157 pt. T1c. 0.2ml GS ≤6 No grade 4 or 5 by biopsy. PSAD 0.1ng/ml/gm, 50%. PSAD 0.15ng/ml/gm, <3mm cancer Predict value for a significant disease 95% 73% of their patients were insignificant tumor.
Active Surveillance The aim is to avoid unnecessary treatment on low- grade tumor that not affect the life or health for the next 5-10y. Life expectancy > 10y have risk of metastasis. Compliance.
Active Surveillance 31% will progress (GS, %specimen involvement, NO + biopsy
Active Surveillance About ½ of the patient on AS remain free of progression within 10y. Definitive treatment is appropriate in those with progression.
299 pt. 55M F/U, 60% remaining on AS. At 8y: OS 85% DSS 99%
AS for whom? Eligibility criteria: Clinically confined PCa (T1-T2). Gleason score < 7. PSA < 15-20 ng/mL. Prostatic biopsy (at 5y 83% have N sample)
AS progression Criteria to define cancer progression: PSAD: between < 2 and < 4 years; Gleason score progression to > 7 at re-biopsy, at intervals ranging from 1-4 years.
SUMMARY Pt with life expectancy <10y, GS ≤ 6 are suitable for AS. AS may be safe alternative to immediate treatment in compliant men with low risk of progression.
Radical Prostatectomy Salvage RP: Has higher complication rate. Incontinence 44% Bladder neck contraction 22% Ward et al 2005
Radical Prostatectomy Selection of pt for RP: Life expectancy at least 10y (upper limit 75y). Pre-op clinical & pathologic parameter.
Radical Prostatectomy Contraindication of nerve sparing: Extensive cancer in biopsy (>50%). PSA > 10ng/ml GS > 7 Site of the tumor T2 disease. Adhesion of the NV bundle to the prostate. Poor erection pre-op. Lack of sexual relationship. Medical illness adverse erection.
Radical Prostatectomy Post-op ED should be D/W pt. Complication of adjuvant therapy (HT, RT).
Radical Prostatectomy Adverse prognostic feature: Perineural invasion. Extracapsular extension. + surgical margin. SV invasion. L.N. metastasis. High PSA is the early sign of recurrence.
Radical Prostatectomy Complications: Continent 90%. Eerection: 95% 40y 50% 70y. It return partially at 3-6M up to 3y. Complications < 10%. Mortality rare.
RP is a reasonable option in a selected pt. The pt must be inform about multimodal approach. T3N0M0 PC (431pt) Adjuvant RT Better met-free survival with RT. Thompson Adjuvant ADT vs observation in +LN 11.9 f/u Better OS with ADT. Messing et al
Pelvic LN dissection Limited “Obturator. Ext.iliac”, 8-10. Extend, 20. Therapeutic role Morbidity of eLND (x3) Lymphoedema. Lymphocele. DVT. PE
RADIATION THERAPY 3D-CRT IMRT It is comparable result with RP (?? Not the same end point). Standard dose 76-80Gy. IMRT limit outside radiation by 1-1.5cm.
RADIATION THERAPY Side effect: Microvascular injury. IBS, rectal bleeding, bladder irritability, hematuria. Relative C/I: Prior TURP (urethral stricture, seeds of brachiotherapy not hold). Severe LUTS. IBD.
RADIATION THERAPY WITH HORMONAL They include the locally advanced prostate cancer (T2c-4) STAD-RT vs LTAD-RT. Improvement of all end point with LTAD-RT except OS.
RADIATION THERAPY WITH HORMONAL Increase OS in high risk group (more with LAD-RT).
RADIATION THERAPY Endpoints for failure: PSA ↓ within 2-3y. PSA measurement Q6M. PSA bounce. Definition of PSA failure.
RADIATION THERAPY Result: 50% cure rate for clinically localized PC. HT for 2-3y can be given after RT. EB-RT can combined with brachytherapy.
BRACHYTHERAPY Indication: stage cT1b- T2a N0, M0; Gleason score < 6 assessed on a sufficient number of random biopsies. Initial PSA level of < 10 ng/mL. < 50% of biopsy cores involved with cancer. Prostate volume of < 50 cm3. IPSS < 12.
BRACHYTHERAPY To be given under GA or regional anesthesia. Ioden-125 (145Gy), palladium-103(125Gy). CT scan after implant. Results: Cancer control: 5y 85% 8y 80% progression-free survival rate.