【作者】 王凯臣；

【导师】 孔祥波；

【作者基本信息】 吉林大学 ， 外科学， 2004， 硕士

【摘要】 肾癌是最常见的泌尿系统恶性肿瘤，其发病率约占全身恶性肿瘤的2%-3%，位居泌尿生殖系肿瘤的第二位。在美国每年大约有30000例新诊断的肾癌患者，其中约12000例死亡。在美国和西欧国家，肾癌位于致死性癌症的第十位。大约百分之四十肾癌患者死于远处转移，百分之二十五至四是接受局部治疗的患者将发展为远处转移。远处转移患者平均生存时间为6-10个月。随着超声和CT等影像学的广泛应用，肾癌的确诊率不断提高，临床上无明显症状而在体检时偶然发现的肾癌亦日渐增多。对肾癌的治疗方法及治疗效果提出更多的问题。目的：探讨肾细胞癌的不同手术方式、根治术前肾动脉栓塞及免疫治疗肾癌治疗中的临床应用价值。材料和方法： 现收集了1997年1月至2002年12月经吉林大学中日联谊医院泌尿外科诊断和手术治疗的179例肾细胞癌患者的临床资料及部分术后随访情况。其中男性患者118例，女性61例。年龄27～74岁，平均57.6岁。肿瘤发生于左侧者87例，右侧者92例。术前均经影响学检查诊断为肾脏肿瘤。其中172例接受了肾癌根治术，行区域性淋巴结清扫者133例，行根治性肾切除术加扩大淋巴结清扫术39例；其余7例行保留肾组织手术。其中78例术前行肾动脉造影加栓塞术再行肾癌根治术；31例于术中或术后接受了免疫治疗。对上述患者的临床资料、治疗效果及部分患者术后随访情况分别进行分组对照，并作统计学分析。结果： 接受肾癌根治术患者中行区域性淋巴结清扫组（133例）与扩大淋巴结清扫组（39例）进行比较，在手术时间、术后住院时间、术后肠功能恢复时间、术后下床活动时间及术中输血比率上前者明显优<WP=47>于后者，两组有显著性差异（P<0.05）；而在术后5年生存率方面两组无显著性差异（P>.05）。小肾癌（直径≤3.0cm）行肾癌根治术（22例）与保留肾组织手术（7例）进行比较，在手术时间、术后住院时间、术后5年生存率方面两组均无显著性差异（P>0.05），但行保留肾组织手术组术后容易发生尿漏、出血等并发症。行根治术患者中术前行选择性肾动脉栓塞者78例，肿瘤直径平均10.5cm，手术证实栓塞效果满意，利于术中剥离及完整切除肿瘤，并且术中出血少。结论：肾癌根治性切除术被认为是治疗肾癌的经典的术式。区域性淋巴结清扫术与扩大淋巴结清扫术患者5年生存率无显著性差别。并且区域性淋巴结清除术手术操作简单，耗时短，术中术后并发症少。对于小肾癌，与保肾单位手术相比，肾癌根治术并不能明显提高患者5年生存率，保肾单位手术是治疗局限性小肾癌的有效手段，但术后易发生尿漏、出血等并发症。对于较大的肾癌，术前行肾动脉栓塞可手术顺利切除病灶提供更便利的条件，提高了肿瘤的切除率。免疫治疗是继手术治疗肾癌之后的又一种主要临床治疗方式，特别是最近肿瘤疫苗的研究为广大肿瘤患者带来了新的曙光，其中值得提出的是主动特异性免疫治疗（ASI）、树突细胞（DC）~肿瘤细胞融合疫苗及热休克蛋白-缩氨酸复合体(HSPPC)。主动特异性免疫治疗是一种安全、特异性高、无毒副作用的治疗肿瘤的方法，在肿瘤疫苗中是应用临床治疗最早的方案，可作为外科手术治疗的主要的后续治疗手段，它能明显提高患者的免疫功能，增强患者机体抗肿瘤能力，已达到控制肿瘤、预防肿瘤复发的目的。以树突细胞为基础的免疫治疗具有很好的耐受性与可行性，这为转移性肾细胞癌的治疗提供了一个有希望的前景。进一步的研究就着重于树突细胞的治疗效果、持久性及副反应等方面。DC-肿瘤细胞融合疫苗的研究仍处于临床试验阶段，如果这一研究结果得到证实，那么这将是播散性<WP=48>和致死性癌症的选择性无毒性免疫治疗的一个前所未有的进展。肾癌患者也将受益非凡。HSPPC是一种安全可靠、无毒副作用、临床疗效满意、使用方便的肿瘤疫苗，作为一种能引起癌-特异性免疫反应并且能保留健康细胞的有效手段，在激活细胞免疫反应特异性对抗肿瘤方面将呈现出非常美好的应用前景。更多还原

【Abstract】 In the US about 32,000 new cases (~12,000 deaths) of kidney cancer yearly. RCC is the 10th leading cause of cancer death in the US and Western Europe. About 40% of RCC patients die due to distant metastases. about 25% –40% of RCC patients treated for localized disease will develop metastatic disease. Median survival time for patients with mRCC is 6 to 10 months. Objective To evaluate the clinical results of different operative procedures and renal tumor embolization before operation、immuno-therapy for renal cell carcinomas.Methods The clinical data of 179 patients with renal cell carcinoma diagnosed and operated in our department in the time from 1997.1 to 2002.12 were reviewed, including 133 cases received radical nephrectomy, 39 cases received nephrectomy and extended lymphadenectomy, 7 cases received nephron sparing surgery; 78 cases received renal artery embolization of tumor, after 3~5d radical nephrectomy was carried out for them; 31cases received immunotherapy in or after operation. Then the clinical data was analyzed completely.Results 133 cases underwent regional radical nephrectomy and 39 cases underwent extended radical nephrectomy were compared. The former has more virtue than the later in many cases, such as the time of operation、the time of postoperation adimission, the rate of blood transfusion, and so on, the two groups have significant difference(P<0.05). But the 5-year survival rate of them have no significant difference (P<0.05). There were 29 small renal cell <WP=50>carcinomas, 22 cases underwent radical nephrectomy and 7 cases received nephron sparing surgery. The time of operation、the time of postoperation adimission, the 5-year survival rate of two groups have no significant difference（P<0.05）, but patients after nephron sparing surgery often had some complications, such as hemorrhage, fistula of urine. 78 cases were received renal artery embolization of tumor, the average diagmeter of tumors is 10.5cm. 3~5days later radical nephrectomy were carried out for them. In the operations, we found that the sizes of carcinomas were decreased, the edema aroud tumors became obvious, and bleeding was reduced, which were convenient for operations and prolonged survivals. Conclusions Radical nephrectomy is the typical procedure of operation for treatent of renal cell carcinomas. But the 5-year survival rate of regional radical nephrectomy and extended radical nephrectomy have no significant difference (P<0.05). In addition, regional radical nephrectomy is more simple than the extended radical nephrectomy, and the time of the former is shorter than the later; For the small renal tumors, radical nephrectomy can not improve the 5-year survival more obviously than the nephron sparing surgery, but nephron sparing surgery often lead to some complications, such as hemorrhage、fistula of urine; Selective renal artery embolization is a safe, effective approach with less complications for the treatment of the larger renal carcinomas, and renal artery embolization as a valuable treatment should be widely applied; Immunotherapy is another important theraputic approach in addition to surgery, especially tumor vaccine (ASI, DC, HSPPS )have excellent clinical results for the treatment of <WP=51>later stage tumors or metastatic renal cell carcinoma.更多还原