Skinner D G, Pritchett T R, Lieskovsky G, Boyd S D, Stiles Q R
University of Southern California Medical Center, Department of Urology, Los Angeles 90033.
Ann Surg. 1989 Sep;210(3):387-92; discussion 392-4. doi: 10.1097/00000658-198909000-00014.
In 1972 we first reported that vena caval extension by tumor thrombus was a potentially curable lesion provided that complete removal could be achieved. We have developed a technique for safe removal of extensive vena caval thrombi extending up to the right atrium without the need for cardiopulmonary bypass or hypothermic cardioplegia. Cardiopulmonary bypass, however, is advocated for some type III thrombi, but the addition of the pump and heparinization compounds the magnitude of the procedure. We use a right thoracoabdominal approach for tumors arising from either kidney with vascular isolation of the vena cava from its insertion into the right atrium to the iliac bifurcation. From 1972 to 1988, 56 patients ranging in age from 31 to 76 years were evaluated and 53 underwent radical nephrectomy with en bloc vena caval tumor thrombectomy. Of these patients, 21 had subhepatic caval thrombus extension (level 1); 24 had extension into the intrahepatic vena cava (level 2), and 8 had thrombi extending into the heart (level 3). Overall 1-, 3-, and 5-year survival was 56%, 34%, and 25%, respectively. Crucial to survival was complete surgical excision. Successful extirpation of all apparent tumor was possible in 75% of the patients in this series. With an expected 5-year survival rate of 57% for those without metastatic disease to other organs, we continue to advocate an aggressive optimistic approach for patients if there is no preoperative evidence of metastatic disease.
1972年，我们首次报道，只要能够实现肿瘤血栓的完全清除，腔静脉内肿瘤血栓延伸是一种潜在可治愈的病变。我们已经开发出一种技术，可安全清除延伸至右心房的广泛腔静脉血栓，而无需体外循环或低温心脏停搏。然而，对于某些III型血栓，主张采用体外循环，但增加泵和肝素化会使手术的复杂性增加。对于起源于任何一侧肾脏且腔静脉从其插入右心房至髂总分叉处进行血管隔离的肿瘤，我们采用右胸腹联合入路。1972年至1988年，对56例年龄在31至76岁之间的患者进行了评估，其中53例接受了根治性肾切除术并整块切除腔静脉肿瘤血栓。在这些患者中，21例有肝下腔静脉血栓延伸（1级）；24例延伸至肝内腔静脉（2级），8例血栓延伸至心脏（3级）。总体1年、3年和5年生存率分别为56%、34%和25%。生存的关键是手术完全切除。在本系列中，75%的患者能够成功切除所有可见肿瘤。对于无其他器官转移疾病的患者，预期5年生存率为57%，如果术前没有转移疾病的证据，我们继续主张对患者采取积极乐观的治疗方法。
