Lokal İleri Prostat Kanserine Yaklaşım
Özet
Prostat kanseri, erkeklerde en sık görülen ikinci kanser türü olup, tarama amaçlı PSA kullanımının artmasıyla erken evrelerde daha fazla yakalanmaktadır. Tanı ve evrelemede klinik muayene, PSA değerleri, histolojik derecelendirme (Gleason skoru/ISUP derecesi) ve TNM sınıflandırması temel alınmaktadır. Lokal ileri evre prostat kanseri (T3-4M0), tümörün prostat kapsülünü aştığı ancak uzak metastaz yapmadığı grubu tanımlar. Bu evredeki hastaların yönetimi için kesin bir fikir birliği bulunmamakla birlikte, nüks riskinin yüksek olması multimodal tedavi yaklaşımlarını zorunlu kılmaktadır. Tek başına monoterapi uygulamaları sağkalımı olumsuz etkilerken; radikal prostatektomi (RP) ve genişletilmiş pelvik lenf nodu diseksiyonu (ePLND) cerrahi seçeneği olarak öne çıkmaktadır. Ayrıca cerrahi sonrası veya birincil tedavi olarak radyoterapi (RT) ve uzun süreli hormonoterapi (AHT/ADT) kombinasyonları, kanser spesifik ve genel sağkalımı artırmada en etkin sonuçları vermektedir. Tedavi sonrası takipte ilk 3 yıl boyunca düzenli anamnez, rektal muayene ve PSA takibi hayati önem taşır. Günümüzde tamamlayıcı tedavi endikasyonlarını netleştirmek amacıyla deneysel çalışmalar devam etmektedir.
Prostate cancer is the second most common type of cancer diagnosed in men globally, and with the widespread use of PSA screening, it is increasingly detected at early stages. Diagnosis and staging are fundamentally based on clinical examinations, PSA levels, histological grading systems (Gleason score/ISUP grade), and the TNM classification. Locally advanced prostate cancer (T3-4M0) describes a state where the tumor has extended beyond the prostate capsule without causing distant metastasis. Although there is no absolute consensus on managing this stage, the high risk of recurrence necessitates multimodal treatment approaches, as single monoterapies negatively impact survival rates. Radical prostatectomy (RP) combined with extended pelvic lymph node dissection (ePLND) stands out as a prominent surgical intervention. Furthermore, combining radiotherapy (RT) and long-term hormone therapy (AHT/ADT) either post-surgery or as a primary treatment yields the most effective results in improving cancer-specific and overall survival. Post-treatment follow-up crucially involves regular medical history evaluations, digital rectal examinations, and PSA monitoring during the first three years. Currently, clinical trials continue to further clarify and refine the indications for these complementary combination therapies.
Referanslar
Ng, K.L., The Etiology of Prostate Cancer. Exon Publications, 2021: p. 17-27, Camberley GU16 7UJ, UK.
Ludwig, D. R., Fraum, T. J., Fowler, K. J., & Ippolito, J. E. (2018). Imaging in Prostate Cancer: Magnetic Resonance Imaging and Beyond. Missouri medicine, 115(2), 135–141.
Wein, A. J., Kavoussi, L. R., Novick, A. C., Partin, A. W., & Peters, C. A. (2011). Campbell-Walsh urology: expert consult premium edition: enhanced online features and print, 4-volume set. Elsevier Health Sciences.
Pierorazio, P. M., Ross, A. E., Han, M., Epstein, J. I., Partin, A. W., & Schaeffer, E. M. (2012). Evolution of the clinical presentation of men undergoing radical prostatectomy for high‐risk prostate cancer. BJU international, 109(7), 988-993.
Perera, M., Papa, N., Roberts, M., Williams, M., Udovicich, C., Vela, I., ... & Murphy, D. G. (2020). Gallium-68 prostate-specific membrane antigen positron emission tomography in advanced prostate cancer—updated diagnostic utility, sensitivity, specificity, and distribution of prostate-specific membrane antigen-avid lesions: a systematic review and meta-analysis. European urology, 77(4), 403-417.
Milonas, D., Baltrimavicius, R., Grybas, A., Gudinaviciene, I., Trumbeckas, D., Kincius, M., ... & Jievaltas, M. (2011). Outcome of surgery in locally advanced pT3a prostate cancer. Central European journal of urology, 64(4), 209.
Moris, L., Cumberbatch, M. G., Van den Broeck, T., Gandaglia, G., Fossati, N., Kelly, B., ... & Wiegel, T. (2020). Benefits and risks of primary treatments for high-risk localized and locally advanced prostate cancer: an international multidisciplinary systematic review. European urology, 77(5), 614-627.
