Can we improve the definition of high-risk, hormone naïve, non-metastatic prostate cancer?

Comparison of bone lesion distribution between prostate cancer and multiple myeloma with whole-body MRI

PURPOSE

To assess the distribution of bone lesions in patients with prostate cancer (PCa) and those with multiple myeloma (MM) using whole-body magnetic resonance imaging (MRI); and to assess the added value of four anatomical regions located outside the thoraco-lumbo-pelvic area to detect the presence of bone lesions in a patient-based perspective.

MATERIALS AND METHODS

Fifty patients (50 men; mean age, 67±10 [SD] years; range, 59-87 years) with PCa and forty-seven patients (27 women, 20 men; mean age, 62.5±9 [SD] years; range, 47-90 years) with MM were included. Three radiologists assessed bone involvement in seven anatomical areas reading all MRI sequences.

RESULTS

In patients with PCa, there was a cranio-caudal increasing prevalence of metastases (22% [11/50] in the humeri and cervical spine to 60% [30/50] in the pelvis). When the thoraco-lumbo-pelvic region was not involved, the prevalence of involvement of the cervical spine, proximal humeri, ribs, or proximal femurs was 0% in patients with PCa and≥4% (except for the cervical spine, 0%) in those with MM.

CONCLUSION

In patients with PCa, there is a cranio-caudal positive increment in the prevalences of metastases and covering the thoraco-lumbo-pelvic area is sufficient to determine the metastatic status of a patient with PCa. In patients with MM, there is added value of screening all regions, except the cervical spine, to detect additional lesions.

Whole-body MRI to assess bone involvement in prostate cancer and multiple myeloma: comparison of the diagnostic accuracies of the T1, short tau inversion recovery (STIR), and high b-values diffusion-weighted imaging (DWI) sequences

PURPOSE

To compare the diagnostic accuracy of whole-body T1, short tau inversion recovery (STIR), high b-value diffusion-weighted imaging (DWI), and sequence combinations to detect bone involvement in prostate cancer (PCa) and multiple myeloma (MM) patients.

MATERIALS AND METHODS

We included 50 consecutive patients with PCa at high risk for metastasis and 47 consecutive patients with a histologically confirmed diagnosis of MM who received whole-body MRI at two institutions from January to December 2015. Coronal T1, STIR, and reconstructed coronal high b-values DWI were obtained for all patients. Two musculoskeletal radiologists read individual sequences, pairs of sequences (T1-DWI, T1-STIR, and STIR-DWI), and all combined (T1-STIR-DWI) to detect bone involvement. Receiver operating characteristic curve analysis was used to assess diagnostic performance according to a "best valuable comparator" combining baseline and 6-month imaging and clinical and biological data. Interobserver agreement was calculated.

RESULTS

Interobserver agreement for individual and combined MRI sequences was very good in the PCa group and ranged from good to very good in the MM group (0.76-1.00). In PCa patients, T1-DWI, T1-STIR, and T1-STIR-DWI showed the highest performance (sensitivity = 100% [95% CI = 90.5-100%], specificity = 100% [75.3-100%]). In MM patients, the highest performance was achieved by T1-STIR-DWI (sensitivity = 100% [88.4-100%], specificity = 94.1% [71.3-100%]). T1-STIR-DWI significantly outperformed all sequences (p < 0.05) except T1-DWI (p = 0.49).

CONCLUSION

In PCa patients, a combination of either T1-DWI or T1-STIR sequences is not inferior to a combination of three sequences to detect bone metastases. In MM, T1-STIR-DWI and T1-DWI had the highest diagnostic performance for detecting bone involvement.

KEY POINTS

• The sequences used in Whole Body MRI studies to detect bone involvement in prostate cancer and myeloma were evaluated. • In prostate cancer, any pairwise combinations of T1, STIR, and DWI have high diagnostic value. • In myeloma, the combinations T1-STIR-DWI or T1-DWI sequences should be used.

