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Mao Y, Hu M, Yang G, Gao E, Xu W. Cytoreductive prostatectomy improves survival outcomes in patients with oligometastases: a systematic meta-analysis. World J Surg Oncol 2022; 20:255. [PMID: 35945562 PMCID: PMC9361652 DOI: 10.1186/s12957-022-02715-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Whether cytoreductive prostatectomy (CRP) should be performed in patients with oligometastatic prostate cancer (OPC) remains controversial. The goal of this systematic meta-analysis was to assess the efficacy of CRP as a treatment for OPC. METHODS This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Data sources included publications in the PubMed, Embase, the Cochrane Library, EBSCO, and Web of Science (SCI) databases as of May 2022. Eligible articles included prospective studies comparing the efficacy of CRP to a lack of CRP in patients with OPC. RESULTS In total, 10 publications incorporating 888 patients were analyzed. Tumor-reducing prostatectomy was found to have no significant effect on long-term or short-term OS [OR = 2.26, 95% CI (0.97, 5.28), P = 0.06] and [OR = 1.73, 95% CI (0.83, 3.58), P = 0.14], but it significantly improved patient long-term or short-term CSS [OR = 1.77, 95% CI (1.01, 310), P = 0.04] and [OR = 2.71, 95% CI (1.72, 4.29), P < 0.0001] and PFS [OR = 1.93, 95% CI (1.25, 2.97), P = 0.003]. CONCLUSION These results suggest that cytoreductive prostatectomy can confer survival benefits to OPC patients. TRIAL REGISTRATION INPLASY protocol 202260017 https://doi.org/10.37766/inplasy2022.6.0017 .
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Affiliation(s)
- Yifeng Mao
- Department of Urology, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China.,Anhui Province Key Laboratory of Translational Cancer Research, Bengbu Medical University, Bengbu, 233030, Anhui, China
| | - Mingqiu Hu
- Department of Urology, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China. .,Anhui Province Key Laboratory of Translational Cancer Research, Bengbu Medical University, Bengbu, 233030, Anhui, China. .,Department of Urology, Maoming People's Hospital, Maoming, 525000, Guangdong, China.
| | - Gaowei Yang
- Department of Urology, Maoming People's Hospital, Maoming, 525000, Guangdong, China
| | - Erke Gao
- Department of Urology, Maoming People's Hospital, Maoming, 525000, Guangdong, China
| | - Wangwang Xu
- Department of Urology, Maoming People's Hospital, Maoming, 525000, Guangdong, China
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2
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Mandoorah Q, Benamran D, Pinar U, Seisen T, Abdessater M, Iselin C, Rouprêt M. Biochemical relapse predictive factors in patients with lymph node metastases during radical prostatectomy. Prog Urol 2022; 32:1462-1468. [DOI: 10.1016/j.purol.2022.07.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 07/10/2022] [Accepted: 07/18/2022] [Indexed: 10/15/2022]
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3
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Cheng B, Ye S, Bai P. The efficacy of cytoreductive surgery for oligometastatic prostate cancer: a meta-analysis. World J Surg Oncol 2021; 19:160. [PMID: 34051809 PMCID: PMC8164769 DOI: 10.1186/s12957-021-02265-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/12/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUNDS At present, the application of tumor reduction surgery in oligometastatic prostate cancer has aroused extensive discussion among urologists, but clinicians have not reached a consensus on this issue. The purpose of this study was to evaluate the effect of cytoreductive surgery for patients with oligometastatic prostate cancer by meta-analysis. METHODS All relevant studies were systematically searched through The Cochrane Library, PubMed, Web of Science, EMBASE, and China Biomedical Literature Database (CBM) up to December 2019. All the previous clinical studies on the comparison of long-term efficacy between the cytoreductive surgery group and the endocrine therapy group were included in the search. The included studies were analyzed using Stata ver.14.0. The research has been registered on PROSPERO website with the registration number of crd42021224316. The relevant registration information can be obtained from the website: https://www.crd.york.ac.uk/prospero . RESULTS The case presentation is as follows: ten studies were identified that met the conclusion criteria. The total number of samples was 804; 449 patients underwent cytoreductive surgery, and 355 patients underwent endocrine therapy, and we conducted a meta-analysis of studies to compare the prognosis of endocrine therapy and cytoreductive surgery for treating prostate cancer. After all the studies were analyzed, we found that between cytoreductive surgery and endocrine therapy, a significant difference existed in overall survival (HR = 0.635, 95% CI 0.443-0.908, P = 0.013), cancer-specific survival (HR = 0.407, 95% CI 0.243-0.681, P = 0.001), and progression-free survival (HR = 0.489, 95% CI 0.315-0.758, P = 0.001), while there were no significant difference in progresses to castration-resistant prostate cancer (HR = 0.859, 95% CI 0.475-1.554, P = 0.616). CONCLUSION The cytoreductive surgery held advantages in overall survival, cancer-specific survival, and progression-free survival. Therefore, compared with endocrine therapy, cytoreductive surgery could be a more suitable approach in treating oligometastatic prostate cancer.
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Affiliation(s)
- Bisheng Cheng
- Zhongshan Hospital Affiliated to Xiamen University, Xiamen, 361001, China
| | - Shuchao Ye
- Zhongshan Hospital Affiliated to Xiamen University, Xiamen, 361001, China
| | - Peiming Bai
- Zhongshan Hospital Affiliated to Xiamen University, Xiamen, 361001, China.
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Contemporary Trends and Survival Outcomes After Aborted Radical Prostatectomy in Lymph Node Metastatic Prostate Cancer Patients. Eur Urol Focus 2019; 5:381-388. [DOI: 10.1016/j.euf.2018.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 12/22/2017] [Accepted: 01/12/2018] [Indexed: 11/21/2022]
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5
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Tsumura H, Ishiyama H, Tabata KI, Sekiguchi A, Kawakami S, Satoh T, Kitano M, Iwamura M. Long-term outcomes of combining prostate brachytherapy and metastasis-directed radiotherapy in newly diagnosed oligometastatic prostate cancer: A retrospective cohort study. Prostate 2019; 79:506-514. [PMID: 30585345 DOI: 10.1002/pros.23757] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 11/29/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Systemic Therapy in Advancing or Metastatic Prostate Cancer: Evaluation of Drug Efficacy (STAMPEDE) trial showed the survival benefit for prostate radiotherapy in newly diagnosed prostate cancer patients with a low metastatic burden. The result raises the next question whether additional radiotherapy to metastatic sites could improve the survival in those with a low metastatic burden. METHODS We evaluated the efficacy and safety of prostate-directed radiotherapy (PDRT) with or without metastasis-directed radiotherapy (MDRT) in newly diagnosed oligometastatic patients who underwent combination of high-dose-rate prostate brachytherapy, external beam radiotherapy, and androgen deprivation therapy. Forty patients with bone metastasis and node positive prostate cancer were retrospectively analyzed. Of these, 22 (55%), 3 (7%), and 15 (38%) patients had N1M0, M1a, and M1b, respectively. Eighteen patients (45%) received MDRT to all metastatic sites. All patients initially underwent ≧6 months of androgen deprivation therapy. Oligometastatic disease was defined as presence of five or fewer metastatic lesions. Median follow-up period was 62.5 months. RESULTS Of the 40 patients, the 5-year castration-resistant prostate cancer (CRPC)-free survival rate and cancer-specific survival was 64.4% and 87.9%, respectively. Pre- or post-treatment predictive value including prostate-specific antigen (PSA) at diagnosis ≥20 ng/mL, Gleason grade group 5, positive biopsy core rate ≥51%, PSA nadir level of ≥0.02 ng/mL after the radiotherapy, and no MDRT were significantly associated with progression to CRPC. Patients with MDRT had significantly higher probability of achieving a PSA level of <0.02 ng/mL than those without the therapy (88.8% vs 54.5%, P = 0.0354) and consequently had a better CRPC-free survival than those without the therapy (HR 0.319, 95%CI: 0.116-0.877). Comparing PDRT alone, PDRT with MDRT did not significantly increase the incidences of genitourinary and gastrointestinal toxicities. CONCLUSIONS This single-institutional study revealed the feasibility of combining prostate brachytherapy and MDRT for newly diagnosed oligometastatic prostate cancer. This combined approach has potential to prolong CRPC-free survival.
