Vigilancia activa en cáncer de próstata en un grupo de pacientes asistidos en el Centro Docente Asociado de Oncología Médica Rivera: Cooperativa Médica de Rivera (COMERI) / Active surveillance in prostate cancer in a group of patients assisted at the Rivera Associated Teaching Center for Medical Oncology: Rivera Medical Cooperative (COMERI) / Vigilância ativa do câncer de próstata em um grupo de pacientes atendidos no Rivera Associated Teaching Center for Medical Oncology: Rivera Medical Cooperative (COMERI)

Introducción: En Uruguay el cáncer de próstata ocupa el primer lugar en incidencia y el tercer lugar en mortalidad en el hombre. La mayoría de estos cánceres se diagnostican en estadios precoces. Hoy en día, para pacientes con adenocarcinoma de muy bajo riesgo, bajo riesgo o riesgo intermedio favorable, la vigilancia activa es una opción adecuada. Objetivos: Describir una población de pacientes con cáncer de próstata de muy bajo riesgo, bajo riesgo o riesgo intermedio favorable, en vigilancia activa en COMERI. Material y métodos: Estudio descriptivo, observacional, retrospectivo. Se incluyeron pacientes con cáncer de próstata de muy bajo riesgo, bajo riesgo o riesgo intermedio favorable, tratados entre 2010 y 2018 en COMERI. Se recopilaron datos en el sistema de registro clínico electrónico. Resultados: Se incluyeron 33 pacientes, la mediana de edad al diagnóstico fue de 74 años. Todos los pacientes fueron sometidos a controles clínicos y determinación de PSA cada 3 meses. El tacto rectal se realizó en forma anual. El tiempo mediano de vigilancia activa fue de 33 meses. Durante el seguimiento, se observaron pocas variaciones en los valores de PSA. El 21% de los pacientes fue sometido a una nueva biopsia durante el seguimiento activo, y en todos los casos, el Gleason se mantuvo incambiado. Ningún paciente abandonó la modalidad de vigilancia activa. Conclusión: En nuestro entorno, la vigilancia activa se considera una opción terapéutica válida para pacientes altamente seleccionados con cáncer de próstata de muy bajo riesgo, bajo riesgo o riesgo intermedio favorable, y es bien aceptada por ellos.

Introduction: In Uruguay, prostate cancer ranks first in incidence and third in mortality among men. The majority of these cancers are diagnosed at early stages. Nowadays, active surveillance is an appropriate option for patients with adenocarcinoma of very low risk, low risk, or favorable intermediate risk. Objectives: To describe a population of patients with prostate cancer of very low risk, low risk, or favorable intermediate risk under active surveillance at COMERI. Materials and Methods: Descriptive, observational, retrospective study. Patients with prostate cancer of very low risk, low risk, or favorable intermediate risk treated between 2010 and 2018 at COMERI were included. Data were collected from the electronic clinical registry system. Results: Thirty-three patients were included, with a median age at diagnosis of 74 years. All patients underwent clinical monitoring and PSA determination every 3 months. Digital rectal examination was performed annually. The median time of active surveillance was 33 months. During follow-up, there were few variations in PSA values. 21% of patients underwent a repeat biopsy during active surveillance, and in all cases, the Gleason score remained unchanged. No patient discontinued active surveillance. Conclusion: In our setting, active surveillance is considered a valid therapeutic option for highly selected patients with prostate cancer of very low risk, low risk, or favorable intermediate risk, and it is well accepted by them.

Introdução: No Uruguai, o câncer de próstata ocupa o primeiro lugar em incidência e o terceiro lugar em mortalidade entre os homens. A maioria desses cânceres é diagnosticada em estágios precoces. Atualmente, para pacientes com adenocarcinoma de risco muito baixo, baixo risco ou risco intermediário favorável, a vigilância ativa é uma opção adequada. Objetivos: Descrever uma população de pacientes com câncer de próstata de risco muito baixo, baixo risco ou risco intermediário favorável sob vigilância ativa em COMERI. Material e métodos: Estudo descritivo, observacional, retrospectivo. Foram incluídos pacientes com câncer de próstata de risco muito baixo, baixo risco ou risco intermediário favorável, tratados entre 2010 e 2018 em COMERI. Os dados foram coletados no sistema de registro clínico eletrônico. Resultados: Foram incluídos 33 pacientes, com mediana de idade no diagnóstico de 74 anos. Todos os pacientes foram submetidos a controles clínicos e determinação de PSA a cada 3 meses. O toque retal foi realizado anualmente. O tempo médio de vigilância ativa foi de 33 meses. Durante o acompanhamento, houve poucas variações nos valores de PSA. 21% dos pacientes foram submetidos a uma nova biópsia durante a vigilância ativa, e em todos os casos, o Gleason permaneceu inalterado. Nenhum paciente abandonou a modalidade de vigilância ativa. Conclusão: Em nosso ambiente, a vigilância ativa é considerada uma opção terapêutica válida para pacientes altamente selecionados com câncer de próstata de risco muito baixo, baixo risco ou risco intermediário favorável, e é bem aceita por eles.

[Treatment of prostate cancer using high-intensity focused ultrasound, literature review.] / Tratamiento del cáncer de próstata con ultrasonido focalizado de alta intensidad, revisión de la literatura.

