Fournier G, Mangin P
Service d'Urologie, CHU Morvan, Brest.
Presse Med. 1995 Oct 28;24(32):1465-70.
Rising incidence, resulting from diagnosis together with the increasing age in the population, and high mortality combine to make cancer of the prostate a leading cause of death in men. Despite early, and unfortunately overly optimistic, hopes placed in oestrogen therapy, management of patients with metastatic cancer of the prostate remains one of the major challenges facing urologists. For stage D1 (invasion of the iliac nodes), systemic treatment is required, based on androgen deprivation, with five years disease free survival ranging from 55% to 95%. Radical prostatectomy is not indicated in cases of pathologically confirmed macroscopic nodal involvement, but the question remains controversial for patients with microscopic metastases. Pelvic radiotherapy at "curative doses" is not indicated because of the lack of any improvement over hormone therapy alone. Controversies still exist about timing of androgen deprivation (early or deferred endocrine treatment) either for stage D1 or stage D2 asymptomatic patients, but controlled studies are ongoing. Immediate endocrine therapy is however clearly indicated in stage D2 symptomatic disease and leads to improvement of symptoms (mainly bone pain) in up to 80% of patients. When there is spinal cord compression adding corticosteroids can be useful; surgery or radiotherapy are indicated particularly in cases of vertebral instability or neurological involvement. Current protocols are based on maximal androgen deprivation combining medical or surgical castration and anti-androgens. Prognosis is very poor at relapse despite hormone therapy (stage D3). Survival rate at 1 year is only 50%. It is essential that anti-androgens be withdrawn at this time since clinical improvement can be observed in some patients (anti-androgen withdrawal syndrome). None of the second line treatments (hormonal or chemotherapy) have led to any improvement in survival time. Treatments only alleviate patient discomfort and improve quality of life. The lack of progress over the last 50 years in the treatment of advanced stage cancer of the prostate means that the only way to cure future patients will be conditioned by early diagnosis and treatment during the less advanced stages.
发病率上升，这是由诊断水平提高以及人口老龄化共同导致的，加上高死亡率，使得前列腺癌成为男性死亡的主要原因之一。尽管早期曾对雌激素疗法寄予厚望，不幸的是这种期望过于乐观，但前列腺癌转移患者的管理仍然是泌尿外科医生面临的主要挑战之一。对于D1期（髂淋巴结受累），需要进行基于雄激素剥夺的全身治疗，五年无病生存率在55%至95%之间。在病理证实有肉眼可见的淋巴结受累的情况下，不建议进行根治性前列腺切除术，但对于有微小转移的患者，这个问题仍存在争议。由于与单纯激素治疗相比没有任何改善，因此不建议采用“治愈剂量”的盆腔放疗。对于D1期或D2期无症状患者，雄激素剥夺的时机（早期或延迟内分泌治疗）仍存在争议，但相关对照研究正在进行。然而，对于D2期有症状的疾病，立即进行内分泌治疗显然是必要的，高达80%的患者症状（主要是骨痛）会得到改善。当出现脊髓压迫时，加用皮质类固醇可能会有帮助；手术或放疗尤其适用于椎体不稳定或有神经受累的情况。目前的方案基于最大程度的雄激素剥夺，联合药物或手术去势及抗雄激素药物。尽管进行了激素治疗，但复发时预后很差（D3期）。1年生存率仅为50%。此时必须停用抗雄激素药物，因为部分患者可观察到临床改善（抗雄激素撤药综合征）。二线治疗（激素治疗或化疗）均未使生存时间得到任何改善。治疗仅能减轻患者不适并提高生活质量。在过去50年中晚期前列腺癌治疗方面缺乏进展，这意味着治愈未来患者的唯一途径将取决于早期诊断和在疾病较早期阶段进行治疗。
