Improved decision making in intermediate-risk prostate cancer: a multicenter study on pathologic and oncologic outcomes after radical prostatectomy

No detrimental effect of a positive family history on postoperative upgrading and upstaging in men with low risk and favourable intermediate-risk prostate cancer: implications for active surveillance

Purpose

To assess whether a first-degree family history or a fatal family history of prostate cancer (PCa) are associated with postoperative upgrading and upstaging among men with low risk and favourable intermediate-risk (FIR) PCa and to provide guidance on clinical decision making for active surveillance (AS) in this patient population.

Methods

Participants in the German Familial Prostate Cancer database diagnosed from 1994 to 2019 with (1) low risk (clinical T1c–T2a, biopsy Gleason Grade Group (GGG) 1, PSA < 10 ng/ml), (2) Gleason 6 FIR (clinical T1c–T2a, GGG 1, PSA 10–20 ng/ml), and (3) Gleason 3 + 4 FIR (clinical T1c–T2a, GGG 2, PSA < 10 ng/ml) PCa who were subsequently treated with radical prostatectomy (RP) were analysed for upgrading, defined as postoperative GGG 3 tumour or upstaging, defined as pT3–pT4 or pN1 disease at RP. Logistic regression analysis was used to assess whether PCa family history was associated with postoperative upgrading or upstaging.

Results

Among 4091 men who underwent RP, mean age at surgery was 64.4 (SD 6.7) years, 24.7% reported a family history, and 3.4% a fatal family history. Neither family history nor fatal family history were associated with upgrading or upstaging at low risk, Gleason 6 FIR, and Gleason 3 + 4 FIR PCa patients.

Conclusion

Results from the current study indicated no detrimental effect of family history on postoperative upgrading or upstaging. Therefore, a positive family history or fatal family history of PCa in FIR PCa patients should not be a reason to refrain from AS in men otherwise suitable.

Electronic supplementary material

The online version of this article (10.1007/s00345-020-03485-5) contains supplementary material, which is available to authorized users.

Intermediate-risk Prostate Cancer: Stratification and Management

CONTEXT

Intermediate-risk prostate cancer consists of a highly heterogeneous group of patients. Owing to this heterogeneity and variable prognoses, it is challenging to provide uniform treatment recommendations for men in this group.

OBJECTIVE

To review the current literature regarding the best available evidence for stratification and treatment of intermediate-risk prostate cancer patients.

EVIDENCE ACQUISITION

We searched Medline and EMBASE, through September 2019 without year or language restriction, supplemented with hand search.

EVIDENCE SYNTHESIS

Different treatment options with good long-term oncological outcomes are available for intermediate-risk prostate cancer patients. Best available evidence with long follow-up exists for radical prostatectomy and dose-escalated radiotherapy with short-term androgen deprivation. In favorable intermediate-risk patients, active surveillance and brachy-monotherapy also represent two valid treatment options. In carefully selected men, partial gland ablation represents a reasonable option. Patient preferences and comorbidities should also be considered.

CONCLUSIONS

Treatment options for intermediate-risk patients range from active surveillance to partial gland ablation, radical prostatectomy, and various radiotherapy methods. The best stratification and the optimal treatment remain controversial. Classification systems, such as the National Cancer Comprehensive Network guidelines, stratify this large cohort into subgroups with favorable or unfavorable disease, which may simplify treatment recommendations but still leave substantial variability within strata. Advanced imaging may further improve current stratification systems of intermediate-risk patients.

PATIENT SUMMARY

In this review, we assessed the current literature regarding the best available evidence for stratification and treatment of intermediate-risk prostate cancer patients.

Improvement of the intermediate risk prostate cancer sub-classification by integrating MRI and fusion biopsy features

INTRODUCTION

Treatment decision-making for intermediate-risk prostate cancer (CaP) is mainly based on grade and tumor involvement on systematic biopsy. We aimed to assess the added value of multi-parametric magnetic resonance imaging (mpMRI) and targeted biopsy (TB) features for predicting final pathology and for improving the well-established favourable/unfavourable systematic biopsy-based sub-classification.

