Outcomes of locally advanced prostate cancer： a single institution study of 209 patients in Japan

Aim:To investigate the outcomes for Asian populations with locally advanced/clinical stage Ⅲ prostate cancer(PCa)treated with currently prevailing modalities.Methods:We reviewed the record of 209 patients with clinical stage ⅢPCa,who were treated at Niigata Cancer Center Hospital between 1992 and 2003.Treatment options included hor-mone therapy-combined radical prostatectomy(RP HT),hormone therapy-combined external beam irradiation(EBRT HT)and primary hormone therapy(PHT).Results:The 5-and 10-year overall survival rates were 80.3%and 46.1% in all cohorts,respectively.The survival rates were 87.3% and 66.5% in the RP HT group,94.9% and70.0% in the EBRT HT group and 66.1% and 17.2% in the PHT group,respectively.A significant survival advantagewas found in the EBRT HT group compared with that in the PHT group(P<0.0001).Also,the RP HT group hadbetter survival than the PHT group(P=0.0107).The 5-and 10-year disease-specific survival rates for all cases were92.5% and 80.0%,respectively.They were 93.8% and 71.4% in the RP HT group,96.6% and 93.6% in theEBRT HT group and 88.6% and 62.3% in the PHT group,respectively.A survival advantage was found in theEBRT HT group compared with the PHT group(P=0.029).No significant difference was found in disease-specificsurvival between the EBRT HT and RP HT groups or between the RP HT and PHT groups.Conclusion:Althoughour findings indicate that radiotherapy plus HT has a survival advantage in this stage of PCa,we recommend therapiesthat take into account the patients'social and medical conditions for Asian men with clinical stage Ⅲ PCa.(Asian JAndrol 2006 Sep;8:555-561)     

A retrospective study of the treatment of locally advanced prostate cancer by six institutions in eastern and north-eastern Japan

OBJECTIVE: To investigate patients with locally advanced prostate cancer treated at six academic institutions in eastern and north-eastern Japan from 1988 to 2000, to facilitate the establishment of Japanese guidelines for the diagnosis and treatment of locally advanced prostate cancer. PATIENTS AND METHODS: The study included 391 eligible patients with locally advanced prostate cancer who were treated by radical prostatectomy (RP), radiotherapy and/or primary hormone therapy. Disease-specific survival rates for these patients were assessed in relation to their clinicopathological characteristics and the types of treatment they received. The Mann-Whitney U-test, Kruskal-Wallis, chi-square and log-rank test were used for statistical analysis, as appropriate. RESULTS: In all, 128 patient with lower prostate-specific antigen levels (P = 0.023) and/or better performance status (P = 0.001) had RP. Neoadjuvant hormone therapy before RP was the treatment in 68 (53%) of these 128 patients; 66 (52%) received immediate adjuvant hormone therapy. Of 87 patients treated with radiotherapy, 75 (86%) had external beam radiotherapy (EBRT) as the primary treatment with no brachytherapy, and 12 (14%) had brachytherapy as the primary method. Neoadjuvant hormone therapy was given to 56 of the 87 patients (64%); 48 (55%) received immediate adjuvant hormone therapy. Of the 176 patients treated with primary hormone therapy alone, combined androgen blockade and surgical or medical castration was the treatment in 76 (43%) and 85 (48%), respectively. Disease-specific survival rates at 5 years for patients treated with RP, EBRT and primary hormone therapy were 90%, 98%, and 89%, respectively. CONCLUSION: The treatments provided by the participating institutions did not differ significantly from those set out in European and American guidelines, and short-term disease-specific survival rates for each treatment did not differ significantly from those of historical controls. Further investigation may facilitate the establishment of Japanese guidelines for the diagnosis and treatment of locally advanced prostate cancer.     

