Cancer-specific survival after metastasis following primary radical prostatectomy compared with radiation therapy in prostate cancer patients: results of a population-based, propensity score-matched analysis

Artificial intelligence for the diagnosis of clinically significant prostate cancer based on multimodal data: a multicenter study

BACKGROUND

The introduction of multiparameter MRI and novel biomarkers has greatly improved the prediction of clinically significant prostate cancer (csPCa). However, decision-making regarding prostate biopsy and prebiopsy examinations is still difficult. We aimed to establish a quick and economic tool to improve the detection of csPCa based on routinely performed clinical examinations through an automated machine learning platform (AutoML).

METHODS

This study included a multicenter retrospective cohort and two prospective cohorts with 4747 cases from 9 hospitals across China. The multimodal data, including demographics, clinical characteristics, laboratory tests, and ultrasound reports, of consecutive participants were retrieved using extract-transform-load tools. AutoML was applied to explore potential data processing patterns and the most suitable algorithm to build the Prostate Cancer Artificial Intelligence Diagnostic System (PCAIDS). The diagnostic performance was determined by the receiver operating characteristic curve (ROC) for discriminating csPCa from insignificant prostate cancer (PCa) and benign disease. The clinical utility was evaluated by decision curve analysis (DCA) and waterfall plots.

RESULTS

The random forest algorithm was applied in the feature selection, and the AutoML algorithm was applied for model establishment. The area under the curve (AUC) value in identifying csPCa was 0.853 in the training cohort, 0.820 in the validation cohort, 0.807 in the Changhai prospective cohort, and 0.850 in the Zhongda prospective cohort. DCA showed that the PCAIDS was superior to PSA or fPSA/tPSA for diagnosing csPCa with a higher net benefit for all threshold probabilities in all cohorts. Setting a fixed sensitivity of 95%, a total of 32.2%, 17.6%, and 26.3% of unnecessary biopsies could be avoided with less than 5% of csPCa missed in the validation cohort, Changhai and Zhongda prospective cohorts, respectively.

CONCLUSIONS

The PCAIDS was an effective tool to inform decision-making regarding the need for prostate biopsy and prebiopsy examinations such as mpMRI. Further prospective and international studies are warranted to validate the findings of this study.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100048428. Registered on 06 July 2021.

Assessment of oligometastasis status of prostate cancer following combined robot-assisted radical prostatectomy and androgen deprivation versus androgen deprivation therapy alone using PSA percentage decline rate

Objective

To compare the tumor control in prostate cancer patients with oligo-metastasis following combined robot-assisted radical prostatectomy and androgen deprivation versus androgen deprivation therapy alone based on total prostate-specific antigen (tPSA) assessment.

Methods

Medical data of a total of 18 prostate cancer patients with oligometastasis administered in The First Affiliated Hospital of Nanchang University from March 2017 to March 2018 were prospectively collected. 10 patients received a combined therapy of robot-assisted radical prostatectomy and pharmaceutical androgen deprivation (RARP+ADT group), while 8 patients received pharmaceutical androgen deprivation therapy alone (ADT group). Then demographic characteristics, prostate volume, tumor characteristics and tPSA data were analysised and compared. Statistical analysis was performed using t-test for continuous variables and Pearson chi-square test or Fisher's exact test for categorical variables.

Results

No significant difference was found in patients' age (p = 0.075), prostate volume (p = 0.134) and number of bone metastasis (p = 0.342). Pre-treatment Gleason score was significantly lower in RA group (p = 0.003). Patients in RARP+ADT group had significantly lower pre-treatment tPSA (p = 0.014), while no statistical difference was noted in reexamined tPSA (p = 0.140) on follow-up. No statistical difference was noted in tPSA decline rates (declined tPSA value per day) in RARP+ADT and ADT group (8.1 ± 4.7 verse 7.5 ± 8.0 ng/ml/d, p = 0.853). However, tPSA percentage decline rate (declined tPSA percentage per day) was significantly higher in RARP+ADT group (11.6 ± 1.5%/d verses 2.9 ± 2.2%/d, p< 0.001). Immediate urinary continence was achieved in 9 patients (90%) upon removal of urethral catheter on post-operative day 7 in RARP+ADT group.

Conclusion

ADT alone and in combination with RARP both provide effective tumor control in patients suffering from prostate cancer with oligometastasis. ADT combined with RARP exhibited significant advantage in PSA percentage decline rate without compromising patients' urinary continence. Long-term tumor control requires further follow-up.

Urine Exosomal AMACR Is a Novel Biomarker for Prostate Cancer Detection at Initial Biopsy

Objectives

The aim of this study is to identify and validate urine exosomal AMACR (UE-A) as a novel biomarker to improve the detection of prostate cancer (PCa) and clinically significant PCa (Gleason score ≥ 7) at initial prostate biopsy.

Methods

A total of 289 first-catch urine samples after the digital rectal exam (DRE) were collected from patients who underwent prostatic biopsy, and 17 patients were excluded due to incomplete clinical information. Urine exosomes were purified, and urinary exosomal AMACR (UE-A) was measured by enzyme-linked immunosorbent assay (ELISA). The diagnostic performance of UE-A was evaluated by receiver operating characteristic (ROC) analysis, decision curve analysis (DCA), and waterfall plots.

Results

The expression of AMACR in PCa and csPCa was significantly higher than that in BPH and non-aggressive (p < 0.001). The UE-A presented good performance in distinguishing PCa from BPH or BPH plus non-significant PCa (nsPCa) from csPCa with an area under the ROC curve (AUC) of 0.832 and 0.78, respectively. The performance of UE-A was further validated in a multi-center cohort of patients with an AUC of 0.800 for detecting PCa and 0.749 for detecting csPCa. The clinical utility assessed by DCA showed that the benefit of patients using UE-A was superior to PSA, f/t PSA, and PSAD in both the training cohort and the validation cohort in terms of all threshold probabilities. Setting 95% sensitivity as the cutoff value, UE-A could avoid 27.57% of unnecessary biopsies, with only 4 (1.47%) csPCa patients missed.

Conclusions

We demonstrated the great performance of UE-A for the early diagnosis of PCa and csPCa. UE-A could be a novel non-invasive diagnostic biomarker to improve the detection of PCa and csPCa.

