肾嫌色细胞癌临床特征分析

目的 探讨肾嫌色细胞癌的临床特点并分析其预后.方法 对1998年1月至2008年1月期间收治的29例肾嫌色细胞癌患者的临床资料包括临床表现、影像学检查、治疗方法、Ptnm分期和生存期随访等,进行回顾性分析.结果 所有29例患者均缺乏典型的临床症状,术前影像学检查亦未发现特异性表现.23例患者行根治性肾切除术,6例行保留肾单位手术(NSS),病理分期:Pt1n0m0 11例,Pt2n0m0 8例,pT3aN0M0 5例,Pt1nm0 3例,Pt2n1m0 2例.26例患者获得随访,随访24～144个月,平均90个月;3例死于心脑血管疾病,6例局部复发后4例再次手术,1例远处转移,21例无瘤生存.与同期肾透明细胞癌患者相比,累积5年生存率两者分别为83.9%和63.8%,差异无统计学意义(P＞0.05),累积10年生存率分别为77.9%和49.9%,差异具有统计学意义(P＜0.01).结论 肾嫌色细胞癌是一种少见的具有特殊形态的肾细胞癌病理亚型,主要通过病理学予以鉴别诊断,手术切除是治疗初发或复发的肾嫌色细胞癌的首选方法,其预后较好.

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Objectives To explore the clinical, pathological features and prognosis of patients with chromophobe renal cell carcinoma. Methods From January 1998 to January 2008, clinical data of 29 patients with chromophobe renal cell carcinoma including clinical manifestations, imaging examinations,treatment models, pTNM stages and follow-up results, were summarized to investigate its features and prognosis. Results All cases had no obvious clinical and preoperative imaging presentation. There were 23 patients underwent radical nephrectomy, and 6 cases underwent nephron sparing surgery. Postoperative pathological findings confirmed the diagnosis of chromophobe renal cell carcinoma. Macroscopically, the cut surface of the tumors were generally beige in color. Histologically, it showed polygonal chromophobe cells and small round eosinophilic cells with eccentric hyaline degeneration. These tumor cells had a clear and sharp membrane, lightly stained abundant cytoplasm with a fine reticular translucent pattern and irregular nuclei. And a perinuclear halo was often seen in these cells. Histochemically, the tumor cells generally show a diffuse and strong reaction for CK-8 with a negative expression of Vimentin. The pTNM stages of the tumor were as follows, pT1N0M0 in 11 cases, pT2N0M0 in 8 cases, pT3aN0M0 in 5 cases, pT1N1M0 in 3 cases,pT2N1M0 in 2 cases. Twenty-six cases of patients were followed up (24 to 144 months, with an average of 90 months), 3 cases died of cardio-cerebrovascular disease, and local recurrence involved in 6 cases with reoperation in 4 cases, as well as distant metastasis in 1 case. Twenty-one cases survived with tumor-free.The statistical results indicated that the survival rates of the patients with chromophobe renal cell carcinoma in five years and ten years were 83.9%, 77.9%, respectively, compared with renal cell carcinoma of the same stage 63. 8% and 49. 9% at the same periods, and there is no difference in the survival rate of five years( P ＞ 0. 05 ) but significant difference in that of ten years ( P ＜ 0. 01 ). Conclusions Chromophobe renal cell carcinoma is a morphologically uncommon subtype of renal cell carcinoma with the good prognosis. Definite diagnosis depends on its typical pathological feature. Radical nephrectomy is the first choice for the treatment of chromophobe renal cell carcinoma.     

肾细胞癌组织中DLK1蛋白表达及与临床病理学特征的相关性研究

目的 探讨不同组织类型的肾细胞癌组织中DLK1蛋白表达与肾癌临床病理特征及转移的关系.方法 采用免疫组织化学方法,检测94例肾原发透明细胞癌、76例乳头状肾细胞癌、45例嫌色细胞癌、71例透明细胞癌远处转移灶、24例透明细胞癌淋巴结转移灶及18例正常肾组织标本中DLK1蛋白表达情况,分析其与临床病理特征及转移的相关性.结果 正常肾组织近端及远端肾小管中DLK1蛋白表达均为阳性,透明细胞癌、乳头状肾细胞癌及嫌色细胞癌组织低表达率分别为33.0%(31/94)、27.6%(21/76)及33.3%(15/45),与正常肾组织相比,差异有统计学意义(P＜0.05),3种类型肾癌组织之间DLK1蛋白表达差异无统计学意义(P＞0.05).DLK1蛋白表达水平与透明细胞癌患者性别(男60例,女34例)、年龄(≥55岁50例,＜55岁44例)、病理分期(Ⅰ期41例,Ⅱ期9例,Ⅲ期21例,Ⅳ期23例)及淋巴结转移状态(无转移76例,有转移18例)等无明显相关性(P＞0.05).透明细胞癌原发灶、淋巴结转移灶、远处转移灶肿瘤组织中DLK1蛋白表达差异无统计学意义(P＞0.05).结论 不同类型的肾细胞癌组织中DLK1蛋白表达降低.DLK1蛋白低表达与透明细胞癌的临床病理特征及肿瘤转移无关.

