Variables in predicting survival based on treating "PSA-only" relapse

Spine metastasis in patients with prostate cancer: Survival prognosis assessment

BACKGROUND

Patients presenting spine metastasis (SpM) from prostate cancer (PC) form a heterogeneous population, through this study, we aimed to clarify and update their prognostic assessment.

METHODS

The patient data used in this study was obtained from a French national multicenter database of patients treated for PC with SpM between 2014 and 2017. A total of 72 patients and 365 SpM cases were diagnosed.

RESULTS

The median overall survival time for all patients following the event of SpM was 28.8 months. First, we identified three significant survival prognostic factors of PC patients with SpM: good Eastern Cooperative Oncology Group/World Health Organization personnel status (Status 0 hazard ratio [HR]: 0.031, 95% confidence interval [CI]: 0.008-0.127; p < .0001) or (Status 1 HR: 0.163, 95% CI: 0.068-0.393; p < .0001) and SpM radiotherapy (HR: 2.923, 95% CI: 1.059-8.069; p < .0001). Secondly, the presence of osteolytic lesions of the spine (vs. osteoblastic) was found to represent an independent prognosis factor for longer survival [HR: 0.424, 95% CI: 0.216-0.830; p = .01]. Other factors including the number of SpM, surgery, extraspinal metastasis, synchrone metastasis, metastasis-free survival, and SpM recurrence were not identified as being prognostically relevant to the survival of patients with PC.

CONCLUSION

Survival and our ability to estimate it in patients presenting PC with SpM have improved significantly. Therefore, we advocate the relevance of updating SpM prognostic scoring algorithms by incorporating data regarding the timeline of PC as well as the presence of osteolytic SpM to conceive treatments that are adapted to each patient.

Prostate cancer trajectory-map: clinical decision support system for prognosis management of radical prostatectomy

Purpose

Prostate cancer has a low mortality rate and requires persistent treatment; however, treatment decisions are challenging. Because prostate cancer is complex, the outcomes warrant thorough follow-up evaluation for appropriate treatment. Electronic health records (EHRs) do not present intuitive information. This study aimed to develop a Clinical Decision Support System (CDSS) for prognosis management of radical prostatectomy.

Methods

We used data from 5,199 prostate cancer patients from three hospitals' EHRs in South Korea, comprising laboratory results, surgery, medication, and radiation therapy. We used open source R for data preprocessing and development of web-based visualization system. We also used R for automatic calculation functionalities of two factors to visualize the data, e.g., Prostate-Specific Antigen Doubling Time (PSADT), and four Biochemical Recurrence (BCR) definitions: American Society of Therapeutic Radiology and Oncology (ASTRO), Phoenix, consecutive PSA > 0.2 ng/mL, and PSA > 0.2 ng/mL.

Results

We developed the Prostate Cancer Trajectory Map (PCT-Map) as a CDSS for intuitive visualization of serial data of PSA, testosterone, surgery, medication, radiation therapy, BCR, and PSADT.

Conclusions

The PCT-Map comprises functionalities for BCR and PSADT and calculates and visualizes the newly added patient data automatically in a PCT-Map data format, thus optimizing the visualization of patient data and allowing clinicians to promptly access patient data to decide the appropriate treatment.

Concentration-Dependent Effects of Zinc Sulfate on DU-145 Human Prostate Cancer Cell Line: Oxidative, Apoptotic, Inflammatory, and Morphological Analyzes

Zinc takes part in several of cellular signaling pathways, containing defense against free radicals, apoptosis, and inflammation. However, interaction between zinc and prostate cancer progression is poorly understood. Therefore, zinc treatment in DU-145 human prostate cancer cells was investigated. First, zinc sulfate (ZnSO₄) concentrations with antiproliferative effect were determined using MTT assay. Then, ZnSO₄-induced oxidative damage was evaluated by malondialdehyde (MDA) levels, glutathione (GSH) levels, total oxidant status (TOS) levels, and total antioxidant status (TAS) levels. Apoptotic effects of ZnSO₄ were determined by measuring biochemical and immunohistochemical parameters including caspase 3 (CASP3), cytochrome C (CYC), Bcl-2-associated X protein (Bax), and B cell CLL/lymphoma 2 (Bcl-2) levels. Inflammatory effects of ZnSO₄ were investigated by measuring interleukin-6 (IL-6) levels and tumor necrosis factor-alpha (TNF-α) levels. Finally, morphological analysis was performed using hematoxylin-eosin staining. We found that ZnSO₄ caused a concentration-dependent increase in oxidative stress, apoptosis, and inflammation pathways. Moreover, there were a number of morphological alterations in treated cells depending on the ZnSO₄ concentration. Consequently, our data showed that zinc acts as a regulator of increased oxidative damage and apoptosis through the upregulation of TNF-α and IL-6.

The therapeutic efficacy of I131-PSCA-mAb in orthotopic mouse models of prostate cancer

Background

Prostate stem cell antigen (PSCA) is upregulated in prostate cancer tissues. Here we aimed to study the therapeutic efficacy of a monoclonal antibody of PSCA-labeled I¹³¹ (I¹³¹-PSCA-mAb) in orthotopic mouse models of prostate cancer.

Methods

The proliferation, apoptosis and invasion abilities of PC-3 and LNCaP cells treated with I¹³¹-PSCA-mAb were measured by methyl thiazolyl tetrazolium assay, flow cytometry and transwell culture, respectively. The human prostate cancer models were established by orthotopic implantation of PC-3 and LNCaP cells in nude mice. I¹³¹-PSCA-mAb distribution and tumor cell apoptosis in the tumor-bearing nude mice were measured.

