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Query: UMLS:C0376358 (prostate cancer)
 59,338 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Prostate cancer recurrence (after prior local treatment) that is detectable only by a rise in serum prostate specific antigen (PSA) level is a very common problem facing clinicians. Given that the majority of contemporary era men with PSA-only or biochemical recurrence are relatively young and otherwise healthy, treatment requires approaches that both improve clinical outcomes and preserve quality of life. Treatment is in one of two broad categories, additional local therapies, termed "salvage" local therapy and systemic therapies. For radical prostatectomy patients, salvage external beam radiotherapy to the prostate bed is commonly employed, being reserved for early biochemical recurrence in men with low risk at distant metastases. For primary radiation patients, salvage radical prostatectomy or cryotherapy can similarly be used for those men felt not to harbor distant metastases. Systemic therapy generally involves hormonal therapy. Traditional hormonal therapy (orchiectomy, luteinizing hormone-releasing hormone agonists or maximum androgen blockade) is the current mainstay of systemic treatment for biochemical recurrence, although non-traditional approaches, such as antiandrogen monotherapy, are increasingly being used. There is a critical need for new pharmaceutical agents to treat this growing stage of prostate cancer. However, it has been difficult to demonstrate efficacy due to the long natural history until death and the survival endpoint currently required by the U.S. Food and Drug Administration. New data show that PSA Doubling time (PSA-DT) during PSA recurrence may be a valid surrogate for death from the disease and may be used to accelerate drug approval. This monograph will attempt to provide a complete balanced discussion of the evaluation and treatment of biochemical recurrence of prostate cancer after prior primary local therapy.
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PMID:Treatment of PSA only recurrence of prostate cancer after prior local therapy. 1651 95

The survival benefit demonstrated by docetaxel-based therapy in two randomized trials, Southwest Oncology Group (SWOG) 99-16 and TAX 327, has changed the perception of chemotherapy in men with hormone-refractory prostate cancer from nihilism to optimism. These survival improvements are of similar magnitude to those found in trials that established chemotherapeutic regimens for metastatic breast, lung, or colorectal cancer. The timing of chemotherapy in the aforementioned solid tumors is much more clearly defined than in men with metastatic prostate cancer. Traditionally, chemotherapy in men with hormone-resistant prostate cancer was reserved for symptomatic patients only; the inclusion of symptomatic and asymptomatic patients in SWOG 99-16 and TAX 327 has raised several questions regarding the optimal use of chemotherapy in these patients. When is the best time to initiate docetaxel-based chemotherapy? Is it appropriate to use chemotherapy in high-risk patients as adjuvant therapy? Although retrospective analysis of current trials may provide hypothesis, only properly designed randomized clinical trials will answer these questions.
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PMID:Cytotoxic chemotherapy for prostate cancer: Who and when? 1690 54

The major goal for prostate cancer imaging in the next decade is more accurate disease characterization through the synthesis of anatomic, functional, and molecular imaging information. No consensus exists regarding the use of imaging for evaluating primary prostate cancers. Ultrasonography is mainly used for biopsy guidance and brachytherapy seed placement. Endorectal magnetic resonance (MR) imaging is helpful for evaluating local tumor extent, and MR spectroscopic imaging can improve this evaluation while providing information about tumor aggressiveness. MR imaging with superparamagnetic nanoparticles has high sensitivity and specificity in depicting lymph node metastases, but guidelines have not yet been developed for its use, which remains restricted to the research setting. Computed tomography (CT) is reserved for the evaluation of advanced disease. The use of combined positron emission tomography/CT is limited in the assessment of primary disease but is gaining acceptance in prostate cancer treatment follow-up. Evidence-based guidelines for the use of imaging in assessing the risk of distant spread of prostate cancer are available. Radionuclide bone scanning and CT supplement clinical and biochemical evaluation (prostate-specific antigen [PSA], prostatic acid phosphate) for suspected metastasis to bones and lymph nodes. Guidelines for the use of bone scanning (in patients with PSA level > 10 ng/mL) and CT (in patients with PSA level > 20 ng/mL) have been published and are in clinical use. Nevertheless, changes in practice patterns have been slow. This review presents a multidisciplinary perspective on the optimal role of modern imaging in prostate cancer detection, staging, treatment planning, and follow-up.
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PMID:Imaging prostate cancer: a multidisciplinary perspective. 1739 47

