jak nauczyć starego psa nowych sztuczek

CZY KAŻDY GUZ NERKI
NALEŻY LECZYĆ ?
czyli...
jak nauczyć starego psa nowych sztuczek ?
Marcin Słojewski
Marcin Słojewski
Szczecin
TAK
dlaczego tak?
jak?
NIE
SRM = T1a (4cm)
?
dlaczego nie?
co dalej?
contrast-­‐enhancing mass within the kidney with the largest dimension <4cmcm
0
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E U R O P E A N U R O L O G Y 5 9 ( 2 0 1 1 ) 1 3 5 – 14411
EUROPEAN UROLOGY 59 (2011) 135–141
Fig. 3 – Age-adjusted mortality rates of renal cell carcinoma (RCC) of (A) all stages and (B) stratified according to disease stage, US Surveillance
3 – Age-adjusted mortality rates of renal cell carcinoma (RCC) of (A) all stages and (B) stratified according to disease stage, US Surveillance
Fig.
3 – Age-adjusted
mortality
of renal
cell carcinoma
(RCC) =
ofRCC
(A) of
allall
stages
andopen
(B) stratified
according
to disease
stage, US Surveillance
Epidemiology
and End
Results rates
database,
1988–2006.
Closed circles
stages;
circles = localized
RCC;
upside-down
demiology
and End
Results database,
1988–2006.
Closed circles
stages;
open
= localized
RCC;
3 – Age-adjusted
mortality
rates of renal
cell carcinoma
(RCC) =ofRCC
(A)of
allall
stages
and
(B) circles
stratified
according
to upside-down
disease stage, US Surveillance
Epidemiology
and End
Results
1988–2006.
Closed circles
= RCC
of
stages;
circles = localized
upside-down
triangles
= distant
RCC;
squaresdatabase,
= regional
RCC.
3Results
– Age-adjusted
mortality
rates
of renal
cell= carcinoma
(RCC) of
(A) circles
all all
stages
andopen
(B) RCC;
stratified
accordingRCC;
to disease
stage, US Surveillance
ngles
= distant
RCC;
squares
= regional
RCC.
emiology
and Fig.
End
database,
1988–2006.
Closed
circles
RCC of all stages;
open
= localized
upside-down
triangles
=
distant
RCC;
squares
=
regional
RCC.
End Results
gles = distant Epidemiology
RCC; squares =and
regional
RCC. database, 1988–2006. Closed circles = RCC of all stages; open circles = localized RCC; upside-down
triangles = distant RCC; squares = regional RCC.
Administrative,
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support: Perrotte, Karakiewicz.
exclusionwith
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detailedon
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lusion
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more
ailed information
staging,
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exclusion
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with
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lackOther
of (specify):
moreKarakiewicz,
Other
(specify):
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detailed
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on
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Supervision:
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None.
histopathologic
review
represent
important
potential
ailed
information
on
staging,
and
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topathologic
review
represent
important
potential
Supervision:
Karakiewicz,
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Other (specify):
None.
detailedthat
information
on represent
staging,
and
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histopathologic
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(specify): None.
maythe
have
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current
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opathologic
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represent
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ses
that maybiases
have
affected
current
findings.
Financial
disclosures:
I certifyofthat
all conflicts
of interest, including
Other
(specify):
Financial
disclosures:
I certify
thatNone.
all conflicts
interest,
including
histopathologic
review
represent
important
potential
biases
that
may
have
affected
the
current
findings.
Financial
disclosures:
I and
certify
that all conflicts
of interest,
including
ses that may have affected the current findings.
specific
financial
interests
relationships
and affiliations
relevant
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Cance
■ REFERENCES
pling with molecular profiling may help
de
specially consider4. Hollin
1. Chow WH, Devesa SS. Contemporary epidemiology of renal cell
incide
mine
which
renal
lesions
are
less
biologic
many small renal
cancer. Cancer J 2008; 14:288–301.