Einfluss von lokalen Therapiemaßnahmen auf die Biologie des fortschreitenden Prostatakarzinoms

Hintergrund

In den letzten 15 Jahren zeigt sich ein Trend hin zu einem längeren Überleben beim metastasierten Prostatakarzinom. Neben dem durch neue Medikamente bedingten Fortschritt deuten retrospektive Daten auch auf einen möglichen positiven Effekt einer früheren Primärtumorbehandlung hin.

Fragestellung

Kann eine Primärtumorbehandlung im Falle einer späteren Metastasierung die Prognose der betroffenen Patienten verbessern und wenn ja, über welche Mechanismen?

Material und Methode

Wir werteten die klinischen Langzeitergebnisse von 115 Patienten aus, die bei T4-Prostatakarzinomen nach induktiver Hormontherapie an unserer Klinik prostatektomiert worden waren. Weiterhin erfolgte eine kritische Durchsicht und Diskussion der zur oben genannten Fragestellung vorhandenen Literatur.

Ergebnisse

Von den 115 Patienten hatten 84 im weiteren Verlauf ein biochemisches Rezidiv erlitten, waren also definitiv durch die radikale Prostatektomie nicht geheilt. Das tumorspezifische und das Gesamtüberleben dieser 84 Patienten lag nach 150 Monaten bei 61 % bzw. 44 %. Bemerkenswert war die Beobachtung, dass diese Patienten ein überraschend gutes und langes Ansprechen auf eine Hormontherapie zeigten. Von den 84 Patienten waren nach durchschnittlich 95 Monaten Nachbeobachtungszeit noch 47 am Leben. 31 von ihnen, also ungefähr zwei Drittel, standen immer noch unter einer Standardhormontherapie. Nur 13 hatten eine Resistenz gegen die primäre Hormontherapie entwickelt und entsprechend eine tertiäre Hormontherapie erhalten, auf die sie teilweise aber auch wieder langfristig sensibel blieben.

Schlussfolgerungen

Die Primärtumorentfernung, zumindest unter den beschriebenen Begleitumständen, scheint die Entwicklung einer Hormonresistenz beim metastasierten Prostatakarzinom hinauszögern und in Einzelfällen sogar ganz verhindern zu können.

Survival analysis and prognostic factors of palliative radiotherapy in patients with metastatic colorectal cancer: a propensity score analysis

Background

Radiation therapy (RT) is known to have beneficial effects on the palliative treatment of patients with advanced cancer. However, valid data on this treatment method are limited, especially for patients with metastatic colorectal cancer (mCRC). This study aimed to identify prognostic factors and investigate the outcomes of mCRC patients who received palliative RT.

Methods

A total of 488 mCRC patients who underwent systemic therapy with or without palliative RT between 2014 and 2019 were included in the study. Of the 488 patients, 155 received systemic treatment combined with palliative RT (RT group), while 333 were only administered systemic treatment (non-RT group). Propensity score matching (PSM) was conducted to eliminate possible bias, and overall survival (OS) was calculated using the Kaplan-Meier (KM) method. A log-rank test was used to compare the survival outcomes of each group, and a multivariate analysis was conducted using a Cox proportional hazards model.

Results

The RT group had a higher OS than that of the non-RT group (P=0.001). After PSM, the median OS of the RT group was 50.8 months, and for the non-RT group it was 32.2 months (P=0.003). Subgroup analysis revealed that RT had a better effect on the OS of patients who had synchronous metastasis, or who didn't receive targeted therapy or local treatment (including surgery, ablation, and intervention). Multivariate analysis of the whole cohort showed that palliative RT was associated with improved OS. Moreover, multivariate analysis of the RT group showed that systemic therapy before RT, and the site of RT was in the liver and lung, were independent prognostic factors affecting survival time.

Conclusions

We demonstrated that systemic treatment followed by palliative RT led to a better OS for mCRC patients. This combination method can therefore be seen as a suitable treatment approach for patients with mCRC.

Cytoreductive radical prostatectomy versus systemic therapy and radiation therapy in metastatic prostate cancer: A systematic review and meta-analysis

Cytoreductive prostatectomy had gained a lot of interest in treatment of metastatic prostate cancer (mPCa) but this treatment approach is still in the experimental phase. This systematic review and meta-analysis was conducted to shed light on the merits of cytoreductive radical prostatectomy compared to systemic and radiation therapy in treatment of mPCa. In February 2021, summary data from 12 original research papers covering 100,973 patients is abstracted. PubMed/Medline, Scopus, Google Scholar, EMBASE, and the Cochrane Library were all reviewed and 12 publications were chosen for inclusion. The evaluated outcomes were 1-, 3-, and 5-year Cancer-Specific (CSS) and overall survival (OS) rates. Cytoreductive radical prostatectomy had significantly higher survival rate for 1-year (OR: 3.03; 95% CI: 2.30-3.98; p < 0.001), 3-year (OR: 2.47; 95% CI: 2.14-3.51; p < 0.001), and 5-year CSS rates (OR: 2.90; 95% CI: 2.10-4.01; p < 0.001) than systemic therapy in mPCa. Higher significant rates of 1-year (OR: 2.35; 95% CI: 1.65-3.36; p < 0.001), three-year (OR: 2.25; 95% CI: 1.96-2.60; p < 0.001), and 5-year OS rates (OR: 2.54; 95% CI: 2.10-3.08; p < 0.001) were also detected for cytoreductive radical prostatectomy compared to systemic therapy. There were no significant differences in 1-year (OR: 1.21; 95% CI: 0.88-1.66; p = 0.25), 3-year (OR: 1.21; 95% CI: 0.92-1.59; p = 0.18), and 5-year CSS rates (OR: 0.91; 95% CI: 0.58-1.42; p = 0.67) between cytoreductive radical prostatectomy and radiation in mPCa patients. Also, no significant differences in 1-year (OR: 1.06; 95% CI: 0.77-1.47; p = 0.71), 3-year (OR: 0.83; 95% CI: 0.60-1.14; p = 0.25), and 5-year OS rates (OR: 1.84; 95% CI: 0.76-4.45; p = 0.18) were detected between cytoreductive radical prostatectomy and radiation therapy. Cytoreductive radical prostatectomy had significantly higher 1-, 3-, and 5-year CSS and OS rates compared to systemic therapy. Comparable CSS and OS rates were found between cytoreductive radical prostatectomy and radiation therapy.

