肾癌腔静脉转移的治疗方式及预后分析

[目的]探讨肾癌合并静脉癌栓转移患者的治疗及预后情况.[方法]48例肾癌合并静脉癌栓转移患者,其中37例行根治性肾癌切除和癌栓切除术,11例（22.9%）有远处转移.用Kaplan-Meier 法计算肿瘤生存率.log rank 法分析各组生存率的差别.Cox回归模型分析影响肿瘤预后的因素.[结果]肾癌患者总的5年生存率为40.7%.癌栓水平：位于肾静脉6例（12.5%）,膈以下腔静脉29例（60.5%）,侵犯至膈以上腔静脉13例（27%）.各静脉癌栓水平患者的5年生存率无明显差异.无远处转移的5年生存率为56%,有远处转移的5年生存率为8%（P〈0.01）,二者有显著性差异.在无远处转移的癌栓患者中,行肾癌根治术及癌栓取出术者5年生存率为68.3%,未进行手术者5年生存率为18%（P〈0.01）,二者有显著性差异.[结论]远处转移是影响肾癌合并腔静脉转移患者预后的重要因素,癌栓水平对肾癌患者的预后无明显影响,无远处转移者仍应考虑行手术治疗.     

恶性肿瘤患者下腔静脉滤器的应用研究

目的研究下腔静脉滤器在恶性肿瘤患者中的应用,探讨其在预防肺栓塞发生中的作用。方法回顾性分析1998年至2004年,经病理学或细胞学确诊为恶性肿瘤,并于治疗前存在血栓栓塞性疾病的37例患者,安放下腔静脉滤器后肺栓塞的发生情况。结果下腔静脉滤器全部安全置入下腔静脉内,随访1～36个月,滤器无移位,无肺栓塞发生。结论对恶性肿瘤合并血栓栓塞性疾病的患者放置下腔静脉滤器,能安全有效地预防肺栓塞的发生。     

Sonography and Transthoracic Echocardiography for Diagnosis of Systemic Cardiovascular Metastatic Tumor Thrombi

Sonography and transthoracic echocardiography (TTE) are seldom used for assessment of metastatic tumor thrombi in the cardiovascular system in routine clinical practice. We performed this retrospective study to evaluate the combination of sonography with TTE for diagnosis of metastatic tumor thrombi in heart and systemic vessels. Vascular, abdominal, pelvic, and small‐part sonography was applied in 18 patients, and TTE was conducted simultaneously in 14 patients. Tumor thrombi invaded into the inferior vena cava system in 12 patients, superior vena cava system in 5 patients, and aorta in 1 patient; they extended to the right cardiac chambers in 11 patients. Six patients had diagnoses by pathologic examination. The primary neoplasms were identified by conventional imaging in 17 patients. The morphologic and echogenic characteristics of the tumor thrombi were diverse and depended on their original tumors. The thrombi were either contiguous or discrete from the original tumors. The neoplastic vascularity of the thrombi and the invasive extension were the primary characteristics that distinguished them from bland thrombi. Simultaneous application of sonography and TTE is a feasible way to comprehensively evaluate cardiovascular metastatic tumor thrombi in most patients.     

激光切割镍钛合金大支架植入治疗癌栓所致下腔静脉狭窄的疗效

目的:探讨对下腔静脉癌栓导致下腔静脉狭窄的患者行激光切割镍钛合金大支架植入治疗的疗效。方法:对20例例下腔静脉癌栓导致下腔静脉狭窄的患者进行激光切割镍钛合金大支架植入治疗,其中17例患者同时接受常规剂量的经导管动脉化疗栓塞术(transcatheter arterial chemoembolization,TACE)治疗。对所有患者进行数字减影血管造影(digital subtractionangiography,DSA)检查以观察支架情况,并观察所有患者术前、术后肝功能改变。术后对患者进行随访,观察支架通畅情况及患者生存期。结果:在植入1枚镍钛合金大支架后,所有患者的下腔静脉狭窄均得到缓解。随访19例患者,中位生存期为8.71个月,3、6、12个月生存率分别为89.5%、60%、23.1%;患者术后1个月肝功能与术前肝功能相比无显著差异;所有患者支架均通畅。结论:对下腔静脉癌栓导致下腔静脉狭窄的患者进行激光切割镍钛合金大支架植入治疗后,狭窄开通率高,并且且不会造成支架相关的肝静脉堵塞、急性肝功能衰竭等并发症。     

