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1.
N Engl J Med ; 382(10): 917-928, 2020 03 05.
Artículo en Inglés | MEDLINE | ID: mdl-32130814

RESUMEN

BACKGROUND: The use of 12-core systematic prostate biopsy is associated with diagnostic inaccuracy that contributes to both overdiagnosis and underdiagnosis of prostate cancer. Biopsies performed with magnetic resonance imaging (MRI) targeting may reduce the misclassification of prostate cancer in men with MRI-visible lesions. METHODS: Men with MRI-visible prostate lesions underwent both MRI-targeted and systematic biopsy. The primary outcome was cancer detection according to grade group (i.e., a clustering of Gleason grades). Grade group 1 refers to clinically insignificant disease; grade group 2 or higher, cancer with favorable intermediate risk or worse; and grade group 3 or higher, cancer with unfavorable intermediate risk or worse. Among the men who underwent subsequent radical prostatectomy, upgrading and downgrading of grade group from biopsy to whole-mount histopathological analysis of surgical specimens were recorded. Secondary outcomes were the detection of cancers of grade group 2 or higher and grade group 3 or higher, cancer detection stratified by previous biopsy status, and grade reclassification between biopsy and radical prostatectomy. RESULTS: A total of 2103 men underwent both biopsy methods; cancer was diagnosed in 1312 (62.4%) by a combination of the two methods (combined biopsy), and 404 (19.2%) underwent radical prostatectomy. Cancer detection rates on MRI-targeted biopsy were significantly lower than on systematic biopsy for grade group 1 cancers and significantly higher for grade groups 3 through 5 (P<0.01 for all comparisons). Combined biopsy led to cancer diagnoses in 208 more men (9.9%) than with either method alone and to upgrading to a higher grade group in 458 men (21.8%). However, if only MRI-target biopsies had been performed, 8.8% of clinically significant cancers (grade group ≥3) would have been misclassified. Among the 404 men who underwent subsequent radical prostatectomy, combined biopsy was associated with the fewest upgrades to grade group 3 or higher on histopathological analysis of surgical specimens (3.5%), as compared with MRI-targeted biopsy (8.7%) and systematic biopsy (16.8%). CONCLUSIONS: Among patients with MRI-visible lesions, combined biopsy led to more detection of all prostate cancers. However, MRI-targeted biopsy alone underestimated the histologic grade of some tumors. After radical prostatectomy, upgrades to grade group 3 or higher on histopathological analysis were substantially lower after combined biopsy. (Funded by the National Institutes of Health and others; Trio Study ClinicalTrials.gov number, NCT00102544.).


Asunto(s)
Biopsia/métodos , Imagen por Resonancia Magnética , Próstata/patología , Neoplasias de la Próstata/diagnóstico , Neoplasias de la Próstata/patología , Adulto , Anciano , Humanos , Masculino , Persona de Mediana Edad , Clasificación del Tumor , Antígeno Prostático Específico/sangre , Prostatectomía , Neoplasias de la Próstata/cirugía
3.
Medicine (Baltimore) ; 99(7): e18993, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-32049793

RESUMEN

Long non-coding small nucleolar RNA host gene 7 (lncRNA SNHG7) is located on chromosome 9q34.3 in length of 984 bp. SNHG7 has been found to play the role of oncogene in varieties of cancers, and its dysregulation has been found to be associated with carcinogenesis and progression. In the present study, we examined the expression of SNHG7 in prostate cancer tissues and in paired adjacent normal prostate tissues, and we further explored the clinical significance and prognostic value of SNHG7 in prostate cancer patients.A total of 127 prostate cancer tissues were collected from prostate cancer patients who underwent radical prostatectomy between April 2011 and March 2019 at the department of urology, Pudong New Area People's Hospital. Real-time quantitative polymerase chain reaction experiment was performed to detect the relative expressions of SNHG7 in the prostate cancer tissues and normal prostate tissues. The Kaplan-Meier method was used to create survival curves and the log-rank test was used to determine statistical significance. A Cox proportional hazard analysis was used to evaluate the prognostic factors in univariate and multivariate analyses.Compared with paired adjacent normal prostatic tissues, SNHG7 expression was increased in prostate cancer tissues (P < .001). Increased SNHG7 expression correlated with Gleason score (P = .021), bone metastasis (P = .013), pelvic lymph node metastasis (P = .008), and TNM stage (P = .007). Multivariate Cox regression analyses revealed increased SNHG7 expression was independently associated with a poor prognosis of prostate cancer patients (hazard ratio [HR] = 2.839, 95% confidence interval [CI] = 1.921-8.382, P = .038).This study showed that lncRNA-SNHG7 was overexpressed in prostate cancer tissues, and it might contributes to the development and progression of prostate cancer. Furthermore, the SNHG7 expression was associated with the prognosis of prostate cancer, suggesting a potential target for the treatment and prognosis of prostate cancer. Nevertheless, the underlying modulatory mechanism by which SNHG7 aggravates prostate cancer progression need to be further studied.


