What is it?
Prostate neoplasia is currently the most frequent malignant solid neoplasm in men, constitutes about 15% of all male neoplasms and is the second leading cause of cancer-related death of men, after pulmonary neoplasia. The most affected age group is men over the age of 65. The primary risk factor for the development of prostate cancer is age; in addition, there are other important factors such as family history, diet (high intake of vitamin E, lycopene and omega-3 fatty acids seem to be protective factors), race (African-American is at higher risk of cancer) and lifestyle. A not insignificant proportion of patients appear to have a clear hereditary pattern. In recent years, thanks to studies on the human genome, it has been shown that some genetic alterations (see mutations in the BRCA 2 gene) seem to be associated with a higher incidence of prostate cancer, a younger age of onset and a more aggressive disease. In fact, in our institute we have genetic tests, which are performed on saliva and blood samples, aimed at identifying precisely this subgroup of patients, in order to receive adequate genetic counseling in order to propose an appropriate personalized treatment.
Which are the symptoms?
Prostate cancer is an asymptomatic disease in most cases and its diagnosis is often incidental. Possible symptoms are those related to local or systemic progression of the disease with haematuria, acute urinary retention, bone pain, renal failure.
How is it diagnosed?
For this reason, the screening for prostate neoplasia based on the measurement of the blood value of PSA (Prostate Specific Antigen) and rectal examination (minimally invasive procedure that allows to assess the size, shape and consistency of the prostate) has now assumed a certain importance. Currently there are no approved screening protocols in Italy; however, the most recent guidelines suggest a measurement of PSA at or before the age of 50 years in patients considered at risk (e.g. African-American race, familiarity and genetic inheritance), on which to base the timing of subsequent checks of blood values of PSA. The PSA value should be interpreted individually on the basis of the clinical and family history of the individual, since there is no real "normal" value. An elevated PSA value is not sufficient for the diagnosis of prostate neoplasia as there are many conditions other than cancer that cause an alteration of PSA. For this reason it is necessary to undergo more invasive diagnostic tests, the main one being the prostate biopsy under ultrasound guidance. With it, tissue samples of the prostate are obtained through which it is possible to determine the presence of cancer cells inside the gland. In recent years, the use of Multiparametric Resonance Imaging of the prostate has become widespread in clinical practice. Using specific sequences, it is able to study the prostate parenchyma and estimate the probability of neoplastic nodularity in the prostate parenchyma by assigning a score to each (PIRADS SCORE). The use of this technique allows, through the use of specific software, to perform targeted biopsy samples in those suspected areas, superimposing the images previously performed in MRI with those performed in real-time in ultrasound during the biopsy procedure, thus performing the Biopsy Fusion.
How is it treated?
Currently, there are many treatments for prostate cancer, and the choice of therapeutic method depends on the characteristics of the patient and the disease itself. The various therapeutic options include: no-treatment follow-up, surgery (open, laparoscopic, or robotic), radiation therapy, high-intensity focused ultrasound HIFU, cryosurgery, hormone therapy, chemotherapy, or a combination thereof. The standard treatment for prostate cancer in patients with a life expectancy of more than 10 years is surgery, which involves the complete removal of the prostate, seminal vesicles, and possibly locoregional lymph nodes. The aim of the operation is to completely eradicate the disease, to maximize the preservation of urinary retention and erectile function. Modern methods of nerve-sparing surgery that preserve the nerves responsible for erection actually allow most patients to restore both urinary retention and erectile function.
Radiotherapy finds applications at any stage for the treatment of prostate cancer, from the earliest to the metastatic forms. It represents an effective therapeutic alternative to surgery, with results comparable or superior to those of surgical treatment, with a favorable toxicity profile. Different techniques can be used according to the clinical indication: Moderately hypofractionated treatments using Tomotherapy in 28 sessions in case it is necessary to irradiate the pelvic lymph node areas in addition to the prostate gland; hypofractionated stereotaxic treatments with Cyberknife or Tomotherapy in 4-5 sessions when the target is represented only by the prostate gland. A protocol for irradiating the prostate in a single session for curative purposes will be implemented shortly. In series of our patients undergoing radical intent treatment in unfavorable intermediate, high and very high risk, the biochemical disease-free survival at 5 and at 10 years is 94% and 87.8%, respectively.
The other therapeutic alternatives mentioned above retain their role in various possible clinical scenarios, and for this reason, the treatment of a patient with prostate cancer is often interdisciplinary.
Where do we treat it?
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