A Novel Tomato-Soy Juice Induces a Dose-Response Increase in Urinary and Plasma Phytochemical Biomarkers in Men with Prostate Cancer.

Background: Tomato and soy intake is associated with reduced prostate cancer risk or severity in epidemiologic and experimental studies. Objective: On the basis of the principle that multiple bioactives in tomato and soy may act on diverse anticancer pathways, we developed and characterized a tomato-soy juice for clinical trials. In this phase 2 dose-escalating study, we examined plasma, prostate, and urine biomarkers of carotenoid and isoflavone exposure. Methods: Men scheduled for prostatectomy were recruited to consume 0, 1, or 2 cans of tomato-soy juice/d before surgery (mean ± SD duration: 24 ± 4.6 d). The juice provided 20.6 mg lycopene and 66 mg isoflavone aglycone equivalents/177-mL can. Plasma carotenoids and urinary isoflavone metabolites were quantified by HPLC-photometric diode array and prostate carotenoids and isoflavones by HPLC-tandem mass spectrometry. Results: We documented significant dose-response increases (P < 0.05) in plasma concentrations of tomato carotenoids. Plasma concentrations were 1.86-, 1.69-, 1.73-, and 1.69-fold higher for lycopene, ß-carotene, phytoene, and phytofluene, respectively, for the 1-can/d group and 2.34-, 3.43-, 2.54-, and 2.29-fold higher, respectively, for the 2-cans/d group compared with 0 cans/d. Urinary isoflavones daidzein, genistein, and glycitein increased in a dose-dependent manner. Prostate carotenoid and isoflavone concentrations were not dose-dependent in this short intervention; yet, correlations between plasma carotenoid and urinary isoflavones with respective prostate concentrations were documented (R2 = 0.78 for lycopene, P < 0.001; R2 = 0.59 for dihydrodaidzein, P < 0.001). Secondary clustering analyses showed urinary isoflavone metabolite phenotypes. To our knowledge, this is the first demonstration of the phytoene and phytofluene in prostate tissue after a dietary intervention. Secondary analysis showed that the 2-cans/d group experienced a nonsignificant decrease in prostate-specific antigen slope compared with 0 cans/d (P = 0.078). Conclusion: These findings provide the foundation for evaluating a well-characterized tomato-soy juice in human clinical trials to define the impact on human prostate carcinogenesis. This trial is registered at clinicaltrials.gov as NCT01009736.

NCCN Guidelines Insights: Prostate Cancer Early Detection, Version 2.2016.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Prostate Cancer Early Detection provide recommendations for prostate cancer screening in healthy men who have elected to participate in an early detection program. The NCCN Guidelines focus on minimizing unnecessary procedures and limiting the detection of indolent disease. These NCCN Guidelines Insights summarize the NCCN Prostate Cancer Early Detection Panel's most significant discussions for the 2016 guideline update, which included issues surrounding screening in high-risk populations (ie, African Americans, BRCA1/2 mutation carriers), approaches to refine patient selection for initial and repeat biopsies, and approaches to improve biopsy specificity.

Prostate Cancer, Version 1.2016.

The NCCN Guidelines for Prostate Cancer address staging and risk assessment after an initial diagnosis of prostate cancer and management options for localized, regional, and metastatic disease. Recommendations for disease monitoring, treatment of recurrent disease, and systemic therapy for metastatic castration-recurrent prostate cancer also are included. This article summarizes the NCCN Prostate Cancer Panel's most significant discussions for the 2016 update of the guidelines, which include refinement of risk stratification methods and new options for the treatment of men with high-risk and very-high-risk disease and progressive castration-naïve disease.

Value in prostate cancer treatment.

Value in health care is measured by outcomes and expense. An agreed upon desirable outcome can be indexed against the health care expenditure required for procurement. Prostate cancer treatment is an especially difficult subject for investigation of value. The late onset of the disease, coupled with competitive mortality risk, confounds value analysis. When cost considerations are made paramount, observation is the apparent treatment of choice. J. Surg. Oncol. 2016;114:288-290. © 2016 Wiley Periodicals, Inc.

NCCN Clinical Practice Guidelines Prostate Cancer Early Detection, Version 2.2015.

Prostate cancer represents a spectrum of disease that ranges from nonaggressive, slow-growing disease that may not require treatment to aggressive, fast-growing disease that does. The NCCN Guidelines for Prostate Cancer Early Detection provide a set of sequential recommendations detailing a screening and evaluation strategy for maximizing the detection of prostate cancer that is potentially curable and that, if left undetected, represents a risk to the patient. The guidelines were developed for healthy men who have elected to participate in the early detection of prostate cancer, and they focus on minimizing unnecessary procedures and limiting the detection of indolent disease.

