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Munasarjasyöpä
Käypä hoito -suositus |  Julkaistu: 2012-04-26   | Tila: voimassa  |  Aihepiiri(t): Endokrinologia, Kuntoutus, Naistentaudit ja synnytykset, Syöpätaudit
Mikä on Käypä hoito -suositus?
Suomalaisen Lääkäriseuran Duodecimin ja Suomen Gynekologiyhdistyksen asettama työryhmä
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Munasarjasyöpä

Käypä hoito
26.4.2012
Suomalaisen Lääkäriseuran Duodecimin ja Suomen Gynekologiyhdistyksen asettama työryhmä

Koosteet

Potilaalle

Miten viitata Käypä hoito -suositukseen? «»1

Keskeinen sisältö

  • Ilmaantuvuus (8.2/100 000) ei ole 1990-luvulta lähtien muuttunut.
  • Munasarjasyövällä ei ole selviä, spesifisiä oireita.
  • Vatsan alueen pitkittyneistä oireista kärsivillä naisilla tulisi muistaa munasarjasyövän mahdollisuus.
  • BRCA1/2-geenivirheen kantajille suositellaan ehkäisevää munanjohtimien ja munasarjojen poistoa naisen täytettyä 40 vuotta.
  • Hoidon perusta on leikkaus, jolla pyritään täydelliseen kasvainmassan poistoon (optimaalinen leikkaustulos).
  • Jäännöskasvaimen määrä on tärkein ennustetekijä.
  • Paklitakselin ja karboplatiinin yhdistelmä on paras ensivaiheen solunsalpaajahoito.
  • Bevasitsumabin liittäminen ensihoitoon voi pidentää levinneen taudin etenemätöntä aikaa.
  • Munasarjasyövällä on huomattava uusiutumistaipumus.
  • Rutiininomaisen seurannan ei ole osoitettu pidentävän munasarjasyövän sairastaneiden oireettomien potilaiden elinikää.

Tavoitteet

  • Suosituksen tavoitteena on keskittää hoito asiantunteviin yksiköihin ja siten yhdenmukaistaa munasarjasyövän hoitoa ja parantaa tuloksia.

Kohderyhmät

  • Suositus on tarkoitettu sekä perusterveydenhuoltoon että erikoissairaanhoitoon.

Epidemiologia

Ilmaantuvuus

Taulukko 1. Munasarjasyöpien histologinen jakautuminen.
Histologia  %
Ks. artikkelit «FIGO 25th Annual report on the results of treatment in gynecological cancer. Int J Gynecol Obstet 2003;83:1-230»2, «Morrow CP. Malignant and borderline epithelial tumors of ovary: clinical features, staging, diagnosis, intraoperative assessment and review of management. In: Gynelogic Oncology (ed. Coppleson M), siv»3, «Pectasides D, Pectasides E, Kassanos D. Germ cell tumors of the ovary. Cancer Treat Rev 2008;34:427-41 »4.
Epiteliaaliset kasvaimet (karsinoomat) 92–96
– Seroosi 40
– Endometrioidi 10–24
– Musinoosi 3–10
– Kirkassolukarsinooma 5–11
– Erilaistumaton 6
– Sekamuoto 5
– Pahanlaatuinen Brennerin tuumori alle 0.1
Itusolukasvaimet 3–5
Sukupienakasvaimet 5–10

