PRESENTACIÓN CENTRO ONCOLOGICO.pptx

7/29/2019 PRESENTACIN CENTRO ONCOLOGICO.pptx

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CENTRO ESTATAL DE ONCOLOGA.

TERCERA JORNADA DE ONCOLOGA.TUMORES GENITOURINARIOS.

Dr. Rodolfo Woller Vzquez.


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AGRADECE AL DR ERNESTO RIVERA CLAISSE,DIRECTOR DEL CENTRO ESTATAL DE ONCOLOGA PORSU AMABLE INVITACIN A TAN IMPORTANTE EVENTO

DE XV ANIVERSARIO Y NOS HAYA PERMITIDOINTRODUCIR TEMAS DE NUESTRA ESPECIALIDAD ENESTA TERCERA JORNADA ACADMICA.

RESALTAMOS EL GRAN INTERS DE SU DIRECTOR YTAMBIEN FUNDADOR POR SU PREOCUPACINCONSTANTE EN COLOCAR A LA VANGUARDIA A ESTAMUY RECONOCIDA Y NOBLE INSTITUCIN.


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TUMORES GENITOURINARIOS


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DR. CARLOS LEOS GALLEGOS. ISSSTE.

CA DE PROSTATA.

DR. ARMANDO BALTAZARES LPEZ. IMSS.

CA DE PROSTATA.

DR. CARLOS LEOS ACOSTA. HGE DE SSA.

CA TESTICULAR

DR. RODOLFO WOLLER VAZQUEZ. ISSSTESON.

H. MILITAR, SEDENA. CANCER DE VEJIGA


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CANCER (Global)

FRECUENCIA USA MEXICO (incan)

1 596 670 127 930

MORTALIDAD 38 % (2. Causa) 58%

SOBREVIVENCIA ( 5 a.) 68 %


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TERCERA JORNADA ONCOLGICA

DESARROLLO DE CA POR SITIO

TODOS ---------------------------1 EN 2PROSTATA--------------------- -1 EN 6

PULMN Y BRONQUIOS------1 EN 13

COLON Y RECTO----------------1 EN 19

VEJIGA----------------------------1 EN 26

LINFOMA NO HODKING-------1 EN 45

MELANOMA---------------------1 EN 55

RIN----------------------------1 EN 55

Leucemia 1 en 67, Boca 1 en 77, Estomago 1 en 90, TESTICULO, 1 en 500

CNCER DE VEJIGA


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INCIDENCIA

Tumores Genitourinarios


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TUMORES UROLOGICOS Mortalidad


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FRECUENCIA )Ca de Prostata, Vejiga, Rin, Testiculo y

Pene

MAYOR MORTALIDAD-ENF.AVANZADA:Testiculo-25 %

Rin- 20 %Vejiga 6.5 %

Prostata-5.5 %Pene-3 %

TUMORES GENITOURINARIOS.


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COLEGIO SONORENSE DE UROLOGIA

PAPEL DEL UROLOGO EN TGU

Tumores Benignos.

T. Malignos: Localizado------Ciruga---------UrlogoRadioterapia-----RadTx.

Loc. AvanzadoCiruga--------UrologoRadioterapia-----RadTx.

QuimioTx-------Urologo?Avanzada------Ciruga paliativa, Qui-

mioTx, Cuidados Paliativos----?


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TUMORLOCALIZADO

CIRUGIA

RADIOTERAPIA

UROLOGO

RADIOTERAPEUTA

LOCALMENTE

AVANZADO

CIRUGA.

RADIOTX

QUIMIOX

UROLOGO

RADIOTX.

UROLOGO?ONCOLOGO?

T. AVANZADO

CIR. PALIATIVA.

QUIMIOTX

CUIDADOSPALIATIVOS

??

