肾癌并静脉癌栓的影像学诊断与手术方法选择

目的：探讨肾癌并静脉癌栓的影像学诊断与治疗及方法的选择。方法：回顾性分析我科收治的肾癌伴静脉癌栓患者21例的临床资料。结果：MRI精确地诊断出癌栓的范围；20例肾癌根治性切除加癌栓取出术的患者取得了满意的效果。结论：MRI可替代创伤性大、不良反应多的下腔静脉造影，用于确诊肾癌并静脉癌栓；应依据癌栓的类型选择手术方法。     

Suprarenal vena caval occlusion. Principles of operative management.

Retrohepatic occlusion of the inferior vena cava caused by tumor complicates complete resection and not infrequently is associated with life-threatening symptoms that accelerate the lethality of the underlying malignant process. This report summarizes our experience with caval thrombectomy and reconstruction that allowed complete removal of all gross tumor in seven patients with malignant occlusion of the retrohepatic inferior vena cava. Included in this group are five patients with renal cell carcinoma and extension of tumor into the retrohepatic vena cava. Three of these patients had extension of tumor thrombus into the right atrium. A sixth patient had recurrent right adrenal cortical carcinoma with tumor invasion of the vena cava and occlusion to the right atrium. Associated hepatic vein occlusion and secondary Budd-Chiari syndrome also was successfully managed in this patient. The final patient with occlusion of the entire suprarenal vena cava required caval reconstruction after resection of a primary leiomyosarcoma of the retrohepatic portion of the vena cava. Careful planning of the operative procedure, adequate exposure, complete mobilization of the retrohepatic vena cava, and control of the hepatic venous effluent will allow patients with retrohepatic vena caval occlusions to be managed with safety and success.     

Computerized tomographic demonstration of inferior vena caval tumor thrombus from renal angiomyolipoma

A case of renal angiomyolipoma with gross venous tumor thrombus extension into the inferior vena cava is presented. This fatty tumor thrombus is visualized easily by computerized tomography and is confirmed by inferior venacavography, surgery and histology. Macroscopic renal vein and vena caval tumor thrombi rarely occur in patients with angiomyolipoma and may be diagnosed preoperatively by the demonstration of abundant fat within the tumor components.     

肾细胞癌伴静脉癌栓15例临床分析

１９８５～１９９４年治疗肾细胞癌伴静脉癌栓１５例。按癌栓水平分为肾型１０例，肝下型４例，肝上型１例。Ｂ超和ＣＴ检查总确诊率７３％。手术１４例均完整取出癌栓，术后１３例接受５－ＦＵ加ＭＭＣ方案化疗。随访３个月～５年，１例肝下型和２例肾型无瘤存活分别３６、４３、５２个月，余均在术后２年内死亡。认为Ｂ超与ＣＴ互补应用可基本确诊静脉癌栓，除肝上型和已有血管壁浸润者外大部分癌栓可采用松解游离同时渐渐拉出的方式取出，癌栓水平除肝上型外对预后影响不大。     

16 肝细胞癌合并脉管系统癌栓的外科治疗

目的:探讨肝细胞癌（HCC）合并脉管系统癌栓的外科治疗效果。方法:回顾性分析1993年1月—2002年1月采用肝切除和癌栓取出术治疗HCC合并脉管系统癌栓68例的临床资料，其中门静脉癌栓63例，肝左静脉癌栓1例，肝中静脉癌栓合并门静脉左支癌栓1例，肝右静脉、下腔静脉合并门静脉右支癌栓1例，下腔静脉癌栓2例。HCC合并门静脉癌栓患者中6例术后行门静脉化疗。结果:6例术后3个月内死于肝肾功能衰竭， HCC合并脉管系统癌栓患者术后1，3，5年生存率分别为41.7%，20.8%，4.1%。结论:肝切除并癌栓取出术是HCC合并脉管系统癌栓有效的治疗方法，术后辅助治疗能提高治疗的效果。     

