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Kawase M, Ebara S, Tatenuma T, Sasaki T, Ikehata Y, Nakayama A, Toide M, Yoneda T, Sakaguchi K, Teishima J, Makiyama K, Inoue T, Kitamura H, Saito K, Koga F, Urakami S, Koie T. The Impact of Gleason Grade 3 as a Predictive Factor for Biochemical Recurrence after Robot-Assisted Radical Prostatectomy: A Retrospective Multicenter Cohort Study in Japan (The MSUG94 Group). MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58080990. [PMID: 35893105 PMCID: PMC9331947 DOI: 10.3390/medicina58080990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/14/2022] [Accepted: 07/21/2022] [Indexed: 11/18/2022]
Abstract
Background and Objectives: This study’s objective was to examine patients treated with robot-assisted radical prostatectomy (RARP) for intermediate-risk prostate cancer (IR-PCa), and to identify preoperative risk factors for biochemical recurrence (BCR) in these patients in Japan. Materials and Methods: We conducted a retrospective multicenter cohort study of patients with PCa who underwent RARP at 10 institutions in Japan. A total of 3195 patients were enrolled in this study. We focused on patients with IR-PCa who underwent RARP. We obtained data on pre- and postoperative covariates from the enrolled patients. Biochemical recurrence-free survival was the primary endpoint of this study. We also identified useful preoperative predictive factors for BCR in patients with IR-PCa after RARP. Results: A total of 1144 patients with IR-PCa were enrolled in this study. The median follow-up period was 23.7 months. At the end of the follow-up period, 94 (8.2%) patients developed BCR. The 2 and 3 year biochemical recurrence-free survival (BRFS) rates were 92.2% and 90.2%, respectively. Using the Kaplan–Meier method, Gleason grade (GG) 3 was significantly associated with poor BRFS compared with ≤GG 2. In multivariate analysis, GG 3 was a significant predictive factor for BCR in patients with IR-PCa. Conclusions: The results of the study indicated a significant relationship between GG 3 and post-RARP BCR in patients with IR-PCa.
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Affiliation(s)
- Makoto Kawase
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan;
| | - Shin Ebara
- Department of Urology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima 7308518, Japan;
| | - Tomoyuki Tatenuma
- Department of Urology, Yokohama City University, Yokohama 2360004, Japan; (T.T.); (K.M.)
| | - Takeshi Sasaki
- Department of Nephro-Urologic Surgery and Andrology, Mie University Graduate School of Medicine, Tsu 5148507, Japan; (T.S.); (T.I.)
| | - Yoshinori Ikehata
- Department of Urology, University of Toyama, Toyama 9300194, Japan; (Y.I.); (H.K.)
| | - Akinori Nakayama
- Department of Urology, Dokkyo Medical University Saitama Medical Center, Koshigaya 3438555, Japan; (A.N.); (K.S.)
| | - Masahiro Toide
- Department of Urology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo 1138677, Japan; (M.T.); (F.K.)
| | - Tatsuaki Yoneda
- Department of Urology, Seirei Hamamatsu General Hospital, Hamamatsu 4308558, Japan;
| | - Kazushige Sakaguchi
- Department of Urology, Toranomon Hospital, Tokyo 1058470, Japan; (K.S.); (S.U.)
| | - Jun Teishima
- Department of Urology, Kobe City Hospital Organization Kobe City Medical Center West Hospital, Kobe 6530013, Japan;
| | - Kazuhide Makiyama
- Department of Urology, Yokohama City University, Yokohama 2360004, Japan; (T.T.); (K.M.)
| | - Takahiro Inoue
- Department of Nephro-Urologic Surgery and Andrology, Mie University Graduate School of Medicine, Tsu 5148507, Japan; (T.S.); (T.I.)
| | - Hiroshi Kitamura
- Department of Urology, University of Toyama, Toyama 9300194, Japan; (Y.I.); (H.K.)
| | - Kazutaka Saito
- Department of Urology, Dokkyo Medical University Saitama Medical Center, Koshigaya 3438555, Japan; (A.N.); (K.S.)
| | - Fumitaka Koga
- Department of Urology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo 1138677, Japan; (M.T.); (F.K.)
| | - Shinji Urakami
- Department of Urology, Toranomon Hospital, Tokyo 1058470, Japan; (K.S.); (S.U.)
| | - Takuya Koie
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan;
- Correspondence: ; Tel.: +81-58-230-6000
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Single Positive Core Prostate Cancer at Biopsy: Clinicopathological Implications and Risk Factors for Adverse Pathological Outcomes. Clin Genitourin Cancer 2021; 20:e205-e209. [PMID: 35027314 DOI: 10.1016/j.clgc.2021.12.013] [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: 09/22/2021] [Revised: 12/14/2021] [Accepted: 12/18/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Whether one positive core prostate cancer (PCa) is a low-risk disease remains to be determined. We investigated the pathological results of radical prostatectomy specimens diagnosed on single core positive prostate biopsy. METHODS Between January 2013 and December 2019, A total of 3441 consecutive patients treated with radical prostatectomy in our institution were examined. Among them, 293 patients were diagnosed with single positive core PCa on biopsy, and the clinical parameters and pathological findings of their radical prostatectomy specimens were analyzed. RESULTS Of the 293 patients, 108 (36.9%) had undergraded Gleason Scores (GS) based on the biopsy. Positive surgical margins (PSMs), perineural invasion (PNI), extracapsular extension (ECE, pT3a) and seminal vesicle invasion (SVI, pT3b) were found in 16.4%, 15.0%, 3.4% and 2.4% of patients, respectively. In the multivariate analysis, we found that preoperative PSA level predict a significant increased risk of upgraded GS and PSMs, and biopsy GS was is a strong predictor of PNI, upgraded GS, tumor stage pT3 at radical prostatectomy. CONCLUSIONS Single positive core PCa have clinically significance in the radical prostatectomy specimens, with considerable rates of undergrading for the GS, PNI, PSMs, ECE and SVI. For patients with single positive core PCa, other prognostic factors must be considered in the treatment plan.
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Favorable intermediate risk prostate cancer with biopsy Gleason score of 6. BMC Urol 2021; 21:52. [PMID: 33820533 PMCID: PMC8022526 DOI: 10.1186/s12894-021-00827-2] [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: 01/05/2021] [Accepted: 03/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To identify potential prognostic factors among patients with favorable intermediate risk prostate cancer with a biopsy Gleason score 6. METHODS From 2003 to 2019, favorable intermediate risk patients who underwent radical prostatectomy were included in this study. All patients were evaluated preoperatively with MRI. Using PI-RADS scores, patients were divided into two groups, and clinic-pathological outcomes were compared. The impact of preoperative factors on significant pathologic Gleason score upgrading (≥ 4 + 3) and biochemical recurrence were assessed via multivariate analysis. Subgroup analysis was performed in patients with PI-RADS ≤ 2. RESULTS Among the 239 patients, 116 (48.5%) were MRI-negative (PI-RADS ≤ 3) and 123 (51.5%) were MRI-positive (PI-RADS > 3). Six patients in the MRI-negative group (5.2%) were characterized as requiring significant pathologic Gleason score upgrading compared with 34 patients (27.6%) in the MRI-positive group (p < 0.001). PI-RADS score was shown to be a significant predictor of significant pathologic Gleason score upgrading (OR = 6.246, p < 0.001) and biochemical recurrence (HR = 2.595, p = 0.043). 10-years biochemical recurrence-free survival was estimated to be 84.4% and 72.6% in the MRI-negative and MRI-positive groups (p = 0.035). In the 79 patients with PI-RADS ≤ 2, tumor length in biopsy cores was identified as a significant predictor of pathologic Gleason score (OR = 11.336, p = 0.014). CONCLUSIONS Among the patients with favorable intermediate risk prostate cancer with a biopsy Gleason score 6, preoperative MRI was capable of predicting significant pathologic Gleason score upgrading and biochemical recurrence. Especially, the patients with PI-RADS ≤ 2 and low biopsy tumor length could be a potential candidate to active surveillance.
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Peng C, Zhang J, Hou J. Performance characteristics of prostate-specific antigen density and biopsy primary Gleason score to predict biochemical failure in patients with intermediate prostate cancer who underwent radical prostatectomy. Cancer Manag Res 2019; 11:1133-1139. [PMID: 30774441 PMCID: PMC6362965 DOI: 10.2147/cmar.s190443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Prognosis for intermediate-risk prostate cancer (PCa) remains variable; therefore, we aimed to investigate high-risk factors for biochemical recurrence (BCR), and intermediate-risk PCa using radical prostatectomy to identify patients having equivalent BCR-free survival rates when compared to high-risk PCa. Patients and methods A total of 441 medical records were analyzed, including those of 169 intermediate-risk and 272 high-risk PCa patients. Risk factors for time to BCR were tested and analyzed using Kaplan–Meier survival analysis, log-rank tests, and Cox proportion hazards models. Results In the intermediate-risk group, prostate-specific antigen density (PSAD) and primary Gleason pattern were significant preoperative risk factors for BCR. Moreover, BCR-free survival of patients in the intermediate-risk group with a higher PSAD (>0.5 ng/mL/cm3) was comparable with that of patients in the high-risk group (P=0.735). When combining primary Gleason pattern 4 and 3 with PSAD cut-offs 0.3–0.7 ng/mL/cm3, we found that BCR-free survival of patients in the intermediate-risk group with a primary Gleason pattern 4 and PSAD >0.3 ng/mL/cm3 was comparable with that of patients in the high-risk group (P=0.463). Conclusion PSAD and primary Gleason pattern are potential risk factors associated with biochemical failure in intermediate-risk PCa patients after radical prostatectomy. Regarding significant differences in prognosis according to PSAD as well as primary Gleason pattern on biopsy, a subset of the intermediate-risk patients could be identified with outcomes that were equivalent to that of high-risk patients.
