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Ðàê ïðåäñòàòåëüíîé æåëåçû
Äîáðûé äåíü, óâàæàåìûå êîëëåãè!
Ïðîøó âàñ ïðîêîíñóëüòèðîâàòü î òàêòèêå ëå÷åíèÿ ìîåãî îòöà. Îòöó 72 ãîäà. Èç õð. çàáîëåâàíèé - ÈÁÑ, ïîñòîÿííàÿ ôîðìà ÔÏ. Ïîñòîÿííî ïðèíèìàåò òîðâàêàðä 10ìã, êîíêîð 5 ìã, âàðôàðèí 5 ìã. Îñåíüþ 2017 ãîäà ïðè îáñëåäîâàíèè áûëè îáíàðóæåíû âûñîêèå öèôðû ÏÑÀ. Óðîëîãîì íàïðàâëåí â ñòàöèîíàð äëÿ ïðîâåäåíèÿ áèîïñèè ÏÆ. Çàêëþ÷åíèå: Ìàêðîñêîïè÷åñêîå îïèñàíèå: 12 êóñî÷êîâ òêàíè ïðîñòàòû: 12 áåëåñûõ ñòîëáèêîâ. Ìèêðîñêîïè÷åñêîå îïèñàíèå: 1-2;9;11. Ôðàãìåíòû òêàíè ïðåäñòàòåëüíîé æåëåçû ñ î÷àãîâîé æåëåçèñòî-ìûøå÷íîé ãèïåðïëàçèåé ôîêóñàìè àöèíàðíîé àäåíîêàðöèíîìû ñóììà Ãëèñîíà 6 (3+3), çàíèìàþùèå äî 1-3% ïëîùàäè áèîïòàòîâ. 6;12. Ôðàãìåíòû òêàíè ïðåäñòàòåëüíîé æåëåçû ñ ðàçðàñòàíèÿìè àöèíàðíîé êàðöèíîìû ñóììà Ãëèñîíà (4+3), çàíèìàþùèå äî 40% ïëîùàäè áèîïòàòîâ. 3-5;7-8;10. Ôðàãìåíòû òêàíè ïðåäñòàòåëüíîé æåëåçû ñ î÷àãîâîé æåëåçèñòî-ìûøå÷íîé ãèïåðïëàçèåé ôîêóñàìè âûñîêîé ÏÈÍ. Ìîðôîëîãè÷åñêîå çàêëþ÷åíèå: Àöèíàðíàÿ êàðöèíîìà ïðåäñòàòåëüíîé æåëåçû, 3 ïðîãíîñòè÷åñêîé ãðóïïû, ñóììà Ãëèñîíà (4+3), çàíèìàþùèå äî 40% ïëîùàäè áèîïòàòîâ. Ïðîâîäèëîñü ÊÒ ñ êîíòðàñòîì ìàëîãî òàçà, ðåíòãåíîãðàôèÿ ÏÊÎÏ, ÊÒ ÏÊÎÏ, ðàäèîèçîòîïíîå ñêàíèðîâàíèå êîñòåé ñêåëåòà - Ìåòàñòàçû íå îáíàðóæåíû íèãäå. Âðà÷, ïðîâîäèâøèé îáñëåäîâàíèå, ê ñîæàëåíèþ äàòü ïðÿìóþ ðåêîìåíäàöèþ îòêàçàëñÿ. Ñêàçàë, ÷òî óñïåõ îïåðàöèè 50/50, âñþ òêàíü óáðàòü íå óäàñòñÿ, âåëèêà îïàñíîñòü èíñóëüòà è èíòðàîïåðàöèîííîé ñìåðòè. Åñëè áóäåò êîíñåðâàòèâíîå ëå÷åíèå - ó íåãî åñòü 5-10 ëåò.  ñâÿçè ñ ýòèì, ïðîøó äàòü ñîâåò - êàê ëó÷øå ïîñòóïèòü â äàííîì ñëó÷àå? Çàðàíåå áëàãîäàðåí çà îòâåò! |
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Áðàõèòåðàïèÿ?
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Ñïàñèáî!
Ëó÷åâàÿ òåðàïèÿ, â ò.÷. áðàõèòåðàïèÿ, âðà÷îì ïî÷åìó-÷òî íå ðàññìàòðèâàëàñü.  ðàçãîâîðå îí ðàññìàòðèâàë òîëüêî îïåðàöèþ è ãîðìîíàëüíóþ òåðàïèþ. Âû íå â êóðñå, êòî â Ìîñêâå çàíèìàåòñÿ áðàõèòåðàïèåé, êóäà ìîæíî ïî ýòîìó ïîâîäó îáðàòèòüñÿ? |
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Ê ñîæàëåíèþ, íå çíàþ.  Ïèòåðå - ýòî 122-ÿ áîëüíèöà, Â.Ï.Ãîðåëîâ. Äåëàþò â Îáíèíñêå.  Ìîñêâå, íàâåðíîå, â êàêèõ-òî êëèíèêàõ ÔÌÁÀ. Íà÷àëî ãîäà, êâîòû åñòü.
