Manajemen Kanker Manajemen Kanker Prostat Prostat dan Kanker Buli- dan Kanker Buli- Buli Buli Rainy Umbas Rainy Umbas Departemen Urologi Departemen Urologi Rumah Sakit Cipto Mangunkusumo Rumah Sakit Cipto Mangunkusumo Universitas Indonesia Universitas Indonesia
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Manajemen Kanker Manajemen Kanker ProstatProstat
dan Kanker Buli-dan Kanker Buli-BuliBuli
Rainy UmbasRainy UmbasDepartemen UrologiDepartemen UrologiRumah Sakit Cipto Rumah Sakit Cipto Mangunkusumo Mangunkusumo
• Prostate specific antigen (PSA)- cut off level untuk indikasi biopsi: > 4 ng/ml- indikasi biopsi ulang dapat digunakan PSA density (PSAD), free/total PSA (f/t PSA), atau PSA velocity (PSAv)- untuk follow up hasil pengobatan
• PCA3 : pemeriksaan urin setelah dilakukan masase prostat
Trans rectal ultra-sonography (TRUS):Trans rectal ultra-sonography (TRUS):
Dilakukan untuk mengukur volume prostat.• Bila akan memberikan pengobatan dengan 5
alpha reductase inhibitor.• Sebelum tindakan operasi atau termoterapi
Trans rectal ultra-sonography (TRUS) & Trans rectal ultra-sonography (TRUS) & biopsi:biopsi:
Indikasi biopsi prostat:
• Kelainan pada colok dubur
• PSA > 4 ng/mlAnestesi lokal atau regional/umum
Hasil pemeriksaan histopatologi:• Jenis & grade tumor (Gleason score)• Persentase pada setiap “core”
Derajat keganasan (grade)Derajat keganasan (grade)Diagnosis pasti kanker prostat berdasarkan
pemeriksaan histopatologi jaringan biopsi atau reseksi prostat.
Ditentukan jenis tumor dan dibuat klasifikasi derajat sesuai dengan:
• WHO : berdasarkan derajat diferensiasi yaitu baik, sedang, dan buruk (Mostofi)
• Sistem Gleason : berdasarkan pola arsitektur (morfologik) kelenjar prostat yang dibagi antara 1-5. Ditentukan dua kelompok yang paling menonjol dan dijumlah menjadi Gleason score (2-10).
Gleason pathologic grading systemGleason pathologic grading system
Gleason DF. In: Tannenbaum M, ed. Urologic Pathology: The Prostate.Philadelphia, Pa: Lea & Febiger; 1977: 171–197
Pain during prostate biopsyPain during prostate biopsy
How to reduced / avoid:
• Good explanation to reduced anxiety• Treat the inducing factors (prostatitis, ano-
rectal pathology)• Using analgesia in certain condition:
- very anxiety patient- biopsy > 6 core- repeat biopsy
Pain during prostate biopsyPain during prostate biopsyDouble blinded study comparing periprostatic
injection of 1% lidocaine VS Placebo• Degree of pain was scored by VAS, 0-10.• 2.5 mL periprostatic injection around the seminal
vesicel on each side was done with 22 G needle• 18 G needle, 6-12 core.
• No significant difference of complications among these two groups.(Alvarino M & Umbas R, Indon Med J 2005)
n VAS pPlacebo
1% lidocaine
30
30
5.7 ± 1.7
2.1 ± 1.3
< 0.005
Peri-prostatic injectionPeri-prostatic injection
Jones JS et al. Prostate Cancer and Prostatic Diseases (2003) 6, 53–55
Tingkat penyakit (stage)Tingkat penyakit (stage)Berdasarkan sistem TNM (AJCC 2002) yang
ditentukan secara klinis (pemeriksaan fisik dan radio-imajing) atau surgical staging pasca radikal prostatektomi
• T : klinis biasanya dapat ditentukan berdasarkan karakteristik prostat pada pemeriksaan colok dubur. Cara lain adalah dengan bantuan trans-rectal ultrasonography (TRUS) atau MRI
• N : Hanya akurat dengan cara deseksi kelenjar getah bening.
Tingkat penyakit (stage)Tingkat penyakit (stage)• M : Bone scan, MRI, Bone survey
• Surgical staging (pT & pN) berdasarkan pemeriksaan histopatologi terhadap jaringan pasca radikal prostatektomi dan/atau deseksi kgb
Early stage Prostate CancerEarly stage Prostate Cancer
Treatment option for organ confined prostate cancer (T1a-T2b, N0, M0)
• Active surveilance / Watchful Waiting (WW)• Radical prostatectomy• Radiotherapy (EBRT or Brachytherapy)• Primary Androgen deprivation therapy
PADT in early stage Prostate CancerPADT in early stage Prostate CancerAs primary treatment:• Advanced age• Patient refusing curative treatment• Patient unsuitable for curative treatment
due to co-morbidity(Bartsch G et al, 6th International Consultation on new
developments in prostate cancer and prostate disease 2006)
- Could be given immediately or deferred- Continuos or intermittent
Role of PADT in early stage Prostate Role of PADT in early stage Prostate CancerCancerManagement of localized prostate cancer (by order
of preference)(Bartsch G et al, 6th International Consultation on new
developments in prostate cancer and prostate disease 2006)
Risk Life expectancy< 5 years 5-10 years > 10 years
The androgen deprivation The androgen deprivation syndromesyndrome
• Loss of libido• Erectile impotence• Decreased energy
- Metabolic syndrome- Osteoporosis / fracture- Loss of muscle mass- Weight gain- Anaemia- Alteration in lipid
profile- Depression, personality
change
What patients expect What they also get
Recent evidence on IAB in advanced Recent evidence on IAB in advanced prostate cancer patientsprostate cancer patients
• Testosteron recovery:± 90% patients recovered to normal testosteron levels within 18 weeks after 1st ON treatment cessation
• Disease progression & survival:No significant differences between IAB and CAB in term of:
- median time to progression- progression free survival- overall survival
• Tolerability & QoL:- Side effects (hot flushes, gynecomastia, headaches) were significantly more in CAB- Significantly better sexual activity & emotional function were found in patients with IAB therapy(Abrahamsson P-A, Eur Urol, 2010)
IAB vs Orchydectomy
p = 0.35
IAB in advanced Prostate CancerM1 (a/b/c)
Intermittent hormonal therapy
Successful 1st ON treatment(9 months)
Failed within 1st ON treatment
1st OFF treatment
orchydectomyRe-start if PSA ± 15ng/ml
Failed
Successful 2nd ON treatment (9 months)
2nd OFF treatment
3rd ON treatment
Recent evidence on IAB in advanced Recent evidence on IAB in advanced prostate cancer patientsprostate cancer patients
• IAB seems to be as effective as continuous AB with tolerability & QoL advantages
• When to stop & ON treatment duration:- PSA < 4 ng/ml- 9 months therapy
• When to re-start: PSA ± 15 ng/ml.
(Shaw G and Oliver RTD, Surgical Oncology 2009; Abrahamsson P-A, Eur Urol 2010)
Definition of HRPC (Hormone Refractory ProstateCancer or Androgen Independent Prostate Cancer)
1. Serum castration level of Testosteron2. Three consecutive rises of PSA 2 weeks apart
resulting in two 50% increases over the nadir3. Antiandrogen withdrawal for at least 4 weeks4. PSA progression despite secondary hormonal
manipulations5. Progression of osseous or soft tissue lesions