Risk-stratified survival rates and predictors of biochemical recurrence after radical prostatectomy in a Nara, Japan, cohort study

Predictive factors for short-term biochemical recurrence-free survival after robot-assisted laparoscopic radical prostatectomy in high-risk prostate cancer patients

BACKGROUND

We aimed to assess the short-term oncological outcomes of robot-assisted laparoscopic radical prostatectomy to determine the predictive factors associated with biochemical recurrence in high-risk prostate cancer patients.

METHODS

A total of 331 patients with localized prostate cancer underwent robot-assisted laparoscopic radical prostatectomy. Of them, 113 patients were diagnosed with high-risk prostate cancer according to the D'Amico risk group classification. We evaluated the association between pre- or postoperative predictive factors and biochemical recurrence using Cox regression analysis.

RESULTS

The 2-year biochemical recurrence-free survival rate was 65.0% in the high-risk group. On univariate analyses, PSA level > 20 ng/mL, Gleason pattern 5 component on biopsy, pathological stage T3 or higher, perineural invasion, and positive surgical margin were predictive factors for biochemical recurrence. On multivariate analysis, PSA level > 20 ng/mL, Gleason pattern 5 component on biopsy, perineural invasion, and positive surgical margin were identified as independent predictive factors. The 2-year biochemical recurrence-free survival rate was 36.5% for patients with PSA level > 20 ng/mL and/or Gleason pattern 5 component on biopsy.

CONCLUSIONS

PSA level > 20 ng/mL and/or presence of the Gleason pattern 5 component on biopsy are predictive factors for early biochemical recurrence after robot-assisted laparoscopic radical prostatectomy in high-risk prostate cancer patients. We considered that these patients require a combined modality therapy to improve their prognosis.

The impact of the definition of biochemical recurrence following salvage radiotherapy on outcomes and prognostication in patients with recurrent prostate cancer after radical prostatectomy: a comparative study of three definitions

Purpose

The clinical management and follow-up of patients with recurrent prostate cancer after salvage radiotherapy (SRT) has not yet been established, and no standardized definition of biochemical recurrence (BCR) after SRT exists. We compared the impact of applying three different definitions of BCR following SRT on patient outcomes and prognostication.

Subjects

Patients who received salvage androgen-deprivation therapy before the completion of SRT were excluded. The data of 118 men who had undergone salvage radiation as monotherapy for BCR after radical prostatectomy were reviewed. In all patients, SRT comprised irradiation to the prostatic bed (70 Gy) using three-dimensional conformal radiotherapy techniques. Treatment outcomes, including BCR-free survival and prognostic factors, were analyzed and compared among three definitions: The Nara, Radiation Therapy Oncology Group (RTOG) 9601, and GETUG-AFU 16 definitions.

Results

The BCR rate differed significantly among the applied definitions. Multivariate analyses identified the same four independent prognostic factors, including primary Gleason pattern 4 or 5, negative resection margin, prostate-specific antigen (PSA) level before SRT 0.5 or more, and PSA doubling time before SRT <6 months, using the RTOG 9601 and GETUG-AFU 16 definitions, whereas only two of the four factors were identified using the Nara definition. Although the results obtained using the RTOG 9601 and GETUG-AFU 16 definitions were similar, the prognostic value of the four factors differed. According to the RTOG 9601 definition of BCR, a negative resection margin on prostatectomy specimens and short PSA doubling time before SRT were associated with no subsequent response in PSA level.

Conclusions

The applied definition of BCR after SRT can influence the reported BCR-free rate and the potential prognostic factors. Establishment of the standardized definition is needed for the optimal management of patients with recurrent prostate cancer undergoing SRT.

