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Andrew J Stephenson

Publications and source records attributed to Andrew J Stephenson.

At least 19 recordsLinked to original sources
PubMed2006

Defining biochemical recurrence of prostate cancer after radical prostatectomy: a proposal for a standardized definition.

PURPOSE: Prostate-specific antigen (PSA) defined biochemical recurrence (BCR) of prostate cancer is widely used for reporting the outcome of radical prostatectomy (RP). A standardized BCR definition is lacking, and overall progression-free probability and risk of subsequent metastatic disease progression may vary greatly depending on the PSA criterion used. Ten definitions of BCR were evaluated to identify the one that best explains metastatic progression. METHODS: Of 3,125 patients who underwent RP at our institution since 1985, 75 developed distant metastasis during a median follow-up of 49 months. To predict metastasis progression, we modeled the clinical information using multivariable Cox regression analysis. BCR was included in the model as a time-dependent covariate, and separate models were developed for each definition. A goodness-of-fit (R2) statistic was used to determine the Cox model (and thereby the BCR definition) that best explained metastatic progression. RESULTS: The 10-year progression-free probability ranged from 63% to 79%, depending on the BCR definition. The model containing BCR defined as a PSA of at least 0.4 ng/mL followed by another increase best explained metastatic progression (R2 = 0.21). This definition was also associated with a high probability of subsequent secondary therapy, continued PSA progression, and rapid PSA doubling time. CONCLUSION: BCR defined as a PSA value of at least 0.4 ng/mL followed by another increase best explains the development of distant metastasis among 10 candidate definitions, after controlling for clinical variables and the use of secondary therapy. On the basis of this evidence, we propose that this definition be adopted as the standard for reporting the outcome of RP.

Aged↗
PubMed2006

Preoperative nomogram predicting the 10-year probability of prostate cancer recurrence after radical prostatectomy.

An existing preoperative nomogram predicts the probability of prostate cancer recurrence, defined by prostate-specific antigen (PSA), at 5 years after radical prostatectomy based on clinical stage, serum PSA, and biopsy Gleason grade. In an updated and enhanced nomogram, we have extended the predictions to 10 years, added the prognostic information of systematic biopsy results, and enabled the predictions to be adjusted for the year of surgery. Cox regression analysis was used to model the clinical information for 1978 patients treated by two high-volume surgeons from our institution. The nomogram was externally validated on an independent cohort of 1545 patients with a concordance index of 0.79 and was well calibrated with respect to observed outcome. The inclusion of the number of positive and negative biopsy cores enhanced the predictive accuracy of the model. Thus, a new preoperative nomogram provides robust predictions of prostate cancer recurrence up to 10 years after radical prostatectomy.

Aged↗
PubMed2006

Adjunctive nephrectomy at post-chemotherapy retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer.

PURPOSE: Patients with metastatic testicular cancer with residual masses encasing the renal hilum or kidney after platin based chemotherapy may require adjunctive nephrectomy to achieve complete resection at post-chemotherapy retroperitoneal lymph node dissection. We reviewed our experience with adjunctive nephrectomy to assess the impact on cancer control and renal function. MATERIALS AND METHODS: Of 647 post-chemotherapy retroperitoneal lymph node dissection procedures performed at our institution since 1989 adjunctive nephrectomy has been performed in 32 patients (5%). Patient information was obtained from a prospective database. Median followup was 31 months. RESULTS: Of the adjunctive nephrectomy procedures 17 (53%) were performed in high risk settings such as post-salvage chemotherapy, desperation retroperitoneal lymph node dissection, late relapse and reoperative retroperitoneal lymph node dissection. Disease was present in the adjunctive nephrectomy specimen in 21 patients (66%). Following post-chemotherapy retroperitoneal lymph node dissection 7 patients had disease relapse and 5-year disease-free survival was 66%. No case of relapse required substitution for cisplatin due to compromised renal function. Progression to chronic renal insufficiency occurred in 3 patients, 1 of whom required hemodialysis. The calculated creatinine clearance after adjunctive nephrectomy was more than 30% below the age specific norm in 14 patients (50%) and median patient age was 40 years. CONCLUSIONS: Adjunctive nephrectomy at post-chemotherapy retroperitoneal lymph node dissection is most frequently performed in patients with high risk features to ensure the completeness of resection. When indicated, adjunctive nephrectomy should be performed because residual cancer is frequently present and long-term cancer control can be achieved in 66% of patients. Although adjunctive nephrectomy did not interfere with subsequent chemotherapy, the renal reserve in these patients was substantially reduced in 50%, emphasizing the importance of preventative measures to preserve long-term renal function.