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Affiliation(s)
- Hideyasu Tsumura
- Department of Urology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hiromichi Ishiyama
- Department of Radiology and Radiation Oncology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Ken-Ichi Tabata
- Department of Urology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Akane Sekiguchi
- Department of Radiology and Radiation Oncology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Shogo Kawakami
- Department of Radiology and Radiation Oncology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Takefumi Satoh
- Department of Urology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Masashi Kitano
- Department of Radiology and Radiation Oncology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Masatsugu Iwamura
- Department of Urology, Kitasato University School of Medicine, Sagamihara, Japan
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Battaglia A, De Meerleer G, Tosco L, Moris L, Van den Broeck T, Devos G, Everaerts W, Joniau S. Novel Insights into the Management of Oligometastatic Prostate Cancer: A Comprehensive Review. Eur Urol Oncol 2018; 2:174-188. [PMID: 31017094 DOI: 10.1016/j.euo.2018.09.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 09/04/2018] [Accepted: 09/12/2018] [Indexed: 02/01/2023]
Abstract
CONTEXT The current standard of care for metastatic prostate cancer (PCa) is androgen deprivation therapy (ADT) plus either docetaxel or abiraterone. Growing evidence suggests that metastasis-directed therapy (MDT) and/or local therapy targeted to the primary tumour (ie, prostate) may be of benefit in the setting of oligometastatic disease. Several prospective studies are underway; however, until robust evidence is available to guide treatment decisions, physicians are challenged with how best to manage patients with oligometastases. OBJECTIVE This comprehensive review aims to collate the available evidence to date for a role of MDT and/or prostate-targeted therapy in the setting of oligometastatic PCa, as well as discuss ongoing trials in this setting. EVIDENCE ACQUISITION We searched PubMed for the combination of "prostate cancer" and "oligometastatic", "oligometastases", "oligometastasis", "solitary metastases", "stereotactic body radiotherapy", "SBRT", "stereotactic ablative radiotherapy", "SABR", "salvage lymphadenectomy", or "metastasectomy" in publications over the last 20yr. We also searched ClinicalTrials.gov to identify relevant ongoing trials. EVIDENCE SYNTHESIS The studies were divided according to the timing of metastasis into synchronous (ie, detected at the time of primary PCa diagnosis) and metachronous (ie, detected after treatment of the primary tumour), and according to treatment modality into MDT (including salvage lymph node dissection [sLND]) and prostate-targeted treatment. For MDT of synchronous/metachronous metastases, we included 16 completed studies and 11 ongoing prospective studies. In the case of sLND for nodal-only recurrence after primary treatment with curative intent, we included 11 completed studies. Finally, for prostate-targeted treatment of synchronous metastatic PCa, we included 25 completed studies and 11 ongoing prospective studies. In selected patients with oligorecurrent disease, early detection and aggressive treatment of metastatic lesions (surgery or radiotherapy) appears to be a feasible strategy and may delay the use of systemic therapies. MDT is a promising option in oligometastatic PCa patients, but more robust data are needed. In the setting of synchronous oligometastatic disease, aggressive cytoreductive treatment needs further data to confirm the benefits. CONCLUSIONS In this review, we provide a comprehensive overview of the current literature on the treatment of patients with oligometastatic PCa. The data suggest that although ADT plus either docetaxel or abiraterone remains the mainstay of treatment for mPCa, in oligometastatic PCa, improved outcomes may be achieved with metastasis- and prostate-targeted therapies. The studies included in this review are mainly retrospective in nature, limiting the strength of the evidence they provide. Prospective studies are ongoing, and their results are eagerly awaited. PATIENT SUMMARY We reviewed the treatment of patients with prostate cancer that has spread to five sites or fewer. We conclude that while androgen deprivation plus either docetaxel or abiraterone should remain the standard of care, there is evidence that treatment targeted at the metastases and the primary tumour may improve the outcome for the patient and potentially delay the use of systemic treatment.
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Affiliation(s)
- Antonino Battaglia
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Gert De Meerleer
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Lorenzo Tosco
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Lisa Moris
- Department of Cellular and Molecular Medicine, Laboratory of Molecular Endocrinology, KU Leuven, Leuven, Belgium
| | - Thomas Van den Broeck
- Department of Cellular and Molecular Medicine, Laboratory of Molecular Endocrinology, KU Leuven, Leuven, Belgium
| | - Gaëtan Devos
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Wouter Everaerts
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Steven Joniau
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Urology, University Hospitals Leuven, Leuven, Belgium.
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7
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Evaluation and Treatment for High-Risk Prostate Cancer. Prostate Cancer 2018. [DOI: 10.1007/978-3-319-78646-9_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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8
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Pagliarulo V. Androgen Deprivation Therapy for Prostate Cancer. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1096:1-30. [PMID: 30324345 DOI: 10.1007/978-3-319-99286-0_1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the contemporary scene, less than 5% of men with newly diagnosed prostate cancer (PC) have metastases at first presentation, compared to 20-25%, more than 20 years ago. Nonetheless, the use of androgen deprivation therapy (ADT) has increased over the years, suggesting that patients in Europe and United States may receive ADT in cases of lower disease burden, and not always according to evidence based indications. Nonetheless, PC remains the second most common cause of cancer death after lung cancer in American men. Thus, there is a need for more effective, specific and well tolerated agents which can provide a longer and good quality of life while avoiding the side effects related to disease and treatment morbidity.After mentioning the current knowledge on the endocrinology of androgens and androgen receptor, relevant to PC development, as well as the possible events occurring during PC initiation, we will compare different hormonal compounds available for the treatment of PC, both from a pharmacological standpoint, and in terms of contemporary clinical indications.
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Affiliation(s)
- Vincenzo Pagliarulo
- Department of Urology, University "Aldo Moro", Bari, Italy. .,Azienda Ospedaliero-Universitaria Policlinico, Bari, Italy.
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9
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Hu J, Aprikian AG, Cury FL, Vanhuyse M, Zakaria AS, Richard PO, Perreault S, Dragomir A. Comparison of Surgery and Radiation as Local Treatments in the Risk of Locoregional Complications in Men Subsequently Dying From Prostate Cancer. Clin Genitourin Cancer 2017; 16:S1558-7673(17)30266-5. [PMID: 28943330 DOI: 10.1016/j.clgc.2017.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 08/15/2017] [Accepted: 08/28/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Late locoregional complications in prostate cancer (PCa) affect quality of life and require medical interventions. Our objective was to compare late locoregional complications in men dying of castration-resistant PCa (CRPC) who previously received external-beam radiotherapy (EBRT) to radical prostatectomy (RP). No group without previous primary local treatment was included. PATIENTS AND METHODS The cohort consists of CRPC patients who died between 2001 and 2013 and who underwent previous EBRT or RP. The Régie de l'assurance maladie du Québec administrative databases were used to identify late locoregional complications (urologic procedures, minor rectal procedures, and other major surgical procedures) and PCa-related hospitalizations occurring in the last 2 years of life. Multivariable logistic regression and negative binomial regression analyses were performed. RESULTS The cohort comprised 1189 patients; 535 (45%) and 654 (55%) received EBRT and RP, respectively. Overall, 46.4% of patients experienced at least 1 late locoregional complication. Primary local treatment type was not associated with the odds of late locoregional complications (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.72, 1.16). RP was associated with greater odds of PCa-related hospitalization (OR, 1.63; 95% CI, 1.23, 2.17) relative to EBRT, as were the usage of a CRPC treatment (OR, 3.96; 95% CI, 2.83, 5.53) and the occurrence of a late locoregional complication (OR, 2.76; 95% CI, 2.05, 3.69). For the number of PCa-related hospitalization days, RP was not found to be significant (rate ratio, 1.09; 95% CI, 0.90, 1.32). CONCLUSION In this population-based cohort, the risk of late locoregional complications in CRPC was not associated with the type of primary local treatment (RP or EBRT).
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Affiliation(s)
- Jason Hu
- Division of Urology, McGill University, Montreal, Canada
| | | | - Fabio L Cury
- Division of Radiation Oncology, McGill University, Montreal, Canada
| | - Marie Vanhuyse
- Division of Medical Oncology, McGill University, Montreal, Canada
| | | | - Patrick O Richard
- Division of Urology, University of Sherbrooke and CHUS Research Centre, Sherbrooke, Canada
| | | | - Alice Dragomir
- Division of Urology, McGill University, Montreal, Canada.
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10
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Impact of Radical Prostatectomy on Long-Term Oncologic Outcomes in a Matched Cohort of Men with Pathological Node Positive Prostate Cancer Managed by Castration. J Urol 2017; 198:86-91. [DOI: 10.1016/j.juro.2017.01.063] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2017] [Indexed: 11/23/2022]
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11
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Ristau BT, Smaldone MC. Difference of opinion - Radical prostatectomy in metastatic prostate cancer: is there enough evidence? | Opinion: No. Int Braz J Urol 2017; 42:880-882. [PMID: 27716457 PMCID: PMC5066883 DOI: 10.1590/s1677-5538.ibju.2016.05.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Benjamin T Ristau
- Division of Urologic Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
| | - Marc C Smaldone
- Division of Urologic Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
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12
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Mathieu R, Korn SM, Bensalah K, Kramer G, Shariat SF. Cytoreductive radical prostatectomy in metastatic prostate cancer: Does it really make sense? World J Urol 2016; 35:567-577. [PMID: 27502935 DOI: 10.1007/s00345-016-1906-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 07/22/2016] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Surgical removal of the primary tumor in metastatic prostate cancer (mPCa) is becoming a hotly debated issue. The purpose of this review was to summarize the current knowledge on cytoreductive radical prostatectomy (cRP) in this setting. MATERIALS AND METHODS We performed a non-systematic Medline/PubMed literature search of articles published in the field between January 2000 and April 2015. RESULTS Cytoreductive surgery has demonstrated its benefit in various malignancies with a solid biological rationale to justify its assessment in mPCa. cRP appears as a safe and feasible procedure in expert hands and well-selected patients. A growing body of evidence suggests a survival benefit for patients undergoing cRP as a part of a multimodal approach compared to those treated with systemic treatment alone. Nevertheless, little is known about the best clinical and tumor characteristics for the selection of patients most likely to benefit from cRP. The current literature is based on retrospective studies with small cohorts and limited follow-up or large uncontrolled population-based studies. CONCLUSIONS Data from various other malignancies together with the biological rationale and preliminary results in PCa suggest that cytoreductive surgery may be an option in some mPCa patients. The lack of randomized controlled trials and the low level of evidence in the current literature preclude any firms conclusion on the benefit of cRP in mPCa. Ongoing phase II and future phase III studies are mandatory to define the exact role of cRP in mPCa and to identify the patients who are most likely to benefit from cRP.
