What's known on the subject? and What does the study add?
The benefits of androgen deprivation therapy (ADT) are well recognized and a multitude of studies have documented the benefits of ADT in ...conjunction with other therapies. Given the widespread use of ADT due to its important clinical implications, it is imperative that clinicians understand the side effects to limit treatment‐related morbidity. There are numerous well recognized adverse effects of ADT, including vasomotor flushing, loss of libido and impotence, fatigue, gynaecomastia, anaemia, osteoporosis and metabolic complications, as well as effects on cardiovascular health and bone density.
Present study focuses on the most recent evidence‐based treatment options for various side effects of ADT.
Objective
To familiarize clinicians with the various side effects of androgen deprivation therapy (ADT). The present study focuses on the most recent evidence‐based treatment strategies for the common side effects of ADT.
Methods
A PubMed database search was conducted from 2000 to 2012.
All prospective clinical studies were selected, including randomized and non‐randomized clinical trials, as well as meta‐analysis studies concerning preventive and therapeutic interventions for various side effects of ADT.
‘The Oxford 2011 Levels of Evidence’ classification system for treatment benefits was used to categorize selected studies.
Results
Gabapentin shows moderate efficacy for the long‐term treatment of hot flashes in a dose‐dependent manner.
A combined resistance/aerobic exercise programme leads to significant improvement in fatigue, sexual function and cognitive function. A home‐based/group exercise programme also improves fatigue and unfavourable metabolic changes.
Denosumab increases lumbar spine, hip and radius bone mass density, and also reduces the risk of vertebral fractures in men receiving ADT for non‐metastatic prostate cancer.
Metformin coupled with lifestyle intervention is a safe, well‐tolerated intervention for adverse metabolic changes. Toremifene improves the lipid profile.
Intermittent ADT improves early side effects, such as hot flashes, sexual activity, fatigue, and quality of life, although its effect on long‐term side effects remains inconclusive.
Conclusion
Despite significant improvement in management strategies for the side effects of ADT, the best way of preventing side effects is to use ADT only when it is absolutely indicated.
Introduction
The management of clinical stage II seminoma has evolved with a recent emphasis on minimizing long-term morbidity while achieving oncologic cure.
Methods
In this review we discuss the ...available management options for clinical stage II seminoma with an emphasis on the emerging role of surgery in this patient population.
Results
Historically, treatment options available to clinical stage II seminoma patients were limited to radiotherapy and chemotherapy. Survival rates with these options are excellent; however, both are associated with significant long-term morbidities including cardiovascular, pulmonary, and neurologic toxicities. Additionally, higher rates of secondary malignancies are witnessed in this young patient population, decades after successful treatment of the primary cancer. Recently, retroperitoneal lymph node dissection has been proposed as a first-line treatment option for patients with low-volume metastatic seminoma.
Conclusion
The SEMS and PRIMETEST trials are two studies examining the role of primary retroperitoneal lymph node dissection in clinical stage II seminoma, and early data show significant promise.
Purpose Although associated with an overall favorable survival rate, the heterogeneity of non-muscle invasive bladder cancer (NMIBC) affects patients’ rates of recurrence and progression. Risk ...stratification should influence evaluation, treatment and surveillance. This guideline attempts to provide a clinical framework for the management of NMIBC. Materials and Methods A systematic review utilized research from the Agency for Healthcare Research and Quality (AHRQ) and additional supplementation by the authors and consultant methodologists. Evidence-based statements were based on body of evidence strength Grade A, B, or C and were designated as Strong, Moderate, and Conditional Recommendations with additional statements presented in the form of Clinical Principles or Expert Opinions. Results A risk-stratified approach categorizes patients into broad groups of low-, intermediate-, and high-risk. Importantly, the evaluation and treatment algorithm takes into account tumor characteristics and uniquely considers a patient’s response to therapy. The 38 statements vary in level of evidence, but none include Grade A evidence, and many were Grade C. Conclusion The intensity and scope of care for NMIBC should focus on patient, disease, and treatment response characteristics. This guideline attempts to improve a clinician’s ability to evaluate and treat each patient, but higher quality evidence in future trials will be essential to improve level of care for these patients.
