The combination of preoperative prostate specific antigen and postoperative pathological findings to predict prostate specific antigen outcome in clinically localized prostate cancer

Prostate cancer nomograms and their application in Asian men: a review

Nomograms help to predict outcomes in individual patients rather than whole populations and are an important part of evaluation and treatment decision making. Various nomograms have been developed in malignancies to predict and prognosticate clinical outcomes such as severity of disease, overall survival, and recurrence-free survival. In prostate cancer, nomograms were developed for determining need for biopsy, disease course, need for adjuvant therapy, and outcomes. Most of these predictive nomograms were based on Caucasian populations. Prostate cancer is significantly affected by race, and Asian men have a significantly different racial and genetic susceptibility compared to Caucasians, raising the concern in generalizability of these nomograms. We reviewed the existing literature for nomograms in prostate cancer and their application in Asian men. There are very few studies that have evaluated the applicability and validity of the existing nomograms in these men. Most have found significant differences in the performance in this population. Thus, more studies evaluating the existing nomograms in Asian men or suggesting modifications for this population are required.

Hospital readmissions for patients with prostate cancer are higher after radiotherapy than after prostatectomy

Purpose

To compare hospital readmissions, biochemical recurrence rates, incidence of metastasis, and cancer-specific and overall mortality for prostate cancer patients undergoing radiotherapy vs. radical prostatectomy. The secondary outcome was to identify patient and disease characteristics affecting physician’s choice of either therapy.

Materials and Methods

A total of 297 patients diagnosed with prostate cancer between 2008 and 2014 were identified from a single academic center’s cancer database. Clinical information including age, ethnicity, comorbidities, prostate-specific antigen, Gleason score, stage, National Comprehensive Cancer Network (NCCN) risk group, biochemical recurrence, hospital readmissions, and survival outcomes were gathered and analyzed from ambulatory medical records until 2018.

Results

Patients selected for radiotherapy were older and had more comorbidities and NCCN high-risk disease. Biochemical recurrence was higher after radical prostatectomy for locally advanced disease, 59.3% vs. 20.0% (p<0.001), favoring radiotherapy. Hospital readmission was higher for patients with locally advanced disease undergoing radiotherapy, 48.6% vs. 18.5% (p=0.002), and 35.2% vs. 19.7% (p=0.044) for those with localized disease, with most of these readmissions occurring 24 months after the initial therapy. Radiation proctitis and colitis were the most common complications after radiotherapy and accounted for 46.3% of readmissions.

Conclusions

Selection of patients for radiotherapy instead of surgery was influenced by age, significant comorbidities, and NCCN high-risk disease. The incidence of treatment- or cancer-related hospital readmissions was significantly higher for patients undergoing radiotherapy compared with radical prostatectomy, especially for those with locally advanced prostate cancer. This information may be useful in guiding a patient’s choice of therapy.

Expression and subcellular localization of Discoidin Domain Receptor 1 (DDR1) define prostate cancer aggressiveness

BACKGROUND

The Discoidin Domain Receptor 1 (DDR1) is one of the two members of a unique family of receptor tyrosine kinase receptors that signal in response to collagen, which has been implicated in cancer progression. Here, we examined the expression of DDR1 in prostate cancer (PCa), and assessed its potential value as a prognostic marker, as a function of grade, stage and other clinicopathologic parameters.

METHODS

We investigated the association between the expression level and subcellular localization of DDR1 protein and PCa aggressiveness by immunohistochemistry, using tissue microarrays (TMAs) encompassing 200 cases of PCa with various Gleason scores (GS) and pathologic stages with matched normal tissue, and a highly specific monoclonal antibody.

RESULTS

DDR1 was found to be localized in the membrane, cytoplasm, and nuclear compartments of both normal and cancerous prostate epithelial cells. Analyses of DDR1 expression in low GS (≤ 7[3 + 4]) vs high GS (≥ 7[4 + 3]) tissues showed no differences in nuclear or cytoplasmic DDR1in either cancerous or adjacent normal tissue cores. However, relative to normal-matched tissue, the percentage of cases with higher membranous DDR1 expression was significantly lower in high vs. low GS cancers. Although nuclear localization of DDR1 was consistently detected in our tissue samples and also in cultured human PCa and normal prostate-derived cell lines, its presence in that site could not be associated with disease aggressiveness. No associations between DDR1 expression and overall survival or biochemical recurrence were found in this cohort of patients.

CONCLUSION

The data obtained through multivariate logistic regression model analysis suggest that the level of membranous DDR1 expression status may represent a potential biomarker of utility for better determination of PCa aggressiveness.

Influence of Tumor Burden on Serum Prostate-Specific Antigen in Prostate Cancer Patients Undergoing Radical Prostatectomy

Objective

We aimed to assess the correlation between serum prostate-specific antigen (PSA) and tumor burden in prostate cancer (PCa) patients undergoing radical prostatectomy (RP), because estimation of tumor burden is of high value, e.g., in men undergoing RP or with biochemical recurrence after RP.

Patients and Methods

From January 2019 to June 2020, 179 consecutive PCa patients after RP with information on tumor and prostate weight were retrospectively identified from our prospective institutional RP database. Patients with preoperative systemic therapy (n=19), metastases (cM1, n=5), and locally progressed PCa (pT4 or pN1, n=50) were excluded from analyses. Histopathological features, including total weight of the prostate and specific tumor weight, were recorded by specialized uro-pathologists. Linear regression models were performed to evaluate the effect of PSA on tumor burden, measured by tumor weight after adjustment for patient and tumor characteristics.

Results

Overall, median preoperative PSA was 7.0 ng/ml (interquartile range [IQR]: 5.41–10) and median age at surgery was 66 years (IQR: 61-71). Median prostate weight was 34 g (IQR: 26–46) and median tumor weight was 3.7 g (IQR: 1.8–7.1), respectively. In multivariable linear regression analysis after adjustment for patients and tumor characteristics, a significant, positive correlation could be detected between preoperative PSA and tumor weight (coefficient [coef.]: 0.37, CI: 0.15–0.6, p=0.001), indicating a robust increase in PSA of almost 0.4 ng/ml per 1g tumor weight.

Conclusion

Preoperative PSA was significantly correlated with tumor weight in PCa patients undergoing RP, with an increase in PSA of almost 0.4 ng/ml per 1 g tumor weight. This might help to estimate both tumor burden before undergoing RP and in case of biochemical recurrence.

Inverse Stage Migration in Radical Prostatectomy-A Sustaining Phenomenon

Objective: To investigate temporal trends in prostate cancer (PCa) radical prostatectomy (RP) candidates. Materials and Methods: Patients who underwent RP for PCa between January 2014 and December 2019 were identified form our institutional database. Trend analysis and logistic regression models assessed RP trends after stratification of PCa patients according to D'Amico classification and Gleason score. Patients with neoadjuvant androgen deprivation or radiotherapy prior to RP were excluded from the analysis. Results: Overall, 528 PCa patients that underwent RP were identified. Temporal trend analysis revealed a significant decrease in low-risk PCa patients from 17 to 9% (EAPC: -14.6%, p < 0.05) and GS6 PCa patients from 30 to 14% (EAPC: -17.6%, p < 0.01). This remained significant even after multivariable adjustment [low-risk PCa: (OR): 0.85, p < 0.05 and GS6 PCa: (OR): 0.79, p < 0.001]. Furthermore, a trend toward a higher proportion of intermediate-risk PCa undergoing RP was recorded. Conclusion: Our results confirm that inverse stage migration represents an ongoing phenomenon in a contemporary RP cohort in a European tertiary care PCa center. Our results demonstrate a significant decrease in the proportion of low-risk and GS6 PCa undergoing RP and a trend toward a higher proportion of intermediate-risk PCa patients undergoing RP. This indicates a more precise patient selection when it comes to selecting suitable candidates for definite surgical treatment with RP.

