Matenda-Kusintha Mankhwala Osokoneza Khansa Ndi Matenda a Matenda

by Lynne Eldridge, MD; Adayang'aniranso ndi dokotala wodziwika bwino

Bisphosphonates ndi Denosumab chifukwa cha Bone Metastases ndi Adjuvant Therapy

Khansara yomwe yafalikira ku mafupa (mafupa a metastases) ndi ofala kwambiri ndipo ingayambitse kupweteka kochuluka ndi kulemala komwe kumakhudzana ndi fractures ndi mavuto ena. M'zaka zaposachedwapa mankhwala omwe amatchedwa mawotchi osintha mafupa akhala akulimbikitsidwa kwa khansa zambiri kuti azichiza mafupa a mitsempha atangoyamba kupezeka. Pachifukwa ichi, mankhwalawa samachepetsa chiopsezo cha fractures koma nthawi zina amatha kupulumuka.

Monga phindu lachiwiri, mitundu yonse ya mankhwala osokoneza mafupa ali ndi zotsutsana ndi khansa. Kodi muyenera kudziwa chiyani za mankhwala monga Zometa ndi denosumab ngati mukukhala ndi khansa ya metastatic?

Matenda a Matumbo vs. Matenda a Khansa

Anthu akamva za khansa m'mapfupa, zimakhala zosokoneza kwambiri. Nthawi zambiri pamene anthu amalankhula za "khansa ya mfupa" akukamba za mafupa a mitsempha ; khansa yomwe inayambira kudera lina la thupi ndikufalikira mafupa. Ngakhale kuti anthuwa angagwiritse ntchito mawu oti "khansa ya mafupa," khansa yomwe imafalikira ku mafupa sichiti ndi khansara ya mfupa. Mwachitsanzo, khansara ya m'mawere yomwe yafalikira ku mafupa imatchedwa khansara ya mafupa koma makamaka "khansa ya m'mawere ya m'mawere ndi mafupa" kapena khansara ya m'mawere ndi metastases ya fupa. Khansara ya pathupi yaikulu ndi yocheperapo kusiyana ndi mafupa amtundu. Pansi pa microscope, khansara ya mafupa ikhoza kusonyeza maselo a mafupa a khansa. Mosiyanako, ndi metastases ya fupa maselo a khansa mu fupa ali minofu yomweyo ngati khansa yapachiyambi; maselo a khansa pachifuwa cha khansa ya m'mawere, maselo a mapapo a khansa mu fupa (ndi khansa ya m'mapapo) ndi zina zotero.

Ndi khansa yapakhungu yapafupa, kawirikawiri pamakhala fupa limodzi m'mfupa limodzi. Ndi mitsempha ya mafupa, nthawi zambiri pamakhala umboni wa khansara m'madera osiyanasiyana a mafupa kapena mafupa osiyanasiyana.

Khansa Zomwe Zingafalikire Kuti Zidye

Pali khansa zambiri zomwe zimafalitsa mafupa ambiri omwe ali khansa ya m'mawere, khansara yamapapo, kansa ya prostate, ndi multipleeloma ambiri.

Ma khansa ena omwe angafalikire ku fupa amakhala ndi khansa ya impso, khansa ya m'mimba, khansara ya chikhodzodzo, kansa ya uterine, khansara ya chithokomiro, ndi khansa yambiri.

Matenda a metastases amapezeka pafupifupi 70 peresenti ya amayi omwe ali ndi kansa ya m'mawere (mafupa ndiwo malo omwe amapezeka kwambiri a metastases), komanso mafupa a khansa ya m'mawere ndi amodzi omwe amachititsa ululu ndi kulemala kwa amayiwa (ndi amuna). Kwa ambiri a anthu awa, metastases ya mafupa ndi chizindikiro choyamba kuti khansara yatha pambuyo pa zaka kapena zaka makumi ambiri za kukhululukidwa. Matenda ena a mahomoni omwe amagwiritsidwa ntchito pa khansa ya m'mawere (monga aromatase inhibitors) angapangitse mafupa kutayika, kuwonjezeranso vutoli. Mafupa ambiri omwe khansa ya m'mawere imafalikira ndi msana, nthiti, pelvis, ndi mafupa a miyendo ndi manja.

