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Extracapsular Extension Prostate Cancer Treatment

Standard Treatment Options For Stage I Prostate Cancer

Prostate cancer with extracapsular extension

Standard treatment options for patients with stage I prostate cancer include the following:

  • Interstitial implantation of radioisotopes.
  • Watchful waiting or active surveillance/active monitoring

    Asymptomatic patients of advanced age or with concomitant illness may warrant consideration of careful observation without immediate active treatment. Watch and wait, observation, expectant management, and active surveillance/active monitoring are terms indicating a strategy that does not employ immediate therapy with curative intent.

    Evidence :

  • In a retrospective pooled analysis, 828 men with clinically localized prostate cancer were managed by initial conservative therapy with subsequent hormonal therapy given at the time of symptomatic disease progression.
  • This study showed that the patients with grade 1 or grade 2 tumors experienced a disease-specific survival of 87% at 10 years and that their overall survival closely approximated the expected survival among men of similar ages in the general population.
  • Radical prostatectomy

    Radical prostatectomy, usually with pelvic lymphadenectomy is the most commonly applied therapy with curative intent. Radicalprostatectomy may be difficult after a transurethral resection of the prostate .

    Because about 40% to 50% of men with clinically organ-confined disease are found to have pathologic extension beyond the prostate capsule or surgical margins, the role of postprostatectomy adjuvant radiation therapy has been studied.

    Evidence :

    Evidence :

    Autoimmune Disease Toxic Exposure And Cancer

    Since 1974, Robert L. Bard, M.D., PC, DABR, FASLMS, has pioneered noninvasive digital imaging technologies as alternatives to radiation-producing diagnostic systems for evaluating solid organ neoplastic disease. He is internationally recognized as a leader in the field of 21st century 3-D ultrasonographic volumetric Doppler imaging.He specializes in advanced 3-D sonography to detect cancers in numerous organs including the breast, prostate, skin, thyroid, melanoma and other areas. His images are used to accurately guide biopsies, target therapy and provide focused follow-up after treatment.

    Standard Treatment Options For Stage Iv Prostate Cancer

    Standard treatment options for patients with stage IV prostate cancer include the following:

  • Watchful waiting or active surveillance/active monitoring.
  • Hormonal manipulations

    Hormonal treatment is the mainstay of therapy for metastatic prostate cancer. Cure is rarely, if ever, possible, but striking subjective or objective responses to treatment occur in most patients. The cornerstone of hormonal therapy for prostate cancer is medical or surgical castration to stop the production of testosterone by the testes. This is commonly referred to as androgen deprivation therapy and can be achieved with bilateral orchiectomy or with administration of gonadotropin-releasing hormone agonists or antagonists. The most effective purely hormonal approach employs a combination of ADT and one of the following agents:

    • Abiraterone acetate, an inhibitor of cytochrome P450c17, a critical enzyme in androgen biosynthesis.
    • Apalutamide, an androgen receptor antagonist.
    • Enzalutamide, an androgen receptor antagonist.

    Randomized controlled trials have reported that combination therapy with any one of these drugs plus ADT results in longer overall survival than does ADT alone.

  • After a median follow-up of 30.4 months, the trial was stopped because of a clear overall survival benefit in the abiraterone study group: median survival not reached versus 34.7 months OS .
  • The 2-year OS rate was 82.4% in the apalutamide group and 73.5% in the placebo group .
  • Immediate versus deferred hormonal therapy

    Evidence :

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    Randomised Trial Of Adjuvant Radiotherapy Following Radical Prostatectomy Versus Radical Prostatectomy Alone In Prostate Cancer Patients With Positive Margins Or Extracapsular Extension

    • Teuvo L. TammelaAffiliations
    • Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, FinlandDocrates Cancer Center, Helsinki, Finland
    • Tiina LuukkaalaAffiliationsResearch, Development and Innovation Center, Tampere University Hospital and Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
    • Jarno RiikonenAffiliations
    • Pirkko-Liisa Kellokumpu-LehtinenAffiliationsDepartment of Oncology, Tampere University Hospital, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
    • Finnish Cancer RegistryInstitute for Statistical and Epidemiological Cancer Research, Helsinki, FinlandFaculty of Social Sciences, University of Tampere, Tampere, Finland
    • Akseli HemminkiCorrespondenceCorresponding author. Cancer Gene Therapy Group, University of Helsinki, Haartmaninkatu 3, 00290 Helsinki, Finland. Tel. +358 294 125 464.Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, FinlandDocrates Cancer Center, Helsinki, FinlandCancer Gene Therapy Group, Translational Immunology Research Program, University of Helsinki, Helsinki, Finland
    • on behalf of the FinnProstate Group

    Standard Treatment Options For Stage Ii Prostate Cancer

    Extracapsular Extension and Seminal Vesicle Invasion ...