Multiparametric MRI in the management of prostate cancer: an update-a narrative review

The growing interest in multiparametric MRI is leading to important changes in the diagnostic process of prostate cancer. MRI-targeted biopsy is likely to become a standard for the diagnosis of prostate cancer in the next years. Despite it is well known that MRI has no role as a staging technique, it is clear that multiparametric MRI may be of help in active surveillance protocols. Noteworthy, MRI in active surveillance is not recommended, but a proper understanding of its potential may be of help in achieving the goals of a delayed treatment strategy. Moreover, the development of minimally invasive techniques, like laparoscopic and robotic surgery, has led to greater expectations as regard to the functional outcomes of radical prostatectomy. Multiparametric MRI may play a role in planning surgical strategies, with the aim to provide the highest oncologic outcome with a minimal impact on the quality of life. We maintain that a proper anatomic knowledge of prostate lesions may allow the surgeon to achieve a better result in planning as well as in performing surgery and help the surgeon and the patient engage in a shared decision in planning a more effective strategy for prostate cancer control and treatment. This review highlights the advantages and the limitations of multiparametric MRI in prostate cancer diagnosis, in active surveillance and in planning surgery.

Impact of "Time-From-Biopsy-to-Prostatectomy" on Adverse Oncological Results in Patients With Intermediate and High-Risk Prostate Cancer

Objective: Many patients with localized prostate cancer (PCa) do not immediately undergo radical prostatectomy (RP) after biopsy confirmation. The aim of this study was to investigate the influence of “time-from-biopsy-to- prostatectomy” on adverse pathological outcomes.

Materials and Methods: Between January 2014 and December 2019, 437 patients with intermediate- and high risk PCa who underwent RP were retrospectively identified within our prospective institutional database. For the aim of our study, we focused on patients with intermediate- (n = 285) and high-risk (n = 151) PCa using D'Amico risk stratification. Endpoints were adverse pathological outcomes and proportion of nerve-sparing procedures after RP stratified by “time-from-biopsy-to-prostatectomy”: ≤3 months vs. >3 and < 6 months. Medians and interquartile ranges (IQR) were reported for continuously coded variables. The chi-square test examined the statistical significance of the differences in proportions while the Kruskal-Wallis test was used to examine differences in medians. Multivariable (ordered) logistic regressions, analyzing the impact of time between diagnosis and prostatectomy, were separately run for all relevant outcome variables (ISUP specimen, margin status, pathological stage, pathological nodal status, LVI, perineural invasion, nerve-sparing).

Results: We observed no difference between patients undergoing RP ≤3 months vs. >3 and <6 months after diagnosis for the following oncological endpoints: pT-stage, ISUP grading, probability of a positive surgical margin, probability of lymph node invasion (LNI), lymphovascular invasion (LVI), and perineural invasion (pn) in patients with intermediate- and high-risk PCa. Likewise, the rates of nerve sparing procedures were 84.3 vs. 87.4% (p = 0.778) and 61.0% vs. 78.8% (p = 0.211), for intermediate- and high-risk PCa patients undergoing surgery after ≤3 months vs. >3 and <6 months, respectively. In multivariable adjusted analyses, a time to surgery >3 months did not significantly worsen any of the outcome variables in patients with intermediate- or high-risk PCa (all p > 0.05).

Conclusion: A “time-from-biopsy-to-prostatectomy” of >3 and <6 months is neither associated with adverse pathological outcomes nor poorer chances of nerve sparing RP in intermediate- and high-risk PCa patients.

Positive STAT5 Protein and Locus Amplification Status Predicts Recurrence after Radical Prostatectomy to Assist Clinical Precision Management of Prostate Cancer

BACKGROUND

A significant fraction of prostate cancer patients experience post-radical prostatectomy (RP) biochemical recurrence (BCR). New predictive markers are needed for optimizing postoperative prostate cancer management. STAT5 is an oncogene in prostate cancer that undergoes amplification in 30% of prostate cancers during progression.

METHODS

We evaluated the significance of a positive status for nuclear STAT5 protein expression versus STAT5 locus amplification versus combined positive status for both in predicting BCR after RP in 300 patients.

RESULTS

Combined positive STAT5 status was associated with a 45% disadvantage in BCR in Kaplan-Meier survival analysis in all Gleason grade patients. Patients with Gleason grade group (GG) 2 and 3 prostate cancers and combined positive status for STAT5 had a more pronounced disadvantage of 55% to 60% at 7 years after RP in univariate analysis. In multivariate analysis, including the Cancer of the Prostate Risk Assessment Postsurgical nomogram (CAPRA-S) variables, combined positive STAT5 status was independently associated with a shorter BCR-free survival in all Gleason GG patients (HR, 2.34; P = 0.014) and in intermediate Gleason GG 2 or 3 patients (HR, 3.62; P = 0.021). The combined positive STAT5 status improved the predictive value of the CAPRA-S nomogram in both ROC-AUC analysis and in decision curve analysis for BCR.

CONCLUSIONS

Combined positive status for STAT5 was independently associated with shorter disease-free survival in univariate analysis and was an independent predictor for BCR in multivariate analysis using the CAPRA-S variables in prostate cancer.

IMPACT

Our results highlight potential for a novel precision medicine concept based on a pivotal role of STAT5 status in improving selection of prostate cancer patients who are candidates for early adjuvant interventions to reduce the risk of recurrence.

Diagnostic Accuracy of a MR Protocol Acquired with and without Endorectal Coil for Detection of Prostate Cancer: A Multicenter Study

Introduction

The purpose of this study was to compare diagnostic accuracy of a prostate multiparametric magnetic resonance imaging (mpMRI) protocol for detection of prostate cancer between images acquired with and without en-dorectal coil (ERC).

Materials

This study was approved by the regional ethics committee. Between 2014 and 2015, 33 patients (median age 51.3 years; range 42.1-77.3 years) who underwent prostate-MRI at 3T scanners at 2 different institutions, acquired with (mpMRI_ERC) and without (mpMRI_PPA) ERC and who received radical prostatectomy, were included in this retrospective study. Two expert readers (R1, R2) attributed a PI-RADS version 2 score for the most suspect (i. e. index) lesion for mpMRI_PPA and mpMRI_ERC. Sensitivity and positive predictive value for detection of index lesions were assessed using 2 × 2 contingency tables. Differences between groups were tested using the McNemar test. Whole-mount histopathology served as reference standard.

Results

On a quadrant-basis cumulative sensitivity ranged between 0.61-0.67 and 0.76-0.88 for mpMRI_PPA and mpMRI_ERC protocols, respectively (p > 0.05). Cumulative positive predictive value ranged between 0.80-0.81 and 0.89-0.91 for mpMRI_PPA and mpMRI_ERC protocols, respectively. The differences were not statistically significant for R1 (p = 0.267) or R2 (p = 0.508).

