Management of clinically localized prostate cancer

Critics of screening have stated that early detection of prostate cancer does not necessarily reflect a diminishing death rate from the disease. However, several recent reports have demonstrated that the death rate from prostate cancer is decreasing, representing the most compelling validation for aggressive screening. Prostate cancer can be halted only if there is no evidence of systemic or regional metastases and the disease is confined to the surgical field or the radiation template. Surgeons and radiation oncologists must make a concerted effort to exclude men with regional and systemic metastases who are unlikely to benefit from treatment. With the widespread acceptance of prostate-specific antigen screening, a greater proportion of men are being diagnosed with clinically localized prostate cancer. Both radical prostatectomy and radiation therapy are able to halt disease spread in this significant subset of men, but survival outcomes indicate that radical prostatectomy is a more reliable treatment than radiation therapy for clinically localized prostate cancer. Overall, the immediate treatment-related morbidity of radical prostatectomy and radiation therapy in the modern era is quite low. Radical prostatectomy and radiation therapy appear to have a similar impact on continence and erectile function. There is a need for neoadjuvant and adjuvant therapies that can be utilized in those cases where radical prostatectomy and radiation are less likely to completely eradicate or destroy the cancer.     

Screening for carcinoma of the prostate by digital rectal examination in a randomly selected population.

OBJECTIVE--To study the acceptability, costs, psychosocial consequences, and organisation of screening for carcinoma of the prostate. DESIGN--A randomly selected population was personally invited for digital rectal examination by a urologist and a general practitioner. Further examinations were performed if induration was felt. Each man completed a questionnaire on his response to the examination. SETTING--General practices in the area of Norrköping. PATIENTS--1494 Men aged 50-69 randomly selected from a population of 9026. MAIN OUTCOME MEASURE--Prostates having a firm nodular consistency. RESULTS--Carcinoma of the prostate was suspected in 45 of 1163 patients examined; in 10 by the general practitioners, in 10 by the urologists, and in 25 by both. Forty four men had a fine needle aspiration biopsy, and carcinomas were found in 13 cases. Of these, one had been suspected by the general practitioner, four by urologists, and eight by both. The cost for each man was 11.60 pounds, and the cost for each case of carcinoma detected and treated by potentially curative methods was 2477 pounds. Of the 13 men with carcinoma, 10 underwent radical prostatectomy and one radiotherapy. One man had advanced disease and was given endocrine treatment, another was not treated. Only 193 men felt distress during the initial examination. Of the 44 men who had an aspiration biopsy, 25 experienced anxiety. CONCLUSIONS--Screening for carcinoma of the prostate by a urologist or a general practitioner using digital rectal examination is a cost effective method of early diagnosis. Whether such screening leads to prolonged survival, however, remains doubtful.     

Needle biopsy in diagnosis of prostatic cancer

Four methods available for the diagnosis of carcinoma of the prostate-digital rectal evaluation, prostatic smear, needle biopsy and open perineal or transurethral biopsy-were studied and correlated.One hundred ten patients with clinical indications of cancer of the prostate were subjected to needle biopsy and open perineal or transurethral biopsy. Seventy of the same patients had prostatic smear examination. Using the open perineal biopsy or the positive transurethral biopsy as the standard, the accuracy of prostatic palpation, prostatic smear and needle biopsy were obtained.A high degree of correlation (74 per cent) was demonstrated between digital rectal evaluation and positive surgical biopsies in both early and late cases. There were 17 false positive clinical diagnoses. The prostatic smear showed an overall correlation of 45 per cent when compared with the results of positive surgical biopsy. The overall accuracy of needle biopsy was 73 per cent. However, in the last 39 cases, including eight in which the carcinomas were of groups A and B (curable), the needle accuracy was 100 per cent. When there is clinical indication of malignant disease of the prostate, needle biopsy of the lesion is warranted and should be done before definitive or palliative treatment is undertaken.     

The Diagnosis of Early Carcinoma of the Prostate

Careful palpation of the gland is a very important examination procedure in the detection of early carcinoma in the prostate. The finding of a suspicious area requires additional investigation, which must include histological examination of tissue from the suspected lesion. Adequate material for histological studies can usually be obtained by needle biopsy. The percutaneous perineal approach has been found satisfactory for this purpose. In those whose life expectancy is 10 years or more, prostatic carcinoma in its early stages should be treated by radical prostatectomy. For more advanced lesions or for patients whose life expectancy is less, hormonal therapy may be used.     

