Prognostic factors of persistently detectable PSA after radical prostatectomy

Objectives:   To determine predictive factors of detectable prostate-specific antigen (PSA) in patients submitted to radical prostatectomy (RP) and to define the prognostic role of this event.
Methods:   A total of 318 patients who underwent RP between 2002 and 2007 were selected from our prospective database. Selection criteria were: no neo-adjuvant therapy; surgical specimens analyzed and reviewed according to a standardized protocol by two pathologists; clinical stage T1,T2 or T3 N0; pathological stage T2–3/N0–1.
Results:   Median age was 65. 22 years. All patients had a PSA greater than 20 ng/mL (6.9%). Fifty-six patients had poorly differentiated prostate cancer at biopsy (17.6%) and 77 after pathological examination. Cancer stage was cT2/3 in 128 (40.2%) patients, pT3 in 79 (24.8%) patients and pN1 in 20 patients (6.2%). Surgical margins were positive in 89 cases (28%). Thirty-three of the 318 patients had detectable PSA (10.3%) after RP. Multivariate analysis confirmed PSA (odds ratio 3.07; P  = 0.0008), pT3a/b stage (odds ratio 2.72; P  = 0.0466) and nodal metastasis (odds ratio 5.68; P  = 0.0060) as independent predictors of detectable PSA after RP. Detectable PSA had a great impact on prognosis. Twenty-four of these 33 patients experienced a PSA progression and needed a second treatment. In a multivariate model, detectable PSA functioned as an independent predictor of PSA progression (hazard ratio 4.54; P  = 0.0000).
Conclusions:   In our experience, a detectable PSA after RP can be predicted by preoperative PSA, pathological stage and nodal status. Moreover, it represents a significant risk factor of PSA progression. The strong imbalance towards risk factors of systemic disease supports the use of hormonal therapy in case of progression.     

Evaluation of operative complications related to laparoscopic radical prostatectomy

Objectives:   In this decade, there have emerged many alternatives for the therapy of localized prostate cancer, such as brachytherapy, intensity modulated radiation therapy, high intensity focused ultrasound, and retropubic radical prostatectomy. In this retrospective study, we reviewed cases of complications related to laparoscopic radical prostatectomy (LRP) from our institution only, and we evaluated whether this procedure was minimally invasive or not.
Methods:   Between August 2000 and December 2006, a total of 160 patients in our institution underwent LRP as the definitive treatment for clinically localized prostate cancer. We analyzed not only the complications but also the operative time and blood loss to clarify the indications of LRP.
Results:   Major complications were defined as those requiring surgical intervention including laparoscopic repair. A total of nine major complications (5.63%) occurred in six patients (3.75%). In a Cox regression analysis, the estimated blood loss ( P  = 0.0069) and neoadjuvant hormonal therapy ( P  = 0.0019) were significant predictors of long operative time (>6 h) of LRP.
Conclusion:   The indication of LRP in this study was localized prostate cancer at the T1 or T2 stage for which neoadjuvant hormonal therapy had not been administered. We concluded that the operative and postoperative morbidities of LRP are low and that LRP can be routinely carried out by an experienced team.     

Peak flow rate is the best predictor of acute urinary retention following prostate brachytherapy: Our experience and literature review

Objectives:   We prospectively investigated risk factors for acute urinary retention (AUR) following transperineal radioactive seed implantation for prostate cancer.
Methods:   A total of 273 consecutive patients underwent transperineal ultrasound-guided prostate brachytherapy for clinical T1c–T3b prostate cancer. Preoperative factors included age; International Prostate Symptom score; planimetric prostate and transition volumes (TZV) measured by transrectal ultrasound; peak flow rate; post-void residual urine; neoadjuvant hormone therapy; use of pelvic radiation; and T stage. Intra- and postoperative factors included the number of seeds and needles.
Results:   Ten patients (3.6%) showed AUR requiring catheterization. Among preoperative factors, age, International Prostate Symptom score, planimetric prostate volume, planimetric prostate volume and radiation therapy (RT) were not significantly correlated with AUR. PFR ( P  = 0.012) and PVR ( P  = 0.020) of patients having AUR were significantly higher than those not having AUR. Mean TZV was also significantly higher ( P  = 0.038) in the AUR group univariate analysis. Multivariate analysis showed that PFR is the only independent predictor of AUR ( P  = 0.030).
Conclusion:   On univariate analysis, PFR, PVR and TZV were found to be statistically significant predictors of AUR following seed implantation. According to multivariate analysis, only PFR was confirmed to be a significant predictor.     

