肾癌冷冻消融术64例经验总结

Cryoablation of renal cell carcinoma： six-year experience with 64 cases

目的总结冷冻消融术在肾癌保留肾单位手术中的临床应用经验，分析其适应证及治疗效果。方法回顾性分析2012年3月至2018年3月64例行腹腔镜肾癌冷冻消融术及影像学定位引导下冷冻消融术治疗的T1a期肾癌患者的临床资料，其中上海交通大学医学院附属第九人民医院28例，上海长征医院2例，上海长海医院34例。男44例，女20例。年龄35-81岁，平均66岁，其中≥80岁者5例。体重指数（23.9±2.4）kg/m^2 。肿瘤位于左肾29例，右肾32例，双肾3例；孤立肾肾肿瘤4例。有其他部位肿瘤者5例，伴有肾功能不全3例，伴有重症肝炎或肝硬化失代偿期4例，伴有其他合并症39例。术前血肌酐中位值70 μmol/L（48-222 μmol/L）。对一般状况尚可，不能耐受或不愿接受切除性手术的肾癌患者，可行全麻（单孔或普通）腹腔镜下肾癌冷冻消融术；对于全身状况较差无法承受全麻手术，且肿瘤位于背侧的患者，则采用影像学引导冷冻消融术。评估手术并发症，术后采用CT或MRI定期随访评估肿瘤学效果。结果所有手术均顺利完成，未增加切口。术后输血2例，其余病例出血量50 ml（10-110 ml）。肿瘤最大径（2.6±0.9 ）cm（1.2-4.0 cm），手术时间（96.0±24.5）min，术后住院时间（2.7±1.2）d。术后1例因并发出血行数字减影血管造影栓塞止血，其余病例均未出现明显术中及术后并发症。术后复查血肌酐中位值71 μmol/L （49-230 μmol/L），与术前比较差异无统计学意义（P＝0.64）。术后第1周复查肾脏CT或MRI平扫示所有病灶区域呈均匀低密度，CT或MRI增强显示低密度病灶完全无增强，提示消融完全，肿瘤已完全消退。64例随访时间4-72个月，中位时间29个月。1例CT引导下冷冻消融术后6个月复查增强CT示肿瘤复发，遂再次予腹腔镜下冷冻消融术，术后随访40个月未见再次复发；另1例未按规定随访，术后69个月复查增强CT显示肿瘤复发。其余62例未出现局部复发。结论冷冻消融术治疗T1a期肾癌，肿瘤消退效果确切、安全性高、并发症少、对正常肾组织损伤小，且可以多次重复治疗，对高手术风险或多发性肿瘤的肾癌患者优势明显。影像学引导下冷冻消融术适用于无法耐受全麻手术且肿瘤位于背侧的病例，而腹腔镜下冷冻消融术适用于肿瘤位于腹侧，邻近肾门大血管、肾盂、输尿管或其他腹腔脏器，以及多发肿瘤的患者。

ObjectiveTo summarize our clinical experience of cryoablation for renal cancer and to analyze the therapeutic indication, security, selection of cryoablation and outcomes.MethodsSixty-four patients suffered with T1a renal cell carcinoma were enrolled in this study from March 2012 to March 2018. Among them, 5 cases were senile patients（≥80 years）, 5 cases complicated with other cancers, 3 cases complicated with renal insufficiency, 4 cases complicated with decompensated cirrhosis, 3 cases with bilateral renal cancer, 4 cases with solitary kidney cancer and 39 cases with some other complications. The preoperative serum creatinine level was（80.5±38.2）μmol/L. The patients underwent laparoscopic single-site （LESS） renal cryoablation, conventional laparoscopic renal cryoablation, or percutaneous image-guided cryoablation according to individual situation. Contrast-enhanced CT scan or MRI were used during the procedures and follow-up was performed.ResultsAll operations were completed successfully and technical success was achieved as well in all cases. Blood transfusion was necessary for 2 cases because of hemorrhage.The mean diameter of the mass was （2.6±0.90）cm , the median volume of blood loss was 50ml（10-110 ml）, and the mean operation time was（96.0±24.5）min. The median inpatient hospital stay was 3 d（1-6 d）. In one case, digital subtraction angiography（DSA ）embolization was performed due to hemorrhage after surgery. None of the other cases had intraoperative or postoperative complications. The serum creatinine level after surgery was not significantly decreased [postoperative （83.8±42.1） μmol/L, P=0.64]. The contrast-enhanced CT or MRI of the kidneys one week postoperatively showed uniform low density in all lesion areas, which represented complete ablation and regression of the tumor. All cases were followed up regularly. One case showed relapse at the 6th month follow-up and underwent cryoablation again. Another case, who was not regularly followed up, relapsed at 69th month after surgery. No relapse was observed in the other cases during the follow-up.ConclusionsRenal cancer cryoablation is a safe, feasible and efficacious therapy for the patients who suffered from unresectable T1a renal cell carcinoma because of high surgical risk or multifocal lesions.