多发转移性肾癌舒尼替尼新辅助治疗后减瘤手术一例报告并文献复习

Multiple metastatic renal cell carcinoma treated with cytoreductive nephrectomy after neoadjuvant Sunitinib therapy： a case report and literature review

目的报告1例多发转移性肾癌患者舒尼替尼治疗后行减瘤手术的成功经验，探讨新辅助治疗的有效性和治疗方案。方法患者，男，51岁。因无痛性肉眼血尿1周于2010年8月入院。CT检查示左肾下极肿瘤大小6．6cm×6．3cm，左肾静脉瘤栓形成，肾门可见肿大淋巴结，局部浸润，伴肺和右侧胫骨转移（T3bN1M1）。穿刺活检证实为’肾透明细胞癌。采用50mg舒尼替尼4／2方案治疗2个周期，停药2周后行减瘤手术。术前再次对原发肿瘤和转移灶进行影像学评估，术后随访。结果新辅助治疗后，CT复查示左肾肿瘤大小5．1cm×4．4cm（最大径线缩小23％），肾静脉瘤栓体积缩小，局部浸润情况好转，肺转移灶基本消失，右胫骨转移灶无进展。按照RECIST标准判断为疾病稳定。2010年12月成功行减瘤性肾切除术。病理报告肾透明细胞癌Ⅱ级，瘤内有大片坏死，瘤栓局限于肾静脉内。术后6个月复查，原发灶处未见肿瘤复发，肺转移灶完全消失，右胫骨转移灶尢进展。随访至今20个月，未见肿瘤复发及其他远处转移灶，肿瘤控制效果为部分缓解。结论舒尼替尼新辅助治疗能够使原发肿瘤降期，为减瘤手术创造机会，最终提高患者的总体生存期。

Objective To report a multiple metastatic renal cell carcinoma （RCC） case successful-ly treated with cytoreductive nephrectomy after neoadjuvant Sunitinib, and discuss the efficacy and treatmem regime of neoadjuvant targeting therapy. Methods A 51 years man presented with painless gross hematu-ria for one week and admitted into our hospital in August 2010. Abdominal CT demonstrated a 6.6 cm× 6.3 cm left lower pole renal tumor associated with renal vein tumor thrombus, bulky hilar lymph nodes and extensive local invasion. The patient was also found to have lung and right tibial metastasis. The clinical stage was T3bN1 M1. Percutaneous biopsy confirmed clear cell renal carcinoma. Neoadjuvant Sunitinib 50 mg daily was administered with 4 weeks on, 2 weeks off schedule for two cycles. Cytoreductive nephrectomy was preformed 2 weeks after discontinuation of neoadjuvant Sunitinib. Imaging evaluation was performed to assess the primary tumor and metastatic sites. The patient was followed up till present. Results After two cycles of neoadjuvant treatment, CT scan revealed 23% size reduction of left renal tumor to 5.1 cm × 4.4 cm, re-nal vein tumor thrombus regression, local perirenal invasion improvement, lung metastasis resolution and static right tibial metastasis. According to RECIST criteria, the objective response was stabilization of dis-ease （ SD）. Cytoreductive nephrectomy was successfully performed to remove the primary tumor in December 2010. Pathology revealed Fuhrman II renal cell carcinoma with major necrosis in primary tumor and thrombus localized in renal vein. During 6 months of post-operative follow-up, there was no local recurrence,lung metastasis had vanished completely anti tibial metastasis had not progressed. Local recurrence and other distant metastasis were not demonstrated in 20mon fnllow-up till now. Disease control of this patient was par- tial response （PR） by RECIST. Conclusions Neoadjuvant Sunitinib treatment couhl resuh in downstag-ing of primary tumor and facilitate cytoreductive nephrectomy, thus eventually increase patient overall survival.