Halbert Ronald J, Figlin Robert A, Atkins Michael B, Bernal Myriam, Hutson Thomas E, Uzzo Robert G, Bukowski Ronald M, Khan Khuda Dad, Wood Christopher G, Dubois Robert W
Cerner Life Sciences, Beverley Hills, California, USA.
Cancer. 2006 Nov 15;107(10):2375-83. doi: 10.1002/cncr.22260.
New developments in the treatment of patients with metastatic renal cell cancer (MRCC) have suggested a need to reevaluate the role of systemic therapies. The authors convened a panel of medical and urologic oncologists to rate the appropriateness of the main options.
The authors used the RAND/University of California-Los Angeles Appropriateness Method to evaluate systemic therapy options and cytoreductive nephrectomy. After a comprehensive literature review, an expert panel rated the appropriateness of systemic options (108 permutations) and cytoreductive nephrectomy (24 permutations) for patients with MRCC.
The appropriateness evaluation indicated that 27.3% of permutations were rated "appropriate," 46.9% were rated "inappropriate," and 25.8% were rated "uncertain." There was a high rate of agreement (95%). Sunitinib and sorafenib were rated appropriate for patients with low-to-moderate risk regardless of prior treatment. Temsirolimus was rated appropriate for first-line therapy for higher risk patients. Interferon-alpha and low-dose interleukin-2 were rated inappropriate or uncertain. In patients who received prior immunotherapy, cytokines were rated inappropriate. In all permutations for evaluating systemic therapy, enrollment into an investigational trial was considered appropriate, treatment with bevacizumab was uncertain, and thalidomide was inappropriate regardless of risk status or prior therapy. For good surgical risk patients with planned immunotherapy, nephrectomy was rated appropriate in patients who had limited metastatic burden regardless of tumor-related symptoms and in symptomatic patients regardless of metastatic burden. Only the most favorable combination of surgical risk, metastatic burden, and symptoms generated an "appropriate" rating for patients with planned targeted therapy.
The current results begin the process of defining an appropriate role for cytokines, newer targeted therapies, and surgery in the treatment of MRCC.
转移性肾细胞癌（MRCC）患者治疗的新进展表明有必要重新评估全身治疗的作用。作者召集了一组医学和泌尿外科肿瘤学家对主要治疗选择的适宜性进行评分。
作者采用兰德/加利福尼亚大学洛杉矶分校适宜性方法评估全身治疗方案和减瘤性肾切除术。在全面的文献综述之后，一个专家小组对MRCC患者全身治疗方案（108种排列组合）和减瘤性肾切除术（24种排列组合）的适宜性进行了评分。
适宜性评估表明，27.3%的排列组合被评为“适宜”，46.9%被评为“不适宜”，25.8%被评为“不确定”。一致性率很高（95%）。舒尼替尼和索拉非尼被评为对低至中度风险患者适宜，无论其既往治疗情况如何。替西罗莫司被评为对高风险患者一线治疗适宜。α干扰素和低剂量白细胞介素-2被评为不适宜或不确定。在接受过既往免疫治疗的患者中，细胞因子治疗被评为不适宜。在评估全身治疗的所有排列组合中，参加一项临床试验被认为是适宜的，使用贝伐单抗治疗不确定，而沙利度胺无论风险状态或既往治疗如何均不适宜。对于计划进行免疫治疗且手术风险良好的患者，对于转移负担有限的患者，无论有无肿瘤相关症状，肾切除术被评为适宜；对于有症状的患者，无论转移负担如何，肾切除术也被评为适宜。只有手术风险、转移负担和症状的最有利组合才能使计划进行靶向治疗的患者获得“适宜”评分。
目前的结果开启了在MRCC治疗中确定细胞因子、新型靶向治疗和手术的适宜作用的进程。