Adolescent↗
PubMed2005

Role of salvage radical prostatectomy for recurrent prostate cancer after radiation therapy.

Patients with isolated local recurrence of prostate cancer after radiation therapy may potentially be cured of their disease by salvage radical prostatectomy (RP). The stage-specific 5-year cancer-control rates of salvage RP resemble those of standard RP. However, the ability to effectively administer salvage treatment to patients with radiorecurrent disease is compromised by the lack of diagnostic tests with sufficient sensitivity and specificity to detect local recurrence at an early stage while it is amenable to local salvage therapy. By the time biochemical recurrence is declared using the current American Society for Therapeutic Radiology and Oncology definition, the majority of patients have advanced local disease, precluding successful local salvage therapy. When salvage RP is performed at prostate-specific antigen levels of 10 ng/mL or less, an estimated 70% of patients are free of disease at 5 years. With better patient selection and technical modifications, the morbidity associated with salvage RP has improved substantially. Rates of urinary incontinence and anastomotic stricture are acceptable, although one third of patients will experience these complications. Salvage cryotherapy is a minimally invasive alternative to salvage RP, but cancer-control rates appear to be inferior and it does not provide a clear advantage over salvage RP in terms of reduced morbidity. Patients with local recurrence after radiation therapy are at increased risk of metastatic progression and cancer-specific mortality. Currently, salvage RP represents the only curative treatment option for these patients. Salvage RP may favorably alter the natural history of biochemical recurrence after radiation therapy, but it must be instituted early in the course of recurrent disease to be effective.

Biomarkers, Tumor↗
PubMed2005

Postoperative nomogram predicting the 10-year probability of prostate cancer recurrence after radical prostatectomy.

PURPOSE: A postoperative nomogram for prostate cancer recurrence after radical prostatectomy (RP) has been independently validated as accurate and discriminating. We have updated the nomogram by extending the predictions to 10 years after RP and have enabled the nomogram predictions to be adjusted for the disease-free interval that a patient has maintained after RP. METHODS: Cox regression analysis was used to model the clinical information for 1,881 patients who underwent RP for clinically-localized prostate cancer by two high-volume surgeons. The model was externally validated separately on two independent cohorts of 1,782 patients and 1,357 patients, respectively. Disease progression was defined as a rising prostate-specific antigen (PSA) level, clinical progression, radiotherapy more than 12 months postoperatively, or initiation of systemic therapy. RESULTS: The 10-year progression-free probability for the modeling set was 79% (95% CI, 75% to 82%). Significant variables in the multivariable model included PSA (P = .002), primary (P < .0001) and secondary Gleason grade (P = .0006), extracapsular extension (P < .0001), positive surgical margins (P = .028), seminal vesicle invasion (P < .0001), lymph node involvement (P = .030), treatment year (P = .008), and adjuvant radiotherapy (P = .046). The concordance index of the nomogram when applied to the independent validation sets was 0.81 and 0.79. CONCLUSION: We have developed and validated as a robust predictive model an enhanced postoperative nomogram for prostate cancer recurrence after RP. Unique to predictive models, the nomogram predictions can be adjusted for the disease-free interval that a patient has achieved after RP.

Adult↗
PubMed2005

Integration of gene expression profiling and clinical variables to predict prostate carcinoma recurrence after radical prostatectomy.