The prognostic impact of pelvic lymph node metastasis and lymphovascular invasion on bladder cancer

Objectives:   To present long-term results of a single-center series of patients undergoing bilateral pelvic lymphadenectomy and radical cystectomy for bladder cancer and to analyze the impact of pelvic lymph node metastasis and lymphovascular invasion on clinical outcome.
Methods:   Between 1986 and 2005 833 patients were treated with bilateral pelvic lymphadenectomy and radical cystectomy at our institution. 614 of them with valid clinical follow-up information and no neoadjuvant therapy could be evaluated.
Results:   Disease-free and overall survival in the entire cohort was 56.7% and 49.5% at 5 years and 52.4% and 38.2% at 10 years, respectively. 28.1% of all patients had pelvic lymph node metastasis. We found organ-confined tumor stages (≤pT2) in 43.8%. Patients with non-organ-confined tumor stages (≥pT3) and positive pelvic lymph nodes had a significantly shorter overall survival than those without lymph node metastasis ( P  < 0.0001). In the subgroup of ≤pT2, the presence of pelvic lymph node metastasis did not show a statistically significant effect on overall survival ( P  = 0.618). The presence of lymphovascular invasion was associated with an impaired survival ( P  < 0.0001). In multivariate analysis, pathological tumor stage ( P  < 0.0001), lymph node stage (≥pT3) ( P  = 0.004) and lymphovascular invasion ( P  = 0.001) were independent prognostic parameters.
Conclusions:   According to the present series, survival for patients with ≤pT2 does not depend on the lymph node stage. Lymphovascular invasion is an independent parameter of impaired survival and should be determined routinely in cystectomy specimens to identify patients, who may benefit from adjuvant systemic therapy.     

Prediction of organ-confined disease by prostate-specific antigen nadir after neoadjuvant therapy.

BACKGROUND: It is not clear whether or not serum prostate-specific antigen (PSA) levels after androgen deprivation prior to radical prostatectomy (neoadjuvant therapy) have any value in the prediction of the final pathologic stage. METHODS: We conducted a study on 49 patients who underwent retropubic radical prostatectomy following neoadjuvant therapy for clinical stage T1c, T2, and T3a prostate cancer. We evaluated progression-free survival based on the PSA failure rate and the predictive value of the PSA nadir after neoadjuvant therapy and other clinical factors to determine the most important predictor of organ confinement. RESULTS: Of the 49 patients, 30 had organ-confined disease. Of 31 patients without adjuvant therapy after surgery, the PSA failure-free rates at 2 years were 81.6 and 34.3% in the subset of organ-confined disease and non-organ-confined disease, respectively (P= 0.0031). Of the 18 patients with adjuvant androgen deprivation therapy after surgery, the PSA failure-free rate at 2 years was 100% and 59.7% in patients with organ-confined disease and non-organ-confined disease, respectively. Baseline PSA (P=0.037), PSA nadir (P<0.0001) and PSA density (P=0.003) significantly correlated with organ confinement. Multivariate logistic regression analysis revealed that the PSA nadir was the only independent predictor of organ confinement (P = 0.044). CONCLUSIONS: There was a trend that the patients with non organ-confined disease had a higher probability of PSA failure than did the patients with organ-confined disease. The PSA nadir after neoadjuvant therapy was the strongest predictor of organ confinement. The predictive value of the serum PSA nadir should be validated in well-designed larger population-based studies.     

