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A Single Microfocus (5% or Less) of Gleason 6 Prostate Cancer at Biopsy-Can We Predict Adverse Pathological Outcomes?
Source: Urotoday
While a microfocus of Gleason score 6 prostate cancer on biopsy is commonly considered low risk disease, there was a greater than 1/5 risk of pathological upgrading and/or up staging. Patients with Gleason score 6 microfocal prostate cancer should be counseled that they may harbor more aggressive disease, especially when pretreatment clinical risk factors are present, such as advanced age or high clinical prostate specific antigen density.
The team at the University of Chicago looked at patients with only 1 small focus of cancer that was the lower grade (6) on biopsy. Overall 42 patients (22%) had adverse pathological outcomes, including upgrading in 35 [higher gleason score] (18%) and upstaging [cancer outside the prostate] in 16 (8%). I performed a similar study almost 2 years ago that also found the amount and type of cancer is underestimated on biopsy.
From MedWire News
Among prostatectomy patients, those with diets high in high saturated fat (HSF) are almost twice as likely to experience biochemical failure as those who consume a low saturated fat (LSF) diet, say US scientists.
Several studies have indicated that obesity is associated with an increased risk of biochemical failure after treatment with radical prostatectomy or external beam radiation for localized prostate cancer.
Patients at risk of prostate cancer and thos with prostate cancer should reduce their fat intake.
UroToday - Prostate Cancer Progression in the Presence of Undetectable or Low Serum Prostate-Specific Antigen Level
 Overall, 10 (22%) had undetectable serum PSA levels and 30 patients (65%) had PSA of less than 1ng/ml at the time of disease progression. Of the 25 men who had undergone radical prostatectomy, 7 were hormone na�ve at the time of progression. The median increase in PSA was 0.25ng/ml at the time of progression. In 19 patients, there was no increase in PSA from the nadir level at the time of progression. The median PSA doubling time for the cohort was 7.6 months.
Atypical variants of CaP were identified in 21 of 46 patients; including 9 with ductal CaP, 8 with small cell variant, 2 with neuroendocrine tumors and 2 men with sarcomatoid tumors. Metastatic progression was most commonly in the bones, followed by liver, retroperitoneal lymph nodes and lungs. Progression was identified by bone scans, CT or MRI.
In patients with CaP variants, monitoring in addition to PSA may have value.
Cancer 2006;109(2): 198-204
Continue reading "Prostate Cancer: Prostate cancer can metastasize after surgery with even low PSAs rarely" »
Testosterone Replacement May Be Safe After Prostate Cancer
NEW YORK (Reuters Health) Mar 23 - Testosterone replacement therapy (TRT) appears safe for men who experience hypogonadal symptoms after brachytherapy for prostate cancer.
"Men who have undergone potentially curative treatment for prostate cancer but also suffer from severe effects of hypogonadism may benefit from a trial of testosterone replacement, with close monitoring of the PSA," Dr. Michael F. Sarosdy from South Texas Urology and Urologic Oncology, San Antonio, told Reuters Health. "In our experience, most have done well.
This is the first study that I have seen that recommended testosterone replacement after brachytherapy for prostate cancer.
The concern is that testosterone can help make any viable cancer cells grow faster. Since patients with hypogonadism (symptoms of low testosterone) have benefit from having normal levels and most patients with prostate cancer have normal levels of testosterone that we do not suppress, the true risk of a normal testosterone is probably low.
I usually do not like recommending testosterone replacement in any of my prostate cancer patients.
ProstateCenter.com: On ProstateCenter.com, you will find a wide range of sophisticated clinical tools, nomograms, databases and other useful information that enable the delivery of personalized, evidence-based medicine. These Web-enabled problem-focused decision making support tools allow users to forge the increasing amount and diversity of clinical data into real world solutions for patients, all provided in a timely, graphically oriented, colorful, and user-friendly environment, at no cost.
A friend of mine, and excellent robotic surgeon, Dr. Kevin Slawin from Texas has introduced me to a new site.
I liked the nomogram for prostate cancer recurrence after surgery and will find the PSA velocity doubling time very useful.
I saw back my oldest robotic prostate patient today. He is 80 years old and had surgery 3 months ago. He looked great and felt equally well. He had minimal urinary leakage issues by 1 month and was not wearing a protective pad today. He is very active and had been regularly going to watch college sports since a week after surgery.
He was extremely pleased.
I was wondering if someone else had done surgery on octogenarians and came across the above piece from the Mayo clinic.
I think with robotics the near term morbidity is very low in the well selected 80 year old patient.
