{"id":9692,"date":"2019-12-02T12:22:01","date_gmt":"2019-12-02T12:22:01","guid":{"rendered":"https:\/\/jurmed.ro\/medici\/?p=9692"},"modified":"2019-12-02T12:22:01","modified_gmt":"2019-12-02T12:22:01","slug":"neuro-oncologia-specialitate-aflata-la-granita-dintre-neurologie-neurochirurgie-oncologie-si-radioterapie","status":"publish","type":"post","link":"https:\/\/jurmed.ro\/medici\/neuro-oncologia-specialitate-aflata-la-granita-dintre-neurologie-neurochirurgie-oncologie-si-radioterapie\/","title":{"rendered":"Neuro-oncologia, specialitate aflat\u0103 la grani\u0163a dintre Neurologie, Neurochirurgie, Oncologie \u015fi Radioterapie"},"content":{"rendered":"

Interviu cu Dr. Dan Mitrea \u2013 Clinica Neuroaxis<\/strong><\/em><\/p>\n

Ce este neuro-oncologia?<\/p>\n

Neuro-oncologia este o supraspecializare recent ap\u0103rut\u0103 \u00een Rom\u00e2nia, ce adreseaz\u0103 patologiile tumorale ale sistemului nervos. Aceasta presupune diagnosticarea, tratarea \u015fi monitorizarea pacien\u0163ilor cu tumori cerebrale sau spinale, benigne sau maligne. Abodrarea \u00een aceast\u0103 supraspecializare se face \u00een echip\u0103, obiectivul fiind optimizare terapiei, astfel oferind cele mai bune \u015fanse de supravie\u0163uire pentru pacient dar \u015fi limitarea maximal\u0103 a deficitelor neurologice posibile.<\/p>\n

Care este inciden\u0163a neoplasmelor cerebrale?<\/p>\n

Potrivit statisticilor oficiale ale OMS, inciden\u0163a neoplasmelor sistemului nervos central este de aproximativ 6,5% la nivel european, o rat\u0103 sc\u0103zut\u0103 \u00een raport cu alte tipuri de cancer, cum ar fii cancerul mamar sau cel pulmonar. Din statistica general\u0103, \u0163ara noastr\u0103 se situeaz\u0103 la nivel mediu, cu o inciden\u0163\u0103 de aproximativ 7% din totalul cancerelor, ceea ce \u00eenseamn\u0103 \u00een jur de 1400 de cazuri noi anual. \u00cen practica medical\u0103 \u00eens\u0103, s-a observat o cre\u015ftere a num\u0103rului de astfel de cazuri \u015fi, mai mult dec\u00e2t at\u00e2t, o inciden\u0163\u0103 mai ridicat\u0103 \u00een num\u0103rul tinerilor. Din p\u0103cate, tumorile cerebrale afecteaz\u0103 at\u00e2t pacientii tineri c\u00e2t \u015fi cei v\u00e2rstnici \u015fi reprezint\u0103 un procent semnificativ de cazuri \u00een r\u00e2ndul copiillor.<\/p>\n

Ce cauzeaz\u0103 apari\u0163ia neoplasmelor cerebrale?<\/p>\n

Exist\u0103 o \u00eemp\u0103r\u0163ire \u00een 2 categorii de tumori, sunt tumorile cerebrale secundare, determinate de neoplazii ale altor organe \u015fi tumorile cerebrale primare, care sunt determinate de o anumit\u0103 susceptibilitate genetic\u0103 \u015fi\/sau de expunerea la anumi\u0163i factori de mediu. S-a demonstrat c\u0103 expunerea structurilor nervoase la radia\u0163ii ionizate determin\u0103 alterarea ADN \u015fi promoveaz\u0103 oncogeneza. Anumite ierbicide \u015fi pesticide cresc de asemnea inciden\u0163a acestei patologii neoplazice, fermierii av\u00e2nd o inciden\u0163\u0103 de 1,3-3.6x mai mare \u00een compara\u0163ie cu popula\u0163ia general\u0103. Personele care lucreaz\u0103 \u00een domeniul energiei prin expunerea la carburan\u0163i sau chiar curen\u0163i electrici puternici au un risc mai mare de p\u00e2n\u0103 la 2.5x fa\u0163\u0103 de popula\u0163ia general\u0103. Nu s-a demonstrat \u00eenc\u0103 o leg\u0103tur\u0103 de cauzalitate \u00eentre utilizarea telefonului mobil \u015fi cre\u015fterea riscului de tumori cerebrale.<\/p>\n

