保留Retzius间隙的机器人前列腺癌根治术在前列腺中叶突出患者中的应用

目的报道首个应用保留Retzius间隙的机器人前列腺癌根治术(RS-RARP)治疗具有前列腺中叶突出(PML)的前列腺癌患者的病例系列研究,并评价RS-RARP在PML前列腺癌患者中的应用价值。方法收集2017年7月至2019年1月间于南京大学医学院附属鼓楼医院泌尿外科(南京大学泌尿外科研究所)接受同一外科医生行RS-RARP手术的有着明显PML的局限性前列腺癌患者的临床资料。所有患者行前列腺多参数核磁共振(mpMRI)检查。PML由T2加权的正中矢状面图像上进行测量。所有患者随访时间超过1个月。所有患者的病理切片由同一名泌尿外科病理医师进行判读。对患者基本情况、围手术期结果、切缘阳性率和早期尿控恢复进行研究。结果本研究共入组患者41例,中位年龄、中位体质量指数(BMI)、中位初始前列腺特异性抗原(PSA)水平、中位经直肠超声前列腺体积、中位PML、中位手术用时、中位估计手术出血量及中位住院时间分别为:70.0(67～75)岁, 24.0(21.7～26.3)kg/m~2, 8.4(5.5～15.4) ng/ml,40.8(32.4～47.4) ml,11.6(10.5～13.1)mm,155.0(140.0～185.0)min,200.0(125～300)ml,5.0(4.5～8.0)d。研究中,共有7例患者切缘阳性,总体切缘阳性率为17.1%(7/41)。前列腺基底切缘阳性率为0。在pT2期患者中,切缘阳性率为7.7%(2/26);在pT3期患者中,切缘阳性率为33.3%(5/15)。65.9%(27/41)的患者术后1个月内即恢复尿控, 51.2%(21/41)的患者术后即刻恢复尿控。结论对于PML患者,保留Retzius间隙的机器人辅助根治性前列腺癌切除术(RS-RARP)在控制切缘阳性率的前提下,能够改善患者术后早期尿控的恢复。     

LEEP和CKC两种手术方式治疗宫颈原位腺癌的效果分析

目的比较宫颈环形电切术(LEEP)与宫颈冷刀锥切术(CKC)治疗宫颈原位腺癌的临床疗效。方法选取2013年6月至2017年6月在海南西部中心医院治疗的宫颈原位腺癌患者75例,平均年龄(358±65)岁,其中45例采用LEEP治疗(LEEP组),30例采用CKC治疗(CKC组)。观察术中及术后随访情况,比较两组的术中出血量、手术费用、切缘阳性率、残留病灶率及复发率。结果LEEP组的术中出血量低于CKC组［(156±23)ml vs. (461±227)ml］,手术费用也低于CKC组［(08±05)万元 vs.(15±09)万元］,差异有统计学意义(P<0001)。LEEP组的切缘阳性率(178％ vs. 433％)、手术残留病灶率(22％ vs. 167％)和复发率(67％ vs. 233％)均低于CKC组,差异有统计学意义(P<005)。结论LEEP治疗宫颈原位腺癌具有出血量少、切缘阳性率、残留病灶率和复发率低、手术费用少等优点,值得临床推广应用。     

Neck observation versus elective neck dissection in management of clinical T1/2NO oral squamous cell carcinoma: a retrospective study of 232 patients

Objective:The management of early-stage (cT1/2N0) oral squamous cell carcinoma (OSCC) remains a controversial issue.The aim of this study was to compare the clinical outcomes of neck observation (OBS) and elective neck dissection (END) in treating patients with cT1/2N0OSCC.Methods:A total of 232 patients with cT1/2N0OSCC were included in this retrospective study.Of these patients,181 were treated with END and 51 with OBS.The survival curves of 5-year overall survival (OS),diseasespecific survival (DSS),and recurrence-free survival (RFS) rates were plotted using the Kaplan-Meier method for each group,and compared using the Log-rank test.Results:There was no significant difference in 5-year OS and DSS rates between END and OBS groups (OS:89.0％ vs.88.2％,P=0.906;DSS:92.3％ vs.92.2％,P=0.998).However,the END group had a higher 5-year RFS rate than the OBS group (90.1％ vs.76.5％,P=0.009).Patients with occult metastases in OBS group (7/51) had similar 5-year OS rate (57.1％ vs.64.1％,P=0.839) and DSS rate (71.4％ vs.74.4％,P=0.982) to those in END group (39/181).In the regional recurrence patients,the 5-year O S rate (57.1％ vs.11.1％,P=0.011) and D SS rate (71.4％ vs.22.2％,P=0.022) in OBS group (7/51) were higher than those in END group (9/181).Conclusions:The results indicated that OBS policy could obtain the same 5-year OS and DSS as END.Under close follow-up,OBS policy may be an available treatment option for patients with clinical T1/2N0OSCC.     

