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Guidelines on renal cell carcinomaEAU-Guidelines-Renal-Cell-Cancer-2015-v21Guidelines on renal cell carci221、Introduction2、Treatment of localised RCC3、Treatment of locally advanced RCC4、Treatment of advanced/metastatic RCC5、Systemic therapy for advanced/metastatic RCC31、Introduction3DefinitionRenal Cell Carcinoma,RCCRenalcellcarcinomaisakidneycancerthatoriginatesintheliningoftheproximalconvolutedtubule.RCCisthemostcommontypeofkidneycancerinadults.4DefinitionRenal Cell CarcinomaEpidemiology我国目前研究1 马建辉等收集了中国大陆19882002年15年间数据较齐全的11个研究单位的资料，19881992、19931997、19982002年3个时间段我国肾和泌尿系统其他恶性肿瘤的发病率分别为4.2610万、5.4010万、6.6310万人口，发病率呈现逐年上升趋势。我国上海、南京、广州分别排在第245(4.810万)、273(3.210万)、282(2.310万)。America2Renal cell carcinomas represent about 3%of all newly diagnosed visceral cancers in the United States and account for 85%of renal cancers in adults.Approximately 30,000 new cases/year and 12,000 deaths from the disease.1马建辉,李呜,张思维等.中国部分市县肾癌及泌尿系其他恶性肿瘤发病趋势比较研究J.中华泌尿外科杂志,2009,30(8):511-514.DOI:10.3760/cma.j.issn.1000-6702.2009.08.002.2Jemal A,et al:Cancer statistics,2008.CA Cancer J Clin 2008;58:71.5Epidemiology我国目前研究1 1马建辉,李Risk factors1 2The most significant risk factor tobacco(Cigarette smokers have double the incidence of renal cell carcinoma)pipe and cigar smokers are also more susceptible.Additional risk factorsobesity(particularly in women)hypertension;unopposed estrogen therapy;exposure to asbestos,petroleum products,and heavy metals.1McLaughlin JK,Lipworth L:Epidemiologic aspects of renal cell cancer.Semin Oncol 2000;27:115.2 Moore LE,et al:Lifestyle factors,exposures,genetic susceptibility,and renal cell cancer risk:a review.Cancer Invest 2005;23:240.6Risk factors1 2The most siDiagnosis1.Symptoms Physical examination:Physical examination has a limited role in RCC diagnosis Palpable abdominal mass;Palpable cervical lymphadenopathy;Non-reducing varicocele and bilateral lower extremity oedema,which suggests venous involvement.2.Imaging investigationsGuidelines on Renal Cell Carcinoma.European Association of Urology 20157Diagnosis1.SymptomsGuidelines Diagnosis肾癌的临床诊断主要依靠影像学检查；实验室检查作为对患者术前一般状况、肝肾功能以及预后判定的评价指标；确诊则需依靠病理学检查。1推荐必须包括的实验室检查项目：尿素氮、肌酐、肝功能、全血细胞计数、血红蛋白、血钙、血糖、红细胞沉降率、碱性磷酸酶和乳酸脱氢酶(推荐分级C)2推荐必须包括的影像学检查项目：腹部B超或彩色多普勒超声；胸部X线片(正、侧位)、腹部CT平扫和增强扫描(碘过敏试验阴性、无相关禁忌证者)；腹部CT平扫和增强扫描及胸部X线片是术前临床分期的主要依据(推荐分级A）3推荐参考选择的影像学检查项目：KUB：可为开放性手术选择手术切口提供帮助核素肾图或IVU：可用于未行CT增强扫描，无法评价对侧肾功能者核素骨显像：碱性磷酸酶高、有相应骨症状或临床分期期的患者(证据水平I b)胸部CT扫描：胸部x线片有可疑结节、临床分期期的患者(证据水平I b)头部MRI、CT扫描：有头痛或相应神经系统症状患者(证据水平T b)腹部MRI扫描：肾功能不全、超声波检查或CT检查提示下腔静脉瘤栓患者(证据水平I b)。4有条件地区及患者选择的影像学检查项目：肾超声造影、螺旋CT及MRI扫描：主要用于肾癌的诊断和鉴别诊断正电子发射断层扫描(PET)或PETCT：检查费用昂贵，主要用于发现远处转移病灶以及对化疗、细胞因子治疗、分子靶向治疗或放疗的疗效评定。肾细胞癌诊断治疗指南编写组.肾细胞癌诊断治疗指南(2008年第一版)J.