Prostate Cancer: Prostate cancer can metastasize after surgery with even low PSAs rarely

UroToday – Prostate Cancer Progression in the Presence of Undetectable or Low Serum Prostate-Specific Antigen Level

beige_quote.bmpOverall, 10 (22%) had undetectable serum PSA levels and 30 patients (65%) had PSA of less than 1ng/ml at the time of disease progression. Of the 25 men who had undergone radical prostatectomy, 7 were hormone na�ve at the time of progression. The median increase in PSA was 0.25ng/ml at the time of progression. In 19 patients, there was no increase in PSA from the nadir level at the time of progression. The median PSA doubling time for the cohort was 7.6 months.
Atypical variants of CaP were identified in 21 of 46 patients; including 9 with ductal CaP, 8 with small cell variant, 2 with neuroendocrine tumors and 2 men with sarcomatoid tumors. Metastatic progression was most commonly in the bones, followed by liver, retroperitoneal lymph nodes and lungs. Progression was identified by bone scans, CT or MRI.
In patients with CaP variants, monitoring in addition to PSA may have value.

Cancer 2006;109(2): 198-204

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Prostate Cancer Surgery: Open vs. Laparoscopic Prostatecomy Results

UroToday – EAU 2007 ABST[750] – Radical Prostatectomy: A non-randomized Comparative Analysis of Outcomes between the Open and Laparoscopic Approach

Conclusions:
In our institution and during the study period, laparoscopic and retropubic radical prostatectomy provided comparable oncological efficacy, functional and morbidity outcomes.
The laparoscopic approach was associated with lesser blood loss and transfusion rate and higher postoperative hospital visits and readmission rate.

This was a good study by a high volume prostate cancer hospital.
I thought they had a higher rate of laparoscopic readmission rates that I would have expected, although the transfusion rate and blood loss was much less in the lap group.
I look forward to seeing how the robotic results compare to the open and lap data.

Dr. Menon at EAU meeting

UroToday – EAU 2007 – AUA Lecture at the EAU 2007 – “The Role of Robotics in Urology”

The market is primarily coming from patient “advertising” to other patients by word of mouth and use of the internet. The perceived benefit is likely based upon decreased blood loss and quicker recovery. He hypothesized that this leads to decreased surgical and medical complications. Complications have a negative impact on hospital reimbursement. Based upon Medicare data, Begg in the NEJM in 2002 found that the complication rate from open radical prostatectomy was 28-35%. In a study by Dr. Lu-Yao, the surgical complication rates were virtually identical and medical complications were about 13-20%. Pure laparoscopic prostatectomy series report complication rates of about 11%. In his robotic data, medical complications were <1%.

Robotic Prostatectomy Results from Vattikuti Institute

UroToday – European Urology – Vattikuti Institute Prostatectomy: Contemporary Technique and Analysis of Results

Results
Complete follow-up information was obtained in 1142 patients with a minimum follow-up of 12 mo (range: 12–66 mo; median: 36 mo). The actuarial 5-yr biochemical recurrence rate was 8.4% and the actual biochemical recurrence rate was 2.3%. Median duration of incontinence was 4 wk; 0.8% patients had total incontinence at 12 mo. The intercourse rate was 93% in men with no preoperative erectile dysfunction undergoing veil nerve-sparing surgery, although only 51% returned to baseline function.
Conclusions
VIP with veil nerve sparing offers oncologic and continence results that are comparable to the results of conventional nerve-sparing radical prostatectomy. Early potency results are encouraging.


Excellent outcomes are seen from Dr. Menon’s group. It is interesting that even at the most experienced institution, only 51% of their patients had return to baseline sexual function. I believe this number is important and urologists should not only track how many patients can have intercourse with viagra and such, but also how many do not need it anymore and track patients SHIM scores.

Prostate cancer surgery: hospital stays for open vs robotic surgery

Length of Hospital Stay Similar for Robotic Assisted and Conventional Prostatectomy

beige_quote.bmpThe current study prospectively compared length of hospital stay in 374 patients who underwent conventional RP and 629 who underwent LRP between 2002 and 2005. These authors reported that 94.3% of patients undergoing RP and 97.5% undergoing LRP were discharged on or before postoperative day 1. The mean stay for patients receiving RP was 1.25 days compared to 1.17 days for those receiving LRP. Readmission rates were 7% for the RP group and 5% for the LRP group. None of these differences were statistically significant. Unscheduled visits to the emergency room occurred in 10% of both groups. The major cause of hospital visits was ileus. These authors concluded that both groups of patients could be treated on the same clinical pathway as they had similar problems.

