Kostné metastázy pod kontrolou. Vieme ich liečiť!

Napísal Mária Halajová 25. január 2021

Od neznesiteľnej bolesti kostí pri nádorových ochoreniach sa dá uľaviť antirezorpčnou kostnou liečbou. Napriek tomu, že výrazne zvyšuje životný komfort, mnohí pacienti o nej nevedia, respektíve bolesti v kostiach nevenujú dostatok pozornosti, pretože sa ich liečba zameriava na problém primárneho nádoru.

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Čo to kostné metastázy vlastne sú, prečo sa oplatí dostať ich pod kontrolu a ako ich v súčasnej dobe vieme liečiť, pomáha ozrejmiť riaditeľka Národného onkologického inštitútu v Bratislave MUDr. Mária Rečková, PhD..

Kostné metastázy

Ak hovoríme o kostných metastázach, hovoríme o komplikácii primárneho onkologického ochorenia, ktorá vzniká vtedy, keď sa nádor do kosti rozšíril z iného ložiska v tele. Kostné metastázy trápia až 80 percent ľudí, ktorým bola diagnostikovaná rakovina prsníka, prostaty alebo pľúc. Môžu vzniknúť v každej kosti tela, niektoré časti sú však na ochorenie náchylnejšie, čo je spôsobené mierou krvného zásobenia určitých častí kostry. Najčastejšie kostné metastázy postihujú chrbticu (40-50 %), panvu (10-20 %), rebrá (25-30 %), stehenné kosti (5-10%) a lebku (3-5%). Ich najčastejším prvým prejavom býva zlomenina a príčina ich vzniku nie je zatiaľ úplne objasnená. Preto ani lekári nedokážu ich vznik v súčasnosti zastaviť alebo im úplne predchádzať.

Ako vznikajú

Metastázy vznikajú už s existujúcim nádorom a dokážu sa nekontrolovateľne šíriť v podstate do celého tela. „Typický pre nádorové ochorenie je nekontrolovaný rast, porušené signály apoptózy, teda prirodzeného zániku buniek, ale tiež šírenie do blízkeho okolia a tiež do vzdialených orgánov a tkanív. Práve proces šírenia do okolitých a vzdialených orgánov a tkanív krvnou alebo lymfatickou cestou je označovaný ako metastázovanie a metastázy by sme mohli označiť za nádory, ktoré súvisia s pôvodným, takzvaným primárnym nádorom, ale sú lokalizované v iných orgánoch a tkanivách,“ vysvetľuje MUDr. Mária Rečková, PhD., riaditeľka Národného onkologického inštitútu v Bratislave.

Ich vplyv na ďalšie orgány v tele

Takéto rozšírenie metastáz negatívne vplýva na ďalšie orgány v našom tele. „Tým, že sa ochorenie rozšíri do iných orgánov a tkanív, tak ich svojim nekontrolovaným rastom poškodzuje, ale tiež opäť ovplyvňuje prostredie, v ktorom sa nádorové bunky nachádzajú, a v prípade vylučovania rôznych látok, ktoré sa dostávajú do obehu môžu byť ďalej ovplyvňované aj vzdialené orgány a tkanivá, čím sa celý proces zacykluje. Príkladom môžu byť v prípade karcinómu prsníka metastázy v oblasti kostí, pľúc, pečene, alebo mozgu,“ pokračuje ďalej MUDr. Rečková. Podľa nej je metastázovanie typické najmä pre zhubné nádory diagnostikované v neskorom štádiu. „Ak sú diagnostikované v skorom štádiu, nemusí k vytvoreniu metastáz vôbec dôjsť,“ hovorí. „A napríklad v prsnej žľaze sa môžu vyskytovať aj takzvané nezhubné, alebo benígne nádory, ktoré nemetastázujú, napríklad fibroadenóm, papilóm a podobne. Poznanie či ochorenie metastázovalo je dôležité na začiatku stanovenia diagnózy, ale aj v priebehu ochorenia,“ zdôrazňuje odborníčka.

Ako prebieha liečba

Aj v tomto prípade je dôležitá anamnéza pacienta, v rámci ktorej sú zisťované všetky klinické ťažkosti. „Ďalej je to fyzikálne vyšetrenie pri ktorom je možné zistiť napríklad zväčšenie lymfatických uzlín alebo kožné metastázy, prípadne vysloviť podozrenie na postihnutie niektorých orgánov, napríklad pečene pri jej zväčšení, alebo možno podozrenie vysloviť na základe laboratórneho vyšetrenia krvi pri zistení odchýlok od normálu u niektorých laboratórnych parametrov,“ vymenúva spomedzi viacerých možností riaditeľka onkologického inštitútu, MUDr. Rečková.

