T_1期肾肿瘤保留肾单位手术切缘安全范围的探讨

Exploration of optimal surgical margin in nephron-sparing surgery for T_1 renal tumor

目的探讨T1期肾肿瘤保留肾单位手术切缘的安全范围。方法回顾性分析我院泌尿外科行保留肾单位手术的172例对侧肾脏正常的T1期肾肿瘤患者资料。分析切缘大小、围手术期并发症、术中冷冻切片病理、术后石蜡切片病理及肿瘤复发之间的关系。另取同期T1期根治性肾切除标本35例,于体外沿假包膜行肾肿瘤剜除术,取残肾距离切缘2、5和10mm处肾实质送石蜡切片病理检查。结果 172例中,切缘〈2mm组13例,2-5mm组87例,〉5mm组72例。〈2mm组9例行切缘冷冻切片病理检查,1例阳性;2-5mm组38例行切缘冷冻切片病理检查,1例阳性。切缘阳性的2例肿瘤行根治性肾切除术,术后将2例残余肾行石蜡切片病理检查,均未见肿瘤残余。另外,术中行冷冻切片阴性或未行冷冻切片检查,〈2mm组和2-5mm组术后石蜡切片病理检查各有1例切缘阳性,其中,〈2mm组的病例3年后原位复发,行根治性肾切除术;2-5mm组阳性病例密切随访5年,未发现肿瘤复发。172例保留肾单位手术中10例围手术期有并发症发生,其中,2-5mm组3例（3.4%）,〉5mm组7例（9.7%）。平均随访33个月,术后石蜡切片病理切缘阴性的病例中,〈2mm组1例出现影像学可疑复发,穿刺活检阴性,其他两组均无复发。根治性肾切除术后的35例肿瘤剜除后残肾标本中,2例距离切缘2mm处存在肿瘤浸润。结论 T1期肾肿瘤保留肾单位手术切缘控制在2-5mm较为安全合适。若肿瘤包膜完整,没有必要行术中冷冻切片病理检查。

Objective To discusse optimal surgical margin in nephron-sparing surgery for T1 renal tumor. Methods Retrospective analysis of 172 T1 renal tumors with nephron-sparing surgery. Margin size, perioperative complications, recurrence, pathology and frozen paraffin pathological findings were recorded and comparatively analyzed. We also selected radical nephrectomy specimens of 32 patients （T1）, performed surgical enucleation and carefully investigated the surgical margin of 2 mm, 5 mm, 10 mm and the renal pathology. Results There are 13 cases in ~2 mm group, 87 cases in 2-5 mm group, 72 cases in 〉5 mm group. There is one positive margin of 9 cases sent to frozen pathology in 〉2 mm group, while one positive margin of 38 cases in 2-5 ram. After radical nephrectomy, residual renal pathology in paraffin showed no residual tumor. There are 2 cases of tumor invasion margin exists of postoperative pathological paraffin, 1 patient recurrence 3 years later in 〈：2 mm group, 1 patient had no recurrence in 2-5 mm group. There are 3 cases in 2-5 mm group （3.4~/6o）, while 7 cases in ~5 mm group （9.7~~） of the 10 cases of complications. There is 1 patient in 〉2 mm group with suspicious radiographic recurrence while biopsy was negative and the other two groups had no recurrence in the negative margin cases. There are 2 tumor invasion in the surgical margin of 2 mm in 35 renal cancer specimens. Conclusions These results indicate that surgical margin of 2-5 mm for nephron-sparing surgery may be quite safe. There is no need for intraoperative frozen pathology if the tumor capsule is intact.