STAGE IB, HA AND PROXIMAL IIB, CARCINOMA OF THE UTERINE CERVIX, TREATED BY IRRADIATION ALONE OR IN COMBINATION WITH SURGERY

This is a report of a nonrandomized comparison of treatment results of 139 patients with stage IB, HA and proximal IIB carcinoma of the uterine cervix treated by radiation alone and 113 treated with a combination of radiation and surgery. The five-year tumor free acturial survival for the patients with stage IB either with irradiation alone (RT) or combined with surgery (RS) was approximately 87%. For stage Ⅱ the tumor free actuarial five-year survival 79% with patients of RS, and 76% with RT. In the 113 patients treated with RS there were 18 (16%). In the 139 patients treated by RT there were 18 (13%) recurrences of pelvic, 4 local recurrences, 11 combined with parametrial, and free parametrial recurrences. There was no significant difference in the survival and recurrence rate of the patients treated with either method. Major complications were comparable in both groups (RT approximately 25% and RS approximately 10%), but 2/3 of those complications recovered without sequelae. The most frequent minor     

Depth of tumor invasion and tumor-occupied portions of stomach are predictive factors of intra-abdominal metastasis

Objective:Diagnostic laparoscopy is recommended for the pretherapeutic staging of gastric cancer to detect any unexpected or unconfirmed intra-abdominal metastasis.The aim of this study was to evaluate the role and indications of diagnostic laparoscopy in the detection of intra-abdominal metastasis.Methods:Standard diagnostic laparoscopy with peritoneal cytology examination was performed prospectively on patients who were clinically diagnosed with primary local advanced gastric cancer (cT≥2M0).We calculated the rate of intra-abdominal metastases identified by diagnostic laparoscopy,and examined the relationship between peritoneal dissemination (P) and cytology results (CY).Split-sample method was applied to find clinical risk factors for intra-abdominal metastasis.Multivariate logistic regression analysis and receiver-operator characteristic (ROC) analysis were performed in training set to find out risk factors of intra-abdominal metastasis,and then validate it in testing set.Results:Out of 249 eM0 patients,51 (20.5％) patients with intra-abdominal metastasis were identified by diagnostic laparoscopy,including 20 (8.0％) P1CY1,17 (6.8％) P0CY1 and 14 (5.6％) P1CY0 patients.In the training set,multivariate logistic regression analysis and ROC analysis showed that the depth of tumor invasion on computer tomography (CT) scan ≥21 mm and tumor-occupied ≥2 portions of stomach are predictive factors of metastasis.In the testing set,when diagnostic laparoscopy was performed on patients who had one or two of these risk factors,the sensitivity and positive predictive value for detecting intra-abdominal metastasis were 90.0％ and 32.1％,respectively.Conclusions:According to our results,depth of tumor invasion and tumor-occupied portions of stomach are predictive factors of intra-abdominal metastasis.     

1030例早期乳腺癌术后放疗不同年龄组的预后分析

Objective To analyze the prognostic value of age in patients with early stage breast cancer. Methods The clinical characteristics of 1030 patients with early stage breast cancer (the number of positive axillary lymph nodes was less than 3) were retrospectively reviewed. Of all the patients, 468(stage Ⅰ, n = 227; and stage Ⅱ , n = 241) received breast conserving surgery (BCS) and 562 (stage Ⅰ, n =184; and stage Ⅱ, n= 378) received modified mastectomy. Patients were divided into young-age group (≤35,136 patients), middle-age group (> 35-≤60,738 patients) and old-age group (> 60,156 patients).The number of patients without postoperative radiation therapy after BCS is 16, 60 and 39 in the three groups, respectively. Two-dimensional conventional fractionated radiotherapy was administered. The prognostic value of the tumor size, status of axillary lymph nodes or hormonal receptors, postoperative radiation therapy were analyzed. Results The follow-up rate was 97.86%. Of 795 patients followed up more than 5 years, 110,569 and 116 patients were devided into the three groups, respectively. There were 40, 202 and 87 patients without radiation therapy in the three groups. The 5-year recurrence rates of the three groups were 6. 2%, 8. 7% and 10. 4% (χ2 = 1.14, P= 0.567). The 5-year distant metastasis rates were4.3% , 9.5 % and2. 5% (χ2 = 5.31 , P = 0. 070) . The5 - year survival rates were9l. 2% , 92. 6%and 82. 1% (χ2 = 6. 83, P = 0.033). The young-age group had more tumors smaller than 2. 0 cm (65.4%), less positive axillary lymph nodes (13.2%), poorer differential tumor and less positive hormone acceptors (48.0%). Of patients with tumor larger than 2. 0 cm who had no radiotherapy after BCS, the 5-year survival rates were 94%, 87% and 71% (χ2= 20.69, P= 0.000) in the three groups. The corresponding recurrence rates were 23%, 18% ,7%, (χ2 = 9. 97, P = 0. 007), and distant metastasis rates were23%, 25% and 10% (χ2 =8.51, P=0. 014). Conclusions The age is an important prognostic factor in patients with early stage breast cancer undergoing BCS, but not in those undergoing modified mastectomy.     