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Affiliation(s)
- Romain Mathieu
- Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria.,Department of Urology, Rennes University Hospital, Rennes, France
| | - Stephan M Korn
- Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria
| | - Karim Bensalah
- Department of Urology, Rennes University Hospital, Rennes, France
| | - Gero Kramer
- Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria
| | - Shahrokh F Shariat
- Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria. .,Department of Urology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA. .,Department of Urology, Weill Cornell Medical College, New York, NY, USA.
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Chopra S, Alemozaffar M, Gill I, Aron M. Extended lymph node dissection in robotic radical prostatectomy: Current status. Indian J Urol 2016; 32:109-14. [PMID: 27127352 PMCID: PMC4831498 DOI: 10.4103/0970-1591.163303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: The role and extent of extended pelvic lymph node dissection (ePLND) during radical prostatectomy (RP) for prostate cancer patients remains unclear. Materials and Methods: A PubMed literature search was performed for studies reporting on treatment regimens and outcomes in patients with prostate cancer treated by RP and extended lymph node dissection between 1999 and 2013. Results: Studies have shown that RP can improve progression-free and overall survival in patients with lymph node-positive prostate cancer. While this finding requires further validation, it does allow urologists to question the former treatment paradigm of aborting surgery when lymph node invasion from prostate cancer occurred, especially in patients with limited lymph node tumor infiltration. Studies show that intermediate- and high-risk patients should undergo ePLND up to the common iliac arteries in order to improve nodal staging. Conclusions: Evidence from the literature suggests that RP with ePLND improves survival in lymph node-positive prostate cancer. While studies have shown promising results, further improvements and understanding of the surgical technique and post-operative treatment are required to improve treatment for prostate cancer patients with lymph node involvement.
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Affiliation(s)
- Sameer Chopra
- Department of Urology, Catherine and Joseph Aresty USC, Institute of Urology, Center for Advanced Robotic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Mehrdad Alemozaffar
- Department of Urology, Catherine and Joseph Aresty USC, Institute of Urology, Center for Advanced Robotic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Inderbir Gill
- Department of Urology, Catherine and Joseph Aresty USC, Institute of Urology, Center for Advanced Robotic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Monish Aron
- Department of Urology, Catherine and Joseph Aresty USC, Institute of Urology, Center for Advanced Robotic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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14
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Ristau BT, Cahn D, Uzzo RG, Chapin BF, Smaldone MC. The role of radical prostatectomy in high-risk localized, node-positive and metastatic prostate cancer. Future Oncol 2016; 12:687-99. [DOI: 10.2217/fon.15.355] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
A lack of quality evidence comparing management strategies confounds complex treatment decisions for patients with high-risk prostate cancers. No randomized trial comparing surgery to radiation has been successfully completed. Despite inherent selection biases, however, observational and registry data suggest improved outcomes for patients initially managed with prostatectomy. As consensus shifts away from aggressive treatment for low-risk disease and toward multimodal treatment of locally advanced and metastatic disease, there is renewed interest in surgery for local control in patients presenting with high-risk localized, node-positive and minimally metastatic disease. The objective of this review is to examine the evidence evaluating clinical outcomes of patients with high-risk clinically localized, node-positive and metastatic prostate cancer treated with radical prostatectomy.
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Affiliation(s)
- Benjamin T Ristau
- Division of Urology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
| | - David Cahn
- Division of Urology, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Robert G Uzzo
- Division of Urology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
| | - Brian F Chapin
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Marc C Smaldone
- Division of Urology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
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15
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[Cytoreductive radical prostatectomy for prostate cancer with minimal osseous metastases: results of a first feasibility and case control study]. Urologe A 2016; 54:14-21. [PMID: 25519996 DOI: 10.1007/s00120-014-3697-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Androgen deprivation therapy (ADT) represents the standard treatment for patients with prostate cancer (PCA) and osseous metastases. We explored the role of cytoreductive radical prostatectomy in PCA with low volume skeletal metastases in terms of a feasibility study. MATERIAL AND METHODS A total of 23 patients with biopsy proven PCA, minimal osseous metastases (≤3 hot spots on bone scan), absence of visceral or extensive lymph node metastases and a decrease in prostate-specific antigen (PSA) to <1.0 ng/ml after neoadjuvant ADT were included in the feasibility study (group A). The control group (group B) consisted of 38 men with metastatic PCA who were treated by ADT alone. Surgery-related complications, time to castration resistance, symptom-free, cancer-specific and overall survival were analyzed using descriptive statistical analyses. RESULTS The mean age was 61 years (range 42-69 years) and 64 years (47-83) in groups A and B, respectively, with similar patient characteristics in terms of initial PSA level, biopsy Gleason score, clinical stage and extent of metastatic disease. The median follow-up was 34.5 months (7-75 months) and 47 months (28-96 months) in groups A and B, respectively. Median time to castration resistance was 40 months (9-65 months) and 29 months (16-59 months) in groups A and B, respectively (p=0.04). Patients in group A experienced significantly better clinical symptom-free (38.6 versus 26.5 months, p=0.032) and cancer-specific survival rates (95.6% versus 84.2%, p=0.043) whereas the overall survival was similar. In group A none of the men underwent palliative surgical procedures for locally progressing PCA compared to 29% in group B. CONCLUSIONS Cytoreductive radical prostatectomy is feasible in well-selected men with metastatic PCA who responded well to neoadjuvant ADT. These men have a long life expectancy and the risk of locally recurrent PCA and local complications are reduced. Cytoreductive radical prostatectomy might be a treatment option in the multimodal management of PCA with minimal osseous metastases.
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Heidenreich A, Porres D, Pfister D. The Role of Palliative Surgery in Castration-Resistant Prostate Cancer. Oncol Res Treat 2015; 38:670-7. [DOI: 10.1159/000442268] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 11/09/2015] [Indexed: 11/19/2022]
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Zurita AJ, Pisters LL, Wang X, Troncoso P, Dieringer P, Ward JF, Davis JW, Pettaway CA, Logothetis CJ, Pagliaro LC. Integrating chemohormonal therapy and surgery in known or suspected lymph node metastatic prostate cancer. Prostate Cancer Prostatic Dis 2015; 18:276-80. [PMID: 26171883 DOI: 10.1038/pcan.2015.23] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 03/12/2015] [Accepted: 04/08/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Prostate cancer persisting in the primary site after systemic therapy may contribute to emergence of resistance and progression. We previously demonstrated molecular characteristics of lethal cancer in the prostatectomy specimens of patients presenting with lymph node metastasis after chemohormonal treatment. Here we report the post-treatment outcomes of these patients and assess whether a link exists between surgery and treatment-free/cancer-free survival. METHODS Patients with either clinically detected lymph node metastasis or primaries at high risk for nodal dissemination were treated with androgen ablation and docetaxel. Those responding with PSA concentration <1 ng ml(-1) were recommended surgery 1 year from enrollment. ADT was withheld postoperatively. The rate of survival without biochemical progression 1 year after surgery was measured to screen for efficacy. RESULTS Forty patients were enrolled and 39 were evaluable. Three patients (7.7%) declined surgery. Of the remaining 36, 4 patients experienced disease progression during treatment and 4 more did not reach PSA <1. Twenty-six patients (67%) completed surgery, and 13 (33%) were also progression-free 1 year postoperatively (8 with undetectable PSA). With a median follow-up of 61 months, time to treatment failure was 27 months in the patients undergoing surgery. The most frequent patterns of first disease recurrence were biochemical (10 patients) and systemic (5). CONCLUSIONS Half of the patients undergoing surgery were off treatment and progression-free 1 year following completion of all therapy. These results suggest that integration of surgery is feasible and may be superior to systemic therapy alone for selected prostate cancer patients presenting with nodal metastasis.
