Montie J E, el Ammar R, Pontes J E, Medendorp S V, Novick A C, Streem S B, Kay R, Montague D K, Cosgrove D M
Department of Urology, Cleveland Clinic Foundation, Ft. Lauderdale, Florida.
Surg Gynecol Obstet. 1991 Aug;173(2):107-15.
Renal cell carcinoma is a unique neoplasm because of its common propensity to propagate into the renal vein and inferior vena cava (IVC) as tumor thrombus. Historically, the surgical difficulties encountered in removal of these cancers limited the ability of a single institution to obtain experience with large numbers of instances. Between January 1956 and July 1987, 68 patients with renal cell carcinoma extending into the IVC or right atrium underwent radical nephrectomy with vena cava thrombus extraction at the Cleveland Clinic. Twenty-five patients had partial resection of the IVC with reconstruction. Fifteen patients had partial resection and reconstruction of the IVC; however, because of narrowing of the infrarenal IVC, persisting bland thrombus in the proximal IVC or iliac veins or concern regarding postoperative pulmonary emboli, the infrarenal IVC was either ligated or clipped. Seven patients underwent cavectomy with division of the IVC. A right atriotomy was performed upon 14 patients and cardiopulmonary bypass was used in 20 patients, with 17 also having deep hypothermic circulatory arrest. The tumor thrombus was removed intact in 64 per cent of the patients and in multiple small fragments ("piecemeal") in 36 per cent of the patients. The mortality rate was 7 per cent. Survival was examined relative to extent of vena caval thrombus. Patients with extension into the atrium had a significantly worse prognosis than those with other levels of vena caval involvement. Other factors, such as lymph node status, perinephric fat involvement, resection of IVC and intact or "piecemeal" extraction, did not influence the survival rate. Patients with pre-existing metastases preoperatively had an extremely poor survival rate. The techniques now available for surgical resection of all levels of tumor thrombus of the IVC make resection feasible in most patients. In our opinion, the addition of deep hypothermic circulatory arrest has been a significant advance.
肾细胞癌是一种独特的肿瘤，因为它通常易于以肿瘤血栓的形式蔓延至肾静脉和下腔静脉（IVC）。从历史上看，切除这些癌症时遇到的手术困难限制了单一机构积累大量病例经验的能力。1956年1月至1987年7月，68例肾细胞癌延伸至IVC或右心房的患者在克利夫兰诊所接受了根治性肾切除术并取出腔静脉血栓。25例患者进行了IVC部分切除并重建。15例患者进行了IVC部分切除和重建；然而，由于肾下IVC狭窄、近端IVC或髂静脉中存在持续的非感染性血栓或对术后肺栓塞的担忧，肾下IVC被结扎或夹闭。7例患者接受了腔静脉切除术并切断IVC。14例患者进行了右心房切开术，20例患者使用了体外循环，其中17例还进行了深度低温循环停搏。64%的患者肿瘤血栓完整切除，36%的患者肿瘤血栓被切成多个小碎片（“逐块”）切除。死亡率为7%。根据腔静脉血栓的范围对生存情况进行了检查。延伸至心房的患者预后明显比其他腔静脉受累程度的患者差。其他因素，如淋巴结状态、肾周脂肪受累情况、IVC切除以及完整或“逐块”取出，均不影响生存率。术前已有转移的患者生存率极低。目前可用于手术切除IVC各级肿瘤血栓的技术使大多数患者的切除成为可能。我们认为，增加深度低温循环停搏是一项重大进展。
