|Year : 2016 | Volume
| Issue : 6 | Page : 26-28
|Date of Web Publication||30-Nov-2016|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Genitourinary. J Can Res Ther 2016;12, Suppl S2:26-8
Androgen deprivation therapy in prostate cancer: What influence our decisions in clinical practice?
Kuldeep Sharma, Subodh Chandra Pande, Kamal Verma,
Department of Radiotherapy, Artemis Hospitals, Gurgaon, Haryana, India, E-mail: [email protected]
Introduction: To identify the factors which influence a physician's decisions regarding ADT prescription for prostate cancer in the presence of inconsistent practice guidelines. Materials and Methods: We retrospectively analyzed 91 prostate cancer patients treated between 2007 and 2014 to determine these factors and treatment outcomes. Results: Of the 55 radically treated cases, the mean age was 67 years with co-morbidities present in 67% cases. 26% patients were symptomatic at presentation with 0%, 19% and 81% cases in low, intermediate and high risk category, respectively. When divided into ADT (41 cases) and non-ADT (NADT) group (14 cases), more high-risk cases (80% vs 20%, P = 0.05) and all patients with positive nodes fell in ADT group (P = 0.05). Patients in ADT group had a significantly higher mean iPSA than NADT group (54.2 vs 13.9 ng/ml; P = 0.02). The treatment outcomes and toxicities remained comparable between two groups. Overall, 74% patients obtained response to primary treatment (75.6% in ADT and 71.4% in NADT) with ten patients experiencing disease progression during follow-up (FU). Mean PFS was 43 and 32 months in ADT and NADT group (P = 0.24) respectively. Median FU (indirect indicator of survival) was 54.9 and 35.5 months in ADT and NADT group, respectively (P = 0.29). At last FU, 91% patients were alive (88% in ADT and 100% in NADT) with 67% in disease free status. Conclusions: Prognostic risk grouping, node positivity and high iPSA emerged as significant factors that influenced decisions regarding ADT prescription. Other factors like age, co-morbidities, symptoms, Gleason's score and T-stage were found insignificant.
Extreme hypofractionation in carcinoma prostate: PSA kinetics
Tejinder Kataria, th Kushal Narang, Ashu Abhishek, Shyam S. Bisht, Shikha Goyal, Deepak Gupta, Trinanjan Basu, Susovan Banerjee
Division of Radiation Oncology, Medanta Cancer Institute, Medanta - The Medicity, Gurgaon, Haryana, India, E-mail: [email protected]
Objective: There is a well-established radiobiological rationale supporting hypofractionated radiotherapy in prostate cancer. A rapid post-treatment PSA decline and low nadir PSA (nPSA) are linked to improved outcomes. This study aims to analyze PSA kinetics post SBRT with extreme hypofractionation on CyberKnife (CK). Materials and Methods: 54 patients with localized or locally advanced prostate cancer were treated with CK SBRT 35-42 Gy in 5-7 fractions to prostate alone [Radical group] or with conventionally fractionated radiotherapy (CFRT) 45 Gy in 25 fractions to the prostate and pelvic nodes, combined with hypofractionated SBRT boost of 18-21 Gy in 3 fractions on CK [Boost group]. Hormone therapy was added as per D'Amico risk group. PSA kinetics was recorded at 3 monthly intervals. Toxicities were recorded using Common Toxicity Criteria version 4.0. Results: Patients with less than 6 months follow-up were excluded. Of the analyzable 32 patients, median age was 71.5 years and mean BED (α/β = 1.5) was 207 Gy. At a median follow-up of 21 months, the median nPSA was 0.01 ng/ml and median time to attain nPSA was 9 months. The median PSA at 6, 12, and 21 months were 0.03 ng/ml, 0.06 ng/ml, and 0.016 ng/ml respectively. 28% (9/32) patients attained nPSA at 3 months, 62.5% (20/32) by 9 months, and 84.3% (27/32) by 21 months. Two patients had acute Grade 3 rectal toxicity and one had acute Grade 3 bladder toxicity. Conclusion: Patients treated with extremely hypofractionated SBRT on CK experienced earlier and numerically lower nPSA than CFRT results in literature, without appreciable increase in toxicity. The improved PSA kinetics is promising and may translate into superior biochemical control on longer follow-up.
