Presentation on theme: "Overview of Systemic Px in MS malignancies"— Presentation transcript:
1Overview of Systemic Px in MS malignancies งานประชุมวิชาการคณะแพทยศาสตร์ มหาวิทยาลัยขอนแก่น 2009ผศ.พญ.เอื้อมแข สุขประเสริฐภาควิชาอายุรศาสตร์ คณะแพทยศาสตร์ มหาวิทยาลัยขอนแก่น
2Bone tumors Primary bone tumors - Osteosarcoma : Role of systemic Px Secondary bone tumors- Metastatic bone lesion: Where is the 10 and how to manage ?
3Osteosarcoma ESMO Clinical Recommendations for diag, treatment and follow Standard staging in localized tumors1. CT scan chest2. Bone scan3. Routine CBC, Chemistry (Cr,Electrolytes, Mg, ALP andLDH)4. Sperm banking should be consideredESMO guideline. Annals Oncol 2007.
4Treatment Modalities Surgery: local control Radiation: local control (positive margin)Multidrug chemotherapy: systemic control
5Treatment plan Concept 1. Chemotherapy has significantly 5-yr survival rate for pt withlocalized tumors from 20% to 60%*** CT is a “must”2. Surgery is a “must” too !- Retrospective study, all of the patients who were not surgically treated had disease progression and died within 40 months after 1st recurrenceESMO guideline. Annals Oncol 2007.
6Multidrug Chemotherapies in Osteosarcoma First-line chemotherapyHigh-dose Methotrexate (HD-MTX): 8-12 gm/m2Adriamycin: mg/m2Cisplatin: mg/m2Ifosfamide: 8-15 gm/m2Salvage chemotherapyIfosfamide 8-15 gm/m2 alone or combination withEtoposide 100 mg/m2/day x 5 days
7Systemic Chemotherapy in Osteosarcoma Neo-adjuvant CTAdjuvant CTBenefitDisadvantage OS, DFSDelay surgeryLimb-sparingIn vitro senseBenefitDisadvantage OS, DFSNo organ preserveNo delay surgNo measurable lesion
8T-10: Surgery + Adjuvant Chemotherapy Surgery + ChemoSurgery + ChemoSurgerySurgeryEilber F. et al. JCO 1987; 5:21
18Current standard Rx program encourage by EURAMOS MAP regimenCurrent standard Rx program encourage by EURAMOS(European and American Osteosarcoma Study Group)Children’s Oncology Group (COG)Cooperative Osteosarcoma Study Group (COSS)European Osteosarcoma Intergroup (EOI)Scandinavian Sarcoma Group (SSG)
22Biologic Response Modifier & Targeted Therapy in Osteosarcoma Liposome encapsulated muramyl tripeptide phosphatidylethanolamine (MTP-PE, Mifamurtide, Junovan®)Interferon-Pegylated Interferon-Anti-HER2 antibodyExpression of HER2/erb2 correlate with poor survivalIGF-1R monoclonal antibody
23Conclusion for localized osteosarcoma All patients need full staging : CT chest and Bone scanPatient who not fit for limb-sparing surgery- Pathological fracture: Surgery then adjuvant CTPatient who are potentially for limb sparing surgery: Chemo (Cis/A or Cis/A/HDMXin fit < 35 yr) 2-3 cycles: Surgery: Chemo same regimen untilfinish totally of 6 cycles
27Concepts First rule - Try to establish definite “tissue diagnosis” - LN biopsy - liver biopsy- bone biopsy - sputum cytology, FNASecond rule- search for possible “primary” site of involvement- huge liver mass = possible liver 10- huge pulmonary mass = possible lung 10
28ConceptsThird rule- Try to understand several clinicopathological featuresthat help identify patient with “responsive tumors”- Germ cell tumors (especially EGCT)- Lymphoma- Breast cancer, ovarian cancer- Prostate cancer
29Knowledge of Primary Site Improves Survival1 15 Months11 MonthsCancers with favorable treatments2:Germ cell carcinomasOvarian cancerBreast cancerCervical squamous cancerNeuroendocrine cancersProstate cancer1 Abbruzzese et al, JCO, Vol 13, No 8 (August), Pavlidis et al, Eur. J. Cancer, 39, , 2003
303. Men with suspected prostate CA metastasis TREATMENT FAVORABLE SUBSETS3. Men with suspected prostate CA metastasisAll male with blastic metastasisAll male with bone met with histology of adeno CAPSA both in serum and IHC stain in tissue should be performedPx as prostate in case of rising PSA
31What (where) is primary malignancy ? Non-hematologic(> 60% up)- Lung cancer (20%)- Breast CA (20%)- Prostate CA (20%)- Unknown (10%)- RCC (5%)- Colorectal (5%)Hematologic( 20-30%)- MM- Lymphoma
32Bone metastasis : Approach 1. Suspected hematologic malignancy : MM Investigations- ALP ( in MM)- CBC (rouleaux)- Bun/Cr- Globulin- Urine bence jone- Film skull- CaHx & PE- fever- bone pain- anemia- hepatospenomegaly- lymphadenopathy
34Take home messages for bone metastasis of unknown primary 1. All men : PSA2. All women : breast PE, mammogram3. All patient : CXR, ALP, Ca, CBC- Normal ALP Rouleaux, Globulin, Cr, Urine bence- ALP : solid tumors: if PSA normal, breast and CXR no clueCT chest and whole abdomen