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Porcaro AB, Bianchi A, Panunzio A, Gallina S, Serafin E, Tafuri A, Trabacchin N, Orlando R, Ornaghi PI, Mazzucato G, Vidiri S, D'Aietti D, Montanaro F, Brusa D, Patuzzo GM, Artoni F, Baielli A, Migliorini F, De Marco V, Veccia A, Brunelli M, Siracusano S, Cerruto MA, Antonelli A. Tumor upgrading among very favorable intermediate-risk prostate cancer patients treated with robot-assisted radical prostatectomy: how can it impact the clinical course? Int Urol Nephrol 2024; 56:2597-2605. [PMID: 38553619 DOI: 10.1007/s11255-024-04019-3] [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: 12/17/2023] [Accepted: 03/02/2024] [Indexed: 07/25/2024]
Abstract
PURPOSE We sought to investigate predictors of unfavorable tumor upgrading in very favorable intermediate-risk (IR) prostate cancer (PCa) patients treated with robot-assisted radical prostatectomy, in addition to evaluate how it may affect the risk of disease progression. METHODS A very favorable subset of IR PCa patients presenting with prostate-specific antigen (PSA) < 10 ng/mL, percentage of biopsy positive cores (BPC) < 50%, and either International Society of Urological Pathology (ISUP) grade group 1 and clinical stage T2b or ISUP grade group 2 and clinical stage T1c-2b was identified. Unfavorable pathology at radical prostatectomy was defined as the presence of ISUP grade group > 2 (unfavorable tumor upgrading), extracapsular extension (ECE), and seminal vesicle invasion (SVI). Disease progression was defined as the event of biochemical recurrence and/or local recurrence and/or distant metastases. Associations were evaluated by Cox regression and logistic regression analyses. RESULTS Overall, 210 patients were identified between January 2013 and October 2020. Unfavorable tumor upgrading was detected in 71 (33.8%) cases, and adverse tumor stage, including ECE or SVI in 18 (8.6%) and 11 (5.2%) patients, respectively. Median (interquartile range) follow-up was 38.5 (16-61) months. PCa progression occurred in 24 (11.4%) patients. Very favorable IR PCa patients with unfavorable tumor upgrading at final pathology showed a persistent risk of disease progression, which hold significance after adjustment for all factors (Hazard Ratio [HR]: 5.95, 95% Confidence Interval [CI]: 1.97-17.92, p = 0.002) of which PSA was an independent predictor (HR: 1.52, 95% CI 1.12-2.08, p = 0.008). Moreover, these subjects were more likely to belong to the biopsy ISUP grade group 2. CONCLUSIONS Very favorable IR PCa patients hiding unfavorable tumor upgrading were more likely to experience disease progression. Unfavorable tumor upgrading involved about one-third of cases and was less likely to occur in patients presenting with biopsy ISUP grade group 1. Tumor misclassification is an issue to discuss, when counseling this subset of patients for active surveillance because of the risk of delayed active treatment.
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Affiliation(s)
- Antonio Benito Porcaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy.
