Management of renal cell carcinoma with inferior vena cava tumor thrombus

OBJECTIVE: The prognostic implication of radical nephrectomy with inferior vena cava tumor thrombectomy for renal cell carcinoma is still controversial. We investigated the type of renal cell carcinoma with vena cava tumor thrombus for which surgical resection was beneficial. MATERIALS AND METHODS: We retrospectively reviewed the records of 16 patients with renal cell carcinoma and inferior vena cava tumor thrombus. Of these, 10 received surgical treatment and 6 did not. We evaluated the association between the pretreatment serum C-reactive protein (CRP) level and the efficacy of surgery. RESULTS: Among the 8 patients with an elevated pretreatment serum CRP level (CRP > or = 1.0 ng/ml), there was no significant difference of the median disease-specific survival between those who did (20.2 months) and did not undergo surgery (8.2 months; p = 0.1946). On the other hand, among the 8 patients who had a pretreatment serum CRP level within normal limits (CRP < 1.0 ng/ml), the median disease-specific survival of those who did not undergo surgery (80.6 months) was significantly better than that of those who did (50.2 months; p = 0.0136). CONCLUSION: This study suggested that conservative treatment can be recommended for patients with renal cell carcinoma and inferior vena cava tumor thrombus when the pretreatment serum CRP level is normal because tumor progression is usually slow and surgical treatment may actually worsen the prognosis.     

Interleukin-2 immunotherapy followed by resection of residual renal cell carcinoma

We administered 10 (E5) units per kg. interleukin-2, 3 times daily, with or without lymphokine-activated killer cells, to 10 patients with metastatic renal cell carcinoma. All patients had metastases to the lung, and 3 of 5 patients who had previously undergone nephrectomy had metastases to the renal fossa. Of the 9 patients who completed at least 1 course of therapy 3 had complete regression of disease outside the abdomen, including 2 who were rendered disease-free after subsequent cytoreductive surgery (nephrectomy in 1 and resection of the renal fossa recurrence in 1). Viable tumor comprised less than 1% of each surgical specimen. Our results support the view that initial treatment with interleukin-2 immunotherapy, followed by abdominal cytoreductive surgery if the peripheral metastases have regressed, may be preferable to the practice of performing abdominal cytoreductive surgery before administering interleukin-2 immunotherapy for patients with widely metastatic renal cell carcinoma.     

Renal cell carcinoma with tumor thrombus extension: biology,role of nephrectomy and response to immunotherapy

PURPOSE: We outline the biology, prognosis and role of immunotherapy for renal cell carcinoma with gross venous tumor thrombus. MATERIALS AND METHODS: A total of 207 patients with unilateral renal cell carcinoma and tumor thrombus into the renal vein (107) and inferior vena cava (100) who underwent nephrectomy and thrombectomy were compared with 607 without tumor thrombus. RESULTS: At diagnosis 77 patients (37%) had N0M0 disease and 130 (63%) had lymph node (N+) or distant (M1) metastases. Compared with nontumor thrombus cases tumor thrombus was associated with more advanced stage, N+ (26% versus 12%), M1 (54% versus 31%) disease, higher grade and Eastern Cooperative Oncology Group performance status. In N0M0 cases with inferior vena caval tumor thrombus capsular penetration, collecting system invasion and extension into the hepatic vein were more important prognostic variables then the level of inferior vena caval thrombus. In patients with confined N0M0 tumors mean 2 and 5-year survival +/- SD was 83% +/- 8.8% and 72% +/- 10.7% in those with inferior vena caval tumor thrombus, and 90% +/- 9.4% and 68% +/- 16.1% in those with renal vein tumor thrombus, similar to the 93.4% +/- 1.7% and 81 +/- 3.1% rates, respectively, in those without thrombus who had no recurrence within 6 months after nephrectomy. Of patients with M1 disease in whom cytoreductive surgery was done those with and without thrombus showed a similar response to immunotherapy. When there was inferior vena caval and renal vein thrombus, mean 2-year survival was higher after nephrectomy and immunotherapy than after nephrectomy alone (41% +/- 9% and 52% +/- 7% versus 32% +/- 13% and 45% +/- 7%), immunotherapy alone (0% and 13% +/- 12%, respectively) and no treatment (0%). CONCLUSIONS: Renal cell carcinoma with tumor thrombus is associated with worse characteristics. Local tumor extension has greater prognostic importance than the level of inferior vena caval tumor thrombus. Survival is fair in patients with truly confined N0M0 disease and thrombus. The combination of surgery and immunotherapy has a role in thrombus cases. Our data provide the rationale for a prospective study of adjuvant immunotherapy after surgery in N0M0 cases with extensive tumor thrombus.     

