Prostate cancer diagnosis and treatment guidelines

 Third, the treatment of prostate cancer
(a) wait for observation and treatment
waiting to see that the process of active monitoring of prostate cancer, in the event of disease progression or when the clinical symptoms to other treatment [1-7].
Wait observed treatment indications:
(1) low-risk prostate cancer (PSA 4 ~ l0ng/m1, GSl6, clinical stage lT2a) and short life expectancy of patients.
(2) in patients with advanced prostate cancer: only limited than for the treatment of complications associated with extended life and improved quality of life situation.
of clinically localized prostate cancer (T1 ~ 3, Nx or No, Mx, or Mo) suitable for radical treatment of patients who choose to wait observed treatment, patients must understand and accept the risk of local progression and metastasis.
observed in patients who are waiting for close follow-up every 3 months, referral, check the PSA, DRE, if necessary, shorten the time between referral and the impact of examination. For DRE, PSA examination and imaging studies may be considered for patients who progress in other treatment.
(b) of the radical surgical treatment of prostate cancer radical prostatectomy
(referred to as radical mastectomy) is the best treatment for localized prostate cancer effective way, there are three main surgical procedures, namely the traditional perineal, retropubic and the recent development of laparoscopic radical prostatectomy.
1. Indications for radical surgery may cure prostate cancer. surgical indication to consider the clinical stage, life expectancy and health status. Although surgery is no rigid age limits, but should inform patients, with age after 70 years of growth, morbidity and mortality will increase [8-l0]. < br> (1) clinical stage: adapt to limitations of prostate cancer, clinical stage Tl ~ T2c, the patients. for clinical T3, (cT3) of prostate cancer remains controversial, with advocates neoadjuvant therapy underwent radical surgery, can be lower positive margin rates [11-12].
(2) Life expectancy: Life expectancy g10 radical surgery in those who may choose to [13].
(3) Health: Prostate cancer patients were mostly elderly men , the incidence of complications is closely related with the physical condition. Therefore, only in good health, no serious heart and lung disease patients adapt to radical surgery.
(4) PSA or Gleason score of patients with high risk: For PSA> 20 or Gleason score> 8 patients with adenocarcinoma of the limitations in the forefront
stage and life expectancy of compliance with the above conditions, radical surgery may be given other supportive therapy [14-16].
2. surgical contraindications
(4) life expectancy less than 10 years.
3. surgical methods and standards for domestic recommend open retropubic radical prostatectomy and laparoscopic radical prostatectomy.
(1) retropubic radical prostatectomy: open surgical field, the operation simple, the same approach can be completed by the pelvic lymph node dissection, radical aim to achieve.
1) improved pelvic lymph node dissection: abdominal incision, en bloc resection of iliac artery, iliac vein in front of, behind and between the fibers of vascular tissue, down to the inguinal canal, then back to the obturator nerve. suspicious lymph node disease may be frozen section physical examination.
2) radical prostatectomy: Surgical removal of the prostate include the complete, bilateral seminal vesicles and vas deferens ampulla bilateral section of the bladder neck.
to preserve the neurological contraindication: tumor surgery neurovascular bundle may be invaded.
(2) laparoscopic radical prostatectomy: laparoscopic radical prostatectomy is a new technology developed in recent years, its efficacy and similar open surgery, the advantage is less damage, and the anatomy of the surgical field a clear structure, fewer intraoperative and postoperative complications, the disadvantage is more complex technical operations [17]. laparoscopic surgery with open surgical procedures and the scope.
4. surgical time when diagnosis of prostate cancer and in line with the radical operative conditions shall take radical surgery. It has been reported that transrectal biopsy should wait 6 to 8 weeks, may reduce the operative difficulties and complications. transurethral resection of the prostate should wait 12 weeks and then surgery [13].
5. perioperative complications present mortality rate of 0-2.1% of the main complications of severe intraoperative bleeding, rectal injury, postoperative erectile dysfunction, urinary incontinence, vesicourethral anastomotic stricture, urethral stricture, deep venous thrombosis, lymphocele, urinary fistula, pulmonary embolism. laparoscopic radical prostatectomy may also occur along the incision metastasis, switch to open surgery, air embolism, hypercapnia, secondary bleeding and other complications [18,19].