Perineural Invasion and Risk of Lethal Prostate Cancer

Background: Prostate cancer has a propensity to invade and grow along nerves, a phenomenon called perineural invasion (PNI). Recent studies suggest that the presence of PNI in prostate cancer has been associated with cancer aggressiveness.Methods: We investigated the association between PNI and lethal prostate cancer in untreated and treated prostate cancer cohorts: the Swedish Watchful Waiting Cohort of 615 men who underwent watchful waiting, and the U.S. Health Professionals Follow-Up Study of 849 men treated with radical prostatectomy. One pathologist performed a standardized histopathologic review assessing PNI and Gleason grade. Patients were followed from diagnosis until metastasis or death.Results: The prevalence of PNI was 7% and 44% in the untreated and treated cohorts, respectively. PNI was more common in high Gleason grade tumors in both cohorts. PNI was associated with enhanced tumor angiogenesis, but not tumor proliferation or apoptosis. In the Swedish study, PNI was associated with lethal prostate cancer [OR 7.4; 95% confidence interval (CI), 3.6-16.6; P < 0.001]. A positive, although not statistically significant, association persisted after adjustment for age, Gleason grade, and tumor volume (OR 1.9; 95% CI, 0.8-5.1; P = 0.17). In the U.S. study, PNI predicted lethal prostate cancer independent of clinical factors (HR 1.8; 95% CI, 1.0, 3.3; P =0.04).Conclusions: These data support the hypothesis that perineural invasion creates a microenvironment that promotes cancer aggressiveness.Impact: Our findings suggest that PNI should be a standardized component of histopathologic review, and highlights a mechanism underlying prostate cancer metastasis. Cancer Epidemiol Biomarkers Prev; 26(5); 719-26. ©2017 AACR.

Importance of neutrophil/lymphocyte ratio in prediction of PSA recurrence after radical prostatectomy

BACKGROUND

The aim of this study was to research the importance of the neutrophil to lymphocyte ratio (NLR) in prediction of PSA recurrence after radical prostatectomy, which has not been reported so far.

MATERIALS AND METHODS

The data of 175 patients who were diagnosed with localised prostate cancer and underwent retropubic radical prostatectomy was retrospectively examined. Patient pre-operative hemogram parameters of neutrophil count, lymphocyte count and NLR were assessed. The patients whose PSAs were too low to measure after radical prostatectomy in their follow-ups, and then had PSAs of 0,2 ng/mL were considered as patients with PSA recurrence. Patients with recurrence made up Group A and patients without recurrence made up Group B.

RESULTS

In terms of the power of NLR value in distinguishing recurrence, the area under OCC was statistically significant (p<0.001) .The value of 2.494 for NLR was found to be a cut-off value which can be used in order to distinguish recurrence according to Youden index. According to this, patients with a higher NLR value than 2.494 had higher rates of PSA recurrence with 89.7% sensitivity and 92.6% specificity.

CONCLUSIONS

There are certain parameters used in order to predict recurrence with today's literature data.We think that because NLR is easy to use in clinics and inexpensive, and also has high sensitivity and specificity values, it has the potential to be one of the parameters used in order to predict biochemical recurrence in future.

Significance of preoperative butyrylcholinesterase as an independent predictor of biochemical recurrence-free survival in patients with prostate cancer treated with radical prostatectomy

BACKGROUND

Butyrylcholinesterase (BChE) is an alpha-glycoprotein found in the nervous system and liver. Its serum level is reduced in many clinical conditions, such as liver damage, inflammation, injury, infection, malnutrition, and malignant disease. In this study, we analyzed the potential prognostic significance of preoperative BChE levels in patients with prostate cancer (PCa) undergoing radical prostatectomy (RP).

METHODS

We retrospectively evaluated 535 patients with PCa who underwent RP from 1996-2014 at a single institution. Serum BChE was routinely measured in all patients before operation. Covariates included age, preoperative laboratory data [prostate-specific antigen (PSA), hemoglobin, total protein, albumin, BChE, lactate dehydrogenase, C-reactive protein], clinical T, biopsy Gleason score, D'Amico risk classification, and RP with/without neoadjuvant therapy. Univariate and multivariate analyses were performed to identify clinical factors associated with biochemical recurrence-free survival (BRFS). Univariate analyses were performed using the Kaplan-Meier and log-rank methods, and multivariate analysis was performed using a Cox proportional hazard model.

