Biomedical subjects

Louis L Pisters

Publications and source records attributed to Louis L Pisters.

At least 19 recordsLinked to original sources

PubMed2007

Prostate cancer progression in the presence of undetectable or low serum prostate-specific antigen level.

BACKGROUND: The serum prostate-specific antigen (PSA) level after definitive treatment for prostate cancer (PC) is a powerful predictor of outcome. Occasionally, PC progression can occur despite low or undetectable PSA levels. The authors report on the clinical and pathologic characteristics of patients who experienced PC progression with undetectable or low PSA levels. METHODS: From an electronic database of all patients with PC who were treated at The University of Texas M. D. Anderson Cancer Center between 1999 and 2004, a group of 46 patients was identified who had progression to metastatic PC detected with concomitant PSA levels from 0.1 ng/mL to 2 ng/mL. Patient charts were reviewed for tumor stage, Gleason score, pretreatment PSA level, and the presence of atypical histologic variants (ie, ductal, sarcomatoid, or small cell cancers). The nadir PSA level after treatment and the PSA level at the time metastatic PC was detected were determined. The patients were followed semiannually, and imaging studies were obtained at the discretion of treating physicians. The sites of metastasis and histologic confirmation were reported when available. RESULTS: Twenty-three of 46 patients underwent radical prostatectomy, 11 patients received radiation therapy, and 12 received hormone treatment as their initial form of therapy. Progression to metastatic disease with concomitant, undetectable PSA levels occurred in 10 patients, including 3 patients who had not received treatment with hormones. The sites of metastasis included bone (n = 35 patients), liver (n = 7 patients), retroperitoneal lymph nodes (n = 5 patients), lungs (n = 4 patients), and brain (n = 1 patient). Aggressive and locally advanced PC were common features in these patients: Eighty-five percent had Gleason scores >or=7, 63% had clinical T3 or T4 tumors, and 41% had pretreatment PSA levels >10 ng/mL. Atypical histologic variants were observed in 21 patients (46%) and in 8 of 10 patients who progressed with undetectable PSA levels. In 10 patients (22%), metastasis were detected in the presence of an undetectable PSA level. Eight of those patients had small cell carcinoma. In 19 patients (41%), progression to metastasis occurred without any increase in their PSA from the nadir level. Thirty-one patients (67%) were asymptomatic at the time metastasis was detected, and the detection of metastasis in these patients occurred only because of routine imaging studies. CONCLUSIONS: Progression of PC may occur despite undetectable or low PSA levels. Complete physical evaluation and imaging studies may be indicated in the surveillance of patients with high-grade, locally advanced tumors, especially when atypical histologic variants are present.

Aged↗

PubMed2007

Recurrence pattern and proposed surveillance protocol following post-chemotherapy retroperitoneal lymph node dissection.

PURPOSE: We evaluated the recurrence pattern in patients with nonseminomatous germ cell tumors treated with post-chemotherapy retroperitoneal lymph node dissection and determined the optimal surveillance strategy in these patients. MATERIALS AND METHODS: Between 1980 and 2003, 236 patients with clinical stage IIA-III nonseminomatous germ cell tumors underwent post-chemotherapy retroperitoneal lymph node dissection. Patients with increased preoperative tumor markers (alpha-fetoprotein greater than 15 ng/ml and/or beta-human chorionic gonadotropin greater than 2.2 U/ml) were excluded from study resulting in 198 patients for analysis. We retrospectively reviewed medical records for pertinent clinical and treatment related outcomes. In our patient population recurrence developed in 45 (23%) patients and 22 (11%) died of disease at a median followup of 41 months (range 6 to 250) after retroperitoneal lymph node dissection. RESULTS: The clinical stage of testis cancer was IIA in 17, IIB in 49, IIC in 83 and III in 49 patients. Of the 45 patients with postoperative recurrence, 16 had concomitant multiple sites of recurrence with a total of 64 sites reported. Of the cases of recurrence 21 (46.7%) were in those of clinical stage III, 18 (40%) stage IIC and 6 (11.8%) stage IIB disease. The most frequent site of recurrence was the chest (32, 49%), followed by the abdomen (14, 22%), supraclavicular lymph nodes (8, 13%), brain (5, 8%) and other sites (5, 8%). CONCLUSIONS: Based on the recurrence pattern we propose stage specific surveillance guidelines for the followup of patients after post-chemotherapy retroperitoneal lymph node dissection. These guidelines help identify patients at high risk for disease progression and, thus, requiring more stringent postoperative followup.