(c) of prostate cancer with radiotherapy (EBRT)
1. overview of radiation therapy for prostate cancer patients with good effect, wide indication, few complications, for each of the patients. early stage patients (T1 ~ 2NoMo) radical radiotherapy, local control rate and 10-year disease-free survival rates similar to radical prostatectomy. locally advanced prostate cancer (T3 ~ 4NoMo) to support the principles of radiotherapy treatment and endocrine therapy. metastases possible cancer palliative radiotherapy, to reduce symptoms, improve quality of life.
recent three-dimensional conformal radiotherapy (3D-CRT) and intensity modulated radiation therapy (IMRT) and other technology is increasingly used in prostate cancer radiation treatment and become the mainstream
technology.
according to TNM stage, Gleason score, PSA level, age, radiation methods, radiation field size and dose is different, the side effects and efficacy are also different [20-24].
2. Prostate Cancer conventional external radiation therapy [20,26-31]
(1) define the scope of exposure: first determine the tumor volume, target volume and treatment volume. The specific method is through the patient fixation system, application MRI or CT images to determine the objectives and the scope of the surrounding normal tissue, and computer-aided treatment planning system to calculate the central surface of the tumor and surrounding normal tissue dose distribution.
(2) radiation dose: dose of local irradiation of prostate cancer were <55Gy, 55 ~ 60Gy, 60 ~ 65Gy ,60-70Gy and> 70Gy, the recurrence rates were 48%, 36%, 21%, 11% and 10% [25]. With the increasing radiation dose, the local recurrence rate was significantly lower.
( 3) irradiation technology: irradiation alone when the prostate and surrounding area with front and rear and both sides of the vast expanse of open field box irradiation technology. radiation field in the lower bound of the lower edge of the ischial tuberosity, lateral field, including rectal wall after the community. If the seminal vesicle, peripheral tissue invasion and lymph node metastasis to be the whole pelvis irradiation, in two steps: first with the whole pelvic radiation field around the two, the upper bound of the radiation field of a S1 L5 between the lower bound at the lower edge of the ischial tuberosity, both sides of the community in the true outer edge of the pelvis l ~ 2cm. conventional fractionated irradiation 5 times a week, each dose of 1.8 ~ 2.0Gy, total 45Gy. hyperfractionated radiation exposure to 2 times a day, each dose of 1.15 ~ L 3Gy. pelvis after radiotherapy range is further reduced exposure to the prostate area, reached a total of 65 ~ 80Gy. using alloy stereotype protection rectum, anal sphincter, small intestine, bladder, urethra [25].
3.3D-CRT and IMRT
(1) Overview : conformal radiotherapy (3D-CRT) to minimize the advantages of the surrounding normal tissues and organs of the exposure, improving local tumor radiation dose and the target amount of radiation. to improve local tumor control rate and reduce complications. < br> IMRT is a new 3D-CRT technology expansion. thin spiral CT scan, draw the target and normal tissue in patients with the geometric model and create digitally reconstructed map, the higher the dose of external beam conformal level. target Fringe can be up to standard doses. IMRT allows radiation doses up to 81 ~ 86.4Gy, but the side effects of rectum and bladder did not increase [32].
(2) define the illuminated area: first determine the isocenter, Draw the skin tag line, the CT scans, and then three-dimensional anatomical image synthesis of visual images, the CT simulator simulated 3D radiation dose by the physician of.
(3) radiation dose analysis: tumor dose by dose - volume histogram (DVH) for evaluation. If a large tumor may be a new adjuvant endocrine therapy until the tumor volume was reduced further radiotherapy.
different stages of the required minimum dose: T1a, 64 ~ 66Gy; T1b ~ T2 ,66-70Gy; T3, 70 ~ 72Gy; T1-3, patients with incomplete resection, 66 ~ 70Gy; recurrence of prostate cancer, 70 ~ 72Gy; T4, 50 ~ 65Gy.
