiode et al. Transl Cancer Res. .

Abstract

Background: Robot-assisted surgery is widely performed for renal cell carcinoma (RCC) with inferior vena cava (IVC) tumor thrombi. Although many chemotherapeutic options are available for the treatment of unresectable RCC, there are very few reports on robot-assisted radical nephrectomy (RARN) with inferior vena cava thrombectomy (IVCT) after presurgical treatment with immune checkpoint inhibitors and tyrosine kinase inhibitors. We believe that pre-surgical treatment can provide minimally invasive surgical benefits to high-risk patients during the perioperative period.

Case description: A 77-year-old male with right RCC that invaded the IVC (cT3bN0M0, Mayo classification level III) underwent pembrolizumab and axitinib combination therapy because he had high surgical risk due to angina pectoris. The level of the tumor thrombus decreased from level III to II, and RARN with IVCT was then performed. Surgery was performed without complications, and the patient was discharged on postoperative day seven. The pathological diagnosis was clear cell RCC (ypT3b, G2). Adjuvant chemotherapy using pembrolizumab monotherapy is still ongoing.

Conclusions: In this report, the inferior vena cave tumor thrombus level was down staged from level III to level II by treatment with pembrolizumab and axitinib. RARN with IVCT was safely performed without complication completely under robotic assistance.

Keywords: Robot-assisted radical nephrectomy (RARN); case report; immune checkpoint inhibitor (ICI); inferior vena cava thrombectomy (IVCT); pre-surgical treatment.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tcr.amegroups.com/article/view/10.21037/tcr-23-1547/coif). The series “Current Status of Robotic Surgery for Genitourinary Diseases in Japan” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Figures

Figure 1
Figure 1
Contrast-enhanced CT findings in this case. (A) Suspicious findings of clear cell renal cell carcinoma in the right kidney. (B) The tumor thrombus tip reached the confluence of the hepatic vein and IVC. CT, computed tomography; IVC, inferior vena cava.
Figure 2
Figure 2
Determination of effectiveness of chemotherapy confirmed by contrast-enhanced CT findings. (A) The first medical examination (yellow arrows: primary tumor and tumor thrombus tip). (B) After completion of the second course of pembrolizumab (yellow arrows: primary tumor and tumor thrombus tip). (C) After completion of the third course of pembrolizumab (yellow arrows: primary tumor and tumor thrombus tip). CT, computed tomography.
Figure 3
Figure 3
The port positions are set in a similar manner to those of robot-assisted partial nephrectomy. The assistant’s left-hand port uses a wound retractor.
Figure 4
Figure 4
The details of the surgery. (A) The left renal vein and medial IVC is dissected and exposed. (B) The right renal artery is secured caudal to the left renal vein, clipped, and taped. (C) The inferior right hepatic vein is dissected using Endo GIATM at of its confluence with the IVC. (D) The short hepatic vein is identified cephalad to the inferior right hepatic vein and is dissected using a LigasureTM. (E) Intraoperatively, an echo confirms that the tumor tip was slightly cephalic to the inferior right hepatic vein. (F) The IVC and left renal vein are clamped cephalad and caudally using laparoscopic bulldog forceps to enclose the tumor. (G) An incision is made on the IVC and the tumor thrombus is removed. Adhesion to the IVC wall is mild. (H) The IVC wall is sutured using 4-0 PROLENE sutures. IVC, inferior vena cava.
Figure 5
Figure 5
The tumor thrombus is necrotic, and a few viable cells are seen in the primary tumor.
Figure 6
Figure 6
PD-L1 staining. PD-L1-positive immune cells are expressed at the tumor margins. Scale bar: 50 µm. PD-L1, programmed cell death ligand 1.
See this image and copyright information in PMC

References

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