Introduction:
Renal tumors are more common in urinary tumors, second only to bladder tumors. The vast majority of primary renal tumors are malignant, includingRenal cell carcinoma, Wilms tumor (Wilms tumor) and renal pelvis cancer. Benign tumors of the kidney include renal adenomas, angiomyolipoma, hemangiomas, lipomas, fibroids, and renal parablastomas. Renal cancer is also known as renal cell carcinoma, renal adenocarcinoma, clear cell carcinoma, and renal parenchymal cancer. Renal parenchymal carcinoma is an adenocarcinoma derived from renal tubular epithelial cells, 85% is clear cell carcinoma, and some are granulosa cell carcinoma and mixed cell carcinoma.
Cause:
(1) Causes of the disease
Kidney cell cancer is mostly caused by insufficient kidney gas, water is not wet, wet poison is endogenous, or it is exposed to damp heat and toxic poison. It is poisoned by Lifan, and the internal and external Hefei City is caused by water. Kidney deficiency can not take blood for hematuria, waist is the kidney of the house, kidney deficiency is low back pain, damp heat and poisoning, and stagnation of blood stasis forms a mass.
The cause of kidney cancer and renal pelvic cancer is also unknown in modern medicine. It is thought to be related to the long-term stimulating effect of carcinogens. For example, the incidence of renal cancer in smokers is high, and those who take long-term pain and antipyretic phenacetin often occur. The sputum nephritis, renal pelvic cancer and the incidence rate have also increased. Long-term kidney stones and infections can induce epithelial metaplasia and dysplasia, and the latter two can develop into cancer.
The etiology of kidney tumors is still unknown. In recent years, aromatic amines, aromatic hydrocarbons, aflatoxins, nitroso compounds, alkyl compounds, hydrazines, lead, cadmium, etc., and certain drugs such as anticancer drugs, phenacetin have been considered. Coffee, food additives such as statins, amphetamines, diuretics and potassium bromate have carcinogenic effects. Most scholars believe that renal cell carcinoma originates from the proximal convoluted tubules, and the incidence of renal cancer is significantly increased in people who directly inhale tobacco or cigars with tobacco tubes. One study showed that the incidence of kidney cancer in smokers was 1.7 times higher than that of non-smokers. There was a direct and significant relationship between smoking and risk. The relative risk of mild smoking was 1.1, with a moderate 1.9. The severity is 2.3. The extent of smoking and the length of smoking are positively correlated with the incidence of kidney cancer. Even if smokers quit smoking, they are twice as likely to have kidney cancer as never smokers. Dimethylnitrosamine-induced kidney cancer in tobacco has been confirmed in animal experiments. Vecchia believes that smoking and alcohol, occupational exposure and other risk factors can further increase the risk of kidney cancer. Smokers have beta-naphthylamine and ethylamino-7naphthol in the urine. These substances have been shown to cause bladder cancer and may also cause kidney cancer. Luck'e. HerpesVires and mouse milk tumor virus can cause kidney tumors in animals, and the carcinogenic effect on human kidney has not been confirmed. Kidney cancer occurs mostly in men, especially in older men with male hormone decline, which indicates that sex hormones are related to the occurrence of kidney cancer. The exact mechanism is still unclear. The incidence of renal cell carcinoma is higher in overweight women, but not in overweight men. What kind of nutrients contribute to the occurrence of kidney cancer is still unknown. Certain hereditary diseases such as tuberous sclerosis, multiple neurofibromatosis, etc. may be associated with renal cell carcinoma. Kidney stones can be combined with renal pelvic cancer due to long-term local inflammation. Long-term hemodialysis patients induce acquired renal cystic disease and cancer due to accumulation of cysts and carcinogenic substances that cannot be removed by hemodialysis such as polyamines.
In conclusion, in the development of renal cell carcinoma, it may be related to many chemical and biological factors. Smoking and/or obesity, other factors include aluminum phosphate, dimethyl nitrosamine, long-term estrogen intake, aflatoxin B1 and streptozotocin, and certain special diseases such as Von-Hippel-Lindau disease Can cause renal cell carcinoma. Renal cell carcinoma can also occur in some patients with chronic renal failure or acquired renal cysts due to dialysis treatment. About 30% to 50% of long-term dialysis patients can develop acquired renal cysts, of which 6% can occur with kidney cancer with acquired cystic disease.
(two) pathogenesis
Renal cancer is often a single unilateral lesion, about 2% of which are bilateral or multifocal, and the incidence of the left and right sides is similar. Typical kidney cancer is round and disproportionate. According to a group of 100 cases of renal cell carcinoma, the lesions are: upper 44 cases, lower part 41 cases, and multiple lesions 15 cases. The tumor has no histological envelope, but has a pseudo-envelope formed by the compressed renal parenchyma and fibrous tissue. A few are yellow or brown, most with bleeding, necrosis, fibrotic plaque, hemorrhage, necrosis can form cystic. Tumors may have calcifications in a punctate or plaque arrangement. Juvenile patients have more calcifications in renal cell carcinoma than in elderly patients. Tumors can destroy the whole kidney and can invade adjacent adipose tissue, muscle tissue, blood vessels, lymphatic vessels, and the like. Kidney cancer easily expands into the vein to form a tumor thrombus, which can enter the renal vein, inferior vena cava, and even the right atrium. The perirenal fascia is a barrier to prevent localized spread of tumors. Ipsilateral adrenal gland involvement accounts for about 10%, and distant metastasis is common in lung, brain, bone, liver, skin, and thyroid.
Renal cancer tissues and cells are diverse, and the gross specimens can be solid lamella, trabecular, papillary, honeycomb, glandular. A typical renal cancer cell is a transparent cell, which is polygonal, cuboidal or columnar, and has a cell diameter of 10 to 40 μm. Since the cytoplasm contains glycogen and lipids, HE stains cytoplasm transparent or vacuoles. The lipids contained in the cytosol were mainly phosphonates and neutral lipids. Hale colloidal iron staining was observed by electron microscopy. Focal microvilli development and cytoplasmic vesicle formation were observed. The nucleus is small and regular, with a few mitosis. Kidney cancer is a granulosa cell, its cytoplasm is glassy, uniform, and the size of cells and nucleus is different, and the division is more common. Most of the kidney cancers are clear cells, and there are also granulosa cells at the same time. Some kidney cancers are spindle cells, which are difficult to distinguish from fibrosarcoma. The clear cells, granulosa cells or spindle cells of the tumor of kidney cancer may be present alone or in combination.
