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Matsukawa A, Yanagisawa T, Bekku K, Kardoust Parizi M, Laukhtina E, Klemm J, Chiujdea S, Mori K, Kimura S, Fazekas T, Miszczyk M, Miki J, Kimura T, Karakiewicz PI, Rajwa P, Shariat SF. Comparing the Performance of Digital Rectal Examination and Prostate-specific Antigen as a Screening Test for Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol Oncol 2024; 7:697-704. [PMID: 38182488 DOI: 10.1016/j.euo.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/03/2023] [Accepted: 12/13/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND AND OBJECTIVE Although digital rectal examination (DRE) is recommended in combination with prostate-specific antigen (PSA) for detection of prostate cancer (PCa), there are limited data to support its use as a screening/early detection test. Our objective was to assess the diagnostic value of DRE in screening for early detection of PCa. METHODS In August 2023, we queried the PubMed, Scopus, and Web of Science databases to identify prospective studies simultaneously investigating the diagnostic performance of DRE and PSA for PCa screening. The primary endpoints were the positive predictive value (PPV) and cancer detection rate (CDR) of DRE. Secondary endpoints included the PPV and CDR of both PSA alone and in combination with DRE. We conducted meta-regression analysis to compare the CDR and PPV of different screening strategies. This meta-analysis is registered on PROSPERO (CRD42023446940). KEY FINDINGS AND LIMITATIONS We identified eight studies involving 85,798 participants, of which three were randomized controlled trials and five were prospective diagnostic studies, that reported the PPV and CDR of both DRE and PSA for the same cohort. Our analysis revealed a pooled PPV of 0.21 (95% confidence interval [CI] 0.13-0.33) for DRE, which is similar to the PPV of PSA (0.22, 95% CI 0.15-0.30; p = 0.9), with no benefit from combining DRE and PSA (PPV 0.19, 95% CI 0.13-0.26; p = 0.5). However, the CDR of DRE (0.01, 95% CI: 0.01-0.02) was significantly lower than that of PSA (0.03, 95% CI 0.02-0.03; p < 0.05) and the combination of DRE and PSA (0.03, 95% CI 0.02-0.04; p < 0.05). The screening strategy combining DRE and PSA was not different to that of PSA alone in terms of CDR (p = 0.5) and PPV (p = 0.5). CONCLUSIONS AND CLINICAL IMPLICATIONS Our comprehensive review and meta-analysis indicates that both as an independent test and as a supplementary measure to PSA for PCa detection, DRE exhibits a notably low diagnostic value. The collective findings from the included studies suggest that, in the absence of clinical symptoms and signs, DRE could be potentially omitted from PCa screening and early detection strategies. PATIENT SUMMARY Our review shows that the screening performance of digital rectal examination for detection of prostate cancer is not particularly impressive, suggesting that it might not be necessary to conduct this examination routinely.
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Affiliation(s)
- Akihiro Matsukawa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takafumi Yanagisawa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kensuke Bekku
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Mehdi Kardoust Parizi
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Shariati Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Jakob Klemm
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sever Chiujdea
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Spitalul Clinic Judetean Murures, University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Mures, Romania
| | - Keiichiro Mori
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shoji Kimura
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Tamas Fazekas
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Semmelweis University, Budapest, Hungary
| | - Marcin Miszczyk
- Third Department of Radiotherapy and Chemotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Jun Miki
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Kimura
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Canada
| | - Pawel Rajwa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Medical University of Silesia, Zabrze, Poland
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia; Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czechia; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria.
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Chandekar KR, Satapathy S, Singh H, Kumar R, Kumar S, Kakkar N, Mittal BR, Singh SK. Utility of PSMA-PET derived volumetric parameters in initial risk stratification and prediction of prostate cancer metastasis - a head-to-head comparison of the radiotracers 18F-PSMA-1007 and 68Ga-PSMA-11. Nucl Med Commun 2024:00006231-990000000-00314. [PMID: 38932503 DOI: 10.1097/mnm.0000000000001874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
OBJECTIVE This study aimed to explore and compare the utility of baseline 18F-PSMA-1007 and 68Ga-PSMA-11 PET/computed tomography (CT) derived volumetric parameters in initial risk stratification and prediction of prostate cancer (PCa) metastasis. METHODS Forty treatment-naïve, biopsy-proven intermediate-/high-risk PCa patients were prospectively recruited. Each patient underwent PET/CT with 68Ga-PSMA-11 and 18F-PSMA-1007 (within 2 weeks). The maximum and mean standardized uptake values (SUVmax and SUVmean) of primary tumor, prostate PSMA-tumor volume (PSMA-TVp), and prostate total lesion PSMA (TL-PSMAp) were measured. RESULTS PSMA-TVp and TL-PSMAp (with both radiotracers) mostly exhibited moderate-to-strong correlation with Gleason score, serum prostate-specific antigen level and clinical tumor stage (Spearman ρ = 0.361-0.783, P-values ≤0.022). Primary tumor SUVmax values were similar across initial risk categories. PSMA-TVp and TL-PSMAp, however, were significantly higher in high-risk PCa compared to intermediate-risk PCa (P-values ≤0.001). Receiver operating characteristic (ROC) curve analysis revealed that F-PSMA-TVp, Ga-PSMA-TVp, F-TL-PSMAp, and Ga-TL-PSMAp (optimal cutoff values of 20.9, 23.4, 142.5, and 144.8, respectively) could effectively differentiate high-risk from intermediate-risk PCa [area under the ROC curve (AUCs) 0.859-0.898, P-values <0.001] with high sensitivity (~68.8-75%) and excellent specificity (100%). PSMA-TVp and TL-PSMAp (with both radiotracers) could predict presence of regional and extraregional nodal metastasis (AUCs 0.703-0.801, P-values ≤0.03) with moderate sensitivity (~47.8-70.6%) and excellent specificity (~82.6-94.1%). CONCLUSION Our results suggest that baseline PSMA-PET primary tumor volumetric parameters provide a noninvasive, objective, and accurate index for initial risk stratification and can predict presence of regional and extraregional nodal metastasis in PCa patients. Larger studies are warranted to evaluate their incremental role over conventional parameters.
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Affiliation(s)
- Kunal Ramesh Chandekar
- Department of Nuclear Medicine
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi
| | - Swayamjeet Satapathy
- Department of Nuclear Medicine
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi
| | | | | | | | - Nandita Kakkar
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh
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Falkenbach F, Ambrosini F, Kachanov M, Ortner G, Maurer T, Köhler D, Beyersdorff D, Graefen M, Budäus L. PSA-density, DRE, and PI-RADS 5: potential surrogates for omitting biopsy? World J Urol 2024; 42:182. [PMID: 38506941 PMCID: PMC10955031 DOI: 10.1007/s00345-024-04894-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 02/16/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVE In contrast to other malignancies, histologic confirmation prior treatment in patients with a high suspicion of clinically significant prostate cancer (csPCA) is common. To analyze the impact of extracapsular extension (ECE), cT-stage defined by digital rectal examination (DRE), and PSA-density (PSA-D) on detection of csPCA in patients with at least one PI-RADS 5 lesion (hereinafter, "PI-RADS 5 patients"). MATERIALS AND METHODS PI-RADS 5 patients who underwent MRI/Ultrasound fusion biopsy (Bx) between 2016 and 2020 were identified in our institutional database. Uni- and multivariable logistic-regression models were used to identify predictors of csPCA-detection (GGG ≥ 2). Risk models were adjusted for ECE, PSA-D, and cT-stage. Corresponding Receiver Operating Characteristic (ROC) curves and areas under the curve (AUC) were calculated. RESULTS Among 493 consecutive PI-RADS 5 patients, the median age and PSA was 69 years (IQR 63-74) and 8.9 ng/ml (IQR 6.0-13.7), respectively. CsPCA (GGG ≥ 2) was detected in 405/493 (82%); 36/493 patients (7%) had no cancer. When tabulating for PSA-D of > 0.2 ng/ml/cc and > 0.5 ng/ml/cc, csPCA was found in 228/253 (90%, PI-RADS5 + PSA-D > 0.2 ng/ml/cc) and 54/54 (100%, PI-RADS5 + PSA-D > 0.5 ng/ml/cc). Finally, a model incorporating PSA-D and cT-stage achieved an AUC of 0.79 (CI 0.74-0.83). CONCLUSION In PI-RADS 5 patients, PSA-D and cT-stage emerged as strong predictors of csPCA at biopsy. Moreover, when adding the threshold of PSA-D > 0,5 ng/ml/cc, all PI-RADS 5 patients were diagnosed with csPCA. Therefore, straight treatment for PCA can be considered, especially if risk-factors for biopsy-related complications such as obligatory dual platelet inhibition are present.
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Affiliation(s)
- Fabian Falkenbach
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Francesca Ambrosini
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
- Department of Urology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Mykyta Kachanov
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gernot Ortner
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Tobias Maurer
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Köhler
- Department for Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dirk Beyersdorff
- Department for Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Lars Budäus
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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Ge Q, Li J, Yang F, Tian X, Zhang M, Hao Z, Liang C, Meng J. Molecular classifications of prostate cancer: basis for individualized risk stratification and precision therapy. Ann Med 2023; 55:2279235. [PMID: 37939258 PMCID: PMC10653710 DOI: 10.1080/07853890.2023.2279235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 10/30/2023] [Indexed: 11/10/2023] Open
Abstract
Tumour classifications play a pivotal role in prostate cancer (PCa) management. It can predict the clinical outcomes of PCa as early as the disease is diagnosed and then guide therapeutic schemes, such as active monitoring, standalone surgical intervention, or surgery supplemented with postoperative adjunctive therapy, thereby circumventing disease exacerbation and excessive treatment. Classifications based on clinicopathological features, such as prostate cancer-specific antigen, Gleason score, and TNM stage, are still the main risk stratification strategies and have played an essential role in standardized clinical decision-making. However, mounting evidence indicates that clinicopathological parameters in isolation fail to adequately capture the heterogeneity exhibited among distinct PCa patients, such as those sharing identical Gleason scores yet experiencing divergent prognoses. As a remedy, molecular classifications have been introduced. Currently, molecular studies have revealed the characteristic genomic alterations, epigenetic modulations, and tumour microenvironment associated with different types of PCa, which provide a chance for urologists to refine the PCa classification. In this context, numerous invaluable molecular classifications have been devised, employing disparate statistical methodologies and algorithmic approaches, encompassing self-organizing map clustering, unsupervised cluster analysis, and multifarious algorithms. Interestingly, the classifier PAM50 was used in a phase-2 multicentre open-label trial, NRG-GU-006, for further validation, which hints at the promise of molecular classification for clinical use. Consequently, this review examines the extant molecular classifications, delineates the prevailing panorama of clinically pertinent molecular signatures, and delves into eight emblematic molecular classifications, dissecting their methodological underpinnings and clinical utility.
