肾癌并发下腔静脉癌栓的诊断与治疗

目的：提高对肾癌并发下腔静脉癌栓的诊断及治疗经验。方法：分析8例肾癌并发下腔静脉癌栓的诊断方法及治疗措施。结果：术前已明确诊断6例,8例均经手术治疗,1例术中死亡,余7例手术成功。结论：手术切除肾癌并取出癌栓是目前有望治愈的方法之一,手术方式的选择取决于癌栓的大小及部位。手术风险大、难度大,必须警惕癌栓的脱落。     

肾癌下腔静脉癌栓3例

例 1 　 男 ,5 5岁。因间歇性血尿 2个月于 1 999年 1 1月入院。外院 B超检查示右肾肿瘤伴下腔静脉瘤栓。体检 :右上腹可触及约 1 3 cm× 1 1 cm的肿块 ,表面不平 ,上界不清。 CT检查显示右肾中下极有 8.0 cm× 9.0 cm× 1 0 .0 cm低密度不规则肿块影 ,增强扫描后肿块不均匀强化 ,右肾静脉、下腔静脉内见低密度癌栓形成 ,腹膜后淋巴结无肿大 (图1 )。 MRI显示右肾中下极有 8.0 cm× 9.0 cm×1 0 .0 cm的异常信号肿块影 ,边界尚清 ,T1WI呈等信号和部分低信号 ,T2 WI呈高信号 ;右肾静脉及相应水平的下腔静脉内见 3 .0 cm× 4.0 cm的软组…     

肾癌合并Ⅲ型下腔静脉癌栓切除术

目的探讨在TempofilterⅡ腔静脉滤器保护下行肾癌Ⅲ型下腔静脉癌栓切除的安全性及手术方法。方法回顾性分析2006～2009年治疗的7例肾细胞癌合并Ⅲ型下腔静脉癌栓患者的临床资料,术中先在数字减影血管造影下经右侧颈内静脉穿刺放置TempofilterⅡ腔静脉滤器于下腔静脉内癌栓近心端,然后在全肝血流阻断下切开肝下下腔静脉,直视下切除癌栓。结果 7例患者术前均经CT血管造影或磁共振血管造影明确诊断,7例均手术成功,6例癌栓与下腔静脉无明显浸润,1例癌栓浸润下腔静脉侧壁行下腔静脉成形。全组无肺栓塞(PE)发生,无围手术期死亡。结论 TempofilterⅡ腔静脉滤器保护下肾癌下腔静脉癌栓切除是安全的,可有效预防PE的发生,术中全肝血流阻断在无血状态下切开下腔静脉是完全切除癌栓的关键。     

肾癌下腔静脉癌栓的外科治疗及预后

肾癌下腔静脉癌栓的外科治疗及预后曾进，章咏裳肾细胞癌（ＲＣＣ）容易发生肾静脉和下腔静脉（ＩＶＣ）内癌栓，其发病率约占同期ＲＣＣ总数的３％～１０％［１，２］。近年来，随着影像学的日趋发展和普及，Ｂ超、ＣＴ、ＭＲ以及下腔静脉造影等检查都具有较高的诊断正确...     

肾癌伴下腔静脉癌栓4例的手术治疗

目的：提高肾癌（RCC）伴下腔静脉（IVC）癌栓的手术治疗效果。方法：对4例RCC伴IVC癌栓患者在施行肾癌根治性切除、淋巴结清除的同时分别选择行IVC切开、IVC壁切除和IVC节段切除取癌栓术。结果：手术均获成功，无大出血、肺梗塞，术后血尿素氮、肌酐均无明显异常。随访13-34月患者均健在。结论：对本病应采取积极的手术治疗。三种手术方案的选择应取决于癌栓的长度、水平、分型等。     

腔静脉节段切除在肾癌伴下腔静脉癌栓中的应用

报告８例下腔静脉节段切除和系统性淋巴清扫肾癌根治术治疗右肾癌并腔静脉浸润性癌栓。４例无远处转移者中３例术后分别存活３６，４２和１７个月，１例２７个月后死于脑转移。４例有远处转移者术后２例分别存活１３和１４个月，１例肝转移瘤者已存活６个月，１例膈上型癌栓者于术后８小时死于心肺功能衰退。     

