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Re: Pretreatment Total Testosterone Level Predicts Pathological Stage in Patients With Localized Prostate Cancer Treated With Radical Prostatectomy
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LETTERS TO THE EDITOR
We have treated 7 men with radiation neuritis, all with distinct benefit (approximately 1.0% of total men seen with pudendal neuralgia). The National Institutes of Health Chronic Prostatitis Symptom Index is used in all men to measure pain, voiding and quality of life scores before, during and after therapy. This validated pain score includes pain questions that are not a component of any of the scores mentioned in these review articles. Only “crampy abdominal pain” is discussed in those pain scores. Our patient group includes 2 men with external beam therapy only, 4 with brachytherapy only, and 1 with combined brachytherapy and external beam radiotherapy. We have computerized tomography images that show seeds misplaced into Alcock’s canal and the pelvic wall. Seeds at the apex are commonly in position to give greater than therapeutic doses of radiation therapy to the neurovascular bundle. Two additional men with “prostatitis-like pains” had necrotic sloughing prostate tissue. They responded briefly to conservative therapy but required prostatocystectomy and urinary diversion for pain relief.6 Onset of symptoms may occur 1 to several months after completing brachytherapy. In men receiving combined therapy usually the symptom onset is late in the course of the external beam therapy component. Brachytherapy for carcinoma of the prostate is a scientific endeavor with uncertain physical outcomes. Pudendal neuralgia (the chronic pelvic pain syndrome) is a serious complication of pelvic radiation therapy and has been recognized in patients with gynecological and colorectal cancer. Urologists need to be aware of this problem and use appropriate questionnaires in addition to the ones discussed in these review articles. Respectfully, Stanley J. Antolak, Jr. Department of Urology Mayo Clinic 200 First St., SW Rochester, Minnesota 55905
Reply by Merrick et al. Antolak’s insight and suggestions regarding this phenomenon are appreciated.3 In our group the development of chronic pelvic pain following permanent prostate brachytherapy has occurred in 3 of an approximate 2,500 implants (incidence 0.12%). Each of these 3 patients described deep pelvic pain that was worse with urination and was exacerbated by prolonged sitting or walking, with all remaining clinically functional without suicidal ideation. Neither cystoscopy, computerized tomography nor magnetic resonance imaging identified any physical or radiographic abnormality. Treatment with ␣-blockers, anti-inflammatories, steroids and/or pentoxyphylline/vitamin E failed to help. However, detailed dosimetric evaluation demonstrated higher central prostate radiation doses compared to our general brachytherapy population.7 Our group will continue intense evaluation of potential predisposing factors and management of brachytherapy related morbidity, including chronic pelvic pain.8 1. Robert, R., Prat-Pradal, D., Labat, J. J., Bensignor, M., Raoul, S., Rebai, R. et al: Anatomic basis of chronic perineal pain: role of the pudendal nerve. Surg Radiol Anat, 20: 93, 1998 2. Fajardo, L.-G. L. F., Berthrong, M. and Anderson, R. E.: Nervous system; peripheral nerves. In: Radiation Pathology. New York: Oxford University Press, chapt. 23, p. 362, 2001 3. Antolak, S. J., Hough, D. M. and Pawlina, W.: The chronic pelvic pain syndrome after brachytherapy for carcinoma of the prostate. J Urol, 167: 2525, 2002 4. Hough, D. M., Wittenberg, K. H., Pawlina, W., Maus, T. P., King, B. F., Vrtiska, T. J. et al: Chronic perineal pain caused by pudendal nerve entrapment: anatomy and CT-guided perineural injection technique. AJR Am J Roentgenol, 181: 561, 2003 5. Spinner, R.: Personal communication, April 2003 6. Zincke, H.: Personal communication, March 2003 7. Wallner, K., Elliot, K., Merrick, G., Ghaly, M. and Maki, J.: Chronic pelvic pain following prostate brachytherapy. Unpublished data 8. Merrick, G. S., Wallner, K. E. and Butler, W. M.: Minimizing prostate brachytherapy-related morbidity. Unpublished data DOI: 10.1097/01.ju.0000095266.31942.84