Management of Patients with Advanced Prostate Cancer: The Report of the Advanced Prostate Cancer Consensus Conference APCCC 2017

BACKGROUND

In advanced prostate cancer (APC), successful drug development as well as advances in imaging and molecular characterisation have resulted in multiple areas where there is lack of evidence or low level of evidence. The Advanced Prostate Cancer Consensus Conference (APCCC) 2017 addressed some of these topics.

OBJECTIVE

To present the report of APCCC 2017.

DESIGN, SETTING, AND PARTICIPANTS

Ten important areas of controversy in APC management were identified: high-risk localised and locally advanced prostate cancer; "oligometastatic" prostate cancer; castration-naïve and castration-resistant prostate cancer; the role of imaging in APC; osteoclast-targeted therapy; molecular characterisation of blood and tissue; genetic counselling/testing; side effects of systemic treatment(s); global access to prostate cancer drugs. A panel of 60 international prostate cancer experts developed the program and the consensus questions.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The panel voted publicly but anonymously on 150 predefined questions, which have been developed following a modified Delphi process.

RESULTS AND LIMITATIONS

Voting is based on panellist opinion, and thus is not based on a standard literature review or meta-analysis. The outcomes of the voting had varying degrees of support, as reflected in the wording of this article, as well as in the detailed voting results recorded in Supplementary data.

CONCLUSIONS

The presented expert voting results can be used for support in areas of management of men with APC where there is no high-level evidence, but individualised treatment decisions should as always be based on all of the data available, including disease extent and location, prior therapies regardless of type, host factors including comorbidities, as well as patient preferences, current and emerging evidence, and logistical and economic constraints. Inclusion of men with APC in clinical trials should be strongly encouraged. Importantly, APCCC 2017 again identified important areas in need of trials specifically designed to address them.

PATIENT SUMMARY

The second Advanced Prostate Cancer Consensus Conference APCCC 2017 did provide a forum for discussion and debates on current treatment options for men with advanced prostate cancer. The aim of the conference is to bring the expertise of world experts to care givers around the world who see less patients with prostate cancer. The conference concluded with a discussion and voting of the expert panel on predefined consensus questions, targeting areas of primary clinical relevance. The results of these expert opinion votes are embedded in the clinical context of current treatment of men with advanced prostate cancer and provide a practical guide to clinicians to assist in the discussions with men with prostate cancer as part of a shared and multidisciplinary decision-making process.

The role of radical prostatectomy as an initial approach for the treatment of high-risk prostate cancer

CONTEXT

The treatment of high-risk prostate cancer requires a multimodal approach to improve control of the disease. There is still no consensus as to the initial strategy of choice. The aim of this study is to review the results of radical prostatectomy as first step in management of patients with high-risk disease.

ACQUISITION OF EVIDENCE

A search was conducted on PubMed of English and Spanish texts. We included those studies that reported the results of radical prostatectomy in patients with high-risk prostate cancer, as well as those that compared radical prostatectomy with other treatment alternatives. The last search was conducted in November 2015.

SYNTHESIS OF THE EVIDENCE

The advantages of radical prostatectomy include a better pathological analysis, more accurate staging, better local control of the disease and better follow-up and adjuvant therapy strategies. When compared with external radiation therapy plus hormonal blockade, the patients who underwent prostatectomy had greater chances of healing and longer cancer-specific survival. The patients who most benefit from this approach are younger, have fewer comorbidities and no evidence of organ metastases.

CONCLUSIONS

The available scientific evidence to date is not without bias and confounders; however, they appear to favour radical prostatectomy as the initial approach of choice for high-risk prostate cancer.