Results

The inhibitory and apoptosis rates of PC-3 and LNCaP cells treated with I¹³¹-PSCA-mAb reached a maximum of 84%, 80% and 50%, 46%, respectively, which were obviously higher than in the cells treated with I¹³¹-IgG or PSCA-mAb. The invaded number of PC-3 and LNCaP cells treated with I¹³¹-PSCA-mAbe was significantly reduced (P < 0.01) compared with the control group. The ratios of I¹³¹-PSCA-mAb in tumor to intramuscular I¹³¹-PSCA-mAb (T/NT) in tumor-bearing nude mice were increased with time and reached the highest level after 8 h. T/NT stayed above 3.0 after 12 h, and the tumor could still be developed after 24 h. The number of apoptotic cells in tumor tissue of nude mice treated with I¹³¹-PSCA-mAb was larger than that in the control group.

Conclusion

I¹³¹-PSCA-mAb has the potential to become a new targeted therapy drug for the treatment of prostate cancer.

Predictive factors of oncologic outcomes in patients who do not achieve undetectable prostate specific antigen after radical prostatectomy

PURPOSE

We identified factors predicting oncologic outcomes in cases of persistently detectable prostate specific antigen.

MATERIALS AND METHODS

We reviewed the charts of patients treated with radical prostatectomy between 1998 and 2011 at a total of 14 centers. Study inclusion criteria were radical prostatectomy for presumed localized prostate cancer, absent positive nodes and detectable prostate specific antigen, defined as prostate specific antigen 0.1 ng/ml or greater 6 weeks postoperatively. Of the 9,735 radical prostatectomy cases reviewed 496 (5.1%) were eligible for analysis. Predictive factors for oncologic outcomes were assessed in time dependent analyses using the Kaplan-Meier method and Cox regression models.

RESULTS

At 6 weeks prostate specific antigen was 0.1 to 6.8 ng/ml. Biochemical progression was noted in 74.4% of patients and clinical metastasis was noted in 5%. The 2 most powerful predictors of general salvage treatment (vs radiotherapy) were postoperative prostate specific antigen greater than 1 ng/ml (OR 3.46, p=0.032) and prostate specific antigen velocity greater than 0.2 ng/ml per year (HR 6.01, p=0.001). Positive prostate specific antigen velocity was the single factor that independently correlated with the risk of failed salvage therapy (HR 2.6, p=0.001). The 5-year disease-free survival rate was 81.0% in patients with stable or negative prostate specific antigen velocity compared with 58.4% in those with positive prostate specific antigen velocity (p<0.001).

CONCLUSIONS

Patients with detectable prostate specific antigen after radical prostatectomy have a poor biochemical outcome. We identified postoperative prostate specific antigen and prostate specific antigen velocity as independent predictors of progression and failed salvage treatment. In addition to pathological prognostic factors, these factors should be considered early to better stratify patients for adjuvant therapy.

Antiproliferative effects of zinc-citrate compound on hormone refractory prostate cancer

OBJECTIVE

To investigate the antiproliferative effects of zinc-citrate compound on hormone refractory prostate cancer (HRPC).

METHODS

HRPC cell line (DU145) and normal prostate cell line (RWPE-1) were treated with zinc, citrate and zinc-citrate compound at different time intervals and concentrations to investigate the effect of zinc-citrate compound. Mitochondrial (m)-aconitase activity was determined using aconitase assay. DNA laddering analysis was performed to investigate apoptosis of DU145 cells. Molecular mechanism of apoptosis was investigated by Western blot analysis of P53, P21(waf1), Bcl-2, Bcl-xL and Bax, and also caspase-3 activity analysis.

RESULTS

Treatment with zinc-citrate compound resulted in a time- and dose-dependent decrease in cell number of DU145 cells in comparison with RWPE-1. M-aconitase activity was significantly decreased. DNA laddering analysis indicated apoptosis of DU145 cells. Zinc-citrate compound increased the expression of P21(waf1) and P53, and reduced the expression of Bcl-2 and Bcl-xL proteins but induced the expression of Bax protein. Zinc-citrate compound induced apoptosis of DU145 cells by activation of the caspase-3 pathway.

CONCLUSION

Zinc-citrate compound can induce apoptotic cell death in DU145, by caspase-3 activation through up-regulation of apoptotic proteins and down-regulation of antiapoptotic proteins.

Risk Stratification after Biochemical Failure following Curative Treatment of Locally Advanced Prostate Cancer: Data from the TROG 96.01 Trial

Purpose. Survival following biochemical failure is highly variable. Using a randomized trial dataset, we sought to define a risk stratification scheme in men with locally advanced prostate cancer (LAPC). Methods. The TROG 96.01 trial randomized 802 men with LAPC to radiation ± neoadjuvant androgen suppression therapy (AST) between 1996 and 2000. Ten-year follow-up data was used to develop three-tier post-biochemical failure risk stratification schemes based on cutpoints of time to biochemical failure (TTBF) and PSA doubling time (PSADT). Schemes were evaluated in univariable, competing risk models for prostate cancer-specific mortality. The performance was assessed by c-indices and internally validated by the simple bootstrap method. Performance rankings were compared in sensitivity analyses using multivariable models and variations in PSADT calculation. Results. 485 men developed biochemical failure. c-indices ranged between 0.630 and 0.730. The most discriminatory scheme had a high risk category defined by PSADT < 4 months or TTBF < 1 year and low risk category by PSADT > 9 months or TTBF > 3 years. Conclusion. TTBF and PSADT can be combined to define risk stratification schemes after biochemical failure in men with LAPC treated with short-term AST and radiotherapy. External validation, particularly in long-term AST and radiotherapy datasets, is necessary.

