Biochemical outcome after radical prostatectomy or external beam radiation therapy for patients with clinically localized prostate carcinoma in the prostate specific antigen era

Proteomic-based stratification of intermediate-risk prostate cancer patients

Gleason grading is an important prognostic indicator for prostate adenocarcinoma and is crucial for patient treatment decisions. However, intermediate-risk patients diagnosed in the Gleason grade group (GG) 2 and GG3 can harbour either aggressive or non-aggressive disease, resulting in under- or overtreatment of a significant number of patients. Here, we performed proteomic, differential expression, machine learning, and survival analyses for 1,348 matched tumour and benign sample runs from 278 patients. Three proteins (F5, TMEM126B, and EARS2) were identified as candidate biomarkers in patients with biochemical recurrence. Multivariate Cox regression yielded 18 proteins, from which a risk score was constructed to dichotomize prostate cancer patients into low- and high-risk groups. This 18-protein signature is prognostic for the risk of biochemical recurrence and completely independent of the intermediate GG. Our results suggest that markers generated by computational proteomic profiling have the potential for clinical applications including integration into prostate cancer management.

The importance of periprostatic fat tissue thickness measured by preoperative multiparametric magnetic resonance imaging in upstage prediction after robot-assisted radical prostatectomy

PURPOSE

We analyzed the surgical results of patients who were treated and followed up for prostate cancer in our clinic to predict the relationship between periprostatic adipose tissue and patients with and without pathologically upstaged disease.

MATERIALS AND METHODS

The study included patients who had undergone robot-assisted radical prostatectomy and preoperative multiparametric prostate magnetic resonance imaging between 18 February 2019 and 1 April 2022. The patients were divided into two groups, and the surgical and transrectal ultrasound-guided biopsy pathology results were compared according to tumor grade and distribution in 124 patients who met the selection criteria. We analyzed the relationships between upgrading/upstaging and periprostatic adipose tissue thickness (PPATT) and subcutaneous adipose tissue thickness (SATT) as measured in magnetic resonance imaging.

RESULTS

The median PPATT was 4.03 mm, whereas the median SATT was 36.4 mm. Upgrading was detected in 45 patients (36.3%), and upstaging was detected in 42 patients (33.9%). A receiver operating characteristic regression analysis revealed that a PPATT >3 mm was a predictive factor for upstaging after radical prostatectomy (area under curve=0.623, 95% confidence interval [CI] 0.519-0.727, p=0.025). Multivariate logistic regression analyses revealed that prostate specific antigen density ≥0.15 ng/mL/cm3 (odds ratio [OR] 5.054, 95% CI 2.008-12.724, p=0.001), International Society of Urological Pathology grade ≥4 (OR 9.369, 95% CI 2.109-21.626, p=0.003) and higher PPATT (OR 1.358, 95% CI 1.081-1.707, p=0.009) were independent risk factors for upstaging after radical prostatectomy.

CONCLUSIONS

We believe that the PPATT may be a predictive indicator for upstaging after robot-assisted laparoscopic radical prostatectomy.

[18F]DCFPyL PET/CT versus [18F]fluoromethylcholine PET/CT in Biochemical Recurrence of Prostate Cancer (PYTHON): a prospective, open label, cross-over, comparative study

PURPOSE

Primary objective was to compare the per-patient detection rates (DR) of [18F]DCFPyL versus [18F]fluoromethylcholine positron emission tomography/computed tomography (PET/CT), in patients with first prostate cancer (PCa) biochemical recurrence (BCR). Secondary endpoints included safety and impact on patient management (PM).

METHODS

This was a prospective, open label, cross-over, comparative study with randomized treatment administration of [18F]DCFPyL (investigational medicinal product) or [18F]fluoromethylcholine (comparator). Men with rising prostate-specific antigen (PSA) after initial curative therapy were enrolled. [18F]DCFPyL and [18F]fluoromethylcholine PET/CTs were performed within a maximum time interval of 12 days. DR was defined as the percentage of positive PET/CT scans identified by 3 central imaging readers. PM was assessed by comparing the proposed pre-PET/CT treatment with the local treatment", defined after considering both PET/CTs.

RESULTS

A total of 205 patients with first BCR after radical prostatectomy (73%; median PSA = 0.46 ng/ml [CI 0.16;27.0]) or radiation therapy (27%; median PSA = 4.23 ng/ml [CI 1.4;98.6]) underwent [18F]DCFPyL- and/or [18F]fluoromethylcholine -PET/CTs, between July and December 2020, at 22 European sites. 201 patients completed the study. The per-patient DR was significantly higher for [18F]DCFPyL- compared to [18F]fluoromethylcholine -PET/CTs (58% (117/201 patients) vs. 40% (81/201 patients), p < 0.0001). DR increased with higher PSA values for both tracers (PSA ≤ 0.5 ng/ml: 26/74 (35%) vs. 22/74 (30%); PSA 0.5 to ≤ 1.0 ng/ml: 17/31 (55%) vs. 10/31 (32%); PSA 1.01 to < 2.0 ng/ml: 13/19 (68%) vs. 6/19 (32%);PSA > 2.0: 50/57 (88%) vs. 39/57 (68%) for [18F]DCFPyL- and [18F]fluoromethylcholine -PET/CT, respectively). [18F]DCFPyL PET/CT had an impact on PM in 44% (90/204) of patients versus 29% (58/202) for [18F]fluoromethylcholine. Overall, no drug-related nor serious adverse events were observed.

CONCLUSIONS

The primary endpoint of this study was achieved, confirming a significantly higher detection rate for [18F]DCFPyL compared to [18F]fluoromethylcholine, in men with first BCR of PCa, across a wide PSA range. [18F]DCFPyL was safe and well tolerated.

PI-RR: The Prostate Imaging for Recurrence Reporting System for MRI Assessment of Local Prostate Cancer Recurrence After Radiation Therapy or Radical Prostatectomy-A Review

The purpose of this article is to review clinical application of the Prostate Imaging for Recurrence Reporting (PI-RR) system. This system, released in 2021, represents international consensus-based guidelines for the acquisition, interpretation, and reporting of multiparametric MRI performed to detect locally recurrent prostate cancer after radiation therapy or radical prostatectomy. The system reduces variability through use of a standardized and structured reporting approach whereby the overall level of suspicion of recurrence is classified on a 5-point scale. The overall suspicion score is derived from 5-point scales for assessing DWI and dynamic contrast-enhanced (DCE) imaging. Separate scales for both DWI and DCE imaging are provided for evaluation after radiation therapy and after radical prostatectomy. These scales account for the relation between detected abnormalities and the location of the primary tumor on pretreatment imaging. T2-weighted imaging is also assessed on a 5-point scale and is useful for anatomic imaging but does not influence the overall score. Initial retrospective studies have shown promising results with respect to the reproducibility and accuracy of PI-RR in detecting locally recurrent tumor.

Good clinical practice and the use of hypofractionation radiation schedules as weapons to reduce the risk of COVID-19 infections in radiation oncology unit: A mono-institutional experience

BACKGROUND

After coronavirus disease outbreak emerged in 2019, radiotherapy departments had to adapt quickly their health system and establish new organizations and priorities. The purpose of this work is to report our experience in dealing with COVID-19 emergency, how we have reorganized our clinical activity, changed our priorities, and stressed the use of hypofractionation in the treatment of oncological diseases.

MATERIALS AND METHODS

The patients' circuit of first medical examinations and follow-up was reorganized; a more extensive use of hypofractionated schedules was applied; a daily triage of the patients and staff, use of personal protective equipment, hand washing, environment sanitization, social distancing and limitations for the patients' caregivers in the department, unless absolutely essential, were performed; patients with suspected or confirmed COVID-19 were treated at the end of the day. In addition, the total number of radiotherapy treatment courses, patients and sessions, in the period from February 15 to April 30, 2020, comparing the same time period in 2018 were retrospectively investigated. In particular, changes in hypofractionated schedules adopted for the treatment of breast and prostate cancer and palliative bone metastasis were analyzed.

RESULTS

Between February 15, and April 30, 2020, an increased number of treatments was carried out: Patients treated were overall 299 compared to 284 of the same period of 2018. Stressing the use of hypofractionation, 2036 RT sessions were performed, with a mean number of fractions per course of 6.8, compared to 3566 and 12.6, respectively, in 2018. For breast cancer, the schedule in 18 fractions has been abandoned and treatment course of 13 fractions has been introduced; a 27% reduction in the use of 40.5 Gy in 15 fractions, (67 treatments in 2018-49 in 2020) was reported. An increase of 13% of stereotactic body radiation therapy for prostate cancer was showed. The use of the 20 Gy in 4 or 5 sessions for the treatment of symptomatic bone metastasis decreased of 17.5% in favor of 8 Gy-single fraction. Three patients results COVID-19 positive swab: 1 during, 2 after treatment. Only one staff member developed an asymptomatic infection.

CONCLUSIONS

The careful application of triage, anti-contagion and protective measures, a more extensive use of hypofractionation allowed us to maintain an effective and continuous RT service with no delayed/deferred treatment as evidenced by the very low number of patients developing COVID-19 infection during or in the short period after radiotherapy. Our experience has shown how the reorganization of the ward priority, the identification of risk factors with the relative containment measures can guarantee the care of oncological patients, who are potentially at greater risk of contracting the infection.

Clinical significance of unfavorable findings in intermediate-risk prostate cancer patients for predicting treatment outcomes after contemporary, dose-escalated multimodal radiotherapy

PURPOSE

Few studies have documented the long-term oncological outcomes of favorable and unfavorable intermediate-risk (IR) prostate cancer patients treated via contemporary high-dose irradiation. We analyzed the ultimate clinical outcomes of such patients using the current risk sub-stratification schema.

