Recommandations en Onco-Urologie 2010 : Cancer de la prostate

Adherence to Treatment Guidelines and Associated Survival in Older Patients with Prostate Cancer: A Prospective Multicentre Cohort Study

The guidelines on prostate cancer treatment in older men recommend evaluating the patient's underlying health status before treatment selection. We aimed to evaluate the frequency of a guideline-discordant treatment (GDT), identify factors associated with GDT, and assess the relationship between GDT and overall survival. We studied patients with prostate cancer aged 70 or older included in the ELCAPA cohort between 2010 and 2019. Multivariable logistic regression assessed GDT-associated factors. The restricted mean survival time (RMST) assessed the 24- and 36-month OS using stabilized inverse probability of treatment weighting of propensity scores. We included 356 patients (median age: 81 years), and 164 (46%) received a GDT (95% confidence interval (CI) = (41-51%)). Patients with metastases were less likely to receive a GDT (adjusted odds ratio (95% CI) = 0.34 (0.17-0.69); p = 0.003). After weighting, the RMST at 24 months was shorter in the GDT group (13.9 months, vs. 17 months for compliant treatments; difference (95% CI): -3.1 months (-5.3, -1.0); p = 0.004). RMST at 36 months was 18.5 months, vs. 21.8 months (difference: -3.3 months (-6.7, 0.0); p = 0.053). GDT is common in older patients with prostate cancer and especially those with non-metastatic disease. GDT was associated with worse survival, independently of health status and tumour characteristics.

Eligibility criteria according to EAU/ESTRO/SIOG guidelines for exclusive iodine-125 brachytherapy for intermediate-risk prostate adenocarcinoma patients: impact on relapse-free survival

Purpose

Iodine-125 (¹²⁵I) brachytherapy (BT) alone for intermediate-risk (IR) prostate adenocarcinoma (PCA) is controversial. The purpose of the study was to investigate potential predictive factors in selected IR-PCA patients treated with BT.

Material and methods

Among 547 patients treated with ¹²⁵I BT between 2003 and 2013, 149 IR-PCA cases were selected according to NCCN classification after an additional exclusion of patients with prostate specific antigen (PSA) > 15 ng/ml and ISUP group 3. A relapse was defined as a biochemical failure, using ASTRO Phoenix definition, or a relapse identified on imaging. Survival curves were estimated with Kaplan-Meier method. Potential prognostic variables including EAU/ESTRO/SIOG guidelines eligibility criteria were analyzed using univariate and Cox’s proportional hazards regression analysis.

Results

Of the 149 IR patients, 112 were classified as favorable, with 69 cases eligible to BT according to EAU/ESTRO/SIOG guidelines, and 37 patients were identified as unfavorable as per NCCN. Androgen deprivation therapy (ADT) was applied in 6 patients only. Percentage of positive biopsy cores were ≤ 33% and ≥ 50% for 119 and 11 patients, respectively. With a median follow-up of 8.5 years, 30 patients experienced a relapse. 10-year overall survival, progression-free survival (PFS), and relapse-free survival (RFS) were 84% (95% CI: 75-90%), 66% (95% CI: 56-75%), and 77% (95% CI: 67-84%), respectively. Failure to meet EAU/ESTRO/SIOG criteria was significantly associated with a lower RFS (p = 0.0267, HR = 2.37 [95% CI: 1.10-5.08%]).

Conclusions

Brachytherapy is an effective treatment for selected IR-PCA cases. Patients who were not eligible according to EAU/ESTRO/SIOG guidelines demonstrated a lower RFS.

Metastatic prostate cancer: clinical aspects and treatment limitations in a university hospital center in Senegal

Background

Prostate cancer is most often diagnosed at the metastatic stage in many sub-Saharan African countries. The objective of our study is to analyze the management of metastatic prostatic adenocarcinoma based on epidemiological, clinical, therapeutic and evolutionary aspects in developing country context.

Methods

Retrospective study collecting 276 patients from January 1st, 2012 to December 31st, 2019 in Aristide Le Dantec University Hospital in Dakar, Senegal. Parameters studied: age, family history of prostate cancer, reasons for consultation, total Prostate Specific Antigen (PSA), anatomic pathology examination, extension assessment, treatment, nadir PSA, castration resistance, and overall survival.

Results

The average age was 71.4 years. A family history of prostate cancer was noted in 21 patients. Spinal pain was the most noted reason for consultation. The average total PSA level was 1967.1 ng/ml. The majority of patients had moderately differentiated prostate cancer. Bone metastases were the most common. All patients had androgen suppression. A tumor cytoreduction was performed in 89 patients. The average nadir PSA was 193 ng/ml as early as the sixth month. The time to onset of castration resistance ranged from 6 to 30 months. Abiraterone acetate was used in seven patients and docetaxel in 43 patients. The overall survival of the patients was 19.8 ± 1.2 months.

Conclusion

Metastatic prostate cancer was most often symptomatic at the time of diagnosis. Second-line treatments were rarely used during castration resistance. Overall survival was low.

Changes in prostate cancer screening practice by blood PSA testing between 2011 and 2017, a French population-based study

OBJECTIVE

The aim of the study was to determine the trend of first blood prostate-specific antigen (PSA) test prescription in France between 2011 and 2017, based on the assumption that prostate cancer (PCa) screening is expected to decline over the years.

METHOD

Using a representative sample of the French population from the French Health Insurance database, we identified 50-52-year-old men without PCa and without any blood PSA test in the five years before 2011, 2014 and 2017 (January 1-December 31 of each year). For each of these three years, the primary outcome was the first reimbursement of a blood PSA test. We used a logistic regression model with first blood PSA test as the outcome and year as the main explanatory variable. As secondary objectives, we also identified the prescriber's specialty, the urological consultation frequency, and the number of prostate biopsies in the year after the first blood PSA test reimbursement (only for 2011 and 2014).

RESULTS

In 2011, 2014 and 2017, 5 275, 5 792 and 5 887 50-52-year-old men, respectively, were included. The percentage of patients with a first blood PSA test prescription decreased linearly from 2011 to 2017: 15.7% in 2011, 13.2% in 2014, and 12.4% in 2017 (p < .001). Blood PSA testing was mainly prescribed by general practitioners (>95%). The median interval between PSA tests was 13 months in 2011 and 14 months in 2014. Fewer than 10% of men had ≥1 consultation with an urologist during the year after the first blood PSA test. After the first blood PSA test, eight prostate biopsies were performed in 2011 and two in 2014.

