A Novel Nomogram to Identify Candidates for Extended Pelvic Lymph Node Dissection Among Patients with Clinically Localized Prostate Cancer Diagnosed with Magnetic Resonance Imaging-targeted and Systematic Biopsies

Development and External Validation of Nomograms for Predicting Disease-Free Survival and Overall Survival in Patients with cT1-ccRCC After Partial Nephrectomy: A Multicenter Retrospective Study

BACKGROUND

To develop a novel nomogram for predicting 2-year and 5-year disease-free survival (DFS) and overall survival (OS) in patients with cT1-clear cell renal cell carcinoma (ccRCC) undergoing partial nephrectomy (PN).

METHODS

A retrospective study was conducted across five urological centers, including 940 patients who underwent PN for cT1N0M0-ccRCC. Four centers were randomly selected to constitute the training group, while the remaining center served as the testing group. We employed the LASSO and multivariate Cox regression to develop new nomograms. The 1,000 bootstrap-corrected c-index, net reclassification improvement (NRI) and receiver operating characteristic curve were employed to compare the predictive abilities of new nomograms with the widely used UUIS and SSIGN models. Finally, the novel nomograms underwent external validation.

RESULTS

The training group included 714 patients, while the testing group consisted of 226 patients. The bootstrap-corrected c-indexes for the DFS and OS model were 0.870 and 0.902, respectively. In the training cohort, the AUC for the DFS and OS models at 2 years and 5 years were 0.953, 0.902, 0.988, and 0.911, respectively. These values were also assessed in the testing cohort. The predictive capabilities of the new nomograms surpassed those of the UUIS and SSIGN models (NRI > 0). Decision curve analysis demonstrated that the novel nomograms provide greater net benefits compared to the UUIS and SSIGN models.

CONCLUSIONS

Our novel nomograms demonstrated strong predictive ability for forecasting oncological outcomes in cT1-ccRCC patients after PN. These user-friendly nomograms are simple and convenient for clinical application, providing tangible clinical benefits.

A novel nomogram to predict clinically significant prostate cancer in MR assisted lesion biopsies: Turkish urooncology association nomogram

OBJECTIVE

This study aimed to develop a novel nomogram to predict clinically significant prostate cancer in patients undergoing multi-parametric prostate MRI-assisted lesion biopsies, addressing the challenges in deciding on biopsy for patients with PI-RADS 3 lesions and follow-up strategies for patients with negative PI-RADS 4 or 5 lesions.

MATERIALS AND METHODS

A retrospective case-control study was conducted using the Turkish Urooncology Association Databases (UROCaD). The final dataset included 2428 lesion biopsy data. Univariate analysis, logistic regression, and validation were performed, with 1942 and 486 lesion biopsy data in the training and validation datasets, respectively.

RESULTS

Age, initial total PSA value, PSA density, prostate volume, lesion length, DRE findings, and PI-RADS score were significantly different between benign or non-significant cancer and clinically significant prostate cancer groups. The developed nomogram incorporated PSA density, age, PI-RADS score, lesion length, and DRE findings. The mean area under the curve for the 6-fold cross-validation was 0.836, while the area under the curve values for the training and validation datasets were 0.827 and 0.861, respectively. The nomogram demonstrated a sensitivity of 75.6% and a specificity of 74.8% at a cut-off score of 24.9, with positive and negative predictive values of 42.2% and 92.6%, respectively.

CONCLUSION

The TUA nomogram, based on PSA density, age, PI-RADS score, lesion length, and DRE findings, provides a reliable and accurate prediction tool for detecting clinically significant prostate cancer in patients undergoing multi-parametric prostate MRI-assisted lesion (fusion) biopsies, potentially improving patient management and reducing unnecessary biopsies.

Can the Briganti 2019 nomogram be modified to predict lymph node metastasis risk in patients with prostate cancer detected with in-bore biopsy?

OBJECTIVES

We aimed to modify the Briganti 2019 nomogram and to test whether it is valid for patients who were diagnosed with prostate cancer through in-bore prostate biopsies.

METHODS

Data for 204 patients with positive multiparametric prostate MRI and prostate cancer identified either by mpMRI-cognitive/software fusion or in-bore biopsy and who underwent robot-assisted radical prostatectomy and extended pelvic lymph node dissection between 2012 and 2023 were retrospectively analyzed. The Briganti 2019 nomogram was applied to the mpMRI-cognitive/software fusion biopsy group (142 patients) in the original form, and then, two modifications were tested for the targeted component. Original and modified scores were compared. These modifications were adapted for the in-bore biopsy group (62 patients). The final histopathologic stage was regarded as the gold standard.

RESULTS

Nodal metastases were identified in 18/142 (12.6%) of mpMRI-cognitive/software fusion biopsy patients and 8/62 (12.9%) of the in-bore biopsy patients. In the mpMRI-cognitive/software fusion biopsy group, tumor size/core size (%) of targeted biopsy cores and positive core percentage on systematic biopsy were significant parameters for lymph node metastasis based on univariate logistic regression analyses (p < 0.05). With the modifications of these parameters for the in-bore biopsy group, V1 modification of the Briganti 2019 nomogram provided 100% sensitivity and 31.5% specificity (AUC:0.627), while V2 modification provided 75% sensitivity and 46.3% specificity (AUC:0.645).

CONCLUSIONS

Briganti 2019 nomogram may be modified by utilizing tumor size/core size (%) for targeted biopsy cores instead of positive core percentage on systematic biopsy or by not taking both parameters into consideration to detect node metastasis risk of patients diagnosed with in-bore biopsies.

The prostate-gland asymmetry affects the 3- and 12-month continence recovery after RARP in patients with small prostate glands: a single center study

To test the impact of the prostate-gland asymmetry on continence rates, namely 3- and 12-month continence recovery, in prostate cancer (PCa) patients who underwent robot-assisted radical prostatectomy (RARP). Within our institutional database, RARP patients with complete preoperative MRI features and 12 months follow-up were enrolled (2021-2023). The population has been stratified according to the presence or absence of prostate-gland asymmetry (defined as the presence of median lobe or side lobe dominance). Multivariable logistic regression models (LRMs) predicting the continence rate at 3 and 12 months after RARP were fitted in the overall population. Subsequently, the LRMs were repeated in two subgroup analyses based on prostate size (≤ 40 vs > 40 ml). Overall, 248 consecutive RARP patients were included in the analyses. The rate of continence at 3 and 12 months was 69 and 72%, respectively. After multivariable LRM the bladder neck sparing approach (OR 3.15, 95% CI 1.68-6.09, p value < 0.001) and BMI (OR 0.90, 95% CI 0.82-0.97, p = 0.006) were independent predictors of recovery continence at 3 months. The prostate-gland asymmetry independently predicted lower continence rates at 3 (OR 0.33, 95% CI 0.13-0.83, p = 0.02) and 12 months (OR 0.31, 95% CI 0.10-0.90, p = 0.03) in patients with prostate size ≤ 40 ml. The presence of prostate lobe asymmetry negatively affected the recovery of 3- and 12-months continence in prostate glands ≤ 40 mL. These observations should be considered in the preoperative planning and counseling of RARP patients.

2012 Briganti nomogram predict prostate cancer progression in EAU intermediate risk with unfavorable tumor grade: A single center experience

BACKGROUND

To investigate the potential prognostic impact of Briganti's 2012 nomogram in EAU intermediate-risk patients presenting with an unfavorable tumor grade and treated with robot-assisted radical prostatectomy, eventually associated with extended pelvic lymph node dissection.

MATERIALS AND METHODS

From January 2013 to December 2021, the study included 179 EAU intermediate-risk patients presenting with an unfavorable tumor grade (ISUP 3), eventually associated with a PSA of 10-20 ng/ml and/or cT-2b. Briganti's 2012 nomogram was assessed as both a continuous and dichotomous variable, categorized according to the median (risk score ⩾7% vs <7%). Disease progression, defined as biochemical recurrence and/or metastatic progression, was evaluated using Cox proportional hazards in both univariate and multivariate analyses.

RESULTS

Disease progression occurred in 43 (24%) patients after a median (95% CI) follow-up of 78 (65.7-88.4) months. The nomogram risk score predicted disease progression, evaluated both as a continuous variable (hazard ratio, HR = 1.064; 95% CI: 1.035-1.093; p < 0.0001) and as a categorical variable (HR = 3.399; 95% CI: 1.740-6.638; p < 0.0001). This association was confirmed in multivariate analysis, where hazard ratios remained consistent even after adjusting for clinical and pathological factors.

CONCLUSIONS

In EAU intermediate-risk PCa cases presenting with an unfavorable tumor grade and treated surgically, Briganti's 2012 nomogram was associated with disease progression after surgery. Consequently, as the nomogram risk score increased, patients were more likely to experience PCa progression, facilitating the stratification of the patient population into distinct prognostic subgroups.

Japanese clinical practice guidelines for prostate cancer 2023

This fourth edition of the Japanese Clinical Practice Guidelines for Prostate Cancer 2023 is compiled. It was revised under the leadership of the Japanese Urological Association, with members selected from multiple academic societies and related organizations (Japan Radiological Society, Japanese Society for Radiation Oncology, the Department of EBM and guidelines, Japan Council for Quality Health Care (Minds), Japanese Society of Pathology, and the patient group (NPO Prostate Cancer Patients Association)), in accordance with the Minds Manual for Guideline Development (2020 ver. 3.0). The most important feature of this revision is the adoption of systematic reviews (SRs) in determining recommendations for 14 clinical questions (CQs). Qualitative SRs for these questions were conducted, and the final recommendations were made based on the results through the votes of 24 members of the guideline development group. Five algorithms based on these results were also created. Contents not covered by the SRs, which are considered textbook material, have been described in the general statement. In the general statement, a literature search for 14 areas was conducted; then, based on the general statement and CQs of the Japanese Clinical Practice Guidelines for Prostate Cancer 2016, the findings revealed after the 2016 guidelines were mainly described. This article provides an overview of these guidelines.

Feasibility of Using a Novel Drop-In Gamma Probe for 99mTc-PSMA-I&S-Guided Lymph Node Detection During Robot-Assisted Radical Prostatectomy for Primary Prostate Cancer

PURPOSE

Prostate-specific membrane antigen (PSMA)-targeted radioguided surgery (RGS) has gained increased interest in prostate cancer (PCa). This analysis aims to evaluate the feasibility, safety, and limitations of RGS with a novel drop-in gamma probe in primary PCa.