Asunto(s)
Neoplasias Óseas/cirugía , Neoplasias de la Próstata/cirugía , ARN Largo no Codificante/genética , Regulación hacia Arriba , Neoplasias Óseas/genética , Neoplasias Óseas/patología , Regulación Neoplásica de la Expresión Génica , Humanos , Metástasis Linfática , Masculino , Estadificación de Neoplasias , Pronóstico , Prostatectomía , Neoplasias de la Próstata/genética , Neoplasias de la Próstata/patología , Análisis de Supervivencia , Resultado del Tratamiento
4.
Nat Rev Urol ; 17(3): 177-188, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-32086498

RESUMEN

The practice of radical prostatectomy for treating prostate cancer has evolved remarkably since its general introduction around 1900. Initially described using a perineal approach, the procedure was later popularized using a retropubic one, after it was first described as such in 1948. The open surgical method has now largely been abandoned in favour of the minimally invasive robot-assisted method, which was first described in 2000. Until 1980, the procedure was hazardous, often accompanied by massive blood loss and poor outcomes. For patients in whom surgery is indicated, prostatectomy is increasingly being used as the first step in a multitherapeutic approach in advanced local, and even early metastatic, disease. However, contemporary molecular insights have enabled many men to safely avoid surgical intervention when the disease is phenotypically indolent and use of active surveillance programmes continues to expand worldwide. In 2020, surgery is not recommended in those men with low-grade, low-volume Gleason 6 prostate cancer; previously these men - a large cohort of ~40% of men with newly diagnosed prostate cancer - were offered surgery in large numbers, with little clinical benefit and considerable adverse effects. Radical prostatectomy is appropriate for men with intermediate-risk and high-risk disease (Gleason score 7-9 or Grade Groups 2-5) in whom radical prostatectomy prevents further metastatic seeding of potentially lethal clones of prostate cancer cells. Small series have suggested that it might be appropriate to offer radical prostatectomy to men presenting with small metastatic burden (nodal and or bone) as part of a multimodal therapeutic approach. Furthermore, surgical treatment of prostate cancer has been reported in cohorts of octogenarian men in good health with minimal comorbidities, when 20 years ago such men were rarely treated surgically even when diagnosed with localized high-risk disease. As medical therapies for prostate cancer continue to increase, the use of surgery might seem to be less relevant; however, the changing demographics of prostate cancer means that radical prostatectomy remains an important and useful option in many men, with a changing indication.


Asunto(s)
Próstata/cirugía , Prostatectomía/historia , Neoplasias de la Próstata/historia , Procedimientos Quirúrgicos Robotizados/historia , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Escisión del Ganglio Linfático/historia , Escisión del Ganglio Linfático/tendencias , Masculino , Próstata/anatomía & histología , Próstata/patología , Prostatectomía/métodos , Prostatectomía/tendencias , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/cirugía , Procedimientos Quirúrgicos Robotizados/métodos
5.
Br J Radiol ; 93(1106): 20190757, 2020 Feb 01.
Artículo en Inglés | MEDLINE | ID: mdl-31899654

RESUMEN

OBJECTIVE: To evaluate the usefulness of histogram analysis of stretched exponential model (SEM) on diffusion-weighted imaging in evaluating clinically significant prostate cancer (CSC). METHODS: A total of 85 patients with prostate cancer underwent 3 T multiparametric MRI, followed by radical prostatectomy. Histogram parameters of the tumor from the SEM [distributed diffusion coefficient (DDC) and α] and the monoexponential model [MEM; apparent diffusion coefficient (ADC)] were evaluated. The associations between parameters and Gleason score or Prostate Imaging Reporting and Data System v. 2 were evaluated. The area under the receiver operating characteristics curve was calculated to evaluate diagnostic performance of parameters in predicting CSC. RESULTS: The values of histogram parameters of DDC and ADC were significantly lower in patients with CSC than in patients without CSC (p < 0.05), except for skewness and kurtosis. The value of the 25th percentile of α was significantly lower in patients with CSC than in patients without CSC (p = 0.014). Histogram parameters of ADC and DDC had significant weak to moderate negative associations with Gleason score or Prostate Imaging Reporting and Data System v. 2 (p < 0.001), except for skewness and kurtosis. For predicting CSC, the area under the curves of mean ADC (0.856), 50th percentile DDC (0.852), and 25th percentile α (0.707) yielded the highest values compared to other histogram parameters from each group. CONCLUSION: Histogram analysis of the SEM on diffusion-weighted imaging may be a useful quantitative tool for evaluating CSC. However, the SEM did not outperform the MEM. ADVANCES IN KNOWLEDGE: Histogram parameters of SEM may be useful for evaluating CSC.


