Stereotactic Lub Cev Radiotherapy nyob rau hauv Contralateral raum Oligometastasis Los ntawm Lub Raum Cell Carcinoma hauv Tus Neeg Mob Nephrectomized
Apr 17, 2023
Keeb kwm: Lub raum cell carcinoma (RCC) nquag metastasizes rau cov kab mob hauv nruab nrog cev xws li lub ntsws, plab, pob txha, thiab lub hlwb. Txawm hais tias tsis tshua muaj tshwm sim ntawm adrenal qog metastasis los ntawm RCC tau piav qhia, rau peb txoj kev paub, tsis muaj cov xwm txheej tau tshaj tawm txog kev siv lub cev siv hluav taws xob hauv lub cev (SBRT) hauv contralateral raum oligometastatic hauv cov neeg mob nephrectomized nrog RCC.
Raws li cov kev tshawb fawb muaj feem xyuam, cistanche yog ib txwm suav tshuaj ntsuab uas tau siv rau ntau pua xyoo los kho ntau yam kab mob. Nws tau raug tshawb fawb pov thawj kom muajanti-inflammatory, anti-aging, thiabantioxidantkhoom. Cov kev tshawb fawb tau pom tias cistanche muaj txiaj ntsig zoo rau cov neeg mobraug mob raum. Cov khoom xyaw nquag ntawm cistanche paub tias txo qhov mob,txhim kho lub raum ua haujlwmthiab restoreimpaired raum hlwb. Yog li, integrating cistanche nyob rau hauv ibkab mob raumKev npaj kho mob tuaj yeem muab txiaj ntsig zoo rau cov neeg mob hauv kev tswj hwm lawv tus mob.Cistanchepab txo qis proteinuria, txo qis BUN thiab creatinine qib, thiab txo qhov kev pheej hmoo ntxivraum puas. Tsis tas li ntawd, cistanche kuj pab txo cov roj cholesterol thiab triglyceride qib uas tuaj yeem ua rau muaj kev phom sij rau cov neeg mobkab mob raum.
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Case Report:Peb tshaj tawm cov xwm txheej tsis tshua muaj tshwm sim ntawm ib leeg lub raum mob qog noj ntshav los ntawm RCC hauv tus poj niam hnub nyoog 65- xyoo uas tau tshwm sim 1 xyoo tom qab txoj cai radical nephrectomy. Thaum kuaj pom tus mob rov qab los, tus neeg mob tau txais kev kho mob nrog sunitinib rau 9 lub hlis sib law liag, uas ua rau muaj kev cuam tshuam ib nrab ntawm lub raum metastasis. Txhawm rau khaws cov khoom nruab nrog cev thiab sib sau cov lus teb, SBRT raug tswj hwm rau cov khoom seem. Cov phiaj xwm kho tau raug txiav tawm ib ntus 15 hnub ua ntej thiab tom qab SBRT. Tag nrho cov koob tshuaj SBRT yog 40 Gy hauv 5 feem pua ntawm txhua hnub tau muab nrog lub ntim ntim hloov pauv thiab cov txheej txheem duab qhia. Peb lub hlis tom qab, cov duab magnetic resonance tau sau txog qhov ua tiav ntawm tus kab mob, qhov tshwm sim uas tshwm sim ntawm qhov kev soj ntsuam zaum kawg 19 lub hlis tom qab SBRT.
Xaus:Kev sib xyaw ua ke ntawm kev kho mob raws sij hawm thiab SBRT tau muab cov txiaj ntsig zoo hauv tus neeg mob uas muaj lub raum nyob ib leeg uas tau ntsib kev cuam tshuam rau lub raum metastasis los ntawm RCC. Txoj kev kho mob no tau txais txiaj ntsig zoo thiab tswj tus kab mob.
Ntsiab lus:Antineoplastic agents, carcinoma-lub raum cell, tshuaj kho mob, neoplasm metastasis, radiosurgery
Taw qhia
Lub raum cell carcinoma (RCC) yog hom thib peb feem ntau ntawm cov qog nqaij hlav urological tom qab prostate thiab zais zis, thiab ntawm cov neeg mob uas muaj kab mob pib hauv zos uas tau txais nephrectomy, 30 feem pua rau 40 feem pua ntawm cov kab mob metastases.1 RCC paub zoo rau nws hom kev tsis tuaj yeem pom. kis tau thiab muaj peev xwm metastasize rau yuav luag txhua lub cev sai sai lossis tom qab ncua sijhawm; Nws feem ntau metastasizes rau cov qog nqaij hlav hauv cheeb tsam, lub ntsws, lub siab, pob txha, qog adrenal, lub hlwb, thiab tawv nqaij. Metastasis rau lub raum contralateral tsis tshua muaj tshwm sim, tsis muaj cov ntaub ntawv qhia txog peb qhov kev paub txij li lub Yim Hli 2020, thiab qhov tshwm sim ntawm kev txhim kho asynchronous contralateral thawj mob qog noj ntshav yog tsawg. Cov teeb meem tshwm sim yog qhov sib txawv ntawm cov kab mob metastatic los ntawm cov qog asynchronous hauv lub raum tom qab nephrectomy residual raum, nrog rau biopsy tsis tuaj yeem cais tawm ntawm 2 qhov chaw.
