1、1泌尿男生殖系统肿瘤 厦门大学附属中山医院2Kidney Cancer What is a kidney and what function does it serve? What is kidney cancer? How common is kidney cancer and who gets it? How is kidney cancer diagnosed? Does kidney cancer run in families? How is kidney cancer treated? 肾癌 肾脏及其功能 肾癌的概念 肾癌的流行病学 肾癌的诊断 肾癌的家族性相关因素 肾癌的治疗3
2、What is a kidney and what function does it serve? Normally people have two kidneys located in the upper back on the right and left side. The typical adult kidney weighs 150 grams in men and the 135 grams in women. 肾脏及其功能正常情况下,人的腰背部左右两侧各有一个肾脏。成年人的一个肾脏在男性重约150克，在女性重约135克。4 The kidneys primary function
3、 is filtration of excess water, salt and waste products from the blood stream. The kidneys play an important role in regulating blood pressure and controlling the supply of calcium. 肾脏的主要功能是将机体中多余的水份、盐分与代谢废物滤除。肾脏在调节血压与维持钙质的吸收方面也起着重要作用。5 In addition, the kidney makes a factor, called erythropoetin, r
4、esponsible for stimulating production of red blood cells. 另外，肾脏还能分泌一种促红细胞生成素（EPO）的因子，对刺激红细胞的生成起着重要作用。6What is kidney cancer? Most commonly kidney tumors are malignant or cancerous. Kidney cancer occurs when normal kidney cells begin to grow uncontrollably. 肾癌的概念肾癌的概念 大部分常见的肾脏肿瘤是恶性的或癌性的。肾癌的出现是由于肾脏细胞的
5、生长无法受到控制。7 There are four main types of kidney cancer; clear cell, sarcomatoid, chromophobe and papillary. Clear cell is the most common type of kidney cancer and sarcomatoid is the most aggressive (the most likely to spread beyond kidney to other parts of the body). 肾癌主要可分为四种类型，透明细胞癌、肉瘤样癌、嫌色细胞癌及乳头状
6、癌。透明细胞癌时肾癌最常见的类型。而肉瘤样癌的恶性程度最高（其最有可能扩散至肾脏以外身体其他部位）。8 Benign tumors include： angiomyolipoma and oncocytoma. These non-cancerous tumors are considered benign since they do not have the capacity to grow beyond the kidney to other sites in the body. 肾脏良性肿瘤包括：肾血管平滑肌脂肪瘤与肾瘤细胞瘤。这些非癌性肿瘤被认为是良性的，因为它们的生长仅限于肾脏内部。
7、9How common is kidney cancer and who gets it? It is estimated that in the United States during the year 2001, 30,000 people will be diagnosed with kidney cancer. Kidney cancer is the 8th and 10th most common non-skin cancer among American men and women, prospectively. Kidney cancer accounts for 2 -
8、3% of all cancer-related deaths in the United States.肾癌的流行病学肾癌的流行病学 据估计在2001年，美国约有30000例新发的肾癌病例。在非皮肤性恶性肿瘤中，肾癌的患病率在美国男性中居第八位，在美国女性中居第十位。美国约23的癌症相关死亡病例是由肾癌引起。10How is kidney cancer diagnosed? Common symptoms related to kidney cancer include; hematuria (blood in the urine), a mass and/or pain in the fl
9、ank, newly developed left-sided varicocele (swelling of veins around the testicle). 肾癌的诊断肾癌的诊断 与肾癌相关的常见症状包括：血尿、腰胁部肿块与疼痛、新发的进行性的左侧精索静脉曲张（睾丸周围的静脉出现肿胀）11 Although these symptoms can be caused by kidney cancer they are all non-specific and are usually associated with non-cancerous processes. Typically,
10、patients with kidney cancer have no symptoms and are detected incidentally by a radiographic imaging study of the abdomen obtained for unrelated reasons. 尽管上述症状可由肾癌引起，但它们是非特异性的，而且常常与非癌性病理过程有关。经常遇到的情况是，肾癌患者并无自觉症状，只是因为其他原因行腹部影像学检查偶然发现患病的。12 The best test to diagnose kidney cancer is a contrasted CT sc