RESULTS

The median BChE level was 255 U/L (normal range 168-470 U/L). The median age of the enrolled patients was 68 years, and the median PSA level at diagnosis of PCa was 8.39 ng/mL. The median follow-up period was 65 months. The 5-year BRFS rate was 72.9 %. The 5-year BRFS rates in the BChE ≥ 168 and ≤ 167 U/L groups were 77.7 and 55.0 %, respectively (P < 0.001). In univariate analysis, BChE, cT, biopsy Gleason score, and D'Amico risk classification were significantly associated with BRFS. Multivariate analysis revealed that BChE was significantly associated with BRFS.

CONCLUSIONS

This study validated preoperative serum BChE levels as an independent prognostic factor for PCa after RP.

Review by urological pathologists improves the accuracy of Gleason grading by general pathologists

Backgrounds

Urologists use biopsy Gleason scores for patient counseling, prognosis prediction, and decision making. The accuracy of Gleason grading is very important. However, the variability of Gleason grading between general pathologists cannot be overlooked. Here we evaluate the discrepancy in the Gleason grading between 2 urologic pathologists and general pathologists as well as improvement in the accuracy of Gleason grading by general pathologists as a result of review by urologic pathologists.

Methods

The subjects enrolled in the study were 755 patients who underwent prostate needle biopsy at affiliate hospitals of Nara Medical University over a period of 2 years. The biopsy samples were diagnosed by general pathologists. All biopsy samples were sent to Nara Medical University where they were diagnosed by 2 urologic pathologists. The results were then returned to the general pathologists. We compared the diagnostic accuracy of the general pathologists with that of the urologic pathologists for the parameters of no malignancy, atypical small acinar proliferation, high grade prostatic intraepithelial neoplasia and Gleason score (6, 3 + 4, 4 + 3 and 8–10). We then evaluated the concordance rate between the general and urologic pathologists for each of four consecutive 6-month periods.

Results

The overall concordance rate of urologic pathologists and general pathologists in the first, second, third and last 6-month periods was 71.8 % (140/198), 79.8 % (168/225), 89.7 % (166/185) and 89.9 % (133/148), respectively. The concordance rate of the Gleason score between urologic pathologists and general pathologists in the first, second, third and last 6-month periods was 47.5 %(38/80), 62.6 %(57/91),76.9 %(50/65) and 78.7 %(48/61), respectively, and the kappa value was 0.55, 0.68, 0.81 and 0.84, respectively. The concordance rate improved significantly over the course of each period (P = 0.04).

Conclusion

The concordance rate of the Gleason grading between the general pathologists and the urologic pathologists was 47.5 %. However, improvement of the concordance rate as a result of review by the urological pathologist could be seen.

Risk factors of PSA progression and overall survival in patients with localized and locally advanced prostate cancer treated with primary androgen deprivation therapy

BACKGROUND

Primary androgen deprivation therapy (PADT) has played an important role in the treatment of prostate cancer. We sought to identify factors of PSA progression in our series of patients with localized and locally advanced prostate cancer treated with PADT.

METHODS

Six-hundred forty-nine patients with localized and locally advanced prostate cancer who received PADT from 1998 to 2005 by Nara Uro-Oncology Research Group were enrolled. Age, T classification, stage, PSA level at diagnosis, Gleason score, laterality of cancer detected by biopsy and seminal vesicle involvement (SVI) were adopted as parameters of PSA progression. Cox's proportional hazards model was used to determine the predictive factors for PSA progression.

RESULTS

The median follow-up period and the median PSA level at diagnosis were 49 months and 15 ng/mL. The 5-year disease specific survival rate, overall survival rate and PSA progression-free survival (PFS) rate were 97.9 %, 91.9 % and 71.2 %, respectively. The univariate analysis showed that the PSA level at diagnosis, Gleason score, laterality of cancer detected by biopsy and SVI were independent predictive parameters of PSA-PFS. However, by multivariate analysis, only laterality of cancer detected by biopsy (unilateral vs. bilateral) was an independent predictive parameter of PSA-PFS (p = 0.034). The patients were classified into new risk groups base on three factors: PSA level at diagnosis, Gleason score, and laterality of cancer detected by biopsy. The PSA-PFS rates at 5-years in the low- (none or one factor), intermediate- (two factors) and high-risk (three factors) groups were 78.2 %, 62.5 % and 46.9 % (p < 0.001), respectively.