PATIENTS AND METHODS

We included 693 patients with localized IR prostate cancer treated via low-dose-rate brachytherapy (LDR-BT) with or without external beam radiation (EBRT) and with or without androgen-deprivation therapy (ADT) in a single institution. Treatment outcomes (biochemical recurrence-free survival [BCRFS] and clinical progression-free survival [CPFS]) were compared according to the numbers of unfavorable findings.

RESULTS

Out of the 693 IR patients, 292 (42.1%) exhibited favorable disease; the remaining 401 (57.9%) exhibited unfavorable disease. Compared with favorable IR status, unfavorable IR status was associated with shorter BCRFS and CPFS (p < 0.001 and p < 0.001, respectively). Patients with two to three unfavorable factors experienced the worst oncological outcomes (p < 0.001 and p < 0.001). Although patients with one or no unfavorable factors responded similarly to LDR-BT monotherapy, this treatment modality was insufficient for preventing biochemical and clinical progression in patients with multiple unfavorable findings.

CONCLUSION

Long-term treatment outcomes indicate that patients with IR disease scheduled for LDR-BT should undergo multimodal irradiation if they exhibit two or more unfavorable factors at diagnosis.

Extracellular vesicles as a source of prostate cancer biomarkers in liquid biopsies: a decade of research

Prostate cancer is a global cancer burden and considerable effort has been made through the years to identify biomarkers for the disease. Approximately a decade ago, the potential of analysing extracellular vesicles in liquid biopsies started to be envisaged. This was the beginning of a new exciting area of research investigating the rich molecular treasure found in extracellular vesicles to identify biomarkers for a variety of diseases. Vesicles released from prostate cancer cells and cells of the tumour microenvironment carry molecular information about the disease that can be analysed in several biological fluids. Numerous studies document the interest of researchers in this field of research. However, methodological issues such as the isolation of vesicles have been challenging. Remarkably, novel technologies, including those based on nanotechnology, show promise for the further development and clinical use of extracellular vesicles as liquid biomarkers. Development of biomarkers is a long and complicated process, and there are still not many biomarkers based on extracellular vesicles in clinical use. However, the knowledge acquired during the last decade constitutes a solid basis for the future development of liquid biopsy tests for prostate cancer. These are urgently needed to bring prostate cancer treatment to the next level in precision medicine.

Predicting post-radiation genitourinary hospital admissions in patients with localised prostate cancer

PURPOSE

The risk of treatment-related toxicity is important for patients with localised prostate cancer to consider when deciding between treatment options. We developed a model to predict hospitalisation for radiation-induced genitourinary toxicity based on patient characteristics.

METHODS

The prospective South Australian Prostate Cancer Clinical Outcomes registry was used to identify men with localised prostate cancer who underwent curative intent external beam radiotherapy (EBRT) between 1998 and 2019. Multivariable Cox proportional regression was performed. Model discrimination, calibration, internal validation and utility were assessed using C-statistics and area under ROC, calibration plots, bootstrapping, and decision curve analysis, respectively.

RESULTS

There were 3,243 patients treated with EBRT included, of which 644 (20%) patients had a treated-related admission. In multivariable analysis, diabetes (HR 1.35, 95% CI 1.13-1.60, p < 0.001), smoking (HR 1.78, 95% CI 1.40-2.12, p < 0.001), and bladder outlet obstruction (BOO) without transurethral resection of prostate (TURP) (HR 7.49, 95% CI 6.18-9.08 p < 0.001) followed by BOO with TURP (HR 4.96, 95% CI 4.10-5.99 p < 0.001) were strong independent predictors of hospitalisation (censor-adjusted c-statistic = 0.80). The model was well-calibrated (AUC = 0.76). The global proportional hazards were met. In internal validation through bootstrapping, the model was reasonably discriminate at five (AUC 0.75) years after radiotherapy.

CONCLUSIONS

This is the first study to develop a predictive model for genitourinary toxicity requiring hospitalisation amongst men with prostate cancer treated with EBRT. Patients with localised prostate cancer and concurrent BOO may benefit from TURP before EBRT.

Long-term Clinical Outcomes in Favorable Risk Prostate Cancer Patients Receiving Proton Beam Therapy

Purpose

Long-term data regarding the disease control outcomes of proton beam therapy (PBT) for patients with favorable risk intact prostate cancer (PC) are limited. Herein, we report our institution's long-term disease control outcomes in PC patients with clinically localized disease who received PBT as primary treatment.

Methods

One hundred sixty-six favorable risk PC patients who received definitive PBT to the prostate gland at our institution from 2010 to 2012 were retrospectively assessed. The outcomes studied were biochemical failure-free survival (BFFS), biochemical failure, local failure, regional failure, distant failure, PC-specific survival, and overall survival. Patterns of failure were also analyzed. Multivariate Cox proportional hazards modeling was used to estimate independent predictors of BFFS.

Results

The median length of follow-up was 8.3 years (range, 1.2–10.5 years). The majority of patients had low-risk disease (58%, n = 96), with a median age of 64 years at the onset of treatment. Of 166 treated men, 13 (7.8%), 8 (4.8%), 2 (1.2%) patient(s) experienced biochemical failure, local failure, regional failure, respectively. Regional failure was seen in an obturator lymph node in 1 patient and the external iliac lymph nodes in the other. None of the patients experienced distant failure. There were 5 (3.0%) deaths, none of which were due to PC. The 5- and 8-year BFFS rate were 97% and 92%, respectively. None of the clinical disease characteristics or treatment-related factors assessed were associated with BFFS on multivariate Cox proportional hazards modeling (all P > .05).

Conclusion

Disease control rates reported in our assessment of PBT were similar to those reported in previous clinically localized intact PC analyses, which used intensity-modulated radiotherapy, three-dimensional conformal radiotherapy, or radical prostatectomy as definitive therapy. In addition, BFFS rates were similar, if not improved, to previous PBT studies.

Can patients with low-risk prostate cancer really benefit from radical treatment?: A systematic review and network meta-analysis

Radical prostatectomy, radiotherapy and active surveillance are three widely used treatment options for patients with low-risk prostate cancer, but the relative effects are controversial. We searched PubMed, Embase and Web of Science until June 2020, focusing on the studies comparing the effect of radical prostatectomy, radiotherapy and active surveillance in patients with low-risk prostate cancer. Through the random-effects model, dichotomous data were extracted and summarised by odds ratio with a 95% confidence interval. Twenty-two studies containing 185,363 participants were pooled for the comprehensive comparison. The Bayesian mixed network estimate demonstrated the cancer-specific mortality of radical prostatectomy was significantly lower than active surveillance (OR, 0.46; 95% CI 0.34-0.64) and external beam radiation therapy (OR, 0.66; 95% CI 0.46-0.96), but not brachytherapy (OR, 0.63; 95% CI 0.41-1.03). The brachytherapy demonstrated the best treatment ranking probability results in terms of all-cause mortality, while no significant difference was observed when compared with other three treatment modalities. Brachytherapy and radical prostatectomy were associated with a similar risk of cancer-specific mortality, and both of them were significantly superior to active surveillance and external beam radiation therapy; nevertheless, there was no significant difference among the aforementioned treatment methods in all-cause mortality.

Factors affecting urinary frequency after low-dose-rate brachytherapy for prostate cancer

OBJECTIVES

Lower urinary tract symptoms are transiently exacerbated by low-dose-rate brachytherapy (LDR-BT) for prostate cancer and recover to pretreatment levels 1 year thereafter. Generally, these symptoms are influenced by temperature. We aimed to search for factors affecting the lower urinary tract symptoms after seed implant including seasons.

METHODS

We retrospectively enrolled 812 patients who underwent LDR-BT at Nara Medical University Hospital from January 2010 to December 2018 and for whom the International Prostate Symptom Score, Overactive Bladder Symptom Score, and frequency volume charts were available. We investigated the relationships between lower urinary tract symptoms, 24-hours urinary frequency, 24-hours urinary volume before and after seed implant, radiation dose, and season of seed implant.

RESULTS

The mean age was 69.5 years. The mean prostate volume was 24.2 mL. The International Prostate Symptom Score, Overactive Bladder Symptom Score, and 24-hours urinary frequency increased until 3 months and gradually decreased over 6 months after seed implant. Multiple linear regression analysis revealed that 24-hours urinary frequency at 3 months after seed implant was significantly influenced by external beam radiotherapy, larger prostate volume before implant, higher 24-hours urinary frequency at baseline, larger 24-hours urinary volume at 3 months after implant, and performance of implant in summer.

CONCLUSIONS

Lower urinary tract symptoms worsened 3 months after seed implant of LDR-BT regardless of the season of implant. The urinary frequency 3 months after seed implant was slightly lower when seed implant was performed in the summer.

High-dose-rate brachytherapy for prostate cancer: Rationale, current applications, and clinical outcome

Background

High‐dose‐rate brachytherapy (HDR BRT) has been enjoying rapid acceptance as a treatment modality offered to selected prostate cancer patients devoid of risk group, employed either in monotherapy setting or combined with external beam radiation therapy (EBRT) and is currently one of the most active clinical research areas.

Recent findings

This review encompasses all the current evidence to support the use of HDR BRT in various clinical scenario and shines light to the HDR BRT rationale, as an ultimately conformal dose delivery method enabling safe dose escalation to the prostate.

Conclusion

Valid long‐term data, both in regard to the oncologic outcomes and toxicity profile, support the current clinical indication spectrum of HDR BRT. At the same time, this serves as solid, rigid ground for emerging therapeutic applications, allowing the technique to remain in the spotlight alongside stereotactic radiosurgery.