INTRODUCTION: The treatment of prostatecancer has recently been questioned because ofthe adverse effects it causes may out weigh the benefitsin many patients, so, it has increased interest in active surveillance for low-risk diseases and tissue preservation with focal therapy, thereby reducing the burden on medical care and side effects that may occur after radical prostatectomy and radiation therapy. OBJECTIVE: provide updated information on the treatment of prostate cancer with high intensity focused ultrasound therapy. MATERIALS AND METHODS: Bibliographic reviewstudy and systematic analysis of 27 scientific articlesfound in the Medline, Scielo and PubMed databases, whose publication dates correspond to the last 5 years.The search criteria used consisted of terms: prostatic neoplasms, ablation techniques, high-intensity focused ultrasound ablation. RESULTS: Focal therapy is a therapeutic option forlow-risk prostate cancer, clinical studies report a 75% cancer-free survival, 99% cancer-specific survival and 96% metastasis-free survival, the prostate antigen is maintained at values lower than 0.1 ng/ml in long-term controls, while the adverse effects of surgery such as incontinence and sexual impotence are rare. CONCLUSIONS: HIFU is a less invasive option for the treatment of low-risk prostate cancer, with oncological results similar to radiotherapy and radical prostatectomy.

INTRODUCCIÓN: El tratamiento del cáncerde próstata ha sido recientemente cuestionado debido a que los efectos adversos que causa pueden superara los beneficios en muchos pacientes; por lo que ha aumentado el interés en la vigilancia activa de enfermedades de bajo riesgo y la conservación de tejidos conterapia focal reduciendo de esta manera la carga en la atención médica y los efectos adversos secundarios a laprostatectomía radical y a la radioterapia.OBJETIVO: Proporcionar información actualizada sobre el tratamiento del cáncer de próstata con ultrasonido focalizado de alta intensidad.MATERIALES Y MÉTODOS: Estudio de revisión bibliográfica y análisis sistemático de 27 artículos científicos encontrados en las bases de datos Medline, Scielo y PubMed, cuyas fechas de publicación corresponden a los últimos 5 años. El criterio de búsqueda empleado consistió en los siguientes términos Mesh: neoplasias prostáticas, terapia de ablación, ablación con ultrasonido focalizado de alta intensidad.RESULTADOS: La terapia focal es una opción terapéutica para el cáncer de próstata de riesgo bajo, estudios clínicos reportan una sobrevida libre de cáncer del 75%, sobrevida específica de cáncer del 99% y sobrevida libre de metástasis del 96%, el antígeno prostático se mantiene en valores menores de 0,1 ng/ml en controles a largo plazo mientras que los efectos adversos de la cirugía como incontinencia, e impotencia sexual son poco frecuentes. CONCLUSIONES: El HIFU es una opción menos agresiva para el tratamiento del cáncer de próstata de riesgo bajo, con resultados oncológicos similares a la radioterapia y a la prostatectomía radical.

Tratamiento del cáncer de próstata con ultrasonido focalizado de alta intensidad, revisión de la literatura / Treatment of prostate cancer with high-intensity focused ultrasound, a review of the literature

Introducción: El tratamiento del cáncer de próstata ha sido recientemente cuestionado debido a que los efectos adversos que causa pueden superar a los beneficios en muchos pacientes; por lo que haaumentado el interés en la vigilancia activa de enfermedades de bajo riesgo y la conservación de tejidos conterapia focal reduciendo de esta manera la carga en laatención médica y los efectos adversos secundarios a laprostatectomía radical y a la radioterapia.Objetivo: Proporcionar información actualizada sobreel tratamiento del cáncer de próstata con ultrasonidofocalizado de alta intensidadMateriales and métodos: Estudio de revisión bibliográfica y análisis sistemático de 27 artículos científicosencontrados en las bases de datos Medline, Scielo yPubMed, cuyas fechas de publicación corresponden alos últimos 5 años. El criterio de búsqueda empleadoconsistió en los siguientes términos Mesh: neoplasiasprostáticas, terapia de ablación, ablación con ultrasonido focalizado de alta intensidad. Resultados: La terapia focal es una opción terapéutica para el cáncer de próstata de riesgo bajo, estudios clínicos reportan una sobrevida libre de cáncer del75%, sobrevida específica de cáncer del 99% y sobrevida libre de metástasis del 96%, el antígeno prostáticose mantiene en valores menores de 0,1 ng/ml en controles a largo plazo mientras que los efectos adversosde la cirugía como incontinencia, e impotencia sexualson poco frecuentesConclusiones: El HIFU es una opción menos agresiva para el tratamiento del cáncer de próstata de riesgo bajo, con resultados oncológicos similares a la radioterapia y a la prostatectomía radical.(AU)

Introduction: The treatment of prostate cancer has recently been questioned because ofthe adverse effects it causes may outweigh the benefitsin many patients, so, it has increased interest in activesurveillance for low-risk diseases and tissue preservationwith focal therapy, thereby reducing the burden on medical care and side effects that may occur after radicalprostatectomy and radiation therapy.Objetive: provide updated information on the treatment of prostate cancer with high intensity focused ultrasound therapy.Material and methods: Bibliographic reviewstudy and systematic analysis of 27 scientific articlesfound in the Medline, Scielo and PubMed databases,whose publication dates correspond to the last 5 years. The search criteria used consisted of terms: prostaticneoplasms, ablation techniques, high-intensity focusedultrasound ablation.Results: Focal therapy is a therapeutic option forlow-risk prostate cancer, clinical studies report a 75%cancer-free survival, 99% cancer-specific survival and96% metastasis-free survival, the prostate antigen ismaintained at values lower than 0.1 ng/ml in long-termcontrols, while the adverse effects of surgery such asincontinence and sexual impotence are rare.Conclusions: HIFU is a less invasive option for thetreatment of low-risk prostate cancer, with oncologicalresults similar to radiotherapy and radical prostatectomy.(AU)

Does active surveillance avoid overtreatment in prostate cancer? Lessons learned from salvage radical prostatectomies.

