INTRODUCTION

As the two most common subtypes, papillary renal cell carcinoma (PRCC) and clear cell renal cell carcinoma (CCRCC) within the same kidney at the same time are very rare[1,2]. A few articles have reported ipsilateral synchronous PRCC and CCRCC by searching PubMed[3-6]. Accurate diagnosis of RCC is important for prognosis and evaluation of therapeutic response. In clinical practice, ipsilateral synchronous PRCC and CCRCC are often misdiagnosed preoperatively as an isolated mass or multiple lesions due to intrarenal metastasis. As a result, patients may have a short survival after the disease is finally confirmed postoperatively. Here, we describe a case of ipsilateral synchronous PRCC and CCRCC treated by laparoscopic left radical nephrectomy, and review the relevant literature.

CASE PRESENTATION

Chief complaints

A 72-year-old man was admitted to hospital because of a left renal mass found on routine physical examination. The patient had no other chief complaints, such as hematuria, fever or lumber pain.

History of present illness

The patient had no relevant medical history.

History of past illness

The initial impression on ultrasound revealed a hypoechoic lobular mass with a volume of 7.8 cm × 4.8 cm × 2.8 cm in the middle to lower pole of the left kidney. Subsequent computed tomography (CT) scan showed a single endophytic mass of 7.5 cm in diameter, with contrast enhancement (Figure 1A).

Personal and family history

No associated family history was reported.

Physical examination

The patient’s temperature was 36.8 °C, respiratory rate was 18 breaths/min, heart rate was 72 bpm, and blood pressure was 145/92 mmHg. The patient’s height was 172 cm and weight was 86 kg. Physical examination revealed normal vital signs, especially in the lumber areas, the contour was normal, and there was no palpable mass or percussion pain.

聚乙二醇化聚十六烷基氰基丙烯酸酯的合成及其作為納米藥物載體的應(yīng)用研究 ………………………… 王叢瑤等（13）：1780

Laboratory examinations

The results of routine blood tests, routine urine tests and renal function examinations, routine fecal tests, blood biochemistry, immune indices, and tumor markers were all within the normal range.

Imaging examinations

The patient had a long history of hypertension for 20 years, and smoking for 50 years. He denied any other previous medical history.

“好萊塢”如今往往指的是美國(guó)先進(jìn)的影視音樂(lè)工業(yè)，在品牌運(yùn)營(yíng)上更為成熟、高效。電影工業(yè)化的最終目的是打造全產(chǎn)業(yè)生態(tài)鏈，而好萊塢擁有高技術(shù)人才、調(diào)節(jié)資本與產(chǎn)品質(zhì)量的良性循環(huán)、建立專業(yè)化影視基地和建立國(guó)際高水準(zhǔn)的攝影棚等方面，展現(xiàn)了如何打造國(guó)際品牌。

FINAL DIAGNOSIS

The final diagnosis was ipsilateral synchronous PRCC (WHO grade II/III) and CCRCC (WHO grade II/III) in the left kidney according to the imaging and pathological results.

樂(lè)視網(wǎng)成立于2004年11月，2010年8月12日在中國(guó)創(chuàng)業(yè)板上市。樂(lè)視網(wǎng)是唯一一家在境內(nèi)上市的視頻網(wǎng)站，也是全球第一家IPO上市的視頻網(wǎng)站。樂(lè)視網(wǎng)的市值在上市之初為30億元，到2015年最高股價(jià)時(shí)，市值高達(dá)1700多億元，成為創(chuàng)業(yè)板市值最高的公司。

TREATMENT

As the tumor was in the middle to lower pole of the left kidney, a partial nephrectomy was firstly considered by the surgeons to preserve more kidney function. However, after a discussion with the family numbers and the patient, a laparoscopic radical nephrectomy was accepted, as the patient wished for a longer survival time. He finally underwent laparoscopic left radical nephrectomy. The operation went smoothly, and there were no adhesions between the left kidney and peripheral organs. He was discharged on day 6 with no postoperative complications.

