膀胱肿瘤课件_2

膀胱肿瘤 Bladder tumor 业务学习 06-02 一 概述 膀胱肿瘤是泌尿系统最常见的肿瘤，在 我国，其发病率和死亡率均占泌尿系肿瘤的 首位。 A、summarize Bladder cancer accounts for nearly the most common in urinary system. 二 分类 (1)上皮性，占95%以上， 其中乳头状瘤（2%），移行细胞癌（94%），原位癌（ 1%），鳞状细胞癌（2%），腺癌（1%）。 (2)非上皮性 B、classification: (1)Superficial ,more than 95%, approximately 2% of that are papillary cancer,94% are transitional cell cancer. (2)invasive, 三 病因 内在的遗传因素和外在的环境因素，肿瘤 发病是复杂的多种因素作用的结果。 C、 pathogeny Heredity factor inside and environmental factor outside,which is complicated. 1、 遗传易感性： 膀胱肿瘤和性别年龄关系密切，发病率 男性比女性高210倍；60岁以后发病率高， 很少在40岁以前发病。 1 、 Heredity susceptibility: the incidence of bladder cancer increases directly with age and sex, which increases in people after 60 years old and is 2-10 times as common in men as in women. 2、 危险因素： 膀胱癌与环境职业，吸烟，感染，慢性炎 症，结石，异物，盆腔照射，细胞毒化疗药 物等有关。 2. Risk factor: there are environment, occupation, smoking, infection, calculus and so on. 3、 生物学特点： 对膀胱癌生物学行为的研究表明膀胱癌 的发生是一个多阶段过程，包含了多种基因 突变，这些突变又可被分为早期和晚期。 3. Biological characteristic: it contains manifold gene mutation. 四 病理 1、 组织病理 1) 上皮化生和增生 2) 尿路粘膜分化不 良 3) 原位癌 4) 移行细胞癌 5) 鳞状细胞癌 6) 腺癌 1、 Tissue pathology 1) Epithelial metaplasia and hyperplasia 2) Urethral mucous membrane poor differentiation 3) Carcinoma in situ 4) Transitional cell carcinoma 5) Squamous cell carcinoma 6) Adenocarcinom 2、 肿瘤的扩散 1) 直接扩散 2) 淋巴结转移和血行转移 3) 种植性扩散 2、 Diffusion 1) Direct diffusion 2) Lymphatic and vascular spread 3) implantation 五 临床表现 1、 性别与年龄： 膀胱肿瘤高发年龄：5070岁，男性多于 女性，男、女之比约为34：1。 E、Clinical manifestation 1、 Sex and age : the peak incidence is in persons from 50-70 years old, with a male-to-female predominance of 3-4:1. 2、 症状： 最常见的初始症状为无症状性肉眼血尿，同 时可伴有排尿不畅，甚至尿潴留。 2、 Symptoms: the most common symptoms is macroscopic and painless hematuria, with dysuria, even urine retention. 六 诊断 临床上膀胱癌最常见的典型症状为间歇性无痛 性肉眼血尿，约占85，多数为全程血尿，少数 为初始血尿或终末血尿，有的则为镜下血尿。 F、Diagnosis The most common typical symptoms of bladder cancer is intermittence , painless and macroscopic hematuria, nearly account for 85%, majority are total , while minority are original or ultimate, and some are microscopical. 1、 膀胱镜检查 可了解肿瘤的位置、大小、数目及其形态与 基底的情况。膀胱镜检查可初步判断肿瘤的良恶 性以及临床分期。 1、 Cystoscope: Know the location,size,number and modality.Primary estimate that it is benign or malignant and judge the clinical stage. 2、 影像学检查 a) 尿路造影检查：可了解上尿路情况 b) B超：可检出直径0.5cm的肿瘤 c) CT、MRI 2、 Image examine: a) Urography: it examine the superior urine. b) Ultrasonography: it could detect cancer with diameter more than 0.5cm c) CT、MRI 3、 尿脱落细胞学检查 4、 其它 如基因诊断（尿细胞中DNA微卫星的分 析）等。 3、 Urinary cast cytology examine 4、 Others : such as gene diagnosis. 七 治疗 治疗原则和其他肿瘤一样，包括手术、放射治疗、 化学药物治疗、免疫治疗和新技术，但仍以行手术治疗 为主。具体手术的范围和方法应根据肿瘤的分期、分级 、病理类型及肿瘤的大小、部位有无累及邻近器官等综 合分析。 G、Treatment The principle of treatment to bladder cancer is same as other cancers , contains surgery, radiotherapy, chemotherapy ,immunotherapy and so on, while surgery is the main therapy. The range and method of operation must base on the stage ,grade ,pathology ,size and location. 1、 经尿道膀胱肿瘤电切术： 适应症： 低分期、分级、浸润深度不超过膀胱浅 肌层的膀胱移行细胞癌均适宜采用该手术方 法。 1. TURBT(transurethral resection of the bladder tumor) Adaptation: Transitional cell carcinoma with low stage, low grade and depth of infiltration not exceeding superficial muscular layer of bladder. TURBt 禁忌症： a、凡不能达到完全切除肿瘤的目的，如肿瘤位 于膀胱颈部或憩室内； b、分化不良的癌肿，如未分化癌； c、浸润到深层肌肉的癌肿或膀胱癌已侵犯到前 列腺。 