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Kearns JT, Helfand BT. Is Active Surveillance Too Active? Curr Urol Rep 2023; 24:463-469. [PMID: 37436691 DOI: 10.1007/s11934-023-01177-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE OF REVIEW Many prostate cancer active surveillance protocols mandate serial monitoring at defined intervals, including but certainly not limited to serum PSA (often every 6 months), clinic visits, prostate multiparametric MRI, and repeat prostate biopsies. The purpose of this article is to evaluate whether current protocols result in excessive testing of patients on active surveillance. RECENT FINDINGS Multiple studies have been published in the past several years evaluating the utility of multiparametric MRI, serum biomarkers, and serial prostate biopsy for men on active surveillance. While MRI and serum biomarkers have promise with risk stratification, no studies have demonstrated that periodic prostate biopsy can be safely omitted in active surveillance. Active surveillance for prostate cancer is too active for some men with seemingly low-risk cancer. The use of multiple prostate MRIs or additional biomarkers do not always add to the prediction of higher-grade disease on surveillance biopsy.
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Affiliation(s)
- James T Kearns
- Division of Urology, NorthShore University HealthSystem, 2180 Pfingsten Rd., Suite 3000, Glenview, Evanston, IL, 60026, USA.
| | - Brian T Helfand
- Division of Urology, NorthShore University HealthSystem, 2180 Pfingsten Rd., Suite 3000, Glenview, Evanston, IL, 60026, USA
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2
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Salari K, Kowitz J, Twum-Ampofo J, Gusev A, O'Shea A, Anderson MA, Harisinghani M, Kuppermann D, Dahl DM, Efstathiou JA, Lee RJ, Blute ML, Zietman AL, Feldman AS. Impact of a negative confirmatory biopsy on risk of disease progression among men on active surveillance for prostate cancer. Urol Oncol 2023; 41:387.e9-387.e16. [PMID: 37208229 DOI: 10.1016/j.urolonc.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/17/2023] [Accepted: 04/22/2023] [Indexed: 05/21/2023]
Abstract
OBJECTIVE Most prostate cancer active surveillance (AS) protocols suggest a confirmatory biopsy within 12 to 18 months of diagnosis to mitigate the risk of unsampled high-grade disease. We investigate whether the results of confirmatory biopsy impact AS outcomes and could be used to tailor surveillance intensity. METHODS We retrospectively reviewed our institutional database of prostate cancer patients managed by AS from 1997 to 2019 who underwent confirmatory biopsy and ≥3 biopsies overall. Biopsy progression was defined as either an increase in grade group or an increase in the proportion of positive biopsy cores to >34% and was compared between patients with a negative vs positive confirmatory biopsy using the Kaplan-Meier method and Cox proportional hazards regression. RESULTS We identified 452 patients meeting inclusion criteria for this analysis, of whom 169 (37%) had a negative confirmatory biopsy. With a median follow-up of 6.8 years, 37% of patients progressed to treatment, most commonly due to biopsy progression. A negative confirmatory biopsy was significantly associated with biopsy progression-free survival in multivariable analysis (HR 0.54, 95% CI 0.34-0.88, P = 0.013), adjusting for known clinical and pathologic factors, including use of mpMRI prior to confirmatory biopsy. Negative confirmatory biopsy was also associated with an increased risk of adverse pathologic features at prostatectomy but not with biochemical recurrence among men who ultimately underwent definitive treatment. CONCLUSIONS A negative confirmatory biopsy is associated with a lower risk of biopsy progression. While the increased risk of adverse pathology at time of definitive treatment sounds a small cautionary note regarding decreasing surveillance intensity, the majority of such patients have a favorable outcome on AS.
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Affiliation(s)
- Keyan Salari
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Broad Institute of MIT and Harvard, Cambridge, MA.
| | - Jason Kowitz
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jeffrey Twum-Ampofo
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrew Gusev
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Aileen O'Shea
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mark A Anderson
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mukesh Harisinghani
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David Kuppermann
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Douglas M Dahl
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Richard J Lee
- Department of Medicine, Division of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael L Blute
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Anthony L Zietman
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam S Feldman
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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3
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Ferro M, Rocco B, Maggi M, Lucarelli G, Falagario UG, Del Giudice F, Crocetto F, Barone B, La Civita E, Lasorsa F, Brescia A, Catellani M, Busetto GM, Tataru OS, Terracciano D. Beyond blood biomarkers: the role of SelectMDX in clinically significant prostate cancer identification. Expert Rev Mol Diagn 2023; 23:1061-1070. [PMID: 37897252 DOI: 10.1080/14737159.2023.2277366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/26/2023] [Indexed: 10/30/2023]
Abstract
INTRODUCTION New potential biomarkers to pre-intervention identification of a clinically significant prostate cancer (csPCa) will prevent overdiagnosis and overtreatment and limit quality of life impairment of PCa patients. AREAS COVERED We have developed a comprehensive review focusing our research on the increasing knowledge of the role of SelectMDX® in csPCa detection. Areas identified as clinically relevant are the ability of SelectMDX® to predict csPCa in active surveillance setting, its predictive ability when combined with multiparametric MRI and the role of SelectMDX® in the landscape of urinary biomarkers. EXPERT OPINION Several PCa biomarkers have been developed either alone or in combination with clinical variables to improve csPCa detection. SelectMDX® score includes genomic markers, age, PSA, prostate volume, and digital rectal examination. Several studies have shown consistency in the ability to improve detection of csPCa, avoidance of unnecessary prostate biopsies, helpful in decision-making for clinical benefit of PCa patients with future well designed, and impactful studies.
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Affiliation(s)
- Matteo Ferro
- Department of Urology, IEO - European Institute of Oncology, IRCCS - Istituto di Ricovero e Cura a Carattere Scientifico, via Ripamonti 435, Milan 20141, Italy
| | - Bernardo Rocco
- Unit of Urology, Department of Health Science, University of Milan, ASST Santi Paolo and Carlo, Via A. Di Rudini 8, Milan 20142, Italy
| | - Martina Maggi
- Department of Maternal Infant and Urologic Sciences, Policlinico Umberto I Hospital, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185, Rome, Italy
| | - Giuseppe Lucarelli
- Urology, Andrology and Kidney Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, Piazza Umberto I - 70121, Bari, Italy
| | - Ugo Giovanni Falagario
- Department of Urology and Organ Transplantation, University of Foggia, Via A.Gramsci 89/91, 71122 Foggia, Italy
| | - Francesco Del Giudice
- Department of Maternal Infant and Urologic Sciences, Policlinico Umberto I Hospital, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185, Rome, Italy
| | - Felice Crocetto
- Department of Neurosciences and Reproductive Sciences and Odontostomatology, University of Naples Federico II, Via Pansini, 5 - 80131, Naples, Italy
| | - Biagio Barone
- Department of Surgical Sciences, Urology Unit, AORN Sant'Anna e San Sebastiano, Caserta, Via Ferdinando Palasciano, 81100 Caserta , Italy
| | - Evelina La Civita
- Department of Translational Medical Sciences, University of Naples "Federico II", Corso Umberto I 40 - 80138 Naples, Italy
| | - Francesco Lasorsa
- Urology, Andrology and Kidney Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, Piazza Umberto I - 70121, Bari, Italy
