Blute Michael L, Leibovich Bradley C, Lohse Christine M, Cheville John C, Zincke Horst
Department of Urology, Mayo Clinic, Rochester, Minnesota 55905, USA.
BJU Int. 2004 Jul;94(1):33-41. doi: 10.1111/j.1464-410X.2004.04897.x.
To report the surgical management, complications and outcomes over three decades by tumour thrombus level for patients with renal cell carcinoma (RCC) and renal venous extension, as surgery is the most effective treatment.
We assessed 540 patients who underwent surgical resection for RCC with renal venous extension between 1970 and 2000. Early and late surgical complications, including operative mortality, were compared with tumour thrombus level using the chi-square, Fisher's exact and Wilcoxon rank-sum tests. Cancer-specific survival was estimated using the Kaplan-Meier method and compared across tumour thrombus levels using log-rank tests.
There were 349 (64.6%) patients with level 0 thrombus and 191 (35.4%) with inferior vena cava thrombus, including 66 (12.2%) with level I, 77 (14.3%) with level II, 28 (5.2%) with level III, and 20 (3.7%) with level IV thrombus. Patients with a higher thrombus level had more early surgical complications (respectively for level 0 to IV, 8.6%, 15.2%, 14.1%, 17.9% and 30.0%, P < 0.001). However, there was no statistically significant difference in the incidence of late complications by thrombus level (P = 0.445). The incidence of any early surgical complication decreased from 13.4% for patients treated in 1970-1989 to 8.1% for those treated in 1990-2000 (P = 0.064); the respective operative mortality decreased from 3.8% to 2.0% (P = 0.260), and in patients with inferior vena cava thrombus, from 8.1% to 3.8% (P = 0.227). The respective duration of hospitalization decreased from a median of 8 to 7 days (P < 0.001) but the incidence of late complications increased significantly over time (P < 0.001.) Among patients with clear cell RCC, the respective estimated 5-year cancer-specific survival rates (Se, number still at risk) for patients with level 0 to IV thrombus were 49.1 (3.0)% (125), 31.7 (6.4)% (14), 26.3 (6.1)% (11), 39.4 (10.7)% (7) and 37.0 (12.9)% (5), (P = 0.028). There was a statistically significant difference in outcome for patients with level 0 vs those with level >0 thrombus (P = 0.002), but there was no significant difference in outcome by thrombus level among patients with inferior vena cava tumour thrombus (P = 0.868).
The surgical management of RCC with renal venous extension continues to develop. The incidence of early surgical complications and operative death have decreased in recent times with the introduction of improved imaging, surgical monitoring and vascular bypass techniques. There is significantly better cancer-specific survival for patients with renal vein involvement only than those with inferior vena cava involvement.
鉴于手术是最有效的治疗方法，报告过去三十年中肾细胞癌（RCC）伴肾静脉扩展患者按肿瘤血栓水平划分的手术治疗、并发症及预后情况。
我们评估了1970年至2000年间接受手术切除的540例RCC伴肾静脉扩展患者。使用卡方检验、Fisher精确检验和Wilcoxon秩和检验将包括手术死亡率在内的早期和晚期手术并发症与肿瘤血栓水平进行比较。采用Kaplan-Meier方法估计癌症特异性生存率，并使用对数秩检验在不同肿瘤血栓水平之间进行比较。
349例（64.6%）患者血栓水平为0级，191例（35.4%）伴有下腔静脉血栓，其中I级66例（12.2%），II级77例（14.3%），III级28例（5.2%），IV级20例（3.7%）。血栓水平较高的患者早期手术并发症更多（0级至IV级分别为8.6%、15.2%、14.1%、17.9%和30.0%，P<0.001）。然而，血栓水平对晚期并发症发生率无统计学显著差异（P = 0.445）。任何早期手术并发症的发生率从1970 - 1989年治疗患者的13.4%降至1990 - 2000年治疗患者的8.1%（P = 0.064）；手术死亡率分别从3.8%降至2.0%（P = 0.260），下腔静脉血栓患者从8.1%降至3.8%（P = 0.227）。住院时间中位数分别从8天降至7天（P<0.001），但晚期并发症发生率随时间显著增加（P<0.001）。在透明细胞RCC患者中，0级至IV级血栓患者的5年癌症特异性生存率估计值（Se，仍处于风险中的人数）分别为49.1（3.0）%（125）、31.7（6.4）%（14）、26.3（6.1）%（11）、39.4（10.7）%（7）和37.0（12.9）%（5），（P = 0.028）。0级患者与血栓水平>0级患者的预后有统计学显著差异（P = 0.002），但下腔静脉肿瘤血栓患者中不同血栓水平的预后无显著差异（P = 0.868）。
RCC伴肾静脉扩展的手术治疗持续发展。随着影像技术、手术监测和血管旁路技术的改进，近期早期手术并发症和手术死亡的发生率有所下降。仅累及肾静脉的患者癌症特异性生存率显著优于累及下腔静脉的患者。
