癌栓粘连血管壁对非转移性肾细胞癌合并下腔静脉癌栓患者手术及预后的影响

doi:10.19723/j.issn.1671-167X.2021.04.007

摘要/Abstract

摘要：

目的: 评估癌栓粘连静脉壁对肾细胞癌伴下腔静脉癌栓患者手术难度和预后的影响。方法: 对北京大学第三医院泌尿外科于2017年1月至2020年6月收治的94例非转移性肾细胞癌合并下腔静脉癌栓患者进行回顾性队列研究,收集患者的一般情况、临床病理特征、手术及生存信息。按术中发现癌栓粘连静脉壁为标准将患者分为两组,其中64例为癌栓粘连静脉壁组(deep invasive tumor thrombus, DITT), 30例为非粘连组(non-invasive tumor thrombus, NITT)。分别采用卡方检验、t检验和Mann-Whitney U检验进行两组间分类变量和连续变量的单因素比较,绘制Kaplan-Meier曲线并进行多变量Cox回归分析以评估癌栓粘连静脉壁对患者预后的影响。结果: 与NITT组相比,DITT组患者的手术难度明显增加,主要表现为手术时间更长(362.5 vs. 307.5 min,P=0.010),手术出血量更多(1 200 vs. 450 mL,P=0.006),围术期输血量更多(800 vs. 0 mL,P=0.021),血浆输注量更多(200 vs. 0 mL,P=0.001),开放手术占比更高(70.3% vs. 36.7%,P=0.002),术后住院时间更长(9.5 vs. 8.0 d,P=0.036),且发生术后并发症的比例更高(46.9% vs. 13.8%,P=0.002)。DITT与患者的总生存期更差呈正相关(P=0.022),即使在多因素分析中,DITT仍是影响肾细胞癌伴下腔静脉癌栓患者术后总生存率的不良预后因素[HR: 4.635 (1.017~21.116),P=0.047]。结论: 对于非转移性肾细胞癌合并下腔静脉癌栓的患者而言,癌栓粘连静脉壁会明显增加其手术难度,并与患者的不良预后相关。

关键词: 肾细胞癌, 下腔静脉, 癌栓, 预后

Abstract:

Objective: To evaluate the impact of deep invasive tumor thrombus on the surgical complexity and prognosis of patients with renal cell carcinoma complicated with inferior vena cava tumor thrombus. Methods: We retrospectively reviewed the clinical data of 94 patients with non-metastatic renal cell carcinoma complicated with inferior vena cava tumor thrombus, who underwent surgical treatment in Peking University Third Hospital from January 2017 to June 2020. The patient’s general condition, clinicopathological characteristics, surgery and survival information were collected. The patients were divided into two groups based on the intra-operative findings of tumor thrombus adhesion to the venous wall, of which 64 cases were in the deep invasive tumor thrombus (DITT) group and 30 cases were in the non-invasive tumor thrombus (NITT) group. Chi-square, t test and Mann-Whitney U test were used for categorical and continuous variables respectively. Kaplan-Meier plots and multivariable Cox regressions were performed to evaluate the influence of DITT on the prognosis of the patients with renal cell carcinoma with inferior vena cava tumor thrombus. Results: DITT significantly increase the difficulty of surgery for the patients with renal cell carcinoma with venous tumor thrombus, which was mainly reflected in the longer operation time (362.5 vs. 307.5 min, P=0.010), more surgical bleeding (1 200 vs. 450 mL, P=0.006), more surgical blood transfusion (800 vs. 0 mL, P=0.021), more plasma transfusion (200 vs. 0 mL, P=0.001), a higher proportion of open surgery (70.3% vs. 36.7%, P=0.002), a longer post-operative hospital stay (9.5 vs. 8 days, P=0.036), and a higher proportion of post-operative complications (46.9% vs. 13.8%, P=0.002). DITT was associated with worse overall survival of the patients with renal cell carcinoma with inferior vena cava tumor thrombus (P=0.022). Even in the multivariate analysis, DITT was still a poor prognostic factor for the overall survival of these patients [HR: 4.635 (1.017-21.116), P=0.047]. Conclusion: For patients with non-metastatic renal cell carcinoma with inferior vena cava tumor thrombus, DITT will significantly increase the difficulty of surgery, and may lead to poor prognosis.

Key words: Renal cell carcinoma, Inferior vena cava, Tumor thrombus, Prognosis

中图分类号:

R737.11

赵勋,颜野,黄晓娟,董靖晗,刘茁,张洪宪,刘承,马潞林. 癌栓粘连血管壁对非转移性肾细胞癌合并下腔静脉癌栓患者手术及预后的影响[J]. 北京大学学报（医学版）, 2021, 53(4): 665-670.

ZHAO Xun,YAN Ye,HUANG Xiao-juan,DONG Jing-han,LIU Zhuo,ZHANG Hong-xian,LIU Cheng,MA Lu-lin. Influence of deep invasive tumor thrombus on the surgical treatment and prognosis of patients with non-metastatic renal cell carcinoma complicated with venous tumor thrombus[J]. Journal of Peking University (Health Sciences), 2021, 53(4): 665-670.

