膀胱癌診療指引 2011 年 05 月 11 日一修 2012 年 02 月 15 日二修 2013 年 02 月 20 日三修 泌尿道癌醫療團隊共同修訂
修訂原則 參與修訂科別 : 泌尿外科 腫瘤治療科 放射診斷科 病理科 血液腫瘤科 診療指引需符合以下原則 : 一 依據實證醫學精神, 並於指引中註明主要參考文獻 ( 至少為 peer review article), 若引用醫院之資料庫資料, 則需提供分析及討論紀錄 二 參酌國情並經院內共識討論, 且有相關會議紀錄佐證 三 定期檢視改版 ( 至少每年一次, 且明確標示制訂或修訂日期 ) 四 團隊共識後所訂之指引, 應提送癌委會核備後公告
圖一 臨床診斷 膀胱鏡發現 Staging work up ( 視臨床所需 ) 初步評估及手術治療臨床分期最初治療後續追蹤 無任何侵犯 ± 病理檢查 ± 腎盂攝影 ± 逆行性腎盂攝影 ± 腎臟超音波 ± 骨盆腔電腦斷層 ± 骨盆腔核磁共振 ± 病理檢查 ± 腎盂攝影 ± 逆行性腎盂攝影 ± 腎臟超音波胸部 X 光 ± 骨盆腔電腦斷層 Ta-low grade Ta-high grade T1-low grade T1-high grade 膀胱鏡或腎盂攝影侵犯至肌肉層或細胞學檢查 ± 骨盆腔核磁共振 ( 疑似 TCC) T4b ± 血液生化檢查 ± 內視鏡腫瘤刮除如有症狀加做骨頭掃描 內視鏡腫瘤刮除, 病理檢查若分級較高或原位癌之患者, 考慮切片或前列腺尿道切片檢查 Tis T2/T3,T4a No residual Residual BCG x q6months MMC 或觀察 BCG/MMC 或觀察 BCG/MMC 或重複 TURBT 或膀胱全切除或 R/T±C/T 圖 2 膀胱鏡 ±Biopsy / 尿液細胞學每 3 個月一次 ( 共做兩年 ), 之後每 6 個月一次 ( 共做兩年 ), 後每年一次 腎盂攝影每年一次腎臟超音波每年一次 轉移 ± 胸部電腦斷層 ± 腹部 / 骨盆腔電腦斷層或核磁共振 ± 心電圖 ± 內視鏡腫瘤刮除 ± 骨頭掃描 轉移 圖 3
圖二 分期主要治療輔助治療 ct2 ct3 ct4a 無淋巴轉移 CT/MRI 有淋巴轉移無淋巴轉移 CT/MRI 有淋巴轉移 膀胱全切除 ± 術前輔助性化療 ( 建議 ) 膀胱部分切除 (Highly selective) ± 術前輔助性化療 ( 建議 ) 選擇內視鏡腫瘤刮除視腫瘤對化學治療或 * 放射治療的反應 ( 若選擇先使用化學治療或放射治療 ) R/T+C/T( 建議 ) or C/T 病患併有其他疾病或心肺功能不佳, 則單獨選擇內視鏡腫瘤刮除術或化學治療或合併放射治療 見圖三 ( 有 Lympho node metastasis) 膀胱全切除 ± 術前輔助性化療 ( 建議 ) 選擇膀胱保留, 則視腫瘤對化學治療或 * 合併放射治療的反應 選擇內視鏡腫瘤刮除術 +C/T+R/T ( 建議 ) 病患併有其他疾病或心肺功能不佳, 則單獨選擇內視鏡腫瘤刮除術或化學治療或合併放射治療 見圖三 ( 有 Lympho node metastasis) 如前項無加術前輔助治療考慮術後化學治療或放射治療 (pt3-t4 或有淋巴結 ) 考慮化學治療或放射治療 (Adjuvant R/T) ( 病理報告結果 :pt3-t4 有淋巴結 手術邊緣陽性及高惡性度 ) 重新評估腫瘤情形 高風險考慮術後輔助性化學治療 重新評估腫瘤情形 仍有腫瘤 : 1. 可切除者, 則做膀胱全切除 2. 無法手術者, Chemoradiation ±C/T 沒腫瘤 : 1. 觀察 2. 完整放射治療 (66Gy) 3. 考慮化學治療 仍有腫瘤 : 1. 可手術者, 則做膀胱全切除 2. 無法手術者,Chemoradiation± C/T 沒腫瘤 : 1. 觀察 2. 完整放射治療 (66Gy) 3. 化學治療 圖四 * 註 : 40-45Gy 3weak 後或 60-65Gy 2-3 月後
圖三 分期主要治療輔助治療 ct4b 轉移 CT/ MRI CT or MRI Bone scan 無淋巴結 有淋巴結 只有淋巴結轉移 多發瀰漫性轉移 化學治療 ± 放射線治療 化學治療或化學治療 + 放射線治療 化學治療 化學治療 2-3 次 做膀胱鏡及電腦斷層或核磁共振 TURBT and 有反應 無反應 有反應 ( 無殘留腫瘤 ) 無反應 ( 有殘留腫瘤 ) 化學治療 ± 放射線治療 姑息性放射線治療 化學治療 (UB-1-1 or UB-1-2 or UB-1-3) ± 放射線治療或膀胱切除 後線化學治療 (UB-1-1 or UB-1-2 or UB-1-3) ± 放射線治療或更改化學治療藥物或膀胱全切除 安寧緩和
圖四 : 追蹤侵犯肌肉層之腫瘤 (stage T2-T4) 追蹤復發復發後治療 Electrolyte, urine cytology LFT/RFT/CXR 每 6-12 月 IVP/RE 每 6-12 月上泌尿道腹部骨盆影像檢查每 3-6 個月共 2 年, 再追蹤 保留膀胱之局部復發 侵犯性復發 Tis/Ta/T1 膀胱全切除或化學治療 (UB-1-1 or UB-1-2 or UB-1-3) 或放射線治療或內視鏡腫瘤刮除 卡介苗灌注 Or cystectomy 無效 膀胱全切除 假如保留膀胱 FCS+cytology ± Biopsy 每 3-6 月 ( 共做 2 年 ) 而後增加檢查間距 如果膀胱造口 + 經皮尿液分流, 則需自尿留細胞學檢查每 6-12 月一次 保留膀胱細胞學檢查陽性但膀胱鏡及切片為陰性 上泌尿道檢查 + 前列腺尿道切片 上泌尿道檢查 (+) 前列腺尿道切片 見輸尿管治療指引 見攝護腺泌尿上皮癌治療指引 如果膀胱全切除, 尿液細胞學檢查每 6-12 月一次 如果膀胱全切除 + 骨轉移每年需補充維他命 B12 轉移或膀胱全切除術後局部復發 化學治療 (UB-1-1 or UB-1-2 or UB-1-3) +/- 放射線治療或單獨放射線治療 安寧緩和 註 : 目前 BCG 缺貨, 供應中斷, 以 MMC 代替 BCG 使用, 做為膀胱灌注用藥 *FCS= 膀胱境 Biopsy= 切片 MMC= 膀胱內 mitomycin C 灌注 IVP= 腎盂攝影 LFT= 肝功能檢查 CXR= 胸部 X 光 RE= 腎臟超音波 RFT= 腎功能檢查 CT= 電腦斷層檢查 Cytology= 細胞學檢查 BCG= 膀胱內卡介苗灌注 CIS= 原位癌
