目的:更新肾癌的治疗建议。
方法:对2015年至2022年的文献进行了系统回顾。关于诊断的最相关的文章,分类,手术治疗,我们选择了肾癌的药物治疗和随访,并将其纳入建议.因此,在说明证据水平(高或低)的同时更新了建议.
结果:诊断和评估肾癌的金标准是胸部和腹部CT的对比增强。特殊情况下应进行MRI和超声造影检查。在结果会影响治疗决策的情况下,建议进行经皮活检。肾肿瘤应根据pTNM2017分类进行分类,WHO2022分类和ISUP核仁等级。转移性肾癌应根据IMDC标准进行分类。部分肾切除术是T1a肿瘤的金标准治疗方法,可以通过开放方法进行,通过腹腔镜检查或机器人引导。无论患者的年龄如何,都可以考虑对小于2cm大小的肿瘤进行主动监测。消融治疗和积极监测是老年合并症患者的选择。T1b肿瘤应根据肿瘤的复杂性通过部分或根治性肾切除术治疗。根治性肾切除术是局部晚期癌症的一线治疗方法。对于肾切除术后复发的中度和高风险患者,应考虑使用派姆单抗辅助治疗。在转移性患者中:如果可以完成转移,则可以向寡转移患者提供立即的细胞减灭性肾切除术,并结合转移的局部治疗,并且对于完全反应或明显部分反应的患者,可以建议延迟的细胞减灭性肾切除术。对于预后较差或中等的患者,应建议将药物治疗作为一线治疗。在单个或寡转移的情况下,可以提出转移的手术或局部治疗。透明细胞肾癌转移性患者的推荐一线药物是阿西替尼/派姆单抗组合,nivolumab/ipililumab,nivolumab/cabozantinib和lenvatinib/pembrolizumab。Cabozantinib是推荐的一线治疗转移性乳头状癌患者。囊性肿瘤应根据Bosniak分类进行分类。应建议将手术切除作为波斯尼亚III和IV病变的优先事项。建议患者监测适应肿瘤的侵袭性。
结论:这些更新的建议是一个参考,将使法语和法语从业者改善肾癌管理。
OBJECTIVE: To update the recommendations for the management of kidney cancers.
METHODS: A systematic review of the literature was conducted from 2015 to 2022. The most relevant articles on the diagnosis, classification, surgical treatment, medical treatment and follow-up of kidney cancer were selected and incorporated into the recommendations. Therefore, the recommendations were updated while specifying the level of evidence (high or low).
RESULTS: The gold standard for the diagnosis and evaluation of kidney cancer is contrast-enhanced chest and abdominal CT. MRI and contrast-enhanced ultrasound are indicated in special cases. Percutaneous biopsy is recommended in situations where the results will influence the therapeutic decision. Renal tumours should be classified according to the pTNM 2017 classification, the WHO 2022 classification and the ISUP nucleolar grade. Metastatic kidney cancer should be classified according to the IMDC criteria. Partial nephrectomy is the gold standard treatment for T1a tumours and can be performed by an open approach, by laparoscopy or by robot-guidance. Active surveillance of tumours less than 2cm in size can be considered regardless of the patient\'s age. Ablative therapies and active surveillance are options in elderly patients with comorbidity. T1b tumours should be treated by partial or radical nephrectomy depending on the complexity of the tumour. Radical nephrectomy is the first-line treatment for locally advanced cancers. Adjuvant treatment with pembrolizumab should be considered in patients at intermediate and high risk for recurrence after nephrectomy. In metastatic patients: Immediate cytoreductive nephrectomy may be offered to oligometastatic patients in combination with local treatment of metastases if this can be complete and delayed cytoreductive nephrectomy can be proposed for patients with a complete response or a significant partial response. Medical treatment should be proposed as first-line therapy for patients with a poor or intermediate prognosis. Surgical or local treatment of metastases can be proposed in case of single or oligo-metastases. The recommended first-line drugs for metastatic patients with clear cell renal carcinoma are the combinations axitinib/pembrolizumab, nivolumab/ipililumab, nivolumab/cabozantinib and lenvatinib/pembrolizumab. Cabozantinib is the recommended first-line treatment for patients with metastatic papillary carcinoma. Cystic tumours should be classified according to the Bosniak classification. Surgical removal should be proposed as a priority for Bosniak III and IV lesions. It is recommended that patient monitoring be adapted to the aggressiveness of the tumour.
CONCLUSIONS: These updated recommendations are a reference that will allow French and French-speaking practitioners to improve kidney cancer management.