Recent trends in management of urinary bladder malignancies
Vipul Bansal, Anil Kumar Dhull, Rajeev Atri, Vivek Kaushal
Department of Radiotherapy, Pt. B. D. Sharma Pgims, Rohtak, Haryana, India, E-mail: [email protected]
Objectives: Bladder cancer is the fifth most common malignancy overall and the commonest malignancy of the urinary tract. In this review, we aim at the latest updates in the diagnosis and management. Materials and Methods: An electronic search on the recent PubMed database was done for literature on bladder cancer. Results: Approximately 75-80% of newly diagnosed patients have non-muscle invasive bladder cancer (NMIBC). Diagnostic modalities include cystoscopy and urine cytology. For inconspicuous bladder cancer, photodynamic diagnosis and narrow band imaging increases the detection rates and reduces recurrence by improving the completion of bladder resection as compared to standard white light resection. Various urine-based markers and point-of-care tests reduce the frequency of cystoscopy, or improve its sensitivity for detection of tumors. For NMIBC, transurethral resection of bladder tumor (TURBT) including muscularis propria in resected tissue is first line treatment. Adjuvant treatment as intravesical chemotherapy and/or Immunotherapy with electromotive drug administration of mitomycin C or BCG are needed due to high recurrence rate of up to 70%. For muscle-invasive bladder cancer, both laparoscopic radical cystectomy and robotic radical cystectomy have minimized perioperative morbidity, while being equivalent to open radical cystectomy. In patients, who wish for bladder preservation, TURBT followed by chemoradiation regimens has shown equivalent outcomes to radical surgery for selected patients. For metastatic disease, gemcitabine/cisplatin or DDMVAC regimen or atezolizumab is approved. Conclusion: The five year survival rate of bladder cancer has decreased from 81.1% to 77.5% over past 20-years, so extensive trials needs to be done.
Observational study of cone beam CT based interfractional urinary bladder filling variation during IGRT in pelvic malignancies
Shah Manjari , Agarwal Sandeep, Chhabra Akanksha, Mishra Shiv, Shankar Ravi, Srinivasan Shashank, Chandra Ritu, Prekshi, Subramanian Bala, Agarwal Rashi, Singh Dinesh
Department of Radiotherapy, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, India, E-mail: [email protected]
Background : Organ motion is a well-known fact in radiation therapy that limits its precision. It is well documented that for pelvic malignancies patients undergoing radiation therapy, there is correlation between target volume displacement and changes in bladder wall as much as 3 cm. The objective of this study was to observe inter-fractional bladder filling variation during Image guided radiotherapy after following bladder filling protocol. Materials and Methods: 26 patients of pelvic malignancies were enrolled including 9 cervical cancer, 7 endometrial, 5 prostate and 5 colo-rectal cancer patients. Total of 300 scans (26 Planning CT + 274 CBCTs) were performed and bladder was contoured in all scans. Bladder volume, transverse, antero-posterior and longitudinal diameter were measured in maximum dimension of the bladder. All these parameters were compared with the planning CT scan. Results: Patients showed variation in bladder volume with mean 184 cc and standard deviation 90 cc and P-value was 0.761. With increasing bladder volume, its size increases with asymmetry in bladder wall. The mean diameter of bladder was 8.35 cm, 6.69 cm and 5.59 cm in transverse, antero-posterior and longitudinal diameter with standard deviation 1.039, 1.05 and 1.798 cm. Conclusion: Image-guided radiotherapy (IGRT) with verification of the organ position before the daily treatment after following bladder filling protocol has allowed for lessening of inter-fraction bladder wall motion and showed considerable benefits in terms of margin reduction on lateral side as there is less displacement on transverse diameter and more liberal margins should be considered in antero-posterior dimension and longitudinal dimension.