PATIENTS AND METHODS

The data of 13 patients with primary PCa undergoing RGS were analyzed retrospectively. After preoperative administration of 99mTc-PSMA-I&S, a SPECT/CT was conducted and a robotic radical prostatectomy was performed the following day including intraoperative assessment of the lymph node stations using a novel robotic drop-in gamma probe. This was followed by an extended pelvic lymph node dissection (ePLND) with ex vivo control measurement using the drop-in and a conventional rigid gamma probe.

RESULTS

Eleven patients (median PSA value of 11 ng/mL) had high-risk and 2 patients had intermediate-risk PCa. Overall, a median of 22 ePLND lymph nodes were dissected. In 1 patient, preoperative SPECT/CT imaging showed suspicious lymph nodes, which could be confirmed intraoperatively with the robotic drop-in probe and subsequently in the final histopathological analysis. RGS failed to identify 2 patients with micrometastases (<3 mm) preoperatively and intraoperatively. No postoperative complications related to 99mTc-PSMA-I&S RGS or ePLND occurred.

CONCLUSIONS

RGS with the novel drop-in gamma probe and 99mTc-PSMA-I&S allows for a reliable intraoperative screening for lymph node metastases in robot-assisted radical prostatectomy for primary PCa with an acceptable safety profile. However, limitations in the detection of micrometastases need to be overcome before omitting extended ePLND in patients at risk for lymphatic spread.

Is it safe to defer prostate cancer treatment? Assessing the impact of surgical delay on the risk of pathological upstaging after robot-assisted radical prostatectomy

INTRODUCTION

We sought to investigate whether surgical delay may be associated with pathological upstaging in patients treated with robot assisted radical prostatectomy (RARP) for localized and locally advanced prostate cancer (PCa).

MATERIALS AND METHODS

Consecutive firstly-diagnosed PCa patients starting from March 2020 have been enrolled. All the patients were categorized according to EAU risk categories for PCa risk. Uni- and multivariate analysis were fitted to explore clinical and surgical predictors of pathological upstaging to locally advanced disease (pT3/pT4 - pN1 disease).

RESULTS

Overall 2017 patients entered the study. Median age at surgery was 68 (IQR 63-73) years. Overall low risk, intermediate risk, localized high risk and locally advanced disease were recorded in 368 (18.2 %), 1071 (53.1 %), 388 (19.2 %) and 190 (9.4 %), respectively. Median time from to diagnosis to treatment was 51 (IQR 29-70) days. Time to surgery was 56 (IQR 32-75), 52 (IQR 30-70), 45 (IQR 24-60) and 41 (IQR 22-57) days for localized low, intermediate and high risk and locally advanced disease, respectively. Considering 1827 patients with localized PCa, at multivariate analysis ISUP grade group ≥4 on prostate biopsy (HR: 1.30; 95 % CI 1.07-1.86; p = 0.02) and surgical delay only in localized high-risk disease (HR: 1.02; 95 % CI 1.01-1.54; p = 0.02) were confirmed as independent predictors of pathological upstaging to pT3-T4/pN1 disease at final histopathological examination.

CONCLUSIONS

In localized high-risk disease surgical delay could be associated with a higher risk of adverse pathologic findings.

Defining the optimal target-to-background ratio to identify positive lymph nodes in prostate cancer patients undergoing robot-assisted [99mTc]Tc-PSMA radioguided surgery: updated results and ad interim analyses of a prospective phase II study

INTRODUCTION

Prostate-specific membrane antigen radioguided surgery (PSMA-RGS) might identify lymph node invasion (LNI) in prostate cancer (PCa) patients undergoing extended pelvic lymph node dissection (ePLND). The optimal target-to-background (TtB) ratio to define RGS positivity is still unknown.

MATERIALS & METHODS

Ad interim analyses which focused on 30 patients with available pathological information were conducted. All patients underwent preoperative PSMA positron emission tomography (PET). 99m-Technetium-PSMA imaging and surgery ([99mTc]Tc-PSMA-I&S) was administered the day before surgery. In vivo measurements were conducted using an intraoperative gamma probe. Performance characteristics and implications associated with different TtB ratios were assessed.

RESULTS

Overall, 9 (30%) patients had LNI, with 22 (13%) and 80 (11%) positive regions and lymph nodes, respectively. PSMA-RGS showed uptakes in 12 (40%) vs. 7 (23%) vs. 6 (20%) patients for a TtB ratio ≥ 2 vs. ≥ 3 vs. ≥ 4. At a per-region level, sensitivity, specificity and accuracy for a TtB ratio ≥ 2 vs. ≥ 3 vs. ≥ 4 were 72%, 88% and 87% vs. 54%, 98% and 92% vs. 36%, 99% and 91%. Performing ePLND only in patients with suspicious spots at PSMA PET (n = 7) would have spared 77% ePLNDs at the cost of missing 13% (n = 3) pN1 patients. A TtB ratio ≥ 2 at RGS identified 8 (24%) suspicious areas not detected by PSMA PET, of these 5 (63%) harbored LNI, with one pN1 patient (11%) that would have been missed by PSMA PET. Adoption of a TtB ratio ≥ 2 vs. ≥ 3 vs. ≥ 4, would have allowed to spare 18 (60%) vs. 23 (77%) vs. 24 (80%) ePLNDs missing 2 (11%) vs. 3 (13%) vs. 4 (17%) pN1 patients.

CONCLUSIONS

PSMA-RGS using a TtB ratio ≥ 2 to identify suspicious nodes, could allow to spare > 50% ePLNDs and would identify additional pN1 patients compared to PSMA PET and higher TtB ratios.

The value of synthetic MRI in detecting the brain changes and hearing impairment of children with sensorineural hearing loss

Introduction

Sensorineural hearing loss (SNHL) can arise from a diverse range of congenital and acquired factors. Detecting it early is pivotal for nurturing speech, language, and cognitive development in children with SNHL. In our study, we utilized synthetic magnetic resonance imaging (SyMRI) to assess alterations in both gray and white matter within the brains of children affected by SNHL.

Methods

The study encompassed both children diagnosed with SNHL and a control group of children with normal hearing {1.5-month-olds (n = 52) and 3-month-olds (n = 78)}. Participants were categorized based on their auditory brainstem response (ABR) threshold, delineated into normal, mild, moderate, and severe subgroups.Clinical parameters were included and assessed the correlation with SNHL. Quantitative analysis of brain morphology was conducted using SyMRI scans, yielding data on brain segmentation and relaxation time.Through both univariate and multivariate analyses, independent factors predictive of SNHL were identified. The efficacy of the prediction model was evaluated using receiver operating characteristic (ROC) curves, with visualization facilitated through the utilization of a nomogram. It's important to note that due to the constraints of our research, we worked with a relatively small sample size.

Results

Neonatal hyperbilirubinemia (NH) and children with inner ear malformation (IEM) were associated with the onset of SNHL both at 1.5 and 3-month groups. At 3-month group, the moderate and severe subgroups exhibited elevated quantitative T1 values in the inferior colliculus (IC), lateral lemniscus (LL), and middle cerebellar peduncle (MCP) compared to the normal group. Additionally, WMV, WMF, MYF, and MYV were significantly reduced relative to the normal group. Additionally, SNHL-children with IEM had high T1 values in IC, and LL and reduced WMV, WMF, MYV and MYF values as compared with SNHL-children without IEM at 3-month group. LL-T1 and WMF were independent risk factors associated with SNHL. Consequently, a prediction model was devised based on LL-T1 and WMF. ROC for training set, validation set and external set were 0.865, 0.806, and 0.736, respectively.

Conclusion

The integration of T1 quantitative values and brain volume segmentation offers a valuable tool for tracking brain development in children affected by SNHL and assessing the progression of the condition's severity.

Urinary extracellular vesicle-derived miR-126-3p predicts lymph node invasion in patients with high-risk prostate cancer

To investigate extracellular vesicles (EVs), biomarkers for predicting lymph node invasion (LNI) in patients with high-risk prostate cancer (HRPCa), plasma, and/or urine samples were prospectively collected from 45 patients with prostate cancer (PCa) and five with benign prostatic hyperplasia (BPH). Small RNA sequencing was performed to identify miRNAs in the EVs. All patients with PCa underwent radical prostatectomy and extended pelvic lymph node dissection. Differentially expressed miRNAs were identified in patients with and without pathologically-verified LNI. The candidate miRNAs were validated in low-risk prostate cancer (LRPCa) and BPH. Four miRNA species (e.g., miR-126-3p) and three miRNA species (e.g., miR-27a-3p) were more abundant in urinary and plasma EVs, respectively, of patients with PCa. None of these miRNA species were shared between urinary and plasma EVs. miR-126-3p was significantly more abundant in patients with HR PCa with LNI than in those without (P = 0.018). miR-126-3p was significantly more abundant in the urinary EVs of patients with HRPCa than in those with LRPCa (P = 0.017) and BPH (P = 0.011). In conclusion, urinary EVs-derived miR-126-3p may serve as a good biomarker for predicting LNI in patients with HRPCa.

Contemporary Role of Lymph Node Dissection in Genitourinary Cancers: Where Are We in 2023?

CONTEXT

Lymphadenectomy during surgery for genitourinary malignancies has varying benefits.

OBJECTIVE

To review contemporary evidence on lymph node dissection in genitourinary cancers.

EVIDENCE ACQUISITION

We performed a collaborative review to summarize current evidence supporting lymph node dissection in urothelial, prostate, kidney, penile, and testis cancers. We present the evidence on patient selection and recommended dissection templates, and highlight knowledge gaps and ongoing areas of investigation.

EVIDENCE SYNTHESIS

Lymph node dissection remains the reference standard for lymph node staging. Pathologic nodal stage informs prognosis and guides adjuvant treatment. Appropriate template and patient selection are paramount to optimize outcomes and capitalize on the selective therapeutic benefits.

CONCLUSIONS

Accurate staging with lymphadenectomy is contingent on appropriate template selection. The cumulative benefit will depend on judicious patient selection.

PATIENT SUMMARY

We performed a collaborative review by a diverse group of experts in urology. We reviewed current evidence on lymph node dissection.

The Impact of Omitting Contralateral Systematic Biopsy on the Surgical Planning of Patients with a Unilateral Suspicious Lesion on Magnetic Resonance Imaging Undergoing Robot-assisted Radical Prostatectomy for Prostate Cancer

Background and objective

A combined approach of magnetic resonance imaging (MRI)-targeted biopsy (TBx) and bilateral systematic biopsy (SBx) is advised in patients who have an increased risk of prostate cancer (PCa). The diagnostic gain of SBx in detecting PCa for treatment planning of patients undergoing robot-assisted radical prostatectomy (RARP) is unknown. This study aims to determine the impact of omitting contralateral SBx on the surgical planning of patients undergoing RARP in terms of nerve-sparing surgery (NSS) and extended pelvic lymph node dissection (ePLND).

