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Bryant RJ, Oxley J, Young GJ, Lane JA, Metcalfe C, Davis M, Turner EL, Martin RM, Goepel JR, Varma M, Griffiths DF, Grigor K, Mayer N, Warren AY, Bhattarai S, Dormer J, Mason M, Staffurth J, Walsh E, Rosario DJ, Catto JW, Neal DE, Donovan JL, Hamdy FC. The ProtecT trial: analysis of the patient cohort, baseline risk stratification and disease progression. BJU Int 2020; 125:506-514. [PMID: 31900963 PMCID: PMC7187290 DOI: 10.1111/bju.14987] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To test the hypothesis that the baseline clinico-pathological features of the men with localized prostate cancer (PCa) included in the ProtecT (Prostate Testing for Cancer and Treatment) trial who progressed (n = 198) at a 10-year median follow-up were different from those of men with stable disease (n = 1409). PATIENTS AND METHODS We stratified the study participants at baseline according to risk of progression using clinical disease stage, pathological grade and PSA level, using Cox proportional hazard models. RESULTS The findings showed that 34% of participants (n = 505) had intermediate- or high-risk PCa, and 66% (n = 973) had low-risk PCa. Of 198 participants who progressed, 101 (51%) had baseline International Society of Urological Pathology Grade Group 1, 59 (30%) Grade Group 2, and 38 (19%) Grade Group 3 PCa, compared with 79%, 17% and 5%, respectively, for 1409 participants without progression (P < 0.001). In participants with progression, 38% and 62% had baseline low- and intermediate-/high-risk disease, compared with 69% and 31% of participants with stable disease (P < 0.001). Treatment received, age (65-69 vs 50-64 years), PSA level, Grade Group, clinical stage, risk group, number of positive cores, tumour length and perineural invasion were associated with time to progression (P ≤ 0.005). Men progressing after surgery (n = 19) were more likely to have a higher Grade Group and pathological stage at surgery, larger tumours, lymph node involvement and positive margins. CONCLUSIONS We demonstrate that one-third of the ProtecT cohort consists of people with intermediate-/high-risk disease, and the outcomes data at an average of 10 years' follow-up are generalizable beyond men with low-risk PCa.
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Affiliation(s)
- Richard J. Bryant
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Jon Oxley
- Department of Cellular PathologyNorth Bristol NHS TrustBristolUK
| | - Grace J. Young
- Bristol Medical SchoolUniversity of BristolBristolUK
- The Bristol Randomised Trials CollaborationUniversity of BristolBristolUK
| | - Janet A. Lane
- Bristol Medical SchoolUniversity of BristolBristolUK
- The Bristol Randomised Trials CollaborationUniversity of BristolBristolUK
| | - Chris Metcalfe
- Bristol Medical SchoolUniversity of BristolBristolUK
- The Bristol Randomised Trials CollaborationUniversity of BristolBristolUK
| | - Michael Davis
- Bristol Medical SchoolUniversity of BristolBristolUK
| | | | | | - John R. Goepel
- Department of PathologyRoyal Hallamshire HospitalSheffieldUK
| | - Murali Varma
- Department of PathologyUniversity Hospital of WalesCardiffUK
| | | | - Ken Grigor
- Department of PathologyWestern General HospitalEdinburghUK
| | - Nick Mayer
- Department of PathologyUniversity of LeicesterLeicesterUK
| | - Anne Y. Warren
- Department of PathologyUniversity of CambridgeCambridgeUK
| | - Selina Bhattarai
- Department of PathologyLeeds Teaching Hospitals NHS TrustLeedsUK
| | - John Dormer
- Department of PathologyUniversity of LeicesterLeicesterUK
| | | | - John Staffurth
- Division of Cancer and GeneticsSchool of MedicineCardiff UniversityCardiffUK
| | - Eleanor Walsh
- Bristol Medical SchoolUniversity of BristolBristolUK
| | | | | | - David E. Neal
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
- Academic Urology GroupUniversity of CambridgeCambridgeUK
| | - Jenny L. Donovan
- Bristol Medical SchoolUniversity of BristolBristolUK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care WestUniversity Hospitals Bristol NHS Foundation TrustBristolUK
| | - Freddie C. Hamdy
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
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Abstract
PURPOSE OF REVIEW Prostate focal therapy has the potential to preserve urinary and sexual function while eliminating clinically significant cancer in a subset of men with low-volume, organ-confined prostate cancer. This systematic review aims to examine current evidence to determine the efficacy and safety of focal therapy for standard clinical application. RECENT FINDINGS Focal therapy reduces the rate of cancer progression and conversion to radical therapy in men on active surveillance for prostate cancer. As a strategy, success in focal therapy is heavily dependent on the use of imaging and targeted biopsies. Despite advances in these areas, there remains a small but significant risk of under-detecting clinically significant cancer. Similarly, under-estimation of tumor volume may contribute to infield recurrences and close attention must be paid to the ablation margin. Although long-term oncological outcomes remain lacking, focal therapy has a low complication rate, minimal impact on urinary continence and a moderate impact on erectile function. SUMMARY With the appropriate expertise in imaging, targeted biopsy and targeted ablation, focal therapy is a good option in men with low-intermediate risk cancer who are willing to maximize their urinary and sexual function. However, close posttreatment surveillance and the possibility of conversion to whole gland therapy must be accepted.