PREDICTIVE VALUE OF PROSTATE SPECIFIC ANTIGEN NADIR AFTER SALVAGE CRYOTHERAPY

Purpose

We determined nadir prostate specific antigen (PSA) after salvage cyrotherapy to distinguish patients who are potentially cured from those at risk for subsequent biochemical and biopsy proved failure.

Materials and Methods

A total of 146 patients who underwent salvage cyrotherapy were followed a median of 21 months (range 3 to 47) with regular serum PSA analysis and digital rectal examination. Sextant biopsies were performed at 6 months or earlier when PSA increased greater than 2 ng./ml. from the nadir value (biochemical failure) or there was a palpable local recurrence. We compared the incidence of biochemical failure and biopsy specimens positive for cancer to pretreatment PSA and posttreatment nadir PSA.

Results

In 59 of the 146 patients (40%) PSA decreased to an undetectable level within a median of 3 months. In 85 of the 109 patients (78%) who underwent biopsy the specimens were negative for cancer. Low serum PSA nadir values were associated with low pretreatment PSA and a low incidence of biochemical failure. In 6 of 60 patients (10%) in whom PSA nadir was 0.5 ng./ml. or less and in 18 of 49 (37%) with a higher PSA nadir biopsy was positive for cancer.

Conclusions

A PSA nadir of 0.5 ng./ml. or less should be achieved after salvage cryotherapy. Higher nadirs are more likely to be associated with increasing posttreatment PSA and positive biopsies. PSA nadir is a better prognostic indicator of biochemical and biopsy proved failure after salvage cryotherapy than pretreatment PSA.     

INTERLEUKIN-2 BASED IMMUNOTHERAPY FOR METASTATIC RENAL CELL CARCINOMA WITH THE KIDNEY IN PLACE

PURPOSE: We assessed morbidity, response and survival in patients with metastatic renal carcinoma treated with high dose intravenous interleukin-2 (IL-2) based immunotherapy with the primary renal tumor in place. MATERIALS AND METHODS: We retrospectively analyzed the records of patients with metastatic renal carcinoma and the primary kidney tumor in situ who were treated at the surgery branch of the National Cancer Institute. Of the patients 607 were treated with IL-2 based therapy. Patient age, sex, sites of extrarenal disease, morbidity, and response and survival rates were examined. RESULTS: From 1986 to 1996, 51 patients with the majority of disease at extrarenal sites were treated with the primary tumor in place. Treatment involved IL-2 based regimens, reflecting the evolution of immunotherapy at the National Institutes of Health. When evaluating only extrarenal sites, response was complete in 1 and partial in 2 of the 51 cases (6%). No responses were noted in the primary renal tumor. Three patients with responses at extrarenal sites underwent nephrectomy. The duration of response in these 3 cases was greater than 88, 11 and 4 months, respectively. Median survival in all 51 patients was 13 months (range 1 to 86). CONCLUSIONS: Select patients may be treated with IL-2 based immunotherapy with the primary renal tumors in place with morbidity. A randomized study is needed to assess the role of cytoreductive nephrectomy for treating metastatic renal cell carcinoma.     

