摘要
目的提高原发性输尿管癌的诊断和治疗水平。
方法对浙江大学医学院附属第一医院2004年至2007年收治的32例确诊为原发性输尿管癌患者的诊断方法和治疗方法及预后进行回顾性分析。
结果原发性输尿管肿瘤患者32例,其中男19例(59.4%),女13例(40.6%)。年龄44—90岁,平均70.4岁。病程1周至2年,平均6.4月。32例均行B超检查,23例B超(BUS)检查均提示患侧不同程度的肾积水,5例发现输尿管内低回声团块;16例行静脉肾盂造影(IVU),8例病变侧不显影,7例提示肾积水、输尿管充盈缺损;膀胱镜检查28例,发现肿块突入膀胱6例,患侧输尿管口喷血17例;逆行插管11例,逆行造影发现输尿管充盈缺损3例,3例狭窄;CT检查19例,发现输尿管腔内软组织肿块15例;MRU检查6例,均显示输尿管腔截断性梗阻征象。尿细胞学检查15例,阳性4例;3例输尿管镜检查,发现输尿管内乳头状赘生物,后取活检送病理均证实为移行细胞癌。32例原发性输尿管癌均接受手术治疗,包括肾输尿管切除术并膀胱袖式切除术30例,输尿管切除并膀胱部分切除+肾造瘘术1例,输尿管下段切除+输尿管膀胱再植术1例。32例术后均经病理检查证实为原发性输尿管移行细胞癌。术后肿瘤分期Ⅰ期3例,Ⅱ期18例,Ⅲ期9例,Ⅳ期2例。术后肿瘤分级G1-2级6例,G2-3级19例,G3级以上7例。26例获得随访,随访时间6—42个月,3年内死亡者3例,其中1例死于肿瘤复发,肿瘤为高期高级别,2例死于心脑血管意外;23例均存活,其中生存3年以上者10例,均为接受肾、输尿管全长+膀胱袖口状切除术治疗者。
结论原发性输尿管癌的诊断应结合病史及联合应用B超、CT、MRI、膀胱镜及输尿管镜检查以提高诊断率。原发性输尿管癌以手术治疗为主,经典术式为患侧肾、输尿管及膀胱袖口状切除术。但对于孤立肾、对侧肾功能不全、不能耐受手术或双侧上尿路肿瘤等不适于行经典术式的患者以及早期、低期低级肿瘤的患者,可采用保留肾脏的保守性手术,术后应加强随访。
Objective To improve the diagnosis and treatment of primary ureteral cancer.
Methods A retrospective analysis of diagnosis,treatment and prognosis of 32 cases of primary ureteral cancer which was in the First Affiliated Hospital from 2004 to 2007.
Results Between 2004 and 2007 32 patients underwent primary ureteral cancer in our department.The patients consisted of 19 males and 13 females.The range of age was 44 to 90,the history of disease was 1 week to 2 years.All cases were confirmed ultrasound,of which 5 cases were examined tumor in ureter and 23 cases were examined hydronephrosis.16 cases were confirmed intravenous pyelography,of which 8 cases did not develop images in involved kidney and ureter,and 7 cases developed images of filling defect in ureteral lumens.11 cases were confirmed retrograde pyelograph,of which 6 cases developed images of filling defect or stricture in ureteral lumens.19 cases were confirmed CT,of which 15 cases were detected tumors of soft tissue in lumens.6 cases were confirmed MRU,all of which developed images of interrupting obstruction in ureteral lumens.In 15 cases of receiving examination of exfoliocytology,4 cases expressed positive.Examination of cystoscope were given to 28 cases,of which 6 cases were detected neoplasm in ureteric orifice,and 17 cases were detected jetting blood in ureteric orifice.Examination of ureteroscope was given to 3 patients,of which 3 patients were detected tumor in ureter,and later the tumors were all confirmed transitional cell carcinoma by pathological examination.All cases recepted operation.27 cases were given operation of cutting the involved kidney,total length ureter,and urinary bladder like cuffs,1 case was given operation of cutting inferior part of ureter and part urinary bladder and transplantation of ureter and urinary bladder,and 1 case was given operation of cutting the total length ureter,part of the bladder and nephrostomy.32 cases proved to be transitional cell carcinoma by pathological section after operation,of which 3 cases wereⅠstage,18 cases wereⅡstage,9 case wereⅢstage,2 cases wereⅣstage;6 cases were G1-2,19 cases were G2-3,7 cases were over G3.26 cases had been followed-up for 6 to 42 months.3 patients died within 3 years,of which 1 patient died of relapse of tumor,and the cancer was high stage and high grade.2 patients died of accidents.23 patients were still alive,in which 10 patients were still alive after 3 years,who were given operation of cutting the involved kidney,total length ureter,and urinary bladder like cuffs.
