Tumores da bexiga Progressão: o que fazer? Jorge OLiveira

Apresentação em tema: "Tumores da bexiga Progressão: o que fazer? Jorge OLiveira"— Transcrição da apresentação:

1 Tumores da bexiga Progressão: o que fazer? Jorge OLiveira
I CURSO TUMORES DA BEXIGA HOTEL JÚPITER, LISBOA | 26 DE NOVEMBRO DE 2016

2 Cancer statistics, 2015 Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths by Sex, United States, 2015.Estimates are rounded to the nearest 10 and cases exclude basal cell and squamous cell skin cancers and in situ carcinoma except urinary bladder. IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER. CA: A Cancer Journal for Clinicians Volume 65, Issue 1, pages 5-29, 5 JAN 2015 DOI: /caac

3 Estadio

4 Ao diagnóstico primário
Novos casos de tumor vesical 70-80% Não Musculo-invasivo 50-70% recorrência 10-30% progressão 20-30 % Musculo invasivo

5 Definir risco - EORTC Apenas para doentes com mitoC ou 1os –nao inclui a fazer BCG

6 Progressão

7 Progressão doentes BCG
Club UrológicoEspañol de TratamientoOncológico (CUETO) Calculada por 6 factores de Risco Sexo Idade Recorrência prévia Número de tumores Estadio T Cis Grau do tumor

8 Grupos de risco Conceito de evitar a progresão

9 Grupo de Risco Muito Alto
Highest-risk tumour T1G3/HG+CIS T1G3/HG+CIS in prostatic urethra Multiple T1G3/HG T1G3/HG > 3 cm micropapillary variant Ponderar cistectomia imediata

10 Beneficios Numa grande série de tumores de alto risco –txintravesical
27% doentes tx com terapia intravesical agressiva – morreram de outras causas 50% progressão 33% morreram da doença Cistectomia imediata Melhor estadiamento 92% sobrevida aos 10 anos Comparados com 64% de sobrevida aos 10 anos de doentes que teriam doença T1 mas que na peça de cistectomia revelou doença musculo invasiva Erro de subestadiamento em tumores Ta/T1 de 35-62% BCG permite manter bexiga mas até 20% T1G3 tratados com BCG progridem e 11% morrem por progressão em 5 anos Cookson and coworkers (1997) reportedthat 27% ofhigh-riskpatientstreatedinitiallywithaggressiveintravesicaltherapydidwell and diedofother causes, and the samelownumbersurvivedwithanintact, functioningbladder 15 yearsafterdiagnosis. However, approximatelyhalfofpatientsexperiencedprogression, and onethirddiedoftheirdisease. In contrast, patientswhoundergoimmediatecystectomy for clinical T1 tumorsbenefitfrom more accuratepathologicstaging in addition to a 10-year disease-freesurvivalof 92%, comparedwith 64% ofthosewithclinical T1 tumorswhowerefound to actuallyhavemuscleinvasionat the time ofcystectomy( Biancoet al, 2004 ) Largecystectomyseries show a riskofanunderstaging error in TaT1 tumoursof 35-62%

11 TV AG refractário a txintravesical
Se o tratamento inicial – quimioterapia intra-vesical – considerar BCG. MitoC– apenas 20% sobrevida livre de doença neste contexto( Malmstromet al, 1999 ; Steinberget al, 2000 ) Falência BCG – 2º ciclo de BCG - 30% a 50% resposta ( Pansadoro and De Paula, 1987 ; Brakeet al, 2000 ) Modelo frequente nos EUA Mais do que 2 ciclos de BCG ou QT – 80% de falência

12 O que dizem as EAU guidelines

13 Falência pós BCG Presença de baixograunãoéconsideradafalência
Se tumor AG não musculo-invasivo aos 3M Continuar BCG > risco progressão Importância de reRTU Presença de Cis aos 3M e aos 6M Se apenas presente aos 3M – novo ciclo de BCG obtem resposta >50% dos casos Alto risco de progressão – ponderar cistectomia precoce If high-grade, non-muscle-invasive papillary tumour is present at 3 months [225]. Further conservative treatment with BCG is associated with increased risk of progression [149, 226] (LE: 3). If CIS (without concomitant papillary tumour) is present at both 3 and 6 months. If patients with CIS present at 3 months, an additional BCG course can achieve a complete response in > 50% of cases [36] (LE: 3). If high-grade tumour appears during BCG therapy*. * Patients with low-grade recurrence during or after BCG treatment are not considered to be a BCG failure. Presença de baixograunãoéconsideradafalência

14 Progressão Diferença para doença musculo-invasiva primária!
Progression to MIBC significantly decreases CSS. In a review of 19 trials including 3,088 patients, CSS after progression from NMIBC to MIBC was 35%, which is significantly worse compared to patients with MIBC without a history of NMIBC.

15 Pergunta O que fazer aos doentes que não completaram ciclo de BCG?
Muitos poucos dados

16 Marcadores tumorais Poderão os marcadores tumorais ter um papel na decisão de cistectomia precoce? p53 e Rb– estratificação de doentes de alto risco p53+ 75% tx progressão comparado p53- p53+ menor sobrevida Todavia há estudos a contrariar estes dados – papel investigacional ( Peyromaure et al, 2002 ) Some seriessuggestthat tumor markerssuch as p53 and RB maybeuseful for stratifyinghigh-riskpatients for suchdecisions in the future. High-risk p53 lesionshave a 75% progression rate, comparedwith 25% in p53-negative lesions. Survivalis 60% at 10 years in patientswith p53-positive lesions, whereasitis 88% in patientswith p53-negative lesions ( Sarkiset al, 1993 ). Grossman and colleagues (1998) foundthat for T1 lesionsevaluated for p53 and RB, progressionat 5 yearswas 30% ifeithermarkerwas positive and 47% ifbothmarkerswere positive. No progressionwasnoted in lesionsthatwerewildtype for bothmarkers ( Grossmanet al, 1998 ). Although p53 positivitydidnotpredict response for BCG-treatedpatients in anotherstudy, post-BCG p53-positive expressionwas a markerof tumor progression (p53 positive, 82% progression and 41% mortality; p53 negative, 13% progression and 7% mortality) ( Lacomeet al, 1996 ). Otherstudieshaverefutedthesefindings, sothe role of p53 for the predictionof tumor behavior and response to therapyremainsunder debate ( Peyromaureet al, 2002 ).

17 Abordagem individualizada
Doente com progressão Perfomance status Expectativas QoL?

18 Pergunta Poderá o tratamento multimodal ser alternativa em doentes de alto risco, evitando progressão e obter sobrevida = cistectomia?

19 Tratamento Quimioterapia neoadjuvante Cistectomia radical
Tratamento multimodal

20 EAU

21 EAU

22 EAU