RESUMEN
BACKGROUND: Patients with metastatic and locally advanced bladder or prostate cancer may suffer from pelvic symptoms such as pain, obstruction, and hemorrhage. Local tumor growth is associated with significant morbidity and systemic therapy is often ineffective. Local therapies such as bladder irrigation, transurethral resection of the prostate, and fulguration of bleeding vessels provide relief but often require repeated treatments. OBJECTIVES: The aim of this work was to review the current status of palliative pelvic radiotherapy for metastatic bladder and prostate cancer. MATERIALS AND METHODS: The available literature was evaluated and treatment recommendations are proposed depending on different clinical scenarios. RESULTS: To date, no standard regimen exists for the delivery of palliative pelvic radiotherapy. Various radiotherapy schedules manage successful and long-term palliation of pelvic symptoms in most patients and result in acceptable toxicity. For bladder cancer, the most common dose and fractionation regimens range from 20 Gy in 5 fractions to 40 Gy in 20 fractions. Some retrospective studies evaluated 6 weekly fractions of 6 Gy to a total dose of 36 Gy. For prostate cancer, the most common dose and fractionation regimes range from 30 Gy in 10 fractions to 50 Gy in 25 fractions. The symptomatic response rate is between 70 and 95%. CONCLUSIONS: Pelvic radiotherapy for patients with metastatic and locally advanced bladder or prostate cancer provides effective and long-term palliation of a variety of symptoms such as pain, obstruction, and hemorrhage, with acceptable toxicity. Future studies should investigate the optimal target dose and fractionation schedule.
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Quimioradioterapia/estadística & datos numéricos , Neoplasias de la Próstata/mortalidad , Neoplasias de la Próstata/terapia , Radiocirugia/estadística & datos numéricos , Neoplasias de la Vejiga Urinaria/mortalidad , Neoplasias de la Vejiga Urinaria/terapia , Quimioradioterapia/mortalidad , Cistectomía/mortalidad , Cistectomía/estadística & datos numéricos , Medicina Basada en la Evidencia , Femenino , Humanos , Metástasis Linfática , Masculino , Recurrencia Local de Neoplasia/mortalidad , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/prevención & control , Prevalencia , Prostatectomía/mortalidad , Prostatectomía/estadística & datos numéricos , Neoplasias de la Próstata/patología , Radiocirugia/mortalidad , Tasa de Supervivencia , Resultado del Tratamiento , Neoplasias de la Vejiga Urinaria/patologíaRESUMEN
BACKGROUND: There are numerous randomized trials to guide the management of patients with localized (and metastatic) prostate cancer, but only a few (mostly retrospective) studies have specifically addressed node-positive patients. Therefore, there is uncertainty regarding optimal treatment in this situation. Current guidelines recommend long-term androgen deprivation therapy (ADT) alone or radiotherapy plus long-term ADT as treatment options. OBJECTIVES: This overview summarizes the existing literature on the use of radiotherapy for node-positive prostate cancer as definitive treatment and as adjuvant or salvage therapy after radical prostatectomy. In this context, we also discuss several PET tracers in the imaging evaluation of patients with biochemical recurrence of prostate cancer after radical prostatectomy. As for definitive treatment, retrospective studies suggest that ADT plus radiotherapy improves overall survival compared with ADT alone. These studies also consistently demonstrated that many patients with node-positive prostate cancer can achieve long-term survival - and are likely curable - with aggressive therapy. RESULTS: The beneficial impact of adjuvant radiotherapy on survival in patients with pN1 prostate cancer seems to be highly influenced by tumor characteristics. Men with ≤ 2 positive lymph nodes in the presence of intermediate- to high-grade disease, or positive margins, and those with 3 or 4 positive lymph nodes are the ideal candidates for adjuvant radiotherapy (plus long-term ADT) after surgery. CONCLUSION: There is a need for randomized trials to further examine the potential role of radiotherapy as either definitive or adjuvant treatment, for patients with node-positive prostate cancer.
