肾癌伴下腔静脉瘤栓合并血栓的多种影像学比较

doi:10.19723/j.issn.1671-167X.2019.04.014

摘要/Abstract

摘要：

目的:研究肾癌伴下腔静脉瘤栓合并血栓患者的临床及影像资料,分析下腔静脉超声、泌尿系增强CT及增强磁共振3种影像学检查方法对下腔静脉瘤栓伴血栓的诊断效能。方法:选择北京大学第三医院泌尿外科2014年1月至2018年7月的肾癌伴瘤栓病例56例进行回顾性分析,所有患者术前均同时行下腔静脉超声、泌尿系增强CT及增强磁共振检查并完成手术治疗,且术后病理诊断证实为肾癌伴下腔静脉瘤栓。结果:根据术中观察及术后病理诊断证实下腔静脉瘤栓是否合并血栓为标准,将56例患者分为合并血栓组(n=18)及不合并血栓组(n=38)。比较发现,瘤栓合并血栓的患者,瘤栓长度更长[(10.50 ± 5.55) cm vs.(6.66 ± 3.73) cm,P = 0.014];瘤栓直径/下腔静脉(inferior vena cava, IVC)冠状最大径比值更接近1[1.0(0.7,1.0) vs. 0.9 (0.2,1.0), P= 0.004];出现下肢水肿的比例更高[66.7%(12/18) vs.5.3%(2/36),P = 0.005];行下腔静脉节段性切除或下腔静脉横断术的比例更高[66.7%(12/18) vs.15.8%(6/38), P<0.001]。对比下腔静脉超声、泌尿系增强CT及增强磁共振3种影像检查方法,鉴别瘤栓合并血栓,灵敏度最高的是增强磁共振(77.8%),特异性最高的是下腔静脉超声和增强CT(97.4%), 准确性最高的是增强CT及增强磁共振(83.9%),阳性预测值最高的是增强CT(90.9%),阴性预测值最高的是增强磁共振(89.2%)。结论:肾癌伴下腔静脉瘤栓合并血栓的患者,下腔静脉瘤栓长度更长,瘤栓直径/IVC冠状最大径比值更接近1,更易出现下肢水肿。术前需综合多种影像方法,提高诊断的准确率。

关键词: 肾癌, 下腔静脉瘤栓, 血栓, 影像诊断, 超声

Abstract:

Objective: To analyse the clinical and imaging data of patients with renal cell carcinoma (RCC) with inferior vena cava tumor thrombus (IVCTT), and to assess the diagnostic efficacy of ultrasound, enhanced computed tomography (CT) and enhanced magnetic resonance imaging (MRI) in the diagnosis of RCC with IVCTT combined with bland thrombus was assessed.Methods: We retrospectively analyzed the clinical and imaging data of 56 RCC patients with IVCTT who underwent radical nephrectomy and IVC thrombectomy between January 2014 and July 2018 in Department of Urology, Peking University Third Hospital. All the patients underwent US, enhanced CT and enhanced MRI preoperatively, and all the cases were confirmed with RCC with IVCTT by histological evaluation.Results: The criteria of RCC with IVCTT combined with bland thrombus was confirmed by intraoperative observation and postoperative pathology. The 56 patients were divided into bland thrombus group (n=18) and non bland thrombus group (n=38). Compared the two groups, it was found that the length of IVCTT was longer [(10.50 ± 5.55) cm vs.(6.66 ± 3.73) cm, P=0.014]; the ratio of diameter of IVCTT to maximum coronal diameter of IVC was closer to 1 [1.0 (0.7, 1.0) vs. 0.9 (0.2, 1.0), P=0.004]; the proportion of lower limb edema was higher [66.7(12/8)% vs.5.3%(2/36), P=0.005];the proportion of segmental resection or interrupt of IVC was higher [66.7%(12/18) vs.15.8%(6/38), P<0.001], with statistical significance. Compared with the three imaging methods of US, enhanced CT and MRI, the highest sensitivity was MRI (77.8%), the highest specificity was enhanced MRI and enhanced CT (97.4%), the highest accuracy was enhanced CT and enhanced MRI (83.9%), the highest positive predictive value was enhanced CT (90.9%) and the highest negative predictive value was enhanced MRI (89.2%).Conclusion: For the patients that RCC with IVCTT combined with bland thrombus, the length of IVCTT is longer, and the ratio of the diameter of IVCTT to the maximum corona diameter of IVC is closer to 1, and more likely to cause lower limb edema. Preoperative comprehensive evaluation of multiple images is needed to improve the accuracy of diagnosis.

Key words: Renal cell carcinoma, Inferior vena cava tumor thrombus, Bland thrombus, Imaging diagnosis, Ultrasound

中图分类号:

R737.1

李丽伟,刘茁,王国良,张华,陈文,马静,张丽,何为,马潞林,王淑敏. 肾癌伴下腔静脉瘤栓合并血栓的多种影像学比较[J]. 北京大学学报（医学版）, 2019, 51(4): 678-683.

