1
|
Bennett R, Li EV, Ho AY, Aguiar J, Mahenthiran AK, Suk-Ouichai C, Kumar SK, Neill C, Schaeffer EM, Jawahar A, Patel HD, Ross AE. Contemporary Diagnosis of Very Low-risk Prostate Cancer in a Multihospital Health Care System. Eur Urol Oncol 2024:S2588-9311(24)00109-3. [PMID: 38734544 DOI: 10.1016/j.euo.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/07/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024]
Abstract
The National Comprehensive Cancer Network (NCCN) very low risk (VLR) category for prostate cancer (PCa) represents clinically insignificant disease, and detection of VLR PCa contributes to overdiagnosis. Greater use of magnetic resonance imaging (MRI) and biomarkers before patient selection for prostate biopsy (PBx) reduces unnecessary biopsies and may reduce the diagnosis of clinically insignificant PCa. We tested a hypothesis that the proportion of VLR diagnoses has decreased with greater use of MRI-informed PBx using data from our 11-hospital system. From 2018 to 2023, 351/3197 (11%) men diagnosed with PCa met the NCCN VLR criteria. The proportion of VLR diagnoses did not change from 2018 to 2023 (p = 0.8) despite an increase in the use of MRI-informed PBx (from 49% to 82%; p < 0.001). Of patients who underwent combined systematic and targeted PBx and were diagnosed with VLR disease, cancer was found in systematic PBx regions in 79% of cases and in targeted PBx regions in 31% of cases. When performing both systematic and targeted PBx, prebiopsy MRI-based risk calculators could limit VLR diagnosis by 41% using a risk threshold of >5% for Gleason grade group ≥3 PCa to recommend biopsy; the reduction would be 77% if performing targeted PBx only. These findings suggest that VLR disease continues to account for a significant minority of PCa diagnoses and could be limited by targeted PBx and risk stratification calculators. PATIENT SUMMARY: We looked at recent trends for the diagnosis of very low-risk (VLR) prostate cancer. We found that VLR cancer still seems to be frequently diagnosed despite the use of MRI (magnetic resonance imaging) scans before biopsy. The use of risk calculators to identify men who could avoid biopsy and/or biopsy only for lesions that are visible on MRI could reduce the overdiagnosis of VLR prostate cancer.
Collapse
Affiliation(s)
- Richard Bennett
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Eric V Li
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Austin Y Ho
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jonathan Aguiar
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ashorne K Mahenthiran
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chalairat Suk-Ouichai
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Sai K Kumar
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Clayton Neill
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Edward M Schaeffer
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Anugayathri Jawahar
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Hiten D Patel
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ashley E Ross
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| |
Collapse
|
2
|
Valentin B, Arsov C, Ullrich T, Al-Monajjed R, Boschheidgen M, Hadaschik BA, Giganti F, Giessing M, Lopez-Cotarelo C, Esposito I, Antoch G, Albers P, Radtke JP, Schimmöller L. Magnetic Resonance Imaging-guided Active Surveillance Without Annual Rebiopsy in Patients with Grade Group 1 or 2 Prostate Cancer: The Prospective PROMM-AS Study. EUR UROL SUPPL 2024; 59:30-38. [PMID: 38298772 PMCID: PMC10829616 DOI: 10.1016/j.euros.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 02/02/2024] Open
Abstract
Background Multiparametric magnetic resonance imaging (mpMRI) may allow patients with prostate cancer (PC) on active surveillance (AS) to avoid repeat prostate biopsies during monitoring. Objective To assess the ability of mpMRI to reduce guideline-mandated biopsy and to predict grade group upgrading in patients with International Society of Urological Pathology grade group (GG) 1 or GG 2 PC using Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) scores. The hypothesis was that the AS disqualification rate (ASDQ) rate could be reduced to 15%. Design setting and participants PROMM-AS was a prospective study assessing 2-yr outcomes for an mpMRI-guided AS protocol. A 12 mo after AS inclusion on the basis of MRI/transrectal ultrasound fusion-guided biopsy (FBx), all patients underwent mpMRI. For patients with stable mpMRI (PRECISE 1-3), repeat biopsy was deferred and follow-up mpMRI was scheduled for 12 mo later. Patients with mpMRI progression (PRECISE 4-5) underwent FBx. At the end of the study, follow-up FBx was indicated for all patients. Outcome measurements and statistical analysis We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for upgrading to GG 2 in the GG 1 group, and to GG 3 in the GG 2 group on MRI. We performed regression analyses that included clinical variables. Results and limitations The study included 101 patients with PC (60 GG 1 and 41 GG 2). Histopathological progression occurred in 31 patients, 18 in the GG 1 group and 13 in the GG 2 group. Thus, the aim of reducing the ASDQ rate to 15% was not achieved. The sensitivity, specificity, PPV, and NPV for PRECISE scoring of MRI were 94%, 64%, 81%, and 88% in the GG 1 group, and 92%, 50%, 92%, and 50%, respectively, in the GG 2 group. On regression analysis, initial prostate-specific antigen (p < 0.001) and higher PRECISE score (4-5; p = 0.005) were significant predictors of histological progression of GG 1 PC. Higher PRECISE score (p = 0.009), initial Prostate Imaging-Reporting and Data System score (p = 0.009), previous negative biopsy (p = 0.02), and percentage Gleason pattern 4 (p = 0.04) were significant predictors of histological progression of GG 2 PC. Limitations include extensive MRI reading experience, the small sample size, and limited follow-up. Conclusions MRI-guided monitoring of patients on AS using PRECISE scores avoided unnecessary follow-up biopsies in 88% of patients with GG 1 PC and predicted upgrading during 2-yr follow-up in both GG 1 and GG 2 PC. Patient summary We investigated whether MRI (magnetic resonance imaging) scores can be used to guide whether patients with lower-risk prostate cancer who are on active surveillance (AS) need to undergo repeat biopsies. Follow-up biopsy was deferred for 1 year for patients with a stable score and performed for patients whose score progressed. After 24 months on AS, all men underwent MRI and biopsy. Among patients with grade group 1 cancer and a stable MRI score, 88% avoided biopsy. For patients with MRI score progression, AS termination was correctly recommended in 81% of grade group 1 and 92% of grade group 2 cases.
Collapse
Affiliation(s)
- Birte Valentin
- Department of Diagnostic and Interventional Radiology, University of Düsseldorf, Düsseldorf, Germany
| | - Christian Arsov
- Department of Urology, University of Düsseldorf, Düsseldorf, Germany
- Elisabeth-Krankenhaus Rheydt, Department of Urology and Paediatric Urology, Staedtische Kliniken Moenchengladbach GmbH, Moenchengladbach, Germany
| | - Tim Ullrich
- Department of Diagnostic and Interventional Radiology, University of Düsseldorf, Düsseldorf, Germany
| | | | - Matthias Boschheidgen
- Department of Diagnostic and Interventional Radiology, University of Düsseldorf, Düsseldorf, Germany
| | | | - Francesco Giganti
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Markus Giessing
- Department of Urology, University of Düsseldorf, Düsseldorf, Germany
| | | | - Irene Esposito
- Institute of Pathology, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany
| | - Gerald Antoch
- Department of Diagnostic and Interventional Radiology, University of Düsseldorf, Düsseldorf, Germany
| | - Peter Albers
- Department of Urology, University of Düsseldorf, Düsseldorf, Germany
- Division of Personalized Early Detection of Prostate Cancer, German Cancer Research Center, Heidelberg, Germany
| | - Jan Philipp Radtke
- Department of Urology, University of Düsseldorf, Düsseldorf, Germany
- Department of Radiology, German Cancer Research Center, Heidelberg, Germany
| | - Lars Schimmöller
- Department of Diagnostic and Interventional Radiology, University of Düsseldorf, Düsseldorf, Germany
- Department of Diagnostic, Interventional Radiology and Nuclear Medicine, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Herne, Germany
| |
Collapse
|
3
|
Fan Y, Mulati Y, Zhai L, Chen Y, Wang Y, Feng J, Yu W, Zhang Q. Diagnostic Accuracy of Contemporary Selection Criteria in Prostate Cancer Patients Eligible for Active Surveillance: A Bayesian Network Meta-Analysis. Front Oncol 2022; 11:810736. [PMID: 35083157 PMCID: PMC8785217 DOI: 10.3389/fonc.2021.810736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 12/10/2021] [Indexed: 12/24/2022] Open
Abstract
Background Several active surveillance (AS) criteria have been established to screen insignificant prostate cancer (insigPCa, defined as organ confined, low grade and small volume tumors confirmed by postoperative pathology). However, their comparative diagnostic performance varies. The aim of this study was to compare the diagnostic accuracy of contemporary AS criteria and validate the absolute diagnostic odds ratio (DOR) of optimal AS criteria. Methods First, we searched Pubmed and performed a Bayesian network meta-analysis (NMA) to compare the diagnostic accuracy of contemporary AS criteria and obtained a relative ranking. Then, we searched Pubmed again to perform another meta-analysis to validate the absolute DOR of the top-ranked AS criteria derived from the NMA with two endpoints: insigPCa and favorable disease (defined as organ confined, low grade tumors). Subgroup and meta-regression analyses were conducted to identify any potential heterogeneity in the results. Publication bias was evaluated. Results Seven eligible retrospective studies with 3,336 participants were identified for the NMA. The diagnostic accuracy of AS criteria ranked from best to worst, was as follows: Epstein Criteria (EC), Yonsei criteria, Prostate Cancer Research International: Active Surveillance (PRIAS), University of Miami (UM), University of California-San Francisco (UCSF), Memorial Sloan-Kettering Cancer Center (MSKCC), and University of Toronto (UT). I2 = 50.5%, and sensitivity analysis with different insigPCa definitions supported the robustness of the results. In the subsequent meta-analysis of DOR of EC, insigPCa and favorable disease were identified as endpoints in ten and twenty-two studies, respectively. The pooled DOR for insigPCa and favorable disease were 0.44 (95%CI, 0.31–0.58) and 0.66 (95%CI, 0.61–0.71), respectively. According to a subgroup analysis, the DOR for favorable disease was significantly higher in US institutions than that in other regions. No significant heterogeneity or evidence of publication bias was identified. Conclusions Among the seven AS criteria evaluated in this study, EC was optimal for positively identifying insigPCa patients. The pooled diagnostic accuracy of EC was 0.44 for insigPCa and 0.66 when a more liberal endpoint, favorable disease, was used. Systematic Review Registration [https://www.crd.york.ac.uk/prospero/], PROSPERO [CRD42020157048].
Collapse
Affiliation(s)
- Yu Fan
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Department of Urology, Tibet Autonomous Region People's Hospital, Lhasa, China
| | - Yelin Mulati
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
| | - Lingyun Zhai
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuke Chen
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
| | - Yu Wang
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
| | - Juefei Feng
- Department of Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Wei Yu
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
| | - Qian Zhang
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Peking University Binhai Hospital, Tianjin, China
| |
Collapse
|
4
|
Clinical Relevance of Circulating Tumor Cells in Prostate Cancer Management. Biomedicines 2021; 9:biomedicines9091179. [PMID: 34572366 PMCID: PMC8471111 DOI: 10.3390/biomedicines9091179] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/29/2021] [Accepted: 09/04/2021] [Indexed: 02/08/2023] Open
Abstract
Given the low specificity of the routinely used biomarker prostate-specific antigen, circulating tumor cell (CTC) enumeration seems to be particularly useful in the monitoring of prostate cancer. In this review, we focused on a few aspects of CTC enumeration in prostate malignancies: prognostic value in metastatic and non-metastatic tumors, role in the monitoring of treatment outcomes, use as a surrogate marker for survival, and other applications, mostly for research purposes. CTC enumeration, without a doubt, offers an attractive perspective in the management of prostate cancer. However, the vast majority of available data about the role of CTC in this malignancy originate from randomized studies of anticancer agents and do not necessarily translate into real-world clinical practice. Further, most studies on the application of CTC in prostate cancer patients were limited to advanced stages of this malignancy. Meanwhile, the role of CTC in the early stages of prostate cancer, in which some patients may present with occult disseminated disease, is still relatively poorly understood, and should thus be studied extensively. Other obstacles in the widespread application of CTC enumeration in routine clinical practice include considerable discrepancies in the number of cells determined with various commercially available systems.
