Palliative treatment for prostate cancer

Most patients with metastatic prostate cancer suffer to some extent from pain, vertebral compression fractures, pathological fractures and spinal cord compression. Bisphosphonate drugs (zoledronic acid) can be used to prevent these conditions. Studies have shown their high effectiveness in treating pain (response in 70-80% of patients), pathological bone fractures and their consequences, which suggests early use of bisphosphonate drugs when symptoms occur in patients with metastatic prostate cancer.

To relieve pain caused by bone metastases, it is possible to use external beam radiation therapy, treatment with radionuclides (Str, Sa), analgesics, and glucocorticoids.

Spinal cord compression is an emergency condition that requires hormonal treatment (if not previously prescribed), glucocorticoids, radiation therapy, and in some situations, surgical decompression.

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Infravesical obstruction

This complication occurs in both acute and chronic forms. As a rule, hormonal treatment allows to reduce the degree of obstruction in 2/3 of patients, however, from the beginning of treatment until the effect develops, it can take up to 3 months, so measures to divert urine are necessary.

In patients for whom hormonal treatment has failed, TURP may be performed. Surgical treatment is also indicated in cases of massive hematuria with a source in the bladder neck and prostate. The effectiveness of the intervention reaches up to 60%. TURP should be performed with caution due to the high risk of developing urinary incontinence.

Ureteral obstruction

Compression of the ureter with impaired urine outflow from the kidneys is usually a consequence of tumor invasion or metastasis to regional lymph nodes. Clinical manifestations of ureteral obstruction are azotemia, pain, septic reaction, or asymptomatic hydronephrosis.

Treatment of prostate cancer (prostate gland cancer) largely depends on the somatic status of the patient. In case of asymptomatic unilateral hydronephrosis and adequate functional reserves of the contralateral kidney, dynamic observation is possible. In other cases, given that retrograde stent placement is often impossible, the main method of treatment is puncture nephrostomy.

Complications of advanced prostate cancer

Antiandrogen therapy for prostate cancer (prostate cancer) usually does not save patients for long. The focus of therapy for advanced cancer is shifted to maintaining an adequate quality of life and eliminating symptoms. The most problematic symptoms of advanced prostate cancer are bone pain, spinal cord compression, urinary tract obstruction, and anemia.

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Bone pain

Bone pain is the most common symptom in patients with advanced prostate cancer. It typically occurs in the lumbar spine and pelvis, although prostate cancer metastases can be found in any bone. Bone metastases lead to pathological fractures, most commonly femoral neck fractures. Surgical treatment to stabilize the bone is necessary not only for pathological fractures, but also at sites of suspected fractures with significant bone loss (more than 50% of the cortical bone is destroyed).

Treatment of bone pain

Treatment of bone pain is a crucial point in maintaining quality of life. Currently, several measures are possible for pain treatment - radiation therapy and the use of bisphosphonates.

Radiation therapy

Radiation therapy is an effective method of controlling pain associated with tumor growth. For individual sites, the use of radiation therapy can prevent pain in 75% of patients for up to 6 months. Usually, a single or short 2-3-week course is administered (3000 kGy for 10 sessions). When multiple foci are present, local therapy is less effective. An alternative is intravenous administration of radiopharmaceuticals that accumulate in bones (Str, Sa). Short-term pain relief is achieved in 50% of patients. Side effects include thrombocytopenia, leukopenia, which limit the use of more aggressive chemotherapy.

Criteria for the possibility of using radiopharmaceuticals:

• multiple metastases;
• number of leukocytes - more than 3x10 ⁹ /l;
• platelet count - more than 60x10 ⁹ /l;
• life expectancy is more than 3 months.

Bisphosphonates

Bisphosphonates are pyrophosphate analogues (aledronic or clodronic acid), direct inhibitors of osteoclast activity. Their clinical efficacy has been demonstrated in Paget's disease, multiple myeloma, breast cancer patients and lytic bone metastases. Although most prostate cancer bone metastases are osteoblastic, there is a risk of increased osteoclast activity. In patients with antiandrogen therapy, the risk of demineralization is very high. The use of bisphosphonates may be effective in these patients.

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Spinal cord compression

Most often, compression occurs in the thoracic and upper lumbar regions. This is a consequence of a compression fracture of the vertebra affected by the metastasis or intradural tumor growth. The main symptoms are radicular pain, motor weakness, sensory deficit, and bladder dysfunction. This can be either a chronic process or an acute one, accompanied by rapid progression and paraplegia.

Spinal cord compression is an emergency. Immediate antiandrogen treatment is necessary if not already given. MRI is the best method to visualize the area involved.

Successful treatment of spinal cord compression requires appropriate diagnosis and treatment. Immediate administration of glucocorticoids is necessary. The next step is surgical decompression and radiation therapy or radiation therapy alone. In most cases, radiation therapy is effective and allows avoiding surgery. Retrospective analysis has not demonstrated a clear advantage of any treatment approach. Both treatments reduce pain in 2/3 of patients. Complete paraplegia usually remains.

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Infravesical obstruction

Acute or chronic IVO is another common complication of prostate cancer. The use of antiandrogens can reduce the degree of obstruction in 2/3 of patients. However, the effect may develop within 3 months, and, accordingly, drainage of the bladder. TUR of the prostate can be performed in patients with ineffective antiandrogen treatment, as well as in conditions of massive hematuria with a source in the neck of the bladder and in the prostate. The operation must be performed carefully due to the high risk of developing urinary incontinence. Ureteral obstruction

Unilateral or bilateral ureteral obstruction may result from locally advanced prostate cancer due to invasion or compression by enlarged lymph nodes. Clinical manifestations include azotemia, pain, sepsis, and asymptomatic hydronephrosis.

Treatment of prostate cancer (prostate gland cancer) depends on the somatic status of the patient. Asymptomatic unilateral hydronephrosis with preservation of renal function can only be observed. Retrograde stent placement is generally not possible if the base of the bladder and the vesical triangle are involved, due to the difficulty of visualizing the ureteral orifices. Nephrostomy and internal drainage through a nephrostomy tract are possible. Cutaneous urine diversion is rarely used.

Anemia

Anemia rarely develops in patients with advanced forms of prostate cancer. Several factors play a role, including metastatic lesions of erythropoiesis sites (pelvis, long tubular bones, vertebral bodies). Malaise and anorexia can be a consequence of iron deficiency in food. Anemia is also a consequence of chronic cancer. Usually, anemia is latent, and patients tolerate it quite well. Some patients still need treatment, which involves the use of iron preparations, vitamins and erythropoietins. Sometimes blood transfusions (red blood cell mass) are used, which, as a rule, improves the general condition of patients.

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