(四)肉瘤
精索、附睾、睾丸肉瘤是最常见的成人泌尿生殖道肉瘤。脂肪肉瘤是成人最常见的肉瘤亚型,随后为平滑肌肉瘤、恶性纤维组织细胞瘤、横纹肌肉瘤及纤维肉瘤(Coleman et al,2003;Ulbright,2004;Dotan et al,2006;Rodriguez et al,2014)。胚胎横纹肌肉瘤是<30岁患者中最常见的组织学亚型。肉瘤通常来源于精索,位于阴囊内;睾丸原发性间叶细胞瘤十分罕见。这类肿瘤往往表现为单个无痛性可触及的肿块,大部分情况下体积小>5cm(Dotan et al,2006)。超声显示为实性肿块,但不能区分良恶性。所有突破睾丸白膜的阴囊内肿块应行腹股沟探查,并进行组织活检。位于腹股沟管的精索脂肪肉瘤会被误诊为腹股沟疝或脂肪瘤,CT或MRI影像有助于分辨这些病变。
大多数患者在诊断该病时仅为局部病灶。肉瘤应优先行经腹股沟途径进行高位结扎的广泛精索及睾丸切除术。若患者首次手术未能完全切除,则应进行再次广泛切除术 (Coleman et al,2003)。对于脂肪肉瘤而言,治疗最主要的失败原因是局部残留 (Ballo et al,2001;Montgomery and Fisher,2003;Khandekar et al,2013)。一些研究者主张对所有睾丸旁肉瘤,尤其是脂肪肉瘤及局部控制效果存疑的肿瘤采取术后放疗(Ballo et al,2001;Hazariwala et al,2013)。但这一治疗手段的有效性存在争议(Fagundes et al,1996;Coleman et al,2003;Khandekar et al,2013)。有腹膜后或远处转移迹象的患者应给予全身化疗。在进行正常的转移性评估的情况下,对于存在腹膜后淋巴结转移的脂肪肉瘤以外的肉瘤患者应当进行RPLND及术后化疗 (Dang et al,2013)。鉴于精索的淋巴引流包括同侧盆腔、腹股沟和腹膜后淋巴结,应考虑对这些区域进行淋巴结清扫或放疗。睾丸旁肉瘤患者的长期生存率约为50%,其中脂肪肉瘤预后最佳,恶性纤维组织细胞瘤和平滑肌肉瘤预后最差 (Coleman et al,2003;Rodriguez et al,2014)。
参考文献
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(金晓东 吴宏珅 刘家信 编译李宏军李彦锋 姜辰一 审校)