| | - Antonio Brescia
- Department of Urology, IEO - European Institute of Oncology, IRCCS - Istituto di Ricovero e Cura a Carattere Scientifico, via Ripamonti 435, Milan 20141, Italy
| | - Michele Catellani
- Department of Urology, IEO - European Institute of Oncology, IRCCS - Istituto di Ricovero e Cura a Carattere Scientifico, via Ripamonti 435, Milan 20141, Italy
| | - Gian Maria Busetto
- Department of Urology and Organ Transplantation, University of Foggia, Via A.Gramsci 89/91, 71122 Foggia, Italy
| | - Octavian Sabin Tataru
- Department of Simulation Applied in Medicine, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mures, Gh Marinescu 35, 540142 Târgu Mures, Romania
| | - Daniela Terracciano
- Department of Translational Medical Sciences, University of Naples "Federico II", Corso Umberto I 40 - 80138 Naples, Italy
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4
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Piccinelli ML, Luzzago S, Marvaso G, Laukhtina E, Miura N, Schuettfort VM, Mori K, Colombo A, Ferro M, Mistretta FA, Fusco N, Petralia G, Jereczek-Fossa BA, Shariat SF, Karakiewicz PI, de Cobelli O, Musi G. Association between previous negative biopsies and lower rates of progression during active surveillance for prostate cancer. World J Urol 2022; 40:1447-1454. [PMID: 35347414 PMCID: PMC9166841 DOI: 10.1007/s00345-022-03983-8] [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: 01/23/2022] [Accepted: 02/27/2022] [Indexed: 11/04/2022] Open
Abstract
Purpose To test any-cause discontinuation and ISUP GG upgrading rates during Active Surveillance (AS) in patients that underwent previous negative biopsies (PNBs) before prostate cancer (PCa) diagnosis vs. biopsy naive patients. Methods Retrospective analysis of 961 AS patients (2008–2020). Three definitions of PNBs were used: (1) PNBs status (biopsy naïve vs. PNBs); (2) number of PNBs (0 vs. 1 vs. ≥ 2); (3) histology at last PNB (no vs. negative vs. HGPIN/ASAP). Kaplan–Meier plots and multivariable Cox models tested any-cause and ISUP GG upgrading discontinuation rates. Results Overall, 760 (79.1%) vs. 201 (20.9%) patients were biopsy naïve vs. PNBs. Specifically, 760 (79.1%) vs. 138 (14.4%) vs. 63 (6.5%) patients had 0 vs. 1 vs. ≥ 2 PNBs. Last, 760 (79.1%) vs. 134 (13.9%) vs. 67 (7%) patients had no vs. negative PNB vs. HGPIN/ASAP. PNBs were not associated with any-cause discontinuation rates. Conversely, PNBs were associated with lower rates of ISUP GG upgrading: (1) PNBs vs. biopsy naïve (HR:0.6, p = 0.04); (2) 1 vs. 0 PNBs (HR:0.6, p = 0.1) and 2 vs. 0 PNBs, (HR:0.5, p = 0.1); (3) negative PNB vs. biopsy naïve (HR:0.7, p = 0.3) and HGPIN/ASAP vs. biopsy naïve (HR:0.4, p = 0.04). However, last PNB ≤ 18 months (HR:0.4, p = 0.02), but not last PNB > 18 months (HR:0.8, p = 0.5) were associated with lower rates of ISUP GG upgrading. Conclusion PNBs status is associated with lower rates of ISUP GG upgrading during AS for PCa. The number of PNBs and time from last PNB to PCa diagnosis (≤ 18 months) appear also to be critical for patient selection. Supplementary Information The online version contains supplementary material available at 10.1007/s00345-022-03983-8.
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Affiliation(s)
- Mattia Luca Piccinelli
- Department of Urology, IEO European Institute of Oncology, IRCCS, Via Giuseppe Ripamonti 435, Milan, Italy. .,Università degli Studi di Milano, Milan, Italy.
| | - Stefano Luzzago
- Department of Urology, IEO European Institute of Oncology, IRCCS, Via Giuseppe Ripamonti 435, Milan, Italy.,Department of Oncology and Haemato-Oncology, Università Degli Studi Di Milano, 20122, Milan, Italy
| | - Giulia Marvaso
- Department of Radiotherapy, IEO European Institute of Oncology, IRCCS, Via Ripamonti 435, Milan, Italy.,Department of Oncology and Haemato-Oncology, Università Degli Studi Di Milano, 20122, Milan, Italy
| | - Ekaterina Laukhtina
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.,Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Noriyoshi Miura
- Department of Urology, Medical University of Vienna, Vienna, Austria.,Department of Urology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Victor M Schuettfort
- Department of Urology, Medical University of Vienna, Vienna, Austria.,Department of Urology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Keiichiro Mori
- Department of Urology, Medical University of Vienna, Vienna, Austria.,Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Alberto Colombo
- Division of Radiology, IEO European Institute of Oncology, IRCCS, Via Ripamonti 435, Milan, Italy
| | - Matteo Ferro
- Department of Urology, IEO European Institute of Oncology, IRCCS, Via Giuseppe Ripamonti 435, Milan, Italy
| | - Francesco A Mistretta
- Department of Urology, IEO European Institute of Oncology, IRCCS, Via Giuseppe Ripamonti 435, Milan, Italy.,Department of Oncology and Haemato-Oncology, Università Degli Studi Di Milano, 20122, Milan, Italy
| | - Nicola Fusco
- Department of Pathology, IEO European Institute of Oncology, IRCCS, Via Ripamonti 435, Milan, Italy.,Department of Oncology and Haemato-Oncology, Università Degli Studi Di Milano, 20122, Milan, Italy
| | - Giuseppe Petralia
- Precision Imaging and Research Unit, Department of Medical Imaging and Radiation Sciences, IEO European Institute of Oncology IRCCS, 20141, Milan, Italy.,Department of Oncology and Haemato-Oncology, Università Degli Studi Di Milano, 20122, Milan, Italy
| | - Barbara A Jereczek-Fossa
- Department of Radiotherapy, IEO European Institute of Oncology, IRCCS, Via Ripamonti 435, Milan, Italy.,Department of Oncology and Haemato-Oncology, Università Degli Studi Di Milano, 20122, Milan, Italy
| | - Shahrokh F Shariat
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.,Department of Urology, Medical University of Vienna, Vienna, Austria.,Research Division of Urology, Department of Special Surgery, The University of Jordan, Amman, Jordan.,Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic.,Department of Urology, Weill Cornell Medical College, New York, NY, USA.,Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria.,European Association of Urology Research Foundation, Arnhem, Netherlands
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
| | - Ottavio de Cobelli
- Department of Urology, IEO European Institute of Oncology, IRCCS, Via Giuseppe Ripamonti 435, Milan, Italy.,Department of Oncology and Haemato-Oncology, Università Degli Studi Di Milano, 20122, Milan, Italy
| | - Gennaro Musi
- Department of Urology, IEO European Institute of Oncology, IRCCS, Via Giuseppe Ripamonti 435, Milan, Italy.,Department of Oncology and Haemato-Oncology, Università Degli Studi Di Milano, 20122, Milan, Italy
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5
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Ellis EE, Frye TP. Role of multi-parametric magnetic resonance imaging fusion biopsy in active surveillance of prostate cancer: a systematic review. Ther Adv Urol 2022; 14:17562872221106883. [PMID: 35872881 PMCID: PMC9297445 DOI: 10.1177/17562872221106883] [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: 12/31/2021] [Accepted: 05/23/2022] [Indexed: 11/25/2022] Open
Abstract
Background: Our goal is to review current literature regarding the role of multi-parametric magnetic resonance imaging (mpMRI) in the active surveillance (AS) of prostate cancer (PCa) and identify trends in rate of reclassification of risk category, performance of fusion biopsy (FB) versus systematic biopsy (SB), and progression-free survival. Methods: We performed a comprehensive literature search in PubMed and identified 121 articles. A narrative summary was performed. Results: Thirty-two articles were chosen to be featured in this review. SB and FB are complementary in detecting higher-grade disease in follow-up. While FB was more likely than SB to detect clinically significant disease, FB missed 6.4–11% of clinically significant disease. Imaging factors that predicted upgrading include number of lesions on magnetic resonance imaging (MRI), lesion density, and MRI suspicion level. Conclusion: Incorporating mpMRI FB in conjunction with SB should be part of contemporary AS protocols. mpMRI should additionally be used routinely for follow-up; however, mpMRI is not currently sensitive enough in detecting disease progression to replace biopsy in the surveillance protocol.
