Multi-modal treatment for metastatic renal cancer: the role of surgery
Multi-modal treatment for metastatic renal cancer: the role of surgery
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DOI：
10.1007/s00345-010-0530-x
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发表时间：
2010-06-01
影响因子：
3.4
通讯作者：
Russo, Paul
中科院分区：
文献类型：
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作者：
Russo, Paul
转移性肾癌患者的手术干预可以在两种情况下进行：（1）使患者临床上没有原发性疾病和转移的所有部位，称为肾切除术/肾盂切除术，或（2）在开始全身治疗之前，在不可切除的转移性疾病面前切除原发性肿瘤，称为细胞减灭性肾切除术。仔细选择的患者，具有良好的性能状态进行肾切除术和随后的膀胱切除术可能会经历延长生存期的范围内30个月，这可能是由于患者选择因素和手术切除的组合。来自美国和欧洲的随机临床试验已经证明，与单独的细胞因子治疗相比，细胞减灭性肾切除术和细胞因子治疗具有小但显著的生存益处，其在3-6个月的范围内测量，并且与约12个月的总生存期相关。细胞减灭性肾切除术提高生存率的确切机制尚不清楚，但可能与减少大量原发性免疫抑制负荷有关。患者选择因素包括体力状态和血清因素（Hgb、校正的Ca++、LDH），将转移性患者分为风险组，这些风险组与药物和手术治疗的转移性肾癌患者的生存时间密切相关。多激酶和mTOR抑制剂的开发显著改善了未经治疗和先前治疗的转移性肾癌患者的存活率，并且这些药物目前正在新辅助和辅助环境中进行积极的临床研究。
Surgical intervention in the patients with metastatic renal cancer can occur in two settings: (1) to render a patient clinically free of all sites of primary disease and metastases, termed nephrectomy/metastasectomy, or (2) to resect the primary tumor in the face of unresectable metastatic disease prior to the initiation of systemic therapy, termed cytoreductive nephrectomy. Carefully selected patients with good performance status undergoing nephrectomy and subsequent metastasectomy may experience prolonged survival in the range of 30 months, which could be attributed to a combination of patient selection factors and the surgical resections. Randomized clinical trials from the United States and Europe have demonstrated a small but significant survival benefit to cytoreductive nephrectomy and cytokine therapy versus cytokine therapy alone which is measured in the range of 3-6 months and associated with overall survival of approximately 12 months. The precise mechanism by which cytoreductive nephrectomy improves survival is not known but may relate to reduction in the large primary immunosuppressive burden. Patient selection factors including performance status and serum factors (Hgb, corrected Ca++, LDH) stratify metastatic patients into risk groups, which are strongly associated with survival time in both medically and surgically treated patients with metastatic renal cancer. The development of multi-kinase and mTOR inhibitors has markedly improved survival in treatment na < ve and previously treated patients with metastatic renal cancer , and these agents are currently under active clinical investigation in the neo-adjuvant and adjuvant setting.