Matenda a metastases ochokera ku khansa ya m'mapapo ndi yowonongeka, yomwe imakhudza pafupifupi 30 mpaka 40 peresenti ya anthu omwe ali ndi khansara ya m'mapapo. Mafupa omwe amapezeka kwambiri ndi msana, mapira, ndi mafupa apamwamba. Khansara ya m'magazi ndi yodabwitsa kwambiri kuti maselo amatha kukhala mafupa m'manja ndi m'mapazi. Pakati pa anthu omwe ali ndi mafupa a mitsempha ya khansa ya m'mapapo, 22 mpaka 59 peresenti adzakumana ndi "zochitika zokhudzana ndi chigoba" monga kupasuka.

Matenda a metastases amakhalanso ndi kansalu yotchuka ya prostate . Mofanana ndi amayi omwe ali ndi khansara ya m'mawere, mankhwala omwe amachiza mavitamini ndi arojeni amatha kuchepetsa mafupa. Amuna anayi mwa asanu omwe ali ndi khansara ya prostate adzakhala ndi mitsempha yopuma. Malo amodzi a metastases ndi mchiuno, msana, ndi mafupa a m'mimba.

Matenda a metastases ochokera ku myeloma angapo amakhalanso ofala. Pa x-ray, mafupa amatenga maonekedwe a njenjete. Pamene myeloma yambiri imalowa m'matenda, maselo a khansa amachititsa kuti mafupa apangitse mafupa komanso amachititsa mafupa omwe amathyola mafupa (osteoclasts). Nthawi zambiri myeloma imapezeka m'mafupa akuluakulu monga msana, fuga, nkhono, nthiti, ndi mafupa akuluakulu a miyendo.

Mitundu ya Metastases ya Bone

Pali mitundu iwiri yoyamba ya mitsempha ya mafupa: osteolytic ndi osteoblastic. Ndi mafinya osteolytic, chotupa chimayambitsa kupweteka (lysis) wa fupa. Matenda osteolytic metastases amawoneka ndi matumbo ambiri a myeloma komanso amphamvu monga khansa ya m'mawere. Matenda a mitsempha otchedwa masastases amachititsa kuwonjezereka kwa mafupa ndipo amapezeka kwambiri ndi khansa ya prostate. Ambiri mwa khansa ali ndi mitundu yambiri ya mitsempha ya mafupa ngakhale kuti 80 mpaka 85 peresenti ya metastases ndi khansa ya m'mawere ndi osteolytic. Mafupa amayamba kupezeka m'mafupa ndi metastases ya osteolytic kusiyana ndi kupuma kwa thupi.

Mavuto Ochokera ku Matenda a Matenda

Matenda a metastases akhoza kuchepetsa kwambiri umoyo wanu ndi khansara, komabe mankhwala atsopano amachititsa kusiyana kwa anthu ambiri. Osati kokha mafupa a mitsempha amatanthauza kuti khansara yayamba kufalikira ndipo sichirachiritsidwa, koma ikhoza kuchititsa mavuto ambiri.

Kupweteka kwa mafupa a metastases kungakhale koopsa kwambiri ndipo kawirikawiri kumafuna chithandizo ndi ululu wosokoneza bongo limodzi ndi mankhwala odana ndi kutupa.

Matenda a metastases amachititsanso kuti phokoso liphuke m'magawo omwe amachepa ndi chotupa. Pamene mafupa amathyoka m'magazi ndi khansa ya metastatic imatchulidwa ngati kupweteka kwa matenda. Mphuno ya pathologic ikhoza kuchitika ndi kuvulala kwambiri. Kuphatikiza pa kukonzekera kwa mafupa, mafupa a mitsempha amatha kupangitsa kuti zikhale zovuta kuti mafupa athulidwe athe kuchiritsidwa.

Pamene metastases imafika kumtunda, msampha woterewu umatchedwa kupweteka kwa msana. Khansara mumatope angayambe kugwedezeka ndi kupanikiza mitsempha yoyenda kuchokera kumsana wa msana mpaka kufupi ndi theka la thupi. Zizindikiro zimaphatikizapo kupweteka kwapweteka komwe kumapangitsa kuti miyendo, kufooka, ndi kupweteka kwa miyendo, komanso kutaya thupi ndi / kapena chikhodzodzo. Mankhwala opatsirana pogwiritsa ntchito mazira kapena opaleshoni akhoza kulimbitsa msana kuti asakhale ndi umoyo wamuyaya.