介入治疗急性下肢深静脉血栓的疗效观察

【目的】探讨介入治疗急性下肢深静脉血栓的临床疗效。【方法】选择急性下肢深静脉血栓患者168例,经股静脉或经右颈内静脉置入腔静脉滤器后,均行静脉置管溶栓治疗,溶栓治疗结束前复查肺动脉造影及下肢静脉造影,术后6个月复查血管超声。【结果】置入腔静脉滤器168枚均一次性释放成功,释放过程平均耗时1．9min。168例患者溶栓成功率100％,平均溶栓时间9．68d;98．8％（166／168）。患者肢体肿胀、疼痛症状消失或减轻;血栓直径消融75％～100％91例;血栓直径消融50％～75％47例;血栓直径消融小于50％30例,随访期间下肢静脉血栓直径与溶栓治疗结束时相比无增大。【结论】下腔静脉滤器置入术及下肢深静脉置管溶栓术治疗急性下肢深静脉血栓形成具有介入操作技术成功率较高、症状改善明显、血栓消融程度高、损伤小、安全性好的优点。     

磁共振血管成像评价肝移植术后血管形态：11例分析

背景:多数学者认为超声发现血栓形成和血管狭窄的灵敏度比较高,但对血管吻合口的直接显示较困难,磁共振血管造影对血管解剖的显示及并发症的诊断优于多普勒超声。目的:观察磁共振血管造影对肝移植术后血管形态的显示及其对并发症的评估。设计:观察对比实验。单位:南方医科大学附属南方医院影像中心。对象:选择2004-01/2006-12于南方医科大学附属南方医院影像中心收治的11例男性原位肝移植术后患者。年龄40～58岁,平均49岁。术前临床诊断为原发性肝癌2例,重症肝硬化9例,均经病理组织学检测证实,其中9例行原位经典式肝移植,2例行背驮式原位肝移植术。所有患者均对检测项目知情同意。方法:对11例原位肝移植术后患者均用磁共振快速自选回波序列及快速小角度激发梯度回波序列常规扫描、钆喷替酸葡甲胺动态增强3D磁共振血管造影检查,在MRA成像后,迅速采用与平扫FLASH T1WI抑脂序列完全相同参数行轴面和冠状面扫描。根据ECST法计算血管直径狭窄率S(S=[(D-d)/D]×100%),d为最狭窄处内径,D为该处正常管径。判断狭窄的程度:直径狭窄率S在0～30%为正常范围;31%～50%为轻度狭窄;51%～85%为中度狭窄;86%～100%为重度狭窄。分析各序列图像特点。同时行多普勒超声检查。主要观察指标:①磁共振血管造影观察肝移植术后血管形态及对并发症的评估结果。②多普勒超声检查结果。结果:纳入患者11例全部进入结果分析。①磁共振血管造影:显示3例肝动脉、门静脉和下腔静脉吻合口通畅,其中1例供体门静脉管径略小于受体门静脉,1例肝移植术后早期MRT2WI图像见到门静脉周围高信号,持续3周后消失。其余8例中,2例肝动脉过长迂曲,2例肝动脉供体端瘤样轻度扩张,2例门静脉轻度狭窄,位于吻合口,且门静脉供体段与受体段的管径不相等,门静脉肝内分支均正常,2例肝静脉末梢分支杵状扩张,而其下腔静脉未见异常。1例下腔静脉血栓,磁共振血管造影表现为高信号血管腔内椭圆形低无信号区。2例肝静脉末梢分支杵状扩张患者半年后肝静脉末梢分支扩张程度降低,但仍有轻度扩张,下腔静脉血栓治疗1月后复查血栓消失。②多普勒超声检测:1例肝动脉过长迂曲合并肝动脉供体端瘤样轻度扩张诊断为肝动脉过长迂曲,例门静脉轻度狭窄1例诊断为正常,1例诊断为可疑狭窄。未发现肝静脉末梢分支杵状扩张。其余诊断与磁共振血管造影相符。结论:磁共振血管造影可清楚显示肝移植术后血管解剖并准确、快速诊断肝移植术后出现的血管并发症。     

