Seminal vesicle biopsy and laparoscopic pelvic lymph node dissection: implications for patient selection in the radiotherapeutic management of prostate cancer

New implant technique for separation of the seminal vesicle and rectal mucosa for high-dose-rate prostate brachytherapy

PURPOSE

For safer treatment of seminal vesicles (SVs), we initiated a new technique using an anchor applicator for high-dose-rate interstitial brachytherapy (HDR-ISBT) of prostate cancer.

METHODS AND MATERIALS

Between January 2004 and March 2005, 23 intermediate- to high-risk patients were treated with HDR-ISBT as monotherapy. Transrectal ultrasonography guided implantation of the treatment applicator in and around the prostate gland and proximal SV. We used an "anchor" applicator to prevent posterior displacement of the SV. After insertion of the anchor applicator, the actual treatment applicator was implanted at the best position for optimal SV coverage. SV coverage was analyzed using a dose-volume histogram.

RESULTS

Implantation of the applicator on the posterior side of the SV was successful for 43 of 46 SVs (93%). The median percentage of the SVs receiving the prescribed dose was 41% (range 11-86%). Only one case of acute Grade 2 toxicity (3%) was seen.

CONCLUSIONS

Our anchor applicator technique for HDR-ISBT can separate the SV from the rectum. This is the first report of dose-volume histogram analysis of the SV for HDR-ISBT.

Changing the patterns of failure for high-risk prostate cancer patients by optimizing local control

PURPOSE

Standard therapies for high-risk prostate cancer have resulted in suboptimal outcomes with both local and distant failures. Prostate-specific antigen (PSA) and distant metastases rates as well as biopsy outcomes are reported after a regimen of trimodality therapy with hormonal, radioactive seed, and external beam radiation therapy to demonstrate how patterns of failure are changed when local control is optimized.

METHODS AND MATERIALS

From 1994 to 2003, a total of 360 patients with high-risk prostate cancer were treated with trimodality therapy. Patients were defined as being at high risk if they possessed at least one of the following high-risk features: Gleason score 8 to 10, PSA>20, clinical stage t2c to t3, or two or more intermediate risk features: Gleason score 7, PSA>10 to 20, or stage t2b. Patients were followed for a median of 4.25 years (range, 2 to 10 years).

RESULTS

The actuarial 7-year freedom from PSA failure and freedom from distant metastases (FFDM) rates were 83% and 89% respectively. Patients (n=51) developing PSA failure exhibited aggressive disease behavior with short PSA doubling times (median, 5 months) and a 7-year freedom from distant metastases rate of 48%. Local control was high. The last posttreatment biopsy results were negative in 97% of cases (68 of 70 patients). In multivariate analysis, only PSA>20 predicted biochemical failure (p=0.04), and only seminal vesicle status predicted developing distant failure (p=0.01).

CONCLUSIONS

Trimodality therapy results in excellent local control that alters patterns of failure, resulting in similar actuarial biochemical and distant failure rates. Most failures appear to be distant and exhibit biologically aggressive behavior.

Disease-specific survival following the brachytherapy management of prostate cancer

PURPOSE

To determine disease-specific survival (DSS) and associated predictive factors after prostate brachytherapy.

METHODS AND MATERIALS

A total of 1561 patients underwent brachytherapy for prostate cancer from 1990 to 2004 (median follow-up, 3.8 years). Treatment included brachytherapy alone (n = 634), brachytherapy and hormonal therapy (n = 420), and implant and external beam therapy (n = 507).

RESULTS

The DSS and overall survival rates at 10 years were 96% and 74%, respectively. Gleason score significantly impacted DSS, with 10-year rates of 98%, 91%, and 92% for scores of < or = 6, 7, and > or = 8, respectively (p < 0.0001). Multivariate analysis revealed that PSA status after treatment had the most significant effect on DSS. Ten-year DSS rates were 100%, 52%, and 98%, respectively for patients without PSA failure (n = 1430), failure with a doubling time (DT) < or = 10 months (n = 64), and failure with a DT > 10 months (n = 67), respectively (p < 0.0001). In patients with PSA failure, DSS rates were 30%, 67%, and 98%, for those with DT < or = 6 months, > 6-10 months, and > 10 months, respectively (p < 0.0001).

CONCLUSIONS

The 10-year DSS rate supports the efficacy of brachytherapy. Patients dying with disease within 10 years after treatment harbor inherently aggressive cancer with high Gleason scores and short DT.