Adolescent↗

PubMed2006

Surgically managed lymph node-positive prostate cancer: does delaying hormonal therapy worsen the outcome?

OBJECTIVES: To review our experience with the surgical management of lymph node-positive prostate cancer and to determine if there is a benefit to treating such patients with immediate rather than delayed hormonal therapy (HT). PATIENTS AND METHODS: A retrospective analysis from January 1982 to January 2001 identified 100 patients treated by radical retropubic prostatectomy (RP) either alone (70, 23 later received delayed HT) or combined with adjuvant (immediate) HT (30), with the overall median follow-up being 5.2 years. RESULTS: The median patient age at diagnosis was 58.7 years, with 20% having clinical T3 disease, and the median prostate specific antigen (PSA) level at presentation was 10 ng/mL. In 41% of patients the Gleason score on prostatic biopsy was > or = 8. After RP, 30 patients received immediate HT used as an adjuvant after surgery in the absence of any evidence of disease progression, whereas 23 received delayed HT the use of which was provoked secondary to biochemical failure (PSA threshold of 0.2-5.0 ng/mL) with no evidence of metastatic disease. A comparison of the clinical variables between the groups showed a higher median PSA level at diagnosis (P = 0.027) and biopsy Gleason score (P = 0.052) in the delayed HT group. The immediate and delayed HT groups had similar metastatic-free (P = 0.549), disease-specific (P = 0.843) and overall survival (P = 0.843). Overall, biochemical failure developed in half the patients and distant metastasis in 13%, with only nine patients dying from disease. CONCLUSIONS: Immediate and delayed HT provide similar treatment outcomes in patients with surgically managed lymph node-positive prostate cancer.

Adult↗

PubMed2006

Viable malignant germ cell tumor in the postchemotherapy retroperitoneal lymph node dissection specimen: can it be predicted using clinical parameters?

BACKGROUND: The presence of viable tumor in the surgical specimen after postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) is associated with an increased risk of disease progression. The objective of this study was to determine whether the presence of viable tumor in the surgical specimen could be predicted. METHODS: Between 1980 and 2003, 236 patients underwent PC-RPLND for clinical Stage IIA or III nonseminomatous germ cell tumors (NSGCT). The authors retrospectively reviewed the medical records of those patients for pertinent clinical and treatment-related outcomes. A multivariate logistic regression analysis was used to evaluate whether clinical parameters were capable of predicting the presence of viable tumor in the surgical specimen. RESULTS: International Germ Cell Consensus Classification (IGCCC) risk categories could be assigned to 218 patients, with 101 patients in the good-risk category, 32 patients in the intermediate-risk category, and 85 patients in the poor-risk category. The incidence of viable tumor in the good-risk, intermediate-risk, and poor-risk categories was similar (17.8%, 15.6%, and 15.3%, respectively); however, the risk categories predicted disease-specific and recurrence-free survival (P = .022 and P < .0001, respectively). On multivariate analysis, an elevated serum alpha-fetoprotein (AFP) level prior to PC-RPLND (P = .05) and the size of the retroperitoneal mass on pathology review (P = .02) were predictive of viable tumor in the surgical specimen. CONCLUSIONS: Although IGCCC risk categories were correlated with disease-related outcomes, the risk groups had similar incidences of viable tumor. Elevated serum AFP levels prior to surgery and the size of the retroperitoneal mass in the resected specimen may help to predict viable tumor in the PC-RPLND specimen.

