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CLASIFICAREA STADIALA
cancer localizat
cancer avansat locoregional
cancer metastatic
– Necesitate impartire
OBIECTIVE
– indicatiei terapeutice– indicatii asupra prognosticului– aprecierea unitara a rezultatelor diferitelor
metode de tratament– schimbul de informatii : limbaj comun
CLASIFICAREA STADIALA
Reguli generale de clasificare
1. Confirmare HP . Cazurile fara separat2. TNM - Examene minime necesare ; X3. se tine cont de indicatiile privind definirea
teritoriilor limfatice4. T – indici in dreptul simbolului
1. Masurare in 2 diametre (cel mai mare si perpendicular pe primul)
2. Tumora nemasurabila = se folosesc criterii clinice specifice localizarii respective (ex. Col – extensie parametre , vagin)
Trepte de “T”
Tis T0 – nu e decelabila clinic T1,2,3, 4 – trepte progresive T x
daca sunt mai multe tumori : (2)T1, (5)T2 subcategorii a,b,c,d.
Trepte de “N”
• Date clinice (palpare) , paraclinice (limfografie, CT, Eco…)
• N0• N1- regionala mobila; < 2 cm ; consistenta dura, • N2 – bloc adenopatic ; > 2 cm ; fixare supra ;
subjacent• N3 – treapta de gravitate mai mare : ex. Sin,
plamin …..• Nx
Gruparea pe stadii clinice Combinarea diferitelor trepte T, N, M I – IV I si II – considerate curabile III – greu curabil IV – incurabil nu se schimba niciodata indiferent de constatarile facute
in evolutia ulterioara a bolnavului 3 medici oscilare intre 2 stadii – se alege cel mai putin avansat
(pentru a nu falsifica rezultatele terapeutice) NU stadiu I/II sau III/IV …..
completare cea clinica; chir curativa informatii intraoperator in general pT = cT daca este pT = se alege pT, pN ,pM numarul de ganglioni invadati – indicatie
terapeutica ulterioara capsula intacta / nu ; grupare pe stadii
Clasificarea postoperatorie
Clasificarea postop (cont.)
DEFINIREA : - formei HP - mono / pluricentric - dimensiunea exacta a piesei - descriere macro - tesut peritumoral - elemente specifice pentru fiecare
localizare : tegument, IHC…..
Cancer de sanstadiu I
T1a: T T1a: T 0.5 cm 0.5 cm
T1b: 0.5 cm < T T1b: 0.5 cm < T 1 cm 1 cm
T1c: 1 cm < T T1c: 1 cm < T 2 cm 2 cm
T1 N0 M0T1 N0 M0
T T 2 cm 2 cm
T1T1
N0 = no regional lymph node metastasisM0 = no distant metastasis
Cancer de san . Stadiu IIAT2 N0 M0T2 N0 M0
N1 = mobiliM0 = fara metastaze
2 cm < T 2 cm < T << 5 cm 5 cm
Fara tumoraFara tumoraT0T0
T0 T0 T1T1 N1 M0N1 M0}
T2T2
Cancer de sanStadiu IIIA
T0T0T1T1T2T2T3T3
N1 = mobiliN2 = fixati intre ei sau la alte structuriM0 = fara meta la distanta
T3 N1 M0T3 N1 M0 N2 M0N2 M0
Cancer de san Stadiu IV
M1 = metastaze la distanta (fara supraclaviculari ipsilaterali)
orice T orice N M1orice T orice N M1
NSCLC . Stadiu I 2 cm
N0: N0: M0:M0:
Fara invazie lobara
T 3 cm
IaIaT1T1 N0N0 M0M0
IbIbT2T2 N0N0 M0M0
T >3 cm
T + afectare pleura viscerala
T + atelectazie distala
Oricare din :
T= bronsie principala afectata
2 cm distal de carina
2 cmNSCLC. Stadiu II
N1: ipsilateral peribronsici +/- hilariN1: ipsilateral peribronsici +/- hilariM0:M0:
IIaIIaT1T1 N1N1 M0M0
IIbIIbT2T2 N1N1 M0M0
T + atelectazie totala
T3 N0 M0
Oricare din :T+ bronsie principala < 2 cm distal de carina