T1a of only Prostate irradiation without including the seminal vesicles. T1 ~ 3 on irradiation target volume should include the prostate, seminal vesicle and the surrounding 0.5 ~ 0.7cm wide organization. 50Gy radiation dose, may reduce the radiation target volume, only the irradiated prostate area. pelvic lymph nodes appear pelvic lymph node metastasis, suggested that exposure.
4. different stages of prostate cancer, external radiotherapy
(1) of radiotherapy for localized prostate cancer (T1 ~ 2NoMo): For low-risk (T1 ~ T2a, Gleason score l6 and PSA <10ng/m1) the efficacy of prostate cancer with radical prostatectomy, similar to [33]; in risk (T2b or Gleason score = 7 or PSA l0 ~ 20ng/m1) increased dose can increase patients without biochemical recurrence-free survival [34]. limited to high-risk (Gleason score> 7 or PSA> 20ng/m1) dose, while patients with improved application of adjuvant endocrine therapy may improve the outcome [35].
(2) locally advanced prostate cancer radiotherapy (T3 ~ 4No Mo, T1 ~ 4NlMo, pT3NoMo): locally advanced prostate cancer often associated with endocrine therapy combined with radiotherapy applications, the use of new adjuvant endocrine treatment or adjuvant endocrine therapy. external radiotherapy combined with hormonal therapy can significantly improve tumor control rates and survival [36-39]. positive surgical margin after radical radiotherapy in vitro aid, local tumor control rate reached 90% ~ 100%.
(3) metastatic prostate cancer radiotherapy: proliferation of prostate cancer or pelvic lymph node can lead to pelvic pain, constipation, leg swelling, such as ureteral obstruction or hydronephrosis. for palliative radiotherapy, can significantly improve symptoms. of prostate cancer bone metastases with palliative radiotherapy to relieve pain and spinal cord compression.
5. radiotherapy complications in radiotherapy of prostate cancer may occur outside the urinary system and intestinal system side effects and sexual dysfunction. radiotherapy-induced side effects due to a single dose and total dose radiation exposure to the program and the volume varies.
urinary system side effects include: urethral stricture, bladder fistula, hemorrhagic cystitis, hematuria, urinary incontinence, etc.; gastrointestinal side effects include: transient colitis, proctitis caused by diarrhea, abdominal cramps, rectal discomfort and rectal bleeding, small bowel obstruction, etc. require surgery sigmoid colon and small intestine of serious injury, perineal abscess, anal stenosis or chronic rectal bleeding of less than 1%. acute radiation skin side effects of erythema, dry skin and scaling, mainly in the perineal and buttock skin wrinkle fold Department. Other side effects include: pubic bone and soft tissue necrosis, lower limb, the scrotum or penis edema, the incidence rate of less than 1%. radiotherapy the incidence of sexual dysfunction after radical surgery than patients [40,41]. (d) prostate cancer brachytherapy
1. Overview of brachytherapy (brachytherapy), including intracavitary irradiation, interstitial irradiation, are the direct release of radioactive sources are sealed within the organization to be treated or release the body's natural cavity irradiation. brachytherapy for prostate cancer treatment, including short-term and permanent implantation particle implant treatment. which radioactive particles that is planted between the organization of treatment, more commonly used, with the aim of three-dimensional treatment planning system through the accurate positioning, radioactive seed implantation within the prostate to improve localized prostate dose, and reduce the radiation dose in rectum and bladder [42-47].
used permanent 125 iodine implant treatment particles (125I) and 103 palladium (103Pd), half-life of 60 days, respectively 17 days. short treatment used 192 Ir implantation (192Ir).
2. brachytherapy indications recommended reference to the U.S. Association of (American Brachytherapy Society, ABS) standard [48].
(1) meets the following 3 condition for the simple brachytherapy indications.
1) to Tl ~ T2a clinical stages of; 2) Gleason grade was 2 ~ 6;
3) PSA <10ng/ml.
( 2) comply with any of the following conditions brachytherapy plus external radiotherapy indications.