Collapse
|
5
|
Epstein JI. Very low-risk versus low-risk prostate cancer: A distinction worth keeping. Prostate 2021; 81:923-925. [PMID: 34254353 DOI: 10.1002/pros.24197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/08/2021] [Accepted: 07/01/2021] [Indexed: 11/10/2022]
|
6
|
Lee CH, Tan TW, Tan CH. Multiparametric MRI in Active Surveillance of Prostate Cancer: An Overview and a Practical Approach. Korean J Radiol 2021; 22:1087-1099. [PMID: 33856136 PMCID: PMC8236356 DOI: 10.3348/kjr.2020.1224] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/08/2020] [Accepted: 01/08/2021] [Indexed: 12/26/2022] Open
Abstract
MRI has become important for the detection of prostate cancer. MRI-guided biopsy is superior to conventional systematic biopsy in patients suspected with prostate cancer. MRI is also increasingly used for monitoring patients with low-risk prostate cancer during active surveillance. It improves patient selection for active surveillance at diagnosis, although its role during follow-up is unclear. We aim to review existing evidence and propose a practical approach for incorporating MRI into active surveillance protocols.
Collapse
Affiliation(s)
- Chau Hung Lee
- Department of Radiology, Tan Tock Seng Hospital, Singapore
| | - Teck Wei Tan
- Department of Urology, Tan Tock Seng Hospital, Singapore
| | - Cher Heng Tan
- Department of Radiology, Tan Tock Seng Hospital, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
| |
Collapse
|
7
|
Singh S, Patil S, Tamhankar AS, Ahluwalia P, Gautam G. Low-risk prostate cancer in India: Is active surveillance a valid treatment option? Indian J Urol 2020; 36:184-190. [PMID: 33082633 PMCID: PMC7531380 DOI: 10.4103/iju.iju_37_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/08/2020] [Accepted: 05/03/2020] [Indexed: 01/24/2023] Open
Abstract
Introduction and Objective: Carcinoma prostate is considered highly aggressive in Asian countries such as India. This raises an argument whether active surveillance (AS) gives a false sense of security as opposed to upfront radical prostatectomy (RP) in Indian males with low-risk prostate cancer (PCa). We analyzed our prospectively maintained robot-assisted RP (RARP) database to address this question. Materials and Methods: Five hundred and sixty-seven men underwent RARP by a single surgical team from September 2013 to September 2019. Of these, 46 (8.1%) were low risk considering the National Comprehensive Cancer Network criteria. Gleason grade group and stage were compared before and after surgery to ascertain the incidence of upgrading and upstaging. Preoperative clinical and pathological characteristics were analyzed for association with the probability of upstaging and upgrading. Results: The mean age was 60.8 ± 6.8 years. Average prostate-specific antigen level was 6.7 ± 2.0 ng/mL. 40 (86.9%) patients had a T1 stage disease and 6 (13%) patients were clinically in T2a stage. A total of 25 (54.3%) cases were either upstaged or upgraded, 19 (41.3%) showed no change, and the remaining 2 (4.3%) had no malignancy on the final RP specimen. Upstaging occurred in 8 (17.4%) cases: 5 (10.9%) to pT3a and 3 (6.5%) to pT3b. Upgrading occurred in 23 (50%) cases: 19 (41.3%) to Grade 2; 3 (6.5%) to Grade 3; and 1 (2.2%) to Grade 4. Conclusions: There is a 50% likelihood of upstaging or upgrading in Indian males with low-risk PCa eligible for AS. Decision to proceed with AS should be taken carefully.
Collapse
Affiliation(s)
- Shanky Singh
- Department of Urology, AIIMS, Rishikesh, Uttarakhand, India
| | - Saurabh Patil
- Department of Urooncology, Max Institute of Cancer Care, New Delhi, India
| | | | - Puneet Ahluwalia
- Department of Urooncology, Max Institute of Cancer Care, New Delhi, India
| | - Gagan Gautam
- Department of Urooncology, Max Institute of Cancer Care, New Delhi, India
| |
Collapse
|
8
|
|
9
|
Viana PCC, Horvat N, do Santos VR, Lima TC, Romão DDS, Cerri LMDO, de Castro MG, Vargas HA, Miranda JA, Leite CDC, Cerri GG. Is possible to rule out clinically significant prostate cancer using PI-RADS v2 for the assessment of prostate MRI? Int Braz J Urol 2019; 45:724-731. [PMID: 31136114 PMCID: PMC6837601 DOI: 10.1590/s1677-5538.ibju.2018.0382] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 02/27/2019] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES To evaluate the diagnostic performance and interobserver agreement of PI-RADS v2. MATERIALS AND METHODS In this Institutional Review Board approved single-center retrospective study, 98 patients with clinically suspected PCa who underwent 3-T multiparametric MRI followed by MRI/TRUS fusion-guided prostate biopsy were included from June 2013 to February 2015. Two radiologists (R1 and R2) with 8 and 1 years of experience in abdominal radiology reviewed the MRI scans and assigned PI-RADS v2 scores in all prostate zones. PI-RADS v2 were compared to MRI/TRUS fusion-guided biopsy results, which were classified as negative, PCa, and significant PCa (sPCa). RESULTS Sensitivity, specificity, NPV, PPV and accuracy for PCa was 85.7% (same for all metrics) for R1 and 81.6%, 79.6%, 81.2%, 80.0% and 80.6% for R2. For detecting sPCa, the corresponding values were 95.3%, 85.4%, 95.9%, 83.7% and 89.8% for R1 and 93.0%, 81.8%, 93.7%, 86.7% and 86.7% for R2. There was substantial interobserver agreement in assigning PI-RADS v2 score as negative (1, 2, 3) or positive (4, 5) (Kappa=0.78). On multivariate analysis, PI-RADS v2 (p <0.001) was the only independent predictor of sPCa compared with age, abnormal DRE, prostate volume, PSA and PSA density. CONCLUSIONS Our study population demonstrated that PI-RADS v2 had high diagnostic accuracy, substantial interobserver agreement, and it was the only independent predictor of sPCa.
Collapse
Affiliation(s)
| | - Natally Horvat
- Departamento de Radiologia do Hospital Sírio-Libanês, São Paulo, SP, Brasil
| | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Hsiang W, Ghabili K, Syed JS, Holder J, Nguyen KA, Suarez-Sarmiento A, Huber S, Leapman MS, Sprenkle PC. Outcomes of Serial Multiparametric Magnetic Resonance Imaging and Subsequent Biopsy in Men with Low-risk Prostate Cancer Managed with Active Surveillance. Eur Urol Focus 2019; 7:47-54. [PMID: 31147263 DOI: 10.1016/j.euf.2019.05.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 04/11/2019] [Accepted: 05/14/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Outcomes of serial multiparametric magnetic resonance imaging (mpMRI) and subsequent biopsy in monitoring prostate cancer (PCa) in men on active surveillance (AS) have not been defined clearly. OBJECTIVE To determine whether changes in serial mpMRI can predict pathological upgrade among men with grade group (GG) 1 PCa managed with AS. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of men with GG1 on AS with at least two consecutive mpMRI examinations during 2012-2018 who underwent mpMRI/ultrasound fusion or systematic biopsies. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Progression on serial mpMRI was evaluated as a predictor of pathological upgrading to GG≥2 on a follow-up biopsy using clinical, pathological, and imaging factors in binary logistic regression. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were determined. RESULTS AND LIMITATIONS Of 122 patients, 29 men (23.8%) experienced pathological upgrade on the follow-up biopsy. Progression on mpMRI was not associated with pathological upgrade. The sensitivity, specificity, PPV, and NPV of mpMRI progression for predicting pathological upgrade were 41.3%, 54.8%, 22.2%, and 75%, respectively. Age (odds ratio [OR] 1.17, p=0.006), Prostate Imaging Reporting and Data System (PI-RADS) score on initial mpMRI (4-5 vs ≤3, OR 7.48, p=0.01), number of positive systematic cores (OR 1.84, p=0.03), number of positive targeted cores (OR 0.44, p=0.04), and maximum percent of targeted core tumor involvement (OR 1.04, p=0.01) were significantly associated with pathological upgrade. CONCLUSIONS We did not observe an association between mpMRI progression and pathological upgrade; however, a PI-RADS score of 4-5 on initial mpMRI was predictive of subsequent pathological progression. The continued use of systematic and fusion biopsies appears necessary due to risks of reclassification over time. PATIENT SUMMARY Progression on serial multiparametric magnetic resonance imaging during active surveillance (AS) is not associated with progression on the follow-up biopsy. Both systematic and fusion biopsies are necessary to sufficiently capture progression during AS.
Collapse
Affiliation(s)
- Walter Hsiang
- Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | - Kamyar Ghabili
- Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | - Jamil S Syed
- Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | - Justin Holder
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Kevin A Nguyen
- Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | | | - Steffen Huber
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | | | | |
Collapse
|
11
|
Padhani AR, Weinreb J, Rosenkrantz AB, Villeirs G, Turkbey B, Barentsz J. Prostate Imaging-Reporting and Data System Steering Committee: PI-RADS v2 Status Update and Future Directions. Eur Urol 2019; 75:385-396. [PMID: 29908876 PMCID: PMC6292742 DOI: 10.1016/j.eururo.2018.05.035] [Citation(s) in RCA: 183] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 05/29/2018] [Indexed: 12/13/2022]
Abstract
CONTEXT The Prostate Imaging-Reporting and Data System (PI-RADS) v2 analysis system for multiparametric magnetic resonance imaging (mpMRI) detection of prostate cancer (PCa) is based on PI-RADS v1, accumulated scientific evidence, and expert consensus opinion. OBJECTIVE To summarize the accuracy, strengths and weaknesses of PI-RADS v2, discuss pathway implications of its use and outline opportunities for improvements and future developments. EVIDENCE ACQUISITION For this consensus expert opinion from the PI-RADS steering committee, clinical studies, systematic reviews, and professional guidelines for mpMRI PCa detection were evaluated. We focused on the performance characteristics of PI-RADS v2, comparing data to systems based on clinicoradiologic Likert scales and non-PI-RADS v2 imaging only. Evidence selections were based on high-quality, prospective, histologically verified data, with minimal patient selection and verifications biases. EVIDENCE SYNTHESIS It has been shown that the test performance of PI-RADS v2 in research and clinical practice retains higher accuracy over systematic transrectal ultrasound (TRUS) biopsies for PCa diagnosis. PI-RADS v2 fails to detect all cancers but does detect the majority of tumors capable of causing patient harm, which should not be missed. Test performance depends on the definition and prevalence of clinically significant disease. Good performance can be attained in practice when the quality of the diagnostic process can be assured, together with joint working of robustly trained radiologists and urologists, conducting biopsy procedures within multidisciplinary teams. CONCLUSIONS It has been shown that the test performance of PI-RADS v2 in research and clinical practice is improved, retaining higher accuracy over systematic TRUS biopsies for PCa diagnosis. PATIENT SUMMARY Multiparametric magnetic resonance imaging (MRI) and MRI-directed biopsies using the Prostate Imaging-Reporting and Data System improves the detection of prostate cancers likely to cause harm, and at the same time decreases the detection of disease that does not lead to harms if left untreated. The keys to success are high-quality imaging, reporting, and biopsies by radiologists and urologists working together in multidisciplinary teams.
Collapse
Affiliation(s)
- Anwar R Padhani
- Paul Strickland Scanner Centre, Mount Vernon Cancer Centre, Northwood, UK
| | - Jeffrey Weinreb
- Department of Radiology, Yale University School of Medicine, New Haven, USA
| | | | - Geert Villeirs
- Department of Radiology, Ghent University Hospital, Gent, Belgium
| | | | | |
Collapse
|
12
|
Taneja SS. Re: Effects of Pathological Upstaging or Upgrading on Metastasis and Cancer-Specific Mortality in Men with Clinical Low-Risk Prostate Cancer. J Urol 2018; 200:945-946. [DOI: 10.1016/j.juro.2018.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
13
|
Abstract
Objective: The optimal management strategy for prostate cancer (PCa) remains controversial. We performed a systemic review of current progress and controversies regarding the diagnosis and treatment of PCa. Data Sources: We searched PubMed for recently published articles up to July 2017 using the following key words: “prostate cancer,” “progress,” “controversy,” “immunotherapy,” and “prevention.” Study Selection: Articles were obtained and reviewed to provide a systematic review of the current progress and controversies regarding PCa management. Results: The value of serum prostate-specific antigen (PSA) screening remains controversial, but PSA screening is recommended to facilitate the early diagnosis of PCa in high-risk groups. Prostate biopsy via the transrectal or perineal approach has both advantages and disadvantages. There was a significant correlation between testosterone levels and PCa prognosis. The current research is focused on the mechanisms responsible for PCa. Active surveillance has been proposed as a management strategy for low-risk, localized PCa, but there is an urgent need for further clinical studies to establish the criteria for recommending this approach. The main complications of radical resection for PCa are urinary incontinence and erectile dysfunction, though three-dimensional laparoscopic and robot-assisted laparoscopic techniques have obvious advantages over radical surgery. Radiotherapy is also a therapeutic option for PCa, while immunotherapies may alter the prostate tumor microenvironment. Ongoing studies aim to provide guidance on effective sequential and combination strategies. Prevention remains an important strategy for reducing PCa morbidity and mortality. Conclusions: The diagnosis, treatment, and prevention of PCa are complex issues, worthy of intensive study. Further studies are needed to improve the management of PCa.
