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J Urology:争议:高危非转移性肾癌需要行淋巴结清扫吗?

2018-01-19 Wrangx 肿瘤资讯

多数恶性肿瘤需要进行系统淋巴结清扫术,但在肾细胞癌上仍有争议。

多数恶性肿瘤需要进行系统淋巴结清扫术,但在肾细胞癌上仍有争议。近期在Journal of Urology杂志上发表了针对淋巴结清扫最可能获益的高危肾癌患者的研究,但结果令人失望,淋巴结清扫未能带来OS或DFS的获益。

背景

多数泌尿系肿瘤如前列腺癌、膀胱癌和阴茎癌临床淋巴结阴性仍需进行系统淋巴结清扫,但淋巴结清扫在肾细胞癌(RCC)中的价值还不明确。目前指南建议是临床怀疑淋巴结阳性的患者可行淋巴结清扫术。回顾性研究对高危RCC患者行淋巴结清扫的结论是相互矛盾的。EORTC 30881试验是针对淋巴结清扫唯一的研究,结论是临床淋巴结阴性(cN0)患者淋巴结清扫无获益,但该研究纳入多为低中危RCC,病理淋巴结阳性(pN+)率低仅为4%,但该研究不代表整体人群,仍需进一步研究淋巴结清扫真正获益的人群。

高危RCC是否需要辅助治疗还有争议,S-TRAC研究和ASSURE研究抗血管生成的小分子药物可延长DFS但OS无获差异。既然辅助治疗目的是消除微小转移灶,可疑淋巴结阳性患者可能是淋巴结清扫术最获益的人群。二次分析ASSURE研究,评估淋巴结清扫在高危完全切除RCC的作用。首要目的是淋巴结清扫能否延长OS,次要终点是淋巴结清扫对DFS的影响。

方法

ARRURE研究为索拉非尼或舒尼替尼对比安慰剂辅助治疗预后差RCC的研究。将肾切除术后的高危RCC患者1:1:1随机分入索拉非尼组、舒尼替尼组或安慰剂组。高危RCC定义为pT1b G3~4N0或任意T任意N+。对临床淋巴结阳性患者行淋巴结清扫术。首要研究终点为OS,次要终点为DFS、淋巴结清扫影响因素和手术并发症。

结果

1. ASSRUE研究

纳入患者1943例,行肾切除术1942例,行淋巴结清扫术701例(36.1%)。中位淋巴结清扫个数为3个,行淋巴结清扫术患者病理淋巴结阳性率为23.4%(n=164)。cN+较cN-患者淋巴结清扫率更高(99.4%对比30.4%,P<.001),仅有10例(1.98%)cN-患者淋巴结病理阳性。仅1例cN+患者无法行淋巴结清扫。两组间手术并发症无差别(14.2%对比13.4%,P=0.63)。

2. 行淋巴结清扫术患者特点:

行根治性肾切除术占94.5%,开放手术占57.2%,淋巴结清扫组和未清扫组在医疗机构、手术类型(根治性或部分肾切除术)、手术方式(开放或腹腔镜)、是否身上腺切除(P<0.05)有差异,但两组手术切缘阳性率无差别(9.1%对比8.0%,P=0.27)。

3. 生存分析

在调整危险分层、治疗、分级、分期、性别、年龄、体力评分、诊断时症状、LDH水平、贫血、组织和手术类型,中位随访67.9个月,淋巴结清扫与OS无关(HR1.14,P=0.20),与DFS差有关(HR1.27,P=0.001),见下图。



图1:淋巴结清扫和未清扫的OS和DFS曲线

在pN+亚组,5年生存率舒尼替尼(45.7%,P=0.113)或索拉非尼(63.7%,P=0.981)较安慰剂无差异。在pN+亚组,索拉非尼与安慰剂比较中位DFS无差异,但舒尼替尼较安慰剂DFS更差。

结论

对局部高危肾细胞癌,手术中行淋巴结清扫无获益。

点评

该研究结果令人失望,在完全切除的高危RCC患者中淋巴结清扫不能带来生存获益。理论上,对pN+患者接受淋巴结清扫是最有可能获益的人群,但结果并非如此。目前,临床上对于cN+患者普遍进展淋巴结清扫,而对于cN0患者不作为常规。尽管淋巴结清扫不能延长生存,但可提供分期信息。该研究淋巴结清扫没有增加手术并发症的发生,但对于临床可疑结节,首先要考虑手术风险再行淋巴结清扫,因为生存获益有限。

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    2018-01-21 sodoo
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    2018-01-20 1e145228m78(暂无匿称)

    学习了谢谢作者分享!

    0

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    2018-01-20 飛歌

    厉害了我的哥

    0

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    2018-01-19 清风拂面

    很好的文章.学习受益匪浅

    0

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最近,发表于《Lancet Oncology》上的一项2期RESONATE-17研究进一步证实了,口服ibrutinib可作为伴del17p的复发/难治性慢性淋巴细胞白血病(CLL)患者的治疗新选择。Susan O’Brien博士及其同事说,综合其它新型治疗方案的数据来看,通过改变治疗方案选择及其顺序,ibrutinib可能有助于重新评估干细胞移植治疗高危CLL的作用及时间。这些数据标志着靶向治疗

Eur Heart J:左心房功能可识别卒中高危的房颤患者!

由此可见,在CHA2DS2-VASc评分后评估超声心动图上LA储备应变和PA-TDI可以为卒中提供额外的风险分层,并对首次诊断房颤患者抗凝决策提供有用的指导。

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