Carcinoma renale metastatico

Trattamento delle metastasi

Il punto di vista del chirurgo

Alberto Lapini

Nel 2015 erano attesi 10400 casi di tumore del parenchima renale.

Nel 25-30% dei casi si tratta di una malattia metastatica alla diagnosi.Nel 5% dei casi è presente una metastasi

solitaria.

Le forme localizzate alla diagnosi danno metastasi in una percentuale che varia dal 35% al 65%

Metastatic disease

Selection Criteria for surgery as first treatment

Elements in favor

Solitary lesion vs multiple lesions

Site : lung > bones > visceral organs > CNS

Metachronous vs synchronous

Long disease -free interval following initial treatment (> 12 months)

Complete vs incomplete resection*

****

Lung only metastases

Non-lung only metastases

Fattori prognostici

Resezione completa

T Stadio <3

Disease free interval > 12 mesi

“resection must be as complete as possible and include a systematic total mediastinal lymphadenectomy,”

to operate or not to operate

Parameters :

1-Serum Calcium > 10 mg/dL, 2-Hemoglobin less than age-specific lower

limit of normal3-Serum LDH > 300 U/L.

4-Karnofsky < 80%5-Time from nephrectomy to recurrence <

12 months

One point was assigned for each adverse parameter met, up to a maximum of 5 points.

Risk category : favorable-risk (0 points) intermediate-risk (1–2points)poor-risk (3–5 points)

Objective-To determine the survival impact of clinical prognostic factors and theirapplication to stratification of patients according to their prognosis so clinicians may be aided in their management of mRCC.

Intervention-Metastasis resection from various anatomic sites with the aim of completely removing detected lesions.

Multivariable analysis revealed that primary tumour T stage 3(hazard ratio [HR]: 2.8; p < 0.01), primary tumour Fuhrman grade3 (HR: 2.3; p < 0.03), non pulmonary metastases (HR: 3.1; p < 0.03), disease-free interval ≤12 mo (HR: 2.3;p < 0.058), and multiorgan metastases (HR: 2.5; p < 0.04) were independent pretreatment prognostic factors.Leuven-Udine (LU) prognostic groups based on these covariates

were created and analysed with Kaplan-Meier and log-rank tests. The 2- and 5-yr CSS were significantly different; the respective group A CSS rates were 95.8% and 83.1%; group B, 89.9% and 56.4%; group C, 65.6% and 32.6%; and group D, 24.7% and 0% ( p < 0.0001).

“Surgery should be indicated particularly for patientswith resectable disease, good performance status, andpredicted good CSS”

December 1996

May 2008 October 2011

Dicembre 2011: intervento di enucleazione renale robotica

E.I.: ca renale a cellule chiare, G3, pT1 ( 2,4 x 2 x1 cm)

!!La paziente è attualmente libera da malattia!!

Febbraio 2016

Anche se nel 2013 ha eseguito tiroidectomia per metastasi

da RCC e contemporaneamente sono apparse 2 nodularità

della testa del pancreas di circa 1 cm di diametro .

Rifiutando un nuovo intervento opta per trattamento con Tki

che determina la scomparsa dei noduli .

Interrompe terapia ad aprile 2014 per tossicità ematologica

Riprende terapia !!!

EMBOLIZZAZIONE PORTALE

Neoplasia renale destra con metastasi surrenaliche bilaterali

Tumore renale destro con trombosi cavale a partenza dalla vena gonadica interessata per via retrograda da collaterale polare inferiore

Voluminosa massa a sede pelvica sinistra coinvolgente uretere e grossi vasi ( metastasi atipica???)

Kidney Tumors

Bone metastasesTreatment

Prostate(32%), breast (22%), kidney (16%),lung and thyroid cancer have a high risk for metastatic bone disease. In fact, these primary carcinomas account for 80% of all the metastases to the bone

Aim of orthopedic surgery

Achieve adequate pain control Prevent or stabilize pathological fracturesPrevent spinal cord compressionIn selected cases, complete resection may improve the survival rate of the patient.

Kidney Tumors

Bone metastasesTreatment

Multidisciplinary team

Orthopaedic surgeonRadiologistRadiotherapistUrologistOncologist

There is no strict rationale governing the surgical management of skeletal metastases. Clinical, medical, radiological and surgical factors, coupled with the inherent biology of the primary tumor all contribute to the decison making process. Furthermore data about patient survival and quality of life are required

Linee Guida Trattamento Metastasi Ossee

Società Italiana di Ortopedia e Traumatologia

•A large metastatic mass involving 1°and 2° thoracic vertebrae, left paravertebral muscle, 1° left rib and the contiguous pleura, causing radicular compression.

