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CENTRO ESTATAL DE ONCOLOGA.
TERCERA JORNADA DE ONCOLOGA.TUMORES GENITOURINARIOS.
Dr. Rodolfo Woller Vzquez.
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AGRADECE AL DR ERNESTO RIVERA CLAISSE,DIRECTOR DEL CENTRO ESTATAL DE ONCOLOGA PORSU AMABLE INVITACIN A TAN IMPORTANTE EVENTO
DE XV ANIVERSARIO Y NOS HAYA PERMITIDOINTRODUCIR TEMAS DE NUESTRA ESPECIALIDAD ENESTA TERCERA JORNADA ACADMICA.
RESALTAMOS EL GRAN INTERS DE SU DIRECTOR YTAMBIEN FUNDADOR POR SU PREOCUPACINCONSTANTE EN COLOCAR A LA VANGUARDIA A ESTAMUY RECONOCIDA Y NOBLE INSTITUCIN.
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TUMORES GENITOURINARIOS
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TUMORES GENITOURINARIOS
DR. CARLOS LEOS GALLEGOS. ISSSTE.
CA DE PROSTATA.
DR. ARMANDO BALTAZARES LPEZ. IMSS.
CA DE PROSTATA.
DR. CARLOS LEOS ACOSTA. HGE DE SSA.
CA TESTICULAR
DR. RODOLFO WOLLER VAZQUEZ. ISSSTESON.
H. MILITAR, SEDENA. CANCER DE VEJIGA
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CANCER (Global)
FRECUENCIA USA MEXICO (incan)
1 596 670 127 930
MORTALIDAD 38 % (2. Causa) 58%
SOBREVIVENCIA ( 5 a.) 68 %
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TERCERA JORNADA ONCOLGICA
DESARROLLO DE CA POR SITIO
TODOS ---------------------------1 EN 2PROSTATA--------------------- -1 EN 6
PULMN Y BRONQUIOS------1 EN 13
COLON Y RECTO----------------1 EN 19
VEJIGA----------------------------1 EN 26
LINFOMA NO HODKING-------1 EN 45
MELANOMA---------------------1 EN 55
RIN----------------------------1 EN 55
Leucemia 1 en 67, Boca 1 en 77, Estomago 1 en 90, TESTICULO, 1 en 500
CNCER DE VEJIGA
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INCIDENCIA
Tumores Genitourinarios
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TUMORES UROLOGICOS Mortalidad
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FRECUENCIA )Ca de Prostata, Vejiga, Rin, Testiculo y
Pene
MAYOR MORTALIDAD-ENF.AVANZADA:Testiculo-25 %
Rin- 20 %Vejiga 6.5 %
Prostata-5.5 %Pene-3 %
TUMORES GENITOURINARIOS.
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COLEGIO SONORENSE DE UROLOGIA
PAPEL DEL UROLOGO EN TGU
Tumores Benignos.
T. Malignos: Localizado------Ciruga---------UrlogoRadioterapia-----RadTx.
Loc. AvanzadoCiruga--------UrologoRadioterapia-----RadTx.
QuimioTx-------Urologo?Avanzada------Ciruga paliativa, Qui-
mioTx, Cuidados Paliativos----?
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TUMORLOCALIZADO
CIRUGIA
RADIOTERAPIA
UROLOGO
RADIOTERAPEUTA
LOCALMENTE
AVANZADO
CIRUGA.
RADIOTX
QUIMIOX
UROLOGO
RADIOTX.
UROLOGO?ONCOLOGO?
T. AVANZADO
CIR. PALIATIVA.
QUIMIOTX
CUIDADOSPALIATIVOS
??
TUMORES GENITOURINARIOSPAPEL DEL UROLOGO
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CENTRO ESTATAL DE ONCOLOGA
TERCERA JORNADA DE ONCOLOGATUMORES GENITOURINARIOS
Dr. Rodolfo Woller Vzquez
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CA DE VEJIGA. patologa
Ca de Cels. Trans. 90 %Ca de Cels. escamosas 5%,Adenocarcinoma 2 %
Carcinoma Urotelial
70 % A 80% NO invasivos.