Conclusion

Our results suggest that there may be no significant differences for detection of prostate cancer between images acquired with and without an ERC.

The addition of chemotherapy in the definitive management of high risk prostate cancer

In attempt to improve long-term disease control outcomes for high-risk prostate cancer, numerous clinical trials have tested the addition of chemotherapy (CTX)-either adjuvant or neoadjuvant-to definitive local therapy, either radical prostatectomy (RP) or radiation therapy (RT). Neoadjuvant trials generally confirm safety, feasibility, and pre-RP PSA reduction, but rates of pathologic complete response are rare, and no indications for neoadjuvant CTX have been firmly established. Adjuvant regimens have included CTX alone or in combination with androgen deprivation therapy (ADT). Here we provide a review of the relevant literature, and also quantify utilization of CTX in the definitive management of localized high-risk prostate cancer by querying the National Cancer Data Base. Between 2004 and 2013, 177 patients (of 29,659 total) treated with definitive RT, and 995 (of 367,570 total) treated with RP had CTX incorporated into their treatment regimens. Low numbers of RT + CTX patients precluded further analysis of this population, but we investigated the impact of CTX on overall survival (OS) for patients treated with RP +/- CTX. Disease-free survival or biochemical-recurrence-free survival are not available through the National Cancer Data Base. Propensity-score matching was conducted as patients treated with CTX were a higher-risk group. For nonmatched groups, OS at 5-years was 89.6% for the CTX group vs. 95.6%, for the no-CTX group (P < 0.01). The difference in OS between CTX and no-CTX groups did not persist after propensity-score matching, with 5-year OS 89.6% vs. 90.9%, respectively (Hazard ratio 0.99; P = 0.88). In summary, CTX was not shown to improve OS in this retrospective study. Multimodal regimens-such as RP followed by ADT, RT, and CTX; or RT in conjunction with ADT followed by CTX-have shown promise, but long-term follow-up of randomized data is required.

The effect of surgery report cards on improving radical prostatectomy quality: the SuRep study protocol

Background

The goal of radical prostatectomy is to achieve the optimal balance between complete cancer removal and preserving a patient’s urinary and sexual function. Performing a wider excision of peri-prostatic tissue helps achieve negative surgical margins, but can compromise urinary and sexual function. Alternatively, sparing peri-prostatic tissue to maintain functional outcomes may result in an increased risk of cancer recurrence. The objective of this study is to determine the effect of providing surgeons with detailed information about their patient outcomes through a surgical report card.

Methods

We propose a prospective cohort quasi-experimental study. The intervention is the provision of feedback to prostate cancer surgeons via surgical report cards. These report cards will be distributed every 3 months by email and will present surgeons with detailed information, including urinary function, erectile function, and surgical margin outcomes of their patients compared to patients treated by other de-identified surgeons in the study. For the first 12 months of the study, pre-operative, 6-month, and 12-month patient data will be collected but there will be no report cards distributed to surgeons. This will form the pre-feedback cohort. After the pre-feedback cohort has completed accrual, surgeons will receive quarterly report cards. Patients treated after the provision of report cards will comprise the post-feedback cohort. The primary comparison will be post-operative function of the pre-feedback cohort vs. post-feedback cohort. The secondary comparison will be the proportion of patients with positive surgical margins in the two cohorts. Outcomes will be stratified or case-mix adjusted, as appropriate. Assuming a baseline potency of 20% and a baseline continence of 70%, 292 patients will be required for 80% power at an alpha of 5% to detect a 10% improvement in functional outcomes. Assuming 30% of patients may be lost to follow-up, a minimum sample size of 210 patients is required in the pre-feedback cohort and 210 patients in the post-feedback cohort.

Discussion

The findings from this study will have an immediate impact on surgeon self-evaluation and we hypothesize surgical report cards will result in improved overall outcomes of men treated with radical prostatectomy.

Electronic supplementary material

The online version of this article (10.1186/s12894-018-0403-y) contains supplementary material, which is available to authorized users.

External validation of the novel International Society of Urological Pathology (ISUP) Gleason grading groups in a large contemporary Canadian cohort

INTRODUCTION

We sought to test the discriminatory ability of the 2014 International Society of Urological Pathology (ISUP) Gleason grading groups (GGG) for predicting biochemical recurrence (BCR) after robot-assisted radical prostatectomy (RARP) in a large, contemporary, Canadian cohort.

METHODS

A total of 621 patients who underwent RARP in two major Canadian centres were identified in a prospectively maintained Canadian database between 2006 and 2016. Followup endpoint was BCR. Log-rank test, univariable, and multivariable Cox regression analyses were used.

RESULTS

Mean followup was 27.9 months. All five ISUP GGG independently predicted BCR. Statistically significant differences in BCR rates were found between GGG 2 and GGG 3 strata (p<0.001). No statistically significant differences in BCR rates were found between GGG 4 and GGG 5 strata (p=0.3). Relative to GGG 1, the GGG 2, GGG 3, GGG 4, and GGG 5 yielded a 1.10-, 3.44-, 4.18-, and 4.74-fold hazard ratio (HR) increment in BCR, respectively.

CONCLUSIONS

This population-based Canadian cohort study confirms the added discriminatory property of the novel ISUP grading, specifically for GGG 2 and GGG 3 strata. No difference, however, was observed between GGG 4 and GGG 5, likely due to the lower number of patients in these groups. As such, after external validation, the 2014 ISUP GGG appears to retain clinical prognostic significance in a Canadian population.

Wrong to be Right: Margin Laterality is an Independent Predictor of Biochemical Failure After Radical Prostatectomy

OBJECTIVES

To examine the impact of positive surgical margin (PSM) laterality on failure after radical prostatectomy (RP). A PSM can influence local recurrence and outcomes after salvage radiation. Unlike intrinsic risk factors, a PSM is caused by intervention and thus iatrogenic failures may be elucidated by analyzing margin laterality as surgical approach is itself lateralized.

PATIENTS AND METHODS

We reviewed 226 RP patients between 1991 and 2013 with PSM. Data includes operation type, pre/postoperative PSA, surgical pathology, and margin type (location, focality, laterality). The median follow-up was 47 months. Biochemical recurrence after RP was defined as PSA≥0.1 ng/mL or 2 consecutive rises above nadir. Ninety-two patients received salvage radiation therapy (SRT). Failure after SRT was defined as any PSA≥0.2 ng/mL or greater than presalvage. Kaplan-Meier and Cox multivariate analyses compared relapse rates.

RESULTS

The majority of PSM were iatrogenic (58%). Laterality was associated with differences in median relapse: right 20 versus left 51 versus bilateral 14 months (P<0.01). Preoperative PSA, T-stage, Gleason grade, and laterality were associated with biochemical progression on univariate and multivariate analyses. Right-sided margins were more likely to progress than left (hazard ratio, 1.67; P=0.04). More right-sided margins were referred for SRT (55% right vs. 23% left vs. 22% bilateral), but were equally salvaged. Only T-stage and pre-SRT PSA independently influenced SRT success.

CONCLUSIONS

Most PSM are iatrogenic, with right-sided more likely to progress (and sooner) than left sided. Margin laterality is a heretofore unrecognized independent predictor of biochemical relapse and hints at the need to modify the traditional unilateral surgical technique.

