Dariane Charles, Timsit Marc-Olivier, Méjean Arnaud
Department of Urology, hôpital européen Georges-Pompidou, Paris-Descartes University, 20, rue Leblanc, 75015 Paris, France.
Department of Urology, hôpital européen Georges-Pompidou, Paris-Descartes University, 20, rue Leblanc, 75015 Paris, France.
Bull Cancer. 2018 Dec;105 Suppl 3:S229-S234. doi: 10.1016/S0007-4551(18)30377-1.
Introduction > The role of cytoreductive nephrectomy (CN) in combination with targeted therapy has been debated after the results of the CARMENA trial. We decided to reassess the available evidence on the setting of CN in metastatic renal cell carcinoma (mRCC) patients. Methods > Critical review of the literature focusing on CN in mRCC patients. Results > Previous trials demonstrated a survival benefit of CN during the cytokine-era. In the targeted therapies-era, retrospective studies has confirmed the survival benefit of CN but presented inherent selection biases. Recently, the CARMENA trial showed that sunitinib alone was not inferior to CN plus sunitinib, and could be followed by subsequent CN in good-responders patients. CN is found to be a morbid surgery (perioperative mortality rate of 0-13% and major postoperative complications rate of 3-36%) and should be avoided in patients with primary refractory disease, using targeted therapy as a selection tool. Some parameters have been associated with shorter overall survival, leading to propose up-front CN only to patients with good performance status, a high-volume renal tumor and a low metastatic burden. Conclusions > While previous studies demonstrated a survival benefit of CN, the CARMENA trial showed that immediate CN was not necessary in some patients with mRCC, leading to a paradigm shift. Targeted therapy should be proposed as first line treatment, and the response to pre-surgical therapy could be used as a selection tool for subsequent decision of CN in good-responders patients.
引言 > 在CARMENA试验结果公布后，减瘤性肾切除术（CN）联合靶向治疗的作用一直存在争议。我们决定重新评估转移性肾细胞癌（mRCC）患者中CN治疗的现有证据。方法 > 对聚焦于mRCC患者CN治疗的文献进行批判性综述。结果 > 既往试验表明，在细胞因子治疗时代，CN具有生存获益。在靶向治疗时代，回顾性研究证实了CN的生存获益，但存在内在的选择偏倚。最近，CARMENA试验表明，单用舒尼替尼并不劣于CN联合舒尼替尼，且在反应良好的患者中后续可进行CN治疗。CN被发现是一种创伤性手术（围手术期死亡率为0 - 13%，术后主要并发症发生率为3 - 36%），对于原发性难治性疾病患者应避免使用，可将靶向治疗作为一种选择工具。一些参数与较短的总生存期相关，因此建议仅对身体状况良好、肾肿瘤体积大且转移负担低的患者进行 upfront CN治疗。结论 > 虽然既往研究表明CN具有生存获益，但CARMENA试验表明，部分mRCC患者无需立即进行CN治疗，这导致了一种范式转变。应将靶向治疗作为一线治疗方案，术前治疗的反应可作为一种选择工具，用于决定反应良好的患者后续是否进行CN治疗。
