5年以上长期生存肾透明细胞癌伴静脉瘤栓患者的临床病理特征及预后因素

doi:10.19723/j.issn.1671-167X.2026.04.003

摘要/Abstract

摘要：

目的: 分析接受手术治疗的肾透明细胞癌(clear cell renal cell carcinoma，ccRCC)伴静脉瘤栓(venous tumor thrombus，VTT)长期生存患者的临床病理特征，并探究除肿瘤生物学特征外的潜在影响因素，特别关注个体炎症及营养指标。方法: 回顾性分析2014—2019年于北京大学第三医院接受根治性肾切除术联合瘤栓取出术的ccRCC伴VTT患者，将患者分为长期生存组(总生存期≥60个月)和非长期生存组(总生存期 < 60个月)，比较两组患者的临床特征(年龄、性别、体重指数、Mayo分级)、病理特征(T分期、M分期、组织学分级、肉瘤样变、肾周脂肪侵犯)、围术期指标(手术方式、手术时间、术中失血量、并发症)及实验室指标(血小板计数、白蛋白水平、中性粒细胞计数等)的差异。年龄、体重指数、血小板计数、白蛋白水平的最佳截断值采用X-tile软件基于最小P值原则确定。在长期生存组内进一步采用Kaplan-Meier生存分析及Log-rank检验，评估上述指标与远期生存的相关性。结果: 397例ccRCC伴VTT患者中有13.9%实现了长期生存。长期生存组(n=55)和非长期生存组(n=342)在基线血小板计数(P=0.040)、病理T分期(P=0.001)、组织学分级(P=0.006)、手术方式(P < 0.001)，以及是否接受系统治疗(P=0.028)和治疗时机(P=0.003)、治疗方案(P < 0.001)方面差异均有统计学意义。在T分期方面，长期生存组中pT3a期肿瘤的比例显著高于非长期生存组(63.6% vs. 42.4%)，而pT4期肿瘤的比例显著低于非长期生存组(10.9% vs. 33.0%)。长期生存组中低级别肿瘤(G1/G2)的比例也更高(50.9% vs. 31.9%)。在手术方式方面，长期生存组以腹腔镜手术为主(35/55，63.6%)，而非长期生存组的手术方式分布更为均衡，包括开放手术102例(29.8%)、腹腔镜手术123例(36.0%)和机器人手术117例(34.2%)。在系统治疗方面，长期生存组有26例(47.3%)患者接受了系统治疗，且全部为术后辅助治疗(100.0%)，而非长期生存组有215例(62.9%)患者接受了系统治疗，其中160例(74.4%)接受了术后辅助治疗，55例(25.6%)为术前新辅助治疗；长期生存组以靶向单药治疗为主(25/26，96.2%)，而非长期生存组中靶向治疗联合免疫治疗的比例更高(64/215，29.8%)。长期生存组的中位随访时间为81.7个月，对该组的进一步亚组分析表明，年龄 < 70岁(P=0.038)、体重指数≥18.5 kg/m² (P=0.032)、血小板计数159×10⁹/L~273×10⁹/L(P=0.003)及白蛋白>41.4 g/L(P=0.028)与更好的远期生存显著相关，而瘤栓Mayo分级与远期生存无显著相关性(P=0.250)。结论: ccRCC伴VTT患者中存在一定比例长期生存者。除肿瘤病理分期和分级外，个体炎症及营养状态可能是影响其长期生存的相关因素，探索与长期生存相关的预后因素有助于进一步优化高危患者风险分层及治疗策略。

关键词: 癌, 肾细胞, 肿瘤浸润, 静脉血栓形成, 预后, 癌症幸存者

Abstract:

Objective: To characterize the clinicopathological features of long-term survivors among patients with clear cell renal cell carcinoma (ccRCC) and venous tumor thrombus (VTT) who underwent surgical treatment, and to explore potential prognostic factors beyond tumor-related variables, with particular emphasis on host-related inflammatory and nutritional indicators. Methods: The patients with ccRCC and VTT who underwent radical nephrectomy combined with tumor thrombectomy at Peking University Third Hospital between 2014 and 2019 were retrospectively analyzed. The patients were stratified into a long-term survival group (overall survival ≥60 months) and a non-long-term survival group (overall survival < 60 months). The following parameters were compared between the two groups: clinical characteristics (age, sex, body mass index, Mayo classification), pathological features (T stage, M stage, histological grade, sarcomatoid change, perirenal fat invasion), perioperative parameters (surgical approach, operative time, intraoperative blood loss, complications), and laboratory parameters (platelet count, albumin, neutrophil count, etc.). Optimal cutoff values for continuous variables, such as age, body mass index (BMI), platelet count and serum albumin level, were determined using X-tile software based on the minimum P-value principle. Subsequently, Kaplan-Meier survival analysis with Log-rank test was performed within the long-term survival cohort to evaluate the association of the above-mentioned factors with long-term survival. Results: Long-term survival was achieved in 13.9% of 397 patients with ccRCC and VTT. Significant differences were observed between the long-term survival group (n=55) and the non-long-term survival group (n=342) in baseline platelet count (P=0.040), pathological T stage (P=0.001), histological grade (P=0.006), surgical approach (P < 0.001), as well as receipt of systemic therapy (P=0.028), treatment timing (P=0.003), and treatment regimen (P < 0.001). Regarding T stage, the long-term survival group had a significantly higher proportion of pT3a tumors (63.6% vs. 42.4%) and a significantly lower proportion of pT4 tumors (10.9% vs. 33.0%) compared with the non-long-term survival group. The long-term survival group also had a higher proportion of low-grade tumors (G1/G2: 50.9% vs. 31.9%). Regarding surgical approach, laparoscopic surgery predominated in the long-term survival group (35/55, 63.6%), whereas the non-long-term survival group had a more balanced distribution, including open surgery (102/342, 29.8%), laparoscopic surgery (123/342, 36.0%), and robotic surgery (117/342, 34.2%). Regarding systemic therapy, in the long-term survival group, 26 patients (47.3%) received systemic therapy, all of whom (100.0%) received adjuvant therapy. In the non-long-term survival group, 215 patients (62.9%) received systemic therapy, of whom 160 (74.4%) received adjuvant therapy and 55 (25.6%) received neoadjuvant therapy. Regarding treatment regimen, the long-term survival group was predominantly treated with targeted monotherapy (25/26, 96.2%), whereas the non-long-term survival group had a higher proportion of targeted therapy plus immunotherapy combination (64/215, 29.8%). The median follow-up time for the long-term survival group was 81.7 months. Further subgroup analysis of this group showed that age < 70 years (P=0.038), BMI≥18.5 kg/m² (P=0.032), platelet count 159×10⁹/L-273×10⁹/L (P=0.003), and albumin level >41.4 g/L (P=0.028) were significantly associated with better long-term survival, whereas Mayo classification of tumor thrombus showed no significant association with long-term survival (P=0.250). Conclusion: A subset of patients with ccRCC and VTT can achieve long-term survival. Beyond pathological tumor stage and grade, patient-related inflammatory and nutritional status may be associated with long-term survival. Exploring prognostic factors related to long-term survival may help further optimize risk stratification and treatment strategies for high-risk patients.

Key words: Carcinoma, renal cell, Neoplasm invasiveness, Venous thrombosis, Prognosis, Cancer survivors

中图分类号:

R737.11

杜志明, 张纬亮, 赵磊, 邱敏, 马潞林, 颜野, 贺慧颖, 谢睿扬, 张树栋. 5年以上长期生存肾透明细胞癌伴静脉瘤栓患者的临床病理特征及预后因素[J]. 北京大学学报（医学版）, 2026, 58(4): 692-699.

Zhiming DU, Weiliang ZHANG, Lei ZHAO, Min QIU, Lulin MA, Ye YAN, Huiying HE, Ruiyang XIE, Shudong ZHANG. Clinicopathological features and prognostic factors associated with long-term survival (≥5 years) in patients with clear cell renal cell carcinoma and venous tumor thrombus[J]. Journal of Peking University (Health Sciences), 2026, 58(4): 692-699.