Li-wei LI,Zhuo LIU,Guo-liang WANG,Hua ZHANG,Wen CHEN,Jing MA,Li ZHANG,Wei HE,Lu-lin MA,Shu-min WANG. Comparison of various imaging in the diagnosis of renal cell carcinoma with inferior vena cava tumor thrombus combined with bland thrombus[J]. Journal of Peking University(Health Sciences), 2019, 51(4): 678-683.

图/表 5

图1

表1

两组患者临床及影像特征"

Features	n	With bland thrombus (n=18)	Without bland thrombus (n=38)	P
Age/years, $x ? ± s$	56	57.37±8.78	60.21±13.33	0.369
Tumor diameter/cm, $x ? ± s$	56	8.82±3.75	9.04±3.34	0.263
IVCTT length/cm, $x ? ± s$	56	10.50±5.55	6.66±3.73	0.014^*
IVCTT diameter/cm, $x ? ± s$	56	3.54±0.68	2.76±1.04	0.105
Maximum coronal IVC diameter/cm, $x ? ± s$	56	3.63±0.60	3.22±0.65	0.950
IVCTT diameter/maximum coronal IVC diameter, median (min, max)	56	1.0 (0.7,1.0)	0.9 (0.2,1.0)	0.004^*
Gender, n (%)	56			0.773
Male		13 (72.2)	26 (68.4)
Female		5 (27.8)	12 (31.6)
Renal tumor side, n (%)	56			0.419
Right		11 (61)	28 (73.7)
Left		7 (38.9)	9 (23.7)
Blateral		0 (0)	1 (2.6)
Mayo classification, n (%)	56			0.203
Mayo Ⅰ		1 (5.6)	10 (26.3)
Mayo Ⅱ		6 (33.3)	14 (36.8)
Mayo Ⅲ		6 (33.3)	9 (23.7)
Mayo Ⅳ		5 (27.8)	5 (13.2)
Clinical symptoms, n (%)	56			0.005^*
Lower limb edema		12 (66.7)	2 (5.3)
No lower limb edema		6 (33.3)	36 (97.4)
Pathological type, n (%)	56			0.447
ccRCC		16 (88.9)	30 (78.9)
pRCC		2 (11.1)	5 (13.2)
Other		0 (0)	3 (7.9)
Rhabdomyosis or sarcomatoid degeneration, n (%)	50			0.639
Yes		5 (27.8)	7 (21.9)
No		13 (72.2)	25 (78.1)
Nuclear grading, n (%)	53			0.829
Ⅱ		4 (23.6)	8 (22.9)
Ⅲ		9 (52.9)	16 (45.7)
Ⅳ		4 (23.5)	11 (31.4)
Segmental resection or interuption IVC, n (%)	58			<0.001^*
Yes		12 (66.7)	6 (15.8)
No		6 (33.3)	32 (84.2)

表1

表2

表3

表4

参考文献 19

[1]	刘茁, 马潞林, 田晓军 , 等. 根治性肾切除术+下腔静脉癌栓取出术治疗Mayo 0~Ⅳ 级下腔静脉癌栓的临床经验[J]. 中华泌尿外科杂志, 2017,38(11):842-847.
[2]	刘茁, 马潞林, 田晓军 , 等. 肾癌根治性切除加癌栓取出术治疗Mayo Ⅲ 级下腔静脉癌栓的手术技术及临床经验[J]. 北京大学学报(医学版), 2017,49(4):597-602.
[3]	刘茁, 田晓军, 马潞林 . 根治性肾切除术联合Mayo 0-Ⅱ 级静脉癌栓取出术的临床麻醉管理[J]. 现代肿瘤医学, 2017,25(16):2672-2677.
[4]	刘茁, 马潞林, 田晓军 , 等. 腹腔镜和开放肾癌根治性切除+Mayo Ⅱ 级下腔静脉癌栓取出术11例临床分析[J]. 现代泌尿外科杂志, 2017,22(8):603-607.
[5]	马潞林, 刘茁 . 肾癌并肝段和肝以上下腔静脉癌栓的诊治体会[J]. 中华泌尿外科杂志, 2017,38(7):481-484.
[6]	Blute ML, Leibovich BC, Lohse CM , et al. The mayo clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumour thrombus[J] . BJU Int, 2004,94(1):33-41.
[7]	Wang M, Ping H, Niu Y , et al. Pure conventional laparoscopic radical nephrectomy with level II vena cava tumor thrombectomy[J]. Int Braz J Urol, 2014,40(2):266-273.
[8]	程艳, 蔡欣, 刘基巍 . 恶性肿瘤与血栓形成[J]. 临床肿瘤学杂志, 2010,15(4):376-379.
[9]	Ayyathurai R, Garciaroig M, Gorin MA , et al. Bland thrombus association with tumour thrombus in renal cell carcinoma: Analysis of surgical significance and role of inferior vena caval interruption[J]. BJU Int, 2013,110(11b):E449-E455.
[10]	Hutchinson R, Rew C, Chen G , et al. The adverse survival implications of bland thrombus in renal cell carcinoma with venous tumor thrombus[J]. Urology, 2018,115:119-124.
[11]	Blute ML, Boorjian SA, Leibovich BC , et al. Results of inferior vena caval interruption by greenfield filter, ligation or resection during radical nephrectomy and tumor thrombectomy[J]. J Urol, 2007,178(2):440-445.
[12]	马鑫 . 机器人腹腔镜腔静脉瘤栓取出术:新的思考新的策略[J]. 中华腔镜外科杂志: 电子版, 2017,10(5):272-273.
[13]	Quencer KB, Friedman T, Sheth R , et al. Tumor thrombus: Incidence, imaging, prognosis and treatment[J]. Cardiovasc Diagn Ther, 2017,7(Suppl 3):S165-S177.
[14]	Mukai M, Oka T . Mechanism and management of cancer-associated thrombosis[J]. J Cardiol, 2018,72(2):89-93.
[15]	肾癌伴静脉瘤栓北京专家共识[J]. 微创泌尿外科杂志, 2017: 6(6):321-327.
[16]	宋奕宁, 赵艺超, 李建国 . 下腔静脉肿瘤的超声影像诊断与鉴别[J]. 中国超声医学杂志, 2018,34(1):37-39.
[17]	Tarantino L . Contrast-enhanced ultrasound in differentiating malignant from benign portal vein thrombosis in hepatocellular carcinoma[J]. World J Gastroenterol, 2015,21(32):9457-9460.
[18]	Sonavane SN, Malhotra G, Asopa R , et al. Role of fluorine-18 fluorodeoxyglucose positron emission tomography in a case of renal cell carcinoma to differentiate tumor thrombus from bland thrombus[J]. Indian J Nucl Med, 2015,30(4):355-357.
[19]	Sharma P, Kumar R, Jeph S , et al. 18F-FDG PET-CT in the diagnosis of tumor thrombus[J]. Nucl Med Commun, 2011,32(9):782-788.

