Can Anesthetic Technique for Primary Breast Cancer Surgery Affect Recurrence or Metastasis?

Background: Regional anesthesia is known to prevent or attenuate the surgical stress response; therefore, inhibiting surgical stress by paravertebral anesthesia might attenuate perioperative factors that enhance tumor growth and spread. The authors hypothesized that breast cancer patients undergoing surgery with paravertebral anesthesia and analgesia combined with general anesthesia have a lower incidence of cancer recurrence or metastases than patients undergoing surgery with general anesthesia and patient-controlled morphine analgesia.

Methods: In this retrospective study, the authors examined the medical records of 129 consecutive patients undergoing mastectomy and axillary clearance for breast cancer between September 2001 and December 2002.

Results: Fifty patients had surgery with paravertebral anesthesia and analgesia combined with general anesthesia, and 79 patients had general anesthesia combined with postoperative morphine analgesia. The follow-up time was 32 +/- 5 months (mean +/- SD). There were no significant differences in patients or surgical details, tumor presentation, or prognostic factors. Recurrence- and metastasis-free survival was 94% (95% confidence interval, 87-100%) and 82% (74-91%) at 24 months and 94% (87-100%) and 77% (68-87%) at 36 months in the paravertebral and general anesthesia patients, respectively (P = 0.012).     

Salvage Surgery in Patients with Local Recurrence After Radical Prostatectomy

BackgroundSince the introduction of prostate-specific membrane antigen (PSMA) positron emission tomography (PET) imaging, isolated local recurrence after radical prostatectomy (RP) can be delineated accurately.ObjectiveTo describe and evaluate surgical technique, biochemical response, and therapy-free survival (TFS) after salvage surgery in patients with local recurrence in the seminal vesicle bed.Design, setting, and participantsWe retrospectively assessed 40 patients treated with open salvage surgery in two centres (11/2014-02/2020). All patients presented with biochemical recurrence (BCR) after RP with a singular local recurrence at PSMA PET imaging. Thirty-three (82.5%) patients received previous salvage radiation therapy.Surgical procedureOpen salvage surgery with PSMA radioguidance.MeasurementsProstate-specific antigen (PSA) nadir and percentage of patients with complete biochemical response (cBR) without further treatment (PSA < 0.2 ng/ml) after 6–16 wk were assessed. BCR-free survival and TFS were calculated using Kaplan-Meier estimates. Clavien-Dindo complications were evaluated.Results and limitationsPrior to salvage surgery, median PSA was 0.9 ng/ml (interquartile range [IQR]: 0.5–1.7 ng/ml). Postoperatively, median PSA nadir was 0.1 ng/ml (IQR: 0–0.4 ng/ml). In 31 (77.5%) patients, cBR was observed. During the median follow-up of 24.4 months, 22 (55.0%) patients experienced BCR and 12 (30.0%) received further therapy. At 1 yr of follow-up, BCR-free survival rate was 62.2% and TFS rate was 88.3%. Three (7.5%) Clavien-Dindo grade III complications were observed. The main limitations are the retrospective design, short follow-up, and lack of a control group.ConclusionsSalvage surgery of local recurrence within the seminal vesicle bed is feasible. It may present an opportunity in selected, locally recurrent patients to prolong BCR-free survival and increase TFS. Further studies are needed to confirm our findings.Patient summaryWe looked at the outcomes from prostate cancer patients with locally recurrent disease after radical prostatectomy and radiotherapy. We found that surgery in well-selected patients may be an opportunity to prolong treatment-free survival.     

Prostate Cancer Biochemical Recurrence Rates After Robotic-Assisted Laparoscopic Radical Prostatectomy

Background and Objectives:

To determine prostate cancer biochemical recurrence rates with respect to surgical margin (SM) status for patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP).

Methods:

IRB-approved radical prostatectomy database was queried. Patients were stratified as low, intermediate, and high risk according to D’Amico''s risk classification. Postoperative prostate-specific antigen (PSA) values were obtained every 3 mo for the first year, then biannually and annually thereafter. Biochemical recurrence was defined as ≥0.2ng/mL. Patients receiving adjuvant or salvage treatment were included. Positive surgical margin was defined as presence of cancer cells at inked resection margin in the final specimen. Margin presence (negative/positive), margin multiplicity (single/multiple), and margin length (≤3mm focal and >3mm extensive) were noted. Kaplan-Meier curves of biochemical recurrence-free survival (BRFS) as a function of SM were generated. Forward stepwise multivariate Cox regression was performed, with preoperative PSA, Gleason score, pathologic stage, prostate gland weight, and SM as covariates.