OBJECTIVE: Determine whether our institution´s active surveillance (AS) protocol is a suitable strategy to minimise prostate cancer overtreatment. MATERIAL AND METHODS: Retrospective analysis of 516 patients on AS after prostate cancer diagnosis. Population divided into "per-protocol" vs "induced" AS depending on fulfilment of protocol´s inclusion criteria. Radical prostatectomies after AS were selected and stratified based on: reclassification, progression or patient anxiety. Clinicopathological features and biochemical relapse-free survival were studied. Primary endpoint was overtreatment ratio based on the presence of insignificant prostate cancer and adverse pathological features in the surgical specimen. Kaplan-Meier curves were used to estimate the biochemical relapse-free survival and compared with log-rank test. RESULTS: 304 patients fulfilled inclusion criteria; 100 proceeded to radical prostatectomy (31% "induced", 69% "per-protocol" AS). Surgery indications were reclassification, progression and anxiety in 66%, 18% and 16% of patients respectively. Rate of positive lymph nodes was higher in the progression group (11%) compared to reclassification and anxiety (5% and 0% respectively, P = .002). Positive surgical margins were more frequently reported in the progression cohort compared to reclassification (28% vs 20%). Median follow-up from diagnosis until last radical prostatectomy was 48.3 months (32.4-70). 3 year biochemical relapse-free survival in the salvage radical prostatectomy was 85.4% (95 CI 78.3-93.2). Insignificant cancer was noticed in 7% of patients (Epstein´s vs 24% Wolters´ criteria). Rate of patients with adverse pathological features was 36%. CONCLUSIONS: The majority of patients who underwent salvage surgery after AS were not overtreated. Radical prostatectomy should be considered a safe rescue treatment.

¿La vigilancia activa evita el sobretratamiento en el cáncer de próstata? Lecciones aprendidas de prostatectomías radicales de rescate / Does active surveillance avoid overtreatment in prostate cancer? Lessons learned from salvage radical prostatectomies

Objetivo: Determinar si el protocolo de vigilancia activa (VA) de nuestra institución es una estrategia adecuada para minimizar el sobretratamiento del cáncer de próstata.Material y métodosAnálisis retrospectivo de 516 pacientes en VA tras el diagnóstico de cáncer de próstata. La población se dividió en «VA por protocolo» vs. «VA inducida», dependiendo del cumplimiento de los criterios de inclusión del protocolo. Las prostatectomías radicales después de la VA fueron seleccionadas y estratificadas en base a reclasificación, progresión o ansiedad del paciente. Se estudiaron las características clinicopatológicas y la supervivencia libre de recidiva bioquímica. La variable principal del estudio fue el porcentaje de sobretratamiento con relación a la presencia de un cáncer de próstata insignificante y de características patológicas adversas en la pieza quirúrgica. Se utilizaron las curvas de Kaplan-Meier para estimar la supervivencia libre de recidiva bioquímica y se compararon con la prueba log-rank.ResultadosUn total de 304 pacientes cumplieron los criterios de inclusión; 100 procedieron a una prostatectomía radical (31% «VA inducida», 69% «VA por protocolo»). Las indicaciones para la cirugía fueron la reclasificación, la progresión y la ansiedad de los pacientes (66, 18 y 16%, respectivamente). (AU)

Objective: Determine whether our institution's active surveillance (AS) protocol is a suitable strategy to minimise prostate cancer overtreatment.Material and methodsRetrospective analysis of 516 patients on AS after prostate cancer diagnosis. Population divided into «per-protocol» vs «induced» AS depending on fulfilment of protocol's inclusion criteria. Radical prostatectomies after AS were selected and stratified based on reclassification, progression or patient anxiety. Clinicopathological features and biochemical relapse-free survival were studied. Primary endpoint was overtreatment ratio based on the presence of insignificant prostate cancer and adverse pathological features in the surgical specimen. Kaplan-Meier curves were used to estimate the biochemical relapse-free survival and compared with log-rank test.Results304 patients fulfilled inclusion criteria; 100 proceeded to radical prostatectomy (31% «induced», 69% «per-protocol» AS). Surgery indications were reclassification, progression and anxiety in 66%, 18% and 16% of patients, respectively. Rate of positive lymph nodes was higher in the progression group (11%) compared to reclassification and anxiety (5% and 0%, respectively; P=.002). Positive surgical margins were more frequently reported in the progression cohort compared to reclassification (28% vs 20%). Median follow-up from diagnosis until last radical prostatectomy was 48.3months (32.4-70). Three year biochemical relapse-free survival in the salvage radical prostatectomy was 85.4% (95%CI: 78.3-93.2). Insignificant cancer was noticed in 7% of patients (Epstein's vs 24% Wolters’ criteria). Rate of patients with adverse pathological features was 36%. (AU)

Prostate cancer, new treatment advances - immunotherapy. / Cáncer de próstata, nuevas opciones de tratamiento: inmunoterapia.

Prostate cancer (PCa) is the fourth most common cancer in the world and treatment is currently based on surgical removal and/or radiotherapy and/or hormone therapy. In the last few years' immunotherapy has become an important cancer treatment option. While the principles of immunotherapy evolved, only sipuleucel-T was approved by the Food and Drug Administration (FDA) which lead to further studies with other agents, starting a new era in immuno-oncology. A number of vaccines are under clinical investigation as well as checkpoint inhibitors. Despite the current enthusiasm, it is unlikely that any of the approaches alone can dramatically change PCa outcomes, but strategies combination is more promising and provide a reason for optimism. The goal of immunotherapy in PCa does not have to be the complete eradication of advanced disease, but rather the return to an immunologic equilibrium with an indolent disease state. With such concerted efforts, the future of immunotherapy in PCa looks brighter than ever, with many clinical trial results being published soon.