Asunto(s)
Neoplasias de la Próstata/patología , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Imagen de Difusión por Resonancia Magnética/métodos , Humanos , Masculino , Persona de Mediana Edad , Invasividad Neoplásica , Variaciones Dependientes del Observador , Prostatectomía/métodos , Neoplasias de la Próstata/cirugía , Curva ROC , Estudios Retrospectivos
6.
Urology ; 137: 126-132, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-31899229

RESUMEN

OBJECTIVE: To assess the impact of concomitant targeted biopsies (TB) for predicting final disease reclassification in MRI-positive low-risk prostate cancer patients eligible for active surveillance (AS) on systematic biopsies (SB). MATERIALS AND METHODS: From a prospective database, we included all prebiopsy MRI-positive men fulfilling AS criteria at diagnosis (Toronto [n = 114], UCSF [n = 82], or PRIAS [n = 60] criteria) on SB. All patients underwent a combination of SB and software-based fusion TB, and an immediate radical prostatectomy. The primary endpoints were the pathologic upgrading and upstaging rates. RESULTS: Biopsy grade group was upgraded to grade group (GG) 2 and to GG≥3 on TB in 65.9%-76.7% and in 12.2-16.7%, respectively. The rate of GG ≥3 in radical prostatectomy specimens varied from 31.6% to 43.3% with no relation between strictest criteria and lower upgrading rates. The proportion of not organ-confined disease (35%-39%) was comparable among the AS cohorts. Negative TB was strongly associated with the absence of final GG ≥3. Tumor grade on TB was significantly correlated with the risk of final GG ≥3 in both Toronto and UCSF cohorts, not in the PRIAS cohort. In the PRIAS cohort, the only independent predictive factor for GG ≥3 disease was the maximal tumor length in any core (P = .034). CONCLUSION: In MRI-positive patients, the risk of disease reclassification was comparable whatever the SB-based AS criteria used. TB were predictive of final upgrading, with a varied impact according to the AS criteria. SB features remained relevant for reclassification prediction even in case of positive TB. The risk of upstaged disease remains important, approximately one third, and neither TB/SB parameters nor MRI findings could accurately predict it.


Asunto(s)
Biopsia Guiada por Imagen/métodos , Imagen por Resonancia Magnética Intervencional/métodos , Clasificación del Tumor , Próstata , Prostatectomía , Neoplasias de la Próstata , Anciano , Humanos , Masculino , Persona de Mediana Edad , Clasificación del Tumor/métodos , Clasificación del Tumor/estadística & datos numéricos , Estadificación de Neoplasias/métodos , Estadificación de Neoplasias/estadística & datos numéricos , Valor Predictivo de las Pruebas , Próstata/diagnóstico por imagen , Próstata/patología , Prostatectomía/métodos , Prostatectomía/estadística & datos numéricos , Neoplasias de la Próstata/diagnóstico , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/cirugía , Medición de Riesgo
7.
Artículo en Inglés | MEDLINE | ID: mdl-31967211

RESUMEN

Cryptococcosis is an opportunistic fungal infection causes significant disease predominantly in immunocompromised patients. Here we present an excepcional case of disseminated cryptococcosis with pulmonary and cerebral involvement in an immunocompetent patient with no apparent predisposing factors at the time of hospital admission. We described a case of an apparently immunocompetent 66-years old man admitted to hospital with a one-month history of cough, fever and vertigo. During hospitalization, thorax imaging was suggestive of lung metastasis, therefore, he went through several investigations. During hospitalization, he developed neurological symptoms and subsequently underwent a lumbar puncture. Cerebrospinal fluid (CSF) culture was positive for Cryptococcus spp. isolated on Sabouraud's dextrose agar and bird seed agar. In addition, the direct microscopy examination was positive for the India ink test, as well as with the latex agglutination test for cryptococcal polysaccharide antigen (CrAg) in CSF, while serum CrAg was negative. Despite the absence of classic immunocompromising features, he was treated with amphotericin B and fluconazole due to suspected disseminated cryptococcal infection. Later, he was diagnosed with prostatic adenocarcinoma. Upon successful completion of treatment for disseminated cryptococcosis, the patient underwent radical prostate ablation surgery as a treatment forprostatic adenocarcinoma. This exceptional case emphasizes the high degree of suspicion of atypical infections, and in these cases, it is particularly important to consider fungal infections in hitherto healthy patients with no apparent predisposing factors. Although Cryptococcus spp. is predominantly reported in patients with hematological malignancies, cryptococcosis investigation should also be considered as part of the initial workup of patients with a new diagnosis of a solid tumour prior to chemotherapy or radiotherapy.


Asunto(s)
Adenocarcinoma/diagnóstico , Criptococosis/diagnóstico , Neoplasias de la Próstata/diagnóstico , Adenocarcinoma/inmunología , Adenocarcinoma/cirugía , Anciano , Anfotericina B/administración & dosificación , Antifúngicos/administración & dosificación , Criptococosis/tratamiento farmacológico , Criptococosis/inmunología , Fluconazol/administración & dosificación , Humanos , Huésped Inmunocomprometido , Masculino , Neoplasias de la Próstata/inmunología , Neoplasias de la Próstata/cirugía
8.
J Cancer Res Clin Oncol ; 146(2): 537-543, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31915914