Neoadjuvant hormonal therapy and radical prostatectomy in the treatment of clinical stage T3 cancer of the prostate

We evaluated the results of a treatment protocol that consisted of neoadjuvant hormonal therapy followed by radical retropubic prostatectomy (RRP) for clinical stage T3 (cT3) prostate cancer. Sixty-six patients with cT3 prostate cancer underwent staging procedures that included metastatic work-up and evaluation under anesthesia. Neoadjuvant hormonal treatment was given for 3 to 6 months, followed by re-evaluation under anesthesia. Patients considered to have a resectable prostate following neoadjuvant treatment underwent operation. Disease-free survival [prostate-specific antigen (PSA) < 0.1 ng/ml] was calculated by the Kaplan-Meier method for cT3 patients and for a group of patients with clinical stage 1 and 2 disease (cT1-2), who underwent RRP without neoadjuvant hormonal therapy. Patients with pT3 disease in both groups received early adjuvant radiation treatment. Patients in the cT3 group who were not clinically downstaged were treated with radiation. Patients with positive lymph nodes continued hormonal therapy. The pretreatment PSA for the cT3 group was 43.6 ± 55.6 ng/ml, and 10.64 ± 7.18 ng/ml for the cT1-2 group (p < 0.05). Of 66 cT3 patients, 53 (80%) were clinically downstaged and operated on and 47 (71%) underwent RRP. At 36 months, there was no significant difference in the PSA relapse rate between these two groups; both had significantly lower rates than did patients in the cT3 without RRP. At 48 months, 79% (21 patients) of the patients in the cT3-RRP group were disease free compared with 50% of those in the cT3 without RRP (4 patients). Neoadjuvant hormonal therapy for stage cT3 prostate cancer selects patients whose cancer can be controlled by RRP for an extended period of time.     

The potential role of prebiopsy magnetic resonance imaging combined with prostate-specific antigen density in the detection of prostate cancer

Aim:   Two-thirds of patients with a gray-zone prostate-specific antigen (PSA) level undergo unnecessary biopsy. Sensitivity is not yet sufficient to permit the use of modified PSA parameters or magnetic resonance (MR) imaging alone for prostate cancer screening. Thus, we evaluated the combination of MR imaging and PSA density (PSAD) for specificity and sensitivity.
Methods:   During the period April 2004 through March 2006, 185 patients with a PSA level of 4.0–10.0 ng/mL underwent MR imaging and transrectal ultrasonography-guided 8-core biopsy (systemic sextant biopsy of the peripheral zone plus two cores of transition zone). All MR images were interpreted prospectively by two radiologists. An image was considered positive for prostate cancer if any feature indicated a cancerous lesion. Receiver operating characteristic (ROC) curves were used to compare the usefulness of the PSA level, PSAD and PSA transitional zone density (PSATZ) for the detection of prostate cancer.
Results:   Of the 185 patients, 62 had prostate cancer. Sensitivity and specificity of the axial T2-weighted MR imaging findings for cancer detection were 79.0% and 59.4%, respectively. The area under the ROC curve was 0.590 for the PSA level, 0.718 for PSAD and 0.695 for PSATZ. MR imaging findings and PSAD were shown by multivariate analysis to be statistically significant independent predictors of prostate cancer ( P  < 0.001). With a PSAD cut-off value of 0.111, sensitivity was 96.8%, but specificity was 19.5%. Combining MR imaging findings with PSAD increased the specificity to 40% and retained 95% sensitivity.
Conclusion:   MR imaging findings combined with PSAD provide high sensitivity and improve the specificity for the early detection of prostate cancer.     

