Kunkle David A, Egleston Brian L, Uzzo Robert G
Department of Urologic Oncology, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, Pennsylvania 19111, USA.
J Urol. 2008 Apr;179(4):1227-33; discussion 1233-4. doi: 10.1016/j.juro.2007.11.047. Epub 2008 Feb 20.
The incidence of renal cell carcinoma is increasing due to the incidental detection of small renal masses. Resection, predominantly by nephron sparing surgery, remains the standard of care due to its durable oncological outcomes. Active surveillance and ablative technologies have emerged as alternatives to surgery in select patients. We performed a meta-analysis of published data evaluating nephron sparing surgery, cryoablation, radio frequency ablation and observation for small renal masses to define the current data.
A MEDLINE search was performed for clinically localized sporadic renal masses. Patient age, tumor size, duration of followup, available pathological data and oncological outcomes were evaluated.
A total of 99 studies representing 6,471 lesions were analyzed. Significant differences in mean patient age (p <0.001), tumor size (p <0.001) and followup duration (p <0.001) were detected among treatment modalities. The incidence of unknown/indeterminate pathological findings was significantly different among cryoablation, radio frequency ablation and observation (p = 0.003), and a significant difference in the rates of malignancy among lesions with known pathological results was detected (p = 0.001). Compared to nephron sparing surgery significantly increased local progression rates were calculated for cryoablation (RR = 7.45) and radio frequency ablation (RR = 18.23). However, no statistical differences were detected in the incidence of metastatic progression regardless of whether lesions were excised, ablated or observed.
Nephron sparing surgery, ablation and surveillance are viable strategies for small renal masses based on short-term and intermediate term oncological outcomes. However, a significant selection bias exists in the application of these techniques. While long-term data have demonstrated durable outcomes for nephron sparing surgery, extended oncological efficacy is lacking for ablation and surveillance strategies. The extent to which treatment alters the natural history of small renal masses is not yet established.
由于小肾肿块的偶然发现，肾细胞癌的发病率正在上升。由于其持久的肿瘤学疗效，以保留肾单位手术为主的切除术仍然是标准的治疗方法。主动监测和消融技术已成为特定患者手术的替代方案。我们对已发表的数据进行了荟萃分析，评估保留肾单位手术、冷冻消融、射频消融以及对小肾肿块的观察，以确定当前数据。
对临床局限性散发性肾肿块进行了MEDLINE检索。评估了患者年龄、肿瘤大小、随访时间、可用的病理数据和肿瘤学结果。
共分析了代表6471个病灶的99项研究。在不同治疗方式之间，平均患者年龄（p<0.001）、肿瘤大小（p<0.001）和随访时间（p<0.001）存在显著差异。冷冻消融、射频消融和观察之间未知/不确定病理结果的发生率有显著差异（p = 0.003），已知病理结果的病灶中恶性率也有显著差异（p = 0.001）。与保留肾单位手术相比，冷冻消融（RR = 7.45）和射频消融（RR = 18.23）的局部进展率显著增加。然而，无论病灶是切除、消融还是观察，转移进展的发生率均未检测到统计学差异。
基于短期和中期肿瘤学结果，保留肾单位手术、消融和监测是小肾肿块可行的策略。然而，这些技术的应用存在显著的选择偏倚。虽然长期数据表明保留肾单位手术有持久的疗效，但消融和监测策略缺乏广泛的肿瘤学疗效。治疗改变小肾肿块自然病程的程度尚未确定。
