This Month in Adult Urology

Article Outline

• Neoadjuvant Nab-Paclitaxel for Prostate Cancer
• Long-Term Outcomes for Younger Men After Permanent Prostate Brachytherapy
• Molecular Analyte Profiling of Events After Intravesical Bacillus Calmette-Guerin
• Percutaneous Embolization for Grade 5 Renal Trauma
• Tumor Cell Necrosis is Not a Significant Predictor of Survival of Clear Renal Cell Carcinoma
• Criteria for Active Surveillance of Prostate Cancer
• Active Surveillance for Low Risk Prostate Cancer
• Copyright

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Neoadjuvant Nab-Paclitaxel for Prostate Cancer 

Neoadjuvant chemotherapy using taxane for tumors such as breast cancer generally results in a P0 status in up to 15% of patients. Because docetaxel has proven efficacy in patients with hormone refractory prostate cancer, a new nanoparticle colloidal formulation of nab-paclitaxel, which achieves higher concentrations in tumors than docetaxel, was evaluated in this phase II trial reported by Shepard et al (page 1672) from Cleveland, Ohio. Patients with locally advanced prostate cancer (stage T2b, T2c or T3) received 2 cycles of 150 mg/m² nab-paclitaxel weekly for 3 weeks during each 4-week cycle followed by radical prostatectomy with bilateral lymphadenectomy. Although prostate specific antigen was undetectable in 94%, no patient achieved a complete pathological response (P0). Further studies are needed to determine if neoadjuvent nab-paclitaxel can impact biochemical recurrence or overall cancer survival.

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Long-Term Outcomes for Younger Men After Permanent Prostate Brachytherapy 

Controversy exists whether age is an independent risk factor for progression of prostate cancer. The outcomes of 237 men younger than 60 years with localized prostate cancer undergoing permanent prostate brachytherapy were prospectively compared to the outcomes of older cohorts by Shapiro et al (page 1665) from New Hyde Park, New York. Patients were stratified by risk group (low, intermediate and high). A multivariate analysis was performed to determine if disease progression was associated with age and other independent pretreatment variables. Initial prostate specific antigen, biopsy Gleason score, year of treatment, addition of hormones and addition of hormones with radiation correlated with disease progression but age did not. The 5 and 10-year freedom from progression rates were 90.1% and 86% for younger vs older groups. Neither clinical stage nor age was associated with outcome. The authors conclude that brachytherapy can safely be given to younger men with excellent outcomes.

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Molecular Analyte Profiling of Events After Intravesical Bacillus Calmette-Guerin 

Despite the long use of bacillus Calmette-Guerin (BCG) as an intravesical agent to treat bladder cancer, the biochemical mechanism by which it produces its antitumor effect or biomarkers to predict response has not been identified. Bisiaux et al (page 1571) from Paris, France assayed cells and proteins at 2 and 4 hours, and at 1 and 3 weeks after BCG therapy. This complex study is the first to attempt mapping urine analytes with cells of origin. The authors provide a first generation map of the initial inflammatory response to BCG including the cell type involved. A total of 36 specific changes were detected during the third instillation. Some of these proteins were plasma proteins that leaked into urine, and others were cytokines and chemokines produced locally in response to BCG instillation. Others proteins were innate molecules that increased during the boost response. Molecular analyte profiling studies such as this should provide insight into the mechanism of BCG action and shed insight into whether any of these proteins can be used in the future to predict biological response.

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Percutaneous Embolization for Grade 5 Renal Trauma 

Most grade 5 blunt renal injuries require operative intervention. In this retrospective study Brewer et al (page 1737) from Knoxville, Tennessee examined the outcomes for 9 patients in whom embolization was used as the initial treatment for grade 5 blunt renal trauma. Clinical (hemodynamically stable and no open surgery) and technical (bleeding site occluded) success rates were 100%. All patients were hemodynamically stable with complete occlusion of renovascular bleeding at the end of the procedure. There was no need for further surgical or radiological intervention. Median hospital stay was 18 days and mean transfusion rate was 6 units. One patient died of complications related to a chest injury after an intensive care unit stay of 46 days. The authors suggest that percutaneous embolization is safe and effective in properly selected patients.

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Tumor Cell Necrosis is Not a Significant Predictor of Survival of Clear Renal Cell Carcinoma 

Previous studies have suggested that tumor necrosis in clear cell renal carcinoma is an adverse prognostic factor. Klatte et al (page 1558) from Los Angeles, California performed a prospective study of 343 consecutive patients with clear renal cell carcinoma and found tumor necrosis in 227 (66%). The presence and extent of necrosis, pathological features and cancer specific survival were analyzed. The presence of tumor necrosis was not an independent prognostic factor in multivariate analysis. However, an extent based classification predicted survival better than presence alone (74.5% vs 64.6%). When one looked at the extent of necrosis there was an independent prognostic usefulness, as tumors with more than 20% necrosis were predictive of progression. Thus the authors recommend scoring necrosis according to extent based criteria with a 20% cutoff.

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Criteria for Active Surveillance of Prostate Cancer 

At least 5 sets of criteria have been proposed for active surveillance in prostate cancer. Conti et al (page 1628) from San Francisco, California extracted data regarding pathological upgrading and up staging from their institutional oncology data base to determine the proportion of men who would have qualified for active surveillance under these various sets of criteria. More than 1,000 men underwent radical prostatectomy. Overall, 28% experienced a Gleason upgrade, 21% had extracapsular extension and 11% had seminal vesicle involvement. Upgrading varied from 23% to 35%, extracapsular extension 7% to 19% and seminal vesicle involvement 2% to 9% in men who would have qualified for active surveillance by certain inclusion criteria. Not surprisingly the more rigorous the entry criteria used, the lower the progression rate. However, even of men who would have qualified for active surveillance under the most stringent published criteria 23% had upgrading to Gleason 7 or more, 7% had extracapsular extension and 2% had seminal vesicle involvement. The authors suggest that active surveillance criteria be adjusted to greater stringency and that patients be advised accordingly. Most importantly, regardless of criteria used a few men will die of disease.

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Active Surveillance for Low Risk Prostate Cancer 

A cohort of 262 men from 4 institutions were evaluated for disease progression using univariate Cox progression analysis. Eggener et al (page 1635) report that a re-staging biopsy was valuable for excluding patients from active surveillance. If a higher number of cancerous cores were found on the second biopsy then patients were not placed on active surveillance and outcomes improved.