TUMORES GENITOURINARIOSPAPEL DEL UROLOGO


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CENTRO ESTATAL DE ONCOLOGA

TERCERA JORNADA DE ONCOLOGATUMORES GENITOURINARIOS

Dr. Rodolfo Woller Vzquez


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CA DE VEJIGA. patologa

Ca de Cels. Trans. 90 %Ca de Cels. escamosas 5%,Adenocarcinoma 2 %

Carcinoma Urotelial

70 % A 80% NO invasivos.


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CANCER DE VEJIGA


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CANCER DE VEJIGA


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CA DE VEJIGA

Ca de Urotelio 90 %

Ca de cels. escamosas 5%,

Adenocarcinoma 2 %


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INCIDENCIA 7 % (51,230 H 17,580 M)

CA EN GRAL. 9a. Causa ( 357 000)

13a. CAUSA DE MUERTES (145 000)

CUARTA CAUSA DE CA (hombres)

11a. CAUSA EN MUJERES

ENFERMEDAD LETAL: 3 % Muertes (14 100)

CANCER DE VEJIGA.


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PROBABILIDAD CA VEJIGA : 1 en 26

(hombres) 1 en 86 (mujeres)

Disminuye: Raza Blanca 3.5%, afro-am,hispanos (5%)


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FRECUENTE EN HOMBRES (Rel.3 a 1)

EDAD 70 a. (Raro 40 a.)

DIFERENCIAS GEOGRAFICAS:

Europa, medio oriente, 14-24 %

AFRICA Y EGIPTO 70% (ca celsesc)

CANCER DE VEJIGA. Incidencia.


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CANCER DE VEJIGA ETIOLOGA

TABAQUISMO OCUPACION OTROS (Genes,

ingesta lquidos, dieta)

FXS

AMBIENTALES

CALCULOS,

PARASITOS INFECCIONES, PVH,FXS. LOCALESIRRITATIVOS


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CNCER DE VEJIGA. Etiologa.

FACTORES AMBIENTALES:Tabaquismo. Factor ms comn, mal pronostico,

Grado alto

Ocupacin:Aminas aromticas; hule, poliuretano, aluminio,imprenta, fund. Metales

Anilinas; trabajadores ind. agricolas,

colorantes,herbicidas, barnices, explosivos, pintsintticas..


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TABAQUISMO


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CA DE VEJIGA. Etiologa.

Ocupacin:Aminas aromticas; hule, poliuretano, aluminio,

imprenta, fund. MetalesAnilinas; trabajadores ind. agricolas,

colorantes,herbicidas, barnices, explosivos, pintsintticas


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CA DE VEJIGA. Etiologa


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CA DE VEJIGA. Etiologa


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CNCER DE VEJIGA. Etiologa.

Fxs. Irritativos Locales:

Clculos, Parsitos.Infecciones (Bacterias,PVH)

Otros:

Genes,

Dieta

Baja ingesta delquidos, caf o t,

Edulcurantes,

Abuso de analgsicos,Herencia.


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Otros:

Genes,DietaBaja ingesta de lquidos, caf o t,Edulcurantes,

Abuso de analgsicos, Herencia.

CA DE VEJIGA Etiologa.

.


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CANCER DE VEJIGA ETIOLOGIA

GENES

EDULCURANTES

SUPERFICIALES

ANALGESICOS


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CA DE VEJIGA. tumorogenesis


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CA DE VEJIGA PLEOCRONOTOPOCIDAD

Origin, Recurrence, and Invasion

l Primary urothelial cancer is an environmentally caused

tumor that recurs because of persistent genetic changes

within the normal-appearing urothelium.

l Recurrent urothelial tumors occur by activation of nascent normal cells that have some genetic instability by environmental

factors and tumor seeding during transurethral

tumor resection.

l Accumulation of genetic changes leads to cellular proliferation,

loss of cellcell adhesion, and invasion. l The depth of invasion and grade of the tumor are the best

prognostic determinants of urothelial cancer, but molecular

assays are likely to be incorporated into future staging

schemas.