Results of the spanish section of the European Randomized Study of Screening for Prostate Cancer (ERSPC). Update after 21 years of follow-up. / Resultados de la rama española del Estudio Randomizado Europeo de Screening del Cáncer de Próstata (ERSPC). Actualización tras 21 años de seguimiento.

INTRODUCTION AND OBJECTIVE: The objective of the European Randomized Study of Screening for Prostate Cancer (ERSPC) is to assess whether prostate cancer (PCa) screening leads to an improvement of cancer-specific survival. This multicenter study (eight European countries) has recruited more than 180,000 asymptomatic men. After a follow-up period of 16 years, it has been shown that PSA screening reduces PCa mortality by 20%, and that it does not affect all-cause mortality. This article provides updated the results of the Spanish arm of the ERSPC after 21 years of follow-up. MATERIALS AND METHODS: The study invited 18,612 men (aged 45 - 70) of the Spanish section (Getafe and Parla, Madrid) to participate. They were randomly assigned to the intervention arm (serum PSA-based screening) and to the control arm (follow-up without intervention). The diagnoses of PCa were recorded, as well as the PCa-specific and all-cause mortality rates. A comparison between the survival curves of both arms of the study and detailed analysis of the causes of death were performed. RESULTS: The study finally included 4,276 men (2,415 intervention arm, 1,861 control arm). The median age, serum PSA and follow-up time were 57 years, 0.9 ng/ml and 21.1 years, respectively. There were 285 cases with PCa diagnosis, 188 (7.8%) from the intervention arm and 97 (5.2%) from the control arm (p<,001). A total of 216 (75.8%) presented organ-confined disease. There were 994 deaths were recorded; 544 (22.5%) in the intervention arm and 450 (24.2%) in the control arm. No significant differences were detected between the arms of the study in terms of cancer-specific (p=.768) or all-cause (p=.192) mortality rates. The main cause of death was malignant tumors (492 patients, 49.5% of overall mortality), and the most frequent sites were lung and bronchus (29.5%), colon and rectum (14.8%), and hematologic (9.8%). Only 20 patients (0.4% of the patients recruited) died from PCa, with no significant difference between study arms. CONCLUSIONS: In this update of the results of the Spanish section of the ERSPC study after 21 years of follow-up, we have not detected a benefit of PCa screening in terms of overall and cancer-specific survival.

Robot-assisted extended pelvic lymph node dissection in prostate cancer. When and how?

OBJECTIVE: To review the literature evaluating the role of the extended pelvic lymph node dissectione PLND during robot assisted radical prostatectomy (RARP) in the management of PCa patients, as well as the preoperative clinic pathologic factors that predict lymph node metastases (LNM). The technique and current outcomes of robotic ePLND will be presented. METHODS: Medline®/Pubmed® were searched up to august 2018 to find comparative studies of different anatomic limits of pelvic lymph node dissection (PLND) during RARP, open or pure laparoscopic surgery that reported number of nodes retrieved, oncologic outcomes and complications. The search was complemented to identify studies that evaluated diagnostic images and factors that predict LNM. Overall, 44 articles were included for full text review. RESULTS: There is not an imaging technique with an acceptable performance to select patients for PLND, the decision to perform a PLND is based on clinical characteristics described on validated nomograms. Median lymph node yield at RARP range from 5 to 21 depending on the extent of PLND, positivity rate of LN as high as 37% depending on the risk stratification of patients. Robot-assisted can be carried out to any extent with lymph node yields and safety concerns comparable to the open approach. CONCLUSION: Extended pelvic lymph node dissection is recommended to be performed at the time of RARP in intermediate and high-risk patients and cannot be replaced by other modalities. A benefit in terms of oncologic outcomes remains to be established. The robot assisted approach offers shorter length of hospital stay, lower transfusion rates and comparable outcomes compared to other surgical approaches.

ARTICULO SOLO EN INGLES.OBJETIVO: Revisar la literatura que evalúa  el papel de la linfadenectomía pélvica extendida  (LPe) durante la prostatectomía radical asistida por robot  (PRAR) en el manejo de pacientes con cáncer de próstata,  así como los factores clínico-patológicos preoperatorios  que predicen las metástasis ganglionares. Presentamos la técnica de LPe y sus resultados actuales.MÉTODOS: Se realizó una búsqueda bibliográfica en Medline®/Pubmed® hasta agosto 2018 para encontrar estudios comparativos de los diferentes límites anatómicos de la linfadenectomía pélvica duranteprostatectomía radical asistida por robot, abierta olaparoscópica que comunicaran número de ganglios,resultados oncológicos y complicaciones. La búsquedafue complementada para identificar estudios que evaluaran imágenes diagnósticas y factores predictivos demetástasis ganglionares. Finalmente, se incluyeron 44artículos. RESULTADOS: No hay una técnica de imagen que tengauna resolución aceptable para seleccionar pacientespara linfadenectomía. La decisión de practicar linfadenectomíase basa en las características clínicas descritasen nomogramas validados. La mediana del númerode ganglios obtenidos oscila entre 5 y 21 dependiendode la extensión de la linfadenectomía, y la tasa de gangliospositivos es tan alta como el 37% dependiendo dela estratificación del riesgo de los pacientes. La cirugíaasistida por robot puede realizarse con cualquier extensióncon un número de ganglios obtenidos y aspectosde seguridad comparables con el abordaje abierto. CONCLUSION: Se recomienda realizar la linfadenectomíapélvica extendida en el momento de la PRAR enpacientes de riesgo intermedio y alto y no puede reemplazarsepor otras modalidades. Sigue por establecerseun beneficio en términos de resultados oncológicos. Elabordaje asistido por robot ofrece estancias hospitalariasmás cortas, menores tasas de transfusión y resultadoscomparables en comparación con otros abordajesquirúrgicos.

