Adjuvant therapy for high-risk prostate cancer

Adjuvant therapy for high-risk prostate cancer

In a high-risk prostate cancer after radical prostatectomy arises the difficult question of the immediate adjuvant treatment. On the German Association of Urology congress in 2007 there was this an overview.
According to the D'Amico criteria prostate cancer is present with high-risk (engl. high risk) when the PSA level is to let the wood over 20ng/ml or in a biopsy Gleason score of 8-10 is detected or the tumor is palpable and broken through the prostate capsule has (clinical stage T3 from, to see PSA PSA testing , biopsy to see prostate biopsy , Gleason score s classification of prostate cancer , the T stage s growth and spread of prostate cancer ) .

In these cases, a relatively high risk of disease progression is (risk of disease progression) of the first local curative treatment (treatment with local intent healing, ie a radical prostatectomy or radiotherapy). So is the chance that the PSA level after initial treatment within 5-10 years, not to rise again 40-60%. We speak here also of biochemical recurrence-free (eng. biochemical no evidence of disease, bNED, relapse = reappearance of the disease), as a PSA rise again indicating the re-growth of cancer cells, even if they are not using imaging methods (yet) detectable.

Adjuvant (concomitant) therapy after radical prostatectomy aims to kill any remaining cancer cells in the body before it comes to relapse. Hidden residues would be assumed, for example, if the tumor was not likely to be completely removed (referred to in the postoperative histological findings as "positive cut edge" and in the TNM system with R1) when the prostate capsule is broken (from pT3a) and if many lymph nodes are infested (pN1). While in the first case is more of a local post-irradiation into account, speak for the other two circumstances, systemic treatment, ie the treatment of the entire body by means of hormone therapy or chemotherapy.However, the choice of method is always based on the individual findings.

Adjuvant radiotherapy
A postoperative radiotherapy after radical prostatectomy is indicated for positive resection margin or infection of the prostate capsule (R1 or from pT3a), because then there is a high risk of local recurrence. There are currently three descriptive studies (for those interested: EORTC 22911, ARO / AUO, SWOG 8794), in which the adjuvant radiotherapy was compared with the controlled watchful waiting (intervention only if there are signs of a recurrence):

In all studies, the rate of patients without increased PSA rebound in adjuvant radiotherapy to an average of well over 70%. The effect is greatest in a positive cutting edge (R1), but according to a study in a PSA about 10ng/ml, a Gleason score of 8-10, or seminal vesicle invasion (pT3b) not significant (significantly). In addition, there was (so far in only one study) that in adjuvant radiotherapy decrease the rates of local recurrence and metastases and believes that the benefits of this treatment decreases with increasing post-operative PSA level, and it should, if not immediately, then in a PSA to 0.2 ng / ml can be started. Data on overall survival are not yet available.

Adjuvant hormone therapy
An immediate androgen deprivation after radical prostatectomy is mainly used for infection of lymph nodes (pN1) into consideration. Here, as in kapselüberschreitendem growth (pT3a), seminal vesicle invasion (pT3b) and positive resection margins (R1), it seems sensible to plan the use of this treatment on the individual risk of disease progression, possibly in combination with chemotherapy (adjuvant hormonal therapy after radical prostatectomy see also here in the magazine in the articles " hormone therapy: Early is better than postponed "and" New to hormone treatment of prostate cancer ").

Adjuvant chemotherapy
Chemotherapy is after radical prostatectomy in particular to consider at a high risk of progression of more than 80%, a seminal vesicle invasion (pT3b), a Gleason score of 8-10 or an extended lymph node involvement (pN1). After two initial studies can be so that the risk of recurrence and progression-free survival significantly improved in combination with hormonal therapy decreases the risk of recurrence even stronger. Until further results are available adjuvant chemotherapy remains a possibility to be used individually.

Conclusion
After radical prostatectomy to recommend adjuvant therapy in a positive cutting edge steel or infection of the prostate capsule and adjuvant hormone therapy for lymph node involvement, while on adjuvant chemotherapy still be insufficient study results.