T (orice dimensiune) invadeaza peretele toracic, diafragm, pleura mediastinala sau pericardul
NSCLC . Stadiu IIIa
T3T3 N1N1 M0M0T3T3 N2N2 M0M0
T1 T1 N2N2 M0M0T2T2 N2N2 M0M0
N1:N1:N2: ipsilateral mediastinal +/- subcarinal N2: ipsilateral mediastinal +/- subcarinal M0: M0:
<2 cm 2 cm
OR
OR
OR
OR
T2
T peretele toracic sau diafragm
T pleura mediastinala sau pericardul
T 3 cm
T + invazie pleura
viscerala
T + atelectazie
T 3 cmFara invazie bronsie
NSCLC . Stadiu IIIbOrice T, N3, M0Orice T, N3, M0 T4, orice N, M0T4, orice N, M0
ScaleneScaleneSupraclavicularSupraclavicular
T (any size) invading mediastinum, heart, T (any size) invading mediastinum, heart, great vessels, trachea, esophagus, great vessels, trachea, esophagus, vertebral body, or carina vertebral body, or carina or T+ malignant pleural effusionor T+ malignant pleural effusion
Any TAny T
Any NAny N
T4T4
N3: contralateral mediastinal, N3: contralateral mediastinal, contralateral hilar, ipsilateral, or contralateral hilar, ipsilateral, or contralateral scaline or supraclavicular contralateral scaline or supraclavicular nodes involvednodes involved
Humphrey EW, et al. The American Cancer Society Textbook of Clinical Oncology. 1995;221-235.
NSCLC. Stadiu IV
orice T, orice N, M1orice T, orice N, M1
Mountain CF. Chest. 1997;111:1710-1717.
M1: distant metastasisM1: distant metastasis
Brain
Draining lymph nodes
PericardiumLungPleuraLiverAdrenalsSkinBone
NSCLC. Diseminarea limfatica
Secventa invaziei Secventa invaziei ganglionare:ganglionare:
First
Subsequent
From upper lobe
From middle lobe
From lower lobe
Cale de diseminare :Cale de diseminare :
Ginsberg RJ, et al. Cancer: Principles and Practices of Oncology. 5th ed. 1997;858-911.
NSCLC. DiseminareBrain
Draining lymph nodesPericardiumLungPleuraLiverAdrenals
Bone
Ginsberg RJ, et al. Cancer: Principles and Practices of Oncology. 5th ed. 1997;858-911.
PROSTATE CANCERLymphatic spread
Hypogastric nodes
External iliac nodes
Obturator nodes
Iguinal nodes
Ureter
Hypogastric and vesical arteries
Obturator nerve
External iliac artery and vein
Prostate
PROSTATE CANCERStage grouping
Used with the permission of the American Joint Committee on Cancer (AJCC®) Chicago, Illinois. The original source for this material is the AJCC® Cancer Staging Manual, 5th edition (1997) published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.
Stage I T1a N0 M0 G1
Stage I T1a N0 M0 G2,3-4T1b N0 M0 Any GT1c N0 M0 Any GT1 N0 M0 Any GT2 N0 M0 Any G
Stage III T3 N0 M0 Any G
Stage IV T4 N0 M0 Any GAny T N1 M0 Any GAny T N2 M0 Any GAny T N3 M0 Any GAny T Any N M1 Any G
PROSTATE CANCERStage IT1 Clinically inapparent tumor not palpable nor visible by imaging
G1 Well differentiated (slight anaplasia) T1a No MO G1
T1a Tumor incidental histologic finding in 5% or less of tissue resected
N0 No regional lymph node metastasis
M0 No distant metastasis
Used with the permission of the American Joint Committee on Cancer (AJCC®) Chicago, Illinois. The original source for this material is the AJCC® Cancer Staging Manual, 5th edition (1997) published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.
