John H. Lynch

Prognostic significance of dna ploidy in carcinoma of prostate

Flow cytometry was used to measure the DNA content in archived paraffin-embedded human prostatic cancer tissue for 69 patients with known outcomes that presented between 1975 and 1982. Of these, 51 patients had clinically localized lesions and were surgically staged prior to radical prostatectomy, while 18 patients presented with advanced Stage D2 disease. Thirty-six of 37 (97.3%) pathologic Stage B lesions were diploid. In contrast, the majority (72.2%) of patients with metastatic disease had aneuploid tumors. The average Gleason grade for aneuploid tumors was 8.2 +/- 1.98 versus 5.5 +/- 1.89 for diploid tumors (p less than 0.01). For 51 patients with clinically localized tumors, 13.9 percent of diploid tumors with a low Gleason sum (2 to 6) had extracapsular spread of tumor or regional lymph node involvement compared with 83.3 percent of aneuploid tumors with high Gleason scores (7 to 10). The addition of DNA ploidy to degree of glandular differentiation may enhance the prognostic evaluation of prostatic tumors and eventually improve our ability to select patients who are likely to benefit from radical prostatectomy.

Investigating the distribution of prostate cancer using three-dimensional computer simulation.

The objective of this work was to investigate the distribution of prostate cancer using three-dimensional (3-D) computer simulation. Two hundred and eighty-one 3-D computer prostate models were constructed from radical prostatectomy specimens. An algorithm was developed which divided each model into 24 symmetrical regions, and it then detected the presence of tumor within an individual region. The distribution rate of prostate cancer was assessed within each region of all 281 prostate models, and the difference between the rates was statistically analyzed using Mantel-Haenszel methodology. There was a statistically significant higher distribution rate of cancer in the posterior half (57.2%) compared to the anterior half ( 40.5%; P=0.001). The base regions (36.8%) had a statistically significant lower distribution rate than either the mid regions (56.3%; P=0.001) or the apical regions (53.5%; P=0.001). The mid regions did have a statistically significant higher distribution rate compared to the apical regions (P=0.032). There was no statistically significant difference between the distribution rate on the left half (48.5%) compared to that on the right half (49.2%; P=0.494). The spatial distribution of prostate cancer can be analyzed using 3-D computer prostate models. The results illustrate that prostate cancer is least commonly located in the anterior half and base regions of the prostate. Through an analysis of the spatial distribution of prostate cancer, we believe that new optimal biopsy strategies and techniques can be developed.

Anatomic and technical considerations for optimizing recovery of urinary function during robotic-assisted radical prostatectomy.

Purpose of reviewThe advent of robotic-assisted radical prostatectomy purported fewer complications including postprostatectomy incontinence (PPI). PPI is associated with worse quality of life. We evaluate recently reported robot-assisted radical prostatectomy surgical techniques aimed at limiting PPI, describe their anatomic basis and summarize their outcomes. Recent findingsRARP techniques to reduce PPI include bladder neck preservation, bladder neck reconstruction, urethral length preservation, periurethral suspension stitch, posterior reconstruction, combined anterior and posterior reconstruction, preservation of the endopelvic fascia, complete anterior preservation, selective suturing of dorsal venous complex and nerve sparing approach. Outcomes of reconstructive techniques seem to be conflicting, whereas outcomes of techniques aiming to preserve the native urinary continence system seem to hasten urinary function recovery. However, few of these techniques have been shown to affect long-term urinary continence. SummarySurgical techniques preserving the natural urinary continence mechanism appear to improve short-term urinary continence, whereas techniques reconstructing pelvic anatomy have mixed results. The search for the ideal technique to minimize PPI remains hampered by the lack of prospective multi-institutional studies and the long-term follow up. Although reconstructive techniques are safe with few drawbacks, meticulous surgical technique and preservation of the natural continence mechanism should remain the mainstay of PPI prevention.

