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Porcaro AB, Bianchi A, Panunzio A, Gallina S, Serafin E, Tafuri A, Trabacchin N, Orlando R, Ornaghi PI, Mazzucato G, Vidiri S, D'Aietti D, Montanaro F, Brusa D, Patuzzo GM, Artoni F, Baielli A, Migliorini F, De Marco V, Veccia A, Brunelli M, Siracusano S, Cerruto MA, Antonelli A. Tumor upgrading among very favorable intermediate-risk prostate cancer patients treated with robot-assisted radical prostatectomy: how can it impact the clinical course? Int Urol Nephrol 2024; 56:2597-2605. [PMID: 38553619 DOI: 10.1007/s11255-024-04019-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 03/02/2024] [Indexed: 07/25/2024]
Abstract
PURPOSE We sought to investigate predictors of unfavorable tumor upgrading in very favorable intermediate-risk (IR) prostate cancer (PCa) patients treated with robot-assisted radical prostatectomy, in addition to evaluate how it may affect the risk of disease progression. METHODS A very favorable subset of IR PCa patients presenting with prostate-specific antigen (PSA) < 10 ng/mL, percentage of biopsy positive cores (BPC) < 50%, and either International Society of Urological Pathology (ISUP) grade group 1 and clinical stage T2b or ISUP grade group 2 and clinical stage T1c-2b was identified. Unfavorable pathology at radical prostatectomy was defined as the presence of ISUP grade group > 2 (unfavorable tumor upgrading), extracapsular extension (ECE), and seminal vesicle invasion (SVI). Disease progression was defined as the event of biochemical recurrence and/or local recurrence and/or distant metastases. Associations were evaluated by Cox regression and logistic regression analyses. RESULTS Overall, 210 patients were identified between January 2013 and October 2020. Unfavorable tumor upgrading was detected in 71 (33.8%) cases, and adverse tumor stage, including ECE or SVI in 18 (8.6%) and 11 (5.2%) patients, respectively. Median (interquartile range) follow-up was 38.5 (16-61) months. PCa progression occurred in 24 (11.4%) patients. Very favorable IR PCa patients with unfavorable tumor upgrading at final pathology showed a persistent risk of disease progression, which hold significance after adjustment for all factors (Hazard Ratio [HR]: 5.95, 95% Confidence Interval [CI]: 1.97-17.92, p = 0.002) of which PSA was an independent predictor (HR: 1.52, 95% CI 1.12-2.08, p = 0.008). Moreover, these subjects were more likely to belong to the biopsy ISUP grade group 2. CONCLUSIONS Very favorable IR PCa patients hiding unfavorable tumor upgrading were more likely to experience disease progression. Unfavorable tumor upgrading involved about one-third of cases and was less likely to occur in patients presenting with biopsy ISUP grade group 1. Tumor misclassification is an issue to discuss, when counseling this subset of patients for active surveillance because of the risk of delayed active treatment.
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Affiliation(s)
- Antonio Benito Porcaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy.