BACKGROUND: Gene expression profiling of prostate carcinoma offers an alternative means to distinguish aggressive tumor biology and may improve the accuracy of outcome prediction for patients with prostate carcinoma treated by radical prostatectomy. METHODS: Gene expression differences between 37 recurrent and 42 nonrecurrent primary prostate tumor specimens were analyzed by oligonucleotide microarrays. Two logistic regression modeling approaches were used to predict prostate carcinoma recurrence after radical prostatectomy. One approach was based exclusively on gene expression differences between the two classes. The second approach integrated prognostic gene variables with a validated postoperative predictive model based on standard variables (nomogram). The predictive accuracy of these modeling approaches was evaluated by leave-one-out cross-validation (LOOCV) and compared with the nomogram. RESULTS: The modeling approach using gene variables alone accurately classified 59 (75%) tissue samples in LOOCV, a classification rate substantially higher than expected by chance. However, this predictive accuracy was inferior to the nomogram (concordance index, 0.75 vs. 0.84, P = 0.01). Models combining clinical and gene variables accurately classified 70 (89%) tissue samples and the predictive accuracy using this approach (concordance index, 0.89) was superior to the nomogram (P = 0.009) and models based on gene variables alone (P < 0.001). Importantly, the combined approach provided a marked improvement for patients whose nomogram-predicted likelihood of disease recurrence was in the indeterminate range (7-year disease progression-free probability, 30-70%; concordance index, 0.83 vs. 0.59, P = 0.01). CONCLUSIONS: Integration of gene expression signatures and clinical variables produced predictive models for prostate carcinoma recurrence that perform significantly better than those based on either clinical variables or gene expression information alone.

Aged↗
PubMed2005

Long-term oncologic results of salvage radical prostatectomy for locally recurrent prostate cancer after radiotherapy.

PURPOSE: Salvage radical prostatectomy (RP) may potentially cure patients who have isolated local prostate cancer recurrence after radiotherapy (RT). We report the long-term cancer control associated with salvage RP in a consecutive cohort of patients and identify the variables associated with disease progression and cancer survival. METHODS AND MATERIALS: A total of 100 consecutive patients underwent salvage RP with curative intent for biopsy-confirmed, locally recurrent, prostate cancer after RT. Disease progression after salvage RP was defined as a prostate-specific antigen (PSA) level of > or =0.2 ng/mL or by initiation of androgen deprivation therapy. Cancer-specific mortality was defined as active clinical disease progression despite castration. Cox regression analysis was used to evaluate these endpoints. The median follow-up from RT was 10 years (range, 3-27 years) and from salvage RP was 5 years (range, 1-20 years). RESULTS: Overall, the 5-year progression-free probability was 55% (95% confidence interval, 46-64%), and the median progression-free interval was 6.4 years. The preoperative PSA level was the only significant pretreatment predictor of disease progression in the multivariate analysis (p = 0.01). The 5-year progression-free probability for patients with a preoperative PSA level of <4, 4-10, and >10 ng/mL was 86%, 55%, and 37%, respectively. The 10-year and 15-year cancer-specific mortality after salvage RP was 27% and 40%, respectively. The median time from disease progression to cancer-specific death was 10.3 years (95% confidence interval, 7.6-12.9). After multivariate analysis, the preoperative serum PSA level and seminal vesicle or lymph node status correlated independently with disease progression. CONCLUSIONS: Greater preoperative PSA levels are associated with disease progression and cancer-specific death. Long-term control of locally recurrent prostate cancer after definitive RT is possible when salvage RP is performed early in the course of recurrent disease.

Adult↗
PubMed2005

Retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer: impact of patient selection factors on outcome.

PURPOSE: To investigate the impact of patient selection criteria on the outcome of patients with nonseminomatous germ cell testicular cancer (NSGCT) treated by primary retroperitoneal lymph node dissection (RPLND). Since 1999, our criteria have excluded patients with persistent postorchiectomy elevation of serum tumor markers (STM) or clinical stage (CS) IIB disease from RPLND. PATIENTS AND METHODS: Between 1989 and 2002, 453 patients underwent primary RPLND at our institution for CS I to IIB NSGCT. Patient information was obtained from a prospective database. Retroperitoneal pathology and relapse rates were compared for patients treated before and after application of the current selection criteria in 1999. RESULTS: By excluding patients with elevated STM or CS IIB disease after 1999, the proportion of pathologic stage II patients with low-volume (pN1) retroperitoneal disease increased significantly (40% before 1999 v 64% after 1999; P = .01), without significantly affecting the rate of retroperitoneal teratoma (21% v 22%, respectively; P = .89) or pathologic stage I disease (56% v 67%, respectively; P = .06). For patients who did not receive adjuvant chemotherapy, the 4-year progression-free probability improved significantly from 83% before 1999 (95% CI, 79% to 88%) to 96% after 1999 (95% CI, 91% to 100%; P = .005). Elevated postorchiectomy STM (P < .0001), clinical stage (P = .0002), and pre-1999 RPLND (P = .05) were independent pretreatment predictors of progression. CONCLUSION: Excluding patients with CS IIB disease or elevated postorchiectomy STM from primary RPLND has had a favorable impact on the extent of retroperitoneal disease and has significantly reduced the risk of relapse after RPLND. For patients with normal STM and CS I to IIA disease, the low rate of systemic progression and 22% incidence of retroperitoneal teratoma supports RPLND as the preferred primary intervention.