Nine MSN: Partners of cancer patients suffer too
When discussing prostate cancer options and a new diagnosis, I always remind the patient to bring in their wife or loved one. This article points out that wives are also affected significantly by prostate cancer.
I have heard the term Bloodless Surgery many times and am familiar with it. A google search will also give someone who may not be familiar with the term a better understanding of how it is used.
There are many things that can be done to help avoid blood transfusions such as minimizing blood draws, diluting the blood during surgery by giving extra fluids during surgery, and giving medicines to help replenish normal stores.
I personally do not like transfusing blood and feel that even giving a patient his own blood back, is not entirely without risk. There is a chance of bacterial infection and a small chance that the blood can be mixed up. A friend and former Chairman of Surgery at Saint Barnabas Medical Center recently wrote an informative newsletter about the disadvantages of blood transfusions:
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Just as the physical universe is changing so too is the health care
universe. I'm a great believer in the power of change; really the
acceptance of, and adaptation to, change. I remember a warning from my
days as a medical student. Someone told me that as I traveled through a
life in medicine the questions would remain the same but the answers would
change. How true! Here are some questions that have had their answers
revised in light of better understanding.
After a major operation a patient's hemoglobin is stable at 7.5 Gms. The
patient did not receive any blood during surgery. Should the patient
receive 2 units of red cells now or not? Old answer: Give 2 units of
packed red cells now. New answer: Do not transfuse if patient is stable.
Transfusions have many potential complications including an increased risk
for post operative infection. Another question: A patient is scheduled to
come in for an open radical prostatectomy. Should he put one or two units
of his own blood in the bank in case he needs to be transfused? Old
answer: Yes. New answer: No. Blood loses 2,3, DPG and red cells deform
during storage even for a week or two. The best place for his blood is
in his veins. In cardiac surgery risk adjusted morbidity, mortality and
length of stay are all closely correlated with the age of the blood
transfused.
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So all this sounds like I am in favor of bloodless surgery, which I am to an extent.
I have several issues. Any surgery which involves any incision has the potential to lose blood.
There is no such thing as bloodless surgery in the sense that blood will not be lost.
It is safe to lose blood and I think the term should be transfusion-less surgery as a more accurate, but maybe less marketable term.
The other issue is what I feel is my responsibility to inform the patient about what is likely to happen and what can potentially happen. My team at Beth Israel had an abstract presented at a national meeting earlier this year which concluded that we no longer had blood available for transfusion in the operating room. This was after 52 robotic prostatectomies. We are now past 150 robotic prostatectomies and have still not transfused a patient.
I still inform patients that a transfusion is possible, and other than several jehovah witnesses that I have operated on, I ask everyone to sign a blood consent. I am sure there will be a day when I feel one of my patients will need a blood transfusion and since the risks of receiving blood would be much less than the risks of the anemia they would have at the time which could lead to heart attacks and life threatening events, I would give the transfusion.
In conclusion, I tell my patients that it has been transfusion-less so far, but there is a small chance that they may need blood. I tell them I wouldn't advise donating their own blood since the counts they start with would likely be a little lower and it is uncomfortable and likely it will not be needed. If they still want to donate blood, I will be happy to help them arrange to have this done.
Evidence based medicine involves a practitioner using the best available clinical studies and their clinical judgement.
There have been several websites that have helped assimilate all the available information and give a conclusion in easy to read format for physicians and patients alike.
The Cochrane Collaboration is an international not-for-profit organisation, providing up-to-date information about the effects of health care.
They have several reviews about prostatic conditions including screening for prostate cancer.
| Currently,
no robust evidence from randomised controlled trials is available
regarding the impact of screening on quality of life, harms of screening,
or its economic value. Results from two ongoing large scale multicentre
randomised controlled trials that will be available in the next several
years are required to make evidence-based decisions regarding prostate
cancer screening. |
This site applies appropriate strict criteria to choose which papers to use. As more clinical trials enter the literature, the conclusions should be more helpful.
My feelings about PSA screening were previously discussed, but as I state in my thoughts, my views are not unanimous.
I recently saw a patient who had been biopsied by another urologist, found to have cancer and sent to a second urologist for evaluation for surgery. That second urologist does not do robotic prostatectomies and did not mention the option. He was also put off by the size of the prostate as estimated by ultrasound at the time of biopsy, 172 cc's. (A normal prostate in a man in his 20s might measure 25 cc's +/- and a volume of 50-100 cc's is not uncommon in men in the age range of 50-70 that constitute the majority of cancer patients being considered for radical surgery.) The second urologist recommended open surgery, but only after at least 4 months treatment with hormone deprivation (blocking the production of testosterone) to shrink the prostate. He gave him a shot to accomplish reduction (leuprolide) and planned to see him back in 4 months. The patient is now experiencing the side effects of the shot, hot flashes and progressive erectile dysfunction, while he waits for his surgery. Is this necessary?