Biologically effective dose values for prostate brachytherapy: Effects on PSA failure and posttreatment biopsy results

PURPOSE

To analyze the effect of biologically effective dose (BED) values on prostate-specific antigen (PSA) failure and posttreatment biopsy.

METHODS AND MATERIALS

From 1990 to 2003, 1,377 patients had prostate brachytherapy alone (I-125 or Pd-103) (571), hormonal and brachytherapy (371), and trimodality therapy (hormonal, implant, and external beam) (435). Dose was defined as the D90 (dose delivered to 90% of the gland from the dose-volume histogram).

RESULTS

Freedom from PSA failure (FFPF) at 10 years was 87%. The 10-year FFPF for BED<100, >100-120, >120-140, >140-160, <160-180, >180-200, and >200 were 46%, 68%, 81%, 85.5%, 90%, 90%, and 92%, respectively (p<0.0001). BED and Gleason score had the greatest effect, with p values of p<0.0001 in multivariate analysis. Posttreatment positive biopsy rate was 7% (31/446). The positive biopsy rates for BED<or=100, >100-120, >120-140, >140-160, >160-180, >180-200, and >200 were 24% (8/33), 15% (3/20), 6% (2/33), 6% (3/52), 7% (6/82), 1% (1/72), and 3% (4/131), respectively (p<0.0001). BED was the most significant predictor of biopsy outcome in multivariate analysis (p=0.006).

CONCLUSIONS

Biologically effective dose equations provide a method of comparing different isotopes and combined therapies in the brachytherapy management of prostate cancer. The effects of BED on FFPF and posttreatment biopsy demonstrate a strong dose-response relationship.

Combined modality treatment in the management of high-risk prostate cancer

PURPOSE

The efficacy of a multimodality protocol using neoadjuvant and concomitant hormonal therapy, brachytherapy, and three-dimensional conformal external beam radiotherapy (RT) in high-risk prostate cancer was evaluated using biochemical outcomes and posttreatment biopsy results.

METHODS AND MATERIALS

Between February 1994 and November 1999, 132 high-risk patients were treated with combined hormonal therapy (9 months), permanent radioactive seed brachytherapy, and external beam RT, with follow-up ranging from 36 to 88 months (median, 50 months). The eligibility criteria were any of the following: Gleason score 8-10, initial prostate-specific antigen (PSA) level >20 ng/mL, clinical Stage T2c-T3, or positive seminal vesicle biopsy, or two or more of the following: Gleason score 7, PSA level >10-20 ng/mL, or Stage T2b. Twenty percent of patients had a positive seminal vesicle biopsy before therapy. Negative laparoscopic pelvic lymph node dissections were performed in 44% of patients.

RESULTS

The actuarial overall freedom from PSA failure rate was 86% at 5 years. The freedom from PSA failure rate at 5 years was 97% for those with a Gleason score of < or =6 (35 of 36), 85% for a Gleason score of 7 (50 of 59), and 76% for a Gleason score of 8-10 (28 of 37; p = 0.03). A trend was noted toward worse outcomes in seminal vesicle biopsy-positive patients, with a 5-year freedom from PSA failure rate of 74% vs. 89% for all other patients (p = 0.06). Posttreatment prostate biopsies were performed in 47 patients and were negative in 96% at the first biopsy and 100% at the last biopsy.

CONCLUSION

Trimodality therapy with androgen suppression, brachytherapy, and external beam RT for high-risk prostate cancer results in excellent biochemical and pathologically confirmed local control.

Pathologic features the urologist should expect on a prostate biopsy

In recent years, the pathological evaluation of prostate biopsy specimens has made great improvements in diagnostic accuracy and comprehensiveness. In this article, we review major pathological findings on prostate biopsy, their interpretation and reporting, as well as their clinical significance and utility. We discuss especially the clinically relevant histological features in either a positive or negative biopsy. We emphasize that both Gleason score and extent of cancer involvement in a needle core biopsy are important predictors of clinical outcome after either radical prostatectomy or radiation. Special issues regarding diagnosis and grading of minimal cancer on needle core biopsies are discussed. We also highlight the current standards on high-grade prostatic intraepithelial neoplasia and atypical small acinar proliferation on needle core biopsies. In summary, the pathology reports on needle biopsies are far beyond the simple presence or absence of cancer; they contain invaluable information to clinicians on patient management and counseling.

Evidence-based estimate of appropriate radiotherapy utilization rate for prostate cancer

PURPOSE

Current estimates of the proportion of cancer patients who will require radiotherapy (RT) are based almost entirely on expert opinion. The objective of this study was to use an evidence-based approach to estimate the proportion of incident cases of prostate cancer that should receive RT at any point in the evolution of the illness.