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Affiliation(s)
- A J Zurita
- Department of Genitourinary Medical Oncology, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - L L Pisters
- Department of Urology, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - X Wang
- Department of Biostatistics, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - P Troncoso
- Department of Pathology, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - P Dieringer
- Department of Genitourinary Medical Oncology, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - J F Ward
- Department of Urology, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - J W Davis
- Department of Urology, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - C A Pettaway
- Department of Urology, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - C J Logothetis
- Department of Genitourinary Medical Oncology, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - L C Pagliaro
- Department of Genitourinary Medical Oncology, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
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Hashimoto K, Mizuno T, Kitamura H, Shindo T, Takahashi S, Masumori N. The primary local stage at diagnosis predicts regional symptoms caused by local progression in patients with castration-resistant prostate cancer. Urology 2015; 85:430-5. [PMID: 25623712 DOI: 10.1016/j.urology.2014.09.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 08/05/2014] [Accepted: 09/02/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To identify the characteristics that predict occurrence of local progression-related events (LPREs) in patients with castration-resistant prostate cancer (CRPC) to adjust its management. METHODS We retrospectively reviewed the medical records of 39 patients with CRPC. LPREs were defined as regional symptoms caused by local progression and categorized into urinary events and rectal events. Urinary events were defined as ureteral obstruction, acute urinary retention, or hematuria requiring treatment, and rectal events were rectal obstruction or rectal bleeding caused by tumor invasion. RESULTS The median prostate-specific antigen level at diagnosis was 185 ng/mL. During the median follow-up period of 4.4 years, 10 patients (25.6%) had LPREs. Urinary events were observed in 8 patients (20.5%) and rectal events in 2 (5.1%). The proportion of T4 in patients with LPREs was higher than in those without LPREs (70.0% vs. 10.3%; P <.001). Stage T4 at diagnosis was an independent factor to predict LPREs in multivariate analysis (hazard ratio, 8.62; P = .004). The 5-year cumulative incidence of LPREs in patients with stage T4 was 70.0%, whereas in those with stage ≤T3, they were 3.6% (P <.001). CONCLUSION Patients with stage T4 at diagnosis are more likely to have a risk of LPREs than those with stage ≤T3. These results indicate that patients with locally advanced prostate cancer on androgen deprivation therapy need to be closely monitored for early diagnosis of CRPC and treated with the appropriate intervention for LPREs at the appropriate time.
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Affiliation(s)
- Kohei Hashimoto
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Takahiro Mizuno
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hiroshi Kitamura
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tetsuya Shindo
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Satoshi Takahashi
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Naoya Masumori
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan.
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Patrikidou A, Loriot Y, Eymard JC, Albiges L, Massard C, Ileana E, Di Palma M, Escudier B, Fizazi K. Who dies from prostate cancer? Prostate Cancer Prostatic Dis 2014; 17:348-52. [PMID: 25311767 DOI: 10.1038/pcan.2014.35] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 08/02/2014] [Accepted: 08/05/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND During the last 30 years, there has been a major shift in initial staging in prostate cancer (CaP) in Western countries, with the incidence of metastases at diagnosis decreasing from over 50% in the 1970s to currently less than 10%. Yet, CaP is still the second cause of cancer death in men. We used two monthly curated databases of patients with castration-resistant prostate cancer (CRPC) to describe the natural history of patients dying of CaP in the modern era. METHODS The outcome of 190 men with metastatic CRPC treated from 2008 to 2011 was studied. The characteristics of the patients who died from CaP (n = 113 patients, 61%) were analyzed. RESULTS All 113 patients who died of CaP were assessable for the presence of metastases at diagnosis. Sixty-three patients (56%) had detectable metastases at diagnosis: 67%, 11% and 43% had bone, visceral and lymph node metastases, respectively. The median time to CRPC was 16 months and median overall survival (OS) was 5.2 years.Among the patients with localized CaP at diagnosis (n = 50, 44%), 46% had T stage ⩾ 3 and 38% had a Gleason score ⩾ 8. Overall, 64% of patients were classified as having a high-risk CaP. Only 26% who died from CaP had a Gleason score ⩽ 6. Median OS was 8.8 years. CONCLUSIONS In the modern era, approximately half of the patients who die from CaP have metastases at diagnosis. The paradigm of progression from localized disease to metastasis and eventually death is only represented in the other half, although possible initial screening and staging errors ought to be taken into consideration. More efforts are needed to conduct trials in patients with newly diagnosed metastatic CaP.
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Affiliation(s)
- A Patrikidou
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
| | - Y Loriot
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
| | | | - L Albiges
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
| | - C Massard
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
| | - E Ileana
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
| | - M Di Palma
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
| | - B Escudier
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
| | - K Fizazi
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
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Heidenreich A, Pfister D, Porres D. Cytoreductive radical prostatectomy in patients with prostate cancer and low volume skeletal metastases: results of a feasibility and case-control study. J Urol 2014; 193:832-8. [PMID: 25254935 DOI: 10.1016/j.juro.2014.09.089] [Citation(s) in RCA: 184] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2014] [Indexed: 12/23/2022]
Abstract
PURPOSE Androgen deprivation represents the standard treatment for prostate cancer with osseous metastases. We explored the role of cytoreductive radical prostatectomy in prostate cancer with low volume skeletal metastases in terms of a feasibility study. MATERIALS AND METHODS A total of 23 patients with biopsy proven prostate cancer, minimal osseous metastases (3 or fewer hot spots on bone scan), absence of visceral or extensive lymph node metastases and prostate specific antigen decrease to less than 1.0 ng/ml after neoadjuvant androgen deprivation therapy were included in the feasibility study (group 1). A total of 38 men with metastatic prostate cancer who were treated with androgen deprivation therapy without local therapy served as the control group (group 2). Surgery related complications, time to castration resistance, and symptom-free, cancer specific and overall survival were analyzed using descriptive statistical analysis. RESULTS Mean patient age was 61 (range 42 to 69) and 64 (range 47 to 83) years in groups 1 and 2, respectively, with similar patient characteristics in terms of initial prostate specific antigen, biopsy Gleason score, clinical stage and extent of metastatic disease. Median followup was 34.5 months (range 7 to 75) and 47 months (range 28 to 96) in groups 1 and 2, respectively. Median time to castration resistant prostate cancer was 40 months (range 9 to 65) and 29 months (range 16 to 59) in groups 1 and 2, respectively (p=0.04). Patients in group 1 experienced significantly better clinical progression-free survival (38.6 vs 26.5 months, p=0.032) and cancer specific survival rates (95.6% vs 84.2%, p=0.043), whereas overall survival was similar. Of the men in groups 1 and 2, 20% and 29%, respectively, underwent palliative surgical procedures for locally progressing prostate cancer. CONCLUSIONS Cytoreductive radical prostatectomy is feasible in well selected men with metastatic prostate cancer who respond well to neoadjuvant androgen deprivation therapy. These men have a long life expectancy, and cytoreductive radical prostatectomy reduces the risk of locally recurrent prostate cancer and local complications. Cytoreductive radical prostatectomy might be a treatment option in the multimodality management of prostate cancer with minimal osseous metastases.
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Affiliation(s)
| | - David Pfister
- Department of Urology, Uniklinik RWTH Aachen, Aachen, Germany
| | - Daniel Porres
- Department of Urology, Uniklinik RWTH Aachen, Aachen, Germany
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The role of palliative surgery in castration-resistant prostate cancer. Curr Opin Support Palliat Care 2014; 8:250-7. [DOI: 10.1097/spc.0000000000000078] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Dorff TB, Quek ML, Daneshmand S, Pinski J. Evolving treatment paradigms for locally advanced and metastatic prostate cancer. Expert Rev Anticancer Ther 2014; 6:1639-51. [PMID: 17134367 DOI: 10.1586/14737140.6.11.1639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
While men with early stage prostate cancer typically enjoy long-term survival after definitive management, for those who present with locally advanced or metastatic disease, survival is compromised. Multimodality therapy can prolong survival in these patients, with state-of-the-art options including intensity-modulated radiation or brachytherapy in conjunction with androgen ablation, adjuvant androgen ablation and/or chemotherapy with radical retropubic prostatectomy. In addition, novel biological therapies are being explored to target the unique molecular changes in prostate cancer cells and their interactions with the microenvironment. With these advances the outlook will undoubtedly improve, even for patients presenting with advanced disease. Careful application of these emerging therapies to a select group of prostate cancer patients most likely to obtain benefit from them is the challenge for urologists, medical oncologists and radiation oncologists for the future.
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Affiliation(s)
- Tanya B Dorff
- University of Southern California, Norris Comprehensive Cancer Center, Division of Medical Oncology, Los Angeles, CA, USA.
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Won ACM, Gurney H, Marx G, De Souza P, Patel MI. Primary treatment of the prostate improves local palliation in men who ultimately develop castrate-resistant prostate cancer. BJU Int 2013; 112:E250-5. [PMID: 23879909 DOI: 10.1111/bju.12169] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine whether local treatment of primary prostate cancer gives palliative benefit to men who later develop castrate-resistant prostate cancer (CRPC). Local treatments of primary prostate cancer are defined as radical retropubic prostatectomy (RRP) or external beam radiation therapy (EBRT). PATIENTS AND METHODS Patient records were reviewed in five different hospitals in Sydney, Australia, and 263 men with CRPC were identified. Eligible patients comprised men who had progressive disease during androgen deprivation therapy with castrate levels of testosterone. Clinical and pathological data were reviewed and evaluated using the chi-squared test and relative risk analysis to determine the relationship between previous local prostate treatment and complications secondary to local disease. The end-point was complications and morbidity attributed to cancer progression locally (i.e. from the prostate). RESULTS Primary treatment of the prostate by either RRP or EBRT significantly reduces the incidence of local complications compared to no primary treatment (32.6% vs 54.6%; P = 0.001). RRP showed a significantly lower level of local complications compared to EBRT (20.0% vs 46.7%; P = 0.007). The most common local complications were bladder outlet obstruction (35.0%) and ureteric obstruction (15.2%). CONCLUSIONS The present retrospective analysis supports the hypothesis that primary local prostatic treatment gives palliative benefit to men who later develop CRPC. RRP was associated with the lowest local complication rate experienced at the stage of metastatic disease.
