Aktív surveillance a gyakorlatban-összefoglaló közlemény = Active surveillance in practice – Review

Az aktív surveillance (AS) kihasználja a prosztatarák elhúzó- dó természetes lefolyását. Az aktív kezeléseket halasztják, a beteg szigorú protokoll szerint ellenőrzés alatt áll. Progreszszió esetén a kuratív kezelés még akkor történik meg, amikor a beteg biztonságosan meggyógyítható. A cél a kezeléssel kapcsolatos toxicitás minimalizálása a túlélés veszélyeztetése nélkül. Az AS alkalmazhatóságát és biztonságát több vizsgálat igazolta, azonban a vizsgálatok heterogenitása miatt a szakmai irányelvek részben konszenzusra támaszkodnak. Az alacsony kockázatú betegségben szenvedő és 10 év felet- ti várható élettartamú betegeknél az AS-t standard, elsőként választandó kezelésnek kell tekinteni. AS akkor ajánlható, ha ISUP 2 daganat mellett a prosztataspecifikus antigén (PSA) <10 ng/ml, a klinikai stádium <T2a, a daganat kis kiterjedésű, és alacsony a pozitív minták száma. A PSA értéke 20 ng/ml-ig elfogadható lehet, ha a PSA-denzitás alacsony. ISUP 3 vagy kedvezőtlen szövettani eredmény – mint pl. cribriform mintázat, ductalis karcinóma – kizáró tényezők. A követés során rektális digitális vizsgálat (legalább évente) és PSA-vizsgálat elvégzése (legalább 6 havonta), valamint a biopszia rendszeres ismétlése is javasolt. PSA-emelkedés vagy egyéb (pl. multiparametrikus MRI) gyanú esetén szövettani mintavétel szükséges. Aktív terápiára váltás indoka elsősorban a Gleason-érték emelkedése vagy a daganat területének növekedése. A beteg bármikor dönthet aktív kezelés mellett. Ha az életkilátások 10 évnél rövidebbek, „figyelmes várakozás” javasolt. Kiemelendő a felvilágosítás fontossága, a terápiás döntésbe az onkoteammel együtt a beteget is be kell vonni. = Active surveillance (AS) takes advantage of the prolonged natural course of prostate cancer. Active treatments are postponed and the patient is monitored according to a strict protocol. In case of progression, curative treatment is performed while the patient is still safely curable. The intention to treat is curative, aiming to minimize treatment-related toxicity without compromising survival. The feasibility and safety of AS have been demonstrated in several studies, but the heterogeneity of studies means that guidelines are partly based on consensus. For patients with low-risk disease and life expectancy over 10 years, AS should be considered as the standard first-line treatment of choice. AS can be recommended when ISUP 2 is associated with a tumour with PSA <10 ng/ml, clinical stage <T2a and the tumour is small and the number of positive samples is low. PSA up to 20 ng/ml may be acceptable if PSA density is low. ISUP 3 or unfavourable histological findings e.g. cribriform pattern, ductal carcinoma are exclusion factors. Rectal digital examination (at least annually) and PSA testing (at least every 6 months) are recommended during follow-up, as well as regular repeat biopsies. Histological sampling is necessary in case of PSA elevation or other suspicion (e.g. multiparametric MRI). The main indication for switching to active therapy is an increase in Gleason score or an increase in tumour area. The patient may decide to opt for active treatment at any time. If the life expectancy is less than 10 years, „watchful waiting” is recommended. The importance of education should be stressed and the patient should be involved in the therapeutic decision together with the oncoteam

Complex treatment of residual metastatic germ cell cancer: A single center experience

Testicular cancer is the most common solid malignancy among men aged 15-35. Radical orchiectomy and platinum-based chemotherapy (BEP) are curative in the majority of patients, including advanced, metastatic cases. According to current urooncology guidelines all non-seminoma patients harbouring post-chemotherapy residual masses of ≥ 1cm should undergo salvage retroperitoneal lymph node dissection (RPLND). However, only 10% of residual tumors contain viable disease.To assess patient outcomes and complications considering different treatment regimens and clinical characteristics.In a retrospective cross-sectional study patients (n=127) who underwent postchemotherapy RPLND between 2007 and 2023 at our referral center were evaluated. The patients received systemic treatment at various oncology centers. The number of BEP cycles received were occasionally different from standard. Only patients with normal postchemotherapy serum tumor markers and primary testicular or extragonadal germ cell neoplasms were included. Treatment groups were established according to the number of BEP cycles received, and the extent of RPLND (bilateral or modified template). Treatment outcomes and complications were assessed.Standard 3-4 courses of BEP were received by 100 (78,7%) patients, while 11 (8,7%) patients underwent less, and 16 (12,6%) more courses than standard. On histopathologic evaluation viable germ cell tumor, teratoma, and necrosis/fibrosis was present in 26 (20,5%), 67 (52,7%) and 34 (26,8%) of specimen, respectively. In the 5-6 BEP series subgroup high rate of viable disease (37,5%) was found and significantly more nephrectomies were performed, than other chemotherapy subgroups. Extratesticular GCT, viable disease in residual mass or progression after RPLND indicated lower survival. Mild (Clavien-Dindo I-II) or no postoperative complications were reported in 93,7% of cases.The study suggests no significant benefit from exceeding 3-4 courses of BEP. Timely salvage RPLND should be performed in high volume centers for optimal treatment outcomes with acceptable complication rates. Adherence to the Heidenreich criteria is advisable where practical

miR-21, miR-29a, and miR-106b: serum and tissue biomarkers with diagnostic potential in metastatic testicular cancer

The imperative need for sensitive and precise tools is underscored in cancer diagnostics, with biomarkers playing a pivotal role in facilitating early detection and tumor diagnosis. Despite their classical pathological classification, testicular tumors lack valuable markers, emphasizing the necessity to identify and apply serum tumor markers in clinical management. Unfortunately, existing biomarkers exhibit limited sensitivities and specificities. Recent years have witnessed the discovery of novel RNA molecules, presenting a potential breakthrough as diagnostic tools and promising biomarkers. This report presents compelling evidence supporting the detection of early testicular cancer by applying a set of nine microRNAs (miRNAs), establishing them as valuable serum biomarkers for diagnosis. We developed a standardized serum-based measurement protocol and conducted comprehensive statistical analyses on the dataset to underscore the diagnostic accuracy of the miRNA pool. Notably, with a sensitivity exceeding 93%, miR-21, miR-29a, and miR-106b surpass classical serum tumor markers in the context of testicular cancer. Specifically, these miRNAs are poised to enhance clinical decision-making in testicular cancer detection and hold the potential for assessing tumor growth in monitoring chemotherapy outcomes