肾癌伴静脉癌栓外科治疗的疗效观察

目的探讨外科治疗肾癌伴静脉癌栓患者的预后。方法自1994年8月至2004年7月共33例患者行肾癌根治术及静脉癌栓取出术,其中男性26例、女性7例,中位年龄60岁(20~82岁)。肾静脉癌栓15例,下腔静脉癌栓Ⅰ级(肝下水平)9例、Ⅱ级(肝后水平)5例、Ⅲ级(肝上水平)1例、Ⅳ级(右心房水平)3例。采用Kaplan-Meier方法进行生存分析。结果29例患者得到随访,14例死亡,平均生存(16·4±2·9)个月(1~42个月),15例存活,平均随访(17·3±4·6)个月(3~67个月)。1例患者术后第2天死亡,3例失访。5年生存率为16%。肾静脉癌栓患者平均生存(49·9±9·8)个月,明显高于Ⅰ级下腔静脉癌栓患者的(16·7±1·9)个月(P<0·05)。结论肾癌根治性切除加癌栓取出术是治疗肾癌伴静脉癌栓的有效方法,肾静脉癌栓患者的预后好于腔静脉癌栓患者。     

腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓

目的探讨腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓的临床经验和文献分析。 方法女性患者,61岁,临床诊断：右肾癌合并高位肝后下腔静脉癌栓。术前全面评估手术风险,组织多学科会诊为患者制定详尽的围手术期治疗与护理方案,拟行腹腔镜下右侧肾癌根治性切除+高位肝后下腔静脉癌栓取出+腹膜后淋巴结清扫术。术后医护密切配合严密观察患者病情变化,进行围手术期观察处理与护理。 结果手术顺利完成,手术时间390 min,无中转开放手术。术中完全游离右侧和左侧肾静脉、肝后下腔静脉直达第二肝门水平远端,近右肾静脉处下腔静脉内侧壁剪开静脉壁,癌栓下部小灶性侵犯静脉壁,切除部分腔静脉壁完整取出癌栓,恢复左侧肾静脉、腔静脉血流回流无障碍。术后病理提示符合透明细胞癌,癌组织侵犯肾窦脂肪,腹膜后淋巴结（-）。术后随访6个月未见肿瘤复发。 结论腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓安全可行,多学科协助模式为疑难复杂病例提供了一种新的选择,值得临床进一步推广。     

Surgical Management of Renal Cell Carcinoma With Inferior Vena Cava Tumor Thrombus

Background. The optimal management of patients with renal cell carcinoma with inferior vena cava tumor thrombus remains unresolved. Traditional approaches have included resection with or without the use of cardiopulmonary bypass. Chemotherapy has played a minor role except for biotherapeutic agents used for metastatic disease.

Methods. From January 1989 to January 1996, 37 patients with renal cell carcinoma and inferior vena cava tumor thrombus underwent surgical resection. The 27 men and 10 women had a median age of 57 years (range, 29 to 78 years). Thirty-six patients presented with symptoms; 21 had hematuria. Distant metastases were present in 12 patients. Tumor thrombi extended to the infrahepatic inferior vena cava (n = 16), the intrahepatic inferior vena cava (n = 16), the suprahepatic inferior vena cava (n = 3), and into the right atrium (n = 2). All tumors were resected by inferior vena cava isolation and, when necessary, extended hepatic mobilization and Pringle maneuver, with primary or patch closure of the vena cavotomy. Cardiopulmonary bypass was necessary in only 2 patients with intraatrial thrombus.

Results. Complications occurred in 11 patients, and 1 patient died 2 days postoperatively of a myocardial infarction (mortality, 2.7%). Twenty patients are alive; overall 2- and 5-year survival rates were 61.7% and 33.6%, respectively. For patients without lymph node or distant metastases (stage IIIa), 2- and 5-year survival rates were 74% and 45%, respectively. The presence of distant metastatic disease (stage IV) at the time of operation did not have a significant adverse effect on survival, as reflected by 2- and 5-year survival rates of 62.5% and 31.3%, respectively. Lymph node metastases (stage IIIc) adversely affected survival as there were no long-term survivors.

Conclusions. Resection of an intracaval tumor thrombus arising from renal cell carcinoma can be performed safely and can result in prolonged survival even in the presence of metastatic disease. In our experience, extracorporeal circulatory support was required only when the tumor thrombus extended into the heart.     

