The natural course of pT2 prostate cancer with positive surgical margin: predicting biochemical recurrence

Biochemical recurrence of pathological T2+ localized prostate cancer after robotic-assisted radical prostatectomy: A 10-year surveillance

BACKGROUND

pT2+ prostate cancer (PCa), a term first used in 2004, refers to organ-confined PCa characterized by a positive surgical margin (PSM) without extracapsular extension. Patients with a PSM are vulnerable to biochemical recurrence (BCR) following radical prostatectomy (RP); however, whether adjuvant radiotherapy (aRT) is imperative to PSM after RP remains controversial. This study had the longest follow-up on pT2+ PCa after robotic-assisted RP since 2004. Moreover, we discussed our viewpoints on pT2+ PCa based on real-world experiences.

AIM

To conclude a 10-year surveillance on pT2+ PCa and compare our results with those of the published literature.

METHODS

Forty-eight patients who underwent robotic-assisted RP between 2008 and 2011 were enrolled. Two serial tests of prostate specific antigen (PSA) ≥ 0.2 ng/mL were defined as BCR. Various designed factors were analyzed using statistical tools for BCR risk. SAS 9.4 was applied and significance was defined as P < 0.05. Univariate, multivariate, linear regression, and receiver operating characteristic (ROC) curve analyses were performed for statistical analyses.

RESULTS

With a median follow-up period of 9 years, 25 (52%) patients had BCR (BCR group), and the remaining 23 (48%) patients did not (non-BCR group). The median time for BCR test was 4 years from the first postoperative PSA nadir. Preoperative PSA was significantly different between the BCR and non-BCR groups (P < 0.001), and ROC curve analysis of preoperative PSA suggested a cut-off value of 19.09 ng/mL (sensitivity, 0.600; specificity: 0.739). The linear regression analysis showed no correlation between time to BCR and preoperative PSA (Pearson’s correlation, 0.13; adjusted R² = 0.026).

CONCLUSION

Robotic-assisted RP in pT2+ PCa of worse conditions can provide better BCR-free survival. A surgical technique limiting the PSM in favorable situations is warranted to lower the pT2+ PCa BCR rate. Preoperative PSA cut-off value of 19.09 ng/mL is a predictive factor for BCR. Based on our experiences and review of the literature, we do not recommend routine aRT for pT2+ PCa.

[Advanced Prostate Cancer Consensus Conference 2017 : Discussion of the recommendations for diagnosis and treatment of metastatic prostate cancer by a German panel of experts]

In March 2017 the 'Advanced Prostate Cancer Consensus Conference' (APCCC) took place in St. Gallen (Switzerland). The APCCC-panelists are internationally well known experts. With the actual data in mind they discussed treatment options for patients with advanced prostate cancer in order to update the international APCCC-recommendations from the previous meeting in 2015. Recently these consensus recommendations have been published in "European Urology".A group of German experts discussed this year APCCC-votes during the meeting and the recommendations that were concluded from the votes from the German perspective. Reasons for an additional German discussion are country-specific variations that may have influenced the APCCC-votes und recommendations. Due to the concept of the APCCC-meeting the wording of the questions could not always be as necessary.One focus of this year consensus discussion was the treatment of metastatic castration-naive prostate cancer (mCNPC). There are new data which may also influence the therapeutic situation of patients with metastatic castration-resistant prostate cancer (mCRPC). Further points of discussion were the impact of new imaging procedures in the clinical setting as well as the treatment of oligometastatic prostate cancer.

The impact of lymphovascular invasion in patients with prostate cancer following radical prostatectomy and its association with their clinicopathological features: An updated PRISMA-compliant systematic review and meta-analysis

OBJECTIVE

Numerous studies have shown that lymphovascular invasion (LVI) is linked to biochemical recurrence (BCR) in prostate cancer (PCa) patients following radical prostatectomy (RP). However, the actual clinicopathological impacts of LVI remain unclear. Thus, we performed a meta-analysis to evaluate the pathologic and prognostic impacts of LVI in PCa patients.

