Onkologija
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Težke odločitve pri zdravljenju bolnikov z vensko trombembolijo in rakom
Get PDFVenous thromboembolism (VTE) is a frequent complication in cancer patients. Treatment of VTE in these patients in a big challenge, as the risk of thromboembolic complications as well as bleeding is further increased in cancer patients. We will present a few clinical situations that we often encounter in practice, when dilemma arises whether to administer anticoagulation therapy to a patient with VTE and cancer: recurrence of VTE despite treatment, thrombocytopenia, central nervous system tumors, use of inferior vena cava filters, use of new oral anticoagulation medications and accidentally discovered VTE.Venska trombembolija (VTE) je pogost zaplet pri bolnikih z rakom. Zdravljenje VTE pri teh bolnikih predstavlja velik izziv, saj je pri bolnikih z rakom dodatno povečano tako tveganje za trombembolične zaplete kot tudi tveganje za krvavitve. Predstavili bomo nekaj kliničnih situacij, s katerimi se v klinični praksi pogosto srečamo in predstavljajo dileme pri antikoagulacijskem zdravljenju bolnikov z VTE ter rakom, in sicer ponovitve VTE kljub zdravljenju, pojav trombocitopenije, tumorje osrednjega živčevja, uporabo filtrov v spodnji votli veni, uporabo novih peroralnih antikoagulacijskih zdravil in pojav naključno odkrite VTE
Lynparza (olaparib): novo tarčno zdravilo pri raku jajčnikov
Get PDFA new medicine for targeted treatment of patients with recurring serous ovarian or primary peritoneal serous carcinoma (PPSC), who have a mutation of BRCA1/2 genes (somatic mutation), was recently registered in the EU – LynparzaTM (olaparib). Olaparib was registered based on a subanalysis of a study in phase II (9), in which patients with BRCA1/2 gene mutation who received olaparib lived 7 months longer without the disease progressing than patients that were not administered this medicine (11 months vs. 4 months); the difference was statistically relevant (HR 0.18; p < 0.00001). There were no differences in total survival of patients. Olaparib is an oral medication in capsules, so patients can take it at home. The available data shows that the most frequent side effects were nausea and fatigue. 25% of patients took olaparib for two years or more and the therapy was rarely discontinued due to side effects (only 9% of patients), which shows that patients usually tolerate olaparib well, which is a great advantage compared to chemotherapy, which was so far the only available treatment for recurring ovarian cancer (9).Pred kratkim je bilo v EU registrirano novo tarčno zdravilo LynparzaTM (olaparib) za zdravljenje bolnic z recidivnim seroznim karcinomom jajčnikov, jajcevodov ali primarnim peritonealnim seroznim karcinomom (PPSC), ki imajo znano mutacijo v genih BRCA1/2 (somatsko mutacijo ali mutacijo zarodnih celic). Olaparib je bil registriran na osnovi podanalize raziskave faze II (9), v kateri so imele bolnice z mutacijov genih BRCA1/2, ki so bile zdravljene z olaparibom, za 7 mesecev daljše preživetje brez napredovanja bolezni, kot bolnice, ki niso bile zdravljene z olaparibom (11 mesecev proti 4 mesecem); razlika je bila statistično značilna (HR 0,18;p < 0,00001). Razlik v celokupnem preživetju bolnic med skupinama ni bilo. Olaparib je peroralno zdravilo v obliki kapsul, kar omogoča, da ga lahko bolnice jemljejo doma. Po doslej znanih podatkih sta bila najpogostejša neželena učinka blaga slabost in utrujenost. Pri tem je 25 % bolnic prejemalo olaparib dve leti ali več, prekinitev zdravljenja zaradi neželenih učinkov pa je bila redka (le pri 9 % bolnic), kar kaže na to, da je zdravljenje z olaparibom večinoma dobro prenosljivo, to pa predstavlja izrazito prednost v primerjavi s kemoterapijo, ki je bila doslej edina možnost zdravljenja recidivnega raka jajčnikov (9)
Onkološko genetsko svetovanje in testiranje: odnos, poznavanje in praksa zdravnikov na primarni ravni - povzetek Prešernove naloge