Transesophageal echocardiography in the surgical management of renal cell carcinoma with intracardiac extension.

Renal cell carcinomas may extend into the vena cava and the tumor thrombus occasionally involves the right atrium. The operative approach depends upon precise preoperative and intraoperative staging and thrombus localization. We report a case of renal cell carcinoma with complete inferior vena caval and hepatic vein occlusion with tumor extension into the right atrium. Preoperatively, transesophageal echocardiography provided superior images of the tumor and its extension, and intraoperatively allowed continuous monitoring of cardiac function and the removal of tumor from the atrium and inferior vena cava. Its use obviated the need for more costly and invasive preoperative and intraoperative procedures.     

Investigation of 14 renal cell carcinoma cases with tumor thrombus in the inferior vena cava

Renal cell carcinoma tends to progress into the renal vein and inferior vena cava. We investigated 14 cases of renal cell carcinoma with tumor thrombus in the inferior vena cava. Surgery was performed in nine cases and mean survival was 53 months. Two cases are alive 8 years after the operation without recurrence or metastasis. The mean survival of 5 cases without operation was 7 months. Surgical management should be considered as a benefit for RCC patients with tumor thrombus in the inferior vena cava.     

Extensive operations in kidney cancer complicated by tumor thrombus invasion of the inferior vena cava]

Invasion of renal tumor into retroperitoneal major vessels with thrombosis should be characterized as local spread of renal carcinoma and a serious complication. Extensive interventions were conducted in 30 subjects out of 196 nephrectomy cases. Nephrectomy was attended by colectomy (3 cases), pancreatic resection and adrenalectomy (3 cases), resection of the liver (2 cases), one-stage lobectomy (2 cases), adrenalectomy (9 cases), resection of the uterine appendages (1 case), resection of the colon, splenectomy, opening of an intraorganic abscess. 12 patients underwent thrombectomy from the major vein via the thoracophrenoabdominal approach. Cavathrombectomy was carried out in 7 (3.6%) patients, in 3 of which vena cava inferior was resected. Removal of the thrombus from the renal vein with resection of the opening and suturing of the vena cava inferior was performed in 5 patients. The thrombus originated from the right kidney in 9, while from the left one in 3 patients treated surgically. The thrombi occupied 4-10 cm along the renal vein from its opening. The removed kidney weighted from 400 to 3200 g. One death occurred due to pulmonary embolism during the operation, one on day 5 due to cardiopulmonary insufficiency. Histological examinations of the thrombi showed them to consist of fibrin, blood elements and tumor cells within the thrombus. The thrombi grow slowly, undergo organization and vascularization. Tumor cells multiply in the thrombus. Fibrin coating restricts cancer cell free dissemination via the venous system. Cavathrombectomy is considered the only way to prolong survival for the above patients.     

Results of inferior vena caval interruption by greenfield filter, ligation or resection during radical nephrectomy and tumor thrombectomy

PURPOSE: Surgical resection for patients with renal cell carcinoma and venous tumor thrombus may require interruption of the inferior vena cava using a Greenfield filter, ligation or resection. We describe the indications, technique, complications and outcomes of vena caval interruption during nephrectomy with tumor thrombectomy. MATERIALS AND METHODS: We identified 160 patients treated for level II-IV tumor thrombus at our institution between 1970 and 2004. Operative reports were reviewed to establish vena caval interruption. All patients who underwent interruption were assessed for postoperative disability according to the American Venous Forum International Consensus Committee. RESULTS: Vena caval interruption was performed in 40 of 160 cases (25%), including 14 level II, 10 level III and 16 level IV thrombi. A total of 34 patients (85%) were symptomatic at presentation. A Greenfield filter was deployed before cavotomy closure in 4 of 160 patients (2.5%) for bland thrombus of the infrarenal vena cava. Vena caval ligation was used for bland thrombus that completely occluded the infrarenal vena cava in 23 of 160 patients (14.4%), while segmental vena caval resection was performed for tumor thrombus growing into the wall of the vena cava or for tumor thrombus that interfaced with bland thrombus in 13 of 160 (8.1%). Postoperatively no case was class 3 disability, 12 of 40 (30%) were class 2, 12 of 40 (30%) were class 1 and 16 of 40 (40%) showed no disability. CONCLUSIONS: The need to interrupt the inferior vena cava is not infrequent in patients undergoing radical nephrectomy and tumor thrombectomy, and it may be well tolerated postoperatively. Management should be based on the degree of venous occlusion and the presence of bland thrombus.     

Hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with inferior vena caval thrombus

PURPOSE: To our knowledge we present the initial clinical report of hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with tumor thrombus extending into the inferior vena cava. MATERIALS AND METHODS: A 76-year-old man was referred to our medical center with a 12.5 x 10 cm. stage T3b right renal tumor extending into the inferior vena cava. The caval thrombus was limited and completely below the level of the hepatic veins. After preoperative renal embolization via the hand assisted transperitoneal approach the right kidney was completely dissected with the renal hilum. Proximal and distal control of the inferior vena cava was obtained with vessel loops and a single lumbar vein was divided between clips. An endoscopic Satinsky vascular clamp was placed on the inferior vena cava just beyond its juncture with the right renal vein, thereby, encompassing the caval thrombus. The inferior vena cava was opened above the Satinsky clamp and a cuff of the inferior vena cava was removed contiguous with the renal vein. The inferior vena cava was repaired with continuous 4-zero vascular polypropylene suture and the Satinsky clamp was then removed. A literature search failed to reveal any similar reports of laparoscopic radical nephrectomy for stage T3b renal cell cancer. RESULTS: Surgery was completed without complication with an estimated 500 cc blood loss. Pathological testing confirmed stage T3b grade 3 renal adenocarcinoma with negative inferior vena caval and soft tissue margins. CONCLUSIONS: The introduction of vascular laparoscopic instrumentation and the hand assisted approach enabled us to extend the indications for laparoscopic radical nephrectomy to patients with minimal inferior venal caval involvement.     

Renal pelvic cancer with tumor thrombus in the vena cava inferior: a case report

We report a case of right renal pelvic cancer with tumor thrombus in the inferior vena cava. A 65-year-old man with right flank abdominal pain and high fever was reffered to our hospital. Computed tomography showed right renal mass. Magnetic resonance imaging revealed tumor thrombus extending into the renal vein and the inferior vena cava. Preoperative diagnosis was renal cell carcinoma with vena caval thrombus. Radical nephrectomy with thrombectomy and lymphodenectomy was performed. Pathologic evaluation revealed transitional cell carcinoma with tumor thrombus into the vena cava. One course of M-VAC chemotherapy was added and he has been alive for 56 months without recurrence. A literature review of 15 cases of renal pelvic cancer with tumor thrombus in the vena cava in Japan revealed that 7 cases were diagnosed as renal cell carcinoma preoperatively.     

肾癌合并下腔静脉癌栓的多学科联合治疗

目的 探讨肾癌合并下腔静脉癌栓多学科联合治疗的临床意义.方法 经B超和CT检查诊断为右肾癌合并下腔静脉癌栓的患者2例,下腔静脉癌栓Ⅱ级和Ⅳ级各1例.全麻下取腹部人字形切口.泌尿外科行右肾切除;肝胆外科游离腔静脉至第二肝门,于癌栓上下阻断腔静脉和周围分支静脉;血管外科切开腔静脉完整取出癌栓,缝合腔静脉.例2患者腔静脉癌栓距右心房2-3cm,肿瘤侵及腔静脉血管壁及血管内膜,术中建立左股静脉-右心房转流,心肺转流241 min,阻断主动脉18 min,行自体血液回输、腔静脉置换及第二肝门肝静脉-人工血管吻合.分析手术适应证、手术时间、术中出血量、术后住院时间等.结果 2例均成功行根治性右肾切除术,完整取出癌栓.2例分别于术后15、27 d出院.分别随访1、16个月,未发现肿瘤局部复发及远处转移.结论 对于没有淋巴结侵犯和远处转移的肾癌合并下腔静脉癌栓患者,应积极行根治性肾切除术及癌栓取出术,多学科联合协作可缩短手术时间、降低手术风险、减少肿瘤复发、提高患者生存率.