Adult↗

PubMed2006

Predictors of outcome in patients undergoing postchemotherapy retroperitoneal lymph node dissection for testicular cancer.

BACKGROUND: The management of metastatic nonseminomatous germ cell tumors (NSGCT) frequently consists of systemic chemotherapy followed by retroperitoneal lymph node dissection (PC-RPLND). The aim of the present study was to evaluate the authors' PC-RPLND experience and identify predictors of outcome in these patients. METHODS: Between 1980 and 2003, 236 patients with clinical Stage IIA-III NSGCT underwent PC-RPLND. Their medical records were retrospectively reviewed for pertinent clinical and treatment-related outcomes. The 5-year disease-specific and recurrence-free survival was 85% and 75%, respectively, with the median length of follow-up after RPLND 45 months (6-250 months). RESULTS: The median age of patients at diagnosis was 28 years, with all patients receiving systemic chemotherapy (median of 5 cycles) before RPLND. On multivariate analysis, predictors of poorer disease-specific survival (DSS) included systemic symptoms at presentation (P = .05), elevated pre-RPLND serum alpha fetoprotein (AFP, P = .006) and beta-human chorionic gonadotropin (HCG, P = .004), postoperative complications (P = .03), and recurrence (P < .0001). Predictors of poorer recurrence-free survival (RFS) included advanced clinical stage (IIC-III, P = .001) and presence of viable tumor in the RPLND specimen (P = .03). A pre-RPLND serum AFP > 9 ng/mL and HCG > 4.1 mIU/mL were found to predict a worse DSS (P = .03 and .03, respectively). CONCLUSIONS: In patients undergoing PC-RPLND, preoperative tumor markers and the occurrence of postoperative complications or recurrence are predictive of poorer DSS. Advanced clinical stage and viable tumor in the surgical specimen predict worse RFS.

Adolescent↗

PubMed2006

Influence of obesity on biochemical and clinical failure after external-beam radiotherapy for localized prostate cancer.

BACKGROUND: Several reports have shown that obesity is associated with increased risk of biochemical failure after radical prostatectomy. However, limited information is available regarding the impact of obesity on prostate cancer progression after radiotherapy. The current study sought to determine whether obesity was an independent predictor of biochemical failure (BF) and clinical recurrence (CF) among patients treated with external-beam radiotherapy (EBRT). METHODS: A retrospective analysis was performed on 873 patients receiving EBRT as the sole treatment for localized prostate cancer between 1988 and 2001. The Kaplan-Meier method, log-rank test, and Cox proportional hazards analyses were performed. RESULTS: Of the 873 patients, 18% were mildly obese and 5% were moderately to severely obese. Obesity was related to younger age at diagnosis (P < .001), more recent year of diagnosis (P = .03), and race (P = .03), with African-American men having the highest obesity rates. During a mean follow-up of 96 months, 295 patients experienced BF and 127 had CF. On multivariate analysis, controlling for clinical and treatment characteristics, increased body mass index (BMI) significantly predicted BF (hazards ratio [HR] = 1.04; 95% confidence interval [95% CI], 1.02-1.07) with a positive trend by BMI category (P = .001). Similar results were found when the outcome was CF; BMI remained an independent predictor of progression (HR = 1.05; 95% CI, 1.01-1.09), with a statistically significant trend by increased BMI category (P = .03). CONCLUSIONS: The current findings validate the important role of obesity, not only on BF but also on CF, and suggest a link to the biologic basis of tumor progression that can be therapeutically exploited.

Adult↗

PubMed2006

Presalvage prostate-specific antigen (PSA) and PSA doubling time as predictors of biochemical failure of salvage cryotherapy in patients with locally recurrent prostate cancer after radiotherapy.

