Prognostic factors in metastatic prostate cancer

The direct prognosis comparison of 125I low-dose-rate brachytherapy versus laparoscopic radical prostatectomy for patients with intermediate-risk prostate cancer

BACKGROUND

This study aims to compare the clinical outcomes after performing radical prostatectomy (RP) or low-dose-rate brachytherapy (LDR) for patients with intermediate-risk prostate cancer (IRPC).

METHODS

We performed a retrospective analysis on 361 IRPC patients who underwent treatment in Peking Union Medical College Hospital from January 2014 to August 2021, of which 160 underwent RP and 201 underwent Iodine-125 LDR. Patients were followed in clinic monthly during the first three months and at three-month intervals thereafter. Univariate and multivariate regression analyses were conducted to predict biochemical relapse-free survival (bRFS), clinical relapse-free survival (cRFS), cancer-specific survival (CSS), and overall survival (OS). Biochemical recurrence was defined using the Phoenix definition for LDR and the surgical definition for RP. The log-rank test was applied to compare bRFS between the two modalities, and Cox regression analysis was performed to identify factors associated with bRFS.

RESULTS

Median follow-up was 54 months for RP and 69 months for LDR. According to log-rank test, the differences of 5-year bRFS (70.2% vs 83.2%, P = 0.003) and 8-year bRFS (63.1% vs 68.9%, P < 0.001) between RP and LDR groups were statistically significant. Our results also indicated that there was no significant difference in terms of cRFS, CSS, or OS between the two groups. With multivariate analysis of the entire cohort, prostate volume ≤ 30 ml (P < 0.001), positive margin (P < 0.001), and percentage positive biopsy cores > 50% (P < 0.001) were independent factors suggestive of worse bRFS.

CONCLUSIONS

LDR is a reasonable treatment option for IRPC patients, yielding improved bRFS and equivalent rates of cRFS, CSS and OS when compared with RP.

125I low-dose-rate prostate brachytherapy and radical prostatectomy in patients with prostate cancer

Radical prostatectomy (RP) and low-dose-rate prostate brachytherapy (LDR) are two widely used treatment options for patients with T1c-T3a prostate cancer. In the present study, the efficacy of the two treatments was compared. A total of 429 patients who underwent either LDR (n=218) or RP (n=211) between January 2010 and June 2015 were retrospectively reviewed. Biochemical relapse-free survival time (bRFS) and clinical relapse-free survival time (cRFS) were assessed. The log-rank test compared bRFS between the two modalities, and Cox regression identified factors associated with bRFS. The median follow-up time and patient age were 46.6 months and 71 years, respectively. The bRFS at 1, 2 and 5 years was 89.4, 87.2 and 79.9% for LDR, respectively, and 91.0, 82.8 and 72.2% for RP, respectively (P=0.077). The cRFS at 1, 2 and 5 years was 99.1, 97.7 and 94.9% for LDR, respectively, and 99.0, 96.2 and 94.5% for RP, respectively (P=0.630). It was indicated that LDR produced equivalent bRFS and cRFS rates compared with RP. The risk of biochemical failure (bF) was higher for the RP group compared with the LDR group in patients with a Gleason score ≤3+4 (P=0.022) or initial prostate specific antigen ≤10 ng/ml (P=0.002). Based on the univariate and multivariate logistic regression analysis of all 429 patients, T stage ≥T2b was an independent predictor for bF.

Neoadjuvant androgen-deprivation therapy with radical prostatectomy for prostate cancer in association with age and serum testosterone

BACKGROUND

We aimed to identify the candidate prostate cancer patients suitable for neoadjuvant androgen-deprivation therapy (ADT) with radical prostatectomy (RP).

MATERIALS AND METHODS

This study included 711 Japanese patients with clinically localized prostate cancer who were treated with RP between 2000 and 2013. Patients were treated with or without neoadjuvant ADT before RP. The prognostic significance of neoadjuvant ADT on biochemical recurrence (BCR) was analyzed according to various clinicopathological characteristics.

RESULTS

BCR occurred in 186 (26.2%) of 711 patients. The group treated with neoadjuvant ADT showed higher levels of prostate-specific antigen at diagnosis and advanced clinical T-stage, but suppressed pathological T-stage. Neoadjuvant ADT was not associated with the risk of BCR. In subgroup analysis, neoadjuvant ADT was significantly associated with increased BCR in patients aged >65 years [hazard ratio (95% confidence interval), 2.04 (1.13-3.43), P = 0.020]. Among the 53 patients with available serum testosterone levels, neoadjuvant ADT was associated with the risk of BCR according to serum testosterone levels.

CONCLUSION

This study demonstrated that neoadjuvant ADT showed potential deleterious effects in older patients and patients with lower serum testosterone levels, while a possible improved prognosis in patients with high serum testosterone levels treated with neoadjuvant ADT was suggested, warranting further exploration.