CONCLUSION

In localized or locally advanced prostate cancer patients who received PADT, laterality of cancer detected by biopsy was a significant predictor associated with a longer PSA-PFS. Our new risk grouping indicates the usefulness of PSA-PFS.

Factors effective on survival after radical prostatectomy: To what extent is pre-operative biopsy Gleason scoring is confident in predicting the prognosis?

In the present study, the effect of different grades on independent survival from the biochemical relapse was investigated through comparison of the histological grades of the biopsy and prostatectomy materials in patients undergoing radical prostatectomy (RP). A total of 152 patients undergoing RP following biopsy were retrospectively investigated in an attempt to reveal the effect of discordance between needle biopsy Gleason score and RP Gleason score on prostate specific antigen relapse-free survival. Accordingly, while 58.3% (14/24) survival was seen in the patients in Group 1 (high-graded) with Gleason score 7, 93.7% (15/16) survival has been seen in the patients in Group 2 (low-graded) and Group 3 (same Gleason scores) with Gleason score 7. The difference in-between has been statically found significant (P < 0.001). Similarly, while a 10% (1/10) survival is seen in the patients in Group 1 with Gleason score 8 and above, 75% (3/4) survival has been observed in the patients in Group 2 and 3 with Gleason score 8 and above. Also in this comparison, the difference in-between has been statically found significant (P = 0.041). Eventually, different grading, particularly determination of Gleason score higher than the RP specimen biopsy also bring about bad pathologic parameters and shortened survival periods.

Prediction of biochemical recurrence after robot-assisted radical prostatectomy: analysis of 784 Japanese patients

OBJECTIVES

To examine biochemical recurrence after robot-assisted radical prostatectomy in Japanese patients, and to develop a risk stratification model for biochemical recurrence.

METHODS

The study cohort consisted of 784 patients with localized prostate cancer who underwent robot-assisted radical prostatectomy without neoadjuvant or adjuvant endocrine therapy. The relationships of biochemical recurrence with perioperative findings were evaluated. The prognostic factors for biochemical recurrence-free survival were evaluated using Cox proportional hazard model analyses.

RESULTS

During the follow-up period, 80 patients showed biochemical recurrence. The biochemical recurrence-free survival rates at 1, 3, and 5 years were 92.2%, 85.2% and 80.1%, respectively. In univariate analysis, the prostate-specific antigen level, prostate-specific antigen density, biopsy Gleason score, percent positive core, pathological T stage, pathological Gleason score, lymphovascular invasion, perineural invasion and positive surgical margin were significantly associated with biochemical recurrence. In multivariate analysis, prostate-specific antigen density ≥0.4 (P = 0.0011), pathological T stage ≥3a (P = 0.002), pathological Gleason score ≥8 (P = 0.007) and positive surgical margin (P < 0.0001) were independent predictors of biochemical recurrence. The patients were stratified into three risk groups according to these factors. The 5-year biochemical recurrence-free survival rate was 89.4% in the low-risk group, 65.6% in the intermediate-risk group and 30.3% in the high-risk group.

CONCLUSIONS

The prostate-specific antigen density, pathological T stage, pathological Gleason score and positive surgical margin were independent prognostic factors for biochemical recurrence. The risk stratification model developed using these four factors could help clinicians identify patients with a poor prognosis who might be good candidates for clinical trials of alternative management strategies.

Proposed salvage treatment strategy for biochemical failure after radical prostatectomy in patients with prostate cancer: a retrospective study

BACKGROUND

Treatment options for patients with recurrent disease after radical prostatectomy include salvage radiotherapy of the prostatic bed and/or androgen deprivation therapy. To establish an effective treatment strategy for recurrent disease after radical prostatectomy, we retrospectively analyzed the outcome of salvage radiation monotherapy in such cases.