Presence of corpora amylacea among prostate cancer cells: an unrecognised feature of intraductal carcinoma of the prostate

Corpora amylacea (CA) is usually present in benign prostatic ducts and acini, and its presence is considered suggestive of negative or low-risk prostate cancer. The clinicopathological definition of CA among prostate cancer cells (CAPCCs)-described as CA entirely surrounded by invasive cancer cells-has not been discussed. As intraductal carcinoma of the prostate (IDC-P) is a well-known adverse prognostic factor in prostate cancer, this study aimed to elucidate the relationship between CAPCC and IDC-P. We enrolled 366 patients who underwent robotic-assisted radical prostatectomies between 2012 and 2018 at Aichi Medical University Hospital. All surgical specimens were independently reviewed by two genitourinary pathologists. The median age of the patients was 68.5 years; the median serum prostate-specific antigen was 6.49 ng/mL. IDC-P was observed in 143 (39.1%) patients, while the presence of CAPCC was observed in 47 cases (12.8%). Patients with CAPCC were associated with more advanced clinical and pathological T stages, as well as Gleason scores, than those without CAPCC (p=0.018, p<0.001, p=0.036). Notably, the presence of CAPCC was significantly associated with the presence of IDC-P (39 cases) and a high Gleason score compared with the absence of CAPCC (12 cases) (p<0.001 and p=0.036, respectively). The presence of CAPCC is an adverse pathological feature, often closely related to IDC-P. Therefore, CAPCC may be a surrogate finding to detect IDC-P via haematoxylin and eosin staining.

Neoadjuvant Approaches Prior To Radical Prostatectomy

Patients with high-risk localized prostate cancer benefit from multimodality therapy of curative intent. Androgen-deprivation therapy (ADT) combined with radiation improves survival in this population. However, prior clinical trials of neoadjuvant ADT and surgery failed to consistently demonstrate a survival advantage. The development of novel, more potent hormonal agents presents an opportunity to revisit the potential for neoadjuvant therapy to improve long-term outcomes for patients with localized prostate cancer. We review recent advances in neoadjuvant approaches for prostate cancer and emerging clinical trials data supporting the use of neoadjuvant therapy prior to radical prostatectomy.

Characteristics and risk differences of different tumor size on localized prostate cancer: A retrospective cohort study in the SEER database

Objective

We aimed to evaluate the role of tumor size in predicting tumor risk for localized prostate cancer (PCa) patients undergoing radical prostatectomy (RP).

Methods

Twenty‐five thousand, one hundred twenty‐seven men with PCa receiving RP from 2010 to 2015 were extracted from the Surveillance, Epidemiology, and End Results database. Kaplan–Meier plots and multivariable Cox regression analyses were used to illustrate overall survival (OS) according to the tumor size. The tumor size was confirmed by postoperative pathology after RP.

Results

Among overall localized PCa, 84.6% were high‐risk PCa, 9.2% were intermediate‐risk PCa, and 6.2% were low‐risk PCa. Multivariate analyses demonstrated that tumor size ≥21 mm was an independent risk predict factor of low‐risk PCa (odds ratio [OR]: 11.940; 95% CI, 9.404–15.161; p < 0.001) and intermediate‐risk PCa (OR: 1.887; 95% CI, 1.586–2.245; p < 0.001). Tumor sizes ≤5 mm significantly correlated with high‐risk PCa (p < 0.001). Tumor size ≤5 mm had the worst OS in overall localized PCa and high‐risk PCa (p < 0.001).

Conclusions

In localized PCa, tumor sizes ≥21 mm may help predict low or intermediate‐risk PCa, while tumor sizes ≤5 mm might help predict high‐risk PCa. In clinical practice, we should be on high alert for patients with tumors size ≤5 mm due to its poor prognosis after RP.

Immune checkpoint-related serum proteins and genetic variants predict outcomes of localized prostate cancer, a cohort study

BACKGROUND

The clinical predictors and biological mechanisms for localized prostate cancer (PCa) outcomes remain mostly unknown. We aim to evaluate the role of serum immune-checkpoint-related (ICK) proteins and genetic variations in predicting outcomes of localized PCa.

METHODS

We profiled the serum levels of 14 ICK-related proteins (BTLA, GITR, HVEM, IDO, LAG-3, PD-1, PD-L1, PD-L2, Tim-3, CD28, CD80, 4-1BB, CD27, and CTLA-4) in 190 patients with localized PCa. The genotypes of 97 single nucleotide polymorphisms (SNPs) from 19 ICK-related genes were analyzed in an extended population (N = 1762). Meta-data from ArrayExpress and TCGA was employed to validate and to probe functional data. Patients were enrolled and tumor aggressiveness, biochemical recurrence (BCR), and progression information were obtained. Statistical analyses were performed analyzing associations between serum biomarkers, genotypes, mRNA and outcomes.

RESULTS

We showed that serum (s)BTLA and sTIM3 levels were associated with PCa aggressiveness (P < 0.05). sCD28, sCD80, sCTLA4, sGITR, sHVEM and sIDO correlated with both BCR and progression risks (all P < 0.05). We further identified ICK variants were significantly associated with aggressiveness, BCR and progression. Among them, 4 SNPs located in CD80 (rs7628626, rs12695388, rs491407, rs6804441) were not only associated with BCR and progression risk, but also correlated with sCD80 level (P < 0.01). rs491407 was further validated in an independent cohort. The CD80 mRNA expression was associated with BCR (HR, 1.85, 95% CI 1.06-3.22, P = 0.03) in meta-analysis of validation cohorts.

CONCLUSION

We highlight the prognostic value of serum ICK-related proteins for predicting aggressiveness, BCR and progression of PCa. The genetic variations and mRNA expression in CD80 could be predictors and potential targets of localized PCa.

Prognostic Significance of Prostate-Specific Antigen Persistence after Radical Prostatectomy: A Systematic Review and Meta-Analysis

We performed a systematic review and meta-analysis to assess the prognostic value of prostate-specific antigen (PSA) persistence 4-8 weeks after radical prostatectomy (RP) in patients with prostate cancer, using studies from Medline, Scopus, and Cochrane Library, on 10 October 2020. Studies were eligible if they compared patients with postoperative PSA persistence 4-8 weeks after RP to those without such persistence to assess the value of PSA persistence in prognosticating biochemical recurrence (BCR), disease recurrence, cancer-specific mortality (CSM), and overall mortality (OM) by multivariable analysis. Our review and analysis included nine studies published between 2008 and 2019 with 14,455 patients. Of those studies, 12.0% showed postoperative PSA persistence. PSA persistence was associated with BCR (HR: 4.44, 95% CI: 2.84-6.93), disease recurrence (HR: 3.43, 95% CI: 1.62-7.25), and CSM (HR: 2.32, 95% CI: 1.83-2.95). We omitted meta-analysis on the association of PSA persistence with OM due to an insufficient number of studies. PSA persistence was associated with disease recurrence in a sub-group of patients with pathological nodal involvement (HR: 5.90, 95% CI: 3.76-9.24). Understanding detection of PSA persistence at 4-8 weeks after RP might be useful for patient counseling, follow-up scheduling, and clinical decision-making regarding adjuvant therapies.

Do not underestimate anterior prostate cancer

AIMS

With the introduction of magnetic resonance imaging in the diagnosis of prostate cancer and its use in targeted prostate biopsy, an increased incidence of anterior-predominant prostate cancer (APC) has been observed.

METHODS

We enrolled 200 patients who underwent radical prostatectomy at our department between 12/2017 and 04/2019. We evaluated tumour location in the individual segments of the prostate, index tumour location and volume, and compared the postoperative stage, Gleason score, grade group (GG), and the presence of extraprostatic extension (EPE) in APC and posterior prostate cancer (PPC). We assessed the rate of MRI scans prior to prostate surgery as well as the influence of family history and PSA on the presence of APC.

RESULTS

We found a significantly higher rate of anterior tumours than previously reported (37%) and confirmed that these tumours are diagnosed with a significantly larger index tumour volume (P=0.003). We also showed that a mere 6.76% of APCs were low-risk tumours not requiring radical treatment. Furthermore, anterior tumours were found significantly more often (P=0.001) in patients who underwent preoperative MRI. No differences were observed between PSA values, family history, presence of EPE, or locally advanced disease in APC vs. PPC.

CONCLUSIONS

The frequency of anterior tumours is higher than previously thought, and they include tumours requiring radical treatment. When these tumours are neglected, it may lead to patient undertreatment with impact on their life prognosis. Thus, we consider the use of MRI-targeted prostate biopsy to be a necessity both for ruling out APC in the case of repeatedly negative prostate biopsies and, in particular, before patient inclusion in active surveillance.

Prostate Cancer, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology

The NCCN Guidelines for Prostate Cancer include recommendations regarding diagnosis, risk stratification and workup, treatment options for localized disease, and management of recurrent and advanced disease for clinicians who treat patients with prostate cancer. The portions of the guidelines included herein focus on the roles of germline and somatic genetic testing, risk stratification with nomograms and tumor multigene molecular testing, androgen deprivation therapy, secondary hormonal therapy, chemotherapy, and immunotherapy in patients with prostate cancer.

Active monitoring, radical prostatectomy and radical radiotherapy in PSA-detected clinically localised prostate cancer: the ProtecT three-arm RCT

BACKGROUND

Prostate cancer is the most common cancer among men in the UK. Prostate-specific antigen testing followed by biopsy leads to overdetection, overtreatment as well as undertreatment of the disease. Evidence of treatment effectiveness has lacked because of the paucity of randomised controlled trials comparing conventional treatments.

OBJECTIVES

To evaluate the effectiveness of conventional treatments for localised prostate cancer (active monitoring, radical prostatectomy and radical radiotherapy) in men aged 50-69 years.

DESIGN

A prospective, multicentre prostate-specific antigen testing programme followed by a randomised trial of treatment, with a comprehensive cohort follow-up.