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CANCER DE VEJIGA
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CANCER DE VEJIGA
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CA DE VEJIGA
Ca de Urotelio 90 %
Ca de cels. escamosas 5%,
Adenocarcinoma 2 %
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INCIDENCIA 7 % (51,230 H 17,580 M)
CA EN GRAL. 9a. Causa ( 357 000)
13a. CAUSA DE MUERTES (145 000)
CUARTA CAUSA DE CA (hombres)
11a. CAUSA EN MUJERES
ENFERMEDAD LETAL: 3 % Muertes (14 100)
CANCER DE VEJIGA.
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PROBABILIDAD CA VEJIGA : 1 en 26
(hombres) 1 en 86 (mujeres)
Disminuye: Raza Blanca 3.5%, afro-am,hispanos (5%)
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FRECUENTE EN HOMBRES (Rel.3 a 1)
EDAD 70 a. (Raro 40 a.)
DIFERENCIAS GEOGRAFICAS:
Europa, medio oriente, 14-24 %
AFRICA Y EGIPTO 70% (ca celsesc)
CANCER DE VEJIGA. Incidencia.
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CANCER DE VEJIGA ETIOLOGA
TABAQUISMO OCUPACION OTROS (Genes,
ingesta lquidos, dieta)
FXS
AMBIENTALES
CALCULOS,
PARASITOS INFECCIONES, PVH,FXS. LOCALESIRRITATIVOS
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CNCER DE VEJIGA. Etiologa.
FACTORES AMBIENTALES:Tabaquismo. Factor ms comn, mal pronostico,
Grado alto
Ocupacin:Aminas aromticas; hule, poliuretano, aluminio,imprenta, fund. Metales
Anilinas; trabajadores ind. agricolas,
colorantes,herbicidas, barnices, explosivos, pintsintticas..
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TABAQUISMO
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CA DE VEJIGA. Etiologa.
Ocupacin:Aminas aromticas; hule, poliuretano, aluminio,
imprenta, fund. MetalesAnilinas; trabajadores ind. agricolas,
colorantes,herbicidas, barnices, explosivos, pintsintticas
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CA DE VEJIGA. Etiologa
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CA DE VEJIGA. Etiologa
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CNCER DE VEJIGA. Etiologa.
Fxs. Irritativos Locales:
Clculos, Parsitos.Infecciones (Bacterias,PVH)
Otros:
Genes,
Dieta
Baja ingesta delquidos, caf o t,
Edulcurantes,
Abuso de analgsicos,Herencia.
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Otros:
Genes,DietaBaja ingesta de lquidos, caf o t,Edulcurantes,
Abuso de analgsicos, Herencia.
CA DE VEJIGA Etiologa.
.
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CANCER DE VEJIGA ETIOLOGIA
GENES
EDULCURANTES
SUPERFICIALES
ANALGESICOS
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CA DE VEJIGA. tumorogenesis
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CA DE VEJIGA PLEOCRONOTOPOCIDAD
Origin, Recurrence, and Invasion
l Primary urothelial cancer is an environmentally caused
tumor that recurs because of persistent genetic changes
within the normal-appearing urothelium.
l Recurrent urothelial tumors occur by activation of nascent normal cells that have some genetic instability by environmental
factors and tumor seeding during transurethral
tumor resection.
l Accumulation of genetic changes leads to cellular proliferation,
loss of cellcell adhesion, and invasion. l The depth of invasion and grade of the tumor are the best
prognostic determinants of urothelial cancer, but molecular
assays are likely to be incorporated into future staging
schemas.
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CNCER VEJIGA
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CANCER DE VEJIGA CLASIFICACION
T Tumor Primario
Ta Carcinoma Papilar No invasivoTis Carcinoma in situ
T1 Tumor invade a lmina propia
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CANCER DE VEJIGA CLASIFICACION
T2 Tumor invade capa muscular
T2a Invasin a capa superficialT2b Invasion a capa profunda mitad
Externa
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CANCER DE VEJIGA CLASIFICACION
T3 Invasin a tejido perivesical
T3a Invasin microscpicaT3b Invasin macroscpica
T4 Invasin a prstata, vagina, tero,(T4a) pelvis, pared abdominal(T4b).