Conclusion The diagnose of primary ureteral cancer should combine the history with ultrasound,CT,MRI,cystoscope,and ureteroscope to improve the diagnose.Primary ureteral cancer is mainly treated with operation,which is usually cutting the involved kidney,total length ureter,and urinary bladder like cuffs.But as to patients who are not fit to receive the classic operation style such as solitary kidney,renal inadequacy in the opposite kidney,intolerant to operation or tumors of upper urinary tract exist in both sides,conservative operation of reserving kidney can be used,and follow-up should be strengthened.
引文
[1]Kirkali Z,Tuzel E.Transitional cellcarcinoma of the ureter and renal pelvis.Crit Rev Oncol Hematol,2003;47:155-69.
[2]Willem Oosterlinck.Ureteral tumour:a apecific upper urinary tract transitional cell carcinoma.European Urology,2007;51:1164-1165.
[3]Babaian RJ,Johnson DE.Primary carcinoma of the ureter.J Urol,1980;123:357-359.
[4]Hall.MC,Womack S,Sagalowsky AI,et al.Prognostic factors,recurrence,and survival in transitional cell cacinoma of the upper urinary tract:a 30-year experience in 252patients.Urology,1998;52:594-601.
[5]Oosterlinck W,Solsona E,van der Meijden AP,et al.EAU guidelines on diagnosis and treatment of upper urinarytract transitional cell carcinoma.Eur Urol,2004;46:147-154.
[6]Munoz JJ,Ellison LM.Upper tract urothelial neoplasms:incidence and survival during the last 2 decades.J Urol,2000;164:1523-1525.
[7]Guinan P,Vogelzang NJ,Randazzo R,et al.Renal pelvic cancer:a review of 611 Patients treated in Illinois 1975-19 85.Urology,1992;40:393-399.
[8]Jensen OM,Knudsen JB,McLaughlin JK,et al.The Copenhagen case control study of renal pelvis and ureter cancer.Role of smoking and occupational exposures.In J Cancer,1988;41:557-561.
[9]宋宗禄,荣石,李汉忠,等.原发性输尿管肿瘤(附48例报告).中华泌尿外科杂志,1997;18:721-723.
[10]白文俊,朱积川,王晓峰,等.原发性输尿管癌的诊断与处理[J].中华泌尿外科杂志,2000;21(1):31-33.
[11]Planz B,George R,AdamG,et al.Computed tomograph for detection and staging of transitional cell carcinoma of the upper urinary tract.Eur Urol,1995;27:146-150.
[12]颜怀新,柳兴明.原发性输尿管癌的影像学诊断[J].中国医学影像技术.2003;19(11):1585-1586.
[13]李建兴,曹栋威,宋飞,等.输尿管癌的影像学诊断[J].山东医药,1999;39(12):122.
[14]韩立新,吕军,黄新华,等.磁共振尿路造影临床应用研究[J].中华放射学杂志,1997;31:678-681.