RESUMEN

PURPOSE: Here, we re-checked the American Joint Committee on Cancer 7th edition subclassification and confirmed the possibility of percent tumor volume as a prognostic factor for biochemical recurrence in the 8th edition subclassification. METHODS: A total of 1073 patients with pathologic T2 stage disease who underwent radical prostatectomy were included. Exclusion criteria were neoadjuvant therapy and pathologic T3 and N1 disease. Biochemical recurrence-free survival was estimated using the Kaplan-Meier method. Cox hazard regression was used to predict biochemical recurrence. RESULTS: According to the 7th edition subclassification, 141 patients (13.1%) had T2a, 43 (4.0%) had T2b, and 889 (82.9%) had T2c disease. The 7th edition subclassification did not differ significantly on Kaplan-Meier analysis (p = 0.502). Mean percent tumor volume was 8.7 ± 8.0% (interquartile range, 5-10%). Percent tumor volume was positively correlated with initial prostate-specific antigen, grade group, surgical margin, and T2 subclassification (all p < 0.001). The 7th edition subclassification was not a significant factor, whereas percent tumor volume was (hazard ratio, 1.023; 95% confidence interval, 1.005-1.041; p = 0.0128) on multivariate analysis. On Kaplan-Meier analysis, percent tumor volume (> 7.5% vs ≤ 7.5%) differed significantly for biochemical recurrence-free survival (p < 0.001). CONCLUSIONS: The 7th edition pathologic T2 subclassification had poor prognostic value for biochemical recurrence in our cohort. Elimination of the 8th edition subclassification was suitable. Percent tumor volume classified biochemical recurrence prognosis in pathologic T2 stage. Therefore, percent tumor volume can be a candidate factor for the next T2 subclassification.


Asunto(s)
Neoplasias de la Próstata/patología , Anciano , Supervivencia sin Enfermedad , Humanos , Calicreínas/sangre , Masculino , Recurrencia Local de Neoplasia/sangre , Recurrencia Local de Neoplasia/patología , Estadificación de Neoplasias , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Antígeno Prostático Específico/sangre , Prostatectomía , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/cirugía , Estudios Retrospectivos
9.
J Surg Oncol ; 121(4): 620-629, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-31970787

RESUMEN

BACKGROUND AND OBJECTIVES: Recent studies demonstrating decreased survival following minimally invasive surgery (MIS) for cervical cancer have generated concern regarding oncologic efficacy of MIS. Our objective was to evaluate the association between surgical approach and 5-year survival following resection of abdominopelvic malignancies. METHODS: Patients with stage I or II adenocarcinoma of the prostate, colon, rectum, and stage IA2 or IB1 cervical cancer from 2010-2015 were identified from the National Cancer Data Base. The association between surgical approach and 5-year survival was assessed using propensity-score-matched cohorts. Distributions were compared using logistic regression. Hazard ratio for death was estimated using Cox proportional-hazard models. RESULTS: The rate of deaths at 5 years was 3.4% following radical prostatectomy, 22.9% following colectomy, 18.6% following proctectomy, and 6.8% following radical hysterectomy. Open surgery was associated with worse survival following radical prostatectomy (HR, 1.18; 95% CI, 1.05-1.33; P = .005), colectomy (HR, 1.45; 95% CI, 1.39-1.51; P < .001), and proctectomy (HR, 1.28; 95% CI, 1.10-1.50; P = .002); however, open surgery was associated with improved survival following radical hysterectomy (HR, 0.61; 95% CI, 0.44-0.82; P = .003). CONCLUSIONS: These results suggest that MIS is an acceptable approach in selected patients with prostate, colon, and rectal cancers, while concerns regarding MIS resection of cervical cancer appear warranted.


Asunto(s)
Neoplasias Abdominales/mortalidad , Neoplasias Abdominales/cirugía , Neoplasias Pélvicas/mortalidad , Neoplasias Pélvicas/cirugía , Adenocarcinoma/mortalidad , Adenocarcinoma/cirugía , Anciano , Colectomía/mortalidad , Colectomía/estadística & datos numéricos , Neoplasias del Colon/mortalidad , Neoplasias del Colon/cirugía , Femenino , Humanos , Histerectomía/mortalidad , Histerectomía/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos , Proctectomía/mortalidad , Proctectomía/estadística & datos numéricos , Prostatectomía/mortalidad , Prostatectomía/estadística & datos numéricos , Neoplasias de la Próstata/mortalidad , Neoplasias de la Próstata/cirugía , Neoplasias del Recto/mortalidad , Neoplasias del Recto/cirugía , Análisis de Supervivencia , Estados Unidos/epidemiología , Neoplasias del Cuello Uterino/mortalidad , Neoplasias del Cuello Uterino/cirugía
10.
JAMA ; 323(2): 149-163, 2020 01 14.
Artículo en Inglés | MEDLINE | ID: mdl-31935027

