Urinary extracellular vesicle-derived miR-126-3p predicts lymph node invasion in patients with high-risk prostate cancer

To investigate extracellular vesicles (EVs), biomarkers for predicting lymph node invasion (LNI) in patients with high-risk prostate cancer (HRPCa), plasma, and/or urine samples were prospectively collected from 45 patients with prostate cancer (PCa) and five with benign prostatic hyperplasia (BPH). Small RNA sequencing was performed to identify miRNAs in the EVs. All patients with PCa underwent radical prostatectomy and extended pelvic lymph node dissection. Differentially expressed miRNAs were identified in patients with and without pathologically-verified LNI. The candidate miRNAs were validated in low-risk prostate cancer (LRPCa) and BPH. Four miRNA species (e.g., miR-126-3p) and three miRNA species (e.g., miR-27a-3p) were more abundant in urinary and plasma EVs, respectively, of patients with PCa. None of these miRNA species were shared between urinary and plasma EVs. miR-126-3p was significantly more abundant in patients with HR PCa with LNI than in those without (P = 0.018). miR-126-3p was significantly more abundant in the urinary EVs of patients with HRPCa than in those with LRPCa (P = 0.017) and BPH (P = 0.011). In conclusion, urinary EVs-derived miR-126-3p may serve as a good biomarker for predicting LNI in patients with HRPCa.

The Prognostic Role of Preoperative PSMA PET/CT in cN0M0 pN+ Prostate Cancer: A Multicenter Study

CONTEXT

Despite negative preoperative conventional imaging, up to 10% of patients with prostate cancer (PCa) harbor lymph-node involvement (LNI) at radical prostatectomy (RP). The advent of more accurate imaging modalities such as PET/CT improved the detection of LNI. However, their clinical impact and prognostic value are still unclear. We aimed to investigate the prognostic value of preoperative PET/CT in patients node positive (pN+) at RP.

EVIDENCE SYNTHESIS

We retrospectively identified cN0M0 patients at conventional imaging (CT and/or MRI, and bone scan) who had pN+ PCa at RP at 17 referral centers. Patients with cN+ at PSMA/Choline PET/CT but cN0M0 at conventional imaging were also included. Systemic progression/recurrence was the primary outcome; Cox proportional hazards models were used for multivariate analysis.

EVIDENCE ACQUISITION

We included 1163 pN+ men out of whom 95 and 100 had preoperative PSMA and/or Choline PET/CT, respectively. ISUP grade ≥4 was detected in 66.6%. Overall, 42% of patients had postoperative PSA persistence (≥0.1 ng/mL). Postoperative management included initial observation (34%), ADT (22.7%) and adjuvant RT+/-ADT (42.8%). Median follow-up was 42 months. Patients with cN+ on PSMA PET/CT had an increased risk of systemic progression (52.9% vs. 13.6% cN0 PSMA PET/CT vs. 21.5% cN0 at conventional imaging; P < .01). This held true at multivariable analysis: (HR 6.184, 95% CI: 3.386-11-295; P < .001) whilst no significant results were highlighted for Choline PET/CT. No significant associations for both PET types were found for local progression, BCR, and overall mortality (all P > .05). Observation as an initial management strategy instead of adjuvant treatments was related with an increased risk of metastases (HR 1.808; 95% CI: 1.069-3.058; P < .05).

CONCLUSIONS

PSMA PET/CT cN+ patients with negative conventional imaging have an increased risk of systemic progression after RP compared to their counterparts with cN0M0 disease both at conventional and/or molecular imaging.

Urinary extracellular vesicle-derived miR-126-3p predicts lymph node invasion in patients with high-risk prostate cancer

To investigate extracellular vesicles (EVs) biomarkers for predicting lymph node invasion (LNI) in patients with high-risk prostate cancer (HRPCa), plasma and/or urine samples were prospectively collected from 45 patients with prostate cancer (PCa) and five with benign prostatic hyperplasia (BPH). Small RNA sequencing was performed to identify miRNAs in the EVs. All patients with PCa underwent radical prostatectomy and extended pelvic lymph node dissection. Differentially-expressed miRNAs were identified in patients with and without pathologically-verified LNI. The candidate miRNAs were validated in low-risk prostate cancer (LRPCa) and BPH. Four miRNA species (e.g. miR-126-3p) and three miRNA species (e.g. miR-27a-3p) were more abundant in urinary and plasma EVs, respectively, of patients with PCa. None of these miRNA species were shared between urinary and plasma EVs. miR-126-3p was significantly more abundant in patients with HR PCa with LNI than in those without (P = 0.018). miR-126-3p was significantly more abundant in the urinary EVs of patients with HRPCa than in those with LRPCa (P = 0.017) and BPH (P = 0.011). In conclusion, urinary EVs-derived miR-126-3p may serve as a good biomarker for predicting LNI in patients with HRPCa.

Immediate radiotherapy versus observation in patients with node-positive prostate cancer after radical prostatectomy

BACKGROUND

The optimal management of node-positive (pN1) prostate cancer following radical prostatectomy (RP) remains uncertain. Despite randomized evidence, utilization of immediate, life-long androgen deprivation therapy (ADT) remains poor, and recent trials of early salvage radiotherapy included only a minority of pN1 patients. We therefore emulated a hypothetical pragmatic trial of adjuvant radiotherapy versus observation in men with pN1 prostate cancer.

METHODS

Using the RADICALS-RT trial to inform the design of a hypothetical trial, we identified men aged 50-69 years with pT2-3 Rany pN1 M0, pre-treatment PSA < 50 ng/mL prostate cancer in the NCDB from 2006 to 2015 treated with 60-72 Gy of adjuvant RT (aRT) ± ADT within 26 weeks of RP or observation. After estimating a propensity score for receipt of aRT, we estimated absolute and relative treatment effects using stabilized inverse probability of treatment (sIPW) re-weighting.

RESULTS

In total, 3510 patients were included in the study, of whom 587 (17%) received aRT (73% with concurrent ADT). Median follow-up was 40.0 -months, during which 333 deaths occurred. After sIPW re-weighting, baseline characteristics were well-balanced. Adjusted overall survival (OS) was 93% versus 89% at 5-years and 82% versus 79% at 7-years for aRT versus observation (p = 0.11). In IPW-reweighted Cox regression, aRT was associated with a lower risk of all-cause mortality (ACM) than observation, but this did not reach statistical significance (HR 0.70 p = 0.06). In analyses examining heterogeneity of treatment effects, aRT was associated with improved ACM only for men with Gleason 8-10 disease (HR 0.59, p = 0.01), ≥2 positive LNs (HR 0.49, p = 0.04 for 2 positive LNs; HR 0.42, p = 0.01 for ≥3 positive LNs), or negative surgical margins (HR 0.50, p = 0.02).

CONCLUSIONS

In observational analyses designed to emulate a hypothetical target trial of aRT versus observation in pN1 prostate cancer, aRT was associated with improved OS only for men with Gleason 8-10 disease, ≥2 positive LNs, or negative surgical margins.

Sentinel Lymph Node Biopsy in Prostate Cancer: An Overview of Diagnostic Performance, Oncological Outcomes, Safety, and Feasibility

Sentinel node biopsy (SNB) for prostate cancer (PCa) represents an innovative technique aimed at improving nodal staging accuracy. The routinary adoption of this procedure in patients undergoing radical prostatectomy (RP) might be crucial to identify candidates who could effectively benefit from extensive pelvic lymph nodal dissection (ePLND). Despite some promising results, SNB for PCa is still considered experimental due to the lack of solid evidence and procedural standardization. In this regard, our narrative review aimed to analyze the most recent literature in this field, providing an overview of both the diagnostic accuracy measures and the oncological outcomes of SNB.

Management of Pathologic Node-Positive Prostate Cancer following Radical Prostatectomy

PURPOSE OF REVIEW

Approximately 15% of prostate cancer patients have lymph node metastases at the time of radical prostatectomy (RP). However, there is no universally accepted standard of care for these men. The options for treatment in this subset of patients range from observation to a combination of adjuvant androgen deprivation therapy (aADT) and radiation therapy (RT).

RECENT FINDINGS

A recent systematic review showed that there was no clear choice out of the options above to treat these patients. Studies have shown that patients treated with adjuvant radiation therapy have lower all-cause mortality when compared to patients treated with salvage radiation therapy. In this review, we summarize treatment options for pathologic node-positive (pN1) patients and discuss the urgent need for robust clinical trials that includes observation as the control group to help establish a standard of care for treating patients with node-positive prostate cancer after RP.

