Biomedical subjects
Publications and source records attributed to Xavier Rébillard.
The follow-up of prostate cancer is especially justified now that effective treatment options are available in the case of recurrence. Conditions of follow-up of patients with prostate cancer vary according to age, comorbidities, tumour stage, prognostic factors at diagnosis and the pervious treatment sequence.
OBJECTIVE: To define the modalities of prostatic biopsies in patients with suspected prostate cancer, particularly concerning prevention of complications, the number of biopsies and the biopsy schemes ensuring an optimal cancer detection rate, and recording of prognostic elements, all with an acceptable morbidity, METHOD: Review of the literature. RESULTS: Information before biopsy: A preliminary visit with oral and written information is necessary before any biopsy procedure in order to: describe the modalities of the procedure to improve the patient's cooperation, detect contraindications, guide preparation, explain the risks and elements of surveillance, and describe the management in the case of complications (level of evidence: IV-3). PREPARATION BEFORE BIOPSY: A single dose of prophylactic antibiotic is necessary before the examination. Longer antibiotic prophylaxis is necessary in patients with risk factors for infection (level of evidence: II). A rectal enema is recommended (level of evidence: III). Routine urine bacteriology and blood coagulation tests are unnecessary (level of evidence: II). In patients taking anticoagulants, this treatment must be stopped before the examination (level of evidence: IV-2). BIOPSY TECHNIQUE: Local anaesthesia with 1% lidocaine by ultrasound-guided injection into the periprostatic spaces is recommended to improve tolerability, when the number of biopsies is > 6 (level of evidence: II-2). General anaesthesia may be necessary in a minority of cases, for local anatomical reasons or when preferred by the patient. Prostatic aspiration biopsies should be performed via a transrectal approach with ultrasound guidance, especially in the absence of a palpable lesion (level of evidence: IV-1). The examination must start with digital rectal examination and complete analysis of the echostructure of the prostate to identify suspicious zones that will also be aspirated. Biopsy scheme as a function of stage: In the case of palpable or visible lesion (stage T2 or T3), at least six transrectal ultrasound-guided lateral sextant biopsies including the peripheral glandular zone at the base, in the middle and at the apex of each lobe as well as a biopsy in a suspicious zone are necessary for cancer detection and staging. Each biopsy must be identified or embedded separately to facilitate identification by the pathologist (level of evidence: IV-1). In the absence of palpable or visible lesion (stage T1a, b, c), another 6 sextant midlobar biopsies are recommended (12 biopsy plan). In the case of prostate volume < 40-50 cm3, the two midlobar biopsies of the apex may be eliminated (10 biopsy plan) (level of evidence: III-2). In the case of prostate volume > 40-50 cm3, anterior biopsies (4 additional biopsies, 16 biopsy scheme) including the glandular zone of benign hyperplasia are not routinely recommended (level of evidence: III-2). In stage T4, a biopsy in each lobe is sufficient for histological confirmation of the diagnosis. CONCLUSION: Complementary studies are necessary to validate the 12 biopsy or 16 biopsy plans, especially as a function of prostatic volume, clinical stage and biopsy sequence (first or second series).
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Prostate cancer is a public health problem. Currently, it is the most frequent cause of cancer, and the second most common cause of cancer mortality, in men in most developed countries. Its incidence in France in 2000 is close to 40 000 new cases, a consistent increase of 7,9% per year. One man in 8 in France will be diagnosed with prostate cancer in the course of his life. More than half of these cancers are diagnosed before 75 years, most often at a localized stage accessible to a curative treatment. The increasing practice of PSA testing and systematic prostatic biopsies are responsible for this rise in incidence. The mortality is stable at around 10 000 per year in France. Hereditary risk factors permit a definition of a target population for screening. Environmental factors are little known, but a diet rich in fat seems to be associated with a more elevated risk.