RE: PRETREATMENT TOTAL TESTOSTERONE LEVEL PREDICTS PATHOLOGICAL STAGE IN PATIENTS WITH LOCALIZED PROSTATE CANCER TREATED WITH RADICAL PROSTATECTOMY J. C. Massengill, L. Sun, J. W. Moul, H. Wu, D. G. McLeod, C. Amling, R. Lance, J. Foley, W. Sexton, L. Kusuda, A. Chung, D. Soderdahl and T. Donahue J Urol, 169: 1670 –1675, 2003 To the Editor. The authors tested pretreatment total serum testosterone level as a potential staging and prognostic marker in a cohort of 879 patients with localized prostate cancer. They concluded, after multivariate analysis, that pretreatment total testosterone is an independent predictor of extraprostatic disease in patients with localized prostate cancer treated with radical prostatectomy. The authors state that they used the 1992 TNM classification for staging the extent of disease in their patients with prostate cancer. They also state in the methods section that they defined organ confined disease as pT1 and pT2 tumors. Similarly, table 3 in the article shows that 514 patients had “pT2 or lower” disease. The TNM classification is a dual system with a pretreatment clinical classification (cTNM or TNM) and a postoperative pathological classification (pTNM).1–3 To our knowledge pT1 tumors do not exist in the TNM classification system for prostate cancer. Given this fact, we wonder whether the statistical correlation between preoperative serum testosterone and prostate cancer stage is valid. Respectfully, Rabi Tiguert and Brant A. Inman Division of Urology Centre de Recherche L’Hoˆ tel Dieu Que´ bec Centre Hospitalier universitaire de Que´ bec 11, Coˆ te du Palais Que´ bec, Canada G1R2J6 1. Beahrs, O. H.: Handbook for staging of cancer. In: AJCC Manual for Staging of Cancer, 4th ed. Philadelphia: J. B. Lippincott Co., p. 189, 1992 2. Sobin, L. H. and Wittekind, C.: TNM Classification of Malignant Tumours, 5th ed. New York: Wiley-Liss, p. 172, 1997 3. Sobin, L. H. and Wittekind, C.: TNM Classification of Malignant Tumours, 6th ed. New York: Wiley-Liss, p. 184, 2002
Reply by Authors. We appreciate the letter from Tiguert and Inman and their careful reading of our article. It is always gratifying to know that others in the field are reading one’s work. They are correct in noting the error in our use of the 1992 TNM classification. There is, in fact, no “pT1” in this system. On reviewing our data none of our 879 cases were staged as pT1, but we did find 1 case that was pT0, with no tumor found in the radical prostatectomy specimen even though review of the preoperative biopsy showed prostate cancer. The remaining 878 cases were stage pT2 or higher. The classification “pT2 or lower” in table 3 referred to this single pT0 case. In retrospect this would have been better noted in a footnote stating that the dataset contained 1 pT0 case. This single case of pT0 does not change the results of the study—that a low pretreatment total serum testosterone level was an independent predictor of pT3 or greater prostate cancer. We apologize for any confusion this may have caused and again thank the correspondents for their attention to detail. DOI: 10.1097/01.ju.0000095148.84868.ba
RE: RANDOMIZED CONTROLLED TRIAL OF ZOLEDRONIC ACID TO PREVENT BONE LOSS IN MEN RECEIVING ANDROGEN DEPRIVATION THERAPY FOR NONMETASTATIC PROSTATE CANCER M. R. Smith, J. Eastham, D. M. Gleason, D. Shasha, S. Tchekmedyian and N. Zinner J Urol, 169: 2008 –2012, 2003 To the Editor. Mineralization of bone in males and females is mediated by estrogen from embryonic development onward.1 Estrogen is a metabolite of testosterone in males and females. Therefore,
