EAU guidelines on prostate cancer

Global research trends on the links between prostate cancer and erectile dysfunction between 2003 and 2023: A bibliometrics and visualized study

Background

The incidence of prostate cancer (PC) has increased in recent years. Erectile dysfunction (ED) after prostate cancer treatment has aroused extensive attention. Bibliometric analysis was designed to investigate a systematic understanding of developments between PC and ED during the past 20 years.

Methods

Literatures on PC and ED were retrieved from the Web of Science Core Collection database (WoSCC). By using the VOS viewer and CiteSpace software to analysis the metrics of bibliometric literature, such as number of articles, journals, countries, institutions, authors, keywords and associated information. The number of publications per year was statistically analysed and plotted thorough Microsoft Office. In addition, Pajek software was used to adjust the visual map.

Results

A total of 2332 screened articles were included in the analysis. The Journal of Sexual Medicine, ranking first among the analysed journals, published 235 articles. The United States and Canada were leaders in PC and ED research. There is a need to strengthen inter-agency cooperation in this area of research on a global scale. Mulhall JP, as the most prolific author in this area of research, published 80 articles. And Rosen RC was the author with the most co-citated (693 co-citated). The main research focus on the prevention, treatment and management of ED after PC treatment in this field through the keyword analysis.

Conclusions

Research on PC and ED is expected to expand further worldwide. We found ED, as new sustainable treatment modalities, scientific postoperative management and psychological interventions for patients, may become the research hotspots and should be closely concerned in this study.

Treatment prediction with machine learning in prostate cancer patients

There are various treatment modalities for prostate cancer, which has a high incidence. In this study, it is aimed to make predictions with machine learning in order to determine the optimal treatment option for prostate cancer patients. The study included 88 male patients diagnosed with prostate cancer. Independent variables were determined as Gleason scores, biopsy, PSA, SUVmax, and age. Prostate cancer treatments, which are dependent variables, were determined as hormone therapy(n = 30), radiotherapy(n = 28) and radiotherapy + hormone therapy(n = 30). Machine learning was carried out in the Python with SVM, RF, DT, ETC and XGBoost. Metrics such as accuracy, ROC curve, and AUC were used to evaluate the performance of multi-class predictions. The model with the highest number of successful predictions was the XGBoost. False negative rates for hormone therapy, radiotherapy, and radiotherapy + hormone therapy treatments were, respectively, 12.5, 33.3, and 0%. The accuracy values were computed as 0.61, 0.83, 0.83, 0.72 and 0.89 for SVM, RF, DT, ETC and XGBoost, respectively. The three features that had the greatest influence on the treatment model prediction for prostate cancer with XGBoost were biopsy, Gleason score (3 + 3), and PSA level, respectively. According to the AUC, ROC and accuracy, it was determined that the XGBoost was the model that made the best estimation of prostate cancer treatment. Among the variables biopsy, Gleason score, and PSA level are identified as key variables in prediction of treatment.

LDR-Brachytherapy monotherapy appears unsuited for NCCN unfavorable intermediate-risk prostate cancer patients

BACKGROUND

To validate the subdivision of intermediate-risk (IR) prostate cancer (PCa) into favorable intermediate-risk (FIR) and unfavorable intermediate-risk (UIR) PCa in a historical patient cohort and to compare 2 different radiotherapy regimens.

METHODS

Patients with intermediate-risk (IR) PCa, treated either by 125J-LDR-brachytherapy monotherapy (BT) or by combined-modality radiation therapy (CRT), were retrospectively subclassified into FIR and UIR and reanalyzed with regard to biochemical recurrence-free survival (BRFS), metastasis-free survival (MFS), and prostate cancer-specific survival (CSS). Kaplan-Meier product-limit method and log-rank tests were applied to estimate survival probabilities and compare survival, respectively. Uni- and multivariable analyses were performed using Cox proportional hazard regression.

RESULTS

Of 490 IR patients, 252 had received BT (86.5% FIR, 13.5% UIR), and 238 had received CRT (30% FIR, 70% UIR). Retrospective analysis revealed that BRFS at 10 years was 81% for BT, and 94% for CRT in FIR patients. For UIR patients, BRFS at 10 years was 37% for BT, and 89% for CRT. MFS at 10 years for FIR patients was 87% for BT, and 94% for CRT. For UIR patients MFS at 10 years was 78% for BT, and 95% for CRT. In multivariable analysis treatment (BT vs. CRT) was the single associated factor for biochemical recurrence, and for metastases in the UIR group (BFRS, P < 0.001, HR 16.07 (CI 4.23-61.10); MFS, P = 0.011, HR 8.43 (CI 1.62-43.9).

CONCLUSIONS

Subclassification of IR prostate cancer into FIR and UIR subcategories appears mandatory. For FIR patients, outcomes after BT monotherapy were acceptable. However, clinical failure after 125J-LDR-BT in UIR patients was notably increased, suggesting that BT monotherapy was less successful in this risk group. In contrast, the outcome in UIR patients after CRT was excellent.

Expanding the role of PSMA PET in active surveillance

INTRODUCTION

Accurate grading at the time of diagnosis is fundamental to risk stratification and treatment decision making, particularly for men being considered for Active Surveillance (AS). With the introduction of prostate-specific membrane antigen (PSMA) positron emission tomography (PET) there has been considerable improvement in sensitivity and specificity for the detection and staging of clinically significant prostate cancer. Our study aims to determine the role of PSMA PET/CT in men with newly diagnosed low or favourable intermediate risk prostate cancer to better select men for AS.

METHOD

This is a retrospective single centre study performed from January 2019 and October 2022. This study includes men identified from electronic medical record system who had undergone a PSMA PET/CT following newly diagnosed low or favourable-intermediate risk prostate cancer. Primary outcome was to assess the change in management for men being considered for AS following PSMA PET/CT results on the basis of PSMA PET characteristics.

RESULTS

In total, there were 11 of 30 men (36.67%) who were assigned management by AS and 19 of 30 men (63.33%) who had definitive treatment. 15 of the 19 men that needed treatment had concerning features on PSMA PET/CT results. Of the 15 men with concerning features on PSMA PET, 9 (60%) men were found to have adverse pathological features on final prostatectomy features.

CONCLUSION

This retrospective study suggests that PSMA PET/CT has potential to influence the management of men with newly diagnosed prostate cancer that would otherwise be appropriate for active surveillance.

Role of serum cathelicidin in diagnosis of patient with prostatitis and prostate carcinoma

Background

This study investigated the diagnostic role of 75 levels measured in serum prostatitis and prostate carcinoma and in the differentiation of these two conditions.

Methods

The study was conducted with 75 patients histopathologically diagnosed with prostate carcinoma or prostatitis and followed up at the Departments of Urology and Medical Oncology and 21 healthy male subjects. Serum cathelicidin levels were investigated using the ELISA method. Statistical analyses were performed using the SPSS for Windows 22.0 package software. Compliance of the variables to normal distribution was examined using visual and analytic methods. In the Kolmogorov–Smirnov test, cases with a p value of greater than 0.05 were accepted as normal distribution.

Results

A total of 75 patients including 45 diagnosed with prostate carcinoma and 30 diagnosed with prostatitis, as well as 21 healthy control subjects were included in the study. Prostate-specific antigen (PSA) was detected as 23 (4–1200) ng/mL in the patients with prostate carcinoma and as 9.85 (3.9–405 ng/mL) in the patients with prostatitis. The cathelicidin levels were diagnostically significant when assessed by ROC analysis in the prostate cancer, prostatitis and control groups (p = 0.005). The cutoff values derived from the ROC curve analysis were 3.5151 ng/mL for distinguishing prostate cancer from prostatitis, 2.2620 ng/mL for prostate cancer versus control group and 1.2340 ng/mL for prostatitis versus control group.