Pentru partea genetic\u0103, sunt sindrome deja bine cunoscute cu determinism genetic clar cum este Neurofimbromatoza tip 1, gena NF1 ce codific\u0103 o protein\u0103 denumit\u0103 neurofibromin al c\u0103rei rol este de a inhiba cre\u015fterea profiler\u0103rii celulare prin activarea hidrolizei GTP (guanozin trifosfat) la nivelul proteinelor Ras.Tumorile determinate de aceast\u0103 muta\u0163ie sunt ini\u0163ial benigne, dar se pot transforma din neurofibroame \u00een neurosarcoame. Un alt sindrom bine cunoscult este von Hippel Lindau, boala autosomal dominant\u0103, ce se remarc\u0103 prin prezen\u0163a de hemangioblastoame, \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 tumori neuroendocrine, asocierea cu tumori renale \u015fi feocromocitom.<\/p>\n

Exist\u0103 acum dup\u0103 studii patologice \u015fi asocia\u0163ie genetic\u0103 c\u00e2teva polimorfisme asociate cu riscul de a dezolva tumori gliale. Muta\u0163ii la nivelul genelor TERT, CCDC26, CDKN2A\/CDKN2B,\u00a0RTEL1,\u00a0PHLDB1 si EGFR, influeneaz\u0103 carciogeneza, defectele de reparare ale AND-ului, pot determina un anumit r\u0103spuns imun, care \u00een final, \u00eempreun\u0103 cu factorii de mediu duc la dezvoltarea tumorilor cererale primare.<\/p>\n

Cum se diagnosticheaz\u0103 corect?<\/p>\n

Examenul fizic \u015fi evaluarea istoricului personal \u015fi familial este obligatoriu. Urm\u0103toarea etap\u0103 important\u0103 este evalaurea imagistic\u0103, care \u00een func\u0163ie de datele anamnestice se poate rezuma la efectuarea unui IRM cerebral cu substan\u0163\u0103 de contrast (rpreferabil 1.5T nu mai pu\u0163in) dar \u00een cazul \u00een care se supicioneaz\u0103 determin\u0103ri secundare se poate complete \u015fi cu un bilan\u0163 imagistic al regiunilor de interes. Dac\u0103 tumorile cerebrale sau spinale determin\u0103 \u015fi leziuni osoase, este obligatoriu de completat investiga\u0163ia cu un CT.<\/p>\n

\u00cen cazul tumorilor cerebrale, \u00een func\u0163ie localizarea \u015fi particularit\u0103\u0163ile acestora, deficitele neurologice se instaleaz\u0103 \u00eencet, treptat, rar fiind situa\u0163iile \u00een care apare un deficit brusc. Cele din urm\u0103 apar deobicei \u00een urma unei s\u00e2nger\u0103ri tumorale, atunci c\u00e2nd tumora \u00ee\u015fi m\u0103re\u015fte foarte mult volumul, sau c\u00e2nd obstruc\u0163ioneaz\u0103 circula\u0163ia LCR (lichd cefalo-rahidian) determin\u00e2nd hipertensiune intracranian\u0103.<\/p>\n

Aspectul imagistic ne orienteaz\u0103 asupra caracteristicilor tumorii, put\u00e2nd orienta asupra unui diagnostic de etap\u0103. Aceasta se poate completa, la nevoie, cu Spectroscopie RM pentru a avea o idee vis a vis de activitatea metabolic\u0103 de la nivelul procesului tumoral.<\/p>\n