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Affiliation(s)
- Qintao Ge
- Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
- Institute of Urology, Anhui Medical University, Hefei, P.R. China
- Anhui Province Key Laboratory of Genitourinary Diseases, Anhui Medical University, Hefei, P.R. China
| | - Jiawei Li
- Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
- Institute of Urology, Anhui Medical University, Hefei, P.R. China
- Anhui Province Key Laboratory of Genitourinary Diseases, Anhui Medical University, Hefei, P.R. China
| | - Feixiang Yang
- Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
- Institute of Urology, Anhui Medical University, Hefei, P.R. China
- Anhui Province Key Laboratory of Genitourinary Diseases, Anhui Medical University, Hefei, P.R. China
| | | | - Meng Zhang
- Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
- Institute of Urology, Anhui Medical University, Hefei, P.R. China
- Anhui Province Key Laboratory of Genitourinary Diseases, Anhui Medical University, Hefei, P.R. China
| | - Zongyao Hao
- Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
- Institute of Urology, Anhui Medical University, Hefei, P.R. China
- Anhui Province Key Laboratory of Genitourinary Diseases, Anhui Medical University, Hefei, P.R. China
| | - Chaozhao Liang
- Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
- Institute of Urology, Anhui Medical University, Hefei, P.R. China
- Anhui Province Key Laboratory of Genitourinary Diseases, Anhui Medical University, Hefei, P.R. China
| | - Jialin Meng
- Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
- Institute of Urology, Anhui Medical University, Hefei, P.R. China
- Anhui Province Key Laboratory of Genitourinary Diseases, Anhui Medical University, Hefei, P.R. China
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Flach RN, van Dooijeweert C, Aben KKH, Suelmann BBM, Willemse PPM, van Diest PJ, Meijer RP. Interlaboratory Gleason grading variation affects treatment: a Dutch historic cohort study in 30 509 patients with prostate cancer. J Clin Pathol 2023; 76:690-697. [PMID: 35835545 DOI: 10.1136/jcp-2021-208067] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 06/11/2022] [Indexed: 11/04/2022]
Abstract
AIM Substantial variation in Gleason grading (GG) of prostate cancer (PCa) exists between Dutch pathology laboratories. This study investigates its impact on treatment strategies. METHODS Pathology reports of prostate needle biopsies and clinical data of patients with PCa diagnosed between 2017 and 2019 were retrieved from the Dutch nationwide network and registry of histopathology and cytopathology and The Netherlands Cancer Registry. We investigated the impact of grading variation on treatment strategy for patients whose grade was decisive in treatment choice. First, we evaluated the effect of grading practice (low, average or high grading) on active treatment (AT) versus active surveillance in patients with prostate-specific antigen (PSA) <10 ng/mL and cT1c/cT2a disease. Second, we assessed the association of grading practice with performance of pelvic lymph node dissection (PLND) in patients with PSA 10-20 ng/mL or cT2b disease. We used multivariable logistic regression to analyse the relation between laboratories' grading practices and AT or PLND. RESULTS We included 30 509 patients. GG was decisive in treatment strategy for 11 925 patients (39%). AT was performed significantly less often in patients diagnosed by laboratories that graded lower than average (OR=0.77, 95% CI 0.68 to 0.88). Conversely, patients received AT significantly more often when diagnosed in high-grading laboratories versus average-grading laboratories (OR=1.21, 95% CI 1.03 to1.43). PLND was performed significantly less often in patients diagnosed by low-grading versus average-grading laboratories (OR=0.66, 95% CI 0.48 to 0.90). CONCLUSION Our study shows that the odds that a patient undergoes AT or PLND, depends on laboratories' grading practices in a substantial number of patients. This likely influences patient prognosis and outcome, necessitating standardisation of GG to prevent suboptimal patient outcome.
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Affiliation(s)
- Rachel N Flach
- Department of Oncological Urology, UMC Utrecht, Utrecht, The Netherlands
| | | | - Katja K H Aben
- Department of Research & Development, Netherlands Comprehensive Cancer Centre, Utrecht, The Netherlands
- Radboud Institute for Health Sciences, Radboud UMC, Nijmegen, Gelderland, The Netherlands
| | | | | | | | - Richard P Meijer
- Department of Oncological Urology, UMC Utrecht, Utrecht, The Netherlands
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Dekker L, van Reijn-Baggen DA, Han-Geurts IJM, Felt-Bersma RJF. To what extent are anorectal function tests comparable? A study comparing digital rectal examination, anal electromyography, 3-dimensional high-resolution anal manometry, and transperineal ultrasound. Int J Colorectal Dis 2023; 38:12. [PMID: 36645523 PMCID: PMC9842578 DOI: 10.1007/s00384-022-04304-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Anorectal function tests are helpful for objective investigation of anorectal (dys)function. A variety of tests are available, but there is no recommendation when to perform which test. Furthermore, which test is the most accurate is controversial and the correlation between these tests is not very clear. The aim of our study was to examine the correlation of anal pressures and the possibility to diagnose pelvic floor dyssynergia between digital rectal examination (DRE) and several anorectal function tests. METHODS Between January 2020 and April 2022, all men and women aged 18 to 80 years, treated at the Proctos Clinic, who were referred for pelvic floor physical therapy (PFPT) by the surgeon and underwent anorectal function tests, were included. DRE was performed to establish the anal pressure at rest and during squeeze and straining. Anorectal function tests included 3D high-resolution anal manometry (3D-HRAM), balloon expulsion test (BET), transperineal ultrasound (TPUS), and surface electromyography (s-EMG). RESULTS A total of 50 patients, 37 (74%) females, were included. Median age was 51 years. Twenty-three (62%) females had a history of two or more vaginal deliveries. The most frequent reason for referral for PFPT was fecal incontinence in 27 (54%) patients. The assessed pressures and pelvic floor function measured with DRE by the surgeon and the pelvic floor physical therapist during rest, squeeze, and straining correlated in 78%, 78%, and 84%, respectively. Correlation between DRE and 3D-HRAM or s-EMG was better for squeeze pressures than resting pressures. The correlation between s-EMG and 3D-HRAM was better during squeeze than at rest with an agreement of 59% and 37%, respectively. CONCLUSION DRE by an experienced investigator is of sufficient value for daily clinical practice to detect dyssynergia and to measure sphincter tone. Commonly performed anorectal function tests correlate poorly with DRE and with other anorectal function tests. When conservative treatment fails, further investigation is warranted; however, these results should be interpreted with caution. WHAT DOES THIS PAPER ADD TO THE LITERATURE?: Anorectal function tests such as the 3D high-resolution anorectal manometry, balloon expulsion test, surface electromyography, and transperineal ultrasound are all frequently performed in the diagnostic workup in patients with defecation disorders. No previous study has compared these tests regarding their outcomes, nor has the interrater agreement been measured regarding the digital rectal examination by two experienced observers. Furthermore, transperineal ultrasound is in all probability not frequently used and therefore underexposed in the diagnostic workup of patients with dyssynergic defecation.
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Affiliation(s)
- L Dekker
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands.
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands.
| | - D A van Reijn-Baggen
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands
- Department of Urology, Leiden University Center, Leiden, The Netherlands
| | - I J M Han-Geurts
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - R J F Felt-Bersma
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Centers, Location VU, Amsterdam, The Netherlands
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Ching JCF, Lam S, Lam CCH, Lui AOY, Kwong JCK, Lo AYH, Chan JWH, Cai J, Leung WS, Lee SWY. Integrating CT-based radiomic model with clinical features improves long-term prognostication in high-risk prostate cancer. Front Oncol 2023; 13:1060687. [PMID: 37205204 PMCID: PMC10186349 DOI: 10.3389/fonc.2023.1060687] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/10/2023] [Indexed: 05/21/2023] Open
Abstract
Objective High-risk prostate cancer (PCa) is often treated by prostate-only radiotherapy (PORT) owing to its favourable toxicity profile compared to whole-pelvic radiotherapy. Unfortunately, more than 50% patients still developed disease progression following PORT. Conventional clinical factors may be unable to identify at-risk subgroups in the era of precision medicine. In this study, we aimed to investigate the prognostic value of pre-treatment planning computed tomography (pCT)-based radiomic features and clinical attributes to predict 5-year progression-free survival (PFS) in high-risk PCa patients following PORT. Materials and methods A total of 176 biopsy-confirmed PCa patients who were treated at the Hong Kong Princess Margaret Hospital were retrospectively screened for eligibility. Clinical data and pCT of one hundred eligible high-risk PCa patients were analysed. Radiomic features were extracted from the gross-tumour-volume (GTV) with and without applying Laplacian-of-Gaussian (LoG) filter. The entire patient cohort was temporally stratified into a training and an independent validation cohort in a ratio of 3:1. Radiomics (R), clinical (C) and radiomic-clinical (RC) combined models were developed by Ridge regression through 5-fold cross-validation with 100 iterations on the training cohort. A model score was calculated for each model based on the included features. Model classification performance on 5-year PFS was evaluated in the independent validation cohort by average area-under-curve (AUC) of receiver-operating-characteristics (ROC) curve and precision-recall curve (PRC). Delong's test was used for model comparison. Results The RC combined model which contains 6 predictive features (tumour flatness, root-mean-square on fine LoG-filtered image, prostate-specific antigen serum concentration, Gleason score, Roach score and GTV volume) was the best-performing model (AUC = 0.797, 95%CI = 0.768-0.826), which significantly outperformed the R-model (AUC = 0.795, 95%CI = 0.774-0.816) and C-model (AUC = 0.625, 95%CI = 0.585-0.665) in the independent validation cohort. Besides, only the RC model score significantly classified patients in both cohorts into progression and progression-free groups regarding their 5-year PFS (p< 0.05). Conclusion Combining pCT-based radiomic and clinical attributes provided superior prognostication value regarding 5-year PFS in high-risk PCa patients following PORT. A large multi-centre study will potentially aid clinicians in implementing personalised treatment for this vulnerable subgroup in the future.
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Affiliation(s)
- Jerry C. F. Ching
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - Saikit Lam
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
- Research Institute for Smart Aging, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - Cody C. H. Lam
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - Angie O. Y. Lui
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - Joanne C. K. Kwong
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - Anson Y. H. Lo
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - Jason W. H. Chan
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - Jing Cai
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - W. S. Leung
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
- *Correspondence: Shara W. Y. Lee, ; W. S. Leung,
| | - Shara W. Y. Lee
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
- *Correspondence: Shara W. Y. Lee, ; W. S. Leung,
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Lu YC, Huang CY, Cheng CH, Huang KH, Lu YC, Chow PM, Chang YK, Pu YS, Chen CH, Lu SL, Lan KH, Jaw FS, Chen PL, Hong JH. Propensity score matching analysis comparing radical prostatectomy and radiotherapy with androgen deprivation therapy in locally advanced prostate cancer. Sci Rep 2022; 12:12480. [PMID: 35864293 PMCID: PMC9304348 DOI: 10.1038/s41598-022-16700-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 07/14/2022] [Indexed: 11/21/2022] Open
Abstract
To compare clinical outcomes between the use of robotic-assisted laparoscopic radical prostatectomy (RP) and radiotherapy (RT) with long-term androgen deprivation therapy (ADT) in locally advanced prostate cancer (PC), 315 patients with locally advanced PC (clinical T-stage 3/4) were considered for analysis retrospectively. Propensity score-matching at a 1:1 ratio was performed. The median follow-up period was 59.2 months (IQR 39.8–87.4). There were 117 (37.1%) patients in the RP group and 198 (62.9%) patients in the RT group. RT patients were older and had higher PSA at diagnosis, higher Gleason score grade group and more advanced T-stage (all p < 0.001). After propensity score-matching, there were 68 patients in each group. Among locally advanced PC patients, treatment with RP had a higher risk of biochemical recurrence compared to the RT group. In multivariate Cox regression analysis, treatment with RT plus ADT significantly decreased the risk of biochemical failure (HR 0.162, p < 0.001), but there was no significant difference in local recurrence, distant metastasis and overall survival (p = 0.470, p = 0.268 and p = 0.509, respectively). This information supported a clinical benefit in BCR control for patients undergoing RT plus long-term ADT compared to RP.
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Affiliation(s)
- Yu-Cheng Lu
- Department of Urology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chao-Yuan Huang
- Department of Urology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chia-Hsien Cheng
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Kuo-How Huang
- Department of Urology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Chuan Lu
- Institute of Biomedical Engineering, National Taiwan University, No. 1, Changde St., Zhongzheng Dist., Taipei City, 10048, Taiwan.,Department of Urology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Po-Ming Chow
- Department of Urology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Kai Chang
- Department of Urology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yeong-Shiau Pu
- Department of Urology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chung-Hsin Chen
- Department of Urology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shao-Lun Lu
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Keng-Hsueh Lan
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Fu-Shan Jaw
- Institute of Biomedical Engineering, National Taiwan University, No. 1, Changde St., Zhongzheng Dist., Taipei City, 10048, Taiwan
| | - Pei-Ling Chen
- Department of Urology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jian-Hua Hong
- Institute of Biomedical Engineering, National Taiwan University, No. 1, Changde St., Zhongzheng Dist., Taipei City, 10048, Taiwan. .,Department of Urology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.