METHODS AND MATERIALS

A systematic review of the literature was undertaken to identify indications for RT for prostate cancer and to ascertain the level of evidence that supported each indication. An epidemiologic approach was then used to estimate the incidence of each indication for RT in a typical North American population of prostate cancer patients. The effect of sampling error on the estimated appropriate rate of RT was calculated mathematically, and the effect of systematic error using alternative sources of information was estimated by sensitivity analysis.

RESULTS

It was estimated that 61.2% +/- 5.6% of prostate cancer cases develop one or more indications for RT at some point in the course of the illness. The plausible range for this rate was 57.3%-69.8% on sensitivity analysis. Of all prostate cancer patients, 32.2% +/- 3.8% should receive RT in their initial treatment and 29.0% +/- 4.1% later for recurrence or progression. The proportion of cases that ever require RT is risk grouping dependent; 43.9% +/- 2.2% in low-risk disease, 68.7% +/- 3.5% in intermediate-risk disease; and 79.0% +/- 3.8% in high-risk locoregional disease. For metastatic disease, the predicted rate was 66.4% +/- 0.3%.

CONCLUSION

This method provides a rational starting point for the long-term planning of radiation services and for the audit of access to RT at the population level. By completing such evaluations in major cancer sites, it will be possible to estimate the appropriate RT rate for the cancer population as a whole.

The relevance of prostatectomy findings for brachytherapy selection in patients with localized prostate carcinoma

BACKGROUND

The efficacy of brachytherapy for patients with localized prostate carcinoma depends on adequate radiotherapeutic coverage of the primary tumor and its subclinical extraprostatic extensions. Predictive models based on pretherapy factors may be useful to estimate the likelihood for clinically relevant extraprostatic disease and may be incorporated into selection criteria for this procedure.

METHODS

Multivariate logistic regression model building was performed using pretherapy factors in 2905 surgically staged patients with localized prostate carcinoma to estimate the probability of seminal vesicle and/or lymph node involvement. Bootstrap methods were employed to assess the stability of the final model parameters and to determine the sensitivity and specificity of the final model.

RESULTS

Clinical tumor classification, biopsy Gleason score groupings, and serum prostate specific antigen (PSA) levels were associated with seminal vesicle and/or pelvic lymph node involvement. These factors were incorporated into a multivariate model that predicted for these adverse histopathologic features. Allowing for up to a 10% likelihood for seminal vesicle and/or pelvic lymph node involvement, patients with tumors classified as T1c-T2a, Gleason scores of 2-6, and PSA < or = 16 ng/mL; or with tumors classified as T1c-T2a, Gleason scores of 7-10, and PSA < or = 4 ng/mL; or with tumors classified as T2b-T2c, Gleason scores of 2-6, and PSA < or = 6 ng/mL would be potential candidates for brachytherapy alone.

CONCLUSIONS

The predictive model presented may provide criteria whereby an adequately performed prostate brachytherapy procedure is expected to encompass the intraprostatic and adjacent extraprostatic disease. Prostate brachytherapy alone may be considered in these circumstances, whereas the addition of external beam radiotherapy may be reserved for patients with disease that is apt to extend beyond the brachytherapy target volume.

Role of hormonal therapy in the management of intermediate- to high-risk prostate cancer treated with permanent radioactive seed implantation

PURPOSE

To study the impact of hormonal therapy (HTx) on intermediate- to high-risk prostate cancer treated with permanent radioactive seed implantation.

METHODS AND MATERIALS

Patients with Stage T1b-T3bN0 prostate cancer, and Gleason score > or = 7 or prostate-specific antigen (PSA) level >10 ng/mL were treated with seed implantation with or without HTx. Their disease was defined as intermediate risk (PSA 10-20, Gleason score 7, or Stage T2b) or high risk (two or more intermediate criteria, or PSA >20 ng/mL, Gleason score 8-10, or Stage T2c-T3). The median follow-up for 201 eligible patients was 42 months (range 18-110). Biochemical failure was defined as a rising PSA >1.0 ng/mL. Pretreatment disease characteristics, implant dose, and HTx were evaluated using univariate and multivariate analyses.

RESULTS

HTx significantly improved 5-year actuarial freedom from biochemical failure rate, 79% vs. 54% without HTx. In addition, high-dose, PSA < or = 15 ng/mL, intermediate risk, and Stage T2a or lower significantly improved outcome in the univariate analyses. HTx was the most significant predictor of 5-year actuarial freedom from biochemical failure (p <0.0001) in a multivariate analysis. The best outcome was in the intermediate-risk patients treated with a high implant dose and HTx, resulting in a 4-year actuarial freedom from biochemical failure rate of 94%.

