1、泌尿、男生殖系肿瘤 Genitourinary tumor,中南大学湘雅医院泌尿外科 高宁,概 述,泌尿系肿瘤在全身各部位肿瘤中，并不占最重要的地位，但在泌尿系统外科疾病中是常见疾病之一。 The most common genitourinary neoplasms arise in the bladder, kidney, prostate. Testicular cancer is not common.,国外，尤其在欧美国家中，前列腺肿瘤属于最常见的泌尿系肿瘤。 前列腺肿瘤(Prostate tumor)在中国比较少见，近年来有上升趋势。 过去我国常见的生殖系肿瘤中阴(Penis ca
2、ncer)茎癌的发病率巳有明显下降。,Renal tumors,Benign tumors Cystic renal Simple cyst Polycystic kidney Renal hamartoma Malignant renal tumors Primary tumor Renal cell carcinoma Renal adenocarcinoma Nephroblastoma (Wilms tumor) Sarcoma Carcinoma of the Renal Pelvis and Ureter. Secondary tumor,Incidence Adenocarcin
3、oma of the kidney accounts for almost 85% of all renal neoplasms。 Carcinoma of the Renal Pelvis and Ureter accounts for almost 7%-8% of all renal neoplasms。 Nephroblastoma accounts for almost 5%-6% of all renal neoplasms 。 但在成人全身恶性肿瘤中，肾肿瘤仅占1%左右。 而儿童恶性肿瘤肿，肾母细胞瘤可达20%，在小儿腹部肿块性疾病中是最常见的疾病。 肾脏肿瘤以恶性肿瘤多见，任何
4、肾脏的肿瘤在未获得病理学证实以前，应高度怀疑为恶性肿瘤。,Renal cell carcinoma,肾癌亦称为肾细胞癌，在肾肿瘤中占主要地位，肾癌约占肾脏肿瘤的四分之三，是最常见的肾实质恶性肿瘤。 随着诊断水平的提高以及年龄结构老年化的改变，临床上肾癌发病率有明显增高的趋势。 临床上许多无任何证状的肾肿瘤，在体检及超检查中被偶然发现，肾脏的“偶发癌”有所增加。,Etiology,The etiology of renal cell carcinoma is unknown, Several interesting associations have been noted. Estrogens
5、diet. High consumption of fats, oils，milk, and sugar. Renal failure Von Hippel-Lindau disease Toxic agents,Pathology,Renal carcinoma occur with equal frequency in either kidney and are randomly distributed in the upper and lower poles. RCCs originate in the cortex and tend to grow out into perinephr
6、ic tissue. 有1-2%的病例可能双肾同时或先后出现肾癌。,The tumor average 7-8cm in diameter but can grow to fill the entire retroperitoneum. RCCs do not have true capsules but may have a pseudocapsule of compressed renal parenchyma, fibrous tissue, and inflammatory cell. Larger tumor can exhibit hemorrhage, necrosis with
7、 secondary cystic areas , calcification.,RCCs are vascular tumors that tend to spread either by direct invasion through the renal capsule into perinephric fat and adjacent visceral structures or by direct extension into the renal vein. Histologically, RCC is most often a mixed adenocarcinoma contain
8、ing clear cell, granular cell, sarcomatoid cell.,透明细胞癌(the clear cell carcinoma),Clear cells are rounded or polygonal with abundant cytoplasm which contains cholesterol, triglycerides, glycogen, and lipids. 在常规组织脱水过程中被脂溶剂（酒精、二甲苯）等溶解，癌细胞呈现空淡透明而称之为透明细胞。 该类细胞核小、深染、规则、胞桨透明。,颗粒细胞癌(the granular cell carci
9、noma),Granular cells contain less glycogen and lipids, and electron microscopy reveals that the granular cytoplasm contains large numbers of mitochondria and cytosomes.,Sarcomatoid cells are spindle-shaped and form sheets or bundles. This cell type rarely occurs as a pure form and is most commonly a
10、 small component of either the clear cell or granular cell type.,Sarcomatoid cell carcinoma,Tumor staging,Clinical findings,Symptoms and signs hematuria Flank pain Abdominal mass Symptoms secondary to metastatic disease. Paraneoplastic symtoms Erthrocytosis Hypertension Nonmetastatic dysfunction,血 尿