11、an of the abdomen. MRI and ultrasound exams are other commonly used tests. Since these radiographic studies are so good at diagnosing kidney cancer a biopsy of the tumor is rarely indicated. 诊断肾癌最好的检查是腹部增强CT。其他常用的检查有MRI和B超。因影像学检查对肾癌有较高诊断价值，故很少需要活检。13Does kidney cancer run in families? Patients who a
12、re affected with Von Hippel Lindau disease, hereditary papillary renal cell carcinoma or Birt Hogg Dube are far more likely to get kidney cancer. These people typically develop multiple tumors in both kidneys. 肾癌的家族相关性因素肾癌的家族相关性因素 脑视网膜血管瘤病患者，家族中有乳头状肾细胞癌患者或Birt Hogg- Dube综合征患者患肾癌的可能性远远增大。而且这些患者往往是双侧肾
13、脏出现多发性肿瘤。14 There is also a familial form of kidney cancer in which several family members develop the typical form of kidney cancer. Otherwise kidney cancer is not inherited and most patients with kidney cancer are not likely to pass it on to their offspring. 肾癌的家族遗传性也可表现为几个家族成员均患有同一常见类型的肾癌。但是肾癌并非遗
14、传性疾病，而且大部分肾癌患者的后代不大可能再患该病。15How is kidney cancer treated? Since conventional chemotherapy and radiation are not effective for kidney cancer the only curative therapy involves surgical removal of the tumor. Historically the standard treatment for kidney cancer was radical nephrectomy (removal of the
15、entire kidney and adrenal gland). 肾癌的治疗肾癌的治疗 由于传统的放化疗对肾癌起效不大，唯一有效的治疗方法是手术切除肿瘤。历史上肾癌的标准治疗方法是肾癌根治术（切除整个肾脏及其肾上腺）。16 Today the adrenal gland is only removed for tumors that are located in the upper portion of the kidney or involve the adrenal gland。 Tumors that are smaller that 4 centimeters can usually
16、 be treated with a partial nephrectomy (removal only the portion of kidney that contains the tumor while leaving the remainde of the unaffected kidney intact ). 如今，只有肿瘤累及肾上腺或肿瘤位于肾脏上极时才在手术中将肾上腺切除。而对于小于4cm的肿瘤通常是行肾脏部分切除术（仅切除受肿瘤累及的那部分肾脏）。17 For patients with a solitary kidney or kidney failure, a partia
17、l nephrectomy is performed for tumors larger than 4 cm when a sufficient amount of unaffected kidney can be preserved. 当患者出现肾衰或孤立肾等情况时，对于直径大于4cm的肿瘤也可行肾脏部分切除术，以保留一定数量的未受累及的肾实质。18 Today most radical nephrectomies are performed by a laparoscopic technique. During laparoscopic procedures, surgeons opera
18、tes using a camera and instruments placed through small holes in the patients abdomen. 当今，大部分肾根治切除术是通过腹腔镜技术来完成的。在腹腔镜操作过程中，医生将器械与摄像头通过腹部上的小孔置入患者体内进行手术。19 The surgical team views the procedure on a televisions screen. The kidney specimen can be removed after placing it in a protective bag and breaking
19、 it up into multiple small pieces. 手术小组通过观看电视屏幕来实施手术。病变的肾脏在置入一个保护袋后被切下，而后其被绞碎为多个小块。20 Alternatively, the intact specimen can be removed through a small non-muscle cutting incision. The advantage of laparoscopic kidney removal to the patient over standard open radical nephrectomy include; less pain,
20、shorter recovery time and better cosmesis (i.e. much smaller scar). 或者，被切下的肾脏也可而通过一个未切断肌层的小切口完整地从体内移出。腹腔镜下肾脏切除术与标准的开放性肾癌根治术相比较，其优势在于：患者痛楚少，术后恢复快且伤口较为美观。21 Typically patients stay in the hospital 1 - 2 days following laparoscopic nephrectomy and return to normal activity within 2 - 3 weeks. Several s