Collapse
Affiliation(s)
- De-Xin Dong
- Department of Urology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing 100730, China
| | - Zhi-Gang Ji
- Department of Urology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing 100730, China
| |
Collapse
|
14
|
Tsang CF, Lai TCT, Lam W, Ho BSH, Ng ATL, Ma WK, Yiu MK, Tsu JHL. Is prostate specific antigen (PSA) density necessary in selecting prostate cancer patients for active surveillance and what should be the cutoff in the Asian population? Prostate Int 2018; 7:73-77. [PMID: 31384609 PMCID: PMC6664316 DOI: 10.1016/j.prnil.2018.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/02/2018] [Accepted: 03/06/2018] [Indexed: 01/15/2023] Open
Abstract
Background To investigate the role of Prostate Specific Antigen density (PSAD) in selecting prostate cancer patients for active surveillance (AS) and to determine a cutoff PSAD in identifying adverse pathological outcomes. Methods Data from 287 patients who underwent radical prostatectomy for prostate cancer were retrospectively reviewed. Six different AS protocols, the University of Toronto; Royal Marsden; John Hopkins; University of California San Francisco (UCSF); Memorial Sloan Kettering Cancer Center (MSKCC) and Prostate Cancer Research International: Active Surveillance (PRIAS), were applied to the cohort. Pre-operative demographics and pathological outcomes were analysed. Statistical analyses on the predictive factors of adverse pathological outcomes and significance of PSAD were performed. A cutoff PSAD with best balance between sensitivity and specificity in identifying adverse pathological outcome was determined. Results PSAD predicted adverse pathological outcomes better than Prostate Specific Antigen (PSA) level alone. The PSAD was significantly lower (0.12-0.13 ng/dl/ml) in protocols including PSAD (the John Hopkins and PRIAS) compared with the other four protocols not including PSAD as a selection criteria (0.21-0.25 ng/dl/dl, P = 0.00). PSAD predicted adverse pathological outcomes in all protocols not incorporating PSAD as an inclusion criteria (P = 0.00-0.02). By the receiver operator characteristics curve analysis, it was found that a PSAD level of 0.19 ng/ml/ml had the best balance between sensitivity and specificity in predicting pathological adverse disease (Area under curve = 0.63, P = 0.004). Conclusion PSAD is necessary in selecting prostate cancer patients for active surveillance. It predicts adverse pathological outcomes in patients eligible for active surveillance better than PSA level alone. A PSAD cutoff at 0.19 ng/ml/ml has the best balance between sensitivity and specificity in predicting pathological adverse disease. We recommend using AS protocol incorporating PSAD as a selection criteria (in particular the PRIAS protocol with a cutoff PSAD at 0.2 ng/ml/ml) when recruiting prostate cancer patients for AS.
Collapse
Affiliation(s)
- Chiu-Fung Tsang
- Division of Urology, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Terence C T Lai
- Division of Urology, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Wayne Lam
- Division of Urology, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Brian S H Ho
- Division of Urology, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Ada T L Ng
- Division of Urology, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Wai-Kit Ma
- Division of Urology, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Ming-Kwong Yiu
- Division of Urology, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - James H L Tsu
- Division of Urology, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| |
Collapse
|
15
|
Nowinski S, Santaolalla A, O'Leary B, Loda M, Mirchandani A, Emberton M, Van Hemelrijck M, Grigoriadis A. Systematic identification of functionally relevant risk alleles to stratify aggressive versus indolent prostate cancer. Oncotarget 2018; 9:12812-12824. [PMID: 29560112 PMCID: PMC5849176 DOI: 10.18632/oncotarget.24400] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 01/25/2018] [Indexed: 12/20/2022] Open
Abstract
Novel approaches for classification, including molecular features, are needed to direct therapy for men with low-grade prostate cancer (PCa), especially men on active surveillance. Risk alleles identified from genome-wide association studies (GWAS) could improve prognostication. Those risk alleles that coincided with genes and somatic copy number aberrations associated with progression of PCa were selected as the most relevant for prognostication. In a systematic literature review, a total of 698 studies were collated. Fifty-three unique SNPs residing in 29 genomic regions, including 8q24, 10q11 and 19q13, were associated with PCa progression. Functional studies implicated 21 of these single nucleotide polymorphisms (SNPs) as modulating the expression of genes in the androgen receptor pathway and several other oncogenes. In particular, 8q24, encompassing MYC, harbours a high density of SNPs conferring unfavourable pathological characteristics in low-grade PCa, while a copy number gain of MYC in low-grade PCa was associated with prostate-specific antigen recurrence after radical prostatectomy. By combining GWAS data with gene expression and structural rearrangements, risk alleles were identified that could provide a new basis for developing a prognostication tool to guide therapy for men with early prostate cancer.
Collapse
Affiliation(s)
- Salpie Nowinski
- Cancer Bioinformatics, Innovation Hub, Guy's Cancer Centre, King's College London, London, UK
| | - Aida Santaolalla
- Translational Oncology & Urology Research, King's College London, London, UK
| | - Ben O'Leary
- Breast Cancer NOW Centre, The Institute of Cancer Research, The Royal Marsden Hospital, London, UK
| | - Massimo Loda
- Department of Oncologic Pathology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Ayesha Mirchandani
- Cancer Bioinformatics, Innovation Hub, Guy's Cancer Centre, King's College London, London, UK
| | - Mark Emberton
- Division of Surgery and Interventional Science, University College London, London, UK
| | | | - Anita Grigoriadis
- Cancer Bioinformatics, Innovation Hub, Guy's Cancer Centre, King's College London, London, UK
| |
Collapse
|
16
|
Brizmohun Appayya M, Sidhu HS, Dikaios N, Johnston EW, Simmons LAM, Freeman A, Kirkham APS, Ahmed HU, Punwani S. Characterizing indeterminate (Likert-score 3/5) peripheral zone prostate lesions with PSA density, PI-RADS scoring and qualitative descriptors on multiparametric MRI. Br J Radiol 2018; 91:20170645. [PMID: 29189042 PMCID: PMC5965471 DOI: 10.1259/bjr.20170645] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/13/2017] [Accepted: 11/27/2017] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To determine whether indeterminate (Likert-score 3/5) peripheral zone (PZ) multiparametric MRI (mpMRI) studies are classifiable by prostate-specific antigen (PSA), PSA density (PSAD), Prostate Imaging Reporting And Data System version 2 (PI-RADS_v2) rescoring and morphological MRI features. METHODS Men with maximum Likert-score 3/5 within their PZ were retrospectively selected from 330 patients who prospectively underwent prostate mpMRI (3 T) without an endorectal coil, followed by 20-zone transperineal template prostate mapping biopsies +/- focal lesion-targeted biopsy. PSAD was calculated using pre-biopsy PSA and MRI-derived volume. Two readers A and B independently assessed included men with both Likert-assessment and PI-RADS_v2. Both readers then classified mpMRI morphological features in consensus. Men were divided into two groups: significant cancer (≥ Gleason 3 + 4) or insignificant cancer (≤ Gleason 3 + 3)/no cancer. Comparisons between groups were made separately for PSA & PSAD using Mann-Whitney test and morphological descriptors with Fisher's exact test. PI-RADS_v2 and Likert-assessment were descriptively compared and percentage inter-reader agreement calculated. RESULTS 76 males were eligible for PSA & PSAD analyses, 71 for PI-RADS scoring, and 67 for morphological assessment (excluding significant image artefacts). Unlike PSA (p = 0.915), PSAD was statistically different (p = 0.004) between the significant [median: 0.19 ng ml-2 (interquartile range: 0.13-0.29)] and non-significant/no cancer [median: 0.13 ng ml-2 (interquartile range: 0.10-0.17)] groups. Presence of mpMRI morphological features was not significantly different between groups. Subjective Likert-assessment discriminated patients with significant cancer better than PI-RADS_v2. Inter-reader percentage agreement was 83% for subjective Likert-assessment and 56% for PI-RADS_v2. CONCLUSION PSAD may categorize presence of significant cancer in patients with Likert-scored 3/5 PZ mpMRI findings. Advances in knowledge: PSAD may be used in indeterminate PZ mpMRI to guide decisions between biopsy vs monitoring.
Collapse
Affiliation(s)
| | | | - Nikolaos Dikaios
- Centre for Medical Imaging, University College London, Wolfson House, London, UK
| | | | - Lucy AM Simmons
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Alex Freeman
- Department of Pathology, University College London Hospital, London, UK
| | | | - Hashim U Ahmed
- Division of Surgery and Interventional Science, University College London, London, UK
| | | |
Collapse
|
17
|
Galgano SJ, Glaser ZA, Porter KK, Rais-Bahrami S. Role of Prostate MRI in the Setting of Active Surveillance for Prostate Cancer. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1096:49-67. [DOI: 10.1007/978-3-319-99286-0_3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
18
|
Prostate-specific Antigen Density Is a Good Predictor of Upstaging and Upgrading, According to the New Grading System: The Keys We Are Seeking May Be Already in Our Pocket. Urology 2018; 111:129-135. [DOI: 10.1016/j.urology.2017.07.071] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/08/2017] [Accepted: 07/28/2017] [Indexed: 11/29/2022]
|
19
|
Eineluoto JT, Järvinen P, Kenttämies A, Kilpeläinen TP, Vasarainen H, Sandeman K, Erickson A, Mirtti T, Rannikko A. Repeat multiparametric MRI in prostate cancer patients on active surveillance. PLoS One 2017; 12:e0189272. [PMID: 29281647 PMCID: PMC5744936 DOI: 10.1371/journal.pone.0189272] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 11/22/2017] [Indexed: 12/27/2022] Open
Abstract
Introduction This study was conducted to describe the changes in repeat multiparametric MRI (mpMRI) occurring in prostate cancer (PCa) patients during active surveillance (AS), and to study possible associations between mpMRI-related parameters in predicting prostate biopsy (Bx) Gleason score (GS) upgrading >3+3 and protocol-based treatment change (TC). Materials and methods The study cohort consisted of 76 AS patients with GS 3+3 PCa and at least two consecutive mpMRIs of the prostate performed between 2006–2015. Patients were followed according to the Prostate Cancer Research International Active Surveillance (PRIAS) protocol and an additional mpMRI. The primary end points were GS upgrading (GU) (>3+3) in protocol-based Bxs and protocol-based TC. Results Out of 76 patients, 53 (69%) had progression (PIRADS upgrade, size increase or new lesion[s]), while 18 (24%) had radiologically stable disease, and 5 (7%) had regression (PIRADS or size decrease, disappearance of lesion[s]) in repeat mpMRIs during AS. PIRADS scores of 4–5 in the initial mpMRI were associated with GU (p = 0.008) and protocol-based TC (p = 0.009). Tumour progression on repeat mpMRIs was associated with TC (p = 0.045) but not with GU (p = 1.00). PIRADS scores of 4–5 predict GU (sensitivity 0.80 [95% confidence interval (CI); 0.51–0.95, specificity 0.62 [95% CI; 0.52–0.77]) with PPV and NPV values of 0.34 (95% CI; 0.21–0.55) and 0.93 (95% CI; 0.80–0.98), respectively. Conclusion mpMRI is a useful tool not only to select but also to monitor PCa patients on AS.