| | - Alberto Bianchi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | | | - Sebastian Gallina
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Emanuele Serafin
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | | | - Nicolò Trabacchin
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Rossella Orlando
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Paola Irene Ornaghi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Giovanni Mazzucato
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Stefano Vidiri
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Damiano D'Aietti
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Francesca Montanaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Davide Brusa
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Giulia Marafioti Patuzzo
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Francesco Artoni
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Alberto Baielli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Filippo Migliorini
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Vincenzo De Marco
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Alessandro Veccia
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Matteo Brunelli
- Department of Pathology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Salvatore Siracusano
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Maria Angela Cerruto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
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Yang J, Xiao L, Zhou M, Li Y, Cai Y, Gan Y, Tang Y, Hu S. [ 68Ga]Ga‑PSMA‑617 PET-based radiomics model to identify candidates for active surveillance amongst patients with GGG 1-2 prostate cancer at biopsy. Cancer Imaging 2024; 24:86. [PMID: 38965552 PMCID: PMC11229016 DOI: 10.1186/s40644-024-00735-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 06/27/2024] [Indexed: 07/06/2024] Open
Abstract
PURPOSE To develop a radiomics-based model using [68Ga]Ga-PSMA PET/CT to predict postoperative adverse pathology (AP) in patients with biopsy Gleason Grade Group (GGG) 1-2 prostate cancer (PCa), assisting in the selection of patients for active surveillance (AS). METHODS A total of 75 men with biopsy GGG 1-2 PCa who underwent radical prostatectomy (RP) were enrolled. The patients were randomly divided into a training group (70%) and a testing group (30%). Radiomics features of entire prostate were extracted from the [68Ga]Ga-PSMA PET scans and selected using the minimum redundancy maximum relevance algorithm and the least absolute shrinkage and selection operator regression model. Logistic regression analyses were conducted to construct the prediction models. Receiver operating characteristic (ROC) curve, decision curve analysis (DCA), and calibration curve were employed to evaluate the diagnostic value, clinical utility, and predictive accuracy of the models, respectively. RESULTS Among the 75 patients, 30 had AP confirmed by RP. The clinical model showed an area under the curve (AUC) of 0.821 (0.695-0.947) in the training set and 0.795 (0.603-0.987) in the testing set. The radiomics model achieved AUC values of 0.830 (0.720-0.941) in the training set and 0.829 (0.624-1.000) in the testing set. The combined model, which incorporated the Radiomics score (Radscore) and free prostate-specific antigen (FPSA)/total prostate-specific antigen (TPSA), demonstrated higher diagnostic efficacy than both the clinical and radiomics models, with AUC values of 0.875 (0.780-0.970) in the training set and 0.872 (0.678-1.000) in the testing set. DCA showed that the net benefits of the combined model and radiomics model exceeded those of the clinical model. CONCLUSION The combined model shows potential in stratifying men with biopsy GGG 1-2 PCa based on the presence of AP at final pathology and outperforms models based solely on clinical or radiomics features. It may be expected to aid urologists in better selecting suitable patients for AS.
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Affiliation(s)
- Jinhui Yang
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Ling Xiao
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Ming Zhou
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Yujia Li
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Yi Cai
- Department of Urology, Disorders of Prostate Cancer Multidisciplinary Team, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
- National Clinical Research Center for Geriatric Disorders (XIANGYA), Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yu Gan
- Department of Urology, Disorders of Prostate Cancer Multidisciplinary Team, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China.
- National Clinical Research Center for Geriatric Disorders (XIANGYA), Xiangya Hospital, Central South University, Changsha, Hunan, China.
| | - Yongxiang Tang
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China.
- National Clinical Research Center for Geriatric Disorders (XIANGYA), Xiangya Hospital, Central South University, Changsha, Hunan, China.
- Department of Nuclear Medicine, Inselspital, University Hospital Bern, Bern, Switzerland.
| | - Shuo Hu
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China.
- National Clinical Research Center for Geriatric Disorders (XIANGYA), Xiangya Hospital, Central South University, Changsha, Hunan, China.
- Key Laboratory of Biological, Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, Hunan, China.
