Sweeney Paul, Wood Christopher G, Pisters Louis L, Slaton Joel W, Vaporciyan Ara, Munsell Mark, Carpenter Scott, Putnam Joe, Swisher Stephen G, Walsh Garret, Swanson David, Dinney Colin P N
Department of Urology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
Urol Oncol. 2003 Sep-Oct;21(5):327-33. doi: 10.1016/s1078-1439(02)00280-6.
The operative morbidity and mortality of radical nephrectomy are considerably higher when the vena cava is involved by the tumor. The prognostic significance of vena caval extension in this setting remains controversial. We reviewed our experience of vena caval thrombectomy specifically addressing prognostic factors. We retrospectively studied 96 patients treated at our institution between 1985 and 2001. The study population included 28 women and 68 men; (37 left- and 59 right-sided tumors). Twenty-seven patients had metastatic disease at presentation. Prognostic features (age, sex, race, side of tumor, embolization, tumor grade, tumor confinement by renal capsule, cephalic extent of thrombus, nodal status, and presence of distant metastasis) were evaluated using a Cox proportional hazards model (univariate and multivariate). These prognostic features were analyzed in the group as a whole and in the subgroup of patients who did not have metastatic disease at presentation and did not die perioperatively. There were 5 perioperative deaths. Extracapsular tumor extension and regional node involvement were present in 64% and 17% of the patients, respectively. Level of tumor thrombus were as follows: level I (41%), II (29%), III (7%), IV (15%). Fuhrman's grade was 2 in 17%, 3 in 45%, and 4 in 30% of the patients. For all 96 patients, median overall survival (OS) was 35 months. Five-year OS was 35%. The presence of distant metastasis at presentation did not significantly alter median OS (20 months with metastasis vs. 38 months without, P = 0.3), although this finding may have been confounded by selection. The presence of nodal metastasis was associated with decreased OS by multivariate analysis (P < 0.01). After exclusion of patients dying perioperatively and patients with metastasis at presentation, median OS and progression-free survival were 40 and 18 months, respectively (5-year OS was 40%). In the multivariate model, none of the factors examined were associated with OS, but age <58 years, and the presence of extracapsular tumor extension were associated with an increased risk of recurrence. In patients with renal tumors and extension of tumor thrombus into the vena cava, the level of propagation of the thrombus does not predict for OS. Selected patients with metastatic renal cancer may benefit from aggressive surgical resection of the primary tumor and associated tumor thrombus.
当肿瘤累及腔静脉时，根治性肾切除术的手术发病率和死亡率会显著升高。在这种情况下，腔静脉受累的预后意义仍存在争议。我们回顾了我们在腔静脉血栓切除术方面的经验，特别关注预后因素。我们回顾性研究了1985年至2001年间在我们机构接受治疗的96例患者。研究人群包括28名女性和68名男性；（37例左侧肿瘤和59例右侧肿瘤）。27例患者在就诊时已有转移性疾病。使用Cox比例风险模型（单变量和多变量）评估预后特征（年龄、性别、种族、肿瘤侧别、栓塞、肿瘤分级、肾包膜对肿瘤的包绕情况、血栓的头端范围、淋巴结状态和远处转移的存在情况）。在整个组以及就诊时无转移性疾病且围手术期未死亡的患者亚组中分析这些预后特征。有5例围手术期死亡。64%的患者存在肿瘤包膜外扩展，17%的患者存在区域淋巴结受累。肿瘤血栓水平如下：I级（41%）、II级（29%）、III级（7%）、IV级（15%）。17%的患者Fuhrman分级为2级，45%为3级，30%为4级。对于所有96例患者，中位总生存期（OS）为35个月。5年总生存率为35%。就诊时存在远处转移并未显著改变中位总生存期（有转移者为20个月，无转移者为38个月，P = 0.3），尽管这一发现可能因选择偏倚而受到混淆。多变量分析显示，淋巴结转移的存在与总生存期降低相关（P < 0.01）。排除围手术期死亡患者和就诊时已有转移的患者后，中位总生存期和无进展生存期分别为40个月和18个月（5年总生存率为40%）。在多变量模型中，所检查的因素均与总生存期无关，但年龄<58岁以及存在肿瘤包膜外扩展与复发风险增加相关。对于患有肾肿瘤且肿瘤血栓扩展至腔静脉的患者，血栓的扩展程度并不能预测总生存期。部分转移性肾癌患者可能从积极的原发肿瘤及相关肿瘤血栓手术切除中获益。