Focal treatment for prostate cancer is highly intriguing, but poorly supported by the published literature. Further studies, preferably randomized controlled trials, are needed before this can be considered standard therapy. Focal treatment should be reserved for patients with focal disease. Even "clinically insignificant" synchronous tumors are malignant, and carry risk of progression if not treated with the index lesion. Whether these are likely to progress in this setting compared to those managed with active surveillance is unknown. The limited data regarding subtotal or focal cryotherapy suggest that patients properly evaluated for presence of satellite tumors have a low risk of having large unknown satellite tumors. The author requires office-based saturation biopsy prior to considering focal cryotherapy. Observation of prostatic intraepithelial neoplasia (PIN), atypical findings (ASAP), or cancer on the contralateral biopsy cores excludes the patient from consideration of subtotal therapy. MRI offers a potential additional ability to detect occult contralateral tumors. Younger men paradoxically seem to have greater interest in focal therapy while having a higher risk of future malignancy in the untreated areas based on the years of potential risk. However, no age cutoff is established. Without published data to support its use, lumpectomy or freezing only the focus where cancer is believed to exist, will remain limited. Hemispheric or subtotal treatment decreases the amount of untreated tissue. As a result, the local failure rate would be predicted to be lower but is unknown. When performing subtotal treatment, the author freezes almost the entire gland, sparing only the aspect adjacent to the contralateral neurovascular bundle, and has found this practice to be of highly limited utility based on the issues described. Biopsy should be performed following any treatment that fails to target the entire gland. A positive biopsy should be dealt with based on clinical factors as if the patient had not been treated, and a positive biopsy should not preclude active surveillance if deemed appropriate.
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PMID:Focal or subtotal therapy for early stage prostate cancer. 1770 Nov 10

Transrectal ultrasound-guided systemic biopsy is the recommended method in most cases with suspicion of prostate cancer. Transrectal periprostatic injection with a local anesthetic may be offered as effective analgesia; periprostatic nerve block with 1% or 2% lidocaine is the recommended form of pain control. On initial biopsy, a minimum of 10 systemic, laterally directed cores is recommended, with more cores in larger glands. Extended prostate biopsy schemes, which require cores weighted more laterally at the base (lateral horn) and medially to the apex, show better cancer detection rates without increasing adverse events. Transition zone biopsies are not recommended in the first set of biopsies, owing to low detection rates. One set of repeat biopsies is warranted in cases with persistent indication. Saturation biopsy (>/=20 cores) should be reserved for repeat biopsy in patients who have negative results on initial biopsy but who are still strongly suspected to have prostate cancer.
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PMID:Using biopsy to detect prostate cancer. 1914 70