Selecting treatment for high-risk, localized prostate cancer: the case for radical prostatectomy

The most common treatment options for men with clinically localized prostate cancer include radical prostatectomy and radiation therapy. The choice between these options is often controversial, and selecting the optimal treatment poses a great challenge for patients and physicians. Factors important to the decision include age and life expectancy of the patient, the natural history of the prostate cancer, how curable the disease is, and the morbidity of treatment. Use of these criteria to select treatment for a healthy, 70-year-old man presenting with a nonpalpable tumor, stage T1c disease, serum prostate-specific antigen of 12 ng/mL, and an adenocarcinoma with a Gleason score of 8 that is present in 2 of 12 biopsy cores would lead to the choice of radical prostatectomy over radiation therapy. Data show that such a patient has a life expectancy of more than 12.3 years if the prostate cancer can be cured and a high probability of dying from the disease if it is not cured. Data further show that radical prostatectomy in such a patient would confer a survival advantage over radiation therapy without resulting in greater complications or reduction in quality of life.     

Bicalutamide adjuvant to radical prostatectomy

Prostate cancer recurrence affects up to 50% of men in the first 10 years after radical prostatectomy for clinically localized disease. New treatment approaches that reduce this risk are needed. Current published data on the use of adjuvant hormonal therapy in the post-radical prostatectomy setting are limited. New data from the bicalutamide (Casodex) Early Prostate Cancer program show that bicalutamide 150 mg/d, given as immediate adjuvant treatment, produces clear benefits with respect to both progression-free survival and prostate-specific antigen progression when compared with standard management with radical prostatectomy. The greatest improvement of progression-free survival was observed in patient subgroups at highest risk.     

Diagnostic pitfalls in fine needle aspiration of solitary pulmonary nodules: two cases with radio-cyto-histological correlation

Background

Fine needle aspiration is an important tool for diagnosis and preoperative evaluation of solitary nodules of the lung. It provides a definitive diagnosis in most patients at low cost with minimal trauma. However, because of the nature of the study and the presentation of the cells in a more distorted and incomplete tissue structure than a histological slide, false positive results can occur. Prior detailed clinical knowledge about the patient, procedures and methods of radiology in obtaining the aspirate specimen is extremely useful in the accurate interpretation of fine needle cytological specimens.

Case presentation

We report two cases of solitary pulmonary nodules in two elderly females, which were initially diagnosed as malignant by fine needle aspiration biopsy. Both cases subsequently underwent pulmonary lobectomy in which, one turned out to be a pulmonary hamartoma and the other appeared to be a middle lobe syndrome of the right lung with liver tissue contamination at the time of fine needle aspiration of the lung.

Conclusions

We are now strong believers that much care must be taken in the interpretation of fine needle aspiration of solitary nodules of the lung. Complete study of the entire specimen, including the cell block, is warranted, since what one interprets as malignant, could have different features in another part of the sample. Last but not the least, prior knowledge of the complete clinical history of the patient together with the salient radiological findings would greatly facilitate the cytopathologist to reach an accurate diagnosis.     

Epidémiologie,diagnostic et pronostic du cancer de la prostate

Prostate cancer is the most frequent of cancers and represents the third leading cause of death by cancer, for men over 50 years, in France and Europe. The incidence decreases since about ten years. Mass screening is not recommended. Individual early diagnosis is based on a yearly exam including Prostate Specific Antigene (PSA) blood test and a digital rectal exam. The target for this diagnostic approach are men from 50 to 75 years with more than 10 years of life expectancy. A series of prostatic biopsy are carried out in case of clinical and/or biological prostate cancer suspicion. The additional examinations recommended in the assessment of extension of prostate cancer with intermediate and high risk are: MRI, bones scintigraphy, scan CAP (metastatic stage), and sometimes Choline PET-CT. Curative treatments are proposed to men with a probability of survival over 10 years, suffering from localized or locally advanced cancer. Gold standard treatments are: active surveillance, radical prostatectomy, brachytherapy, radiotherapy alone or with surgery and/or hormone therapy. Experimental treatments of localized tumors are: focal treatments (phototherapy dynamic, high intensity focused ultrasound). For the more advanced forms, the interest of early chemotherapy is extensively studied.     

