제 7장. 비뇨기계 항암제 사용법
총론
비뇨기계 암의 unique feature
- Renal insufficiency due to obstructive uropathy from local extension of the tumor or postsurgical or postradiotherapy changes
→ 적절한 dose adjustment 필요함.
(e.g. Use of cisplatin in bladder, germ cell tumor, Use of MTX in ileal conduit and neobladder)
- Local extension in the pelvis
→ local pelvic relapses have the potential to be symptomatic and painful
→ In patient with prior RT, systemic therapy may be important for palliation.
Management of urinary obstruction by tumor
1) Lower tract obstruction
- foley catheter insertion or suprapubic cystostomy
- Surgery, RT, endoscopic resection depending on stage
2) Upper tract obstruction
- Nephrostomy
- Cystoscopically placed stent . - Stenting via nephrostomy tube
Supportive care measures become priority when patients are too debilitated for invasive procedure
● Bladder spasm
Causes: vesicular irritation by cancer, postradiation fibrosis, indwelling catheter, cystits, Anxiety
- Management
- Antibiotics (cystitis)
- Catheter change, bladder irrigation
- Medication
- Oxybutynin chloride (Ditropan): 5mg tid
- NSAIDS
- Blocks of lumbar sympathetic plexus (intractable Bladder pain)
Chemotherapy Order시 유의 사항 및 요령
Chemotherpay 시행 전 확인사항: CBC&D/C (ANC), LFT, Ccr
→ 결과에 따라 dose adjustment
Drug 및 용량을 정확하게 계산, 입력
Pre/post hydration은 cisplatin인 경우 해당 당일 3-4L 시행하나, nephrotoxicity가 적은 경우에는 1-2L/day로 조정해서 시행할 것 (pre, post hydration은 환자 상태에 따라 결정).
퇴원시 delayed emesis에 대한 처방
short term low dose steroid 및 oral antiemetics 투여
의료보험 여부 확인
Dose modifications in pre-existing renal insufficiency
- GFR >60mL/min: 100%
- GFR 30-60mL/min
- Cisplatin, MTX: 50%
- Bleomycin: 75%
- GFR 10-30mL/min
- Cisplatin, MTX: omit
- Bleomycin: 75%
- GFR<10mL/min
- Bleomycin: 50%
- Zoledronic acid (Zometa)
- GFR >60mL/min: 4mg (no dosage adjustment necessary)
- GFR 50-60mL/min: Reduce dose to 3.5mg
- GFR 40-49mL/min: Reduce dose to 3.3mg
- GFR 30-39mL/min: Reduce dose to 3mg
- GFR <30 mL/min: Use is not recommended. ** Carboplatin dose (AUC) by Calvert formula
AUC×[creatinine clearance+25]
(maximum dose: 800mg)
AUC= 5
-Ref) Nature reviews 2009;5:450
Dosing guideline for LFT
liver function에 따른 항암제 dosing은 다음과 같다.
1) Bilirubin<1.5, AST <60인 경우 Paclitaxel은 75% dose 사용
2) Bilirubin이 1.5-3.0, AST 60-180인 경우 Paclitaxel, Docetaxel은 75%, Doxorubicin은 50% dose 사용
3) Bilirubin이 3.1-5.0, AST >180인 경우 Docetaxel, Paclitaxel은 사용하면 안됨, Methotrexate 75% dose 사용
4) Bililirubin>5.0인 경우는 항암제제를 사용하지 못한다.
- Ref) Manual of Clinical oncology 6th edi. 2004; 75page
Pain control
1) 포괄적 통증 평가 항목
- 통증조사 (PQRST)
- : 통증 (position), 특성 (quality), 관련요인 (relieving or aggravating factor), 통증강도 (severity), 통증의 시작 및 시간적 양상 (timing)
2) 통증 강도 평가
- 숫자통증등급 (Numeric rating scale): 1-10
- 얼굴통증등급 (pain affecting faces scale):0, 2, 4, 6, 8, 10
3) 진통제 사용의 일반 원칙
- - 환자 개개인에게 적합한 진통제의 종류, 용량 및 투여 방법 선택
- → 가능하면 경구로, 규칙적으로
4) 통증 강도에 따른 진통제의 선택 (NCCN guideline 2013)
- Pain intensity 1-3 → Non-opioid
- Pain intensity 4-10 → Opioid
- : 진통제 사용으로 인한 addiction은 드물다. 오히려 진통제를 적게 씀으로써 addiction을 유발하게 됨.
