Open/Close Menu Medico Chirurgo-Radiologo Interventista Policlinico Universitario Campus Biomedico

Il trattamento chirurgico rimane il gold-stantard di riferimento nella terapia dei tumori del rene che nell’85% sono rappresentati dal carcinoma a cellule chiare. Tuttavia in alcuni casi il trattamento ablativo, vuoi “termoablativo” (radiofrequenza, microonde) o “crioablativo” (crioablazione), si impone per una serie di circostanze di seguito elencate. In particolare

Dal momento che tali trattamenti non danneggiano il tessuto renale sano se effettuate con precisione, possono essere ripetute varie volte. Sono procedure che devono essere effettuate da radiologi interventisti esperti, con esperienza ampia nei trattamenti ablativi. In questa maniera i rischi connessi con l’intervento sono molto bassi. Nello specifico i rischi sono poco superiori a quelli di una biopsia e sono rappresentati da una soffusione emorragica perilesionale e dal dolore.

Al tempo stesso il calore può essere utilizzato come agente cauterizzante nel caso di sanguinamento attivo insorto durante la procedura

Il radiologo interventista deve essere in grado di poter effettuare trattamenti ablativi sia con il calore (termoablazione) che con il freddo (crioablazione).

Infatti è ben nota la ridotta possibilità, quasi nulla, di ledere le vie escretrici con l’ablazione a freddo nel caso di lesioni centrali rispetto alla termoablazioni. Inoltre la crioablazione dai dati della letteratuta si è dimostrata superiore alla termoablazione nel trattamento delle lesioni > cm 3-3,5.

Inoltre l’operatore deve creare tutte quelle condizioni idonee a proteggere altri organi (anse intestinali, uretere, strutture nervose) dalla sede dell’ablazione mediante l’instillazione locale guidata dall’imaging di liquidi e gas allo scopo di allontanarli dalla sede dell’intervento ed in tale maniera proteggendoli.

La procedura viene effettuata in sedazione profonda e non in anestesia generale.

Il decorso post-operatorio è sicuramente rapido, di pochi giorni, di minor durata rispetto all’intervento chirurgico .

Proprio grazie a queste caratteristiche, tali procedure possono essere ripetute svariate volte, senza alterare i valori della funzionalità renale come evidenziato dai dati della letteratura.

Nel caso di lesioni non operabili > 5 cm si può associare all’ablazione una preliminare embolizzazione allo scopo di ottenere un controllo locale adeguato.

In un recente studio retrospettivo da un registro Medicare (1) sono stati arruolati pazienti  affetti da tumore del rene (RCC) T1a (< 4 cm)  senza evidenza di linfoadenopatie o di metastasi a distanza.

Sono stati arruolati 10218 pazienti affetti da tumore del rene a cellule chiare (RCC) T1aN0M0 nel periodo compreso 2002-2011. Di questi 20820(27.6%) è stata sottoposta a nefrectomia parziale, 4522 (44.2%) a nefrectomia redicale,898 (8,8%) a termoablazione e 1978 (19,4%) a sorveglianza attiva. L’età media dei pazienti sottoposti a termoablazione era superiore a quelli sottoposti a chirurgia standard così come le comorbidità presenti al momento dell’intervento.

Le conclusioni del lavoro sono che la termoablazione garantisce risultati simili alla chirurgia in termini di sopravvivenza tumore-specifico e sopravvivenza globale, con significativa riduzione degli eventi avversi e delle complicanze rispetto alla chirurgia.

Tali risultati sono in accordo con quanto già pubblicato in precedenza (2,3).

Inoltre una recente meta-analisi di Pierorazio (4) evidenzia come la sopravvivenza tumore-specifico non differisca tra i differenti trattamenti di nefrectomia parziale, nefrectomia radicale e di termoablazione per i tumori a cellule chiare localizzati al rene.

Nonostante in i risultati sovrapponibili in termini di sopravvivenza bisogna  riconoscere come oggi l’American Urological Association (AUA) ,la European Association for Urology (EAU) e linee Guida della National Comprehensive Cancer Network (NCCN)  considerino la termoablazione unicamente per il trattamento dei pazienti a rischio elevato di intervento chirurgico in relazione alle comorbidità ed alle condizioni cliniche dal momento che vecchi studi avevano dimostrato un elevata incidenza di recidiva locale del tumore (5-6) dopo trattamenti ablativi.

Tuttavia queste raccomandazioni si riferiscono a vecchi studi in cui la percentuale di recidiva raggiungeva valori di circa 20% (7).

Con lo sviluppo di nuove tecniche ablative e con miglioramento della tecnica la recidiva locale tumorale che necessita di un eventuale secondo intervento è presente in una percentuale variabile dal 4 all’8% per i tumori T1a (8,9).

