Marcos V. Tefilli

Gleason score 7 prostate cancer: a heterogeneous entity? correlation with pathologic parameters and disease-free survival

OBJECTIVES Gleason score 7, in different proportions of grades 3 and 4, is the score most frequently assigned to prostate cancer in our radical prostatectomy specimens (RPSs). We correlated the major grade component of score 7 tumors with clinicopathologic parameters and disease-free survival. METHODS All Gleason score 7 RPSs were classified as having a major grade of 3 or 4 carcinoma. The two groups were compared according to patient age, race, serum prostate-specific antigen (PSA) level, clinical and pathologic stage, tumor volume, and biochemical recurrence. RESULTS Of the 534 patients analyzed, 356 and 178 had major grade 3 or 4 tumors, respectively. Compared with patients with 3+4 tumors, those with 4+3 had significantly more advanced clinical and pathologic stages, larger tumor volume, higher preoperative PSA levels, and older age and a higher proportion were African American (P <0.05 for all above parameters). With a mean follow-up of 34.6 months, patients with 3+4 tumors experienced lower rates of PSA recurrence than did those with 4+3 tumors (P = 0.0021). Furthermore, for the subset of patients with organ-confined disease, multivariable analysis that included race, age, clinical stage, preoperative PSA level, tumor volume, and major grade component found only the latter to be a significant predictor of recurrence, with patients who had major grade 4 component tumors experiencing a higher incidence of PSA recurrence than those with major grade 3 tumors (P = 0.012). CONCLUSIONS The major grade 4 component in Gleason score 7 carcinoma indicates a higher likelihood of biochemical recurrence, particularly for the increasing proportion of patients with organ-confined disease after radical prostatectomy.

Predictors For Maximal Outcome in Patients Undergoing Salvage Surgery For Radio-Recurrent Prostate Cancer

OBJECTIVES To determine preradiation and preoperative clinical staging and postoperative pathologic factors that can predict disease-free survival in patients undergoing salvage surgery for radio-recurrent prostate cancer. METHODS A retrospective review was performed on 40 patients who underwent salvage surgery for radio-recurrent prostate cancer. Preradiation and preoperative clinical staging factors, as well as pathologic stage were analyzed as predictors of disease-free survival. Biochemical failure was defined as a persistent serum prostate-specific antigen (PSA) elevation greater than 0.4 ng/mL. RESULTS As a group, salvage surgery provided excellent clinical disease control in 35 of 40 patients (87.5%). Overall, 18 of 38 (47.4%) patients analyzed had no evidence of biochemical progression. Preradiation clinical stage and pathologically organ-confined disease were statistically significant predictors of disease-free survival (P = 0.03 and P = 0.02, respectively). Seminal vesicle invasion and positive lymph nodes were the worst pathologic prognostic factors. Preoperative clinical T1c disease approached statistical significance in predicting pathologically organ-confined disease and disease-free survival (P = 0.08 and P = 0.07, respectively). CONCLUSIONS Ideal candidates for salvage surgery should have preradiation and preoperative clinically organ-confined disease. All patients with pathologically organ-confined disease following salvage prostatectomy were disease free at a mean follow-up of 36.1 months. Salvage surgery, although technically feasible, should not be widely advocated as an effective curative treatment in patients with locally advanced disease at the time of diagnosis.

LAPAROSCOPIC PROSTATECTOMY WITH VASCULAR CONTROL FOR BENIGN PROSTATIC HYPERPLASIA

Retropubic and suprapubic prostatectomy has been used as an alternative to transurethral prostatic resection in selected patients with large benign prostatic hyperplasia.1 Minimally invasive therapies such as visual laser ablation, electrovaporization and transurethral incision of the prostate are indicated for treatment of the early stages of benign prostatic hyperplasia.1 Recently, the use of holmium laser has been proposed as an alternative approach for the treatment of prostates weighing more than 100 gm.2 We describe the use of laparoscopic resection of large (greater than 75 gm.)1 hyperplastic prostatic adenomas as an alternative to open prostatectomy.

Prognostic indicators in patients with seminal vesicle involvement following radical prostatectomy for clinically localized prostate cancer