Technical features and the demonstrated advantages of the Retzius sparing robotic prostatectomy.

OBJECTIVE: Robot-assisted laparoscopic  radical prostatectomy (RARP) is nowadays considered  the main surgical option for localized prostate cancer (PCa). We recently developed a new approach for RARP  avoiding all the Retzius structures involved in continence  and potency preservation, the so called Retzius-sparing  technique (RSP). The objective of the paper is to report technical aspects and functional results of RSP.  METHODS: We evaluated our data and available literature  regarding RSP, functional results and advantages.  RESULTS: RSP is oncologically safe and guarantee high early continence rates. CONCLUSION: Long-term, prospective, comparative,  and possibly randomized studies are needed but RSP is  now spreading all over the world thanks to the different advantages that offers to patients. The most recognized benefit is surely the achievement of early continence, as well documented in multiple studies and papers, without compromising the oncological outcomes.

ARTICULO SOLO EN INGLES. OBJETIVO: La prostatectomía radical laparoscópica  asistida por robot (PRAR) se considera hoy  en día la principal opción quirúrgica para el cáncer de próstata localizado. Recientemente desarrollamos un  nuevo abordaje para la PRAR evitando todas las estructuras  del Retzius involucradas en la conservación de la continencia y la potencia, la conocida como técnica de prostatectomía conservadora del Retzius (PCR). El objetivo  de este artículo es comunicar los aspectos técnicos  y funcionales de la PCR. MÉTODOS: Evaluamos nuestros datos y la literatura disponible  sobre PCR, resultados funcionales y ventajas. RESULTADOS: La PCR es oncológicamente segura y garantiza  unas tasas altas de continencia precoz. CONCLUSIONES: Son necesarios estudios a largo  plazo, prospectivos, comparativos y posiblemente aleatorizados pero la PCR está actualmente extendiéndose  por todo el mundo gracias a las diferentes ventajas que ofrece a los pacientes. El beneficio más reconocido es  seguramente la consecución de continencia precoz, bien documentada en múltiples estudios y artículos, sin  compromiso de los resultados oncológicos.

Magnetic resonance imaging and prostate cancer: Perspectives from the UK, Europe and USA.

There is yet no international consensus on the role of multiparametric magnetic resonance imaging (mpMRI) for prostate cancer diagnosis, with different uses in different health care systems around the world. In this report we will discuss the use of mpMRI in the United Kingdom, Europe and in the United States of America, comparing the most important guidelines and major papers over the last few years.

Todavia no existe un consenso internacional sobre el papel de la RMN multiparamétrica (RMNmp) en el diagnóstico del cáncer de próstata, condiferentes usos en diferentes sistemas de salud alrededor del mundo. En este artículo, discutiremos la utilización de la RMNmp en el Reino Unido, Europa y los Estados Unidos, comparando las guias de actuación y los artículosimportantes de los últimos años.

The future of molecular and functional imaging in prostate cancer.

The major goal of prostate cancer imaging in the next decade will be more accurate disease diagnostic, characterization and staging through the synthesisof anatomic, functional and molecular imaging.Changes are happening regarding the use of prostate MRI for evaluating primary prostate cancer and PET CT for the staging and recurrence staging of prostate cancer.This review presents a multidisciplinary perspective of the role of prostate MRI and molecular imaging in prostate cancer.

El principal objetivo de las pruebas de imagen en cáncer de próstata en la próxima década será un diagnóstico, caracterización y estadiaje más precisos de la enfermedad, mediante la síntesis de imágenes anatómicas, funcionales y moleculares. Se están produciendo cambios en el uso de la RMN de próstata para evaluar el tumor primario y el PET TAC para el estadiajey estudio de la recurrencia en cáncer de próstata.Esta revisión presenta una perspectiva multidisciplinar sobre el papel de la RMN y las técnicas de imagen molecular en el cáncer de próstata.

Hormone naïve metastatic prostate cancer: How to treat it?

OBJECTIVES: Recent landmark studies (GETUG-AFU 15, CHAARTED, STAMPEDE (docetaxel), LATITUDE and STAMPEDE (abiraterone)) have changed the treatment of hormone sensitive metastatic prostate cancer (mHSPC) from androgen deprivation therapy (ADT) only to combined therapy with either docetaxelor abiraterone acetate plus prednisone (AAP) together with ADT. In this Review we highlight current evidence and recommendations on how to treat men with newly diagnosed mHSPC beyond ADT. METHODS: Narrative overview of available evidence retrieved from pubmed searches, hand searches and authoritative texts. RESULTS: Docetaxel or AAP in combination with ADT improves overall survival (OS) in men fit for combined treatment presenting with newly diagnosed mHSPC. The strongest evidence is for men with high volume mHSPC (four or more bone metastases with at least one outside the axial skeleton and/or visceral metastases) or mHSPC with high risk features (A minimum of two out of three following high-risk features: Gleason score ≥ 8, ≥ 3 bone lesions or visceral metastasis) as per CHAARTED and LATITUDE criteria, respectively. While upfront docetaxel and AAP yield comparable OS improvement, docetaxel has not been shown to increase OS specifically for men with low volume/low risk mHSPC, whereas, a recent post-hoc analysis from the STAMPEDE (abiraterone) trial showed consistent overall survival benefit of AAP plus ADT independent of risk stratification. While these data are limited by their retrospective nature, they do suggest that patients with low-risk mHSPC should be offered AAP. In men with high volume/high risk mHSPC, choosing between six-cycles of docetaxel or AAP until disease progression relies on patient preference, cost and individual assessment of which drug side-effect profile is most suitable. CONCLUSION: Offer men presenting with newly diagnosed mHSPC fit enough for combined therapy either ADT plus docetaxel or AAP.

