Böbrek Kanserlerinde Fokal Tedaviler
Özet
Böbrek tümörleri, özellikle insidental olarak saptanan küçük renal kitlelerin artışı nedeniyle son yıllarda daha sık teşhis edilmektedir. Erken evredeki ve genellikle yavaş büyüyen bu kitlelerin tedavisinde radikal nefrektomi altın standart olsa da, böbrek fonksiyonlarını korumak ve kardiyovasküler riskleri azaltmak amacıyla cT1a ve uygun cT1b evrelerinde nefron koruyucu cerrahiler (parsiyel nefrektomi) öncelikli olarak önerilmektedir. Ancak cerrahi için yüksek risk taşıyan yandaş hastalıklara sahip bireylerde, ileri yaşta veya kırılgan hastalarda, soliter böbrekli ya da bilateral tümörü olan vakalarda alternatif yaklaşımlar devreye girmektedir. Bu doğrultuda, tümör progresyon gösterene kadar kesitsel görüntüleme ve biyopsi eşliğinde takip edilen aktif izlem stratejisi güvenle uygulanabilmektedir. Bunun yanı sıra, dokuyu dondurarak yok eden kriyoablazyon (CRA) ve yüksek frekanslı akımla ısı üreten radyofrekans ablazyon (RFA), cerrahiye kıyasla daha minimal invaziv ve gerektiğinde tekrarlanabilir etkinlik sunmaktadır. Mikrodalga termal ablazyon (MWA), yüksek yoğunluklu odaklanmış ultrason (HIFU) ve geri dönüşümsüz elektroporasyon (IRE) gibi diğer fokal ve deneysel yöntemler de araştırılmaktadır. Sonuç olarak fokal tedaviler ve aktif izlem, uzun dönem takip verileri kısıtlı olsa da cerrahi riski yüksek ve ileri yaştaki hastalar için tatmin edici, güvenli ve fonksiyonel onkolojik alternatifler sağlamaktadır.
Renal tumors are being diagnosed more frequently in recent years, primarily due to the increase in incidentally detected small renal masses. Although radical nephrectomy is the gold standard for treating localized disease, nephron-sparing surgeries (partial nephrectomy) are primarily recommended for cT1a and suitable cT1b stages to preserve renal functions and reduce cardiovascular risks. However, alternative approaches come into play for patients with high surgical risk due to comorbidities, elderly or frail patients, and those with solitary kidneys or bilateral tumors. In this regard, the active surveillance strategy, which involves monitoring the tumor with cross-sectional imaging and biopsy until progression is detected, can be safely implemented. Additionally, cryoablation (CRA), which destroys tissue by freezing, and radiofrequency ablation (RFA), which generates heat using high-frequency current, offer more minimally invasive and repeatable efficacy compared to surgery. Other focal and experimental methods, such as microwave thermal ablation (MWA), high-intensity focused ultrasound (HIFU), and irreversible electroporation (IRE), are also being investigated. Consequently, focal therapies and active surveillance provide satisfactory, safe, and functional oncological alternatives for elderly and high-risk patients, even though long-term follow-up data remain limited.
Referanslar
Padala SA, Barsouk A, Thandra KC et al. Epidemiology of renal cell carcinoma. World J Oncol. 2020; 11(3):79-87.
Capitanio U, Bensalah K, Bex A et al. Epidemiology of renal cell carcinoma. Eur Urol. 2019; 75(1):74-84.
Escudier B, Porta C, Schmidinger M et al. Renal carcinoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2016; 27(Suppl 5):58-68.
Motzer RJ, Jonasch E, Agarwal N et al. Kidney cancer Version 2.2017, NCCN Clinical Practice Guidelines in oncology. JNCCN 2017; 15(6):804-834.
Sebastia C, Corominas D, Musquera M et al. Active surveillance of small renal masses. Insights Imaging 2020; 11:63.
Menon AR, Hussein AA, Attwood KM et al. Active surveillance for risk stratification of all small renal masses lacking predefined clinical criteria for intervention. J Urol. 2021; 206:229-239.
Chawla SN, Crispen PL, Hanlon Al et al. The natural history of observed enhancing renal masses: Meta-Analysis and review of the world literature. J Urol. 2006; 175:425-431.
EAU Guidelines (2022). Renal Cell Carcinoma 2022. (https://uroweb.org/guidelines/renal-cell-carcinoma adresinden ulaşılabilir).
