[Symptomatic renal tumours in metastatic renal cell carcinoma - surgical options].

Abstract:

:Between 15 and 20 % of patients diagnosed with renal cell carcinoma suffer from metastatic disease by the time of diagnosis. In addition to systemic therapy, there are various surgical strategies to treat the primary tumour, e. g. cytoreductive nephrectomy (CN) or palliative nephrectomy (PN). In the immunotherapy era, the standard treatment was to perform CN followed by interferon therapy, based on 2 prospective randomised trials and their combined analysis. Since the introduction of targeted therapy around 2005, data of that quality has been missing and clinicians have had to rely on big retrospective studies, which have confirmed the benefit of CN except for patients with low performance status, cerebral metastases, low life expectancy, and old age. The recently published results of the CARMENA trial, which compared the use of sunitinib versus CN followed by sunitinib in a prospective randomised trial, have now demonstrated non-inferiority of sunitinib alone in patients classified as having intermediate-risk or poor-risk disease. Nevertheless, these results remain debatable given the large number of patients with poor-risk disease and a higher percentage of locally advanced tumours in the nephrectomy-sunitinib group. Indications for palliative nephrectomy are pain, haemorrhage, or severe paraneoplastic syndrome. Since there are excellent supportive and less invasive therapies, e. g. angioembolisation in case of haemorrhage, the decision in favour of surgical intervention should be based on the characteristics of the primary tumour, individual risk factors, and alternative therapies. Technically, palliative nephrectomy can be performed as an open or laparoscopic procedure and even as a partial nephrectomy, if indicated. :Jährlich erkranken in Deutschland über 14 000 Menschen an einem Nierenzellkarzinom. Bei 15 – 20 % liegen bei Diagnosestellung bereits Metastasen vor. Neben der medikamentösen Tumortherapie existieren auch chirurgische Konzepte bei der Behandlung des Primärtumors. Hierbei stehen die zytoreduktive sowie die palliative Nephrektomie (palliative nephrectomy, PN) im Vordergrund. Abhängig vom Wandel der systemischen Tumortherapie wurde auch die Sinnhaftigkeit der zytoreduktiven Nephrektomie (cytoreductive nephrectomy, CN) diskutiert. In der „Zytokin-Ära” etablierte sich die CN gefolgt von einer Therapie mit Interferon basierend auf 2 prospektiven randomisierten Studien und deren kombinierter Metaanalyse. Durch die Etablierung von Targeted-Therapien ab 2005 und das reine Vorliegen von retrospektiven Studien mit teilweise großen Patientenzahlen wurde der Stellenwert der CN kritisch hinterfragt. Mit der Veröffentlichung der CARMENA-Daten liegen nun aktuell erstmalig Daten vor, die die alleinige Therapie mit Sunitinib mit der CN gefolgt von Sunitinib vergleichen. Hierbei konnte gezeigt werden, dass die alleinige medikamentöse Therapie der kombinierten Therapie nicht unterlegen war – zumindest in der Gruppe der intermediate- und poor-risk Patienten. Nichtsdestotrotz bleiben auch diese Daten aufgrund diverser Kritikpunkte, wie dem hohen Anteil von Patienten mit poor-risk Konstellation sowie dem höheren Anteil von lokal fortgeschrittenen Tumorstadien im CN + Sunitinib-Arm, auf dem Prüfstand.Als Gründe für eine palliative Nephrektomie werden therapierefraktäre Schmerzen, Blutungen sowie schwere paraneoplastische Syndrome aufgeführt. Hierbei muss bei der Indikationsstellung berücksichtigt werden, dass gute supportive Therapiemaßnahmen und weniger invasive Therapien verfügbar sind. So können z. B. Blutungen durch Maßnahmen der interventionellen Radiologie in einer Vielzahl der Fälle adäquat kontrolliert werden.Im Rahmen der Entscheidungsfindung ist es unerlässlich, neben den Therapiealternativen, den Lokalbefund des Primärtumors sowie individuelle Risikofaktoren zu evaluieren.Rein technisch kann die palliative Nephrektomie offen oder laparoskopisch erfolgen und falls indiziert auch als Teilnephrektomie.

journal_name

Aktuelle Urol

journal_title

Aktuelle Urologie

authors

Gilbert N,Merseburger AS,Kramer M

doi

10.1055/a-0658-0832

subject

Has Abstract

pub_date

2018-09-01 00:00:00

pages

417-421

issue

5

eissn

0001-7868

issn

1438-8820

journal_volume

49

pub_type

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