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Objective To identify the expression of DLK1 protein in different types of renal cell carcinomas and its correlations with pathological characteristics and metastasis. Methods Immunohistochemistry analysis was performed to evaluate the expression of DLK1 protein in 94 cases of primary clear cell renal cell carcinoma, 76 cases of papillary renal cell carcinoma, 45 cases of chromophobe renal cell carcinoma, 71 cases of distal metastatic and 24 cases of lymph node metastatic clear cell renal cell carcinoma, as well as 18 cases of normal renal tissue. The correlations of DLK1 protein expression with pathological characteristics were analyzed. Results DLK1 protein was expressed in proximal and distal renal tubular epithelial cells in all the normal renal cases. In contrast, DLK1 protein expression was lower in different types of renal cell carcinoma. The low or negative expression of DLK1 protein in clear cell renal cell carcinoma, papillary renal cell carcinoma and chromophobe renal cell carcinoma was 33.0% (31/94), 27.6% (21/76) and 33.3% (15/45), respectively. Compared to normal renal tissue, DLK1 protein expression was significantly down-regulated in renal cell carcinomas (P＞0.05), whereas there was no significant difference on DLK1 protein expressions among the different types (P＞0.05) of renal cell carcinomas. DLK1 protein expression was not correlated with sex (60 male and 34 female cases), age (≥55, 50 cases and 55, 44 cases), grade (41 cases in grade I, 9 cases in grade II, 21 cases in grade III and 23 cases in grade Ⅳ respectively) and lymph node metastasis (76 cases with and 18 cases without lymph node metastasis) in clear cell renal cell carcinoma (P＞0.05). There was also no significant difference among primary, lymph node and distal metastatic lesions of clear cell carcinoma (P＞0.05). Conclusions DLK1 protein expression is commonly down-regulated in different types of renal cell carcinomas. Down-regulation of DLK1 protein expression is not associated with pathological characteristics and metastasis in clear cell renal cell carcinoma.     

多房囊性肾细胞癌的临床分析及其与vonHippel-Lindau基因突变的相关性研究

目的 提高对多房囊性肾细胞癌(MCRCC)的认识及诊治水平,分析MCRCC中von Hippel-Lindau(VHL)基因的作用.方法 回顾性分析2000-2010年17例MCRCC患者资料,占同期收治512例肾癌的3.32%.男11例,女6例.年龄37～61岁,平均46岁.术前常规行B超、CT等检查,误诊为肾盂旁囊肿1例.应用PCR、PCR产物直接测序等方法分析11例MCRCC组织和相应远离病灶的正常组织中VHL基因突变的情况.结果 17例患者行根治性肾切除术14例,其中1例先行囊肿去顶术,术中囊壁组织冰冻病理检查提示透明细胞癌,改行根治性肾切除术;行肾部分切除术3例.肿瘤直径2.2～6.0 cm,平均(3.6±1.2)cm.术后病理均为MCRCC,镜下主要表现为纤维囊壁组织内衬单层或数层肿瘤细胞,核小致密,胞质透亮.TNM分期均为T1N0M0,病理分级G1 14例,G2 3例.术后随访9～36个月,平均12个月,均未见复发及转移.11例MCRCC组织中7例(64%)存在VHL基因突变,而正常组织标本均未发现VHL基因突变.结论 MCRCC作为肾细胞癌的一种少见的独立亚型,病理及临床上易漏诊或误诊.CT等影像学检查有助于术前诊断,因其预后良好,手术方式推荐保留肾单位手术.VHL基因突变与MCRCC的发生存在一定关系.

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Objective To discuss the diagnosis and surgical management of multilocular cystic renal cell carcinoma (MCRCC) and to evaluate the gene function of the mutation of von Hippel-Lindau (VHL) gene in MCRCC. Methods Seventeen MCRCC cases (11 men and 6 women) out of 512 cases of renal cell carcinoma from 2000 to 2010 were retrospectively analyzed. The mean age of the 17 patients was 46 years (37-61 years). Ultrasonography and CT were available in all 17 cases, and 1 case was misdiagnosed as parapelvic renal cyst. The mutation of VHL gene was detected by PCR in the specimens of can-cerous tissue and adjacent normal tissue from 11 cases of MCRCC. Results Three of 17 cases underwent nephron sparing surgery, the others underwent radical nephrectomy. One case underwent unroofing of parapelvic renal cyst, but the rapid frozen pathology of the cyst wall showed renal cell carcinoma of clear type. As a result, radical nephrectomy was eventually performed. All 17 cases were confirmed as MCRCC by eva-luating pathological characteristics, such as the cyst wall lined by single or several layers of clear tumor cells and the nuclei which were small and anachromasis. Clinical stages of all cases were T1N0M0, in which there were 14 cases with pathological T1G1 and 3 cases with pathological T1G2. All patients underwent a follow-up of 9 to 36 months (mean, 12 months) without recurrence or metastasis. Mutation of VHL gene was detected in 7 of 11 cases (64%), but all adjacent normal tissues were negative. Conclusions As a rare subtype of renal cell carcinoma, MCRCC is difficult to diagnose. CT is an essential measure in diagnosis of MCRCC preoperatively. Because of the good prognosis of reported cases, nephron sparing surgery for the treatment of MCRCC is recommended. VHL gene mutations may play an important role in the carcinogenesis of MCRCC.     