Continue reading "Prostate Size a Limitation for Surgery?" »
I am in the process of putting together a personal website that wil be dedicated to prostate cancer and a resource for my patient's and for urologists visiting the training center.
I have updated my statistics for my davinci prostatectomy patients at www.roboticcancer.com
This is a nice review that goes over different patients stories involving open surgery, seeds, HIFU, external beam radiation, and watchful waiting. I think its a good read for patients that are newly diagnosed as it points out there are many treatment options available.
It leaves out cryosurgery (freezing the prostate) and very importantly robotic surgery, which in my opinion will become the standard (or at least the majority choice for therapy among patients with 10 year life expectancies) in the next several years.
My best advice to newly diagnosed men is to seek out a few opinions, then find the therapy that you are most comfortable with and the hospital and doctor that you feel best with.
An excellent review on the abstracts presented at the AUA was done online at medscape.
It offers 1.5 credits for physicians.
One quote that I thought was interesting was:
These 2 studies taken together indicate that there is a steep learning
curve for laparoscopic prostatectomy, even if the robot is used. It is
probably medicolegally advisable for a urologist who has performed less
than 100 of these cases to inform the patient of this fact. |
I think there is a large variation between surgeons on their learning curve. All surgeons should keep statistics and share them with patients.
I stratify my results by patient number and explain the robotic results to patients.
The important factors are blood loss, hospital stay, surgical margins (marker of cancer control), urinary control, and sexual function.
The only factors that were not as good as open looking at the data retrospectively were surgical times and positive margins. I knew the times would be slower to start, the margins I thought would be as good, but were slightly worse than open.
Blood loss was much less than open on operation 1 and no one has ever had a transfusion.
Hospital stays were better immediately and much better after 25 operations.
Cancer control was as good by operation 26 and better by operation 60.
Urinary control was similar for the first 40 and better after, while getting even better after 80.
Sexual function was slightly better immediately and better after 30, and much better after 60.
This past month 2 patients of mine with prior laparoscopic hernia repairs with mesh had successful dvPs. I have done several of these now and do not get overly concerned with this finding in a patient. One of the patient's was from Florida and was advised against robotic prostatectomy from 2 urologists that performed robotics locally due to his prior hernia surgery. This patient actually had recurrent inguinal hernias that we fixed at the same time of his robotic prostatectomy.
I think the open approach will be much more difficult in patients with prior lap hernias and would advise against open prostate surgery, but I do not feel it is a problem for myself while performing robotics. Operative reports from the original lap hernia operation are helpful. If the lining of the abdomen (peritoneum) is not covered over the mesh, this would make the dvP much harder as bowel would likely be adhered to the mesh. If the lap hernia was done extraperitoneal (this is usually the case) or the peritoneum covers the mesh, it should not be a problem.
Lymph node dissections are much more difficult with prior hernia repairs, especially lap hernias and I performed my first of these for lap hernias this past week and found it to be safe even though the mesh was placed lower than usual and partly covered the vein. I inform patients with prior surgery in this area that I may not be able to remove the lymph nodes if the reaction is too severe and I don't feel its safe. The lymph nodes are more useful for staging and giving the patient their prognosis, but not for helping the cure rate. Fortunately I have always been able to remove the lymph nodes when I wanted to so far.
There is an article from physicians at the Cleveland clinic in the journal of clinical oncology:
Aggressiveness of Familial Prostate Cancer
The important points for men who have a family history of prostate cancer is that the 10 year biochemical relapse-free survival were worse for patients with a family history of prostate cancer before 1992, but since then were similar.
I think that awareness and screening has helped survival in patients that probably have more aggressive forms of prostate cancer.
One point that is debated among urologists is the time a patient has to wait between a prostate biopsy and surgery. While I was at Indiana my chairman taught me that time didn't matter. The changes after a biopsy should not affect surgery after several days.
I took this with me to New Jersey and routinely perform robotic prostatetectomy within 6 weeks of biopsy. I havent had any problems with this and I have done surgery as soon as 2 weeks after biopsy. I would appreciate urologist or patient comments on this topic.
Evidence based medicine affirms my position: Urologists and epidemiologists from the University of Iowa have studied this topic.
