Charlotte Piper

Radical retropubic and perineal prostatectomy for clinically localised prostate cancer in renal transplant recipients.

Abstract Objective: To analyse the functional and oncological outcome of consecutive renal-transplant recipients (RTRs) with clinically localised prostate cancer who underwent radical retropubic (RRP) or perineal (RPP) prostatectomy. Patients and methods: Between January 2000 and July 2011 16 patients underwent RRP (group 1) and seven RPP (group 2). In all, 200 consecutive non-RTRs served as the control group, of whom 100 each underwent RRP and RPP, respectively. The mean (range) interval between renal transplantation and RP was 95 (24–206) months, the PSA at the time of diagnosis was 4.5 (3.0–17.5) ng/mL, and the mean patient age was 64 (59–67) years. Results: The mean follow-up was 39 (RRP) and 48 months (RPP). There was no deterioration in graft function. In group 1, 13 and three patients had pT2a-cpN0 and pT3a-bpN0 prostate cancer, respectively, with a Gleason score of 6, 7 and 8 in 11, three and one patients, respectively. In group 2, three and four patients had pT2a-c and pT3a-b disease, respectively, with a Gleason score of 6 and 7 in two and five, respectively. In both groups one patient had a positive surgical margin and was followed expectantly, and all patients have no evidence of disease. Wound infections developed more often in the RPP group (29% vs. 7%), but there were no Clavien grade III–V complications. All patients achieved good continence, and two need one pad/day. Conclusions: RRP and RPP are suitable surgical treatments for prostate cancer in RTRs. RRP might be preferable, as it has the advantage of simultaneous pelvic lymphadenectomy and a lower risk of infectious complications.

The role of palliative surgery in castration-resistant prostate cancer.

Purpose of reviewAndrogen deprivation therapy with luteinising hormone releasing hormone (LHRH) analogues or antagonists represents the treatment of choice in men metastatic prostate cancer (PCA). Depending on the serum concentration of the prostate-specific antigen (PSA) nadir, the survival might vary between 11 and 78 months. About one-third of all patients without local treatment of the primary will develop significant complications of the lower and upper urinary tract because of local progression of PCA. It is the purpose of the review to inform the treating physician about palliative surgical options in men with castration-resistant prostate cancer (CRPC). Recent findingsIn men with CRPC and lower urinary tract symptoms, palliative transurethral resection of the prostate (TUR-P) can be performed with a 60–70% success rate. Infiltration of the pelvic floor, the bladder neck and trigone and the external urethral sphincter can make palliative radical surgery necessary. Bladder neck closure with continent vesicostomy, radical cystoprostatectomy with an incontinent urinary diversion, and anterior and posterior exenteration are individual therapeutic options in men with a good performance status and a considerable life expectancy. Symptomatic involvement of the upper urinary tract can be managed by placement of endoluminal stents or a percutaneous nephrostomy in men with a poor performance. In men with a good response to androgen deprivation therapy (ADT) and a good performance status reconstructive ureteral surgery might be considered and the options of ureteral reimplantation, ureter ileal replacement and a subcutaneous pyelovesical bypass have to be discussed. SummaryThere are various palliative surgical treatment options in the management of men with CRPC and symptomatic deterioration of the lower or the upper urinary tract, which should be considered in well selected patients. The indication to perform one of the above-mentioned surgical approaches needs to be discussed in a multidisciplinary tumour board.

Metastasectomy for renal cell cancer

BACKGROUND Metastasectomy prior to or after systemic medical cancer treatment is performed within a multimodal therapeutic approach in metastatic renal cell cancer (mRCC) to improve the prognosis. The role of metastasectomy in mRCC is controversially discussed and the potential therapeutic benefit is unquantifiable. The purpose of the current review is to critically discuss the available data. METHODS A systematic literature search was carried out in the MedLinedatabase to identify original publications, review articles and editorials with respect to metastasectomy in mRCC and the current European guidelines were also taken into consideration. RESULTS Metastasectomy is one of the approaches for mRCC recommended in the guidelines in cases of stable disease for at least 3 months, complete resectability of all metastatic lesions independent of the anatomic localization and a good performance status of the patient. The median survival time varies between 35 and 55 months. CONCLUSIONS In mRCC metastasectomy is an indiviudal therapeutic approach which might be considered for limited metastatic disease and the presence of good prognostic risk factors to improve average survival time. Especially in renal cell cancer metastasectomy should be considered early.

Comparison of second-line treatments in patients with castration-resistant prostate cancer with PSA relapse after or during docetaxel chemotherapy.