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Affiliation(s)
- Chao Peng
- Department of Urology, First Affiliated Hospital of Soochow University, Suzhou 215006, China,
| | - Jun Zhang
- Department of Urology, First Affiliated Hospital of Soochow University, Suzhou 215006, China,
| | - Jianquan Hou
- Department of Urology, First Affiliated Hospital of Soochow University, Suzhou 215006, China,
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Babacar S, Aissatou B, Cyrille Z, Amath T, Alioune S, Yaya S, Boubacar F, Denis B, Hamidou Z, Thiapato F, Modou N, Seck N, Babacar D, Ahmed F, Khassim N, Mamadou B. Cancer de la prostate localisé à haut risque de récidive: résultats de la prise charge. AFRICAN JOURNAL OF UROLOGY 2018. [DOI: 10.1016/j.afju.2018.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Kang HW, Jung HD, Lee JY, Kwon JK, Jeh SU, Cho KS, Ham WS, Choi YD. The Within-Group Discrimination Ability of the Cancer of the Prostate Risk Assessment Score for Men with Intermediate-Risk Prostate Cancer. J Korean Med Sci 2018; 33:e36. [PMID: 29349945 PMCID: PMC5773849 DOI: 10.3346/jkms.2018.33.e36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 10/28/2017] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Significant clinical heterogeneity within contemporary risk group is well known, particularly for those with intermediate-risk prostate cancer (IRPCa). Our study aimed to analyze the ability of the Cancer of the Prostate Risk Assessment (CAPRA) score to discern between favorable and non-favorable risk in patients with IRPCa. METHODS We retrospectively reviewed the data of 203 IRPCa patients who underwent extraperitoneal robot-assisted radical prostatectomy (RARP) performed by a single surgeon. Pathologic favorable IRPCa was defined as a Gleason score ≤ 6 and organ-confined stage at surgical pathology. The CAPRA score was compared with two established criteria for the within-group discrimination ability. RESULTS Overall, 38 patients (18.7% of the IRPCa cohort) had favorable pathologic features after RARP. The CAPRA score significantly correlated with established criteria I and II and was inversely associated with favorable pathology (all P < 0.001). The area under the receiver operating characteristic curve for the discriminative ability between favorable and non-favorable pathology was 0.679 for the CAPRA score and 0.610 and 0.661 for established criteria I and II, respectively. During a median 37.8 (interquartile range, 24.6-60.2) months of follow-up, 66 patients (32.5%) experienced biochemical recurrence (BCR). Cox regression analysis revealed that the CAPRA score, as a continuous sum score model or 3-group risk model, was an independent predictor of BCR after RARP. CONCLUSION The within-group discrimination ability of preoperative CAPRA score might help in patient counseling and selecting optimal treatments for those with IRPCa.
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Affiliation(s)
- Ho Won Kang
- Department of Urology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Hae Do Jung
- Department of Urology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Joo Yong Lee
- Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Kyou Kwon
- Department of Urology, Severance Check-up, Yonsei University Health System, Seoul, Korea
| | - Seong Uk Jeh
- Department of Urology, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Kang Su Cho
- Department of Urology, Gangnam Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Won Sik Ham
- Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young Deuk Choi
- Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea.
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Aleksic T, Verrill C, Bryant RJ, Han C, Worrall AR, Brureau L, Larré S, Higgins GS, Fazal F, Sabbagh A, Haider S, Buffa FM, Cole D, Macaulay VM. IGF-1R associates with adverse outcomes after radical radiotherapy for prostate cancer. Br J Cancer 2017; 117:1600-1606. [PMID: 28972962 PMCID: PMC5729437 DOI: 10.1038/bjc.2017.337] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 07/20/2017] [Accepted: 08/30/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Activated type 1 insulin-like growth factor receptors (IGF-1Rs) undergo internalisation and nuclear translocation, promoting cell survival. We previously reported that IGF-1R inhibition delays DNA damage repair, sensitising prostate cancer cells to ionising radiation. Here we tested the clinical relevance of these findings. METHODS We assessed associations between IGF-1R and clinical outcomes by immunohistochemistry in diagnostic biopsies of 136 men treated with 55-70 Gy external beam radiotherapy for prostate cancer, comparing results with publicly available transcriptional data in surgically treated patients. RESULTS Following radiotherapy, overall recurrence-free survival was shorter in patients whose tumours contained high total, cytoplasmic and internalised (nuclear/cytoplasmic) IGF-1R. High total IGF-1R associated with high primary Gleason grade and risk of metastasis, and cytoplasmic and internalised IGF-1R with biochemical recurrence, which includes patients experiencing local recurrence within the radiation field indicating radioresistance. In multivariate analysis, cytoplasmic, internalised and total IGF-1R were independently associated with risk of overall recurrence, and cytoplasmic IGF-1R was an independent predictor of biochemical recurrence post radiotherapy. Insulin-like growth factor receptors expression did not associate with biochemical recurrence after radical prostatectomy. CONCLUSIONS These data reveal increased risk of post-radiotherapy recurrence in men whose prostate cancers contain high levels of total or cytoplasmic IGF-1R.
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Affiliation(s)
- Tamara Aleksic
- Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
| | - Clare Verrill
- Department of Cellular Pathology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU UK
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Richard J Bryant
- Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Cheng Han
- Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford OX3 7LJ, UK
| | - Andrew Ross Worrall
- Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
| | - Laurent Brureau
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Stephane Larré
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Geoff S Higgins
- Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford OX3 7LJ, UK
| | - Fahad Fazal
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford OX3 7LJ, UK
| | - Ahmad Sabbagh
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford OX3 7LJ, UK
| | - Syed Haider
- Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
| | - Francesca M Buffa
- Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
| | - David Cole
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford OX3 7LJ, UK
| | - Valentine M Macaulay
- Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford OX3 7LJ, UK
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Kang HW, Jung HD, Lee JY, Kwon JK, Jeh SU, Cho KS, Ham WS, Choi YD. Prostate-specific antigen density predicts favorable pathology and biochemical recurrence in patients with intermediate-risk prostate cancer. Asian J Androl 2017; 18:480-4. [PMID: 26178393 PMCID: PMC4854109 DOI: 10.4103/1008-682x.154313] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
This study was designed to identify clinical predictors of favorable pathology and biochemical recurrence (BCR) in patients with intermediate-risk prostate cancer (IRPCa). Between 2006 and 2012, clinicopathological and oncological data from 203 consecutive men undergoing robot-assisted radical prostatectomy (RARP) for IRPCa were reviewed in a single-institutional retrospective study. Favorable pathology was defined as Gleason score ≤6 and organ-confined cancer as detected by surgical pathology. Logistic regression analysis was used to determine predictive variables of favorable pathology, and the Kaplan–Meier and multivariate Cox regression model were used to estimate BCR-free survival after RARP. Overall, 38 patients (18.7%) had favorable pathology after RARP. Lower quartile prostate-specific antigen density (PSAD) was associated with favorable pathology compared to the highest quartile PSAD after adjusting for preoperative PSA, clinical stage and biopsy Gleason score (odds ratio, 5.42; 95% confidence interval, 1.01–28.97; P = 0.048). During a median 37.8 (interquartile range, 24.6–60.2) months of follow-up, 66 patients experienced BCR. There were significant differences with regard to BCR free survival by PSAD quartiles (log rank, P = 0.003). Using a multivariable Cox proportion hazard model, PSAD was found to be an independent predictor of BCR in patients with IRPCa after RARP (hazard ratio, 4.641; 95% confidence interval, 1.109–19.417; P = 0.036). The incorporation of the PSAD into risk assessments might provide additional prognostic information and identify some patients in whom active surveillance would be appropriate in patients with IRPCa.
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Affiliation(s)
| | | | | | | | | | | | | | - Young Deuk Choi
- Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul; Robot and Minimal Invasive Surgery Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Wilkins A, Dearnaley D, Somaiah N. Genomic and Histopathological Tissue Biomarkers That Predict Radiotherapy Response in Localised Prostate Cancer. BIOMED RESEARCH INTERNATIONAL 2015; 2015:238757. [PMID: 26504789 PMCID: PMC4609338 DOI: 10.1155/2015/238757] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 05/24/2015] [Indexed: 12/16/2022]
Abstract
Localised prostate cancer, in particular, intermediate risk disease, has varied survival outcomes that cannot be predicted accurately using current clinical risk factors. External beam radiotherapy (EBRT) is one of the standard curative treatment options for localised disease and its efficacy is related to wide ranging aspects of tumour biology. Histopathological techniques including immunohistochemistry and a variety of genomic assays have been used to identify biomarkers of tumour proliferation, cell cycle checkpoints, hypoxia, DNA repair, apoptosis, and androgen synthesis, which predict response to radiotherapy. Global measures of genomic instability also show exciting capacity to predict survival outcomes following EBRT. There is also an urgent clinical need for biomarkers to predict the radiotherapy fraction sensitivity of different prostate tumours and preclinical studies point to possible candidates. Finally, the increased resolution of next generation sequencing (NGS) is likely to enable yet more precise molecular predictions of radiotherapy response and fraction sensitivity.
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Affiliation(s)
- Anna Wilkins
- Division of Clinical Studies, The Institute of Cancer Research, London SM2 5NG, UK
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SM2 5NG, UK
| | - David Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SM2 5NG, UK
| | - Navita Somaiah
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SM2 5NG, UK
- Division of Cancer Biology, The Institute of Cancer Research, London SM2 5NG, UK
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Jung JW, Lee JK, Hong SK, Byun SS, Lee SE. Stratification of patients with intermediate-risk prostate cancer. BJU Int 2015; 115:907-12. [PMID: 24612460 DOI: 10.1111/bju.12703] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To identify an appropriate risk stratification system for intermediate-risk prostate cancer (PCa). PATIENTS AND METHODS We reviewed the data on 1559 patients who were treated with radical prostatectomy (RP) at our institution between 2005 and 2013 and classified them according to National Comprehensive Cancer Network (NCCN) risk groups. For our analyses, intermediate-risk PCa was designated as unfavourable intermediate-risk PCa if it met at least one of the following two criteria: biopsy Gleason score 4 + 3 and/or presence of ≥ 2 intermediate-risk criteria. All other men with intermediate-risk PCa were designated as having favourable intermediate-risk disease. Postoperative outcomes, including biochemical recurrence (BCR)-free survival, were calculated and compared using the log-rank test and Cox proportional hazards model. RESULTS In multivariable analysis, biopsy Gleason score 4 + 3 and multiple (≥ 2) intermediate-risk criteria were observed to be independent predictors of BCR risk among men in the intermediate-risk group undergoing RP. The favourable intermediate-risk group had a significantly higher 5-year BCR-free survival compared with the unfavourable intermediate-risk group (87.5 vs 66.5%; P < 0.001). The unfavourable intermediate-risk group had significantly higher 5-year BCR-free survival than the high-risk group (66.5 vs 47.9%; P < 0.001) while the favourable intermediate-risk group had significantly lower 5-year BCR-free survival than the low-risk group (87.5 vs 93.5%; P = 0.002). CONCLUSIONS A marked heterogeneity exists in the biochemical outcomes of contemporary patients with intermediate-risk PCa who undergo definitive RP. According to biopsy Gleason score and number of intermediate-risk criteria present, the intermediate-risk group should be sub-divided into those with favourable and unfavourable intermediate-risk disease.