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CARACTERSTICAS DE GRADO
CA VESICAL NO INVASIVO
OMS 2004PAPILOMA UROTELIAL
Neoplasia Papilar Urotelialde bajo potencial maligno(PUNLMP)
Carcinoma Urotelial papilarde bajo grado Carcinoma Urotelial papilarde alto grado.
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CA DE VEJIGA No Invasivo.
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CA DE VEJIGA PROGRESION Y RECIDIVA
NEOPLASIA UROTELIAL PAPILAR DE BAJOPOTENCIAL MALIGNO
Pueden recurrir, Raramente invaden.
CARCINOMA DE BAJO GRADORecurren mas 60%. Invasin menos 10%
CARCINOMA DE ALTO GRADO
Recurren; Invasin yProgresion 50% . CA. PAPILAR ALTO GRADO MAS Tis---Mismo
%
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CA DE VEJIGA. Diagnstico
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CANCER DE VEJIGA NO INVASIVO.DIAGNOSTICO
HEMATURIA
EXPLORACIN TAC
ECOGRAFA
CITOLOGIA URINARIA
ANALISIS MOLECULARES
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CANCER DE VEJIGA NO INVASIVO.DIAGNOSTICO
HEMATURIA
EXPLORACIN
CITOLOGIA URINARIA
95% especificidad40%-60% sensibilidad
82% en alto riesgo
ECOGRAFA UROTOMOGRAFIA
CISTOSCOPIA
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CANCER DE VEJIGA DETECCION
Painless gross hematuria occurs in 85% of patients with
bladder cancer and requires a complete evaluation that
includes cystoscopy, urine cytology, CT scan, and a PSA
blood test.
Patients with microscopic hematuria require a full evaluation,
but low-risk patients do not require repeat evaluations. High-risk individuals primarily are those with a smoking
history and should be evaluated every 6 months.
lWhite light cystoscopy with random bladder biopsies is the
gold standard for tumor detection, but blue light cystoscopy
may be an adjunct. There are various urine markers that evaluate secreted proteins
or shed cells in the hope of noninvasively detecting
bladder cancer. To date, none of these markers have a high
enough sensitivity or specificity to replace office
cystoscopy.
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CA DE VEJIGA Diagnostico
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CANCER DE VEJIGA NO INVASIVO.DIAGNOSTICO
HEMATURIA
EXPLORACIN
TAC
ECOGRAFA
CITOLOGIA URINARIA
BIOPSIAS DE VEJIGA:
cono fro, citologa positiva, aspecto no papilar,
sospecha de ca in situ (2% en t. bajo riesgo), nodetermina tx intraveical adyuvante.
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CANCER DE VEJIGA Diagnstico
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CANCER DE VEJIGAMARCADORES MOLECULARES
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CA DE VEJIGA RTU DE TUMOR
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CA DE VEJIGA DIAGNSTICO
RTU DE TUMOR SEGUNDA RTU
INFORME DEL ANATOMOPATOLOGO
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CA DE VEJIGA SEGUNDA RTU
TUMOR RESIDUAL POSRTU (incompleta)INICIAL
ENFEREMDAD PERSISTENTE 33%-53%T1 Ta ALTO GRADO.
