- Email: [email protected]
16 Dose volume evaluation for the target
Symposia
Monday, October 25, 2004 $7
14 The value of extended lymphadenectomy for the prognosis of patients with bladder cancer
J. Leissner Radical cystectomy with pelvic lymph node dissection (PLND) is the therapeutic standard for patients with clinically localized, muscle invasive bladder cancer. However, since the introduction of cystectomy for the treatment of bladder cancer, the therapeutic and prognostic value of pelvic lymphadenectomy has been controversial and the distribution of nodal metastases has not been examined in sufficient detail. To assess the value of PLND, we retrospectively analyzed the charts of 506 patients who were cystectomyzed between 1987 and 2000 with curative intention. The number of lymph nodes removed was correlated with the clinical outcome. Patients with 15 and more lymph nodes removed had a significant better prognosis as compared to patients with a more limited PLND (p = 0.0012). In the multivariate analysis of all variables the pN category (p < 0.001), the pT category (p = 0.003), and the number of lymph nodes removed (p = 0.038) were statistically independent prognostic factors. In addition, we conducted a comprehensive prospective analysis of lymph node metastases in 280 patients to obtain precise knowledge about the pattern of lymphatic tumor spread. The cranial border of PLND was set at the level of the inferior mesenteric artery, and the lateral border was the genitofemoral nerve. Positive lymph nodes were most common in the right and left obturator space. Within the other fields the percentage of positive nodes varied only slightly and with no statistical differences. By studying cases of unilateral primary tumors or with only a single metastasis we observed a preferred pattern of metastatic spread. However, there were many exceptions to the rule and we could not identify a well-defined sentinel lymph node. Accordihg to our retrospective study that demonstrates a positive correlation between the extent of PLND and survival, a limited lymphadenectomy decreases the prognosis. Therefore, we strongly recommend extended radical lymphadenectomy for all patients undergoing radical cystectomy to completely remove all metastatic tumor deposits. In addition, our data may serve as a guideline for standardization and quality control of the procedure. Future studies on the outcome after radical cystectomy should specify the extent of surgery and the number of lymph nodes excised to permit a valid comparison of results.
Prostate cancer brachytherapy: predictors for outcome 15 Definition of prognostic factors in localized prostate cancer: PSA, stage and Gleason score
G. Kovacs University Hospital S-H Campus Brachytherapy Centre, Kiel, Germany
Kiel,
Interdisciplinary
Introduction: Defining an optimal tailored treatment in localized prostate cancer is not an easy task in lack of prospective randomized trials. The only way to find out which group of patients profit from a certain treatment method is analysing comparable long term outcome data. Material and Methods: Initial PSA (iPSA), Gleason score (GS) and tumor stage has all independent and significant influence on treatment results. Many authors have shown, that in patients treated with conventional external beam therapy with iPSA > 10ng/mL the PSA failure was over 50%. This cohort of patients
has also a higher probability in both, in extracapsular invasion as well as in the treatment failure rate. Regarding GS it has been found that GS 8-10 patients has a poor prognosis, but GS may not be an accurate predictor of the overall clinical course, The optimal definition of GS needs high level of experience from the pathologist and literature data show high variations in GS after reviewing the histology by an expert. Clinical stage was often defined by digital rectal examination (DRE) and a strong correlation between stage and outcome was stated, however, iPSA and GS are more important factors than clinical stage. There is a considerable degree of uncertainty regarding the value of different imaging methods for local staging. Transrectal ultrasound (TRUS) is in the hand of experienced users one of the most sensitive imaging methods to determine local extent of prostate cancer.
Results: Literature data [1,2] clearly demonstrate, that the combination of different prognostic factors in a given patient cohort can have a significant impact on biochemical outcome. Treatment decision should be influenced not only by outcome results, but also by individual preferences of the patients, This decision often includes often preferences in possible side effects and psycho-oncological factors. Conclusions: In lack of prospective randomized trials the outcome analysis of different experiences is the only method to learn more on optimal patient selection to different treatment methods. The use of numerous prognostic factors and the combination of them results in more homogenous data pools, which are more eligible for drawing real prognostic consequences.
