Staging Pelvic Lymphadenectomy Research Articles

Comparison of sentinel lymph node mapping with standard pelvic lymphadenectomy in patients with grade 1 and 2 endometrial cancer

Objectives: (1) To evaluate sentinel lymph node (SLN) mapping and ultrastaging in the detection of lymph node (LN) metastasis in patients with endometrioid G1, G2 cancers, less than 50% depth of invasion (DOI), any lesion size, and no suspicious adenopathy, and (2) to compare SLN mapped patients with patients treated with pelvic lymphadenectomy and no SLN mapping. Methods: We evaluated all early-stage endometrial cancer cases in a surgery database (September 2010 to September 2013) with G1, G2 endometrial cancers who underwent robotic hysterectomy with staging pelvic lymphadenectomy and no para-aortic lymphadenectomy. Group A (n = 59) underwent SLN mapping followed by pelvic lymphadenectomy and group B (n = 128) underwent only pelvic lymphadenectomy. SLNs were analyzed with H&E staining followed by ultrastaging and immunohistochemistry. Demographic and clinicopathologic data were compared in univariate analyses. Pathology was risk-stratified per Gynecologic Oncology Group (GOG) 249 criteria. Results: The cohort mean age was 61.8 ± 10.0 years (n = 187). All final pathology was endometrioid G1 or G2 and 12 (7.2%) of 167 cases were upstaged to stage IB on final pathology. There were no significant differences in FIGO stages between groups. Mean LN counts for groups A and B were 18.8 ± 8.3 and 18.0 ± 9.3, respectively. Mean SLN count for group A was 3.7 ± 2.2 and the bilateral detection rate was 86.4% (13.6% unilateral). No significant difference between groups for mean DOI (17.5 ± 19.6% vs19.4 ± 21.7%). DOI for Groups A and B were: no invasion (28.8% vs 25%), less than 50% (64.4% vs 64%), and more than 50% (8.5% vs 10.9%). Lymphovascular space invasion in the 2 groups was 8.5% versus 11.7% (P = .62). LN metastasis was detected in 5 (8.5%) of 59 in group A versus 3 (2.3%) of 128 in group B (P = .11). In group A, all metastases were low-volume metastases (1 with micometastasis and 4 with isolated tumor cells). Group B included 2 micro- and 1 macrometastasis. No metastases were detected in the 49 patients with noninvasive carcinoma, 6 (5%) of 120 metastasis with less than 50% DOI, and 2 (10.5%) of 19 cases with more than 50% invasion on final pathology (P > .05). Conclusions: There was a statistical trend toward more LN metastasis in patients with G1, G2 endometrial cancer and frozen section less than 50% DOI using an SLN algorithm compared with patients treated with standard pelvic lymphadenectomy. An expansion of the database analysis to 275 cases would achieve statistical significance.

Risk of Incisional Hernia after Minimally Invasive and Open Radical Prostatectomy

The number of radical prostatectomies has increased. Many urologists have shifted from the open surgical approach to minimally invasive techniques. It is not clear whether the risk of post-prostatectomy incisional hernia varies by surgical approach. In the linked Surveillance, Epidemiology and End Results (SEER)-Medicare data set we identified men 66 years old or older who were treated with minimally invasive or open radical prostatectomy for prostate cancer diagnosed from 2003 to 2007. The main study outcome was incisional hernia repair, as identified in Medicare claims after prostatectomy. We also examined the frequency of umbilical, inguinal and other hernia repairs. We identified 3,199 and 6,795 patients who underwent minimally invasive and open radical prostatectomy, respectively. The frequency of incisional hernia repair was 5.3% at a median 3.1-year followup in the minimally invasive group and 1.9% at a 4.4-year median followup in the open group, corresponding to an incidence rate of 16.1 and 4.5/1,000 person-years, respectively. Compared to the open technique, the minimally invasive procedure was associated with more than a threefold increased risk of incisional hernia repair when controlling for patient and disease characteristics (adjusted HR 3.39, 95% CI 2.63-4.38, p<0.0001). Minimally invasive radical prostatectomy was associated with an attenuated but increased risk of any hernia repair compared with open radical prostatectomy (adjusted HR 1.48, 95% CI 1.29-1.70, p<0.0001). Minimally invasive radical prostatectomy was associated with a significantly increased risk of incisional hernia compared with open radical prostatectomy. This is a potentially remediable complication of prostate cancer surgery that warrants increased vigilance with respect to surgical technique.