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参考文献 24

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Items	OS≥60 months (n=55)	OS < 60 months (n=342)	P value
Age/years, M (P₂₅, P₇₅)	59 (54, 65)	61 (55, 68)	0.290
Sex, n(%)			0.400
Male	43 (78.2)	249 (72.8)
Female	12 (21.8)	93 (27.2)
BMI/(kg/m²), M (P₂₅, P₇₅)	23 (21, 27)	24 (22, 27)	0.230
Surgical approach, n(%)			< 0.001
Open surgery	20 (36.4)	102 (29.8)
Laparoscopic surgery	35 (63.6)	123 (36.0)
Robotic surgery	0 (0)	117 (34.2)
Systemic therapy, n(%)			0.028
Yes	26 (47.3)	215 (62.9)
No	29 (52.7)	127 (37.1)
M stage at diagnosis, n(%)			0.060
M0	45 (81.8)	238 (69.6)
M1	10 (18.2)	104 (30.4)
Mayo classification, n(%)			0.370
0	15 (27.3)	90 (26.3)
Ⅰ	15 (27.3)	51 (14.9)
Ⅱ	17 (30.8)	152 (44.4)
Ⅲ	4 (7.3)	24 (7.0)
Ⅳ	4 (7.3)	25 (7.3)
Intraoperative blood loss/mL, M (P₂₅, P₇₅)	400 (120, 1 300)	500 (200, 1 200)	0.660
Operative time/min, M (P₂₅, P₇₅)	251 (187, 363)	266 (195, 366)	0.800
Perioperative complications, n(%)			0.180
Yes	13 (23.6)	110 (32.2)
No	42 (76.4)	232 (67.8)
Clavien-Dindo grade of complications, n(%)			0.890
0	42 (76.4)	232 (67.8)
Ⅰ	3 (5.5)	22 (6.4)
Ⅱ	9 (16.4)	74 (21.6)
Ⅲ	0 (0)	4 (1.2)
Ⅳ	1 (1.8)	8 (2.3)
Ⅴ	0 (0)	2 (0.6)
Laboratory parameters, M (P₂₅, P₇₅)
Preoperative serum creatinine/(μmol/L)	76 (88, 110)	91 (76, 107)	0.820
Serum creatinine at 1 week postoperatively/(μmol/L)	86 (106, 117)	100 (83, 121)	0.760
Baseline hemoglobin/(g/L)	115 (127, 142)	124 (106, 140)	0.150
Baseline platelet count/(×10⁹/L)	172 (203, 259)	240 (186, 309)	0.040
Baseline neutrophil count/(×10⁹/L)	4.4 (3.3, 5.2)	4.5 (3.4, 5.5)	0.430
Baseline albumin/(g/L)	40 (35, 43)	40 (36, 43)	0.680

Items	OS≥60 months (n=55)	OS < 60 months (n=342)	P value
Side, n(%)			0.440
Left	17 (30.9)	124 (36.3)
Right	38 (69.1)	218 (63.7)
pT stage, n(%)			0.001
pT3a	35 (63.6)	145 (42.4)
pT3b	11 (20.0)	44 (12.9)
pT3c	3 (5.5)	40 (11.7)
pT4	6 (10.9)	113 (33.0)
pN stage, n(%)			0.070
pN0	55 (100.0)	323 (94.4)
pN1	0 (0)	19 (5.6)
Histopathological grade, n(%)			0.006
G1/G2	28 (50.9)	109 (31.9)
G3/G4	27 (49.1)	233 (68.1)
Median tumor diameter/cm, M (P₂₅, P₇₅)	8.3 (6.4, 10.0)	8.4 (6.3, 10.3)	0.810
Sarcomatoid change, n(%)			0.810
Yes	8 (14.5)	54 (15.8)
No	47 (85.5)	288 (84.2)
Perinephric fat invasion, n(%)			0.190
Yes	12 (21.8)	104 (30.4)
No	43 (78.2)	238 (69.6)

Items	Receiving systemic therapy (n=241)		P value
Items	OS≥60 months (n=26)	OS < 60 months (n=215)	P value
Treatment timing, n(%)			0.003
Adjuvant systemic therapy	26 (100.0)	160 (74.4)
Neoadjuvant systemic therapy	0 (0)	55 (25.6)
Treatment regimen, n(%)			< 0.001
Targeted therapy (TKI monotherapy)	25 (96.2)	150 (69.8)
Immunotherapy (PD-1/PD-L1 monotherapy)	0 (0)	1 (0.4)
Targeted therapy plus immunotherapy combination	1 (3.8)	64 (29.8)

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