CONCLUSION

Our results suggest that in France, PCa screening is a primary care issue. Although PCa screening remains controversial and confusion exists about the best practice, our study showed a linear decrease of blood PSA test prescriptions for 50-52-year-old men between 2011 and 2017, although the reason for screening was unknown. As clinical information was not available, additional evidence is needed to determine the real impact of this decrease on the cancer-specific and overall mortality.

Clinical, Histopathological, and Prognostic Characteristics of Patients with Prostate Cancer in Lubumbashi, Democratic Republic of Congo

INTRODUCTION

Prostate cancer is currently a public health problem with a frequency that varies from country to country. This study aims to describe the epidemiological, clinical, and histopathological and outcome features of prostate cancer in Lubumbashi in the Democratic Republic of Congo.

MATERIALS AND METHODS

This was a descriptive longitudinal study of patients diagnosed with prostate cancer at the University Clinics of Lubumbashi. The study period was 3 years (2017 to 2019). Parameters studied were age and clinical, biological (PSA level, prostatic specific antigen), histopathological, and outcome features.

RESULTS

The mean age of patients was 68.7 years (range: 47 and 90 years). The 60 to 69 age group was the most affected (43.18%). Elderly subjects (≥60 years old) represented 89.77% of the cases (n = 79). Voiding disorders were the main reason for consultation in 55.68% of the cases. The mean PSA level was 133.7 ng/ml (range: 4 and 1564.5 ng/ml) at diagnosis and 125.4 ng/ml after 3 months of follow-up (range: 0.16 and 1782.1 ng/ml). Adenocarcinoma was the predominant histological type (100%). In prognosis, 31.82% of patients had a Gleason score greater than 7 and 59.10% had a high risk at the D'Amico risk classification for Prostate Cancer. Hormone therapy was administered alone in 75% of the cases and in combination with pulpectomy in 13.64% of the cases. The 3-year overall survival was 56.82%.

CONCLUSION

Prostate cancer is frequent and has a poor outcome in our country. The establishment of an individual screening policy would be an undeniable advantage in improving the prognosis.

[12-year history of radical surgery indications for the treatment of prostate cancer]

AIM

To analyze the indications of radical prostatectomy and lymph node dissection retained during the last 12 years in an academic surgical center in the Paris region in order to ensure their adequacy in relation to the current clinical guidelines.

METHOD

Monocentric retrospective study of prospectively collected data, between 2007 and 2019. Analysis of the clinical and pathological characteristics which were taken into account during multidisciplinary meeting discussion for the treatment decision, and comparison of their evolution over the four 3-year period corresponding to the clinical guideline updates.

RESULTS

Two thousand eighty-eight consecutive patients treated by radical prostatectomy between 16/03/2007 and 17/03/2019 were included. The proportion of patients classified as low, intermediate or high risk according to D'Amico system was 13.2%, 80.8% and 6.0% respectively. An increase in the frequency of surgical treatment of high-risk cancers has been observed. At the same time, there has been a decrease in the frequency of prostatectomies to treat low-risk cancers.

CONCLUSION

The indications for radical prostatectomy and lymph node dissection have evolved in line with the current clinical guidelines which were taken into consideration in a onco-urological multidisciplinary meeting.

LEVEL OF EVIDENCE

3.

Parameter identification of a model for prostate cancer treated by intermittent therapy

Adenocarcinoma is the most frequent cancer affecting the prostate walnut-size gland in the male reproductive system. Such cancer may have a very slow progression or may be associated with a "dark prognosis" when tumor cells are spreading very quickly. Prostate cancers have the particular properties to be marked by the level of prostate specific antigen (PSA) in blood which allows to follow its evolution. At least in its first phase, prostate adenocarcinoma is most often hormone-dependent and, consequently, hormone therapy is a possible treatment. Since few years, hormone therapy started to be provided intermittently for improving patient's quality of life. Today, durations of on- and off-treatment periods are still chosen empirically, most likely explaining why there is no clear benefit from the survival point of view. We therefore developed a model for describing the interaction between the tumor environment, the PSA produced by hormone-dependent and hormone-independent tumor cells, respectively, and the level of androgens. Model parameters were identified using a genetic algorithm applied to the PSA time series measured in a few patients who initially received prostatectomy and were then treated by intermittent hormone therapy (LHRH analogs and anti-androgen). The measured PSA time series is quite correctly reproduced by free runs over the whole follow-up. Model parameter values allow for distinguishing different types of patient (age and Gleason score) meaning that the model can be individualized. We thus showed that the long-term evolution of the cancer can be affected by durations of on- and off-treatment periods.

[Interest of surgical companionship during the training period of robot-assisted radical prostatectomy]

OBJECTIVE

Study of the learning curve of robot-assisted radical prostatectomy, evaluating intraoperative difficulties and postoperative complications according to Clavien-Dindo classification.

PATIENTS AND METHODS

Retrospective study of our first 157 consecutive patients treated with robot-assisted prostatectomy for localized prostate cancer between September 2011 and December 2014. Comparison of learning for each group of 50 procedures and then comparison between patients operated on by a pair of two seniors specially trained for robotic surgery and patients operated on by one mixed pair including a surgeon junior coached by one senior of the first group.

RESULTS

Only postoperative complications decreased significantly from the 51st patient (P=0.04). The curves showing the evolution of the operative time decreased with a parallel trend between the two pairs, but with more variability in the mixed pair. There was no significant difference in terms of intraoperative difficulties (P=0.59), nor postoperative complications (P=0.56) mainly of grade 2. The blood loss, transfusion rate, duration of hospitalization and readmission rates did not differ. Lymph node dissection did not affect outcomes. For oncological results, the overall rate of positive surgical margins (R+) was 30.6 % in the initial pair against 24.2 % in the mixed group with no significant difference. Nevertheless, the subpopulation study objectified a R+ rate of 12.86 % for pT2 against 42.85 % for pT3.

