局限性肾癌的外科治疗进展

在过去三十年,随着横断面影像学的发展及在临床上的应用增多,使偶然发现的肾肿块数量不断增加,导致无症状、局限性、肾小肿块发生率随之升高。对于临床上发现的局限性肾癌,长期以来根治性肾切除一直是传统治疗的"金标准",但随着早期肾癌检出率的增高以及许多新技术和新观念的出现,应该对肾癌的治疗方式进行重新评估。     

Treatment of localised renal cell carcinoma

Context

The increasing incidence of localised renal cell carcinoma (RCC) over the last 3 decades and controversy over mortality rates have prompted reassessment of current treatment.

Objective

To critically review the recent data on the management of localised RCC to arrive at a general consensus.

Evidence acquisition

A Medline search was performed from January 1, 2004, to May 3, 2011, using renal cell carcinoma, nephrectomy (Medical Subject Heading [MeSH] major topic), surgical procedures, minimally invasive (MeSH major topic), nephron-sparing surgery, cryoablation, radiofrequency ablation, surveillance, and watchful waiting.

Evidence synthesis

Initial active surveillance (AS) should be a first treatment option for small renal masses (SRMs) <4 cm in unfit patients or those with limited life expectancy. SRMs that show fast growth or reach 4 cm in diameter while on AS should be considered for treatment. Partial nephrectomy (PN) is the established treatment for T1a tumours (<4 cm) and an emerging standard treatment for T1b tumours (4-7 cm) provided that the operation is technically feasible and the tumour can be completely removed. Radical nephrectomy (RN) should be limited to those cases where the tumour is not amenable to nephron-sparing surgery (NSS). Laparoscopic radical nephrectomy (LRN) has benefits over open RN in terms of morbidity and should be the standard of care for T1 and T2 tumours, provided that it is performed in an advanced laparoscopic centre and NSS is not applicable. Open PN, not LRN, should be performed if minimally invasive expertise is not available. At this time, there is insufficient long-term data available to adequately compare ablative techniques with surgical options. Therefore ablative therapies should be reserved for carefully selected high surgical risk patients with SRMs <4 cm.

Conclusions

The choice of treatment for the patient with localised RCC needs to be individualised. Preservation of renal function without compromising the oncologic outcome should be the most important goal in the decision-making process.     

Follow-up of patients after nephrectomy for renal cell carcinoma

Follow-up of patients after nephrectomy for renal cell carcinoma is often inadequate. The sooner secondary lesions are identified and treated the better. Routine annual admission of these patients is urged for abdominal angiography, bone scan, chest roentgenograms, and specialized diagnostic procedures as indicated.     

Prognostic significance of tumour size in patients after tumour nephrectomy for localised renal cell carcinoma

OBJECTIVES: Staging of the primary tumour is accepted as the most important prognostic factor in organ confined renal cell carcinoma. METHODS: The outcome of 286 patients with non-metastatic RCC treated by radical nephrectomy at our institution between 1968 and 1992 was evaluated retrospectively. The median follow-up was 114 +/- 62.6 months. In T1/T2 tumours, the validity of tumour size cut-off points for predicting survival outcome was tested. RESULTS: According to the 1997 TNM classification, 168 patients (59%) showed pathological stage T1 (72 stage T1a, 96 stage T1b), 30 (10%) showed stage T2, 84 patients (29%) demonstrated T3 tumours (53 stage T3a, 31 stage T3b), and 4 patients (2%) presented with T4 tumours. The median survival estimated by Kaplan-Meier analysis for T1a, T1b, T2, T3a, T3b and T4 tumours was over 300 months, 187.0 +/- 32.76; 177.0 +/- 1.21; 121.0 +/- 2.57; 124.0 +/- 11.82 and 52.0 +/- 18.38 months, respectively. Regarding survival in T1/T2 tumours Cox regression analysis yielded the highest significance level for a tumour size cut-off point at 4 cm (p = 0.003; 95%CI 1.511-6.991), but no prognostic value for a cut-off point at 7 cm (T1 vs. T2) (p = 0.375; 95%CI 0.655-3.071). CONCLUSIONS: Tumour size is an important prognostic factor in patients with organ confined RCC. The recently specified new cut-off point of 4 cm for T1a/T1b tumours is feasible for separating groups with different survival after tumour nephrectomy and should be considered as the new boundary between T1 and T2 stages. Hence, a more accurate prediction of prognostic differences between these groups should be possible.     