Collapse
Affiliation(s)
- Juho T. Eineluoto
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- * E-mail:
| | - Petrus Järvinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anu Kenttämies
- Medical Imaging Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tuomas P. Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Vasarainen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kevin Sandeman
- Department of Pathology (HUSLAB), University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Andrew Erickson
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Pathology (HUSLAB), University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tuomas Mirtti
- Department of Pathology (HUSLAB), University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Finnish Institute for Molecular Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Medicum, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti Rannikko
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
20
|
Jeon HG, Yoo JH, Jeong BC, Seo SI, Jeon SS, Choi HY, Lee HM, Ferrari M, Brooks JD, Chung BI. Comparative rates of upstaging and upgrading in Caucasian and Korean prostate cancer patients eligible for active surveillance. PLoS One 2017; 12:e0186026. [PMID: 29136019 PMCID: PMC5685613 DOI: 10.1371/journal.pone.0186026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 09/22/2017] [Indexed: 11/19/2022] Open
Abstract
Purpose To investigate the impact of race on the risk of pathological upgrading and upstaging at radical prostatectomy (RP) in an Asian (Korean) and Western (Caucasian) cohort eligible for active surveillance (AS). Materials and methods We performed a retrospective cohort study of 854 patients eligible for AS who underwent RP in United States (n = 261) and Korea (n = 593) between 2006 and 2015. After adjusting for age, PSA level, and prostate volume, we utilized multivariate logistic regression analysis to assess the effect of race on upgrading or upstaging. Results There were significant differences between Caucasian and Korean patients in terms of age at surgery (60.2 yr. vs. 64.1 yr.), PSA density (0.115 ng/mL/mL vs. 0.165 ng/mL/mL) and mean number of positive cores (3.5 vs. 2.4), but not in preoperative PSA values (5.11 ng/mL vs. 5.05 ng/mL). The rate of upstaging from cT1 or cT2 to pT3 or higher was not significantly different between the two cohorts (8.8% vs. 11.0%, P = 0.341). However, there were higher rates of upgrading to high-grade cancer (Gleason 4+3 or higher) in Korean patients (9.1%) when compared to Caucasian counterparts (2.7%) (P = 0.003). Multivariate logistic regression analysis showed that age (OR 1.07, P < 0.001) and smaller prostate volume (OR 0.97, P < 0.001), but not race, were significantly associated with upstaging or upgrading. Conclusions There were no differences in rates of upgrading or upstaging between Caucasian and Korean men eligible for active surveillance.
Collapse
Affiliation(s)
- Hwang Gyun Jeon
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Ho Yoo
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byong Chang Jeong
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Il Seo
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Soo Jeon
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Han-Yong Choi
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Moo Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
| | - Michelle Ferrari
- Department of Urology, Stanford University Medical Center, Stanford, CA, United States of America
| | - James D. Brooks
- Department of Urology, Stanford University Medical Center, Stanford, CA, United States of America
| | - Benjamin I. Chung
- Department of Urology, Stanford University Medical Center, Stanford, CA, United States of America
| |
Collapse
|
21
|
Current Role of Magnetic Resonance Imaging in Prostate Cancer. CURRENT RADIOLOGY REPORTS 2017. [DOI: 10.1007/s40134-017-0255-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
22
|
van der Poel HG, van den Bergh RCN. Difference of opinion - Active surveillance in intermediate risk prostate cancer: is it safe? Opinion: Yes. Int Braz J Urol 2017; 42:413-7. [PMID: 27286101 PMCID: PMC4920555 DOI: 10.1590/s1677-5538.ibju.2016.03.03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
|
23
|
Eleven-year management of prostate cancer patients on active surveillance: what have we learned? TUMORI JOURNAL 2017. [PMID: 28623636 PMCID: PMC6379800 DOI: 10.5301/tj.5000649] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE To evaluate the outcomes of active surveillance (AS) on patients with low-risk prostate cancer (PCa) and to identify predictors of disease reclassification. METHODS In 2005, we defined an institutional AS protocol (Sorveglianza Attiva Istituto Nazionale Tumori [SAINT]), and we joined the Prostate Cancer Research International: Active Surveillance (PRIAS) study in 2007. Eligibility criteria included clinical stage ≤T2a, initial prostate-specific antigen (PSA) <10 ng/mL, and Gleason Pattern Score (GPS) ≤3 + 3 (both protocols); ≤25% positive cores with a maximum core length containing cancer ≤50% (SAINT); and ≤2 positive cores and PSA density <0.2 ng/mL/cm3 (PRIAS). Switching to active treatment was advised for a worsening of GPS, increased positive cores, or PSA doubling time <3 years. Active treatment-free survival (ATFS) was assessed using the Kaplan-Meier method. Factors associated with ATFS were evaluated with a multivariate Cox proportional hazards model. RESULTS A total of 818 patients were included: 200 in SAINT, 530 in PRIAS, and 88 in personalized AS monitoring. Active treatment-free survival was 50% after a median follow-up of 60 months. A total of 404/818 patients (49.4%) discontinued AS: 274 for biopsy-related reclassification, 121/404 (30%) for off-protocol reasons, 9/404 (2.2%) because of anxiety. Biopsy reclassification was associated with PSA density (hazard ratio [HR] 1.8), maximum percentage of core involvement (HR 1.5), positive cores at diagnostic biopsy (HR 1.6), older age (HR 1.5), and prostate volume (HR 0.6) (all p<0.01). Patients from SAINT were significantly more likely to discontinue AS than were the patients from PRIAS (HR 1.65, p<0.0001). CONCLUSIONS Five years after diagnosis, 50% of patients with early PCa were spared from active treatment. Wide inclusion criteria are associated with lower ATFS. However, at preliminary analysis, this does not seem to affect the probability of unfavorable pathology.
Collapse
|
24
|
Tosoian JJ, Loeb S, Epstein JI, Turkbey B, Choyke PL, Schaeffer EM. Active Surveillance of Prostate Cancer: Use, Outcomes, Imaging, and Diagnostic Tools. AMERICAN SOCIETY OF CLINICAL ONCOLOGY EDUCATIONAL BOOK. AMERICAN SOCIETY OF CLINICAL ONCOLOGY. ANNUAL MEETING 2017. [PMID: 27249729 DOI: 10.14694/edbk_159244] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Active surveillance (AS) has emerged as a standard management option for men with very low-risk and low-risk prostate cancer, and contemporary data indicate that use of AS is increasing in the United States and abroad. In the favorable-risk population, reports from multiple prospective cohorts indicate a less than 1% likelihood of metastatic disease and prostate cancer-specific mortality over intermediate-term follow-up (median 5-6 years). Higher-risk men participating in AS appear to be at increased risk of adverse outcomes, but these populations have not been adequately studied to this point. Although monitoring on AS largely relies on serial prostate biopsy, a procedure associated with considerable morbidity, there is a need for improved diagnostic tools for patient selection and monitoring. Revisions from the 2014 International Society of Urologic Pathology consensus conference have yielded a more intuitive reporting system and detailed reporting of low-intermediate grade tumors, which should facilitate the practice of AS. Meanwhile, emerging modalities such as multiparametric magnetic resonance imaging and tissue-based molecular testing have shown prognostic value in some populations. At this time, however, these instruments have not been sufficiently studied to consider their routine, standardized use in the AS setting. Future studies should seek to identify those platforms most informative in the AS population and propose a strategy by which promising diagnostic tools can be safely and efficiently incorporated into clinical practice.
Collapse
Affiliation(s)
- Jeffrey J Tosoian
- From the Brady Urological Institute, Departments of Urology and Pathology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Urology and Population Health, New York University, New York, NY; Molecular Imaging Program, National Cancer Institute, Bethesda, MD; Department of Urology, Northwestern University, Chicago, IL
| | - Stacy Loeb
- From the Brady Urological Institute, Departments of Urology and Pathology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Urology and Population Health, New York University, New York, NY; Molecular Imaging Program, National Cancer Institute, Bethesda, MD; Department of Urology, Northwestern University, Chicago, IL
| | - Jonathan I Epstein
- From the Brady Urological Institute, Departments of Urology and Pathology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Urology and Population Health, New York University, New York, NY; Molecular Imaging Program, National Cancer Institute, Bethesda, MD; Department of Urology, Northwestern University, Chicago, IL
| | - Baris Turkbey
- From the Brady Urological Institute, Departments of Urology and Pathology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Urology and Population Health, New York University, New York, NY; Molecular Imaging Program, National Cancer Institute, Bethesda, MD; Department of Urology, Northwestern University, Chicago, IL
| | - Peter L Choyke
- From the Brady Urological Institute, Departments of Urology and Pathology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Urology and Population Health, New York University, New York, NY; Molecular Imaging Program, National Cancer Institute, Bethesda, MD; Department of Urology, Northwestern University, Chicago, IL
| | - Edward M Schaeffer
- From the Brady Urological Institute, Departments of Urology and Pathology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Urology and Population Health, New York University, New York, NY; Molecular Imaging Program, National Cancer Institute, Bethesda, MD; Department of Urology, Northwestern University, Chicago, IL
| |
Collapse
|
25
|
Tosoian JJ, Carter HB. Active Surveillance of Localized Prostate Cancer: Acknowledging Uncertainty. J Clin Oncol 2016; 34:4452. [DOI: 10.1200/jco.2016.67.8888] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jeffrey J. Tosoian
- Jeffrey J. Tosoian and H. Ballentine Carter, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - H. Ballentine Carter
- Jeffrey J. Tosoian and H. Ballentine Carter, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
26
|
|
27
|
Active surveillance for intermediate-risk prostate cancer. Prostate Cancer Prostatic Dis 2016; 20:1-6. [PMID: 27801900 PMCID: PMC5303136 DOI: 10.1038/pcan.2016.51] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 06/16/2016] [Accepted: 07/11/2016] [Indexed: 12/31/2022]
Abstract
Background Utilization of active surveillance (AS) for prostate cancer is increasing. Optimal selection criteria for this approach are undefined and questions remain on how best to expand inclusion beyond typical men with very low or low risk disease. We sought to review the current experience with AS for men with intermediate risk features. Methods Pubmed was queried for all relevant original publications describing outcomes for men with prostate cancer managed with AS. Outcomes for patients with intermediate risk features as defined by the primary investigators were studied when available and compared with similar risk men undergoing immediate treatment. Results Cancer specific survival for men managed initially with AS is similar to results published with immediate radical intervention. A total of 5 published AS series describe some outcomes for men with intermediate risk features. Definitions of intermediate risk vary between studies. Men with Gleason 7 disease experience higher rates of clinical progression and are more likely to undergo treatment over time. Intermediate risk men with Gleason 6 disease have similar outcomes to low risk men. Men with Gleason 7 disease appear at higher risk for metastatic disease. Novel technologies including imaging and biomarkers may assist with patient selection and disease surveillance. Conclusions The contemporary experiences of AS for men with intermediate risk features suggest that although these men are at higher risk for eventual prostate directed treatment, some are not significantly compromising chances for longer-term cure. Men with more than minimal Gleason pattern 4, however, must be carefully selected and surveyed for early signs of progression and may be at increased risk of metastases. Incorporating information from advanced imaging and biomarker technology will likely individualize future treatment decisions while improving overall surveillance strategies.
Collapse
|
28
|
Magnetic Resonance Imaging-Transrectal Ultrasound Guided Fusion Biopsy to Detect Progression in Patients with Existing Lesions on Active Surveillance for Low and Intermediate Risk Prostate Cancer. J Urol 2016; 197:640-646. [PMID: 27613356 DOI: 10.1016/j.juro.2016.08.109] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2016] [Indexed: 12/26/2022]
Abstract
PURPOSE Active surveillance is an established option for men with low risk prostate cancer. Multiparametric magnetic resonance imaging with magnetic resonance imaging-transrectal ultrasound fusion guided biopsy may better identify patients for active surveillance compared to systematic 12-core biopsy due to improved risk stratification. To our knowledge the performance of multiparametric magnetic resonance imaging in following men on active surveillance with visible lesions is unknown. We evaluated multiparametric magnetic resonance imaging and magnetic resonance imaging-transrectal ultrasound fusion guided biopsy to monitor men on active surveillance. MATERIALS AND METHODS This retrospective review included men from 2007 to 2015 with prostate cancer on active surveillance in whom magnetic resonance imaging visible lesions were monitored by multiparametric magnetic resonance imaging and fusion guided biopsy. Progression was defined by ISUP (International Society of Urological Pathology) grade group 1 to 2 and ISUP grade group 2 to 3. Significance was considered at p ≤0.05. RESULTS A total of 166 patients on active surveillance with 2 or more fusion guided biopsies were included in analysis. Mean followup was 25.5 months. Of the patients 29.5% had pathological progression. Targeted biopsy alone identified 44.9% of patients who progressed compared to 30.6% identified by systematic 12-core biopsy alone (p = 0.03). Fusion guided biopsy detected 26% more cases of pathological progression on surveillance biopsy compared to systematic 12-core biopsy. Progression on multiparametric magnetic resonance imaging was the sole predictor of pathological progression at surveillance biopsy (p = 0.013). Multiparametric magnetic resonance imaging progression in the entire cohort had 81% negative predictive value, 35% positive predictive value, 77.6% sensitivity and 40.5% specificity in detecting pathological progression. CONCLUSIONS Multiparametric magnetic resonance imaging progression predicts the risk of pathological progression. Patients with stable multiparametric magnetic resonance imaging findings have a low rate of progression. Incorporating fusion guided biopsy in active surveillance nearly doubled our detection of pathological progression compared to systematic 12-core biopsy.