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Affiliation(s)
| | - Thomas P Frye
- University of Rochester Medical Center, 601 Elmwood Ave Box 656, Rochester, NY 14620, USA
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6
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Considering Predictive Factors in the Diagnosis of Clinically Significant Prostate Cancer in Patients with PI-RADS 3 Lesions. Life (Basel) 2021; 11:life11121432. [PMID: 34947963 PMCID: PMC8708599 DOI: 10.3390/life11121432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/08/2021] [Accepted: 12/14/2021] [Indexed: 11/16/2022] Open
Abstract
The use of multi-parametric magnetic resonance imaging (mpMRI) in conjunction with the Prostate Imaging Reporting and Data System (PI-RADS) is standard practice in the diagnosis, surveillance, and staging of prostate cancer. The risk associated with lesions graded at a PI-RADS score of 3 is ambiguous. Further characterization of the risk associated with PI-RADS 3 lesions would be useful in guiding further work-up and intervention. This study aims to better characterize the utility of PI-RADS 3 and associated risk factors in detecting clinically significant prostate cancer. From a prospectively maintained IRB-approved dataset of all veterans undergoing mpMRI fusion biopsy at the Southeastern Louisiana Veterans Healthcare System, we identified a cohort of 230 PI-RADS 3 lesions from a dataset of 283 consecutive UroNav-guided biopsies in 263 patients from October 2017 to July 2020. Clinically significant prostate cancer (Gleason Grade ≥ 2) was detected in 18 of the biopsied PI-RADS 3 lesions, representing 7.8% of the overall sample. Based on binomial analysis, PSA densities of 0.15 or greater were predictive of clinically significant disease, as was PSA. The location of the lesion within the prostate was not shown to be a statistically significant predictor of prostate cancer overall (p = 0.87), or of clinically significant disease (p = 0.16). The majority of PI-RADS 3 lesions do not represent clinically significant disease; therefore, it is possible to reduce morbidity through biopsy. PSA density is a potential adjunctive factor in deciding which patients with PI-RADS 3 lesions require biopsy. Furthermore, while the risk of prostate cancer for African-American men has been debated in the literature, our findings indicate that race is not predictive of identifying prostate cancer, with comparable Gleason grade distributions on histology between races.
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7
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Epstein JI, Amin MB, Fine SW, Algaba F, Aron M, Baydar DE, Beltran AL, Brimo F, Cheville JC, Colecchia M, Comperat E, da Cunha IW, Delprado W, DeMarzo AM, Giannico GA, Gordetsky JB, Guo CC, Hansel DE, Hirsch MS, Huang J, Humphrey PA, Jimenez RE, Khani F, Kong Q, Kryvenko ON, Kunju LP, Lal P, Latour M, Lotan T, Maclean F, Magi-Galluzzi C, Mehra R, Menon S, Miyamoto H, Montironi R, Netto GJ, Nguyen JK, Osunkoya AO, Parwani A, Robinson BD, Rubin MA, Shah RB, So JS, Takahashi H, Tavora F, Tretiakova MS, True L, Wobker SE, Yang XJ, Zhou M, Zynger DL, Trpkov K. The 2019 Genitourinary Pathology Society (GUPS) White Paper on Contemporary Grading of Prostate Cancer. Arch Pathol Lab Med 2021; 145:461-493. [PMID: 32589068 DOI: 10.5858/arpa.2020-0015-ra] [Citation(s) in RCA: 124] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Controversies and uncertainty persist in prostate cancer grading. OBJECTIVE.— To update grading recommendations. DATA SOURCES.— Critical review of the literature along with pathology and clinician surveys. CONCLUSIONS.— Percent Gleason pattern 4 (%GP4) is as follows: (1) report %GP4 in needle biopsy with Grade Groups (GrGp) 2 and 3, and in needle biopsy on other parts (jars) of lower grade in cases with at least 1 part showing Gleason score (GS) 4 + 4 = 8; and (2) report %GP4: less than 5% or less than 10% and 10% increments thereafter. Tertiary grade patterns are as follows: (1) replace "tertiary grade pattern" in radical prostatectomy (RP) with "minor tertiary pattern 5 (TP5)," and only use in RP with GrGp 2 or 3 with less than 5% Gleason pattern 5; and (2) minor TP5 is noted along with the GS, with the GrGp based on the GS. Global score and magnetic resonance imaging (MRI)-targeted biopsies are as follows: (1) when multiple undesignated cores are taken from a single MRI-targeted lesion, an overall grade for that lesion is given as if all the involved cores were one long core; and (2) if providing a global score, when different scores are found in the standard and the MRI-targeted biopsy, give a single global score (factoring both the systematic standard and the MRI-targeted positive cores). Grade Groups are as follows: (1) Grade Groups (GrGp) is the terminology adopted by major world organizations; and (2) retain GS 3 + 5 = 8 in GrGp 4. Cribriform carcinoma is as follows: (1) report the presence or absence of cribriform glands in biopsy and RP with Gleason pattern 4 carcinoma. Intraductal carcinoma (IDC-P) is as follows: (1) report IDC-P in biopsy and RP; (2) use criteria based on dense cribriform glands (>50% of the gland is composed of epithelium relative to luminal spaces) and/or solid nests and/or marked pleomorphism/necrosis; (3) it is not necessary to perform basal cell immunostains on biopsy and RP to identify IDC-P if the results would not change the overall (highest) GS/GrGp part per case; (4) do not include IDC-P in determining the final GS/GrGp on biopsy and/or RP; and (5) "atypical intraductal proliferation (AIP)" is preferred for an intraductal proliferation of prostatic secretory cells which shows a greater degree of architectural complexity and/or cytological atypia than typical high-grade prostatic intraepithelial neoplasia, yet falling short of the strict diagnostic threshold for IDC-P. Molecular testing is as follows: (1) Ki67 is not ready for routine clinical use; (2) additional studies of active surveillance cohorts are needed to establish the utility of PTEN in this setting; and (3) dedicated studies of RNA-based assays in active surveillance populations are needed to substantiate the utility of these expensive tests in this setting. Artificial intelligence and novel grading schema are as follows: (1) incorporating reactive stromal grade, percent GP4, minor tertiary GP5, and cribriform/intraductal carcinoma are not ready for adoption in current practice.
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Affiliation(s)
- Jonathan I Epstein
- From the Departments of Pathology (Epstein, DeMarzo, Lotan), McGill University Health Center, Montréal, Quebec, Canada.,Urology (Epstein), David Geffen School of Medicine at UCLA, Los Angeles, California (Huang).,and Oncology (Epstein), The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Mahul B Amin
- Department of Pathology and Laboratory Medicine and Urology, University of Tennessee Health Science, Memphis (Amin)
| | - Samson W Fine
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York (Fine)
| | - Ferran Algaba
- Department of Pathology, Fundacio Puigvert, Barcelona, Spain (Algaba)
| | - Manju Aron
- Department of Pathology, University of Southern California, Los Angeles (Aron)
| | - Dilek E Baydar
- Department of Pathology, Faculty of Medicine, Koç University, İstanbul, Turkey (Baydar)
| | - Antonio Lopez Beltran
- Department of Pathology, Champalimaud Centre for the Unknown, Lisbon, Portugal (Beltran)
| | - Fadi Brimo
- Department of Pathology, McGill University Health Center, Montréal, Quebec, Canada (Brimo)
| | - John C Cheville
- Department of Pathology, Mayo Clinic, Rochester, Minnesota (Cheville, Jimenez)
| | - Maurizio Colecchia
- Department of Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (Colecchia)
| | - Eva Comperat
- Department of Pathology, Hôpital Tenon, Sorbonne University, Paris, France (Comperat)
| | | | | | - Angelo M DeMarzo
- From the Departments of Pathology (Epstein, DeMarzo, Lotan), McGill University Health Center, Montréal, Quebec, Canada
| | - Giovanna A Giannico
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee (Giannico, Gordetsky)
| | - Jennifer B Gordetsky
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee (Giannico, Gordetsky)
| | - Charles C Guo
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston (Guo)
| | - Donna E Hansel
- Department of Pathology, Oregon Health and Science University, Portland (Hansel)
| | - Michelle S Hirsch
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Hirsch)
| | - Jiaoti Huang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California (Huang)
| | - Peter A Humphrey
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut (Humphrey)
| | - Rafael E Jimenez
- Department of Pathology, Mayo Clinic, Rochester, Minnesota (Cheville, Jimenez)
| | - Francesca Khani
- Department of Pathology and Laboratory Medicine and Urology, Weill Cornell Medicine, New York, New York (Khani, Robinson)
| | - Qingnuan Kong
- Department of Pathology, Qingdao Municipal Hospital, Qingdao, Shandong, China (Kong).,Kong is currently located at Kaiser Permanente Sacramento Medical Center, Sacramento, California
| | - Oleksandr N Kryvenko
- Departments of Pathology and Laboratory Medicine and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida (Kryvenko)
| | - L Priya Kunju
- Department of Pathology, University of Michigan Medical School, Ann Arbor, Michigan (Kunju, Mehra)
| | - Priti Lal