SUBCLASIFICACIN DE ESTADIO REAL(18%-34%) BIOPSIA SIN TEJIDO MUSCULAR (Ta alto Grado,
T1)
INVASIN MUSC. (10%) NO SE REALIZA TUMORES MULTIPLES GRANDES AUMENTA SOBREVIDA SIN RECIDIVAS REALIZARLA 2- 6 SEMANAS POSRTU INICIAL
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Clculo de Recurrencia y Progresion
Factor Recurrencia Progresin
No. de tumores
Unico 0 02 a 7 3 3> 8 6 3
Dimetro de tumor< 3 cm 0 0> 3 cm 3 3
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Cis concomitante Recidiva Progresin
No 0 0
Si 1 6
Grade (1973 OMS)
G1 0 0
G2 1 0
G3 2 5
Total Score 0 - 17 0 - 23
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Origin, Recurrence, and Invasion
l Primary urothelial cancer is an environmentally causedtumor that recurs because of persistent genetic changes
within the normal-appearing urothelium.
l Recurrent urothelial tumors occur by activation of nascent
normal cells that have some genetic instability by environmental
factors and tumor seeding during transurethraltumor resection.
l Accumulation of genetic changes leads to cellular proliferation,
loss of cellcell adhesion, and invasion.
l The depth of invasion and grade of the tumor are the best
prognostic determinants of urothelial cancer, but molecularassays are likely to be incorporated into future staging
schemas.
CA DE VEJIGA PRONOSTICO
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FREQUENCY
%
PROGRESSION % DEATHS
Noninvasive
Papilloma 10 0-1 0 Papillary urothelial
neoplasm of low malignant
potential
20 3 0-1
Papillary cancer low
grade (TaG1)
20 5-10 1-5
Papillary cancer high
grade (TaG3)
30 15-40 10-25
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CA DE VEJIGA. HISTORIA NATURAL
Ta BAJO GRADO RARAMENTE PROGRESAN(5%), Recurren 50%-70%
Ta alto grado (6.9%) igual a alto riesgo Cis invade 40%-83% sin tx. T1 alto grado recurren 80%
progresan 50% a 3 aos Ta T1
50%-70% Recurren en 5 aosy 26% Mueren
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ESTADIO T1CANCER RESIDUAL 30%
PROGRESION7%/AO
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CA DE VEJIGA PRONOSTICO
ALTO GRADO
Ta G3
RECURREN 3 a.PROGRESAN 5 a. 20%
10 a. 30%-40%
MUEREN 10 a. 10%-26%
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CA DE VEJIGA PRONOSTICO
T1 ALTO GRADO
Recurrencia 1 ao 50%
3 aos 80%5 aos 90%
Progresan 5 aos 50%
Cis concomitante 80%
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CA DE VEJIGA Pronstico
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MMC, THIOTEPA, EPIRUBICINA (80 mgs), GEMCITABINA
PREVIENEN IMPLANTACIN DE CELS. TUMORALESPREFERENTEMENTE USADA EN PAC . BAJO RIESGO DE
RECURRENCIA.MMC(40 mgs-UNA DOSIS, 6-24 HS DESPUES RTU.
T1 ALTO GRADO, 6 SEM (DUDOSO)
NO IMPACTA EN RIESGO DE PROGRESIN
CANCER DE VEJIGAQUIMIOTERAPIA INTRAVESICAL ADYUVANTE
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CANCER DE VEJIGA QUIMIOTERAPIA
Intravesical Chemotherapyl Intravesical chemotherapy has a clear impact on tumorrecurrence when immediately instilled after TURBT and inthe adjuvant setting. There is no clear evidence of an impacton progression.l Combinations of various chemotherapeutic agents and
chemotherapycombined with BCG have not demonstratedmajor benefit combined with single-agent treatment, withthe exception of interferon.l In general, side effects of chemotherapy tend to be lesscommon and less severe than those for BCG, but BCG is
more efficacious.
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RESPUESTA INMUNE MASIVA (CITOKINAS)
INICIO 2-4 SEMA PORSRTU RETENER EN VEJIGA 2 HS
RIESGO INTERM ALTO DE RECIDIVA, RIESGOINTERM. PROGRESION: 1 AO
RIESGO ALTO DE PROGRESIN (post-quimioterapia)BCG (3 AOS)
CA DE VEJIGA INMUNOTERAPIA
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CANCER DE VEJIGA INMUNOTERAPIA
Immunotherapyl Intravesical BCG has higher efficacy than intravesicalchemotherapy.l BCG should be used cautiously for patients with low-riskdisease because of concern about side effects.l BCG is the only agent shown to delay or reduce high-grade
tumor progression.l The optimum dosage and the treatment schedule for BCGare undetermined, but results are better with maintenancetherapy, if tolerated.l BCG is contraindicated in the setting of a disrupted urotheliumbecause of the risk of intravasation and septic death.