Türk Üroloji Derneği, uroturk, (2010) Yanaral F. & Balbay, M.D., Lokal İleri Evre Prostat Kanseri. (10/10/2022 tarihinde https://uroturk.org.tr/urolojiData/Books/478/lokal-ileri-evre-prostat-kanseri.pdf adresinden ulaşılmıştır).
Mottet, N., van den Bergh, R. C., Briers, E., Van den Broeck, T., Cumberbatch, M. G., De Santis, M., ... & Cornford, P. (2021). EAU-EANM-ESTRO-ESUR-SIOG guidelines on prostate cancer—2020 update. Part 1: screening, diagnosis, and local treatment with curative intent. European urology, 79(2), 243-262.
Adolfsson, J., Tribukait, B., & Levitt, S. (2007). The 20-yr outcome in patients with well-or moderately differentiated clinically localized prostate cancer diagnosed in the pre-PSA era: the prognostic value of tumour ploidy and comorbidity. European urology, 52(4), 1028-1035.
Sooriakumaran, P., Khaksar, S. J., & Shah, J. (2006). Management of prostate cancer. Part 2: localized and locally advanced disease. Expert review of anticancer therapy, 6(4), 595-603.
Thompson, I. M. (1993). Clinical stage C carcinoma of the prostate. AUA Update Series, 12, 82-87.
Heidenreich, A., Varga, Z., & Von Knobloch, R. (2002). Extended pelvic lymphadenectomy in patients undergoing radical prostatectomy: high incidence of lymph node metastasis. The Journal of urology, 167(4), 1681-1686.
Bader, P., Burkhard, F. C., Markwalder, R., & Studer, U. E. (2003). Disease progression and survival of patients with positive lymph nodes after radical prostatectomy. Is there a chance of cure?. The Journal of urology, 169(3), 849-854.
Kumar, S., Shelley, M., Harrison, C., Coles, B., Wilt, T. J., & Mason, M. (2006). Neo‐adjuvant and adjuvant hormone therapy for localised and locally advanced prostate cancer. Cochrane Database of Systematic Reviews, (4).
Messing, E. M., Manola, J., Yao, J., Kiernan, M., Crawford, D., Wilding, G., ... & Eastern Cooperative Oncology Group study EST 3886. (2006). Immediate versus deferred androgen deprivation treatment in patients with node-positive prostate cancer after radical prostatectomy and pelvic lymphadenectomy. The lancet oncology, 7(6), 472-479.
Hull, G. W., Rabbani, F., Abbas, F., Wheeler, T. M., Kattan, M. W., & Scardino, P. T. (2002). Cancer control with radical prostatectomy alone in 1,000 consecutive patients. The Journal of urology, 167(2 Part 1), 528-534.
Van Poppel, H., & Joniau, S. (2008). An analysis of radical prostatectomy in advanced stage and high-grade prostate cancer. European urology, 53(2), 253-259.
Loeb, S., Smith, N. D., Roehl, K. A., & Catalona, W. J. (2007). Intermediate-term potency, continence, and survival outcomes of radical prostatectomy for clinically high-risk or locally advanced prostate cancer. Urology, 69(6), 1170-1175.
van Poppel, H. (2014). Locally advanced and high risk prostate cancer: The best indication for initial radical prostatectomy?. Asian Journal of Urology, 1(1), 40-45.
Van Poppel, H., Goethuys, H., Callewaert, P., Vanuytsel, L., Van de Voorde, W., & Baert, L. (2000). Radical prostatectomy can provide a cure for well–selected clinical stage T3 prostate cancer. European urology, 38(4), 372-379.
Morgan, W. R., Bergstralh, E. J., & Zincke, H. (1993). Long-term evaluation of radical prostatectomy as treatment for clinical stage C (T3) prostate cancer. Urology, 41(2), 113-120.
Ward, J. F., & Zincke, H. (2003). Radical prostatectomy for the patient with locally advanced prostate cancer. Current Prostate Reports, 1(1), 5-13.
Van Poppel, H., Vekemans, K., Da Pozzo, L., Bono, A., Kliment, J., Montironi, R., ... & Collette, L. (2006). Radical prostatectomy for locally advanced prostate cancer: results of a feasibility study (EORTC 30001). European Journal of Cancer, 42(8), 1062-1067.
Soeterik, T. F. W., Van Melick, H. E., Dijksman, L. M., Stomps, S., Witjes, J. A., & Van Basten, J. P. A. (2020). Nerve sparing during robot-assisted radical prostatectomy increases the risk of ipsilateral positive surgical margins. The Journal of urology, 204(1), 91-95.