Results:

At our institution, 1437 patients underwent RALP (2003-2009). Of these, 1159 had sufficient data and were included in our analysis. Mean follow-up was 16 mo. Kaplan-Meier curves demonstrated significant increase in BRFS in low-risk and intermediate-risk groups with negative SM. Overall BRFS at 5 y was 72%. Gleason score, pathologic stage, and SM status were significant prognostic factors in multivariate analysis.

Conclusions:

Negative surgical margins resulted in lower biochemical recurrence rates for low-risk and intermediate-risk groups. Multifocal and longer positive margins were associated with higher biochemical recurrence rates compared with unifocal and shorter positive margins. Documenting biochemical recurrence rates for RALP is important, because this treatment for localized prostate cancer is validated.     

Risk-Adjusted Hazard Rates of Biochemical Recurrence for Prostate Cancer Patients after Radical Prostatectomy

Background

Current prostate cancer (PCa) follow-up guidelines do not account for the risk of disease relapse.

Objective

To examine the annual hazard rate (anHR) of biochemical recurrence (BCR) according to risk strata in patients treated with radical prostatectomy (RP) for localised PCa. These rates might be used to devise a risk-adjusted follow-up.

Design, setting, and participants

From January 1992 to December 2005, 2911 patients underwent RP for localised PCa in one institution. This cohort was used to identify three distinct risk groups for BCR. A cohort of 2875 patients operated on in a second institution was used for validation purpose.

Intervention

RP, prostate-specific antigen (PSA) tests.

Measurements

Cox regression models addressing BCR were used to identify significant predictors and cut-offs for risk group stratification. The anHR for BCR was calculated (number of events divided by number of patients at risk) for each risk group.

Results and limitations

Three risk groups could be identified: (1) low risk (23.7%), defined as PSA <11 ng/ml plus clinical stage T1c plus pathological Gleason <6 plus negative surgical margins plus organ confined tumour; (2) high risk (18.9%), defined as PSA >22 ng/ml or seminal vesicle invasion or pathological Gleason sum >8 or lymph node invasion or clinical stage T3; and (3) intermediate risk (57.4%), defined as all other patients. The anHR for the low-risk groups remained very low throughout follow-up (0–2.6). The anHR in the intermediate-risk group was initially low but remained elevated (1.3–7.2). The anHR for the high-risk group was initially markedly high (up to 32) and remained elevated during follow-up.

Conclusions

Annual hazard rates of BCR differ according to risk strata. These data might be used to devise a risk-adjusted follow-up protocol. Low-risk patients appear to need less frequent follow-up, whereas high-risk patients might need to be followed more frequently, relative to the current recommendations.     

Prostate Cancer Recurrence in Kidney Transplant Recipient 15 Years After Radical Prostatectomy: A Case Report

Incidence of malignant tumors in kidney transplant recipients is higher than nontransplanted population due to many factors, such as immunosuppression therapy and complex donor-recipient interaction. Genitourinary malignancies have been reported as the second most common malignancy in kidney transplant recipients. In this regard, prostate cancer is the most common neoplasm. Herein, we describe a rare case of prostate cancer recurrence after 15 years in a patient who underwent kidney transplant after radical prostatectomy.     

Costs of Radical Prostatectomy for Prostate Cancer: A Systematic Review

ContextRobot-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted as a new approach for radical prostatectomy (RP) in patients with prostate cancer (PCa). The use of new technology may increase costs for RP.ObjectiveTo summarize data on direct costs of various approaches to RP and to discuss the consequences of cost differences.Evidence acquisitionA systematic literature search was performed in March 2012 using the PubMed, Web of Science, and Cochrane Library databases. A complex search strategy was applied. Articles were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Articles reporting on direct costs of RP (open retropubic [RRP], radical perineal [RPP], laparoscopic [LRP], RALP) in men with clinically localized PCa were eligible for study inclusion.Evidence synthesisOf 1218 articles initially screened by title, the multistep, systematic search identified 11 studies presenting direct costs of different approaches to RP. Of the 11 studies, 7 compared the costs of different RP approaches. Minimally invasive RP (MIRP) (ie, LRP or RALP) was more expensive than RRP in most studies, mainly due to increased surgical instrumentation costs. In the comparative studies, costs ranged from (in US dollars) $5058 to $11 806 for MIRP and from $4075 to $6296 for RRP, with RALP having the highest direct costs. In one study applying standardized, health economic-evaluation criteria, RALP was not found to be cost effective. Limitations of this review include significant differences in observational study designs and an absence of prospective comparative studies. Moreover, there are limited post-RP data on the costs of adjuvant treatments and other health care–related expenses after PCa surgery.ConclusionsFew studies compared direct costs of different approaches to RP. The use of new technology, particularly RALP, results in added costs for the procedure. Cost effectiveness of new technologies should be assessed before widespread adoption. To date, in the lone study to evaluate this, RALP was not found to be cost effective from a health care, economic standpoint. However, longer follow-up of patients is required to better evaluate its impact on overall costs and quality of PCa care.     