LETTERS TO THE EDITOR
We have treated 7 men with radiation neuritis, all with distinct benefit (approximately 1.0% of total men seen with pudendal neuralgia). The National Institutes of Health Chronic Prostatitis Symptom Index is used in all men to measure pain, voiding and quality of life scores before, during and after therapy. This validated pain score includes pain questions that are not a component of any of the scores mentioned in these review articles. Only “crampy abdominal pain” is discussed in those pain scores. Our patient group includes 2 men with external beam therapy only, 4 with brachytherapy only, and 1 with combined brachytherapy and external beam radiotherapy. We have computerized tomography images that show seeds misplaced into Alcock’s canal and the pelvic wall. Seeds at the apex are commonly in position to give greater than therapeutic doses of radiation therapy to the neurovascular bundle. Two additional men with “prostatitis-like pains” had necrotic sloughing prostate tissue. They responded briefly to conservative therapy but required prostatocystectomy and urinary diversion for pain relief.6 Onset of symptoms may occur 1 to several months after completing brachytherapy. In men receiving combined therapy usually the symptom onset is late in the course of the external beam therapy component. Brachytherapy for carcinoma of the prostate is a scientific endeavor with uncertain physical outcomes. Pudendal neuralgia (the chronic pelvic pain syndrome) is a serious complication of pelvic radiation therapy and has been recognized in patients with gynecological and colorectal cancer. Urologists need to be aware of this problem and use appropriate questionnaires in addition to the ones discussed in these review articles. Respectfully, Stanley J. Antolak, Jr. Department of Urology Mayo Clinic 200 First St., SW Rochester, Minnesota 55905
Reply by Merrick et al. Antolak’s insight and suggestions regarding this phenomenon are appreciated.3 In our group the development of chronic pelvic pain following permanent prostate brachytherapy has occurred in 3 of an approximate 2,500 implants (incidence 0.12%). Each of these 3 patients described deep pelvic pain that was worse with urination and was exacerbated by prolonged sitting or walking, with all remaining clinically functional without suicidal ideation. Neither cystoscopy, computerized tomography nor magnetic resonance imaging identified any physical or radiographic abnormality. Treatment with ␣-blockers, anti-inflammatories, steroids and/or pentoxyphylline/vitamin E failed to help. However, detailed dosimetric evaluation demonstrated higher central prostate radiation doses compared to our general brachytherapy population.7 Our group will continue intense evaluation of potential predisposing factors and management of brachytherapy related morbidity, including chronic pelvic pain.8 1. Robert, R., Prat-Pradal, D., Labat, J. J., Bensignor, M., Raoul, S., Rebai, R. et al: Anatomic basis of chronic perineal pain: role of the pudendal nerve. Surg Radiol Anat, 20: 93, 1998 2. Fajardo, L.-G. L. F., Berthrong, M. and Anderson, R. E.: Nervous system; peripheral nerves. In: Radiation Pathology. New York: Oxford University Press, chapt. 23, p. 362, 2001 3. Antolak, S. J., Hough, D. M. and Pawlina, W.: The chronic pelvic pain syndrome after brachytherapy for carcinoma of the prostate. J Urol, 167: 2525, 2002 4. Hough, D. M., Wittenberg, K. H., Pawlina, W., Maus, T. P., King, B. F., Vrtiska, T. J. et al: Chronic perineal pain caused by pudendal nerve entrapment: anatomy and CT-guided perineural injection technique. AJR Am J Roentgenol, 181: 561, 2003 5. Spinner, R.: Personal communication, April 2003 6. Zincke, H.: Personal communication, March 2003 7. Wallner, K., Elliot, K., Merrick, G., Ghaly, M. and Maki, J.: Chronic pelvic pain following prostate brachytherapy. Unpublished data 8. Merrick, G. S., Wallner, K. E. and Butler, W. M.: Minimizing prostate brachytherapy-related morbidity. Unpublished data DOI: 10.1097/01.ju.0000095266.31942.84
