Multiparametric Magnetic Resonance Imaging Predicts Postoperative Pathology but Misses Aggressive Prostate Cancers as Assessed by Cell Cycle Progression Score

PURPOSE

We identified prognostic biomarkers in prostate cancer by a radiogenomics strategy that integrates gene expression using the cell cycle progression score and medical images.

MATERIALS AND METHODS

We obtained institutional review board approval and written informed consent from 106 men with prostate cancer, including 60% at low risk, who underwent multiparametric magnetic resonance imaging before radical prostatectomy was done and a cell cycle progression score was determined. The correlation between the results of multiparametric magnetic resonance imaging and Gleason grade or cell cycle progression score was assessed by logistic regression.

RESULTS

Patients with primary Gleason grade greater than 3 had a longer median maximal tumor diameter (13 vs 10 mm) and a lower median apparent diffusion coefficient (0.745 vs 0.88×10(-3) mm2 per second, each p=0.0001) than those with primary Gleason grade 3 or less. Maximal diameter 10 mm or greater (OR 4.9, 95% CI 1.7 to 14.0, p=0.0012) and apparent diffusion coefficient 0.80×10(-3) mm2 per second or less (OR 7.5, 95% CI 3.0 to 18.7, p<0.0001) were significantly associated with primary Gleason grade greater than 3. The combined measure of maximal diameter less than 10 mm and apparent diffusion coefficient greater than 0.80×10(-3) mm2 per second identified only index lesions harboring primary Gleason grade 3. However, 7 of those lesions showed a molecular pattern of high risk lethal prostate cancer (cell cycle progression score greater than 0).

CONCLUSIONS

Multiparametric magnetic resonance imaging is able to predict low and high risk Gleason scores in the tumor. However, the cell cycle progression score did not completely match the imaging result. These findings suggest that management of early stages prostate cancer could strongly benefit by performing magnetic resonance imaging targeted biopsy coupled with molecular analysis.

Accuracy of the prostate health index versus the urinary prostate cancer antigen 3 score to predict overall and significant prostate cancer at initial biopsy

BACKGROUND

It remains unclear whether the Prostate Health Index (PHI) or the urinary Prostate-Cancer Antigen 3 (PCA-3) score is more accurate at screening for prostate cancer (PCa). The aim of this study was to prospectively compare the accuracy of PHI and PCA-3 scores to predict overall and significant PCa in men undergoing an initial prostate biopsy.

METHODS

Double-blind assessments of PHI and PCA-3 were conducted by referent physicians in 138 patients who subsequently underwent trans-rectal ultrasound-guided prostate biopsy according to a 12-core scheme. Predictive accuracies of PHI and PCA-3 were assessed using AUC and compared according to the DeLong method. Diagnostic performances with usual cut-off values for positivity (i.e., PHI >40 and PCA-3 >35) were calculated, and odds ratios associated with predicting PCa overall and significant PCa as defined by pathological updated Epstein criteria (i.e., Gleason score ≥7, more than three positive cores, or >50% cancer involvement in any core) were estimated using logistic regression.

RESULTS

Prevalences of overall and significant PCa were 44.9% and 28.3%, respectively. PCA-3 (AUC = 0.71) was the most accurate predictor of PCa overall, and significantly outperformed PHI (AUC = 0.65; P = 0.03). However, PHI (AUC = 0.80) remained the most accurate predictor when screening exclusively for significant PCa and significantly outperformed PCA-3 (AUC = 0.55; P = 0.03). Furthermore, PCA-3 >35 had the best accuracy, and positive or negative predictive values when screening for PCa overall whereas these diagnostic performances were greater for PHI >40 when exclusively screening for significant PCa. PHI > 40 combined with PCA-3 > 35 was more specific in both cases. In multivariate analyses, PCA-3 >35 (OR = 5.68; 95%CI = [2.21-14.59]; P < 0.001) was significantly correlated with the presence of PCa overall, but PHI >40 (OR = 9.60; 95%CI = [1.72-91.32]; P = 0.001) was the only independent predictor for detecting significant PCa.