MATERIALS AND METHODS

From a prospective database of 377 intermediate risk CaP cases, we evaluated the performance of the standard intermediate risk classification (IRC), and the predictive factors for unfavourable disease on final pathology aiming to build a new model. Overall unfavourable disease (OUD) was defined by any pT3-4 and/or pN1 and/or grade group (GG) ≥ 3.

RESULTS

The standard IRC was found to be predictive for unfavourable disease in this population. However, in multivariable analysis regression, ECE on mpMRI and GG ≥3 on TB remained the 2 independent predictive factors for OUD disease (HR = 2.7, P = 0.032, and HR = 2.41, P = 0.01, respectively). By using the new IRC in which unfavorable risk was defined by ECE on mpMRI and/or GG ≥3 on TB, the proportion of unfavorable cases decreased from 62.3% to 34.1% while better predicting unfavorable disease in RP speciments. The new model displayed a better accuracy than the standard IRC for predicting OUD (AUC: 0.66 vs. 0.55).

CONCLUSIONS

The integration of imaging and TB features drastically improves the intermediate risk sub-classification performance and better discriminates the unfavourable risk group that could benefit from more aggressive therapy such as neo-adjuvant and/or adjuvant treatment, and the favourable group that could avoid over-treatment. External validation in other datasets is needed.

Comparison between Zumsteg classification and Briganti nomogram for the risk of lymph-node invasion before radical prostatectomy

PURPOSE

To evaluate the performance of the Zumsteg classification to estimate the risk of lymph-node invasion (LNI) compared with the Briganti nomogram (BN) in prostatectomy patients with intermediate-risk prostate cancer (IRPC).

METHODS

We included consecutive patients who had extended pelvic lymph-node dissection associated with radical prostatectomy for IRPC. To be classified favorable intermediate risk (FIR), patients could only have one intermediate-risk factor, fewer than 50% positive biopsies and no primary Gleason score of 4.

RESULTS

On the 387 patients included, 149 (38.5%) and 238 (54.3%) were classified FIR and unfavorable intermediate risk (UIR), respectively, and 212 (54.8%) had a BN inferior to 5%. Thirty-eight patients (9.8%) had LNI: 6 FIR patients (4.0%) versus 32 UIR patients (13.4%) and 14 patients (6.6%) with a BN inferior to 5% versus 24 patients (13.7%) with a BN superior to 5%. Eight patients with a BN inferior to 5%, but classified UIR, had LNI. Sensitivity to detect LNI was higher with the Zumsteg classification than with the BN: 84.2% (CI 95% [68-93]) versus 63.2% (CI 95% [46-78]). Both screening tests were concordant to predict LNI (kappa coefficient of 0.076, p < 0.05 for Zumsteg and Briganti) CONCLUSIONS: Zumsteg classification appeared to be more sensitive and as effective (despite the impossibility to make decision curve analysis) than the BN to estimate the risk of LNI. Regarding the modest number of pN+ patients, further studies are needed to see the interest of proposing ePLND for UIR patients only.

Estudio de concordancia entre los resultados de la puntuación de Gleason de biopsias de próstata y los de la prostatectomía radical en pacientes con cáncer de próstata localizado

Introducción. Existen diferencias entre la concordancia de la puntuación de Gleason en biopsias prostática y la patología final.Objetivos. Determinar la concordancia de las puntuaciones de Gleason obtenidas por biopsia de próstata y por prostatectomía radical (PR) en un hospital de IV nivel en Bogotá D.C., Colombia.Materiales y métodos. Estudio retrospectivo de pruebas diagnósticas realizado en un hospital de alta complejidad de Bogotá D.C. Fueron resisados los resultados de las PR y las biopsias prostáticas, clasificando los pacientes según D’Amico y la división por grupos realizada por patólogos. La concordancia diagnóstica se determinó mediante la estimación del coeficiente de Kappa ponderado.Resultados. Se incluyeron 180 pacientes con promedio de edad de 61 años. La exactitud diagnóstica de la puntuación de Gleason dada por biopsia fue de 52%, con supraestadificación del 34% y subestadificación del 14%. El índice Kappa ponderado entre la puntuación de Gleason de la biopsia prostática y la PR fue de 0.37 (p=0.000), y por grupos de 0.4 (p=0.000), con concordancia aceptable para la muestra.Conclusiones. La concordancia de la biopsia de próstata con la PR es baja con tendencia a la supraestadificación, lo que podría tener un impacto negativo en el manejo de los pacientes con cáncer de próstata localizado.