1) clinical stage T2b, T2c;
2) Gleason grade 8 ~ 10;
3) PSA> 20ng/ml;
4) peripheral nerve involvement;
5) more positive biopsy results;
6) bilateral biopsy result was positive;
7) MRI examination with prostate specific package extracellular violations.
first foreign scholars have suggested that the majority of re-radiation brachytherapy to reduce radiation complications [49].
(3) Gleason grade of 7 or PSA, should receive according to 10-20ng/m1 determine whether the specific circumstances of the joint external radiotherapy.
(4) brachytherapy (or combined external radiotherapy) combined with endocrine therapy indications: prostate volume> 60ml, feasible neoadjuvant endocrine therapy to shrink the prostate.
3. contraindications
(1) absolute contraindication
1) expected survival of less than 5 years;
2) TURP or poor prognosis after large defects;
3) generally poor;
4) had distant metastasis.
(2) relative contraindications
1) glands than 60ml;
2) with previous history of TURP;
3) highlight the middle;
4 ) severe diabetes;
5) history of multiple pelvic radiation therapy and surgery.
patients each particle dosimetry after planting should be assessed [46], usually with CT evaluation. Particle CT prematurely after planting Check edema and hemorrhage due to prostate and show increased prostate volume, this time to make a dose assessment will underestimate the doses to the prostate. It was suggested dose 4 weeks after planting to assess the most appropriate [50-51]. If you find a low-dose area should be replanted in time for the particles added; If you find a wide range of low-dose region, the line could be considered outside the radiation [45].
4. technology and standards of simple close-treated patients, 125I prescription dose 144Gy, 103Pd is 115 ~
120Gy; joint foreign radiotherapy, external radiotherapy dose of 40 ~ 50Gy, and the radiation dose 125I and 103Pd were adjusted to
100 ~ 110Gy and 80 ~ 90Gy.
lines all patients implant treatment particles before planting treatment plan should be developed, according to three-dimensional treatment planning system gives the desired dose distribution. usually first with the transrectal ultrasound (TRUS) to determine prostate volume, according to TRUS prostate contours depicted and the cross-section to develop treatment plans, including the planting of needle position, the particle number and activity. intraoperative TRUS should again be used to plan, according to the dose distribution curve particle placement, while the particle growing process should also use real-time transrectal ultrasound to guide the operation, are subject to change due to deviation of the needle implanted dose brought about changes in the distribution [52,53]. It should be noted that the prostate target volume prescription dose coverage should include the prostate and the surrounding 3-8mm range. So the prostate target volume is about 1.75 times the actual volume of the prostate [54,55].
5. complication complications including short-term complications and long-term complications. usually within a year is defined as short-term complications complications and complications occurring after the year is defined as the long-term complications [56]. These complications mainly related to the urinary tract, rectal and sexual function and so on.
short-term complications: urinary frequency, urgency and urinary pain and other urinary tract irritation, dysuria and nocturia increased [57-61]. stool frequency increased and rectal tenesmus and other irritation, proctitis (mild blood in the stool, ulcer and even prostate rectal fistula), etc. [62]. < br> Long-term complications in chronic urinary retention, urethral stricture, urinary incontinence is common.
short, brachytherapy for prostate cancer is the second radical prostatectomy and external radiotherapy after radical is expected for another method of localized prostate cancer , more effective, less invasive, especially suitable for radical prostatectomy can not tolerate the elderly patients with prostate cancer.
(e) the forefront of experimental local treatment of cancer, friends
local treatment of prostate cancer, in addition to radical prostatectomy surgery, external beam radiation and internal radiation close proven methods, etc., but also including: prostate cancer cryotherapy (cryo-surgical ablation of the prostate, CSAP), high intensity focused ultrasound (high-intensity focused ultrasound, HIFU) and organizations Radiofrequency ablation of tumor (radiofrequency interstitial tumour ablation, RITA) and other experimental topical treatment. and radical prostate surgery and radiotherapy compared with clinically localized prostate cancer, its treatment effect, but also the need for more clinical studies to assess the long-term and increase [63,64]. In this introduction, clinical reference purposes only.