Why are pretreatment prostate-specific antigen levels and biochemical recurrence poor predictors of prostate cancer survival?

BACKGROUND

The value of pretreatment (initial) prostate-specific antigen (iPSA) and biochemical recurrence (BR) as prognostic factors for survival remains unclear. The authors sought to determine why using randomized trial data with 7-year minimum follow-up.

METHODS

In the Trans-Tasman Radiation Oncology Group 96.01 trial, 802 men with T2b, T2c, T3, or T4 N0 prostate cancer (PC) were randomized to radiotherapy alone or with 3 or 6 months neoadjuvant androgen deprivation between 1996 and 2000. Cox modeling was used to identify outcome predictors at follow-up landmark points.

RESULTS

Higher iPSA was found to be a potent predictor of BR-free survival (P < .01) but was not prognostic for prostate cancer-specific survival (PCSS) from randomization. Patients experiencing BR had unfavorable initial prognostic factors compared with patients who did not. After BR, these factors were not prognostic for PC death in models adjusted for time to BR (TTBR). In these models, TTBR predicted PCSS more satisfactorily than the occurrence of BR itself. Survival probability 5 years after BR exceeded 90% for men with TTBR >/=4 years; however, it dropped to 44% +/- 6% for men with TTBR <1 year. After BR, rapid PSA doubling time (DT), low iPSA, and short TTBR were identified as the most important predictors of inferior PCSS.

CONCLUSIONS

When BR occurs, prognostic factors for survival change. Low iPSA, short TTBR, and rapid PSA DT take over at this point, providing reasons why iPSA and occurrence of BR alone predict PCSS unsatisfactorily.

The role of imaging in the detection of prostate cancer local recurrence after radiation therapy and surgery

PURPOSE OF REVIEW

The aim of this article is to review novel MRI and nuclear medicine methods for detecting and planning salvage treatment for prostate cancer local recurrence after radical prostatectomy or radiation therapy.

RECENT FINDINGS

Traditional methods for detecting local recurrence (i.e., digital rectal exam or transrectal ultrasound and digital rectal exam or transrectal ultrasound-guided biopsy) have limited accuracy in determining the presence and extent of local recurrence and therefore have limited ability to guide salvage therapy. Recent studies indicate that conventional T1 and T2-weighted prostate MRI could improve the detection of recurrent prostate cancer after radical prostatectomy or radiation therapy and salvage treatment planning. Promising new sequences could further increase the accuracy of MRI. In addition, the use of technically improved PET/computed tomography scanners with new tracers like (11)C and (18)F choline and acetate might offer better assessment of recurrent prostate cancer than (18)F-2-fluoro-D-deoxyglucose-PET and monoclonal antibody imaging with the prostate specific membrane antigen antibody (111)In-capromab pendetide (ProstaScint).

SUMMARY

With systemic therapies for recurrent prostate cancer after radical prostatectomy or radiation therapy being noncurative, the application of MRI and nuclear medicine modalities can help to identify patients who have isolated local recurrence amenable to salvage treatment.

Rising prostate-specific antigen after primary treatment of prostate cancer: sequential hormone manipulation

OBJECTIVE

To evaluate systematically the current endocrine treatment options for patients with biochemical recurrence after radical prostatectomy or radiation therapy for localized prostate cancer.

METHODS

Literature search of PubMed documented publications and abstracts from international meetings. Key items included timing and type of salvage hormone therapy, length of its application and handling of side effects.

RESULTS

The majority of patients with isolated prostate-specific antigen (PSA) relapse are not candidates for salvage treatment with curative intent. The PSA threshold that triggers initiation of hormonal therapy is debatable and should be based also on pretreatment risk assessment. Intermittent androgen suppression is an emerging concept to circumvent the unresolved controversy of early versus deferred endocrine therapy. Since the tumor load at time of recurrence is low, peripheral androgen blockade with an antiandrogen and a 5alpha-reductase inhibitor is an acceptable first choice. In case of progression, addition of a LHRH analogue would be the next step. Antiandrogen withdrawal and second-line antiandrogens are clinically of limited value.

CONCLUSIONS

Biochemical-only progression after definitive treatment in curative intent is different from objective or even symptomatic relapse and allows for sequential hormonal therapy with a variety of compounds.

Management of asymptomatic rise in prostatic-specific antigen in patients with prostate cancer

Biochemical failure after curative-intent therapies is an increasingly common dilemma confronting patients and physicians. No definition of biochemical failure exists that can be applied to all forms of treatment and that is not to some degree affected by the follow-up interval, pretreatment prognostic factors, or the frequency of prostatic-specific antigen (PSA) testing. Available imaging techniques lack sensitivity in detection of occult micrometastases. Prognostic factors such as tumor characteristics and PSA kinetics should be considered when recommending second-line therapies. For those patients with suspected localized recurrence, second-line treatment with salvage therapies may provide long-term disease control. Hormonal therapy, although most commonly employed for PSA recurrence, is of palliative benefit only. Currently, the most appropriate therapeutic intervention for asymptomatic patients with evidence of biochemical failure remains undefined.

Expression signatures that correlated with Gleason score and relapse in prostate cancer

Predicting prognosis in prostate carcinoma remains a challenge when using clinical and pathologic criteria only. We used an array-based DASL assay to identify molecular signatures for predicting prostate cancer relapse in formalin-fixed, paraffin-embedded (FFPE) prostate cancers, through gene expression profiling of 512 prioritized genes. Of the 71 patients that we analyzed, all but 3 had no evidence of residual tumor (defined as negative surgical margins) following radical prostatectomy and no patient received adjuvant therapy following surgery. All of the 71 patients had an undetectable serum PSA following radical prostatectomy. Follow-up period was 44+/-15 months. Highly reproducible gene expression patterns were obtained with these samples (average R(2)=0.99). We identified a panel of 11 genes that correlated positively and 5 genes that correlated negatively with Gleason grade. A gene expression score (GEX) was derived from the expression levels of the 16 genes. We assessed the prognostic value of these genes and found the GEX significantly correlated with disease relapse (p=0.007). These results suggest that the approach we used is effective for expression profiling in heterogeneous FFPE tissues for cancer diagnosis/prognosis biomarker discovery and validation.