11、(hematuria),The hematuria is the more common symptoms.Sixty percent of patients present with gross or microscopic hematuria. 血尿的出现意味着肿瘤巳侵犯肾盂、肾盏，只有当肿瘤组织侵入肾盂、肾盏后才有可能出现血尿。血尿不是肾癌的早期表现。 血尿多为间歇性、无痛性、全程肉眼血尿，,常因出血过多而形成血块，引起肾绞痛或肾区胀痛。 血块通过输尿管时而被塑形，形成条状血块。 血尿亦可表现为镜下血尿，并可自行停止而被患者误认为“自愈”。,腰痛(Flank pain),多数为胀痛或钝痛
12、，一般局限在腰部，约50%可出现腰痛。亦为晚期肾癌的临床表现。 腰痛的原因： 疼痛常因肿块充胀肾包膜引起，肾脏表面神经末稍受压迫。 血块在通过输尿管的过程中引起输尿管痉挛或血块引起尿路的梗阻。 肿块侵犯肾周脏器或腰背筋膜、腰大肌而出现持续性腰痛。,肿 块(palpable mass),正常肾脏不容易被触及，在肾癌其肿块达到相当大的体积以前，肿块很难被发现。 约有1/4-1/3病人在就诊时发现肾脏肿块，肿块一般表面光滑、质地较硬，无压痛或轻压痛。 可随呼吸活动，但当肿块巨大时不随呼吸活动，侵犯邻近器官或肌肉组织时则完全固定，不易推动。,肾外表现,常见有：发热、消瘦、贫血、血压增高、血沉增高，肝功
13、能受损，红细胞增多以及一些内分泌异常。 癌栓侵犯肾静脉时，可出现症状性精索静脉曲张。,Diagnosis,病史及体查 影像学检查 Ultrasonography Intravenous Urography(IVU) and Renal Angiography Radionuclide Imaging:,超检查可达早期诊断目的。 其特征为：低回声、结构不均匀之肿块。 多普勒超声仪显示肿块血流丰富。 彩色超还能了解是否存在静脉癌栓。 肾癌较肯定时，一般不主张在超下穿刺活检，以免引起出血和肿瘤扩散。,KUB+IVP了解双肾功能及肾盂、肾盏形态，肾癌时 肾外形增大，轮廓改变，偶有肿瘤钙化，肾盂、肾盏挤
14、压变形、狭窄或充填缺损。,Intravenous Urography,检查，平扫肿块值在30-50之间，增强后值明显低于正常肾实质。,CT scan,Renal angiograph： 肿瘤血管异常丰富，并可见“血管湖”样改变。 Guiding the operative approach 动脉造影可同时行肾动脉栓塞。,检查，在T1加权成像上显示为非均值等信号或低信号肿块，T2加权成像显示为高信号肿块。 同位素扫描(SPECT)：对于骨骼及肝脏转移灶有一定意义。,鉴别诊断,肾囊肿(renal cysts) 肾血管平滑肌脂肪瘤(renal hamartoma),Treatment,Radical
15、 nephrectomy is the primary treatment for localized RCC. Its goal is to achieve the removal of tumor and to take a wide margin of normal tissue. Radical nephrectomy entails en bloc removal of the kidney and its enveloping fascia including the ipsilateral adrenal , proximal one-half of the ureter , a
16、nd lymph nodes up to the area of transection of the renal vessels.,伴有静脉癌栓的患者，若无局部及远处转移，可于肾癌根治的同时行静脉癌栓摘除。 晚期肾癌，可行肾动脉栓塞术，免疫治疗、化学治疗及内分泌治疗。 双侧及孤肾肾癌，可行肾部分切除或肿瘤剜出术治疗。 过继免疫治疗，（细胞、细胞和白细胞介素-2等免疫活性治剂）可能有一定前途。,问题,肾癌的主要临床表现是什么？为什么说肾癌的三大主要症状都是晚期肾癌的临床表现？ 根治性肾切除的手术范围是什么？ 根治性肾切除术中，你对同侧肾上腺切除及区域淋巴结的清扫有什么看法？,肾 盂 肿 瘤 T
17、umors of the pelvis and ureter,Carcinoma of the pelvis and ureter are rare, accounting for only 4% of urothelial cancers. the ratio of bladder-renalpelvis-ureteral carcinoma is approxmately 51:3:1 与输尿管肿瘤、膀胱肿瘤都起源于尿路移行上皮，又同属尿路范围，故临床上又统称为尿路移行上皮细胞肿瘤。,As with bladder carcinoma Smoking Exposure to certain
18、 industrial dyess Solvents are associated with an increased risk of upper urinary tract transitional cell carcinoma.,Etiology,Pathology,The majority of renal pelvic and ureteral cancers (90%-97%) are transitional cell carcinoma. Grading is similar to that for bladder carcinoma. Papillomas account fo
19、r approximately 15-20% of case. 肾盂和输尿管癌具有多中心性、可种植性、复发性、浸润性和转移性。 由于肾盂壁薄，周围淋巴丰富，其主要沿淋巴途径转移，早期即可发生。 远处可转移到肺、骨、脑等部位；鳞癌极少见，占10%左右。腺癌极少见。 肾盂及输尿管癌常导致同侧上尿路梗阻，引起肾积水和肾功能受损。,Clinical Finding,Gross hematuria is noted in 70-90% of Patients. Flank pain, present in 8-50%, is the result of ureteral obstruction from