Collapse
|
29
|
PTEN loss and chromosome 8 alterations in Gleason grade 3 prostate cancer cores predicts the presence of un-sampled grade 4 tumor: implications for active surveillance. Mod Pathol 2016; 29:764-71. [PMID: 27080984 PMCID: PMC4925272 DOI: 10.1038/modpathol.2016.63] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 02/17/2016] [Accepted: 02/23/2016] [Indexed: 12/11/2022]
Abstract
Men who enter active surveillance because their biopsy exhibits only Gleason grade 3 (G3) frequently have higher grade tumor missed by biopsy. Thus, biomarkers are needed that, when measured on G3 tissue, can predict the presence of higher grade tumor in the whole prostate. We evaluated whether PTEN loss, chromosome 8q gain (MYC) and/or 8p loss (LPL) measured only on G3 cores is associated with un-sampled G4 tumor. A tissue microarray was constructed of prostatectomy tissue from patients whose prostates exhibited only Gleason score 3+3, only 3+4 or only 4+3 tumor (n=50 per group). Cores sampled only from areas of G3 were evaluated for PTEN loss by immunohistochemistry, and PTEN deletion, LPL/8p loss and MYC/8q gain by fluorescence in situ hybridization. Biomarker results were compared between Gleason score 6 vs 7 tumors using conditional logistic regression. PTEN protein loss, odds ratio=4.99, P=0.033; MYC/8q gain, odds ratio=5.36, P=0.010; and LPL/8p loss, odds ratio=3.96, P=0.003 were significantly more common in G3 cores derived from Gleason 7 vs Gleason 6 tumors. PTEN gene deletion was not statistically significant. Associations were stronger comparing Gleason 4+3 vs 6 than for Gleason 3+4 vs 6. MYC/8q gain, LPL/8p loss and PTEN protein loss measured in G3 tissue microarray cores strongly differentiate whether the core comes from a Gleason 6 or Gleason 7 tumor. If validated to predict upgrading from G3 biopsy to prostatectomy these biomarkers could reduce the likelihood of enrolling high-risk men and facilitate safe patient selection for active surveillance.
Collapse
|
30
|
More Favorable Pathological Outcomes in Men with Low Risk Prostate Cancer Diagnosed on Repeat versus Initial Transrectal Ultrasound Guided Prostate Biopsy. J Urol 2016; 195:1767-72. [DOI: 10.1016/j.juro.2015.12.079] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2015] [Indexed: 11/17/2022]
|
31
|
Bosco C, Cozzi G, Kinsella J, Bianchi R, Acher P, Challacombe B, Popert R, Brown C, George G, Van Hemelrijck M, Cahill D. Confirmatory biopsy for the assessment of prostate cancer in men considering active surveillance: reference centre experience. Ecancermedicalscience 2016; 10:633. [PMID: 27170833 PMCID: PMC4854226 DOI: 10.3332/ecancer.2016.633] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To evaluate how accurate a 12-core transrectal biopsy derived low-risk prostate cancer diagnosis is for an active surveillance programme by comparing the histological outcome with that from confirmatory transperineal sector biopsy. SUBJECTS AND METHODS The cohort included 166 men diagnosed with low volume Gleason score 3+3 prostate cancer on initial transrectal biopsy who also underwent a confirmatory biopsy. Both biopsy techniques were performed according to standard protocols and samples were taken for histopathology analysis. Subgroup analysis was performed according to disease severity at baseline to determine possible disease parameters of upgrading at confirmatory biopsy. RESULTS After confirmatory biopsy, 34% demonstrated Gleason score upgrade, out of which 25% were Gleason score 3+4 and 8.5% primary Gleason pattern 4. Results remained consistent for the subgroup analysis and a weak positive association, but not statistically significant, between prostate specific antigen (PSA), age, and percentage of positive cores, and PCa upgrading at confirmatory biopsy was found. CONCLUSION In our single centre study, we found that one-third of patients had higher Gleason score at confirmatory biopsy. Furthermore 8.5% of these upgraders had a primary Gleason pattern 4. Our results together with previously published evidence highlight the need for the revision of current guidelines in prostate cancer diagnosis for the selection of men for active surveillance.
Collapse
Affiliation(s)
- Cecilia Bosco
- King’s College London, Division of Cancer Studies, Cancer Epidemiology Group, London SE1 9RT, UK
| | - Gabriele Cozzi
- European Institute of Urology, Division of Urology, Milan, Italy
| | - Janette Kinsella
- Guy’s and St Thomas’ Hospital NHS Foundation Trust, London SE1 9RT, UK
| | - Roberto Bianchi
- Guy’s and St Thomas’ Hospital NHS Foundation Trust, London SE1 9RT, UK
| | - Peter Acher
- Southend University Hospital NHS Foundation Trust, Southend SS0 0RY, UK
| | | | - Rick Popert
- Guy’s and St Thomas’ Hospital NHS Foundation Trust, London SE1 9RT, UK
| | - Christian Brown
- King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Gincy George
- King’s College London, Division of Cancer Studies, Cancer Epidemiology Group, London SE1 9RT, UK
- Guy’s and St Thomas’ Hospital NHS Foundation Trust, London SE1 9RT, UK
| | - Mieke Van Hemelrijck
- King’s College London, Division of Cancer Studies, Cancer Epidemiology Group, London SE1 9RT, UK
| | - Declan Cahill
- Guy’s and St Thomas’ Hospital NHS Foundation Trust, London SE1 9RT, UK
| |
Collapse
|
32
|
Scarpato KR, Barocas DA. Use of mpMRI in active surveillance for localized prostate cancer. Urol Oncol 2016; 34:320-5. [PMID: 27036218 DOI: 10.1016/j.urolonc.2016.02.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 02/21/2016] [Accepted: 02/26/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION In an effort to limit prostate cancer (PCa) overdiagnosis and overtreatment, which have occurred in response to widespread prostate specific antigen testing, numerous strategies aimed at improved risk stratification of patients with PCa have evolved. Multiparametric magnetic resonance imaging (MRI) is being used in concert with prostate specific antigen testing and prostate biopsies to improve sensitivity and specificity of these tests. There are limited data on how multiparametric MRI can be incorporated into active surveillance (AS) protocols. EVIDENCE ACQUISITION A PubMed literature search of available English language publications on PCa, AS, and MRI was conducted. Appropriate articles were selected and included for review. Bibliographies were also used to expand our search. EVIDENCE SYNTHESIS Data from 41 studies were reviewed. AS inclusion criteria and protocols varied among studies, as did indications for use of MRI. Technological improvements are briefly highlighted. Studies are broadly categorized and discussed according to the role of MRI in patient selection, disease staging, and monitoring in AS protocols. CONCLUSIONS Although improvements in MRI technology have been useful for biopsy guidance and in the diagnosis and staging of PCa, this literature search demonstrates that more prospective research is needed, specifically regarding how this promising technology can be incorporated into AS protocols.
Collapse
Affiliation(s)
- Kristen R Scarpato
- Department of Urologic Surgery, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville TN 37232.
| | - Daniel A Barocas
- Department of Urologic Surgery, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville TN 37232
| |
Collapse
|
33
|
Tosoian JJ, Carter HB, Lepor A, Loeb S. Active surveillance for prostate cancer: current evidence and contemporary state of practice. Nat Rev Urol 2016; 13:205-15. [PMID: 26954332 DOI: 10.1038/nrurol.2016.45] [Citation(s) in RCA: 164] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Prostate cancer remains one of the most commonly diagnosed malignancies worldwide. Early diagnosis and curative treatment seem to improve survival in men with unfavourable-risk cancers, but significant concerns exist regarding the overdiagnosis and overtreatment of men with lower-risk cancers. To this end, active surveillance (AS) has emerged as a primary management strategy in men with favourable-risk disease, and contemporary data suggest that use of AS has increased worldwide. Although published surveillance cohorts differ by protocol, reported rates of metastatic disease and prostate-cancer-specific mortality are exceedingly low in the intermediate term (5-10 years). Such outcomes seem to be closely associated with programme-specific criteria for selection, monitoring, and intervention, suggesting that AS--like other management strategies--could be individualized based on the level of risk acceptable to patients in light of their personal preferences. Additional data are needed to better establish the risks associated with AS and to identify patient-specific characteristics that could modify prognosis.
Collapse
Affiliation(s)
- Jeffrey J Tosoian
- Brady Urological Institute, Johns Hopkins Medical Institutions, 600 N. Wolfe Street, Baltimore, Maryland 21287-2101, USA
| | - H Ballentine Carter
- Brady Urological Institute, Johns Hopkins Medical Institutions, 600 N. Wolfe Street, Baltimore, Maryland 21287-2101, USA
| | - Abbey Lepor
- Department of Urology, New York University, 550 1st Avenue (VZ30 #612), New York, New York 10016, USA
| | - Stacy Loeb
- Department of Urology, New York University, 550 1st Avenue (VZ30 #612), New York, New York 10016, USA.,Depatment of Population Health, New York University. 550 1st Avenue (VZ30 #612), New York, New York 10016, USA.,The Laura &Isaac Perlmutter Cancer Center, New York University, 550 1st Avenue (VZ30 #612), New York, New York 10016, USA
| |
Collapse
|
34
|
Stem cells, biomarkers and genetic profiling: approaching future challenges in Urology. Urologia 2016; 83:4-13. [PMID: 26940971 DOI: 10.5301/uro.5000165] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2016] [Indexed: 12/13/2022]
Abstract
Urological research is facing future challenges, the most difficult one is the fast and meaningful transfer of the massive amount of data from research basic to clinical practice. Between the most important issues that research should focus in the next years are targeting of tumor stem cells, clinical application of biomarkers, and wide application of genetic profiling of urological neoplasms. Several clinical implications are expected, from diagnosis to selection of candidates for different treatment modalities, to modulation of sequential treatment plans, to prognosis. A number of clinical trials based on research data from the hottest issues are in the pipeline. In this review, we will focus on new insights from recent work worlwide in urological research, with particular attention to high-risk nonmuscle-invasive and muscle-invasive bladder cancer, prostate cancer, and kidney cancer. Cancer care is moving towards a personalized approach in patient management. The most important issues in urological research point strongly in this direction and show an enormous potential for the rapid landing of Urology in the era of personalized medicine.