Get PDFIt is estimated that 5–10% of cancer types are hereditary. Cancer genetic counseling is indicated for people with high risk of hereditary cancer. A report by the Clinic for Oncological Genetic Counseling of the Institute of Oncology Ljubljana shows that Slovenian doctors do not refer patients to cancer genetic counseling and testing frequently enough, especially when it comes to hereditary colorectal cancer. The purpose of the study was to determine how much general practitioners in Slovenia know about hereditary types of cancer and why they do not refer their patients to counseling and testing. As part of our cross-sectional study, we sent a link to an anonymous questionnaire to Slovenian general practitioners. The responses show that 49% of the respondents did not refer a single patient to counseling and testing in the past year, while 22% of the respondents are not familiar enough with the indications for sending a patient to counseling and testing. 41% of the respondents do not have enough time for checking family history for cancer. On average, the doctors responded to 8.5 ± 3.2 (out of 18) questions i.e. 47% about hereditary types of cancer correctly. When it came to hereditary breast cancer, women answered correctly to 11% more questions than men. Doctors who referred at least one patient to counseling in the past year correctly answered 4% more questions on average than doctors who referred no patients. General practitioners in Slovenia do not refer patients and their relatives to cancer genetic counseling and testing frequently enough, because they are not sufficiently familiar with indications for such referral and because they do not have the time to check the family history for cancer as part of their regular work.Ocenjuje se, da je 5 do 10 % rakov dednih. Za osebe, ki imajo visoko verjetnost za dednega raka, je indicirano onkološko genetsko svetovanje. Poročila Ambulante za onkološko genetsko svetovanje Onkološkega inštituta Ljubljana kažejo, da slovenski zdravniki, predvsem na področju dednega raka debelega črevesa in danke, bolnike premalo napotujejo na onkološko genetsko svetovanje ter gensko testiranje. Namen raziskave je bil ugotoviti, koliko splošni zdravniki in specialisti družinske medicine v Sloveniji vedo o družinskih ter dedno pogojenih oblikah raka in zakaj na svetovanje ter testiranje ne napotujejo svojih pacientov. V okviru presečne raziskave smo slovenskim splošnim zdravnikom in specialistom družinske medicine poslali povezavo do anonimnega spletnega vprašalnika. Pri tem odgovori kažejo, da 49 % vprašanih v zadnjem letu na svetovanje in testiranje ni napotilo nobenega bolnika, 22 % zdravnikov pa ni dovolj seznanjenih z indikacijami za napotitev na svetovanje in testiranje. Nadalje 41 % zdravnikov nima dovolj časa za preverjanje družinske anamneze v smislu raka. Na 18 zastavljenih vprašanj o dednih rakih so povprečno pravilno odgovorili na 8,5 ± 3,2 oziroma 47-odstotno. Na vprašanja o dednem raku dojk so ženske zbrale 11 % več pravilnih odgovorov kot moški. Zdravniki, ki so napotili vsaj enega bolnika, so pravilno rešili povprečno 4 % več vprašanj kot tisti, ki niso napotili nobenega bolnika. Splošni zdravniki v Sloveniji premalo napotujejo bolnike in njihove svojce na onkološko genetsko svetovanje ter testiranje, ker niso dovolj seznanjeni z indikacijami za napotitev in ker nimajo dovolj časa za preverjanje družinske anamneze v smislu raka pri svojih bolnikih med rednim delom
Sistemsko zdravljenje napredovalega medularnega karcinoma ščitnice
No full textMedullary thyroid carcinoma originates from neuroendocrine cells of the thyroid which secrete calcitonin. Calcitonin is a specific marker for medullary thyroid cancer. Therapy with tyrosine kinase inhibitors can be applied to treat locally advanced or metastatic medullary thyroid cancer with progressing symptoms. Registered substances used are vandetanib and cabozantinib, and sorafenib and sunitinib are also effective. Treatment is determined individually based on the burden of the cancer and secondary diseases. Supportive treatment (targeted at the symptoms) is also very important.Medularni karcinom ščitnice nastane iz nevroendokrinih celic ščitnice, ki izločajo kalcitonin. Kalcitonin je specifičen marker medularnega raka ščitnice. Pri lokalno napredovalem ali metastaskem medularnem raku ščitnice ob simptomtskem progresu prihaja v poštev zdravljenje s tirozin kinaznimi inhibitorji. Registrirani substanci sta vandetanib in cabozantinib, učinkoviti pa sta tudi sorafenib in sunitinib. Izbira zdravljenja je individualizirana glede na breme bolezni in spremljajoče bolezni. Zelo pomembno je tudi podporno (na simptome usmerjeno) zdravljenje. ; slv - slovensk