利用無(wú)人機(jī)進(jìn)行工程測(cè)量時(shí)，需要考慮在山地、礦區(qū)和叢林等特殊的環(huán)境條件下使用的效果。在工程測(cè)量范圍內(nèi)，應(yīng)對(duì)無(wú)人機(jī)進(jìn)行合理的升降設(shè)置，設(shè)置滑翔距離，使其能夠順利完成起飛。對(duì)于大型無(wú)人機(jī)而言，當(dāng)不能滿足其起飛的條件時(shí)，需結(jié)合自然環(huán)境適當(dāng)調(diào)節(jié)起飛的高度，提高對(duì)風(fēng)力的抵抗能力，并有效防止因山間大風(fēng)的干擾造成無(wú)人機(jī)墜毀。另外，運(yùn)用無(wú)人機(jī)測(cè)繪技術(shù)還需考慮無(wú)人機(jī)重量、機(jī)械設(shè)備的外形等會(huì)影響起飛狀態(tài)的因素，再結(jié)合實(shí)際情況調(diào)整無(wú)人機(jī)機(jī)械設(shè)備的參數(shù)，以便提高操作過(guò)程中的安全性，并滿足工程測(cè)繪過(guò)程中的測(cè)量需求。

OUTCOME AND FOLLOW-UP

用體積散射函數(shù)β(θ)表示一個(gè)散射體積元在準(zhǔn)直光束中傳輸時(shí)所產(chǎn)生的射散,式(2)。其描述的是入射光束在水中的某個(gè)散射體上的散射角度的分布:

DISCUSSION

Renal cell carcinoma (RCC) is the most common solid mass of the kidney and comprises 2%-3% of all cancers in adults[7]. The incidence of RCC has risen over the past few years due to incidental detection[8]. RCC is divided into CCRCC and non CCRCC subtypes, while the most common subtype of non-CCRCC is PRCC. The combination of different subtypes has rarely been reported[9]. The incidence of ipsilateral synchronous PRCC and CCRCC is approximately 4.8%[10]. The rarity of the disease may contribute to its misdiagnosis in clinical practice. As in our case, an initial diagnosis of angiomyolipoma (AML) was suspected.

The underlying etiology of ipsilateral synchronous PRCC and CCRCC is still unclear, which partly affects the understanding of clinicians. The best known possible etiological factors for RCC are smoking, obesity, and hypertension[11]. Smoking is implicated as the key etiology of RCC, and heavy smoking is associated with increased risk. Ustuner[3] reported coexisting PRCC and CCRCC in the same kidney in 2014. That patient presented with a 40-year history of smoking and a 2.03 relative risk (RR) of renal cancer. A meta-analysis by Hunt[13] revealed that men who smoked 1–9, 10–20 or ≥ 21 cigarettes/d had an RR of 1.60, 1.83 and 2.03, respectively. Nonetheless, the relationships between obesity or hypertension and the disease are not yet firmly established. In our case, a history of smoking and hypertension for many years was noted, while obesity was not mentioned as an etiological factor.

Ultrasound or abdominal CT can reveal the lesion preoperatively. Most CCRCCs are hypervascular, the degree of enhancement quickly decreases in the parenchyma phase, presenting as “fast in and fast out”. In contrast, there is no predominant enhancement in the three phases of PRCC revealed by CT, as the vessels of the fibrovascular core are thin and sparse in the papilla[13]. Unfortunately, there is still a 3.5% risk of missing coexisting tumors in RCC[10]. Up to 70% of multifocal lesions are missed on preoperative imaging due to small size or adjacent location of the lesions. Our case was diagnosed preoperatively as a single mass both by ultrasound and CT. Missing the second mass was not only a radiological misdiagnosis, but also reflected a lack of awareness of the imaging features of the ipsilateral synchronous PRCC and CCRCC, and this could have had a serious effect on the treatment strategy. Excessive dependence on radiological findings to obtain an accurate preoperative diagnosis of the ipsilateral synchronous PRCC and CCRCC is undesirable.

Diagnosis and subclassification of RCC must be based primarily on pathology. Our case was initially diagnosed with AML, because of the similar gross features (Figure 1B). A cut surface color of yellow–brown could create confusion with AML, as the latter is well circumscribed, has extended borders, and contains soft yellow regions admixed with firm tan regions. Most PRCCs are bilateral and multifocal, and areas of hemorrhage and necrosis are commonly seen in PRCC; thus, confusion with other tumors is understandable.

In addition, differential diagnosis is necessary between PRCC and collecting duct carcinoma, when the latter has a papillary pattern. Nevertheless, collecting duct carcinoma often presents as a high-grade tumor with predominant desmoplastic stroma, and occurs in the medulla. CK7 may be expressed in both tumors, but negativity for CEA, 34βE12 and some other biomarkers can help to exclude PRCC. When thinking back to our first gross diagnosis, if the epithelioid subtype of AML was exhibited, CCRCC might be misclassified initially as AML. CCRCC is always positive for Vimentin, CD10 and CAIX, but negative for the biomarkers of AML, such as HMB45 and SMA. Careful attention to the morphology and immunohistochemistry may help to establish the correct diagnosis.