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9
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Signature for Prostate Cancer Based on Autophagy-Related Genes and a Nomogram for Quantitative Risk Stratification. DISEASE MARKERS 2022; 2022:7598942. [PMID: 35860692 PMCID: PMC9293571 DOI: 10.1155/2022/7598942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 06/10/2022] [Indexed: 11/17/2022]
Abstract
Background. Prostate cancer (PCa) ranks as the most common malignancy and the second leading cause of cancer-related death among males worldwide. The essential role of autophagy in the progression of PCa and treatment resistance has been preliminarily revealed. However, comprehensive molecular elucidations of the correlation between PCa and autophagy are rare. Method. We obtained transcription information and corresponding clinicopathological profiles of PCa patients from TCGA, MSKCC, and GEO datasets. LAASO analysis was employed to select gene signatures and estimate the autophagy score for each patient. Correlations between the signature and prognosis of PCa were investigated by K-M and multivariate Cox regression analyses. A nomogram was established on the basis of the above results. Further validations relied on ROC, calibration analysis, decision curve analysis, and external cohorts. Variable activated signaling pathways were revealed using GSVA algorithms, and the genetic alteration landscape was elucidated via the oncodrive module from the “maftools” R package. In addition, we also examined the therapeutic role of the signature based on phenotype data from GDSC 2016. Result. Six autophagy-related genes were eventually selected to establish the signature, including ULK1, CAPN10, FKBP5, UBE2T, NLRC4, and BNIP3L. We used these genes and corresponding coefficients to calculate an autophagy score (AutS) for each patient in this study. A high AutS group and a low AutS group were divided on the mean AutS of the patients. Longer overall survival, higher Gleason score and PSA, and better response to ADT were observed in patients with high AutS. Meanwhile, we found that high AutS PCa was related to more proliferation-associated signaling activation and higher genetic mutation frequencies, manifesting a poor prognosis. A nomogram was constructed based on GS, T stage, PSA, and AutS as covariates. Its discriminative efficacy and clinical value were validated using robust statistical methods. Finally, we tested its prognostic value through two external cohorts and six published signatures. Conclusion. The autophagy-related gene signature is a highly discriminative model for risk stratification and drug therapy in PCa, and a nomogram incorporating AutS might be a promising tool for precision medicine.
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10
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Ball RY, Cardenas R, Winterbone MS, Hanna MY, Parker C, Hurst R, Brewer DS, D’Sa L, Mills R, Cooper CS, Clark J. The Urine Biomarker PUR-4 Is Positively Associated with the Amount of Gleason 4 in Human Prostate Cancers. Life (Basel) 2021; 11:life11111172. [PMID: 34833048 PMCID: PMC8622091 DOI: 10.3390/life11111172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 11/16/2022] Open
Abstract
The Prostate Urine Risk (PUR) biomarker is a four-group classifier for predicting outcome in patients prior to biopsy and for men on active surveillance. The four categories correspond to the probabilities of the presence of normal tissue (PUR-1), D’Amico low-risk (PUR-2), intermediate-risk (PUR-3), and high-risk (PUR-4) prostate cancer. In the current study we investigate how the PUR-4 status is linked to Gleason grade, prostate volume, and tumor volume as assessed from biopsy (n = 215) and prostatectomy (n = 9) samples. For biopsy data PUR-4 status alone was linked to Gleason Grade group (GG) (Spearman’s, ρ = 0.58, p < 0.001 trend). To assess the impact of tumor volume each GG was dichotomized into Small and Large volume cancers relative to median volume. For GG1 (Gleason Pattern 3 + 3) cancers volume had no impact on PUR-4 status. In contrast for GG2 (3 + 4) and GG3 (4 + 3) cancers PUR-4 levels increased in large volume cancers with statistical significance observed for GG2 (p = 0.005; Games-Howell). These data indicated that PUR-4 status is linked to the presence of Gleason Pattern 4. To test this observation tumor burden and Gleason Pattern were assessed in nine surgically removed and sectioned prostates allowing reconstruction of 3D maps. PUR-4 was not correlated with Gleason Pattern 3 amount, total tumor volume or prostate size. A strong correlation was observed between amount of Gleason Pattern 4 tumor and PUR-4 signature (r = 0.71, p = 0.034, Pearson’s). These observations shed light on the biological significance of the PUR biomarker and support its use as a non-invasive means of assessing the presence of clinically significant prostate cancer.
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Affiliation(s)
- Richard Y. Ball
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK; (R.Y.B.); (L.D.); (R.M.)
| | - Ryan Cardenas
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK; (R.C.); (M.S.W.); (R.H.); (D.S.B.); (C.S.C.)
| | - Mark S. Winterbone
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK; (R.C.); (M.S.W.); (R.H.); (D.S.B.); (C.S.C.)
| | - Marcelino Y. Hanna
- Urology Department Castle Hill, Hull University Teaching Hospital, Castle Rd, Cottingham HU16 5JQ, UK;
| | - Chris Parker
- Institute of Cancer Research, Sutton SM2 5NG, UK;
- Royal Marsden Hospital, Sutton SM2 5PT, UK
| | - Rachel Hurst
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK; (R.C.); (M.S.W.); (R.H.); (D.S.B.); (C.S.C.)
| | - Daniel S. Brewer
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK; (R.C.); (M.S.W.); (R.H.); (D.S.B.); (C.S.C.)
- Earlham Institute, Norwich NR4 7UZ, UK
| | - Lauren D’Sa
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK; (R.Y.B.); (L.D.); (R.M.)
| | - Rob Mills
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK; (R.Y.B.); (L.D.); (R.M.)
| | - Colin S. Cooper
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK; (R.C.); (M.S.W.); (R.H.); (D.S.B.); (C.S.C.)
| | - Jeremy Clark
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK; (R.C.); (M.S.W.); (R.H.); (D.S.B.); (C.S.C.)
- Correspondence:
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11
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Kim CJ, Dong L, Amend SR, Cho YK, Pienta KJ. The role of liquid biopsies in prostate cancer management. LAB ON A CHIP 2021; 21:3263-3288. [PMID: 34346466 DOI: 10.1039/d1lc00485a] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Liquid biopsy has emerged as a complement to invasive tissue biopsy to guide cancer diagnosis and treatment. The common liquid biopsy biomarkers are circulating tumor cells (CTCs), extracellular vesicles (EVs), and circulating tumor DNA (ctDNA). Each biomarker provides specific information based on its intrinsic characteristics. Prostate cancer is the second most common cancer in males worldwide. In men with low-grade localized prostate cancer, the disease can often be managed by active surveillance. For men who require treatment, the 5-year survival rate of localized prostate cancer is the highest among all cancer types, but the metastatic disease remains incurable. Metastatic prostate cancer invariably progresses to involve multiple bone sites and develops into a castration-resistant disease that leads to cancer death. The need to appropriately diagnose and guide the serial treatment of men with prostate cancer has led to the implementation of many studies to apply liquid biopsies to prostate cancer management. This review describes recent advancements in isolation and detection technology and the strength and weaknesses of the three circulating biomarkers. The clinical studies based on liquid biopsy results are summarized to depict the future perspective in the role of liquid biopsy on prostate cancer management.
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Affiliation(s)
- Chi-Ju Kim
- The Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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12
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Miyamoto S, Goto K, Honda Y, Terada H, Fujii S, Ueno T, Fukuoka K, Sekino Y, Kitano H, Ikeda K, Hieda K, Inoue S, Hayashi T, Teishima J, Takeshima Y, Yasui W, Awai K, Matsubara A. Tumor contact length of prostate cancer determined by a three-dimensional method on multiparametric magnetic resonance imaging predicts extraprostatic extension and biochemical recurrence. Int J Urol 2021; 28:1012-1018. [PMID: 34227174 DOI: 10.1111/iju.14633] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 06/03/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the clinical benefit of tumor contact length as a predictor of pathological extraprostatic extension and biochemical recurrence in patients undergoing prostatectomy. METHODS A total of 91 patients who underwent 3T multiparametric magnetic resonance imaging before prostatectomy from April 2014 to July 2019 were included. A total of 94 prostate cancer foci were analyzed retrospectively. We evaluated maximum tumor contact length, which was determined to be the maximum value in the three-dimensional directions, as a predictor of pathological extraprostatic extension and biochemical recurrence. RESULTS A total of 19 lesions (20.2%) had positive pathological extraprostatic extension. Areas under the curves showed maximum tumor contact length to be a significantly better parameter to predict pathological extraprostatic extension than the Prostate Imaging Reporting and Data System (P = 0.002), tumor maximal diameter (P = 0.001), prostate-specific antigen (P = 0.020), Gleason score (P < 0.001), and clinical T stage (P < 0.001). Multivariate analysis showed maximum tumor contact length (P = 0.003) to be an independent risk factor for predicting biochemical recurrence. We classified the patients using preoperative factors (prostate-specific antigen >10, Gleason score >3 + 4 and maximum tumor contact length >10 mm) into three groups: (i) high-risk group (patients having all factors); (ii) intermediate-risk group (patients having two of three factors); and (iii) low-risk group (patients having only one or none of the factors). Kaplan-Meier curves showed that the high-risk group had significantly worse biochemical recurrence than the intermediate-risk group (P = 0.042) and low-risk group (P < 0.001). CONCLUSIONS Our findings suggest that maximum tumor contact length is an independent predictor of pathological extraprostatic extension and biochemical recurrence. A risk stratification system using prostate-specific antigen, Gleason score and maximum tumor contact length might be useful for preoperative assessment of prostate cancer patients.
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Affiliation(s)
- Shunsuke Miyamoto
- Departments of, Department of, Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Keisuke Goto
- Departments of, Department of, Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yukiko Honda
- Department of, Diagnostic Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroaki Terada
- Department of, Diagnostic Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinsuke Fujii
- Departments of, Department of, Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takeshi Ueno
- Departments of, Department of, Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.,Department of Urology, Nakatsu Daiichi Hospital, Nakatsu, Japan
| | - Kenichiro Fukuoka
- Departments of, Department of, Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yohei Sekino
- Departments of, Department of, Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroyuki Kitano
- Departments of, Department of, Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kenichiro Ikeda
- Departments of, Department of, Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Keisuke Hieda
- Departments of, Department of, Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shogo Inoue
- Departments of, Department of, Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tetsutaro Hayashi
- Departments of, Department of, Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Jun Teishima
- Departments of, Department of, Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yukio Takeshima
- Department of, Pathology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Wataru Yasui
- Department of, Molecular Pathology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuo Awai
- Department of, Diagnostic Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akio Matsubara
- Departments of, Department of, Urology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.,Hiroshima General Hospital, Hatsukaichi, Japan
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14
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Hou Y, Zhang YH, Bao J, Bao ML, Yang G, Shi HB, Song Y, Zhang YD. Artificial intelligence is a promising prospect for the detection of prostate cancer extracapsular extension with mpMRI: a two-center comparative study. Eur J Nucl Med Mol Imaging 2021; 48:3805-3816. [PMID: 34018011 DOI: 10.1007/s00259-021-05381-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/25/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE A balance between preserving urinary continence as well as sexual potency and achieving negative surgical margins is of clinical relevance while implementary difficulty. Accurate detection of extracapsular extension (ECE) of prostate cancer (PCa) is thus crucial for determining appropriate treatment options. We aimed to develop and validate an artificial intelligence (AI)-based tool for detecting ECE of PCa using multiparametric magnetic resonance imaging (mpMRI). METHODS Eight hundred and forty nine consecutive PCa patients who underwent mpMRI and prostatectomy without previous radio- or hormonal therapy from two medical centers were retrospectively included. The AI tool was built on a ResNeXt network embedded with a spatial attention map of experts' prior knowledge (PAGNet) from 596 training patients. Model validation was performed in 150 internal and 103 external patients. Performance comparison was made between AI, two experts using a criteria-based ECE grading system, and expert-AI interaction. RESULTS An index PAGNet model using a single-slice image yielded the highest areas under the receiver operating characteristic curve (AUC) of 0.857 (95% confidence interval [CI], 0.827-0.884), 0.807 (95% CI, 0.735-0.867), and 0.728 (95% CI, 0.631-0.811) in training, internal, and external validation data, respectively. The performance of two experts (AUC, 0.632 to 0.741 vs 0.715 to 0.857) was lower (paired comparison, all p values < 0.05) than that of AI assessment. When experts' interpretations were adjusted by AI assessments, the performance of two experts was improved. CONCLUSION Our AI tool, showing improved accuracy, offers a promising alternative to human experts for ECE staging using mpMRI.
