[Criticisms to patient selection in active surveillance in prostate cancer]. / Criticas a la selección de pacientes en vigilancia activa en cancer de prostata.

OBJECTIVES: Active treatment in localized prostate cancer, in its various types, is assumed as a valid alternative. The effect of the possible overtreatment has raised that options such as active surveillance are offered as an alternative to active treatments, without evidence about its validity in many points. The objective of this study is to analyze the current controversies to define candidates to this alternative, follow up criteria, impact on quality of life and evidence bases to do it. METHODS: We perform an analysis updating the Medline search with the terms localized prostate cancer and active surveillance, analyzing the articles and their evidence, as well as guidelines recommendations. RESULTS: Selection criteria for candidates to active surveillance are heterogeneous, without evidence of uniformity. Likewise, follow up and its criteria or progression are not well defined. The impact on progression, or delay in decision-making, have not been analyzed and we lack of studies of highest evidence including comparative studies for cancer specific or global survival results. CONCLUSIONS: Although AS seems to be a reasonable alternative in many patients with localized prostate cancer, we still need to define many features of inclusion and decision-making. Comparative studies are needed to better define selection and validity of active surveillance.

Outcomes and patterns of use of Radium-223 in metastatic castration-resistant prostate cancer.

Introduction: Radium-223 dichloride (Ra-223) is recommended as a treatment option for metastatic castration-resistant prostate cancer (mCRPC) patients with symptomatic bone metastases and no visceral disease, after docetaxel failure, or in patients who are not candidates to receive it. In this study, we aimed to ambispectively analyze overall survival (OS) and prognostic features in mCRPC in patients receiving Ra-223 as per clinical routine practice and identify the most suitable treatment sequence. Patients and methods: This study is observational, multicentric, and ambispective. Eligibility criteria included mCRPC patients treated with Ra-223, with an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2, without visceral metastases, and no more than three cm involved lymph nodes. Results: A total of 145 patients were included; the median age was 73.97 years, and a Gleason score of more than or equal to 7 in 61 (48%) patients; 73 (81%) had previously received docetaxel. The most important benefit was reached by those patients who received Ra-223 in the second-line setting, with a median OS of 17 months (95% CI, 12-21), and by patients who received six cycles of treatment, with a median OS of 19 months (95% CI, 14-21). An alkaline phosphatase (ALP) decrease was also identified as a prognosis marker. When performing the multivariate analysis, the time to develop castration-resistant disease longer than 24 months was the most important prognostic factor to predict the evolution of the patients receiving Ra-223. Ra-223 was well tolerated, with thrombocytopenia, anemia, and diarrhea being the main adverse events. Conclusion: There is a benefit for those patients who received Ra-223 in the second-line setting, regardless of prior use of docetaxel. In addition, a survival benefit for patients presenting with a decline in ALP was observed.

Mesothelioma of the tunica vaginalis. Case report.

OBJECTIVE: To report a case of a mesothelioma of the tunica vaginalis and to review the published literature. METHODS / RESULTS: A 61-year-old patient complained of one-month increase of right scrotum size with pain. An ultrasound showed a right hydrocele with a mass attached to the tunica vaginalis. He didn't refer any urological history or known exposure to asbestos. Blood levels of tumor markers (alpha-fetoprotein and beta-HCG) were within normal limits. We performed a radical inguinal orchiectomy with an en-bloc resection of the tunica vaginalis. The pathology described a potentially malignant biphasic mesothelioma. The patient has remained asymptomatic with negative extension studies after 10 years of follow up. CONCLUSIONS: Paratesticular mesotheliomas are rare tumors (approximately 250 cases reported )with uncertain etiology (only 30-40% are associated with asbestos exposure). The age range is between 50-70 years. Its presentation is usually as a scrotal mass with recurrent reactive hydrocele, which may delay early diagnosis. During surgery, intraoperative biopsy is recommended. It is important to do a differential diagnosis with other benign diseases. Treatment is only curative in early stages with radical orchidectomy and resection in-block of the tunica vaginalis. Despite being multidisciplinary, it is not curative in most cases due to rapid local and distant spread.

[Testosterone deficit syndrome in the old male]. / Síndrome de deficit de testosterona en el anciano.

Epidemiological studies have demonstrated that prevalence of hypogonadism in old males increases with every additional decade of life. These males present various symptoms including decrease of sexual function, decrease of cognitive function, altered lipid profile, increased visceral adiposity, changes in bone density and muscular strength secondary to atrophy. Currently, testosterone injections and gel preparations are the most used. Testosterone replacement therapy provides significant symptomatic improvements for men with late start hypogonadism. Long-term benefits and risks of testosterone replacement therapy will be more evident when testosterone effects are studied on all health related parameters over a prolonged period of time. There is a large ongoing multicentric randomized clinical trial sponsored by NIH for testosterone control in old men with low testosterone levels. Its results may give answers to the possible benefits and risks of testosterone replacement in aging males. If an aging male is diagnosed as late-start hypogonadism, the urologist should discuss with the patient potential benefits and risks of testosterone therapy. Aging males with significant erythrocytosis, untreated sleep apnea, prostate cancer and high risk of cardiovascular events must be excluded from testosterone replacement therapy. Currently, there are not enough evidences to clearly state that the benefits of testosterone replacement therapy in aging males are better than the risks of this treatment. A general recommendation cannot be given that testosterone replacement therapy may be applied to all aging males with low testosterone levels independently of significant signs or symptoms.

[Advanced prostate cancer and quality of life.] / Cáncer de próstata avanzado y calidad de vida.

OBJECTIVES: The therapeutic range in advanced and castration resistant prostate cancer is widening. Therapies must offer real clinical efficacy, and they also should be acceptable and desirable for patients, specially in advanced disease. We analyze the value of quality of life analysis in patients with advanced prostate cancer. METHODS: We performed a bibliographic review (Pubmed) with the various health related quality of life scales available and different clinical trials on advanced prostate cancer. RESULTS: There are numerous therapeutic options but, due to variations in study design, a different evaluation of adverse events and different therapeutic regimens, comparisons are difficult. A common method to interpret results is not available, so most of the times that interpretation is left to statistical significance, which is not always well correlated with clinical significance. CONCLUSIONS: To propose the most adequate treatment in patient`s interest, we need results focused on patients that combine not only quantity or overall survival but also quality of life. Parameters such as QALY should be included in clinical trials as evaluation objectives in order to favor decision taking.

[What has changed in the epidemiology and screening of prostate cancer?]. / ¿Qué ha cambiado en la epidemiología y el cribado del cáncer de próstata?

OBJECTIVE; The objective of this study is to review the evolution and changes of prostate cancer epidemiology and to perform an analysis of the current status of prostate cancer screening based on the various studies and scientific societies recommendations. METHODS; We performed a bibliographic review of relevant papers in relation to prostate cancer epidemiology and screening, with special focus on international and multicentric trials on population screening. RESULTS; The current number and profile of patients being diagnosed of prostate cancer have changed significantly from the pre-PSA era to the present time. Early diagnosis and screening strategies have caused an increase in incidence and a decrease in cancer mortality in some countries. CONCLUSIONS; Systematic screening, despite inconsistencies in some studies, seems to improve prostate cancer specific mortality. The introduction of new biomarkers, imaging techniques such as mpMRI as well as less aggressive therapeutic alternatives, probably open windows to the future for a better diagnosis and treatment of the disease.