Bosniak Ⅱ～Ⅲ类型肾囊肿处理方式的再思考

目的 探讨BosniakⅡ类和Ⅲ类囊肿的治疗原则. 方法 2005-2008年手术治疗BosniakⅡ类和Ⅲ类囊肿68例,其中男48例,女20例;年龄23～ 78岁,平均40岁.病变位于左侧37例,右侧31例;病变直径2.1 ～9.5 cm,平均5.1 cm.BosniakⅡ类囊肿31例,其中ⅡF 13例,Ⅲ类囊肿37例.术前诊断为良性病变49例,行肾囊肿去顶减压术,其中5例术中冰冻切片提示恶性病变行根治性肾切除,4例术后病理切片提示恶性病变行二期根治性肾切除.术前诊断为恶性病变19例,其中行肾部分切除术14例,一期行根治性肾切除5例. 结果 68例患者中,病理报告恶性病变21例(30.9％),良性病变47例(69.1％).BosniakⅡ类囊肿中恶性病变3例(9.7％),Ⅲ类囊肿中恶性病变18例(48.6％).术前诊断为良性病变而病理诊断为恶性病变行根治性肾切除9例(18.4％,9/49),术前诊断为恶性病变而术后病理诊断为良性7例(36.8％,7/19).42例患者获随访,随访时间8 ～ 65个月,平均31个月.其中恶性病变15例,良性病变27例.恶性病变患者术后1～4年出现肿瘤复发和(或)转移3例,良性病变术后2～5年出现复发性囊肿6例. 结论 BosniakⅡ类和Ⅲ类囊肿手术时应尽可能行部分肾切除,也可以将囊肿完全切除后行冰冻切片,因为仅取部分囊壁组织有可能漏诊其他部位的恶性病变.     

Bosniak Ⅱ～Ⅳ级肾囊性占位临床与病理学特点分析

目的探讨BosniakⅡ~Ⅳ级肾囊性占位临床与病理学特点。方法回顾性分析上海交通大学医学院附属仁济医院从2008年1月至2012年12月CT诊断为囊性肾脏占位(BosniakⅡ、ⅡF、Ⅲ、Ⅳ)的170例患者的病例资料,其中Ⅱ级囊肿73例,ⅡF级囊肿34例、Ⅲ级囊肿38例、Ⅳ级囊肿25例。男105例,女65例;年龄20~85岁,平均(56±14.2)岁;病灶位于左侧87例,右侧66例,双侧17例。80例接受手术治疗的患者中,Ⅱ级囊肿18例,ⅡF级囊肿8例,Ⅲ级囊肿30例,Ⅳ级囊肿24例;行腹腔镜肾囊肿去顶减压术25例,腹腔镜肾部分切除术15例,腹腔镜根治性肾切除术7例,开放肾癌根治术6例,开放肾部分切除术27例。其余90例进行了影像学的随访。分析不同分型囊性肾脏占位的良恶性比例、病理学特点、随访结果。结果手术病例中Ⅱ级囊肿恶性病例为1例(5.6%),ⅡF级1例(12.5%),Ⅲ级16例(53.3%),Ⅳ级21例(87.5%),组间比较有明显统计学差异(P0.01)。术后病理结果:恶性肿瘤共39例(透明细胞癌31例,乳头状癌8例),Fuhrman分级均为Ⅰ级。良性病例共41例(单纯囊肿26例,囊肿伴出血3例,囊肿伴感染5例,囊性肾瘤4例,错构瘤3例)。术后患者随访时间为6~65月,平均随访25月,恶性病例均无发生局部复发或远处转移。影像学随访病例中BosniakⅡ级为55例,ⅡF级26例,Ⅲ级为8例,Ⅳ级为1例,随访时间为6~64月,其中1例Ⅱ级(1.8%)进展至ⅡF级,其余病例均未进展。结论Ⅱ、ⅡF级囊肿恶性率较低、进展缓慢建议定期随访,而Ⅲ、Ⅳ级恶性率较高应积极手术处理。但由于囊性肾癌组织学分级往往较低,其术后复发、进展及远处转移率较低,保肾手术是首选的治疗方案。     

