肾实质浸润型尿路上皮癌临床诊治特点分析

Analysis of diagnosis and treatment of invasive renal parenchymal urothelial carcinoma

目的探讨肾实质浸润型尿路上皮癌的临床诊治特点。方法回顾性分析首都医科大学附属北京朝阳医院2014年1月至2020年12月收治的23例肾实质浸润型尿路上皮癌患者的临床资料。男12例, 女11例;年龄(67.3±10.1)岁。无症状9例, 仅腰部不适7例, 仅肉眼血尿4例, 血尿合并腰部不适3例;伴多发膀胱肿瘤1例。3例术前行MRI检查, 19例术前行增强CT检查, 1例同时行MRI及增强CT检查。MRI检查示肾分叶状等T1、混杂T2信号, 边界不清晰, 且DWI可见明显弥散受限;增强CT检查示占位无明显增强, 边界不清晰。肿瘤位于左侧15例, 右侧8例。术前1例行细针穿刺活检诊断为尿路上皮癌, 2例采用输尿管软镜取标本病理未报告肿瘤;22例术前诊断不明确, 无法确定肿瘤性质。所有患者均行手术治疗, 其中行腹腔镜根治性肾切除术20例, 肾输尿管切除+膀胱袖状切除术3例。结果术后病理标本可见灰白色占位, 高级别浸润性尿路上皮癌侵及肾实质, G_(3)级;T_(3a)期9例, T_(3b)期14例;9例清扫肾门淋巴结, 其中淋巴结转移5例。术后21例获得随访, 随访时间(18.6±6.7)个月。术后膀胱复发3例, 转移5例(腹腔转移2例, 同侧肾上腺、肝、腰大肌转移各1例)。至末次随访, 共8例死亡(38.1%, 8/21), 其中7例因肿瘤转移或复发死亡(均为T3b期患者), 1例因心梗伴肺部感染死亡。仅侵犯肾窦的3例中, 1例死于肿瘤复发或转移;仅侵犯肾周脂肪的4例中, 3例死于肿瘤复发或转移。结论肾实质浸润型尿路上皮癌早期不易诊断, 临床生物学行为不佳, 总体预后差。对于术前诊断为肾实质浸润型尿路上皮癌者, 建议行腹腔镜肾输尿管切除+膀胱袖状切除术;如术前诊断不明确但高度怀疑者, 根据术中快速冰冻病理结果决定手术方式。

Objective To investigate the clinical features of diagnosis and treatment of renal parenchymal invasive urothelial carcinoma.Methods The clinical data of 23 patients with renal parenchymal invasive urothelial carcinoma admitted to Beijing Chaoyang Hospital Affiliated to Capital Medical University from January 2014 to December 2020 were retrospectively analyzed.There were 12 males and 11 females.The mean age was(67.3±10.1)years old.Among them,7 cases complained of painless hematuria and 9 cases were asymptomatic.Three cases underwent preoperative MRI examination,19 patients underwent preoperative enhanced CT examination,and 1 patient underwent both MRI and enhanced CT examination.MRI examination showed renal lobulated and other T1 mixed with T2 signals,the boundary was not clear,and DWI showed obvious restricted diffusion.The tumor was located on the left side in 15 cases and on the right side in 8 cases.Preoperative diagnosis was made by fine needle aspiration biopsy in 1 patient,and specimens were obtained by flexible ureteroscope in 2 patients.No tumor was reported.The preoperative diagnosis of 22 patients was unclear and the nature of the tumor could not be determined.One patient was considered to have urothelial carcinoma by fine needle aspiration.All patients were treated by surgery,including 20 cases of laparoscopic radical nephrectomy and 3 cases of nephroureterectomy with bladder sleeve resection.Results Postoperative pathological specimens showed yllow-white mass,high-grade invasive urothelial carcinoma invading renal parenchyma.Nine cases were T_(3a) stage,14 cases were T_(3b) stage,and 5 cases were lymph node metastasis.The average postoperative follow-up time was(18.6±6.72)months,2 patients were lost to fllow-up,8 patients died,and the overall mortality rate was 38.1%.Seven patients died of recurrence or metastasis.There were 3 cases of bladder recurrence and 5 cases of metastasis after operation.Conclusions Renal parenchymal infiltrating urothelial carcinoma is difficult to diagnose in the early stage,with poor clinical biological behavior and poor overall prognosis.For patients diagnosed with renal parenchymal invasive urothelial carcinoma preoperatively,laparoscopic nephroureterectomy+bladder sleeve resection is recommended.