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【摘要】 目的 探讨肾结石合并肾盂鳞状细胞癌的早期诊断与治疗。方法 报告肾结石合并肾盂鳞状细胞癌2例,结合相关文献探讨其早期诊断及治疗方法。结果 2例均有典型肾绞痛病史及合并血尿,CT检查提示肾盂癌2例。2例术中经冰冻病理确诊后,行根治性患肾切除术,1例术后行全身化疗,5个月后死于全身衰竭,另一类术后随访18个月无复发。2例病理诊断均为鳞状细胞癌。结论 肾结石合并肾盂鳞状细胞癌恶性程度高、预后差,临床表现缺乏特异性,易误诊和漏诊,提高对本病的认识,对可疑病例进行多项必要的辅助检查,有助于明确诊断。治疗以根治性患肾切除为主。
【关键词】 肾结石;肾盂;鳞状细胞癌;诊断;治疗
Early diagnosis and treatment of renal calculi associated with squamous cell carcinoma of the renal pelvis:a report of 2 cases
LI Huai-fu, XU Zhe-qing,ZHENG Hao,et al.Department of Urology,the Fifth Affilcated Hospital of Sun Yat-sen University,Zhuhai 519000, China
【Abstract】 Objective To investigate the early diagnosis and treatment of renal calculi associated with squamous cell carcinoma of the renal pelvis.Methods 2 cases of squamous cell carcinoma of the renal pelvis associated with renal calculi were reported in our department.The literature was reviewed to discuss the early diagnosis and treatment.Results Both of the 2 patients presented with typical renal colic and hematuria,2 cases of renal pelvic tumor were diagnosed by CT.Radical nephrectomy was performed for the 2 patients after squamous cell carcinoma was detected with frozen section during operation. One patient received systemic chemotherapy and died from cancer collapse after 5 months,the other developed no recurrence during follow-up of 18 months. Both of the 2 cases were proved squamous cell carcinoma in pathology after operation. Conclusion Squamous cell carcinoma of the renal pelvis associated with renal calculi has an aggressive behavior and unfavourable prognosis,and it may be easily misdiagnosised and missed because its clinical manifestation is lack of specificit. Once a case is suspected squamous cell carcinoma of the renal pelvis, many necessary assistance examinations should be performed for diagnosis and the optimal treatment is radical nephrectomy.
【Key words】 Renal calculi;Renalpelvis;Squamous carcinoma;Diagnosis;Therapy
肾结石合并肾盂鳞状细胞癌临床少见,症状隐匿,早期诊断较为困难,易误诊及漏诊。现将本院收治2例肾结石合并肾盂鳞状细胞癌报告如下。
1 病例资料
