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Comment sélectionner au mieux les candidats aux biopsies de prostate ? Rôle des outils traditionnels et apport des nouveaux marqueurs du cancer de la prostate
2011
- Réf : Prog Urol, 2011, 21, S88, suppl. S3


En 2010, la détection précoce du cancer de la prostate continue de s’appuyer sur le toucher rectal et le dosage du PSA sérique total. Cependant, la sélection des patients candidats aux biopsies prostatiques nécessite de mettre le PSA en perspective avec le volume prostatique et de prendre en compte son évolution au cours du temps. Les dérivés du PSA tels que la densité du PSA, la vélocité du PSA et le rapport PSA libre / PSA total sont des compléments utiles. Toutefois, le choix de la valeur seuil reste mal précisé et dépend du rapport sensibilité / spécificité souhaité. Les véritables innovations viennent de la recherche fondamentale qui a donné des marqueurs potentiels d’agressivité du cancer de la prostate et des outils de biologie moléculaire utilisables en routine comme le score PCA-3, les gènes de fusion et le pro-PSA. La place de ces nouveaux marqueurs pour le diagnostic et le pronostic du cancer de la prostate reste encore à préciser.


In 2010, early detection of prostate cancer continues to rely on digital rectal examination and serum total PSA. However, selecting patients for prostate biopsy requires taking into account the prostate volume and the evolution of PSA over time. PSA derivatives such as PSA density, PSA velocity and the ratio free PSA / total PSA are useful supplements. However, the choice of the threshold value is not well defined and depends on the relative sensitivity and specificity desired. The real innovations come from basic research that has found potential markers of aggressiveness of prostate cancer and molecular biology tools used routinely as the PCA-3 score and the pro-PSA. The role of these new markers for diagnosis and prognosis of prostate cancer remains unclear.

Controverses dans le cancer de la prostate localisé : épidémiologie, dépistage et stadification
2011
- Réf : Prog Urol, 2011, 21, S75, suppl. S3


La prise en charge diagnostique et thérapeutique du cancer de la prostate localisé fait débat au sein de la communauté urologique. Alors que l’incidence de la maladie a augmenté de manière importante du fait du dépistage, les données récentes de la littérature ont montré qu’une prise en charge sans discernement conduisait à un risque élevé de sur-traitement et de morbidité inutile. Le développement de nouvelles stratégies de dépistage et de diagnostic s’appuyant sur les progrès de la biologie (pro-PSA, PCA3 urinaire, polymorphisme génétique) et de l’imagerie (IRM de diffusion) contribue à progressivement mieux caractériser les cancers de prostate localisés et ainsi mieux adapter leur prise en charge. Lors du congrès de l’AFU 2010, de nombreux travaux avaient pour objectif de mieux cibler les sujets à risque au sein de la population et de mieux identifier les cancers à potentiel évolutif parmi les cancers diagnostiqués. Cela passe par une meilleure connaissance des facteurs de risque (âge, antécédents familiaux, mélanodermie, exposition aux hormones stéroïdiennes), la définition de critères plus fins pour la mise en oeuvre d’un dépistage ciblé et une stadification plus précise afin d’apporter une réponse thérapeutique adaptée.


Diagnosis and treatment of localized prostate cancer is debated within the urological community. While the incidence of the disease has increased significantly due to the screening, recent data from the literature showed that indiscriminate support led to a high risk of over-treatment and unnecessary morbidity. The development of new strategies for detection and diagnosis, based on the progress of biology (pro-PSA, urinary PCA3, genetic polymorphism) and imaging (diffusion MRI), helps to better characterize localized prostate cancers and to better adapt their support. At the 2010 AFU Congress, many studies aimed to better target patients at risk of cancer within the population and to better identify cancers with a high potential of evolution among the diagnosed cancers. This requires a better knowledge of risk factors (age, family history, black race, exposition to steroid hormones), the definition of finer criteria for targeted screening and a more accurate staging to make an appropriate therapeutic response.

