Bintz M, Cogbill T H, Klein A S
Department of Vascular Surgery, Gundersen/Lutheran Medical Center, La Crosse, WI.
J Vasc Surg. 1987 Dec;6(6):566-71.
Renal cell carcinoma extends into the inferior vena cava in 5% of patients undergoing exploratory surgery for this malignancy. If the tumor is left unresected, death within 1 year is certain. In addition, caval occlusion may result in massive lower extremity edema, ascites, hepatic failure, and pulmonary embolus. During the past 17 years, 12 patients with renal cell carcinoma extending into the inferior vena cava were treated at a single institution by radical nephrectomy and caval tumor extraction. There were 10 men (83%) and ages ranged from 50 to 78 years (mean 63 years). There was one operative death (8%) caused by refractory coagulopathy. Long-term follow-up was achieved for all survivors. One- and 3-year survival rates by life-table method were 73% and 27%, respectively. Mean survival time after resection was 32 months. Careful preoperative planning is essential. The optimal approach for venacaval tumor extraction or resection is dictated by the cephalad extent of tumor seen on preoperative thoracoabdominal CT scan, ultrasound, or inferior venacavography. Disease limited to the infrahepatic vena cava is best approached with a thoracoabdominal incision through the eighth intercostal space. Extension of tumor to the hepatic veins or right atrium requires median sternotomy in combination with an abdominal incision for complete removal. An ellipse of vena cava around the origin of the renal vein is excised with the specimen. The resultant incision is closed by lateral phleborrhaphy. Late sequelae of the mild caval narrowing were not observed. An aggressive multispecialty surgical policy for caval extraction and resection of renal cell carcinoma resulted in extended patient survival and excellent palliation.
在因这种恶性肿瘤接受探查性手术的患者中，5%的肾细胞癌会侵犯下腔静脉。如果肿瘤未切除，1年内必死无疑。此外，腔静脉阻塞可能导致大量下肢水肿、腹水、肝衰竭和肺栓塞。在过去17年中，一家机构对12例肾细胞癌侵犯下腔静脉的患者进行了根治性肾切除术和腔静脉肿瘤切除术。其中男性10例（83%），年龄在50至78岁之间（平均63岁）。有1例手术死亡（8%），原因是难治性凝血病。所有幸存者均获得了长期随访。采用生命表法计算的1年和3年生存率分别为73%和27%。切除术后的平均生存时间为32个月。术前仔细规划至关重要。术前胸部和腹部CT扫描、超声或下腔静脉造影显示的肿瘤头端范围决定了腔静脉肿瘤切除或切除术的最佳入路。局限于肝下腔静脉的疾病最好通过经第八肋间的胸腹联合切口处理。肿瘤延伸至肝静脉或右心房时，需要正中胸骨切开术联合腹部切口以完整切除。在切除标本时，连同肾静脉起始部周围的椭圆形腔静脉一并切除。由此产生的切口通过侧方静脉缝合关闭。未观察到轻度腔静脉狭窄的晚期后遗症。对于肾细胞癌的腔静脉肿瘤切除和切除术采取积极的多专科手术策略可延长患者生存期并实现良好的姑息治疗效果。