Obsevanje v globokem zadržanem vdihu po operaciji raka dojk
Get PDFBreast cancer has high incidence and prevalence. Long-termcause-specific survival of breast cancer patients has increased overthe past decades primarily due to early detection, advanced surgical techniques, systemic therapy and new radiation techniques. Due to higher share of patients who receive radiation and longer survival,ever more patients risk the occurrence of late unwanted effects of the treatment. For the majority of patients, the benefits of radiation with lower chance of disease recurrence greatly surpass the risk of developing cardiovascular complications, the cumulative incidence of which increases with every received dose per heart. Preventing late heart damage has become an important part of comprehensive treatment of breast cancer patients. When planning the therapy, benefits of supplementary radiotherapy and potential risk of side effects are assessed for each patient individually by taking into account dose volume parameters of the radiotherapy plan and existing risk factors for cardiovascular disease, since the presence of these indicates higher absolute risk of late heart damage. The latest radiotherapy techniques are gaining importance, as they allow us to improve dose-volume parameters of radiotherapy plans. Deep inspiration breath-hold radiotherapy technique allows us to significantly lower the average dose of ionizing radiation received by the heart, lung, and liver compared to traditional radiation technique, while the radiation dose per planned target volume remains the same. When taking a deep breath, the diaphragm pulls the heart posteriorly, mediallyand inferiorly – away from the thoracic wall. Deep inspiration breath-hold radiotherapy technique is recommended for all patients with indications for radiation therapy after breast-conserving surgery or mastectomy of the left breast, with or without simultaneous radiation of local lymph nodes, in the event of unfavorable anatomy and when parasternal lymph nodes are included in the radiation field after cancer surgery of the right breast. This paper describes a new radiotherapy method – the deep inspiration breath-hold techniqueRak dojk ima visoko incidenco in prevalenco. Dolgoročno vzročno specifično preživetje bolnic z rakom dojk se je v zadnjih desetletjih izboljšalo predvsem zaradi zgodnjega odkrivanja, naprednih kirurških tehnik, sistemske terapije in novih tehnik obsevanja. Zaradi večjega deleža obsevanih bolnic in daljšega preživetja je več bolnic izpostavljenih tveganju za razvoj poznih neželenih učinkov zdravljenja. Za večino obsevanih bolnic je dobrobit obsevanja z zmanjšanim tveganjem ponovitve bolezni veliko večja od tveganja za razvoj poznih srčno-žilnih zapletov, katerih kumulativna incidenca se povečuje z vsako dodatno prejeto dozo na srce. Preprečevanje poznih okvar srca postaja pomemben del celostne obravnave bolnic z rakom dojk. Ob načrtovanju zdravljenja ocenjujemo koristi dopolnilnega obsevanja in možna tveganja za pojav neželenih učinkov za vsako posamezno bolnico: upoštevamo dozno-volumske parametre obsevalnega načrta in individualne že obstoječe dejavnike tveganja za srčno-žilne bolezni, saj prisotnost le teh napoveduje višje absolutno tveganje za pozno okvaro srca. Moderne obsevalne tehnike imajo vedno večji pomen, saj omogočajo izboljšanje dozno-volumskih parametrov obsevalnih načrtov. Obsevanje v globokem zadržanem vdihu v primerjavi s standardnim obsevanjem značilno zniža povprečno prejeto dozo ionizirajočega sevanja na srce, pljuča in jetra, ob sicer nespremenjeni obsevalni dozi, na planirni tarčni volumen v prsnem košu. Pri globokem vdihu trebušna prepona odmakne srce posteriorno, medialno in inferiorno: stran od stene prsnega koša. Obsevanje v globokem vdihu je priporočeno za vse bolnice, pri katerih obstaja indikacija za obsevanje po ohranitveni operaciji ali mastektomiji zaradi raka leve dojke z ali brez sočasnega obsevanja regionalnih bezgavk, v primeru neugodne anatomije in ko so po operaciji raka desne dojke v obsevalno polje zajete tudi parasternalne bezgavke. V prispevku je opisana nova metoda obsevanja - obsevanje v globokem zadržanem vdihu. ; slv - slovensk