Controverses, débats et défis : comment construire l'urologie de demain ?
2011
- Réf : Prog Urol, 2011, 21, S73, suppl. S3




 

Évolution de l'imagerie moderne et développement des biopsies de prostate ciblées pour le diagnostic du cancer de la prostate
2011
- Réf : Prog Urol, 2011, 21, S93, suppl. S3


Les biopsies prostatiques constituent l’examen de référence pour établir le diagnostic et évaluer le pronostic du cancer de la prostate. Pourtant la réalisation des biopsies prostatiques échoguidées est un geste relativement aveugle où l’imagerie sert plus à repérer l’organe qu’à cibler la tumeur. Les progrès de l’imagerie réalisés ces dernières années avec le développement de systèmes de localisation 3D permettent d’envisager de nouvelles pratiques. Plusieurs outils existent et sont en cours d’évaluation pour permettre, sous échographie, d’enregistrer la localisation des biopsies prostatiques (cartographie) et de guider les biopsies, éventuellement en fusionnant des images IRM. D’autres outils sont en cours de développement pour robotiser la réalisation des biopsies sous échographie ou dans l’IRM.


Prostatic biopsies are the standard procedure to diagnose of prostate cancer and provide historical prognostic criteria. However the prostatic biopsies are relatively blind and the echography is more useful to identify the organ than to target the tumour. Advances in imaging in recent years with the development of 3D can allow new practices. Several tools exist and are being evaluated to allow recording the location of prostate biopsies under echography (mapping) and to guide biopsy, possibly by fusing MRI images. Other tools are being developed for the implementation of robotics biopsies under ultrasound or MRI.

Innovations chirurgicales et stratégies thérapeutiques dans les carcinomes à cellules rénales
2011
- Réf : Prog Urol, 2011, 21, S84, suppl. S3


Depuis ces dernières années, la prise en charge du carcinome à cellules rénales a constamment évolué et repose désormais sur deux concepts : la conservation néphronique dans les formes localisées et le contrôle de l’angiogénèse dans les formes métastatiques. Les principales voies de recherche dans la stratégie diagnostique consistent à développer de nouveaux outils permettant d’identifier plus formellement les lésions découvertes en imagerie, grâce à des marqueurs biologiques ou moléculaires comme les micro-ARN, et de prédire la fonction rénale après chirurgie. Sur le plan chirurgical, les indications de la néphrectomie partielle ne sont maintenant plus limitées que par la faisabilité technique. Des outils comme le score néphrométrique RENAL permettent d’évaluer le risque de totalisation ou de durée de clampage pédiculaire. De plus, le développement important de la chirurgie robot-assistée apporte des résultats très prometteurs. Dans les formes avancées de cancer du rein, les progrès récents ont permis un allongement important de la survie sans récidive, cependant la survie globale reste peu modifiée avec 40 % de mortalité spécifique. Les nouvelles thérapies ciblées ont ouvert la voie à une nouvelle approche ; les études attendues ces prochaines années pourraient modifier les stratégies thérapeutiques et conduire à une nouvelle stadification des patients.


In recent years, the management of renal cell carcinomas has changed significantly and is now based on two concepts: preservation of renal function in localized forms and control of angiogenesis in metastatic forms. The main ways of research in the diagnostic strategy is to develop new tools to identify more precisely the lesions discovered by imaging, thanks to biological or molecular markers as micro-RNA, and to predict renal function after surgery. Surgical indications for partial nephrectomy are now only limited by technical feasibility. In this regard, tolls like the RENAL nephrometric score help to evaluate the risk of total nephrectomy or the duration of clamping. Furthermore, the important development of robotically assisted surgery provides very promising results. In advanced forms of renal cell carcinomas, recent advances have led to a considerable prolongation of recurrence-free survival, but overall survival remains the same with 40 % of specific mortality. New targeted therapies have paved the way for a new approach and studies expected in the coming years could change the therapeutic strategies and lead to a new staging of patients.

