肾癌癌栓的病理特点及预后分析

Pathological features and prognostic value of renal tumor thrombus

目的探讨肾癌癌栓的病理特点及其对预后的预测价值。 方法回顾性分析2015年1月至2017年1月我院手术治疗的55例肾癌合并静脉癌栓患者的临床资料。男46例，女9例；年龄29～82岁，平均60岁。体重指数16.4～33.0 kg/m2，平均24.2 kg/m2。肾肿瘤位于右侧37例，左侧18例。肿瘤直径2.0～21.1 cm，平均8.0 cm。癌栓Mayo分级0级13例，Ⅰ级11例，Ⅱ级19例，Ⅲ级7例，Ⅳ级5例。行开放手术25例，腹腔镜手术30例。对患者术后癌栓病理蜡块重新阅片，记录癌栓的病理分型、核分级、肿瘤成分、血管壁粘连情况。术后对所有患者进行随访，分析肾癌癌栓病理特点与预后的关系。 结果55例癌栓病理分型为肾透明细胞癌47例，Ⅱ型乳头状肾细胞癌8例。癌栓病理核分级1级4例，2级20例，3级25例，4级6例。癌栓大片坏死11例，局灶或无坏死38例，肉瘤样变6例。癌栓与血管广泛粘连20例，局灶或无粘连35例。癌栓是否有血管粘连与癌栓病理分型、肿瘤成分相关（P＝0.021，P＝0.036）。随访时间1～32个月，中位时间17个月，术后1年生存率为87.3%。肿瘤成分、血管粘连情况和核分级不同的患者存在生存差异，其中肉瘤样变者总体生存率（33.3%）明显低于无坏死者（84.8%，P＝0.003）和大片坏死者（100.0%，P＝0.002）；癌栓与血管广泛粘连者总体生存率（65.0%）明显低于局灶或无粘连者（94.3%，P＝0.005）；癌栓核分级1、2、3、4级患者总体生存率分别为100%、95%、80%、50%（P＝0.045），随着核分级升高，总生存率降低。不同癌栓Mayo分级、病理分型的患者无生存差异（P＝0.426，P＝0.604）。 结论肾癌癌栓病理有助于预测预后，病理分型和Mayo分级不同的患者生存率无明显差异，癌栓存在肉瘤样变、肿瘤核分级升高以及癌栓与血管粘连是不良的预后因素。

ObjectiveTo investigate the pathological features and prognostic value of renal tumor venous thrombus. MethodsThe clinical data of 55 cases of renal cell carcinoma with inferior vena cava tumor thrombus treated from January 2015 to January 2017 were collected and analyzed retrospectively, including 46 males and 9 females, with the mean age of 60 years （29-82 years）, and the body mass index of 16.4-33.0 kg/m2 （mean 24.2 kg/m2）. Renal tumors are located on the right side of 37 cases and on the left side of 18 cases. The diameter of the tumor was 2.0-21.1 cm （mean 8.0 cm）. Mayo classification were 13 cases of grade 0, 11 cases of grade Ⅰ, 19 cases of grade Ⅱ, 7 cases of grade Ⅲ, and 5 cases of grade Ⅳ. The patients′ paraffin pathology was reviewed and the classification, grade, nuclear grade, tumor composition, and vascular wall adhesion were recorded. All patients were followed up after surgery and the relationship between the characteristics and the prognosis was analyzed. ResultsThere were 47 cases of renal clear cell carcinoma and 8 cases of papillary renal cell carcinoma type 2. Nuclear grade was 4 cases of grade 1, 20 cases of grade 2, 25 cases of grade 3, and 6 cases of grade 4. There were 11 cases of large tumor necrosis, 6 cases of sarcoma, and 38 cases of focal or no necrosis. There were 20 cases of extensive blood vessels adhesion of cancer thrombus, and 35 cases of focal or no adhesion. Vascular adhesion was associated with pathological types and tumor types （P=0.021, P=0.036）. The median follow-up duration was 17 months. The postoperative one-year survival rate was 87.3%. Overall survival was different in patients with different tumor types, vascular adhesion and nuclear grade, among which the overall survival rate （33.3%） of the sarcoma group was significantly lower than that of the non-necrotic group （84.8%, P=0.003） and large necrotic group （100.0%, P=0.002）. Overall survival rate （65.0%） was significantly lower in the vascular extensive adhesion group than in the focal or non-adhesion group （94.3%, P=0.005）. The survival rate decreased as nuclear grade increased, among which the overall survival rate of patients at level 1, 2, 3 and 4 were 100%, 95%, 80% and 50% respectively （P=0.045）. There was no difference in survival among patients with different Mayo grading and pathological classification （P=0.426, P=0.604）. ConclusionsThe pathology of tumor thrombus in renal cancer helps to predict prognosis. There is no significant difference in survival among patients with different pathological types and Mayo grades. Sarcoma, advanced tumor nuclear grade and vascular adhesion of tumor thrombus are adverse prognostic factors.