METASTATIC RENAL CELL CARCINOMA WITH CONCURRENT INFERIOR VENA CAVAL INVASION: LONG-TERM SURVIVAL AFTER COMBINATION THERAPY WITH RADICAL NEPHRECTOMY, VENA CAVAL THROMBECTOMY AND POSTOPERATIVE IMMUNOTHERAPY

PURPOSE: We report our experience using aggressive multimodal therapy in a high risk group of patients with metastatic renal cell carcinoma and concurrent inferior vena caval extension. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients in our kidney cancer database who had metastatic renal cell carcinoma and tumor thrombus extension into the inferior vena cava at the initial diagnosis. Patients were included in the study if they underwent radical nephrectomy and inferior venal caval thombectomy, and immunotherapy was planned for the postoperative period. Tumor size and grade, metastatic sites, level of vena caval extension, surgical complications and overall survival were obtained from the medical records. The primary end point analyzed was overall survival. RESULTS: We identified 31 cases of metastatic renal cell cancer with extensive disease and vena caval extension. Of the patients 23% had an isolated lung metastasis, and 53% had metastasis in the lung and at other sites. The remaining patients had involvement primarily at nonpulmonary metastatic sites, including lymph node in 38%, soft tissue in 13%, liver in 29% and bone in 10%. Average blood loss during nephrectomy was 3,200 cc (median 2,100) and the rate of major complications was 12%. Of the patients 80% underwent the full course of surgery and postoperative immunotherapy. At a mean followup of 18 months (34 for survivors) 26% of the patients are alive. Actuarial overall 5-year survival of the group was 17%. Tumor thrombus level did not correlate with overall survival, while immunotherapy, tumor grade and metastatic site provided significant prognostic information. In patients with an isolated pulmonary metastasis the 5-year survival rate was 43%, while in those with low grade tumors it was 52%. CONCLUSIONS: In contrast to the poor results of surgery only in patients with renal cell carcinoma and concurrent inferior venal caval invasion, reasonable 5-year survival may be achieved after combined aggressive surgery and immunotherapy. Patients in whom metastasis was limited to the lungs and those with grade 1 to 2 tumors had a better prognosis. With careful planning and experienced immunotherapists therapy may be completed in the majority of this high risk group of patients.     

Prostate Specific Antigen Regression and Progression after Androgen Deprivation for Localized and Metastatic Prostate Cancer

To identify prostate specific antigen (PSA) functions of prognostic significance in regard to treatment with androgen deprivation for prostate cancer we analyzed the pretreatment PSA, PSA half-life, PSA nadirs, times to PSA elevation and PSA doubling times in 245 patients with localized and 78 with metastatic disease who were treated with this modality. There was a direct correlation between the pretreatment PSA and the time to PSA elevation in patients with localized cancer (p = 0.000003) but no significant correlation in those with metastatic cancer. The PSA half-life was highly variable and did not correlate with other PSA functions of prognostic significance. Incremental increases in the PSA nadir correlated with the time to PSA elevation in patients with localized and metastatic cancer (p less than 0.000001 and p = 0.00009, respectively), and with other parameters of prognostic significance. The median PSA doubling time in 26 patients with localized cancer in whom distant metastases did not develop (7.5 months) was significantly longer than that in 7 in whom new metastases developed (2.5 months) and in 43 with preexisting metastatic cancer (2.5 months) (p less than 0.05 and p less than 0.0001, respectively). In the 7 patients with localized cancer in whom metastases developed the median of the ratios of the PSA when the metastases were manifest and the pretreatment PSA was 0.14, and in 24 patients with preexisting metastatic cancer the median of the ratios of the antemortem PSA and the pretreatment PSA was 1.2. These data show that PSA synthesis by prostate cancer is reduced after androgen deprivation but that the PSA nadir and PSA doubling time following treatment provide important prognostic information.     

Salvage surgery of chemorefractory germ cell tumors with elevated tumor markers

PURPOSE: We evaluated the prognostic criteria for salvage surgery in patients with persistent marker elevation after chemotherapy for metastatic germ cell tumors. MATERIALS AND METHODS: Of 125 men who underwent post-chemotherapeutic resection of residual tumors 30 had persistent marker elevation at surgery. This group was subdivided into 17 patients with no evidence of disease, 7 dead of disease and 6 others. Outcome analysis was performed in the subgroups with regard to preoperative and postoperative parameters. Mean followup was 120.3 months (range 1 to 228) after surgery. RESULTS: Of the 30 patients 17 (57%) with persistently elevated tumor markers after chemotherapy were long-term survivors after salvage surgery. Overall persistent viable cancer and teratomatous elements were identified in 64% and 11% of cases, respectively. Significantly more patients died of disease who had a poor prognosis according to International Germ Cell Cancer Collaborative Group guidelines. Embryonal carcinoma was the predominant initial histology in this group and residual disease was more often located at various sites, for example the viscera, with a lower chance of complete surgical resection. Marker status before surgery, and chemotherapeutic pretreatment and postoperative histological findings did not differ significantly in patients with no evidence of disease and those dead of disease. CONCLUSIONS: Salvage surgery results in long-term success in greater than 50% of patients. Complete resection is the most important single parameter for a favorable outcome. Even patients with visceral metastasis benefit from surgery. Our data do not justify omitting surgery in certain subgroups.     