- Perelman School of Medicine, University of Pennsylvania, Philadelphia (Lal)
| | - Mathieu Latour
- Department of Pathology, CHUM, Université de Montréal, Montréal, Quebec, Canada (Latour)
| | - Tamara Lotan
- From the Departments of Pathology (Epstein, DeMarzo, Lotan), McGill University Health Center, Montréal, Quebec, Canada
| | - Fiona Maclean
- Douglass Hanly Moir Pathology, Faculty of Medicine and Health Sciences Macquarie University, North Ryde, Australia (Maclean)
| | - Cristina Magi-Galluzzi
- Department of Pathology, The University of Alabama at Birmingham, Birmingham (Magi-Galluzzi, Netto)
| | - Rohit Mehra
- Department of Pathology, University of Michigan Medical School, Ann Arbor, Michigan (Kunju, Mehra)
| | - Santosh Menon
- Department of Surgical Pathology, Tata Memorial Hospital, Parel, Mumbai, India (Menon)
| | - Hiroshi Miyamoto
- Departments of Pathology and Laboratory Medicine and Urology, University of Rochester Medical Center, Rochester, New York (Miyamoto)
| | - Rodolfo Montironi
- Section of Pathological Anatomy, School of Medicine, Polytechnic University of the Marche Region, United Hospitals, Ancona, Italy (Montironi)
| | - George J Netto
- Department of Pathology, The University of Alabama at Birmingham, Birmingham (Magi-Galluzzi, Netto)
| | - Jane K Nguyen
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio (Nguyen)
| | - Adeboye O Osunkoya
- Department of Pathology, Emory University School of Medicine, Atlanta, Georgia (Osunkoya)
| | - Anil Parwani
- Department of Pathology, Ohio State University, Columbus (Parwani, Zynger)
| | - Brian D Robinson
- Department of Pathology and Laboratory Medicine and Urology, Weill Cornell Medicine, New York, New York (Khani, Robinson)
| | - Mark A Rubin
- Department for BioMedical Research, University of Bern, Bern, Switzerland (Rubin)
| | - Rajal B Shah
- Department of Pathology, The University of Texas Southwestern Medical Center, Dallas (Shah)
| | - Jeffrey S So
- Institute of Pathology, St Luke's Medical Center, Quezon City and Global City, Philippines (So)
| | - Hiroyuki Takahashi
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan (Takahashi)
| | - Fabio Tavora
- Argos Laboratory, Federal University of Ceara, Fortaleza, Brazil (Tavora)
| | - Maria S Tretiakova
- Department of Pathology, University of Washington School of Medicine, Seattle (Tretiakova, True)
| | - Lawrence True
- Department of Pathology, University of Washington School of Medicine, Seattle (Tretiakova, True)
| | - Sara E Wobker
- Departments of Pathology and Laboratory Medicine and Urology, University of North Carolina, Chapel Hill (Wobker)
| | - Ximing J Yang
- Department of Pathology, Northwestern University, Chicago, Illinois (Yang)
| | - Ming Zhou
- Department of Pathology, Tufts Medical Center, Boston, Massachusetts (Zhou)
| | - Debra L Zynger
- Department of Pathology, Ohio State University, Columbus (Parwani, Zynger)
| | - Kiril Trpkov
- and Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada (Trpkov)
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8
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O'Connor LP, Wang AZ, Yerram NK, Long L, Ahdoot M, Lebastchi AH, Gurram S, Zeng J, Harmon SA, Mehralivand S, Merino MJ, Parnes HL, Choyke PL, Shih JH, Wood BJ, Turkbey B, Pinto PA. Changes in Magnetic Resonance Imaging Using the Prostate Cancer Radiologic Estimation of Change in Sequential Evaluation Criteria to Detect Prostate Cancer Progression for Men on Active Surveillance. Eur Urol Oncol 2021; 4:227-234. [PMID: 33867045 PMCID: PMC9310665 DOI: 10.1016/j.euo.2020.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/07/2020] [Accepted: 09/17/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND The ability of serial magnetic resonance imaging (MRI) to capture pathologic progression during active surveillance (AS) remains in question. OBJECTIVE To determine whether changes in MRI are associated with pathologic progression for patients on AS. DESIGN, SETTING, AND PARTICIPANTS From July 2007 through January 2020, we identified all patients evaluated for AS at our institution. Following confirmatory biopsy, a total of 391 patients who underwent surveillance MRI and biopsy at least once were identified (median follow-up of 35.6 mo, interquartile range 19.7-60.6). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS All MRI intervals were scored using the "Prostate Cancer Radiologic Estimation of Change in Sequential Evaluation" (PRECISE) criteria, with PRECISE scores =4 considered a positive change in MRI. A generalized estimating equation-based logistic regression analysis was conducted for all intervals with a PRECISE score of <4 to determine the predictors of Gleason grade group (GG) progression despite stable MRI. RESULTS AND LIMITATIONS A total of 621 MRI intervals were scored by PRECISE and validated by biopsy. The negative predictive value of stable MRI (PRECISE score <4) was greatest for detecting GG1 to?=?GG3 disease (0.94 [0.91-0.97]). If 2-yr surveillance biopsy were performed exclusively for a positive change in MRI, 3.7% (4/109) of avoided biopsies would have resulted in missed progression from GG1 to?=?GG3 disease. Prostate-specific antigen (PSA) density (odds ratio 1.95 [1.17-3.25], p?=? 0.01) was a risk factor for progression from GG1 to =GG3 disease despite stable MRI. CONCLUSIONS In patients with GG1 disease and stable MRI (PRECISE score <4) on surveillance, grade progression to?=?GG3 disease is not common. In patients with grade progression detected on biopsy despite stable MRI, elevated PSA density appeared to be a risk factor for progression to?=?GG3 disease. PATIENT SUMMARY For patients with low-risk prostate cancer on active surveillance, the risk of progressing to grade group 3 disease is low with a stable magnetic resonance image (MRI) after 2?yr. Having higher prostate-specific antigen density increases the risk of progression, despite having a stable MRI.
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Affiliation(s)
- Luke P O'Connor
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Alex Z Wang
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Nitin K Yerram
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Lori Long
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Michael Ahdoot
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Amir H Lebastchi
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Sandeep Gurram
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Johnathan Zeng
- Center for Interventional Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Stephanie A Harmon
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Bethesda, MD, USA
| | - Sherif Mehralivand
- Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Maria J Merino
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Howard L Parnes
- Division of Cancer Prevention, National Cancer Institutes, National Institutes of Health, Bethesda, MD, USA
| | - Peter L Choyke
- Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Joanna H Shih
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Bradford J Wood
- Center for Interventional Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Baris Turkbey
- Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Peter A Pinto
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
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9
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Bloom JB, Daneshvar MA, Lebastchi AH, Ahdoot M, Gold SA, Hale G, Mehralivand S, Sanford T, Valera V, Wood BJ, Choyke PL, Merino MJ, Turkbey B, Parnes HL, Pinto PA. Risk of adverse pathology at prostatectomy in the era of MRI and targeted biopsies; rethinking active surveillance for intermediate risk prostate cancer patients. Urol Oncol 2021; 39:729.e1-729.e6. [PMID: 33736975 DOI: 10.1016/j.urolonc.2021.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 02/11/2021] [Accepted: 02/21/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE Men with intermediate risk (IR) prostate cancer (CaP) are often excluded from active surveillance (AS) due to higher rates of adverse pathology (AP). We determined our rate of AP in men who underwent multiparametric MRI (MpMRI) with combined biopsy (CB) consisting of targeted biopsy (TB) and systematic biopsy (SB) prior to radical prostatectomy (RP). METHODS A retrospective review was conducted of men with Gleason Grade Group (GG) 2 disease who underwent RP after SB alone or after preoperative MRI with CB. AP was defined as either pathologic stage T3a (AP ≥ T3a) or pathologic stage T3b (AP ≥ T3b) and/or GG upgrading. Rates of AP were determined for both groups and those who fit the National Comprehensive Cancer Network (NCCN) definition of favorable IR (FIR) or the low volume IR (LVIR) criteria. Multivariable logistic regression was used to determine predictive factors. RESULTS The overall rate of AP ≥ T3b was 21.2% in the SB group vs. 8.6% in the MRI with CB group, P = 0.006. This rate was lowered to 6.8% and 5.6% when men met the definition of NCCN FIR or LVIR, respectively. Suspicion for extraprostatic extension (EPE) (OR 7.65, 95% CI 1.77-33.09, P = 0.006) and positive cores of GG 2 on SB (OR 1.43, 95% CI 1.05-1.96, P = 0.023) were significant for predicting AP ≥ T3b. CONCLUSIONS Rates of AP at RP after MRI with CB are lower than studies prior to the adoption of this technology, suggesting that more men with IR disease may be considered for AS. However, increasing cores positive on SB and MRI findings suggestive of EPE remain unsafe.
