对肾细胞癌临床分期的新设想

肾细胞癌简称肾癌,是泌尿外科领域最常见的恶性肿瘤之一。其发病率占泌尿系肿瘤之第二位。肾癌准确的分期直接关系到对其制定正确合理的治疗方案和判断患者的预后,因此极为重要。1968后,Robson在Flocks和Kadseky分类基础上提出了肾癌四期分期法;2002年AJCC(美国癌症联合委员会)的TNM分期法得到国内外广泛的临床应用。但随着临床研究的进展出现了新的观点,到2009年,AJCC对肾癌TNM分期又提出了4点修改意见。可见,随着科学的发展,临床研究的深入,对肾癌的诊治和分期必然会出现一些新观点、新动向,应及时增添进肾癌的分期之中。鉴于上述,我们试图提出一个更简明扼要、易于临床操作、实用性强的新方案,供同道们探讨,起抛砖引玉之效应。我们的方案主要强调先将肾癌的临床表现划为三大类型,即局限型肾癌、局部进展型(或称局部浸润转移型)肾癌和转移型肾癌。然后在每一大类型中再依据肿瘤体积、浸润、转移的不同分为4个期(A期、B期、C期、D期)。本文新分期法简单明了,一目了然,易操作,实用性强。     

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.     

年龄因素与成人肾恶性肿瘤临床发病特点的关系

目的 探讨年龄因素与成人肾恶性肿瘤临床发病特点的关系。方法 回顾性分析442例成年肾恶性肿瘤患者的临床资料，并按年龄分为〈40岁组、40～60岁组和〉60岁组，对3组患者发病性别比例、症状表现、病理表现、临床分期、淋巴结转移等方面进行比较，分析年龄因素与成人肾恶性肿瘤发病特点的关系。结果 3组男女比例分别为1．2：1．0、1．8：1．0、2．3：1．0，〈40岁组与〉60岁组比较差异有统计学意义（X^2=4．543，P=0．033）；偶发癌所占比例〈40岁组与〉60岁组均低于40～60岁组，但组间差异无统计学意义（P〉0．05）；肾细胞癌在各种肾实质恶性肿瘤中的比例表现出随年龄增长而增加的趋势，且〈40岁组与〉60岁组比较差异有统计学意义（P=0．045）；〉60岁组肾盂肿瘤比例为26．6％，显著高于其他2组（P≤0．001）；〈40岁组中10．2％的患者病理检查结果显示肿瘤为高度分化不良或未成熟组织肿瘤，高于其他2组，但仅与〉60岁组间差异有统计学意义（P=0．019）；3组临床分期构成比之间两两比较差异均有统计学意义（P≤0．011）；〈40岁组中25．4％的患者出现淋巴结转移，与其他2组比较差异均有统计学意义（P≤0．003）。结论 年龄与成人肾恶性肿瘤临床发病特点之间关系密切，不同年龄人群具有不同的发病特点。     

肾肿瘤的诊治进展 肾细胞癌分类、分级、分期现状和预后因素

肾细胞癌(renal cell carcinoma，RCC)是最常见的肾恶性肿瘤。肾肿瘤中80％以上为RCC，约40％的RCC病人最终因肿瘤进展恶化而死亡。当诊断为RCC时已有20％。30％发生转移，即使能切除，术后仍有30％-50％在局部复发。Pantuck等报告自1950年肾恶性肿瘤发病率与病死率逐渐上升，至2001年发病率上升了126％，病死率上升了36．5％。     

肾细胞癌的大小,分期与生存率

为明确肾肿瘤大小、分期及生存率之间的关系，回顾分析了自１９８０年１月～１９９１年６月收治的肾癌患者６１８例。结果表明：肾癌大小、分期和生存率三者密切相关，较大的肿瘤其分期普遍增高（Ｐ≤０．０００１），且生存率明显下降（Ｐ≤０．０００１）。在Ｒｏｂｓｏｎ分期为Ⅱ、Ⅲ、Ⅳ期时，肿瘤大小可预示患者的生存率。     

一侧肾透明细胞癌并发乳头状肾细胞癌1例

患者,男,74岁.无痛性肉眼血尿半年,超声检查示左肾占位入院.B超示左肾中上方见一圆形无回声区,大小约58 mm×57 mm×76 mm,形态欠规则,略呈分叶状,边界清,见包膜回声.超声造影检查:上方无回声区未见增强.KUB IVP示左肾未显影,内见钙化灶.CT示左肾中上极占位,直径约75 mm,肿瘤经造影后增强,肾周未见肿瘤侵犯,未见肿大淋巴结.     