Methods

Case files from 80 men with biopsy-proven PCa were studied. All men had a unilateral suspicious lesion on MRI, and underwent TBx and bilateral SBx. Case files were presented to five urologists for the surgical planning of RARP. Each case file was presented randomly using two different sets of information: (1) results of TBx + bilateral SBx, and (2) results of TBx + ipsilateral SBx. The urologists assessed whether they would perform NSS and/or ePLND.

Key findings and limitations

A change in the surgical plan concerning NSS on the contralateral side was observed in 9.0% (95% confidence interval [CI] 6.4-12.2) of cases. Additionally, the indication for ePLND changed in 5.3% (95% CI 3.3-7.9) of cases. Interobserver agreement based on Fleiss' kappa changed from 0.44 to 0.15 for the indication of NSS and from 0.84 to 0.83 for the indication of ePLND.

Conclusions and clinical implications

In our series, the diagnostic information obtained from contralateral SBx has limited impact on the surgical planning of patients with a unilateral suspicious lesion on MRI scheduled to undergo RARP.

Patient summary

In patients with one-sided prostate cancer on magnetic resonance imaging, omitting biopsies on the other side rarely changed the surgical plan with respect to nerve-sparing surgery and the indication to perform extended lymph node dissection.

Which Patients with Prostate Cancer and Lymph Node Uptake at Preoperative Prostate-specific Membrane Antigen Positron Emission Tomography/Computerized Tomography Scan Are at a Higher Risk of Prostate-specific Antigen Persistence After Radical Prostatectomy? Identifying Indicators of Systemic Disease by Integrating Clinical, Magnetic Resonance Imaging, and Functional Imaging Parameters

BACKGROUND

The role of local therapies including radical prostatectomy (RP) in prostate cancer (PCa) patients with clinical lymphadenopathies on prostate-specific membrane antigen (PSMA) positron emission tomography/computerized tomography (PET/CT) has scarcely been explored. Limited data are available to identify men who would benefit from RP; on the contrary, those more likely to benefit already have systemic disease.

OBJECTIVE

We aimed to assess the predictors of prostate-specific antigen (PSA) persistence in surgically managed PCa patients with lymphadenopathies on a PSMA PET/CT scan by integrating clinical, magnetic resonance imaging (MRI), and PSMA PET/CT parameters.

DESIGN, SETTING, AND PARTICIPANTS

We identified 519 patients treated with RP and extended lymph node dissection, and who received preoperative PSMA PET between 2017 and 2022 in nine referral centers. Among them, we selected 88 patients with nodal uptake at preoperative PSMA PET (miTxN1M0).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The outcome was PSA persistence, defined as a PSA value of ≥0.1 ng/ml at the first measurement after surgery. Multivariable logistic regression models tested the predictors of PSA persistence. Covariates consisted of biopsy International Society of Urological Pathology (ISUP) grade group, clinical stage at MRI, and number of positive spots at a PET/CT scan. A regression tree analysis stratified patients into risk groups based on preoperative characteristics.

RESULTS AND LIMITATIONS

Overall, lymph node invasion (LNI) was detected in 63 patients (72%) and 32 (36%) experienced PSA persistence after RP. At multivariable analyses, having more than two lymph nodal positive findings at PSMA PET, seminal vesicle invasion (SVI) at MRI, and ISUP grade group >3 at biopsy were independent predictors of PSA persistence (all p < 0.05). At the regression tree analysis, patients were stratified in four risk groups according to biopsy ISUP grade, number of positive findings at PET/CT, and clinical stage at MRI. The model depicted good discrimination at internal validation (area under the curve 78%).

CONCLUSIONS

One out of three miN1M0 patients showed PSA persistence after surgery. Patients with ISUP grade 2-3, as well as patients with organ-confined disease at MRI and a single or two positive nodal findings at PET are those in whom RP may achieve the best oncological outcomes in the context of a multimodal approach. Conversely, patients with a high ISUP grade and extracapsular extension or SVI or more than two spots at PSMA PET should be considered as potentially affected by systemic disease upfront.

PATIENT SUMMARY

Our novel and straightforward risk classification integrates currently available preoperative risk tools and should, therefore, assist physician in preoperative counseling of men candidates for radical treatment for prostate cancer with positive lymph node uptake at prostate-specific membrane antigen positron emission tomography.

Bioinformatics in urology - molecular characterization of pathophysiology and response to treatment

The application of bioinformatics has revolutionized the practice of medicine in the past 20 years. From early studies that uncovered subtypes of cancer to broad efforts spearheaded by the Cancer Genome Atlas initiative, the use of bioinformatics strategies to analyse high-dimensional data has provided unprecedented insights into the molecular basis of disease. In addition to the identification of disease subtypes - which enables risk stratification - informatics analysis has facilitated the identification of novel risk factors and drivers of disease, biomarkers of progression and treatment response, as well as possibilities for drug repurposing or repositioning; moreover, bioinformatics has guided research towards precision and personalized medicine. Implementation of specific computational approaches such as artificial intelligence, machine learning and molecular subtyping has yet to become widespread in urology clinical practice for reasons of cost, disruption of clinical workflow and need for prospective validation of informatics approaches in independent patient cohorts. Solving these challenges might accelerate routine integration of bioinformatics into clinical settings.

Magnetic resonance imaging targeted biopsy in biopsy-naïve patients and the risk of overtreatment in prostate cancer: a grading issue

OBJECTIVE

To evaluate the impact of applying the 2014 and 2019 International Society of Urological Pathology (ISUP) recommendations on grade group distribution and concordance with radical prostatectomy (RP).

MATERIALS AND METHODS

Overall, 655 biopsy-naïve patients diagnosed by magnetic resonance imaging (MRI) targeted and systematic biopsies for Prostate Imaging Reporting and Data System score ≥3 lesions were identified from a prospectively maintained database from 2016 and 2022. Clinically significant prostate cancer was detected in 249 patients, of whom 69 underwent RP. Wilcoxon signed rank and McNemar's tests were used to compare the ISUP grade group distribution and concordance with RP after applying the 2014 (i.e., highest grade) and 2019 (i.e., global grade) ISUP recommendations, respectively.

RESULTS

Compared to the 2014 ISUP recommendations, the 2019 ISUP recommendations were associated with a significant decrease in ISUP Grade Group 4 (range of difference from -13% to -5%) and an increase in ISUP Grade Group 2 (range of difference from +6% to +11%) in MRI targeted biopsy only, MRI targeted with perilesional biopsies, and MRI targeted with systematic biopsies (all P < 0.01). In patients who underwent RP, a significant decrease in downgrading was observed with all biopsy strategies (range of difference from -19% to -12%; P ≤ 0.008), along with an increase in concordance with RP specimen (range of difference from +12% to +13%; P ≤ 0.02). The use of the 2019 ISUP recommendation was associated with RP specimen a lower treatment burden.

CONCLUSIONS

The use of the 2019 ISUP recommendations mitigates the grade migration induced by MRI targeted biopsy and improves the concordance with the final RP specimen.

Clinical parameters for the prediction of occult lymph node metastasis in patients with negative PSMA-PET

BACKGROUND

Depending on the risk of LN metastasis ePLND at RP is recommended. As ePLND has potential side effects, and diagnostics have improved substantially, our objective was to evaluate the performance of the Briganti 2019 nomogram in a contemporary cohort with preoperative negative PSMA-PET.

METHODS

Patients with intermediate- and high-risk prostate cancer (CaP), undergoing RP and ePND at our center with preoperative negative [68Ga]Ga-PSMA-11 PET were included. The Accuracy of the nomogram was assessed using ROC analysis. The association of clinical parameters with the presence of LN metastasis was assessed using logistic regression. Specimen of prostate and LNs in patients with false negative PSMA-PET were additionally stained for AR and PSMA expression and assessed by IHC.

RESULTS

The study included 108 patients, 28% intermediate- and 72% high-risk. Twelve patients harbored occult LN metastasis. Accuracy of the nomogram was 0.62. [68Ga]Ga-PSMA-11 PET showed a NPV of 89%. IHC showed expression of PSMA and AR in the primary and LN metastasis in all patients. On logistic regression analysis only DRE (OR 2.72; 95%CI 1.01-7.35; P = 0.05) and percentage of cores with significant CaP (OR 1.29; 95%CI 1.05-1.60; P = 0.02) showed a significant association with LN metastasis.

CONCLUSION

The currently used nomogram is suboptimal in detecting patients with occult LNM. While the cut-off value to perform ePLND can be increased slightly following a negative PSMA-PET scan, more accurate methods of identifying these patients are needed. Whether ePLND can have a therapeutic benefit, as opposed to a diagnostic only, needs to be re-evaluated in the PSMA-PET era.

A Comprehensive Overview of Intraoperative Complications during Retzius-Sparing Robot-Assisted Radical Prostatectomy: Single Series from High-Volume Center

BACKGROUND

Intraoperative complications (ICs) are invariably underreported in urological surgery despite the recent endorsement of new classification systems. We aimed to provide a detailed overview of ICs during Retzius-sparing robot-assisted radical prostatectomy (RS-RARP).

METHODS

We prospectively collected data from 1891 patients who underwent RS-RARP at a single high-volume European center from January 2010 to December 2022. ICs were collected based on surgery reports and categorized according to the Intraoperative Adverse Incident Classification (EAUiaiC). The quality criteria for accurate and comprehensive reporting of intraoperative adverse events proposed by the Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) Global Surgical Collaboration Project were fulfilled. To better classify the role of the RS-RARP approach, ICs were classified into anesthesiologic and surgical ICs. Surgical ICs were further divided according to the timing of the complication in RARP-related ICs and ePNLD-related ICs.

RESULTS

Overall, 40 ICs were reported in 40 patients (2.1%). Ten out of thirteen ICARUS criteria were satisfied. According to EAUiaiC grading of ICs, 27 (67.5%), 7 (17.5%), 2 (5%), 2 (5%), and 2 (5%) patients experienced Grade 1, 2, 3, 4A, and 4B, respectively. When we classified the ICs, two cases (5%) were classified as anesthesiologic ICs. Among the 38 surgical ICs, 16 (42%) were ePNLD-related, and 22 (58%) were RARP-related. ICs led to seven (0.37%) post-operative sequelae (four non-permanent and three permanent). Patients who suffered ICs were significantly older (67 years vs. 65 years, p = 0.02) and had a higher median BMI (27.0 vs. 26.1, p = 0.01), but did not differ in terms of comorbidities or tumor characteristics (all p values ≥ 0.05).