20、 blood clots or tumor fragments, renal pelvic or ureteral obstruction by the tumor itself, or regional invasion by the tumor. A flank mass owing to hydronephrosis or a large tumor is detected in approximately 10-20%.,Diagnosis,无痛性肉眼全程血尿伴一侧上尿路进行性梗阻为肾盂及输尿管癌的特点。 Findings on intravenous Urography in pat
21、ients with upper urany tract cancers are usually abnormal. The most common abnormalities identified include an intraluminal fill defect, unilateral nonvisualization of the collecting system, and hydronephrosis. The use of rigid and flexible ureteropyeloscopys has allowed direct visualization of uppe
22、r urinary tract abnormalities. And biopysy 超、检查一般意义不大。梗阻时，可表现为肾积水。,Treatment,Treatment of renal pelvic and ureteral tumors should based primarily on grade, stage, position, and multiplicity. The standard therapy for both tumor types has been nephroureterectomy The operation is performed for proximal
23、 ureteral or pelvic cancer, the entire distal with a small cuff of bladder needs to be removed to avoid recurrence 孤肾输尿管癌可将肿瘤段输尿管切除后，行输尿管对端吻合术。 Endoscopic excision alone should be considered only for low-grade and noninvasive tumors,问题,肾盂肿瘤的手术范围是什么？为什么？ 肾盂移行上皮肿瘤患者，是否应对膀胱进行详细检查？,肾 母 细 胞 瘤 Nephroblast
24、oma,Nephroblastoma also known as Wilms tumor, is the most common solid renal tumor of childhood. accounting for roughly 5% of childhood cancer.In 5% of cases the tumor are bilateral,Etiology,肾胚胎瘤确切病因不清楚，可能与WT和WT基因突变有关，近来亦发现其可能与遗传因素有关。有遗传倾向者，可为双侧性或多中心发病。,Pathogenesis & pathology,肾母细胞瘤为胚胎性肿瘤，它起源于后肾胚基，
25、肿瘤内含有胚胎性肾组织。是上皮和间质组成的混合性肿瘤，包含有腺体、神经、肌肉、软骨及脂肪等。肿瘤切面呈黄色，质地较软，可有囊性变程和块状出血，肿瘤组织与正常组织分界不清。,肾母细胞瘤一般发展较快，以日计算； 肿瘤以局部扩展和浸润方式生长，早期即可直接侵犯周围肾组织，肾周脂肪囊以及附近器官。极少侵入肾盂、肾盏。 肾胚胎瘤常以血行方式播散，并可引起静脉瘤栓。肿瘤亦可沿淋巴途径转移。,Clinical finding,The diagnosis of Wilms tumor is most commonly made after the discovery of an asymptomatic ma
26、ss by a family member or a physician during a routine physical examination. Common symptoms include abdominal pain and distention, anorexia, nausea and vomiting, fever, and hwmaturia.,Diagnosis,Symptoms and signs Abdominal mass and pain Laboratoy analysis Urinalysis may show evidence of hematuria An
27、emia may be present Ultrasonography 可见肾脏实质性占位病变，同时可了解肾静脉及下腔静脉有无瘤栓，以及腹膜后淋巴结有无肿瘤转移。,静脉肾盂造影检查 （KUB+IVP）：可见肾集合系统受压或破坏，肾功能受损。 检查 可了解肿瘤部位、大小、有否局部淋巴结转移，周围器官是否受累，肾静脉及腔静脉有无瘤栓。 下腔静脉及肾静脉造影. 可了解有无静脉瘤栓形成及其波及范围。 胸部照片 Wilms瘤可早期出现肺部肿瘤。,Differential diagnosis,Hydronephrosis Intrarenal neuroblastoma Mesoblastic nephr
28、oma Cystic kidney Rare sarcomas,Treatment,Surgical measures: Radical nephrectomy Radiation therapy Recongnized as a radiosensitive tumor chemotherapy： Including actinomycin D, vincristine 双侧肾母细胞瘤，尽可能行保留正常肾组织的外科手术。术后再配合放射治疗及化学药物治疗。 肾母细胞瘤的基因治疗可能有一定苗头。,问题,肾母细胞瘤的主要临床表现是什么?其治疗方法有哪些?,Bladder Carcinomas,Th
29、e bladder carcinomas is the most common cancer of the genitourinary tract. The average age at diagnosis is 65 years. Approximately 85% are localized to the bladder and 15% have spread to regional lymph nodes or distant site.,Industrial toxins Continuous contact with aniline dye, a-naphthylamine, 4-a