RESUMEN

Importance: Understanding adverse effects of contemporary treatment approaches for men with favorable-risk and unfavorable-risk localized prostate cancer could inform treatment selection. Objective: To compare functional outcomes associated with prostate cancer treatments over 5 years after treatment. Design, Setting, and Participants: Prospective, population-based cohort study of 1386 men with favorable-risk (clinical stage cT1 to cT2bN0M0, prostate-specific antigen [PSA] ≤20 ng/mL, and Grade Group 1-2) prostate cancer and 619 men with unfavorable-risk (clinical stage cT2cN0M0, PSA of 20-50 ng/mL, or Grade Group 3-5) prostate cancer diagnosed in 2011 through 2012, accrued from 5 Surveillance, Epidemiology and End Results Program sites and a US prostate cancer registry, with surveys through September 2017. Exposures: Treatment with active surveillance (n = 363), nerve-sparing prostatectomy (n = 675), external beam radiation therapy (EBRT; n = 261), or low-dose-rate brachytherapy (n = 87) for men with favorable-risk disease and treatment with prostatectomy (n = 402) or EBRT with androgen deprivation therapy (n = 217) for men with unfavorable-risk disease. Main Outcomes and Measures: Patient-reported function, based on the 26-item Expanded Prostate Index Composite (range, 0-100), 5 years after treatment. Regression models were adjusted for baseline function and patient and tumor characteristics. Minimum clinically important difference was 10 to 12 for sexual function, 6 to 9 for urinary incontinence, 5 to 7 for urinary irritative symptoms, and 4 to 6 for bowel and hormonal function. Results: A total of 2005 men met inclusion criteria and completed the baseline and at least 1 postbaseline survey (median [interquartile range] age, 64 [59-70] years; 1529 of 1993 participants [77%] were non-Hispanic white). For men with favorable-risk prostate cancer, nerve-sparing prostatectomy was associated with worse urinary incontinence at 5 years (adjusted mean difference, -10.9 [95% CI, -14.2 to -7.6]) and sexual function at 3 years (adjusted mean difference, -15.2 [95% CI, -18.8 to -11.5]) compared with active surveillance. Low-dose-rate brachytherapy was associated with worse urinary irritative (adjusted mean difference, -7.0 [95% CI, -10.1 to -3.9]), sexual (adjusted mean difference, -10.1 [95% CI, -14.6 to -5.7]), and bowel (adjusted mean difference, -5.0 [95% CI, -7.6 to -2.4]) function at 1 year compared with active surveillance. EBRT was associated with urinary, sexual, and bowel function changes not clinically different from active surveillance at any time point through 5 years. For men with unfavorable-risk disease, EBRT with ADT was associated with lower hormonal function at 6 months (adjusted mean difference, -5.3 [95% CI, -8.2 to -2.4]) and bowel function at 1 year (adjusted mean difference, -4.1 [95% CI, -6.3 to -1.9]), but better sexual function at 5 years (adjusted mean difference, 12.5 [95% CI, 6.2-18.7]) and incontinence at each time point through 5 years (adjusted mean difference, 23.2 [95% CI, 17.7-28.7]), than prostatectomy. Conclusions and Relevance: In this cohort of men with localized prostate cancer, most functional differences associated with contemporary management options attenuated by 5 years. However, men undergoing prostatectomy reported clinically meaningful worse incontinence through 5 years compared with all other options, and men undergoing prostatectomy for unfavorable-risk disease reported worse sexual function at 5 years compared with men who underwent EBRT with ADT.


Asunto(s)
Antagonistas de Andrógenos/efectos adversos , Braquiterapia/efectos adversos , Medición de Resultados Informados por el Paciente , Prostatectomía/efectos adversos , Neoplasias de la Próstata/terapia , Radioterapia/efectos adversos , Anciano , Antagonistas de Andrógenos/uso terapéutico , Terapia Combinada , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Neoplasias de la Próstata/tratamiento farmacológico , Neoplasias de la Próstata/radioterapia , Neoplasias de la Próstata/cirugía , Radioterapia/métodos , Disfunciones Sexuales Fisiológicas/etiología , Resultado del Tratamiento , Incontinencia Urinaria/etiología , Espera Vigilante
11.
Int J Radiat Oncol Biol Phys ; 106(2): 282-290, 2020 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-31669564

RESUMEN

PURPOSE: Our purpose was to compare toxicity and biochemical control in postprostatectomy patients treated with conventional (66 Gy) or dose-intensified (72 Gy) radiation therapy. METHODS AND MATERIALS: Patients who had stage pT3-4, positive surgical margins, or rising prostate-specific antigen ≥ 0.2 ng/mL after radical prostatectomy were randomly assigned to receive either 66 Gy in 33 fractions or 72 Gy in 36 fractions. A primary endpoint was to assess the difference in biochemical progression-free survival (bPFS) between these 2 cohorts, and secondary endpoints were to assess differences in genitourinary (GU), gastrointestinal (GI), and hematologic toxicities between these 2 cohorts. bPFS was estimated by the Kaplan-Meier method and toxicities were compared using the χ2 test. RESULTS: Between September 2011 and November 2016, 144 patients were enrolled: 71 patients to the 66 Gy cohort and 73 patients to the 72 Gy cohort. The median follow-up time was 48.5 months (range, 14-79 months). There was no difference in 4-year bPFS between the 66 Gy and 72 Gy cohorts (75.9% vs 82.6%; P = .299). However, in patients with a higher Gleason score (8-10), the 72 Gy cohort had statistically significant improvement in bPFS compared with the 66 Gy cohort (79.7% vs 55.7%; P = .049). Toxicity analysis showed no difference in ≥2 acute or late GI or GU toxicities between these 2 cohorts. A total of 48 patients were scored as urinary incontinence before radiation therapy, of which 39 (81.3%) reported incontinence recovery or stable at 1-year follow-up, and only 9 (18.8%) patients reported worsening. There was no difference between the 2 cohorts in urinary incontinence either at baseline or at 1-year follow-up. CONCLUSIONS: Dose escalation (72 Gy) demonstrated no improvement in 4-year bPFS compared with the 66 Gy regimen. However, the dose escalation was not associated with greater acute or late GU or GI toxicities and did not increase urinary incontinence.