Removing the urinary catheter on post-operative day 2 after robot-assisted laparoscopic radical prostatectomy: a feasibility study from a single high-volume referral centre

The indwelling urinary catheter (UC) is a significant bother for men after radical prostatectomy (RP) and should be removed as soon as possible without jeopardizing the outcome. Our aim was to assess the feasibility and safety of its removal on postoperative day (POD) 2 after robot-assisted laparoscopic RP (RALP). A consecutive series of patients undergoing RALP for localized prostate cancer (PCa) were prospectively enrolled. Inclusion criteria were: no bladder-neck reconstruction, watertight urethrovesical anastomosis at 150 ml filling, ≤ 200 ml of intraoperative bleeding, ≤ 80 ml of fluid from the drain on POD 1, clear urine from the UC on POD 2. Patients were discharged on POD 2. Continence was assessed at catheter removal and 1, 3 and 6 months after surgery. Urethrovesical anastomosis was performed with a standard technique on 3 layers. Sixty-six patients were enrolled. The UC was removed on POD 2 in all the cases and 96.4% of the patients were discharged on POD 2. Re-catheterization was needed 16 times and it was always performed easily. Twenty-four complications were reported by 20 patients, mostly Clavien-Dindo (CD) grade II; 2 CD IIIB complications were observed. No anastomotic strictures were diagnosed. At catheter removal, 29% of the patients were completely continent, 41% at 1 month, 67% at 3 months and 92% at 6 months. In selected patients, removing the UC 48 h after RALP is feasible and safe and has no negative impact on continence if compared with the best international standards.

External Validation of the Pathologic Nodal Staging Score for Prostate Cancer: A Population-based Study

BACKGROUND

We sought to externally validate our pathologic nodal staging score (pNSS) model, which allows for quantification of the likelihood that a pathologically node-negative patient will not have lymph node (LN) metastasis after radical prostatectomy for prostate cancer (PCa) in a population-based cohort.

PATIENTS AND METHODS

We analyzed data from 50,598 patients treated with radical prostatectomy and pelvic LN dissection using the Surveillance, Epidemiology, and End Results database. We estimated the sensitivity of pathologic nodal staging using a β-binomial model and developed a novel pNSS model, which represents the probability that a patient's PCa has been correctly staged as node negative as a function of the number of examined LNs. These findings were compared against those from the original cohort of 7135 patients.

RESULTS

The mean and median number of LNs removed was 6.5 and 5, respectively (range, 1-89; interquartile range, 2-8), and 96.9% of the patients (n = 49,020) had stage pN0. Similar to the original cohort, the probability of missing a positive LN decreased with the increasing number of LNs examined. In both the validation and the original cohort, the number of LNs needed to correctly stage a patient's disease as node negative increased with more advanced tumor stage, higher Gleason sum, positive surgical margins, and higher preoperative prostate-specific antigen levels.

CONCLUSION

We have confirmed that the number of examined LNs needed for adequate nodal staging in PCa depends on the pathologic tumor stage, Gleason sum, surgical margins status, and preoperative prostate-specific antigen. We externally validated our pNSS in a population-based cohort, which could help to refine decision-making regarding the administration of adjuvant therapy.

Comparative analysis of short - term functional outcomes and quality of life in a prospective series of brachytherapy and Da Vinci robotic prostatectomy

Introduction

There is a growing interest in achieving higher survival rates with the lowest morbidity in localized prostate cancer (PC) treatment. Consequently, minimally invasive techniques such as low-dose rate brachytherapy (BT) and robotic-assisted prostatectomy (RALP) have been developed and improved. Comparative analysis of functional outcomes and quality of life in a prospective series of 51BT and 42Da Vinci prostatectomies DV

Materials and Methods

Comparative analysis of functional outcomes and quality of life in a prospective series of 93 patients with low-risk localized PC diagnosed in 2011. 51patients underwent low-dose rate BT and the other 42 patients RALP. IIEF to assess erectile function, ICIQ to evaluate continence and SF36 test to quality of life wee employed.

Results

ICIQ at the first revision shows significant differences which favour the BT group, 79% present with continence or mild incontinence, whereas in the DV group 45% show these positive results. Differences disappear after 6 months, with 45 patients (89%) presenting with continence or mild incontinence in the BT group vs. 30 (71%) in the DV group. 65% of patients are potent in the first revision following BT and 39% following DV. Such differences are not significant and cannot be observed after 6 months. No significant differences were found in the comparative analysis of quality of life.

Conclusions

ICIQ after surgery shows significant differences in favour of BT, which disappear after 6 months. Both procedures have a serious impact on erectile function, being even greater in the DV group. Differences between groups disappear after 6 months.

Contemporary grading of prostate cancer: 2017 update for pathologists and clinicians

The Gleason grading system for prostate cancer (PCa) was developed in the 1960s by DF Gleason. Due to changes in PCa detection and treatment, the application of the Gleason grading system has changed considerably in pathology routine practice. Two consensus conferences were held in 2005 and in 2014 to update PCa Gleason grading. This review provides a summary of the changes in the grading of PCa from the original Gleason grading system to the prognostic grade grouping, as well as a discussion of the clinical significance of the percentage of Gleason patterns 4 and 5.

Treatment Decision Regret Among Long-Term Survivors of Localized Prostate Cancer: Results From the Prostate Cancer Outcomes Study

Purpose To determine the demographic, clinical, decision-making, and quality-of-life factors that are associated with treatment decision regret among long-term survivors of localized prostate cancer. Patients and Methods We evaluated men who were age ≤ 75 years when diagnosed with localized prostate cancer between October 1994 and October 1995 in one of six SEER tumor registries and who completed a 15-year follow-up survey. The survey obtained demographic, socioeconomic, and clinical data and measured treatment decision regret, informed decision making, general- and disease-specific quality of life, health worry, prostate-specific antigen (PSA) concern, and outlook on life. We used multivariable logistic regression analyses to identify factors associated with regret. Results We surveyed 934 participants, 69.3% of known survivors. Among the cohort, 59.1% had low-risk tumor characteristics (PSA < 10 ng/mL and Gleason score < 7), and 89.2% underwent active treatment. Overall, 14.6% expressed treatment decision regret: 8.2% of those whose disease was managed conservatively, 15.0% of those who received surgery, and 16.6% of those who underwent radiotherapy. Factors associated with regret on multivariable analysis included reporting moderate or big sexual function bother (reported by 39.0%; OR, 2.77; 95% CI, 1.51 to 5.0), moderate or big bowel function bother (reported by 7.7%; OR, 2.32; 95% CI, 1.04 to 5.15), and PSA concern (mean score 52.8; OR, 1.01 per point change; 95% CI, 1.00 to 1.02). Increasing age at diagnosis and report of having made an informed treatment decision were inversely associated with regret. Conclusion Regret was a relatively infrequently reported outcome among long-term survivors of localized prostate cancer; however, our results suggest that better informing men about treatment options, in particular, conservative treatment, might help mitigate long-term regret. These findings are timely for men with low-risk cancers who are being encouraged to consider active surveillance.