Mankhwala a hypercalcemia a malignancy kapena mkulu wa calcium m'magazi amatha chifukwa cha kutulutsa kashiamu kuchoka m'zigawo za mafupa kupita m'magazi. Zikuganiza kuti anthu 10 mpaka 15 peresenti ya anthu omwe ali ndi khansa yapadera adzavutika ndi matendawa (omwe ali ndi zifukwa zinanso kuphatikizapo mafupa a metastases).

Kuperewera kwa kuyenda chifukwa cha kuphulika sikungowonjezera khalidwe la moyo koma kungakuike pangozi ya mavuto ena. Kuopsa kwa magazi m'magazi mwa anthu omwe ali ndi khansara kwawonjezeka kale, ndipo kutaya thupi kumabweretsa chiopsezo chokhala ndi mitsempha yambiri ya mitsempha kapena pulmonary emboli

Mankhwala a Metastases a Matenda

Pakalipano pali zosiyana zambiri zomwe zingapezeke pochiza mafupa. Zina mwa mankhwala omwe amagwiritsidwa ntchito pa khansa yamtunduwu imathandizanso kuchepetsa mitsempha ya mafupa. Mankhwalawa angaphatikizepo mankhwala enaake , mankhwala othandizira, ma antibodies monoclonal , ndi immunotherapy mankhwala. Palinso mankhwala omwe amalumikiza mafupa amtundu makamaka. Izi zikuphatikizapo:

Mankhwala othandiza mafilimu: Mankhwalawa ndi mankhwala omwe amapezeka m'derali ndipo amachepetsa kwambiri ululu wonsewo komanso kuti pangakhale kupasuka.
Radiopharmaceuticals: Radiopharmaceutics ndi mankhwala omwe mankhwala a radiation amamangiriridwa ndi mankhwala ena omwe angathe kuikidwa mu magazi. Zitsanzo ndi Strontium-89 ndi Radium-223. Popeza kuti ma particles of radiation amanyamula kudzera m'magazi kwa mafupa onse m'thupi, angakhale othandiza makamaka kwa anthu omwe ali ndi ambiri kapena ambiri omwe amapezeka m'magazi.
Opaleshoni: Amafunika opaleshoni kuti athetse bata kapena kufooketsa mafupa owonongeka kuti athetse kutaya.
Tizilombo ta radiotherapy (SBRT) ndi mankhwala a proton : Pali maselo angapo okha (oligometastatic disease), kuthetsa masastases ndi mankhwala monga stereotactic body radiotherapy kapena mankhwala a proton angapangidwe ndi kuyesa, koma izi ndizo zachilendo.
Othandizira osokoneza mafupa: Izi zidzafotokozedwa pansipa.

Mankhwala a Matenda a Matenda (Bone-Modifying Agents)

Pali magulu awiri oyambirira a mankhwala omwe amagwiritsidwa ntchito pochiritsa mafupa. Izi zikuphatikizapo bisphosphates (monga Zometa) ndi denosumab. Mankhwala osokoneza bongo amalimbikitsidwa kwa aliyense amene ali ndi khansa ya m'mawere kumthambo, ndipo nthawi zambiri amagwiritsidwa ntchito ndi ziwalo zina zolimba (monga khansa ya m'mapapo). Mankhwala ena (monga mankhwala a radiation) nthawi zambiri amafunikira pamodzi ndi mankhwala opweteka ululu.

Agent-modifying agents angathandize anthu omwe ali ndi khansa m'njira zingapo.