243 Background: Docetaxel was the first agent with a proven survival benefit and improved quality of life in patients with castration resistant prostate cancer. Recently there are two new agents, Cabazitaxel (Caba) and Abiraterone Acetate (AA) approved for the second-line treatment in case of progressive disease after Docetaxel. We compared the PSA response and complication rate of these three different second-line treatment options: Caba, AA and Docetaxel Re-Challenge (R-Doc). METHODS The data of 71 patients with progressive disease after/during Docetaxel chemotherapy were analyzed retrospectively. 25 patients with R-Doc, 27 patients with AA and 19 patients with Caba. All patients except two had a PSA-Response or stable disease to primary docetaxel chemotherapy. Mean patient age was 74 years for R-Doc, 71 for AA and 69 for Caba with a mean PSA before initiating treatment of 45 ng/ml, 162ng/ml and 563ng/ml. RESULTS PSA response rates (>50% regression) were seen in 14 (56%), 8 (38%) and 6 (32%) patients respectively. PSA stabilization was seen in 7 (28%), 2 (9,5%) and 7 (36,8%) patients. Haematologic complications grade >=3 were seen more frequently in R-Doce (32%) and Caba (42%) compared to AA (4%). Cardiovascular complications >= grade 3 were seen in 30% of the patients with AA whereas none of the patients with R-Doc or Caba had cardiovascular grade 3 or 4 side effects. CONCLUSIONS With AA, Caba and the possibility of R-Doc there are compareable treatment options with regard to PSA response rates, even if a stable disease can be seen more frequently in Caba and R-Doc. As the drugs have different side effects the first second line treatment should be considered to the patients characteristics and comorbidity in the palliative setting. PSA progression free survival and overall survival data are awaited.

Metastasenresektion beim Nierenzellkarzinom

BACKGROUND Metastasectomy prior to or after systemic medical cancer treatment is performed within a multimodal therapeutic approach in metastatic renal cell cancer (mRCC) to improve the prognosis. The role of metastasectomy in mRCC is controversially discussed and the potential therapeutic benefit is unquantifiable. The purpose of the current review is to critically discuss the available data. METHODS A systematic literature search was carried out in the MedLinedatabase to identify original publications, review articles and editorials with respect to metastasectomy in mRCC and the current European guidelines were also taken into consideration. RESULTS Metastasectomy is one of the approaches for mRCC recommended in the guidelines in cases of stable disease for at least 3 months, complete resectability of all metastatic lesions independent of the anatomic localization and a good performance status of the patient. The median survival time varies between 35 and 55 months. CONCLUSIONS In mRCC metastasectomy is an indiviudal therapeutic approach which might be considered for limited metastatic disease and the presence of good prognostic risk factors to improve average survival time. Especially in renal cell cancer metastasectomy should be considered early.

Radical salvage prostatectomy for locally recurrent prostate cancer after radiation therapy.

47 Background: Radical salvage prostatectomy (SRP) is one local treatment option with curative intent in patients failing radiation therapy (RT) for localized prostate cancer (PCA). We compared the surgical, histological and functional outcome of a large cohort of patients who underwent SRP for locally recurrent PCA following LDR - brachytherapy (BRT). METHODS 66 consecutive patients with locally recurrent PCA after BRT underwent retropubic SRP and pelvic lymphadenectomy. Preoperative PSA, PSA doubling time, PSA prior to initial RT, biopsy Gleason score, number of positive biopsies, cT stage, neoadjuvant androgen deprivation were correlated with pathohistological stage, complications and functional outcome by uni- and multivariate analysis. RESULTS Mean preop. PSA was 5.6 (2-13.5) ng/ml; mean preoperative biopsy Gleason score was y5.6 (4-9). 1 patient (1.5%) experienced a rectal lesion, mean blood loss was 430 (200-900) ml, none of the patients received blood transfusions. Pathohistology demonstrated organ confined prostate cancer pT2a-2c in 38 (57.5%) patients, stage pT3a and stage pT3b was identified in 14 (21.1%) patients and in 14 (21.1%) patients, respectively. Positive surgical margins were diagnosed in 9 (13.6%) patients and 12 (15.1%) patients harboured lymph node metastases. Functional outcome was good with a continence rate of 82%; the mean time until recovery of continence was 8.4 (6-14) months. After a mean follow-up of 22.5 (1-72) months, 28% of the patients experienced a PSA relapse defined as any PSA increase > 0.2 ng/ml validated by 2 consecutive measures. CONCLUSIONS SRP can be performed safely and with a low morbidity in biopsy proven locally recurrent PCA following BRT. However, our data demonstrate an unfavourable histology with locally advanced disease in about 40% of the patients who all were diagnosed with low risk prostate cancer. These data question the quality of the selection process for patients being counselled for BRT and the data raise the possibility of both intrinsic radioresistance of prostate cancer or poorly performed BRT.

Surgical management of testicular cancer patients with complex postchemotherapy residual masses: Aachen University experience.