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No.	Gender	Age/ years	Renal tumor side	Renal tumor diameter/cm	Pathology	Nuclear grading	IVCTT length	Mayo	IVC resection	Bland thrombus location	length in imaging/ cm	Imaging diagnosis
No.	Gender	Age/ years	Renal tumor side	Renal tumor diameter/cm	Pathology	Nuclear grading	IVCTT length	Mayo	IVC resection	Bland thrombus location	length in imaging/ cm	US	MRI	CT
1	M	62	L	5.80	ccRCC	3	11.30	Ⅳ	No	Proximal	-	0	0	0
2	M	67	R	3.60	ccRCC	2	16.40	Ⅳ	Interruption	Distal	12.94	0	1	1
3	M	53	R	7.70	ccRCC	4	18.60	Ⅱ	Segmental	Distal	8.50	0	1	0
4	M	53	R	6.40	ccRCC	4	20.00	Ⅳ	Segmental	Distal	2.00	0	1	1
5	F	62	R	10.30	ccRCC	3	20.00	Ⅲ	Interruption	Distal,contralateral	12.25	0	1	1
6	M	50	R	5.80	ccRCC	3	6.60	Ⅲ	Segmental	Distal,contralateral	2.70	1	1	1
7	M	71	R	7.20	ccRCC	3	15.50	Ⅲ	Interruption	Distal	8.80	0	1	1
8	M	45	R	10.30	ccRCC	2	10.00	Ⅳ	Interruption	Distal	2.13	0	1	1
9	M	58	L	13.00	ccRCC	3	6.25	Ⅱ	Interruption	Distal	3.30	0	1	0
10	M	47	L	15.50	pRCC	3	6.20	Ⅲ	No	Contralateral,	-	0	0	0
11	M	58	L	14.50	ccRCC	4	5.00	Ⅲ	Interruption	Distal	1.30	0	1	1
12	F	69	L	10.90	ccRCC	3	14.30	Ⅳ	No	Distal	1.30	0	1	0
13	F	67	R	3.80	pRCC	3	9.40	Ⅱ	Segmental	Distal,contralateral	11.75	1	1	1
14	M	62	R	4.50	ccRCC	2	5.48	Ⅱ	Interruption	Distal, contralatera	7.84	0	1	1
15	M	48	R	12.00	ccRCC	4	6.90	Ⅲ	Segmental	Distal	2.00	0	1	0
16	F	41	R	6.80	ccRCC	3	3.20	Ⅱ	No	Contralateral	-	0	0	0
17	M	57	L	13.30	ccRCC	4	5.80	Ⅱ	No	Contralateral	-	0	0	0
18	F	63	R	7.30	ccRCC	2	8.00	Ⅰ	No	Distal	1.13	1	1	1

Imaging diagnosis result		Surgical pathologic diagnosis
Imaging diagnosis result		With bland thrombus (n=18)	Without bland thrombus (n=38)
US	Positive	3	1
	Negative	15	37
Enhanced MRI	Positive	14	5
	Negative	4	33
Enhanced CT	Positive	10	1
	Negative	8	37

Imaging diagnosis	Sensitivity	Specificity	Accuracy	Positive predictive value	Negative predictive value
US	16.8	97.4^*	71.4	75.0	71.2
Enhanced MRI	77.8^*	86.8	83.9^*	73.7	89.2^*
Enhanced CT	55.7	97.4^*	83.9^*	90.9^*	82.2