Evaluation of the changing landscape of prostate cancer diagnosis and management from 2005 to 2016

Germline DNA-Repair Genes and HOXB13 Mutations in Korean Men with Metastatic Prostate Cancer: Data from a Large Korean Cohort

PURPOSE

Germline mutations in DNA damage repair (DDR) genes such as BRCA2 have been associated with prostate cancer (PC) risk but has not been thoroughly evaluated for metastatic prostate cancer (mPC) in Asian men. This study attempts to evaluate frequency of DDR mutations in the largest cohort of Koreans.

MATERIALS AND METHODS

We recruited 340 patients with mPC unselected for family history of cancer and compared to 495 controls. Whole genome sequencing was applied to assess germline pathogenic/likely pathogenic variants (PV/LPVs) in 26 DDR genes and HOXB13, including 7 genes (ATM, BRCA1/2, CHEK2, BRIP1, PALB2, and NBN) associated with hereditary PC. Comparisons to published Caucasian and Japanese cohorts were performed.

RESULTS

Total of 28 PV/LPVs were identified in 30 (8.8%) patients; mutations were found in 13 genes, including BRCA2 (15 men [4.41%]), ATM (2 men [0.59%]), NBN (2 men [0.59%], and BRIP1 (2 men [0.59%]). Only one patient had HOXB13 mutation (0.29%). A lower rate of overall germline variant frequency was observed in Korean mPC compared to Caucasians (8.8% vs. 11.8%), but individual variants notably differed from Caucasian and geographically similar Japanese cohorts. PV/LPVs in DDR genes tended to increase gradually with higher Gleason scores (GS 7, 7.1%; GS 8, 7.5%; GS 9-10, 9.9%).

CONCLUSIONS

BRCA2 was the most frequently mutated gene common to different cohorts supporting its importance, but differences in variant distribution in Korean mPC underscore the need for ethnic-specific genetic models. Future ethnic-specific analyses are warranted to verify our findings.

Temporal changes of PIRADS scoring by radiologists and correlation to radical prostatectomy pathological outcomes

Purpose

To assess temporal improvement of prostate image reporting and data system (PIRADS) 3-5 lesion correlation to histopathologic findings from radical prostatectomy (RP) in prostate cancer (PCa).

Materials and methods

A total of 1481 patients who underwent RP for biopsy-proven PCa between 2015 and 2019 were divided into 14 groups of 100 sequential readings for the evaluation of histopathological correlation with PIRADS readings. Temporal trends of PIRADS distribution and predictive performance for RP pathology were evaluated to assess underlying changes in prostate magnetic resonance imaging (MRI) interpretation by radiologists.

Results

PIRADS 4-5 lesions were significantly correlated with the increasing rates of Gleason Group (GG) upgrade (p = 0.044) and decreasing rate of GG downgrade (p = 0.016) over time. PIRADS ≥3 lesions read after median 2 years of experience were shown to independently predict intermediate-high-risk (GG ≥ 3) PCa (odds ratio 2.93, 95% confidence interval 1.00-8.54; P= 0.049) in RP pathology. Preoperative GG ≥ 3 biopsy lesions with PIRADS 4-5 lesions were significantly more susceptible to GG upgrade (P= 0.035) and GG ≥ 4 RP pathology (p = 0.003) in experienced reads, in contrast to insignificant findings in early readings (p = 0.588 and 0.248, respectively).

Conclusion

Preoperative MRI reports matched with RP pathology suggest an improved prediction of adverse pathology in PIRADS 3-5 lesions over time, suggesting a temporal change in PIRADS interpretation and predictive accuracy. Institutions with low volume experience should use caution in solely relying on MRI for predicting tumor characteristics. Future prospective trials and larger scale assessments are required to further validate our results.

State of the art of radiomic analysis in the clinical management of prostate cancer: A systematic review

We present the current clinical applications of radiomics in the context of prostate cancer (PCa) management. Several online databases for original articles using a combination of the following keywords: "(radiomic or radiomics) AND (prostate cancer or prostate tumour or prostate tumor or prostate neoplasia)" have been searched. The selected papers have been pooled as focus on (i) PCa detection, (ii) assessing the clinical significance of PCa, (iii) biochemical recurrence prediction, (iv) radiation-therapy outcome prediction and treatment efficacy monitoring, (v) metastases detection, (vi) metastases prediction, (vii) prediction of extra-prostatic extension. Seventy-six studies were included for qualitative analyses. Classifiers powered with radiomic features were able to discriminate between healthy tissue and PCa and between low- and high-risk PCa. However, before radiomics can be proposed for clinical use its methods have to be standardized, and these first encouraging results need to be robustly replicated in large and independent cohorts.