肾癌伴下腔静脉癌栓的诊断与治疗

目的 探讨肾癌伴下腔静脉癌栓的诊断及治疗。方法 回顾性分析1997年1月至2003年11月21例肾癌伴下腔静脉癌栓患者资料，男13例，女8例，平均年龄50岁。右侧13例，左侧8例。临床表现主要为腰痛和（或）血尿。经彩色多普勒超声、CT和MRI确诊。Ⅰ型癌栓3例，Ⅱ型10例，Ⅲ型6例，Ⅳ型2例。其中行肾癌根治术加下腔静脉癌栓取出术15例，肾癌根治术加下腔静脉节段切除术4例。结果 19例手术者中，8例术后仅存活3～13个月，11例随访4～57个月至今，无瘤生存8例，带瘤生存3例。2例未行手术者分别于3、5个月后死亡。结论 彩色多普勒超声、CT和MRI对肾癌伴下腔静脉癌栓诊断率较高，可准确判断癌栓位置。对无淋巴结和远处转移者，积极行肾癌根治术加下腔静脉癌栓取出术或下腔静脉节段切除术治疗效果满意。     

肾细胞癌癌栓伸延至下腔静脉时的外科处理

肾细胞癌(以下简称肾癌)累及肾静脉或下腔静脉为手术证实后常被放弃治疗。目前,由于术前已能明确癌栓所处的部位及下腔静脉被侵犯的程度,所以能够大胆地采用一些手术方法并获得了一定的成功。一、病理学肾癌往往侵入肾静脉并形成肾静脉血栓。癌栓伸延至下腔静脉有三种方式:①癌栓从肾静脉直接伸延,自由浮动;②癌栓附着和侵犯下腔静     

肾癌伴肾静脉或下腔静脉癌栓11例分析

通过对11例肾癌伴肾静脉或下腔静脉癌栓患者的临床分析,认为肾癌伴静脉癌栓者90.9％有包块或疼痛;术前诊断十分重要,CT的诊断率(100％)显著高于B超(42.9％),下腔静脉造影可作为CT的辅助检查方法;手术仍是治疗肾静脉或下腔静脉癌栓的唯一有效方法。     

肾细胞癌合并下腔静脉癌栓患者发生术后早期并发症的临床分析

目的 分析手术治疗肾细胞癌合并下腔静脉癌栓术后早期并发症的发生情况.方法 回顾性分析2015年2月-2016年4月北京大学第三医院泌尿外科收治的27例肾细胞癌合并下腔静脉癌栓患者的临床资料.27例患者中,男性21例,女性6例.年龄47～84岁,平均(61.7±9.8)岁々体重指数为17.6 ～ 30.8 kg/m2,平均(22.2±2.9) kg/m2.右侧肾细胞癌合并下腔静脉癌栓者18例,左侧者9例.肿瘤直径为3.6 ～21.1 cm,平均(8.5±3.6)cm.下腔静脉癌栓分级(美国Mayo医学中心分级法):0级6例(22.2％),Ⅰ级6例(22.2％),Ⅱ级8例(29.6％),Ⅲ级5例(18.5％),Ⅳ级2例(7.4％).行腹腔镜下肾癌根治性切除术+下腔静脉癌栓取出术者14例,行开放肾癌根治性切除术+下腔静脉癌栓取出术者13例.采用改良Clavien分级系统评估术后早期并发症.≥Ⅲ级并发症定义为严重并发症.结果 本组27例患者中,14例出现术后早期并发症(51.9％).发生乳糜漏2例,予饮食控制及皮下注射生长抑素后治愈;发生下肢静脉血栓3例,予低分子肝素治疗后好转;发生术后肺部感染3例,予抗生素抗感染治疗后治愈;发生双侧大腿皮疹1例,考虑为抗生素所致过敏有关,予停用致敏药物,静脉滴注维生素C及葡萄糖酸钙处理后治愈.术后严重并发症者5例(18.5％),包括术后腹腔积液1例,行B超引导下穿刺引流后好转;术后肾功能不全合并高钾血症者2例,行血液透析治疗后好转;发生术后血压下降、心搏骤停1例,发生术后低氧血症、感染中毒性休克及多器官功能不全1例,此2例患者均死亡.结论 肾癌根治性切除术和下腔静脉癌栓取出术治疗肾细胞癌合并下腔静脉癌栓患者存在发生术后早期并发症甚至严重并发症的可能.充分了解并发症发生原因及特点,加强预防和及时有效的处理,是降低其发病率的关键措施.     