[15]卢延,洪闻,陆立,等.磁共振泌尿系造影对尿路梗阻性病变的诊断价值[J].中华放射学杂志,1999;33:617-620.
[16]韩见知,庄乾元.实用腔内泌尿外科学[M].广州:广东科技出版社,2001;169-169.
[17]张永康.重视输尿管癌的诊断和治疗[J].中华放射学杂志,1999:33:617-620.
[18]Seaman EK,Shawin KM,Benson MC.Treatment options for appertractt ransitional cell carcinoma[J].Urol Cin North Anl,1993;20:349-352.
[19]GlermsG,Edwards L.Endurologieal management of upper tract urothelial tumor.J Uro1,1993;150:2-5.
[20]SehillingA,BoweringR,KeiditsehE.Use of the Nd:YAGlaser in the treatment of ureter tumors and urethral condylomata acumineta.Euro Urol,1986;12:30-34.
[21]Colombo R,lev A,et al.Local microwave hyperthermia and intravesical chemotherapy as bladder sparing treatment for select multifocal and unresectable superficial bladder tumors.J Uml,1998;159(3):783-787.
[22]Keeley FX Jr,Bibbo M,Bagley DH.Ureteroscopic treatment and surveillance of upper urinary tract transitional cell carcinoma.J Urol,1997;157:1560-1565.
[23]Badalament RA,O'Toole RV,Kenworthy P,et al.Prognostic factors in patients with primary transitional cell carcinoma of the upper urinary tract.J Urol,1990;144:859-863.
[24]Zungri E,Chechile G,Algaba F,et al.Treatment of transitional cell carcinoma of the ureter:15 the controversy justified?Eur Urol,1990;17:276-280.
[25]Lehmann J,Suttmann H,Kovac I,et al.Transitional cell carcinoma of the ureter:prognostic factors influencing progression and survival.European Urology,2006 Nov 17;Epub ahead of Print.
[26]Park S,Hong B,Kim CS,et al.The impact of tumor location on prognosis of transitional cell carcinoma of the upper urinary tract.J Urol,2004;171:621-625.
[27]Tachibana S,Takeuchi M,Uehara Y The architecture of the musculature of the guinea-pig ureter as examined by scanning electron microscopy.J Urol,1985;134:582-586.
[28]H.G. van der Poela,N.Antoninib,H.van Tinterenb,S.Horenblasa,et al.Upper urinary tract cancer:location is correlated with prognosis.European Urology,2005;48:438-444.
[29]Hanna MK,Jeffs RD,Sturgess JM,Barkin M.Ureteral structure and ultrastructure .Part I.The normal human ureter. J Urol,1976;116:718-724.
[30]Catto JW,Azzouzi AR,Amira N, et al.Distinct patterns of microsatellite instability are seen in tumours of the urinary tract.Oncogene,2003;22:869-706.
[31]Hartmann A,Zanardo L,Bocker-Edmonston T, et al.Frequent microsatellite instability in sporadic tumors of the upper urinary tract.Cancer Res,2002;62:796-802.
[32]Amira N,Rivet J,Soliman H, et al.Microsatellite instability in urothelial carcinoma of the upper urinary tract.J Urol,2003;170:1151-1154.
[1]Kirkali Z,Tuzel E.Transitional cell carcinoma of the ureter and renal pelvis.Crit Rev Oncol Hematol,2003;47:155-69.
[2]Willem Oosterlinck.Ureteral tumour:a apecific upper urinary tract transitional cell carcinoma.European Urology,2007;51:1164-1165.
[3]Jemal A,Murray T,Ward E,et al.Cancer statistics,2005,CA Cancer J Clin,2005;55:10-30.
[4]Willem Oosterlinck.Ureteral tumour:A specific upper urinary tract transitional cell carcinoma.Uuropean urology,2007;51:1164-1165.