Complexed prostate-specific antigen for the diagnosis of biochemical recurrence after radical prostatectomy

OBJECTIVES

To determine the validity of using complexed prostate-specific antigen (cPSA) levels for diagnosing biochemical recurrence after radical prostatectomy (RP).

PATIENTS AND METHODS

With linear regression modelling, we determined threshold cPSA levels for biochemical recurrence in patients after RP for clinically localized prostate cancer. We calculated sensitivity, specificity, predictive values, and likelihood ratio tests of each threshold for diagnosing biochemical recurrence using total PSA (tPSA) as the reference standard.

RESULTS

In the regression models, tPSA and cPSA were highly correlated (r = 0.99). For the diagnosis of biochemical recurrence, tPSA thresholds of 0.20 and 0.40 ng/mL corresponded to cPSA thresholds of 0.12 ng/mL (95% confidence interval 0.08-0.17) and 0.29 (0.22-0.28) ng/mL, respectively. For the detection of biochemical recurrence, a cPSA threshold of 0.12 ng/mL had a sensitivity of 96%, specificity of 88%, positive predictive value of 89%, negative predictive value of 88%, positive likelihood ratio of 8, and negative likelihood ratio of 0.05; the respective values for a cPSA threshold of 0.29 ng/mL were 96%, 96%, 96%, 96%, 24 and 0.04.

CONCLUSIONS

cPSA has high validity for the diagnosis of biochemical recurrence after RP. Pending external validation, cPSA might be useful for biochemical surveillance after RP.

Survival benefit for early hormone ablation in biochemically recurrent prostate cancer

PURPOSE

To determine whether early initiation of androgen ablation in patients with biochemically recurrent prostate cancer, but without clinically evident metastases, is associated with improved overall or disease-specific survival. To describe subgroups, based on PSA kinetics, which are most likely to benefit from early androgen ablation.

MATERIALS AND METHODS

A retrospective cohort of 124 patients, who were definitively treated by external beam radiotherapy between 1988 and 1999, and subsequently received androgen ablation for biochemical (92 patients) or clinically metastatic (32 patients) failure, was reviewed. Median follow-up time was 6.2 years. Overall survival, disease-specific survival, and hormonal control were examined and compared for patients whose hormone ablation was started early (prostate-specific antigen [PSA] <or=15 ng/ml or PSA doubling time >7 months) or late in the course of their biochemical failure.

RESULTS

All patients had biochemical response to hormone initiation, with a median PSA nadir of 0.05 ng/ml. Early initiation of hormone ablation resulted in statistically significant improvement in all outcome measures. Multivariate analysis indicated that PSA doubling time at hormone initiation was the most consistent predictor of outcome. The 5-year overall survival was 78% for patients whose androgen ablation was initiated at doubling time <or=7 months and 93% for patients when initiated at doubling time >7 months. Mean survival improved from 84.9 +/- 4.6 (doubling time <or=7) to 115.3 +/- 8.4 months (doubling time >7). Survival for patients started on hormones with doubling time <5 months was similar to that of patients with clinical metastases.

CONCLUSIONS

This survival benefit justifies the use of androgen ablation in patients whose doubling time approaches 7 months. A randomized trial is needed to confirm these findings, investigate potential benefit for patients with longer doubling times, and gather data on the morbidity of early hormone ablation, including quality of life issues.

Variation in the Definition of Biochemical Recurrence in Patients Treated for Localized Prostate Cancer: The American Urological Association Prostate Guidelines for Localized Prostate Cancer Update Panel Report and Recommendations for a Standard in the Reporting of Surgical Outcomes

PURPOSE

The American Urological Association Prostate Guideline Update Panel was charged with updating the Guidelines for Clinically Localized Prostate Cancer. In assessing outcomes with treatment, it became apparent that a highly variable number of definitions exist with respect to biochemical recurrence. Herein, we review the variability in published definitions of biochemical recurrence and make recommendations directed toward improving this terminology by recommending a standard definition in patients treated with radical prostatectomy.

MATERIALS AND METHODS

Four PubMed literature searches were performed between May 2001 and April, 2004 and covered articles published from 1991 through early 2004. The search terms included the MeSH major headings of prostate cancer and prostatic neoplasm. All potentially relevant articles were retrieved and a more detailed screen for relevance was performed. An article was considered relevant if it reported treatment outcomes of patients with clinical T1 or T2N0M0 prostate cancer. Data extractors recorded the definition of biochemical recurrence and definitions were then collapsed into categories representing the same criteria. The results of biochemical failure were subcategorized by initial treatment.

RESULTS

Of 13,800 citations, a total of 436 articles were selected. Among these, a total of 145 articles contained 53 different definitions of biochemical recurrence for those treated with radical prostatectomy. Of these, the most common definition (35) was a prostate specific antigen of >0.2 ng/mL or a slight variation thereof. In addition, a total of 208 articles reported 99 different definitions of biochemical failure among those treated with radiation therapy. Of these, the American Society for Therapeutic Radiology and Oncology definition (70) and/or a variation thereof was the most commonly reported. In total, 166 different definitions of biochemical failure were identified. Following radical prostatectomy, the Panel recommends defining biochemical recurrence as an initial serum prostate specific antigen of > or =0.2 ng/mL, with a second confirmatory level of prostate specific antigen of >0.2 ng/mL. The Panel recommends the use of the American Society for Therapeutic Radiology and Oncology criteria for patients treated with radiation therapy and acknowledges that these criteria will soon be updated although not yet published.