Cancer-related pain and quality of life in prostate cancer patients: Assessment using the Functional Assessment of Prostate Cancer Therapy

The objective of this study was to assess disease-associated pain and quality of life (QOL) in patients with prostate cancer (PC). A total of 102 PC patients (clinical stage B, C: 20, D2: 82) patients were enrolled. QOL was assessed using the Functional Assessment of Cancer Therapy, General and Prostate (FACT-G/P). Disease-specific pain response was assessed using the visual analog scale and the face rating scale. In patients with stage D2 PC, mean age, serum prostate-specific antigen level, and performance status were 72.5 ± 7.1 years (range, 55–88), 217 ± 467 ng/mL (range, 0.1–2600), and 1.4 (0–4), respectively. The score of physical well-being and FACT-P was significantly lower in stage D2 patients, compared with those of stage B/C ( P  = 0.02, 0.0088, respectively). Performance status, extent of disease, and the visual analog scale were related with a poor QOL score ( P  = 0.0054, 0.01, <0.0001, respectively). Thirty-two patients (39%) had disease-specific pain, and 25 patients received a related treatment. Ten patients under morphine analgesics maintained better QOL in almost all domains, compared with the seven patients without any painkillers. Combined use of FACT and pain scales enhances the objective assessment of QOL and pain status in PC patients. Control of disease-associated pain is crucial to improving QOL in stage D2 PC patients.     

Long-term outcome following radical prostatectomy in men with clinical stage T3 prostate cancer

PURPOSE: We evaluated patients at our institution who underwent radical prostatectomy for clinical stage T3 prostate cancer to determine their long-term clinical outcomes. MATERIALS AND METHODS: We reviewed our prospective surgical database and identified 176 men who underwent radical retropubic prostatectomy for clinical stage T3 prostate cancer from 1983 to 2003. Clinical and pathological data were reviewed and evaluated in a Cox proportional hazards model to determine preoperative predictors of biochemical recurrence. Clinical progression following biochemical recurrence was evaluated and clinical failure was defined as the development of clinical metastases or progression to hormone refractory prostate cancer. RESULTS: Of the 176 patients with cT3 prostate cancer 64 (36%) received neoadjuvant hormonal therapy. At a mean followup of 6.4 years 84 (48%) patients had disease recurrence with a median time to biochemical recurrence of 4.6 years. The actuarial 10-year probability of freedom from recurrence was 44%. On multivariate analysis biopsy Gleason score, pretreatment serum prostate specific antigen and year of surgery were independent predictors of biochemical recurrence. Neoadjuvant hormonal therapy was not a significant predictor of biochemical recurrence. Following biochemical recurrence clinical failure developed in 30 of 84 (36%) men with a median time of 11 years. Overall the 5, 10 and 15-year probabilities of death from prostate cancer were 6%, 15% and 24%, respectively. CONCLUSIONS: More than half (52%) of our patients remained free of disease recurrence following radical prostatectomy. In our series neoadjuvant hormonal therapy offered no advantage with respect to disease recurrence. Radical prostatectomy remains an integral component in the treatment of select patients with clinical stage T3 prostate cancer.     

Oncological impact of neoadjuvant hormonal therapy on permanent iodine‐125 seed brachytherapy in patients with low‐ and intermediate‐risk prostate cancer

Objectives

To determine whether neoadjuvant hormonal therapy improves oncological outcomes of patients with localized prostate cancer treated with permanent brachytherapy.

Methods

Between January 2004 and November 2014, 564 patients underwent transperineal ultrasonography‐guided permanent iodine‐125 seed brachytherapy. We retrospectively analyzed low‐ or intermediate‐risk prostate cancer based on the National Comprehensive Cancer Network guidelines. The clinical variables were evaluated for influence on biochemical recurrence‐free survival, progression‐free survival, cancer‐specific survival and overall survival.