| | - Alberto Bianchi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | | | - Sebastian Gallina
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Emanuele Serafin
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | | | - Nicolò Trabacchin
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Rossella Orlando
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Paola Irene Ornaghi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Giovanni Mazzucato
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Stefano Vidiri
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Damiano D'Aietti
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Francesca Montanaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Davide Brusa
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Giulia Marafioti Patuzzo
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Francesco Artoni
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Alberto Baielli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Filippo Migliorini
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Vincenzo De Marco
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Alessandro Veccia
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Matteo Brunelli
- Department of Pathology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Salvatore Siracusano
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Maria Angela Cerruto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
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Porcaro AB, Bianchi A, Gallina S, Panunzio A, Tafuri A, Serafin E, Orlando R, Mazzucato G, Ornaghi PI, Cianflone F, Montanaro F, Artoni F, Baielli A, Ditonno F, Migliorini F, Brunelli M, Siracusano S, Cerruto MA, Antonelli A. Prognostic Impact and Clinical Implications of Adverse Tumor Grade in Very Favorable Low- and Intermediate-Risk Prostate Cancer Patients Treated with Robot-Assisted Radical Prostatectomy: Experience of a Single Tertiary Referral Center. Cancers (Basel) 2024; 16:2137. [PMID: 38893256 PMCID: PMC11171498 DOI: 10.3390/cancers16112137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 05/25/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
OBJECTIVES To assess the prognostic impact and predictors of adverse tumor grade in very favorable low- and intermediate-risk prostate cancer (PCa) patients treated with robot-assisted radical prostatectomy (RARP). METHODS Data of low- and intermediate PCa risk-class patients were retrieved from a prospectively maintained institutional database. Adverse tumor grade was defined as pathology ISUP grade group > 2. Disease progression was defined as a biochemical recurrence event and/or local recurrence and/or distant metastases. Associations were assessed by Cox's proportional hazards and logistic regression model. RESULTS Between January 2013 and October 2020, the study evaluated a population of 289 patients, including 178 low-risk cases (61.1%) and 111 intermediate-risk subjects (38.4%); unfavorable tumor grade was detected in 82 cases (28.4%). PCa progression, which occurred in 29 patients (10%), was independently predicted by adverse tumor grade and biopsy ISUP grade group 2, with the former showing stronger associations (hazard ratio, HR = 4.478; 95% CI: 1.840-10.895; p = 0.001) than the latter (HR = 2.336; 95% CI: 1.057-5.164; p = 0.036). Older age and biopsy ISUP grade group 2 were independent clinical predictors of adverse tumor grade, associated with larger tumors that eventually presented non-organ-confined disease. CONCLUSIONS In a very favorable PCa patient population, adverse tumor grade was an unfavorable prognostic factor for disease progression. Active surveillance in very favorable intermediate-risk patients is still a hazard, so molecular and genetic testing of biopsy specimens is needed.
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Affiliation(s)
- Antonio Benito Porcaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Alberto Bianchi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Sebastian Gallina
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Andrea Panunzio
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | | | - Emanuele Serafin
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Rossella Orlando
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Giovanni Mazzucato
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Paola Irene Ornaghi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Francesco Cianflone
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Francesca Montanaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Francesco Artoni
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Alberto Baielli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Francesco Ditonno
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Filippo Migliorini
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Matteo Brunelli
- Department of Pathology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy;
| | - Salvatore Siracusano
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy;
| | - Maria Angela Cerruto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
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Anceschi U, Flammia RS, Tufano A, Morelli M, Galfano A, Luciani LG, Misuraca L, Dell’Oglio P, Tuderti G, Brassetti A, Ferriero MC, Bove AM, Mastroianni R, Prata F, Sperduti I, Petralia G, Secco S, Di Trapani E, Mattevi D, Cai T, Bocciardi AM, Simone G. Proficiency score as a predictor of early trifecta achievement during the learning curve of robot-assisted radical prostatectomy for high-risk prostate cancer: Results of a multicentric series. Curr Urol 2024; 18:110-114. [PMID: 39176300 PMCID: PMC11337992 DOI: 10.1097/cu9.0000000000000213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/04/2023] [Indexed: 08/24/2024] Open
Abstract