Conclusions

In this study we showed that the serum cathelicidin levels were significantly higher in the patients diagnosed with prostate carcinoma. Measurement of serum cathelicidin levels could be used as a diagnostic marker in prostate carcinoma as well as facilitating differential diagnosis to strengthen the diagnostic suspicion before prostate biopsy and distinguish the diagnosis from prostatitis cases.

High Throughput Isolation and Data Independent Acquisition Mass Spectrometry (DIA-MS) of Urinary Extracellular Vesicles to Improve Prostate Cancer Diagnosis

Proteomic profiling of extracellular vesicles (EVs) represents a promising approach for early detection and therapeutic monitoring of diseases such as cancer. The focus of this study was to apply robust EV isolation and subsequent data-independent acquisition mass spectrometry (DIA-MS) for urinary EV proteomics of prostate cancer and prostate inflammation patients. Urinary EVs were isolated by functionalized magnetic beads through chemical affinity on an automatic station, and EV proteins were analyzed by integrating three library-base analyses (Direct-DIA, GPF-DIA, and Fractionated DDA-base DIA) to improve the coverage and quantitation. We assessed the levels of urinary EV-associated proteins based on 40 samples consisting of 20 cases and 20 controls, where 18 EV proteins were identified to be differentiated in prostate cancer outcome, of which three (i.e., SERPINA3, LRG1, and SCGB3A1) were shown to be consistently upregulated. We also observed 6 out of the 18 (33%) EV proteins that had been developed as drug targets, while some of them showed protein-protein interactions. Moreover, the potential mechanistic pathways of 18 significantly different EV proteins were enriched in metabolic, immune, and inflammatory activities. These results showed consistency in an independent cohort with 20 participants. Using a random forest algorithm for classification assessment, including the identified EV proteins, we found that SERPINA3, LRG1, or SCGB3A1 add predictable value in addition to age, prostate size, body mass index (BMI), and prostate-specific antigen (PSA). In summary, the current study demonstrates a translational workflow to identify EV proteins as molecular markers to improve the clinical diagnosis of prostate cancer.

Definitions of "Cure" After Low-Dose-Rate Brachytherapy in Low- and Intermediate-Risk Prostate Cancer: Phoenix or Surgical?

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.

The Comprehensive Analysis of Hub Gene ARRB2 in Prostate Cancer

Methods

The differential expressed genes (DEGs) were screened from the gene expression profile GSE30994 related to PRAD and then analyzed by protein-protein interaction (PPI) to screen the hub gene. Subsequently, the relation between hub gene and pan cancers, PRAD prognosis, and immunotherapy was analyzed. Besides, the effects of hub gene on the growth and metastasis of PRAD cell lines and inflammatory factors (IFs) were detected by functional experiments.

Results

276 upregulated and 1,861 downregulated DEGs were analyzed from GSE30994 gene expression profiles. Through enrichment analysis, it was found that upregulated DEGs were significantly enriched in nitric oxide-mediated signal transduction, insulin signaling pathway, etc. Through PPI networks, ARRB2 was determined as the hub gene that was highly expressed in pan cancers, including PRAD, and contributed to poor prognosis of PRAD patients. Immunoassay showed that ARRB2 was associated with B cells, NK cells, endothelial cells, etc. and also connected with tumor-infiltrating lymphocytes (TILs). Next, the signature model analysis revealed that ARRB2 had a clinical value in predicting PRAD prognosis. In functional experiments, ARRB2 was highly expressed in PRAD cell lines, promoted PRAD cell growth and metastasis, and positively associated with IFs.

Conclusion

ARRB2 has a good prognostic ability in PRAD, and it could be a potential target of PRAD immunotherapy, which offers new directions for PRAD research.

The role of MRI in prostate cancer: current and future directions

There has been an increasing role of magnetic resonance imaging (MRI) in the management of prostate cancer. MRI already plays an essential role in the detection and staging, with the introduction of functional MRI sequences. Recent advancements in radiomics and artificial intelligence are being tested to potentially improve detection, assessment of aggressiveness, and provide usefulness as a prognostic marker. MRI can improve pretreatment risk stratification and therefore selection of and follow-up of patients for active surveillance. MRI can also assist in guiding targeted biopsy, treatment planning and follow-up after treatment to assess local recurrence. MRI has gained importance in the evaluation of metastatic disease with emerging technology including whole-body MRI and integrated positron emission tomography/MRI, allowing for not only better detection but also quantification. The main goal of this article is to review the most recent advances on MRI in prostate cancer and provide insights into its potential clinical roles from the radiologist's perspective. In each of the sections, specific roles of MRI tailored to each clinical setting are discussed along with its strengths and weakness including already established material related to MRI and the introduction of recent advancements on MRI.

Artificial Intelligence-Based Prognostic Model for Urologic Cancers: A SEER-Based Study

Simple Summary

We describe a risk profile reconstruction model for cancer-specific survival estimation for continuous time points after urologic cancer diagnosis. We used artificial intelligence (AI)-based algorithms, a national cancer registry data, and accessible clinical parameters for the risk-profile reconstruction. We derived a risk stratification model and estimated the minimum follow-up duration and the likelihood for risk stability in prostate, kidney, and testicular cancers. The estimated follow-up duration was in alignment with recognized clinical guidelines for these cancers. Moreover, the estimated follow-up duration was differed by the cancer origin and the disease dissemination status. Overall, the reconstruction of the population’s risk profile for the cancer-specific prognostic score estimation is feasible using AI and has potential application in clinical settings to improve risk stratification and surveillance management.

Abstract

Background: Prognostication is essential to determine the risk profile of patients with urologic cancers. Methods: We utilized the SEER national cancer registry database with approximately 2 million patients diagnosed with urologic cancers (penile, testicular, prostate, bladder, ureter, and kidney). The cohort was randomly divided into the development set (90%) and the out-held test set (10%). Modeling algorithms and clinically relevant parameters were utilized for cancer-specific mortality prognosis. The model fitness for the survival estimation was assessed using the differences between the predicted and observed Kaplan–Meier estimates on the out-held test set. The overall concordance index (c-index) score estimated the discriminative accuracy of the survival model on the test set. A simulation study assessed the estimated minimum follow-up duration and time points with the risk stability. Results: We achieved a well-calibrated prognostic model with an overall c-index score of 0.800 (95% CI: 0.795–0.805) on the representative out-held test set. The simulation study revealed that the suggestions for the follow-up duration covered the minimum duration and differed by the tumor dissemination stages and affected organs. Time points with a high likelihood for risk stability were identifiable. Conclusions: A personalized temporal survival estimation is feasible using artificial intelligence and has potential application in clinical settings, including surveillance management.

Adjuvant or Salvage Radiation Therapy for Prostate Cancer after Prostatectomy: Current Status, Controversies and Perspectives

Simple Summary

The management of patients with biochemical recurrence after prostatectomy has undergone significant changes in recent years. Currently, close monitoring of prostate-specific antigen (PSA) with early salvage radiotherapy (RT) in case of recurrence is the standard of care based on several randomized trials and a meta-analysis that has demonstrated its non-inferiority to adjuvant RT. Uncertainties remain regarding the management of patients at very high risk of recurrence, including appropriate selection criteria for adjuvant hormone therapy, and the role of imaging in refining the treatment strategy. This review explains this paradigm shift, raises points of controversy, and suggests ways to think about the future.

Abstract

Nearly one-third of the patients who undergo prostatectomy for prostate cancer have a biochemical recurrence (BCR) during follow-up. While several randomized trials have shown that adjuvant radiation therapy (aRT) improves biochemical control, this strategy has not been widely used because of the risk of toxicity and the fear of overtreating patients who would not have relapsed. In addition, the possibility of close PSA monitoring in the era of ultrasensitive assays enables to anticipate early salvage strategies (sRT). Three recent randomized trials and their meta-analysis have confirmed that aRT does not improve event-free survival compared to sRT, imposing the latter as the new standard of treatment. The addition of androgen deprivation therapy (ADT) to RT has been shown to improve biochemical control and metastasis-free survival, but the precise definition of to whom it should be proposed is still a matter of debate. The development of genomic tests or the use of artificial intelligence will allow more individualized treatment in the future. Therapeutic intensification with the combination of new-generation hormone therapy and RT is under study. Finally, the growing importance of metabolic imaging (PET/CT) due to its performance especially for low PSA levels will help in further personalizing management strategies.

Real world treatment utilization patterns in patients with castration-resistant prostate cancer

BACKGROUND

Studies describing treatment utilization for castration-resistant prostate cancer (CRPC) are limited. We aimed to describe the treatment utilization of a contemporary population-based CRPC cohort between 2006 and 2016.

METHODS

We identified 1699 men with a PC diagnosis between 2005 and 2015, who developed CRPC between 2006 and 2015 in the Stockholm region of Sweden. Demographic information, stage and grade at PC diagnosis, stage at CRPC, prostate-specific antigen (PSA) nadir, PSA doubling time, treatment utilization rate within 1 year of CRPC diagnosis, reason for stopping therapy, treatment sequence trajectory, overall and PC specific survival was described.

RESULTS

Treatment for men with de novo metastatic disease (n = 463) was 32%, treatment for men with progressive metastatic disease after PC diagnosis (n = 66) was 44%, treatment for men with nonmetastatic CRPC (n = 113) was 34% and treatment for those with an unknown stage at time of CRPC diagnosis (n = 857) was 12%. Docetaxel was used in 39%, abiraterone acetate plus prednisone in 15%, enzalutamide in 13%, cabazitaxel in 11% and radium-223 in 5% of treatments. Treatment increased from 22% in 2006-2009 for metastatic cancer to 50% in 2013-2015 (p < .001). Factors associated with treatment were an unknown stage at diagnosis (OR: 0.3, 95% CI: 0.2-0.4), age ≥75 years (OR: 0.2, 95% CI: 0.1 - 0.3), PSA doubling time >3 months (OR: 0.4, 95% CI: 0.3 - 0.6) and a diagnosis between 2013 and 2015 (OR: 3.4, 95% CI: 2.0 - 5.8).

CONCLUSIONS

Despite treatment availability, in this large real-world cohort we found treatment utilization to remain low.

Prostate cancer follow-up costs in Germany from 2000 to 2015

Purpose

The main objective of this study is to estimate and evaluate 10-year follow-up costs after prostate cancer treatment with curative (surgery, radiotherapy) and non-curative intent (hormone, androgen deprivation) per patient in Germany in 2000, 2008, and 2015.

Methods

Prostate cancer follow-up recommendations were extracted from the European Association of Urology guidelines from 2000 to 2015. Per patient costs were calculated with a detailed micro-costing approach considering direct and indirect medical expenses. Input parameters were derived from expert interviews, literature research, and official scales of tariffs. Costs for insurers, providers, and payers were included to estimate societal costs.

Results

Mean 10-year follow-up costs per patient after treatment with curative intent amounted to EUR 4415 in 2000, EUR 4224 in 2008 (p < 0.001), and EUR 5159 in 2015 (p < 0.001). Costs after hormone therapy with metastasis cumulated to EUR 10,846 in 2000, EUR 9818 in 2008 (p < 0.001), and EUR 11,978 in 2015 (p < 0.001). While insurers covered 37% of costs in 2000 (EUR 1664), only 23% of costs were reimbursed in 2015 (EUR 1195; p < 0.001). Cost sources mainly included consultations (55%), transportation (18%), and imaging (27%).

Conclusion

Early detection and advances in prostate cancer treatment increased 10-year survival rates beyond 80% in Germany, ultimately expanding the number of survivors requiring follow-up. Statutory insurers reacted by decreasing the reimbursement rates to reduce per patient cost by up to 46%. Consequently, the economic burden was mainly shifted to payers and providers.

Implications for Cancer Survivors

Equitable and effective follow-up schedules covered by insurance funds are necessary to care for prostate cancer patients.

The diagnostic value of PET/CT imaging with the 68Ga-labeled PSMA-ligand in the follow up assessment of prostate cancer after therapy

Background

The aim of this study is to investigate the role of PET/CT imaging with the 68Ga-labeled PSMA-ligand in the follow up assessment of post-operative and post-therapeutic cases of prostate cancer. All data were collected and analyzed retrospectively, enrolling 30 patients (their age range from 53 to 80 years with a mean age 67.8). The patients had been referred to a private imaging center for their assessment by 68Ga-labeled PSMA-ligand PET/CT.

Results

By 68Ga-labeled PSMA-ligand PET/CT, prostatic recurrent/residual neoplastic lesion was depicted in 23 (76.6%) patients, nodal metastases was present in 7 (23.3%) patients, and distant metastasis was present in 11 (36.6%) patients. The clinical and/or PSA level and/or radiological follow-up and/or the histopathological assessment for the patients served as a reference in the present study.The 68Ga-labeled PSMA-ligand PET/CT had sensitivity, specificity, positive predictive value, negative predictive value, and an overall accuracy (96.5%, 100%, 100%, 50%, and 96.6%) respectively.

Conclusion

68Ga-labeled PSMA-ligand PET/CT is a very helpful tool for detection of prostatic cancer residual/recurrent lesions and restaging which can help in performing treatment plans and improve the clinical outcome and survival of the patients.

Lack of Racial Survival Differences in Metastatic Prostate Cancer in National Cancer Data Base (NCDB): A Different Finding Compared to Non-metastatic Disease

Background: Inconsistent findings have been reported in the literature regarding racial differences in survival outcomes between African American and white patients with metastatic prostate cancer (mPCa). The current study utilized a national database to determine whether racial differences exist among the target population to address this inconsistency.

Methods: This study retrospectively reviewed prostate cancer (PCa) patient data (N = 1,319,225) from the National Cancer Database (NCDB). The data were divided into three groupings based on the metastatic status: (1) no metastasis (N = 318,291), (2) bone metastasis (N = 29,639), and (3) metastases to locations other than bone, such as brain, liver, or lung (N = 952). Survival probabilities of African American and white PCa patients with bone metastasis were examined through parametric proportional hazards Weibull models and Bayesian survival analysis. These results were compared to patients with no metastasis or other types of metastases.

Results: No statistically supported racial disparities were observed for African American and white men with bone metastasis (p = 0.885). Similarly, there were no racial disparities in survival for those men suffering from other metastases (liver, lung, or brain). However, racial disparities in survival were observed among the two racial groups with non-metastatic PCa (p < 0.001) or when metastasis status was not taken into account (p < 0.001). The Bayesian analysis corroborates the finding.

Conclusion: This research supports our previous findings and shows that there are no racial differences in survival outcomes between African American and white patients with mPCa. In contrast, racial disparities in the survival outcome continue to exist among non-metastatic PCa patients. Further research is warranted to explain this difference.

A Weak and Semi-supervised Segmentation Method for Prostate Cancer in TRUS Images

The purpose of this research is to exploit a weak and semi-supervised deep learning framework to segment prostate cancer in TRUS images, alleviating the time-consuming work of radiologists to draw the boundary of the lesions and training the neural network on the data that do not have complete annotations. A histologic-proven benchmarking dataset of 102 case images was built and 22 images were randomly selected for evaluation. Some portion of the training images were strong supervised, annotated pixel by pixel. Using the strong supervised images, a deep learning neural network was trained. The rest of the training images with only weak supervision, which is just the location of the lesion, were fed to the trained network to produce the intermediate pixelwise labels for the weak supervised images. Then, we retrained the neural network on the all training images with the original labels and the intermediate labels and fed the training images to the retrained network to produce the refined labels. Comparing the distance of the center of mass of the refined labels and the intermediate labels to the weak supervision location, the closer one replaced the previous label, which could be considered as the label updates. After the label updates, test set images were fed to the retrained network for evaluation. The proposed method shows better result with weak and semi-supervised data than the method using only small portion of strong supervised data, although the improvement may not be as much as when the fully strong supervised dataset is used. In terms of mean intersection over union (mIoU), the proposed method reached about 0.6 when the ratio of the strong supervised data was 40%, about 2% decreased performance compared to that of 100% strong supervised case. The proposed method seems to be able to help to alleviate the time-consuming work of radiologists to draw the boundary of the lesions, and to train the neural network on the data that do not have complete annotations.

PSMA PET Scan Era: A Changing Paradigm PSMA PET and Lymph Node Dissection for Prostate Cancer Management

OBJECTIVES

Staging of extra-prostatic prostate cancer has traditionally been assessed by computerised tomography (CT), bone scan, and where indicated, pelvic lymph node dissection at the time of surgery. The advent of the prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scan shows promise in improving the accuracy of preoperative staging of this cancer. The role of pelvic lymph node dissection and its associated morbidity will be examined. This article will review current literature assessing the current role of PSMA PET and lymph node dissection in the staging and treatment of prostate cancer.

DATA SOURCES

Peer-reviewed literature and databases, including Medline and PubMed.

CONCLUSIONS

PSMA PET/CT appears to be a promising and superior staging investigation that may replace bone scan and CT scan in guiding treatment decision-making. It has high specificity and positive predictive value, thus in patients with low-risk prostate cancer, unnecessary extended pelvic lymph node dissection (ePLND) may be avoided. It would also help detect lymph nodes in patients with intermediate- or high-risk prostate cancer where ePLND may be required. ePLND remains the gold standard in staging high-risk patients because the PSMA PET/CT scan may under-stage the cancer.

IMPLICATION FOR NURSING PRACTICE

Given the increased utilisation of PSMA PET/CT scan as a primary staging investigation in clinical practice for prostate cancer and as an alternative to bone scan and CT scan, it is timely for prostate cancer specialist nurses to understand and recognise the specificity and sensitivity of PSMA PET/CT scans in prostate cancer staging. Because ePLND is the gold standard for staging high-risk disease, prostate cancer specialist nurses should be aware of the complications associated with pelvic lymph node dissection to optimise supportive care for men affected by complications from ePLND.

Vibrational spectroscopy of liquid biopsies for prostate cancer diagnosis

Background:

Screening for prostate cancer with prostate specific antigen and digital rectal examination allows early diagnosis of prostate malignancy but has been associated with poor sensitivity and specificity. There is also a considerable risk of over-diagnosis and over-treatment, which highlights the need for better tools for diagnosis of prostate cancer. This study investigates the potential of high throughput Raman and Fourier Transform Infrared (FTIR) spectroscopy of liquid biopsies for rapid and accurate diagnosis of prostate cancer.

Methods:

Blood samples (plasma and lymphocytes) were obtained from healthy control subjects and prostate cancer patients. FTIR and Raman spectra were recorded from plasma samples, while Raman spectra were recorded from the lymphocytes. The acquired spectral data was analysed with various multivariate statistical methods, principal component analysis (PCA), partial least squares discriminant analysis (PLS-DA) and classical least squares (CLS) fitting analysis.

Results:

Discrimination was observed between the infrared and Raman spectra of plasma and lymphocytes from healthy donors and prostate cancer patients using PCA. In addition, plasma and lymphocytes displayed differentiating signatures in patients exhibiting different Gleason scores. A PLS-DA model was able to discriminate these groups with sensitivity and specificity rates ranging from 90% to 99%. CLS fitting analysis identified key analytes that are involved in the development and progression of prostate cancer.

Conclusions:

This technology may have potential as an alternative first stage diagnostic triage for prostate cancer. This technology can be easily adaptable to many other bodily fluids and could be useful for translation of liquid biopsy-based diagnostics into the clinic.

Prediction models for prostate cancer to be used in the primary care setting: a systematic review

OBJECTIVE

To identify risk prediction models for prostate cancer (PCa) that can be used in the primary care and community health settings.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE and Embase databases combined from inception and up to the end of January 2019.

ELIGIBILITY

Studies were included based on satisfying all the following criteria: (i) presenting an evaluation of PCa risk at initial biopsy in patients with no history of PCa, (ii) studies not incorporating an invasive clinical assessment or expensive biomarker/genetic tests, (iii) inclusion of at least two variables with prostate-specific antigen (PSA) being one of them, and (iv) studies reporting a measure of predictive performance. The quality of the studies and risk of bias was assessed by using the Prediction model Risk Of Bias ASsessment Tool (PROBAST).

DATA EXTRACTION AND SYNTHESIS

Relevant information extracted for each model included: the year of publication, source of data, type of model, number of patients, country, age, PSA range, mean/median PSA, other variables included in the model, number of biopsy cores to assess outcomes, study endpoint(s), cancer detection, model validation and model performance.

RESULTS

An initial search yielded 109 potential studies, of which five met the set criteria. Four studies were cohort-based and one was a case-control study. PCa detection rate was between 20.6% and 55.8%. Area under the curve (AUC) was reported in four studies and ranged from 0.65 to 0.75. All models showed significant improvement in predicting PCa compared with being based on PSA alone. The difference in AUC between extended models and PSA alone was between 0.06 and 0.21.

CONCLUSION

Only a few PCa risk prediction models have the potential to be readily used in the primary healthcare or community health setting. Further studies are needed to investigate other potential variables that could be integrated into models to improve their clinical utility for PCa testing in a community setting.

Testosterone therapy may reduce prostate cancer risk due to testosterone deficiency at a young age via stabilizing serum testosterone levels

Objectives: To investigate whether testosterone replacement therapy (TRT) reduces prostate cancer (PCa) risk via stabilizing serum testosterone (T) levels beyond simply elevating serum T levels and whether TRT reduces PCa risk due to low serum T levels at a young age.Methods: We analyzed data of 776 hypogonadal men from a urology center in Bremerhaven, Germany through 2004-2016 to investigate whether the TRT group has more stable T levels and whether TRT can reduce the risk of PCa due to low serum T levels at an early age. We derived an index, Maximum Decline of T Relative to Baseline (MDRB), to describe the magnitude of T declines and variations over time.Results: We found the TRT group has more stable serum T levels (e.g. smaller drop-offs) during the follow-up period as compared to the non-TRT group, and the mean of MDRB is significantly higher in the untreated group (1.553 nmol/L VS 0.013 nmol/L; p-value < .001). TRT significantly reduces the risk of PCa associated with T deficiency at a young age (p-value = .00087).Conclusions: TRT may reduce PCa risk via maintaining serum T levels within individual's normal range; T surveillance may be needed for males who have low serum T levels at a young age to monitor abnormal variations of T levels and ensure timely treatment when necessary to reduce PCa risk.

Comparison of Tumor Volume Parameters on Prostate Cancer Biopsies

CONTEXT.—

Prostate biopsy reports require an indication of prostate cancer volume. No consensus exists on the methodology of tumor volume reporting.

OBJECTIVE.—

To compare the prognostic value of different biopsy prostate cancer volume parameters.

DESIGN.—

Prostate biopsies of the European Randomized Study of Screening for Prostate Cancer were reviewed (n = 1031). Tumor volume was quantified in 6 ways: average estimated tumor percentage, measured total tumor length, average calculated tumor percentage, greatest tumor length, greatest tumor percentage, and average tumor percentage of all biopsies. Their prognostic value was determined by using either logistic regression for extraprostatic expansion (EPE) and surgical margin status after radical prostatectomy (RP), or Cox regression for biochemical recurrence-free survival (BCRFS) and disease-specific survival (DSS) after RP (n = 406) and radiation therapy (RT) (n = 508).

RESULTS.—

All tumor volume parameters were significantly mutually correlated (R2 > 0.500, P < .001). None were predictive for EPE, surgical margin, or BCRFS after RP in multivariable analysis, including age, prostate-specific antigen, number of positive biopsies, and grade group. In contrast, all tumor volume parameters were significant predictors for BCRFS (all P < .05) and DSS (all P < .05) after RT, except greatest tumor length. In multivariable analysis including only all tumor volume parameters as covariates, calculated tumor length was the only predictor for EPE after RP (P = .02) and DSS after RT (P = .02).

CONCLUSIONS.—

All tumor volume parameters had comparable prognostic value and could be used in clinical practice. If tumor volume quantification is a threshold for treatment decision, calculated tumor length seems preferential, slightly outperforming the other parameters.

Comparison of outcome endpoints in intermediate- and high-risk prostate cancer after combined-modality radiotherapy

PURPOSE

To compare a standard radio-oncological and a surgical biochemical failure definition after combined-modality radiation therapy (CRT) in men with intermediate- and high-risk prostate cancer.

METHODS

425 men were treated with external beam radiotherapy (59.4 Gy, 33 fractions) and ¹²⁵J seed-brachytherapy (S-BT, 100 Gy). Biochemical recurrence (BR) was defined either as radio-oncologic (rBR), using a +2 ng/mL prostate-specific antigen (PSA) increase above a nadir value, or as surgical (sBR), using a 2-year posttreatment PSA of ≥0.2 ng/mL. Biochemical recurrence-free, metastasis-free, cancer-specific, and overall survival were calculated at 5 and 10 years using the Kaplan-Meier method. Standard validation tests were used to compare both thresholds.

RESULTS

After a median of 7 years, overall recurrence rates were 10.4% and 31.5% for rBR and sBR definitions, respectively. Both failure definitions proved sensitive for the prediction of metastases and cancer-specific death, whereas the rBR definition was significantly more specific. The accuracies of a correct prediction of metastases and death of prostate cancer were 73.1% vs. 96.2% and 72.2% vs. 92.9% for sBR vs. rBR, respectively. The inferior validity results of the sBR definition were attributable to a PSA-bounce phenomenon occurring in 56% of patients with sBR. Still, using the less suitable sBR definition, the results of CRT compared favorably to BRFS rates of surgical interventions.

CONCLUSION

After CRT, the radio-oncological (aka Phoenix) failure definition is more reliable than a fixed surgical endpoint. Exclusively in high-risk patients, sBR offers a direct comparison across surgical and nonsurgical treatment options at 5 and 10 years.

Comparison of prostate cancer detection rates between the Vienna nomogram and the 10-core biopsy protocol

OBJECTIVE

To compare the Vienna nomogram and the 10-core prostate biopsy protocol regarding whether there is superiority in prostate cancer detection.

METHODS

Between January and December 2012, a total of 215 patients applying to our outpatient clinic with lower urinary tract symptoms were evaluated, prospectively. Patients with a prostate-specific antigen level of 2.5-10 ng/mL and/or suspicious digital rectal examination were included in the study. Exclusion criteria were determined as recent pelvic radiotherapy, lower urinary tract surgery, history of acute urinary retention, or indwelling urinary catheter. Biopsies were taken systematically with at least 10 cores considering prostate volume and patient age. According to Vienna nomogram, in patients requiring 6- or 8-core biopsies, tissue sampling was completed to 10 cores (our standard protocol), whereas in patients requiring more than 10 cores additional tissue sampling was performed.

RESULTS

After the determination of inclusion/exclusion criteria, 170 patients were enrolled in our study. The median (min-max) age, prostate-specific antigen value, and prostate volume were 65 (48-86) years, 7.6 ng/dL (2.5-10), and 55 cc (17-150), respectively. Prostate cancer was detected in 49 (28.8%) patients with transrectal ultrasound-guided prostate biopsy according to the Vienna nomogram. We found that our standard 10-core biopsy protocol would have diagnosed prostate cancer in 46 (27.1%) patients in the same study group showing no statistically significant difference (p > 0.005).

CONCLUSION

The findings of this study suggest that considering cancer detection rates no statistically significant differences were found between both methods. Further prospective research in this aspect is needed to define the ultimate prostate biopsy protocol.

Prognostic role of chromogranin A in castration-resistant prostate cancer: A meta-analysis

We aimed to investigate the prognostic value of chromogranin A (CgA) in castration-resistant prostate cancer (CRPC). We conducted a systematic literature search of PubMed, Web of Science, and EMBASE for citations published prior to September 2017 that described CgA and CRPC and performed a standard meta-analysis on survival outcomes. Our meta-analysis included eight eligible studies with 686 patients. The results were as follows: progression-free survival (PFS) was associated with CgA level (hazard ratio [HR] = 2.47, 95% confidence interval [CI]: 1.47-4.14, P = 0.0006); PFS was relative to CgA change (HR = 9.22, 95% CI: 3.03-28.05, P < 0.0001); and overall survival (OS) was relative to CgA level (HR = 1.47, 95% CI: 1.15-1.87, P = 0.002). When we divided the patients into two groups according to therapy status, the result for OS relative to CgA level was an HR of 1.26 (95% CI: 1.09-1.45, P = 0.001) in the first-line hormonal therapy group, and an HR of 2.33 (95% CI: 1.40-3.89, P = 0.001) in the second-line hormonal therapy or chemotherapy group. This meta-analysis indicated that a high CgA level had a negative influence on OS and PFS in CRPC patients. In addition, CRPC patients with a rising CgA had a shorter PFS. Further studies are needed to verify the prognostic value of CgA in CRPC.

Risk of prostate cancer for men fathering through assisted reproduction: nationwide population based register study

OBJECTIVE

To compare the risk and severity of prostate cancer between men achieving fatherhood by assisted reproduction and men conceiving naturally.

DESIGN

National register based cohort study.

SETTING

Sweden from January 1994 to December 2014.

PARTICIPANTS

1 181 490 children born alive in Sweden during 1994-2014 to the same number of fathers. Fathers were grouped according to fertility status by mode of conception: 20 618 by in vitro fertilisation (IVF), 14 882 by intra-cytoplasmic sperm injection (ICSI), and 1 145 990 by natural conception.

MAIN OUTCOME MEASURES

Prostate cancer diagnosis, age of onset, and androgen deprivation therapy (serving as proxy for advanced or metastatic malignancy).

RESULTS

Among men achieving fatherhood by IVF, by ICSI, and by non-assisted means, 77 (0.37%), 63 (0.42%), and 3244 (0.28%), respectively, were diagnosed as having prostate cancer. Mean age at onset was 55.9, 55.1, and 57.1 years, respectively. Men who became fathers through assisted reproduction had a statistically significantly increased risk of prostate cancer compared with men who conceived naturally (hazard ratio 1.64, 95% confidence interval 1.25 to 2.15, for ICSI; 1.33, 1.06 to 1.66, for IVF). They also had an increased risk of early onset disease (that is, diagnosis before age 55 years) (hazard ratio 1.86, 1.25 to 2.77, for ICSI; 1.51, 1.09 to 2.08, for IVF). Fathers who conceived through ICSI and developed prostate cancer received androgen deprivation therapy to at least the same extent as the reference group (odds ratio 1.91; P=0.07).

CONCLUSIONS

Men who achieved fatherhood through assisted reproduction techniques, particularly through ICSI, are at increased risk for early onset prostate cancer and thus constitute a risk group in which testing and careful long term follow-up for prostate cancer may be beneficial.

Role of native Thiol, total Thiol and dynamic Disulphide in diagnosis of patient with prostate cancer and prostatitis

BACKGROUND

Our study investigates whether Native Thiol, Total Thiol and disulphide levels measured in serum of patients with prostate cancer and prostatitis and of healthy subjects, have any role in differential diagnosis.

MATERIALS AND METHODS

Patients followed up for histopathologically verified diagnosis of prostate cancer and prostatitis in 2016-2017 at the Medicalpark Gaziantep Hospital Urology Clinic were included in the study. Native Thiol (NT), Total Thiol (TT), Dynamic Disulphide (DD) levels in serum were measured by a novel automated method.