肾细胞癌微血管密度与癌细胞转移的相关性

目的 探讨肾细胞癌（肾癌）微血管密度与癌细胞转移的相关，以寻找判断肾癌细胞转移的可靠指标。方法 用和八因子相关抗原（Ｆｓ因子）的单克隆抗体对３２例肾癌石蜡切片行免疫组织化学染色，计数２００倍视野内染色的微血管数（即微务管密度）。根据临床和术后病理检查是否存在癌细胞转移将患分为两组。结果 有癌细胞转移平均微血管密度为７６±，无癌细胞转移为４４±２０，两间有显性差异（Ｐ〈０．０５）；ｌｏｇｉ     

乳头状肾细胞癌的临床病理表现

目的 探讨乳头状肾细胞癌的临床病理表现,提高对此类型肾癌的认识。方法 回顾性分析9例乳头状肾细胞癌患者临床病理资料并进行随访。结果 9例乳头状肾细胞癌占同肾癌的1.9％,平均发病年龄52岁。无自觉症状者5例,血尿4例。7例行肾癌根治术,1例行肾输尿管全长切除术,1例保留肾单位的肿瘤切除术。肿瘤最大径4－15cm,多位于肾皮质,淡黄色到金黄色,单灶或多灶性结节性长。均以乳头或乳头管状结构为主,乳头轴心可见泡沫细胞。9例均有细胞角蛋白CK7表达。Fuhrman病理分级G13例、G24例、 G32例。TNM病理分期pT27例、pT3a1例、pT3bN1V1b1例。随访7例无瘤生存36－134个月,1例G2pT3b者无瘤生存11个月,1例G3pT3a者13个月后死于肾癌转移。结论 乳头状肾细胞癌是少见的肾癌,表现为低分期,预后好。     

肾透明细胞癌患者术前血小板分布宽度与临床病理特征相关性分析

目的:活化的血小板可以增加肿瘤细胞的增殖与侵袭能力,血小板分布宽度(PDW)是血小板活化的重要指标之一。本研究旨在分析患者术前PDW与肾透明细胞癌(CCRCC)临床病理特征的相关性。方法:回顾性分析2014年12月～2017年12月我院收治255例CCRCC患者的临床资料,包括年龄、性别、吸烟饮酒史、血小板计数(PLT)、平均血小板体积(MPV)、PDW、肿瘤部位和大小、病理分级和分期等。根据ROC曲线确定PDW临界值,分为低PDW组(PDW≤12.25 fl)和高PDW组(PDW12.25 fl)。比较两组患者在临床特征和病理特征方面的差异,并分析影响CCRCC病理分期的相关因素。结果:低PDW组与高PDW组在年龄、性别、肿瘤部位、吸烟及饮酒等方面比较差异无统计学意义(P0.05),PLT、MPV比较差异有统计学意义(P0.05)。在病理特征方面,低PDW组与高PDW组在病理分期、肿瘤大小及淋巴结转移等方面比较差异有统计学意义(P0.05)。此外,多因素Logistic回归分析发现,PWD与CCRCC病理分期呈良好的相关性。结论:CCRCC患者术前低PDW值预示肿瘤病理分期较高、体积较大且易出现淋巴结转移,PDW是CCRCC患者病理分期的独立影响因素,可能成为评价CCRCC患者术前病理特征的检测指标。     

Association between age and clinical characteristics of renal cell carcinoma in adult patients

AIM: To study the association between age and clinical characteristics of renal cell carcinoma in adult patients. METHODS: Three hundred and ten patients with renal cell carcinoma were classified into three groups: or=60 years group. The clinical characteristics of the three groups were compared to define the association. RESULTS: The male/female ratio was 1.3/1, 2.0/1, 3.3/1 in the three groups, respectively, and a significant difference appeared when comparing the or=60 years group (P=0.010). The respective percentage of incidental renal cell carcinoma was 27.9%, 43.2%, 31.2%, and it was significantly higher in the 41-59 years group than the >or=60 years group (P=0.047). The incidence of poorly differentiated renal cell carcinoma decreased with age increasing (11.6% vs 5.2% vs 2.7%), and there was significant difference between the or=60 years group (P=0.038). In the 相似文献   

pT1 substaging in renal cell carcinoma: validation of the 2002 TNM staging modification of malignant renal epithelial tumors