多排螺旋CT多期增强扫描对肾癌肾静脉瘤栓的诊断价值

目的 评价多排螺旋CT多期增强扫描在肾癌肾静脉瘤栓诊断中的价值.方法 22例经手术病理证实的肾癌患者,均于术前行多排螺旋CT增强扫描,观察肾静脉内和下腔静脉内有无瘤栓及瘤栓的范围,并与手术结果进行对照.评价CT对肾静脉和下腔静脉的显示情况.结果 22例患者,均为单侧肾癌.手术病理共发现22处肾静脉瘤栓和8例下腔静脉内瘤栓.CT对肾癌瘤栓的检出率为100%.CT诊断22支肾静脉内有瘤栓,8支下腔静脉内有瘤栓.结论 多排螺旋CT增强扫描对肾癌瘤栓的诊断具有较高的临床价值.     

彩色多普勒超声对肾癌并下腔静脉癌栓完全梗阻的临床应用价值

目的 探讨彩色多普勒超声在右肾癌合并下腔静脉癌栓完全梗阻诊断及治疗中的应用价值.方法 分析3例右肾癌伴下腔静脉癌栓完全梗阻者行右肾根治十下腔静脉整段切除术前超声检查结果.结果 3例接受手术者中2例超声随访16个月,无瘤生存,1例术后13个月死亡.结论 彩色多普勒超声对判断下腔静脉癌栓梗阻部位及程度具有较高临床实用价值,可为临床术前术式选择、估测手术风险及准备相应对策提供可靠信息.     

机械性血栓清除术治疗下腔静脉滤器相关血栓的疗效评价

目的:评价机械性血栓清除术(PMT)治疗下腔静脉滤器相关血栓的临床有效性及安全性。方法:回顾性分析2017年1月一2019年3月14例下腔静脉滤器置入术后12~14d出现下腔静脉滤器相关血栓的患者,比较PMT前后红细胞及肾功能变化,有无症状性肺栓塞以及PMT的血栓清除效果,是否成功回收滤器及有无下腔静脉损伤。结果:PMT前后红细胞及肾功能水平改变无统计学意义,均无症状性肺栓塞发生,PMT后血栓清除Ⅲ级12例(85.71%),Ⅱ级2例(14.29%)联合应用CDT治疗后血栓清除达Ⅲ级,所有患者均成功回收滤器,无下腔静脉损伤发生。结论:PMT可安全、有效的清除下腔静脉滤器相关血栓,从而提高滤器回收的成功率。     

MRI、MDCT检测肾癌下腔静脉癌栓及癌栓侵犯血管壁价值的系统评价

目的对MRI、MDCT检测下腔静脉癌栓及癌栓侵犯血管壁的价值进行系统评价。方法计算机检索PubMed、EMbase、Cochrane图书馆、MELINE（Ovid）、CBM、CNKI、VIP及WanFang Data的相关英文及中文文献,检索时限为2000年1月～2012年2月。按照纳入和排除标准选择文献、提取资料和评价纳入研究的方法学质量后,采用RevMan5、Meta—disc1．4软件对纳入文献进行异质性检验及Meta分析。结果共纳入6篇文献,244例患者,246例肾癌。Meta分析结果显示：MRI和MDCT组的敏感度分别为0．963、0．952,特异度分别为0．969、0．979,＋LR分别为9．759、15．57,-LR分别为0．091、0．108,dOR分别为198．71、251．54。各组合并效应量间均无统计学差异（P〉0．05）。MDCT组的SROC曲线下面积（AUC）为0．9818,Q^＊0．9407。结论MRI与MDCT诊断肾癌下腔静脉癌栓的差异无统计学意义。由于现有资料有限,今后还应更多地进行关于癌栓侵犯血管壁的原始研究。     

肾癌伴下腔静脉癌栓27例围术期护理

目的:探讨肾癌伴下腔静脉癌栓患者围术期的护理方法.方法:对27例肾癌伴下腔静脉癌栓患者做好术前、术中及术后护理.结果:本组痊愈出院26例,死亡1例.结论:对肾癌伴下腔静脉癌栓患者进行完善的围术期护理,可提高手术成功率,降低并发症的发生,改善患者生存质量.     