Continue reading "I have prostate cancer: Do I have to wait 6 weeks to have my surgery?" »
A normal sized prostate is roughly the size of a walnut. This weights about 20-30 grams. Prostates all have different sizes and shapes. This has important implications for patients with benign prostate problems, as well as patients with cancer. It has an impact on the side effects expected with radiation, the need for hormones prior to certain therapies, as well as the difficulty in removing a prostate.
Continue reading "Prostate size: Not all prostates are created equally" »
Since Dr. Patrick Walsh described the nerve sparing techniques for radical prostatectomy, urologists have been trying to spare the nerves responsible for erections. There is a debate among urologists on who is a good candidate for nerve sparing. Id like to ask urologists their opinion. Please vote on the poll below and add a comment below if you have time.
I would like to thank James Mtume and Bob Pickett for having me on their show today.
We had an excellent discussion with several points that Id like to summarize. I will also be taking questions from their listeners that can be emailed to
dsavatta@njurology.com
The broadcast can be heard on a series of MP3 files archived on my website.
Continue reading "Prostate cancer on The Open Line" »
I have been invited to discuss prostate cancer on The Open Line. The show will air Sunday, May 21, from 11:00 am to noon on 98.7 KISS FM out of NYC. Phone calls will be received.
The Open Line Show has been called by numerous leaders and journalists as “One of the most important talk shows in America. . . Its impact is enormous†and ranked by Talkers Magazine as one of the top 100 Talk Shows in America.
There is a new web-based tool that can help men over the age of 55 calculate their risk of having prostate cancer by biopsy.
Researchers from the University of Texas Health Science Center in San Antonio, the Fred Hutchinson Cancer Research Center in Seattle, the University of Colorado, and the NCI created a statistical model to determine a man's risk of having prostate cancer based on age, race, family history of prostate cancer, PSA level, digital rectal exam result, and previous biopsy results.
I think this is a nice tool for patients and physicians alike.
In the February 2005 issue of UROLOGY, Dr. Miki et al from Kyoto, Japan descibes their initial experience using a running suture anastamosis during minilaparotomy radical retropubic prostatectomy for prostate cancer. They performed this anastamosis in 21 patients, utilizing a 6-cm midline incision. They used the Ethicon Endostitch device and a double-arm absorbable suture, starting at the 6 o'clock position. (similar to the priniciple used in the Van Velthoven anastamosis during robotic prostatectomy). Early continence was excellent among these 21 patients, but the initial 2 patients did develop early bladder neck contractures requiring dilation. Time to perform the anastamosis was 15 minutes on average.
Why post this on a robotic surgery blog? I think this is indicative of the trend in surgery towards minimally-invasive approaches. With the advancement of robotics & laparoscopy, "traditional" open surgeons are feeling compelled to minimize morbidity of their comparable open operations. However, I have issues with this minilaparotomy operation which I feel, erroneously, focuses on open & laparoscopic surgeons' obsession with "incision size".
Continue reading ""Mini-Incision" Radical Prostatectomy?" »
One of the most difficult things that a urologist has to do is to tell his patient that he has cancer. I recently had a somewhat heated debate with my partner in robotic surgery.
Prostate cancer is the leading solid organ cancer in men and is diagnosed by a biopsy in the office. The reasons for a biopsy are given by the urologist when scheduling the procedure and the urologist is present for the biopsy.
I have had discussions with my partners about the two main ways of doing this for prostate cancer and there is a difference in opinion. The two ways are over the phone or face to face.
Continue reading "Telling someone they have prostate cancer" »
The younger the patient, the more years he has to live. Cure rates are extremely important and long term side effects are equally important.
Continue reading "What is your youngest robotic prostatectomy patient?" »
Every now and then I get a really good question from a patient that I have never heard before. I am making a new category on my blog for these type of questions.
A patient of mine who was recently diagnosed with prostate cancer asked me today if his wife could catch prostate cancer. His concern stemmed from the fact that his original presenting symptom was blood in the semen.
Continue reading "Is Prostate Cancer Transmissible?" »
Many patients are undergoing non-surgical therapies of their prostate cancer with curative intent.
These include seeds, external beam radiation, and cryosurgery. What are their alternatives if they fail therapy?
Continue reading "Robotic Prostatectomy after Radiation or Cryosurgery" »
A presentation at the AUA Western section meeting was reviewed in the Urology Times November 2005 issue:
UT article: Smokers face higher risk of TCC after radiation
Patients that have a history of smoking are 13 more likely to get bladder cancer (transitional cell cancer) after radiation as compared to patients who get radiation and have not smoked.
Continue reading "Smokers have increased risk of bladder cancer after radiation therapy for prostate cancer" »
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