Prognostic factors in localised and regionally advanced renal cell carcinoma

In the last 10 years, several factors have been identified to confer a prognostic effect on renal cancer outcome. Pathologic stage, nuclear and histologic grade are the most frecuent studied and the most important at this moment. We evaluated those factors and introduced some others, looking for new parameters that could be useful. 96 cases of non methastatic renal cell cancer were included in our study. We found that as was mentioned by other authors pathologic and Furhman stage are the stronger prognostic factors but the presence of palpable tumor, pain and weight lost had significance too.     

Squamous cell carcinoma of the renal pelvis after curative retroperitoneal radiotherapy for seminoma

We report the case of a 71-year-old male who presented with squamous cell carcinoma of the renal pelvis in a solitary functioning kidney, 34 years after orchidectomy and adjuvant retroperitoneal radiotherapy for stage II seminoma. This rare second malignancy occurred in the radiation treatment field. Second malignancies are an uncommon but serious sequela of radiotherapy, with potential for significant health problems in patients with complete remission of primary disease. To our knowledge, this is the first report of squamous cell carcinoma of the renal pelvis occurring after radiation treatment.     

肾细胞癌的外科治疗(附81例报告)

目的　探讨肾细胞癌的治疗方法。　方法　总结 81例肾癌治疗经验 ,行肾癌根治性切除术 73例、姑息性肾切除 6例、肾肿瘤剜除术 2例。其中 38例术前行肾动脉造影加栓塞术再行肾癌根治术。　结果　 81例术后病理诊断 ,透明细胞癌 5 2例 ,颗粒细胞癌 19例 ,混合细胞癌 6例 ,囊性肾细胞癌 4例。 81例中 6 5例随访 12～ 110个月 ,5年生存率 :Ⅰ期 83.9% ,Ⅱ期 78.9% ,Ⅲ期 33.3% ,Ⅳ期 16 .7%。　结论　肾癌根治术前肾动脉栓塞是保证手术成功和良好预后的较好方法。保肾手术适应证选择恰当是关系预后的重要因素。     

Operative treatment of renal cell carcinoma

Renal cell carcinoma represents the fifth most frequent malignant tumor in humans. At the time of diagnosis, 20% of the patients already manifest metastases. A further 20-30% of the patients develop systemic metastases in the postoperative course. Despite continued advances in pharmacological treatment options, cancer surgery tailored to the individual tumor findings constitutes the only curative treatment option.     

Neoadjuvant treatment of renal cell carcinoma

Renal cell carcinoma is a potentially devastating cancer, and when metastatic, remains incurable with currently available systemic therapy. Surgical nephrectomy remains the only proven modality which can offer curative options for patients with resectable disease. Further, cytoreductive nephrectomy continues to play a role in the metastatic disease setting. The use of targeted therapy as an adjunct to surgical resection is beginning to be explored in both of these clinical scenarios. Immediate questions regarding preoperative treatment with VEGF pathway targeted therapy include issues surrounding the safety of these agents in use in the perioperative time period, the expectations for response in the primary tumor, the optimal duration of therapy, and the clinical settings in which this therapy may be most beneficial. This review will discuss the current experience with neoadjuvant or preoperative therapy in locally advanced or metastatic renal cell carcinoma and will overview the challenges and opportunities which lie ahead for this form of multimodality therapy.     

Follow-up guidelines for nonmetastatic renal cell carcinoma based on the occurrence of metastases after radical nephrectomy.

OBJECTIVE: To define guidelines for the follow-up management of nonmetastatic renal cell carcinoma (RCC), by assessing tumour recurrences and the clinical course in patients who had undergone radical nephrectomy. PATIENTS AND METHODS: The records of 187 patients with pT1-3, N0-X, M0 RCC who underwent radical nephrectomy between 1982 and 1997 were reviewed prospectively. Clinicopathological variables were compared with the time of first recurrence, site of metastasis and reason for diagnosis. RESULTS: Metastases were diagnosed in 98 sites in 56 of the 187 patients (30%). The risk for developing metastases increased with stage; 80% of the patients had their metastases diagnosed within 3 years (median 14.5 months) after nephrectomy. The time to first diagnosis was longer for patients with pT1 tumours and for those with skeletal metastases. The cause-specific 5-year survival rate for pT1 tumours was 95%, for pT2 87% and for pT3 tumours 37%. All patients with diploid pT1-2 RCC survived, having a survival advantage over those with aneuploid pT1-2 tumours (P=0.018). Also, pT1-2 tumours of < 5 cm were associated with better survival rates. Among 74 patients with pT3 tumours, 45 got metastases; DNA ploidy in these tumours did not influence survival. Of 30 patients with lung metastases, 28 were diagnosed during follow-up, while 25 of 26 other metastatic sites were diagnosed because of symptoms. CONCLUSIONS: The risk for tumour progression depends mainly on stage; these results indicate no need for follow-up in patients with diploid pT1-2 tumours or with aneuploid pT1 tumours of < 5 cm. For patients with aneuploid pT1-2 tumours of > 5 cm and pT3 tumours, follow-up is indicated.     

