THE "NEW" PROSTATE CANCER INFOLINK

Today’s prostate cancer news reports address articles on:

• The role of MRI in prostate cancer diagnosis
• The accuracy of different types of MR imaging
• Removal of the seminal vesicles in surgical treatment of low-risk disease
• Current treatment strategies for advanced prostate cancer

Ahmed et al. propose  increased use of MRI, not only in those with a diagnosis of prostate cancer but also for men before a prostate biopsy. They argue that use of MRI before a biopsy can triage men with raised PSA levels, to select for biopsy those with significant cancer that requires treatment. They also state that this approach could improve risk stratification by selecting those who require adjuvant therapy or dose escalation, and that MRI evaluation of cancer burden could be important in active surveillance regimens to select those needing intervention. While The “New” Prostate Cancer InfoLink does not disagree with this argument in theory, from a practical point of view the cost is almost certainly prohibitive. It would add billions of dollars a year to the US health-care budget.

Weinreb et al. have reported the results of an American College of Radiology Imaging Network (ACRIN)-coordinated, prospective, multi-center study, conducted between February 2004 and June 2005,  and designed to determine the incremental benefit of combined endorectal magnetic resonance (MR) imaging and MR spectroscopic imaging, as compared with endorectal MR imaging alone, for sextant localization of peripheral zone (PZ) prostate cancer. The trial enrolled 134 men with biopsy-proved prostate adenocarcinoma who were  scheduled to undergo radical prostatectomy at seven institutions. T1-weighted, T2-weighted, and spectroscopic MR sequences were performed at 1.5 T by using a pelvic phased-array coil in combination with an endorectal coil. Complete data were available for 110 patients (mean age, 58 years; range, 45-72 years). The results showed that, in patients who undergo radical prostatectomy, the accuracy of combined 1.5-T endorectal MR imaging-MR spectroscopic imaging for sextant localization of peripheral zone prostate cancer is equal to that of MR imaging alone.

Gofrit et al. have reported data suggesting that surgical excision of the seminal vesicles is of minimal value and may cause undue harm in > 99 percent of radical prostatectomies on men with a biopsy Gleason score of ≤ 6 and other low-risk indicators. They note that dissection of the seminal vesicles can damage the pelvic plexus, compromise trigonal, bladder neck, and cavernosal innervation, and contribute to delayed gain of continence and erectile function. They evaluated data from 1,003 patients (mean age, 59.7 years) with prostate cancer who underwent robot-assisted laparoscopic prostatectomy between February 2003 and July 2007. Seminal vesicle invasion (SVI) was found in just 46 patients (4.6 percent) overall. Biopsy Gleason score, preoperative PSA, clinical  stage, percentage of positive cores, and maximal percentage of cancer in a core all had a significant impact on the risk for SVI. However, only 4/634 patients (0.6 percent) with a biopsy Gleason score of ≤ 6 suffered from SVI, as opposed to 42/369 patients (11.4 percent) with higher Gleason scores. The other question that needs to be addressed, if we are to really be honest, is the percentage of those 1,003 patients that actually needed treatment at all.

Friedlander and Ryan have reviewed current strategies to slow initial and castration-resistant tumor growth through the use of hormonal agents such as LHRH analogs, antiandrogens, and adrenolytic agents, focusing on defining the optimal timing, combinations, and use of these agents, as well as on novel drug development.

Filed under: Diagnosis, Management, Risk, Treatment | Tagged: advanced, low risk, magnetic resonance imaging, MRI, seminal vesicles, surgery