Urm\u0103toare etap\u0103 importan\u0103 \u00een diagnostic este o interven\u0163ie neurochirurgical\u0103, dac\u0103 este posibil\u0103. Biopsia stereotaxia este cea mai des folosit\u0103 metod\u0103 de explorare a \u0163estului tumoral, chiar \u015fi la nivelul structurilor trunchiului cerebral, dar exist\u0103 situa\u0163ii, cu tumor ice pot fi excizate per-primam.<\/p>\n

Planul operator se discut\u0103 \u00een cel mai mic detaliu cu neurochirurgul, abordarea fiind una c\u00e2t mai pu\u0163in invaziv\u0103, limit\u00e2nd c\u00e2t mai mult deficitele neurologice. \u00cen cazul \u00een care tumorile sunt mari, \u015fi deviaz\u0103 mult structurile cerebrale, se poate face o tractografie RM pentru a detemina raportul acesteia cu aceste structure. Dac\u0103 pacientul prezint\u0103 tumor\u0103 \u00eentr-o zon\u0103 func\u0163ional\u0103 important\u0103 cum este limbajul se poate face examinare fIRM (rezonan\u0163\u0103 magnetic\u0103 func\u0163ional\u0103) sau, neurchirurgul poate decide asupra unei procedui \u00een care pacientul este trezit \u00een opera\u0163ie.<\/p>\n

Exist\u0103 acum metode \u00een teste pentru diagnsoticul serologic al tumorilor cerebrale, una din metodele aflate \u00een teste este bombardarea tumorii cu unde electromagnetice \u015fi stimuarea cu ultrasunete a barierei hematonecefalice astfel \u00eenc\u00e2t compu\u015fi ai tumorii s\u0103 intre \u00een circuitul sangvin \u015fi s\u0103 poat\u0103 fi analiza\u0163i din s\u00e2nge. Acestea sunt trialuri, nu sunt \u00eenc\u0103 metode certificate de diagnostic.<\/p>\n

Cum se face diferen\u0163ierea \u00eentre tumorile benigne \u015fi cele maligne la creier?<\/p>\n

Diferen\u0163a \u00eentre tumora bening\u0103, malign\u0103 \u015fi determin\u0103ri secundare \u00eencepe de la examenul clinic \u015fi se termin\u0103 la examinarea anatomopatologic\u0103. Este de asemenea important de \u015ftiut c\u0103 sunt anumite tumori care de\u015fi sunt benigne, sau de grani\u0163\u0103, necesit\u0103 monitorizare imagistic\u0103 \u015fi clinic\u0103 constant\u0103, deoarece pot vira \u00een tumori maligne. Exist\u0103 o clasificare clar\u0103 anatomopatolgic\u0103 la care s-a ad\u0103ugat recent \u015fi diangosticare molecular\u0103, ce \u00eemparte tumorile pe diferite categorii. Aceasta ne ajut\u0103 la \u00eencadrarea corect\u0103 a acestora, stabilirea prognosticului, a planului de tratament optim, precum \u015fi programul de monitorizare al pacien\u0163ilor. Se \u015ftie de exemplu c\u0103 anumite muta\u0163ii, cum este muta\u0163ia 1p19q pot influen\u0163a prognosticul bolii, \u015fi fac dinferen\u0163a \u00eentre tumorile oligodendrogliale. Acestea combinate cu muta\u0163ia IDH (1-2) \u015fi alte muta\u0163ii clasific\u0103 tumorile \u015fi stabilesc traseul ce trebuie urmat at\u00e2t din punct de vedere terapeutic c\u00e2t \u015fi al monitoriz\u0103rii post-terapeutice.<\/p>\n

Ne pute\u0163i spune o abodrare optim\u0103 pentru tratarea tumorilor cerebrale primare?<\/p>\n

