الفهرس 
Pathology of locally advanced prostate cancerOnly 14 pages are availabe for public view
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Abstract
Prostate cancer is the second most commonly diagnosed cancer in men in the European union and the third most common cause of cancer related death in men in the western world.
The wide spread use of the measurement serum prostatic specific antigen (PSA) level as a diagnostic tool has resulted in a 20% increase in the detection of clinically localized prostate cancer. Despite this, approximately one-third of newly diagnosed cases are regarded as locally advanced at the time of diagnosis
The identification of patients with locally advanced disease was based on clinical examination (e.g., digital rectal examination) and clear evidence of spread outside of the prostate capsule (clinical stage T3a), involvement of the seminal vesicles (cT3b), or involvement of adjacent organs (cT4).
The goals of treatment of locally advanced T3 prostate cancers are to cure the disease, prolong survival or metastasis-free survival and improve quality of life. The treatment of T3 prostate cancer can be RP, RT, HT and combinations.
Watchful waiting is an option for asymptomatic patients with well-differentiated and moderately differentiated T3 tumours and a life expectancy <10 years. Watchful waiting can be considered as the treatment option of choice for certain patients. However, it is rarely advocated because of the high risk of metastasis and disease progression in patients with cT3 disease.
RP alone was not adapted to cure locally advanced tumours because of the tumour volume and the high incidence of positive pelvic lymph nodes. RP can be proposed to selected healthy patients with locally advanced tumours presenting these clinical parameters: PSA <20ng/ml, > or equal T3a, and biopsy Gleason score < or equal 8 and The patient should be young and healthy with a life expectancy >10yr. But is traditionally discouraged for clinical T3 prostate cancer, mainly because of the increased risk of both lymph node metastases and local or distant relapse.
RP for locally advanced T3 prostate cancer must focus on a more radical extirpation including an extensive lymph node dissection, clean apical dissection, neurovascular bundle resection at least at the tumour bearing site, complete resection of the seminal vesicles and mostly resection of the bladder neck.
Results of radical prostatectomy series suggest that RP remains a treatment option for good prognosis patients with locally advanced prostate cancer. It has been reported that RP for cT3 locally advanced prostate cancer can be carried out with acceptable morbidity and mortality and is especially beneficial in patients who are clinically over-staged (17-30% of cT3 are pT2) and in those with moderately or well-differentiated disease and with a relatively low PSA.
Salvage radical prostatectomy has been used successfully to eradicate locally recurrent cancer after definitive radiotherapy, but complications are common
Therefore, preference is given to a combination therapy of hormonal treatment (HT) and radiotherapy (RT). However, this combination treatment has never been proven superior to surgical treatment either in monotherapy or in combination with RT or HT.
External Beam Radiotherapy has been commonly employed for the management of locally advanced prostate cancer. Recent developments in conformal radiotherapy (CFRT) and intensity modulated radiotherapy (IMRT) permit the safe introduction of high dose treatments.
Traditional hormonal therapies comprise androgen ablation using bilateral orchiectomy, estrogens or LHRH agonists with or without anti-androgens. Other treatment regimens including intermittent hormonal therapy, 5a-reductase inhibitors, and anti-androgens alone or in combination with 5a-reductase inhibitors have also been of interest in recent years.
Neoadjuvant hormonal therapy has little value before radical prostatectomy (it decreases the risk of positive margins but has no effect on risk of PSA recurrence) .On the other hand, hormonal therapy for three to six months before and during radiotherapy for stage T3-4 disease (and not continued after completion of radiation) reduces local recurrence rates, although it has not yet been shown to prolong overall survival.
Primary cryotherapy is more appropriate for small volume disease and represents a good option for many patients who do not wish to undergo RP or radiation therapy (RT).