Advances in the Management of Post-Radical Prostatectomy Erectile Dysfunction: Treatment Strategies When PDE-5 Inhibitors Don't Work

Phosphodiesterase type-5 (PDE-5) inhibitors have revolutionized the treatment of post-radical prostatectomy erectile dysfunction. For those patients who undergo a non-nerve-sparing radical prostatectomy or whose condition fails to respond to PDE-5 inhibitors, alternative treatment with intracavernous injection therapy, transurethral alprostadil, vacuum erection devices, and recently described combination therapy is available. The goals of therapy are to provide the patient with a means of obtaining an erection so that the patient and his partner may resume sexual relations as soon as possible following radical prostatectomy. There is evidence that early institution of treatment may promote improvement in the return of spontaneous erections in patients who have undergone nerve preservation. In patients who undergo non-nerve-sparing procedures, therapy may improve penile rigidity. Intracavernous injection therapy, transurethral alprostadil, and vacuum devices are highly effective in the management of post-prostatectomy erectile dysfunction. High dropout rates, which are not related to adverse effects, have been described with all 3 modalities. Pre- and postoperative counseling may improve patient and partner satisfaction.     

E-1899: An Eastern Cooperative Oncology Group Study Comparing Ketoconazole Plus Hydrocortisone with Docetaxel Plus Estramustine for Asymptomatic, Androgen-Independent, Nonmetastatic Prostate Cancer Patients with Rising PSA Levels

Many prostate cancer patients with rising prostate-specific antigen (PSA) levels following radical prostatectomy or radiotherapy receive "early" hormonal therapy, despite its uncertain benefit. When these patients ultimately progress to androgen independence, their management remains controversial, with many receiving second-line hormonal therapy. Chemotherapy for the treatment of advanced prostate cancer has a defined palliative benefit; studies to establish its potential impact on survival are ongoing. E-1899 is an intergroup phase III trial comparing second-line hormonal therapy with ketoconazole plus hydrocortisone with docetaxel plus estramustine in patients with androgen-independent prostate cancer with rising PSA levels who have no evidence of metastases.     

胰岛素抵抗在前列腺癌治疗前后动态变化的临床观察

目的:探讨胰岛素抵抗程度在前列腺癌治疗过程中动态变化及胰岛素抵抗程度与前列腺癌预后的关系。方法:选择前列腺癌惠者50名。平均年龄72岁。将前列腺癌患者根据治疗方法分为前列腺癌根治术组、手术去势组、药物去势组;根据有无复发转移分为复发转移组、无复发转移组。采用己糖激酶法测定空腹葡萄糖,放免法测定空腹胰岛素(Fasting serum insulin FINS)水平。运用HOMA模型中的胰岛素抵抗计算公式计算胰岛素抵抗指数(insulin resistance index IRI)。组间比较采用配对t检验。结果:前列腺癌患者在手术后的胰岛素抵抗指数明显下降,与手术前胰岛素抵抗指数存在统计学差异(P<0.05)。前列腺癌根治组的IRI值和手术去势组与药物去势组都存在统计学差异(P<0.05),但手术去势组和药物去势组两组之间不存在统计学差异(P>0.05)。前列腺癌治疗后无复发转移组的IRI值明显低于复发转移组,两组间IRI存在统计学差异(P<0.05)。结论:前列腺癌患者胰岛素抵抗程度与肿瘤治疗经过、效果有关。胰岛素抵抗指数有助于前列腺癌患者判断治疗效果,判断预后。     

Carcinoma of the prostate; diagnosis and treatment

About 28 per cent of men between the ages of 71 and 75 have cancer of the prostate. Many of them do not die of the disease, but with the life span ever increasing, this problem is becoming more important. In the early stages the condition is asymptomatic; when the symptoms of urinary obstruction arise, the cancer is usually too advanced for cure. Cure depends on early diagnosis and, therefore, on routine rectal examination. The solitary hard nodule of early prostatic cancer becomes a stony hard fixed prostate as the condition progresses. X-ray and acid phosphatase studies are of help only after the cancer has metastasized. As many as 50 per cent of patients with rectally palpable early carcinoma of the prostate can be cured by radical perineal prostatectomy. Often, simple enucleation or transurethral resection is sufficient to effect cure in the case of occult carcinoma. However, some observers believe that when cancer is detected by microscopic examination of a prostate that has been removed, a radical operation should be done as soon after the initial operation as feasible. Early orchidectomy and estrogen therapy are of considerable help in slowing the process of advanced prostatic cancer and may postpone the need of transurethral resection to relieve obstruction. When these measures fail, bilateral adrenalectomy, cortisone therapy, pituitary irradiation, and pituitary extirpation have been employed, with moderate success, in an effort to diminish the androgen level.     