Amatha kulimbitsa mafupa omwe amakhudzidwa ndi metastases kuti achepetse kupweteka konse komanso chiopsezo cha zophulika
Mankhwala ambiri omwe amagwiritsidwa ntchito pa khansa ya m'mawere ndi kansa ya prostate, amatha kuonjezera chiwopsezo cha matenda a osteoporosis, komanso kuphatikizapo mafupa a mitsempha amachititsa kuti anthu aziphulika. Izi ndi zofunika makamaka pamene anthu akukhala ndi moyo wautali ndi khansa.
Chifukwa cha zomwe zimachitika pamagulu a mafupa, mafupa osintha mafupa angachepetse chiopsezo cha mitsempha ya mafupa yomwe imapezeka pamalo oyambirira (khansa ya m'mawere komanso khansa ya prostate mpaka pano). Kuopsa kwa mafupa a metastases kunachepetsedwa ndi theka la magawo atatu, pamene chiwerengero cha anthu ochepa kwambiri chinachepa ndi chimodzi mwa zisanu ndi chimodzi.
Kafukufuku waposachedwa akuyang'ana mawonekedwe osintha mafupa ndi khansara yamapapu, zikuwoneka kuti mankhwalawa akhoza kusintha zonsezi kuti zisapite patsogolo komanso popanda moyo.

Bisphosphonates (Zometa)

Bisphosphonates ndi mankhwala omwe amayamba kugwiritsidwa ntchito pochizira matenda a mitsempha ndipo kenako anawathandiza kuthandizira mafupa. Akagwiritsidwa ntchito kwa khansa yomwe yafalikira ku mafupa akhoza kuchita ntchito ziwiri. Sizitha kuchepetsa kuperewera kwa mafupa koma amakhala ndi zotsatira zotsutsana ndi khansa. Amagwira ntchito poletsa kupweteka kwa fupa kuti apititse patsogolo fupa.

Mabisphosphonates omwe amagwiritsidwa ntchito kwambiri pakhungu la metastases ndi awa:

Zometa (zoledronic acid): Zometa ndi mankhwala osokoneza bongo omwe amagwiritsidwa ntchito pa mitsempha ya mafupa osiyanasiyana.
Aredia (pamidronate) : Aredia ndi mankhwala a bisphosphonate. Amavomereza khansara ya m'mawere ndi myeloma zambiri.

Zotsatira zowopsa za Zometa ndi Aredia ndi matenda ofanana ndi matenda a chimfine kwa masiku angapo oyamba mutalowa. Zotsatira zina zochepa za bisphosphonates zomwe zimaperekedwa mwachisawawa zimaphatikizapo kuwonongeka kwa impso, kuchepa kwa calcium, minofu, mgwirizano, ndi / kapena kupweteka kwa mafupa (zomwe zingathe kuchitika nthawi iliyonse pambuyo pa chithandizo), zophulika zachilendo za mkazi, ndi mafinya oopsa. Bisphosphonates silingakonzedwe kwa anthu okhala ndi matenda a impso.

Chosavuta koma choopsa chochitika chogwiridwa ndi Zometa ntchito (ndi zina bisphosphonates) ndi osteonecrosis wa nsagwada. Matendawa amadziwika ndi kuphulika kwapang'onopang'ono m'dera la mafupa omwe ali ndi mphamvu kapena maxilla ndipo zingakhale zovuta kwa Iwo Sidziŵika momwe nthawi zambiri zimakhalira, koma chiopsezo cha pafupifupi 2 peresenti chinapezeka mwa amayi omwe anachitidwa ndi Zometa monga khansa ya adjuvant pa khansa ya m'mawere oyambirira. Osteonecrosis ikhoza kuchitika ndi mankhwala alionse mu gulu la bisphosphonates koma 94 peresenti ya milandu imapezeka ndi mankhwala osokoneza bongo amphisoni ndipo sizodabwitsa kwambiri ndi mankhwala osokoneza bongo.

Osteonecrosis ya nsagwada ndizovuta ngati anthu akudwala matenda a chingamu, alibe ukhondo wabwino wa mano, kapena amachitidwa njira zamano monga kuchotsa mano. Palinso umboni wakuti kukonzekera kukayezetsa mano kwa miyezi itatu iliyonse ndikugwiritsa ntchito mankhwala oletsa njira monga kuchotsa dzino kumachepetsa chiopsezo. Njira zochiritsira zimaphatikizapo opaleshoni, opinthitsa, antibiotics, ndi mankhwala ophera okosijeni.

Mabisphosphonates amavomerezedwanso kwa amayi omwe amatha kupha khansa omwe ali ndi khansa ya m'mawere. M'mayesero a zachipatala, Zometa anapezedwa kuti achepetse chiopsezo chokhala ndi mitsempha ya mafupa ndi gawo limodzi mwa magawo atatu.

