Terapia cytoredukcyjna u pacjentów z przerzutami

Terapia cytoredukcyjna u pacjentów z przerzutami

Nieprzeczytany postautor: Mac » 10 paź 2016, 16:21

Znalazłem ciekawy artykuł na temat pozytywnego wpływu podjętego leczenia radykalnego u pacjentów z przerzutami. Do tej pory większość publikacji i standardów z którymi się zapoznałem odrzucała korzyści płynące z prostatektomii i radykalnej radioterapii w przypadku stwierdzenia przerzutów.
Warto przeczytać:


Radiation Therapy or Radical Surgery Seen to Benefit Prostate Cancer Patients with Newly Found Metastasis
https://prostatecancernewstoday.com/201 ... 0-71765073



Local Therapy Improves Overall Survival in Patients with Newly Diagnosed Metastatic Prostate Cancer
http://www.redjournal.org/article/S0360-3016(16)30785-4/fulltext
Rocznik 1961

Historia badań PSA: 05.2009 - PSA 2,364 / 10.2010 - PSA 2,53 / 01.2013 - PSA 3,16 / 11.2013 - PSA 4,71 / 04.2014 - PSA 3,81 f/t 0.12 / 06. 2014 levoxa / 07.2014 - 3,82 / 11.2014 - PSA 4,23 f/t 0,11 / 03.2015 - PSA 4,62 / 04.2015 - PSA 4,09 /
Badania dodatkowe: DRE (12.2013): DRE+ wyczuwalny guzek ok. 8 mm, TRUS (02.2014): OK, Biopsja (02.2014): brak utkania nowotworowego (6 rdzeni), MRI (12.2014) gruczoł krokowy 38×32×38 (24ml) o zachowanej budowie strefowej, strefy przejściowe gruczolakowato przebudowane, nie uwidoczniono w badaniu MR typowej zmiany w kierunku CaP itp. (aparat 3 teslowy, 32 kanały - badanie przed i po kontraście z badaniem dynamicznym i dyfuzją), Test PCA3 (12.2014): Score 87 (very high), Biopsja saturacyjna (02.2015): Adenocarcinoma tubulare G1, Gleason 7(3+4) w jednym wycinku /apex strona prawa/, PIN 1 w jednym wycinku, ASAP w jednym wycinku (20 rdzeni).

RP (05.05.2015) (metodą otwartą) w MSS w Warszawie
Badanie histopatologiczne: Rodzaj materiału (węzły chłonne zasłonowe, prostata, powięź Denovillersa), Rozpoznanie: Fragmenty tkanki tłuszczowej z drobnym węzłem chłonnym bez zmian nowotworowych, Fragmenty tkanki tłuszczowej bez zmian nowotworowych, Gruczoł krokowy 2,5×4,0×3,0 Adenocarcinoma prostatae w skali Gleasona 7 (3+4); rak nacieka wierzchołek stercza po obu stronach, oba płaty stercza (przekroje 1-5) oraz podstawę stercza po stronie prawej; utkanie nie nacieka torebki stercza; we wszystkich wycinkach margines chirurgiczny jest bez zmian nowotworowych, Fragment tkanki tłuszczowej bez zmian nowotworowych.
Powikłania: po RP - zatorowość płucna, trzymanie moczu po 3 tygodniach od wyjęcia cewnika - bez problemów, oddawanie moczu bez większych problemów po 3 miesiącach od RP, potencja? coś się zaczyna ruszać :).

PSA po RP: 05.08.2015 - 0,003 / 04.11.2015 - 0,008 / 05.02.2016 - 0,007 / 05.05.2016 - 0,017 / 25.08.2016 - 0,012 / 9.11.2016 - 0,011 / 6.02.2017 - poniżej 0,003 / 5.05.2017 - 0,021 / 4.08.2017 - 0,018 / 6.11.2017 - 0,013 / 6.02.2018 - 0,011 / 5.05.2018 - 0,014 / 16.08.2018 - 0,016 / 3.11.2018 - 0,02 / 5.02.2019 - 0,021 / 5.05.2019 - 0,019 / 20.07.2019 - 0.019 / 6.11.2017 - 0,007 / 5.02.2020 - 0,014 ng/ml / 09.06.2020 - 0,02 ng/ml / 23.09.2020 - 0,013 ng/ml 19.05.2021 - 0,092 ng/ml 18.08.2021 - 0,011 ng/ml, 15.12.2021 - 0,016 ng/ml, 21.02.2023 - 0,024 ng/ml
Mac
 
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Re: Leczenie radykalne u pacjentów z przerzutami

Nieprzeczytany postautor: bela71 » 10 paź 2016, 19:24

Się dołożę do tematu, bo to co linkujesz, to badania retrospektywne, z danych o przebiegu choroby. Poniżej krytyczny opis retrospektywnego niemieckiego badania i link do badania klinicznego właśnie nad cytoredukcją.