BosniakⅡ~Ⅳ级肾囊性占位临床与病理学特点分析简

目的 探讨Bosniak Ⅱ-Ⅳ级肾囊性占位临床与病理学特点。方法 回顾性分析上海交通大学医学院附属仁济医院从2008年1月至2012年12月CT诊断为囊性肾脏占位（BosniakⅡ、ⅡF、Ⅲ、Ⅳ）的170例患者的病例资料,其中Ⅱ级囊肿73例,ⅡF级囊肿34例、Ⅲ级囊肿38例、Ⅳ级囊肿25例。男105例,女65例;年龄20-85岁,平均（56±14.2）岁;病灶位于左侧87例,右侧66例,双侧17例。80例接受手术治疗的患者中,Ⅱ级囊肿18例,ⅡF级囊肿8例,Ⅲ级囊肿30例,Ⅳ级囊肿24例;行腹腔镜肾囊肿去顶减压术25例,腹腔镜肾部分切除术15例,腹腔镜根治性肾切除术7例,开放肾癌根治术6例,开放肾部分切除术27例。其余90例进行了影像学的随访。分析不同分型囊性肾脏占位的良恶性比例、病理学特点、随访结果。结果 手术病例中Ⅱ级囊肿恶性病例为1例（5.6%）,ⅡF级1例（12.5%）,Ⅲ级16例（53.3%）,Ⅳ级21例（87.5%）,组间比较有明显统计学差异（P＜001）。术后病理结果：恶性肿瘤共39例（透明细胞癌31例,乳头状癌8例）,Fuhrman分级均为Ⅰ级。良性病例共41例（单纯囊肿26例,囊肿伴出血3例,囊肿伴感染5例,囊性肾瘤4例,错构瘤3例）。术后患者随访时间为6-65月,平均随访25月,恶性病例均无发生局部复发或远处转移。影像学随访病例中BosniakⅡ级为55例,ⅡF级26例, Ⅲ级为8例,Ⅳ级为1例,随访时间为6-64月,其中1例Ⅱ级（1.8%）进展至ⅡF级,其余病例均未进展。结论 Ⅱ、ⅡF级囊肿恶性率较低、进展缓慢建议定期随访,而Ⅲ、Ⅳ级恶性率较高应积极手术处理。但由于囊性肾癌组织学分级往往较低,其术后复发、进展及远处转移率较低,保肾手术是首选的治疗方案。     

BosniakⅠ型肾囊性病变发生癌变的诊治经验(附5例报告)

目的:总结BosniakⅠ型肾囊性占位病变发生癌变的诊治经验。方法:回顾性分析5例BosniakⅠ型肾囊性恶性病变的B超、CT、病理特征、治疗方法和随访结果:男3例,女2例;年龄42～72岁,平均54岁。患侧腰酸1例,体检发现4例。囊腔直径5.5～8.0cm。术前B超及CT均诊断为肾囊肿。结果:5例均行腹腔镜下肾囊肿去顶术,术后病理检查诊断为透明细胞癌,再次行根治性肾切除术。5例随访6～33个月,4例无瘤存活,1例因心血管疾病死亡。结论:重视BosniakⅠ型肾囊性病变的影像学和病理学特征,术中行冷冻切片病理检查是提高BosniakⅠ型囊性肾癌诊治水平的关键。     

腹腔镜肾部分切除术治疗肾内生型复杂肾囊性病变的临床探讨

目的:探讨肾内生型复杂肾囊性病变行腹腔镜肾部分切除术(laparoscopic partial nephrectomy,LPN)的可行性和安全性。方法:回顾性分析我院2016年5月~2017年2月诊治的7例内生型复杂肾囊性病变患者的临床资料,所有患者均在腹腔镜超声(laparoscopic ultrasonography,LUS)协助下行LPN。男2例,女5例;年龄33~59岁,平均41.2岁;2例位于肾中部,2例位于肾上极,3例位于肾下极;囊肿直径2.5~3.5cm,平均2.9cm。Bosniak分型:Ⅱ型1例,ⅡF型3例,Ⅲ型2例,Ⅳ型1例。结果:本组7例患者均在LUS协助下成功进行LPN。手术时间65~110 min,平均72 min;术中出血量20~80 ml,平均42 ml;肾动脉阻断时间16~24min,平均19.2min。手术前后血肌酐无明显变化。术后病理结果肾透明细胞癌7例,所有切缘均阴性。结论:对于位于肾实质内部的内生型复杂肾囊肿,LUS可以协助手术医师行LPN,能完整切除肾实质内部的内生型复杂肾囊性病变,无论病理结果为良性还是恶性,均达到治疗目的。     