Asunto(s)
Neoplasias de la Próstata/radioterapia , Adulto , Anciano , Anciano de 80 o más Años , Progresión de la Enfermedad , Fraccionamiento de la Dosis de Radiación , Estudios de Seguimiento , Enfermedades Gastrointestinales/etiología , Humanos , Calicreínas/sangre , Estimación de Kaplan-Meier , Leucopenia/etiología , Masculino , Márgenes de Escisión , Persona de Mediana Edad , Clasificación del Tumor , Periodo Posoperatorio , Supervivencia sin Progresión , Antígeno Prostático Específico/sangre , Prostatectomía , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/cirugía , Radioterapia Ayuvante/estadística & datos numéricos , Radioterapia Guiada por Imagen/efectos adversos , Radioterapia de Intensidad Modulada/efectos adversos , Terapia Recuperativa/estadística & datos numéricos , Factores de Tiempo , Incontinencia Urinaria/complicaciones , Incontinencia Urinaria/radioterapia , Trastornos Urinarios/etiología
12.
Urology ; 136: 180-189, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31704459

RESUMEN

OBJECTIVE: To compare 10-year oncologic treatment outcomes of radical prostatectomy (RP) vs external beam radiation therapy (EBRT) vs brachytherapy (BT) for patients with intermediate-risk prostate cancer (IRPC). METHODS: A retrospective analysis using propensity score matching was performed on 1503 IRPC patients who underwent treatment from 2004 to 2007. Eight hundred and nineteen underwent RP, 574 underwent EBRT to a median dose of 75.3 Gray, and 110 underwent BT using Iodine-125. Biochemical failure was defined by the American Urological Association definition of failure for RP, and the Phoenix definition for EBRT and BT. RESULTS: Median follow-up was 10.0 years for RP, 9.6 for EBRT, and 9.8 for BT. Neoadjuvant androgen deprivation therapy was given in 0.6% of RP, 58.9% of EBRT, and 12.7% of BT patients, P <.0001. Only 14% of BT received supplemental external radiation. The adjusted 10-year freedom from biochemical failure was 80.2% for BT vs 57.1% for RP vs 57.0% for EBRT, P = .0003. Subset analysis of unfavorable IRPC also showed improved freedom from biochemical failure with BT, P <.0001. There were no significant differences in metastases-free survival or prostate cancer-specific survival after adjusting for age and Charlson comorbidity index. CONCLUSION: BT using Iodine-125, used alone or in combination with supplemental external radiation, is a reasonable treatment option for IRPC patients, yielding equivalent rates of metastases-free survival and prostate cancer-specific survival.


Asunto(s)
Braquiterapia , Prostatectomía , Neoplasias de la Próstata/radioterapia , Neoplasias de la Próstata/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Historia del Siglo XVII , Humanos , Masculino , Prostatectomía/métodos , Neoplasias de la Próstata/patología , Radioterapia/métodos , Estudios Retrospectivos , Medición de Riesgo , Factores de Tiempo , Resultado del Tratamiento
14.
Urology ; 136: 176-179, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31715271

RESUMEN

OBJECTIVE: To assess the risk of biochemical recurrence (BCR) in small low-grade prostate tumors following radical prostatectomy (RP), which are defined as clinically insignificant based on the existing criteria developed by Stamey and Epstein. MATERIALS AND METHODS: We identified 3784 men who underwent RP in Western Australia from September 1998 to March 2019. These patients had a Gleason sum (GS) of ≤6 or 3+4, prostate confined and negative margins. Pathological data analysis was performed using logistic regression modeling. RESULTS: Median follow-up was 96.8 months. BCR occurred in 110 men (2.91%). There was no statistical difference in the rates of failure for patients with a tumor volume <0.5 mL vs 0.5-2.0 mL when comparing (i) those with Gleason 6, or (ii) those with Gleason 3+4. Furthermore, there was no statistical difference in rates of failure when comparing patients with a tumor volume of ≤2 mL vs >2 mL when the percentage of Gleason pattern 4 was ≤20%. However, once the percentage of Gleason pattern 4 increased to 30%, there was a significant increase in BCR in the larger tumors (> 2 mL). CONCLUSION: This study did not support either Stamey's or Epstein's criteria of insignificant cancer based on volumes of less than 0.5 mL, GS <7 and confined margin negative disease. No risk free cancer was identified, as all groups demonstrated some risk of BCR. This study redefines the entity of insignificant cancer as rather "low risk" cancer and expands its scope to include smaller tumors with minor Gleason pattern 4 components.