RESULTS

NT, TT, DD, NT / TT ratios, DD / TT ratio and DD / NT ratio were measured as 118.4 ± 36.8μmoL / L, 150.3 ± 45.3μmoL / L, 15.9 ± 7μmoL / L, 78.8 ± 7μmoL / L, 10.5 ± 3.5μmoL / L, 13.8 ± 5.8μmoL / L respectively in patients with prostate cancer; as 116.4 ± 40.5μmoL / L, 147.5 ± 50.1μmoL / L, 15.5 ± 8.7μmoL / L, 79.7 ± 9μmoL / L, 10.1 ± 4.5μmoL / L, 13.5 ± 7.2μmoL / L in patients with prostatitis and as 144.1 ± 21.2μmoL / L, 191 ± 32.3μmoL / L, 23.4 ± 10.1μmoL / L, 76.1 ± 98.3μmoL / L, 11.9 ± 4.1μmoL / L, 16.4 ± 6.9μmoL / L in healthy subjects. Significant difference was detected between groups of NT, TT and DD levels (p = 0.008, p = 0.001, p = 0.002). No significant difference was detected in terms of the NT / TT, DD / TT and DD / NT rates (p = 0.222, p = 0.222, p = 0.222).

CONCLUSIONS

Serum NT, TT, DD levels in patients with prostatitis and prostate cancer were found significantly lower compared to the control group. This indicates that just as inflammation, prostate cancer also increases oxidative stress on tissues.

Circulating cell-free DNA integrity as a diagnostic and prognostic marker for breast and prostate cancers

BACKGROUND

Cancer incidence and its related mortality is rising and is currently the second leading cause of death globally. In Africa, breast and prostate cancer in females and males, respectively, are the worst globally. However, biomarkers for their early detection and prognosis are not well developed. This study sought to investigate circulating cell-free DNA (ccfDNA) integrity and its potential utility as diagnostic and/or prognostic biomarker. Circulating cell-free DNA (ccfDNA) is degraded DNA fragments released into the blood plasma. In healthy individuals, the source of ccfDNA is solely apoptosis, producing evenly sized shorter DNA fragments. In cancer patients, however, necrosis produces uneven longer cell-free DNA fragments in addition to the shorter fragments originating from apoptosis. DNA integrity, expressed as the ratio of longer fragments to total DNA, may be clinically useful for the detection of breast and prostate cancer progression.

METHODS

Sixty-four (64) females, consisting of 32 breast cancer patients and 32 controls, and 61 males (31 prostate cancer patients and 30 controls) were included in the study. Each participant donated 5 ml peripheral blood from which sera were separated. Real-time qPCR was performed on the sera to quantify ALU 115 and 247 levels, and DNA integrity (ALU247/ALU115) determined.

RESULTS & CONCLUSION

ALU species 115 and 247 levels in serum were elevated in breast and prostate cancer patients compared to their counterpart healthy controls. DNA integrity was higher in prostate cancer patients than in the control, but in breast cancer patients was lower compared to their controls. In prostate but not in breast cancers, DNA integrity increased with disease severity and higher staging.

Combined-modality 125J-seed-brachytherapy, external beam radiation and androgen deprivation therapy of unfavorable-risk prostate cancer: report of outcomes and side-effects

PURPOSE

To analyze outcomes and complication rates in an unselected cohort of men with unfavorable (NCCN intermediate and high-risk) PCa receiving combined-modality radiation treatment (CRT).

METHODS

Patients received androgen deprivation therapy for 1 year and combined-modality radiation treatment (CRT) consisting of external-beam radiotherapy (EBRT, 59.4 Gy, 33 fractions) and ¹²⁵J seed-brachytherapy (S-BT, 100 Gy). Subgroups, including WHO group 3-5, and initial PSA (iPSA) < 20 and > 20 ng/ml were identified. Biochemical recurrence-free (BRFS), metastasis-free (MFS), cancer-specific (CSS) and overall survival (OS) were calculated at 5 and 10 years using the Kaplan-Meier method. Subgroups were compared using log-rank test and Cox proportional hazards regression. Urogenital and gastrointestinal side-effects were reported according to the CTCAE classification.

RESULTS

After a median of 6.9 years (range 2-13) calculated 5- and 10-year rates for the whole cohort of 425 men were 92.8% and 82.5% for BRFS, 95.1%, and 88.8% for MFS, 98.2%, and 95.1 for CSS, and 95.4%, and 80.1% for OS, respectively. Univariate (UVA) and multivariate analysis (MV) identified a group with unfavorable outcome with iPSA > 20 ng/ml, comprising 24% of all patients, in which 55% of recurrences, 54% of metastases and 71% of cancer-specific deaths occurred. Side-effects were limited, with < 5% of patients complaining of genitourinary and 0.5% of gastrointestinal AEs after 5 years.

CONCLUSION

CRT is an excellent treatment option for men with unfavorable PCa. In a subgroup of patients with iPSA > 20 ng/ml further, possibly systemic, treatment options should be identified.

Serum biomarkers of inflammation for diagnosis of prostate cancer in patients with nonspecific elevations of serum prostate specific antigen levels

Background

Lactate dehydrogenase (LDH) and C-reactive protein (CRP) are biomarkers of inflammation commonly used in medicine. The aim was to evaluate the utility of serum LDH and CRP levels for diagnosis of prostate cancer (PC) in men with nonspecific elevations of serum total prostate specific antigen (PSA) levels.

Methods

The following serum biomarkers were measured in patients with PSA between 4 and 10 ng/mL: LDH, CRP and free-PSA. The free-to-total serum PSA ratio (%fPSA) was (free-PSA/PSA) ×100. Patients were classified into two groups according to diagnosis of prostate biopsy: PC and NOT PC patients. Logistic regression was used for develop a probabilistic model to predict PC patients. Diagnostic accuracy was determined using receiver operating characteristic (ROC) curves, calculating the area under the ROC curve (AUC).

Results

We studied 232 patients with ages between 43 and 98 years old (median =72), 200 NOT PC and 32 PC patients. CRP was not statistically significantl to differentiate between PC and NOT PC patients. Probabilistic model (%) was 100× (1+ e^−Z)⁻¹; (Z =0.0070× LDH –0.1589× %fPSA –1.4898). The AUCs were 0.657 (P=0.0048), 0.802 (P<0.0001), and 0.844 (P<0.0001) for serum LDH levels, %fPSA values and probabilistic model, respectively.

Conclusions

CRP was not useful to differentiate benign from malignant prostate disease, in contrast LDH could be used for diagnosis of PC. A probabilistic model using LDH and %fPSA can improve the diagnostic accuracy in patients with PSA between 4 and 10 ng/mL.

Clinically occult prostate cancer cases may distort the effect of testosterone replacement therapy on risk of PCa

BACKGROUND

Although prostate cancer (PCa) screening is conducted before testosterone replacement therapy (TRT), clinically occult PCa cases may exist.

METHODS

To evaluate whether the possible inclusion of occult PCa cases distorts the effect of TRT on risk of PCa, we followed 776 hypogonadal males (TRT = 400, non-TRT = 376) from a urology center in Germany from 2004 to 2016, with a mean follow-up period of 7 years. We assumed occult cases might take 1-2 years (latency period) to become clinically detectable after receiving TRT. We selected several latency periods (12/18/24 months) and compared the risk of PCa in the TRT and non-TRT group over the latency period, from the end of latency period till the end of follow-up, and over the whole follow-up time.

RESULTS

Overall, 26 PCa cases occurred in the non-TRT group vs 9 cases in the TRT group. Within 18 months of follow-up, 9 cases occurred in the TRT group vs 0 cases in the non-TRT group; from the end of 18 months till the end of follow-up, 26 cases occurred in the non-TRT group vs 0 cases in the TRT group. The adjusted table showed seemingly adverse effects of TRT on PCa development within 18 months (p = 0.0301) and beneficial effects from the end of 18 months till the end of follow-up (p = 0.0069). Similar patterns were observed for 12 or 24 months as the latency period.