SETTING

Prostate-specific antigen testing in primary care and treatment in nine urology departments in the UK.

PARTICIPANTS

Between 2001 and 2009, 228,966 men aged 50-69 years received an invitation to attend an appointment for information about the Prostate testing for cancer and Treatment (ProtecT) study and a prostate-specific antigen test; 82,429 men were tested, 2664 were diagnosed with localised prostate cancer, 1643 agreed to randomisation to active monitoring (n = 545), radical prostatectomy (n = 553) or radical radiotherapy (n = 545) and 997 chose a treatment.

INTERVENTIONS

The interventions were active monitoring, radical prostatectomy and radical radiotherapy.

TRIAL PRIMARY OUTCOME MEASURE

Definite or probable disease-specific mortality at the 10-year median follow-up in randomised participants.

SECONDARY OUTCOME MEASURES

Overall mortality, metastases, disease progression, treatment complications, resource utilisation and patient-reported outcomes.

RESULTS

There were no statistically significant differences between the groups for 17 prostate cancer-specific (p = 0.48) and 169 all-cause (p = 0.87) deaths. Eight men died of prostate cancer in the active monitoring group (1.5 per 1000 person-years, 95% confidence interval 0.7 to 3.0); five died of prostate cancer in the radical prostatectomy group (0.9 per 1000 person-years, 95% confidence interval 0.4 to 2.2 per 1000 person years) and four died of prostate cancer in the radical radiotherapy group (0.7 per 1000 person-years, 95% confidence interval 0.3 to 2.0 per 1000 person years). More men developed metastases in the active monitoring group than in the radical prostatectomy and radical radiotherapy groups: active monitoring, n = 33 (6.3 per 1000 person-years, 95% confidence interval 4.5 to 8.8); radical prostatectomy, n = 13 (2.4 per 1000 person-years, 95% confidence interval 1.4 to 4.2 per 1000 person years); and radical radiotherapy, n = 16 (3.0 per 1000 person-years, 95% confidence interval 1.9 to 4.9 per 1000 person-years; p = 0.004). There were higher rates of disease progression in the active monitoring group than in the radical prostatectomy and radical radiotherapy groups: active monitoring (n = 112; 22.9 per 1000 person-years, 95% confidence interval 19.0 to 27.5 per 1000 person years); radical prostatectomy (n = 46; 8.9 per 1000 person-years, 95% confidence interval 6.7 to 11.9 per 1000 person-years); and radical radiotherapy (n = 46; 9.0 per 1000 person-years, 95% confidence interval 6.7 to 12.0 per 1000 person years; p < 0.001). Radical prostatectomy had the greatest impact on sexual function/urinary continence and remained worse than radical radiotherapy and active monitoring. Radical radiotherapy's impact on sexual function was greatest at 6 months, but recovered somewhat in the majority of participants. Sexual and urinary function gradually declined in the active monitoring group. Bowel function was worse with radical radiotherapy at 6 months, but it recovered with the exception of bloody stools. Urinary voiding and nocturia worsened in the radical radiotherapy group at 6 months but recovered. Condition-specific quality-of-life effects mirrored functional changes. No differences in anxiety/depression or generic or cancer-related quality of life were found. At the National Institute for Health and Care Excellence threshold of £20,000 per quality-adjusted life-year, the probabilities that each arm was the most cost-effective option were 58% (radical radiotherapy), 32% (active monitoring) and 10% (radical prostatectomy).

LIMITATIONS

A single prostate-specific antigen test and transrectal ultrasound biopsies were used. There were very few non-white men in the trial. The majority of men had low- and intermediate-risk disease. Longer follow-up is needed.

CONCLUSIONS

At a median follow-up point of 10 years, prostate cancer-specific mortality was low, irrespective of the assigned treatment. Radical prostatectomy and radical radiotherapy reduced disease progression and metastases, but with side effects. Further work is needed to follow up participants at a median of 15 years.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN20141297.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 37. See the National Institute for Health Research Journals Library website for further project information.

External evaluation of the Briganti nomogram to predict lymph node metastases in intermediate-risk prostate cancer patients

PURPOSE

The Briganti nomogram can be used with a threshold of 5% to decide when to offer lymph node dissection during radical prostatectomy. The objective of the study was to assess the accuracy of the Briganti nomogram on intermediate-risk prostate cancer patients managed in a single academic department.

METHODS

We retrospectively reviewed the files of all patients managed by radical prostatectomy (RP) and bilateral pelvic lymph node dissection (BPLND) in our center between 2005 and 2017. The overall accuracy of the model in predicting metastatic lymph node disease was quantified by the construction of a receiver-operator characteristic (ROC) curve. A calibration plot was drawn to represent the relationship between the predicted and observed frequencies.

RESULTS

We included 285 patients, among whom 175 (61.4%) were classified as intermediate risk as defined by D'Amico. The median follow-up was 60 (34-93) months. Twenty-seven patients (9.5%) were diagnosed with lymph node metastases. The median number of lymph nodes removed was 10 (7-14). The mean Briganti score was 19.3% in patients with lymph node involvement (LNI) and 6.3% in patients without LNI. Focusing on intermediate-risk patients, 91(52%) and 84 (48%) had a Briganti score < 5% and ≥ 5%, respectively, among whom 6 (6.6%) and 7(8.3%) had lymph node metastases. The accuracy of the score was low for intermediate risk patients with an area under the curve (AUC) of 53.1% (95% CI 0.45-0.61).

CONCLUSION

The Briganti nomogram in our retrospective cohort showed low accuracy for the prediction of lymph node involvement in an intermediate-risk prostate cancer population.

Photodynamic diagnosis and therapy for urothelial carcinoma and prostate cancer: new imaging technology and therapy

Photodynamic technology using light-sensitive and fluorescent substances has an important role in an accurate diagnosis for a variety of malignancies, including bladder cancer and prostate cancer. Light-sensitive and fluorescent substances accumulate specifically in tumor cells compared to normal tissue, and by light irradiation and excitation at each specific wavelength, tumor lesion, blood flow, lymph node and so on show fluorescence. 5-Aminolevulinic acid (ALA) is converted to protoporphyrin IX (PpIX) into mitochondria. PpIX is excited by blue light, red fluorescence is emitted in the mitochondria. This phenomenon is the mechanism of ALA-mediated photodynamic diagnosis (ALA-PDD). ALA-PDD has made it possible to visualize smaller lesions and flat lesions that were previously difficult to visualize by endoscope using a white-light source. So accurate diagnosis and complete resection become possible during operation. The accumulation of PpIX in the mitochondria also induces direct mitochondrial damage and subsequent cell death by red and green light. This biological reaction is the ALA-mediate photodynamic therapy (ALA-PDT). ALA-PDT has been developed as a modality for minimum invasive cancer treatment that utilizes low-energy light and photosensitizer. Vascular-activated photosensitizer induces rapid tumor ablation by PDT involving direct tumor cell killing as well as damage to the exposed microvasculature. We summarize the clinical outcomes of PDD and PDT for urothelial carcinoma and prostate cancer.

Association of preoperative urethral parameters on magnetic resonance imaging and immediate recovery of continence following Retzius-sparing robot-assisted radical prostatectomy

Background

Studies regarding predictive factors of urinary continence following Retzius-sparing radical prostatectomy (RP) is limited. This study was designed to evaluate association of urethral parameters on preoperative magnetic resonance imaging (MRI) and immediate recovery of urinary continence following Retzius-sparing robot assisted radical prostatectomy (RS-RARP).

Methods

This retrospective cohort study enrolled 156 patients with clinically localized prostate cancer who underwent MRI before RS-RARP. We measured the following structures on preoperative MRI: minimal residual membranous urethral length (mRUL), peri-urethral sphincter complex (PSC) thickness, urethral wall thickness (UWT), the thicknesses of the levator ani muscle (LAM) and obturator internus muscle (OIM). Immediate urinary continence was defined as patients reported freedom from using safety pad within 7 days after removal of urinary catheter. Patients were divided into two groups according the median of each parameter on MRI. We retrospectively analyzed the patients in term of preoperative clinical factors and postoperative urinary continence.

Results

A total of 100 patients (64.1%) reported immediate urinary continence after RS-RARP. Immediate urinary continence was significantly more in patients with longer mRUL (≥8.70 mm) than in patients with shorter mRUL (<8.70 mm; P=0.000). On multivariable analysis, longer mRUL was significantly related to immediate urinary continence after RS-RAPA (odds ratio 8.265; P=0.000). PSC, UWT, LAM and OIM were not associated with immediate urinary continence.

Conclusions

Our results firstly demonstrated that preoperative mRUL measured on MRI was an independent predictor of immediate urinary continence following RS-RARP. Therefore, preservation of membranous urethra is still the anatomical basis of better urinary outcome after RS-RARP.

BIT-ART: Multicentric Comparison of HDR-brachytherapy, Intensity-modulated Radiotherapy and Tomotherapy for Advanced Radiotherapy in Prostate Cancer

BACKGROUND/AIM

The aim of the study was to evaluate acute and late genitourinary (GU) and gastrointestinal (GI) toxicity in patients with high- or intermediate-risk prostate cancer.

PATIENTS AND METHODS

We evaluated data of patients from three Radiation Oncology Departments (Rome, Lübeck and Perugia). Patients treated in Rome underwent exclusive intensity-modulated-radiotherapy (IMRT) or IMRT plus high-dose-rate interventional radiotherapy (HDR-IRT). IMRT plus two fractions HDR-IRT was performed in Lübeck, while in Perugia Helical Tomotherapy was performed. The Common Toxicity Criteria for Adverse Event (Version 4.03) scale was used to describe acute and late toxicity.

