경희대학교 의과대학·의학전문대학원

비뇨생식기종양

방광암

신장암

전립선암

고환암

난소암

자궁경부암

방광암

• Epidemiology: smoking

• Treatment

complete endoscopic resection  intravesical BCG

– Invasive: cystectomy  systemic chemotherapy

– metastatic: chemotherapy

• Curative or palliative

• CR rate: 5-38%, median survival; 9.3-33months

– Chemotherapy

• Adjuvant, neoadjuvant, palliative

신장암

• 발생율: 3,598명/년 (1.8%), 남/녀: 2,520 /1,078명 • 항암화학요법에 반응을 잘 안한다

• 생물학적치료(면역치료 등)에 반응을 한다

– Interferon alpha, interleukin-2

• 자연적으로 치유되기도 한다 • 최신치료법으로 표적치료제가 많이 개발되었고, 현재 표준치료로 되어 있음

신장암의 병기와 예후

2기 Invade renal capsule, confined to Gerota fascia

85% 3기 Involve renal vein/vena cava,

hilar lymph node

60%

4기 Invade adjacent organs or

distant metastasis

신장암의 치료

• Localized tumor: stage I, II and selected III

– radical nephrectomy

• Advanced disease

– Cytotoxic chemotherapy: rare response – Immunotherapy

• Interferon alpha & IL-2: 10-20% response

– Surgery

• Control pain, bleeding

• Metastatectomy: solitary or CNS

• Cytoreductive surgery before systemic tx in selected cases

– New agents

• Tyrosine kinase inhibitors, VEGF inhibitor(multi-targeted)

– Sunitinib, Sorafenib(40% response rate)

• mTOR inhibitor: Temsirolimus, Everolimus

– Poor prognosis, sunitinib/sorafenib refractory

Molecular Pathways & Targeted Therapies in RCC

Sunitinib vs Interferon alfa in metastatic renal cell carcinoma

N engl J Med 2007;356:115-124

Sorafenib in advanced clear cell renal cell carcinoma

N Engl J Med 2007;356:125-134

CR PR SD Sorafenib, N=451 1(<1%) 43(10%) 333(74%) Placebo, N=452 0 8(2%) 239(53%)

전립선암

• 발생율: 7,848명/년(3.9%)

– 한국남자암발생 5위 (7.6%)

Treatment:

Clinically localized disease

• Treatment modalities

– Radical prostatectomy – Radiation therapy

• External beam RT, Brachytherapy

– Active surveillance

• Monitoring illness at fixed interval with no treatment • Case selection is critical

• Consideration factor for choice of therapy

– Presence of symptoms

– Probability that untreated tumor will adversely affect quality or duration of survival.

– Curability by single-modality therapy or both local & systemic therapy

• Primary outcomes

– Cancer control & treatment related morbidities

• Continence, sexual potency, bowel function • Prognostic model

– Initial T stage, Gleason score, baseline PSA

Treatment:

Rising PSA

• Definition:

– Rising PSA after surgery and/or radiation – No evidence of disease on scan

• Central issue

– Persistent disease in primary site or systemic disease

• Localized disease

– Radiation, Salvage prostatectomy

• Systemic disease

– Immediate therapy is not always required

• Median time to metastatic progression: 8 yrs • Free of metastases at 5 yrs: 63%

– Prognostic factors:

Treatment:

Metastatic disease

• Noncastrate

– Deplete/lower androgens

• Surgical orchiectomy • Medical orchiectomy

– Testosterone lowering agents

» GnRH agonist/antagonist: » leuprolide, goserelin/degarelix » Estrogen(diethylstilbestrol)

– Antiandrogen

» Flutamide, bicalutamide, nilutamide

• Castrate

– Castration testosteron level:< 50ng/ml – Discontinue all hormonal therapy:

• withdrawal response

– 2nd_-3rd _{line hormone therapy}

– Chemotherapy: docetaxel, mitoxantrone

고환암

• Origin: primordial germ cells

• Extragonadal

– Mediastinum, retroperitoneum, pineal gland

• Disease of young age

– 호발연령: 20-40세

• 백인>흑인

• 호발지역: Scandinavia, New Zealand

• 발생율: 206명/년(한국남성암의 0.1%)