5) 마약성 진통제
- (1) 종류
약품명 | 투여 간격 | 제형 |
---|---|---|
Short acting | ||
Morphine IV, p.o | PRN | IV S-morphineⓇ (5mg/mL, 10mg/1mL, 15mg/1mL) p.o S-morphineⓇ (15mg/T) |
Hydromorphone | 4-6h, PRN | p.o JurnistaⓇ (2mg/T) |
Oxycodone | 4-6h, PRN | IR codonⓇ (5mg/T) |
Dihydrocodein | 4-6h, PRN | Hydrocodone 7.5mgⓇ (Hydrocodone 7.5mg+AAP 500mg/T) |
Long acting | ||
Codein phosphate | 4-6h | Tacopen (acetaminophen 250mg +ibuprofen 200mg+codein phosphate 10mg/T) |
Oxycodone ER | 12h | Oxycontin 서방정 (10, 20, 40, 80mg/T) |
Oxycodine HCl+naloxone | 12h | Targin (5/2.5mg, 10/5mg, 20/10mg, 40/20mg/T) |
Fentanyl patch | 72h | Durogesic patch (12.5, 25, 50, 75, 100ug/h)
fentamax patch (12.5, 25, 50, 75, 100ug/h) |
Jurnista | 24h | Hydromorphone OROS (8, 16, 32mg/T) |
* Demerol은 사용하지 않는다 (side effect & addiction risk).
2) 동등 진통 용량
- IV morphine 10mg= oral morphine 30mg =oxycontin 20mg, targin 20mg=jurnista 8mg=durogesic patch 12.5ug/hr
3) 투여 방법 및 제제변경에 따른 투여량의 조절
- (1) 동등진통용량를 사용한다.
- (2) 새 약제의 초회용량은 불완전한 교차내성 (incomplete crosstolerance)을 고려하여 동등진통용량의 50-75%를 투여한다.
- (3) 전에 사용하던 진통제로 통증조절이 불충분하였던 경우에는 새 약제의 초회용량은 동등 진통용량의 75-100%를 투여한다.
- (4) 돌발성 통증 (breakthrough pain)에 대비하여 새로 결정된 약제 1일 약제의 10-15%를 필요한 경우 (prn)에 복용 할 수 있도록 처방한다.
4) 부작용
- (1) respiratory depression & cardiovascular collapse
- ① naloxone 0.4-2mg IV (20-40ug/min) iv & repeated 3-5 min interval
- subsequent doses of opioids delayed or reduced
- ② naloxone을 1:10으로 dilution시켜 slowly infusion: naloxone 2mg+p/s 20cc
- (dose titrated to respiratory rate & level of consciousness)
- ③ comatose patient: naloxone 투여 전에 endotracheal tube insertion
- (to prevent aspiration due to withdrawal-induced salivation & vomiting)
- (2) Sedation & cognitive impairment
- ① psychostimulant drug
- (methylphenidate or dextroamphetamine)
- : 2.5-5mg once or twice daily (8am & 1pm)
- ② persistent confusion or delirium
- : haloperidol 0.5-1mg two to three times daily
- (3) GI toxicity
- ① constipation 예방이 필수적임.