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Affiliation(s)
- Andy C M Won
- Urological Cancer Outcomes Centre, Sydney Medical School, Sydney, NSW, Australia
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Gakis G, Boorjian SA, Briganti A, Joniau S, Karazanashvili G, Karnes RJ, Mattei A, Shariat SF, Stenzl A, Wirth M, Stief CG. The role of radical prostatectomy and lymph node dissection in lymph node-positive prostate cancer: a systematic review of the literature. Eur Urol 2013; 66:191-9. [PMID: 23735200 DOI: 10.1016/j.eururo.2013.05.033] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 05/13/2013] [Indexed: 11/17/2022]
Abstract
CONTEXT Because pelvic lymph node (LN)-positive prostate cancer (PCa) is generally considered a regionally metastatic disease, surgery needs to be better defined. OBJECTIVE To review the impact of radical prostatectomy (RP) and pelvic lymph node dissection (PLND), possibly in conjunction with a multimodal approach using local radiotherapy and/or androgen-deprivation therapy (ADT), in LN-positive PCa. EVIDENCE ACQUISITION A systematic Medline search for studies reporting on treatment regimens and outcomes in patients with LN-positive PCa undergoing RP between 1993 and 2012 was performed. EVIDENCE SYNTHESIS RP can improve progression-free and overall survival in LN-positive PCa, although there is a lack of high-level evidence. Therefore, the former practice of aborting surgery in the presence of positive nodes might no longer be supported by current evidence, especially in those patients with a limited LN tumor burden. Current data demonstrate that the lymphatic spread takes an ascending pathway from the pelvis to the retroperitoneum, in which the internal and the common iliac nodes represent critical landmarks in the metastatic distribution. Sophisticated imaging technologies are still under investigation to improve the prediction of LN-positive PCa. Nonetheless, extended PLND including the common iliac arteries should be offered to intermediate- and high-risk patients to improve nodal staging with a possible benefit in prostate-specific antigen progression-free survival by removing significant metastatic load. Adjuvant ADT has the potential to improve overall survival after RP; the therapeutic role of a trimodal approach with adjuvant local radiotherapy awaits further elucidation. Age is a critical parameter for survival because cancer-specific mortality exceeds overall mortality in younger patients (<60 yr) with high-risk PCa and should be an impetus to treat as thoroughly as possible. CONCLUSIONS Increasing evidence suggests that RP and extended PLND improve survival in LN-positive PCa. Our understanding of surgery of the primary tumor in LN-positive PCa needs a conceptual change from a palliative option to the first step in a multimodal approach with a significant improvement of long-term survival and cure in selected patients.
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Affiliation(s)
- Georgios Gakis
- Department of Urology, University Hospital Tübingen, Eberhard-Karls University Tübingen, Germany.
| | | | - Alberto Briganti
- Department of Urology, Urological Research Institute, University Vita-Salute San Raffaele, Milan, Italy
| | - Steven Joniau
- Department of Urology, University Hospital K.U. Leuven, Leuven, Belgium
| | | | | | - Agostino Mattei
- Department of Urology, Kantonsspital Lucerne, Lucerne, Switzerland
| | | | - Arnulf Stenzl
- Department of Urology, University Hospital Tübingen, Eberhard-Karls University Tübingen, Germany
| | - Manfred Wirth
- Department of Urology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Christian G Stief
- Department of Urology, Ludwig-Maximilians-University, Munich-Grosshadern, Germany
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Laparoscopic radical prostatectomy plus extended lymph nodes dissection for cases with non-extra node metastatic prostate cancer: 5-year experience in a single Chinese institution. J Cancer Res Clin Oncol 2013; 139:871-8. [PMID: 23417085 DOI: 10.1007/s00432-013-1395-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 02/05/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To investigate the functional and oncologic outcomes of patients with locally advanced or lymph node metastatic prostate cancer (PCa) treated by laparoscopic radical prostatectomy (LRP) in a single Chinese institution. METHODS From June 2004 to June 2011, a total of 152 cases including 105 locally advanced PCa and 47 lymph node metastatic PCa who were treated by LRP with extended lymph node dissection (ePLND) were enrolled in this study. Surgical records, urinary continence, complications, and oncologic outcomes were presented. RESULTS The mean operation time and bleeding were 240 min and 110 ml, respectively. After 12-87 months (median 48 m) of follow-up, 91.4 and 94.7 % of the patients were urinary continence at 6 and 12 m, respectively. Eighty biochemical recurrent diseases were observed. The 3- and 5-year biochemical progression-free survival rates were 59.2 and 47.3 %, respectively. Multivariate analysis showed that Gleason score (HR: 1.66, 95 % CI: 1.05-2.64, P = 0.031), pathological stage (HR: 1.64, 95 % CI: 1.2-2.23, P = 0.002), and surgical margin status (HR: 1.75, 95 % CI: 1.04-2.95, P = 0.035) were independent predictive factors for subsequent biochemical relapse. The 3- and 5-year overall and cancer-specific survival rates were 90.2, 86.0 and 95.8, 92.3 %, respectively. There were no significant differences in biochemical recurrence-free (42.6 vs. 49.5 %, P = 0.491), overall (83.4 vs. 87.3 % P = 0.503), and cancer-specific survival rates (92.3 vs. 94.9 %, P = 0.801) between lymph node-positive and -negative PCa. CONCLUSION With favorable functional and oncologic outcomes in this cohort of 152 patients, we concluded that LRP plus ePLND is feasible for patients with locally advanced non-extra node metastatic PCa.
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Schiavina R, Borghesi M, Brunocilla E, Manferrari F, Fiorentino M, Vagnoni V, Baccos A, Pultrone CV, Rocca GC, Rizzi S, Martorana G. Differing risk of cancer death among patients with lymph node metastasis after radical prostatectomy and pelvic lymph node dissection: identification of risk categories according to number of positive nodes and Gleason score. BJU Int 2013; 111:1237-44. [PMID: 23331345 DOI: 10.1111/j.1464-410x.2012.11602.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Riccardo Schiavina
- Department of Urology; S. Orsola-Malpighi Hospital; University of Bologna; Bologna; Italy
| | - Marco Borghesi
- Department of Urology; S. Orsola-Malpighi Hospital; University of Bologna; Bologna; Italy
| | - Eugenio Brunocilla
- Department of Urology; S. Orsola-Malpighi Hospital; University of Bologna; Bologna; Italy
| | - Fabio Manferrari
- Department of Urology; S. Orsola-Malpighi Hospital; University of Bologna; Bologna; Italy
| | | | - Valerio Vagnoni
- Department of Urology; S. Orsola-Malpighi Hospital; University of Bologna; Bologna; Italy
| | - Alessandro Baccos
- Department of Urology; S. Orsola-Malpighi Hospital; University of Bologna; Bologna; Italy
| | | | | | - Simona Rizzi
- Department of Urology; S. Orsola-Malpighi Hospital; University of Bologna; Bologna; Italy
| | - Giuseppe Martorana
- Department of Urology; S. Orsola-Malpighi Hospital; University of Bologna; Bologna; Italy
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Outcomes after radical prostatectomy for patients with clinical stages T1-T2 prostate cancer with pathologically positive lymph nodes in the prostate-specific antigen era. Urol Oncol 2012; 31:1441-7. [PMID: 22516714 DOI: 10.1016/j.urolonc.2012.03.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Revised: 03/07/2012] [Accepted: 03/07/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate the outcomes of radical prostatectomy (RP) and pelvic lymph node dissection (PLND) for clinically organ confined prostate cancer (CaP) with regional lymph node metastases (pN1) treated in the era of prostate-specific antigen (PSA) screening. MATERIALS AND METHODS A single institution cohort of 2,487 men with cT1-T2 CaP treated with open radical prostatectomy and pelvic lymph node dissection between 1988 and 2008 were analyzed. Kaplan-Meier and Cox proportional regression models were used to analyze overall survival (OS), clinical recurrence-free survival (cRFS), and biochemical recurrence-free survival (bRFS). RESULTS Overall, 150 out of 2,487 patients (6%) had pN1 disease, with a median follow-up of 10.4 years. The predicted 10-year OS, cRFS, and bRFS rates for patients with pN0 and pN1 were 86% and 74% (Log rank P < 0.001), 97% and 84% (Log rank P < 0.001), and 88% and 57% (Log rank P < 0.001), respectively. In the subset of pN1 patients treated with surgery only (n = 49), the predicted 10-year OS, cRFS, and bRFS rates were 81%, 80%, and 59%, respectively. Exploratory univariate regression analysis showed that age (P = 0.003), total number of lymph nodes identified (P = 0.040), and total number of positive lymph nodes identified (P = 0.004) were associated with OS. Total number of positive lymph nodes (LNs) identified was also significantly associated with cRFS (P = 0.05). CONCLUSIONS The incidence of pN1 in patients with cT1-T2 CaP treated with surgery in the era of PSA screening was low. RP and PLND demonstrated therapeutic efficacy in a subset of pN1 patients treated with surgery alone.
