[Clinical and histopathological parameters of prostate cancer: influence of anthropometric indices]

BACKGROUND

Adipose tissue is increasingly considered as an endocrinal active organ and may have an influence on the development and progression of prostate cancer. Adverse body fat distribution, considered a risk factor for cardiovascular disease, is not reflected by the body mass index (BMI).

OBJECTIVE

The purpose of this work was to assess anthropometric indices which provide a better estimate of body fat distribution and to evaluate their association with clinical and histopathological parameters of prostate cancer.

PATIENTS AND METHODS

In patients scheduled for radical prostatectomy between March 2011 and March 2013, height, weight, waist circumference (WC) and hip circumference were measured, then the BMI, waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) were calculated. The relationships between anthropometric measures and indices and clinical and histopathological features of PCA were evaluated with uni- and multivariate analyses.

RESULTS

In 668 patients available for evaluation, obesity rates were 22.8 %, 50.6% and 30.2 % as defined by BMI ≥ 30, WHR ≥ 1 and WHtR ≥ 0.6, respectively. On univariate analysis, WC and WHtR ≥ 0.6 correlated with tumor volume (TV) > 2.1 cm(2) (p < 0.05), respectively. WC and WHtR were independent predictors of a TV ≥ 2.1 cm(2) (p < 0.05) and a WHtR ≥ 0.6 was an independent predictor of a TV ≥ 2.1 cm(2) (p < 0.018, risk ratio 1.506, 95 % confidence interval 1.072-2.115).

CONCLUSION

In general a higher degree of adiposity seems to correlate with a higher tumor volume. Whether anthropometric indices have prognostic impact needs to be clarified during follow-up.

[Cystectomy in elderly patients: analysis of complications using the Clavien-Dindo classification]

Radical cystectomy (RC) represents the gold standard in the treatment of muscle invasive urothelial cancer of the bladder. Due to improvements in operation techniques and perioperative care it has become a good and safe procedure even in elderly patients. In recent years the Clavien-Dindo classification has been frequently used for complication assessment in urological research. The Charlson comorbidity index without age correction can be used in treatment planning for RC to identify patients at risk.

[Complications of radical retropubic prostatectomies based on the Martin criteria]

BACKGROUND

In 2002 the ten Martin criteria were proposed which should be met when reporting complications following surgery. Only a few studies have evaluated complication rates after open retropubic radical prostatectomy using these criteria. In this study we report on complications of open retropubic radical prostatectomy using the standardized Clavien-Dindo reporting methodology.

PATIENTS AND METHODS

The overall complication rate was 28.6% (907 of 3,172). We registered 1,069 medical or surgical complications in 907 patients. Of these, 714 complications were grade I (66.8%), 195 grade II (18.2%), 139 grade III (13%), and 17 grade IV (1.6%), respectively. The mortality rate (grade V) was 0.1% (4 of 3,172). Older age (hazard ratio 1.049, p=0.023) and a performed lymphadenectomy (hazard ratio 1.804, p=0.024) were independent predictors for high-grade complications (grade III or greater) on multivariate analysis.

RESULTS

Between 08/2003 and 06/2010 complications of 3172 consecutive men who underwent open retropubic radical prostatectomy at a single center were recorded prospectively. Complications which occurred within a period of 30 days postoperatively were graded retrospectively according to the Clavien-Dindo classification. Clinical and histopathological risk factors were statistically evaluated for an association with complication grades. All 10 Martin criteria were fulfilled.

CONCLUSIONS

Using the Clavien-Dindo classification as a standardized reporting methodology, we observed an acceptable overall complication rate of 28.6%. In the majority (85% of all complications) lower grade complications occurred. In this series older age and a lymphadenectomy were risk factors for high-grade complications (III-V). A patient's age remains an important factor when considering the indication for radical prostatectomy.

[Postoperative monitoring of anastomosis after radical retropubic prostatectomy Transrectal ultrasound can replace cystography?]

OBJECTIVE

We determined if transrectal ultrasound (TRUS) is as reliable as cystography in detecting vesicourethral extravasates after radical retropubic prostatectomy (RRP).