CONCLUSIONS

Intraoperative complications during RS-RARP are relatively infrequent, but should not be underestimated. Patients suffering from ICs are older, have a higher body mass index, a higher rate of intraoperative blood transfusion, and a longer length of stay.

Urinary extracellular vesicle-derived miR-126-3p predicts lymph node invasion in patients with high-risk prostate cancer

To investigate extracellular vesicles (EVs) biomarkers for predicting lymph node invasion (LNI) in patients with high-risk prostate cancer (HRPCa), plasma and/or urine samples were prospectively collected from 45 patients with prostate cancer (PCa) and five with benign prostatic hyperplasia (BPH). Small RNA sequencing was performed to identify miRNAs in the EVs. All patients with PCa underwent radical prostatectomy and extended pelvic lymph node dissection. Differentially-expressed miRNAs were identified in patients with and without pathologically-verified LNI. The candidate miRNAs were validated in low-risk prostate cancer (LRPCa) and BPH. Four miRNA species (e.g. miR-126-3p) and three miRNA species (e.g. miR-27a-3p) were more abundant in urinary and plasma EVs, respectively, of patients with PCa. None of these miRNA species were shared between urinary and plasma EVs. miR-126-3p was significantly more abundant in patients with HR PCa with LNI than in those without (P = 0.018). miR-126-3p was significantly more abundant in the urinary EVs of patients with HRPCa than in those with LRPCa (P = 0.017) and BPH (P = 0.011). In conclusion, urinary EVs-derived miR-126-3p may serve as a good biomarker for predicting LNI in patients with HRPCa.

Prognostic factors among patients with pathological Grade Group 5 prostate cancer based on robot-associated radical prostatectomy specimens from a large Japanese cohort (MSUG94)

PURPOSE

There are no definitive prognostic factors for patients with pathological Grade Group 5 (pGG 5) prostate cancer (PCa) undergoing robot-associated radical prostatectomy (RARP). This study aimed to explore the prognostic factors among patients with pGG 5 PCa in a large Japanese cohort (MSUG94).

METHODS

This retrospective, multi-institutional cohort study was conducted between 2012 and 2021 at ten centers in Japan and included 3195 patients. Patients with clinically metastatic PCa (cN1 or cM1) and those receiving neoadjuvant and/or adjuvant therapy were excluded. Finally, 217 patients with pGG5 PCa were analyzed.

RESULTS

The median follow-up period was 28.0 months. The 3- and 5-year biochemical recurrence-free survival (BCRFS) rates of the overall population were 66.1% and 57.7%, respectively. The optimal threshold value (47.2%) for the percentage of positive cancer cores (PPCC) with any GG by systematic biopsy was chosen based on receiver operating characteristic curve analysis. Univariate analysis revealed that the prostate-specific antigen level at diagnosis, pT, pN, positive surgical margins (PSMs), lymphovascular invasion, and PPCC were independent prognostic factors for BCRFS. A multivariate analysis revealed that PSMs and PPCC were independent prognostic factors for BCRFS. Using these two predictors, we stratified BCRFS, metastasis-free survival (MFS), and castration-resistant PCa-free survival (CRPC-FS) among patients with pGG 5 PCa.

CONCLUSION

The combination of PSMs and PPCC may be an important predictor of BCRFS, MFS, and CRPC-FS in patients with pGG 5 PCa undergoing RARP.

Clinical application of machine learning models in patients with prostate cancer before prostatectomy

BACKGROUND

To build machine learning predictive models for surgical risk assessment of extracapsular extension (ECE) in patients with prostate cancer (PCa) before radical prostatectomy; and to compare the use of decision curve analysis (DCA) and receiver operating characteristic (ROC) metrics for selecting input feature combinations in models.

METHODS

This retrospective observational study included two independent data sets: 139 participants from a single institution (training), and 55 from 15 other institutions (external validation), both treated with Robotic Assisted Radical Prostatectomy (RARP). Five ML models, based on different combinations of clinical, semantic (interpreted by a radiologist) and radiomics features computed from T2W-MRI images, were built to predict extracapsular extension in the prostatectomy specimen (pECE+). DCA plots were used to rank the models' net benefit when assigning patients to prostatectomy with non-nerve-sparing surgery (NNSS) or nerve-sparing surgery (NSS), depending on the predicted ECE status. DCA model rankings were compared with those drived from ROC area under the curve (AUC).

RESULTS

In the training data, the model using clinical, semantic, and radiomics features gave the highest net benefit values across relevant threshold probabilities, and similar decision curve was observed in the external validation data. The model ranking using the AUC was different in the discovery group and favoured the model using clinical + semantic features only.

CONCLUSIONS

The combined model based on clinical, semantic and radiomic features may be used to predict pECE + in patients with PCa and results in a positive net benefit when used to choose between prostatectomy with NNS or NNSS.

A non-invasive 25-Gene PLNM-Score urine test for detection of prostate cancer pelvic lymph node metastasis

BACKGROUND

Prostate cancer patients with pelvic lymph node metastasis (PLNM) have poor prognosis. Based on EAU guidelines, patients with >5% risk of PLNM by nomograms often receive pelvic lymph node dissection (PLND) during prostatectomy. However, nomograms have limited accuracy, so large numbers of false positive patients receive unnecessary surgery with potentially serious side effects. It is important to accurately identify PLNM, yet current tests, including imaging tools are inaccurate. Therefore, we intended to develop a gene expression-based algorithm for detecting PLNM.

METHODS

An advanced random forest machine learning algorithm screening was conducted to develop a classifier for identifying PLNM using urine samples collected from a multi-center retrospective cohort (n = 413) as training set and validated in an independent multi-center prospective cohort (n = 243). Univariate and multivariate discriminant analyses were performed to measure the ability of the algorithm classifier to detect PLNM and compare it with the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram score.

RESULTS

An algorithm named 25 G PLNM-Score was developed and found to accurately distinguish PLNM and non-PLNM with AUC of 0.93 (95% CI: 0.85-1.01) and 0.93 (95% CI: 0.87-0.99) in the retrospective and prospective urine cohorts respectively. Kaplan-Meier plots showed large and significant difference in biochemical recurrence-free survival and distant metastasis-free survival in the patients stratified by the 25 G PLNM-Score (log rank P < 0.001 and P < 0.0001, respectively). It spared 96% and 80% of unnecessary PLND with only 0.51% and 1% of PLNM missing in the retrospective and prospective cohorts respectively. In contrast, the MSKCC score only spared 15% of PLND with 0% of PLNM missing.

CONCLUSIONS

The novel 25 G PLNM-Score is the first highly accurate and non-invasive machine learning algorithm-based urine test to identify PLNM before PLND, with potential clinical benefits of avoiding unnecessary PLND and improving treatment decision-making.

Rational use of Ga-68 PSMA PET-CT according to nomograms and risk groups for the detection of lymph node metastasis in prostate cancer

OBJECTIVES

The aim was to ensure efficient utilization of PSMA PET-CT by examining the correlation of pathological lymph node metastasis with nomogram scores and risk classifications.

METHODS AND MATERIALS

Robot-assisted radical prostatectomy and bilateral pelvic lymph node dissections for pelvic lymph nodes were performed using the same template. Bilaterally pelvic lymph nodes were removed within the boundaries of genitofemoral nerves, psoas muscle and lateral pelvic wall laterally, ureteric crossing of the iliac vessels superiorly, lateral bladder wall medially, Cooper ligaments distally, and endopelvic fascia, neurovascular bundles and internal iliac arteries posteriorly. Clinical nomograms were used to calculate the probability of lymph node metastasis preoperatively. Using receiver operating characteristics analysis, discriminatory cut-offs were calculated. The diagnostic performance of PSMA PET-CT was determined for detecting lymph node metastasis.

RESULTS

For 81 patients, the median age was 64 years. The median PSA was 6.8 ng/ml. Most patients were in the D'Amico intermediate (56.8%) and high (37%) risk groups. Median Briganti 2017, MSKCC, and Partin scores were 35 (4-99), 37 (8-90), and 12 (2-38), respectively, in pN1 patients. The area under the curve for Briganti 2017, MSKCC, Partin nomograms and PSMA PET-CT scans were 0.852, 0.871, 0.862, and 0.588. Sensitivity, specificity, positive predictive value and negative predictive value for Ga-68 PSMA PET-CT for lymph node metastasis detection were 21.4%, 94%, 42.9%, and 85.1%, respectively, for the whole group. By using higher threshold values for clinical nomograms (Briganti 2017 >32, MSKCC >12, Partin >5), PSMA PET-CT had higher sensitivity (42.9, 30, 27.2) in detecting lymph node metastasis.

CONCLUSIONS

Patients in the D'Amico high-risk group and those with high nomogram scores are the best candidates who will benefit from preoperative PSMA PET-CT staging to estimate lymph node metastasis.

Versius robotic surgical system: case series of 18 robot-assisted radical prostatectomies

OBJECTIVE

To present the results of the first series of patients treated with robot-assisted radical prostatectomy (RARP) with the use of the Versius® Surgical System (CMR Surgical Ltd., Cambridge, UK). RARP has demonstrated better perioperative outcomes compared to open RP. However, RARP remains limited by platform availability and cost-effectiveness issues. The increasing competition from new robotic surgical platforms may further drive utilisation of the robotic approach.

PATIENTS AND METHODS

Data were collected prospectively for our first 18 consecutive patients with localised prostate cancer who underwent RARP at our centre over a 3-month period. We recorded parameters, including patient demographics and perioperative outcomes. We also report our optimised set-up with regard to trocar placement, bedside unit placement, and overall composition of the operating room for this procedure. Describing the incremental modifications carried out to achieve reductions in set-up and operating times to optimise utilisation of the Versius system.

RESULTS

The median (interquartile range [IQR]) set-up time was 8.5 (7-10) min. The median (IQR) console time was 201 (170-242) min. The median (IQR) operative time was 213 (186-266) min. The median (IQR) total surgery time was 226 (201-277) min. Bilateral pelvic lymphadenectomy median (IQR) time was 19 (17-20) min. There were no complications and/or limitations related to the use of the Versius system including need for conversion. There were no relevant intra- or postoperative complications at the 1-month follow-up related to the use of the Versius system. Patients were discharged after a median (IQR) of 4 (3.75-5) days, and the transurethral catheter was removed after a mean (range) of 8 (7-14) days. Continence at 2 months was achieved in 72.2% of the patients.

CONCLUSIONS

Performing RARP using the Versius system is feasible, safe, and easily reproducible. Our set-up enables a rapid docking approach and efficient completion of the surgery.

