Tsuji Y, Goto A, Hara I, Ataka K, Yamashita C, Okita Y, Kamidono S
Department of Surgery, Division II, Kobe University School of Medicine, Japan.
J Vasc Surg. 2001 Apr;33(4):789-96. doi: 10.1067/mva.2001.111996.
The outcome of patients who underwent radical resection of renal cell carcinoma extending into the vena cava was retrospectively analyzed, and risk factors for long-term survival were investigated.
From 1983 to 1999, 33 patients who had renal cell carcinoma with inferior vena caval tumor extension underwent 34 surgical procedures. There were 27 men and six women with an average age of 60.1 years. Twenty-two cases (64.7%) were classified as stage III (T1-2 N1 M0 or T3 N0-1 M0), and 12 cases (35.3%) as stage IV (T4 or N2-3 or M1). Coexistent lung metastasis was found in seven cases (20.6%). The tumor thrombi invaded into the inferior vena cava below the hepatic hilum in 19 cases, below the orifice of hepatic veins in 12, and above the diaphragm in 3. Cardiopulmonary bypass graft was applied in 13 cases (38.2%). Inferior vena cava was reconstructed by direct suture (n = 19), polytetrafluoroethylene patch angioplasty (n = 13), or graft replacement (n = 2).
Two patients died during the early postoperative period because of retrohepatic caval injury and intraoperative pulmonary embolism. Late death occurred in 16 patients; the causes of death were tumor recurrence in 15 and acute pulmonary embolism as a result of graft thrombosis in 1. Overall 1-, 5-, and 10-year survival rates were 70%, 44%, and 26.4%, respectively. One- and 5-year survival rates were 81.3% and 52.9% for stage III and 50% and 31.2% for stage IV; a statistically significant correlation was found between surgical staging and survival (P =.049). Patients without lymph node metastasis had a significant survival advantage over those with lymph node metastasis (P =.022). There was no significant difference in survival on the basis of the presence or absence of synchronous lung metastasis (P =.291). The degree of local extension of the tumor or the level of tumor thrombus did not tend to influence survival.
Surgical prognosis in patients with renal cell carcinoma extending into the vena cava was determined by the staging of the tumor, especially lymph node status, and not by the level of tumor thrombus or the presence of concurrent lung metastasis. The use of cardiopulmonary bypass graft is recommended for the resection of tumor thrombus extending over the diaphragm.
回顾性分析行根治性切除累及下腔静脉的肾细胞癌患者的预后，并研究长期生存的危险因素。
1983年至1999年，33例肾细胞癌伴下腔静脉肿瘤延伸患者接受了34次手术。其中男性27例，女性6例，平均年龄60.1岁。22例（64.7%）被归类为Ⅲ期（T1-2 N1 M0或T3 N0-1 M0），12例（35.3%）为Ⅳ期（T4或N2-3或M1）。7例（20.6%）发现并存肺转移。肿瘤血栓侵犯至肝门以下的下腔静脉19例，肝静脉开口以下12例，膈肌以上3例。13例（38.2%）应用了体外循环血管移植术。下腔静脉通过直接缝合重建（n = 19）、聚四氟乙烯补片血管成形术（n = 13）或移植置换（n = 2）。
2例患者术后早期因肝后下腔静脉损伤和术中肺栓塞死亡。16例发生晚期死亡；死亡原因15例为肿瘤复发，1例为移植血栓形成导致的急性肺栓塞。总体1年、5年和10年生存率分别为70%、44%和26.4%。Ⅲ期患者1年和5年生存率分别为81.3%和52.9%，Ⅳ期患者分别为50%和31.2%；手术分期与生存之间存在统计学显著相关性（P = 0.049）。无淋巴结转移患者的生存优势显著高于有淋巴结转移患者（P = 0.022）。基于是否存在同步肺转移，生存无显著差异（P = 0.291）。肿瘤局部扩展程度或肿瘤血栓水平对生存无明显影响。
累及下腔静脉的肾细胞癌患者的手术预后取决于肿瘤分期，尤其是淋巴结状态，而非肿瘤血栓水平或并存肺转移的存在。对于切除延伸至膈肌以上的肿瘤血栓，建议使用体外循环血管移植术。
