EAU指南解读之肾细胞癌(RCC)的治疗ppt课件.pptx

Guidelinesonrenalcellcarcinoma EAU Guidelines Renal Cell Cancer 2015 v2 1 Introduction2 TreatmentoflocalisedRCC3 TreatmentoflocallyadvancedRCC4 Treatmentofadvanced metastaticRCC5 Systemictherapyforadvanced metastaticRCC Definition RenalCellCarcinoma RCCRenalcellcarcinomaisakidneycancerthatoriginatesintheliningoftheproximalconvolutedtubule RCCisthemostcommontypeofkidneycancerinadults Epidemiology 我国目前研究 1 马建辉等收集了中国大陆1988 2002年15年间数据较齐全的11个研究单位的资料 1988 1992 1993 1997 1998 2002年3个时间段我国肾和泌尿系统其他恶性肿瘤的发病率分别为4 26 10万 5 40 10万 6 63 10万人口 发病率呈现逐年上升趋势 我国上海 南京 广州分别排在第245 4 8 10万 273 3 2 10万 282 2 3 10万 America 2 Renalcellcarcinomasrepresentabout3 ofallnewlydiagnosedvisceralcancersintheUnitedStatesandaccountfor85 ofrenalcancersinadults Approximately30 000newcases yearand12 000deathsfromthedisease 1 马建辉 李呜 张思维等 中国部分市县肾癌及泌尿系其他恶性肿瘤发病趋势比较研究 J 中华泌尿外科杂志 2009 30 8 511 514 DOI 10 3760 cma j issn 1000 6702 2009 08 002 2 JemalA etal Cancerstatistics 2008 CACancerJClin2008 58 71 Riskfactors 1 2 Themostsignificantriskfactor tobacco Cigarettesmokershavedoubletheincidenceofrenalcellcarcinoma pipeandcigarsmokersarealsomoresusceptible Additionalriskfactorsobesity particularlyinwomen hypertension unopposedestrogentherapy exposuretoasbestos petroleumproducts andheavymetals 1 McLaughlinJK LipworthL Epidemiologicaspectsofrenalcellcancer SeminOncol2000 27 115 2 MooreLE etal Lifestylefactors exposures geneticsusceptibility andrenalcellcancerrisk areview CancerInvest2005 23 240 Diagnosis 1 SymptomsPhysicalexamination PhysicalexaminationhasalimitedroleinRCCdiagnosis Palpableabdominalmass Palpablecervicallymphadenopathy Non reducingvaricoceleandbilaterallowerextremityoedema whichsuggestsvenousinvolvement 2 Imaginginvestigations GuidelinesonRenalCellCarcinoma EuropeanAssociationofUrology2015 Diagnosis 肾癌的临床诊断主要依靠影像学检查 实验室检查作为对患者术前一般状况 肝肾功能以及预后判定的评价指标 确诊则需依靠病理学检查 1 推荐必须包括的实验室检查项目 尿素氮 肌酐 肝功能 全血细胞计数 血红蛋白 血钙 血糖 红细胞沉降率 碱性磷酸酶和乳酸脱氢酶 推荐分级C 2 推荐必须包括的影像学检查项目 腹部B超或彩色多普勒超声 胸部X线片 正 侧位 腹部CT平扫和增强扫描 碘过敏试验阴性 无相关禁忌证者 腹部CT平扫和增强扫描及胸部X线片是术前临床分期的主要依据 推荐分级A 3 推荐参考选择的影像学检查项目 KUB 可为开放性手术选择手术切口提供帮助核素肾图或IVU 可用于未行CT增强扫描 无法评价对侧肾功能者核素骨显像 碱性磷酸酶高 有相应骨症状或临床分期 期的患者 证据水平Ib 胸部CT扫描 胸部x线片有可疑结节 临床分期 期的患者 证据水平Ib 头部MRI CT扫描 有头痛或相应神经系统症状患者 证据水平Tb 腹部MRI扫描 肾功能不全 超声波检查或CT检查提示下腔静脉瘤栓患者 证据水平Ib 4 有条件地区及患者选择的影像学检查项目 肾超声造影 螺旋CT及MRI扫描 主要用于肾癌的诊断和鉴别诊断正电子发射断层扫描 PET 或PET CT 检查费用昂贵 主要用于发现远处转移病灶以及对化疗 细胞因子治疗 分子靶向治疗或放疗的疗效评定 肾细胞癌诊断治疗指南 编写组 肾细胞癌诊断治疗指南 2008年第一版 J 中华泌尿外科杂志 2009 30 1 63 69 GuidelinesonRenalCellCarcinoma EuropeanAssociationofUrology2015 Staging TreatmentoflocalisedRCC T1 2N0M0 ForthisGuidelinesversion anupdatedsearchwasperformeduptoMay31st 2013 Surgicaltreatment AdrenalectomyPartialnephrectomy PN VSradicalnephrectomy RN Lymphnodedissectionforclinicallynegativelymphnodes cN0 Embolisation Inpatientsunfitforsurgery orwithnon resectabledisease embolisationcancontrolsymptoms includinggrosshaematuriaorflankpain Surgicaltreatment Surgicaltreatment Radicalnephrectomy LaparoscopicvsOpenRN Radicalnephrectomy Hand assistedvsstanderdlaparoscopicRN Partialnephrectomy LaparoscopicvsOpenPN ConclusionandRecommendations LaparoscopicRN Lowermorbidity similaroncologicaloutcomesT1 PNT2orlocalisedmassesnottreatablebyPN LaparoscopicRN Therapeuticapproachesasalternativestosurgery Population basedanalysesshowasignificantlylowercancer specificmortalityforpatientstreatedwithsurgerycomparedtonon surgicalmanagementfortumors75years SurveillanceActivesurveillanceisdefinedastheinitialmonitoringoftumoursizebyserialabdominalimaging US CT orMRI withdelayedinterventionreservedfortumoursshowingclinicalprogressionduringfollow up AblativetherapiesCryoablation 冷冻消融术 Radiofrequencyablation 射频消融术 Others microwaveablation laserablation andhigh intensityfocusedUSablation Recommendations TreatmentoflocallyadvancedRCC Clinicallypositivelymphnodes cN