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Affiliation(s)
- Ying Hou
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Yi-Hong Zhang
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, 3663 N. Zhongshan Rd., Shanghai, 200062, China
| | - Jie Bao
- Department of Radiology, The First Affiliated Hospital of Soochow University, 188#, Shizi Road, Jiangsu Province, 215006, Suzhou, China
| | - Mei-Ling Bao
- Department of Pathology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Road, Jiangsu Province, 210029, Nanjing, China
| | - Guang Yang
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, 3663 N. Zhongshan Rd., Shanghai, 200062, China
| | - Hai-Bin Shi
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Yang Song
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, 3663 N. Zhongshan Rd., Shanghai, 200062, China.
| | - Yu-Dong Zhang
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China.
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15
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Chang CM, McIntosh AG, Shapiro DD, Davis JW, Ward JF, Gregg JR. Does a screening digital rectal exam provide actionable clinical utility in patients with an elevated PSA and positive MRI? BJUI COMPASS 2021; 2:188-193. [PMID: 35475129 PMCID: PMC8988521 DOI: 10.1002/bco2.69] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/11/2020] [Accepted: 12/14/2020] [Indexed: 01/08/2023] Open
Abstract
Objective To define the value of a digital rectal exam (DRE) in the prostate‐magnetic resonance imaging (MRI) era. Prostate MRI is increasingly used in men with elevated prostate‐specific antigen (PSA) prior to biopsy. Methods A retrospective study was performed in men with elevated PSA undergoing MRI followed by MRI fusion with systematic biopsy and men with elevated PSA/active surveillance with negative MRI followed by biopsy. Baseline clinicopathologic characteristics and DRE findings were collected. We examined performance of a positive DRE on sensitivity and specificity of diagnosing clinically significant prostate cancer (CSPC). Results A total of 339 patients had elevated PSA and positive MRI followed by MRI fusion guided with systematic biopsy. Pre‐biopsy DRE was documented in 286/339 patients, who were included in further analysis. About 81.6% positive, 78.7% questionable, and 55.8% negative DRE patients had CSPC. Positive DRE had 21.8% sensitivity and 91.3% specificity for CSPC. Positive or questionable DRE had 42.1% sensitivity and 81.5% specificity. Among 148 men with non‐CSPC (GG1)‐targeted biopsy, 28 had systematic biopsy with CSPC. About 5/28 had positive DRE and 8/28 had positive or questionable DRE. Twenty‐seven patients were included who had elevated PSA/on active surveillance with negative MRI and biopsy done within 2 years. About 77.8% had negative, 7.4% had questionable, and 14.8% men had positive DRE. About 7.4% had CSPC and all had a negative DRE. Conclusions Our study provides limited evidence for the value of a DRE. However, it does show occasional benefit in detecting GG2 or higher disease and given the lack of cost and side effects, should still be considered.
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Affiliation(s)
- Courtney M. Chang
- McGovern Medical School University of Texas Houston TX USA
- The University of Texas MD Anderson Cancer Center Houston TX USA
| | | | | | - John W. Davis
- The University of Texas MD Anderson Cancer Center Houston TX USA
| | - John F. Ward
- The University of Texas MD Anderson Cancer Center Houston TX USA
| | - Justin R. Gregg
- McGovern Medical School University of Texas Houston TX USA
- The University of Texas MD Anderson Cancer Center Houston TX USA
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16
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Oncologic Outcomes after Localized Prostate Cancer Treatment: Associations with Pretreatment Prostate Magnetic Resonance Imaging Findings. J Urol 2020; 205:1055-1062. [PMID: 33207133 DOI: 10.1097/ju.0000000000001474] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE We investigated whether T2-weighted magnetic resonance imaging findings could improve upon established prognostic indicators of metastatic disease and prostate cancer specific survival. MATERIALS AND METHODS For a cohort of 3,406 consecutive men who underwent prostate magnetic resonance imaging before prostatectomy (2,160) or radiotherapy (1,246) between 2001 and 2006, T2-weighted magnetic resonance imaging exams were retrospectively interpreted and categorized as I) no focal suspicious lesion, II) organ confined focal lesion, III) focal lesion with extraprostatic extension or IV) focal lesion with seminal vesicle invasion. Clinical risk was recorded based on European Association of Urology (EAU) guidelines and the Cancer of the Prostate Risk Assessment (CAPRA) scoring system. Survival probabilities and c-indices were estimated using Cox models and inverse probability censoring weights, respectively. RESULTS The median followup was 10.8 years (IQR 8.6-13.0). Higher magnetic resonance imaging categories were associated with a higher likelihood of developing metastases (HR 3.5-18.1, p <0.001 for all magnetic resonance imaging categories) and prostate cancer death (HR 3.1-29.7, p <0.001-0.025); these associations were statistically independent of EAU risk categories, CAPRA scores and treatment type (surgery vs radiation). Combining EAU risk or CAPRA scores with magnetic resonance imaging categories significantly improved prognostication of metastases (c-indices: EAU: 0.798, EAU + magnetic resonance imaging: 0.872; CAPRA: 0.808, CAPRA + magnetic resonance imaging: 0.877) and prostate cancer death (c-indices: EAU 0.813, EAU + magnetic resonance imaging: 0.889; CAPRA: 0.814, CAPRA + magnetic resonance imaging: 0.892; p <0.001 for all). CONCLUSION Magnetic resonance imaging findings of localized prostate cancer are associated with clinically relevant long-term oncologic outcomes. Combining magnetic resonance imaging and clinicopathological data results in more accurate prognostication, which could facilitate individualized patient management.
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17
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Ashrafi AN, Yip W, Aron M. Neoadjuvant Therapy in High-Risk Prostate Cancer. Indian J Urol 2020; 36:251-261. [PMID: 33376260 PMCID: PMC7759181 DOI: 10.4103/iju.iju_115_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/26/2020] [Accepted: 06/30/2020] [Indexed: 01/07/2023] Open
Abstract
High-risk prostate cancer (PCa) is associated with higher rates of biochemical recurrence, clinical recurrence, metastasis, and PCa-specific death, compared to low-and intermediate-risk disease. Herein, we review the various definitions of high-risk PCa, describe the rationale for neoadjuvant therapy prior to radical prostatectomy, and summarize the contemporary data on neoadjuvant therapies. Since the 1990s, several randomized trials of neoadjuvant androgen deprivation therapy (ADT) have consistently demonstrated improved pathological parameters, specifically tumor downstaging and reduced extraprostatic extension, seminal vesicle invasion, and positive surgical margins without improvements in cancer-specific or overall survival. These studies, however, were not exclusive to high-risk patients and were limited by suboptimal follow-up periods. Newer studies of neoadjuvant ADT in high-risk PCa show promising pathological and oncological outcomes. Recent level 1 data suggests neoadjuvant chemohormonal therapy (CHT) may improve longer-term survival in high-risk PCa. Immunologic neoadjuvant trials are in their infancy, and further study is required. Neoadjuvant therapies may be promising additions to the multimodal therapeutic landscape of high-risk and locally advanced PCa in the near future.
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Affiliation(s)
- Akbar N. Ashrafi
- USC Institute of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, California, USA
- Division of Surgery, North Adelaide Local Health Network, SA Health, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Wesley Yip
- USC Institute of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, California, USA
| | - Monish Aron
- USC Institute of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, California, USA
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18
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McNally CJ, Ruddock MW, Moore T, McKenna DJ. Biomarkers That Differentiate Benign Prostatic Hyperplasia from Prostate Cancer: A Literature Review. Cancer Manag Res 2020; 12:5225-5241. [PMID: 32669872 PMCID: PMC7335899 DOI: 10.2147/cmar.s250829] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 04/09/2020] [Indexed: 12/20/2022] Open
Abstract
Prediction of prostate cancer in primary care is typically based upon serum total prostate-specific antigen (tPSA) and digital rectal examination results. However, these tests lack sensitivity and specificity, leading to over-diagnosis of disease and unnecessary, invasive biopsies. Therefore, there is a clinical need for diagnostic tests that can differentiate between benign conditions and early-stage malignant disease in the prostate. In this review, we evaluate research papers published from 2009 to 2019 reporting biomarkers that identified or differentiated benign prostatic hyperplasia (BPH) from prostate cancer. Our review identifies hundreds of potential biomarkers in urine, serum, tissue, and semen proposed as useful targets for differentiating between prostate cancer and BPH patients. However, it is still not apparent which of these candidate biomarkers are most useful, and many will not progress beyond the discovery stage unless they are properly validated for clinical practice. We conclude that this validation will come through the use of multivariate panels which can assess the value of biomarker candidates in combination with clinical parameters as part of a risk prediction calculator. Implementation of such a model will help clinicians stratify patients with prostate cancer symptoms in primary care, with tangible benefits for both the patient and the health service.
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Affiliation(s)
- Christopher J McNally
- Randox Laboratories Ltd, Crumlin, Co. Antrim BT29 4QY, Northern Ireland.,Biomedical Sciences Research Institute, Ulster University, Coleraine BT52 1SA, Northern Ireland
| | - Mark W Ruddock
- Randox Laboratories Ltd, Crumlin, Co. Antrim BT29 4QY, Northern Ireland
| | - Tara Moore
- Biomedical Sciences Research Institute, Ulster University, Coleraine BT52 1SA, Northern Ireland
| | - Declan J McKenna
- Biomedical Sciences Research Institute, Ulster University, Coleraine BT52 1SA, Northern Ireland
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McKay RR, Feng FY, Wang AY, Wallis CJD, Moses KA. Recent Advances in the Management of High-Risk Localized Prostate Cancer: Local Therapy, Systemic Therapy, and Biomarkers to Guide Treatment Decisions. Am Soc Clin Oncol Educ Book 2020; 40:1-12. [PMID: 32412803 PMCID: PMC10182417 DOI: 10.1200/edbk_279459] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
High-risk prostate cancer accounts for approximately 15% of all prostate cancer diagnoses. Patients with high-risk disease have an increased risk of developing biochemical recurrence, metastases, and death from prostate cancer. As the optimal management of high-risk disease in patients with prostate cancer continues to evolve, the contemporary treatment paradigm is moving toward a multidisciplinary integrated approach of systemic and local therapy for patients with high-risk disease. The strategies for definitive, adjuvant, and salvage local treatment, including radical prostatectomy or radiation therapy, serve as the backbone of therapy for patients with localized disease. Systemic therapy decisions regarding use in combination with surgery, choice of therapy (hormone therapy, chemotherapy), and treatment duration continue to be refined. As more effective hormonal agents populate the treatment landscape for advanced prostate cancer, including abiraterone and next-generation antiandrogens, an opportunity is provided to explore these treatments in patients with localized disease in the hope of improving the long-term outcome for patients. Integration of innovative blood and tissue-based biomarkers to guide therapy selection for patients with high-risk disease is an area of active research. Contemporary studies are using such biomarkers to stratify patients and select therapies. In this review, we summarize contemporary evidence for local treatment strategies, systemic therapy options, and biomarkers in development for the management of high-risk prostate cancer in patients.