Renal cell carcinoma with tumor thrombus extension into the vena cava: prospective long-term followup

PURPOSE: We prospectively evaluated long-term survival in patients with renal cell carcinoma extending to the inferior vena cava. MATERIALS AND METHODS: From 1993 and thereafter we followed 86 men and 48 women with a median age of 64 years (range 28 to 86) with renal cell carcinoma and tumor thrombus involvement of the inferior vena cava. Cancer specific survival was analyzed based on clinical therapy, tumor extent, thrombus level and grading. RESULTS: Median followup was 16.4 months (range 0 to 178.9). At the time of this report 97 cancer specific deaths had occurred. Of the 134 patients 111 underwent radical nephrectomy, cavotomy and thrombus extraction, of whom 30 had distant metastases at surgery, and 23 were treated with embolization and immunotherapy. These nonsurgical patients who refused surgery had a high tumor load or a low Karnofsky performance status that may have affected survival. They died at a median of 6.9 months (range 0.1 to 23.6). Patients treated surgically, including those with metastases, had a significantly higher median survival of 19.8 months (range 0 to 178.9). Surgical patients with localized tumor (N0M0) had significantly higher median survival than those with metastatic (NxM1) disease (51.7 months, range 0 to 178.9 vs 6.9, range 0.6 to 149.7). Surgical patients with metastatic disease who underwent interferon and interleukin based immunotherapy had significantly higher median survival than those who did not (13.5 months, range 2.5 to 149.7 vs 5.1, range 0.6 to 24.0). On multivariate analysis localized tumor stage (N0M0) vs advanced tumor stage (N+M0 and NxM1), Fuhrman grade groups 1 and 2 vs 3 and 4, and tumor thrombus levels I and II vs III and IV were independent prognostic factors. CONCLUSIONS: Currently radical surgery represents the only chance of long-term survival for patients with renal cell carcinoma and tumor thrombus extension in the inferior vena cava. Median cancer specific survival is significantly higher with localized tumor. However, even with metastatic disease radical surgery can prolong survival, especially when immunotherapy is added. Fuhrman grade and tumor thrombus level are also prognostic factors.     

The role of cytoreductive nephrectomy in the era of molecular targeted therapy

While the widespread use of imaging has resulted in an increasing number of incidentally detected renal cancers, up to one third of patients present with metastatic disease and a significant number of those with clinically localized disease subsequently develop metastasis. The prognosis for patients with metastatic disease has traditionally been poor, with a 2-year survival of only 10 to 20%. However, over the past decade a number of developments have enhanced the treatment of these patients. Phase III trials have demonstrated a significant improvement in overall survival for well-selected patients undergoing cytoreductive nephrectomy prior to immunotherapy. Meanwhile, the recent introduction of molecular targeted agents has resulted in improved response rates and tolerability compared with immunotherapy, and has prompted a re-evaluation of the role and timing of surgery in patients with advanced disease. This review examines the role of surgical therapy for patients with metastatic disease in the new era of molecular targeted therapy.     

C-reactive protein in patients undergoing cardiac surgery

Among 25 patients undergoing cardiac surgery with the aid of cardiopulmonary bypass, 13 who recovered uneventfully all had normal (less than 2 mg/litre) levels of serum C-reactive protein pre-operatively. In contrast, 10 of the 12 patients who suffered from various postoperative complications, including two who died, had abnormally raised levels of C-reactive protein pre-operatively. All patients showed a major acute phase response to surgery with peak C-reactive protein levels at about 46 hours but, whereas the uncomplicated cases showed a characteristic smooth biphasic pattern of declining levels thereafter, the complicated cases all exhibited significant alterations of this pattern. The occurrence during the postoperative period of a secondary rise in C-reactive protein or the failure of the level to continue falling, generally preceded clinical evidence of intercurrent infection. Pre-operative measurement of serum C-reactive protein may thus make a valuable contribution to the assessment of patients requiring elective cardiac surgery; regular postoperative monitoring can provide early warning of serious complications.     