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CNCER VEJIGA


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CANCER DE VEJIGA CLASIFICACION

T Tumor Primario

Ta Carcinoma Papilar No invasivoTis Carcinoma in situ

T1 Tumor invade a lmina propia


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T2 Tumor invade capa muscular

T2a Invasin a capa superficialT2b Invasion a capa profunda mitad

Externa


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T3 Invasin a tejido perivesical

T3a Invasin microscpicaT3b Invasin macroscpica

T4 Invasin a prstata, vagina, tero,(T4a) pelvis, pared abdominal(T4b).


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CARACTERSTICAS DE GRADO

CA VESICAL NO INVASIVO

OMS 2004PAPILOMA UROTELIAL

Neoplasia Papilar Urotelialde bajo potencial maligno(PUNLMP)

Carcinoma Urotelial papilarde bajo grado Carcinoma Urotelial papilarde alto grado.


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CA DE VEJIGA No Invasivo.


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CA DE VEJIGA PROGRESION Y RECIDIVA

NEOPLASIA UROTELIAL PAPILAR DE BAJOPOTENCIAL MALIGNO

Pueden recurrir, Raramente invaden.

CARCINOMA DE BAJO GRADORecurren mas 60%. Invasin menos 10%

CARCINOMA DE ALTO GRADO

Recurren; Invasin yProgresion 50% . CA. PAPILAR ALTO GRADO MAS Tis---Mismo

%


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CA DE VEJIGA. Diagnstico


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CANCER DE VEJIGA NO INVASIVO.DIAGNOSTICO

HEMATURIA

EXPLORACIN TAC

ECOGRAFA

CITOLOGIA URINARIA

ANALISIS MOLECULARES


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HEMATURIA

EXPLORACIN

CITOLOGIA URINARIA

95% especificidad40%-60% sensibilidad

82% en alto riesgo

ECOGRAFA UROTOMOGRAFIA

CISTOSCOPIA


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CANCER DE VEJIGA DETECCION

Painless gross hematuria occurs in 85% of patients with

bladder cancer and requires a complete evaluation that

includes cystoscopy, urine cytology, CT scan, and a PSA

blood test.

Patients with microscopic hematuria require a full evaluation,

but low-risk patients do not require repeat evaluations. High-risk individuals primarily are those with a smoking

history and should be evaluated every 6 months.

lWhite light cystoscopy with random bladder biopsies is the

gold standard for tumor detection, but blue light cystoscopy

may be an adjunct. There are various urine markers that evaluate secreted proteins

or shed cells in the hope of noninvasively detecting

bladder cancer. To date, none of these markers have a high

enough sensitivity or specificity to replace office

cystoscopy.


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CA DE VEJIGA Diagnostico


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HEMATURIA

EXPLORACIN

TAC

ECOGRAFA

CITOLOGIA URINARIA

BIOPSIAS DE VEJIGA:

cono fro, citologa positiva, aspecto no papilar,

sospecha de ca in situ (2% en t. bajo riesgo), nodetermina tx intraveical adyuvante.


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CANCER DE VEJIGA Diagnstico


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CANCER DE VEJIGAMARCADORES MOLECULARES


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CA DE VEJIGA RTU DE TUMOR


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CA DE VEJIGA DIAGNSTICO

RTU DE TUMOR SEGUNDA RTU

INFORME DEL ANATOMOPATOLOGO


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CA DE VEJIGA SEGUNDA RTU

TUMOR RESIDUAL POSRTU (incompleta)INICIAL

ENFEREMDAD PERSISTENTE 33%-53%T1 Ta ALTO GRADO.