l Interferon- has not been shown to have benefit comparedwith BCG for primary treatment but appears to work wellin combination with low-dose BCG, especially for salvage
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CA DE VEJIGA ENF. REFRACTARIA
Management of Refractory Diseasel Patients who fail to respond to an initial course of intravesicaltherapy after TURBT are at high risk of recurrence orprogression.l Failure after initial chemotherapy or BCG is most appropriately
treated with a subsequent course of BCG because itsefficacy in this setting is significantly greater than that ofchemotherapy.l Patients at high risk for progression should be consideredfor cystectomy.l Failure to respond to an initial course of intravesical therapy
is occasion to reconsider cystectomy. Failure to respond toa second course is an indication for immediate cystectomyunless contraindicated or the patient chooses to pursueclinical trials.
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CISTECTOM IA INMEDIATA
FALLA DE BCG
RIESGO MAYOR DEPROGRESIN T. NO INV.
CA RECURRENTE
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Riesgo bajo de recidiva y progresin3 meses.
NEGATIVA- 9. mes despues una vez/ao, 5 aos
Riesgo alto de progresin:Cistoscopia y citologia en 3 meses.
NEGATIVA, cistoscopias y citologias cada 3 m.en 2 aos, cada4 meses en tercer ao, cada 6
meses - 5 aos, anualmente.
Riesgo intermedio de progresinEsquema Intermedio cistoscopia y citologia,
CA RECURRENTECISTOSCOPIA DE SEGUIMIENTO
CA DE VEJIGA
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CA DE VEJIGAVIGILANCIA Y PREVENCION
Surveillance and Preventionl Cystoscopy is the hallmark of surveillance. The optimumschedule is undefined but may be individualized on thebasis of risk.l Table 818 demonstrates reasonable surveillance protocols
based on clinical scenarios. Guidelines for management areshown in Table 819.l A number of tumor markers have shown the ability toimprove upon the sensitivity of cytology, but specificity islower for most.l Increased fluids, smoking cessation, and a low-fat diet are
recommended.
CA DE VEJIGA P ti
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CA DE VEJIGA Pronstico
CA VESICAL M j
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CA VESICAL Manejo
Pathologic, Morphologic and Clinicalatures Accurate determination of stage and grade Surgical quality TURBT and bladder biopsies
Recommend rereview and 2nd TUR for T1G3 Variant histology: micropapillary Focality single vs. multiple Presence of CIS
Age Status at 3 month followup Size Future: Molecular profiling
CA DE VEJIGA
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TX INTRAVESICALTaG3, Cis, T1G3
78%
CA DE VEJIGA
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PACIENTES CON GRANDES Y MULTIPLES
TUMORES (MAS DE 3 CMS) Y ALTAMENTERECURRENTES (MAS DE UNA RECURRENCIA PORAO) TIENEN MAS RIESGO DE RECURRENCIAMIENTRAS QUE PACIENTES CON TUMORESESTADIO T1, ALTO GRADO Y Cis , TIENEN EL
MAYOR RIESGO DE PROGRESIN.
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Table 4: Probability of recurrence and progression
according to total scoreRecurrence Prob. Prob. Recurrence
score recurrence recurrence risk group
1 year 5 years
0 15% 31% Low risk
1-4 24% 46%
Intermediate risk
5-9 38% 62%
10-17 61% 78% High risk
Progression Prob. Prob. Progression
score progression progression risk group
1 year 5 years
0 0.2% 0.8% Low risk
2-6 1% 6% Intermediate risk
7-13 5% 17%
14-23 17% 45%
High risk
Note: electronic calculators for Tables 3 and 4 are availab at
http://www.eortc.be/tools/bladdercalculator/
CA DE VEJIGA SEGUIMIENTO
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a. The prompt detection of muscle invasive and high-grade
non-muscle invasive recurrences is critical since a delay indiagnosis and therapy threatens a patients life.
b. Tumour recurrence in the low-risk group is nearly always
low stage and low grade. Small, non-invasive (Ta), lowgrade
papillary recurrences do not present an immediate
danger to the patient and their early detection is not essentialfor successful therapy.
c. The result of the first cystoscopy after TUR at 3 months is
a very important prognostic factor for recurrence and for
progression. The first cystoscopy should thus always be
performed 3 months after TUR in all patients with nonmuscleinvasive bladder tumour.