复杂肾囊性病变行腹腔镜肾部分切除术的临床分型探讨

目的:探讨复杂肾囊性病变行腹腔镜肾部分切除术(LPN)的可行性和临床分型。方法:回顾性分析2015年12月～2018年2月我院诊治的复杂肾囊性病变21例,均行LPN。男8例,女13例;年龄28～65岁,平均44.5岁;囊肿直径2.5～5.5cm,平均3.7cm。Bosniak分型:Ⅰ型6例,ⅡF型7例,Ⅲ型6例,Ⅳ型2例。依据LPN的处理难度和病变的深浅位置进行临床分型:肾外突型10例,肾中央型5例,肾窦型2例,肾门型2例,混合型2例。结果本组21例患者均成功行LPN。手术时间50～135min,平均77.2min;肾动脉阻断时间10～30min,平均16.4min。手术前后肌酐无明显变化。术后病理结果显示:肾透明细胞癌18例,单纯肾囊肿3例,所有切缘阴性。结论:依据手术的处理难度和病变的深浅位置进行初步临床分型:肾外突型、肾中央型、肾窦型、肾门型和混合型。肾外突型需要保证切除干净和囊肿不破裂;肾中央型和肾窦型需要借助腹腔镜超声精确定位;肾窦型病变多需切破肾集合系统以保证切缘阴性;肾门型需要注意对肾动脉、肾静脉和肾盂的保护,需严密分层缝合,减少漏尿和出血等风险。     

Bosniak分级在肾脏囊性病变的MSCT诊断中的应用价值观察

目的:研究Bosniak分级对肾脏囊性病变患者的临床应用,分析肾脏囊性病变患者MSCT(多层螺旋CT)的诊断价值。方法:临床纳入39例我院2014年11月～2017年10月期间收治的肾脏囊性病变患者,所有患者均经病理证实为肾脏囊性病变。对所有患者进行MSCT检查,同时进行Bosniak分级,分析Bosniak分级与病理结果的关系。结果:仅2例患者只行MSCT平扫,其余37例患者均在MSCT平扫后进行增强扫描。病灶位置:左肾21例,右肾18例。病灶直径:病灶最小者1. 2×1. 6 cm,病灶最大者7. 6×8. 5 cm。CT值:-2～62 HU。平扫见低密度患者33例,高密度患者4例,混杂密度患者2例。37例患者增强扫描,其中32例患者见不同程度强化。其中Ⅰ级患者4例,Ⅱ级患者9例,ⅡF级患者5例,Ⅲ级患者12例,Ⅳ级患者9例。Bosniak分级Ⅰ级、Ⅱ级病理检出良性比例明显高于恶性,Bosniak分级Ⅳ级病理检出恶性比例明显高于良性,均P 0. 05。Bosniak分级ⅡF级、Ⅲ级病理检出良恶性比例差异无统计学意义,P 0. 05。Bosniak分级越高,病理结果恶性程度占比例越高。结论:Bosniak分级对肾脏囊性病变的诊断具有指导意义,但对Bosniak分级中ⅡF级、Ⅲ级的肾脏囊性病变患者诊断不足。     

透明细胞乳头状肾癌1例

<正>患者,女,46岁,因"体检发现左肾囊肿并进行性增大7年"于2016年4月就诊我院。患者2009年体检发现左肾囊肿,未进一步处理。平素无血尿、腰痛、发热及尿路刺激症状。定期复查后,发现囊肿逐渐增大。半个月前患者在我院就诊,行CTU检查提示左肾上极无强化低密度影,直径约48mm,边缘见分隔,伴强化增高及点状钙化,印象:左肾囊性病变(BosniakⅢ型),左肾下部小囊肿     