Intermittent androgen suppression in patients with prostate cancer

OBJECTIVES: To evaluate intermittent androgen suppression (IAS) in patients with prostate cancer and to try to define predictive factors for biochemical progression. PATIENTS AND METHODS: From 1989 to 2001, 146 patients received IAS as a primary treatment for localized, advanced or metastatic prostate cancer (72 men) or as a treatment for prostate-specific antigen (PSA) recurrence after radical prostatectomy (RP) and/or radiation therapy (74 men). Androgen-deprivation treatment (ADT) was continued up to 6 months after PSA became undetectable or a nadir PSA level was reached. ADT was then re-instituted when the PSA level was> 4 ng/mL for patients who had RP or> 10 ng/mL for the others. RESULTS: After a mean (range) follow-up of 45.6 (12-196.9) months, 24 patients had biochemical progression. These patients were younger than those with no biochemical progression (67 vs 72 years, P = 0.004) and had a statistically higher Gleason score (7.21 vs 6.52, P = 0.01) and PSA level (111.1 vs 32.1 ng/mL, P = 0.05), and a shorter first phase without treatment (7.6 vs 11.2 months, P = 0.05). Overall 5-year metastatic disease free survival of 91.3%. The overall 5-year biochemical recurrence-free survival was 68%. Using multivariate analysis, a Gleason score of >or= 8 (P = 0.021), first-phase duration with no treatment of < 1 year (P = 0.044), positive lymph nodes or metastatic disease at the time of starting IAS (P = 0.023) and age < 70 years (P = 0.037) were the strongest predictors of biochemical progression. CONCLUSION: IAS appeared to be a feasible treatment; the best candidates being those aged> 70 years with localized prostate cancer and a Gleason score of 相似文献   

Radical prostatectomy vs radiation therapy and androgen-suppression therapy in high-risk prostate cancer

Study Type – Therapy (retrospective cohort analysis) Level of Evidence 2b What's known on the subject? and What does the study add? Prostate cancer is generally considered to be high risk when the prostate‐specific antigen (PSA) concentration is >20 ng/mL, the Gleason score is ≥8 or the American Joint Commission on Cancer (AJCC) tumour (T) category is ≥2c. There is no consensus on the best treatment for men with prostate cancer that includes these high‐risk features. Options include external beam radiation therapy (EBRT) with androgen suppression therapy (AST), treatment with a combination of brachytherapy, EBRT and AST termed combined‐modality therapy (CMT) or radical prostatectomy (RP) followed by adjuvant RT in cases where there are unfavourable pathological features, e.g. positive surgical margin, extracapsular extension and seminal vesicle invasion. While outcomes for both approaches have been published independently these treatments have not been compared in the setting of a prospective RCT where confounding factors related to patient selection for RP or CMT would be minimised. These factors include age, known prostate cancer prognostic factors and comorbidity. RCTs that compare RP to radiation‐based regimens have been attempted but failed to accrue.

OBJECTIVE

• ? To assess the risk of prostate cancer‐specific mortality after therapy with radical prostatectomy (RP) or combined‐modality therapy (CMT) with brachytherapy, external beam radiation therapy (EBRT) and androgen‐suppression therapy (AST) in men with Gleason score 8–10 prostate cancer.

PATIENTS AND METHODS

• ? Men with localised high‐risk prostate cancer based on a Gleason score of 8–10 were selected for study from Duke University (285 men), treated between January 1988 and October 2008 with RP or from the Chicago Prostate Cancer Center or within the 21st Century Oncology establishment (372) treated between August 1991 and November 2005 with CMT.
• ? Fine and Gray multivariable regression was used to assess whether the risk of prostate cancer‐specific mortality differed after RP as compared with CMT adjusting for age, cardiac comorbidity and year of treatment, and known prostate cancer prognostic factors.

RESULTS

• ? As of January 2009, with a median (interquartile range) follow‐up of 4.62 (2.4–8.2) years, there were 21 prostate cancer‐specific deaths.
• ? Treatment with RP was not associated with an increased risk of prostate cancer‐specific mortality compared with CMT (adjusted hazard ratio [HR] 1.8, 95% confidence interval [CI] 0.6–5.6, P= 0.3).
• ? Factors associated with an increased risk of prostate cancer‐specific mortality were a PSA concentration of <4 ng/mL (adjusted HR 6.1, 95% CI 2.3–16, P < 0.001) as compared with ≥4 ng/mL, and clinical category T2b, c (adjusted HR 2.9; 95% CI 1.1–7.2; P= 0.03) as compared with T1c, 2a.

CONCLUSION

• ? Initial treatment with RP as compared with CMT was not associated with an increased risk of prostate cancer‐specific mortality in men with Gleason score 8–10 prostate cancer.

     

Adjuvant versus salvage radiation therapy for prostate cancer and the risk of death

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To investigate whether salvage radiation therapy (RT) for prostate‐specific antigen (PSA) failure can provide the same result as adjuvant RT, which decreases the risk of all‐cause mortality (ACM) for men with positive margins (R1), or extra‐capsular or seminal vesicle extension (pT3).