超声及超声造影在肾细胞癌伴下腔静脉瘤栓合并血栓诊断中的价值

目的探讨超声及超声造影在肾细胞癌伴下腔静脉瘤栓合并血栓诊断中的价值。 方法回顾性纳入北京大学第三医院2015年1月至2018年5月行手术治疗的肾细胞癌合并下腔静脉瘤栓患者113例。所有患者均于术前行下腔静脉超声检查，对无法确认瘤栓或者血栓的22例患者行超声造影检查，均取得术后病理结果。以术后病理为"金标准"，将患者分为合并血栓组27例、不合并血栓组86例。对2组患者的临床资料、病理及超声特征进行对比分析，绘制不同参数评估血栓形成的ROC曲线，计算曲线下面积（AUC）。应用四格表计算超声造影诊断下腔静脉瘤栓合并血栓的敏感度、特异度、准确性、阳性预测值及阴性预测值。 结果合并血栓组较不合并血栓组的瘤栓Mayo分级更高（P=0.011）；肿瘤最大长径更小[（7.42±2.87）cm vs（9.37±2.88）cm，P=0.013]；瘤栓更宽[（25.82±13.79）mm vs（19.79±10.73）mm，P=0.019]；残余管腔未见血流信号者更多[（19/27，70.4%）vs（37/86，43.0%），P=0.016]；肾肿瘤未见无回声坏死区者更多[（17/27，63.0%）vs（34/86，39.5%），P=0.046]；瘤栓肾静脉入口处前后径更大[（26.90±8.12）mm vs （20.59±6.87）mm，P<0.001]；腔静脉节段性切除比例更高[（12/27，44.4%） vs （9/86，10.5%），P<0.001]。绘制肿瘤最大长径评估血栓形成的ROC曲线，得出AUC为0.668（P=0.006），最佳截断值为<6.90 cm；瘤栓宽度评估血栓形成的AUC为0.669（P=0.016），最佳截断值为>24.6 mm；瘤栓肾静脉汇入下腔静脉入口处前后径评估血栓形成的AUC为0.766（P<0.001），最佳截断值为>23.6 mm。超声造影诊断下腔静脉瘤栓合并血栓的敏感度、特异度、准确性、阳性预测值及阴性预测值分别为71.4%、93.3%、86.3%、83.3%及87.5%。 结论肿瘤越小、瘤栓越宽越容易形成血栓；超声造影可提高下腔静脉瘤栓合并血栓的诊断效能，但仅依据栓子是否增强鉴别血栓和瘤栓可能存在偏差。     

Surgery for hepatocellular carcinoma with tumor thrombosis in inferior vena cava: A case report

BACKGROUNDHepatocellular carcinoma (HCC) accompanied by a tumor thrombus is very common. However, the treatment strategy is controversial and varies by the location of the thrombus.CASE SUMMARYWe report herein a case of HCC with a tumor thrombus in the suprahepatic inferior vena cava (IVC), which was successfully treated by hepatectomy combined with thrombectomy following sorafenib chemotherapy. A 47-year-old woman with chronic hepatitis was diagnosed with HCC. Computed tomography and magnetic resonance imaging showed that the tumor lesion was located in the right half of the liver, and a tumor thrombus was detected in the suprahepatic IVC near the right atrium. After multi-departmental discussion and patient informed consent, right major hepatectomy and total removal of the tumor thrombus were successfully performed under cardiopulmonary bypass. There were no serious complications after surgery. Following sorafenib treatment, no recurrence has been detected so far (11 mo later).CONCLUSIONSurgical treatment followed by adjuvant sorafenib therapy might be an acceptable choice for HCC patients with tumor thrombosis in the IVC.     