Innovations dans le traitement hormonal du cancer de la prostate localement avancé et/ou métastatique
2011
- Réf : Prog Urol, 2011, 21, S96, suppl. S3


Découvert il y a plus de 40 ans, le traitement hormonal conserve un rôle central dans le traitement du cancer de la prostate avancé et continue à évoluer. La suppression de la testostérone sérique reste l’élément principal du traitement systémique du cancer de la prostate dans sa forme disséminée. Les antagonistes de la LH-RH permettent d’éviter le retard à la castration des agonistes et semblent montrer un bénéfice clinique en termes de contrôle du PSA. Durant la phase de résistance à la castration extra-cellulaire, le récepteur aux androgènes reste l’élément dominant. La stéroïdogénèse intracellulaire peut être bloquée par l’abiratérone. L’amplification et la mutation du récepteur aux androgènes peuvent être contrôlées par des anti-androgènes de seconde génération. Ainsi, ces nouvelles molécules, déjà ou prochainement disponibles, vont renouveler en profondeur l’hormonothérapie et les schémas thérapeutiques du cancer de la prostate.


Discovered over 40 years ago, hormonal therapy remains the cornerstone therapy of advanced prostate cancer and continues to evolve. Suppression of serum testosterone remains the mainstay of systemic treatment of prostate cancer. Antagonists of LH-RH are now available and can prevent the castration delay of agonists. They seem to have a clinical benefit in terms of PSA control. During the phase of resistance to extracellular castration, the androgen receptor is the dominant element. Intracellular steroidogenesis can be blocked by Abiraterone. Amplification and mutation of the androgen receptor may be controlled by antiandrogens of second generation. Thus, these new molecules, already or soon available, will renew the strategy of prostate cancer treatment.

Prise en charge thérapeutique des cancers de la prostate à haut risque : actualités et perspectives
2011
- Réf : Prog Urol, 2011, 21, S80, suppl. S3


Les formes avancées du cancer de la prostate regroupent les situations mettant en jeu le pronostic vital du patient à moyen ou à court terme. Elles sont responsables de la deuxième cause de mortalité par cancer en France. Pourtant, leur prise en charge est mal codifiée et confronte cliniciens et chercheurs au problème thérapeutique. Si les principales options restent la chirurgie, la radiothérapie et l’hormonothérapie, seules ou en association, leur place respective tend à se préciser. L’association radio-hormonothérapie constitue le traitement de référence, mais la chirurgie première donne des résultats intéressants avec la possibilité d’une prise en charge multi-modale. Les moyens diagnostiques s’améliorent également, permettant une prise en charge plus adaptée au profil évolutif de ces patients. La recherche de facteurs prédictifs (dosage précoce du PSA, délai d’atteinte du PSA nadir) contribue également à proposer un meilleur suivi. La létalité du cancer de la prostate diminue actuellement de 2,5 % par an grâce au dépistage plus précoce et aux progrès des traitements des formes avancées. Les progrès techniques de la chirurgie et de la radiothérapie, associés aux nouvelles voies de blocage hormonal, comme les antagonistes de la LH-RH, devraient poursuivre cette tendance.


Advanced prostate cancers include situations involving the patient’s survival in the medium or short run. They are responsible for the second leading cause of death by cancer in France. However, their management is poorly codified and confronts clinicians and researchers to therapeutic problems. Even if the main options remain surgery radiotherapy and hormone therapy, alone or in combination, their places tends to be clarified. The association radio-hormonotherapy is the gold standard, but surgery first has interesting results with the possibility of multi-modal salvage treatment if necessary. Similarly, improved diagnostic tools allow a more personal management of these patients and the search for predictive factors (early PSA assay, time to reach PSA nadir) contribute to provide better monitoring. The mortality of prostate cancer decreases by 2.5 % per year due to earlier detection of cancer and advances in treatment of advanced forms. Technical advances in surgery and radiotherapy, associated with new ways of androgeno-suppression should continue this trend.