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 Ìîñêâå ó íàñ â ÐÍÖÐÐ ïðîâîäÿò. Çàïèøèòåñü íà ïðèåì ê Öèáóëüñêîìó Àëåêñåþ Äìèòðèåâè÷ó
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Êñòàòè, à ïî÷åìó îòåö íà âàðôàðèíå? ÍÎÀÊ áûëè áû áåçîïàñíåå. Èëè åñòü êàêèå-òî äîïîëíèòåëüíûå îñîáåííîñòè?
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Ñïàñèáî áîëüøîå!
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Äà. Ýòî èìåííî ò.í. "ñîâêîâûå" îñîáåííîñòè. À òî÷íåå - öåíà âîïðîñà. Ëüãîò ó îòöà íåò, à óáåäèòü åãî ïîêóïàòü õîðîøèå ïðåïàðàòû - êðàéíå òðóäíî. Îíè ñ ìàòóøêîé ïîëðàéîíà îáõîäÿò, âûáèðàÿ ñåáå íàèäåøîâåéøèå ïðåïàðàòû. Íà ìîè íåîäíîêðàòíûå ïðåäëîæåíèÿ ïîêóïàòü ñàìîìó - ãíåâíûé êîììóíèñòè÷åñêèé îòêàç, ÷òî, ìîë ýòî ãîñóäàðñòâî äîëæíî "ïðèñòðóíèòü" àïïåòèòû ôàðìêîìïàíèé. Âîò îòòóäà è âàðôàðèí äî ñèõ ïîð.
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Âñå òðè ÍÎÀÊ, çàðåãèñòðèðîâàííûå â ÐÔ - æèçíåííîâàæíûå, ò.å. ïî "êîììóíèñòè÷åñêèì ïîíÿòèÿì" äîëæíû ïðåäîñòàâëÿòüñÿ áåñïëàòíî ïî ëüãîòå. À òî, ÷òî ëüãîò íåò - íå ïðàâäà, èõ íàäî ïðîñòî îôîðìèòü, ïîâîäîâ äëÿ èíâàëèäíîñòè ó Âàøåãî îòöà äîñòàòî÷íî. "Ìû íå ìîæåì æäàòü ìèëîñòåé îò ãîñóäàðñòâà, âçÿòü èõ ó íåãî - íàøà çàäà÷à!"
Ïîñòàðàéòåñü äîíåñòè äî íåãî ìûñëü, ÷òî âàðôàðèí ñàì ïî ñåáå äîñòàòî÷íî îïàñåí, à óæ â âèäå ñàìûõ äåøåâûõ äæåíåðèêîâ íåèçâåñòíîãî êà÷åñòâà - òåì áîëåå. Ýòî ðåàëüíî ìîæåò áûòü âîïðîñ æèçíè è ñìåðòè. (Êàê ÿ ïîíèìàþ, è ÌÍÎ êîíòðîëèðóåòñÿ îò ñëó÷àÿ ê ñëó÷àþ?). |
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Íîðìàëüíî ñ êîíòðîëåì. Ìíå ïðèøëîñü ïîäàðèòü åìó êîàãó÷åê (íå çíàåò, ñêîëüêî ñòîèò). Âàðôàðèí áåðåò íèêîìåäîâñêèé.
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Êîàãó÷åê ïîìîãàåò ïàöèåíòàì áîëåå ÷àñòî ïðåáûâàòü â òåðàïåâòè÷åñêîì äèàïàçîíå, ÷òî àññîöèèðóåòñÿ ñ èäåíòè÷íîé åôôåêòèâíîñòüþ/áåçîïàñíîñòüþ ñ ÄÎÀÊ - â òàáëèöå, ÷àñòü TTR > 65
[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
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 ñâåòå îáíàðóæåíèÿ ðàêà ïðåäñòàòåëüíîé æåëåçû, àïèêñàáàí ïîõîæå îáëàäàåò íàèëó÷øèì ïðîôèëåì ýôôåêòèâíîñòü/áåçîïàñíîñòü ïî ñðàâíåíèþ ñ âàðôàðèíîì è èíûìè DOAC:
Compared with warfarin, rates of bleeding (hazard ratio [95% confidence interval]) were similar in rivaroxaban (1.09 [0.79, 1.39]) and dabigatran (0.96 [0.72, 1.27]) users, whereas apixaban users experienced lower rates (0.37 [0.17, 0.79]). Rates of ischemic stroke did not differ among anticoagulant users. Compared with warfarin, rate of VTE (hazard ratio [95% confidence interval]) was lower among rivaroxaban (0.51 [0.41, 0.63]), dabigatran (0.28 [0.21, 0.38]), and apixaban (0.14 [0.07, 0.32]) users. In head-to-head comparisons among DOACs, dabigatran users had lower rates of VTE than rivaroxaban users; apixaban users had lower rates of VTE and severe bleeding than rivaroxaban users. --- Blood Adv. 2018 Feb 13;2(3):200-209. Comparative effectiveness of direct oral anticoagulants and warfarin in patients with cancer and atrial fibrillation. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |