Changes in Gleason score grading on serial follow-up biopsies in prostate cancer patients undergoing active surveillance

Transition from active surveillance to observation in prostate cancer patients older than 75 years. A long follow-up series

INTRODUCTION

The world population is ageing, and life expectancy is increasing. This situation will have a great impact on the management of patients with prostate cancer, especially in those of low risk, susceptible to a conservative management under active surveillance (AS). Regarding these patients' profile, it is necessary to answer the following questions: ¿for how long to continue with the AS scheme?, ¿which tests will be required?, ¿is it possible to carry out a transition to observation with oncological safety? The objective of this work is to analyse those patients with prostatic cancer who have been in AS with 75 years of age or more and assess the safety of the observation in an AS series with a long follow-up.

MATERIAL AND METHODS

We analysed our prospective cohort of AS patients between the years 1999 and 2018,including those who had been in follow-up with 75 years or more. They were offered treatment with curative intent when there were progression criteria and transition to observation under the urologist's decision. Some intermediate risk patients were included in the analysis. Comorbidity changes were analysed with the Charlson comorbidity index at entry and exit of AS. The progression and mortality of the patients were studied according to the management they received.

RESULTS

From 347 AS patients, 90 patients fulfilled the afore mentioned criteria and 15 (16.7%) were intermediate risk. The median follow-up was 6.4 years and 73 (81.1%) had low comorbidity (Charlson<2).There were 40 (44.4%) patients who left AS, 17 (18.9%) of them went to observationand the rest, 21 (23.3%), received curative treatment. There was a significant difference in comorbidity, measured by the Charlson index, at entry and exit of AS (P<.05) among patients receiving active treatment and the ones submitted to observation.No case of cancer-specific death or progression was observed in the observation group.

CONCLUSION

The transition from an active surveillance management to observation of prostate cancer elderly patients, as well as the decision to carry out a treatment with curative intent, seems controversial. In our series, this transition in patients older than 75 years does not increase the oncological risk.

Clinical performance of transperineal template guided mapping biopsy for therapeutic decision making in low risk prostate cancer

OBJECTIVES

To evaluate the role of Transperineal Template guided Mapping Biopsy (TTMB) in determining the management strategy in patients with low risk prostate cancer (PCa).

METHODS

We retroscpectively evaluated 169 patients who underwent TTMB at our institution from February 2008 to June 2011. Ninety eight of them harbored indolent PCa defined as: Prostate Specific Antigen<10ng/ml, Gleason score 6 or less, clinical stage T2a or less, unilateral disease and a maximum of one third positive cores at first biopsy and<50% of the core involved. TTMB results were analyzed for Gleason score upgrading and upstaging as compared to initial TransRectal UltraSound (TRUS) biopsies and its influence on the change in the treatment decisions.

RESULTS

TTMB detected cancer in 64 (65%) patients. The upgrade, upstage and both were noted in 33% (n=21), 12% (n=8) and 7% (n=5) respectively of the detected cancers. The disease characteristics was similar to initial TRUS in 30 (48%) patients and TTMB was negative in 34 (35%) patients. Prostate volume was significantly smaller in patients with upgrade and/or upstage noted at TTMB (45.4 vs 37.9; P=.03). TTMB results influenced 73.5% of upgraded and/or upstaged patients to receive radical treatment while 81% of the patients with unmodified stage and/or grade continued active surveillance or focal therapy.

CONCLUSIONS

In patients with low risk PCa diagnosed by TRUS, subsequent TTMB demonstrated cancer upgrade and/or upstage in about one-third of the patients and resulted in eventual change in treatment decision.