BACKGROUND: The value of presalvage cryotherapy serum PSA level in predicting biochemical failure in patients with local recurrence of prostate cancer (PCa) after radiotherapy was documented; however, little is known about the predictive value of prostate-specific antigen (PSA) doubling time (DT) in this patient group. The purpose of the current study was to evaluate serum PSA level and PSA DT as predictors of salvage cryotherapy outcomes in patients being treated for postradiotherapy locally recurrent PCa. METHODS: The charts of patients treated with salvage cryotherapy were retrospectively reviewed for locally recurrent PCa at the M. D. Anderson Cancer Center from January 1980 to July 2004. Patients who received neoadjuvant or adjuvant hormone therapy were excluded. We assessed pre- and postradiotherapy clinical data, pre- and postsalvage cryotherapy clinical data, and other variables. Kaplan-Meier and log rank tests were performed to assess unadjusted survival probabilities and 2-group survival comparisons, respectively. Cox proportional hazards regression models were used to assess the effect of patient characteristics in predicting overall, disease-specific, and biochemical failure-free survival. RESULTS: Forty-nine patients met the eligibility criteria. The median age of patients at diagnosis was 66 years (58-81 years) with the initial clinical stage before radiotherapy most commonly T2 (n = 25) or T3 (n = 21). The median presalvage cryotherapy serum PSA level was 5.9 ng/mL (0.4-23.1 ng/mL) and the presalvage prostatic biopsies were frequently high grade (Gleason grade > or =8 in 51% of patients). The median postsalvage cryotherapy serum PSA level was 0.1 ng/mL (0.1-9.5 ng/mL), and biochemical failure (defined as a serum PSA level > or =2 ng/mL above the postsalvage cryotherapy PSA nadir) occurred in 26 patients. In these 26 patients, there was a statistically significant difference between pre- and postsalvage cryotherapy PSA DTs (12.3 months to 5.6 months, respectively; P = .02). A presalvage cryotherapy serum PSA level >10 ng/mL (P = .002) and PSA DT < or =16 months (P = .06) were found to predict the subsequent risk of biochemical failure. CONCLUSIONS: Presalvage PSA and PSA DT can predict biochemical failure of salvage cryotherapy, although the predictive value of PSA DT only trended toward significance. The statistically significant difference in pre- and postsalvage cryotherapy PSA DTs was reflective of aggressive tumor biology.

Aged↗

PubMed2006

Impact of fellowship training on pathologic outcomes and complication rates of radical prostatectomy.

BACKGROUND: The study was conducted to assess the results of radical prostatectomy (RP) performed by fellowship-trained surgeons in the first year of independent practice. METHODS: A prospective cohort study of 66 men who underwent RP performed by 2 recently graduated fellowship-trained surgeons (C.J.R., n = 27; A.M.K., n = 39) in their first year of independent practice was undertaken. Preoperative, operative, and postoperative data were collected and analyzed. Median follow-up of the cohort is 12.5 months. RESULTS: The median patient age was 61.2 +/- 6.9 years (range, 44-74 years), the median prostate-specific antigen level was 5 ng/mL (range, 1.2-39.4 ng/mL), and the median prostate biopsy-determined Gleason score was 7. Of the 66 men, 25 (38%) underwent a bilateral nerve-sparing RP, 20 (30%) underwent a unilateral nerve-sparing RP, and 21 (32%) underwent a nonnerve-sparing procedure. Forty-two men (63%) underwent a pelvic lymph node dissection. The median operative time was 201 minutes. Median estimated blood loss was 734 mL (range, 300-1600 mL). There were 4 major complications--a pulmonary embolism in 3 patients and an intraoperative rectal injury in 1. Pathologic classification was as follows: pT2, 74%; pT3a, 23%; pT3b, 2%; and pN+, 2%. The positive margin rate was 14% overall and only 2% in men with pT2 disease. CONCLUSIONS: Results of RP performed by fellowship-trained surgeons in their first year of practice compare favorably with results of RP in a large series reported by more experienced surgeons. Being trained in an environment where an experienced surgeon serves as first assistant to the trainee appears to abbreviate the learning curve associated with this procedure.

Adult↗

PubMed2006

Biochemical disease-free survival in men younger than 60 years with prostate cancer treated with radical prostatectomy.

