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

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)

(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