膀胱癌化療處方 Chemotherapy regimen 治療目的組套編碼處方內容 CCRT UBRT-1 Cisplatin + Fluorouracil Cisplatin 20 mg/m 2 /day IV over 4 hour,days 1 to 5 Fluorouracil 375 mg/m 2 /day IV continuous infusion 24 hours, days 1-5 During wk 1 and 5 of XRT UBRT-2 Weekly Gemcitabine 27 Gemcitabine 1000mg/m 2 IV over 30 min, days 1,8,15,22,29,36 weekly * 6 cycles UBRT-3 Weekly Cisplatin 26 Cisplatin 30 mg/m 2 IV over 4 hour, days 1,8,15,22,29,36 weekly * 6 cycles UBRT-4 Weekly Carboplatin 26 Carboplatin AUC 2 IV over 90 min, days 1,8,15,22,29,36 weekly * 6 cycles UBRT-5 Mitomycin-C + Fluorouracil 25 Mitomycin-C 12mg/m 2 IV bolus over 10 min, day 1 Fluorouracil 500mg/m 2 /day IV continuous infusion 24 hours, days 1-5 & 16-20
膀胱癌化療處方 Chemotherapy regimen 治療目的組套編碼處方內容 Neo-adjuvant Adjuvant Metastasis UBNAP1 CG regimen 1 (v) Gemcitabine 1000mg/m 2 IV over 30 minutes, days 1,8,15 Cisplatin 70mg/m 2 IV over 6 hours, day 2 Repeat every 28 days UBNAP2 UBNAP3 MVAC 1 (v) Methotrexate 30 mg/m 2 IV over 15 minutes, days 1, 15, 22 Vinblastine 3 mg/m 2 IV over 10 minutes, days 2, 15, 22 Doxorubicin 30 mg/m 2 IV over 10 minutes, day 2 Cisplatin 70 mg/m 2 IV over 6 hours, day 2 Repeat every 28 days TC regimen 2 (v) Paclitaxel 225 mg/m 2 IV over 3 hours, day 1 Carboplatin AUC=6x(GFR+25) IV over 90 minutes, day 1 Repeat every 21 days With GCSF support ; UBNAP4 CMV regimen,q3w 23 Methotrexate 30 mg/m 2 IV bolus, days 1,8 Vinblastine 4 mg/m 2 IV bolus, days 1,8 Cisplatin 100mg/m 2 IV over 6 hour, day 2 Folinic acid 15mg (oral or IV) Q6H x 4 doses, 24hrs after MTX on D2-9 Repeat every 21 days
Radiation therapy Treatment type RT technique Total dose Fraction size / # Fractions Neoadjuvant RT T3b or T4 Adjuvant CT Radical radiotherapy (post TURBT) T2-T4 Conventionally Fractionated RT Conventionally Fractionated RT Conventionally Fractionated RT 45-50Gy to UB 45Gy to UB (or pelvic node) 55-60Gy to tumor bed (sparing small intestine) 45Gy to pelvic node 50.4Gy to UB 60-66Gy to primary tumor 1.8-2Gy/ fraction 1.8-2Gy/ fraction 1.8-2Gy/ fraction Note Indications: (1)Extravesicle disease (2)Postive surgical margin (3)Postive pelvic lymph node (4)Locally advanced disease(t3-t4) (5)High grade tumors 註 : 實際治療分次劑量 總治療次數, 應與處方劑量差異在 ±1Gy 內 註 : 放射治療詳細流程清參照膀胱癌放射治療標準政策與執行規範
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