Combined analysis of CRMP4 methylation levels and CAPRA-S score predicts metastasis and outcomes in prostate cancer patients

The present study analyzed the predictive value of combined analysis of collapsin response mediator protein 4 (CRMP4) methylation levels and the Cancer of the Prostate Risk Assessment (CAPRA-S) Postsurgical score of patients who required adjuvant hormone therapy (AHT) after radical prostatectomy (RP). We retrospectively analyzed 305 patients with prostate cancer (PCa) who received RP and subsequent androgen deprivation therapy (ADT). Two hundred and thirty patients with clinically high-risk PCa underwent immediate ADT, and 75 patients with intermediate risk PCa underwent deferred ADT. CRMP4 methylation levels in biopsies were determined, and CAPRA-S scores were calculated. In the deferred ADT group, the values of the hazard ratios for tumor progression and cancer-specific mortality (CSM) in patients with ≥15% CRMP4 methylation were 6.81 (95% CI: 2.34–19.80) and 12.83 (95% CI: 2.16–26.10), respectively. Receiver-operating characteristic curve analysis indicated that CRMP4 methylation levels ≥15% served as a significant prognostic marker of tumor progression and CSM. In the immediate ADT group, CAPRA-S scores ≥6 and CRMP4 methylation levels ≥15% were independent predictors of these outcomes (uni- and multi-variable Cox regression analyses). The differences in the 5-year progression-free survival between each combination were statistically significant. Combining CAPRA-S score and CRMP4 methylation levels improved the area under the curve compared with the CRMP4 or CAPRA-S model. Therefore, CRMP4 methylation levels ≥15% were significantly associated with a poor prognosis and their combination with CAPRA-S score accurately predicted tumor progression and metastasis for patients requiring AHT after RP.

Index tumor volume on MRI as a predictor of clinical and pathologic outcomes following radical prostatectomy

PURPOSE

Index tumor volume (ITV) measured on radical prostatectomy (RP) specimens has been shown to be associated with adverse pathologic and oncologic outcomes. We evaluate the value of ITV calculated from prostate multiparametric MRI (mpMRI) in predicting adverse clinical and pathologic outcomes.

MATERIALS AND METHODS

Data from a prospectively maintained, single-institution database were analyzed for patients who underwent mpMRI prior to RP (2007-2016). Index tumor was defined as a T2-visible lesion with the longest diameter. Adverse pathologic outcomes were extraprostatic extension (EPE), lymph node invasion (LNI), seminal vesicle invasion (SVI), and positive margins (PM). Logistic and Cox proportional hazard regression were used to assess associations with adverse pathology and biochemical recurrence (BCR), respectively.

RESULTS

Of the 455 patients included, EPE, LNI, SVI and PM were present in 23.5%, 6.2%, 5.5% and 15.7% patients, respectively. Patients with adverse pathologic outcomes had larger median ITV. ITV was found to be an independent predictor of EPE (OR 1.22, p = 0.010), LNI (OR 1.39, p = 0.001), and SVI (OR 1.28, p = 0.009), but not PM (OR 1.03, p = 0.522). Combination of ITV and PSA was found to have predictive ability comparable to that of modified Partin tables (EPE:ITV + PSA_AUC = 0.71 vs. Partin_AUC = 0.71; LNI:ITV + PSA_AUC = 0.92 vs. Partin_AUC = 0.90, SVI:ITV + PSA_AUC = 0.78 vs. Partin_AUC = 0.82). 5 year BCR-free survival (median follow-up 24.9 months) was higher for patients with ITV < 2 cc (84.1% vs. 58.5%, p = 0.001). However, ITV was not found to be an independent predictor of BCR (HR 1.69, p = 0.130).

CONCLUSIONS

We demonstrate that ITV measured on mpMRI is a predictor of adverse pathologic and clinical outcomes and can aid in preoperative risk assessment.