METHODS

Data from 61 men who had undergone salvage radiation monotherapy for biochemical recurrent disease after radical prostatectomy were retrospectively reviewed. In all patients, salvage radiotherapy consisted of iraradiation to the prostatic bed (70 Gy) using three-dimensional conformal radiotherapy techniques. Treatment outcome was analyzed to identify predictive factors of salvage radiotherapy.

RESULTS

The biochemical recurrence-free survival after salvage radiation monotherapy at 2 and 5 years was 55% and 38%, respectively. Cox proportional regression models revealed that the independent predictive factors for biochemical recurrence were Gleason Score ≥ 8, negative surgical margin, and PSA velocity ≥ 0.38 ng/mL/year. Negative surgical margin and PSA velocity ≥ 0.8 ng/mL/year were significantly associated with poor response in the serum PSA levels after salvage radiotherapy.

CONCLUSIONS

Based on our findings, we propose a treatment strategy for biochemical recurrent disease after radical prostatectomy. Patients with Gleason score ≤ 7, positive surgical margin, and PSA velocity < 0.38 ng/mL/year are categorized the most favorable group, so that eradication by salvage radiation monotherapy could be expected. Other patients could be divided to two groups depending on surgical margin status and PSA velocity: 1) patients who might require combination of SRT and short-term androgen deprivation therapy and 2) patients who should be treated by androgen deprivation monotherapy.

Efficiency of pretreatment risk stratification systems for prostate cancer in a Japanese population treated with radical prostatectomy

OBJECTIVE

To determine whether the currently available pretreatment risk classification systems are applicable in Japanese prostate cancer patients.

METHODS

Using data obtained from 1264 consecutive patients with prostate cancer treated with radical prostatectomy at four hospitals in Japan, biochemical recurrence-free survival rates were estimated and compared between the D'Amico, the National Institute for Health and Clinical Excellence, the Cancer of the Prostate Strategic Urological Research Endeavor, the National Comprehensive Cancer Network, and the European Society of Medical Oncology risk groups by using the Kaplan-Meier method and log-rank test.

RESULTS

The 5-year biochemical recurrence-free survival rates in the D'Amico low-, intermediate-, and high-risk groups were 88.3%, 84.7% and 66.9%, respectively (low and intermediate risk vs high risk, P < 0.001). The 5-year biochemical recurrence-free survival rates in the National Institute for Health and Clinical Excellence, National Comprehensive Cancer Network, and European Society of Medical Oncology low-, intermediate- and high-risk groups were 88.3%, 84.3%, and 60.3%, respectively (low and intermediate risk vs high risk, P < 0.001). The 5-year biochemical recurrence-free survival rates in the Cancer of the Prostate Strategic Urological Research Endeavor low-, intermediate-, and high-risk groups were 90%, 83.5% and 60.3%, respectively (low and intermediate risk vs high risk, P < 0.001). Low- and intermediate-risk groups according to any of the risk stratification systems did not show significant differences in biochemical recurrence-free survival.

CONCLUSION

Current risk stratification systems do not discriminate between low- and intermediate-risk groups in the Japanese population. A novel, pretreatment risk stratification system including other prognostic factors is necessary for an adequate prostate cancer risk assessment in the Japanese population.

Disease-specific outcomes of radical prostatectomies in Northern Norway; a case for the impact of perineural infiltration and postoperative PSA-doubling time

Background

Prostate cancer is the most common male malignancy and a mayor cause of mortality in the western world. The impact of clinicopathological variables on disease related outcomes have mainly been reported from a few large US series, most of them not reporting on perineural infiltration. We therefore wanted to investigate relevant cancer outcomes in patients undergoing radical prostatectomy in two Norwegian health regions with an emphasis on the impact of perineural infiltration (PNI) and prostate specific antigen- doubling time (PSA-DT).