Prognostic impact of prior local therapy in castration-resistant prostate cancer

OBJECTIVE

This study aimed to reveal the prognostic values of prior local therapy in first-line therapy using androgen receptor-axis targeting agents (abiraterone or enzalutamide) or docetaxel for castration-resistant prostate cancer (CRPC).

METHODS

The study included 303 patients treated with first-line therapy for non-metastatic and metastatic CRPC. The association between prior local therapy and therapeutic outcome including progression-free survival and overall survival was investigated by univariate and multivariate analyses as well as propensity score-matched analysis.

RESULTS

In univariate analysis, local prior therapy was associated with a lower risk of all-cause mortality (hazard ratio, 0.56, 95% confidence interval, 0.40-0.79; P = 0.0009). Overall survival, but not progression-free survival, was better among patients with prior local therapy compared with patients without prior local therapy even after multivariate analysis and propensity score-matched analysis.

CONCLUSIONS

This study robustly indicated that prior local treatment was prognostic for overall survival among patients with CRPC. This finding is useful to predict patient prognosis in CRPC.

The comparison of the survival outcome between robotic-assisted radical prostatectomy and radiation therapy for localized prostate cancer in men over 70 years: Korean Nationwide Observational Study

This study aimed to investigate the survival after robotic-assisted radical prostatectomy (RARP) in comparison with radiation therapy (RT) in elderly patients (≥ 70 years) with non-metastatic prostate cancer (PCa), given the contemporary Korean life span of 80 years. From the National Health Insurance Sharing Service data, men aged ≥ 70 years diagnosed with PCa from 2006 through 2016 undergoing RARP or RT without systemic chemotherapy or prolonged androgen deprivation therapy (ADT) were identified, then the mortality was compared after adjusting host factors. Data revealed 13,952 patients with RARP (N = 7535) or RT (N = 6417). Patients who underwent RARP were younger (73.81 ± 3.58 vs. 75.05 ± 3.83 years) and had a higher income. While the majority of the RARP group (94.1%) received no additional therapy, 57.4% of the RT group combined ADT. The adjusted mortality rate for total patients was lower in the RARP group (HR = 0.767, 95% CI 0.072-0.818, p < 0.0001). From the age of 75 years, more patients underwent RT (n = 3239) than RARP (n = 2478). When dividing patients by this age cut-off, the adjusted mortality for the younger patient (70-74 years) was lower in the RARP group than the RT group (HR = 0.580, p < 0.0001). In contrast, the adjusted mortality rate for men older than 75 years was similar (HR = 0.98, 95% CI 0.897-1.07, p = 0.649). This study demonstrates that even the patient over 75 years old who could afford to undergo robotic-assisted radical prostatectomy for non-metastatic PCa had a similar survival in comparison with RT, which had long been a standard of care for this particular age group.

Castration-resistant prostate cancer without metastasis at presentation may achieve cancer-specific survival in patients who underwent prior radical prostatectomy

PURPOSE

Radical prostatectomy (RP) is relatively better oncological outcomes in patients with prostate cancer (PCa). However, the incidence of castration-resistant PCa (CRPC) and PCa-specific mortality in patients with biochemical recurrence (BCR) after RP remains unclear. The aim of this study was to evaluate the cancer-specific survival (CSS) in patients with CRPC after RP, in particular those who had metastases or not.

METHODS

We retrospectively reviewed the data of 1582 consecutive patients who underwent RP between July 1996 and January 2019. The enrolled patients had histologically confirmed stage T1a-T3b PCa without lymph node involvement or distant metastasis. The endpoints were oncological outcomes, including CSS and BCR, in patients with PCa with or without metastases at the time of diagnosis with CRPC.

RESULTS

A total of 1474 patients were enrolled in this study. By the end of the follow-up period, 352 patients (24.6%) in the enrolled patients had BCR after RP. A total of 42 patients (2.9%) developed CRPC and 18 (1.3%) had died of PCa. With regard to metastasis in patients who diagnosed CRPC, the 5-year CSS rate was 100% for nonmetastatic CRPC (nmCRPC) patients and 53.8% for metastatic CRPC (mCRPC) patients after RP. The 5-year CSS rate was 100% for nmCRPC patients and 27.1% for mCRPC patients after the diagnosis with CRPC.

CONCLUSIONS

CRPC is one of the lethal causes with PCa death. However, nmCRPC may achieve relatively good prognosis in patients with PCa after RP.

Risk of complications and urinary incontinence following cytoreductive prostatectomy: a multi-institutional study

Emerging evidence has suggested that cytoreductive prostatectomy (CRP) allows superior oncologic control when compared to current standard of care androgen deprivation therapy alone. However, the safety and benefit of cytoreduction in metastatic prostate cancer (mPCa) has not been proven. Therefore, we evaluated the incidence of complications following CRP in men newly diagnosed with mPCa. A total of 68 patients who underwent CRP from 2006 to 2014 at four tertiary surgical centers were compared to 598 men who underwent radical prostatectomy for clinically localized prostate cancer (PCa). Urinary incontinence was defined as the use of any pad. CRP had longer operative times (200 min vs 140 min, P < 0.0001) and higher estimated blood loss (250 ml vs 125 ml, P < 0.0001) compared to the control group. However, both overall (8.82% vs 5.85%) and major complication rates (4.41% vs 2.17%) were comparable between the two groups. Importantly, urinary incontinence rate at 1-year after surgery was significantly higher in the CRP group (57.4% vs 90.8%, P < 0.0001). Univariate logistic analysis showed that the estimated blood loss was the only independent predictor of perioperative complications both in the unadjusted model (OR: 1.18; 95% CI: 1.02–1.37; P = 0.025) and surgery type-adjusted model (OR: 1.17; 95% CI: 1.01–1.36; P = 0.034). In conclusion, CRP is more challenging than radical prostatectomy and associated with a notably higher incidence of urinary incontinence. Nevertheless, CRP is a technically feasible and safe surgery for selecting PCa patients who present with node-positive or bony metastasis when performed by experienced surgeons. A prospective, multi-institutional clinical trial is currently underway to verify this concept.

