Annales D Urologie最新文献

The first medical consultation with the urologist is the occasion to explain to the patient the importance of the initial PSA value, the periodic PSA measurements and the need of prostate biopsy for definitive confirmation. The next consults will focus on basic facts concerning the cancer of the prostate in general and the tumor of the patient in particular, and to present to the patient in a clear and objective way the main advantages and drawbacks of the various therapeutic options. These medical consults are key elements for the quality of physician-patient relationships, as each of them will be an opportunity to provide the best possible information to a patient which is often anxious.

The pretreatment PSA level, the Gleason score, the presence of lymph-node metastases, the status of surgical positive margins are poor pathological risk factors for patients who have a pathologic stage T3 prostate cancer. The increase in PSA level during the year prior to diagnostic is associated with the risk of death due to prostate cancer following radical prostatectomy or external beam radiation therapy. The assessment of locoregional extension is indicated for such patients. The extended pelvic lymphadenectomy remains the most accurate procedure for a correct staging of the detection of nodal involvement in these patients with high-risk localized prostate cancer. For such patients with a high-risk of progression and, whose the life expectancy is greater than 10 years, treatment must be a combined modality therapy since radical prostatectomy alone correlates with a poor clinical outcome. Adjuvant hormonal therapy following local curative treatment by prostatectomy (or radiotherapy) needs to be often considered. Collegial decision-making is by far the most appropriate setting for the discussion among medical specialists of these complex clinical cases for patients often having associated medical conditions and whose adjuvant treatment will have a significant impact of their future quality of life.

Difficult clinical cases of locally advanced prostate cancer at high-risk of progression should be discussed during a collegial decision-making process with different clinical specialists (surgeon, radiotherapist, oncologist, chemotherapist). Scientific consensus exists to give an adjuvant therapy after initial curative local treatment in patients with unfavourable prognostic features. For patients with locally advanced prostate cancer extending beyond the capsule (pT3) or with positive surgical margins, studies have shown that immediate postoperative radiotherapy is to eradicate the microscopic disease left in the surgical bed. Studies have shown the potential benefit of cytotoxic chemotherapy in terms of overall survival and median time to progression in patients with metastatic hormone-refractory prostate cancer. Active clinical research is underway to study neoadjuvant systemic chemotherapy before radical prostatectomy. There are also currently several clinical trials that are investigating the addition of chemotherapy in patients at high-risk of progression in the postprostatectomy setting. Antiandrogen therapy after radical prostatectomy has been shown in randomised studies to significantly reduce the risk of objective clinical progression in patients with high-risk localized prostate cancer. Immediate hormonal therapy with bicalutamide is a valuable therapeutic option in men having prostate cancer with such clinicopathological features.

Adjuvant bicalutamide monotherapy after radical prostatectomy improves the overall survival in patients with locally advanced prostate cancer. The main adverse event of the non-steroidal antiandrogen is the development of gynecomastia against which prophylactic breast irradiation can be administered. Therapeutic local radiotherapy using a very small number of fractions is a well-tolerated management option. Symptom improvement is observed in about half of the patients. Radiotherapy-related adverse effects are often mild (erythema, skin irritation) and transient. Tamoxifen has been also shown to be effective in prevention and treatment of gynecomastia induced by adjuvant therapy by bicalutamide in two-third of patients. Long-term safety of this prophylactic and therapeutic approach needs to be investigated through appropriate trials. Further evaluation of the optimal dose and duration of treatment with tamoxifen in this setting is reauired.

Although malignant tumours occur at all ages, cancer disproportionately strikes individuals in the age group 65 years and older. The increasing statistical life expectancy of men together with the introduction of prostate specific antigen (PSA) as a screening tool have both contributed to a rising number of elderly men with a diagnosis of prostate cancer. Age is generally considered to be a key prognostic factor in terms of therapeutic decision making, perhaps as important as PSA level and Gleason score. Even in men over 70 years, treatment without curative intent may deprive frail patients of years of life. When considering local treatment, strong consideration should be given to radical surgery. Modern radical prostatectomy is associated with low perioperative morbidity, excellent clinical outcomes as well as long term disease control. Besides, overdiagnosis has led to the concept of expectant management for screening-detected small-volume, low grade disease, with intention of providing therapy for those men experiencing disease progression.

Screening for prostate cancer is currently based on the assessment of blood prostate specific antigen (PSA). Although PSA was shown to be an adequate tool in prostate cancer screening, beginning from 4.0 ng/mL, its specificity is less significant. In men with a PSA between 4.0 and 10 ng/mL its predictive value is low. Therefore, there is a need for new instruments likely to improve the specificity of blood PSA levels between 4.0 and 10 ng/mL and the screening for prostate cancer in subjects with low PSA. Recent data are reviewed.

The presence of positive surgical margins on radical prostatectomy specimen is an adverse prognostic factor. Parameters supposed to influence surgical margin status includes pathology method analysis, surgical technique, tumoural and non tumoural patient parameters, and neoadjuvant hormonal therapy. Regarding the surgical technique, surgeon's experience and neuro-vascular bundles preservation are the most important factors of margin status, whereas surgical approach, bladder neck conservation, intraoperative frozen analysis, and bleeding are minor factors. Non tumoural patient parameters influencing surgical margin status include patient's age and weight, and prostate gland weight. For tumoural parameters, pathological stage and tumour volume are more important factors than the tumour grade and PSA. Five preoperative tumoural risk factors of positive surgical margins are particularly important, including abnormal digital rectal examination, preoperative PSA > 10ng/mL, biopsy Gleason score ≥7, number of positive biopsy cores ≥ 2, and suspicion of extraprostatic extension on radical prostatectomy specimen.