Denosumab (Xgeva ndi Prolia)

Xgeva ndi Prolia (denosumab) ndi antioclonal antibody (anti-man-made antibody) yomwe ingachepetse mavuto (monga zophulika) omwe amagwirizanitsidwa ndi mitsempha ya mafupa. Pali mitundu iwiri ya mankhwala awa omwe ali ndi zizindikiro zosiyana ndi khansa. Amapatsidwa mwa jekeseni milungu iwiri iliyonse.

Denosumab amagwira ntchito pomangirira ndi kutulutsa kachilombo ka puloteni (RANKL) yomwe imayendetsa mafupa. Pali mitundu iwiri ikuluikulu ya maselo m'mapfupa: mafinya omwe amachititsa mafupa kukula, komanso mafinya omwe amathyola mafupa. Denosumab imaletsa mafinysi komanso imapangitsa kuti mafupa aziwonjezeka.

Mu kafukufuku wa 2016, denosumab inayesedwa mu mayesero atatu osiyana siyana omwe akuyang'aniridwa ndi khansa ya m'mawere, khansara ya prostate, ndi phunziro lachitatu ndi anthu omwe anali ndi matumbo ambiri a myeloma kapena odwala kwambiri osati khansa ya khansa kapena prostate. Ndi khansa ya m'mawere ndi kansa ya prostate, denosumab anali wamkulu kuposa Zometa pochepetsa chiopsezo cha zophulika zokhudzana ndi mitsempha ya mafupa. Ndi mitsempha yambiri ya myeloma ndi zina (monga denosumab inali yofanana ndi Zometa.

Ndi khansa yamapapu, phunziro la 2015 linapeza kuti poyerekeza ndi Zometa, denosumab inachepetsera chiopsezo cha kupasuka kumene kumachitika ndi 17 peresenti. Zikuwonekeranso kuchepetsa kukula kwa mitsempha ya mafupa, kuchepetsa chigoba kukula, ndi kupulumuka kwa nthawi yayitali.

Denosumab nayenso anapepetsera chiopsezo cha matenda odwala matenda a khansa ya m'mawere ndi kansa ya prostate (yokhudzana ndi kugwiritsa ntchito aromatase inhibitors mu khansa ya m'mawere ndi atrogen chithandizo chopanda khansa ya prostate),

Zotsatira za denosumab ndizofanana ndi bisphosphonates koma mankhwalawa ndi omwe amachititsa kuti pakhale njira ya calcium yochepa komanso yogwiritsidwa ntchito nthawi yaitali. Pa chifukwa chimenechi, nthawi zambiri amalandirira kashiamu ndi vitamini D. Mosiyana ndi bisphosphonates, denosumab ingagwiritsidwe ntchito kwa anthu omwe ali ndi vuto la impso. Mofanana ndi bisphosphonates, pali chiopsezo chochepa cha osteonecrosis cha nsagwada ndi mankhwala awa.

Malangizo Othandizira Kuthandizira Matenda Ndi Mitsempha ya Matenda

Kafukufuku wothandizira osintha mafupa athandiza kutsata malangizo omwe alipo kwa ena khansa.

Kwa khansa ya m'mawere yamatenda, ndi metastases ya mafupa, malangizo a American Society of Clinical Oncology ochokera mu 2017 amalimbikitsa amayi kuti azichiritsidwa ndi mankhwala awa:

Xgeva kapena Prolia 120 mg mwachindunji milungu iwiri iliyonse
Aredia 90 mg IV iliyonse masabata 3 mpaka 4
Zometa 4 mg IV masabata khumi ndi awiri kapena masabata atatu kapena 4

Kwa kansalu ya prostate, ndondomeko zothandizidwa ndi matenda a 2017 zinalimbikitsanso kuti mawotchi oyambitsa mafupa ayambidwe panthawi ya matenda a mafupa a mitsempha. Zosankha zikuphatikizapo:

Xgeva / Prolia (denosumab) 120 mg mwachindunji milungu iwiri iliyonse
Zometa 4 mg IV masabata khumi ndi awiri kapena masabata atatu kapena 4