Innovative standardized reporting template for prostate mpMRI improves clarity and confidence in the report

PURPOSE

The goal of the current study was to evaluate the effect of a standardized prostate mpMRI reporting template on urologists' understanding and confidence in counselling a patient on the results of the MRI. To do this we performed a survey study to assess the understanding and confidence of urologists reviewing reports prior to (pre) and after (post) adoption of a standardized mpMRI template.

METHODS

Six urologists reviewed ten pre- and post- mpMRI templated reports and completed a survey to assess the clarity of key elements and the confidence in counseling the patient. The urologists were blinded to the study objective. Nonparametric constrained permutation test for significance was performed to compare the results prior to and after implementation of the template.

RESULTS

29 pre- and 30 post-template mpMRI reports were reviewed. The average score for the post-template reports was significantly higher (10.7 ± 0.6 vs 7.5 ± 2.7 [ p< 0.001]) regardless of the reviewer. Urologists were also overall more confident in counselling patients when the standardized mpMRI reporting template had been used.

CONCLUSION

Implementation of a standardized template for reporting of prostate mpMRI findings resulted in improved clarity and confidence in counselling patients. Radiologists should consider implementing a standardized reporting template to improve clinicians' understanding and confidence of the report.

Adoption of immunotherapy in the community for patients diagnosed with metastatic melanoma

BACKGROUND

The introduction of immune checkpoint inhibitors has led to a survival benefit in patients with advanced melanoma; however data on the adoption of immunotherapy in the community are scarce.

METHODS

Using the National Cancer Database, we identified 4725 patients aged ≥20 diagnosed with metastatic melanoma in the United States between 2011 and 2015. Multinomial regression was used to identify factors associated with the receipt of treatment at a low vs. high immunotherapy prescribing hospital, defined as the bottom and top quintile of hospitals according to their proportion of treating metastatic melanoma patients with immunotherapy.

RESULTS

We identified 246 unique hospitals treating patients with metastatic melanoma. Between 2011 and 2015, the proportion of hospitals treating at least 20% of melanoma patients with immunotherapy within 90 days of diagnosis increased from 14.5 to 37.7%. The mean proportion of patients receiving immunotherapy was 7.8% (95% Confidence Interval [CI] 7.47-8.08) and 50.9% (95%-CI 47.6-54.3) in low and high prescribing hospitals, respectively. Predictors of receiving care in a low prescribing hospital included underinsurance (no insurance: relative risk ratio [RRR] 2.44, 95%-CI 1.28-4.67, p = 0.007; Medicaid: RRR 2.10, 95%-CI 1.12-3.92, p = 0.020), care in urban areas (RRR 2.58, 95%-CI 1.34-4.96, p = 0.005) and care at non-academic facilities (RRR 5.18, 95%CI 1.69-15.88, p = 0.004).

CONCLUSION

While the use of immunotherapy for metastatic melanoma has increased over time, adoption varies widely across hospitals. Underinsured patients were more likely to receive treatment at low immunotherapy prescribing hospitals. The variation suggests inequity in access to these potentially life-saving drugs.

Is There an Optimal Curative Option in HIV-Positive Men with Localized Prostate Cancer? A Systematic Review

Aims

We aimed to compare the outcome of curative treatment options in localised Prostate Cancer (PCa) amongst HIV positive (HIV+) men.

Methods

A systematic search of the Cochrane Library of Systematic Reviews, the Scopus and PubMed databases was performed (January 1995 to November 2015) using pre-determined search terms. Outcome measures for comparison included the rate of biochemical failure (BCF), survival benefit and complications.

Results

A total of 14 eligible articles were identified for inclusion, representing a total of 202 HIV+ men with PCa. Radical Prostatectomy was performed in 40/153 compared to 109/153 patients undergoing alternative (non-surgical) treatments options. Only 3 studies compared outcomes within their respective study cohort. One study (n = 10) reported BCF results with 1/2 BCF patient in the surgical arm vs. 1/8 BCF positive patients in the non-surgical arm (mean 46 months follow-up), while two other studies reported no occurrences of BCF within both arms of their studies.

Conclusion

Due to paucity in the literature, there is insufficient evidence to support a certain treatment modality arm specifically for HIV+ men with localized PCa. An individualized management algorithm seems feasible within this cohort, until more definitive studies are performed.

Quantitative characterisation of clinically significant intra-prostatic cancer by prostate-specific membrane antigen (PSMA) expression and cell density on PSMA-11

OBJECTIVES

To quantitatively characterize clinically significant intra-prostatic cancer (IPC) by prostate-specific membrane antigen (PSMA) expression and cell density on PSMA-11 positron emission tomography/magnetic resonance (PET/MR).

