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Prostate Cancer: Management of Complications of the Disease and Its Therapy

Posted by admin on June 21st, 2011 No Comments

The prostate is the leading cancer site in American men, accounting for 29% of new cancer cases and a projected 184,500 new cases in 1998. Also in 1998, 39,200 men will die from complications of the disease, illustrating that prostate cancer is not an insignificant disease of the elderly. In 1994, the latest year for which the reported deaths for prostate cancer by age in the United States are available, 11,789 men between 55 and 74 years of age, and 22,712 men older than 74 years, died of prostate cancer. Of the men newly diagnosed with prostate cancer in 1993, 59% had clinically localized disease, 18% had locally advanced (stage C and Dl) tumors, and 10% presented with distant metastases. Patients with advanced disease at presentation are likely to suffer both local and systemic complications of the disease, which the practicing physician must carefully monitor and treat. These patients are unlikely to obtain lifetime freedom from disease and should be followed at 3 to 6 month intervals for local and distant disease progression. Natural History Prognosis at the time of initial diagnosis is clearly Read more [...]

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Osseous Metastases

Posted by admin on June 21st, 2011 No Comments

Persistent bone pain in the back or hip region is one of the most common presenting symptoms of metastatic disease. The imaging modality of choice in this situation is the radionuclide bone scan. This will reveal the most common sites of spread to be the spine (74%, most commonly the lumbar and thoracic region), ribs (70%), pelvis (60%), femur (44%), and shoulder (41%). Demonstrable metastases are most commonly osteoblastic or mixed osteoblastic-osteolytic, with pure osteolytic comprising approximately 10% of lesions. Treatment of the prostate cancer patient who has osseous metastases is primarily palliative. The aim of therapy is to relieve pain, prevent pathologic fracture, and to improve mobility and functional status. This usually demands a multidisciplinary approach, involving a urologist, medical oncologist, radiotherapist, nurse, and pain control specialist. The mainstay of systemic treatment of the prostate cancer patient with osseous metastases is androgen deprivation. Approximately 80% of men with osseous metastases will have symptomatic improvement with androgen deprivation alone. Objective Read more [...]

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Spinal Cord Compression and Other Complications of Osseous Metastases

Posted by admin on June 21st, 2011 No Comments

Complications of osseous metastases include spinal cord compression, seen ultimately in 10% of men with prostate cancer (which is second only to lung cancer as an etiologic cause), pathologic vertebral compression fracture, pathologic long bone fracture (most commonly of the femur and humerus), hypercalcemia, and bone marrow failure. Nearly all patients with complications of osseous metastases complain of pain. In the case of spinal cord and nerve root compression, decreased sensation usually precedes motor symptoms and may be detected on careful examination. Magnetic resonance imaging is frequently used to evaluate spinal cord compression, due to its high sensitivity and ability to image the vertebral bodies and paraspinal and intraspinal soft tissues. On Tl-weighted images, bone metastases tend to stand out as focal or diffuse hypointense (dark) lesions against a background of higher signal intensity marrow. Compared to myelography, magnetic resonance imaging is noninvasive, directly visualizes cord compression, and can measure the extent of tumor outside the thecal sac along the entire cord. In Read more [...]

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Management of Pain from Osseous Metastases

Posted by admin on June 21st, 2011 No Comments

Radiation therapy is used to manage symptomatic bone metastases that are unresponsive to androgen deprivation. For the patient with one or a few sites of localized pain secondary to osseous metastases, local radiotherapy may be administered. The optimal dose/fractionation scheme is not clearly defined although local radiotherapy is most often administered in several fractions of 3 Gy each. If so treated, approximately 75% of treated patients will experience effective pain control for up to 6 months without serious hematologic or gastrointestinal side affects. Wide-field therapy may be administered for patients with multiple painful bony metastases. This is most frequently administered as hemibody radiotherapy, usually as a single dose (6 to 8 Gy). Pain relief will occur within a few days in up to 70% of patients. Fractionated hemibody radiotherapy (30 Gy per 10 fractions) has been evaluated in this application. In a phase II study, fractionated hemibody radiotherapy was associated with improved pain control at 1 year (70% versus 15%) and decreased requirement for retreatment (13% versus 71%). Alternatively, Read more [...]

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Chemoprevention of Cancer of the Prostate

Posted by admin on June 21st, 2011 No Comments

With a dramatic increase in the number of prostate cancers detected as a result of prostate-specific antigen screening and the resulting public focus on the disease, a lot of attention has been placed on how to respond to this public health threat. While the focus of the 1970s and early 1980s was the optimal management of metastatic disease, the recognition that the most promising advances (e.g., combined androgen deprivation for newly diagnosed metastatic disease and suramin for hormone-refractory disease) made little, if any, impact on the survival and often worsened morbidity, more emphasis has been placed on early detection, especially using prostate-specific antigen, and therapy. While it has been anecdotally observed that with the increased focus on early detection, there has been a concomitant fall in the rate of metastatic disease as well as in prostate cancer mortality, that these events were due to screening and treatment remains a subject of considerable debate. One item of consensus, however, regarding early detection and treatment is that morbidity and cost accrue from this approach. Read more [...]