Zilonda zina zonse zokhudzana ndi mitsempha ya mafupa zimatha kupatsidwa ndi zotsatirazi:

Zometa 4 mg IV iliyonse masabata 3 mpaka 4
Denosumab 120 mg mwachindunji milungu iwiri iliyonse

Asanayambe Kuchiza

Musanayambe kulandira chithandizo ndi denosumab kapena bisphosphonates, tikulimbikitsidwa kuti anthu ayambe kufufuza bwino mano pofunafuna umboni wa matenda a chingamu ndi kuti ntchito iliyonse ya mano yomwe iyenera kuchitika iyenera kuchitika musanayambe mankhwalawa.

Mfundo Yofunika Kwambiri pa Matenda-Mmene Mungasinthire Matenda a Matenda Amadzimadzi Kuchokera Kumimba Yolimba

Matenda a metastases ali ovuta kwa anthu ambiri omwe ali ndi kansa ya metastatic ndipo angathe kuchepetsa moyo ndi moyo. Agulu-osintha mankhwalawa ndi njira yatsopano ndipo tsopano akulimbikitsidwa atangoyamba kumene kufufuza mafupa a metastases kwa khansa zambiri.

Mabisphosphonates monga Aredia ndi Zometa angachepetse chiopsezo cha zophulika, ndipo kenaka amachititsa kuti azivutika komanso osasunthika. Denusomab imathandiza kuchepetsa kupweteka kwa magazi komanso kungakhale yapamwamba kwambiri kwa bisphosphonates kwa khansa ya m'mawere ndi prostate. Maphunziro onse awiriwa amakhala ndi chiopsezo chachikulu cha osteonecrosis wa nsagwada, ndipo kufufuza kwa mano kumayang'anitsitsa zizindikiro za matenda a chingamu.

Kuwonjezera pa kuchepetsa chiopsezo cha kupasuka, mankhwalawa amathandiza kuthandizira kuperewera kwa mafupa chifukwa cha mankhwala ochizira omwe amapezeka m'mawere ndi khansa ya prostate. Zonse ziwiri za bisphosphonates ndi denosumab zikuwoneka kuti zili ndi ntchito yowononga khansa, zomwe zimapindulitsa anthu omwe amasankha kugwiritsa ntchito mankhwalawa. Ndipotu, kuwonjezera pa anthu omwe ali ndi kansa ya m'mawere, Zometa tsopano ikuvomerezeka kuti khansa ya m'mawere isanakwane monga mankhwala adjuvant pofuna kuchepetsa mwayi woti khansara ya m'mawere idzafalikira mafupa poyamba.

> Zotsatira:

> Beth-Tasdogan, N., Mayer, B., Hussein, H., ndi O. Zolk. Zothandizira Kuthetsa Mankhwala Osteonecrosis Okhudzana ndi Mankhwala. Dongosolo la Cochrane la Zosintha Zogwirizana . 2017. 10: CD012432.

> Coleman, R. Impact ya Matenda-Matenda Otsatiridwa pa Matenda Otsalira ndi Kupulumuka mu Khansara Yamatumbo. Oncology (Williston Park) . 2016. 30 (8): 695-702.

> Dhesy-Pind, S., Fletcher, G., Blanchette, P. et al. Kugwiritsira Ntchito Adjuvant Bisphosphonates ndi Mafupa Ena-Othandiza Kusintha Khansa Yamatumbo: CancerCare Ontario ndi American Society of Clinical Oncology Clinical Practice Guideline. Journal of Clinical Oncology . 2017. 35 (18): 2062-2081.

> Gravalos, C., Rodriquez, C., Sabino, A. et al. SEOM Clinical Guideline for Metastases Zamthambo Kuchokera Kumimba Yolimba (2016). Chipatala ndi Chitembenuzidwe cha Oncology . 2016. 18 (12): 1243-1253.

> Gul, G., Sendur, M., Aksoy, S., Sever, A., ndi K. Altundaq. Kubwereza Kwambiri kwa Denosumab kwa Matenda a Metastasis kwa Odwala Amene Ali ndi Matenda Olimba. Zofufuza Zamakono Zamakono ndi Maganizo . 2016. 32 (1): 133-45.