Bland and tumor thrombi in abdominal malignancies: magnetic resonance imaging assessment in a large oncologic patient population

The purpose of this study was to examine the distribution of venous thrombi associated with primary or secondary abdominal malignancies on magnetic resonance (MR) imaging with respect to thrombus type (bland vs. tumor), tumor sites, tumor types, and veins involved in a large oncologic patient population. In a retrospective review of 10,908 oncologic patients, MR imaging studies identified 142 (1.3%) showing venous thrombi, of which 55 (0.5%) were bland and 87 (0.79%) were tumor thrombus. Bland thrombi were most commonly seen in liver (35%; 19/55) and retroperitoneal malignancies (24%; 13/55) and were most often located in the inferior vena cava (45%; 25/55) and the portal vein (22%; 12/55). Tumor thrombi were most commonly seen in renal (55%; 48/87) and liver (32%; 28/87) malignancies. The prevalence of tumor thrombi was 8.8% (48/545) in primary renal, 4.7% (6/126) in primary retroperitoneal, 2.9% (19/634) in primary liver, and 1.8% (9/479) in secondary liver malignancies. Tumor thrombi were most commonly located in the inferior vena cava (57%; 50/87), the renal vein (48%; 42/87), and the portal vein (29%; 25/87).     

肾癌伴下腔静脉癌栓的手术治疗

目的探讨手术治疗肾癌伴下腔静脉癌栓的效果。方法回顾性分析2004年10月至2006年3月共5例肾癌伴下腔静脉癌栓患者的临床资料,男3例,女2例,平均49.8岁。5例均为右侧,肾静脉型(Ⅰ型)1例,肝下型(Ⅱ型)2例,肝内型(Ⅲ型)2例。均行肾癌根治性切除加下腔静脉切开取栓术。结果1例因癌栓脱落引起肺栓塞术中死亡外,余4例手术顺利。1例癌栓侵犯腔静脉壁,术后局部复发和肺部转移,17个月死亡。其余3例分别随访7个月、9个月、23个月,均未发现肿瘤复发和远处转移。结论对于未发现有远处转移的肾癌下腔静脉癌栓,肾癌根治性切除加下腔静脉切开取栓术是积极有效的治疗方法。     

Color Doppler sonography of bile duct tumor thrombi in hepatocellular carcinoma.

OBJECTIVE: To determine with the use of color Doppler sonography whether bile duct tumor thrombi had detectable vasculature in hepatocellular carcinoma. METHODS: Among 491 patients with tissue-proven hepatocellular carcinoma, 9 (1.8%) had bile duct tumor thrombi. All 9 patients had spectral Doppler sonography guided by color Doppler sonography (3.75-MHz convex probe). RESULTS: All 9 patients had dilated bile ducts with isoechoic thrombi. Eight patients had tumors infiltrating into and obstructing adjacent major bile ducts. The other patient had common hepatic duct tumor emboli that were not adjacent to primary tumors. Color signals were detectable within bile duct tumor thrombi in 7 patients. All of them had pulsatile waveforms on spectral analyses. CONCLUSIONS: Bile duct tumor thrombosis with obstructive jaundice was a rare complication of hepatocellular carcinoma. A detectable color signal with pulsatile waveforms was shown in most cases by color Doppler sonography with spectral analyses.     

Intraoperative transesophageal sonographic monitoring of tumor thrombus in the inferior vena cava during radical nephrectomy and thrombectomy for renal cell carcinoma

We report the case of a 58-year-old woman with renal cell carcinoma in whom real-time transesophageal sonographic monitoring of the tumor thrombus in the inferior vena cava provided dynamic information, allowing us to determine the appropriate operative procedure to use. Observation of the thrombus throughout the operation showed that mobilization of the liver resulted in compression of the inferior vena cava against the spine, increasing the risk of migration of the tumor thrombus and reinforcing the need to maintain adequate positioning of the liver to prevent such compression. The surgery was completed successfully, and the patient's postoperative course was uneventful. We recommend the use of real-time transesophageal sonographic monitoring of the tumor thrombus during such surgical procedures.     