Results

A total of 484 patients with low‐risk (259 patients) or intermediate‐risk disease (225 patients) were evaluated. Of these, 188 received neoadjuvant hormonal therapy. With a median follow up of 71 months, the 5‐year actuarial biochemical recurrence‐free survival rates of patients who did and did not receive neoadjuvant hormonal therapy were 92.9% and 93.6%, respectively (P = 0.2843). When patients were stratified by risk group, neoadjuvant hormonal therapy did not improve biochemical recurrence‐free survival outcomes in low‐ (P = 0.8949) or intermediate‐risk (P = 0.1989) patients. The duration or type of hormonal therapy was not significant in predicting biochemical recurrence. In a multivariate analysis, Gleason score, pretreatment prostate‐specific antigen, clinical T stage, and prostate dosimetry, primary Gleason score and positive core rate were significant predictive factors of biochemical recurrence‐free survival, whereas neoadjuvant hormonal therapy was insignificant. Furthermore, neoadjuvant hormonal therapy did not significantly influence progression‐free survival, cancer‐specific survival or overall survival.

Conclusions

In patients with low‐ or intermediate‐risk disease treated with permanent prostate brachytherapy, neoadjuvant hormonal therapy does not improve oncological outcomes. Its use should be restricted to patients who require prostate volume reduction.     

Clinicopathological significance of neoadjuvant hormonal therapy prior to radical prostatectomy: whole section analysis

We investigated whether the histopathological effect (cell viability) of neoadjuvant hormonal treatment before radical prostatectomy for clinically localized prostate cancer is involved in the biochemical outcome, i.e., androgen independency. Non-randomized prospective trial was carried out between September 1996 and April 2001 involving the patients with clinical stage T1-3 prostate cancer, including 62 who underwent radical prostatectomy after receiving neoadjuvant hormonal treatment for an average of 6.3 months and 76 who underwent radical prostectomy only. All resected specimens were histopathologically diagnosed by whole section analysis. The patients receiving neoadjuvant hormonal treatment were categorized into 4 groups according to the histological change in the resected prostate. There were 8 patients in G0 (all viable cells), 11 patients in G1 (more than 50% viable cells), 26 patients G2 (more than 50% non-viable cells) and 17 patients in G3 (no cancer cells). No difference in the patient background (prostate specific antigen, stage, Gleason score, positive core Nr, duration of neoadjuvant therapy) was observed in any group, except for the duration of (p < 0.05). Multivariate hazards analyses revealed that only the duration of neoadjuvant hormonal treatment was independently associated with excellent responders with grade 3 histological effect. Neoadjuvant hormonal therapy prior to radical operation resulted in various histopathological changes in the prostate, but it is not clear whether the histological effects of hormonal treatment might be involved in the outcome. A longer follow-up randomized prospective trial is necessary.     

Efficacy of primary hormonal therapy for patients with localized and locally advanced prostate cancer: A retrospective multicenter study

AIM: A retrospective review of patients with localized and locally advanced prostate cancer was performed to evaluate the efficacy of primary hormonal therapy and predict long-term prognosis in these patients. METHODS: A total of 628 patients who were diagnosed with stage T1c to T3 prostate cancer were treated with primary hormonal therapy at participating institutions. The patients were classified based on pretreatment prostate-specific antigen (PSA) level, Gleason score, and time to nadir PSA level. Disease-specific and progression-free survival rates were investigated, and compared among the subgroups. RESULTS: The mean age of patients was 74.5 years, and median pretreatment PSA level was 14.0 ng/mL. A total of 399 patients (63.5%) were treated with combined androgen blockade (CAB), and 229 patients (36.5%) were treated with castration monotherapy. The disease-specific survival rate of all 628 patients was 89.1% at 8 years. The group that showed a good response to primary hormonal therapy (Group G, pretreatment PSA level < or =20 ng/mL, Gleason score < or =7, and time to nadir PSA < or =6 months) accounted for approximately one-third of the total number of T1c-T3 patients. Disease-specific and progression-free survival rates at 8 years in Group G were 98.9% and 82.0%, respectively. These rates increased to 100% and 87.3%, respectively, in patients receiving CAB treatment in Group G. CONCLUSIONS: The results indicate the usefulness of primary hormonal therapy, especially CAB treatment, for patients showing a good response to hormonal therapy in long-term control of localized and locally advanced prostate cancer.     