CONCLUSION

The early involvement of a junior surgeon who did not receive specific training, but benefiting from the guidance of a senior surgeon, did not compromise the results while allowing a faster learning curve with a rate of operative complications close to the one observed by the senior pair.

LEVEL OF EVIDENCE

4.

[Prostate cancer: Quality assessment of clinical management in the Midi-Pyrenean region in 2011]

OBJECTIVES

Assessing the quality of the clinical management of prostate cancer in the Midi-Pyrenean region in 2011.

METHODS

The study population was randomly selected among new cases of prostate cancer presented in Multidisciplinary Team Meeting (MTM) in 2011. The indicators defined with the professionals have evaluated the quality of the diagnostic care, when treatment started and at the time of the MTM.

RESULTS

Six hundred and thirty-three new patients were included (median age at diagnosis=69years, min: 48; max: 93). In diagnostic period, 92% of patients had a prostate biopsy. Performing a pelvic MRI, an abdomino-pelvic CT and bone scintigraphy concerned respectively 53%, 55% and 61% of intermediate or high-risk patients. The Gleason score, surgical margins and pathological stage were included in over 98% patient records treated by radical prostatectomy. A PSA assay in 3months after prostatectomy was found in 59% of surgical patients. The MTM was performed before treatment to 83% of patients. About three-quarters of surgical patients with stage pT≥3 or pN1 or with no healthy margins were discussed in MTM after surgery.

CONCLUSION

Most of the studied indicators reach a high level. However, the lower level of realization of complementary examinations may question about their real place, accessibility and traceability.

LEVEL OF EVIDENCE

4.

Current practice and access to prostate MR imaging in France

PURPOSE

To obtain an overview of the degree of discrepancy between current clinical practice of prostate magnetic resonance imaging (MRI) in France and recommendations.

MATERIALS AND METHODS

A brief survey was sent to 1229 members of the French society of urology in order to identify their indications of prostate MRI and its impact on patient management. The urologists were asked to answer several questions regarding age, practice modality, prostate MRI examinations (technique, indication before first biopsy, second biopsy, cancer staging, active surveillance, recurrence, focal therapy) and quality of reports.

RESULTS

A total of 445 responses were received (participation rate of 36%). The mean delay for obtaining an appointment for prostate MRI ranged between 15-30 days in 54%. Fifty-four percent of MRI reports contained a PIRADS score and 23% a Likert score. The indications of multiparametric-MRI were tumor detection/location prior to repeat biopsy (90%), cancer staging (85%), management of patients under active surveillance (85%), selection of candidates to focal therapy (63%), tumor detection/location in biopsy naïve patients (53%), detection of local recurrence after radical (51%). Only 119 urologists (28.6%) had access to image fusion (MRI and transrectal ultrasound) and 351 (85.4%) used cognitive fusion. Mostly, targeted biopsies are done by urologists alone (nearly 80%), a very few are done by radiologists (8%) or by the two of them in collaboration (12%).

CONCLUSION

The majority of urologists consider that prostate MRI is essential for the management of patients with prostate cancer. Practices are ahead of recommendations particularly before the first biopsy and in active surveillance.

[Can preoperative prostate MRI before radical prostatectomy predict extracapsular extension and the side of the index lesion?]

AIM

To evaluate the role of preoperative multi-parametric magnetic resonance imaging (MP-MRI) in patients undergoing radical prostatectomy. Specifically, the accuracy of MP-MRI in detecting extracapsular extension (ECE) and individuating the side of the index lesion have been explored.

METHODS

Thirty-five consecutive patients undergoing radical prostatectomy have been retrospectively analyzed. The MRI exam incorporated T2-weighted imaging, diffusion-weighted imaging and dynamic contrast enhancement in all patients. χ(2) test was performed to assess an association between an MP-MRI suggestive of ECE and pathologic ECE; similar tests were performed to study the association between the MRI-detected side of the index lesion and its true localization on final pathology. Univariate logistic regression models were constructed to evaluate possible predictors of ECE, including MP-MRI suspected ECE.

RESULTS

Seventeen percent (6/35) of men presented ECE on final pathology. MP-MRI was predictive of pathologic ECE with a negative predictive value and specificity of 93% and 90%, respectively. Global accuracy of MP-MRI in predicting ECE was 86%. MRI-detected ECE was significantly predictive of pathologic ECE on logistic regression (OR: 17.3, 95% CI: 2.2-138.2, P=0.007). Moreover, MRI significantly predicted the side of the index lesion (P=0.012).

CONCLUSIONS

In this single center cohort, preoperative MP-MRI was significantly predictive of ECE and side of the index lesion. Further studies are necessary to individuate patients who can benefit from preoperative MP-MRI.

LEVEL OF EVIDENCE

5.

[Prostate cancer treated with androgen deprivation therapy: Care and monitoring in daily practice]

OBJECTIVE

Our purpose was to identify measures implemented by urologists and radiation oncologists at the initiation of a 6-month formulation of luteinizing hormone releasing hormone (LHRH) agonist in patients with advanced PCa.

MATERIAL

This cross-sectional cohort survey was conducted during 6 months. Participants completed a questionnaire of 15 items on the first prescription of an androgen deprivation therapy (ADT), the parameters prescribed for monitoring and information provided to patients.

RESULTS

The median age of the 1100 enrolled patients was 75 years (range: 51-98 years); 245 patients (29.0%) were metastatic and 411 (39.4%) had a Gleason score ≥ 8. Prior to the treatment initiation, the dosage of the total testosterone was not very often performed (4.8%). Associated comorbidities such as arterial hypertension (53.6%) and hypercholesterolemia (31.8%) did not constitute a barrier to the initiation of ADT, alone (60.5%) or combined with anti-androgens (61%). According to the recommendations of the French Association of Urology (AFU), fasting glycemia was required in 427 patients (41.1%), lipid profile in 380 (36.1%), a blood count in 219 (21.1%) and bone densitometry in 111 (10.8%). The advice given to patients involved diet and lifestyle rules (61%). The potential risks of adverse events (AEs) mentioned were mainly hot flashes (95.5%).

CONCLUSION

Some recommendations seem insufficiently followed by the French specialists on information and monitoring procedures of ADT, especially in the cardiovascular field.