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Carcinoma/radioterapia , Carcinoma/secundario , Imagen por Resonancia Magnética/métodos , Neoplasias de la Próstata/radioterapia , Radioterapia/métodos , Carcinoma/patología , Medicina Basada en la Evidencia , Alemania , Humanos , Metástasis Linfática , Masculino , Estadificación de Neoplasias , Neoplasias de la Próstata/patología , Resultado del TratamientoRESUMEN
BACKGROUND: Biochemical recurrence after radical prostatectomy (RP) is associated with risk indicators, including Gleason score, preoperative PSA level, tumor stage, seminal vesicle invasion, and positive surgical margins. The 5-year biochemical progression rate among predisposed patients is as high as 50-70%. Post-RP treatment options include adjuvant radiotherapy (ART, for men with undetectable PSA) or salvage radiotherapy (SRT, for PSA persisting or re-rising above detection threshold). Presently, there are no published randomized trials evaluating ART vs. SRT directly. METHODS: Published data on ART and SRT were reviewed to allow a comparison of the two treatment approaches. RESULTS: Three randomized phase III trials demonstrated an almost 20% absolute benefit for biochemical progression-free survival after ART (60-64 Gy) compared to a "wait and see" policy. The greatest benefit was achieved in patients with positive margins and pT3 tumors. SRT can be offered to patients with elevated PSA after RP. In 30-70% of SRT patients, PSA will decrease to an undetectable level, thus giving a second curative chance. The rate of side effects for both treatments is comparably low. The role of irradiation of pelvic lymph nodes and the additional use of hormone therapy and radiation dose are discussed. CONCLUSION: It remains unclear whether early SRT initiated after PSA failure is equivalent to ART. Where SRT is indicated, it should be started as early as possible.
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Prostatectomía , Neoplasias de la Próstata/radioterapia , Neoplasias de la Próstata/cirugía , Tiempo de Tratamiento , Biomarcadores de Tumor/sangre , Terapia Combinada , Supervivencia sin Enfermedad , Estudios de Seguimiento , Adhesión a Directriz , Humanos , Irradiación Linfática , Imagen por Resonancia Magnética , Masculino , Clasificación del Tumor , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/radioterapia , Recurrencia Local de Neoplasia/cirugía , Estadificación de Neoplasias , Neoplasia Residual/patología , Neoplasia Residual/radioterapia , Neoplasia Residual/cirugía , Antígeno Prostático Específico/sangre , Neoplasias de la Próstata/mortalidad , Neoplasias de la Próstata/patología , Dosificación Radioterapéutica , Planificación de la Radioterapia Asistida por Computador , Radioterapia Adyuvante/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto , Terapia Recuperativa/métodosRESUMEN
Approximately 50-60% of patients with tumor stage pT3R1 after radical prostatectomy (RP) who do not receive adjuvant therapy develop biochemical progression. At present it is unclear whether these patients should undergo immediate adjuvant irradiation or whether a wait and see approach should be adopted while monitoring PSA until the PSA level rises from zero and then initiate salvage radiotherapy (SRT).Three randomized trials showed that an absolute improvement of 20% in the 5-year biochemical no evidence of disease (bNED) could be achieved by administering adjuvant radiotherapy with 60 Gy in patients with tumor stage pT3R1, even with a PSA level around zero after RP. The rate of serious late effects is low. On the other hand, there are numerous, albeit retrospective studies, which provide evidence that SRT after an increase in PSA above zero is an effective treatment, but with higher total doses of 66-70 Gy and a higher rate of late effects. Prognostic factors such as the PSA level before radiotherapy is started, PSA doubling time, R1 resection, PSA velocity, and the Gleason score have a significant impact on both the return of the PSA level to zero and the bNED. Depending on the risk factor, between 20 and 70% of patients again achieve PSA levels around zero after SRT. Retrospective comparative studies suggest a benefit of adjuvant radiotherapy; prospective randomized trials do not exist.Adjuvant radiotherapy after RP in stage pT3R1 tumor and SRT in cases of PSA rising above zero or persistent PSA levels are valid options for the management of high-risk patients after RP. SRT requires higher total doses and thus carries a higher risk of late complications. A benefit has been demonstrated for bNED, but not for survival. The approach should be discussed with the individual patient.