DETECTION OF EARLY LYMPH NODE METASTASES IN PROSTATE CANCER BY LAPAROSCOPIC RADIOISOTOPE GUIDED SENTINEL LYMPH NODE DISSECTION

Radioisotope guided sentinel lymph node (SLN) dissection (SLND) for prostate cancer has been shown to increase the sensitivity of detecting early metastases in open pelvic lymph node dissection. We developed a technique that allows SLND to be performed by laparoscopy in conjunction with laparoscopic radical prostatectomy. In 71 consecutive patients SLND was performed by 1 surgeon preceding laparoscopic radical prostatectomy. Mean preoperative prostate specific antigen was 8.88 ng/ml (range 2.1 to 25.4). At 24 hours prior to surgery 3 ml (200 MBq) Tc labeled human albumin colloid were injected into the prostate gland under transrectal ultrasound guidance. An especially designed laparoscopic gamma probe was used to measure radioactivity during surgery. SLNs were identified and removed. If frozen section analysis showed metastases, extended pelvic lymph node dissection was performed. Radioactivity was detected on 2, 1 and no sides in 50 (70.4%), 19 (26.7%) and 2 patients (2.8%), respectively. In 81 of the 142 pelvic side walls (54.7%) SLNs were exclusively outside of the obturator fossa. Histopathological examination showed metastases to SLNs in 9 patients (12.9%). Eight of the 11 detected metastases (72.7%) were outside of the obturator fossa. Lymph node metastases were exclusively found in Tc marked lymph nodes. Mean tumor size was 1.7 mm (range 0.2 to 3.9). SLND is feasible by laparoscopy. It detects micrometastases outside of the obturator fossa in a significant number of patients. We noted that the transperitoneal approach allowing wide exposure and a gamma probe with a 90-degree lateral energy window is the most important factor to enable successful laparoscopic SLND.

TRANSITION ZONE CANCERS UNDERMINE THE PREDICTIVE ACCURACY OF PARTIN TABLE STAGE PREDICTIONS

The Partin tables represent the most widely used predictor of pathological stage in men with localized prostate cancer (PCa). The accuracy and performance of the tables have been tested across different populations. However, to our knowledge the potential limitations that may stem from differences between transition zone (TZ) and peripheral zone (PZ) prostate cancers has not been explored. We tested the predictive accuracy and performance of the Partin tables according to TZ vs PZ tumor predominance. Preoperative serum prostate specific antigen, clinical stage and biopsy Gleason sum data on 1,990 patients treated with radical retropubic prostatectomy were used to define the 2001 Partin probabilities of organ confinement and seminal vesicle invasion (SVI). Data on 1,320 patients who underwent staging pelvic lymphadenectomy and radical retropubic prostatectomy were used to define the probabilities of lymph node invasion (LNI) and organ confined disease (OC). ROC area under the curve was used to assess the predictive accuracy of the 2001 Partin tables relative to observed extracapsular extension (ECE), SVI, LNI and OC. Performance characteristics for each prediction were explored graphically with local regression, nonparametric smoothing plots. Results were compared between 222 TZ cancers and 1,768 PZ cancers. The 1,990 radical retropubic prostatectomy specimens demonstrated ECE in 689 cases (34.6%) (TZ in 58 or 27.1% and PZ in 631 or 35.8%) and SVI in 224 (TZ in 13 or 6.1% and PZ in 211 or 11.9%). The 1,320 lymphadenectomy specimens demonstrated LNI in 56 cases (TZ in 2 or 0.9% and PZ in 54 or 4.6%). OC was found in 784 cases (59.4%) (TZ in 95 or 69.9% and PZ in 689 or 58.2%). Predictive accuracy was for ECE 76.4% (TZ 69.0% and PZ 77.2%), 78.0% for SVI (TZ 73.5% and PZ 78.3%), 78.6% for LNI (TZ 44.5% and PZ 79.9%) and 79.4% for OC (TZ 73.8% and PZ 80.0%). The biological tumor characteristics of TZ PCa differ from those of PZ PCa. These differences appear to undermine the accuracy of pathological stage predictions.