Surgical considerations for patients with metastatic renal cell carcinoma

Among patients with renal cell carcinoma (RCC), 25–30% present with metastatic disease at the time of initial diagnosis. Despite the ever-increasing array of treatment options available for these patients, surgery remains one of the cornerstones of therapy. Proper patient selection for cytoreductive surgery is paramount to its effective use in the management of patients with metastatic RCC despite the decrease in reported morbidity rates. We explore the evolving role cytoreductive surgery in metastatic RCC spanning the immunotherapy era to the targeted therapy era. Despite significant advances in the management of patients with metastatic RCC, further evidence on the definitive role of cytoreductive surgery in the targeted therapy era is awaited through large randomized trials.     

Serum beta-2-microglobulin levels in urological cancer.

Serum beta-2-microglobulin levels were measured in patients with renal, vesical and prostatic cancer. Measurements were made only on samples with a serum creatinine less than or equal to 105 mumol./l. to eliminate the possibility of elevated beta-2-microglobulin being a result of impaired renal function. This criterion eliminated 28 to 50 per cent of the patients with bladder cancer and 73 per cent of those who had undergone nephrectomy for renal carcinoma, which, obviously, limits the value of beta-2-microglobulin measurement for the surveillance in these cancers. Beta-2-microglobulin values in patients with prostatic cancer were seldom increased to more than 3.0 mg./l. In bladder cancer patients with normal serum creatinine the frequency of an elevated serum beta-2-microglobulin increased with the increase in tumor stage.     

The longitudinal relationship between the systemic inflammatory response, circulating T-lymphocytes, interleukin-6 and -10 in patients undergoing immunotherapy for metastatic renal cancer

OBJECTIVE

To examine the longitudinal relationship between the systemic inflammatory response, circulating T‐lymphocyte subpopulations, interleukin‐6 and ‐10 in patients undergoing immunotherapy for metastatic renal cancer, as the inflammation‐based Glasgow Prognostic Score (GPS) provides additional prognostic information in patients with advanced renal cancer, but the basis of the relationship between the systemic inflammatory response and poorer survival is not clear, and nor is the effect of immunotherapy on related variables.

PATIENTS AND METHODS

The study included 23 patients with metastatic renal cancer and starting immunotherapy. Samples of blood were drawn for routine laboratory analysis and to quantify cytokines using enzyme‐linked immunosorbent assays before immunotherapy, and repeated after 2 weeks of treatment.

RESULTS

Most patients had a good performance status, favourable or intermediate Memorial Sloane‐Kettering Cancer Center (MSKCC) risk scores, and with elevated C‐reactive protein (>10 mg/L), GPS (1 or 2), interleukin‐6 (>4 pg/mL) and interleukin‐10 (>10 pg/mL). Patients who completed one cycle of immunotherapy were more likely to have a normal MSKCC (P < 0.05) or GPS (P < 0.05) scores, whilst the percentage of lymphocytes was lower (P < 0.05). The MSKCC and the GPS scores did not alter significantly during one cycle of immunotherapy. Similarly, leukocyte counts, CD4+ and CD8+ T‐lymphocytes, interleukin‐6 and ‐10 concentrations did not change significantly.

CONCLUSIONS

The pretreatment systemic inflammatory response and its related lymphopenia are important in determining the tolerance to immunotherapy in patients with metastatic renal cancer. Immunotherapy is not associated with changes in circulating T‐lymphocytes, nor the systemic inflammatory response.     