Dorin R, Jackson M, Cusano A et al. Active surveillance of renal masses: An analysis of growth kinetics and clinical outcomes stratified by radiological characteristics at diagnosis. Int Braz J Urol. 2014; 40(5):627-636.
Hawken SR, Krishnan NK, Ambani SN et al. Effect of delayed resection after initial surveillance and tumor growth rate on final surgical pathology in patients with small renal masses (SRMs). Urol Oncol. 2016; 34(11):486.e9-486.e15.
Whelan EA, Mason RJ, Himmelman JG et al. Extended duration of Active Surveillance of small renal masses: A Prospective Cohort Study. J Urol. 2019; 202(1):57-61.
McIntosh AG, Ristau BT, Ruth K et al. Active surveillancefor localized renal masses: Tumor growth, delayed interventions rates and >5-yr clinical outcomes. Eur Urol. 2018; 74:157-164.
Hoffmann NE, Bischof JC. The cryobiology of cryosurgical injury. Urology. 2002; 60(Suppl 2A):40-49.
Maccini M, Sehrt D, Pompeo A et al. Biophysiologic considerations in cryoablation: A practical mechanistic molecular review. Int Braz J Urol. 2011; 37(6):693-696.
Yan X, Zhang M, Chen X et al. Image-guided percutaneous renal cryoablation for stage 1 renal cell carcinoma with high surgical risk. World J Surg Oncol. 2015; 13:200-205.
Stacul F, Sachs C, Giudici F et al. Cryoablation of renal tumors: long term follow up from a multicenter experience. Abdom Radiol. 2021; 46(9):4476-4488.
Garnon J, Van Strijen MJ, Nielsen TK et al. Safety of percutaneous renal cryoablation: an international multicentre experience from the EuRECA retrospective percutaneous database. Eur Radiol. 2019; 29(11):6293-6299.
Uemura T, Kato T, Nagahara A et al. Therapeutic and Clinical Outcomes of Robot-assisted Partial Nephrectomy Versus Cryoablation for T1 Renal Cell Carcinoma. In Vivo 2021; 35(3):1573-1579.
Bihindi B, Mason RJ, Haddad MM et al. Outcomes after cryoablation versus partial nephrectomy for sporadic renal tumors in a solitary kidney. A Propensity score analysis. Eur Urol. 2018; 73:254-259.
Caputo PA, Zargar H, Ramirez D et al. Cryoablation versus partial nephrectomy for clinical T1b renal tumors: A matched group comparative analysis. Eur Urol. 2017; 71:111-117.
Deng W, Chen L, Wang Y et al. Cryoablation versus partial nephrectomy for clinical stage T1 renal masses: A systematic review and meta-analysis. J Cancer. 2019; 10:1226-1236.
Upton MP, Parker RA, Youmans A et al. Histologic Predictors of Renal Cell Carcinoma Response to Interleukin-2-Based Therapy. J Immunother. 2005; 28(5):488-495.
Vaddepally RK, Kharel P, Pandey R et al. Review of indications of FDA approved immune checkpoint inhibitors per NCCN guidelines with the level of evidence. Cancers (Basel) 2020; 12(3):738.
Günizi H, Günizi ÖC. PDL-1 expression in inverted papilloma. Turk J Health S. 2022; 3(1):5-8.
Hinshaw JL, Lee FT. Image-guided ablation of renal cell carcinoma. Magn Reson Imaging Clin N Am. 2004; 12:429–447.
Wah TM, Irving HC, Gregory W et al. Radiofrequency ablation (RFA) of renal cell carcinoma (RCC): experience in 200 tumours. BJU Int. 2014; 113:416-428.
Lam CJ, Wong NC, Voss M et al. Surveillance post-radiofrequency ablation for small renal masses: Recurrence and followup. Can Urol Assoc J. 2020; 14(12):398-403.
Kim SD, Yoon SG, Sung GT. Radiofrequency Ablation of renal tumors: Four-year follow-up results in 47 patients. Korean J Radiol. 2012; 13(5):625-633.
Yin X, Cui L, Li F et al. Radiofrequency ablation versus partial nephrectomy in treating small renal tumors. Medicine 2015; 94(50):e2255.
Park JM, Yang SW, Shin JH et al. Oncological and Functional Outcomes of Laparoscopic Radiofrequency Ablation and Partial Nephrectomy for T1a Renal Masses: A Retrospective Single-center 60 Month Follow-up Cohort Study. Urol J. 2019; 16(1):44-49.
