A. Benchikh El Fegoun

PSA et suivi après traitement du cancer de la prostate

A first serum total PSA assay is recommended during the first three months after treatment. When PSA is detectable, PSA assay should be repeated three months later to confirm this elevation and to estimate the PSA doubling time (PSADT). In the absence of residual cancer, PSA becomes undetectable by the first month after total prostatectomy: less than 0.1 ng/ml (or less than 0.07 ng/ml) for the ultrasensitive assay method and less than 0.2 ng/ml for the other methods. In the presence of residual cancer, PSA either does not become undetectable or increases after an initial undetectable period. A consensus has been reached to define recurrence as PSA greater than 0.2 ng/ml confirmed on two successive assays. After external beam radiotherapy, PSA can decrease after a mean interval of one to two years to a value less than 1 ng/ml (predictive of recurrence-free survival). Biochemical recurrence after radiotherapy is defined by an increase of PSA by 2 ng or more above the PSA nadir, whether or not it is associated with endocrine therapy. After endocrine therapy, the PSA nadir is correlated with recurrence-free survival. PSA is decreased for a mean of 18 to 24 months followed by a rise in PSA, corresponding to hormone-independence. The time to recurrence or the time to reach the nadir and the PSA doubling time after local therapy with surgery or radiotherapy have a diagnostic value in terms of the site of recurrence, local or metastatic and a prognostic value for survival and response to complementary radiotherapy or endocrine therapy. A PSADT less than eight to 12 months is correlated with a high risk of metastatic recurrence and 10-year mortality. The histological and biochemical characteristics in favour of local recurrence are Gleason score less or equal to seven (3+4), elevation of PSA after a period greater than 12 months and PSADT greater than 10 months. In other cases, recurrence is predominantly metastatic. The risk of demonstrating metastasis in the case of biochemical recurrence after total prostatectomy and before endocrine therapy depends on the PSA level and the PSADT. No consensus has been reached concerning the indication for complementary investigations by bone scan and abdominopelvic CT in patients with biochemical recurrence after treatment of localized cancer without endocrine therapy. However, when PSADT greater than six months, the risk of metastasis is less than 3% even for PSA greater than 30 ng/ml. When PSADT less than six months and PSA greater than 10 ng/ml, the risk of metastasis is close to 50%.

Article de revuePSA et suivi après traitement du cancer de la prostatePSA and follow-up after treatment of prostate cancer

A first serum total PSA assay is recommended during the first three months after treatment. When PSA is detectable, PSA assay should be repeated three months later to confirm this elevation and to estimate the PSA doubling time (PSADT). In the absence of residual cancer, PSA becomes undetectable by the first month after total prostatectomy: less than 0.1 ng/ml (or less than 0.07 ng/ml) for the ultrasensitive assay method and less than 0.2 ng/ml for the other methods. In the presence of residual cancer, PSA either does not become undetectable or increases after an initial undetectable period. A consensus has been reached to define recurrence as PSA greater than 0.2 ng/ml confirmed on two successive assays. After external beam radiotherapy, PSA can decrease after a mean interval of one to two years to a value less than 1 ng/ml (predictive of recurrence-free survival). Biochemical recurrence after radiotherapy is defined by an increase of PSA by 2 ng or more above the PSA nadir, whether or not it is associated with endocrine therapy. After endocrine therapy, the PSA nadir is correlated with recurrence-free survival. PSA is decreased for a mean of 18 to 24 months followed by a rise in PSA, corresponding to hormone-independence. The time to recurrence or the time to reach the nadir and the PSA doubling time after local therapy with surgery or radiotherapy have a diagnostic value in terms of the site of recurrence, local or metastatic and a prognostic value for survival and response to complementary radiotherapy or endocrine therapy. A PSADT less than eight to 12 months is correlated with a high risk of metastatic recurrence and 10-year mortality. The histological and biochemical characteristics in favour of local recurrence are Gleason score less or equal to seven (3+4), elevation of PSA after a period greater than 12 months and PSADT greater than 10 months. In other cases, recurrence is predominantly metastatic. The risk of demonstrating metastasis in the case of biochemical recurrence after total prostatectomy and before endocrine therapy depends on the PSA level and the PSADT. No consensus has been reached concerning the indication for complementary investigations by bone scan and abdominopelvic CT in patients with biochemical recurrence after treatment of localized cancer without endocrine therapy. However, when PSADT greater than six months, the risk of metastasis is less than 3% even for PSA greater than 30 ng/ml. When PSADT less than six months and PSA greater than 10 ng/ml, the risk of metastasis is close to 50%.