患者女,63岁,以“左侧腰部疼痛伴全程肉眼血尿1个月余”于2002年10月入院。患者在既往19年中曾多次诊断为左肾多发结石,先后3次在外院行左肾切开取石术。查体:双肾区无明显压痛及叩击痛。KUB+IVU提示:左肾多发结石,左侧肾盂、肾盏明显扩张,左侧输尿管中下段显影不满意。入院诊断:左肾多发结石并左肾积水;入院后行CT检查提示左肾下极体积增大,可见一3 cm×2 cm大小软组织影,CT值为36.3 Hu,略低于周围正常肾实质,增强后轻度强化,但仍低于正常周围肾实质,周围不光滑,与正常组织分界不清,尿细胞学检查未找到恶性细胞。常规术前准备后,经原腰部切口手术探查见患肾下极皮质变薄,呈囊性感,穿刺抽取少量豆腐渣样液体,于皮质变薄区切开取出2 cm×2 cm×3 cm大小结石一枚及泥沙样结石。同时切口处组织送冰冻检查提示左肾盂低分化鳞状细胞癌,即行根治性左肾切除加部分输尿管切除术及淋巴清扫术,术后常规行放化疗,5个月后死于全身衰竭。
患者男,67岁,以“体检发现右肾结石3年,伴血尿20 d”于2006年10月入院。专科查体:双肾区不饱满,无压痛及叩击痛;双侧输尿管走行区无压痛。尿常规白细胞(+++)/Hp、红细胞(+++)/Hp,B超提示右肾上极可见一2.3 cm×1.6 cm 大小的强回声光团,无明显声影。IVU提示右肾结石并积水,CT提示右肾上极体积增大,可见一2.5 cm ×2 cm 大小软组织影,CT值为37.6 Hu,略低于周围正常肾实质,增强后轻度强化,但仍低于周围的肾脏实质,周围不光整,与正常组织分界不清。尿细胞学检查未找到恶性细胞。入院诊断:右肾结石合并感染,肾盂癌待排。手术探查见患肾上极皮质变薄,呈囊性感,穿刺抽出少量乳白色液体,于皮质变薄处切开,取出2 cm×2 cm×2 cm 大小褐色结石1枚。同时切取切口处组织送冰冻检查提示左肾盂高分化鳞状细胞癌。行根治性左肾切除加部分输尿管切除术,术后随访18个月无复发。
2 讨论
肾盂鳞状细胞癌临床少见,约占上尿路恶性肿瘤的0.7%～7%[1-2]。 由于鳞状细胞癌恶性程度高且肾盂壁较薄,肾盂鳞状细胞癌早期即可能出现淋巴转移和扩散,多数患者在确诊时已为晚期,预后差。因此,对肾盂鳞状细胞癌的早期诊治尤为关键。一般认为其发生的主要原因是由于在结石以及结石并发感染所致炎症的长期刺激下,肾盂上皮发生异常增生,或鳞状上皮化生形成白斑,继而发生癌变[3],本病例2即有肾结石合并感染。由于肾盂鳞状细胞癌患者中50%以上有结石病史,且往往表现为结石或感染的症状,早期极易漏诊。要提高本病的早期诊断率,对余下几点应着重关注①对于肾结石病史长,近期内症状异常加重,难以用梗阻、感染来解释,甚至肾区触及实质性包块,应警惕合并肾盂肿瘤的可能。不仅要满足于肾结石并肾积水及无功能肾的诊断,忽视了对一些特殊表现的分析,未行进一步检查;②排泄性尿路造影和逆行尿路造影检查,见肾盂僵硬、边缘毛糙或充盈缺损,如果肾周围有肿瘤浸润则肾外形模糊不清;③B超超声检查对肾盂肿瘤的早期诊断有一定帮助,Tlili[4]等报道4例肾结石合并肾盂癌,术前均被超声发现。B超声像图中有肾结构形态不清、脓肾、脓腔密度不均匀等表现时,应及时作尿脱落细胞学检查和CT检查;④尿脱落细胞学检查对上尿路肿瘤诊断意义重大,对分化良好的肿瘤有80%的假阴性,而低分化癌的阳性率可达60%左右,但由于合并感染和肉眼血尿的存在使脱落细胞学检查诊断非常困难;⑤CT扫描可提供足够多诊断依据,包括肾盂肿瘤、肾周围组织的肿瘤浸润及肾门淋巴结的转移本组2例术前CT检查都提示肾盂癌的诊断;⑥MRI可使扩张的肾盂及其内在的肿瘤充分显影而且无需使用显影剂,较CT安全可靠,即使肾功能严重受损者亦可使用,所以MRI对已发生梗阻,排泄性尿路造影不显影者尤为适用;⑦输尿管镜检有助于明确诊断,Blute[5]报道采用输尿管软镜可使肾盂鳞癌的确诊率达86%,但该项检查可能引起肿瘤种植、扩散;⑧术中注意对病变性质的判断,发现可疑情况,应及时送快速冰冻切片以明确诊断。本组病例均行冰冻切片明确了诊断,避免了漏诊。
总之,提高对本病的认识,对可疑病例进行多项必要的辅助检查,对早期正确诊断有重要意义。肾盂鳞状细胞癌与肾盂移行细胞癌不同,一般不发生输尿管、膀胱的种植转移,因此仅行根治性患肾切除及输尿管部分切除即可。但由于肾盂结石合并鳞状细胞癌早期难以诊断,如条件允许,除行根治性患肾切除外,应行输尿管全长切除[1,6]。此外肾盂鳞癌易出现局部浸润和淋巴结转移,故还应行淋巴结清扫术。术后应辅以放疗、化疗或免疫治疗,但肾盂鳞状细胞癌多呈低分化、恶性度高、进展快,可形成腔静脉癌栓及广泛骨髓转移。这对肾盂移行上皮细胞肿瘤是罕见的。对于肾结石病史较长者,尤其是结石周围肾组织具有异常的影像学改变时,应考虑到伴发肾盂鳞状细胞癌的可能,不能排除肿瘤者应手术探查。在行肾盂切开取石术中,如发现肾结石周围组织有异常改变,应常规取材行术中冰冻检查,防止伴发肾盂鳞癌的可能。
参考文献
[1] Holmng S, Lele SM, Johansson SL. Squamous cell carcinoma of the renal pelvis and ureter: incidence, symptoms, treatment and outcome. J Urol,2007,178(1):51-56.
[2] Kayaselcuk F, Bal N, Guvel S,et al.Carcinosarcoma and squamous cell carcinoma of the renal pelvis associated with nephrolithiasis: a case report of each tumor type.Pathol Res Pract,2003,199(7):489-492.