Laparoscopic radical prostatectomy: perioperative complications in an initial and consecutive series of 80 cases.

We retrospectively evaluated the intraoperative and early postoperative complications of the initial experience with the first 80 laparoscopic radical prostatectomies performed at our institution. Between January 17, 2001 and July 24, 2002, 80 patients between 53 and 78 years old (mean age 63.8) with clinically localized prostate cancer underwent laparoscopic radical prostatectomy with the Montsouris technique. A total of 24 (30%) staging pelvic lymphadenectomy were performed. The inpatient and outpatient medical records as well as all complications were reviewed. The pathological tumor stage revealed 18 pT2a (22.5%), 29 pT2b (36.25%), 21 pT3a (26.25%), 10 pT3b (12.5%), 1 pT4 (1.25%), 1 pT4 N1 (1.25%). No conversion was necessary in all cases. Mean operative time was 218 minutes (range 150-420) overall, mean blood loss was 376 ml (range 50-1000) and the mean postoperative hospital stay was 4.5 days (range 3-9). The mean and the median duration of bladder catheterization were respectively 11 and 10 days (range 7-23). Injury to the epigastric vessels was detected intraoperatively in 5 cases (6.25%) with immediate hemostasis achieved. There was 1 death (1.25%) 35 days after a cerebrovascular accident occurred on postoperative day 3. We observed 1 (1.25%) postoperative ileus, hemoperitoneum in 5 cases (6.25%), 2 (2.5%) acute urinary retentions, 6 (7.5%) anastomotic leakages, 1 (1.25%) anastomotic stricture, 1 (1.25%) hydrocele and 2 (2.5%) urinary tract infections. In our initial experience laparoscopic radical prostatectomy was performed with no complications in 77.5% of patients. We observed major and minor complications respectively in 16.25% and 6.25% of the patients. Our series provides evidence that the laparoscopic approach is feasible and associated with acceptable perioperative morbidity.

20-YEAR OUTCOME OF PATIENTS WITH T1–3N0 SURGICALLY STAGED PROSTATE CANCER TREATED WITH EXTERNAL BEAM RADIATION THERAPY

Patients with surgically staged localized prostate cancer treated with external beam radiation therapy were retrospectively analyzed for 15 and 20-year overall and cause specific survival. The need for additional therapy was also evaluated. We analyzed 145 patients who received external beam radiotherapy after negative staging pelvic lymphadenectomy. Followup data were available for 129 patients. Overall and cause specific survival was calculated with the Kaplan-Meier method. Median followup was 14.9 years. Actuarial overall survival at 15 and 20 years was 45.9% and 24.6%, respectively. Cause specific survival at 15 and 20 years was 64.5% and 37.7% for having all patients dying of unknown causes censored, and 54.4% and 30.1% for those dying of unknown causes categorized as having prostate cancer, respectively. Of the patients who survived 47% were on hormonal therapy. Longer followup after external beam radiation therapy continues to demonstrate a decrease in cause specific survival. Many patients ultimately require hormonal therapy.

Evaluation of artificial neural networks for the prediction of pathologic stage in prostate carcinoma