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Affiliation(s)
- Rana R McKay
- University of California San Diego, San Diego, CA
| | - Felix Y Feng
- University of California San Francisco, San Francisco, CA
| | - Alice Y Wang
- Vanderbilt University Medical Center, Nashville, TN
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Draulans C, Everaerts W, Isebaert S, Gevaert T, Oyen R, Joniau S, Lerut E, De Wever L, Weynand B, Vanhoutte E, De Meerleer G, Haustermans K. Impact of Magnetic Resonance Imaging on Prostate Cancer Staging and European Association of Urology Risk Classification. Urology 2019; 130:113-119. [DOI: 10.1016/j.urology.2019.04.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/18/2019] [Accepted: 04/18/2019] [Indexed: 10/26/2022]
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Abstract
Diagnosis of prostate cancer (PCa) and adequate staging play a fundamental role for clinical and patient care. Despite major advances in biology and imaging, rectal examination and prostate-specific antigen (PSA) blood test remain the cornerstone for screening, and multiparametricmagnetic resonance imaging (mpMRI) for local staging. Recent advances in mpMRI lead to standardised interpretation and increased prescription by clinicians in order to improve detection of clinically significant PCa and select patients requiring targeted biopsies. However its indication remains controversial in biopsy-naïve patients. Nuclear medicine is also in a continuous evolution and utilisation of new radiopharmaceutical agent like choline or 68gallium with computed tomography or magnetic resonance imaging has led to the improvement in the detection of lymph nodes, distant metastases and prostate recurrence. Considering this very heterogneneous disease, combined utilisation of these tools will help clinicians and patients in choosing the most appropriate and personalised treatment.
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22
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Nabid A, Souhami L. Reply to Pirus Ghadjar and Thomas Wiegel's Letter to the Editor re: Abdenour Nabid, Nathalie Carrier, André-Guy Martin, et al. Duration of Androgen Deprivation Therapy in High-risk Prostate Cancer: A Randomized Phase III Trial. Eur Urol 2018;74:432-31. Eur Urol 2018; 75:e63. [PMID: 30773206 DOI: 10.1016/j.eururo.2018.10.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/12/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Abdenour Nabid
- Radiation Oncology, Centre Hospitaler Universitaire de Sherbrooke, Sherbrooke, Canada.
| | - Luis Souhami
- McGill University Health Centre, Montreal, Canada
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Construction of a Preoperative Radiologic-Risk Signature for Predicting the Pathologic Status of Prostate Cancer at Radical Prostatectomy. AJR Am J Roentgenol 2018; 211:805-811. [PMID: 29995494 DOI: 10.2214/ajr.17.19360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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24
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Wang J, Wu CJ, Bao ML, Zhang J, Shi HB, Zhang YD. Using support vector machine analysis to assess PartinMR: A new prediction model for organ-confined prostate cancer. J Magn Reson Imaging 2018; 48:499-506. [PMID: 29437268 DOI: 10.1002/jmri.25961] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/19/2018] [Indexed: 12/17/2022] Open
Affiliation(s)
- Jing Wang
- Center for Medical Device Evaluation, CFDA; Beijing China
| | - Chen-Jiang Wu
- Department of Radiology; First Affiliated Hospital with Nanjing Medical University; Nanjing China
| | - Mei-Ling Bao
- Department of Pathology; First Affiliated Hospital with Nanjing Medical University; Nanjing China
| | - Jing Zhang
- Department of Radiology; First Affiliated Hospital with Nanjing Medical University; Nanjing China
| | - Hai-Bin Shi
- Department of Radiology; First Affiliated Hospital with Nanjing Medical University; Nanjing China
| | - Yu-Dong Zhang
- Department of Radiology; First Affiliated Hospital with Nanjing Medical University; Nanjing China
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Pereira-Azevedo N, Braga I, Verbeek JF, Osório L, Cavadas V, Fraga A, Carrasquinho E, Cardoso de Oliveira E, Nieboer D, Roobol MJ. Prospective evaluation on the effect of interobserver variability of digital rectal examination on the performance of the Rotterdam Prostate Cancer Risk Calculator. Int J Urol 2017; 24:826-832. [PMID: 28901582 DOI: 10.1111/iju.13442] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 08/02/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the level of agreement between digital rectal examination findings of two urologists and its effect on risk prediction using the digital rectal examination-based Rotterdam Prostate Cancer Risk Calculator. METHODS The study sample consisted of a prospective cohort of asymptomatic unscreened men with prostate-specific antigen ≤50.0 ng/mL and transrectal ultrasound volume ≤110 mL who underwent transrectal ultrasound-guided prostate biopsy. Both urologists' digital rectal examination findings were graded normal or abnormal (nodularity and/or induration), and volume classified as 25, 40 or 60 mL, according to the risk calculator algorithm. Interrater agreement analysis using Cohen's kappa (κ) statistic was carried out to determine consistency of digital rectal examination outcome and volume assessment. Receiver operating characteristic curve analysis and calibration plots were constructed to determine the effect of interrater differences. Decision curve analysis was applied to evaluate the clinical usefulness of the model. RESULTS Of the 241 men included in the study, 41% (n = 98) had prostate cancer (81 were clinically significant, i.e. Gleason ≥3 + 4). There was substantial agreement in the digital rectal examination (abnormal/normal; κ = 0.78; P < 0.001) and volume estimation (κ = 0.79; P < 0.001). Receiver operating characteristic analyses showed good discrimination (0.75-0.78) and were comparable for both urologists. In the high-risk cohort, at a probability threshold of 25%, the risk calculator reduced the prostate biopsy rate by 9%, without missing cancers. CONCLUSIONS Slight differences in digital rectal examination findings seem to have very limited impact on the performance of the Rotterdam Prostate Cancer Risk Calculator. Therefore, this can be considered a useful prostate biopsy outcome prediction tool.
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Affiliation(s)
- Nuno Pereira-Azevedo
- Department of Urology, Erasmus University Medical Center, Rotterdam, the Netherlands.,Urology Department, Porto Hospital Centre, Porto, Portugal
| | - Isaac Braga
- Urology Department, Porto Hospital Centre, Porto, Portugal.,Life and Health Sciences Research Institute, School of Health Sciences, University of Minho and ICVS/3B's, Braga/Guimarães, Portugal
| | - Jan Fm Verbeek
- Department of Urology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Luís Osório
- Urology Department, Porto Hospital Centre, Porto, Portugal
| | - Vítor Cavadas
- Urology Department, Porto Hospital Centre, Porto, Portugal
| | - Avelino Fraga
- Urology Department, Porto Hospital Centre, Porto, Portugal
| | | | | | - Daan Nieboer
- Department of Urology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Center, Rotterdam, the Netherlands
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26
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Prognostic Significance of Digital Rectal Examination and Prostate Specific Antigen in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Arm. J Urol 2017; 197:363-368. [DOI: 10.1016/j.juro.2016.08.092] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2016] [Indexed: 11/20/2022]
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[TNM-Classification of localized prostate cancer : The clinical T-category does not correspond to the required demands]. Urologe A 2016; 55:1564-1572. [PMID: 27830286 DOI: 10.1007/s00120-016-0264-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The TNM staging system for localized prostate cancer (PCa) divides tumors based on clinical parameters into a clinical (c)T category and, after radical prostatectomy (RP), a pathological (p)T category. OBJECTIVES This study examines the extent to which the cT and the pT category correspond to each other and whether the two categories differ in their prediction for organ-confined disease. PATIENTS AND METHODS Data of 687 RP patients were collected in a prospective, noninterventional, multicenter health service research study for the treatment of localized PCa (HAROW). Group comparisons were performed by analysis of variance and student t‑test as well as the chi-squared test or the Fisher exact test. RESULTS Clinical cT1 category (62.9%) and pathological pT2c category (56.6%) were diagnosed most frequently. The correspondence of cT and pT category was 15% for cT2a , 10.5% for cT2b, and 55% for cT2c. An extraprostatic extension (≥pT3) was observed for the categories cT1 and cT2 in 23.5% and 36.4% (p < 0.001), differences in the subcategories cT2a-c were not significant: cT2a = 28.8%, cT2b = 42.1%, and cT2c = 38.8% (p = 0.194). Tumors with a pathologically extraprostatic extension were not recognized clinically in >50%. CONCLUSIONS For localized PCa there is low agreement between clinical and pathologic T category, thus, often leading to understaging. An adaptation of the T classification of the TNM system with division into "not palpable" and "palpable" appears sufficient for a prognostic prediction.
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Yilmaz Ö, Kurul Ö, Ates F, Soydan H, Aktas Z. Does an asymmetric lobe in digital rectal examination include any risk for prostate cancer? results of 1495 biopsies. Int Braz J Urol 2016; 42:704-9. [PMID: 27564280 PMCID: PMC5006765 DOI: 10.1590/s1677-5538.ibju.2014.0598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 04/05/2016] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Despite the well-known findings related to malignity in DRE such as nodule and induration, asymmetry of prostatic lobes, seen relatively, were investigated in a few studies as a predictor of prostate cancer so that there is no universally expected conclusion about asymmetry. We aimed to compare cancer detection rate of normal, asymmetric or suspicious findings in DRE by using biopsy results. MATERIALS AND METHODS Data of 1495 patients underwent prostate biopsy between 2006-2014 were searched retrospectively. Biopsy indications were abnormal DRE and or elevated PSA level( >4ng/mL). DRE findings were recorded as Group 1: Benign DRE, Group 2: Asymmetry and Group 3: Nodule/induration. Age, prostatic volume , biopsy results and PSA levels were recorded. RESULTS Mean age, prostate volume and PSA level were 66.72, 55.98 cc and 18.61ng/ mL respectively. Overall cancer detection rate was 38.66 % (575 of 1495). PSA levels were similar in group 1 and 2 but significantly higher in group 3. Prostatic volume was similar in group 1 and 2 and significantly lower in Group 3. Malignity detection rate of group 1,2 and 3 were 28.93%, 34.89% and 55.99% respectively. Group 1 and 2 were similar (p=0.105) but 3 had more chance for cancer detection. CONCLUSION Nodule is the most important finding in DRE for cancer detection. Only na asymmetric prostate itself does not mean malignity.
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Affiliation(s)
- Ömer Yilmaz
- GATA Haydarpasa Teaching Hospital, Department of Urology, Istanbul, Turkey
| | - Özgür Kurul
- GATA Haydarpasa Teaching Hospital, Department of Urology, Istanbul, Turkey
| | - Ferhat Ates
- GATA Haydarpasa Teaching Hospital, Department of Urology, Istanbul, Turkey
| | - Hasan Soydan
- GATA Haydarpasa Teaching Hospital, Department of Urology, Istanbul, Turkey
| | - Zeki Aktas
- GATA Haydarpasa Teaching Hospital, Department of Urology, Istanbul, Turkey
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Jaunarena JH, Villamil W, Martínez PF, Gueglio G, Giudice CR. The role of radical prostatectomy as an initial approach for the treatment of high-risk prostate cancer. Actas Urol Esp 2016; 40:353-60. [PMID: 26794623 DOI: 10.1016/j.acuro.2015.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 12/03/2015] [Accepted: 12/04/2015] [Indexed: 12/31/2022]
Abstract
CONTEXT The treatment of high-risk prostate cancer requires a multimodal approach to improve control of the disease. There is still no consensus as to the initial strategy of choice. The aim of this study is to review the results of radical prostatectomy as first step in management of patients with high-risk disease. ACQUISITION OF EVIDENCE A search was conducted on PubMed of English and Spanish texts. We included those studies that reported the results of radical prostatectomy in patients with high-risk prostate cancer, as well as those that compared radical prostatectomy with other treatment alternatives. The last search was conducted in November 2015. SYNTHESIS OF THE EVIDENCE The advantages of radical prostatectomy include a better pathological analysis, more accurate staging, better local control of the disease and better follow-up and adjuvant therapy strategies. When compared with external radiation therapy plus hormonal blockade, the patients who underwent prostatectomy had greater chances of healing and longer cancer-specific survival. The patients who most benefit from this approach are younger, have fewer comorbidities and no evidence of organ metastases. CONCLUSIONS The available scientific evidence to date is not without bias and confounders; however, they appear to favour radical prostatectomy as the initial approach of choice for high-risk prostate cancer.