30、minobiphenyl, and benzidine used in the rubber, leather, textile, and dye industries may account for up to 25% of instances of bladder cancer. Cigarette smoking Other risk factors Include cyclophosphamide, alkylating agents such as thiotepa.,Etiology,局部刺激 膀胱癌发病还可能与膀胱内慢性刺激或病毒感染有关。如感染、结石、尿路梗阻、尿潴留等，可造成
31、膀胱粘膜增生、腺性膀胱炎等。 寄生虫病寄生于膀胱内的埃及血吸虫病。,Pathology,膀胱肿瘤的病理结构主要与肿瘤的组织类型、细胞的分化程度、生长方式及浸润深度有关，其中最主要的是细胞的分化程度和肿瘤的浸润深度。 膀胱肿瘤具有多中心性、可种植性、浸润性、复发性和转移性。,histopathology Ninety-eight percent of all bladder cancers are epithelial malignancies, with the majority being transition cell carcinoma. Adenocarcinomas account
32、for less than 2% of all bladder cancers. Primary adenocarcinomas of the bladder may be preceded by cystits and metaplasia. Squmous cell carcinoma accounts for beteen 5 and 10% of all bladder cancers and is often associated with a history of chronic infection.,Transitional cell carcinoma Papillary tr
33、ansitional cell carcinoma most of these tumors are small and noninvasive. Sessile transitional cell carcinoma Appears as a less frondular, more solid lesion with a broad base. These tumors have a greater tendecy to be invasive. Carcinoma in situ Squamous cell carcinoma Adenocarcinoma Other types,Tum
34、or classification,Grade of tumorscurrently, most pathologists use a three-grade system proposed by mostofi。 grade：mild anaplasia 上皮层数增加，超过层，极向排列轻度紊乱，染色质增加，无细胞核异常。 grade：moderate anaplasia 上皮结构增加，极向排列消失，核大而浓染，可见核分裂相。 grade：marked anaplasia 不能分辨移行细胞，细胞明显非典型性改变，胞核异常，胞桨与胞核比例失调，可见核有丝分裂。,Stage of tumors,t
35、he UICC staging system即国际分类法。 Staging proceures Cystoscopy Biopsy Transurethral resection of bladder tumor Bimanual edamination Pelvic US CT MRI Other studies,UICC staging,膀胱肿瘤扩散 主要是向深部浸润，亦可沿肌肉内淋巴扩散以及血行转移，血行转移多在晚期，可转移至肺、肝、骨。 生长部位 以三角区和输尿管附近最多，其次为两侧壁、后壁、顶部、前壁。,Clinical Finding,Hematuria is the presen
36、ting symptom in 85-90% of patient with bladder cancer. It may be gross or microscopic ,intermittent rather than constant。 It is accompanied by symptoms of vesical irritability: frequency, urgency, dysuria Symptoms of advanced disease include bone pain , flank pain and ureteral obstruction.,膀胱三角区及膀胱颈
37、部肿瘤可致梗阻及排尿困难。较大的肿瘤或邻近膀胱颈内口时可出现排尿困难。 肿瘤晚期可扪及下腹部包块，可造成严重贫血、消瘦、下肢浮肿等。 转移症状：,Diagnosis,Signs and symptom Urinary cytology Cystoscopy 可了解肿瘤的大小、数量、生长方式、生长部位及肿瘤与输尿管口、膀胱颈的关系。同时可作活检而确诊。 Flow cytometry DNA analysis Radiologic examinations 静脉尿路造影：除可见膀胱内负影外，还可了解上尿路是否正常。,及检查 可了解膀胱癌浸润程度，以及与周围脏器的关系。 超可作为初步诊断的检查手段。
38、 Other urine tests Bladder tumor antigen(BTA),NMP22, FDP.,Treatment,膀胱肿瘤的治疗，原则上以手术治疗为主。手术方式的选择，目前主要取决于肿瘤浸润的深度及肿瘤生长的部位。 膀胱浅表肿瘤：可经尿道行肿瘤电切、电烙或激光治疗。 膀胱单个浸润癌应行包括肿瘤基部周围半径厘米膀胱壁在内的膀胱部分切除。若切除范围包括输尿管口，则应同时行输尿管膀胱再植术。,膀胱三角区及颈部较大的浸润癌，膀胱多发性浸润癌，术后短期内复发的多发性癌以及膀胱低分化癌，应行膀胱全切，肠道代膀胱术。 膀胱肿瘤术后应定期复查，了解膀胱及尿道是否有肿瘤复发。 保留膀胱的手术，术后应行膀胱药物灌注局部化疗。 无法手术切除的膀胱癌，可行姑息性手术治疗。,问题,膀胱肿瘤的手术方式主要取决于什么？ 移行上皮肿瘤的生物学特性是什么？ 确诊膀胱肿瘤的最好方法是什么？,谢 谢,