Enumeration and molecular characterization of circulating tumor cell using an in vivo capture system in squamous cell carcinoma of head and neck

Objective:Detection rate and isolation yield of circulating tumor cell (CTC) are low in squamous cell carcinoma of head and neck (SCCHN) with in vitro approaches due to limited sample volumes.In this study,we applied the CellCollector to capture CTC in vivo from peripheral blood.Methods:In total,the study included 22 cases with 37 times of detection.All of the patients were newly diagnosed with locally advanced or metastatic SCCHN,including laryngocarcinoma (40.9％,9/22) and hypopharyngeal carcinoma (59.1％,13/22).All patients received CTC analysis before treatment.Three patients received induction chemotherapy.Sixteen patients received surgical therapy,of which 13 patients received postoperative detection.Two patients received both induction chemotherapy and surgery treatment.Patients underwent two successive CellCollector applications 24 h before and 7 d after surgical therapy.Nine healthy volunteers were enrolled as the control group.Epidermal growth factor receptor variant type Ⅲ (EGFRⅧ) expression was analyzed with fluorescent dye labeled antibody.Results:With CellCollector isolation,72.7％ (16/22) of the patients were positive for ≥1 CTC (CTC;range,1-17 cells) before treatments and 46.7％ (7/15) of patients were CTC positive for ≥1 CTC (CTC;range,1-29 cells) after surgical therapy.Moreover,the detection rate of CellCollector (82.4％,14/17;CTC count range,0-17) in advanced SCCHN (stage Ⅲ-Ⅳ) was much higher than that in early stages (stage Ⅰ-Ⅱ,40.0％,2/5;CTC count range,0-2) (P＜0.05).EGFRⅧ expression of CTC was also analyzed with fluorescence staining.One CTCEGFRⅧ-positive patient was detected from six CTC-positive patients,and the positive expression of EGFRⅧ was also found in the tumor tissue of this patient.Conclusions:In vivo detection of CTCs had high sensitivity in SCCHN,which might improve CTC application in clinic.     

1030例早期乳腺癌术后放疗不同年龄组的预后分析

Objective To analyze the prognostic value of age in patients with early stage breast cancer. Methods The clinical characteristics of 1030 patients with early stage breast cancer (the number of positive axillary lymph nodes was less than 3) were retrospectively reviewed. Of all the patients, 468(stage Ⅰ, n = 227; and stage Ⅱ , n = 241) received breast conserving surgery (BCS) and 562 (stage Ⅰ, n =184; and stage Ⅱ, n= 378) received modified mastectomy. Patients were divided into young-age group (≤35,136 patients), middle-age group (> 35-≤60,738 patients) and old-age group (> 60,156 patients).The number of patients without postoperative radiation therapy after BCS is 16, 60 and 39 in the three groups, respectively. Two-dimensional conventional fractionated radiotherapy was administered. The prognostic value of the tumor size, status of axillary lymph nodes or hormonal receptors, postoperative radiation therapy were analyzed. Results The follow-up rate was 97.86%. Of 795 patients followed up more than 5 years, 110,569 and 116 patients were devided into the three groups, respectively. There were 40, 202 and 87 patients without radiation therapy in the three groups. The 5-year recurrence rates of the three groups were 6. 2%, 8. 7% and 10. 4% (χ2 = 1.14, P= 0.567). The 5-year distant metastasis rates were4.3% , 9.5 % and2. 5% (χ2 = 5.31 , P = 0. 070) . The5 - year survival rates were9l. 2% , 92. 6%and 82. 1% (χ2 = 6. 83, P = 0.033). The young-age group had more tumors smaller than 2. 0 cm (65.4%), less positive axillary lymph nodes (13.2%), poorer differential tumor and less positive hormone acceptors (48.0%). Of patients with tumor larger than 2. 0 cm who had no radiotherapy after BCS, the 5-year survival rates were 94%, 87% and 71% (χ2= 20.69, P= 0.000) in the three groups. The corresponding recurrence rates were 23%, 18% ,7%, (χ2 = 9. 97, P = 0. 007), and distant metastasis rates were23%, 25% and 10% (χ2 =8.51, P=0. 014). Conclusions The age is an important prognostic factor in patients with early stage breast cancer undergoing BCS, but not in those undergoing modified mastectomy.     