Neoadjuvant therapy before radical prostatectomy: Where have we been? Where are we going?

Prostate cancer is curable only when treated at an early stage, when the tumor is still localized to the prostate gland. However, even in apparent cases of clinically localized disease, unsuspected extracapsular disease may significantly increase the risk of primary treatment failure. This risk is especially high if the patient has > or =1 of the following risk factors: a serum prostate-specific antigen level of >20 ng/ml, a Gleason score of >7, locally advanced disease (clinical stage T3/T4), and extensive disease on prostate biopsy. Various regimens of neoadjuvant hormonal therapy, chemotherapy, or both have produced mixed results and, in general, have not significantly influenced the rate of disease relapse (as defined by prostate-specific antigen level) in high-risk patients with localized prostate cancer. In addition, anti-angiogenic agents, gene therapy, molecular targeting agents, and other promising new therapies have been investigated in a neoadjuvant setting with limited results. Therefore, this patient population continues to pose a therapeutic dilemma for physicians.     

Radiation therapy in the management of locally advanced prostate cancer

Locally advanced prostate cancer generally refers to those patients with clinical stages T3-4 disease. Patients with locally advanced cancer frequently are included in clinical trials that examine treatment for patients at high risk for relapse based on presenting prostate-specific antigen, high Gleason score, or advanced clinical stage. There is a growing body of evidence that suggests that men with localized prostate cancer benefit from high-dose radiation therapy delivered with three-dimensional conformal radiation therapy, intensity-modulated radiation therapy, or proton beam therapy. Most importantly, neoadjuvant and adjuvant androgen-deprivation therapy have significantly improved outcomes in men with locally advanced or high-risk prostate cancer. Although questions remain regarding the optimal timing and duration of adjuvant hormonal therapy, a combination of long-term androgen deprivation started before radiation therapy and continued for 2 years represents a North American standard of care for this patient population.     

Hormone/Antihormone Withdrawal and Dexamethasone for Hormone-Refractory Prostate Cancer

Background Flutamide withdrawal has been reported to benefit patients with hormone-refractory prostate cancer. Several studies have also demonstrated that a combination of corticosteroids and testicular androgen ablation lowers serum androgen levels and improves clinical response. The purpose of this study was to examine the effect of withdrawal of oral hormonal agents and administration of dexamethasone in stage D3 prostate cancer patients.
Methods Sixteen patients with hormone-refractory prostate cancer were enrolled in the study. All patients had osseous metastasis and elevated serum prostate-specific antigen. Nine had been treated with chlormadinone acetate, 4 with estramustine phosphate, and 3 with flutamide as first-line hormonal therapy. All patients had also been treated either with bilateral orchiectomy (13 cases) or a luteinizing hormone-releasing hormone (LH-RH) agonist (3 cases). Seven patients whose disease progressed following hormone withdrawal were treated with oral dexamethasone (initially 1.5mg/day, then tapered to 0.5 mg/day).
Results Eight patients demonstrated a decrease in prostate-specific antigen of greater than 50% following hormone withdrawal. The time to cancer progression for these 8 patients was 2 to 15 months (mean, 4 months). Among the patients receiving dexamethasone, 4 showed a greater than 90% decrease in prostate-specific antigen after 3 months' treatment. The time to disease progression for these 4 patients was 3 to 11 months.
Conclusion In treating hormone-refractory advanced prostate cancer, the first pharmacologic manipulation should be withdrawal of the oral component of combined hormonal therapy. Patients whose disease progresses after hormone withdrawal should then be treated with glucocorticoids such as dexamethasone.     