PATIENTS AND METHODS

Between October 2005 and February 2006 we prospectively investigated 100 consecutive patients undergoing RRP. The vesicourethral anastomosis was proven 6 days after operation by a combined investigation with TRUS and cystography.

RESULTS

In the majority of patients (79%) the vesicourethral anastomosis was watertight on postoperative day 6 (POD) or showed minimal leakage (8%) so that the urinary catheter was removed. Different degrees of paravasates were detected in 21 patients. Because of small, moderate, or marked paravasations the indwelling catheter was removed on POD 9, 14, and 21 in 5, 3, and 5 patients, respectively. Every paravasate documented by cystography had been detected by TRUS before. Therefore, TRUS showed no false-negative result in detecting insufficient anastomosis. In two patients paraurethral fluid was detected by TRUS mimicking anastomotic paravasation, without confirmation by cystography.

CONCLUSIONS

TRUS can safely replace cystography to detect anastomotic leakage after radical prostatectomy.

[Transrectal ultrasound-guided punch biopsies of the prostate. Indication, technique, results, and complications]

The golden standard for diagnosis of prostate cancer is transrectal ultrasound-guided systematic biopsy (TRUS-Bx). The optimal number of cylinders, sampling design, and indications for repeat biopsy are still in a state of flux. At the beginning of the 1980s, considerable doubts persisted regarding the benefit of ultrasound-guided punch biopsy for the diagnosis of prostate cancer. The examination on a chair with a fixed ultrasound head caused the patient substantial discomfort. Besides, in the pre-PSA era, most prostate carcinomas were detected by palpation and digitally guided biopsies were easily obtained. Indeed, the DRU procedure alone exhibited low sensitivity. Keetch et al. found that in only 25% of patients with abnormal palpatory findings and PSA between 4 and 20 ng/ml was a carcinoma revealed upon biopsy. On the other hand, patients with suspicious palpatory findings and proven malignancy suffered more frequently from locally advanced and systemic metastasizing tumors. As a result of restaging based on PSA, in most series more than half of the detected carcinomas presented normal palpatory findings. Ultrasound examination made precise imaging of zonal structures possible and thus offered the advantage of precision guidance for tissue biopsy despite lower sensitivity and specificity for diagnosis of suspicious lesions. Furthermore, calculation of prostate volume was possible. At the end of the 1980s, Hodge defined the systematic sextant biopsy as the first golden standard for early detection of prostate cancer. This meant the systematic removal of three punch cylinders from both lateral lobes of the prostate in the parasagittal midline at various levels (apex, middle, and base).

Serummarker in der Fr�herkennung und dem Staging des Prostatakarzinoms

Prostate-specific antigen (PSA) is by far the most important tumor marker in urology and has revolutionized early detection, staging, treatment, and aftercare of prostate cancer [77]. Despite these merits, inadequacies have surfaced which prohibit characterizing PSA as a perfect tumor marker. First, PSA is not a marker for prostate cancer as such:benign prostate hyperplasia, prostatitis [40,69], or prostatic manipulation [66] influence serum concentrations of PSA and lead to biopsies that are costly and potentially harmful. In the entire PSA range between 4 and 10 ng/ml, the specificity at a sensitivity of 95% continues to remain unsatisfactory. Furthermore, 30-40% of all men develop prostate cancer, but only 9-11% a clinically significant tumor burden, and 2.5-4.3% of all men die from prostate cancer. The vast majority of all carcinomas are thus in significant in terms of the patient's life expectancy. PSA is incapable of differentiating these clinically insignificant carcinomas from significant ones. Finally, prevalence of prostate cancer is increasing due to higher life expectancy. On the other hand, particularly patients aged 50-70 years are the ones who develop an aggressive form of carcinoma and profit from early detection and treatment. The global term "total PSA"encompasses a heterogeneous blend of bound and free molecular forms of PSA. Complexed PSA represents the major form of total PSA. The smaller portion, free PSA, is enzymatically inactive. In addition, different isoforms of free PSA exist Recent studies provide support for clinical application of these isoforms for early detection of prostate cancer. Clinical measurement of human glandular kallikrein 2 (hK2) serves as a complementary marker to PSA for early detection of prostate cancer and constitutes a considerable improvement over PSA as a staging marker for clinically localized prostate cancer. This overview summarizes established and potentially new forms of PSA and hK2 for early detection and staging of prostate cancer.