SURGICAL COMPLICATIONS RELATED TO ROBOTIC PROSTATECTOMY: PROSPECTIVE ANALYSIS

INTRODUCTION AND OBJECTIVES: Robotic assisted radical prostatectomy (RALP) is now readily available worldwide, but a recent study of Medicare beneficiaries has raised a concern with regard to surgical morbidity related to the procedure. We have performed a critical analysis of our RALP complication profiles, stratified by our learning curve. METHODS: We have reviewed the surgical complications of our first 618 RALP cases performed by a single surgeon since 2003. Surgical data including all complications within 1 year of RALP have been collected prospectively in our ongoing IRB approved prostate cancer database. Multivariate analyses were utilized to identify risk factors for complications. RESULTS: There were 85 (13.8%) patients who experienced perioperative complications, which consisted of 44 major (7.1%) and 41 minor (6.6%) complications. When stratified by our learning curve, there was a significant reduction in overall complications over time. Of major complications, 15 (2.4%) and 12 (1.9%) patients developed a bladder neck contracture and inguinal/incisional hernia at a median follow-up of 3 and 4 months, respectively. There was no mortality or perioperative transfusion in this cohort. No risk factors other than surgeon’s experience were associated with surgical complications. CONCLUSIONS: In our prospective analysis of RALP related complications, the surgeon’s learning curve appears to be the greatest factor in influencing surgical morbidities. Our results reinforce the current wisdom that the surgeon’s experience is the most critical factor in determining surgical outcomes. Careful patient selection and judicious use of the daVinci system are advised during an early learning curve of RALP to minimize surgical complications.

Clinical characteristics and management of late symptom flare following stereotactic body radiation therapy for clinically localized prostate cancer.

194 Background: Stereotactic body radiation therapy (SBRT) is increasingly utilized as primary treatment for clinically localized prostate cancer. While acute urinary symptoms are well recognized, late toxicities of SBRT have not been fully described. Here, we characterize the clinical features of late symptom flare and describe symptom management approaches. Methods: Two hudred sixteen patients with clinically localized prostate cancer were treated with SBRT between February 2008 and January 2011 at Georgetown University Hospital. Twenty-nine patients who experienced late-symptom flare were included in this retrospective analysis. Treatment was delivered using the CyberKnife (35 Gy to 36.25 Gy in five fractions). Prevalence of urinary toxicities was determined using CTCAE v.4. Patient-reported urinary symptoms were assessed using the American Urological Association Symptom Score (AUA) and the Expanded Prostate Cancer Index Composite (EPIC) short form. Results: Median age was 66 with 55% being of African ...

Stereotactic body radiation therapy (SBRT) following procedures for benign prostatic hyperplasia (BPH): A report on early toxicity.

165 Background: When treating patients with prostate cancer, hypofractionation with SBRT takes advantage of radiobiologically favorable factors as compared to conventional fractionation. However, this may increase the risk of urinary toxicity, especially in patients with prior procedures for BPH. Herein, we report early urinary toxicity following SBRT in patients with a history of procedures for BPH.nnnMETHODSnThirty three patients treated with SBRT for localized prostate cancer from February 2009 to October 2011 at Georgetown University Hospital with history of a prior procedure for BPH were included in this retrospective analysis. Treatment was delivered using the CyberKnife with doses of 35 Gy-36.25 Gy in 5 fractions. Toxicities were scored using the CTCAE v.3. Cystoscopy findings were retrospectively reviewed. Patient-reported urinary symptoms were assessed using the American Urological Association Symptom Score (AUA).nnnRESULTSnThe median age was 70 years (range, 64 - 84). The median follow-up time was 18.7 months (range 9.2 - 38.9). Grade 2 or 3 urinary toxicity occurred in 9 patients and there were no grade 4 or 5 toxicities. Hematuria occurred in 12 patients. The median time to onset of hematuria from SBRT was 6 months (range 1 - 30). Grade 1 hematuria occurred in 7 patients, grade 2 in 4 patients and 1 patient experienced grade 3. Cystoscopy was performed in 9 of these patients at a median time of 9 months (range 3-27). Eight had hyperemia or evidence of bleeding from the prostatic urethra and 5 of these patients also had evidence of bleeding from the bladder neck/wall. All patients except one, who died from other causes, are still being followed and hematuria has resolved in 9 of the 12 patients. The median baseline AUA symptom score of 7 increased to 11 at 1 month, however decreased to a median score of 6 at 3 months. The median AUA symptom score increased to 9 at 1 year.nnnCONCLUSIONSnA history of prior transurethral resection of prostate may predispose patients to increased urinary toxicity and hematuria following prostate SBRT. Stricter urethra/bladder neck dosimetric criteria or alternative fractionation regimens may be required to decrease urinary toxicity in these patients.