Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; ORSI Academy, Melle, Belgium; Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.
ORSI Academy, Melle, Belgium; Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium; Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Eur Urol Oncol. 2019 Jul;2(4):365-378. doi: 10.1016/j.euo.2019.04.007. Epub 2019 May 18.
The current role of cytoreductive nephrectomy (CN) is controversial.
Review of the available evidence about criteria defining CN optimal candidates.
Collaborative critical narrative review of the literature focusing on CN oncological outcomes, perioperative morbidity, eligibility criteria, presurgical systemic therapy, and surgical factors.
In contrast to observational studies, the Clinical Trial to Assess the Importance of Nephrectomy (CARMENA) trial demonstrated noninferiority of targeted therapy alone relative to CN with targeted therapy. CN is associated with a significant risk of perioperative mortality (0-13%) and major complications (3-36%). Metastatic burden, haematological parameters, performance status, sarcopenia, and genetic mutations have been proposed as CN eligibility criteria. Comprehensive models including local and systemic factors are recommended. The Immediate Surgery or Surgery after sunitinib Malate In Treating Patients with Kidney Cancer (SURTIME) trial reported similar progression-free rate after immediate or deferred CN, and suggests that presurgical systemic therapy can identify candidates for CN, avoiding unnecessary surgery in nonresponders without increasing the risk of perioperative complications. Minimally invasive and nephron-sparing CNs are established surgical strategies in selected patients.
No benefit of upfront CN is observed for intermediate- and poor-risk patients who require systemic therapy in randomised controlled trials, and systemic therapy deserves priority over CN in patients with metastatic renal cell carcinoma. These findings are not applicable to all patients with metastatic kidney cancer. CN has a role in favourable cases not requiring immediate systemic therapy or in symptomatic patients. Individual patient selection to identify those patients who might profit the most from CN is critical; however, clinical decision making should be based on comprehensive models. Presurgical systemic therapy is a promising option to avoid unnecessary CN, which is associated with major morbidity.
Consideration for systemic therapy deserves priority over cytoreductive nephrectomy (CN) in patients with metastatic renal cell carcinoma. In patients eligible for systemic therapy, CN does not offer a survival benefit. The indications for CN should be evaluated on an individual basis. Risk scores and response to presurgical systemic therapy can be used for subsequent decision making.
目前，细胞减灭性肾切除术（CN）的作用存在争议。
综述有关定义 CN 最佳候选者标准的现有证据。
协作性关键文献综述，重点关注 CN 的肿瘤学结果、围手术期发病率、入选标准、术前系统治疗和手术因素。
与观察性研究相反，临床试验评估肾切除术的重要性（CARMENA）试验表明，与 CN 联合靶向治疗相比，单独靶向治疗无劣效性。CN 与围手术期死亡率（0-13%）和主要并发症（3-36%）显著相关。转移负担、血液学参数、表现状态、恶病质和遗传突变已被提议作为 CN 的入选标准。建议使用包括局部和全身因素的综合模型。Immediate Surgery or Surgery after sunitinib Malate In Treating Patients with Kidney Cancer（SURTIME）试验报告称，立即或延迟 CN 后无进展生存率相似，并表明术前系统治疗可识别适合 CN 的患者，避免对无反应者进行不必要的手术，而不会增加围手术期并发症的风险。在选定的患者中，微创和保留肾单位的 CN 是已确立的手术策略。
随机对照试验中，需要系统治疗的中危和高危患者接受 CN 没有获益，系统治疗在转移性肾细胞癌患者中应优先于 CN。这些发现不适用于所有转移性肾细胞癌患者。CN 适用于不需要立即进行系统治疗的有利病例或有症状的患者。识别最有可能从 CN 中获益的患者的个体患者选择至关重要；然而，临床决策应基于综合模型。术前系统治疗是避免不必要 CN 的一种有前途的选择，CN 与主要发病率相关。
转移性肾细胞癌患者应优先考虑系统治疗而非细胞减灭性肾切除术（CN）。在有系统治疗适应证的患者中，CN 不能带来生存获益。CN 的适应证应根据个体情况进行评估。风险评分和术前系统治疗的反应可用于后续决策。
