Primary therapy of metastatic prostate carcinoma with depot gonadotropin-releasing hormone analogue goserelin versus estramustine phosphate. The Prostate Cancer Study Group

Pattern of somatic androgen receptor gene mutations in patients with hormone-refractory prostate cancer

Progression to hormone-refractory growth of prostate cancer has been suggested to be mediated by androgen receptor (AR) gene alterations. We analyzed AR for mutations and amplifications in 21 locally recurrent prostate carcinomas treated with orchiectomy, estrogens, or a combination of orchiectomy and estramustine phosphate using fluorescence in situ hybridization, single-strand conformation polymorphism, and DNA sequence analyses. Amplification was observed in 4 of 16 (25%) and amino acid changing mutations was observed in 7 of 21 (33%) of the tumors, respectively. Two (50%) tumors with AR amplification also had missense mutation of the gene. Four of five (80%) cancers that were treated with a combination of orchiectomy and estramustine phosphate had a mutation clustered at codons 514 to 533 in the N-terminal domain of AR. In functional studies, these mutations did not render AR more sensitive to testosterone, dihydrotestosterone, androstenedione, or beta-estradiol. Tumors treated by orchiectomy had mutations predominantly in the ligand-binding domain. In summary, we found molecular alterations of AR in more than half of the prostate carcinomas that recurred locally. Some tumors developed both aberrations, possibly enhancing the cancer cell to respond efficiently to low levels of androgens. Furthermore, localization of point mutations in AR seems to be influenced by the type of treatment.

Treatment of high-grade, high-stage prostate cancer with estramustine phosphate or diethylstilbestrol. A double-blind study. The SPCG-1 Study Group. Scandinavian Prostate Cancer Group

Between 1984 and 1989, 197 patients with T1-4, NX, M1, G2-3 or G3 prostate cancer were randomized to treatment with 560 mg estramustine phosphate (EMP, Estracyt, Emcyt) or 3 mg diethylstilbestrol (DES) per day in a double blind study with stratification on presence or absence of cancer pain at start. A total of 194 patients were evaluated for efficacy of therapy. Time to progression (p = 0.054), to treatment failure (p = 0.036), cancer-specific survival (p = 0.068) as well as overall survival (p = 0.021) were longer in the DES group. There were more patients with prognostic parameters indicating bad prognosis in the EMP group. This trial was designed to study whether EMP had better effect than DES as the primary treatment of high-grade, disseminated prostate cancer. The results did not confirm this hypothesis. On the contrary, treatment with DES had relatively good effect on this very aggressive form of prostate cancer.

Pretherapeutic erythrocyte polyamine spermine levels discriminate high risk relapsing patients with M1 prostate carcinoma

BACKGROUND

Androgen deprivation is currently the standard treatment for patients with metastatic prostate carcinoma. Few reliable prognostic markers are able to select, at diagnosis, patients who will respond favorably and durably to hormone ablation. Circulating polyamines, markers of cell proliferation that are elevated in prostate carcinoma, have been evaluated as a prognostic tool.

METHODS

Eighty-eight patients with untreated, M1 classified prostate carcinoma who received endocrine therapy between 1988 and 1993 were included in this study. Performance status, hemoglobin, alkaline phosphatases, prostate specific antigen, Gleason tumor grade, extent of disease by bone scan, and circulating erythrocyte spermidine and spermine were correlated with observed progression free and cause-specific survivals. Multiple correspondence analysis and ascending hierarchical classification were performed to determine significant pretreatment prognostic factors.

RESULTS

Pretreatment performance status, alkaline phosphatase, hemoglobin, and erythrocyte spermine levels were correlated with progression, with hemoglobin and erythrocyte spermine level being the most significant independent variables (P < 0.00001 and P < 0.0001, respectively). With regard to cause specific survival, only hemoglobin and spermine erythrocyte levels were significant independent variables (P < 0.0001 and P < 0.0005, respectively). Patients with spermine levels of less than 9 nmol/8.10(9) had a statistically better outcome than patients with 9 nmol/8.10(9) or more erythrocytes. Erythrocyte spermine was the best sole determinant of progression. A test combining spermine with performance status or hemoglobin improved each variable's predictive values.

CONCLUSIONS

Circulating erythrocyte spermine levels, extracted from a blood sample, can discriminate, at diagnosis, patients with hormone-refractory from those with hormone-responsive metastatic prostate carcinoma.

How is androgen-dependent metastatic prostate cancer best treated?

The principles of management of newly diagnosed metastatic prostate cancer have changed little since the time of Huggins and his colleagues. Modern clinicians have many more weapons in their therapeutic armamentarium than those pioneers, but little progress has been made in improving the survival of men with this disease. The results of androgen deprivation are comparable using any one of a number of different monotherapy approaches. The use of combined androgen blockade may improve survival in men with minimal disease but at considerable economic cost and with significant impairment of quality of life. The benefit of this therapy for men with more extensive disease is uncertain. New modalities such as intermittent androgen blockade or combination therapies are exciting, but unproven.