2.1

Data collection

The clinical, pathological, and laboratory variables were collected through the electronic medical record system. Preoperative contrast-enhanced CT, MR, and ultrasound were reviewed to determine the features of the primary tumor.

2.2

Statistical analysis

Non-normally distributed continuous variables were described as the median and interquartile range (IQR). Normally distributed continuous variables are described as mean ± standard deviation. Categorical variables were calculated using frequency counts and percentages. The analysis of variance (ANOVA) test or Kruskal-Wallis test was used to compare the continuous variables. The Chi-square test or Fisher’s exact test was used to compare the categorical variables.

The Kaplan-Meier method was performed to analyze the survival rate, and the survival difference between groups was compared using the log-rank test. The max stat method (max stat package, R software) was used to determine the optimal cutoff value of continuous variables according to survival outcomes.

A multivariate Cox proportional hazards model was fitted for OS by including all the statistically significant covariates from the univariate Cox models. Using the regression coefficients of the independent prognostic factors from the multivariate Cox regression model, a nomogram for predicting the probability of survival was established. Harrell’s concordance index (C-index) and time-dependent receiver operating characteristic curves was used to evaluate predictive accuracy. Bootstrap validation (300 resamples) was conducted and calibration was assessed graphically using plots of the predicted probability of OS versus the actual proportion of surviving patients.

Two experienced radiologists independently assessed the presence of extensive necrosis and thickened tumor thrombus. Inter-observer agreement was evaluated using Cohen’s kappa coefficient. R software (version 3.5.0; http://www.r-project.org ) was used to establish and calibrate the nomogram and conduct other statistical analyses; P< 0.05 was considered statistically significant.

3.1

The prognosis controversial of the level of IVCTT and tumor size

The current 8th edition of the AJCC TNM staging system categorizes patients with IVCTT into T3b and T3c based on whether the tumor thrombus exceeds the diaphragmatic level. However, this classification has been found to be insufficient for the prognosis of patients who undergo RNTE [ ]. Follow research also found that the Mayo Clinic classification, which further subdivided the height of the IVCTT by 3 levels, is also inadequate for prognosis [ ]. Consistently, our study demonstrated that the extent of the tumor thrombus remains without prognostic value for postoperative stratification. ( Fig. 1 A, Fig. 1 B). In our cohort, we found that tumor size had no significant prognostic value ( Fig. 1 C), which is consistent with the findings of previous studies [ , , ].

The level of IVCTT classified by T3B, T3C (A), the level of IVCTT classified by mayo levels I – IV (B) and tumor size based on TNM staging (C) does not possess significant value for postoperative survival stratification.

3.2

The establishment of the primary tumor score

3.2.1

Thickness of IVCTT

In clinical practice, the morphology of tumor thrombus varies from person to person and can be described as a cylindrical shape with significantly different thicknesses ( Fig. 2 A–D). The thickness degree(TD) indicates the extent to which the tumor thrombus grows along the short axis after entering the inferior vena cava; in other words, it indicates whether the IVCTT is skinny or chubby. The measurement of TD is shown in Fig. S1 . Range from 0,25 to 5.90, TD demonstrated varied morphological features. The best cut-off value of TD for indicating survival in our cohort was 1.23 ( Fig. S2 ), and accordingly, 129 of our patients were classified as having a chubby thrombus, and 53 were classified as having a skinny thrombus. The difference in survival between the 2 groups was significant ( Fig. 2 E).

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