[How radical nephrectomy compares to partial nephrectomy for the treatment of pT1a papillary renal cell carcinomas?]

PURPOSE

Our objective was to compare oncologic results of nephron sparing surgery (NSS) versus radical nephrectomy (RN) in T1aN0-x M0 papillary renal cell carcinoma (PRCC).

PATIENTS AND METHODS

We retrospectively reviewed 277 patients treated for a pT1aN0M0 PRCC selected from an academic database from 12 centres. We compared the clinico-pathological features by using Chi-square and Student statistical analyses. Survivals analyses using Kaplan-Meier and Log-rank models were performed.

RESULTS

The two groups were composed by 186 patients treated by NSS and 91 by RN. The TNM stage was fixed and the two groups were, in terms of age and Fuhrman grade, comparable. Median age at diagnosis was 59 years (27-85). Median tumor size was 2.7 cm (0.4-4). The average follow-up was 49 months (1-246). Very few events arose in both groups: two local recurrences were observed in the NSS group (1.07%), three patients died of cancer in the NSS treated group (1.6%) and five in the RN treated group (5.5%). The five and 10 cancer-specific survival rate were comparable in the two groups (98% vs. 100% and 98% vs. 97%). The specific survival curves were perfectly similar for both groups (log rank test, p=0.25).

CONCLUSION

NSS is equivalent to RN as far as oncologic control of pT1aN0M0 PRCC is concerned.

Efficacy of venlafaxine, medroxyprogesterone acetate, and cyproterone acetate for the treatment of vasomotor hot flushes in men taking gonadotropin-releasing hormone analogues for prostate cancer: a double-blind, randomised trial

BACKGROUND

Hot flushes are the most common complaints reported by men undergoing androgen suppression treatment for prostate cancer. We designed a randomised double-blind trial to compare the efficacy of three drugs, each of which has proven effective for preventing hot flushes in previous studies.

METHODS

Men with prostate cancer with an indication for androgen suppression were enrolled in the study at 106 urology centres in France between April 14, 2004, and April 20, 2007. All patients were treated for 6 months with leuprorelin (11.25 mg). At month 6, patients who spontaneously asked for treatment, or those who presented with 14 hot flushes or more during the week before the visit, were randomly assigned to either venlafaxine 75 mg daily, medroxyprogesterone acetate 20 mg daily, or cyproterone acetate 100 mg daily. All patients received two indistinguishable pills in the morning and one in the evening from week 1 to week 8, and one indistinguishable pill in the morning from week 9 to week 10, to comply with the double-blind design. Random assignment with a block size of three was done centrally, by fax, and each patient was given a randomisation number. The allocation sequence was stratified by centre. Assessment was done at inclusion, at randomisation, and then at 4 weeks, 8 weeks, and 12 weeks after randomisation. Participants completed a daily hot-flush diary for 1 week, and a quality of life questionnaire before each visit throughout the study. The primary outcome was the change in median daily hot-flush score between randomisation and 1 month. All patients who received at least one study treatment dose were included in the efficacy analysis. This trial is registered with ClinicalTrials.gov, number NCT01011751.

FINDINGS

Of the 919 men initially enrolled, 311 were randomly assigned to one of the study treatments at 6 months: 102 to venlafaxine, 101 to cyproterone, and 108 to medroxyprogesterone. 309 patients were included in the efficacy analysis, since two were excluded for protocol deviations (one in the cyproterone and one in the medroxyprogesterone group; both were excluded because they were already undergoing treatment with serotonin reuptake inhibitor antidepressants at randomisation). The change in median daily hot-flush score between randomisation and 1 month was -47.2% (IQR -74.3 to -2.5) in the venlafaxine group, -94.5% (-100.0 to -74.5) in the cyproterone group, and -83.7% (-98.9 to -64.3) in the medroxyprogesterone group. The decrease from baseline was significant for all three groups (p<0.0001). Pairwise comparison of treatment groups adjusted by the Bonferroni method confirmed that the decreases in hot-flush score were significantly larger in the cyproterone and medroxyprogesterone groups than in the venlafaxine group, regardless of the interval considered (p<0.0001 in all cases). There was no significant difference between the cyproterone and medroxyprogesterone groups (p>0.2 in all cases). Serious side-effects occurred in four, seven, and five patients in the venlafaxine, cyproterone, and medroxyprogesterone groups, respectively, of which none, one (dyspnoea), and one (urticaria) were considered related to the drug, respectively.

INTERPRETATION

After 6 months of treatment with leuprorelin, venlafaxine, cyproterone, and medroxyprogesterone proved to be effective in reducing hot flushes. However, the hormonal treatments cyproterone and medroxyprogesterone were significantly more effective than venlafaxine. As cyproterone is a recognised treatment in prostate cancer, and its use could interfere with hormonal therapy, medroxyprogesterone could be considered to be the standard treatment for hot flushes in men undergoing androgen suppression for prostate cancer.

FUNDING

Takeda Laboratories, Puteaux, France.

