Dergiler / Türk Üroloji Dergisi/Turkish Journal of Urology / 2006 / Cilt: 32 - Sayı: 2
Böbrek hücreli kanserlerde multifokalite ile ilişkili klinik ve patolojik faktörler
- Sayfa
- 168–173
- DOI
- —
Özet
Radikal nefrektomi, Böbrek Hücreli Kanserde (BHK) standart tedavi yöntemidir. Ancak günümüzde nefron koruyucu cerrahi küçük, düşük klinik evreli ve periferal yerleşimli BHK'larda tedavi seçeneği olmuştur. Fakat uygulanışı multifokalite riski olması nedeniyle tartışmalıdır. Bu çalışmanın amacı; böbrek tümörü nedeniyle radikal nefrektomi yapılan ve patolojisi BHK olan 65 hastada multifokalite oranını ve klinik-patolojik risk faktörlerini belirlemek idi. Ocak 2002-Ocak 2004 tarihleri arasında böbrek tümörü nedeniyle radikal nefrektomi yapılan ve patolojisi BHK olan 65 hasta çalışmaya dahil edildi. Patoloji materyalleri boyut, histopatolojik tip, grade, vasküler invazyon, böbrek kapsülü ve lenfatik invazyon yönünden incelendi. Primer tümör psödokapsülünün ötesindeki tümörler 'satellit tümör' olarak kabul edildi. Hastaların ortalama yaşı 57.6 (13-78) idi. Tümör 34 hastada sağ, 31 hastada sol böbrek yerleşimli idi. 65 hastanın 11'inde (%16.9) multifokal tümör belirlendi. Multifokal ve unifokal hastalığa sahip hastalar arasında tümör boyutu, tümör yerleşimi, grade, patolojik ve klinik evre açısından istatistiksel anlamlı fark saptandı (p<0.05). Literatürde değişik oranlarda ve değişik parametrelerle ilişkili multifokal BHK bildirilmiştir. Multifokalitenin ilişkili olduğu net bir parametre ortaya konulamamış yada bu konuda fikir birlikteliği sağlanamamıştır. Bizim çalışmamızın sonuçlarına göre ileri evre ve sol böbrek yerleşimli tümörlerde mümkün olduğu kadar nefron koruyucu cerrahi uygulanmamalıdır ve ameliyat sonrası takip multifokalite riski nedeniyle dikkatli yapılmalıdır.
Abstract
Introduction: Renal cell carcinoma (RCC) is the most common type of renal tumors and constitutes 3% of all malignancies. Radical nephrectomy with lymphadenectomy is the standard approach in treatment. On the other hand, nephron sparing surgery (NSS) has been an alternative treatment in patients with small tumor volume, low clinical stage and peripheral localization recently. Nephron sparing surgery was described initially in 1890 but, it became popular not long ago due to detecting tumors incidentally at low stage and small diameter by the use of advanced imaging techniques. However, its use instead of radical nephrectomy remains controversial because of the risk of existing, clinically undetectable satellite lesion (multifocality). The aim of this study was to determine the rate of clinically occult tumor multifocality in 65 patients with RCC, who underwent radical nephrectomy for renal tumor and to evaluate the clinical and pathological factors associated with multifocality. Materials and Methods: From January 2002 to January 2004, 65 patients who underwent radical nephrectomy for renal tumor and had postoperative pathologic diagnosis of RCC were included in the study. Physical examination and preoperative imaging techniques including Computerized Tomography (CT), renal ultrasonography (USG) and chest radiography were performed routinely in all patients to identify multifocality. The kidney samples were first step sectioned at 1 cm intervals and then at 3 mm intervals and examined for multifocality. Pathological features included tumor size, histological subtype, nuclear grade, vascular invasion, renal invasion, renal capsular invasion and lymphatic invasion. Staging was defined according to the TNM staging system. Tumors at the further side of pseudocapsule of primer tumor were defined as 'satellite tumor'. Multivariate analyze was performed to identify the risk factors associated with multifocality. Results: The mean age of 65 patients (22 women and 43 men) included in the study was 57.6 (13-78). Evaluating patients according to tumor localization, 34 and 31 patients had tumor at right and left kidney, respectively. Of the 65 patients 11 (16.9%) had multifocal tumor. Only 1 case (1.5%) had evidence of multifocality on preoperative imaging and, therefore, occult multifocality undetected on preoperative imaging was present in 15.3% of radical nephrectomies (10 of 65). In comparing patients with multifocal disease those with unifocal disease, the groups were significantly different with regard to tumor size, nuclear grade, pathological stage, clinical stage and tumor localization (p<0.05). Conclusion: NSS has been appeared to be an alternative treatment to radical nephrectomy for selected patients with small, incidentally discovered tumors. Despite this, the high frequency of multifocal renal cortical tumors reported in the literature has caused some urologists to be concerned about recurrence due to satellite tumors missed at NSS. Multifocality has been reported to be 7-25% in previous reports. In our study, multifocality rate was determined as 16.9%. Several clinical and pathological features were associated with multifocality, including tumor size, tumor localization, grade, pathologic stage and clinical stage. These results suggest that NSS may not be adequate in patients with advanced stage and tumor localized at left kidney. Close follow-up should be performed due to risk of multifocality.