Active surveillance as a successful management strategy for patients with clinical stage I germ cell testicular cancer

BACKGROUND

Cancer-specific survival for patients with clinical stage I (CSI) germ cell testicular cancer (GCTC) is outstanding after inguinal orchidectomy regardless the treatment utilized. This study evaluated whether active surveillance (AS) of such patients yielded similar health outcomes to other therapeutic strategies such as adjuvant chemotherapy, radiotherapy or primary retroperitoneal lymphadenectomy as described in the literature.

PATIENTS AND METHODS

Patients with CSI GCTC were screened between January 2012 and December 2016. Patients had previously undergone inguinal orchidectomy as the primary treatment and chosen AS as their preferred management strategy after receiving information about all available strategies.

RESULTS

Out of 91 patients screened, 82 patients selected AS as their preferred management strategy. Relapse rate in the overall population was 20% (95% CI 12-30) and median time to relapse was 11.5 months (range 1.0-35.0). In patients with seminomatous tumors, relapse rate decreased to 13% and median time to relapse was 13 months; whereas in patients with non-seminomatous tumors, relapse rate was 33% (IA) or 29% (IB) and median time to relapse was 12 months in stage IA and 4.5 months in stage IB patients. All relapses were rescued with three or four cycles of chemotherapy and two also required a retroperitoneal lymphadenectomy. All patients are currently alive and free of disease.

CONCLUSIONS

The clinical outcomes of patients with CSI GCTC managed by AS in this series were excellent. This strategy limited the administration of active treatments specifically to the minority of patients who relapsed without compromising performance.

Non-steroidal antiandrogen monotherapy compared with luteinising hormone-releasing hormone agonists or surgical castration monotherapy for advanced prostate cancer

BACKGROUND

Non-steroidal antiandrogens and castration are the main therapy options for advanced stages of prostate cancer. However, debate regarding the value of these treatment options continues.

OBJECTIVES

To assess the effects of non-steroidal antiandrogen monotherapy compared with luteinising hormone-releasing hormone agonists or surgical castration monotherapy for treating advanced stages of prostate cancer.

SEARCH METHODS

We searched the Cochrane Prostatic Diseases and Urologic Cancers Group Specialized Register (PROSTATE), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science with Conference Proceedings, three trial registries and abstracts from three major conferences to 23 December 2013, together with reference lists, and contacted selected experts in the field and manufacturers.

SELECTION CRITERIA

We included randomised controlled trials comparing non-steroidal antiandrogen monotherapy with medical or surgical castration monotherapy for men in advanced stages of prostate cancer.

DATA COLLECTION AND ANALYSIS

One review author screened all titles and abstracts; only citations that were clearly irrelevant were excluded at this stage. Then, two review authors independently examined full-text reports, identified relevant studies, assessed the eligibility of studies for inclusion, assessed trial quality and extracted data. We contacted the study authors to request additional information. We used Review Manager 5 for data synthesis and used the fixed-effect model for heterogeneity less than 50%; we used the random-effects model for substantial or considerable heterogeneity.

