Prostatos vėžys: samprata apie riziką. Ramūnas Mickevičius Urologijos klinika LSMU KK Druskininkai
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1 Prostatos vėžys: samprata apie riziką Ramūnas Mickevičius Urologijos klinika LSMU KK Druskininkai
2 Terminas PROSTATOS VĖŽYS pacientui kelia nerimą, įtampą, baimę mirčiai. Kas metai Lietuvoje naujai diagnozuojama apie 3000 naujų prostatos vėžio atvejų ir apie 500 nuo jo miršta. Pacientų sergančių prostatos vėžiu išgyvenamumas priklauso nuo kelių veiksnių.
3 Prostatos vėžio rizikos aspektai Ligos nustatymas (kada pradėti ieškoti ligos?) Prostatos vėžys nustatytas
4 Ligos nustatymas Vyro amžius. AUA rekomendacijos: (1) PSA skriningas nerekomenduojamas vyrams iki 40 m. (2) nerekomenduojamas PSA skriningas vidutinės rizikos vyrams m. (3) rekomenduojamas tyrimas vyrams m. (4) nerekomenduojamas PSA skriningas vyrams >70 m. ar vyrams galintiems išgyventi <10-15 metų.
5 Ligos nustatymas Pagal EAU rekomendacijas: Pradinis PSA tyrimas pasiūlytas pacientams nuo 40 metų, nuo kada galima skaičiuoti skrininginį intervalą (GR: B). (Börgermann C, Loertzer H, Hammerer P, et al. Problems, objective, and substance of early detectionof prostate cancer]. Urologe A 2010 Feb;49(2): Skrininginis intervalas 8 metai, turėtų būti pakankamas, jei pradinis PSA < 1 ng/ml Roobol MJ, Roobol DW, Schröder FH. Is additional testing necessary in men with prostate-specific antigen levels of 1.0 ng/ml or less in a population-based screening setting? (ERSPC, section Rotterdam). Urology 2005 feb;65(2):343-6.
6 Ligos nustatymas Net ir esant neaukštoms PSA reikšmėms yra tam tikra tikimybė agresyvaus PCa. Thompson IM, Pauler DK, Goodman PJ, et al. Prevalence of prostate cancer among men with a prostate-specific antigen level < or =4.0 ng per milliliter. N Engl J Med 2004 May
7 Ligos nustatymas Rizikos veiksnių buvimas. Prostatos vėžio įtarimas tiriant pirštu yra prielaida manyti apie labiau agresyvų PCa (Gleason 7). Okotie OT, Roehl KA, Han M, et al Characteristics of prostate cancer detected by digital rectal examination only. Urology 2007 Dec;70(6): Gosselaar C, Roobol MJ, Roemeling S, et al. The role of the digital rectal examination in subsequent screening visits in the European randomized study of screening for
8 Ligos nustatymas Jei vienas artimas giminaitis sirgęs PCa šansas susirgti yra mažiausiai 2 kart didesnis. Jei du ir daugiau artimų giminaičių šansas padidėja 5 11 kartų.
9 Prostatos vėžys nustatytas Rizikai įvertinti sukurta daugybė nomogramų, lentelių, rizikos skaičiuoklių, atsiranda nauji markeriai ir jų deriniai (pro PSA, PCA3, TMPRSS2:ERG, tumoro supresorius PTEN), tobulinami tyrimų metodai (kontrastu sustiprinantis TRUS, realaus laiko elastografija, TRUS paremtas prostatos histoskenavimu, multiparametrinis BMR).
10 Prostatos vėžys nustatytas Išgyvenamumas sergant prostatos vėžiu priklauso nuo: prostatos vėžio rizikos laipsnio, gretutinių ligų, paciento amžiaus.