Radical prostatectomy is one of the standard treatment of localised prostate cancer. It is considered that cure is obtain if PSA value is undetectable (< 0,1 ng/mL) for at least 5 to 7 years post surgery. 8 to 9 men out of 10 are currently cured by prostatectomy if the cancer is detected at organ confined stage, with PSA < 10 ng/mL. Major technical progress related to patient setting, surgical approach, instrumentation, periprostatic fascial exposure and surgical strategy clearly decreased perioperative morbidity and late effects (erectile dysfunction and incontinence). Laparoscopic approach was described mainly by French teams since 1997 and represents a validated alternative to the gold standard suprapubic open approach.
Prostate cancer has become the most frequent cancer and the second cause of cancer mortality in men. This public health problem is becoming increasingly important due to the increasing life expectancy. At the present time, prostate cancer will be discovered in one in every eight men during their lifetime. Prostate cancer represents 25% of all new cases of male cancers. Prostate cancer screening is designed to detect early stage, asymptomatic prostate cancer, as the patient's chances of cure are higher when the cancer is diagnosed at an early stage. The conclusions of the ANAES evaluation in 1998 did not recommend mass screening for prostate cancer. Several international prospective randomized studies based on serum PSA assay, sometimes associated with digital rectal examination, are currently underway. France is participating in the European ERSPC study (European Randomized Study of Screening for Cancer Prostate) and is organizing a national study on high-risk populations. While waiting for the final results of these studies, a recommendation needs to be proposed to inform general practitioners and specialists about optimal use of the currently available tests. Based on the conclusions of its oncology committee (composed of urologists, medical oncologists, radiotherapists, pathologists and radiologists), the Association Française d'Urologie proposes a recommendation concerning prostate cancer screening and defines its modalities, especially concerning the target population, screening tests and the information given to men before screening. The Association Française d'Urologie recommends prostate cancer screening by PSA assay (prostate specific antigen) and digital rectal examination annually between the ages of 50 and 75 years, and from the age of 45 years in men with a family or ethnic risk. If total PSA is above the normal value of the test or if digital rectal examination is abnormal, referral to a urologist is recommended. Information concerning the limits, benefits and risks of screening and the available treatment options must be given before performing these examinations.
The literature regarding the efficacy and the morbidity of the HIFU treatment for localized prostate cancer is poor. The main published studies were carried out by 4 teams using the device available in Europe. Despite a follow-up too short to allow a relevant assessment of the HIFU efficacy in terms of definitive cure of localized prostate cancer, the last published results from the European Multicentric Study and from Gelet may consider the HIFU treatment as a valuable alternative option for well and moderately differentiated tumors, with an initial PSA < or = 15 ng/ml, in men with a life expectancy between 5 and 15 years. When considering patients presenting a localized cancer with a low or intermediate risk for disease recurrence, the HIFU preliminary results are similar to those reported for the other therapeutic options. The high risk patients should not be considered for HIFU treatment as a monotherapy, but for a combined treatment which might include HIFU. The role of the HIFU treatment as a salvage therapy for local recurrence after radiotherapy looks promising. In the context of a prospective evaluation of the HIFU practice in this indication, the urologists using this technology will receive an appropriate training, and will include all their patient data in a dedicated database hold by the Association Française d'Urologie for a longitudinal study. This AFU evaluation will conclude on the positioning of the HIFU treatment among the other treatment options for localized prostate cancer, its indications versus watchful waiting in elderly and confirm the low HIFU-related morbidity, mainly focusing on the impact on the urinary symptoms and the sexual function. In clinical cases which do not match with the standard recommendations, separate analysis or specific protocols will be considered. For the young patients (life expectancy over 15 years), appropriate information must be delivered, explaining that the reference treatment of localized prostate cancer is the radical prostatectomy or the external beam radiation therapy, and that HIFU is not currently validated for them. The HIFU procedure is now standardized. The learning curve is short (approximately 10 to 15 patients) for urologists with skills in ultrasound imaging. The main advantages of the HIFU treatment are its low morbidity, the option for repeated HIFU treatment, the possible treatment of patients who previously underwent prostate resection, the early local control with biopsies and, if needed, a radiotherapy may be performed after HIFU, without increased morbidity.