How to choose proper local treatment in men aged ≥75 years with cT2 localized prostate cancer?

BACKGROUND

For localized prostate cancer (PCa), radical prostatectomy (RP) and radiotherapy (RT) are two standard interventions to decrease PCa mortality. Contemporary studies contained the elderly people; analyses focusing on patients over 75 years of age were still lacking.

METHOD

In the Surveillance Epidemiology and End Results (SEER) database (2004-2015), people over 75 years of age with cT2 stage were selected in our research. Multivariable Cox proportional hazard models were used to analyze cancer-specific mortality (CSM) and overall mortality (OM) after adjustment. The propensity score matching was performed to assume the randomization. An instrument variate (IVA) was used to calculate the unmeasured confounders.

RESULTS

Radical prostatectomy is superior to RT in OM and CSM after adjustment for covariates (HR = 0.54, 95% CI = 0.47-0.62, P < 0.001 and HR = 0.30, 95% CI = 0.20-0.45, P < 0.001, respectively). The cox model after matching indicated similar consequence (OM: HR = 0.53, 95% CI = 0.46-0.62, P < 0.001; CSM: HR = 0.27, 95% CI = 0.17-0.43, P < 0.001). In the IVA-adjusted model, the effect of treatment changed slightly (OM: HR = 0.65, 95% CI = 0.54-0.78, P < 0.001; CSM: HR = 0.21, 95% CI = 0.12-0.37, P < 0.001). Subgroup analyses showed that for patients with GS = 7, those received RP obtained the highest risk decline for overall death (HR = 0.41, 95% CI = 0.32-0.52); and for patients with younger age, those received RP obtained the highest risk decline for CSM (HR = 0.11, 95% CI = 0.01-0.52).

CONCLUSION

Patients over 75 years of age with cT2 stage will obtain more benefit from RP compared with RT, especially for patients with GS = 7 and younger age.

Different therapeutic regimens in the treatment of metastatic prostate cancer by performing a Bayesian network meta-analysis

BACKGROUND

Although androgen deprivation therapy with or without chemotherapy are currently the mainstay of therapy for metastatic prostate cancer, accumulating data suggested the survival benefits from definitive local therapy such as radical prostatectomy or radiation therapy. Hence, this network meta-analysis was aimed to provide a hierarchy of different therapeutic regimens for mPCa.

METHODS

Relevant studies were retrieved comprehensively by searching the online databases of PubMed, EMBASE and Web of Science, published before July 1st, 2018. With the help of R-3.4.0 software and "gemtc-0.8.2" package, network meta-analysis was performed by random-effect model within a Bayesian framework. Hazard ratios and corresponding 95% credible intervals were calculated by Markov chain Monte Carlo methods. The surface under the cumulative ranking curve was also incorporated to rank the corresponding therapeutic regimens.

RESULTS

A total of 55,363 cases from 17 studies were ultimately involved in this study. Ten different therapeutic regimens and three clinical endpoints were finally assessed. As illustrated by our results, local therapy (such as radical prostatectomy or radiation therapy) could provide a relatively more favorable survival rate than systematic therapies (no local therapy, androgen deprivation therapy or androgen deprivation therapy + chemotherapy). Meanwhile, in the comparison of radiation therapy, brachytherapy and intensity modulated radiation therapy were among the best two therapies. Furthermore, radical prostatectomy had a relatively lower cancer specific mortality or all-cause mortality than brachytherapy or intensity modulated radiation therapy, in the comparison of local therapy, whereas brachytherapy showed a relatively longer overall survival than radical prostatectomy.

CONCLUSIONS

Our results indicated that local therapy was better than no local therapy. In a comprehensive comparison of three clinical endpoints (overall survival, cancer specific mortality or all-cause mortality), radical prostatectomy had a relatively lower cancer specific mortality or all-cause mortality than radiation therapy, whereas brachytherapy was superior to radical prostatectomy for overall survival.

Palliative beam radiotherapy offered real-world survival benefit to metastatic rectal cancer: A large US population-based and propensity score-matched study

Purpose: Radiotherapy (RT) has been reported to effectively palliate many symptoms of patients with metastatic rectal cancer (mRC). The objective of this study was to evaluate the survival benefit of RT in mRC. Methods: A retrospective population-based cohort study was performed using the Surveillance, Epidemiology, and End Results Program (SEER) database. Patient baseline demographic characteristics between the RT and no-RT groups were compared using Pearson chi-square tests. The outcome of interest was cause-specific survival (CSS). Propensity score (PS) matching and Cox proportional hazards regression analyses were performed to evaluate the prognostic power of variables on CSS. Results: A total of 8851 patients with mRC were identified in the SEER database. Multivariable Cox regression analysis showed that RT was a protective factor in mRC (hazard ratio [HR]= 0.702, 95% confidence interval [CI]=0.665-0.741, p<0.001). In subgroup analysis, multivariate Cox analysis demonstrated that patients of both surgery and no-surgery subgroups treated with RT had better CSS than those not treated with RT (HR=0.654, 95%CI=0.607-0.704, p<0.001 for the surgery group; HR=0.779, 95%CI=0.717-0.847, p<0.001 for the no-surgery group), PS matching resulted in 4170 mRC patients and RT group presented significantly improved survival benefit than no-RT group (22.0 vs. 13.5%, P <0.001). In surgery subgroup after PS matching, in especial, RT group showed more evidently improved survival benefit than no-RT group (30.3 vs. 18.0%, p <0.001). Conclusion: Using the SEER database, we definitely demonstrated that RT was associated with a significant survival advantage beyond the relief of a variety of pelvic symptoms in the setting of mRC. This study strongly supports the use of RT in selected patients with mRC, especially in patients who have undergone surgery. More studies need to be conducted to accurately define the role of RT in mRC.

