肾癌骨转移患者的病情评估和治疗策略选择

Condition assessment and treatment strategy selection for patients with renal cell carcinoma bone metastasis

目的探讨肾癌骨转移患者的病情评估和治疗策略选择。方法回顾性分析南京医科大学第一附属医院2006年1月至2018年12月收治的43例肾癌伴骨转移患者的临床资料,男29例,女14例。年龄21~87岁,平均55.4岁。肾肿瘤Fuhrman分级1~2级者21例;肿瘤分期T1期19例,N0期20例。43例均完成肾脏原发灶手术,术后病理诊断均为透明细胞癌。术后采用酪氨酸激酶抑制剂行分子靶向治疗,治疗过程顺利,无明显不适主诉。所有患者经术后病理检查确认或影像学资料提示骨转移灶为肾细胞癌来源。四肢骨转移22例,脊柱转移12例,多发骨转移9例。四肢转移病灶根据患者的全身情况、骨疼痛、骨折风险和骨转移病变范围进行评估,脊柱病灶根据Tokuhashi评分、Harrington评分、Tomita评分、椎体稳定性评估等评分进行评估。22例四肢骨转移者、12例脊柱转移者病情评估后均符合二次手术指征,与患者沟通后,13例四肢骨转移者和6例脊柱转移者接受局部治疗(局部治疗组),包括手术完全切除和脊柱固定;其余患者行保守治疗(保守治疗组),接受局部放疗和双磷酸盐治疗。局部治疗组19例,男13例,女6例;年龄21~77岁,平均54.9岁;分别为四肢骨转移13例、脊柱转移6例;原发肿瘤平均直径(4.7±1.6)cm,Fuhrman分级1~2级10例,肿瘤分期T1期13例,N0期15例。保守治疗组24例,男16例,女8例;年龄30~87岁,平均56岁;分别为四肢骨转移9例、脊柱转移6例、多发骨转移9例;原发肿瘤直径(5.6±1.9)cm,Fuhrman分级1~2级11例,肿瘤分期T1期16例,N0期15例。结果本研究43例随访时间6年,随访过程中局部治疗组1、2、5年总体生存率分别为100.0%、89.4%、73.7%;保守治疗组1、2、5年总体生存率分别为87.5%、62.5%、16.7%。局部治疗组与保守治疗组比较,2年和5年生存率差异均有统计学意义(P=0.044,P=0.000)。局部治疗组中,四肢骨转移者的5年生存率显著高于保守治疗组(P=0.011)。脊柱转移者中,局部治疗组的疼痛均有不同程度减轻,未发生脊柱失稳状况及瘫痪;保守治疗组中3例发生截瘫,与局部治疗组比较差异有统计学意义(P=0.046)。局部治疗组中9例多发骨转移患者均因多器官衰竭死亡。结论在分子靶向治疗的同时,根据评估结果针对有二次手术适应证的骨转移病灶进行局部治疗,包括完全切除和脊柱固定,可明显改善肾癌骨转移患者的生存率和生活质量。

Objective To investigate the assessment and treatment strategy of patients with renal cell carcinoma.Methods The clinical data of 43 patients with renal cell carcinoma and bone metastases admitted to the First Affiliated Hospital of Nanjing Medical University from January 2006 to December 2018 were retrospectively analyzed.The follow-up time was 6 years,with an average age of 55.4 years(21-87 years).There were 29 males,14 females,22 cases of limb bone metastasis,12 cases of spinal metastasis,9 cases of multiple bone metastasis,21 cases of Fuhrman grade 1 and 2,19 cases of T1,and 20 cases of N0.All patients were confirmed by postoperative pathological examination or imaging data suggesting that bone metastasis are from renal cell carcinoma.Forty-three patients underwent primary renal surgery,and molecular targeted therapy was used after the operation.The treatment process was smooth,no obvious discomfort,and postoperative pathology showed clear cell carcinoma.22 patients with limb bones metastasis and 12 patients with spinal metastasis included in the study all met the indications for secondary surgery after the disease assessment.After communicating with the patient,13 patients with limbs metastasis and 6 patients with spinal metastasis received local treatment,including complete resection of the extremities and spinal fixation,the remaining 15 patients and 9 patients with multiple bone metastasis were treated conservatively.There were 19 patients in the local treatment group,13 patients with limbs bone metastasis,6 patients with spinal bone metastasis,the average age was 54.9 years,the average diameter of the primary tumor was 4.7 cm.There were 24 patients in the conservative treatment group,9 patients with limbs metastasis,6 patients with spinal metastases and 9 cases with multiple bone metastasis,with an average age of 56 years and a primary tumor diameter of 5.6 cm.Limb metastatic lesions were evaluated according to the patient's general condition,bone pain,fracture risk,and bone metastasis.Spinal lesions were evaluated according to Tokuhashi score,Harrington score,Tomita score,vertebral stability assessment,and molecular targeted therapy.Aminokinase inhibitors,conservative treatment with local radiotherapy and bisphosphonate treatment.Results During the follow-up period,the 1-year overall survival rate of the local treatment group was 100.0%,the 2-year overall survival rate was 89.4%,and the 5-year overall survival rate was 73.7%.The 1-year overall survival rate of the conservative treatment group was 87.5%,and the 2-year overall survival rate was 62.5%.The 5-year overall survival rate was 16.7%.The 2-year and 5-year survival rates of the local treatment group were statistically different(P=0.044,P=0.000)compared with the conservative treatment group.For patients with limb bone metastasis,the 5-year survival rate was significantly higher in patients receiving topical treatment than in the conservative treatment group(P=0.011).For spinal metastasis,spinal pain in the local treatment group was alleviated to varying degrees.No spinal instability and spasticity were observed after follow-up.In the spine patients who received conservative treatment,3 patients developed paraplegia,which was statistically different from local treatment(P=0.046).Another 9 patients with multiple bone metastases did not undergo local surgery,and all died after multiple organ failure.Conclusions At the same time of molecular targeted therapy,according to the evaluation results,selective treatment of bone metastases with secondary surgical indications,including complete resection of the extremities and spinal fixation,can significantly improve the survival and quality of life of those patients.