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Detection of Individual Prostate Cancer Foci via Multiparametric Magnetic Resonance Imaging. Eur Urol 2018; 75:712-720. [PMID: 30509763 DOI: 10.1016/j.eururo.2018.11.031] [Citation(s) in RCA: 174] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 11/10/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Multiparametric magnetic resonance imaging (mpMRI) undoubtedly affects the diagnosis and treatment of localized prostate cancer (CaP). However, clinicians need a better understanding of its accuracy and limitations in detecting individual CaP foci to optimize management. OBJECTIVE To determine the per-lesion detection rate for CaP foci by mpMRI and identify predictors of tumor detection. DESIGN, SETTING, AND PARTICIPANTS We carried out a retrospective analysis of a prospectively managed database correlating lesion-specific results from mpMRI co-registered with whole-mount pathology (WMP) prostatectomy specimens from June 2010 to February 2018. Participants include 588 consecutive patients with biopsy-proven CaP undergoing 3-T mpMRI before radical prostatectomy at a single tertiary institution. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We measured mpMRI sensitivity in detecting individual CaP and clinically significant (any Gleason score ≥7) CaP foci and predictors of tumor detection using multivariate analysis. RESULTS AND LIMITATIONS The final analysis included 1213 pathologically confirmed tumor foci in 588 patients with primarily intermediate- (75%) or high-risk (12%) CaP. mpMRI detected 45% of all lesions (95% confidence interval [CI] 42-47%), including 65% of clinically significant lesions (95% CI 61-69%) and nearly 80% of high-grade tumors. Some 74% and 31% of missed solitary and multifocal tumors, respectively, were clinically significant. The majority of missed lesions were small (61.1% ≤1cm); 28.3% were between 1 and 2cm, and 10.4% were >2cm. mpMRI missed at least one clinically significant focus in 34% of patients overall, and in 45% of men with multifocal lesions. On multivariate analysis, smaller, low-grade, multifocal, nonindex tumors with lower prostate-specific antigen density were more likely to be missed. Limitations include selection bias in a prostatectomy cohort, lack of specificity data, an imperfect co-registration process, and uncertain clinical significance for undetected lesions. CONCLUSIONS mpMRI detects less than half of all and less than two-thirds of clinically significant CaP foci. The moderate per-lesion sensitivity and significant proportion of men with undetected tumor foci demonstrate the current limitations of mpMRI. PATIENT SUMMARY Magnetic resonance imaging of the prostate before surgical removal for prostate cancer finds less than half of all individual prostate cancer tumors. Large, solitary, aggressive tumors are more likely to be visualized on imaging.
