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中华临床医师杂志(电子版) ›› 2019, Vol. 13 ›› Issue (02) : 81 -86. doi: 10.3877/cma.j.issn.1674-0785.2019.02.001

所属专题: 文献

临床研究

DDD肾肿瘤评分系统应用于肾肿瘤手术决策的临床分析
张中元1, 朱军1, 虞巍1, 潘喜1, 谌诚1, 范宇1, 韩文科1, 林健1, 王刚1, 宋毅1, 赵峥1, 郝金瑞1, 王鹤2, 王霄英2, 张晓春1, 周利群1, 李学松1,()   
  1. 1. 100034 北京大学第一医院泌尿外科,北京大学泌尿外科研究所,国家泌尿、男性生殖系肿瘤研究中心
    2. 100034 北京大学第一医院医学影像科
  • 收稿日期:2018-12-20 出版日期:2019-01-15
  • 通信作者: 李学松

Application of DDD nephrometry score to surgical decision-making for renal tumors

Zhongyuan Zhang1, Jun Zhu1, Wei Yu1, Xi Pan1, Cheng Shen1, Yu Fan1, Wenke Han1, Jian Lin1, Gang Wang1, Yi Song1, Zheng Zhao1, Jinrui Hao1, He Wang2, Xiaoying Wang2, Xiaochun Zhang1, Liqun Zhou1, Xuesong Li1,()   

  1. 1. Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Beijing 100034, China
    2. Department of Radiology, Peking University First Hospital, Beijing 100034, China
  • Received:2018-12-20 Published:2019-01-15
  • Corresponding author: Xuesong Li
  • About author:
    Corresponding author: Li Xuesong, Email:
引用本文:

张中元, 朱军, 虞巍, 潘喜, 谌诚, 范宇, 韩文科, 林健, 王刚, 宋毅, 赵峥, 郝金瑞, 王鹤, 王霄英, 张晓春, 周利群, 李学松. DDD肾肿瘤评分系统应用于肾肿瘤手术决策的临床分析[J/OL]. 中华临床医师杂志(电子版), 2019, 13(02): 81-86.

Zhongyuan Zhang, Jun Zhu, Wei Yu, Xi Pan, Cheng Shen, Yu Fan, Wenke Han, Jian Lin, Gang Wang, Yi Song, Zheng Zhao, Jinrui Hao, He Wang, Xiaoying Wang, Xiaochun Zhang, Liqun Zhou, Xuesong Li. Application of DDD nephrometry score to surgical decision-making for renal tumors[J/OL]. Chinese Journal of Clinicians(Electronic Edition), 2019, 13(02): 81-86.

目的

探讨DDD肾肿瘤评分系统对于肾肿瘤手术的指导意义。

方法

选择北京大学第一医院泌尿外科2013年1月至2017年9月收治2977例病理诊断为肾细胞癌的患者进行病例回顾,筛选病例资料包含泌尿系增强CT的患者561例,收集患者的年龄、性别、手术方式等数据,对其术前CT或磁共振进行回顾分析并进行RENAL及DDD(D1为位于肾内的肿瘤的最长径;D2为肿瘤边界距离肾髓质或肾窦和集合系统的最短距离;D3肿瘤距离肾动静脉主干的距离)系统评分。将各径线D1、D2、D3评分与手术方式进行Mann-Whitney秩和检验,进一步使用Mann-Whitney秩和检验方法,比较不同DDD系统评分与RENAL评分对手术方式的决策影响。

结果

RENAL及DDD系统评分均可分为3组:低度、中度、高度。对于肾部分切除(PN)与肾根治性切除(RN)的比较分析,RENAL及DDD系统评分差异具有统计学意义(P<0.001),评分越低,行肾部分切除术的比率越高。对于腹腔镜肾部分切除术(LPN)与腹腔镜肾根治性切除术(LRN),RENAL及DDD系统评分差异具有统计学意义(P<0.001),评分越低,行腹腔镜部分肾切除的比率越高。对于LRN及开放肾根治切除术(ORN)的比较分析显示,低分组及中分组在使用RENAL及DDD系统评分差异均无统计学意义(P值分别为0.135和0.602),但是低分组与高分组比较时两评分系统差异均具有统计学意义(P值分别为0.025和<0.018),评分越高,行开放肾根治性切除术的比率越高。