Peritoneal Flap for Lymphocele Prophylaxis Following Robotic-assisted Radical Prostatectomy with Lymph Node Dissection: The Randomised Controlled Phase 3 PELYCAN Trial

BACKGROUND

Symptomatic lymphoceles (SLCs) after transperitoneal robotic-assisted radical prostatectomy with pelvic lymph node dissection (PLND) are common. Evidence from randomised controlled trials (RCTs) on the impact of peritoneal flaps (PFs) on lymphocele (LC) reduction is inconclusive.

OBJECTIVE

To show that addition of PFs leads to a reduction of postoperative SLCs.

DESIGN, SETTING, AND PARTICIPANTS

An investigator-initiated, prospective, parallel, double-blinded, adaptive, phase 3 RCT was conducted. Recruitment took place from September 2019 until December 2021; 6-month written survey-based follow-up was recorded. Stratification was carried out according to potential LC risk factors (extended PLND, diabetes mellitus, and anticoagulation) and surgeons; 1:1 block randomisation was used. Surgeons were informed about allocation after completion of the last surgical step.

INTERVENTION

To create PFs, the ventral peritoneum was incised bilaterally and fixated to the pelvic floor.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was SLCs. Secondary endpoints included asymptomatic lymphoceles (ALCs), perioperative parameters, and postoperative complications.

RESULTS AND LIMITATIONS

In total, 860 men were screened and 551 randomised. Significant reductions of SLCs (from 9.1% to 3.7%, p = 0.005) and ALCs (27.2% to 10.3%, p < 0.001) over the follow-up period of 6 mo were observed in the intention-to-treat analysis. Operating time was 11 min longer (p < 0.001) in the intervention group; no significant differences in amount (80 vs 103, p = 0.879) and severity (p = 0.182) of postoperative complications (excluding LCs) were observed. The survey-based follow-up might be a limitation.

CONCLUSIONS

This is the largest RCT evaluating PF creation for LC prevention and met its primary endpoint, the reduction of SLCs. The results were consistent among all subgroup analyses including ALCs. Owing to the subsequent reduction of burden for patients and the healthcare system, establishing PFs should become the new standard of care.

PATIENT SUMMARY

A new technique-creation of bilateral peritoneal flaps-was added to the standard procedure of robotic-assisted prostatectomy for lymph node removal. It was safe and decreased lymphocele development, a common postoperative complication and morbidity. Hence, it should become a standard procedure.

Preoperative Factors for Lymphovascular Invasion in Prostate Cancer: A Systematic Review and Meta-Analysis

Lymphovascular invasion (LVI) is one of the most important prognostic factors in prostate cancer (PCa) and is correlated with worse survival rates, biochemical recurrence (BCR), and lymph node metastasis (LNM). The ability to predict LVI preoperatively in PCa may be useful for proposing variations in the diagnosis and management strategies. We performed a systematic review and meta-analysis to identify preoperative clinicopathological factors that correlate with LVI in final histopathological specimens in PCa patients. Systematic literature searches of PubMed, Embase, and Web of Science were performed up to 31 January 2023. A total of thirty-nine studies including 389,918 patients were included, most of which were retrospective and single-center. PSA level, clinical T stage, and biopsy Gleason score were significantly correlated with LVI in PCa specimens. Meta-analyses revealed that these factors were the strongest predictors of LVI in PCa patients. Prostate volume, BMI, and age were not significant predictors of LVI. A multitude of preoperative factors correlate with LVI in final histopathology. Meta-analyses confirmed correlation of LVI in final histopathology with higher preoperative PSA, clinical T stage, and biopsy Gleason score. This study implies advancements in risk stratification and enhanced clinical decision-making, and it underscores the importance of future research dedicated to validation and exploration of contemporary risk factors in PCa.

Prognostic Value of PSMA PET/CT in Prostate Cancer

Prostate-specific membrane antigen (PSMA) is a transmembrane glycoprotein expressed in the majority of prostate cancer (PCa). PSMA has an enzymatic function that makes metabolic substrates such as folate available for utilization by PCa cells. Intracellular folate availability drives aggressive tumor phenotype. PSMA expression is, therefore, a marker of aggressive tumor biology. The large extracellular domain of PSMA is available for targeting by diagnostic and therapeutic radionuclides, making it a suitable cellular epitope for theranostics. PET imaging of radiolabeled PSMA ligands has several prognostic utilities. In the prebiopsy setting, intense PSMA avidity in a prostate lesion correlate well with clinically significant PCa (csPCa) on histology. When used for staging, PSMA PET imaging outperforms conventional imaging for the accurate staging of primary PCa, and findings on imaging predict post-treatment outcomes. The biggest contribution of PSMA PET imaging to PCa management is in the biochemical recurrence setting, where it has emerged as the most sensitive imaging modality for the localization of PCa recurrence by helping to guide salvage therapy. PSMA PET obtained for localizing the site of recurrence is prognostic, such that a higher lesion number predicts a less favorable outcome to salvage radiotherapy or surgical intervention. Systemic therapy is given to patients with advanced PCa with distant metastasis. PSMA PET is useful for predicting response to treatments with chemotherapy, first- and second-line androgen deprivation therapies, and PSMA-targeted radioligand therapy. Artificial intelligence using machine learning algorithms allows for the mining of information from clinical images not visible to the human eyes. Artificial intelligence applied to PSMA PET images, therefore, holds great promise for prognostication in PCa management.

De-Escalation of Therapy for Prostate Cancer

Prostate cancer (PCa) is the second most commonly diagnosed cancer in men with around 1.4 million new cases every year. In patients with localized disease, management options include active surveillance (AS), radical prostatectomy (RP; with or without pelvic lymph node dissection), or radiotherapy to the prostate (with or without pelvic irradiation) with or without hormonotherapy. In advanced disease, treatment options include systemic treatment(s) and/or treatment to primary tumour and/or metastasis-directed therapies (MDTs). Specifically, in advanced stage, the current trend is earlier intensification of treatment such as dual or triple combination systemic treatments or adding treatment to primary and MDT to systemic treatment. However, earlier treatment intensification comes with the cost of increased morbidity and mortality resulting from drug-/treatment-related side effects. The main goal is and should be to provide the best possible care and oncologic outcomes with minimum possible side effects. This chapter will explore emerging possibilities to de-escalate treatment in PCa driven by enhanced insights into disease biology and the natural course of PCa such as AS in intermediate-risk disease or salvage versus adjuvant radiotherapy in post-RP patients. Considerations arising from advancements in PCa imaging and technological advancements in surgical and radiation therapy techniques including omitting pelvic lymph node dissection in the era of prostate-specific membrane antigen positron emitting tomography, the potential of MDT to delay/omit systemic treatment in metachronous oligorecurrence, and the efficacy of hypofractionation schemes compared with conventional fractionated radiotherapy will be discussed.

Use of the ISUP e-learning module improves interrater reliability in prostate cancer grading

AIMS

Prostate cancer (PCa) grading is an important prognostic parameter, but is subject to considerable observer variation. Previous studies have shown that interobserver variability decreases after participants were trained using an e-learning module. However, since the publication of these studies, grading of PCa has been enhanced by adopting the International Society of Urological Pathology (ISUP) 2014 grading classification. This study investigates the effect of training on interobserver variability of PCa grading, using the ISUP Education web e-learning on Gleason grading.

METHODS

The ISUP Education Prostate Test B Module was distributed among Dutch pathologists. The module uses images graded by the ISUP consensus panel consisting of 24 expert uropathologists. Participants graded the same 10 images before and after e-learning. We included those who completed the tests before and after training. We evaluated variation in PCa grading in a fully crossed study design, using linearly weighted kappa values for each pathologist, comparing them to other pathologists and to the ISUP consensus panel. We analysed the improvement in median weighted kappas before and after training, using Wilcoxon's signed rank-test.

RESULTS

We included 42 pathologists. Inter-rater reliability between pathologists improved from 0.70 before training to 0.74 after training (p=0.01). When compared with the ISUP consensus panel, five pathologists improved significantly, whereas the kappa of one pathologist was significantly lower after training. All pathologists who improved significantly, graded with less than substantial agreement before training.

CONCLUSIONS

ISUP Prostate Test B e-learning reduces variability in PCa grading. E-learning is a cost-effective method for standardisation of pathology.

Comparison of Multiparametric MRI, [68Ga]Ga-PSMA-11 PET-CT, and Clinical Nomograms for Primary T and N Staging of Intermediate-to-High-Risk Prostate Cancer

PURPOSE OF THE REPORT

Although multiparametric magnetic resonance imaging (mpMRI) is commonly used for the primary staging of prostate cancer, it may miss non-enlarged metastatic lymph nodes. Positron emission tomography-computed tomography targeting the prostate-specific membrane antigen (PSMA PET-CT) is a promising method to detect non-enlarged metastatic lymph nodes, but more data are needed.

MATERIALS AND METHODS

In this single-center, prospective study, we enrolled patients with intermediate-to-high-risk prostate cancer scheduled for radical prostatectomy with pelvic node dissection. Before surgery, prostate imaging with mpMRI and PSMA PET-CT was used to assess lymph node involvement (LNI), extra-prostatic extension (EPE), and seminal vesicle involvement (SVI). Additionally, we used clinical nomograms to estimate the risk of these three outcomes.

RESULTS

Of the 74 patients included, 61 (82%) had high-risk prostate cancer, and the rest had intermediate-risk cancer. Histopathology revealed LNI in 20 (27%) patients, SVI in 26 (35%), and EPE in 52 (70%). PSMA PET-CT performed better than mpMRI at detecting LNI (area under the curve (AUC, 95% confidence interval): 0.779 (0.665-0.893) vs. 0.655 (0.529-0.780)), but mpMRI was better at detecting SVI (AUC: 0.775 (0.672-0.878) vs. 0.585 (0.473-0.698)). The MSKCC nomogram performed well at detecting both LNI (AUC: 0.799 (0.680-0.918)) and SVI (0.772 (0.659-0.885)). However, when the nomogram was used to derive binary diagnoses, decision curve analyses showed that the MSKCC nomogram provided less net benefit than mpMRI and PSMA PET-CT for detecting SVI and LNI, respectively.

CONCLUSIONS

mpMRI and [68Ga]Ga-PSMA-11 PET-CT are complementary techniques to be used in conjunction for the primary T and N staging of prostate cancer.

Can contralateral lymph-node metastases be ruled out in prostate cancer patients with only unilaterally positive prostate biopsy?

PURPOSE

Our study evaluated the diagnostic benefits of bilateral pelvic lymphadenectomy in prostate cancer patients with unilaterally positive prostate biopsy.