Clinical outcome of surgical management for patients with renal cell carcinoma involving the inferior vena cava

BACKGROUND: The objective of this study was to evaluate the clinical outcome after surgical management of renal cell carcinoma (RCC) extending to the inferior vena cava (IVC). METHODS: This study included a total of 55 patients (41 men and 14 women; mean age, 59.3 years) with RCC (39 right- and 16 left-sided tumors) involving the IVC, who underwent radical nephrectomy and tumor thrombectomy between 1983 and 2005 at a single institution in Japan. The level of thrombus was classified as follows: level I, infrahepatic; level II, intrahepatic; level III, suprahepatic; and level IV, extending to the atrium. Clinicopathological data from these patients were retrospectively reviewed to identify factors associated with survival. RESULTS: There were 11 and 18 patients who were diagnosed as having lymph node and distant metastases, respectively. Twenty-two patients had tumor thrombus in level I, 20 in level II, 10 in level III, and 3 in level IV. Pathological examinations demonstrated that 34 and 21 patients had clear cell carcinoma and non-clear cell carcinoma, respectively, 42, 9 and 4 were pT3b, pT3c and pT4, respectively, and 6, 35 and 14 were Grades 1, 2 and 3, respectively. Cancer-specific 1-, 3- and 5-year survival rates of these 55 patients were 74.5%, 51.4% and 30.3%, respectively. Among several factors examined, clinical stage (P = 0.047), lymph node metastasis (P = 0.016), histological subtype (P = 0.034) and tumor grade (P < 0.001) were significantly associated with cancer-specific survival by univariate analysis. Furthermore, multivariate analysis demonstrated clinical stage (P = 0.037) and tumor grade (P < 0.001) as independent predictors of cancer-specific survival irrespective of other significant factors identified by univariate analysis. CONCLUSIONS: In patients with RCC involving the IVC, biological aggressiveness characterized by tumor grade rather than tumor extension would have more potential prognostic importance; therefore, more intensive multimodal therapy should be considered in patients with high grade RCC with tumor thrombus extending into the IVC.     

腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓

目的探讨腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓的临床经验和文献分析。 方法女性患者,61岁,临床诊断：右肾癌合并高位肝后下腔静脉癌栓。术前全面评估手术风险,组织多学科会诊为患者制定详尽的围手术期治疗与护理方案,拟行腹腔镜下右侧肾癌根治性切除+高位肝后下腔静脉癌栓取出+腹膜后淋巴结清扫术。术后医护密切配合严密观察患者病情变化,进行围手术期观察处理与护理。 结果手术顺利完成,手术时间390 min,无中转开放手术。术中完全游离右侧和左侧肾静脉、肝后下腔静脉直达第二肝门水平远端,近右肾静脉处下腔静脉内侧壁剪开静脉壁,癌栓下部小灶性侵犯静脉壁,切除部分腔静脉壁完整取出癌栓,恢复左侧肾静脉、腔静脉血流回流无障碍。术后病理提示符合透明细胞癌,癌组织侵犯肾窦脂肪,腹膜后淋巴结（-）。术后随访6个月未见肿瘤复发。 结论腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓安全可行,多学科协助模式为疑难复杂病例提供了一种新的选择,值得临床进一步推广。     

Resection of the abdominal inferior vena cava for complicated renal cell carcinoma with tumour thrombus