- ② opioid-induce nausea & vomiting
- a. central type; constant, not worsened by eating
- ⇒ dopamine-blocking drug such as phenothiazine
- b. peripheral type: intermittent, exacerbated by eating
- ⇒ prokinetic drug (metoclopramide, cisapride)
- a. central type; constant, not worsened by eating
- (4) Myoclonus: severe시 benzodiazepine
- (clonazepam 0.25-0.5mg po tid daily)
- (5) urinary retention
- (6) noncardiac pulmonary edema
- (7) dry mouth, pruritus, dizziness, sleep disturbance, sexual dysfunction
- (8) 예시
- * Renal cell cancer c multiple metastasis
- C/C Generalized pain (esp, flank pain) NRS 8점
- Basal pain control (외래에서 사용함): durogesic 25ug/hr IV morphine PRN 5mg에 NRS 0-4로 감소 (하루 3회 사용으로 통증 조절됨)
- 퇴원예정 basal opioid dose와 돌발성 통증을 예방하기위한 PRN 용량의 계산
- 총 morphine사용량: PRN morphine 양 15mg (5mg×3회)+IV morphine 20mg (durogesic 25ug/hr와 동등량)=35mg
- - 사용 iv morphine 15mg의 75%=11.25mg (=durogesic 12.5ug/hr)
- - Total durogesic 25+12.5=37.5ug/hr로 전환
- - PRN용량:24hr opioid 요구량의 10% 즉, 37.5ug=iv morphine 30mg 이므로 iv morphine 3mg임=IR codon 5mg
Nausea & Vomiting control
- The most common side effect
- Type
Acute: <24h
Delayed >24h
anticipatory of emesis
- Risk Factors
Young
Female
heavily pretreated patients without a history of alcohol or drug use
history of motion or morning sickness
- Highly emetogenic drugs (>90%)
Cisplatin
- moderately emetogenic drugs (30-90% risk)
Carboplatin, Mitoxantrone, and Ifosfamide
- low-risk (10-30%) agents
Docetaxel, Gemcitabine, Paclitaxel, Etoposide,
- minimal risk (<10%)
antibodies, bleomycin, and vinblastine
1) Anticipatory emesis
- ① chemotherapy 24시간 전에 발생: psychologic mechanism 관여
- ② 치료: Lorazepam 0.5-1.5mg 2-3일전부터 투여
2) 발생 시간에 따른 분류
- ① acute chemotherapy induced emesis
- - chemoTx 1-2hr후에 발생
- - 5HT3 antagonist:
- Kytril (Granisetron): 3mg IV or 2mg PO, Zofran
- (Ondansetron): 8mg IV or 16mg PO,
- Anzemet (Dolesetron): 100mg IV or PO, Navoban
- (Tropisetron): 5mg IV & 5days PO
- Aloxi (Palonosetron): 0.25mg IV 1회
- Dexamethasone 20mg IV
- Metochlopramide
- ② Delayed
- - chemoTx 24-72시간 이후
- Emend (aprepitant)
3) Antiemetics order내기
- (1) High emetogenetics (90% 이상)-(e.g Bladder cancer시 GC chemo, MVAC chemo)
Day1 | Day2 | Day3 | Day4 |
---|---|---|---|
Emend 125mg DB | Emend 80mg DB | Emend 80mg DB | |
5HT3 antagonist IV | |||
Dexa 10mg IV/p.o | Dexa 10mg IV/p.o | Dexa 10mg IV/p.o | Dexa 10mg IV/p.o |
- (2) Moderate emetogenetics (30-90%) (e.g Prostate cancer 시 Mitoxantrone+PD chemo)
Day1 | Day2 | Day3 |
---|---|---|
5HT3 antagonist IV | 5HT3 antagonist p.o | 5HT3 antagonist p.o |
Dexa 10mg IV | Dexa 10mg IV | Dexa 10mg IV |
IV 투여 및 Nutrition
1) IV 투여 속도의 조절
- - bolus투여의 경우: 어떤 약제이든 최소 3분이상, 5ml/min (60gtt)이하의 속도로 투여해야 한다.
- cf) continous infusion: 정확한 시간을 지키기 위해서는 infusion pump를 사용할 것, 특히 24시간 continuous infusion시에는 총 투여기간이 늘어 지지 않도록 매일 같은 시간에 교체하도록 할 것.
