Klatte Tobias, Pantuck Allan J, Riggs Stephen B, Kleid Mark D, Shuch Brian, Zomorodian Nazy, Kabbinavar Fairooz F, Belldegrun Arie S
Department of Urology, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California 90095-1738, USA.
J Urol. 2007 Oct;178(4 Pt 1):1189-95; discussion 1195. doi: 10.1016/j.juro.2007.05.134. Epub 2007 Aug 14.
We identified prognostic factors for renal cell carcinoma with tumor thrombus extension and assessed whether the current T3 classification could be improved.
We studied clinicopathological parameters in 321 consecutive patients who were surgically treated for renal cell carcinoma with tumor thrombus extension. Disease specific survival was evaluated with univariate and multivariate analysis. Harrell's C-index was used to assess the prognostic accuracy of prognostic models.
Tumor thrombus extended into the renal vein in 166 patients, the inferior vena cava in 137 and the atrium in 18. Metastatic renal cell carcinoma was found in 198 patients (62%). The thrombus level had no impact on clinicopathological parameters or survival but perioperative morbidity and mortality increased with cranial extension of the thrombus. Mean followup was 49 months. Five and 10-year disease specific survival rates were 36% and 24%, respectively. On multivariate analysis Eastern Cooperative Oncology Group performance status, lymph node and distant metastases, sarcomatoid features and perinephric fat invasion were independent prognostic factors. Weight loss, anemia, collecting system invasion, incomplete surgical resection, nuclear grade and T classification were also significant prognosticators on univariate analysis. For patients with advanced disease the number of metastatic sites and the disease-free interval further predicted prognosis. The overall immunotherapy response rate was 19%, which decreased with cranial extension of the thrombus. Redefinition of the T3 classification with the incorporation of fat invasion improved prognostic accuracy, as shown by an increase in the C-index.
Eastern Cooperative Oncology Group performance status, metastatic status, sarcomatoid features and concomitant perinephric fat invasion are the most powerful prognostic factors of survival in renal cell carcinoma with tumor thrombus extension. Our data indicate that a redefinition of the current T3 classification may improve its predictive accuracy. We propose that T3 renal cell carcinoma with fat invasion or thrombus extension alone should be classified as T3a, while that with thrombus extension plus fat invasion should be classified as T3b.
我们确定了伴有肿瘤血栓延伸的肾细胞癌的预后因素，并评估当前的T3分类是否可以改进。
我们研究了321例接受手术治疗的伴有肿瘤血栓延伸的肾细胞癌患者的临床病理参数。采用单因素和多因素分析评估疾病特异性生存率。使用Harrell's C指数评估预后模型的预后准确性。
166例患者的肿瘤血栓延伸至肾静脉，137例延伸至下腔静脉，18例延伸至心房。198例患者（62%）发现有转移性肾细胞癌。血栓水平对临床病理参数或生存率无影响，但围手术期发病率和死亡率随血栓向头端延伸而增加。平均随访49个月。5年和10年疾病特异性生存率分别为36%和24%。多因素分析显示，东部肿瘤协作组（Eastern Cooperative Oncology Group）体能状态、淋巴结和远处转移、肉瘤样特征和肾周脂肪浸润是独立的预后因素。单因素分析显示，体重减轻、贫血、集合系统侵犯、手术切除不完全、核分级和T分类也是显著的预后因素。对于晚期疾病患者，转移部位数量和无病间期进一步预测预后。总体免疫治疗缓解率为19%，随血栓向头端延伸而降低。纳入脂肪浸润重新定义T3分类提高了预后准确性，C指数增加表明了这一点。
东部肿瘤协作组体能状态、转移状态、肉瘤样特征和伴随的肾周脂肪浸润是伴有肿瘤血栓延伸的肾细胞癌生存的最有力预后因素。我们的数据表明，重新定义当前的T3分类可能会提高其预测准确性。我们建议，仅伴有脂肪浸润或血栓延伸的T3肾细胞癌应分类为T3a，而伴有血栓延伸加脂肪浸润的应分类为T3b。