142例侵袭性纤维瘤病的临床特点及预后分析

目的 分析侵袭性纤维瘤病的临床特征及预后因素,为临床治疗提供依据.方法 回顾分析本院1983-2009年治疗的142例侵袭性纤维瘤病患者的临床资料,观察临床特点及治疗方式对预后影响.采用Logrank单因素分析及Cox多因素回归分析评估可能影响局部预后的危险因素.结果 随访率为93.7%,随访满5、10者分别为63例、6例.本组病例男女比例为1∶1.8,18～35岁女性为高发人群(25.4%).病变部位发生于躯干(55.6%)及四肢(31.7%)多见.5、10年局部复发率分别为24.4%、31.1%,生存率均为99.3%.单因素分析发现肿瘤大小(χ2=4.37,P=0.037)和切缘情况(χ2=12.36,P=0.002)为肿瘤复发的危险因素.多因素分析发现切缘情况为独立的复发危险因素(RR=2.129;χ2=9.47,P=0.002),放疗为侵袭性纤维瘤病的保护因素(RR=0.360;χ2=4.95,P=0.026).放疗后切缘阳性患者10年局部复发率从70.1%降至20.7%(χ2=4.22,P=0.040);而切缘阴性患者从19.8%降至10.4%(χ2=0.90,P=0.344).结论 根治性切除为侵袭性纤维瘤病的首选治疗,术后放疗可以降低切缘阳性患者的局部复发率,但对切缘阴性患者的意义尚需大样本临床研究证实.

Abstract：

Objective Aggressive fibromatosis is a rare kind of soft tissue tumor and was evaluated by few large studies. This study was to evaluate the clinical characteristics and identify the prognostic factors of this disease. Methods One hundred and forty-two patients with aggressive fibromatosis treated from January 1983 to August 2009 in Tianjin Medical University Cancer Hospital were retrospectively reviewed.The prognostic value of clinical and treatment factors was analyzed. Univariate analysis was performed with Log-rank test and Multivariate analysis was performed with Cox regression model. Results The follow-up rate is 93.7% and the median follow up time was 54 months (range,6 -208 months). Sixty-three patients had a minimum follow up time of 5 years and 6 patients had a minimum follow up time of 10 years. The male/female ratio was 1/1.84. The disease was most popular in women aged from 18 to 35 years old. The disease frequently occurred in the trunk (55.6%) and extremity (31.7%). All patients received surgery,and 46 received radiotherapy. The 5-year and 10-year local recurrence rates were 24. 4% and 31.1%,respectively. The 5-year and 10-year overall survival rates were both 99. 3%. Univariate analysis revealed that factors correlated with local recurrence were tumor size ( χ2 = 4. 37, P = 0. 037 ) and margin status (χ2 = 12. 36,P =0. 002). Multivariate analysis revealed that margin status was an independent risk factor (RR = 2. 219; χ2 = 9. 47,P = 0. 002) and radiotherapy was an independent protective factor ( RR = 0. 360;χ2 = 4. 95, P = 0. 026 ) for disease recurrence. When radiotherapy was delivered, the 10-year local recurrence rate decreased from 70. 1% to 20. 7% in patients with positive margin ( χ2 = 4. 22, P = 0. 040 )and decreased from 19.8% to 10.4% (χ2= 0.90, P= 0.344) in patients with negative margin.Conclusions Radical resection is the mainstay of treatment for aggressive fibromatosis. Postoperative radiotherapy can reduce the recurrent rate for patients with positive margin. In patients with negative margin,the role of radiotherapy should to be further evaluated in large clinical trials.     

Effects of dosimetric inadequacy on local control and toxicities in the patients with T4 nasopharyngeal carcinoma extending into the intracranial space and treated with intensity-modulated radiotherapy plus chemotherapy

Background:To protect neurological tissues,underdosing occurs in most cases ofT4 nasopharyngeal carcinoma (NPC) with intracranial extension.In this study,we aimed to evaluate the effect of dosimetric inadequacy on local control and late neurological toxicities for patients treated with intensity-modulated radiotherapy (IMRT) plus chemotherapy.Methods:We prospectively enrolled patients who had non-metastatic T4 NPC with intracranial extension treated between January 2009 and November 2013.The prescribed dose was 66.0-70.4 Gy to the primary planning target volume (primary gross tumor volume [GTVp;i.e.,the nasopharyngeal tumor] + 5.0 mm).Dose-volume histogram parameters were calculated,including minimum point dose (Dmin) and dose to 95％ of the target volume (D9s).All patients received chemotherapy with the cisplatin,5-fluorouracil,and docetaxel regimen.Survivals were estimated using the Kaplan-Meier method and compared using the log-rank test.Results:In total,41 patients were enrolled.The local partial response rate was 87.8％ after induction chemotherapy.With a median follow-up of 51 months,7 patients experienced failure in the nasopharynx;the 3-year local failure-free survival and overall survival rates of the 41 patients were 87.4％ and 90.2％,respectively.The actual mean Dmin to the GTVp was 55.2 Gy (range 48.3-67.3 Gy),and D9s was 61.6 Gy (range 52.6-69.0 Gy).All doses received by neurological organs remained well within their dose constraints.No patients developed temporal lobe necrosis or other neurological dysfunctions.Conclusions:With relative underdosed IMRT plus effective chemotherapy,the patients achieved satisfactory local control with few late toxicities of the central nervous system.Determining the acceptable extent of dosimetric inadequacy requires further exploration.     