2) Nutrition에 대한 처치
하루에 필요한 열량은 적어도 2,000kcal (체중당 25-35kcal) 유지-단백질 60g (체중당 1-2g)
- 1. 식사의 50% 섭취-1,000cal (단백질 15g)
- 짝수날 Intralipos 500ml+newcare 2can
- 홀수날 freamine 500ml+newcare 3can (2-3일마다 IVH3)
- 2. 식사의 20-30% 섭취-1,600cal (단백질 42g)
- 짝수날 IVH3 1000ml+intralipose 500ml
- 홀수날 freamine 500ml+20%DW 1000ml+newcare 3can
- 3. 식사를 못함-2,000cal (단백질 60g)
- 짝수날 IVH3 1,000ml+Intralipose 500ml+newcare 2can
- 홀수날 IVH3 1,000ml+20%DW 1,000ml+newcare 2can
- (cf. IVH3에는 cafsol 포함되어 있음.)
비뇨기계 암 항암제의 독성
Commonly Used Chemotherapeutic Agents in Urologic Oncology, and Their Toxicity
Agent | Activity | Common Toxicities |
---|---|---|
Cisplatin | Bladder cancer, germ cell tumors, prostate cancer | Renal insufficiency, peripheral neuropathy, auditory toxicity, myelosuppression |
Carboplatin | Bladder cancer, germ cell tumors | Myelosuppression |
Bleomycin | Germ cell tumors | Fever, chills, pulmonary fibrosis |
Doxorubicin | Bladder cancer, prostate cancer | Myelosuppression, mucositis, cardiomyopathy |
Etoposide (VP-16) | Germ cell tumors, prostate cancer | Myelosuppression |
5-Fluorouracil | Renal cell carcinoma, bladder cancer, Prostate cancer | Mucositis, diarrhea, myelosuppression |
Floxuridine (FUdR) | Renal cell carcinoma | Mucositis, diarrhea |
Methotrexate | Germ cell tumors, bladder cancer | Mucositis, myelosuppression, renal toxicity |
Ifosfamide | Germ cell tumors | Myelosuppression, neurologic (CNS) toxicity, cystitis |
Vinblastine | Renal cell carcinoma, bladder cancer, germ cell tumors, prostate cancer | Peripheral, autonomic neuropathy; myelosuppression |
Estramustine | Prostate cancer | Nausea, thromboembolic events |
Paclitaxel (Taxol) | Bladder cancer, germ cell tumors, prostate cancer | Myelosuppression, neuropathy |
Docetaxel (Taxotere) | Bladder cancer, germ cell tumors, prostate cancer | Myelosuppression, neuropathy |
Gemcitabine (Gemzar) | Bladder cancer | Myelosuppression |
- Myelosuppression
Maximal neutropenia occurs 6-14days after conventional doses.
Leucogen (GM-CSF) 투여
1. Indication: granulocytopenia (<1,000)
2. Use: a. Leucogen (GM-CSF)-400ug/sc 는 호중구수가 1,000개 이하일 때 보험이 인정되며 모두 10회까지 인정하게 된다.
3. side effect: 발열, 오한, 두통 등이 발생할 수 있으므로 투여 30분에서 1시간전에서 AAP 2T
# OD PO를 처방하기도 한다.
4. 투여 후 Daily CBC check
5.부작용이 심하여 계속 투여하기가 어려운 경우는 Gracin (G-CSF)로 change함.
*. leucogen은 solid cancer에만 보험 인정되며, Gracin은 hematologic malignancy에만 보험 인정된다.
반응 평가 및 F/U 시의 검사
1) 반응 평가는 WHO criteria 혹은 RECIST criteria를 따른다.
- 모든 항암제 투여 후 반응 평가는 항암 2-3주기 마다 CT를 시행한다.
2) 항암 치료후 stable disease 이상의 소견이 없었던 경우 6개월 이전에 전이 또는 재발하여 동일 제제 재 투여 시에 삭감되므로 주의한다.
3) 검사실 검사 (CBC & D/C) 등은 매 주기 시작 시기, 그리고 외래 방문하여 항암제 투여 시 시행한다 (e.g. Bladder cancer시 MVAC의 경우 입원시, D15, D22때, GP 의 경우 입원시, D8, D15일 때).
각론
(실제 order form은 병원 마다 pre/post hydration 용량, 전처치 등이 다르므로 각각의 Regimen만을 다루기로 한다. 또한 사전신청요법, 의보 100% regimen은 다루지 않는다.)