CONCLUSION

In this retrospective review, HTx improved outcome in intermediate- to high-risk prostate cancer patients treated with brachytherapy. HTx was the most important prognostic factor in the univariate and multivariate analyses.

Prostate brachytherapy in patients with prostate volumes >/= 50 cm(3): dosimetic analysis of implant quality

OBJECTIVES

Permanent implantation with (125)I in patients with localized prostate cancer who have prostate volumes >/= 50 cm(3) is often technically difficult owing to pubic arch interference. The objective of this study was to describe dosimetry outcomes in a group of patients who were implanted using the real-time ultrasound-guided technique who had prostate volumes >/= 50 cm(3).

MATERIALS AND METHODS

A total of 331 patients received an (125)I prostate seed implant from January 1, 1995, to June 1, 1999, of whom 66 (20%) had prostate volumes >/= 50 cm(3) at the time of the procedure. The real-time seed implant method was used in all patients and consisted of intraoperative planning and real-time seed placement using a combination of axial and sagittal ultrasound imaging. Pubic arch interference was managed using an extended lithotomy position or by angling the tip of the ultrasound probe in an anterior direction. No preimplant pubic arch CT scan study was performed and no patients were excluded from treatment because of prostate size. Implant quality was assessed using CT-based dosimetry performed 1 month postimplant. Dose-volume histograms for the prostate, bladder, rectum, and urethra volumes were generated. The target dose for these implants was 160 Gy and an adequate implant was defined as the dose delivered to 90% of the prostate (D90) >/= 140 Gy. The dose delivered to 95% of the prostate (D95) and doses to 30% of the rectal (DRECT30) and urethral (DURE30) volumes were also calculated.

RESULTS

Prostate volumes in the 66 patients ranged from 50 to 93 cm(3) (median 57, mean 61 cm(3)). Total activity implanted was 27.8-89.1 mCi (median 57 mCi), with a range in activity per seed of 0.36-0.56 mCi (median 0.4 mCi). The prostate D90s and D95s ranged from 13,245 to 22,637 cGy (median 18,750) and 11,856 to 20,853 cGy (median 16,725), respectively. Only one patient (1.5%) had a D90 < 140 Gy. The DURE30 values ranged from 15,014 to 27,800 cGy (median 20,410) and the DRECT30 values were 3137-9910 cGy (median 5515).

CONCLUSION

Implantation of the large prostate can be accomplished using the real-time method. A total of 98.5% of the patients receive a high-quality implant. In addition, these implants should not put patients at increased risk for significant urinary and bowel complications because urethral and rectal doses can be kept at acceptable levels.

Does prostate brachytherapy treat the seminal vesicles? A dose-volume histogram analysis of seminal vesicles in patients undergoing combined PD-103 prostate implantation and external beam irradiation

PURPOSE

Combined brachytherapy of the prostate and external beam irradiation (EBRT) of the prostate and seminal vesicles (SV) is becoming a popular treatment for high-risk prostate cancer. Dose-volume histogram (DVH) analysis of the SV in patients undergoing this treatment was performed to determine the dose distribution to the SV and the adequacy of this treatment in patients with potential SV involvement.

METHODS AND MATERIALS

Twenty-five consecutive patients were treated with a Pd-103 implant of the prostate alone and 45 Gy of EBRT to the prostate and SV. Attempts were not made to implant the SV but seeds were routinely placed at the junction of the prostate and SV. All patients underwent CT-based postimplant dosimetric analysis 1 month after implantation. As part of this analysis, DVH were generated for the prostate and total SV volume (SVT). In addition, the SV was divided into 6-mm-thick volumes identified as SV1, SV2, SV3, SV4, and SV5 starting from the junction of the prostate and SV and extending distally. DVH were also generated for these structures. Delivered dose was defined as the D90 (dose delivered to 90% of the organ on DVH).

RESULTS

The median volumes in cc of the prostate, SVT, SV1, SV2, SV3, SV4, and SV5 were 34.33, 9.75, 2.7, 3.48, 2.92, 3.18, and 1.96 respectively. The SVT contained from 0-9 seeds (median 2). There was little dose delivered to the SVT and SV volumes from the implanted prostate. The median D90 values for the prostate, SVT, SV1, SV2, SV3, SV4, and SV5 were 8615 cGy, 675 cGy, 3100 cGy, 1329 cGy, 553 cGy, 246 cGy, and 67 cGy, respectively. The dose delivered to the prostate covered small percentages of SV. The percents of SV volumes covered by the prostate D90 were 11, 35, 3.3, 0, 0, and 0 for SVT, SV1, SV2, SV3, SV4, and SV5, respectively.

