Winston E. Barzell

Prostatic adenocarcinoma: relationship of grade and local extent to the pattern of metastases.

In 100 consecutive cases of prostatic adenocarcinoma treated by pelvic lymphadenectomy and interstitial implantation of 125I the relationship of tumor stage, size and grade was analyzed relative to the incidence and site of metastases, and the response of the primary tumor to irradiation. High stage, large size and poor histological differentiation were associated with a significantly higher probability of pelvic node metastases. The response of the primary tumor to irradiation was significantly higher among patients with small stage B tumors and/or those with negative pelvic lymph nodes. Important determinants of metastases subsequent to 125I implantation were the large size of the primary tumor, poor histological differentiation, seminal vesicle invasion, large (more than 3 cc) volume of lymph node metastases and absence of local prostatic response to irradiation.

Appropriate Patient Selection in the Focal Treatment of Prostate Cancer: The Role of Transperineal 3-Dimensional Pathologic Mapping of the Prostate—A 4-Year Experience

This study was undertaken to evaluate the usefulness of transperineal mapping biopsy of the prostate as a staging procedure in the appropriate selection of patients for treatment with focal cryoablation. Between October 2001 and January 2006, a total of 80 patients underwent extensive template-guided transperineal pathologic mapping of the prostate (3-DPM), in conjunction with repeat transrectal ultrasound (TRUS)-guided biopsies. Before 3-DPM was performed, the following clinical variables were recorded: age, prostate-specific antigen (PSA), percent free PSA, total prostate volume, transition zone volume, Gleason score, TNM stage, number of positive cores, and maximum percent of positive cores. Results of 3-DPM were compared with those of TRUS-guided biopsies to determine patient suitability for focal cryoablation; this served as the study end point. Of 80 study patients, 43 (54%) were deemed unsuitable for focal cryoablation. When compared with 3-DPM in assessing patient suitability for focal cryoablation repeat TRUS-guided biopsies yielded a false-negative rate of 47%, a sensitivity of 54%, and a negative predictive value of 49%. None of the pre-3-DPM variables correlated significantly with patient suitability for focal ablation. Treatment selected by the 80 study patients included total gland cryoablation (30%), expectant management (23%), radical prostatectomy (18%), focal cryoablation (11%), external irradiation (10%), brachytherapy (6%), and combined external irradiation and brachytherapy (1%); 1% were undecided about treatment selection. In this study, we demonstrated that 3-DPM (1) effectively excluded patients with clinically significant unsuspected cancer outside the area destined to be ablated, (2) appeared to do so more effectively than repeat TRUS-guided biopsies, and (3) was able to precisely locate the site of the cancer to be selectively ablated.

Transperineal 3D mapping biopsy of the prostate: An essential tool in selecting patients for focal prostate cancer therapy

INTRODUCTION The pathologic literature indicates that 25% of prostate cancer patients have a single tumor without evidence for multifocal disease. Previously published results indicate that a focal cryoablative prostate cancer treatment may provide good cancer control with decreased morbidity. Proper selection of patients who have only unifocal disease, however, is critical for such a management strategy to be successful. In this study, we present our experience with transperineal 3D mapping biopsy used as an additional staging procedure prior to focal prostate cancer therapy. METHODS The biopsy method consisted of a transperineal approach carried out under transrectal ultrasound guidance. Samples were taken every 5 mm throughout the volume of the prostate using a brachytherapy grid. Each sample was labeled separately as to its grid location. RESULTS One hundred ten patients, all of whom had unilateral disease on transrectal ultrasound (TRUS) biopsies, were restaged using the 3D mapping method prior to focal therapy. The median number of cores taken was 46 (SD +/- 19). Bilateral cancer was demonstrated in 60 patients (55%, all of whom had only unilateral cancer shown on TRUS biopsy. The Gleason score was increased in 25 patients (23%) over the TRUS biopsy. Complications were self-limited and included 9 patients (8%) who required short term indwelling catheter drainage and 2 with hematuria. CONCLUSIONS Transperineal 3D mapping biopsy of the prostate is well tolerated and provides superior staging information compared with TRUS biopsy. It should be an essential component in selecting patients for focal prostate cancer therapy.

Complications of 125Iodine Implantation and Pelvic Lymphadenectomy in the Treatment of Prostatic Cancer

The operative, postoperative and late complications experienced by 300 consecutive patients who underwent 125iodine implantation and pelvic lymphadenectomy for localized prostatic cancer were analyzed. Of the patients reviewed 68 per cent had clinical stage B lesions, while 32 per cent had clinical stage C lesions. The incidence of intraoperative complications was 6 per cent. There were 2 postoperative deaths and 23 per cent of the patients had postoperative complications. Of 177 patients followed postoperatively for 6 months or more (mean 29.3 months) late morbidity was experienced by 49 (28 per cent). The incidence of impotence in 109 patients who were potent preoperatively and who were followed for a minimum of 15 months was 7 per cent.