SUBCLASIFICACIN DE ESTADIO REAL(18%-34%) BIOPSIA SIN TEJIDO MUSCULAR (Ta alto Grado,

T1)

INVASIN MUSC. (10%) NO SE REALIZA TUMORES MULTIPLES GRANDES AUMENTA SOBREVIDA SIN RECIDIVAS REALIZARLA 2- 6 SEMANAS POSRTU INICIAL


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Clculo de Recurrencia y Progresion

Factor Recurrencia Progresin

No. de tumores

Unico 0 02 a 7 3 3> 8 6 3

Dimetro de tumor< 3 cm 0 0> 3 cm 3 3


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Cis concomitante Recidiva Progresin

No 0 0

Si 1 6

Grade (1973 OMS)

G1 0 0

G2 1 0

G3 2 5

Total Score 0 - 17 0 - 23


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Origin, Recurrence, and Invasion

l Primary urothelial cancer is an environmentally causedtumor that recurs because of persistent genetic changes

within the normal-appearing urothelium.

l Recurrent urothelial tumors occur by activation of nascent

normal cells that have some genetic instability by environmental

factors and tumor seeding during transurethraltumor resection.

l Accumulation of genetic changes leads to cellular proliferation,

loss of cellcell adhesion, and invasion.

l The depth of invasion and grade of the tumor are the best

prognostic determinants of urothelial cancer, but molecularassays are likely to be incorporated into future staging

schemas.

CA DE VEJIGA PRONOSTICO


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FREQUENCY

%

PROGRESSION % DEATHS

Noninvasive

Papilloma 10 0-1 0 Papillary urothelial

neoplasm of low malignant

potential

20 3 0-1

Papillary cancer low

grade (TaG1)

20 5-10 1-5

Papillary cancer high

grade (TaG3)

30 15-40 10-25


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CA DE VEJIGA. HISTORIA NATURAL

Ta BAJO GRADO RARAMENTE PROGRESAN(5%), Recurren 50%-70%

Ta alto grado (6.9%) igual a alto riesgo Cis invade 40%-83% sin tx. T1 alto grado recurren 80%

progresan 50% a 3 aos Ta T1

50%-70% Recurren en 5 aosy 26% Mueren


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ESTADIO T1CANCER RESIDUAL 30%

PROGRESION7%/AO


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ALTO GRADO

Ta G3

RECURREN 3 a.PROGRESAN 5 a. 20%

10 a. 30%-40%

MUEREN 10 a. 10%-26%


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T1 ALTO GRADO

Recurrencia 1 ao 50%

3 aos 80%5 aos 90%

Progresan 5 aos 50%

Cis concomitante 80%


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CA DE VEJIGA Pronstico


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MMC, THIOTEPA, EPIRUBICINA (80 mgs), GEMCITABINA

PREVIENEN IMPLANTACIN DE CELS. TUMORALESPREFERENTEMENTE USADA EN PAC . BAJO RIESGO DE

RECURRENCIA.MMC(40 mgs-UNA DOSIS, 6-24 HS DESPUES RTU.

T1 ALTO GRADO, 6 SEM (DUDOSO)

NO IMPACTA EN RIESGO DE PROGRESIN

CANCER DE VEJIGAQUIMIOTERAPIA INTRAVESICAL ADYUVANTE


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CANCER DE VEJIGA QUIMIOTERAPIA

Intravesical Chemotherapyl Intravesical chemotherapy has a clear impact on tumorrecurrence when immediately instilled after TURBT and inthe adjuvant setting. There is no clear evidence of an impacton progression.l Combinations of various chemotherapeutic agents and

chemotherapycombined with BCG have not demonstratedmajor benefit combined with single-agent treatment, withthe exception of interferon.l In general, side effects of chemotherapy tend to be lesscommon and less severe than those for BCG, but BCG is

more efficacious.


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RESPUESTA INMUNE MASIVA (CITOKINAS)

INICIO 2-4 SEMA PORSRTU RETENER EN VEJIGA 2 HS

RIESGO INTERM ALTO DE RECIDIVA, RIESGOINTERM. PROGRESION: 1 AO

RIESGO ALTO DE PROGRESIN (post-quimioterapia)BCG (3 AOS)

CA DE VEJIGA INMUNOTERAPIA


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CANCER DE VEJIGA INMUNOTERAPIA