Prostate cancer early detection, version 1.2014. Featured updates to the NCCN Guidelines.

The NCCN Guidelines for Prostate Cancer Early Detection provide recommendations for men choosing to participate in an early detection program for prostate cancer. These NCCN Guidelines Insights highlight notable recent updates. Overall, the 2014 update represents a more streamlined and concise set of recommendations. The panel stratified the age ranges at which initiating testing for prostate cancer should be considered. Indications for biopsy include both a cutpoint and the use of multiple risk variables in combination. In addition to other biomarkers of specificity, the Prostate Health Index has been included to aid biopsy decisions in certain men, given recent FDA approvals.

Prostate cancer, version 2.2014.

Prostate cancer has surpassed lung cancer as the most common cancer in men in the United States. The NCCN Guidelines for Prostate Cancer provide multidisciplinary recommendations on the clinical management of patients with prostate cancer based on clinical evidence and expert consensus. NCCN Panel guidance on treatment decisions for patients with localized disease is represented in this version. Significant updates for early disease include distinction between active surveillance and observation, a new section on principles of imaging, and revisions to radiation recommendations. The full version of these guidelines, including treatment of patients with advanced disease, can be found online at the NCCN website.

Complications after double-barreled wet colostomy compared to separate urinary and fecal diversion during pelvic exenteration: time to change back?

OBJECTIVE: To assess complications associated with double-barreled wet colostomy (DBWC) in the first six months after pelvic exenteration as compared to separate urinary and fecal diversion (SUD). METHODS: A single institution retrospective chart review was conducted of all patients who underwent a pelvic exenteration between 2000 and 2011. Patients were included if the procedure involved at least a urinary diversion and a perineal phase. Patient demographics and complications in the first 6months after surgery were recorded. RESULTS: Thirty-three patients met inclusion criteria (12 DBWC and 21 SUD). The majority of patients had recurrent cervical cancer (58%) followed by vaginal, vulva, and endometrial cancer. All patients had previously received radiation. 10/12 patients with a DBWC and 67% of SUD had pelvic reconstruction. Median length of stay (LOS) was shorter for DBWC (14.5 vs. 20days, p=.01). Median operating times were shorter for DBWC (610 vs. 702minutes, p=.04). No urinary conduit or anastomotic bowel leaks occurred in the DBWC group compared to 5 (24%) and 2 (9.5%), respectively, in the SUD group (p=.06 for any leak). 58% of the DBWC and 62% of the SUD group required re-operation, and there were no 30-day peri-operative deaths. CONCLUSIONS: DBWC can be performed safely at the time of pelvic exenteration. We found reduced operating times, shorter LOS, and a trend toward fewer urinary conduit and/or bowel anastomotic leaks in DBWC exenteration patients. DBWC may be favorable over more technically challenging SUD in this heavily radiated population that generally has a limited overall survival.

Prostate cancer, version 1.2014.

The NCCN Guidelines for Prostate Cancer provide multidisciplinary recommendations on the clinical management of patients with prostate cancer. This report highlights notable recent updates. Radium-223 dichloride is a first-in-class radiopharmaceutical that recently received approval for the treatment of patients with symptomatic bone metastases and no known visceral disease. It received a category 1 recommendation as both a first-line and second-line option. The NCCN Prostate Cancer Panel also revised recommendations on the choice of intermittent or continuous androgen deprivation therapy based on recent phase III clinical data comparing the 2 strategies in the nonmetastatic and metastatic settings.

Multimodal imaging and detection strategy with 124 I-labeled chimeric monoclonal antibody cG250 for accurate localization and confirmation of extent of disease during laparoscopic and open surgical resection of clear cell renal cell carcinoma.

Renal cell carcinoma (RCC) accounts for approximately 85% to 90% of all primary kidney malignancies, with clear cell RCC (ccRCC) constituting approximately 70% to 85% of all RCCs. This study describes an innovative multimodal imaging and detection strategy that uses (124)I-labeled chimeric monoclonal antibody G250 ((124)I-cG250) for accurate preoperative and intraoperative localization and confirmation of extent of disease for both laparoscopic and open surgical resection of ccRCC. Two cases presented herein highlight how this technology can potentially guide complete surgical resection and confirm complete removal of all diseased tissues. This innovative (124)I-cG250 (ie, (124)I-girentuximab) multimodal imaging and detection approach, which would be clinically very useful to urologic surgeons, urologic medical oncologists, nuclear medicine physicians, radiologists, and pathologists who are involved in the care of ccRCC patients, holds great potential for improving the diagnostic accuracy, operative planning and approach, verification of disease resection, and monitoring for evidence of disease recurrence in ccRCC patients.