Prevention of recurrence after curative treatment for hepatocellular carcinoma

Hepatocellular carcinoma often recurs even after curative treatment. In addition to its high frequency of metastasis, hepatocellular carcinoma recurrence is characterized by multicentric carcinogenesis arising in the liver damaged by viral infection with the hepatitis B or hepatitis C virus. This is considered to complicate the initial treatment and recurrence prevention strategy for hepatocellular carcinoma, and accordingly, there is no established adjuvant therapy to prevent recurrence. Preventive adjuvant therapy should be administered to high-risk patients, and should be optimized based on individual risk factors. This review will summarize the current status and future prospects of preventive therapy for the recurrence of hepatocellular carcinoma after curative treatment. Although transcatheter arterial embolization/chemoembolization prior to curative treatment can induce tumor necrosis in some patients, several studies have failed to show any improvement in survival. Postoperative interferon therapy may contribute to prolonging the survival in specific groups of patients. No established adjuvant therapy against advanced hepatocellular carcinoma that prevents metastasis has been established so far. Novel treatment strategies incorporating molecular and immunological mechanisms are expected in the future.     

A case of renal cell carcinoma after successful treatment of Wilms tumor

This case report documents the eighth reported case of renal cell carcinoma (RCC) occurring after treatment of Wilms tumor. Although secondary malignancies after treatment of Wilms tumors are not infrequent, RCC as the second malignancy is rare. We discuss a 17-year-old girl whose RCC was diagnosed 12.5 years after diagnosis of a Wilms tumor. In addition, we review the literature on the subject. Renal cell carcinoma has been proposed as a consequent of chemoradiation; however, a genetic susceptibility must be considered. Because it is routine to assess the functional status of the remaining solitary kidney by annual ultrasonography, we recommend assessing for the presence of secondary renal malignancies and perhaps continuing routine ultrasounds long-term.     

移植肾功能丧失后的动脉栓塞治疗

目的 探讨移植肾功能丧失后动脉栓塞治疗的技术要点、远期疗效及应用价值. 方法 对11例移植肾功能丧失的患者行移植肾动脉栓塞术.术后对患者进行长期随访,采用彩色多普勒超声检查术后3个月、6个月及1年时移植肾大小及其血流情况,并记录血压、尿液变化以及有无与移植肾相关的并发症. 结果 11例患者均成功地实施了移植肾动脉栓塞术,术中和术后均没有发生与介入栓塞术相关的外科并发症.术后3个月、6个月及1年时行彩色多普勒检查发现移植肾血流消失、移植肾萎缩. 结论 移植肾动脉栓塞术具有安全、微创和简便的优点,是一种完全可以代替移植肾切除的治疗方法.     

转移性肾癌的治疗进展

转移性肾癌目前尚无标准的治疗方法.过去的20多年中,一直以干扰素(IFN)或白介素2(IL-2)等免疫治疗作为主要治疗手段,但副作用及效率低,限制其广泛临床应用.靶向治疗的发展极大程度地改变了转移性肾癌的治疗手段,抗血管内皮生长因子(VEGF)及哺乳动物霄帕霉索靶蛋白(mTOR)抑制物已经成为标准的治疗.目前对此类药物的大量研究正在进行中.本文旨在对转移性肾癌在手术、免疫、靶向等治疗方面的进展进行综述.     

转移性肾癌的治疗进展

转移性肾癌目前尚无标准的治疗方法.过去的20多年中,一直以干扰素(IFN)或白介素2(IL-2)等免疫治疗作为主要治疗手段,但副作用及效率低,限制其广泛临床应用.靶向治疗的发展极大程度地改变了转移性肾癌的治疗手段,抗血管内皮生长因子(VEGF)及哺乳动物霄帕霉索靶蛋白(mTOR)抑制物已经成为标准的治疗.目前对此类药物的大量研究正在进行中.本文旨在对转移性肾癌在手术、免疫、靶向等治疗方面的进展进行综述.     

转移性肾癌的治疗进展

转移性肾癌目前尚无标准的治疗方法.过去的20多年中,一直以干扰素(IFN)或白介素2(IL-2)等免疫治疗作为主要治疗手段,但副作用及效率低,限制其广泛临床应用.靶向治疗的发展极大程度地改变了转移性肾癌的治疗手段,抗血管内皮生长因子(VEGF)及哺乳动物霄帕霉索靶蛋白(mTOR)抑制物已经成为标准的治疗.目前对此类药物的大量研究正在进行中.本文旨在对转移性肾癌在手术、免疫、靶向等治疗方面的进展进行综述.