肾癌多中心病灶和假包膜外肿瘤浸润的病理研究

目的 探讨保留肾单位手术(NSS)治疗肾癌时肿瘤周围正常肾组织安全有效的切除范围.方法2005年10月至2008年10月肾癌标本131例,其中行肾癌根治术103例,行NSS 28例.先行大体病理检查,然后分别在肿瘤假包膜外侧和距离肿瘤边缘3、5、10、15 mm各层面取材,每个层面取4块组织,HE组织染色.观察有无肾癌多中心病灶和假包膜外肿瘤的浸润范围等病理指标,分别测量病变到肿瘤边缘的距离,并统计肿瘤大小与以上指标的相关性.结果 131例肾癌标本中,肿瘤直径＜4.0 cm者61例,均未发现肿瘤周围浸润和卫星灶.肿瘤直径4～7 cm者46例,发现肿瘤周围浸润或卫星灶3例(6.5%),其中G3透明细胞癌1例,分别在距离肿瘤10、15 mm处发现卫星灶;集合管癌1例和G3透明细胞癌伴肉瘤样癌1例距离肿瘤周围15 mm均可见肿瘤浸润生长,集合管癌患者同时伴有远处转移和肾静脉瘤栓.肿瘤直径＞7 cm者24例,有肿瘤周围浸润或卫星灶4例(16.7%),其中1例G3透明细胞癌在肿瘤周围3 mm处发现卫星灶,另3例G2、G3透明细胞癌在肿瘤周围15 mm范围发现肿瘤浸润生长;有肾静脉瘤栓4例(16.7%);远处转移2例(8.3%).肿瘤直径与肿瘤周围浸润生长和卫星灶之间呈显著相关性(P＜0.05).结论直径＜4 cm的肾癌,行距离肿瘤周围正常肾组织切除宽度小的NSS,甚至简单的肿瘤剜除术安全有效;对部分仔细选择的4～7 cm肾癌,只要技术可行能够完整切除肿瘤,采用NSS治疗合理可行;而对于＞7 cm的肾癌,不建议行NSS.

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Objective To explore the safe and effective width of a healthy parenchymal surgical margin in nephron-sparing surgery (NSS) for renal cell carcinoma. Methods From October, 2005to October, 2008, 131 renal carcinoma specimens (103 cases performed by radical nephrectomy and 28 cases by NSS) were studied. The tissue materials were taken at the site of pseudo-capsule, 3, 5, 10,15 mm laterally from the tumor edge respectively and HE staining. Specimens were examined grossly and microscopically for multifocal tumors, infiltration of tumor pseudo-capsule and other pathological features. The correlation between the renal tumor size and the pathological features were analyzed statistically. Results There were 131 specimens of renal carcinoma. In 61 cases with tumor diameter ＜4 cm, no case (0.0%) had multifocal tumors and infiltration of tumor pseudo-capsule. In 46 cases with tumor diameter 4-7 cm, multifocal tumors were found in 3 cases (6.5%), and infiltration of tumor pseudo-capsule was found in 2 cases. Among the 46 cases there was 1 collecting duct cancer accompanied with distant metastasis and renal vein tumor embolus. In 24 cases with tumor diameter ＞7cm, multifocal tumors were found in 4 cases (16. 7%) and infiltration of tumor pseudo-capsule was found in 3 cases. Four cases (16.7%) had renal vein tumor embolus. Two cases (8.3%) had distant metastasis. The renal tumor size was apparently associated with multifocal tumors and infiltration of tumor pseudo-capsule (P＜0. 05). Conclusions Mini-margin NSS, even simple enucleoresection, is a safe and effective approach for treating localized renal tumor of ＜4 cm. For carefully selected patients with tumor 4-7 cm, NSS is reasonable and feasible. But for the patient with tumor ＞7 cm,NSS is not recommended.     