1. prostate cancer cryotherapy (CSAP) CSAP is considered the treatment of clinically localized prostate cancer can be considered. and radiotherapy compared The advantage is no radiation risk, lower rate of rectal injury, but the postoperative voiding dysfunction and a higher incidence of impotence [65].
CSAP to target frozen, with the guidance of TRUS in the prostate were 12 local home ~ 15 17G freezing probe (cry-oneedles), to more accurately and freeze and destroy prostate cancer, while the surrounding tissue is not affected. In addition, the urethral sphincter and bladder neck and other parts of the temperature sensors placed for temperature monitoring, and with a fine catheter into the urethra warm liquids to avoid hypothermia frostbite. cryotherapy for prostate cancer, the general need to make two TRUS-guided treatment of freeze-thaw cycle, the central part of the gland and neurovascular bundles parts of the temperature can be reduced to -40 ��, in order to ensure effective treatment of cancer [66-70].
(1) CSAP indications
1) localized prostate cancer: �� is not suitable for surgery or life expectancy <10 years of localized prostate cancer; �� serum PSA <20ng/m1; �� Gleason score <7; �� prostate volume l40ml, to ensure the effective freezing range. such as the prostate volume> 40ml, neoadjuvant endocrine treatment in advance so that glandular reduce the size.
2) palliative localized topical treatment and remedial treatment: can be used for prostate cancer metastasis has occurred palliative local treatment to control local tumor development, alleviate symptoms caused by [71], and prostate cancer chemotherapy, endocrine therapy after the remedial treatment [73,74].
(2) CSAP complications: CSAP common complications include erectile dysfunction, tissue loss, urinary incontinence, pelvic pain, urinary retention, rectal fistula, bladder outlet obstruction [73,74].
2. high intensity focused ultrasound for prostate cancer (HIFU) HIFU treatment is the use of piezoelectric crystal or other acoustic lens ultrasonic generator,
in vitro high-energy emission ultrasound, and ultrasonic energy in the body will focus on selected organs and tissues in the region [76]. have been reported in the literature on HIFU treatment of prostate cancer cases less than 1000 cases, there is no randomized controlled clinical study, the average follow-up time are less than 2 years [77-80]. the largest group in the study included 559 cases, low-risk prostate cancer patients, followed up for 6 months after the biopsy-negative patients 87.2%, PSA bottoming (mean 1.8ng/ml).
HIFU complications include urinary retention, urinary incontinence, erectile dysfunction.
3. radiofrequency ablation of tumor tissue within the tumor tissue ablation (RITA) is a direct stab needle electrodes were tumor location, device monitoring and control by radiofrequency ablation unit and computer control, the high-power RF energy transmitted through the electrodes to the tumor tissue ablation, the use of tumor tissue by conductive molecular ion and the polarization direction of radio frequency alternating current to make rapid changes, so that frictional heat tumor tissue itself. When temperature above 60 ��, the tumor tissue leads to irreversible coagulation necrosis, in order to achieve therapeutic purposes.
So far, only 3 small samples of I / �� clinical trial of the RITA and the feasibility of prostate cancer safety [81-83], preliminary results showed a therapeutic effect on prostate cancer.
(f)
endocrine therapy of prostate cancer as early as 1941, Huggins and Hodges discovered surgical castration and estrogen may delay the the progress of metastatic prostate cancer and prostate cancer for the first time confirmed the removal of androgen responsiveness. prostatic cells in the absence of androgen stimulation will occur under conditions of apoptosis. any inhibitory activity in the treatment of androgen may be called for the removal of androgen therapy. androgen removal, mainly through the following strategies: �� suppression of testosterone secretion: surgical castration or medical castration (luteinizing hormone releasing hormone analogue, LHRH-A); �� androgen receptor blocking combination: drugs with anti-competitive closed androgen androgen androgen receptor and prostate cell binding. their combination can achieve the purpose of maximum androgen blockade. Other strategies include inhibiting the synthesis of adrenal source of androgen, and the inhibition such as testosterone into DHT.
endocrine therapy aims to reduce androgen levels, inhibit the synthesis of adrenal source of androgen, inhibit the testosterone into dihydrotestosterone, or blocking androgen binding to its receptor to suppress or control the growth of prostate cancer cells.
endocrine treatment methods include: �� castration; �� maximum androgen blockade; �� intermittent endocrine therapy; �� radical treatment neoadjuvant endocrine therapy; �� adjuvant endocrine therapy.
