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.     

PSA at postoperative three months can predict biochemical recurrence in patients with pathological T3 prostate cancer following radical prostatectomy

Objectives: To identify the prognostic factors and determine which pT3 prostate cancer patients can be safely followed up after surgery without any adjuvant treatment. Methods: A retrospective review was carried out on 106 patients with pT3 prostate cancer. All preoperative and postoperative parameters, including the postoperative serum prostate‐specific antigen (PSA) level at 3 months after surgery, were assessed by univariate and multivariate analyses. Results: Mean follow‐up period was 18 months. The overall biochemical recurrence‐free rate was 53.7% and 34.1% at 12 and 36 months, respectively. On univariate analysis, all preoperative clinical factors were significantly correlated with biochemical progression. On multivariate analysis, pathological Gleason score, pathological stage and postoperative PSA were significant predictors. Among those with undetectable PSA after surgery, 38 patients (88.4% of 43) did not have disease progression during the follow‐up period. On the other hand, of the 27 patients with detectable PSA that was not defined as progressive (range 0.01–0.20), 22 (81.5%) had biochemical disease progression. The progression free probability was significantly different between these two groups (P‐value < 0.0001). Conclusions: pT3 prostate cancer patients showing low pathological Gleason score, without seminal vesicle invasion, and undetectable postoperative PSA values have low probability of PSA progression. Careful follow up including periodic PSA assessment and clinical observation represents an adequate strategy in the management of these patients.     

Percent carcinoma in prostatectomy specimen is associated with risk of recurrence after radical prostatectomy in patients with pathologically organ confined prostate cancer

PURPOSE: We evaluated tumor size, measured as the percent of the prostate involved by cancer, as a predictor of tumor recurrence after radical prostatectomy in patients with pathologically organ confined prostate cancer. MATERIALS AND METHODS: One of us (WJC) performed radical retropubic prostatectomy in 1,850 men who had pathologically organ confined prostate cancer with tumor size recorded between January 1988 and February 2003. The percent of prostate tissue involved by carcinoma in the radical prostatectomy specimen was estimated by visual inspection. We compared clinicopathological characteristics in patients who did and did not have tumor recurrence and stratified them by percent of tumor in the prostatectomy specimen. We also evaluated the relationship between percent of cancer and biochemical evidence of cancer recurrence. RESULTS: Patients who had recurrence were slightly older (mean age 62 vs 60 years, p = 0.004), and had higher mean preoperative prostate specific antigen (8.6 vs 6.3 ng/ml, p <0.0001) and a higher proportion of poorly differentiated tumors (Gleason grades 8 to 10) (7% vs 1%, p = 0.001). The mean percent of cancer was higher in men with recurrence (11% vs 7%, p <0.0001). Men with 10% or greater of the gland involved by cancer had a 10% recurrence rate compared with a 5% rate in men in whom cancer involved less than 10% of the gland (p = 0.001). The 5-year recurrence-free survival rate was 94%, 91% and 82% in patients with less than 10%, 10% to 20% and greater than 20% of the gland involved. The multivariate Cox model indicated that the percent of cancer involvement of the prostate provides unique predictive information about the risk of cancer recurrence (p = 0.0001). The estimated 5-year recurrence-free survival rate based on the Cox model indicated that patients with greater than 20% of the gland involved by tumor, clinical stage T2/T3 and Gleason sum >/=7 were at substantial risk of cancer recurrence. CONCLUSIONS: Tumor size measured as the percent of cancer is an independent predictor of cancer recurrence after radical prostatectomy in patients with pathologically organ confined prostate cancer.     

The outcome of patients with pathological Gleason score >or=8 prostate cancer after radical prostatectomy

OBJECTIVE

To analyse the outcome of patients undergoing radical prostatectomy (RP) for Gleason 8–10 clinically localized prostate cancer, and to evaluate the prognostic value of well‐known predictors of progression.

PATIENTS AND METHODS

In all, 1480 patients had RP between 1988 and 2006, of whom 180 had pathological Gleason score ≥8 and negative lymph nodes. Biochemical progression‐free survival was determined using the Kaplan‐Meier method. The effect of preoperative prostate‐specific antigen (PSA) level, pathological stage and margin status was assessed with univariate and multivariate analyses.