METHODS

Our retrospective analysis included clinical, surgical, and histopathological data of 440 prostate cancer patients treated with radical prostatectomy and bilateral sentinel-guided and risk-adapted complementary extended pelvic lymphadenectomy at our hospital between 2015 and 2022. We performed multiparametric logistic regression analysis to identify the most relevant predictive factors for detecting lymph-node metastasis in this group of patients.

RESULTS

Overall, 373 patients (85%) had histopathologically bilateral tumours and 45 (10%) pN1 status, of which 22 (49%) also had lymph-node metastasis contralateral to the side of the positive prostate biopsy. In two patients with confirmed unilateral disease in prostatectomy specimens, bilateral lymph-node metastases were observed. Eight pN1 patients would have been missed by unilateral pelvic lymphadenectomy, resulting in a false-negative rate of 18%, 82% sensitivity, and 98% accuracy. Clinical tumour category, International Society of Urological Pathology grade, and percentage of prostate biopsy cores that are positive, as well as number of dissected lymph nodes contralateral to positive prostate biopsy, were determined as the most relevant predictive factors for detecting lymph-node metastasis. Our analysis was limited by its retrospective nature as well as by the fact that 80% of the patients did not receive MRI-targeted biopsy.

CONCLUSION

Our study highlights the diagnostic value of bilateral pelvic lymphadenectomy and the need for careful planning in surgery for prostate cancer patients with unilaterally positive prostate biopsy.

Development and External Validation of a Novel Nomogram to Predict the Probability of Pelvic Lymph-node Metastases in Prostate Cancer Patients Using Magnetic Resonance Imaging and Molecular Imaging with Prostate-specific Membrane Antigen Positron Emission Tomography

BACKGROUND

Preoperative assessment of the probability of pelvic lymph-node metastatic disease (pN1) is required to identify patients with prostate cancer (PCa) who are candidates for extended pelvic lymph-node dissection (ePLND).

OBJECTIVE

To develop a novel intuitive prognostic nomogram for predicting pathological lymph-node (pN) status in contemporary patients with primary diagnosed localized PCa, using preoperative clinical and histopathological parameters, magnetic resonance imaging (MRI), and prostate-specific membrane antigen (PSMA) positron emission tomography (PET).

DESIGN, SETTING, AND PARTICIPANTS

In total, 700 eligible patients who underwent robot-assisted radical prostatectomy and ePLND were included in the model-building cohort. The external validation cohort consisted of 305 surgically treated patients. Logistic regression with backward elimination was used to select variables for the Amsterdam-Brisbane-Sydney nomogram.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Performance of the final model was evaluated using the area under the receiver operating characteristic curve (AUC), calibration plots, and decision-curve analyses. Models were subsequently validated in an external population.

RESULTS AND LIMITATIONS

The Amsterdam-Brisbane-Sydney nomogram included initial prostate-specific antigen value, MRI T stage, highest biopsy grade group (GG), biopsy technique, percentage of systematic cores with clinically significant PCa (GG ≥2), and lymph-node status on PSMA-PET. The AUC for predicting pN status was 0.81 (95% confidence interval [CI] 0.78-0.85) for the final model. On external validation, the Amsterdam-Brisbane-Sydney nomogram showed superior discriminative ability to the Briganti-2017 and Memorial Sloan Kettering Cancer Center (MSKCC) nomograms (AUC 0.75 [95% CI 0.69-0.81] vs 0.67 [95% CI 0.61-0.74] and 0.65 [95% CI 0.58-0.72], respectively; p < 0.05), and similar discriminative ability to the Briganti-2019 nomogram (AUC 0.78 [95% CI 0.71-0.86] vs 0.80 [95% CI 0.73-0.86]; p = 0.76). The Amsterdam-Brisbane-Sydney nomogram showed excellent calibration on external validation, with an increased net benefit at a threshold probability of ≥4%.

CONCLUSIONS

The validated Amsterdam-Brisbane-Sydney nomogram performs superior to the Briganti-2017 and MSKCC nomograms, and similar to the Briganti-2019 nomogram. Furthermore, it is applicable in all patients with newly diagnosed unfavorable intermediate- and high-risk PCa.

PATIENT SUMMARY

We developed and validated the Amsterdam-Brisbane-Sydney nomogram for the prediction of prostate cancer spread to lymph nodes before surgery. This nomogram performs similar or superior to all presently available nomograms.

Current magnetic resonance imaging-based diagnostic strategies for prostate cancer

Recent developments in multiparametric MRI and MRI-targeted biopsy have made it possible to detect clinically significant cancers more accurately and efficiently than ever before. Furthermore, software that enables easy MRI/US image fusion has been developed and is already available on the market, and this has provided a tailwind for the spread of MRI-based prostate cancer diagnostic strategies. Such precise diagnosis of prostate cancer localization is essential for highly accurate focal therapy. In addition, a recent large-scale study applying MRI to community screening for prostate cancer has reported its usefulness. By contrast, concerns about overdiagnosis and overtreatment, the existence of inter-reader variability in MRI diagnosis, and issues with current MRI-targeted biopsy have emerged. In this article, we review the development of multiparametric MRI and MRI-targeted biopsy to date and the current issues and discuss future directions.

Transperineal template saturation and conventional biopsy for stage prediction in prostate cancer

OBJECTIVE

To evaluate the performance of risk calculators (RCs) predicting lymph node invasion (LNI) and extraprostatic extension (EPE) in men undergoing transperineal magnetic resonance imaging/transrectal ultrasound (TRUS)-fusion template saturation biopsy (TTSB) and conventional systematic TRUS-guided biopsy (SB).

PATIENTS AND METHODS

The RCs were tested in a consecutive cohort of 645 men undergoing radical prostatectomy with extended pelvic LN dissection between 2005 and 2019. TTSB was performed in 230 (35.7%) and SB in 415 (64.3%) men. Risk of LNI and EPE was calculated using the available RCs. Discrimination, calibration, and clinical usefulness stratified by different biopsy techniques were assessed.

RESULTS

Lymph node invasion was observed in 23 (10%) and EPE in 73 (31.8%) of cases with TTSB and 53 (12.8%) and 158 (38%) with SB, respectively. RCs showed an excellent discrimination and acceptable calibration for prediction of LNI based on TTSB (area under the curve [AUC]/risk estimation: Memorial Sloan Kettering Cancer Center [MSKCC]-RC 0.79/-4%, Briganti (2012)-RC 0.82/-4%, Gandaglia-RC 0.81/+6%). These were comparable in SB (MSKCC-RC 0.78/+2%; Briganti (2012)-RC 0.77/-3%). Decision curve analysis (DCA) revealed a net benefit at threshold probabilities between 3% and 6% when TTSB was used. For prediction of EPE based on TTSB an inferior discrimination and variable calibration were observed (AUC/risk estimation: MSKCC-RC 0.71/+8% and Martini (2018)-RC 0.69/+2%) achieving a net benefit on DCA only at risk thresholds of >17%. Performance of RCs for prediction of LNI and EPE based on SB showed comparable results with a better performance in the DCA for LNI (risk thresholds 1-2%) and poorer performance for EPE (risk threshold >20%). This study is limited by its retrospective single-institution design.

CONCLUSIONS

The potentially more accurate grading ability of TTSB did not result in improved performance of preoperative RCs. Prediction tools for LNI proved clinical usefulness while RCs for EPE did not.

Identification of the Optimal Candidates for Nodal Staging with Extended Pelvic Lymph Node Dissection Among Prostate Cancer Patients Who Underwent Preoperative Prostate-specific Membrane Antigen Positron Emission Tomography. External Validation of the Memorial Sloan Kettering Cancer Center and Briganti Nomograms and Development of a Novel Tool

BACKGROUND

Although the therapeutic role of extended pelvic lymph node dissection (ePLND) in patients with prostate cancer (PCa) is still under debate, this procedure is recommended for staging purposes in selected cases. Nomograms for predicting lymph node invasion (LNI) do not account for prostate-specific membrane antigen (PSMA) positron emission tomography (PET) imaging, which is characterized by a high negative predictive value for nodal metastases.

OBJECTIVE

To externally validate models predicting LNI in patients with miN0M0 PCa at PSMA PET and to develop a novel tool in this setting.

DESIGN, SETTING, AND PARTICIPANTS

Overall, 458 patients with miN0M0 disease undergoing radical prostatectomy (RP) and ePLND at 12 centers between 2017 and 2022 were identified.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES

Available tools were externally validated using calibration plots, the area under the receiver operating characteristic curve (AUC), and decision curve analyses to assess calibration, discrimination, and the net benefit. A novel coefficient-based model was developed, internally validated, and compared with available tools.

RESULTS AND LIMITATIONS

Overall, 53 patients (12%) had LNI. The AUC was 69% for the Briganti 2012, 64% for the Briganti 2017, 73% for the Briganti 2019, and 66% for the Memorial Sloan Kettering Cancer Center nomogram. Multiparametric magnetic resonance imaging stage, biopsy grade group 5, the diameter of the index lesion, and the percentage of positive cores at systematic biopsy were independent predictors of LNI (all p ≤ 0.04). Internal cross-validation confirmed a coefficient-based model with AUC of 78%, better calibration, and a higher net benefit in comparison to the other nomograms assessed. Use of a 5% cutoff would have spared 47% ePLND procedures (vs 13% for the Briganti 2019 nomogram) at the cost of missing only 2.1% LNI cases . The lack of central review of imaging and pathology represents the main limitation.

CONCLUSIONS

Tools for predicting LNI are associated with suboptimal performance for men with miN0M0 PCa. We propose a novel model for predicting LNI that outperforms available tools in this population.

PATIENT SUMMARY

Tools currently used to predict lymph node invasion (LNI) in prostate cancer are not optimal for men with negative node findings on PET (positron emission tomography) scans, leading to a high number of unnecessary extended pelvic lymph node dissection (ePLND) procedures. A novel tool should be used in clinical practice to identify candidates for ePLND to reduce the risk of unnecessary procedures without missing LNI cases.

Senhance robotic radical prostatectomy: A single-centre, 3-year experience

BACKGROUND

Senhance Surgical System is a novel robotic platform used in University Hospital Centre Zagreb since February 2019. In this study, we present our 3-year experience with this platform.

PATIENTS AND METHODS

Data were prospectively collected for 200 patients who underwent extraperitoneal robotic radical prostatectomy (RRP) from May 2019 to March 2022.

RESULTS

The median age of the patients was 65 years, and the prostate-specific antigen was 6.9 ng/mL. Clinically, most of the patients had T1c stage. The estimated blood loss was 250 mL, and there were 6 conversions to laparoscopic and 2 to open prostatectomy. There were 15 early postoperative complications, 11 Clavien-Dindo classification grade I, 3 grade II and 1 grade IV. Functional outcomes in the first 150 patients: 140 patients (93.3%) had good urinary control. Thirteen patients underwent additional oncological treatment.