Immunotherapyl Intravesical BCG has higher efficacy than intravesicalchemotherapy.l BCG should be used cautiously for patients with low-riskdisease because of concern about side effects.l BCG is the only agent shown to delay or reduce high-grade

tumor progression.l The optimum dosage and the treatment schedule for BCGare undetermined, but results are better with maintenancetherapy, if tolerated.l BCG is contraindicated in the setting of a disrupted urotheliumbecause of the risk of intravasation and septic death.

l Interferon- has not been shown to have benefit comparedwith BCG for primary treatment but appears to work wellin combination with low-dose BCG, especially for salvage


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CA DE VEJIGA ENF. REFRACTARIA

Management of Refractory Diseasel Patients who fail to respond to an initial course of intravesicaltherapy after TURBT are at high risk of recurrence orprogression.l Failure after initial chemotherapy or BCG is most appropriately

treated with a subsequent course of BCG because itsefficacy in this setting is significantly greater than that ofchemotherapy.l Patients at high risk for progression should be consideredfor cystectomy.l Failure to respond to an initial course of intravesical therapy

is occasion to reconsider cystectomy. Failure to respond toa second course is an indication for immediate cystectomyunless contraindicated or the patient chooses to pursueclinical trials.


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CISTECTOM IA INMEDIATA

FALLA DE BCG

RIESGO MAYOR DEPROGRESIN T. NO INV.

CA RECURRENTE


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Riesgo bajo de recidiva y progresin3 meses.

NEGATIVA- 9. mes despues una vez/ao, 5 aos

Riesgo alto de progresin:Cistoscopia y citologia en 3 meses.

NEGATIVA, cistoscopias y citologias cada 3 m.en 2 aos, cada4 meses en tercer ao, cada 6

meses - 5 aos, anualmente.

Riesgo intermedio de progresinEsquema Intermedio cistoscopia y citologia,

CA RECURRENTECISTOSCOPIA DE SEGUIMIENTO

CA DE VEJIGA


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CA DE VEJIGAVIGILANCIA Y PREVENCION

Surveillance and Preventionl Cystoscopy is the hallmark of surveillance. The optimumschedule is undefined but may be individualized on thebasis of risk.l Table 818 demonstrates reasonable surveillance protocols

based on clinical scenarios. Guidelines for management areshown in Table 819.l A number of tumor markers have shown the ability toimprove upon the sensitivity of cytology, but specificity islower for most.l Increased fluids, smoking cessation, and a low-fat diet are

recommended.

CA DE VEJIGA P ti


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CA DE VEJIGA Pronstico

CA VESICAL M j


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CA VESICAL Manejo

Pathologic, Morphologic and Clinicalatures Accurate determination of stage and grade Surgical quality TURBT and bladder biopsies

Recommend rereview and 2nd TUR for T1G3 Variant histology: micropapillary Focality single vs. multiple Presence of CIS

Age Status at 3 month followup Size Future: Molecular profiling

CA DE VEJIGA


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TX INTRAVESICALTaG3, Cis, T1G3

78%

CA DE VEJIGA


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PACIENTES CON GRANDES Y MULTIPLES

TUMORES (MAS DE 3 CMS) Y ALTAMENTERECURRENTES (MAS DE UNA RECURRENCIA PORAO) TIENEN MAS RIESGO DE RECURRENCIAMIENTRAS QUE PACIENTES CON TUMORESESTADIO T1, ALTO GRADO Y Cis , TIENEN EL

MAYOR RIESGO DE PROGRESIN.


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Table 4: Probability of recurrence and progression

according to total scoreRecurrence Prob. Prob. Recurrence

score recurrence recurrence risk group

1 year 5 years

0 15% 31% Low risk

1-4 24% 46%

Intermediate risk

5-9 38% 62%

10-17 61% 78% High risk

Progression Prob. Prob. Progression

score progression progression risk group

1 year 5 years

0 0.2% 0.8% Low risk

2-6 1% 6% Intermediate risk

7-13 5% 17%

14-23 17% 45%

High risk

Note: electronic calculators for Tables 3 and 4 are availab at

http://www.eortc.be/tools/bladdercalculator/

CA DE VEJIGA SEGUIMIENTO


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a. The prompt detection of muscle invasive and high-grade

non-muscle invasive recurrences is critical since a delay indiagnosis and therapy threatens a patients life.

