肾癌管理流程图（点击查看更清楚）

 

Campbell教授：我认为对我来说最有趣的事是，对于那些符合根治性肾切除标准且有一定肿瘤复发风险、对侧肾功能正常的患者，我们确实努力去完善这个标准，对其行根治性肾切除，使他们获得最好的治愈效果。但对于那些不符合这个标准的患者，则行保留肾单位手术。有了这个严格的标准，我们行肾根治性切除术将会更合理。

 

然而，现在我们对部分并不需要行根治性手术的患者做了根治术，而对确实需要行根治术的患者则做了保留肾的手术。我们确实偶然碰到过一些需要行根治术的高危患者行保留肾手术后出现局部复发。希望我们现在的工作能为如何选择根治手术或保留肾单位手术定出更为符合临床使用的标准，从而更好地指导临床决策。

 

《肿瘤瞭望》：Localized Renal Masses是新指南的一种新定义吗，是否意味着我们不需要在术前准确区分肿瘤的良恶性？

 

Campbell教授：我们主要关注那些在没有做任何治疗之前，肿瘤是呈局灶性生长的患者，而非是否行手术治疗的问题。局灶性指的是肿瘤局限于肾内而没有侵犯至临近器官或者淋巴结，甚至远处转移。指南关注的是早期的肾癌。我们知道在某些患者中，肿瘤看起来是局限在肾内，但是真实的情况是局部进展期肿瘤，指南对此类的患者的治疗也作了相关的解释。最终的病理分期可能是局部进展期（如T3期），组织类型高级别分化较差的侵袭性肿瘤。指南对这些患者的治疗也作了推荐，特别关注了临床医生最难处理的问题

Prof. Campbell: We focus on patients where we think the tumor is clinically localized before any management in undertaken， whether that be surgery or otherwise. Localized refers to whether the tumor is confined to the kidney as opposed to breaking out into the adjacent organs and lymph nodes or metastatic. This Guideline is focused on earlier stage kidney cancer. We know that in some patients where it looks locally confined can end up being locally advanced， so the Guidelines also include statements about how those patients should be managed. The final pathology may come back as high-stage (e.g. locally advanced T3) or the histology may come back as a high-grade， poorly differentiated aggressive cancer. The Guidelines also cover how those patients should be managed but with a special focus on what is most pertinent to the urologist.

 

Campbell教授：指南对影像学方面的评估作了相当详细的推荐。我们更主张高分辨率薄层扫面，无论是否做增强扫面。指南包括实验室检查和转移性病变的评估，以及如何作临床分期和慢性肾功能不全的评估。指南还包括对患者的建议宣教内容，如术后肾功能的改变，术后肿瘤复发等风险。而且还包括选择性肾肿物穿刺活检及后续治疗的推荐。到目前为止，肾癌主要还是采取手术治疗的方式，对大部分患者来说还是主要推荐保留肾单位的手术，虽然有部分患者也推荐性热消融治疗或者根治性手术。对于一些年纪较大，预期寿命有限，任何侵入性治疗均可能发生不良后果的患者，积极主动监测也是一个好的选择。

Prof. Campbell:The Guidelines provide very specific recommendations about evaluation in terms of imaging. We favor cross-sectional， high-resolution， with and without contrast imaging. It includes definitive statements about laboratory evaluation and metastatic workup. It includes recommendations for staging the status and degree of chronic kidney disease. It includes statements about counseling， the functional issues related to management， the potential risks， and the oncological considerations. We also have very clear statements about the selective utilization of renal mass biopsy and then management. Kidney cancer is still mostly a surgical disease， and generally， partial nephrectomy is still the preferred management for most patients， but there is also a clear role for the selective utilization of thermal ablation as well as the selective utilization of radical nephrectomy. There is also a clear role for active surveillance in patients who may be older， patients with limited life expectancy or frailer patients where any intervention may have negative consequences.