青年肾肿瘤伴瘤栓的临床病理特征及预后分析

doi:10.19723/j.issn.1671-167X.2023.05.005

摘要/Abstract

摘要：

目的: 回顾性分析2016年1月至2022年12月于北京大学第三医院因肾肿瘤伴瘤栓行手术治疗的患者(年龄≤40岁)临床资料，评估手术效果，探讨其临床病理特征与预后之间的关系。方法: 回顾17例青年肾肿瘤伴瘤栓患者的临床资料，总结其临床病理特征和预后情况。按照有无症状、2017年美国癌症联合委员会(American Joint Committee on Cancer, AJCC)的临床分期、术后有无联合辅助治疗进行分组，采用Kaplan-Meier方法描绘生存曲线，并采用Log-rank检验比较不同组间患者术后生存时间、无进展生存时间的差异，分析临床病理特征和预后的关系。结果: 17例患者均接受静脉瘤栓取出术，其中，肾根治性切除术16例(94.1%)，保留肾单位术1例(5.9%)；术前有症状者12例(70.6%)，无症状者5例(29.4%)；良性肾肿瘤2例(11.8%)，恶性肾肿瘤15例(88.2%)，包括肾透明细胞癌1例(6.7%)，非透明细胞癌14例(93.3%)。15例恶性肾肿瘤中，AJCC临床Ⅲ期8例(53.3%)，Ⅳ期7例(46.7%)。术后联合多种辅助治疗者6例(40%)，未联合多种辅助治疗者9例(60%)。随访时间2~78个月，中位随访时间41个月，随访中死亡3例(20%)。患者术后中位生存时间39.0 (2.3，77.8)个月，无进展生存时间16.4 (2.3，77.8)个月。根据术前有无症状(P=0.307，P=0.302)、AJCC临床分期(P=0.340，P=0.492)、术后有无联合辅助治疗(P=0.459，P=0.253)分组，青年肾肿瘤伴瘤栓患者的术后生存时间、无进展生存时间差异无统计学意义。结论: 青年肾肿瘤伴瘤栓患者多出现症状，病理类型更复杂多样，恶性肿瘤合并瘤栓中非透明细胞癌的比例更高，有症状及非透明细胞癌与不良预后可能存在一定潜在相关性，外科手术联合辅助治疗是青年肾肿瘤伴瘤栓患者相对安全、有效的治疗方式。

关键词: 青年人, 肾肿瘤, 瘤栓, 临床病理特征, 预后

Abstract:

Objective: To retrospectively analyze clinical data of patients under 40 years old who underwent surgical treatment for renal tumors with tumor thrombus from January 2016 to December 2022 at Peking University Third Hospital, and to evaluate the surgical effect and investigate the relationship between clinicopathological characteristics and prognosis. Methods: The clinical data of 17 young patients with renal tumor thrombus were retrospectively analyzed, and the clinicopathological features and prognosis were summarized. The patients were grouped according to the presence or absence of symptoms, 2017 American Joint Committee on Cancer (AJCC) clinical stage, and postoperative combined adjuvant therapy. Kaplan-Meier method was used to plot the survival curve, and Log-rank test was used to compare the differences in postoperative survival time and progression-free survival time between the different groups. The relationship between clinicopathological features and prognosis was analyzed. Results: All the 17 patients received venous tumor thrombectomy, including 16 patients (94.1%) who underwent radical nephrectomy and 1 patient (5.9%) who underwent partial nephrectomy. Twelve patients (70.6%) had symptoms and 5 (29.4%) had no symptoms before operation. A total of 17 renal tumors were observed, with 2 patients (11.8%) identified as benign and 15 patients (88.2%) classified as malignant. Among the malignant tumors, 1 patient (6.7%) was diagnosed as clear cell carcinoma, while the remaining 14 patients (93.3%) were categorized as non-clear cell carcinoma. In terms of tumor stage, 8 patients (53.3%) were classified as stage Ⅲ according to the AJCC classification, while 7 patients (46.7%) were categorized as stage Ⅳ. Additionally, 6 patients (40%) received multiple adjuvant therapy, while 9 patients (60%) did not undergo such treatment. The follow-up period ranged from 2 to 78 months, with a median follow-up of 41 months. During this time, 3 patients (20%) died. The median survival time after surgery was 39.0 (2.3, 77.8) months, and the progression-free survival time was 16.4 (2.3, 77.8) months. There was no significant difference in postoperative survival time and progression-free survival time among young patients with renal tumor with tumor thrombus, based on the presence of symptoms before surgery (P=0.307, P=0.302), clinical stage of AJCC (P=0.340, P=0.492), and postoperative adjuvant therapy (P=0.459, P=0.253) group. Conclusion: The pathological types of young patients with renal tumor with tumor thrombus are more complex and varied due to symptoms, and the proportion of non-clear cell carcinoma in malignant tumor with tumor thrombus is higher. Symptomatic and non-clear cell carcinoma may be potentially associated with poor prognosis. Surgical operation combined with adjuvant therapy is a relatively safe and effective treatment for young patients with renal tumor and tumor thrombus.