CONCLUSIONS

Although PCA-3 score is the best predictor for PCa overall at initial biopsy, our findings strongly indicate that PHI should be used for population-based screening to avoid over-diagnosis of indolent tumors that are unlikely to cause death.

Long-term functional outcomes after artificial urinary sphincter implantation in men with stress urinary incontinence

OBJECTIVE

To evaluate long-term functional outcomes of artificial urinary sphincters (AUSs) and to determine how many men required explantation because of stress urinary incontinence (SUI) caused by sphincter deficiency after prostate surgery.

PATIENTS AND METHODS

Men who had undergone placement of an AUS (American Medical Systems AMS 800®) between 1984 and 1992 to relieve SUI caused by sphincter deficiency after prostate surgery were included. Continence, defined as no need for pads, was assessed at the end of the follow-up. Kaplan-Meier survival curves estimated the survival rate of the device without needing explantation or revision.

RESULTS

In all, 57 consecutive patients were included with a median (interquartile range, IQR) age of 69 (64-72) years. The median (IQR) duration of follow-up was 15 (8.25-19.75) years. At the end of follow-up, 25 patients (43.8%) still had their primary AUS. The AUS was explanted in nine men because of erosion (seven) and infection (two). Survival rates, without AUS explantation, were 87%, 87%, 80%, and 80% at 5, 10, 15, and 20 years, respectively. Survival rates, without AUS revision, were 59%, 28%, 15%, and 5% at 5, 10, 15, and 20 years, respectively. At the end of the follow-up, in intention-to-treat analysis, 77.2% of patients were continent.

CONCLUSION

In the long term (>10 years) the AMS 800 can offer a high rate of continence to men with SUI caused by sphincter deficiency, with a tolerable rate of explantation and revision.

Botulinum toxin injections in the management of non-neurogenic overactive bladders in children

INTRODUCTION

Non-neurogenic detrusor overactivity in children leads to varying degrees of functional impairments (urinary urgency, pollakiuria, urge incontinence, nocturia). Botulinum toxin has shown its effectiveness in the management of detrusor overactivity in neurological patients.

OBJECTIVES

To evaluate the relevance of intravesical Botulinum toxin injections for the treatment of non-neurogenic overactive bladders in children. These pediatric patients were resistant to all the usual therapeutics (e.g. bladder/bowel rehabilitation, anticholinergic drugs, management of diet/hygiene habits and constipation, percutaneous posterior tibial nerve stimulation).

MATERIALS AND METHODS

8 children (mean age: 12.5years), 5 girls, 3 boys with daytime and/or nighttime incontinence and non-neurogenic detrusor overactivity validated by urodynamic testing. Urodynamic testing was conducted before the injections as well as 6weeks and 1year post injections. We used Dysport® 8 Speywood Units/kg injected via cystoscopy into 25 different sites.

RESULTS

We noted improvements without any complaints during bladder voiding for all patients, in 6 patients the overactivity disappeared after 1 injection. Compliance was improved early-on in half the cases and at 1year for all cases (from 12% to 61%, p=0.01). Noninhibited contractions decreased constantly in both frequency and intensity. Clinical symptoms improved: mean of 7.75 daytime urinary incontinence episodes (IE) per week before the injection vs. 3 after the procedure (p=0.04). For nighttime IE the improvement was even more noticeable with 7.38 nighttime IE episodes per week before the injection vs. 2.06 after the procedure (p=0,02).

CONCLUSION

Intradetrusor Botulinum toxin injections are a potential therapeutic option for the management of non-neurogenic detrusor overactivity in children resistant to the usual treatments.