MAIN RESULTS

Eleven studies involving 3060 randomly assigned participants were included in this review. The quality of evidence is hampered by risk of bias. Use of non-steroidal antiandrogens decreased overall survival (hazard ratio (HR) 1.24, 95% confidence interval (CI) 1.05 to 1.48, six studies, 2712 participants) and increased clinical progression (one year: risk ratio (RR) 1.25, 95% CI 1.08 to 1.45, five studies, 2067 participants; 70 weeks: RR 1.26, 95% CI 1.08 to 1.45, six studies, 2373 participants; two years: RR 1.14, 95% CI 1.04 to 1.25, three studies, 1336 participants), as well as treatment failure (one year: RR 1.19, 95% CI 1.02 to 1.38, four studies, 1539 participants; 70 weeks: RR 1.27, 95% CI 1.05 to 1.52, five studies, 1845 participants; two years: RR 1.14, 95% CI 1.05 to 1.24, two studies, 808 participants), compared with medical or surgical castration. The quality of evidence for overall survival, clinical progression and treatment failure was rated as moderate according to GRADE. Predefined subgroup analyses showed that use of non-steroidal antiandrogens, compared with castration, was less favourable for overall survival, clinical progression (at one year, 70 weeks, two years) and treatment failure (at one year, 70 weeks, two years) in men with metastatic disease. Use of non-steroidal antiandrogens also increased the risk for treatment discontinuation due to adverse events (RR 1.82, 95% CI 1.13 to 2.94, eight studies, 1559 participants), including events such as breast pain (RR 22.97, 95% CI 14.79 to 35.67, eight studies, 2670 participants), gynaecomastia (RR 8.43, 95% CI 3.19 to 22.28, nine studies, 2774 participants) and asthenia (RR 1.77, 95% CI 1.36 to 2.31, five studies, 2073 participants). The risk of other adverse events, such as hot flashes (RR 0.23, 95% CI 0.19 to 0.27, nine studies, 2774 participants), haemorrhage (RR 0.07, 95% CI 0.01 to 0.54, two studies, 546 participants), nocturia (RR 0.38, 95% CI 0.20 to 0.69, one study, 480 participants), fatigue (RR 0.52, 95% CI 0.31 to 0.88, one study, 51 participants), loss of sexual interest (RR 0.50, 95% CI 0.30 to 0.83, one study, 51 participants) and urinary frequency (RR 0.22, 95% CI 0.11 to 0.47, one study, 480 participants) was decreased when non-steroidal antiandrogens were used. The quality of evidence for breast pain, gynaecomastia and hot flashes was rated as moderate according to GRADE. The effects of non-steroidal antiandrogens on cancer-specific survival and biochemical progression remained unclear.

AUTHORS' CONCLUSIONS

Currently available evidence suggests that use of non-steroidal antiandrogen monotherapy compared with medical or surgical castration monotherapy for advanced prostate cancer is less effective in terms of overall survival, clinical progression, treatment failure and treatment discontinuation due to adverse events. Evidence quality was rated as moderate according to GRADE. Further research is likely to have an important impact on results for patients with advanced but non-metastatic prostate cancer treated with non-steroidal antiandrogen monotherapy. However, we believe that research is likely not necessary on non-steroidal antiandrogen monotherapy for men with metastatic prostate cancer. Only high-quality, randomised controlled trials with long-term follow-up should be conducted. If further research is planned to investigate biochemical progression, studies with standardised follow-up schedules using measurements of prostate-specific antigen based on current guidelines should be conducted.

First-line treatment of metastatic prostate cancer. Androgen suppression for symptomatic disease

Prostate cancer sometimes metastasizes, especially to bone, which may cause pain, fractures and spinal cord compression. What are the best first-line treatment options for patients with metastatic prostate cancer? To answer this question, we conducted a review of the literature, using the standard Prescrire methodology. Suppressing androgen secretion by surgically removing the testicles (orchiectomy) or by administering a gonadorelin agonist relieves the pain associated with bone metastases in about 80% of patients. This treatment has a clear impact on symptoms, despite the lack of clinical trials versus placebo or no treatment. Its impact on overall survival is uncertain. In terms of survival, goserelin therapy appears to have similar efficacy to orchiectomy. The efficacy of other gonadorelin agonists is less well documented. Degarelix, a gonadorelin antagonist, does not appear to provide a therapeutic advantage over gonadorelin agonist. In 2012, oestrogen should not be used in the treatment of metastatic prostate cancer, because of its cardiovascular adverse effects. Antiandrogen monotherapy, preferably with flutamide, appears to be less beneficial than orchiectomy in terms of survival. Overall, adverse effects are more frequent with nonsteroidal antiandrogens than with gonadorelin agonists, but sexual dysfunction is less frequent. Cyproterone, a steroidal antiandrogen, seems to have fewer adverse effects leading to treatment discontinuation than nonsteroidal antiandrogens. There is no firm evidence that starting hormonal therapy before metastases become symptomatic is beneficial. When symptoms have disappeared and the PSA level is low, one option is to temporarily interrupt gonadorelin agonist therapy if it is poorly tolerated, even though this may shorten survival by a few months. The addition of a nonsteroidal antiandrogen to androgen suppression therapy slightly improves 5-year survival, preventing about 3 deaths per 100 patients, but at a cost of additional adverse effects. First-line hormonal treatments are initially very effective in relieving symptoms of metastatic prostate cancer. Our analysis of the available data suggests that the best treatment option is androgen suppression with goserelin. Flutamide monotherapy is an alternative for some patients.