Key words: Young adult, Kidney neoplasms, Tumor thrombus, Clinicopathologic features, Prognosis

中图分类号:

R737.11

薛子璇,唐世英,邱敏,刘承,田晓军,陆敏,董靖晗,马潞林,张树栋. 青年肾肿瘤伴瘤栓的临床病理特征及预后分析[J]. 北京大学学报（医学版）, 2023, 55(5): 802-811.

Zi-xuan XUE,Shi-ying TANG,Min QIU,Cheng LIU,Xiao-jun TIAN,Min LU,Jing-han DONG,Lu-lin MA,Shu-dong ZHANG. Clinicopathologic features and prognosis of young renal tumors with tumor thrombus[J]. Journal of Peking University (Health Sciences), 2023, 55(5): 802-811.

图/表 6

表1

表2

17例青年肾肿瘤伴瘤栓患者的手术及病理资料"

Items	Data	Items	Data
Surgical methods		Histopathological type
Radical nephrectomy	16 (94.1%)	Malignant renal tumors (n=15)
Partial nephrectomy	1 (5.8%)	Clear cell renal carcinoma	1 (5.8%)
Thrombectomy	17 (100.0%)	Papillary renal cell carcinoma	5 (29.4%)
Lymph node dissection	6 (35.2%)	Nephroblastoma	3 (17.6%)
Adrenalectomize	8 (47.1%)	Ewing’s sarcoma	3 (17.6%)
Metastasectomy	1 (5.8%)	Fumarate hydratase deficient renal cell carcinoma	1 (5.8%)
Surgical approach		TFE3-rearanged renal cell carcinoma	1 (5.8%)
Simple laparoscopy	4 (23.5%)	Unclassified renal cell carcinoma	1 (5.8%)
Robot-assisted laparoscopy	2 (11.7%)	Benign renal tumors (n=2)
Laparoscopy converted to open surgery	1 (5.8%)	Epithelioid angiomyolipoma	1 (5.8%)
Open surgery	10 (58.8%)	Angiomyolipoma	1 (5.8%)
ASA classification		Lymphatic metastasis	3 (17.6%)
1	2 (11.7%)	Adrenal metastasis	1 (5.8%)
2	15 (88.2%)	Renal capsule involved	9 (52.9%)
Operative time/min	294 (148, 561)	Vascular involved	17 (100.0%)
Surgical bleeding volume/mL	600 (20, 4 500)	Perineal fat sac involved	6 (35.2%)
Surgical blood transfusion volume/mL	300 (0, 2 700)	Renal sinuses/pelvis involved	16 (94.1%)
Plasma transfusion volume/mL	400 (0, 1 600)	pT stage (n=15)
Postoperative hospital stay/d	8 (2, 18)	T3a	2 (13.3%)
Postoperative complications		T3b	9 (60.0%)
Fever	5 (29.4%)	T4	4 (26.7%)
Anemia	1 (5.8%)	pN stage (n=15)
Hypokalemia	1 (5.8%)	Nx	9 (60.0%)
Hypoalbuminemia	2 (11.7%)	N0	3 (20.0%)
Lymphatic fistula	2 (11.7%)	N1	3 (20.0%)
Pulmonary infection	1 (5.8%)	pM stage (n=15)
Seroperitoneum	1 (5.8%)	M0	11 (76.4%)
Intestinal obstruction	1 (5.8%)	M1	4 (23.5%)
Pulmonary embolism	1 (5.8%)	Immunohistochemistry	14 (82.3%)
Clavien classification system		P504S (+)	6 (35.2%)
Ⅰ	8 (47.0%)	Ki-67 (+)	6 (35.2%)
Ⅱ	8 (47.0%)	P53(wild-type) (+)	5 (29.4%)
Ⅲ	1 (5.8%)	PAX-8 (+)	5 (29.4%)
		TFE3 (+)	4 (23.5%)