Percutaneous Acetabuloplasty Compared With Open Reconstruction for Extensive Periacetabular Carcinoma Metastases

For destructive metastatic periacetabular disease, options include open acetabular reconstruction or percutaneous cement acetabuloplasty (PA). We reviewed 28 consecutive patients with Harrington grade II or III lesions, 17 who underwent Harrington-type or anti-protrusio reconstruction and 11 who underwent PA. Primary outcome measures were performance status (PS), ambulatory status (0=unassisted ambulation, 1=assisted ambulation, 2=nonambulatory), and 10-point VAS score. The surgery group had better pain reduction than the PA group at 3 months (3.6 vs. 1.5 points, P=0.04), and a trend at final follow-up (3.8 vs. 1.4 points, P=0.06). Improvement in ambulatory status was better in the surgery group at 3 months only (0.53 vs. -0.14, P=0.03). Thus compared with PA, open reconstruction may provide improved pain relief and ambulation.

Prognostic Utility of PET in Prostate Cancer

Many standard nonimaging-based prediction tools exist for prostate cancer. However, these tools may be limited in individual cases and need updating based on the improved understanding of the underlying complex biology of the disease and the emergence of the novel targeted molecular imaging methods. A new platform of automated predictive tools that combines the independent molecular, imaging, and clinical information can contribute significantly to patient care. Such a platform will also be of interest to regulatory agencies and payers as more emphasis is placed on supporting those interventions that have quantifiable and significant beneficial impact on patient outcome.

Skeletal metastases in 301 breast cancer patients: patient survival and complications after surgery

The aim was to identify prognostic variables associated with survival in 301 breast cancer patients after surgical treatment of skeletal metastases. The study period was 1986-2012. The median age at surgery was 61 (interquartile-range [IQR] 52-70) years. The cumulative 1-, 2-, and 5-year survival after surgery was 45% (95% CI 39-51), 27% (22-32), and 8% (5-12), respectively. The median follow-up time was 1 (IQR 0.2-2) year. Age over 60 years (Hazard ratio [HR] 1.9) and hemoglobin levels <110 g/L (HR 2) increased the risk of death after surgery. Patients with impending fractures (HR 0.4) had a lower death rate. The overall neurological function in patients with spinal metastases improved after surgery (p < 0.001). The complication rate was 25%, including 14% re-operations. Survival data and analysis of complications of this large cohort of surgically treated breast cancer patients help to set appropriate expectations for the patients, families, and medical staff.

Imatinib and prostate cancer: lessons learned from targeting the platelet-derived growth factor receptor

INTRODUCTION

The platelet derived growth factor (PDGF) signaling pathway has been implicated in both epithelial and stromal mechanisms of prostate cancer progression and postulated as a target for therapy in bone metastases. Imatinib mesylate is a potent inhibitor of the platelet-derived growth factor receptor (PDGFR) and its activity has been tested in preclinical models and in Phase I and II clinical trials.

AREAS COVERED

This review summarizes the preclinical data on PDGF/PDGFR in prostate cancer, and reviews the clinical and correlative data using imatinib as a PDGFR inhibitor.

EXPERT OPINION

To date, the use of imatinib to treat men with prostate cancer has been ineffective, and PDGFR inhibition may in fact accelerate advanced forms of the disease and antagonize taxane efficacy. Given the major discordance between preclinical models and clinical experimentation, an accurate understanding of the PDGF-regulated interactions between metastatic prostate cancer and the bone micro-environment is evidently warranted. Correlations of pharmacodynamic monitoring of imatinib-induced PDGFR inhibition with progression-free and overall survival outcomes have led to the hypothesis that PDGF may function as a homeostatic factor in bone metastases. Recent laboratory studies defining PDGFR-regulated pericytes as gatekeepers of metastases may relate to these clinical observations.

Pathological subtrochanteric fractures in 194 patients: a comparison of outcome after surgical treatment of pathological and non-pathological fractures

BACKGROUND

The surgical treatment of pathological subtrochanteric fractures has been associated with technical difficulties and frequent failures. We analyzed survival, risk factors for death, and outcome after surgical treatment.

METHODS

The study group consisted of 194 patients with pathological subtrochanteric femur fractures operated during 1999-2009. Cox multiple-regression analysis was performed to study risk factors and results were expressed as hazard ratios (HR). We included a control group with non-pathological subtrochanteric fractures (n = 87) for comparison.

RESULTS

The median age at surgery was 68 (29-96) years in the study group and 82 (66-101) in the controls. The 1-year survival rate after surgery was 33% (95% CI: 26-40) in the study group and 85% (79-93) in the controls. In the study group, the risk of death after surgery was increased for patients ≥65 years of age (HR 1.5, 95% CI: 1.1-2.1), with a moderate (HR 2.2, 1.5-3.4) and poor (HR 2.9, 1.6-5.2) Karnofsky score, with visceral metastases (HR 1.6, 1.1-2.3), and perioperative hemoglobin levels <100 g/L (HR 2.2, 1.3-3.7). In patients with pathological fractures, there was no statistically significant difference concerning reoperation rates comparing intramedullary nails (9%) with endoprostheses (6%; P = 0.3).

CONCLUSIONS

Surgery for pathological subtrochanteric femur fractures is a relatively safe and effective procedure.