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Pagliarulo V, Bracarda S, Eisenberger MA, Mottet N, Schröder FH, Sternberg CN, Studer UE. Contemporary role of androgen deprivation therapy for prostate cancer. Eur Urol 2012; 61:11-25. [PMID: 21871711 PMCID: PMC3483081 DOI: 10.1016/j.eururo.2011.08.026] [Citation(s) in RCA: 174] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 08/11/2011] [Indexed: 10/17/2022]
Abstract
CONTEXT Androgen deprivation therapy (ADT) for prostate cancer (PCa) represents one of the most effective systemic palliative treatments known for solid tumors. Although clinical trials have assessed the role of ADT in patients with metastatic and advanced locoregional disease, the risk-benefit ratio, especially in earlier stages, remains poorly defined. Given the mounting evidence for potentially life-threatening adverse effects with short- and long-term ADT, it is important to redefine the role of ADT for this disease. OBJECTIVE Review the published experience with currently available ADT approaches in various contemporary clinical settings of PCa and reported serious treatment-related adverse events. This review addresses the level of evidence associated with the use of ADT in PCa, focusing upon survival outcome measures. Furthermore, this paper discusses evolving approaches targeting androgen receptor signaling pathways and emerging evidence from clinical trials with newer compounds. EVIDENCE ACQUISITION A comprehensive review of the literature was performed, focusing on data from the last 10 yr (January 2000 to July 2011) and using the terms androgen deprivation, hormone treatment, prostate cancer and adverse effects. Abstracts from trials reported at international conferences held in 2010 and 2011 were also evaluated. EVIDENCE SYNTHESIS Data from randomized controlled trials and population-based studies were analyzed in different clinical paradigms. Specifically, the role of ADT was evaluated in patients with nonmetastatic disease as the primary and sole treatment, in combination with radiation therapy (RT) or after surgery, and in patients with metastatic disease. The data suggest that in men with nonmetastatic disease, the use of primary ADT as monotherapy has not shown a benefit and is not recommended, while ADT combined with conventional-dose RT (<72Gy) for patients with high-risk disease may delay progression and prolong survival. The postoperative use of ADT remains poorly evaluated in prospective studies. Likewise, there are no trials evaluating the role of ADT in patients with biochemical relapses after surgery or RT. In patients with metastatic disease, there is a clear benefit in terms of quality of life, reduction of disease-associated morbidity, and possibly survival. Treatment with bilateral orchiectomy, luteinizing hormone-releasing hormone agonist therapy, with and without antiandrogens has been associated with various serious adverse events, including cardiovascular disease, diabetes, and skeletal complications that may also affect mortality. CONCLUSIONS Although ADT is an effective treatment of PCa, consistent long-term benefits in terms of quality and quantity of life are predominantly evident in patients with advanced/metastatic disease or when ADT is used in combination with RT (<72Gy) in patients with high-risk tumors. Implementation of ADT should be evidence based, with special consideration to adverse events and the risk-benefit ratio.
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Boorjian SA, Eastham JA, Graefen M, Guillonneau B, Karnes RJ, Moul JW, Schaeffer EM, Stief C, Zorn KC. A critical analysis of the long-term impact of radical prostatectomy on cancer control and function outcomes. Eur Urol 2011; 61:664-75. [PMID: 22169079 DOI: 10.1016/j.eururo.2011.11.053] [Citation(s) in RCA: 167] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 11/28/2011] [Indexed: 01/24/2023]
Abstract
CONTEXT The optimal management strategy for men with newly diagnosed clinically localized prostate cancer remains a matter of debate. Numerous series have reported cancer control and quality-of-life (QoL) outcomes following treatment with radical prostatectomy (RP). OBJECTIVE Critically review published oncologic and functional outcomes after RP, and evaluate factors associated with these outcome measures. EVIDENCE ACQUISITION A review of the literature was performed using the Medline and Web of Sciences databases. Relevant reports published between 1980 and 2011 identified using the keywords prostate cancer, radical prostatectomy, prostate-specific antigen, biochemical recurrence, incontinence, and erectile dysfunction were reviewed and summarized. EVIDENCE SYNTHESIS Cancer control rates following RP largely depend on the definition of treatment efficacy. While up to 40% of men have been reported to experience postoperative biochemical recurrence on long-term follow-up, death from prostate cancer has been noted in <10% of men at 15 yr after surgery in contemporary series. For men with high-risk disease, surgery affords pathologic staging, thereby facilitating the selective application of secondary therapies, and has been associated with decreased mortality risk versus radiation in retrospective series. Reported functional outcomes after surgery, particularly urinary continence and erectile dysfunction, have varied greatly to date. These assessments have been limited by nonstandardized reporting methodology. The use of robot-assisted radical prostatectomy has increased in recent years, and while follow-up is thus far short, available data do not suggest the superiority of either approach in terms of functional or oncologic outcomes. CONCLUSIONS RP is associated with excellent long-term cancer control. Continued efforts to conduct prospective assessments of postoperative functional outcomes are necessary using validated QoL instruments. The importance of surgical approach will also require further study, incorporating comparative oncologic, functional, and economic data.
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Affiliation(s)
- Stephen A Boorjian
- Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, MN 55905, USA.
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Siemens DR. Why all prostate cancer surgery should include an adequate lymph node dissection. Can Urol Assoc J 2010; 4:427-9. [PMID: 21191508 DOI: 10.5489/cuaj.10185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- D Robert Siemens
- Associate Professor, Departments of Urology, Oncology, Anatomy and Cell Biology, Queen's University, Kingston, ON
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Steuber T, Budäus L, Walz J, Zorn KC, Schlomm T, Chun F, Ahyai S, Fisch M, Sauter G, Huland H, Graefen M, Haese A. Radical prostatectomy improves progression-free and cancer-specific survival in men with lymph node positive prostate cancer in the prostate-specific antigen era: a confirmatory study. BJU Int 2010; 107:1755-61. [PMID: 20942833 DOI: 10.1111/j.1464-410x.2010.09730.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
STUDY TYPE Therapy (outcomes research). LEVEL OF EVIDENCE 2b. What's known on the subject? and What does the study add? Historically, surgeons were reluctant to perform radical prostatectomy (RP) in LN positive disease. Nowadays, a shift towards multimodal treatment strategies in such patients, comprising RP with extended lymph node dissection followed by radiation and/or hormonal therapy can be detected. However, this change of paradigm is not supported by evidence derived from treatment guidelines. Retrospective studies on this topic, comprising small numbers of patients from the pre-PSA era in the US suggest a survival advantage, if RP is performed. Our analyses of cancer control rates between patients with discontinued vs. completed prostatectomy revealed a superior clinical progression free- and cancer specific-survival rate in those patients with completed prostatectomy. These results add knowledge on treatment outcome of a current patient population since previous retrospective studies include patients from the pre-PSA era. OBJECTIVE To assess the prognostic role of radical prostatectomy (RP) in lymph node (LN) positive patients with prostate cancer (PCa) in a contemporary RP cohort. PATIENTS AND METHODS Between 1992 and 2004, 158 consecutive patients with clinically localized PCa and regional LN metastasis were identified. Fifty patients underwent LN dissection and discontinued RP, combined with early hormonal therapy (HT) (RP-), whereas, in 108 patients, RP was completed followed by adjunctive HT (RP+). Clinical progression-free- (CPFS) and cancer-specific survival (CSS) were studied using Kaplan-Meier analysis. Disease characteristics and the impact of RP on CPFS and CSS were further assessed using Cox proportional hazard models. A matched pair analysis between RP- and RP+ patients was performed based on clinical and pathological factors. RESULTS Median follow-up was 98 months (interquartile range, 88-113). Five- and 10-year CPFS was 77% and 61% for RP+ patients vs 61% and 31%, for RP- patients (P=0.005), respectively. A similar trend was observed for CSS (84% and 76% for RP+ vs 81% and 46% for RP-; P=0.001). Type of treatment (RP- vs RP+) and number of positive LN were multivariate predictors of CPFS and CSS (all P≤0.05). In the matched pair analyses, RP+ patients showed superior CPFS and CSS (P<0.005). CONCLUSIONS RP had a beneficial impact, resulting in the superior survival of patients with LN positive PCa after controlling for LN tumour burden in a contemporary RP series. The findings obtained in the present study support the role of RP as an important component of multimodal strategies of LN positive PCa.