Asunto(s)
Recurrencia Local de Neoplasia/epidemiología , Prostatectomía , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/cirugía , Humanos , Masculino , Persona de Mediana Edad , Clasificación del Tumor , Medición de Riesgo
15.
J Cancer Res Clin Oncol ; 146(1): 221-227, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31612318

RESUMEN

PURPOSE: To evaluate biochemical recurrence (BCR) risk in men with localized prostate cancer (PC) of pathological Gleason score (pGS) 8-10. Although such patients have low BCR-free survival (BCRFS) following radical prostatectomy (RP), they are not recommended for adjuvant radiation therapy (ART) as per current guidelines. METHODS: Among an adjuvant treatment-naïve cohort between 1995 and 2015, 1272 men were identified and categorized into group 1 [pGS7 (3 + 4) and pT3; n = 654], group 2 [pGS7 (4 + 3) and pT3; n = 408], and group 3 (pGS 8-10 and pT2; n = 210). The BCR risk of group 3 was compared with that of groups 1 and 2 who are the candidates for ART. RESULTS: At a median follow-up of 60 months (interquartile range: 39-86), 432 men experienced BCR. BCRFS was lower in group 3 than in groups 1 and 2 (p < 0.001 and p = 0.021, respectively). In multivariate analysis, this association persisted and surgical margin (SM) was found to be a significant BCR predictor. Although statistically not significant, BCRFS was lower in group 3 with positive SM (PSM) than in group 2 with PSM (p = 0.101). BCRFS was significantly worse in group 3 with negative SM (NSM) than in group 1 with PSM (p = 0.038), while it was better in group 2 with PSM (p = 0.297). CONCLUSION: Localized high-grade PC with PSM showed lower BCRFS and that with NSM showed better BCRFS without statistical significance than locally advanced GS 7 PC with PSM that are eligible for ART.


Asunto(s)
Recurrencia Local de Neoplasia/patología , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/cirugía , Anciano , Estudios de Cohortes , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Clasificación del Tumor , Estadificación de Neoplasias , Prostatectomía , Neoplasias de la Próstata/radioterapia , Radioterapia Ayuvante , Estudios Retrospectivos , Factores de Riesgo
16.
Urology ; 135: 117-123, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31568795

RESUMEN

OBJECTIVE: To elucidate the accuracy of MRI and MRI-ultrasound fusion guided targeted biopsy (TBx) on risk stratification in men who underwent subsequent radical prostatectomy (RP). MATERIALS AND METHODS: A single-center, retrospective study was performed in men at risk for prostate cancer who (n = 140) underwent TBx and RP between November 2012 and August 2018. Comparisons were made between patients clinically staged by preoperative MRI and TBx Gleason grade group (GGG) and stage after RP. Multivariable regression was performed to identify factors associated with MRI and TBx compared to RP grading, staging, and consistency with National Comprehensive Cancer Network (NCCN) risk stratification. RESULTS: There was an increase in NCCN risk stratification in 47 men (33.6%) and a decrease in 17 men (12.1%) compared to the resected prostate. GGG upgrading and downgrading occurred in 35 (25.0%) and 31 men (22.1%), respectively. Upstaging occurred in 41 men (29.3%). In adjusted analysis for age, BMI, PSA Density (PSAD), median maximal diameter of the regions of interest, and PIRADS, men with PIRADS 4 were less likely to be upgraded (OR 0.26, 95% CI 0.08-0.81, P = .020) than PIRADS 3. PSAD ≥ 0.15 ng/mL/cc was associated with upstaging (OR 3.92, 95% CI 1.60-9.62, P = .003). CONCLUSION: Accurate risk stratification is critical for disease management, mandated by the increasing use of active surveillance, partial gland ablation, and androgen deprivation therapy with radiation therapy for men with unfavorable intermediate and high-risk prostate cancer. This study confirms the need for advances in imaging and biomarker to increase the accuracy of pretreatment staging.


Asunto(s)
Imagen Multimodal/métodos , Próstata/patología , Prostatectomía , Neoplasias de la Próstata/diagnóstico , Anciano , Biopsia con Aguja Gruesa/estadística & datos numéricos , Humanos , Biopsia Guiada por Imagen/estadística & datos numéricos , Imagen por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Clasificación del Tumor , Estadificación de Neoplasias , Valor Predictivo de las Pruebas , Próstata/diagnóstico por imagen , Próstata/cirugía , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/cirugía , Estudios Retrospectivos , Medición de Riesgo/métodos , Medición de Riesgo/estadística & datos numéricos , Ultrasonografía Intervencional/métodos
17.
J Urol ; 203(2): 344-350, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31502941

RESUMEN

PURPOSE: Few groups have investigated the combined effects of PTEN loss and ERG expression on the outcomes of metastasis of or death from prostate cancer in surgically treated patients. We examined the association of PTEN/ERG status with lethal prostate cancer in patients treated with radical prostatectomy. MATERIALS AND METHODS: Included in analysis were 791 patients with clinically localized prostate cancer treated with radical prostatectomy at a single institution. Genetically validated immunohistochemistry assays for PTEN and ERG were performed on tissue microarrays. Multivariable Cox proportional hazard models were used to assess the association of PTEN/ERG status with lethal prostate cancer (defined as metastasis or prostate cancer specific death), adjusting for patient age, race, pathological grade and stage, and surgical margin status. RESULTS: Median followup in the cohort was 12.8 years. Of 791 cases 203 (25%) demonstrated PTEN loss and 330 of 776 (43%) were ERG positive. On multivariable analysis PTEN loss (HR 1.9, 95% CI 1.2-3.0, p=0.012) but not ERG expression (HR 0.6, 95% CI 0.4-1.1, p=0.11) was associated with an increased risk of lethal prostate cancer. The association of PTEN loss with lethal disease only remained among men with ERG negative tumors (HR 2.3, 95% CI 1.3-4.1, p=0.005) and not ERG positive tumors (HR 1.1, 95% CI 0.6-2.1, p=0.81). CONCLUSIONS: PTEN loss is associated with an increased risk of lethal prostate cancer after radical prostatectomy and this risk is most pronounced in the subgroup of patients with ERG negative tumors. This work corroborates the use of PTEN and ERG status for risk stratification in surgically treated patients.