Purpose Enhanced recovery after surgery protocols aim to improve patient care and decrease complications and hospital stay. We evaluated our enhanced recovery after surgery protocol, focusing on ...length of stay, early complication and readmission rates after radical cystectomy for bladder cancer. Materials and Methods From May 2012 to July 2013 a perioperative protocol was applied in 126 consecutive patients who underwent open radical cystectomy and urinary diversion. Nonconsenting patients (2), those with previous diversion (2) and prolonged postoperative intubation (3), and those who underwent additional surgery (9) were excluded from study. The protocol focuses on avoiding bowel preparation and nasogastric tube, early feeding, nonnarcotic pain management and the use of cholinergic and μ-opioid antagonists. Outcomes were compared to those in matched controls from our bladder cancer database. Results A total of 110 patients with a median age of 69 years were included in analysis, of whom 68% underwent continent urinary diversion. Of the patients 82% had a bowel movement by postoperative day 2. Median length of stay was 4 days. The 30-day minor and major complication rates were 64% and 14%, respectively. The most common minor complication was anemia requiring transfusion in 19% of patients, urinary tract infection in 13% and dehydration in 10%. The latter 2 complications were the most common etiologies for readmission. The 30-day readmission rate was 21% (23 patients). Patients 75 years old or older had a longer length of stay (5 vs 4 days, p = 0.03) and a higher minor complication rate (72% vs 51%, p = 0.04) than younger patients. Conclusions Our enhanced recovery after surgery protocol expedites bowel function recovery and shortens hospital stay after RC and urinary diversion without an increase in the hospital readmission rates.
Abstract Purpose This article aims to critically review the current recommendations with regard to the role of surgery following salvage chemotherapy, growing teratoma syndrome, late relapse, as well ...as malignant transformation. Methods All the literature published in English and available on Pubmed pertaining to refractory germ cell tumors was reviewed and the relevant articles, as well as our own institutional experience were included in this review. Results There is universal agreement that patients with non-seminoma who have residual tumor measuring greater than one centimeter should undergo post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) for resection of potential teratoma or viable germ cell tumor. The role of surgical resection is less clear in patients who are deemed to have germ cell tumors refractory to chemotherapy. Patients with residual masses following second line therapy, those with growing teratoma, late relapse, and malignant transformation should all be considered for upfront surgical resection. Compared with the typical PC-RPLND, these operations are generally more complex, with a higher proportion requiring adjunctive procedures; and should be performed in experienced, tertiary referral centers. Conclusion Patients who have complete resection of disease are sill curable and patients with chemorefractory disease should have evaluation by an expert surgeon.
The role of cytoreductive nephrectomy (CN) in the management of metastatic renal cell carcinoma (mRCC) in the targeted therapy (TT) era is controversial.
To assess if CN versus no CN is associated ...with improved overall survival (OS) in patients with mRCC treated in the TT era and beyond, characterize the morbidity of CN, identify prognostic and predictive factors, and evaluate outcomes following treatment sequencing.
Medline, EMBASE, and Cochrane databases were searched from inception to June 4, 2018 for English-language clinical trials, cohort studies, and case-control studies evaluating patients with mRCC who underwent and those who did not undergo CN. The primary outcome was OS. Risk of bias was evaluated using the Cochrane Collaborative tools.
