Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus
Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus
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DOI：
10.1016/s0003-4975(97)00329-9
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发表时间：
1997-06-01
影响因子：
4.6
通讯作者：
Putnam, JB
中科院分区：
文献类型：
--
作者：
Nesbitt, JC;Soltero, ER;Putnam, JB
背景肾细胞癌合并下腔静脉癌栓的最佳治疗方法尚未解决。传统的手术方法包括采用或不采用体外循环的切除术。除了用于转移性疾病的生物素类药物外，化疗发挥了次要作用。自1989年1月至1996年1月，对37例肾癌合并下腔静脉癌栓患者行手术切除。27名男性和10名女性的中位年龄为57岁（范围为29至78岁）。36例患者出现症状; 21例出现血尿。12例患者存在远处转移。肿瘤血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）和右心房（n = 2）。所有肿瘤均通过下腔静脉隔离切除，必要时，扩大肝脏动员和Pringle手法，并进行下腔静脉切开术的一期或补片闭合。只有2例患有房内血栓的患者需要体外循环。结果。11例患者发生并发症，1例患者在术后2天内死于心肌梗死（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%。对于无淋巴结或远处转移的患者（IIIa期），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）对生存率没有显著的不良影响，2年和5年生存率分别为62.5%和31.3%。淋巴结转移（IIIc期）对生存率有不利影响，因为没有长期生存者。切除肾细胞癌引起的腔内癌栓是安全的，即使存在转移性疾病也能延长生存期。根据我们的经验，只有当癌栓延伸到心脏时才需要体外循环支持。(C)1997年，美国胸外科医师协会（Society of Thoracic Surgeons）
Background. 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.Methods. 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.Results. Complications occurred in 11 patients, and 1 patient died in 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 was no long-term survivors.Conclusions. 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 metastic disease. In our experience, extracorporeal circulatory support was required only when the tumor thrombus extended into the heart. (C) 1997 by The Society of Thoracic Surgeons.