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Affiliation(s)
- Thomas Steuber
- Martini-Clinic, Prostate Cancer Center, Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
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Wiegand LR, Hernandez M, Pisters LL, Spiess PE. Surgical management of lymph-node-positive prostate cancer: improves symptomatic control. BJU Int 2010; 107:1238-42. [DOI: 10.1111/j.1464-410x.2010.09657.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Song J, Li M, Zagaja GP, Taxy JB, Shalhav AL, Al-Ahmadie HA. Intraoperative frozen section assessment of pelvic lymph nodes during radical prostatectomy is of limited value. BJU Int 2010; 106:1463-7. [DOI: 10.1111/j.1464-410x.2010.09402.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kamidono S, Ohshima S, Hirao Y, Suzuki K, Arai Y, Fujimoto H, Egawa S, Akaza H, Hara I, Hinotsu S, Kakehi Y, Hasegawa T. Evidence-based clinical practice Guidelines for Prostate Cancer (Summary - JUA 2006 Edition). Int J Urol 2008; 15:1-18. [PMID: 18184166 DOI: 10.1111/j.1442-2042.2007.01959.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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35
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Gjertson CK, Asher KP, Sclar JD, Goluboff ET, Olsson CA, Benson MC, McKiernan JM. Local Control and Long-Term Disease-Free Survival for Stage D1 (T2-T4N1-N2M0) Prostate Cancer After Radical Prostatectomy in the PSA Era. Urology 2007; 70:723-7. [DOI: 10.1016/j.urology.2007.05.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Revised: 03/20/2007] [Accepted: 05/15/2007] [Indexed: 01/02/2023]
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Boorjian SA, Thompson RH, Siddiqui S, Bagniewski S, Bergstralh EJ, Karnes RJ, Frank I, Blute ML. Long-Term Outcome After Radical Prostatectomy for Patients With Lymph Node Positive Prostate Cancer in the Prostate Specific Antigen Era. J Urol 2007; 178:864-70; discussion 870-1. [PMID: 17631342 DOI: 10.1016/j.juro.2007.05.048] [Citation(s) in RCA: 191] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE While the incidence of lymph node positive prostate cancer has decreased during the prostate specific antigen era, the optimal treatment of these patients remains in question. We examined the impact of lymph node metastases on the outcome of patients following radical prostatectomy and investigated prognostic factors that affect survival. MATERIALS AND METHODS We identified 507 men treated with radical prostatectomy between 1988 and 2001 who had lymph node positive disease. Of the 507 patients 455 (89.7%) were treated with adjuvant hormonal therapy. Median followup was 10.3 years (IQR 6.1-13.5). Postoperative survival rates were estimated using the Kaplan-Meier method and the impact of various clinicopathological factors on outcome was analyzed using Cox proportional hazard regression models. RESULTS Ten-year cancer specific survival for patients with positive lymph nodes was 85.8% with 56% of the men free from biochemical recurrence at last followup. On multivariate analysis pathological Gleason score 8-10 (p = 0.004), positive surgical margins (p = 0.016), nondiploid tumor ploidy (p = 0.023) and 2 or greater positive nodes (p = 0.001) were adverse predictors of cancer specific survival. Tumor stage, year of surgery and total number of nodes removed did not significantly affect outcome. Adjuvant hormonal therapy decreased the risk of biochemical recurrence (p <0.001) and local recurrence (p = 0.004) but it was not associated with systemic progression (p = 0.4) or cancer specific survival (p = 0.4). CONCLUSIONS Radical prostatectomy may offer long-term survival to patients with lymph node positive prostate cancer. Gleason score, margin status, tumor ploidy and the number of involved nodes predict survival, while the role of adjuvant hormonal therapy continues to be defined.
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Affiliation(s)
- Stephen A Boorjian
- Department of Urology and Division of Biostatistics, Mayo Medical School and Mayo Clinic, Rochester, Minnesota 55905, USA
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Swanson GP, Riggs MW, Herman M. Long-term outcome for lymph node-positive prostate cancer. Prostate Cancer Prostatic Dis 2007; 11:198-202. [PMID: 17519924 DOI: 10.1038/sj.pcan.4500983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although the number of men with lymph node-positive prostate cancer has declined, it is still significant and the challenge remains on how best to treat these patients. Only long-term follow-up can give a true indication of the outcome in prostate cancer. We evaluated our experience in treating lymph node-positive prostate cancer with a median follow-up of 10.2 years. The overall 5-year survival was 78% and the 10-year survival was 56%. Length of tumor control depends on the type of treatment given. Adding androgen ablation improves the duration of control dramatically, although optimal timing is still uncertain.
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Affiliation(s)
- G P Swanson
- The Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
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Johnstone PAS, Assikis V, Goodman M, Ward KC, Riffenburgh RH, Master V. Lack of survival benefit of post-operative radiation therapy in prostate cancer patients with positive lymph nodes. Prostate Cancer Prostatic Dis 2007; 10:185-8. [PMID: 17211440 DOI: 10.1038/sj.pcan.4500940] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Randomized data from SWOG 8794 and EORTC 22911 confirm the benefit of post-operative radiation therapy (RT) for selected patients with pT3 prostate cancer (CaP) after radical prostatectomy (RP). However, data regarding the potential benefit of RT for patients post-RP with positive lymph node (+LN) involvement are limited. We analyzed the Surveillance Epidemiology End Results (SEER) registry for population-based data on efficacy of post-operative RT for +LN patients after RP. As LN data have only been captured by SEER since 1988, we analyzed data for 1988-1992, with specific attention to 10-year relative survival (defined as observed survival divided by the survival of a gender-, age- and race-matched population cohort without disease). Specifically analyzed were data for 1921 patients with nonmetastatic prostate cancer who underwent surgery alone, or surgery followed by RT, and who had +LNs documented. SEER does not code the interval between surgery and RT, so the ratio of patients receiving salvage versus adjuvant therapy is unknown. Using follow-up data through 2002, post-diagnosis survival was examined by number of +LNs. There was no significant relative survival benefit for +LN patients receiving post-operative RT (chi(2)P=0.270). These data do not support routine use of post-operative RT for patients with +LNs in the surgical specimen.
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Affiliation(s)
- P A S Johnstone
- Radiation Oncology Department, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Daneshmand S, Quek ML, Stein JP, Lieskovsky G, Cai J, Pinski J, Skinner EC, Skinner DG. Prognosis of patients with lymph node positive prostate cancer following radical prostatectomy: long-term results. J Urol 2006; 172:2252-5. [PMID: 15538242 DOI: 10.1097/01.ju.0000143448.04161.cc] [Citation(s) in RCA: 243] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We determined the prognostic factors that affect recurrence and survival in patients with lymph node positive prostate cancer. MATERIALS AND METHODS Between 1972 and 1999, 1,936 patients underwent radical retropubic prostatectomy and pelvic lymph node dissection for clinically organ confined prostate cancer. A total of 235 patients (12.1%) were found to have disease metastatic to the lymph nodes (stage D1). Of the patients 69% received no adjuvant treatment. We reviewed the tumor stage (TNM), Gleason score, number and percent of involved lymph nodes (lymph node density), preoperative prostate specific antigen when available and adjuvant treatment. Overall survival and recurrence-free survival were estimated using Kaplan-Meier plots. RESULTS Followup was 1 to 24 years (median 11.4). Overall median survival was 15 years. Overall clinical recurrence-free survival at 5, 10 and 15 years was 80%, 65% and 58%, respectively. Patients who had 1 or 2 positive lymph nodes had a clinical recurrence-free survival of 70% and 73% at 10 years, respectively, vs 49% in those who had 5 or more involved lymph nodes (p = 0.0031). When stratified by lymph node density, patients with a lymph node density of 20% or greater were at higher risk for clinical recurrence compared to those with a density of less than 20% (relative risk = 2.32, p <0.0001). On stratified log rank test only prostate cancer T stage, and the number and percent of positive lymph nodes correlated with recurrence-free and overall survival. CONCLUSIONS Local tumor bulk and the number/percent of involved lymph nodes significantly affect disease progression and the survival rate. Radical prostatectomy may offer long-term survival in patients who have limited tumor bulk and nodal involvement.
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Affiliation(s)
- Siamak Daneshmand
- Department of Urology, Kenneth Norris Jr. Comprehensive Cancer Center, University of Southern California Keck School of Medicine, Los Angeles, California, USA
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Kroepfl D, Loewen H, Roggenbuck U, Musch M, Klevecka V. Disease progression and survival in patients with prostate carcinoma and positive lymph nodes after radical retropubic prostatectomy. BJU Int 2006; 97:985-91. [PMID: 16643480 DOI: 10.1111/j.1464-410x.2006.06129.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine disease progression and survival in patients with lymph node-positive prostate carcinoma after ascending radical retropubic prostatectomy (RP) and pelvic lymphadenectomy with different forms of postoperative adjuvant treatment. PATIENTS AND METHODS We analysed 82 patients with lymph node metastases at the time of surgery and who had a RP between 1993 and 2002. Data from clinical records and follow-up questionnaires were used. Overall survival, time to clinical disease progression and time to biochemical progression were used as endpoints to assess the outcome. Clinical progression was defined as documented local recurrence or distant metastases, and biochemical as an increase in prostate-specific antigen (PSA) of > or = 0.4 ng/mL. Variables analysed included PSA level, Gleason score before and after RP, clinical and pathological stage, number of positive lymph nodes and hormone therapy after RP. The statistical assessment included univariate regression analysis, and to analyse the distribution of clinical findings in different groups, Mantel-Haenszel statistics were used to test for differences in the numbers of patients. Survival and progression-free interval were assessed by Kaplan-Meier estimates and differences between groups calculated by log-rank statistics and Cox regression models. RESULTS The median (range) follow-up was 55 (10-125) months. Adjuvant hormonal treatment was used in 77 patients, five of whom had immediate adjuvant radiotherapy, and nine delayed radiotherapy because of local progression or symptomatic bone metastases; five had no additional treatment. The rates for 5- and 10-year overall survival, clinical progression-free survival and biochemical progression-free survival were 84% and 79%, 83% and 77%, and 70% and 60%, respectively. Ten patients died (12%), eight (10%) of them from the cancer; bone metastases were detected in nine (11%). Local recurrences developed in three (4%) patients, 10 (12%) had a PSA increase of > or = 0.4 ng/mL alone and 58 (71%) had no signs of progression, but two died from other causes. CONCLUSIONS Most patients with prostate cancer who had RP and pelvic lymphadenectomy followed by adjuvant hormone therapy, and who had lymph node metastases at the time of surgery, had excellent overall and progression-free survival in the long term.