[Can nomograms derived in the U.S. applied to German patients? A study about the validation of preoperative nomograms predicting the risk of recurrence after radical prostatectomy]

In patients suffering from prostate cancer, preoperative nomograms, which predict the risk of recurrence may provide a helpful tool in regard to the counselling and planning of an appropriate therapy. The best known nomograms were published by the Baylor College of Medicine, Houston and the Harvard Medical School, Boston. We investigated these nomograms derived in the U.S. when applied to German patients. Data from 1003 patients who underwent radical prostatectomy at the University-Hospital Hamburg were used for validation. Nomogram predictions of the probability for 2-years (Harvard nomogram) and 5-years (Kattan nomogram) freedom from PSA recurrence were compared with actual follow-up recurrence data using areas under the receiver-operating-characteristic curves (AUC). The recurrence free survival after 2 and 5 years was 78% and 58%, respectively. The AUC of the Harvard nomogram predicting 2-years probability of freedom from PSA recurrence was 0.80 vs. Kattan-Nomogram 5-years prediction of 0.83. Thereby, the Kattan nomogram showed a significant higher predictive accuracy (p=0.0274). For that reason preoperative nomograms derived in the U.S. can be applied to german patients. However, we would recommend the utilization of the Kattan nomogram due to its higher predictive accuracy.

Pathological and clinical characteristics of large prostate cancers predominantly located in the transition zone

Prostate carcinomas located in the transition zone are suspected to behave differently from the more frequent peripheral zone cancers. In this study, large transition zone prostate cancers were investigated for pathological and clinical features. From 365 consecutive radical prostatectomy specimens, 73 cases were disclosed with tumours larger than 10 cm(3). Of these, 14 were predominantly (>70% tumour area) located in the transition zone. Pathological investigations included a complete histological work-up, immunohistochemistry for p53 and bcl-2, and interphase cytogenetics for chromosomes 7, 8, 17, and X. Despite large tumour volumes and high preoperative prostate specific antigen (PSA)-values, most tumours showed quite favourable pathological features. Only two of these patients suffered from a postoperative PSA-recurrence during a median follow-up of 50 months. For comparison, 36 cases that contained tumours predominantly located in the peripheral zone mostly displayed adverse prognostic signs and 68.8% of these patients suffered from postoperative PSA-recurrence. We conclude that the peculiar pathological and clinical characteristics of large prostate cancers in the transition zone might be important for prognostic considerations.

Analysis of molecular isoforms of PSA and their ratios in men with PSA-relapse after radical prostatectomy

BACKGROUND

The aim of this study was the longitudinal comparison of % f-PSA in patients before radical prostatectomy and after PSA relapse. Is % f-PSA a consistent tumor specific parameter or does this ratio change during untreated tumor progression?

MATERIALS AND METHODS

In this study 41 out of 420 patients with untreated increasing PSA-progression (> 0.5 ng/ml) were analysed. Patients with neoadjuvant or adjuvant hormonal therapy were excluded. T-PSA were f-PSA were analyzed by Immulite DPC (Diagnostic Products Coop., CA) and Abbott Axsym (Abbott Park, Il, USA).

RESULTS

Pre-operative % f-PSA ratio was 10.6% (range 4.6-22%; Std. dev.: 4.9); T-PSA concentration was 26.4 ng/ml (range 5.5-10.2 ng/ml Std. dev.: 20.3). In men with PSA relapse after radical prostatectomy % f-PSA ratio was 14.73% (range 2.2-4.5% Std. dev.: 9.7). Repeated post-operative % f-PSA measurements resulted in 12.94% f-PSA (range 2.7-3.8% Std. dev.: 9.9%) with a regression of R = 0.57. All men with pre-operative elevated % f-PSA (> 15%) had post-operative elevated % f-PSA.

CONCLUSIONS

The data indicates that post-operative % f-PSA is a constant tumor specific parameter in men with untreated PSA relapse after radical prostatectomy. Post-operative % f-PSA was higher compared with pre-operative % f-PSA concentrations. No correlation with Gleason score or pathological stage was found.