Molecular targeted therapy tau txhim kho qhov kev cia siab ntawm cov neeg mob nrog metastatic RCC. Lub tyrosine kinase inhibitor sunitinib muaj kev tshaj tawm txog kev muaj sia nyob nruab nrab ntawm 11.5 lub hlis thiab tag nrho cov ciaj sia taus ntawm 26 lub hlis uas tuaj yeem ncav cuag 40 lub hlis nrog kev kho kom txaus.1,2 Nyob ntawm lawv lub hnub nyoog thiab keeb kwm, cov neeg mob metastatic RCC tuaj yeem tau txais kev kho mob sib txawv. , suav nrog kev phais, kev kho mob molecular, thiab immunotherapy.3 Thaum tus qauv kev saib xyuas rau metastatic RCC yog kev kho mob, kev kho mob hauv zos ntawm metastases tseem muaj teeb meem.
Lub xeev oligometastatic yog ib qho kab mob tshiab (ntau yam txhais nrog 1 txog 5 metastases) uas yog amenable rau kho cov tswv yim kho mob.4 Cov neeg mob uas tswj cov qog thawj zaug thiab cov kab mob oligometastatic tuaj yeem kho tau zoo nrog cov kev kho mob hauv zos xws li kev phais lossis kab mob metastasis-directed radiotherapy. .5 Ib qho kev phais tau qhia tias cov neeg mob uas tau xaiv RCC tau txais kev kho mob-tsim metastasectomy muaj sia nyob nrog lub sijhawm tsis muaj kab mob ntev dua piv nrog cov neeg mob uas tsis tau txais cov tshuaj metastasectomy.6 Lwm cov koob qhia tau tias muaj kev ciaj sia zoo dua tom qab tshem tawm ntawm ntau qhov txwv metastases.7 Cov kev tshawb pom no tau pom. uas ua tiav metastasectomy hauv cov neeg mob xaiv nrog oligometastatic RCC tuaj yeem txhim kho kev ciaj sia thiab kev ua neej zoo. Stereotactic lub cev radiotherapy (SBRT), ib hom kev kho mob hauv zos hauv zos hauv cov neeg mob uas muaj tus lej tsawg (tsawg dua lossis sib npaug rau 5) ntawm cov metastases nyob deb, tau piav qhia thaum Lub Kaum Hli 2018 ntawm European Society for Medical Oncology Congress hauv Munich, Lub Tebchaws Yelemees, raws li "ib qho thev naus laus zis tshiab hauv kev kho hluav taws xob xa hluav taws xob, tso cai rau qhov muaj peev xwm kho tau hauv cov neeg mob oligometastatic." Kev xaiv ntawm SBRT lossis kev phais yuav tsum tau ua raws li qhov xwm txheej thiab qhov zoo tshaj plaws los ntawm pab pawg ntau yam.
Vim hais tias RCC feem ntau suav hais tias yog cov qog hluav taws xob tiv thaiv kab mob, cov kab mob sib kis tau zoo tau siv keeb kwm yav dhau los rau ob peb lub sijhawm thiab tsuas yog muaj kev mob siab rau.9 Txawm li cas los xij, tsis ntev los no (2019) cov ntaub ntawv xov tooj cua tau pom tias cov qog radioresistance tuaj yeem kov yeej nrog kev nce koob tshuaj, tshwj xeeb tshaj yog los ntawm kev nce ntxiv. koob tshuaj ib feem.10 SBRT, txhais raws li 1 mus rau 5 kev kho mob ntawm high-dose hluav taws xob xa mus rau cov qog nqaij hlav, tau pib siv los tswj lub hlwb metastases tab sis kuj tau siv rau extracranial metastases.11,12 SBRT tso cai rau kev tswj hwm ntawm sab nraud nqaj nrawm. hypofractionated siab koob tshuaj rau cov metastasis thiab spares ib puag ncig cov ntaub so ntswg noj qab haus huv los ntawm kev poob sai ntawm koob tshuaj sab nraum lub hom phiaj.