Analysis of the surgical approach in prostate cancer staging: results from the surveillance, epidemiology and end results program

Surgery is not used as a criterion for staging prostate cancer, although there is evidence that the number of analyzed and affected lymph nodes have prognosis value. The aim of this study was to determine whether there are significant differences in staging criteria in patients who underwent prostatectomy compared to those who did not, and whether the number of affected and analyzed lymph nodes (LN) plays a prognostic role. In this retrospective study, a test cohort consisting of 404,210 newly diagnosed men with prostate cancer, between 2004 and 2010, was obtained from the 17 registries (Nov 2021 submission); a validation consisting of 147,719 newly diagnosed men with prostate cancer between 2004 and 2019 was obtained from the 8 registries (Nov 2021 submission). Prostate cancer-specific survival was analyzed by Kaplan-Meier curves, survival tables and Cox regression; overall survival was analyzed only to compare Harrell's C-index between different staging criteria. In initial analyses, it was observed that the prognostic value of lymph node metastasis changes according to the type of staging (clinical or pathological), which is linked to the surgical approach (prostatectomy). Compared with T4/N0/M0 patients, which are also classified as stage IVA, N1/M0 patients had a shorter [adjusted HR: 1.767 (1429-2184), p < 0.0005] and a longer [adjusted HR: 0.832 (0.740-0.935), p = 0.002] specific survival when submitted to prostatectomy or not, respectively. Analyzing separately the patients who were submitted to prostatectomy and those who were not, it was possible to obtain new LN metastasis classifications (N1: 1 + LN; N2: 2 + LNs; N3: > 2 + LNs). This new (pathological) classification of N allowed the reclassification of patients based on T and Gleason grade groups, mainly those with T3 and T4 disease. In the validation group, this new staging criterion was proven to be superior [specific survival C-index: 0.908 (0.906-0.911); overall survival C-index: 0.788 (0.786-0.791)] compared to that currently used by the AJCC [8th edition; specific survival C-index: 0.892 (0.889-0.895); overall survival C-index: 0.744 (0.741-0.747)]. In addition, an adequate number of dissected lymph nodes results in a 39% reduction in death risk [adjusted HR: 0.610 (0.498-0.747), p < 0.0005]. As main conclusion, the surgery has a major impact on prostate cancer staging, mainly modifying the effect of N on survival, and enabling the stratification of pathological N according to the number of affected LN. Such a factor, when considered as staging criteria, improves the prognosis classification.

Mid-term oncologic outcomes of radical prostatectomy in lymph node metastatic prostate cancer patients

OBJECTIVES

Lymph node invasion (LNI) has been reported in 10-15% of pelvic lymph node dissection during radical prostatectomy (RP). The objective of this study was to describe the mid-term oncological outcomes in prostate cancer (PCa) patients with metastatic lymph node.

METHODS

We conducted a retrospective study at two French referral centers including consecutive cN0 PCa patients who underwent RP and extended pelvic lymph node dissection and had lymph node metastases on final pathological analysis (pN1) between January 2000 and May 2020. Follow-up was per institution, which generally included a PSA level measurement every 3 to 12 months for 5 years and annually thereafter.

RESULTS

A total of 123 patients were included: two (1.6%) low-risk, 64 (52%) intermediate-risk and 57 (46.4%) high-risk PCa according to the D'Amico risk classification. The median number of nodes removed and metastatic nodes per patient was 15 (IQR 11-22) and 1 (IQR 1-2), respectively. Adverse pathological features, i.e., ≥pT3a stage, ISUP grade ≥3, and positive surgical margins were reported in 113 (91.9%), 103 (83.7%), and 73 (59%) of cases, respectively. Postoperative treatment was administered in 104 patients, including radiotherapy alone (n=6), androgen deprivation therapy alone (n=27) or combination with androgen deprivation therapy and radiotherapy (n=71). The mean follow-up was 42.7 months. The estimated 3-year biochemical-free survival, clinical recurrence-free survival, and cancer-specific survival was 66% and 85% and 98.8%, respectively. In Cox regression analysis, the number of metastatic nodes was associated with clinical recurrence (P=0.04) and a persistently elevated PSA with biochemical recurrence (P<0.001).

CONCLUSION

The management of lymph node metastatic PCa patients is challenging. Risk stratification of node-positive patients, based on postoperative PSA levels and pathologic features being identified, should help physicians determine which patient would best benefit from multimodal treatment.

LEVEL OF EVIDENCE: 4

Prediction of pelvic lymph node metastases and PSMA PET positive pelvic lymph nodes with multiparametric MRI and clinical information in primary staging of prostate cancer

Purpose

To compare the accuracy of multiparametric MRI (mpMRI), ⁶⁸Ga-PSMA PET and the Briganti 2019 nomogram in the prediction of metastatic pelvic lymph nodes (PLN) in prostate cancer, to assess the accuracy of mpMRI and the Briganti nomogram in prediction of PET positive PLN and to investigate the added value of quantitative mpMRI parameters to the Briganti nomogram.

Method

This retrospective IRB-approved study included 41 patients with prostate cancer undergoing mpMRI and ⁶⁸Ga-PSMA PET/CT or MR prior to prostatectomy and pelvic lymph node dissection. A board-certified radiologist assessed the index lesion on diffusion-weighted (Apparent Diffusion Coefficient, ADC; mean/volume), T2-weighted (capsular contact length, lesion volume/maximal diameters) and contrast-enhanced (iAUC, k_ep, K^trans, v_e) sequences. The probability for metastatic pelvic lymph nodes was calculated using the Briganti 2019 nomogram. PET examinations were evaluated by two board-certified nuclear medicine physicians.

Results

The Briganti 2019 nomogram performed superiorly (AUC: 0.89) compared to quantitative mpMRI parameters (AUCs: 0.47-0.73) and ⁶⁸Ga-PSMA-11 PET (AUC: 0.82) in the prediction of PLN metastases and superiorly (AUC: 0.77) in the prediction of PSMA PET positive PLN compared to MRI parameters (AUCs: 0.49-0.73). The addition of mean ADC and ADC volume from mpMRI improved the Briganti model by a fraction of new information of 0.21.

Conclusions

The Briganti 2019 nomogram performed superiorly in the prediction of metastatic and PSMA PET positive PLN, but the addition of parameters from mpMRI can further improve its accuracy. The combined model could be used to stratify patients requiring ePLND or PSMA PET.

The Changing Face of cN0M0 Prostate Cancer Being Found With pN+ After Surgery in the Contemporary Era: Results of an International European Survey on Disease Management

INTRODUCTION

The urological community's opinion over the management of men being found with pathologically positive nodes (pN+) following radical prostatectomy (RP) performed with curative intent after preoperative negative conventional staging (cN0M0) has never been assessed. This remains crucial, especially considering the advent of novel imaging modalities. Our aim was to investigate the current opinion on management of pN+ cN0M0 prostate cancer (PCa) in the European urological community.

METHODS

Following validation, a 31-item survey, complying with the Cherries checklist, was distributed using a web link from December 2021 to April 2022 to 10 urological societies mailing list. Social media (Twitter, Facebook) were also used.

RESULTS

We received 253 replies. The majority were Urologists (96.8%), younger than 60 (90.5%); 5.2% did not have access to PET-scans; 78.9% believed pN+ is a multifaceted category; 10-years CSS was marked as 71 to 95% by 17.5%. Gold standard management was stated not being ADT by 80.8% and being RT±ADT by 52.3%. Early sRT±ADT was considered an option vs. aRT±ADT by 72.4%. In case of BCR 71% would perform and decide management based on PSMA-PET whilst 3.7% would not perform PSMA-PET. pN+ management is still unclear for 77.1%. On multivariate analysis PSMA-PET availability related to a lower and higher likelihood of considering aRT±ADT as standard and of considering early salvage versus aRT respectively (P < .05).

CONCLUSIONS

The Urological community has an acceptable awareness of pN+ disease and management, although it may overestimate disease aggressiveness. The majority consider pN+ PCa as a multifaceted category and rely on a risk-adapted approach. Expectant compared to immediate upfront management and new imaging modalities are increasingly considered.

Aumento da Incidência de Recidiva Bioquímica após Prostatectomia Radical em Centro de Formação em Urologia Oncológica no Brasil: Doenças mais Avançadas estão sendo submetidas à Cirurgia?

Introdução: O câncer de próstata e a neoplasia maligna mais incidente em homens, representando 29% dos diagnósticos da doença no Brasil, segundo o Instituto Nacional de câncer Jose Alencar Gomes da Silva (INCA). Esse câncer e suspeito em alterações do toque retal e/ou do nível sérico do antígeno prostático especifico (PSA) total, sendo o diagnóstico definitivo feito por estudo histopatológico. Objetivo: Verificar a associação entre parâmetros clínicos e anatomopatológicos após prostatectómica radical com recidiva bioquímica ao longo do seguimento. Método: Estudo retrospectivo observacional dos parâmetros clínicos (idade, PSA inicial, toque retal, classificação histopatológica da International Society of Urological Pathology (ISUP), escala de D’Amico e estádio clínico) e anatomopatológicos (grau ISUP da peça cirúrgica, margens cirúrgicas, extensão extracapsular tumoral e presença de linfonodos acometidos), de 177 pacientes submetidos a prostatectomia radical em serviço de uro-oncologia de junho/2010-maio/2018. Resultados: A recidiva bioquímica ocorreu em 44,1% dos casos no tempo de seguimento médio de 34,9 meses. A análise univariada demonstrou PSA inicial >9 ng/mL, toque retal alterado, classificação patológica ISUP 4 e 5, risco D’Amico alto e estagio clinico TNM T3 como fatores diretamente associados a recidiva bioquímica. As margens cirúrgicas foram positivas em 46,3%; em 47,7%, identificou-se extensão extraprostática tumoral. Linfonodos positivos em 10,9% e vesículas seminais comprometidas ocorreram em 21,8%. Conclusão: Fatores clinico-patológicos podem ser preditores de recidiva bioquímica. Nesses casos, foi identificado padrão clinico pré-tratamento supostamente mais agressivo em comparação a literatura em geral. Além disso, deve-se considerar a curva de aprendizado dos cirurgiões em formação no serviço, o que pode resultar em maiores taxas de margens cirúrgicas positivas.

