Журнал «Медицина неотложных состояний» 8 (63) 2014
Вернуться к номеру
Modern Methods of Treatment of Renal Cell Carcinoma
Авторы: Vinnyck Yu.O., Zelenskyi R.O. - Kharkiv Regional Clinical Cancer Center, Kharkiv, Ukraine
Рубрики: Медицина неотложных состояний
Версия для печати
renalcell carcinoma, surgery, interventional radiology.
More than 100 years is the leading surgical method in the treatment of renal tumors.
Radical nephrectomy — removal of a single block of the kidney with fatty tissue and fascia retroperitoneal space Herota. One-step removed lymph nodes from the legs of the diaphragm to the bifurcation of the aorta and the confluence of the common iliac veins.
Ipsilateral adrenalectomy, if the location of the tumor in the upper pole of the kidney. This type of surgery has its place firmly in the everyday practice, in cases I, II and III stages of the disease provides a five-year survival rate of 82.5%, 78.7% and 51.1% of patients, respectively.
Organ surgery. Resection of the kidney Wells first performed in 1884, 15 years after executed in 1869 by Simon G. nephrectomy and described Czerny in 1890. In 1950 V. Vermooten was one of the first who advocated the benefits of organ operations for kidney cancer based on the fact that renal cell carcinoma is expansive growth, compressing normal renal parenchyma and forms fibrous pseudocapsule. For a long time resection was performed only in cases of metastatic lesions contralateral body or in anatomically or functionally single kidney.
Show nephrectomy. This volume of surgery, except radical means to remove, if indicated, blood clots in the inferior vena cava resection of the tail of the pancreas, splenectomy, adjacent peritoneum, resection of the colon or liver resection.
To date, implementation of the principles of radical nephrectomy include early ligation of the renal artery and vein removal kidney withperirenal fat and fascia Herota, remove the ipsilateral adrenal gland and implementation of regional lymphadenectomy. The most important aspect is the removal of the kidney with fascia Herota since the last invasion observed in 25% of cases.
A characteristic feature of recent years is the increase in species diversity of operations for kidney cancer, depending on the clinical situation. Clearly traced desire to choose the range of surgery, the most adequate stage of the process, localization of tumor sites in the kidney, as contralateral kidney and physical status of the patient. Most were carried out major operations, including removal of tumor thrombus in the inferior vena cava and the right heart, and surgery to remove a solitary metastatic lesion foci skeleton and lungs simultaneously with nephrectomy.
The main difference thrombectomy of a radical nephrectomy is a need to mobilize, control and resection of the inferior vena cava, which turns ordinary abdominal operations in vascular and may be some technical difficulties. The main methodological aspects thrombectomy are the question of surgical approach when performing nephrectomy with thrombectomy is a subject of frequent debate. Each of the three main existing approaches — right sided thoracoabdominal, median and bilateral subcostal laparotomnoy — has its advantages and disadvantages. Most believed that midline laparotomy is the most convenient access to most cases of kidney cancer with IVC tumor thrombosis.
Methods of thrombectomy depends on the level of tumor thrombus. Depending on the length and value of the hepatic veins to distinguish 4 types of IVC thrombus: perirenalni, subpechinkovi, intrahepatic (retropechinkovi) and nadpechinkovi. The first three species belong to the group subdiaphragmatic blood clots. Nadpechinkovi, they naddiafrahmalni clots divided into vnutriperikardialni and vnutrishnoperedserdni. The prevalence of thrombus is an important factor when choosing a method of surgical treatment. For planning surgical technique and prediction of treatment outcomes is of great importance not only to the length of the tumor thrombus, but its degree of fixation and ingrowth in the vascular wall.
Embolization can reduce the blood supply and tumor size as a result of it aseptic necrosis, reduce blood loss during surgery. In cases of inoperable tumors that suprovodzhyutsya intense pain and hematuria, hematuria embolization helps stop and pain [21]. Combined treatment of localized forms of NCC, which include tumor categories T1a, T1b, T2, includes several species from minimally invasive (organ) with T1a to orhanounosnyh operational benefits — radykalnoy nephrectomy in categories T1b, T2. In locally advanced RN category T3 performed radical or (if indicated) roshyrena nephrectomy, including thrombectomy in category T3b-T3s. Also, when using preoperative kidney tumors embolization.