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Affiliation(s)
- Jonathan B Bloom
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Michael A Daneshvar
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Amir H Lebastchi
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Michael Ahdoot
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Samuel A Gold
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Graham Hale
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Sherif Mehralivand
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD; Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD; Department of Urology and Pediatric Urology, University Medical Center Mainz, Mainz, Germany
| | - Thomas Sanford
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD; Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Vladimir Valera
- Urologic Oncology 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
| | - Maria J Merino
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Baris Turkbey
- Molecular Imaging Program, 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
| | - Peter A Pinto
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD; Department of Urology and Pediatric Urology, University Medical Center Mainz, Mainz, Germany.
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10
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von Landenberg N, Hanske J, Noldus J, Roghmann F, Tully KH, Wald J, Berg S, Brock M. Probability of Prostate Cancer Diagnosis following Negative Systematic and Targeted MRI: Transrectal Ultrasound Fusion Biopsy: A Real-Life Observational Study. Urol Int 2021; 105:446-452. [PMID: 33498059 DOI: 10.1159/000513075] [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: 08/31/2020] [Accepted: 11/16/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The risk of occult prostate carcinoma (PCa) after negative multiparametric MRI (mpMRI)-transrectal fusion biopsy (F-Bx) is unknown. To determine the false-negative predictive value, we examined PCa detection after prior negative F-Bx. METHODS Between December 2012 and November 2016, 491 patients with suspected PCa and suspicious mpMRI findings underwent transrectal F-Bx. Patients with benign pathology (n = 191) were eligible for our follow-up (FU) survey. Patient characteristics and clinical parameters were correlated to subsequent findings of newly detected PCa. RESULTS Complete FU with a median of 31 (interquartile range: 17-39) months was available for 176/191 (92.2%) patients. Of those, 54 men had either surgical interventions on the prostate or re-Bxs. Newly detected PCa was evident in 14/176 (7.95%) patients stratified to ISUP ≤2 in 10 and ≥3 in 4 cases. The comparison of patients with newly detected PCa to those without cancerous findings in FU showed significant differences in prostate-specific antigen (PSA) density (0.16 vs. 0.13 ng/mL2) and prostate volume (45 vs. 67 mL, both p < 0.05). Both factors are significant predictors for newly detected cancer after initial negative F-Bx. CONCLUSION Only PSA density (>0.13 ng/mL2) and small prostate volume are significant predictors for newly detected PCa after initial negative F-Bx. Despite negative mpMRI/TRUS F-Bx results, patients should be further monitored due to a risk of developing PCa over time. Notwithstanding the limitation of our study that not all patients underwent another Bx, we assume that the false-negative rate is low but existing. Our data represent a real-world scenario.
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Affiliation(s)
| | - Julian Hanske
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Joachim Noldus
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Florian Roghmann
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Karl H Tully
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Jan Wald
- Department of Radiology and Nuclear Medicine, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Sebastian Berg
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Marko Brock
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
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11
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Singh S, Sandhu P, Beckmann K, Santaolalla A, Dewan K, Clovis S, Rusere J, Zisengwe G, Challacombe B, Brown C, Cathcart P, Popert R, Dasgupta P, Van Hemelrijck M, Elhage O. Negative first follow-up prostate biopsy on active surveillance is associated with decreased risk of upgrading, suspicion of progression and converting to active treatment. BJU Int 2020; 128:72-78. [PMID: 33098158 DOI: 10.1111/bju.15281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the risk of disease progression and conversion to active treatment following a negative biopsy while on active surveillance (AS) for prostate cancer (PCa). PATIENTS AND METHODS Men on an AS programme at a single tertiary hospital (London, UK) between 2003 and 2018 with confirmed low-intermediate-risk PCa, Gleason Grade Group <3, clinical stage <T3 and a diagnostic prostate-specific antigen (PSA) level of <20 ng/mL. This cohort included men diagnosed by transrectal ultrasonography guided (12-14 cores) or transperineal (median 32 cores) biopsy. Multivariate Cox hazards regression analysis was undertaken to determine (i) risk of upgrading, (ii) clinical or radiological suspicion of disease progression, and (iii) transitioning to active treatment. Suspicion of disease progression was defined as any biopsy upgrading, >30% positive cores, magnetic resonance imaging (MRI) Likert score >3/T3 or PSA level of >20 ng/mL. Conversion to treatment included radical or hormonal treatment. RESULTS Among the 460 eligible patients, 23% had negative follow-up biopsy findings. The median follow-up was 62 months, with one to two repeat biopsies and two MRIs per patient during that period. Negative biopsy findings at first repeat biopsy were associated with decreased risk of converting to active treatment (hazard ration [HR] 0.18, 95% confidence interval [CI] 0.09-0.37; P < 0.001), suspicion of disease progression (HR 0.56, 95% CI: 0.34-0.94; P = 0.029), and upgrading (HR 0.48, 95% CI 0.23-0.99; P = 0.047). Data are limited by fewer men with multiple follow-up biopsies. CONCLUSION A negative biopsy finding at the first scheduled follow-up biopsy among men on AS for PCa was strongly associated with decreased risk of subsequent upgrading, clinical or radiological suspicion of disease progression, and conversion to active treatment. A less intense surveillance protocol should be considered for this cohort of patients.
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Affiliation(s)
- Sohail Singh
- School of Medical Education, Faculty of Life Sciences and Medicine, King's College London, London, UK.,The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Preeti Sandhu
- School of Medical Education, Faculty of Life Sciences and Medicine, King's College London, London, UK.,The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Kerri Beckmann
- Translational Oncology and Urology Research, Faculty of Life Sciences and Medicine, King's College London, London, UK.,University of South Australia Cancer Research Institute, University of South Australia, Adelaide, SA, Australia
| | - Aida Santaolalla
- Translational Oncology and Urology Research, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Kamal Dewan
- School of Medical Education, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Sharon Clovis
- The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jonah Rusere
- The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Grace Zisengwe
- The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Christian Brown
- The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Paul Cathcart
- The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rick Popert
- The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Prokar Dasgupta
- The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Immunology and Microbial Sciences, Kings College London, London, UK
| | - Mieke Van Hemelrijck
- Translational Oncology and Urology Research, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Oussama Elhage
- The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Immunology and Microbial Sciences, Kings College London, London, UK
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12
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O'Connor LP, Wang AZ, Yerram NK, Lebastchi AH, Ahdoot M, Gurram S, Zeng J, Mehralivand S, Harmon S, Merino MJ, Parnes HL, Choyke PL, Turkbey B, Wood BJ, Pinto PA. Combined MRI-targeted Plus Systematic Confirmatory Biopsy Improves Risk Stratification for Patients Enrolling on Active Surveillance for Prostate Cancer. Urology 2020; 144:164-170. [PMID: 32679272 PMCID: PMC8916164 DOI: 10.1016/j.urology.2020.06.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/29/2020] [Accepted: 06/28/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate the efficacy of combined MRI-targeted plus systematic 12-core biopsy (Cbx) to aid in the selection of patients for active surveillance (AS). METHODS From July 2007 to January 2020, patients with Gleason Grade Group (GG) 1 or GG 2 prostate cancer were referred to our center for AS consideration. All patients underwent an MRI and confirmatory combined MRI-targeted plus systematic biopsy (Cbx), and AS outcomes based on Cbx results were compared. Cox regression was used to identify predictors of AS failure, defined as progression to ≥ GG3 disease on follow-up biopsies. RESULTS Of 579 patients referred for AS, 79.3% (459/579) and 20.7% (120/579) had an initial diagnosis of GG1 and GG2 disease, respectively. Overall, 43.2% of patients (250/579) were upgraded on confirmatory Cbx, with 19.2% (111/579) upgraded to ≥ GG3. For the 226 patients followed on AS, 32.7% (74/226) had benign, 45.6% (103/226) had GG1, and 21.7% (49/226) had GG2 results on confirmatory Cbx. In total, 28.8% (65/226) of patients eventually progressed to ≥ GG3, with a median time to AS failure of 89 months. The median time from confirmatory Cbx to AS failure for the negative, GG1, and GG2 groups were 97, 97, and 32 months, respectively (p < .001). On multivariable regression, only age (hazard ratio 1.06 [1.02-1.11], p < .005) and GG on confirmatory Cbx (hazard ratio 2.75 [1.78-4.26], p < .005) remained as positive predictors of AS failure. CONCLUSION The confirmatory combined MRI-targeted plus systematic biopsy provides useful information for the risk stratification of patients at the time of AS enrollment.