Low pretreatment serum total testosterone is associated with a high incidence of Gleason score 8-10 disease in prostatectomy specimens: data from ethnic Chinese patients with localized prostate cancer

What's known on the subject? and What does the study add? Previous data from clinically localized prostate cancer (PCa) series treated with radical prostatectomy (RP) have suggested that low preoperative serum total testosterone level is associated with more aggressive PCa; however, the definition of low preoperative total testosterone level varied among these studies (from 220 ng/dL to 387 ng/dL). Moreover, no relevant data exist in the literature regarding ethnic Chinese patients. The study shows that the most widely used threshold for low pretreatment total testosterone level (total testosterone < 300 ng/dL) is not appropriate for ethnic Chinese patients, because it could not distinguish patients with more aggressive PCa from those with less aggressive disease. Setting the threshold at the level of total testosterone < 250 ng/dL works better, because pretreatment total testosterone < 250 ng/dL is associated with a significantly higher incidence of Gleason score 8-10 disease in RP specimens.

OBJECTIVE

• To investigate the relationship between preoperative serum total testosterone level and prognostic factors of Chinese patients with clinically localized prostate cancer (PCa).

PATIENTS AND METHODS

• A total of 110 patients with localized PCa, treated by radical prostatectomy (RP), were included in this prospective study. • Clinical and pathological data from each patient were collected. Total testosterone was measured on the morning of surgery. • Total testosterone levels for each patient were compared using two thresholds: threshold 1 (total testosterone <300 ng/dL vs total testosterone ≥ 300 ng/dL) and threshold 2 (total testosterone <250 ng/dL vs total testosterone ≥ 250 ng/dL).

RESULTS

• The median preoperative total testosterone level was 346 ng/dL. Gleason scores of ≤ 6, 7 and ≥ 8 were found in the RP specimens from 21 (19.1%), 67 (60.9%) and 22 (20.0%) patients, respectively. • Compared with those with low grade disease, patients with high grade disease (Gleason score ≥ 8) in RP specimens had a significantly lower preoperative total testosterone. • When comparing 35 patients with hypogonadism with 75 patients with eugonadism, classified by threshold 1, no significant relationships were found. • When comparing 18 patients with hypogonadism with 92 patients with eugonadism, classified by threshold 2, pathological Gleason score ≥ 8 tumours were more common in patients with hypogonadism.

CONCLUSION

• Setting the threshold for hypogonadism at the level of pretreatment serum total testosterone <250 ng/dL is appropriate for ethnic Chinese patients with localized PCa, because patients with pretreatment total testosterone <250 ng/dL are associated with a higher incidence of Gleason score 8-10 disease in RP specimens.

Prostate cancer in the senior men from rural areas in east district of China: contemporary management and 5-year outcomes at multi-institutional collaboration

OBJECTIVE

Prostate cancer is an underreported and emerging problem in China. Here we summarize the data for Chinese patients with prostate cancer (PCa), describe available treatment options, and report 5-year outcomes at multiple tertiary care institutions.

PATIENTS AND METHODS

A series of 1611 patients (mean age 76.51 years) diagnosed with PCa were enrolled. Survival rates for patients were analyzed using the Kaplan-Meier method. Prognostic factors for disease-specific survival were analyzed using the log-rank test and Cox proportional hazards model.

RESULTS

Seven hundreds and thirty-two patients with a prostate tumor clinical stage of III or IV and 879 with a tumor clinical stage of I or II were diagnosed. The disease-specific survival rates at 1, 3 and 5 years were 94.6%, 81.3% and 72.6%, respectively. Five-year disease-specific survival rates were 99.2% for patients with low clinical stage PCa who underwent radical prostatectomy, 76.5% for those who underwent transurethral resection of the prostate plus hormone therapy, 38% for those who received hormone therapy plus radiation therapy and 29% for those that received hormone therapy alone.

CONCLUSIONS

In keeping with a lack of prostate-specific antigen (PSA)-based screening, Chinese men present later in life and course of their disease, with over 27% men dying of PCa at five years. Debulking of tumors by surgery and radiation therapy for high grade tumor may provide some survival benefit in the senior men but further study is required to validate these findings. It is important of the annual use of PSA test for men over 50 years old to detect the PCa in the early stage in this nation.

Surgery for skeletal metastases in lung cancer

BACKGROUND AND PURPOSE

Most lung cancer patients with skeletal metastases have a short survival and it is difficult to identify those patients who will benefit from palliative surgery. We report complication and survival rates in a consecutive series of lung cancer patients who were operated for symptomatic skeletal metastases.

METHODS

This study was based on data recorded in the Karolinska Skeletal Metastasis Register. The study period was 1987-2006. We identified 98 lung cancer patients (52 females). The median age at surgery was 62 (34-88) years. 78 lesions were located in the femur or spine.

RESULTS

The median survival time after surgery was 3 (0-127) months. The cumulative 12-month survival after surgery was 13% (95% CI: 6-20). There was a difference between the survival after spinal surgery (2 months) and after extremity surgery (4 months) (p = 0.03). Complete pathological fracture in non-spinal metastases (50 patients) was an independent negative predictor of survival (hazard ratio (HR) = 1.8, 95% CI: 1-3). 16 of 31 patients with spinal metastases experienced a considerable improvement in their neurological function after surgery. The overall complication rate was 20%, including a reoperation rate of 15%.

INTERPRETATION

Bone metastases and their subsequent surgical treatment in lung cancer patients are associated with high morbidity and mortality. Our findings will help to set appropriate expectations for these patients, their families, and surgeons.