Collapse
|
35
|
Nyame YA, Murphy AB, Bowen DK, Jordan G, Batai K, Dixon M, Hollowell CMP, Kielb S, Meeks JJ, Gann PH, Macias V, Kajdacsy-Balla A, Catalona WJ, Kittles R. Associations Between Serum Vitamin D and Adverse Pathology in Men Undergoing Radical Prostatectomy. J Clin Oncol 2016; 34:1345-9. [PMID: 26903577 DOI: 10.1200/jco.2015.65.1463] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Lower serum vitamin D levels have been associated with an increased risk of aggressive prostate cancer. Among men with localized prostate cancer, especially with low- or intermediate-risk disease, vitamin D may serve as an important biomarker of disease aggression. The aim of this study was to assess the relationship between adverse pathology at the time of radical prostatectomy and serum 25-hydroxyvitamin D (25-OH D) levels. METHODS This cross-sectional study was carried out from 2009 to 2014, nested within a large epidemiologic study of 1,760 healthy controls and men undergoing prostate cancer screening. In total, 190 men underwent radical prostatectomy in the cohort. Adverse pathology was defined as the presence of primary Gleason 4 or any Gleason 5 disease, or extraprostatic extension. Descriptive and multivariate analyses were performed to assess the relationship between 25-OH D and adverse pathology at the time of prostatectomy. RESULTS Eighty-seven men (45.8%) in this cohort demonstrated adverse pathology at radical prostatectomy. The median age in the cohort was 64.0 years (interquartile range, 59.0 to 67.0). On univariate analysis, men with adverse pathology at radical prostatectomy demonstrated lower median serum 25-OH D (22.7 v 27.0 ng/mL, P = .007) compared with their counterparts. On multivariate analysis, controlling for age, serum prostate specific antigen, and abnormal digital rectal examination, serum 25-OH D less than 30 ng/mL was associated with increased odds of adverse pathology (odds ratio, 2.64; 95% CI, 1.25 to 5.59; P = .01). CONCLUSION Insufficiency/deficiency of serum 25-OH D is associated with increased odds of adverse pathology in men with localized disease undergoing radical prostatectomy. Serum 25-OH D may serve as a useful biomarker in prostate cancer aggressiveness, which deserves continued study.
Collapse
Affiliation(s)
- Yaw A Nyame
- Yaw A. Nyame, Cleveland Clinic, Cleveland, Ohio; Adam B. Murphy, Diana K. Bowen, Gregory Jordan, Michael Dixon, Stephanie Kielb, Joshua J. Meeks, and William J. Catalona, Northwestern University, Chicago; Courtney M.P. Hollowell, Cook County Health and Hospitals System; Peter H. Gann, Virgilia Macias, and Andre Kajdacsy-Balla, University of Illinois at Chicago, Chicago, IL; and Ken Batai and Rick Kittles, University of Arizona, Tucson, AZ
| | - Adam B Murphy
- Yaw A. Nyame, Cleveland Clinic, Cleveland, Ohio; Adam B. Murphy, Diana K. Bowen, Gregory Jordan, Michael Dixon, Stephanie Kielb, Joshua J. Meeks, and William J. Catalona, Northwestern University, Chicago; Courtney M.P. Hollowell, Cook County Health and Hospitals System; Peter H. Gann, Virgilia Macias, and Andre Kajdacsy-Balla, University of Illinois at Chicago, Chicago, IL; and Ken Batai and Rick Kittles, University of Arizona, Tucson, AZ.
| | - Diana K Bowen
- Yaw A. Nyame, Cleveland Clinic, Cleveland, Ohio; Adam B. Murphy, Diana K. Bowen, Gregory Jordan, Michael Dixon, Stephanie Kielb, Joshua J. Meeks, and William J. Catalona, Northwestern University, Chicago; Courtney M.P. Hollowell, Cook County Health and Hospitals System; Peter H. Gann, Virgilia Macias, and Andre Kajdacsy-Balla, University of Illinois at Chicago, Chicago, IL; and Ken Batai and Rick Kittles, University of Arizona, Tucson, AZ
| | - Gregory Jordan
- Yaw A. Nyame, Cleveland Clinic, Cleveland, Ohio; Adam B. Murphy, Diana K. Bowen, Gregory Jordan, Michael Dixon, Stephanie Kielb, Joshua J. Meeks, and William J. Catalona, Northwestern University, Chicago; Courtney M.P. Hollowell, Cook County Health and Hospitals System; Peter H. Gann, Virgilia Macias, and Andre Kajdacsy-Balla, University of Illinois at Chicago, Chicago, IL; and Ken Batai and Rick Kittles, University of Arizona, Tucson, AZ
| | - Ken Batai
- Yaw A. Nyame, Cleveland Clinic, Cleveland, Ohio; Adam B. Murphy, Diana K. Bowen, Gregory Jordan, Michael Dixon, Stephanie Kielb, Joshua J. Meeks, and William J. Catalona, Northwestern University, Chicago; Courtney M.P. Hollowell, Cook County Health and Hospitals System; Peter H. Gann, Virgilia Macias, and Andre Kajdacsy-Balla, University of Illinois at Chicago, Chicago, IL; and Ken Batai and Rick Kittles, University of Arizona, Tucson, AZ
| | - Michael Dixon
- Yaw A. Nyame, Cleveland Clinic, Cleveland, Ohio; Adam B. Murphy, Diana K. Bowen, Gregory Jordan, Michael Dixon, Stephanie Kielb, Joshua J. Meeks, and William J. Catalona, Northwestern University, Chicago; Courtney M.P. Hollowell, Cook County Health and Hospitals System; Peter H. Gann, Virgilia Macias, and Andre Kajdacsy-Balla, University of Illinois at Chicago, Chicago, IL; and Ken Batai and Rick Kittles, University of Arizona, Tucson, AZ
| | - Courtney M P Hollowell
- Yaw A. Nyame, Cleveland Clinic, Cleveland, Ohio; Adam B. Murphy, Diana K. Bowen, Gregory Jordan, Michael Dixon, Stephanie Kielb, Joshua J. Meeks, and William J. Catalona, Northwestern University, Chicago; Courtney M.P. Hollowell, Cook County Health and Hospitals System; Peter H. Gann, Virgilia Macias, and Andre Kajdacsy-Balla, University of Illinois at Chicago, Chicago, IL; and Ken Batai and Rick Kittles, University of Arizona, Tucson, AZ
| | - Stephanie Kielb
- Yaw A. Nyame, Cleveland Clinic, Cleveland, Ohio; Adam B. Murphy, Diana K. Bowen, Gregory Jordan, Michael Dixon, Stephanie Kielb, Joshua J. Meeks, and William J. Catalona, Northwestern University, Chicago; Courtney M.P. Hollowell, Cook County Health and Hospitals System; Peter H. Gann, Virgilia Macias, and Andre Kajdacsy-Balla, University of Illinois at Chicago, Chicago, IL; and Ken Batai and Rick Kittles, University of Arizona, Tucson, AZ
| | - Joshua J Meeks
- Yaw A. Nyame, Cleveland Clinic, Cleveland, Ohio; Adam B. Murphy, Diana K. Bowen, Gregory Jordan, Michael Dixon, Stephanie Kielb, Joshua J. Meeks, and William J. Catalona, Northwestern University, Chicago; Courtney M.P. Hollowell, Cook County Health and Hospitals System; Peter H. Gann, Virgilia Macias, and Andre Kajdacsy-Balla, University of Illinois at Chicago, Chicago, IL; and Ken Batai and Rick Kittles, University of Arizona, Tucson, AZ
| | - Peter H Gann
- Yaw A. Nyame, Cleveland Clinic, Cleveland, Ohio; Adam B. Murphy, Diana K. Bowen, Gregory Jordan, Michael Dixon, Stephanie Kielb, Joshua J. Meeks, and William J. Catalona, Northwestern University, Chicago; Courtney M.P. Hollowell, Cook County Health and Hospitals System; Peter H. Gann, Virgilia Macias, and Andre Kajdacsy-Balla, University of Illinois at Chicago, Chicago, IL; and Ken Batai and Rick Kittles, University of Arizona, Tucson, AZ
| | - Virgilia Macias
- Yaw A. Nyame, Cleveland Clinic, Cleveland, Ohio; Adam B. Murphy, Diana K. Bowen, Gregory Jordan, Michael Dixon, Stephanie Kielb, Joshua J. Meeks, and William J. Catalona, Northwestern University, Chicago; Courtney M.P. Hollowell, Cook County Health and Hospitals System; Peter H. Gann, Virgilia Macias, and Andre Kajdacsy-Balla, University of Illinois at Chicago, Chicago, IL; and Ken Batai and Rick Kittles, University of Arizona, Tucson, AZ
| | - Andre Kajdacsy-Balla
- Yaw A. Nyame, Cleveland Clinic, Cleveland, Ohio; Adam B. Murphy, Diana K. Bowen, Gregory Jordan, Michael Dixon, Stephanie Kielb, Joshua J. Meeks, and William J. Catalona, Northwestern University, Chicago; Courtney M.P. Hollowell, Cook County Health and Hospitals System; Peter H. Gann, Virgilia Macias, and Andre Kajdacsy-Balla, University of Illinois at Chicago, Chicago, IL; and Ken Batai and Rick Kittles, University of Arizona, Tucson, AZ
| | - William J Catalona
- Yaw A. Nyame, Cleveland Clinic, Cleveland, Ohio; Adam B. Murphy, Diana K. Bowen, Gregory Jordan, Michael Dixon, Stephanie Kielb, Joshua J. Meeks, and William J. Catalona, Northwestern University, Chicago; Courtney M.P. Hollowell, Cook County Health and Hospitals System; Peter H. Gann, Virgilia Macias, and Andre Kajdacsy-Balla, University of Illinois at Chicago, Chicago, IL; and Ken Batai and Rick Kittles, University of Arizona, Tucson, AZ
| | - Rick Kittles
- Yaw A. Nyame, Cleveland Clinic, Cleveland, Ohio; Adam B. Murphy, Diana K. Bowen, Gregory Jordan, Michael Dixon, Stephanie Kielb, Joshua J. Meeks, and William J. Catalona, Northwestern University, Chicago; Courtney M.P. Hollowell, Cook County Health and Hospitals System; Peter H. Gann, Virgilia Macias, and Andre Kajdacsy-Balla, University of Illinois at Chicago, Chicago, IL; and Ken Batai and Rick Kittles, University of Arizona, Tucson, AZ
| |
Collapse
|
36
|
Helpap B, Bubendorf L, Kristiansen G. [Prostate cancer. Part 2: Review of the various tumor grading systems over the years 1966-2015 and future perspectives of the new grading of the International Society of Urological Pathology (ISUP)]. DER PATHOLOGE 2016; 37:11-6. [PMID: 26792002 DOI: 10.1007/s00292-015-0124-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The continued development of methods in needle biopsies and radical prostatectomy for treatment of prostate cancer has given special emphasis to the question of the prognostic relevance of the various systems of grading. The classical purely histological grading system of Gleason has been modified several times in the past decades and cleared the way for a new grading system by the prognostic grading of Epstein. Assessment of the old and also modified combined histological and cytological grading of Mostofi, the World health Organization (WHO) and the urologic-pathological working group of prostate cancer in connection with the Gleason grading (combined Gleason-Helpap grading), has led to considerably improved rates of concordance between biopsy and radical prostatectomy and to improved estimations of prognosis beside its contribution to the development of a more practicable grading system for clinical use.
Collapse
Affiliation(s)
- B Helpap
- Institut für Pathologie, Hegau-Bodensee-Kliniken, Akademisches Lehrkrankenhaus, Universität Freiburg, 78207, Postfach 720, Singen, Deutschland.
| | - L Bubendorf
- Abteilung Zytopathologie, Institut für Pathologie, Universität Basel, Basel, Schweiz
| | - G Kristiansen
- Institut für Pathologie, Universität Bonn, Bonn, Deutschland
| |
Collapse
|
37
|
Horrill T. Active surveillance in prostate cancer: a concept analysis. J Clin Nurs 2016; 25:1166-72. [PMID: 26786713 DOI: 10.1111/jocn.13111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2015] [Indexed: 11/27/2022]
Abstract
AIM To report an analysis of the concept of active surveillance. BACKGROUND Prostate cancer has become more prevalent since the introduction of PSA screening, however, many men are diagnosed with low-risk disease that may not require treatment. Active surveillance is a treatment strategy used to avoid treatment and related adverse effects when immediate treatment is not necessary. A universal definition is lacking. DESIGN Concept analysis. DATA SOURCES The CINAHL, PubMed, Scopus, Cochrane Library and Google Scholar databases were searched for literature published between 1980 and 2014 using the term active surveillance. METHODS The method of Walker and Avant (2010) was used to analyse the concept of active surveillance, specifically within the context of prostate cancer. RESULTS Key attributes of active surveillance emerging from the analysis include: regular and purposeful monitoring, early detection of disease progression and planned curative intervention if necessary. Multiple terms are used in the literature to refer to the concept of active surveillance. Active surveillance can cause uncertainty, and prompt men to make lifestyle changes and seek more information on prostate cancer. CONCLUSION Active surveillance is not well understood, and ambiguity remains around the concept. Active surveillance and watchful waiting are used interchangeably in the literature and in clinical practice, but in fact do not refer to the same strategy. Active surveillance can generate significant uncertainty for the patient and family, which may be a barrier to choosing it as a treatment strategy and nursing research in this area is limited. RELEVANCE TO CLINICAL PRACTICE Nurses need a clear understanding of active surveillance and how it differs from other strategies in order to reduce ambiguity around the concept. Nurses must be aware of the uncertainty accompanying active surveillance, and a need exists for continued nursing research in this area.