Cytoreductive radical prostatectomy in patients with prostate cancer and low volume skeletal metastases: results of a feasibility and case-control study.
https://www.ncbi.nlm.nih.gov/pubmed/25254935

i komentarz, który dobrze podsumowuje to, na co powinniśmy zwracać uwagę:

Re: Cytoreductive Radical Prostatectomy in Patients with Prostate Cancer and Low Volume Skeletal Metastases - Results of a Feasibility and Case-control Study

Experts’ summary:
This retrospective cohort study assessed the feasibility and oncologic benefit of cytoreductive radical prostatectomy (CRP) for metastatic prostate cancer (PCa).
Twenty-three men with oligometastatic PCa (M1b, three or more hot spots) without bulky pelvic lymph nodes were offered CRP after androgen deprivation therapy (ADT) for at least 6 mo to achieve a prostate-specific antigen (PSA) level <1.0 ng/ml and clinical remission or stability.
ADT was continued for at least 2 yr following CRP.
The study group and control group (n = 38) were well balanced with respect to disease burden, primary tumor characteristics, and patient comorbidities.

Open CRP was performed with acceptable perioperative complication rates and continence results (91% used no pad or one pad per day).
Specimens analyzed by step sectioning revealed residual PCa (mean: 18 ml), 83% with pT3 disease, 14% with positive margins, and 57% with lymph node involvement.
Median follow-up was 35 mo and 37 mo for CRP and control groups, respectively.
Median time to castrate-resistant prostate cancer (CRPC) was longer following CRP (40 vs 29 mo,p = 0.01).
Cancer-specific survival (CSS; 96% vs 84%,p = 0.04) but not overall survival (91% vs 79%,p = 0.05) was improved.
The need for percutaneous or surgical intervention due to local progression was greater in the control group (29%).



Experts’ comments:
Registry-based analyses have suggested an overall and disease-specific survival benefit with CRP[1] and [2].
These studies lack information on ADT administration, patient comorbidities, and metastatic burden, which represent potential selection biases among those receiving CRP.
Despite a biological rationale for controlling the source of future metastases [3], CRP must be adopted judiciously in light of potential surgical morbidity and impact on quality of life.
This study demonstrates the feasibility of CRP with acceptable perioperative morbidity and functional outcomes.
When combined with systemic treatment, which is the current standard of care, CRP increased time to CRPC and improved CSS while reducing secondary treatments for local progression.
Whether similar benefits will accrue in patients with widespread metastatic disease remains to be seen.

This retrospective study should be interpreted cautiously in light of equivocal overall survival.

Furthermore, 32% (12 patients) in the control group failed to achieve PSA <1.0 ng/ml after 6 mo of ADT, potentially signaling more aggressive tumor biology. Prospective randomized trials (ClinicalTrials.gov identifier NCT01751438 ) are required to further define oncologic and quality of life benefits and to identify the ideal target population [4] for CRP.
In addition, informative genomic profiling of residual PCa in the prostatectomy specimen after ADT induction [5] could identify prognostic markers and propensity for ADT resistance and ultimately guide targeted treatment.


Standard of Care Versus Metastases-directed Therapy for PETdetected Nodal Oligorecurrent Prostate Cancer Following Multimodality Treatment- A Multi-institutional Case-control Study.pdf



Tutaj cytowane badanie kliniczne drugiej fazy prowadzone w Ameryce Północnej (120 osób):

Best Systemic Therapy or Best Systemic Therapy (BST) Plus Definitive Treatment (Radiation or Surgery)

Currently, a phase II clinical trial (NCT01751438) that is accruing patients at MD Anderson Cancer Center, will randomize patients with hormone-sensitive, M1 prostate cancer to best-systemic therapy or best-systemic therapy plus radiation or surgery with the primary end-point being progression-free survival. Furthermore, patients must have a life expectancy of >2 years, ECOG performance status of 0 or 1, a candidate for surgery or radiation, and finally, initiation of systemic therapy no longer than 6 months prior to randomization. This may help to address the utility of cytoreduction, but the decision of whether to offer radiation or surgery is left to the discretion of the physician, which raises the possible issue of selection bias. Additional prospective studies will certainly be needed.