囊性肾细胞癌的临床分析

1992年 1月～ 2 0 0 1年 4月 ,我院共收治肾细胞癌患者 181例 ,其中囊性肾细胞癌 12例 ,现报告如下。一、临床资料1 病例资料及诊断 :本组 12例 ,男10例 ,女 2例。年龄 14～ 76岁 ,平均 5 0岁。患者中 ,肿瘤位于左侧 8例 ,右侧 4例 ;上极 2例 ,下极 3例 ,中份 3例 ,占据肾大部分 4例。血尿 3例 ,腰痛 1例 ,1例行颅骨肿瘤切除后病理诊断为透明细胞癌 ,进一步检查发现肾原发病灶。体检 :Ｂ超发现 7例。根据Ｂｏｓｎｉａｋ[1] 肾囊性肿块分类 :Ⅰ类为单纯性囊肿 ;Ⅱ类为有少许并发症的囊性病变 ,属良性 ;Ⅲ类为有较多并发症的囊性病变 ,一些属…     

术中冷冻病理在复杂性肾囊肿治疗决策中的价值探讨

目的:探讨术中冷冻病理在复杂性肾囊肿治疗决策中的价值。方法:2010年1月~2015年12月我院收治复杂性肾囊肿患者52例,其中行术中冷冻者11例,Bosniak分级Ⅱ级1例,ⅡF级4例,Ⅲ级3例和Ⅳ级3例,8例报告为肾囊肿、肾囊肿伴出血或伴纤维组织增生,2例为肾透明细胞癌,1例为嗜酸细胞性肿瘤。结果:术后病理与冷冻病理符合者6例(54.5%),3例冷冻病理为肾囊肿者或多房肾囊肿者术后病理分别为肾透明细胞癌Ⅰ级、肾乳头状瘤和囊性肾瘤;1例冷冻病理为透明细胞癌者术后病理为多房性肾囊肿;1例冷冻为嗜酸细胞性肿瘤者术后病理为嗜酸性乳头状细胞癌,该例患者术后1年出现肿瘤复发和远处转移,于术后27个月死于肿瘤转移。结论:在处理复杂肾囊肿时应以保留肾单位手术为首选,对于怀疑有恶性可能但无法行肾部分切除时或术中发现血性囊液或囊壁结节时,可行术中冷冻病理决定手术方案。术中冷冻病理检查对于确诊及决定手术方式有一定帮助,但因取材、病理科医生阅片误差、肿瘤性质及冷冻病理技术限制,术中冷冻诊断复杂性肾囊肿仍有一定误诊率可能造成肾脏切除或肿瘤种植。     

An evaluation of Bosniak's radiological classification of cystic renal masses

OBJECTIVE: To determine the clinical usefulness of Bosniak's classification of cystic renal masses, the differentiation of which remains difficult despite significant advances in diagnostic imaging. PATIENTS AND METHODS: The computed tomography (CT) findings of all histopathologically examined cystic renal masses diagnosed at our institution were analysed retrospectively; 35 patients with cystic renal masses were treated between 1986 and 1998. Tissues surgically removed were examined pathologically and the final diagnosis compared with the preoperative CT category of Bosniak's classification. RESULTS: The histopathological examined showed cystic renal cell carcinoma in 21 patients, a benign renal cyst in 12, haemangiosarcoma in one and transitional cell carcinoma in one. Most of the 35 masses (26, 74%) were found incidentally during evaluation for an unrelated disease or a routine health check. All 11 masses of Bosniak category I were benign and one category II mass was malignant. All 10 masses of category III and 12 of category IV were malignant. CONCLUSIONS: Bosniak's classification is useful for differentiating category I, III and IV cystic renal masses. There were too few samples to allow meaningful conclusions to be drawn for category II renal masses. It is critical to differentiate between complicated cysts of category II and III because of the major implications for prognosis and clinical management.     

Comparación entre tomografía computarizada y resonancia magnética en la evaluación de quistes renales complejos empleando la clasificación de Bosniak

