肾癌患者凝血功能与肿瘤分期及转移的关系

目的 探讨肾癌患者凝血功能与肿瘤大小、分期及转移之间的关系.方法 2004-2009年连续收治肾癌患者290例.男181例,女109例.平均年龄(56.3±13.5)岁.其中透明细胞癌252例、乳头状癌19例、嫌色细胞癌5例、囊性肾癌3例,其他类型11例.临床分期Ⅰ期202例(T1a 118例,T1b 82例),Ⅱ期32例,Ⅲ期32例,Ⅳ期24例.N0264例,N1 11例,N2 15例.M0 273例,M1 17例.病理明确诊断为肾良性肿瘤186例作为对照组.比较2组患者术前纤维蛋白原(Fib)、凝血酶原时间(PT)、部分活化凝血酶原时间(APTT)及国际标准化比值(INR)水平.结果 肾癌组患者术前Fib值(39.6±15.6)g/L,对照组(32.8±8.2)g/L,2组比较差异有统计学意义(P<0.05);肾癌组PT(11.2±1.3)s、APTT(31.7±5.2)s、INR 1.0±0.1,对照组分别为(11.1±1.3)s、(32.4±4.2)s、1.0±0.1,2组比较差异均无统计学意义(P>0.05).肾癌T1a、T1b、Ⅱ、Ⅲ、Ⅳ期组患者Fib分别为(32.6±6.6)、(36.1±8.7)、(48.8±21.6)、(49.9±17.9)、(59.7±19.2)g/L,其中T1a组与对照组比较差异无统计学意义(P=0.88),其他组与对照组比较差异均有统计学意义(P<0.01).肾癌组高纤维蛋白原血症(Fib>44.0 g/L)者74例(25.5%),以病理检查为标准,高纤维蛋白原血症预测肿瘤转移的敏感性为60.5%,特异性为80.6%,阳性预测值为35.1%,阴性预测值为92.1%.结论 肾癌伴淋巴结及远处转移者血清Fib升高,肿瘤直径>4 cm者发生转移的可能性较大.术前Fib水平尤其是高纤维蛋白原血症有助于预测肿瘤转移,并协助制定手术治疗策略.     

血沉与肾癌肿瘤大小及分期的相关性分析

目的分析肾细胞癌患者血沉增快程度和肿瘤大小及分期的相关性。方法2000年1月至2004年12月原发性肾透明细胞癌患者173例,均行根治性肾切除术并经病理证实。男120例,女53例。年龄37～86岁,平均61岁。肿瘤最大径≤2.5cm者30例,2.6～5.0cm者130例,>5.0cm者13例。临床分期T130例,T2125例,T317例,T41例。173例患者术前均行血沉检查。按血沉增快程度分4组,红细胞沉降率<25mm/h为轻度增快组(A组)、25mm/h～为中度增快组(B组),50mm/h～为高度增快组(C组)、>100mm/h为极度增快组(D组)。对4组肿瘤大小及分期进行差异性分析和相关性研究。结果血沉正常者89例,A组18例,B组49例,C组14例,D组3例。A～D4组肿瘤大小差异性分析显示,χ2=13.621,P=0.003;Spearman相关分析显示相关系数为0.341,P=0.002。A～D4组间肿瘤分期差异性分析显示,χ2=5.959,P=0.114;Spearman相关系数为0.208,P=0.057。结论血沉与肾细胞癌肿瘤大小呈正相关,与肿瘤分期间不存在相关性。     

肝脏手术与凝血和纤溶功能异常

肝脏的疾病和手术容易引起凝血和纤溶功能失衡而诱发凝血病。近年来对其发生机制作了进一步的研究，对肝外科中凝血紊乱的监测和防治方面也取得了一些新的进展，本文就其有关内容进行了复习。     