[3] Sivaramakrishna B, Aron M, Ansari MS, et al.Squamous cell carcinoma of the renal pelvis manifesting after percutaneous nephrolithotomy for long standing calculus.Int Urol Nephrol,2004,36(2):149-151.
[4] Tlili G K,Gharbi J H,Atallah R,et al.Squamous cell carcinoma of the renal pelvis with inferior vena caval extension.Int J Urol,2000,7(8):316-320.
[5] Blute M L,Segura J W,Patterson D E, et al.Impact of endourology on diagnosis and management of upper urinary tract urothelial cancer. J Urol, 1989, 141(6); 1298-1301.
[6] 张利朝,胡卫列,李清荣,等.肾盂铸形结石并发肾盂鳞状细胞癌6例报告.临床泌尿外科杂志,2006,21(10):790-791.
【关键词】 肾结石;肾盂;鳞状细胞癌;诊断;治疗
Early diagnosis and treatment of renal calculi associated with squamous cell carcinoma of the renal pelvis:a report of 2 cases
LI Huai-fu, XU Zhe-qing,ZHENG Hao,et al.Department of Urology,the Fifth Affilcated Hospital of Sun Yat-sen University,Zhuhai 519000, China
【Abstract】 Objective To investigate the early diagnosis and treatment of renal calculi associated with squamous cell carcinoma of the renal pelvis.Methods 2 cases of squamous cell carcinoma of the renal pelvis associated with renal calculi were reported in our department.The literature was reviewed to discuss the early diagnosis and treatment.Results Both of the 2 patients presented with typical renal colic and hematuria,2 cases of renal pelvic tumor were diagnosed by CT.Radical nephrectomy was performed for the 2 patients after squamous cell carcinoma was detected with frozen section during operation. One patient received systemic chemotherapy and died from cancer collapse after 5 months,the other developed no recurrence during follow-up of 18 months. Both of the 2 cases were proved squamous cell carcinoma in pathology after operation. Conclusion Squamous cell carcinoma of the renal pelvis associated with renal calculi has an aggressive behavior and unfavourable prognosis,and it may be easily misdiagnosised and missed because its clinical manifestation is lack of specificit. Once a case is suspected squamous cell carcinoma of the renal pelvis, many necessary assistance examinations should be performed for diagnosis and the optimal treatment is radical nephrectomy.