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Affiliation(s)
- Luke P O'Connor
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Alex Z Wang
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Nitin K Yerram
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Amir H Lebastchi
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Michael Ahdoot
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Sandeep Gurram
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Johnathan Zeng
- Center for Interventional Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Sherif Mehralivand
- Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Stephanie Harmon
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Frederick, MD
| | - Maria J Merino
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Howard L Parnes
- Division of Cancer Prevention, National Cancer Institutes, National Institutes of Health, Bethesda, MD
| | - Peter L Choyke
- Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Baris Turkbey
- Molecular Imaging Program, 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 A Pinto
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
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13
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O'Connor LP, Lebastchi AH, Horuz R, Rastinehad AR, Siddiqui MM, Grummet J, Kastner C, Ahmed HU, Pinto PA, Turkbey B. Role of multiparametric prostate MRI in the management of prostate cancer. World J Urol 2020; 39:651-659. [PMID: 32583039 DOI: 10.1007/s00345-020-03310-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 06/11/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Prostate cancer has traditionally been diagnosed by an elevation in PSA or abnormal exam leading to a systematic transrectal ultrasound (TRUS)-guided biopsy. This diagnostic pathway underdiagnoses clinically significant disease while over diagnosing clinically insignificant disease. In this review, we aim to provide an overview of the recent literature regarding the role of multiparametric MRI (mpMRI) in the management of prostate cancer. MATERIALS AND METHODS A thorough literature review was performed using PubMed to identify articles discussing use of mpMRI of the prostate in management of prostate cancer. CONCLUSION The incorporation of mpMRI of the prostate addresses the shortcomings of the prostate biopsy while providing several other advantages. mpMRI allows some men to avoid an immediate biopsy and permits visualization of areas likely to harbor clinically significant cancer prior to biopsy to facilitate use of MR-targeted prostate biopsies. This allows for reduction in diagnosis of clinically insignificant disease as well as improved detection and better characterization of higher risk cancers, as well as the improved selection of patients for active surveillance. In addition, mpMRI can be used for selection and monitoring of patients for active surveillance and treatment planning during surgery and focal therapy.
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Affiliation(s)
- Luke P O'Connor
- Urologic Oncology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Amir H Lebastchi
- Urologic Oncology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Rahim Horuz
- Department of Urology, Istanbul Medipol University, Istanbul, Turkey
| | | | - M Minhaj Siddiqui
- Division of Urology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jeremy Grummet
- Department of Surgery, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Christof Kastner
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Hashim U Ahmed
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Peter A Pinto
- Urologic Oncology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Baris Turkbey
- Molecular Imaging Program, National Cancer Institute, NIH, 10 Center Drive Room B3B85, Bethesda, MD, USA. .,, 10 Center Drive Room B3B85, Bethesda, MD, 20814, USA.
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14
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Correas JM, Halpern EJ, Barr RG, Ghai S, Walz J, Bodard S, Dariane C, de la Rosette J. Advanced ultrasound in the diagnosis of prostate cancer. World J Urol 2020; 39:661-676. [PMID: 32306060 DOI: 10.1007/s00345-020-03193-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 03/30/2020] [Indexed: 12/17/2022] Open
Abstract
The diagnosis of prostate cancer (PCa) can be challenging due to the limited performance of current diagnostic tests, including PSA, digital rectal examination and transrectal conventional US. Multiparametric MRI has improved PCa diagnosis and is recommended prior to biopsy; however, mp-MRI does miss a substantial number of PCa. Advanced US modalities include transrectal prostate elastography and contrast-enhanced US, as well as improved B-mode, micro-US and micro-Doppler techniques. These techniques can be combined to define a novel US approach, multiparametric US (mp-US). Mp-US improves PCa diagnosis but is not sufficiently accurate to obviate the utility of mp-MRI. Mp-US using advanced techniques and mp-MRI provide complementary information which will become even more important in the era of focal therapy, where precise identification of PCa location is needed.
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Affiliation(s)
- Jean-Michel Correas
- Department of Adult Radiology, Paris University and Necker University Hospital, 149 rue de Sèvres, 75015, Paris Cedex 15, France.
| | - Ethan J Halpern
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Richard G Barr
- Department of Radiology, Northeastern Ohio Medical University, Rootstown, OH, USA
| | - Sangeet Ghai
- Department of Medical Imaging, Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada
| | - Jochen Walz
- Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France
| | - Sylvain Bodard
- Department of Adult Radiology, Paris University and Necker University Hospital, 149 rue de Sèvres, 75015, Paris Cedex 15, France
| | - Charles Dariane
- Department of Urology, Paris University and European Hospital Georges Pompidou, Paris, France
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15
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Essid MA, Chakroun M, Nouhaud FX, Lair M, Gobet F, Pfister C. Evolution of prostate cancer diagnosis: retrospective analysis of magnetic resonance imaging/ultrasound fusion guided biopsies protocol in routine practice and patients management. Transl Androl Urol 2020; 9:629-636. [PMID: 32420169 PMCID: PMC7215024 DOI: 10.21037/tau.2020.02.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Magnetic resonance imaging (MRI) is today strongly recommended in prostate cancer (PCa) diagnosis. Therefore, MRI/ultrasound (MRI/US) fusion-guided biopsy is becoming the new standard patients management. Methods We report our experience during the last 4 years using this technique, with a protocol of 6 random cores (instead of the most used 12 cores protocol) associated to the target cores (2 to 3 per lesion). Our study involved 236 patients including real life routine practice: biopsy naïve patients (n=107), patients with previous negative standard prostate biopsies (n=67) and patients in PCa active surveillance (n=62). Finally, 76 patients have a robotic radical prostatectomy. Results Mean age of the population was 66 years. Median PSA was 8.5 ng/mL. Overall and significant cancer detection were respectively 66.6% and 38.5%, with a large difference considering biopsy history: 63.5% in biopsy naïve patient, 53.7% in patient with previous negative biopsies and 82.3% in patients under active surveillance. Targeted biopsies missed 28 cancers among 8 were significant and standard biopsies missed 33 cancers among 14 were significant. Moreover, concordance between biopsy samples and radical prostatectomy specimens was evaluated at 80%. Conclusions Comparing to literature data, similar results were observed in our retrospective study, even with reduced random cores, suggesting a real change in patients management in particular in active surveillance group with a reclassification rate of 56.4% using the Epstein criteria.