CARCINOMA OF THE PROSTATE—Diagnosis and Treatment

About 28 per cent of men between the ages of 71 and 75 have cancer of the prostate. Many of them do not die of the disease, but with the life span ever increasing, this problem is becoming more important.In the early stages the condition is asymptomatic; when the symptoms of urinary obstruction arise, the cancer is usually too advanced for cure. Cure depends on early diagnosis and, therefore, on routine rectal examination. The solitary hard nodule of early prostatic cancer becomes a stony hard fixed prostate as the condition progresses. X-ray and acid phosphatase studies are of help only after the cancer has metastasized. As many as 50 per cent of patients with rectally palpable early carcinoma of the prostate can be cured by radical perineal prostatectomy. Often, simple enucleation or transurethral resection is sufficient to effect cure in the case of occult carcinoma. However, some observers believe that when cancer is detected by microscopic examination of a prostate that has been removed, a radical operation should be done as soon after the initial operation as feasible. Early orchidectomy and estrogen therapy are of considerable help in slowing the process of advanced prostatic cancer and may postpone the need of transurethral resection to relieve obstruction. When these measures fail, bilateral adrenalectomy, cortisone therapy, pituitary irradiation, and pituitary extirpation have been employed, with moderate success, in an effort to diminish the androgen level.     

Evaluation and treatment of men with biochemical prostate-specific antigen recurrence following definitive therapy for clinically localized prostate cancer

Early detection and monitoring by serum prostate-specific antigen (PSA) measurement has increased the number of men presenting with potentially curable prostate cancer. Most will choose radical prostatectomy or some form of radiation therapy for treatment, but some will have evidence of biochemical disease recurrence following therapy, shown by a rising PSA level without other clinical evidence of disease. Radical prostatectomy involves the removal of all prostate tissue, causing the serum PSA to decline to undetectable levels within four to six weeks following surgery; a subsequent rise in the serum PSA to a detectable level indicates disease recurrence. Patients should be evaluated to assess whether rising PSA levels indicate local recurrence or early metastatic disease. The advantages of salvage radiation, endocrine therapy, and other treatment modalities in local disease recurrence must be weighed against potential side effects and the resulting decrease in quality of life. Radiation therapy does not immediately eradicate all PSA-producing cells; therefore the persistence of a detectable PSA does not necessarily imply residual cancer, but rising PSA levels indicate treatment failure. Salvage surgery can be performed after radiotherapy for the purpose of removing all viable cancer cells, but should be weighed against a higher incidence of surgical complications; cryoablation offers a less invasive therapeutic modality.     

Cancer de la prostate : la maladie localisée

Localized prostate cancer is characterized by a tumor confined to the prostate gland at clinical evaluation. Since the onset of PSA screening, the detection of localized prostate cancer has increased. Prognosis factors are clinical stadification, PSA value, PSA doubling time, tumor volume related to needle biopsy pathologic findings (Gleason score, percentage biopsies involved). Treatment depends on tumor prognosis, symptoms and performance status of the patient. Localized prostate cancer can be treated by surgery (radical prostatectomy, high intensity focused ultrasound) or radiotherapy (conformational radiation therapy, brachytherapy). Active follow-up can be proposed to very low risk patients.     

Carcinoma of the cervix

Studies by eminent surgeons to reevaluate the place of radical operations in the treatment of carcinoma of the cervix-now that extensive procedures have become less hazardous-apparently have led to confusion in some minds as to choice between surgical and radiation therapy. Pending outcome of the studies, general employment of surgical treatment is unwarranted. Radiation is the treatment of choice in most cases, particularly if the lesion is in an early stage, although radical operation is indicated in certain rare early cases in which delivery of an effective dose of radiation to involved areas is technically difficult. Elsewise it appears at present that operation should be used only in cases of stages III or IV carcinoma-in which results by either means of treatment are poor.One hundred and seven patients were treated with a combination of x-ray and radium irradiation. X-ray was used first to reduce the hazard of implanting the radium. The "five-year arrest" rates were as follows: For 22 patients with stage I lesion, 70 per cent; for 31 with stage II, 55.7 per cent; 33 with stage III, 39.7 per cent; 21 with stage IV, 0. Eighteen patients with diagnosis of carcinoma of the cervix who had had subtotal hysterectomy were treated. The stage of the disease could not be determined. In this group the five-year arrest rate was 52 per cent.     

Gleason grading of prostate carcinoma in needle biopsies vs. radical prostatectomy specimens

The Gleason grading system for prostatic carcinoma is the dominant method used around the world in research and in daily practice. It is based on glandular architecture. The grading system should be applied to all prostatic tissue samples, including needle core biopsies and radical prostatectomy specimens. Its prognostic value was tested in a large population with long-term follow-up that included use of survival as an end point. The Gleason grading system shows a reasonable degree of correlation between biopsy and radical prostatectomy specimens. Several sources of discrepancy between these 2 types of specimen have been identified. Further educational endeavors are needed to arrive at a greater consensus and accuracy in the use of the Gleason system.     