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Affiliation(s)
- Jin-Woo Jung
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Keun Lee
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung Kyu Hong
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seok-Soo Byun
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Eun Lee
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
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Sooriakumaran P, Ploumidis A, Nyberg T, Olsson M, Akre O, Haendler L, Egevad L, Nilsson A, Carlsson S, Jonsson M, Adding C, Hosseini A, Steineck G, Wiklund P. The impact of length and location of positive margins in predicting biochemical recurrence after robot-assisted radical prostatectomy with a minimum follow-up of 5 years. BJU Int 2014; 115:106-13. [DOI: 10.1111/bju.12483] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Prasanna Sooriakumaran
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
| | | | - Tommy Nyberg
- Clinical Cancer Epidemiology; Department of Oncology-Pathology; Karolinska Institutet; Stockholm Sweden
| | - Mats Olsson
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
| | - Olof Akre
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
- Clinical Epidemiology Unit; Department of Medicine Solna; Karolinska Institutet; Stockholm Sweden
| | - Leif Haendler
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
| | - Lars Egevad
- Department of Pathology; Karolinska University Hospital; Stockholm Sweden
| | - Andreas Nilsson
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
| | - Stefan Carlsson
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
| | - Martin Jonsson
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
| | - Christofer Adding
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
| | - Abolfazl Hosseini
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
| | - Gunnar Steineck
- Clinical Cancer Epidemiology; Department of Oncology-Pathology; Karolinska Institutet; Stockholm Sweden
| | - Peter Wiklund
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
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Noronha MR, Quintal MMQ, Magna LA, Reis LO, Billis A, Meirelles LR. Controversial predictors of biochemical recurrence after radical prostatectomy: a study from a Latin American (Brazilian) institution. Int Braz J Urol 2014; 39:779-92. [PMID: 24456770 DOI: 10.1590/s1677-5538.ibju.2013.06.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 07/04/2013] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To analyze controversial clinicopathologic predictors of biochemical recurrence after surgery: age, race, tumor extent on surgical specimen, tumor extent on needle biopsy, Gleason score 3 + 4 vs 4 + 3, and amount of extent of extraprostatic extension and positive surgical margins. MATERIALS AND METHODS The needle biopsies and the correspondent surgical specimens were analyzed from 400 patients. Time to recurrence was analyzed with the Kaplan-Meier curves and risk of shorter time to recurrence using Cox univariate and multivariate analysis. RESULTS Except for age, race, maximum percentage of cancer per core, and number of cores with cancer, all other variables studied were significantly predictive of time to biochemical recurrence using the Kaplan-Meier curves. In univariate analysis, except for focal extraprostatic extension, age, race, focal positive surgical margins, and maximum extent and percentage of cancer per core, all other variables were significantly predictive of shorter time to recurrence. On multivariate analysis, diffuse positive surgical margins and preoperative PSA were independent predictors. CONCLUSIONS Young patients and non-whites were not significantly associated with time to biochemical recurrence. The time consuming tumor extent evaluation in surgical specimens seems not to add additional information to other well established predictive findings. The higher predictive value of Gleason score 4 + 3 = 7 vs 3 + 4 = 7 discloses the importance of grade 4 as the predominant pattern. Extent and not simply presence or absent of extraprostatic extension should be informed. Most tumor extent evaluations on needle biopsies are predictive of time to biochemical recurrence, however, maximum percentage of cancer in all cores was the strongest predictor.
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Affiliation(s)
- Marcelo R Noronha
- Department of Pathology, School of Medical Sciences, State University of Campinas (Unicamp), Campinas, SP, Brazil
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Keane FK, Chen MH, Zhang D, Loffredo MJ, Kantoff PW, Renshaw AA, D'Amico AV. The likelihood of death from prostate cancer in men with favorable or unfavorable intermediate-risk disease. Cancer 2014; 120:1787-93. [DOI: 10.1002/cncr.28609] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 12/28/2013] [Accepted: 01/13/2014] [Indexed: 11/12/2022]
Affiliation(s)
- Florence K. Keane
- Harvard Radiation Oncology Program; Harvard Medical School; Boston Massachusetts
| | - Ming-Hui Chen
- Department of Statistics; University of Connecticut; Storrs Connecticut
| | - Danjie Zhang
- Department of Statistics; University of Connecticut; Storrs Connecticut
| | - Marian J. Loffredo
- Department of Radiation Oncology; Dana Farber Cancer Institute and Brigham and Women's Hospital; Boston Massachusetts
| | - Philip W. Kantoff
- Department of Medical Oncology; Dana Farber Cancer Institute and Brigham and Women's Hospital; Boston Massachusetts
| | | | - Anthony V. D'Amico
- Department of Radiation Oncology; Dana Farber Cancer Institute and Brigham and Women's Hospital; Boston Massachusetts
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Zhang H, Messing EM, Travis LB, Hyrien O, Chen R, Milano MT, Chen Y. Age and Racial Differences among PSA-Detected (AJCC Stage T1cN0M0) Prostate Cancer in the U.S.: A Population-Based Study of 70,345 Men. Front Oncol 2013; 3:312. [PMID: 24392353 PMCID: PMC3870291 DOI: 10.3389/fonc.2013.00312] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 12/09/2013] [Indexed: 11/27/2022] Open
Abstract
Purpose: Few studies have evaluated the risk profile of prostate-specific antigen (PSA)-detected T1cN0M0 prostate cancer, defined as tumors diagnosed by needle biopsy because of elevated PSA levels without other clinical signs of disease. However, some men with stage T1cN0M0 prostate cancer may have high-risk disease (HRD), thus experiencing inferior outcomes as predicted by a risk group stratification model. Methods: We identified men diagnosed with stage T1cN0M0 prostate cancer from 2004 to 2008 reported to the surveillance, epidemiology, and end results (SEER) program. Multivariate logistic regression was used to model the probability of intermediate-risk-disease (IRD) (PSA ≥ 10 ng/ml but <20 ng/ml and/or GS 7), and high-risk-disease (HDR) (PSA ≥ 20 ng/ml, and/or GS ≥ 8), relative to low-risk disease (LRD) (PSA < 10 ng/ml and GS ≤ 6), adjusting for age, race, marital status, median household income, and area of residence. Results: A total of 70,345 men with PSA-detected T1cN0M0 prostate cancer were identified. Of these, 47.6, 35.9, and 16.5% presented with low-, intermediate-, and high-risk disease, respectively. At baseline (50 years of age), risk was higher for black men than for whites for HRD (OR 3.31, 95% CI 2.85–3.84). The ORs for age (per year) for HRD relative to LRD were 1.09 (95% CI 1.09–1.10) for white men, and as 1.06 (95% CI 1.05–1.07) for black men. Further, among a subgroup of men with low PSA (<10 ng/ml) T1cN0M0 prostate cancer, risk was also higher for black man than for white men at baseline (50 years of age) (OR 2.70, 95% CI 2.09–3.48). The ORs for age (per year) for HRD relative to LRD were 1.09 (95% CI 1.09–1.10) for white men, and as 1.06 (95% CI 1.05–1.07) for black men. Conclusion: A substantial proportion of men with PSA-detected prostate cancer as reported to the SEER program had HRD. Black race and older age were associated with a greater likelihood of HRD.
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Affiliation(s)
- Hong Zhang
- Department of Radiation Oncology, University of Rochester Medical Center , Rochester, NY , USA
| | - Edward M Messing
- Department of Urology, University of Rochester Medical Center , Rochester, NY , USA
| | - Lois B Travis
- Department of Radiation Oncology, University of Rochester Medical Center , Rochester, NY , USA
| | - Ollivier Hyrien
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center , Rochester, NY , USA
| | - Rui Chen
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center , Rochester, NY , USA
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester Medical Center , Rochester, NY , USA
| | - Yuhchyau Chen
- Department of Radiation Oncology, University of Rochester Medical Center , Rochester, NY , USA
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The Impact of Tumor Size in Breast Needle Biopsy Material on Final Pathologic Size and Tumor Stage. Am J Surg Pathol 2013; 37:739-44. [DOI: 10.1097/pas.0b013e31828c63d0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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D'Amico AV. Personalizing the management of men with intermediate-risk prostate cancer. Eur Urol 2013; 64:903-4. [PMID: 23545122 DOI: 10.1016/j.eururo.2013.03.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 03/15/2013] [Indexed: 11/18/2022]
Affiliation(s)
- Anthony V D'Amico
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, USA.
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Furubayashi N, Nakamura M, Hishikawa K, Fukuda A, Matsumoto T, Nishiyama K, Yamanaka T, Hasegawa Y. Radical prostatectomy as radical cure of prostate cancer in a high-risk group: A single-institution experience. Mol Clin Oncol 2012; 1:337-342. [PMID: 24649172 DOI: 10.3892/mco.2012.39] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 09/26/2012] [Indexed: 11/06/2022] Open
Abstract
This study aimed to evaluate the possibility of performing radical prostatectomy (RP) alone to achieve radical cure of prostate cancer in a high-risk group. Between August 1998 and December 2008, 436 Japanese patients underwent antegrade RP following the exclusion of 139 patients. According to the D'Amico criteria, the low-, intermediate- and high-risk groups comprised 63, 122 and 112 patients, respectively. Twenty-five patients who were classified into the high-risk group based only on T2c stage, were evaluated as a separate intermediate/high-risk group. Results of the multivariate analysis revealed that of the preoperative characteristics only a biopsy Gleason score was a significant predictor in patients with and without PSA failure (P=0.017). After a median follow-up period of 60 months, the PSA failure-free rates in the low-, intermediate-, high- and intermediate/high-risk groups were 96.5, 92.2, 76.8 and 95.0%, respectively. No statistically significant difference was detected in the high- and intermediate/high-risk groups (P=0.064). Thus, patients classified into the high-risk group based on cT2 stage only, are considered to be potentially eligible for radical treatment by surgery alone, and should not be evaluated as high-risk patients.