RESULTS

Of the 180 patients, the Gleason score in the RP specimen was 8, 9 or 10 in 70%, 27% and 3%, respectively; 24% had stage pT2 disease, 30% stage pT3a, 25% stage pT3b and 20% stage pT4a. The 5‐ and 7‐year biochemical progression‐free survival was 73 and 65% for stage pT2, 40% and 27% for stage pT3a, and 30% for stage pT3b (log rank test, P < 0.001). In the univariate model, preoperative PSA level, pathological stage and surgical margins were predictors of survival. In the multivariate analysis, preoperative PSA level and extracapsular extension predicted biochemical progression‐free survival.

CONCLUSION

Gleason 8–10 tumours have a poor prognosis. Patients with a PSA level of <10 ng/mL and stage pT2 disease have the greatest likelihood of having a longer progression‐free survival after RP.     

循环肿瘤细胞对胃癌手术患者预后的判断价值

目的探讨接受手术治疗的胃癌患者循环肿瘤细胞(circulating tumor cells,CTC)的临床意义并评估其对胃癌患者预后的判断价值。方法采用病例对照研究方法,回顾性收集2015年4月至2017年7月期间在中国人民解放军总医院第一医学中心普通外科医学部行胃癌根治性手术治疗且术后进行CTC检查的胃癌患者的临床病理资料,根据CTC水平与患者生存情况绘制受试者操作特征曲线(ROC),确定最佳截断值,根据此截断值将患者分成CTC阳性组和CTC阴性组,探究2组患者之间的临床病理特征差异。对胃癌患者进行随访并记录生存情况,随访截止时间为2020年9月30日。采用Kaplan-Meier法计算3年总生存率并绘制生存曲线,采用Cox回归模型对患者预后因素进行单因素和多因素分析,探寻影响胃癌术后患者生存的因素。结果本研究共纳入胃癌患者242例。ROC曲线分析结果显示,患者生存差异最具统计学意义的CTC截断值是1,即患者血液中检出CTC就被视为阳性,其中CTC阳性组49例(20.2%),阳性CTC细胞数为1~32个/7.5 mL、中位数为2个/7.5 mL;CTC阴性组193例(79.8%)。比较2组患者的基线资料显示患者在年龄、性别、肿瘤部位、手术方式、切除类型、吻合方式、肿瘤直径、淋巴结转移和神经侵犯方面的差异均无统计学意义(均P>0.05),在体质量指数、脉管癌栓、肿瘤分化程度、肿瘤病理类型和肿瘤TNM分期方面差异均具有统计学意义(均P<0.05)。242例胃癌患者术后随访时间为3~67个月,中位随访时间为42个月,CTC阳性组和CTC阴性组3年总生存率分别为49.0%和72.5%,差异具有统计学意义(χ²=17.129,P<0.001)。单因素分析结果显示:年龄、肿瘤部位、切除类型、吻合方式、肿瘤直径、淋巴结转移、脉管癌栓、神经侵犯、肿瘤分化程度、肿瘤TNM分期和CTC是否阳性是影响胃癌患者总生存率的影响因素(均P<0.05)。多因素分析结果显示,年龄>60岁[HR=3.009,95%CI为(1.807,5.010),P<0.001]、肿瘤TNM分期为Ⅲ~Ⅳ期[HR=3.082,95%CI为(1.504,6.317),P=0.002]和CTC阳性[HR=2.488,95%CI为(1.475,4.197),P=0.001]是影响胃癌患者生存的独立危险因素。结论 CTC与胃癌术后患者的预后有关,可以作为判断胃癌术后患者预后的潜在指标。     

Prognostic factors for and outcome of locally advanced prostate cancer after radical prostatectomy

Study Type – Therapy (case series)
Level of Evidence 2b

OBJECTIVE

To present the outcomes of cT3N0M0 prostate cancer after radical prostatectomy (RP) and determine the prognostic factors in biochemical progression‐free survival (BPFS), clinical progression‐free survival (CPFS), cancer‐specific survival (CSS) and overall survival (OS) after long‐term follow‐up of 10 years.

PATIENTS AND METHODS

In all, 164 patients who were assessed as clinical T3 prostate cancer by digital rectal examination (DRE), underwent RP and bilateral pelvic lymphadenectomy at Erasmus MC between 1977 and 2004 without neoadjuvant treatment. Preoperative staging computed tomography showed no signs of metastasis. Kaplan–Meier curves were constructed to show BPFS, CPFS, CSS and OS. Cox proportional hazard analysis was used to determine prognostic indicators of disease progression.

