Department of Urology, Department of Surgery Division of Transplantation, University of Miami Miller School of Medicine, Miami, FL 33101, USA.
BJU Int. 2012 Dec;110(11 Pt B):E449-55. doi: 10.1111/j.1464-410X.2012.11128.x. Epub 2012 Apr 30.
What's known on the subject? and What does the study add? The surgical implications of renal cell carcinoma with coexisting bland and tumour thrombi of the inferior vena cava is not well described. In this study we review our experience managing these tumours. On multivariate analysis, we found that the presence of bland thrombus was associated with an increased need for surgical interruption of the inferior vena cava.
• To study the role of interruption of the inferior vena cava (IVC) in patients with renal cell carcinoma (RCC) and associated bland and tumour thrombi.
• We reviewed 129 consecutive patients with the preoperative diagnosis of RCC with tumour thrombus who underwent radical nephrectomy and tumour thrombectomy in one academic institution between May 1997 and February 2011.
• Percentages of patients with levels I, II, III and IV tumour thrombus were 29%, 13%, 48% and 9%, respectively. • The perioperative mortality rate was 2.3%. There were 29 (22%) perioperative complications recorded. • In all, 19 patients underwent surgical interruption of the IVC by ligation or segmental resection, including one level II, 14 level III and four level IV thrombi. • A total of 15 patients (12%) had bland thrombus associated with the tumour thrombus; four of these underwent intraoperative IVC filter placement and eight underwent surgical IVC interruption. • Advanced level of tumour thrombus was the only significant factor predicting association of bland thrombus (odds ratio [OR]= 2.09, 95% confidence interval [CI]: 1.082-4.037, P= 0.028). • On multivariate analysis, level of thrombus (OR = 3.1, 95% CI: 1.30-7.74, P= 0.011) and association of bland thrombus (OR = 9.07, 95% CI: 2.42-34.01, P= 0.001) were significant factors for IVC interruption.
• Surgical interruption of the IVC is a feasible option in selected patients with chronic IVC obstruction. Association of bland thrombus with tumour thrombus should alert the surgical team to the potential for a challenging surgery. • Precise preoperative imaging to assess the degree of venous obstruction and to help with differentiation between bland and tumour thrombus is key to achieving a surgical outcome with minimal morbidity.
研究肾细胞癌（RCC）合并下腔静脉（IVC）内良、肿瘤血栓患者中 IVC 阻断的作用。
我们回顾了 1997 年 5 月至 2011 年 2 月在一家学术机构接受根治性肾切除术和肿瘤血栓切除术的术前诊断为 RCC 伴肿瘤血栓的 129 例连续患者。
肿瘤血栓分别为 I 级、II 级、III 级和 IV 级的患者比例为 29%、13%、48%和 9%。围手术期死亡率为 2.3%。记录了 29 例（22%）围手术期并发症。共 19 例患者接受了 IVC 结扎或节段切除的手术阻断，包括 1 例 II 级、14 例 III 级和 4 例 IV 级血栓。共有 15 例（12%）患者伴有肿瘤血栓的良血栓；其中 4 例术中放置 IVC 滤器，8 例行 IVC 阻断术。肿瘤血栓的高级别是唯一显著预测良血栓的因素（比值比[OR]=2.09，95%置信区间[CI]：1.082-4.037，P=0.028）。多变量分析显示，血栓程度（OR=3.1，95%CI：1.30-7.74，P=0.011）和良血栓的相关性（OR=9.07，95%CI：2.42-34.01，P=0.001）是 IVC 阻断的显著因素。
在慢性 IVC 梗阻的选定患者中，IVC 阻断是可行的选择。肿瘤血栓合并良血栓应提醒手术团队注意手术难度大的可能性。精确的术前影像学检查评估静脉阻塞程度，并帮助区分良、肿瘤血栓是实现最小发病率手术结果的关键。