METHODS

Following the guidance of the PRISMA statement, relevant studies were collected systematically from the PubMed, EMBASE, and Web of Science databases to identify relevant studies published before June 2018. The hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated to investigate the association of LVI with BCR and clinicopathological features.

RESULTS

A total of 20 studies including 25,570 patients (106-6678 per study) with PCa were incorporated into this meta-analysis. Overall pooled analysis suggested that LVI was associated with a higher BCR risk both in univariate (pooled HR=1.50, 95% CI: 1.34-1.68, P <.001) and multivariate analyses (pooled HR=1.25, 95% CI: 1.17-1.34, P <.001). In addition, LVI was closely correlated with extraprostatic extension (yes vs no: OR = 4.23, 95% CI: 1.86-9.61, P <.001), pathological GS (≥7 vs <7: OR = 5.46, 95% CI: 2.25-13.27, P <.001), lymph node metastases (yes vs no: OR = 18.56, 95% CI: 7.82-44.06, P <.001), higher pathological stage (≥ T3 vs < T2: OR = 6.75, 95% CI: 5.46-8.36, P <.001), positive surgical margin (positive vs negative: OR = 2.42, 95% CI: 1.57-3.72, P <.001) and seminal vesicle invasion (yes vs no: OR = 5.72, 95% CI: 2.45-13.36, P <.001).

CONCLUSIONS

This study suggests that LVI in histopathology is associated with a higher risk of BCR and advanced clinicopathological features in PCa patients and could serve as a poor prognostic factor in patients who underwent RP.

[Active surveillance for low-risk prostate cancer]

Autopsy studies have confirmed the high prevalence of latent prostate cancer; however, only a certain portion of patients require definite treatment. Active surveillance is one of the treatment options which, according to national and international guidelines, should be offered to patients with newly diagnosed low-risk prostate cancer. Prostate cancer-specific survival is high in these patients; therefore, curative treatment, such as radical prostatectomy, external beam radiotherapy and brachytherapy may be initially deferred in order to avoid therapy-related side effects. In order to qualify for active surveillance, strict inclusion criteria have to be met; nevertheless, the reliable identification of low-risk prostate cancer patients is not always possible. Patients under active surveillance are followed up regularly with prostate-specific antigen (PSA) testing, digital rectal examination (DRE) and repeat prostate biopsies. Due to the heterogeneity of primary prostate tumors precise molecular diagnostic techniques could allow individualized treatment strategies in the future.

[Gap between postulated and real outcome quality of radical prostatectomy]

BACKGROUND

Certified Prostate Centers proclaim congruent process and outcome quality results for treatment of prostate carcinoma. Therapy in accordance with the guidelines after presentation of the patient in an interdisciplinary conference and regular documented follow up are not in themselves a guarantee for good quality results (complication free, continence, erectile function, negative surgical margins, biochemical recurrence free), and are significantly influenced by factors not contained within the certification framework.

DISCUSSION

An association between exceeding the minimum number of operations and quality assurance exists, if at all, only vaguely and on no account justifies the absolute numbers necessary for certification. Although good measuring instruments for a Pentafecta analysis are available, the gathering of quality results for a center are limited to questionnaires for functional quality results and in the non-differentiated request for a pT2R1 rate of under 10 % for oncological quality results.

CONCLUSIONS

The reasons for this systematic ignoring of the for the patient so important quality results with a simultaneous excessive regard for standardizing organizational procedure processes are manifold. They comprise valid verifiability of process quality, the unclear effects of standardized treatment pathways on actual operation quality and the capitulation to statistical and patient determined problems with sufficient acquisition of comparable functional OP results. Whereas the outcome quality is more important than the process quality for patients with prostate carcinoma, the certified centers conduct themselves in exactly the opposite manner, thus creating a virtually insoluble dilemma.