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Affiliation(s)
| | - Motonobu Nakamura
- Departments of Urology, National Kyushu Cancer Center, Fukuoka, Japan
| | - Ken Hishikawa
- Departments of Urology, National Kyushu Cancer Center, Fukuoka, Japan
| | - Atsushi Fukuda
- Departments of Urology, National Kyushu Cancer Center, Fukuoka, Japan
| | - Takashi Matsumoto
- Departments of Urology, National Kyushu Cancer Center, Fukuoka, Japan
| | | | - Takeharu Yamanaka
- Institute for Clinical Research, National Kyushu Cancer Center, Fukuoka, Japan
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18
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High-grade prostatic adenocarcinoma present in a single biopsy core is associated with increased extraprostatic extension, seminal vesicle invasion, and positive surgical margins at prostatectomy. Urology 2011; 79:863-8. [PMID: 22173174 DOI: 10.1016/j.urology.2011.10.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 08/30/2011] [Accepted: 10/08/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the pathologic outcome of prostate-specific antigen-screened patients with high-grade (Gleason score ≥ 8) prostate cancer limited to 1 biopsy core, without clinical evidence of disease. METHODS Ninety-two patients with only 1 biopsy core with cancer and treated by radical prostatectomy were divided into 4 groups according to the biopsy Gleason score: 3 + 3 = 6 (23 cases), 3 + 4 = 7 (25 cases), 4 + 3 = 7 (20 cases), and ≥ 8 (24 cases). RESULTS Cases with Gleason score ≥ 8 showed a significantly higher proportion of extraprostatic extension (50%), positive surgical margins (21%), and seminal vesicle invasion (12%) when compared with the other groups. Patients with Gleason score ≥ 8 in the biopsy had a 25-fold increased in the odds ratio for extraprostatic extension in the prostatectomy. The incidence of extraprostatic extension was higher in those with prostatic cancer involving ≥ 50% of one core (88%) compared with cases involving <50% (32%). CONCLUSION In patients with prostate cancer limited to 1 biopsy core, the presence of Gleason score ≥ 8 significantly increased the incidence of extraprostatic extension, positive surgical margins, and seminal vesicle invasion. The odds ratio was substantially higher in patients with ≥ 50% of Gleason ≥ 8 in the biopsy core. These data might be taken into account for proper clinical management of this set of patients.
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Porten SP, Cooperberg MR, Konety BR, Carroll PR. The example of CaPSURE: lessons learned from a national disease registry. World J Urol 2011; 29:265-71. [PMID: 21347810 PMCID: PMC3099175 DOI: 10.1007/s00345-011-0658-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 02/02/2011] [Indexed: 11/29/2022] Open
Abstract
Introduction Although randomized controlled trials (RCTs) remain the gold standard for determining evidence-based clinical practices, large disease registries that enroll large numbers of patients have become paramount as a relatively cost-effective additional tool. Methods We highlight the advantages of disease registries focusing on the example of prostate cancer and the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE™) registry. Results CaPSURE collects approximately 1,000 clinical and patient-reported variables, in over 13,000 men that are enrolled. Thus far, CaPSURE has yielded over 130 peer-reviewed publications, with several others in press, in key areas of risk migration, practice patterns, outcome prediction, and quality of life outcomes. Conclusions Disease registries, like CaPSURE complement RCTs and CaPSURE, have provided a means to better understand many aspects of prostate cancer epidemiology, practice patterns, oncologic and HRQOL outcomes, and costs of care across populations. Specialized observational disease registries such as CaPSURE provide insight and have broad implications for disease management and policy.
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Affiliation(s)
- Sima P Porten
- Department of Urology, UCSF Helen Diller Comprehensive Cancer Center, University of California, San Francisco, CA, USA
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20
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Various morphometric measurements of cancer extent on needle prostatic biopsies: which is predictive of pathologic stage and biochemical recurrence following radical prostatectomy? Int Urol Nephrol 2011; 43:697-705. [DOI: 10.1007/s11255-011-9901-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 01/19/2011] [Indexed: 10/18/2022]
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21
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Bott SRJ, Ahmed HU, Hindley RG, Abdul-Rahman A, Freeman A, Emberton M. The index lesion and focal therapy: an analysis of the pathological characteristics of prostate cancer. BJU Int 2011; 106:1607-11. [PMID: 20553262 DOI: 10.1111/j.1464-410x.2010.09436.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To determine the pathological characteristics of radical prostatectomy specimens with respect to index and secondary lesions. METHODS A total of 100 consecutive radical prostatectomy specimens examined at a single hospital were assessed. Patients undergoing salvage prostatectomy or those who had received neoadjuvant hormonal manipulation were excluded. Preoperative data and the number, volume and Gleason grade of each tumour focus were recorded. Criteria used to define a clinically significant lesion were tumour volume ≥0.5 mL and/or Gleason pattern 4 or 5 and/or extra-capsular disease. RESULTS Overall, 374 foci were examined. The median number of tumours per patient was 3.5 (range 1-15). The overall median tumour volume was 1.4 mL (range 0.1-18.2), the median volume of the largest (index) tumour was 0.95 mL (range 0.1-18.2) and the median volume of the largest secondary tumour was 0.2 mL (range 0.05-1.7). There were no patients in whom the index lesion was insignificant and secondary tumours were significant (by grade or extra-capsular disease). Seventy-seven fulfilled the clinical parameters of low-to-intermediate-risk disease. If focal therapy can be delivered with the aim of ablating all clinically significant disease, with untreated areas harbouring no cancer or clinically insignificant disease, between 58.5 and 67.5% might have been suitable for such a strategy. CONCLUSIONS The proportion of men with low-to-intermediate-risk prostate cancer who may potentially be suitable for a focal therapy approach is unknown. The key question is whether the volume of individual lesions points to clinically significant cancer and whether ablation of these lesions alone would lead to cancer control. This research question is currently undergoing evaluation within a prospective clinical trial.
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22
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Rosenthal SA, Sandler HM. Treatment strategies for high-risk locally advanced prostate cancer. Nat Rev Urol 2010; 7:31-8. [PMID: 20062072 DOI: 10.1038/nrurol.2009.237] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
High-risk prostate cancer can be defined by the assessment of pretreatment prognostic factors such as clinical stage, Gleason score, and PSA level. High-risk features include PSA >20 ng/ml, Gleason score 8-10, and stage T3 tumors. Patients with adverse prognostic factors have historically fared poorly with monotherapeutic approaches. Multimodal treatment utilizing combined androgen suppression and radiotherapy has improved survival rates for patients with high-risk prostate cancer. In addition, multiple randomized trials in patients treated with primary radical prostatectomy have demonstrated improved outcomes with the addition of adjuvant radiotherapy. Improved radiotherapy techniques that allow for dose escalation, and new systemic therapy approaches such as adjuvant chemotherapy, present promising future therapeutic alternatives for patients with high-risk prostate cancer.
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Affiliation(s)
- Seth A Rosenthal
- Radiation Oncology Centers, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento, CA 95815, USA.
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Isbarn H, Karakiewicz PI, Ahyai SA, Chun FK, Jeldres C, Haese A, Heinzer H, Zacharias M, Heuer R, Eichelberg C, Steuber T, Budäus L, Köllermann J, Salomon G, Schlomm T, Perrotte P, Fisch M, Huland H, Graefen M. Differences in histopathological and biochemical outcomes in patients with low Gleason score prostate cancer. BJU Int 2010; 105:818-23. [DOI: 10.1111/j.1464-410x.2009.08841.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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24
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Liauw SL, Fricano J, Correa D, Weichselbaum RR, Jani AB. Dose-escalated radiation therapy for intermediate-risk prostate cancer. Cancer 2009; 115:1784-90. [DOI: 10.1002/cncr.24176] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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25
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Lee HJ, Kim SJ, Cho HJ, Ha US, Hong SH, Lee JY, Kim JC, Kim SW, Hwang TK. Outcome of Laparoscopic Radical Prostatectomy in High-Risk Prostate Cancer. Korean J Urol 2009. [DOI: 10.4111/kju.2009.50.11.1101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Ho Jae Lee
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Su Jin Kim
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hyuk Jin Cho
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - U-Syn Ha
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sung-Hoo Hong
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Ji Youl Lee
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Joon Chul Kim
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sae Woong Kim
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Tae-Kon Hwang
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
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Pathological upgrading and up staging with immediate repeat biopsy in patients eligible for active surveillance. J Urol 2008; 180:1964-7; discussion 1967-8. [PMID: 18801515 DOI: 10.1016/j.juro.2008.07.051] [Citation(s) in RCA: 226] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Indexed: 11/24/2022]
Abstract
PURPOSE Active surveillance with selective delayed intervention is a treatment regimen used in patients with low risk prostate cancer. Decision making is based on pretreatment prostate specific antigen, clinical stage and prostate biopsy results. We reviewed our experience with immediate repeat biopsy in patients eligible for active surveillance with selective delayed intervention. MATERIALS AND METHODS A retrospective review was done of the records of consecutive patients who underwent repeat biopsy within 3 months of a first positive biopsy from March 2002 to June 2007. Patients were considered eligible if they had prostate specific antigen less than 10 ng/ml, clinical stage T2a or less, Gleason pattern 3 or less, 3 or fewer positive cores and no single core with 50% or greater cancer involvement. RESULTS A total of 104 patients met eligibility criteria. Of the 104 repeat biopsies performed 27 (26%) were negative, 59 (57%) had a Gleason score of 6 or less and 17 (16%) had a Gleason score of 7. One patient had a Gleason score of 9, while 10 of 104 (10%) had greater than 3 cores involved on repeat biopsy and 12 (12%) had 50% or greater involvement of at least 1 core. Of 104 cases (27%) 28 were upgraded and/or up staged. Treated cases that were upgraded and/or up staged were more likely to show higher pathological stage and grade at radical prostatectomy than those that were not (p = 0.003 and p = 0.001, respectively). CONCLUSIONS Immediate repeat biopsy in cases of active surveillance with selective delayed intervention resulted in 27% being upgraded or up staged and those were more likely to show higher grade and stage disease at radical prostatectomy. We recommend repeat biopsy because it improved our discrimination of who are the best candidates for active surveillance with selective delayed intervention.