The National Institutes of Health (NIH) has redefined prostatitis into four distinct entities. Category I is acute bacterial prostatitis. It is an acute prostatic infection with a uropathogen, often with systemic symptoms of fever, chills and hypotension. The treatment hinges on antimicrobials and drainage of the bladder because the inflamed prostate may block urinary flow. Category II prostatitis is called chronic bacterial prostatitis. It is characterized by recurrent episodes of documented urinary tract infections with the same uropathogen and causes pelvic pain, urinary symptoms and ejaculatory pain. It is diagnosed by means of localization cultures that are 90% accurate in localizing the source of recurrent infections within the lower urinary tract. Asymptomatic inflammatory prostatitis comprises NIH category IV. This entity is, by definition, asymptomatic and is often diagnosed incidentally during the evaluation of infertility or prostate cancer. The clinical significance of category IV prostatitis is unknown and it is often left untreated. Category III prostatitis is called chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). It is characterized by pelvic pain for more than 3 of the previous 6 months, urinary symptoms and painful ejaculation, without documented urinary tract infections from uropathogens. The syndrome can be devastating, affecting 10-15% of the male population, and results in nearly 2 million outpatient visits each year. The aetiology of CP/CPPS is poorly understood, but may be the result of an infectious or inflammatory initiator that results in neurological injury and eventually results in pelvic floor dysfunction in the form of increased pelvic muscle tone. The diagnosis relies on separating this entity from chronic bacterial prostatitis. If there is no history of documented urinary tract infections with a urinary tract pathogen, then cultures should be taken when patients are symptomatic. Prostatic localization cultures, called the Meares-Stamey 4 glass test, would identify the prostate as the source for a urinary tract infection in chronic bacterial prostatitis. If there is no infection, then the patient is likely to have CP/CPPS. For healthcare providers, the focus of therapy is symptomatic relief. The first therapeutic measure is often a 4- to 6-week course of a fluoroquinolone, which provides relief in 50% of men and is more efficacious if prescribed soon after symptoms begin. Second-line pharmacotherapy involves anti-inflammatory agents for pain symptoms and alpha-adrenergic receptor antagonists (alpha-blockers) for urinary symptoms. Potentially more effective is pelvic floor training/biofeedback, but randomized controlled trials are needed to confirm this. Third-line agents include 5alpha-reductase inhibitors, glycosaminoglycans, quercetin, cernilton (CN-009) and saw palmetto. For treatment refractory patients, surgical interventions can be offered. Transurethral microwave therapy to ablate prostatic tissue has shown some promise. The treatment algorithm provided in this review involves a 4- to 6-week course of antibacterials, which may be repeated if the initial course provides relief. Pain and urinary symptoms can be ameliorated with anti-inflammatories and alpha-blockers. If the relief is not significant, then patients should be referred for biofeedback. Minimally invasive surgical options should be reserved for treatment-refractory patients.
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PMID:Chronic prostatitis: management strategies. 1919 37

Prostate cancer is a disease typical of the elderly with a peak of incidence at 80 years. As most patients aged > or = 70 years show impairment of physical and/or cognitive performance, a complete geriatric assessment should be mandatory before planning any oncological treatment, in order to remove treatable conditions and to estimate the individual cancer-independent survival probability. In unfit patients with early prostate cancer watchful waiting represent the best strategy when the chance of living <10 years and the benefit from any upfront active treatment would be poor. Radiotherapy should be sometimes offered to vulnerable patients having high risk prostate cancer. Even in locally advanced prostate cancer active treatment could be deferred in asymptomatic patients, with short individual cancer-independent survival and well or moderately differentiated tumour. When hormonal deprivation therapy is administered a great attention should be paid to potential adverse events, that could precipitate the physical performance and accelerate the development of severe frailty. In the metastatic setting, the best supportive care, including bisphosphonates, should have the priority in the management of unfit patients. Chemotherapy, with Docetaxel as the standard regimen, should be reserved to patients showing diffuse symptoms, rapidly increasing PSA and/or presence of visceral metastasis, after all steps of endocrine therapy were covered. As regard the second line, a number of possibilities are available, but none have been tested in vulnerable and frail patients. At the present a number of issues about prostate cancer in unfit senior adults patients are still unsolved and should be debated in the light of results from dedicate prospective trials.
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PMID:Treatment of prostate cancer in unfit senior adult patients. 1948 81