Collapse
|
38
|
Tosoian JJ, Loeb S, Epstein JI, Turkbey B, Choyke P, Schaeffer EM. Active Surveillance of Prostate Cancer: Use, Outcomes, Imaging, and Diagnostic Tools. Am Soc Clin Oncol Educ Book 2016; 35:e235-45. [PMID: 27249729 PMCID: PMC4917301 DOI: 10.1200/edbk_159244] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Active surveillance (AS) has emerged as a standard management option for men with very low-risk and low-risk prostate cancer, and contemporary data indicate that use of AS is increasing in the United States and abroad. In the favorable-risk population, reports from multiple prospective cohorts indicate a less than 1% likelihood of metastatic disease and prostate cancer-specific mortality over intermediate-term follow-up (median 5-6 years). Higher-risk men participating in AS appear to be at increased risk of adverse outcomes, but these populations have not been adequately studied to this point. Although monitoring on AS largely relies on serial prostate biopsy, a procedure associated with considerable morbidity, there is a need for improved diagnostic tools for patient selection and monitoring. Revisions from the 2014 International Society of Urologic Pathology consensus conference have yielded a more intuitive reporting system and detailed reporting of low-intermediate grade tumors, which should facilitate the practice of AS. Meanwhile, emerging modalities such as multiparametric magnetic resonance imaging and tissue-based molecular testing have shown prognostic value in some populations. At this time, however, these instruments have not been sufficiently studied to consider their routine, standardized use in the AS setting. Future studies should seek to identify those platforms most informative in the AS population and propose a strategy by which promising diagnostic tools can be safely and efficiently incorporated into clinical practice.
Collapse
Affiliation(s)
- Jeffrey J Tosoian
- Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, Phone: 410-955-2139, , Fax: 410-955-0833
| | - Stacy Loeb
- Department of Urology and Population Health, New York University, New York, NY 10016, , Phone: 646-825-6358
| | - Jonathan I Epstein
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA, , Phone: 410-955-5043
| | - Baris Turkbey
- Molecular Imaging Program, National Cancer Institute, Bethesda, MD, USA, , Phone: 301-443-2315
| | - Peter Choyke
- Molecular Imaging Program, National Cancer Institute, Bethesda, MD, USA, , Phone: 301-402-8409
| | | |
Collapse
|
39
|
Romero-Otero J, García-Gómez B, Duarte-Ojeda JM, Rodríguez-Antolín A, Vilaseca A, Carlsson SV, Touijer KA. Active surveillance for prostate cancer. Int J Urol 2015; 23:211-8. [PMID: 26621054 DOI: 10.1111/iju.13016] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 10/20/2015] [Indexed: 12/20/2022]
Abstract
It is worth distinguishing between the two strategies of expectant management for prostate cancer. Watchful waiting entails administering non-curative androgen deprivation therapy to patients on development of symptomatic progression, whereas active surveillance entails delivering curative treatment on signs of disease progression. The objectives of the two management strategies and the patients enrolled in either are different: (i) to review the role of active surveillance as a management strategy for patients with low-risk prostate cancer; and (ii) review the benefits and pitfalls of active surveillance. We carried out a systematic review of active surveillance for prostate cancer in the literature using the National Center for Biotechnology Information's electronic database, PubMed. We carried out a search in English using the terms: active surveillance, prostate cancer, watchful waiting and conservative management. Selected studies were required to have a comprehensive description of the demographic and disease characteristics of the patients at the time of diagnosis, inclusion criteria for surveillance, and a protocol for the patients' follow up. Review articles were included, but not multiple papers from the same datasets. Active surveillance appears to reduce overtreatment in patients with low-risk prostate cancer without compromising cancer-specific survival at 10 years. Therefore, active surveillance is an option for select patients who want to avoid the side-effects inherent to the different types of immediate treatment. However, inclusion criteria for active surveillance and the most appropriate method of monitoring patients on active surveillance have not yet been standardized.
Collapse
Affiliation(s)
| | | | | | | | - Antoni Vilaseca
- Urology Department, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Sigrid V Carlsson
- Urology Department, Memorial Sloan Kettering Cancer Center, New York City, New York, USA.,Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Karim A Touijer
- Urology Department, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| |
Collapse
|
40
|
Lendínez-Cano G, Alonso-Flores J, Beltrán-Aguilar V, Cayuela A, Salazar-Otero S, Bachiller-Burgos J. Comparison of pathological data between prostate biopsy and radical prostatectomy specimen in patients with low to very low risk prostate cancer. Actas Urol Esp 2015; 39:482-7. [PMID: 25895440 DOI: 10.1016/j.acuro.2015.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 02/12/2015] [Accepted: 02/14/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To analyze the correlation between pathological data found in radical prostatectomy and previously performed biopsy in patients at low risk prostate cancer. MATERIAL AND METHODS A descriptive, cross-sectional study was conducted to assess the characteristics of radical prostatectomies performed in our center from January 2012 to November 2014. The inclusion criteria were patients with low-risk disease (cT1c-T2a, PSA≤10ng/mL and Gleason score≤6). We excluded patients who had fewer than 8 cores in the biopsy, an unspecified number of affected cores, rectal examinations not reported in the medical history or biopsies performed in another center. RESULTS Of the 184 patients who underwent prostatectomy during this period, 87 met the inclusion criteria, and 26 of these had<3 affected cores and PSA density≤.15 (very low risk). In the entire sample, the percentage of undergrading (Gleason score≥7) and extracapsular invasion (pT3) was 18.4% (95% CI 10.3-27.6) and 10.35% (95% CI 4.6-17.2), respectively. The percentage of positive margins was 21.8% (95% CI 12.6-29.9). In the very low-risk group, we found no cases of extracapsular invasion and only 1 case of undergrading (Gleason 7 [3+4]), representing 3.8% of the total (95% CI 0-12.5). Predictors of no correlation (stage≥pT3a or undergrading) were the initial risk group, volume, PSA density and affected cores. CONCLUSIONS Prostate volume, PSA density, the number of affected cores and the patient's initial risk group influence the poor pathological prognosis in the radical prostatectomy specimen (extracapsular invasion and Gleason score≥7).
Collapse
|
41
|
Filippou P, Welty CJ, Cowan JE, Perez N, Shinohara K, Carroll PR. Immediate Versus Delayed Radical Prostatectomy: Updated Outcomes Following Active Surveillance of Prostate Cancer. Eur Urol 2015; 68:458-63. [DOI: 10.1016/j.eururo.2015.06.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 06/10/2015] [Indexed: 10/23/2022]
|
42
|
Kang HW, Lee JY, Kwon JK, Jeh SU, Jung HD, Cho KS, Ham WS, Choi YD. Pathologic Outcomes in Men with Low-risk Prostate Cancer Who Are Potential Candidates for Contemporary, Active Surveillance Protocols. J Korean Med Sci 2015; 30:932-6. [PMID: 26130957 PMCID: PMC4479948 DOI: 10.3346/jkms.2015.30.7.932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/09/2015] [Indexed: 11/20/2022] Open
Abstract
The purpose of this study was to determine whether contemporary active surveillance (AS) protocols could sufficiently discriminate significant from indolent tumors in men with low-risk prostate cancer. We retrospectively analyzed 312 patients with low-risk prostate cancer treated with radical prostatectomy. After exclusion of patients with fewer than 10 cores taken at biopsy and those who received neo-adjuvant treatment, 205 subjects satisfied the final inclusion criteria. Five widely accepted AS protocols were employed in this study. A total of 82.0% of the patients met the inclusion criteria of at least one protocol, and 18% did not meet any criteria of published AS protocols. A significant proportion of patients had non-organ-confined disease (8.6% to 10.6%) or a Gleason score of 7 or greater (18.6% to 23.9%) between the different AS criteria. Among patients who did not meet any AS criteria, 32.4% of patients had a pathologically insignificant cancer. Our results indicated a significant adverse pathology in patients who met the contemporary AS protocols. On the other hand, some patients in whom expectant management would be appropriate did not meet any criteria of published AS protocols. None of the clinical or histological criteria reported to date is able to sufficiently discriminate aggressive tumors from indolent ones.
Collapse
Affiliation(s)
- Ho Won Kang
- Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Joo Yong Lee
- Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Kyou Kwon
- Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Seong Uk Jeh
- Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hae Do Jung
- Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kang Su Cho
- Department of Urology, Gangnam Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Won Sik Ham
- Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young Deuk Choi
- Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
- Robot and Minimal Invasive Surgery Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
43
|
Anderson CB, Sternberg IA, Karen-Paz G, Kim PH, Sjoberg D, Vargas HA, Touijer K, Eastham JA, Ehdaie B. Age is Associated with Upgrading at Confirmatory Biopsy among Men with Prostate Cancer Treated with Active Surveillance. J Urol 2015; 194:1607-11. [PMID: 26119671 DOI: 10.1016/j.juro.2015.06.084] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE Active surveillance is increasingly recommended for older men with low risk prostate cancer. Although older men have higher all cause mortality, they also have higher prostate cancer specific mortality. We hypothesized that older age is associated with an increased risk of Gleason score upgrading at confirmatory biopsy when controlling for prostate volume. MATERIALS AND METHODS We retrospectively reviewed data on 1,130 patients with prostate cancer who were treated with active surveillance from 1991 through 2011. We included 646 patients with clinical Gleason 6 or less, stage T2a or less prostate cancer, a confirmatory biopsy within 2 years of diagnostic biopsy and prostate magnetic resonance imaging before confirmatory biopsy. The primary outcome was Gleason score upgrading to 7 or greater on confirmatory biopsy. We used logistic regression to estimate the effect of age on upgrading, adjusting for magnetic resonance imaging prostate volume and other potential confounders. RESULTS Median age was 66 years (IQR 61-72) and median magnetic resonance imaging prostate volume was 41 ml (IQR 29-55). At confirmatory biopsy disease was upgraded in 55 of 646 patients (9%) and unchanged in 290 (45%) and biopsy was negative in 297 (46%). Older age was associated with higher odds of upgrading (adjusted OR 1.05, 95% CI 1.01-1.09, p=0.009). Larger prostate volume was associated with lower odds of upgrading (adjusted OR 0.80/10 ml increase, 95% CI 0.7-0.9, p=0.012). CONCLUSIONS Our findings suggest that older age is associated with an increased risk of misclassification on diagnostic biopsy. Older men who are interested in active surveillance should be counseled about the risks and benefits of confirmatory biopsy.
Collapse
Affiliation(s)
- Christopher B Anderson
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Itay A Sternberg
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gal Karen-Paz
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Philip H Kim
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel Sjoberg
- Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Karim Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James A Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Behfar Ehdaie
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
| |
Collapse
|
44
|
Abstract
PUPOSE OF REVIEW The review covers arguments for and against removing the label of 'cancer' in Gleason score 6 prostate tumors. RECENT FINDINGS While there are a number of factors that determine whether men elect active surveillance, the most powerful predictor remains the Gleason score. Gleason grading remains a robust and powerful predictor of outcome in patients with prostate cancer. A pure Gleason score 6 (GS6) tumor is exceedingly unlikely to cause harm in the near term, and there have been discussions regarding whether the term cancer should still be applied. In this review, we update the largely clinico-pathological arguments that have led to the suggestion to remove the cancer label from GS6 tumors, and we provide counter arguments on the basis of practical matters of needle biopsy sampling, classical histopathology, and molecular biology findings. SUMMARY The implications are that by retaining the label of cancer and implementing the recently proposed concept of prognostic groups, with patients harboring GS6 tumors placed into the lowest category, there is still a strong rationale in support of the choice of active surveillance or watchful waiting for most patients with GS6 lesions.