RESULTS

At a median follow-up of 28 months, all 51 patients were alive and disease-free. Patients treated by HDR-IRT plus VMAT showed only G1-2 genitourinary- gastrointestinal (GU-GI) acute and late toxicity. Univariate analysis showed a lower risk of acute GU toxicity (p=0.048) in IMRT+HDR-IRT.

CONCLUSION

Low grade and less acute GU toxicity was observed in patients undergoing HDR-IRT boost.

Tumour location determined by preoperative MRI is an independent predictor for positive surgical margin status after Retzius-sparing robot-assisted radical prostatectomy

OBJECTIVE

To investigate the influence of tumour location zone on positive surgical margin (PSM) status after Retzius-sparing robot-assisted radical prostatectomy (RS-RARP).

MATERIALS AND METHODS

A total of 203 consecutive patients with prostate cancer (PCa) who underwent RS-RARP at our centre were divided into three cohorts according to the tumour zonal origin described on preoperative magnetic resonance imaging (MRI). Clinical and pathological characteristics were compared among the three groups. The associations of clinicopathological variables with PSM status after RS-RARP were also evaluated.

RESULTS

The rates of PSM in patients with transition zone (TZ) and mixed origin tumours were significantly higher than in patients with peripheral zone tumours (P < 0.01). Of the PSMs in patients with TZ and mixed origin cancers, 42.0% and 40.9%, respectively, were located at the anterior part of the gland. On multivariate analysis, presence of a TZ tumour was significantly associated with a higher PSM rate after RS-RARP (P < 0.01). Sub-analysis showed that high-risk patients with TZ tumours had a higher risk of PSM after RS-RARP (P < 0.01).

CONCLUSION

Presence of a TZ tumour is an independent risk factor for PSMs after RS-RARP. Preoperative identification of TZ tumours might aid surgical planning for the Retzius-sparing technique, especially in high-risk patients.

[Recommendations CCAFU on the management of cancers of the urogenital system during an epidemic with Coronavirus COVID-19]

Objectif

La population française est confrontée à la pandémie de COVID-19 et le système de santé a été réorienté en urgence pour la prise en charge des patients atteints du coronavirus. La prise en charge des cancers de l’appareil urinaire et génital masculin doit être adaptée à ce contexte.

Matériel et méthode

Un avis d’experts documenté par une revue de la littérature a été formulé par le Comité de Cancérologie de l’Association Française d’Urologie (CCAFU).

Résultats

La prise en charge médicale et chirurgicale des patients atteints de cancers de l’appareil urinaire et génital masculin doit être adaptée en modifiant les modalités de consultation, en priorisant les interventions en fonction du pronostic intrinsèque des cancers en tenant compte des comorbidités du patient. La protection des urologues vis-à-vis du COVID-19 doit être prise en considération.

Conclusion

Le CCAFU émet un avis d’experts quant aux mesures à prendre pour adapter la prise en charge des cancers de l’appareil urinaire et génital masculin au contexte de pandémie par COVID-19.

In Organ-confined Prostate Cancer, Tumor Quantitation Not Found to Aid in Prediction of Biochemical Recurrence

In the eighth edition AJCC staging, all organ-confined disease is assigned pathologic stage T2, without subclassification. We investigated whether total tumor volume (TTV) and/or maximum tumor diameter (MTD) of the index lesion are useful in improving prediction of biochemical recurrence (BCR) in pT2 patients. We identified 1657 patients with digital tumor maps and quantification of TTV/MTD who had pT2 disease on radical prostatectomy (RP). Multivariable Cox regression models were used to assess whether TTV and/or MTD are independent predictors of BCR when adjusting for a base model incorporating age, preoperative prostate-specific antigen, RP grade group, and surgical margin status. If either tumor quantification added significantly, we calculated and reported the c-index. Ninety-five patients experienced BCR after RP; median follow-up for patients without BCR was 5.7 years. The c-index was 0.737 for the base model. Although there was some evidence of an association between TTV and BCR (P=0.088), this did not meet conventional levels of statistical significance and only provided a limited increase in discrimination (0.743; c-index improvement: 0.006). MTD was not associated with BCR (P>0.9). In analyses excluding patients with grade group 1 on biopsy who would be less likely to undergo RP in contemporary practice (622 patients; 59 with BCR), TTV/MTD was not a statistically significant predictor (P=0.4 and 0.8, respectively). Without evidence that tumor quantitation, in the form of either TTV or MTD of the index lesion, is useful for the prediction of BCR in pT2 prostate cancer, we cannot recommend its routine reporting.

Associations between self-reported physical activity, quality of life, and emotional well-being in men with prostate cancer on active surveillance

OBJECTIVE

The relationship between physical activity (PA) and quality of life (QOL) relative to active treatment for prostate cancer (PCa) has been well-studied; however, little is known about this relationship during active surveillance (AS). Moreover, whether PA is associated with better emotional well-being (EWB) in men with low-risk PCa requires further investigation. Accordingly, we examined the association between self-reported PA and the average change in QOL and EWB over time during AS.

METHODS

A total of 630 men on AS were included in this retrospective, longitudinal study from AS initiation until AS discontinuation. Generalized estimated equations were used to determine the association between self-reported PA (independent variable) and QOL and EWB (dependent variables) over time, adjusting for participants' age.

RESULTS

QOL was higher over time in active ( β ^ (95%CI) = 1.14 (0.11, 2.16), P = .029) and highly active participants ( β ^ (95%CI) = 1.62 (0.58, 2.67), P = .002) compared to their inactive counterparts. Highly active participants had 55% greater odds of experiencing high EWB relative to inactive participants (OR (95%CI) = 1.55 (1.11, 2.16), P = .010). In men with low EWB at baseline (median = 3 months after diagnosis), the highest levels of PA (>1000 metabolic equivalent-minutes per week) were associated with high EWB over time (OR (95%CI) = 2.17 (1.06, 4.46), P = .034).

CONCLUSIONS

These data further support the importance of PA as a supportive care strategy for men on AS. Our findings suggest that engaging in higher volumes of PA post-diagnosis may be beneficial particularly for men exhibiting low emotional well-being early on during AS.

Ten-year Mortality, Disease Progression, and Treatment-related Side Effects in Men with Localised Prostate Cancer from the ProtecT Randomised Controlled Trial According to Treatment Received

BACKGROUND

The ProtecT trial reported intention-to-treat analysis of men with localised prostate cancer (PCa) randomly allocated to active monitoring (AM), radical prostatectomy, and external beam radiotherapy.

OBJECTIVE

To determine report outcomes according to treatment received in men in randomised and treatment choice cohorts.

DESIGN, SETTING, AND PARTICIPANTS

This study focuses on secondary care. Men with clinically localised prostate cancer at one of nine UK centres were invited to participate in the treatment trial comparing AM, radical prostatectomy, and radiotherapy.

INTERVENTION

Two cohorts included 1643 men who agreed to be randomised; 997 declined randomisation and chose treatment.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Health-related quality of life impacts on urinary, bowel, and sexual function were assessed using patient-reported outcome measures. Analysis was carried out based on treatment received for each cohort and on pooled estimates using meta-analysis. Differences were estimated with adjustment for known prognostic factors using propensity scores.

RESULTS AND LIMITATIONS

According to treatment received, more men receiving AM died of PCa (AM 1.85%, surgery 0.67%, radiotherapy 0.73%), whilst this difference remained consistent with chance in the randomised cohort (p=0.08); stronger evidence was found in the exploratory analyses (randomised plus choice cohort) when AM was compared with the combined radical treatment group (p=0.003). There was also strong evidence that metastasis (AM 5.6%, surgery 2.4%, radiotherapy 2.7%) and disease progression (AM 20.35%, surgery 5.87%, radiotherapy 6.62%) were more common in the AM group. Compared with AM, there were higher risks of sexual dysfunction (95% at 6mo) and urinary incontinence (55% at 6mo) after surgery, and of sexual dysfunction (88% at 6mo) and bowel dysfunction (5% at 6mo) after radiotherapy. The key limitations are the potential for bias when comparing groups defined by treatment received and outdating of the interventions being evaluated during the lengthy follow-up required in trials of screen-detected PCa.

CONCLUSIONS

Analyses according to treatment received showed increased rates of disease-related events and lower rates of patient-reported harms in men managed by AM compared with men managed by radical treatment, and stronger evidence of greater PCa mortality in the AM group.

PATIENT SUMMARY

More than 90 out of every 100 men with localised prostate cancer do not die of prostate cancer within 10yr, irrespective of whether treatment is by means of monitoring, surgery, or radiotherapy. Side effects on sexual and bladder function are much better after active monitoring, but the risks of spreading of prostate cancer are more common.

Mechanisms of decision-making in preoperative assessment for older adult prostate cancer patients-A qualitative study

BACKGROUND AND OBJECTIVE

Little research exists which investigates the contextual factors and hidden influences that inform surgeons and surgical teams decision-making in preoperative assessment when deciding whether to or not to operate on older adult prostate cancer patients living with aging-associated functional declines and illnesses. The aim of this study is to identify and examine the underlying mechanisms that uniquely shape preoperative surgical decision-making strategies concerning older adult prostate cancer patients.

METHODS

Qualitative methodologies were used that paired ethnographic field observations with semistructured interviews for data collection. An inductive thematic analysis approach was used to identify, analyze, and describe patterns in the data.

RESULTS

Factors underlining surgical decision-making originated from the context of two categories: (1) clinical and surgery-specific factors; and (2) non-patient factors. Thematic subcategories included personal experiences, methods of assessment during medical encounters, anticipation of outcomes, perceptions of preoperative assessment instruments for frailty and multimorbidity, routines and workflow patterns, microcultures, and indirect observation and second-hand knowledge.

CONCLUSION

Surgeon's personal experiences has a significant impact on the decision-making processes during preoperative assessments. However, non-patient factors such as institutional microcultures passively and actively influence decision-making process during preoperative assessment.