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Affiliation(s)
| | | | | | - Michael Lair
- Department of Radiology, Rouen University Hospital, Rouen, France
| | - Françoise Gobet
- Department of Pathology, Rouen University Hospital, Rouen, France
| | - Christian Pfister
- Department of Urology, Rouen University Hospital, Rouen, France.,Clinical Investigation Center, Inserm 6204, Onco-Urology, Rouen, France
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Confirmatory multiparametric magnetic resonance imaging at recruitment confers prolonged stay in active surveillance and decreases the rate of upgrading at follow-up. Prostate Cancer Prostatic Dis 2020; 23:94-101. [PMID: 31249386 DOI: 10.1038/s41391-019-0160-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/06/2019] [Accepted: 05/12/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND To understand the value of multiparametric magnetic resonance imaging (mpMRI) and targeted biopsies at recruitment on active surveillance (AS) outcomes. MATERIALS AND METHODS This retrospective single-center study enrolled two cohorts of 206 and 310 patients in AS. The latter group was submitted to mpMRI and targeted biopsies at recruitment. Kaplan-meier curves quantified progression-free survival (PFS) and Bioptic-PFS (B-PFS: no upgrading or >3 positive cores) in the two cohorts. Cox-regression analyses tested independent predictors of PFS and B-PFS. In patients submitted to radical prostatectomy (RP) after AS, significant cancer (csPCa) was defined as: GS ≥ 4 + 3 and/or pT ≥ 3a and/or pN+ . Logistic-regression analyses predicted csPCa at RP. RESULTS AND LIMITATIONS Median time follow-up and median time of persistence in AS were 46 (24-70) and 36 (23-58) months, respectively. Patients submitted to mpMRI at AS begin, showed greater PFS at 1- (98% vs. 91%), 3- (80% vs. 57%), and 5-years (70% vs. 35%) follow-up, respectively (all p < 0.01). At Cox-regression analysis only confirmatory mpMRI± targeted biopsy (HR: 0.3; 95% CI 0.2-0.5; p < 0.01) at AS begin was an independent predictor of PFS. Globally, 50 (16%) vs. 128 (62%) and 26 (8.5%) vs. 64 (31%) [all p < 0.01] men in the two groups experienced any-cause and bioptic AS discontinuation, respectively. Patients submitted to confirmatory mpMRI experienced greater 1-(98% vs. 93%), 3-(90% vs. 75%), and 5-years (83% vs. 56%) B-PFS, respectively (all p < 0.01). At Cox-regression analysis, mpMRI±-targeted biopsy at AS begin was associated with B-PFS (HR: 0.3; 95% CI 0.2-0.6; p < 0.01). No differences were recorded in csPCa rates between the two groups (22% vs. 28%; p = 0.47). Limitations of the study are the single-center retrospective nature and the absence of long-term follow-up. CONCLUSIONS Confirmatory mpMRI±-targeted biopsies are associated with higher PFS and B-PFS during AS. However, a non-negligible percentage of patients experience csPCa after switching to active treatment.
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Jayadevan R, Felker ER, Kwan L, Barsa DE, Zhang H, Sisk AE, Delfin M, Marks LS. Magnetic Resonance Imaging-Guided Confirmatory Biopsy for Initiating Active Surveillance of Prostate Cancer. JAMA Netw Open 2019; 2:e1911019. [PMID: 31509206 PMCID: PMC6739900 DOI: 10.1001/jamanetworkopen.2019.11019] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
IMPORTANCE Transrectal, ultrasonography-guided prostate biopsy often fails to disclose the severity of underlying pathologic findings for prostate cancer. Magnetic resonance imaging (MRI)-guided biopsy may improve the characterization of prostate pathologic results, but few studies have examined its use for the decision to enter active surveillance. OBJECTIVE To evaluate whether confirmatory biopsy findings by MRI guidance are associated with the risk of pathologic disease upgrading among patients with prostate cancer during active surveillance. DESIGN, SETTINGS, AND PARTICIPANTS This retrospective cohort study used prospectively obtained registry data from 332 men with prostate cancer of Gleason grade group (GG) 2 or lower who were referred for active surveillance at a large academic medical center from January 1, 2009, through December 31, 2017. EXPOSURES All confirmatory and follow-up biopsies were performed using MRI guidance with an MRI-ultrasonography fusion device. Patients underwent repeated MRI-guided biopsies every 12 to 24 months. At follow-up sessions, in addition to obtaining systematic samples, lesions seen on MRI were targeted and foci of low-grade prostate cancer were obtained again using tracking technology. Active surveillance was terminated with detection of at least GG3 disease or receipt of treatment. MAIN OUTCOMES AND MEASURES The primary outcome was upgrading to at least GG3 disease during active surveillance. Secondary outcomes were the associations of MRI lesion grade, prostate-specific antigen (PSA) level, PSA density, and biopsy method (targeted, systematic, or tracked) with the primary outcome. RESULTS Of 332 patients (mean [SD] age, 62.8 [7.6] years), 39 (11.7%) upgraded to at least GG3 disease during follow-up. The incidence of upgrading was 7.9% (9 of 114) when the confirmatory biopsy finding was normal, 11.4% (20 of 175) when the finding showed GG1 disease, and 23.3% (10 of 43) when the finding was GG2 disease (P = .03). Men with GG2 disease were almost 8 times more likely to upgrade during surveillance compared with those with normal findings but only among those with low PSA density (hazard ratio [HR], 7.82; 95% CI, 2.29-26.68). A PSA density of at least 0.15 ng/mL/mL was associated with increased risk of upgrading among patients with normal findings (HR, 7.21; 95% CI, 1.98-26.24) or GG1 disease (HR, 2.86; 95% CI, 1.16 to 7.03) on confirmatory biopsy. A total of 46% of pathologic disease upgrades would have been missed if only the targeted biopsy was performed and 65% of disease upgrades were detected only with tracked biopsy. CONCLUSIONS AND RELEVANCE The findings suggest that confirmatory biopsy with MRI guidance is significantly associated with future disease upgrading of prostate cancer, especially when combined with PSA density, and should be considered as an appropriate entry point for active surveillance. Systematic and targeted biopsies were additive in detection of clinically significant cancers. Repeated biopsy at sites at which findings were previously abnormal (tracking biopsy) facilitated detection of cancers not suitable for continued active surveillance.
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Affiliation(s)
- Rajiv Jayadevan
- Department of Urology, David Geffen School of Medicine at University of California, Los Angeles
| | - Ely R. Felker
- Department of Radiology, David Geffen School of Medicine at University of California, Los Angeles
| | - Lorna Kwan
- Department of Urology, David Geffen School of Medicine at University of California, Los Angeles
| | - Danielle E. Barsa
- Department of Urology, David Geffen School of Medicine at University of California, Los Angeles
| | - Haoyue Zhang
- Department of Urology, David Geffen School of Medicine at University of California, Los Angeles
| | - Anthony E. Sisk
- Department of Pathology, David Geffen School of Medicine at University of California, Los Angeles
| | - Merdie Delfin
- Department of Urology, David Geffen School of Medicine at University of California, Los Angeles
| | - Leonard S. Marks
- Department of Urology, David Geffen School of Medicine at University of California, Los Angeles
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Tan GH, Finelli A, Ahmad A, Wettstein MS, Chandrasekar T, Zlotta AR, Fleshner NE, Hamilton RJ, Kulkarni GS, Ajib K, Nason G, Perlis N. A novel predictor of clinical progression in patients on active surveillance for prostate cancer. Can Urol Assoc J 2019; 13:250-255. [PMID: 31496491 DOI: 10.5489/cuaj.6122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Active surveillance (AS) is standard of care in low-risk prostate cancer (PCa). This study describes a novel total cancer location (TCLo) density metric and aims to determine its performance in predicting clinical progression (CP) and grade progression (GP). METHODS This was a retrospective study of patients on AS after confirmatory biopsy (CBx). We excluded patients with Gleason ≥7 at CBx and <2 years followup. TCLo was the number of locations with positive cores at diagnosis (DBx) and CBx. TCLo density was TCLo/prostate volume (PV). CP was progression to any active treatment while GP occurred if Gleason ≥7 was identified on repeat biopsy or surgical pathology. Independent predictors of time to CP or GP were estimated with Cox regression. Kaplan-Meier analysis compared progression-free survival (PFS) curves between TCLo density groups. Test characteristics of TCLo density were explored with receiver operating characteristic (ROC) curves. RESULTS We included 181 patients who had CBx from 2012-2015 and met inclusion criteria. The mean age of patients was 62.58 years (standard deviation [SD] 7.13) and median followup was 60.9 months (interquartile range [IQR] 23.4). A high TCLo density score (>0.05) was independently associated with time to CP (hazard ratio [HR] 4.70; 95% confidence interval [CI] 2.62-8.42; p<0.001) and GP (HR 3.85; 95% CI 1.91-7.73; p<0.001). ROC curves showed TCLo density has greater area under the curve than number of positive cores at CBx in predicting progression. CONCLUSIONS TCLo density is able to stratify patients on AS for risk of CP and GP. With further validation, it could be added to the decision-making algorithm in AS for low-risk localized PCa.