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Porcaro AB, Bianchi A, Gallina S, Panunzio A, Tafuri A, Serafin E, Orlando R, Mazzucato G, Ornaghi PI, Cianflone F, Montanaro F, Artoni F, Baielli A, Ditonno F, Migliorini F, Brunelli M, Siracusano S, Cerruto MA, Antonelli A. Prognostic Impact and Clinical Implications of Adverse Tumor Grade in Very Favorable Low- and Intermediate-Risk Prostate Cancer Patients Treated with Robot-Assisted Radical Prostatectomy: Experience of a Single Tertiary Referral Center. Cancers (Basel) 2024; 16:2137. [PMID: 38893256 PMCID: PMC11171498 DOI: 10.3390/cancers16112137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 05/25/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
OBJECTIVES To assess the prognostic impact and predictors of adverse tumor grade in very favorable low- and intermediate-risk prostate cancer (PCa) patients treated with robot-assisted radical prostatectomy (RARP). METHODS Data of low- and intermediate PCa risk-class patients were retrieved from a prospectively maintained institutional database. Adverse tumor grade was defined as pathology ISUP grade group > 2. Disease progression was defined as a biochemical recurrence event and/or local recurrence and/or distant metastases. Associations were assessed by Cox's proportional hazards and logistic regression model. RESULTS Between January 2013 and October 2020, the study evaluated a population of 289 patients, including 178 low-risk cases (61.1%) and 111 intermediate-risk subjects (38.4%); unfavorable tumor grade was detected in 82 cases (28.4%). PCa progression, which occurred in 29 patients (10%), was independently predicted by adverse tumor grade and biopsy ISUP grade group 2, with the former showing stronger associations (hazard ratio, HR = 4.478; 95% CI: 1.840-10.895; p = 0.001) than the latter (HR = 2.336; 95% CI: 1.057-5.164; p = 0.036). Older age and biopsy ISUP grade group 2 were independent clinical predictors of adverse tumor grade, associated with larger tumors that eventually presented non-organ-confined disease. CONCLUSIONS In a very favorable PCa patient population, adverse tumor grade was an unfavorable prognostic factor for disease progression. Active surveillance in very favorable intermediate-risk patients is still a hazard, so molecular and genetic testing of biopsy specimens is needed.
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Affiliation(s)
- Antonio Benito Porcaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Alberto Bianchi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Sebastian Gallina
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Andrea Panunzio
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | | | - Emanuele Serafin
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Rossella Orlando
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Giovanni Mazzucato
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Paola Irene Ornaghi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Francesco Cianflone
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Francesca Montanaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Francesco Artoni
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Alberto Baielli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Francesco Ditonno
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Filippo Migliorini
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Matteo Brunelli
- Department of Pathology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy;
| | - Salvatore Siracusano
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy;
| | - Maria Angela Cerruto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37129 Verona, Italy; (A.B.P.); (A.B.); (S.G.); (A.P.); (E.S.); (R.O.); (G.M.); (P.I.O.); (F.C.); (F.M.); (F.A.); (A.B.); (F.M.); (M.A.C.); (A.A.)
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Anceschi U, Flammia RS, Tufano A, Morelli M, Galfano A, Luciani LG, Misuraca L, Dell’Oglio P, Tuderti G, Brassetti A, Ferriero MC, Bove AM, Mastroianni R, Prata F, Sperduti I, Petralia G, Secco S, Di Trapani E, Mattevi D, Cai T, Bocciardi AM, Simone G. Proficiency score as a predictor of early trifecta achievement during the learning curve of robot-assisted radical prostatectomy for high-risk prostate cancer: Results of a multicentric series. Curr Urol 2024; 18:110-114. [PMID: 39176300 PMCID: PMC11337992 DOI: 10.1097/cu9.0000000000000213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/04/2023] [Indexed: 08/24/2024] Open
Abstract
Background Recently, an innovative tool called "proficiency score" was introduced to assess the learning curve for robot-assisted radical prostatectomy (RARP). However, the initial study only focused on patients with low-risk prostate cancer for whom pelvic lymph node dissection (PLND) was not required. To address this issue, we aimed to validate proficiency scores of a contemporary multicenter cohort of patients with high-risk prostate cancer treated with RARP plus extended PLND by trainee surgeons. Material and methods Between 2010 and 2020, 4 Italian institutional prostate-cancer datasets were merged and queried for "RARP" and "high-risk prostate cancer." High-risk prostate cancer was defined according to the most recent European Association of Urology guidelines as follows: prostate-specific antigen >20 ng/mL, International Society of Urological Pathology ≥4, and/or clinical stage (cT) ≥ 2c on preoperative imaging. The selected cohort (n = 144) included clinical cases performed by trainee surgeons (n = 4) after completing their RARP learning curve (50 procedures for low-risk prostate cancer). The outcome of interest, the proficiency score, was defined as the coexistence of all the following criteria: a comparable operation time to the interquartile range of the mentor surgeon at each center, absence of any significant perioperative complications Clavien-Dindo Grade 3-5, no perioperative blood transfusions, and negative surgical margins. A logistic binary regression model was built to identify the predictors of 1-year trifecta achievement in the trainee cohort. For all statistical analyses, a 2-sided p < 0.05 was considered significant. Results A proficiency score was achieved in 42.3% patients. At univariable level, proficiency score was associated with 1-year trifecta achievement (odds ratio, 8.77; 95% confidence interval, 2.42-31.7; p = 0.001). After multivariable adjustments for age, nerve-sparing, and surgical technique, the proficiency score independently predicted 1-year trifecta achievement (odds ratio, 9.58; 95% confidence interval, 1.83-50.1; p = 0.007). Conclusions Our findings support the use of proficiency scores in patients and require extended PLND in addition to RARP.
