Guidelines EAU uroonkologických nádorů a reálná praxe. (kazuistiky)
Kongres ČUS 2012 Ostrava
Kasuistika 1.
Z.Z. , 51 let
Muž Základní anamnéza: RA:O OA:interně se neléčí,nebyl váž. nemocen, trombocytemie operace:O FA: 0 Transfuze:0 Dieta:3 Riziková anamnéza :0 (dřevomodelář) Kazuistika 1
Kazuistika č.1 UA: negat 3/09 makrohematurie UTZ - TU útvar 63x59mm s nejasným vztahem k m.m. IVU – negativní defekt v m.m. CT MP : Rozsáhlá tumorózní infiltrace močového měchýře, v.s. infiltrace okolí.Není jednoznačná infiltrace dalších struktur v malé pánvi. Pánevní cévy jsou v intimním kontaktu s moč. měchýřem, vlevo jsou odtlačeny.Nejsou zvětšené lymfatické uzliny. Kazuistika 1
Rtg
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Lab: Urea 3,8, krea 80 KO: leu 8,5, hgb 118!, tro 351!
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UCSK – infiltrace vertexu, zadní, levé, přední stěny TUR-T paliat. -malobuněčný karcinom pTX
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Bimanuální palpace – rezistence velikosti pěsti v podbřišku + fixace vlevo od m.m.
Diseminace negativní
+ It is a disease of advancing age, with most cases occurring in the 7th and 8th decades Quek ML, Nichols PW, Yamzon J, et al. Radical cystectomy for primary neuroendocrine tumors of the bladder: the university of southern california experience. J Urol 2005;174(1):93–6.
Postup??
RACE? Surgery alone may be adequate therapy for early stage SCCB Quek ML, Nichols PW, Yamzon J, et al. Radical cystectomy for primary neuroendocrine tumors of the bladder: the university of southern california experience. J Urol 2005;174(1):93–6. Mangar SA, Logue JP, Shanks JH, Cooper RA, Cowan RA, Wylie JP. Small-cell carcinoma of the urinary bladder: 10-year experience. Clin Oncol (R Coll Radiol) 2004;16(8):523–7. Choong NW, Quevedo JF, Kaur JS. Small cell carcinoma of the urinary bladder. The Mayo Clinic experience. Cancer 2005;103(6):1172–8.
Neoadjuvantní CHT + RACE? In a review of 106 patients with SCCB, chemotherapy was significantly associated with improved outcome; indeed on multivariateanalysis cisplatin-based chemotherapy was the only factor predictive of prolonged survival. Mackey JR, Au HJ, Hugh J, Venner P. Genitourinary small cellcarcinoma: determination of clinical and therapeutic factors associated with survival. J Urol 1998;159(5):1624–9.
Pouze CHT? Cisplatin-based chemotherapy in fit patients with distant metastases and may produce complete remission with survival of over 3 years in selected cases, though median survival is typically less than 12 months. Siefker-Radtke AO, Dinney CP, Abrahams NA, et al. Evidence supporting preoperative chemotherapy for small cell carcinoma of the bladder: a
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retrospective review of the M. D. Anderson cancer experience. J Urol 2004;172(2):481–4 Choong NW, Quevedo JF, Kaur JS. Small cell carcinoma of the urinary bladder. The Mayo Clinic experience. Cancer 2005;103(6):1172–8
C i
Na základě mezioborové konzultace : Cisplatina/Vepesid + RACE 3-6/2009 – 3. cykly CHT 6/2009 CT moč.měchýře : tumor stabilizované velikosti,bez vzdálených ložiskových změn.V malé pánvi ve stěně m.m.tu infiltrace velikosti 10x9x9cm, okolní struktury infiltrovány nejsou, ilické uzliny normální, jen oj.paraaortálně separované uzliny do 2 cm Minimální remise, KI 90, klinicky po CHT přehodnocení stadiacT3N1-2M0, klinické stadium III-IV
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Další postup? RACE? Pokračovat v CHT a vyčkat redukce ca? konkomitance DDP/ Radioterapie ? In one prospective study, 8 patients with limited-stage SCCB (any T stage, N1,M0) received sequential platinum- based chemotherapy and radiotherapy (56–70 Gy, fractionation schedule not stated). All attained a clinical complete response, and median survival was 15 months (range 11–52 months). Bex A, Nieuwenhuijzen JA, Kerst M, et al. Small cell carcinoma of bladder: a single-center prospective study of 25 cases treated in analogy to small cell lung cancer. Urology 2005;65(2):295–9.
