The significance of palliative surgery in castration-resistant prostate cancer

If prostate cancer recurs after primary treatment, deprivation therapy with LHRH analogues or antagonists is the treatment of choice in men with metastatic prostate cancer. However, this treatment only achieves palliative results. Median time to progression ranges between 11 and 78 months. After the introduction of Docetaxel as a first-line treatment in castration-resistant prostate cancer (CRPCA) and cabazitaxel as a second-line chemotherapy, several new drugs containing abiraterone, enzalutamide, radium 223 and sipuleucel-T have become available, which can lead to complete or partial remissions in metastasis, but do not have an effect on the prostate itself as has been shown recently. As a result of local progression of CRPCA, local complications of the urinary tract such as subvesical obstruction, recurrent gross haematuria with or without clotting, upper urinary tract dilatation, rectourethral or rectovesical fistulae and rectal obstruction will occur in about one third of all patients. Several surgical treatment options are available to manage the aforementioned complications. In patients with local progressive CRPCA and lower urinary tract symptoms, palliative TUR-P, radical prostatectomy or radical cystoprostatectomy with urinary diversion and even anterior and posterior exenteration can be performed in selected patients, requiring a preoperative multiparametric MRI of the prostate and the pelvic floor along with a laboratory examination to optimise surgical techniques and perioperative outcomes. In case of symptomatic involvement of the upper urinary tract system, the placement of endoluminal DJ stents or percutaneous nephrostomy in men with a poor performance status and a short life expectancy is the treatment of choice. In men with an ECOG performance status of 0 to 1, reconstructive surgery such as ureteral reimplantation, ileal ureteral replacement or placement of a subcutaneous pyelovesical bypass is an appropriate treatment option. To summarise, the aforementioned palliative surgical treatment options should be provided for selected patients and performed by well-experienced urologists

Prostate cancer: surgical complications

Radical prostatectomy (RP), performed as an open, laparoscopic or robotic procedure, remains the gold standard for patients with localised prostate cancer who can be cured with surgery and have a life expectancy of at least 10 years. Today, RP is also used as a first-line treatment for locally advanced prostate cancer, possibly in a multimodal setting with adjuvant radiation/hormonal therapy. The increasing experience of surgeons, better knowledge of anatomy and refinements of surgical techniques have greatly improved oncological and functional outcomes. In our article we would like to give an overview of the complications associated with this surgical procedure

Testis-Sparing Surgery in Patients with Germ Cell Cancer: Indications and Clinical Outcome

Testicular cancer affects mainly young men between 20 and 30 years of age. Due to the availability of effective chemotherapy, the majority of patients are cured. Despite an increased risk of metachronous testicular cancer, it should be carefully considered whether immediate orchiectomy is indicated. This mini review gives an account of the available literature on testis-sparing surgery in patients with unilateral or bilateral synchronous or metachronous testicular cancer. (c) 2018 S. Karger GmbH, Freibur

Metastatic surgery in testis cancer

Purpose of review In testis cancer, prognosis is excellent even in metastatic disease. Treatment and timing of patients with multiple metastatic deposits can be challenging. This review was performed to underline the current guideline recommendations. Recent findings Depending on the primary histology, the indication of further surgical resections differ. In seminoma, residual tumor resections are performed according to the results of a flouoro-deoxy-D-glucose-PET. Positive results must be considered critically, and to recent results it is advisable to first repeat flouoro-deoxy-D-glucose-PET to avoid overtreatment. In nonseminomatous germ cell cancer, complete remissions in good prognosis patients are followed and can be spared from surgery. All other patients still need to undergo postchemotherapy retroperitoneal lymph node dissection. In bone metastases, significant histology is found in 80% so that one should go for complete resection. In liver metastases, resections can be performed according to the histology in the retroperitoneum. Both resections, including vessel replacement, are usually performed in one session underlining the complex multidisciplinary approach. Pulmonal metastases, at least in one lobe, need to be resected. Brain metastases are rare with no standard treatment recommendation. Summary Every patient should be presented in a multidisciplinary tumor board. Surgical interventions should be done in tertiary referral centers to achieve the best oncologic outcome and reduced morbidity