Metastatic Renal Cancer
Predictors of short survival
Poor prognosis patients are defined as those with ≥ 3 predictors of short survival
- LDH level > 1.5 times upper limit of normal
- Hgb level < lower limit normal
- Corrected serum calcium level > 10mg/dl
- Interval of less than a year from original diagnosis to the start of systemic therapy
- Karnofsky PS ≤ 70
- ≥ 2 sites of organ metastasis
NCCN guideline 2013.
1) Sunitinib (Sutene)-clear cell type 경우
- Sunitinib 50mg PO for 4weeks, 2weeks off every 6-week toxicity 시 감량: 37.5mg/day
- Response Rate: 31% PFS:11months Ref> NEJM 2007;356:115-124
2) Sorafenib (Nexavar)-clear cell type 경우
- Nexavar 400mg PO Bid (공복시 복용)
- toxicity 시 감량: 400mg/day → 400mg EOD
- PFS:5.5months vs 2.8month (sorafenib vs placebo)
- RR: 10% vs 8%(sorafenib vs placebo Ref> NEJM 2007;356:125-134
3) Pazopanib (Votrient)-clear cell type 경우
- 800mg/day PO toxicity 시 감량: 400mg/day
- Pazopanib vs. placebo 9.2 vs. 4.2months Ref> JCO 2010;28:1061
4) Temsirolimus (Torisel)-non clear cell type, poor prognosis in clear cell type
- Temsirolimus 25mg iv for 30min weekly
- overall survival:10.9month PFS:3.8month Response
- Rate:8.6% Ref> NEJM 2007;356:2271-2281
5) Everolimus (Afinitor)-second line
- 10mg/day PO toxicity 시 감량: 5mg/day
- mPFS: everolimus vs. placebo 4.0 vs. 1months
6) High dose IL-2
- 대상: ECOG PS 0-1, normal organ function
- HD IL-2 (600,000 U/kg/dose IV every 8hrs on days 1 through 5 and 15 to 19 [maximum 28 doses]) every 12weeks
- Ref> JCO 2005;23:133
Advanced Bladder Cancer (upper tract urothelial cancer도 같다.)
1) M-VAC (every 28days)
- Methotrexate 30mg/m2+P/S 100ml iv for 10min Day1, Day15, Day22
- Leucovorin (Folsan) 15mg iv q 6hr,×3 (after 6hrs MTX iv)
- (prevention of GI mucosa and Bone Marrow)
- Vinblastine 3mg/m2+P/S 100ml iv bolus Day2, Day15, Day22
- Doxorubicine 30mg/m2+P/S 100ml iv for 10min Day2
- Cisplatin 70mg/m2+P/S 500ml iv Day2
- CR 15%, PR 35%, MST 13months
- ※ On day 15, 22
- WBC >2,000/uL, Platelet >75,000/uL → full dose 이하 → 회복된 후 67% dose로 회복하는데 2주 이상 소요될 경우 생략
- Ref> JCO 1990 8:1050, 1992 10:1066
2) Gemcitabine+Cisplatin (q 4wks)
- Gemcitabine 1,000mg/m2 Day1, Day8, Day15
- Cisplatin 70mg/m2 Day2
- GC versus MVAC: response rate 49.4/45.7%, median OS13.8/14.8 mo
- 매 cycle 시작시 환자 CBC 시행하여 WBC 3천개 이상, PLT 10만개 이상 인 것을 확인하고 시작해야함. → 안되면 오를 때까지 기다릴 것.
- 8일째, 15일째 G 투여시 CBC시행하여 WBC 1,900개 미만이거나 PLT가 75,000개 미만, ANC 1,000개 미만이면 omit 한다 (Non-hematologic toxicity는 모두 Grade 3이상일 때 omit).
- DOSE 감량 (보험기준은 첫 시작시 최대용량에서 80%까지는 인정됨, 그 후 DOSE 감량은 70%까지 보험인정됨.)
- (1) 8일째, 15일째 때 ANC 1,000개 미만이면서 fever가 있었거나 PLT 75,000개 미만이거나 non-hematologic toxicity가 Grade 3이상이 발생하였으면 다음 투여부터는 처음 100%로 투여하였으면 75%로 감량하여 사용하여야 하며, 감량 후에도 발생한다면 70%로 투여하는 것을 권장함 (그러면 ANC 1,000개 미만 만 보인다면? → 용량 감량은 필요없음.).