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Gordetsky J, Rais-Bahrami S, Epstein JI. Pathological Findings in Multiparametric Magnetic Resonance Imaging/Ultrasound Fusion-guided Biopsy: Relation to Prostate Cancer Focal Therapy. Urology 2017; 105:18-23. [DOI: 10.1016/j.urology.2017.02.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 02/01/2017] [Accepted: 02/15/2017] [Indexed: 10/20/2022]
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Tay KJ, Schulman AA, Sze C, Tsivian E, Polascik TJ. New advances in focal therapy for early stage prostate cancer. Expert Rev Anticancer Ther 2017. [PMID: 28635336 DOI: 10.1080/14737140.2017.1345630] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Prostate focal therapy offers men the opportunity to achieve oncological control while preserving sexual and urinary function. The prerequisites for successful focal therapy are to accurately identify, localize and completely ablate the clinically significant cancer(s) within the prostate. We aim to evaluate the evidence for current and upcoming technologies that could shape the future of prostate cancer focal therapy in the next five years. Areas covered: Current literature on advances in patient selection using imaging, biopsy and biomarkers, ablation techniques and adjuvant treatments for focal therapy are summarized. A literature search of major databases was performed using the search terms 'focal therapy', 'focal ablation', 'partial ablation', 'targeted ablation', 'image guided therapy' and 'prostate cancer'. Expert commentary: Advanced radiological tools such as multiparametric magnetic resonance imaging (mpMRI), multiparametric ultrasound (mpUS), prostate-specific-membrane-antigen positron emission tomography (PSMA-PET) represent a revolution in the ability to understand cancer function and biology. Advances in ablative technologies now provide a menu of modalities that can be rationalized based on lesion location, size and perhaps in the near future, pre-determined resistance to therapy. However, these need to be carefully studied to establish their safety and efficacy parameters. Adjuvant strategies to enhance focal ablation are under development.
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Affiliation(s)
- Kae Jack Tay
- a Department of Urology , Singapore General Hospital, SingHealth Duke-NUS Academic Medical Center , Singapore.,b Division of Urology, Department of Surgery , Duke University Medical Center , Durham , NC , USA.,c Duke Cancer Institute , Durham , NC , USA
| | - Ariel A Schulman
- b Division of Urology, Department of Surgery , Duke University Medical Center , Durham , NC , USA.,c Duke Cancer Institute , Durham , NC , USA
| | - Christina Sze
- b Division of Urology, Department of Surgery , Duke University Medical Center , Durham , NC , USA.,c Duke Cancer Institute , Durham , NC , USA
| | - Efrat Tsivian
- b Division of Urology, Department of Surgery , Duke University Medical Center , Durham , NC , USA.,c Duke Cancer Institute , Durham , NC , USA
| | - Thomas J Polascik
- b Division of Urology, Department of Surgery , Duke University Medical Center , Durham , NC , USA.,c Duke Cancer Institute , Durham , NC , USA
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Stratification of aggressive prostate cancer from indolent disease—Prospective controlled trial utilizing expression of 11 genes in apparently benign tissue. Urol Oncol 2016; 34:255.e15-22. [DOI: 10.1016/j.urolonc.2015.12.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 12/21/2015] [Accepted: 12/22/2015] [Indexed: 11/22/2022]
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Bryant RJ, Sjoberg DD, Vickers AJ, Robinson MC, Kumar R, Marsden L, Davis M, Scardino PT, Donovan J, Neal DE, Lilja H, Hamdy FC. Predicting high-grade cancer at ten-core prostate biopsy using four kallikrein markers measured in blood in the ProtecT study. J Natl Cancer Inst 2015; 107:djv095. [PMID: 25863334 PMCID: PMC4554254 DOI: 10.1093/jnci/djv095] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Many men with elevated prostate-specific antigen (PSA) levels in serum do not have aggressive prostate cancer and undergo unnecessary biopsy. Retrospective studies using cryopreserved serum suggest that four kallikrein markers can predict biopsy outcome. Methods: Free, intact and total PSA, and kallikrein-related peptidase 2 were measured in cryopreserved blood from 6129 men with elevated PSA (≥3.0ng/mL) participating in the prospective, randomized trial Prostate Testing for Cancer and Treatment. Marker levels from 4765 men providing anticoagulated plasma were incorporated into statistical models to predict any-grade and high-grade (Gleason score ≥7) prostate cancer at 10-core biopsy. The models were corrected for optimism by 10-fold cross validation and independently validated using markers measured in serum from 1364 men. All statistical tests were two-sided. Results: The four kallikreins enhanced prostate cancer detection compared with PSA and age alone. Area under the curve (AUC) for the four kallikreins was 0.719 (95% confidence interval [CI] = 0.704 to 0.734) vs 0.634 (95% CI = 0.617 to 0.651, P < .001) for PSA and age alone for any-grade cancer, and 0.820 (95% CI = 0.802 to 0.838) vs 0.738 (95% CI = 0.716 to 0.761) for high-grade cancer. Using a 6% risk of high-grade cancer as an illustrative cutoff, for 1000 biopsied men with PSA levels of 3.0ng/mL or higher, the model would reduce the need for biopsy in 428 men, detect 119 high-grade cancers, and delay diagnosis of 14 of 133 high-grade cancers. Models exhibited excellent discrimination on independent validation among men with only serum samples available for analysis. Conclusions: A statistical model based on kallikrein markers was validated in a large prospective study and reduces unnecessary biopsies while delaying diagnosis of high-grade cancers in few men.