387 Background: Post-chemotherapy retroperitoneal lymphadenectomy (PC-RPLND) represents the treatment of choice in patients with residual masses following chemotherapy for advanced non-seminomatous testicular germ cell tumors (NSGCT). Involvement of the abdominal aorta, the inferior vena cava or the thoracic/lumbar spine are rare but need complete resection for curative intent. We report on our single center experience in the management of such complex cases. Methods: Between January 2009 and September 2014 post-chemotherapeutic retroperitoneal lymph node dissection (PCRPLND) was performed in 162 patients (pts) with advanced NSGCT. Fourteen pts (4.9%) fulfilled the criteria of a GTS: enlarging metastatic mass in the retroperitoneum or visceral organs during systemic chemotherapy with normalized or regredient tumor markers. In all cases of GTS a complete radical bilateral PCRPLND including the resection of adjacent visceral and vascular structures was performed. Results: Median patient age was 24.5 (18 to ...

Vascular anomalies in patients undergoing retroperitoneal lymph node dissection.

382 Background: Anomalies of the renal vessels usually are clinically silent and might depicted during CT scanning of the abdomen for staging purposes of urological malignancies. Awareness of these rare anomalies is crucial especially in patients undergoing staging for germ cell tumors in order to avoid overstaging and unnecessary therapy. We report on the incidence of renal vessel anomalies in an unselected group of patients undergoing retroperitoneal lymph node dissection (RPLND) for testis cancer. Methods: 245 patients with testicular germ cell tumors underwent primary or secondary RPLND following inductive chemotherapy. Prior to RPLND, all patients underwent abdominal staging by CT scans or by MRI in selected cases. CT scans were reviewed with regard to the detection of vascular anomalies of the vena cava inf., renal veins, renal arteries, and iliac vessels. CT findings were correlated with intraoperative findings. Results: Overall, vascular anomalies were encountered in 39 patients (15.9%): retroaort...

Cell-free DNA as a prognostic marker for response to taxan-based chemotherapy in patients with prostate cancer (CaP).

228 Background: PSA is of limited value for predicting response to chemotherapy in castration resistant CaP patients. Nevertheless there is no better biological marker to control therapy response. cfDNA showed significant results in prostae cancer diagnostics and predicting recurrence after radical prostatectomy. We analyzed for the first time the role of cfDNA in castration resistant CaP predicting response to chemotherapy. METHODS We analyzed cfDNA isolated from an EDTA blood sample from 58 patients taken before initiating a first or second-line taxan based chemotherapy. 54 (93,1%), 8 (13,8%) and 3 (5.1%) of the patients had bone, lymph node or parenchymatous metastases respectively. Patients were selected according to PSA response after at least 3 cycles of chemotherapy to 30% (A), 50% (B) and 80% (C) decrease under chemotherapy. The concentration of cfDNA at the beginning of the therapy was correlated to PSA resonse at the end of the treatment. RESULTS Mean PSA and cfDNA concentration at therapy initiation was 391 (0,1-2663)ng/ml and 32,5 (8,93-136,63)ng/ml. In group A there was a trend of higher cfDNA concentration in the patients not achieving a PSA decrease of at least 30% (24,6ng/ml versus 35.5ng/ml) not reaching statistical significance (p=0,078). CONCLUSIONS Patients with PSA decrease of less than 30% and PSA progression under chemotherapy have the poorest outcome. cfDNA is easy to investigate and is probably of importance to distinguish patients profiting from chemotherapy in a palliative setting. These data should be validated in a larger patient cohort.

Diagnostic accuracy of PET scan in salvage lymph node resections in patients with prostate cancer (CaP).

215 Background: PET-CT scans in patients with CaP are often used to identify either local recurrent disease or suspected lymph node metastases in early biochemical recurrent disease. The diagnostic accuracy is controversial. We want to show our experience of PET-CT and its diagnostic accuracy in salvage lymph node dissection. METHODS 21 patients treated with radical prostatectomy between 1997 and 2009 presented with PET-CT´s and biochemical recurrent disease and were treated by salvage lymph node dissection to prolong the time to either androgene deprivation or chemotherapy. Diagnostic accuracy was correlated per patient and per lymph nodes. RESULTS Mean PSA at time of lymph node dissection was 2,73 (0,4-8,4)ng/ml. 17 (81%) received prior radiotherapy and 6 (29%) received androgene deprivation. In total 203 lymph nodes were resected with 58 (29%) harbouring metastasis in 15 (71%) patients. This leads to a Sensitivity, Specifity, positive and negative predictive value of 69%, 12%, 76% and 88% concerning lymph node detection and 70%, 0%, 93% and 0% concerning the calculation per patient. At time of analysis follow-up was available in 5 patients with a biochemical recurrence free survival of 5 (3-12) months. CONCLUSIONS The value of PET-CT in salvage lymph node dissection is under debate and must be questioned according to our results in this setting.