Assessment of fine needle aspiration as a screening test for occult prostatic carcinoma

As part of an ongoing study of objective parameters of prognostic value in prostatic carcinoma, a routine procedure was developed to aspirate all prostates prior to surgery. These targets were different from those of other workers in the field of prostatic fine needle aspiration (FNA), who generally advocate that FNA be confined to suspicious nodules. The aspirations were performed by a large group of practicing urologists who had no special training in prostatic FNA except for guidelines provided by their peers and information available in the literature. This approach permitted an assessment of the performance of FNA as a screening test rather than as a diagnostic procedure. During the period from January 1983 to February 1987, 1,683 patients had prostatic FNAs performed (plus subsequent histologic study). The following diagnoses were rendered: "inadequate/scanty specimen" in 625 cases (37%), "negative/atypical" in 844 cases (50%) and "suspicious/positive" in 214 cases (13%). Histologic examination showed stage A1 prostatic adenocarcinoma in 18 patients. The cytologic diagnoses on these 18 patients were inadequate/scanty in 3 (17%), negative/atypical in 13 (72%) and suspicious/positive in 2 (11%). Of the 214 patients with a positive/suspicious diagnosis by FNA, the diagnosis of prostatic carcinoma was confirmed by tissue evidence in 200; the other 14 patients had either no evidence of prostatic carcinoma on surgical biopsy (needle biopsy/transurethral resection/suprapubic prostatectomy) or had no surgical biopsy. Eight of the 14 patients developed clinical evidence of carcinoma, 1 died of urinary bladder carcinoma and 1 was lost to follow-up. In the remaining four patients, there is still no evidence of prostatic carcinoma after about one-and-one-half years of follow-up. These results indicate that (1) specialized training is required in order to obtain adequate smears by prostatic FNA; (2) prostatic FNA is not a good screening technique for detecting stage A1 prostatic carcinoma; and (3) a positive diagnosis by prostatic FNA, even when not confirmed by tissue biopsy, is still an indication of disease.     

Fine needle aspiration cytology of pulmonary carcinoid tumors

Twenty-four cases coded as pulmonary carcinoid tumors initially sampled by fine needle aspiration (FNA) biopsy were reviewed in order to determine the cytologic features most useful in making the FNA diagnosis. The diagnosis of carcinoid tumor had been confirmed in 23 cases; the remaining case, though closely resembling a carcinoid tumor on the FNA specimen, proved to be a sclerosing hemangioma of the lung. Comparison of the original and review interpretations of the FNA specimens revealed that all typical spindle cell carcinoids and all atypical carcinoids were correctly diagnosed and classified. Of the 15 typical round cell carcinoids, the original cytologic diagnosis was lymphoma in 2 cases and benign bronchial lining cells in 2 cases. Thus, it appears that diagnostic errors are most likely in "typical" carcinoids. Review of the FNA findings suggests that the frequently stripped cytoplasm (with resulting non-cohesive bare nuclei), coupled with the almost universal plexiform vascularity (seen in 21 of 23 cases), should allow an accurate cytologic diagnosis in virtually all cases.     

CARCINOMA OF THE CERVIX

Studies by eminent surgeons to reevaluate the place of radical operations in the treatment of carcinoma of the cervix—now that extensive procedures have become less hazardous—apparently have led to confusion in some minds as to choice between surgical and radiation therapy. Pending outcome of the studies, general employment of surgical treatment is unwarranted. Radiation is the treatment of choice in most cases, particularly if the lesion is in an early stage, although radical operation is indicated in certain rare early cases in which delivery of an effective dose of radiation to involved areas is technically difficult. Elsewise it appears at present that operation should be used only in cases of stages III or IV carcinoma—in which results by either means of treatment are poor.One hundred and seven patients were treated with a combination of x-ray and radium irradiation. X-ray was used first to reduce the hazard of implanting the radium. The “five-year arrest” rates were as follows: For 22 patients with stage I lesion, 70 per cent; for 31 with stage II, 55.7 per cent; 33 with stage III, 39.7 per cent; 21 with stage IV, 0. Eighteen patients with diagnosis of carcinoma of the cervix who had had subtotal hysterectomy were treated. The stage of the disease could not be determined. In this group the five-year arrest rate was 52 per cent.