Wang Bin-Shuai, Li You-Zhao, Fang Yang-Yi, Zhang Shu-Dong, Ma Lu-Lin
Department of Urology, Peking University Third Hospital, Peking University, Beijing 100191, China.
Department of Urology, Beijing Rehabilitation Hospital, Capital Medical University, Beijing 100041, China.
Chin Med J (Engl). 2020 Sep 5;133(17):2078-2083. doi: 10.1097/CM9.0000000000000828.
Renal cell carcinoma (RCC) has the propensity to lead to venous tumor thrombus (VTT). Nephrectomy with tumor thrombectomy is an effective treatment option but is a technically challenging surgical procedure that is accompanied by a high rate of complications. The aims of this study were to investigate pre-operative imaging parameters for the assessment of inferior vena cava (IVC) wall invasion due to a tumor thrombus in patients with RCC and to identify predictors from the intra-operative findings.
Clinical and imaging data were collected from 110 patients who underwent nephrectomy with IVC tumor thrombectomy (levels I-IV) for RCC and IVC tumor thrombus at the Peking University Third Hospital between May 2015 and March 2018. Univariable and multivariable logistic regression and receiver operating characteristic curves were used to assess the correlations between pre-operative imaging features and intra-operative macroscopic invasions of the IVC wall by tumor thrombus.
Among the 110 patients, 41 underwent partial or segmental resection of IVC. There were univariate associations of pre-operative imaging parameters that could be used to predict the need for IVC resection, including those of the Mayo classification, maximum anterior-posterior (AP) diameter of the renal vein at the renal vein ostium (RVo), maximum AP diameter of the VTT at the RVo and IVC occlusion. For the multivariable analysis, the AP diameter of the VTT at the RVo and IVC occlusion were associated with a significantly increased risk of invasion of the IVC wall by tumor thrombus. The optimum imaging thresholds included an AP diameter of the VTT at the RVo larger than 17.0 mm and the presence of IVC occlusion, with which we predicted invasions of the IVC wall requiring IVC resection. The probabilities of intra-operative IVC resection for patients without both independent factors, with an AP diameter of the VTT at the RVo larger than 17.0 mm, with IVC occlusion, and with both concurrent factors were 5%, 23%, 56%, and 66%, respectively.
An increase in the AP VTT diameter at the RVo and the presence of complete occlusion of the IVC are independent risk factors for a high probability of IVC wall invasion by tumor thrombus.
肾细胞癌（RCC）易于导致静脉瘤栓（VTT）形成。肾切除术联合肿瘤血栓切除术是一种有效的治疗选择，但这是一项技术上具有挑战性的外科手术，且并发症发生率较高。本研究的目的是探讨术前影像学参数，以评估RCC患者因肿瘤血栓导致的下腔静脉（IVC）壁侵犯情况，并从术中发现中识别预测因素。
收集了2015年5月至2018年3月期间在北京大学第三医院接受RCC和IVC肿瘤血栓肾切除术（I-IV级）的110例患者的临床和影像学数据。采用单变量和多变量逻辑回归以及受试者工作特征曲线来评估术前影像学特征与术中肿瘤血栓对IVC壁的宏观侵犯之间的相关性。
在这110例患者中，41例接受了IVC的部分或节段性切除。术前影像学参数存在单变量关联，可用于预测IVC切除的必要性，包括梅奥分类、肾静脉开口处肾静脉的最大前后径（AP）、肾静脉开口处VTT的最大AP直径以及IVC闭塞情况。对于多变量分析，肾静脉开口处VTT的AP直径和IVC闭塞与肿瘤血栓侵犯IVC壁的风险显著增加相关。最佳影像学阈值包括肾静脉开口处VTT的AP直径大于17.0 mm以及存在IVC闭塞，据此我们预测了需要进行IVC切除的IVC壁侵犯情况。对于无这两个独立因素、肾静脉开口处VTT的AP直径大于17.0 mm、存在IVC闭塞以及同时存在这两个因素的患者，术中进行IVC切除的概率分别为5%、23%、56%和66%。
肾静脉开口处VTT的AP直径增加以及IVC完全闭塞是肿瘤血栓侵犯IVC壁可能性较高的独立危险因素。