A 10 cm solid mass on left kidney with venous thrombus in renal vein.

Radical nephrectomy, retroperitoneal lymphadenectomy

Pathology: ccRCC, Fuhrman G2, pT3a N2.

Indications for surgerySpinal surgery is undertaken, where possible, before the developmentof spinal cord compression in those with a life expectancy, tumour type and physiological status favouring surgical intervention over conservative treatment.

Indications for surgery are:Mechanical. Instability is typically manifest as mechanical axial pain exacerbated by movement, standing, and walking.CT scan is the best imaging modality to assess bone quality, the risk of fracture and potential or actual collapse requiring stabilisation.Neurological. Impending or actual cord compromise. MRI will normally demonstrate neural compression whether or not there is an associated neurological deficit.Palliative. Pain not responding to conservative measures.Oncological. Patients with an apparently truly solitary metastasis in whom curative strategies may occasionally be indicated. Usually this is only considered for renal cell and thyroid carcinomas.

proximal femur metastasis

from renal cell carcinoma

SOD Ortopedia

Oncologica

AOU Careggi

Preoperative

selective arterial

embolization SOD Ortopedia

Oncologica

AOU Careggi

Firenze

Surgical

treatment:

resection and

cemented

megaprosthesis

(with cement

reinforcing all

the canal)

SOD Ortopedia

Oncologica

AOU Careggi

Firenze

Male, 73 y.,

affected by iliac metastasis

from renal cell carcinoma

SOD Ortopedia

Oncologica

AOU Careggi

Firenze

Treatment:

preop embolization, curettage with

the aid of cryosurgery, cement fillingand hip replacement SOD Ortopedia

Oncologica

AOU Careggi

Firenze

Hip replacement aided by

cement filling aftercurettage, ring and screws

SOD Ortopedia

Oncologica

AOU Careggi

Male, 57 y., left femur metastasis

SOD Ortopedia

Oncologica

AOU Careggi

Firenze

Preop treatment with

percutaneous ct-guided

RF thermoablation

SOD Ortopedia

Oncologica

AOU Careggi

Firenze

Surgical treatment:

resection and

megaprosthesis

SOD Ortopedia

Oncologica

AOU Careggi

Firenze

M.A. anni 65

Dicembre 2013

Ricovero ospedaliero (Siena) per lombo-sciatalgia ingravescente

Accertamenti strumentali (TC Torace addome e RMN colonna)

evidenziavano a livello osseo:

sovvertimento strutturale di D12 con invasione del

canale midollare ; altre lesioni di minor entità a

livello di S1 e S3 versante destro e

1° articolazione costo sternale destra.

A livello toracico: numerosi linfonodi mediastinici

A livello addominale :

lesione renale di 8x7x8 a livello del rene sinistro

e lesione di circa 4 cm di diametro a livello

del surrene sinistro.

Venne eseguita biopsia ossea che dimostrava

la presenza di una metastasi da carcinoma renale

a cellule chiare.

Venne eseguita radioterapia su segmenti ossei

e stabilizzazione chirurgica D11-L1.

Inizia terapia con Sunitinib 50 mg poi 37.5 mg

Ad agosto 2016 una rivalutazione clinico strumentale dimostrava la

presenza di malattia attiva solo a livello renale e surrenale sinistra.

Per tossicità interrompe terapia .

Rivalutazione a ottobre con conferma della stabilità di malattia

Gennaio 2017

Nefrectomia allargata sinistra con surrenectomia omolaterale

With the exception of brain and possibly bone metastases,

metastasectomy remains by default the only local treatment for

most sites.

Retrospective comparative studies consistently point towards a

benefit of complete metastasectomy in mRCC patients in terms

of overall survival, cancer-specific survival and delay of systemic

therapy.

Recommendations

No general recommendations can be made. The decision to

resect metastases has to be taken for each site, and on a

case-by-case basis; performance status, risk profiles, patient

preference and alternative techniques to achieve local control

such as stereotactic radiotherapy, must be considered.

Patients with metastatic renal cell carcinoma should be considered for multimodal therapy, including surgery of metastatic lesions. A proportion of patients will achieve long-term survival with aggressive surgical resection.