CA DE VEJIGA SEGUIMIENTO
CA VESICAL
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Recommendations for follow-up cystoscopy
Patients with tumours at low risk of recurrence andprogression should have a cystoscopy at 3 months.
If negative, the following cystoscopy is advised at 9
months and consequently yearly for 5 years. (Grade of
recommendation: C)
Patients with tumours at high risk of progression should
have a cystoscopy and urinary cytology at 3 months.If negative, the following cystoscopies and cytologies
should be repeated every 3 months for a period of 2
years, every 4 months in the third year, every 6 months
thereafter until 5 years, and yearly thereafter.
A yearly exploration of the upper tract is recommended.
(Grade of recommendation: C)
Patients with intermediate-risk of progression (about
one-third of all patients) should have an in-between follow-
up scheme using cystoscopy and cytology, adapted
according to personal and subjective factors. (Grade of
recommendation: C)
CA VESICAL CISTOSCOPIA DE SEGUIMIENTO
CA DE VEJIGA Invasivo
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CA DE VEJIGA Invasivo
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TUMORES GENITOURINARIOS
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CONSIDERACIONES ONCLOGICAS:
Ca P. TUMOR MAS COMUN (33 %)
Ca de VEJIGA OCUPA CUARTO LUGAR (7 %) CaP , 2. Causa de fallecimientos (10 %)
Ca de VEJIGA 9. Causa de fallecimientos (3%)
AMBOS DEL HOMBRE VIEJO (Ca de VEJIGAcon relacin 3 a 1)
CA DE VEJIGA Di Ci t i
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CA DE VEJIGA Diag. Cistoscopico
CA VESICAL Recurrente
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CA VESICAL. Recurrente
Recurrent TumorsA hallmark of urothelial cancer is
the high recurrence rate thatapproaches 80% for highmalignant potential, nonmuscle-invasive
bladder cancer
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TUMORES GENITOURINARIOS
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TUMORES GENITOURINARIOS
MORTALIDAD EN ETAPAS AVANZADAS
Testiculo-25 %
Rin-20 %
Vejiga-6.5 %
Prstata-5.5%
Pene-3 %
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TUMORES DE UROTELIO
ETIOLOGIA:
Tabaquismo,
Factores ocupacionales,
Factores irritativos locales,
Carcinogenicos,
Radioterapia, Otros: Genes, baja ingesta de lquidos, caf o t,
edulcurantes, abuso de analgsicos, herencia.
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CA DE VEJIGA Diagnstico
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CA DE VEJIGA. Diagnstico
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OBJETIVOS: GENERAL, Centro de Referencia
ESPECIFICOS:
COADYUVAR en mejor atencin y beneficio alos pacientes con neoplasias, CONCIENTIZAR de la importancia y necesidad
de trabajar local, interinstitucional ymultidisciplinariamente para
OBTENER mejores resultados diagnticos,teraputicos y controles estadisticos en laRegin.
TUMORES GENITOURINARIOS
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CONSECUENCIA:
Incremento en Quimioterapia
TUMORES GENITOURINARIOS
CANCER DE VEJIGA Diagnstico
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CANCER DE VEJIGA Diagnstico
CA DE VEJIGA
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CA. DE VEJIGARESECCION TRANSURETRAL
MULTIFOCALIDAD
TAMAO TUMORAL
TUMORES PREVIOS
PROFUNDIDAD
PRESENCIA DE CA IN SITU
TUMORES PREVIOS
TIEMPO DE SEGUIMIENTO