In Ukraine aretriokapillyarnoyi embolization method was proposed by prof. AV Kukushkin in 1989. The author managed in some patients to achieve blockade not only major intrarenal arterial systems, but also adipose branches, play value in subsequent recanalization.
Analysis of published data on prognostic factors and treatment methods NCC should be noted that the feasibility of predicting recurrence discussed at all symposia devoted to treatment of patients with renal cell carcinoma, which are both in Ukraine and abroad. In publications over the last ten years, more attention is paid to the preoperative evaluation of prognostic factors in patients with NCC. Identifying patterns of metastasis depending on the location of the primary tumor foci in the kidney — is a promising direction prediction NCC. On the other hand, the progressive development of interventional radiology techniques has brought new opportunities for the treatment of patients with NCC.
1. Bruner B., Breau R.H., Lohse C.M. Renal nephrometry score is associated with urine leak after partial nephrectomy. BJU Int. 2011 Jul;108(1):67-72. doi: 10.1111/j.1464-410X.2010.09837.x. Epub 2010 Nov 18.
2. Black P., Filipas D., Fichtner J. Nephron sparing surgery for central renal tumors: experience with 33 cases. J Urol. 2000 Mar;163(3):737-43.
3. Chapin B.F., Wood C.G. The RENAL NephrometryNomogram: Statistically Significant, But Is It Clinically Relevant.Eur Urol. 2011 Aug;60(2):249-51; discussion 251-2. doi: 10.1016/j.eururo.2011.04.005. Epub 2011 Apr 16.
4. Campbell S.C., Novick A.C., Belldegrun A. Guideline for management of the clinical T1 renal mass. J Urol. 2009 Oct;182(4):1271-9. doi: 10.1016/j.juro.2009.07.004. Epub 2009 Aug 14.
5. Canter D., Kutikov A., Manley B. Utility of the R.E.N.A.L. nephrometry scoring system in objectifying treatment decision-making of the enhancing renal mass.Urology. 2011 Nov;78(5):1089-94. doi: 10.1016/j.urology.2011.04.035.
6. Cha E.K., Ng C.K., Jeun B. Preoperative radiographic parameters predict long-term renal impairment following partial nephrectomy.World J Urol. 2013 Aug;31(4):817-22. doi: 10.1007/s00345-011-0694-z. Epub 2011 May 21.
7. Clark A.T., Breau R.H., Morash C. Preservation of renal function following partial or radical nephrectomy using 24-h creatinine clearance.Eur Urol. 2008 Jul;54(1):143-49. doi: 10.1016/j.eururo.2008.03.037. Epub 2008 Mar 27.
8. Ficarra V., Novara G., Secco S. Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery.Eur Urol. 2009 Nov;56(5):786-93. doi: 10.1016/j.eururo.2009.07.040. Epub 2009 Aug 4.
9. Finley D.S., Lee D.I., Eichel L. Fibrin glue-oxidized cellulose sandwich for laparoscopic wedge resection of small renal lesions.J Urol. 2005 May;173(5):1477-81.
10. Hayn M.H., Schwaab T., Underwood W. RENAL nephrometry score predicts surgical outcomes of laparoscopic partial nephrectomy.BJU Int. 2011 Sep;108(6):876-81. doi: 10.1111/j.1464-410X.2010.09940.x. Epub 2010 Dec 16.
11. Hafez K.S., Novick A.C., Butler B.P. Management of small solitary unilateral renal cell carcinomas: impact of central versus peripheral tumor location. J Urol. 2012 Apr;159(4):1156-60.
12. Huang W.C., Levey A.S., Serio A.M. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study.Lancet Oncol. 2006 Sep;7(9):735-40.