Expression of urokinase-type plasminogen activator system in non-metastatic prostate cancer

PURPOSE

To investigate the prognostic role of expression of urokinase-type plasminogen activator system members, such as urokinase-type activator (uPA), uPA-receptor (uPAR), and plasminogen activator inhibitor-1 (PAI-1), in patients treated with radical prostatectomy (RP) for prostate cancer (PCa).

METHODS

Immunohistochemical staining for uPA system was performed on a tissue microarray of specimens from 3121 patients who underwent RP. Cox regression analyses were performed to investigate the association of overexpression of these markers alone or in combination with biochemical recurrence (BCR). Decision curve analysis was used to assess the clinical impact of these markers.

RESULTS

uPA, uPAR, and PAI-1 were overexpressed in 1012 (32.4%), 1271 (40.7%), and 1311 (42%) patients, respectively. uPA overexpression was associated with all clinicopathologic characteristics of biologically aggressive PCa. On multivariable analysis, uPA, uPAR, and PAI-1 overexpression were all three associated with BCR (HR: 1.75, p < 0.01, HR: 1.22, p = 0.01 and HR: 1.20, p = 0.03, respectively). Moreover, the probability of BCR increased incrementally with increasing cumulative number of overexpressed markers. Decision curve analysis showed that addition of uPA, uPAR, and PAI-1 resulted in a net benefit compared to a base model comparing standard clinicopathologic features across the entire threshold probability range. In subgroup analyses, overexpression of all three markers remained associated with BCR in patients with favorable pathologic characteristics.

CONCLUSION

Overexpression of uPA, uPAR, and PAI-1 in PCa tissue were each associated with worse BCR. Additionally, overexpression of all three markers is informative even in patients with favorable pathologic characteristics potentially helping clinical decision-making regarding adjuvant therapy and/or intensified follow-up.

Are targeted prostate biopsies ready to replace systematic prostate biopsies?

OBJECTIVES

To evaluate the efficacy and efficiency of systematic prostatic biopsy (SPB) and cognitive fusion PB (CFPB) to diagnose prostate cancer (PCa) and significant PCa (SPCa), and to analyse if CFPB could safely replace SPB.

MATERIAL AND METHODS

A cohort of 314 consecutive men having PI-RADS ≥2 in a pre-biopsy 3T mp-MRI were prospectively subjected to trans-rectal ultrasound CFPB (two cores per suspicious area until a maximum of three areas) and a 12 peripheral core SPB. SPCa was considered when the WHO grade was higher than 2 (Gleason 4+3 or higher).

RESULTS

PCa was diagnosed in 133 patients (42.4%), being 83 (62.4%) SPCa. SPB detected PCa in 114 men (85.7%) while CFPB in 103 (77.4%), P<.001. SPB detected SPCa in 64 men (77.1%) while CFPB in 71 (85.5%), P<.001. In 52 of the 81 men (64.2%) SPCa was detected in SPB and CFPB. In 19 men SPCa was only detected in CFPB (23.5%) while in 10, it was only detected in SPB (12.3%). 33.1 cores were needed to diagnose one PCa in SPB while 8.5 in CFPB, P<.001. 58.9 cores were needed to diagnose one SPCa in SPB, while 12.4 in CFPB, P<.001.

CONCLUSIONS

CFPB are more effective and also more efficient than SPBs in detecting SPCa. However, CFPBs still can't safely replace SPBs because they are not able to detect up to 15% of SPCa.

Overexpression of certain transient receptor potential and Orai channels in prostate cancer is associated with decreased risk of systemic recurrence after radical prostatectomy

BACKGROUND

Several studies had suggested the potential role of calcium signaling in prostate cancer (PCa) prognosis and agressiveness. We aimed to investigate selected proteins contributing to calcium (Ca²⁺ ) signaling, (Orai, stromal interaction molecule (STIM), and transient receptor potential (TRP) channels) and involved in cancer hallmarks, as independent predictors of systemic recurrence after radical prostatectomy (RP).

METHODS

A case-control study including 112 patients with clinically localized PCa treated by RP between 2002 and 2009 and with at least 6-years' follow-up. Patients were divided into two groups according to the absence or presence of systemic recurrence. Expression levels of 10 proteins involved in Ca²⁺ signaling (TRPC1, TRPC4, TRPV5, TRPV6, TRPM8, STIM1, STIM2, Orai1, Orai2, and Orai3), were assessed by immunohistochemistry using tissue microarrays (TMAs) constructed from paraffin-embedded PCa specimens. The level of expression of the various transcripts in PCa was assessed using quantitative polymerase chain reaction (qPCR) analysis. RNA samples for qPCR were obtained from fresh frozen tissue samples of PCa after laser capture microdissection on RP specimens. Relative gene expression was analyzed using the 2-▵▵Ct method.

RESULTS

Multivariate analysis showed that increased expression of TRPC1, TRPC4, TRPV5, TRPV6, TRPM8, and Orai2 was significantly associated with a lower risk of systemic recurrence after RP, independently of the prostate-specific antigen (PSA) level, percentage of positive biopsies, and surgical margin (SM) status (P = .007, P = .01, P < .001, P = .0065, P = .007, and P = .01, respectively). For TRPC4, TRPV5, and TRPV6, this association was also independent of Gleason score and pT stage. Moreover, overexpression of TRPV6 and Orai2 was significantly associated with longer time to recurrence after RP (P = .048 and .023, respectively). Overexpression of TRPC4, TRPV5, TRPV6, and Orai2 transcripts was observed in group R- (3.71-, 5.7-, 1.14-, and 2.65-fold increase, respectively).

CONCLUSIONS

This is the first study to suggest the independent prognostic value of certain proteins involved in Ca²⁺ influx in systemic recurrence after RP: overexpression of TRPC1, TRPC4, TRPV5, TRPV6, TRPM8, and Orai2 is associated with a lower risk of systemic recurrence. TRPC4, TRPV5, and TRPV6 appear to be particularly interesting, as they are independent of the five commonly used predictive factors, that is, PSA, percentage of positive biopsies, SM status, Gleason score, and pT stage.

Effect of external beam radiotherapy on second primary cancer risk after radical prostatectomy

INTRODUCTION

We aimed to investigate the effect of radiotherapy (RT) in contemporary patients treated with radical prostatectomy (RP) compared to RP alone for non-metastatic prostate cancer (PCa) on the incidence of second primary cancers (SPCs).

METHODS

Within the Surveillance, Epidemiology, and End Results (SEER) database (2004-2015), we identified patients with PCa as the only or first primary cancer, who underwent RP and RT or RP alone. Cumulative incidence plots and multivariable Cox regression models tested for SPC rate differences according to treatment type: RP and RT vs. RP alone. Subgroup analyses focused on pelvic, primary pelvic, and non-pelvic SPCs, as well as on late SPCs (>5 years after PCa diagnosis).

RESULTS

Of 152 161 patients, 7.1% (n=10 870) received RP and RT. Overall, 6.6 vs. 5.0% developed SPCs after RP and RT vs. RP alone, respectively (p<0.001). Cumulative incidence rates at 10 years after PCa diagnosis for RP and RT vs. RP were 12.0 vs. 8.7% (p<0.001), 2.0 vs. 1.2% (p<0.001), 2.1 vs. 1.3% (p<0.001), and 9.9 vs. 7.4% (p<0.001) for overall SPCs, primary pelvic SPCs, overall pelvic SPCs, and non-pelvic SPCs, respectively. Multivariable Cox regression models revealed an increased risk after RP and RT vs. RP alone for overall (hazard ratio [HR] 1.2; p<0.001), primary pelvic (HR 1.5; p<0.01), pelvic (HR1.4; p<0.001), non-pelvic (HR1.1; p<0.01), late overall (HR 1.2; p=0.01), and late non-pelvic SPCs (HR1.2; p=0.03).

CONCLUSIONS

RP with RT was associated with moderately increased risk of SPCs compared to RP alone. This observation should be thoroughly discussed at informed consent and considered during followup.

The GP Score, a Simplified Formula (Bioptic Gleason Score Times Prostate Specific Antigen) as a Predictor for Biochemical Failure after Prostatectomy in Prostate Cancer

Objectives

We used a new GP score (Gleason score multiplied by prostate-specific antigen) without the T stage as a predictive value for biochemical failure (BCF) after prostatectomy.

Materials and Methods

We assessed 459 prostate cancer patients who underwent prostatectomies at our institution. Three sub-groups were defined in terms of D'Amico classification risk (low, intermediate, and high) and Gleason score (low, < 50; intermediate, 50-100; and high GP score, > 100). Risk factors for BCF were evaluated by multivariate analysis with a Cox hazard model. A log-rank test was used to compare the BCF rate in the 2 groups.

Results

There was nosignificant difference in the non-BCF rate between the lowrisk and low GP score subgroups or the intermediate risk andintermediate GP score subgroups. In contrast, the non-BCFrate of the high GP score subgroup (42.1%) was significantlylower than that of the high-risk subgroup (66.1%, log-rankp = 0.008). Based on multivariate analysis, a high GP score(p = 0.001; HR 3.78; 95%CI 1.95-7.35) was a significant independent risk factor for BCF after prostatectomy.

Conclusion

The GP score, consisting of two absolute numbers, may be a valuable predictive factor for BCF after prostatectomy, especially in the high-risk failure group.