Enhanced Visualization of Intravascular and Left Atrial Appendage Thrombus with the Use of a Thrombus-Targeting Ultrasonographic Contrast Agent (MRX-408A1): In Vivo Experimental Echocardiographic Studies

Echocardiographic evaluation for the recognition of intravascular and left atrial appendage thrombus remains a difficult problem. A thrombus-specific ultrasonographic contrast agent has the potential for an alternative approach for their delineation. The aim of this study was to investigate the usefulness of thrombus-specific contrast agent MRX-408A1 for the detection of acute experimentally created intravascular and intracardiac thrombus. In the first study, we created inferior vena cava thrombus in 9 dogs. With the use of fundamental 2-dimensional echocardiography imaging, we recorded images of the inferior vena cava thrombus at baseline (n = 9), with the thrombus-specific contrast agent MRX-408A1 (n = 9), and with nonspecific contrast agent MRX-113 (n = 6). In the second study, we created a left atrial appendage thrombus in 8 dogs. We imaged left atrial appendage thrombus at baseline and during MRX-113 and MRX-408A1 infusion. Thrombus was successfully created in all dogs in study 1 and in 6 of 8 dogs in study 2. MRX-408A1 produced a visually apparent increase in ultrasonographic contrast enhancement of the thrombus in all cases in which thrombus was found on autopsy. In both studies, MRX-408A1 increased the videointensity of the thrombus significantly compared with baseline images and images obtained during MRX-113 infusion. The size of the visually detectable thrombus on the image was also significantly larger during MRX-408A1 infusion than at baseline and during MRX-113 infusion. These data provide in vivo demonstration of the efficacy of a thrombus-specific contrast agent, MRX-408A1, in the detection of acute intravascular and intracardiac thrombus. It has the potential to improve the diagnostic accuracy of ultrasonography for the detection of acute thrombi at various cardiovascular sites in the clinical setting.     

术前及术中超声造影对下腔静脉癌栓是否合并血栓的诊断价值

目的探讨术前及术中超声造影对下腔静脉癌栓是否合并血栓的诊断价值。 方法选取2017年10月至2019年3月解放军总医院收治的发现肾肿瘤伴下腔静脉癌栓并行腹腔镜手术治疗的患者60例，所有患者均于术前及术中行超声造影检查，以典型增强模式判断癌栓是否合并血栓，并最终取得术后病理结果。以术后病理结果为"金标准"，计算术前及术中超声造影评估癌栓合并血栓的敏感度、特异度、准确性、阳性预测值和阴性预测值。 结果60例下腔静脉癌栓患者均接受了机器人辅助腹腔镜下根治性肾切除联合下腔静脉内癌栓切除术。根据病理结果，下腔静脉癌栓合并血栓者10例（16.7%），其中术前超声造影漏诊2例，另有2例癌栓头部坏死组织被术前及术中超声造影误诊为血栓。术前与术中超声造影评估癌栓合并血栓的敏感度、特异度、准确性、阳性预测值、阴性预测值分别为80.0%、96.0%、93.3%、80.0%、96.0%和100.0%、96.0%、96.7%、83.3%、100.0%。 结论术前及术中超声造影对下腔静脉癌栓是否合并血栓有较好的鉴别诊断效能，可为手术方式的选择提供重要信息和依据，具有较高的临床应用价值。     

多层螺旋CT静脉血管成像价值探讨

目的探讨多层螺旋CT静脉血管造影的应用价值.方法收集不同部位CT静脉血管造影21例,颈静脉及门静脉系统血管造影由上肢静脉注入对比剂,下腔静脉及下肢造影由小隐静脉注入对比剂,行三维重建及多平面重建,结合临床资料分析血管成像技术及诊断价值.结果静脉血管CT造影表现不同于动脉CT造影,不同部位的静脉血管表现不同.21例中发现颈鼻咽癌侵犯血管1例,血管走行纡曲1例;下腔静脉瘤1例,肿瘤压迫下腔静脉1例;门静脉高压1例,疑肠系膜上静脉内血栓1例;11例下肢静脉血栓.结论不同部位的静脉影像表现存在差异,不同的重建技术对血管的显示有影响.下腔静脉造影应注意假象的存在.