21、tudies have shown that laparoscopic nephrectomy for kidney cancer provides the same opportunity for cure as does conventional open radical nephrectomy. 通常，患者在腹腔镜手术后仅需住院12天，而且23周内即可恢复正常活动。已有一些研究表明在对肾癌的治愈机会上，腹腔镜下肾切除术与传统的开放性肾癌根治术所取得的效果是一致的。22 The standard treatment for metastatic kidney cancer (kidney
22、cancer that has spread beyond the kidney to other parts of the body) is immunotherapy (induces the body to fight off cancer in the same way that it fights off infection). 对转移性肾癌（肿瘤已累及肾脏以外身体其他部位）的标准治疗方案是免疫治疗（诱导机体像抵抗感染一样发挥抗肿瘤作用）。23 The most effective and commonly used form of immunotherapy is IL2. Oth
23、er therapies including interferon gamma are used alone or in combination with IL2. It is believed that in most cases immunotherapy is more effective after the primary kidney tumor has been surgically removed. 最有效以及最常用的免疫治疗方法是使用IL-2。其他治疗方案包括使用干扰素-,可单独使用也可联合IL-2一起使用。目前认为，将原发的肾脏肿瘤手术切除后再予免疫治疗疗效更为明显。24Bl
24、adder Cancer Who gets bladder cancer and what causes it? What is bladder cancer? How is bladder cancer diagnosed? How is bladder cancer treated? Prevention 膀胱癌膀胱癌 流行病学与病因学 组织病理学 诊断 治疗 预防2526Who gets bladder cancer and what causes it?(1)It is estimated that in 2001, 54,300 people (39,200 men and 15,1
25、00 women) will be diagnosed with, and 12,400 people (8,300 men and 4,100 women) will die from bladder cancer in the United States. Bladder cancer is the 4th most common non-cutaneous malignancy among men in the United States, and the 8th most common cancer among women. 流行病学与病因学（流行病学与病因学（1）在美国，于2001年
26、诊断为膀胱癌的病例数为54300名（男性39200名，女性15100名），于同一年死于膀胱癌的病例数为12400名（男性8300名，女性4100名）。在美国男性非皮肤源性癌症患者中，膀胱癌为第四常见恶性肿瘤。而在美国女性癌症患者中，其为第八常恶性肿瘤27 The incidence of bladder cancer increases with age among men and women. The typical age of presentation is in the 7th decade of life can be seen in patients as early as the
27、 3rd decade of life. 膀胱癌的发病率随年龄增长而增加。其常见于6070岁患者，但在2030岁的患者也可见到。28Who gets bladder cancer and what causes it?(2) The most significant risk factor for bladder cancer is cigarette smoking. It has been estimated that cigarette smoking accounts for approximately 60% of all bladder cancer cases, and incr
28、eases bladder cancer risk by 2.5-fold. In addition prior therapy with cytoxan (cyclophosphamide) or pelvic irradiation can likewise increase ones risk of bladder cancer. 流行病学与病因学（流行病学与病因学（2） 引起膀胱癌最重要的危险因子是吸烟。据估计，约60膀胱癌患者发病与吸烟有关。吸烟能使膀胱癌发病的危险性增加2.5 倍。另外，予以环磷酰胺化疗或盆腔灌注也有可能增加患膀胱癌的危险性29 Occupation exposur
29、es can also be important risk factors for bladder cancer; aniline and other chemical dyes, combustion gases from coal and heavy metals have all been implicated. 职业因素同样可以成为膀胱癌发病的重要危险因子。苯胺及某些化学染剂，煤或重金属燃烧后的气体物质都被认为与膀胱癌的发病有关。30 Consumption of large quantities of phenacitin-containing analgesics can lead
30、 to bladder cancer development as long as 25 years from the time of exposure. 有人进行长达25年的追踪研究表明大量使用含有非那西丁的止痛剂可以诱导膀胱癌的发生31 Although some have suggested that coffee and artificial sweeteners may increase bladder cancer risk, this has never been conclusively shown. 尽管有人曾提出咖啡与人工甜味剂可增加膀胱癌发病的危险性，但这一点从未得到证实
