Prostat Kanserinde Fokal Tedaviler
Özet
Prostat kanserinde fokal tedaviler, radikal yöntemlerin inkontinans ve erektil disfonksiyon gibi yan etkilerini azaltmayı ve aktif izlemin getirdiği anksiyete ile progresyon riskinden kaçınmayı amaçlayan yenilikçi yaklaşımlardır. Radikal prostatektomi örneklerinde hastalığın %50-91 oranında multifokal olduğu görülse de kanserin seyrini esasen en büyük tümör odağı olan indeks lezyon belirlemektedir. Bu doğrultuda,Multiparametrik MR (mpMR) ve füzyon biyopsi entegrasyonu sayesinde agresif lezyonlar net olarak tanımlanabilmekte ve fokal tedaviler için uygun hastalar seçilebilmektedir. Tedavi seçenekleri arasında kriyoterapi, HIFU, radyofrekans ablasyon, fokal lazer ablasyonu, irreversibl elektroporasyon ve vasküler hedeflenmiş fotodinamik tedavi gibi termal ve non-termal yöntemler yer almaktadır. Bu işlemler genellikle günübirlik olarak uygulanmakta olup uygulama yolları (perineal veya rektal) ve anestezi gereksinimleri yönteme göre değişiklik göstermektedir. Takip sürecinde PSA değişkenliği ve doku skarları nedeniyle her 3 ayda bir parmakla rektal muayene ve PSA ölçümü ile 6-12. aylarda mpMR kontrolü ve 1. yılda kontrol biyopsisi önerilir. Fokal tedaviler morbiditeyi azaltma ve tekrarlanabilirlik avantajları sunsa da multifokalite nedeniyle lezyon atlama ve kontrlateral nüks riskleri barındırmaktadır. Son yıllarda klinik çalışmalar artsa da bu yöntemler henüz araştırma aşamasında olup onkolojik etkinlik için daha fazla karşılaştırmalı çalışmaya ihtiyaç duyulmaktadır.
Focal treatments for prostate cancer are innovative approaches that aim to reduce side effects of radical methods, such as incontinence and erectile dysfunction, while avoiding the anxiety and risk of progression associated with active surveillance. Although radical prostatectomy specimens show that the disease is multifocal in 50-91% of cases, the course of the cancer is primarily determined by the index lesion, which is the largest tumor focus. Accordingly, thanks to the integration of multiparametric MRI (mpMRI) and fusion biopsy, aggressive lesions can be clearly identified, and suitable patients can be selected for focal therapy. Treatment options include thermal and non-thermal methods such as cryotherapy, HIFU, radiofrequency ablation, focal laser ablation, irreversible electroporation, and vascular-targeted photodynamic therapy. These procedures are generally performed on an outpatient basis, and their administration routes (perineal or rectal) and anesthesia requirements vary depending on the method. Due to PSA variability and tissue scarring during follow-up, a digital rectal examination and PSA measurement every 3 months, an mpMRI at 6-12 months, and a control biopsy at the 1st year are recommended. While focal treatments offer advantages such as reduced morbidity and repeatability, they carry risks of missing lesions and contralateral recurrence due to multifocality. Although clinical studies have increased in recent years, these methods are still in the early research phase, and more comparative studies are needed for oncological efficacy.
Referanslar
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