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Affiliation(s)
- Richard J Bryant
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Daniel D Sjoberg
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Andrew J Vickers
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Mary C Robinson
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Rajeev Kumar
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Luke Marsden
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Michael Davis
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Peter T Scardino
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Jenny Donovan
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - David E Neal
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
| | - Hans Lilja
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL).
| | - Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, UK (RJB, RK, LM, HL, FCH); Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (DDS, AJV); Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MCR); School of Social and Community Medicine, University of Bristol, UK (MD); Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center (PTS, HL); Department of Oncology, University of Cambridge, UK (DEN); Departments of Laboratory Medicine (Clinical Chemistry Service) and Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY (HL); Department of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, Skåne University Hospital, Malmö, Sweden; and Institute of Biomedical Technology, University of Tampere, Finland (HL)
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Loeb S, Montorsi F, Catto JW. Future-proofing Gleason Grading: What to Call Gleason 6 Prostate Cancer? Eur Urol 2015; 68:1-2. [PMID: 25769986 DOI: 10.1016/j.eururo.2015.02.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 02/27/2015] [Indexed: 11/15/2022]
Abstract
At the 2014 International Society of Urological Pathology meeting, changes to prostate cancer grading were discussed including new prognostic Gleason grade groups 1-5 representing Gleason scores of 3+3, 3+4, 4+3, 8, and 9-10, respectively.
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Affiliation(s)
- Stacy Loeb
- Department of Urology and Population Health, New York University, NY, USA.
| | - Francesco Montorsi
- Division of Oncology/Unit of Urology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - James W Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
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10
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Le JD, Tan N, Shkolyar E, Lu DY, Kwan L, Marks LS, Huang J, Margolis DJA, Raman SS, Reiter RE. Multifocality and prostate cancer detection by multiparametric magnetic resonance imaging: correlation with whole-mount histopathology. Eur Urol 2014; 67:569-76. [PMID: 25257029 DOI: 10.1016/j.eururo.2014.08.079] [Citation(s) in RCA: 327] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 08/31/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND Multiparametric magnetic resonance imaging (mp-MRI) is increasingly used in prostate cancer (CaP). Understanding the limitations of tumor detection, particularly in multifocal disease, is important in its clinical application. OBJECTIVE To determine predictors of CaP detection by mp-MRI as confirmed by whole-mount histopathology. DESIGN, SETTING, AND PARTICIPANTS A retrospective study was performed of 122 consecutive men who underwent mp-MRI before radical prostatectomy at a single referral academic center. A genitourinary radiologist and pathologist collectively determined concordance. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The odds of tumor detection were calculated for clinical, MRI, and histopathologic variables using a multivariate logistic regression model. RESULTS AND LIMITATIONS The 122 patients had 283 unique histologically confirmed CaP tumor foci. Gleason score was 6 in 21 (17%), 7 in 88 (72%), and ≥8 in 13 (11%) patients. Of the 122 cases, 44 (36%) had solitary and 78 (64%) had multifocal tumors. Overall mp-MRI sensitivity for tumor detection was 47% (132/283), with increased sensitivity for larger (102/141 [72%] >1.0 cm), higher-grade (96/134 [72%] Gleason ≥7) tumors, and index tumors (98/122 [80%]). Index tumor status, size, and prostate weight were significant predictors of detection in a multivariate analysis, and multifocality did not adversely impact detection of index tumors. A prostatectomy population was necessary by design, which may limit the ability to generalize these results. CONCLUSIONS Sensitivity for tumor detection increased with tumor size and grade. Index tumor status and tumor size were the strongest predictors of tumor detection, regardless of tumor focality. Some 80% of index tumors were detected, but nonindex tumor detection, even of high-grade lesions, was poor. These findings have important implications for focal therapy. PATIENT SUMMARY We evaluated the ability of magnetic resonance imaging (MRI) to detect cancer in patients undergoing prostatectomy. We found that tumor size and grade were important predictors of tumor detection, and although cancer is often multifocal, MRI is often able to detect the worst focus of cancer.
