Naitoh J, Kaplan A, Dorey F, Figlin R, Belldegrun A
Department of Urology, University of California-Los Angeles, USA.
J Urol. 1999 Jul;162(1):46-50. doi: 10.1097/00005392-199907000-00012.
We report our experience using aggressive multimodal therapy in a high risk group of patients with metastatic renal cell carcinoma and concurrent inferior vena caval extension.
We retrospectively reviewed the records of all patients in our kidney cancer database who had metastatic renal cell carcinoma and tumor thrombus extension into the inferior vena cava at the initial diagnosis. Patients were included in the study if they underwent radical nephrectomy and inferior venal caval thombectomy, and immunotherapy was planned for the postoperative period. Tumor size and grade, metastatic sites, level of vena caval extension, surgical complications and overall survival were obtained from the medical records. The primary end point analyzed was overall survival.
We identified 31 cases of metastatic renal cell cancer with extensive disease and vena caval extension. Of the patients 23% had an isolated lung metastasis, and 53% had metastasis in the lung and at other sites. The remaining patients had involvement primarily at nonpulmonary metastatic sites, including lymph node in 38%, soft tissue in 13%, liver in 29% and bone in 10%. Average blood loss during nephrectomy was 3,200 cc (median 2,100) and the rate of major complications was 12%. Of the patients 80% underwent the full course of surgery and postoperative immunotherapy. At a mean followup of 18 months (34 for survivors) 26% of the patients are alive. Actuarial overall 5-year survival of the group was 17%. Tumor thrombus level did not correlate with overall survival, while immunotherapy, tumor grade and metastatic site provided significant prognostic information. In patients with an isolated pulmonary metastasis the 5-year survival rate was 43%, while in those with low grade tumors it was 52%.
In contrast to the poor results of surgery only in patients with renal cell carcinoma and concurrent inferior venal caval invasion, reasonable 5-year survival may be achieved after combined aggressive surgery and immunotherapy. Patients in whom metastasis was limited to the lungs and those with grade 1 to 2 tumors had a better prognosis. With careful planning and experienced immunotherapists therapy may be completed in the majority of this high risk group of patients.
我们报告了在一组高风险的转移性肾细胞癌合并下腔静脉受累患者中使用积极多模式治疗的经验。
我们回顾性分析了肾癌数据库中所有初诊时患有转移性肾细胞癌且肿瘤血栓延伸至下腔静脉的患者记录。如果患者接受了根治性肾切除术和下腔静脉血栓切除术，并且计划在术后进行免疫治疗，则纳入本研究。从病历中获取肿瘤大小、分级、转移部位、腔静脉延伸水平、手术并发症和总生存期。分析的主要终点是总生存期。
我们确定了31例患有广泛疾病和腔静脉延伸的转移性肾细胞癌患者。其中23%的患者有孤立性肺转移，53%的患者肺部及其他部位有转移。其余患者主要累及非肺部转移部位，包括淋巴结转移占38%，软组织转移占13%，肝转移占29%，骨转移占10%。肾切除术中平均失血量为3200毫升（中位数2100毫升），主要并发症发生率为12%。80%的患者接受了完整的手术及术后免疫治疗。平均随访18个月（幸存者为34个月），26%的患者存活。该组患者的5年精算总生存率为17%。肿瘤血栓水平与总生存期无关，而免疫治疗、肿瘤分级和转移部位提供了重要的预后信息。孤立性肺转移患者的5年生存率为43%，低级别肿瘤患者的5年生存率为52%。
与仅行手术治疗的肾细胞癌合并下腔静脉侵犯患者的不良结果相比，积极的手术联合免疫治疗后可实现合理的5年生存率。转移局限于肺部的患者以及1至2级肿瘤患者预后较好。通过精心规划和经验丰富的免疫治疗师，大多数高风险患者组可完成治疗。