CONCLUSIONS

TRT may make occult PCa cases detectable within early phase of treatment and present a beneficial effect in the long run. Future longitudinal studies are needed to confirm findings from our exploratory analyses.

A novel and innovative device to retract rectum during radiation therapy of pelvic tumors

An effective radiotherapy treatment entails maximizing radiation dose to the tumor while sparing the surrounding and normal tissues. With the advent of SBRT with extreme hypo-fractionation in treating tumors including prostate where ablative dose is delivered in smaller number of fractions, rectum remains a dose-limiting organ and at the risk of rectal toxicity or secondary cancer. The same limitation of rectal toxicity exists for high-dose rate (HDR) treatments of cervical, endometrial, or prostate cancer when creating even a short distance between the anterior rectal wall and field of radiation is ideal in delivering ablative dose to the target. An effective solution to such problem is to physically displace rectum as the organ at risk. This research presents an organ retractor device that is designed to displace the rectum away from the path of radiation beam employing a Nitinol shape memory alloy that is designed for displacing the rectum upon actuation. A control system regulates the motion in a reproducible and safe manner by creating the desirable shape in moving the anterior rectal wall. The study finds the novel organ retractor device to be a promising tool that can be applied in a clinical setting for minimizing dose to the rectum during treatment of pelvic tumors, and creating the potential to deliver an ablative dose to tumor volume or to escalate the dose when needed.

The risk of prostate cancer mortality and cardiovascular mortality of nonmetastatic prostate cancer patients: A population-based retrospective cohort study

PURPOSE

To assess the risk of prostate cancer (PCa) specific mortality (PCSM) compared to cardiovascular disease mortality (CVDM), or other-cause mortality (OCM) of men with nonmetastatic PCa according to PCa risk groups, primary treatment, and age.

PATIENTS AND METHODS

This retrospective population-based cohort study identified 1,908 nonmetastatic PCa patients in the cancer registry Zurich and Zug, diagnosed between 2000 and 2009 living in the City of Zurich. Multiple imputation methods were applied to handle missing PCa information. Fine and Gray competing risk regression analysis was used to estimate subdistribution hazard ratios for the outcomes PCSM, CVDM, or OCM RESULTS: Ten years after diagnosis the cumulative probability of PCSM and CVDM was 16.4% and 10.0%, respectively. We observed an increased adjusted risk of PCSM in men treated with androgen deprivation therapy (ADT) compared to surgery, but could not observe an association between ADT and CVDM. The probability of PCSM was significantly higher for patients on active surveillance or watchful waiting, compared to surgery. Age and PCa risk categories were positively associated with risk of PCSM, whereas there was no evidence for an association with CVDM or OCM based on risk groups.

CONCLUSIONS

Overall, men with PCa were more likely to die from non-PCa related outcomes. Nevertheless, the analyses showed a high proportion of PCSM among men on ADT, older men and men with a high-risk tumor. However, further research is needed to understand comprehensively the benefits of the respective treatments.

Target definition in salvage postoperative radiotherapy for prostate cancer: 18F-fluorocholine PET/CT assessment of local recurrence

PURPOSE

Inadequate clinical target volume (CTV) definition is likely to be a major contributing factor to local recurrence (LR) rate after radiotherapy. Our aims were to identify sites of prostate cancer LR in biochemical recurrence post-prostatectomy using ¹⁸F-Fluorocholine (18F-FCH) positron emission tomography/computed tomography (PET/CT) and to compare different CTV-delineation guidelines in a cohort of postoperative patients.

MATERIAL AND METHODS

Thirty-six patients presenting with LR within the prostatic bed on 18F-FCH PET/CT between 10/2011 and 06/2016 were included in this retrospective study. Median PSA at the time of 18F-FCH PET/CT was 2.7 ng/mL (0.8-9.4) and median PSA doubling time was 11 months (3-28). For each patient, the CTV_RTOG, CTV_FROGG and CTV_EORTC following the corresponding guidelines were outlined and compared. Forty-one LR were delineated using a gradient-based method and the percentage of FCH uptake included in each CTV was evaluated.

RESULTS

The anastomosis was the most common recurrence site (52.8%), followed by the retrovesical region (31.7%) and the bladder neck (7%). The median SUV max value was 4.8 (2.3-16.1). The percentage of LR entirely included in the CTV_RTOG was not significantly different from that included in the CTV_FROGG (84% versus 83%, p = .5). Significantly more recurrences were included in the CTV_RTOG volume compared to the CTV_EORTC (84% versus 68%, p=.006), due to a better coverage of the bladder neck and retrovesical regions. Six out of 10 relapses occurring in the posterior region of the anastomosis were not covered by any of the CTVs.

CONCLUSIONS

In our study, the CTV_RTOG and CTV_FROGG ensured the best coverage of LR seen on 18F-FCH PET/CT. When outlining the prostatic fossa, greater coverage of the posterior vesico-urethral region may allow better coverage of potential microscopic disease.

Intermittent, low-dose, antiandrogen monotherapy as an alternative therapeutic option for patients with positive surgical margins after radical prostatectomy

The aim of the present study was to determine whether oncologic outcomes and adverse events associated with active on/off intermittent antiandrogen monotherapy (daily bicalutamide, 50 mg per day) are comparable with those of standard external beam radiation therapy (EBRT) or combined androgen blockade (CAB) therapy in prostate cancers with positive surgical margins after radical prostatectomy. Two hundred twenty-three patients with positive surgical margins post-radical prostatectomy who underwent active surveillance (AS, n = 32), EBRT without hormone therapy (n = 55), intermittent antiandrogen monotherapy without EBRT (IAAM, n = 50), or CAB without EBRT (n = 86), between 2007 and 2014, were reviewed retrospectively. Pathologic outcomes, biochemical recurrence rates, radiological disease progression, and adverse events were collected from medical records. Biochemical recurrence rates, biochemical recurrence-free survival rates, and radiological recurrence were not different between the groups (P = 0.225, 0.896, and 0.284, respectively). Adverse event rates and severities were lower for IAAM compared with EBRT or CAB (both P < 0.05), but were comparable to those for AS (P = 0.591 and 0.990, respectively). Grade ≥3 adverse events were not reported in the IAAM or AS groups. Erectile dysfunction and loss of libido rates were lower in the IAAM group compared with the EBRT and CAB groups (P = 0.032). Gastrointestinal complications were more frequently reported in the EBRT group (P = 0.008). Active on/off IAAM treatment might be an appropriate treatment option for patients with positive surgical margins after radical prostatectomy. Furthermore, regarding oncologic outcomes, IAAM was comparable to standard EBRT but had a milder adverse event profile.

Network meta-analysis of the efficacy and adverse effects of several treatments for advanced/metastatic prostate cancer

This network meta-analysis was conducted to compare the efficacy and adverse effects of several treatments for advanced/metastatic prostate cancer (PC). The PubMed and Cochrane Library databases were searched for randomized controlled trials of treatments for advanced/metastatic PC. Eighteen studies covering 6,340 patients were included in this analysis. The calculated were odds ratios, 95% confidence intervals, and the surface under the cumulative ranking (SUCRA) curve. Pairwise meta-analysis showed that overall survival rates achieved with radiotherapy or endocrine therapy were lower than obtained with radiotherapy + endocrine therapy. The endocrine therapy includes estrogen therapy, luteinizing hormone-releasing hormone agonist (LHRH-A), anti-androgen therapy (ADT), ADT + LHRH-A and estrogen therapy + LHRH-A, and its SUCRA values indicated that for overall response rate, estrogen therapy + LHRH-A ranked the highest (92.6%); for overall survival rate, ADT ranked the highest (75.2%); for anemia, estrogen therapy ranked the highest (88.2%); and for diarrhea and hot flushes, ADT ranked the highest (diarrhea, 87.4%; hot flushes, 89.3%). Cluster analysis on the endocrine therapy showed that ADT + LHRH-A achieved the highest overall survival and overall response rates in the treatment of advanced/metastatic PC. Estrogen therapy and ADT had the lowest incidences of diarrhea and anemia. Thus, combined radiotherapy + endocrine therapy had higher overall survival rate, and among the endocrine therapy, in terms of overall response rate and overall survival rate, ADT + LHRH-A may be a better regimen in the treatment of advanced or metastatic PC.

