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Cheung DC, Fleshner N, Sengupta S, Woon D. A narrative review of pelvic lymph node dissection in prostate cancer. Transl Androl Urol 2020; 9:3049-3055. [PMID: 33457278 PMCID: PMC7807357 DOI: 10.21037/tau-20-729] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Pelvic lymph node dissection (PLND) is an important component in the staging and prognostication of prostate cancer. We performed a narrative review to assess the literature surrounding PLND: (I) the current guideline recommendations and contemporary utilization, (II) the calculation of patient-specific risk to perform PLND using available nomograms, (III) to review the extent of dissection, and its associated outcomes and complications. Due to the improved lymph node yield, better staging, and theoretical improvement in the control of micro-metastatic disease, guidelines have supported the use of (extended-) PLND in patients deemed to be at intermediate or high risk of lymph node involvement (often at a threshold of 5% on modern risk nomograms). However, in practice, real-world utilization of PLND varies considerably due to multiple reasons. Conflicting evidence persists with no clear oncological benefit to PLND, and a small, but important, risk of morbidity. Complications are rare, but include lymphoceles; thromboembolic events; and more rarely, obturator nerve, vascular, and ureteric injury. Furthermore, changing disease incidence and stage migration in the context of earlier detection overall have led to a decreased risk of nodal disease. The trade-offs between the benefits, harms, and risk tolerance/threshold must be carefully considered between each patient and their clinician.
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Affiliation(s)
| | - Neil Fleshner
- Division of Urology, University of Toronto, Toronto, Canada
| | - Shomik Sengupta
- Eastern Health Clinical School, Monash University, Melbourne, Australia.,Urology Unit, Eastern Health, Victoria, Australia
| | - Dixon Woon
- Urology Unit, Eastern Health, Victoria, Australia
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[Trivialization of prostate cancer? : Stage shift and possible causes]. Urologe A 2019; 58:1461-1468. [PMID: 31531694 DOI: 10.1007/s00120-019-01039-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND According to the strongly negative grade D recommendation of the U.S. Preventive Services Task Force in 2012, the prostate-specific antigen (PSA) test was not only not recommended but was also warned against. As a result in the USA there was a stage shift towards more advanced tumor stages under the newly detected prostate cancers; however, in contrast to the highly questionable American PLCO study, the European ERSPC study showed a clear reduction in prostate cancer-related mortality. OBJECTIVE In this patient cohort it was investigated whether the tumor stage distribution in curatively treated prostate cancer has significantly changed, whether this has an influence on the perioperative results and complication rates and how these changes could have occurred. MATERIAL AND METHODS Patients after radical prostatectomy from 2008 to 2010 were compared to those from 2017. Demographic data, intraoperative courses, perioperative and postoperative complications and histopathological results were compared. RESULTS A total of 1276 operations were analyzed. Preoperative PSA levels showed a significant increase in 2017 (10.5 ± 13.4 ng/ml vs. 8.4 ± 9.1 ng/ml, p = 0.032). The pathological staging revealed a 20% increase in T3 tumors (49.4% versus 29.0%, p < 0.001). Correspondingly, moderately and poorly differentiated cancers and therefore those with higher aggressiveness were significantly more frequent with 11.2% (p < 0.001) and 10.4% (p < 0.001), respectively. The number of patients with lymph node metastases at prostatectomy even increased fourfold (4.5% vs. 16.9%, p < 0.001). CONCLUSION In the radical prostatectomy group, there was a shift to unfavorable and metastatic tumor stages. This negative trend seems largely to be caused by a lower acceptance of early detection by means of PSA determination.
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Tuncel M, Souvatzoglou M, Herrmann K, Stollfuss J, Schuster T, Weirich G, Wester HJ, Schwaiger M, Krause BJ. [(11)C]Choline positron emission tomography/computed tomography for staging and restaging of patients with advanced prostate cancer. Nucl Med Biol 2008; 35:689-95. [PMID: 18678354 DOI: 10.1016/j.nucmedbio.2008.05.006] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 05/06/2008] [Accepted: 05/21/2008] [Indexed: 11/17/2022]
Abstract
INTRODUCTION To evaluate [(11)C]Choline positron emission tomography (PET)/computed tomography (CT) for staging and restaging of patients with advanced prostate cancer and to compare the diagnostic performance of PET, CT and PET/CT. METHODS Forty-five consecutive patients with advanced prostate cancer underwent [(11)C]Choline-PET/CT between 5/2004 and 2/2006. RESULTS Overall, 295 lesions were detected: PET alone, 178 lesions; diagnostic CT, 221 lesions; PET/CT (low-dose CT), 272 lesions; PET/CT (diagnostic CT), 295 lesions. Two thirds of the lesions were located in the bone; one third in the prostate, lymph nodes, periprostatic tissue and soft tissue (lung, liver). The use of diagnostic CT did not result in a statistically significant difference with respect to lesion localization certainty and lesion characterization (P=.063, P=.063). PET-negative but PET/CT-positive lesions were mostly localized in the bone (78%, 91/117) as were PET-positive and CT-negative lesions (72%, 53/74). Of the latter, 91% (48/53) represented bone marrow and 9% (5/53) cortical involvement. CONCLUSIONS Staging and restaging with [(11)C]Choline PET/CT in patients with advanced prostate cancer improve the assessment of local and regional recurrent as well as metastatic disease including skeletal manifestations. [(11)C]Choline PET/CT (with a low-dose CT) results in improved localization and lesion characterization. [(11)C]Choline PET/CT provides an added value for skeletal manifestations. [(11)C]Choline PET/CT changed disease management in 11 (24%) of 45 patients with advanced prostate cancer.
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Affiliation(s)
- Murat Tuncel
- Department of Nuclear Medicine, Klinikum rechts der lsar, Technische Universität München, Munich, Germany
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Algaba F, Trias I, Arce Y. Natural history of prostatic carcinoma: the pathologist's perspective. Recent Results Cancer Res 2007; 175:9-24. [PMID: 17432551 DOI: 10.1007/978-3-540-40901-4_2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The stem (basal) cells of prostate acini are considered the origin of prostate cancer. Between these cells and the final secretory cells, different intermediate or transit cells can be observed, and every one of them can evolve into malignant cells, explaining the biological variability of prostatic cancer. The exact changes between normal gland and prostatic intraepithelial neoplasia (PIN) are not yet known, but a post-inflammatory atrophy lesion is being studied in this respect. The PIN lesion is considered the pre-invasive change of prostatic cancer and its presence in needle biopsy is clinically used for follow-up of the patient. The progressive knowledge of the stromal invasion in prostate cancer (loss of some cell-cell adhesion molecules and expression of others) can be correlated with the Gleason grading system, and the molecular changes in the progression to androgen-independent carcinoma can be used as a prognostic marker in conjunction with the classical pathological markers.