Neoadjuvant degarelix with or without apalutamide followed by radical prostatectomy for intermediate and high-risk prostate cancer: ARNEO, a randomized, double blind, placebo-controlled trial

BACKGROUND

Recent retrospective data suggest that neoadjuvant androgen deprivation therapy can improve the prognosis of high-risk prostate cancer (PCa) patients. Novel androgen receptor pathway inhibitors are nowadays available for treatment of metastatic PCa and these compounds are promising for early stage disease. Apalutamide is a pure androgen antagonist with a very high affinity with the androgen receptor. The combination of apalutamide with degarelix, an LHRH antagonist, could increase the efficacy compared to degarelix alone.

OBJECTIVE

The primary objective is to assess the difference in proportions of minimal residual disease at prostatectomy specimen between apalutamide + degarelix vs placebo + degarelix. Various secondary endpoints are assessed: variations of different biomarkers at the tumour level (tissue microarrays to evaluate DNA-PKs, PARP, AR and splice variants, PSMA, etc.), whole transcriptome sequencing, exome sequencing and clinical (PSA and testosterone kinetics, early biochemical recurrence free survival, quality of life, safety, etc.) and radiological endpoints.

METHODS

ARNEO is a single centre, phase II, randomized, double blind, placebo-controlled trial. The plan is to include at least 42 patients per each of the two study arms. Patients with intermediate/high-risk PCa and who are amenable for radical prostatectomy with pelvic lymph node dissection can be included. After signing an informed consent, every patient will undergo a pelvic 68Ga -PSMA-11 PSMA PET/MR and receive degarelix at standard dosage and start assuming apalutamide/placebo (60 mg 4 tablets/day) for 12 weeks. Within thirty days from the last study medication intake the same imaging will be repeated. Every patient will undergo PSA and testosterone testing the day of randomization, before the first drug intake, and after the last dose. Formalin fixed paraffin embedded tumour samples will be collected and used for transcriptome analysis, exome sequencing and immunohistochemistry.

DISCUSSION

ARNEO will allow us to answer, first, whether the combined treatment can result in an increased proportion of patients with minimal residual disease. Secondly, It will enable the study of the molecular consequences at the level of the tumour. Thirdly, what the consequences are of new generation androgen receptor pathway inhibitors on 68Ga -PSMA-11 PET/MR. Finally, various clinical, safety and quality of life data will be collected.

TRIAL REGISTRATION

EUDRaCT number: 2016-002854-19 (authorization date 3rd August 2017). clinicalTrial.gov: NCT03080116 .

External validation of a nomogram for identification of pathologically favorable disease in intermediate risk prostate cancer patients

OBJECTIVE

To establish an external validation of the new nomogram from Gandaglia et al which provides estimates of the probability of pathological favorable disease in pre-operatively defined intermediate-risk PCa.

PATIENTS AND METHODS

Overall, 2928 intermediate-risk PCa patients according to the D'Amico classification undergoing RP and bilateral lymph node dissection in seven academic centres between 2000 and 2011. Pathologically favorable PCa was defined as low-grade organ-confined disease. The Receiver Operating Characteristic (ROC) curve was obtained to quantify the overall accuracy (Area Under the Curve, AUC) of the model to predict specimen-confined (SC) disease. Calibration curve was then constructed to illustrate the relationship between the risk-estimates obtained by the model and the observed proportion of SC disease. Kaplan-Meier method was used for PSA recurrence-free survival (PSA-RFS) assessment.

RESULTS

Median age was 68 years. 10.6% patients finally presented pathologically favorable disease characteristics at RP. A higher PSAD (OR = 0.01; 95%CI = 0.00-0.04; P < 0.0001) and percentage of positive cores (OR = 0.97; 95%CI = 0.96-0.98; P < 0.0001) were associated with a reduced probability of favorable disease at RP in multivariate analysis. ROC curve analysis showed strongest accuracy of the model (AUC = 0.82; 95%CI = 0.79-0.84). Favorable PCa had a significantly better PSA recurrence-free survival rates as compared to unfavorable PCa after RP (94.2% vs 74.4% at 4 years, P < 0.0001).

CONCLUSIONS

This external validation of the Gandaglia nomogram shows relevant accuracy with one out of ten patients in this intermediate risk PCa group with pathologically proven organ-confined disease. This validated risk calculator can help physician to distinguish favorable intermediate risk PCa that can be treated by conservative approach or safer nerve-sparing surgery.