Methods

We conducted a retrospective analysis of 535 prostatectomy patients at three hospitals between 1995 and 2005 estimating biochemical failure- (BFFS), clinical failure- (CFFS) and prostate cancer death-free survival (PCDFS) with the Kaplan-Meier method. We investigated clinicopathological factors influencing risk of events using cox proportional hazard regression.

Results

After a median follow-up of 89 months, 170 patients (32%) experienced biochemical failure (BF), 36 (7%) experienced clinical failure and 15 (3%) had died of prostate cancer. pT-Stage (p = 0.001), preoperative PSA (p = 0.047), Gleason Score (p = 0.032), non-apical positive surgical margins (PSM) (p = 0.003) and apical PSM (p = 0.031) were all independently associated to BFFS. Gleason score (p = 0.019), PNI (p = 0.012) and non-apical PSM (p = 0.002) were all independently associated to CFFS while only PNI (P = 0.047) and subgroups of Gleason score were independently associated to PCDFS. After BF, patients with a shorter PSA-DT had independent and significant worse event-free survivals than patients with PSA-DT > 15 months (PSA-DT = 3-9 months, CFFS HR = 6.44, p < 0.001, PCDFS HR = 13.7, p = 0.020; PSA-DT < 3 months, CFFS HR = 11.2, p < 0.001, PCDFS HR = 27.5, p = 0.006).

Conclusions

After prostatectomy, CFFS and PCDFS are variable, but both are strongly associated to Gleason score and PNI. In patients with BF, PSA-DT was most strongly associated to CF and PCD. Our study adds weight to the importance of PSA-DT and re-launches PNI as a strong prognosticator for clinically relevant endpoints.

How to select the optimal therapy for early-stage prostate cancer

Selecting the "optimal therapy" for the patient with localized prostate cancer may be one of the most challenging medical decisions facing the oncologist. Most patients will have a number of appropriate therapeutic options available to them. Before determining which therapy is most appropriate for a patient, a critical question which needs to be asked is whether any therapy is necessary, especially for those who present with early-stage, low-grade, low-volume disease. Furthermore, given the lack of randomized trials available to guide physicians regarding the superiority of one therapy over another, it is important to consider the different side-effect profiles relevant for each treatment modality. The potential toxicities of therapy impact quality-of-life outcomes and play an important role for most patients in their individual selection of a particular therapy. In addition, there are other important issues that need to be considered, which include the medical condition of the patient and emotional and psychological considerations, as well as family/peer viewpoints or perceived notions of a particular therapy. This review will discuss the relevant issues in the decision making and treatment selection for the patient.

Significance of neoadjuvant hormonal therapy in radical retropubic prostatectomy: a retrospective single-surgeon study

PURPOSE

The purpose of this study was to evaluate whether neo-adjuvant hormonal therapy (NHT) prior to radical retropubic prostatectomy (RRP) for prostate cancer (PCa) is beneficial in terms of surgical outcomes and for preventing or delaying biochemical recurrence via single-surgeon case series study.

MATERIALS AND METHODS

Fifty-three men underwent RRP by a single surgeon. The patients were divided into two groups according to whether or not NHT was performed prior to RRP. The study was analyzed retrospectively. We evaluated clinical parameters, surgical parameters, and biochemical recurrence rate. Group 1 (n=34) was treated with RRP only, while Group 2 (n=19) underwent RRP along with NHT.

RESULTS

There were no significant differences in clinical, operation-related and pathological factors between the two groups (p>0.05). There was also no significant difference in biochemical recurrence rate between the two groups at the last follow-up, although Group 2 tended to have a lower PCa recurrence rate than Group 1 and the initial prostate-specific antigen (PSA) level was significantly higher in Group 2 than Group 1 (p=0.0496).

CONCLUSION

The present single-surgeon case series study revealed a trend toward a lower rate of PCa recurrence in NHT+RRP treated patients compared to those treated with RRP alone, but this did not reach statistical significance, despite the fact that NHT+RRP patients exhibited higher serum PSA levels preoperatively. Prospective studies with a longer duration of observation and a greater number of patients would be helpful in evaluating NHT more definitively.