CONCLUSIONS

A high degree of variability in the definition of biochemical recurrence exists following treatment for localized prostate cancer. Strict definitions for biochemical recurrence are necessary to identify men at risk for disease progression and to allow meaningful comparisons among patients treated similarly. The Panel acknowledges the American Society for Therapeutic Radiology and Oncology criteria and future modifications thereof for those receiving radiation therapy and recommends the newly developed American Urological Association criteria for those treated with radical prostatectomy. The purpose for the establishment of this standard is for data reporting purposes and for comparison of similarly treated patients. It is not intended to represent a threshold value for which to initiate treatment. The Panel acknowledges that the clinical decision to initiate treatment will be dependent on multiple factors including patient and physician interaction rather than a specific prostate specific antigen threshold value.

Estado actual del ultrasonido de alta frecuencia (HIFU) en el tratamiento del adenocarcinoma prostático

OBJECTIVE

To evaluate the current state of high intensity focused ultrasound as therapeutical option of prostatic carcinoma (PCa)

METHODS

We completed an extense review of urologic literature on the role of HIFU on the treatment of PCa.

RESULTS

This technique is nowadays usually being indicated in Europe as treatment of many cases of either primary or relapsed PCa after radiotherapy. Although some reports suggest that HIFU is very effective as treatment for low and medium risk localized PCa patients, no randomized series comparing this technique with conventional therapies have been presented yet. Great disparity in criteria to define free-disease survival is detected, which make difficult the interpretation of results.

CONCLUSIONS

Experience of some groups in HIFU is highly promising. Local tumour destruction is evident both in primary and relapsed PCa cases. To make conclusions in the long-term, controlled-randomized trials must be designed, with follow-up to measure benefits in global survival and quality of live. Comparisons must be completed with conventional techniques, and a uniform definition of disease free-survival is necessary.

Das Lokalrezidiv des Prostatakarzinoms: Hormontherapie

BACKGROUND

The majority of patients receive HT after biochemical progression despite primary therapy of prostate cancer with curative intent. It is difficult to differentiate at a low rise in PSA level, e.g., <or=1 ng/ml, between local or systemic recurrence.

MATERIAL AND METHODS

The PSA doubling time (DT) is the most reliable surrogate parameter to decide if HT should be initiated. In practice, however, the trigger PSA is used instead. The latter is closely related to the timing of HT. A high PSA is a contraindication for local salvage therapy. Intermittent HT is apparently as effective as continuous HT and shortens the time of HT exposure.

RESULTS

Traditional HT employs a LHRH agonist, however, the side effect profile is a disadvantage due to the long duration of this treatment, e.g., sarcopenia, osteopenia, or even cognitive impairment. The alternative is nontraditional HT: nonsteroidal antiandrogen (AA) alone such as bicalutamide 150 mg or peripheral androgen blockade (AA plus 5alpha-reductase inhibitor).

CONCLUSION

Even after a long duration of the latter HT the side effects are less pronounced (gynecomastia) and treatable. Particularly in patients with high-risk primary tumors [Gleason score 7(4+3)-10 or an initially high PSA], nontraditional HT may be followed by secondary HT.

Detectable Prostate Specific Antigen Between 60 and 120 Days Following Radical Prostatectomy for Prostate Cancer: Natural History and Prognostic Significance

PURPOSE

Following radical retropubic prostatectomy for prostate cancer, if the serum prostate specific antigen fails to become undetectable, occult micrometastatic disease is suspected. We assessed the natural history of disease progression, and predictors of recurrence and survival in this group of patients.

MATERIALS AND METHODS

We identified 303 men treated with radical retropubic prostatectomy for prostate cancer between 1990 and 1999, who had a detectable prostate specific antigen between 60 and 120 days postoperatively. Systemic recurrence-free and cancer specific survival were estimated using the Kaplan-Meier method, and analyzed using Cox proportional hazards models.

RESULTS

Clinical and pathological features were more adverse among men whose postoperative prostate specific antigen was detectable. These men had poorer systemic recurrence-free survival and cancer specific survival compared to men with an undetectable postoperative prostate specific antigen, and even men whose prostate specific antigen subsequently became detectable. These differences persisted after multivariate adjustment for preoperative prostate specific antigen, specimen Gleason score, seminal vesicle and margin status. With a median followup of 8.5 years, 50 systemic recurrences and 26 deaths from cancer were observed. Gleason score and the prostate specific antigen doubling time were multivariate predictors of systemic recurrence, while Gleason score, margin status and seminal vesicle invasion were predictors of death from cancer.

CONCLUSIONS

A detectable prostate specific antigen immediately following radical retropubic prostatectomy confers an increased risk of progression and death, but only in a subset of patients, who may be identified on the basis of pathological features and prostate specific antigen doubling time. In future such patients may be suitable for trials of systemic therapy.

History of diabetes, clinical features of prostate cancer, and prostate cancer recurrence-data from CaPSURE (United States)

OBJECTIVES

There is a growing epidemiologic literature suggesting an inverse association between history of diabetes and risk of incident prostate cancer. To our knowledge, the relationship between diabetes and tumor features and risk of recurrence among men with prostate cancer has not been examined previously. We hypothesized that men with diabetes would present with more favorable prostate cancer and experience lower risk of recurrence.

