肾癌多中心病灶和假包膜外肿瘤浸润的病理研究

A pathological study for multifocal tumors and infiltration of tumor pseudo-capsule of renal cancer

目的探讨保留肾单位手术（NSS）治疗肾癌时肿瘤周围正常肾组织安全有效的切除范围。方法2005年10月至2008年10月。肾癌标本131例，其中行肾癌根治术103例，行NSS28例。先行大体病理检查，然后分别在肿瘤假包膜外侧和距离肿瘤边缘3、5、10、15mm各层面取材，每个层面取4块组织，HE组织染色。观察有无肾癌多中心病灶和假包膜外肿瘤的浸润范围等病理指标，分别测量病变到肿瘤边缘的距离，并统计肿瘤大小与以上指标的相关性。结果131例肾癌标本中，肿瘤直径〈4．0cm者61例，均未发现肿瘤周围浸润和卫星灶。肿瘤直径4～7cm者46例，发现肿瘤周围浸润或卫星灶3例（6．5％），其中G3透明细胞癌1例，分别在距离肿瘤10、15mm处发现卫星灶；集合管癌1例和G3透明细胞癌伴肉瘤样癌1例距离肿瘤周围15mm均可见肿瘤浸润生长，集合管癌患者同时伴有远处转移和肾静脉瘤栓。肿瘤直径〉7cm者24例，有肿瘤周围浸润或卫星灶4例（16．7％），其中1例G3透明细胞癌在肿瘤周围3mm处发现卫星灶，另3例G2、G透明细胞癌在肿瘤周围15mm范围发现肿瘤浸润生长；有肾静脉瘤栓4例（16．7％）；远处转移2例（8．3％）。肿瘤直径与肿瘤周围浸润生长和卫星灶之间呈显著相关性（P〈O．05）。结论直径〈4cm的肾癌，行距离肿瘤周围正常肾组织切除宽度小的NSS，甚至简单的肿瘤剜除术安全有效；对部分仔细选择的4～7cm肾癌，只要技术可行能够完整切除肿瘤，采用NSS治疗合理可行；而对于〉7cm的肾癌，不建议行NSS。

Objective To explore the safe and effective width of a healthy parenchymal surgical margin in nephron-sparing surgery （NSS） for renal cell carcinoma. Methods From October, 2005 to October, 2008, 131 renal carcinoma specimens （103 cases performed by radical nephrectomy and 28 cases by NSS） were studied. The tissue materials were taken at the site of pseudo capsule, 3, 5, 10, 15 mm laterally from the tumor edge respectively and HE staining. Specimens were examined grossly and microscopically for multifocal tumors, infiltration of tumor pseudo-capsule and other pathological features. The correlation between the renal tumor size and the pathological features were analyzed statistically. Results There were 131 specimens of renal carcinoma. In 61 cases with tumor diameter 〈4 cm, no case （0.0%） had multifocal tumors and infiltration of tumor pseudo capsule. In 46 cases with tumor diameter 4 7 cm, multifocal tumors were found in 3 cases （6. 5~）, and infiltration of tumor pseudo-capsule was found in 2 cases. Among the 46 cases there was 1 collecting duct cancer ac- companied with distant metastasis and renal vein tumor embolus. In 24 cases with tumor diameter 〉7 cm, multifocal tumors were found in 4 cases （16.7%） and infiltration of tumor pseudo-capsule was found in 3 cases. Four cases （16.7%） had renal vein tumor embolus. Two cases （8.3%） had distant metastasis. The renal tumor size was apparently associated with muhifocal tumors and infiltration of tumor pseudo capsule （P〈0, 05）. Conclusions Mini-margin NSS, even simple enucleoresection, is a safe and effective approach for treating localized renal tumor of 〈4 cm. For carefully selected pa tients with tumor 4--7 cm, NSS is reasonable and feasible. But for the patient with tumor 〉7 cm, NSS is not recommended.