Novel Insights into the Management of Oligometastatic Prostate Cancer: A Comprehensive Review

CONTEXT

The current standard of care for metastatic prostate cancer (PCa) is androgen deprivation therapy (ADT) plus either docetaxel or abiraterone. Growing evidence suggests that metastasis-directed therapy (MDT) and/or local therapy targeted to the primary tumour (ie, prostate) may be of benefit in the setting of oligometastatic disease. Several prospective studies are underway; however, until robust evidence is available to guide treatment decisions, physicians are challenged with how best to manage patients with oligometastases.

OBJECTIVE

This comprehensive review aims to collate the available evidence to date for a role of MDT and/or prostate-targeted therapy in the setting of oligometastatic PCa, as well as discuss ongoing trials in this setting.

EVIDENCE ACQUISITION

We searched PubMed for the combination of "prostate cancer" and "oligometastatic", "oligometastases", "oligometastasis", "solitary metastases", "stereotactic body radiotherapy", "SBRT", "stereotactic ablative radiotherapy", "SABR", "salvage lymphadenectomy", or "metastasectomy" in publications over the last 20yr. We also searched ClinicalTrials.gov to identify relevant ongoing trials.

EVIDENCE SYNTHESIS

The studies were divided according to the timing of metastasis into synchronous (ie, detected at the time of primary PCa diagnosis) and metachronous (ie, detected after treatment of the primary tumour), and according to treatment modality into MDT (including salvage lymph node dissection [sLND]) and prostate-targeted treatment. For MDT of synchronous/metachronous metastases, we included 16 completed studies and 11 ongoing prospective studies. In the case of sLND for nodal-only recurrence after primary treatment with curative intent, we included 11 completed studies. Finally, for prostate-targeted treatment of synchronous metastatic PCa, we included 25 completed studies and 11 ongoing prospective studies. In selected patients with oligorecurrent disease, early detection and aggressive treatment of metastatic lesions (surgery or radiotherapy) appears to be a feasible strategy and may delay the use of systemic therapies. MDT is a promising option in oligometastatic PCa patients, but more robust data are needed. In the setting of synchronous oligometastatic disease, aggressive cytoreductive treatment needs further data to confirm the benefits.

CONCLUSIONS

In this review, we provide a comprehensive overview of the current literature on the treatment of patients with oligometastatic PCa. The data suggest that although ADT plus either docetaxel or abiraterone remains the mainstay of treatment for mPCa, in oligometastatic PCa, improved outcomes may be achieved with metastasis- and prostate-targeted therapies. The studies included in this review are mainly retrospective in nature, limiting the strength of the evidence they provide. Prospective studies are ongoing, and their results are eagerly awaited.

PATIENT SUMMARY

We reviewed the treatment of patients with prostate cancer that has spread to five sites or fewer. We conclude that while androgen deprivation plus either docetaxel or abiraterone should remain the standard of care, there is evidence that treatment targeted at the metastases and the primary tumour may improve the outcome for the patient and potentially delay the use of systemic treatment.

Impact of prior local therapy on overall survival in men with metastatic castration-resistant prostate cancer: Results from Shared Equal Access Regional Cancer Hospital

OBJECTIVES

To evaluate the impact of previous local treatment on survival in men with newly diagnosed metastatic castration-resistant prostate cancer.

METHODS

We carried out a retrospective study of patients newly diagnosed with metastatic castration-resistant prostate cancer in the year 2000 or later from eight Veterans Affairs Medical Centers. Patients were categorized based on prior local therapy (none, prostatectomy ± radiation or radiation alone). Overall and cancer-specific survival was estimated by the Kaplan-Meier method. Cox proportional hazards regression models were used to test the association between prior local treatment and survival.

RESULTS

Of 729 patients, 284 (39%) underwent no local treatment, 176 (24%) underwent radical prostatectomy ± radiation and 269 (37%) underwent radiation alone. On multivariable analysis, men with prior prostatectomy had improved overall (hazard ratio 0.71, P = 0.005) and cancer-specific survival (hazard ratio 0.55, P < 0.001) compared with men with no prior local therapy. This improvement in overall (hazard ratio 0.89, P = 0.219) and cancer-specific survival (hazard ratio 0.87, P = 0.170) was not seen in men with prior radiation alone. After further adjusting for comorbidity with the Charlson Comorbidity Index, patients with prior prostatectomy still had improved overall survival (hazard ratio 0.70, P = 0.003), whereas this was not seen in patients who received prior radiation alone (hazard ratio 0.88, P = 0.185).

CONCLUSIONS

Independent of patient- and disease-related factors, men with metastatic castration-resistant prostate cancer who had undergone prior radical prostatectomy have improved overall and cancer-specific survival compared with those with no prior local therapy.

Analysis of hematological parameters as prognostic markers for toxicity and survival of 223Radium treatment

²²³Radium (²²³Ra) has emerged as treatment prolonging survival in patients with metastatic castration-resistant prostate cancer (CRPC). As ²²³Ra can cause hematotoxicity (HT), pre-existing hematopoiesis might influence the efficacy of ²²³Ra and the rate of hematotoxicity, but as to our knowledge such data has not been published yet, we retrospectively conducted an analysis on patients receiving ²²³Ra.

54 patients treated with ²²³Ra had a median survival of 67 weeks, which was significantly reduced in patients with pre-existing Hb toxicity (Tox) grade 2 (48 weeks P = 0.008) as compared to grade 1 (67 weeks) and normal levels of Hb (not reached); survival in patients with Plt Tox grade 1 was significantly reduced (44 weeks) as compared to normal Plt counts (71 weeks, P = 0.033). Patients with impaired hematopoiesis regarding Hb and Plts developed significantly more grade 3 and 4 HT (Hb < 10 g/dl: 42.9% [3/7] vs 10.6% [5/47], P < 0.001; Plt < 150 G/L: 28.6% [2/7] vs 6.4% [3/47], P = 0.002) and received significantly fewer treatment cycles (Hb <10 g/dl: 5.1 vs 5.8, P = 0.04; Plt < 150 G/L: 3.4 vs 5.6, P < 0.001). These results imply that pre-existing impaired hematopoiesis, in particular thrombocytopenia and anemia, before ²²³Ra therapy, is an important risk factor for worse outcome of treatment with ²²³Ra.

