肾和肾上腺恶性肿瘤合并下腔静脉瘤栓的外科治疗

Treatment of renal or adrenal tumor with cancer thrombus in the inferior vena cava

目的提高肾和肾上腺恶性肿瘤伴下腔静脉瘤栓的治疗效果。方法1985年1月至2008年4月收治肾和肾上腺恶性肿瘤合并下腔静脉瘤栓患者29例，均经彩色多普勒超声、CT及MRI检查确诊。瘤栓分型：Ⅰ型7例、Ⅱ型10例、Ⅲ型8例、Ⅳ型4例。其中肾上腺肿瘤4例，肾肿瘤25例。TNM分期：T2N0M0 23例，T2N1M0 1例，T2N1M1，1例，T3N0M0 1例，T3N1M1 2例，T3N2M0 1例。肿瘤平均直径8．7（4．0～16．0）cm。瘤栓平均长度：Ⅰ型3．2（2．5～4．0）cm，Ⅱ型5．3（4．5～6．0）cm，Ⅲ型8．2（6．5～9．0）cm，Ⅳ型15．1（12．0～18．5）cm。29例均在全麻下行肾或肾上腺肿瘤根治性切除加下腔静脉瘤栓切除术。结果29例手术均获成功。术后病理报告：肾透明细胞癌18例、肾肉瘤样癌3例、肾乳头腺癌2例、肾细胞癌（未分化型）1例、肾颗粒细胞癌1例、肾上腺皮质癌3例、肾上腺转移性恶性黑色素瘤1例。失访3例，余26例平均随访35（O～62）个月，患者3年生存率58％（15／26），5年生存率42％（11／26）。T2、T3患者3年生存率分别为64％（14／22）、25％（1／4），5年生存率分别为45％（10／22）、25％（1／4）。Ⅰ、Ⅱ、Ⅲ和Ⅳ型瘤栓患者3年生存率分别为4／6、5／8、5／8和1／4，5年生存率分别为3／6、4／8、3／8和1／4。膈肌以下瘤栓患者3、5年生存率分别为64％（14／22）、45％（10／22），膈肌以上瘤栓患者分别为1／4、1／4。肾和肾上腺恶性肿瘤伴下腔静脉瘤栓无转移患者的3、5年生存率为12／18、9／18，有转移患者分别为3／8、2／8。3例术前出现转移患者生存时间分别为6、10、22个月。结论根治性肿瘤切除和下腔静脉取栓治疗无淋巴和远处转移的肾和肾上腺恶性肿瘤合并下腔静脉瘤栓效果良好；即使存在远处转移，外科手术仍可以提高患者生活质量，延长患者生存期。

Objective To discuss the treatment of renal or adrenal tumor with cancer thrombus in the inferior vena cava. Methods From Jan 1984 to Apr 2008, 29 cases of renal or adrenal malignancy with thrombosis involving the inferior vena cava underwent treatment. The diagnoses were confirmed by Doppler ultrasonography, CT and MRI. In the 29 surgical patiens the tumor thrombus was level Ⅰ in 7, level Ⅱ in 10, level Ⅲ in 8 and level Ⅳ in 4. According to TNM classification,23 cases were classified to T2 N0 M0, 1 case was T2 N1 M0, 1 case was T2 N1 M1 , 1 case was T3 N0 M0, 2 case were T3 N1 M1 and 1 ease was T3 Nz M0. The mean tumor size was 8.7（4.0--16. 0）cm in diameter. The mean tumor thrombosis length was 3.2（2.5--4.0）cm in level Ⅰ, 5.3（4.5--6.0）era in level Ⅱ , 8.2 （6.5--9.0）cm in level Ⅲ and 15.1（12.0--18.5）cm in level Ⅳ. Results The operation was per-formed successfully in 29 patients. Pathological examination showed that 18 eases of clear cell earcino-ma, 3 cases sarcomatoid carcinoma, 2 cases renal papillary adenocarcinoma, 1 case renal cell carcinoma （undifferentiated）, 1 case granule carcinoma, 3 cases adrenocortical carcinoma and 1 case metastatic malignant melanoma of adrenal gland. Of 29 patients, 3 were out of contact. Twenty six patients were followed up for 35（0--62） months after treatment, 3- and 5 year survival rates were 15/26 and 11/26. Three-year survival rates for stage T2 and T3 were 14/22 and 1/4. Five-year survival rates for stage T2 and T3 were 10/22 and 1/4. Three year survival rates for level Ⅰ, Ⅱ, Ⅲ and Ⅳ were 4/6, 5/8, 5/ 8 and 1/4. Five-year survival rates for level Ⅰ ,Ⅱ ,Ⅲ and Ⅳ were 3/6, 4/8, 3/8 and 1/4. Three year survival rates for a tumor thrombus in the below or above diaphragm were 14/22 versus 1/4, 5- year survival rates were 10/22 versus 1/4. Three year and 5-year survival rates for the patients with- out distant metastases and lymph node involvement were 12/18 and 9/18. Three year and 5-year sur vival rates for the patients with distant metastases and lymph node involvement were 3/8 and 2/8. The 3 surgical patients with metastatic disease died at 6, 10, 22 months. Conclusions Surgical treatment could be the preferred approach for the patients of renal or adrenal tumor with cancer thrombus in the inferior vena cava without distant metastases and lymph node involvement. It could improve the quality of life and may prolong survival.