Primary renal neuroendocrine tumour: A case report
Kampra Gupta, Rohitashwa Dana, R. K. Spartacus
Department of Radiotherapy, Sawai Man Singh Medical College and Attached Hospitals, Jaipur, Rajasthan, India, E-mail: [email protected]
Introduction: Primary neuroendocrine tumors (NET) of kidney are extremely rare. Less than 100 cases have been reported. Gastrointestinal tract is the most common site, followed by respiratory system. Renal NET are unusual because neuroendocrine cells are not found in renal parenchyma. They present a spectrum of disease with variable biologic potential-well differentiated NET (carcinoid), well differentiated neuro endocrine carcinoma, poorly differentiated neuroendocrine carcinoma [large cell neuroendocrine carcinoma (LCNEC)] and small cell carcinoma (SCC). Materials and Methods: A 42 year old woman presented with pain abdomen in left flank region, non radiating type for 10 days and episodic haematuria. There was no history of any other complaint. Physical examination revealed vague lump in left lumbar region. CECT abdomen revealed an ill defined enhancing lesion in upper and mid pole of left kidney (45 × 51 × 43 mm). There were also multiple sub-centimetric pre, paraaortic and mesenteric lymphnodes. Left renal vein and IVC were normal. Provisional diagnosis of renal cell carcinoma was made. She underwent left radical nephrectomy and histopathology report revealed malignant neoplasm showing neuroendocrine features. On Immunohistochemistry, tumour cells were positive for Chromogranin A, CD 56 and negative for Uroplakin II, P40 and CD10. KI index was 25% to 30%. A diagnosis of well differentiated neuroendocrine tumour was made. Metastatic workup showed no other abnormality. The institutional tumor board decided on adjuvant chemotherapy (cisplatin and etoposide) based on the proliferative index. Conclusions: Primary treatment of renal NET is surgical resection for localised disease. There is no standard treatment for locally advanced or metastatic disease owing to the rarity of this entity.
Primary adenocarcinoma of urinary bladder: A rare case report
Nupur Bansal, Paramjeet Kaur, Ashok K. Chauhan, Anil Khurana, Yashpal Verma
Department of Radiotherapy, Pt BDS PGIMS, Rohtak, Haryana, India, E-mail: [email protected]
Objectives: Adenocarcinoma of the urinary bladder arising from the urothelial lining is an uncommon malignant neoplasm, accounting for 0.5% to 2.0% of all malignant vesical tumors. The histological and pathological type of bladder cancer is mainly urothelial carcinoma, also called transitional cell carcinoma, accounting for approximately 90%. Several therapeutic modalities have been used in the management of primary adenocarcinoma of the bladder; however, most of the published reports are based on relatively few cases, rendering the establishment of definitive therapeutic strategies difficult and inconclusive. Case Summary: A 60 year old male presented with chief complaints of hematuria associated with lower back pain for the past four months. Patient was a chronic smoker and chronic alcoholic. There was not any other associated chronic illness. CT scan demonstrated growth involving posterior wall of bladder with involvement of bilateral vesicoureteric junction. Transurethral resection of urinary bladder revealed moderately differentiated papillary adenocarcinoma. Deeper biopsy was free from tumor infiltration. Patient was given neoadjuvant chemotherapy with gemcitabine and carboplatin followed by radical radiotherapy (60 Gy/30 Fr/6 weeks). Patient is asymptomatic at 4 months of follow up. Conclusion: Some of the available therapeutic modalities include radical or partial cystectomy, transurethral resection, radiotherapy as adjuvant or definite treatment and chemotherapy. As in the present case, especially in elderly individuals, radical radiotherapy with neoadjuvant chemotherapy may prove beneficial in improving the survival outcomes and locoregional control of the disease.
Leiomyosarcoma prostate response to radiation; a rare case report
Department of Radiotherapy, Reginal Cancer Centre, Trivandrum, Kerala, India, E-mail: [email protected]
Introduction: Leiomyosarcoma of the prostate is an extremely rare neoplasm that accounts for less than 0.1% of primary prostate malignancies. A case report of leiomyosarcoma of prostate treated with radiotherapy is presented here. Case Report: A 38 year old gentleman was evaluated for dysuria and hematuria of 2 months duration. Digital rectal examination revealed grade III prostatomegaly. Serum PSA value was 0.6 ng/ml. MRI scan showed grossly enlarged prostate protruding into bladder with homogenous T 2 -hyperintense mass and mild contrast enhancement. Biopsy showed high grade spindle cell sarcoma in keeping with leiomyosarcoma. [Figure 1] FDG PET showing intense uptake of FDG in the prostate with no evidence of disease activity elsewhere in the body.