METHODS

We studied 1638 men at Duke University who underwent radical prostatectomy for unfavourable‐risk prostate cancer and whose postoperative PSA was undetectable. Cox regression was used to evaluate whether salvage vs adjuvant RT in men with a rapid (<10 months) or slow (≥10 months) PSA doubling time (DT) was associated with the risk of ACM, adjusting for adverse features (pT3, R1, Gleason score 8–10), age, preoperative PSA level, comorbidity and hormonal therapy use.

RESULTS

Despite fewer men with two or more adverse features (61 vs 82%; P = 0.016), salvage for a rapid PSA DT vs adjuvant RT increased the risk of ACM [adjusted hazard ratio (AHR) = 3.42; 95% confidence interval (CI) = 1.27–9.20; P = 0.015]. There was no difference (AHR = 1.39; 95% CI = 0.50–3.90; P = 0.53) in the risk of ACM among men who received salvage for a slow PSA DT or adjuvant RT. Nearly all (90%) men with a slow PSA DT had Gleason score ≤7 and the majority (59%) had at most pT3 or R1 disease.

CONCLUSION

Radiation therapy after PSA failure as compared with adjuvant RT was not associated with an increased risk of ACM in men with Gleason score ≤7 and pT3R0 or pT2R1 disease.     

Endocrine therapy with or without radical prostatectomy for T1b-T3N0M0 prostate cancer

BACKGROUND: We retrospectively compared the 5-year survival rates of T1b-T3N0M0 prostate cancer patients treated either by endocrine therapy plus radical prostatectomy or endocrine therapy alone. METHODS: Clinical T1b-T3N0M0 prostate cancer patients were enrolled at 104 institutions in Japan. They were assigned to study 1 (n = 176), if they were indicated to prostatectomy, if not indicated, they were assigned to study 2 (n = 151). The indication of prostatectomy was based on the clinical judgement of physicians and/or patients. Those assigned to study 1 underwent prostatectomy and adjuvant endocrine therapy with or without preoperative androgen deprivation. Those assigned to study 2 were treated with leuprorelin acetate with or without chlormadinone acetate. They were followed-up every 3 months until death or for 5 years and over. RESULTS: Those assigned to study 1 were younger (mean age 67.2 vs 75.7 years), less advanced in clinical stage, and had lower prostate specific antigen levels (mean 43.8 vs 103.6 ng/mL). Death for any reason was observed less frequently in study 1 (n = 29, 16%) than study 2 (n = 50, 33%), and the 5-year overall survival rate was higher in study 1 (87 vs. 68%). However, prostate cancer deaths were comparatively seldom (9% in study 1 and 7% in study 2), resulting in the identical 5-year cause specific survival rate in both study groups (91%). In both study groups the overall survival was almost equal to the natural survival of age-matched men. CONCLUSIONS: Endocrine therapy offers a reasonable survival rate in T1b-T3 prostate cancer patients within a 5-year follow-up. Observation will be extended to determine 10-year outcomes.     

Salvage radical prostatectomy for recurrent prostate cancer after radiation therapy

Salvage radical prostatectomy is considered for patients with locally recurrent prostate cancer after external beam radiotherapy. Between 2001 and 2004, 32 men treated with curative intent with radiotherapy for prostate cancer were subsequently treated with salvage surgery for clinically localized prostate cancer. We assessed the morbidity associated with this procedure and the outcome of the patients. Thirty-two patients underwent salvage radical prostatectomy. Initial pre-radiation median prostate-specific antigen was 13 ng/ml. Pre-radiation disease was clinical stage T1b in five cases, T2a in 10, T2b in 10 and T3a in seven. Mean operative time was 122 minutes, intraoperative blood loss was 550 ml and hospital stay and catheterization time were 5 and 12 days, respectively. There was biochemical failure in eight patients after salvage radical prostatectomy and 24 patients are biochemical non evidence of disease (bNED). In recurrent prostate local disease with prostate-specific antigen <10 ng/ml and life expectancy greater than 10 years, salvage radical prostatectomy is a reasonable treatment option.     

Understanding the pathological features of focality, grade and tumour volume of early-stage prostate cancer as a foundation for parenchyma-sparing prostate cancer therapies: active surveillance and focal targeted therapy

What's known on the subject? and What does the study add? The recent shift of pathological stage migration towards earlier forms suggested great potential for the introduction of focal therapy into urological practice. A body of the literature showed increasing frequency of unilateral and unifocal lesions that can be efficiently treated with tumour ablative techniques. The internal panel of experts has done a comprehensive review of the largest mostly single institution studies and their own trials with the aim of evaluating a value of main pathological features of early stage prostate cancer as a background to developing a concept of focal therapy. Analysis data including latest developments will help to better understand the purpose, meaning and patient selection of different kinds of focal targeted ablation of prostate cancer.