RESULTS

The mean (range) follow‐up was 100 (1–291) months. At 5, 10 and 15 years, BPFS was 50.4%, 43.0% and 38.3%, respectively, CPFS was 79.7%, 68.7% and 63.5%, CSS was 93.4%, 80.3% and 66.3%, and OS was 87.1%, 67.2% and 37.4%. Multivariate Cox proportional hazard analysis showed that surgical tumour grade, margin and node status were significant factors in CPFS and CSS. Surgical tumour grade, node status and preoperative PSA level were significant factors in BPFS

CONCLUSION

RP for clinically locally advanced prostate cancer may produce acceptable long‐term BPFS, which is comparable with published results of radiotherapy with adjuvant endocrine therapy. Pathological tumour grade and node status were significant predicting factors in BPFS and CPFS, as well as tumour‐specific survival after 100 months follow‐up.     

Prognostic significance of capsular invasion and capsular penetration in patients with clinically localized prostate cancer undergoing radical prostatectomy

One hundred thirty patients with an observed follow-up of more than 10 years after radical prostatectomy were restaged with regard to local extent of the tumor in relation to the prostate capsule. Of 112 patients with surgically staged negative pelvic lymph nodes, 62 had a tumor-free prostate capsule, 24 had capsular invasion without penetration, and 26 had tumors extending through the capsule of the prostate. Observed overall and disease-free 10-year-survival rates were 79% and 69.4%, respectively, in patients with absence of capsular involvement and 70.8% and 66.7%, respectively, in patients with capsular invasion alone. In patients with capsular penetration, however, the survival rates significantly decreased to 57.7% (P = 0.018) and to 38.5 (P = 0.017), respectively. The overall progression rate was found to be significantly higher in patients with tumors extending through the prostatic capsule (46.2%), as compared to those with absence of capsular involvement (21%; P = 0.014) as well as to those with capsular invasion alone without penetration (25%; P = 0.034). Thus, in contrast to capsular invasion alone, capsular penetration means a poor prognostic indicator, which accounts for a reduced survival expectancy and a higher progression rate following radical prostatectomy. Therefore, tumors with capsular invasion and those with capsular penetration should not be grouped together in the same tumor stage as done in the 1987 edition of the TNM tumor clasification system. © 1995 Wiley-Liss, Inc.     

前列腺根治术前肥胖相关的生化指标对前列腺癌患者预后的意义

目的:探讨前列腺癌根治术(RP)前肥胖相关生化指标[总胆汁酸、空腹血糖(FBG)、血尿酸、总胆固醇、甘油三酯、高密度脂蛋白(HDL)、低密度脂蛋白(LDL)]预测前列腺癌患者预后的价值.方法:选取635例前列腺癌手术患者,根据指南分为低、中、高危三组,在RP前检测并收集其肥胖相关生化指标.根据各指标的正常值,将各组前列...     

Surgical margin status after radical retropubic prostatectomy

This month there are two mini-reviews on aspects of prostate cancer. The first, from the USA, presents the implications of surgical margin status after radical prostatectomy and the potential role of adjuvant radiation therapy. The second, from the USA and Belgium, discusses the use of hormonal therapy for PSA-only recurrence of prostate cancer after previous local therapy. In the third mini-review, the condition known as hypoactive sexual desire disorder is described, and that it is often ignored or erroneously treated as erectile dysfunction suggests to the authors that education of doctors and patients is required. Finally, there is a mini-review of conventional and alternative methods for providing analgesia in renal colic.     

Association of circulating tumor cells with tumor‐related methylated DNA in patients with hormone‐refractory prostate cancer

Objectives: To assess whether circulating tumor cells with tumor‐related methylated DNA can be used to predict survival in patients with hormone‐refractory prostate cancer. Methods: Blood samples from 76 patients with hormone‐refractory prostate cancer were analyzed. Circulating tumor cells were enumerated with the CellSearch System in whole blood. This system was developed using an epithelial cell adhesion molecule antibody‐based immunomagnetic capture and automated staining methodology. Hypermethylation at adenomatosis polyposis coli, glutathione‐S‐transferase‐π, prostaglandin‐endoperoxide synthase 2, multidrug resistance 1 and Ras association domain family 1 isoform A was analyzed using a sensitive SYBR green methylation‐specific polymerase chain reaction. Patient charts were retrospectively examined. Results: Median overall survival time was 19.3 months (range 11–48). Of the 76 patients, 47 (62%) had five or more circulating tumor cells, with a median overall survival of 12.0 months compared with 26.0 months for patients with fewer than five circulating tumor cells (P < 0.001). Circulating tumor cells were detected in 36 of 39 (92%) patients with tumor‐related methylated DNA but only 11 of 37 (30%) patients without methylated DNA (P < 0.001). Thirty‐nine (51%) patients had one or more methylated marker. Their median overall survival time was 12.0 months compared with 48.0 months or more for patients without methylated DNA (P < 0.001). Prostate‐specific antigen‐doubling time, circulating tumor cells and methylated DNA were independent predictors of overall survival time. Conclusions: Hormone refractory prostate cancer patients with circulating tumor cells and/or tumor‐related methylated DNA show a significantly poorer outcome than those without these blood markers.     

