Adverse pathology and undetectable ultrasensitive prostate-specific antigen after radical prostatectomy: is adjuvant radiation warranted?

Impact of Gleason score of the tumor at the positive surgical margin as a prognostic factor

Although numerous studies have reported that a positive surgical margin (PSM) is the most important predictive factor for biochemical recurrence (BCR) of prostate cancer (PCa), only a small number of studies have evaluated the predictive value of the Gleason score (GS) of the tumor at the margin in radical prostatectomy (RP). The present study aimed to investigate the preoperative factors that predict PSM and the significant predictive factors for BCR in cases with PSM. In addition, it was examined whether documenting the GS of the tumor at the margin in pathological reports is useful as a predictive factor for BCR. Data of 241 patients with PCa who underwent RP at Kurume University Hospital (Kurume, Japan) between January 2007 and December 2011 were retrospectively reviewed. The median follow-up period was 72 months and 122 patients had at least one PSM. The time to BCR was significantly shorter in patients with PSM than in those with a negative surgical margin. Multivariate analysis demonstrated that >10 ng/ml prostate-specific antigen at diagnosis (P=0.024) and >25% positive core at biopsy (P=0.041) were independent prognostic preoperative factors for PSM. The GS of the tumor at the margin was equal, lower and higher than those of the main tumor in 74 (60.7%), 16 (13.1%) and 32 (26.2%) RPs, respectively. The BCR rates were 35.7, 55.1 and 82.1% in patients whose GS of the tumor at the margin was 6, 7 and 8-10, respectively (P=0.0017). The GS of the tumor at the PSM (P=0.038) and anatomic location of the PSM (P=0.04) were identified as independent prognostic preoperative factors for BCR, whereas the GS of the main tumor and margin length were not. These results suggest that documenting the GS at the margin in pathological reports is useful as a predictive factor for BCR.

Robotic radical prostatectomy: analysis of midterm pathologic and oncologic outcomes: A historical series from a high-volume center

Background

Identifying predictors of positive surgical margins (PSM) and biochemical recurrence (BCR) after radical prostatectomy (RP) may assist clinicians in formulating prognosis. Aim of the study was to report the midterm oncologic outcomes, to identify the risk factors for PSM and BCR and assess the impact of the PSM on BCR-free survival following robot-assisted laparoscopic radical prostatectomy (RALP).

Methods

From 2005 to 2010, 1679 consecutive patients underwent transperitoneal RALP. Data was retrospectively collected by an independent statistical company and analyzed in 2014. Median postoperative follow-up was 33.5 mo. BCR was defined as any detectable serum prostate-specific antigen (PSA) ≥ 0.2 ng/mL in two consecutive measurements. BCR-free survival was estimated using the Kaplan–Meier method. Univariate and multivariate analysis were applied to identify risk factors for PSM and BCR.

Results

In pN0/pNx cancers, pathologic stage was pT2 in 1186 patients (71.8%), pT3 in 455 patients (27.6%), and pT4 in 11 patients (0.6%). PSM rate was 17.4% and 36.9% of pT2 and pT3 cancers, respectively. Pathologic Gleason score was < 7, = 7 and > 7 in 42.1%, 53% and 4.9% of the patients, respectively. Overall BCR-free survival was 73.1% at 5 years; the 5-year BCR-free survival was 87.9% for pT2 with negative surgical margins. PSA, Gleason score (both bioptic and pathologic), pathologic stage (pT) and surgeon's volume were significant independent predictors of PSM. PSA, pathologic Gleason score, pT and PSM were significant independent predictors of BCR-free survival. Seminal vesicle-sparing, nerve-sparing approach and the extent of nerve-sparing (intra vs interfascial dissection) did not negatively affect margin status or BCR rates.

Conclusions

PSMs are a predictor of BCR. Being the only modifiable factor influencing the PSM rate, surgical experience is confirmed as a key factor for high-quality oncologic outcomes.

Long- versus short-term androgen deprivation therapy with high-dose radiotherapy for biochemical failure after radical prostatectomy: a randomized controlled trial

Radical prostatectomy is a well-established treatment option in the management of localized and locally advanced prostate cancer. An extended lymphadenectomy is performed in case of substantial risk for lymph node involvement. When biochemical recurrence (BCR) occurs, salvage radiotherapy (SRT) is performed. The benefit in terms of BCR-free survival (FS) and metastasis-FS by adding 6 months of androgen deprivation therapy (ADT) compared with SRT only has already been established. Retrospective evidence suggests that a longer schedule of ADT may be more beneficial compared with 6 months. This multicenter open-label randomized trial will include patients who need SRT after experiencing BCR post-radical prostatectomy with lymphadenectomy and pN0-status. Patients will be randomized for ADT duration (6 vs 24 months). Primary end point is distant metastasis-FS.

