Salvage radical prostatectomy for radio-recurrent prostate cancer: is this a viable option?

Salvage Cryosurgery for Recurrent Prostate Cancer After Radiation Therapy: A Seven-Year Follow-up

Cryosurgery of the prostate presents as an efficient therapy following failed radiation therapy. We report on a 7-year retrospective analysis evaluating the morbidity adn biochemical disease-free survival(bDFS) of this therapy. Between 1993 and 2001, 59 patients who had been previously treated with radiation therapy and had rising serum prostate-specific antigen(PSA) values underwent salvage cryoablation of the prostate for localized, histologically proven, recurrent prostate cancer. Serial serum PSA testing was performed, and biopsies were taken at 6, 12, and 24 months, and again at 5 years, and any time the PSA rose above 0.5 ng/mL. Patients were stratified along clinical parameters. The combined postsalvage bDFS rate using a PSA cutoff of 0.5 ng/mL was 59% and 69% with a 1.0 ng/mL PSA cut off. Using a PSA threshold of 0.5 ng/mL as evidence of biochemical recurrence, 61%, 62%, and 50% of patients with <4 ng/mL, 4-10 ng/mL, and > 10 ng/mL PSA, respectively, remain biochemically relapse free at 7 years. A threshold of 1.0 ng/mL yielded a disease-free status of 78%, 74%, and 46% respectively. Patients biopsies showed no evidence of residual or recurrent disease. Improved survival rates and no known latent complications indicate cryosurgery is a promising form of treatment for radiation-resistant prostate cancer. This 7-year analysis shows a promising validation of cryosurgery as an efficacious treatment modality for locally confined T1-T3 prostate cancer following primary radiation therapy failure.

Detection of alpha-methylacyl-coenzyme A racemase in postradiation prostatic adenocarcinoma

OBJECTIVES

To assess the utility of alpha-methylacyl-coenzyme A racemase (AMACR), also known as P504S, immunohistochemistry in the detection of postradiation prostatic adenocarcinoma in surgical specimens. Pathologic diagnosis of postradiation prostate cancer is difficult because of the radiation-induced cytologic changes in benign and malignant epithelial cells. AMACR/P504S is a recently identified molecular marker for prostatic adenocarcinoma. It has been demonstrated that AMACR is overexpressed in the vast majority of prostatic adenocarcinoma cases by cDNA microarray, RNA analysis, Western blotting, and immunohistochemistry.

METHODS

A total of 80 prostate glands, including 40 irradiated prostate specimens (28 with adenocarcinoma and 12 benign prostates) and 40 nonirradiated prostate specimens (20 with adenocarcinoma and 20 benign prostates), were examined. The specimens were obtained after salvage radical prostatectomy (n = 25), transurethral resection (n = 4), or needle biopsy (n = 11). All samples were immunohistochemically analyzed for AMACR.

RESULTS

All 48 carcinoma cases (28 of 28 irradiated and 20 of 20 nonirradiated specimens) showed strongly positive AMACR/P504S immunostaining. AMACR immunostaining was negative for all irradiated (n = 12) and nonirradiated (n = 20) benign prostates, as well as the irradiated benign glands adjacent to carcinoma. 34betaE12 confirmed the presence of basal cells in all benign prostates (32 of 32) and the absence of basal cells in carcinoma (0 of 48).

CONCLUSIONS

Our results demonstrate that AMACR is a highly specific and sensitive indicator of postradiation prostate cancer. AMACR immunostaining facilitates the challenging differentiation between prostatic adenocarcinoma and radiation-induced atypia in benign prostatic epithelium and may be of exceptional value in limited needle biopsies.

Radical prostatectomy for locally advanced primary or recurrent rectal cancer

AIM

Three papers including five patients have described en bloc radical prostatectomy for locally advanced rectal cancer.

METHODS

Six patients (median age 63 years) underwent en bloc radical prostatectomy for locally advanced (3) or recurrent (3) rectal cancer involving the prostate. Quality of life questionnaires were answered postoperatively and the data prospectively entered in a database.

RESULTS

One primary case had low anterior resection (LAR), the others abdominoperineal resections (APR) of R0 stage. Two recurrent cases had APRs and one tumour resection-all R1 stage. Anastomotic leakage led to construction of an ileal conduit in one patient and in two healed on conservative treatment. Follow up was 10-50 months. One patient died from distant metastases at 29 months postoperatively, one was operated for a single lung metastasis and one has disseminated lung metastases. None has developed local recurrence. Four of the five with anastomoses had good quality of life and none wanted an ileal conduit.

CONCLUSION

In spite of a relatively high urinary leak rate the total complication rate seems to be lower than after pelvic exenteration. En bloc radical prostatectomy seems an option in selected patients otherwise needing pelvic exenteration for locally advanced or recurrent rectal cancer.