Currently, the standard for predicting pathologic stage from information available at the time of prostate biopsy is the "Partin nomograms" that were derived using logistic regression analysis. The authors retrospectively reviewed a large series of men with clinically localized prostate carcinoma who underwent staging pelvic lymphadenectomy and radical retropubic prostatectomy. They then utilized pathologic and clinical data at the time of prostate biopsy to develop and test an artificial neural network (ANN) to predict the final pathologic stage for this group of men. They then compared the results of ANN with the previous nomograms. Five thousand seven hundred forty-four men were treated at the authors' institution from 1985 to 1998. An ANN was developed using two randomly selected training and validation sets for predicting pathologic stage. Input variables included age, preoperative serum prostate specific antigen level, clinical TNM (tumor, lymph node, and metastasis) classification, and Gleason score from the biopsy specimen. Outcomes included organ confinement and lymph node involvement status. The ANN was slightly superior to the nomograms in predicting pathologic stage, such as organ confinement and lymph node involvement status. In predicting organ confinement and lymph node involvement status, ANN was more accurate and had a larger area under ROC than the nomograms based on the logistic regression method. Artificial neural network models can be developed and used to better predict final pathologic stage when preoperative pathologic and clinical features are known.

ROBOTIC ASSISTED, LAPAROSCOPIC PELVIC LYMPH NODE DISSECTION IN HUMANS

We evaluate the feasibility and efficacy of robotic assisted, laparoscopic pelvic lymph node dissection for locally advanced prostate cancer staging. Robotic assisted, laparoscopic pelvic lymph node dissection was performed in 10 consecutive patients with mainly T3 M0 prostatic carcinoma (robotic group). Operative, postoperative and pathological parameters were compared with the results of the last 10 patients undergoing conventional, laparoscopic pelvic lymph node dissection performed with similar indications by the same operator (laparoscopy group). All operations were performed according to the established protocol with no specific intraoperative or postoperative complications. No conversion was required, and no technical incidents were observed in the robotic group. Mean operating time plus or minus standard deviation for the robotic group was 125 +/- 57 minutes (range 75 to 215), significantly longer than that for the laparoscopy group, which was 60 +/- 15 minutes (p = 0.0013). In the robotic group 2 patients presented with postoperative lymphoceles revealed in 1 by deep venous thrombosis and in the second by obturator pain. In the laparoscopy group 1 patient presented with acute urinary retention. The histological results concerning the number of lymph nodes removed were similar in both groups (p = 0.5). We show the technical feasibility of robotic assisted, laparoscopic pelvic lymph node dissection in humans. Although the benefit of this technique has not yet been established, predictable technological improvements would suggest the development of telesurgery and an improved precision of surgical procedure.

Evaluation of artificial neural networks for the prediction of pathologic stage in prostate carcinoma

BACKGROUND. Currently, the standard for predicting pathologic stage from information available at the time of prostate biopsy is the Partin nomograms that were derived using logistic regression analysis. The authors retrospectively reviewed a large series of men with clinically localized prostate carcinoma who underwent staging pelvic lymphadenectomy and radical retropubic prostatectomy. They then utilized pathologic and clinical data at the time of prostate biopsy to develop and test an artificial neural network (ANN) to predict the final pathologic stage for this group of men. They then compared the results of ANN with the previous nomograms. METHODS. Five thousand seven hundred forty-four men were treated at the authors' institution from 1985 to 1998. An ANN was developed using two randomly selected training and validation sets for predicting pathologic stage. Input variables included age, preoperative serum prostate specific antigen level, clinical TNM (tumor, lymph node, and metastasis) classification, and Gleason score from the biopsy specimen. Outcomes included organ confinement and lymph node involvement status. RESULTS. The ANN was slightly superior to the nomograms in predicting pathologic stage, such as organ confinement and lymph node involvement status. CONCLUSIONS. In predicting organ confinement and lymph node involvement status, ANN was more accurate and had a larger area under ROC than the nomograms based on the logistic regression method. Artificial neural network models can be developed and used to better predict final pathologic stage when preoperative pathologic and clinical features are known.

