Résultats du traitement chirurgical des métastases de cancer du rein —A propos de 65 métastases opérées

Abstract

Several reports have assessed that the prognosis of metastatic renal cell carcinoma was better if patient’s general condition was good, if primary tumor had been resected, if the time between nephrectomy and metastasis was long, if metastases are only pulmonary and bone marrow was not involved. The bone metastases of renal cell cancer have a bad reputation because of their haemorragic caracteristics and their resistance to radiotherapy.

In the Orthopaedic and Traumatologic Department of the University hospital in Strasbourg, the authors had operated on 65 metastatic renal cell cancers. There were 55 patients (41 were men and 14 female), aged of 60 (range 41–84). Eight of them had 2 operations and 1 had 3 metastatic localisations.

In 23% the metastases were present at the time of primary tumor diagnosis; in 17% the metastasis was even a signal metastasis. There were pathologic fractures in half of the cases (33 cases) and in the other half the metastasis had not fractured. The commonest site was the femur (40 of the 65 cases). The second site was the humerus (15 cases). There were also 7 vertebrae, 6 of them with neurologic deficit.

The authors performed closed osteosynthesis in 27 cases (15 intramedullary nails, 7 Ender nails, 4 bipolar pinnings, 1 gamma nail), arthroplasty in 19 cases (6 standard prosthesis and 13 reconstruction prostheses) and an open osteosynthesis in 12 cases. They performed also 3 vertebrectomies by an anterior approach and 4 posterior decompressions and stabilisations.

The average post operative survival was 15 months (range 0-109). Six patients died in the first post-operative month. Three non specific complications were observed: 2 prosthetic dislocations and one infected nail failure. 6 tumor extensions were observed on 2 prostheses, 3 intramedullary nails and 1 open osthesynthesis.

The results were good for pain in 83% of the patients, the functional result good or fair in 78%.

The efficacy of adjuvant medications was discussed, based on the literature data. Two groups of metastatic renal cell cancer were studied: the first with multiple metastases and a high speed progressive disease, the other with single metastasis and a low speed progressive disease. The surgical indications should be different in the two groups.

Résumé

Les auteurs présentent une série rétrospective de 65 métastases de cancer rénal opérée. Les patients âgés en moyenne de 60 ans 8 mois ont eu une survie moyenne de 15mois (extrêmes de 0 à 109 mois). Le traitement a consisté en 27 ostéosynthèses à foyer fermé (42 %), 19 arthroplasties (29 %), et 15 ostéosynthèses à foyer ouvert (29 %). 3 complications non spécifiques (2 luxations et 1 fracture de clou sur médullite) et 6 reprises évolutives (sur 2 prothèses, 3 clous, et 1 ostéosynthèse à foyer ouvert) sont survenues. Six patients sont décédés dans le mois post-opératoire. Malgré tout, le résultat antalgique est satisfaisant chez 83 % des malades, le résultat fonctionnel bon ou acceptable chez 78 % d’entre eux.