Microscopically, PRCC may be confused with CCRCC when a solid growth with clear cytoplasm is seen, and CCRCC with a papillary pattern or eosinophilic cytoplasm can be confused with PRCC. In this situation, the classic morphological features of the two tumors are helpful in distinguishing them, such as whether a pseudopapillary pattern was observed. Due to the different immunoprofiles shown in PRCC and CCRCC, immunohistochemical staining may also offer an important clue to the diagnosis. PRCC is strongly positive for CK8/18, CK 7 and P504s, while CCRCC is strongly positive for CD10, CAIX and Vimentin. CK7 may be expressed in both tumors, but PRCC often shows a diffuse cytoplasm positive for CK7, while no positivity is observed in CCRCC. Our case showed similar findings to those described in the literature, with strong positive staining for CK7 in PRCC and negative staining in CCRCC (Figure 2).

Unfortunately, there has been little research on the molecular pathology of ipsilateral synchronous PRCC and CCRCC, even though the characteristic cytogenetic alterations of PRCC and CCRCC have been revealed, which is partly due to a lack of awareness of this rare entity. Further study should focus on these aspects using modern molecular techniques.

企業(yè)技術(shù)創(chuàng)新是一個(gè)復(fù)雜過(guò)程，影響企業(yè)技術(shù)創(chuàng)新的因素很多，主要是人的因素，包括技術(shù)團(tuán)隊(duì)、高管團(tuán)隊(duì)等。技術(shù)創(chuàng)新是一個(gè)團(tuán)隊(duì)任務(wù)，必須通過(guò)科學(xué)有效的團(tuán)隊(duì)建設(shè)，發(fā)揮團(tuán)隊(duì)每個(gè)成員的能力。要重視每個(gè)微觀元素的影響，才能提升企業(yè)技術(shù)創(chuàng)新的能力。在企業(yè)技術(shù)創(chuàng)新過(guò)程中，高管薪酬激勵(lì)是一種方式。值得注意的是，采用科學(xué)合理的方法進(jìn)行激勵(lì)，能對(duì)團(tuán)隊(duì)產(chǎn)生正向激勵(lì)的效果，否則可能對(duì)團(tuán)隊(duì)產(chǎn)生負(fù)面影響[5]。

The aim of surgical management for multifocal renal tumors is not only to prevent recurrence and metastasis, but also to minimize the number of surgical procedures and prolong kidney function. Both laparoscopic, robotic and partial nephrectomy for multiple lesions of ipsilateral renal tumors have been reported[14-17]. Some studies have compared the two main surgical options for managing this subset of patients, and similar tumor-specific survival was observed for patients treated with nephron sparing surgery (NSS) and radical nephrectomy[18-21]. Regardless of which surgical mode is selected, the right balance between oncological control and renal function preservation should be considered. Although a single mass was diagnosed preoperatively, our patient still underwent laparoscopic radical nephrectomy with the aim of achieving a long-term survival. Different tumors have different prognoses and vary in aggressiveness[22]. If a single mass is confirmed, to preserve more renal function and improve quality of life, NSS may be performed. Dependence on preoperative imaging can lead to missing multifocal lesions[10,23]. Thus, complete mobilization and inspection of the entire kidney is justified when performing NSS to identify multifocal disease[23]. In such a situation, whether an adequate surgical range is obtained, or whether a long life-time survival is achieved, should be considered. Accurate preoperative diagnosis is also key to achieving long-term survival.

Informed written consent was obtained from the patient for publication of this report and any accompanying images.

The diplomatic vague language shows the art of diplomatic language.The official could combine flexibility and principle together to make a decent expression.

The authors declare that they have no conflicts of interest.

As the incidence of ipsilateral synchronous PRCC and CCRCC is low, a lack of awareness or experience may exist among clinicians. If there are multifocal masses in a single kidney, intrarenal metastasis is always initially considered, and the possibility of coexisting ipsilateral synchronous tumors may be ignored. However, as the prognosis of PRCC and CCRCC differs, the therapeutic strategies may differ, such as surgery or adjuvant chemotherapy. Even though they have a low incidence rate, different histological subtypes of multiple ipsilateral synchronous RCCs need to be classified as a special entity postoperatively, due to the different therapeutic strategies performed. Further studies are still needed to make a comparison and comment on the course of the disease as this is only a single case without any controls, and the clinical implications are limited.