Vertebral augmentation procedures are currently widely performed to treat vertebral compression fractures. The purpose of this study was to determine the frequency of underlying previously unrecognized etiology in a consecutive series of patients undergoing kyphoplasty to treat vertebral compression fractures. A prospective histological evaluation of vertebral body biopsy specimens from presumed osteoporotic vertebral compression fractures were performed in order to identify aforementioned causes. Over a 2-year period, vertebral body biopsies from 154 vertebral levels were performed in 75 patients undergoing kyphoplasty for vertebral compression fractures. All patients received a preoperative workup that included plain radiographs, MRI, whole body bone scan, and laboratory examinations. Bone specimens were obtained from affected vertebral bodies and submitted for histologic evaluation to identify the prevalence of an underlying cause. All specimens demonstrated fragmented bone with variable amounts of unmineralised bone, signs of bone-remodeling and/or fracture-healing. In 11 patients underlying pathology other than osteoporosis was identified (prostate cancer, 1; pancreatic cancer, 1; colon cancer, 1; breast cancer, 2; multiple myeloma, 3; leukemia, 1; and lung cancer, 2). In all but one patient the results of the biopsy confirmed the diagnosis suspected from the preoperative workup. For the last patient, namely the one with pancreatic cancer, the workup did not identify the origin of the primary tumor, although the patient was considered to have a compression fracture secondary to metastatic disease of unknown origin, the vertebral biopsy suggested the presence of adenocarcinoma which eventually was proven to be pancreatic cancer. In augmentation procedures for vertebral compression fractures, bone biopsy should be reserved for the patients where the preoperative evaluation raises the suspicion of a non-osteoporotic etiology.
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PMID:Routine needle biopsy during vertebral augmentation procedures. Is it necessary? 2037 42

Therapeutic Education (TE) means to build a partnership between doctors and patients comparing knowledge and therapeutic procedures to manage the disease and its treatment. Patients cannot be a mere passive beneficiary of therapeutic services, but they must play an active role, be conscious and participate in charging proper and community health. Patient TE is a pathway characterized by an "educational diagnosis" including identification of patient demands about pathology; an "educational-therapeutic policy" based on assignment of tasks and rules to manage every aspect of pathology; and the "evaluation" of results of patients' educational process. The aim of TE is to allow the patients to know their pathology, to properly perform therapeutic procedures, to self-manage and prevent complications and to adopt a correct lifestyle. It can be useful to organize theoretical and practical lessons reserved to groups of patients. TE can be applied to urologic pathologies. These pathologies are often chronic diseases and affect elderly patients, who are organically and psychologically fragile. Urologic patients must often manage urostomies, urinary drains, complex follow-up plans. The patients' learning about procedures and disease management represents a professional duty of the urologic team: bladder and prostate cancer, urinary drains management are fields where we can apply a TE plan to support and safeguard the patients' health.
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PMID:[Therapeutic education in urology: a fundamental resource for the sick and the health carers]. 2108 49

Prostate-specific antigen (PSA) is a protein produced by the prostate, and this protein may be elevated for several reasons, including prostatitis, benign prostatic hypertrophy and/or cancer. PSA is not cancer-specific, cannot be used as a cancer marker and it has been demonstrated that there is no level of PSA that is definitive for prostate cancer. The value of the PSA test varies when used for screening, diagnosis, prognosis or as a signal of disease recurrence. Misuse of the test for screening has created unnecessary anxiety and costs, and has led to the significant overdiagnosis and overtreatment of men. More important than whether or not to screen is how one acts upon the data from a single test; with the exception of extremely high double- or triple-digit levels of PSA, it is prudent only to use a single PSA determination as a baseline, with biopsy and cancer treatment reserved for those with significant PSA changes over time, or for those with clinical manifestations mandating immediate therapy. Using the PSA test to monitor disease progression or recurrence is appropriate, provided one understands that absolute levels of PSA are rarely meaningful; it is the relative change in PSA levels over time that provides insight, but not definitive proof of a cancerous condition necessitating therapy. PSA secretion is under hormonal control and thus PSA levels may be affected differently by the type of drug therapy, by the stage of a patients' disease, and by genetic factors suggesting some men are 'high PSA producers'. Until a validated alternative test for prostate cancer is found and adopted, the current flawed PSA test needs to be used more judiciously and not used for routine screening as studies have demonstrated that screening, as defined, does not lead to a reduction in patient mortality. All men, their families and their physicians need to understand the significant limitations of PSA testing.
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PMID:Prostate-specific antigen testing across the spectrum of prostate cancer. 2186 72


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