Luokitus

Taulukko 2. Munasarjasyövän levinneisyysluokittelu (FIGO) 2009 «FIGO 25th Annual report on the results of treatment in gynecological cancer. Int J Gynecol Obstet 2003;83:1-230»2.
Luokka Levinneisyys
Aste I Kasvain on rajoittunut munasarjoihin.
IA Kasvain on vain toisessa munasarjassa. Munasarjan kapseli on ehjä. Pinnassa ei ole kasvainta. Askiteksessa ja huuhtelunäytteissä ei ole kasvainsoluja.
IB Kasvain on molemmissa munasarjoissa. Munasarjojen kapselit ovat ehjät. Pinnassa ei ole kasvainta. Askiteksessa ja huuhtelunäytteissä ei ole kasvainsoluja.
IC Toisessa tai kummassakin munasarjassa on kasvain. Lisäksi munasarjan kapseli on revennyt, munasarjan pinnassa on kasvainta tai askiteksessa tai huuhtelunäytteissä on kasvainsoluja.
Aste II Toisessa tai kummassakin munasarjassa ja lantion alueella on kasvain.
IIA Kasvain on levinnyt kohtuun tai munanjohtimiin. Askiteksessa ja huuhtelunäytteissä ei ole kasvainsoluja.
IIB Kasvainta on muissa lantion kudoksissa muttei kasvainsoluja askiteksessa eikä huuhtelunäytteissä.
IIC Kasvain on levinnyt muihin lantion elimiin, ja askiteksessa tai huuhtelunäytteissä on kasvainsoluja.
Aste III Toisessa tai kummassakin munasarjassa on kasvain. Kasvainta on peritoneumissa lantion ulkopuolella tai alueellisissa imusolmukkeissa. Maksassa on pinnallisia etäpesäkkeitä.
IIIA Lantion alueella on primaarikasvain, ja sen leviäminen lantion ulkopuolelle peritoneumiin on mikroskooppisesti varmistettu. Imusolmukkeissa ei ole kasvainkudosta.
IIIB Vatsaontelon pesäkkeet ovat alle 2 cm:n kokoisia, eikä imusolmukkeissa ole kasvainkudosta.
IIIC Vatsaontelon pesäkkeet ovat yli 2 cm:n kokoisia, tai imusolmukkeissa on kasvainkudosta.
Aste IV Toisessa tai kummassakin munasarjassa on kasvain. Vatsaontelon ulkopuolella on etäpesäkkeitä. Pleuranesteessä on kasvainsoluja ja maksassa parenkyymipesäkkeitä.

Suojatekijät

Riskitekijät

Seulonta

  • Seulonnan tavoitteena on löytää munasarjasyöpä varhaisvaiheessa, koska taudin levinneisyysaste toteamisen aikaan vaikuttaa oleellisesti ennusteeseen. Ks. kohta Ennuste «»2.
  • Seulonnan päätarkoitus on vähentää kuolleisuutta.
  • Seulonnassa käytössä olevat menetelmät ovat
    • gynekologinen rektovaginaalinen palpaatiotutkimus
    • transvaginaalinen kaikukuvaus
    • CA 125:n määritys.
  • Mikään näistä menetelmistä yksinään tai yhdistettynä ei ole riittävän herkkä eikä tarkka.
  • Toistaiseksi ei ole näyttöön perustuvaa tietoa siitä, että oireettoman väestön tai suuressa sairastumisvaarassa olevien naisten seulonnat vaikuttaisivat heidän munasarjasyöpäkuolleisuuteensa «Toistaiseksi ei ole olemassa näyttöön perustuvaa tietoa siitä, että oireettoman väestön tai suuressa sairastumisvaarassa olevien naisten seulonnat vaikuttaisivat heidän munasarjasyöpäkuolleisuuteensa.»D.
    • Sellaisille naisille, joilla on todettu BRCA1- tai BRCA2-mutaatio, työryhmä suosittaa vuosittaisia gynekologikäyntejä, jotka sisältävät gynekologisen tutkimuksen, transvaginaalisen kaikukuvauksen, CA 12-5:n määrityksen ja erityisesti sairastumisriskin vähentämiseen tähtäävien toimenpiteiden suunnittelun. Vastaavaa seurantaa suositellaan myös niille naisille, joiden suvusta ei ole pystytty tunnistamaan alttiusmutaatioita, mutta perinnöllisyyslääkäri arvioi naisen kuuluvan riskiryhmään.

Oireet

Taulukko 3. Munasarjasyövän aiheuttamia oireita ja kliinisiä löydöksiä levinneisyyden mukaan.
Varhaisvaihe ( %) Levinnyt vaihe ( %)
Ks. artikkelit «Flam F, Einhorn N, Sjövall K. Symptomatology of ovarian cancer. Eur J Obstet Gynecol Reprod Biol 1988;27:53-7 »13, «Chan YM, Ng TY, Lee PW ym. Symptoms, coping strategies, and timing of presentations in patients with newly diagnosed ovarian cancer. Gynecol Oncol 2003;90:651-6 »14.
Lantion tai vatsan kasvain 40 75
Vatsan turpoaminen (askites) 27 24–30
Vatsakipu 17 11
Suolisto-oireet (pahoinvointi, ummetus) 14 24
Verenvuoto 12 12
Virtsavaivat 10 5
Heikotus tai kuume 4 15
Hengenahdistus tai selkäkipu 2 8
Laihtuminen 7
Väsymys ei tietoa