中华泌尿外科杂志,2009,30(1):63-69.8Diagnosis肾癌的临床诊断主要依靠影像学检查；实验室检Guidelines on Renal Cell Carcinoma.European Association of Urology 2015Staging9Guidelines on Renal Cell CarciTreatment of localised RCC(T1-2N0M0)For this Guidelines version,an updated search was performed up to May 31 st,2013.10Treatment of localised RCC(T1Surgical treatmentAdrenalectomyPartialnephrectomy(PN)VSradicalnephrectomy(RN)Lymphnodedissectionforclinicallynegativelymphnodes(cN0)Embolisation：Inpatientsunfitforsurgery,orwithnon-resectabledisease,embolisationcancontrolsymptoms,includinggrosshaematuriaorflankpain11Surgical treatmentAdrenalectomSurgical treatmentConclusions LEPN achieves similar oncological outcomes to RN for clinically localised tumours(cT1).1b Ipsilateral adrenalectomy during RN or PN has no survival advantage.3 In patients with localised disease without evidence of LN metastases,there is no survival advantage of LND in conjunction with RN.1b In patients unfit for surgery with massive haematuria or flank pain,embolisation can be a beneficial palliative approach.312Surgical treatmentConclusions Surgical treatmentRecommendations GRSurgery is recommended to achieve cure in localised RCC.BPN is recommended in patients with T1a tumours.APN should be favoured over RN in patients with T1b tumour,whenever feasible.BIpsilateral adrenalectomy is not recommended when there is no clinical evidence of invasion of the adrenal gland.B LND is not recommended in localised tumour without clinical evidence of LN invasion.A13Surgical treatmentRecommendatiRadical nephrectomyLaparoscopic vs Open RNItemsLaparoscopicOpenPeri-operative blood lossLessmoreAnalgesic requirementLowerHigherHospital stayShorterLongerOperation timeShorterLongerConvalescence timeShorterLongerOncological outcomes*similarsimilarBlood reansfusionSimilarSimilarComplicationsSimilarSimilarPost-operative QoL scoreSimilarsimilar*Need RCT14Radical nephrectomyLaparoscopiRadical nephrectomyHand-assisted vs standerd laparoscopic RNItemsHand-assistedstanderdOperation timeShorterLongerHospital stayLongerShorterTime to non-strenuous activitiesLongerShorterOSsimilarsimilarCSSsimilarsimilarRFSsimilarsimilar15Radical nephrectomyHand-assistPartial nephrectomyLaparoscopic vs Open PNItemsLaparoscopicOpenPeri-operative blood lossLessmoreOperation timeShorterLongerConvalescence timeShorterLongerWarm ischaemia timeShorterLongerGFR declineGreaterLessPFS and OSsimilarsimilarPost-operative mortalitySimilarSimilarComplicationsSimilarSimilarPost-operative QoL scoreSimilarsimilar16Partial nephrectomyLaparoscopiConclusion and RecommendationsLaparoscopic RN:Lower morbidity,similar oncological outcomesT1:PNT2 or localised masses not treatable by PN:Laparoscopic RN17Conclusion and RecommendationsTherapeutic approaches as alternatives to surgeryPopulation-based analyses show a significantly lower cancer-specific mortality for patients treated with surgery compared to non-surgical management for tumors 75 years).18Therapeutic approaches as alteSurveillanceActive surveillance is defined as the initial monitoring of tumour size by serial abdominal imaging(US,CT,or MRI)with delayed intervention reserved for tumours showing clinical progression during follow-up.Ablative therapiesCryoablation(冷冻消融术)Radiofrequency ablation(射频消融术)Others：microwaveablation,laserablation,andhigh-intensityfocusedUSablation.19Surveillance19RecommendationsRecommendationsGRDue to the low quality of available data no recommendation can be make on RFA and cryoablation.CIn the elderly and/or comorbid patients with small renal masses and limited life expectancy,active surveillance,RFA and