METHODS

Retrospective study approved by the institutional review board with informed written consent obtained. Patients with a solitary, biopsy-proven prostate cancer, Gleason score (GS) ≥7, presenting for initial evaluation by PET/computerised tomography (PET/CT), underwent early prostate PET/MR immediately after PSMA-11 tracer injection. PET/MR [MRI-based attenuation correction (MRAC)] and PET/CT [CT-based AC (CTAC)] maximal standardised uptake value (SUVmax) and minimal and mean apparent diffusion coefficient (ADCmin, ADCmean; respectively) in normal prostatic tissue (NPT) were compared to IPC area. The relationship between SUVmax, ADCmin and ADCmean measurements was obtained.

RESULTS

Twenty-two patients (mean age 69.5±5.0 years) were included in the analysis. Forty-four prostate areas were evaluated (22 IPC and 22 NPT). Median MRAC SUVmax of NPT was significantly lower than median MRAC SUVmax of IPC (p < 0.0001). Median ADCmin and ADCmean of NPT was significantly higher than median ADCmin and ADCmean of IPC (p < 0.0001). A very good correlation was found between MRAC SUVmax with CTAC SUVmax (rho = -0.843, p < 0.0001). A good inverse relationship was found between MRAC SUVmax and CTAC SUVmax with ADCmin (rho = -0.717, p < 0.0001 and -0.740, p < 0.0001; respectively; Z = 0.22, p = 0.82, NS) and with MRAC SUVmax and ADCmean (rho = -0.737, p < 0.0001).

CONCLUSIONS

PET/MR SUVmax, ADCmin and ADCmean are distinct biomarkers able to differentiate between IPC and NPT in naïve prostate cancer patients with GS ≥ 7.

KEY POINTS

• PSMA PET/MR metrics differentiate between normal and tumoural prostatic tissue. • A multi-parametric approach combining molecular and anatomical information might direct prostate biopsy. • PSMA PET/MR metrics are warranted for radiomics analysis.

An unusual localization of seven months delayed pelvic lymphocele following radical retropubic prostatectomy: Case report and literature review

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Lymphocele after radical prostatectomy leading major complications is rare.

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Lymphocele is the most common cause of hospital readmission after radical prostatectomy.

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Lymphocele can be seen in atypical regions after radical prostatectomy.

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Percutaneous interventions can be used for pelvic lymphocele treatment.

Introduction

A pelvic lymphocele is a collection of lymphatic fluid that develops after extensive lymphadenectomies in surgeries such as urological malignancies or renal transplantation. Pelvic lymphoceles may cause complications such as fever, abdominal pain, leg swelling, genital swelling and flank pain. This report summarizes the management of a pelvic lymphocele after open radical retropubic prostatectomy with bilateral lymphadenectomy.

Presentation of case

Herein, we present a case in which a pelvic lymphocele developed seven months post-radical open retropubic prostatectomy and through this patient we discussed the lymphocele following radical prostatectomy. The pelvic lymphocele occurred along the sciatic nerve from the sciatica foramen to the intergluteal muscles. The patient was treated with three drainage catheters. This localization is an atypical and unusual for lymphocele after radical retropubic prostatectomy.

Discussion

Lymphocele formation that leads to major complications after radical prostatectomy is rare. Lymphocele formation is most commonly seen in the early postoperative period, but it should be considered in patients with fever, abdominal pain or leg swelling during the late postoperative period. Lymphocele formation was the most common cause of hospital readmission after radical prostatectomy.

Conclusion

Lymphocele formation can be seen in atypical regions and can lead to unexpected complications after radical prostatectomy. Therefore, it should be brought to mind when complaints such as fever and lower extremity swelling occurred in patients underwent extensive lymph node dissection. Surgical treatment options are available, but percutaneous interventions can also be used.

Review of Gallium-68 PSMA PET/CT Imaging in the Management of Prostate Cancer

Over 90% of prostate cancers over-express prostate specific membrane antigen (PSMA) and these tumor cells may be accurately targeted for diagnosis by 68Ga-PSMA-positron emission tomography/computed tomography (68Ga-PSMA-PET/CT) imaging. This novel molecular imaging modality appears clinically to have superseded CT, and appears superior to MR imaging, for the detection of metastatic disease. 68Ga-PSMA PET/CT has the ability to reliably stage prostate cancer at presentation and can help inform an optimal treatment approach. Novel diagnostic applications of 68Ga-PSMA PET/CT include guiding biopsy to improve sampling accuracy, and guiding surgery and radiotherapy. In addition to facilitating the management of metastatic castrate resistant prostate cancer (mCRPC), 68Ga-PSMA can select patients who may benefit from targeted systemic radionuclide therapy. 68Ga-PSMA is the diagnostic positron-emitting theranostic pair with the beta emitter Lutetium-177 PSMA (177Lu-PSMA) and alpha-emitter Actinium-225 PSMA (225Ac-PSMA) which can both be used to treat PSMA-avid metastases of prostate cancer in the molecular tumor-targeted approach of theranostic nuclear oncology.