We identified 63 reports on 56 studies. Risk of bias was considered moderate or serious for 50 studies. CN was associated with improved OS among patients with mRCC in 10 nonrandomized studies, while one randomized trial (CARMENA) found that OS with sunitinib alone was noninferior to that with CN followed by sunitinib. The risk of perioperative mortality and Clavien ≥3 complications ranged from 0% to 10.4% and from 3% to 29.4%, respectively, with no meaningful differences between upfront CN or CN after presurgical systemic therapy (ST). Notably, 12.9–30.4% of patients did not receive ST after CN. Factors most consistently prognostic of decreased OS were progression on presurgical ST, high C-reactive protein, high neutrophil-lymphocyte ratio, poor International Metastatic renal cell carcinoma Database Consortium (IMDC)/Memorial Sloan Kettering Cancer Center (MSKCC) risk classification, sarcomatoid dedifferentiation, and poor performance status. At the same time, good performance status and good/intermediate IMDC/MSKCC risk classification were most consistently predictive of OS benefit with CN. In a randomized trial investigating the sequence of CN and ST (SURTIME), an OS trend was observed with CN after a period of ST in patients without progression compared with upfront CN. However, the study was underpowered and results are exploratory.
Currently, ST should be prioritized in the management of patients with de novo mRCC who require medical therapy. CN maintains a role in patients with limited metastatic burden amenable to surveillance or metastasectomy, and may potentially be considered in patients with favorable response after initial ST or for symptom's palliation.
In the contemporary era, receiving systemic therapy is the priority in metastatic kidney cancer. Nephrectomy still has a role in patients with limited burden of metastases, well-selected patients based on established prognostic and predictive factors, and patients with a favorable response after initial systemic therapy.
In the targeted therapy era and beyond, systemic therapy is a priority in the management of de novo metastatic renal cell carcinoma. However, cytoreductive nephrectomy still has a role in patients with limited metastatic burden amenable to surveillance or metastasectomy, well-selected patients based on established prognostic and predictive factors, and patients with a favorable response after initial systemic therapy.
The role of surgery in metastatic bladder cancer (BCa) is unclear.
In this collaborative review article, we reviewed the contemporary literature on the surgical management of metastatic BCa and ...factors associated with outcomes to support the development of clinical guidelines as well as informed clinical decision-making.
A systematic search of English language literature using PubMed-Medline and Scopus from 1999 to 2016 was performed.
The beneficial role of consolidation surgery in metastatic BCa is still unproven. In patients with clinically evident lymph node metastasis, data suggest a survival advantage for patients undergoing postchemotherapy radical cystectomy with lymphadenectomy, especially in those with measurable response to chemotherapy (CHT). Intraoperatively identified enlarged pelvic lymph nodes should be removed. Anecdotal reports of resection of pulmonary metastasis as part of multimodal approach suggest possible improved survival in well-selected patients. Cytoreductive radical cystectomy as local treatment has also been explored in patients with metastatic disease, although its benefits remain to be assessed.
Consolidative extirpative surgery may be considered in patients with clinically evident pelvic or retroperitoneal lymph nodal metastases but only if they have had a response to CHT. Surgery for limited pulmonary metastases may also be considered in very selected cases. Best candidates are those with resectable disease who demonstrate measurable response to CHT with good performance status. In the absence of data from prospective randomized studies, each patient should be evaluated on an individual basis and decisions made together with the patient and multidisciplinary teams.
Surgical resection of metastases is technically feasible and can be safely performed. It may help improve cancer control and eventually survival in very selected patients with limited metastatic burden. In a patient who is motivated to receive chemotherapy and to undergo extirpative surgical intervention, surgery should be discussed with the patient among other consolidation therapies in the setting of multidisciplinary teams.
A multimodal approach that includes radical cystectomy and lymphadenectomy seems to improve cancer control and survival in bladder cancer patients with nodal metastasis. Metastasectomy is feasible and can be safely performed with a possible survival advantage in well-selected patients.
The introduction of cisplatin-based chemotherapy has revolutionized the care of patients with disseminated testicular germ cell tumors. Although a majority are cured with chemotherapy alone, surgical ...resection continues to play a role because one-third will have residual mass after chemotherapy. In this article, we review the current indications for postchemotherapy resection in nonseminomatous germ cell tumors, including masses greater than 1 cm, resection after salvage chemotherapy, with elevated markers, after late relapse, and for growing teratoma syndrome. We also highlight technical considerations of this often-challenging surgery, including the need for adjunctive procedures, extraretroperitoneal resections, and modern techniques to minimize morbidity.
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