Prostate cancer

Prostate cancer is biologically and clinically a heterogeneous disease and its imaging evaluation will need to be tailored to the specific phases of the disease in a patient-specific, risk-adapted manner. We first present a brief overview of the natural history of prostate cancer before discussing the role of various imaging tools, including opportunities and challenges, for different clinical phases of this common disease in men. We then review the preclinical and clinical evidence on the potential and emerging role of positron emission tomography with various radiotracers in the imaging evaluation of men with prostate cancer.

The evolutionary impact of androgen levels on prostate cancer in a multi-scale mathematical model

Background

Androgens bind to the androgen receptor (AR) in prostate cells and are essential survival factors for healthy prostate epithelium. Most untreated prostate cancers retain some dependence upon the AR and respond, at least transiently, to androgen ablation therapy. However, the relationship between endogenous androgen levels and cancer etiology is unclear. High levels of androgens have traditionally been viewed as driving abnormal proliferation leading to cancer, but it has also been suggested that low levels of androgen could induce selective pressure for abnormal cells. We formulate a mathematical model of androgen regulated prostate growth to study the effects of abnormal androgen levels on selection for pre-malignant phenotypes in early prostate cancer development.

Results

We find that cell turnover rate increases with decreasing androgen levels, which may increase the rate of mutation and malignant evolution. We model the evolution of a heterogeneous prostate cell population using a continuous state-transition model. Using this model we study selection for AR expression under different androgen levels and find that low androgen environments, caused either by low serum testosterone or by reduced 5α-reductase activity, select more strongly for elevated AR expression than do normal environments. High androgen actually slightly reduces selective pressure for AR upregulation. Moreover, our results suggest that an aberrant androgen environment may delay progression to a malignant phenotype, but result in a more dangerous cancer should one arise.

Conclusions

The model represents a useful initial framework for understanding the role of androgens in prostate cancer etiology, and it suggests that low androgen levels can increase selection for phenotypes resistant to hormonal therapy that may also be more aggressive. Moreover, clinical treatment with 5α-reductase inhibitors such as finasteride may increase the incidence of therapy resistant cancers.

Reviewers

This article was reviewed by Ariosto S. Silva (nominated by Marek Kimmel) and Marek Kimmel.

Platelet-derived growth factor receptor inhibition and chemotherapy for castration-resistant prostate cancer with bone metastases

PURPOSE

To further assess preclinical and early clinical evidence that imatinib mesylate, a platelet-derived growth factor receptor (PDGFR) inhibitor, modulates taxane activity in prostate cancer and bone metastases, a randomized study was conducted.

EXPERIMENTAL DESIGN

Men with progressive castration-resistant prostate cancer with bone metastases (n = 144) were planned for equal randomization to i.v. 30 mg/m(2) docetaxel on days 1, 8, 15, and 22 every 42 days with 600 mg imatinib daily or placebo, for an improvement in median progression-free survival from 4.5 to 7.5 months (two-sided alpha = 0.05 and beta = 0.20). Secondary end points included differential toxicity and bone turnover markers, tumor phosphorylated PDGFR (p-PDGFR) expression, and modulation of p-PDGFR in peripheral blood leukocytes.

RESULTS

Accrual was halted early because of adverse gastrointestinal events. Among 116 evaluable men (57 docetaxel + imatinib; 59 docetaxel + placebo), respective median times to progression were 4.2 months (95% confidence interval, 3.1-7.5) and 4.2 months (95% confidence interval, 3.0-6.8; P = 0.58, log-rank test). Excess grade 3 toxicities (n = 23) in the docetaxel + imatinib group were principally fatigue and gastrointestinal. Tumor p-PDGFR expression was observed in 12 of 14 (86%) evaluable bone specimens. In peripheral blood leukocytes, p-PDGFR reduction was more likely in docetaxel + imatinib-treated patients compared with docetaxel + placebo (P < 0.0001), as were reductions in urine N-telopeptides (P = 0.004) but not serum bone-specific alkaline phosphatase (P = 0.099).

CONCLUSIONS

These clinical and translational results question the value of PDGFR inhibition with taxane chemotherapy in prostate cancer bone metastases and are at variance with the preclinical studies. This discordance requires explanation.

Clinical features of metastatic bone disease and risk of skeletal morbidity

The skeleton is the most common organ to be affected by metastatic cancer and the site of disease that produces the greatest morbidity. Skeletal morbidity includes pain that requires radiotherapy, hypercalcemia, pathologic fracture, and spinal cord or nerve root compression. From randomized trials in advanced cancer, it can be seen that one of these major skeletal events occurs on average every 3 to 6 months. Additionally, metastatic disease may remain confined to the skeleton with the decline in quality of life and eventual death almost entirely due to skeletal complications and their treatment. The prognosis of metastatic bone disease is dependent on the primary site, with breast and prostate cancers associated with a survival measured in years compared with lung cancer, where the average survival is only a matter of months. Additionally, the presence of extraosseous disease and the extent and tempo of the bone disease are powerful predictors of outcome. The latter is best estimated by measurement of bone-specific markers, and recent studies have shown a strong correlation between the rate of bone resorption and clinical outcome, both in terms of skeletal morbidity and progression of the underlying disease or death. Our improved understanding of prognostic and predictive factors may enable delivery of a more personalized treatment for the individual patient and a more cost-effective use of health care resources.