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Affiliation(s)
- J H Jaunarena
- Servicio de Urología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - W Villamil
- Servicio de Urología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - P F Martínez
- Servicio de Urología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - G Gueglio
- Servicio de Urología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - C R Giudice
- Servicio de Urología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Assessment of the Performance of Magnetic Resonance Imaging/Ultrasound Fusion Guided Prostate Biopsy against a Combined Targeted Plus Systematic Biopsy Approach Using 24-Core Transperineal Template Saturation Mapping Prostate Biopsy. Prostate Cancer 2016; 2016:3794738. [PMID: 27293898 PMCID: PMC4884827 DOI: 10.1155/2016/3794738] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 04/12/2016] [Indexed: 11/17/2022] Open
Abstract
Objective. To compare the performance of multiparametric resonance imaging/ultrasound fusion targeted biopsy (MRI/US-TBx) to a combined biopsy strategy (MRI/US-TBx plus 24-core transperineal template saturation mapping biopsy (TTMB)). Methods. Between May 2012 and October 2015, all patients undergoing MRI/US-TBx at our institution were included for analysis. Patients underwent MRI/US-TBx of suspicious lesions detected on multiparametric MRI +/− simultaneous TTMB. Subgroup analysis was performed on patients undergoing simultaneous MRI/US-TBx + TTMB. Primary outcome was PCa detection. Significant PCa was defined as ≥Gleason score (GS) 3 + 4 = 7 PCa. McNemar's test was used to compare detection rates between MRI/US-TBx and the combined biopsy strategy. Results. 148 patients underwent MRI/US-TBx and 80 patients underwent MRI/US-TBx + TTMB. In the MRI/US-TBx versus combined biopsy strategy subgroup analysis (n = 80), there were 55 PCa and 38 significant PCa. The detection rate for the combined biopsy strategy versus MRI/US-TBx for significant PCa was 49% versus 40% (p = 0.02) and for insignificant PCa was 20% versus 10% (p = 0.04), respectively. Eleven cases (14%) of significant PCa were detected exclusively on MRI/US-TBx and 7 cases (8.7%) of significant PCa were detected exclusively on TTMB. Conclusions. A combined biopsy approach (MRI/US-TBx + TTMB) detects more significant PCa than MRI/US-TBx alone; however, it will double the detection rate of insignificant PCa.
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31
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Reese AC. Clinical and Pathologic Staging of Prostate Cancer. Prostate Cancer 2016. [DOI: 10.1016/b978-0-12-800077-9.00039-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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32
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Alberts AR, Schoots IG, Roobol MJ. Prostate-specific antigen-based prostate cancer screening: Past and future. Int J Urol 2015; 22:524-32. [PMID: 25847604 DOI: 10.1111/iju.12750] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/29/2015] [Accepted: 02/01/2015] [Indexed: 12/21/2022]
Abstract
Prostate-specific antigen-based prostate cancer screening remains a controversial topic. Up to now, there is worldwide consensus on the statement that the harms of population-based screening, mainly as a result of overdiagnosis (the detection of clinically insignificant tumors that would have never caused any symptoms), outweigh the benefits. However, worldwide opportunistic screening takes place on a wide scale. The European Randomized Study of Screening for Prostate Cancer showed a reduction in prostate cancer mortality through prostate-specific antigen based-screening. These population-based data need to be individualized in order to avoid screening in those who cannot benefit and start screening in those who will. For now, lacking a more optimal screening approach, screening should only be started after the process of shared decision-making. The focus of future research is the reduction of unnecessary testing and overdiagnosis by further research to better biomarkers and the value of the multiparametric magnetic resonance imaging, potentially combined in already existing prostate-specific antigen-based multivariate risk prediction models.
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Affiliation(s)
- Arnout R Alberts
- Department of Urology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ivo G Schoots
- Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Center, Rotterdam, the Netherlands
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Prostate Specific Antigen as a Tumor Marker in Prostate Cancer: Biochemical and Clinical Aspects. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2015; 867:93-114. [PMID: 26530362 DOI: 10.1007/978-94-017-7215-0_7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In this chapter the use of prostate specific antigen (PSA) as a tumor marker for prostate cancer is discussed. The chapter provides an overview of biological and clinical aspects of PSA. The main drawback of total PSA (tPSA) is its lack of specificity for prostate cancer which leads to unnecessary biopsies. Moreover, PSA-testing poses a risk of overdiagnosis and subsequent overtreatment. Many PSA-based markers have been developed to improve the performance characteristics of tPSA. As well as different molecular subforms of tPSA, such as proPSA (pPSA) and free PSA (fPSA), and PSA derived kinetics as PSA-velocity (PSAV) and PSA-doubling time (PSADT). The prostate health index (phi), PSA-density (PSAD) and the contribution of non PSA-based markers such as the urinary transcripts of PCA3 and TMPRSS-ERG fusion are also discussed. To enable further risk stratification tumor markers are often combined with clinical data (e.g. outcome of DRE) in so-called nomograms. Currently the role of magnetic resonance imaging (MRI) in the detection and staging of prostate cancer is being explored.
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Klaassen Z, Singh AA, Howard LE, Feng Z, Trock B, Terris MK, Aronson WJ, Cooperberg MR, Amling CL, Kane CJ, Partin A, Han M, Freedland SJ. Is clinical stage T2c prostate cancer an intermediate- or high-risk disease? Cancer 2014; 121:1414-21. [PMID: 25492369 DOI: 10.1002/cncr.29147] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 10/20/2014] [Accepted: 10/24/2014] [Indexed: 01/29/2023]
Abstract
BACKGROUND Clinical stage T2c (cT2c) is an indeterminate factor in prostate cancer (PC) risk stratification. According to the D'Amico grouping and American Urological Association guidelines, cT2c is a high risk, whereas the National Comprehensive Cancer Network and the European Urological Association classify cT2c as an intermediate risk. This study assessed whether cT2c tumors without other high-risk factors (clinical stage T2c, not otherwise specified [cT2c-NOS]) behaved as an intermediate or high risk through an analysis of biochemical recurrence (BCR) after radical prostatectomy. METHODS Two thousand seven hundred fifty-nine men from the Shared Equal Access Regional Cancer Hospital (SEARCH) Database and 12,900 men from Johns Hopkins Hospital (JHH) from 1988-2011 and 1982-2012, respectively, were analyzed. Patients were grouped into low-risk (prostate-specific antigen [PSA] < 10 ng/mL, Gleason sum ≤ 6, and cT1-T2a), intermediate-risk (PSA = 10-20 ng/mL, Gleason sum = 7, or cT2b), and high-risk PC categories (PSA > 20 ng/mL, Gleason sum = 8-10, or cT3). Men with cT2c tumors who were not otherwise at high risk (ie, PSA< 20 ng/mL and Gleason sum < 8) were placed into a separate category termed cT2c-NOS. Associations between cT2c-NOS and intermediate- and high-risk patients and BCR were tested with the log-rank test and Cox proportional analysis models. RESULTS Ninety-nine men (4%) from SEARCH and 202 men (2%) from JHH had tumors classified as cT2c-NOS. The cT2c-NOS patients had a BCR risk similar to that of the intermediate-risk patients (SEARCH, P = .27; JHH, P = .23) but a significantly lower BCR risk in comparison with the high-risk patients (SEARCH, P < .001; JHH, P < .001). When they were specifically compared with intermediate- and high-risk patients, after adjustments for year and center, cT2c-NOS patients had outcomes comparable to those of intermediate-risk patients (SEARCH, P = .53; JHH, P = .54) but significantly better than those of high-risk patients (SEARCH, P = .003; JHH, P < .001). CONCLUSIONS Patients with cT2c disease without other high-risk features had outcomes similar to the outcomes of patients with intermediate-risk PC and significantly better than the outcomes of patients with high-risk PC. These findings suggest that men with cT2c disease should be considered to be at intermediate risk.
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Affiliation(s)
- Zachary Klaassen
- Medical College of Georgia, Georgia Regents University, Augusta, Georgia
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Chang AJ, Autio KA, Roach M, Scher HI. High-risk prostate cancer-classification and therapy. Nat Rev Clin Oncol 2014; 11:308-23. [PMID: 24840073 DOI: 10.1038/nrclinonc.2014.68] [Citation(s) in RCA: 296] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Approximately 15% of patients with prostate cancer are diagnosed with high-risk disease. However, the current definitions of high-risk prostate cancer include a heterogeneous group of patients with a range of prognoses. Some have the potential to progress to a lethal phenotype that can be fatal, while others can be cured with treatment of the primary tumour alone. The optimal management of this patient subgroup is evolving. A refined classification scheme is needed to enable the early and accurate identification of high-risk disease so that more-effective treatment paradigms can be developed. We discuss several principles established from clinical trials, and highlight other questions that remain unanswered. This Review critically evaluates the existing literature focused on defining the high-risk population, the management of patients with high-risk prostate cancer, and future directions to optimize care.
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Affiliation(s)
- Albert J Chang
- Department of Radiation Oncology, University of California, San Francisco, 1600 Divisadero Street, Suite H-1031, San Francisco, CA 94115, USA
| | - Karen A Autio
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, Weill Cornell Medical College, New York, NY 10065, USA
| | - Mack Roach
- Department of Radiation Oncology, University of California, San Francisco, 1600 Divisadero Street, Suite H-1031, San Francisco, CA 94115, USA
| | - Howard I Scher
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, Weill Cornell Medical College, New York, NY 10065, USA
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Ploussard G, Nicolaiew N, Mongiat-Artus P, Terry S, Allory Y, Vacherot F, Abbou CC, Desgrandchamps F, Salomon L, de la Taille A. Left lobe of the prostate during clinical prostate cancer screening: the dark side of the gland for right-handed examiners. Prostate Cancer Prostatic Dis 2014; 17:157-62. [PMID: 24513649 DOI: 10.1038/pcan.2014.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Revised: 01/07/2014] [Accepted: 01/12/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND The predictive value of the abnormality side during digital rectal examination (DRE) has never been studied, suggesting that physicians examined the left lobe of the gland as well as the right lobe. We aimed to assess the predictive value of the side of DRE abnormality for prostate cancer (PCa) detection and aggressiveness in right-handed urologists. METHODS An analysis of a prospective database was carried out that included all consecutive men undergoing prostate biopsies between 2001 and 2012. The main end point was the predictive value of the abnormality side during DRE for cancer detection in clinically suspicious unilateral T2 disease. The diagnostic performance of left- versus right-sided abnormality was also assessed in terms of sensitivity, specificity and negative/positive predictive values. RESULTS Overall, 308 patients had a suspicious unilateral clinical disease (detection rate 57.5%). The cancer detection rate was significantly higher in case of left-sided compared with right-sided clinical T2 stage (odds ratio 2.1). In case of left-sided disease, the number of positive cores, the rate of perineural invasion, the rate of primary grade 4 pattern and the percentage of cancer involvement per core were significantly higher compared with those reported for right-sided disease. The predictive value of abnormality laterality for cancer detection and aggressiveness remained statistically independent in multivariate models. The positive predictive value for cancer detection was 64.6 in case of suspicious left-sided disease versus 46.9 in case of right-sided disease. CONCLUSIONS The risks of detecting PCa and aggressive disease on biopsy are significantly higher when DRE reveals a suspicious left-sided clinical disease as compared with right-sided disease. Right-handed physicians should be aware of this variance in diagnostic performance and potential underdetection of left-sided clinical disease, and should improve their examination of the left lobe of the gland by conducting longer exams or changing the patient's position.