https://clinicaltrials.gov/ct2/show/NCT01751438
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4215584/



I drugie, belgijskie (80 osób):

Local Treatment With RP for Newly-diagnosed mPCa (LoMP)
https://clinicaltrials.gov/ct2/show/NCT ... 721&rank=1



A tu pozytywny artykuł z Australii:


Role of cytoreductive prostatectomy in non-organ confined prostate cancer

Patient selection
Although the aforementioned trials demonstrate that removing the primary tumour is beneficial to the patient, it is important to note that these results are most applicable in only a subgroup of men with certain characteristics. Age ≥70 years, PSA ≥20 ng/mL, high-grade disease and pelvic lymphadenopathy were all determined by Culp et al to act as independent factors that increased cancer-specific mortality. Five-year overall survival and disease-specific survival were greatest in men with one or fewer factors – 77.3% [95% CI, 67.4-84.5] and 89.9% respectively. Patients with two factors showed rates of 53.1% [95% CI, 38.9-65.4] and 68.5%, but these were still superior to those who had neither surgery nor radiotherapy. The subset of men with three or more of the above factors who had their primary cancer treated, showed no significant difference to those who did not. In concordance with other literature, further analysis revealed that patients over 70 years of age, or those with a PSA above 20 ng/mL, were less likely to benefit from local therapy.11

Furthermore, it is those patients with a relatively low burden of metastatic disease who are most likely to benefit from this approach. Oligometastatic disease usually refers to patients with five or less sites of recurrent metastatic disease following prior treatment of the primary prostate cancer. There is considerable interest in targeting oligometastatic disease in these cases using ablative techniques such as stereotactic radiotherapy, or extirpative approaches such as salvage pelvic lymph node dissection.30 However, the definition of oligometastatic disease is contingent of the sensitivity of the imaging used to identify metastases. Conventional imaging such as CT and bone scanning have poor sensitivity and the use of more advanced imaging, such as 68Ga-PSMA PET scanning, will improve selection of patients with truly low volume metastatic disease.30-32

http://cancerforum.org.au/forum/2015/no ... te-cancer/
Nie masz wymaganych uprawnień, aby zobaczyć pliki załączone do tego posta.
Tata ur.1936 Od 2005 leczenie BPH, PSA przy finasterydzie oscylujące między 5 a 11(!).
Po odstawieniu Proscaru VII.2012 PSA 20,81ng/ml, biopsja GL 4+3, zatarta torebka, scyntygrafia czysto. cT3NxM0 Gleason 7 (4+3)
X.2015 Apo-Flutam (1mc), Diphereline co 3m-ce, zmieniona po roku na Eligard 45. 4.XII.12 PSA 1,15.
XII.2012-I.2013 RT 65 Gy IGRT w 25 frakcjach (Wieliszew).
PSA 21.II.13 - 0,089; 25.IV.13 - 0,076; VI.13 - 0,067; IX.13 - 0,065; XII.13 - 0,044,(testosteron 0,035); III.2014 - 0,057, (T<0,025 od tego momentu); V.14 - 0,021; IX.14 - 0,016; XI.14 - 0,009; I.2015 - 0,01; IV.15 - 0,011 KONIEC HT VIII.15 PSA - 0,008; XI.15 PSA 0,010, T 0,14; II 2016 PSA 0,025, T 0,4; V 2016 PSA 0,017, T 0,68; VIII 2016 PSA 0,021, T 0,9; XI 2016 PSA 0,016, T 0,966; III 2017 PSA 0,003[?], T 1,38; IX 2017 PSA 0,035 T 1,63; XI 2017 PSA 0,051, T 1,79; I 2018 PSA 0,06, T 2,13; II 18 PSA 0,06, T 1,84; IV 18 PSA 0,05 T 1,88; XII 18 PSA 0,05, T 1,57; III 2019 PSA 0.07, T 1,75; V 19 PSA 0.08, T 1,66

3.12.15 – Kolonoskopia i APC zmian naczyniowych (angiodysplazja odbytnicy po RT); 2016 2 serie czopków łagodzących podkrwawianie; 29.05.2017 - ponowna koagulacja laserowa niewielkich zmian naczyniowych w odbycie - zaobserwowana znaczna poprawa stanu śluzówki jelita w porównaniu do 2015
Wątek: http://rak-prostaty.pl/viewtopic.php?f=2&t=2137
bela71
 
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