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Dr. Luis M. Zetina Toach Oncomdica.

Multimdica Guatemala

CARCINOMA DE PROSTATA (Hormono-Resistente)

PRINCIPALES CAUSAS DE PRINCIPALES CAUSAS DE MORTALIDAD MORTALIDAD


33.5%

% DEL TOTAL DE MUERTES

23.5%

6.7% 4.3% 4.0% 3.7% 2.2% 1.4%


di o

1.2%
he p tic a

1.2%
HI V

1.2%
di o Ho m ici

Ce re br ov as E cu nf. la r Ac cid en te s EN cr f, n . O ica b pu stru lm cti on va ar Ne u In mon flu a en e za

Di ab et es

C nc er

ov as cu la r

En f. Ca rd i

US data/Adapted from Cancer Journal for Clinicians, 2002

Ci rro sis

Su ici

RAZONES DEL INCREMENTO EN INCIDENCIA


FACTORES HEREDITARIOS
METABOLISMO CARCINOGENOS

FACTORES PERSONALES
ANCESTROS

SEXO ABSORCION CARCINOGENOS REPARACION DE DAO GENETICO EXPOSICION AL SOL O RADIACION


RESPUESTA INMUNE A INFECCION FUERTE PREDISPOSICION AL CANCER

CREENCIAS PESO Y TALLA EDAD


STATUS SOCIO ECONOMICO

TABACO

MENARQUIA MENOPAUSIA
DIETA

EMBARAZO CONSUMO DE ALCOHOL

VIRUS PARASITOS

COMPORTAMIENTO SEXUAL

EXPOSICION A QUIMICOS FACTORES AMBIENTALES

OCUPACION

HABITOS ALIMETICIOS

ESTADO NUTRICIONAL ESTILO DE VIDA

INCIDENCIA CANCER MUJERES tasa por 100,000 Todos los sitios, en mujeres Tasa de incidencia cruda x 100,000

99x100,000

INCIDENCIA DE CANCER HOMBRE Tasa por 100,000 Todos los sitios , Hombres Tasa cruda por 100,000

92x100,00

Female cancer statistics


Estimated incidence Estimated deaths

Melanoma of skin Thyroid Breast Lung & bronchus Pancreas Colon & rectum Ovary Uterine corpus Urinary bladder Non-Hodgkins lymphoma All others

3% 2% 30% 12% 2% 11% 4% 6% 2% 4% 22%

2% 15% 25% 5% 2% 11% 5% 2% 5% 4% 2% 21%

Brain & other nervous system Breast Lung & bronchus Pancreas Stomach Colon & rectum Ovary Uterine corpus Non-Hodgkins lymphoma Leukemia Multiple myeloma All others

Adapted from Greenlee RT, et al. CA Cancer J Clin. 2000;50:16.

Male cancer statistics


Estimated incidence Estimated deaths

Melanoma of skin Oral cavity & pharynx

4% 3%

3% Esophagus 31% Lung & bronchus 5% Pancreas 3% Liver & intrahepatic bile duct 3% Stomach 10% Colon & rectum 11% Prostate 3% Urinary bladder 4% Leukemia 5% Non-Hodgkins lymphoma 22% All others
Adapted from Greenlee RT, et al. CA Cancer J Clin. 2000;50:16.

Lung & bronchus 14% Pancreas Kidney & renal pelvis 2% 3%

Colon & rectum 10% Prostate 29% Urinary bladder Leukemia Non-Hodgkins lymphoma 6% 3% 5%

All others 19%

ARMAS PARA LA DESTRUCCION, CONTROL Y PREVENCION DEL CANCER


QUIMIO TERAPIA CIRUGIA Tumor RADIOTERAPIA

Angiogenesis
Invasion y metastasis

TERAPIA BIOLOGICA

Apoptosis HORMONO TERAPIA Proliferacion Oncogenes TERAPIA GENICA

Adaptado Hong, MDACC

OPINION PUBLICA PESIMISTA............