肾盂鳞状细胞癌临床特点分析

目的 探讨肾盂鳞状细胞癌的诊治特点.方法 回顾性分析1991年10月至2009年5月收治8例肾盂鳞状细胞癌患者资料.临床表现血尿8例,腰痛7例,腹部包块1例.B超检查8例,IVU检查8例,CT检查4例.术前诊断为肿瘤3例,诊断为肾结石5例,结石术中发现肿瘤并经冰冻病理确诊2例.8例患者均经手术治疗,行根治性肾输尿管切除4例、单纯性肾切除3例、姑息性切除术1例.结果 8例病理诊断均为鳞状细胞癌.中分化6例,高分化和低分化各1例;pT1 1例,pT2 1例,pT3 3例,pT4 3例;淋巴结转移2例.获随访7例,失访1例.术后生存时间2～42个月,中位时间6个月,患者均死于肿瘤复发及转移.结论 肾盂鳞状细胞癌恶性程度高,常合并结石,术前诊断困难,确诊时多为中晚期,术后短期内易复发转移,预后极差.

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Objective To review the diagnosis and treatment of squamous cell carcinoma of renal pelvis. Methods The clinical data from October 1991 to May 2009 of eight cases of squamous cell carcinoma of renal pelvis were reviewed and analyzed retrospectively. The symptoms of the patients were hematuria (eight cases), pain (seven cases) and abdominal mass (one case). All patients underwent B-ultrasound and IVU examination and four cases underwent CT scan. Three cases were diagnosed as having a tumor before surgery. Five cases were diagnosed as renal calculus, two of the five cases were diagnosed by intraoperative frozen section. Radical nephroureterectomy were performed in four cases, nephrectomy in three cases and palliative resection in one case. Results Histological classification revealed that six cases were moderately differentiated, one case was well differentiated and one case was poorly differentiated. Two cases had stage pT1/pT2 and six cases had stage pT3/pT4. 2 cases had regional lymph nodes metastasis. Seven cases were followed-up. All patients died of tumor recurrence or metastasis. The median tumor specific survive time was six months (range from two months to 42 months). Conclusions Squamous cell carcinoma of renal pelvis is often occurs concurrently with urolithiasis which could lead to difficulty in diagnose before operation. As the most of the patients were diagnosed with advanced stage disease, squamous cell carcinoma of renal pelvis tended to early recurrence and metastasis and the prognosis was very poor.     

经皮肾镜技术治疗上尿路肿瘤的初步经验

目的 评价经皮肾镜技术在上尿路肿瘤中的应用效果.方法 2006年6月至2010年6月经皮肾镜治疗上尿路肿瘤患者8例(10侧).男6例(7侧),女2例(3侧).年龄52～72岁,平均61岁.孤立肾4例,慢性肾功能不全2例,双侧肾盂肿瘤2例.高级别肿瘤4侧,低级别肿瘤6侧.肿瘤直径0.5～3.5 cm,平均2.6 cm.患者均接受经皮肾镜激光或电刀肿瘤切除术,术中留置输尿管支架管,术后经肾造瘘管灌注化疗药物.结果 8例手术均获成功,手术时间45～95 min,平均73 min;术中出血量20～300 ml,平均50 ml,术后SCr水平较术前下降或无明显变化.随访10～36个月,采用CT、MRI及输尿管镜检观察肿瘤复发情况.1例死于肿瘤转移,2例肿瘤局部复发.余5例未见肿瘤复发.结论 经皮肾镜技术治疗上尿路肿瘤安全可行,手术效果良好,对不宜行肾输尿管切除术的上尿路肿瘤患者来说是一种良好的选择.

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Objective To evaluate the application of percutaneous nephroscopy in the treatment of upper urinary tract transitional cell carcinoma, particularly renal pelvic carcinoma. Methods From June 2006 to June 2010, eight cases (with 10 sides) of renal pelvic carcinoma received percutaneous nephroscopy tumor resection. There were six males (with 7 sides) and two females (with 3 sides) in the study group. There were six cases with solitary kidney and two cases with bilateral renal pelvic tumors. There were four cases with high-grade tumors and six cases with low-grade tumors. The age of patients ranged from 52 to 72 yrs (average 61.2 yrs). Tumor sizes ranged from 0.5 to 3.5 cm (average 2.6 cm). Patients were treated with laser or electrocautery through percutaneous nephroscopy. A ureteral stent was placed in the patients after the procedure. Chemotherapy was administered postoperatively through the nephrostomy tube. Results All the operations were successfully completed uneventfully. The operative time was 45-95 min (average 73 min), estimated blood loss was 20-300 ml (average 50 ml). No remarkable differences were found in serum creatinine levels before and after operation. After 10 to 36 mon. follow-up by CT, MRI, and ureteroscopy, one patient died of tumor metastasis and two patients had local tumor recurrence. The remaining patients had no local recurrence. Conclusions Percutaneous nephroscopy in treating renal pelvic tumor is safe and feasible. This is a better choice for the renal pelvic carcinoma patients who are unsuitable for ureteronephrectomy.     

