Prostat Kanseri Definitif Tedavisi Sonrası Biyokimyasal Nükse Yaklaşım
Özet
Prostat kanseri definitif tedavisi (radikal prostatektomi [RP] ve radyoterapi [RT]) sonrası biyokimyasal nüks (BCR), sırasıyla %27 ve %53 oranlarında gözlenen önemli bir klinik sorundur. BCR tanımında RP için PSA düzeyinin 0.4 ng/mL eşiğini aşması, RT için ise nadir değerden 2 ng/mL'den fazla artış kriter alınır. Nüks saptandığında, lokal veya uzak metastaz ayrımının yapılması prognoz açısından kritiktir; bu süreçte hastalar EAU kriterlerine göre düşük ve yüksek riskli olarak sınıflandırılır. Metastazların değerlendirilmesinde Ga 68-PSMA PET/BT, özellikle düşük PSA seviyelerinde yüksek duyarlılık ve özgüllük gösteren en etkili görüntüleme yöntemi olarak öne çıkmaktadır. RP sonrası nükslerde erken kurtarma radyoterapisi (SRT) sistemik progresyon riskini %75 azaltırken, agresif seyirli vakalarda SRT'ye androjen deprivasyon tedavisinin (ADT) eklenmesi sağkalımı iyileştirir. Pelvik lenf nodu nükslerinde metastaza yönelik ablasyon veya kurtarma lenf nodu diseksiyonu (sLND) tercih edilebilir. RT sonrası lokal nükslerin yönetiminde kurtarma radikal prostatektomisi (SRP), kurtarma kriyoablasyonu (SCAP), kurtarma brakiterapisi, saptanmış stereotaktik ablatif vücut radyoterapisi (SABR) ve kurtarma HIFU gibi seçenekler mevcuttur. Bu lokal kurtarma yöntemleri benzer nükssüz sağkalım oranları sunmakla birlikte, özellikle SRP yüksek morbidite, idrar kaçırma ve erektil disfonksiyon riskleri taşır. Uygun risk profiline sahip veya yaşam beklentisi kısa olan hastalarda ise aktif gözlem uygulanabilir bir alternatiftir.
Biochemical recurrence (BCR) after definitive treatment for prostate cancer (radical prostatectomy [RP] and radiotherapy [RT]) is a significant clinical issue observed at rates of 27% and 53%, respectively. In defining BCR, a PSA threshold exceeding 0.4 ng/mL for RP and an increase of more than 2 ng/mL above the nadir value for RT are considered criteria. Upon diagnosing recurrence, differentiating between local or distant metastasis is critical for prognosis, and patients are stratified into low- and high-risk groups based on EAU criteria. For evaluating metastases, Ga 68-PSMA PET/CT stands out as the most effective imaging modality, demonstrating high sensitivity and specificity, particularly at low PSA levels. After RP, early salvage radiotherapy (SRT) reduces the risk of systemic progression by 75%, while adding androgen deprivation therapy (ADT) to SRT in aggressive cases improves survival. For pelvic lymph node recurrences, metastasis-directed ablation or salvage lymph node dissection (sLND) can be preferred. Management options for local recurrence after RT include salvage radical prostatectomy (SRP), salvage cryoablation (SCAP), salvage brachytherapy, stereotactic ablative body radiotherapy (SABR), and salvage HIFU. Although these local salvage modalities offer similar recurrence-free survival rates, SRP carries high risks of morbidity, urinary incontinence, and erectile dysfunction. Alternatively, active surveillance remains a viable option for patients with low-risk profiles or limited life expectancy.
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