Biomarkers, Tumor↗
PubMed2005

Management of patients with low-stage nonseminomatous germ cell testicular cancer.

Management options for patients with clinical stage (CS) I nonseminomatous germ cell testicular cancer (NSGCT) include surveillance, retroperitoneal lymph node dissection (RPLND), or two cycles of bleomycin-etoposide-cisplatin (BEP x 2) chemotherapy. The optimal management of these patients is controversial, as cure rates of 97% or greater are reported with each of these treatment modalities. Patients without evidence of lymphovascular invasion, a predominant component of embryonal carcinoma, or advanced pathologic (p) T stage (pT 2 or greater) are at low risk for occult metastases and are optimal candidates for surveillance. Compliance with diagnostic testing and imaging is essential for a successful surveillance strategy to detect and treat metastases at an early stage. For patients who are not candidates for surveillance, RPLND offers several advantages over chemotherapy. RPLND alone is curative in 50% to 80% of CS I patients with pathologic stage (PS) II, and an estimated 75% of CS I patients avoid chemotherapy (as adjuvant therapy or for treatment of relapse). Virtually all patients are cured following two cycles of adjuvant chemotherapy for PS II disease, which is reserved for patients with high-volume (PN2-3) retroperitoneal disease. The poor outcome of patients with late retroperitoneal recurrence from unresected, chemorefractory germ cell testicular cancer indicates that RPLND is a vital component to the long-term cure of patients with NSGCT. Approximately 20% to 30% of patients with PS II disease have retroperitoneal teratoma (which is chemoresistant), and an estimated 5% of PS II patients have chemoresistant viable cancer following BEP x 2 as primary therapy. When RPLND is omitted, these patients are at risk for late recurrence with potentially lethal consequences. Patients who relapse after RPLND are "chemotherapy-naïve" and cured in virtually all cases with good-risk chemotherapy regimens. When nerve-sparing techniques are employed to preserve ejaculation, RPLND is also associated with a more favorable long-term toxicity profile compared with chemotherapy. In the absence of conclusive evidence from a randomized trial, we believe RPLND is the treatment of choice for patients with CS I NSGCT who are not candidates for surveillance, as it offers the greatest likelihood of long-term cure with considerably less morbidity than primary chemotherapy.

Humans↗
PubMed2005

Recovery of erectile function after salvage radical prostatectomy for locally recurrent prostate cancer after radiotherapy.

OBJECTIVES: To analyze the feasibility of neurovascular bundle (NVB) preservation and peripheral nerve grafting during salvage radical prostatectomy (RP) for radiorecurrent prostate cancer and analyze their effect on the recovery of potency. METHODS: Of 100 patients who underwent salvage RP with curative intent from 1984 to 2003, 7 patients had bilateral NVBs preserved, 22 had a unilateral NVB preserved with (n = 11) and without (n = 11) a unilateral nerve graft, and 9 had bilateral NVBs resected with bilateral nerve grafts. Preoperative erections were graded as normal (grade 1) in 12 patients and full but recently diminished (grade 2) in 16. Recovery of potency after salvage RP was defined as erections satisfactory for intercourse, with or without the use of sildenafil. RESULTS: Overall, 6 patients recovered potency after salvage RP, and the 5-year actuarial recovery rate was 16% (95% confidence interval 4% to 28%). The 6 patients who recovered erections all had preoperative grade 1 to 2 erections, and 5 had bilateral NVBs preserved. Only 1 of 11 patients who had a unilateral nerve graft recovered potency. No patient with bilateral nerve grafts recovered potency. The 5-year actuarial recovery rate among patients with preoperative grade 1 to 2 erections was 45% (95% confidence interval 16% to 75%). CONCLUSIONS: Compared with standard RP, the overall potency results after salvage RP are poor. However, select patients with good preoperative erectile function who have bilateral NVB preservation may recover erections sufficient for intercourse aided by sildenafil. Peripheral nerve grafts did not appear to influence the recovery of erections in this patient population.