J Natl
Campbell SC. Management
of small renal masses.
and, thereby,
helpAUA
identify appro
ctive surveillance2.isLane BR,aggressive
5. Frank
Update Series 2009; 28:313–324.
renal
candidates
for observation
(FIGURE 2).size. J
3. Volpe A,ate
Panzarella
T, Rendon RA, Haider
MA, Kondylis FI, Jewett
MA. The natural history of incidentally detected small renal masses.
6. Russo
Cancer 2004; 100:738–745.
4. Hollingsworth
JM, Miller DC, Daignault
S, Hollenbeck
Risin
546
$-&7&-"/%$-*/*$+063/"-0'.&%*$*/&
70-6.&t
/6.#&3 BK.
"6(645
f renal cell
incidence of small renal masses: a need to reassess treatment ef
J Natl Cancer Inst 2006; 98:1331–1334.
asses. AUA
5. Frank I, Blute ML, Cheville JC, Lohse CM, Weaver AL, Zincke H.
renal tumors: an analysis of pathological features related to tum
iswstęp
FI, Jewett
size. J Urol
2003;
170:2217–2220.
nt zmian w ciągu ostatnich
20 lat,
poprzednio
radykalnie, potem obserwacja nt
renal
masses. nerek zmusiła
6. Russo
partial
nephrectomy
be performed for
niewydolności
nas P.
doShould
zmiany elective
podejścia,
co więcej
wiemy już że
im wiekszy guz tym b prawdopodobne ze jest zlosliwy
nauka „starego psa nowych sztuczek”
& t / 6 . # & 3 " 6 ( 6 4 5 Incidence per 100,000
lity per 100,000
nce the
ly,
have
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billion1
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localon kidney
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Surveillance,
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Program and the
during
ional
statistics and
v/.
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erp://progressreport.
much
egun to
mortality
as in
renKidney
tute’s
billion1(NCI)
earch
increased
kidney
ear (FY) 2006
. In addition,
Incide
present a true
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agnosis during
mortality rate
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creasing
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nd
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men as in
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U.S. Kidney Cancer Mortality
Mortality per 100,000
cer
U.S. Kidney Cancer Mortality
White Males
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Overall Rate
African-American Males
African-American Females
NCI Kidney Cancer Research Investment
rends in
Trends
in NCI
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Funding for
for Kidney
Kidney
ancer Research
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Research
The
The National
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Cancer Institute’s
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research increased
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In addition,
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NCI
NCI supported
supported $7.6
$7.6 million
million in
in kidney
kidney cancer
cancer
esearch
esearch in
in FY
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and 2010
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the American
American Recovery
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and Reinvestment
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ct (ARRA).
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(ARRA).33
White
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Males
WhiteFemales
Females
OverallRate
Rate
African-American
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NCI
NCI Kidney
Kidney Cancer
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Investment
ource:
ource: NCI
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of Budget
Budget and
and Finance
Finance (http://obf.cancer.
(http://obf.cancer.
ov).
ov).
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The estimated
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NCI investment
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based on
on funding
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broad range
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peer-reviewed scientific
scientific
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For additional
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andbudgeting
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NationalInstitutes
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http://www.nih.gov/about/.
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For more
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regarding ARRA
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funding at
at
NCI,
NCI, see
see http://www.cancer.gov/aboutnci/recovery/
http://www.cancer.gov/aboutnci/recovery/
recoveryfunding.
recoveryfunding.
Fiscal
Fiscal Year
Year
Kidney
KidneyCancer
CancerFunding
Funding
Total
TotalNCI
NCIBudget
Budget
Snapshots
Snapshots can
can be
be found
found online
online at:
at:
http://www.cancer.gov/aboutnci/servingpeople/cancer-statistics/snapshots
http://www.cancer.gov/aboutnci/servingpeople/cancer-statistics/snapshots
y $3.1 billion1
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Surveillance,
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statistics and
ata: Surveillance,
Program and the
ional statistics and
ogressreport.