PROSTATE CANCERStage II
T1a N0 M0 G2, 3-4 T1b N0 M0 Any G
T1a Tumor incidental histologic finding in 5% or less of tissue resected
T1b Tumor incidental histologic finding in more than 5% of tissue resected
N0 No regional lymph node metastasisM0 No distant metastasis
T1c N0 M0 Any G
T1c Tumor identified by needle biopsy (e.g., because of elevated PSA)
T1 clinically inapparent tumor not palpable nor visible by imaging
Used with the permission of the American Joint Committee on Cancer (AJCC®) Chicago, Illinois. The original source for this material is the AJCC® Cancer Staging Manual, 5th edition (1997) published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.
PROSTATE CANCERStage II (cont’d)
T2a N0 M0 Any GT2b N0 M0 Any G T2c N0 M0 Any G
T2a Tumor involves one lobe
T2b Tumor involves both lobes
N0 No regional lymph node metastasis
M0 No distant metastasis
T2 Tumor confined within prostate*
Used with the permission of the American Joint Committee on Cancer (AJCC®) Chicago, Illinois. The original source for this material is the AJCC® Cancer Staging Manual, 5th edition (1997) published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.
*Note: Tumor found in one or both lobes by needle biopsy, but not palpable or reliably visible by imaging, classified as T1c.
PROSTATE CANCERStage III
T3a N0 M0 Any GT3b N0 M0 Any G
T3c N0 M0 Any G
T3a Extracapsular extension(unilateral or bilateral)
T3b Tumor invades seminal vesicle(s)
N0 No regional lymph node metastasis
M0 No distant metastasis
T3 Tumor extends through the prostate capsule*
Used with the permission of the American Joint Committee on Cancer (AJCC®) Chicago, Illinois. The original source for this material is the AJCC® Cancer Staging Manual, 5th edition (1997) published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.
*Note: Invasion into the prostatic apex or into (but not beyond) the prostatic capsule is not classified as T3, but as T2.
T4 N0 M0 Any GAny T N1 M0 Any GAny T Any N M1 Any G
PROSTATE CANCERStage IV T4 Tumor is fixed or invades adjacent
structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall
M1 Distant metastases
M1a Nonregional lymph node(s)
M1b Bone(s)
M1c Other site(s)
N1 Metastasis in regional lymph node or nodes
Used with the permission of the American Joint Committee on Cancer (AJCC®) Chicago, Illinois. The original source for this material is the AJCC® Cancer Staging Manual, 5th edition (1997) published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.