Introduction and objectivesThe Bosniak classification of cystic renal lesions was first published in 1986 based on computed tomography (CT). In the present study, we aimed to investigate the effect of magnetic resonance imaging (MRI) on Bosniak category compared with CT, and to determine how this effect changed the treatment modality in the evaluation of complex renal cysts.Material and methodsData of 144 patients were collected retrospectively. After exclusion criteria, 102 cystic renal lesions with a Bosniak category of at least IIF on CT or MRI between 2013 and 2016 were evaluated by 2 abdominal radiologists. The demographic data, Bosniak category, interobserver agreement, and pathologic data of patients who underwent surgery were recorded.ResultsThe coherence between MRI and CT was 75.5%. The Bosniak classification of 17 patients was upgraded with MRI, and the treatment modality changed in 10 patients, and they underwent surgery. The Bosniak category was downgraded from III to IIF in 6 patients out of 8 whose Bosniak category was downgraded with MRI and the treatment modality changed. Surgery was performed in one patient out of these 6 patients, and the pathology was reported as benign. Progression was detected in the follow-up at month 18 of 1 patient out of 5, and surgery was performed. The pathology was reported as renal cell carcinoma. The pathology result was reported as RCC in 35 (68.6%) patients out of 51 who underwent surgery. Progression was detected in 7 patients out of 51 who were followed up (13.7%), and the pathology results were reported as RCC. The majority of the malignant tumors were low stage and grade.ConclusionsMRI may be successfully used in the evaluation of renal cystic lesions. In particular, the challenging Bosniak IIF and all Bosniak III lesions must be evaluated using MRI before making the decision for surgery. The upgrading of Bosniak category with MRI is more possible compared with CT due to its high-contrast resolution, therefore further studies are required to identify whether it was the cause of overtreatment of Bosniak III lesions.     

Laparoscopic deroofing of a renal cyst: the hidden invasion

Cysts of the kidney usually originate from the renal parenchyma after tubule obstruction; rarely pyelocalyceal cysts occur, originating from transitional urothelium. Neoplasia is a rare but possible complication. A 45-year-old man was found to have a cyst related to the right kidney. Computed tomography demonstrated minimal calcification in the wall (Bosniak II). Symptom-relieving percutaneous drainage yielded clear fluid; resultant cytology was negative. After rapid reaccumulation, laparoscopic deroofing was performed. No communication within the renal pelvis was detected however histology revealed transitional cell carcinoma. An open radical nephroureterectomy was performed; adjuvant chemotherapy was given. Three previous cases of malignancy in a pyelocalyceal cyst have been reported. This is the first reported after laparoscopic deroofing of a cyst. Despite widespread use of the Bosniak renal cyst classification, the management of category II cysts remains contentious. This case should serve as a warning to clinicians that seemingly benign cysts of the kidney may harbor underlying neoplasia. Intraoperative frozen section should be considered in all cases where preoperative imaging suggests Bosniak II classification.     

囊性肾癌5例报告并文献复习

目的:探讨囊性肾癌的早期诊断及治疗方法。方法:回顾性分析2008年1月~2012年8月间收治的5例囊性肾癌患者的临床资料,1例术前影像学检查提示双侧肾脏占位病变,一侧为囊性占位病变;4例显示单侧肾脏单发囊性占位病变,左肾3例,右肾1例;其中男3例,女2例;年龄46~68岁,平均56.4岁;肿瘤体积21.84~208ml,平均101.96ml。按照Bosniak分类,Ⅱ类1例,Ⅲ类2例,Ⅳ类2例;T1期2例,T2期2例,T3期1例。3例术前诊断为囊性肾癌,1例为肾脏囊肿,1例为肾嗜酸性细胞瘤合并囊性肾癌。2例行肾癌根治术,2例行肾部分切除术,1例行囊肿去顶减压术后2周行肾癌根治术。并结合相关文献复习进行分析讨论。结果:5例患者术后病理检查报告证实为透明细胞癌2例,乳头状细胞癌1例,多房囊性肾癌1例,嗜酸细胞腺瘤伴囊性变1例。平均随访34.4个月(10~66个月),1例发生骨骼及肺部转移,余4例均无复发转移。结论:囊性肾癌是一种广义上的肾癌分类,有四种分型;与其他类型肾癌相比,大部分恶性程度较低。囊性肾癌的术前诊断主要依赖于影像学检查,对于可疑病例,术中需行快速冷冻病理检查。对此类肿瘤,建议行保留肾单位手术。     

Malignant B-cell lymphoma in renal cyst wall

Renal cysts are frequently found in adults older than 50 years of age. Bosniak type III and IV cysts are commonly associated with malignancy, but most Bosniak I and II lesions are benign, and the optimal management has not been clearly defined. Although computed tomography and ultrasound examinations have improved diagnostic accuracy, some masses will remain indeterminate and require more invasive evaluation. We report a patient with a Bosniak type II renal cyst associated with malignant B-cell lymphoma in the cyst wall diagnosed after laparoscopic renal exploration.     