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Prostatectomía , Neoplasias de la Próstata/radioterapia , Neoplasias de la Próstata/cirugía , Biomarcadores de Tumor/sangre , Terapia Combinada , Supervivencia sin Enfermedad , Humanos , Masculino , Estadificación de Neoplasias , Pronóstico , Próstata/patología , Antígeno Prostático Específico/sangre , Neoplasias de la Próstata/mortalidad , Neoplasias de la Próstata/patología , Radioterapia Adyuvante , Ensayos Clínicos Controlados Aleatorios como Asunto , Terapia RecuperativaRESUMEN
Depending on the tumor stage, 15-60% of patients develop a rise in PSA from levels around zero following radical prostatectomy. It is unclear whether this involves a local, systemic, or a mixed form of local/systemic progression. In addition to a multitude of retrospective studies, the results of three randomized trials are available that have already been published in full or in abstract form. For pT3 prostate cancer with extraprostatic extension, data are available from three randomized trials that consistently evidence an absolute decrease in biochemical progression rate of 20% after 4-5 years. These findings confirm the results of numerous retrospective studies. The large majority of authors employ total radiation doses of 60 Gy with single doses of 2 Gy. One randomized trial has shown that an increased local control rate is the basis for prolonged biochemical progression-free survival. The rate of acute and late radiation sequelae after three-dimensionally planned prostatic fossa radiotherapy (RT) with 60 Gy is very low; the rate of more severe late sequelae is <2%. Data on the status of pT2 prostate cancer with positive surgical margins are worse. The current findings are controversial and require further investigations. Basically, however, adjuvant RT is also possible for pT2 cancers with positive surgical margins. The efficacy of adjuvant RT for patients with positive surgical margins of pT3 carcinomas, whether or not they achieve PSA levels around zero, has been substantiated. A prolongation of survival time has, however, not yet been established because the follow-up period is too short. Randomized trials are still needed for cases of organ-confined prostate cancer (pT2 R1). It is unclear whether adjuvant RT is superior to RT when PSA levels increase beyond zero after radical prostatectomy. Randomized trials addressing this issue are still lacking.
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Recurrencia Local de Neoplasia/prevención & control , Prostatectomía/métodos , Neoplasias de la Próstata/radioterapia , Neoplasias de la Próstata/cirugía , Radioterapia Adyuvante/métodos , Humanos , Masculino , Traumatismos por Radiación/etiología , Traumatismos por Radiación/prevención & control , Radioterapia Adyuvante/efectos adversos , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del TratamientoAsunto(s)
Carcinoma de Células de Merkel/radioterapia , Neoplasias Cutáneas/radioterapia , Carcinoma de Células de Merkel/tratamiento farmacológico , Carcinoma de Células de Merkel/cirugía , Terapia Combinada , Humanos , Recurrencia Local de Neoplasia/tratamiento farmacológico , Recurrencia Local de Neoplasia/radioterapia , Neoplasias Cutáneas/tratamiento farmacológico , Neoplasias Cutáneas/cirugíaRESUMEN
Locally confined prostate cancer (PCa) can be treated by various treatment options (e.g. radical prostatectomy or radiation therapy) with comparable results but different possible side effects. Therefore, treatment recommendations can vary between urologists and radiation oncologists. In 2001 the Charite-Campus Benjamin Franklin (CBF, Berlin), established the first interdisciplinary consulting service for prostate cancer patients in Germany. The aim was to offer a comprehensive and neutral consultation on all treatment options and to make treatment recommendations. The study examines what benefits may be derived from this type of consultation. A total of 362 patients presented to the consulting service between May 2001 and April 2003. Two questionnaires were used. The first one contained epidemiological questions as well as questions covering information already available on PCa. It also examined feelings and fears about the disease and possible treatment options. The second questionnaire was completed 2 weeks after the consultation to evaluate the treatment decision, determine the patient's satisfaction with the consultation and trace the development of feelings and fears. Of the patients, 334 (92.2%) were completely assessable. All patients had already obtained information about the disease and possible treatment options and wished to be involved in the decision-making process through objective and neutral consultation. Nearly all of them had a great fear of the possible side effects of therapy. Such a comprehensive consultation is time-consuming (average of 35 min) but largely received a very positive assessment in that a total of 66% found it either helpful (n=74, 22%) or very helpful (n=147, 44%). Patients felt they had been completely informed in 92% of the cases. Only 22 (9.7%) had still failed to make a decision after 2 weeks, 115 patients had stage T1c, PSA <10 ng/ml and a Gleason score < or =7. In these cases an equivalent recommendation for radical prostatectomy, percutaneous radiotherapy or permanent seed implantation was given. Of these, 49 (43.4%) decided on the surgical intervention, 48 (42.5%) on a type of radiotherapy and only 18 (15.6%) remained undecided. The histological examination of prostatectomy specimens from patients who had decided to undergo radical surgery at CBF showed a significant decrease in the rate of extracapsular disease extension (> or =T3) from 38% to 20% during the observation period. The interdisciplinary approach has made the process of deciding on an appropriate treatment much easier for the patient. The time-consuming consultation enables better selection of individual treatment modalities and their possible side effects from the point of view of both the patients and the attending physicians. In this study, patients chose either radical surgery or radiotherapy with equal frequency.
