Yasuhisa Fujii

Long-term Oncological Outcome and Risk Stratification in Men with High-risk Prostate Cancer Treated with Radical Prostatectomy

OBJECTIVE To evaluate the long-term oncological outcome of radical prostatectomy for patients with high-risk prostate cancer. METHODS Among 378 patients with prostate cancer who underwent radical prostatectomy at our hospital, 189 had high-risk prostate cancer defined as presenting with at least one of the following high-risk factors: prostate-specific antigen >20 ng/ml, clinical T3 and biopsy Gleason score ≥8. RESULTS The median follow-up was 8.1 years. Of all patients, 106 and 61 had one and two high-risk factors, respectively, and the remaining 22 had all three high-risk factors. Pathological examination of the prostatectomy specimens revealed organ-confined disease, specimen-confined disease and lymph node metastasis in 80 (42%), 102 (54%) and 22 (12%), respectively. The 10-year prostate-specific antigen failure-free and local progression-free survival rates were 48.5 and 87.6%, respectively. The 10-year cancer-specific and overall survival rates were 94.1 and 88.7%, respectively. The 10-year prostate-specific antigen failure-free survivals of patients with one, two and all three high-risk factors were 58.5, 39.9 and 22.7%, respectively (P = 0.0001). Of the 106 patients with one high-risk factor only, the high Gleason score group had the best 10-year prostate-specific antigen failure-free survival (69.1%); in particular, that of patients without Gleason grade 5 was 100% (P= 0.032). CONCLUSIONS Approximately half of patients with high-risk prostate cancer can be cured by radical prostatectomy without any adjuvant treatment. Radical prostatectomy for high-risk prostate cancer provides good long-term local cancer control and cancer-specific survival. In particular, radical prostatectomy for patients with only one high-risk factor can be considered a valuable therapeutic option as the first treatment.

Prognostic Significance of Cancer Volume Involving Seminal Vesicles in Patients With pT3bpN0 Prostate Cancer

OBJECTIVES To investigate the prognostic effect of the prostate cancer (PCa) volume involving the seminal vesicles (CVSVs) in the radical prostatectomy specimen from patients with Stage pT3bpN0 PCa. METHODS We retrospectively reviewed the clinical records of 27 patients with Stage pT3bpN0 PCa who had undergone radical prostatectomy alone. We measured the CVSVs using a grid method on the glass slide under microscopic inspection and investigated the association of the CVSVs with clinicopathologic variables. RESULTS Prostate-specific antigen (PSA) failure was confirmed in 11 of the 27 patients (41%) during a median follow-up of 34 months. The 3-year PSA failure-free survival rate was 48%. The median CVSVs was 1.14 cm(3). On univariate analysis, a CVSVs of >1.63 cm(3) was associated with positive surgical margins (P = .018), bilateral seminal vesicle involvement (P = .03), a long maximal tumor dimension (P = .031), and a greater preoperative PSA level (P = .0007). The 3-year PSA failure-free survival rate for those with a CVSVs of <or=1.63 cm(3) vs >1.63 cm(3) was 80% and 0%, respectively (P = .0009). On multivariate analysis, only the PSA level and CVSVs were identified as significant and independent predictors of PSA failure. Stratifying patients into 3 risk groups by these predictors, the PSA failure-free survival rate for patients with a PSA level >or=10 ng/mL and a CVSVs of >1.63 cm(3) was significantly worse than for any other group. CONCLUSIONS The CVSVs is useful and invaluable as an independent predictor of PSA failure in patients with Stage pT3bpN0 PCa. The measurement of the CVSVs is simple and helped to determine the indication for adjuvant treatment after radical prostatectomy.

Gasless Single Port Surgery for Renal Cell Carcinoma: Minimum Incision Endoscopic Surgery

Advances in minimally invasive urologic surgery have accumulated rapidly in recent years with the advent of laparoscopic and robot-assisted surgeries (Clayman, 1991; Guillonneau, 1999; Dasgupta, 2009; Lee, 2009). The procedures for renal cell carcinoma (RCC), radical nephrectomy and partial nephrectomy are among those that have benefited from such innovation. Both laparoscopic surgery and robot-assisted surgery have markedly reduced the invasiveness of surgeries compared to conventional open procedures; laparoscopic surgery is characterized by the use of endoscopy, insufflation with carbon dioxide (CO2) gas, and insertion of instruments from several trocar ports, while robot-assisted surgery also incorporates stereovision and state-of-the-art movable instruments.

