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We have to be prepared for the coming new era of prostate cancer management. A number of new agents targeting the androgen–androgen receptor axis, including CYP17 antagonists and MDV3100, have been in development for castration-resistant prostate cancer (CRPC). Another important issue of prostate cancer is how to prolong or avoid becoming castration resistant. In this issue, two Review Articles focus on the daily management of hormonal treatment in prostate cancer.

Van Poppel (Leuven, Belgium) and Klotz (Toronto, Canada) reviewed an update of gonadotropin-releasing hormone. We have been using gonadotropin-releasing hormone (GnRH) agonists for many years as the established androgen-deprivation therapy (ADT). There are several drawbacks in using GnRH agonists, including initial testosterone surge-associated delays to reduce the testosterone to the castrated level. Furthermore, microsurges in testosterone levels occur each time GnRH agonists are injected. These phenomena with GnRH antagonists can be avoided. GnRH antagonists have the potential to delay the onset of CRPC. This review clearly provides useful information regarding GnRH antagonists based on recent clinical data.

Intermittent androgen deprivation (IAD) has been an option for ADT. At first, IAD was proposed based on the hypothesis that cycles of withdrawal and replacement of androgen could maintain androgen-dependent status, thus achieving a delay in CRPC. Gruca et al. (Ludwigshafen, Germany) reviewed IAD, focusing on safety and tolerability. As stated in the Editorial Comment by Akakura, when utilizing IAD in clinical practice, IAD has been recognized to have the benefit of reducing side-effects and improving the quality of life (QOL). A total of 13 clinical studies were analyzed in the review. Interestingly, the authors divided the side-effects into short-term and long-term side-effects. Short-term side-effects include hot flushes and sexual dysfunction. Long-term side-effects include bone loss, anemia, obesity and cardiovascular disease. In comparison with continuous androgen deprivation therapy, the benefits of IAD were observed for the short-term side-effects mainly during the off-treatment phase, whereas the data for the long-term side-effects were not as conclusive. This Review Article is of great help for considering the safety and QOL issues of ADT in daily practice.

Shifting our eyes to prostate cancer surgery, how many lymph nodes or how wide do we dissect lymph nodes in radical prostatectomy? Considering the low percentage of positive lymph nodes and uncertainty of the therapeutic role in wide resection, we have not paid much attention to the number of dissected lymph nodes. Abdollah et al. (Milan, Italy) showed informative data regarding the relationship between the extent of pelvic lymph node dissection (PLND) and the rate of lymph node metastases. They analyzed a large North American cohort that included 20 789 patients. The overall lymph node metastases rate was 2.5%. By receiver operating curve analyses, removing 20 lymph nodes yielded 90% probability of correctly staging lymph nodes metastases. Notably, the positive relationship between increasing lymph nodes count and the rate of pN1 was independent of serum prostate-specific antigen value, tumor stage or grade. This indicates that extended PLND warrants accurate staging.

Last but not least, precise prebiopsy evaluation of prostate cancer is another important issue in avoiding unnecessary biopsies and sampling errors. For this, magnetic resonance imaging (MRI) stands at the forefront providing anatomical, metabolic and physiological information. Kumar et al. (New Delhi, India) reviewed various MRI methods including proton magnetic resonance spectroscopy, diffusion weighted imaging and dynamic contrast enhanced MRI. These modalities have a role in the targeted biopsy sites, avoiding unnecessary biopsies and predicting the outcome of biopsies.

Conflict of interest

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  2. Conflict of interest

None declared.