Regulation of vascular endothelial growth factor in prostate cancer

Prostate cancer (PCa) is the most common malignancy affecting men in the western world. Although radical prostatectomy and radiation therapy can successfully treat PCa in the majority of patients, up to ~30% will experience local recurrence or metastatic disease. Prostate carcinogenesis and progression is typically an androgen-dependent process. For this reason, therapies for recurrent PCa target androgen biosynthesis and androgen receptor function. Such androgen deprivation therapies (ADT) are effective initially, but the duration of response is typically ≤24 months. Although ADT and taxane-based chemotherapy have delivered survival benefits, metastatic PCa remains incurable. Therefore, it is essential to establish the cellular and molecular mechanisms that enable localized PCas to invade and disseminate. It has long been accepted that metastases require angiogenesis. In the present review, we examine the essential role for angiogenesis in PCa metastases, and we focus in particular on the current understanding of the regulation of vascular endothelial growth factor (VEGF) in localized and metastatic PCa. We highlight recent advances in understanding the role of VEGF in regulating the interaction of cancer cells with tumor-associated immune cells during the metastatic process of PCa. We summarize the established mechanisms of transcriptional and post-transcriptional regulation of VEGF in PCa cells and outline the molecular insights obtained from preclinical animal models of PCa. Finally, we summarize the current state of anti-angiogenesis therapies for PCa and consider how existing therapies impact VEGF signaling.

Formal consensus method to evaluate the conformity of prescription of a recently approved chemotherapy treatment in an observatory study

Cabazitaxel is a second line chemotherapy drug recently approved for the treatment of metastatic castration-resistant prostate cancer. A first panel of French experts and a second independent panel of European experts were convened to assess the conformity of prescription of cabazitaxel with a Delphi consensus method. A two-round modified Delphi consensus process was conducted. This methodology is based on experts’ opinion obtained in a systematic manner. The process was divided into five steps: (i) elaboration of the questionnaire, (ii) rating, (iii) analysis, (iv) discussion of the points with absence of consensus following rating of the questionnaire, and (v) final reporting. Consensus was defined according to RAND method and all analyses were conducted according to the same methodology. At the end of the two rounds of rating and a synthesis meeting, of the 26 items included in the Summary of Product Characteristics (SPC), 11 items were judged appropriate with strong consensus by the two independent panels of experts. These items can therefore be considered of prime importance to evaluate conformity of cabazitaxel prescription in the context of observatory studies as well as in further clinical trials using this new taxane. Our findings further provide important evidence about the value of the Delphi consensus and highlight a requirement for “conformity” standards to assist practitioners in a safe chemotherapy drug prescription.

Epithelial-mesenchymal transition in prostate cancer is associated with quantifiable changes in nuclear structure

BACKGROUND

Prostate cancer progression is concomitant with quantifiable nuclear structure and texture changes as compared to non-cancer tissue. Malignant progression is associated with an epithelial-mesenchymal transition (EMT) program whereby epithelial cancer cells take on a mesenchymal phenotype and dissociate from a tumor mass, invade, and disseminate to distant metastatic sites. The objective of this study was to determine if epithelial and mesenchymal prostate cancer cells have different nuclear morphology.

METHODS

Murine tibia injections of epithelial PC3 (PC3-Epi) and mesenchymal PC3 (PC3-EMT) prostate cancer cells were processed and stained with H&E. Cancer cell nuclear image data was obtained using commercially available image-processing software. Univariate and multivariate statistical analysis were used to compare the two phenotypes. Several non-parametric classifiers were constructed and permutation-tested at various training set fractions to ensure robustness of classification between PC3-Epi and PC3-EMT cells in vivo.

RESULTS

PC3-Epi and PC3-EMT prostate cancer cells were separable at the single cell level in murine tibia injections on the basis of nuclear structure and texture remodeling associated with an EMT. Support vector machine and multinomial logistic regression models based on nuclear architecture features yielded AUC-ROC curves of 0.95 and 0.96, respectively, in separating PC3-Epi and PC3-EMT prostate cancer cells in vivo.

CONCLUSIONS

Prostate cancer cells that have undergone an EMT demonstrated an altered nuclear structure. The association of nuclear changes and a mesenchymal phenotype demonstrates quantitative morphometric image analysis may be used to detect cancer cells that have undergone EMT. This morphometric measurement could provide valuable prognostic information in patients regarding the likelihood of [future] metastatic disease.