Cancer UrologyCancer UrologyОнкоурология1726-97761996-1812Publishing House ABV Press65010.17650/1726-9776-2017-13-1-101-111PROSTATE CANCERРАК ПРЕДСТАТЕЛЬНОЙ ЖЕЛЕЗЫCombined chemohormonalradiation treatment of highand very-high-risk non-metastatic prostate cancerКомплексное гормонохимиолучевое лечение больных неметастатическим раком предстательной железы группы высокого и очень высокого риска прогрессированияKaprinA. D.КапринА. Д.
Russian Federation

4 Korolyova St., Obninsk 249031

Андрей Дмитриевич Каприн, доктор медицинских наук, профессор, академик РАН, генеральный директор ФГБУ «НМИРЦ» Минздрава России

alex_troy@mail.ruTroyanovA. V.ТрояновА. В.
Russian Federation

4 Korolyova St., Obninsk 249031

Контакты: Алексей Владимирович Троянов 

SPIN-код: 4504-1800

alex_troy@mail.ruIvanovS. A.ИвановС. А.
Russian Federation

4 Korolyova St., Obninsk 249031

Сергей Анатольевич Иванов, доктор медицинских наук, заместитель директора по научной и лечебной работе МРНЦ им.А.Ф.Цыба

alex_troy@mail.ruKaryakinO. V.КарякинО. Б.
Russian Federation

4 Korolyova St., Obninsk 249031

Олег Борисович Карякин, доктор медицинских наук, профессор, заведущий отделением лучевого и хирургического лечения урологических заболеваний с группой брахитерапии рака предстательной железы МРНЦ им.А.Ф.Цыба.

alex_troy@mail.ruA.F. Tsyb Medical Radiological Research Center – branch of the National Medical Research Radiological CenterМедицинский радиологический научный центр им А.Ф. Цыба – филиал ФГБУ «Национальный медицинский исследовательский радиологический центр»300320171311011112601201717032017https://oncourology.abvpress.ru/oncur/article/view/650

Introduction. Treatment of highand very-high-risk prostate cancer appears to be extremely difficult. External beam radiation therapy combined with long-term androgen deprivation therapy (ADT) plays the main role, though low treatment effectiveness compared to one of intermediateand low-risk groups pushes towards finding new treatment options and modalities.

Objective: to enlighten data from modern publications and reviews concerning combined treatment uncluding (or not) chemotherapy and different types of radiation therapy.

Risk stratification. Several organizations (NCCN, NICE, ESMO, AUA, EAU and others) offer risk stratification systems. The NCCN system includes the very-high-risk group (Т3b–T4). Nowadays high-risk is set (EAU) when stages ≥ T2c or prostatic specific antigen > 20 ng/ml or Gleason score 8–10 appear.

External beam radiation therapy. Recommended dose is ≥ 74 Gy not depending on risk group. Low overall 10-years survival rate makes searching for new effective treatments inevitable.

ADT. Long-term regimens (2–3 years) of ADT in high-risk prostate cancer is undoubtable and neccecary. Biochemical progression-free survival can be achieved by using luteinizing hormone-releasing hormone antagonists in long-term regimens.

Brachytherapy. Brachytherapy alone and its combination with external beam radiation therapy show high effectiveness concerning progressionfree survival. In high-risk group survival rates are significantly lower. Improvement can be achieved by using adjuvant long-term ADT and other systemic therapy. Nowadays the results of such clinical trials are not available.

Chemotherapy. Chemotherapy as part of combination treatment of non-metastatic hormonal-sensitive high-risk prostate cancer is proved to be effective (increasing progression-free and overall survival), but still rarely used treatment option.

Conclusion. Reviews, meta-analyses and phase III clinical trials results show improvement of progression-free survival (and some – overall survival) when using a multimodal approach with chemotherapy. Combination treatment of taxane-base chemotherapy, luteinizing hormonereleasing hormone antagonists as ADT and brachytherapy alone or with external beam radiation therapy seems to be extremely perspective and needing further investigation. 

Введение. Лечение больных раком предстательной железы (РПЖ) группы высокого и очень высокого риска прогрессирования представляет большую сложность. Лучевая терапия в сочетании с длительной гормональной терапией (ГТ) играет ключевую роль, однако низкая эффективность лечения по сравнению с таковой в группе пациентов промежуточного и низкого риска прогрессирования вынуждает искать новые лечебные алгоритмы и подходы.

Цель работы – анализ существующих публикаций и обзоров касательно комплексного лечения как с включением химиотерапии, так и без него, а также различных видов лучевой терапии.

Оценка риска прогрессирования. Системы классификации и оценки риска прогрессирования предложены различными организациями (NCCN, NICE, ESMO, AUA, EAU и др.). Система классификации NCCN включает группу очень высокого риска (Т3b–4). В настоящее время принадлежность к группе высокого риска (EAU) определяется при стадии ≥ T2c, или при уровне простатического специфического антигена > 20 нг/мл, или при сумме баллов по шкале Глисона 8–10.

Лучевая терапия. Рекомендованная доза облучения составляет ≥ 74 Гр вне зависимости от группы риска. Низкий уровень 10-летней общей выживаемости при РПЖ высокого риска прогрессирования вынуждает искать более эффективные подходы терапии. ГТ. Применение режимов длительной (2–3 года) ГТ при РПЖ высокого риска прогрессирования не вызывает сомнений и является обязательным. Увеличение выживаемости без биохимического рецидива возможно при использовании антагонистов лютеинизирующего гормона рилизинг-гормона в долгосрочных режимах.

Внутритканевая лучевая терапия. Брахитерапия, как и сочетание ее с дистанционной лучевой терапией, показывает высокие результаты в отношении безрецидивной выживаемости. В группе высокого риска отмечается значительно более низкая выживаемость, поэтому возможно улучшение эффективности лечения при использовании длительной адъювантной ГТ и иной системной терапии. В настоящее время результаты подобных исследований не опубликованы.

Химиотерапия. Химиотерапия как часть комплексного лечения неметастатического гормоночувствительного РПЖ высокого и очень высокого риска прогрессирования является доказанно эффективным (увеличивая безрецидивную и общую выживаемость пациентов), но еще мало распространенным видом лечения.

Заключение. Обзоры, метаанализы и результаты рандомизированных исследований III фазы сообщают о преимуществах в отношении безрецидивной выживаемости при использовании мультимодального подхода с включением химиотерапии. Комбинация химиотерапии на основе таксанов, ГТ в виде антагонистов лютеинизирующего гормона рилизинг-гормона и лучевой терапии в виде брахитерапии или сочетанной терапии видится крайне перспективной и требующей дальнейшего изучения. 

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