Pathological grade of renal cancer: The renal morphological grading system proposed by Fuhrman et al. (1982) has been accepted and adopted by most scholars in the world.
Grading according to the shape and size of the nucleus has the advantages of clear standards and easy to grasp. When there are different grades of cells in different grades in the same tumor or in the same region, the highest grade of cancer cells is the final grade of pathological diagnosis. For example, most cells are G2, and a few tumors with G3 should be designated as G3.
Staging: Renal cancer staging is not uniform, and it is currently widely used in Robson's staging and TNM staging.
Robson staging:
Stage I: The tumor is confined to the renal capsule.
Stage II: The tumor penetrates the renal capsule and invades the fat around the kidney, but is confined to the renal fascia. The renal vein and local lymph nodes are not infiltrated.
Stage III: Tumor invades the renal vein or local lymph nodes, with or without inferior vena cava, and involvement of fat around the kidney.
Stage IV: distant metastasis or invasion of adjacent organs.
The above is a simplified Robson staging, which is easy to apply. The disadvantage is that the prognosis of stage II and III is the same. The TNM staging proposed by the International Anti-Cancer Association in 1987 is as follows.
TNM staging:
T0: no primary tumor.
T1: The maximum diameter of the tumor is ≤2.5 cm, which is confined within the renal capsule.
T2: The maximum diameter of the tumor is >2.5 cm, which is confined within the renal capsule.
T3: Tumors invade large blood vessels, adrenal glands, and peri-renal tissues, and are confined to the renal fascia.
T3a: Invades the periplasmic adipose tissue or adrenal gland.
T3b: Invades the renal vein or inferior vena cava.
T4: Invades the renal fascia.
N0: no lymph node metastasis.
Nl: single, unilateral lymph node metastasis, maximum diameter ≤ 2.5cm.
N2: multiple local lymph node metastasis, or a single lymph node with a maximum diameter of 2 to 5 cm.
N3: The maximum diameter of the locally metastatic lymph nodes exceeds 5 cm.
M1: Transfer in the distance.
symptom:
The clinical manifestations of renal cell carcinoma vary from typical triads, hematuria, pain, and possible renal masses to more concealed peri-tumor syndrome. Triads often occur in the late stages, and usually only 10% of patients have typical symptoms, most of which are accidentally discovered. The location of the kidney is concealed. When the lesion occurs, most of it is through the change of urine. As a signal to remind the patient to seek medical treatment, hematuria is a common symptom of kidney cancer. However, before the appearance of hematuria, the clinical manifestations of renal cancer vary widely, sometimes the tumor volume. Very large, even signs of metastasis such as lungs and bones, can be without any symptoms. In addition to the three typical symptoms of hematuria, back pain and mass, kidney cancer also has many extra-renal manifestations of non-urinary system, such as fever, abnormal liver function, anemia, hypertension, polycythemia and hypercalcemia.
1. Hematuria Gross hematuria or microscopic hematuria is the most common symptom. Most cases show tumor invasion of the renal pelvis and renal pelvis, which is intermittent, often without pain. Clinically, it is often called intermittent, painless gross hematuria, which is a unique symptom of urinary tumors. However, colic can occur when a blood clot passes through the ureter.
2. Most of the low back pain is dull pain, discomfort, and is limited to the waist or back. Because the tumor envelope grows, the renal capsule tension increases, and if the tumor invades the surrounding tissues of the kidney, it can cause pain. Persistent pain appears, suggesting that the tumor has invaded the nerves and lumbar spine. Hematuria is coagulated into a cord-like blood clot in the ureter and is excreted in the urine, which can cause renal colic.
3. In patients with kidney cancer, the waist and upper abdomen can reach 10% of the mass, sometimes it is the only sign. The mass is hard and the surface is uneven or nodular. When the patient is thin and the tumor is at the lower pole, a physical examination can cause a mass. If the mass is fixed, it indicates that there is infiltration around the kidney and the prognosis is poor. There are not many cases of hematuria, low back pain and lumps triad at the same time, if they occur at the same time. It is often a sign of advanced tumors. The flank pain (abdominal) and the mass are common in children and more common in adults; the tumor located in the lower pole of the kidney is easily accessible. The mass is substantial, no tenderness, and moves with the breath.
4. The varicocele kidney tumor invades the renal vein, or the tumor compresses the internal spermatic vein, which often occurs on the left side. When the inferior vena cava is invaded, it can be accompanied by lower extremity edema.
5. Systemic symptoms of fever is one of the common extrarenal manifestations of kidney cancer, with low fever or high fever, accounting for 45% below 38 °C, accounting for 7% above 38 °C, and a few can be as high as 39 °C. Elevated body temperature is likely to be related to the heat source produced by kidney cancer tissue, and is not directly related to tumor necrosis and hemorrhage. The body temperature returned to normal after renal cancer resection. 2% to 3% of patients with renal cancer show only fever in the clinic. Therefore, the cause of middle-aged and elderly people is unexplained. It is thought that kidney cancer may be possible in order to carry out related examinations.
Because kidney cancer is a highly malignant tumor, many patients have obvious cachexia, anemia, hypothermia, loss of appetite and other cachexia manifestations, sometimes with lung and bone metastases, or due to pathological fractures.
Patients with large amounts of hematuria can cause anemia. Clinically, some patients with kidney cancer do not have hematuria, but there is obvious anemia, indicating that the patient's anemia is related to hematuria. There are other reasons. Some people think that it is related to tumor toxin or the destruction of a large number of kidney tissues affecting hematopoietic function.
About 15% of renal clear cell carcinomas have reversible liver dysfunction, and liver function returns to normal after renal cancer resection. Therefore, liver dysfunction is not a contraindication for renal cancer surgery. The indicators of abnormal liver function include increased serum alkaline phosphatase activity, delayed bromine sulfonium excretion, decreased plasma albumin, prolonged prothrombin time, elevated indirect bilirubin, and abnormal globulin. The liver function of most patients recovers after renal cancer resection. If the liver function persists abnormally, it indicates that there are residual foci or metastases in the body. These patients have poor prognosis.