Contraindication: a. operation can not resect the total focus, such as it locates at cervix or diverticulum of bladder; b. poor differentiation , such as undifferentiated carcinoma; c. carcinoma infiltrates to deep muscular layer or entrench to prostate. 2、 开放手术 1) 膀胱部切术： 适应症：a、范围较局限的浸润性乳头状瘤; b、远离膀胱三角区及颈部区域的肿瘤； c、TUR不易切除部位的肿瘤； d、膀胱憩室肿瘤 2. Open operation 1) Partial cystectomy: Adaptation: a. local infiltration papilloma. b. far from the triangle and cervix of bladder. c. TUR can not resect it. d. carcinoma locates at diverticulum of bladder 膀胱部切的禁忌症： a、多灶性原位癌；b、肿瘤侵犯前列腺、尿道； c、膀胱三角区及颈部肿瘤；d、多发性浅表性肿瘤，估 计切除后不能保持膀胱足够的容量；e、膀胱曾作过放射 治疗；f、肿瘤已侵犯膀胱外组织。 Contraindication: a. multiple carcinoma in situ; b. carcinoma entrenches to prostate or urethra; c. carcinoma in triangle and cervix of bladder. d. multiple superficial cancer which resected leading to inadequate cystic capacity. e. bladder after radiotherapy; f. carcinoma infiltrates tissue outside of bladder. 2 ) 全膀胱切除术： 适应症： a、肿瘤范围较大，分散的多发性肿瘤，不宜 作局部切除者； b、肿瘤位于膀胱三角区附近； 2) total cystectomy： Adaptation: a). large range dispersive multiple carcinoma, not suitable for partial cystectomy . b). cancer near triangle of bladder. c、肿瘤位于膀胱颈部的浸润性肿瘤； d、反复复发的浅表性膀胱癌； e、多灶性原位癌腔内化疗失败，级别迅速升 高者，或原位癌侵犯前列腺尿道及远端尿道者 。 c). infiltration cancer near cervix of bladder . d). repeat recrudescent superficial cystic carcinoma. e). multiple carcinoma in situ whose grade rapid raises after chemotherapy lost ,or carcinoma in situ infiltrates prostate and far -forth urethra . 膀胱全切的手术范围 切除整个膀胱，男性还需切除前列腺和精囊 ，同时应作尿流改道。根治性膀胱切除术还 应包括盆腔淋巴结清扫。 Operation range: includes total bladder, while prostate and spermatophore for male, and changing urethral route. 3、膀胱腔内灌注化疗： 膀胱肿瘤术后复发率较高，而浅表性肿 瘤即或TURBT后亦面临肿瘤复发的问题。因 此，为防止复发，术后应立即进行膀胱腔内灌 注化疗。化学治疗药物如赛替哌、丝裂霉素等 。 3. Intravesical chemotherapy: intravesical chemotherapy after operation.such as thiotepa , mitomycin and so on. 4、 放射治疗： 膀胱癌的放射治疗效果不理想，目前主要用 于晚期肿瘤病人的姑息治疗，或手术、化疗 病人的辅助治疗。 4. Radiotherapy: the effect is not ideal, presently it is used for appeasement therapy of afternoon patient , or assistant therapy of operation and chemotherapy. 5、 化学治疗 浸润性膀胱癌可选择化学治疗，途径有 静脉化疗和动脉内灌注化疗。 6、 基因治疗： 目前还处于研究阶段。 5. Chemotherapy It is suitable for infiltration cancer. 6. Gene therapy At present it is still under research. 八 预后及随访 1) 膀胱肿瘤的治疗效果与肿瘤类型有关。局 灶性原位癌预后较好。膀胱鳞状上皮细胞癌 和腺癌均为广基肿瘤，恶性程度高，预后较 差。 F、Prognosis and investigation 1)The therapeutic effect relates to type of carcinoma. Prognosis of localization carcinoma in situ is well, while Prognosis of squamous cell carcinoma and adenocarcinoma is poor. 2) 浅表性膀胱肿瘤术后复发率约为5070 ，因此浅表性肿瘤术后，临床随访在整个 膀胱肿瘤治疗过程中具有重要意义。在预防 复发治疗期间应每3个月做一次膀胱镜检查， 如果随访期间出现肉眼血尿，应随时提前做 膀胱镜复查。 2) Because relapse rate of superficial cystic carcinoma accounts for 50%-70%, clinical investigation is very important. Currently, patient take a cystoscopic examine every 3 months, and if they appearing macroscopic hematuria , it should bring forword. 九 预防 1、针对病因采取预防措施：改善染料、橡胶等工 业生产条件，禁止吸烟，避免长期大量服用致膀 胱癌的药物。 2、 高度重视血尿病人的密切随访. I、Prevention 1、 Adopting measure aim at pathogeny : forbidding smoking, improving condition of rubber industry. 2、 Paying more attention to consanguineous invest