Characterising the castration-resistant prostate cancer population: a systematic review

BACKGROUND

Castration-resistant prostate cancer (CRPC) is an advanced form of prostate cancer associated with poor survival rates. However, characterisation of the disease epidemiology is hampered by use of varying terminology, definition and disease management. The aim of this review was to conduct a systematic review to provide greater clarity on the sum of the available epidemiologic evidence and to guide future research into the disease prevalence, progression, characteristics and outcome.

METHODS

Systematic searches of PubMed and Embase were performed in March 2010 to identify relevant observational studies relating to the epidemiology, progression and outcomes of CRPC. Further studies were identified for inclusion in our review through manual searches of the authors' bibliographical databases and the reference lists of the included articles.

RESULTS

We identified 12 articles (10 full papers and 2 abstracts) reporting studies that included a total of 71,179 patients observed for up to 12 years for evaluation in our review. Five studies looked at the prevalence of CRPC in patients with prostate cancer. Together, the data indicate that 10-20% of prostate cancer patients develop CRPC within approximately 5 years of follow-up. Two studies reported the prevalence of bone metastases present at diagnosis of CRPC. Together, ≥ 84% were shown to have metastases at diagnosis. Of those patients with no metastases present at diagnosis of CRPC, 33% could expect to develop them within 2 years. The median survival of patients with CRPC was reported in five studies, with values varying from 9 to 30 months. A pooled, sample-weighted survival estimate calculated from the survival data included in this review is 14 months. Very few studies that met our inclusion criteria evaluated treatment patterns in CRPC. One study reported that only 37% of patients with CRPC received chemotherapy, with the remainder receiving only steroids and supportive care. The most common palliative therapies administered to patients with skeletal symptoms were radiotherapy, radionuclide therapy, bisphosphonates and opioids.

CONCLUSIONS

This review highlights the poor prognosis of patients with CRPC, and demonstrates a survival of 9-13 months in those patients with metastatic CRPC. Furthermore, progression to CRPC is associated with deterioration in quality of life, and few therapeutic options are currently available to patients with CRPC. However, epidemiologic study of these patients is hampered by differing terminology, definitions and treatment paradigms. Our review highlights the need for further well-designed, epidemiological studies of CRPC, using standardised definitions and methods.

Effect of post-natal castration on sepsis mortality in rats

PURPOSE

To investigate the influence of castration in early periods of development on survival to experimental acute sepsis.

METHODS

Four groups of 10 (ten) Wistar rats were used. The groups were comprised of males (M), females (F), males castrated on the fourth day of life (CM) and males castrated on the fourth day of life with testosterone replacement (CMR). Sepsis was induced by ligature and cecal perforation in adult life.

RESULTS

The analysis of death within 24 hours following sepsis induction showed greater mortality between the M and the CMR groups as compared to the CM and F (p=0.0180) groups. Multiple correspondence analysis (MCA) indicates an association between the M and the CMR groups for death within 24 hours as well as a relationship between the F and the CM groups for the absence of death and death up to 24 hours following sepsis induction. Statistical analysis of the Kaplan-Meier survival curve through log-rank demonstrates a significant difference among the four groups (p=0.0055) and between the M and the F (p=0.0005) groups.

CONCLUSION

Data suggest a better survival to sepsis within 24 hours for the F and CM groups, the presence or absence of testosterone in early periods of post-natal life being responsible for these findings.

Gender identity disorder. Is this a potentially fatal condition?

A person with a Gender Identity Disorder (GID) is a person who strongly identifies with the other sex. The individual may identify with the opposite sex to the point of believing that he/she is, in fact, a member of the other sex who is trapped in the wrong body. The treatment option is sex reassignment surgery. In Pakistan There is no specialized facility sex reassignment surgery. This case report deals with possible serious outcome of GID in Pakistan as a result of castration procedure which is carried out by 'gurus' in Pakistan. A systemic research in our country to this effect is required to find out the outcome of GID in Pakistan.