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Affiliation(s)
- Ferran Algaba
- Department of Pathology, Fundacion Puigvert, Barcelona, Spain
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Randomized Prospective Evaluation of Extended Versus Limited Lymph Node Dissection in Patients With Clinically Localized Prostate Cancer. J Urol 2003. [DOI: 10.1097/00005392-200301000-00035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Clark T, Parekh DJ, Cookson MS, Chang SS, Smith ER, Wells N, Smith JA. Randomized prospective evaluation of extended versus limited lymph node dissection in patients with clinically localized prostate cancer. J Urol 2003; 169:145-7; discussion 147-8. [PMID: 12478123 DOI: 10.1016/s0022-5347(05)64055-4] [Citation(s) in RCA: 208] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The low rate of pelvic node metastasis in most contemporary series of patients undergoing radical prostatectomy for carcinoma of the prostate has been attributed to earlier and better patient selection than historical series. Alternatively, it has been suggested that the limited dissection commonly performed misses nodal metastasis in a substantial number of patients. To assess the value of an extended node dissection in detecting nodal metastasis, we performed a randomized prospective study. MATERIALS AND METHODS A total of 123 patients undergoing radical prostatectomy were randomized to an extended node dissection on the right versus the left side of the pelvis with the other side being a limited dissection. The extended dissection included removal of all external iliac nodes to a point above the bifurcation of the common iliac artery, the obturator nodes and the presacral nodes. The limited dissection included only the nodes along the external iliac vein and obturator nerve. RESULTS Mean patient age was 61 years. Clinical stage was T1c in 88 patients (72%), T2a in 26 (21%), T2b in 7 (6%) and T3 in 2 (1%). Mean preoperative prostate specific antigen was 7.4 ng./ml. Pelvic lymph node metastasis was histologically confirmed in 8 patients (6.5%). Positive nodes were found on the side of the extended dissection in 4 patients, on the side of the limited dissection in 3 and on both sides in 1. Complications possibly attributable to the node dissection included lymphocele in 4 patients, lower extremity edema in 5, deep venous thrombosis in 2, ureteral injury in 1 and pelvic abscess in 1. These complications occurred 3 times more often on the side of the extended dissection (p = 0.08). CONCLUSIONS Extended node dissection in contemporary series of patients undergoing radical prostatectomy identifies few with nodal metastases not found by a more limited dissection. A trend toward an increased risk of complications attributable to the lymphadenectomy occurs with an extended dissection.
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Affiliation(s)
- Travis Clark
- Department of Urologic Surgery, Vanderbilt University, Nashville, TN, USA
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Burkhard FC, Bader P, Schneider E, Markwalder R, Studer UE. Reliability of preoperative values to determine the need for lymphadenectomy in patients with prostate cancer and meticulous lymph node dissection. Eur Urol 2002; 42:84-90; discussion 90-2. [PMID: 12160577 DOI: 10.1016/s0302-2838(02)00243-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The only definite way to determine lymph node metastasis, an unfavorable prognostic factor in prostate cancer is lymphadenectomy. Due to increased morbidity and the increasing trend towards minimally invasive surgery, ways to avoid or at least limit lymphadenectomy are being sought. We routinely performed a meticulous lymphadenectomy in all patients and the goal of this study was to evaluate which of the previously proposed criteria determining who needs a lymphadenectomy can be applied in our patients. PATIENTS AND METHODS Patients with clinically localized prostate cancer confirmed by fine needle aspiration cytology, without neoadjuvant hormone therapy, negative pelvic and abdominal CT scans and negative bone scan underwent a radical prostatectomy with simultaneous bilateral extended lymphadenectomy. RESULTS Between 1989 and 1999, 463 patients were included in this study. The median age was 64 (range 44-76) years and the median PSA was 11.0 (range 0.42-172) ng/ml. A median of 21 nodes were removed per patient. One hundred and nine (24%) had lymph node metastasis: 17% of patients with a PSA value < or =20 ng/ml and 12% with a PSA value < or = 10 ng/ml. None of the patients with a preoperative grading of 1 and a PSA value < or =10 ng/ml and 10% of the "low-risk patients" with a PSA value < or = 10 ng/ml and a preoperative grading <3 had lymph node metastases. Seven percent with a PSA value < or = 10 ng/ml and a prostatectomy Gleason score under 7 were found to be node positive. CONCLUSIONS A significant number of patients would have been understaged and left with diseased nodes when applying preoperative PSA value < or = 10 ng/ml and grading <3/Gleason <7 as criteria for omitting lymphadenectomy. Therefore we consider meticulous lymphadenectomy a must for correct staging in all patients undergoing radical prostatectomy for prostate cancer, with the exception of patients with a grading of 1 and a PSA < or = 10 ng/ml.
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Affiliation(s)
- Fiona C Burkhard
- Department of Urology, University Hospital Berne, Anna Seiler Haus, CH-3010, Berne, Switzerland.
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Tiguert R, Kabbani W, Sakr W, Gheiler EL, Pontes JE. Origin and racial distribution of glandular tissue in the anterior compartment of the prostate: an autopsy study. Prostate 1999; 39:310-5. [PMID: 10344222 DOI: 10.1002/(sici)1097-0045(19990601)39:4<310::aid-pros13>3.0.co;2-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND We previously reported that African-American men (AAM) have tumors located in the anterior compartment more often than American Caucasian men (ACM) in radical prostatectomy specimens [Tiguert et al.: Prostate 37:230-235, 1998]. In this study, we evaluated the distribution of glandular tissue in the anterior compartment of normal prostate specimens, with specific attention to the anterior fibromuscular area, in order to determine the frequency and origin of glands in this region. METHODS We analyzed 94 prostatectomy specimens obtained from autopsied men between ages 20-30 years. Men in this age group were chosen because few pathological changes are present in the prostate in this age range. The anterior compartment of the prostate was defined by drawing a horizontal line, anterior to the urethra, through the midpoint of the anterior-posterior diameter parallel to the rectal surface. In each slide, anterior compartment prostatic tissue was identified and characterized as peripheral zone, transitional zone, and fibromuscular stroma. Any glandular elements identified in the anterior prostatic compartment were recorded in terms of zonal origin and number of glands. RESULTS Prostates from 76 AAM and 18 ACM were examined. Overall, prostatic glands were absent in the anterior compartment in only 2% of cases. Glands were derived from the peripheral zone only in 6 (6.5%) cases, peripheral zone and transitional zone in 53 (56.5%), transitional zone only in 13 (14%), and anterior fibromuscular stroma in 20 (21%). There was no difference between the two races in terms of the number of glands present. The morphology of the peripheral zone was not different between the two races, with glands from the peripheral zone joining in the anterior compartment in 33% of AAM compared to 56% of ACM (P = 0.123). CONCLUSIONS Anterior prostatic glands can arise from the peripheral zone, transitional zone, or fibromuscular stroma. There are no racial differences in terms of the number of anterior glandular elements, and also in the architecture of the peripheral zone.