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Affiliation(s)
- Umberto Anceschi
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy
| | - Rocco Simone Flammia
- Urologic Clinic, Department of Maternal-Child and Urologic Sciences, Sapienza University of Rome, Italy
| | - Antonio Tufano
- Urologic Clinic, Department of Maternal-Child and Urologic Sciences, Sapienza University of Rome, Italy
| | - Michele Morelli
- Ospedale Niguarda Ca’ Granda, Department of Urology, Milan, Italy
| | - Antonio Galfano
- Ospedale Niguarda Ca’ Granda, Department of Urology, Milan, Italy
| | | | - Leonardo Misuraca
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy
| | - Paolo Dell’Oglio
- Ospedale Niguarda Ca’ Granda, Department of Urology, Milan, Italy
| | - Gabriele Tuderti
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy
| | - Aldo Brassetti
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy
| | | | - Alfredo Maria Bove
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy
| | - Riccardo Mastroianni
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy
| | - Francesco Prata
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy
| | - Isabella Sperduti
- Department of Biostatistical Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | | | - Silvia Secco
- Ospedale Niguarda Ca’ Granda, Department of Urology, Milan, Italy
| | | | - Daniele Mattevi
- Department of Urology, APSS Santa Chiara Regional Hospital, Trento, Italy
| | - Tommaso Cai
- Department of Urology, APSS Santa Chiara Regional Hospital, Trento, Italy
| | | | - Giuseppe Simone
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy
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5
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Baboudjian M, Uleri A, Beauval JB, Touzani A, Diamand R, Roche JB, Lacetera V, Lechevallier E, Roumeguère T, Simone G, Benamran D, Fourcade A, Fiard G, Peltier A, Ploussard G. MRI lesion size is more important than the number of positive biopsy cores in predicting adverse features and recurrence after radical prostatectomy: implications for active surveillance criteria in intermediate-risk patients. Prostate Cancer Prostatic Dis 2024; 27:318-322. [PMID: 37452146 DOI: 10.1038/s41391-023-00693-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/06/2023] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION To determine associations between prostate cancer (PCa) tumor burden measured on biopsy or multiparametric magnetic resonance imaging (mpMRI) and outcomes in intermediate-risk (IR) International Society of Urological Pathology (ISUP) grade 2 men managed with primary radical prostatectomy (RP). METHODS This retrospective, multicenter study was conducted in eight referral centers. The cohort included IR PCa patients who had ISUP 2 at biopsy. We defined biopsy tumor burden as low/high based on the absence/presence of more than 25% positive cores. Tumor burden on imaging was defined as low/high based on maximum lesion diameter, <15 mm and ≥15 mm at mpMRI, respectively. The histological endpoint of the study was adverse features at RP, defined as ≥pT3a stage and/or lymph node invasion and/or ISUP ≥3 at final pathology. The clinical endpoint was biochemical recurrence (BCR) after RP. RESULTS A total of 698 IR patients was included, of whom 335 (48%) had adverse features. In multivariate logistic regression analysis, there was no statistical association between tumor burden at biopsy and adverse features (p = 0.7). Tumor size ≥15 mm at mpMRI was significantly associated with adverse pathology (OR 1.65, 95%CI 1.14-2.39; p = 0.01). No significant association was observed between tumor burden at biopsy and BCR (p = 0.4). Tumor size ≥15 mm at mpMRI was significantly associated with BCR (HR 1.96, 95% CI 1.01-3.80; p = 0.04). CONCLUSIONS Our data support extending the inclusion criteria to ISUP 2 men with >25% positive cores, provided they have a low tumor size at mpMRI (<15 mm). Prospective studies should be performed to validate these findings.
