腎癌預(yù)后及隨訪課件

腎細(xì)胞癌的預(yù)后及隨訪

prognosisandsurveillanceofrenalcellcarcinomaPart1:預(yù)后因素1.解剖學(xué)因素2.組織病理學(xué)因素3.臨床因素4.分子遺傳學(xué)因素5.預(yù)后預(yù)測系統(tǒng)及量表1.解剖學(xué)因素Campbell-WalshUrology;10Thedition

2.組織病理學(xué)因素

（GradingSystem）FuhrmanSA,LaskyLC,LimasC.Prognosticsignificanceofmorphologicparametersinrenalcellcarcinoma.AmJSurgPathol1982Oct;6(7):655-63.organ-confinedtumorsZhangC,LiX,HaoH,etal.BJUInternational2012;110:E481-485.LeibovichBC,LohseCM,CrispenPL.etal.JUrol2012;183:1309-13162.組織病理學(xué)因素(Subtype)ccRCCweremorethan3timesaslikelytodieofRCCthanpatientswithpapillaryandchromophobeRCC(HR3.29,95%CI2.59–4.18,p<0.001)ccRCCwerealmost4timesaslikelytohaveprogressiontodistantmetastasisthanpapillaryandchromophobeRCC(HR3.82,95%CI2.86–5.11,P<0.001)2.組織病理學(xué)因素(otherfactors)LeibovichBC,LohseCM,CrispenPL.etal.JUrol2012;183:1309-1316ALLM02,662Pts2.組織病理學(xué)因素(otherfactors)MicrovascularInvasion(CSS)ALL

M0M1

KroegerN,RampersaudEN,PatardJ,etal.JUrol2012;187:418-4233.臨床因素體能狀況癥狀惡液質(zhì)樣癥狀年齡貧血ESRLeibovichBC,LohseCM,CrispenPL.etal.JUrol2012;183:1309-13163.臨床因素（age）5yrCSSfortheyoungandtheoldwere92%and84%5yrOSfortheyoungandtheoldwere91%vs77%AzizA,MayM,ZigeunerR,etal.JUrol2014;191:310-315.3.臨床因素（ESR&Aneamia)ChoiY,ParkB,KimK,etal.BrJCa2013;108:387-394.ChoiY,ParkB,KimK,etal.BrJCa2013;108:387-394ESR:>22mmperhourformales,>29mmperhourforfemalesMultivariateanalyses:PatientswithhighlevelESRVSlowlevels:HR2.10(95%CI:1.21–3.67)5-yrCSSPatientswithanaemiaVSpatientswithout,theHR(95%CIs)was2.01(1.22–3.29)Cutoff:Hb:<13.5gdl-1formales,<12gdl-1forfemales;Hct:<41%formales,<36%forfemales4.分子遺傳學(xué)因素CarbonicanhydraseIX(CaIX),VEGF,HIF,Ki67(proliferation),p53,PTEN(cellcycle),E-cadherin,CRP,andCD44(celladhesion)這些標(biāo)記物并未改善當(dāng)前預(yù)后分析系統(tǒng)的預(yù)測精確性這些標(biāo)記物無助于發(fā)現(xiàn)新的臨床預(yù)測因子5.預(yù)后預(yù)測系統(tǒng)及量表Kattan(61-81%)UISS(81%)SSIGN(81-88%)Karakiewicz(89%)FlaniganRC,PolcariAJ,HugenCM.IntJUrol2011;18:20-31.5.預(yù)后預(yù)測系統(tǒng)及量表Karakiewiczetal.J.Clin.Oncol.2007;25:13165.預(yù)后預(yù)測系統(tǒng)及量表PART2:隨訪術(shù)后并發(fā)癥腎臟功能術(shù)后復(fù)發(fā)遠(yuǎn)處轉(zhuǎn)移時(shí)間間隔檢查內(nèi)容Cost-EffectivenessRiskstratification術(shù)后隨訪的目的是什么？新發(fā)病灶預(yù)示局部疾病還是系統(tǒng)性疾??？針對該病灶有無有效治療方式？早發(fā)現(xiàn)早治療是否能否使患者生存獲益？UISSEAUguidelineI期(T1N0M0)項(xiàng)目（年）0.51.01.52.02.53.04.05.0H&P&&&血液生化&&&腹部影像PNBaseline3-12m&&&RNFirst

3-12m&&&胸部影像&&&其他器官影像根據(jù)臨床癥狀決定檢查項(xiàng)目II-III期(T1-2N1M0;T3NxM0)項(xiàng)目（年）0.511.522.5345H&P3-6m&&血液生化&&&腹部影像Baseline3-6m&&胸部影像Baseline3-6m&&其他器官影像根據(jù)臨床癥狀決定檢查項(xiàng)目腹部影像及胸部影像在5年后根據(jù)臨床需要進(jìn)行檢查3651例患者，1088例復(fù)發(fā)（29.8%)中位隨訪時(shí)間9yr（5.7-14.4yr）中位復(fù)發(fā)時(shí)間1.9yr（IQR0.6-5.5yr）LR-PN、LR-RN、M/HR分別需隨訪15,21,14yr才能實(shí)現(xiàn)95%發(fā)現(xiàn)率StewartSB,ThompsonRH,PsutkaSP,etal.JClinOncol2014;doi:10.1200/JCO.2014.58.3195指南推薦的隨訪策略是否完美？2%relatedcancerBrennerDJ,HallEJ.NEnglJMed2007;357:2277-84.DiagnosticRadiationExposureDuring

SurveillanceinPatientsWithpT1aRCC252pT1apts,8ptsrecurrenceMeanradiationdosesinyears1,2to5,and>6aftersurgerywere11.4,47.0,and13.8mSv,respectivelyRelativerisksofradiationinducedsolidcancersandleukemiawere1.05and1.12,respectivelyLipskyMJ,ShapiroEY,HrubyGY,etal.Urol2013;80:1190-1195.58mRCCptsMedianfollowup31.4mMedianPFS12.4m(48ptswiththebestresponseSD)47ptsPDatthetimeofdatacutoffParkI,LeeJ,AhnJH,etal.