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Affiliation(s)
- R Tiguert
- Wayne State University School of Medicine and Barbara Ann Karmanos Cancer Institute, Detroit, Michigan, USA
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STONE NELSONN, STOCK RICHARDG, PARIKH DHAVAL, YEGHIAYAN PAULA, UNGER PAMELA. PERINEURAL INVASION AND SEMINAL VESICLE INVOLVEMENT PREDICT PELVIC LYMPH NODE METASTASIS IN MEN WITH LOCALIZED CARCINOMA OF THE PROSTATE. J Urol 1998. [DOI: 10.1016/s0022-5347(01)62393-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- NELSON N. STONE
- From the Departments of Urology, Radiation Oncology and Pathology, Mount Sinai School of Medicine and Medical Center New York, New York
| | - RICHARD G. STOCK
- From the Departments of Urology, Radiation Oncology and Pathology, Mount Sinai School of Medicine and Medical Center New York, New York
| | - DHAVAL PARIKH
- From the Departments of Urology, Radiation Oncology and Pathology, Mount Sinai School of Medicine and Medical Center New York, New York
| | - PAULA YEGHIAYAN
- From the Departments of Urology, Radiation Oncology and Pathology, Mount Sinai School of Medicine and Medical Center New York, New York
| | - PAMELA UNGER
- From the Departments of Urology, Radiation Oncology and Pathology, Mount Sinai School of Medicine and Medical Center New York, New York
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Asbell SO, Martz KL, Shin KH, Sause WT, Doggett RL, Perez CA, Pilepich MV. Impact of surgical staging in evaluating the radiotherapeutic outcome in RTOG #77-06, a phase III study for T1BN0M0 (A2) and T2N0M0 (B) prostate carcinoma. Int J Radiat Oncol Biol Phys 1998; 40:769-82. [PMID: 9531360 DOI: 10.1016/s0360-3016(97)00926-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate survival and time to metastatic disease in patients treated for localized prostatic carcinoma in a Phase III radiotherapy (RT) protocol, Radiation Therapy Oncology Group (RTOG) 77-06. Patients with T18N0M0 (A2) or T2N0M0 (B) disease after lymphangiogram (LAG) or staging laparotomy (SL) were randomized between prophylactic radiation to the pelvic lymph nodes and prostatic bed vs. prostatic bed alone. The outcome of both treatment arms, as well as a comparison of the LAG group, to that of the SL group, are updated. METHODS AND MATERIALS A total of 449 eligible males were entered into RTOG protocol 7706 between 1978 and 1983. Lymph node staging was mandatory but at the physician's discretion; 117 (26%) patients had SL, while 332 (74%) had LAG. Follow-up was a median of 12 years and a maximum of 16 years. For those randomized to receive prophylactic pelvic lymph nodal irradiation, 45 Gy of megavoltage RT was delivered via multiple portals in 4.5-5 weeks, while all patients received 65 Gy in 6.5-8 weeks to the prostatic bed. RESULTS There was no significant difference in survival whether treatment was administered to the prostate or prostate and pelvic lymph nodes. The SL group had greater 12-year survival than the LAG group (48% vs. 38%, p = 0.02). Disease-free survival was statistically significant, with 38% for the SL group vs. 26% for the LAG group (p = 0.003). Bone metastasis was less common in the SL group (14%) than the LAG group (27%) (p = 0.003). CONCLUSION At 12-year median follow-up, there still was no survival difference in those patients treated prophylactically to the pelvic nodes and prostatic bed vs. the prostatic bed alone. Those patients not surgically staged with only LAG for lymph node evaluation were less accurately staged, as reflected by a statistically significant reduced survival and earlier metastases.
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Affiliation(s)
- S O Asbell
- Albert Einstein Medical Center, Philadelphia, PA 19141, USA
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Stone NN, Stock RG, Unger P. Laparoscopic pelvic lymph node dissection for prostate cancer: comparison of the extended and modified techniques. J Urol 1997; 158:1891-4. [PMID: 9334624 DOI: 10.1016/s0022-5347(01)64161-2] [Citation(s) in RCA: 163] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE We compared the results of extended (obturator, hypogastric, common and external iliac nodes) to modified (obturator and hypogastric nodes only) laparoscopic pelvic lymph node dissection in patients with clinically localized prostate cancer. MATERIALS AND METHODS A total of 189 patients with stage T1 to T3 prostate cancer underwent modified (150) or extended (39) laparoscopic pelvic lymph node dissection for pelvic nodal assessment before definitive treatment. RESULTS Twice as many lymph nodes were removed via extended than modified laparoscopic pelvic lymph node dissection (mean 17:8 versus 9.3). The overall positivity rate was 23 of 189 lymph nodes (12.2%), including 14 of 150 (7.3%) for modified and 9 of 39 (23.1%) for extended dissection (p = 0.02). Two patients (22%) who underwent extended dissection had positive lymph nodes in the external iliac area. Patients who presented with the high risk features of prostate specific antigen (PSA) greater than 20 ng./ml., Gleason score 7 or greater, or stage T2b disease or greater had a 26.5% (p = 0.0002), 22% (p = 0.0006) or 16.4% (p = 0.003) likelihood of positive lymph nodes, respectively. For extended versus modified laparoscopic pelvic lymph node dissection node positivity in high risk patients was 27% versus 18.8% (p = 0.4), 30 versus 26.4% (p = 0.8) and 25.4 versus 14.6% (p = 0.17) for Gleason score 7 or greater, PSA greater than 20 ng./ml. and disease stage T2b to T3a, respectively. Patients who underwent the extended procedure had a higher complication rate (35.9 versus 2%, p < 0.0001). No laparotomy was required. CONCLUSIONS Despite yielding a 2-fold higher node count and higher node positivity rate, extended laparoscopic pelvic lymph node dissection offers no advantage over modified laparoscopic pelvic lymph node dissection for diagnosing positive lymph nodes when results are analyzed by prognostic factors. The extended procedure is associated with a much higher complication rate. In patients with the high risk features of PSA greater than 20 ng./ml., Gleason score 7 or greater and stage T2b to T3a disease modified laparoscopic pelvic lymph node dissection can be performed safely and effectively to help identify those who may benefit most from curative therapy.
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Affiliation(s)
- N N Stone
- Department of Urology, Mount Sinai School of Medicine, New York, New York, USA
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Rees MA, Resnick MI, Oesterling JE. Use of prostate-specific antigen, Gleason score, and digital rectal examination in staging patients with newly diagnosed prostate cancer. Urol Clin North Am 1997; 24:379-88. [PMID: 9126235 DOI: 10.1016/s0094-0143(05)70384-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CT Scan, MR Imaging Scan, and Pedal Lymphangiography. Patients with a PSA greater than 25 ng/mL, a Gleason score greater than 6, and a positive DRE should undergo CT scan with FNA of lymph nodes at least 6 mm in size. Otherwise, CT scan, MR imaging scan, and pelvic lymphangiogram are not indicated. This should eliminate use of these staging studies in over 90% of patients with newly diagnosed adenocarcinoma of the prostate. Pelvic Lymph-Node Dissection. Pelvic lymph-node dissection can be safely eliminated in patients who meet the following predictive criteria: 1. PSA not more than 5 ng/mL or 2. Gleason score not more than 5 or 3. A combination of the following: PSA not more than 25 ng/mL, Gleason score not more than 7, and negative DRE. Following these criteria should eliminate the need for pelvic lymphadenectomy in 60% of patients with newly diagnosed prostate cancer.
