Prostate Cancer and COVID-19

Liječenja raka prostate tijekom pandemije COVID-19 pretrpjelo je, kao i u slučaju drugih bolesti, značajne promjene. Jedinstvenost ovih promjena ogleda se u činjenici da je pogođen čitav svijet i da su se zdravstveni sustavi, pa tako i briga za onkološke bolesnike, morali prilagoditi novonastaloj situaciji. Dostupnost zdravstvenih ustanova, liječnika i drugog zdravstvenog osoblja kao i mogućnost provođenja liječenja varirali su u čitavom svijetu ovisno o epidemiološkoj situaciji. U samom početku pandemije svi zahvati, osim najhitnijih, bili su odgođeni zbog prihvata i zbrinjavanja bolesnika s COVID-19. Taj je period pandemije za dio bolesnika obilježila odgoda liječenja raka prostate, poglavito kirurškog, čime je stvoreno veliko psihološko opterećenje i za bolesnike i za liječnike. U zemljama koje su pandemiju stavile pod kontrolu postupno popuštanje protuepidemijskih javnozdravstvenih mjera rezultiralo je normalizacijom zdravstvene skrbi i nastavkom redovitog liječenja onkoloških bolesnika.Prostate cancer treatment during the COVID-19 pandemic underwent, as was the case with other diseases, significant changes. The uniqueness of this situation is reflected in the fact that the whole world has been affected and that healthcare systems, including care for cancer patients, was forced to adapt to the new situation. The availability of facilities, physicians, and other healthcare personnel, including the possibility of conducting treatment, varied around the world depending on the epidemiological situation. At the very beginning of the pandemic, all interventions, except the most urgent ones, were postponed to make room for the reception and care of patients with COVID-19. This period of the pandemic was marked by a delay in the treatment of prostate cancer, especially surgery, for the majority of patients, and became a great psychological burden for both patients and doctors. In countries that have brought the pandemic under control, the gradual easing of anti-epidemic public health measures has resulted in the normalization of healthcare and continuation of regular treatment of cancer patients

Niskorizični rak prostate: aktivno liječenje ili aktivni nadzor?

The widely used screening for prostate cancer with prostate specific antigen has resulted in identification of potentially lethal prostate cancers at a much more curable stage and has been associated with significant falls in prostate cancer mortality. In spite of the fact that prostate cancer is one of the deadliest malignancies in men, the advent of sensitive diagnostic testing has also resulted in detection of low risk cancers due to the high incidence of latent prostate cancer in aging men and prolonged natural history of the disease. This, in turn, has entailed the problem of cancer overdiagnosis and subsequent overtreatment. Approximately 6 times as many men will be diagnosed with the disease as will die from it. Active surveillance appeared as a response to the clearly documented risks of overdiagnosis and overtreatment of low risk prostate cancer for localized prostate cancer. It entails initial expectant management rather than immediate therapy, with ‘curative-intent’ treatment deferred until there is evidence that the patient is at an increased risk of disease progression. This approach attempts to balance the risks and side effects of overtreatment against the possibility of disease progression and lost opportunity for cure. A systematic literature review brings current knowledge on the subject.Široka uporaba za prostatu specifičnog antigena (PSA) rezultirala je otkrivanjem potencijalno smrtonosnih karcinoma prostate u nižem, lječivom stadiju te je povezana sa značajnim padom smrtnosti od raka prostate. Unatoč činjenici da je rak prostate jedna od najsmrtonosnijih malignih bolesti u muškaraca, pojava osjetljivih dijagnostičkih testova također je rezultirala otkrivanjem karcinoma niskog rizika zbog visoke učestalosti latentnog raka prostate u muškaraca starije dobi i dugog prirodnog tijeka bolesti. Dakle, pojavio se i problem pretjeranog dijagnosticiranja indolentne bolesti i posljedičnog suvišnog liječenja. Kod šest puta više ljudi će biti dijagnosticirana bolest nego što će ih umrijeti od nje. Aktivni nadzor pojavio se kao odgovor na jasno dokumentirani rizik pretjerane dijagnoze i pretjeranog liječenja kod lokaliziranog raka prostate niskog rizika. To podrazumijeva početno praćenje s odgodom “pristupa s namjerom liječenja” dok se ne pojave dokazi povećanog rizika za progresiju bolesti. Ovaj pristup pokušava uravnotežiti rizike i nuspojave pretjeranog liječenja u odnosu na mogućnost napredovanja bolesti i izgubljenu priliku za liječenje. Sustavni pregled literature donosi današnje spoznaje o ovoj temi