Quality of lymphadenectomy is equivalent with robotic and open cystectomy using an extended template.

PURPOSE: Extended lymph node dissection for bladder cancer provides better staging, cancerous node removal and potentially survival. Minimally invasive techniques have been criticized about the ability to adequately perform extended lymph node dissection. We compared the extended lymph node dissection quality of robotic and open cystectomy by assessing node yield and positivity. MATERIALS AND METHODS: We compared extended lymph node dissection in 120 open and 35 robotic cystectomy cases. Extended lymph node dissection included skeletonization of structures in each nodal group below the aortic bifurcation (common iliac, external iliac, obturator, hypogastric and presacral nodes). Nodes were processed identically but submitted as 1 or 2 packets for robotic cases and as 10 or more packets for open surgery cases. RESULTS: The mean±SD node count in the open group was 36.9±14.8 (range 11 to 87) and in the robotic group the mean yield was 37.5±13.2 (range 18 to 64). Only 12 of 120 open (10%) and 2 of 35 robotic (6%) cases had fewer than 20 nodes. A total of 36 open (30%) and 12 robotic (34%) cases were node positive. Open extended lymph node dissection identified 80% and 90% confidence of accurate staging as pN0 when obtaining 23 and 27 nodes, respectively. A node count of 23 or 27 was achieved in 87% and 77% of open cases, and in 91% and 83% of robotic cases, respectively. Of patients with open surgery 36% received neoadjuvant chemotherapy compared to 31% of those with robotic surgery. CONCLUSIONS: No difference was identified in the lymph node yield or the positive node rate when comparing open and robotic extended lymph node dissection. Local recurrence and survival data are needed to confirm whether the 2 techniques are oncologically equivalent.

Prostate cancer, Version 3.2012: featured updates to the NCCN guidelines.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Prostate Cancer provide multidisciplinary recommendations for the clinical management of patients with prostate cancer. These NCCN Guidelines Insights highlight notable recent updates. Abiraterone acetate is a first-in-class hormonal agent that represents a new standard of care for patients with metastatic castration-recurrent prostate cancer who have previously received docetaxel (category 1 recommendation). Abiraterone acetate also received category 2B recommendations in the prechemotherapy setting for asymptomatic patients or symptomatic patients who are not candidates for docetaxel. The NCCN Prostate Cancer Panel also added new indications for existing agents, including the option of sipuleucel-T as second-line therapy. In addition, brachytherapy in combination with external beam radiation therapy with or without androgen deprivation therapy is now an alternative for patients with high-risk localized tumors or locally advanced disease.

Amide proton transfer MR imaging of prostate cancer: a preliminary study.

PURPOSE: To evaluate the capability of amide proton transfer (APT) MR imaging for detection of prostate cancer that typically shows a higher tumor cell proliferation rate and cellular density leading to an MRI-detectable overall elevated mobile protein level in higher grade tumors. MATERIALS AND METHODS: Twelve patients with biopsy-proven prostate cancer were imaged on a 3 Tesla MR imaging system before prostatectomy. APT-MR images were acquired by means of a single-slice single-shot turbo spin echo sequence with a saturation prepulse preparation using 33 different frequency offsets (-8 to 8 ppm, interval 0.5 ppm). For quantification we used the APT ratio (APTR) based on the asymmetry of the magnetization transfer ratio at 3.5 ppm in respect to the water signal. Tumor and peripheral zone benign regions of interest (ROIs) were delineated based on whole mount pathology slides after prostatectomy. RESULTS: APTR in prostate cancer ROIs was 5.8% ± 3.2%, significantly higher than that in the peripheral zone benign regions (0.3% ± 3.2%, P = 0.002). CONCLUSION: APT-MR imaging is feasible in prostate cancer detection and has the potential to discriminate between cancer and noncancer tissues.

How do commonly performed lymphadenectomy templates influence bladder cancer nodal stage?

PURPOSE: Determining pathological nodal stage in patients with bladder cancer is important for prognosis. We determined how the extent of lymphadenectomy and the lymph node count influence accurate nodal staging. MATERIALS AND METHODS: The study included 120 patients who underwent at least extended lymphadenectomy at radical cystectomy. Different anatomical templates for lymphadenectomy were evaluated for nodal staging accuracy. The cumulative percent was plotted to determine a lymph node count that confidently identified node positive cases. RESULTS: The mean +/- SD total lymph node count in the study population was 36.9 +/- 14.8 at extended lymphadenectomy. Of the patients 36 (30%) had lymph node metastasis, including 14 (39%) with metastasis involving the common iliac and/or presacral lymph nodes. Limited, standard and extended lymphadenectomy accurately identified 75%, 88.9% and 100% of node positive cases, respectively. Removing 23 and 27 lymph nodes provided 80% and 90% confidence, respectively, that a case was accurately staged as pN0. No patient had lymph node metastasis above the aortic bifurcation without nodal metastasis below the aortic bifurcation and none had a change in pN stage by extending lymphadenectomy above the aortic bifurcation. CONCLUSIONS: To accurately identify node positive and negative cases, and correctly assign pN stage in node positive cases it is necessary to perform extended lymphadenectomy. Identifying at least 23 to 27 lymph nodes on final pathological evaluation provides a high level of confidence that a case is correctly staged as node positive or negative.