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Affiliation(s)
- M A Rees
- Department of Urology, University of Virginia Health Sciences Center, Charlottesville, USA
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Powell CR, Huisman TK, Riffenburgh RH, Saunders EL, Bethel KJ, Johnstone PA. Outcome for Surgically Staged Localized Prostate Cancer Treated With External Beam Radiation Therapy. J Urol 1997. [DOI: 10.1016/s0022-5347(01)64854-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Curt R. Powell
- From the Departments of Urology, Laboratory (Pathology Division), Clinical Investigation and Radiology (Radiation Oncology Division), Naval Medical Center, and Radiation Oncology Division, University of California, San Diego, California
| | - Thomas K. Huisman
- From the Departments of Urology, Laboratory (Pathology Division), Clinical Investigation and Radiology (Radiation Oncology Division), Naval Medical Center, and Radiation Oncology Division, University of California, San Diego, California
| | - Robert H. Riffenburgh
- From the Departments of Urology, Laboratory (Pathology Division), Clinical Investigation and Radiology (Radiation Oncology Division), Naval Medical Center, and Radiation Oncology Division, University of California, San Diego, California
| | - Eric L. Saunders
- From the Departments of Urology, Laboratory (Pathology Division), Clinical Investigation and Radiology (Radiation Oncology Division), Naval Medical Center, and Radiation Oncology Division, University of California, San Diego, California
| | - Kelly J. Bethel
- From the Departments of Urology, Laboratory (Pathology Division), Clinical Investigation and Radiology (Radiation Oncology Division), Naval Medical Center, and Radiation Oncology Division, University of California, San Diego, California
| | - Peter A.S. Johnstone
- From the Departments of Urology, Laboratory (Pathology Division), Clinical Investigation and Radiology (Radiation Oncology Division), Naval Medical Center, and Radiation Oncology Division, University of California, San Diego, California
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Lund GO, Winfield HN, Donovan JF, See WA, Loening SA, Williams RD. Laparoscopic Pelvic Lymph Node Dissection Following Definitive Radiotherapy for Carcinoma of the Prostate. J Urol 1997. [DOI: 10.1016/s0022-5347(01)65198-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Greg O. Lund
- Department of Urology, University of Iowa College of Medicine, Iowa City, Iowa
| | - Howard N. Winfield
- Department of Urology, University of Iowa College of Medicine, Iowa City, Iowa
| | - James F. Donovan
- Department of Urology, University of Iowa College of Medicine, Iowa City, Iowa
| | - William A. See
- Department of Urology, University of Iowa College of Medicine, Iowa City, Iowa
| | - Stefan A. Loening
- Department of Urology, University of Iowa College of Medicine, Iowa City, Iowa
| | - Richard D. Williams
- Department of Urology, University of Iowa College of Medicine, Iowa City, Iowa
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Laparoscopic Pelvic Lymph Node Dissection Following Definitive Radiotherapy for Carcinoma of the Prostate. J Urol 1997. [DOI: 10.1097/00005392-199702000-00036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Naraghi R, Becich MJ, O'Donnell W, Bahnson RR. Routine frozen section of pelvic lymph node specimens prior to radical retropubic prostatectomy is unnecessary in patients with prostate specific antigen. Urol Oncol 1996; 2:141-5. [DOI: 10.1016/s1078-1439(96)00074-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Pantel K, Braun S, Passlick B, Schlimok G. Minimal residual epithelial cancer: diagnostic approaches and prognostic relevance. PROGRESS IN HISTOCHEMISTRY AND CYTOCHEMISTRY 1996; 30:1-60. [PMID: 8724405 DOI: 10.1016/s0079-6336(96)80013-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- K Pantel
- Institut für Immunologie, Ludwig-Maximilians-Universität, München, Germany
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Affiliation(s)
- M A Rosen
- Department of Urology, Froedtert Memorial Lutheran Hospital, Milwaukee, WI 53226, USA
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Pantel K, Aignherr C, Köllermann J, Caprano J, Riethmüller G, Köllermann MW. Immunocytochemical detection of isolated tumour cells in bone marrow of patients with untreated stage C prostatic cancer. Eur J Cancer 1995; 31A:1627-32. [PMID: 7488413 DOI: 10.1016/0959-8049(95)00290-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The micrometastatic spread of tumour cells is usually missed by conventional diagnostic techniques, although this spread largely determines the prognosis of patients with primary epithelial cancers. By use of the monoclonal antibody, CK2, to epithelial cytokeratin component number 18 (CK18), individual disseminated carcinoma cells present in bone marrow of cancer patients can now be identified. In the present study, this approach has been applied to patients with virginal stage C adenocarcinoma of the prostate. Double-sided aspirates of iliac bone marrow from 24 of 44 evaluable patients (54.4%) exhibited between one and 38 CK18-positive cells per sample of 2 x 10(6) mononuclear cells. In 13 of these 24 positive patients, CK-positive cells were only detected in one of the two aspirates analysed. There was no statistically significant correlation between this finding and established risk factors, such as the volume and histological grade of the primary tumour or the concentration of prostate specific antigen and prostatic acid phosphatase in serum. The follow-up time is too short to provide meaningful data on the prognostic significance of isolated CK18-positive cells in bone marrow, which, however, has been recently demonstrated in other types of primary epithelial cancers. In conclusion, the presence of prostatic tumour cells in bone marrow might be interpreted as an indicator of the metastatic capacity of an individual primary tumour. The immunocytochemical detection of these cells may, therefore, be useful for increasing the precision of current tumour staging, and to monitor minimal residual cancer in an individual patient.
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Affiliation(s)
- K Pantel
- Institut für Immunologie der Universität München, Germany
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20
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Grenabo L, Grundtman S, Hedelin H. Laparoscopic obturator lymph node dissection in patients with prostatic cancer. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY 1995; 29:51-5. [PMID: 7618051 DOI: 10.3109/00365599509180539] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The result of 33 laparoscopic obturator lymph node dissections in patients with locally confined prostatic cancer are presented and compared with open surgery dissections. The hospitalization time was 3 days with the laparoscopic technique, a reduction by 50% compared with open surgery. The operation time was increased from 60 to 100 minutes. No serious complications were encountered. The postoperative recovery was fast and uneventful. The number of glands dissected out was slightly lower than that at open surgery. Obturator lymph node metastases were found in 15% of the patients in the laparoscopic series.
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Affiliation(s)
- L Grenabo
- Department of Surgery, Sahlgrenska Hospital, University of Göteborg, Sweden
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21
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van Andel G, Vleeming R, Kurth K, de Reijke TM. Incidental carcinoma of the prostate. SEMINARS IN SURGICAL ONCOLOGY 1995; 11:36-45. [PMID: 7538693 DOI: 10.1002/ssu.2980110106] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Transrectal ultrasonography (TRUS), digital rectal examination (DRE), and quantification of serum prostate-specific antigen (PSA) are accepted and evaluated methods for detecting prostate cancer. Positive predictive values (PPV) of DRE and TRUS are low, and only slightly enhanced when used in combination with PSA. PSA lacks sufficient sensitivity and specificity to be used alone as a screening test for prostate cancer. The parameters PSA-density and PSA-velocity make PSA a better tumor marker, but they are not reliable on an individual basis. Age-specific reference ranges have the potential to make PSA a more sensitive tumor marker for men less than 60 years of age and a more specific one for men beyond 60 years. With currently available diagnostic methods approximately 10% of patients undergoing transurethral or open resection of the prostate for presumed benign prostatic hyperplasia will have carcinoma detected in the histologic material. In 392 patients successively treated in our clinic for presumed BPH and thoroughly investigated to exclude prostatic carcinoma (DRE, TRUS, biopsy when PSA > 4 ng/ml or PSA-D > 0.15), the tumor was found incidentally in 4%. Another finding in this study was the detection of prostatic carcinoma by random biopsy in patients without a palpable or visible tumor by imaging and without PSA increase (> 4 ng/ml). Biopsies were performed because of a hypoechoic zone in the opposite lobe which turned out to be negative. Such tumors cannot be properly classified in the current TNM system. Treatment options for patients with incidental prostatic carcinoma are age- and stage-dependent. Patients less than 60 years old may be treated with a curative approach, irrespective of the T category (T1a or T1b); patients with a life expectancy longer than 10 years and a pT1b incidental carcinoma likewise should be offered a curative therapy.