Pretreatment Serum Testosterone Level as a Predictive Factor of Pathological Stage in Localized Prostate Cancer Patients Treated with Radical Prostatectomy

OBJECTIVE

Pretreatment serum level of testosterone (T) is a potential prognostic factor for prostate cancer. The present study was conducted to evaluate the clinical significance of pretreatment serum T level in patients with clinically localized prostate cancer.

MATERIALS AND METHODS

The subjects were 82 clinically localized prostate cancer patients treated with radical prostatectomy, whose pretreatment T levels were recorded. We investigated clinical and pathological factors such as pretreatment serum T level, age, pretreatment PSA or pathological Gleason score concerning the association with pathological stage and biochemical recurrence.

RESULTS

The mean pretreatment T level was significantly lower in patients with non-organ-confined prostate cancer (pT3-T4, N1; 3.44+/-1.19 ng/ml) than in patients with organ-confined cancer (pT2; 4.33+/-1.42 ng/ml) (p=0.0078). Multivariate analysis demonstrated that pathological Gleason score, pretreatment serum T level and pretreatment PSA were significant predictors of extraprostatic disease. When the patients were divided into high and low T level groups according to the median value, pretreatment T levels were not significantly associated with PSA recurrence rates (p=0.7973).

CONCLUSIONS

A lower pretreatment T level appears to be predictive of extraprostatic disease in patients with localized prostate cancer.

Platelet-Derived Growth Factor Receptor Inhibitor Imatinib Mesylate and Docetaxel: A Modular Phase I Trial in Androgen-Independent Prostate Cancer

Purpose

To study the platelet-derived growth factor receptor (PDGFR) inhibitor imatinib mesylate in androgen-independent prostate cancer (AIPC), alone and in combination with docetaxel, we designed a modular phase I trial. Our goals were to (1) evaluate the toxicity and maximum-tolerated dose of docetaxel with imatinib, and (2) evaluate the decline of prostate-specific antigen (PSA) induced by imatinib alone, and imatinib and docetaxel.

Patients and Methods

Twenty-eight men with AIPC and bone metastases were enrolled to receive imatinib 600 mg daily lead-in for 30 days, then imatinib 600 mg daily and one of six possible doses of docetaxel weekly for 4 weeks every 6 weeks.

Results

During the imatinib lead-in module, one dose-limiting toxicity (DLT) event was observed, while two (7%) of 28 had PSA decline (both < 50%). With imatinib and docetaxel, cycle 1 DLT was found in three of 12 patients at docetaxel 30 mg/m2, in three of four patients at docetaxel 45 mg/m2, and in five of six patients at docetaxel 35 mg/m2. DLTs (n = 40 total events) were principally fatigue (35%) and nausea (20%). Eight (38%) of 21 had PSA decline greater than 50%, and six (29%) of 21 had PSA decline less than 50%. Serial PSA declines beyond 18 months were observed. PDGFR-expressing tumor declined on serial bone marrow biopsies with combination therapy alone.

Conclusion

With imatinib 600 mg daily, the maximum-tolerated dose of docetaxel was determined to be 30 mg/m2 weekly for 4 weeks every 6 weeks. Long-term responses were observed. The role of imatinib in modulating outcomes to docetaxel in AIPC is being tested in a randomized phase II trial.

Impact of haemoglobin levels on the outcome of cancers treated with chemotherapy

Anaemia is the most frequently observed haematological abnormality faced by cancer patients. Yet, its impact on tumour biology is not well understood. Several recent retrospective clinical studies showed that anaemia is not only a negative prognostic factor but also, in some situations, a negative predictive parameter in chemotherapy-treated patients with solid tumours or haematological malignancies. These include lymphomas, leukaemias, non-small-cell lung cancer, ovarian cancer, cervical cancer, urothelial and renal cancers, and head and neck carcinoma. The basis for the impact of anaemia on prognosis or outcome of chemotherapy is complex. In vitro and animal models have shown that cellular hypoxia, the consequence of anaemia, may provide a selection pressure for tumour cells with higher rates of mutation, which may ultimately result in increased metastatic potential, increased cellular growth, therapy resistance, and decreased apoptotic potential. There is also evidence to indicate that the anaemia itself may induce a feedback mechanism that results in angiogenesis. Finally, the effect of anaemia on the pharmacokinetics of cytostatics may be an underestimated parameter for therapeutic outcome. The treatment of anaemia in patients with cancer undergoing chemotherapy may improve outcome in terms of both response rate to treatment and survival.

Clinical significance of pulmonary metastases in stage D2 prostate cancer patients

Several prognostic factors such as the extent of bone metastases (EOD) in advanced prostate cancer (PCa) have been reported. Metastasis of the lung is rarely a significant clinical factor in the management of prostate cancer. The present study evaluates the clinical significance of lung metastases. We retrospectively reviewed the PCa database to identify patients with pulmonary metastases at initial diagnosis. The medical records of the patients were examined with respect to age, histologic grade, EOD score, marker response to endocrine therapy and clinical outcome. We then compared several potential clinical factors between patients with and without pulmonary metastases. Next, we retrospectively reviewed autopsy records of 60 Japanese patients who died of hormone-refractory metastatic PCa with particular focus upon metastatic profiles. A comparative study of stage D(2) patients with (n=20) and without (n=77) pulmonary metastases found no significant differences in EOD score, performance status, marker response and survival. Only tumor grade was better in the group with, than without pulmonary metastases (P=0.0120, chi-square analysis). In the series of autopsies, we found pulmonary metastases in 38 cases (63%), following metastases of the bone (57 cases, 95%) and lymph nodes (52 cases, 87%). A retrospective analysis of survival showed that patients with bone or lymph node metastases had a positive relative risk. In contrast, lung metastasis could be a positive prognostic indicator, although the findings were not statistically significant. These data suggest that the presence of pulmonary metastasis has no ominous impact on clinical course and disease outcome even in patients with disseminated prostate cancer.