Prostate Cancer and COVID-19

Liječenja raka prostate tijekom pandemije COVID-19 pretrpjelo je, kao i u slučaju drugih bolesti, značajne promjene. Jedinstvenost ovih promjena ogleda se u činjenici da je pogođen čitav svijet i da su se zdravstveni sustavi, pa tako i briga za onkološke bolesnike, morali prilagoditi novonastaloj situaciji. Dostupnost zdravstvenih ustanova, liječnika i drugog zdravstvenog osoblja kao i mogućnost provođenja liječenja varirali su u čitavom svijetu ovisno o epidemiološkoj situaciji. U samom početku pandemije svi zahvati, osim najhitnijih, bili su odgođeni zbog prihvata i zbrinjavanja bolesnika s COVID-19. Taj je period pandemije za dio bolesnika obilježila odgoda liječenja raka prostate, poglavito kirurškog, čime je stvoreno veliko psihološko opterećenje i za bolesnike i za liječnike. U zemljama koje su pandemiju stavile pod kontrolu postupno popuštanje protuepidemijskih javnozdravstvenih mjera rezultiralo je normalizacijom zdravstvene skrbi i nastavkom redovitog liječenja onkoloških bolesnika.Prostate cancer treatment during the COVID-19 pandemic underwent, as was the case with other diseases, significant changes. The uniqueness of this situation is reflected in the fact that the whole world has been affected and that healthcare systems, including care for cancer patients, was forced to adapt to the new situation. The availability of facilities, physicians, and other healthcare personnel, including the possibility of conducting treatment, varied around the world depending on the epidemiological situation. At the very beginning of the pandemic, all interventions, except the most urgent ones, were postponed to make room for the reception and care of patients with COVID-19. This period of the pandemic was marked by a delay in the treatment of prostate cancer, especially surgery, for the majority of patients, and became a great psychological burden for both patients and doctors. In countries that have brought the pandemic under control, the gradual easing of anti-epidemic public health measures has resulted in the normalization of healthcare and continuation of regular treatment of cancer patients

Does Prostate Specific Antigen (PSA) Screening Reduce Prostate Cancer Mortality?

Unatoč činjenici da je rak prostate jedna od najsmrtonosnijih malignih bolesti muškaraca učinak testiranja muškaraca putem antigena specifičnog za prostatu (PSA) na smrtnost od raka prostate je dvojben. Europska randomizirana studija probira za karcinom prostate (ERSPC) pokazala je redukciju smrtnosti specifične za karcinom za 27% nakon 13 godina praćenja u korist probira. Nasuprot tomu američka studija US Prostate, Lung, Colorectal, and Ovarian cancer screening trial (PLCO) nije pokazala redukciju mortaliteta u skupini podvrgnutoj probiru. Neovisno o učinku na smrtnost, povoljni rezultati probira raka prostate uključuju veći broj bolesnika s lokaliziranom bolešću i povećanje broja dobro diferenciranih tumora. Međutim, rizik od pretjeranog dijagnosticiranja indolentne bolesti i posljedičnoga pretjeranog liječenja te njegova utjecaja na kvalitetu života argumenti su protiv probira. Suvremene spoznaje nalažu preispitivanje dosadašnjih preporuka uporabe PSA.In spite of the fact that prostate cancer is one of the deadliest malignancies in men, the effect of prostate-specific antigen (PSA) screening on prostate cancer mortality remains debated. The European Randomized Study of Screening for Prostate Cancer (ERSPC) demonstrated a statistically significant 27% decrease in prostate cancer-specific mortality after 13 years of follow-up in screened vs. Unscreened men. In contrast, the prostate arm of the US Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) found no benefit from screening. Irrespective of mortality impact, favourable results from prostate cancer screening include an increasing number of men with localised disease and an increase in the number of well-differentiated tumours. However, the risk of overdiagnosis and subsequent overtreatment, including its effects on the quality of life, offers arguments against screening. The present knowledge requires a review of the previous recommendations on the use of PSA

Početna iskustva u usporedbi CT-vođene radiofrekventne i mikrovalne ablacije u terapiji karcinoma bubrega

Percutaneous ablative techniques under imaging guidance have become a frequently used treatment method in the therapy of primary T1a or secondary renal tumours, especially in patients who were burdened with comorbidities and are not surgical candidates. Radiofrequency ablation with single or multiple electrodes has been the primary ablative technique used and the mainstay of percutaneous therapy for a long time but with the evolution of technologies, microwave ablation and cryoablation have emerged as possibly more effective methods of treatment. After the initial experience with CT-guided radiofrequency ablation for renal carcinoma treatment in 6 patients, we started using microwave ablation with the following 6 patients. Our results showed microwave ablation to have bett er results in achieving complete tumour ablation, while requiring shorter hospitalization time and better patient satisfaction. There have not been any major complications, while minor complications were more frequent with microwave ablation. Due to shorter procedure time patients treated with microwave ablation, we no longer used general anaesthesia but only local anaesthetic with conscious sedation.Perkutane ablativne tehnike pod kontrolom slikovnih metoda su postale često korištena metoda u terapiji primarnih tumora bubrega T1a stadija ili sekundarnih bubrežnih tumora, ponajprije kod pacijenata koji zbog komorbiditeta nisu primarno kirurški kandidati. Radiofrekventna ablacija s jednom ili više elektroda je bila prva korištena ablativna metoda i dugo vremena glavna okosnica perkutane terapije, no s razvojem novih tehnologija, mikrovalna ablacija i krioablacija su se pojavile kao potencijalno učinkovitije opcije liječenja. Nakon početnih iskustava s CT-vođenom radiofrekventnom ablacijom karcinoma bubrega kod šest pacijenata, započeli smo koristiti mikrovalnu ablaciju kod idućih šest pacijenata. Naši rezultati su pokazali da s mikrovalnom ablacijom postižemo bolje rezultate u smislu potpune ablacije tumora uz kraće potrebno vrijeme hospitalizacije i veću razinu zadovoljstva pacijenata nakon zahvata. Nisu zabilježene veće komplikacije, dok su manje komplikacije bile učestalije nakon mikrovalne ablacije. Pacijenti tretirani mikrovalnom ablacijom nisu zahtijevali opću anesteziju zbog kraćeg vremena ablacije