OBJECTIVE

? To better understand the biology and incidence of the cancer foci within the prostate through a comprehensive literature review and a review of our own data, to establish the current level of knowledge regarding the pathological foundation for active surveillance (AS) or focal therapy (FT).

PATIENTS AND METHODS

? A systematic review of the literature was performed, searching PubMed® from January 1994 to July 2009. ? Electronic searches were limited to the English language using the keywords ‘prostate cancer’, ‘histopathology’, ‘radical prostatectomy’, ‘pathological stage’ and ‘focal therapy’. ? The authors’ own data were also analysed and are presented.

RESULTS

? Recent data have shown a significant pathological stage migration towards earlier disease comprising unilateral pT2a/b prostate cancer (PCa). ? The cancer volume of the clinically significant tumour (index lesion) has been proposed as a driving force of PCa progression and therefore should be identified and treated at an early stage. ? In general, most satellite lesions do not appear to be life‐threatening. ? Other pathological features, such as Gleason score, extraprostatic extension and the spatial distribution of PCa within the prostate, remain important selective criteria for AS or FT.

CONCLUSION

? The present study reviews the current knowledge of cancer focality, aggression and tumour volume. Further research is needed to better understand the biologic behaviour of each of the tumour foci within a cancerous prostate, and to employ this information to selected patients for no therapy (AS), parenchyma‐preserving approaches (FT) or whole gland radical therapy.     

腹腔镜下根治性前列腺切除术治疗TURP术后偶发前列腺癌的配对分析

目的探讨经尿道前列腺切除术(TURP)后偶发前列腺癌行腹腔镜根治性前列腺切除术(LRP)在外科手术、肿瘤学及尿控等方面的影响。方法回顾性分析自2012年1月至2017年12月北部战区总医院泌尿外科285例接受了LRP治疗的男性患者的临床资料。其中37例患者术前已接受过TURP治疗(TURP组),另外选取37例没有接受过TURP的患者与之配对(对照组)。运用相关统计学方法比较两组患者在围手术期并发症、外科手术、肿瘤及尿控等方面的差异。结果两组患者在年龄、体质指数、血清前列腺特异性抗原(PSA)水平以及术前和术后Gleason评分等方面无统计学差异。TURP组与对照组相比患者出血量较多[(555.4±238.4)vs.(237±111.3)mL,P<0.05]、手术时间较长[(256.7±65.3)vs.(215.2±62.3)min,P<0.05]、输血概率大(5.4%vs.0.0%,P<0.05)、并发症发生率较高(43.2%vs.13.5%,P<0.05)。TURP组的手术阳性切缘率与对照组相比(35.1%vs.24.3%)差异无统计学意义(P=0.353)。手术后12个月的尿控率两组相似,但在3个月时TURP组的尿控率较低(40.5%vs.70.2%)。在平均随访36.5个月后,TURP组和对照组分别有10.8%和8.1%的患者出现生化复发,差异无统计学意义。结论TURP后LRP需要更长的手术时间、失血更多、并发症发生率更高和更差的短期尿控,但两组患者远期肿瘤切除效果及远期尿控没有差异,所以TURP后行LRP的疗效是安全可靠的。     

The role of surgery in high-risk localised prostate cancer

? The optimal management of high-risk localised prostate cancer is a major challenge for urologists and oncologists. It is clear that multimodal therapy including radical local treatment is needed in these men to achieve the best outcomes. ? External beam radiotherapy (EBRT) is an essential component of therapy either as a primary or adjuvant treatment. However, the role of radical prostatectomy (RP) is more controversial. Both methods are currently valid therapy options. ? There have been many individual studies of EBRT and RP in high-risk disease, but no good quality large prospective randomized trials. ? In EBRT, combination with neoadjuvant plus long-term adjuvant androgen-deprivation therapy (ADT) has been conclusively shown to improve outcomes and is widely considered the standard of care. ? However, the role of RP has achieved recent prominence with several important studies. Published data from prospective randomized trials in patients after RP have shown that in men with adverse pathological features at surgery, the addition of adjuvant RT improves biochemical-free and progression-free survival. ? More recently, studies from large-volume centres comparing EBRT and RP have provided intriguing suggestions of better outcomes with RP as the primary treatment. ? An important question therefore, is which of the two methods provides the best outcome in men with localised high-risk disease. Crucially, does the combination of RP and selective adjuvant EBRT provide clinically significant better outcomes compared with EBRT alone? ? In this review we discuss the current evidence for the role of RP for high-risk localised prostate cancer and define the parameters and urgent need for a prospective trial to test the role of surgery for this group of patients.     