Quality of life in T1–3N0 prostate cancer patients treated with radiation therapy with minimum 10-year follow-up

Purpose: To describe patient-reported quality of life using a validated survey in a cohort of patients who are long-term survivors of definitive radiotherapy for T1–3N0 prostate cancer. Methods and Materials: Survivors of a previously reported cohort of prostate cancer patients treated with staging pelvic lymphadenectomy and definitive radiotherapy between November 1974 and August 1988 were queried using a questionnaire incorporating the RAND 36-Item Health Survey and the University of California, Los Angeles Prostate Cancer Index. Responses were reviewed and analyzed. Of the 146 N0 patients, 88 have survived for 10 years postdiagnosis. Fifty-six (64%) of these patients were still alive with valid addresses and were mailed copies of the questionnaires, of which 46 (82%) responded. Median potential follow-up from date of diagnosis was 13.9 years, with a median age of responders of 80 years. Results: The mean sexual function score was 15.4, with a bother score of 42. The mean urinary function score was 65, with a bother score of 61. The mean bowel function score was 72.6, with a bother score of 64.8. The amount of patient bother reported in the sexual category is similar to that previously reported for cohorts of prostate cancer patients undergoing radiotherapy or observation. This is despite the fact that sexual function was similar to that previously reported for patients postprostatectomy. Patient-reported function and bother scores in urinary and bowel categories were somewhat more severe than a previously reported radiotherapy cohort with shorter follow-up. Conclusions: With long follow-up, most patients who underwent radiotherapy for prostate cancer in the era described exhibit somewhat worse bladder, bowel, and erectile function than recently published controls without prostate cancer. In this cohort of older men with long follow-up, erectile function is similar to reported prostatectomy series. However, patient bother related to erectile function is similar to that of controls in earlier published radiotherapy series. Worse urinary and bowel function may be due to progressive symptoms with aging and longer follow-up, or to the radiotherapy techniques performed during the era in question.

External beam radiation monotherapy for prostate cancer.

To clarify the implications and limitations of external beam radiation monotherapy for localized prostate cancer, the long-term outcomes and prognostic factors were investigated. Between 1976 and 1994, 91 patients with untreated prostate cancer were treated with external beam radiation therapy alone. Thirty-two were classified as T1b, eight were T2a, four were T2b and 47 were T3. Pelvic lymphadenectomy was carried out in 69 cases; 57 were staged as pN0, eight were pN1, four were pN2 and 22 were pNX. Linac X-rays were used in 55 cases, fast neutron in 15 and a combination of the two in 21. No other therapy was given until relapse and when relapse was evident endocrine therapy was started. The observation period ranged from 3 to 206 months with a median of 78 months. Local control rate and disease-free, cause-specific and overall survivals at 10 years were 74.0, 49.6, 74.2 and 39.2%, respectively. By univariate analysis, T category, pN category and histologic grade were significant prognostic indicators for disease-free survival. Multivariate analysis revealed that T category was an independent prognostic factor. In T2b and T3 diseases, pN0/1 patients demonstrated significantly better disease-free survival than pNX. A favorable long-term outcome was achieved by external beam radiation monotherapy in patients with minimally extended prostate cancer (T1b and T2a). For locally advanced disease (T2b and T3), staging pelvic lymphadenectomy would be useful for the selection of patients.

SECOND PRIMARY MALIGNANCIES IN T1-3N0 PROSTATE CANCER PATIENTS TREATED WITH RADIATION THERAPY WITH 10-YEAR FOLLOWUP

Purpose The risk of patients with prostate cancer to have second primary malignancies is unclear. Population and autopsy based studies have shown no increased risk, which is at variance with several institutional analyses. A retrospective review was performed with comparison to expected cancer data from the Connecticut Tumor Registry. Materials and Methods Records of a cohort of prostate cancer patients treated with staging pelvic lymphadenectomy and definitive radiotherapy between November 1, 1974 and July 7, 1987 were reviewed. Median potential followup from date of diagnosis was 10.9 years. Results Of the 164 patients 150 (91.5%) had followup to death or to August 1995, with data available in part on 4 of the remaining patients. In 43 patients 51 second primary malignancies developed. Increased frequency of lymphomas, and kidney, bladder and rectal lesions (all p <0.001) was observed concurrently with diagnosis of prostate cancer, although this may be due to bias since full staging for the prostate cancer may have led to their diagnosis. An increased frequency of renal lesions in the 1 to 4-year followup period (p = 0.032) also was observed. Two sarcomas and a leukemia were putatively radiation induced but their frequency was not significantly different from the comparison baseline. Conclusions Much of the apparent increase in second primary malignancies associated with prostate cancer noted by some authors may be attributed to bias in the staging process. Renal cancers may occur more frequently in patients with prostate cancer but the distribution of these lesions is inconsistent with a field defect mechanism of cancer induction.

