术前新辅助靶向治疗联合机器人辅助腔镜手术治疗转移性肾癌

Preoperative neoadjuvant targeted therapy combined with robot-assisted laparoscopic surgery for metastatic renal cell carcinoma

目的:对术前新辅助靶向治疗联合机器人腔镜手术治疗转移性肾癌的疗效进行评价。方法:回顾性分析我院2013年12月~2017年12月收治的18例术前新辅助靶向治疗联合机器人辅助腔镜手术治疗的转移性肾癌患者,对新辅助靶向治疗效果、不良反应以及机器人辅助腔镜手术的疗效进行评价。结果:舒尼替尼组10例患者治疗前原发灶直径为(5.21±0.71)cm,治疗后为(4.36±0.82)cm,P=0.024;索拉非尼组7例患者治疗前原发灶直径为(5.14±1.13)cm,治疗后为(4.6±1.4)cm,P=0.442;接受阿西替尼治疗的1例患者原发灶直径由5.2cm降至4.5cm;18例患者的原发灶直径由(5.18±0.85)cm降至(4.46±1.03)cm,P=0.029。接受舒尼替尼患者治疗前肺转移灶直径为(3.44±0.19)cm,治疗后为(2.87±0.19)cm,P=0.049;接受索拉非尼患者治疗前肺转移灶直径为(3.13±0.18)cm,治疗后为(2.73±0.18)cm,P=0.141;接受阿西替尼治疗的患者肺转移灶直径由2.8cm降至2.2cm;18例患者的肺转移灶直径由(3.28±0.13)cm降至(2.77±0.13)cm,P=0.009。接受舒尼替尼患者肝转移转移灶治疗前为3.5cm,治疗后为2.6cm;接受索拉非尼的患者治疗前肝转移灶直径为4.1cm,治疗后为3.8cm;接受阿西替尼治疗的患者肝转移灶直径由3.3cm降至2.2cm;3例患者的肝转移灶直径由(3.63±0.24)cm降至(3.10±0.35)cm,P=0.278,所有接受新辅助靶向治疗的患者仅发生1~2级不良反应。所有患者接受机器人辅助腔镜手术,其中行保留肾单位手术(NSS)17例,行根治性肾切除术(RN)1例。接受保留肾单位手术的患者术中肾动脉阻断时间为(12.64±1.69)min。术前与术后患者肾小球滤过率(GFR)比较差异无统计学意义。结论:术前新辅助靶向治疗可降低转移性肾癌的原发肿瘤直径,为患者赢得行NSS时机。机器人辅助腔镜手术具有热缺血时间短、创伤小等优势,可最大限度保护患者肾脏功能,使患者长期受益。这一结论仍需要大量多中心随机对照试验证实。

Objective：To evaluate the efficacy of preoperative neoadjuvant targeted therapy combined with robotic laparoscopic surgery for metastatic renal cell carcinoma.Method：We retrospectively analysed 18 metastatic renal cell carcinoma patients treated with preoperative neoadjuvant targeted therapy combined with robotic surgery from December 2013 to December 2017 in our center.The effect and adverse events of neoadjuvant targeted therapy,and the efficacy of robot-assisted laparoscopic surgery were evaluated.Result：The diameter of the primary lesion in the sunitinib group was（5.21±0.71）cm before neoadjuvant targeted therapy and（4.36±0.82）cm after therapy,P=0.024.In the sorafenib group,the diameter of the primary lesion was（5.14±1.13）cm before neoadjuvant targeted therapy and（4.6±1.4）cm after therapy,P=0.442.In one patient treated with axitinib,the diameter of the primary lesion decreased from 5.2 cm to 4.5 cm and the diameter of the primary lesion in all patients decreased from（5.18±0.85）cm to（4.46±1.03）cm,P=0.029.All patients receiving neoadjuvant targeted therapy experienced grade 1-2 adverse events.All patients underwent robot-assisted laparoscopic surgery,including 17 nephron sparing surgery（NSS）and 1 radical nephrectomy（RN）.The intraoperative renal arterial blockade time in patients receiving NSS was（12.64±1.69）min.There was no difference in glomerular filtration rate between preoperative and postoperative data.Conclusion：Preoperative neoadjuvant targeted therapy can reduce the diameter of primary tumors in metastatic renal cancer and provide patients with an opportunity to retain NSS.Robot-assisted laparoscopic surgery has advantages of short warm ischemia time and less trauma.It can maximize the protection of renal function.This conclusion still needs a large number of multicenter randomized controlled trials to confirm.