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Shikanov SA, Thong A, Gofrit ON, Zagaja GP, Steinberg GD, Shalhav AL, Zorn KC. Robotic Laparoscopic Radical Prostatectomy for Biopsy Gleason 8 to 10: Prediction of Favorable Pathologic Outcome with Preoperative Parameters. J Endourol 2008; 22:1477-81. [DOI: 10.1089/end.2008.0091] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sergey A. Shikanov
- Section of Urology, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Alan Thong
- University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Ofer N. Gofrit
- Department of Urology, Hadassah Medical Center, Jerusalem, Israel
| | - Gregory P. Zagaja
- Section of Urology, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Gary D. Steinberg
- Section of Urology, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Arieh L. Shalhav
- Section of Urology, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Kevin C. Zorn
- Section of Urology, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
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Rioja Zuazu J, Zudaire Berbera J, Rincon Mayans A, Rosell Costa D, Robles Garcia J, Berian Polo J. Adenocarcinoma de próstata gleason clínico 8-10: influencia pronóstica en la supervivencia libre de progresión bioquímica. Actas Urol Esp 2008; 32:792-8. [DOI: 10.1016/s0210-4806(08)73937-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Villamón-Fort R, Martínez-Jabaloyas JM, Soriano-Sarriá P, Ramos-Soler D, Pastor-Hernández F, Gil-Salom M. Percentage of Cancer in Prostate Biopsies as Prognostic Factor for Staging and Postoperative Biochemical Failure after Radical Prostatectomy. Urol Int 2007; 78:328-33. [PMID: 17495491 DOI: 10.1159/000100837] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2006] [Accepted: 09/26/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess if the percentage of cancer in prostate needle biopsies provides independent prognostic information for predicting pathological stage and/or biochemical relapse after radical prostatectomy. METHODS One hundred and forty prostate cancer patients who underwent radical prostatectomy were evaluated. Preoperative parameters analyzed were patient age, PSA, clinical stage, and the information obtained from sextant biopsies (Gleason score, maximum percentage of cancer in a core, percentage of tissue with cancer in all biopsies and the number of cores positive for cancer). Univariate and multivariate analyses (logistic regression) for the dependent variables (prostate cancer, organ-confined and biochemical relapse) were performed. RESULTS The tumor was organ-confined in 73.6% of patients. In those patients studied for disease progression (n = 126), no biochemical recurrence was observed in 76.2%. In the multivariate analysis for organ-confined disease, the total percentage of biopsy tissue with cancer, the preoperative PSA level, the Gleason score and the clinical stage were the most accurate predictive factors of pathological stage. The multivariate analysis for the study of biochemical failure indicated that only the total percentage of biopsy tissue with cancer, the preoperative PSA level and the Gleason score were independent predictive factors. According to the logistic regression analysis for disease recurrence, 3 risk groups could be identified: low risk (less than 10% probability of disease progression), intermediate risk (30%) and high risk (more than 70%). CONCLUSIONS The percentage of cancer in prostate biopsy provides independent prognostic information for predicting pathological stage and the risk of biochemical failure after radical prostatectomy.
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Affiliation(s)
- Rafael Villamón-Fort
- Department of Urology, Hospital Clínico Universitario de Valencia, Valencia, Spain
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30
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Krejcarek SC, Chen MH, Renshaw AA, Loffredo M, Sussman B, D'Amico AV. Prediagnostic Prostate-Specific Antigen Velocity and Probability of Detecting High-Grade Prostate Cancer. Urology 2007; 69:515-9. [PMID: 17382156 DOI: 10.1016/j.urology.2006.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2006] [Revised: 09/11/2006] [Accepted: 11/16/2006] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Men with high-grade prostate cancer experience a survival benefit when androgen suppression therapy is combined with radiotherapy (RT) compared with RT alone. We evaluated whether an association exists between the pretreatment prostate-specific antigen (PSA) velocity and high-grade prostate cancer at diagnosis, controlling for known predictors of high-grade disease. METHODS The study cohort consisted of 358 men with Stage T1c-T4 prostate cancer treated with external beam RT from 1989 to 2002. Univariate and multivariate logistic regression analyses were used to assess whether an association exists between the pretreatment PSA velocity, PSA level, age, clinical T stage, and Gleason score 4+3 or greater compared with Gleason score 3+4 or less prostate cancer. RESULTS Of the 358 men, 73 had a Gleason score of 4+3 or greater. The median PSA velocity was 2.71 ng/mL/yr (interquartile range 1.09 to 12.6) for men with a Gleason score of 4+3 or greater and 1.24 ng/mL/yr (interquartile range 0.71 to 3.37) for men with a Gleason score of 3+4 or less. All clinical covariates were significantly associated (P < or = 0.05) with a Gleason score of 4+3 or greater on univariate analysis. On multivariate analysis, the PSA velocity (odds ratio 1.06, 95% confidence interval 1.02 to 1.10, P = 0.004), age (odds ratio 1.07, 95% confidence interval 1.02 to 1.13, P = 0.008), and clinical T stage (odds ratio 2.17, 95% confidence interval 1.21 to 3.92, P = 0.01) were significantly associated with the detection of Gleason score 4+3 or greater prostate cancer. CONCLUSIONS The prediagnostic PSA velocity, patient age, and clinical T stage were significantly associated with high-grade prostate cancer at diagnosis. Because a biopsy Gleason score of 4+3 or greater is associated with a prostatectomy Gleason score of 7 or greater in the vast majority of cases, these parameters can identify men at high risk of harboring occult high-grade prostate cancer, permitting improved selection of RT fields and the use of androgen suppression therapy.
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Affiliation(s)
- Stephanie C Krejcarek
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
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31
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Roach M, Weinberg V, Sandler H, Thompson I. Staging for prostate cancer: time to incorporate pretreatment prostate-specific antigen and Gleason score? Cancer 2007; 109:213-20. [PMID: 17167758 DOI: 10.1002/cncr.22403] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The American Joint Committee on Cancer (AJCC) staging system for prostate cancer is based primarily based on clinical tumor (T) classification. In this article, the authors summarize arguments for incorporating additional pretreatment parameters and creating a new staging system for prostate cancer. METHODS Men with localized prostate cancer who received treatment with external beam radiation alone were analyzed using the 1997 AJCC staging system compared with a system that included pretreatment prostate-specific antigen (pPSA) level and Gleason score (GS). Multivariate analyses using a Cox proportional-hazards model were carried out to evaluate T classification, GS, and pPSA as predictors of overall survival (OS), disease-specific survival (DSS), and freedom from PSA failure (FFPF). RESULTS.: Based on pretreatment characteristics in a series of contemporary patients, only 0.6% of patients were classified with AJCC stage I disease, 16.0% were classified with AJCC stage III disease, and 83.4% were classified with AJCC stage II disease. Multivariate analyses indicated the independent statistical significance of T classification, GS, and pPSA in predicting OS, DSS, and FFPF (model chi-square value, P < .0001 for each). Using these 3 predictors, subsets of patients who had similar outcomes were combined to provide examples of the insensitivity of the AJCC system for predicting outcomes. Incorporating pPSA and GS allowed the identification of differences in OS, DSS, and FFPF for subsets of patients with AJCC stage II disease (P < .0001, P = .005, and P < .0001, respectively). CONCLUSIONS The current AJCC staging system does not divide contemporary patients with prostate cancer into prognostic subgroups and does not identify patients who have comparable biochemical control and survival. The AJCC staging system for prostate cancer should be changed to incorporate pPSA, GS, and risk stratification.
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Affiliation(s)
- Mack Roach
- Department of Radiation Oncology, University of California San Francisco Comprehensive Cancer Center, University of California San Francisco, San Francisco, California 94143-1708, USA.
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Poissonnier L, Chapelon JY, Rouvière O, Curiel L, Bouvier R, Martin X, Dubernard JM, Gelet A. Control of prostate cancer by transrectal HIFU in 227 patients. Eur Urol 2007; 51:381-7. [PMID: 16857310 DOI: 10.1016/j.eururo.2006.04.012] [Citation(s) in RCA: 202] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2005] [Accepted: 04/18/2006] [Indexed: 12/30/2022]
Abstract
PURPOSE To evaluate the results of high-intensity focused ultrasound (HIFU) treatment of localized prostate cancer with reference to disease-related prognostic factors. MATERIALS AND METHODS Patients with T1-2 localized prostate cancers, prostate specific antigen (PSA) <or=15 ng/ml, Gleason score <or=7, prostate volume <or=40 cc and no previous radical treatment for prostate cancer were treated with the Ablatherm HIFU device. Follow-up included PSA measurements, and prostate biopsies 3 months after HIFU and in cases of rising PSA. Failure was defined as any positive biopsy or a PSA >1 ng/ml with three consecutive rises. RESULTS The study included 227 patients. Mean follow-up was 27+/-20 months (12-121 months). Eighty-six percent had negative control biopsies. Median nadir PSA was 0.10 ng/ml. The actuarial 5-year disease-free survival rate (DFSR), combining pathologic and biochemical outcomes, was 66%. DFSR showed a significant decrease when stratified according to initial PSA level: 90% with PSA <or=4 ng/ml versus 57% and 61% with PSA between 4.1 and 10, and between 10.1 and 15 ng/ml, respectively. Incontinence and bladder neck stricture decreased with the treatment procedure standardization from 28% and 31% to 9% and 6%, respectively. CONCLUSIONS HIFU for localized prostate cancer offered high control of local disease with low morbidity. The ability to repeat the HIFU treatment is of major interest.