The role of cytoreductive nephrectomy in the management of metastatic renal cell carcinoma

Cytoreductive nephrectomy can be an important and effective component of a multidisciplinary treatment approach to metastatic renal cell carcinoma in carefully selected patients. The results of retrospective single institution series and randomized multicenter phase III trials suggest that removal of the primary tumor, even in the setting of metastatic disease, can significantly prolong survival and delay time to progression. It may also enhance the response to systemic therapy in the postoperative period. When employing initial cytoreductive nephrectomy as part of an overall treatment approach, careful patient selection is critical to success. A poor performance status (ECOG performance status less than 1), significant comorbidities that make surgical intervention high risk, or high-volume metastatic disease, and the presence of brain, liver, or bone metastases, or of atypical (sarcomatoid) histology have all been shown to be associated with an extremely poor prognosis. Patients exhibiting these clinical phenotypes should not be considered for initial cytoreductive nephrectomy as part of their treatment paradigm. Instead, they should receive some form of upfront systemic therapy (immunotherapy or novel therapy) and then be considered for delayed nephrectomy as part of a surgical consolidation approach after an interval of treatment if their disease kinetics demonstrate stable or regressing disease in response to systemic therapy. Patients who do not demonstrate these poor prognostic features should be considered for upfront cytoreductive nephrectomy as part of their overall treatment approach because of the potential it offers for palliation from local tumor symptoms, a delay in the time to disease progression, an improved response to systemic therapy, and improved overall survival.     

胃癌卵巢转移瘤68例临床病理及预后分析

目的探讨胃癌卵巢转移瘤的临床病理特征、治疗方法及影响预后的力量对比素。方法回顾性分析68例胃癌卵巢转移患者的临床特征、治疗和生存情况及预后因素。结果本组胃癌卵巢转移瘤患者的中位年龄46岁．67．6％为绝经前期者．双侧卵巢转移者占64．7％．52．9％的肿瘤组织学类型为印戒细胞癌。均采用手术联合化疗为主的综合治疗。全组中位总体生存期14．1个月．中位无进展生存期6．7个月。1、3、5年的生存率分别为54．8％、14．9％和0。单因素分析显示,胃癌根治程度（P=0．000）、淋巴结转移数（P=0．043）、卵巢转移瘤组织学类型（P=0．003）、转移灶范围（P=0．000）、肿瘤细胞减灭术（P=0．008）和卵巢转移瘤的化疗（P=0．000）与患者预后相关。多凶素分析显示,肿瘤细胞减灭术（P=0．025）、转移灶范围（P=0．008）是影响胃癌卵巢转移瘤患者预后的独立因素。转移灶局限于卵巢者与超出卵巢者相比,总体生存期（P〈0．01）和无进展生存期（P〈0．05）显著延长。满意的减灭术（残留肿瘤小于或等于2cm）可以显著延长患者的总体生存期（P〈0．01）和无进展生存期（P〈0．01）。结论胃癌卵巢转移瘤患者的预后较差．转移灶范同是胃癌卵巢转移瘤患者的独立危险因素．满意的减灭术可以改善患者的预后。     

The role of C-reactive protein in graft dysfunction after renal transplantation

PURPOSE: We investigated whether serial daily measurements of serum C-reactive protein could help differentiate episodes of transplant dysfunction due to rejection, infection, cyclosporin A nephrotoxicity or acute tubular necrosis in renal allograft recipients. MATERIALS AND METHODS: Morning serum was obtained daily from 134 patients during the first 30 days after renal transplantation. All episodes of graft dysfunction were recorded and compared to transplant biopsies. C-reactive protein concentrations were correlated with postoperative graft function and the various causes of graft dysfunction. RESULTS: All patients demonstrated an increase in C-reactive protein in response to surgery and a maximum level was reached on day 2 after transplantation. Mean C-reactive protein concentration was significantly increased for delayed (61.50 microg./ml.) compared to primary (mean 38.01) graft function (p = 0.001, Mann-Whitney U test). There were significant increases in C-reactive protein for bacterial infections other than asymptomatic bacteriuria (33.98 microg./ml), interstitial graft rejection (16.43) and acute tubular necrosis (30.50) compared to uneventful courses. C-reactive protein was unchanged for viral infections or cyclosporin A toxicity. CONCLUSIONS: Serial C-reactive protein measurements help to identify renal transplant dysfunction of different origins. However, rejection, infection and acute tubular necrosis show similar patterns of C-reactive protein increase. Thus, C-reactive protein is unable to discriminate the causes of renal graft dysfunction. Biopsy remains the gold standard for the differential diagnosis of renal allograft dysfunction.     