[5]Oosterlinck W,Solsona E,van der Meijden AP,et al.EAU guidelines on diagnosis and treatment of upper urinarytract transitional cell carcinoma.Eur Urol,2004;46:147-154.
[6]Hall MC,Womack S,Sagalowsky AI,et al.Prognostic factors,recurrence,and survival in transitional cell carcinoma of the upper urinary tract:a 30-year experience in 252patients.Urology,1998;52:594-601.
[7]Hurle R,Losa A,Manzetti A,et al.Upper urinary tract tumors developing after treatment of superficial bladder cancer:7-year follow-up of 591consecutive patients.Urology,1999;53:1144-8.
[8]Kakizoe T,Fujita J,Murase T,et al.Transitional cell carcinoma of the bladder in patients with renal pelvic and ureteral cancer.J Urol,1980;124:17-19.
[9]Babaian RJ,Johnson DE.Primary carcinoma of the ureter.J Urol,1980;123:357-359.
[10]Park S,Hong B,Kim CS,et al.The impact of tumor location on prognosis of transitional cell carcinoma of the upper urinary tract.J Urol,2004:171:621-625.
[11]孔垂泽.肾盂、输尿管肿瘤诊断和治疗进展.辽宁医学杂志,1999;6:287-289.
[12]夏连营,王广有,启史铎.B超在原发性输尿管肿瘤诊断中的应用[J].中华超声影像学杂志,1998;7(7):230-232.
[13]郑加贺,马洁韬,赵旭东,等.螺旋CT诊断原发性输尿管癌的价值[J].中国医学影像学杂志,2004;12(1):12-13;16.
[14]Kirkali Z,Tuzel E.Transitional cell carcinoma of the ureterand renal Pelvis[J].Crit Rev Oncol Hematol,2003;47(2):155-169.
[15]董震,王晓,侯四川等.泌尿系上尿路肿瘤临床诊断方法的评价.齐鲁医学杂志.2004:4:335-336.
[16]Planz B,George R.,Adam G,et al.Computed tomography for detection and staging of transitional cell carcinoma of the upper urinary tract.Eur Urol,1995;27:146-150.
[17]McCoy JG,Honda H,Reznicek M,et al.Computerized tomography for detection and staging of localized and pathologically defined upper tract urothelial tumors[J].J Urol,1991;146(6):1500-1503.
[18]颜怀新,柳兴明.原发性输尿管癌的影像学诊断[J].中国医学影像技术,2003;19(11):1585-1586.
[19]李建兴,曹栋威,宋飞,等.输尿管癌的影像学诊断[J].山东医药,1999;39(12):122.
[20]韩立新,吕军,黄新华,等.磁共振尿路造影临床应用研究[J].中华放射学杂志,1997;31:678-681.
[21]卢延,洪闻,陆立,等.磁共振泌尿系造影对尿路梗阻性病变的诊断价值[J].中华放射学杂志,1999;33:617-620.
[22]Mills IM,Laniado ME,patel A.The role of endoscopy in the management of patients with upper urinary tract transitional cell carcinoma.BJU Int,2001;87:150-162.
[23]韩见知,庄乾元.实用腔内泌尿外科学[M].广州:广东科技出版社,2001;169-169.
[24]张永康.重视输尿管癌的诊断和治疗[J].中华放射学杂志,1999;33:617-620.
[25]Elliott DS,Blute ML,Patterson DE,et al.Long term follow up of endoscopically treated upper urinary tract transitional cell carcinoma.Urology,1996;47:819-825.
[26]吴锋,钟文智,刘统成.输尿管镜致输尿管损伤的原因分析.中国内镜杂志,2001;7(4):88-89.
[27]Keeley FX,Bibbo M,Bagley DH.Ureeroscopic treatment and surveillance of upper urinary tract transitional cell carcinoma.J Urol,1997;157:1560-1565.
[28]Kerbl K,Clayman RV.Incision of the ureterovesical junction for endoscopic surveillance of transitional cell cancer of the upper urinary tract.J Urol,1993;150:1440-1443.