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HIFU and cryosurgery for prostate cancer

UroToday – EAU 2007 – Minimally Invasive and Other Treatment Strategies in Localized Prostate Cancer

The authors conclude that this treatment modality is appropriate for patients with localized CaP who are not candidates for surgery. The oncological outcomes appear inferior to rates reported for radiotherapy and surgery.

2 abstracts were summarized from the EAU’s meeting: The HIFU one showed relatievly safe results, but cancer cures that were less than radiation or surgery. This is the first generation device they were using and I expect the results to improve.
I think HIFU will be FDA approved in the US in the next 2-3 years.
The cryosurgical study was for radiation failures and gave the following results and side effects:

The 5-year biochemical recurrence free survival was 73% for low-risk patient, 45% for intermediate-risk men and 11% for high-risk patients. The reported complications included incontinence (13%), erectile dysfunction (86%), LUTS (16%), prolonged perineal pain (4%), urinary retention (2%) and rectovesical fistula (1%).

Prostate Cancer: Surgery for locally advanced prostate cancer

Prostatectomy Effective for SV-Negative Locally Advanced Prostate Cancer

beige_quote.bmpAt a mean follow-up of 37.2 months (median, 21.2 months), the pT3 (pT3a plus pT3b) patients’ overall and disease-specific 10-year survival rates were 77% and 92%, respectively, and at 15 years, 52% and 75%. These results are similar to those of previous studies for overall survival of patients with advanced prostate cancer who undergo radical prostatectomy.
However, in the present study, Dr. Suttmann said, “The main issue is that you have 10-year disease-specific survival for those with pT3a of 92%, which is probably as much as those with pT2 tumors, while disease-specific survival is much worse for those who have pT3b disease, and so have seminal vesicle involvement.”
Although Dr. Suttmann indicated that they had not included any specific analysis for prognostic factors, he said, “We would still conclude that radical prostatectomy [with or without hormonal therapy] is a pretty good therapeutic option for those with pT3 disease.

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Prostate Cancer: Is PSA Screening effective

There were 2 articles summarized from the EAU 2007 conference on Urotoday.
They seemed to be conflicting, with one saying that delaying therapy did not seem to hurt many people and the other concluding that screening helped.
UroToday – EAU 2007 – Session on Prostate Cancer Screening:

beige_quote.bmpDr. Pelzer, Innsbruck presented data that the pathologic characteristics of PC detected in screened patients is favorable compared to PC detected in non-screened men. Of 997 RPs performed 1999-2006, 806 men were treated for screen detected PC and 191 were referred for surgery and not screen detected. Patient age and PSA levels were similar between the groups. The screen detected patients had statistically lower pathologic stages at surgery and lower Gleason scores. The rate of positive surgical margins was 11.7% in the screened group and 24.4% in the non-screened group. The worse pathologic variables suggest that the non-screened group is at higher risk for disease relapse compared to the screened patients. Dr. Pelzer, Innsbruck presented data that the pathologic characteristics of PC detected in screened patients is favorable compared to PC detected in non-screened men. Of 997 RPs performed 1999-2006, 806 men were treated for screen detected PC and 191 were referred for surgery and not screen detected. Patient age and PSA levels were similar between the groups. The screen detected patients had statistically lower pathologic stages at surgery and lower Gleason scores. The rate of positive surgical margins was 11.7% in the screened group and 24.4% in the non-screened group. The worse pathologic variables suggest that the non-screened group is at higher risk for disease relapse compared to the screened patients.

In the screening studies in Europe the screening only gets done every 4 years. They are still very useful and I look forward to seeing their results.
As the study I quoted points out, even though patients by be “curable” as defined by having disease confined to the prostate, there is still a higher volume of cancer and there is probably more people that will not be cured by surgery as evidenced by the higher positive margin rate.

Prostate Cancer: Obese men are more likely to have worse pathology reports than expected

Dr. Koop – Biopsy Underestimates Prostate Cancer in Overweight Men:

beige_quote.bmpResearchers compared the biopsy grade to the cancer grade following radical prostatectomy, which is the removal of the prostate. In 1,113 men who underwent radical prostatectomy between 1996 and 2005 within the Shared Equal Access Regional Cancer Hospital database, 299 men, or 27 percent, had more severe cancer than suggested by biopsy. In 123 patients, or 11 percent, cancer diagnosis was actually less severe.

This was an interesting study that concluded that obesity is one of the risk factors for upgrading at the time of pathological analysis.
The last time I reviewed my database I found that 30% of my gleason 6 cancers were upgraded to 7. I have not done an analysis to see which patients are more at risk yet.

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