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Affiliation(s)
- G Ploussard
- 1] INSERM U955 Eq07 Departments of Urology and Pathology, APHP, CHU Henri Mondor, Créteil, France [2] Department of Urology, APHP, CHU Saint-Louis, Paris, France
| | - N Nicolaiew
- INSERM U955 Eq07 Departments of Urology and Pathology, APHP, CHU Henri Mondor, Créteil, France
| | | | - S Terry
- INSERM U955 Eq07 Departments of Urology and Pathology, APHP, CHU Henri Mondor, Créteil, France
| | - Y Allory
- INSERM U955 Eq07 Departments of Urology and Pathology, APHP, CHU Henri Mondor, Créteil, France
| | - F Vacherot
- INSERM U955 Eq07 Departments of Urology and Pathology, APHP, CHU Henri Mondor, Créteil, France
| | - C-C Abbou
- INSERM U955 Eq07 Departments of Urology and Pathology, APHP, CHU Henri Mondor, Créteil, France
| | | | - L Salomon
- INSERM U955 Eq07 Departments of Urology and Pathology, APHP, CHU Henri Mondor, Créteil, France
| | - A de la Taille
- INSERM U955 Eq07 Departments of Urology and Pathology, APHP, CHU Henri Mondor, Créteil, France
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Thompson J, Lawrentschuk N, Frydenberg M, Thompson L, Stricker P. The role of magnetic resonance imaging in the diagnosis and management of prostate cancer. BJU Int 2013; 112 Suppl 2:6-20. [PMID: 24127671 DOI: 10.1111/bju.12381] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The diagnosis of prostate cancer has long been plagued by the absence of an imaging tool that reliably detects and localises significant tumours. Recent evidence suggests that multi-parametric MRI could improve the accuracy of diagnostic assessment in prostate cancer. This review serves as a background to a recent USANZ position statement. It aims to provide an overview of MRI techniques and to critically review the published literature on the clinical application of MRI in prostate cancer. TECHNICAL ASPECTS The combination of anatomical (T2-weighted) MRI with at least two of the three functional MRI parameters - which include diffusion-weighted imaging, dynamic contrast-enhanced imaging and spectroscopy - will detect greater than 90% of significant (moderate to high risk) tumours; however MRI is less reliable at detecting tumours that are small (<0.5 cc), low grade (Gleason score 6) or in the transitional zone. The higher anatomical resolution provided by 3-Tesla magnets and endorectal coils may improve the accuracy, particularly in primary tumour staging. SCREENING The use of mpMRI to determine which men with an elevated PSA should undergo biopsy is currently the subject of two large clinical trials in Australia. MRI should be used with caution in this setting and then only in centres with established uro-radiological expertise and quality control mechanisms in place. There is sufficient evidence to justify using MRI to determine the need for repeat biopsy and to guide areas in which to focus repeat biopsy. IMAGE-DIRECTED BIOPSY MRI-directed biopsy is an exciting concept supported by promising early results, but none of the three proposed techniques have so far been proven superior to standard biopsy protocols. Further evidence of superior accuracy and core-efficiency over standard biopsy is required, before their costs and complexities in use can be justified. TREATMENT SELECTION AND PLANNING When used for primary-tumour staging (T-staging), MRI has limited sensitivity for T3 disease, but its specificity of greater than 95% may be useful in men with intermediate-high risk disease to identify those with advanced T3 disease not suitable for nerve sparing or for surgery at all. MRI appears to be of value in planning dosimetry in men undergoing radiotherapy, and in guiding selection for and monitoring on active surveillance.
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Affiliation(s)
- James Thompson
- St Vincents Prostate Cancer Centre, Garvan Institute of Medical Research, Department of Surgery Research, University of New South Wales, Sydney, New South Wales
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The Impact of Clinical Stage on Prostate Cancer Survival Following Radical Prostatectomy. J Urol 2013; 189:1707-12. [DOI: 10.1016/j.juro.2012.11.065] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 11/07/2012] [Indexed: 01/24/2023]
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Artificial neural networks and prostate cancer--tools for diagnosis and management. Nat Rev Urol 2013; 10:174-82. [PMID: 23399728 DOI: 10.1038/nrurol.2013.9] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Artificial neural networks (ANNs) are mathematical models that are based on biological neural networks and are composed of interconnected groups of artificial neurons. ANNs are used to map and predict outcomes in complex relationships between given 'inputs' and sought-after 'outputs' and can also be used find patterns in datasets. In medicine, ANN applications have been used in cancer diagnosis, staging and recurrence prediction since the mid-1990s, when an enormous effort was initiated, especially in prostate cancer detection. Modern ANNs can incorporate new biomarkers and imaging data to improve their predictive power and can offer a number of advantages as clinical decision making tools, such as easy handling of distribution-free input parameters. Most importantly, ANNs consider nonlinear relationships among input data that cannot always be recognized by conventional analyses. In the future, complex medical diagnostic and treatment decisions will be increasingly based on ANNs and other multivariate models.
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Abstract
BACKGROUND Any form of screening aims to reduce disease-specific and overall mortality, and to improve a person's future quality of life. Screening for prostate cancer has generated considerable debate within the medical and broader community, as demonstrated by the varying recommendations made by medical organizations and governed by national policies. To better inform individual patient decision-making and health policy decisions, we need to consider the entire body of data from randomised controlled trials (RCTs) on prostate cancer screening summarised in a systematic review. In 2006, our Cochrane review identified insufficient evidence to either support or refute the use of routine mass, selective, or opportunistic screening for prostate cancer. An update of the review in 2010 included three additional trials. Meta-analysis of the five studies included in the 2010 review concluded that screening did not significantly reduce prostate cancer-specific mortality. In the past two years, several updates to studies included in the 2010 review have been published thereby providing the rationale for this update of the 2010 systematic review. OBJECTIVES To determine whether screening for prostate cancer reduces prostate cancer-specific mortality or all-cause mortality and to assess its impact on quality of life and adverse events. SEARCH METHODS An updated search of electronic databases (PROSTATE register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CANCERLIT, and the NHS EED) was performed, in addition to handsearching of specific journals and bibliographies, in an effort to identify both published and unpublished trials. SELECTION CRITERIA All RCTs of screening versus no screening for prostate cancer were eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS The original search (2006) identified 99 potentially relevant articles that were selected for full-text review. From these citations, two RCTs were identified as meeting the inclusion criteria. The search for the 2010 version of the review identified a further 106 potentially relevant articles, from which three new RCTs were included in the review. A total of 31 articles were retrieved for full-text examination based on the updated search in 2012. Updated data on three studies were included in this review. Data from the trials were independently extracted by two authors. MAIN RESULTS Five RCTs with a total of 341,342 participants were included in this review. All involved prostate-specific antigen (PSA) testing, with or without digital rectal examination (DRE), though the interval and threshold for further evaluation varied across trials. The age of participants ranged from 45 to 80 years and duration of follow-up from 7 to 20 years. Our meta-analysis of the five included studies indicated no statistically significant difference in prostate cancer-specific mortality between men randomised to the screening and control groups (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.86 to 1.17). The methodological quality of three of the studies was assessed as posing a high risk of bias. The European Randomized Study of Screening for Prostate Cancer (ERSPC) and the US Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial were assessed as posing a low risk of bias, but provided contradicting results. The ERSPC study reported a significant reduction in prostate cancer-specific mortality (RR 0.84, 95% CI 0.73 to 0.95), whilst the PLCO study concluded no significant benefit (RR 1.15, 95% CI 0.86 to 1.54). The ERSPC was the only study of the five included in this review that reported a significant reduction in prostate cancer-specific mortality, in a pre-specified subgroup of men aged 55 to 69 years of age. Sensitivity analysis for overall risk of bias indicated no significant difference in prostate cancer-specific mortality when referring to the meta analysis of only the ERSPC and PLCO trial data (RR 0.96, 95% CI 0.70 to 1.30). Subgroup analyses indicated that prostate cancer-specific mortality was not affected by the age at which participants were screened. Meta-analysis of four studies investigating all-cause mortality did not determine any significant differences between men randomised to screening or control (RR 1.00, 95% CI 0.96 to 1.03). A diagnosis of prostate cancer was significantly greater in men randomised to screening compared to those randomised to control (RR 1.30, 95% CI 1.02 to 1.65). Localised prostate cancer was more commonly diagnosed in men randomised to screening (RR 1.79, 95% CI 1.19 to 2.70), whilst the proportion of men diagnosed with advanced prostate cancer was significantly lower in the screening group compared to the men serving as controls (RR 0.80, 95% CI 0.73 to 0.87). Screening resulted in a range of harms that can be considered minor to major in severity and duration. Common minor harms from screening include bleeding, bruising and short-term anxiety. Common major harms include overdiagnosis and overtreatment, including infection, blood loss requiring transfusion, pneumonia, erectile dysfunction, and incontinence. Harms of screening included false-positive results for the PSA test and overdiagnosis (up to 50% in the ERSPC study). Adverse events associated with transrectal ultrasound (TRUS)-guided biopsies included infection, bleeding and pain. No deaths were attributed to any biopsy procedure. None of the studies provided detailed assessment of the effect of screening on quality of life or provided a comprehensive assessment of resource utilization associated with screening (although preliminary analyses were reported). AUTHORS' CONCLUSIONS Prostate cancer screening did not significantly decrease prostate cancer-specific mortality in a combined meta-analysis of five RCTs. Only one study (ERSPC) reported a 21% significant reduction of prostate cancer-specific mortality in a pre-specified subgroup of men aged 55 to 69 years. Pooled data currently demonstrates no significant reduction in prostate cancer-specific and overall mortality. Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity. Overdiagnosis and overtreatment are common and are associated with treatment-related harms. Men should be informed of this and the demonstrated adverse effects when they are deciding whether or not to undertake screening for prostate cancer. Any reduction in prostate cancer-specific mortality may take up to 10 years to accrue; therefore, men who have a life expectancy less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial. No studies examined the independent role of screening by DRE.
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Affiliation(s)
- Dragan Ilic
- Department of Epidemiology&PreventiveMedicine, School of PublicHealth&PreventiveMedicine,MonashUniversity,Melbourne,Australia.
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DiBlasio CJ, Derweesh IH, Maddox MM, Mehrazin R, Yu C, Malcolm JB, Aleman MA, Patterson AL, Wake RW, Kattan MW. Nomogram to predict prostate cancer diagnosis on primary transrectal ultrasound-guided prostate biopsy in a contemporary series. Curr Urol 2013; 6:141-5. [PMID: 24917732 DOI: 10.1159/000343528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Accepted: 05/31/2012] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Transrectal ultrasound-guided biopsy (TRUSB) remains the mainstay for prostate cancer (CaP) diagnosis. Numerous variables have shown associations with development of CaP. We present a nomogram that predicts the probability of detecting CaP on TRUSB. METHODS After obtaining institutional review board approval, all patients undergoing primary TRUSB for CaP detection at a single center at our institution between 2/2000 and 9/2007 were reviewed. Patients undergoing repeat biopsies were excluded, and only the first biopsy was included in the analysis. Variables included age at biopsy, race, clinical stage, prostate specific antigen (PSA), number of cores removed, TRUS prostate volume (TRUSPV), body mass index, family history of CaP, and pathology results. S-PLUS 2000 statistical software was utilized with p < 0.05 considered significant. Cox proportional hazards regression models with restricted cubic splines were utilized to construct the nomogram. Validation utilized bootstrapping, and the concordance index was calculated based on these predictions. RESULTS A total of 1,542 consecutive patients underwent primary TRUSB with a median age of 64.2 years (range 34.9-89.2 years), PSA of 5.7 ng/ml (range 0.3-3,900 ng/ml), number of cores removed of 8.0 (range 1- 22) and TRUSPV of 36.4 cm(3) (range 9.6-212.0 cm(3)). CaP was diagnosed in 561 (36.4%) patients. A nomogram was constructed incorporating age at biopsy, race, PSA, body mass index, clinical stage, TRUSPV, number of cores removed, and family history of CaP. The concordance index when validated internally was 0.802. CONCLUSIONS We have developed and internally validated a model predicting cancer detection in men undergoing TRUSB in a contemporary series. This model may assist clinicians in risk-stratifying potential candidates for TRUSB, potentially avoiding unnecessary or low-probability TRUSB.