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Affiliation(s)
- Laura Poissonnier
- Urology, Radiology and Pathology Department, Edouard Herriot Hospital, Lyon, France
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Roach M, Weinberg V, Nash M, Sandler HM, McLaughlin PW, Kattan MW. Defining High Risk Prostate Cancer With Risk Groups and Nomograms: Implications for Designing Clinical Trials. J Urol 2006; 176:S16-20. [PMID: 17084158 DOI: 10.1016/j.juro.2006.06.081] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2006] [Indexed: 11/18/2022]
Abstract
PURPOSE Death from prostate cancer is usually preceded by metastases and it usually occurs in men with high risk disease who experienced biochemical failure with a short prostate specific antigen doubling time. We developed a model for determining disease specific survival in prostate cancer. MATERIALS AND METHODS We used the model for defining high risk prostate cancer that was developed by the Radiation Therapy Oncology Group and combined it with the Kattan nomogram for predicting the risk of metastases. We selected 414 Radiation Therapy Oncology Group intermediate and high risk patients who were treated with external beam radiotherapy alone. Excluded were patients with low risk disease. The Kaplan-Meier product limit method was used to estimate the probability of freedom from biochemical failure, overall survival and disease specific survival. RESULTS A significant difference was observed in freedom from biochemical failure, disease specific survival and overall survival among the 3 tertiles created by the nomogram using the cutoff points less than 8.5%, 8.5% to 15% and greater than 15% (p <0.001, 0.0002 and 0.0003, respectively). Only the risk of metastases using the categorized nomogram score (less than 8.5% and 8.5% to 15% vs greater than 15%), not preradiotherapy prostate specific antigen or Radiation Therapy Oncology Group risk (Radiation Therapy Oncology Group 2 vs 3), was a significant predictor of disease specific and overall survival for intermediate/high risk patients and intermediate/high risk with 15% or less risk for metastases. CONCLUSIONS We combined a risk group stratification scheme for disease specific survival with a nomogram predicting the risk of metastases and created a model that may be useful for designing phase III trials with metastases and disease specific survival as study end points.
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Affiliation(s)
- Mack Roach
- Department of Radiation Oncology, Comprehensive Cancer Center, University of California-San Francisco, 1600 Divisadero Street, San Francisco, CA 94143, USA.
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Chan JM, Latini DM, Cowan J, Duchane J, Carroll PR. History of diabetes, clinical features of prostate cancer, and prostate cancer recurrence-data from CaPSURE (United States). Cancer Causes Control 2006; 16:789-97. [PMID: 16132789 DOI: 10.1007/s10552-005-3301-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2004] [Accepted: 03/08/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVES There is a growing epidemiologic literature suggesting an inverse association between history of diabetes and risk of incident prostate cancer. To our knowledge, the relationship between diabetes and tumor features and risk of recurrence among men with prostate cancer has not been examined previously. We hypothesized that men with diabetes would present with more favorable prostate cancer and experience lower risk of recurrence. METHODS We identified 691 men with diabetes at the time of prostate cancer diagnosis, among 6722 men diagnosed with prostate cancer in 1989 to 2002 within CaPSURE(TM), a community-based prostate cancer registry study. We compared clinical and socio-demographic variables by diabetes status, using chi2 tests, t-tests, and multinomial logistic regression. We examined recurrence rates for prostate cancer among patients with and without diabetes using Kaplan-Meier log-rank tests and Cox proportional hazard models. RESULTS In multivariate analyses, history of diabetes was not associated with any diagnostic clinical parameter, and treatment-specific recurrence rates for prostate cancer generally did not differ by diabetes history. Among men with low-prognostic risk or who were younger at prostate cancer diagnosis, being diabetic (versus not) was associated with an elevated risk of recurrence after radiation therapy, in multivariate analyses. CONCLUSIONS Contrary to data suggesting that diabetes may be modestly protective against risk of incident prostate cancer, we did not observe any evidence of an inverse association between history of diabetes and aggressiveness at diagnosis or risk of recurrence, in this population of men with prostate cancer.
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Affiliation(s)
- J M Chan
- Department of Urology, University of California, San Francisco, CA 94143-1695, USA.
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Wolf MS, Knight SJ, Lyons EA, Durazo-Arvizu R, Pickard SA, Arseven A, Arozullah A, Colella K, Ray P, Bennett CL. Literacy, race, and PSA level among low-income men newly diagnosed with prostate cancer. Urology 2006; 68:89-93. [PMID: 16844451 DOI: 10.1016/j.urology.2006.01.064] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2005] [Revised: 12/19/2005] [Accepted: 01/24/2006] [Indexed: 01/02/2023]
Abstract
OBJECTIVES Among men with newly diagnosed prostate cancer, prostate-specific antigen (PSA) levels are higher and the cancer stage more advanced for African Americans than for whites. An earlier study found that after adjustment for literacy, race was no longer a significant predictor of advanced stage at presentation. We investigated whether, after adjusting for literacy, race was a significant independent predictor of greater PSA levels among men with newly diagnosed prostate cancer. METHODS Consecutive patients with newly diagnosed prostate cancer from four outpatient care facilities in Chicago were interviewed and given a literacy assessment (n = 308). The PSA level at diagnosis was obtained from the medical charts. Logistic regression models were used to identify predictors of high PSA levels (greater than 20 ng/mL) at presentation. RESULTS African-American men were three times more likely to have low literacy skills (sixth grade or less: 22.9% versus 7.1%; P <0.001) than were white men. In turn, men with low literacy skills were more than twice as likely to have a PSA level greater than 20 ng/mL at diagnosis (33.3% versus 13.5%; P = 0.009). On multivariate analyses, significant predictors of high PSA levels included low literacy (adjusted odds ratio 2.5, 95% confidence interval 1.5 to 4.2) and older age (age 65 to 74 years, adjusted odds ratio 2.6, 95% confidence interval 2.1 to 3.1 versus older than 74 years, adjusted odds ratio 3.4, 95% confidence interval 1.8 to 6.6), but not African-American race. CONCLUSIONS In the current era in which PSA testing is common, low literacy may be an important and potentially overlooked factor associated with higher PSA levels at prostate cancer diagnosis among African-American and white men.
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Affiliation(s)
- Michael S Wolf
- Robert H. Lurie Comprehensive Cancer Center, Institute for Healthcare Studies and Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Crippa A, Srougi M, Dall'Oglio MF, Antunes AA, Leite KR, Nesrallah LJ, Ortiz V. A new nomogram to predict pathologic outcome following radical prostatectomy. Int Braz J Urol 2006; 32:155-64. [PMID: 16650292 DOI: 10.1590/s1677-55382006000200005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2006] [Indexed: 05/08/2023] Open
Abstract
OBJECTIVE To develop a preoperative nomogram to predict pathologic outcome in patients submitted to radical prostatectomy for clinical localized prostate cancer. MATERIALS AND METHODS Nine hundred and sixty patients with clinical stage T1 and T2 prostate cancer were evaluated following radical prostatectomy, and 898 were included in the study. Following a multivariate analysis, nomograms were developed incorporating serum PSA, biopsy Gleason score, and percentage of positive biopsy cores in order to predict the risks of extraprostatic tumor extension, and seminal vesicle involvement. RESULTS In univariate analysis there was a significant association between percentage of positive biopsy cores (p < 0.001), serum PSA (p = 0.001) and biopsy Gleason score (p < 0.001) with extraprostatic tumor extension. A similar pathologic outcome was seen among tumors with Gleason score 7, and Gleason score 8 to 10. In multivariate analysis, the 3 preoperative variables showed independent significance to predict tumor extension. This allowed the development of nomogram-1 (using Gleason scores in 3 categories - 2 to 6, 7 and 8 to 10) and nomogram-2 (using Gleason scores in 2 categories - 2 to 6 and 7 to 10) to predict disease extension based on these 3 parameters. In the validation analysis, 87% and 91.1% of the time the nomograms-1 and 2, correctly predicted the probability of a pathological stage to within 10% respectively. CONCLUSION Incorporating percent of positive biopsy cores to a nomogram that includes preoperative serum PSA and biopsy Gleason score, can accurately predict the presence of extraprostatic disease extension in patients with clinical localized prostate cancer.
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Affiliation(s)
- Alexandre Crippa
- Division of Urology, Federal University of Sao Paulo, UNIFESP, Sao Paulo, SP, Brazil.
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Abstract
Prostate cancer remains the most common noncutaneous human malignancy, and the second most lethal tumor among men. However, the natural history of the disease is often prolonged, and the survival benefits of local therapy for men with low-risk tumors may not be realized for a decade or more, as is increasingly well demonstrated in long-term observational cohorts in both the United States and Europe. A significant proportion of men with prostate cancer may be overdiagnosed, in the sense that diagnosis may not improve their lifespan or quality of life. However, the extent to which overdiagnosis represents a true problem relates to the consistency with which diagnosis leads invariably to active treatment. Prostate cancer is diagnosed at progressively earlier stages and with lower risk features; despite these trends, patients are less likely now than a decade ago to undergo a trial of active surveillance. Rates of brachytherapy and hormonal therapy use, in particular, have risen markedly. Important progress has been made in recent years in prostate cancer risk assessment. These advances, in combination with biomarkers in later stages of development, should be expected in the coming years to yield further improvements in clinicians' ability to diagnose prostate cancer early, and guide appropriately selected patients toward increasingly tailored treatment.