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Affiliation(s)
- G van Andel
- Department of Urology, University of Amsterdam, The Netherlands
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22
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Bluestein DL, Bostwick DG, Bergstralh EJ, Oesterling JE. Eliminating the need for bilateral pelvic lymphadenectomy in select patients with prostate cancer. J Urol 1994; 151:1315-20. [PMID: 7512662 DOI: 10.1016/s0022-5347(17)35239-4] [Citation(s) in RCA: 215] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To determine if the preoperative variables of serum prostate specific antigen (PSA), primary Gleason grade from the biopsy specimen and local clinical stage as determined from digital rectal examination can accurately predict the pelvic lymph node status in patients with clinically localized prostate cancer, we reviewed the medical records of 1,632 patients who underwent bilateral pelvic lymphadenectomy at our institution between January 1988 and December 1991. Using logistic regression analysis, serum PSA was found to be the best predictor of pelvic lymph node metastases (p < 0.0001). The predictive power of serum PSA could be enhanced considerably by taking into account the Gleason grade (p < 0.001) and local clinical stage (p < 0.001). A statistical model using all 3 variables was developed that allows the practicing urologist to estimate on an individual basis the probability of pelvic lymph node involvement. Using a conservative cutoff point of less than 3% as an acceptable false-negative rate, 61% of the patients with clinical stages T1a to T2b (A1 to B1) disease and 29% of those with clinical stages T1a to T2c (A1 to B2) prostate cancer may be spared an open or laparoscopic staging bilateral pelvic lymphadenectomy. As a result, patient morbidity can be decreased and a significant economic savings to the health care system can be realized. This observation has particular importance for prostate cancer patients being managed with radical perineal prostatectomy or definitive radiation therapy.
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Affiliation(s)
- D L Bluestein
- Department of Urology, Mayo Clinic, Rochester, Minnesota 55905
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23
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Hanks GE, Krall JM, Hanlon AL, Asbell SO, Pilepich MV, Owen JB. Patterns of Care and RTOG studies in prostate cancer: long-term survival, hazard rate observations, and possibilities of cure. Int J Radiat Oncol Biol Phys 1994; 28:39-45. [PMID: 8270458 DOI: 10.1016/0360-3016(94)90139-2] [Citation(s) in RCA: 80] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE This study was undertaken to show the long-term survival and probability of cure of prostate cancer patients treated with external beam radiation in USA national surveys and in the prospective clinical trials of the RTOG. METHODS AND MATERIALS Two national patterns of care surveys of patients treated in 1973 and 1978 are reported along with two RTOG prospective trials (7506 and 7706). Hazard rates represent the risk of death and are compared to the rate expected for a normal population. RESULTS For patients with Stage A cancers, the survival is not different from the expected survival for any of the reported surveys. The hazard rate for death does not significantly exceed the expected hazard rate out to 15 years. For patients with Stage B cancer, there is a decrease in survival below expected and hazard rates show a continuing excess mortality as long as 15 years after treatment. For patients with Stage C cancers, there is a more rapid decrease in survival that then becomes parallel to the expected survival. Hazard rates indicate there has been a return to expected mortality at 15 years. CONCLUSION These data make a strong argument for the long-term cure of prostate cancer by external beam radiation, and support the continued use and study of radiation therapy as a curative modality in prostate cancer. No similar national data is available for any other method of management.
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Affiliation(s)
- G E Hanks
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111
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24
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Lannon SG, el-Araby AA, Joseph PK, Eastwood BJ, Awad SA. Long-term results of combined interstitial gold seed implantation plus external beam irradiation in localised carcinoma of the prostate. BRITISH JOURNAL OF UROLOGY 1993; 72:782-91. [PMID: 8281413 DOI: 10.1111/j.1464-410x.1993.tb16268.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Carcinoma of the prostate is one of the leading causes of death in men. Patients with localised disease can be treated with radiotherapy, but controversy still exists regarding the most effective therapeutic technique. We report 180 patients with surgical stage A2-C prostate cancer treated between 1976 and 1986 by pelvic lymphadenectomy and radioactive gold seed implantation followed by external irradiation. Annual post-treatment biopsies were performed up to 5 years in most patients. Regular follow-up included a digital rectal examination, prostatic acid phosphatase and bone scan. One hundred and sixty-four patients had complete follow-up data at the end-point of data collection (December 1991). The actuarial 10-year cancer-free survival rates were 83.0% and 91.3% for stages A2 and B1 respectively. The incidence of positive biopsy at 2 and 5 years was 13% and 17.1% respectively for the whole series. A firm correlation was defined between biopsy result and subsequent development of local progression, distant metastases and overall survival. Combined interstitial gold seed implantation plus external beam irradiation represent a valid option for the treatment of patients with localised prostatic cancer.
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Affiliation(s)
- S G Lannon
- Department of Urology, Victoria General Hospital, Dalhousie University, Halifax, Canada
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25
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Schuessler WW, Pharand D, Vancaillie TG. Laparoscopic standard pelvic node dissection for carcinoma of the prostate: is it accurate? J Urol 1993; 150:898-901. [PMID: 8345606 DOI: 10.1016/s0022-5347(17)35643-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The acceptably low morbidity of laparoscopic pelvic lymphadenectomy has allowed us to perform the procedure systematically on all patients who presented with localized adenocarcinoma of the prostate. Data on 147 consecutive cases enable us to state that the overall accuracy and morbidity of this method are equal if not better than the rates available in the literature for open procedures. In addition, analysis shows that the standard dissection is more accurate than the obturator dissection because in 30% of the patients with positive nodes malignant infiltrates were found in the iliac specimen only. Finally, it appears that patients in whom the malignancy was detected by ultrasound only may not require lymphadenectomy because in our group of 28 patients no positive nodes were detected.
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26
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Danella JF, deKernion JB, Smith RB, Steckel J. The contemporary incidence of lymph node metastases in prostate cancer: implications for laparoscopic lymph node dissection. J Urol 1993; 149:1488-91. [PMID: 7684789 DOI: 10.1016/s0022-5347(17)36424-8] [Citation(s) in RCA: 120] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The incidence of lymphatic metastases in 229 consecutive patients with clinically localized prostatic cancer was assessed. Only 13 patients had nodal metastases, for an incidence of 5.7%. A monoclonal prostatic specific antigen value of more than 40 ng./ml. correlated with a positive predictive value of 53% for nodal metastases. Routine laparoscopic node dissection is unnecessary considering the low incidence of nodal metastases.