肾癌患者核素骨显像必要性分析

目的 探讨肾癌患者核素骨显像检查的必要性.方法 行核素骨显像的肾癌患者152例.男106例,女46例.年龄11～86岁,平均56岁.肿瘤直径1.5～20.0 cm,平均6 cm.TNM和AJCC分期:I期88例,其中T1a47例、T1b41例;Ⅱ期38例;Ⅲ期16例,其中T3a10例、T3b6例;Ⅳ期10例.组织学分级高分化90例,中分化43例,低分化19例.应用Logistic回归对10项可能影响肾癌骨转移的临床病理学因素进行分析.结果 152例患者中核素骨显像异常33例,其中骨转移22例(14.5%).126例局限性肾癌中发生骨转移11例(8.7%);16例局部进展性肾癌中发生骨转移5例(31.2%);10例转移性肾癌中发生骨转移6例(60%).Logistic回归分析结果表明肾癌骨转移与临床分期相关,肾癌中有骨痛症状者骨转移率为40.9%(9/22).结论局限性肾癌(Ⅰ、Ⅱ期)患者不必常规行骨显像检查,有骨痛症状情况下可考虑使用;临床分期≥Ⅲ期者,不管有无骨痛症状均应考虑核素骨显像检查. 能影响肾癌骨转移的临床病理学因素进行分析.结果 152例患者中核素骨显像异常33例,其中骨转移22例(14.5%).126 局限性肾癌中发生骨转移11例(8.7%);16例局部进展性肾癌中发生骨转移5例(31.2%);10例转移性肾癌中发生骨转移6例(60%).Logistic回归分析结果表明肾癌骨转移与临床分期相关,肾癌中有骨痛症状者骨转移率为40.9%(9/22).结论局限性肾癌(Ⅰ、Ⅱ期)患者不必常规行骨显像检查,有骨痛症状情况下可考虑使用;临床分期≥Ⅲ期者,不管有无骨痛症状均应考虑核素骨显像检查. 能影响肾癌骨转移的临床病理学因素进行     

肾脏小肿块的诊断和治疗（附80例报告）

目的：提高实性或复杂性囊性肾脏小肿块（SRM）的诊断与治疗水平。方法：回顾性分析80例经B超、CT或MRI证实为实性或复杂性囊性SRM患者的临床资料：实性SRM患者75例。BosniakIII级、Ⅳ级囊性SRM患者各3例和2例。良性SRM息者12例,怀疑恶性SRM患者68例。其中行开放根治性肾切除术、腹腔镜根治性肾切除术和开放性保留肾单位手术各52例、5例和11例．对12例良性SRM患者及4例术后病理检查证实为良性者每6～12个月随访1次;对术后病理检查证实为恶性者64例术后每3～6个月密切随访1次。连续3年,以后每年1次。结果：对12例良性SRM患者及4例术后病理检查证实为良性者密切随访未见肿块明显增大、复发或恶变;68例怀疑为恶性SRM患者中,术后病理检查确诊者64例。随访62例无肿瘤复发或转移,1例术后30个月出现肿瘤复发．1例术后16个月死于肿瘤转移。结论：明确SRM的良、恶性,对恶性SRM患者采取合适的治疗方法。仍然是临床处理SRM的关键。     

Complex renal cystic masses: current standards and controversies

Bosniak classification system is the only preoperative diagnostic tool that has proven its efficiency in the management of complex renal cystic masses. However, it is reader dependent, despite its clear definition of each category. The overall incidence of malignancy in each category did not change significantly over the past 20 years. Current limitations are interobserver variability among readers and a fact that a significant proportion of Bosniak III masses have benign character. The goal is to depict these masses preoperatively and spare the patients of unnecessary surgeries, which raises the question: What particular findings will help in differentiating a Bosniak IIF lesion from a Bosniak III lesion? Do we need to define critical variables that could improve accuracy of Bosniak classification by developing a future nomogram or risk calculator? Some radiologists and urologists erroneously tend to group Bosniak II and IIF in one category and observe them regularly. It seems that radiographic growth itself is insufficient factor for intervention. The change of internal architecture and presence of enhancement play the most important role in depicting malignant lesions during the time frame of active surveillance.