Upregulated KDM4B promotes prostate cancer cell proliferation by activating autophagy

Castration-resistant prostate cancer (CRPC) causes most of the deaths in patients with prostate cancer (PCa). The androgen receptor (AR) axis plays an important role in castration resistance. Emerging studies showed that the lysine demethylase KDM4B is a key molecule in AR signaling and turnover, and autophagy plays an important role in CRPC. However, little is known about whether KDM4B promotes CRPC progression by regulating autophagy. Here we used an androgen-independent LNCaP (LNCaP-AI) cell line to assay aberrant KDM4B expression using qPCR and western blot analysis and investigated the function of KDM4B in regulating cell proliferation. We found that KDM4B was markedly increased in LNCaP-AI cells compared with LNCaP cells. KDM4B level was significantly correlated with the Gleason score in PCa tissues. In vitro, KDM4B overexpression in CRPC cells promoted cell proliferation, whereas knockdown of KDM4B significantly inhibited cell proliferation. Upregulated KDM4B contributed to activate Wnt/β-catenin signaling and autophagy. Moreover, KDM4B activated autophagy by regulating the Wnt/β-catenin signaling. Finally, we demonstrated that autophagy inhibition attenuated KDM4B-induced CRPC cell proliferation. Our results provided novel insights into the function of KDM4B-driven CRPC development and indicated that KDM4B may be served as a potential target for CRPC therapy.

Management Strategies and Patient Selection After a Hospital Funding Reform for Prostate Cancer Surgery in Canada

IMPORTANCE

Hospital funding reforms for prostate cancer surgery may have altered management of localized prostate cancer in the province of Ontario, Canada.

OBJECTIVE

To determine whether changes in hospital funding policy aimed at improving health care quality and value were associated with changes in the management of localized prostate cancer or the characteristics of patients receiving radical prostatectomy (RP) for localized prostate cancer.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, interrupted time series study used linked population-based administrative data regarding adults in Ontario with incidental localized prostate cancer and those who underwent RP for localized prostate cancer. Patients who underwent RP were compared with patients who underwent surgical procedures for localized renal cell carcinoma, which was not included in the policy change but was subjected to similar secular trends and potential confounders. Monthly outcomes were analyzed using interventional autoregressive integrated moving average models. Data were collected from January 2011 to November 2017 and analyzed in January 2019.

EXPOSURES

Funding policy change in April 2015 from flexible block funding for all hospital-based care to prespecified payment amounts per procedure for treatment of localized prostate cancer, coupled with the dissemination of a diagnosis-specific handbook outlining best practices.

MAIN OUTCOMES AND MEASURES

Initial management (RP vs radiation therapy vs active surveillance) and tumor risk profiles per management strategy among incident cases of localized prostate cancer. Additional outcomes were case volume, mean length of stay, proportion of patients returning to hospital or emergency department within 30 days, proportion of patients older than 65 years, mean Charlson Comorbidity Index, and proportion of minimally invasive surgical procedures among patients undergoing RP for localized prostate cancer.

RESULTS

A total of 33 128 patients with incident localized prostate cancer (median [interquartile range (IQR)] age, 67 [61-73] years; median [IQR] cases per monthly observation interval, 466 [420-516]), 17 159 patients who received radical prostatectomy (median [IQR] age, 63 [58-68] years; median [IQR] cases per monthly observation interval, 209 [183-225]), and 5762 individuals who underwent surgery for renal cell carcinoma (median [IQR] age, 62 [53-70] years; median [IQR] cases per monthly observation interval, 71 [61-77]) were identified. By the end of the observation period, radical prostatectomy and radiation therapy were used in comparable proportions (30.3% and 28.9%, respectively) and included only a small fraction of low-risk patients (6.4% and 2.9%, respectively). No statistically significant association of the funding policy change with most outcomes was found.

CONCLUSIONS AND RELEVANCE

The implementation of funding reform for hospitals offering RP was not associated with changes in the management of localized prostate cancer, although it may have encouraged more appropriate selection of patients for RP. Mostly preexisting trends toward guideline-conforming practice were observed. Co-occurring policy changes and/or guideline revisions may have weakened signals from the policy change.

Neoadjuvant chemotherapy before radical prostatectomy for locally advanced prostate cancer: Protocol for a systematic review and meta-analysis

BACKGROUND

To evaluate the effectiveness and safety of neoadjuvant chemotherapy (NAC) for locally advance prostate patients undergoing radical prostatectomy.

METHODS

PubMed/Medline, EMBASE, Web of Science, Ovid, Web of Knowledge, and Cochrane Library will be searched for studies related to the topic. The identification, inclusion and exclusion flow charts will be conducted according to PRISMA guidelines. The identified reports will be critically appraised using GRADE approach. Bias and heterogeneity of included studies will be assessed, and outcome measurements from individual studies will be combined with 95% confidence interval using a fixed- or random-effects model if qualified.

RESULTS

This study will provide evidence and data on the tolerance and efficacy of NAC followed by radical prostatectomy (RP).

CONCLUSION

The application of taxanes-based chemotherapy has been widened to metastatic hormone sensitive prostate cancer in recent years. To be more vigorous, whether neoadjuvant administration of these cytotoxic agents can improve the outcome of RP in locally advance prostate cancer patients has been explored. This study aims to synthesis data regarding the adverse effect, response rate, recurrence, and survival from multiple trials, and to guide the healthcare practitioners using an evidence-based approach.

Feasibility and Initial Results: Fluciclovine Positron Emission Tomography/Ultrasound Fusion Targeted Biopsy of Recurrent Prostate Cancer

PURPOSE

We assessed the feasibility and cancer detection rate of fluciclovine (¹⁸F) positron emission tomography-ultrasound fusion targeted biopsy vs standard template biopsy in the same patient with biochemical failure after nonsurgical therapy for prostate cancer.

MATERIALS AND METHODS

A total of 21 patients with a mean ± SD prostate specific antigen of 7.4 ± 6.8 ng/ml and biochemical failure after nonoperative prostate cancer treatment underwent fluciclovine (¹⁸F) positron emission tomography-computerized tomography (mean 364.1 ± 37.7 MBq) and planning transrectal prostate ultrasound with 3-dimensional image reconstruction. Focal prostatic activity on positron emission tomography was delineated and co-registered with planning ultrasound. During the subsequent biopsy session computer generated 12-core template biopsies were performed and then fluciclovine defined targets were revealed and biopsied. Histological analysis of template and targeted cores were completed.

RESULTS

Template biopsy was positive for malignancy in 6 of 21 patients (28.6%), including 10 of 124 regions and 11 of 246 cores, vs targeted biopsy in 10 of 21 (47.6%), including 17 of 50 regions and 40 of 125 cores. Five of 21 patients had positive findings on targeted biopsy only and 1 of 21 had positive findings on template biopsy only. An additional case was upgraded from Grade Group 2 to 3 on targeted biopsy. Extraprostatic disease was detected in 8 of 21 men (38.1%) with histological confirmation in all 3 who underwent lesion biopsy.

CONCLUSIONS

Fluciclovine positron emission tomography real-time ultrasound fusion guidance for biopsy is feasible in patients with biochemical failure after nonsurgical therapy for prostate cancer. It identifies more recurrent prostate cancer using fewer cores compared with template biopsy in the same patient. Further study is required to determine in what manner targeted biopsy may augment template biopsy of recurrent prostate cancer.

Validity of the Patient-Reported Outcome Measurement Information System (PROMIS) Sexual Interest and Satisfaction Measures in Men Following Radical Prostatectomy

PURPOSE

Patient-reported outcomes after radical prostatectomy have focused on erectile function. To date, no studies have validated the Patient-Reported Outcome Measurement Information System (PROMIS) Sexual Interest and Satisfaction single item measures in patients with prostate cancer, nor have studies examined how these measures relate to erectile function. In addition, data are lacking with regard to the clinical responsiveness of these measures to treatment. We sought to validate and examine the clinical utility of these measures in men after radical prostatectomy.

PATIENTS AND METHODS

We identified men who underwent a robotic radical prostatectomy from May 2014 to January 2016 in the Michigan Urological Surgery Improvement Collaborative. A single item from the PROMIS Global Satisfaction With Sex Life subdomain and a single item from the PROMIS Interest in Sexual Activity subdomain were administered. Erectile function was also assessed. Differences between baseline and 24-month T-scores for both PROMIS interest and satisfaction were examined. Multilevel models were constructed to examine change over time.

RESULTS

A total of 1,604 patients were included in the analysis. Convergent and discriminant validity of the PROMIS measures was supported. The mean PROMIS interest T-score decreased significantly from baseline to 3 months (P = .001) and significantly increased from 3 months to 24 months in this cohort, with 24-month scores exceeding baseline scores (P < .001). The mean PROMIS satisfaction T-score declined from baseline to 3 months and increased from 3 months to 24 months (P < .002).

CONCLUSION

PROMIS Global Satisfaction With Sex Life and Interest in Sexual Activity single-item measures are fundamental measures in prostate cancer survivorship. Patients are interested in sex despite functional losses and can salvage satisfaction, thereby giving insight into attainable patient-centered survivorship goals for sexual recovery after radical prostatectomy.