b. Tumour recurrence in the low-risk group is nearly always

low stage and low grade. Small, non-invasive (Ta), lowgrade

papillary recurrences do not present an immediate

danger to the patient and their early detection is not essentialfor successful therapy.

c. The result of the first cystoscopy after TUR at 3 months is

a very important prognostic factor for recurrence and for

progression. The first cystoscopy should thus always be

performed 3 months after TUR in all patients with nonmuscleinvasive bladder tumour.

CA DE VEJIGA SEGUIMIENTO

CA VESICAL


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Recommendations for follow-up cystoscopy

Patients with tumours at low risk of recurrence andprogression should have a cystoscopy at 3 months.

If negative, the following cystoscopy is advised at 9

months and consequently yearly for 5 years. (Grade of

recommendation: C)

Patients with tumours at high risk of progression should

have a cystoscopy and urinary cytology at 3 months.If negative, the following cystoscopies and cytologies

should be repeated every 3 months for a period of 2

years, every 4 months in the third year, every 6 months

thereafter until 5 years, and yearly thereafter.

A yearly exploration of the upper tract is recommended.

(Grade of recommendation: C)

Patients with intermediate-risk of progression (about

one-third of all patients) should have an in-between follow-

up scheme using cystoscopy and cytology, adapted

according to personal and subjective factors. (Grade of

recommendation: C)

CA VESICAL CISTOSCOPIA DE SEGUIMIENTO

CA DE VEJIGA Invasivo


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CA DE VEJIGA Invasivo


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CONSIDERACIONES ONCLOGICAS:

Ca P. TUMOR MAS COMUN (33 %)

Ca de VEJIGA OCUPA CUARTO LUGAR (7 %) CaP , 2. Causa de fallecimientos (10 %)

Ca de VEJIGA 9. Causa de fallecimientos (3%)

AMBOS DEL HOMBRE VIEJO (Ca de VEJIGAcon relacin 3 a 1)

CA DE VEJIGA Di Ci t i


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CA DE VEJIGA Diag. Cistoscopico

CA VESICAL Recurrente


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CA VESICAL. Recurrente

Recurrent TumorsA hallmark of urothelial cancer is

the high recurrence rate thatapproaches 80% for highmalignant potential, nonmuscle-invasive

bladder cancer


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MORTALIDAD EN ETAPAS AVANZADAS

Testiculo-25 %

Rin-20 %

Vejiga-6.5 %

Prstata-5.5%

Pene-3 %

TUMORES DE UROTELIO


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TUMORES DE UROTELIO

ETIOLOGIA:

Tabaquismo,

Factores ocupacionales,

Factores irritativos locales,

Carcinogenicos,

Radioterapia, Otros: Genes, baja ingesta de lquidos, caf o t,

edulcurantes, abuso de analgsicos, herencia.


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CA DE VEJIGA Diagnstico


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CA DE VEJIGA. Diagnstico


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OBJETIVOS: GENERAL, Centro de Referencia

ESPECIFICOS:

COADYUVAR en mejor atencin y beneficio alos pacientes con neoplasias, CONCIENTIZAR de la importancia y necesidad

de trabajar local, interinstitucional ymultidisciplinariamente para

OBTENER mejores resultados diagnticos,teraputicos y controles estadisticos en laRegin.



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CONSECUENCIA:

Incremento en Quimioterapia




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CA DE VEJIGA


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CA. DE VEJIGARESECCION TRANSURETRAL

MULTIFOCALIDAD

TAMAO TUMORAL

TUMORES PREVIOS

PROFUNDIDAD

PRESENCIA DE CA IN SITU

TUMORES PREVIOS

TIEMPO DE SEGUIMIENTO

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PRESENTACIÓN CENTRO ONCOLOGICO.pptx