Peb tshaj tawm cov xwm txheej tsis tshua muaj tshwm sim ntawm ib leeg lub raum metastasis los ntawm RCC uas tshwm sim 1 xyoos tom qab txoj cai radical nephrectomy thiab tau kho nrog kev kho mob thiab SBRT.
CAS REPORT
Ib tug {{0}}-xyoo-laus poj niam tsim contralateral lub raum metastasis 1 xyoo tom qab sab laug radical nephrectomy rau ntshiab cell RCC. Tus neeg mob tau raug xa mus rau peb lub tuam tsev thaum lub Plaub Hlis 2018 thiab muaj kev noj qab haus huv tag nrho, nrog rau Karnofsky Performance Status qhab nia ntawm 100 feem pua. Nws cov keeb kwm kev kho mob suav nrog ntshav qab zib mellitus, arterial hypertension, thiab hypothyroidism pharmacologically tswj tau zoo. Cov cim ntawm lub cev muaj raws li nram no: taw qhia, kev sib koom tes, thiab kev taug kev autonomous; tsis muaj kev kuaj mob neurologic txawv txav; ntshav siab 125/70 mmHg thiab mem tes 75/min; tsis kub taub hau; thiab ua haujlwm ntawm lub plab thiab zais zis. Cov kev kuaj sim niaj hnub suav nrog kev suav ntshav kom tiav, kuaj lub raum thiab lub siab ua haujlwm, thiab suav cov electrolyte nyob rau hauv ib txwm muaj. Radical txoj cai nephrectomy tau ua thaum lub Plaub Hlis 2016, thiab kev tshawb pom tom qab kev kho mob tau lees paub qhov pom tseeb ntawm cov cell RCC qib 2 qog nqaij hlav (pT2N0M0 theem II) raws li American Joint Committee on Cancer 2017 cancer staging.13 Tsis muaj kev rov tshwm sim thaum rov qab mus txog thaum Lub Xya hli ntuj 2017, thaum tag nrho lub cev xam tomography (CT) qhia ib tug 24- hli enhanced loj nyob rau hauv lub raum sab laug nyob rau hauv tsis muaj lwm yam cim ntawm metastasis nyob rau hauv lub hlwb, lub ntsws, lub siab, plab lymph nodes, thiab cov pob txha. Tus neeg mob tsis kam muab biopsy, yog li contralateral raum metastasis es tsis yog asynchronous thawj qog tau kuaj pom raws li lub sij hawm luv luv los ntawm nephrectomy-14 lub hlis-thiab qhov chaw ntawm qhov chaw ntawm qhov txhab.
Tus neeg mob pib lub hom phiaj kev kho mob nrog sunitinib, noj ntawm koob tshuaj 50 mg ntawm qhov ncauj ib zaug ib hnub rau 4 lub lis piam ntawm txhua 6- lub lim tiam. Cuaj hlis tom qab, lub raum metastasis tau txo los ntawm 24 hli mus rau 12 hli. Tus neeg mob cov ntaub ntawv tau tham los ntawm pawg kws kho mob urological multidisciplinary ntawm peb lub tsev kho mob, thiab SBRT cov lus qhia rau lub raum residual lesion (Daim duab 1) tau koom nrog rau txhua tus kws kho mob tshwj xeeb nrog lub hom phiaj los sib sau cov lus teb tau nrog kev kho mob. Cov phiaj xwm kho tau raug txiav tawm ib ntus 15 hnub ua ntej thiab tom qab SBRT. Txhawm rau txheeb xyuas lub hom phiaj zoo dua, tus neeg mob tau kawm nrog kev sib nqus resonance imaging (MRI).
Kev npaj CT scan tau txais nrog tus neeg mob nyob rau hauv lub supine txoj hauj lwm nyob rau hauv ib tug immobilization ntaus ntawv, thiab ib tug tshwj xeeb tsim kev koom tes system (lub cev ncej) tau siv rau qhov tseeb localization ntawm lub qog. Lub ntsej muag lub ntsej muag lub ntsej muag tau siv los txo qis kev teeb tsa. MIMvista, version 6.6 (MIM Software Inc) tau siv rau ntim contouring thiab duab fusion ntawm MRIs nrog kev npaj CT. Tag nrho cov qog nqaij hlav (GTV) tau txhais tias yog qhov pom pom qhov pom ntawm qhov pom ntawm qhov sib txawv hauv qhov sib piv-txhim kho T2- hnyav MRI ib ntus. Clinical target volume (CTV) yog coincident nrog GTV, thiab npaj lub hom phiaj ntim (PTV) yog GTV/CTV ntxiv rau ntxiv 4 hli nyob rau hauv tag nrho cov lus qhia. Tus txha caj qaum, ib qho kev nyab xeeb ntawm qaum qaum (txoj kev npaj cawm lub ntim), lub raum sab laug, thiab lub plab me me tau txiav txim siab raws li lub cev muaj kev pheej hmoo (Daim duab 2).
SBRT tau raug tswj hwm los ntawm kev siv cov txheej txheem volumetric modulated arc therapy thaum tsis muaj kev ua pa dawb lossis ua tsis taus pa, tsim nrog Monaco Treatment Planning system (Elekta AB) ntawm Monte Carlo algorithm. Kev kho mob tau xa tuaj siv Elekta Synergy linear accelerator nrog 6-MV x-ray beam zog yam tsis muaj lub ntsej muag lim-dawb hom thiab ib qho arc ntawm 340 degree tig clockwise ntawm 190 degree mus rau 170 degree . Qhov kev txheeb xyuas tsis meej ntawm Monte Carlo algorithm yog 1 feem pua, thiab cov koob tshuaj zaum kawg tau suav nrog daim phiaj daws teeb meem ntawm 2 hli. Cov koob tshuaj yog tag nrho ntawm 40 Gy hauv 5 feem ntawm txhua hnub sib law liag, nrog 95 feem pua ntawm PTV tau txais tsawg kawg yog 95 feem pua ntawm cov tshuaj noj. Cov koob tshuaj txwv tau txais yuav yog cov uas tau hais los ntawm Hanna thiab al (ie, Dmean yog 40 Gy; V10Gy rau lub raum ib leeg yog 28 feem pua ) .14 Cov PTV thiab cov kab mob hauv lub cev uas muaj kev pheej hmoo yog qhia nyob rau hauv lub Rooj.
Tus neeg mob tsis tau txais cov tshuaj premedications thiab tsis muaj kev mob tshwm sim thaum kho. Tsis muaj kev hloov kho lub raum ua haujlwm tau pom 1 lub lis piam tom qab SBRT. creatinine thiab creatinine tshem tawm qhov tseem ceeb ua ntej SBRT thiab tom qab SBRT tseem nyob ruaj khov (1.4 mg / dL thiab 38 mL / min, feem). Txhawm rau tiv thaiv tau CT iodine contrast nephrotoxicity, radiologic follow up with MRI tau ua 3 lub hlis tom qab SBRT thiab txhua 4 lub hlis tom qab. Thaum kawg ntawm kev soj ntsuam 19 lub hlis tom qab SBRT, MRI tau pom cov lus teb tiav; qhov kho qhov txhab tsis pom lawm (Daim duab 3).
Kev sib tham
Hauv metastatic RCC, kev kho mob yog lub hauv paus ntawm kev kho mob. Targeted therapy nrog tyrosine kinase inhibitors thiab checkpoint inhibitors tau raug tsim los ua ib qho kev kho mob zoo rau metastatic RCC, tab sis tsuas yog ib pawg neeg ntawm cov neeg mob ua tiav cov lus teb tom qab cov phiaj xwm kho.15 Ntxiv cov kev xav tau los txhim kho cov neeg ua haujlwm zoo. Ib lub tswv yim tso siab rau kev sib koom ua ke ntawm cov phiaj xwm kev kho mob nrog cov xov tooj cua, yog li ua rau muaj kev nkag siab zoo ntawm RCC rau cov txiaj ntsig ntawm ionizing hluav taws xob vim yog kev sib koom ua ke ntawm cov qauv no.16 Hauv ntau cov kev tshawb fawb soj ntsuam, SBRT tau pom tias muaj txiaj ntsig zoo hauv kev tswj cov pob txha thiab mob ntsws metastases los ntawm RCC.17 Txawm li cas los xij, cov ntaub ntawv tsawg muaj nyob ntawm SBRT kev ua tau zoo hauv RCC cuam tshuam rau lwm yam kabmob. Nyob rau hauv ib tug yav tom ntej theem 2 mus sib hais, Svedman et al tau tsim hais tias SBRT rau cov neeg mob uas muaj thawj thiab metastatic RCC muab ib tug siab npaum li cas ntawm cov kev tswj hauv zos (98 feem pua ) .18 Wersäll thiab cov npoj yaig tau pom qhov kev tswj hwm hauv cheeb tsam ntawm 90 feem pua tom qab SBRT ntawm metastatic RCC rau lub ntsws, lub raum txaj, cov qog nqaij hlav, thiab cov qog adrenal.19 Altoos li al, tshuaj xyuas cov lus teb ntawm SBRT piv rau cov kev siv hluav taws xob fractionated rau