Lokalize Hastalığın Tedavisinden Sonra Lokal Olarak Tekrarlayan RCC
Özet
Lokalize renal hücreli karsinom (RCC) sonrası lokal nüks (LR), hastaların %1,8-6,4'ünde görülen ve kötü prognozla ilişkili bir durumdur. Literatürde LR tanımında heterojenlik bulunmakla birlikte, genellikle kalan böbrekte, renal fossada, ipsilateral adrenal bezde veya bölgesel lenf nodlarında meydana gelen nüksleri kapsar. Nefron koruyucu cerrahi (PN) veya termal ablasyon sonrasında, primer tümörün eksik rezeksiyonu, mikrovasküler yayılım veya multifokalite nedeniyle tümör taşıyan böbrekte nüks gelişebilir. T1b ve üzeri veya yüksek nefrometrili tümörlerde nüks riski daha yüksektir. Bu durumda tamamlayıcı nefrektomi, ablasyon veya tekrar PN gibi seçenekler mevcuttur; tekrar PN onkolojik kontrol sağlasa da üriner ekstravazasyon gibi yüksek komplikasyon riski taşır. Radikal nefrektomi (RN) sonrası izole fossa nüksü ise %1-3 oranında, genellikle ileri evre (T3-4) ve yüksek dereceli tümörlerde görülür. RN sonrası nüks için medyan süre 14,5-36 aydır ve negatif sınırlarla cerrahi rezeksiyon en etkin tedavi seçeneğidir. Son yıllarda robot yardımlı cerrahi yaklaşımlar (sRAPN/sRARN) başarılı lokal nükssüz ve metastasız sağkalım oranları sunmaktadır. Erken nüks (<3-12 ay), sarkomatoid farklılaşma ve cerrahi sınır pozitifliği kötü prognostik faktörlerdir; cerrahinin imkansız olduğu durumlarda radyoterapi gibi palyatif yöntemler tercih edilir.
Local recurrence (LR) after localized renal cell carcinoma (RCC) is observed in 1.8-6.4% of patients and is associated with a poor prognosis. Although there is heterogeneity in its definition within the literature, LR generally encompasses recurrences in the remaining kidney, renal fossa, ipsilateral adrenal gland, or regional lymph nodes. Following nephron-sparing surgery (PN) or thermal ablation, recurrence can develop in the tumor-bearing kidney due to incomplete resection of the primary tumor, microvascular dissemination, or multifocality. The risk of recurrence is higher in tumors staged T1b and above or those with high nephrometry scores. In such cases, options like completion nephrectomy, ablation, or repeat PN are available; although repeat PN provides oncological control, it carries a high risk of complications such as transient urinary extravasation. Isolated fossa recurrence after radical nephrectomy (RN) occurs at a rate of 1-3%, mostly reported in advanced stages (T3-4) and high-grade tumors. The median time to recurrence after RN ranges from 14.5 to 36 months, and surgical resection with negative margins remains the most effective treatment option. In recent years, robot-assisted surgical approaches (sRAPN/sRARN) have presented successful local recurrence-free and metastasis-free survival rates. Early recurrence (<3-12 months), sarcomatoid differentiation, and positive surgical margins are poor prognostic factors; when surgery is unfeasible, palliative methods such as radiation therapy are preferred.
Referanslar
Margulis V, McDonald M, Tamboli P, Swanson DA, Wood CG. Predictors of oncological outcome after resection of locally recurrent renal cell carcinoma. J Urol. 2009 May;181(5):2044–51. https://doi.org/10.1016/j.juro.2009.01.043 PMID: 19286220
Itano NB, Blute ML, Spotts B, Zincke H. Outcome of isolated renal cell carcinoma fossa recurrence after nephrectomy. J Urol. 2000 Aug;164(2):322–5. PMID: 10893575
Thompson RH, Atwell T, Schmit G, Lohse CM, Kurup AN, Weisbrod A, et al. Comparison of partial nephrectomy and percutaneous ablation for cT1 renal masses. Eur Urol. 2015 Feb;67(2):252–9. https://doi.org/10.1016/j.eururo.2014.07.021 PMID: 25108580
Bruno JJ, Snyder ME, Motzer RJ, Russo P. Renal cell carcinoma local recurrences: impact of surgical treatment and concomitant metastasis on survival. BJU Int. 2006 May;97(5):933–8. https://doi.org/10.1111/j.1464-410X.2006.06076.x PMID: 16643473