[Morbidity of extended pelvic lymphadenectomy during robot-assisted laparoscopic prostatectomy for localized cancer prostate]

OBJECTIVES

To assess the morbidity specific of extended pelvic lymphadenectomy during robot-assisted laparoscopic radical prostatectomy in a 8 year retrospective study.

MATERIAL

We carried out a single-center, single-surgeon retrospective study on 342 consecutive patients who underwent a robot-assisted laparoscopic radical prostatectomy and extended pelvic lymphadenectomy, from July 2010 to March 2018. Postoperative complications were recorded up to 3 months after the operation.

RESULTS

Thirty (8.8%) patients had at least one complication related to lymphadenectomy including 1 vascular injury (0.3%), 7 injuries of the obturator nerve (2%), 5 venous thromboembolic complications (1.5%) including 4 pulmonary embolisms, 10 symptomatic lymphoceles (2.9%) and 8 lymphoedemas (2.3%). Of these complications, 13 were classified Clavien 1 (43.3%), 8 Clavien 2 (26.7%), 7 Clavien 3a (23.3%) and 2 Clavien 3b (6.7%). In univariate analysis a high age (P=0.04), high BMI (P<0.01) and pT stage (P=0.02) were significantly associated with complication whereas in multivariate analysis, only age (P=0.02) and BMI (P<0.01) lived were. In univariate analysis high BMI (P=0.04) and lymph node involvement (P=0.04) were associated with lymphatic complication. We did not find any other specific risk factor for the other complications.

CONCLUSION

With 8.8% of overall complications related to lymphadenectomy and 5% of complication classified Clavien grade 2 or higher, extended pelvic lymphadenectomy was not very morbid. Age and BMI were risk factors for a overall complication. BMI and lymph node involvement were risk factors for lymphatic complications.

LEVEL OF PROOF

4.

Predictive value of Cribriform and Intraductal Carcinoma for the Nomogram-Based Selection of Prostate Cancer Patients for Pelvic Lymph Node Dissection

OBJECTIVE

To assess the predictive value of biopsy-identified cribriform carcinoma and/or intraductal carcinoma (CR/IDC) within the Briganti and MSKCC nomograms predicting lymph node metastasis (LNM) in patients with primary prostate cancer (PCa).

METHODS

We retrospectively included 393 PCa patients who underwent radical prostatectomy with extended pelvic lymph node dissection at three tertiary referral centers. We externally validated two prediction tools: the Briganti 2012 nomogram and the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram. Both nomograms were augmented with CR/IDC. The original model was compared with the CR/IDC-updated model using the likelihood ratio test. The performance of the prediction tools was assessed using calibration, discrimination, and clinical utility.

RESULTS

Overall, 109 (28%) men were diagnosed with LNM. Calibration plots of the Briganti and MSKCC nomograms demonstrated an underestimation of the LNM risk across clinically relevant thresholds (≤15%). The addition of CR/IDC to the Briganti nomogram increased the fit of the data (χ²(1)=4.30, p=0.04), but did not improve the area under the curve (AUC) (0.69, 95% CI 0.63-0.75 vs. 0.69, 95% CI 0.64-0.75). Incorporation of CR/IDC in the MSKCC nomogram resulted in an increased fit on the data (χ²(1)=10.04, p<0.01), but did not increase the AUC (0.66, 95% CI 0.60-0.72 vs 0.68, 95% CI 0.62-0.74). The addition of CR/IDC to the Briganti and MSKCC nomograms did not improve the clinical risk prediction.

CONCLUSIONS

Incorporation of CR/IDC into the two clinically most used pre-radical prostatectomy nomograms does not improve LNM prediction in a multinational, contemporary PCa cohort.

External Validation and Comparison of Two Nomograms Predicting the Probability of Lymph Node Involvement in Patients subjected to Robot-Assisted Radical Prostatectomy and Concomitant Lymph Node Dissection: A Single Tertiary Center Experience in the MRI-Era

Introduction

To externally validate and directly compare the performance of the Briganti 2012 and Briganti 2019 nomograms as predictors of lymph node invasion (LNI) in a cohort of patients treated with robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection (ePLND).

Materials and Methods

After the exclusion of patients with incomplete biopsy, imaging, or clinical data, 752 patients who underwent RARP and ePLND between December 2014 to August 2021 at our center, were included. Among these patients, 327 (43.5%) had undergone multi-parametric MRI (mpMRI) and mpMRI-targeted biopsy. The preoperative risk of LNI was calculated for all patients using the Briganti 2012 nomogram, while the Briganti 2019 nomogram was used only in patients who had performed mpMRI with the combination of targeted and systematic biopsy. The performances of Briganti 2012 and 2019 models were evaluated using the area under the receiver-operating characteristics curve analysis, calibrations plot, and decision curve analysis.

Results

A median of 13 (IQR 9–18) nodes per patient was removed, and 78 (10.4%) patients had LNI at final pathology. The area under the curves (AUCs) for Briganti 2012 and 2019 were 0.84 and 0.82, respectively. The calibration plots showed a good correlation between the predicted probabilities and the observed proportion of LNI for both models, with a slight tendency to underestimation. The decision curve analysis (DCA) of the two models was similar, with a slightly higher net benefit for Briganti 2012 nomogram. In patients receiving both systematic- and targeted-biopsy, the Briganti 2012 accuracy was 0.85, and no significant difference was found between the AUCs of 2012 and 2019 nomograms (p = 0.296). In the sub-cohort of 518 (68.9%) intermediate-risk PCa patients, the Briganti 2012 nomogram outperforms the 2019 model in terms of accuracy (0.82 vs. 0.77), calibration curve, and net benefit at DCA.

Conclusion

The direct comparison of the two nomograms showed that the most updated nomogram, which included MRI and MRI-targeted biopsy data, was not significantly more accurate than the 2012 model in the prediction of LNI, suggesting a negligible role of mpMRI in the current population.

Features and management of men with pN1 cM0 prostate cancer after radical prostatectomy and lymphadenectomy: a systematic review of population-based evidence

PURPOSE OF REVIEW

To investigate the features and optimal management of pN+ cM0 prostate cancer (PCa) according to registry-based studies.

RECENT FINDINGS

Up to 15% of PCa patients harbor lymph node invasion (pN+) at radical prostatectomy plus lymph node dissection. Nonetheless, the optimal management strategy in this setting is not well characterized.

SUMMARY

We performed a systematic review including n = 13 studies. Management strategies comprised 13 536 men undergoing observation, 11 149 adjuvant androgen deprivation therapy (aADT), 7,075 adjuvant radiotherapy (aRT) +aADT and 705 aRT. Baseline features showed aggressive PCa in the majority of men. At a median follow-up ranging 48-134months, Cancer-related death was 5% and overall-mortality 16.6%. aADT and aRT alone had no cancer-specific survival or overall survival advantages over observation only and over not performing aRT, respectively. aADT plus aRT yielded a survival benefit compared to observation and aADT, which in one study, were limited to certain intermediate-risk categories. Age, Gleason, Charlson score, positive surgical margins, pathological stage, and positive nodes number, but not prostate specific antigen, were most relevant prognostic factors. Our work further confirmed pN+ PCa is a multifaceted disease and will help future research in defining its optimal management based on different risk categories to maximize survival and patient's quality of life.

Magnetometer-Guided Sentinel Lymph Node Dissection in Prostate Cancer: Rate of Lymph Node Involvement Compared with Radioisotope Marking

Simple Summary

Pelvic lymph node dissection is recommended in prostate cancer according to the patients’ individual risk for nodal metastases. Targeted removal of sentinel lymph nodes increases the number of detected lymph node metastases in patients with prostate cancer. We previously established magnetometer-guided sentinel lymph node dissection in patients with prostate cancer to overcome logistical and technical disadvantages associated with the standard radioisotope-guided technique. This retrospective study compared the magnetometer-guided and standard techniques in terms of their ability to detect lymph node metastases. Using the magnetometer-guided technique, more sentinel lymph nodes were detected per patient. The detected rates of lymph node involvement matched the predictions in both techniques equally well. Our findings confirm the reliability of magnetometer-guided sentinel lymph node dissection and highlight the importance of the sentinel technique for detecting lymph node metastases in prostate cancer.