急性主动脉夹层的凝血功能特点及围术期变化

目的:分析急性主动脉夹层患者基础凝血功能的特点及其在传统输血策略下围术期发生的变化,探讨该变化对于术后经验性输血策略的影响。方法:选择2012年9月—2013年1月在深低温停循环下接受全主动脉弓替换加象鼻支架手术的急性主动脉夹层患者20例,分别在麻醉诱导后(T1)、体外循环复温至36℃(T2)、鱼精蛋白中和后15 min(T3)、以及术后4 h(T4)4个时相点对每例患者抽取血样进行血栓弹力图检测,评价整体血凝块形成强度(MA)、凝血因子功能(R)、血小板功能(MAp)及功能性纤维蛋白原(MAf)水平,对各时相点的样本进行配对样本t检验。结果:急性夹层患者MAf基础水平(T1)较高,为(21.1±5.4)mm。各项指标在T2时相点时均显著低于T1时相点(P<0.05);在T3时相点仅有MAp基本恢复至术前水平(P>0.05),而其他指标仍显著低于T1;经过输血治疗后,T4时相点的MAp显著高于术前(P<0.05),MAf水平仍维持低水平并显著低于术前(P<0.05),而R、MA基本恢复术前状态(P>0.05)。结论:急性主动脉夹层患者基础凝血功能活化,术中纤维蛋白原损失较血小板损失更为严重,常规输血治疗可能导致纤维蛋白原补充不足而血小板补充过量。     

肝门阻断前后凝血及纤溶功能的变化

目的：探讨肝脏手术对凝血功能的影响。方法：采用肝功能正常的动物模型，观察常温下肝门阻断对凝血、纤功能的影响。结果：肝门阻断４５分钟不影响Ⅱ、Ⅴ、Ⅶ、Ⅹ因子的活性，而纤维蛋白原含量明显增高；蛋白Ｃ活性在术后第３天明显低于术中和对照组；血浆纤溶酶原激活物抑制剂的活性在术中明显下降，术后第３天基本恢。结论：常温下肝门阻断可引起术中和术后早期的凝血及纤溶活性增强，两系统在较高水平上处于动态平衡。如此时术中     

肿瘤干细胞及肾癌相关研究进展

肾癌是一种少见的对放疗和化疗均不敏感的实体瘤，其病因和病理机理尚不清楚。近年来，肿瘤干细胞的研究受到关注。人们发现干细胞和肿瘤干细胞具有许多共同的特性，还可能有类似的细胞表面标志。我们对肿瘤干细胞与肾癌的相关研究进展综述如下。     

肾癌阴茎转移致阴茎异常勃起1例报告

本院于2012年2月收治1例阴茎异常勃起患者,现报告如下。1病例报告患荷男性,69岁,因阴孳持续性勃起2周伴排尿困难入院。既往1个月前行左。肾癌根治术,病理回报左肾透明细胞癌合并肉瘤样‘肾细胞癌,腹主动脉淋巴结无转移。人院时查体：阴茎持续勃起状态,阴茎海绵体坚硬,触痛明显,阴茎海绵体根部可触及数枚蚕豆粒大小硬结．阴茎头较软。     

肝脏手术与凝血和纤溶功能异常(综述)

肝脏的疾病和手术容易引起凝血和纤溶功能失衡而诱发凝血病。近年来对其发生机制作了进一步的研究,对肝外科中凝血紊乱的监测和防治方面也取得了一些新的进展,本文就其有关内容进行复习。     

肾癌双侧肾上腺转移5例报告

目的总结分析肾癌对侧和双侧肾上腺转移的临床特点,探讨其诊断、治疗和预后。方法回顾性分析仁济医院2004年12月至2013年6月间5例双侧肾癌肾上腺转移患者的临床资料,5例患者中,男3例,女2例,平均69.2岁。肾癌根治术后迟发转移1例,为术后随访时影像学发现,再次行手术切除同侧肾上腺,术后病理证实为透明细胞癌转移;原发灶手术前发现肾上腺异常4例,术后均予免疫或分子靶向药物保守治疗。结果 5例患者发现转移后平均随访时间29.6个月,予IFN-α免疫治疗3例,2例死亡,1例病情稳定(SD);索拉非尼靶向治疗2例,目前均为SD。结论肾癌双侧肾上腺转移较为罕见,根据患者既往病史,结合影像学检查多数可明确诊断,考虑到对转移灶积极手术可能导致肾上腺皮质功能不全,多数患者应予免疫或靶向药物保守治疗。     