6. Symptoms of endocrine disorders Experimental and clinical studies have shown that kidney cancer can secrete a variety of endocrine substances. Causes a series of symptoms. The same tumor can secrete several endocrine hormones, causing the following manifestations:
Kidney cancer mergerPolycythemiaThe case of 2%, the study proved that the exudate of renal tumor has the effect of increasing the activity of erythropoietin, while the normal kidney tissue has no effect, indicating that the occurrence of polycythemia is related to the increase of erythropoietin activity. When the kidney cancer is removed, the red blood cells increase and disappear. Recurrence of tumor recurrence or metastasis.
The incidence of hypertension in patients with renal cancer accounts for about 10%, which may be due to the following reasons: 1 the tumor directly invades the renal artery; 2 the tumor compresses the renal artery, causing renal ischemia; 3 the tumor is formed by arteriovenous fistula, and the heart output The amount increases; 4 the tumor itself produces factors such as renin, causing hypertension. In patients with hypertension caused by renal cell carcinoma, the measured value of plasma renin activity is increased. The renal cell carcinoma tissue and the surrounding renal tissue are measured for renin content, which indicates that the renin in renal cell carcinoma is significantly higher than that in cancer. Kidney tissue. 57 cases of renal cell carcinoma have been reported. The plasma renin level was measured before surgery, and the result was 37%. The renin level was related to the progression and malignancy of the tumor. In the advanced and malignant kidney cancer, renin may follow. Raise. Poor prognosis.
Kidney cancer with high calcium is 3% to 16.8%, and most of them are advanced lesions. In the past, bone metastasis was the main cause of renal cell carcinoma complicated with hypercalcemia. However, patients with renal cell carcinoma without bone metastasis also had hypercalcemia, and blood calcium returned to normal after tumor resection. Some scholars have suggested that kidney cancer tissues secrete both parathyroid hormone and erythropoietin. Fahn (1991) reported 218 cases of renal cell carcinoma, of which 9.2% were hypercalcemia. The relationship between clinical stage and hypercalcemia was 3% in stage I, 5.9% in stage II, 14.1% in stage III, and IV without bone metastasis. The period is 18.9%. Parathyroid hormone is currently considered to be a factor of malignant hypercalcemia.
Renal cancer tissues have been reported to secrete glucagon and glycogen-like active substances. Causes gastrointestinal motility and absorption dysfunction. When patients with kidney cancer have intestinal dysfunction, they cause poor digestion and absorption. Protein loss. The tumor returned to normal after resection. The carcinoembryonic antigen in the blood of renal cancer is increased, and the lesion is decreased after resection.
Gross or microscopic hematuria is the most common sign, followed by low back pain, spasms and masses and unexplained fever. Hypertension can occur due to segmental ischemia or renal pedicle compression, and sometimes due to increased erythropoietin activity. Secondary polycythemia occurs.
Renal cell carcinoma detected by abdominal ultrasound and CT is gradually increased. It is found by radioisotope bone or renal perfusion scan. Ultrasound and intravenous urography can confirm the presence of the mass, while CT provides the density of the mass, local enlargement and Information on lymph node and vein involvement.
Magnetic resonance imaging can further provide information on the expansion to adjacent structures, particularly the renal vein and inferior vena cava, and most have replaced inferior vena cava angiography. Aortic angiography and selective renal angiography can be used to determine the nature of renal cell carcinoma. And can provide a more accurate description of the number of renal arteries and blood vessel types before surgery, especially before nephron retention. Chest X-ray is necessary due to frequent lung metastases.
Renal cell carcinoma has no special manifestations in the early stage, patients can have no symptoms, and occasionally found by B-ultrasound examination due to physical examination or other reasons. In the past, kidney cancer was often diagnosed based on hematuria, low back pain, and abdominal mass. However, most of these triads are advanced renal cell carcinoma with poor prognosis. Recently, with the extensive application of B-ultrasound, CT and other examinations, the diagnostic accuracy of renal cancer has been greatly improved.
diagnosis:
1. Renal cysts: Typical renal cysts are easily differentiated from renal cancer from imaging examinations, but when there is bleeding or infection in the cyst, it is often misdiagnosed as a tumor. Some of the renal clear cell carcinomas are evenly distributed inside, showing a weak hypoechoic, which is easily misdiagnosed as a very common renal cyst during physical examination screening. Cloix reported 32 surgical findings of “complex cystic masses of the kidneys” and found that 41 of them were kidney cancers. For benign renal cysts with irregular wall thickening and high central density, it is difficult to use any of the above-mentioned methods for identification. It is often necessary to comprehensively analyze and judge, and if necessary, biopsy can be performed under B-guided guidance. It is not advisable to give up the follow-up or reckless surgery. It is characterized by low back pain and lumps, but no severe hematuria, which is a cystic mass. The flat urinary tract shows an eggshell-like or striped-like calcification. IVU (venous urinary tract angiography) showed renal parenchymal space-occupying lesions. Renal angiography lesions are avascular regions with smooth borders, and the surrounding vessels are curved. Ultrasound examination revealed a circular, anechoic dark area with clear boundaries in the renal parenchyma.
2. Renal hamartoma: also known as renal angiomyolipoma, is a relatively common benign tumor of the kidney, with the widespread development of imaging studies, more and more seen in the clinic. In the typical hamartoma, due to the presence of fat components, qualitative diagnosis can be made on B-ultrasound, CT and MRI images, which is clinically easy to distinguish from renal cell carcinoma. Renal hamartoma B-ultrasound showed a medium-strong echogenic area. CT showed a negative CT area in the mass. After the enhanced scan, it was still negative. Angiography showed that the tumor blood vessels contracted with the blood vessels of the kidney itself after injection of adrenaline. Renal cell carcinoma B-ultrasound showed moderate to low echo, the CT value of the tumor was lower than that of normal renal parenchyma, and the CT value increased after the enhanced scan, but it was not as obvious as normal kidney tissue. Angiography showed that the kidney itself vasoconstricted after injection of adrenaline, but The tumor blood vessels do not shrink, and the tumor blood vessel characteristics are more obvious.
