Nesbitt J C, Soltero E R, Dinney C P, Walsh G L, Schrump D S, Swanson D A, Pisters L L, Willis K D, Putnam J B
Department of Thoracic and Cardiovascular Surgery, The University of Texas M. D. Anderson Cancer Center, Houston 77030, USA.
Ann Thorac Surg. 1997 Jun;63(6):1592-600. doi: 10.1016/s0003-4975(97)00329-9.
The optimal management of patients with renal cell carcinoma with inferior vena cava tumor thrombus remains unresolved. Traditional approaches have included resection with or without the use of cardiopulmonary bypass. Chemotherapy has played a minor role except for biotherapeutic agents used for metastatic disease.
From January 1989 to January 1996, 37 patients with renal cell carcinoma and inferior vena cava tumor thrombus underwent surgical resection. The 27 men and 10 women had a median age of 57 years (range, 29 to 78 years). Thirty-six patients presented with symptoms; 21 had hematuria. Distant metastases were present in 12 patients. Tumor thrombi extended to the infrahepatic inferior vena cava (n = 16), the intrahepatic inferior vena cava (n = 16), the suprahepatic inferior vena cava (n = 3), and into the right atrium (n = 2). All tumors were resected by inferior vena cava isolation and, when necessary, extended hepatic mobilization and Pringle maneuver, with primary or patch closure of the vena cavotomy. Cardiopulmonary bypass was necessary in only 2 patients with intraatrial thrombus.
Complications occurred in 11 patients, and 1 patient died 2 days postoperatively of a myocardial infarction (mortality, 2.7%). Twenty patients are alive; overall 2- and 5-year survival rates were 61.7% and 33.6%, respectively. For patients without lymph node or distant metastases (stage IIIa), 2- and 5-year survival rates were 74% and 45%, respectively. The presence of distant metastatic disease (stage IV) at the time of operation did not have a significant adverse effect on survival, as reflected by 2- and 5-year survival rates of 62.5% and 31.3%, respectively. Lymph node metastases (stage IIIc) adversely affected survival as there were no long-term survivors.
Resection of an intracaval tumor thrombus arising from renal cell carcinoma can be performed safely and can result in prolonged survival even in the presence of metastatic disease. In our experience, extracorporeal circulatory support was required only when the tumor thrombus extended into the heart.
肾细胞癌合并下腔静脉瘤栓患者的最佳治疗方案仍未确定。传统方法包括在有或没有体外循环辅助的情况下进行切除术。除了用于转移性疾病的生物治疗药物外，化疗作用较小。
1989年1月至1996年1月，37例肾细胞癌合并下腔静脉瘤栓患者接受了手术切除。27例男性和10例女性，中位年龄57岁（范围29至78岁）。36例患者有症状；21例有血尿。12例患者有远处转移。瘤栓延伸至肝下下腔静脉（n = 16）、肝内下腔静脉（n = 16）、肝上下腔静脉（n = 3）及右心房（n = 2）。所有肿瘤均通过下腔静脉隔离切除，必要时扩大肝脏游离和Pringle手法，对腔静脉切口进行一期或补片缝合。仅2例心房内血栓患者需要体外循环。
11例患者出现并发症，1例患者术后2天死于心肌梗死（死亡率2.7%）。20例患者存活；总体2年和5年生存率分别为61.7%和33.6%。无淋巴结或远处转移（Ⅲa期）的患者，2年和5年生存率分别为74%和45%。手术时存在远处转移性疾病（Ⅳ期）对生存无显著不良影响，2年和5年生存率分别为62.5%和31.3%。淋巴结转移（Ⅲc期）对生存有不利影响，无长期存活者。
肾细胞癌引起的腔内瘤栓切除术可安全进行，即使存在转移性疾病也可延长生存期。根据我们的经验，仅当瘤栓延伸至心脏时才需要体外循环支持。