CONCLUSIONS

DVH analysis of the SV reveals that dose generated from an implanted prostate contributes little to the SV. Those patients at high risk for SV involvement may be undertreated with combined EBRT to prophylactic doses and prostate implantation.

Prostate brachytherapy: treatment strategies

PURPOSE

Patients who present with localized and locally advanced prostate cancer may be candidates for prostate brachytherapy. We evaluated the treatment outcomes in a diverse group of prostate cancer patients who presented with low, moderate and high risk features.

MATERIALS AND METHODS

A total of 301 patients who presented with T1 to T3 prostate cancer were treated with brachytherapy alone or combined with hormonal therapy and/or external beam irradiation. Of these patients 109 at low risk with prostate specific antigen (PSA) 10 ng./ml. or less, Gleason score 6 or less and clinical stage T2a or less were treated with 125iodine alone, 152 at moderate risk with PSA greater than 10 ng./ml., Gleason score greater than 6 or stage T2b or greater were treated with 125iodine or 103palladium or combined implant alone with 5 months of hormonal therapy, and 40 at high risk with PSA greater than 15 ng./ml., Gleason 8 or greater, clinical stage T2c to T3 or positive seminal vesicle biopsy (20) were treated with combination brachytherapy, external beam irradiation and 9 months of hormonal therapy. Patients with a positive seminal vesicle biopsy (T3c disease) and negative pelvic lymph nodes were included in the high risk group, and the walls of the seminal vesicles were also treated with implantation. Followup was performed every 6 months with digital rectal examination and ultrasound evaluation. Prostate biopsy was routinely recommended 2 years after completion of the radiation. Failure was defined as PSA increase on 2 consecutive determinations above 1 ng./ml. or evidence of local recurrence on digital rectal examination, transrectal ultrasound or biopsy. Kaplan-Meier projections were used to calculate progression-free survival rates.

RESULTS

Of the 109 patients at low risk followed from 1 to 7 years (median 18 months) 91% were free of PSA failure at 4 years. No patient experienced urinary incontinence following implantation, although grade 1 to 2 radiation proctitis occurred in 5 (4.5%). Of the 152 patients at moderate risk 73 received implantation and 79 received implantation combined with hormonal therapy. The 4-year biochemical freedom from failure rate for the hormone group was 85% versus 58% for the no hormone group (p = 0.08). The difference was more significant for those with Gleason score 7 or greater (90 versus 43%, p = 0.01) and for those with PSA greater than 10 ng./ml. (87 versus 59%, p = 0.04). Grade 1 to 2 radiation proctitis occurred in 1 of the 79 patients (1.3%) receiving hormonal therapy and in 3 (4%) treated with implantation only. There were no cases of urinary incontinence. Of the 40 patients at high risk 71% were free of biochemical failure at 3 years. Of the 4 patients with failure (10%) 3 (75%) originally had positive seminal vesicle biopsies. Five patients experienced gastrointestinal complications, although none was grade 3 or 4. The actuarial freedom from grade 2 proctitis was 82%. No patient experienced urinary incontinence. Prostate biopsies were negative in 87% of the low risk, 96.8 (hormone group) versus 68.6% (no hormone group) of the moderate risk (p = 0.0023) and 86% of the high risk patients.

CONCLUSIONS

Brachytherapy appears to offer comparable results to external beam irradiation and radical prostatectomy when patients are stratified by disease extent. Adopting a strategy of implant alone, implant with hormonal therapy or implant with hormonal therapy and external beam irradiation in patients who present with low to high risk features can improve the overall results in the more advanced cases.

Improved freedom from PSA failure with whole pelvic irradiation for high-risk prostate cancer

PURPOSE

To determine the impact of whole pelvic irradiation on the risk of PSA failure in prostate cancer patients, at high predicted risk for lymph node involvement, receiving definitive radiotherapy.