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Affiliation(s)
- Darko Kroepfl
- Division of Urology, Paediatric Urology and Urologic Oncology, Kliniken Essen-Mitte, Germany.
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Abstract
With improved awareness and screening, the incidence of lymph node-positive prostate cancer has declined dramatically over the last 50 years. Stage of cancer, prostate-specific antigen, and grade are risk factors for positive lymph nodes; and those factors, along with the number of involved lymph nodes, are prognostic factors for outcome. Although the numbers have declined, the number of men with lymph node-positive prostate cancer remains significant, and the current challenge is how best to treat these patients. Commonly used treatments include any combination of androgen ablation, surgery, and radiation. There have been a few studies with chemotherapy, and no treatment has been proven superior to the others. Consequently, there remain several reasonable alternatives to treatment, and long-term survival is not unusual.
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Affiliation(s)
- Gregory P Swanson
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229, USA.
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Johnson MA, Iversen P, Schwier P, Corn AL, Sandusky G, Graff J, Neubauer BL. Castration triggers growth of previously static androgen-independent lesions in the transgenic adenocarcinoma of the mouse prostate (TRAMP) model. Prostate 2005; 62:322-38. [PMID: 15389779 DOI: 10.1002/pros.20148] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Androgen-deprivation remains the standard of care for metastatic prostate cancer, yet its total impact on the course of disease is incompletely established. METHODS We have examined the long-term effects of castration upon the progression of established cancer in the TRAMP transgenic mouse model of prostate cancer. Mice castrated at 15-weeks of age, as well as intact littermates, were followed until spontaneous death from cancer. RESULTS Statistical analyses of age-at-death versus primary tumor mass revealed that mice segregate into two categories of response to androgen-deprivation. In Category One, the act of castration paradoxically triggers the growth of microscopic androgen-independent lesions, as evidenced by a statistical synchronization of primary tumor growth. Delaying castration until 20-weeks of age delays the synchronized growth of these tumors, as well as the deaths of the host mice. In Category Two, castration eliminates or substantially delays primary tumor growth, but fails to eliminate metastases. so that castration is found to impart no long-term survival advantage. CONCLUSIONS We propose a two-step model for the alteration of androgen signaling in prostate cancer capable of explaining the above paradoxical results, which is based upon the dualistic role of androgens as both survival and differentiation factors. This model makes specific predictions for clinical intervention that are discussed in light of published studies.
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Affiliation(s)
- Mac A Johnson
- Cancer Research Division, Lilly Research Laboratories, Eli Lilly and Co., Lilly Corporate Center, Indianapolis, Indiana 02139, USA.
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Abstract
The discovery and the utilisation of the prostate specific antigen (PSA) that allows early diagnosis of prostate cancer, have considerably improved the management of this disease. Before the PSA era, prostate cancer was just a disease of the old man, generally detected at an advanced stage and incurable, with a fatal outcome delayed by the androgenic deprivation. Since early 1990's, prostate cancer has become primarily a disease of the man of 60 years, detectable earlier, and curable provided no extraprostatic dissemination has occurred. Early treatment of prostate cancer has benefited from important advances in surgical and radio-therapeutic techniques (conformational irradiation, brachytherapy), with, as principal goal, the combination of a better survival and the reduction of the potential adverse effects that alter quality of life. A better definition of the characteristics of the tumours in terms of progression regarding various parameters (clinical stage, PSA, tumoral differentiation) have resulted, despite the heterogeneity of the disease, in the determination of subgroups of tumours with different prognosis, which leads to an improved therapeutic strategy. The assessment of men's life expectancy (< or > 10 years) is the second primary parameter on which is based the indication for curative or non curative therapy in case of localized tumour. Roughly, before the age of 75, a curative therapy is indicated whereas after this age a surveillance is reasonable as first-line treatment, followed by hormone therapy in case of onset of symptoms indicating some progression of the disease (urinary symptoms, bone lesion). At a Later stage, in case of a metastatic or locally advanced cancer, hormone therapy by androgenic deprivation is highly indicated. The hormone sensitivity characterizes prostate cancer; it has been discovered more than 50 years ago by Charles Huggins (Nobel prize-winner). This hormone therapy is a palliative treatment since its efficacy is transient (ineluctable occurrence of hormone resistance in a variable time delay), but it constitutes an essential therapeutic means with a well-established efficacy. Hormone therapy has progressively improved, with the renunciation of oestrogen therapy and surgical castration which has been replaced by luteinizing hormone-releasing hormone (LH-RH) analogues, and/ or anti-androgens. Numerous works have resulted in a better rationalization of the prescription (date of treatment initiation, interest of combined androgenic deprivation, ...) but uncertainties remain, such as the therapeutic interest of intermittent treatment, or of earlier hormone therapy combined with the treatment of the primitive tumour (adjuvant hormone therapy). Finally, at the time of the hormonal escape of which the molecular mechanisms remain unclear, no therapy has proven any efficacy in survival lengthening, and the treatment remains palliative and symptomatic. Although improved knowledge of prostate cancer aetiology is expected for a real disease prevention, early diagnosis at a curable stage of the disease (by PSA assessment) remains the only means for mortality reduction.
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Affiliation(s)
- G Fournier
- Service d'urologie, Centre hospitalier universitaire de Brest, hôpital de la Cavale Blanche, boulevard Tanguy-Prigent, 29609 Brest, France.
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Zwergel U, Lehmann J, Wullich B, Schreier U, Remberger K, Zwergel T, Stoeckle M. Lymph node positive prostate cancer: long-term survival data after radical prostatectomy. J Urol 2004; 171:1128-31. [PMID: 14767285 DOI: 10.1097/01.ju.0000113202.37783.1f] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We retrospectively reviewed the outcome in our patients with prostate cancer and regional positive lymph nodes who underwent prostatectomy. MATERIALS AND METHODS Between January 1984 and December 2002, 147 men were found to have local lymph node metastases after surgery, of whom 135 underwent further androgen ablation, including 88% within 6 weeks after prostatectomy. We especially determined overall, cancer specific and progression-free survival rates. RESULTS Median patient age was 63.2 years (range 46 to 75 years). Postoperative followup was up to 214 months (median 41.9). There was 1 death secondary to surgery. To date 49 patients (33.3%) had disease progression, including 6 with a prostate specific antigen increase later than 100 months after surgery, and 36 (24.5%) died, including 22 of prostate cancer and 14 of other causes. Overall and cause specific survival probabilities at 5, 10 and 15 years were 76.6% and 86.5%, 60.1% and 73.7%, and 47.2% and 57.9%, respectively. Median overall survival was 144 months and median cancer specific survival was greater than 145 months. Overall progression-free probabilities at 5, 10 and 15 years were 72.7%, 49.8% and 31.6%, respectively. Biochemical progression-free survival rates were 77.4% after 5, 53.0% after 10 and 33.7% after 15 years. CONCLUSIONS Since three-quarters of our patients were likely not to die of prostate cancer within the 10 years after surgery despite histological evidence of lymph node metastases, radical prostatectomy with or without hormonal therapy is a viable option for patients with local lymph node involvement, particularly in view of long-term survival.
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Affiliation(s)
- Ulrike Zwergel
- Department of Urology, University of Saarland, Homburg/Saar, Germany
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Tanaka M, Suzuki N, Nakatsu H, Murakami S, Matsuzaki O, Shimazaki J. Significance of capsular attachment and invasion of cancer tissues in prostate cancer. Int J Urol 2003; 10:309-14. [PMID: 12757602 DOI: 10.1046/j.1442-2042.2003.00630.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND There is a discrepancy in tumor node metastasis (TNM) staging of capsular attachment and invasion; the condition was classified as pT3 in 1987, then as pT2 in 1992. Because capsular finding associated with radical prostatectomy is an important prognostic factor, the present study was conducted to characterize clinicopathological states of cancer tissues attached to and invading the capsule. METHODS Specimens removed by radical prostatectomy exhibiting pT2 or pT3 from 90 patients who did not receive any treatment before surgery were classified as Loc (24%, cancer tissues localized and apart from capsule), Inv (59%, attached to and invading but not penetrating capsule) and Pen (17%, penetrating capsule). Their clinicopathological profiles were examined. RESULTS Gleason score, volume of cancer tissues, seminal vesicle invasion, positive surgical margin and regional lymph node metastasis of Inv were distributed between those of Loc and Pen. Postoperative management was decided as routine check-up or endocrine therapy according to pathological findings. Median follow-up was 59 months. Prostate-specific antigen (PSA) relapse occurred in 13 patients, one of whom died of prostate cancer. The remaining of these patients lived. Rate of PSA relapse was not different between Loc and Inv, mainly due to endocrine therapy to Inv with high risk factors. CONCLUSION Pathological profile of Inv lies between those of Loc and Pen. Therefore, pT2a (1997) would be subclassified as Loc and Inv. Patients with Inv may be required to receive the respective management according to clinicopathological profile, which would be different to that of Loc.
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Affiliation(s)
- Masashi Tanaka
- Department of Urology, Asahi General Hospital, Chiba, Japan.
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