Asunto(s)
Fosfohidrolasa PTEN/análisis , Prostatectomía , Neoplasias de la Próstata/química , Neoplasias de la Próstata/cirugía , Humanos , Masculino , Persona de Mediana Edad , Prostatectomía/métodos , Regulador Transcripcional ERG/análisis , Resultado del Tratamiento
18.
J Urol ; 203(2): 338-343, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31437119

RESUMEN

PURPOSE: Pelvic lymph node dissection represents the gold standard of lymph node staging in patients with prostate cancer. We sought to assess the effect of extended pelvic lymph node dissection on oncologic outcomes in patients with characteristics of D'Amico intermediate or high risk prostate cancer treated with radical prostatectomy. MATERIALS AND METHODS: In a multi-institutional database of 4 centers we identified 9,742 patients who underwent radical prostatectomy from 2000 to 2017 with or without pelvic lymph node dissection. Only patients with a greater than 5% probability of lymph node invasion according to the Briganti nomogram were included in study. We performed 2:1 propensity score matching to account for potential differences between the 2 cohorts. Cox regression models were used to test the effect of pelvic lymph node dissection on biochemical recurrence, metastasis and cancer specific mortality. RESULTS: Overall 707 patients (7.3%) did not undergo pelvic lymph node dissection, of whom 520 and 187 harbored D'Amico intermediate and high risk characteristics, respectively. A median of 14 lymph nodes (IQR 8-21) were removed in the pelvic lymph node dissection cohort and 1,714 of these cases (19.0%) harbored lymph node metastasis. After propensity score matching the biochemical recurrence-free, metastasis-free and cancer specific mortality-free survival rates were 60.4% vs 65.6% (p=0.07), 87.0% vs 90.0% (p=0.06) and 95.2% vs 96.4% (p=0.2) for pelvic lymph node dissection vs no pelvic lymph node dissection 120 months after radical prostatectomy. Multivariable Cox regression models adjusted for postoperative and preoperative tumor characteristics revealed that pelvic lymph node dissection performed at radical prostatectomy was no independent predictor of biochemical recurrence, metastasis or cancer specific mortality (all p ≥0.1). CONCLUSIONS: There was no significant difference in oncologic outcomes in patients with D'Amico high or intermediate risk prostate cancer in whom pelvic lymph node dissection was or was not performed at radical prostatectomy. The therapeutic value of pelvic lymph node dissection remains unclear.


Asunto(s)
Escisión del Ganglio Linfático/métodos , Prostatectomía , Neoplasias de la Próstata/cirugía , Humanos , Metástasis Linfática , Masculino , Pelvis , Prostatectomía/métodos , Neoplasias de la Próstata/clasificación , Neoplasias de la Próstata/patología , Estudios Retrospectivos , Medición de Riesgo , Resultado del Tratamiento
19.
J Urol ; 203(2): 320-330, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31437121

RESUMEN

PURPOSE: We report oncologic outcomes in patients treated with focal therapy for prostate cancer. MATERIALS AND METHODS: We retrospectively analyzed a single institution cohort of men with localized prostate cancer who received focal therapy using high intensity focused ultrasound or cryotherapy from 2009 to 2018. Focal therapy was offered for low or intermediate risk disease (prostate specific antigen less than 20 ng/ml, Gleason score 7 or less and clinical stage T2b or less). Patients with previous prostate cancer treatment or less than 6 months of followup were excluded from study. Failure was defined as local or systemic salvage treatment, a positive biopsy Gleason score of 7 or greater in-field or out-of-field in nontreated patients, prostate cancer metastasis or prostate cancer specific death. Cox regression analysis was done to identify independent predictors of failure after focal therapy. RESULTS: Of the 309 patients included in study 190 and 119 were treated with high intensity focused ultrasound and cryotherapy, respectively. Median followup was 45 months. At 1, 3 and 5 years the failure-free survival rate was 95%, 67% and 54%, and the radical treatment-free survival rate was 99%, 79% and 67%, respectively. The 5-year metastasis-free survival rate was 98% and no prostate cancer specific death was registered in this cohort. Before focal therapy a biopsy Gleason score of 7 (3 + 4) or greater (HR 2.4, p <0.001) and nadir prostate specific antigen (HR 2.2, p <0.001) were independently associated with failed focal therapy. In the salvage focal therapy setting in-field recurrence after primary focal therapy was associated with poorer failure-free survival (p=0.02). CONCLUSIONS: Almost half of the men were free of focal therapy failure 5 years after treatment. Still, a significant proportion experienced recurrence at the midterm followup. The preoperative biopsy Gleason score and nadir prostate specific antigen were significantly associated with treatment failure.


Asunto(s)
Criocirugia , Ultrasonido Enfocado de Alta Intensidad de Ablación , Prostatectomía/métodos , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/cirugía , Anciano , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento
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