Maximum intensity projection (MIP) image (A) of baseline 18F-FDG PET/CT scan. Intense FDG uptake (SUV max: 13.02 red arrow, B-E). Post treatment scan shows no abnormal tracer uptake in the normal sized prostate gland (green arrow). Considering the extent of disease, surgery was deferred. The patient was offered radical radiotherapy. Using IGRT technique 74 Gy/37 F was delivered to prostate and peri-prostatic region. Review PET/CT scan done in the sixth month post-treatment showed complete resolution of disease activity with reduction in size of prostate. Patient attained clinical and radiological complete remission and is on follow up. Discussion: For leiomyosarcoma prostate, radical surgery is the curative option preferred in localized disease. With use of precision technique and higher doses, radical radiotherapy needs to be explored as a curative primary treatment in young adults with lesser treatment related morbidity.
Defining the role of gallium 68-PSMA PET CT scan in prostate cancer
P. S. Sridhar, Kumar G. Kallur, th J. Vijaya Kumar, G. R. Prashanth, S. Shivakumar Swamy, N. Madhusudhan, K. Roopesh, G. H. Abhilash, M. Praveen Kumar, B. S. Ajai Kumar
Department of Radiotherapy, Health Care Global Enterprises Ltd., Bengaluru, Karnataka, India, E-mail: [email protected]
Background: Prostate cancer is biologically and clinically a heterogeneous disease that makes imaging evaluation challenging. One of the important challenges in this cancer is to detect recurrent disease. With Computed Tomography scans, conventional Magnetic Resonance Imaging (MRI) scans, conventional Positron Emission Tomography (PET) scans and PSA it is difficult for assessment. Therefore we analyse the role of Ga68-PSMA imaging in prostate cancer which is a new PET tracer. Materials and Methods: PET scans were evaluated in 260 patients of histopathologically provened prostate carcinoma. These patients were scanned using Ga68-PSMA either for staging or response evaluation. Results: A total of 336 PSMA scans were performed. As a base line evaluation Ga68-PSMA scan was able to detect extra prostatic disease in 53.2% of cases. The sensitivity of Ga68-PSMA scan at baseline in histopathologically diagnosed prostate cancer was 95% with 95% CI ranging from 86% to 98%. The positive predictive value was high at 98% with 95% CI ranging from 91% to 99%. In 26 (10%) patients where surgical castration was done, Ga68-PSMA scan was able to detect disease progression/castration resistance in 100% of cases. The outcome of castration resistant prostate cancer was compared with other cases where castration was not done. In those who did not undergo castration, there was a significant better response by hormone therapy (P = 0.03) and radiotherapy (P = 0.01) on Ga68-PSMA. The sensitivity of Ga68-PSMA response with biochemical response was 66.7% with 95% CI ranging between 46%-82.7%. Ga68-PSMA response did not correlate with biochemical response. Conclusion: Ga68-PSMA has good sensitivity for diagnostic work up, restaging, response evaluation and as a prognostic marker in prostate cancer.
Leiomyosarcoma of prostate: A rare case report
S. K. Rout, S. Padhi, P. Meher, S. Mohanty, B. R. Routray, L. Pattanayak, N. Panda
Department of Radiotherapy, A. H. Regional Cancer Center, Cuttack, Odisha, India, E-mail: [email protected]
Prostate leiomyosarcoma is an extremely rare and an aggressive neoplasm, that accounts for less than 0.1% of primary prostate malignancies. Here we present a case of primary leiomyosarcoma prostate of age 40 yr, who presented with recurrent urinary obstruction and burning micturation. On histopathological evaluation it was found to be primary leiomyosarcoma and which was later confirmed by immunohistochemistry. Further we did a review of 54 cases reported in literature to discuss the clinical, diagnostic and therapeutic aspects of this uncommon tumour. Median survival was estimated to be 17 months. The sole factors predictive of long term survival are negative surgical margins and absence of metastasis at presentation. Radical surgery is the mainstay of definitive treatment and adjuvant therapy may provide better local control and overall survival. We present this case of leiomyosarcoma of prostate and review literature due to its diagnostic and therapeutic challenges. Due to its rarity, definitive treatment recommendation are yet to be established, but multidisciplinary approach has to be done to yield better results. Further studies are warranted to establish the consensus for treatment.
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