MATERIALS AND METHODS

Between October 1987 and December 1995, 506 patients with clinically localized prostate cancer were treated with definitive radiotherapy at UCSF and affiliated institutions. Treatment consisted of 4-field whole pelvic irradiation followed by a prostate-only boost, or prostate-only treatment (median follow-up was 35 months and 30 months, respectively). PSA failure was defined as: 1. a PSA value > or = 1 ng/ml; or 2. a PSA value that rose > or = 0.5 ng/ml in < or = 1 year posttreatment on two consecutive measurements, with the first rise defined as the time of failure. The calculated risk of lymph node positivity (%rLN+) was defined as 2/3(iPSA) + 10(GS-6), and high risk was defined as %rLN+ > or = 15%. Univariate and multivariate analyses were performed.

RESULTS

A total of 201 high-risk patients were identified. High-risk patients who received whole pelvic irradiation had significantly improved freedom from PSA failure compared to those who received prostate-only treatment (median PFS = 34.3 months vs. 21.0 months; p = 0.0001). Potential confounding variables, including initial PSA, Gleason score, T stage, radiation dose, year of treatment, use of three-dimensional (3D) conformal techniques, and use of hormone therapy, did not account for the observed difference in time to PSA failure. Multivariate analysis revealed type of radiation treatment to be the most significant independent predictor of outcome.

CONCLUSION

Whole pelvic radiotherapy significantly improves the PSA failure-free survival in patients with a high calculated risk of lymph node positivity.

[Probability of seminal vesicle involvement in localized prostatic carcinoma. Significance in conformal radiotherapy]

PURPOSE

The development of objective criteria for selecting patients for seminal vesicle irradiation on radical radiotherapy for prostate cancer will be important for successful planning of 3D conformal radiotherapy.

MATERIALS AND METHODS

Based on morphometric studies from radical prostatectomy specimens, new imaging modalities with potential in the investigation of patients with gross seminal vesicle involvement and clinical factors with potential in the identification of patients with subclinical disease the development of objective guidelines is possible.

RESULTS

Clinical tumor stage as determined by digital rectal examination, diagnostic tumor biopsy (Gleason Score), and pretherapy serum prostate-specific antigen value were significant factors for the probability of involvement of seminal vesicles. Studies show that seminal vesicle involvement is unlikely if the PSA is < 4 ng/ml or 4 to 10 ng/ml and Gleason Score < 7 and stage < or = T2b. In contrast, involvement of seminal vesicles is highly likely with levels above 20 ng/ml. In patients with PSA levels between 10 and 20 ng/ml and Gleason Score < 7 ultrasonographic findings with regard to tumor volume and localization will be useful to determine the extent of the target volume. For treatment planning a significant reduction in the volumes of irradiation to the rectum and bladder is evident when seminal vesicles were excluded.

CONCLUSION

Prospective use of the objective criteria will be useful in the selection of patients for seminal vesicle involvement and should be an integral part in 3D conformal radiotherapy of prostate cancer.

Prostate, breast and gynecological cancer markers RAK with homology to HIV-1

Breast and gynecological cancer-associated antigens RAK p120, p42 and p25 exhibit molecular, immunological and genetic homology to HIV-1 proteins. Normal tissues, including the majority of tissues adjacent to cancer, do not express these unique cancer markers. Antigens RAK are now detected in 100% of prostate cancer and in the majority of prostate benign hyperplasia (BPH) cases. Polymerase chain reaction (PCR) with HIV-1 gp41-derived primers revealed prostate cancer-associated DNA fragments of similar size (140 bp) as in HIV-1 genome. Ninety-five percent of BPH samples obtained from prostate cancer patients tested PCR-positive. For comparison, only 61.9% of BPH samples obtained from cancer-free patients tested PCR-positive. The DNA fragments amplified in prostate cancer and in BPH showed more than 90% homology to the HIV-1 gene for gp41. The obtained results strongly suggest that a retrovirus related to HIV-1 may be associated with cancers of the reproductive system.

The effect of prognostic factors on therapeutic outcome following transperineal prostate brachytherapy