It can be seen that the distinguishing point between renal cancer and renal hamartoma is that there is no adipose tissue in the renal cancer and adipose tissue in the hamartoma. However, in a few cases, renal cell carcinoma tissue also contains adipose tissue, which causes misdiagnosis. In addition, it is not uncommon for a hamartoma with few fat components to be misdiagnosed as kidney cancer. Of the 49 patients with hamartoma admitted to our hospital from 1984 to 1996, 11 were diagnosed with kidney cancer because of preoperative ultrasound and low echo and/or CT for moderate to high density tumors. Analysis of the causes of misdiagnosis are: some hamartomas are mainly composed of smooth muscle, less fat components; intratumoral hemorrhage, masking fat components, resulting in B-ultrasound and CT can not be discerned; tumor volume is small, due to volumetric effects, CT is difficult to measure the true tumor density. In this case, add a thin layer of CT scan, if necessary, B-guided needle cytology can help diagnose. Some authors believe that the CT features of hamartomabial hemorrhage masking adipose tissue are more significant, but less interference with B-ultrasound results.
3. Renal lymphoma: Renal lymphoma is rare but not uncommon. Dimopoulos et al reported that 6 of 210 renal tumor patients were primary renal lymphoma. Renal lymphoma is characterized by a lack of imaging, with multiple nodular or diffuse moist kidneys, which increases the shape of the kidney. The retroperitoneal lymph nodes are mostly affected. Three of the 4 patients admitted to our hospital in recent years were not diagnosed before surgery, and the other one was confirmed by preoperative biopsy.
4. Kidney yellow granuloma: a rare type of severe chronic renal parenchymal infection. Morphologically, there are two manifestations: one is diffuse, the kidney is enlarged, the shape is abnormal, the internal structure is disordered, and it is not easy to be confused with the tumor; the other is focal, and the kidney has localized substantial nodular echo. , lack of specificity, sometimes difficult to identify with tumors. However, these patients generally have symptoms of infection, the kidney area can reach a tender mass, and there are a lot of white blood cells or pus cells in the urine. As long as you look closely, the differential diagnosis is not difficult.
5. Renal sputum cancer can also appear intermittent painless full-length gross hematuria, but the degree is heavier and occurs early and frequently. IVU and retrograde angiography showed irregular filling defects in the renal pelvis and renal pelvis, no significant changes in kidney size and morphology, and no renal axis rotation. A neoplasm that protrudes into the renal pelvis cavity can be seen by a pyeloscopy. Tumor cells were found in urine exfoliated cells.
6. Renal angiomyolipoma may have low back pain, waist and abdomen mass and hematuria. The urinary tract plain film can be seen in irregular low-density areas; the ultrasonography is a number of evenly distributed intense light spots; the renal angiographic parenchyma is arranged in layers by onion skin samples due to the different tissue density of the components. CT examination showed a mass with uneven density, containing more fat, CT value -40 ~ -90Hu. The tumor is prone to spontaneous rupture and bleeding, resulting in sudden severe hematuria or shock.
7. Adult renal embryonal tumors are characterized by low back pain and lumps. However, the mass of the tumor grows rapidly, and the patient often has an abdominal mass as the main symptom, and hematuria is less serious. Retrograde pyelography showed that the renal pelvis and renal pelvis often disappeared due to tumor destruction. Ultrasound examination is a small scattered spot with a brightness equal to or slightly stronger than the echo of the renal cortex.
8. Perirenal cysts are characterized by low back pain, mass and high blood pressure. But it has a history of lumbar trauma or kidney surgery. The edge of the lump is unclear. IVU showed that the kidneys were shrunk and shifted outwards, accompanied by poor rotation and renal pelvic displacement, and the contrast agent spilled into the cyst to form a cloud-like image.
9. Polycystic kidney low back pain, mass and hematuria are similar to this disease, but the lesion is bilateral. Hypertension and renal dysfunction are more common. IVU showed a marked increase in renal shadow, which was generally separated and stretched with curved impressions with smooth edges. Ultrasound examination showed that the kidneys were enlarged and the contour was wavy. The renal parenchyma was scattered in circular liquid dark areas of different sizes and did not communicate with each other. CT examination revealed that the renal parenchyma was filled with vesicular low-density areas of varying sizes.
10. The subcapsular hematoma in addition to the tumor, hypothermia and hematuria, as well as the primary disease such as renal arteriosclerosis, renal infarction, renal trauma and so on. A sudden onset of illness, a greater amount of bleeding can occur in shock. IVU can be seen in the renal and ureteral pressure shift.
11. The clinical manifestations of renal abscess are low back pain and renal enlargement, but there is fever, obvious pain in the kidney area, and increased white blood cells. IVU can be seen in the deformation and displacement of the renal pelvis and renal pelvis. However, renal angiography has no tumor blood vessels, and the central avascular region is surrounded by proliferating blood vessels. The renal subcapsular vasodilatation is distorted, and marginal venous return is seen in the venous phase. The CT examination showed a circular low-density area with a clear intrarenal boundary. The CT value was 10 to 25 Hu. After the enhanced scan, the thick-walled enhancement ring was the abscess wall.
12. The fake spider-like renal pelvis IVU also showed an enlargement of the kidney, an elongation of the kidney, and a widening of the ankle distance. However, the patient has no back pain, hematuria, or lumps. Ultrasonography showed no abnormal findings except for long axis growth of the kidney. Renal angiography showed normal blood vessels at all levels.
complication:
Often secondary polycythemia occurs. Renal cell tumors often metastasize to the lungs, bones, liver, etc. There are also many non-urinary extra-renal manifestations such as hyperthermia, abnormal liver function, anemia, hypertension, polycythemia and high Calcemia and the like. The most serious complication is death.
A small number of kidney cancers have an increase in gonadotropin, which causes mammary gland enlargement, areola pigmentation and loss of libido in men. Women cause hairy and amenorrhea.
1. Secondary amyloidosis occurs in patients with renal cell carcinoma. Amyloidosis itself can lead to renal failure, and patients with renal cell carcinoma secondary to amyloidosis have a poor prognosis. Proteinuria and nephrotic syndrome can also occur in patients with renal cell carcinoma.