[Use of MRI before biopsy in diagnosis of prostate cancer: Single-operator study]

The diagnostic for prostate cancer is changing. To improve the detection of this cancer, urologists expect a lot from the contribution of magnetic resonance imaging (MRI). What is the role of this imaging in prostate cancer detection? This is a retrospective study, from 2011 to 2013, mono-centric and single-operator. Of the 464 needle biopsy of the prostate (BP), we excluded those with PSA>20 ng/mL or digital rectal examination (DRE)>T3. The remaining 430 BP were submitted or not to a 1.5 tesla MRI with pelvic antenna. The primary aim is the overall detection of prostate cancer. Secondary aim was the detection rate during the first series of BP and repeat BP, between the two groups in the MRI group. MRI and MRI without populations are comparable for age (63.3 vs 64.6), PSA (6.10 vs 6.13), DRE>T1c, prostate volume (55.4 cm(3) vs 51.7 cm(3)). There is no significant difference in overall detection between the two groups (P=0.12). There is no significant difference in cancer detection between the first BP (P=0.13) and the repeat BP (P=0.07). There is a significant difference in the early detection of BP MRI group (P=0.03) but not for the BP repeat MRI group (P=0.07). For 108 BP iterative MRI group, there were 67 BP targeted "mentally" with MRI: 18 cancers were detected, making a 25% detection rate. This study helps to highlight the value of MRI in the early rounds of BP but we can ask the value of this imaging during repeat biopsies. Targeted biopsies "mentally" do not have the expected detection sensitivity and seems to require a three-dimensional reconstruction to be more effective.

LEVEL OF EVIDENCE

5.

What risk of prostate cancer led urologist to recommend prostate biopsies?

OBJECTIVE

The aim of this study was to estimate the risk of prostate cancer that led urologists to perform prostate biopsies.

PATIENTS AND METHODS

Eight hundred and eight patients had prostate biopsies in 5 tertiary centres in 2010. Following data were collected: age, PSA, DRE, prostate volume, negative prior prostate biopsy and estimated life expectancy (> or <10 years). The risk of prostate cancer was calculated by validated nomogram of PCPT-CRC and SWOP-PRI and correlated with pathological biopsy results.

RESULTS

In final analysis, 625 patients were included, 568 (90.9%) had a life expectancy greater than 10 years. Prostate cancer was found in 291 (46.6%) cases. These patients were older (66.7 ± 6.8 vs 64.3 ± 5.6 years, P < 0.001), had higher PSA values (10 ± 7.9 vs 7.7 ± 4.3 ng/mL, P < 0.0001) and the prostate volume decreased (43.8 ± 19.8 vs 51.3 ± 20.7 mL, P < 0.0001) compared with healthy subjects. Digital Rectal Examination was more frequently suspicious in the group of patients with prostate cancer (43.6% vs 18.9%, P < 0.0001). Risk of prostate cancer estimated was 50.6 ± 14% for PCPT-CRC without ATCD, 56.2 ± 12.8% with PCPT-CRC ATCD and 31.2 ± 17.3% for SWOP-PRI. The likelihood of high-risk prostate cancer was 22.4 ± 16.9% with the PCPT-CRC, and 14.8 ± 18.2% with SWOP-PRI.

CONCLUSION

This study showed that urologists performed prostate biopsies when the risk of cancer was high.

[Existence of pattern 5 on radical prostatectomy: poor prognostic factor associated with a lower biochemical recurrence-free survival]

OBJECTIVES

To analyze the impact of the existence of Gleason grade 5 on the adverse pathology and biochemical recurrence-free survival of patients.

PATIENTS

Three hundred and seventy-two prostatectomies were performed between 1999 and 2011 in our institution for localised prostate adenocarcinoma. We examined the existence of grade 5 of the specimen to determine the reliability of prostate biopsies in the diagnosis of grade 5 and the association of grade 5 with other histoprognostic factors. Biochemical recurrence-free survival was analyzed according to the presence of grade 5 in the final specimen.

RESULTS

In total, all histological data and biochemical recurrence-free survival were available for 321 patients who were included in the study. Sixty-eight had Gleason grade 5 (majority or third minority pattern) on the specimen while 253 had not. Grade 5, rarely diagnosed on biopsy (sensitivity=26.47 %) was correlated independently with the extracapsular extension (OR=2.1; CI 95 [1.1-3.9]), the seminal vesicle invasion (OR=3.8; CI 95 [1.7-8.7]) and positive surgical margins (OR=2.0; CI 95 [1.1-3.6]). Overall survival was similar in both groups but the biochemical recurrence-free survival was statistically lower in the presence of grade 5 (HR=3.7; CI 95 [1.8-7.6]). Biochemical recurrence-free survival was not different than grade 5 is predominant or third minority pattern (HR=1.01; CI 95 [0.3-2.8]). On multivariate analysis, grade 5 was an independent risk factor for biochemical recurrence (P=0.005) as well as seminal vesicle invasion (P=0.047).

CONCLUSION

The existence of grade 5 in the surgical specimen whatever the percentage was a poor prognostic factor associated with increased tumor aggressiveness and reduced biochemical recurrence-free survival.

LEVEL OF EVIDENCE

5.

[Observational survey of the French Urological Association evaluating intermittent hormonal modalities treatment in prostate cancer in France]

OBJECTIVE

To assess clinical practice of intermittent hormone therapy (IHT) among urologists members of the French Association of Urology.

METHODS

Internet-based observational survey evaluating IHT modalities in prostate cancer using questionnaire sent to 941 urologists.

RESULTS

Two hundred and sixty nine urologists participated in the survey (response rate 28.6 %) including 90.3 % prescribing IHT. The main reasons for IHT were improvement of quality of life in 94.2 %, clinical tolerance in 73.7 %, decreased costs and oncological equivalence in 44 %. The indications were localized prostate cancer (low risk 22.6 %, intermediate 19.8 %, high 14 %), locally advanced (59.7 %), metastatic (63.4 %), biochemical recurrence after local treatment (prostatectomy 62.1 %, radiotherapy 73.7 %). A PSA <2 ng/mL was considered as the threshold for androgen deprivation therapy break in 70 % of cases regardless of the IHT indication. The PSA threshold selected for the re-initiation of treatment was 4 ng/mL in 37.9 % and 10 ng/mL in 36.6 % of cases. The cycle of IHT was 6 months in 60 % of cases.