PURPOSE We identify prognostic factors in patients with seminal vesicle involvement and negative lymph nodes following radical prostatectomy for clinically localized prostate cancer. MATERIALS AND METHODS A total of 93 patients who underwent radical prostatectomy and had seminal vesicle invasion without lymph node metastasis were evaluated. Patients who underwent neoadjuvant/adjuvant hormonal or radiation therapy were excluded from study. Preoperative serum prostate specific antigen (PSA), biopsy and radical prostatectomy specimen Gleason score, surgical margin status, presence of extraprostatic extension and evidence of biochemical disease progression were determined prospectively. Biochemical failure was defined as a single serum PSA elevation greater than 0.4 ng./ml. RESULTS The presence of positive surgical margins (p = 0.001), and Gleason score 7 or higher from preoperative biopsies (p = 0.03) and from the radical prostatectomy specimen (p = 0.01) were significant predictors of disease progression at a median followup of 43.3 months. Patients with preoperative PSA less than 10 ng./ml. had a better disease-free survival (p = 0.07). On multivariate analysis, after adjusting for biopsy Gleason score, prostatectomy Gleason score and serum PSA, positive surgical margins remained a statistically significant predictor of disease progression (p = 0.002). CONCLUSIONS Surgical margin status is an independent predictor of disease recurrence in patients with seminal vesicle involvement and negative lymph nodes following radical prostatectomy. Serum PSA 10 ng./ml. or greater and specimen Gleason score 7 or greater also were adverse prognostic factors in these patients. Conversely, patients with negative surgical margins and lymph nodes have a better prognosis than previously expected, despite seminal vesicle invasion.

Lymph node size does not correlate with the presence of prostate cancer metastasis

OBJECTIVES To determine whether lymph node size is a surrogate marker for lymph node metastasis. METHODS We reviewed 980 patients who underwent radical retropubic prostatectomy with bilateral pelvic lymph node dissection for clinically localized prostate cancer, of whom 63 had lymph node metastases. A comparable group of patients with prostate cancer undergoing radical prostatectomy who did not have lymph node involvement was identified using the following parameters: serum prostate-specific antigen level, clinical and pathologic stage, and pre- and postoperative Gleason score. The axial and longitudinal dimensions of the nodes from patients with and without metastases were analyzed to assess the significance of lymph node size in predicting the presence of metastases. All patients had negative preoperative computed tomography (CT) and bone scans. Of the 63 patients with lymph node metastases, 48 had tissue available for measuring the dimensions of the lymph nodes. RESULTS A total of 76 metastatic and 92 negative lymph nodes were identified from the patients with and without metastatic nodes, respectively. The mean nodal longitudinal size was 1.65 cm (range 0.2 to 6.5) and 3.50 cm (range 0.5 to 9) for positive and negative nodes, respectively (P = 0.0001). The mean axial nodal size was 0.8 cm (range 0.2 to 3.2) and 1.0 cm (range 0.2 to 2.2) for positive and negative lymph nodes, respectively. In 56 metastatic nodes (74%), the axial size was less than 1 cm and in 20 (26%) less than 5 mm. CONCLUSIONS Lymph node size should not be used as a surrogate for the presence of lymph node metastases. Although no patient had enlarged lymph nodes by CT scan criteria (greater than 1.5 cm), 6 (8%) of 48 and 19 (12%) of 48 patients with and without lymph node metastases, respectively, had nodes with an axial dimension greater than 1.5 cm.

Management of primary urethral cancer

OBJECTIVES To determine the best therapeutic approach for treatment of patients with urethral cancer according to tumor location and clinical-pathologic stage. METHODS A retrospective review of 21 consecutive patients diagnosed with primary urethral carcinoma was performed. Clinical-pathologic staging, treatment modality, and outcome were analyzed. RESULTS The overall survival rate was 62%. In patients with clinical Stage Ta-2N0M0 tumors, 8 of 9 patients (89%) are free of disease compared to 5 of 12 patients (42%) with Stage T3-4N0-2M0 tumors (P = 0.03). Best treatment outcome for patients with Stage T3 disease or higher was obtained when multimodality therapy (neoadjuvant chemotherapy and radiation therapy with or without surgery) was administered, with a disease-free survival rate of 60%. CONCLUSIONS Clinical-pathologic stage was a strong predictor of disease-free survival rate. For patients with Ta-2N0M0 tumors, multimodality therapy may not be required. Conversely, best treatment outcomes in patients with T3-4N0-2M0 tumors are obtained by administering a multimodal therapy combining chemotherapy and radiation therapy with surgical resection.

Urinary diversion-related outcome in patients with pelvic recurrence after radical cystectomy for bladder cancer

