【作者】 孟平；

【导师】 王禾；

【作者基本信息】 第四军医大学 ， 外科学， 2007， 硕士

【摘要】 肾癌发病率在泌尿系肿瘤中仅次于膀胱癌位于第二位。目前估计全世界肾癌发病率每年增加2%,全世界每年死于肾癌者近10万例。近半数的肾癌患者首次就诊时已属晚期,约40%的患者术后出现复发、转移,未接受治疗者的3年存活率低于5%,由于肾细胞癌恶性程度较高,对放疗和化疗均不敏感,免疫治疗也难以取得理想效果,目前只有手术是较可靠的治疗手段。随着B超在临床的广泛应用,早期肾癌越来越多。早期肾癌相对与晚期肾癌其发生多中心病灶和转移的可能性较低,是肾癌保留肾单位手术的选择性适应症。目前肾部分切除术是治疗早期肾癌较好方法。对于T1a的早期肾癌,肾部分切除术和根治性肾癌切除术的治疗效果和预后无明显区别。一般认为肾部分切除术的适应证为:单一肾癌,双肾癌,孤立肾癌或对侧肾功能低下时。近来认为对于小于4cm的小肾癌及部分T1b也可适用于肾部分切除手术方法。肾癌切除的目的是最大限度的切除肿瘤组织以减少肿瘤复发率。然而,肾部分切除术其切除范围的大小还存在争议。小于4cm的肾癌多中心病灶和转移的可能性较低,肾部分切除术的疗效明显好于大于4cm的肾癌患者。本课题通过病理切片确定肿瘤浸润范围及通过免疫组化检测肾癌癌组织及癌旁组织受累情况的研究,为手术更彻底地切除肿瘤,防止局部复发提供依据。目的:早期肾癌出现多中心病灶和转移灶的可能性小,特别适合行保留肾单位的肾肿瘤切除术。本研究探讨直径4cm以下肾癌保肾手术的安全切除范围及Ki-67和PCNA在肾癌及癌旁组织中的表达。方法:直径≤4cm肾癌根治术标本41例,标本分层切开,观察肾内原发癌及癌旁病变累犯范围;并对41例肾癌切除标本采用免疫组化方法,检测癌和癌旁组织Ki-67和PCNA表达情况,分析肿瘤向周边浸润及周围组织癌变趋向的规律。结果:41例肾癌平均直径(3.3±0.8)cm(0.8-4.0cm),17.0%(7/41)存在1种以上假包膜外癌灶。形态学观察显示,癌旁0.2cm、0.5cm处高危病变的比例明显高于处1cm、2cm处,且癌变组织多局限于癌旁1cm范围内。随距原发癌越远,癌旁组织Ki-67和PCNA阳性的比例逐渐降低,且癌旁0.2cm与0.5cm、1cm、2cm的表达有差别。癌变组织阳性组7例中,Ki-67和PCNA高表达4例。结论:直径≤4cm肾癌保肾手术安全切缘须包括假包膜外1cm以内的正常肾实质。同时对癌旁组织Ki-67和PCNA阳性表达者应扩大切除范围,达到切缘阴性,降低局部复发率。更多还原

【Abstract】 Renal cell carcinoma (RCC) is one of the malignant tumors which is secondary to carcinoma of urinary bladder in the urinary carcinoma.It’s estimated that the morbility of RCC is increased 2% annumly and about 100,000 patients died from this kind of carcinomas every year in the world. About half members of those patients are in their late stage when they were firstly diagnosed of this cancer,about 40% will be recurrenced after and metabasised before radical renal resection,the survival rate is lower than 3% within 3 years who had not received any treatment.RCC has more malignant and insensitivity to radiotherapy and chemotherapy,and immunotherapy is also has little effect on it.Radical nephrectomy has been proven to be an effective choice for cure of localized renal cell carcinoma (RCC).Renal cell carcinoma (RCC) of 4 cm or less is with a low incidence of multicentricity and metastasis and is usually considered suitable for nephron sparing surgery (NSS).Open partial nephrectomy,or nephron sparing surgery (NSS),is now considered the standard of care for the treatment of small renal tumors.The oncologic efficacy and safety of NSS for the treatment of stage - T1a renal tumors has been repeatedly demonstrated to be equivalent to radical nephrectomy.NSS initially was reserved for patients with solitary kidneys,impaired renal function,hereditary tumor syndromes,bilateral renal tumors, and those with significant comorbidities predisposing to future renal failure.The indications have expanded recently to allow elective partial nephrectomy in the setting of a normal contralateral kidney.Furthermore , recent data demonstrate that partial nephrectomy for larger tumors (T1b),which have been historically treated with radical nephrectomy,is a viable option when surgical margins can safely be achieved.Renal cell carcinoma (RCC) of 4 cm or less is with a low incidence of multicentricity and metastasis and is usually considered suitable for nephron sparing surgery (NSS).It is widely accepted that tumor excision with a surrounding margin of normal parenchyma is the safest approach to ensure no residual tumor in the renal remnant. However agreement on the optimal margin in nephron sparing surgery has never been reached.RCC of 4 cm or less was with a lower incidence of multicentricity and NSS in these tumors has showed an excellent long term results compared with those of larger than 4 cm.This pilot study was designed to investigate the distance between extra-pseudocapsule lesions and primary tumors,and to suggest the optimal margin in NSS for RCC 4 cm or less.Objective Renal cell carcinoma (RCC) of 4 cm or less is with a low incidence of multicentricity and metastasis and is usually considered suitable for nephron - sparing surgery (NSS).To explore the excision extension in nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) 4 cm or less in diameter and study Ki-67 and PCNA expression.Methods Forty-one kidneys with RCC 4 cm or less in diameter resected by radical nephrectomy were prospectively studied. The kidney samples were sectioned and examined using immunohistochemistry to observe pathological changes and expressions of Ki - 67 and PCNA in primary tumor and paracarcinoma tissues.Results The diameter of 41 primary tumors was 3.3±0.8cm(range 0.8–4.0cm). Of these,17.0%(7/41) with positive cancer lesions beyond pseudocapsule. Along with the further distance from primary tumor , the proportions of positive expressions of Ki-67 and PCNA in paracarcinoma tissue were decreased gradually. The ratio of strong expression was 57.4% (4/7)in the group with extra-pseudocapsule cancer lesions.Conclusions These data suggest that when NSS is performed in RCC 4 cm or less in diameter,a margin of more than 1 cm of adjacent parenchyma should be excised with the tumor. It is necessary to choice individual treatment for RCC with strong expression of Ki-67 and PCNA.更多还原