CONCLUSION

This survey provided a snapshot of the practice of IHT in France. Even in the absence of level of evidence 1 trials in the literature, most urologists used IHT in their clinical practice, for many indications, especially in case of biochemical recurrence after local treatment.

LEVEL OF PROOF

3.

[Comparative study of histological results between resection and biopsy of the prostate]

PURPOSE

To evaluate the histological correlation between transuretral resection chips and biopsy cores within a population of patients who underwent resection of prostate (TURP) and prostate biopsies (BPx).

PATIENTS AND METHODS

Clinical and tumoral data of 77 patients who had both procedures simultaneously or with a slight delay were collected. According to the presence of prostate cancer (Pca), 4 groups were defined: group 1 (TURP and BPx negative), group 2 (TURP positive, BPx negative), group 3 (TURP negative, BPx positive), group 4 (TURP and BPx positive). Means and proportions were compared using Anova and χ(2) test, respectively.

RESULTS

The patients were older in groups 3 and 4 (79 and 76 respectively, P=0.65). The PSA was higher in the groups 3 and 4 (64 and 55 ng/mL) than the groups 1 and 2 (10.6 et 16 respectively, P=0.23). The number of positive biopsy was higher in the group 4 than the group 3 (5.6 vs. 4.6, P<0.0001), the chips were more invaded in the group 4 than the group 2 (41% vs. 11% P<0.0001), the Gleason score at TURP was higher in the group 4 than the group 2 (7.5 vs. 6.2 P<0.0001).

CONCLUSION

Our study underlines that the Pca of transition and peripheral zones seems to have distinct characteristics. When chips of TURP and BPx were both invaded, it was due to an aggressive cancer. The decision to explore the peripheral zone in the case of positive TURP must take clinical context into consideration.

DNA comparison between operative and biopsy specimens to investigate stage pT0 after radical prostatectomy

PURPOSE

The aim was to eliminate, by DNA comparison, any identity mismatch between operative and biopsy specimens and to analyse the determinants of all pT0 prostate cancers occurred in a single institution.

METHODS

All prostate pT0 cases in a single institution over 20 years were investigated. None of the patients had been diagnosed after a transurethral resection of the prostate nor had they received neoadjuvant hormonal treatment. The biopsies performed in other centres had been referred for a centralized pathologic re-analysis. DNA analysis was performed in samples from operative and biopsy specimens, and pairs of tissues were blindly constituted. Correct matching was verified in each pair and compared to the original database in order to comment on the occurrence of identity mismatches in the series.

RESULTS

Nineteen patients (0.77 %) had been diagnosed as having pT0 prostate cancer among the 2,462 RP procedures performed over 19 years. The biopsy re-analysis invalidated the initial diagnosis of prostate cancer in one biopsy set performed elsewhere. Among 12 entirely processed cases, the biochemistry procedure evaluated as "very unlikely" the occurrence of an error in tissue identification in the biopsy setting, during the surgical procedure or the pathological analysis. No identification error of tissue samples was established in this first verified pT0 series.

CONCLUSIONS

Although it must be suspected, specimen identification error was not a cause for pT0 prostate cancer. Only after a full pathological and DNA verification, the pT0 stage remains a sole entity, unexplained in most cases.

[Neoadjuvant before surgery treatments: state of the art in prostate cancer]

GOAL

To study the impact of systemic treatment in neoadjuvant strategy before surgery in prostate cancer.

MATERIALS

Literature reviews with data analysis from PubMed search using the keywords "neoadjuvant", "chemotherapy", "hormonal therapy", "prostate surgery", "radical prostatectomy", but also reports from ASCO and ESMO conferences. The articles on neoadjuvant treatment before radiotherapy were excluded.

RESULTS

First studies with former therapy are more than 15-years-old and with questionable methodology: lack of power to have a clear idea of the impact on survival criteria such as overall survival or relapse-free survival. However, the impact of neoadjuvant hormone therapy on the classic risk factors for relapse (positive margins, intraprostatic disease, positive lymph nodes) was demonstrated by these studies and a Cochrane meta-analysis. The association with hormone therapy seems mandatory in comparison to treatment based solely on chemotherapy and/or targeted therapy. Promising data on the use of new drugs and their combinations arise: abiraterone acetate combined with LHRH analogue showed a fast PSA decrease and higher rates of pathologic complete response. Other results are promising with hormonal blockages at various key points.

CONCLUSION

Studies with 2nd generation anti-androgene agents or enzyme inhibitors seem to show very promising results. To provide answers about the effectiveness of current neoadjuvant strategy in terms of survival, other studies are needed: randomized phase III or phase II exploring predictive biomarkers. The design of such trials requires a multidisciplinary approach with urologists, oncologists, radiologists and methodologists.

[Stage IV prostate cancer in Guadeloupe, a French Caribbean archipelago]

OBJECTIVES

To study clinical characteristics, in terms of survival and response to treatment, of patients with non-localized prostate cancer at diagnosis in an Afro-Caribbean population from Guadeloupe.

METHODS

Cases of stage IV prostate cancer (T4N0M0, TxN1M0 and TxNxM1) at diagnosis in the Pointe à Pitre Hospital were selected from 1995 to 2012 and studied.

RESULTS

One hundred and eighty-three patients were included. Median age at diagnosis was 70.3 years old (79.2% were more than 65 years). A total of 81.5% of them was TxNxM1 and 11.5% was TxN1M0. Median disease free survival was 18.5 months. Median overall survival was 49.0 months.

CONCLUSION

This study about non-localized prostate cancer at diagnosis in an Afro-Caribbean population from a French Caribbean archipelago seemed to show no difference with general population suffering from the same disease, although prostate cancer incidence in this area is one of the highest in the world.

[Prostate cancer and new hormonal treatments: mechanism of action and main clinical results]

INTRODUCTION

New drugs have recently been developed, through a better understanding of the mechanisms involved in the progression of prostate cancer, including castration-resistant ones (CRPC). This article aims to describe the mechanisms of action of these new hormonal treatments and their major clinical outcomes and development programs.

MATERIALS AND METHODS

A bibliographic research in French and English using Medline(®) and Embase(®) using the keywords "castration-resistant prostate cancer", "abiraterone acetate", "orteronel", "enzalutamide", and "clinical trials" was performed.