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Opportunities for Chemoprevention

Posted by admin on June 21st, 2011 No Comments

Vitamin E The term "vitamin E" is used to refer to a group of naturally occurring substances that have vitamin E activity including a-, β-, δ-, and y-tocopherols (that have saturated side chains) and tocotrienols (that have unsaturated side chains). These agents have some degree of difference in biopotency with the naturally occurring d-a-tocopherol approximately 30% more potent than the synthetic forms — d- or d, l-a-tocopherol alone, acetate, or succinate. The principal food sources of vitamin E are vegetable and seed oils as well as alfalfa and lettuce. A primary function of vitamin E is as an antioxidant, interacting with free radicals (e.g., singlet oxygen, superoxide anion, organic peroxide radicals, hydrogen peroxide, and others) that are generated as a normal part of cellular metabolism. These free radicals can interact with cellular structures, primarily membranes, and lead to cellular damage, generally through lipid peroxidation. Over time, the oxidative stress in humans increases and, similarly, with aging, the endogenous antioxidant capability (from glutathione, vitamins A, C, Read more [...]

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Anorectal Complications of Prostate Surgery

Posted by admin on June 21st, 2011 No Comments

Major iatrogenic injuries of the anorectum during prostate surgery are unusual occurrences. They are, however, challenging and troublesome clinical situations to treat. Minor injuries, including functional alterations, may be more common than have been appreciated in the past. Fortunately, proper, precise, and prompt management of iatrogenic injuries of the anorectum usually leads to successful outcomes. Successful outcomes in managing iatrogenic anorectal injuries incurred during prostate surgery begin with careful preoperative planning. The surgeon must thoroughly understand the technical aspects of the planned procedure and the challenges unique to his or her patient, such as prior surgeries or radiation therapy in the area being operated on. Preoperative planning should include an assessment of the functional status of the anorectum with respect to bowel function and continence to feces. The diagnosis, the patient's history and functional status, and the experience and capabilities of the operating surgeon should all be considered when deciding on the operation best suited for the patient. Read more [...]

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Repair of Rectal Injuries

Posted by admin on June 21st, 2011 No Comments

Rectal injuries noted at the time of prostate surgery may be repaired with primary closure without fecal diversion in most cases. Diversion is indicated in patients who have undergone radiation therapy, have had previous anorectal surgery at the site of the injury, or when there have been devastating iatrogenic injuries. Primary repair has been successful using a variety of techniques, depending more on surgical principles and personal experience than on any one type of repair. All repair techniques have the following in common: debridement of devitalized tissue, mobilization of the rectum sufficiently to allow for a tension-free repair, the use of broad-spectrum antibiotics postoperatively, short-term wound drainage, and the use of absorbable suture materials. Although many authors have used double layer closures in repairs, a single layer repair is reliable if adequate mobilization of the rectum cannot be accomplished to accommodate a double layer, tension-free repair. There is little evidence to support the use of antibiotics for more than 24 to 72 hours after an intraoperative repair. TABLE. Read more [...]

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Fecal Incontinence

Posted by admin on June 21st, 2011 No Comments

Fecal incontinence is difficult to assess in an objective manner because there is no widely accepted scoring or grading system by which to compare patients. It is difficult to score or grade due to great differences in opinion existing between surgeons, patients, socioeconomic groups, and ethnic groups as to what constitutes fecal incontinence. Nevertheless, a number of scoring systems do exist that provide reasonably reproducible assessments when compared to themselves. TABLE. Colostomy Type Advantages and Disadvantages Type of Colostomy Advantages Disadvantages Special Considerations Loop transverse Ease of construction Prone to prolapse Create from left side of transverse colon to decrease prolapse potentia Distant from pelvic surgery/irradiation Relatively liquid stool May be created under local anesthesia Loopsigmoid Solid stool Near pelvic surgery or irradiation May be converted to end colostomy Irrigation possible Releases rectal backpressure via mucus fistula side of stoma Mobility maybe limited End sigrinoid Solid stool Near Read more [...]

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Node-Positive Prostate Cancer

Posted by admin on June 21st, 2011 No Comments

Node-Positive Prostate Cancer: the Case for Observation There has been much progress made in the diagnosis and staging of prostate cancer in recent years. The advent of biochemical techniques prostate-specific antigen testing, reverse-transcriptase polymerase chain reaction and imaging technologies (computerized tomography, radioisotape scans, magnetic resonance imaging) have greatly facilitated the diagnosis of TxN+ adenocarcinoma of the prostate. Surgical, radiotherapeutic, and hormonal treatments, either as monotherapy or in combination, have likewise progressed. The therapeutic dilemma in treating node-positive prostate cancer is compounded by a lack of prospective randomized trials pitting control populations against monotherapy, combinations of therapies, and observation or deferred treatment. This chapter summarizes the available treatments for node-positive prostate cancer and compares the results of monotherapy, combinations of therapies, and deferred treatment. The case for observation of node-positive prostate cancer (with or without deferred treatment) will then be made. The value Read more [...]

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