Lee Z, Jegede OA, Haas NB, Pins MR, Messing EM, Manola J, et al. Local Recurrence Following Resection of Intermediate-High Risk Nonmetastatic Renal Cell Carcinoma: An Anatomical Classification and Analysis of the ASSURE (ECOG-ACRIN E2805) Adjuvant Trial. J Urol. 2020 Apr;203(4):684–9. https://doi.org/10.1097/JU.0000000000000588 PMID: 31596672
Antonelli A, Furlan M, Tardanico R, Fisogni S, Sodano M, Carobbio F, et al. Features of Ipsilateral Renal Recurrences After Partial Nephrectomy: A Proposal of a Pathogenetic Classification. Clin Genitourin Cancer. 2017 Oct;15(5):540–7. https://doi.org/10.1016/j.clgc.2017.04.028 PMID: 28533051
Kreshover JE, Richstone L, Kavoussi LR. Renal cell recurrence for T1 tumors after laparoscopic partial nephrectomy. J Endourol. 2013 Dec;27(12):1468–70. https://doi.org/10.1089/end.2013.0197 PMID: 24074156
Wah TM, Irving HC, Gregory W, Cartledge J, Joyce AD, Selby PJ. Radiofrequency ablation (RFA) of renal cell carcinoma (RCC): experience in 200 tumours. BJU Int. 2014 Mar;113(3):416–28. https://doi.org/10.1111/bju.12349 PMID: 24053769
Mouracade P, Chavali JS, Kara O, Dagenais J, Maurice MJ, Nelson RJ, et al. Imaging strategy and outcome following partial nephrectomy. Urol Oncol. 2017 Nov;35(11):660.e1-660.e8. https://doi.org/10.1016/j.urolonc.2017.06.052 PMID: 28863862
Johnson A, Sudarshan S, Liu J, Linehan WM, Pinto PA, Bratslavsky G. Feasibility and outcomes of repeat partial nephrectomy. J Urol. 2008 Jul;180(1):89–93; discussion 93. https://doi.org/10.1016/j.juro.2008.03.030 PMID: 18485404
Herout R, Graff J, Borkowetz A, Zastrow S, Leike S, Koch R, et al. Surgical resection of locally recurrent renal cell carcinoma after nephrectomy: Oncological outcome and predictors of survival. Urol Oncol. 2018 Jan;36(1):11.e1-11.e6. https://doi.org/10.1016/j.urolonc.2017.08.021 PMID: 28927783
Thomas AZ, Adibi M, Borregales LD, Hoang LN, Tamboli P, Jonasch E, et al. Surgical Management of Local Retroperitoneal Recurrence of Renal Cell Carcinoma after Radical Nephrectomy. J Urol. 2015 Aug;194(2):316–22. https://doi.org/10.1016/j.juro.2015.02.2943 PMID: 25758610
Dekernion JB, Ramming KP, Smith RB. The natural history of metastatic renal cell carcinoma: a computer analysis. J Urol. 1978 Aug;120(2):148–52. https://doi.org/10.1016/s0022-5347(17)57082-2 PMID: 78992
Srivastava A, Patel HD, Joice GA, Semerjian A, Gorin MA, Johnson MH, et al. Incidence of T3a up-staging and survival after partial nephrectomy: Size-stratified rates and implications for prognosis. Urol Oncol. 2018 Jan;36(1):12.e7-12.e13. https://doi.org/10.1016/j.urolonc.2017.09.005 PMID: 28970053
Russell CM, Lebastchi AH, Chipollini J, Niemann A, Mehra R, Morgan TM, et al. Multi-institutional Survival Analysis of Incidental Pathologic T3a Upstaging in Clinical T1 Renal Cell Carcinoma Following Partial Nephrectomy. Urology. 2018 Jul;117:95–100. https://doi.org/10.1016/j.urology.2018.04.002 PMID: 29678662
Psutka SP, Heidenreich M, Boorjian SA, Bailey GC, Cheville JC, Stewart-Merrill SB, et al. Renal fossa recurrence after nephrectomy for renal cell carcinoma: prognostic features and oncological outcomes. BJU Int. 2017 Jan;119(1):116–27. https://doi.org/10.1111/bju.13620 PMID: 27489013
Martini A, Turri F, Barod R, Rocco B, Capitanio U, Briganti A, et al. Salvage Robot-assisted Renal Surgery for Local Recurrence After Surgical Resection or Renal Mass Ablation: Classification, Techniques, and Clinical Outcomes. Eur Urol. 2021 Dec;80(6):730–7. https://doi.org/10.1016/j.eururo.2021.04.003 PMID: 34088520
Rieken M, Kluth LA, Fajkovic H, Capitanio U, Briganti A, Krabbe L-M, et al. Predictors of Cancer-specific Survival After Disease Recurrence in Patients With Renal Cell Carcinoma: The Effect of Time to Recurrence. Clin Genitourin Cancer. 2018 Aug;16(4):e903–8. https://doi.org/10.1016/j.clgc.2018.03.003 PMID: 29653814