图/表 5

图1

表1

DITT组和NITT组临床和病理特征比较"

Items	DITT (n=64)	NITT (n=30)	t/U/χ²	P value
Age/years	60.4±8.9	59.4±10.9	0.453	0.652
Gender			3.548	0.060
Male	52 (81.3%)	19 (63.3%)
Female	12 (18.8%)	11 (36.7%)
Side			0.121	0.728
Left	17 (26.6%)	9 (30.0%)
Right	47 (73.4%)	21 (70.0%)
Clinical symptoms			1.294	0.523
No clinical symptoms	13 (20.3%)	7 (23.3%)
Local symptoms	36 (56.3%)	19 (63.3%)
Systemic symptoms	15 (23.4%)	4 (13.3%)
BMI/(kg/m²)	24.7±3.5	24.0±2.8	0.893	0.374
Tumor diameter/cm	8.1±2.9	9.1±2.8	1.684	0.096
Hb/(g/L)	120.3±20.4	130.3±20.7	2.203	0.030
Neu/(×10⁹/L)	4.8±1.7	4.2±1.1	1.784	0.078
Plt/(×10⁹/L)	255.0±118.6	262.7±77.8	0.325	0.746
ALP/(U/L)	91.6±37.6	85.6±22.5	0.802	0.424
Alb/(g/L)	39.1±5.1	40.5±4.4	1.257	0.212
Ca/(mg/L)	2.3±0.2	2.2±0.1	0.552	0.583
SCr/(μmol/L)	100.2±25.3	90.8±20.4	1.766	0.081
SCr after surgery/(μmol/L)	116.5±54.2	101.9±37.7	1.259	0.211
ASA score			5.876	0.053
1	3 (4.7%)	2 (6.7%)
2	50 (78.1%)	28 (93.3%)
3	11 (17.2%)	0 (0)
pN stage			4.099	0.052
N0	56 (87.5%)	30 (100.0%)
N1	8 (12.5%)	0 (0)
Mayo classification			8.755	0.033
Ⅰ	11 (17.2%)	12 (40.0%)
Ⅱ	40 (62.5%)	15 (50.0%)
Ⅲ	8 (12.5%)	0 (0)
Ⅳ	5 (7.8%)	3 (10.0%)
Pathology type			0.424	0.769
Clear cell carcinoma	52 (81.3%)	26 (86.7%)
Non clear cell carcinoma	12 (18.7%)	4 (13.3%)
Fuhrman grade			0.419	0.518
Ⅰ-Ⅱ	27 (42.9%)	15 (50.0%)
Ⅲ-Ⅳ	36 (57.1%)	15 (50.0%)
Surgical approach			9.601	0.002
Laparoscopic surgery	19 (29.7%)	19 (63.3%)
Open surgery	45 (70.3%)	11 (36.7%)
IVC resection			13.464	<0.001
No	42 (65.6%)	30 (100.0%)
Yes	22 (34.4%)	0 (0)
Operative time/min	362.5 (305.3, 429.8)	307.5 (254.5, 374.0)	644.0	0.010
Surgical bleeding volume/mL	1 200 (325, 2 500)	450 (200, 800)	621.0	0.006
Surgical blood transfusion volume/mL	800 (0, 1 600)	0 (0, 600)	689.0	0.021
Plasma transfusion volume/mL	200 (0, 750)	0 (0, 0)	598.0	0.001
Post-operative hospital stay/d	9.5 (7.0, 13.0)	8.0 (6.0, 9.3)	702.5	0.036
Post-operative adjuvant targeted therapy			2.546	0.111
No	23 (35.9%)	16 (53.3%)
Yes	41 (64.1%)	14 (46.7%)
Post-operative complications			9.417	0.002
No	34 (53.1%)	25 (86.2%)
Yes	30 (46.9%)	4 (13.8%)

表1

表2

图2

表3

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Items	DITT (n=40)	NITT (n=15)	U/χ²	P value
Operative time/min	368.5 (306.5, 525.0)	302.0 (258.0, 355.0)	139	0.002
Surgical bleeding volume/mL	1 450 (525, 2 925)	400 (200, 800)	152.5	0.005
Surgical blood transfusion volume/mL	800 (0, 1 600)	0 (0, 400)	202	0.054
Plasma transfusion volume/mL	400 (0, 800)	0 (0, 0)	155	0.003
Post-operative hospital stay/d	11.0 (7.0, 13.0)	8.0 (6.0, 9.0)	190	0.036
Open surgery	30 (75.0%)	4 (26.7%)	10.8	0.001
Post-operative complications	22 (55.0%)	2 (13.3%)	7.7	0.006

Items	HR	95%CI	P value
DITT	4.635	1.017-21.116	0.047
Mayo classification	2.046	1.161-3.604	0.013
Hb	-	-	0.484
Non-clear cell carcinoma	4.275	1.495-12.229	0.007
Fuhrman grade (Ⅲ-Ⅳ vs. Ⅰ-Ⅱ)	-	-	0.719