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Affiliation(s)
- Jesse D Le
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Nelly Tan
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Eugene Shkolyar
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - David Y Lu
- Department of Pathology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Lorna Kwan
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Leonard S Marks
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Jiaoti Huang
- Department of Pathology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Daniel J A Margolis
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Steven S Raman
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Robert E Reiter
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
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Jambor I, Kähkönen E, Taimen P, Merisaari H, Saunavaara J, Alanen K, Obsitnik B, Minn H, Lehotska V, Aronen HJ. Prebiopsy multiparametric 3T prostate MRI in patients with elevated PSA, normal digital rectal examination, and no previous biopsy. J Magn Reson Imaging 2014; 41:1394-404. [PMID: 24956412 DOI: 10.1002/jmri.24682] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 06/06/2014] [Indexed: 12/22/2022] Open
Abstract
PURPOSE To find the diagnostic accuracy of 3T multiparametric magnetic resonance imaging (mpMRI) and mpMRI targeted transrectal ultrasound (TRUS)-guided biopsy using visual coregistration (TB) in patients with elevated prostate-specific antigen (PSA), normal digital rectal examination, and no previous biopsy. MATERIALS AND METHODS Fifty-five patients at two institutions underwent mpMRI, consisting of anatomical T2 -weighted imaging (T2 W), diffusion-weighted imaging (DWI), proton magnetic resonance spectroscopy ((1) H-MRS), and dynamic contrast-enhanced MRI (DCE-MRI), followed by TB in addition to 12 core systematic TRUS-guided biopsy (SB). Histopathological scorings of biopsy (n = 38) and prostatectomy (n = 17) specimens were used as the reference standard for calculation of diagnostic accuracy values. Clinically significant prostate cancer (SPCa) was defined as 3 mm core length of Gleason score 3+3 or any Gleason grade 4. RESULTS The sensitivity, specificity, accuracy, and area under the curve (AUC) values for the detection of SPCa on the sextant level for T2 W+DWI+(1) H-MRS+DCE-MRI were 72%, 89%, 85%, and 0.81, respectively. The corresponding values for T2 wi+DWI were 61%, 96%, 87%, and 0.79, respectively. The overall PCa detection rate per core in 53 patients was 21% (138 of 648 cores) for SB and 43% (33 of 77 cores) for TB (P < 0.001). CONCLUSION Prebiopsy mpMRI is an accurate tool for PCa detection and biopsy targeting in patients with elevated PSA.
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Affiliation(s)
- Ivan Jambor
- Department of Diagnostic Radiology, University of Turku, Turku, Finland
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Oxley J. Understanding the Histopathology. Prostate Cancer 2014. [DOI: 10.1002/9781118347379.ch3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Budd WT, Seashols S, Weaver D, Joseph C, Zehner ZE. A networks method for ranking microRNA dysregulation in cancer. BMC SYSTEMS BIOLOGY 2013; 7 Suppl 5:S3. [PMID: 24564923 PMCID: PMC4028974 DOI: 10.1186/1752-0509-7-s5-s3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Despite the lack of agreement on their exact roles, it is known that miRNAs contribute to cancer progression. Many studies utilize methods to detect differential regulation of miRNA expression. It is prohibitively expensive to examine all potentially dysregulated miRNAs and traditionally, researchers have focused their efforts on the most extremely dysregulated miRNAs. These methods may overlook the contribution of less differentially expressed but more functionally relevant miRNAs. The purpose of this study was to outline a method that not only utilizes differential expression but ranks miRNAs based on the functional relevance of their targets. This work uses a networks based approach to determine the sum node degree for all experimentally verified miRNA targets to identify potential regulators of prostate cancer initiation, progression and metastasis. RESULTS Here, we present a method for identifying functionally relevant miRNAs that contribute to prostate cancer development. This paper shows that miRNAs preferentially regulate highly connected, central proteins within a protein-protein interaction network. Known targets of miRNAs differentially regulated during prostate cancer progression are enriched in pathways with known involvement in tumorigenesis. To demonstrate the applicability of our method, we utilized a unique model of prostate cancer progression to identify five miRNAs that may contribute to the oncogenic state of the cell. Three of these miRNAs have been shown by other studies to have a role in cancer but their exact role in prostate cancer remains undefined. CONCLUSION Developing methods to determine which miRNAs to carry forward into biological and biochemical analyses is important as traditional approaches often overlook miRNAs that contribute to oncogenesis. Our method applied to a model of prostate cancer progression was able to identify miRNAs with roles in prostate cancer development.