A PESAR DE LA EVIDENCIA CIENTIFICA DE MEJORIA EN: SOBREVIDA, PREVENCION, CONTROL Y PROBABLE CURACION HASTA EN FORMAS AGRESIVAS.............

Opinin Pblica Pesimista..........


Factores emocionales Prejuicios Retardo en el tratamiento Nociones preconcebidas por parte de mdicos, familiares y amigos. Sobre todo : FALTA DE CONOCIMIENTO

Clinical Case Interactive Presentation

A 62-year-old Guatemalan-American male with a medical history of cirrhosis secondary to hepatitis C and chronic obstructive pulmonary disease presumed secondary to previous smoking is seen for a routine check-up. Four years ago, he was diagnosed with metastatic prostate adenocarcinoma with bony disease, and leuprolide injections with bicalutamide were initiated. He has also received monthly zolendronic acid, which was switched to ibandronic acid following EMEA approval. The patient has no specific complaints and has been compliant with both diuretic and inhaler therapy. Hepatic and pulmonary functions appear to be well compensated. Recently, his PSA level, which had always remained below 4 ng/mL, had risen to 36 ng/mL. Antiandrogen therapy was withdrawn and his PSA level decreased to below 5 ng/mL.

Clinical case Inter active presentation

During his current visit, the patient describes a nagging pain in the lower thoracic vertebral column, pelvis, left shoulder, and several ribs, which has gradually increased over the last few weeks. He denies bowel or bladder dysfunction, sensory changes, or weakness. His Eastern Cooperative Oncology Group (ECOG) performance status is 1. Measurement of his PSA indicates an increase to 52 ng/mL. Physical examination reveals normal vital signs. The breath sounds are somewhat distant but the cardiac examination is normal. There is moderate tenderness to palpation over the lower thoracic spine. No neurologic deficits are appreciated. The patient is anxious to receive additional treatment, if required, because he wants to attend his daughter's wedding, scheduled to take place in 10 months.

Prostate Cancer Inter active case Presentation


What would be the first action would you take?
1.

2. 3.

A. Initiate chemotherapy with docetaxel every 21 days and prednisone twice daily. B. Obtain an MRI scan of the spine. C. Administer a radiopharmaceutical agent.

Answer Analysis
I

Answer B is the best choice, because spinal cord compression is the most feared skeletal complication related to prostate cancer. In more than 90% of patients who suffer from spinal cord compression, the initial presenting symptom is back pain. Furthermore, the optimal time to diagnose and treat spinal cord compression is before the development of any neurologic signs or symptoms. Answer A is suboptimal. While chemotherapy with docetaxel and prednisone is indicated, a patient presenting with new pain over the vertebral column should first be evaluated for the possibility of impending spinal cord compression. Answer C is suboptimal. Although radiopharmaceuticals can be considered for patients with pain at multiple sites, they do not constitute adequate treatment for a patient in whom spinal cord compression is suspected. Furthermore, treatment with radiopharmaceuticals has not been associated with improved survival in a phase 3 clinical trial. Thus, radiopharmaceuticals are generally reserved for patients who are no longer eligible for chemotherapy.

MRI of Spine

Clinical case:
What treatment would you recommend? A. Initiate therapy with high-dose dexamethasone and external beam radiation therapy to T6-T9. B. Initiate chemotherapy with mitoxantrone and prednisone to treat pain. C. Refer for surgical decompression.

Answer A is the best choice. Steroids plus radiation therapy remains the standard approach for patients with spinal cord compression who are free of neurologic deficits. Answer B is suboptimal because chemotherapy has not been shown to be useful in preventing the progression of spinal cord compression from prostate cancer. Answer C is suboptimal. Although a randomized trial showed that surgical decompression and steroids, followed by radiation therapy, produced outcomes superior to only steroids and radiation therapy in patients who presented with significant neurologic deficits, there are no phase 3 data to support this aggressive approach in patients who are neurologically intact on presentation.

The patient reports prompt reduction in pain after initiation of steroids and completion of a 2-week course of external beam radiation therapy.