CONCLUSION

RRP performed with the Senhance robotic platform is a feasible and safe procedure with good initial results.

Can Machine Learning Models Detect and Predict Lymph Node Involvement in Prostate Cancer? A Comprehensive Systematic Review

(1) Background: Recently, Artificial Intelligence (AI)-based models have been investigated for lymph node involvement (LNI) detection and prediction in Prostate cancer (PCa) patients, in order to reduce surgical risks and improve patient outcomes. This review aims to gather and analyze the few studies available in the literature to examine their initial findings. (2) Methods: Two reviewers conducted independently a search of MEDLINE databases, identifying articles exploring AI's role in PCa LNI. Sixteen studies were selected, and their methodological quality was appraised using the Radiomics Quality Score. (3) Results: AI models in Magnetic Resonance Imaging (MRI)-based studies exhibited comparable LNI prediction accuracy to standard nomograms. Computed Tomography (CT)-based and Positron Emission Tomography (PET)-CT models demonstrated high diagnostic and prognostic results. (4) Conclusions: AI models showed promising results in LN metastasis prediction and detection in PCa patients. Limitations of the reviewed studies encompass retrospective design, non-standardization, manual segmentation, and limited studies and participants. Further research is crucial to enhance AI tools' effectiveness in this area.

A Novel Nomogram to Identify Candidates for Focal Therapy Among Patients with Localized Prostate Cancer Diagnosed via Magnetic Resonance Imaging-Targeted and Systematic Biopsies: A European Multicenter Study

BACKGROUND

Suitable selection criteria for focal therapy (FT) are crucial to achieve success in localized prostate cancer (PCa).

OBJECTIVE

To develop a multivariable model that better delineates eligibility for FT and reduces undertreatment by predicting unfavorable disease at radical prostatectomy (RP).

DESIGN, SETTING, AND PARTICIPANTS

Data were retrospectively collected from a prospective European multicenter cohort of 767 patients who underwent magnetic resonance imaging (MRI)-targeted and systematic biopsies followed by RP in eight referral centers between 2016 and 2021. The Imperial College of London eligibility criteria for FT were applied: (1) unifocal MRI lesion with Prostate Imaging-Reporting and Data System score of 3-5; (2) prostate-specific antigen (PSA) ≤20 ng/ml; (3) cT2-3a stage on MRI; and (4) International Society of Urological Pathology grade group (GG) 1 and ≥6 mm or GG 2-3. A total of 334 patients were included in the final analysis.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was unfavorable disease at RP, defined as GG ≥4, and/or lymph node invasion, and/or seminal vesicle invasion, and/or contralateral clinically significant PCa. Logistic regression was used to assess predictors of unfavorable disease. The performance of the models including clinical, MRI, and biopsy information was evaluated using the area under the receiver operating characteristic curve (AUC), calibration plots, and decision curve analysis. A coefficient-based nomogram was developed and internally validated.

RESULTS AND LIMITATIONS

Overall, 43 patients (13%) had unfavorable disease on RP pathology. The model including PSA, clinical stage on digital rectal examination, and maximum lesion diameter on MRI had an AUC of 73% on internal validation and formed the basis of the nomogram. Addition of other MRI or biopsy information did not significantly improve the model performance. Using a cutoff of 25%, the proportion of patients eligible for FT was 89% at the cost of missing 30 patients (10%) with unfavorable disease. External validation is required before the nomogram can be used in clinical practice.

CONCLUSIONS

We report the first nomogram that improves selection criteria for FT and limits the risk of undertreatment.

PATIENT SUMMARY

We conducted a study to develop a better way of selecting patients for focal therapy for localized prostate cancer. A novel predictive tool was developed using the prostate-specific antigen (PSA) level measured before biopsy, tumor stage assessed via digital rectal examination, and lesion size on magnetic resonance imaging (MRI) scans. This tool improves the prediction of unfavorable disease and may reduce the risk of undertreatment of localized prostate cancer when using focal therapy.

Personalised indocyanine-guided lymphadenectomy for prostate cancer: a randomised clinical trial

OBJECTIVES

To study the safety and efficacy of a personalised indocyanine-guided pelvic lymph node dissection (PLND) against extended PLND (ePLND) during radical prostatectomy (RP).

PATIENTS AND METHODS

Patients who were candidates for RP and lymphadenectomy, with intermediate- or high-risk prostate cancer (PCa) according to the National Comprehensive Cancer Network guidelines, were enrolled in this randomised clinical trial. Randomisation was made 1:1 to indocyanine green (ICG)-PLND (only ICG-stained LNs) or ePLND (obturator fossa, external, internal, and common iliac and presacral LNs). The primary endpoint was the complication rate within 3 months after RP. Secondary endpoints included: rate of major complications (Clavien-Dindo Grade III-IV), time to drainage removal, length of stay, percentage of patients classified as pN1, number of LNs removed, number of metastatic LNs, rate of patients with undetectable prostate-specific antigen (PSA), biochemical recurrence (BCR)-free survival, and rate of patients with androgen-deprivation therapy at 24 months.

RESULTS

A total of 108 patients were included with a median follow-up of 16 months. In all, 54 were randomised to ICG-PLND and 54 to ePLND. The postoperative complication rate was higher in the ePLND (70%) vs the ICG-PLND group (32%) (P < 0.001). Differences between major complications in both groups were not statically significant (P = 0.7). The pN1 detection rate was higher in the ICG-PLND group (28%) vs the ePLND group (22%); however, this difference was not statistically significant (P = 0.7). The rate of undetectable PSA at 12 months was 83% in the ICG-PLND vs 76% in the ePLND group, which was not statistically significant. Additionally, there were no statistically significant differences in BCR-free survival between groups at the end of the analysis.

CONCLUSIONS

Personalised ICG-guided PLND is a promising technique to stage patients with intermediate- and high-risk PCa properly. It has shown a lower complication rate than ePLND with similar oncological outcomes at short-term follow-up.

The role of nuclear medicine tracers for prostate cancer surgery: from preoperative to intraoperative setting

PURPOSE OF REVIEW

There has been a growing interest in the use of novel molecular imaging modalities for the management of prostate cancer (PCa), spanning from diagnostic to therapeutic settings. The aim of this review is to provide a comprehensive overview of recently published studies investigating the use of novel nuclear medicine tracers across different stages of PCa management.

RECENT FINDINGS

Emerging evidence supports the use of molecular imaging for preoperative staging of PCa, where prostate-specific membrane antigen (PSMA) PET has shown superior accuracy compared to conventional imaging for the detection of nodal and distant metastases, which needs to be translated to new risk stratification. A role for PSMA PET has been proposed for PCa diagnosis, with local activity associated with histology. Surgical guidance, using either visual feedback or gamma-ray detectors to identify tissues with accumulated radio-labeled tracers, may improve the ability to resect locoregional diseases and thus maximize oncological control. PSMA targeted therapy (Lu-PSMA) has been mainly investigated in the castration-resistant setting, but might have a role in earlier settings such as neoadjuvant treatment.

SUMMARY

Novel molecular imaging using PSMA-based tracers could significantly improve PCa management in the diagnosis, staging, and intraoperative guidance settings, potentially leading to personalized and effective treatment decisions.

Development and external validation of a novel prognostic nomogram for overall survival in prostate cancer patients with bone metastatic: a retrospective study of the SEER-based and a single Chinese center

BACKGROUND

Prostate cancer (PCa) patients with bone metastases (BM) often face a poor prognosis, a leading contributor to mortality within this group. This study aims to develop a novel prognostic nomogram to predict overall survival for them.

METHODS

We retrospectively analyzed PCa patients with BM from Surveillance, Epidemiology, and End Results (SEER) database and our hospital. Independent prognostic factors were identified using univariate and multivariate Cox regression analyses for the creation of a nomogram. Calibration curves and receiver operating characteristic (ROC) curves, along with the concordance index (C-index) and decision curve analysis (DCA), were employed to evaluate the performance of the constructed nomogram.

RESULTS

A total of 12,344 PCa patients with BM, derived from 2010 to 2019 SEER database, were randomly allocated into a training cohort (n = 8640) and an internal validation cohort (n = 3704). Additionally, an external validation cohort (n = 126) from our hospital. The novel nomogram integrates multiple factors: age, race, histopathology, organ metastasis, chemotherapy, Gleason score, and prostate-specific antigen (PSA). C-index for the training, internal validation, and external validation cohorts were 0.770 (0.766-0.774), 0.756 (0.749-0.763), and 0.751 (0.745-0.757) respectively. Similarly, the area under the curve (AUC) for each cohort exhibited comparable results (training cohort-3-year: 0.682, 6-year: 0.775, 9-year: 0.824; internal validation cohort-3-year: 0.681, 6-year: 0.750, 9-year: 0.806; external validation cohort-2-year: 0.667, 3-year: 0.744, 4-year: 0.800), indicating that the nomogram possesses robust discriminative ability. Calibration curve and DCA curve further proved the reliability and accuracy of the prognostic nomogram.

CONCLUSION

This study determined the independent risk factors for prostate cancer (PCa) patients with bone metastasis (BM) and subsequently developed a robust prognostic nomogram to predict overall survival (OS). This tool can serve to guide precise clinical treatment strategies for these patients.

Intermediate-term oncological and functional outcomes in prostate cancer patients treated with perineal robot-assisted radical prostatectomy: A single center analysis

Objective

In the last 10 years, robotic platforms allowed to resume of some alternative surgical approaches, including perineal robot-assisted radical prostatectomy (p-RARP). Herein, we present in detail the oncological and functional outcomes of patients who underwent p-RARP with a median follow-up of 30 months.

Methods

Patients presenting low- or intermediate-risk prostate cancer and prostate volume up to 60 mL who underwent p-RARP between November 2018 and November 2022 were selected. Baseline, intraoperative, pathological, and postoperative data were collected and then analyzed.

Results

Thirty-seven p-RARP cases were included. Such patients presented mean age of 62 years and a mean Charlson comorbidity index of 4. Body mass index of ≥25 kg/m2 was reported by 24 (64.9%) patients, as well as 7 (18.9%) patients reported a past surgical history. Mean prostate volume and median prostate-specific antigen were 41 mL and 6.2 ng/mL, respectively. The median operative time was 242 min. The positive surgical margin rate was 45.9%. In terms of postoperative complications, 10 patients reported complications with any grade; however, a single case (2.7%) of major (Clavien-Dindo grade ≥3) complication was observed. No patient with biochemical recurrence or distant metastasis was reported at 2 years of follow-up. Recovery of continence rates were 67.6%, 75.7%, and 92.9%, at 6 months, 12 months, and 24 months after surgery, respectively.