Tali studi dimostrano come la percentuale di complicanze sia significativamente inferiore nei pazienti sottoposti termoablazione rispetto alla nefrectomia parziale ed alla nefrectomia radicale in linea con quanto già evidenziato precedentemente; inoltre la termoablazione in questo lavoro come nei precedenti dimostra un minore impatto sulla funzionalità renale a lungo termine (8,10).

Onishi (11) ha inoltre dimostrato di come i trattamenti ablativi tumore del rene siano correlati ad un miglioramento di tutti gli aspetti della qualità della vita rispetto alla riduzione degli stessi valori quando sottoposti ad intervento di nefrectomia parziale sulla base delle risposte elencate nei questionari forniti ai pazienti.

Aoun (12) ha evidenziato un tasso di recidiva del 3,2% in 347 tumori del rene a cellule chiare sottoposti a crioablazione con un tasso di complicanze maggiori (³ 3)  del 2,8%.

David Breen (13) ha evidenziato una percentuale di recidiva del 2,8% e 6,1% rispettivamente a 3 e 5 anni in 221 tumori del rene sottoposti a crioablazione

BIBLIOGRAFIA

  1. Xing M1, Kokabi N1, Zhang D1, Ludwig JM1, Kim HS1.Comparative Effectiveness of Thermal Ablation, Surgical Resection, and Active Surveillance for T1a Renal Cell Carcinoma: A Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked Population Study. Radiology. 2018 May 8:171407. doi: 1148/radiol.2018171407
  2. Olweny EO, Park SK, Tan YK, Best SL, Trimmer C, Cadeddu JA. Radiofrequency ablation versus partial nephrectomy in patients with solitary clinical T1a renal cell carcinoma: comparable oncologic outcomes at a minimum of 5 years of follow-up. Eur Urol 2012;61(6):1156–1161
  3. Arnoux V, Descotes JL, Sengel C, Terrier N, Rambeaud JJ, Long JA. Perioperative outcomes and mid-term results of radiofrequency ablation and partial nephrectomy in indications of renal tumor treatment and imperative nephron-sparing procedure in French]. Prog Urol 2013;23(2):99–104.
  4. Pierorazio PM, Johnson MH, Patel HD, et al. Management of renal masses and localized renal cancer: systematic review and meta-analysis. J Urol 2016;196(4):989–999.
  5. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Kidney Cancer. Version 3.2018. https://www.nccn.org/professionals/physician_gls/pdf/kidney.pdf. Published January 15,2018. Updated February 6, 2018. Accessed February 11, 2018
  6. Ljungberg B, Bensalah K, Canfield S, et al. EAU guidelines on renal cell carcinoma: 2014 update. Eur Urol 2015;67(5):913–924.
  7. Gervais DA, Arellano RS, McGovern FJ, McDougal WS, Mueller PR. Radiofrequency ablation of renal cell carcinoma: part 2, Lessons learned with ablation of 100 tumors. AJR Am J Roentgenol 2005;185(1):72–80.
  8. Olweny EO, Park SK, Tan YK, Best SL, Trimmer C, Cadeddu JA. Radiofrequency ablation versus partial nephrectomy in patients with solitary clinical T1a renal cell carcinoma: comparable oncologic outcomes at a minimum of 5 years of follow-up. Eur Urol 2012;61(6):1156–1161.
  9. Psutka SP, Feldman AS, McDougal WS, McGovern FJ, Mueller P, Gervais DA. Long-term oncologic outcomes after radiofrequency ablation for T1 renal cell carcinoma. Eur Urol 2013;63(3):486–492.
  10. Lucas SM, Stern JM, Adibi M, Zeltser IS, Cadeddu JA, Raj GV. Renal function outcomes in patients treated for renal masses smaller than 4 cm by ablative and extirpative techniques. J Urol 2008;179(1):75–79; discussion 79–80.
  11. Onishi T, Nishikawa K, Hasegawa Y, et al. Assessment of health-related quality of life after radiofrequency ablation or laparoscopic surgery for small renal cell carcinoma: a prospective study with medical outcomes Study 36-Item Health Survey (SF-36). Jpn J Clin Oncol 2007;37(10):750–754.
  12. Aoun HD, Littrup PJ, Jaber M, Memon F, Adam B, Krycia M, Prus M, Heath E, Pontes E. Percutaneous Cryoablation of Renal Tumors: Is It Time for a New Paradigm Shift? J Vasc Interv Radiol. 2017 Oct;28(10):1363-1370. doi: 10.1016/j.jvir.2017.07.013. Epub 2017 Aug 26.
  13. Breen DJ, King AJ, Patel N, Lockyer R, Hayes M.Image-guided Cryoablation for Sporadic Renal Cell Carcinoma: Three- and 5-year Outcomes in 220 Patients with Biopsy-proven Renal Cell Carcinoma. 2018 Nov;289(2):554-561. doi: 10.1148/radiol.2018180249. Epub 2018 Aug 7.

Figure

Figura 1.