Actualités concernant la prise en charge et le suivi des tumeurs vésicales infiltrant le muscle (TVIM) en 2010
2011
- Réf : Prog Urol, 2011, 21, S38, suppl. S2




 


The urothelial carcinoma of the prostate is an entity which is necessary to recognize. The infiltration of the prostatic stroma is a major prognostic factor. The 2009 pTNM classification distinguish carcinoma in situ of the urethra with involvement of prostatic acini (pT2) from direct invasion of prostatic stroma through outside involvment (pT4).

In case of non metastatic muscle invasive bladder cancer with major lymphatic invasion, the standard treatment remains neoadjuvant chemotherapy followed by radical cystectomy and extended lymphadenectomy. Only some patients can hope a complete response after neoadjuvant chemotherapy. For these responders, we can sometimes discuss, at an individual level, a bladder conservative strategy with an intensive surveillance.

Actualités concernant la prise en charge et le suivi des tumeurs vésicales n'infiltrant pas le muscle en 2010
2011
- Réf : Prog Urol, 2011, 21, S34, suppl. S2




 


The aim of this article is to make a synthesis of news headlines concerning the follow-up and the management of non-muscle invasive bladder tumors. The diagnosis and the follow-up of non-muscle invasive bladder are based on flexible cystoscopy associated with urinary cytology. At present time, no molecular marker, and no imaging allows to reduce the rhythm and the modalities of surveillance such as defined by the guidelines. Early cystectomy is the current option for BCG-refractory high risk bladder tumor. Rarely, some conservative options, such as endovesical chemotherapy, could be discussed at an individual level.

Cas cliniques de cancer du rein des JOUM 2010
2011
- Réf : Prog Urol, 2011, 21, S27, suppl. S2




 


Three clinical cases have shown the superiority of sunitinib in first line therapy intermediate risk metastatic clear cell renal carcinoma and a best safety of bevacizumab plus interferon, the current lack of high level of evidence arguments for the neo-adjuvant treatment of kidney cancer, the importance to prevent mucositis during a mTOR inhibitors treatment and the diagnostic pitfalls of its pulmonary complications.

Le point sur les différents types histologiques de cancer du rein et leur traitement spécifique
2011
- Réf : Prog Urol, 2011, 21, S23, suppl. S2




 


There are 9 histological types of renal carcinoma. The most frequent is the renal clear cell carcinoma that has the multilocular cystic renal cell carcinoma and the Xp11–2 translocation renal cell carcinoma as main differential diagnosis and for which treatment is standardized. In other histologic forms, the most efficient medical treatments of metastatic diseases may be: sorafenib in the chromophobe renal cell carcinoma, mTOR inhibitors in papillar renal carcinomas, chemotherapy in Bellini carcinoma.

Le point sur les lésions dermatologiques du pénis : comment repérer les lésions précancéreuses du pénis ?
2011
- Réf : Prog Urol, 2011, 21, S50, suppl. S2




 


Penile sqamous cell carcinoma is a highly evolving tumor. Thus an early diagnosis is a major matter in order to avoid tumoral spread and mutilating surgery. Intra-epithelial neoplasia is a carcinoma in situ involving a disorganized cytological structure and intraepithelial architecture without any change on the derma. It has a bimodal pathogenesis: it can be induced by papilloma virus HPV infection and thus Bowen’s disease or Bowenoïd papulosis, or by a lichen sclerosus. Bowen’s disease concerns mainly men after 50 years old. There are not any spontaneous remission and it transforms slowly in 20–30% of the cases into a squamous cell carcinoma. Its treatment is surgical removal of the lesion. The Bowenoïd papulosis concerns mainly young men. These lesions are rarely invasive and are likely to regress spontaneously. It can be treated conservatively. The lichen sclerosis is an inflammatory chronic disease which etiology is still unknown. It is localized on the glans and the prepuce. Its treatment is essentially circumcision. After treatment, patients must be followed-up and biopsies must be performed for any sign of degeneration.