Radical Redo Surgery for Local Rectal Cancer Recurrence Improves Overall Survival: A Single Center Experience

Background  To date, the survival benefit of redo surgery in locally recurrent rectal adenocarcinoma remains unclear. Study Design  In an institutional study, operations for recurrence were retrospectively analyzed. Survival was calculated using the Kaplan–Meier plot and Cox regression analysis. Results  A total of 72 patients with local recurrence were explored or resected. In 38 patients, there was synchronous distant organ recurrence. Forty-five of 72 were re-resected and in 37 of 45 cases, R0 situations were achieved. In 11 of 38 metastasized patients, both local and distant organ recurrence were successfully removed. For obtaining tumor control, resections of inner genitals, bladder, and sacral bone were necessary in 10, 4, and 11 patients, respectively. Survival was better for patients re-resected with a median overall survival of 54.9 months, as compared with 31.1 months among non-resected patients (p = 0.0047, log-rank test). Subgroup analysis revealed that a benefit of re-resection was observed to a lesser extent in synchronous local and in distant disease. Cox analysis showed that initial Dukes stage and complete resections of local recurrences were independently determining prognosis (relative risk 1.762 and 0.689, p = 0.008 and p = 0.002, respectively). Conclusions  Radical surgery for local recurrence can improve survival if complete tumor clearance is achieved, and concomitant distant tumor load should not principally preclude re-resection.     

Topography of Prostate Cancer Recurrence After Radiation Therapy: A Detailed Mapping Study of Salvage Radical Prostatectomy Specimens

In men who do not respond to initial radiation therapy, accurate knowledge of the site of cancer recurrence or persistence is necessary to understand treatment failure. We evaluated the pathologic characteristics of recurrent/persistent prostate cancer with tumor maps from the whole-mount slides of salvage radical prostatectomies performed between 2000 and 2014. Of 216 consecutive patients, detailed tumor maps were available for 77. Sixty-nine patients (90%) were found to have tumor in the apex, of which 46% occurred in the most apical 3 mm. Fifty-three patients (69%) had tumors at a distance of ≤5 mm from the urethra. Five patients had tumor directly involving the urethra, all of whom had urethral invasion at the apex. Seminal vesicle involvement was seen in 32 patients (42%), two of whom had tumor only in the seminal vesicles. Sixty-two patients (81%) had tumors in the distal apex, periurethral area, or seminal vesicles, that is, areas that are not routinely biopsied. Targeting these areas could improve the accuracy of biopsy when cancer recurrence is suspected.

Ki-67 Expression is a Prognostic Marker of Prostate Cancer Recurrence after Radical Prostatectomy

Purpose

We assessed the cellular proliferation of clinically localized prostate cancer by immunohistochemistry using the monoclonal antibody MIB to Ki-67 antigen in an attempt to identify associations between proliferative indexes and disease progression following radical prostatectomy.

Materials and Methods

Ki-67 proliferative antigen was evaluated using MIB 1 monoclonal antibody in archival paraffin embedded radical prostatectomy specimens from 180 patients followed for 1 to 9 years (mean 4.4). The percentage of tumor nuclei expressing Ki-67 antigen was measured and assigned an MIB 1 score (none or rare-negative, 1+-low score and 2 to 4+-high score) and analyzed for prostate specific antigen, stage, age, race, grade and serological recurrence postoperatively.

Results

There was a significant association between MIB 1 score and nuclear grade (p less than 0.001), Gleason score (p less than 0.001) and pathological stage (p = 0.01). Patients with a high MIB 1 score had earlier progression and a lower 5-year recurrence-free survival rate (44 percent) than those with negative MIB 1 scores (71 percent, p less than 0.001). In multivariate Cox regression analysis with backward elimination, pathological stage (p less than 0.01), pretreatment prostate specific antigen (p = 0.04) and MIB 1 score (p = 0.05) were statistically significant predictors of disease-free survival, and patients with a high MIB 1 score were 3.1 times as likely to have recurrence as those with a negative score. Controlling for stage, patients with organ confined disease and a high MIB 1 score had a lower 5-year disease-free survival rate (68 percent) than those with a low MIB 1 score (95 percent, p greater than 0.01).