Etiology & Genetics

• Cryptorchidism

• Testicular feminization syndrome

• Klinefelter’s syndrome

– Mediastinal tumor

• Incidence of another testis: 2%

• Chromosome 12

– Excess copy number, i(12p)

• Tumor marker

Treatment (1)

• vascular/lymphatic invasion or extends into tunica,

spermatic cord, scrotum(T2-4)

– Surveillance

• No vascular/lymphatic invasion(T1) – Cure rate: > 95%

• Stage II, nonseminoma

– Modified bilateral RPLND

– High-volume(> 6 nodes, > 2cm node) • 2 cycles of adjuvant chemotherapy – Cure rate: > 98%

• Stage I & II seminoma

– Inguinal orchiectomy & retroperitoneal radiation – Cure rate: 98%

Treatment (2)

• Advanced GCT

– Stage IIc & stage III

– Chemotherapy: cisplatin, etoposide, bleomycin – Cure rate: 70-80%

– Risk-directed chemotherapy

• Salvage chemotherapy

– 2nd _{line chemotherapy}

• Cure rate: 25%

– High dose chemotherapy & stem cell support

• Post-treatment complication

– Infertility, ejaculatory dysfunction

Incidence, Epidemiology, Etiology

• Pathologic classification

– Epithelial, stromal, germ cell tumor

• 발생율: 1,981명/년(여성암 2.0%, 10위)

• Peak age: eighth decade

• Risk factors

– Infertility, nulliparity, frequent miscarriages, use of

ovulation-inducing drugs(clomiphene)

– Reducing factor: pregnancy, breast feeding, oral

contraceptive

• Familial syndrome

– Hereditary breast/ovarian cancer

• BRCA1&2 mutation

– Lynch type II cancer family syndrome

Diagnosis, Screening, Pathology

• Routine pelvic examination

• CA125

– Postmenopausal women, asymptomatic pelvic mass,

CA125  65U/ml

• Screening

– Annual pelvic examination, transvaginal ultrasound,

CA125 in family history of ovarian cancer

• Subtype of common epithelial tumors

– Serous(50%), mucinous(25%), endometroid(15%), clear

cell(5%), Brenner tumors(1%)

Staging, Prognostic factors

• Staging laparotomy

– Manual inspection of diaphragm, peritoneal surfaces,

total abdominal hysterectomy, bilateral salpingo-oophorectomy, partial omentectomy

• 5-year survival

– Stage I(90-95%), II(70-80%), III(20-50%), IV(1-5%)

• Prognostic factors

– Residual disease, histologic grade, decline of CA125 – Expression of p53, EGFR

Treatment (1)

• Stage I&II, microscopic or no residual disease

• no adjuvant therapy

– Stage I with poor histologic grade, stage II:

• adjuvant therapy (cisplatin based chemotherapy or

total-abdominal irradiation)

• Stage III, minimal residual tumor (<1cm)

• Advanced disease(Stage III, IV), bulky residual

tumor

– Combination chemotherapy followed by cytoreductive

surgery

Treatment (2)

• Recurred disease

– Disease-free interval: > 6 months

• Reinduction with same regimen

• Intraperitoneal chemotherapy

• New drugs

– topotecan, gemcitabine, liposomal doxorubicin, – bevacizumab

자궁경부암

• 발생율: 3857명/년 (여성암 3.9%, 7위)

2010년 암발생율

Treatment

• Stage 0 (carcinoma in situ)

– Cone biopsy, abdominal hysterectomy

• Stage IA

– Total or vaginal hysterectomy

• Stage IB-IIA

– Radical hysterectomy, Radiation therapy

• Stage IIB – IVA

– Radical radiation

– Concurrent chemoradiotherapy

• Platinum based chemotherapy • 30-50% risk reduction

• Unresectable advanced/Recurrent

– Palliative chemothx: cisplatin, 5-FU, irinotecan – Response of combination chemotherapy: 50-60%