CONCLUSION

This was a rare case of ipsilateral synchronous PRCC and CCRCC with two histological variants. The diagnosis of ipsilateral synchronous PRCC and CCRCC can be established through detailed clinical history, imaging findings, and most importantly, pathological examination and immunohistochemical staining. As the prognosis of the two tumors differs, careful clinical decision-making and appropriate surgical management are required to manage the disease. The above descriptions are expected to help understand the disease, and improve diagnosis in the future. If optimally applied, these tactics can achieve long life expectancy and long-term preservation of renal function in patients with ipsilateral synchronous PRCC and CCRCC.

FOOTNOTES

Yin J was involved in acquisition of the data and drafting and completing the manuscript; Zheng M was involved in the literature review; all authors gave final approval for publication, took full responsibility for the work as a whole, including the study design, access to data, and the decision to submit and publish the manuscript.

Effective adjuvant therapies are necessary to reduce recurrence andmetastasis, such as autologous tumor vaccines, carbonic anhydrase IX monoclonal antibody, tyrosine kinase inhibitors and novel immunotherapies, which have significantly improved the overall survival of patients with RCC in recent years[14,24,25]. To date, most studies have focused on the identification of an effective adjuvant therapy for CCRCC, in order to improve the outcome of patients with high-risk RCC, while the optimal treatment option for PRCC has not yet been established[26]. As most PRCCs are associated with a better outcome than CCRCCs in patients without metastases, the regular treatment strategies and follow-up employed for patients with CCRCC are sufficient for patients with nonmetastatic PRCC[27]. In addition, more research on the novel gene signatures of RCC may improve the survival of patients with PRCC and CCRCC, and should be conducted in clinical trials[28]. For patients with ipsilateral synchronous PRCC and CCRCC, a regular adjuvant therapy for CCRCC may be sufficient.

There are insufficient data to compare different types of RCC in the same kidney with unilateral multifocal tumors in terms of survival. Bilateral synchronous renal tumors have been evaluated[29,30], but there are no such data for unilateral synchronous RCC of different types. The prognosis of PRCC is more favorable than that of CCRCC, as the former is less aggressive. Capaccio[2] reported three patients who had unilateral synchronous PRCC and CCRCC treated by radical nephrectomy, and only one died from the disease 5 year after surgery. Ustuner[3] described a 67-year-old man with unilateral synchronous PRCC and CCRCC, who was disease-free at the 6 mo and 1 year follow-up. The present case was disease-free with no recurrence or metastasis after 25 mo.

After 25 mo follow-up, the patient was free from disease with no recurrence or metastasis on CT, and renal function was within the normal range. He was continuously followed up.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

辛迪·舍曼以自己為模特，這種獨(dú)特性令其在媒體與文化評(píng)論中占得一席之地。相反的，斯各格蘭德并沒(méi)有此類以作品尋求辨識(shí)度的想法。這位藝術(shù)家否認(rèn)她的作品反映著某個(gè)特定的意圖。盡管如此，許多觀眾還是感受到了《放射性的貓》與《原子的爭(zhēng)論》(the debates on the atom)之間的關(guān)聯(lián)，將《綠房子》解讀為對(duì)全球溫室效應(yīng)問(wèn)題的暗示，并將《也許是嬰兒》(Maybe Babies)視作對(duì)人流這一社會(huì)問(wèn)題的評(píng)論。

Jing Yin 0000-0002-7365-4991; Mo Zheng 0000-0003-0488-2517.

其次是比喻修辭格的使用。將血珠比作“紅豆”，二者有顏色和形狀上的相似之處。刺破手流出的血珠如此鮮艷，喻涵了對(duì)丈夫的幾多相思。

Xing YX

A

控制系統(tǒng)是剪板機(jī)實(shí)現(xiàn)精確高效工作的前提，控制系統(tǒng)的設(shè)計(jì)在剪板機(jī)的設(shè)計(jì)過(guò)程中顯得尤為重要?？刂葡到y(tǒng)的控制方式有很多，但是目前比較常用的有單片機(jī)和PLC等方式，本文剪板機(jī)的控制系統(tǒng)的核心控制方式采用PLC控制。

Xing YX