RESULTS

the androgen signaling pathway remains the cornerstone of advanced cancers management. Hence, some molecules target the androgen biosynthesis, as abiraterone acetate and orteronel, which are selective inhibitors of the enzyme CYP17. Others act as antagonists of the androgen receptor: the enzalutamide, RNA-509 and ODM201. Finally, galeterone combines the two effects.

CONCLUSION

Progress conferred by these molecules in terms of overall survival and quality of life in patients with metastatic CRPC, suggest that their use at earlier stages of the disease could reduce morbidity and mortality from prostate cancer. Determining the best strategy for sequence or combination therapy to optimize the use of these new molecules should be investigated.

[Corticotherapy in castration-resistant prostate cancer]

INTRODUCTION

Corticosteroids are commonly used in the treatment of prostate cancer resistant to castration (PCRC), partly due to the inhibitory effects on adrenal androgen production acting as a pituitary suppressant.

METHODS

A literature search was conducted in PubMed/MEDLINE database using the following key words: prostate cancer; castration resistance; metastasis; corticotherapy.

RESULTS

Corticosteroids exert direct anti-tumoral activities mediated by the glucocorticoids receptor and involving cellular/tissue functions as growth, apoptosis, inflammation, metastasis, differentiation and angiogenesis. As a pain relieving agents, corticosteroids significantly relieve PCRC clinical symptoms, especially those due to bone metastasis. In the comparative arm of phase II-III trials, corticosteroids administered daily produce a PSA decline. Among the adverse effects due to corticosteroids, bone loss and cardiovascular risk should be carefully monitored. In association with abiraterone acetate, corticosteroids increase overall survival in PCRC patients, and reduce the mineralocorticoid side effects of abiraterone.

CONCLUSION

Corticosteroids in monotherapy for PCRC have a limited efficacy. In association with abiraterone acetate it reduces the mineralocorticoid toxicity and enhances the androgenic suppression.

[Preoperative endorectal MRI in prostate cancer: a monocentric retrospective cohort]

INTRODUCTION

The aim of the study was to assess the added value of a prostatic MRI performed in a non-expert center before radical prostatectomy for prostate cancer.

PATIENTS AND METHODS

All patients considered for a radical prostatectomy for a clinically localised prostate cancer in our institution between June 2006 and April 2011 were analysed. They underwent a systematic endorectal 1.5 T MRI [eMRI] (T2 and diffusion-weighted imaging). The procedure was performed at least 8 weeks after transrectal ultrasound guided prostate biopsies. They were analyzed by a single experimented genitourinary radiologist. The preoperative characteristics and biopsy data were collected, as the eMRI interpretation using a systematic scale. Correlation between eMRI and final histopathology has been analyzed (standardized pathological report using the Stanford procedure). We considered the following points: extracapsular extension, seminal vesicle invasion and cancer localisation. Cancer localization was analyzed both by halves (left/right) and on sextant-basis (base, middle, apex, left and right respectively). For each data, sensitivity, specificity, positive (PPV) and negative predictive value (NPV) were calculated. Finally, we compared the results with those from the Partin's table and the Kattan's nomogram for T stage.

RESULTS

Two hundred and fifteen patients underwent a radical prostatectomy, having a mean age of 63 ± 6 years, a mean PSA: 7.8 ± 3.8 ng/mL. One hundred and fifty-nine patients had organ confined disease. Fifty-six had pT3 disease (50 pT3a and 6 pT3b). Sensibilities and specificities were the following: for extracapsular extension 26% and 96%; for seminal vesicle invasion 17% and 98%; for cancer localisation 64% and 74%; for prediction of left or right side 81% and 48%.

DISCUSSION

MRI showed equal performances compared to the Partin's table and the Kattan's nomogram for T stage. It showed lower performance compared to biopsy results for cancer localization (sensitivity 88%, specificity 70%). Literature provides wide ranges of results for eMRI. The results of this study were at the low limit of these ranges but reflect everyday practice. When performed, as it was in our study, eMRI did not seem to be accurate for staging. It had at best a very limited added value compared to the existing tools.

[Ureteral metastasis of prostatic adenocarcinoma: case report and literature review]

Ureteral metastases of prostatic adenocarcinoma are very rare. We report the case of a 66-year-old man with a right ureteral metastasis of prostate cancer. Only 10 cases have been reported in the literature these last 30 years. Most patients had a multimetastatic prostate cancer. Local treatment is not standardized. Hormonotherapy seems to be the most appropriate treatment in first intention.

[Management of rectourethral fistulas with the York Mason procedure: surgical techniques and outcomes]

OBJECTIVE

To report our experience for the management of urethro-rectal fistula by the York Mason technique.

PATIENTS AND METHODS

We retrospectively analyzed the data of patients treated surgically for FUR by the technique of York Mason, between 2000 and 2012.

RESULTS

Seventeen patients were included in the study. All patients had a bowel diversion before surgery. We observed four recurrences of FUR (23.5%). Recurrences occurred in a radiation field for two patients and in a oncologic recurrence for 1 patient. The fourth recurrence was treated by a second procedure of York Mason successfully.

CONCLUSION

In our study, the York Mason technique was safe and reproducible for the treatment of FUR. The main factor of failure was a history of pelvic radiotherapy.

[Hormonal treatment in prostate cancer]

AIM

To describe drugs used in the hormonal treatment (hormonotherapy) of prostate cancer.

MATERIAL

Bibliographical search was performed from the database Medline (National Library of Medicine, PubMed) and websites of the HAS and the ANSM. The search was focused on the characteristics, the mode of action, the efficiency and the side effects of the various drugs concerned.

RESULTS

LHRH analogs and the antiandrogens remain the cornerstone in the treatment of locally advanced and metastatic prostate cancer. New therapeutic classes emerged recently (inhibitor of the synthesis of the androgen, the new antiandrogens) and allowed to grow again the limits of the hormone resistance and define the concept castration-resistant prostate cancer.

CONCLUSION

The hormonal treatment of the prostate cancer grew rich of new therapeutic classes which are going to change the medical care of the prostate cancer in the coming years and the urologist must play its full part.