保留Retzius间隙的机器人辅助根治性前列腺切除术在中叶突出患者中的优势#br#

目的研究保留Retzius间隙的机器人辅助根治性前列腺切除术（RS-RARP）对显著中叶突出（PML）患者的疗效。方法收集2017年7月至2019年12月于南京大学附属鼓楼医院行传统机器人辅助根治性前列腺切除术（RARP）和RS-RARP的患者资料，并比较了两组患者的基本情况，围手术期结果以及短期肿瘤学和尿控结局。结果共78例患者入组，其中39例接受了传统的RARP，39例接受了RS-RARP。 RS-RARP组的操作时间较短（P＜0.05）。两组患者的总切缘阳性率及基底部切缘阳性率差异无统计学意义（P＞0.05）。在12个月的随访时间中，两组患者的生化复发率差异无统计学意义（P＞0.05），尿失禁恢复率差异有统计学意义（P＜0.05）。结论RS-RARP治疗显著PML患者，具有更短的操作时间及更好的尿控结果，值得临床推广应用。     

Retzius-sparing robot-assisted radical prostatectomy after previous trans-urethral resection of the prostate: Assessment of functional and oncological outcomes

Backgroundno data exist concerning functional and oncological outcomes of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP), in patients previously treated with trans-urethral resection of the prostate (p-TURP), for benign prostate obstruction. Our study addressed the impact of p-TURP on immediate and 12-months urinary continence recovery (UCR), as well as peri-operative outcomes and surgical margins, after RS-RARP.Methodsall patients treated with RS-RARP for prostate cancer at a single high-volume European institution, between 2010 and 2021, were identified and stratified according to p-TURP status. Logistic, Poisson and Cox regression models were performed.ResultsOf 1386 RS-RARP patients, 99 (7%) had history of p-TURP. Between p-TURP and no-TURP patients no differences were detected regarding both intra- and post-operative complications (p values = 0.9). The rates of immediate UCR were 40 vs 67% in p-TURP vs no-TURP patients (p < 0.001). At 12 months from RS-RARP, the rates of UCR were 68 vs 94% in p-TURP vs no-TURP patients (p < 0.001). At multivariable logistic and Cox regression models, p-TURP was independently associated, respectively, with lower immediate (odds ratio [OR]: 0.32, p < 0.001) and 12-months UCR (hazard ratio: 0.54, p < 0.001). At multivariable Poisson analyses, p-TURP predicted longer operative time (rate ratio: 1.08, p < 0.001) but not longer length of stay or time to catheter removal (p values > 0.05). Positive surgical margins rates were 23 vs 17% in p-TURP vs no-TURP patients (p = 0.1), which translated in a non-statistically significant multivariable OR of 1.14 (p = 0.6).Conclusionsp-TURP does not increase surgical morbidity but portends longer operative time and worse urinary continence after RS-RARP.     

Prognostic significance of positive surgical margins in patients with extraprostatic carcinoma after radical prostatectomy

BACKGROUND: A significant number of prostate adenocarcinoma patients undergoing radical prostatectomy are found to have microscopic extraprostatic disease extension. A majority of these patients have focal extraprostatic extension limited to one or both sides of the prostate. In addition, positive surgical margins are a common pathologic finding in this patient subgroup. In the current study, the authors evaluated the impact of positive surgical margins as an independent predictive factor for prostate specific antigen (PSA) progression in patients with pT3a/b N0M0 carcinoma. METHODS: The Mayo Clinic prostate cancer registry list provided 1202 patients with pT3a/b NO prostate carcinoma (no seminal vesicle or regional lymph node involvement) who underwent a radical prostatectomy between 1987-1995. To reduce confounding variables, patients who received preoperative therapy or adjuvant therapy were excluded, resulting in 842 patients who were eligible for analysis. RESULTS: A total of 354 patients (42%) had > or = 1 positive surgical margins whereas 488 patients (58%) demonstrated no margin involvement. The sites of margin positivity were as follows: apex (n = 163), base (n = 47), posterior prostate (n = 227), and anterior prostate (n = 11). A total of 111 patients had > or = 2 positive surgical margins. The 5-year survival free of clinical recurrence and/or biochemical failure (postoperative PSA level > 0.2 ng/mL) for patients with no positive surgical margins was 76% and was 65% for patients with 1 positive surgical margin (P = 0.0001). There was no significant difference in biochemical disease progression between patients with 1 versus those with > or = 2 surgical margins (65% vs. 62%). Multivariate analysis revealed that positive surgical margins were a significant predictor (P = 0.0017) of clinical disease recurrence and biochemical failure (relative risk, 1.55; 95% confidence interval, 1.18-2.04) after controlling for preoperative PSA, Gleason score, and DNA ploidy. CONCLUSIONS: In the current study, positive surgical margins were found to be a significant predictor of disease recurrence in patients with pT3a/b NO prostate carcinoma, a finding that is independent of PSA, Gleason score, and DNA ploidy. The benefit of adjuvant therapy in optimizing recurrence-free survival remains to be tested.     