Value of C-reactive protein in detecting complications after open-heart surgery in children

Measurements of serum C-reactive protein (CRP) and body temperature daily for 14 days after primary open-heart surgery were retrospectively reviewed in 206 children with mean age 4.6 years. CRP rose postoperatively, reaching maximum (128 +/- 57 mg/l) on day 2. Postoperative complications occurred in 78 children (38%), 14 of whom died. CRP concentrations were significantly higher in patients with complications than in those with uneventful recovery. Rising age was associated with greater elevation of CRP levels. Body temperature was higher in children with complications. The age of the child thus modified the CRP response to surgery and to postoperative complications. Serial measurements of CRP may be useful in detecting postoperative complications in children who have undergone open-heart surgery.     

肿瘤肾脏切除在转移性肾细胞癌治疗中的意义

转移性肾细胞癌的治疗是肾癌治疗的难点。以往认为转移性肾细胞癌切除肿瘤原发灶是没有意义的。但随着肾癌免疫治疗和靶向治疗的发展,越来越多的证据证明肿瘤肾脏切除在转移性肾细胞癌的治疗中有着重要意义。本文通过复习相关文献对肿瘤肾脏切除术在转移性肾细胞癌治疗中的意义作简单介绍。     

Should radical nephrectomy be performed in the face of surgically incurable disease?

The role of cytoreductive nephrectomy in the management of metastatic renal cancer remains controversial. Recent trials, like SWOG 8949 have suggested the usefulness of this approach at least in selected patients with good performance status and other favorable indicators. The timing of cytoreductive nephrectomy has also been controversial and remains so to this time.CommentaryAn estimated 30,000 new cases of renal cell carcinoma (RCC) are detected annually in the U.S. In approximately one-third of these cases, metastatic disease is diagnosed at presentation. Multi-modality treatment combines biologic response modifier (BRM) therapy with surgery in an attempt to improve survival with either form of treatment alone. The optimal timing of surgery relative to BRM therapy continues to be debated.Prior to the advent of multi-modality therapy, there were relatively few indications for nephrectomy in patients with metastatic RCC. The incidence of spontaneous regression of metastatic RCC following removal of the primary tumor is only 1–4% and, therefore, nephrectomy on this basis is not justified. There is a palliative role for nephrectomy in selected patients with metastatic RCC who are experiencing severe disability from associated local symptoms; however, some patients in this category can be managed with percutaneous renal angioinfarction. A small subset of patients with a solitary metastasis may benefit from nephrectomy and resection of the metastatic lesion based on reported 5-year survival rates of up to 30–35%.There has been controversy concerning the appropriate timing of adjuvant or cytoreductive nephrectomy in the multi-modality approach to treatment of metastatic RCC. Many protocols have involved preliminary removal of the primary tumor before the administration of BRM therapy. The rationale for this has been to enhance response rates to BRM therapy by reducing tumor volume and, in some cases, to provide immunoreactive cells for treatment. A drawback of this approach was that many patients underwent nephrectomy without subsequently receiving BRM therapy due to postoperative morbidity/mortality or rapid tumor progression. This prompted interest in an alternative approach of delayed adjuvant nephrectomy wherein BRM therapy was administered initially and nephrectomy was subsequently performed only in those patients who demonstrated a response to systemic therapy.The relative merits of initial versus delayed adjuvant nephrectomy in conjunction with BRM therapy for metastatic RCC have recently been clarified through two phase III prospective multicenter clinical trials conducted in Europe (EORTC) and the United States (SWOG). The results of both of these carefully done studies have indicated improved survival with initial nephrectomy followed by BRM therapy. The latter comprised interferon monotherapy in both studies, which opens the studies to criticism, however the essential observation of extended survival with preliminary nephrectomy appears to be valid. On this basis, there is now objective evidence to suggest that initial cytoreductive nephrectomy is the preferred approach in patients with metastatic RCC who are candidates for multi-modality therapy. The most appropriate candidates for such therapy remain patients with good performance status and low-volume (preferably pulmonary) metastatic disease. The ability to perform cytoreductive nephrectomy laparoscopically in some of these patients, with reduced morbidity, is a further development that has strengthened the argument in favor of initial nephrectomy.Andrew C. Novick, M.D.