cryoablation can be offered.C20RecommendationsRecommendationsTreatmentoflocallyadvancedRCCClinicallypositivelymphnodes(cN+)LocallyadvancedunresectableRCCRCCwithvenousthrombus21Treatment of locally advanced Clinicallypositivelymphnodes(cN+)LNDisjustifiedButtheextentofLNDiscontroversial22Clinically positive lymph nodeLocallyadvancedunresectableRCCEmbolisationcancontrolsymptomsgrosshaematuriaorflankpainTheeffectofneoadjuvanttargetedtherapytodownsizetumoursisunknown.23Locally advanced unresectable RCCwithvenousthrombusTraditionallyundergosurgerytoremovethekidneyandtumourthrombusPre-operativeembolisation(T3RCC)（increasingoperatingtime,bloodloss,hospitalstayandperi-operativemortality）TheroleofIVCfiltersandbypassproceduresremainuncertain24RCC with venous thrombusTraditAdjuvanttherapySeveralRCTsofadjuvantsunitinib,sorafenib,pazopanib,axitinibandeverolimusareongoing.Atpresent,thereisnoevidencefortheuseofadjuvantVEGF-RormTORinhibitors.Thereisnoindicationforadjuvanttherapyfollowingsurgery.25Adjuvant therapySeveral RCTs oTreatment of Advanced/Metastatic Renal Cell Carcinoma26Treatment of Advanced/MetastatContentsI.What is Advanced/Metastatic Renal Cell Carcinoma(RCC)?II.How to Treat it?27ContentsWhat is Advanced/MetasI.What is Advanced/Metastatic Renal Cell Carcinoma28What is Advanced/Metastatic ReII.How to Treat it?1.How to treat the primary lesion？2.Howto deal with the metastases of RCC?29How to Treat it?How to treat tII.How to Treat it?Protocol 1:Cytoreductive nephrectomy combined with interferon-alpha.Protocol 2:Cytoreductive nephrectomy with simultaneous complete resection of a single metastasis or oligometastases.1.How to treat the primary lesion？Cytoreductive Nephrectomy:Indications:Patients with good performance status,large resectable primary tumor and low metastatic volume,no sarcomatoid tumor.30How to Treat it?How to treat tII.How to Treat it?Embolisation of primary tumor:Indications:Patients unfit for surgery,or with non-resectable disease.1.How to treat the primary lesion？31How to Treat it?Embolisation oII.How to Treat it?Metastasectomy:Indications: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,must be considered.Metastases in lung,pancreas,liver et al could be considered.Metastases in brain or possibly bone may be excluded.2.Howto deal with the metastases of RCC?32How to Treat it?MetastasectomyII.How to Treat it?Embolization of bone metastases:Indications:Embolization prior to resection;or for relieving symptomsProtocol 1:Embolization prior to resection of hypervascular bone or spinal metastases.Protocol 2:Embolization of bone or paravertebral metastases.2.Howto deal with the metastases of RCC?33How to Treat it?Embolization oII.How to Treat it?Stereotactic Radiotherapy:Indications:Bone and brain metastases.2.Howto deal with the metastases of RCC?34How to Treat it?Stereotactic RSystemic therapy for advanced/metastatic RCC1 Chemotherapy2 Immunotherapy3 Targeted therapies4 Monoclonal antibody against circulating VEGF5 mTOR inhibitors6 Therapeutic strategies and recommendations35Systemic therapy for advanced/1、ChemotherapyConclusionLEIn mRCC 5-FU combined with immunotherapy has equivalent efficacy to IFN-.1bRecommendationGRIn