11 Aukštos rizikos PCa apibrėžimas Patrick J. Bastian a,*, Stephen A. Boorjian b, Alberto Bossi c, Alberto Briganti d, Axel Heidenreich e, Stephen J. Freedland f, Francesco Montorsi d, Mack Roach IIIg, Fritz SchroØder h, Hein van Poppel i, Christian G. Stief a, Andrew J. Stephenson j, Michael J. Zelefsky High-Risk Prostate Cancer: From Definition to Contemporary Management EUROPEAN UROLOGY 6 1 ( )
12 Rizika Pagal D Amico: Žema (low risk PSA 10, a Gleason score 6, arba klin. stad. T1-2a) Vidutinė (intermidiate risk - PSA 10-20, Gleason score 7, arba klin. stad. T2b) Aukšta (high risk - PSA >20, Gleason score 8, arba klin. stad. T2c-3a)
13 Aukštos rizikos PCa (PSA >20, Gleason score 8, arba klin. stad. T2c-3a) Aukštos rizikos PCa naujai diagnozuojama apie 15%. Cooperberg MR, Broering JM, Carroll PR. Time trends and local variation in primary treatment of localized prostate cancer. J Clin Oncol 2010;28:
14 the American Surveillance, Epidemiology and End Results tyrimas parodė, kad PCa pacientų su klin. stadija T1c Gleason scores 5 7 mirštamumas dėl gretutinės patologijos (dviejų ir daugiau ligų) per 10 metų pacientams virš 65m. yra didesnis lyginant su rizika mirti nuo prostatos vėžio (apie 74% pacientų 66 74m. nuo diagnozės nustatymo ir 83% - nuo 75m. miršta nuo gretutinės patologijos) Albertsen PC, Moore DF, Shih W, Lin Y, Li H, Lu-Yao GL. Impact o comorbidity on survival among men with localized prostate cancer. J Clin Oncol 2011;29:
15 Pacientams virš 65 metų diagnozavus PCa klinikinėje stadijoje T2, Gleason 8 10 rizika numirti nuo prostatos vėžio yra panaši, kaip ir nuo gretutinių ligų. Albertsen PC, Moore DF, Shih W, Lin Y, Li H, Lu-Yao GL. Impact o comorbidity on survival among men with localized prostate cancer. J Clin Oncol 2011;29:
16 Vyrams numirti nuo PCa rizika palyginti didelė net ir po RP, jei PSA prieš diagnozės nustatymą per metus pakilo daugiau nei 2.0 ng/ml. Anthony V. D'Amico, M.D., Ph.D., Ming-Hui Chen, Ph.D., Kimberly A. Roehl, M.P.H., and William J. Catalona, M.D. Preoperative PSA Velocity and the Risk of Death from Prostate Cancer after Radical Prostatectomy N Engl J Med 2004; 351:
17 Pacientų amžius <59 iki 70+ (viso 4000 pacientų) Aukštos rizikos vėžys Vertinti pagal Charlson gretutinių ligų indeksą
18 Aukštos rizikos PCa buvo jaunų vyrų mirties priežastis, kuriai įtaką turėjo rizikos faktorių kiekis.
19 Vyresniems, be gretutinės patologijos, vyrams rizika numirti nuo aukštos rizikos PCa buvo panaši, kaip ir jauniems vyrams.
20 Vyresniems vyrams su gretutine patologija rizika numirti nuo kitų ligų didesnė nei nuo PCa.
21 Išvados 1. Gydyti reikia pacientus, kuriems yra rizika numirti nuo prostatos vėžio. 2. Gerai pasverti radikalaus gydymo prasmę gretutinėmis patologijomis sergantiems pacientams. 3. Neatmesti galimybės radikaliai gydyti vyresnio amžiaus sveikų vyrų, neturinčių gretutinės patologijos. 4. Reikalingi nauji markeriai ar jų deriniai bei tyrimo metodai, naujos rizikos skaičiuoklės kas leistų tiksliau nustatyti, kuris prostatos vėžys yra agresyvus.
22 Ačiū už dėmesį
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