Les essais cliniques français GETUG et AFU en cours concernant les carcinomes urothéliaux et les cancers du rein et de prostate

Resume La collaboration de l’Association Francaise d’Urologie (AFU) et du Groupe d’Etude des Tumeurs Uro-Genitales (GETUG) permet de plus en plus de credibiliser les essais cliniques francais d’onco-urologie. Ces etudes se placent aux memes rangs que les etudes nordamericaines ou europeennes. La participation des urologues y est essentielle. C’est pourquoi il nous a semble necessaire de faire une mise au point sur les essais en cours afin d’accroitre encore le recrutement provenant de tous les praticiens acteurs de l’oncourologie.

Prise en charge des métastases osseuses du cancer de la prostate. À propos d’un cas

Androgen deprivation therapy with LHRH agonists is the gold standard in the treatment of metastatic prostate cancer. This treatment leads to decrease the bone mass, thus bone mineral density evaluation is recommended after one year of hormonal treatment to measure bone loss. Bisphosphonate is recommended when metastasis occurred during hormonal resistance phase to reduce bone events. The necessity of preventive treatment and the appropriate schedule is not well established. Long term fracture risk should be ideally evaluated with a CT scan and an MRI. Fragmented and focal radiotherapy is considered as the treatment of choice to decrease localized pain. Metastasis surgery has functional results and should be performed before major neurologic symptoms occur. Metabolic radiotherapy is an option for multifocal bone metastases.Resume La privation androgenique par agonistes de la LHRH reste le traitement de reference de premiere intention du cancer de prostate a la phase metastatique. Compte tenu des consequences sur la perte osseuse, une mesure de la densite osseuse apres 1 an d’hormonotherapie peut etre conseillee afin d’evaluer la perte osseuse. Un traitement par bisphophonate est recommande en cas de metastase lors de l’hormonoresistance afin de diminuer le risque d’evenement osseux. La place des traitements preventifs et les schemas therapeutiques sont encore mal defini La radiotherapie conformationelle multi-fractionnee est le traitement de choix des metastases osseuses symptomatiques peu nombreuses. L’association d’un scanner et d’une IRM permet d’evaluer de maniere optimale le risque fracturaire des metastases osseuses. La chirurgie des metastases osseuses est une chirurgie fonctionnelle qui doit etre realisee avant l’installation d’un deficit neurologique important. Enfin la radiotherapie metabolique peut etre proposee en cas de localisation multifocale.

Les nouveautés 2009 sur le cancer de la prostate : les points forts de l’ASTRO, l’EAU, l’ASCO et l’AUA

Resume En 2009, le cancer de la prostate a fait l’objet de nombreuses communications dans les congres internationaux d’urologie, d’oncologie et de radiotherapie. L’evenement majeur a ete la presentation des resultats des etudes de depistage de masse europeenne ERSPC et americaine PLCO. Plusieurs communications concernent la prevention, l’histoire naturelle de la maladie et les nouveaux marqueurs tumoraux comme le PCa3 et le gene de fusion TMPRSS2 : ERG. L’hormonotherapie adjuvante a ete evaluee chez les patients a haut risque de recidive. L’association hormonotherapie-radiotherapie permettrait de reduire la recidive biologique, la mortalite specifique et la mortalite globale des patients porteurs d’une tumeur localement avancee. Le THI pourrait etre une option chez les patients metastatiques hormono-sensibles. L’interet du denosumab et du toremifene a ete evalue dans la prevention du risque fracturaire sous hormonotherapie. Le mecanisme de proliferation tumorale en situation d’echappement hormonal a ete precise et 2 nouvelles molecules l’abiraterone et le MDV 3100 apparaissent prometteuses.

Fusionsbiopsie der Prostata liefert zuverlässige Ergebnisse

Die transrektale Sonografie mit systematischer Biopsie gilt derzeit als Standard fur die Diagnose eines Prostatakarzinoms. Allerdings ist das Verfahren nicht immer prazise – hochgradige Erkrankungen konnen ubersehen und niedrig maligne Veranderungen ubertherapiert werden. Die Fusionsbiopsie konnte eine Alternative darstellen, aber dazu muss sie zuverlassig reproduzierbar sein. Das haben Mediziner aus den USA gepruft.

Cancer de la prostate localement avancé et hormonothérapie

Resume En cas de recidive biologique precoce apres chirurgie les differents types d’hormonotherapie de 1 re ligne ont une efficacite similaire. Il existe un avantage en termess de mortalite specifique et en termess de progression locale et metastatique a debuter l’hormonotherapie precocement apres la recidive biologique. L’association d’une radiotherapie adjuvante debutee precocement permettrait de reduire le taux de recidive locale et metastatique dans les cancers localement avances. En cas d’echappement hormonal, le syndrome de retrait des anti-androgenes doit etre recherche de maniere systematique avant de debuter une chimiotherapie ou toute autre therapeutique. Des anti-androgenes de seconde generation (abiraterone et MDV 3100) seront disponibles prochainement, ils ont une action sur les voies d’echappement hormonal et les resultats des etudes de phase II sont prometteurs.