Costs and complications of equine castration: a UK practice-based study comparing 'standing nonsutured' and 'recumbent sutured' techniques

REASONS FOR PERFORMING STUDY

Clinicians are often asked to guide owners and trainers over the relative advantages and disadvantages of equine castration performed in either the standing horse with an open unsutured scrotal wound with healing by second intention, or a recumbent horse under general anaesthesia in aseptic conditions, with sutured scrotal skin allowing primary wound closure.

OBJECTIVES

To identify types and frequency of complications following the 2 differing approaches, and to compare the financial cost associated with each procedure, based on practice charges.

METHODS

Veterinary expenses of 217 horses castrated by a Newmarket equine veterinary practice over an 18-month period were analysed. Of these, Group 1 (n = 121) were castrated standing and nonsutured by one of 2 ambulatory clinicians and Group 2 (n = 96) castrated in recumbency, in aseptic equine hospital conditions.

RESULTS

Group 1 had a complication prevalence of 22% with no mortalities, and Group 2 a significantly lower complication prevalence of 6% (P = 0.001) with a mortality rate of 1%. The financial cost of Group 1, without complications, was approximately one-third of the cost of uncomplicated Group 2. However, the cost of Group 1 with complications increased to approximately two-thirds of the cost of an uncomplicated Group 2 castration.

CONCLUSIONS

Even though the complication prevalence for Group 1 castrations leaving an open scrotal wound was significantly higher than for a recumbent horse with a sutured scrotal wound in a hospital, the average cost of Group 1 was still less, even taking into account the additional follow-up costs associated with treating such complications.

POTENTIAL RELEVANCE

This report provides a benchmark for the outcome of 2 methods of castration based on a database obtained from particular circumstances within the practice involved. Further studies are required to corroborate and take into account future development in surgical and anaesthetic techniques.

Management of the postpubertal patient with cryptorchidism: an updated analysis

PURPOSE

Management of the postpubertal cryptorchid testis depends on patient age at presentation. Based on the belief that the risk of death from surgery first exceeds the risk of death from testis cancer at age 32 years patients younger than 32 years are advised to undergo orchiectomy, while those older than 32 years are advised to remain under close observation. However, the data on which this recommendation is based are now a quarter-century old. During this interval significant improvements have been made in perioperative care and germ cell tumor therapy. We revisited the topic using contemporary data to determine whether and how recommendations on management of the postpubertal cryptorchid testis should be changed.

MATERIALS AND METHODS

Contemporary data on germ cell mortality in the United States were obtained from the National Center for Health Statistics. From these data the lifetime risk of death from germ cell cancer in the general population was calculated for each 5-year interval between ages 15 and 60 years. Since the lifetime risk of germ cell tumor is believed to be higher in patients with cryptorchidism than in the general population, the lifetime risk of eventual death from germ cell tumor in the cryptorchid population was calculated by multiplying each 5-year lifetime risk by 9.7, which is the generally accepted relative risk of germ cell tumor in a cryptorchid testis. Contemporary literature on perioperative mortality was reviewed and we estimated the current mortality of orchiectomy based on American Society of Anesthesiologists (ASA) class. Mortality rates were plotted to determine the age when operative mortality exceeds the risk of mortality from germ cell malignancy.

RESULTS

While perioperative mortality and germ cell neoplasia mortality decreased in the last 25 years, the relative decrease in perioperative mortality was significantly greater. Thus, in ASA class I or II cases mortality from orchiectomy began to exceed mortality from germ cell cancer at age 50 years.

CONCLUSIONS

Improvements in therapy for germ cell neoplasia and perioperative care in the last 25 years have dramatically decreased the mortality of each cause. However, the decrease in perioperative mortality has been greater. In contrast to a generation ago, accidental death during routine elective surgery is now extremely rare in healthy patients. Thus, we advocate orchiectomy in all healthy males (ASA I and II) who present with postpubertal cryptorchidism until age 50 years.

Is scrotal violation per se a risk factor for local relapse and metastases in stage I nonseminomatous testicular cancer?

OBJECTIVES

To determine the risk of local recurrence and relapse in patients with Stage I nonseminomatous testicular cancer with scrotal violation.

METHODS

From 1983 to 1998, 75 patients with clinical Stage I nonseminomatous testicular cancer who were initially treated with orchiectomy and surveillance alone were retrospectively reviewed.