METHODS

We identified 691 men with diabetes at the time of prostate cancer diagnosis, among 6722 men diagnosed with prostate cancer in 1989 to 2002 within CaPSURE(TM), a community-based prostate cancer registry study. We compared clinical and socio-demographic variables by diabetes status, using chi2 tests, t-tests, and multinomial logistic regression. We examined recurrence rates for prostate cancer among patients with and without diabetes using Kaplan-Meier log-rank tests and Cox proportional hazard models.

RESULTS

In multivariate analyses, history of diabetes was not associated with any diagnostic clinical parameter, and treatment-specific recurrence rates for prostate cancer generally did not differ by diabetes history. Among men with low-prognostic risk or who were younger at prostate cancer diagnosis, being diabetic (versus not) was associated with an elevated risk of recurrence after radiation therapy, in multivariate analyses.

CONCLUSIONS

Contrary to data suggesting that diabetes may be modestly protective against risk of incident prostate cancer, we did not observe any evidence of an inverse association between history of diabetes and aggressiveness at diagnosis or risk of recurrence, in this population of men with prostate cancer.

Biochemical Recurrence after Localized Treatment

The quoted incidence of biochemical recurrence (BCR) after localized treatment varies significantly and depends on numerous well-known prognostic factors; however, it likely occurs in at least 30%-40% of patients who receive localized treatment. Because the clinical significance of BCR is often unclear, and depends in many cases on unknown factors, it is difficult to select the best treatment and determine when best to institute that therapy. This review examines some of the issues associated with BCR and attempts to shed some light on this common but controversial clinical scenario. Some treatment strategies discussed in this article include salvage radiotherapy after radical prostatectomy, salvage therapy after radiotherapy, and hormonal therapy.

Endorectal MR Imaging before Salvage Prostatectomy: Tumor Localization and Staging

PURPOSE

To evaluate retrospectively the accuracy of endorectal magnetic resonance (MR) imaging for the depiction of tumor, extracapsular extension (ECE), and seminal vesicle invasion (SVI) before salvage prostatectomy in patients with locally recurrent prostate cancer after radiation therapy, by using pathologic analysis as the reference standard.

MATERIALS AND METHODS

The Institutional Review Board granted exempt status for this HIPAA-compliant study, with a waiver of informed consent. Forty-five consecutive patients (age range, 43-76 years) were identified who underwent salvage radical prostatectomy for prostate cancer at Memorial Sloan-Kettering Cancer Center between December 1, 1998, and October 31, 2004, and who underwent endorectal MR imaging prior to surgery. Tumor localization and determination of local stage with MR imaging were performed independently by two radiologists. Interpretations were compared to pathologic findings from surgical specimens. Interrater variability was estimated with the kappa statistic. Areas under the receiver operating characteristic curve (AUCs) were used to assess the accuracy of endorectal MR imaging in tumor detection and determination of ECE and SVI.

RESULTS

Findings of histologic examination showed that tumor was present in all patients. For tumor detection, the AUC value for reader 1 was 0.75 (95% confidence interval [CI]: 0.67, 0.84), whereas the AUC value for reader 2 was 0.61 (95% CI: 0.52, 0.71). The AUC values for prediction of ECE were 0.87 (95% CI: 0.80, 0.94) for reader 1 and 0.76 (95% CI: 0.67, 0.85) for reader 2. The AUC values for prediction of SVI were 0.76 (95% CI: 0.62, 0.90) for reader 1 and 0.70 (95% CI: 0.56, 0.85) for reader 2. For all variables, the kappa statistics used to assess interrater agreement between readers were fair (0.45, 0.52, and 0.47 for tumor location, ECE, and SVI, respectively).

CONCLUSION

Endorectal MR imaging following radiation therapy can help identify tumor sites and depict ECE and SVI with reasonable accuracy in patients with recurrent prostate cancer.

Circulating tumor cells predict survival in patients with metastatic prostate cancer

OBJECTIVES

To determine whether circulating tumor cells (CTCs) predict for survival in patients with metastatic prostate cancer (PCa) and to compare its prognostic abilities with other clinical factors.

METHODS

Blood samples from 37 patients with metastatic PCa were analyzed for CTCs. CTCs were enriched from 7.5 mL blood using magnetic nanoparticles targeting the epithelial cell adhesion molecule and then fluorescently labeled. The samples were analyzed by multiparameter flow cytometry, and events with appropriate light scatter properties that were nucleic acid dye positive, cytokeratin positive, and CD45 negative were defined as CTCs.

RESULTS

The number of CTCs found ranged from 0 to 8586 per 7.5 mL (mean 530 +/- 1887, median 5). A threshold of 5 or more CTCs per 7.5 mL of blood was used to evaluate the ability of CTCs to predict for overall survival. Of the 37 patients, 23 (62%) had 5 or more CTCs, with a median overall survival of 0.70 year compared with more than 4 years for those patients with fewer than 5 CTCs (log-rank P = 0.002, Cox hazards ratio 7.4). In the subset of 26 patients with hormone-refractory PCa, the presence of CTCs was the most significant parameter predictive of survival in univariate and multivariate analyses.

CONCLUSIONS

In this pilot study, the presence of 5 or more CTCs in 7.5 mL blood was associated with poor overall survival in patients with metastatic PCa.

The role of luteinizing hormone-releasing hormone therapy in locally advanced prostate cancer and biochemical failure: considerations for optimal use

BACKGROUND

More patients are being diagnosed with prostate cancer at an earlier age with earlier stage disease because of advances in screening and detection. Investigators continue to explore the use of hormone therapy, particularly luteinizing hormone-releasing hormone (LHRH) analogues, earlier in the course of disease.

OBJECTIVE

This review summarizes clinical evidence regarding the safety and efficacy of LHRH analogues in the treatment of locoregional disease or following biochemical failure.

