Silver D A, Stroumbakis N, Russo P, Fair W R, Herr H W
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
J Urol. 1997 Sep;158(3 Pt 1):768-71. doi: 10.1097/00005392-199709000-00020.
The clinical impact of ureteral carcinoma in situ identified at the time of radical cystectomy for bladder cancer has been poorly studied. We discuss our experience with this clinical problem in the context of published reports.
A total of 31 patients with concomitant ureteral carcinoma in situ was retrospectively identified among 401 consecutive radical cystectomies. End points analyzed included positive urinary cytology, upper tract recurrence of carcinoma and cancer specific survival.
Ureteral margins were positive in 21 patients and negative in 10. Among 30 patients in whom it was performed frozen section failed to detect carcinoma in situ in 5 (16.6%) and sequential ureteral resection did not result in a negative margin in 15 (50%). In 3 patients upper tract carcinoma recurred at the anastomosis (1) and renal pelvis/ureter (2) at a median of 51 months (mean 49, range 36 to 59) following cystectomy. Positive cytology and upper tract carcinoma recurrence were not significantly associated with ureteral margin status, clinical or pathological bladder tumor stage or prior bacillus Calmette Guerin treatment. Median followup was 22.9 months (mean 31.8, range 2.0 to 74.2), during which 7 of the 31 patients died of metastatic bladder cancer.
Concomitant ureteral carcinoma in situ is uncommon, and is rarely associated with local morbidity. It appears to confer increased risk for upper tract carcinoma recurrence, irrespective of margin status. In our experience upper tract carcinoma recurrence is heralded by positive cytology and generally appears only with protracted followup. Prognosis appears to be determined by the bladder tumor. Given the lack of morbidity and mortality attributable to concomitant ureteral carcinoma in situ, and the limited ability of frozen section examination to assist in its extirpation, the value of intraoperative identification of concomitant ureteral carcinoma in situ is questionable and expectant management is advised.
对于在膀胱癌根治性膀胱切除术时发现的输尿管原位癌的临床影响，目前研究较少。我们结合已发表的报告来讨论我们在这一临床问题上的经验。
在连续401例根治性膀胱切除术中，共回顾性鉴定出31例合并输尿管原位癌的患者。分析的终点指标包括尿细胞学阳性、上尿路癌复发及癌症特异性生存率。
21例患者输尿管切缘阳性，10例阴性。在30例行冰冻切片检查的患者中，5例（16.6%）未检测到原位癌，15例（50%）连续输尿管切除术后切缘仍为阳性。3例患者在膀胱切除术后中位51个月（平均49个月，范围36至59个月）时，上尿路癌在吻合口（1例）和肾盂/输尿管（2例）复发。尿细胞学阳性和上尿路癌复发与输尿管切缘状态、临床或病理膀胱肿瘤分期或既往卡介苗治疗无显著相关性。中位随访时间为22.9个月（平均31.8个月，范围2.0至74.2个月），在此期间，31例患者中有7例死于转移性膀胱癌。
合并输尿管原位癌并不常见，且很少与局部发病率相关。无论切缘状态如何，它似乎都会增加上尿路癌复发的风险。根据我们的经验，上尿路癌复发以尿细胞学阳性为先兆，通常仅在长期随访中出现。预后似乎由膀胱肿瘤决定。鉴于合并输尿管原位癌不会导致发病率和死亡率增加，且冰冻切片检查在其切除中的辅助能力有限，术中识别合并输尿管原位癌的价值值得怀疑，建议采取观察性处理。