    Standard treatment options for patients with stage II prostate cancer include the following:

  • Interstitial implantation of radioisotopes.
  • Watchful waiting or active surveillance/active monitoring

    Asymptomatic patients of advanced age or with concomitant illness may warrant consideration of careful observation without immediate active treatment. Watch and wait, observation, expectant management, and active surveillance/active monitoring are terms indicating a strategy that does not employ immediate therapy with curative intent. .

    Evidence :

  • In a retrospective pooled analysis, 828 men with clinically localized prostate cancer were managed by initial conservative therapy with subsequent hormonal therapy given at the time of symptomatic disease progression.
  • This study showed that the patients with well-differentiated tumors or moderately well-differentiated tumors experienced a disease-specific survival of 87% at 10 years and that their overall survival closely approximated the expected survival among men of similar ages in the general population.
  • The decision to treat should be made in the context of the patients age, associated medical illnesses, and personal desires.
  • Radical prostatectomy

    Radical prostatectomy, usually with pelvic lymphadenectomy is the most commonly applied therapy with curative intent. Radical prostatectomy may be difficult after a transurethral resection of the prostate .

    Evidence :

    Evidence :

  • About 50% of the men had palpable tumors.
  • Evidence :

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    Extraprostatic Extension And Positive Margins

    Conceptually, as with most cancers, men that have cancer extending outside of the gland and/or positive margins are at a high risk of recurrence. Early it on, it was thought that those patients had such a high risk of recurrence that they were ânot curable by surgery aloneâ. As our experience with prostate cancer has evolved to where it is not as advanced at presentation, the prognosis has improved, but those factors do still offer some prediction as to recurrence.

    Both extraprostatic extension and margin status offer prognostic information. Various studies find that one may be more dominant than the other, but in most cases, it is really hard to separate the two. The likelihood of being significant on multivariate analysis depends on the multiple other factors with which they are evaluated. For example, if SV positive or LN positive patients are included, margin status or EPE may not be independently predictive due to the overwhelming risk of failure associated with those two factors. Although at times they are the most predictive factor, as a stand alone factor, they usually don’t have the overwhelming failure risk associated with SV positive, LN positive and high grade cancers. With that, it is the additional risk they convey in addition to other factors that make them so important.

    Table 4

    74%50%

    Adjuvant Radiotherapy In Prostate Cancer Patients With Positive Margins Or Extracapsular Extension

    Chandler Bronkema1,2#, Nikola Rakic1,2#, Firas Abdollah1

    1Vattikuti Urology Institute, Wayne State University School of Medicine , USA

    #These authors contributed equally to this work.

    Correspondence to:

    Provenance: This is an invited article commissioned by the Section Editor Dr. Peng Zhang .

    Submitted Oct 29, 2019. Accepted for publication Nov 07, 2019.

    doi: 10.21037/atm.2019.11.44

    In men with localized prostate cancer , radical prostatectomy is often the treatment of choice and has shown exceptional long-term outcomes . In patients with adverse pathological features at surgery , randomized trials recommend adjuvant radiotherapy to achieve optimal disease control . In clinical practice, the decision to treat patients with aRT is dependent on several variables, the primary factors including: disease characteristics, degree of added benefit, and risk of unnecessary radiation-related complications. While the role of aRT in patients with adverse pathology at surgery has been extensively explored, the exact benefit in those patients who have some adverse features, but still localized disease, such as a pT2 disease with a positive margin, or pT3a disease with a negative margin remains to be fully elucidated. In view of this void in recent literature, Hackman et al. reported on the Finnish randomized trial .

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    Digital Imaging Reduces Complications

    Fear of complications deters patients from seeking medical intervention so many opt for noninvasive diagnostic options. Cancer treatment effectiveness depends on the precise tumor volume and depth penetration measurements. However, many cancers provoke a benign local immune response or there may be co-existant inflammatory reaction that simulates a larger area of malignancy, such as cicatrix formation accompanying chronic prostatitis, that is indistinguishable on MRI from a stone or malignancy. Imaging highlights the true border of the tumor, optimizing targeting for healthy tissue sparing and resulting in a narrower treatment zone and lesser side effects.