Rezec\u0163ia chirurgical\u0103 total\u0103 asigur\u0103 cele mai mari \u015fanse de remisie. Planificarea \u015fi efectuarea corect\u0103 a opera\u0163iei va influen\u0163a prognosticul bolii. Majoritatea studiile efectuate p\u00e2n\u0103 acum au demonstrat superioaritatea chirurgiei \u00een cazul tumorilor cerebrale primare \u00een fa\u0163a oric\u0103rei alte metode terpeutice. Sigur exit\u0103 tumori la care chirurgia este imposibil\u0103 sau sunt at\u00e2t de mici \u00eenc\u00e2t se pot aborda nonivaziv prin radioterapie stereotaxic\u0103, dar ca \u015fi principiu general, chirurgia corect efectuat\u0103 r\u0103m\u00e2ne \u00een momentul de fa\u0163\u0103 metod\u0103 de elec\u0163ie \u00een tratarea tumorilor.<\/p>\n

\u00cen cazul tumorilor benigne, chirurgia este de multe ori suficient\u0103, nu este nevoie de tratament adi\u0163ional.<\/p>\n

La tumorile cerebrale malgine este nevoie de tratament adjuvant. Aceasta const\u0103 \u00een radioterapie \u015fi chimioterapie. Tratamentul poate fi f\u0103cut concomitent \u00een prim\u0103 faz\u0103, urm\u00e2nd ca apoi pacientul s\u0103 continue serialul de chimioterapie pentru \u00eenc\u0103 c\u00e2teva luni.<\/p>\n

Tratamentul chimioterapic este ales \u00een func\u0163ie de aspectul pathologic al tumorii \u015fi a testelor moleculare. Subliniez aici importan\u0163a testelor moleculare, a\u015fa cum am spus \u015fi mai devreme, aceasta ne arat\u0103 \u201cagresivitatea tumorii\u201d indic\u0103 un r\u0103spuns terapeutic, poten\u0163ialul de recidiv\u0103.<\/p>\n

Exit\u0103 acum, fa\u0163\u0103 de acum 10 ani, mai multe op\u0163iuni terapeutice, mai ales de la introducerea terapiei targetat\u0103 (anticorpi-monoclonali), care au dus la \u00eembun\u0103t\u0103\u0163irea supravie\u0163uirii pacien\u0163ilor.<\/p>\n

Sunt acum aflate \u00een studii diferite abord\u0103ri terpateutice, cum ar fi tratament targetate pentru muta\u0163ia IDH, imunoterapia sau vaccinarea pacien\u0163ilor cu aceste tumori. Cred c\u0103 \u00een urm\u0103torii ani vom vedea o evolu\u0163ie spectaculoas\u0103 a tratamentelor adresate acestor terapii.<\/p>\n","protected":false},"excerpt":{"rendered":"

Interviu cu Dr. Dan Mitrea \u2013 Clinica Neuroaxis Ce este neuro-oncologia? Neuro-oncologia este o supraspecializare recent ap\u0103rut\u0103 \u00een Rom\u00e2nia, ce adreseaz\u0103 patologiile tumorale ale sistemului nervos. Aceasta presupune diagnosticarea, tratarea […]<\/p>\n","protected":false},"author":9,"featured_media":9701,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[276,277],"tags":[],"class_list":["post-9692","post","type-post","status-publish","format-standard","has-post-thumbnail","category-interviu","category-neurologie"],"yoast_head":"\nNeuro-oncologia, specialitate aflat\u0103 la grani\u0163a dintre Neurologie, Neurochirurgie, Oncologie \u015fi Radioterapie<\/title>\n<meta name=\"description\" content=\"Neuro-oncologia, specialitate aflat\u0103 la grani\u0163a dintre Neurologie, Neurochirurgie, Oncologie \u015fi Radioterapie - Interviu Dr. Dan Mitrea \u2013 Clinica Neuroaxis\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/jurmed.ro\/medici\/neuro-oncologia-specialitate-aflata-la-granita-dintre-neurologie-neurochirurgie-oncologie-si-radioterapie\/\" \/>\n<meta property=\"og:locale\" content=\"ro_RO\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Neuro-oncologia, specialitate aflat\u0103 la grani\u0163a dintre Neurologie, Neurochirurgie, Oncologie \u015fi Radioterapie\" \/>\n<meta property=\"og:description\" content=\"Neuro-oncologia, specialitate aflat\u0103 la grani\u0163a dintre Neurologie, Neurochirurgie, Oncologie \u015fi Radioterapie - 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