David Thüer

Prognostic Parameters, Complications, and Oncologic and Functional Outcome of Salvage Radical Prostatectomy for Locally Recurrent Prostate Cancer after 21st-Century Radiotherapy

BACKGROUND Salvage radical prostatectomy (SRP) for radiorecurrent prostate cancer (PCa) is a second local treatment with curative intent in patients with true organ-confined recurrent PCa. OBJECTIVE We evaluated preoperative prognostic risk factors to predict organ-confined, locally recurrent PCa after primary radiotherapy (RT). DESIGN, SETTING, AND PARTICIPANTS Fifty-five men with biopsy-proven, locally recurrent PCa underwent SRP and extended pelvic lymph node dissection (ePLND) after external-beam radiotherapy (EBRT) or low- or high-dose brachytherapy. MEASUREMENTS Prostate-specific antigen (PSA), clinical stage, biopsy Gleason score prior to RT and SRP, PSA nadir, time to recurrence, PSA doubling time (PSA DT), PSA prior to surgery, and pathohistology of the SRP specimen were analysed to predict organ-confined recurrent disease. Uni- and multivariate statistical analysis was performed. RESULTS AND LIMITATIONS Forty (72.7%) and 15 (27.3%) patients demonstrated organ-confined and locally advanced PCa, respectively. Eleven patients (20%) and seven patients (12.7%) had lymph node metastases and positive surgical margins (PSM), respectively. On multivariate analysis, biopsy Gleason score prior to SRP (p=0.02), <50% positive biopsy cores (p=0.001), PSA DT >12 mo (p=0.001), and low-dose brachytherapy (p=0.001) were significant predictors of organ-confined PCa with negative surgical margins (NSM). Limitations of the study are its retrospective nature and the relatively low number of patients. CONCLUSIONS SRP is a surgically challenging but effective secondary local treatment of radiorecurrent PCa with curative intent. The identified predictive parameters will help to select patients most suitable for SRP with long-term cure and good functional outcome.

Postchemotherapy Retroperitoneal Lymph Node Dissection in Advanced Testicular Cancer: Radical or Modified Template Resection

BACKGROUND The anatomical extent of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) has been discussed controversially for many years. OBJECTIVE To evaluate the necessity of PC-RPLND with modified or radical template resection in patients with advanced nonseminomatous germ-cell tumors (NSGCT) and residual masses following systemic chemotherapy. DESIGN, SETTING, AND PARTICIPANTS The charts of 152 consecutive patients who were treated at two tertiary referral centers were retrospectively reviewed. INTERVENTION All patients underwent PC-RPLND, with 54 and 98 patients undergoing a radical template resection and 98 patients undergoing a modified template resection. Modified template resection was performed if the location of the residual mass corresponded to the primary landing zone of testis cancer and the residual mass measured < or = 5 cm in diameter. In all other cases a full bilateral PC-RPLND was chosen. MEASUREMENTS The following data were analyzed: location of the residual mass, extent of surgery, length of surgery, treatment-associated complications, nerve-sparing approach, adjunctive surgical procedures, postoperative morbidity, duration of hospital stay, early and late complications, relapse rates, cancer-specific survival rates, and overall survival rates. RESULTS AND LIMITATIONS Overall, 84 patients (55.2%) had necrosis/fibrosis, 45 (29.6%) had mature teratoma, and 23 (15.1%) had vital cancer in the surgical specimens. Antegrade ejaculation was preserved in 85% and 25% of patients undergoing modified and bilateral PC-RPLND (p=0.02), respectively. Eight recurrences (5.2%) were observed after a mean follow-up of 39 mo (range 6-105 mo): one patient had an in-field relapse following modified PC-RPLND, and seven patients had recurrences outside the boundaries of full bilateral PC-RPLNDs. The 2-yr disease-free survival rates were 78.6% and 92.8% for bilateral and modified PC-RPLND, respectively. The limitations of this study were a short follow-up, a limited number of patients, and the retrospective nature of the study. CONCLUSIONS Full bilateral PC-RPLND is the standard approach to extensive residual masses. In well-defined masses a modified template PC-RPLND does not interfere with oncologic outcome but decreases treatment-associated morbidity.