[Critical haematuria after prostate biopsies with RIVAROXABAN. Case report]

Managing patients with new oral anticoagulants in perioperative period is not yet well protocolized. We report a clinical case of a critical haematuria after prostate biopsies to a patient treated with RIVAROXABAN. Monitoring and treatment of the haematuria have been difficult due to the lack of biological control and antidote for this treatment.

[Comparative study of radical prostatectomy versus external beam radiotherapy (75.6 Gy) combined with hormone therapy for prostate cancer of intermediate D'Amico risk classification]

INTRODUCTION

Thirty-three percent of the localized cancers belongs initially to the group of intermediate risk of D'Amico. The standard treatments validated by the French Association of Urology are the radical prostatectomy and the external beam radiotherapy.

OBJECTIVES

We retrospectively compared the carcinologic results of the radical prostatectomy±adjuvant treatment (RP) and the external beam radiotherapy combining high dose (75.6 Gy) and short hormonotherapy (RH), in the treatment of intermediate risk prostate cancer. The series consisted of 143 patients treated between 2000 and 2006 in the department of Urology and Kidney transplantation of the Conception Hospital, Marseilles. The main assessment criteria was the survival without biological recurrence (SBR).

RESULTS

The median follow-up was 90 months [59-51]. The 5 years and 8 years SBR were 85% and 73% in the RH group, versus 74% and 65% with RP (P=0.196). There was a significant difference between the series: on the age of diagnosis (63.9 versus 73.3 years, P<0.001), the Charlson score of comorbidity (2 versus 3, P<0.001) and the number of intermediate criteria per patients (one intermediate criteria: RP 74% versus 57%, P<0.01).

CONCLUSION

According to our study, there was no superiority of the radical prostatectomy±adjuvant treatment or the external radiotherapy combining high dose and concomitant short hormonotherapy on the survival without biological recurrence at 5 and 8 years. Many studies confirm that a concomitant hormonotherapy increases the carcinologic control, even with a high rate external beam radiotherapy.

A new sign for detection of extracapsular extension of prostatic adenocarcinoma: sum of positive sextants per lobe combining interpretation of magnetic resonance imaging and prostate biopsy results

BACKGROUND

The objective of this study was to assess the possibility of improving the reliability of preoperative detection of extracapsular extension (ECE) in each prostate lobe by using a new sign called sum of positive sextants per lobe (SPS-L), combining interpretation of MRI and prostate biopsy results.

PATIENTS AND METHODS

We reviewed the charts of 590 patients undergoing radical prostatectomy between 2002 and 2007. All patients were assessed by preoperative 1.5 Tesla MRI using an integrated endorectal and pelvic phased array coil. A sextant was defined as "positive" when tumor infiltration was observed on a biopsy sample or a pathologic image was observed on MRI (0 = absent, 1 = present). A score, called sum of positive sextants per lobe (SPS-L), was defined as the sum of positive sextants on biopsy samples and positive sextants on MRI (MRI-L) for each lobe. A second score taking into account the presence or absence of ECE visualized on MRI (T3 MRI-L + SPS-L) was also tested for the detection of ECE per lobe.

RESULTS

On multivariate analysis, the SPS-L and T3 MRI-L + SPS-L scores were significantly higher in the presence of ECE and extensive ECE (P < .0001). The areas under receiver operating characteristic (ROC) curves were significantly greater for the T3 MRI-L + SPS-L score than for the positive biopsy result per lobe (PB(+)/L) rate (P < .0001).

CONCLUSION

The use of indirect signs (SPS-L) associated with direct signs (T3 MRI) allows the preoperative detection of ECE per lobe by endorectal 1.5 Tesla MRI with high sensitivity.

[Single center experience of (18F)-fluorocholine positron emission tomography: analysis of its impact on salvage local therapy in patients with prostate adenocarcinoma]

PURPOSE

To assess usefulness of ((18)F)-fluorocholine positron emission tomography (PET) for localizing relapse in patients with biochemical relapse from prostate adenocarcinoma and its impact on indications of salvage local therapy.

PATIENTS AND METHODS

An ((18)F)-fluorocholine PET coupled with computed tomography was performed in 28 patients with biochemical progression from prostate adenocarcinoma. At the time of ((18)F)-fluorocholine PET, median prostate specific antigen (PSA) was 3.0 ng/mL (from 0.34 to 93 ng/mL) and 17 patients (60.7%) received hormone therapy. Eighteen patients from this cohort were potentially candidates to salvage radiotherapy.

RESULTS

A pathologic uptake was shown in 11 patients (39.3%) and 17 patients (60.7%) had no pathologic uptake. Median PSA was 2.4 ng/mL (0.33 to 36 ng/mL) in case of negative ((18)F)-fluorocholine PET, versus 6.75 ng/mL (1.21 to 93 ng/mL) in case of pathologic uptake (P=0.04). Among the 17 patients candidates to salvage radiotherapy, ((18)F)-fluorocholine PET helped deciding for salvage radiotherapy in five patients, since it showed only centropelvic pathologic uptake (27.7%). In one patient, it showed metastatic and radiotherapy was contraindicated. After prostatectomy, ((18)F)-fluorocholine PET was positive in only one patient candidate to salvage radiotherapy (9.1%), showing anastomotic relapse.

CONCLUSION

((18)F)-fluorocholine was positive in about a third of patients with biochemical progression. Its clinical impact is being prospectively investigated.

[Prognostic impact of tumors localized at the prostatic apex]

OBJECTIVE

The apex is a particular region of the prostate in its surgical dissection and pathological analysis. We sought to evaluate the prognostic value of the apical localization of prostate tumors.

METHOD

From 1988 to 2010, data pre- (age, clinical stage, preoperative PSA, biopsy Gleason score) and postoperative (prostate weight, pathologic stage TNM 2010, Gleason score, margin status) of 2765 total prostatectomies were collected prospectively. These data were compared according to existence or absence of tumor at the apex. The prognostic impact of tumor at the apex on biochemical recurrence-free survival (PSA>0.2 ng/mL) has been studied in univariate and multivariate models.