Aged↗
PubMed2005

Retroperitoneal lymph node dissection in patients with low stage testicular cancer with embryonal carcinoma predominance and/or lymphovascular invasion.

PURPOSE: The outcome after primary retroperitoneal lymph node dissection (RPLND) was analyzed in patients with clinical stage I-IIA nonseminomatous germ cell testicular cancer with embryonal carcinoma predominance (ECP) or lymphovascular invasion (LVI). MATERIALS AND METHODS: Between 1989 and 2002, 267 patients with clinical stage I-IIA nonseminomatous germ cell testicular cancer, and ECP and/or LVI underwent RPLND. Patient information was obtained from a prospective database. Median followup was 53 months. RESULTS: Overall 42% of patients had pathological stage (PS) II disease, of whom 54% had low volume (PN1) disease and 16% had retroperitoneal teratoma. The 5-year progression-free probability was 90% overall, 90% for PS I and 86% for PN1. All patients with relapse were continuously free of disease following standard chemotherapy with or without resection of residual masses and the 10-year actuarial overall survival was 100%. When adjuvant chemotherapy was restricted to patients with PN2 disease, the estimated 5-year relapse rate was 9% and an estimated 72% of patients avoided chemotherapy. CONCLUSIONS: The low risk of systemic relapse in patients with PS I and PN1 after RPLND alone combined with the 16% incidence of retroperitoneal teratoma and the favorable morbidity profile supports RPLND over primary chemotherapy for the treatment of patients with low stage disease with ECP and/or LVI who are not candidates for surveillance. An estimated 72% of patients are spared the potential toxicity of chemotherapy if adjuvant therapy is restricted to patients with PN2. After primary RPLND and selective adjuvant chemotherapy late recurrence is distinctly uncommon and long-term cancer control is anticipated in essentially all patients.

Chemotherapy, Adjuvant↗
PubMed2004

Salvage radiotherapy for recurrent prostate cancer after radical prostatectomy.

CONTEXT: Salvage radiotherapy may potentially cure patients with disease recurrence after radical prostatectomy, but previous evidence has suggested that it is ineffective in patients at the highest risk of metastatic disease progression. OBJECTIVE: To delineate patients who may benefit from salvage radiotherapy for prostate cancer recurrence by identifying variables associated with a durable response. DESIGN, SETTING, AND PATIENTS: Retrospective review of a cohort of 501 patients at 5 US academic tertiary referral centers who received salvage radiotherapy between June 1987 and November 2002 for detectable and increasing prostate-specific antigen (PSA) levels after radical prostatectomy. MAIN OUTCOME MEASURE: Disease progression after salvage radiotherapy, defined as a serum PSA value > or =0.1 ng/mL above the postradiotherapy PSA nadir confirmed by a second PSA measurement that was higher than the first by any amount, by a continued increase in PSA level after treatment, or by the initiation of androgen deprivation therapy after treatment. RESULTS: Over a median follow-up of 45 months, 250 patients (50%) experienced disease progression after treatment, 49 (10%) developed distant metastases, 20 (4%) died from prostate cancer, and 21 (4%) died from other or unknown causes. The 4-year progression-free probability (PFP) was 45% (95% confidence interval [CI], 40%-50%). By multivariable analysis, predictors of progression were Gleason score of 8 to 10 (hazard ratio [HR], 2.6; 95% CI, 1.7-4.1; P<.001), preradiotherapy PSA level greater than 2.0 ng/mL (HR, 2.3; 95% CI, 1.7-3.2; P<.001), negative surgical margins (HR, 1.9; 95% CI, 1.4-2.5; P<.001), PSA doubling time (PSADT) of 10 months or less (HR, 1.7; 95% CI, 1.2-2.2; P =.001), and seminal vesicle invasion (HR, 1.4; 95% CI, 1.1-1.9; P =.02). Patients with no adverse features had a 4-year PFP of 77% (95% CI, 64%-91%). When treatment was given for early recurrence (PSA level < or =2.0 ng/mL), patients with Gleason scores of 4 to 7 and a rapid PSADT had a 4-year PFP of 64% (95% CI, 51%-76%) and of 22% (95% CI, 6%-38%) when the surgical margins were positive and negative, respectively. Patients with Gleason scores of 8 to 10, positive margins, and receiving early salvage radiotherapy had a 4-year PFP of 81% (95% CI, 57%-100%) when the PSADT was longer than 10 months and of 37% (95% CI, 16%-58%) when the PSADT was 10 months or less. CONCLUSIONS: Gleason score, preradiotherapy PSA level, surgical margins, PSADT, and seminal vesicle invasion are prognostic variables for a durable response to salvage radiotherapy. Selected patients with high-grade disease and/or a rapid PSADT who were previously thought to be destined to develop progressive metastatic disease may achieve a durable response to salvage radiotherapy.