Diagnostiikka

Kasvainmerkkiaineet

Kaikukuvaukset

RMI:n (Risk of Malignancy Index) käyttö munasarjakasvaimen erotusdiagnostiikassa

  • Yhdistämällä menopaussivaihe (pre- tai postmenopaussi), kaikukuvauslöydös ja CA 125 -arvo kaavaan "MP-vaihe x kaikukuvausindeksi x CA 125 -arvo" saadaan RMI-arvo.
  • Arvo yli 200 viittaa pahanlaatuiseen kasvaimeen. Ks. taulukko «RMI:n (Risk of Malignancy Index) laskentaperusteet.»4.
  • RMI-arvoa voidaan käyttää pyrittäessä keskittämään pahanlaatuisten kasvainten leikkaukset gynekologisen onkologian keskuksiin.
Taulukko 4. RMI:n (Risk of Malignancy Index) laskentaperusteet.
Pisteet
Ks. artikkelit «Tingulstad S, Hagen B, Skjeldestad FE ym. Evaluation of a risk of malignancy index based on serum CA125, ultrasound findings and menopausal status in the pre-operative diagnosis of pelvic masses. Br J»29, «Tingulstad S, Hagen B, Skjeldestad FE ym. The risk-of-malignancy index to evaluate potential ovarian cancers in local hospitals. Obstet Gynecol 1999;93:448-52 »30.
Vaihe Premenopaussi 1
Postmenopaussi 4
Kaikukuvauslöydös Jos yksi seuraavista tai simplex-kysta 1
Jos kaksi tai useampia seuraavista: 4
– monilokeroisuus
– kiinteät alueet, yli 3 mm:n papillit
– askites
– molemminpuolinen muutos
CA 125 -arvo

ROMA (Risk of Malignancy Algorithm) munasarjasyöpää epäiltäessä

Kerros- ja magneettikuvaukset

Laparoskopia

Rajalaatuiset (borderline, semimaligni) kasvaimet

Leikkaushoito

Solunsalpaajahoito

Ennuste

Epiteliaalinen munasarjasyöpä

Leikkaushoito

Ensileikkaus

Ensileikkauksen tekniikka

  1. Riittävän näkyvyyden takaamiseksi tehdään alakeskiviilto.
  2. Peritoneaalinesteen määrä mitataan ja siitä otetaan sytologiset näytteet. Jos askitesta ei ole, otetaan huuhtelunäytteet (fossa Douglasi, parakoliset ja palleakaarten alaiset tilat). Näytteet voidaan tutkia erillisinä tai yhdessä.
  3. Kaikki vatsakalvon pinnat visualisoidaan ja palpoidaan huolellisesti etäpesäkkeisen taudin toteamiseksi, samoin palleakaaret, suoliston seroosa ja suolilieve. Kaikista epäilyttävistä kohdista (myös arpikiinnikkeistä) otetaan biopsianäyte.
  4. Vatsapaita tarkastetaan huolellisesti ja ainakin infrakolinen osa poistetaan. Lisäksi umpilisäke poistetaan «Leblanc E, Querleu D, Narducci F ym. Surgical staging of early invasive epithelial ovarian tumors. Semin Surg Oncol 2000;19:36-41 »52.
  5. Kohtu ja sen sivuelimet poistetaan ekstrafaskiaalisesti.
  6. Mahdollisuuksien mukaan resekoidaan kaikki jäljellä oleva kasvainkudos.
  7. Jos kasvain on alun perin vain lantion tai munasarjojen alueella ja kaikki kasvainkudos on saatu poistetuksi, otetaan lisäksi
    • peritoneumbiopsianäytteet
      • fossa Douglasista
      • molemmin puolin lantion sivuseinämistä
      • molemmin puolin parakolisista tiloista
      • palleakaarista.
  8. Imusolmukkeet

Sytoreduktio ("debulking")

Ultraradikaali kirurgia

Hedelmällisyyden säilyttävä kirurgia

Leikkaus neoadjuvanttihoidon jälkeen (intervallileikkaus)

Uusintaleikkaukset

Levinneisyyden uusintamääritys (restaging)

Sekundaarinen sytoreduktio

Uusiutuneen taudin leikkaushoito

Palliatiivinen kirurgia

  • Palliatiivinen leikkaus tehdään useimmiten suoli- tai virtsatietukoksen aiheuttamien oireiden vuoksi elämänlaadun parantamiseksi. Eniten palliatiivisesta leikkauksesta hyötyvät sellaiset potilaat, joilla on hitaasti kasvavan tuumorin aiheuttama tukos.

Solunsalpaajahoito epiteliaalisessa munasarjasyövässä

Sädehoito epiteliaalisessa munasarjasyövässä

  • Sädetyksen ja radioisotooppien merkityksestä ensivaiheen hoidossa ei ole riittävää näyttöä.