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27
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Gerber GS, Rukstalis DB, Chodak GW. The role of laparoscopic lymphadenectomy in staging and treatment of urological tumours. Ann Med 1993; 25:127-9. [PMID: 8489747 DOI: 10.3109/07853899309164154] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Laparoscopic lymphadenectomy for managing a variety of urological malignancies is likely to continue to increase in popularity. It is essential that the role of these procedures be critically evaluated to ensure that they offer significant benefit without added morbidity as compared with standard techniques. The challenge for the future is to better define selection criteria for laparoscopic surgery, particularly in men with clinically localized prostate cancer, so that both staging methods and therapy can be tailored to the individual patient.
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Affiliation(s)
- G S Gerber
- Division of Urology, University of Chicago, IL
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28
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Abstract
BACKGROUND The management of early stage prostatic cancer is controversial. METHODS Pertinent literature concerning the conservative management of early stage prostatic cancer by early endocrine therapy (EET) or by deferred treatment (DT) was reviewed. RESULTS EET has not been systematically studied. Available evidence suggests that early stage prostatic cancer often progresses slowly and that DT results in a cancer-specific mortality of approximately 80% at 10 years. CONCLUSIONS EET warrants clinical investigation. DT is a management option, at least in patients with a life expectancy of 10 years or less.
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Affiliation(s)
- W F Whitmore
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021
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29
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Abstract
BACKGROUND Prostate cancer commonly presents with positive pelvic lymph nodes. The appropriate management of patients with prostate cancer is controversial and no satisfactory randomized trials have been conducted. METHODS Available literature was reviewed, particularly concerning long-term survival after primary surgery or radiation therapy with or without adjuvant androgen deprivation. RESULTS With surgery, 10-40% of patients with low volume nodal disease are 10-year, no evidence of disease (NED) survivors and with radiation, 10-20% of node-positive patients are free of failure at 10 years. Few studies include past treatment and prostate specific antigen (PSA) data. It also appears that androgen deprivation may improve survival after surgery. CONCLUSIONS At least 40,000 patients of all clinical stages will have node-positive prostate cancer in 1992. A careful systematic investigation by prospective trial of the available treatment options is needed to establish the optimal management of these prostate cancers.
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Affiliation(s)
- G E Hanks
- Fox Chase Cancer Center/University of Pennsylvania, Philadelphia
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30
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Gerber GS, Rukstalis DB, Levine LA, Chodak GW. Current and future roles of laparoscopic surgery in urology. Urology 1993; 41:5-9. [PMID: 7678363 DOI: 10.1016/0090-4295(93)90188-g] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
There is little doubt that laparoscopy will gain an increasing role in urologic surgery. Pelvic node dissection, varicocelectomy, and evaluation of nonpalpable undescended testes are already widely performed. As improved instrumentation is developed expressly designed for urologic applications, there will be even greater interest and wider applicability of laparoscopic techniques. However, as this occurs, it is essential that each new procedure be critically evaluated to be certain that it offers significant benefit without added morbidity as compared with standard techniques.
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Affiliation(s)
- G S Gerber
- Department of Surgery, University of Chicago, Illinois
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31
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Davidson PJ. Diagnosis, prognosis and management of incidentally found prostate cancer. UROLOGICAL RESEARCH 1993; 21:1-8. [PMID: 7681241 DOI: 10.1007/bf00295184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Incidentally discovered cancer of the prostate may be divided into focal and diffuse disease. The focal tumour tends to be of low grade and low-volume and in the majority of patients runs a clinically benign course. In 10-15% of untreated patients, however, progression occurs by 10 years after diagnosis. At the same stage of follow-up 30-63% of the patients have died of other causes, with no evidence of recurrence. In patients with low-grade focal cancer of the prostate, radical prostatectomy may be curative. An alternative management option is to closely observe these patients. Digital rectal examination, prostatic specific antigen, transrectal prostatic ultrasound and repeated prostatic biopsies can all make contributions to the follow-up of these patients.
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32
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Anscher MS, Prosnitz LR. Prognostic significance of extent of nodal involvement in stage D1 prostate cancer treated with radiotherapy. Urology 1992; 39:39-43. [PMID: 1637367 DOI: 10.1016/0090-4295(92)90038-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The records of 107 patients with newly diagnosed adenocarcinoma of the prostate irradiated with curative intent at Duke University Medical Center from 1970 through 1983 were reviewed. Forty patients (37%) underwent standard bilateral pelvic lymph node dissection (PLND) prior to beginning irradiation. Twenty-four patients (22%) were found to have pelvic nodal metastases (Stage D1). Those found to have a single microscopically positive node at PLND may be curable with irradiation. In contrast, those with more extensive nodal metastases appear to be incurable with radiotherapy. Additional studies are needed to confirm or refute these findings.
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Affiliation(s)
- M S Anscher
- Duke Comprehensive Cancer Center, Duke University Medical Center, Division of Radiation Oncology, Durham, North Carolina
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33
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Larsen MP, Carter HB, Epstein JI. Can stage A1 tumor extent be predicted by transurethral resection tumor volume, per cent or grade? A study of 64 stage A1 radical prostatectomies with comparison to prostates removed for stages A2 and B disease. J Urol 1991; 146:1059-63. [PMID: 1895422 DOI: 10.1016/s0022-5347(17)38000-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We studied 64 totally embedded radical prostatectomy specimens of stage A1 prostate cancer. The transurethral resection specimens were studied and compared to previously studied stages A2 and B cancer in which tumor volumes also were calculated. At radical prostatectomy 6% of the specimens had no residual cancer, 74% had minimal cancer and 20% had substantial cancer. Although most stages A2 and B tumors were larger, there was overlap among all stages. Transurethral resection tumor volume, per cent and grade were not statistically correlated with either radical prostatectomy residual tumor volume, or whether tumor was classified as minimal or substantial. Gleason sum 2 to 4 versus 5 to 7 tumor on transurethral resection showed no difference in predicting radical prostatectomy residual tumor or minimal versus substantial tumor status. Because 20% of all stage A1 cancers have substantial tumor at radical prostatectomy unpredictable by transurethral resection, radical prostatectomy remains an option for young men with stage A1 prostate cancer.