Adult↗
PubMed2004

Salvage therapy for locally recurrent prostate cancer after external beam radiotherapy.

The greatest obstacle in the cure of patients with locally recurrent prostate cancer after radiation therapy is the lack of early detection markers. The majority of patients who are candidates for local salvage therapy have locally advanced disease, precluding successful salvage therapy. A low pretreatment prostate specific antigen (PSA) has shown to be a favorable prognostic variable for disease progression, regardless of the specific local salvage therapy used. Of all the local salvage treatment options for these patients, we believe that salvage radical prostatectomy (RP) offers patients the greatest likelihood of a cure. The salvage RP results approach those achieved with standard RP for patients of similar pathologic stage. When patients are treated early in the course of recurrent disease (preoperative PSA < 10 ng/mL), an estimated two-thirds of patients will be disease-free 5 years after salvage RP alone. With better patient selection and continued technical modifications, the morbidity associated with salvage RP has substantially improved. Perioperative complications approach those observed with standard RP and approximately two-thirds of patients will recover urinary continence. Select patients may also recover functional erections when nerve-sparing techniques are used. Salvage cryotherapy and brachytherapy are minimally invasive alternatives to salvage RP. The cancer control results of these procedures appear to be inferior to results achieved with salvage RP. Each of these procedures is associated with significant morbidity and do not appear to provide a clear advantage over salvage RP in terms of posttreatment complications, urinary continence, and erectile function. A long-term cure is possible for patients with locally recurrent prostate cancer after radiation therapy. Local salvage therapy must be instituted early to be successful in the course of progressive disease.

Adult↗
PubMed2004

Variations in PSA doubling time in patients with prostate cancer on "watchful waiting": value of short-term PSADT determinations.

OBJECTIVES: In watchful waiting patients with localized prostate cancer, the prostate-specific antigen doubling time (PSADT) has been suggested to correlate with disease progression and is often used to determine the need for therapy. In these studies, all available prostate-specific antigen data throughout the observation period were used to determine the PSADT. However, the correlation between the short-term and long-term assessments of PSADT in this population is unknown. Our aim was to determine the correlation between short-term PSADT measurements and long-term PSADT among men with prostate cancer on observation. METHODS: In a prospective cohort of 108 watchful waiting patients, the correlation of the overall PSADT with the PSADT measured during short-term intervals was analyzed. The level of agreement in classifying patients as having a rapid PSADT (24 months or less) was also evaluated. RESULTS: The median interval of observation was 36 months. According to the various methods used, the median PSADT was 82 months using all prostate-specific antigen values, 128 months using the first three values (early), 78 months using the last three values (late), and 144 months using the first and last values only (2-point). The PSADT measured over short-term intervals demonstrated a weak correlation with the overall PSADT (Spearman's rho 0.53 for early, 0.56 for late, and 0.50 for 2-point PSADT). A statistically significant agreement was noted in the classification of rapid PSADT between the overall PSADT measurement and early PSADT measurement (kappa 0.67). Less agreement was found in the classification, however, with the late and 2-point PSADT and the overall PSADT. CONCLUSIONS: In untreated patients with localized prostate cancer, the PSADT varies considerably depending on the interval evaluated.

Adenocarcinoma↗
PubMed2004

The value of radiotherapy in treating recurrent prostate cancer after radical prostatectomy.