Behavioral patterns of prostate adenocarcinoma following an 125I implant and pelvic node dissection

Abstract This study is based on 208 patients with adenocarcinoma of the prostate, treated between February 1970 and September 1976 with a combined technique of retropubic bilateral pelvic lymphadenectomy and interstitial implantation of the prostate with 125 I sources. All patients were classified according to the criteria proposed by Willet Whitmore 13 and the UICC (International Union Against Cancer) 11 clinical staging. 128 patients were clinically stage B ( T 1 : 65, T 2 : 40 and T 3 : 23) and 80 patients were clinically stage C ( T 4 ). The patients were analyzed for clinicopathological behavioral patterns according to age, tumor extent, size, location and grade. These variables also were correlated with mode of initial nodal involvement, subsequent recurrence, and corresponding survival patterns. Analysis of this material points to a high overall frequency of lymph node metastases (40%), varying according to the size and extent of the primary tumor. The incidence of positive nodes relative to clinical stage B is 29% ( T 2 : 9%, T 2 : 40%, T 3 : 65%) and clinical stage C ( T 4 ) 59%. The association of the initial lymph node status with the subsequent development of distant metastases allows the identification of three major groups of patients in terms of survival and probability of distant cancer spread. The first group consists of patients with disease limited to the prostate having negative regional nodes. The second group consists of patients having either extra-prostatic extension with negative nodes or smaller prostatic tumors with positive nodes. The third group includes those patients with large prostatic tumors with or without extra-prostatic extension and positive nodes.

A critical analysis of response criteria in patients with prostatic cancer treated with CIS-diamminedichloride platinum II

Cis‐diamminedichloride platinum II (DDP), 50–70 mg/m2 iv, q 3w was administered to 25 patients with Stage D adenocarcinoma of the prostate. Since the assessment of tumor regression in a disease‐oriented phase II study demands a clear end‐point of response, case selection was restricted to patients who had objectively measurable lesions, i.e., nodes, skin, lung and liver metastasis. Partial remission occurred in 3 (12%) and stabilization of disease in 1 patient. Responders lived 53 weeks vs. 20 weeks for non‐responders. In the dosage and schedule used in this protocol, DDP was not an active agent in the treatment of prostatic cancer. Various patient characteristics are examined and correlations made between remission rates and survival in this study vs. 4 other response schemata. A critical analysis of patient selection, “lead time”—diagnosis to chemotherapy, and the definitions of the terms “measurable” lesions, “evaluable” parameters, “objective response”, stabilization of disease and response criteria employed in the 4 schemata are also discussed.

Group Consensus Reports from the Consensus Conference on Focal Treatment of Prostatic Carcinoma, Celebration, Florida, February 24, 2006

( EPORT OF CONSENSUS GROUP 1: ATHOBIOLOGY OF PROSTATE CANCER: MPLICATIONS FOR FOCAL THERAPY ocal ablative therapy may be reasonable for some atients with prostate cancer; selection factors include variety of clinical and pathologic factors in combiation with informed patient choice. Our group evalated 4 specific pathologic features that may influence his treatment decision. We reviewed the published iterature for applicable studies regarding the natural istory of prostate cancer, multifocality, cancer volme, and accuracy of cancer detection by current ethods. Results were as follows:

A biopsy simulation study to assess the accuracy of several transrectal ultrasonography (TRUS)‐biopsy strategies compared with template prostate mapping biopsies in patients who have undergone radical prostatectomy

Study Type – Diagnostic (validating cohort)

Diamminedichloride platinum II and cyclophosphamide in the treatment of advanced urothelial cancer

Diamminedichloride platinum II (DDP), 1.6 mg/kg and cyclophosphamide, 250–1000 mg/m2, were administered intravenously every 3–4 weeks to 36 patients with advanced, measurable urothelial cancer. Partial remissions were achieved in 15/32 (47%) adequately treated patients and 2 (6%) additional patients obtained minor remissions. The median duration of response was 7 months with responders surviving 11 months (range 2‐15+) vs. 4 months (range 1‐9) for nonresponders (p < 0.01). Most patients refused or delayed further therapy because of intense vomiting and persistent nausea and unmaintained remissions persisted for 1‐9 months, median 2.0 months. There was no statistical difference between responders and nonresponders when examined for age, sex, tumor grade, prior therapy and site of metastasis. Serum carcinoembryonic antigen which was elevated (>5 ng%) in 70% of patients and correlated with response or progression of disease should be used as a biologic marker in Phase II trials in bladder cancer. Computerized transaxial tomograms also were useful in corroborating intraabdominal and pelvic responses and should be followed sequentially when pelvic lesions are used as response parameters. Although there was a slight prolongation in the duration of response of 2 months (5 vs. 7 months) when the results obtained with DDP used singly are compared with the combination of DDP and cyclophosphamide in the schedule and dosage employed in this protocol, there was no increase in the number of remissions or in survival. In essence, this study confirms the anti‐tumor activity of DDP in the treatment of urothelial cancers.

Adjuvant chemotherapy combination of vinblastine, actinomycin D, bleomycin, and chlorambucil following retroperitoneal lymph node dissection for stage II testis tumor

In an attempt to reduce recurrence of nonseminomatous germ cell tumors of testis stage II, 62 patients were treated with vinblastine, actinomycin D, bleomycin, and chlorambucil after retroperitoneal lymph node dissection. Of the patients, 84% have remained in complete remission with median follow‐up of three years: 33/33 stage II‐A (N‐1,N‐2A) and 19/29 (66%) stage II‐B (N‐2B,N‐3). The relapse rate in patients who had histologic evidence of extranodal extension of the tumor (N‐3) was 54% (7/13). This program did not cause any serious toxicity. Adjuvant chemotherapy is effective in reducing relapses. More recently, with the current availability of chemotherapy with a high efficacy for control of disseminated disease, patients with resected stage II‐A (N‐1,N‐2A) have been followed closely and treated only if they developed evidence of recurrence. Patients with resected stage II‐B (N‐2B,N‐3) have been placed on a more aggressive adjuvant program. Cancer 47:840–844, 1981.