Uusiutuneen epiteliaalisen munasarjasyövän solunsalpaajahoito

Solunsalpaajille herkät kasvaimet

Solunsalpaajille resistentit kasvaimet

Solunsalpaajat

Ennuste ja ennustetekijät

Ei-epiteliaaliset munasarjakasvaimet

Itusolukasvaimet

Dysgerminooma

Muut itusolukasvaimet

Sukupienakasvaimet

Granuloosasolukasvaimet

Sertolin ja Leydigin solukasvaimet

Palliatiivinen hoito

Hoidon porrastus

Psykososiaalinen tuki ja kuntoutus

  • Munasarjasyöpään sairastuminen aiheuttaa vaikean psyykkisen kriisin, joka heijastuu muutoksena kaikilla elämän osa-alueilla. Ulkopuolinen apu on usein tarpeen «Hipkins J, Whitworth M, Tarrier N ym. Social support, anxiety and depression after chemotherapy for ovarian cancer: a prospective study. Br J Health Psychol 2004;9:569-81 »133.
  • Vakava sairaus ja raskaat hoidot vaikuttavat potilaan minäkuvaan naisena, seksuaaliseen identiteettiin, parisuhteeseen ja perhe-elämään.
  • Sopeutumiseen vaikuttavat ratkaisevasti taudin luonne, kulku, ennuste, potilaan ikä ja elämäntilanne ja aiemmat psyykkiset voimavarat.
  • Myös syöpään sairastuneen omaiset tarvitsevat usein tukea.
  • Psykososiaalisen tuen ja kuntoutuksen perusta ovat hoitohenkilökunnan ja perheen antama tuki, syöpäjärjestöjen ylläpitämät neuvontapalvelut (puhelinpalvelut, vastaanotot), ensitietokurssit, sopeutumisvalmennuskurssit ja kuntoutuspalvelut.

Seuranta

Suomalaisen Lääkäriseuran Duodecimin ja Suomen Gynekologiyhdistyksen asettama työryhmä

Munasarjasyöpä-suosituksen historiatiedot «Munasarjasyöpä, Käypä hoito -suosituksen historiatiedot»6

Puheenjohtaja:

Arto Leminen, dosentti, naistentautien ja synnytysten sekä gynekologisen onkologian erikoislääkäri, osastonylilääkäri; HYKS Naistenklinikka

Jäsenet:

Annika Auranen, LT, naistentautien ja synnytysten sekä gynekologisen onkologian erikoislääkäri; TYKS Naistenklinikka

Ralf Bützow, dosentti, naistentautien ja synnytysten sekä patologian erikoislääkäri, osastonylilääkäri; HUSLAB, patologian vastuualue

Sakari Hietanen, dosentti, naistentautien ja synnytysten sekä gynekologisen onkologian erikoislääkäri, osastonylilääkäri; TYKS Naistenklinikka

Marja Komulainen, LT, naistentautien ja synnytysten sekä gynekologisen onkologian erikoislääkäri, apulaisylilääkäri; KYS:n naistentautien ja synnytysten palveluryhmä

Tapio Kuoppala, dosentti, naistentautien ja synnytysten sekä gynekologisen onkologian erikoislääkäri; TAYS:n naistentautien ja synnytysten vastuualue

Johanna Mäenpää, professori, naistentautien ja synnytysten sekä gynekologisen onkologian erikoislääkäri, ylilääkäri; TaY/TAYS:n naistentautien ja synnytysten vastuualue

Ulla Puistola, dosentti, naistentautien ja synnytysten sekä gynekologisen onkologian erikoislääkäri osastonylilääkäri; OYS Naistenklinikka

Maarit Vuento, LT, naistentautien ja synnytysten sekä gynekologisen onkologian erikoislääkäri, vt. osastonylilääkäri; TAYS:n Naistentautien ja synnytysten vastuualue

Piia Vuorela, Käypä hoito -toimittaja, dosentti, naistentautien ja synnytysten erikoislääkäri; HYKS Naistenklinikka

Merja Yliskoski, LT, naistentautien ja synnytysten sekä gynekologisen onkologian erikoislääkäri, palliatiivisen lääketieteen erityispätevyys, osastonylilääkäri; Keski-Suomen keskussairaala, Jyväskylä, naistentaudit ja synnytykset

Sidonnaisuudet

Annika Auranen: Osallistunut ulkomaiseen koulutustilaisuuteen (GlaxoSmithKline, Sobi, Novo Nordisk). Osallistunut lääkealan yrityksen asiantuntijatyöryhmään (AstraZeneca).

