tumorile vezicale 2011

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Tumorile vezicale

Dr. Mihly Zoltn Attila

Cancerul vezical

Problem major de sntate public Cost socio-economic ridicat Malignitate subestimat De exclus n cazul hematuriei macroscopice ! Prognostic nefavorabil

Diagnostic tardiv Tratat necorespunzator

Epidemiologie

FrecvenaCc urogenital locul 2 brbai locul 4 femei locul 9 brbai/femei = 3:1 (Europa) brbai/femei = 7:1 (SCM Cluj-Napoca)

Mortalitate - anual n Europa36.500 brbai 13.000 femeiBladder Cancer: Highlights from 2006 Antonio Alcaraz, European Urology Supplements 6 (2007) 737-744

Epidemiologie

Incidena variabil 30/100.000 Europa de Vest Vrsta de apariie 40 ani (4-89 ani) Incidena maxim ntre 60-70 ani

Factori de riscFumatulCarcinogenii industriali

Staging and gradingTable 1 - 2002 TNM classification of urinary bladder cancer T: Primary tumor Tx To Primary tumor cannot be assesed No evidence of primary tumor

Ta Tis T1T2T2a T2b T3 T3a T3b

Non-invasive papillary carcinoma Carcinoma in situ flat tumor Tumor invades subepithelial connective tissueTumor invades muscleTumor invades superficial muscle Tumor invades deep muscle Tumor invades perivesical tissue Microscopically Macroscopically

T4T4a T4b

Tumor invades any of the following: prostate, uterus, vagina, pelvic wall, abdominal wallTumor invades prostate, uterus or vagina Tumor invades pelvic wall or abdominal wall

Sobin DH, Wittekind CH TNM classifications of malignant tumors New York

Staging and grading1973 WHO grading Urothelial papilloma

Grade 1:Grade 2: Grade 3:

Well differentiatedModerately differentiated Porrly differentiatedPapillary Hyperplasia PUNLMP

2004 WHO grading Urothelial papilloma

Papillary urothelial neoplasm of low malignant potential (PUNLMP)Low-grade papillary urothelial carcinoma High-grade papillary urothelial carcinomaUrothelial PapillomaLow-grade Papillary Urothelial Carcinoma

High-grade Papillary Urothelial Carcinoma

Clasificare

70-80% Superficiale

Ta, T1, CIS

Invaziv / metastatic

T2, T3, T4; N, M

Tu vezicale superficiale

70 % tumori papilare cu potenial sczut de malignitate

Numeroase reinterventii dupa diagnostic Prognostic general bun Die from other causes

30 % tumori cu atingerea lamina propria

Grad histologic ridicat CIS Grup de risc crescut Recidiv, progresie, deces

Subtipuri patologice

Carcinom cu celule tranzitionale >90%Nested Micropapillary

Carcinom squamos ~ 5%Adenocarcinoame ~ 1%

American Urological Association. Guidelines for the management of NMIBC (stages Ta, T1, Tis) 2007 update.

IBCG, EAU, FICBT, NCCN, AUA

Diagnosticultrasonography, cytology, tumor markers, cystoscopy, TURBT, bladder biopsies, IVU, CT, MRI

Simptomatologie clinica

HEMATURIAMicroscopica 5 RBC/HPF Macroscopica investigatie urologica completa

Simptome mai putin comuneBladder iritability Polakiurie Imperiozitate mictionala Disurie

Kirkali Z, Chan T, Manoharan M,et al. Bladder Cancer: Eidemiology, staging and grading, and diagnosis. Urology 2005;66:4-34

Diagnostic

Ultrasonografia

De prima intentie

RRVS

Cause of haematuria

Imaging diagnostic testsIVU CT MRI

Diagnostic

Citologia urinara

Specificitate >90% Sensibilitate 5 cm

Peter Whelan. The treatement of non-muscle invasive bladder cancer with intravesical chemotherapy and immunotherapy. E Urol Suppl 6 (2007) 568-571

Tratamentul tumorilor vezicale invazive localizate (T2, T3, T4a, No,Mo)

Cistectomia radicalaBarbat: vezica urinara, prostata, vezicule seminale, ggl limfarici pelvini Femeie: vezica, uter, ovare, trompe, col uterin, perete anterior vaginal, ggl limfatici pelvini (pelvectomie anterioara)

Derivatie urinara

Alternative la tratamentul standard

RadioterapieRadioterapie extern (external-beam radiation therapy) cu hiperfracionare Radioterapie interstiial Ir 192

Cistectomie pariala Chemoterapie sistemica cu M-VAC, Gemcitabin Chemoterapie intraarterial

Tratamentul cancerului vezical metastatic

Chemoterapie sitemic de rutin cu ageni multiplii M-VAC, Gemcitabine Cisplatin Cistectomie de salvare - paliativHematurie severa Dureri intense

Concluzii

Prevenirea

Factori de risc ocopationali

Diagnostic precoceHematuria - subestimata Campanii de informare

Stadializare si tratament corect Respectarea protocoalelor

Marco Grasso. Bladder cancer: A Major Public Health Issue. Eur Urol Supplements 2008:7:510-515