Background Recently, an innovative tool called "proficiency score" was introduced to assess the learning curve for robot-assisted radical prostatectomy (RARP). However, the initial study only focused on patients with low-risk prostate cancer for whom pelvic lymph node dissection (PLND) was not required. To address this issue, we aimed to validate proficiency scores of a contemporary multicenter cohort of patients with high-risk prostate cancer treated with RARP plus extended PLND by trainee surgeons. Material and methods Between 2010 and 2020, 4 Italian institutional prostate-cancer datasets were merged and queried for "RARP" and "high-risk prostate cancer." High-risk prostate cancer was defined according to the most recent European Association of Urology guidelines as follows: prostate-specific antigen >20 ng/mL, International Society of Urological Pathology ≥4, and/or clinical stage (cT) ≥ 2c on preoperative imaging. The selected cohort (n = 144) included clinical cases performed by trainee surgeons (n = 4) after completing their RARP learning curve (50 procedures for low-risk prostate cancer). The outcome of interest, the proficiency score, was defined as the coexistence of all the following criteria: a comparable operation time to the interquartile range of the mentor surgeon at each center, absence of any significant perioperative complications Clavien-Dindo Grade 3-5, no perioperative blood transfusions, and negative surgical margins. A logistic binary regression model was built to identify the predictors of 1-year trifecta achievement in the trainee cohort. For all statistical analyses, a 2-sided p < 0.05 was considered significant. Results A proficiency score was achieved in 42.3% patients. At univariable level, proficiency score was associated with 1-year trifecta achievement (odds ratio, 8.77; 95% confidence interval, 2.42-31.7; p = 0.001). After multivariable adjustments for age, nerve-sparing, and surgical technique, the proficiency score independently predicted 1-year trifecta achievement (odds ratio, 9.58; 95% confidence interval, 1.83-50.1; p = 0.007). Conclusions Our findings support the use of proficiency scores in patients and require extended PLND in addition to RARP.
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Affiliation(s)
- Umberto Anceschi
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy
| | - Rocco Simone Flammia
- Urologic Clinic, Department of Maternal-Child and Urologic Sciences, Sapienza University of Rome, Italy
| | - Antonio Tufano
- Urologic Clinic, Department of Maternal-Child and Urologic Sciences, Sapienza University of Rome, Italy
| | - Michele Morelli
- Ospedale Niguarda Ca’ Granda, Department of Urology, Milan, Italy
| | - Antonio Galfano
- Ospedale Niguarda Ca’ Granda, Department of Urology, Milan, Italy
| | | | - Leonardo Misuraca
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy
| | - Paolo Dell’Oglio
- Ospedale Niguarda Ca’ Granda, Department of Urology, Milan, Italy
| | - Gabriele Tuderti
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy
| | - Aldo Brassetti
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy
| | | | - Alfredo Maria Bove
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy
| | - Riccardo Mastroianni
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy
| | - Francesco Prata
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy
| | - Isabella Sperduti
- Department of Biostatistical Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | | | - Silvia Secco
- Ospedale Niguarda Ca’ Granda, Department of Urology, Milan, Italy
| | | | - Daniele Mattevi
- Department of Urology, APSS Santa Chiara Regional Hospital, Trento, Italy
| | - Tommaso Cai
- Department of Urology, APSS Santa Chiara Regional Hospital, Trento, Italy
| | | | - Giuseppe Simone
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy
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Porcaro AB, Bianchi A, Panunzio A, Gallina S, Tafuri A, Serafin E, Orlando R, Mazzucato G, Vidiri S, D’Aietti D, Montanaro F, Marafioti Patuzzo G, Artoni F, Baielli A, Ditonno F, Rizzetto R, Veccia A, Gozzo A, De Marco V, Brunelli M, Cerruto MA, Antonelli A. The impact of prognostic group classification on prostate cancer progression in intermediate-risk patients according to the European Association of Urology system: results in 479 patients treated with robot-assisted radical prostatectomy at a single tertiary referral center. Ther Adv Urol 2024; 16:17562872241229260. [PMID: 38348129 PMCID: PMC10860426 DOI: 10.1177/17562872241229260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 01/03/2024] [Indexed: 02/15/2024] Open
Abstract
Background Treatment outcomes in intermediate-risk prostate cancer (PCa) may be impaired by adverse pathology misclassification including tumor upgrading and upstaging. Clinical predictors of disease progression need to be improved in this category of patients. Objectives To identify PCa prognostic factors to define prognostic groups in intermediate-risk patients treated with robot-assisted radical prostatectomy (RARP). Design Data from 1143 patients undergoing RARP from January 2013 to October 2020 were collected: 901 subjects had available follow-up, of whom 479 were at intermediate risk. Methods PCa progression was defined as biochemical recurrence and/or local recurrence and/or distant metastases. Study endpoints were evaluated by statistical methods including Cox's proportional hazards, Kaplan-Meyer survival curves, and binomial and multinomial logistic regression models. Results After a median (interquartile range) of 35 months (15-57 months), 84 patients (17.5%) had disease progression, which was independently predicted by the percentage of biopsy-positive cores ⩾ 50% and the International Society of Urological Pathology (ISUP) grade group 3 for clinical factors and by ISUP > 2, positive surgical margins and pelvic lymph node invasion for pathological features. Patients were classified into clinical and pathological groups as favorable, unfavorable (one prognostic factor), and adverse (more than one prognostic factor). The risk of PCa progression increased with worsening prognosis through groups. A significant positive association was found between the two groups; consequently, as clinical prognosis worsened, the risk of detecting unfavorable and adverse pathological prognostic clusters increased in both unadjusted and adjusted models. Conclusion The study identified factors predicting disease progression that allowed the computation of highly correlated prognostic groups. As the prognosis worsened, the risk of PCa progression increased. Intermediate-risk PCa needs more prognostic stratification for appropriate management.