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Neoplasias de la Próstata/terapia , Derivación y Consulta , Encuestas y Cuestionarios , Humanos , Masculino , Grupo de Atención al PacienteRESUMEN
BACKGROUND: Choroidal metastasis is the most common ocular tumor, in most cases related to breast and lung cancer. Radiotherapy (RT) mostly is the therapy of choice. However, there is a lack of data about the results of uniformly, prospective treated patients. PATIENTS AND METHODS: Between November 1994 and September 1997, 37 patients with 49 metastatic eyes were enrolled into the study. 25 patients (68%) had unilateral and 12 patients (32%) had bilateral metastases. 21 patients had breast cancer as primary tumor, 12 patients lung cancer, and 4 patients other tumors. 3 patients were excluded from analysis, 34 patients with 46 involved eyes were available for analysis. 29 of those patients had symptomatic metastases, 5 patients had asymptomatic choroidal metastases. RT was performed with bi- or unilateral asymmetric fields, total dose was 40 Gy with a single dose of 2 Gy, 5 fractions per week. 12 patients (35%) had a chemotherapy following RT due to diagnosis of general tumor progression. Endpoints of the study were visual acuity (VA), local tumor control, survival, and side effects. RESULTS: The median follow up was 6 months, 22 out of 34 patients died of metastatic disease. In 17 of symptomatic eyes (53%) an increase of VA and in 11 of symptomatic eyes (34%) a 'no change' was achieved. The local tumor control rate after 18 months was 83%. One patient with asymptomatic metastasis (1/14 eyes) developed symptoms until death. The median survival time was 15 months. Altogether, in 2 patients late side effects (6%) were observed (1 patients with bilateral retinopathy, 1 patient with optic nerve atrophy). CONCLUSIONS: RT with 40 Gy is highly effective in the treatment of symptomatic and asymptomatic choroidal metastases, VA was stable or improved in almost 90% of treated eyes. The rate of side effects is low. Copyright 2000 S. Karger GmbH, Freiburg
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AIM: To determine the frequency of visually asymptomatic choroidal metastasis in patients with disseminated breast cancer and its dependence on the incidence of metastasis by number and site of other organ metastases. METHODS: From January 1995 until April 1997 120 patients irradiated for disseminated breast cancer underwent ophthalmological screening for choroidal metastasis. No patient was symptomatic for ocular disease. 68 out of 120 patients were found to have metastases in one organ and 52 patients had metastases in more than one organ. 80% of the patients had bone metastases, 25% lung metastases, 22% liver metastases, 15% brain metastases, and 22% had metastases in other organs. RESULTS: Six patients (5%) were found to have asymptomatic choroidal metastases. Five patients had unilateral and one patient bilateral metastases. 52 patients with more than one involved organ had a significantly higher risk for asymptomatic choroidal metastasis (6/52, 11%) than 68 patients with metastases in only one organ (0/68) (p = 0.006). In univariate analysis a significantly higher risk was seen for patients with lung metastases (14% choroidal metastases versus 2% in patients without lung metastases, p = 0.03) and for patients with brain metastases (17% choroidal metastases versus 3% in those without brain metastases, p = 0.04). CONCLUSION: In disseminated breast cancer the incidence of asymptomatic choroidal metastases was 5% and increased to 11% when more than one organ was involved in metastatic spread. Risk factors for choroidal metastases were dissemination of disease in more than one organ and the presence of lung and brain metastases.