[Influence of plasmatic testosterone during natural history of prostate cancer: a review]

INTRODUCTION

Prostate cancer (PCa) is the most common disease in male patients and it has the particularity to be androgen dependent. The aim of the current study was to provide an overview about the interest of testosterone dosage during the management of PCa regardless of the stage of the disease. PATIENTS ET METHODS: A systematic review of the literature was done from the PubMed database by searching the following key words alone or in combination: prostate cancer; testosterone; risk; aggressiveness; hormonotherapy; active surveillance; prognosis; androgen; cardiovascular risk; biochemical recurrence.

RESULTS

The level of plasmatic testosterone depends on the moment of the day with a peak between the end of the night and in the morning. We can test either the whole testosterone level, the free testosterone level or the bioavailable testosterone. The bioavailable testosterone is more representative of the presence of androgen in tissues but a specialized laboratory is mandatory. The testosterone plasmatic rate is potentially useful during several steps of the PCa management: in localized prostate cancer cases, men with low testosterone levels are more likely to have an aggressive disease and are therefore not good candidates for active surveillance. An extensive radical prostatectomy should be considered in case of young men since these patients are more likely to recur subsequently; in advanced prostate cancer cases, a testosterone level has to be less or equal to 0.2 ng/mL to guarantee an appropriate castration when a patient is undergoing an androgen deprivation treatment. A dissociation between the trend of PSA and testosterone levels can be the starting point of the castration-resistant period of the disease.

CONCLUSION

The testosterone level can bring useful information regarding the profile of PCa and its ability to evolve during the whole natural history of the disease.

Andropause (androgen deficiency of the aging male): diagnosis and management

Androgen deficiency of the aging male is a pathological syndrome and should not be viewed simply as a stage in physiological aging. It is often overlooked despite evidence for a deleterious impact on many physiological processes and on quality of life. Its identification should be part of the routine practice of physicians in charge of this population, in particular general practitioners and specialists treating associated comorbidities (e.g. metabolic syndrome, diabetes, cardiovascular disorders) or sexual dysfunction. The consultant urologist has a key role to play in prostate surveillance before and during treatment. Treatment is often simple with few side-effects. However, long-term benefits and side effects need to be investigated in prospective studies.

Relationship between the size and position of substituents on 7H-pyrido[4,3-c]carbazole monomers and dimers and their DNA binding and anti-tumor properties

Among the various DNA intercalating molecules prepared in our laboratory, ditercalinium, made up of two 7H-pyrido[4,3-c]carbazole rings linked by a rigid bis-ethylbipiperidine chain (NSC 366241) displays high anti-tumor properties. This dimeric molecule elicits its cytotoxicity through an original mechanism of action. At the molecular level, interaction of ditercalinium with the self-complementary d(CpGpCpG)2 nucleotide has been studied by 1H n.m.r. and the geometry of the bis-intercalating complex has been elucidated. Ditercalinium bis-intercalates through the major groove with the convex face of the 7H-pyrido[4,3-c]carbazole ring oriented toward the sugar moiety. Previous studies have shown the strong modulating effect brought about by substitution of the intercalating ring by methyl groups on both the DNA binding and anti-tumor potency of 7H-pyridocarbazole monomers and dimers. In order to further investigate structure activity relationships in the ditercalinium and related monomers series, a new family of monomeric and dimeric 7H-pyrido[4,3-c]carbazoles was prepared with ethyl, isopropyl or hydroxyethyl substitution on position 6 or 7 of the aromatic ring. DNA binding and anti-tumor potency of these compounds are reported. In contrast to their methylated analogs, none of the 6- or 7-substituted monomers studied here are active although most of them remain able to intercalate into DNA. Substitution of dimeric molecules by substituents of increasing size induces a progressive decrease in the anti-tumor potency, concomitantly with a disappearance of bis-intercalative properties. The modulating effect of the size of substituents on the DNA binding and anti-tumor properties of dimers is more pronounced in the 7-substituted series. These results are discussed in relation to the geometry of intercalation of ditercalinium and its related monomer into d(CpGpCpG)2.