Rectal cancer in young adults: a series of 102 patients at a tertiary care centre in India

Objective  Rectal cancer in young patients is uncommon. There is little information on rectal cancer in young adults in India. The aim of this study was to determine the relative incidence of rectal cancer in young patients in India and identify any differences in histological grade and pathological stage between younger and older cohorts.
Method  All adult patients presenting at a tertiary colorectal unit with primary rectal adenocarcinoma between September 2003 and August 2007 were included. Patients were divided into two groups: 40 years and younger, and older than 40 years. Details regarding patient demographics, preoperative assessment, management and tumour grade and stage were obtained from a prospectively maintained database.
Results  One hundred and two of 287 patients (35.5%) were 40 or younger at presentation. Younger patients were more likely to present with less favourable histological features (52.0% vs 20.5% ( P  < 0.001)) and low rectal tumours (63.0% vs 50.0%) ( P  = 0.043), but were equally likely to undergo curative surgery compared to the older group ( P  = 0.629). Younger patients undergoing surgery had a higher pathological T stage (T0–2 18.9%, T3 62.3%, T4 19.7% vs 34.5%, 56.0%, 9.5%) ( P  = 0.027) and more advanced pathological N stage (N0 31.1%, N1 41.0%, N2 27.9% vs 53.4%, 26.7%, 17.2%) ( P  = 0.014).
Conclusion  The relative number of young patients with rectal cancer in this Indian series is higher than figures reported in western populations. The reasons for this are not clear. The histopathological features of rectal tumours in young patients in this study are consistent with similar studies in Western populations.     

Neoadjuvant hormonal therapy before radical prostatectomy and risk of prostate specific antigen failure

PURPOSE: To date there is little information on the long-term effect of neoadjuvant hormonal therapy on prostate cancer progression. We performed a prospective study to determine whether patients with prostate cancer receiving neoadjuvant hormonal therapy before radical prostatectomy (hormonal therapy group) have a lower risk of prostate specific antigen (PSA) failure than those treated with radical prostatectomy alone (prostatectomy group). We also evaluated whether type of neoadjuvant hormonal therapy and duration were associated with the risk of PSA failure. MATERIALS AND METHODS: We followed 680 men initially treated for prostate cancer with radical prostatectomy between January 1988 and December 1997 at our university hospital. Of the patients 292 received neoadjuvant hormonal therapy. Median followup was 38 months. Cox regression analysis was used to assess the association between neoadjuvant hormonal therapy and PSA failure (greater than 0.3 ng./ml.) controlling for age, clinical stage, grade, initial PSA and adjuvant therapies. RESULTS: Surgical margins were positive less often in the hormonal therapy (25%) than the prostatectomy (47%) group (p = 0.0001). PSA failure was observed in 163 patients and the 5-year failure rate was 33%. No difference in risk of PSA failure was observed overall between the hormonal therapy and prostatectomy groups (hazards ratio 0.94, 95% confidence interval 0.68 to 1.30). Treatments with antiandrogen alone for any duration, and those combining antiandrogen and luteinizing hormone-releasing hormone analogue for 3 months or less were not associated with improved survival. However, patients receiving combined therapy for more than 3 months had a significantly lower risk of PSA failure than those treated with radical prostatectomy alone (hazards ratio 0.52, 95% confidence interval 0.29 to 0.93). CONCLUSIONS: Prolonged neoadjuvant hormonal therapy combining antiandrogen and luteinizing hormone-releasing hormone analogue may improve disease-free survival after radical prostatectomy.     

Neoadjuvant therapy and prostate cancer: what a urologist should know

PURPOSE OF REVIEW: Prostate cancer is curable only when treated at an early stage, when the tumor is still localized to the prostate gland. However, even in apparent cases of clinically localized disease, unsuspected extracapsular disease may significantly increase the risk of primary treatment failure. This risk is especially high if the patient has one or more of the following risk factors: a serum prostate-specific antigen level >20 ng/ml, a Gleason score >7, locally advanced disease (clinical stage T3/T4), and extensive disease on prostate biopsy. RECENT FINDINGS: Various regimens of neoadjuvant hormonal therapy and/or chemotherapy have produced mixed results and generally have not influenced the rate of disease relapse (defined by prostate-specific antigen level) in high-risk patients with localized prostate cancer. In addition, antiangiogenic agents, gene therapy, molecular targeting agents, and other promising new therapies have been investigated in a neoadjuvant setting with limited results. SUMMARY: Despite considerable advances, high-risk localized prostate cancer remains an extremely refractory disease. In patients with high-risk prostate cancer, single-modality treatment in the form of surgery offers a 5-year biochemical disease-free survival rate of no better than 50%. To further elucidate optimal treatment regimens for these patients we must actively enrol patients in clinical trials.     