RE: PRETREATMENT TOTAL TESTOSTERONE LEVEL PREDICTS PATHOLOGICAL STAGE IN PATIENTS WITH LOCALIZED PROSTATE CANCER TREATED WITH RADICAL PROSTATECTOMY J. C. Massengill, L. Sun, J. W. Moul, H. Wu, D. G. McLeod, C. Amling, R. Lance, J. Foley, W. Sexton, L. Kusuda, A. Chung, D. Soderdahl and T. Donahue J Urol, 169: 1670 –1675, 2003 To the Editor. The authors tested pretreatment total serum testosterone level as a potential staging and prognostic marker in a cohort of 879 patients with localized prostate cancer. They concluded, after multivariate analysis, that pretreatment total testosterone is an independent predictor of extraprostatic disease in patients with localized prostate cancer treated with radical prostatectomy. The authors state that they used the 1992 TNM classification for staging the extent of disease in their patients with prostate cancer. They also state in the methods section that they defined organ confined disease as pT1 and pT2 tumors. Similarly, table 3 in the article shows that 514 patients had “pT2 or lower” disease. The TNM classification is a dual system with a pretreatment clinical classification (cTNM or TNM) and a postoperative pathological classification (pTNM).1–3 To our knowledge pT1 tumors do not exist in the TNM classification system for prostate cancer. Given this fact, we wonder whether the statistical correlation between preoperative serum testosterone and prostate cancer stage is valid. Respectfully, Rabi Tiguert and Brant A. Inman Division of Urology Centre de Recherche L’Hoˆ tel Dieu Que´ bec Centre Hospitalier universitaire de Que´ bec 11, Coˆ te du Palais Que´ bec, Canada G1R2J6 1. Beahrs, O. H.: Handbook for staging of cancer. In: AJCC Manual for Staging of Cancer, 4th ed. Philadelphia: J. B. Lippincott Co., p. 189, 1992 2. Sobin, L. H. and Wittekind, C.: TNM Classification of Malignant Tumours, 5th ed. New York: Wiley-Liss, p. 172, 1997 3. Sobin, L. H. and Wittekind, C.: TNM Classification of Malignant Tumours, 6th ed. New York: Wiley-Liss, p. 184, 2002
Reply by Authors. We appreciate the letter from Tiguert and Inman and their careful reading of our article. It is always gratifying to know that others in the field are reading one’s work. They are correct in noting the error in our use of the 1992 TNM classification. There is, in fact, no “pT1” in this system. On reviewing our data none of our 879 cases were staged as pT1, but we did find 1 case that was pT0, with no tumor found in the radical prostatectomy specimen even though review of the preoperative biopsy showed prostate cancer. The remaining 878 cases were stage pT2 or higher. The classification “pT2 or lower” in table 3 referred to this single pT0 case. In retrospect this would have been better noted in a footnote stating that the dataset contained 1 pT0 case. This single case of pT0 does not change the results of the study—that a low pretreatment total serum testosterone level was an independent predictor of pT3 or greater prostate cancer. We apologize for any confusion this may have caused and again thank the correspondents for their attention to detail. DOI: 10.1097/01.ju.0000095148.84868.ba
RE: RANDOMIZED CONTROLLED TRIAL OF ZOLEDRONIC ACID TO PREVENT BONE LOSS IN MEN RECEIVING ANDROGEN DEPRIVATION THERAPY FOR NONMETASTATIC PROSTATE CANCER M. R. Smith, J. Eastham, D. M. Gleason, D. Shasha, S. Tchekmedyian and N. Zinner J Urol, 169: 2008 –2012, 2003 To the Editor. Mineralization of bone in males and females is mediated by estrogen from embryonic development onward.1 Estrogen is a metabolite of testosterone in males and females. Therefore,