Firek P, Richter S, Jaekel J, Brehmer B, Heidenreich A
EURO-Prostatazentrum Aachen, Klinik und Poliklinik für Urologie und Kinderurologie, Universitätsklinikum der RWTH Aachen, Pauwelsstrraße 30, 52074 Aachen, Deutschland.
Urologe A. 2012 Mar;51(3):398-402. doi: 10.1007/s00120-011-2762-9.
Metastatic renal cell carcinoma (mRCC) still poses a challenge to therapists in spite of the availability of multiple innovative molecular treatment options. Complete remission is rare and in cases of partial remission it is often unclear if necrosis or vital carcinoma tissue persists. We report on a cohort of patients who underwent metastasectomy after neoadjuvant therapy with multi-tyrosine kinase inhibitors (MTKI).
In 2009 a total of 11 patients (7 male and 4 female) underwent metastasectomy after achievement of ≥ 3 months stable partial remission. All patients received either sunitinib (n=7, mean 5.5 cycles), bevacizumab and interferon (IFN)-α2a (n=2, mean 8.5 months), temsirolimus (n=1, mean 9 months) or a combination of sunitinib followed by temsirolimus (n=1). Of the patients 7 presented with retroperitoneal lymph node metastases with a mean diameter of 3.5-12 cm, 2 patients with pulmonary metastases, 1 patient with lymph node and pancreas tail metastases and 1 female patient showed residual disease in the vena cava.
All metastases were completely resected with negative surgical margins. In 82% of the cases histologically active, Ki-67 positive renal cell cancer tissue was identified. The following adjunctive interventions were necessary: vena cava resection with vascular prosthesis and reimplantation of the renal vein (n=3), partial liver resection (n=1), splenectomy (n=1) and pancreas tail resection (n=1). There were no significant perioperative complications but 1 patient developed fascial dehiscence and underwent revision surgery and 1 patient developed clinically insignificant pancreatitis. After a median follow-up of 12 months (range 8-19 months) 5 patients had no recurrence and 6 of the patients showed liver (n=3), lung (n=2) or bone (n=1) recurrences from which 3 patients died.
Metastasectomy of mRCC is associated with a low rate of complications in experienced centers. Surgical resection of metastatic disease is indicated to achieve complete remission with a favorable prognosis because of biologically active kidney cancer tissue. Patients with isolated and resectable metastases are ideal candidates for such a procedure.
尽管有多种创新的分子治疗方案，但转移性肾细胞癌（mRCC）对治疗师来说仍然是一个挑战。完全缓解很少见，在部分缓解的情况下，通常不清楚坏死组织或存活的癌组织是否持续存在。我们报告了一组在接受多酪氨酸激酶抑制剂（MTKI）新辅助治疗后接受转移灶切除术的患者。
2009年，共有11例患者（7例男性和4例女性）在达到≥3个月的稳定部分缓解后接受了转移灶切除术。所有患者均接受了舒尼替尼（n = 7，平均5.5个周期）、贝伐单抗和干扰素（IFN）-α2a（n = 2，平均8.5个月）、替西罗莫司（n = 1，平均9个月）或舒尼替尼联合替西罗莫司（n = 1）治疗。其中7例患者出现腹膜后淋巴结转移，平均直径为3.5 - 12 cm，2例患者出现肺转移，1例患者出现淋巴结和胰尾转移，1例女性患者腔静脉有残留病灶。
所有转移灶均被完全切除，手术切缘阴性。在82%的病例中，组织学上有活性、Ki-67阳性的肾癌细胞组织被识别出来。需要进行以下辅助干预：腔静脉切除并置入血管假体及肾静脉再植术（n = 3）、部分肝切除术（n = 1）、脾切除术（n = 1）和胰尾切除术（n = 1）。围手术期无明显并发症，但1例患者出现筋膜裂开并接受了修复手术，1例患者出现临床意义不大的胰腺炎。中位随访12个月（范围8 - 19个月）后，5例患者无复发，6例患者出现肝转移（n = 3）、肺转移（n = 2）或骨转移（n = 1），其中3例患者死亡。
在经验丰富的中心，mRCC转移灶切除术的并发症发生率较低。由于存在生物学活性的肾癌组织，手术切除转移病灶以实现完全缓解并获得良好预后是必要的。孤立且可切除转移灶的患者是这种手术的理想候选人。