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U.S. Kidney Cancer Mortality
Mortality per 100,000
on kidney
U.S. Kidney Cancer Mortality
Mortality per 100,000
cently begun to
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≠
๏ dla wielu guzów (SRM) nefrektomia =
overtreatment
๏ SRM stanowią heterogeniczną grupę zmian
๏ 20% to agresywne RCC
๏ kompromis pomiędzy ryzykiem onkologicznym a
„nefrologicznym”
wstęp nt zmian w ciągu ostatnich 20 lat, poprzednio radykalnie, potem obserwacja nt
niewydolności nerek zmusiła nas do zmiany podejścia, co więcej wiemy już że
nauka „starego psa nowych sztuczek”
OPN - open partial nephrectomy
LPN - lap. partial nephrectomy
RPN - robotic partial nephrectomy
ORN - open radical nephrectomy
LRN - lap. radical nephrectomy
CRYO - krioterapia
RFA- radiofrequency ablation
AS(WW) - active surveillance (watchful waiting)
Table 10a: Local Re
Study
Type
Cryo
RFA
LPN
OPN
LRN
ORN
# of
studies
10
10
17
21
8
10
Percent
90.6
87.0
98.4
98.0
99.2
98.1
Lower
Limit
83.8
83.2
97.1
97.4
98.2
97.3
Upper
Limit
94.
90.
99.
98.
99.
98.
Local recurrence-free
Comparisons: Table 10b presents statistica
ORN local RFS rates were statistically sim
local RFS rates for cryoablation and RFA.
summarizes the OS data.
Study
Type
# of
studies
Percent
Cryo
RFA
LPN
OPN
LRN
ORN
5
8
12
17
7
9
96.5
93.2
98.0
89.0
92.8
81.9
Table 13a: O
Lower Uppe
Limit Limi
85.5
82.2
96.1
85.3
86.4
65.5
99.
97.
99.
91.
96.
91.
Interpretation:
Assurvival
with the other survival a
10 yrs overall
precludes meaningful comparisons. Simila
rates had short follow-up durations and tre
Table 11a: Metastatic R
Study
Type
AS
Cryo
RFA
LPN
OPN
LRN
ORN
# of
studies
12
10
10
17
21
8
10
Percent
97.7
95.3
97.8
98.8
96.7
95.7
89.8
Lower
Limit
95.5
91.1
95.5
97.8
95.6
93.9
85.3
Upper
Limit
98.9
97.5
98.9
99.4
97.5
97.0
93.1
Interpretation: Overall, it is noteworthy that
metastatic free survival
of intervention type, likely reflecting the ind
However, the presence of confounding facto
zadziwia długi czas AS ale to prawdopodobnie wynika z tego ze te badania maja swoja
specyfike
nast slajd
interventions with the highest rates have sho
OGRANICZENIA PRAC DOT.
OBSERWACJI SRM
๏ brak potwierdzenia histopatologicznego (20% zmian
łagodnych)
๏ krótki czas obserwacji (2-3 lata)
๏ selekcja guzów i chorych kwalifikowanych do obserwacji
Poster
presented at:
DOI: 10.3252/pso.eu.27eau.2012
Nilay Patel
Renal tumours: Minimally invasive treatments and surveillance
1118--P
27eau
to badanie potwierdza poprzednie stwierdzenia ale z zastrzeżeniem stosunkowo krótkiego
okresu obserwacji ale tylko patrzeć jak pojawią się prace wieloletnie
Jakie są wskazania do obserwacji?
Jakie jest ryzyko złośliwego charakteru SRM?
Jakie jest ryzyko progresji miejscowej i odległej?
Jakie jest ryzyko związane z obserwacją lub
odroczeniem leczenia?
Jaki powinien być schemat obserwacji?
Czy wzrost guza w badaniach
obrazowych oznacza wzrost
ryzyka meta?
TAK
SRM (<4cm)
każdy 1cm wzrostu guza = 3,5% wzrost ryzyka M+
mours than either the RN or PN groups (age = 71
ze = 2.2 cm v 2.66 cm v 2.69 cm).
a median follow up of 34 months the mean growth
tempo wzrostu guza pozostaje głównym czynnikiem oceny jego agresywności
s 0.21 cm/year. 53% of SRMs managed with AS
nstrated negative or zero growth.
1-4 mm/rok
1-4% ryzyko meta
T1b 4-7cm
๏ wyższe ryzyko obserwacji!