Argus T® versus Advance® Sling for postprostatectomy urinary incontinence: A randomized clinical trial

Objective

To compare the results of two slings, Argus T® and Advance®, for the treatment of postprostatectomy urinary incontinence (PPUI). Material and Methods: From December 2010 to December 2011, 22 patients with PPUI were randomized as follows: 11 (mean age 62.09(±5.30)) underwent treatment with Advance® and 11 (mean age 62.55(±8.54)) with Argus T®. All patients were evaluated preoperatively with urodynamic testing, quality of life questionnaire (ICIQ-SF), voiding diary and 24-hour pad test. Exclusion criteria were: neurological diseases, severe detrusor overactivity and urethral stenosis. Evaluation was performed at 6, 12 and 18 months after the surgery. After implantation of the Argus T® sling, patients who experienced urine leakage equal to or greater than the initial volume underwent adjustment of the sling tension. Results were statistically analyzed using the Fisher’s test, Kolmogorov-Smirnov test, Friedman’s non-parametric test or the Mann-Whitney test.

Results

Significant improvement of the 24-hour pad test was observed with the Argus T® sling (p=0.038) , With regard to the other parameters, there was no significant difference between the two groups. Removal of the Argus T® device due to perineal pain was performed in one patient (9%). Despite non uniform results, both devices were considered useful to improve quality of life (ICIQ-SF): Argus T® (p=0.018) and Advance® (p=0.017).

Conclusions

Better results were observed in the 24h pad test and in levels of satisfaction with the Argus T® device. Both slings contributed to improve quality of life (ICIQ-SF), with acceptable side effects.

One is the new six: The International Society of Urological Pathology (ISUP) patient-focused approach to Gleason grading

N/A

Risk stratification of prostate cancer: integrating multiparametric MRI, nomograms and biomarkers

Accurate risk stratification of prostate cancer is achieved with a number of existing tools to ensure the identification of at-risk patients, characterization of disease aggressiveness, prediction of cancer burden and extrapolation of treatment outcomes for appropriate management of the disease. Statistical tables and nomograms using classic clinicopathological variables have long been the standard of care. However, the introduction of multiparametric MRI, along with fusion-guided targeted prostate biopsy and novel biomarkers, are being assimilated into clinical practice. The majority of studies to date present the outcomes of each in isolation. The current review offers a critical and objective assessment regarding the integration of multiparametric MRI and fusion-guided prostate biopsy with novel biomarkers and predictive nomograms in contemporary clinical practice.

Biochemical recurrence risk factors in surgically treated high and very high-risk prostate tumors

Introduction

High and very high-risk prostate cancers are tumors that display great variation in their progression, making their behaviour and consequent prognosis difficult to predict. We analyse preoperative and postoperative risk factors that could influence biochemical recurrence of these tumors.

Material and methods

We carried out univariate and multivariate analyses in an attempt to establish statistically significant preoperative (age, rectal examination, PSA, biopsy Gleason score, uni/bilateral tumor, affected cylinder percentage) and postoperative (pT stage, pN lymph node affectation, Gleason score, positive surgical margins, percentage of tumor affectation, perineural infiltration) risk factors, as well as their relationship with biochemical recurrence (PSA >0.2 ng/mL).

Results

We analysed 276 patients with high and very high-risk prostate cancer that were treated with laparoscopic radical prostatectomy (LRP) between 2003-2007, with a mean follow-up of 84 months. Incidence of biochemical recurrence is 37.3%. Preoperative factors with the greatest impact on recurrence are suspicious rectal exam (OR 2.2) and the bilateralism of the tumor in the biopsy (OR 1.8). Among the postoperative factors, the presence of a LRP positive surgical margins (OR 3.4) showed the greatest impact, followed by the first grade of the Gleason score (OR 3.3).

Conclusions

The factor with the greatest influence on biochemical recurrence when it comes to surgery and high and very high-risk prostate cancer is the presence of a positive margin, followed by the Gleason score. Preoperative factors (PSA, biopsy Gleason score, rectal examination, number of affected cylinders) offered no guidance concerning the incidence of BCR.

Oncological outcomes following robotic-assisted radical prostatectomy in a multiracial Asian population

This study evaluates the oncological outcomes of RARP in a multiracial Asian population from a single institution. All suitable patients from 1st January 2003-30th June 2013 were identified from a prospectively maintained cancer registry. Peri-operative and oncological outcomes were analysed. Significance was defined as p < 0.05. There were n = 725 patients identified with a mean follow-up duration 28 months. The mean operative time, EBL and LOS were 186 min, 215 ml and 3 days, respectively. The pathological stage was pT2 in 68.6% (n = 497/725), pT3 in 31.3% (n = 227/725) and n = 1 patient with pT4 disease. The pathological Gleason scores (GS) were 6 in 27.9% (n = 202/725), GS 7 in 63.6% (n = 461/725) and GS ≥ 8 in 8.0 % (n = 58/725). The node positivity rate was 5.8% (n = 21/360). The positive margin rates were 31.0% (n = 154/497) and 70.9% (n = 161/227) for pT2 and pT3, respectively, and decreasing PSM rates are observed with surgical maturity. The biochemical recurrence rates were 9.7% (n = 48/497) and 34.2% (n = 78/228) for pT2 and pT3/T4, respectively. On multivariate analysis, independent predictors of BCR were pathological T stage and pathological Gleason score. Post-operatively, 78.5% (n = 569/725) of patients had no complications and 17.7% (n = 128/725) had minor (Clavien grade I-II) complications. This series, representing the largest from Southeast Asia, suggests that RARP can be a safe and oncologically feasible treatment for localised prostate cancer in an institution with moderate workload.

Prognostic value of seminal vesicle involvement due to prostate cancer in radical prostatectomy specimens

OBJECTIVE

To study the influence, in terms of prognosis, of the finding of seminal vesicle involvement in patients with prostate adenocarcinoma treated with radical prostatectomy.

MATERIAL AND METHOD

We reviewed a series of patients with seminal vesicle involvement with clinically localized prostate adenocarcinoma who underwent radical prostatectomy between 1989 and 2009, focusing on their clinical-pathological characteristics, biochemical progression-free survival (BPFS) and specific survival (SS). We assessed the variables that influenced BPFS and designed a risk model.

RESULTS

A total of 127 out of 1,132 patients who underwent surgery (11%) presented seminal vesicle invasion (i.e., pT3b). In the multivariate study of the entire series (Cox model), pT3b affects the BPFS (HR: 2; 95% CI: 1.4-3.3; P=.001). Other influential factors were the affected borders, initial prostate-specific antigen levels, pathological Gleason score and the presence of palpated tumor. The pT3b tumors have poorer clinical-pathological variables when compared with pT2 and pT3a tumors. Sixty-five percent of the patients evidenced biochemical progression. The BPFS was significantly poorer for pT3b (40 ± 4% and 28 ± 4% at 5 and 10 years, respectively) than for pT2 and pT3a (P<.0001). The SS was also poorer in patients with pT3b tumors (91 ± 2% and 76 ± 4% at 5 and 10 years, respectively) (P<.0001). The predictors within the pT3b patient group were: PSA levels >10 ng/mL (HR: 1.9; 95% CI: 1.04-3.6; P=.04) and pathological Gleason score 8-10 (HR: 2.1; 95% CI: 1.2-3.5; P=.03). We designed a risk model that accounts for the variables involved, which entails 2 groups with different BPFS (P=.004): Group 1 (0-1 variable), with a BPFS of 46 ± 7% and 27 ± 8% at 5 and 10 years, respectively; and Group 2 (2 variables), with a BPFS of 14 ± 7% and 5 ± 5% at 5 and 10 years, respectively.