结论

DDD肾肿瘤评分系统评分是一种直观简便的描述肾肿瘤解剖特征的综合评估体系,具有良好的稳定性,可以反映肾肿瘤手术的难度,协助临床医师进行肾肿瘤的手术决策。

Objective

To present a DDD scoring system to access the surgical complexity of renal tumors to assist in the surgical decision-making process.

Methods

We retrospectively evaluated 561 patients who were histopathologically diagnosed with renal cell carcinoma with available imaging data between January 2013 and September 2017. The surgical approaches, as well as RENAL and DDD scores, were compared. We performed a review of the available English literature published in the last decade and relating to the surgical anatomy pertinent to renal mass excision, and established a solid single renal mass scoring system, the DDD nephrometry score, based on the three most reproducible and pertinent features that characterize the critical anatomical attributes of renal tumors. Each feature in our nephrometry score was designated by an English letter, forming the acronym DDD: (D1)iameter (scores tumor size as the maximal diameter inside the kidney), (D2)epth of the deepest portion of the tumor with the medulla and collecting system or sinus, and (D3) istance (shortest from the mass to the main renal vessels). The points of D1, D2, and D3 were summed as DDD score and tumors were stratified into three complexity levels. The relationships between each D variate and the operation method options were tested by the Mann-Whitney rank sum test. The further Mann-Whitney rank sum test was used to compare the different effects of DDD nephrometry score and RENAL score on surgery method choice.

Results

In this cohort, 383 (68.3%) patients were men and 178 (31.7%) were women. The mean age was (57.3±11.9) years, and mean BMI was (25.1±3.5) kg/m2. Mean D1 was (4.3±2.0) cm. D2 was 1 pt in 50 (8.9%) patients, 2 pts in 110 (19.6%), and 3 pts in 401 (71.5%). D3 was 1 pt in 357 (63.6%) patients, 2 pts in 33 (5.9%), and 3 pts in 171 (30.5%). There were 36 (6.4%), 186 (33.2%), and 339 (60.4%) patients in the low, moderate, and high DDD score groups, and 140 (25.0%), 289 (51.5%), and 132 (23.5%) in the low, moderate, and high RENAL score groups, respectively. Regarding surgical procedures, 329 (58.6%) patients′ tumors were removed by radical nephrectomy (RN), in which 47 (8.4%) were removed by open radical nephrectomy (ORN) and 282 (50.2%) by laparoscopic radical nephrectomy (LRN); 232 (41.4%) patients′ tumors were removed by partial nephrectomy (PN), in which 32 (5.7%) were removed by open partial nephrectomy (OPN) and 200 (35.7%) by laparoscopic partial nephrectomy (LPN). For partial nephrectomy (PN) rate, significant differences were observed between any two RENAL or DDD score groups (P<0.001 for all), and there was a higher PN rate with the lower score group. Likewise, the same results were observed in the laparoscopic group, and the laparoscopic partial nephrectomy (LPN) rate was higher with the lower score group (P<0.001 for all). As for laparoscopic nephrectomy (LRN) or open nephrectomy (ORN), differences were not significant between low and moderate RENAL or DDD score groups (P=0.135 and P=0.602, respectively), but significant between the low and high groups (P=0.025, <0.018). High DDD score and RENAL groups had significant more patients undergoing ORN than low and moderate groups, respectively.

Conclusions

DDD score is based on only three variants and all of them are intuitive and pellucid. Even junior urologists and radiologists could easily master this system and it can be measured easily on preoperative CT images. The DDD score could be used to reflect the surgical complexity and assist to make treatment decisions for patients with renal tumors.