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Affiliation(s)
- Antonio Benito Porcaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Piazzale Stefani 1, Verona 37126, Italy
| | - Alberto Bianchi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Sebastian Gallina
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Emanuele Serafin
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Rossella Orlando
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Giovanni Mazzucato
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Stefano Vidiri
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Damiano D’Aietti
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Francesca Montanaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Giulia Marafioti Patuzzo
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Francesco Artoni
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Alberto Baielli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Francesco Ditonno
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Riccardo Rizzetto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Alessandro Veccia
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Alessandra Gozzo
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Vincenzo De Marco
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Matteo Brunelli
- Department of Pathology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Maria Angela Cerruto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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Influence of Active Surveillance on Gleason Score Upgrade and Prognosis in Low- and Favorable Intermediate-Risk Prostate Cancer. Curr Oncol 2022; 29:7964-7978. [PMID: 36290907 PMCID: PMC9600547 DOI: 10.3390/curroncol29100630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 11/18/2022] Open
Abstract
Few studies have focused on the link between active surveillance (AS) and Gleason score upgrade (GSU) and its impact on the prognosis of patients with prostate cancer (PCa). This study aimed to analyze the effect of AS duration on GSU and prognostic value based on risk stratification. All eligible patients were risk-stratified according to AUA guidelines into low-risk (LR), favorable intermediate-risk (FIR), and unfavorable intermediate-risk (UIR) PCa. Within the Surveillance, Epidemiology, and End Results Program (SEER) database, 28,368 LR, 27,243 FIR, and 12,210 UIR PCa patients were included. The relationship between AS duration and GSU was identified with univariate and multivariate logistic regression. Discrimination according to risk stratification of AS duration and GSU was tested by Kaplan-Meier analysis and competing risk regression models. The proportion of patients who chose AS was the highest among LR PCa (3434, 12.1%), while the proportion in UIR PCa was the lowest (887, 7.3%). The AS duration was only associated with GSU in LR PCa, with a high Gleason score (GS) at diagnosis being a strong predictor of GSU for FIR and UIR PCa. Kaplan-Meier analysis indicated that long-term surveillance only made a significant difference in prognosis in UIR PCa. The competing risk analysis indicated that once GS was upgraded to 8 or above, the prognosis in each group was significantly worse. AS is recommended for LR and FIR PCa until GS is upgraded to 8, but AS may not be suitable for some UIR PCa patients.