The objectives of this study were to examine the effect of both disease and treatment related prognostic factors on biochemical control and post-treatment biopsy. Two-hundred fifty-eight patients underwent interactive ultrasound guided transperineal prostate implantation for T1-T2 prostate cancer using Iodine-125 (139 patients) and Palladium-103 (119 patients) and were followed from 6-67 months (median, 19). Hormonal therapy with 3 months of leuprolide and flutamide prior to implantation and two months given after the implant was used in 96 patients. Pre-treatment prostate-specific antigen (PSA) had the most significant effect on biochemical failure. Freedom from biochemical failure (FFBF) rates at 4 years were 75% for patients with PSA 1.3-10 ng/ml (144), 74% for patients with PSA 10.1-20 ng/ml (73), and 34% for patients with PSA > 20 ng/ml (41) (P = 0.0004). Gleason score also had a significant effect on FFBF rates. Four-year rates were 81%, 65% and 47% for patients with scores of 2-4 (68), 5-6 (130), and > or = 7 respectively (60) (P = 0.01). These two factors were also significant in multivariate analysis (P = 0.002, 0.007, respectively). Gleason score was the only factor to significantly affect post-treatment biopsy results. Patients with scores of 2-6 had 85% (63/ 74) negative 2-year biopsies versus 62% (13/21) for patients with scores > or = 7 (P = 0.02). Low-risk patients (PSA < or = 10 ng/ml, scores < 7 and stage < T2a) had a 4-year FFBF rate of 88% as compared to 60% for high-risk patients (PSA > 10 ng/ml, score > 6 or stage > or = T2b) (P = 0.02) and had a 95% negative biopsy rate versus 76% for high-risk patients (P = 0.06). Low-risk patients demonstrate high FFBF and negative biopsy rates following implantation. Patients presenting with higher risk prognostic factors such as PSA > 20 ng/ml or Gleason scores > or = 7 may require more aggressive treatment regimens.

Laparoscopic pelvic lymph node dissection for prostate cancer: comparison of the extended and modified techniques

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.

Equivalent 5-year bNED in select prostate cancer patients managed with surgery or radiation therapy despite exclusion of the seminal vesicles from the CTV

PURPOSE

Prostate Specific Antigen (PSA) failure free survival was determined for select prostate cancer patients managed definitively with external beam radiation therapy to the prostate only or radical retropubic prostatectomy.

METHODS AND MATERIALS

A logistic regression multivariable analysis evaluating the variables of PSA, biopsy Gleason score, and clinical stage was used to evaluate the endpoint of pathologic seminal vesicle invasion (SVI) in 749 consecutive prostate cancer patients managed with a radical retropubic prostatectomy. In a subgroup of 332 surgically and 197 radiation managed patients who did not have the clinical predictors of SVI, PSA failure free survival (bNED) was determined. Comparisons were made using the log rank test between surgically and radiation managed patients in this subgroup. In this subgroup, radiation managed patients were treated to a median dose of 66 Gy (66-70 Gy) to the prostate only.

RESULTS

The pretreatment PSA (> 10 ng/ml), biopsy Gleason score (> or = 7), and clinical stage (T2b, 2c, or 3) were found to be significant independent predictors (p < 0.001) of SVI. Only 2% of patients without any of these factors had SVI and 17% had extracapsular extension (15% microscopic; 2% macroscopic). In this subgroup the 5-year bNED rates were equivalent [84 vs. 89% (p = 0.67)] for surgically and radiation managed patients, respectively.

CONCLUSIONS

Conventional dose external beam radiation therapy directed at the prostate alone resulted in 5-year bNED rates equivalent to surgery on retrospective comparison in patients with clinical stage T1,2a, PSA < or = 10 ng/ml, and biopsy Gleason < or = 6 prostate cancer.

The role of color Doppler and staging biopsies in prostate cancer detection

OBJECTIVES

To review the current published data on the role of color Doppler sonography and sonographically-guided staging biopsies in the detection and staging of prostate cancer. This article also discusses the role of color Doppler sonography in defining the ideal patients for neoadjuvant chemotherapy.

METHODS

Peer-reviewed reports in the radiologic, urologic, and medical literature were reviewed. Data from our own institution served as illustrative material.

RESULTS

Color Doppler sonography using state of the art ultrasound equipment produced from the mid 1990s onward can define areas of hypervascularity in the prostate. When located in the peripheral zone and associated with definable lesions, these areas likely represent carcinoma. More importantly, when isoechoic areas contain hypervascular foci with chaotic flow, cancer is also likely. In 93% of sites that contain normal vascularity, prostate cancer was not detected by biopsy. Staging biopsies are not frequently performed in current clinical practice. A positive seminal vesicle biopsy is associated with capsular penetration in 100% and positive lymph nodes in 50% of patients with prostate cancer.

CONCLUSIONS

Color Doppler sonography and staging biopsies may have a more significant role as newer alternative therapies for prostate cancer become popular. These two techniques show promise for increasing the accuracy of pretreatment staging over current algorithms, which are less than adequate.

Seminal vesicle biopsy: accuracy and implications for staging of prostate cancer

OBJECTIVES

Seminal vesicle biopsy (SVB) is a new technique for detecting the spread of prostate cancer to the seminal vesicles. A comparison of findings following SVB in patients undergoing radiation therapy with pathologic findings following radical retropubic prostatectomy (RRP) was made to evaluate the accuracy of this test and its use in the staging of prostate cancer.