- (2) 환자가 75세 이상이거나 PS score 1 이상시 GC 모두 80%로 시작하는 것이 좋음 (Cisplatin은 GFR 계산하여야함) → 그 후 위에서 언급한 문제가 발생하였다면 70%로 감량하여 사용
- (3) 용량을 감량하였음에도 불구하고 toxicity를 보인다면 8일째를 10일째로 옮기고 15일째를 17일째로 옮긴다 (그러나 28일 주기는 맞춰야 한다.).
- JCO 2000;17:3068-3077 * Gemcitabine+Cisplatin chemoTx 예시
- D1
- 1. Check V/S 8hr
- 2. Regular hospital diet
- 3. Ambulation
- 4. Prehydration P/S 1,000cc (88cc/hr)
- 5. Chemo
- Gemcitabine 1,000mg/m2(체표면적 계산해서 용량 결정)-50cc/hr
- 6. Posthydration P/S 1,000cc (88cc/hr)
- D2
- 1. Check the V/S q 4hr
- 2. Ambulation
- 3. SD (Soft Diet)
- 4. Check the body wight
- 5. Observation of the fever
- 6. Medication (진통제, 소화제, 진경제+환자에 따라 복용 필요한 약)
- 7. Hydration & Chemotherapy
- ① P/S-Bag 1,000ml D3 (P/S or D/S or D/W Bag 1,000ml)
- ② Dexamethasone 5mg IV (20mg)
- ③ Nasea 0.3mg IV
- ④ Mannitol 15% 250ml D2 (100ml)
- ⑤ Lasix 20mg=Furix=Furosix IV
- ⑥ P/S-Bag 1,000ml D3 (P/S or D/S or D/W Bag 1,000ml) (prehydration)
- ⑦ Cisplatin70mg/m2+P/S 500mL=sod. chlorid 0.9% 500mL
- ⑧ P/S-Bag 1,000ml D3 (P/S or D/S or D/W Bag 1,000ml)
- D8, 15 (외래에서)
- 1. CBC 보고 결정 (WBC, ANC, PLT)
- 2. Chemo
- Gemcitabine 1,000mg/m2 (체표면적 계산해서 용량 결정)
- - 50cc/hr
- 3. Posthydration P/S 500cc (300cc/hr)
- 4. prn med (소화제, 항구토제 등)
Metastatic Prostate Cancer
Androgen deprivation therapy
- Basics of hormonal control of the prostate
- Therapeutic approaches to androgen deprivation therapy
1) Bilateral orchiectomy
- : Within 24hours of surgical castration, testosterone levels are reduced by more than 90%
2) Inhibition of LHRH
- (1) LHRH agonist
- synthetic analogs of native LHRH
- initial exposure to agonists of LHRH results in a flare of LH testosterone levels
- : known as the ‘testosterone surge’ or ‘flare up’ phenomenon (begins within 2-3days of the first injection and lasts through approximately the first week of therapy)
- : result in a severe, life-threatening exacerbation of symptoms
- → co-administration of an antiandrogen (for only 21-28 days)
- Goserelin acetate (Zoladex): 3.6mg sc monthly
- Leuprorelin acetate (Leuplin): 3.75mg sc monthly
- Leuprolide acetate: 7.5mg sc monthly
3) Antiandrogens
- Compete with testosterone and DHT for binding sites on their receptors in the prostate cell nucleus: promoting apoptosis and inhibiting prostate cancer growth
- - Steroidal antiandrogens
- : Cyproterone Acetate, Megesterol acetate, medroxyprogesterone acetate
- - Non-steroidal or pure antiandrogen
- : Flutamide (250mg tid), bicalutamide (50mg po daily), nilutamide (150mg daily)
4) Antiandrogen withdrawal phenomenon
- 정의: experience a decline in PSA level, objective
- responses with the withdrawal of the antiandrogen from the combination with LHRH agonist
- - Declines in PSA level are seen
- → within 4weeks with flutamide withdrawal
- → within 6weeks with bicalutamide, nilutamide withdrawal
- - Declines in PSA level of more than 50% (15-30%), and median duration of 3.5-5months
Castration resistant prostate cancer
1) CRPC without Symptom or minimal Symptom
- (1) Observation
- (2) 2nd hormonal Tx
- - Ketoconazole: 200mg tid+prednisolone 5mg bid
- 그외 Alternative antiandrogen, High dose antiandrogen, Estrogen, Glucocorticoid 등이 있음.