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Prostate cancer tumour features on template prostate-mapping biopsies: implications for focal therapy. Eur Urol 2013; 66:12-9. [PMID: 24207133 PMCID: PMC4062939 DOI: 10.1016/j.eururo.2013.09.045] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Accepted: 09/25/2013] [Indexed: 01/17/2023]
Abstract
Background Focal therapy is being offered as a viable alternative for men with localised prostate cancer (PCa), but it is unclear which men may be suitable. Objective To determine the proportion of men with localised PCa who are potentially suitable for focal therapy. Design, setting, and participants Our institutional transperineal template prostate-mapping (TTPM) biopsy registry of 377 men from 2006 to 2010 identified 291 consecutive men with no prior treatment. Intervention TTPM biopsies using a 5-mm sampling frame. Outcome measurements and statistical analysis Suitability for focal therapy required the cancer to be (1) unifocal, (2) unilateral, (3) bilateral/bifocal with at least one neurovascular bundle avoided, or (4) bilateral/multifocal with one dominant index lesion and secondary lesions with Gleason ≤3 + 3 and cancer core involvement ≤3 mm. Binary logistic regression modelling was used to determine variables predictive for focal therapy suitability. Results and limitations The median age was 61 yr, and the median prostate-specific antigen was 6.8 ng/ml. The median total was 29 cores, with a median of 8 positive cores. Of 239 of 291 men with cancer, 29% (70 men), 60% (144 men), and 8% (20 men) had low-, intermediate-, and high-risk PCa, respectively. Ninety-two percent (220 men) were suitable for one form of focal therapy: hemiablation (22%, 53 men), unifocal ablation (31%, 73 men), bilateral/bifocal ablation (14%, 33 men), and index lesion ablation (26%, 61 men). Binary logistic regression modelling incorporating transrectal biopsy parameters showed no statistically significant predictive variable. When incorporating TTPM parameters, only T stage was a significant negative predictor for suitability (p = 0.001) (odds ratio: 0.001 [95% confidence interval, 0.000–0.048]). Limitations of the study include potential selection bias caused by tertiary referral practise and lack of long-term results on focal therapy efficacy. Conclusions Focal therapy requires an accurate tool to localise individual cancer lesions. When such a test, TTPM biopsy, was applied to men with low- and intermediate-risk PCa, most of the men were suitable for a tissue preservation strategy.
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Arumainayagam N, Ahmed HU, Moore CM, Freeman A, Allen C, Sohaib SA, Kirkham A, van der Meulen J, Emberton M. Multiparametric MR imaging for detection of clinically significant prostate cancer: a validation cohort study with transperineal template prostate mapping as the reference standard. Radiology 2013; 268:761-9. [PMID: 23564713 DOI: 10.1148/radiol.13120641] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
PURPOSE To evaluate the diagnostic performance of multiparametric (MP) magnetic resonance (MR) imaging for prostate cancer detection by using transperineal template prostate mapping (TTPM) biopsies as the reference standard and to determine the potential ability of MP MR imaging to identify clinically significant prostate cancer. MATERIALS AND METHODS Institutional review board exemption was granted by the local research ethics committee for this retrospective study. Included were 64 men (mean age, 62 years [range, 40-76]; mean prostate-specific antigen, 8.2 ng/mL [8.2 μg/L] [range, 2.1-43 ng/mL]), 51 with biopsy-proved cancer and 13 suspected of having clinically significant cancer that was biopsy negative or without prior biopsy. MP MR imaging included T2-weighted, dynamic contrast-enhanced and diffusion-weighted imaging (1.5 T, pelvic phased-array coil). Three radiologists independently reviewed images and were blinded to results of biopsy. Two-by-two tables were derived by using sectors of analysis of four quadrants, two lobes, and one whole prostate. Primary target definition for clinically significant disease necessary to be present within a sector of analysis on TTPM for that sector to be deemed positive was set at Gleason score of 3+4 or more and/or cancer core length involvement of 4 mm or more. Sensitivity, negative predictive value, and negative likelihood ratio were calculated to determine ability of MP MR imaging to rule out cancer. Specificity, positive predictive value, positive likelihood ratio, accuracy (overall fraction correct), and area under receiver operating characteristic curves were also calculated. RESULTS Twenty-eight percent (71 of 256) of sectors had clinically significant cancer by primary endpoint definition. For primary endpoint definition (≥ 4 mm and/or Gleason score ≥ 3+4), sensitivity, negative predictive value, and negative likelihood ratios were 58%-73%, 84%-89%, and 0.3-0.5, respectively. Specificity, positive predictive value, and positive likelihood ratios were 71%-84%, 49%-63%, and 2.-3.44, respectively. Area under the curve values were 0.73-0.84. CONCLUSION Results of this study indicate that MP MR imaging has a high negative predictive value to rule out clinically significant prostate cancer and may potentially have clinical use in diagnostic pathways of men at risk.