    Hormonal Therapy And Its Complications

    Diagnosis of Stage 3 Prostate Cancer

    Several different hormonal approaches are used in the management of various stages of prostate cancer.

    These approaches include the following:

    Abiraterone acetate

    Abiraterone acetate has been shown to improve OS when added to ADT in men with advanced prostate cancer who have castration-sensitive disease. Abiraterone acetate is generally well-tolerated however, it is associated with an increase in the mineralocorticoid effects of grade 3 or 4 hypertension and hypokalemia compared with ADT alone. It may also be associated with a small increase in respiratory disorders.

    Bilateral orchiectomy

    Benefits of bilateral orchiectomy include the following:

    • Ease of the procedure.
    • Immediacy in lowering testosterone levels.
    • Low cost relative to the other forms of ADT.

    Disadvantages of bilateral orchiectomy include the following:

    • Psychological effects.
    • Osteoporosis.

    Bilateral orchiectomy has also been associated with an elevated risk of coronary heart disease and myocardial infarction.

    Estrogen therapy

    Estrogens at a dose of 3 mg qd ofdiethylstilbestrol will achieve castrate levels of testosterone. Likeorchiectomy, estrogens may cause loss of libido and impotence. Estrogens also cause gynecomastia, and prophylactic low-dose radiation therapy to the breasts is given to prevent this complication.

    Luteinizing hormone-releasing hormone agonist therapy

    Evidence :

    Antiandrogen therapy

    ADT

    Evidence :

    Antiadrenal therapy

    Also Check: What Age Do Males Get Prostate Cancer

    Mri Findings Help Forecast Prostate Cancer Prognosis

    Date:
    Radiological Society of North America
    Summary:
    Magnetic resonance imaging findings in patients about to undergo radiation therapy for prostate cancer can help predict the likelihood that the cancer will return and spread post-treatment, according to a new study.

    Magnetic resonance imaging findings in patients about to undergo radiation therapy for prostate cancer can help predict the likelihood that the cancer will return and spread post-treatment, according to a new study.

    “This is the first study to show that MRI detection and measurement of the spread of prostate cancer outside the capsule of the prostate is an important factor in determining outcome for men scheduled to undergo radiation therapy,” said study co-author Fergus V. Coakley, M.D., professor of radiology and urology, vice chair for clinical services and section chief of abdominal imaging in the Department of Radiology at University of California, San Francisco.

    Prostate cancer forms in tissues of the prostate, a gland in the male reproductive system. The National Cancer Institute estimates 186,320 new cases of prostate cancer will be diagnosed in the U.S. in 2008, mostly in men over age 65. When diagnosed and treated early, the five-year survival rate for patients with prostate cancer is nearly 100 percent. However, once the cancer spreads or recurs beyond the prostate, the chance of survival drops significantly.

    Story Source:

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    Hi Scott And Welcome To Our

    Hi Scott and welcome to our forum. But of course we all are saddened for the reasons that you had to find our corner of the web.

    I am by no means a doctor nor am I in the medical field. I would agree that not having the positive margins is indeed a good sign. So try not to worry and heal.

    You didn’t mention when your surgery was so hoping you are well on the road to recovery. As the doctor may have explained to you when they remove your prostate during surgery they ink it and then send to the lab. The lab doesn’t want to see any cancer cells in the inked area. If they find that it is considered a positive margin.

    I had my surgery 4 years ago and was also a Gleason 7. I did have a positive margin. I just recently started IMRT radiation due to my PSA slowly starting to rise. I’m just over the half way point in the radiation.

    Follow your Doctors advice and get those PSA checks. Its a bother but it is best to find out as early as possible if the PSA does start to rise. Then you can follow up.

    Of course the Gleason 7 is borderline aggressive but I think you will do fine.