Collapse
Affiliation(s)
- Ibrahim Kulac
- aDepartment of Pathology bDepartment of Urology cDepartment of Oncology dThe Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins eThe Brady Urological Research Institute
| | | | | | | | | |
Collapse
|
45
|
Changes in Gleason score grading on serial follow-up biopsies in prostate cancer patients undergoing active surveillance. Actas Urol Esp 2015; 39:139-43. [PMID: 25305107 DOI: 10.1016/j.acuro.2014.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 08/24/2014] [Accepted: 08/25/2014] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Active surveillance for prostate cancer has grown systematically in the recent years with more robust mid-term outcomes. However, changes in Gleason score during serial biopsies are not detailed in many of these reports. OBJECTIVES To evaluate changes in Gleason score on follow-up biopsies in low-risk prostate cancer in patients undergoing AS program in our center. MATERIAL AND METHODS Series of patients diagnosed of prostate cancer between 2004 and 2013 have been analyzed. The inclusion criteria were: PSA ≤ 10 ng/ml + Gleason ≤ 6 + T1c/T2a + ≤ 2 positive cores, and no more than 50% of affected core. The pathology of each of the biopsies was analyzed. RESULTS We studied a series of 175 patients undergoing AS. Mean follow-up was 3.96 years (SD 2.4). Follow-up biopsies with Gleason scores ≥ 7 were: 5.72% in the first biopsy, 7.39% and 7.41% in subsequent biopsies. By contrast, in 42.03% of cases did not show evident tumor involvement in the first biopsy, 40.74% and 51.85% in the second and third biopsies respectively. Median stay in the AS program was: 90.99 months (95% CI: 53.53-128.46) in patients with first positive biopsy vs. 96.66 months (95% CI: 63.19-130.13) in those without evidence of tumor. CONCLUSIONS In our series the pathological data of the first 3 biopsies remain stable in terms of the positive biopsy rate, Gleason score, or indication of active treatment proportions. Those patients who do not show evidence of malignancy in the first follow-up biopsy are less likely to need active treatment than the other patients in the series.
Collapse
|
46
|
Bratt O, Folkvaljon Y, Loeb S, Klotz L, Egevad L, Stattin P. Upper limit of cancer extent on biopsy defining very low-risk prostate cancer. BJU Int 2015; 116:213-9. [DOI: 10.1111/bju.12874] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Ola Bratt
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
- Department of Urology; Helsingborg Hospital; Lund University; Lund and Helsingborg Sweden
| | - Yasin Folkvaljon
- Regional Cancer Centre; Uppsala/Örebro; Uppsala University Hospital; Uppsala Sweden
| | - Stacy Loeb
- Department of Urology; New York University and Manhattan Veterans Affairs Medical Center; New York NY USA
| | - Laurence Klotz
- Sunnybrook Health Sciences Centre; University of Toronto; Toronto ON Canada
| | - Lars Egevad
- Department of Pathology; Karolinska University Hospital; Stockholm Sweden
| | - Pär Stattin
- Department of Surgical and Perioperative Sciences; Umeå University; Umeå Sweden
| |
Collapse
|
47
|
Walton Diaz A, Shakir NA, George AK, Rais-Bahrami S, Turkbey B, Rothwax JT, Stamatakis L, Hong CW, Siddiqui MM, Okoro C, Raskolnikov D, Su D, Shih J, Han H, Parnes HL, Merino MJ, Simon RM, Wood BJ, Choyke PL, Pinto PA. Use of serial multiparametric magnetic resonance imaging in the management of patients with prostate cancer on active surveillance. Urol Oncol 2015; 33:202.e1-202.e7. [PMID: 25754621 DOI: 10.1016/j.urolonc.2015.01.023] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 01/25/2015] [Accepted: 01/26/2015] [Indexed: 12/23/2022]
Abstract
INTRODUCTION We evaluated the performance of multiparametric prostate magnetic resonance imaging (mp-MRI) and MRI/transrectal ultrasound (TRUS) fusion-guided biopsy (FB) for monitoring patients with prostate cancer on active surveillance (AS). MATERIALS AND METHODS Patients undergoing mp-MRI and FB of target lesions identified on mp-MRI between August 2007 and August 2014 were reviewed. Patients meeting AS criteria (Clinical stage T1c, Gleason grade ≤ 6, prostate-specific antigen density ≤ 0.15, tumor involving ≤ 2 cores, and ≤ 50% involvement of any single core) based on extended sextant 12-core TRUS biopsy (systematic biopsy [SB]) were included. They were followed with subsequent 12-core biopsy as well as mp-MRI and MRI/TRUS fusion biopsy at follow-up visits until Gleason score progression (Gleason ≥ 7 in either 12-core or MRI/TRUS fusion biopsy). We evaluated whether progression seen on mp-MRI (defined as an increase in suspicion level, largest lesion diameter, or number of lesions) was predictive of Gleason score progression. RESULTS Of 152 patients meeting AS criteria on initial SB (mean age of 61.4 years and mean prostate-specific antigen level of 5.26 ng/ml), 34 (22.4%) had Gleason score ≥ 7 on confirmatory SB/FB. Of the 118 remaining patients, 58 chose AS and had at least 1 subsequent mp-MRI with SB/FB (median follow-up = 16.1 months). Gleason progression was subsequently documented in 17 (29%) of these men, in all cases to Gleason 3+4. The positive predictive value and negative predictive value of mp-MRI for Gleason progression was 53% (95% CI: 28%-77%) and 80% (95% CI: 65%-91%), respectively. The sensitivity and specificity of mp-MRI for increase in Gleason were also 53% and 80%, respectively. The number needed to biopsy to detect 1 Gleason progression was 8.74 for SB vs. 2.9 for FB. CONCLUSIONS Stable findings on mp-MRI are associated with Gleason score stability. mp-MRI appears promising as a useful aid for reducing the number of biopsies in the management of patients on AS. A prospective evaluation of mp-MRI as a screen to reduce biopsies in the follow-up of men on AS appears warranted.
Collapse
Affiliation(s)
- Annerleim Walton Diaz
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Nabeel Ahmad Shakir
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Arvin K George
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Soroush Rais-Bahrami
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Baris Turkbey
- Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Jason T Rothwax
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Lambros Stamatakis
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Cheng William Hong
- Center for Interventional Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Mohummad Minhaj Siddiqui
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Chinonyerem Okoro
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Dima Raskolnikov
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Daniel Su
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Joanna Shih
- Biometric Research Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Hui Han
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Howard L Parnes
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Maria J Merino
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Richard M Simon
- Biometric Research Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Bradford J Wood
- Center for Interventional Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Peter L Choyke
- Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Peter A Pinto
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD; Center for Interventional Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD.
| |
Collapse
|
48
|
de Cerqueira M, Laranja W, Sanches B, Monti C, Reis L. Burden of focal cryoablation versus brachytherapy versus active surveillance in the treatment of very low-risk prostate cancer: a preliminary head-to-head comprehensive assessment. Eur J Cancer Care (Engl) 2015; 24:929-37. [PMID: 25752993 DOI: 10.1111/ecc.12307] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2015] [Indexed: 11/30/2022]
Affiliation(s)
- M.A. de Cerqueira
- Urology Department; Pontifical Catholic University of Campinas (PUC-Campinas); Campinas São Paulo Brazil
- Urology Department; School of Medical Sciences; University of Campinas (Unicamp); Campinas São Paulo Brazil
| | - W.W. Laranja
- Urology Department; School of Medical Sciences; University of Campinas (Unicamp); Campinas São Paulo Brazil
| | - B.C.F. Sanches
- Urology Department; School of Medical Sciences; University of Campinas (Unicamp); Campinas São Paulo Brazil
| | - C.R. Monti
- Radium Institute; Campinas São Paulo Brazil
| | - L.O. Reis
- Urology Department; School of Medical Sciences; University of Campinas (Unicamp); Campinas São Paulo Brazil
- Faculty of Medicine (Urology); Center for Life Sciences; Pontifical Catholic University of Campinas (PUC-Campinas); Campinas São Paulo Brazil
| |
Collapse
|
49
|
Swanson GP, Epstein JI, Ha CS, Kryvenko ON. Pathological characteristics of low risk prostate cancer based on totally embedded prostatectomy specimens. Prostate 2015; 75:424-9. [PMID: 25417762 PMCID: PMC4612573 DOI: 10.1002/pros.22928] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 10/14/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Surveillance and focal therapy are increasingly considered for low risk prostate cancer (PC). We describe pathological characteristics of low risk PC at radical prostatectomy in contemporary patients. METHODS Five-hundred-fifty-two men from 2008 to 2012 with low risk (stage T1c/T2a, PSA ≤ 10 ng/ml, Gleason score ≤6) PC underwent radical prostatectomy. Slides were re-reviewed to grade and stage the tumor, map separate tumor nodules, and calculate their volumes. RESULTS Ninety-three (16.9%) men had prostatectomy Gleason score 3 + 4 = 7 or higher and were excluded. Five (0.9%) men had no residual carcinoma. Remaining 454 patients composed the study cohort. The median age was 57 years (36-73) and median PSA 4.4 ng/ml (0.4-9.9). Racial distribution was 77.5% Caucasian, 15.5% African American, and 7% other. The median total tumor volume was 0.38 cm(3) (0.003-7.22). Seventy percent of the patients had bilateral tumor and 34% had a tumor nodule >0.5 cm(3) . The index lesion represented 89% (median) of the total tumor volume. Extraprostatic extension and positive margin were present in 5.7% and 9% of cases, respectively. The tumor nodules measuring >0.5 cm(3) were located almost equally between the anterior (53%) and peripheral (47%) gland. The relationship between PSA and total tumor volume was weak (r = 0.13, P = 0.005). The relationship between PSA density and total tumor volume was slightly better (r = 0.26, P < 0.001). CONCLUSIONS Low risk prostate cancer is generally a low volume disease. Gleason score upgrade is seen in 16.9% of cases at radical prostatectomy. While the index lesion accounts for the bulk of the disease, the cancer is usually multifocal and bilateral. Neither PSA nor PSA density correlates well with the total tumor volume. Prostate size has a significant contribution to PSA level. These factors need to be considered in treatment planning for low risk prostate cancer.
Collapse
Affiliation(s)
- Gregory P. Swanson
- Department of Radiation Oncology, UT Health Science Center, San Antonio, Texas
| | - Jonathan I. Epstein
- Departments of Pathology, Urology, and Oncology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Chul S. Ha
- Department of Radiation Oncology, UT Health Science Center, San Antonio, Texas
| | - Oleksandr N. Kryvenko
- Departments of Pathology and Urology, University of Miami Miller School of Medicine, Miami, Florida
- Correspondence to: Oleksandr N. Kryvenko, MD, Department of Pathology, University of Miami, 1400 NW 12th Avenue, Room 4100, Miami, FL 33136.
| |
Collapse
|
50
|
Evaluation of MRI-TRUS fusion versus cognitive registration accuracy for MRI-targeted, TRUS-guided prostate biopsy. AJR Am J Roentgenol 2015; 204:83-91. [PMID: 25539241 DOI: 10.2214/ajr.14.12681] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The purpose of this article is to compare transrectal ultrasound (TRUS) biopsy accuracies of operators with different levels of prostate MRI experience using cognitive registration versus MRI-TRUS fusion to assess the preferred method of TRUS prostate biopsy for MRI-identified lesions. SUBJECTS AND METHODS; One hundred patients from a prospective prostate MRI-TRUS fusion biopsy study were reviewed to identify all patients with clinically significant prostate adenocarcinoma (PCA) detected on MRI-targeted biopsy. Twenty-five PCA tumors were incorporated into a validated TRUS prostate biopsy simulator. Three prostate biopsy experts, each with different levels of experience in prostate MRI and MRI-TRUS fusion biopsy, performed a total of 225 simulated targeted biopsies on the MRI lesions as well as regional biopsy targets. Simulated biopsies performed using cognitive registration with 2D TRUS and 3D TRUS were compared with biopsies performed under MRI-TRUS fusion. RESULTS Two-dimensional and 3D TRUS sampled only 48% and 45% of clinically significant PCA MRI lesions, respectively, compared with 100% with MRI-TRUS fusion. Lesion sampling accuracy did not statistically significantly vary according to operator experience or tumor volume. MRI-TRUS fusion-naïve operators showed consistent errors in targeting of the apex, midgland, and anterior targets, suggesting that there is biased error in cognitive registration. The MRI-TRUS fusion expert correctly targeted the prostate apex; however, his midgland and anterior mistargeting was similar to that of the less-experienced operators. CONCLUSION MRI-targeted TRUS-guided prostate biopsy using cognitive registration appears to be inferior to MRI-TRUS fusion, with fewer than 50% of clinically significant PCA lesions successfully sampled. No statistically significant difference in biopsy accuracy was seen according to operator experience with prostate MRI or MRI-TRUS fusion.
Collapse
|