Cell-free DNA as a surrogate marker in patients with CRPCA undergoing taxane-based chemotherapy.

e584 Background: Taxane-based chemotherapy is one of the first-line life prolonging therapeutic approaches in metastatic castration-resistant prostate cancer (mCRPCA). Until now, there is no valid surrogate marker directly reflecting therapeutic response. Prostate specific antigen (PSA) and imaging studies are used to monitor therapy. The aim of this study was to assess whether circulating cell-free DNA (cfDNA) is suitable as a predictive and prognostic marker. Methods: cfDNA was isolated in 74 patients with mCRPCA receiving taxane based chemotherapy. Median serum cfDNA - concentration was correlated with localization of metastasis and tumor burden (bone, lymph node and visceral). In addition we examined the change of cfDNA - concentration under treatment. The median serum cfDNA - concentration at the time of 1st, 5th and 10th cycle of chemotherapy was correlated with PSA response (&gt;80%, &gt;50%, &lt;30% decrease). Results: We identified 21 patients with a PSA decrease &gt;80%, 41 patients with a PSA decrease &gt;50%, 12 patients with a PSA decrease &lt;30 % and 15 patients with a PSA rise during treatment. Median cfDNA concentration in patients with a PSA decrease of &gt;80% was 34.96 ng/ml, in patients with a PSA decrease &gt; 50% 34.96 ng/ml and in patients with a PSA decrease &lt; 30% 38.475 ng/ml. The Median cfDNA concentration in patients with a PSA rise was 31.25 ng/ml. Median cfDNA concentration in patients with lymph node metastasis was 33.78 ng/ml, with bone metastasis &lt; 3 34.24 ng/ml, bone metastasis &gt;3 31.97 ng/ml and with visceral metastasis 34.57 ng/ml. There was no significant correlation between median cfDNA - concentration and type of metastasis (cfDNA vs. PSA bone metastasis &lt;3, P = 0,56938, cfDNA vs. PSA bone metastasis &gt;3 P = 0.472, cfDNA vs. PSA lymph node metastasis P = 0.423). There was no significant change of median cfDNA concentration under treatment ( P &gt; 0.05). Conclusions: Although cfDNA-concentration is a prognostic and predictive marker for survival and therapy response as shown recently, our findings suggest that cfDNA as a surrogate marker is unsuitable. </jats:p

Antiangiogenic therapies in urogenital malignancies

The use of antiangiogenic agents in cancer therapy has become an attractive target in oncological research. However, concerning the uro-oncological field, current guidelines only recommend the use of antiangiogenic agents in metastatic renal cell cancer. Yet in recent years, several approaches for sequential treatment with angiogenesis inhibitors in other urogenital malignancies apart from renal cell cancer are ongoing. Thus, the present review article aims to provide an overview about clinical studies with antiangiogenic agents in prostate-, bladder-, testicular-, as well as penile cancer patients. For this, a literature search was conducted using Medline; moreover we performed a systematic review of data presented at this year's important urooncological meetings. Preliminary data revealed that there are several promising studies ongoing in prostate-, bladder-, testicular-, as well as penile cancer; however, larger studies should be conducted to optimize the use of antiangiogenic agents in clinical practice

Personalised medicine in prostate cancer

Prostate cancer is the most common cancer in men. Its incidence increases with age. New treatment options have been introduced and there is a clear trend to more aggressive treatment in newly diagnosed metastatic disease. While prolonged survival of patients has been achieved, the new expensive drugs are associated with an increased burden on the healthcare system. Meanwhile, similarly to other tumour entities, there is a pool of different drugs available with comparable oncologic efficacy, but different side-effects. Effective diagnostic investigation and treatment decisions require additional factors, above and beyond clinical parameters, for a more individual treatment approach. In castration-resistant prostate cancer (CRPCA), there are promising molecular markers for treatment decisions. In metastatic disease, liquid biopsies and next generation sequencing of metastatic biopsies allow for genetic analysis. These will provide more insight into tumour dynamics and allow for patient selection. This review concentrates on molecular markers in CRPCA