Oncologie

, Volume 14, Issue 2, pp 79–86 | Cite as

La prise en charge du cancer de la prostate à haut risque: chirurgie ou hormonoradiothérapie

Mise au Point Update

Résumé

Parmi les modalités thérapeutiques des cancers de la prostate à haut risque, la prostatectomie totale est reconnue au même titre que l’hormonoradiothérapie, mais son rôle reste controversé en monothérapie et mal évalué dans le traitementmultimodal. L’association radiothérapie et hormonothérapie de longue durée est le traitement de référence dans les cancers localement avancés. Le bilan d’extension préthérapeutique s’appuie sur les données de l’imagerie et de la médecine nucléaire, il vise à éliminer les métastases ganglionnaires ou à distance. Techniquement, la prostatectomie totale commence par un curage ganglionnaire étendu puisune exérèse tissulaire élargie. Lamorbidité est comparable à la chirurgie conservatrice sauf pour la dysérection due à l’absence recommandée de préservation nerveuse. Les résultats des séries intégrant la chirurgie au traitement multimodal montrent une survie spécifique à dix ans de 85 % et à 15 ans de 75 % comparables à ceux de l’hormonoradiothérapie. Pour les cancers localement avancés ou à haut risque, l’addition d’une hormonothérapie à la radiothérapie externe améliore la survie sans progression clinique et/ou biologique et la survie globale. Le contrôle local est toujours nécessaire, et certains patients bénéficieront d’une attitude locale « agressive » (chirurgicale, radiochirurgicale ou par escalade de dose), d’autres d’un traitement hormonal adjuvant plus court, certains probablement nécessiteront une intensification du traitement général: l’optimisation de ces approches thérapeutiques fait actuellement l’objet d’essais thérapeutiques contrôlés.

Mots clés

Cancer de la prostate à haut risque Prostatectomie totale Lymphadénectomie pelvienne étendue Hormonoradiothérapie 

Management of high-risk prostate cancer: surgery or radiotherapy with hormonal treatment

Abstract

Among the different treatment options recommended for high-risk prostate cancer (HRPC), radical prostatectomy (RP) is recognized along with radiotherapy, but its role is still controversial in monotherapy and difficult to evaluate in combined treatments. The results of clinical trials combining an external radiotherapy with a long-term androgen deprivation in locally advanced tumours sustain the principle of a multidisciplinary management in HRPC. Clinical and histological data associated with the MRI assessment remain essential and enhance the preoperative multidisciplinary decision, especially regarding nodal and distant metastases. An enlarged RP with an extended pelvic lymphadenectomy can be considered a viable alternative to radiotherapy and hormonal therapy. Morbidity of the procedure is similar to RP for organ-confined tumours, despite more erectile dysfunction due to non-sparing RP is observed in most of the cases. Oncological results of recent studies show 10-year and 15-year specific survival rates to be around 85% and 75% respectively, similar to those with hormonoradiotherapy. For high-risk and locally advanced prostate cancers, combined androgen deprivation and radiotherapy improved progression-free survival and overall survival. Local control is always necessary, but some patients will benefit from local aggressive treatment (surgery, postoperative radiotherapy or high dose radiotherapy), some may have a shorter adjuvant treatment, and probably some will need an intensification of general therapy: optimization of these approaches need further randomized trials.

Keywords

High risk prostate cancer Radical prostatectomy Extended pelvic lymphadenectomy Radiotherapy Concomitant hormonal treatment 

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Copyright information

© Springer Verlag France 2012

Authors and Affiliations

  1. 1.Département d’urologie, CHU de Toulouseuniversité Paul-SabatierToulouseFrance
  2. 2.Département d’oncologie-radiothérapieinstitut BergoniéBordeauxFrance

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