Abstract

Sentinel pelvic lymph node dissection (sPLND) enables the targeted removal of lymph nodes (LNs) bearing the highest metastasis risk. In prostate cancer (PCa), sPLND alone or combined with extended PLND (ePLND) reveals more LN metastases along with detecting sentinel LNs (SLNs) outside the conventional ePLND template. To overcome the disadvantages of radioisotope-guided sPLND in PCa treatment, magnetometer-guided sPLND applying superparamagnetic iron oxide nanoparticles as a tracer was established. This retrospective study compared the nodal staging ability between magnetometer- and radioisotope-guided sPLNDs. We analyzed data of PCa patients undergoing radical prostatectomy and magnetometer- (848 patients, 2015–2021) or radioisotope-guided (2092 patients, 2006–2015) sPLND. To reduce heterogeneity among cohorts, we performed propensity score matching and compared data considering sentinel nomogram-based probabilities for LN involvement (LNI). Magnetometer- and radioisotope-guided sPLNDs had SLN detection rates of 98.12% and 98.09%, respectively; the former detected more SLNs per patient. The LNI rates matched nomogram-based predictions in both techniques equally well. Approximately 7% of LN metastases were detected outside the conventional ePLND template. Thus, we confirmed the reliability of magnetometer-guided sPLND in nodal staging, with results comparable with or better than radioisotope-guided sPLND. Our findings highlight the importance of the sentinel technique for detecting LN metastases in PCa.

Can Negative Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography Avoid the Need for Pelvic Lymph Node Dissection in Newly Diagnosed Prostate Cancer Patients? A Systematic Review and Meta-analysis with Backup Histology as Reference Standard

CONTEXT

The role of positron emission tomography/computed tomography (PET/CT) with prostate-specific membrane antigen (PSMA) in the primary staging for patients with prostate cancer (PCa) is still debated.

OBJECTIVE

To analyze published studies reporting the accuracy of PSMA PET/CT for detecting lymph node invasion (LNI) at pelvic lymph node dissection (PLND).

EVIDENCE ACQUISITION

A search of PubMed/MEDLINE, Cochrane library's Central, EMBASE and Scopus databases, from inception to May 2021, was conducted. The primary outcome was to evaluate the sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of PSMA PET/CT in detecting LNI on a per-patient level. As a secondary outcome, NPV of PET PSMA was tested on a per-node-level analysis. Detection rates were pooled using random-effect models. Preplanned subgroup analyses tested the diagnostic accuracy after stratification for the preoperative risk group. PPV and NPV variation over LNI prevalence was evaluated. Only studies including extended PLND (ePLND) as the reference standard test were included.

EVIDENCE SYNTHESIS

Twenty-seven studies, with a total of 2832 participants, were included in quantitative synthesis. The sensitivity, specificity, PPV, and NPV of PSMA PET/CT for LNI were, respectively, 58% (95% confidence interval [CI] 50-66%), 95% (95% CI 93-97%), 79% (95% CI 72-85%), and 87% (95% CI 84-89%), with overall moderate heterogeneity between studies. At bivariate analysis, the diagnostic accuracy of PSMA PET/CT estimated through summary receiver operating characteristic-derived area under the curve was 84% (95% CI 81-87%). On a per-node level, NPV of PET PSMA was 97% (95% CI 96-99%). At subgroup analyses, according to preoperative risk groups, sensitivity, specificity, PPV, and NPV were 51%, 93%, 73%, and 81%, respectively, in high-risk patients. Over the LNI prevalence range of 5-40%, PPV increased from 59% to 91%, while NPV decreased from 99% to 84%.

CONCLUSIONS

PSMA PET/CT scan provides promising accuracy in the field of primary nodal staging for PCa. The high NPV in men with a lower risk of LNI might be clinically useful to reduce the number of unnecessary PLND procedures performed. Conversely, in high-risk patients, negative PSMA PET/CT cannot replace staging ePLND.

PATIENT SUMMARY

In this systematic review and meta-analysis, we demonstrated that prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) scan may optimize the primary nodal staging and surgical management of prostate cancer patients candidate to radical prostatectomy. The high negative predictive value in men with a lower risk of lymph node invasion might be clinically useful for reducing the number of useless pelvic lymph node dissection (PLND) procedures performed. Conversely, in high-risk patients, negative PSMA PET/CT cannot allow avoiding of PLND.

Temporal Trends and Predictors in Diagnosing Pathologic Node-Positive Prostate Cancer in Clinically Node-Negative Patients

INTRODUCTION

Managing pathologically node positive (pN+) prostate cancer (PCa) is controversial. We describe temporal patterns and predictors of pN+ PCa in men with initially surgically managed clinically node negative (cN-) PCa.

MATERIALS AND METHODS

This observational retrospective analysis of nonmetastatic, cN- PCa uses the National Cancer Database. Multivariable logistic regression was used to identify covariates associated with pN+ disease. Cox proportional hazards modeling and Kaplan-Meier analysis were used to evaluate survival patients undergoing radical prostatectomy with or without pelvic lymph node dissection (PLND).

RESULTS

The rates of radical prostatectomy in men with grade group (GG) 4 and GG5 increased from 47.6% to 53.1% and from 42.5% to 49.5%, respectively. The annual rate increased from 2.02% in 2010 to 5.12% in 2017 (P < .001). The annual rates of PLND increased from 54.3% to 71.7%. The most significant predictor of pN+ PCa was ISUP GG4 (odds ratio [OR] 12.5, P< .001) and GG 5 (OR 26.2, P < .001). Rates of pN+ identification increased from 5.5% to 9.4% in men with GG4 and from 13.4% to 19.5% in men with GG5 (P< .001). In GG4 and GG5, patients undergoing PLND had superior survival to those managed without PLND (P < .01).

CONCLUSION

Among patients with cN- PCa, the diagnosis of pN+ PCa has become more common over time. GG4 and GG5 are the strongest independent predictors of pN+ disease. Because incidental pN+ results in upstaging these data are useful for informing discussions before radical prostatectomy.

Contemporary update of SPECT tracers and novelties in radioguided surgery: a perspective based on urology

Recent technical advances and implementation of novel radiotracers have further increased the potential of radioguided surgery for a broad variety of malignancies. Indeed, the possibilities for future applications of novel radiotracers in diverse oncological strategies has become more promising than ever. This literature review aims to provide a contemporary update on a selected group of radiotracers and evaluates the usability of radioguided surgery and sentinel node procedures, focusing on most promising advances. For example, the impact of targeted radiotracers on prostate specific membrane antigen (PSMA), CD206 receptor-targeted agents (^99mTc-tilmanocept), and hybrid tracers adding fluorescence to radioguidance (ICG-^99mTc-nanocolloid) as well as targeting hypoxia-induced carbonic anhydrase IX (CAIX) will be covered. Furthermore, future outlooks on the implementation of gold nanoparticles (AuNP's), but also technical advances in improved radiotracer detection by hybrid gamma devices will be discussed.

Prognostic Significance of Prostate-Specific Antigen Persistence after Radical Prostatectomy: A Systematic Review and Meta-Analysis

We performed a systematic review and meta-analysis to assess the prognostic value of prostate-specific antigen (PSA) persistence 4-8 weeks after radical prostatectomy (RP) in patients with prostate cancer, using studies from Medline, Scopus, and Cochrane Library, on 10 October 2020. Studies were eligible if they compared patients with postoperative PSA persistence 4-8 weeks after RP to those without such persistence to assess the value of PSA persistence in prognosticating biochemical recurrence (BCR), disease recurrence, cancer-specific mortality (CSM), and overall mortality (OM) by multivariable analysis. Our review and analysis included nine studies published between 2008 and 2019 with 14,455 patients. Of those studies, 12.0% showed postoperative PSA persistence. PSA persistence was associated with BCR (HR: 4.44, 95% CI: 2.84-6.93), disease recurrence (HR: 3.43, 95% CI: 1.62-7.25), and CSM (HR: 2.32, 95% CI: 1.83-2.95). We omitted meta-analysis on the association of PSA persistence with OM due to an insufficient number of studies. PSA persistence was associated with disease recurrence in a sub-group of patients with pathological nodal involvement (HR: 5.90, 95% CI: 3.76-9.24). Understanding detection of PSA persistence at 4-8 weeks after RP might be useful for patient counseling, follow-up scheduling, and clinical decision-making regarding adjuvant therapies.

Adjuvant radiotherapy in node positive prostate cancer patients: a debate still on. when, for whom?

OBJECTIVE

To evaluate the impact of adjuvant radiotherapy (aRT) in patients with prostate cancer (PCa) found to have pathological positive lymph nodes (pN1s) after radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND) with regard to distant recurrence-free survival (RFS), according to both main tumour pathological characteristics and number of positive lymph nodes. Biochemical RFS, local RFS, overall survival (OS) and acute and late toxicity were assessed as secondary endpoints.