METHODS

Relevant information from clinical studies was identified through a MEDLINE search of the medical literature published in English in the last 5 years (search terms: LHRH and prostate cancer). The search included prospective and retrospective clinical studies on LHRH therapy in locally advanced prostate cancer. Additional relevant publications published before 1999 were identified from citations in the resulting articles.

RESULTS

The available clinical evidence suggests that the use of LHRH analogues as adjuvant or neoadjuvant therapy in conjunction with radiation therapy may improve survival outcomes. Few studies have evaluated the use of LHRH analogues after biochemical failure. However, several related studies indicate that initiating hormone therapy earlier rather than later may provide some clinical benefit. When considering early initiation of LHRH therapy, the potential risks of long-term treatment must be considered. Physiologic changes, such as deterioration of body composition and bone quality, may have important effects on the risk of developing cardiovascular disease and osteoporosis.

CONCLUSIONS

Although some clinical evidence supports the use of LHRH analogues as adjuvant or neoadjuvant therapy or following biochemical failure, further study is needed. In the meantime, clinicians should carefully weigh the potential benefits and risks of early hormone therapy when making treatment decisions.

[Prostate cancer recurrence after radical prostatectomy and salvage radiotherapy]

OBJECTIVE

To evaluate the efficacy of the radiotherapy to prostatic bed in patients with biochemical recurrence for prostate cancer after radical prostatectomy.

MATERIAL AND METHODS

We analyse the results of 292 patients underwent radical prostatectomy for localized prostate cancer T1-T2 between January 1992 and June 2003, with an average folow-up of 36 months (range 6 months to 12 years). We detect biochemical recurrence (PSA >0.20 ng/ml) in 75 (26%) patients. Of 75 patients with biochemical recurrence, 9 (12%) was diagnosed of local recurrence by the following criteria: a) The first PSA obtained 6 weeks after radical prostatectomy <0.20 ng/ml. b) The time to biochemical recurrence >6 months. c) The prostate specific antigen doubling time >6 months. d) The prostate specific antigen velocity after radical prostatectomy <0.75 ng/ml/year. e) The prostate specific antigen level after radical prostatectomy <2.5 ng/ml. The 9 patients diagnosed of local recurrence received an average dose of 56.42 Gy in the prostate bed.

RESULTS

Of all 9 patients with local recurrence, 7 (77.7%) has complete response with an average time of follow-up of 25 months (6-30 months). The time between the radiotherapy and the response, in patients with complete response, was lower than 3 months. Were not observed significant adverse effects associated to radiotherapy.

CONCLUSIONS

The salvage radiotherapy may be beneficial in select patients with local recurrence. The characteristics of prostate specific antigen elevation are useful in distinguishing men with local recurrence from those with distant metastases.

Evidencia Científica actual sobre la utilidad del Ultrasonido de Alta Intensidad (HIFU) en el tratamiento del Adenocarcinoma Prostático

OBJECTIVES

To evaluate in the literature scientific evidence on the use of High-Intensity Focal Ultrasound (HIFU) in the treatment of prostatic carcinoma (PC).

METHOD

Three database are searched: PubMed, Cochrane Library, HTA database. Several articles were selected taking into account number of cases, inclusion criteria, duration of follow-up period. We have evaluated the best evidence available through a systematic review of clinical efficacy and cost-effectiveness of HIFU in the treatment of PC. We analized global survival, disease-free survival, and quality of life, including complications, adversal effects and acceptance of the technique.

RESULTS

Publications available are focused on two main indications of the therapy: first step of management of PC and salvage therapy for locally recurrent PC after external beam radiotherapy. It was very difficult to draw conclusions on the relative benefits of the HIFU: lack of high or medium quality evidence and no comparisons between this technique an standard treatments. In relation to results on cost-effectiveness, no relevant studies were identified in order to get conclusions on the quality of the treatment. Most of reports offered disparity in the definition of free survival disease concept. This fact produce some misunderstanding of results and conclusions cannot be drawn correctly. Inclusion criteria were also heterogeneous between authors.

CONCLUSIONS

No high-quality clinical evidence can be established currently on the utility of HIFU as treatment of prostatic cancer. An important fact to stress is the capacity of therapy to produce tumour necrosis both as first-step treatment and as salvage therapy. No conclusions can be drawn in the long-term due to the paucity of controlled and randomized trials with adequate follow-up to establish benefits in terms of global survival and quality of life (balance adversal effects/benefits), lack of comparisons with standard options as long as different definitions of free-survival disease.

PSA relapse prostate cancer: the importance of tailored therapy

Prostate specific antigen (PSA) is an invaluable tumor marker in the detection of early prostate cancer as well as a predictor of recurrence after treatment of localized disease. Current practice entails the use of factors such as pretherapy grade, stage and PSA, PSA doubling time, nature of previous therapy and patient age and functional status for a treatment recommendation. For a PSA relapse post radical prostatectomy, radiation therapy to the prostatic fossa is a primary therapeutic consideration. With careful patient selection, about 30 to 40% of patients are rendered disease free using this approach. For patients with radiation therapy as the primary treatment for their prostate cancer, salvage prostatectomy can be considered, but is rarely feasible. Systemic therapy with hormones is standard if patients are not candidates for the above mentioned salvage local therapies or if they relapse after exhaustive local therapies. Unfortunately androgen suppressive therapy is unlikely to induce cure, or prolonged remissions in PSA relapse prostate cancer. The strategy of addition of chemotherapy or biologic therapy to androgen suppressive therapy is under active investigation. The goal of this therapy is to make an impact on the time to progression to metastatic prostate cancer and correspondingly decrease prostate cancer related mortality. Preliminary results of studies incorporating early chemotherapy in combination with androgen suppressive therapy are encouraging, with improvement in time to progression and overall survival. The evaluation of biologic agents and agents with better toxicity profiles is ongoing. This is very important to make therapy widely applicable and to enable prolonged administration especially in a disease such as prostate cancer with a relatively long natural history. Strategies of adjuvant and neoadjuvant therapy in locally advanced prostate cancer are exploring the possibility of reducing the chance of PSA relapse by treating micrometastatic disease. This review discusses the current practices in risk stratification and management of PSA relapse prostate cancer. It also highlights the major clinical trials and areas of active investigation in this field.