Conclusions

Proliferative activity as measured by the Ki-67 proliferative antigen, MIB 1, appears to be a prognostic marker of recurrent prostate cancer after radical prostatectomy.     

Hospitalization Costs for Radical Prostatectomy Attributable to Robotic Surgery

Background

With health technology innovation responsible for higher health care costs, it is essential to have accurate estimates regarding the differential costs between robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP).

Objective

To describe the total hospitalization costs attributable to robotic and open surgery for radical prostatectomy (RP).

Design, setting, and participants

Using a population-based cohort by merging the Nationwide Inpatient Sample (NIS) and the American Hospital Association (AHA) survey from 2006 to 2008, we identified 29 837 prostate cancer patients who underwent RP.

Interventions

ORP and RARP.

Outcome measurements and statistical analysis

The primary outcome was total hospitalization costs adjusted to year 2008 US dollars. Generalized estimating equations were used to identify patient and hospital characteristics associated with total hospitalization costs and to estimate costs of ORP and RARP adjusted for case mix and hospital teaching status, location, and annual case volume.

Results and limitations

Overall, 20 424 (68.5%) patients were surgically treated with RARP, and 9413 (31.5%) patients underwent ORP. Compared to ORP, patients undergoing RARP had shorter median length of stay (1 d vs 2 d; p < 0.001) and were less likely to experience any postoperative complications (8.2% vs 11.3%; p < 0.001). However, patients undergoing RARP had higher median hospitalization costs ($10 409 vs $8862; p < 0.001). After adjusting for patient and hospital features, RARP was associated with higher total hospitalization costs compared to ORP ($11 932 vs $9390; p < 0.001). Our results are limited by a study design using retrospective population-based data.

Conclusions

Despite RARP having lower complications and shorter length of stay than ORP, total hospitalization costs are higher for patients treated with RARP compared with those treated with ORP.     

Robot-Assisted Radical Prostatectomy After Previous Prostate Surgery

Background and Objectives:

Our objective is to clarify the effect of previous transurethral resection of the prostate (TURP) or open prostatectomy (OP) on surgical, oncological, and functional outcomes after robot-assisted radical prostatectomy (RARP).

Methods:

Between August 1, 2009, and March 31, 2013, 380 patients underwent RARP. Of these, 25 patients had undergone surgery for primary bladder outlet obstruction (TURP, 20 patients; OP, 5 patents) (group 1). A match-paired analysis was performed to identify 36 patients without a history of prostate surgery with equivalent clinicopathologic characteristics to serve as a control group (group 2). Patients followed up for 12 months were assessed.

Results:

Both groups were similar with respect to preoperative characteristics, as mean age, body mass index, median prostate-specific antigen, prostate volume, clinical stage, the biopsy Gleason score, D''Amico risk, the American Society of Anesthesiologists (ASA) classification score, the International Prostate Symptom Score, continence, and potency status. RARP resulted in longer console and anastomotic time, as well as higher blood loss compared with surgery-naive patients. We noted a greater rate of urinary leakage (pelvic drainage, >4 d) in group 1 (12% vs 2,8%). The anastomotic stricture rate was significantly higher in group 1 (16% vs 2.8%). No difference was found in the pathologic stage, positive surgical margin, and nerve-sparing procedure between the groups. Biochemical recurrence was observed in 12% (group 1) and 11.1% (group 2) of patients, respectively. No significant difference was found in the continence and potency rates.

Conclusions:

RARP after TURP or OP is a challenging but oncologically promising procedure with a longer console and anastomosis time, as well as higher blood loss and higher anastomotic stricture rate.     

腹膜外径路腹腔镜前列腺癌根治术(附65例报告)

目的:探讨腹膜外径路腹腔镜PCa根治术的初步体会。方法:经腹膜外径路进行腹腔镜PCa根治术65例。结果:64例(98.5%)成功,手术时间100～440min,平均172min。出血量150～800ml,平均340ml,7例(10.8%)患者输红细胞悬液2～4U。1例术中发生直肠损伤,2例术后发生尿外渗。6例(9.2%)患者术后病理提示切缘阳性。58例(89.2%)患者术后3个月尿控良好。结论:腹膜外径路腹腔镜PCa根治术是安全、可行的。且因避免了术中、术后对腹腔内肠管的干扰,降低了手术并发症,利于术后患者的恢复,值得在临床推广应用。