The fate of 10-year clinically recurrence-free survivors after definitive radiotherapy for T1-3N0M0 prostate cancer.

We recently reported the outcome of 168 patients treated with pelvic lymphadenectomy and definitive radiation therapy. This report is a subanalysis of those patients (pts) who were clinically without evidence of disease (NED) 10 years after a negative staging pelvic lymphadenectomy and definitive radiation therapy for prostate cancer. One hundred of our original cohort of 168 patients had at least ten year follow-up. 76 patients had pathologically negative lymph nodes and had not received hormonal therapy. Forty-two N0 patients with sufficient follow-up were alive and clinically NED 10 years post-operatively. Distribution by disease stage at diagnosis was: Stage A2: 12 pts; Stage B: 19 pts; Stage B2/C: 6 pts; Stage C: 5 pts. Median follow-up was 13.3 years, with a minimum follow-up of 10 years. Of the 42 patients clinically NED at 10 years, 5 pts died subsequently without PSA data, remaining clinically NED a median of 13 y 3 m postoperatively; 37 patients were alive and without evidence of disease off all therapy at 10 years post-operatively. Bone scans were performed on 8 of the 9 patients with PSA over 4.0 ng/ml or on hormonal therapy. These revealed a single patient with diffuse but asymptomatic bone metastases. Ultrasound-guided sextant biopsies were performed on one 78-year-old patient with elevated PSA 19 years post-operatively, revealing an asymptomatic local recurrence. Patients who survive clinically NED for 10 years have a low likelihood of clinical failure, even in the presence of PSA values between 4.0 and 10 ng/ml. In these patients, PSA trends are of greater utility than absolute values.

The staging pelvic lymphadenectomy: implications as an adjunctive procedure for clinically localized prostate cancer.

To evaluate the utility of staging pelvic lymphadenectomy and to identify factors associated with nodal metastases in which a node dissection would be of clinical benefit. A retrospective analysis (1989-1993) was performed on 303 consecutive patients who underwent staging bilateral modified pelvic lymph node dissection for clinically localized prostate cancer. Multivariate logistic regression analysis was used to evaluate age, race, clinical stage, prostate-specific antigen (PSA) level and Gleason score for predicting nodal metastases. Twenty-eight patients had nodal metastases, giving an overall prevalence of 9.2%. PSA and Gleason score (both P < 0.001) were significantly predictive of nodal involvement when combined or as independent variables. Relative to PSA and Gleason score, the patients' age, race and clinical stage were less relevant. Sensitivity analysis determined that combining a PSA of > or = 20 ng/mL (normal 0-4) and a Gleason score of > or = 8 gave a negative predictive value of 92% with a specificity of 99%, a positive predictive value of 67% and an overall accuracy of 91% for predicting nodal metastases. From this data, lymph node metastases are unlikely in patients with clinically localized prostate cancer who have a PSA of < 20 ng/mL and a Gleason score < 8, and that a pelvic lymph node dissection as an adjunctive procedure should be avoided in such individuals.

Excellent long-term survival and absence of vaginal recurrences in 332 patients with low-risk stage I endometrial adenocarcinoma treated with hysterectomy and vaginal brachytherapy without formal staging lymph node sampling: Report of a prospective trial