CONCLUSION

Seminal vesicle involvement severely and negatively affects the BPFS and SS. We designed a risk model with the independent influential variables in BPFS (pathological Gleason score 8-10 and PSA levels >10 ng/mL). This model confirms that pT3b tumors are a heterogeneous group, which includes an important group with better prognosis when surgical treatment is performed.

African-american race is a predictor of seminal vesicle invasion after radical prostatectomy

INTRODUCTION

The purpose of the study was to determine whether racial differences exist in the pattern of local disease progression among men treated with radical prostatectomy (RP) for localized prostate cancer (PCa), which is currently unknown. In this study we evaluated the pattern of adverse pathologic features in an identical cohort of African-American (AA) and Caucasian (CS) men with PCa.

PATIENTS AND METHODS

The overall cohort consisted of 1104 men (224 AA, and 880 CS) who underwent RP between 1990 and 2012. We compared preoperative factors and pathologic outcomes after RP across race groups. Multivariate analysis was used to identify factors predictive of adverse pathologic outcomes. The effect of race on adverse pathologic outcomes and biochemical control rate (BCR) was evaluated using multivariate regression model and Kaplan-Meier analysis.

RESULTS

The 10-year BCR was 59% versus 82% in AA and CS men, respectively (P = .003). There was no significant difference in extraprostatic spread (P = .14), positive surgical margin (P = .81), lymph node involvement (P = .71), or adverse pathologic features (P = .16) across race groups. However, among patients with ≥ 1 adverse pathologic features, AA men had higher rate of seminal vesicle invasion (SVI) compared with CS men (51% vs. 30%; P = .01). After adjusting for known predictors of adverse pathologic features AA race remained a predictor of SVI.

CONCLUSION

AA men have an increased risk of SVI after RP, particularly among men with Gleason ≤ 6 disease. This might represent racial differences in the biology of PCa disease progression, which contribute to poorer outcomes in AA men.

Low pre-operative levels of serum albumin predict lymph node metastases and ultimately correlate with a biochemical recurrence of prostate cancer in radical prostatectomy patients

Introduction

To date, only few studies focusing on the issue of host general and immune activity have been performed in localized prostate cancer (PCa). The aim of this study was to elucidate potent non tumor–related biomarkers that express aggressiveness of PCa treated by radical prostatectomy (RP).

Materials and methods

Data from 179 patients who underwent RP were analyzed. The correlations between various kinds of non tumor–related factors in addition to tumor–related factors and biochemical recurrence (BCR) were analyzed. The correlations between pre–, intra– and post–operative factors were also analyzed.

Results

Thirty–two cases (17.9%) had a BCR. The factors found to be significantly predictive of BCR using a Cox–proportional hazard model were the pre–operative serum prostate specific antigen (PSA) level and the existence of pathological lymph node metastasis (LNM). A low pre–operative serum albumin level (<4.0 g/dl) was significantly correlated with BCR univariately. Logistic regression analysis revealed that a low pre–operative serum albumin level, an American Society of Anesthesiologists (ASA) score above class 2, and a Gleason score above 8 in the biopsy specimens were significantly predictive of pathological LNM.

Conclusions

Tumor–related characteristics are more important for predicting BCR. However, our results suggest that low pre–operative serum albumin level may indicate extensive disease of clinically localized PCa and may ultimately be correlated with BCR. Although multiple reasons may account for the significance of the serum albumin level, it is noteworthy that delayed diagnostic and therapeutic procedures in comorbid patients with low serum albumin levels may lead to PCa progression.

Course of the type of patient who is candidate for radical prostatectomy over 2 decades (1989-2009)

OBJECTIVE

To know the changes experienced by the patient profile candidate for radical prostatectomy over the last 2 decades in our institution..

MATERIAL AND METHODS

We analyze retrospectively a series of 1.132 patients with prostate cancer stadium T1-T2, submitted to radical prostatectomy during the period 1989-2009. The series divides in five homogeneous groups as for the number of patients and arranged chronologically. There uses the free survival of biochemical progression (SLPB) as criterion principal forecast.

RESULTS

In spite of the changes in the diagnosis and treatment of the disease, from the point of view of the forecast (SLPB) we estimate two groups different from patients: the first 250 controlled ones and the rest. The point of chronological cut places in this series in 1.999. We find significant differences in the majority of the clinical-pathological variables as PSA's level to the diagnosis (P <0,001), percentage of palpable tumors (P <0,001), clinical stadium (P <0,001), Gleason in the prostate biopsy (P =0,004), groups at risk of D'Amico (P <0,001), pathological stage (P <0,001), and percentage of patients with lymph node (P <0,001). Nevertheless, there are not detected differences of statistical significance in the Gleason of the specimen of prostatectomy (P =0,06) and in the percentage of surgical margins (P =0,6).

CONCLUSIONS

This study analyzes a patients' wide proceeding sample from the whole Spanish geography and presents some important information that reflect the evolution that has suffered the cancer of prostate located, so much regarding the diagnosis as to the forecast, in our country in the last 20 years.

Prostate cancer severity associations with neighborhood deprivation

Background. The goal of this paper was to examine neighborhood deprivation and prostate cancer severity. Methods. We studied African American and Caucasian prostate cancer cases from the Pennsylvania State Cancer Registry. Census tract-level variables and deprivation scores were examined in relation to diagnosis stage, grade, and tumor aggressiveness. Results. We observed associations of low SES with high Gleason score among African Americans residing in neighborhoods with low educational attainment (OR = 1.34, 95% CI = 1.13–1.60), high poverty (OR = 1.39, 95% CI = 1.15–1.67), low car ownership (OR = 1.46, 95% CI = 1.20–1.78), and higher percentage of residents on public assistance (OR = 1.32, 95% = 1.08–1.62). The highest quartile of neighborhood deprivation was also associated with high Gleason score. For both Caucasians and African Americans, the highest quartile of neighborhood deprivation was associated with high Gleason score at diagnosis (OR = 1.34, 95% CI = 1.19–1.52; OR = 1.71, 95% CI = 1.21–2.40, resp.). Conclusion. Using a neighborhood deprivation index, we observed associations between high-grade prostate cancer and neighborhood deprivation in Caucasians and African-Americans.

Combined Robotic-Assisted Retroperitoneoscopic Partial Nephrectomy and Extraperitoneal Prostatectomy. First Case Reported

A 54-year-old man with a history of prostate cancer and clear cell renal cell carcinoma of the left kidney underwent concomitant robot-assisted laparoscopic partial nephrectomy and radical prostatectomy. We report, to our knowledge, the first case of a concomitant retroperitoneal robotic-assisted partial nephrectomy and extraperitoneal radical prostatectomy.

Predictive and prognostic models in radical prostatectomy candidates: a critical analysis of the literature

CONTEXT

Numerous predictive and prognostic tools have recently been developed for risk stratification of prostate cancer (PCa) patients who are candidates for or have been treated with radical prostatectomy (RP).

OBJECTIVE

To critically review the currently available predictive and prognostic tools for RP patients and to describe the criteria that should be applied in selecting the most accurate and appropriate tool for a given clinical scenario.

EVIDENCE ACQUISITION

A review of the literature was performed using the Medline, Scopus, and Web of Science databases. Relevant reports published between 1996 and January 2010 identified using the keywords prostate cancer, radical prostatectomy, predictive tools, predictive models, and nomograms were critically reviewed and summarised.

