病理T3a期肾细胞癌肾部分切除与根治性肾切除的回顾性匹配研究

doi:10.19723/j.issn.1671-167X.2025.04.012

摘要/Abstract

摘要：

目的: 评估临床T1(clinical T1，cT1)期术后升级为病理T3a(pathological T3a，pT3a)期肾细胞癌(renal cell carcinoma，RCC) 患者应用肾部分切除术(partial nephrectomy，PN)的远期肿瘤学结局。方法: 回顾研究北京大学第三医院2013年2月至2022年12月427例术后评估为pT3aN0M0期的RCC患者，其中33例cT1术后升级为pT3a的RCC患者均接受了PN(PN组)，而394例术后未升级的pT3a RCC患者均接受了根治性肾切除术(radical nephrectomy，RN，RN组)，根据基线特征以1 ∶ 1的比例进行倾向性评分匹配，使用Kalan-Meier曲线评估总生存期(overall survival, OS)、癌症特异性生存期(cancer-specific survival, CSS)和无病生存期(disease-free survival, DFS)，并使用对数秩检验和Cox回归模型进行多因素分析。结果: 匹配前，PN组(n = 33)与RN组(n = 394)相比，肾周脂肪浸润(perirenal fat invasion，PFI; 45.5% vs. 15.2%)和肾段静脉受累(42.4% vs. 20.8%)的比例更高，而肾盂肾窦侵犯(renal sinus invasion，RSI; 21.2% vs. 73.6%)及合并肾静脉癌栓(0% vs. 15.2%)的比例较低，差异有统计学意义(P < 0.05)。匹配后，PN组(n = 33)和RN组(n = 33)的基线特征具有可比性。PN和RN组在手术时间、出血量、平均住院日、并发症发生率、阳性切缘率、中转开放手术的比例方面差异无统计学意义(P ＞0.05)，但PN组术后估算的肾小球滤过率(estimated glomerular filtration rate，eGFR)更高[76.9 (55.4，87.3) mL/(min·1.73 m²) vs. 61.7 (56.8，73.5) mL/(min·1.73 m²)，P < 0.05]，表明其对肾功能的保留效果更好。两组在OS、CSS和DFS方面差异无统计学意义(P ＞0.05)。多因素分析显示，肾静脉侵犯(renal vein invasion，RVI)、较高的肿瘤Fuhrman分级(Ⅲ~Ⅳ)以及伴有肉瘤样分化特征是pT3a RCC患者的DFS和CSS的独立危险因素(P < 0.05)。结论: 对于cT1升级为pT3a的RCC患者，PN在更大程度上保留了肾功能，并且肿瘤学结局可能与RN的效果相当。RVI、较高的肿瘤Fuhrmann分级以及伴有肉瘤样分化特征是pT3N0M0期RCC患者的独立危险因素。

关键词: 肾细胞癌, 肾部分切除术, 根治性肾切除术, 病理T3a期

Abstract:

Objective: To evaluate the long-term oncological outcomes of partial nephrectomy (PN) in patients with renal cell carcinoma (RCC) who were clinically staged as clinical T1 (cT1) preoperatively but upstaged to pathological T3a (pT3a) after surgery. Methods: A total of 427 RCC patients postoperatively diagnosed as pT3aN0M0 at Peking University Third Hospital from February 2013 to December 2022 were retrospectively reviewed. Among them, 33 cT1 patients upstaged to pT3a RCC received PN (PN group), while 394 non-upstaged pT3a RCC patients underwent radical nephrectomy (RN, RN group). Propensity score matching was performed at a 1 ∶ 1 ratio based on baseline characteristics. The Kaplan-Meier method was used to assess overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS), with Log-rank tests and Cox regression models for multivariate analysis. Results: Before matching, the PN group (n = 33) had significantly higher rates of perirenal fat invasion (PFI, 45.5% vs. 15.2%) and segmental renal vein involvement (42.4% vs. 20.8%), but lower rates of renal sinus invasion (RSI, 21.2% vs. 73.6%) and renal vein tumor thrombus (0% vs. 15.2%) compared with the RN group (n = 394, all P < 0.05). After matching, baseline characteristics were comparable between the PN group (n = 33) and RN group (n = 33). No significant differences were observed in operative time, blood loss, mean hospital stay, complication rate, positive margin rate, or conversion to open surgery between the two groups (P > 0.05). However, the PN group showed significantly higher estimated glomerular filtration rate (eGFR) postoperatively [76.9 (55.4, 87.3) mL/(min·1.73 m²) vs. 61.7 (56.8, 73.5) mL/(min·1.73 m²), P < 0.05], indicating better renal function preservation. No significant differences were found in OS, CSS, or DFS between the groups (P > 0.05). Multivariate ana-lysis identified renal vein invasion (RVI), higher Fuhrman grades (Ⅲ-Ⅳ), and sarcomatoid differentiation as independent risk factors for DFS and CSS in the pT3a RCC patients (P < 0.05). Conclusion: For cT1 RCC patients upstaged to pT3a, PN preserves renal function more effectively while achieving com-parable oncological outcomes to RN. RVI, higher Fuhrmann grade, and sarcomatoid differentiation are independent risk factors for pT3N0M0 RCC patients.

Key words: Renal cell carcinoma, Partial nephrectomy, Radical nephrectomy, Pathological T3a

中图分类号:

R737.11

周泽臻, 葛力源, 张帆, 邓绍晖, 颜野, 张洪宪, 王国良, 刘磊, 黄毅, 张树栋. 病理T3a期肾细胞癌肾部分切除与根治性肾切除的回顾性匹配研究[J]. 北京大学学报（医学版）, 2025, 57(4): 704-710.