LocallyadvancedunresectableRCCRCCwithvenousthrombus Clinicallypositivelymphnodes cN LNDisjustifiedButtheextentofLNDiscontroversial LocallyadvancedunresectableRCC EmbolisationcancontrolsymptomsgrosshaematuriaorflankpainTheeffectofneoadjuvanttargetedtherapytodownsizetumoursisunknown RCCwithvenousthrombus TraditionallyundergosurgerytoremovethekidneyandtumourthrombusPre operativeembolisation T3RCC increasingoperatingtime bloodloss hospitalstayandperi operativemortality TheroleofIVCfiltersandbypassproceduresremainuncertain Adjuvanttherapy SeveralRCTsofadjuvantsunitinib sorafenib pazopanib axitinibandeverolimusareongoing Atpresent thereisnoevidencefortheuseofadjuvantVEGF RormTORinhibitors Thereisnoindicationforadjuvanttherapyfollowingsurgery TreatmentofAdvanced MetastaticRenalCellCarcinoma Contents WhatisAdvanced MetastaticRenalCellCarcinoma RCC HowtoTreatit WhatisAdvanced MetastaticRenalCellCarcinoma HowtoTreatit Howtotreattheprimarylesion HowtodealwiththemetastasesofRCC HowtoTreatit Protocol1 Cytoreductivenephrectomycombinedwithinterferon alpha Protocol2 Cytoreductivenephrectomywithsimultaneouscompleteresectionofasinglemetastasisoroligometastases Howtotreattheprimarylesion CytoreductiveNephrectomy Indications Patientswithgoodperformancestatus largeresectableprimarytumorandlowmetastaticvolume nosarcomatoidtumor HowtoTreatit Embolisationofprimarytumor Indications Patientsunfitforsurgery orwithnon resectabledisease Howtotreattheprimarylesion HowtoTreatit Metastasectomy Indications Thedecisiontoresectmetastaseshastobetakenforeachsite andonacase by casebasis performancestatus riskprofiles patientpreferenceandalternativetechniquestoachievelocalcontrol mustbeconsidered Metastasesinlung pancreas liveretalcouldbeconsidered Metastasesinbrainorpossiblybonemaybeexcluded HowtodealwiththemetastasesofRCC HowtoTreatit Embolizationofbonemetastases Indications Embolizationpriortoresection orforrelievingsymptomsProtocol1 Embolizationpriortoresectionofhypervascularboneorspinalmetastases Protocol2 Embolizationofboneorparavertebralmetastases HowtodealwiththemetastasesofRCC HowtoTreatit StereotacticRadiotherapy Indications Boneandbrainmetastases HowtodealwiththemetastasesofRCC Systemictherapyforadvanced metastaticRCC 1Chemotherapy2Immunotherapy3Targetedtherapies4MonoclonalantibodyagainstcirculatingVEGF5mTORinhibitors6Therapeuticstrategiesandrecommendations 1 Chemotherapy metastaticrenalcellcarcinoma mRCC 2 Immunotherapy 1 IFN monotherapyandcombinedwithbevacizumab2 Interleukin 23 Vaccinesandtargetedimmunotherapy Targetedtherapies vonHippel Lindau VHL inactivation hypoxia induciblefactor HIF accumulation overexpressionofvascularendothelialgrowthfactor VEGFandplatelet derivedgrowthfactor PDGF neoangiogenesis ThisprocesssubstantiallycontributestothedevelopmentandprogressionofRCC sunitinib bevacizumab pazopanib temsirolimus everolimus axitinib 7 4 3Targetedtherapies Tyrosinekinaseinhibitors sorafenib sunitinib pazopanib axitinib anoralmultikinaseinhibitor anoraltyrosinekinaseinhibitorandhasantitumourandanti angiogenicactivity anoralangiogenesisinhibitor anoralselectivesecond generationinhibitorofVEGFR 1 2 and 3 MonoclonalantibodyagainstcirculatingVEGF Bevacizumabmonotherapy bevacizumab IFN IFN BevacizumabisahumanisedmonoclonalantibodyandthecombinationhashighermedianFPSthanthemonontherapy 7 4 4MonoclonalantibodyagainstcirculatingVEGF 5 mTORinhibitors Temsirolimus aspecificinhibitorofmTOR Everolimus anoralmTORinhibitor whichisestablishedinthetreatmentofVEGF refractorydisease 6 Therapeuticstrategiesandrecommendations Therapyfortreatment nai vepatientswithclear cellmRCCSequencingtargetedtherapyFollowingprogressionofdiseasewithVEGF targetedtherapy TreatmentafterprogressionofdiseasewithmTORinhibitionTreatmentafterprogressionofdiseasewithcytokinesTreatmentaftersecond linetargetedtherapyCombinationof