OBJECTIVES: To determine the biochemical disease-free survival rates in patients 60 years old or younger who were treated with surgery for localized prostate cancer. METHODS: We reviewed the medical records of 291 patients 60 years old or younger who had undergone radical prostatectomy as the sole primary treatment for prostate cancer. Follow-up prostate-specific antigen (PSA) levels were measured 6 to 8 weeks after surgery and 4 to 6 months thereafter. Biochemical failure was defined as a detectable PSA level (greater than 0.01 ng/mL). The median follow-up of the entire study group was 50 months. RESULTS: Eighty-one percent of the patients presented with a serum PSA level of 10 ng/mL or less, and 52% had a Gleason score of less than 7 on prostate biopsy. The radical prostatectomy specimens showed organ-confined disease in 72% of patients, and 83% of tumors had a Gleason score of 7. The 1, 5, and 7-year biochemical disease-free survival rate was 99%, 91%, and 91%, respectively. The fitted multivariate Cox proportional hazards model showed that having a prostatectomy specimen Gleason score greater than 7 or seminal vesicle invasion or nodal disease significantly increased the risk of biochemical failure. CONCLUSIONS: In the PSA era, men with prostate cancer who are 60 years old or younger and treated with surgery have an excellent biochemical disease-free outcome.

Age Factors↗

PubMed2006

Selenium accumulation in prostate tissue during a randomized, controlled short-term trial of l-selenomethionine: a Southwest Oncology Group Study.

PURPOSE: Epidemiologic and clinical data suggest that selenium could prevent prostate cancer, but it has not been shown that supplemental selenium leads to an increased concentration of selenium in prostate tissue compared with adjacent tissue. EXPERIMENTAL DESIGN: We conducted a randomized, controlled, short-term trial of l-selenomethionine (SeMet) versus observation in men with organ-confined prostate cancer. The primary endpoint was the measurement of selenium concentration in prostate tissue and seminal vesicle (SV). We assessed baseline selenium levels in serum and in toenail specimens (reflecting long-term intake) and post-intervention selenium levels in serum, and in prostate and SV tissues using hydride generation atomic fluorescence spectroscopy. RESULTS: Sixty-six eligible patients were randomly assigned to the SeMet (n = 34) or observation (n = 32) arm; both arms had similar baseline patient characteristics. Baseline serum selenium was similar in the two groups (P = 0.64). Baseline toenail selenium levels were slightly higher in the SeMet group than in the control group (P = 0.07). After the intervention, the mean serum selenium level increased 15% in the SeMet arm and was higher than in the observation arm (P = 0.001). The selenium concentration in prostate tissue was 22% higher in the SeMet arm (n = 26) than in the observation arm (n = 25; 1.80 versus 1.47 ppm; P = 0.003, Wilcoxon rank sum test) and remained significantly higher after adjusting for chronic selenium intake (P = 0.021, ANCOVA). SV selenium concentration was similar in both groups (P = 0.384) and was lower than in prostate tissue. CONCLUSIONS: The present study is the first to show that selenium taken as oral supplementation accumulates preferentially in the human prostate gland as opposed to the SV. These findings support the hypothesis that oral selenium supplementation may contribute to the cancer preventive effects of selenium.

Adenocarcinoma↗

PubMed2006

Surgery for locally advanced disease.

Locally advanced prostate cancer is diagnosed in approximately one in four new cases of prostate cancer. The estimated disease-specific mortality rate resulting from monotherapy with either surgery or radiotherapy is a disappointing 75%. A multimodality treatment approach could offer more promising results. In addition, several key factors related to surgical treatment of locally advanced prostate cancer may optimize the oncologic results and minimize patient morbidity. In this report, we summarize some of the anatomic features and technical concepts associated with the surgical management of this disease and review recently published results of the outcomes of surgery and neoadjuvant or adjuvant chemohormonal therapy for locally advanced prostate cancer.

