Treatment of limited-stage high-risk prostate cancer

one,

We all know that clinically, prostate cancer is divided into high-risk, intermediate-risk, and low-risk according to PSA, Gleason score, and clinical stage, in order to guide treatment and judge prognosis. According to data from the Prostate Cancer Strategic Collaboration Group, since 1991, high-risk prostate cancer has accounted for 31.2% of new prostate cancers in the United States. The incidence of prostate cancer in my country is much lower than that in Europe and the United States, but because the current application of PSA screening in China is still imperfect, at least 35.8% of patients have progressed to high-risk prostate cancer when diagnosed. High-risk prostate cancer is difficult to predict because of its biological behavior, and there are great differences in clinical treatment effects. The 5-year biochemical recurrence rate is greater than 50%, which is a difficult point in the treatment of prostate cancer.

II. Definition

The current definition is: clinical stage ≥ T2c, or PSA>20ng/ml, or Gleason score ≥8. Studies have shown that only in patients with PSA>20ng/ml, 33% of the postoperative pathological stage is T2. 57.9% have a Gleason score of 20ng/ml and a Gleason score of ≥8. This group of high-risk patients is unlikely to benefit from surgery.

3. The value of surgical treatment in the treatment of high-risk prostate cancer

Surgical treatment of high-risk prostate cancer, especially prostate cancer with clinical stage T3, is highly controversial, mainly due to uncertain efficacy and high perioperative complications. In the past, it was believed that high-risk prostate cancer was not suitable for surgery, and more conservative radical radiotherapy or endocrine therapy was preferred. In recent years, with the further in-depth study of high-risk prostate cancer, especially the development of anatomical radical prostatectomy, surgical complications have been significantly reduced, and the survival rate has been greatly improved. Surgical treatment has once again become a hot topic of concern.

A large number of retrospective studies have shown that postoperative pathology has confirmed that 13% to 27% of patients have overestimated the stage. The 10-year biochemical recurrence-free rate after radical surgery for patients with prostate cancer with a clinical stage of T3 is 51%, the tumor-specific survival rate is 91.6%, and the overall survival rate is 77%. The final pathological confirmation is T2, accounting for 23.5%, and pT3b-4 is 20%. Statistical analysis shows that there are statistically significant differences in biochemical progression-free survival and clinical progression-free survival between pT3a and pT3b-4. However, there is no such difference between pT3a and pT2. Therefore, high-risk patients with pT3a after surgery can still benefit from surgery.

Studies have shown that extended pelvic lymph node dissection in radical surgery can not only clarify the clinical stage in high-risk patients, but also significantly delay the survival of patients with positive lymph nodes.

Neoadjuvant endocrine therapy is not recommended for patients before surgery.

Adjuvant endocrine therapy: Studies have shown that it can delay the progression of high-risk prostate cancer, but whether it can improve the patient's overall survival rate is still unclear.

The local recurrence rate of pT3 prostate cancer is as high as 30%. Postoperative adjuvant radiotherapy is mainly for patients with pT3 and positive resection margins. Immediate radiotherapy is currently advocated.

Surgery or radiotherapy

In clinical work, whether to choose surgery or radiotherapy for high-risk prostate cancer is a problem that clinicians need to face. A large retrospective study conducted on high-risk prostate cancer showed that radical surgery and radical radiotherapy combined with adjuvant endocrine therapy have similar efficacy, but are better than radical radiotherapy alone. Compared with radical radiotherapy, radical surgery can reduce the risk of distant metastasis of prostate cancer and tumor-specific mortality. Therefore, if there are no contraindications to surgery, more aggressive surgery is currently preferred.