OBJETIVOS: Estudios de referencia recientes (GETUG-AFU 15, CHAARTED, STAMPEDE (docetaxel), LATITUDE y STAMPEDE (abiraterone)) han cambiado el tratamiento del cáncer de próstata hormonosensible metastásico (CPHSm) de la terapia de deprivación androgénica sola a la terapia combinada bien con docetaxel o abiraterona acetato y prednisona junto con deprivación androgénica. En esta revisión, destacamos la evidencia actual y recomendaciones sobrecómo tratar a los hombres con CPHSm de reciente diagnóstico más allá de la deprivación androgénica.MÉTODOS: Repaso narrativo de la evidencia disponible obtenida por busquedas en PubMed, búsquedas manuales y textos fidedignos. RESULTADOS: Docetaxel o abiraterona más prednisona en combinación con deprivación androgénica mejoran  la supervivencia global (SG) en pacientes adecuados para tratamiento combinado que presentan un CPHSm de reciente diagnóstico. La mejor evidencia es en varones con CPHSm de alto volumen (cuatro o más metástasis óseas con al menos una fuera del esqueleto axialy/o metástasis viscerales) o CPHSm con características de alto riesgo (un mínimo de dos de las tres siguientes características de alto riesgo: Puntuación de Gleason≥ 8, ≥ 3 lesiones óseas o metástasis viscerales) según los criterios de CHAARTED y LATITUDE respectivamente. Aunque docetaxel inicial y abiraterona más prednisona ofrecen una mejora comparable de la supervivenciaglobal, docetaxel no ha demostrado que mejore la supervivencia global específicamente en hombres con CPHSm de bajo volumen/bajo riesgo; mientras que un reciente análisis post-Hoc del estudio STAMPEDE (Abiraterona) mostró un beneficio consistente en supervivencia global de abiraterona más prednisona junto con deprivación androgénica independientemente de la estratificación por riesgo. Aunque estos datos están limitados por su naturaleza retrospectiva, sugieren que a los pacientes con CPHSm de bajo riesgo debería ofrecérseles abiraterona más prednisona. En varones con CPHSm de alto volumen/alto riesgo, elegir entre seis ciclos de docetaxel o abiraterona-prednisona hastaque la enfermedad progrese se basa en la preferencia del paciente, el coste y la evaluación individual sobre qué perfil de efectos colaterales farmacológicos es más adecuado. CONCLUSIONES: Ofrecer terapia de deprivación andrógénica con docetaxel o abiraterona + prednisona a los pacientes que presentan un CPHSm de recientediagnóstico.

Vivências de homens com câncer de próstata / Men's experiences with prostate cancer

Objetivo: descrever as vivências de homens em tratamento oncológico para o câncer de próstata. Método: estudo qualitativo, exploratório, descritivo, desenvolvido com 30 homens com câncer de próstata em tratamento oncológico num hospital de grande porte. A produção de dados foi realizada por meio de entrevista semiestruturada. Para a organização e análise dos dados, foi empregada a técnica da Análise de Conteúdo, na modalidade Análise Temática. Resultados: a análise dos dados permitiu a identificação de três categorias: >, >, >. Conclusão: o diagnóstico e o tratamento do câncer de próstata provocam modificações significativas na vida dos pacientes. Constatou-se que o apoio da esposa e a espiritualidade são estratégias positivas para o enfrentamento da doença.

Molecular imaging for prostate cancer: Performance analysis of 68Ga-PSMA PET/CT versus choline PET/CT. / Toma de imágenes molecular del cáncer de próstata: análisis de rendimiento de 68Ga-PSMA PET/TC frente a PET/TC colina.

INTRODUCTION: There is a need for a precise and reliable imaging to improve the management of prostate cancer. In recent years the PET/CT with choline has changed the handling of prostate cancer in Europe, and it is commonly used for initial stratification or for the diagnosis of a biochemical recurrence, although it does not lack limitations. Other markers are being tested, including the ligand of prostate-specific membrane antigen (PSMA), that seems to offer encouraging prospects. The goal of this piece of work was to critically review the role of choline and PSMA PET/CT in prostate cancer. EVIDENCE ACQUISITION: A systematic literature review of databases PUBMED/MEDLINE and EMBASE was conducted searching for articles fully published in English on the PET marker in prostate cancer and its clinical application. EVIDENCE SYNTHESIS AND DISCUSSION: It seems as 68Ga-PSMA PET/CT is better than PET/CT in prostate cancer to detect primary prostate lesions, initial metastases in the lymph nodes and recurrence. However, further research is required to obtain high-level tests. Also, other PET markers are studied. Moreover, the emergence of a new PET/MR camera could change the performance of PET imaging.

Oncological outcomes in patients potentially eligible for active surveillance who underwent radical prostatectomy.

