RESUMEN
OBJECTIVES: To examine by race how frequently the data after radical prostatectomy translates into a substantial change in prognosis. Many nomograms exist to predict the survival outcomes using the pretreatment clinical parameters and post-treatment pathologic parameters. Race might be an important factor affecting their predictive ability. METHODS: Kattan nomograms were used to calculate the pretreatment and post-radical prostatectomy 5-year progression-free probability for each patient. The difference between the nomogram scores was used to divide the patients into 3 groups. A decrease in probability of >or=15 percentage points was classified as a significant increase in the probability of recurrence, an increase of >or=15 points was classified as a significant decrease in the probability of recurrence, and an absolute change of <15 points was considered no significant change. RESULTS: The data from 1709 (132 black and 1577 white) men were analyzed. Among the black men, 26.5% had an increase in the probability of recurrence, 57.6% had no change, and 15.9% had a decrease in the probability of recurrence. Among the white men, 13.8% had an increase in the probability of recurrence, 64.5% had no change, and 21.7% had a decrease in the probability of recurrence. Black men were twice as likely to have a significant increase in the probability of recurrence postoperatively compared with white men after adjusting for preoperative prostate-specific antigen level, clinical stage, and biopsy Gleason sum (odds ratio 2.0, 95% confidence interval 1.3-3.1, P = .002). CONCLUSIONS: These data could assist clinicians when counseling black men regarding their treatment options according to their preoperative risk profile.
Asunto(s)
Negro o Afroamericano , Recurrencia Local de Neoplasia/epidemiología , Prostatectomía , Población Blanca , Adulto , Anciano , Humanos , Masculino , Persona de Mediana Edad , Nomogramas , Pronóstico , Prostatectomía/métodos , Medición de RiesgoRESUMEN
OBJECTIVE: To describe how frequently new information obtained at surgery translates into a substantial change in the risk of recurrence for patients with localized prostate cancer, and to determine what factors contribute to this increase in risk, as the preferred therapy for prostate cancer is often chosen based on available preoperative variables and therefore appropriate decision-making requires an accurate preoperative assessment. PATIENTS AND METHODS: Using the Columbia Comprehensive Clinical Database of Urologic Oncology, we retrospectively analysed 3460 men who had radical prostatectomy (RP) for prostate cancer from 1988 to 2006. Kattan nomograms were used to calculate the 5-year progression-free probabilities before and after RP. The difference between these nomogram scores was used to divide patients into three groups, those with a decrease in the probability of disease-free survival (DFS) of > or =15%, those with an increase in the probability of DFS of > or =15%, and those with an absolute change of <15%. RESULTS: In all, 1804 men with complete data before and after RP were analysed; 1220 (68.4%) had no significant change in nomogram score, 238 (13.3%) had a significant increase and 327 (18.3%) had a significant decrease in the probability of recurrence. Those patients with an increased probability of recurrence had a greater proportion of patients with pathological Gleason sum of > or =8, higher rates of extraprostatic capsular invasion, positive margins, seminal vesical invasion and lymph node involvement (all P < 0.001). CONCLUSION: Accurate risk predictions both before and after RP are central to effective patient counselling and optimal management. Notably, 13.3% of the present patients were faced with a substantial increase of > or =15% in their risk of biochemical failure after pathological variables became available.
Asunto(s)
Recurrencia Local de Neoplasia/patología , Próstata/patología , Prostatectomía/métodos , Neoplasias de la Próstata/patología , Métodos Epidemiológicos , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Nomogramas , Cuidados Preoperatorios/métodos , Pronóstico , Próstata/cirugía , Neoplasias de la Próstata/cirugía , Factores de Riesgo , Resultado del TratamientoRESUMEN
High-risk, localized prostate cancer represents a complex and diverse disease with many available treatment modalities. Patients are often deemed high risk because they are at increased risk for biochemical failure after primary intervention. However, these "high-risk" men may not be at significant risk of dying from their cancer. In this review, an attempt will be made to better define high-risk patients and help identify men at increased risk for mortality, not simply biochemical failure, after a diagnosis of localized prostate cancer. A review of available monotherapies as well as previously successful multimodality treatments will also be presented. Finally, this review will provide a glimpse into the future direction of high-risk prostate cancer multimodal therapy by providing a synopsis several current randomized clinical trials using effective systemic adjuvant therapies following local treatment.