31、。32What is bladder cancer?(1) The vast majority of bladder cancers diagnosed in the United States are transitional cell cell type (transitional cell carcinoma). Multiple grading schemes have been used; most commonly tumors are grouped into 3 grades corresponding to low, moderate and high grade. Grad
32、e is also a strong predictor of tumor aggressiveness and the risk of disease progression. 组织病理学（组织病理学（1） 在美国，大部分膀胱癌属 移行细胞癌。按照已使用的多级划分方案，大部分常见膀胱肿瘤可划分为3个等级，即低级、中级与高级。 分级也是预测肿瘤的侵袭性与今后发展的一个重要指标。33 Carcinoma in situ (CIS) is type of transitional cell carcinoma which is characterized microscopically by a
33、pathologist as highly atypical cells confined to the bladder lining. 原位癌（Carcinoma in situ, CIS)是移行细胞癌的一种类型，其显微镜下病理学特征是局限于膀胱粘膜的上皮组织呈高度异形性。 34 This pre-malignant lesion is the pre-cursor lesion to a high grade invasive bladder cancer and its presence portends a worse prognosis 这种癌前病变预示着其可有高度侵袭性，它的存在提
34、示预后不良。35What is bladder cancer?(2) Squamous cell carcinoma accounts for 5% of bladder cancers in the United States, but 80% in Egypt. Chronic infection (typically by parasites not prevalent in the U.S.) and chronic irritation (from long term (many years) indwelling bladder catheters) may also predis
35、pose patients to development of squamous cell carcinoma . 组织病理学组织病理学(2) 在美国，膀胱癌患者中有5为鳞癌。而在埃及，该比率达80。慢性感染（常见的是寄生虫感染，该病在美国没有流行）、慢性刺激（多年膀胱内置管）可诱使病人发生鳞癌36 Adenocarcinoma of the bladder is rare accounting for fewer than 2% of all bladder cancers. Most commonly adenocarcinoma of the bladder develops from
36、a urachal remnant or in patients who were born with bladder exstrophy. 膀胱腺癌较少见，其比率在全部膀胱癌病例中仅占不到2%。大部分膀胱腺癌常见于有脐尿管残迹患者或先天性膀胱外翻患者。37How is bladder cancer diagnosed?(1) The most common symptom is blood in the urine (hematuria), either grossly (seen by the naked eye) or microscopically. Other symptoms in
37、clude symptoms of bladder irritability - burning, frequency and urgency. 诊断（诊断（1） 最常见的症状是血尿，可以是肉眼血尿，也可以是镜下血尿。其他还包括膀胱刺激症状如烧灼样痛、尿频及尿急。38 In many cases, the initial suspicion of a bladder tumor is made only after microscopic traces of blood are found on a routine urinalysis. 在很多病例中，最初怀疑膀胱肿瘤往往是因为尿常规镜检发现
38、尿中带血。39Of note, the hematuria frequently is intermittent and a negative urinalysis does not exclude bladder cancer. All patients with hematuria should be evaluated by a urologist with a urine cytology (washing of bladder cells), cystoscopy (see below), and intravenous urogram (x-ray test). 需要指出的是，膀胱
39、癌的血尿症状常是间歇性的。阴性的尿分析结果并不能排除膀胱癌的诊断。所有出现血尿的患者都应由泌尿科医生进行尿细胞学检查、膀胱镜检查及静脉尿路造影以对病情作进一步评估。40How is bladder cancer diagnosed?(2) Cystoscopy (a technique performed in which urologist exams the inside of the bladder with a lighted telescope) is the primary diagnostic tool for bladder cancer, and the cystoscopi
40、c appearance of a tumor can usually provide significant clues regarding the grade and stage of the tumor. 诊断（诊断（2） 膀胱镜检查（泌尿科医生用一种带光源的内窥镜来检查膀胱粘膜面的一项技术）是诊断膀胱癌的首选方式。膀胱镜检查结果通常能对肿瘤的分期与分级提供重要线索。41 Low grade superficial tumors appear as delicate fronds while high grade invasive tumors appear like a solid m