Residency training: where do we go from here.

Residency training in urologic surgery should change to an educational experience driven by outcomes instead of process. The needs analysis for curriculum modification has been completed and defines the competencies (enduring skills) of the complete physician. The challenge now rests with organizational leaders of urology to design programs that ensure the acquisition of these characteristics and conserve time and economic resources.

Comparison of real-time intraoperative ultrasound-based dosimetry with postoperative computed tomography-based dosimetry for prostate brachytherapy.

PURPOSE: To evaluate whether real-time intraoperative ultrasound (US)-based dosimetry can replace conventional postoperative computed tomography (CT)-based dosimetry in prostate brachytherapy. METHODS AND MATERIALS: Between December 2001 and November 2002, 82 patients underwent (103)Pd prostate brachytherapy. An interplant treatment planning system was used for real-time intraoperative transrectal US-guided treatment planning. The dose distribution was updated according to the estimated seed position to obtain the dose-volume histograms. Postoperative CT-based dosimetry was performed a few hours later using the Theraplan-Plus treatment planning system. The dosimetric parameters obtained from the two imaging modalities were compared. RESULTS: The results of this study revealed correlations between the US- and CT-based dosimetry. However, large variations were found in the implant-quality parameters of the two modalities, including the doses covering 100%, 90%, and 80% of the prostate volume and prostate volumes covered by 100%, 150%, and 200% of the prescription dose. The mean relative difference was 38% and 16% for doses covering 100% and 90% of the prostate volume and 10% and 21% for prostate volumes covered by 100% and 150% of the prescription dose, respectively. The CT-based volume covered by 200% of the prescription dose was about 30% greater than the US-based one. Compared with CT-based dosimetry, US-based dosimetry significantly underestimated the dose to normal organs, especially for the rectum. The average US-based maximal dose and volume covered by 100% of the prescription dose for the rectum was 72 Gy and 0.01 cm(3), respectively, much lower than the 159 Gy and 0.65 cm(3) obtained using CT-based dosimetry. CONCLUSION: Although dosimetry using intraoperative US-based planning provides preliminary real-time information, it does not accurately reflect the postoperative CT-based dosimetry. Until studies have determined whether US-based dosimetry or postoperative CT-based dosimetry can better predict patient outcomes, the American Brachytherapy Society recommendation of CT-based postimplant dosimetry should remain the standard of care.

Consumption of dietary supplements and over-the-counter and prescription medications in men participating in the Prostate Cancer Prevention Trial at an academic center.

OBJECTIVE: It is hypothesized that dietary patterns, individual nutrients, and specific prescription and over-the-counter medications may influence prostate carcinogenesis. Little information is available regarding the use of these products among men who are participating in prevention trials targeting prostate cancer. MATERIALS AND METHODS: A total of 92 men (mean age 69 years) participating in the Prostate Cancer Prevention Trial (PCPT) at an academic center were asked to bring all nutritional supplements and medications to regularly scheduled study visits. RESULTS: Data were collected on 86 of 92 men. We found that 85% of men in the PCPT regularly consumed at least 1 nutritional supplement. The mean (+/-standard deviation) number of dietary supplements consumed per man was 3.3 +/- 3.5 (range 0-21). A multivitamin and multimineral (73%) supplement was the most common product consumed. Single-nutrient supplements regularly consumed included: vitamin E (48%), vitamin C (31%), calcium (24%), and selenium (7%). Of men, 36% reported consumption of herbal products. Medications frequently consumed during the study period that may influence prostate carcinogenesis included nonsteroidal antiinflammatory drugs (57%), antihypertensives (49%), lipid lowering agents (27%), and aspirin (64%). CONCLUSIONS: Participants in the PCPT at an academic center have a high propensity for dietary supplement use. Many, such as vitamin E and selenium, are hypothesized to influence the risk of prostate cancer. Several of the medications commonly consumed, including aspirin, nonsteroidal antiinflammatory drugs, and statins, are being investigated as chemopreventive agents. Investigators designing prostate cancer chemoprevention trials should consider including detailed documentation of exposure to these products that may influence study outcomes.