PATIENTS AND METHODS

A retrospective cohort of 187 consecutive patients with pN1 PCa were treated with aRT at the IEO, European Institute of Oncology IRCCS, Milan, Italy. aRT on the tumour bed and pelvis was administered within 6 months of RP. Androgen deprivation therapy was administered according to the guidelines. Univariate and multivariate Cox regression analyses predicting biochemical RFS, local RFS, distant RFS and OS rates were performed to assess whether the number of pN1s represented an independent prognostic factor. The Youden index was computed to find the optimal threshold for the number of pN1s able to discriminate between patients with or without biochemical and clinical relapse.

RESULTS

At 5 years, local RFS, distant RFS, biochemical RFS and OS were 68%, 71%, 56% and 94%, respectively. The median follow-up was 49 months. The number of pN1s was significantly associated with biochemical RFS, local RFS and distant RFS. The best threshold for discriminating between patients with or without biochemical and clinical relapse was five pN1s. In multivariate analyses, the number of pN1s was confirmed to be an independent predictor of biochemical RFS, local RFS and distant RFS, but not of OS. Multivariate analyses also showed an increased risk of biochemical relapse for increasing values of initial prostate-specific antigen and for patients with tumour vascular invasion. Local and distant RFS were also inversely correlated with significantly reduced risk for International Society of Urological Pathology grade group <3 (group 1 or 2 compared to group 3).

CONCLUSIONS

Our data confirmed the encouraging outcomes of patients with pN1 PCa treated with adjuvant treatments and the key role represented by the number of pN1s in predicting biochemical RFS, clinical RFS and distant RFS. Large prospective cohort studies and randomized clinical trials are needed to confirm these results and to identify the subgroup of patients with pN1 PCa who would most benefit from aRT.

Management of Patients with Node-positive Prostate Cancer at Radical Prostatectomy and Pelvic Lymph Node Dissection: A Systematic Review

CONTEXT

Optimal management of prostate cancer (PCa) patients with lymph node invasion at radical prostatectomy and pelvic lymph node dissection still remains unclear.

OBJECTIVE

To assess the effectiveness of postoperative treatment strategies for pathologically node-positive PCa patients. The secondary aim was to identify the most relevant prognostic factors to guide the management of pN1 patients.

EVIDENCE ACQUISITION

A systematic review was performed in January 2020 using Medline, Embase, and other databases. A total of 5063 articles were screened, and 26 studies including 12 537 men were selected for data synthesis and included in the current review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations.

EVIDENCE SYNTHESIS

Ten-year biochemical recurrence (BCR)-free, clinical recurrence-free, cancer-specific (CSS), and overall (OS) survival rates ranged from 28% to 56%, 70% to 92%, 72% to 98%, and 60% to 87.6%, respectively. A total of seven, five, and six studies assessed the oncological outcomes of observation, adjuvant radiotherapy (aRT), or adjuvant androgen deprivation therapy (ADT), respectively. Initial observation followed by salvage therapies at the time of recurrence represents a safe option in selected patients with a low disease burden. The use of aRT with or without ADT might improve survival in men with locally advanced disease and a higher number of positive nodes. Risk stratification according to pathological Gleason score, number of positive nodes, pathological stage, and surgical margins status is the key to risk stratification and selection of the optimal postoperative therapy. Limitations of this systematic review are the retrospective design of the studies included and the lack of data on adverse events.

CONCLUSIONS

While the majority of men with pN1 disease would experience BCR after surgery, long-term disease-free survival has been reported in selected patients. Management options to improve oncological outcomes include observation versus adjuvant therapies such as aRT and/or ADT. Disease characteristics should be used to select the optimal postoperative management for pN1 PCa patients.

PATIENT SUMMARY

Finding node-positive prostate cancer after a radical prostatectomy often leads to high postoperative prostate-specific antigen levels and is overall a poor prognostic factor. However, this does not necessarily translate into poor survival for all men. Management can be tailored to the severity of disease and options include observation, androgen deprivation therapy, and/or radiotherapy.

Histological comparison between predictive value of preoperative 3-T multiparametric MRI and 68 Ga-PSMA PET/CT scan for pathological outcomes at radical prostatectomy and pelvic lymph node dissection for prostate cancer

OBJECTIVE

To evaluate the ability of preoperative multiparametric magnetic resonance imaging (mpMRI) and a gallium-68 prostate-specific membrane antigen positron emission tomography/computed tomography (⁶⁸ Ga-PSMA PET/CT) scan to predict pathological outcomes and also identify a group of men with a <5% risk of histological pelvic lymph node metastasis (LNM) at pelvic lymph node dissection (PLND) performed during a robot-assisted laparoscopic radical prostatectomy (RALP) for prostate cancer. We then aimed to compare these results to known risk calculators for LNM, including the Cancer of the Prostate Risk Assessment (CAPRA) score, Memorial Sloan Kettering Cancer Centre (MSKCC) and Briganti nomograms.

PATIENTS AND METHODS

Between July 2014 and September 2019 only men who had both a preoperative mpMRI and staging ⁶⁸ Ga-PSMA PET/CT at our institution followed by a RALP with PLND referred to a single specialist uropathology laboratory were considered for inclusion. The data were collected retrospectively prior to February 2019 and in a prospective manner thereafter. A model was built to allocate probabilities of the men with a negative ⁶⁸ Ga-PSMA PET/CT scan having a <5% risk of histologically LNM at RALP based on the preoperative radiological staging.

RESULTS

A total of 233 consecutive men met the inclusion criteria of which 58 men (24.9%) had a LNM identified on PLND histology. The median (range) International Society of Urological Pathology (ISUP) Grade was 5 (1-5) and the median (range) prostate-specific antigen level was 7.4 (1.5-72) ng/mL. The median (range) number of resected lymph nodes was 16 (1-53) and the median (range) number of positive nodes identified on histology was 2 (1-22). Seminal vesicle invasion on mpMRI was more common in node-positive men than in the absence of LNM (31% vs 12%). The maximum standardised uptake value of the primary tumour on ⁶⁸ Ga-PSMA PET/CT was higher in men with LNM (median 9.2 vs 7.2, P = 0.02). Suspected LNM were identified in 42/233 (18.0%) men with ⁶⁸ Ga-PSMA PET/CT compared with 22/233 (9.4%) men with mpMRI (P = 0.023). The positive and negative predictive value for ⁶⁸ Ga-PSMA PET/CT was 66.7% and 84.3% respectively, compared to 59.1% and 78.7% for mpMRI. A predictive model showed only two men (4.2%) with a negative preoperative ⁶⁸ Ga-PSMA PET/CT would be positive for a histological LNM if they are ISUP Grade < 5 and Prostate Imaging-Reporting and Data System (PI-RADS) <5; or ISUP Grade 5 with PI-RADS < 4. An inspection of three additional variables: CAPRA score, MSKCC and Briganti nomograms did not improve the predictive probability for this group. However, of the 61 men with ISUP Grade 4-5 malignancy and also a PI-RADS 5 mpMRI, 20 (32.8%) men had a microscopic LNM despite a negative preoperative ⁶⁸ Ga-PSMA PET/CT.

CONCLUSION

Preoperative ⁶⁸ Ga-PSMA/PET CT was more sensitive in identifying histological pelvic LNM than 3-T mpMRI. Men with a negative ⁶⁸ Ga-PSMA PET/CT have a lower risk of LNM than predicted with CAPRA scores or MSKCC and Briganti nomograms. We identified that the combination of a negative preoperative ⁶⁸ Ga-PSMA PET/CT, ISUP biopsy Grade <5 and PI-RADS <5 prostate mpMRI, or an ISUP Grade 5 with PI-RADS <4 on mpMRI was associated with a <5% risk of a LNM. The addition of CAPRA scores, MSKCC and Briganti nomograms did not improve the predictive probability within this model. Conversely, men with ISUP Grade 4-5 malignancy associated with a PI-RADS 5 prostate mpMRI had a >30% risk of microscopic LNM despite a negative preoperative ⁶⁸ Ga-PSMA PET/CT and this high-risk group would appear suitable for an extended PLND at the time of a radical prostatectomy.

The Role of 68Ga-PSMA Positron Emission Tomography/Computerized Tomography for Preoperative Lymph Node Staging in Intermediate/High Risk Patients With Prostate Cancer: A Diagnostic Meta-Analysis

Purpose: To evaluate the accuracy of ⁶⁸Ga-PSMA positron emission tomography/computerized tomography (PET/CT) for preoperative lymph node staging using histopathological results of pelvic lymph node dissection (PLND) as reference standard in patients with intermediate/high risk of prostate cancer.

Material and Methods: A systematic search of PubMed, Embase, and the Cochrane Library was completed up to May 2020. We included studies investigating accuracy of ⁶⁸Ga-PSMA PET/CT in primary lymph node staging before radical prostatectomy and PLND. The pooled sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic odds ratio (DOR), and the summary receiver operating characteristic (SROC) curve with an area under the curve (AUC) were synthesized.