1. indications [84]
1) metastatic prostate cancer, including the N1 and M1 of (castration, maximum androgen blockade, intermittent hormonal therapy).
2) Limitations or early prostate cancer locally advanced prostate cancer, radical prostatectomy can not or radiation therapy (castration, maximum androgen blockade, intermittent hormonal therapy).
3) radical prostatectomy or radical radiotherapy Neoadjuvant endocrine therapy prior to (castration, maximum androgen resistance
off).
4) with radiation therapy adjuvant endocrine therapy (castration, maximum androgen blockade).
5) local recurrence after curative treatment , but not further local treatment (castration, maximum androgen blockade, intermittent hormonal therapy).
6) distant metastases after curative treatment (castration, maximum androgen blockade, intermittent hormonal therapy) .
7) of androgen-independent continuous androgen suppression (castration).
2. castration (Castration)
(1) surgical castration: surgical castration testosterone can quickly and continued to decline to very low levels (castration level). The main adverse reaction is the psychological impact on patients.
(2) medical castration: luteinizing hormone releasing hormone analogue (LHRH-a) is a synthetic luteinizing releasing hormone,
the products listed are: leuprolide (Leuprorelin), goserelin (goserelin), triptorelin (in ptorelin). After the injection of LHRH-a, testosterone gradually increased, at 1 week reached its highest point (a transient increase testosterone), and then gradually decreased to 3 to 4 weeks to reach castration levels [85], but 10% of patients can not reach castration levels of testosterone [3] . LHRH-a has become the standard treatment for androgen removal of one of the methods.
the initial injection of LHRH-a when a transient increase of testosterone, so the beginning of the day should be given the injection of anti-androgen drugs for two weeks, against a transient increase of testosterone caused by the exacerbation (Flare-up) [87]. for spinal cord compression have been suffering from bone metastases
, should be used with caution LHRH-a, may choose to quickly lower the testosterone level of surgical castration.
(3) estrogen: estrogen effects in prostate mechanisms include: reduced LHRH secretion, inhibit androgen activity, direct inhibition of testicular Leydig cell function, as well as direct toxicity of prostate cells [88]. < br> The most common estrogen is diethylstilbestrol. oral diethylstilbestrol lmg, 3mg, or 5mg / day, can achieve the same effect as castration, but the cardiovascular adverse events was significantly increased. Despite the low dose of diethylstilbestrol (such as lmg / day), and also the application of low-dose warfarin (1mg / day), or low-dose aspirin (75 ~ 100mg / day) prevention, cardiovascular adverse events is still high [89], therefore, should be cautious in the application. Estrogen is one of the classic endocrine therapy.
surgical castration, medical castration or estrogen therapy, the patient survival rate of tumor progression-free survival rate is basically the same.
3 . maximum androgen blockade (maximal androgen blockade, MAB)
(1) Purpose: to remove or block both testicular and adrenal sources of androgen source.
(2) Method: The method used to potential plus anti-androgen drugs. anti-androgen drugs are two major categories: one is steroids, the representative of megestrol acetate; another non-steroidal drugs, mainly bicalutamide (Bicalutamide) and flutamide (Flutamide).
(3) Results: Combined non-steroidal anti-androgen drugs androgen MAB method, compared with castration alone prolong overall survival of 3 to 6 months, the average 5-year survival rate of 2.9% [90], for localized prostate cancer, the longer the application of MAB therapy, PSA recurrence rate is lower [91]. The MAB Bicalutamide combination therapy, compared with castration alone can reduce the risk of death 20%, and may be extended progression-free survival [92].