Clinical stage T1c prostate cancer: pathologic outcomes following radical prostatectomy in black and white men

BACKGROUND: The incidence of prostate cancer in black men is 50% to 70% higher than among age-matched white men. Black men have a twofold higher mortality rate and overall tend to have higher serum prostate-specific antigen (PSA) levels than white men. To determine whether racial differences exist in men whose prostate cancer was diagnosed based solely on an elevated serum PSA level, we compared clinical and pathologic features in black and white men undergoing radical prostatectomy (RP) for clinical stage T1c prostate cancer. METHODS: We used a prospectively collected database to identify all men undergoing RP for clinical T1c prostate cancer between July 1995 and October 2000. A total of 129 consecutive men (56 black men and 73 white men) were compared for age at diagnosis, serum PSA level, biopsy Gleason score, pathologic stage, RP specimen Gleason score, incidence of lymph node metastasis, and incidence of positive surgical margins. RESULTS: Statistically significant differences were not found by race in patients' ages, serum PSA levels, biopsy Gleason score, pathologic stage, incidence of lymph node metastases, or incidence of positive surgical margins. The RP specimen Gleason score was more heterogeneous in black men than white men (P=0.02). CONCLUSIONS: Racial differences in the incidence and mortality rate of prostate cancer are well known, but differences in the clinical and pathologic features between black and white men with prostate cancer identified solely based on an elevated serum PSA level with negative results on digital rectal examination (clinical stage T1c ) have been poorly studied. Our results suggest that men with clinical stage T1c prostate cancer have similar clinical and pathologic findings regardless of race. These results suggest that early-detection programs using serum PSA testing for prostate cancer in black men potentially can result in improvements in prostate cancer outcomes in this high-risk group.     

A long-term study of the efficacy of treatment of localized prostate cancer

This paper presents a retrospective comparison of patients undergoing treatment for clinically localized prostate cancer. We reviewed the age, grade, and stage at diagnosis as well as the survival and recurrence rates of 222 patients treated for carcinoma of the prostate with either radical prostatectomy (RP) or radiotherapy (XRT) at four Army medical centers. Mean follow-up was 8.02 years (range 0.026–32.5 years). Stage and grade were similar in patients receiving either RP or XRT. Kaplan-Meier estimates showed that patients who underwent RP had a significantly greater disease-specific survival (p = 0.0001) and a significantly lower rate of distant metastases (p = 0.006) than did those who received XRT. There was no significant difference in the rate of local progression (p = 0.276) or in the mean time to local progression (XRT = 3.5, RP = 4.0 years) or to distant metastases (XRT = 3.79, RP = 4.52 years). Cox proportional hazards model incorporating age, stage, grade, and treatment type demonstrated that those patients who received XRT had more than two times the risk of dying of their disease than did those who underwent RP (risk ratio = 2.37; 95% confidence interval = 1.49–3.76). These data in similar groups of patients suggest that metastasis-free survival is improved in those who receive RP compared with XRT and that this translates into an enhanced survival advantage. Further study of larger groups of patients stratified by risk factors in randomized, prospective trials with longer follow-up will improve our ability to determine the best treatment for clinically localized prostate cancer.     

腹腔镜下经腹膜外前列腺癌根治术(附25例报告)

目的 探讨经腹膜外途径腹腔镜下前列腺癌根治术在治疗前列腺癌中的价值。方法 2003年6月至2006年1月我院共收治前列腺癌患者25例，年龄62-78岁（平均68．5岁），病史2周-6年，所有患者均接受腹腔镜下前列腺癌根治术。结果 所有手术均顺利完成，手术时间210-380min，半均245min，术中出血量500-1200mL，（平均850mL，），所有患者均于术后2周拔除导尿管。3例出现尿漏，于拔管前消失；3例术后出现轻度尿失禁，经辅助治疗后好转，术后PSA0-0．08μg／L，随访1-10月，未见肿瘤复发。结论 腹腔镜下经腹膜外前列腺癌根治术是一种安全有效的治疗方法，术中视野清晰、止血可靠、创伤小、腹腔并发症少、患者住院时间短、恢复快，值得临床推广。