Correlation of margin status and extraprostatic extension with progression of prostate carcinoma.

BACKGROUND: The correlation of surgical margins and extraprostatic extension (EPE) with progression is uncertain with regard to prostate carcinoma patients treated by radical prostatectomy. The objective of this study was to define factors predictive of cancer progression; emphasis was placed on surgical margins and their relation to extraprostatic extension. METHODS: The study group consisted of 377 patients who were treated by radical retropubic prostatectomy and bilateral pelvic lymphadenectomy at the Mayo Clinic between 1986 and 1993. All specimens were totally embedded and whole-mounted. Patients ranged in age from 41 to 79 years (mean, 65 years). Those with seminal vesicle invasion or lymph node metastasis and those treated preoperatively with radiation or androgen deprivation were excluded. Final pathologic T classifications were pT2a (41 patients), pT2b (237), and pT3a (99). Progression was defined as biochemical failure (prostate specific antigen [PSA] >0.2 ng/mL), clinical or biopsy-proven local recurrence, or distant metastasis. The mean follow-up was 5.8 years (range, 0.2-11.4 years). Seventy-nine patients who received adjuvant treatment within 3 months after surgery were excluded from survival analysis. RESULTS: The overall margin positivity rate was 29%. Seventy-two patients (19%) had only positive surgical margins without evidence of EPE ("surgical incision"), 53 (14%) had only EPE, 37 (10%) had both, and 215 (57%) had neither. Positive margins were correlated with the finding of EPE (P = 0.003). Progression free survival rates at 5 and 10 years were 88% and 67%, respectively. In univariate analysis, preoperative PSA concentration, positive surgical margins, Gleason grade, cancer volume, and DNA ploidy were significant in predicting progression (P values, <0.001, <0.001, 0.01, 0.007, and <0.001, respectively). In multivariate analysis, margin status and DNA ploidy were independent predictors of progression (relative risk for margin status, 1.9; 95% confidence interval [CI], 1.1-3.4; P = 0.03; relative risk for DNA ploidy, 5.1; 95% CI, 2.4-10.9; P<0.001). Among patients with positive margins, 5-year progression free survival was 78% for those with negative EPE and 55% for those with positive EPE. CONCLUSIONS: Surgical margin status and DNA ploidy were independent predictors of progression after radical prostatectomy. To improve cancer control, adjuvant therapy may be considered for patients with positive surgical margins or nondiploid cancer.     

Variation in Positive Surgical Margin Status After Radical Prostatectomy for pT2 Prostate Cancer

IntroductionWe evaluated patient, hospital, and cancer-specific factors associated with positive surgical margin (PSM) variability after radical prostatectomy in pT2 prostate cancer in the United States.Patients and MethodsA total of 45,426 men from 1152 hospitals with pT2 prostate cancer and known margin status after radical prostatectomy were identified using the National Cancer Database (2010-2015). Data on patient, cancer, hospital factors, and surgical approach were extracted. A mixed effects logistic regression model was computed to examine factors associated with PSM and partial R² values to assess the relative contributions of patient, cancer, and hospital variables to PSM status.ResultsMedian PSM rate of 8.5% (interquartile range, 5.2%-13.0%). Robotic (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.83-0.99) and laparoscopic (OR, 0.74; 95% CI, 0.64-0.90) surgical approach, academic institution (OR, 0.87; 95% CI, 0.76-1.00) and high hospital surgical volume (>297 cases [OR], 0.83; 95% CI, 0.70-0.99) were independently associated with a lower PSM. Black men (OR, 1.13; 95% CI, 1.01-1.26) and adverse cancer-specific features (prostate-specific antigen [PSA], 10-20; PSA >20; cT3 stage; Gleason 7, 8, 9-10; all P > .01) were independently associated with a higher PSM. Patient-specific, hospital-specific, and cancer-specific factors had a contribution of 2.3%, 3.9%, and 15.2%, respectively, to the variation in PSM. Facility had a contribution of 23.7% to the variation in PSM.ConclusionCancer-specific factors account for 15.2% of PSM variation with the remaining 84.8% of PSM variation due to patient, hospital, and other factors not accounted within the model. Noncancer-specific factors represent addressable factors that are important for policy-makers in efforts to improve patient outcome.     

Continence after radical prostatectomy with bladder neck preservation.