Tissue polypeptide-specific antigen (TPS) determinations before and during intermittent maximal androgen blockade in patients with metastatic prostatic carcinoma

OBJECTIVE

To evaluate the prognostic significance of serially measured tissue polypeptide-specific antigen (TPS) levels in patients with metastatic prostatic carcinoma treated with intermittent maximal androgen blockade (MAB). To determine its value with respect to predicting response to treatment and time to clinical progression. Finally to compare TPS with prostate-specific antigen (PSA) measurements in terms of prognostic impact in patients with metastatic prostatic carcinoma.

METHODS AND PATIENTS

TPS and PSA measurements were performed before start of and monthly during intermittent MAB in 68 patients participating in EORTC protocol 30954. Both TPS and PSA were measured in serum. Fifty-six patients from eight centers were included in the final analysis because at least three TPS values were available. TPS and PSA values were correlated with clinical course of the disease. Median follow-up was 21.3 months. Three patient groups were defined on clinical grounds: (a) clinically progressive disease (n=18); (b) clinically stable disease (n=33); and (c) patients who did not reach a predefined nadir PSA value following 9 months of treatment (n=5).

RESULTS

Pretreatment TPS was significantly higher in the clinically progressive patients than in the other patient groups (p=0.0041). When grouping patients according to their pretreatment TPS values (cut-off value of 100 U/l) the pretreatment TPS value (>100 U/l) proved to be a statistically significant prognostic factor with respect to time to progression: elevated TPS was associated with a 3.8 increased risk for progressive disease (p=0.0055). Pretreatment PSA (>100 ng/ml) was of no prognostic value for time to progression. In five patients increase of TPS coincided with or preceded clinical progression during treatment, whereas PSA remained normal.

CONCLUSION

Additional value of pretreatment TPS measurements in metastatic prostate cancer patients is found in defining the patients with rapid clinical progression. Following MAB an increase in TPS signifies clinical progression even if PSA is found to remain normal.

Assessment of tumour response to chemotherapy for metastatic colorectal cancer: accuracy of the RECIST criteria

Evaluation of tumour size modifications in response to treatment is a critical issue in the management of advanced malignancies. In 1981, the World Health Organization (WHO) established guidelines for tumour response assessment. These WHO1981 criteria were recently simplified in a revised version, named RECIST (Response Evaluation Criteria in Solid Tumours), which uses unidimensional instead of bidimensional measurements, a reduced number of measured lesions, withdrawal of the progression criteria based on isolated increase of a single lesion, and different shrinkage threshold for definitions of tumour response and progression. In order to validate these new guidelines, we have compared results obtained with both classifications in a prospective series of 91 patients receiving chemotherapy for metastatic colorectal cancer. Data from iterative tomographic measurements were fully recorded and reviewed by an expert panel. The overall response and progression rates according to the WHO1981 criteria were 19% and 58%, respectively. Using RECIST criteria, 16 patients were reclassified in a more favourable subgroup, the overall response rate being 28% and the progression rate 45% (non-weighted kappa concordance test 0.72). When isolated increase of a single measurable lesion is not taken into account for progression with the WHO1981 criteria, only 7 patients were reclassified and the kappa test was satisfying, i.e. > or =0.75, for the whole population as well as for each of the responding and progressive subgroups. Since it provides concordant results with a simplified method, the use of RECIST criteria is recommended for evaluation of treatment efficacy in clinical trials and routine practice.

5alpha-reductase 2 polymorphisms as risk factors in prostate cancer

Prostate cancer is a significant cause of death in Western countries and is under the strong influence of androgens. The steroid 5alpha-reductase 2 catalyzes the metabolism of testosterone into the more potent androgen dihydrotestosterone in the prostate gland. The enzyme is a target in pharmacological treatment of benign prostatic hyperplasia using specific inhibitors such as finasteride. Makridakis et al. have characterized the V89L and A49T polymorphisms in recombinant expression systems. The L allelic variant has a lower Vmax/Km ratio than the V variant. In the A49T polymorphism, the T variant has an increased Vmax/Km ratio. We performed a population-based case-control study of the impact of the SRD5A2 V89L and A49T polymorphisms on the risk of prostate cancer. We also studied the relation between the genotypes and age at diagnosis, tumor, node, metastasis stage, differentiation grade, prostate specific antigen and heredity. The study included 175 prostate cancer patients and 159 healthy controls that were matched for age. There was an association with SRD5A2 V89L LL genotype and metastases at the time of diagnosis, OR 5.67 (95% CI 1.44-22.30) when adjusted for age, differentiation grade, T-stage and prostate specific antigen. Heterozygous prostate cancer cases that carried the SRD5A2 A49T AT genotype were significantly younger than cases that carried the AA genotype, (mean age 66 years vs 71, P = 0.038). The SRD5A2 V89L and A49T polymorphisms were, however, not associated with altered prostate cancer risk. Further studies of the V89L polymorphism may lead to better understanding of the etiology of prostate cancer metastases.

