肾癌合并静脉癌栓的外科治疗体会

Surgical treatment for patients with renal cell carcinoma and venous thrombosis

目的探讨根治性肾切除术＋静脉癌栓取出术的有效性和安全性，以及术前是否行肾动脉栓塞对围手术期情况的影响。方法回顾性分析2006年9月至2014年12月收治的15例肾癌合并静脉癌栓患者的临床资料。男8例，女7例。年龄16～75岁。术前均行影像学检查提示肾脏占位并静脉癌栓，肿瘤直径5．4～14．5cm。静脉癌栓分级：0级4例，I级2例，Ⅱ级6例，Ⅲ级3例。根据术前是否行肾动脉栓塞分为栓塞组（5例）和非栓塞组（10例）。栓塞组术前1d行肾动脉栓塞。两组均于全麻下行根治性肾切除术＋静脉癌栓取出术。结果本组15例均成功行根治性肾切除术，其中14例成功取出静脉癌栓，1例因肾静脉与主动脉粘连严重癌栓无法取出。平均手术时间（243．3±77．0）min，术中平均失血量（1373．3±1440．9）ml，平均输血量（533．3±521．9）ml，术后平均住院时间（12．7±5．2）d。围手术期未发生癌栓脱落栓塞等并发症。栓塞组与非栓塞组患者在手术时间、术中失血量、术中输血量、术后住院时间等指标上差异均无统计学意义（P〉0．05）。8例术后获随访，随访时间6～96个月。4例无瘤生存；2例分别于术后30、55个月死亡；1例术后6个月肿瘤复发；1例术前口服舒尼替尼6个月后行手术治疗，但术中癌栓无法切除，术后继续口服舒尼替尼治疗18个月，癌栓无进展，肿瘤无远处转移。结论根治性肾切除术＋静脉癌栓取出术是治疗肾癌合并静脉癌栓的有效方法。术前行肾动脉栓塞不能显著降低围手术期出血等风险。

Objective To investigate the efficacy and safety of radical nephrectomy associated with venous thrombectomy and the role of preoperative angioembolization. Methods From Sep 2006 to Dec 2014,the data from 15 cases with renal cell carcinoma and venous tumor thrombus were collected and analyzed retrospectively. The 15 patients included 8 men and 7 women, whose age ranged from 16 to 75 years. Before operation, all patients underwent imaging examinations which demonstrated the renal tumor and venous thrombus. The tumors size ranged from 5.4 to 14. 5 cm. The levels of venous thrombus included 0 grade in 4 cases, I grade in 2 cases, Ⅱ grade in 6 cases and m grade in 3 cases. The 15 patients were divided into angioembolization group （ n = 5 ） and non-angioembolization group （ n = 10 ） according to the conduction of preoperative angioembolization. Results All cases successful accepted the nephrectomy. The venous thrombeetomy were undergone in 14 cases except for one case due to the severe adhesion between renal vein and aorta. The average operative time was 243.3 ± 77.0 min. The mean blood loss was 1 373.3 ± 1 440. 9 ml and the volume of blood transfusion was 533.3 ± 521.9 ml. The average time of postoperative hospital stay was 12.7± 5.2 days. Symptomatic tumor thrombus embolism didn＇t occur in all cases, perioperatively. There were no significant difference between these two groups in operative time, blood loss, blood transfusion volume and postoperative hospital stay （ P 〉 0. 05 ）. Eight cases were followed up with a period of 6 to 69 months. Four cases had disease-free survival during follow up. Two cases died at 30 and 55 months after surgery, respectively. One had tumor recurrence at 6 months after surgery. One patient accepted a 6-months target therapy （sunitinib） before surgery. However,his thrombus could not be removed during the operation. After the operation,he continued to choose the target drug therapy for 18 months. No progression for thrombosis or metastasis has been found. Conclusions Nephrectomy and venous thrombectomy could be safe and effective for renal cell carcinoma associated with venous thrombosis. Preoperative angioembolization could not reduce the perioperative risk such as blood loss.