PURPOSE: Bladder neck preservation during radical prostatectomy has been advocated for improving urinary continence. We evaluate bladder neck preservation looking at continence rates, surgical cancer control and bladder neck contracture. MATERIALS AND METHODS: A total of 40 patients underwent retropubic radical prostatectomy for clinically localized carcinoma of the prostate. The prostatic urethra was dissected in continuity with the bladder away from the lumen of the prostate, which allows for a true urethra-to-urethra anastomosis. RESULTS: Continence was noted immediately in 26 patients, within 2 weeks in 9 and within 6 weeks in 3. Only 2 patients required pads 3 months postoperatively. Microscopic positive surgical margins were noted in 2 of 40 patients. In 1 patient the urethral margins were not involved with carcinoma. In the other patient the urethra was not the sole positive margin and microscopic positive margins were noted elsewhere. Early results of cancer control were good. CONCLUSIONS: Early follow-up of this technique of radical retropubic prostatectomy suggest that preservation of the continence mechanism at the level of the bladder neck and prostatic urethra results in significantly improved postoperative urinary continence without adversely affecting cancer control.     

Positive resection margin and/or pathologic T3 adenocarcinoma of prostate with undetectable postoperative prostate-specific antigen after radical prostatectomy: to irradiate or not?

PURPOSE: To evaluate the efficacy of postoperative adjuvant radiotherapy (RT) for positive resection margin and/or pathologic T3 (pT3) adenocarcinoma of the prostate with undetectable postoperative prostate-specific antigen (PSA) levels. METHODS AND MATERIALS: We retrospectively analyzed 125 patients with a positive resection margin and/or pT3 adenocarcinoma of the prostate who had undetectable postoperative serum PSA levels after radical prostatectomy. Seventy-three patients received postoperative adjuvant RT and 52 did not. Follow-up ranged from 1.5 to 12.0 years (median 4.2 for the irradiated group and 4.9 for the nonirradiated group). PSA outcome was available for all patients. Freedom from failure was defined as the maintenance of a serum PSA level of < or =0.2 ng/mL, as well as the absence of clinical local recurrence and distant metastasis. RESULTS: No difference was found in the 5-year actuarial overall survival between the irradiated and nonirradiated group (94% vs. 95%). However, patients receiving adjuvant RT had a statistically superior 5-year actuarial relapse-free rate, including freedom from PSA failure, compared with those treated with surgery alone (88% vs. 65%, p = 0.0013). In the irradiated group, 8 patients had relapse with PSA failure alone. None had local or distant recurrence. In the nonirradiated group, 15, 1, and 2 had PSA failure, local recurrence, and distant metastasis, respectively. On Cox regression analysis, pre-radical prostatectomy PSA level and adjuvant RT were statistically significant predictive factors for relapse, and Gleason score, extracapsular invasion, and resection margin status were not. There was a suggestion that seminal vesicle invasion was associated with an increased risk of relapse. The morbidity of postoperative adjuvant RT was acceptable, with only 2 patients developing Radiation Therapy Oncology Group Grade 3 genitourinary complications. Adjuvant RT had a minimal adverse effect on urinary continence and did not cause serious gastrointestinal toxicity. CONCLUSION: Postoperative adjuvant RT was associated with a lower risk of relapse, including freedom from PSA failure, compared with observation alone for pT3 and/or margin-positive disease with undetectable postoperative PSA levels. This was accomplished with a minimal risk of serious RT morbidity.     

Importance of margin extent as a predictor of outcome after adjuvant radiotherapy for Gleason score 7 pT3N0 prostate cancer

PURPOSE: To evaluate, in Gleason score 7, pT3N0 prostate cancer patients with positive surgical margins, the predictors of progression-free survival and to identify a patient subgroup that would benefit from immediate adjuvant postoperative radiotherapy (ART). METHODS AND MATERIALS: Between November 1989 and August 1998, 76 men underwent radical prostatectomy and were found to have capsular penetration (pT3N0), surgical Gleason score 7, tumor present at the resection margin, and an undetectable postoperative prostate-specific antigen (PSA) level. All surgical specimens underwent whole-mount serial sectioning to determine the degree of margin positivity (focal vs. extensive). Of the 76 men, 45 underwent early ART (within 6 months with a median dose of 64.8 Gy), and 31 had no immediate treatment. We defined freedom from PSA failure (bNED) as the absence of two consecutive PSA rises >0.2 ng/mL. RESULTS: The median follow-up time was 5.1 years (range, 2-10 years). The ART and non-ART patients were similar with respect to preoperative PSA level, Gleason score (4 + 3 vs. 3 + 4), presence of seminal vesicle invasion, and margin extent. On univariate analysis, margin extent was predictive for improved bNED (5-year bNED rate of 92% vs. 58%, p = 0.010, for men with focal and extensive margins, respectively). Gleason score (4 + 3 vs. 3 + 4), seminal vesicle invasion, and ART were not statistically significant predictors. On multivariate analysis, the preoperative PSA level, margin extent, and ART were independent significant factors. In the group with extensive surgical margins, men receiving ART had a significantly greater 5-year bNED survival rate compared with the non-ART patients (73% vs. 31%, p = 0.004). CONCLUSION: These data suggest that the amount of microscopic residual tumor significantly affects bNED after radical prostatectomy for Gleason score 7, pT3N0 prostate cancer. In addition, men with pathologic evidence of microscopic local disease appear to benefit from early ART compared with untreated controls.     