EVIDENCE SYNTHESIS

We identified 16 predictive and 22 prognostic validated tools that address a variety of end points related to RP. The majority of tools are prediction models, while a few consist of risk-stratification schemes. Regardless of their format, the tools can be distinguished as preoperative or postoperative. Preoperative tools focus on either predicting pathologic tumour characteristics or assessing the probability of biochemical recurrence (BCR) after RP. Postoperative tools focus on cancer control outcomes (BCR, metastatic progression, PCa-specific mortality [PCSM], overall mortality). Finally, a novel category of tools focuses on functional outcomes. Prediction tools have shown better performance in outcome prediction than the opinions of expert clinicians. The use of these tools in clinical decision-making provides more accurate and highly reproducible estimates of the outcome of interest. Efforts are still needed to improve the available tools' accuracy and to provide more evidence to further justify their routine use in clinical practice. In addition, prediction tools should be externally validated in independent cohorts before they are applied to different patient populations.

CONCLUSIONS

Predictive and prognostic tools represent valuable aids that are meant to consistently and accurately provide most evidence-based estimates of the end points of interest. More accurate, flexible, and easily accessible tools are needed to simplify the practical task of prediction.

Polymorphisms in the AR and PSA genes as markers of susceptibility and aggressiveness in prostate cancer

The study of genes involved in androgen pathway can contribute to a better knowledge of prostate cancer. Our aim was to examine if polymorphisms in prostate-specific antigen (PSA) and androgen receptor (AR) genes were involved in prostate cancer risk and aggressiveness. Genotypes were determined by PCR-RFLP (PSA) or using a 377 ABI DNA Sequencer (AR). PSA(G/G) genotype (OR = 1.78, 95% CI = 1.06–2.99) and AR short CAG repeats (OR = 1.89, 95% CI = 1.21–2.96) increased risk for prostate cancer and were related with tumor aggressiveness. About 38.3% of tumors showed microsatellite instability. In conclusion, polymorphisms in these genes may be indicated as potential biomarkers for prostate cancer.

Base excision repair genes XRCC1 and APEX1 and the risk for prostate cancer

Prostate cancer is the second cause of cancer death in Brazilian men. One of the relevant phenomena to the inherited susceptibility is the presence of allelic variants in genes involved with the DNA repair pathway. The aim of this study was to analyze the frequencies of prevalent, heterozygous and rare genotypes of the base excision repair genes APEX1 and XRCC1 in a case-control study and relate the genotypes with tumoral aggressiveness. DNA from peripheral blood of 172 patients and 172 controls were analyzed by RFLP-PCR method. The polymorphisms were also evaluated in relation to clinical and pathological parameters. The OR (Odds Ratio) and confidence interval (CI = 95%) were used in the association study and the Chi-square and ANOVA tests for the evaluation of histopathological parameters. The rare genotypes frequencies of the gene APEX1 increased the risk for the development of prostate cancer (OR = 1.68 95% CI 1.10-2.58). No association was found for the gene XRCC1 (OR = 0.82 95% CI 0.53-1.27). The combined analysis for both genes did not show association with this neoplasia (OR = 1.27 95% CI 0.79-20.5). The relationship of XRCC1 and APEX1 genotypes with cancer aggressiveness through the correlation with histopathological parameters, did not find any association. Our results suggest that the polymorphism in the gene APEX1 may be indicated as a potential marker for prostate cancer risk.

Critical review of prostate cancer predictive tools

Prostate cancer is a very complex disease, and the decision-making process requires the clinician to balance clinical benefits, life expectancy, comorbidities and potential treatment-related side effects. Accurate prediction of clinical outcomes may help in the difficult process of making decisions related to prostate cancer. In this review, we discuss attributes of predictive tools and systematically review those available for prostate cancer. Types of tools include probability formulas, look-up and propensity scoring tables, risk-class stratification prediction tools, classification and regression tree analysis, nomograms and artificial neural networks. Criteria to evaluate tools include discrimination, calibration, generalizability, level of complexity, decision analysis and ability to account for competing risks and conditional probabilities. The available predictive tools and their features, with a focus on nomograms, are described. While some tools are well-calibrated, few have been externally validated or directly compared with other tools. In addition, the clinical consequences of applying predictive tools need thorough assessment. Nevertheless, predictive tools can facilitate medical decision-making by showing patients tailored predictions of their outcomes with various alternatives. Additionally, accurate tools may improve clinical trial design.

Inappropriate treatment of prostate cancer caused by heterophilic antibody interference

BACKGROUND

A 58-year-old man, without any personal or familial risk factors for prostate cancer, visited his primary care physician for a first routine prostate cancer screening with a serum PSA test.

INVESTIGATIONS

Serum PSA test, digital rectal examination, prostate biopsy and pathological analysis, repeat serum PSA tests and pathological re-evaluation, abdominal tomodensitometry, whole-body bone scan and prostatic MRI.

DIAGNOSIS

Highly elevated serum PSA indicative of advanced prostate cancer at high risk for metastasis.

MANAGEMENT

The patient was started on androgen deprivation therapy with goserelin acetate and bicalutamide. At 3 months, he was asymptomatic, his prostate was atrophic on digital rectal examination and he had suppressed serum testosterone. However, his serum PSA level remained highly elevated in the absence of any radiographic evidence of advanced cancer. A repeat PSA test using a different assay returned a negligible PSA concentration; evaluation with blocker agents revealed the presence of heterophilic antibody interference with the original PSA assay. The patient was rediagnosed as having a likely low-grade prostate adenocarcinoma; androgen deprivation therapy was stopped, and he was deemed a candidate for watchful waiting. At 15 months, his serum PSA level remained stable at a low level, and prostatic dynamic MRI showed no sign of tumor in the prostate or in the pelvis.

The independent value of tumour volume in a contemporary cohort of men treated with radical prostatectomy for clinically localized disease

OBJECTIVE

To determine if prostate tumour volume is an independent prognostic factor in a contemporary cohort of men who had a radical prostatectomy (RP) for clinically localized disease, as the effect of tumour volume on prostate cancer outcomes has not been consistently shown in the era of widespread screening with prostate-specific antigen (PSA).

PATIENTS AND METHODS

The study included 856 men who had RP from 1998 to 2007 for localized prostate cancer. Tumour volume based on pathology was analysed as a continuous and categorized (<0.26, 0.26-0.50, 0.51-1.00, 1.01-2.00, 2.01-4.00, >4.00 mL) variable using Cox proportional hazards regression and Kaplan-Meier analysis. A multivariable analysis was also conducted controlling for PSA level, Gleason grade, surgical margins, and pathological stage.

RESULTS

Tumour volume had a positive association with grade and stage, but did not correlate with biochemical recurrence-free survival on univariate analysis as a continuous variable (hazard ratio 1.00, P = 0.09), and was only statistically significant for volumes of >4 mL as a categorical variable. No tumour volume was an independent predictor of prostate cancer recurrence on multivariate analysis. There was no difference between tumour volume and time to cancer recurrence for organ-confined tumours using Kaplan-Meier analysis. In low-risk patients (PSA level <10 ng/mL, Gleason score < or = 6, clinical stage T1c/T2a) tumour volume did not correlate with biochemical recurrence-free survival in univariate or multivariable analysis.