Ruiz VA, Batelsson S, Onkama E et al. Split renal function after treatment of small renal masses: Comparison between radiofrequency ablation and laparoscopic partial nephrectomy. Acta Radiologica 2021; 62(9):1248-1256.
Pan XW, Cui XM, Huanh H et al. Radiofrequency ablation versus partial nephrectomy for treatment of renal masses: A systematic review and meta-analysis. Kaohsiung J Med Sci. 2015; 31(12):649-58.
Turna B, Kaouk JH, Frota R et al. Minimally Invasive Nephron Sparing Management for Renal Tumors in Solitary Kidneys. J Urol. 2009; 182(5):2150-2157.
Shi H, li J, Fan Z et al. Comparison of radiofrequency ablation versus cryoablation for T1 renal tumors: An evidence-based analysis of comparative outcomes. Front Oncol. 2022; 12:802437.
Andrews JR, Atwell T, Schmit G et al. Oncologic outcomes following partial nephrectomy and percutaneous ablation for cT1 renal masses. Eur Urol. 2019; 76:244-251.
Yong C, Mott SL, Laroia S et al. Outcomes of Microwave Ablation for Small Renal Masses: A Single Center Experience. J Endourol. 2020; 34(11):1134-1140.
Ruiz VA, Dahlman P, Brekkan E et al. Microwave ablation of 105 T1 renal tumors: technique efficacy with a mean follow-up of two years. Acta Radiologica 2020; Online. (PubMed ID: 32910687 ile ulaşılabilir)
John JB, Anderson M, Dutton T et al. Percutaneous microwave ablation of renal masses in a UK cohort. BJU Int. 2021; 127(4):486-494.
Filippiadis DK, Gkizas C, Chrysofos M et al. Percutaneous microwave ablation of renal cell carcinoma using a high power microwave system: focus upon safety and efficacy. Int. J. Hyperth. 2018; 34(7):1077-1081.
Choi SH, Kim JW, Kim JH et al. Efficacy and Safety of Microwave Ablation for Malignant Renal Tumors: An Updated Systematic Review and Meta-Analysis of the Literature Since 2012. Korean J Radiol. 2018; 19(5):938-949.
Anglickis M, Anglickiene G, Andreikaite G et al. Microwave Thermal Ablation versus Open Partial Nephrectomy for the Treatment of Small Renal Tumors in Patients Over 70 Years Old. Medicina 2019; 55:664
Uhling J, Strauss A, Rücker G et al. Partial nephrectomy versus ablative techniques for small renal masses: A systematic review and network meta-analysis. Eur Radiol. 2019; 29:1293-1307.
De Cobelli F, Papa M, Panzeri M et al. Percutaneous Microwave Ablation Versus Cryoablation in the Treatment of T1a Renal Tumors. Cardiovasc Intervent Radiol. 2020; 43:76-83.
Nabi G, Goodman C, Melzer A. High intensity focused ultrasound treatment of small renal masses: Clinical effectiveness and technological advances. Indian J Urol, 2010; 26(3):331-337.
Ritchie RW, Leslie T, Phillips R et al. Extracorporeal high intensity focused ultrasound for renal tumours: a 3-year follow-up. BJU Int. 2010; 106(7):1004–1009.
Klingler HC, Susani M, Seip R et al. A Novel Approach to Energy Ablative Therapy of Small Renal Tumours: Laparoscopic High-Intensity Focused Ultrasound. Eur Urol. 2008; 53:810-818.
Klatte T, Marberger M. High-intensity focused ultrasound for the treatment of renal masses: current status and future potential. Curr Opin Urol. 2009; 19:188–191.
Klatte T, Kroeger N, Zimmermann U et al. The contemporary role of ablative treatment approaches in the management of renal cell carcinoma (RCC): focus on radiofrequency ablation (RFA), high‑intensity focused ultrasound (HIFU), and cryoablation. World J Urol. 2014; 32:597–605.
Pech M, Janitzky A, Wendler JJ et al. Irreversible Electroporation of Renal Cell Carcinoma: A First-in-Man Phase I Clinical Study. Cardiovasc Intervent Radiol 2011; 34:132–138.
Trimmer CK, Khosla A, Morgan M et al. Minimally Invasive Percutaneous Treatment of Small Renal Tumors with Irreversible Electroporation: A Single-Center Experience. J Vasc Interv Radiol. 2015; 26(10):1465-1471.
Stafford RJ, Fuentes D, Elliott AA et al. Laser-Induced Thermal Therapy for Tumor Ablation. Crit Rev Biomed Eng. 2010 ;38(1):79-100.52.