2) CRPC with Symptom
- (1) Docetaxel+prednisolone
- Docetaxel 75mg/m2+P/S 200ml IV for 1hr Day1+PRD 5mg bid po q 3wks
- RR: 70% (PR: 38%, CR: 32%), median survival: 12.7 mo response rate of reduction in PSA 45%
- - Ref) NEJM 2004;351:1502-1512
** Docetaxel 투여시 전처치 및 주의사항
- - Prevention of hypersensitive reaction
1) dexamethasone 20mg iv before 30min of chemotherapy(Day1) 2) dexamethasone (8mg orally twice daily, Day 2-3)
- steroid 전처치: hypersensitivity 감소, fluid retention 감소, asthenia 감소
3) pheniramine 1x iv
4) ranitidine 50mg iv
- Dose reduction from toxicity
1) 20% dose reduction:
- prolonged grade 4 neutropenia (>7days)
- grade 4 thrombocytopenia
- grade ≥2 liver toxicity
- grade ≥3 diarrhea
- grade ≥3 cutaneous toxicity
2) Discontinue
- grade > 2 renal toxicity: Clcr < 60ml/min
- grade 3 liver toxicity
- grade ≥ 3 neuropathy
- grade 4 cutaneous toxicity
- grade 3 anaphylactoid reaction
* Docetaxel chemoTx 예시 (OPD)
- 1. Prehydration P/S 500cc (300cc/hr)
- 2. dexamethasone 10mg iv
- 3. metoclopramide 10mg iv
- 4. chemo
- Docetaxel 75mg/m2+P/S 200cc (200cc/hr)
- 5. posthydration P/S 500cc (300cc/hr)
- 6. med) solondo (prednisolone) 5mg bid for 21days PRN med
- (2) Mitoxantrone+prednisolone (이 regimen은 pain palliation이 목적임.)
- Mitoxantrone (Mitron) 12mg/m2+P/S 100ml IV Day1+PRD 5mg BID for 21days
- Ref> JCO 1996;14:1756
** 새로운 약제들
1) Abiraterone acetate, androgen synthesis inhibitor (CYP 17 inhibitor)- CRPC, docetaxel 사용 전, 혹은 후 Abiraterone acetate 1,000mg once a day+prednisolone 5mg bid
- OS: 14.8 month PFS: 5.6 month
- Ref> NEJM 2011;364:1995, 2013;368;138
2) Enzalutamide (MDV 3,100), New androgen receptor inhibitors - CRPC, docetaxel fail 후에 Enzalutamide 160mg once a day
- OS: 18.4 month
- Ref> NEJM 2012;367:1187
3) Cabazitaxel- CRPC, docetaxel fail 후
- Cabazitaxel 25mg/m2 iv over 1hr every 3weeks+prednisolone 5mg bid
- OS: 15.1 month, PFS: 2.8 month
- Ref> Lancet 2010;376:1147
** Spinal cord compression
- Dexamethsone 10mg loading after 4mg q 6hr+RT
Germ Cell Tumor
** 분류
Nonseminomatous GCT:
Embryonal carcinoma, Teratoma,
Choriocarcinoma, Endodermal sinus tumor
Seminoma
Tumor markers:
hCG: nonseminoma/seminoma
αFP: only nonseminoma histology LDH
BEP regimen (every 3wks)
Bleomycin 30 U/day+P/S 100ml iv for 30mins Day2, Day9, Day16
Etoposide 100mg/m2+P/S 400ml iv over 1hr Day1-5
Cisplatin 20mg/m2+P/S 200ml iv for 30mins Day1-5
Ref> NEJM 1987 316:1435
Bleomycin-induced pulmonary fibrosis: 400U 이상