经脐单孔多通道腹腔镜下肾切除术20例报告

目的 总结经脐单孔多通道腹腔镜下肾切除术的临床经验并评估其安全性和有效性.方法 2008年12月至2010年8月对20例患者行经脐单孔多通道腹腔镜下肾切除术.其中肾癌根治术9例(左肾8例,右肾1例;均为T1期),右输尿管癌肾切除1例,无功能肾切除10例(左侧5例,右侧5例).取脐旁2 cm切口进入腹腔,置入单孔多通道套件,5 mm一体化腹腔镜下,以普通腹腔镜器械及可弯器械相配合,完成肾切除术.根治性肾切除标本取出时需适当扩大脐部切口至6 cm.结果 20例中,1例右输尿管癌肾切除和1例右侧无功能肾切除因出血致视野不清,中转开放手术;18例手术顺利完成(2例肾癌根治术增加5 mm辅助通道),平均手术时间为197(85～510)min,平均出血量为126(50～400)ml,术中术后均未输血,术后平均住院时间6(3～14)d,术后平均留置引流管4(0～14)d.结论 经脐单孔多通道腹腔镜下肾切除术安全有效,且瘢痕较小,无功能肾切除术后几乎无瘢痕,美容效果佳.其临床治疗效果尚需大样本中远期随访和对照研究进一步证实.

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Objective To summarize the clincical experience of transumbilical Laparoendoscopic Single-site (LESS) nephrectomy and to evaluate its safety and efficacy. Methods From December 2008 to August 2010, we have performed 20 cases of transumbilical LESS nephrectomy by Tri-Port system, of which 9 patients underwent LESS radical nephrectomy (left 8, right 1, stage T1 ), 1 patient underwent LESS radical resection of right ureteral carcinoma, 10 patients underwent LESS simple nephrectomy (left 5, right 5). The Tri-Port system was inserted transperitoneally through a 2 cm umbilical incision. A 5-mm 30° telescope was introduced through the port to visualize the operative field. Flexible equipment and standard laparoscopic equipment were used to perform the procedures.The incisions were extended to about 6cm in order to remove the specimens. Results Conversion to open surgery was necessary in one LESS radical resection of right ureteral carcinoma and one LESS simple nephrectomy, while the remaining 18 cases were successful (the addition of a single 5-mm port was necessary in 2 cases of LESS radical nephrectomy). The mean operative time was 197 min (85-510 min), mean estimated blood loss was 126 ml (50-400 ml), without blood transfusion in the perioperative period, mean postoperative hospital stay was 6.3 d (3-14 d), and mean duration of catheter drainage was 3.6 d (0- 14 d). Conclusions Transumbilical LESS nephrectomy is feasible, safe,minimally invasive and cosmetic. Long-term follow-up and a clinical control study are needed for evaluating clinical outcomes.     

肾癌区域淋巴结转移的临床分析

目的 了解肾癌区域淋巴结转移的临床特点及发生发展规律,提高对本病的诊治效果.方法 回顾性分析2004年1月至2008年12月19例肾癌伴有区域淋巴结转移患者的资料.男15例,女4例.年龄29～77岁,中位年龄57岁.肿瘤位于左肾12例,右肾7例.腹膜后肿大淋巴结最大径1.5～5.0 cm,中位数2.8 cm,其中4例影像学检查未发现肿大淋巴结,术中探查证实.行腹膜后肿大淋巴结切除11例,区域淋巴结清扫8例.结果 肾癌发生区域淋巴结转移占同期收治肾癌的1.6%(19/1213).术后19例均获随访,随访时间8～78个月,中位数34个月.无瘤生存6例,带瘤生存7例,死亡6例,5年生存率68.4%.腹膜后区域淋巴结清扫组与肿大淋巴结切除组生存期及术后复发转移率比较差异均无统计学意义(P=0.644;P=0.319).结论 肾癌发生单纯区域淋巴结转移少见,术前影像学可能漏诊,部分患者通过区域淋巴结清扫或肿大淋巴结切除可获得无瘤生存.

Abstract：

Objective To discuss the characteristics of renal cell carcinoma with regional lymph node metastasis at diagnosis. Methods The data of 19 patients diagnosed with renal cell carcinoma with regional lymph node metastases at diagnosis from January 2004 to December 2008 were reviewed.The median age was 57 years (29-77).The study group included 15 males and four females.The primary tumor was located in the left kidney in 12 patients and fight in seven patients.The median maximam diameter of retroperitoneal lymph nodes was 2.8 cm(1.5-5.0).The lymph nodes in four patients were not detected by the preoperative image examination,but were confirmed by intraoperative exploration.Eleven cases had enlarged retroperitoneal lymph nodes resected and eight had regional lymph nodes dissected. Results The patients with regional lymph node metastases at diagnosis of renal celI carcinoma accounted for 1.6% (19/1213) of the total renal cell carcinoma cases.With a median follow-up of 34 months,six patients were survival without progression,and seven were survival with progression.giving a 5-year survival rate of 68.4%.The survival and recurrence rates after surgery were not significantly different by Fisher test(P=0.644 and 0.319 respectively) between the patients who underwent retroperitoneal regional lymph node dissection and those who underwent enlarged lymph node resection. Condmiom Renal cell carcinoma with regional lymph node metastasis at diagnosis is uncommon.Some patients may achieve long-term tumor-free survival through regional lymph node dissection or enlarged Iymph nodes resection.     