Decreased expression of MT1E is a potential biomarker of prostate cancer progression

Differentiation of indolent and aggressive prostate carcinoma (PCa) at the time of diagnosis is currently one of the major challenges. This study aimed at identification of prognostic biomarkers to aid in predicting biochemical recurrence (BCR) of the disease. Microarray-based gene expression profiling in tissues of 8 BCR and 8 No-BCR cases revealed expression differences of 455 genes, most of which were down-regulated in BCR cases. Eleven genes were selected for validation by real-time PCR in the first PCa cohort (N = 55), while seven of them were further validated in the second, independent, PCa cohort (N = 53). Down-regulation of MT1E (p < 0.001) and GPR52 (p = 0.002) expression and up-regulated levels of EZH2 (p = 0.025) were specific biomarkers of BCR in at least one of the two PCa cohorts, but only MT1E expression retained the independent prognostic value in a multivariate analysis (p < 0.001). DNA methylation analysis (114 PCa and 24 non-cancerous tissues) showed frequent MT1E methylation in PCa (p < 0.001) and was associated (p < 0.010) with the down-regulated expression in one PCa cohort. The results of our study suggest MT1E down-regulation as a potential feature of aggressive PCa.

Predictors for progression of metastatic prostate cancer to castration-resistant prostate cancer in Indians

Background & objectives:

There is lack of data on natural history and progression of prostate cancer (PC) which have implications in the management of the disease. We undertook this retrospective study to analyze factors predicting progression of metastatic PC to castration-resistant prostate cancer (CRPC) in Indian men.

Methods:

Complete records of 223 of the 489 patients with metastatic PC were obtained from computerized data based system in a tertiary care hospital in north India between January 2000 to June 2012. Patients with follow up of < 6 months were excluded. Age (≤ and > 65 yr), baseline PSA (< and ≥ 50 ng/ml), bone scan and Gleason score (≤7 and >7) were recorded. Extent of bone disease (EOD) was stratified according to the number of bone lesions i.e., < 5, 5-10, > 10. CRPC was defined as two consecutive PSA rise of > 50 per cent from nadir or an absolute value of > 5 ng/ml.

Results:

Mean age of patients was 61.5 ± 12.45 yr and their PSA level was 325.6 ± 631.35 ng/dl. Of the 223 patients, 193 (86%) progressed to CRPC at median time of 10.7 (4-124) months. Median follow up was 24 (6-137) months. On univariate and multivariate analyses EOD on bone scan was found to be a significant predictor (P=0.006) for time to CRPC. Median time to CRPC was 10 months (CI 95%, 7.5-12.48) with >10 lesions or super scan versus 16 months (CI 95%, 10.3-21.6) with <10 bone lesion (P=0.01). Ninety (46.6 %) patients of CRPC died with median time to death from time of CRPC 21 (10-120) months.

Interpretation & conclusions:

Median time for progression of metastatic PC to CRPC ranged from 10-16 months depending on the extent of the bone involvement. In Indians, the aggressive course of advanced prostate cancer warrants further clinical trials to explore the need for additional treatment along with initial castration.

Pharmacotherapeutic Targeting of G Protein-Coupled Receptors in Oncology: Examples of Approved Therapies and Emerging Concepts

G protein-coupled receptors (GPCRs) are involved in numerous physio-pathological processes, including the stimulation of cancer progression. In this regard, it should be mentioned that although GPCRs may represent major pharmaceutical targets, only a few drugs acting as GPCR inhibitors are currently used in anti-tumor therapies. For instance, certain pro-malignancy effects mediated by GPCRs are actually counteracted by the use of small molecules and peptides that function as receptor antagonists or inverse agonists. Recently, humanized monoclonal antibodies targeting GPCRs have also been developed. Here, we review the current GPCR-targeted therapies for cancer treatment, summarizing the clinical studies that led to their official approval. We provide a broad overview of the mechanisms of action of the available anti-cancer drugs targeting gonadotropin-releasing hormone, somatostatin, chemokine, and Smoothened receptors. In addition, we discuss the anti-tumor potential of novel non-approved molecules and antibodies able to target some of the aforementioned GPCRs in different experimental models and clinical trials. Likewise, we focus on the repurposing in cancer patients of non-oncological GPCR-based drugs, elucidating the rationale behind this approach and providing clinical evidence on their safety and efficacy.

Androgen deprivation therapy in the treatment of locally advanced, nonmetastatic prostate cancer: practical experience and a review of the clinical trial evidence

Following new scientific insights, initial management for patients with high-risk nonmetastatic prostate cancer has changed considerably and rapidly over the last few years. Several clinical and pathologic variables should be taken into account when deciding the best treatment choice for those patients. These variables are summarized and discussed in detail. High radiation doses to the prostate are essential to achieve good local control in patients with high-risk nonmetastatic disease. Addition of androgen deprivation therapy (ADT) to radiation therapy has significantly improved overall survival and cancer-specific survival compared with radiation therapy alone without significantly increasing toxicity. Long-term neo(adjuvant) ADT (2-3 years) to radiation therapy significantly improved cancer-specific survival compared with short-term ADT (4-6 months). Radical prostatectomy with extended pelvic lymph node dissection is considered a reasonable option in experienced hands. ADT alone is an inappropriate treatment option for patients with high-risk nonmetastatic disease. Management decisions for these patients should be discussed by a multidisciplinary team.

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.

Levator Ani Necrosis: An Exceptional Complication Occurring after "High Intensity Focused Ultrasound" of the Prostate

High intensity focused ultrasound (HIFU) is a minimally invasive treatment option that might be considered in the management of localized prostate cancer. It is a well-tolerated treatment with few minor urologic complications and no major toxicities. In this paper, we report to our knowledge the first case of levator ani necrosis in a patient treated with HIFU, manifesting as sturdy perineal pain, which took years of NSAID intake and serial MRIs to demonstrate partial improvement. Therefore, we regard HIFU as a serious potential treatment option that still requires longer follow-up data before its approval in the personalized treatment panel of prostate cancer.

PSMA PET and Radionuclide Therapy in Prostate Cancer

Prostate cancer (PCa) is the most common malignancy in men and a major cause of cancer death. Accurate imaging plays an important role in diagnosis, staging, restaging, detection of biochemical recurrence, and for therapy of patients with PCa. Because no effective treatment is available for advanced PCa, there is an urgent need to develop new and more effective therapeutic strategies. To optimize treatment outcome, especially in high-risk patients with PCa, therapy for PCa is moving rapidly toward personalization. Medical imaging, including positron emission tomography (PET)/computed tomography (CT), plays an important role in personalized medicine in oncology. In the recent years, much focus has been on prostate-specific membrane antigen (PSMA) as a promising target for imaging and therapy with radionuclides, as it is upregulated in most PCa. In the prostate, one potential role for PSMA PET imaging is to help guide focal therapy. Several studies have shown great potential of PSMA PET/CT for initial staging, lymph node staging, and detection of recurrence of PCa, even at very low prostate-specific antigen values after primary therapy. Furthermore, studies have shown that PSMA PET/CT has a higher detection rate than choline PET/CT. Radiolabeled PSMA ligands for therapy show promise in several studies with metastatic PCa and is an area of active investigation. The "image and treat" strategy, with radiolabeled PSMA ligands, has the potential to improve the treatment outcome of patients with PCa and is paving the way for precision medicine in PCa. The aim of this review is to give an overview of recent advancement in PSMA PET and radionuclide therapy for PCa.