thoracic, plab, tawv nqaij, thiab cov nqaij mos RCC, qhia txog kev tswj tus nqi ntawm 12 thiab 24 lub hlis. Raws li, ntawm 100 feem pua thiab 93.41 feem pua rau SBRT vs 62.02 feem pua thiab 35.27 feem pua rau kev siv hluav taws xob sib xyaw ua ke.20 Hauv kev tshawb nrhiav kev rov qab los ntawm ntau qhov chaw Italian tshawb xyuas cov txiaj ntsig ntawm kev kho mob nrog SBRT hauv 57 cov kab mob uas tsis yog hlwb thib ob tau kuaj pom hauv RCC, Tab sis cov neeg mob metabolic 48. et al tau tshaj tawm txog 1-xyoo kev tswj hwm hauv cheeb tsam ntawm 87.7 feem pua ntawm SBRT, thiab 18 tus neeg mob (37.5 feem pua) cuam tshuam txoj kev kho mob tas li tom qab SBRT.21 Cov kev tshawb fawb no qhia tias SBRT tuaj yeem ua tau zoo hauv kev tswj cov kab mob RCC ntau dua li qis- koob tshuaj siv hluav taws xob.
Lub radioresistance ntawm RCC tuaj yeem kov yeej los ntawm cov txiaj ntsig radiobiologic uas tau txais los ntawm hypofractionation thiab cov koob tshuaj ntau dua uas tau tswj hwm nrog SBRT. Tshwj xeeb, SBRT nyob rau hauv cov qog hypervascular xws li RCC ua rau endothelial raug mob thiab cov teebmeem antiangiogenic.16 Yog li, nyob rau hauv qhov chaw metastatic, thiab tshwj xeeb tshaj yog nyob rau hauv cov theem oligometastatic nrog cov qog nqaij hlav tsawg, SBRT tuaj yeem sawv cev rau qhov kev cog lus hauv zos kho kev xaiv ua ke nrog. tshuaj tshiab. Nyob rau hauv peb cov ntaub ntawv tsis tshua muaj ntawm RCC nyob rau hauv ib tug twb nephrectomized tus neeg mob nrog contralateral lub raum metastasis ib feem teb rau 1 xyoo ntawm lub hom phiaj kev kho mob, peb txiav txim siab mus nrhiav ib tug radical lub hom phiaj los ntawm kev tswj SBRT ntawm cov residual raum lesion. Hauv qhov xwm txheej ntawm lub raum tom qab kev phais mob, qhov teeb meem tseem ceeb yog xa cov tshuaj ablative rau cov qog nqaij hlav thaum ua haujlwm tsis zoo ntawm cov nephrons los ntawm hluav taws xob raug mob. Cov txheej txheem SBRT, nrog hypofractionated radiotherapy, high-precision irradiation, thiab kev txheeb xyuas txhua hnub lub hom phiaj los ntawm cone beam CT, tso cai rau peb mus txog lub hom phiaj yam tsis muaj kev puas tsuaj ntawm tus neeg mob lub raum kev ua haujlwm.
TEEB MEEM
Txawm hais tias peb paub tias "tus nqos tsis ua rau lub caij nplooj ntoo hlav," qhov tsis tshua muaj tshwm sim tau piav qhia hauv peb cov ntaub ntawv qhia txog qhov ua tau thiab kev ua tau zoo ntawm SBRT ua ke nrog kev kho rau lub raum oligometastatic los ntawm RCC hauv cov neeg mob uas muaj lub raum nyob ib leeg.
TXOJ CAI
Tag nrho cov txheej txheem ua tiav hauv txoj kev tshawb fawb no nrog tib neeg cov neeg koom nrog yog los ntawm cov qauv kev coj ncaj ncees ntawm lub koom haum thiab / lossis pawg tshawb fawb hauv tebchaws thiab nrog rau 1964 Helsinki Tshaj Tawm thiab nws cov kev hloov kho tom qab lossis cov qauv coj sib piv. Cov ntaub ntawv tso cai tau txais los ntawm tus neeg mob nrog rau hauv txoj kev tshawb no. Cov neeg sau ntawv tsis muaj nyiaj txiag lossis muaj tswv yim txaus siab rau cov ntsiab lus ntawm tsab xov xwm no.
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