Conclusion

p-RARP is a challenging but safe minimally invasive approach for selected patients with prostate cancer suitable for radical prostatectomy, showing outstanding functional recovery. Despite positive surgical margin rates being relatively high, no cases of biochemical recurrence or distant metastasis were reported after a median follow-up of 30 months.

Development and External Validation of a Machine Learning Model for Prediction of Lymph Node Metastasis in Patients with Prostate Cancer

BACKGROUND

Pelvic lymph node dissection (PLND) is the gold standard for diagnosis of lymph node involvement (LNI) in patients with prostate cancer. The Roach formula, Memorial Sloan Kettering Cancer Center (MSKCC) calculator, and Briganti 2012 nomogram are elegant and simple traditional tools used to estimate the risk of LNI and select patients for PLND.

OBJECTIVE

To determine whether machine learning (ML) can improve patient selection and outperform currently available tools for predicting LNI using similar readily available clinicopathologic variables.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective data for patients treated with surgery and PLND between 1990 and 2020 in two academic institutions were used.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We trained three models (two logistic regression models and one gradient-boosted trees-based model [XGBoost]) on data provided from one institution (n = 20267) with age, prostate-specific antigen (PSA) levels, clinical T stage, percentage positive cores, and Gleason scores as inputs. We externally validated these models using data from another institution (n = 1322) and compared their performance to that of the traditional models using the area under the receiver operating characteristic curve (AUC), calibration, and decision curve analysis (DCA).

RESULTS AND LIMITATIONS

LNI was present in 2563 patients (11.9%) overall, and in 119 patients (9%) in the validation data set. XGBoost had the best performance among all the models. On external validation, its AUC outperformed that of the Roach formula by 0.08 (95% confidence interval [CI] 0.042-0.12), the MSKCC nomogram by 0.05 (95% CI 0.016-0.070), and the Briganti nomogram by 0.03 (95% CI 0.0092-0.051; all p < 0.05). It also had better calibration and clinical utility in terms of net benefit on DCA across relevant clinical thresholds. The main limitation of the study is its retrospective design.

CONCLUSIONS

Taking all measures of performance together, ML using standard clinicopathologic variables outperforms traditional tools in predicting LNI.

PATIENT SUMMARY

Determining the risk of cancer spread to the lymph nodes in patients with prostate cancer allows surgeons to perform lymph node dissection only in patients who need it and avoid the side effects of the procedure in those who do not. In this study, we used machine learning to develop a new calculator to predict the risk of lymph node involvement that outperformed traditional tools currently used by oncologists.

Role of IL-17A and IL-17RA in Prostate Cancer with Lymph Nodes Metastasis: Expression Patterns and Clinical Significance

Prostate cancer (PCa) is the second most frequently diagnosed cancer among men. The use of IL-17A and its receptor IL-17RA as prognostic markers for PCa has shown promising results. We analyzed the clinical data of 77 patients with PCa after radical prostatectomy with lymphadenectomy and lymph node metastasis (LN+). We assessed the expression levels of IL-17A and IL-17RA in cancer cells in prostate and, for the first time, also in LN+. Prostate IL-17A expression positively correlated with BMI (p = 0.028). In LN+, the expression of IL-17A was positively correlated with the percentage of affected lymph nodes (p = 0.006) and EAU risk groups (p = 0.001). Additionally, in the group with high IL-17A expression in LN+, the extracapsular extension (ECE) of the prostate was significantly more frequent (p = 0.033). Also, significant correlations with the level of IL-17RA expression was found-expression was higher in prostate than in LN+ (p = 0.009); in LN+, expression positively correlated with the EAU risk group (p = 0.045), and in the group of high expression in LN+ ECE of lymph nodes was detected significantly more often (p = 0.009). Our findings support the potential role of IL-17A and IL-17RA as PCa markers; however, further studies are needed to determine their roles and potential clinical applications.

Impact of the time elapsed between prostate biopsy and surgery on the accuracy of nomograms predicting lymph node invasion in patients with clinically localized prostate cancer

We aimed to investigate whether the performance characteristics of available nomograms predicting lymph node invasion (LNI) in prostate cancer patients undergoing radical prostatectomy (RP) change according to the time elapsed between diagnosis and surgery. We identified 816 patients who underwent RP with extended pelvic lymph node dissection (ePLND) after combined prostate biopsy at 6 referral centers. We plotted the accuracy (ROC-derived area under the curve [AUC]) of each Briganti nomogram according to the time elapsed between biopsy ad RP. We then tested whether discrimination of the nomograms improved after accounting for the time elapsed between biopsy ad RP. The median time between biopsy and RP was 3 months. The LNI rate was 13%. The discrimination of each nomogram decreased with increasing time elapsed between biopsy and surgery, where the AUC of the 2019 Briganti nomogram was 88% vs. 70% for men undergoing surgery <2 vs. >6 months from the biopsy. The addition of the time elapsed between biopsy ad RP improved the accuracy of all available nomograms (P < 0.003), with the Briganti 2019 nomogram showing the highest discrimination. Clinicians should be aware that the discrimination of available nomograms decreases according to the time elapsed between diagnosis and surgery. The indication of ePLND should be carefully evaluated in men below the LNI cut-off who had a diagnosis more than 6 months before RP. This has important implications when considering the longer waiting lists related to the impact of COVID-19 on healthcare systems.

The predictive value of machine learning and nomograms for lymph node metastasis of prostate cancer: a systematic review and meta-analysis

BACKGROUND

In clinical practice, there are currently a variety of nomograms for predicting lymph node metastasis (LNM) of prostate cancer. At the same time, some scholars have introduced machine learning (ML) into the prediction of LNM of prostate cancer. However, the predictive value of nomograms and ML remains controversial. Based on this situation, this systematic review and meta-analysis was performed to explore the predictive value of various nomograms currently recommended and newly-developed ML models for LNM in prostate cancer patients.

EVIDENCE ACQUISITION

Cochrane, PubMed, Embase, and Web of Science were searched up to November 1, 2022. The risk of bias in the included studies was evaluated using the Prediction model Risk of Bias Assessment Tool (PROBAST). The concordance index (C-index), sensitivity, and specificity were adopted to evaluate the predictive accuracy of the models.

RESULTS

Thirty-one studies (18,803 patients) were included. Seven kinds of nomograms currently recommended, dominated by Briganti nomogram or MSKCC nomogram, were covered in the included studies. For newly-developed ML models, the C-index for LNM prediction in the training set and validation set was 0.846 [95%CI (0.818, 0.873)] and 0.862 [95%CI (0.819-0.905)] respectively. Most ML models in the training set were based on Logistic Regression (LR), which had a sensitivity of 0.78 [95%CI (0.70, 0.85)] and a specificity of 0.85 [95%CI (0.77, 0.90)] in the training set, and a sensitivity of 0.81 [95%CI (0.67, 0.89)] and a specificity of 0.82 [95%CI (0.75, 0.88)] in the validation set. For the recommended nomograms, the C-index in the validation set was 0.745 [95%CI (0.701, 0.790)] for the Briganti nomogram and 0.714 [95%CI (0.662, 0.765)] for the MSKCC nomogram.

CONCLUSION

The predictive accuracy of ML is superior to existing clinically recommended nomograms, and appropriate updates can be conducted to existing nomograms according to special situations.

Development and external validation of a multivariable [68Ga]Ga-PSMA-11 PET-based prediction model for lymph node involvement in men with intermediate or high-risk prostate cancer

PURPOSE

To develop and evaluate a lymph node invasion (LNI) prediction model for men staged with [68Ga]Ga-PSMA-11 PET.

METHODS

A consecutive sample of intermediate to high-risk prostate cancer (PCa) patients undergoing [68Ga]Ga-PSMA-11 PET, extended pelvic lymph node dissection (ePLND), and radical prostatectomy (RP) at two tertiary referral centers were retrospectively identified. The training cohort comprised 173 patients (treated between 2013 and 2017), the validation cohort 90 patients (treated between 2016 and 2019). Three models for LNI prediction were developed and evaluated using cross-validation. Optimal risk-threshold was determined during model development. The best performing model was evaluated and compared to available conventional and multiparametric magnetic resonance imaging (mpMRI)-based prediction models using area under the receiver operating characteristic curves (AUC), calibration plots, and decision curve analysis (DCA).

RESULTS

A combined model including prostate-specific antigen, biopsy Gleason grade group, [68Ga]Ga Ga-PSMA-11 positive volume of the primary tumor, and the assessment of the [68Ga]Ga-PSMA-11 report N-status yielded an AUC of 0.923 (95% CI 0.863-0.984) in the external validation. Using a cutoff of  ≥ 17%, 44 (50%) ePLNDs would be spared and LNI missed in one patient (4.8%). Compared to conventional and MRI-based models, the proposed model showed similar calibration, higher AUC (0.923 (95% CI 0.863-0.984) vs. 0.700 (95% CI 0.548-0.852)-0.824 (95% CI 0.710-0.938)) and higher net benefit at DCA.

CONCLUSIONS

Our results indicate that information from [68Ga]Ga-PSMA-11 may improve LNI prediction in intermediate to high-risk PCa patients undergoing primary staging especially when combined with clinical parameters. For better LNI prediction, future research should investigate the combination of information from both PSMA PET and mpMRI for LNI prediction in PCa patients before RP.

Development and validation of novel nomogram to identify the candidates for extended pelvic lymph node dissection for prostate cancer patients in the robotic era

OBJECTIVES

To determine candidates for extended pelvic lymph node dissection using a novel nomogram to assess the risk of lymph node invasion in Japanese prostate cancer patients in the robotic era.

METHODS

A total of 538 patients who underwent robot-assisted radical prostatectomy with extended pelvic lymph node dissection in three hospitals were retrospectively analyzed. Medical records were reviewed uniformly and the following data collected: prostate-specific antigen, age, clinical T stage, primary and secondary Gleason score at prostate biopsy, and percentage of positive core numbers. Finally, data from 434 patients were used for developing the nomogram and data from 104 patients were used for external validation.

RESULTS

Lymph node invasion was detected in 47 (11%) and 16 (15%) patients in the development and validation set, respectively. Based on multivariate analysis, prostate-specific antigen, clinical T stage ≥3, primary Gleason score, grade group 5, and percentage of positive cores were selected as variables to incorporate into the nomogram. The area under the curve values were 0.781 for the internal and 0.908 for the external validation, respectively.

CONCLUSIONS

The present nomogram can help urologists identify candidates for extended pelvic lymph node dissection concomitant with robot-assisted radical prostatectomy among patients with prostate cancer.