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Pokračování CHT 3. cyklů Cisplatina/Vepesid á 3-4 týdny 8/2009 operace – inop. nález, infiltrace přední stěny břišní, stěn pánevních , ilických cév, kličky ilea Paliatívní CHT Exitus letalis 11/2009 (8 měsíců od stanovení dg.) Kazuistika 1
Resume Agresivní, zřídkavá malignita Častá detekce v pozdním stadiu u starších můžů Nezodpovězený dotaz optimální lokální terapie Trend výzkumu do budoucna: - včasná detekce, objevení více efektivní systémové terapie Kazuistika 1
Kazuistika č.2
S.G. , 74 let Žena Základní anamnéza: OA: hypertenze, ICHS, CHRI, aneuryzma abdom. aorty Operace: 2006 RANEU l.sin, pT2,N0,M0 GIII 2/09 multi PTCA na RIA FA:Presid, Betaxa, Amprilan, Monotab, Anopyrin Euphyllin, Atrovent, Mucosolvan Rizika: 0 Kazuistika 2
EAU Guidelines: Recurrence of disease in the bladder occurs in 30-51% of UUT-UCC patients (10,11), whereas recurrences in the contralateral upper tract are observed in 2-6% (12,13).
1980 nefropexe l.dx., litiatická anamnéza 09/06 RANEU l.sin. TCC pánvičky led. pT2,N0,M0 GIII 02/07 CSK, cytol. - susp. maligní bb, kontrolní CSK, randombiopsie a cytologie negatívní. Kazuistika 2
2007 CT, IVU negat 05/09 hyperemické ložisko na pravé stěně 8mm- T1GIII , TURT negat Diseminace negat
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Th
Adjuvantní léčba Okamžitá pooperační instilace The effect of the immediate instillation of chemotherapy occurs during the first and second year (129,130) (LE: 1b). It has been calculated from the data of five randomised trials (130) that the reduction of recurrence lasts for a period of approximately 500 days. EAU Guidelines 2011
Adjuvantní instilace The choice between further chemotherapy or immunotherapy largely depends on the risk that needs to be reduced: recurrence or progression. A combined analysis of EORTC and Medical Research Council data, comparing intravesical chemotherapy to TUR alone, has demonstrated that chemotherapy prevents recurrence but not progression (131) (LE: 1a) EAU Guidelines 2011
7.2.2 Optimal BCG schedule For optimal efficacy, BCG must be given in a maintenance schedule (140,144-146) (LE: 1a). In the EORTCGU group meta-analysis, only patients who received maintenance BCG benefited. In the four trials in which no maintenance was given, no reduction in progression was observed. In the 20 trials in which some form of BCG maintenance was given, a reduction of 37% in the odds of progression was observed (p = 0.00004). The meta-analysis was unable to determine which BCG maintenance schedule was the most effective (146). In their meta-analysis, Böhle et al. have concluded that at least 1 year of maintenance BCG is required to obtain the superiority of BCG over MMC for prevention of recurrence or progression (140,145). Although some modifications have been tried, induction BCG instillations are classically given according to the empirical 6-weekly induction schedule that was introduced by Morales in 1976 (149). However, many different maintenance schedules have been used, ranging from a total of 10 instillations given in 18 weeks, to 27 instillations over 3 years (150). The optimal number of induction instillations and the optimal frequency and duration of maintenance instillations remain unknown (151). EAU Guidelines 2011
Okamžitá instilace nepodána – atypický makroskopický nález 9/09 indukce BCG 6x 12/09 CSK, biop. zarudlého ložiska pravá stěna TCC pT1GIII Pacientka poučena o RACE! 3/2010 BCG 6x 6/2010 BCG 3x 9/2010 BCG 3x
11/11, CSK,b zadní stěna - pT1GIII 01/12 TURT zadní stěna - pozit. okraj resekce pT1 GIII - po výkonu těžká sepse 04/12 reTURT („navalitá“ sliznice zadní stěna) pT1GIII
BCG selhání Failure of intravesical BCG immunotherapy Treatment with BCG is considered to have failed in following situations: a. Whenever muscle-invasive tumour is detected during follow-up. b. If high-grade, non-muscle-invasive tumour is present at both 3 and 6 months (166). In patients with tumour present at 3 months, an additional BCG course can achieve a complete response in > 50% of cases, both in patients with papillary tumours and CIS (37,166), but with increasing risk of progression (167,168). c. Any worsening of the disease under BCG treatment, such as a higher number of recurrences, higher T- stage or higher grade, or appearance of CIS, in spite of an initial response (LE: 3). EAU Guidelines 2011
Konzervatívní postup? TURT + instilace? RACE? Kazuistika 2
Riziko recidívy v 1. resp. 5.roce: 38% resp 62% Riziko progrese v 1. resp. 5.roce: 5% resp 17%
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8/12 RACE + derivace sec. Bricker (histol. multifokální CIS m.m.) Komplikace – apatie, nechutenství, urea 28, krea 142 , sek. hojení rány Albumin 28, CB 62 Propuštěna do domácí péče 26.poop. den
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Exitus letalis 30. poop. den na interním oddělení – celkový metabol. rozvrat organismu (ARI, sepse)
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Děkuji za pozornost
