Prostat Kanserinde Aktif İzlem
Özet
Aktif izlem (Aİ), düşük riskli prostat kanseri (PCa) hastalarında aşırı tedaviyi azaltmak ve cerrahi veya radyasyon gibi küratif tedavilerin inkontinans ile erektil disfonksiyon gibi yan etkilerini ertelemek amacıyla kullanılan konservatif bir yönetim stratejisidir. PSA izlemi, mpMRI ve düzenli tekrar biyopsileriyle hastalığın seyrinin dikkatli takibini içerir; progresyon saptanması durumunda iyiliştirici tedaviye geçilir. Semptomatik ilerleme olana kadar tedavi uygulanmayan "bekle gör" yaklaşımından, hastaların tedaviye uygunluğu ve küratif amaç taşıması yönüyle ayrılır. EAU kılavuzlarına göre 10 yıl üzeri yaşam beklentisi, cT1c-cT2 evresi, PSA ≤10 ng/ml, Gleason ≤3+3 ve ≤2 pozitif kor gibi kriterlere sahip hastalar Aİ için en uygun adaylardır. PSA yoğunluğu, patolojik olarak kribriform/intraduktal paternlerin olmaması ve BRCA1/2 gibi genetik mutasyonların bulunmaması hasta seçiminde kritik rol oynar. Genç hastalarda grade artışı riski daha düşükken, Gleason 3+4 (GG2) grubunda Aİ kullanımı halen tartışmalıdır. Uzun vadeli çalışmalarda Aİ'nin 10 yıllık genel ve kansere özgü sağkalımı tehlikeye atmadığı ve hastaların yaşam kalitesini anlamlı derecede koruduğu gösterilmiştir. Ancak kesin dahil etme kriterleri ve takip protokolleri henüz tam olarak standardize edilmemiştir.
Active surveillance (AS) is a conservative management strategy used to reduce overtreatment in patients with low-risk prostate cancer (PCa) and to postpone the side effects of curative treatments, such as surgery or radiation, including incontinence and erectile dysfunction. It involves careful monitoring of the disease course through PSA surveillance, mpMRI, and regular repeat biopsies, switching to curative treatment upon detection of progression. It differs from the "watchful waiting" approach, which does not apply treatment until symptomatic progression occurs, in terms of patients' eligibility for treatment and its curative intent. According to EAU guidelines, patients with a life expectancy of over 10 years, stage cT1c-cT2, PSA ≤10 ng/ml, Gleason ≤3+3, and ≤2 positive cores are considered the most appropriate candidates for AS. PSA density, the absence of pathological cribriform/intraductal patterns, and the lack of genetic mutations such as BRCA1/2 play a critical role in patient selection. While younger patients have a lower risk of grade upgrading, the use of AS in the Gleason 3+4 (GG2) group remains controversial. Long-term studies have demonstrated that AS does not compromise 10-year overall and cancer-specific survival and significantly preserves the patients' quality of life. However, definitive inclusion criteria and follow-up protocols have not yet been fully standardized.
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