RESUMEN
INTRODUCTION AND OBJECTIVES: The aim of this study was to investigate prognostic factors and to establish a prognostic model using them for upfront cytoreductive nephrectomy (CN) in patients with metastatic renal cell carcinoma (mRCC) treated with immune checkpoint inhibitor (ICI) and/or tyrosine kinase inhibitor (TKI). MATERIALS AND METHODS: Two hundred eleven patients who were diagnosed as mRCC at initial diagnosis and were treated with TKI and/or ICI were classified into 2 groups: those undergoing CN (upfront CN group, 117 cases) and those who initially underwent systemic therapy (non-upfront CN group, 94 cases). In the upfront CN group, the patients' background and overall survival (OS) were compared with those in the other two groups, and prognostic factors were analyzed. A prognostic model of the upfront CN group was established. RESULTS: The median of the observation period for the upfront CN group was 25 months. The rates of patients with clear cell histology, with a Karnofsky performance status (KPS) of ≥ 80%, with a single metastatic organ, with a normal pretreated C-reactive protein level, and with an intermediate risk according to the International mRCC Database Consortium (IMDC) model were significantly higher than those in the non-upfront CN group (87.2% and 30.9%, p < 0.0001; 92.3% and 77.7%, p = 0.0025; 41.9% and 24.5%, p = 0.0080; 47.9% and 13.8%, p < 0.0001; 66.7% and 45.7%, p = 0.0023, respectively). The 50% OS in the upfront CN group was 33.1 months, significantly better than that in the non-upfront CN group (11.1 months, p < 0.0001), and these results were consistent regardless of their prognostic risk level. Multivariate analysis showed that multiple metastatic organs and a KPS of < 80% were independent predictive factors for OS (hazard ratio: 1.653 and 2.995, p = 0.0339 and 0.0054, respectively). Using these two parameters to stratify the upfront CN group, the 50% OSs in cases with no risk factors, in those with one factor, and in those with two factors were 43.4 months, 29.1 months, and 7.7 months, respectively (p < 0.0001). CONCLUSION: The upfront CN group was able to be stratified by our prognostic model into three subgroups with different prognoses. This model can provide useful information for making decisions in consideration of upfront CN in patients with mRCC.
Asunto(s)
Antineoplásicos , Carcinoma de Células Renales , Neoplasias Renales , Antineoplásicos/uso terapéutico , Carcinoma de Células Renales/tratamiento farmacológico , Carcinoma de Células Renales/cirugía , Procedimientos Quirúrgicos de Citorreducción , Femenino , Humanos , Inhibidores de Puntos de Control Inmunológico/uso terapéutico , Neoplasias Renales/tratamiento farmacológico , Neoplasias Renales/cirugía , Masculino , Nefrectomía/métodos , Pronóstico , Inhibidores de Proteínas Quinasas/uso terapéutico , Estudios RetrospectivosRESUMEN
AIM: Although perineal approaches for radical prostatectomy have recently gained renewed attention as excellent methods for minimally invasive surgery, the most commonly used techniques, Belt's and Young's approaches, have inadequacies regarding the topographical relationship between the rectourethral and levator ani muscles. METHODS: Using macroscopic observations of sagittal slices of 27 male pelvises and smooth muscle immunohistochemical staining of semiserial sections of another eight pelvises, we investigated the topographical anatomy of the perineal structures and their interindividual variations in elderly Japanese men. RESULTS: The inferomedial edge of the levator ani was located 5-15 mm lateral to the midsagittal plane in an area between the urethra and the rectum. The rectourethral smooth muscle had a superoinferior thickness of 5-10 mm and occupied a space between the right and left levator slings. The levator was adjacent to, or continuous with, the striated anal sphincters. A thick connective tissue septum, composed of smooth muscle, was evident between the rectal smooth muscle and the anal sphincter-levator ani complex. CONCLUSION: Because the connective tissue septum guides the surgeon's finger upwards towards the rectoprostatic space, Belt's approach appears relatively easy; however, rectal injury can sometimes occur if the surgeon loses this guidance. In contrast, if the levator edge is identified as the first step in Young's approach, the rectourethral muscle can be precisely divided, leaving a 3-5-mm margin from the rectum and sphincter-levator complex. Clinical investigations are now required to modify Young's approach based on the present results.