Localized Prostate Cancer in Patients Under the Age of 60

Citation: Akim Kogui Douro, Khalid Lmezguidi, Youness Boukhlifi, Arnaud Tayiri, Abdellatif Janane, Ahmed Ameur, Mohamed Alami. Localized Prostate Cancer in Patients Under the Age of 60. Biomed J Sci & Tech Res 33(2)-2021. BJSTR. MS.ID.005376.


Introduction
Prostate cancer (PCa) remains the second cause of cancer death in men, it is a public health problem especially in elderly patients with 35.5% cases diagnosed after 75 years. it is rare before the age of 60 with 9%. The risk factors for PCa are the age melanoderm ethnicity and a family history of PCa, in which case they occur five to ten years earlier than in the general population [1,2]. The heterogeneity of its genetic an environmental factor, make this cancer an uncertain prognosis and its real incidence in young men is difficult to assess because most men of this age do not have screening, and varies according to countries, ethnicity and age [1][2][3][4]. The Screening of Pca is based on digital rectal examination (DRE) and rate of the prostate specific antigen (PSA) [5][6][7]. Since the use of PSA as a test for Pca, more and more young men are diagnosed in the early stages of the disease [5,6]. Few published data regarding PCa in young men have reported conflicting results.
Some have suggested that PCa in young men has a better prognosis than that in older men, while others have reported an unfavorable prognosis [7,8].
Radical prostatectomy (RP) remains the standard treatment for localized PCa, reducing mortality by 10 to 15% at 10 years, through its efficacy in terms of cancer control and increased overall survival [9][10][11]. Through the study 20 cases of localized PCa in patients under 60 years treated by RP carried out in the urology department of the military teaching hospital of Rabat and a review of the different published series, we propose to analyze the particularities of this cancer in this age group.

Materials and Methods
This is a retrospective study including all patients treated for localized PCa by RP and whose age is less than 60 years at the

Digital Rectal Examination (DRE)
The DRE was considered normal by the urologist in 80% of the cases, and 4 patients presented with induration or a palpable prostate nodule with the DRE (Figure 3). The results of the paraclinical examinations for diagnostic purposes:  Analysis of the prostate biopsy data (  Bone Scintigraphy: There was suspicion of a secondary lesion in one patient and CT scan with a bone window helped to correct the diagnosis and rule out the metastatic nature of this lesion, which was in fact arthritis ( Table 2). After the extension assessment, the most frequent stage was the T2b stage present in 30% of the patients, followed by the T1c, T2a and T2c stages present in 15% of the patients for each, the T1a and T1b stages present in two patients, then stage T3a present in a single patient which represents 5% of the sample studied. All patients were classified as N0. According to D' Amico criteria, the CaP located in our series was located in a low-risk group (≤T2a and G≤6 and PSA <10) in 25% of cases, at intermediate risk (T2b or G = 7 or 10 <PSA ≤20) in 45% of cases, and at high risk (T2c or G> 7 or PSA> 20) in 30% of cases

Pathology Results of the Operating Specimen
The correlation between the clinical data (stage cT and GS) and those of the pathological study prostate specimen was identical in 15% of the cases for the stages cT -pT and 80% of the cases for the Gleason scores (SGb SGp) (Figure 7). upstaging of the Gleason stage and / or grade to a higher level was observed in 75% and 15% of the cases, respectively. Downward migration of the Gleason stage or grade was observed in 10 % and 5% of cases respectively. When we analyze more closely the cases of upgrading from the clinical stage to the (15 patients) (Figure 8) We find that the progression of the stage occurred in the same group of low risk (≤Pt2b). However, in the rest of the cases (80%), we only moved to a high-risk group (≥ pT2c). Upgrading from an organ-confined stage (≤cT2c) to a locally advanced stage (pT3a-b) was observed in 5 patients.  In the rest of the cases, the migration of the Gleason grade was done in the same prognosis group, not eliminating the advantage of performing a RP.

Adjuvant Therapy
The rate of positive surgical margins in our series was 25%.
In the 5 patients, the surgical margins were focal and very limited (R1), The status of surgical margins is one of the major factors of biological recurrence which determines whether or not an adjuvant treatment is necessary after surgery. The attitude in our service is to monitor patients (PSA) and treat only in the event of a biological recurrence (PSA> 0.2 ng / ml confirmed at two successive dosages).

In our series 2 patients had benefited from external radiotherapy
Combined with short-term hormone therapy, and one patient received hormone therapy alone.

Discussion
Prostate cancer is a real public health problem by its frequency, with great variability in incidence and mortality worldwide. Active surveillance leads to the identification of the most aggressive forms, to delaying treatment for a few years and thereby delaying the date of onset of urinary and sexual complications from treatment. However, active surveillance has not yet been validated as an alternative to immediate treatment in young men [16,17].
Total prostatectomy is one of the benchmark treatments for CaP localized in patients whose life expectancy, estimated by age and associated poly-pathologies, is greater than or equal to 10 years [18][19][20]. External radiotherapy is a validated alternative to total prostatectomy, with similar carcinological results in the medium term [22][23][24][25][26][27]. In young men, few studies are available concerning external radiotherapy for CaP [22][23][24][25]. Rosser, et al. [24] compared the results of external radiotherapy in 98 patients under the age of 60 and 866 older patients in one study and this concluded that young age thus appears to be a factor in poor prognosis [22][23][24].
Brachytherapy is an alternative to total prostatectomy for tumors with a low risk of progression, its carcinological results at 12 years are similar to those of total prostatectomy. Few data have been published regarding prostate cancer (CaP) in young men. In addition, the few studies that have analyzed the prognosis of CaP in this population have resulted in conflicting results [28].

Carcinological Results
In 1995, an American study analyzed the impact of age on survival without biological recurrence after total prostatectomy [29]. The rate of biological recurrence was significantly lower in young patients than in older patients. The study by Magheli et al.

Functional Results
Age in itself represents, outside of any surgical context, a predictor of incontinence by sphincter insufficiency and a The Indications for the Prostate Biopsy were a total PSA level ≥4 ng / ml regardless of the digital rectal examination.

Conclusion
The PCa of the young man does not have characteristics different from that of the older man. Young age does not seem to influence the oncologic results of the different treatments. On the other hand, young men seem to have less risk of severe urinary and sexual complications, especially after RP. There are no specific recommendations for the management of PCa in young men.
a localized PCa, two options can be conceived, the first option is to want to limit the urinary and sexual complications of radical prostatectomy. treatment such as brachytherapy, or even active surveillance, can meet this objective. The second option, on the contrary, consists in being more "aggressive" from the outset, given the usual long-life expectancy. Offering a total prostatectomy makes it possible to reserve for the patient the possibility of adjuvant or remedial radiotherapy in the event of locally advanced disease or local recurrence.