An analysis of risk factors for biochemical progression in patients with seminal vesicle invasion: validation of Kattan's nomogram in a pathological subgroup

OBJECTIVE

To assess the ability of a recently published nomogram to predict failure after radical retropubic prostatectomy (RRP) in a cohort of patients with seminal vesicle invasion (SVI) of the resected specimen, widely regarded as a very poor prognostic factor in patients with prostate cancer.

PATIENTS AND METHODS

Men with SVI after RRP were analysed retrospectively; patients with positive lymph nodes, adjuvant radiotherapy or hormone therapy were excluded. Age, race, baseline prostate specific antigen (PSA) level, clinical stage, Gleason score, margin status, perineural invasion, capsular invasion, laterality and route of invasion were recorded. Biochemical recurrence was defined as one PSA measurement of 0.4 ng/mL. Biochemical disease-free survival probability was plotted using the Kaplan-Meier method. Kattan's nomogram was applied to each patient and a receiver-operator characteristic (ROC) curve produced to assess the test's reliability.

RESULTS

In all, 67 patients with SVI were identified (mean age 64.6 years, sd 5.9; median follow-up 30.5 months). Biochemical disease-free survival was significantly better for men with negative margins, unilateral SVI and perineural invasion. No other significant factors were detected. The median (95% confidence limit) area under the ROC curve was 0.739 (0.604-0.847).

CONCLUSION

There were significant prognostic differences for three of the factors assessed. Although components of the Kattan nomogram were not significant in this group its predictive value approached that found originally, suggesting that it can be applied to patients with SVI in helping to direct adjuvant therapy and guide postoperative counselling.

American Society of Clinical Oncology recommendations for the initial hormonal management of androgen-sensitive metastatic, recurrent, or progressive prostate cancer

PURPOSE

To develop a clinical practice guideline for the management of men with metastatic, recurrent, or progressive carcinoma of the prostate. The focus of this document is on the use, combinations, and timing of various forms of androgen deprivation therapy (ADT) for the palliation of men with androgen-sensitive disease.

METHODS

An expert panel and writing committee were formed. The questions to be addressed by the guideline were determined, and a systematic review of the literature was performed, which included a search of online databases, bibliographic review, and consultation with content experts. A priori criteria were used to select studies for analysis and study authors were contacted when necessary.

RESULTS

There were 10 randomized controlled trials, six systematic reviews, and one Markov model available to inform the guidelines.

CONCLUSION

A full discussion between practitioner and patient should occur to determine which therapy is best for the patient. Bilateral orchiectomy or luteinizing hormone releasing hormone agonists are the recommended initial treatments. Nonsteroidal antiandrogen therapy may be discussed as an alternative, but steroidal antiandrogens should not be offered as monotherapy. Patients willing to accept the increased toxicity of combined androgen blockage for a small benefit in survival should be offered nonsteroidal antiandrogen in addition to castrate therapy. Until data from studies using modern medical diagnostic/biochemical tests and standardized follow-up schedules become available, no specific recommendations can be issued regarding the question of early versus deferred ADT. A discussion about the pros and cons of early versus deferred ADT should occur.

Natural history of disease progression in patients who fail to achieve an undetectable prostate-specific antigen level after undergoing radical prostatectomy

BACKGROUND

To the authors' knowledge, the natural history of disease progression to distant metastasis is unknown in men who fail to achieve an undetectable prostate-specific antigen (PSA) level after radical retropubic prostatectomy (RRP),. The authors assessed the clinical outcome of men with a persistently detectable PSA level after RRP for clinically localized prostate carcinoma.

METHODS

Between 1989 and 2002, 160 men failed to achieve an undetectable PSA level (>/= 0.1 ng/mL) after undergoing RRP for clinically localized prostate carcinoma. No patient received adjuvant therapy before documented metastasis. The Kaplan-Meier method was used to estimate distant metastasis-free survival. Univariate and multivariate Cox proportional hazards regression was used to assess the ability of clinical and pathologic variables to predict distant metastasis-free survival.

RESULTS

The probability of distant metastasis-free survival at 3 years, 5 years, and 10 years was reported to be 68%, 49%, and 22%, respectively. Seventy-five men (47%) developed distant metastases after RRP (median time to metastases of 5.0 years; range, 0.5-13 years). The combination of RRP Gleason score, seminal vesicle status, and lymph node status resulted in 3 risk groups for the prediction of distant metastasis-free survival (hazards ratio [HR] = 1.6; P < 0.01). The slope of PSA changes approximately 3-12 months after RRP at a cutoff value >/= 0.05 was found to be even more predictive of distant metastasis-free survival (HR = 2.9; P < 0.01).

CONCLUSIONS

Many patients remained free of metastatic disease for an extended period despite failing to achieve an undetectable PSA level after undergoing RRP for clinically localized prostate carcinoma. However, other patients experienced rapid disease progression to distant metastasis. The authors defined clinical (PSA slope) and pathologic (Gleason score) prognostic variables to help identify those patients with a higher risk of developing distant metastasis after undergoing RRP.