The role of radical prostatectomy for the treatment of metastatic prostate cancer: a systematic review and meta-analysis

The recommended therapy by EAU guidelines for metastatic prostate cancer (mPCa) is androgen deprivation therapy (ADT) with or without chemotherapy. The role of radical prostatectomy (RP) in the treatment of mPCa is still controversial. Hence, a meta-analysis was conducted by comprehensively searching the databases PubMed, EMBASE and Web of Science for the relevant studies published before September 1st, 2017. Our results successfully shed light on the relationship that RP for mPCa was associated with decreased cancer-specific mortality (CSM) (pooled HR = 0.41, 95%CI = 0.36–0.47) and enhanced overall survival (OS) (pooled HR = 0.49, 95%CI = 0.44–0.55). Subsequent stratified analysis demonstrated that no matter how RP compared with no local therapy (NLT) or radiation therapy (RT), it was linked to a lower CSM (pooled HR = 0.36, 95%CI = 0.30–0.43 and pooled HR = 0.56, 95%CI 0.43–0.73, respectively) and a higher OS (pooled HR = 0.49, 95%CI = 0.44–0.56 and pooled HR = 0.46, 95%CI 0.33–0.65, separately). When comparing different levels of Gleason score, M-stage or N-stage, our results indicated that high level of Gleason score, M-stage or N-stage was associated with increased CSM. In summary, the outcomes of the present meta-analysis demonstrated that RP for mPCa was correlated with decreased CSM and enhanced OS in eligible patients of involved studies. In addition, patients with less aggressive tumors and good general health seemed to benefit the most. Moreover, no matter compared with NLT or RT, RP showed significant superiority in OS or CSM. Upcoming prospective randomized controlled trials were warranted to provide more high-quality data.

The outcome of prostate cancer patients treated with curative intent strongly depends on survival after metastatic progression

BACKGROUND

Five-year survival in patients with localized prostate cancer (PCa) is nearly 100%, but metastatic disease still remains incurable. Clinical management of metastatic patients has become increasingly complex as novel therapeutic strategies have emerged. This study aims at evaluating the impact of the first metastatic progression on the outcome of PCa patients treated with curative intent.

METHODS

The analysis was conducted using data of 913 cases of localized PCa diagnosed between 2000 and 2014. All patients were treated with curative surgery (N = 382) or radiotherapy (N = 531) with or without adjuvant therapy. All metastases were radiologically documented. The prognostic impact of the first site of metastasis on metastasis-free survival (MFS) and PCa-specific survival (PCaSS) was investigated by univariate and multivariate analyses.

RESULTS

One hundred and thirty-six (14.9%) patients developed a metastatic hormone-sensitive PCa and had a median PCaSS of 50.4 months after first metastatic progression. Bone (N = 50, 36.8%) and LN or locoregional (N = 52, 38.2%) metastases occurred more frequently with a median PCaSS of 39.7 and 137 months respectively (p < 0.0001). Seven patients developed visceral metastasis only (5.1%; liver, lung, brain) and 27 (19.9%) concurrent metastases; this last group was associated with the worst survival with a median value of only 17 months. Thus, each subgroup exhibited a survival after metastasis significantly different from each other. In multivariate analysis the site of the first metastasis was an independent prognostic factor for PCaSS along with Gleason score at diagnosis. The correlation between survival and first site of metastasis was confirmed separately for each therapy subgroup. Median metastasis-free survival from primary diagnosis to first metastasis was not correlated with the first site of metastasis.

CONCLUSIONS

In non-metastatic PCa patients treated with curative intent, the PCa-specific survival time depends on the time after metastatic progression rather than the time from diagnosis to metastasis. Moreover, the site of first metastasis is an independent prognostic factor for PCaSS. Our data confirm that the first metastatic event may confer a differential prognostic impact and may help in identifying patient at high risk of death supporting the treatment-decision making process following metastatic progression.

Testing radical prostatectomy in men with prostate cancer and oligometastases to the bone: a randomized controlled feasibility trial

This is the Protocol of the ethically-approved TRoMbone study.

Role of radical prostatectomy in metastatic prostate cancer: A review

CONTEXT

Recent demonstration of efficacy with the use of chemohormonal therapy for men with metastatic prostate cancer (mPCa) has expanded the therapeutic options for these patients. Furthermore, multimodal therapy to treat systemic disease in the context of locoregional control has gained increasing interest. Concomitantly, the role of radical prostatectomy (RP) in multimodal treatment for locally advanced prostate cancer is expanding. As a result, there is interest in investigating the potential benefit of cytoreductive RP in mPCa.

OBJECTIVE

To review the literature regarding the role of cytoreductive prostatectomy in the setting of mPCa.

EVIDENCE ACQUISITION

MEDLINE and PubMed electronic databases were queried for English language articles related to patients with mPCa who underwent RP from January 1990 to June 2016. Key words used in our search included cytoreductive prostatectomy, radical prostatectomy, and metastatic prostate cancer. Preclinical, retrospective, and prospective studies were included.

EVIDENCE SYNTHESIS

There are no published randomized control trials examining the role of cytoreduction in mPCa. Local symptoms are high in mPCa and often provide a necessity for palliative procedures with the impact on oncologic outcomes being uncertain. Recently, preclinical and retrospective population-based data suggest a benefit from treatment of the primary tumor in metastatic disease. Potential mechanisms mediating this benefit include prevention of symptomatic local progression and modulation of disease biology, resulting in an improvement in progression-free and overall survival. Current literature supports the feasibility of cytoreductive prostatectomy as it is associated with acceptable side effects that are comparable to RP for high-risk localized disease. In aggregate, these data compel prospective evaluation of the hypothesis that cytoreductive prostatectomy improves the outcome of men with mPCa.

CONCLUSIONS

Cytoreductive prostatectomy in mPCa is a feasible procedure that may improve outcomes for men when combined with multimodal management. Preclinical, translational, and retrospective evidence supports local therapy for metastatic disease. However, currently, evidence is limited and is subject to bias. The results of ongoing prospective randomized trials are required before incorporating this therapeutic strategy into clinical practice.