Results: Eleven studies comprising 904 patients were identified. Based on per-patient analysis, the pooled sensitivity and specificity reached 0.63 (95% CI: 0.46–0.78) and 0.93 (95% CI: 0.88–0.96), respectively, with the DOR of 22 (95% CI: 10–47). An overall accuracy was revealed by the SROC curve with AUC of 0.91 (95% CI: 0.88–0.93). Using the lymph node as unit, the pooled sensitivity and specificity were 0.70 (95% CI: 0.49–0.85) and 0.99 (95% CI: 0.96–1.00), respectively. And the DOR reached 167 (95% CI: 40–695) with an AUC of 0.96 (95% CI: 0.94–0.98). The pooled PPV and NPV all reached above 0.8 on basis of per-patient or per-node analysis.

Conclusions:⁶⁸Ga-PSMA PET/CT represented as a promising test for preoperative lymph node staging and patients without lymph node metastatic status can rarely be misdiagnosed. However, its sensitivity ought to be improved before forgoing PLND.

Standardized and Simplified Robot-assisted Superextended Pelvic Lymph Node Dissection for Prostate Cancer: The Monoblock Technique

BACKGROUND

Extended pelvic lymph node dissection (ePLND) remains the most accurate procedure for lymph node staging in intermediate- and high-risk prostate cancer (PCa) patients undergoing radical prostatectomy (RP). A superextended pelvic lymph node dissection (sePLND) can be considered in selected very-high-risk PCa patients.

OBJECTIVE

To demonstrate a reproducible robot-assisted technique for sePLND at the time of RP for PCa.

DESIGN, SETTING, AND PARTICIPANTS

From June 2016 to August 2019, 41 consecutive patients with localized PCa and very high risk for lymph node invasion (LNI) received a robot-assisted RP and a standardized 10-step monoblock ePLND, followed by a 5-step monoblock sePLND. Very high risk for LNI was defined as ≥30% risk for LNI, as calculated by the Briganti 2017 nomogram.

SURGICAL PROCEDURE

After performing the ePLND template resection (harvesting lymph nodes from the obturator region, external and internal iliac vessels, and common iliac vessels up to the ureter crossing), the 5-step monoblock sePLND approach was performed. The sePLND template was tailored to the common iliac vessels up to the aortic and caval bifurcation as well as the presacral region.

MEASUREMENTS

Lymph node yield, perioperative complications.

RESULTS AND LIMITATIONS

Overall, 41 patients received sePLND, reporting a median (interquartile range [IQR]) number of nodes removed of 23 (19-29). Median operative time (including RP, ePLND, and sePLND) was 256 min. Median preoperative prostate-specific antigen was 12 ng/mL (IQR 6.45-17.6). Disease stage pT <3 was found in 10 (24.4%) patients, pT3a in nine (22%) patients, pT3b in 21 (51.2%) patients, and pT4 in one (2.4%) patient. Of the treated patients, 54% revealed LNI: five (4.9%) in a solitary node, five (4.9%) in two to five nodes, and 12 (29.3%) in more than five nodes. Considering perioperative complications, three (7.3%) patients experienced Clavien I-II and four (9.7%) experienced Clavien ≥ III complications. Median hospital stay was 6 d. No patient underwent postoperative blood transfusion.

CONCLUSIONS

The 5-step sePLND approach is a reproducible and feasible technique for PCa patients at a very high risk of LNI.

PATIENT SUMMARY

In our study, we aimed to provide surgeons with a step-by-step technique for lymph node dissection, which aims to collect possibly metastatic lymph nodes of prostate cancer in an even more extended version ("superextended") than a standard ("extended") lymph node dissection.

Applied anatomy of pelvic lymph nodes and its clinical significance for prostate cancer:a single-center cadaveric study

Background

Pelvic lymph node dissection (PLND) is one of the most important steps in radical prostatectomy (RP). Not only can PLND provide accurate clinical staging to guide treatment after prostatectomy but PLND can also improve the prognosis of patients by eradicating micro-metastases. However, reports of the number of pelvic lymph nodes have generally come from incomplete dissection during surgery, there is no anatomic study that assesses the number and variability of lymph nodes. Our objective is to assess the utility of adopting the lymph node count as a metric of surgical quality for the extent of lymph node dissection during RP for prostate cancer by conducting a dissection study of pelvic lymph nodes in adult male cadavers.

Methods

All 30 adult male cadavers underwent pelvic lymph node dissection (PLND), and the lymph nodes in each of the 9 dissection zones were enumerated and analyzed.

Results

A total of 1267 lymph nodes were obtained. The number of lymph nodes obtained by limited PLND was 4–22 (14.1 ± 4.5), the number obtained by standard PLND was 16–35 (25.9 ± 5.6), the number obtained by extended PLND was 17–44 (30.0 ± 7.0), and the number obtained by super-extended PLDN was 24–60 (42.2 ± 9.7).

Conclusions

There are substantial inter-individual differences in the number of lymph nodes in the pelvic cavity. These results have demonstrated the rationality and feasibility of adopting lymph node count as a surrogate for evaluating the utility of PLND in radical prostatectomy, but these results need to be further explored.

Development and validation of hub genes for lymph node metastasis in patients with prostate cancer

Lymph node metastasis is one of the most important independent risk factors that can negatively affect the prognosis of prostate cancer (PCa); however, the exact mechanisms have not been well studied. This study aims to better understand the underlying mechanism of lymph node metastasis in PCa by bioinformatics analysis. We analysed a total of 367 PCa cases from the cancer genome atlas database and performed weighted gene co-expression network analysis to explore some modules related to lymph node metastasis. Gene Ontology analysis and pathway enrichment analysis were conducted for functional annotation, and a protein-protein interaction network was built. Samples from the International Cancer Genomics Consortium database were used as a validation set. The turquoise module showed the most relevance with lymph node metastasis. Functional annotation showed that biological processes and pathways were mainly related to activation of the processes of cell cycle and mitosis. Four hub genes were selected: CKAP2L, CDCA8, ERCC6L and ARPC1A. Further validation showed that the four hub genes well-distinguished tumour and normal tissues, and they were good biomarkers for lymph node metastasis of PCa. In conclusion, the identified hub genes facilitate our knowledge of the underlying molecular mechanism for lymph node metastasis of PCa.

Significance of examined lymph-node count in accurate staging and long-term survival in patients undergoing radical prostatectomy: a population-based study

PURPOSE

The number of examined lymph node (ELN) is regarded as the critical quality index for cancer care. We scrutinize the relationship among ELN number, accurate staging, and long-term survival in prostate cancer (Pca).

METHODS

Population-based data on Pca patients in 2004-2015 from the US SEER database were investigated. The connection among ELN number and stage migration, overall survival (OS), and prostate cancer-specific survival (CSS) were evaluated by performing multivariable-adjusted logistic, Cox proportional hazards, and fine-gray competing-risk regression models, respectively. LOWESS smoother was used to fit the series of ELN number, odds ratios (OR), and hazard ratios (HR), while the Chow test was used to resolve the structural breakpoints. Subgroup and interaction analyses were performed in different risk populations.

RESULTS

Overall, 84,838 patients were analyzed. Serial improvements were seen in stage migration (OR, 1.072, P < 0.001), OS (HR, 0.991; P < 0.001), and CSS (HR, 0.983; P < 0.001) per additional ELN after adjusting for confounders. Subgroup analysis revealed that the ELN number gains the most staging and survival benefits in high-risk population (P for interaction < 0.001). Cut-point analyses suggested that an optimal number of 12 ELNs, which was verified by the cumulative incidence curve, had a strong capability to distinguish different probabilities of CSS.

CONCLUSIONS

Higher quantities of ELNs are related to more-accurate nodal staging and long-term survival of Pca patients undergoing RP. We highlight that 12 ELNs are the optimal cut-point for the high-risk population to investigate the quality of LN detection and stratifying postoperative prognosis.

Comparison between Zumsteg classification and Briganti nomogram for the risk of lymph-node invasion before radical prostatectomy

PURPOSE

To evaluate the performance of the Zumsteg classification to estimate the risk of lymph-node invasion (LNI) compared with the Briganti nomogram (BN) in prostatectomy patients with intermediate-risk prostate cancer (IRPC).

METHODS

We included consecutive patients who had extended pelvic lymph-node dissection associated with radical prostatectomy for IRPC. To be classified favorable intermediate risk (FIR), patients could only have one intermediate-risk factor, fewer than 50% positive biopsies and no primary Gleason score of 4.