Asunto(s)
Neoplasias de la Próstata/terapia , Terapia Combinada , Humanos , Escisión del Ganglio Linfático , Masculino , Terapia Neoadyuvante , Prostatectomía , Neoplasias de la Próstata/tratamiento farmacológico , Neoplasias de la Próstata/radioterapia , Neoplasias de la Próstata/cirugía , Factores de RiesgoRESUMEN
OBJECTIVE: To examine whether pathological tumour diameter assists in predicting conventional vs other histological subtypes in renal cortical tumours (RCTs) of Asunto(s)
Carcinoma de Células Renales/patología
, Corteza Renal/patología
, Neoplasias Renales/patología
, Nefrectomía/métodos
, Adulto
, Anciano
, Anciano de 80 o más Años
, Carcinoma de Células Renales/cirugía
, Estudios de Cohortes
, Femenino
, Humanos
, Corteza Renal/cirugía
, Neoplasias Renales/cirugía
, Masculino
, Persona de Mediana Edad
, Estadificación de Neoplasias
, Pronóstico
, Análisis de Regresión
, Factores de Riesgo
, Adulto Joven
RESUMEN
OBJECTIVES: To assess the likelihood of biochemical disease-free survival, urinary continence, and sexual potency after radical retropubic prostatectomy (RRP) as an aggregate outcome, the "trifecta" analysis. METHODS: From the Columbia University Urologic Oncology Database of 2522 patients from 1988 to 2005, 503 had undergone RRP by a single surgeon. Of these, 87 patients were excluded: 31 with inadequate follow-up, 47 who had undergone additional confounding therapy, and 9 with insufficient data for the trifecta analysis. The final sample of 416 patients was stratified according to preoperative prostate-specific antigen level, Gleason sum, and clinical stage. Biochemical disease-free survival, continence, and potency were defined, respectively, as a prostate-specific antigen level of less than 0.2 ng/mL, not requiring daily pads, and having an erection sufficient for intercourse with or without oral pharmacotherapy. Patients achieving all three positive outcomes, the trifecta, were analyzed using analysis of variance. RESULTS: Risk stratification identified 225 low-risk, 144 intermediate-risk and 47 high-risk patients whose biochemical disease-free survival rate was 96.4%, 90.3%, and 78.7% at a median follow-up period of 4.4, 4.8, and 7.1 years, respectively. The corresponding continence rates were 93.8%, 94.4%, and 93.3% and the potency rates were 81.3%, 67.7%, and 69.6% with at least 1 year of follow-up. Of the 314 analyzable patients, 130 (72.6%) of 179 low-risk, 61 (58.1%) of 105 intermediate-risk, and 12 (40.0%) of 30 high-risk patients achieved the trifecta. The trifecta rates were significantly different between the low and intermediate-risk (P = 0.04) and low and high-risk (P = 0.001) groups. CONCLUSIONS: Preoperative (RRP) low-risk patients are more likely to remain disease-free, continent, and potent after surgery than are patients of higher risk. Physicians should consider aggregate outcomes when counseling patients regarding the clinical outcomes after RRP.
