Preoperative androgen deprivation therapy for localized prostate cancer: delayed biochemical recurrence in high-risk disease

Neoadjuvant Hormonal Therapy for Prostate Cancer: Morphologic Features and Predictive Parameters of Therapy Response

The primary goals of neoadjuvant hormonal therapy (NHT) in prostate cancer (PCa) are to reduce the size of the tumor, lower positive surgical margin rate, attempt to reach pathologic remission, and improve survival. Although NHT has not been recommended by the National Comprehensive Cancer Network as a primary treatment option for patients with localized PCa, NHT is increasingly used in clinical trials for locally advanced PCa. More importantly, with the development of novel androgen signaling inhibitors, such as abiraterone and enzalutamide, there has been renewed interests in revisiting the role of such treatment in the neoadjuvant setting. Following NHT, the PCa tissues shows characteristic morphologic alterations. Of note, the collapse of malignant glands most likely leads to an artificial increase of Gleason score in the residual disease. Communicating these changes to the clinician in a way that can help assess the tumor's response poses a challenge for pathologists. In addition, little is known of morphologic features and predictive makers both in pretreated and posttreated specimens that can be of value in predicting tumor response to NHT. In the current review, we summarize the morphologic changes associated with neoadjuvant-treated PCa, focusing on the predictive value of pathologic parameters to therapy response. We also describe the evaluation system in the stratification of pathologic response to NHT in PCa management.

Optimizing the role of androgen deprivation therapy in advanced prostate cancer: Challenges beyond the guidelines

BACKGROUND

For specific clinical indications, androgen deprivation therapy (ADT) will induce disease prostate cancer (PC) regression, relieve symptoms and prolong survival; however, ADT has a well-described range of side effects, which may have a detrimental effect on the patient's quality of life, necessitating additional interventions or changes in PC treatment. The risk-benefit analysis for initiating ADT in PC patients throughout the PC disease continuum warrants review.

METHODS

A 14-member panel comprised of urologic and medical oncologists were chosen for an expert review panel, to provide guidance on a more judicious use of ADT in advanced PC patients. Panel members were chosen based upon their academic and community experience and expertise in the management of PC patients. Four academic members of the panel served as group leaders; the remaining eight panel members were from Large Urology Group Practice Association practices with proven experience in leading their advanced PC clinics. The panel members were assigned to four separate working groups, and were tasked with addressing the role of ADT in specific PC settings.

RESULTS

This article describes the practical recommendations of an expert panel for the use of ADT throughout the PC disease continuum, as well as an algorithm summarizing the key recommendations. The target for this publication is all providers (urologists, medical oncologists, radiation oncologists, or advanced practice providers) who evaluate and manage advanced PC patients, regardless of their practice setting.

CONCLUSION

The panel has provided recommendations for monitoring PC patients while on ADT, recognizing that PC patients will progress despite testosterone suppression and, therefore, early identification of conversion from castrate-sensitive to castration resistance is critical. Also, the requirement to both identify and mitigate side effects of ADT as well as the importance of quality of life maintenance are essential to the optimization of patient care, especially as more combinatorial therapeutic strategies with ADT continue to emerge.

Radical Prostatectomy for High-risk Localized or Node-Positive Prostate Cancer: Removing the Primary

PURPOSE OF REVIEW

We reviewed the literature to determine what role, if any, radical prostatectomy should play in the treatment of high-risk and/or node-positive prostate cancer.

RECENT FINDINGS

The AUA, NCCN, and EAU all include radical prostatectomy as a treatment option for high-risk prostate cancer based on evidence that has shown improvements in biochemical-free and disease-specific survival. Lymph node-positive patients may also derive benefit from radical prostatectomy with lymph node dissection, however, only retrospective studies with high risk of selection bias have been published to date. High-risk prostate cancer is a heterogeneous disease representing a wide range of disease characteristics. Radical surgery, historically avoided in such patients, may now be considered a valid treatment option for select cases. The adverse effects of surgery using modern techniques lead to similar quality of life outcomes as radiation therapy, and treatment of the primary tumor is likely beneficial when compared to ADT alone.

The long-term outcomes of radical prostatectomy for very high-risk prostate cancer pT3b-T4 N0-1 on definitive histopathology

INTRODUCTION

The study aimed to assess long-term outcomes in patients with very high-risk prostate cancer (PCa) - pT3b-T4 N0-1 using the definitive histopathology following radical retropubic prostatectomy (RRP).

MATERIAL AND METHODS

We have analyzed 114 patients with very high-risk PCa who underwent RRP between 1995 and 2012. Biochemical and clinical progression-free survival (BPFS, CPFS), cancer-specific and overall survival (CSS, OS) curves were constructed according to the Kaplan-Meier method. Univariate and multivariate Cox regression analysis was utilized to determine predictability of clinical and pathological parameters.

RESULTS

At the 5 and 10 year mark, the BPFS was 71.3% and 35%, respectively; the CPFS was 86.8% and 69.2%, respectively; the CSS was 98% and 76.3%, respectively and the OS was 90.3% and 62.4%, respectively. Sixteen patients (14%) had lymph-node involvement. Positive surgical margins were present in 64 (56.1%) patients. Neo-adjuvant androgen deprivation therapy (ADT) was received by 22 (19.3%) patients. Adjuvant ADT alone or in combination with external radiotherapy was received by 59 (51.8%) patients. No adjuvant treatment was needed in 29 (25.4%) patients. In univariate and multivariate analysis, neo-adjuvant ADT was associated with an increased risk of BPFS and CPFS.

CONCLUSIONS

Therapy applied in patients with very high-risk PCa was multimodal in most cases, with RP usually being the first step. The study confirmed that very high-risk PCa is a heterogeneous disease. A significant subset of patients remain without adjuvant therapy treatment.