经尿道前列腺电切术术后前列腺偶发癌腹腔镜下前列腺癌根治术临床观察

目的:探讨经尿道前列腺电切(TURP)术后发现前列腺偶发癌行腹腔镜下前列腺癌根治术的经验。方法:2005年4月至2011年12月收治既往行TURP术后发现前列腺癌的患者4例,免疫组化提示p504s阳性,3例在TURP术后3个月行腹腔镜下前列腺癌根治术,1例患者术后1.5月行腹腔镜下前列腺癌根治术。结果:4例手术顺利完成,均为经腹膜外途径。术后病理前列腺腺癌2例,Gleason评分为6～7分,1例报告为高级别上皮瘤变,1例未见癌。术后4例患者控尿功能好。随访1～79个月,4例患者无明显尿失禁,无转移表现,未出现ED现象。结论:在腹腔镜技术熟练的条件下,TURP术后前列腺偶发癌行腹腔镜下前列腺癌根治术疗效满意。     

经尿道前列腺电切术后的腹腔镜下前列腺癌根治术

目的 探讨TURP术后发现前列腺癌行腹腔镜下前列腺癌根治术的手术技巧及经验.方法 2007年4月至2010年7月收治既往行TURP术后发现前列腺癌的患者5例,平均年龄73岁,TURP术后平均(2.8±1.1)个月行腹腔镜下前列腺癌根治术.结果 5例手术顺利完成,其中经腹腔途径1例,经腹膜外途径4例.平均手术时间(227.6±38.4)min,术中平均出血(130.0±152.5)ml,术后平均随访(16.1±15.9)个月,最长40个月,5例均存活,控尿功能好,无明显尿失禁.结论 TURP术后行腹腔镜下前列腺癌根治术疗效满意,先前的TURP术增加了腹腔镜操作难度,但在腹腔镜技术熟练的条件下是可行的.

Abstract：

Objective To describe our experience in laparoscopic radical prostatectomy (LRP)for incidental prostate cancer after TURP. Methods From April 2007 to July 2010, 5 patients with incidental prostate cancer after TURP were treated with a mean age of 73 years. The patients underwent LRP (2.8± 1.1) months after TURP. Results The five cases of LRP were performed successfully, with 1 case of transperitoneal approach and 4 cases of extraperitoneal approach. Mean operation time was (227.6±38.4) min, mean blood loss was (130±152.5) ml, and the mean follow-up was (16.1 ± 15.9) months. All five patients survived, and their urinary function was good without any incontinence. Conclusions Previous TURP represents a technical challenge when performing LRP, but highly skilled surgeons trained to perform LRPs can handle it.     

Perioperative complications of radical retropubic prostatectomy in patients with locally advanced prostate cancer: a comparison with clinically localized prostate cancer

Radical prostatectomy (RP) continues to be an effective surgical therapy for prostate carcinoma, particularly for organ-confined prostate cancer (PCa). Recently, RP has also been used in the treatment of locally advanced prostate cancer. However, little research has been performed to elucidate the perioperative complications associated with RP in patients with clinically localized or locally advanced PCa. We sought to analyse the incidence of complications in these two groups after radical retropubic prostatectomy (RRP). From June 2002 to July 2010, we reviewed 379 PCa patients who underwent RRP in our hospital. Among these cases, 196 had clinically localized PCa (T_1a–T_2c: group 1), and 183 had locally advanced PCa (≥T_3a: group 2). The overall complication incidence was 21.9%, which was lower than other studies have reported. Perioperative complications in patients with locally advanced PCa mirror those in patients with clinically localized PCa (26.2% vs. 17.8%, P=0.91). Our results showed that perioperative complications could not be regarded as a factor to consider in regarding RP in patients with cT₃ or greater.