[29]Baglry DH.Ureteral access with flexible ureteroscopes effect of the size of the endoscope.J Urol,2001;165:71.
[30]Shalhav A1,Dunn MD Portis AJ,et al.Laparoscopic nephroureterectomy for upper tract transitional cell carcinoma:the Washington University experience.J Urol,2000;163:1100-1104.
[31]Murphy DP,Sung GT,Meraney AM,et al.Laparoscopic radical nephroureterectomy for uppper tract transitional cell carcinoma:single center experience with 60 cases.J Urol,2001;165:3.
[32]Guinan P,Vogelzang NJ,Randazzo R,et al.Renal pelvic cancer:a review of 611 patients treated in Illion is 1975-1985.Cancer Incidence and End Results Committee.Urology.1992;40:393-399.
[33]Ozsahin M,Zouhair A,Villa S,et al.Prognostic factors in urothelial renal pelvis and ureter tumours:a multicentre rare cancer network study.Eur J Cancer.1999;35:738-743.
[34]Rabbani F,Perrotti M,Russo P,Herr HW.Upper-tract tumors after an initial diagnosis of bladder cancer:argument for long-term surveillance.J Clin Oncol.2001; 19:94-100.
[35]Mullerad M,Russo P,Golijanin D,et al.Bladder cancer as a prognostic factor for upper tract transitional cell carcinoma.J Urol.2004;172:2177-2181.
[36]Hong B,Park S,Hong JH,et al.Prognostic value of lymphovascular invasion in transitional cell carcinoma of upper urinary tract.Urology.2005;65:692-696.
[37]van der Poel HG,Antonini N,van Tinteren H,et al.Upper urinary tract cancenlocation is correlated with prognosis.Eur Urol.2005;48:438-444.
[38]Akdogan B,Dogan HS,Eskicorapci SY,et al.Prognostic significance of bladder tumor history and tumor location in upper tract transitional cell carcinoma.J Urol.2006;176:48-52.
[39]Lee SH,Lin JS,Tzai TS,et al.Prognostic factor of primary transitional cell carcinoma of the upper urinary tract.Eur Urol.1996;29:266-270.
[40]Sylvester RJ,van der Meijden APM,Oosterlinck W,et al.Predicting recurrence and progression in individual patients with stage Ta/T1 bladder cancer using EORTC risk tables:a combined analysis of 2596 patients from seven EORTC trials.Eur Urol,2006;49:466-77.
[41]HubenRP,Mounzer AM,Mu (?)hy GP.Tumor grade and stage as Prognostievariables in uPPer traet urothelial tumors.Cancer,1988;62:2016-2020.
[42]张永康.重视输尿管癌的诊断和治疗[J].中华放射学杂志,1999;33:617-620。
[43]Seaman EK,Shawin KM,Benson MC.Treatment options for appertract transitional cell carcinoma[J].Urol Cin North Anl,1993;20:349-352.
[44]Glenns G.Edwards L.Endurological management of upper tract urothelial tumor.J Urol,1993;150:2-5.
[45]Schilling A,Bowering R,Keiditsch E.Use of the Nd:YAGlaser in the treatment of ureter tumors and urethral condylomata acumineta.Euro Urol,1986;12:30-34.
[46]Lehmann J,Retz M,Nurnberg N,et al.The superior prognostic value of humoral factors compared with colecular proliferation markers in renal cell carcinoma.Cancer,2004; 101:1552-1562.
[47]Stauffer M.Nephrogenic hepatoslenomegaly.Gastroenterology 1961;40:694-700.
[48]Jorgensen T,Kanagasingam Y,Kaalhus O,et al.Prognostic factors in patients with metastatic(stage D2) prostate cancer:experience from the Scandinavian Prostatic Cancer Group Study-2.J Urol,1997; 158:164-170.