Clinical Trial Registration: NCT04242017 ( ClinicalTrials.gov )

Positive surgical margin is associated with biochemical recurrence risk following radical prostatectomy: a meta-analysis from high-quality retrospective cohort studies

Background and purpose

Although numerous studies have shown that positive surgical margin (PSM) is linked to biochemical recurrence (BCR) in prostate cancer (PCa), the research results have been inconsistent. This study aimed to explore the association between PSM and BCR in patients with PCa following radical prostatectomy (RP).

Materials and methods

In accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), PubMed, EMBASE and Wan Fang databases were searched for eligible studies from inception to November 2017. The Newcastle–Ottawa Scale was used to assess the risk of bias of the included studies. Meta-analysis was performed by using Stata 12.0. Combined hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs) were calculated using random-effects or fixed-effects models.

Results

Ultimately, 41 retrospective cohort studies of high quality that met the eligibility criteria, comprising 37,928 patients (94–3294 per study), were included in this meta-analysis. The results showed that PSM was associated with higher BCR risk in both univariate analysis (pooled HR = 1.56; 95% CI 1.46, 1.66; p < 0.001) and multivariate analysis (pooled HR = 1.35; 95% CI 1.27, 1.43; p < 0.001). Moreover, no potential publication bias was observed among the included studies in univariate analysis (p-Begg = 0.971) and multivariate analysis (p-Begg = 0.401).

Conclusions

Our meta-analysis demonstrated that PSM is associated with a higher risk of BCR in PCa following RP and could serve as an independent prognostic factor in patients with PCa.

Electronic supplementary material

The online version of this article (10.1186/s12957-018-1433-3) contains supplementary material, which is available to authorized users.

Stratification model based on early postprostatectomy prostate-specific antigen kinetics may help to reduce the risk of overtreatment in candidates for adjuvant radiotherapy

OBJECTIVE

The aim of this study was to construct a stratification model based on early postoperative kinetics of prostate-specific antigen (PSA) to select the most suitable high-risk patients for early intervention after radical prostatectomy (RP).

MATERIALS AND METHODS

The study evaluated 205 men who had undergone RP without any adjuvant treatment. All of the patients had positive surgical margins, extracapsular extension and/or seminal vesicle invasion. The patients underwent multiple ultrasensitive PSA measurements on days 14, 30, 60 and 90 after RP, and subsequently at 3 month intervals. The ability of particular PSA measurements to predict biochemical recurrence (BCR) was assessed using the area under the curve (AUC). A sequential mathematical decision procedure was constructed to create a stratification model.

RESULTS

During the median follow-up of 45.9 months, 106 patients (51%) experienced BCR. Prediction of BCR in terms of the AUC for PSA measurements on days 14, 30, 60 and 90 after the surgery was 0.61, 0.70, 0.80 and 0.82, respectively. In the multivariate analysis, only PSA after RP remained as a predictor of progression-free survival (p < 0.001). The stratification model based on calculated cut-off values for PSA on day 30 (0.068 ng/ml) and PSA on day 60 (0.015 ng/ml) reduced the potential overtreatment rate by 37%.

CONCLUSIONS

The results imply that ultrasensitive PSA values obtained very early after RP correlate with the presence of recurrent disease in high-risk patients. Incorporating these readily available variables into risk stratification models may help to individualize the administration of adjuvant radiotherapy and thus to minimize overtreatment.

Evaluation of a 24-gene signature for prognosis of metastatic events and prostate cancer-specific mortality

OBJECTIVES

To determine the prognostic potential of a 24-gene signature, Sig24, for identifying patients with prostate cancer who are at risk of developing metastases or of prostate cancer-specific mortality (PCSM) after radical prostatectomy (RP).

PATIENTS AND METHODS

Sig24 scores were calculated from previously collected gene expression microarray data from the Cleveland Clinic and Mayo Clinic (I and II). The performance of Sig24 was determined using time-dependent c-index analysis, Cox proportional hazards regression and Kaplan-Meier survival analysis.

RESULTS

Higher Sig24 scores were significantly associated with higher pathological Gleason scores in all three cohorts. Analysis of the Mayo Clinic II cohort, which included time-to-event information, indicated that patients with high Sig24 scores also had a higher risk of developing metastasis (hazard ratio [HR] 3.78, 95% confidence interval [CI]: 1.96-7.29; P < 0.001) or of PCSM (HR 6.54, 95% CI: 2.16-19.83; P < 0.001).

CONCLUSIONS

The findings of the present study show the applicability of Sig24 for the prognosis of metastasis or PCSM after RP. Future studies investigating the combination of Sig24 with available prognostic tests may provide new approaches to improve risk stratification for patients with prostate cancer.