肾癌伴MayoⅣ级下腔静脉瘤栓不同术式疗效的多中心回顾性研究

A multicenter retrospective study of renal cell carcinoma with Mayo levelⅣinferior vena cava tumor thrombus:comparison of different surgical approaches

目的探讨不同术式治疗肾癌伴MayoⅣ级下腔静脉瘤栓的疗效及安全性。方法回顾性分析2013年6月至2020年5月国内三家临床中心(解放军总医院18例,上海交通大学医学院附属仁济医院11例,南方医科大学南方医院7例)收治的36例肾癌伴MayoⅣ级下腔静脉瘤栓患者的临床及病理资料。男25例,女11例;中位年龄56.5(53~67)岁;体质指数(24.18±2.55)kg/m^(2)。肾肿瘤直径(8.42±3.25)cm;下腔静脉瘤栓长度(12.89±2.50)cm;术前临床分期T3c期34例,T4期2例。根据瘤栓近心端是否侵入右心房,将MayoⅣ级瘤栓分为Ⅳa级和Ⅳb级(301分级)。本研究Ⅳa级6例,Ⅳb级30例。Ⅳa级瘤栓患者行免体外循环(CPB)机器人辅助下腔静脉瘤栓取出术(免CPB组,6例),Ⅳb级瘤栓患者行CPB下机器人辅助下腔静脉瘤栓取出术(CPB组,12例)或深低温停循环技术(DHCA)辅助开放下腔静脉瘤栓取出术(CPB/DHCA组,18例)。3组患者年龄、性别、体质指数、临床分期、术前转移情况、肿瘤直径、瘤栓长度差异均无统计学意义(P>0.05)。比较不同组间围手术期资料、并发症及术后长期生存情况。结果36例手术均顺利完成。免CPB组较CPB组有更短的第一肝门阻断时间[17.5(15~36)min与36.5(12~102)min,P=0.044]、更少的术中出血量[2350(1000~3000)ml与3500(1500~12000)ml,P=0.043]和更低的异体输血量[1250(500~2000)ml与2185(700~5800)ml,P=0.049]。免CPB组较CPB/DHCA组术中异体输血量更少[1250(500~2000)ml与2700(1200~10000)ml,P=0.003]。各组在手术时间、术后住院时间等方面差异均无统计学意义(P>0.05)。本研究36例中,23例(64%)出现严重并发症(Clavien-Dindo分级≥Ⅲ级),其中Ⅲ级9例(25%),Ⅳ级12例(33%),Ⅴ级2例(6%);2例术后死于凝血功能障碍伴多器官功能衰竭(Ⅴ级)。组间并发症发生率差异均无统计学意义(P>0.05),但免CPB组≥Ⅳ级并发症发生率相对较低[17%(1/6)与42%(5/12)与44%(8/18)]。34例术后获得长期随访,中位随访28.5(14.5~39.6)个月,16例(47.1%)死于肾癌。免CPB组、CPB组和CPB/DHCA组中位无进展生存时间分别为16.4、12.3、18.0个月(P=0.695),中位总生存时间分别为30.1、30.2、37.7个月(P=0.674),差异均无统计学意义。结论相较于CPB下机器人辅助下腔静脉瘤栓取出术和DHCA辅助开放手术,免CPB机器人辅助下腔静脉瘤栓取出术治疗肾癌伴MayoⅣ级下腔静脉瘤栓,具有热缺血时间短、术中出血量少、术后严重并发症发生率低等优势,对于严格选择的MayoⅣ级瘤栓患者是可选的手术方法。

Objective To explore the clinical efficacy and safety of different surgical procedures of Mayo levelⅣinferior vena cava tumor thrombus(IVC-TT).Methods The clinical and pathological data of 36 patients with Mayo levelⅣtumor thrombus were collected in three large clinical centers in China,including 18 cases in PLA General Hospital,7 cases in Nanfang Hospital,and 11 cases in Renji Hospital.There were 25 males and 11 females.The median age was 56.5 years(53-67 years old).The average body mass index was 24.18±2.55 kg/m^(2).The average diameter of renal tumors was 8.24±3.25 cm.The average length of inferior vena cava tumor thrombus was 12.89±2.50 cm.Mayo levelⅣtumor thrombus were divided into levelⅣa and levelⅣb(301 classification)based on the criterion of whether the proximal end of the thrombus has invaded the right atrium.Among them,levelⅣa patients underwent robot-assisted inferior vena cava thrombectomy without cardiopulmonary bypass(CPB-free group,6 cases).LevelⅣb patients underwent robot-assisted inferior vena cava thrombectomy with cardiopulmonary bypass(CPB group,12 cases)or cardiopulmonary bypass with deep hypothermic circulatory arrest assisted inferior vena cava thrombectomy(CPB/DHCA group,18 cases).The baseline data of the three groups of patients were comparable.The perioperative results and long-term survival data after surgery were compared with different surgical methods for gradeⅣcancer thrombosis.Results All operations were successfully completed.Compared with the CPB group,the CPB-free group had a shorter first portal blocking time[17.5(15-36)min vs.36.5(12-102)min,P=0.044],less intraoperative bleeding[2350(1000-3000)ml vs.3500(1500-12000)ml,P=0.043]and a lower allogeneic blood transfusion[1250(500-2000)ml vs.2185(700-5800)ml,P=0.049].Compared with the CPB/DHCA group,the CPB-free group had an advantage in reducing intraoperative allogeneic blood transfusion[1250(500-2000)ml vs.2700(1200-10000)ml,P=0.003].There were no significant differences between groups in terms of duration of surgery and postoperative hospital stay.Among the 36 patients in this group,23(64%)developed major complications(levelⅢor above),including 9(25%)gradeⅢ,12(33%)gradeⅣ,and 2(6%)gradeⅤ.The CPB-free group had a relatively low complication rate of gradeⅣor above[17%(1/6)vs.42%(5/12)vs.44%(8/18)].There were no statistical differences in median progression-free survival(16.4 vs.12.3 vs.18.0 months,P=0.695)and overall survival(30.1 vs.30.2 vs.37.7 months,P=0.674)between the groups.Conclusions Robot-assisted inferior vena cava thrombectomy without cardiopulmonary bypass has the advantages of short ischemia time of organs,less intraoperative bleeding,and low incidence of major complications,which can be used as a safe and feasible surgical strategy for selected levelⅣtumor thrombus.