Management of Loclized Prostate Cancer課件

1、management of localized prostate cancer仁濟(jì)醫(yī)院泌尿外科 陳勇輝 患者 男性 55歲 因psa 5.2 ng/ml （2年前psa 2.0 ng/ml ）dre沒(méi)有異常發(fā)現(xiàn)(stage t1c)，穿刺活檢顯示：發(fā)現(xiàn)腫瘤（4/8）， gleason 3+4 = 7 。 而后進(jìn)行恥骨后前列腺癌根治術(shù)。病理顯示：雙側(cè)gleason 8分, 局部侵及包膜外,未累及精囊，切緣、淋巴結(jié)均為陰性。分期 t1c - tumor identified by needle biopsy (because of elevated psa level); tumors found

2、 in 1 or both lobes by needle biopsy but not palpable or reliably visible by imaging t3a - extracapsular extension (unilateral or bilateral) 主持討論專(zhuān)家 eric a klein, md professor of surgery cleveland clinic lerner college of medicine management of prostate cancer, 2nd edition: edited by eric a klein md主

3、持討論專(zhuān)家 william k. oh, md assistant professor of medicine, harvard medical school主持討論專(zhuān)家 w. robert lee, m.d.associate professor and vice chairman of radiation oncologyattending physician, north carolina baptist hospitalfurther immediate treatment ？ a no adjuvant therapy b adjuvant radiation therapy to

4、the prostate bed c adjuvant radiation therapy to the prostate bed and whole pelvis d immediate androgen deprivation therapy e clinical trial of chemotherapyresult 50% no adjuvant therapy 0% adjuvant radiation therapy to the prostate bed 25% adjuvant radiation therapy to the prostate bed and whole pe

5、lvis 25% immediate androgen deprivation therapy 0% clinical trial of chemotherapy 術(shù)后 psa 下降至 0.1 ng/ml。 但是，術(shù)后 18個(gè)月 psa 為 0.2 ng/ml。 病人感覺(jué)良好，無(wú)任何不適癥狀。 性欲如常，服用萬(wàn)艾可能正常勃起。what do you recommend? a no treatment b salvage radiation therapy to the prostate bed c immediate adt d cryosurgery e chemotherapy f cli

6、nical trial result 50% no treatment 50% salvage radiation therapy to the prostate bed 0% immediate adt 0% cryosurgery 0% chemotherapy 0% clinical trialsalvage therapy patients who have psa (biochemical) failure following radical prostatectomy and have no evidence of metastatic disease have the optio

7、ns of watchful waiting, radiotherapy, or hormonal ablation as salvage therapy. the choice of therapy depends on the timing of the recurrence (ie, soon after surgery) and the rate of psa level elevation. salvage therapy expectant management is an option for patients with presumed local recurrence unf

8、it for, or unwilling to undergo, radiation therapy psa recurrence indicative of systemic relapse is best treated by early adt resulting in decreased frequency of clinical metastases lhrh analogues/orchiectomy or bicalutamide at 150 mg/day can both be used when there is indication for hormonal therap

9、y 他選擇行補(bǔ)救性放療 但是, psa持續(xù)升高（3年內(nèi)），升高至 psa 5.0 ng/ml psa的倍增時(shí)間約為8個(gè)月 which imaging tests do you order? a bone scan b ct scan of the abdomen and pelvis c prostascint scan d pet scan e endorectal prostate mri f chest x-ray result 100% bone scan 0% ct scan of the abdomen and pelvis 0% prostascint scan 0% pet s

10、can 0% endorectal prostate mri 0% chest x-rayimaging tests following radical prostatectomy, ct scans of the pelvis and abdomen are of low sensitivity and specificity in patients with psa levels 20 ng/ml or a psa velocity of 1-2.0 ng/ml but is not yet part of routine clinical use. 患者行骨掃描和 ct掃描均無(wú)異常發(fā)現(xiàn)

11、患者近來(lái)有了新配偶，對(duì)保留性功能非?？释?你建議如何治療？ what do you recommend? a continued observation b bilateral orchiectomy c lhrh agonist alone d lhrh antagonist alone e lhrh agonist + antiandrogen f antiandrogen aloneresult 50% continued observation 0% bilateral orchiectomy 0% lhrh agonist alone 0% lhrh antagonist alone

12、 0% lhrh agonist + antiandrogen 50% antiandrogen alone 使用3個(gè)月的抑那通（ leuprolide acetate）,psa 低至不能被檢測(cè) 患者出現(xiàn)熱潮紅（hot flashes）、疲勞感、體重增加 10-kg 、情緒抑郁 是否需停止去雄治療（ adt）what do you recommend? a discontinue leuprolide until the psa rises b switch to diethylstilbestrol (des) c continue leuprolide and add megestrol

13、acetate d continue leuprolide and add a selective serotonin reuptake inhibitor (ssri) for hot flashes and depression e switch to an antiandrogen aloneresult 0% discontinue leuprolide until the psa rises 0% switch to diethylstilbestrol (des) 50% continue leuprolide and add megestrol acetate 0% contin

14、ue leuprolide and add a selective serotonin reuptake inhibitor (ssri) for hot flashes and depression 50% switch to an antiandrogen alonethree main reasons renewed interest in oestrogens can be ascribed to : deleterious side-effects and high costs of long-term adt, oestrogens suppress testosterone le

15、vels and do not seem to lead to bone loss and cognitive declinethree main reasons secondly, oestrogenic compounds (des, des-diphosphate, and the herbal supplement, pc spes) have been shown to induce psa-response rates as high as 86% in phase ii trials with patients diagnosed with hormone-refractory

16、prostate cancer (hrpc) thirdly, a new oestrogen receptor-beta (er-b), possibly involved in prostate tumourigenesis, has been discovered 在ssri 藥物（百優(yōu)解）不能控制其熱潮紅后他選擇間歇性療法 骨密度測(cè)定顯示在髖骨和脊柱有明顯骨量減少intermittent hormone therapy intermittent hormone therapy refers to cycles on androgen ablation and cycles off an

17、drogen ablation to keep the psa level low and to minimize the adverse physical effects of androgen blockade. what do you recommend at this point? a calcium + vitamin d only b calcium, vitamin d, and alendronate c calcium, vitamin d, and zoledronic acid d calcium, vitamin d, and desresult 50% calcium

18、 + vitamin d only 50% calcium, vitamin d, and alendronate 0%calcium, vitamin d, and zoledronic acid 0% calcium, vitamin d, and des the three treatment modalities for primary therapy - radical prostatectomy (rp), external beam radiotherapy (ebrt), and brachytherapy - confer similar success rates radical prostatectomy represents an excellent choice for sexually active patients with early localized prostate cancer and favorable prognoses disease-free 10-year survival rates for early localized disease radical prostatectomy (80-95%) brachytherapy and external radi