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Affiliation(s)
- Michael Baboudjian
- Department of Urology, La Croix du Sud Hôpital, Quint Fonsegrives, France.
- Department of Urology, North Hospital, Aix-Marseille University, APHM, Marseille, France.
- Department of Urology, La Conception Hospital, Aix-Marseille University, APHM, Marseille, France.
| | - Alessandro Uleri
- Department of Urology, Fundació Puigvert, Autonoma University of Barcelona, Barcelona, Spain
| | | | - Alae Touzani
- Department of Urology, La Croix du Sud Hôpital, Quint Fonsegrives, France
| | - Romain Diamand
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Vito Lacetera
- Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Eric Lechevallier
- Department of Urology, La Conception Hospital, Aix-Marseille University, APHM, Marseille, France
| | - Thierry Roumeguère
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Giuseppe Simone
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Daniel Benamran
- Division of Urology, Geneva University Hospitals, Geneva, Switzerland
| | - Alexandre Fourcade
- Department of Urology, Hôpital Cavale Blanche, CHRU Brest, Brest, France
| | - Gaelle Fiard
- Department of Urology, Grenoble Alpes University Hospital, Université Grenoble Alpes, CNRS, Grenoble INP, TIMC, Grenoble, France
| | - Alexandre Peltier
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
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6
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Zattoni F, Matrone F, Bortolus R, Giannarini G. Navigating the evolving diagnostic and therapeutic landscape of low- and intermediate-risk prostate cancer. Asian J Androl 2024:00129336-990000000-00183. [PMID: 38738954 DOI: 10.4103/aja20249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/08/2024] [Indexed: 05/14/2024] Open
Abstract
ABSTRACT In this nonsystematic review of the literature, we explored the changing landscape of detection and treatment of low- and intermediate-risk prostate cancer (PCa). Through emphasizing improved cancer assessment with histology classification and genomics, we investigated key developments in PCa detection and risk stratification. The pivotal role of prostate magnetic resonance imaging (MRI) in the novel diagnostic pathway is examined, alongside the benefits and drawbacks of MRI-targeted biopsies for detection and tumor characterization. We also delved into treatment options, particularly active surveillance for intermediate-risk PCa. Outcomes are compared between intermediate- and low-risk patients, offering insights into tailored management. Surgical techniques, including Retzius-sparing surgery, precision prostatectomy, and partial prostatectomy for anterior cancer, are appraised. Each technique has the potential to enhance outcomes and minimize complications. Advancements in technology and radiobiology, including computed tomography (CT)/MRI imaging and positron emission tomography (PET) fusion, allow for precise dose adjustment and daily target monitoring with imaging-guided radiotherapy, opening new ways of tailoring patients' treatments. Finally, experimental therapeutic approaches such as focal therapy open new treatment frontiers, although they create new needs in tumor identification and tracking during and after the procedure.