    Keep us posted with any further questions and your PSA

    lewvino

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    Quantifiable Digital Scanning Versus Biopsy

    The new optical dermatologic modalities of reflectance confocal microscopy and optical coherence tomography are highly accurate in detecting malignant capsular penetration and are used in other solid organ tumors such as breast, thyroid and prostate tumors with great accuracy, but limited depth penetration. Highly suspect areas are then checked for spread to the seminal vesicles, and a search is performed for lymphadenopathy to verify the disease is locoregionally confined and surgical intervention is unlikely at this time. Patients are reassured since they simultaneously see the 3-D picture as the real time exam proceeds in thoroughly logical, systematic staging. Four-dimensional sequencing permits image-guided biopsy of the most virulent area of the tumor and allows the pathologist to focus on strongly suspicious regions of the lymph node mass excised during prostatectomy. Similarly, during examination the patient may personally visualize extraprostatic disease or seminal vesical invasion so plans for radiation or other therapies may be initiated in a timely manner.

    What Is Locally Advanced Prostate Cancer

    Extracapsular extension of prostate cancer on various ...

    Locally advanced prostate cancer is cancer that has started to break out of the prostate, or has spread to the area just outside the prostate.

    Watch our animation to find out more about the different stages of prostate cancer:

    You may hear locally advanced prostate cancer called stage T3 or T4 prostate cancer. It may have spread to your:

    • prostate capsule, which is the outer layer of the prostate
    • seminal vesicles, which are two glands that sit behind your prostate and store some of the fluid in semen
    • lymph nodes near your prostate, which are part of your immune system
    • bladder, which is the part of the body where urine is stored
    • back passage
    • pelvic wall.

    Different doctors may use the term locally advanced prostate cancer to mean slightly different things, so ask your doctor or nurse to explain exactly what they mean. They can explain your test results and the treatment options available. Or you could call our Specialist Nurses for more information and support.

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    If Treatment Does Not Work

    Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.

    This diagnosis is stressful, and for many people, advanced cancer may be difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.

    People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment, including a hospital bed, can make staying at home a workable option for many families. Learn more about advanced cancer care planning.

    After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

    Seminal Vesicle And Lymph Node Positive

    The determination of risk is not straightforward. As discussed earlier, the three standard prognostic factors are Gleason score, PSA and stage. There are subgroups in each that appear to have a very high risk of recurrence. So the first place to start is whether there are any single factors that portend such a great risk that they alone would indicate the need for adjuvant treatment. One that easily falls into this category is that of positive lymph node metastasis. The risk of failure in these patients is non-controversial and we won’t discuss it further. We would submit that the second of these is that of seminal vesicle involvement, which has been extensively studied .

    Table 1

    56%

    Definition of failure and disease free survival: based on biochemical failure and includes biopsy proven local recurrence and radiologically detected distant metastasis

    * 2 year endpoint for all groups. Mar+ is margin positive Mar- is margin negative EPE+ is extraprostatic extension present EPE- is extraprostatic extension absent foc is focal Ext is extensive Est is established Gl is Gleason score

    The limitations of the small numbers of patients in the more favorable subgroups make selecting those patients for avoidance of intervention a risky proposition. In a subgroup analysis of the SWOG adjuvant study , all the subgroups benefitted from adjuvant radiation to the same degree .

    Also Check: Late Stage Prostate Cancer Treatment

    Standard Treatment Options For Stage Iii Prostate Cancer

    Standard treatment options for patients with stage III prostate cancer include the following:

  • Watchful waiting or active surveillance/active monitoring.
  • External-beam radiation therapy with or without hormonal therapy

    EBRT alone, luteinizing hormone-releasing hormone agonist, or orchiectomy, in addition to EBRT, should be considered. Definitive radiation therapy should be delayed until 4 to 6 weeks after transurethral resection to reduce the incidence of stricture.

    Hormonal therapy should be considered in conjunction with radiation therapy especially in men who do not have underlying moderate or severe comorbidities. Several studies have investigated its utility in patients with locally advanced disease.

    Evidence :

  • Although patients in the Radiation Therapy Oncology Group RTOG-9413 trial showed a 15% estimated risk of lymph node involvement and received whole-pelvic radiation therapy compared with prostate-only radiation therapy, overall survival and PSA failure rates were not significantly different.
  • In a randomized trial, 875 men with locally advanced nonmetastatic prostate cancer were randomly assigned to receive 3 months of an LH-RH agonist plus long-term flutamide with or without EBRT. Nineteen percent of the men had tumor stage T2, and 78% of the men had stage T3.
  • At 10 years, both overall mortality and the prostate cancer-specific mortality favored combined hormonal and radiation therapy.
  • Two smaller studies, with 78 and 91 patients each, have shown similar results.
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