OBJECTIVES To evaluate the impact of urinary diversion on disease status, complications, and subsequent treatment in patients with pelvic tumor recurrence after radical cystectomy for bladder cancer. METHODS A retrospective review of 201 consecutive cases of radical cystectomy for bladder cancer, performed at our institution between March 1991 and March 1996, identified 33 patients (16.4%) with disease recurrence in the pelvis with or without systemic metastasis. Urinary diversion in patients with tumor recurrence was an ileal conduit, continent cutaneous diversion, or orthotopic neobladder in 19, 3, and 11 patients, respectively. The mean follow-up for all patients undergoing cystectomy was 25.9 months (range 8 to 75). The mean time to diagnosis of local disease recurrence after cystectomy was 13.9 months (range 5 to 50). RESULTS In 21 (63.6%) of 33 patients, pelvic recurrence and systemic metastasis were present simultaneously. Disease recurrence was associated with poor outcome: only 8 patients (24.2%) were alive and disease free, 7 of whom had isolated local recurrence without evidence of systemic metastasis. There was no difference in overall survival or type of therapy delivered once disease recurrence was diagnosed between patients with an orthotopic neobladder and those with a cutaneous (continent or incontinent) urinary diversion. The only diversion-related complication resulting from pelvic recurrence was 1 case of tumor invasion into an orthotopic neobladder, requiring conversion to an ileal conduit. CONCLUSIONS The type of urinary diversion did not impact a patients risk of complications, the ability to receive salvage treatment, or overall survival once pelvic recurrence was diagnosed. Patients at high risk of pelvic recurrence should not be excluded from receiving an orthotopic urinary diversion.

Long-Term Mechanical Reliability of Multicomponent Inflatable Penile Prosthesis: Comparison of Device Survival

OBJECTIVES To determine the mechanical reliability of multicomponent inflatable penile prosthesis, comparing five different types of devices, as well as the two-piece versus three-piece as a group. METHODS We followed 83 patients with two-piece and 283 patients with three-piece inflatable penile prostheses for a mean time of 66 months. At a cutoff of 63 months, mechanical complication rates were reviewed and statistically analyzed. RESULTS Thirty-one device-related complications occurred, and all were secondary to fluid leakage. The Mentor Alpha-1 prosthesis was significantly better than the Mentor Mark-II in terms of mechanical reliability (P = 0.01). A trend was noted toward the AMS 700 Ultrex inflatable penile prosthesis having fewer mechanical complications than the Mentor Mark-II (P = 0.06). In addition, a trend toward all three-piece prostheses being more mechanically reliable than the two-piece was noted (P = 0.08). The Mentor Alpha-1 device had a higher cumulative proportional survival (0.957) than all other devices (0.842 for AMS 700 Ultrex, 0.839 for AMS 700 CX, 0.783 for Mentor GFS, and 0.750 for Mentor Mark-II). CONCLUSIONS As a group, a trend was noted toward the three-piece prosthesis having better mechanical reliability than the two-piece prosthesis. Comparisons between the individual types of prostheses showed thatthe Mentor Alpha-1 device was significantly more mechanically reliable than the Mentor Mark-II device, and a trend was noted toward the AMS 700 Ultrex device having fewer mechanical complications than the Mentor Mark-II. The Mentor Alpha-1 prosthesis had the highest cumulative proportional survival.

Role of radical prostatectomy in patients with prostate cancer of high Gleason score

The routine use of serum prostate‐specific antigen (PSA) testing combined with digital rectal examination has lowered tumor volume and clinical‐pathological stage of men undergoing radical prostatectomy. Therefore, we may identify more men with poorly differentiated tumors of early clinical stage. In order to identify those who may benefit from radical prostatectomy, we evaluated known prognostic variables in patients with prostate cancer of high Gleason score (8–10).

Complications in laparoscopic radical cystectomy. The South American experience with 59 cases.

OBJECTIVE In this study, we have gathered the second largest series yet published on laparoscopic radical cystectomy in order to evaluate the incidence and cause of intra and postoperative complication, conversion to open surgery, and patient mortality. MATERIALS AND METHODS From 1997 to 2005, 59 laparoscopic radical cystectomies were performed for the management of bladder cancer at 3 institutions in South America. Twenty nine patients received continent urinary diversion, including 25 orthotopic ileal neobladders and 4 Indiana pouches. Only one case of continent urinary diversion was performed completely intracorporeally. RESULTS Mean operative time was 337 minutes (150-600). Estimated intraoperative blood loss was 488 mL (50-1500) and 12 patients (20%) required blood transfusion. All 7 (12%) intraoperative complications were vascular in nature, that is, 1 epigastric vessel injury, 2 injuries to the iliac vessels (1 artery and 1 vein), and 4 bleedings that occurred during the bladder pedicles control. Eighteen (30%) postoperative complications (not counting mortalities) occurred, including 3 urinary tract infections, 1 pneumonia, 1 wound infection, 5 ileus, 2 persistent chylous drainage, 3 urinary fistulas, and 3 (5%) postoperative complications that required surgical intervention (2 hernias - one in the port site and one in the extraction incision, and 1 bowel obstruction). One case (1.7%) was electively converted to open surgery due to a larger tumor that precluded proper posterior dissection. Two mortalities (3.3%) occurred in this series, one early mortality due to uncontrolled upper gastrointestinal bleeding and one late mortality following massive pulmonary embolism. CONCLUSIONS Laparoscopic radical cystectomy is a safe operation with morbidity and mortality rates comparable to the open surgery.