Purpose : The value of adjuvant radiation therapy and staging pelvic lymphadenectomy in patients with low-risk, early-stage endometrial cancer is controversial. The aim of this study was to report the long-term survival, rate of recurrences, and complications in patients with Stage I endometrial cancer, Grade 1–2, with < 50% myometrial invasion treated with hysterectomy (without formal staging pelvic and periaortic lymph node sampling or lymphadenectomy) and postoperative vaginal brachytherapy. Methods and Materials : A total of 303 patients with pathologic Stage I endometrial cancer, Grade 1–2, with < 50% myometrial invasion and nonmalignant peritoneal cytology, were treated with total abdominal hysterectomy, bilateral salpingo-oophorectomy, and postoperative vaginal brachytherapy (30 Gy to point 0.5 cm depth) in a prospective study extending from 1958 to 1994. In addition, 29 additional Stage I, Grace 1–2 patients with < 50% myometrial invasion and malignant peritoneal cytology were treated with 1 year of progesterone therapy. Patients were followed for 1.2–32 years (median 8.1 y). Results : Six patients had recurrences and died secondary to disease. There were no vaginal recurrences. The 5-, 10-, 20-, and 30-year disease-free survivals of the 303 patients with nonmalignant peritoneal cytology were 98.9%, 97.8%, 96.7%, and 96.7%, respectively. Patients with malignant peritoneal cytology had a 5- and 10-year disease-free survival of 100%. Significant radiation complications occurred in 2.1% of the patients. Conclusion : In patients with low-risk, Stage I endometrial cancer, hysterectomy and adjuvant postoperative vaginal brachytherapy provide excellent long-term survival, eliminate vaginal recurrences, and are not associated with significant complications. The addition of 1 year of progesterone therapy to patients with malignant cytology provides 100% long-term survival. Based on these results, patients with low-risk, Stage I endometrial adenocarcinoma do not need formal staging pelvic and periaortic lymphadenectomy.

Outcome for Surgically Staged Localized Prostate Cancer Treated With External Beam Radiation Therapy

Purpose A retrospective analysis was performed on patients with surgically staged localized prostate cancer treated with external beam radiation therapy for 10-year overall, cause specific and disease-free survivals based on lack of clinical recurrence and 2 separate prostate specific antigen criteria for cure. Materials and Methods We analyzed 145 patients who received external beam radiation therapy after a negative staging pelvic lymphadenectomy for prostate cancer. Followup data were available for 129 patients (90%). Disease was stage A in 29 patients (22.5%), stage B in 64 (49.6%), stage B2/C in 2 (17%) and stage C in 14 (10.9%). Average potential followup from date of diagnosis was 11.5 years (minimum 7.2). Of the patients 87 potentially can be followed for longer than 10 years. Disease-free survival was based on a normal digital rectal examination, lack of symptoms suspicious for metastasis and application of 2 separate prostate specific antigen criteria of 4 ng./ml. or less (group 1), or 1.5 ng./ml. or less (group 2). Survival was analyzed with the Kaplan-Meier actuarial method. Results Actuarial overall survival at 10 and 15 years was 63.7 and 49.6, respectively, and cause specific survival was 84.2 and 80%, respectively. Disease-free survival was 54.5 and 32.4%, respectively, for group 1, and 42.3 and 9.6%, respectively, for group 2. Conclusions The improved patient selection inherent in surgical staging before definitive external beam radiation therapy provides for improved overall and cause specific survival over that of patients without surgical staging. Biochemical disease-free survival also appears to be improved.

Pretreatment transperitoneal laparoscopic staging pelvic and paraaortic lymphadenectomy in large (≤5 cm) stage IB2 cervical carcinoma: Report of a pilot study: Recio F.O.; Piver M.S.; Hempling R.E. USA Gynecol Oncol 1996 63/3 (333–336)

International Journal of Gynecology & ObstetricsVolume 56, Issue 3 p. 301-302 Citations from the literature oncology Pretreatment transperitoneal laparoscopic staging pelvic and paraaortic lymphadenectomy in large (≤5 cm) stage IB2 cervical carcinoma: Report of a pilot study Recio F.O.; Piver M.S.; Hempling R.E. USA Gynecol Oncol 1996 63/3 (333–336) First published: 15 December 1997 https://doi.org/10.1016/S0020-7292(97)83394-2AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume56, Issue3March 1997Pages 301-302 RelatedInformation

Comparison of laparoscopic and minilaparotomy pelvic lymphadenectomy for prostate cancer staging in a community practice

