20 to be a less aggressive tumour, whereas a PSA of greater than 20 ng/ml indicates a high risk. Next, the clinical staging or extent of the tumour must be determined. Magnetic resonance imaging (MRI) is recommended to guide prostate biopsy and provides valuable information regarding the extent of the tumour. The combined PSA, grade group score and local extent of disease (T stage) is used to group patients into risk groups. Local management varies for very low risk to ultra high risk patients. In high-risk cases (PSA > 20 ng/ml, Gleason GG 3-5, or clinical T3 or T4), it is necessary to investigate for possible lymph node and/or systemic metastases. Conventional imaging utilises computed tomography (CT) scan of the abdomen and pelvis and bone scintigraphy. PSMA PET/CT and whole-body MRI have been proven to be more accurate than conventional imaging, but it has not yet been proven that this translates into better clinical outcomes for patients. Other factors that are used to determine risk are the the PSA density (total PSA (ng/ml) divided by prostate volume (ml) on MRI), the number of positive biopsy cores, and the percentage of cancer in each fragment. In patients with a reduced life expectancy (10 years) we may forego local treatment as these patients may succumb form other conditions and not prostate cancer. Treatment Options The following options are available: • Active surveillance in low risk groups • Watchful waiting in asymptomatic patients with reduced life-expectancy Active treatments: • Radical prostatectomy • Radiotherapy • Combination with androgen deprivation therapy (ADT) Choice of therapy The UK based PROTECT trial was conducted between 1999 and 2009 outcomes of different treatment modalities - namely radical prostatectomy (RP), radiation therapy (RT) and active monitoring (AM). The outcomes, after fteen years of follow-up, were published recently. In this trial survival was almost identical in both the RP and RT groups (and surprisingly, also in the AM group, although a (2) discussion on this topic is not relevant to this article). Several factors determine the choice of therapy. The ideal surgical candidate is a t, relatively young patient, with intermediate risk disease. Surgery may also be of benet if the prostate is rather large and if the patient has signicant lower urinary tract symptoms (LUTS). Patients are usually discharged from hospital after a few days. Radiotherapy may not be appropriate for all patients. It is not advisable in patients with inammatory bowel disease or those who have had previous pelvic radiation therapy. In patients with severe LUTS, RT may cause acute obstruction, and it is advisable to address urinary ow prior to starting treatment, often with neo-adjuvant ADT. Any risk group can be treated with RT, with the addition of ADT and/or pelvic nodal areas as appropriate. Unfortunately, radiation therapy is typically delivered in daily sessions for a duration of four to seven weeks, which may be costly and inconvenient. Newer radiotherapy techniques and schedules using 4 weeks or even 5 -7 days of treatment have been evaluated and have been found to be equally safe and as effective as 6-7 week treatment schedules. Androgen deprivation therapy (ADT) is often added when RT is the chosen treatment modality. Gonadotropin-releasing hormone (GnRh) agonists are widely used. In intermediate-risk disease ADT is given for six months with RT, and in high- and very high-risk disease for two years. In two STAMPEDE trials, the addition of the androgen biosynthesis inhibitor, abiraterone, achieved improved oncologic outcomes when combined with ADT and RT in highrisk disease (metastasis-free survival of 82% vs 69% at six years), but also with signicantly higher rates of (3) grade 3 toxicity (57% vs 37%). Radiation therapy Radiotherapy in the past Radiotherapy may be delivered through external beam radiotherapy(EBRT) or brachytherapy. EBRT uses a source of radiotherapy that is located outside the patient and is uses beams that pass through normal tissue to reach the prostate. Brachytherapy uses radioactive sources implanted into the prostate or indirectly applied through tubes implanted into the prostate. Depending on the risk group EBRT, brachytherapy alone and in combination may be used for localized disease. In the 1990’s, radiation therapy techniques were rather simple. The treatment target was localised with CT planning, a necessary margin added to compensate for localisation uncertainties, and treatment was delivered as a “four-eld box”. Signicant amounts of normal tissue was also included in this box-shaped treatment volume (bladder, rectum) necessitating lowering of the overall RT dose to try to limit long-term complications. RT was delivered over at least seven weeks (35 - 40 daily fractions of 2Gy each, excluding weekends). Such long treatment schedules hold many logistic and practical limitations, especially in resourceconstrained sectors where long waiting times and high patient numbers are common. However the shorter schedules now possible with better image guidance allows for higher doses to be delivered over shorter periods with equal success. UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
RkJQdWJsaXNoZXIy NTIyOTQ=