2. Renal cell carcinoma often occurs with multiple organ tumors.
treatment:
(a) treatment
Metastatic renal cell carcinoma has a poor prognosis. Traditional chemotherapy drugs are ineffective either alone or in combination with progestational drugs. In some patients, immunotherapy can reduce tumors and prolong survival. Interleukin-2 has been approved for metastatic kidneys. Cellular cancer; different combinations of this drug and other biological agents are still under study. The spontaneous remission of metastatic lesions after nephrectomy is rare and cannot be the reason for nephrectomy. Transabdominal radical nephrectomy and local cleaning Lymph nodes are the standard treatment for the treatment of local lesions. Renal unit retention (renal partial resection) is feasible and appropriate in some patients and even normal contralateral kidney. Tumors of the renal vein and inferior vena cava, no Lymph nodes and distant metastases can still be treated surgically.
The most effective treatment for renal cancer is radical nephrectomy. The resection includes the fascia and fat around the kidney, the upper ureter and the renal hilar lymph nodes, and the upper pole tumor should be removed from the ipsilateral adrenal gland. Ligation of the renal pedicle blood vessels during surgery can reduce bleeding and spread. Preoperative renal artery embolization can reduce intraoperative bleeding. The radiation and chemotherapy treatment of kidney cancer is not effective. Immunotherapy has a certain effect on metastatic cancer, and the most used is interferon. Surgical treatment is the only effective treatment for renal cancer. Radiation therapy, chemotherapy, and immunotherapy have no positive effect. Statistics have no effect on 5-year survival rate.
Surgical treatment
(1) radical nephrectomy: is the basic treatment of renal cancer, the scope of surgery includes resection of kidney, perirenal fat, perirenal fascia and ipsilateral adrenal gland. The transabdominal approach provides good exposure. Ligation of the renal artery during surgery, followed by ligation of the renal vein, can reduce intraoperative bleeding and prevent the spread of tumor cells, sometimes arteriovenous can also be ligated together. Because kidney cancer has more chances to spread to the kidney, after the renal pedicle is ligated, the perirenal fascia is not cut, but separated between the posterior peritoneum and the lumbar muscle, and then the whole piece is removed. A silver clip is placed in the kidney area before the end of the operation to provide a marker for postoperative radiotherapy. Simple nephrectomy is only used for advanced renal cancer, for palliative resection to relieve symptoms, such as pain, bleeding, control of fever, and poor general or complicated organ diseases, can not tolerate radical surgery.
(2) regional lymph node dissection: regional radical lymph node dissection for radical nephrectomy can reduce local tumor recurrence rate, improve survival rate, and also contribute to accurate clinical stage. After regional lymph node dissection, the 5-year survival rate of stage I cases was 87.4%, and that of stage II was 60.6%. Stage III was 44%, and the 5-year survival rate without lymph node dissection was only 33%.
The extent of lymph node dissection is as follows: the right side starts from the diaphragmatic foot and descends along the vena cava to the abdominal aortic bifurcation. The left lymph node dissection range, including the left flank and the aortic anterior lymph nodes, starts from the left diaphragmatic muscle and descends to the aortic bifurcation. The anterior and posterior aortic lymph nodes must be removed.
(3) Treatment of vena cava tumor thrombus: About 10% of patients with renal cell carcinoma can spread to the vena cava, and the tumor thrombus is divided into subhepatic type and hepatic type in the vena cava. Patients with vena cava tumor thrombus without distant metastasis and regional lymph node infiltration did not affect the survival rate of patients after thrombectomy.
1 Inferior vena cava tumor thrombus: the upper and lower vena cava and contralateral renal vein in the range of embolization are controlled first, and the vena cava is incision and the tumor thrombus is aspirated. For liver surgery, it is advisable to use a chest-abdominal incision, or to extend the abdominal incision upwards, to cut the sternum and pericardium in the median, to control the proximal vena cava on the iliac crest, and to cut the sacral, coronal and triangular ligaments to better reveal the posterior hepatic In the vena cava, the hepatic vein is blocked with a non-invasive forceps, the liver circulation is controlled, and then the balloon catheter is inserted into the distal vena cava of the tumor thrombus until the tumor plug is over, and after filling the balloon, the vein plug is completely removed.
2 intravenous bypass thrombectomy: the use of intravenous bypass to remove the vena cava tumor thrombus, through the right lumbar incision, cut the happy bag in the 7th intercostal, put a cannula directly into the right atrium, another casing from The right femoral vein was inserted into the inferior vena cava, the two cannulas were connected to the venous pump, the vein above the tumor thrombus was clamped, the venous pump was opened, and the venous bypass began to work. At this time, the surgeon can remove the tumor plug in a clear field of view. If the tumor infiltrates the wall of the vena cava, the tumor plug and the vein wall are removed together, and the artificial vein is used to replace the defective vein wall as appropriate. This is a safe and effective method.
(4) renal artery embolization: renal cell carcinoma is a multi-vascular tumor, surgery is easy to hemorrhage, through the femoral artery puncture, selective renal artery cannulation, injection of thrombogenic material, so that the artery is occluded. The main artery of the renal artery or its branches is selected according to the location and extent of the tumor. Embolization can achieve the following purposes: 1 large tumors before renal artery embolization, tumor necrosis, renal tumor surface vein atrophy, tumor shrinkage, renal edema, easy to separate tumors, shorten surgery time, reduce bleeding during surgery To improve the surgical resection rate. 2 facilitate the ligation of renal blood vessels before nephrectomy to reduce the spread of tumor cells. 3 For large tumors that are difficult to remove, the tumor shrinks after embolization. Thereby increasing the chance of surgical resection. 4 palliative embolization treatment, can control and relieve the symptoms of patients, such as hematuria, reduction of mass, pain relief, improvement of symptoms, fever and high blood pressure. 5 activate the host's immune mechanism. 6 patients with renal hemorrhage, renal artery embolization is also a good indication. Because renal artery embolism can cause pain, fever, intestinal paralysis, etc., should not be routinely applied.