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Affiliation(s)
- M P Larsen
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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34
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35
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Chybowski FM, Keller JJ, Bergstralh EJ, Oesterling JE. Predicting radionuclide bone scan findings in patients with newly diagnosed, untreated prostate cancer: prostate specific antigen is superior to all other clinical parameters. J Urol 1991; 145:313-8. [PMID: 1703240 DOI: 10.1016/s0022-5347(17)38325-8] [Citation(s) in RCA: 257] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Presently, the standard staging evaluation of prostate cancer includes digital rectal examination, measurement of serum tumor markers and a radionuclide bone scan. To evaluate the ability of local clinical stage, tumor grade, serum acid phosphatase, serum prostatic acid phosphatase (PAP) and serum prostate specific antigen (PSA) to predict bone scan findings, a retrospective review of 521 randomly chosen patients (mean age 70 years, range 44 to 92 years) with newly diagnosed, untreated prostate cancer was performed. Local clinical stage, tumor grade, acid phosphatase, PAP and PSA all correlated positively with bone scan findings (p less than 0.0001). Using receiver operating characteristic curves, however, PSA had the best over-all correlation with bone scan results. The median serum PSA concentration in patients with a positive bone scan was 158.0 ng./ml., whereas men with a negative bone scan had a median serum PSA level of 11.3 ng./ml. (p less than 0.0001). Using multivariate logistic regression analysis, local clinical stage, tumor grade, acid phosphatase and PAP were evaluated in combination with PSA to assess whether these parameters increased the ability of PSA alone to predict bone scan findings. None of these clinical parameters, irrespective of the combination used, contributed appreciably to the predictive power of PSA alone. A probability plot with 95% confidence intervals was constructed that allows the practicing urologist to estimate on an individual basis the probability of a positive bone scan for any given serum PSA value. The most significant finding of this study, however, was the negative predictive value of a low serum PSA concentration for bone scan findings. In 306 men with a serum PSA level of 20 ng./ml. or less only 1 (PSA 18.2 ng./ml.) had a positive bone scan (negative predictive value 99.7%). This finding would suggest that a staging radionuclide bone scan in a previously untreated prostate cancer patient with a low serum PSA concentration may not be necessary.
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Affiliation(s)
- F M Chybowski
- Department of Urology, Mayo Clinic, Rochester, Minnesota 55905
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36
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Soffen EM, Hanks GE, Hwang CC, Chu JC. Conformal static field therapy for low volume low grade prostate cancer with rigid immobilization. Int J Radiat Oncol Biol Phys 1991; 20:141-6. [PMID: 1993623 DOI: 10.1016/0360-3016(91)90150-3] [Citation(s) in RCA: 138] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The ability to improve existing standards of treating prostate cancer was investigated. To deliver a homogenous dose to the prostate with as little normal tissue margin as practical, seven patients with low volume carcinoma of the prostate were immobilized with alpha cradle body casts prior to using a CT-based 3D treatment planning system and beam's eye view (BEV) template. All patients had clinical Stage B-1 prostate cancer of favorable histologic differentiation (Gleason Score 2-5). A four field box technique was used, each beam having a single customized cerrobend block cut-out conforming to the exact contour of the prostate. To assess the accuracy of this process, daily port films were taken for 5 consecutive days and compared to a matched control group who were treated in a similar fashion, but were not casted. Dose volume histograms illustrate an average of 14% of bladder dose and 14% of rectal dose that can be eliminated using this technique when compared to field sizes and block placement in our previous technique. Daily setup variation was markedly improved using the cast, with a median daily variation of 1 mm as compared to 3 mm without the cast. The average range of movement for each of the seven casted patients was 3.3 mm as compared to 8 mm for the seven uncasted patients. Immobilization eliminated the worst 10% of all daily positioning errors. Using CT treatment planning with the patient casted and BEV allows for precise block placement with the prostate gland in its proper orientation during daily treatment. With improved immobilization and precise localization of the prostate gland, margins around the target can be made significantly smaller, and this may translate into a decrease in acute and/or late complications.
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Affiliation(s)
- E M Soffen
- Department of Radiation Oncology, University of Pennsylvania School of Medicine, Philadelphia
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37
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Whitmore WF. Natural History of Low-Stage Prostatic Cancer and the Impact of Early Detection. Urol Clin North Am 1990. [DOI: 10.1016/s0094-0143(21)01364-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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38
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Fallon B, Williams RD. Current Options in the Management of Clinical Stage C Prostatic Carcinoma. Urol Clin North Am 1990. [DOI: 10.1016/s0094-0143(21)01379-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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39
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Abstract
Stage A1 carcinoma of the prostate because of its small volume and low grade has been regarded as clinically insignificant and requiring no treatment. Recent long-term studies of the untreated natural history of this disease suggests otherwise. Review of our long-term follow-up of untreated incidental carcinoma of the prostate diagnosed between 1966 and 1975 has demonstrated a 16 percent progression rate requiring therapy. This finding suggests Stage A1 prostate carcinoma is not a dismissible diagnosis but demands accurate staging, closer follow-up to uncover progression, and consideration of definitive therapy following diagnosis.
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Affiliation(s)
- C R Roy
- Department of Urology, Fitzsimons Army Medical Center, Aurora, Colorado
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40
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Vesey SG, Goble M, Ferro MA, Stower MJ, Hammonds JC, Smith PJ. Quantification of prostatic cancer metastatic disease using prostate-specific antigen. Urology 1990; 35:483-6. [PMID: 1693796 DOI: 10.1016/0090-4295(90)80099-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The serum prostate-specific antigen (PSA) of 58 men with benign prostatic hypertrophy (BPH) and 17 men with carcinoma of the prostate (CaP) was correlated with the weight of prostatic tissue resected at transurethral prostatectomy (TURP). A significant correlation was identified between the weight of resected BPH tissue and the serum PSA (p less than or equal to 0.001; r = 0.54). No such correlation was seen in the CaP patients. By arbitrarily dividing the serum PSA by the prostate weight, it was possible to devise an index. This index corrected PSA in relation to prostatic size and unlike PSA in isolation did not differ significantly between normal controls and those with BPH. The index in CaP was significantly greater than that of either controls or BPH (p less than or equal to 0.001). Furthermore the index of metastatic CaP (M1) was significantly higher than that of nonmetastatic disease (MO) (p = 0.05). The higher index found in CaP would seem to be related to the bulk metastatic tumor, either manifest or occult. Comparing the index of CaPs to that found in normal and benign disease (a constant) offers a possible means of estimating the extent of local and metastatic tumor mass.
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Affiliation(s)
- S G Vesey
- Department of Urology, Bristol Royal Infirmary, England
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41
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Abstract
Among 753 autopsy prostatic cancer cases with a metastasis, 476 (63%) had a lymph node metastasis, whereas 277 (37%) did not. Two different lymph node metastatic patterns were observed: Type 1, combined metastasis involving the pelvic and paraaortic lymph nodes; and Type 2, metastasis to the paraaortic lymph nodes, but not to the pelvic lymph nodes. Type 1 metastasis cases showed a significantly more frequent metastasis to the bladder and rectum, and a less frequent metastasis to the lungs and liver. Hydronephrosis occurred more frequently (P less than 0.01) in the Type 1. Furthermore, in the Type 1 cases the lymph node metastasis appeared to be continuously invasive, but in the Type 2 cases, metastasis appeared to be the skip type or some metastases may have spread via the vertebral vein bypass route and may have been associated with a hematogenous metastasis.