Les microcalcifications testiculaires, conduite à tenir
2011
- Réf : Prog Urol, 2011, 21, S46, suppl. S2




 


Testicular microlithiases are calcite concretions in the convoluted seminiferous tubules lumen. Their ultrasound aspect is a hyper-echogenous area without any shadow in the testicular parenchyma. Their size is smaller than 2mm and there are more than 5. The surface of the gland is respected. Their incidence is about 5% which more important than the incidence of TGT. The association between testicular microlithiasis and TGT has been initially established by retrospective studies but has never been confirmed by recent prospective studies. Their rate is higher for patients with TGT risk factors (cryptorchidism, intratubular germ cell neoplasia and family history). There are not any official guidelines about the management of testicular microlithiasis. An individual screening depending on the clinical situation can be performed: it could be a simple self examination, ultrasound, or testicular biopsies.

Les nouveautés 2010 : Les points forts de l'ASCO-GU, EAU, ASCO, AUA…
2011
- Réf : Prog Urol, 2011, 21, S16, suppl. S2




 


The main news in kidney oncourology are PET CaIX as potential new diagnostic and monitoring tool, the lack of progress in terms of drug combination therapy, the sequential approach remains the standard, lack of progress also in selecting good candidates for immunotherapy, the possible benefit of nephrectomy, that only the CARMENA study will determine, and the emergence of determining the risk of recurrence after nephrectomy using genomic study.

Concerning non muscle invasive bladder cancer, endoscopic diagnosis seems improved by the NBI and immunofluorescence. The staging of pT1 tumors may evolve. The poor prognosis of Cis was stressed. The indication of cystectomy for BCG failure has been clarified.

For muscle invasive bladder cancer, the prognostic impact of lympho-vascular invasion was reported. The importance of an extended lymphadenectomy has been demonstrated. In cases of symptomatic bone metastases, zoledronic acid increased overall survival.

An analysis of performance and drawbacks of radio-hormonotherapy was performed. The denosumab and zoledronic acid were compared in prevention of bone loss during androgen deprivation. The antagonists of LH-RH, the cabazitaxel and immunotherapies could be part of the therapies for advanced prostate cancer.

For penile cancer treatment, in case of suspicious nodes, ultrasound guided cytopuncture is useful. For testis cancer, therecurrence rate for stage I seminoma has been estimated, at 15%. The PET-scan is also helpful to assess the nodal tumoral spread during the staging and the follow-up of patients treated by chemotherapy.

Les nouveaux marqueurs biologiques du cancer de la prostate
2011
- Réf : Prog Urol, 2011, 21, S63, suppl. S2




 


Biomarkers of prostate cancer can assess a presence risk or an evolution risk of the disease. The integration of temporal and clinical data during the interpretation of a PSA dosage improves its performance. Trough a performing algorithm, the Phi index (Prostate Health Index) combines the results of total PSA, free PSA, and pro-PSA. The ration of urinary PCA3 and urinary PSA determines a powerful marker to be used in difficult diagnostic situations. Gene fusions in prostate cancer are promising biomarkers and eventual therapeutic targets. The cost of these new biomarkers is limiting their current use to individual situations.

Les voies anti-angiogéniques du futur
2011
- Réf : Prog Urol, 2011, 21, S13, suppl. S2




 


The metastatic process comprises several steps all dependent on different factors: cell proliferation and the Raf-MEK-ERK pathway, initiation, migration and angiogenesis via VEGF and collagenases (which digest the extracellular matrix), metastatic progression in bloodstream and implantation in a target tissues via CXCR4 according to the gradient of SDF1 chemokine. At present, inhibition of VEGF by antiangiogenic the treatment results in the activation of alternative pathways and recovery of metastasis process. The future of targeted therapies will integrate alternative paths, including CXCR4/SDF1 ones.

Prévention osseuse dans le traitement du cancer de la prostate
2011
- Réf : Prog Urol, 2011, 21, S58, suppl. S2




 


The bone loss and the fracture risk are enhanced in patients with hormonal deprivation for prostate cancer. The demineralisation can be quantified by BMD (Bone Mineral Density) and prevented by lifestyle and diet therapeutics or new therapeutic agents. These agents may have a preventive effect on metastasis occurrence, but it has to be confirmed. An intra-venous biphosphonate or a sub-cutaneous RANK-inhibitor administration prevent from bone metastasis-related events.

