Zacek Pavel, Brodak Milos, Gofus Jan, Dominik Jan, Moravek Petr, Louda Miroslav, Podhola Miroslav, Vojacek Jan
Department of Cardiac Surgery, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital in Hradec, Kralove, Czechia.
Department of Urology, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital in Hradec, Kralove, Czechia.
Front Oncol. 2023 Feb 1;13:1137804. doi: 10.3389/fonc.2023.1137804. eCollection 2023.
Renal cell carcinoma (RCC) with tumor thrombus extension into the right atrium (level IV) is a rare life-threatening clinical condition that can only be managed by means of a combined urological and cardiac surgical approach. The early and late outcomes of this radical treatment were analyzed in a large single-institution series over a period of 30 years.
In 37 patients with RCC and intracardiac tumor thrombus extension, nephrectomy was performed followed by the extraction of the intracaval and intracardiac tumor thrombus under direct visual control during deep hypothermic circulatory arrest (DHCA). Recently, in 13 patients, selective aortic arch perfusion (SAAP) was instituted during DHCA.
In all patients, precise removal of the tumor thrombus was accomplished in a bloodless field. The mean duration of isolated DHCA was 15 ± 6 min, and 31.5 ± 10.2 min in the case of DHCA + SAAP, at a mean hypothermia of 22.7 ± 4°C. In-hospital mortality was 7.9% (3 patients). In Kaplan-Meier analysis, the estimated median survival was 26.4 months whereas the 5-year cancer-related survival rate was 51%.
Despite its complexity, this extensive procedure can be performed safely with a generally uneventful postoperative course. The use of cardiopulmonary bypass with DHCA, with the advantage of SAAP, allows for a safe, precise, and complete extirpation of intracaval and intracardiac tumor mass. Late outcomes after radical surgical treatment in patients with RCC and tumor thrombus reaching up in the right atrium in our series justify this extensive procedure.
肾细胞癌（RCC）伴肿瘤血栓延伸至右心房（IV级）是一种罕见的危及生命的临床情况，只能通过泌尿外科和心脏外科联合手术的方式进行治疗。在一个大型单机构系列研究中，对这种根治性治疗的早期和晚期结果进行了为期30年的分析。
在37例患有RCC和心内肿瘤血栓延伸的患者中，先进行肾切除术，然后在深低温循环停搏（DHCA）期间直视下摘除腔静脉和心内肿瘤血栓。最近，在13例患者中，在DHCA期间采用了选择性主动脉弓灌注（SAAP）。
在所有患者中，均在无血视野下精确切除了肿瘤血栓。单纯DHCA的平均持续时间为15±6分钟，DHCA + SAAP的情况下为31.5±10.2分钟，平均体温为22.7±4°C。住院死亡率为7.9%（3例患者）。在Kaplan-Meier分析中，估计中位生存期为26.4个月，而5年癌症相关生存率为51%。
尽管该手术复杂，但可以安全地进行，术后过程通常平稳。采用带DHCA的体外循环并结合SAAP的优势，能够安全、精确且完整地切除腔静脉和心内肿瘤肿块。在我们的系列研究中，RCC和肿瘤血栓延伸至右心房的患者接受根治性手术治疗后的晚期结果证明了这种广泛手术的合理性。