Clinical utility of indium 111-capromab pendetide immunoscintigraphy in the detection of early, recurrent prostate carcinoma after radical prostatectomy

BACKGROUND: Despite the ability of radical prostatectomy to eradicate prostate carcinoma, biochemical evidence of recurrent prostate carcinoma may be seen in approximately 40% of patients 15 years after they undergo surgery. Localization of recurrent disease after radical prostatectomy is difficult and may greatly influence subsequent clinical management. The authors examined the utility of indium 111 ((111)In)-capromab pendetide immunoscintigraphy to detect recurrent prostate carcinoma radiographically in men with early biochemical evidence of failure (serum prostate specific antigen [PSA] < or = 4.0 ng/mL) and assessed the minimum serum PSA level necessary for imaging recurrent disease. METHODS: Between May 1987 and August 1995, 255 hormone-na?ve men with a mean (+/- standard deviation) age of 65 years +/- 7 years who underwent radical prostatectomy for clinically localized prostate carcinoma were followed without adjuvant therapy until early PSA recurrence in this multicenter study. Preoperatively, all patients had negative bone scans and pathologically negative lymph nodes, and they did not undergo hormonal ablation, chemotherapy, or radiation therapy preoperatively or postoperatively until the (111)In-capromab pendetide scan was performed. All men in this study had postoperative serum PSA levels < or = 4.0 ng/mL at the time of radionuclide imaging. All men underwent imaging with the capromab pendetide scan to localize recurrent disease, and charts were reviewed to document clinical evidence of recurrence. RESULTS: Pathologic findings included mean Gleason scores of 6.7 +/- 1.2; pathologic tumors classified as pT2a (18%), pT2b (26%), pT3a (38%), pT3b (16%), and pT4a (2%); a pathologic lymph node status of pN0 (100%); positive surgical margins (44%); and perineural invasion (42%). Capromab pendetide uptake was seen in 72% of 255 men throughout a range of patients' postoperative serum PSA levels (0.1-4.0 ng/mL), with 31% of men having local uptake (prostatic fossa) only. Of 151 men who underwent additional imaging studies, 16 of 139 men (12%) and 15 of 92 men (16%) showed evidence of recurrent disease by bone scintigraphy and computed tomography scans, respectively. Gleason score, pathologic stage, perineural invasion, and margin status were not correlated significantly with the (111)In-capromab pendetide scan. CONCLUSIONS: Capromab pendetide imaging can localize early PSA recurrence and may guide appropriate treatment after patients undergo radical prostatectomy. No minimum serum PSA value was needed to potentially detect radiographic disease after surgery. Further confirmatory studies and long-term follow-up of this cohort documenting response to salvage therapy are needed to validate these imaging findings.     

Prognostic value of surgical margin status for biochemical recurrence following radical prostatectomy

OBJECTIVE: We evaluated the preoperative parameters to predict a positive surgical margin (SM) at radical prostatectomy for patients with prostate cancer. In addition, the prognostic factors for biochemical recurrence were determined in patients with positive SMs. METHODS: We retrospectively analysed 238 patients with prostate cancer who underwent retropubic radical prostatectomy and bilateral pelvic lymph node dissection from May 1985 to July 2005 in our hospital. Biochemical recurrence was defined as an increase of undetectable prostate-specific antigen (PSA) to 0.2 ng/ml or greater. RESULTS: Of the 238, 82 patients (34.4%) had positive SMs. On multivariate analysis, preoperative PSA (>/=10 ng/ml), clinical T stage (>/=T2a) and the positive core rate (>/=35%) were parameters that could predict a positive SM. During the median follow-up of 31.2 months, 48 patients (20.2%) developed biochemical recurrence. The 5-year biochemical progression-free survival rates were 81.7% and 62.6% in patients with negative and positive SMs, respectively (P < 0.001). In the Cox proportional hazards model, preoperative PSA of >/=20 ng/ml and a pathological T stage of pT3a/pT3b were significant risk factors for biochemical recurrence in patients with positive SMs. CONCLUSIONS: SM status at radical prostatectomy depends on preoperative PSA, clinical stage and the positive core rate. Patients with a positive SM had a higher risk for biochemical recurrence than those with a negative one. Patients with a positive margin had a higher risk for biochemical recurrence if they exhibited preoperative PSA of >/=20 ng/ml and/or pathological T stage of pT3a/pT3b.