Commonly used embolic materials are: autologous blood clots, muscles, absorbent gelatin sponges, stainless steel rings, absolute ethanol, and the like. Renal artery embolization is commonly used in the Department of Urology, Fudan University. METHODS: Anhydrous ethanol was mixed with 76% compound diatrizoate in a ratio of 4:1. The renal artery trunk injection rate should be <1.5 ml/s, and the branch should be 0.5 ml/s to reduce renal pain and embolism. Before injection, 0.5% procaine 3 ~ 5ml or 1% lidocaine 3 ~ 5ml, according to the size of the tumor to determine the amount of ethanol, usually 5 ~ 10ml.
In order to improve the therapeutic effect, the embolic agent may be injected into the renal artery together with the anticancer drug or the anticancer drug may be injected first, and then the embolic agent may be injected. Commonly used mitomycin c (MMC) microcapsules, the embolization time is longer, the effective concentration of mitomycin that escapes after the capsule is dissolved in the kidney for 6h, less systemic adverse reactions. The main component of mitomycin microcapsules is 80% mitomycin and 20% ethylcellulose, with an average particle diameter of 225 μm and a total amount of mitomycin of 20-40 mg. The embolization treatment can be performed again after 1 month.
(5) Treatment of special cases in the treatment of renal cancer:
1 treatment of metastatic renal cell carcinoma: In some cases, when the diagnosis of renal cancer is clear, it has been found to have metastasis, and most of them are multiple metastases, of which pulmonary metastasis is common.
For metastatic renal cell carcinoma, most experts believe that a single metastases should be resected with kidney and metastases, supplemented with chemotherapy or immunotherapy. The clinical manifestations of lung metastases are mainly cough, hemoptysis and dyspnea, but many cases are asymptomatic and are often found during routine fluoroscopy or chest radiography. Isolated lung metastases should be treated with lobes or wedges, with a 5-year survival rate of 25% to 35%. Multiple metastatic renal cell carcinoma, if conditions permit, should be treated with comprehensive treatment after resection of the primary tumor, which can alleviate symptoms, prolong survival, and occasionally report that the metastasis disappears on its own, so it should be actively treated for metastatic renal cell carcinoma.
2 treatment of bilateral renal cancer and isolated renal cancer: A. Simultaneous or sequential renal cancer is rare, and 5 of the 230 kidneys admitted to the Institute of Urology of Fudan University in the past 5 years. The principle of treatment is that the kidney on one side of the larger tumor is used for radical nephrectomy, and the side of the smaller tumor is partially nephrectomized, partially excised or removed. If the lesions on both sides are more limited, bilateral partial nephrectomy, local tumor resection or removal of the tumor is performed. Novick had 20 patients with intact renal cell carcinoma who underwent bilateral renal cell carcinoma with a 3-year survival rate of 90% and a local recurrence of 6%. B. Kidney cancer can occur in congenital isolated kidneys, due to kidney disease, one side of the kidney is not functional or has been nephrectomized. For isolated kidney and kidney cancer, the principle of treatment is to remove the cancer tissue as much as possible, retain enough kidney tissue, and strive to continue the survival without dialysis. For the early localized lesions of isolated renal cell carcinoma, the tumor is small and the capsule is intact, and the tumor is removed. If the tumor is located at the pole of the kidney, partial nephrectomy is performed. Multiple or central tumors may be considered for in vitro surgery, including partial nephrectomy, tumor resection, and removal, followed by autologous kidney transplantation. Multiple tumors and tumors have a wide range, and can be highly selective anticancer drug embolization or radical nephrectomy, postoperative hemodialysis.
2. Other treatments
(1) Radiation therapy: Radiation therapy is basically ineffective for renal cell carcinoma. Radiation therapy before and after surgery has been reported to improve patient survival. As an auxiliary treatment before and after surgery, it is suitable for: 1 The tumor grows rapidly in a short period of time, and the symptoms of systemic poisoning are obvious. 2 preoperative radiotherapy can reduce the tumor volume and reduce the spread of intraoperative cancer cells. 3 pairs of surgical resection is not complete, postoperative radiotherapy can reduce local recurrence. 4 advanced tumors, radiotherapy can relieve the symptoms of toxicity, reduce pain, hematuria. Currently mainly applicable to:
(2) Immunotherapy: At present, the application of immunotherapy, lymphokine-activated killer cells (LAK) plus adiponectin (interleukin 2), is the most popular.
Including: 1 interferon is an effective method for treating metastatic renal cancer by enhancing the activity of natural killer cells and cytotoxicity against tumors and inhibiting the division of tumor cells. Usage: Interferon 3 million U, intramuscular injection, once every other day or 5 times a week for 3 consecutive months. reusable. 2 Aldileukin (IL-2): can promote and regulate the immune function of lymphocytes. 3 tumor infiltrating lymphocytes (TIL): the patient's TIL is isolated, cultured, expanded and returned before surgery, which can improve the body's lymphocyte response and enhance the patient's anti-tumor ability.
1 non-specific immunotherapy: BCG is injected subcutaneously in the inner thigh, 5mg each time, once a week for 6 weeks; can be used alone or in combination with hormone or chemotherapy. Although it has no direct anti-tumor effect, it can expand the effect of cellular and humoral immune responses through immunocompetent cells to enhance the host's anti-tumor ability. The actual efficacy needs further observation.
2 specific immunotherapy:
A. Immunoribonucleic acid (IRNA) can reduce end stage renal cell carcinoma with an effective rate of 22% and less adverse reactions.
B. Interferon, a naturally occurring protein with a molecular weight of 15,000 to 210,000, inhibits intracellular protein synthesis by inhibiting intracellular protein synthesis by inhibiting tumor cell division. Interferon can enhance the activity of natural killer cells (NK cells) and is currently the most effective drug for the treatment of specific renal cancer.