OBJECTIVE: To determine whether there are differences in the oncological outcomes after radical prostatectomy (adverse pathology and biochemical recurrence) based on clinical selection criteria used in two active surveillance (AS) protocols. MATERIAL AND METHODS: 442 patients diagnosed with localized prostate cancer (CP) underwent radical prostatectomy at our institution between August 2003 and December 2009. We selected patients with low-risk CP, which could have been included in an AS program. Patients were divided into two groups: group i, those who met the most strict surveillance criteria described by Epstein (PSAD<.15; T1/T2a;<2 positive core, Gleason≤6,<50% involvement of the core) and group ii, those meeting the more open criteria described by Klotz (PSA≤10 or<15 at age 70, Gleason≤6 or<7 [3+4] in over 70 years). We compared both groups to determine differences in pathological stage, positive surgical margins and biochemical recurrence after radical prostatectomy. RESULTS: Of the 442 patients 48% (213 patients) had low-risk PC, and become potential candidates for an AS program. Of the patients operated on 17% (76 patients) met the criteria for AS as of Epstein's and 48% (213 patients) according to Klotz. Comparing patients in both groups there were no statistically significant differences in the presence of pT3 (7.9% vs 10.8%) P=.55, positive margins (22.4% vs. 28.3%) P=.41, nor in biochemical recurrence at 3 years (5.3% vs 5.6%) P=.86. CONCLUSIONS: In our series of patients theoretically candidates for inclusion in a program of active surveillance, we found no differences in the percentage of patients with pathological stage pT3, positive margins and biochemical recurrence according to clinical inclusion criteria currently used.

Guía de práctica clínica para la detección temprana, diagnóstico, tratamiento integral, seguimiento y rehabilitación de pacientes con diagnóstico de cáncer de próstata: para pacientes y cuidadores / Clinical Practice Guideline (CPG) for the early detection, diagnosis, treatment, follow-up and rehabilitation of prostate cancer: for patients and caregivers

Orientar a profesionales, gestores y usuarios del sector salud sobre la detección temprana, diagnóstico y tratamiento, seguimiento y rehabilitación urológica en hombres con riesgo, sospecha o con confirmación clínica de cáncer de próstata en Colombia, de acuerdo con la mejor evidencia disponible, como estrategia para mejorar la calidad de la atención.

Correlation between the complex PSA/total PSA ratio and the free PSA/total PSA ratio, sensitivity and specificity of both markers for the diagnosis of prostate cancer.

OBJECTIVE: To compare the behaviour of the PSAcomplex/PSAtotal percentage (PSAc%) against the PSA free/PSA total (PSAl%) and analyse both markers for their usefulness in diagnosing prostate cancer. MATERIAL AND METHODS: We measured total PSA (PSAt), free PSA (PSAl), complex PSA (PSAc), PSAl% and PSAc% levels in 158 patients. Of these, 98 (62%) were biopsied for presenting PSAt≥3 ng/dl and PSAl%<20, PSAt>10, suspicious rectal examination or suspicious ultrasound node. We performed linear regression and Passing-Bablok regression analyses. The ROC curves were calculated to study the sensitivity and specificity of PSAl% and PSAc% and were compared to each other. The prostate cancer diagnoses were analysed by PSAl% and PSAc% by applying the χ(2) test. RESULTS: The correlation coefficient (r) was good (0.7447, P<.0001), and the index of determination (r(2)) was 0,5. The result of the Passing-Bablok analysis was a slope of 1.658 (1.452 to 1.897) and an intersection of 2.044 (-0,936 to 5.393). The optimal cutoff for PSAl% (≤14.7854) showed a sensitivity of 89.29% [95% CI, 0,642-0,823] and a specificity of 54.29% (95% CI, 0,642-0,823). The optimal cutoff for PSAc% (>89.7796) had a sensitivity of 71.43% (95% CI, 0,616-0,802) and a specificity of 71.43% (95% CI, 0,616-0,802). There were no significant differences when comparing the areas under the curve of both markers (P=.59). The PPV of PSAl% was less than that of PSAc% (45.7% vs. 71%). CONCLUSION: There was a good correlation between PSAl% and PSAc%. PSAc% has demonstrated greater specificity and efficacy than PSAl% in the diagnosis of prostate cancer.

Prostatectomía radical asistida por robot da Vinci: experiencia inicial en 50 casos consecutivos / Da Vinci robot-assisted radical prostatectomy: initial experience in 50 consecutive cases

Objective: To report our initial experience in 50 cases submitted to a Robotic Radical Prostatectomy (RRP), evaluating results and the learning curve. Material and Methods: From January to October 2010 we performed 50 consecutives cases of RRP with the da Vinci S-HD Surgical System®. The database was performed prospectively, and was analyzed retrospectively. We evaluate demographic data (age, body mass index) and perioperative data such as clinical stage, preoperative PSA (Prostate Specific Antigen), Gleason Score, ASA, operative times, estimated blood loss, morbidity, hospital stay, time of bladder catheterization and positive margins. A statistical analysis of exponential regression was performed to estimate the learning curve. Results: The mean age was 62 years and the most frequent clinical stage was T1c (84 percent). The mean PSA was 6.36 ng/mL and in 50 percent of the patients the Gleason Score was 7. The median surgical time was 199 minutes. The mean blood loss was 666 mL (50-4.000 mL). The hospital stay and the average bladder catheterization time were 2 and 6 days, respectively. There were 2 conversions to a laparoscopic approach, none to open surgery, and 8 percent of postoperative complication (all Clavien 1). Inmediat urinary continence and potency rates were 88.3 percent and 33.3 percent, respectively. When comparing the 25 initial cases versus the last 25, there was a decrease in surgical time and estimated blood loss (254 minutes vs 189 minutes and 876 mL vs 467 mL, respectively). We also found a lower rate of positive margins (20 percent vs 12 percent). The learning curve statistically estimated is 40 procedures. Conclusion: The surgeon's experience determine a decrease in surgical time, intraoperative bleeding and especially in the rate of positive margins.