Objectives To compare the cost-effectiveness and morbidity of minilaparotomy (MINILAP) and laparoscopic pelvic lymphadenectomy (LAP) in a community practice setting. Methods We reviewed our experience with 44 consecutive patients with prostate cancer who had staging pelvic lymphadenectomy from January 1992 through April 1995 in a general health maintenance organization urology practice. Of this group, 22 men had LAP and 22 men had MINILAP. Results MINILAP and LAP groups were similar in age (mean 67 years), Gleason score (mean 7.2 and 6.8), prostate-specific antigen level (mean 46 and 49 ng/mL), and clinical stage (T1 to T3). Operative time was statistically significantly shorter for MINILAP (mean 1.2 hours) than for LAP (mean 2.9 hours). Complication rate was 9.1% for MINILAP and 31.8% for LAP. Lymph node metastasis was found in 45% of MINILAP patients and in 27% of LAP patients. Mean initial hospital stay was 1.0 day for MINILAP and 1.6 days for LAP. Total hospital stay including hospital readmission for complications was 1.5 days for MINILAP and 2.6 days for LAP. Cost of MINILAP was at least $1900 less than that of LAP because of shorter total hospital stay, shorter operation time, and lower equipment cost. Conclusions Compared with LAP, MINILAP was more cost-effective and produced less morbidity. Patient satisfaction with the procedures was similar. MINILAP is an excellent alternative to LAP for prostate cancer staging in general urology practice.

Pretreatment Transperitoneal Laparoscopic Staging Pelvic and Paraaortic Lymphadenectomy in Large (≥5 cm) Stage IB2 Cervical Carcinoma: Report of a Pilot Study

Twelve patients with large stage IB2 (5–8 cm) cervical carcinoma underwent transperitoneal laparoscopically directed pelvic and paraaortic lymph node dissection prior to the initiation of radiation therapy. The mean length of operation was 176 min and the mean estimated blood loss was 60 cc. An average of 25 lymph nodes were retrieved from each patient: 18 pelvic lymph nodes and 7 paraaortic lymph nodes. No patients were hospitalized for more than 24 hr. No operative complications were observed. Pelvic nodal metastases were diagnosed in three patients, all of whom had negative computerized tomography (CT) scans prior to surgery. All patients began radiation therapy within 1 week of surgery. Laparoscopically directed lymphadenectomy for patients with stage IB2 cervical carcinoma is technically feasible, is associated with minimal morbidity, short hospital stay, and minimal delay prior to radiation therapy, and can add valuable information to radiation treatment planning.

The role of free/total prostate-specific antigen ratio in the prediction of final pathologic stage for men with clinically localized prostate cancer

Objectives The combined use of total prostate-specific antigen (PSA), clinical stage, and Gleason score accurately predicts final pathologic stage for men with clinically localized prostate cancer. Recently, the free/ total PSA ratio has been proposed as an adjunct for early detection of prostate cancer. We examined the association between free/total PSA and pathologic stage. Methods In a prospective study, 301 consecutive men with clinically localized prostate cancer (average age 58.8 years, range 45–72) underwent a staging pelvic lymphadenectomy and radical prostatectomy. Total PSA and free PSA were measured from preoperative sera. Pathologic stage was determined as organ-confined (OC, n = 169), capsular penetration (CP+, n = 108), seminal vesicle involvement (SV+, n = 13) and lymph node involvement (LN+, n = 11). Results Overall, 292/301 (97%) of the free/total PSA values were <25%, and thus suspicious for prostate cancer. Combination of total PSA, Gleason score, and clinical stage predicted well OC ( P = 0.00001) and LN+ ( P = 0.023); whereas, replacing total PSA with free/total PSA ratio did not improve the prediction of OC ( P = 0.0007) nor LN+ ( P = 0.03). Conclusions The free/total PSA ratio cutoff point of 25% had high sensitivity for prostate cancer among a group of men with clinically localized disease. The free/total PSA ratio did not significantly improve the prediction of pathologic stage provided by total PSA when used alone or in combination with Gleason score and clinical stage. These preliminary data demonstrate that free/total PSA levels provide no additional information for pathologic stage prediction when combined with Gleason score and clinical stage in men with clinically localized prostate cancer.