Evolution.
The patient returns to the clinic after completing radiation therapy. Steroids have been tapered. The patient reports resolution of back pain but complains of increasing pain at other sites. Inguinal lymph nodes are palpable on physical examination. You order a bone scan and a CT scan of the abdomen and pelvis. A complete metabolic profile shows a modestly elevated alkaline phosphatase level (1.2 x upper limit of normal [ULN]) with normal AST, ALT, bilirubin, creatinine, and electrolytes. The bone scan reveals metastases to the cervical, thoracic, and lumbar spine as well as multiple lytic lesions in the ribs, the sternum, the proximal left humerus, the mid right humeral diaphysis, and in the pelvis

Clinical case Prostate Cancer

QUESTION: What would you now recommend for ongoing management?


A) Initiate chemotherapy with docetaxel and prednisone. B) Initiate radiopharmaceutical therapy. C) Initiate chemotherapy with mitoxantrone and prednisone D) Otro

Answer A is the best choice. Chemotherapy with docetaxel and prednisone is the only treatment that has demonstrated a survival benefit in hormonerefractory prostate cancer (HRPC). Although the patient has a history of liver disease, his liver function tests suggest that he should not be at increased risk of docetaxel toxicity. Liver function tests should be monitored closely during therapy. Answer B is suboptimal because radiopharmaceuticals have not been shown to prolong survival in HRPC, although they can provide pain relief. Answer C is suboptimal. M itoxantrone and prednisone could be considered in patients who are intolerant to docetaxel. However, a recently published randomized trial showed that docetaxel plus prednisone provided both superior pain relief and improved survival compared with combination mitoxantrone and prednisone. The patient responds to docetaxel and prednisone, as evidenced by a decrease in serum PSA, improvement in pain, and resolution of inguinal adenopathy.

Sipuleucel T (Provenge)

three basic steps. First, a patient's own white blood cells, primarily antigen-presenting cells (APCs), are extracted in a leukapheresis procedure. Then, the blood product is incubated with a fusion protein consisting of two parts, the antigen prostatic acid phosphatase (PAP), which is present in most prostate cancer cells, and an immune signaling factor granulocyte-macrophage colony stimulating factor (GM-CSF) that helps the APCs to mature. Finally, the activated blood product is re-infused into the patient to cause an immune response against cancer cells carrying the PAP antigen.[1][2] A complete Sipuleucel-T treatment repeats three courses over the span of a month, with two weeks between successive courses.

Conclusion:
The patient completes 10 cycles of therapy with docetaxel and prednisone. At the conclusion of therapy, his PSA level is 3.0 ng/mL. A CT scan shows complete disappearance of enlarged lymph nodes, and a bone scan shows no new lesions.

Caso Clnico Cncer de Prstata

Persiste elevacin de PSA. 154 ng/ML y dolor seo intenso. (Her 2 ??, Bevacizumab?). Creatinina sube 2.9 mg/dl Opciones para dolor: Metadona PO Morfina infusin continua Zamario (Quadramet) Bloqueo raqudeo y catter epidural con morfina Fentanil Ibandronato, dosis de carga 6 x 4 Excelente respuesta paliativa

1. 2. 3. 4. 5.

Impacto de la enfermedad

sea metasttica

Las metstasis seas son una complicacin catastrfica para muchos pacientes con cncer. No solo porque causan dolor intratable, fracturas patolgicas despus de un dao trivial , compresin medular e hipercalcemia, sino tambin significa que el proceso maligno es incurable

Gregory R. Mundy MD. San Antonio Texas.

Mundy GR. Cancer. 1997:80:1546-1556

La Carga de Metstasis seas DOLOR

Discapacidad

Hipercalcemia

Anemia

Compresin Medular

Fracturas

Efectos secundarios de tratamientos

Dependencia de Familiares

Inconvenientes Visitas al Hospital o Clnica

COSTO

$ 4832-36,475

JK F-18 Bone tomogram 1/9/03

T.E Delea. Pro Asco, 8094, 2005

Pobre calidad de vida

JK F-18 Bone tomogram 4/22/04

Reduccin Rho inhibe citoesqueleton

Reduccin Ras promueve Apoptosis

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