Abstract：

Objective To evaluate the surgical treatment for renal cell carcinoma with inferior vena cava tumor thrombus and the clinical significance of multidisciplinary treatment. Methods Two cases of renal cell carcinoma with inferior vena cava thrombus diagnosed by Doppler ultrasonography and CT were included in this retrospective analysis. The tumor thrombus was in level Ⅱ in one case and in level Ⅳ in the other. Coagulation test and complete blood count were done again before surgery. Human albumin, fibrinogen, prothrombin complex, plasma, platelet, UW and irrigating solution were prepared before the operation.Under general anesthesia, surgery was performed using abdomen inverted Y shaped incision. Right radical nephrectomy was finished by the urological surgeon; the vena cava was completely dissected from the renal vein level to the secondary porta of the liver by the hepatobiliary surgeon, the vena cava and the surrounding branch vein were blocked in the upper and lower vena cava tumor thrombus; tumor thrombus was removed completely by the vascular surgeon. In one case (patient with level Ⅳ thrombus ) where the tumour thrombus invaded the wall of the vena cava, the thrombus was found to be extending to the cavo-atrial junction but not into the right atrium. The left femoral venous-right atrial bypass was established, the cardiopulmonary bypass lasted for 241 mia, and the aorta was blocked for 18 min. Salvage autotransfusion was used during surgery, and the hepatic vein of the secondary liver porta was anastomosed to artificial vascular graft.The data for surgical indication, operation time, operative blood loss and postoperative hospital stay were analyzed. Results Right radical nephrectomy and inferior vena cava thrombectomy were performed successfully, and the two patients were discharged on the 15th and 27th day after surgery, respectively. The two patients were followed up for 1 and 16 months after surgery, respectively, and both survived without local recurrence and distant metastasis. Conclusion Radical nephrectomy and inferior vena cava thrombectomy is the preferred method for patients without metastasis, and multidisciplinary cooperation could shorten the operation time, reduce the tumor recurrence and increase the survival rate of patients.     

Laparoscopic radical nephrectomy with level II vena caval thrombectomy: survival porcine study

PURPOSE: Inferior vena caval tumor thrombus due to renal cell carcinoma generally precludes laparoscopic techniques for radical nephrectomy. We developed the technique of laparoscopic infrahepatic (level II) inferior vena caval thrombectomy in a survival porcine model. MATERIALS AND METHODS: Of the 7 female pigs used in the study 2 were acute and 5 were chronic animals which were allowed to survive for 6 weeks postoperatively. Laparoscopic right radical nephrectomy and inferior vena caval thrombectomy were performed in accordance with established open surgical principles, including vascular control and intracorporeal reconstruction of the vena cava and left renal vein. RESULTS: Complete removal of the simulated caval thrombus was successful in each case without intraoperative or postoperative complications. Average operative time was 160 minutes. Postoperatively inferior venacavography showed a patent vena cava and left renal vein in all animals. CONCLUSIONS: Laparoscopic radical nephrectomy was successful in an animal model simulating renal cell carcinoma with infrahepatic vena caval tumor thrombus. Clinical application of this technique appears possible.     

Diagnostic and therapeutic approach to the extension of kidney cancer to the vena cava

In the light of their experience with 16 cases seen over 5 years, the authors analyze the diagnostic and therapeutic tools for assessment of the vena cava thrombi that complicate 5 to 10% of renal carcinomas. Cavography still plays a central part in the detection of vena cava lesions. Localization of the upper extremity of the thrombus is needed to decide upon the operative technique and can be achieved by free flow inferior cavography for free floating thrombi; for complete thrombi, the two most informative procedures appear to be echocardiography (to evaluate the right atrium and intrathoracic inferior vena cava) and inferior cavography by the superior route; it seems that computed tomography provides no additional information in the assessment of extensive spread to the inferior vena cava. 14 patients were treated surgically: the surgical approach is dictated by the location of the thrombus and should allow control of the vena cava proximal to the thrombi. Two patients with a thrombus that extended into the right atrium had surgery using extracorporeal circulation; because this method is especially safe, extension of its indications to retrohepatic thrombi may be justified. The absence of operative mortality and comparison of results to those previously reported in the literature confirm the value of surgical treatment of vena cava lesions, especially if there is no lymph node involvement.     