CAG polymorphic repeat lengths in androgen receptor gene among Japanese prostate cancer patients: potential predictor of prognosis after endocrine therapy

BACKGROUND

Several investigators have examined the clinical significance of the length of the CAG repeat at the N-terminal region of the androgen receptor in the pathogenesis of prostate cancer. Because the clinical significance of CAG repeat length during the course of prostate cancer in Japanese patients is unknown, the present study analyzed CAG repeat length in relation to several potential clinical factors.

MATERIALS AND METHODS

A total of 88 Japanese patients with prostate cancer and a control group of 53 patients with benign prostatic disease were enrolled in this study. The length of the CAG repeat was determined by PCR sequencing and analyzed in relation to several clinical factors.

RESULTS

The length of the CAG repeat did not significantly differ between prostate cancer and benign prostatic disease. Although not statistically different with regard to clinical stage and serum PSA level, the CAG repeat length was associated with histological grade and age at diagnosis. In addition, the CAG repeat length in CR and in non CR patients significantly differed at 22.1 +/- 2.4 and 24.4 +/- 3.0, respectively (P = 0.0264), suggesting that the CAG repeat length can act as a molecular marker with which to predict response to endocrine therapy in stage D prostate cancer patients.

CONCLUSIONS

A shorter CAG repeat length appears to predict a response to endocrine therapy, showing a positive prognostic value and indicating good prognosis in the metastatic stage of prostate cancer patients.

Hypogonadism following prostate-bed radiation therapy for prostate carcinoma

BACKGROUND

The degree of testicular damage resulting from primary treatment of prostate carcinoma by external beam radiation therapy (EBRT) to the prostate bed has not been determined. If significant testicular damage has occurred, the resulting endocrine changes may result in modified tumor behavior, contribute to postradiation impotence, and may aggravate other signs and symptoms of hypogonadism, potentially influencing a patient's choice of primary treatment for his tumor.

METHOD

Three to eight years after primary treatment for localized prostate carcinoma, serologic evaluation for hypogonadism was undertaken in 33 men who had received EBRT and in 55 similar men who had received radical prostatectomy (RP). No subjects had developed recognized tumor recurrence, and none had undergone hormonal treatment since primary therapy.

RESULTS

Among men of similar age, prior treatment with EBRT was associated with significantly more frequent hypogonadism than prior treatment with RP. In men with EBRT, total testosterone levels averaged 27.3% less, free testosterone levels 31.6% less, dihydrotestosterone levels 33.4% less, luteinizing hormone (LH) levels 52.7% greater, and follicle-stimulating hormone (FSH) levels 100% greater than those values in men who had prior treatment with RP. Differences between postradiation and postsurgical men in LH and FSH levels were most prominent in men older than 70 years.

CONCLUSIONS

Three to eight years after primary treatment for prostate carcinoma, striking hormone differences were present between men who had received EBRT to the prostate bed and those with prior RP. These differences strongly suggested that prominent and permanent testicular damage was sustained during EBRT, frequently severe enough to cause hypogonadism.

Functional and oncological outcome of acetabular reconstruction for the treatment of metastatic disease

BACKGROUND

Metastatic disease of the acetabulum can be painful and disabling. Operative intervention is indicated for patients who fail to respond adequately to nonoperative treatment. We evaluated the functional and oncological outcome of acetabular reconstruction after curettage for the treatment of refractory symptomatic acetabular metastases.

METHODS

Fifty-five patients with metastatic disease of the acetabulum were treated with operative acetabular reconstruction combined with a total hip replacement. The most common primary tumor was carcinoma of the breast (eighteen patients), followed by carcinoma of the kidney (seven patients) and carcinoma of the prostate (seven patients). Forty (73 percent) of the patients presented with multiple skeletal metastases, and eighteen (33 percent) had associated visceral metastases. Twenty-eight (51 percent) had severe pain requiring continuous use of narcotics, twenty-four (44 percent) had moderate pain requiring periodic use of narcotics, and the remaining three (5 percent) had mild pain requiring use of non-narcotic analgesics. Eighteen (33 percent) of the patients could not walk, twenty-three (42 percent) needed a walker or crutches, twelve (22 percent) used a single cane, and two (4 percent) walked without assistive devices. Intralesional curettage of the tumor was performed in all of the patients. Fifty-four of the hips were reconstructed with a protrusio cup and one, with a hemipelvis endoprosthesis. Large defects were reinforced with cement and pin or screw fixation (the modified Harrington technique), which allowed transmission of weight-bearing forces to the remaining intact pelvis. Thirty-six acetabular reconstructions were performed with antegrade pins or cannulated screws; fifteen, with long retrograde screws; and four, with cement.