Asunto(s)
Disfunción Eréctil/etiología , Antígeno Prostático Específico/sangre , Prostatectomía/efectos adversos , Neoplasias de la Próstata/cirugía , Incontinencia Urinaria/etiología , Supervivencia sin Enfermedad , Humanos , Masculino , Persona de Mediana Edad , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/patología , Medición de RiesgoRESUMEN
OBJECTIVE: To determine if the fractional percentage of tumour volume (FPTV) removed at cytoreductive nephrectomy predicts disease-specific survival (DSS), as metastatic renal cell carcinoma ((M+)RCC) is associated with poor overall survival with only a 10-20% patient survival at 2 years. PATIENTS AND METHODS: The Columbia Urologic Oncology Database was reviewed; 1016 patients had renal surgery from 1988 to 2005, 78 patients with (M+)RCC underwent nephrectomy. The FPTV removed was determined using pathological and imaging reports. The patients were stratified as having a > or <90% FPTV. Kaplan-Meier analysis with log-rank test was used to determine survival advantage between groups. A Cox proportional hazard model was used for FPTV in both univariate and multivariate analyses. Secondary analyses were conducted to determine if the size of the primary tumour or volume of metastases affected outcome and if the FPTV affected hospitalization time. RESULTS: In all, 55 patients had their FPTV calculated exactly; 45 had a >90% FPTV. The median DSS times were 11.6 and 2.9 months for patients with >90% and <90% FPTV removed (P = 0.002). The hazard ratio for death was 0.24 for patients with a >90% FPTV in a univariate model (P = 0.016) and 0.29 in multivariate analysis (P = 0.02). Patients with a <90% FPTV spent a greater percentage of time hospitalized before death, 21.2% vs 6.5% (P = 0.03). CONCLUSION: For patients with (M+)RCC, overall survival is limited, but can be extended by cytoreductive nephrectomy. The FPTV expected to be removed is a simple and available method to counsel patients regarding the benefits of surgical intervention.
Asunto(s)
Carcinoma de Células Renales/cirugía , Neoplasias Renales/cirugía , Nefrectomía/métodos , Carcinoma de Células Renales/mortalidad , Carcinoma de Células Renales/patología , Carcinoma de Células Renales/secundario , Estudios de Cohortes , Femenino , Humanos , Neoplasias Renales/mortalidad , Neoplasias Renales/patología , Tiempo de Internación , Masculino , Persona de Mediana Edad , Calidad de Vida , Análisis de Regresión , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVE: To examine the relationship between the presence of high-grade prostatic intraepithelial neoplasia (HGPIN) in retropubic radical prostatectomy (RP) specimens and cancer-specific outcomes, including pathological variables and biochemical disease-free survival (bDFS), as HGPIN shares many histopathological characteristics with prostate carcinoma and has been considered a precursor lesion to prostate cancer. PATIENTS AND METHODS: The Columbia University Urologic Oncology Database was reviewed; 3460 patients were identified who underwent RP between 1988-2006, and 2133 with or without HGPIN and >12 months of follow-up were included in the analysis. Analysis of variance methods were used to evaluate the relationship between HGPIN and pathological stage, Gleason sum, perineural invasion, multifocality, extraprostatic extension, margin and nodal status. Kaplan-Meier analysis with the log-rank test and a multivariate Cox proportional hazard model fitted for preoperative prostate-specific antigen (PSA) level, Gleason sum and pathological stage were used to assess differences in bDFS. RESULTS: In all, 1885 (88.4%) patients had HGPIN in the RRP specimen and 248 (11.6%) had no HGPIN. There was no significant difference in the distribution of PSA level (P = 0.27), pathological stage (P = 0.18) or Gleason sum (P = 0.84) between patients with and with no HGPIN. The HGPIN-positive group had higher rates of perineural invasion (69.9 vs 57.5%; P = 0.003) and multifocality (63.0 vs 38.4%; P < 0.001). Patients with no HGPIN had a better bDFS, at 87.3% vs 81.0% at a median follow-up of 50 months, and 73.6% vs 67.0% at 9 years (P = 0.045). The risk of biochemical failure was 1.9 times greater in the HGPIN-positive group than the negative group (P = 0.006) when controlling for PSA level, pathological stage and Gleason sum. CONCLUSIONS: In addition to traditional pathological prognostic variables, the absence of HGPIN in RRP specimens, although found in a minority of patients, denotes a significantly lower rate of tumour multifocality, perineural invasion and ultimately biochemical recurrence.