【Key words】 Renal calculi;Renalpelvis;Squamous carcinoma;Diagnosis;Therapy
肾结石合并肾盂鳞状细胞癌临床少见,症状隐匿,早期诊断较为困难,易误诊及漏诊。现将本院收治2例肾结石合并肾盂鳞状细胞癌报告如下。
1 病例资料
患者女,63岁,以“左侧腰部疼痛伴全程肉眼血尿1个月余”于2002年10月入院。患者在既往19年中曾多次诊断为左肾多发结石,先后3次在外院行左肾切开取石术。查体:双肾区无明显压痛及叩击痛。KUB+IVU提示:左肾多发结石,左侧肾盂、肾盏明显扩张,左侧输尿管中下段显影不满意。入院诊断:左肾多发结石并左肾积水;入院后行CT检查提示左肾下极体积增大,可见一3 cm×2 cm大小软组织影,CT值为36.3 Hu,略低于周围正常肾实质,增强后轻度强化,但仍低于正常周围肾实质,周围不光滑,与正常组织分界不清,尿细胞学检查未找到恶性细胞。常规术前准备后,经原腰部切口手术探查见患肾下极皮质变薄,呈囊性感,穿刺抽取少量豆腐渣样液体,于皮质变薄区切开取出2 cm×2 cm×3 cm大小结石一枚及泥沙样结石。同时切口处组织送冰冻检查提示左肾盂低分化鳞状细胞癌,即行根治性左肾切除加部分输尿管切除术及淋巴清扫术,术后常规行放化疗,5个月后死于全身衰竭。
患者男,67岁,以“体检发现右肾结石3年,伴血尿20 d”于2006年10月入院。专科查体:双肾区不饱满,无压痛及叩击痛;双侧输尿管走行区无压痛。尿常规白细胞(+++)/Hp、红细胞(+++)/Hp,B超提示右肾上极可见一2.3 cm×1.6 cm 大小的强回声光团,无明显声影。IVU提示右肾结石并积水,CT提示右肾上极体积增大,可见一2.5 cm ×2 cm 大小软组织影,CT值为37.6 Hu,略低于周围正常肾实质,增强后轻度强化,但仍低于周围的肾脏实质,周围不光整,与正常组织分界不清。尿细胞学检查未找到恶性细胞。入院诊断:右肾结石合并感染,肾盂癌待排。手术探查见患肾上极皮质变薄,呈囊性感,穿刺抽出少量乳白色液体,于皮质变薄处切开,取出2 cm×2 cm×2 cm 大小褐色结石1枚。同时切取切口处组织送冰冻检查提示左肾盂高分化鳞状细胞癌。行根治性左肾切除加部分输尿管切除术,术后随访18个月无复发。
2 讨论
肾盂鳞状细胞癌临床少见,约占上尿路恶性肿瘤的0.7%～7%[1-2]。 由于鳞状细胞癌恶性程度高且肾盂壁较薄,肾盂鳞状细胞癌早期即可能出现淋巴转移和扩散,多数患者在确诊时已为晚期,预后差。因此,对肾盂鳞状细胞癌的早期诊治尤为关键。一般认为其发生的主要原因是由于在结石以及结石并发感染所致炎症的长期刺激下,肾盂上皮发生异常增生,或鳞状上皮化生形成白斑,继而发生癌变[3],本病例2即有肾结石合并感染。由于肾盂鳞状细胞癌患者中50%以上有结石病史,且往往表现为结石或感染的症状,早期极易漏诊。要提高本病的早期诊断率,对余下几点应着重关注①对于肾结石病史长,近期内症状异常加重,难以用梗阻、感染来解释,甚至肾区触及实质性包块,应警惕合并肾盂肿瘤的可能。不仅要满足于肾结石并肾积水及无功能肾的诊断,忽视了对一些特殊表现的分析,未行进一步检查;②排泄性尿路造影和逆行尿路造影检查,见肾盂僵硬、边缘毛糙或充盈缺损,如果肾周围有肿瘤浸润则肾外形模糊不清;③B超超声检查对肾盂肿瘤的早期诊断有一定帮助,Tlili[4]等报道4例肾结石合并肾盂癌,术前均被超声发现。