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Affiliation(s)
- Matthew R Cooperberg
- Department of Urology, UCSF Comprehensive Cancer Center, University of California, San Francisco, CA 94115-1711, USA
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Antunes AA, Srougi M, Dall'Oglio MF, Crippa A, Campagnari JC, Leite KRM. The percentage of positive biopsy cores as a predictor of disease recurrence in patients with prostate cancer treated with radical prostatectomy. BJU Int 2005; 96:1258-63. [PMID: 16287441 DOI: 10.1111/j.1464-410x.2005.05823.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To analyse the prognostic value of the percentage of positive biopsy cores (PPBC) in determining the pathological features and biochemical outcome of patients with prostate cancer treated by radical prostatectomy, as published data evaluating the prognostic value of PPBC in such patients have limitations. PATIENTS AND METHODS A group of 534 patients with clinically localized prostate cancer was selected. The PPBC was defined as the number of positive biopsy cores/total number of biopsy cores x 100, and grouped into categories of <25%, 25.1-50%, 50.1-75% and 75.1-100%. Patients were divided in low-, intermediate- and high-risk groups according to the usual variables. RESULTS The mean follow-up was 60.5 months. PPBC was associated with the preoperative serum prostate-specific antigen (PSA) level, biopsy Gleason score and clinical stage. On multivariate analysis, PPBC was a significant predictor of extraprostatic disease and seminal vesicle involvement. Of patients in the four PPBC categories, 16%, 27%, 33% and 60%, respectively, had biochemical recurrence (P < 0.001), and on Cox regression analysis, PPBC was an independent predictor of disease recurrence. After segregating patients into risk groups the PPBC further stratified patients using thresholds of 75% (P = 0.006), 25% (P = 0.026) and 50% (P = 0.011) for low-, intermediate- and high-risk groups, respectively. CONCLUSIONS We confirmed, with a longer follow-up, the clinical utility of the PPBC in determining the pathological features and biochemical outcome of patients with prostate cancer treated with radical prostatectomy, and established thresholds for use in patients in the three risk groups.
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Affiliation(s)
- Alberto A Antunes
- Division of Urology, Paulista School of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
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Dall'Oglio MF, Crippa A, Oliveira LC, Neves Neto JF, Leite KR, Srougi M. Prediction of pathological stage in prostate cancer through the percentage of involved fragments upon biopsy. Int Braz J Urol 2005; 31:445-51. [PMID: 16255790 DOI: 10.1590/s1677-55382005000500005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2005] [Accepted: 05/16/2005] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION The need for defining the extension of disease in patients undergoing radical prostatectomy due to prostate adenocarcinoma is a relevant factor cure in such individuals. In order to identify a new independent preoperative factor for predicting the extension of prostate cancer, we assessed the role of the percentage of positive fragments upon biopsy. MATERIALS AND METHODS A retrospective study compared the percentage of positive fragments on biopsy with the extension of disease as defined by the pathological examination of the surgical specimen from 898 patients undergoing radical prostatectomy due to clinically localized prostate cancer. RESULTS On the univariate analysis, the percentage of positive fragments on biopsy showed a statistical significance for predicting confined disease (p < 0.001), which was found in 66.7% of the cases under study. Additionally, we observed that the total number of removed fragments exerts no influence on the extension of the disease (p = 0.567). CONCLUSION the percentage of positive fragments is an independent factor for predicting the pathological stage of prostate adenocarcinoma, and the number of removed fragments is not related to the extension of the disease.
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Affiliation(s)
- Marcos F Dall'Oglio
- Division of Urology, Paulista School of Medicine, Federal University of Sao Paulo, UNIFESP, Sao Paulo, SP, Brazil.
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Maygarden SJ, Pruthi R. Gleason grading and volume estimation in prostate needle biopsy specimens: evolving issues. Am J Clin Pathol 2005; 123 Suppl:S58-66. [PMID: 16100868 DOI: 10.1309/28ftju4tb2d77242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
The Gleason grading system for prostate cancer is a powerful tool that can help choose therapy and predict outcome for patients. The clinical use and problem areas of the Gleason grading system are reviewed. The issues discussed include grade discrepancies between prostate biopsy and resection specimens, grading small foci of tumor, diagnosing and grading cribriform lesions, reporting the grade when 3 grades of cancer are present in a specimen, and assignment of grade when multiple cores of differing grades are present. Finally, differing ways of communicating tumor volume and the percentage of high-grade carcinoma in prostate biopsy cores are considered.
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Affiliation(s)
- Susan J Maygarden
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC 27599-7525, USA
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Antunes AA, Leite KR, Dall'Oglio MF, Crippa A, Nesrallah LJ, Srougi M. Prostate biopsy: is age important for determining the pathological features in prostate cancer? Int Braz J Urol 2005; 31:331-7. [PMID: 16137401 DOI: 10.1590/s1677-55382005000400006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2005] [Accepted: 06/08/2005] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The influence of age on the aggressiveness of prostate cancer (PCa) is controversial. This study aims to assess the influence of age in determining the pathological features of biopsies from patients diagnosed with PCa. PATIENTS AND METHODS We selected 1422 patients with clinical suspicion of PCa; among them, 547 (38.5%) had received a diagnosis of adenocarcinoma. Patients were categorized into the following age groups: up to 50 years old, 51 to 60 years, 61 to 70 years, 71 to 80 years, and over 80 years. The evaluated variables were histological grade, presence of perineural invasion and estimate of tumor volume through measurement of the maximum percentage of tissue with cancer in one fragment and total percentage of tissue with cancer in the sample. RESULTS The mean age of patients was 66.4 years, with age range from 32 to 94 years. The estimate of tumor volume by maximum percentage of tissue with cancer in one fragment (p = 0.064), total percentage of tissue with cancer in the sample (p = 0.443), and Gleason score (p = 0.485) were not statistically different in relation to the age groups under study. The presence of perineural invasion occurred more frequently among the 50 years and 81 years age groups when compared with patients aged from 51 to 60 and from 61 to 80 years (p = 0.005). CONCLUSIONS Age did not represent a determining factor for pathological findings concerning Gleason score and estimate of tumor volume by the variables in use.
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Affiliation(s)
- Alberto A Antunes
- Laboratory of Surgical and Molecular Pathology, Syrian Lebanese Hospital, Sao Paulo, SP, Brazil.
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Cooperberg MR, Pasta DJ, Elkin EP, Litwin MS, Latini DM, DuChane J, Carroll PR. The University of California, San Francisco Cancer of the Prostate Risk Assessment score: a straightforward and reliable preoperative predictor of disease recurrence after radical prostatectomy. J Urol 2005; 173:1938-42. [PMID: 15879786 PMCID: PMC2948569 DOI: 10.1097/01.ju.0000158155.33890.e7] [Citation(s) in RCA: 522] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Multivariate prognostic instruments aim to predict risk of recurrence among patients with localized prostate cancer. We devised a novel risk assessment tool which would be a strong predictor of outcome across various levels of risk, and which could be easily applied and intuitively understood. MATERIALS AND METHODS We studied 1,439 men diagnosed between 1992 and 2001 who had undergone radical prostatectomy and were followed in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) database, a longitudinal, community based disease registry of patients with prostate cancer. Disease recurrence was defined as prostate specific antigen (PSA) 0.2 ng/ml or greater on 2 consecutive occasions following prostatectomy or a second cancer treatment more than 6 months after surgery. The University of California, San Francisco-Cancer of the Prostate Risk Assessment (UCSF-CAPRA) score was developed using preoperative PSA, Gleason score, clinical T stage, biopsy results and age. The index was developed and validated using Cox proportional hazards and life table analyses. RESULTS A total of 210 patients (15%) had recurrence, 145 by PSA criteria and 65 by second treatment. Based on the results of the Cox analysis, points were assigned based on PSA (0 to 4 points), Gleason score (0 to 3), T stage (0 to 1), age (0 to 1) and percent of biopsy positive cores (0 to 1). The UCSF-CAPRA score range is 0 to 10, with roughly double the risk of recurrence for each 2-point increase in score. Recurrence-free survival at 5 years ranged from 85% for a UCSF-CAPRA score of 0 to 1 (95% CI 73%-92%) to 8% for a score of 7 to 10 (95% CI 0%-28%). The concordance index for the UCSF-CAPRA score was 0.66. CONCLUSIONS The UCSF-CAPRA score is a straightforward yet powerful preoperative risk assessment tool. It must be externally validated in future studies.
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Affiliation(s)
| | | | | | | | | | | | - Peter R. Carroll
- To whom correspondence should be addressed, at UCSF/Mt. Zion Cancer Center, 1600 Divisadero St, 3d Floor, San Francisco, CA 94115-1711. tel (415)353-7098, fax (415)353-7093,
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Meng MV, Elkin EP, Latini DM, Duchane J, Carroll PR. TREATMENT OF PATIENTS WITH HIGH RISK LOCALIZED PROSTATE CANCER: RESULTS FROM CANCER OF THE PROSTATE STRATEGIC UROLOGICAL RESEARCH ENDEAVOR (CaPSURE). J Urol 2005; 173:1557-61. [PMID: 15821485 DOI: 10.1097/01.ju.0000154610.81916.81] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Pretreatment risk assessment models facilitate more appropriate selection of treatment for prostate cancer. However, men with high risk disease remain a challenge with significant potential for primary treatment failure. We characterize patterns of treatment for high risk prostate cancer in a community based cohort. MATERIALS AND METHODS In the Cancer of the Prostate Strategic Urological Research Endeavor (CaPSURE) database, a longitudinal disease registry of men with prostate cancer, we identified those with nonmetastatic, high risk disease based on T stage, tumor grade and serum prostate specific antigen (PSA). Differences in primary treatment, and the use of neoadjuvant and adjuvant therapy in patients at low, intermediate and high risk were assessed. In the high risk cohort predictors of the type of primary treatment, and the use of neoadjuvant and adjuvant androgen therapy were identified. RESULTS Of the cancers 34%, 40% and 26% were low, intermediate and high risk, respectively. Differences in primary treatment type among the 3 risk groups were statistically significant (p <0.0001) with increasing external beam radiation therapy and androgen deprivation, and decreased surgery, brachytherapy and surveillance in men with high risk cancers. In this group older age, higher PSA and nonprivate insurance were associated with decreased use of radical prostatectomy. More than half of the men at high risk receiving radiation therapy also received androgen deprivation, which was significantly higher than in the low and intermediate risk groups (p <0.0001). Factors associated with androgen deprivation in high risk disease were primary therapy, PSA, Gleason sum, T stage, body mass index, insurance status and ethnicity. PSA and Gleason sum were the primary determinants of adjuvant radiation after prostatectomy. CONCLUSIONS Men with high risk but nonmetastatic prostate cancer are more likely to receive radiation therapy as well as androgen deprivation with the latter as primary therapy or in conjunction with local treatment. These data stress the importance of pretreatment risk stratification, education regarding appropriate combinations of local and systemic therapies, and the consideration of novel clinical trials in patients at higher risk.