RESULTS

On the 387 patients included, 149 (38.5%) and 238 (54.3%) were classified FIR and unfavorable intermediate risk (UIR), respectively, and 212 (54.8%) had a BN inferior to 5%. Thirty-eight patients (9.8%) had LNI: 6 FIR patients (4.0%) versus 32 UIR patients (13.4%) and 14 patients (6.6%) with a BN inferior to 5% versus 24 patients (13.7%) with a BN superior to 5%. Eight patients with a BN inferior to 5%, but classified UIR, had LNI. Sensitivity to detect LNI was higher with the Zumsteg classification than with the BN: 84.2% (CI 95% [68-93]) versus 63.2% (CI 95% [46-78]). Both screening tests were concordant to predict LNI (kappa coefficient of 0.076, p < 0.05 for Zumsteg and Briganti) CONCLUSIONS: Zumsteg classification appeared to be more sensitive and as effective (despite the impossibility to make decision curve analysis) than the BN to estimate the risk of LNI. Regarding the modest number of pN+ patients, further studies are needed to see the interest of proposing ePLND for UIR patients only.

Prostate specific antigen (PSA) persistence 6 weeks after radical prostatectomy and pelvic lymph node dissection as predictive factor of radiographic progression in node-positive prostate cancer patients

Purpose: To evaluate the prognostic value of early postoperative prostate specific antigen (PSA) levels after radical prostatectomy (RP) and pelvic lymph node dissection (PLND) in prostate cancer patients with lymph node invasion (LNI).

Materials and Methods: The retrospective analysis involved 96 patients who had a diagnosis of LNI with available data on the first PSA level at postoperative 6 weeks after RP and PLND between 2002 and 2014 at our institution. PSA persistence was defined as PSA ≥ 0.1 ng/ml at 6 weeks after surgery. Radiographic progression was defined as positive imaging during follow-up after the onset of biochemical recurrence, consisting of a bone scan and/or computed tomography (CT) and/or magnetic resonance imaging and/or 18F-(2-deoxy-2-fluoro-D-glucose positron emission tomography/CT scan. Comparative analysis of patients with and without PSA persistence was done, and Kaplan-Meier curve analysis with log-rank test and Cox proportional hazard regression models assessed radiographic progression free survival (PFS).

Results: Fifty two (54.2%) patients displayed PSA persistence. Kaplan-Meier curve analysis showed significantly decreased 5-year radiographic PFS (64.2% vs. 93.2%, log-rank, p=0.009) in the PSA persistence group compared to the no PSA persistence group. In a multivariate analysis, PSA persistence was a statistically significant predictor of radiographic PFS.

Conclusions: Early assessment of PSA after surgery is important for predicting radiographic progression in node-positive prostate cancer patients. Risk stratification based on the early PSA value after surgery would be helpful to identify patients who may benefit from early adjuvant therapies.

Pelvic lymph node dissection in prostate cancer staging: evaluation of morbidity and oncological outcomes

BACKGROUND

To evaluate the morbidity of different surgical approaches for pelvic lymph node dissection (PLND), to evaluate the influence of morbidity on radiotherapy (RT) planning and to evaluate a possible therapeutic effect of a more extensive yield of PLND.

METHODS

From 2000-2016, 228 patients received staging PLND before primary RT in a single tertiary care center. Nine patients were excluded for the evaluation of morbidity. Fifty patients were operated in an open approach, 96 laparoscopic and 73 robot-assisted (RA). Clavien-Dindo classification was used for evaluating complications. Predictors of biochemical recurrence (BCR), clinical relapse (CR), cancer-specific survival (CSS) and overall survival (OS) were evaluated by regression analyses to determine a possible therapeutic effect.

RESULTS

Minimal invasive surgery (laparoscopic or RA) caused five times less major complications (22% vs. 4.3%, p = .001) and a median 3 days shorter hospital stay (5 days versus 2 days, p < .001). Major complications resulted in a delayed (23 days, p < .001) RT start but no oncological effect was seen. Independent oncological predictors were the number of positive nodes (BCR, CR, CSS, OS), a lower age (CR), a higher level of initial prostate-specific antigen (PSA) (BCR) and post-RT PSA (BCR).

CONCLUSION

Minimal invasive surgery can diminish major complications which delay RT start. Nodal staging proved to be of importance for prognosis but no therapeutic effect was seen of performing PLND as such.

Rise in Node-Positive Prostate Cancer Incidence in Context of Evolving Use and Extent of Pelvic Lymphadenectomy

BACKGROUND

The incidence of node-positive prostate cancer has risen and might be partially explained by evolving use of lymphadenectomy at a population level. We assessed trends of node-positive prostate cancer in context of extent of lymphadenectomy among men treated surgically for prostate cancer.

PATIENTS AND METHODS

This was a retrospective study using data from a population-based cancer registry to identify men older than 50 years of age diagnosed with prostate cancer from 2010 to 2015 without distant metastases. We considered extent of node dissection as ordinal (1-4, 5-9, 10-14, 15-19, ≥20) and dichotomous (1-14, ≥15) variables. We fit multivariable models to assess trends in receipt of extended lymphadenectomy and then estimated odds of node-positive cancer on the basis of extent of lymphadenectomy.

RESULTS

We identified 280,156 men diagnosed from 2010 to 2015; 5355 men (1.9%) had positive lymph nodes. Incidence of positive nodes increased from 6.4 to 8.4 cases per 100,000 men from 2010 to 2015 (standardized rate ratio, 1.31; 95% confidence interval [CI], 1.20-1.44). Compared with 2010, prostatectomy patients with high-risk (odds ratio [OR], 1.66; 95% CI, 1.42-1.95) and intermediate-risk tumors (OR, 1.66; 95% CI, 1.47-1.88) were more likely to undergo extended lymphadenectomy in 2015. Among high-risk patients, men with ≥20 nodes removed were 7 times more likely to have positive nodes, versus <5 removed (6.1% for 1-4 vs. 32.4% for ≥20; OR, 7.32; 95% CI, 6.16-8.71). After adjusting for extent of dissection, odds of node-positive disease did not increase between 2010 and 2015 (OR, 1.17; 95% CI, 0.98-1.39) among high-risk patients.

CONCLUSION

Increased incidence of node-positive prostate cancer in the United States is partially explained by more frequent use of extended lymphadenectomy.

Pathologically Node-Positive Prostate Carcinoma - Prevalence, Pattern of Care and Outcome From a Population-Based Study

AIMS

To evaluate the prevalence, patterns of care and outcome of pathologically node-positive (pN+) prostate cancer (P-Ca) after radical prostatectomy from a provincial population database.

PATIENTS AND METHODS

Patients were identified from a provincial cancer registry and a genitourinary cancer outcomes unit (2005-2014). Of a total of 4723 patients who underwent radical prostatectomy, 167 patients with pN+ P-Ca were identified (28/2181 from 2005-2007 and 139/2542 from 2010-2014). Persistently elevated postoperative prostate-specific antigen (PSA) ≥ 0.2 ng/ml was noted in 52 (31%) patients, 23 (44.2%) of whom had salvage androgen deprivation therapy plus radiotherapy (ADT + RT), 25 (48%) were managed with ADT alone and four (7.8%) had no treatment. Of 115 patients with postoperative PSA <0.2 ng/ml, 47 (41%) had ADT alone and 50 (43.5%) had ADT + RT. Survival estimation was carried out using the Kaplan-Meier method. The association of prognostic factors with survival was evaluated using univariate and multivariate analysis and was limited to the newer cohort (2010-2014).

RESULTS

The median age was 64 years; the median baseline PSA was 12.5 ng/mL (range 2.5-108.4). After a median follow-up of 48 months, overall survival at 5 and 10 years for the entire cohort were 89% and 81%, respectively, and distant metastasis-free survival (DMFS) at the same time points were 77% and 58%, respectively. For the newer cohort, 5-year overall survival and DMFS were 91.5% and 76%, respectively. On univariate analysis, persistently elevated postoperative PSA ≥0.2 ng/ml (P = 0.0003), seminal vesicle involvement (P = 0.027), ≥2 nodes (P = 0.035) and ADT alone (P = 0.054) had a poor prognostic impact on DMFS, whereas margin involvement had a marginally negative influence on overall survival (P = 0.06). On multivariate analysis, postoperative PSA ≥0.2 ng/ml (hazard ratio 4.4, 95% confidence interval 1.7-11.4; P = 0.002) continued to have a significant association with DMFS. On a sensitivity analysis, postoperative PSA ≥0.1 also had a significant association with DMFS on univariate and multivariate analysis (hazard ratio 3.69, 95% confidence interval 1.32-10.29; P = 0.01). Similarly, postoperative PSA ≥0.4 ng/ml had a significant association with DMFS (hazard ratio 3.87, 95% confidence interval 1.58-9.46, P = 0.003).

CONCLUSION

This study showed a notable difference in the proportion of pN+ P-Ca patients between two different time cohorts. A significant association of persistently elevated postoperative PSA with DMFS was noted in our study. This must be accounted for while tailoring postoperative treatment in pN+ P-Ca.