Ralf Bützow: Ei sidonnaisuuksia.

Sakari Hietanen: Toiminut lääkealan yritysten tilaisuuksissa asiantuntijana ja saanut niistä asiantuntijapalkkion (Roche, MSD, Amgen). Ollut kutsuttuna luennoitsijana lääkealan yritysten tilaisuuksissa (Roche, MSD, Amgen SOBI, GSK).

Marja Komulainen: Osallistunut lääkealan yritysten (Biovitrum, Sobi, Roche) rahoittamana ulkomaan kongressimatkoihin. Toiminut asiantuntijana lääkealan yritykselle ja saanut siitä palkkion (Schering-Blough).

Tapio Kuoppala: Osallistunut lääkealan yritysten kustantamiin lääketieteellisiin kongresseihin (Roche, Leopharma, Jansen-Cilag).

Arto Leminen: Toiminut lääkealan yritysten asiantuntijana, luennoitsijana ja koulutustilaisuuksissa (Biovitrum, Boehringer-Ingelheim, Sanofi-aventis, Roche, Sobi, Leo). Osallistunut kongressimatkoille lääkealan yritysten rahoittamana (Biovitrum, Boehringer-Ingelheim, Sanofi-aventis, Roche, Sobi, Leo).

Johanna Mäenpää: Luennoinut lääkealan yrityksen järjestämissä koulutustilaisuuksissa (Sanofi-aventis). Suunnitellut ja toteuttanut lääkealan yrityksen kanssa tutkimusseminaareja (Sanofi-aventis). Osallistunut työnantajan nimeämänä edustajana ulkomaisiin kokouksiin lääkealan yritysten kustantamana (Suomen Roche, GSK, SOBI). Toiminut asiantuntijana lääkealan yrityksille (Astra Zeneca, Schering-Plough, Amgen, Roche, MSD, Janssen-Cilag). Työnantaja on saanut lääkealan yritykseltä apurahan tutkimukseen (Roche).

Ulla Puistola: Osallistunut tai luennoinut kongresseissa lääkealan yrityksen kustantamana (Astra Zeneca, Boehringer Ingelheim, GSK, Amgen, Roche, Sanofi Aventis, Sanofi Pasteur MSD, MSD). Toimii Advisory Boardin jäsenenä (Astra Zeneca, Roche, GSK), Suomen syöpäyhdistyksen hallituksessa, Pohjois-Suomen syöpäyhdistyksen hallituksessa ja NSGO-CTU Executive Boardin jäsenenä.

Maarit Vuento: Toiminut luennoitsijana lääkealan yrityksen järjestämissä koulutustilaisuuksissa (Bayer Oy). Osallistunut ulkomaiseen kongressiin TAYS:n naistentautien ja synnytysten vastuualueen nimettynä virallisena edustajana (Amgen AB, AstraZeneca Oy, Leiras Oy, MSD Finland Oy, Roche Oy, Sobi Oy).

Piia Vuorela: Ei sidonnaisuuksia.

Merja Yliskoski: Osallistunut työantajan määräämänä ulkomaisiin kongresseihin lääkealan yritysten kustantamana (GSK, Swedish Orphan Biovitrium). Toiminut asiantuntijana lääkealan yrityksen neuvottelukunnassa (Amgen, Swedish Orphan Biovitrium).

Kirjallisuusviite

Munasarjasyöpä (online). Suomalaisen Lääkäriseuran Duodecimin ja Suomen Gynekologiyhdistyksen asettama työryhmä. Helsinki: Suomalainen Lääkäriseura Duodecim, 2012 (viitattu pp.kk.vvvv). Saatavilla internetissä: www.kaypahoito.fi

Tarkemmat viittausohjeet: «http://www.kaypahoito.fi/web/kh/viittaaminen»3

Vastuun rajaus

Käypä hoito -suositukset ovat parhaiden asiantuntijoiden laatimia yhteenvetoja yksittäisten sairauksien diagnostiikan ja hoidon vaikuttavuudesta. Ne eivät korvaa lääkärin tai muun terveydenhuollon ammattilaisen omaa arviota yksittäisen potilaan parhaasta mahdollisesta diagnostiikasta ja hoidosta hoitopäätöksiä tehtäessä.

Tiedonhakukäytäntö

Systemaattinen kirjallisuushaku on hoitosuosituksen perusta. Lue lisää artikkelista khk00007

Kirjallisuutta

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