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.     

T1b期肾细胞癌:根治切除手术还是部分切除手术

<正>肾细胞癌(renal cell carcinoma,RCC)是泌尿系统第二大肿瘤,2013年美国新发肾或肾盂癌65 150例,死亡13 680例[1]。肾癌根治术(radical nephrectomy,RN)是局限性肾细胞癌的标准治疗方式。同时,随着RCC特性及其生长规律研究的不断深入,肾部分切除术(partial nephrectomy,PN)适用范围正在不断扩大[2-3]。目前对于临床T1a期的RCC,国际上     

肾嫌色细胞癌21例临床分析及文献复习

目的 提高肾嫌色细胞癌的诊治水平和对此类型肾癌的认识.方法 回顾性分析21例肾嫌色细胞癌的临床资料.男11例,女10例.年龄27 ～ 85岁,平均52岁.11例行腹腔镜下肾癌根治术,8例行腹腔镜下肾部分切除术,2例行开放肾癌根治术.结果 术后病理证实为肾嫌色细胞癌.病理分期:pT1N0M0 13例,pT2N0M0 5例,pT3aN1 M0 2例,pT4N0M0 1例.Fuhrman病理分级:G1 6例,G2 14例,G31例.术后随访19例,时间3～36个月,平均17个月,1例死于心脏病,1例术后6个月局部复发,给予索拉非尼治疗2个月后肺部感染死亡,1例术后12个月后出现肺转移,给予索拉非尼治疗1个月后死亡,16例无瘤生存.结论 肾嫌色细胞癌是一种具有特殊形态的少见肾癌类型.肾根治性切除术是治疗肾嫌色细胞癌的首选方法.与同期、同级的其他类型肾癌相比,肾嫌色细胞癌预后较好.     

乳头状肾细胞癌临床分析

目的：总结分析乳头状肾细胞癌的临床特点,提高其诊治水平.方法：回顾性分析2003～2009年收治的乳头状肾细胞癌的临床资料.并与同期53例肾透明细胞癌比较.结果：乳头状肾细胞癌组患者年龄57.3（47～78）岁,皆为男性,占同期肾细胞癌9.4%.就诊时3例无症状,2例出现肉眼血尿,1例双侧腰痛伴腹部包块.肿瘤平均最大径为6.6（2.6～16.0）cm,未见多中心病灶.TNM分期：T1a N0 M0 3例,T1b N0 M0 1例,T2 No M0 2例 病理分型I型3例,Ⅱ型3例 Fuhrman分级Ⅱ级2例,Ⅲ级4例.与肾透明细胞癌相比,乳头状肾细胞癌好发于男性,影像学检查不具备恶性肿瘤特征,确诊有赖于病理和免疫组织化学检查.临床分期皆为I期或Ⅱ期.就诊时无一例出现远处转移.结论：乳头状肾细胞癌在临床表现上与肾透明细胞癌相似,但在影像学表现、病理形态及生物学行为上均与肾透明细胞癌有所不同.根治性肾切除术是目前首选治疗方式.靶向治疗有可能成为转移性乳头状肾细胞癌治疗的新方向.     

青年型肾癌56例报告

目的探讨青年型肾癌的临床特征及诊治措施。方法青年型肾癌56例。男36例,女20例。平均发病年龄32.4岁。偶发癌20例,症状癌36例。病程2 d～4年。临床症状有肉眼血尿18例、腰腹胀痛23例、消瘦乏力2例、发热3例、可触及肿块2例,其中有2项以上症状者12例。单侧55例,双侧1例。56例患者均行B超、CT检查,11例患者行KUB加IVU检查,2例行MR检查。50例行根治性肾切除,6例行保留肾单位手术。术后随访7～108个月,平均64个月。结果B超诊断错构瘤4例,多囊肾1例,肾脏炎性肿块1例,肾肿瘤50例;B超检出率89.3%。CT诊断为错构瘤2例,肾肿瘤54例;CT检出率96.4%。行MR检查2例,诊断肾肿瘤1例,错构瘤1例。9例有症状者行KUB加IVU检查,5例示肾集合系统受压,1例未显影,1例示肾盏破坏,2例示肾外形增大;2例偶发癌者行KUB加IVU检查均未见明显异常。20例偶发癌者肿瘤直径1.8～10.0 cm,平均4.8 cm;其中T1N0M0者16例,T2N0M0者3例,T3N0M0者1例。36例有症状者肿瘤直径2.5～13.0 cm,平均8.7 cm;其中T1N0M0者20例,T2N0M0者7例,T3N0M0者4例,淋巴结阳性者5例。偶发癌组20例中仅1例(T3N0M0)行根治术者于术后19个月肾窝复发,再次手术治疗,于术后53个月死于全身转移;偶发癌组的5年存活率为92.3%。症状癌组中8例因癌死亡,4例失访,5年存活率为66.7%。2组5年存活率比较差异有统计学意义(P=0.042)。结论青年型肾癌恶性程度与普通人群肾癌相仿,根治性肾切除是主要的治疗方式,合适的患者可行保留肾单位手术。     