Chemotherapy, Adjuvant↗

PubMed2006

Chylous ascites after post-chemotherapy retroperitoneal lymph node dissection: review of the M. D. Anderson experience.

PURPOSE: We determined the clinical presentation, risk factors and optimal treatment of chylous ascites that develop after retroperitoneal lymph node dissection in patients with testicular cancer. MATERIALS AND METHODS: We retrospectively reviewed the records of 329 patients who underwent post-chemotherapy retroperitoneal lymph node dissection at our institution, of whom 23 (7%) had chylous ascites postoperatively. Clinical and pathological parameters were entered into a database. RESULTS: Mean patient age at chylous ascites presentation was 32.1 years. On univariate and multivariate logistic regression analyses increasing amounts of preoperative chemotherapy (OR 1.24) and intraoperative blood loss (OR 1.33) were predictive of chylous ascites. The clinical presentation of chylous ascites consisted of abdominal fullness and distention in all patients. Initial treatment was paracentesis alone or combined with total parenteral nutrition in 77% of patients. An abdominal drain was used for persistent ascites in 10 patients. In patients treated conservatively the rate of resolution of chylous ascites was 77%. Only 23% of patients required peritoneovenous shunt placement. However, shunt use was associated with an 80% surgical revision rate. CONCLUSIONS: Conservative treatment resolves most cases of postoperative chylous ascites. An abdominal catheter drain should be considered for significant or recurring chylous ascites. When a peritoneovenous shunt is required, it may be needed for an extensive period for resolution and there are significant complications associated with its use. Increasing amounts of preoperative chemotherapy and operative blood loss raise the likelihood of chylous ascites.

Adult↗

PubMed2006

The case for early cystectomy in the treatment of nonmuscle invasive micropapillary bladder carcinoma.

PURPOSE: Micropapillary bladder carcinoma is a rare variant of UC. Due to paucity of data regarding treatment outcomes, patients with nonmuscle invasive micropapillary UC often receive intravesical therapy in an attempt at bladder preservation. MATERIALS AND METHODS: We reviewed the records of all patients evaluated at our institution who had micropapillary UC of the bladder. Of these, 44 had nonmuscle invasive disease at presentation and form the basis of this report. RESULTS: Mean patient age was 64.3 years (range 45 to 81) with a male-to-female ratio of 13:1. Stage distribution at presentation was 5 Ta (11%), 4 CIS (9%) and 35 T1 (80%). Median CSS was 81 months. Kaplan-Meier estimates of 5 and 10-year CSS rates were 64% and 26%, respectively. Intravesical BCG therapy was attempted in 27 patients (61%). Of these 27 patients, 67% (18 of 27) had progression (cT2 or greater), including 22% in whom metastatic disease developed. Only 19% of patients (5 of 27, all T1) remain disease-free with an intact bladder at a median followup of 30 months. A total of 30 patients (68%) underwent cystectomy. Among patients who underwent cystectomy after progression (18), median CSS was 61.7 months with no patient surviving 10 years, whereas among those undergoing cystectomy as initial therapy (12), median survival was not reached and the 10-year CSS rate was 72%. CONCLUSIONS: Intravesical BCG therapy appears to be ineffective against micropapillary UC. Our results suggest that the optimal treatment strategy for nonmuscle invasive micropapillary UC is radical cystectomy performed before progression.

Aged↗

PubMed2006

Suburethral sling at the time of radical prostatectomy in patients at high risk of postoperative incontinence.