4. radical neoadjuvant endocrine therapy (neoadjuvant hormornal therapy, NHT)
(1) Objective: Radical prostatectomy before patients with prostate cancer endocrine therapy for some time to reduce the tumor volume, lower clinical stage, lower rates of prostate tumor positive surgical margin, and thus extend the survival rate.
(2) Methods: LHRH-a and anti-androgen The MAB method, also can be used alone LHRH-a, anti-androgen drugs or estradiol nitrogen mustard, but the efficacy of MAB method is more reliable. 3 to 9 months.
(3) Results: Neoadjuvant treatment may reduce the clinical stage [93], can reduce prostate cancer-positive surgical margin rate of [94-98], reduce the local recurrence rate [93], longer than 3 months of treatment may be extended for PSA recurrence-free survival [99], and the role of overall survival to be longer follow-up. neoadjuvant therapy did not reduce the lymph nodes and seminal vesicle invasion [97].
5. intermittent hormonal therapy (intermittent hormonal therapy, IHT) in the absence or low levels of androgens state, the survival of prostate cancer cells to androgen through additional access to anti-apoptotic potential and continue to grow, thereby prolonging the progression to androgen-dependence of the time [100]. IHT's benefits include improved patient quality of life may be prolonged androgen dependent time, there may be a survival advantage, reducing the cost of treatment [101]. IHT from clinical studies indicate that during the treatment significantly improved the quality of life of patients, such as sexual desire recovery. enable tumor cells to prolonged androgen dependent, while the disease progress or survival time is a big negative impact. IHT is more suitable for localized foci of infection and local recurrence after treatment [102-108].
(1) IHT treatment modalities: multiple use of MAB method, also used medical castration (LHRH -a), such as Goserelin, Leuprolide, and Buserelin, or steroid cyproterone acetate (CPA) [102-108].
(2) IHT stop treatment standards: various reports vary, recommended stopping the domestic PSAl0.2ng/ml drug standards, the continued 3-6 months [108].
(3) intermittent treatment restarted after the standard treatment: different reports has yet to reach a unified standard. different as reported in the literature : PSA> 4ng/m1 after; PSA rose to 10 ~ 20ng/m1 time; PSA ~ 20ng/m1 after; PSA level before treatment, rose 1 / 2; currently recommended when PSA ~ 4ng/m1 begin a new round of treatment [108].
(4) IHT indications: limitations of prostate cancer, not radical surgery or radiotherapy; patients with locally advanced (T3 ~ T4 period); positive margin after radical pathology; radical surgery or radiotherapy relapse.
(5) IHT's significance and potential risks are likely to remain hormone dependent prostate cancer cells, retard the progress of prostate cancer cells to a non-hormone dependent of the time, which may prolong survival of patients.
treatment Potential risks: whether to accelerate the androgen-dependent development of non-hormone dependent; in the treatment of intermittent progress of the lesions whether [108,109].
6. adjuvant endocrine treatment of prostate cancer (adjuvant thormonal therapy, AHT) AHT
prostate cancer is radical resection or radical radiotherapy [110], combined with endocrine therapy. the purpose of cutting edge treatment of residual disease, residual positive lymph nodes, small metastases and improve the long-term survival.
7, PSA> 20ng/ml) [111.112].
4) limitations of risk factors associated with prostate cancer (Gleason ~ 7, PSA ~ 20ng/m1), radical radiotherapy AHT.
5) locally advanced prostate cancer after radiotherapy AHT.
(2) method [112-115]
1) maximum androgen blockade (MAB).
2) medical castration   3) anti-androgen (anti-androgens): including steroidal and non-steroidal.
4) surgical castration
(3) timing: most advocates began immediately after surgery or radiotherapy [116 -119].
Overall, AHT treatment mainly for positive margins, pT3, pN + and lpT2 of patients with risk factors, the majority reported in the literature can delay time to disease progression, but can improve the survival rate is no unanimous conclusion . the choice of treatment time and the time limit should be considered in patients with pathological stage, treatment side effects and costs, is still ...