RESULTS

One thousand eight hundred seventeen tumors had a location at the apex (65.7%). In univariate analysis, there was a significant difference in the clinical stage, the biopsy and pathological Gleason score, the result of curage, the pathological stage and the margin status between apical tumors and others. With a mean decline of 34.6 months, 502 patients had a biochemical recurrence (18.1%). Disease-free survival at 10 years was 60.7% for tumor at the apex versus 65.9% in other cases. The location at the apex was significantly associated with biochemical recurrence on univariate analysis (P=0.01). After adjustment for clinical and pathological stage, PSA level, Gleason score and surgical margins, the apex was not anymore a pejorative independent predictor (P=0.0087).

CONCLUSION

The existence of tumor in the prostatic apex was associated with more aggressive tumoral criteria and was an independent and pejorative predictor of biochemical recurrence-free survival at 10 years in univariate analysis. The apical localization could be an additional argument in the decision of adjuvant therapy after prostatectomy.

[Androgen deprivation therapy for prostate cancer and osteoporotic risk]

Androgen deprivation therapy represents an important part of the management of prostate cancer. However, epidemiological data have shown that it is a well-established cause of osteoporosis and increased risk of fracture. So far no consensus guidelines have been published regarding the screening and treatment of osteoporosis in men with prostate cancer. Here we report the design of a new questionnaire, derived from the FRAX(®) ("Fracture Risk Assessment Tool") algorithm, to evaluate the risk of fracture in those patients. In accordance with recent reviews and on the basis of their experience, our French board of experts recommends systematic screening for osteoporosis with dual energy x- ray absorptiometry scans, practice of exercise and calcium and vitamin D supplementation, and selective treatment with bisphosphonates in men at greatest osteoporotic risk.

[Functional MRI by general radiologists in prediction of side-specific extracapsular extension after radical prostatectomy: what value in daily practice?]

OBJECTIVE

To evaluate the performance of functional MRI (FMRI) performed by general radiologists (GR) in detection of side-specific extracapsular extension (SSECE) prostate cancer (PCa).

METHODS

We retrospectively analyzed 79 patients who underwent FMRI with pelvic phased array coil before radical prostatectomy (RP) performed at University Hospital (UH) of Nîmes. Twelve GR (including three from UH) interpreted the images during their daily practice. FMRI results were dichotomized as positive or negative and confronted to pathological reports for SSECE and side-specific seminal vesicle invasion (SSSVI), with calculation of diagnostic values. The influence of interval between biopsy and FMRI, diffusion-weighted sequence (DWS) and intensity of FMRI, on the diagnostic performance were assessed by Fisher's exact test.

RESULTS

A SSECE and a SSSVI were observed at FMRI and pathology respectively on 14 (8.8%) and 38 (24.1%) prostate lobes, and on six (3.8%) and seven (4.4%) prostate lobes. The sensitivity, specificity, positive and negative predictive values of FMRI for SSECE were respectively 24%, 96%, 64% and 80%; and for SSSVI were 14%, 97%, 17% and 96% respectively. The time between biopsy and FMRI, intensity of FMRI and DWS, did not influence the sensitivity and specificity of fMRI at Fisher test.

CONCLUSION

This study found that preoperative prostate FMRI performed by GR has good specificity but poor sensitivity in predicting SSECE on pathological reports.

[Influence of plasmatic testosterone during natural history of prostate cancer: a review]

INTRODUCTION

Prostate cancer (PCa) is the most common disease in male patients and it has the particularity to be androgen dependent. The aim of the current study was to provide an overview about the interest of testosterone dosage during the management of PCa regardless of the stage of the disease. PATIENTS ET METHODS: A systematic review of the literature was done from the PubMed database by searching the following key words alone or in combination: prostate cancer; testosterone; risk; aggressiveness; hormonotherapy; active surveillance; prognosis; androgen; cardiovascular risk; biochemical recurrence.

RESULTS

The level of plasmatic testosterone depends on the moment of the day with a peak between the end of the night and in the morning. We can test either the whole testosterone level, the free testosterone level or the bioavailable testosterone. The bioavailable testosterone is more representative of the presence of androgen in tissues but a specialized laboratory is mandatory. The testosterone plasmatic rate is potentially useful during several steps of the PCa management: in localized prostate cancer cases, men with low testosterone levels are more likely to have an aggressive disease and are therefore not good candidates for active surveillance. An extensive radical prostatectomy should be considered in case of young men since these patients are more likely to recur subsequently; in advanced prostate cancer cases, a testosterone level has to be less or equal to 0.2 ng/mL to guarantee an appropriate castration when a patient is undergoing an androgen deprivation treatment. A dissociation between the trend of PSA and testosterone levels can be the starting point of the castration-resistant period of the disease.

CONCLUSION

The testosterone level can bring useful information regarding the profile of PCa and its ability to evolve during the whole natural history of the disease.

[Novel agents for the therapy of castration-resistant prostate cancer: overview of pivotal studies and new strategies to come]

OBJECTIVE

Recently, new agents have been developed in the treatment of prostate cancer. Our aim was to review phase III studies that involved novel agents in the treatment of castration resistant prostate cancer.

METHODS

PubMed databases were searched for original articles published with the search terms: prostate cancer, castration resistant, metastatic, targeted therapy, biologic agents, immunotherapy and clinical trials. Proceedings from 2008 of conferences of the American Society of Clinical Oncology, American Urological Association, and the European Association of Urology were also searched. We included phase III studies that involved: abiraterone, MDV 3100, cabazitaxel, sipuleucel-T, radium-223, and denosumab.

RESULTS

Abiraterone and MDV 3100 are two new hormotherapies that showed an increased overall survival of 15 and 18 months respectively before after docetaxel based chemotherapy in randomized trials. Cabazitaxel became the standard second line chemotherapy after docetaxel. Sipuleucel-T has emerged as the first approved vaccine in prostate cancer. It showed a 22 % reduction of mortality and a prolonged survival time of 4.1 months compared to placebo. A radium-223 based metabolic radiotherapy has showed a better overall survival, delayed and reduced skeletal-related events in placebo controlled randomized trials. Denosumab also delayed the first skeletal-related event in a zoledronic acid controlled trial (20.7 versus 17.1 months, P=0.0002). Moreover, Denosumab delays bone metastases by 4.1 months compared to placebo.

CONCLUSION

The novel agents that emerged in the treatment of prostate cancer showed an efficacy in placebo controlled trials. They added new tools in the armamentarium of therapies of castration resistant prostate cancer.