OBJECTIVE: To evaluate the insertion of a urethral sling at the time of radical prostatectomy (RP) in men at high risk of urinary incontinence after RP. PATIENTS AND METHODS: Between 1998 and 2000, 49 of 871 men undergoing RP at The University of Texas M.D. Anderson Cancer Center, were identified as at risk of urinary incontinence after RP, based on their age (>65 years), previous transurethral resection of the prostate, previous radiation therapy, clinical stage, and obesity (body mass index of > or = 30 kg/m2). These 49 men had a suburethral sling inserted at the time of RP, and incontinence after surgery was evaluated using pad counts and patient-completed questionnaires. Retrospectively, incontinence rates and complications in these men were compared with 122 men also at high risk of urinary incontinence after RP who did not have a sling inserted at the time of RP (control group). RESULTS: In all, 29 of 49 men (59%) with a suburethral sling reported using either no pad or one pad per day for urinary leakage at 6 months after RP, compared with 83 of 118 (70%) in the control group. At 12 months after RP, 34 of 46 (74%) men with a suburethral sling reported using no or one pad, compared with 75 of 89 (84%) in the control group. Seventeen (35%) men were treated for urethral stricture in the sling group and 17 (14%) in the control group (P = 0.001). CONCLUSIONS: The urethral sling modification concurrent with RP is feasible, but does not decrease incontinence compared with a similar group of high-risk patients who did not have the sling modification. In addition, the stricture rate in the sling group was unacceptably high. Currently, we do not recommend the use of a urethral sling at the time of RP.

Aged↗

PubMed2006

Histological changes in prostate biopsies after salvage cryotherapy: effect of chronology and the method of biopsy.

OBJECTIVES: To examine changes in prostate biopsies at different intervals after salvage cryotherapy and the effect of biopsy type (transrectal ultrasonography-guided vs transurethral resection, TUR), as the sequence and extent of histological changes occurring in the prostate after salvage cryotherapy for local failure of prostate cancer treatment are unknown. PATIENTS AND METHODS: In all, 158 prostate biopsies from 150 patients were examined histologically after salvage cryotherapy for prostate cancer after radiotherapy had failed. Specimens were grouped by time from cryotherapy and biopsy technique. RESULTS: Biopsies showed hyalinization, necrosis, inflammation and residual cancer. Hyalinization became predominant over time, most notably in biopsies with no residual cancer. Core biopsies showed more hyalinization and regenerating glands, while TUR biopsies showed more necrosis and inflammation. CONCLUSIONS: Tissue cryo-injury and reactive changes last for >1 year; more extensive cryo-injury suggests more effective cancer ablation. A long-term follow-up is necessary, as prostate cancer might remain indolent for >1 year.

Analysis of Variance↗

PubMed2006

Nephroureterectomy for treating upper urinary tract transitional cell carcinoma: Time to change the treatment paradigm?

OBJECTIVE: To evaluate factors associated with disease recurrence and survival in patients undergoing nephroureterectomy for upper urinary tract transitional cell carcinoma (UUT-TCC) in one centre over an 18-year period. PATIENTS AND METHODS: The records of patients who had a nephroureterectomy for UUT-TCC at our institution from 1986 to 2004 were reviewed for clinical, pathological and treatment period data. Cox's proportional hazards regression model was used to test the statistical significance of several potential prognostic factors for recurrence and survival. RESULTS The median overall duration of follow-up was 2.5 years for 184 patients. Significant prognosticators for disease-specific survival (DSS) by univariate analysis were tumour stage (P < 0.01), tumour grade (P < 0.01), node-positive disease (P < 0.01), multifocality (P = 0.03), previous cystectomy (P < 0.01) and synchronous bilateral UUT-TCC (P = 0.02). On multivariate analysis, only tumour stage (P = 0.03) and grade (P = 0.01) correlated with DSS. The median recurrence-free survival duration was 2.4 years. In 44 patients, the disease recurred outside the bladder; 15 (8.2%) had local recurrence, 20 (10.9%) distant metastasis, and nine (4.9%) both local and distant recurrence. Bladder tumours occurred in 40 (26.1%) patients with no previous cystectomy. The evaluation of treatment outcome during three periods of the study showed no significant effect on DSS. CONCLUSION: Tumour stage and grade correlated with DSS in this cohort, with no improvement in outcome over the 18-year period assessed. Patients with high-stage and high-grade disease continue to fare poorly, suggesting a need for changing the treatment protocol. Judiciously applying a multimodal approach to the management of high-risk patients by incorporating neoadjuvant chemotherapy and surgical resection might provide, for the first time, the opportunity to improve patient outcome.

