António Quintela – Maria Joaquina Mauricio
A decisão terapêutica deve ser individualizada e suportada num racional sólido para que o benefício clínico seja máximo com o mínimo de toxicidade. A melhor decisão deverá ser centrada num doente único, integrando o seu estado geral, idade e comor - bi lidades, submetido ou não a tratamentos prévios, no qual se enxertou uma doença histologicamente distinta e categorizada num determinado grupo de risco. Actual men - te o tratamento dos doentes com CCRm de células claras pode ser dividido em duas grandes categorias:
1) Doentes previamente não tratados, refractários ou intolerantes a imunoterapia. 2) Doentes que falharam ao tratamento com VEGF. Globalmente as linhas de co ndu ção da nossa decisão são suportadas em evidência científica o que nos permite resumi-las da seguinte forma:
7.2.1. Terapêutica de 1ª Linha
– Doentes com prognóstico bom ou intermédio
Alguns doentes têm uma doença indolente pelo que se recomenda um período de observação antes de iniciar tratamento sistémico, particularmente se o crescimento tumoral é lento e o doente está assintomático.
Três opções terapêuticas estão disponíveis e aprovadas com base na melhoria da SLP: bevacizumab +IFN, sunitinib ou pazopanib.
– Doentes com prognóstico mau
Temsirolimus é a única droga com evidência nivel 1 para este grupo de doentes.
Porém, quer o sunitinib quer o sorafenib, podem ser opções terapêuticas válidas. Para alguns doentes os melhores cuidados sintomáticos podem ser a melhor proposta de abordagem.
7.2.2. Terapêutica de 2ª Linha
Após 1ª linha com TKI, quer o everolimus quer o axitinib são activos. Ambas as drogas mostraram melhoria de SLP mas não da SG. Baseado em estudos de fase III o sorafenib pode ser uma opção. A evidência de que um inibidor tirosina cinase é activo em 2ª linha após citoquinas foi demonstrada para o sorafenib, pazopanib, axitinib e mesmo para o sunitinib.
7.2.3. Terapêutica de 3ª Linha
Actualmente podem acontecer dois cenários:
Doentes já tratados com 2 TKI (ou um TKI e bevacizumab) para os quais se recomenda o everolimus. Doentes tratados com VEGF e mTOR, para os quais se
recomenda o sorafenib. Pode também tentar-se um outro TKI ou tentar nova men - te (rechallenge) o mesmo TKI.
Tabela 2: Algoritmo para o tratamento sistémico do CCRm Células Claras.
Linha de tratamento Grupo de risco Standard Opções
1ª linha
Bom/intermédio
Sunitinib Beva + IFN Pazopanib
Altas doses de IL2 Sorafenib Beva + IFN
Mau Temsirolimus Sunitinib
Sorafenib 2ª linha Pós citoquinas Axitinib Sorafenib Pazopanib Sunitinib Pós TKI Axitinib Everolimus Sorafenib
3ª linha Pós 2 TKI Everolimus
Pós TKI e m-TOR Sorafenib
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