**3.2 Pre-treatment management in high risk prostate cancer**

A critical assessment of the location, size, and extent of the primary tumor provides prognostic information, is essential for treatment planning.

D'Amico and colleagues have defined high-risk prostate cancer as that associated with any 1 of 3 risk factors: biopsy Gleason score ≥8, PSA ≥20 ng/mL, or clinical stage ≥T2c. (11)

More recently, D'Amico and colleagues refined their high-risk definition to incorporate an absolute number of high-risk features (stage ≥T2b, biopsy Gleason score ≥7, and pretreatment PSA >20 ng/mL). (14) Patients are classified into 1 of 3 high-risk groups, defined by the presence of 1, 2, or all 3 features. Probability of death from prostate cancer was highest among men with 3 high-risk features.

High-risk patients with aggressive tumors (PSA >20 ng/mL and Gleason sum >7), advanced local lesions (T3-T4), or patients with symptoms suggestive for metastatic disease, should have imaging studies. (17)

While not uniformly accurate, there are some imaging studies that help us to identificate the high rish disease:


provide insufficient evidence to allow confident statements to be made about the relative beneficial and harmful effects of RP and AS for patients with localised prostate cancer.(44) Klotz L et al. assure that active surveillance with treatment reserved for evidence of rapid PSA progression or increase in tumor volume or grade is associated with about a 3% risk of

In the other hand, patients with prostate cancer continue to present with metastatic disease or to relapse following initial hormone therapy; for these men, the optimal combination and

For these patients, (T2c-T3-T4 or PSA >20 or Gleason score ≥8) it is very important to give information about the different treatment options, and trying to adequate them to their live

Urologist, traditionally recommended radiotherapy or androgen deprivation therapy over RP, not because oncologic outcomes were better with radiotherapy, but because incontinence and

Actually, RP and radiotherapy have potential benefits and cumulative toxicities that must be matched to disease characteristics and patient expectations in selecting a treatment course. (48)

A critical assessment of the location, size, and extent of the primary tumor provides

D'Amico and colleagues have defined high-risk prostate cancer as that associated with any 1

More recently, D'Amico and colleagues refined their high-risk definition to incorporate an absolute number of high-risk features (stage ≥T2b, biopsy Gleason score ≥7, and pretreatment PSA >20 ng/mL). (14) Patients are classified into 1 of 3 high-risk groups, defined by the presence of 1, 2, or all 3 features. Probability of death from prostate cancer was

High-risk patients with aggressive tumors (PSA >20 ng/mL and Gleason sum >7), advanced local lesions (T3-T4), or patients with symptoms suggestive for metastatic disease, should

While not uniformly accurate, there are some imaging studies that help us to identificate the

Magnetic Resonance Imaging (MRI) provides additional information about the local

MRI has been used primarily to determine local disease extent. Body MRI has a role in

 Bone Scan, which is highly sensitive but relatively nonspecific because areas of increased radiotracer uptake are not always secondary to osteoblastic activity from

 Transrectal ultrasonography (TRUS) is extremely useful for guiding needle biopsies. Computed tomography (CT) scans poorly the prostate and lack of sensitivity and

DRE provides some evidence of the cancer's size and pathologic stage.

lession, it has largely replaced CT in the local staging of prostate cancer.

identifying seminal vesicle involvement, but not extra capsular extension.

of 3 risk factors: biopsy Gleason score ≥8, PSA ≥20 ng/mL, or clinical stage ≥T2c. (11)

impotence rates with RP were higher, and cure rates was discouraging. (47)

**3.2 Pre-treatment management in high risk prostate cancer** 

prognostic information, is essential for treatment planning.

specificity for detecting extraprostatic extension.

highest among men with 3 high-risk features.

have imaging studies. (17)

metastases. (17)

high rish disease:

prostate cancer death at 10 years. (46)

sequencing of new medical treatments must be defined. (45)

**Advanced prostate cancer** 

**High risk prostate cancer** 

expectancy and quality of live.

An alternative to patients risk-grouping with similar but not identical risk features is use of multivariable models such as nomograms. These models incorporate data from all risk factors relevant to the probability of treatment failure and proportionately weigh their relative contribution in order to calculate a risk score. (48)

Eastham et al. demonstrate that high-risk patients were more likely to exhibit adverse pathologic features and to have biochemical progression. Nevertheless, roughly one-third of high-risk patients (22% to 63%, depending on the definition) had organ-confined cancers and roughly half (41% to 74%) remained progression-free 10 years after surgery alone. These results confirm that current definitions of high risk disease are unreliable in identifying patients who cannot be cured by local therapy. (48)