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Affiliation(s)
- Christopher J DiBlasio
- Department of Urology, University of Tennessee Health Sciences Center, Memphis, Tenn., USA ; Department of Urology, North Shore Medical Group of the Mount Sinai School of Medicine, Huntington, N.Y., USA
| | - Ithaar H Derweesh
- Department of Urology, University of Tennessee Health Sciences Center, Memphis, Tenn., USA
| | - Michael M Maddox
- Department of Urology, University of Tennessee Health Sciences Center, Memphis, Tenn., USA
| | - Reza Mehrazin
- Department of Urology, University of Tennessee Health Sciences Center, Memphis, Tenn., USA
| | - Changhong Yu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - John B Malcolm
- Department of Urology, University of Tennessee Health Sciences Center, Memphis, Tenn., USA
| | - Michael A Aleman
- Department of Urology, University of Tennessee Health Sciences Center, Memphis, Tenn., USA
| | - Anthony L Patterson
- Department of Urology, University of Tennessee Health Sciences Center, Memphis, Tenn., USA
| | - Robert W Wake
- Department of Urology, University of Tennessee Health Sciences Center, Memphis, Tenn., USA
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
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van Vugt HA, Kranse R, Steyerberg EW, van der Poel HG, Busstra M, Kil P, Oomens EH, de Jong IJ, Bangma CH, Roobol MJ. Prospective validation of a risk calculator which calculates the probability of a positive prostate biopsy in a contemporary clinical cohort. Eur J Cancer 2012; 48:1809-15. [DOI: 10.1016/j.ejca.2012.02.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 02/01/2012] [Accepted: 02/09/2012] [Indexed: 11/26/2022]
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Hattangadi JA, Chen MH, D'Amico AV. Early detection of high-grade prostate cancer using digital rectal examination (DRE) in men with a prostate-specific antigen level of <2.5 ng/mL and the risk of death. BJU Int 2012; 110:1636-41. [PMID: 22757982 DOI: 10.1111/j.1464-410x.2012.11354.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
UNLABELLED Study Type--Prognosis (inception cohort) Level of Evidence 2a. What's known on the subject? and What does the study add? There is little data on the utility of digital rectal examination (DRE) as a diagnostic tool in the era of prostate-specific antigen (PSA) testing. Using a population-based database, we found that detection of prostate cancer while still localized among men with high-grade PSA-occult disease may result in survival benefit. OBJECTIVE • To determine whether detection of high-grade prostate cancer while still clinically localised on digital rectal examination (DRE) can improve survival in men with a normal prostate-specific antigen (PSA) level. PATIENTS AND METHODS • From the Surveillance, Epidemiology and End Results database, 166,104 men with prostate cancer diagnosed between 2004 and 2007 were identified. • Logistic regression was used to identify factors associated with the occurrence of palpable, PSA-occult (PSA level of <2.5 ng/mL), Gleason score 8-10 prostate cancer. • Fine and Gray's and Cox multivariable regressions were used to analyse whether demographic, treatment, and clinicopathological factors were associated with the risk of prostate cancer-specific mortality (PCSM) and all-cause mortality (ACM), respectively. RESULTS • Both increasing age (adjusted odds ratio [aOR] 1.02, 95% confidence interval (CI) 1.01-1.03; P < 0.001) and White race (aOR 1.26, 95% CI 1.03-1.54; P = 0.027) were associated with palpable, Gleason 8-10 prostate cancer. Of 166,104 men, 685 (0.4%) had this subset of prostate cancer. • Significant factors associated with risk of PCSM included PSA level (adjusted hazard ratio [aHR] 0.71, 95% CI 0.51-0.99; P = 0.04), higher Gleason score (aHR 2.20, 95% CI 1.25-3.87; P = 0.006), and T3-T4 vs T2 disease (aHR 3.11, 95% CI 1.79-5.41; P < 0.001). • Significant factors associated with risk of ACM included age (aHR 1.03, 95% CI 1.01-1.06; P = 0.006), higher Gleason score (aHR 2.05, 95% CI 1.36-3.09; P < 0.001), and T3-T4 vs T2 disease (aHR 2.11, 95% CI 1.38-3.25, P < 0.001) CONCLUSIONS • Clinically localised disease on DRE among men with PSA-occult high-grade prostate cancer was associated with improved PCSM and ACM, suggesting that DRE in this cohort (older age and White race) may have the potential to improve survival.
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Huang J, Vicini FA, Williams SG, Ye H, McGrath S, Ghilezan M, Krauss D, Martinez AA, Kestin LL. Percentage of Positive Biopsy Cores: A Better Risk Stratification Model for Prostate Cancer? Int J Radiat Oncol Biol Phys 2012; 83:1141-8. [DOI: 10.1016/j.ijrobp.2011.09.043] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 09/10/2011] [Accepted: 09/26/2011] [Indexed: 01/27/2023]
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Ferro M, Bruzzese D, Perdonà S, Mazzarella C, Marino A, Sorrentino A, Di Carlo A, Autorino R, Di Lorenzo G, Buonerba C, Altieri V, Mariano A, Macchia V, Terracciano D. Predicting prostate biopsy outcome: prostate health index (phi) and prostate cancer antigen 3 (PCA3) are useful biomarkers. Clin Chim Acta 2012; 413:1274-8. [PMID: 22542564 DOI: 10.1016/j.cca.2012.04.017] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 04/12/2012] [Accepted: 04/12/2012] [Indexed: 12/30/2022]
Abstract
Indication for prostate biopsy is presently mainly based on prostate-specific antigen (PSA) serum levels and digital-rectal examination (DRE). In view of the unsatisfactory accuracy of these two diagnostic exams, research has focused on novel markers to improve pre-biopsy prostate cancer detection, such as phi and PCA3. The purpose of this prospective study was to assess the diagnostic accuracy of phi and PCA3 for prostate cancer using biopsy as gold standard. Phi index (Beckman coulter immunoassay), PCA3 score (Progensa PCA3 assay) and other established biomarkers (tPSA, fPSA and %fPSA) were assessed before a 18-core prostate biopsy in a group of 251 subjects at their first biopsy. Values of %p2PSA and phi were significantly higher in patients with PCa compared with PCa-negative group (p<0.001) and also compared with high grade prostatic intraepithelial neoplasia (HGPIN) (p<0.001). PCA3 score values were significantly higher in PCa compared with PCa-negative subjects (p<0.001) and in HGPIN vs PCa-negative patients (p<0.001). ROC curve analysis showed that %p2PSA, phi and PCA3 are predictive of malignancy. In conclusion, %p2PSA, phi and PCA3 may predict a diagnosis of PCa in men undergoing their first prostate biopsy. PCA3 score is more useful in discriminating between HGPIN and non-cancer.
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Affiliation(s)
- Matteo Ferro
- Department of Urology, University of Naples Federico II, Naples, Italy
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Oon SF, Pennington SR, Fitzpatrick JM, Watson RWG. Biomarker research in prostate cancer--towards utility, not futility. Nat Rev Urol 2012; 8:131-8. [PMID: 21394176 DOI: 10.1038/nrurol.2011.11] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The identification of an appropriate clinical question is critical for any biomarker project. Despite rapid advances in technology, few biomarkers have been forthcoming for prostate cancer. This could be because the clinical questions under investigation have not actually originated from clinical practice. These clinical questions are difficult to identify in the complex and heterogeneous pathogenesis of prostate cancer. In this Review, we have developed a prostate cancer 'roadmap' to identify the aspects of prostate cancer that may be amenable to biomarker discovery and serve as a guide for future projects in prostate cancer biomarker research.
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Affiliation(s)
- Sheng Fei Oon
- UCD School of Medicine and Medical Science, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland.
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Cammann H, Jung K, Meyer HA, Stephan C. Avoiding pitfalls in applying prediction models, as illustrated by the example of prostate cancer diagnosis. Clin Chem 2011; 57:1490-8. [PMID: 21920913 DOI: 10.1373/clinchem.2011.166959] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The use of different mathematical models to support medical decisions is accompanied by increasing uncertainties when they are applied in practice. Using prostate cancer (PCa) risk models as an example, we recommend requirements for model development and draw attention to possible pitfalls so as to avoid the uncritical use of these models. CONTENT We conducted MEDLINE searches for applications of multivariate models supporting the prediction of PCa risk. We critically reviewed the methodological aspects of model development and the biological and analytical variability of the parameters used for model development. In addition, we reviewed the role of prostate biopsy as the gold standard for confirming diagnoses. In addition, we analyzed different methods of model evaluation with respect to their application to different populations. When using models in clinical practice, one must validate the results with a population from the application field. Typical model characteristics (such as discrimination performance and calibration) and methods for assessing the risk of a decision should be used when evaluating a model's output. The choice of a model should be based on these results and on the practicality of its use. SUMMARY To avoid possible errors in applying prediction models (the risk of PCa, for example) requires examining the possible pitfalls of the underlying mathematical models in the context of the individual case. The main tools for this purpose are discrimination, calibration, and decision curve analysis.
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Affiliation(s)
- Henning Cammann
- Institute of Medical Informatics, Charite´ –Universita¨ tsmedizin Berlin, Germany
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Age-specific PCA3 score reference values for diagnosis of prostate cancer. World J Urol 2011; 30:405-10. [PMID: 21877172 DOI: 10.1007/s00345-011-0749-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 08/11/2011] [Indexed: 12/24/2022] Open
Abstract
PURPOSE We evaluated the impact of age on PCA3 score and the utility of age-specific reference values in predicting initial prostate biopsy (pBx) outcomes. PATIENTS AND METHODS This single-center, retrospective study included 205 men who underwent an initial 14-core TRUS-guided pBx due to PSA > 3.0 ng/ml or suspicious digital-rectal examination (DRE). PCA3 scores were measured with the Progensa assay. Linear regression models were fit to identify factors that impact PCA3 score and to determine age-specific reference values. Predictive accuracies of logistic regression models predicting presence of prostate cancer (PCa) were analyzed. RESULTS The positive biopsy rate was 37%. In multivariable linear regression, age (P < 0.001), presence of PCa (P < 0.001), and multifocal HG-PIN (P = 0.012) were independent predictors of PCA3 score. Age showed the strongest impact on PCA3 score (T = 4.77). The upper 95% confidence interval of PCA3 score in each age category was defined as the age-specific limit. A PCA3-score over the age-specific limit (PCA3-age) was associated with an 4.17-fold increased odds of being diagnosed with PCa (P < 0.001). In multivariable logistic regression models predicting the presence of PCa, predictive accuracy of a base model (age, DRE, PSA, volume) increased from 69.6 to 75.4% (P = 0.037) by adding the continuous PCA3 score, to 73.9% (P = 0.098) with the 35 cutoff (PCA3-35) and to 77.1% (P = 0.008) with PCA3-age. CONCLUSIONS PCA3 score increases with age, independent of PCa presence. Age-specific PCA3 score reference values are superior to PSA, continuous PCA3 score, and PCA3-35 in predicting initial pBx outcome. Therefore, an age-adjusted PCA3 score should be used for interpretation of the results.
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Reese AC, Sadetsky N, Carroll PR, Cooperberg MR. Inaccuracies in assignment of clinical stage for localized prostate cancer. Cancer 2010; 117:283-9. [PMID: 21210472 DOI: 10.1002/cncr.25596] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Revised: 05/26/2010] [Accepted: 06/08/2010] [Indexed: 11/08/2022]
Abstract
BACKGROUND Recent data have suggested that clinical T stage is not independently associated with biochemical recurrence of localized prostate cancer after radical prostatectomy. One explanation for this lack of predictive power may be the inaccurate application of staging criteria. METHODS Data from men in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) database with localized prostate cancer (clinical T1-T2) were analyzed. Correct stage was determined by digital rectal examination (DRE) and transrectal ultrasound (TRUS) findings and was compared with the clinical stage reported directly by the practitioner. DRE/TRUS findings and biopsy results were evaluated to determine factors influencing staging errors. The ability of corrected stage to predict biochemical disease recurrence after prostatectomy was assessed using multivariable analysis. RESULTS Clinical stage was assigned incorrectly in 1370 of 3875 men (35.4%). Errors more commonly resulted in patient downstaging than upstaging (55.1% vs 44.9%; P < .001). Patients with TRUS lesions were more likely to be staged incorrectly than those with abnormal DRE findings (65.8% vs 38.2%; P < .001). Biopsy laterality was found to strongly influence stage assignment. Even after correction of staging errors, there was no association noted between clinical stage and biochemical disease recurrence after radical prostatectomy. CONCLUSIONS Errors in applying clinical staging criteria for localized prostate cancer are common. TRUS findings are frequently disregarded, and practitioners incorrectly incorporate biopsy results when assigning stage. However, staging errors do not appear to account for the inconsistent reliability of clinical stage in predicting prostate cancer outcomes. These findings further challenge the utility of a DRE-based and/or TRUS-based staging system for risk assessment of localized prostate cancer.
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Affiliation(s)
- Adam C Reese
- Department of Urology, UCSF Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, California 94143, USA.
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