Interferon alpha is secreted by stimulated leukocytes and transformed lymphoblasts, which are produced by virally infected fibroblasts, whereas gamma-interferons are T lymphocytes stimulated by foreign antigens or mitogens. produce. The usage of interferon is:
a. Interferon 3 × 106U / d, intramuscular injection, 5 times a week, 6 weeks for a course of treatment, interval 1-2 months, can be reused, the effective rate is 20%.
b. Interferon (recombinant human interferon), 0.25 mg, 1 time / d, intramuscular injection, a total of 8 days, repeated application after 3 to 4 months. Some scholars believe that the periodic application of γ-human interferon is better than long-term continuous application. Another scholar believes that if interferon treatment has no obvious effect for 3 months, it should be discontinued.
c. Human leukocyte interferon, 1 million U, 1 time / d, intramuscular injection, for 5 to 10 days for a course of treatment.
d.Interferon alphaversusVincristineIn combination, the tumor shrinkage rate increased from 15% to 30%. Interferon is quite toxic, manifested as a cold-like reaction, chills, high fever, muscle pain, fatigue, loss of appetite, vomiting, etc. The use of indomethacin and aspirin can alleviate the above adverse reactions.
C.Aldileukin (interleukin 2): Aldileukin (Interleukin 2) is a small molecular weight glycoprotein produced by activated T4 cells that allows T lymphocytes to proliferate continuously, so it is called T cell growth factor. IL-2-activated cytotoxic T cells and NK cells have the effect of killing tumor cells, and this effect of aldileukin (interleukin 2) is an "inherited immunotherapy" for renal cell carcinoma. Specifically, the patient's lymphocytes are separated and stimulated with a large dose of interleukin (interleukin 2) in vitro to grow cells to form lymphokine-activated killer cells (LAK cells), and then LAK cells are injected into the patient. At the same time, continuous administration of interleukin (interleukin 2) can reduce renal cell carcinoma and metastatic cancer. Some scholars believe that this method is particularly suitable for metastatic renal cell carcinoma. Adileukin (interleukin 2) is highly toxic, can cause leakage of capillaries, and lower blood pressure caused by decreased peripheral vascular resistance. It can also cause chills, high fever, liver damage, anemia, and thrombocytopenia. The specific method is: first, intravenous injection of high-dose interleukin (interleukin 2), starting from 4 to 5 days; in the second week, lymphocytes are cultured in medium containing IL-2 to produce LAK cells. In the third week, these cells were reinfused into the patient. The response rate of adiploid (interleukin 2) plus LAK is 35% to 40%. If the toxicity is strong, changing the dose can reduce the toxicity. Other methods of increasing patient immunity are specific immunostimulants such as BCG.
(3) Hormone therapy: It has been proved that some kidney cancers are related to hormonal imbalance in the body. Normal kidney and kidney cancer tissues contain androgen and progesterone receptors. In patients with advanced kidney cancer, hormones can alleviate symptoms and prolong survival, which may be related to hormone receptors. The commonly used hormone is medroxyprogesterone (progesterone, progesterone) 150mg, once / d, for 3 to 6 months. Hormone therapy is based on the long-term use of estrogen to cause kidney tumors in male hamsters. The above findings lead to the use of progesterone formulations as a basis for hormone therapy in advanced renal cell carcinoma. For example, progesterone preparation plus testosterone or anti-estrogen drugs alone or in combination with corticosteroids.
Kidney cancer has a significant dependence on hormones. Hormones can alleviate symptoms and prolong survival in patients with advanced kidney cancer, which may be related to hormone receptors. However, most patients with advanced renal cell carcinoma have no significant effect on hormone therapy in the above manner, and the total response rate is less than 5%. Commonly used hormones are:
1 medroxyprogesterone (Angong)Progesterone), 3 times / d, 100 ~ 200mg each time, orally.
2 Hydroxyprogesterone acetate (hydroxyprogesterone), 800 mg each time, intramuscularly, twice a week.
3 testosterone propionate, 100mg each time, intramuscular injection, 2 times a week; or long-acting C testosterone, once a week, 400mg each time, intramuscular injection.
4Prednisolone(Prednisolone), 20mg each time, once a day, orally. The combination of progesterone and corticosteroids or hormones with immunologic agents and chemotherapy can increase the efficacy of advanced kidney cancer.
(4) Chemotherapy: The chemotherapy effect of renal cell carcinoma is very limited. According to the literature, commonly used chemotherapy drugs include VLB and mitomycin (MMC).Hydroxyurea, doxorubicin (doxorubicin), bleomycin, eufloxacin,Cyclophosphamide, fluorouracil and cisplatin. The remission rate of single drug is <15%, but the effective rate of VLB is 25%, so it is a more effective drug. At present, most chemotherapy experts advocate a combination of drugs to improve the synergistic effect of killing cancer cells and reduce toxicity, especially the combination of vinblastine sulfate (VLB) with other drugs, the effect is significantly better than single drug. Combination drugs such as vinblastine sulfate (VLB) and cyclophosphamide (CTX), hydroxyurea, progesterone and prednisone (prednisone), vinblastine sulfate (VLB) and progesterone. Some people (1985) used MVP, in which vinblastine sulfate (VLB) 5mg intravenously,Methotrexate(MTX) 500mg 6h intravenous drip and peomycin 100mg intravenously, add 15 mg of leucovorin every 3 hours orally, and change to 15 mg every 6 hours after 24 hours, a total of 12 times, the effective rate was 36%. In the treatment of the MVP regimen, the fluid should be given a solution of sodium bicarbonate. Another effective rate of MVB regimen for advanced renal cell carcinoma was 36%, MVB regimen was: VLB 4 mg/m2; methotrexate (MTX) was given bleomycin (BLM) 30 mg/d after intramuscular injection. Once a week. 10 to 20 hours after the injection of the above three drugs, oral leucovorin, 15 mg each time, a total of 12 times. The MVB program was repeated once every 2 weeks.
3. Chinese medicine treatment
(1) Chinese medicine on the pathogenesis of renal cell carcinoma: Chinese medicine does not have the name of "renal cell carcinoma", according to its clinical manifestations, it belongs to traditional Chinese medicine "blood stasis", "back pain", "blood leaching", "accumulation" and other diseases category. Chinese medicine believes that this disease is caused by lack of righteousness, emotional stagnation, sinister poisoning, and eating, causing yin and yang disorders in the body, and qi and blood reversal, causing qi stagnation, blood stasis, phlegm, dampness, heat and poison. It is a certificate of this virtual standard.
(2) TCM syndrome differentiation treatment of renal cell carcinoma: The basic treatment principle is: Fuzheng Xiexie, Yiqi Huoxue, Ruanjian Sanjie, Qingre and dampness. According to the different stages of the disease, the individual response of the patient can be specifically focused on the clinical evidence.
