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1、前列腺癌治疗新进展及争议,单击此处添加标题,单击此处添加标题,根治性前列腺切除术后病理为T3N0M0的术后即刻外放射治疗对于根治性前列腺切除术后病理为T3N0M0，特别是肿瘤切缘阳性的患者，术后即刻行外放射治疗能显著提高患者的总生存时间、延长患者无生化复发和临床复发时间。患者术后出现生化复发，但PSA值未超过0.5 ng/mL时进行补救性放射治疗，可显著提高患者的肿瘤特异性生存时间,外放射治疗,高风险（T14 N1M0)期前列腺癌的放射治疗对于高风险的(T14NlM0)前列腺癌，无其他严重疾病的患者，盆腔放射治疗后即刻长时间应用内分泌辅助治疗能提高患者的总生存时间,内分泌治疗,单一抗雄激素治疗
2、（Antiandrogen Monotherapy，AAM） 目的：单一应用较高剂量的雄激素受体拮抗剂，抑制雄激素对前列腺癌的刺激作用及雄激素依赖的前列腺癌细胞的生长，而且几乎不影响患者血清睾酮和黄体生成素的水平。 适应症：适合于治疗局部晚期，无远处转移的前列腺癌患者，即T34NxM0期 方法：推荐应用非类固醇类抗雄激素药物，如比卡鲁胺150mg口服每日一次 结果：与药物或手术去势相比，总生存期无显著差异；服药期间，患者的性能力和体能均明显提高，心血管疾病和骨质疏松发生率降,热点及争议,1,前列腺癌的筛查与PSA,2,等待观察治疗 & 主动监测,3,前列腺癌不同手术方式比较,4,前列腺癌激素治
3、疗,5,去势治疗的争议,前列腺癌的筛查是否必要？,美国将不再对正常老年人群做PSA筛查，公众医疗保险不再覆盖PSA筛查项目。前列腺癌已经超乎寻常地被美国医师过度治疗。如果老年人没有前列腺癌相关的症状及主诉，医生不得检查PSA前列腺癌的死亡率并没有因为PSA筛查的早期发现而降低，相反，过早干预前列腺癌不但有过度治疗的嫌疑，而且增加了早期前列腺癌患者的围手术期死亡风险（2012 AUA）,前列腺癌的筛查是否必要？,ERSPC 研究开始于2001年，8个欧洲国家实施的随机对照研究，旨在评价 PSA筛查对前列腺癌死亡率的影响研究数据证实，PSA筛查能降低死亡率21%,前列腺癌的筛查是否必要？,筛查并没
4、有显着减少前列腺癌的死亡率，也没有降低患者的总死亡率EBM: 前列腺癌筛查累积10年才能获得益处，应该告知预期寿命10-15年的男性，前列腺癌的筛查是无意义的，且有过度诊断及过度治疗的风险EBM成本效益研究，55-64岁的人群进行多短期（1-3年）筛查更符合成本效益比，再较高年龄（70岁以上）进行筛查，会导致更多的误诊，造成较高的成本,PCA3 （前列腺癌抗原3基因） PCA3 was found to be a better predictor of prostate cancer than PSA in the total population as well as the initial
5、 biopsy population, but was not superior to PSA in the repeat biopsy population PCA3基因在良性前列腺增生和其他泌尿系患者中均无表达，特异性达100 外周血PCA3 mRNA和PSA mRNA检测是PCa诊断的良好指标, 联合检测可弥补PCA3 mRNA敏感度低和PSA mRNA特异度低的不足,而更有利于PCa诊断;PCA3 mRNA可能为PCa微转移诊断的良好指标,PCA3 和PSA 联合筛查,主动监测,是否所有PC患者都需要进行积极治疗？,Outcome following surveillance of m
6、en with screen-detected prostate cancer. Results from the gothenburg randomised population-based prostate cancer screening trial Conlusions :A large proportion of men with screen-detected PC can be managed with surveillance Surveillance appears safe for men with low risk PC bur may also be an altern
7、ative for selected men with intermediate risk PC,低危PC患者主动监测治疗是安全的,主动监测,是否增加过渡到手术治疗患者发生尿失禁的风险,Active surveillance failure for prostate cancer: does the delay in treatment increase the risk of urinary incontinence?（ Can J Urol. 2012 Jun;19(3):6287-92. ）The UI rates in our cohort of active surveillance
8、 patients who move on to active treatment are similar to patients who undergo treatment immediately after prostate cancer is diagnosed as quoted in the literature. This suggests that active surveillance, as an initial mode of therapy, does not increase the risk of UI if active treatment occurs at a