Approximately 25-40% of men who undergo radical retropubic prostatectomy (RRP) for the treatment of clinically localized prostate cancer will experience biochemical recurrence. A rapid prostate-specific antigen (PSA) doubling time or high-grade disease are risk factors for progression to bone metastases and cancer-specific mortality. Salvage external-beam radiotherapy (EBRT) to the prostate fossa is the only curative therapy for patients with biochemical recurrence after RRP, but it is used relatively infrequently to treat recurrent prostate cancer because of a widespread perception that most patients have systemic recurrence, and its reported lack of efficacy for high-risk disease. However, in a large, multicenter study of patients who received salvage EBRT for a rising PSA level after RRP, a substantial proportion of patients with high-grade disease and/or a rapid PSA doubling time were observed to have a favorable outcome after salvage EBRT if it was administered at low PSA values. This suggests that salvage EBRT could provide long-term cancer control for patients at the highest risk of progression to bone metastases and cancer-specific mortality. A nomogram that predicts the 3-year progression-free probability after salvage EBRT has been developed to facilitate the selection of patients for this potentially curative therapy. In the absence of other curative therapies, all patients with recurrent prostate cancer should be considered for salvage EBRT, particularly those with positive surgical margins. To be successful, salvage EBRT should be administered at the earliest evidence of recurrent disease, once a rising PSA trend as been confirmed.

Humans↗
PubMed2004

Complications of radical and partial nephrectomy in a large contemporary cohort.

PURPOSE: Standardized criteria for reporting the early complications of urological procedures are lacking. We reviewed the early complications of radical nephrectomy (RN) and partial nephrectomy (PN) in a large contemporary cohort using a standardized complication grading scale. MATERIALS AND METHODS: Between 1995 and 2002, 1,049 patients underwent RN (66%) or PN (34%) for renal cortical neoplasm. Records were reviewed for perioperative complications. Complications were graded using a 5-tiered scale based on the severity of impact or intensity of therapy required. RESULTS: A total of 235 complications occurred in 180 patients (17%). Overall 55% and 31% of complications were grade I and grade II, respectively. There were 3 perioperative deaths (0.2%). PN was not associated with more complications compared to RN when accounting for other variables. PN cases had more procedure related complications compared to RN (9% versus 3%, respectively, p = 0.0001) due to complications of urinary leak and the reintervention rate was subsequently higher (2.5% versus 0.6%, p = 0.02). All but 1 of the reinterventions for PN involved either endoscopy or radiology. By multivariate analysis operative time (p <0.0001) and solitary kidney (p = 0.06) were associated with procedure related complications of PN. CONCLUSIONS: RN and PN are associated with low rates of serious morbidity and mortality. Compared to RN, PN is associated with higher rates of procedure related complications, the majority of which are minor. Overall, however, PN is not associated with more complications than RN.

Adolescent↗
PubMed2004

Impact of unnecessary exploratory laparotomy on the treatment of patients with metastatic germ cell tumor.

PURPOSE: Patients with testicular germ cell tumors (GCTs) may undergo unnecessary diagnostic or surgical procedures when this diagnosis is not considered. In a cohort of patients who underwent exploratory laparotomy for unsuspected metastatic GCT we determined the impact of this surgery on morbidity, therapeutic delay and cancer therapy. MATERIALS AND METHODS: Between 1980 and 2001, 40 patients who underwent exploratory laparotomy for unsuspected metastatic GCT were later referred to our department for management. Patient records were reviewed retrospectively. RESULTS: Mean patient age at exploratory laparotomy was 34 years. All patients had a midline retroperitoneal mass and 14 had disease at other sites. At the time of evaluation at our institution abnormalities on physical examination and testicular sonogram were identified in 8 (20%) and 22 (55%) patients, respectively. Elevated serum alpha-fetoprotein and/or beta-human chorionic gonadotropin were identified in 26 patients (65%). Eight patients (22%) experienced complications from exploratory surgery. The median interval from laparotomy to chemotherapy was 29 days and in 48% of patients the delay in therapy was 30 days or greater. Of patients with a delay of 30 days or greater 60% required intensive chemotherapy (multiple regimens, or high dose or salvage chemotherapy) compared to 26% with a delay of less than 30 days (p = 0.01). CONCLUSIONS: Exploratory laparotomy contributes to therapeutic delay in a substantial number of patients and it complicates cancer therapy. At presentation evidence to suggest GCT was present in all patients, which highlights the importance of physician awareness in making a prompt diagnosis.

Adolescent↗