OBJECTIVE: To describe our experience of excising the inferior vena cava (IVC) without a graft; en bloc resection of a renal cell carcinoma (RCC) with the renal vein and vena cava tumour thrombus and a segment of the entire abdominal IVC is technically feasible, but traditionally, after resection, attempts are made to restore continuity with the use of synthetic or homologous venous grafts. PATIENTS AND METHODS: Between May 1997 and September 2004, 60 patients (mean age 62 years) underwent surgical resection of a renal tumour with a thrombus extending into the IVC. To resect the entire evident tumour, excision of the affected portion of the IVC was required in three patients (5%); the IVC was not reconstructed. RESULTS: The three patients were aged 38, 39 and 74 years; the mean operative duration was 5.88 h, the mean (range) estimated blood loss was 833 (500-1000) mL, the mean number of blood units transfused was 3.3 (0-7) units, and the mean follow-up was 24 months. The course after surgery was uneventful; specifically, none of the patients had a venous thrombosis or a pulmonary embolus. CONCLUSIONS: RCC has a propensity to invade the renal vein and IVC. Occasionally the thrombus invades the wall of the IVC and complete removal requires excision of a circumferential portion of the IVC; this can be done safely without a graft.     

肝癌合并下腔静脉癌栓的外科治疗

目的总结7例肝癌合并下腔静脉（inferior vena cava,IVC）癌栓患者的手术方法及治疗经验。方法自2003年7月至2005年5月,我们为7例肝癌合并IVC癌栓的患者实施了肝癌切除及右心房和（或）IVC切开取栓手术。所有患者均采用全肝血流阻断来控制IVC血流。根据癌栓上极位置的不同,分别采用5种不同术式：（1）静脉转流,心脏停搏,右心房及下腔静脉切开取栓1例;（2）静脉转流,心脏不停搏,心包内高位阻断下腔静脉,右心房和（或）下腔静脉切开取栓2例;（3）经腹部切口切开膈肌,心包内高位阻断下腔静脉,下腔静脉切开取栓1例;（4）经腹部切口,经膈肌腔静脉裂孔小切口,心包外高位阻断肝上下腔静脉,下腔静脉切开取栓1例;（5）经腹部切口,肝上阻断下腔静脉,下腔静脉切开取栓2例。结果所有手术均获成功,术后并发症包括胸腔积液2例,右膈下积液1例,切口感染1例。7例患者的生存时间为2周～26个月,平均9．8个月。已死亡的6例患者术后生存时间分别为13、9、11、2、17个月和2周,尚生存的1例患者已无瘤生存26个月。结论对合适病例实施肝癌切除和IVC切开取栓手术是安全可行的。手术治疗可以避免右心流人道阻塞和肺动脉栓塞造成的猝死,并有可能获得相对提高的生存时间和生活质量。     

Prognostic factors of renal cell carcinoma with extension into inferior vena cava

Objective:   To evaluate the prognosis of our series of patients with renal cell carcinoma (RCC) and tumor thrombus involving inferior vena cava (IVC) treated with nephrectomy and thrombectomy.
Methods:   In 46 patients with unilateral RCC extending into IVC who underwent nephrectomy and thrombectomy (T3b in 38 patients, T3c in 6, T4 in 2, N+ in 15, M1 in 21), overall and cancer-specific survival rates were estimated, and the univariable and multivariable analysis were carried out to determine the prognostic factors among age, gender, performance status, fever, inflammatory laboratory parameters, nodal and distant metastasis, tumor thrombus level, pathological parameters and postoperative interferon-α administration.
Results:   The median age was 66.5 (range 35–79) years. The median follow-up was 18.0 (mean 36.7 ± 38.7) months. The overall and cancer-specific 5-year survival rates were 32.9% and 40.0%, respectively. The univariate analysis revealed that fever (hazard ratio: HR 4.03), C-reactive protein (HR 4.89), grade of tumor cell (HR 3.83), and lymph node metastasis (HR 5.99) were independent prognostic factors of cause-specific survival in all patients. The multivariate analysis demonstrated that lymph node metastasis (HR 4.13) was the only independent prognostic factor of cause-specific survival. The extension level or postoperative interferon-α administration did not influence the prognosis of patients with tumor thrombus involving IVC.
Conclusions:   Aggressive surgery should be considered first in RCC patients with any levels of tumor thrombus. However, patients with both IVC involvement and nodal metastasis showed significantly poor prognosis, and development of novel intensive multidisciplinary therapies will be needed.