Supervivencia del cáncer de próstata resistente a la castración en la práctica clínica y el papel del tratamiento / Survival of Castration-Resistant Prostate Cancer in Clinical Practice and the Role of Treatment

Resumen Objetivo: Evaluar en un contexto de práctica clínica la ventaja de supervivencia para pacientes con cáncer de próstata resistente a castración (CPRC) tratado activamente con diversos tratamientos que incluyen acetato de abiraterona (AA) y prednisona con o sin docetaxel. Material y método: Se analiza la supervivencia de pacientes con CPRC y se compara un grupo tratado con AA y prednisona (n = 33) con un control histórico formado por pacientes consecutivos tratados una década antes en la misma institución exclusivamente con retirada de antiandrógeno y medidas paliativas (n = 31). Se analizan variables clínico-patológicas predictivas de pronóstico en la población activamente tratada. Se evalúa la respuesta global a AA y el intervalo libre de progresión radiológica. Resultados: La supervivencia cáncer específica a 2 años fue 79% para pacientes tratados activamente y 17,2% para control (log-rank, p < 0,0001). Cinco de 13 pacientes con AA post-docetaxel (38,5%) recibieron después de AA quimioterapia de segunda línea (4 cabazitaxel y 1 vinorelbina) y 1 (7,7%) hormonoterapia con enzalutamida. Tres de 20 pacientes tratados con AA sin quimioterapia (15%) recibieron enzalutamida y solo 1 (5%) fue tratado con docetaxel. Los pacientes de menor edad (<65años; p = 0,02) y sin metástasis al diagnóstico (p = 0,04) tuvieron mejor pronóstico. Aquellos de PSA más alto (>45ng/ml; p = 0,09) y patrón de Gleason 5 en la biopsia se comportaron de manera más desfavorable. Globalmente el 75,8% tuvieron respuesta a AA (80% pre- y 69,2% post-quimioterapia; p = 0,1) y el 52,4% estuvieron libre de progresión radiológica al año (47,9% pre y 49,8% post-quimioterapia; log-rank, p = 0,3). Conclusión: El tratamiento de pacientes con CPRC prolonga la expectativa de supervivencia en un entorno de práctica clínica y es posible identificar factores predictivos de pronóstico en estos pacientes.

Abstract Purpose: To assess, in a clinical practice context, the survival advantages of patients with castration-resistant prostate cancer (CRPC) actively treated with several treatments that include abiraterone acetate (AA) and prednisone, with or without docetaxel. Material and Methods: An analysis was performed on patient survival with CRPC, and was compared to a group treated with AA and prednisone (n = 33), with a historical control treated exclusively with anti-androgen withdrawal and palliative measures (n = 31). In the population actively treated, variables predictive of prognosis were analysed, as well as an evaluation of the overall response to AA and radiographic progression-free survival. Results: Cancer-specific survival at 2 years was 79% for patients actively treated and 17.2% for control group (P<.0001). Five (38.5%) of 13 patients treated with AA post-docetaxel received second-line chemotherapy after AA (4 cabazitaxel, 1 vinorelbine), and one (7.7%) enzalutamide. Three (15%) of 20 patients treated with AA without chemotherapy received enzalutamide and 1(5%) docetaxel. The younger patients (<65yrs; P=.02) without metastases at diagnosis (P=.04) had better prognoses. Patients with higher PSA levels (>45 ng/ml; P=.09) and a Gleason pattern 5 in the biopsy had less favourable outcomes. There was a 75.8% over response to AA (80% preand 69.2%post-chemotherapy; P=.1), and 69.2%post-chemotherapy; P=.1), and 52.4% were radiographic progression-free at 1 year of treatment (47.9% pre- and 49.8% post-chemotherapy; P=.3). Conclusion: Treatment of CRPC patients extends survival expectations in a clinical practice setting and prognostic predictors can be identified in these patients.

Partial splenic embolization to permit continuation of systemic chemotherapy.

Systemic chemotherapy treatments, commonly those that comprise oxaliplatin, have been linked to the appearance of distinctive liver lesions that evolves to portal hypertension, spleen enlargement, platelets sequestration, and thrombocytopenia. This outcome can interrupt treatment or force dosage reduction, decreasing efficiency of cancer therapy. We conducted a prospective phase II study for the evaluation of partial splenic embolization in patients with thrombocytopenia that impeded systemic chemotherapy continuation. From August 2014 through July 2015, 33 patients underwent partial splenic embolization to increase platelets count and allow their return to treatment. Primary endpoint was the accomplishment of a thrombocyte level superior to 130 × 109 /L and the secondary endpoints were the return to chemotherapy and toxicity. Partial splenic embolization was done 36 times in 33 patients. All patients presented gastrointestinal cancer and colorectal malignancy was the commonest primary site. An average of 6.4 cycles of chemotherapy was done before splenic embolization and the most common regimen was Folfox. Mean platelet count prior to embolization was 69 × 109 /L. A total of 94% of patients achieved primary endpoint. All patients in need reinitiated treatment and median time to chemotherapy return was 14 days. No grade 3 or above adverse events were identified. Aiming for a 50% to 70% infarction area may be sufficient to achieve success without the complications associated with more extensive infarction. Combined with the better safety profile, partial splenic embolization is an excellent option in the management of thrombocytopenia, enabling the resumption of systemic chemotherapy with minimal procedure-related morbidity.

Hepatic arterial infusion plus systemic chemotherapy as third-line or later treatment in colorectal liver metastases.

BACKGROUNDS: The present study aimed to evaluate benefit of hepatic arterial infusion chemotherapy (HAI) combined with systemic chemotherapy (SCT) for patients with colorectal liver metastases (CLMs) in a palliative setting. METHODS: This was a retrospective single-center study including 43 consecutive patients with CLM after failure of standard SCT. Among them, 20 (47 %) patients underwent HAI combined with SCT (Group A) and 23 historical control patients who had received SCT with or without targeted agent treatment (Group B). RESULTS: The two groups had similar characteristics. Compared with SCT alone, HAI combined with SCT prolonged survival (median 19.8 vs. 9.0 months; P = 0.045). Median hepatic progression-free survival was significantly longer for HAI combined with SCT vs. SCT alone (median 8.1 vs. 4.7 months; P = 0.027), as were response rates (25 and 0 %; P = 0.038) and progression-free survival (median 5.7 vs. 3.0 months; P = 0.02). Three patients (15 %) achieved conversion to potentially curative surgery. Grade 3/4 toxicities for Group A and Group B were neutropenia (5 and 8.7 %, respectively), anemia (5 and 0 %, respectively), and hyperbilirubinemia (0 and 4.3 %, respectively). Other complications were mostly grade 1 or 2. CONCLUSIONS: HAI combined with SCT treatment can improve overall survival compared with SCT alone in highly advanced CLM refractory to intravenous chemotherapy.