Pilot trial of adjuvant paclitaxel plus androgen deprivation for patients with high-risk prostate cancer after radical prostatectomy: results on toxicity, side effects and quality-of-life

Therapeutic strategy remains unclear with no clear consensus for men with high-risk prostate cancer (PCa) after radical prostatectomy. We aimed to evaluate into a prospective randomized trial the effectiveness and feasibility of adjuvant weekly paclitaxel combined with androgen deprivation therapy (ADT) in these patients. A total of 47 patients with high-risk PCa were randomized 6 weeks after radical prostatectomy: ADT alone versus combination of ADT and weekly paclitaxel. Toxicity, quality-of-life and functional results were compared between the two arms. All 23 patients completed eight cycles of paclitaxel. Toxicity was predominantly of grade 1-2 severity. There were no differences in EORTC QLQ-C30 scores between the two groups and between baseline and last assessment at 24 months after surgery. Urinary continence was complete at 1 year after surgery for all patients and no significant differences were noted at each assessment between the two groups. The interim analysis of this trial confirms the feasibility of weekly paclitaxel in combination with ADT in men at high-risk PCa with curative intent. This adjuvant combined therapy does not alter quality-of-life and continence recovery after surgery plus ADT. A larger cohort is awaited to determine the oncological outcomes of this strategy.

[The screening of prostate cancer in 2009: overview of the oncology committee of the French Urological Association]

OBJECTIVE

To analyze the impact of screening on prostate cancer (PCa) mortality, and to discuss the main points of controversy regarding this screening.

METHODS

A bibliographic analysis was made using Medline services (keywords: prostate cancer, screening). Only the randomized studies regarding the impact of PCa screening on specific mortality were taken into account.

RESULTS

Two randomized studies, comparing one group of screened men with another group of nonscreened men, were published this year with conflicting results. The American study PLCO included 76,693 men. After a follow-up of 7 years, it did not report a significant difference in terms of specific mortality between both arms: 2/10,000 deaths in the control group versus 1.7/10,000 in the screened arm (RR=1.13; IC 95%: 0.75-1.7). The European study ERSPC included 182,160 men. After 9 years of follow-up, it showed a significant 20% reduction of specific mortality rate in the screened group (RR=0.80; IC 90%: 0.65-0.98; p=0.04). Methodologically, the European study seems to be superior to the American study, in which the control group was biased by a high percentage of preinclusion screening.

CONCLUSIONS

This is the first time that a large randomized study shows a benefit of PCa screening regarding specific mortality. However, this issue remains to be clarified, due to the lack of data regarding the risk of "overdiagnosis" and the economic impact of screening.

Robot-assisted extraperitoneal laparoscopic radical prostatectomy: experience in a high-volume laparoscopy reference centre

OBJECTIVE

To describe our current procedure of robot-assisted laparoscopic radical prostatectomy (RALP), and to assess the effect of the learning curve on perioperative data, early oncological outcomes and functional results, as RALP has increasingly become a treatment option for men with localized prostate cancer.

PATIENTS AND METHODS

In all, 206 consecutive men had a RALP between July 2001 and November 2008 for localized prostate cancer. Among the overall cohort, the 175 men operated on by the same surgeon were distributed into five groups according to the chronological order of the procedures. The mean follow-up after RALP was 18.3 months. Patient demographics, surgical data and postoperative variables were collected into a prospective database. Data were compared by chronological groups into single-surgeon cohort.

RESULTS

The median operative time and blood loss were 140 min and 350 mL, respectively. The complication rate was 8.3%. Cancers were pT3-4 in 34.5%. The mean hospital stay and duration of bladder catheterization were 4.3 and 8.2 days, respectively. The rate of positive surgical margins (PSMs) was 17.2% in pT2 cancers. The recovery rate of continence was 98% at 12 months. Intraoperative time, blood loss and length of hospital stay were significantly improved after a short learning curve. The continence recovery, the rate and the length of PSM were also improved beyond the learning curve, but difference was not statistically significant.

CONCLUSIONS

RALP is a safe and reproducible procedure and offers a short learning curve for experienced laparoscopic surgeons. Beyond the learning curve, continued experience might also provide further improvements in terms of operative, pathological and functional results.

The prognostic significance of bladder neck invasion in prostate cancer: is microscopic involvement truly a T4 disease?

Since the widespread of prostate-specific antigen-based screening, prostate cancer at clinical stage T4 has become rare. Most bladder invasion is actually detected on radical prostatectomy specimens as a microscopic bladder neck involvement (BNI). The 2002 Tumour-Node-Metastasis (TNM) classification system classified prostate cancer with BNI within a unified pT4 category and rendered it equivalent to invasion into the pelvic wall musculature or external sphincter; this decision is controversial. Various series have assessed the clinical relevance and the effect of BNI on prognosis. This evidence-based review provides evidence that BNI should be assigned within the subset of pT3 stage, and that further improvement of the actual TNM staging system should be considered. However, BNI remains strongly associated with adverse pathology and should be regarded as a factor that worsens the prognosis of the underlying tumour stage.