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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