Zezhen ZHOU, Liyuan GE, Fan ZHANG, Shaohui DENG, Ye YAN, Hongxian ZHANG, Guoliang WANG, Lei LIU, Yi HUANG, Shudong ZHANG. A retrospective matching study of partial nephrectomy and radical nephrectomy for pathological T3a stage renal cell carcinoma[J]. Journal of Peking University (Health Sciences), 2025, 57(4): 704-710.

图/表 4

表1

倾向性评分匹配前后PN组和RN组患者的基线资料"

Items	Before propensity score matching		P value	After propensity score matching		Pvalue
Items	PN (n = 33)	RN (n = 394)	P value	PN (n = 33)	RN (n = 33)	Pvalue
Age/years, n(%)			0.879			>0.999
＜65	18 (54.5)	203 (51.5)		18 (54.5)	18 (54.5)
≥ 65	15 (45.5)	191 (48.5)		15 (45.5)	15 (45.5)
Gender, n(%)			0.164			＞0.999
Male	26 (78.8)	257 (65.2)		26 (78.8)	27 (81.8)
Female	7 (21.2)	137 (34.8)		7 (21.2)	6 (18.2)
Laterality, n(%)			＞0.999			0.460
Left	18 (54.5)	215 (54.6)		18 (54.5)	14 (42.4)
Right	15 (45.5)	179 (45.4)		15 (45.5)	19 (57.6)
ASA level, n(%)			0.146			0.920
1	6 (18.2)	82 (20.8)		6 (18.2)	7 (21.2)
2	25 (75.8)	291 (73.9)		25 (75.8)	23 (69.7)
3	1 (3.0)	20 (5.1)		1 (3.0)	2 (6.1)
4	1 (3.0)	1 (0.3)		1 (3.0)	1 (3.0)
Comorbidity, n(%)	14 (42.4)	166 (42.1)	＞0.999	14 (42.4)	17 (51.5)	0.622
Hypertension	14 (42.4)	141 (35.8)		14 (42.4)	14 (42.4)
Diabetes	6 (18.2)	52 (13.2)		6 (18.2)	9 (27.3)
CHD	1 (3.0)	21 (5.3)		1 (3.0)	2 (6.1)
CVD	2 (6.1)	21 (5.3)		2 (6.1)	1 (3.0)
Surgery history	12 (36.4)	104 (26.4)		12 (36.4)	11 (33.3)
Tumor diameter /cm, n(%)			＜0.001			>0.999
≤4	26 (78.8)	61 (15.5)		26 (78.8)	26 (78.8)
>4, ≤7	7 (21.2)	202 (51.3)		7 (21.2)	7 (21.2)
>7	0 (0)	131 (33.2)		0 (0)	0 (0)
eGFR/ [mL/(min·1.73 m²)], M (P₂₅, P₇₅)	88.9 (64.0, 99.3)	86.7 (72.6, 97.6)	0.956	88.9 (64.0, 99.3)	89.3 (79.6, 97.7)	0.830
Renal vein thrombosis, n(%)	0 (0)	60 (15.2)	0.031	0 (0)	0 (0)	>0.999
PFI, n(%)	15 (45.5)	60 (15.2)	＜0.001	15 (45.5)	16 (48.5)	＞0.999
RSI, n(%)	7 (21.2)	290 (73.6)	＜0.001	10 (30.3)	12 (36.4)	0.794
Segmental renal vein extension, n(%)	14 (42.4)	82 (20.8)	0.008	14 (42.4)	15 (45.5)	＞0.999
Histology, n(%)			＞0.999			>0.999
ccRCC	29 (87.9)	346 (87.8)		29 (87.9)	29 (87.9)
nccRCC	4 (12.1)	48 (12.2)		4 (12.1)	4 (12.1)
Fuhrman grading, n(%)			0.072			0.782
Ⅰ-Ⅱ	25 (75.8)	229 (58.1)		25 (75.8)	23 (69.7)
Ⅲ-Ⅳ	8 (24.2)	165 (41.9)		8 (24.2)	10 (30.3)
Sarcomatoid differentiation, n(%)	0 (0)	9 (2.3)	＞0.999	0 (0)	0 (0)	>0.999

表1

表2

图1

图2

参考文献 28

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Items	PN (n=33)	RN (n=33)	P value
Nephrectomy techniques, n(%)			0.672
Laparoscopic nephrectomy	29 (87.9)	31 (93.9)
Robot-assisted laparoscopic nephrectomy	4 (12.1)	2 (6.1)
Surgical approach, n(%)			0.622
Retroperitoneal	15 (45.5)	18 (54.5)
Transperitoneal	18 (54.5)	15 (45.5)
Open conversion, n(%)	1 (3.0)	3 (9.1)	0.613
Operative time/min, ${\bar x}$±s	159.0±57.8	148.0±70.8	0.281
Blood loss/mL, M (P₂₅, P₇₅)	50.0 (20, 100)	20.0 (20, 50)	0.372
Postoperative eGFR [mL/(min·1.73m²], M (P₂₅, P₇₅)	76.9 (55.4, 87.3)	61.7 (56.8, 73.5)	0.016
Complications, n(%)	6 (18.2)	8 (24.2)	0.763
PSM, n(%)	1 (3.3)	0 (0)	＞0.999
Postoperative hospital stays/d，${\bar x}$±s	6.1±2.4	5.9±2.1	0.818

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