B超声像图中有肾结构形态不清、脓肾、脓腔密度不均匀等表现时,应及时作尿脱落细胞学检查和CT检查;④尿脱落细胞学检查对上尿路肿瘤诊断意义重大,对分化良好的肿瘤有80%的假阴性,而低分化癌的阳性率可达60%左右,但由于合并感染和肉眼血尿的存在使脱落细胞学检查诊断非常困难;⑤CT扫描可提供足够多诊断依据,包括肾盂肿瘤、肾周围组织的肿瘤浸润及肾门淋巴结的转移本组2例术前CT检查都提示肾盂癌的诊断;⑥MRI可使扩张的肾盂及其内在的肿瘤充分显影而且无需使用显影剂,较CT安全可靠,即使肾功能严重受损者亦可使用,所以MRI对已发生梗阻,排泄性尿路造影不显影者尤为适用;⑦输尿管镜检有助于明确诊断,Blute[5]报道采用输尿管软镜可使肾盂鳞癌的确诊率达86%,但该项检查可能引起肿瘤种植、扩散;⑧术中注意对病变性质的判断,发现可疑情况,应及时送快速冰冻切片以明确诊断。本组病例均行冰冻切片明确了诊断,避免了漏诊。
总之,提高对本病的认识,对可疑病例进行多项必要的辅助检查,对早期正确诊断有重要意义。肾盂鳞状细胞癌与肾盂移行细胞癌不同,一般不发生输尿管、膀胱的种植转移,因此仅行根治性患肾切除及输尿管部分切除即可。但由于肾盂结石合并鳞状细胞癌早期难以诊断,如条件允许,除行根治性患肾切除外,应行输尿管全长切除[1,6]。此外肾盂鳞癌易出现局部浸润和淋巴结转移,故还应行淋巴结清扫术。术后应辅以放疗、化疗或免疫治疗,但肾盂鳞状细胞癌多呈低分化、恶性度高、进展快,可形成腔静脉癌栓及广泛骨髓转移。这对肾盂移行上皮细胞肿瘤是罕见的。对于肾结石病史较长者,尤其是结石周围肾组织具有异常的影像学改变时,应考虑到伴发肾盂鳞状细胞癌的可能,不能排除肿瘤者应手术探查。在行肾盂切开取石术中,如发现肾结石周围组织有异常改变,应常规取材行术中冰冻检查,防止伴发肾盂鳞癌的可能。
参考文献
[1] Holmng S, Lele SM, Johansson SL. Squamous cell carcinoma of the renal pelvis and ureter: incidence, symptoms, treatment and outcome. J Urol,2007,178(1):51-56.
[2] Kayaselcuk F, Bal N, Guvel S,et al.Carcinosarcoma and squamous cell carcinoma of the renal pelvis associated with nephrolithiasis: a case report of each tumor type.Pathol Res Pract,2003,199(7):489-492.
[3] Sivaramakrishna B, Aron M, Ansari MS, et al.Squamous cell carcinoma of the renal pelvis manifesting after percutaneous nephrolithotomy for long standing calculus.Int Urol Nephrol,2004,36(2):149-151.
[4] Tlili G K,Gharbi J H,Atallah R,et al.Squamous cell carcinoma of the renal pelvis with inferior vena caval extension.Int J Urol,2000,7(8):316-320.
[5] Blute M L,Segura J W,Patterson D E, et al.Impact of endourology on diagnosis and management of upper urinary tract urothelial cancer. J Urol, 1989, 141(6); 1298-1301.
[6] 张利朝,胡卫列,李清荣,等.肾盂铸形结石并发肾盂鳞状细胞癌6例报告.临床泌尿外科杂志,2006,21(10):790-791.