Department of Urology, University of Pisa, Pisa, Italy.
Urol Oncol. 2011 Nov-Dec;29(6):745-50. doi: 10.1016/j.urolonc.2009.09.018. Epub 2009 Dec 6.
We retrospectively evaluated the outcome of the surgical treatment of patients with renal cell carcinoma (RCC) and extensive inferior vena cava (IVC) involvement. Our aim was to investigate if a particular surgical technique could reduce morbidity and complications associated with this condition.
From 1996 to 2007, 22 patients with RCC and extensive IVC involvement underwent radical surgical treatment with the intention to avoid, whenever possible, sternotomy and cardiopulmonary bypass. The level of the tumor thrombus was I (<2 cm above the renal vein) in 2 patients, II (below the intrahepatic vena cava) in 9 patients, III (intrahepatic vena cava below the diaphragm) in 7 patients, and IV (atrial) in 4 patients. Extracorporeal vascular bypass was used for 4 patients with level IV and for 2 patients with level III tumor thrombi, with hypothermic circulatory arrest in 2 patients. Extensive liver mobilization techniques were adopted in 16 patients. Overall and cancer-specific survival (CSS) were analyzed based on tumor extent (N0M0, N+M+), pathologic stage (pT3b, pT3c, pT4), thrombus level, and caval wall infiltration.
Two patients died within 1 month of surgery and the remaining 20 patients have a mean follow-up of 32.2 months (range 6-90): 8 are alive (overall survival 40%), but 2 with disease (CSS 30%). A total of 10 severe complications developed in 8 patients (36%). Both overall and CSS were significantly associated with tumor stage (Log-rank P = 0.0237 and 0.0465), presence of nodal or systemic metastases (Log-rank P = 0.0835 and 0.0669; Wilcoxon's test P = 0.0407 and 0.0411), and caval wall infiltration (Log-rank P = 0.0200 and 0.0418).
Despite the low overall survival, related to the high percentage of nodal and systemic metastases, aggressive surgical management with resection of synchronous metastatic disease for symptom palliation and cytoreduction, followed by immunotherapy is justified in this setting. A transabdominal approach to RCC and IVC involvement, even in patients with level III thrombus, can provide the surgeon with an exposure similar to thoracoabdominal incisions without the complications associated with thoracotomy.
我们回顾性评估了手术治疗肾细胞癌（RCC）伴广泛下腔静脉（IVC）受累患者的结果。我们的目的是研究特定的手术技术是否可以降低与该疾病相关的发病率和并发症。
1996 年至 2007 年，22 例 RCC 伴广泛 IVC 受累患者接受根治性手术治疗，旨在尽可能避免胸骨切开术和心肺旁路术。肿瘤血栓水平为 I 级（肾静脉上方<2cm）的患者有 2 例，II 级（肝内静脉下方）的患者有 9 例，III 级（膈肌以下肝内静脉）的患者有 7 例，IV 级（心房）的患者有 4 例。4 例 IV 级患者和 2 例 III 级肿瘤血栓患者采用体外血管旁路，2 例患者采用低温循环停搏。16 例患者采用广泛肝动员技术。根据肿瘤范围（N0M0、N+M+）、病理分期（pT3b、pT3c、pT4）、血栓水平和腔静脉壁浸润，分析总生存率和癌症特异性生存率（CSS）。
2 例患者术后 1 个月内死亡，其余 20 例患者的平均随访时间为 32.2 个月（6-90 个月）：8 例存活（总生存率为 40%），但 2 例有疾病（CSS 为 30%）。8 例患者共发生 10 例严重并发症（36%）。总生存率和 CSS 均与肿瘤分期显著相关（Log-rank P=0.0237 和 0.0465），淋巴结或全身转移（Log-rank P=0.0835 和 0.0669；Wilcoxon 检验 P=0.0407 和 0.0411），腔静脉壁浸润（Log-rank P=0.0200 和 0.0418）。
尽管总体生存率较低，与淋巴结和全身转移的高百分比有关，但在这种情况下，通过切除同步转移性疾病以缓解症状和细胞减灭，并随后进行免疫治疗，进行积极的手术治疗是合理的。对于 RCC 和 IVC 受累患者，即使是血栓水平为 III 级的患者，也可以通过腹部入路为外科医生提供类似于胸腹联合切口的暴露，而不会出现与开胸相关的并发症。