Sentinel node evaluation in prostate cancer

Sentinel lymph node (SLN) based pelvic lymph node dissection (PLND) in prostate cancer (PCa) is appealing over the time, cost and morbidity classically attributed to conventional PLND during radical prostatectomy. The initial report of feasibility of the SLN concept in prostate cancer was nearly 20 years ago. However, PLND based on the SLN concept, either SLN biopsy of a single node or targeted SLN dissection of multiple nodes, is still considered investigational in PCa. To better appreciate the challenges, and potential solutions, associated with SLN-based PLND in PCa, this review will discuss the rationale behind PLND in PCa and evaluate current SLN efforts in the most commonly diagnosed malignancy in men in the US.

Pretreatment Multiparametric Magnetic Resonance Imaging Findings Are More Accurate Independent Predictors of Outcome Than Clinical Variables in Localized Prostate Cancer

PURPOSE

To prospectively determine whether multiparametric magnetic resonance imaging (mpMRI)-based staging is a more accurate independent predictor of outcome than traditional clinical variables for patients undergoing brachytherapy and external beam radiation therapy.

METHODS AND MATERIALS

The primary endpoints were biochemical (nadir plus 2 ng/mL) and metastatic failure. Descriptive, univariate, and multivariate competing risks analyses were performed. The cumulative incidence rates were estimated to describe the cumulative risk of the events of interest. The magnitude of the increased risk was estimated using univariate and multivariate subdistribution hazard ratios.

RESULTS

A total of 185 patients had undergone prospective treatment (123 with high risk and 62 with intermediate risk). The median age was 71 years (range 56-82). Of the patients, 20.5% had mpMRI-determined (mrT) stage mrT1-mrT2b, 37.3% had mrT2c, 31% had mrT3a, and 11.2% had mrT3b. The Gleason score was 6 in 22.2%, 7 in 49.5%, and 8 to 10 in 28.2%. The median baseline prostate-specific antigen was 11.7 ng/mL (range 2.9-153). After a median follow-up period of 46 months (range 16-70), 15 patients (8.1%) had developed biochemical failure and 9 (4.9%) had developed distant metastases. None of the traditional clinical variables (prostate-specific antigen, Gleason score, clinical stage) predicted for biochemical or metastatic failure. The multivariate competing risk analysis demonstrated that the 2 independent predictors of biochemical failure were the presence of extraprostatic extension (EPE; mrT3a; hazard ratio [HR] 4.80; P = .035) and presence of seminal vesicle invasion (SVI; mrT3b; HR 10.17; P = .003) on mpMRI. The only independent predictor of metastatic failure was the percentage of positive cores on prostate biopsy (HR 13.95; P = .014). After excluding patients with SVI, the only independent predictor of biochemical failure and metastatic failure was the presence of EPE (stage mrT3a) on mpMRI (HR 4.36; P = .042; and HR 5.76; P = .010, respectively).

CONCLUSIONS

The pretreatment mpMRI findings might be more accurate independent predictors of the outcome than traditional clinical variables. In particular, the presence of EPE, SVI and a greater percentage of positive cores on biopsy predicted for a worse prognosis.

Prostate Imaging-Reporting and Data System Version 2: Beyond Prostate Cancer Detection

The main purpose of Prostate Imaging-Reporting and Data System Version 2 (PI-RADSv2) is to effectively detect clinically significant prostate cancers (csPCa) using multiparametric magnetic resonance imaging. Since the first introduction of PI-RADSv2, researchers have validated its diagnostic performance in identifying csPCa, and these promising data have influenced biopsy and treatment schemes. However, in this article, we focused on the potential of PI-RADSv2 in relation to various aspects of PCa such as Gleason score, tumor volume, extraprostatic extension, lymph node metastasis, and postoperative biochemical recurrence, beyond prostate cancer detection.

Image-guided, whole-pelvic, intensity-modulated radiotherapy for biochemical recurrence following radical prostatectomy in high-risk prostate cancer patients

Background

The optimal field size of salvage radiotherapy (SRT) for biochemical recurrence, particularly for patients with high-risk prostate cancer, remains undefined. This retrospective analysis was performed to investigate oncological outcomes as well as treatment-related toxicity following salvage intensity-modulated radiotherapy (IMRT) to the whole pelvis and to compare the results with other studies implementing a small field size of the prostate bed.

Methods

The medical records of 170 patients with high-risk prostate cancer who received SRT for biochemical recurrence following prostatectomy were reviewed. Whole-pelvic IMRT was administered with a median dose of 66 Gy in 30 fractions. To improve treatment accuracy, an endorectal balloon device and daily cone-beam computed tomography were utilized. Androgen-deprivation therapy combined with SRT was administered to 97 (57.1%) patients.

Results

Eventually, 68 (40.0%) patients showed biochemical progression (BCP) after SRT. With a median follow-up period of 56 months, the 5-year BCP-free survival was 38.6%. The overall and cause-specific survival rates were 90.9% and 96.7%, respectively. Regarding BCP-free survival analysis, pathological T stage, persistent prostate-specific antigen (PSA) elevation after prostatectomy, and preSRT PSA level were significant prognostic factors on univariate analysis. On multivariate analysis, pathological T stage and preSRT PSA value retained their significance. Acute and late grade-3 genitourinary toxicities were observed in one (0.6%) and five (2.9%) patients, respectively. One patient each developed acute and late grade-3 gastrointestinal toxicity.

Conclusion

SRT to whole pelvis using IMRT and image guidance is as safe as SRT to the prostate bed, but its efficacy should be confirmed in ongoing randomized trials. PreSRT PSA was the only controllable prognostic factor, suggesting the benefit of early SRT.

Identifying candidates for super-extended staging pelvic lymph node dissection among patients with high-risk prostate cancer

OBJECTIVES

To assess if the preoperative lymph node invasion (LNI) risk could be used to tailor the extent of pelvic lymph node dissection (PLND) according to individual profile in patients with prostate cancer (PCa) undergoing radical prostatectomy (RP), and to identify those who would benefit from the removal of the common iliac and pre-sacral nodes.

PATIENTS AND METHODS

A total of 471 patients with high-risk PCa treated with RP and a super-extended PLND that included the removal of the pre-sacral and common iliac nodes between 2006 and 2016 were identified. The risk of LNI was calculated according to the Briganti nomogram. Multivariable logistic regression analyses assessed the association between LNI risk and involvement of the common iliac and pre-sacral regions. The risk of positive common iliac and pre-sacral nodes was plotted over the LNI risk using the LOWESS-smoothed fit curve.

RESULTS

The median preoperative LNI risk was 25.5%. The median number of nodes removed was 23, and 171 (36.3%) patients had LNI. Overall, 61 (13.0%) and 28 patients (5.9%), respectively, had positive common iliac and pre-sacral nodes alone or in combination with other sites. The LNI risk was associated with the involvement of the common iliac and pre-sacral regions (all P < 0.001). The proportion of patients with positive common iliac and pre-sacral nodes progressively increased according to the LNI risk. The adoption of a 30% threshold would result in avoiding the removal of the common iliac and pre-sacral nodes in >60% cases, with a risk of missing LNI in these regions of <5%.

CONCLUSIONS

Fewer than 5% of patients with an LNI risk of <30% harbour positive common iliac and pre-sacral nodes. A super-extended PLND that includes the dissection of these regions should be considered exclusively in patients with an LNI risk ≥30%.

Is More Always Better? An Assessment of the Impact of Lymph Node Yield on Outcome for Clinically Localized Prostate Cancer with Low/Intermediate Risk Pathology (pT2-3a/pN0) Managed with Prostatectomy Alone

The clinical impact of lymph node dissection extent remains undetermined in the contemporary setting, as reflected in care pattern variations. Despite some series demonstrating a direct relationship between number of lymph nodes identified and detection of nodal involvement, the correlation between lymph node yield and disease control or survival outcomes remains unclear. Patients with clinically localized prostate cancer, pre-RP PSA <30, and pT2-3a/N0 disease at RP were retrospectively identified from two databases for inclusion. Those who received pre- or post-RP radiotherapy or hormone therapy were excluded. Kaplan-Meier method was employed for survival probability estimation. Cox regression models were used to assess bRFS differences between subsets. From 2002 to 2010, 667 eligible patients were identified. The median age was 61 yrs. (range, 43-76), with median PSA 5.6 ng/dL (0.9-28.0). At RP, most patients had pT2c (64%) disease with Gleason Score (GS) ≤6 (43%) or 7 (48%); 218 (33%) patients had positive margins (M+). At median clinical and PSA follow-up of 96 and 87 months, respectively, 146 patients (22%) experienced PSA failure with an estimated bRFS of 81%/76% at 5/8 years. For patients who underwent LND, univariable analysis identified PSA (at diagnosis), higher GS (≥7, at biopsy or RP), intermediate/high risk stratification, M+ as adversely associated with bRFS (all p < 0.01). A higher number of LNs excised was not associated with improved bRFS for the entire cohort (HR = 0.97, p = 0.27), nor for any clinical risk stratum, biopsy GS, or RP GS subgroup. This study did not demonstrate an association between LN yield and bRFS in patients with clinically localized pT2-3a/pN0 prostate cancer managed with RP alone, either in the entire population or with substratification by clinical risk stratum or GS.