腹腔镜治疗肾错构瘤并肾静脉及下腔静脉瘤栓1例并文献复习

目的：探讨全腹腔镜治疗肾错构瘤并肾静脉及下腔静脉瘤栓的可行性分析。方法：回顾性分析1例腹腔镜治疗肾错构瘤并肾静脉及下腔静脉瘤栓患者的临床资料。患者,女,26岁,体检时发现右肾占位,B超示右肾窦内可见5．1cm×2．7cm高回声占位,边界欠规则,内见血流。CT示右肾盂旁可见一不规则团块状混杂密度影,大小为4．5cm×2．9cm×1．9cm,可见脂肪成分,最低密度-40HU;病变软组织部分明显强化,增强前后CT值分别为31HU和97HU,病变主要位于肾窦,部分延伸至肾静脉及腔静脉内。检索Pubmed和CBM数据库相关文献进行复习。结果：患者在全麻下行腹腔镜右肾切除及肾静脉、下腔静脉取栓术,瘤栓进入下腔静脉0．6cm。病理诊断右肾错构瘤。术后随访6个月无肿瘤复发和转移。结论：肾错构瘤并。肾静脉及下腔静脉瘤栓临床罕见,对选择性病例行腹腔镜肾切除并行肾静脉及下腔静脉取栓术安全可行。     

The detection of renal carcinoma extension into the renal vein and inferior vena cava: a prospective comparison of venacavography and magnetic resonance imaging

Accurate preoperative evaluation of the inferior vena cava and renal vein in patients with renal cell carcinoma is mandatory to plan a successful surgical approach. The presence of venous extension may alter transfusion and anesthetic requirements, as well as require the addition of a vascular surgeon to the operative team. Venacavography traditionally has been considered the most reliable method to identify tumor thrombus, although magnetic resonance imaging has been proposed as a possible noninvasive alternative. We compared prospectively the accuracy of these 2 methods in 44 consecutive patients with renal cell carcinoma who subsequently underwent nephrectomy. Of the 44 patients 11 (25%) had tumor extension into the inferior vena cava and 17 (39%) had involvement of the renal vein at operation. Venacavography and magnetic resonance imaging correctly identified 9 of the 11 patients (82%) with inferior vena caval thrombus. When the results of both tests were combined, all 11 cases of vena caval extension were identified. Venacavography was slightly more sensitive (71%) in identifying the presence of renal vein thrombus than magnetic resonance imaging (65%) but these differences were not statistically significant. Magnetic resonance imaging better localized the thrombus within the renal vein. We conclude that venacavography and magnetic resonance imaging offer equal diagnostic accuracy in the identification of venous extension of renal cell carcinoma. The combination of both tests results in higher diagnostic yield than either test alone. Neither test by itself is reliable in the presence of a large, bulky adenopathic lesion that compresses the inferior vena cava.     

腹腔镜下根治性肾切除并肾静脉及腔静脉取栓术

目的 探讨腹腔镜下根治性肾切除并肾静脉及腔静脉取栓术的可行性. 方法 右肾占位病变患者2例.增强CT显示1例肿物部分延伸至肾静脉及腔静脉内,1例右肾静脉内可见充盈缺损并突入腔静脉内.均在全麻下行经后腹腔镜下根治性右肾切除及肾静脉、腔静脉取栓术.术中放置4个穿刺套管针,切断肾动脉后游离腔静脉及肾静脉,腔镜血管阻断钳部分阻断腔静脉,切开腔静脉取出瘤栓,缝合腔静脉,完整切除肾脏及瘤栓. 结果 2例患者的腔静脉瘤栓长度分别为0.3和1.0 cm,均安全取出,术后恢复良好,5 d出院.病理诊断分别为上皮样肾血管平滑肌脂肪瘤和肾透明细胞癌1～2级.术后随访5个月未见肿瘤复发和转移. 结论 对选择性肾肿瘤并肾静脉及腔静脉瘤栓患者行腹腔镜下根治性肾切除并肾静脉及腔静脉取栓术安全可行.