Multidisciplinary intervention of early, lethal metastatic prostate cancer: Report from the 2015 Coffey-Holden Prostate Cancer Academy Meeting

BACKGROUND

The 2015 Coffey-Holden Prostate Cancer Academy Meeting, themed: "Multidisciplinary Intervention of Early, Lethal Metastatic Prostate Cancer," was held in La Jolla, California from June 25 to 28, 2015.

METHODS

The Prostate Cancer Foundation (PCF) sponsors an annual, invitation-only, action-tank-structured meeting on a critical topic concerning lethal prostate cancer. The 2015 meeting was attended by 71 basic, translational, and clinical investigators who discussed the current state of the field, major unmet needs, and ideas for addressing earlier diagnosis and treatment of men with lethal prostate cancer for the purpose of extending lives and making progress toward a cure.

RESULTS

The questions addressed at the meeting included: cellular and molecular mechanisms of tumorigenesis, evaluating, and targeting the microenvironment in the primary tumor, advancing biomarkers for clinical integration, new molecular imaging technologies, clinical trials, and clinical trial design in localized high-risk and oligometastatic settings, targeting the primary tumor in advanced disease, and instituting multi-modal care of high risk and oligometastatic patients.

DISCUSSION

This article highlights the current status, greatest unmet needs, and anticipated field changes that were discussed at the meeting toward the goal of optimizing earlier interventions to potentiate cures in high-risk and oligometastatic prostate cancer patients.

[Comparative oncologic and functional outcomes of prostate cancer surgery with other curative treatments]

OBJECTIVE

Review of the comparative results of different treatment strategies (surgery, radiotherapy, ultrasound, surveillance) of prostate cancer, in which the main goal is the local control and the second target is the tolerance of the side effects of those treatments.

MATERIALS AND METHODS

Review of literature using Medline databases selected based on scientific relevance. Clinical keys centered on the oncological and functional outcomes of comparative series between different curative treatments.

RESULTS

The numerous comparative series between surgery and other therapeutic modalities are essentially retrospective with significant methodological bias that is difficult to overcome in order to formulate the optimal thesis. However, there is a clear tendency toward surgery usually with young patients who have intermediate risk tumors without important comorbidity.

CONCLUSION

In the absence of randomized comparative series with significant power, the oncological and functional results of the radical prostatectomy with or without adjuvant treatment seem at least the same, in a selected population of patients, compared with the combination of radiotherapy-hormonotherapy in terms of survival, without biochemical recurrence, disease-specific survival and overall survival, for the aggressive tumors necessitating curative local treatments.

[Oncological principles for local control of primary tumor]

OBJECTIVE

Review of the databases of carcinogenesis and the principles of local control of the primary tumor in order to decrease the risk of tumor progression and predict metastatic behavior.

MATERIALS AND METHODS

Review of the literature using Medline databases based on scientific relevance. Research was centered on the characteristics of solid tumor development, the basics of local control of the primary tumor, latest advance in genomics and the oncological principles applied on prostate cancer surgery.

RESULTS

The cornerstone in order to cure a local or locally advanced cancer is to eradicate the primary tumor. This should be done using effective methods that can assure local control, decrease the risk of progression and metastasis. The oncological surgery is the most important step in order to have this tumor control, beside radiotherapy and systemic therapy associated. In localized prostate cancer, surgery remains the gold standard between the multiple therapeutic modalities proposed.

CONCLUSION

The local control of solid malignant tumor is primordial in order to change the natural history of the disease and decrease its risk of progression. This is the goal of oncological surgery, and starting from these principles radical prostatectomy was favored.

The role for surgery in high-risk prostate cancer

High-risk prostate cancer (PCa) refers to a very heterogeneous subgroup of disease. Recent series have shown very promising results of radical prostatectomy (RP)-alone or part as a multimodality approach-in patients with high-risk PCa, with satisfactory survival curves even though biochemical recurrence rate was high. Adjuvant treatment (radiotherapy (RT) alone or combined with androgen deprivation) was necessary in 20 to 54 % of patients, notably in cases with positive surgical margins. As for functional outcomes, urinary continence was preserved in about 92 % of cases and overall potency in 60 %. When comparing RP versus RT as primary treatment for high-risk PCa, a recent meta-analysis found surgery to be associated with an improved cancer-specific mortality compared with RT. In selected high-risk PCa young patients, surgery appears to be a valid option. Patients should however be informed of the possibility of adjuvant treatment, as part of a multimodal approach.

Can Angiotensin-Converting Enzyme Inhibitors Reduce the Incidence, Severity, and Duration of Radiation Proctitis?

PURPOSE

To determine whether participants taking angiotensin-converting enzyme inhibitors (ACEIs) and treated with radical radiation therapy with neoadjuvant/adjuvant hormone therapy have less incidence, severity, and duration of radiation proctitis.

METHODS AND MATERIALS

A propensity score analysis of 817 patients who underwent radical radiation therapy with neoadjuvant or adjuvant hormone therapy as primary line management in a cohort study during 2009 to 2013 was conducted. Patients were stratified as follows: group 1, hypertensive patients taking ACEIs (as a study group); group 2, nonhypertensive patients not taking ACEIs; and group 3, hypertensive patients not taking ACEIs (both as control groups). The incidence, severity, and duration of proctitis were the main outcome. χ(2) tests, Mann-Whitney U tests, analysis of variance, risk ratio (RR), confidence interval (CI), Kaplan-Meier plots, and log-rank tests were used.

RESULTS

The mean age of the participants was 68.91 years, with a follow-up time of 3.38 years. Based on disease and age-matched comparison, there was a statistically significant difference of proctitis grading between the 3 groups: χ(2) (8, n=308) = 72.52, P<.001. The Mann-Whitney U test indicated that grades of proctitis were significantly lower in hypertensive patients taking ACEIs than in nonhypertensive patients not taking ACEIs and hypertensive patients not taking ACEIs (P<.001). The risk ratio (RR) of proctitis in hypertensive patients taking ACEIs was significantly lower than in hypertensive patients not taking ACEIs (RR 0.40, 95% CI 0.30-0.53, P<.001) and in nonhypertensive patients not taking ACEIs (RR 0.58, 95% CI 0.44-0.77, P<.001). Time to event analysis revealed that hypertensive patients taking ACEIs were significantly different from the control groups (P<.0001). Furthermore, hypertensive patients taking ACEIs had significantly faster resolution of proctitis (P<.0001).

