Cancer UrologyCancer UrologyОнкоурология1726-97761996-1812Publishing House ABV Press37510.17650/1726-9776-2014-10-3-31-39DIAGNOSIS AND TREATMENT OF URINARY SYSTEM TUMORS. RENAL CANCERДИАГНОСТИКА И ЛЕЧЕНИЕ ОПУХОЛЕЙ МОЧЕПОЛОВОЙ СИСТЕМЫ. Рак почкиPredictors of the immediate results of thrombectomy in kidney cancer patients with venous tumor thrombosisФакторы прогноза непосредственных резу льтатов тромбэктомии у больных раком почки с опух олевым венозным тромбозомDavydovM. I.ДавыдовМ. И.
Russian Federation
MatveevV. B.МатвеевВ. Б.
Russian Federation
VolkovaM. I.ВолковаМ. И.
Russian Federation
mivolkova@rambler.ruZhuzhginovaO. V.ЖужгиноваО. В.
Russian Federation
LomidzeS. V.ЛомидзеС. В.
Russian Federation
FeoktistovP. I.ФеоктистовП. И.
Russian Federation
NekhaevI. V.НехаевИ. В.
Russian Federation
KlimovA. V.КлимовА. В.
Russian Federation
KalininS. A.КалининС. А.
Russian Federation
N.N. Blokhin Russian Cancer Research Center, Russian Academy of Medical Sciences, MoscowФГБУ «РОНЦ им. Н.Н. Блохина» РАМН, Москва3009201410331390711201407112014https://oncourology.abvpress.ru/oncur/article/view/375

Objective: to identify the predictors of perioperative complications and deaths in surgically treated patients with kidney cancer complicated by venous tumor thrombosis.

Subjects and methods. The investigation included data on 463 kidney cancer patients with venous tumor thrombosis. The patients, median age was 57 years. The male / female ratio was 2.5:1. Perirenal, subhepatic, retrohepatic, and supradiaphragmatic tumor thrombi were diagnosed in 161 (34.8 %), 135 (29.2 %), 82 (17.7 %), and 85 (18.3 %) patients, respectively. Regional and distant metastases occurred in 90 (19.4 %) and 145 (31.3 %) cases, respectively. All the patients underwent thrombectomy, retroperitoneal lymphadenectomy; a tumor-affected kidney was removed in 452 (97.6 %) patients.

Results. Median surgery duration was 259 (30–580) min; median blood loss was 3500 (100–27 000) ml. The incidence of intraoperative complications was 24.6 % (114 / 463); mortality was 0.9 % (4 / 463). The independent risk factors of intraoperative complications were cranial margin of a tumor thrombus (odds ratio (OR) 1.9; 95 % CI 1.4–2.6; p < 0.0001) and circular resection of the inferior vena cava (OR 5.8; 95 % CI 1.2–27.8; p < 0.0001). The incidence of postoperative complications was 25.7 % (118 / 459);mortality was 6.0 % (28 / 459). Resurgery was required in 31 (6.8 %) cases. Regression analysis identified the risk factors of postoperative complications (highly located cranial thrombus margin (OR 2.6; 95 % CI 1.1–6.4; p = 0.037) and lactate acidosis (OR27.1; 95 % CI 1.2–613.1; p = 0.038), postoperative death (hepatic vein thrombosis (OR 15.6; 95 % CI 4.5–54.3; p < 0.0001),lactate acidosis (OR 23.1; 95 % CI 3.4–158.4; p = 0.001) thrombus removal from the heart (OR 5.0; 95 % CI 2.1–12.2; p < 0.0001)),perioperative death (cranial thrombus margin (OR 1.9; 95 % CI 1.2–3.2); р = 0.007), contralateral renal vein thrombosis (O R 4.4;95 % CI 1.2–15.8; p = 0.025), lactate acidosis (OR 28.4; 95 % CI 4.9–165.1; p < 0.0001), and low creatinine clearance (OR 4.6;95 % CI 1.9–24.9; p = 0.017).

Conclusion. Thrombectomy in patients with T3a–cNxMx kidney cancer is a technically difficult intervention associated with the high incidence of complications and death, which must be performed only in specialized centers. The identified risk factors may serve as criteria for predicting the results of thrombectomy.

Цель исследования – выделение факторов прогноза периоперационных осложнений и смертности у больных раком почки (РП), осложненным опухолевым венозным тромбозом, подвергнутых хирургическому лечению.

Материалы и методы. В исследование включены данные 463 больных РП с опухолевым венозным тромбозом, подвергнутых тромбэктомии. Медиана возраста – 57 лет. Соотношение мужчин и женщин – 2,5:1. Периренальный опухолевый тромб диагностирован у 161 (34,8 %), подпеченочный – у 135 (29,2 %), ретропеченочный – у 82 (17,7 %), наддиафрагмальный – у 85 (18,3 %) пациентов. Регионарные метастазы имели место в 90 (19,4 %), отдаленные – в 145 (31,3 %) случаях. Всем больным выполненатромбэктомия, забрюшинная лимфаденэктомия; опухолево-пораженную почку удалили 452 (97,6 %) пациентам.

Результаты. Медиана длительности операции – 259 (30–580) мин, медиана кровопотери – 3500 (100–27 000) мл. Частота интраоперационных осложнений составила 24,6 % (114/463), летальность – 0,9 % (4/463). Независимыми факторами риска интраоперационных осложнений являлись краниальная граница опухолевого тромба (отношение шансов (ОШ) 1,9; 95 % доверительный интервал (ДИ) 1,4–2,6; p < 0,0001) и циркулярная резекция нижней полой вены (НПВ) (ОШ 5,8; 95 % ДИ 1,2–27,8; p < 0,0001). Частота послеоперационных (п/о) осложнений – 25,7 % (118/459), летальность – 6,0 % (28/459). Повторные операции потребовались в 31 (6,8 %) наблюдении. В регрессионном анализе выделены факторы риска п/о осложнений (высокое расположение краниальной границы тромба (ОШ 2,6; 95 % ДИ 1,1–6,4; p = 0,037) и лактат-ацидоз (ОШ 27,1; 95 % ДИ 1,2–613,1; p = 0,038)), п/о смерти (тромбоз печеночных вен (ОШ 15,6; 95 % ДИ 4,5–54,3; p < 0,0001), лактат-ацидоз (ОШ 23,1; 95 % ДИ 3,4–158,4; p = 0,001) и удаление тромба из сердца (ОШ 5,0; 95 % ДИ 2,1–12,2; p < 0,0001)) и периоперационной смерти (краниальная граница тромба (ОШ 1,9; 95 % ДИ 1,2–3,2; р = 0,007), тромбоз контралатеральной почечной вены (ОШ 4,4; 95 % ДИ 1,2–15,8; p = 0,025), лактат-ацидоз (ОШ 28,4; 95 % ДИ 4,9–165,1; p < 0,0001) и низкий клиренс креатинина (ОШ 4,6; 95 % ДИ 1,9–24,9; p = 0,017)).

Выводы. Тромбэктомия у больных РП T3a–cNxMx – технически сложное вмешательство, ассоциированное с высокой частотой осложнений и летальностью, которое должно выполняться только в специализированных центрах. Выделенные факторы риска могут служить критериями для прогнозирования результатов тромбэктомии.

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