术前全身炎症反应指数和纤维蛋白原在肾癌切除术后肿瘤预后的影响

目的:探讨肾癌患者术前全身炎症反应指数(systemic inflammation response index,SIRI)和纤维蛋白原(fibrinogen,FIB)在预后评估中的临床价值。方法:回顾性分析2011年1月—2014年12月我院收治肾癌患者的临床及术后随访资料;采用受试者工作曲线(ROC)确定SIRI和FIB的最佳临界值。分析低SIRI组与高SIRI组和低FIB组与高FIB组临床特征间的差异;运用Kaplan-Meier法计算生存率,通过log-rank检验比较组间的生存率差异;通过Cox比例风险回归模型分析影响肾癌预后的影响因素。采用所有5年生存率的独立预后指标,包括Fuhrman分级,SIRI值,FIB值建立列线图,预测患者5年生存率。结果:本研究共收集188例肾癌患者,ROC曲线确定SIRI和FIB的最佳临界值分别为1.81和3.42 g/L,分为高SIR组、低SIRI组,高FIB组、低FIB组。术前SIRI水平与组间患者肿瘤大小、TNM分期、Fuhrman分级、淋巴结转移、高血压病史密切相关(P0.05);术前FIB水平与组间患者年龄、TNM分期、Fuhrman分级、淋巴结转移、有无高血压密切相关(P0.05)。Cox多因素回归分析结果显示,SIRI1.81、FIB3.42 g/L、Fuhrman分级是影响肾癌预后的独立危险因素。列线图结果发现可以预测患者术后5年生存率。结论:高SIRI和FIB是影响肾癌预后不良的独立危险因素,对预测患者术后生存状况有积极的作用。     

Rare presentation of renal cell carcinoma: Solitary sternal metastasis

Renal cell carcinoma (RCC) may present as metastatic disease. However, RCC with solitary sternal metastasis is rare. We report a rare case of RCC with synchronous solitary sternal metastasis. The patient underwent radical nephrectomy, sternal tumour resection and reconstruction as a one‐stage procedure. The role of open sternal biopsy is also described. Review of the literature was carried out and a reasonably lengthy survival was observed. We concluded that radical surgical resection and reconstruction may offer the best chance of survival in managing RCC with solitary sternal metastasis in renal cell carcinoma.     

Solitary psoas muscle metastasis after radical nephrectomy for renal cell carcinoma

Skeletal muscle is a very rare location for the metastasis of renal cell carcinoma (RCC) and only one case of solitary metastasis to the psoas muscle has been reported. We present a 63-year-old male patient with late recurrence (14 years) after left side radical nephrectomy for RCC. He first visited Chikushi Hospital, Fukuoka University, Japan in January 2000 for a postoperative follow-up because he had shifted residence to the area. Follow-up was by abdominal computed tomography (CT) and chest X-ray. In December 2001, a CT scan showed a 1.5 cm enhanced mass in the right psoas muscle without any other metastasis. The mass was resected that month and histological study showed RCC metastasis.     

Urethral metastasis from renal cell carcinoma

A case of metastasis to the prostatic urethra after transurethral resection of the prostate from a previously resected renal cell carcinoma (RCC) is reported here. Solitary urethral metastasis from RCC is extremely rare. Only four cases of urethral metastasis from RCC have been previously reported in the literature.     

舒尼替尼在晚期肾细胞癌治疗中的运用

目的：探讨苹果酸舒尼替尼对晚期肾细胞癌治疗的安全性和有效性。方法：晚期肾细胞癌患者22例,男18例,女4例,平均年龄56岁,均为转移性或难以手术的肾细胞癌患者。采用舒尼替尼治疗,其中18例为一线治疗,4例为二线治疗。均为单一服药,口服50mg／d,每4周停药2周者16例;口服37．5mg／d,连续服药者6例。持续用药至肿瘤进展或出现不可耐受的并发症。以6周为1个治疗周期,至少每2个治疗周期进行疗效评价。结果：1例患者服药不足2周期内死亡,可评价病例21例。部分缓解6例（28．6％）,疾病稳定13例（61．9％）,疾病进展2例（9．5％）,无完全缓解病例。常见的不良反应包括手足皮肤反应、皮疹、疲劳乏力、骨髓抑制、味觉变化等。结论：舒尼替尼治疗晚期肾癌患者效果确切,不良反应多数可控制,但对于KPS评分较低,一般情况差,肿瘤负荷大的患者,运用时需慎重。     