METHODS

Four hundred nine patients with clinically localized adenocarcinoma of the prostate gland were evaluated for treatment: 222 patients underwent SVB prior to radiation therapy and 187 patients underwent RRP. Clinical stages in patients undergoing SVB included T1a (1 patient), T1b (4), T1c (35), T2a (49), T2b (96), and T2c (37); RRP clinical stages included T1b (3 patients), T1c (48), T2a (57), T2b (66), and T2c (13). The Gleason scores in patients undergoing SVB were 2 to 4 in 50 men, 5 to 6 in 110 men, and 7 and greater in 62 men; the Gleason scores in patients undergoing RRP were 2 to 4 in 53 men, 5 to 6 in 94 men, and 7 and greater in 40 men. Prostate-specific antigen (PSA) values ranged from 1.3 to 190 ng/mL (median 10.75) in men undergoing SVB and ranged from 0.5 to 140.6 ng/mL (median 9.0) in men undergoing RRP.

RESULTS

The overall incidence of seminal vesicle involvement as determined by the two techniques was the same. Seminal vesicle involvement was found in 33 of 222 patients (15%) undergoing SVB and in 27 of 187 (14%), of the RRP specimens (P = 0.9). When the two groups were further divided by three prognostic categories (clinical stage, PSA level, and grade), there was no difference in the incidence of seminal vesicle involvement between the two methods, except in the patients with Gleason score of 4 or less. In these patients, 5 of 53 (9%) had seminal vesicle involvement in the RRP group, compared with none of the 50 men in the SVB group (P = 0.02). Disease that was not organ confined was found in 69 of 187 prostatectomy specimens (37%). Of these patients, 27 of 69 (39%) had seminal vesicle involvement.

CONCLUSIONS

SVB is an accurate method of detecting seminal vesicle invasion based on comparisons with radical prostatectomy findings. Its importance lies in its ability to detect a large percentage of patients with non-organ-confined disease and in its use in modifying treatment planning accordingly.

Prostate specific antigen findings and biopsy results following interactive ultrasound guided transperineal brachytherapy for early stage prostate carcinoma

BACKGROUND

Interactive, transrectal, ultrasound-guided transperineal implantation is a new technique for performing permanent brachytherapy implants of the prostate. Prostate specific antigen (PSA) findings, biopsy results, and morbidity are examined to demonstrate its efficacy and safety in treating early stage prostate carcinoma.

METHODS

Ninety-seven patients underwent permanent implants for classifications T1 to T2 adenocarcinoma of the prostate gland with a median follow-up of 18 months (range: 6-51 months). Seventy-nine patients had negative laparoscopic pelvic lymph node dissections prior to implantation. Patients with positive lymph nodes were not implanted. The radioactive isotope used was I-125 in 71 patients and Pd-103 in 26 patients.

RESULTS

PSA failure was defined as two consecutive increases in PSA above the nadir level. The actuarial freedom from PSA failure (FFPF) at 2 years was 76% for the entire group. Stage significantly affected FFPF. Patients classified as T1b to T2a (35) had a FFPF of 91% at 2 years compared with 68.5% for patients classified as T2b to T2c (62) (P = 0.04). The pre-treatment PSA also significantly affected FFPF. Patients with PSA values of < or = 10 ng/mL (44) had a FFPF of 83% at 2 years. A similar rate of 82% was found in patients with PSA values of 10.1 to 20 ng/mL (29). Patients with PSA values > 20 ng/mL (24) had a significantly poorer FFPF at 2 years of 58% (P = 0.02). The PSA values of patients free from a PSA failure (82) ranged from 0.1 to 12.9 ng/mL with a median of 0.8 ng/mL. Transrectal prostate biopsies were performed 18 to 36 months posttreatment in 39 patients. Negative biopsies were found in 74% (29/39) of cases. The procedure was associated with an actuarial preservation of erectile function rate and sexual potency at 2 years of 96% and 79%, respectively. There were no cases of urinary incontinence or radiation cystitis. Associated morbidity included urinary retention requiring catheterization in 4% of the patients, outlet obstruction requiring a transurethral resection of the prostate in 2% and Grade 2 rectal complications in 1%.

CONCLUSIONS

Interactive, ultrasound-guided transperineal brachytherapy results in a low PSA failure rate, high negative biopsy rate, and is associated with low morbidity and preservation of erectile function.