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Affiliation(s)
- Guan Hee Tan
- Division of Urology, Princess Margaret Cancer Center and Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Antonio Finelli
- Division of Urology, Princess Margaret Cancer Center and Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Ardalan Ahmad
- Division of Urology, Princess Margaret Cancer Center and Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Marian S Wettstein
- Division of Urology, Princess Margaret Cancer Center and Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Thenappan Chandrasekar
- Department of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Alexandre R Zlotta
- Division of Urology, Princess Margaret Cancer Center and Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Neil E Fleshner
- Division of Urology, Princess Margaret Cancer Center and Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Robert J Hamilton
- Division of Urology, Princess Margaret Cancer Center and Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Girish S Kulkarni
- Division of Urology, Princess Margaret Cancer Center and Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Khaled Ajib
- Division of Urology, Princess Margaret Cancer Center and Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Gregory Nason
- Division of Urology, Princess Margaret Cancer Center and Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Nathan Perlis
- Division of Urology, Princess Margaret Cancer Center and Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Division of Urology, University of Toronto, Toronto, ON, Canada
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Gnanapragasam VJ, Barrett T, Thankapannair V, Thurtle D, Rubio-Briones J, Domínguez-Escrig J, Bratt O, Statin P, Muir K, Lophatananon A. Using prognosis to guide inclusion criteria, define standardised endpoints and stratify follow-up in active surveillance for prostate cancer. BJU Int 2019; 124:758-767. [PMID: 31063245 DOI: 10.1111/bju.14800] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To test whether using disease prognosis can inform a rational approach to active surveillance (AS) for early prostate cancer. PATIENTS AND METHODS We previously developed the Cambridge Prognostics Groups (CPG) classification, a five-tiered model that uses prostate-specific antigen (PSA), Grade Group and Stage to predict cancer survival outcomes. We applied the CPG model to a UK and a Swedish prostate cancer cohort to test differences in prostate cancer mortality (PCM) in men managed conservatively or by upfront treatment in CPG2 and 3 (which subdivides the intermediate-risk classification) vs CPG1 (low-risk). We then applied the CPG model to a contemporary UK AS cohort, which was optimally characterised at baseline for disease burden, to identify predictors of true prognostic progression. Results were re-tested in an external AS cohort from Spain. RESULTS In a UK cohort (n = 3659) the 10-year PCM was 2.3% in CPG1, 1.5%/3.5% in treated/untreated CPG2, and 1.9%/8.6% in treated/untreated CPG3. In the Swedish cohort (n = 27 942) the10-year PCM was 1.0% in CPG1, 2.2%/2.7% in treated/untreated CPG2, and 6.1%/12.5% in treated/untreated CPG3. We then tested using progression to CPG3 as a hard endpoint in a modern AS cohort (n = 133). During follow-up (median 3.5 years) only 6% (eight of 133) progressed to CPG3. Predictors of progression were a PSA density ≥0.15 ng/mL/mL and CPG2 at diagnosis. Progression occurred in 1%, 8% and 21% of men with neither factor, only one, or both, respectively. In an independent Spanish AS cohort (n = 143) the corresponding rates were 3%, 10% and 14%, respectively. CONCLUSION Using disease prognosis allows a rational approach to inclusion criteria, discontinuation triggers and risk-stratified management in AS.
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Affiliation(s)
- Vincent J Gnanapragasam
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK.,Department of Urology, Cambridge University Hospitals NHS Trust, Cambridge, UK.,Cambridge Urology Translational Research and Clinical Trials Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Tristan Barrett
- Department of Radiology, University of Cambridge, Cambridge, UK
| | | | - David Thurtle
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK
| | | | | | - Ola Bratt
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Par Statin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Kenneth Muir
- Department of Public Health and Epidemiology, University of Manchester, Manchester, UK
| | - Artitaya Lophatananon
- Department of Public Health and Epidemiology, University of Manchester, Manchester, UK
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20
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Cost-effectiveness Analysis of Active Surveillance Strategies for Men with Low-risk Prostate Cancer. Eur Urol 2019; 75:910-917. [DOI: 10.1016/j.eururo.2018.10.055] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/26/2018] [Indexed: 01/06/2023]
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Abstract
Prostate cancer remains among the most commonly diagnosed malignancies worldwide in men. In patients with low-risk prostate cancer, the risk of metastasis and mortality is very low; therefore, a tumor surveillance strategy can be used. In patients undergoing active surveillance, curative active therapy is postponed without compromising opportunities for cure until there is evidence of progression or the patient desires active therapy. The aim of active surveillance in prostate cancer patients is to minimize treatment-related toxicity without impairing patient survival. To maintain patients under active surveillance, the following criteria should be met: prostate-specific antigen (PSA) ≤10 ng/ml, Gleason score ≤6, cT1 or cT2a, ≤2 biopsy cores with <50% cancer involvement of every positive core. Follow-up in active surveillance patients is based on repeat biopsy, serial PSA measurements, and digital rectal examination.
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Affiliation(s)
- E Erne
- Klinik für Urologie, Eberhard Karls Universität Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - S Kaufmann
- Radiologische Klinik, Diagnostische und Interventionelle Radiologie, Eberhard Karls Universität Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - K Nikolaou
- Radiologische Klinik, Diagnostische und Interventionelle Radiologie, Eberhard Karls Universität Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - A Stenzl
- Klinik für Urologie, Eberhard Karls Universität Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - J Bedke
- Klinik für Urologie, Eberhard Karls Universität Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland.
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Standardized Magnetic Resonance Imaging Reporting Using the Prostate Cancer Radiological Estimation of Change in Sequential Evaluation Criteria and Magnetic Resonance Imaging/Transrectal Ultrasound Fusion with Transperineal Saturation Biopsy to Select Men on Active Surveillance. Eur Urol Focus 2019; 7:102-110. [PMID: 30878348 DOI: 10.1016/j.euf.2019.03.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/04/2019] [Accepted: 03/01/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Contemporary selection criteria for men with prostate cancer (PC) suitable for active surveillance (AS) are unsatisfactory, leading to high disqualification rates based on tumor misclassification. Conventional biopsy protocols are based on standard 12-core transrectal ultrasound (TRUS) biopsy. OBJECTIVE To assess the value of magnetic resonance imaging (MRI)/TRUS fusion biopsy over 4-yr follow-up in men on AS for low-risk PC. DESIGN, SETTING, AND PARTICIPANTS Between 2010 and 2018, a total of 273 men were included. Of them, 157 men with initial 12-core TRUS biopsy and 116 with initial MRI/TRUS fusion biopsy were followed by systematic and targeted transperineal MRI/TRUS fusion biopsies based on Prostate Cancer Research International Active Surveillance criteria. MRI from follow-up MRI/TRUS fusion biopsy was assessed using the Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) scoring system. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS AS-disqualification rates for patients on AS initially diagnosed by either 12-core TRUS biopsy or by MRI/TRUS fusion biopsy were compared using Kaplan-Meier estimates, log-rank tests, and regression analyses. We also analyzed the influence of negative primary MRI and PRECISE scoring to predict AS disqualification using Kaplan-Meier estimates, log-rank tests, and receiver operating characteristic (ROC) curve analysis. RESULTS AND LIMITATIONS Of men diagnosed by 12-core TRUS biopsy, 59% were disqualified from AS based on the results of subsequent MRI/TRUS fusion biopsy. In the initial MRI fusion biopsy cohort, upgrading occurred significantly less frequently (19%, p<0.001). ROC curve analyses demonstrated good discrimination for the PRECISE score with an area under the curve of 0.83. No men with a PRECISE score of 1 or 2 (demonstrating absence or downgrading of lesions in follow-up MRI) were disqualified from AS. In our cohort, a negative baseline MRI scan was not a predictor of nondisqualification from AS. Limitations include transperineal approach and extended systematic biopsies used with MRI/TRUS fusion biopsy, which may not be representative of other centers. CONCLUSIONS MRI/TRUS fusion biopsies allow a reliable risk classification for patients who are candidates for AS. The application of the PRECISE scoring system demonstrated good discrimination. PATIENT SUMMARY In this study, we investigated the value of multiparametric magnetic resonance imaging (MRI) and MRI/transrectal ultrasound (TRUS) fusion biopsies for the assessment of active surveillance (AS) reliability using the Prostate Cancer Radiological Estimation of Change in Sequential Evaluation criteria. Standard TRUS biopsies lead to significant underestimation of prostate cancer. In contrast, MRI/TRUS fusion biopsies allowed for a more reliable risk classification. For appropriate inclusion into AS, men should receive either an initial or a confirmatory MRI/TRUS fusion biopsy.
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