CONCLUSION

Patients who were taking ACEIs were significantly less likely to have high-grade proctitis after radical radiation therapy with neoadjuvant or adjuvant hormone therapy (P<.001). The intake of ACEIs was significantly associated with a reduced risk of radiation-induced proctitis and also with acceleration of its resolution.

Complications after radical prostatectomy or radiotherapy for prostate cancer: results of a population-based, propensity score-matched analysis

OBJECTIVE

To assess rates of treatment-related complications after radical prostatectomy or radiotherapy monotherapy, using propensity score matching to account for baseline differences between these patient populations.

METHODS

On the basis of a population-based study of men undergoing surgery or radiotherapy for prostate cancer in Ontario between 2002 and 2009, we undertook a propensity score-matched analysis including age, comorbidity, and year of treatment to assess treatment-related complication end points. These included hospital admission; urologic, rectal, or anal procedures; open surgeries; and secondary malignancies.

RESULTS

From the original cohort of 32,465 patients, 15,870 (48.9%) had surgery and 16,595 (51.1%) had radiation. Propensity score matching produced 8797 pairs (17,594 patients). Among these, when compared with patients treated with surgery, those treated with radiation experienced fewer admissions to hospital (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.78-0.92) and urologic procedures (HR, 0.50; 95% CI, 0.46-0.53) at year 1 but higher rates at year 3 (HR, 5.65; 95% CI, 4.61-6.91 and HR, 1.86; 95% CI, 1.62-2.13, respectively) and year 5. Although there was no significant difference in open surgeries at year 1, patients undergoing radiotherapy were at higher risk by year 3 (HR, 2.06; 95% CI, 1.23-3.47) and this rose by year 5. Over the study period, patients undergoing radiotherapy experienced more rectal-anal procedures (HR, 2.64; 95% CI, 2.37-2.95) and were diagnosed with more secondary malignancies (HR, 2.44; 95% CI, 1.16-5.14). Direct matching produced similar results.

CONCLUSION

From a propensity score-matched analysis, we found that patients undergoing radiation therapy for prostate cancer had higher rates of long-term complications in all 5 categories studied than patients undergoing surgery.

The biology and treatment of oligometastatic cancer

Clinical reports of limited and treatable cancer metastases, a disease state that exists in a transitional zone between localized and widespread systemic disease, were noted on occasion historically and are now termed oligometastasis. The ramification of a diagnosis of oligometastasis is a change in treatment paradigm, i.e. if the primary cancer site (if still present) is controlled, or resected, and the metastatic sites are ablated (surgically or with radiation), a prolonged disease-free interval, and perhaps even cure, may be achieved. Contemporary molecular diagnostics are edging closer to being able to determine where an individual metastatic deposit is within the continuum of malignancy. Preclinical models are on the outset of laying the groundwork for understanding the oligometastatic state. Meanwhile, in the clinic, patients are increasingly being designated as having oligometastatic disease and being treated owing to improved diagnostic imaging, novel treatment options with the potential to provide either direct or bridging therapy, and progressively broad definitions of oligometastasis.

Cytoreductive prostatectomy: evidence in support of a new surgical paradigm (Review)

Prostate cancer (PCa) remains the second ranked cause of cancer deaths in the United States. The current standard of care for metastatic prostate cancer (mPCa) includes systemic therapies with no option for surgery. In contrast, in other malignancies such as breast and kidney cancer, cyto-reduction plays an integral role in the treatment of metastatic disease. In this framework, there are emerging data that suggest a potential oncologic benefit to cytoreduction in mPCa. The majority of the data are retrospective in nature suggesting that patients with mPCa who had prior radical prostatectomy (RP) had a better survival, as well as improved response to systemic therapy. Similarly, patients who presented with metastatic disease and received definitive local therapy (RP or radiation) had greater survival than patients who received no treatment. In order to confer maximum potential benefit, operating in the setting of mPCa must be technically feasible with acceptable morbidity. It has been demonstrated in many studies that operating on locally advanced disease (T3a/b) does have similar morbidity as lower stage cancer. This may be applicable in the metastatic setting, because although PCa may have metastasized, it may remain locally advanced. On the molecular level there are a number of explanations concerning the potential benefit of cytoreduction. However, these ideas remain speculative with no concrete evidence to date.

Increased association of the ERG oncoprotein expression in advanced stages of prostate cancer in Filipinos

BACKGROUND

Filipinos with prostate cancer (CaP) are at increased risk of harboring advanced stages and lower survival rates compared to other Asians. This study aims to investigate prevalence of ETS-related gene (ERG) oncoprotein overexpression in Filipinos as surrogate of TMPRSS2-ERG gene fusions, using a highly specific monoclonal antibody (ERG-MAb), and conduct the first attempt to study the role of genetic alterations in the aggressive tumor biologic behaviour of CaP among Filipinos.

METHODS

This case-matched, case-control retrospective study evaluated ERG expression in Filipino patients diagnosed with CaP and its effect on stage and Gleason grade of their disease. Men who underwent radical prostatectomy for organ-confined disease at the University of the Philippines-Philippine General Hospital (UP-PGH) comprised the organ-confined cohort. Age-matched adults who had trans-rectal ultrasound-guided prostate (TRUSP) biopsy or trans-urethral resection of the prostate (TURP) with bilateral orchiectomy for T4 or stage IV CaP composed the advanced disease cohort.

RESULTS

Overall ERG expression frequency of 23.08% (N = 104) was demonstrated, with a higher rate observed in the advanced disease cohort (32.69%) compared to the organ-confined group (13.46%). Furthermore, ERG overexpression was only detected among intermediate and high-risk tumors. A high-specificity (98.08%) of the ERG-MAb for malignant prostatic cells was likewise demonstrated.

CONCLUSIONS

In contrast to higher ERG frequency in Western countries, it is much lower in Filipino CaP, which is similar to lower rates noted from other Asian countries. The 98.08% specificity of ERG oncoprotein for prostate tumor cells combined with its increased association in advanced disease, suggests for prognostic potential of ERG that may aid clinicians in treatment decisions for Filipino CaP patients.