Objetivo: Comunicar nuestra experiencia inicial en 50 casos de Prostatectomía Radical Robótica (PRR), evaluando resultados y curva de aprendizaje. Material y Métodos: Desde enero a octubre de 2010 se realizaron 50 PRR con el sistema da Vinci S-HD®. La base de datos fue confeccionada en forma prospectiva y se evaluaron en forma retrospectiva los datos demográficos (edad, índice de masa corporal), estadio clínico, valor de Antígeno Prostático Específico (APE), Score de Gleason, ASA, tiempos quirúrgicos, sangrado estimado, complicaciones, estadía hospitalaria, tiempo de sonda vesical y tasa de márgenes positivos. Se realizó un análisis estadístico de regresión exponencial para estimar la curva de aprendizaje del método. Resultados: La edad media fue de 62 años y el estadio clínico más frecuente fue el T1c (84 por ciento). El valor medio de APE fue de 6,36 ng/mL. El score de Gleason en un 50 por ciento correspondió al 7 y la media del ASA a 2. La mediana del tiempo quirúrgico fue de 199 minutos. El sangrado medio estimado fue de 666 mL (50-4.000 mL). La media de la estadía hospitalaria y el tiempo de sonda fueron de 2 y 6 días, respectivamente. Hubo 2 conversiones a cirugía laparoscópica, ninguna a cirugía abierta y un 8 por ciento de complicaciones postoperatorias (todas Clavien 1). La tasa de continencia y de potencia inmediata fue de 88,3 por ciento y 33,3 por ciento, respectivamente. Cuando comparamos los 25 casos iniciales versus los 25 finales hubo un descenso significativo en el tiempo quirúrgico y sangrado estimado (254 minutos vs 189 minutos y 876 mL vs 467 mL, respectivamente). También encontramos una menor tasa de márgenes positivos en el grupo 2 (12 por ciento vs 20 por ciento). El análisis estadístico determinó la curva de aprendizaje en 40 procedimientos. Conclusión: Una mayor experiencia del cirujano, determina una disminución en los tiempos quirúrgicos, sangrado intraoperatorio y sobre todo en la tasa de márgenes positivos.

Proliferación de acinos pequeños atípicos (ASAP) en biopsias prostáticas transrectales / Atipical small acinar proliferation in transrectal prostatic biopsy

Introducción: El 2-5 por ciento de biopsias prostáticas transrectales (BpTr) contienen proliferaciones de pequeñosacinos sospechosos de cáncer, pero que no cumplen criterios diagnósticos de malignidad, denominados ASAP (“Atypical Small Acinar Proliferation”). Se ha identificado adenocarcinoma en 34- 60 por ciento de biopsias posteriores, sugiriéndose repetir BpTr en presencia de ASAP. Materiales y métodos: revisamos la prevalencia de ASAP en las BpTr realizadas entre enero de 2000y diciembre de 2005 y la asociación con cáncer prostático al realizar seguimiento con una nueva BpTr.Resultados: Se realizaron 2389 BpTr, identificándose ASAP en el 2,6 por ciento de estas. Se diagnosticóadenocarcinoma prostático en 39,5 por ciento de los pacientes con seguimiento histológico.Conclusiones: ASAP posee alta asociación con cáncer prostático en pacientes sometidos a seguimientocon BpTr, alertando la necesidad de un nuevo control histológico.

Introduction: About 2 percent to 5 percent of prostate needle biopsies contain atypical small acinar proliferation (ASAP) that is suspicious of cancer but is not clearly malignant. Prostate cancer has been identified in34-60 percent of biopsies on follow up. This finding suggests repeat prostate needle biopsy in the presence of ASAP.Material and methods: We reviewed ASAP prevalence on prostate needle biopsies between January 2000 and December 2005 and the relation with adenocarcinoma on histological follow up.Results: A total of 2389 prostate needle biopsies were performed, ASAP was founded in 2.6 percent. Prostaticadenocacinoma was founded in 39.5 percent patients with histological follow up.Conclusions: The ASAP finding has high association with prostate adenocarcinoma in patients with histological follow up warning to perform an histological control.

Management of advanced prostate cancer: [revisão] / Tratamento do câncer de próstata avançado: [review]

Geriatricians and general practitioners often follow patients with metastatic prostate cancer. The epidemiology and basic treatment principles of metastatic prostate cancer are discussed aiming to update the topic for the non-oncologist. Hormone manipulation remains the basis of treatment, usually up to a second line of therapy. Selected cases are treated successfully with intermittent androgen ablation. When new hormone-independent clones arise, chemotherapy should be added to therapy that confers improved survival as well as better quality of life when based on taxanes. In specific situations, additional measures such as bisphosphonates and radiation therapy should be included in the treatment. As a rule, the public health system makes available the necessary medication to ensure treatment for the vast majority of patients in Brazil.

Pacientes com câncer de prostata metastático estão freqüentemente sob os cuidados de geriatras e clínicos gerais. Discutimos a epidemiologia e os princípios básicos do tratamento do câncer de próstata metastático, visando atualizar o não-oncologista no assunto. A base do tratamento continua sendo a manipulação hormonal, inclusive como tratamento de segunda linha. Casos selecionados podem ser tratados com ablação androgênica intermitente de maneira eficaz. Quando se desenvolvem clones de células hormônio-independentes, quimioterápicos são incorporados na terapia. A quimioterapia confere não só benefício em sobrevida, mas também na qualidade de vida, quando baseado em taxanos. Medidas adicionais como o uso de bisfosfonados e radioterapia devem ser incorporadas no tratamento em situações especiais. De modo geral, o sistema público de saúde do Brasil disponibiliza todas as medicações necessárias ao adequado tratamento dos pacientes no país.