PURPOSE: Tumor size has been used as one of the criteria to stratify renal cell carcinoma (RCC) into different pathological stages (pT). The recent 2002 UICC/TNM classification of malignant epithelial renal tumors is modified to substratify pT1 RCC into pT1a (less than 4.0 cm) and pT1b (greater than 4.0 but less than 7.0 cm). In this study we ascertained if this stage modification has prognostic relevance. MATERIALS AND METHODS: A total of 259 consecutive radical nephrectomy specimens of organ confined RCC from 1970 to 1997 at 1 institution, including 153 of conventional RCC (CRCC), 71 of papillary RCC, 28 of chromophobe RCC, 1 of collecting duct carcinoma and 6 of RCC not otherwise specified, with a mean clinical followup of 7.5 years (median 6.4) were included in the study. RESULTS: There were 115 pT1a (44.4%), 95 pT1b (36.7%) and 49 pT2 tumors (18.9%). Disease recurrences (DR) and disease specific death occurred in 2 (1.7%) and 0 cases (0%) of pT1a, 7 (7.3%) and 5 (5.3%) of pT1b, and 16 (32.6%) and 12 (24.5%) of pT2. DR for pT1b was higher compared with pT1a (all histological subtypes RR 3.68), although this difference was not statistically significant (p = 0.106). If only CRCCs were analyzed, DR in the pT1b group was statistically higher compared with pT1a (RR 8.54, p = 0.047). Disease specific survival in pT1a could not be evaluated because no deaths occurred in this subgroup. DR and disease specific survival were significantly different between pT1b and pT2 tumors for all histological subtypes (RR 5.51, p = 0.001 and 5.49, p = 0.001) and for the CRCC subtype (RR 5.50, p = 0.001 and 5.18, p = 0.005, respectively). Using size as a continuous variable the logarithmic change in tumor size was a significant predictor of DR (RR 8.82, p = 0.001). All statistical analyses were adjusted for age and sex. CONCLUSIONS: Substaging RCC into pT1a and pT1b yields prognostically important information, validating the 2002 TNM modification for malignant renal epithelial malignancies. The substratification of pT1 is particularly useful in tumors with CRCC histology.     

The influence of pNx/pN0 grouping in a multivariate setting for outcome modeling in patients with clear cell renal cell carcinoma

PURPOSE: Lymphadenectomy, especially extended lymphadenectomy, is not commonly performed in patients undergoing a radical nephrectomy for clear cell renal cell carcinoma. Surgeons may sample suspicious regional lymph nodes, but the lymph node status of many patients with renal cell carcinoma remains unknown, termed stage pNx. Outcome models based on large institutional reviews have been criticized for grouping stages pNx and pN0 cases because of concern that the pNx category may include unrecognized stages pN1/pN2 disease. We evaluated cancer specific survival differences in patients with clear cell renal cell carcinoma and a lymph node stage of pNx, pN0 or pN1/pN2. MATERIALS AND METHODS: We searched the registry at our institution for patients who underwent radical nephrectomy for clear cell histology renal cell carcinoma between 1970 and 1998. Those with distant metastases at surgery were excluded from study. Clinical features obtained from the medical record included age at surgery, history of tobacco use, hypertension and symptomatic disease at presentation. A single urological pathologist reviewed all tumor specimens for nuclear grade, tumor necrosis, surgical margin status, 1997 tumor stage and lymph node status. These features were compared in patients with stages pNx and pN0 tumors. Cox proportional hazards models were used to compare cancer specific survival in univariate fashion, and after adjusting for tumor stage and grade. RESULTS: The study cohort consisted of 1,535 patients with sporadic, unilateral clear cell renal cell carcinoma who underwent radical nephrectomy. There were 600 patients (39%) with stage pNx, 870 (57%) with stage pN0 and 65 (4%) with stages pN1/pN2 tumors. At an average of 4.2 years after surgery 414 patients died of renal cell carcinoma. On univariate analysis patients with stage pN0 tumors were significantly more likely to die of renal cell carcinoma than those with stage pNx tumors (risk ratio 1.40, 95% confidence interval 1.12 to 1.75, p = 0.003). However, after adjusting for tumor stage and nuclear grade the difference in outcome for stages pNx and pN0 tumors was not statistically significant (risk ratio 1.07 95% confidence interval 0.85 to 1.34, p = 0.583). Patients with stage pNx disease were significantly less likely to be symptomatic at presentation (p = 0.002), have tumors that were less than 5 cm. (p <0.001) and of lower stage (p <0.001) and grade (p = 0.005), and to have tumors with necrosis (p = 0.024) than patients with stage pN0 disease. CONCLUSIONS: Combining stages pNx and pN0 cases to create outcome prediction models after radical nephrectomy for clear cell renal cell carcinoma is appropriate in a multivariate setting that includes tumor stage and grade. Clinical features available preoperatively and during surgery can help guide the decision to perform limited lymph node sampling. When the tumor is 5 cm. or greater, shows pathological necrosis or is advanced grade 3 or 4, lymph node sampling adds little prognostic information.     