Prise en charge et suivi des tumeurs de la voie excrétrice supérieure en 2010
2011
- Réf : Prog Urol, 2011, 21, S43, suppl. S2




 


The aim of this article is to make a synthesis of news headlines concerning the management of upper tract urinary carcinoma.

For non muscle-invasive upper tract urinary tumors, ureteroscopy with biopsies is a part of the systematic diagnostic assessment in case of suspicious imaging. For muscle-invasive upper tract urinary tumors, there is low level of evidence of expert’s opinion guidelines about neoadjuvant or adjuvant chemotherapy. These therapeutic strategies can be sometimes discussed, by arguing analogy with bladder tumors.

Séminome de stade I : les choix thérapeutiques : surveillance, radiothérapie, chimiothérapie. À propos d'un cas
2011
- Réf : Prog Urol, 2011, 21, S53, suppl. S2




 


The management guide-lines about stage I seminoma (pT1 à pT4, No, Mo) recommend to perform a surveillance, an adjuvant chemotherapy based on carboplatine, or a radiotherapy. However, these options are not equivalent for side effects and relapse risk. Debates are in progress in order to simplify the surveillance protocols which remain essential because of the tumoral relapses for 15% of the patients. The occurrence of a tumoral relapse during the follow-up does not decrease the specific survival. The para-aortic 20 Gy radiotherapy is efficient on the seminoma and decreases the relapse risk. Its main side-effect is a long-term risk of secondary cancer. Carboplatine chemotherapy is also an efficient option which provides good results on the specific survival and the survival without progression. Very few studies assess the long-term side effects of chemotherapy. In the end, the therapeutic decision must be taken with the patient after informing him about all the therapeutic options.

Stratégies thérapeutiques du cancer de la prostate résistant à la castration
2011
- Réf : Prog Urol, 2011, 21, S68, suppl. S2




 


The treatment of a castration-resistant prostate cancer can be immediate or delayed according to the circumstances and the time of its occurrence. New therapeutic targets have been determined with basic tumor biology studies. Treatments available or on development are various and range from estrogens to new anti-androgens. Endothelin inhibitors, abiraterone, MDV3100 or RD162 are the most promising examples but they require to enrol patients in therapeutic trials.

Comment améliorer les résultats de la chirurgie du cancer de prostate ?
2011
- Réf : Prog Urol, 2011, 21, S7, suppl. S1




 


This work summarizes the highlights of the satellite symposium of the seventh edition of the European Robotic Urology Symposium. Treatment options of T3 prostate cancer were discussed, including the results of the Tap 032 study. In this phase III study, 264 patients with locally advanced prostate cancer were randomized to be treated by leuproreline 11,25 mg for 3 years alone or radiotherapy plus leuproreline 11,25 mg for 3 years. The median of disease free survival (Phoenix definition : PSA nadir + 2 ng/ml) was significantly longer in the group of patients treated with the combined treatment (6,96 years vs 3,46 years, p = 0,0005). No statistical difference was observed in specific survival (93,2% vs 86,1%, p = 0,11). In the second part of the satellite symposium, perioperative, oncological, and functional outcomes of laparoscopic robotic-assisted radical prostatectomy were presented, as well as today and future developments of robotic surgery.

L'essentiel du congrès de l'ERUS 2010
2011
- Réf : Prog Urol, 2011, 21, S1, suppl. S1




 


This work summarizes the highlights of what was presented at the seventh edition of the European Robotic Urology Symposium meeting which took place in Bordeaux, France, from September 29 to October 1, 2010. Future developments of robotic surgery and training in robotic were discussed. Robotic assisted laparoscopic radical prostatectomy was largely discussed. The use of robotic in renal and bladder surgery was also developed. The congress contained update lectures, debates, live cases transmission of robotic surgery, and poster and video communications.