41、ass. 低分级的浅表性膀胱肿瘤质地软，呈分叶状；高分级的浸润性膀胱肿瘤质地硬，呈团块样。42high grade invasive tumors appear like a solid mass. 高分级浸润性肿瘤呈质硬团块样外观43 Initial treatment includes transurethral resection of bladder tumor (TURBT) - that is, resection of the suspicious lesion done through the cystoscope. This is typically done in the
42、operating room under anesthesia. 初始处理措施包括经尿道膀胱肿瘤切除术，即在膀胱镜下对可疑病灶进行切除。这通常要求患者在麻醉条件下并且在手术室内进行。44transurethral resection of bladder tumor (TURBT) 经尿道膀胱肿瘤切除术45 Attempts are typically made to excise the entire suspicious lesion at this setting. Evaluation of the specimen confirms the diagnosis of bladder
43、cancer and also helps in the grading of the cancer. 手术过程中应尽可能将全部可疑病灶切除。对切除的标本进行检查能进一步明确诊断，而且有助于肿瘤分级。46 Most importantly, the pathology evaluation of the specimen provides information on the stage of the cancer: the primary goal of staging is to determine if the cancer is superficial (stage Ta to T1)
44、 or invasive(stage T2 or higher).(submucosa muscle invasive) 最为重要的是，通过对标本进行病理学检查能获取有关肿瘤分期的信息。而分期的首要目的是看肿瘤是浅表性（TaT1期）或是浸润性（T2期或更高分期）（粘膜下肌层受侵犯）47(submucosa)muscle invasive48 CT examination of the abdomen and pelvis should be obtained in patients with invasive bladder cancers to evaluate the extent of
45、the local tumor and to determine if the cancer has spread (metastasized) to other areas of the body. 对浸润性膀胱癌患者应进行腹部与盆腔的CT检查，以评估肿瘤局部浸润状况并且明确肿瘤是否转移至身体其他部位。49 Intravenous urograms should also be obtained in patients with bladder cancer in order to exclude the presence tumor in the kidneys (renal pelvis
46、) or ureters. 膀胱癌患者同样应行静脉尿路造影，以排除肾盂或输尿管的肿瘤。50How is bladder cancer treated?(1) Superficial Disease The majority of patients with superficial tumors (stage Ta or T1) can be effectively treated with transurethral resection alone, especially those with Ta, low grade tumors. 治治 疗疗 浅表性膀胱肿瘤 大多数浅表性膀胱肿瘤患者（分
47、期Ta期或T1期）仅予经尿道切除术就可获得有效治疗。该方法尤其适用于那些Ta期、低分级的肿瘤。51 Although T1 (superficial but into lamina propia layer) are technically considered non-invasive, these tumors are likely to progress to muscle invasive (T2) disease these patients must be followed more closely than those with Ta tumors. 尽管T1 期肿瘤（属浅表性，
48、但固有层受累及）从理论上认为是非侵袭性的，但这些肿瘤较有可能浸润肌层，发展成为T2期肿瘤，因此这类患者比Ta期患者应进行更密切地随访。52 In certain cases of superficial tumors (high grade or T1 tumors), additional therapies may include instillations of medicines into the bladder (intravesical therapy with agents such as BCG, Mitomycin, or Thiotepa) which are perfor
49、med to help prevent recurrences. 在某些浅表性膀胱癌病例（高分级或T1期肿瘤）还应给予其他治疗，这包括行膀胱内药物灌注（例如卡介苗，丝裂霉素或噻替哌），以预防复发。53 BCG (Bacille Calmette-Guerin) is the most effective and commonly used form of intravesical therapy: a standard course of BCG consists of 6 weekly instillations. Because bladder cancers do have a high
50、 rate of recurrences, frequent surveillance cystoscopies in the ensuing months and years are required. 卡介苗卡介苗（Bacille CalmetteGuerin，BCG）是最有效与最常使用的灌注制剂。一个标准疗程为6周，每周灌注一次。 由于膀胱癌有较高复发率，因此在数月或数年内定期进行膀胱镜检是必要的。54How is bladder cancer treated?(2) Invasive Disease Patients whose cancer invades into the blad
