Moorman-Voestermans C G, Aronson D C, Staalman C R, Delemarre J F, de Kraker J
Department of Pediatric Surgery, University of Amsterdam, Emma Childrens' Hospital AMC, The Netherlands.
J Pediatr Surg. 1998 Feb;33(2):165-70. doi: 10.1016/s0022-3468(98)90425-0.
After nephrectomy for unilateral Wilms' tumor (WT), two potential hazards threaten the remaining kidney. The development of a metachronous WT (2% to 3%), and decrease in renal function after chemotherapy. Our study aims included: (1) to clarify how many WT patients could benefit from partial nephrectomy (PN) without jeopardizing the high cure rate, (2) to establish the function of the kidney remnant, and (3) to test the radiological criteria for preoperative selection of PN candidates.
A retrospective analysis of 90 consecutive cases of histologically verified WT (1982 to 1992) was carried out. Data were studied independently by the surgeon, the radiologist, and the pathologist. The preoperative selection criteria for PN were functioning kidney, tumor confined to upper or lower pole leaving two thirds of the kidney tumor free, and no hilar or vascular structures involved. After PN, renal function was estimated by a calculated creatinine clearance (CC) combined with the assessment of the relative function of each kidney by renal scintigraphy.
There were 46 boys and 44 girls with median age at diagnosis of 3 years 6 months (range, 3 months to 16 years 7 months). Stage I disease occurred in 40 patients, stage II in 23, stage III in 16, and stage IV occurred in 11 patients. Nearly all patients received preoperative chemotherapy. Radiological analysis of 85 available data sets (5 missing) suggested that PN was possible in 13 patients, and data were inconclusive in two. All 13 patients selected by the radiologist appeared to be in agreement with the pathological criteria for resectability. Of these cases, complete resection by PN was performed in five, could have been possible in retrospect in two, and appeared impossible in six. In two more patients, PN was performed; in both cases the radiologist had predicted PN to be impossible. Median follow-up after PN was 61 months, range, 45 to 167 months. Two patients died of distant metastasis, and no local recurrence occurred. Five are in remission with a median CC level of 110 mL/min, range, 85 to 124. Relative functions of the kidney remnants were 20% to 50%. Contralateral nephrectomy for progressive obstruction was performed in one, but CC level remained normal (85 mL/min). Comparing the preoperative radiological prediction with the combined surgical and pathological findings in a 2 x 2 frequency table, the sensitivity of the radiological findings could be calculated to be 80%, the specificity 97%, and the accuracy 87%.
(1) Partial nephrectomy is safe in approximately 10% of Wilms' tumor patients. (2) The function of the kidney remnant remains well, and even permits contralateral nephrectomy. (3) Preoperative imaging shows an accuracy of 87% to predict the possibility for partial nephrectomy.
单侧肾母细胞瘤（WT）肾切除术后，剩余肾脏面临两种潜在风险。异时性WT的发生（2%至3%），以及化疗后肾功能下降。我们的研究目的包括：（1）明确多少WT患者可从保留肾单位手术（PN）中获益而不影响高治愈率，（2）确定残余肾的功能，（3）测试术前选择PN候选者的影像学标准。
对90例经组织学证实的WT连续病例（1982年至1992年）进行回顾性分析。数据由外科医生、放射科医生和病理科医生独立研究。PN的术前选择标准为功能正常的肾脏、肿瘤局限于上极或下极且肾脏三分之二无肿瘤，以及未累及肾门或血管结构。PN术后，通过计算肌酐清除率（CC）结合肾闪烁显像评估每个肾脏的相对功能来估计肾功能。
有46例男孩和44例女孩，诊断时的中位年龄为3岁6个月（范围为3个月至16岁7个月）。I期疾病发生在40例患者中，II期在23例中，III期在16例中，IV期发生在11例患者中。几乎所有患者都接受了术前化疗。对85份可用数据集（5份缺失）的放射学分析表明，13例患者可能适合PN，2例数据不明确。放射科医生选择的所有13例患者似乎都符合可切除性的病理标准。在这些病例中，5例通过PN进行了完整切除，回顾性分析有2例本可进行，6例似乎不可能。另有2例患者接受了PN；在这两例中，放射科医生都预测PN不可能进行。PN后的中位随访时间为61个月，范围为45至167个月。2例患者死于远处转移，无局部复发。5例缓解，CC中位水平为110 mL/分钟，范围为85至124。残余肾的相对功能为20%至50%。1例因进行性梗阻行对侧肾切除术，但CC水平仍正常（85 mL/分钟）。在一个2×2列联表中比较术前放射学预测与手术和病理联合结果，放射学结果的敏感性可计算为80%，特异性为97%，准确性为87%。
（1）约10%的肾母细胞瘤患者行保留肾单位手术是安全的。（2）残余肾的功能保持良好，甚至允许行对侧肾切除术。（3）术前影像学预测保留肾单位手术可能性的准确性为87%。