Neoadjuvant therapy before radical prostatectomy for clinical T3/T4 carcinoma of the prostate: 5-year followup,Phase II Southwest Oncology Group Study 9109

PURPOSE: Several investigators have examined the role of hormonal therapy before definitive local therapy for locally advanced prostate cancer to improve outcome. We evaluated the resectability rate and clinical response rate to 16 weeks of total androgen blockage therapy for clinically locally prostate cancer before radical prostatectomy, and progression-free survival in this multi-institutional study. MATERIALS AND METHODS: Southwest Oncology Group 9109 was a phase II feasibility study designed to treat patients with clinical stage C prostate cancer (T3, T4, N0 and M0). Cases were classified by stage T3 versus T4 and bulky (greater than 4 cm.) versus nonbulky (or less 4 cm.) disease. The neoadjuvant agents used were goserelin and flutamide before radical prostatectomy. RESULTS: A total of 62 patients were accrued to the study and 1 patient was ineligible. There were 2 protocol deviations and these patients refused to undergo prostatectomy after hormonal therapy. Four patients went off protocol treatment because they were not considered surgical candidates. The racial distribution was 72% white, 20% black, 7% Hispanic and 2% Asian. Clinical stage at diagnosis was T3 in 97% and T4 in 3% of cases. Of the patients 39% were diagnosed with bulky disease. Of the 61 eligible patients 55 (90%) underwent a prostatectomy. The 5-year progression-free survival estimate was 70% (24 of 61 cases failed) and the 5-year survival estimate was 90% (11 of 61 deaths). Most of the patients in this trial would have been considered inoperable and referred to radiation oncology. CONCLUSIONS: Neoadjuvant hormonal therapy followed by radical prostatectomy is reasonable and appropriate for clinical stage T3 prostate cancer. A progression-free and overall 5-year survival of 70% and 90%, respectively, compares favorably to Radiation Therapy Oncology Group neoadjuvant trial outcomes for this stage of prostate cancer.     

The clinical characteristics of renal cell carcinoma in female patients

Objective:   To investigate the clinical characteristics of renal cell carcinoma (RCC) in female patients.
Methods:   The clinical characteristics including sex, age at diagnosis, histological tumor size, histological subtype, Fuhrman nuclear grade and pathological tumor–node–metastasis (TNM) stage of 881 consecutive patients treated with (partial) nephrectomy for RCC from 1998 to 2006 were analyzed. Characteristics of different gender groups and different female age groups were compared. The one-way anova and t -test were used to compare means. Pearson's χ²-test and the likelihood ratio test were used to compare ratios.
Results:   Low-grade tumors accounted for 79.3% of female patients and 64.1% of male patients ( P  < 0.001). The percentage of stage T1–2 was 76.6% in female patients while it was only 68.5% in male patients ( P  = 0.011). Also, female patients had more T1–2N0M0 tumors (73.0% vs 64.3%, P  = 0.009). Once female patients were classified into three groups according to age diagnosis (≤40, 41–59 and ≥60 years) young female patients seemed to have more tumors with unfavorable histology (8.7% vs 5.1% vs 4.3%), Fuhrman grade 3–4 (23.9% vs 23.1% vs 17.7%) and stage T3–4 (28.3% vs 23.1% vs 22.0%).
Conclusion:   Compared with male patients, female patients had lower stage and grade tumors. However, younger female patients had more tumors with unfavorable histology, and higher stage and grade compared to older female patients.