18F-Fluciclovine Parameters on Targeted Prostate Biopsy Associated with True Positivity in Recurrent Prostate Cancer

We evaluated ¹⁸F-fluciclovine uptake parameters that correlate with true positivity for local recurrence in non-prostatectomy-treated patients. Methods: Twenty-one patients (prostate-specific antigen level, 7.4 ± 6.8 ng/mL) with biochemical recurrence after nonprostatectomy local therapy (radiotherapy and cryotherapy) underwent dual-time-point ¹⁸F-fluciclovine (364.1 ± 37.7 MBq) PET/CT from pelvis to diaphragm. Prostatic uptake over background was delineated and coregistered to a prostate-biopsy-planning ultrasound. Transrectal biopsies of ¹⁸F-fluciclovine-defined targets were completed using a 3-dimensional visualization and navigation platform. Histologic analyses of lesions were completed. Lesion characteristics including SUV_max, target-to-background ratio (TBR), uptake pattern, and subjective reader's suspicion level were compared between true-positive (malignant) and false-positive (benign) lesions. Univariate analysis was used to determine the association between PET and histologic findings. Receiver-operating-characteristic curves were plotted to determine discriminatory cutoffs for TBR. Statistical significance was set at a P value of less than 0.05. Results: Fifty lesions were identified in 21 patients on PET. Seventeen of 50 (34.0%) targeted lesions in 10 of 21 patients were positive for malignancy. True-positive lesions had a significantly higher SUV_max (6.62 ± 1.70 vs. 4.92 ± 1.27), marrow TBR (2.57 ± 0.81 vs. 1.69 ± 0.51), and blood-pool TBR (4.10 ± 1.17 vs. 2.99 ± 1.01) than false-positive lesions at the early time point (P < 0.01) and remained significant at the delayed time point, except for blood-pool TBR. Focal uptake (odds ratio, 12.07; 95% confidence interval, 2.98-48.80; P < 0.01) and subjective highest suspicion level (odds ratio, 10.91; 95% confidence interval, 1.19-99.69; P = 0.03) correlated with true positivity. Using the receiver-operating-characteristic curve, optimal cutoffs for marrow TBR were 1.9 (area under the curve, 0.82) and 1.8 (area under the curve, 0.85) at early and delayed imaging, respectively. With these cutoffs, 15 of 17 malignant lesions were identified at both time points; however, fewer false-positive lesions were detected at the delayed time point (5/33) than at the early time point (11/33). Conclusion: True positivity of ¹⁸F-fluciclovine-targeted prostate biopsy in non-prostatectomy-treated patients correlates with focal uptake, TBR (blood pool and marrow), and subjective highest suspicion level. A marrow TBR of 1.9 at the early time point and 1.8 at the delayed time point had optimal discriminating capabilities. Despite the relatively low intraprostate positive predictive value (34.0%) with ¹⁸F-fluciclovine, application of these parameters to interpretative criteria may improve true positivity in the treated prostate.

Long-term survival of patients with prostate cancer in Martinique: Results of a population-based study

BACKGROUND

Martinique has one of the highest incidences of prostate cancer (PCa) worldwide. We analysed overall survival (OS) among patients with PCa in Martinique, using data from a population-based cancer registry between 2005 and 2014.

METHODS

The log-rank test was used to assess the statistical differences between survival curves according to age at diagnosis, risk of disease progression including Gleason score, stage at diagnosis and Prostate Specific Antigen (PSA). A multivariable Cox model was constructed to identify independent prognostic factors for OS.

RESULTS

A total of 5045 patients were included with a mean age at diagnosis of 68.1±9.0 years [36.0 - 98.0 years]. Clinical stage was analysed in 4999 (99.1% of overall), 19.5% were at low risk, 34.7% intermediate and 36.9% at high risk. In our study, 8.9% of patients with available stage at diagnosis, were regional/metastatic cancers. Median PSA level at diagnosis was 10.4 ng/mL. High-risk PCa was more frequent in patients aged 65-74 and ≥75 years as compared to those aged <65 years (36.6% and 48.8% versus 28.7% respectively; p<0.0001). One-year OS was 96.3%, 5-year OS was 83.4 and 10-year OS was 65.0%. Median survival was not reached in the whole cohort. High-risk PCa (HR=2.32; p<0.0001), regional/metastatic stage (HR= 9.51; p<0.0001) and older age (65-74 and ≥75 years - respectively HR=1.70; and HR=3.38), were independent prognostic factors for OS (p<0.0001).

CONCLUSION

This study provides long term data that may be useful in making cancer management decisions for patients with PCa in Martinique.

Intensity-modulated radiation therapy for elderly patients (aged ≥75 years) with localized prostate cancer: Comparison with younger patients (aged <75 years)

The aim of the present study was to evaluate the efficacy and safety of intensity-modulated radiation therapy (IMRT) for elderly patients with prostate cancer (age ≥75 years) compared with younger patients (<75 years). The numbers of patients enrolled into the elderly and younger groups were 238 and 853, respectively. More than half of the patients in the elderly group were high-risk, and the total risk of the elderly group was higher than that of younger group. The median follow-up periods for the elderly and younger groups were 42 (range, 2-108) and 49 (range, 2-120) months, respectively. All patients were treated with IMRT at a dose of 74-78 Gy with or without androgen-deprivation therapy. The biochemical failure-free rates (BFFRs) at 3-year follow-up for the elderly and younger groups were 93.3 and 95.7%, respectively; there was no significant difference between the 2 groups in regard to the BFFR. The clinical failure-free rates (CFFR) at 3-year follow-up for the elderly and younger groups was 95.8 and 98.5%, respectively; the 2 groups did not differ significantly in regard to the CFFR. The cumulative incidence rates of gastrointestinal toxicity (grade ≥2) and genitourinary toxicity (grade ≥2) at 3-year follow-up were 10.5 and 1.3%, respectively; there was no significant difference between the elderly and younger groups. It was concluded that in prostate cancer patients aged 75 years or older, IMRT has a treatment effect equivalent to that in patients <75 years old; adverse events are also comparable.

The importance of sexuality, changes in erectile functioning and its association with self-esteem in men with localized prostate cancer: data from an observational study

Background

Treatment for localized prostate cancer (PCa) can cause long-term changes in erectile functioning. However, data on the importance of sexuality and possible consequences of altered erectile functioning on self-esteem in men with localized PCa are lacking.

Methods

Self-report questionnaires were completed by 292 men with PCa, initially managed with active surveillance (AS) or radical prostatectomy (RP). Independent t-tests were conducted to evaluate group differences. A sequential multiple regression model was fitted to analyze the associations between the importance of sexuality, changes in erectile functioning and impairment of self-esteem. Interaction effects were tested using simple slope analyses.

Results

Participants were 70 ± 7.2 years old and 66.5% rated sex as being “rather/very important”. The two groups differed markedly in changes in erectile functioning, importance of sexuality and impairment of self-esteem (p < .001), with higher values in RP patients. Regression analysis showed that after adjustment for control variables and importance of sexuality, changes in erectile functioning were still associated with impairment of self-esteem (B = .668, SE = .069, p < .001). The interaction of changes in erectile functioning and importance of sexuality reached significance (B = .318, SE = .062, p < .001).

Conclusions

RP patients report more changes in erectile functioning than AS patients. Moreover, in men with localized PCa, erectile functioning and self-esteem are closely related. Sexuality seems to be important for the majority of these men. Physicians should address the possibility of erectile dysfunction and its potential effects on psychological well-being before the treatment decision.

An Evaluation of Response to Therapy in Patients Undergoing Radiotherapy or Surgery in the Treatment of Prostate Cancer

Objective:

This study compared biochemical recurrence (BR), biochemical recurrence-free survival (BRFS) and overall survival (OS) rates and therapeutic methods in patients undergoing definitive radiotherapy (RT) or radical prostatectomy (RP) because of diagnosis of prostate cancer.

Method:

Files of 128 patients undergoing RP (n=82) or RT (n=46), who did not receive salvage therapy, and with serum PSA levels monitored three-monthly for at least two years were examined retrospectively. Patients were assigned into low, intermediate and high risk groups based on D’Amico risk classifications. RP was performed in the surgical arm and in the RT arm 70-74 Gy RT were applied using 3D conformal RT technique.

Results:

BR was not detected among low risk group patients over 10-year follow-up. No difference was determined between the treatment arms in BR in the intermediate risk patients, while the RT arm was statistically significantly better among the high risk patients (p=0.04). OS rates in the low, intermediate, and high risk groups were 97.1%, 93.8%, and 92.3%, respectively, in the RP, and 81.8%, 92.9%, and 90.5%, respectively, in RT (p>0.05) group. BRFS rates in the intermediate and high risk groups were 92.3%, vs 95.2% in RP, and 79.6%, vs 81.6% in RT (p>0.05).

Conclusion:

There was no significant difference between BRFS and OS rates in the two arms of prostate cancer treatment, although RT was better in the high risk group patients in terms of BR. Longer-term studies involving high-dose RT techniques applied with maximum protection of normal tissue and supporting the effectiveness of RT are needed.

Calcium Bisphosphonate Nanoparticles with Chelator-Free Radiolabeling to Deplete Tumor-Associated Macrophages for Enhanced Cancer Radioisotope Therapy

Tumor-associated macrophages (TAMs) are often related with poor prognosis after radiotherapy. Depleting TAMs may thus be a promising method to improve the radio-therapeutic efficacy. Herein, we report a biocompatible and biodegradable nanoplatform based on calcium bisphosphonate (CaBP-PEG) nanoparticles for chelator-free radiolabeling chemistry, effective in vivo depletion of TAMs, and imaging-guided enhanced cancer radioisotope therapy (RIT). It is found that CaBP-PEG nanoparticles prepared via a mineralization method with poly(ethylene glycol) (PEG) coating could be labeled with various radioisotopes upon simple mixing, including gamma-emitting ^99mTc for single-photon-emission computed tomography (SPECT) imaging, as well as beta-emitting ³²P as a therapeutic radioisotope for RIT. Upon intravenous injection, CaBP(^99mTc)-PEG nanoparticles exhibit efficient tumor homing, as evidenced by SPECT imaging. Owning to the function of bisphosphonates as clinical drugs to deplete TAMs, suppressed angiogenesis, normalized tumor vasculatures, enhanced intratumoral perfusion, and relieved tumor hypoxia are observed after TAM depletion induced by CaBP-PEG. Such modulated tumor microenvironment appears to be highly favorable for cancer RIT using CaBP(³²P)-PEG as the radio-therapeutic agent, which offers excellent synergistic therapeutic effect in inhibiting the tumor growth. With great biocompatibility and multifunctionalities, such CaBP-PEG nanoparticles constituted by Ca²⁺ and a clinical drug would be rather attractive for clinical translation.