外科手术直视下在体原位肾肿瘤射频消融临床研究

Experimental study of surgery-guided radiofrequency ablation for renal tumors at original position in vivo

目的探讨肾肿瘤射频消融(RFA)的有效性、安全性及技术参数。方法选择临床根治性肾肿瘤切除术病例30例,均为单侧单发肿瘤,按肿瘤最大直径(φmax)及RFA前是否阻断肾动脉分组:A组φmax≤4.0cm,10例,其中A1组5例,RFA前先阻断肾动脉,A2组5例,RFA前不阻断肾动脉;B组4.0cm<φmax<6.0cm,10例,其中B1组5例,RFA前先阻断肾动脉,B2组5例,RFA前不阻断肾动脉;C组φmax≥6.0cm,10例,其中C1组5例,RFA前先阻断肾动脉,C2组5例,RFA前不阻断肾动脉。经开放或腹腔镜手术,先游离肾肿瘤及肾蒂血管,每组RFA前阻断或不阻断各5例,直视下对肾肿瘤进行单次RFA,消融频率均为450kHz,再根治性切除肾肿瘤,将肿瘤进行病理切片检查,获得肾肿瘤内部及边缘消融灶的病理表现,分析病理结果与肿瘤大小、消融时间及RFA前阻断肾动脉与否之间的关系。结果所有病例均为肾细胞癌,其中透明细胞癌25例,集合管癌5例。消融参数、RFA前阻断肾动脉与否及肿瘤大小与病理结果关系如下:A组消融时间10min,A1组消融灶直径约(5.2±0.5)cm,A2组消融灶直径约(4.5±0.6)cm(A1vs.A2,P=0.035);B组消融时间12min,B1组消融灶直径约(5.4±0.4)cm,B2组消融灶直径约(4.6±0.5)cm(B1vs.B2,P=0.028);C组消融15min,C1组消融灶直径约(5.5±0.6)cm,C2组消融灶直径约(4.8±0.8)cm(C1vs.C2,P=0.038)。A、B、C组消融直径分别为(5.0±0.6)cm、(5.1±0.1)cm、(5.1±0.4)cm,组间两两比较无统计学差异(P>0.05)。结论在选择性病例中,肾肿瘤射频消融是安全有效的,其疗效与肿瘤的大小密切相关,对φmax≤4.0cm的小肾癌,RFA完全可以获得超过肿瘤直径的消融直径,达到"根治"的疗效。对于φmax≥4.0cm的大肾癌,单次RFA无法获得"根治"的疗效;在相同条件下,消融前阻断肾动脉能获得更大的消融直径;在消融10min的情况下,再单纯延长消融时间无法获得更大的消融直径。

Objective To study the efficiency, safety and technical parameter of radiofrequency ablation （RFA） for renal tumors. Methods Thirty patients who suffered single renal tumor and underwent radical tumor nephrectomy were divided to three groups according to the tumor diameter （φmax） and whether the renal artery was blocked or not before RFA：Group A （φmax ≤4. 0 cm）, 10 cases including A1 （the renal artery was blocked before RFA） 5 cases and A2 （the renal artery was not blocked before RFA）5 cases. Group B （4. 0 cm 〈 φmax 〈6.0 cm）, 10 cases including Bl（the renal artery was blocked before RFA） 5 cases and B2 （the renal artery was not blocked before RFA） 5 cases. Group C （cpmax≥6.0 cm）, 10 cases including C1 （the renal artery was blocked before RFA） 5 cases and C2 （the renal artery was not blocked before RFA） 5 cases. Renal tumors were received single RFA （frequency 450 kHz） after the tumors and renal pedicle blood vessel were exposed by the open or laparoscopic surgery. And then the tumor tissue was examined by pathological histologic analysis after radical resection of these tumors. Moreover, the relationship between pathological examination and tumor diameter, melting time and whether the renal artery was blocked or not before RFA was analyzed. Results All 30 cases were renal cell carcinoma including 25 cases clear cell carcinoma and 5 cases collecting duct carcinoma. The melting time of Group A was 10 min and the ablation diameter of A1 was （5. 2±0. 5） cm,A2 was （4. 5 ±0. 6） cm （A1 vs. A2,P =0. 035）. And the melting time of Group B was 12 min and the ablation diameter of B1 was （5.4 ±0. d） cm,B2 was （4. 6 ±0. 5） cm （B1 vs. B2 ,P = 0. 028）. Furthermore,the melting time of Group C was 15 min and the ablation diameter of C1 was （5.5 ± O. 6） cm,C2 was （4. 8 ±0. 8） cm （ C1 vs. C2,P =0. 038）. There was no significant difference among the average ablation diameter of Group A, B, C which was （5.0 ±0. 6） cm, （5. 1 ±0. 1 ） cm, and （5.1 ±0. 4） cm separately （ P 〉 0.05）. Conclusions The RFA was safe and effective for the selective renal carcinoma patients and the effect was related to the tumor diameter. RFA could achieve sufficient ablation diameter which was larger than the tumor diameter in the small renal carcinoma （φmax≤4.0 cm） and get the cure effects. However,single RFA couldn＇t cure the large renal carcinoma （φmax ≥4.0 cm）. Larger ablation diameter would be obtained when the renal artery was blocked prior to RFA. But no more ablation diameter could be generated by simple extension of ablation time when already melted 10 min.