  1. Tumore a cellule chiare confermato dalla biopsia eco-guidata di 1 cm in paziente con pregresso tumore del retto e del polmone
  2. Dopo conferma dell’esame istologico viene effettuata ablazione a radiofrequenza (RFA) della durata di 8 minuti. Paziente dimesso il giorno dopo senza complicanze.

Figura 2

Tumore a cellule chiare in sede centrale in paziente monorene per pregressa nefrectomia sinistra. Procedura di crioablazione (CRA) con 3 criosonde e dissezione con gas della giunzione pielo-ureterale e protezione delle vie escretrici con stent mono-J. Il controllo a 7 anni documenta la completa assenza di malattia nella sede trattata.

Figura 3

Ablazione a microonde di tumore del rene di 18 mm confermato alla preliminare  biopsia in pregressa crioablazione del rene di destra. Paziente dimesso il giorno dopo la procedura.

Figura 4

  1. Tumore a cellule chiare di 42 mm del rene di destra sottoposto a crioablazione con 5 criosonde complicata da un piccolo sanguinamento autolimitantesi che non ha richiesto terapia. Il controllo locale ottenuto con la crioablazione è stato completo.
  2. Dopo 3 anni il controllo locale nella sede tratta è completo mentre sono comparsi due ulteriori piccoli tumori in sedi differenti del rene. Si effettua un nuovo trattamento con controllo locale completo. Paziente dimesso il giorno dopo senza complicanze. A distanza di 5 anni dal primo intervento e di 2 anni dal secondo il paziente è libero da malattia.
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    В посольстве рассказали, что информация о случившемся поступила на телефон экстренной связи консульского отдела 15 декабря. Полученные сведения были переданы камбоджийским правоохранительным органам, которые сейчас проводят оперативно-розыскные мероприятия в отношении похищенной россиянки.

    «Посольство находится в постоянном контакте с национальной полицией и отслеживает развитие ситуации с пропавшей Анастасией Шередько», — сообщили в посольстве.

    О предполагаемом похищении российской гражданки стало известно накануне, 17 декабря. Ее подруга сообщила «Ленте.ру», что она пропала 12 декабря после встречи с гражданином Китая, с которым познакомилась в интернете. Сначала мужчина утверждал, что Шередько уехала домой и ему неизвестно, где она находится, однако позднее потребовал от друзей женщины 10 тысяч долларов за информацию о ее местонахождении. При этом мужчина отказался предоставить видео с россиянкой, заявив, что Анастасия уже якобы «у других людей». Друзья и близкие пропавшей жалуются на бездействие местных правоохранительных органов.

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  910. 21 Dicembre 2021

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  913. 22 Dicembre 2021

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  914. 22 Dicembre 2021

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  918. 23 Dicembre 2021

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  921. 23 Dicembre 2021

    [url=https://adti.uz][img]https://i.ibb.co/xDZWdvV/133.jpg[/img][/url]

    Over the years of independence, the institute has trained more than 13000 physicians (including 800 clinical interns, 1116 masters, 200 postgraduates and 20 doctoral students) in various directions.

    870 staff work at the institute at present,[when?] including 525 professorial-teaching staff in 55 departments, 34 of them are Doctors of science and 132 candidates of science. 4 staff members of the professorial-teaching staff of the institute are Honoured Workers of Science of the Republic of Uzbekistan, 3 – are members of New-York and 2 – members of Russian Academy of Pedagogical Science.

    The institute has been training medical staff on the following faculties and directions: Therapeutic, Pediatric, Dentistry, Professional Education, Preventive Medicine, Pharmacy, High Nursing Affair and Physicians’ Advanced Training. At present[when?] 3110 students have been studying at the institute (1331 at the Therapeutic faculty, 1009 at the Pediatric, 358 at the Dentistry, 175 students at the Professional Education Direction, 49 at the faculty of Pharmacy, 71 at the Direction of Preventive Medicine, 117 ones study at the Direction of High Nursing Affair).

    Today graduates of the institute are trained in the following directions of master’s degree: obstetrics and gynecology, therapy (with its directions), otorhinolaryngology, cardiology, ophthalmology, infectious diseases (with its directions), dermatovenereology, neurology, general oncology, morphology, surgery (with its directions), instrumental and functional diagnostic methods (with its directions), neurosurgery, public health and public health services (with its directions), urology, narcology, traumatology and orthopedics, forensic medical examination, pediatrics (with its directions), pediatric surgery, pediatric anesthesiology and intensive care, children’s cardiology and rheumatology, pediatric neurology, neonatology, sports medicine.

    The clinic of the institute numbers 700 seats and equipped with modern diagnostic and treating instrumentations: MRT, MSCT, Scanning USI, Laparoscopic Center and others.

    There are all opportunities to carry out sophisticated educational process and research work at the institute.

    Source:
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    Peoples’ Friendship Institute, Faculty of Medicine

  922. 23 Dicembre 2021

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