Smernice za zdravljenje bolnikov z rakom požiralnika in ezofagogastričnega stika (EGS)
No full textOesophageal cancer is a relatively rate tumor with high mortality. It is most frequent in men in their sixties or seventies. In the past years, a constant increase in the incidence of adenocarcinoma of the distal esophagus and esophagogastric juncture (EGS) has been observed in the West. This can probably be attributed changing lifestyle with increases obesity incidence and gastroesophageal reflux disease. The latest, 7th review of the TNM Classification classifies both – cancer of the esophagus and cancer of the esophagogastric juncture – as oesophageal cancer. In a select group of patients this disease is curable, however the treatment is long, usually combined and with high morbidity that can significantly impact the patient’s quality of life. Due to the specific anatomy, cancer of the esophagus and cancer of the esophagogastric juncture develop metastasis early, and the prognosis is worse compared to other gastrointestinal cancers.Rak požiralnika je razmeroma redek tumor z veliko umrljivostjo. Pogosteje zbolijo moški v 6. ali 7. desetletju življenja. V zadnjih letih v zahodnem svetu opažamo stalen porast incidence adenokarcinoma distalnega požiralnika in ezofagogastričnega stika (EGS). Vzrok je najverjetneje posledica spremenjenega načina življenja s povišano incidenco debelosti in gastroezofagealne refluksne bolezni. Nova, 7. Revizija TNM klasifikacije, uvršča rak požiralnika in EGS skupaj pod rak požiralnika. Pri izbrani skupini bolnikov je bolezen ozdravljiva, vendar je zdravljenje dolgotrajno, praviloma kombinirano in z visoko morbiditeto, ki lahko precej zmanjša kakovost bolnikovega življenja. Zaradi specifične anatomije rak požiralnika in EGS zgodaj zaseva in je zato v primerjavi z ostalimi malignomi prebavil prognostično slabši
Povzetek smernic za obravnavo bolnic z rakom jajčnikov, jajcevodov in s primarnim peritonealnim seroznim rakom
Get PDFGuidelines for Treating Patients with Ovarian Cancer and Primary Peritoneal Serous Carcinoma were published separately for the first time after 2002. Back then guidelines for all gynecologic cancers were collected in one booklet, however new facts and discoveries as well as the development of new drugs require a more in-depth approach to treating these patients. Authors of this article are especially pleased that the first separate guidelines were published on 13 November 2015 accompanying the 1st School of Gynecology with the title Ovarian Cancer, and an updated version was published when the School of Gynecology was repeated on 18 March 2016. Rare types of ovarian cancer were left out of these guidelines on purpose (such as germ cell or stromal cancer), due to different treatment path and course of the disease. Guidelines are available in two printed versions – as a pocket book and in large format – and in electronic form on the website of the Institute of Oncology, where they will be regularly updated. We did not want the Slovenian guidelines to be based solely on similar foreign documents, and we added our experience with treating these diseases.Smernice za obravnavo bolnic z rakom jajčnikov, jajcevodov in s primarnim peritonealnim seroznim rakom so izšle v samostojni obliki prvič po letu 2002. Tistega daljnega leta so bile smernice za vse ginekološke rake še združene v eni knjižici, dandanes pa nova dejstva in spoznanja ter razvoj novih zdravil terjajo bolj poglobljen pristop k obravnavi teh bolnic. Avtorji smo še posebej veseli dejstva, da so prve samostojne smernice izšle ob 1. Ginekološki šoli z naslovom Rak jajčnikov, 13. novembra 2015, nekoliko dopolnjena 2. izdaja smernic pa je izšla ob ponovitvi šole 18. marca 2016. Namenoma smo iz teh smernic izpustili redke vrste raka jajčnikov (kot na primer germinalni in stromalni rak), saj sta klinična pot in potek bolezni pri teh oblikah drugačni. Smernice so na voljo v dveh knjižnih izdajah, v velikem formatu in žepni obliki, v spletni obliki pa so dostopne na spletni strani Onkološkega inštituta, kjer se bodo tudi sproti posodabljale. Slovenskih smernic nismo želeli le povzeti po vzoru tujih, temveč smo v njih vnesli tudi naše izkušnje z zdravljenjem teh bolezni