肾嫌色细胞癌(附15例报告)

目的　提高肾嫌色细胞癌的诊治水平和对此类型肾癌的认识。　方法　回顾性分析15例肾嫌色细胞癌的临床资料。男 10例 ,女 5例。年龄 4 7～ 74岁 ,平均 5 7岁。均行根治性肾切除术。　结果　术后病理证实为肾嫌色细胞癌。病理分期 :pT1N0 M0 6例 ,pT2 N0 M0 5例 ,pT3bN0 M0 2例 ,pT1N2 M0 1例 ,pT2 N2 M0 1例。病理分级 :G2 10例 ,G3 5例。 11例获随访 ,随访 2～ 31个月 ,平均19个月 ,1例死于心脏病 ,1例局部复发 ,9例无瘤生存。　结论　肾嫌色细胞癌是一种具有特殊形态的少见肾癌类型。肾根治性切除术是治疗肾嫌色细胞癌的首选方法。与同期、同级的其他类型肾癌相比 ,肾嫌色细胞癌预后较好。     

Organ-sparing operative therapy of kidney tumors

In 24 (4.8%) of 503 patients with renal tumors, the growth was located in solitary or residual kidneys, and the overall renal function was diminished. This was the indication used for tumor enucleation or partial nephrectomy. Of the patients with renal cell carcinoma, 75% were free of tumor after a mean follow-up of 27 months (8-65). There were 18 patients with stage 1 (T1, T2, N0, M0) and 2 with stage 2 tumors. Three patients had a angiomyolipoma and one underwent nephrectomy because of a late postoperative complication. This outcome compares favorably with the results of radical nephrectomy in cases with normal kidney function. In conclusion, enucleation or partial nephrectomy is justified in patients with impaired renal function and may be considered in patients with T1, G1 tumors in normal functioning kidneys.     

Tumor size and regional lymph node metastasis in patients with M0 renal cell carcinoma: analysis in those having regional lymph node dissection

We evaluated the relationship between regional lymph node metastasis and tumor size in patients with M0 renal cell carcinoma who received regional lymph node dissection. The study involved 234 of the 247 patients with localized renal cell carcinoma who underwent radical nephrectomy with lymph node dissection at our institute between 1985 and 1999. Patients were arbitrarily classified into 3 groups by the greatest diameter of the tumor on preoperative computed tomography (CT): 4.0 cm or less (group A), 4.1 to 7.0 cm (group B), and 7.1 cm or more (group C). The incidence of lymph node metastasis was assessed in each group. The current study showed that 11 (4.7%) of the 234 patients with lymph node dissection together with radical nephrectomy were lymph node positive. The incidences of lymph node metastasis were 4.0% in group A, 2.3% in group B, and 8.4% in group C (p = 0.79). Of these 11 patients with lymph node metastasis, 2 (18.2%) have so far survived for over 5 years following surgery. Although the role of regional lymph node dissection with radical nephrectomy might be limited and controversial in renal cell carcinoma, urological surgeons should always be aware of possible metastasis for any tumor size.     

Laparoscopic radical nephrectomy for renal cell carcinoma--transperitoneal anterior approach

PURPOSE: To evaluate the usefulness of transperitoneal anterior approach in laparoscopic radical nephrectomy for patients with renal cell carcinoma. MATERIAL: Ten patients (Eight males and two females) with small renal cell carcinoma less than 7 cm in diameter were treated with laparoscopic radical nephrectomy between June 1997 and May 1999. Clinical stage was T1aN0M0 in 6 cases and T1bN0M0 in 4 cases. METHOD: Of the 10 patients, the initial four received preoperative embolization of the renal artery. Under general anesthesia laparoscopic radical nephrectomy via transperitoneal anterior approach was performed in all patients. This procedure facilitates initiated early access to the renal vessels as does open radical nephrectomy. The kidney was dissected en bloc with Gerota's fascia and delivered from the small skin incision without morcellation. RESULT: Two patients needed conversion to open surgery. The mean operating time of eight patients except for conversion cases was 247 minutes and the mean blood loss was 258 ml. There was no major complication associated with laparoscopic procedure. CONCLUSION: Transperitoneal anterior approach in laparoscopic radical nephrectomy is a suitable and useful procedure for the treatment of small renal cell carcinoma because it enables us to avoid possible tumor manipulation by early access to the renal vessels as open radical nephrectomy.     