Formulare diagnostic se incepe cu forma HP (adenocc, cc, sarcom …) localizare elemente suplimentare despre tumora stadiul clinic + TNM
Adenocarcinom mamar drept, CSE , T2N1Mo (IIB)- daca evolueaza . ……. . Metastaze hep….- daca se prezinta cu stadiu IV- localizarea
metastazei
Grad de diferentiere
G1 = grad crescut de diferentiere G2 = moderat G3 = scazut G4 = nediferentiat Gx
SBR (Scale Bloom Richardson), scor Gleason
Markeri tumorali
2 categorii :– produsi directi ai celulelor tumorale– reactivi – prodisi de organism ca rezultat al
neoplaziei
MkT produsi de tumora
constituienti ai memebranei celulare sintetizati activi
Markerul :– constituient celular normal DAR in exces
(calcitonina)– produs metabolic anormal / ectopic (sindroame
paraneoplazice)
Constituienti ai membranei celulare
Antigenele oncofetale: – CEA : colon, rect, sin, plamin, stomac, vezica , esofag,
pancreas– AFP : hepatice, tumori germinale testiculare, ovariene
Mucinglicoproteinele :– CA 15.3 : sin– CA 19.9 :pancreas– CA 125 : ovar
alte glicoproteine :– PSA : prostata– LASA (acid sialic legat de lipide) : tu. conjunctive si
epiteliale
Produsi metabolici celulari enzime :
– FAP : in formele ce depasesc capsula– FA : meta osoase , hep (indiferent de tu primara) osteosarcom– LDH : limfoame , meta hep– GGT : meta hep– NSE : SCLC
hormoni :– beta-HCG : tu trofoblastice, testiculare– calcitonina, tiroglobulina : tiroidian (bine dif)– VIP, GIP, insulina, glucagon : tu digestive, tumori carcinoide :
serotonina– cataboliti urinari ai acidului vanil mandelic : neuroblastom,
feocromocitom– ACTH , ADH, parathormon : paraneo (BP)
AFP
dozare radioimunologica, ng/ml VN < 15 ng/ml T1/2 serica = 5-7 zile la pacientii cu seminom pur existenta
elementelor neseminomatoase poate fi crescuta
– 10-20 % in stadiile I– 20-40 % in stadiile II cu volum tumoral mic– 40-60 % volum tumoral mare
ß-HCG produsa de sincitiotrofoblast subunitarea alfa – identica cu LH, FS, TSH subunitatea beta – distincta valori crescute in : seminomatos / neseminomatos T1/2 = 18-36 ore Valori crescute :
– 10-20 % stadii I– 20-30 % stadii II– 40-60 % tumori neseminomatoase stadii avansate– 15-25 % stadii avansate seminom pur
false cresteri :– reactii incrucisate cu LH– hipogonadism indus terapeutic– productie pituitara de HCG
LDH
factor de prognostic independent in tumorile avansate
folosit in decizia terapeutica valori crescute :
– 60% in tumorile nonseminomatoase avansate
– 80% din tumorile seminomatoase avansate
PSA PSA : aprobat de FDA
> 50 ani (45 ani la cei cu AHC I) annual la cei cu speranta > 10 ani glicoproteine cu activitate serinproteazica PSA
– boli benigne - prostatita, HBP– tuseu prostatic– retentie urinara
> 10 ng/ml = cc. 2% din cei cu PSA > 10 ng/ml = HBP
combinare PSA + TR+ Eco = 75-80% detectare
oncogene :– factori de crestere : PDGF, EGF, VEGF (leucemii, cancer
mamar..)– proteine membranare :
receptori : erb-B, fms : receptor EGF, insulina si receptorul IGF - cc mamar, limfoame, hepatic
protein kinaze (tk) - src (LMC) , abl (limfom) – proteina C : ras – leucemii, tu epiteliale, sin, neuroblastom– proteine nucleare – myc : sin, leucemie mieloblastica,
neuroblastom markeri tumorali diversi
– imunoglobuline
Produsi metabolici celulari
Aplicatii clinice . DEPISTARE Nu sunt specifici!!!!! cazuri cu risc crescut de cancer – diag. precoce sarcini molare – HCG – coiocarcinom polipoza familiala CEA + informatii
endoscopice calcitonina – familii cu cc tiroidian medular AFP – cirotici, purtatori B,C, coroborarea markerilor cu metode specifice de
investigatie la populatiile cu risc creste valoarea lor diagnostica si le confera o specificitate ridicata
meta cu punct de plecare neprecizat – orientare : PSA , FAP , acid vanilmandelic,
valori : volum tumoral important , prognostic rezervat
prognostic si mai rezervat daca sunt crescuti 2
stabilire origine celulara a diferitelor tumori : tu testicular , HP seminom + AFP - trat neseminom
prognostic redus, intermediar, rezervat stadiu I in testicul – subdivizat in functie de pozitivitatea markerilor :
– I seric– I cu markeri negativ
Aplicatii clinice .
Diag. Clasif. Stad. Valoare prognostica