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Affiliation(s)
- Maxwell V Meng
- Department of Urology, Program in Urologic Oncology, Urologic Outcomes Research Group, University of California-San Francisco Cancer Center, University of California-San Francisco, San Francisco, California 94115-1711, USA.
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Antunes AA, Dall'Oglio MF, Sant'Anna AC, Paranhos M, Leite KRM, Srougi M. Prognostic value of the percentage of positive fragments in biopsies from patients with localized prostate cancer. Int Braz J Urol 2005; 31:34-41. [PMID: 15763006 DOI: 10.1590/s1677-55382005000100007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2004] [Accepted: 01/20/2005] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess the prognostic value of the percentage of positive fragments (PPF) in biopsies from patients with localized prostate cancer (PCa) undergoing radical prostatectomy. MATERIALS AND METHODS During the period from March 1991 to November 2000, 440 patients were selected. Cases receiving neoadjuvant or adjuvant hormone therapy, or adjuvant radiotherapy, were excluded, as were cases presenting Gleason scores higher than 6 at biopsy. PPF was defined as the total number of fragments divided by the total number of biopsy fragments times 100. This variable was initially divided into categories from 0 to 25%, 25.1% to 50%, 50.1 to 75% and 75% to 100%. During the postoperative period, patients were assessed every 2 months for 1 year, then every 6 months for 5 years, and then yearly. Biochemical recurrence was defined as serum PSA higher than or equal to 0.4 ng/mL. Median follow-up was 60 months. RESULTS One hundred and nine (24.8%) of the 440 patients under study had biochemical recurrence. In the univariate analysis, PPF significantly influenced disease-free survival (log-rank, p < 0.001), and patients with PPF between 75 and 100% presented a risk of a biochemical recurrence of the disease 3 times higher than patients with PPF between 0 and 25% (p < 0.001). After the Cox regression analysis, both serum PSA (p = 0.001) and PPF (p < 0.001) showed to be independent predictive factors for disease-free survival following surgery. CONCLUSION PPF measurement in biopsy is a simple and practical method, which should be routinely used as a predictive factor for biochemical recurrence in patients with PCa presenting Gleason scores between 2 and 6.
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Affiliation(s)
- Alberto A Antunes
- Division of Urology, Paulista School of Medicine, Federal University of Sao Paulo, UNIFESP, Sao Paulo, SP, Brazil
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Cooperberg MR, Broering JM, Latini DM, Litwin MS, Wallace KL, Carroll PR. Patterns of practice in the United States: insights from CaPSURE on prostate cancer management. Curr Urol Rep 2004; 5:166-72. [PMID: 15161564 DOI: 10.1007/s11934-004-0033-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) is a national disease registry of more than 10,000 patients with prostate cancer treated at 31 primarily community-based sites across the country. The database tracks oncologic and health-related quality-of-life outcomes. Because the urologists participating in the project treat according to their usual practices, CaPSURE facilitates the study of trends in disease-management strategies, offering a reflection of "real world" practice patterns. This review highlights key studies during the past several years that document downward risk migration, validates widely used prognostic nomograms, establishes prostate-specific antigen doubling time as a surrogate endpoint for disease-specific mortality, assesses the impact of treatment on patient-reported quality of life, and presents national trends in imaging test use and primary treatment strategies for localized disease.
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Affiliation(s)
- Matthew R Cooperberg
- University of California, San Francisco, Mount Zion Cancer Center, 1600 Divisadero Street, 6th Floor, San Francisco, CA 94115-1711, USA
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Freedland SJ, Terris MK, Csathy GS, Kane CJ, Amling CL, Presti JC, Dorey F, Aronson WJ. PREOPERATIVE MODEL FOR PREDICTING PROSTATE SPECIFIC ANTIGEN RECURRENCE AFTER RADICAL PROSTATECTOMY USING PERCENT OF BIOPSY TISSUE WITH CANCER, BIOPSY GLEASON GRADE AND SERUM PROSTATE SPECIFIC ANTIGEN. J Urol 2004; 171:2215-20. [PMID: 15126788 DOI: 10.1097/01.ju.0000124463.13319.0a] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We developed a preoperative model to risk stratify patients for prostate specific antigen (PSA) failure following radical prostatectomy (RP) and identify those at high risk who would be potential candidates for neoadjuvant clinical trials. MATERIALS AND METHODS A retrospective survey of 459 patients from the SEARCH Database treated with RP between 1990 and 2002 was done. Multivariate analysis was used to compare the preoperative variables of patient age, race, PSA, biopsy Gleason score, clinical stage and percent of prostate needle biopsy tissue with cancer for the ability to predict time to PSA recurrence following RP. Significant independent predictors were combined to create a novel risk grouping model. RESULTS On multivariate analysis biopsy Gleason score (p < 0.001), percent of biopsy tissue with cancer (p < 0.001) and serum PSA (p = 0.001) were the only significant independent predictors of PSA failure. Combining these 3 significant predictors of PSA failure using previously published cutoff points for each variable generated a 4 tier preoperative model for predicting biochemical failure following RP (HR 1.91 for each 1 risk category increase, CI 1.62 to 2.26, p < 0.001). The model further stratified patients who were already stratified into low, intermediate and high risk groups based on a previously described model using PSA, biopsy Gleason score and clinical stage. A simplified table was developed to predict the risk of biochemical recurrence within 2 years following surgery, as stratified by percent of tissue with cancer, PSA and biopsy Gleason score. CONCLUSIONS A combination of serum PSA, biopsy Gleason score and percent of prostate biopsy tissue with cancer define a new preoperative model for predicting PSA failure following RP. This model further stratified patients who were already stratified based on PSA, biopsy Gleason score and clinical stage, and it can be used preoperatively to identify patients at high risk who would be candidates for neoadjuvant clinical trials. Using this model an easy to use table was developed to predict preoperatively the 2-year risk of PSA recurrence following RP.
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Affiliation(s)
- Stephen J Freedland
- Department of Urology, Johns Hopkins School of Medicine, Baltimore, Maryland 21287, USA.
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Abstract
PURPOSE OF REVIEW This paper will review the current staging system for prostate adenocarcinoma patients, and will also review new information that can be combined with clinical and pathological staging in order to assess a patient's risk of success or failure of treatment. RECENT FINDINGS There has been significant stage migration of prostate cancer patients in the past 15 years, such that patients are currently being diagnosed younger, with lower clinical stages and serum prostate-specific antigen levels, and a lower risk of metastatic disease than previously. The incorporation of the results of extended prostate biopsy schemes, with stage, grade and serum prostate-specific antigen levels, improves the risk assessment of newly diagnosed prostate cancer patients. New imaging techniques, such as transrectal ultrasound Doppler flow and magnetic resonance spectroscopy hold promise for improving risk assessment. Molecular biomarkers may improve risk assessment in the future, although none are currently approved by the US Food and Drug Administration for this indication. Gene chip arrays may further refine risk assessment and assist with the identification of therapeutic targets. SUMMARY There has been significant stage migration of prostate cancer patients in the prostate-specific antigen era. Incorporating biopsy information into nomograms and risk assessment equations improves upon clinical staging and risk assessment. New imaging techniques, molecular markers and gene chip arrays hold promise for future risk assessment.
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Affiliation(s)
- Adam B Hittelman
- Department of Urology, University of California San Francisco, 94143, USA
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Cooperberg MR, Broering JM, Litwin MS, Lubeck DP, Mehta SS, Henning JM, Carroll PR. THE CONTEMPORARY MANAGEMENT OF PROSTATE CANCER IN THE UNITED STATES: LESSONS FROM THE CANCER OF THE PROSTATE STRATEGIC UROLOGIC RESEARCH ENDEAVOR (CAPSURE), A NATIONAL DISEASE REGISTRY. J Urol 2004; 171:1393-401. [PMID: 15017184 DOI: 10.1097/01.ju.0000107247.81471.06] [Citation(s) in RCA: 258] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE The epidemiology and treatment of prostate cancer have changed dramatically in the prostate specific antigen era. A large disease registry facilitates the longitudinal observation of trends in disease presentation, management and outcomes. MATERIALS AND METHODS The Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) is a national disease registry of more than 10000 men with prostate cancer accrued at 31 primarily community based sites across the United States. Demographic, clinical, quality of life and resource use variables are collected on each patient. We reviewed key findings from the data base in the last 8 years in the areas of disease management trends, and oncological and quality of life outcomes. RESULTS Prostate cancer is increasingly diagnosed with low risk clinical characteristics. With time patients have become less likely to receive pretreatment imaging tests, less likely to pursue watchful waiting and more likely to receive brachytherapy or hormonal therapy. Relatively few patients treated with radical prostatectomy in the database are under graded or under staged before surgery, whereas the surgical margin rate is comparable to that in academic series. CaPSURE data confirm the usefulness of percent positive biopsies in risk assessment and they have further been used to validate multiple preoperative nomograms. CaPSURE results strongly affirm the necessity of patient reported quality of life assessment. Multiple studies have compared the quality of life impact of various treatment options, particularly in terms of urinary and sexual function, and bother. CONCLUSIONS The presentation and management of prostate cancer have changed substantially in the last decade. CaPSURE will continue to track these trends as well as oncological and quality of life outcomes, and will continue to be an invaluable resource for the study of prostate cancer at the national level.
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Affiliation(s)
- Matthew R Cooperberg
- Department of Urology, University of California-San Francisco/Mt Zion Comprehensive Cancer Center, San Francisco, California 94115-1711, USA
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Re: Improved Clinical Staging System Combining Biopsy Laterality and TNM Stage for Men With T1c and T2 Prostate Cancer: Results From the Search Database: Reply by Authors. J Urol 2004. [DOI: 10.1016/s0022-5347(05)62467-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Buyyounouski MK, Horwitz EM, Hanlon AL, Uzzo RG, Pollack A. Re: improved clinical staging system combining biopsy laterality and TNM stage for men with T1c and T2 prostate cancer: results from the search database. J Urol 2004; 171:1246-7; author reply 1247. [PMID: 14767321 DOI: 10.1097/01.ju.0000112942.17306.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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