肾移植受者并发恶性肿瘤34例临床分析

Profiles of malignant tumors following kidney transplantation:an analysis of 34 cases

目的分析总结肾移植受者并发恶性肿瘤的发生情况、治疗措施及转归。方法回顾性分析1983—2011年温州医学院附属第一医院肾移植中心规范随访、接受免疫抑制治疗半年以上的1400例肾移植受者发生恶性肿瘤的临床资料,诊断均经组织病理学检查证实,采用手术治疗、免疫抑制剂调整等综合治疗。结果发生恶性肿瘤34例(2.43%),患者发生恶性肿瘤时平均年龄为(52±10)岁,中位诊断时间为移植术后74(8～325)个月。其中泌尿系统肿瘤18例(Ⅰ～Ⅱ期12例,Ⅲ～Ⅳ期6例),并发两个以上部位肿瘤15例;消化系统肿瘤6例,血液系统肿瘤2例,其他肿瘤8例。治疗实体肿瘤患者手术为主,并减少1/3～1/2免疫抑制剂剂量(有些患者用西罗莫司替换他克莫司或环孢素),辅以化疗、放疗和免疫治疗等综合治疗。34例恶性肿瘤患者除3例失访,至今存活22例,肿瘤术后中位生存时间37(4～67)个月,其中肾功能正常15例、血清肌酐轻度升高6例、移植肾切除后返回血液透析治疗1例;9例死亡患者肿瘤切除术后中位生存时间32(3～100)个月,死因多为肿瘤广泛转移。结论肾移植受者术后肿瘤发生率较高,尤以泌尿系统肿瘤多见,其特点为多部位、易复发。肿瘤发生后根据病理分级分期积极手术治疗并调整免疫抑制方案,配合其他方法综合治疗可以提高患者存活率。

Objective To summarize the occurrence, treatment, and outcomes of malignant tumors after kidney transplantation. Methods A retrospective study was performed on 1400 renal allograft recipients who received standard immunosuppressive treatment at least half a year between 1983 and 2011 in the First Affiliated Hospital of Wenzhou Medical College. All tumors were confirmed by histopathological examination and were treated with comprehensive measurements including surgeries and adjustment of immunosuppressants. Results Thirty-four of 1400 recipients developed malignant tumors with an incidence of 2.43%. The mean age of these patients was （52 ± 10 ） years when diagnosed as having malignant tumors and the diagnostic time after transplantation was 8-325 months, with an average of 84 months. Of these tumors, 18 cases were in urological system（pathologically, 12 cases were at stage Ⅰ - Ⅱ and 6 at stage Ⅲ-Ⅳ）, 6 cases in digestive system, 2 cases in blood system, and 8 cases in other systems. In urological system, 15 cases had tumors at multiple sites. The main treatment of the cancer was surgery on solid tumors and adjustment of immunsuppressive therapy such as reducing the dose of agents by 1/3 or 1/2 and replacing FK506 or CsA with sirolimus when patients＇ serum creatinine 〈 150 μmol/L and 24 h urine protein 〈 1.5 g, and combining with other adjuvant therapies such as chemotherapy, radiation therapy, and immune therapy. At the end of study, 9 patients died with a median survival time of 32 （3-100） months after surgery; 22 patients were alive with normal renal function in 15 patients, moderately elevated serum creatinine in 6 patients, and hemodialysis in 1 patient. The other 3 patients were lost during follow up. Conclusions The incidence of malignant tumors especially urological carcinoma following renal transplantation is significantly increased. Malignant tumors in urological system are characterized by tumors at multiple sites and easily relapses. Appropriate surgeries based on pathological classification and adjustment of immunosuppressant protocols accompanied by other comprehensive treatments can improve patients＇ survival after tumor occurrence.