Eastern Cooperative Oncology Group performance status predicts bone metastasis in patients presenting with renal cell carcinoma: implication for preoperative bone scans

PURPOSE: We identified a subset of patients with renal cell carcinoma (RCC) who have a high likelihood of presenting with bone metastasis and would most benefit from a preoperative bone scan. MATERIALS AND METHODS: A database of 1,357 patients undergoing nephrectomy and/or immunotherapy for RCC at our institution was queried. Patients presenting with metastasis to the bones were identified and stratified according to T stage, Eastern Cooperative Oncology Group (ECOG) score, musculoskeletal symptoms and alkaline phosphatase. RESULTS: Of the patients 37% presented with metastasis. Bone metastasis was identified in 14% of patients. The incidence of bone metastasis was 5.4%, 13.8%, 15.4% and 28.2% in patients with T1 to T4 lesions, and 1.4%, 19% and 41% in those with an ECOG score of 0 to 2 and greater, respectively. T stage and ECOG score were then integrated. Bone metastasis was confirmed in 0.046%, 3.8%, 1.4% and 0% of patients with T1 to T4/ECOG 0 disease, and in 13.4%, 20%, 21.5% and 31% of those with T1 to T4/ECOG greater than 0 disease, respectively (p < 0.0001). Only 1.4% of patients with an ECOG score of 0 harbored bone metastasis, of whom 71% complained of musculoskeletal pain, 100% manifested extraosseous metastases and 25% had increased alkaline phosphatase at presentation. CONCLUSIONS: Performance status is an important predictor of bone metastasis in patients presenting with presumed RCC lesions. Bone scan should be performed in patients with an ECOG score of greater than 0 regardless of T stage but is unnecessary in those presenting with an ECOG score of 0, particularly when lacking symptoms and extraosseous metastasis.     

Pancreatic metastasis of renal cell carcinoma: presentation, treatment and survival

PURPOSE: The pancreas is an uncommon site of metastasis from renal cell carcinoma, comprising 2% of pancreatic tumors removed in sizable series of operations. To our knowledge the role of operative resection in the setting of metastatic malignancy to the periampullary region has not yet been defined. We reviewed the records of 6 women and 2 men who underwent pancreatic resection due to malignancy and analyzed various prognostic factors. MATERIALS AND METHODS: Between 1985 and 1995, 269 patients underwent pancreatic resection for malignancy at our hospitals, including 150 (56%) for pancreatic duct cancer, 65 (24%) for carcinoma of the ampulla, 27 (10%) for distal bile duct cancer, 19 (7%) for duodenal carcinoma and 8 (3%) for renal cell carcinoma metastasis. We reviewed the records of these latter 8 cases, and analyzed demographics, primary tumor type, disease-free interval, resection type, concomitant other organ resection, histological examination of the specimen, morbidity, adjuvant therapy and survival. RESULTS: Pancreatic metastasis of renal cell carcinoma was managed by duodenopancreatectomy in 5 patients and total pancreatectomy in 3. There were no perioperative deaths. Mean tumor size in cases of a solitary pancreatic metastasis was 4 cm. (range 1.5 to 8). In the 3 patients treated with total pancreatectomy there were 2, 5 and 3 pancreatic metastases, respectively. Pathological examination revealed negative lymph nodes in all cases. Mean survival was 48 months. At study end 6 patients were alive at 24, 26, 30, 46, 84 and 88 months, while 2 died at 13 and 70 months, respectively. CONCLUSIONS: We advocate aggressive surgical resection when possible. Surgical removal of metastatic lesions prolongs survival but radical lymph node dissection is not mandatory. We also recommend careful long-term followup of patients with a history of renal cell carcinoma.     

Retroperitoneal cystic metastasis from a small clear cell renal carcinoma

A 39-year-old housewife was referred to our hospital for the treatment of a small renal tumor. A 25 x 35 mm cystic mass that had been detected by computerized tomography scan just caudal to the renal hilus proved to be a metastasis from the renal carcinoma of clear cell type. The pathogenesis may have been due to tumor cells obstructing a lymphatic vessel draining the kidney. Cystic metastasis from renal cell carcinoma is very rare and this appears to be the second published case in the world.