1 damp heat accumulation type: symptoms of waist and abdomen pain, bulging discomfort, hematuria, body trap, waist and abdomen lumps, low heat mouth bitterness, loss of appetite, tongue fat, yellow greasy or greasy moss, slippery pulse or number of turns.
The principle of treatment: heat and dampness, detoxification.
Basic side: Bazheng powder addition and subtraction: rhubarb 10g, branch 12g, talc 20g, glutinous 20g, buckwheat 20g, Mutong 6g, psyllium 30g, licorice tip 10g, wick grass 3g. It can be added to Hedyotis diffusa, red peony, achyranthes, etc.
2 gas knot blood stasis type: Zheng see waist swelling pain, can touch the mass, hard to move, urine with blood clots, dull complexion, dark tongue or stagnant spots, thin fur, pulse string or sputum or knot generation.
The principle of treatment: qi and stagnation, blood circulation and siltation.
Basic side: 膈下逐泥汤 addition and subtraction: peach kernel 10g, safflower 10g, angelica 10g, Chuanxiong 10g, paeonol 12g, red peony root 20g, Wulingzhi 10g, black peony 10g, yuanhu 10g, oyster shell 12g, fragrant 10g, licorice 6g, can be added verbena, scutellaria, woody, scorpion and so on.
3 Zhengxue silt type: Zheng Jian block hard, low back pain, drama, frequent hematuria, dark complexion, body weight loss, fatigue, shortness of breath, vomiting, poor, dark purple tongue, no moss, fine pulse and sputum.
The principle of treatment: qi and nourishing blood, promoting blood circulation and silt.
The basic side: Bazhen Tang combined with Shaofuzhuyu decoction: fried Wulingzhi 10g, Jiaopuhuang 10g, Yuanhu 12g, Angelica 10g, red peony root 20g, Chuanxiong 10g, cumin 3g, Codonopsis 30g, Atractylodes 10g, 茯苓15g, 20g of raw land, 10g of licorice. You can add bandits, verbena, etc.
(3) Chinese patent medicine:
1 anti-cancer Ping Pill: 0.5 ~ 1g each time, 3 times / d, orally half an hour after a meal. Suitable for kidney cancer damp heat accumulation type.
2 Bushen Yangxue Pills: 9g, 3 times / d each time, fasting warm water delivery service, do not eat spicy during the medication. It is suitable for those who are debilitated after surgery or after chemotherapy.
3 rhubarb zhe worm pill: 3 ~ 6g each time, 2 times / d, orally. It is suitable for people with blood stasis and blood stasis.
(two) prognosis
The histological structure of renal cell carcinoma has no effect on prognosis, and the prognosis of papillary cystadenocarcinoma is still good. The degree of differentiation of cancer cells affects the prognosis, the prognosis of clear cell carcinoma is good, the prognosis of granulosa cell carcinoma and mixed type is slightly worse, and the prognosis of spindle cell carcinoma and small cell carcinoma is the worst. The 5-year survival rate after nephrectomy is 35% to 40%, and the 10-year survival rate is 17% to 30%. The prognosis of renal cancer is sometimes difficult to estimate, and metastasis can occur 20 years, 30 years or more after nephrectomy.
For renal vein or inferior vena cava tumor thrombus, if the surgery can be completely removed, the prognosis is good; if the tumor invades the vein wall, the affected vein wall should be removed, otherwise the prognosis is poor; the tumor invades the perirenal fat and renal fascia, such as Can radical resection, nearly half can survive for 5 years; local lymph node metastasis, poor prognosis, rarely survive for 5 years; kidney cancer invades adjacent organs, the survival time is shorter. Tumor size has no significant effect on prognosis.
prevention:
1. First-level prevention and quit smoking and drinking hobbies, establish good living habits, conduct regular and moderate physical exercise, and strictly protect personnel exposed to cadmium industrial environment.
(1) quit smoking, do not drink alcohol.
(2) Use antipyretics with caution, such as phenacetin.
(3) Kidney diseases such as kidney cysts should be actively treated.
(4) Regularly participate in physical exercise, balance diet, increase nutrition, maintain a happy mood, and increase immunity.
(5) Regularly eat foods that have anti-cancer and anti-cancer effects.
2. Secondary prevention screening is one of the early methods for the detection of renal tumors. A simple B-ultrasound kidney examination method is adopted; those with fast erythrocyte sedimentation rate, high blood calcium and anemia should be further examined. The main complaints and clinical manifestations of renal cancer patients are variable, the location of the kidney is concealed, and it is difficult for early self-diagnosis and self-examination. Hematuria is the most common symptom of renal tumors, often painless, intermittent whole blood urine, pay attention to hematuria in the elderly. Often considered to be caused by benign prostatic hyperplasia and stones, should be alert to the possibility of kidney cancer. Hematuria with low back pain and mass accounted for only 10% of renal tumors, should be alert to the appearance of extrarenal appearance, such as fever, hypertension, hypercalcemia, erythrocyte sedimentation rate, anemia, abnormal liver function, weight loss, erythrocytosis and supine position The disappeared left varicocele may have kidney cancer and should be treated promptly. Regular health checkups, especially for those who have history of exposure to carcinogenic mutagens, focus on blood and urine routines, and B-ultrasound examination of the kidneys, so that tumors less than 1 cm in diameter can be found early. Once kidney cancer is discovered, surgical resection should be pursued as soon as possible. Radical nephrectomy includes removal of perirenal fascia, fat, adrenal gland, lymphoid tissue, and middle and upper ureter. The renal vein and inferior vena cava tumor thrombus should be removed. Renal cancer is poorly treated with chemotherapy and radiotherapy, and immunotherapy has a certain effect.
3. Third-grade prevention of cachexia in patients with advanced disease, local pain is obvious, and intra-tumor hemorrhage causes severe anemia. Supportive therapy, blood transfusion, intravenous high nutrition, palliative nephrectomy or selective regional intra-arterial chemotherapy plus embolization can be used. Severe bleeding, pain and extra-tumor syndrome, compression of surrounding organs, etc., symptomatic treatment such as pain relief, reduce patient suffering and prolong patient life.
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