Risk Stratification of High-grade Prostate Cancer Treated with Antegrade Radical Prostatectomy with Intended Wide Resection

OBJECTIVE The aim of this study was to assess the surgical outcome of high-grade prostate cancer (PCA) treated with antegrade radical prostatectomy with intended wide resection (aRP) and to establish the risk stratification. METHODS A consecutive 77 Japanese patients with Gleason score 8-10 PCA were treated with aRP alone and excluding patients with persistently elevated prostate-specific antigen (PSA), prospectively observed without any treatment until PSA failure was confirmed. PSA failure-free, cancer-specific and overall survival curves were generated with Kaplan-Meier method and the difference between groups was assessed with log-rank test. Coxs proportional hazards model was used to elucidate predictors of PSA failure. RESULTS During a median follow-up of 6 years, PSA failure was observed in 41 (53%) of the 77 patients. Five- and 10-year PSA failure-free survival rates of the entire cohort were 44.6% and 40.1%, respectively. Both overall and cancer-specific survival rates of the entire cohort at 5 and 10 years were 96.8% and 87.9%, respectively. In a multivariate analysis, PSA (P = 0.008), specimen confinement (SC) (P = 0.006) and persistently elevated PSA after aRP were identified as significant and independent predictors of PSA failure. When stratifying patients into three risk groups according to PSA level and SC status, PSA failure-free survival rate in patients with PSA < 10 ng/ml and specimen-confined disease (SCD) was significantly better than that in those of any other groups. CONCLUSIONS Good prognosis can be expected in patients with high-grade PCA treated with aRP alone when PSA < 10 ng/ml and the tumor was removed as an SCD.

Combination chemotherapy of ifosfamide, 5-fluorouracil, etoposide and cisplatin as perioperative treatment in lymph node positive bladder carcinoma patients treated by radical cystectomy

Objectives:  To evaluate the efficacy and toxicity of perioperative combination chemotherapy with ifosfamide, 5‐fluorouracil, etoposide and cisplatin (IFEP) in bladder cancer patients with regional lymph node metastases treated by radical cystectomy.

Renal Cell Carcinoma in Dialysis Patients with End Stage Renal Disease: Focus on Surgery and Pathology

In 1977, Dunnill et al. from Oxford at first reported that 14 of 30 dialysis patients with end stage renal disease (ESRD) examined at autopsy had acquired cystic disease of the kidney (ACDK) and that six of these 14 patients had renal cell carcinoma (RCC), including one with distant RCC metastatsis.1 It is now well established that patients with ESRD are more prone to RCCs with an incidence of approximately 3 to 5 %.2-5 These studies may misrepresent the true incidence RCC because they primarily relay upon screening radiology, particularly ultrasonography (US), for detection. Better estimate was provided by a single-center study in which most renal transplant patients undergo ipsilateral native nephrectomy at surgery. Based upon strict pathologic criteria reported by Denton et al., prevalence of ACDK, renal adenoma and RCC and oncocytoma were found in 33%, 14%, 4.2% and 0.6% of 260 patients6, which may be lower than the true incidence given that only one kidney was removed. Chen et al. found higher incidence of RCCs vs. the general population, with a standardized incidence ratio of RCC in dialysis patients of 24.1 (p <.01)7. Ishikawa et al. were able to demonstrate that time spent on haemodialysis was the most important risk factor for ACDK and also for the development of RCC. This important observation did highlight the key features of ACDK developing on haemodialysis and apparently increasing the likelihood of RCC2,8,9. Hughson’s work suggested that during this time there was a progression of cystic lesions from simple to complex or hyperplastic cysts and on to renal tumor formation10. A recent nation-wide survey in Japan revealed a 15-fold increase in the number of dialysis patients with RCC in the last 2 decades8. Reasons for this rapid increase can be postulated as follows: the increasing number of dialysis patients: the increasing duration of dialysis in these patients: and the prevalence of tumor screening in dialysis patients by imaging studies. The prevalence of ACDK in the haemodialysis population in Japan appears to be higher than that in the USA or Europe and patient survival on dialysis in Japan is significantly longer. These are probably because of different patterns of primary renal disease and reduced cardiovascular comorbidity compared with Western populations11. The presence of RCCs also appears to vary within different populations. Kojima’s study of 2624

Successful 2-year-long remission following repeated salvage surgery in a patient with chemotherapy-resistant metastatic nonseminomatous germ cell tumor

A 34 year-old man with a diagnosis of nonseminomatous testicular cancer with retroperitoneal lymph node metastasis (T1N3M0S2, stage IIIb; intermediate prognosis, made after right inguinal orchiectomy was performed) was referred to our hospital after having had a total of eight courses of systemic chemotherapy and external-beam radiotherapy to the retroperitoneal region in the previous 1 year. His serum α-fetoprotein (AFP) level remained elevated. Two courses of paclitaxel, etoposide, and cisplatin combined chemotherapy (TEP; paclitaxel 120 mg/m2 day 1, etoposide 80 mg/m2 days 2–5, cisplatin 20 mg/m2 days 2–5) failed to normalize the AFP level. During the following 2 years he underwent salvage surgery four times; infrarenal retroperitoneal lymph node dissection (RPLND), left neck lymph node dissection, thoracic duct excision, and suprarenal RPLND. Viable cancer cells were found in all surgically resected specimens, except for the neck lymph node specimen. The serum AFP level was normalized and he has been well without relapse for 2 years after the last surgery. The present case suggests that repeated salvage surgery may be beneficial in selected patients with a chemotherapy-resistant metastatic germ cell tumor.