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Affiliation(s)
- Nimalan Arumainayagam
- Division of Surgery and Interventional Sciences, University College, Charles Bell House, 67-73 Riding House St, London W1W 7EJ, England
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Valerio M, Ahmed HU, Emberton M, Lawrentschuk N, Lazzeri M, Montironi R, Nguyen PL, Trachtenberg J, Polascik TJ. The role of focal therapy in the management of localised prostate cancer: a systematic review. Eur Urol 2013; 66:732-51. [PMID: 23769825 PMCID: PMC4179888 DOI: 10.1016/j.eururo.2013.05.048] [Citation(s) in RCA: 244] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 05/24/2013] [Indexed: 12/17/2022]
Abstract
CONTEXT The incidence of localised prostate cancer is increasing worldwide. In light of recent evidence, current, radical, whole-gland treatments for organ-confined disease have being questioned with respect to their side effects, cancer control, and cost. Focal therapy may be an effective alternative strategy. OBJECTIVE To systematically review the existing literature on baseline characteristics of the target population; preoperative evaluation to localise disease; and perioperative, functional, and disease control outcomes following focal therapy. EVIDENCE ACQUISITION Medline (through PubMed), Embase, Web of Science, and Cochrane Review databases were searched from inception to 31 October 2012. In addition, registered but not yet published trials were retrieved. Studies evaluating tissue-preserving therapies in men with biopsy-proven prostate cancer in the primary or salvage setting were included. EVIDENCE SYNTHESIS A total of 2350 cases were treated to date across 30 studies. Most studies were retrospective with variable standards of reporting, although there was an increasing number of prospective registered trials. Focal therapy was mainly delivered to men with low and intermediate disease, although some high-risk cases were treated that had known, unilateral, significant cancer. In most of the cases, biopsy findings were correlated to specific preoperative imaging, such as multiparametric magnetic resonance imaging or Doppler ultrasound to determine eligibility. Follow-up varied between 0 and 11.1 yr. In treatment-naïve prostates, pad-free continence ranged from 95% to 100%, erectile function ranged from 54% to 100%, and absence of clinically significant cancer ranged from 83% to 100%. In focal salvage cases for radiotherapy failure, the same outcomes were achieved in 87.2-100%, 29-40%, and 92% of cases, respectively. Biochemical disease-free survival was reported using a number of definitions that were not validated in the focal-therapy setting. CONCLUSIONS Our systematic review highlights that, when focal therapy is delivered with intention to treat, the perioperative, functional, and disease control outcomes are encouraging within a short- to medium-term follow-up. Focal therapy is a strategy by which the overtreatment burden of the current prostate cancer pathway could be reduced, but robust comparative effectiveness studies are now required.
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Affiliation(s)
- Massimo Valerio
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, University College Hospitals NHS Foundation Trust, London, UK; Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
| | - Hashim U Ahmed
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, University College Hospitals NHS Foundation Trust, London, UK
| | - Mark Emberton
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, University College Hospitals NHS Foundation Trust, London, UK
| | - Nathan Lawrentschuk
- Department of Surgery, University of Melbourne; and Ludwig Institute for Cancer Research, Austin Hospital, Melbourne, Australia
| | - Massimo Lazzeri
- Department of Urology, Ospedale San Raffaele Turro, San Raffaele Scientific Institute, Milan, Italy
| | - Rodolfo Montironi
- Section of Pathological Anatomy, Polytechnic University of the Marche Region, School of Medicine, United Hospitals, Ancona, Italy
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Centre, Harvard Medical School, Boston, MA, USA
| | - John Trachtenberg
- Division of Urology, Department of Surgical Oncology, University Health Network; and Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Thomas J Polascik
- Division of Urology, Department of Surgery, and Duke Cancer Institute, Duke University Medical Centre, Durham, NC, USA
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