Bloqueo androgénico total en el manejo del cáncer de próstata neuroendocrino / Androgen-deprivation therapy in the management of neuroendocrine prostate cancer

Introducción: El carcinoma prostático neuroendocrino constituye menos de 1 % de las neoplasias prostáticas, con menos de 200 casos en la literatura. El objetivo de esta investigación fue describir la experiencia en el manejo del carcinoma neuroendocrino de próstata con bloqueo androgénico total. Material y métodos: Estudio retrospectivo, descriptivo y observacional, en el que se revisaron los expedientes de pacientes con sospecha de cáncer de próstata sometidos a biopsia transrectal o resección transuretral de próstata, de enero de 2000 a diciembre de 2007. Fueron seleccionados pacientes con diagnóstico anatomopatológico de carcinoma neuroendocrino en sus variantes pura y mixta. Se analizó edad, estadio clínico, antígeno prostático específico, estudios de gabinete, tratamiento y sobrevida. Resultados: Se incluyeron 10 casos con edad media de 66.5 años; los síntomas al momento del diagnóstico estaban asociados a invasión metastásica a distancia, siendo el principal el dolor óseo. Se identificó un tacto sospechoso en todos los pacientes y solo en tres (30 %) el antígeno prostático específico fue sospechoso de cáncer. Los estudios de extensión determinaron actividad metastásica ósea, locorregional, pulmonar y hepática. En seis (60 %) se documentó la variante mixta (adenocarcinoma acinar más carcinoma neuroendocrino), con una sobrevida promedio de 11.6 meses, y en cuatro (40 %) se registró carcinoma neuroendocrino puro, con una sobrevida promedio de siete meses. Conclusiones: El carcinoma neuroendocrino de próstata es infrecuente, agresivo y un ejemplo de neoplasia prostática que no expresa el antígeno prostático específico, con mala respuesta al bloqueo androgénico total en etapa avanzada.

BACKGROUND: Prostatic neuroendocrine carcinomas comprise <1% of all prostate neoplasms, and approximately 200 cases have been reported in the literature. We undertook this study to describe the experience in the management of prostatic neuroendocrine carcinoma with androgen-deprivation therapy (ADT). METHODS: We designed a retrospective, descriptive and observational study. In patients with suspicion of prostate cancer, transrectal ultrasonography-guided biopsy (TRUS) or transurethral resection of prostate (TURP) was carried out during the period from January 2000 to December 2007. Patients were selected by anatomopathological diagnostic study of neuroendocrine carcinoma including pure and mixed variants. Characteristics analyzed were age, clinical stage, prostate-specific antigen (PSA), imaging studies, treatment and survival. RESULTS: Ten cases were included with a median age of 66.5 years. Symptoms at diagnosis were associated with metastasis to other organs, one with bone metastasis, and presenting pain in 100% of the cases. A suspicious rectal digital examination was detected in 100% of the patients. In three (30%) patients, PSA was suspicious for prostate cancer. The extension studies showed bone, locoregional, lung and hepatic metastases. In six (60%) patients mixed variant was documented (acinar adenocarcinoma and neuroendocrine carcinoma) with a median survival of 11.6 months. In four patients (40%), pure neuroendocrine carcinoma was documented with a median survival of 7 months. CONCLUSIONS: Prostatic neuroendocrine carcinoma is uncommon, aggressive and represents a prostatic neoplasia without PSA expression. In advanced disease, very low response is reached with ADT.

Dos métodos para la toma de biopsia transrectal de próstata ecodirigida: sistemática versus ecosospechosa / Two methods for transrectal ultrasound-guided biopsy of the prostate: systematic vs guided for suspect echogenic lesion

OBJECTIVE: We undertook this study to determine the efficiency of ultrasound-guided transrectal prostate biopsy applying two techniques: systematic extended vs. suspicious sonographic areas. METHODS: Medical files and histopathological reports were reviewed of patients who were treated at the Specialties Hospital of the 21st Century Medical National Center in Mexico City with suspicion of prostate cancer (T1, T2 and PSA <10 ng/ml). Patients had ultrasound-guided transrectal prostate biopsy applying two techniques: systematic extended vs. hypoechoic suspicious sonographic areas. Studies were carried out from January 1, 2005 to July 2006. RESULTS: Of 145 selected patients submitted to ultrasound-guided transrectal prostate biopsy, systematic extended biopsy (group I) was carried out in 73 (50.3%), taking on average 11.75 cylinders per patient. In 72 (49.6%) patients, biopsies were taken on suspicious sonographic areas (group II), taking on average 4.02 cylinders. In group I, 36 (49.3%) patients were positive vs. group II, where 20 (27.7%) patients were positive (p <0.01) with an estimation of risk in favor of group I, determining a probability 2.5 times higher of positivity with this technique (95% confidence interval: range 1.2-5) and a better performance in 22%. CONCLUSIONS: Systematic extended ultrasound-guided transrectal prostate biopsy represents a technique with a higher rate of efficiency than using ultrasound-guided transrectal prostate biopsy in suspicious sonographic areas and has proven over time to be the superior prostate biopsy technique for diagnosis of prostate cancer. It must be considered the method of choice.