RESULTS

Of 75 patients with Stage I nonseminomatous testicular cancer, 13 had scrotal violation. The surgical margins and the spermatic cords were free of tumor in all patients. Five patients (38%) in the scrotal violation group and 17 patients (27%) in the inguinal orchiectomy group experienced relapses. The difference was not significant (P = 0.41). Local recurrence was not observed in either group. All relapses, except one in the standard inguinal orchiectomy group, were treated successfully with chemotherapy and postchemotherapy surgery, if needed. The progression rate and survival were not significantly different between the two groups.

CONCLUSIONS

Scrotal violation without positive surgical margins and tumor spillage does not adversely affect relapse rate and survival. Therefore, scrotal violation per se is not an exclusion criterion for the surveillance-only policy in patients with Stage I nonseminomatous testicular germ cell cancer.

[A clinical study on 109 cases with testicular tumor]

One hundred and nine patients with testicular tumors were treated in our hospital between 1970 and 1994. The patients ranged in age from 4 months to 73 years with an average of 35.3 years. The most frequent chief complaint was painless swelling of the scrotal contents. Of 106 germinal tumors, 61 cases were of pure seminomas, and the other 45 cases contained non-seminomatous elements. The remaining 3 cases were non-germinal tumors; 2 malignant lymphomas and one rhabdomyosarcoma. Clinical staging classified them into 80 cases of stage I, 21 cases of stage II, and 8 cases of stage III. The five-year survival rate calculated by the Kaplan-Meier method was 79.6% in total, and 85.0, 91.7, 66.7 and 50.0% in stage I, IIA, IIB, and III, respectively. A comparison with the 5-year survival rate before 1980 (69.9%) when computed tomographic (CT) equipment and chemotherapy including cisplatin were introduced in our hospital, showed significant improvement after 1981 (89.4%).

Conservative management with symptomatic treatment and delayed hormonal manipulation is justified in men with locally advanced carcinoma of the prostate

OBJECTIVE

To examine the clinical course following surveillance and symptomatic treatment, and compare the outcomes of immediate and delayed hormonal treatment in men with locally advanced prostatic cancer.

PATIENTS AND METHODS

Of a consecutive series of 199 men (mean age 74 years) with T2-T4 Nx M0 prostatic cancer, 110 (55%) were followed until death and the rest had a mean follow-up of 4.2 years. Fifty-one men received immediate orchidectomy, 88 had this treatment delayed until metastatic progression, and 60 had the treatment in the intervening period. The actuarial survival was compared with the expected survival for an age-matched healthy population in Scotland. The adjusted effect of the timing for hormonal manipulation was assessed by including it with age, Gleason score and clinical stage in a multiple Cox regression.

RESULTS

The actuarial survival for the whole group was 17% less at 5 years and 15% less at 10 years when compared with the expected survival for an age-matched population in Scotland. This was despite the fact that their nodal status was unknown and also those with occult metastasis (elevated serum prostatic acid phosphatase, M1a) at presentation were not excluded. In terms of metastatic progression, overall survival and cause-specific survival, there was no significant difference between immediate and delayed hormonal treatment.

CONCLUSION

A conservative approach with surveillance and symptomatic treatment for locally advanced prostatic cancer is justified by the present evidence on disease progression and survival, which do not differ from alternative methods of treatment as reported in contemporary literature. This study has the limitations relative to the ideal of a prospective randomized trial on immediate versus delayed hormonal treatment, but the lack of significant differences in outcome even after adjustment for other established prognostic factors does suggest that there may be little to be gained from an immediate orchidectomy.

Treatment of advanced localised prostatic cancer by orchiectomy, radiotherapy, or combined treatment. A Medical Research Council Study. Urological Cancer Working Party--Subgroup on Prostatic Cancer

A total of 277 patients with apparently localised prostatic cancer (T2-T4 NXMO) were allocated at random to receive radiotherapy alone (88), orchiectomy alone (90) and combined therapy (99) between 1980 and 1985. The main outcome measures were survival, time to appearance of metastases and treatment of local disease progression by further transurethral resection. Orchiectomy, whether alone or with radiotherapy, produced a significant delay in detection of metastases when compared with radiotherapy alone. There were no statistically significant differences between the 3 treatment groups in local disease control or in overall survival.