๏ tempo wzrostu 1,43cm/rok
๏ 1/9 chorych rozwinie M+
๏ 1cm wzrostu = 22% wzrost ryzyka M+
wciąż średnica guza oceniana wyjściowo w badaniach obrazowych jest podstawowym
czynnikiem prognostycznym
ta informacja niesie ze sobą niezwykle istotne przesłanki dla rokowania i podejmowania
decyzji terapeutycznych
jednak...
Czy brak wzrostu guza w
badaniach obrazowych oznacza
brak jego agresywności?
NIE
te guzy które wykazują progresję wymiarów mają taki sam odsetek rozpoznania zmian
złośliwych jak te, które się w badaniach obrazowych nie powiększają
FAKTY
๏ 50% guzów <1cm to zmiany złośliwe
(3-4cm - 80%)
๏ 20% SRM (RCC) to zmiany high-grade
i/lub pT3a
wciąż średnica guza oceniana wyjściowo w badaniach obrazowych jest podstawowym
czynnikiem prognostycznym
ta informacja niesie ze sobą niezwykle istotne przesłanki dla rokowania i podejmowania
decyzji terapeutycznych
jednak...
BIOPSJA
2001
diagnostic accuracy 82%
false negative 18%
ryzyko rozsiewu
krwawienia
diagnostic accuracy 95%
false negative <1%
CT guidance
Renal Mass
Guideline for Management
of the Clinical Stage 1
Renal Mass
Renal Mass Clinical Panel Members:
Andrew C. Novick, MD, Chair
Steven C. Campbell, MD, PhD, Co-Chair
Arie Belldegrun, MD
Michael L. Blute, MD
George Kuoche Chow, MD
Ithaar H. Derweesh, MD
Jihad H. Kaouk, MD
Raymond
Leveillee,
MD, FRCS-G
Renal Mass J.Clinical
Panel Members:
Surena
Andrew F.
C. Matin,
Novick,MD
MD, Chair
Paul
Russo,
MD
Steven
C. Campbell,
MD, PhD, Co-Chair
Robert Guy Uzzo, MD
Arie Belldegrun, MD
Michael L. Blute, MD
George Kuoche Chow, MD
Ithaar H. Derweesh, MD
Jihad H. Kaouk, MD
Raymond J. Leveillee, MD, FRCS-G
Surena F. Matin, MD
Paul Russo, MD
Robert Guy Uzzo, MD
Consultants:
Martha M. Faraday, PhD
Linda Whetter, DVM, PhD
Michael Marberger, MD
AUA Staff:
Heddy Hubbard, PhD, FAAN
Edith Budd
Michael Folmer
Katherine Moore
Consultants:
Kadiatu
Martha
M.Kebe
Faraday, PhD
Linda Whetter, DVM, PhD
Michael Marberger, MD
AUA Staff:
Heddy Hubbard, PhD, FAAN
Edith Budd
Michael Folmer
Katherine Moore
Kadiatu Kebe
Patient with clinical T1 renal mass
Standards are presented in green boxes; Recommendations are
presented in yellow boxes; Options are presented in red boxes.
Key: AS, active surveillance; CKD, chronic kidney disease; CT, computed
tomography; FNA, fine needle aspiration; MRI, magnetic resonance
imaging; PN, partial nephrectomy; RFA, radiofrequency ablation;
RN, radical nephrectomy; TA, thermal ablation
EVALUATION
• High quality cross sectional imaging study (CT or MRI) with and without contrast (in the presence of adequate renal function) to assess contrast enhancement, exclude angiomyolipoma, assess for locally invasive features, define the
relevant anatomy and evaluate the status of the contralateral kidney
• Percutaneous renal mass core biopsy with or without FNA for patients in whom it might impact management, particularly patients with clinical or radiographic findings suggestive of lymphoma, abscess or metastasis
COUNSELING
• Review the current understanding of the natural history of clinical T1 renal masses, the relative risks of benign vs. malignant pathology and the potential role of AS
• Review the available treatment options and the attendant benefits and risks, including oncologic considerations, renal functional considerations and potential morbidities
• Discuss the potential advantages of a nephron sparing treatment approach in the imperative and elective settings, including the avoidance of dialysis and reduced risk of CKD with its attendant morbidity and mortality
INDEX PATIENT 1:
Healthy; Clinical T1a
STANDARD PN:
INDEX PATIENT 2:
Major comorbidities
Increased surgical risk
Clinical T1a
Complete surgical excision
by PN is a standard of care and should be
strongly considered.