Türkeri, L. (2007). Lokal ileri evre prostat kanserinin tedavisi. Üroonkoloji Kitabı. Birinci basım. Özen H, Türkeri L. Ankara: Ertem Basım Yayın, 220-223.
Labrie, F., Cusan, L., Gomez, J. L., Diamond, P., Suburu, R., Lemay, M., ... & Candas, B. (1995). Downstaging by combination therapy with flutamide and an LHRH agonist before radical prostatectomy. Cancer surveys, 23, 149-156.
Aus, G., Abrahamsson, P. A., Ahlgren, G., Hugosson, J., Lunberg, S., Schain, M., ... & Pedersen, K. (1998). Hormonal treatment before radical prostatectomy: a 3-year followup. The Journal of urology, 159(6), 2013-2017.
Zincke, H., Lau, W., Bergstralh, E., & Blute, M. L. (2001). Role of early adjuvant hormonal therapy after radical prostatectomy for prostate cancer. The Journal of urology, 166(6), 2208-2215.
Bolla, M., van Poppel, H., Collette, L., van Cangh, P., Vekemans, K., Da Pozzo, L., ... & Piérart, M. (2005). Postoperative radiotherapy after radical prostatectomy: a randomised controlled trial (EORTC trial 22911). The Lancet, 366(9485), 572-578.
Van der Kwast, T. H., Bolla, M., Van Poppel, H., Van Cangh, P., Vekemans, K., Da Pozzo, L., ... & Collette, L. (2007). Identification of patients with prostate cancer who benefit from immediate postoperative radiotherapy: EORTC 22911. Journal of Clinical Oncology, 25(27), 4178-4186.
Mason, M. D., Parulekar, W. R., Sydes, M. R., Brundage, M., Kirkbride, P., Gospodarowicz, M., ... & Warde, P. (2015). Final report of the intergroup randomized study of combined androgen-deprivation therapy plus radiotherapy versus androgen-deprivation therapy alone in locally advanced prostate cancer. Journal of Clinical Oncology, 33(19), 2143.
Mottet, N., Bellmunt, J., Bolla, M., Briers, E., Cumberbatch, M. G., De Santis, M., ... & Cornford, P. (2017). EAU-ESTRO-SIOG guidelines on prostate cancer. Part 1: screening, diagnosis, and local treatment with curative intent. European urology, 71(4), 618-629.
Horwitz, E. M., Bae, K., Hanks, G. E., Porter, A., Grignon, D. J., Brereton, H. D., ... & Shipley, W. U. (2008). Ten-year follow-up of radiation therapy oncology group protocol 92-02: a phase III trial of the duration of elective androgen deprivation in locally advanced prostate cancer. Journal of Clinical Oncology, 26(15), 2497-2504.
Fahmy, O., Khairul-Asri, M. G., Hadi, S. H., Gakis, G., & Stenzl, A. (2017). The role of radical prostatectomy and radiotherapy in treatment of locally advanced prostate cancer: a systematic review and meta-analysis. Urologia internationalis, 99(3), 249-256.
Pilepich, M. V., Winter, K., John, M. J., Mesic, J. B., Sause, W., Rubin, P., Lawton, C., Machtay, M., & Grignon, D. (2001). Phase III radiation therapy oncology group (RTOG) trial 86-10 of androgen deprivation adjuvant to definitive radiotherapy in locally advanced carcinoma of the prostate. International journal of radiation oncology, biology, physics, 50(5), 1243–1252. https://doi.org/10.1016/s0360-3016(01)01579-6
Laverdière, J., Gomez, J., Cusan, L., Suburu, E. R., Diamond, P., Lemay, M., ... & Labrie, F. (1997). Beneficial effect of combination hormonal therapy administered prior and following external beam radiation therapy in localized prostate cancer. International Journal of Radiation Oncology* Biology* Physics, 37(2), 247-252.
Oh, W. K., Kantoff, P. W., Weinberg, V., Jones, G., Rini, B. I., Derynck, M. K., ... & Small, E. J. (2004). Prospective, multicenter, randomized phase II trial of the herbal supplement, PC-SPES, and diethylstilbestrol in patients with androgen-independent prostate cancer. Journal of clinical oncology, 22(18), 3705-3712.
Perera, M., Papa, N., Christidis, D., Wetherell, D., Hofman, M. S., Murphy, D. G., ... & Lawrentschuk, N. (2016). Sensitivity, specificity, and predictors of positive 68Ga–prostate-specific membrane antigen positron emission tomography in advanced prostate cancer: a systematic review and meta-analysis. European urology, 70(6), 926-937.
