Novotny R, Chlupac J, Marada T, Borovicka V, Vik V, Voska L, Janousek L, Fronek Jiri
Transplant Surgery Department, Institute for Clinical and Experimental Medicine, Videnska1958/9, 14021, Prague, Czech Republic.
Second Faculty of Medicine, Charles University, Prague, Czech Republic.
J Med Case Rep. 2018 Oct 25;12(1):313. doi: 10.1186/s13256-018-1845-2.
Advanced renal cell carcinoma in some cases causes malignant intravascular thrombus with the potential for growth into the inferior vena cava or even the right atrium. Renal cell carcinoma is accompanied by malignant intravascular thrombus in up to 10% of cases. We present an overview of three patients diagnosed as having renal cell carcinoma with malignant intravascular thrombus requiring radical nephrectomy combined with inferior vena cava thrombectomy.
Three patients diagnosed as having renal cell carcinoma were indicated for renal cell carcinoma combined with inferior vena cava thrombectomy between 2014 and 2017 at our department: a 69-year-old white Caucasian woman, a 74-year-old white Caucasian woman, and a 58-year-old white Caucasian woman. According to the Novick classification of inferior vena cava tumor thrombus, there was one infrahepatic (level II) and two supradiaphragmatic (level IV) malignant intravascular thrombi. The average age of these patients was 67 years (range 58-74 years). All patients underwent radical nephrectomy combined with inferior vena cava thrombectomy through transabdominal approach. In patients with level IV malignant intravascular thrombus, transesophageal echocardiogram was used to guide the placement of the inferior vena cava cross-clamp above the diaphragm. In one patient the pericardium was opened to place a cross-clamp above a tumor just below the right atrium. There were no postoperative mortalities to date with an average follow-up of 23 months (range 2-48 months). To date, no patient has demonstrated recurrent inferior vena cava malignant intravascular thrombus requiring secondary inferior vena cava thrombectomy or any other treatment. A comparison of estimated blood loss and transfusion rate was not significantly different in all three cases.
Despite the technical complexity of the procedure, caval thrombectomy combined with radical nephrectomy currently represents the only radical treatment for renal cell carcinoma accompanied by malignant intravascular thrombus with good mid-term oncological outcomes.
在某些情况下，晚期肾细胞癌会导致恶性血管内血栓形成，有可能延伸至下腔静脉甚至右心房。肾细胞癌伴有恶性血管内血栓形成的病例占比高达10%。我们现概述3例被诊断为肾细胞癌合并恶性血管内血栓形成且需要行根治性肾切除术联合下腔静脉血栓切除术的患者情况。
2014年至2017年间，我科有3例被诊断为肾细胞癌的患者接受了肾细胞癌联合下腔静脉血栓切除术：1例69岁的白种女性、1例74岁的白种女性和1例58岁的白种女性。根据诺维克下腔静脉肿瘤血栓分类，有1例肝下型（Ⅱ级）和2例膈上型（Ⅳ级）恶性血管内血栓。这些患者的平均年龄为67岁（范围58 - 74岁）。所有患者均通过经腹途径接受了根治性肾切除术联合下腔静脉血栓切除术。对于Ⅳ级恶性血管内血栓患者，采用经食管超声心动图引导在膈上方放置下腔静脉阻断钳。1例患者打开心包，在右心房下方的肿瘤上方放置阻断钳。目前尚无术后死亡病例，平均随访23个月（范围2 - 48个月）。迄今为止，没有患者出现复发性下腔静脉恶性血管内血栓而需要再次行下腔静脉血栓切除术或其他任何治疗。3例患者的估计失血量和输血率比较差异无统计学意义。
尽管该手术技术复杂，但目前下腔静脉血栓切除术联合根治性肾切除术是肾细胞癌合并恶性血管内血栓形成的唯一根治性治疗方法，中期肿瘤学预后良好。