图1 DDD肾肿瘤评分系统[15]
表1 DDD评分和手术方式的关系[例(%)]
DDD评分 PN(232例) RN(329例) Z P LRN(482例) ORN(79例) Z P LPN(200例) LRN(282例) Z P
D1 ? ? -15.900 <0.001 ? ? -5.019 <0.001 ? ? -14.900 <0.001
? 1分 21(100.0) 0(0) ? ? 21(100.0) 0(0) ? ? 21(100.0) 0(0) ? ?
? 2分 80(92.0) 7(8.0) ? ? 80(92.0) 7(8.0) ? ? 73(91.3) 7(8.8) ? ?
? 3分 81(68.6) 37(31.4) ? ? 104(88.1) 14(11.9) ? ? 69(66.3) 35(33.7) ? ?
? 4分 32(28.8) 79(71.2) ? ? 101(91.0) 10(9.0) ? ? 25(24.8) 76(75.2) ? ?
? 5分 11(11.6) 84(88.4) ? ? 83(87.4) 12(12.6) ? ? 8(9.6) 75(90.4) ? ?
? 6分 6(10.0) 54(90.0) ? ? 52(86.7) 8(13.3) ? ? 3(5.8) 49(94.2) ? ?
? 7分 1(3.4) 28(96.6) ? ? 19(65.5) 10(34.5) ? ? 1(5.3) 18(94.7) ? ?
? 8分 0(0) 18(100.0) ? ? 13(72.2) 5(27.8) ? ? 0(0) 13(100.0) ? ?
? 9分 0(0) 12(100.0) ? ? 4(33.3) 8(66.7) ? ? 0(0) 4(100.0) ? ?
? 10分 0(0) 4(100.0) ? ? 2(50.0) 2(50.0) ? ? 0(0) 2(100.0) ? ?
? 11分 0(0) 2(100.0) ? ? 1(50.0) 1(50.0) ? ? 0(0) 1(100.0) ? ?
? 12分 0(0) 2(100.0) ? ? 1(50.0) 1(50.0) ? ? 0(0) 1(100.0) ? ?
? 13分 0(0) 1(100.0) ? ? 1(100.0) 0(0) ? ? 0(0) 1(100.0) ? ?
? 14分 0(0) 1(100.0) ? ? 0(0) 1(100.0) ? ? - - ? ?
D2 ? ? -10.394 <0.001 ? ? -1.491 0.136 ? ? -10.008 <0.001
? 1分 40(80.0) 10(20.0) ? ? 45(90.0) 5(10.0) ? ? 36(80.0) 9(20.0) ? ?
? 2分 81(73.6) 29(26.4) ? ? 98(89.1) 12(10.9) ? ? 73(74.5) 25(25.5) ? ?
? 3分 111(27.7) 290(72.3) ? ? 339(84.5) 62(15.5) ? ? 91(26.8) 248(73.2) ? ?
D3 ? ? -10.555 <0.001 ? ? -4.342 <0.001 ? ? -9.549 <0.001
? 1分 206(57.7) 151(42.3) ? ? 323(90.5) 34(9.5) ? ? 182(56.3) 141(43.7) ? ?
? 2分 9(27.3) 24(72.7) ? ? 29(87.9) 4(12.1) ? ? 7(24.1) 22(75.9) ? ?
? 3分 17(9.9) 154(90.1) ? ? 130(76.0) 41(24.0) ? ? 11(8.5) 119(91.5) ? ?
表2 DDD评分和RENAL评分分级后与肾部分切除术或肾根治切除术的关系[例(%)]
表3 DDD评分和RENAL评分分级后与腹腔镜肾部分切除术或腹腔镜肾根治切除术的关系[例(%)]
表4 DDD评分和RENAL评分分级后与开放肾根治切除术或腹腔镜肾根治切除术的关系[例(%)]
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