STANDARD RN: Should be discussed as
alternate standard of care if PN is not technically
feasible as determined by the urologic surgeon.
OPTION TA: Cryoablation or RFA should be
discussed as less invasive treatment options, but
local tumor recurrence is more likely, measures
of success are not well defined, and surgical
salvage may be difficult.
OPTION AS:
AS with delayed intervention
should be discussed as option for patients
wishing to avoid treatment and willing to assume
oncologic risk.
INDEX PATIENT 3:
Healthy; Clinical T1b
STANDARD RN:
Should be discussed as
standard of care for patients with a normal
contralateral kidney.
STANDARD PN:
STANDARD RN:
Complete surgical
excision by PN should
be discussed as a
standard of care with
increased surgical risk in
this patient.
Should be discussed as
standard of care with
increased risk of CKD
and surgical
complications in this
patient.
RECOMMENDATION
TA: Cryoablation or
RFA should be discussed as
less invasive treatment
options which may be
advantageous in this high
surgical risk patient,
acknowledging the
increased risk of local
tumor recurrence
compared to surgical
excision.
STANDARD PN: Complete surgical excision
by PN should be discussed as an alternative
standard of care, particularly when there is a
need to preserve renal function.
as an acceptable approach
which can delay or avoid
the need for intervention
in this high risk patient.
STANDARD RN:
Should be discussed as standard
of care for patients with a normal contralateral kidney,
although it can be associated with surgical morbidity
and an increased risk of CKD in this patient.
RECOMMENDATION PN: Complete surgical
excision by PN should be discussed as a recommended
modality when there is a need to preserve renal
function, although it can be associated with increased
urologic morbidity in this patient.
OPTION TA:
RECOMMENDATION
AS: Should be offered
INDEX PATIENT 4:
Major comorbidities; Increased
surgical risk; Clinical T1b
Cryoablation or RFA
can/may be discussed as
a treatment option
which is less effective
due to an increased risk
of local recurrence. TA
may represent
suboptimal management
for this healthy patient.
OPTION AS: AS with
delayed intervention
can/may be discussed as an
option in patients who
want to avoid surgery and
are willing to accept an
increased risk of tumor
progression compared to
RN or PN. AS may
represent suboptimal
management for this
healthy patient.
Copyright © 2009 American Urological Association Education and Research, Inc.®
RECOMMENDATION AS:
AS should be
discussed with patients who want to avoid surgery or
who are considered high risk for surgical therapy.
OPTION TA: Cryoablation or RFA can/may be
discussed as a treatment option which is less effective
due to an increased risk of local recurrence.
44
SRM
starsi
młodzi
NSS
nieobciążeni
obciążeni
biopsja
biopsja
high grade
zmiana łagodna
low grade
termo
obs.
POSTULAT 1
potrzeba nowego
biomarkera jako czynnika
oceny ryzyka i prognozy
POSTULAT 2
ograniczyć rolę
leczenia radykalnego
na rzecz NSS
POSTULAT 3
częściej rozważać opcję
obserwacji, biopsji i
termoterapii
ale kiedy?
๏ krótki czas przeżycia
๏ ryzyko okołozabiegowe > korzyści z postawy
proaktywnej
czy wiąże się z tym jakiekolwiek ryzyko?
1-4 mm/rok
1-4% ryzyko meta
RYZYKO?
๏ niskie ale realne ryzyko progresji
๏ utrata „okna czasowego” odpowiedniego do
aktywnego leczenia
๏ metoda niepolecana dla młodych, nieobciążonych
?
๏ wzrastająca rola biopsji i diagnostyki molekularnej
(proteomika, badania genetyczne)
๏ rozwój technik obrazowych
๏ wzrastająca rola obserwacji w związku ze
wzrostem długości życia
๏ nefrektomia radykalna rzadkością?
Think different
Think different