Aged↗

PubMed2005

Symptomatic local recurrence of prostate carcinoma after radiation therapy.

BACKGROUND: Symptomatic local recurrence of prostate carcinoma (SLRPC) after radiation therapy (RT) is associated with morbidity and debilitating symptoms that have a substantial impact on the patient's quality of life. Most reports on the results of RT for localized prostate carcinoma (PC) do not address this endpoint. The objective of this study was to determine the incidence of SLRPC and to identify the risk factors for this endpoint. METHODS: The medical charts of 1006 patients who received RT for localized PC at the University of Texas M. D. Anderson Cancer Center between 1987 and 1997 were reviewed. Local symptoms were defined as hematuria, voiding symptoms, urinary obstruction, and pelvic pain. Progressive symptoms accompanied by either confirmatory histology or cystoscopic findings were attributed to PC. Univariate and multivariate analyses using Cox proportional hazards models were applied to identify risk predictors. RESULTS: Among 964 patients for whom follow-up data were available, 277 patients had prostate-specific antigen (PSA) progression, and 45 patients died of PC during a median follow-up of 9.4 years. In total, 33 patients (3.4%) developed SLRPC. In patients who experienced biochemical progression, the actuarial 5-year incidence of SLRPC was 8.3%. Among the patients who had developed SLRPC, 23 patients (69.7%) died of PC at a median of 25.3 months from the onset of local symptoms. Adverse histologic tumor subtypes (ductal, small cell, and sarcomatoid) were associated significantly with SLRPC (hazard ratio, 8.4; 95% confidence interval, 2.99-23.63). Clinical T classification at diagnosis, Gleason score, and initial PSA level showed a trend toward an increased hazard ratio. CONCLUSIONS: SLRPC after radiotherapy therapy was an uncommon but clinically significant event. Aggressive histologic subtypes were predictive of this endpoint. Clinical T classification, Gleason score, and initial prostate-specific antigen levels also may have predictive value.

Aged↗

PubMed2005

Transrectal ultrasound versus magnetic resonance imaging for detection of rectal wall invasion by prostate cancer.

BACKGROUND: This study compared the accuracy of transrectal ultrasound (TRUS) versus magnetic resonance imaging (MRI) in the detection of rectal wall involvement by prostate cancer in patients undergoing salvage total pelvic exenteration (TPE) or cystoprostatectomy. METHODS: We identified 16 patients who underwent TPE and 24 patients who underwent cystoprostatectomy for locally advanced prostate cancer as salvage procedures with palliative intent. Patients were examined by TRUS, MRI, or both within the month preceding surgery. Histologic evidence of rectal involvement with prostate cancer was considered the gold standard diagnostic criterion in patients undergoing TPE. Among patients undergoing cystoprostatectomy, posterior prostatic surgical margins and clinical evidence of rectal wall recurrence during a median follow-up duration of 18.6 months were considered the gold standard. The sensitivity, specificity, and overall accuracy with which TRUS and MRI detected rectal wall involvement were compared. RESULTS: Fifteen (93.7%) of the patients who underwent TPE had histologically-proven rectal wall involvement with prostate cancer. Rectal and perineal recurrence developed 10 months after surgery in 1 (4.1%) patient in the cystoprostatectomy group. The sensitivity, specificity, and overall accuracy of TRUS were: 92.9 (66.1-99.8), 87.0 (66.4-97.2), and 89.2 (74.6-97.0), respectively. The sensitivity, specificity, and overall accuracy of MRI were: 54.6 (23.4-83.3), 100 (76.8-100.0), and 80 (59.3-93.2), respectively. CONCLUSIONS: TRUS is a highly sensitive diagnostic modality for rectal wall involvement in patients with locally advanced prostate cancer. Although MRI is very specific, it cannot reliably rule out rectal involvement in the presence of a positive TRUS.

Aged↗