Tumor size predicts synchronous metastatic renal cell carcinoma: implications for surveillance of small renal masses

PURPOSE: Active surveillance of small incidental renal masses is associated with slow radiographic growth and a low risk of metastatic progression. Radiographic tumor size, in the absence of histological data, is the only prognostic indicator available when considering active surveillance. To better define the relationship between tumor size and the metastatic potential of small renal masses, we investigated whether radiographic tumor size predicts for the presence of synchronous metastases in renal cell carcinoma. MATERIALS AND METHODS: We reviewed our institutional tumor registry to identify sporadic pathologically verified renal cell carcinoma treated during an 8-year period. We analyzed data regarding primary tumor size and the presence of biopsy proven synchronous metastatic disease at presentation. All N+M0 and nonpathologically confirmed M+ disease was excluded from analysis. RESULTS: We compared 110 cases of renal cell carcinoma with biopsy proven synchronous metastatic disease at presentation to 250 controls with clinically localized renal cell carcinoma. Tumors associated with synchronous metastasis were significantly larger than localized lesions (median 8.0 cm [range 2.2 to 20.0] vs 4.5 cm [range 0.3 to 17.5], p <0.0001). The probability of synchronous metastasis increased with increasing primary tumor size (p <0.0001). There were no patients with tumors 2 cm or smaller who presented with biopsy confirmed metastatic disease and less than 5% (5 of 110) of all synchronous metastasis occurred in tumors 3.0 cm or smaller. Logistic regression models determined that the odds of synchronous metastasis increased by 22% for each 1 cm increase in tumor size. CONCLUSIONS: Radiographic tumor size is a significant clinical predictor of the presence of biopsy proven synchronous metastatic renal cell carcinoma. In our series the odds of presenting with synchronous, biopsy proven metastatic disease increased by 22% with each 1 cm increase in tumor size. A 100% odds increase, or doubling of the risk of metastasis, occurs with a 3.5 cm increase in primary tumor size. These data have important implications for extent of disease evaluations in patients with large tumors and for the active surveillance of small enhancing renal masses.     

The utility of screening renal ultrasonography: identifying renal cell carcinoma in an elderly asymptomatic population

OBJECTIVE: To evaluate the efficacy and utility of screening renal ultrasonography (RUS) in older patients with a high prevalence of risk factors for renal cell carcinoma (RCC), as with the widespread use of advanced imaging techniques the identification of incidental RCC has increased, and although previous studies in low-risk groups reported little use for screening RUS, its utility in high-risk groups is unknown. PATIENTS AND METHODS: From 1993 to 1997, screening RUS was completed for 6678 consecutive patients in conjunction with the Aneurysm Detection and Management study. Patient demographics, medical and social history were recorded for each patient. Screening RUS was completed by one ultrasonographer using a 3.5-MHz sector scanner. A urologist verified any abnormalities identified by RUS during consultation. Additional imaging tests were obtained selectively and intervention was recommended based on the results of the genitourinary evaluation. RESULTS: From the screened population of 6678 patients, 817 (12.3%) renal anomalies were found, including a solid renal mass in 22 (0.32%), simple renal cysts in 627 (9.4%), hydronephrosis in 21 (0.31%), renal calculi in 121 (1.8%), or other abnormalities in 24 (0.36%). Treatment was completed for 15 renal cancers; 13 were organ-confined on pathological review. At a mean follow-up of >55 months, 12 of the 15 patients with RCC survived. CONCLUSIONS: In this older cohort, retroperitoneal RUS was an effective tool for case-finding by detecting significant findings in an asymptomatic population. The prevalence of solid renal masses (0.32%) was higher than reported with other screening protocols. Although probably not the best method for generalized primary screening, the use of RUS may still be beneficial for 'secondary' screening in a more selected patient population.     

The clinical characteristics of renal cell carcinoma in female patients

Objective:   To investigate the clinical characteristics of renal cell carcinoma (RCC) in female patients.
Methods:   The clinical characteristics including sex, age at diagnosis, histological tumor size, histological subtype, Fuhrman nuclear grade and pathological tumor–node–metastasis (TNM) stage of 881 consecutive patients treated with (partial) nephrectomy for RCC from 1998 to 2006 were analyzed. Characteristics of different gender groups and different female age groups were compared. The one-way anova and t -test were used to compare means. Pearson's χ²-test and the likelihood ratio test were used to compare ratios.
Results:   Low-grade tumors accounted for 79.3% of female patients and 64.1% of male patients ( P  < 0.001). The percentage of stage T1–2 was 76.6% in female patients while it was only 68.5% in male patients ( P  = 0.011). Also, female patients had more T1–2N0M0 tumors (73.0% vs 64.3%, P  = 0.009). Once female patients were classified into three groups according to age diagnosis (≤40, 41–59 and ≥60 years) young female patients seemed to have more tumors with unfavorable histology (8.7% vs 5.1% vs 4.3%), Fuhrman grade 3–4 (23.9% vs 23.1% vs 17.7%) and stage T3–4 (28.3% vs 23.1% vs 22.0%).
Conclusion:   Compared with male patients, female patients had lower stage and grade tumors. However, younger female patients had more tumors with unfavorable histology, and higher stage and grade compared to older female patients.