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Definitions of "Cure" After Low-Dose-Rate Brachytherapy in Low- and Intermediate-Risk Prostate Cancer: Phoenix or Surgical? Adv Radiat Oncol 2022; 8:101112. [PMID: 36845613 PMCID: PMC9943771 DOI: 10.1016/j.adro.2022.101112] [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: 08/18/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose The aim of this study was to compare a surgical with a Phoenix-derived definition of cure at 4 years after treatment by 125J low-dose-rate brachytherapy (LDR-BT) in patients with low- and intermediate-risk prostate cancer. Methods and Materials A total of 427 evaluable men with low-risk (62.8%) and intermediate-risk (37.2%) prostate cancer were treated with LDR-BT (160 Gy). Cure was defined at 4 years either as not having experienced a biochemical recurrence by the Phoenix definition, or by a surgical definition, using a posttreatment prostate-specific antigen of ≤0.2 ng/mL. Biochemical recurrence-free survival (BRFS), metastasis-free survival (MFS), and cancer-specific survival were calculated at 5 and 10 years using the Kaplan-Meier method. Standard diagnostic test evaluations were used to compare both definitions with regard to later metastatic failure or cancer-specific death. Results At 48 months, 427 patients were evaluable with a Phoenix-defined and 327 with a surgical-defined cure. At 5 and 10 years BRFS was 97.4% and 89% and MFS was 99.5% and 96.3% in the Phoenix-defined cure cohort, and BRFS was 98.2% and 92.7% and MFS was 100% and 99.4% in the surgical-defined cure cohort. Specificity for cure was 100% for both definitions. Sensitivity was 97.4% for the Phoenix and 96.3% for the surgical definition. The positive predictive value was 100% for both, whereas the negative predictive value was 29% for the Phoenix and 7.7% for the surgical definition. Accuracies of a correct prediction of cure were 94.8% and 96.3% for the Phoenix and the surgical definition, respectively. Conclusions Both definitions are useful for a reliable assessment of cure after LDR-BT in patients with low-risk and intermediate-risk prostate cancer. Cured patients might follow a less stringent follow-up schedule from 4 years onward, whereas patients not achieving cure at 4 years should be monitored for an extended time.
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Russell JR, Siddiqui MM. Active surveillance in favorable intermediate risk prostate cancer: outstanding questions and controversies. Curr Opin Oncol 2022; 34:219-227. [PMID: 35266907 DOI: 10.1097/cco.0000000000000827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Active surveillance has become the preferred management strategy for patients with low risk prostate cancer, but it is unclear if active surveillance can be safely extended to favorable intermediate risk (FIR) prostate cancer patients. Furthermore, defining a favorable intermediate risk prostate cancer population safe for active surveillance remains elusive due to paucity of high-level data in this population. This article serves to review relevant data, particularly the safety of active surveillance in grade group 2 patients, and what tools are available to aid in selecting a favorable subset of intermediate risk patients. RECENT FINDINGS Active surveillance studies with long-term data appear to report worsened survival outcomes in intermediate risk patients when compared to those undergoing definitive treatment, but there exists a subset of intermediate risk patients with nearly equivalent outcomes to low risk patients on active surveillance. Tools such as percentage and total length of Gleason pattern 4, tumor volume, prostate specific antigen density, magnetic resonance imaging, and genomic modifiers may help to select a favorable subset of intermediate risk prostate cancer appropriate for active surveillance. SUMMARY Active surveillance is a viable strategy in select patients with low volume group grade 2 (GG2) prostate cancer. Prospective and retrospective data in the FIR population appear to be mostly favorable in regards to survival outcomes, but there exists some heterogeneity with respect to long-term outcomes in this patient population.
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Affiliation(s)
- J Ryan Russell
- Division of Urology, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
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Moretti K. Active surveillance for intermediate risk prostate cancer could be risky for the patient. World J Urol 2022; 40:1079-1080. [PMID: 34212236 DOI: 10.1007/s00345-021-03767-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/12/2021] [Indexed: 12/13/2022] Open
Affiliation(s)
- Kim Moretti
- Australian Centre for Precision Health, School of Health Sciences, Division of Health Sciences, University of South Australia, Adelaide, Australia.
- Faculty of Medicine Nursing and Health Sciences, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia.
- Discipline of Surgery, University of Adelaide, Adelaide, Australia.
- South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC), Adelaide, Australia.
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