后腹腔镜根治性肾癌切除术

目的　评价后腹腔镜下肾癌根治术的安全性及疗效。　方法　2002年 11月至2004年7月于后腹腔镜下行肾癌根治术 46例。男 24例,女 22例。年龄 23~86岁,平均 58岁。3例因无痛性全程肉眼血尿就诊,余 43例为B超体检发现。所有患者腹部均未触及肿物。B超检查报告肿物直径1. 5~8. 0cm,平均 4. 5cm,肿瘤位于肾上极 17例,肾中部 13例,肾下极 16例。46例均行CT检查, 41例行MRI检查,报告肿物大小均与B超相符,术前临床分期:T1N0M0 3例,T2N0M0 38例,T3aN0M0 5例。　结果　本组手术时间 60~255min,平均 145min;出血量 20 ~1000ml,平均 133ml; 32例肿瘤位于肾上极、瘤体>6cm、肿瘤与肾血管关系紧密者均行肾上腺切除。3例发生手术并发症,其中1例为生殖腺静脉损伤,出血约 1000ml转开放手术; 1例用直线切割器切右肾静脉时,误将腔静脉切割封闭了一半,但未出血; 1例为直线切割器切断肾动脉后残端喷血,用钛夹止血。病理报告:肾透明细胞癌 41例,囊性肾细胞癌 2例,嫌色细胞癌 1例,错构瘤 1例,嗜酸细胞瘤 1例。随访 1~20个月,平均 9个月, 1例因肾癌肝转移,于术后 1年死亡,其余病例仍无瘤生存。　结论　后腹腔镜下肾癌根治术安全可靠,疗效良好。     

Hand assisted laparoscopic radical nephrectomy for renal carcinoma using a new abdominal wall sealing device

PURPOSE: We report our initial experience with a hand assisted laparoscopic radical nephrectomy for patients with renal carcinoma, and compare our results to those of conventional open radical nephrectomy. MATERIALS AND METHODS: The clinical data on 6 consecutive patients who underwent hand assisted laparoscopic radical nephrectomy for stage T1N0M0 renal cell carcinoma were reviewed. We performed hand assisted laparoscopic surgery using the new LAP DISC* abdominal wall sealing device. We compared the results of this procedure with those of conventional open radical nephrectomy in 12 patients with stage T1N0M0 renal cell carcinoma. RESULTS: The hand assisted laparoscopic radical nephrectomy for renal carcinoma was successfully performed without any major or minor complications in all 6 patients. Mean operation time for the laparoscopic group was significantly longer than that for the open surgery group (303 minutes versus 224 minutes, p = 0.0042). However, no significant difference was observed in mean estimated blood loss for the 2 groups (264 ml. in the laparoscopic group versus 341 ml. in the open surgery group). The frequency of parenteral analgesia postoperatively in the laparoscopic group was significantly lower than that in the open surgery group (16.7% versus 75.0%, p = 0.043). In addition, the laparoscopic group seemed to recover more rapidly than the open surgery group. The abdominal wall sealing device was easy to attach to the abdominal wall, and allowed rapid hand removal and reinsertion. CONCLUSIONS: Our preliminary results indicate that a hand assisted laparoscopic radical nephrectomy with the abdominal wall sealing device is an effective and safe surgical procedure, and is less invasive than open radical nephrectomy.     

Renal cell carcinoma in children: single-center experience

Purpose

The aim of the study was to report the experience with renal cell carcinoma (RCC) in children.

Materials and Methods

We conducted a retrospective study on renal adenocarcinoma cases treated in our center between 1993 and 2008. The age limit was established at 15 years. We collected data on personal history, diagnostic age, sex, clinical presentation, tumor laterality, diagnostic procedure, and tumor stage according to TNM classification proposed by the International Union Against Cancer (2002), surgical technique, pathologic subtype, and outcome.

Results

Six children were included in this study (4 girls and 2 boys) with a mean age of 9.5 years (range, 4-14 years). Tumor affected the right side in 4 patients and the left side in 2. Follow-up ranged from 9 to 140 months (mean, 85). Two patients were diagnosed as stage T1aN0M0, another was T1bN2M0, and 2 were T2N0M0, whereas the last one was T3N2M0. Radical nephrectomy was performed in 5 patients, whereas partial nephrectomy was adopted in one patient. The most common histologic subtype was translocation morphology RCC. One patient had local recurrence, whereas the other 5 are currently disease-free.

Conclusion

Renal cell carcinoma is a rare histologic type of tumor in children, with certain features that differ from those in adults. In general, RCC in children tends to present later than Wilms' tumor and is usually associated with signs and/or symptoms of disease. In localized cases, the treatment of choice is radical nephrectomy.