13. Hew M.N., Baseskioglu B., Barwari K. Critical appraisal of the PADUA classification and assessment of the R.E.N.A.L. nephrometry score in patients undergoing partial nephrectomy.J Urol. 2011 Jul;186(1):42-6. doi: 10.1016/j.juro.2011.03.020. Epub 2011 May 14.
14. Kutikov A., Uzzo R.G. The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth.J Urol. 2009 Sep;182(3):844-53. doi: 10.1016/j.juro.2009.05.035. Epub 2009 Jul 17.
15. Lifshitz D.A., Shikanov S., Jeldres C. Laparoscopic partial nephrectomy: predictors of prolonged warm ischemia.J Urol. 2009 Sep;182(3):860-5. doi: 10.1016/j.juro.2009.05.039. Epub 2009 Jul 17.
16. Patard J.-J. Toward Standardized Anatomical Classifications of Small Renal Tumors.Eur Urol. 2009 Nov;56(5):794-5. doi: 10.1016/j.eururo.2009.09.001. Epub 2009 Sep 5.
17. vanPoppel H., Da Pozzo L., Albrecht W. A prospective randomized EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma.Eur Urol. 2011 Apr;59(4):543-52. doi: 10.1016/j.eururo.2010.12.013. Epub 2010 Dec 22.
18. Porpiglia F., Volpe A., Billia M. Assessment of risk factors for complications of laparoscopic partial nephrectomy. Eur Urol. 2007 Oct;52(4):1170-8. Epub 2007 Apr 11.
19. Samplaski M.K., Hernandez A., Gill I.S. C-index is associated with functional outcomes after laparoscopic partial nephrectomy.J Urol. 2010 Dec;184(6):2259-63. doi: 10.1016/j.juro.2010.08.031. Epub 2010 Oct 30.
20. Simmons M.N. Morphometric characterization of kidney tumors.CurrOpin Urol. 2011 Mar;21(2):99-103. doi: 10.1097/MOU.0b013e32834208d6.
22. Simhan J., Smaldone M.C., Tsai K.J. Objective measures of renal mass anatomic complexity predict rates of major complications following partial nephrectomy.Eur Urol. 2011 Oct;60(4):724-30. doi: 10.1016/j.eururo.2011.05.030. Epub 2011 May 25
23. Simmons M.N., Ching C.B., Samplaski M.K. Kidney tumor location measurement using the C-index method.J Urol. 2010 May;183(5):1708-13. doi: 10.1016/j.juro.2010.01.005. Epub 2010 Mar 17.
24. Simmons M.N., Hillyer S.P., Lee B.H. Diameter-Axial-Polar Nephrometry: Integration and оptimization of R.E.N.A.L. and Сentrality Index Scoring Systems.J Urol. 2012 Aug;188(2):384-90. doi: 10.1016/j.juro.2012.03.123. Epub 2012 Jun 13.
25. Simhan J., Smaldone M.C., Tsai K.J. Objective measures of renal mass anatomic complexity predict rates of major complications following partial nephrectomy.Eur Urol. 2011 Oct;60(4):724-30. doi: 10.1016/j.eururo.2011.05.030. Epub 2011 May 25.
26. Thompson R.H., Boorjian S.A., Lohse C.M. Radical nephrectomy for pT1a renal masses may be associated with decreased overall survival compared with partial nephrectomy. J Urol. 2008 Feb;179(2):468-71; discussion 472-3.
27. Volpe A., Terrone C. Anatomic classification systems of renal tumors: new, useful tools in renal surgical oncology. Eur Urol. 2011 Oct;60(4):731-3. doi: 10.1016/j.eururo.2011.07.038. Epub 2011 Jul 21.
28. Zini L., Patard J.J., Capitanio U. Cancer-specific and non-cancer-related mortality rates in European patients with T1a and T1b renal cell carcinoma.BJU Int. 2009 Apr;103(7):894-8. doi: 10.1111/j.1464-410X.2008.08252.x. Epub 2008 Dec 2.