9、later date.,主动监测并未增加手术治疗发生尿失禁的风险,主动监测 根治手术,不同手术方式的比较,Total intraoperative complication rates were significantly higher for ORP (1.5%) versus RALP (0.4%) ( p 0.0001) and for LRP (1.6%) versus RALP (0.4%) ( p 0.0001). For total perioperative complication rates(17.9% ORP, 11.1% LRP, and 7.8% RALP), RAL
10、P versus ORP ( p 0.0001) and versus LRP ( p = 0.002)were significantThe EBL and transfusion rates for ORP (745.3 ml; 16.5%) were higher than for LRP (377.5 ml; 4.7%) and RALP (188.0 ml; 1.8%).,不同手术方式的比较,RALP had the shortest hospital stay, both in the US studies (1.4 d) and in the non-US studies (4.
11、0 d), with LRP intermediate (2.1 d US,6.3 d non-US), and ORP having the longest length of stay (3.1 d US, 9.9 d non-US Conversion rates were low for both LRP (0.7%) and RALP (0.3%) and not significantly different between the modalities,Nerve injuries were significantly higher for LRP (2.0%) compared
12、 with RALP (0.4%; p = 0.0006) Ureteral injuries were statistically higher for ORP (1.5%) compared with RALP (0.1%; p = 0.012) and LRP (0.2%; p = 0.02). There was a significantly higher rectal injury rate for LRP (1.0%) versus RALP (0.3%; p = 0.0002) and versus ORP (0.5%; p = 0.0002).,微创手术和机器人辅助手术优于开
13、放手术 机器人辅助手术根治切除手术的并发症更少,前列腺癌的激素治疗,To compare intermittent androgen deprivation therapy (ADT) and continuous ADT after 6 months of induction of ADT in patients with metastatic prostate cancer (PCa). This is an open-label randomized multi-centre study conducted in 58 centres in Europe. Of 383 selected
14、 patients, 173 had a PSA level below 4 ng/mL after 6 months of induction of ADT and were randomized. Median overall survival (52 vs 42 months, P= 0.75) and median progression-free survival (15.1 vs 20.7 months, P= 0.74) were not significantly different between continuous and intermittent ADT.,前列腺癌的激
15、素治疗,This first randomized trial comparing continuous with intermittent ADT in metastatic PCa suggests that intermittent ADT might be as safe as continuous ADT.,间断性激素治疗是安全的 不影响前列腺癌生存率,有学者提出前列腺癌的去势治疗增加了肿瘤的上皮间质转化进而诱导前列腺癌提出去势抵抗前列腺癌治疗的新方法，如采用Clusterin抑制剂，mircro-RNA等,去势治疗的争议,前列腺癌的筛查有助于降低死亡率，但应对过度诊断和过度治疗予以重视 PCA3 mRNA和PSA mRNA检测是PCa诊断的良好指标, 联合检测更有利于PCa诊断；PCA3 mRNA可能为PCa微转移诊断的良好指标 微创手术、机器人辅助手术总体上要优于开放性手术 激素治疗方面，间断治疗不影响患者生存率，且可减少患者的用药次数 早期、低危PC患者不建议主动监测治疗，可行局部治疗 新的去势抵抗前列腺癌治疗方法提出,启 示,谢谢聆听！,