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Affiliation(s)
- H Saitoh
- Department of Urology, Saitama Medical Center, Saitama Medical School, Kawagoe, Japan
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42
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Christensen WN, Partin AW, Walsh PC, Epstein JI. Pathologic findings in clinical stage A2 prostate cancer. Relation of tumor volume, grade, and location to pathologic stage. Cancer 1990; 65:1021-7. [PMID: 2404561 DOI: 10.1002/1097-0142(19900215)65:4<1021::aid-cncr2820650430>3.0.co;2-l] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Transurethral resections (TUR) and totally embedded radical prostatectomies from 39 clinical Stage A2 prostate cancers were morphometrically analyzed and compared with 56 prior similarly studied clinical Stage B cancers. All the clinical A2 radical prostatectomies contained residual tumor with 26% having capsular penetration. Clinical Stage A2 tumors were much more heterogeneous than clinical Stage B tumors with respect to tumor location, grade, and amount. In particular, many clinical A2 cases were predominantly central or central and anterior in location (59%) and low-grade compared with clinical Stage B cases where most lesions were posterior, peripheral, and intermediate grade. Percent of tumor in TUR best predicted final pathologic stage versus TUR grade or volume. Despite statistically significant correlations between tumor percent and/or grade on TUR and final stage, predictability of final stage for individual patients from TUR data was poor. The complex interrelation of tumor location, grade, and amount resulted in wide and overlapping ranges for these parameters for organ-confined and nonconfined cases.
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Affiliation(s)
- W N Christensen
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
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43
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Abstract
Conceptual advances include attempts to achieve uniformity among systems for characterizing and reporting experiences with prostatic cancer, better understanding of the zonal anatomy of the prostate, and recognition of probable precursor lesions to prostatic cancer. Prostatic-specific antigen, transrectal ultrasonography, and fine-needle aspiration biopsy are major innovations in diagnosis and staging of prostatic cancer. The varied and unpredictable behavior of prostatic cancer has stimulated the search for reliable indicators of the biologic potential of the disease. Management of localized prostatic cancer remains controversial. A nerve-sparing technique of radical retropubic prostatectomy accomplishes total removal of the prostate with possible preservation of sexual potency. Linear accelerator irradiation is an acceptable alternative treatment. Interstitial irradiation with a variety of radionuclides remains under investigation using ultrasound to enhance distribution of radiation sources. Endocrine therapy may prove especially advantageous if administered before development of bone metastasis.
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Affiliation(s)
- W F Whitmore
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021
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44
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Abstract
Reliable study results are scarce in prostate cancer for several reasons. The treated tumors represent a wide variety of natural history and therapeutic response. One assumes to select 'soft' or minimally toxic treatment for patients with good prognostic factors while aggressive treatment is reserved for infaust prognosis. Stage, grade and prognostic factors may influence the indication and choice of treatment. Better treatment selection will depend on the outcome of actual ongoing randomized trials, the development of new drugs or existing drugs in new indications and, above all, basic studies on the growth potential and invasiveness of the prostate cancer cell. Defining the correct treatment for the right cancer in the right patient is our clinical challenge for the next decade.
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Affiliation(s)
- L Denis
- Department of Urology-Endocrinology, Algemeen Ziekenhuis, Middelheim, Antwerp, Belgium
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Asbell SO, Martz KL, Pilepich MV, Baerwald HH, Sause WT, Doggett RL, Perez CA. Impact of surgical staging in evaluating the radiotherapeutic outcome in RTOG phase III study for A2 and B prostate carcinoma. Int J Radiat Oncol Biol Phys 1989; 17:945-51. [PMID: 2808056 DOI: 10.1016/0360-3016(89)90140-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Radiation Therapy Oncology Group (RTOG) protocol 7706 was a randomized Phase III study designed to test the value of elective (prophylactic) pelvic irradiation in addition to prostatic irradiation in patients with carcinoma of the prostate with no clinical evidence of tumor extension through the capsule. Eligible patients were those who had clinical Stage T1bNOMO (A2) or T2NOMO (B), who did not have curative surgery, and who had no evidence of lymph node metastases. Assessment of the regional lymphatics was mandatory but, at the discretion of the investigator, lymphangiography (LAG) or staging lymphadenectomy (SL) could be used. A total of 445 eligible and analyzable patients were entered in the study between 1978 and 1983 when the study was closed. The median follow-up was 7 years; minimum follow-up was 5 years. There were no significant differences in survival or local control whether treatment was administered to the prostate or to the prostate and pelvic lymph nodes. The nodal status for 117 (26%) patients was assessed by staging lymphadenectomy (SL) whereas for 328 (74%) patients it was assessed by lymphangiography (LAG). Pretreatment characteristics felt to have impact on survival were evaluated and found to be free of serious imbalance between the staging lymphadenectomy and lymphangiography groups. Compared to the lymphangiography group, the staging lymphadenectomy group showed better overall survival (87% to 76% at 5 years, p = .02), better disease-free survival (76% to 63% at 5 years, p = .008) and better metastases-free survival (88% to 82% at 5 years, p = .04). There was no difference between the groups in local control. The lymphangiography evaluation of pelvic nodes was clearly inferior for demonstration of the absence of pelvic node metastasis as reflected by reduced survival and increased metastasis.
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Affiliation(s)
- S O Asbell
- Department of Radiation Therapy, Albert Einstein Medical Center, Philadelphia, PA 19141
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Abstract
The prognosis and proper treatment of Stage A1 carcinoma of the prostate remain unsettled. We report on 60 patients with Stage A1 prostate cancer (less than 5 foci of well-differentiated tumor) diagnosed between 1960 and 1980. Mean duration of follow-up was 7.5 years with a range of one to twenty years. Three patients (5%) suffered disease progression at two, five, and nineteen years of follow-up, and all died of their tumor. Thirty-four patients (56%) have died of other causes. Number of tumor foci had no correlation with chance of disease progression. Extended follow-up of these patients suggests that the vast majority with Stage A1 carcinoma of the prostate will not suffer from morbidity or mortality of the disease but will more commonly succumb to other intervening disease processes.
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Affiliation(s)
- I M Thompson
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas
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Walther PJ. The role of radical prostatectomy in the management of prostatic adenocarcinoma. World J Urol 1989. [DOI: 10.1007/bf01576843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Asbell SO, Krall JM, Pilepich MV, Baerwald H, Sause WT, Hanks GE, Perez CA. Elective pelvic irradiation in stage A2, B carcinoma of the prostate: analysis of RTOG 77-06. Int J Radiat Oncol Biol Phys 1988; 15:1307-16. [PMID: 3058656 DOI: 10.1016/0360-3016(88)90225-8] [Citation(s) in RCA: 152] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
From 1978 to 1983 the Radiation Therapy Oncology Group conducted a study to evaluate the role of elective pelvic lymph node irradiation in carcinoma of the prostate. Eligible patients were those with clinical Stage A2 (occult disease with more than 3 positive chips and poorly differentiated tumor) and Stage B without clinical (lymphangiogram) or biopsy evidence of lymph node involvement. The patients were randomized to receive 6.5 weeks of either prostatic bed irradiation only 6500 cGy at 180-200 cGy per treatment or pelvic node irradiation to 4500 cGy with a boost of 2000 cGy to the prostatic bed bringing the total dose to 6500 cGy. As of February, 1988, the median follow up has been 7 years and there were 445 analyzable cases who were evaluated for local control, incidence of distant metastases, ned (no evidence of disease) survival and survival. The results of the study revealed no statistically significant benefit of elective pelvic irradiation.
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Affiliation(s)
- S O Asbell
- Albert Einstein Medical Center, Department of Radiation Therapy, Philadelphia, PA 19141
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