CONCLUSIONS

There is no evidence that tumour volume is an independent predictor of prostate cancer outcome and it should not be considered as a marker of tumour risk, behaviour or prognosis.

Does chemotherapy have a role before hormone-resistant disease develops?

Recent studies have demonstrated a survival benefit for chemotherapy in metastatic hormone-resistant prostate cancer. In other malignancies such as breast or colorectal cancer, use of active chemotherapy regimens earlier in the course of the disease has resulted in improvements in disease-free and overall survival. This review discusses the status of chemotherapy in prostate cancer and addresses evidence regarding the use of chemotherapy in hormone-sensitive disease, alone and in combination with androgen deprivation therapy.

MR imaging of the prostate in clinical practice

Magnetic resonance imaging (MRI) is the imaging tool of choice in the evaluation of prostate cancer. The main applications of MR imaging in the management of prostate cancer are: (1) to guide targeted biopsy when prostate cancer is clinically suspected and previous ultrasound-guided biopsy results are negative; (2) to localize and stage prostate cancer and provide a roadmap for treatment planning; and (3) to detect residual or locally recurrent cancer after treatment. Other MR techniques such as proton MR spectroscopic imaging (MRSI), diffusion-weighted imaging (DWI), and contrast-enhanced MRI (CE-MRI) complement conventional MR imaging by providing metabolic and functional information that can improve the accuracy of prostate cancer detection and characterization. In everyday clinical practice, and to account for patient comfort, MR imaging studies are limited to 1 h. To obtain consistently high-quality images, a well-designed protocol is necessary. Routine MR imaging can be supplemented by other MR techniques such as MRSI, DWI or CE-MRI depending on the expertise available and the clinical questions that need to be answered. This review summarizes the role of MR imaging in the management of prostate cancer and describes practical approaches to implementing anatomic, metabolic and functional MR imaging techniques in the clinic.

Imaging in genitourinary cancer from the urologists' perspective

It is well established that advances in imaging may lead to early cancer detection, more accurate tumour staging and consequently adequate treatment, better monitoring of the disease and enhanced surveillance for recurrences after treatment. This manuscript reviews the current use of imaging in genitourinary cancer and explores the impact of imaging findings in clinical management. Additionally, an effort has been made to present the emerging imaging modalities and also their possible role in diagnosis and treatment of these cancers.

Radiation therapy in prostate cancer

Adenocarcinoma of the prostate is one of the most frequently diagnosed cancers of men in the Western hemisphere and is second only to lung cancer for male cancer mortality. Most patients are diagnosed in the early/clinically localized stage, which can be treated curatively with radiation therapy alone. Innovative methods such as brachytherapy, three-dimensional conformal radiotherapy (3D-CRT), and IMRT (intensity modulated radiotherapy) are able to deliver very high tumoricidal doses to the diseased prostate, with minimal side effects to the surrounding tissue. Radiation therapy combined with hormonal treatment can be curative in locally advanced disease. Radiation therapy is also very effective in alleviating symptoms of metastatic prostate cancer (bone metastases, spinal cord compression, and bladder outlet obstruction).

Prostate cancer in the elderly

Prostate cancer is the second leading cause of cancer deaths among men. Despite earlier diagnosis due to prostate specific antigen (PSA) screening, it is still a disease of the elderly. Diagnosis is based on digital rectal examination (DRE) and PSA assessment. Refinements in PSA testing (age-specific reference ranges, free PSA, PSA density and velocity) increased specificity and limited unnecessary prostate biopsies. Diagnosis in earlier stages (T1 and T2) commonly leads to cure with current treatment modalities. These include radical prostatectomy, external beam radiotherapy and brachytherapy. Other treatment options under development include cryotherapy and high-intensity focused ultrasound. Metastatic prostate cancer is incurable and treatment is based on hormonal therapy. Cytotoxic chemotherapy has only limited role in hormone-independent prostate cancer. Radioisotopes and biphosphonates may alleviate bone pain and prevent osteoporosis and pathological fractures. Follow-up is based on PSA. Prognostic factors for recurrence include stage, Gleason score, pre- and posttreatment PSA. Quality of life issues play an important role in selecting treatment, especially in the elderly due to comorbidities that may negatively affect the overall quality of life. A holistic approach is recommended addressing all quality of life issues without focus only in cancer control.

Validation study of the accuracy of a postoperative nomogram for recurrence after radical prostatectomy for localized prostate cancer

PURPOSE

A postoperative nomogram for prostate cancer was developed at Baylor College of Medicine. This nomogram uses readily available clinical and pathologic variables to predict 7-year freedom from recurrence after radical prostatectomy. We evaluated the predictive accuracy of the nomogram when applied to patients of four international institutions.

PATIENTS AND METHODS

Clinical and pathologic data of 2,908 patients were supplied for validation, and 2,465 complete records were used. Nomogram-predicted probabilities of 7-year freedom from recurrence were compared with actual follow-up in two ways. First, the area under the receiver operating characteristic curve (AUC) was calculated for all patients and stratified by the time period of surgery. Second, calibration of the nomogram was achieved by comparing the predicted freedom from recurrence with that of an ideal nomogram. For patients in whom the pathologic report does not distinguish between focal and established extracapsular extension (an input variable of the nomogram), two separate calculations were performed assuming one or the other.

RESULTS

The overall AUC was 0.80 when applied to the validation data set, with individual institution AUCs ranging from 0.77 to 0.82. The predictive accuracy of the nomogram was apparently higher in patients who were operated on between 1997 and 2000 (AUC, 0.83) compared with those treated between 1987 and 1996 (AUC, 0.78). Nomogram predictions of 7-year freedom from recurrence were within 10% of an ideal nomogram.

CONCLUSION

The postoperative Baylor nomogram was accurate when applied at international treatment institutions. Our results suggest that accurate predictions may be expected when using this nomogram across different patient populations.

Undetectable ultrasensitive PSA after radical prostatectomy for prostate cancer predicts relapse-free survival

Radical retropubic prostatectomy is considered by many centres to be the treatment of choice for men aged less than 70 years with localized prostate cancer. A rise in serum prostate-specific antigen after radical prostatectomy occurs in 10-40% of cases. This study evaluates the usefulness of novel ultrasensitive PSA assays in the early detection of biochemical relapse. 200 patients of mean age 61. 2 years underwent radical retropubic prostatectomy. Levels < or = 0.01 ng ml-1 were considered undetectable. Mean pre-operative prostate-specific antigen was 13.3 ng ml-1. Biochemical relapse was defined as 3 consecutive rises. The 2-year biochemical disease-free survival for the 134 patients with evaluable prostate-specific antigen nadir data was 61.1% (95% CI: 51.6-70.6%). Only 2 patients with an undetectable prostate-specific antigen after radical retropubic prostatectomy biochemically relapsed (3%), compared to 47 relapses out of 61 patients (75%) who did not reach this level. Cox multivariate analysis confirms prostate-specific antigen nadir < or = 0.01 ng ml-1 to be a superb independent variable predicting a favourable biochemical disease-free survival (P < 0.0001). Early diagnosis of biochemical relapse is feasible with sensitive prostate-specific antigen assays. These assays more accurately measure the prostate-specific antigen nadir, which is an excellent predictor of biochemical disease-free survival. Thus, sensitive prostate-specific antigen assays offer accurate prognostic information and expedite decision-making regarding the use of salvage prostate-bed radiotherapy or hormone therapy.