Biopsy quantitative patohistology and seral values of prostate specific antigen-alpha (1) antichymotrypsine complex in prediction of adverse pathology findings after radical prostatectomy

In this prospective study we examined the utility of parameters obtained on prostate needle biopsy and prostate specific antigen-alpha(1)-antichymotripsine complex (PSA-ACT) to predict adverse pathologic findings after radical prostatectomy. 45 consecutive patients assigned for radical prostatectomy due to clinically localized prostate cancer were included in the study. Prostate biopsy parameters such as number of positive cores, the greatest percentage of tumor in the positive cores, Gleason score, perineural invasion, unilaterality or bilaterality of the tumor were recorded. PSA-ACT was determined using sandwich immunoassay chemiluminiscent method (Bayer, Tarrytown, New York). We analyzed relationship of preoperative PSA, PSA-ACT and quantitative biopsy parameters with final pathology after prostatectomy. Adverse findings were considered when extracapsular extension of cancer (pT3) was noted. Postoperatively, 29 (64.4 %) patients were diagnosed with pT2 disease and 16 (35.6 %) with pT3 disease. There was a significant difference in localized vs. locally advanced disease in number of positive biopsy cores (p<0.001), greatest percentage of tumor in the core (p=0.008), localization of the tumor (p=0.003) and perineural invasion (p=0.004). Logistic regression was used to develop a model on the multivariate level. It included number of positive cores and PSA-ACT and was significant on our cohort with the reliability of 82.22%. The combination of PSA-ACT and a large scale of biopsy parameters could be used in prediction of adverse pathologic findings after radical prostatectomy. Clinical decisions and patients counselling could be influenced by these predictors but further confirmation on a larger population is necessary

Validation of Epstein biopsy criteria for insignificant prostate cancer in contemporary cohort of Croatian patients [Patohistološki nalazi bolesnika s rakom prostate liječenih radikalnom prostatektomijom koji su bili podobni za aktivni nadzor]

Only few reports validated contemporary Epstein criteria for insignificant prostate cancer, and only one being from Europe. Patients with insignificant prostate cancer should be offered active surveillance and spared radical treatment. In our study we tested Epstein biopsy criteria for predicting unfavorable final pathology and biochemical relapse in low risk prostate cancer patients, who were eligible for active surveillance but where treated with radical prostatectomy. Between January 2003 and January 2008, 586 patients were subjected to radical prostatectomy in our institution. Among them, 106 where eligible for active surveillance according to Epstein biopsy criteria for insignificant prostate cancer. We analyzed the presence of adverse pathological findings in the final pathohistological specimen after radical prostatectomy which excludes low risk disease. Adverse pathohistological findings were noted in 41 (38.6%) patients, who could have been offered active surveillance. During the follow up of 48 (12-72) months, biochemical relapse was noted in 6 (5.6%) patients. Although active surveillance is becoming more popular because of the long natural course of prostate cancer and fear of overtreatment of patients with indolent course of disease, both doctors and patients must be aware of potentially significant disease in this group and limitations of current preoperative criteria defining low risk patients

Validation of Epstein Biopsy Criteria for Insignificant Prostate Cancer in Contemporary Cohort of Croatian Patients

Only few reports validated contemporary Epstein criteria for insignificant prostate cancer, and only one being from Europe. Patients with insignificant prostate cancer should be offered active surveillance and spared radical treatment. In our study we tested Epstein biopsy criteria for predicting unfavorable final pathology and biochemical relapse in low risk prostate cancer patients, who were eligible for active surveillance but where treated with radical prostatectomy. Between January 2003 and January 2008, 586 patients were subjected to radical prostatectomy in our institution. Among them, 106 where eligible for active surveillance according to Epstein biopsy criteria for insignificant prostate cancer. We analyzed the presence of adverse pathological findings in the final pathohistological specimen after radical prostatectomy which excludes low risk disease. Adverse pathohistological findings were noted in 41 (38.6 %) patients, who could have been offered active surveillance. During the follow up of 48 (12 – 72) months, biochemical relapse was noted in 6 (5.6%) patients. Although active surveillance is becoming more popular because of the long natural course of prostate cancer and fear of overtreatment of patients with indolent course of disease, both doctors and patients must be aware of potentially significant disease in this group and limitations of current preoperative criteria defining low risk patients