patients with clear-cell mRCC,chemotherapy is not considered effective.Bmetastatic renal cell carcinoma,mRCC 361、ChemotherapyConclusionLEIn m2、Immunotherapy1.IFN-monotherapy and combined with bevacizumab2.Interleukin-23.Vaccines and targeted immunotherapy372、Immunotherapy1.IFN-monotRecommendationGRMonotherapy with IFN-or HD bolus IL-2 is not routinely recommended as first-line therapy in mRCC.A38RecommendationGRMonotherapy wiTargeted therapiesTargeted therapiesvon Hippel-Lindau(VHL)inactivationhypoxia-inducible factor(HIF)accumulationoverexpression of vascular endothelial growth factor(VEGF and platelet-derived growth factor(PDGF)neoangiogenesisThis process substantially contributes to the developmentand progression of RCC.sunitinibbevacizumabpazopanibtemsirolimuseverolimusaxitinib7.4.3 Targeted therapies39Targeted therapiesvon Hippel-LTyrosine kinase Tyrosine kinase inhibitorsinhibitorssorafenibsunitinibpazopanibaxitiniban oral multikinase inhibitoran oral tyrosine kinase inhibitor and has antitumour and anti-angiogenic activityan oral angiogenesis inhibitoran oral selective second-generation inhibitor of VEGFR-1,-2,and-3.40Tyrosine kinase inhibitorssoraMonoclonal antibody against circulating Monoclonal antibody against circulating VEGFVEGFBevacizumab monotherapybevacizumab+IFN-IFN-Bevacizumab is a humanised monoclonal antibody and the combination has higher median FPS than the monontherapy7.4.4 Monoclonal antibody against circulating VEGF41Monoclonal antibody against ci5、mTOR inhibitorsTemsirolimus:a specific inhibitor of mTOR.Everolimus:an oral mTOR inhibitor,which is established in the treatment of VEGF-refractory disease.425、mTOR inhibitorsTemsiroli6、Therapeutic strategies and recommendationsTherapy for treatment-naive patients with clear-cell mRCCSequencing targeted therapyFollowing progression of disease with VEGF-targeted therapy436、Therapeutic strategies and Treatment after progression of disease with mTOR inhibitionTreatment after progression of disease with cytokinesTreatment after second-line targeted therapyCombination of targeted agents44Treatment after progression ofNon-clear-cell renal cancer No phase III trials of patients with non-clear-cell RCC have been reported.The most common non-clear-cell subtypes are papillary type 1 and 2 RCCs.Another trial investigated foretenib(a dual MET/VEGFR2 inhibitor)in patients with papillary RCC.Collecting-duct cancers are resistant to systemic therapy.45Non-clear-cell renal cancer NReferences1Guidelines on Renal Cell Carcinoma.European Association of Urology 20152马建辉,李呜,张思维等.中国部分市县肾癌及泌尿系其他恶性肿瘤发病趋势比较研究J.中华泌尿外科杂志,2009,30(8):511-514.DOI:10.3760/cma.j.issn.1000-6702.2009.08.002.3Jemal A,et al:Cancer statistics,2008.CA Cancer J Clin 2008;58:71.4McLaughlin JK,Lipworth L:Epidemiologic aspects of renal cell cancer.Semin Oncol 2000;27:115.5 Moore LE,et al:Lifestyle factors,exposures,genetic susceptibility,and renal cell cancer risk:a review.Cancer Invest 2005;23:240.6肾细胞癌诊断治疗指南编写组.肾细胞癌诊断治疗指南(2008年第一版)J.中华泌尿外科杂志,2009,30(1):63-69.46References1Guidelines on RenTHANKS FOR YOUR LISTENING!47THANKS FOR YOUR LISTENING!47
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