RESULTS

The median period of survival was nine months. Patients with visceral metastases had a median period of survival of three months compared with twelve months for patients without visceral metastases (p < 0.001). Patients with breast cancer presented later in the disease process (p < 0.004) and lived longer than did those with other carcinomas (p < 0.004). Forty-five patients were evaluated three months after reconstruction. Thirty-four (76 percent) of them had relief of pain as determined by decreased use of narcotics. Nine of the eighteen patients who could not walk preoperatively regained the ability to walk. Fourteen of the seventeen patients who originally were able to walk in the community retained that ability. Thirty-three patients were available for evaluation at six months. Twenty-five (76 percent) still had relief of pain, and nineteen (58 percent) were able to walk and function in the community. Overall, fourteen (25 percent) of the fifty-five patients had moderate local progression of the disease, and five of these patients had failure of the fixation. Fourteen early complications developed in twelve (22 percent) of the patients. One patient (2 percent) died perioperatively.

CONCLUSIONS

Patients who have acetabular metastases that are refractory to radiation and chemotherapy have a short life expectancy. The early, gratifying results of reconstruction validate the role of operative treatment as a short-term palliative procedure. Protrusio acetabular cups presumably compensate for deficiencies of the medial wall, while cement and pin fixation can be used effectively to reconstruct large defects in the acetabular column and dome. The low rate of fixation failure supports the biomechanical principles of the reconstruction. Generally, the reconstructions are sufficiently durable to exceed the life expectancy of the patients.

Pretreatment plasma testosterone and estradiol levels in patients with locally advanced or metastasized prostatic cancer. FINNPROSTATE Group

BACKGROUND

Studies concerning pretreatment plasma hormonal environment in relation to stage of prostatic cancer have given conflicting results. The aim of the present study was to compare the pretreatment plasma testosterone (T), free T (fT), estradiol (E2), and free E2 (fE2) levels in patients with locally advanced (T3-4 M0) and metastatic (T1-4 M1) prostatic cancer, and to further examine the effect of the patients' general condition on these levels.

METHODS

The present series consisted of 238 patients (Finnprostate 6 study). The variables analyzed were E2, fE2, T, fT, age, body mass index (BMI), sex hormone binding globulin capacity (SHBG), prostate-specific antigen (PSA), alkaline phosphatase (ALP), hemoglobin concentration (Hb), erythrocyte sedimentation rate (ESR), and performance status (PS).

RESULTS

The E2 and fE2 levels were significantly higher in M0 patients than in M1 patients, with no significant differences in T and fT levels. In multivariate analyses, a decline in performance status (PS), an increase in ESR, or a decrease in Hb, were related to a decrease in T, fT, E2, or fE2 levels.

CONCLUSIONS

Pretreatment plasma estradiol was significantly lower in M1 patients than in M0 patients, but there were no significant differences in T levels, although the poor general condition was related to a decrease in the pretreatment levels of both testosterone and estradiol.

Analysis and presentation. Clinical trials on prostate cancer

OBJECTIVE

To present guidelines for the analysis and presentation of clinical trials on prostate cancer.

METHODS

Textbooks in statistics and oncology were searched for information, as were separate articles on the topic. Previously published advice was fused with own experience.

RESULTS

Minimum key points are given for the sections: Introduction, Materials and Methods, Results, Discussion, and Summary. The importance of 1 primary question in any clinical trial is stressed. The value of a detailed presentation of the trial design, the patient population and the inclusion/exclusion criteria, the characterization of the disease, the treatment schedules, and toxicity is underlined. Application of various statistical methods for different endpoints is suggested. Maturity of data, time for publication, and avoidance of publication bias are discussed. Some common pitfalls in the statistical analyses of clinical results are indicated. The impact of prognostic factors, proper staging procedures, and secondary treatments on the interpretation of survival analysis is pointed out. A shift from the (mis-)use of the P value in favor of confidence intervals is strongly encouraged. The use of comparing the survival of responders versus nonresponders is to be abandoned. A few practical hints concerning the presentation are offered. The minimum of data that should be presented in absolute numbers is indicated. Also, the data that should be provided in both graphic and numeric format are exemplified. Examples of essential graphic illustrations are provided. The need for improvements in the design analysis, and presentation of clinical trials is reemphasized. Finally, numerous references are listed. The article is addressed not only to authors and readers of clinical trials, but also to editors of medical journals.

CONCLUSION

The suggested guidelines may be useful in the analysis, presentation, and interpretation of clinical trials on prostate cancer. Moreover, compliance with these guidelines may facilitate comparisons with other similar trials and also, the incorporation of single studies into metaanalyses.

Quantitative bone scintigraphy in patients with prostatic carcinoma treated with LH-RH analogues

In 14 men with prostatic carcinoma, quantitative scintigraphy of the vertebrae from Th10 to L5 was performed before and 2 weeks and 2 and 6 months after start of treatment with luteinizing hormone-releasing hormone (LH-RH) analogues. Serum prostate-specific antigen (PSA) was also determined. The patients with normal bone scintigram showed no change in gamma camera count rate during the study, but fall in PSA values. The patients with abnormal bone scintigram responded to treatment with flare phenomenon, with increased count rate at 2 weeks, followed by fall to pretreatment level at 2 months. PSA showed decrease as early as 2 weeks after the start of treatment. Bone scintigraphy was found to be useful before therapy, especially in patients with elevated PSA levels, and after 2 months, when the flare phenomenon had subsided. Serial measurement of PSA provided a guide to disease activity.