表2

表3

图1

图2

图3

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Items	Data	Items	Data
Gender		Position
Male	8 (47.1%)	Superior	6 (35.2%)
Female	9 (52.9%)	Intermediate	3 (17.6%)
Age/years	31 (6, 39)	Below-intermediat	1 (5.8%)
BMI/(kg/m²)	24.1 (11.7, 32.0)	Upper-intermediat	7 (41.1%)
Clinical symptoms		Tumor shape
Backache	8 (47.0%)	Convex profile	11 (64.7%)
Blood urine	3 (17.0%)	Endophytic type	6 (35.2%)
Abdominal mass	1 (5.8%)	Transfer situation
Physical examination findings	5 (29.4%)	Lymph nodes	7 (41.1%)
Course of disease/d	30 (1, 730)	Adrenal metastasis	4 (23.5%)
Previous history		Liver metastasis	3 (17.6%)
Hypertension	1 (5.8%)	Multiple metastases	1 (5.8%)
Diabetes	1 (5.8%)	Inferior vena cava metastasis	17 (100.0%)
Operations	5 (29.4%)	Mayo classification
Hepatitis B carrier	1 (5.8%)	Ⅰ	3 (17.6%)
Smoking history	1 (5.8%)	Ⅱ	9 (52.9%)
Preoperative assay		Ⅲ	5 (29.4%)
Hemoglobin/(g/L)	126 (92, 150)	cT stage (n=15)
Albumin/(g/L)	41.4 (28.3, 46.8)	T3a	1 (6.7%)
Scr/(μmol/L)	83 (53, 118)	T3b	7 (46.7%)
Affected side GFR/(mL/min)	32.1 (12.9, 77.4)	T4	7 (46.7%)
Healthy side GFR/(mL/min)	69.9 (38.0, 117.6)	cN stage (n=15)
Ultrasound B	13 (76.4%)	Nx	3 (20.0%)
CT (plain scan/enhanced scan/PET-CT)	16 (94.2%)	N0	6 (40.0%)
MRI (plain scan/enhanced scan/CEMRA)	13 (76.4%)	N1	6 (40.0%)
Tumor diameter/cm	11.7 (4.0, 17.8)	cM stage (n=15)
Tumor thrombus length/cm	4.5 (1.5, 12.0)	M0	11 (73.3%)
Clinical impression		M1	4 (26.7%)
Benign renal hamartoma	2 (11.8%)	2017 AJCC clinical stage
Malignant renal tumors	15 (88.2%)	Ⅲ	8 (53.3%)
Side		Ⅳ	7 (46.7%)
Left	7 (41.1%)
Right	10 (58.8%)

Items	Data	Items	Data
Malignant renal tumors (n=15)		Postoperative therapy	14 (93.3%)
Alive	12 (80.0%)	Targeted therapy	6 (40.0%)
Dead	3 (20.0%)	Chemotherapy	1 (6.7%)
Recurrence	8 (53.3%)	Immunotherapy	1 (6.7%)
Symptoms	3 (20.0%)	Combination therapy	6 (40.0%)
Physical examination findings	5 (33.3%)	Radiotherapy+targeted therapy	1 (6.7%)
Postoperative metastasis	8(53.3%)	Immunotherapy+targeted therapy	1 (6.7%)
Liver	2 (13.3%)	Chemotherapy+targeted therapy	1 (6.7%)
Liver+mesentery	1 (6.7%)	Radiotherapy+chemotherapy	1 (6.7%)
Liver+bone+pelvic cavity	1 (6.7%)	Radiotherapy+targeted+immunotherapy	1 (6.7%)
Bone+lung	1 (6.7%)	Surgery+targeted+ chemotherapy	1 (6.7%)
Adrenal gland	1 (6.7%)
Spleen+pancreas+psoas muscle	1 (6.7%)	Benign renal tumors (n=2)
Extensive peritoneal metastasis	1 (6.7%)	Alive	2 (100.0%)
Survival time/month	39.0 (2.3, 77.8)	Recurrence	0 (0)
Progression-free survival time/month	16.4 (2.3, 77.8)	Survival time/month	35.2 (19.5, 50.8)
Time to recurrence/month	12.0 (4.4, 25.2)	Progression-free survival time/month	35.2 (19.5, 50.8)
Duration of treatment/month	3 (1, 52)

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