Podľa nej ďalšími vyšetreniami, ktoré môžu napomôcť odhaliť metastázy, sú zobrazovacie vyšetrenia, ako napríklad röntgenové, alebo ultrazvukové vyšetrenie, či vyšetrenie pomocou počítačovej tomografie (CT), prípadne PET-CT, alebo magnetickej rezonancie (NMR), scintigrafie kostí a podobne. „Niekedy je potrebné zobrať vzorku tkaniva a zistiť či sa jedná o metastázu,“ dodáva.

Napríklad pri karcinóme prsníka je podľa Márie Rečkovej základnou metódou pri lokalizovanom náleze liečba chirurgická. „Chirurgická liečba môže byť individuálne indikovaná aj v prípade metastatického ochorenia. Ďalej sa používa rádioterapia, a tzv. systémová liečba, ktorou je súhrnne označovaná chemoterapia, hormonálna liečba, biologická liečba (napr. anti-HER2 liečba, či liečba „ciklibmi“, či m-TOR inhibítor) a tiež imunoterapia,“ hovorí na záver MUDr. Mária Rečková, PhD. z Národného onkologického inštitútu v Bratislave.

Význam liečby kostných metastáz

Kostné metastázy patria k ochoreniam, ktoré síce ešte nevieme úplne vyliečiť či odstrániť, ale vieme ich niekoľkými liečebnými metódami dostať pod kontrolu. Čiže ide o paliatívnu liečbu a jej hlavným cieľom je spomaliť ochorenie a zároveň zlepšiť kvalitu života pacienta. Dĺžka a kvalita života pacientov s kostnými metastázami by mali byť rovnocennými hodnotami, ktoré idú ruka v ruke, vedľa seba.

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    Pravé ovárium jednoznačne nediferencujem, vľavo ovárium guľovité do 3,5cm, drobnocystickej štrukt. Parauterinne sú prítomné varikózne plexy.

    Močový mechúr tenkostenný, bez RTG kontrastného patologického obsahu. Parailicky a ingvinálne sublimitné LU. Bez ascitu.



    V zachytenom skelete sa zobrazuje niekoľko lytických lézií MTS charakteru - najväčšie lézie sú v tele Th11 veľk. 27mm - hrozí patol. fraktúra stavca, bez výraznejšej mäkkotkanivovej komponenty. V ľavej ilickej kosti v oblasti SI skĺbenia lézia veľk. 40mm.



    Záver:

    - st. po QE a EA l.dx. - v oblasti prsníka v CT obraze bez zrejmej lokálnej recidívy, ale v pravej axile sa t.č. zobrazujú dve denznejšie nodularity, ktoré by mohli súvisieť so zákl. ochorením - v prípade klinickej potreby doplniť cielené USG vyš.

    - pribudlo viacpočetné MTS postihnutie skeletu lytického charakteru - najväčšie lézie v ľavej ilickej kosti v oblasti SI zhybu a v tele Th11 - hrozí patol. fraktúra stavca

    - zväčšený uterus nehomogénnej štruktúry - možný súvis s podávanou terapiou (Tamoxifen), korerolovať s gynekolog. vyšetrením

    - ostatný CT nález je bez podstatnej dynamiky od 07/2023

    ___________________________________________________________________________________



    Ž i a d a n k a

    Požiadavka zo dňa 18.10.2024 11:17

    MUDr. Michaela Kubičková

    Amb. klin. onkol. OKO A I., Klinika klinickej onkológie

    Národný onkologický ústav



    Vyšetrenie:

    CT - CT hrudníka + brucha + panvy

    Epikríza: OA: st.p. QE a EA l.dx. v 10/2017 + CHT, RAT, HT- TMX doteraz, t.č. elevacia markerov

    Otázka, ktorá má byť vyšetrením zodpovedaná: recidiva?

    Bolo požadované vyšetrenie už v minulosti realizované? Kedy a kde?: ano

    Hodnota kreatinínu/glomerulárna filtrácia: 75

    Alergia na jódové preparáty, alebo iné: nie



    Dg: C50.9

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