Literature [1]Vicini FA, Martinez A, Hanks G, et al.: Cancer 2002; 95(10):2126-2135 [2]D'Amico A V, Desjardin A, ChungA, et al.: Cancer 1998;82:1887-1896 16 Dose volume evaluation for the target
P. Lavaqnini Abstract not received 17 Dose volume considerations for urethral, rectal and erectile function for patients treated with permanent interstitial implantation
M. Zelefsky Memorial Sloan-Kettering Cancer Ctr, Radiation Oncology, New York. USA In order to achieve optimal tumor control with minimal treatment -related morbidity after prostate brachytherapy, careful treatment planning is essential. It is a trivial matter to deliver high doses to the prostate with insertion of more seeds and more activity within the gland; yet without meticulous adherence to dose volume constraints of relevant normal tissue structures, post-treatment complications will be significant. Several reports in the published literature suggest that there are dose volume constraints for the urethra, rectum and neurovascular bundle that should be achieved during prostate brachytherapy treatment planning to minimize treatment related complications. It appears that acute urinary symptoms and late urinary morbidity after TPI correlate with the central target doses and the proximity of seed placement to the urethra. We
Monday, October 25, 2004 $7
14 The value of extended lymphadenectomy for the prognosis of patients with bladder cancer
J. Leissner Radical cystectomy with pelvic lymph node dissection (PLND) is the therapeutic standard for patients with clinically localized, muscle invasive bladder cancer. However, since the introduction of cystectomy for the treatment of bladder cancer, the therapeutic and prognostic value of pelvic lymphadenectomy has been controversial and the distribution of nodal metastases has not been examined in sufficient detail. To assess the value of PLND, we retrospectively analyzed the charts of 506 patients who were cystectomyzed between 1987 and 2000 with curative intention. The number of lymph nodes removed was correlated with the clinical outcome. Patients with 15 and more lymph nodes removed had a significant better prognosis as compared to patients with a more limited PLND (p = 0.0012). In the multivariate analysis of all variables the pN category (p < 0.001), the pT category (p = 0.003), and the number of lymph nodes removed (p = 0.038) were statistically independent prognostic factors. In addition, we conducted a comprehensive prospective analysis of lymph node metastases in 280 patients to obtain precise knowledge about the pattern of lymphatic tumor spread. The cranial border of PLND was set at the level of the inferior mesenteric artery, and the lateral border was the genitofemoral nerve. Positive lymph nodes were most common in the right and left obturator space. Within the other fields the percentage of positive nodes varied only slightly and with no statistical differences. By studying cases of unilateral primary tumors or with only a single metastasis we observed a preferred pattern of metastatic spread. However, there were many exceptions to the rule and we could not identify a well-defined sentinel lymph node. Accordihg to our retrospective study that demonstrates a positive correlation between the extent of PLND and survival, a limited lymphadenectomy decreases the prognosis. Therefore, we strongly recommend extended radical lymphadenectomy for all patients undergoing radical cystectomy to completely remove all metastatic tumor deposits. In addition, our data may serve as a guideline for standardization and quality control of the procedure. Future studies on the outcome after radical cystectomy should specify the extent of surgery and the number of lymph nodes excised to permit a valid comparison of results.
Prostate cancer brachytherapy: predictors for outcome 15 Definition of prognostic factors in localized prostate cancer: PSA, stage and Gleason score
G. Kovacs University Hospital S-H Campus Brachytherapy Centre, Kiel, Germany
Kiel,
Interdisciplinary
Introduction: Defining an optimal tailored treatment in localized prostate cancer is not an easy task in lack of prospective randomized trials. The only way to find out which group of patients profit from a certain treatment method is analysing comparable long term outcome data. Material and Methods: Initial PSA (iPSA), Gleason score (GS) and tumor stage has all independent and significant influence on treatment results. Many authors have shown, that in patients treated with conventional external beam therapy with iPSA > 10ng/mL the PSA failure was over 50%. This cohort of patients
has also a higher probability in both, in extracapsular invasion as well as in the treatment failure rate. Regarding GS it has been found that GS 8-10 patients has a poor prognosis, but GS may not be an accurate predictor of the overall clinical course, The optimal definition of GS needs high level of experience from the pathologist and literature data show high variations in GS after reviewing the histology by an expert. Clinical stage was often defined by digital rectal examination (DRE) and a strong correlation between stage and outcome was stated, however, iPSA and GS are more important factors than clinical stage. There is a considerable degree of uncertainty regarding the value of different imaging methods for local staging. Transrectal ultrasound (TRUS) is in the hand of experienced users one of the most sensitive imaging methods to determine local extent of prostate cancer.
Results: Literature data [1,2] clearly demonstrate, that the combination of different prognostic factors in a given patient cohort can have a significant impact on biochemical outcome. Treatment decision should be influenced not only by outcome results, but also by individual preferences of the patients, This decision often includes often preferences in possible side effects and psycho-oncological factors. Conclusions: In lack of prospective randomized trials the outcome analysis of different experiences is the only method to learn more on optimal patient selection to different treatment methods. The use of numerous prognostic factors and the combination of them results in more homogenous data pools, which are more eligible for drawing real prognostic consequences.
Literature [1]Vicini FA, Martinez A, Hanks G, et al.: Cancer 2002; 95(10):2126-2135 [2]D'Amico A V, Desjardin A, ChungA, et al.: Cancer 1998;82:1887-1896 16 Dose volume evaluation for the target
P. Lavaqnini Abstract not received 17 Dose volume considerations for urethral, rectal and erectile function for patients treated with permanent interstitial implantation
M. Zelefsky Memorial Sloan-Kettering Cancer Ctr, Radiation Oncology, New York. USA In order to achieve optimal tumor control with minimal treatment -related morbidity after prostate brachytherapy, careful treatment planning is essential. It is a trivial matter to deliver high doses to the prostate with insertion of more seeds and more activity within the gland; yet without meticulous adherence to dose volume constraints of relevant normal tissue structures, post-treatment complications will be significant. Several reports in the published literature suggest that there are dose volume constraints for the urethra, rectum and neurovascular bundle that should be achieved during prostate brachytherapy treatment planning to minimize treatment related complications. It appears that acute urinary symptoms and late urinary morbidity after TPI correlate with the central target doses and the proximity of seed placement to the urethra. We