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Affiliation(s)
- Fabio Zattoni
- Urologic Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padua, Italy
| | - Fabio Matrone
- Department of Radiotherapy, National Cancer Institute (CRO), Aviano 33081, Italy
| | - Roberto Bortolus
- Department of Radiotherapy, National Cancer Institute (CRO), Aviano 33081, Italy
| | - Gianluca Giannarini
- Urology Unit, Santa Maria Della Misericordia University Hospital, Udine 33100, Italy
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7
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Porcaro AB, Bianchi A, Panunzio A, Gallina S, Tafuri A, Serafin E, Orlando R, Mazzucato G, Vidiri S, D’Aietti D, Montanaro F, Marafioti Patuzzo G, Artoni F, Baielli A, Ditonno F, Rizzetto R, Veccia A, Gozzo A, De Marco V, Brunelli M, Cerruto MA, Antonelli A. The impact of prognostic group classification on prostate cancer progression in intermediate-risk patients according to the European Association of Urology system: results in 479 patients treated with robot-assisted radical prostatectomy at a single tertiary referral center. Ther Adv Urol 2024; 16:17562872241229260. [PMID: 38348129 PMCID: PMC10860426 DOI: 10.1177/17562872241229260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 01/03/2024] [Indexed: 02/15/2024] Open
Abstract
Background Treatment outcomes in intermediate-risk prostate cancer (PCa) may be impaired by adverse pathology misclassification including tumor upgrading and upstaging. Clinical predictors of disease progression need to be improved in this category of patients. Objectives To identify PCa prognostic factors to define prognostic groups in intermediate-risk patients treated with robot-assisted radical prostatectomy (RARP). Design Data from 1143 patients undergoing RARP from January 2013 to October 2020 were collected: 901 subjects had available follow-up, of whom 479 were at intermediate risk. Methods PCa progression was defined as biochemical recurrence and/or local recurrence and/or distant metastases. Study endpoints were evaluated by statistical methods including Cox's proportional hazards, Kaplan-Meyer survival curves, and binomial and multinomial logistic regression models. Results After a median (interquartile range) of 35 months (15-57 months), 84 patients (17.5%) had disease progression, which was independently predicted by the percentage of biopsy-positive cores ⩾ 50% and the International Society of Urological Pathology (ISUP) grade group 3 for clinical factors and by ISUP > 2, positive surgical margins and pelvic lymph node invasion for pathological features. Patients were classified into clinical and pathological groups as favorable, unfavorable (one prognostic factor), and adverse (more than one prognostic factor). The risk of PCa progression increased with worsening prognosis through groups. A significant positive association was found between the two groups; consequently, as clinical prognosis worsened, the risk of detecting unfavorable and adverse pathological prognostic clusters increased in both unadjusted and adjusted models. Conclusion The study identified factors predicting disease progression that allowed the computation of highly correlated prognostic groups. As the prognosis worsened, the risk of PCa progression increased. Intermediate-risk PCa needs more prognostic stratification for appropriate management.
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Affiliation(s)
- Antonio Benito Porcaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Piazzale Stefani 1, Verona 37126, Italy
| | - Alberto Bianchi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Sebastian Gallina
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Emanuele Serafin
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Rossella Orlando
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Giovanni Mazzucato
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Stefano Vidiri
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Damiano D’Aietti
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Francesca Montanaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Giulia Marafioti Patuzzo
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Francesco Artoni
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Alberto Baielli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Francesco Ditonno
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Riccardo Rizzetto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Alessandro Veccia
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Alessandra Gozzo
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Vincenzo De Marco
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Matteo Brunelli
- Department of Pathology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Maria Angela Cerruto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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8
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Mjaess G, Peltier A, Roche JB, Lievore E, Lacetera V, Chiacchio G, Beatrici V, Mastroianni R, Simone G, Windisch O, Benamran D, Fourcade A, Nguyen TA, Fournier G, Fiard G, Ploussard G, Roumeguère T, Albisinni S, Diamand R. A Novel Nomogram to Identify Candidates for Focal Therapy Among Patients with Localized Prostate Cancer Diagnosed via Magnetic Resonance Imaging-Targeted and Systematic Biopsies: A European Multicenter Study. Eur Urol Focus 2023; 9:992-999. [PMID: 37147167 DOI: 10.1016/j.euf.2023.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/12/2023] [Accepted: 04/21/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Suitable selection criteria for focal therapy (FT) are crucial to achieve success in localized prostate cancer (PCa). OBJECTIVE To develop a multivariable model that better delineates eligibility for FT and reduces undertreatment by predicting unfavorable disease at radical prostatectomy (RP). DESIGN, SETTING, AND PARTICIPANTS Data were retrospectively collected from a prospective European multicenter cohort of 767 patients who underwent magnetic resonance imaging (MRI)-targeted and systematic biopsies followed by RP in eight referral centers between 2016 and 2021. The Imperial College of London eligibility criteria for FT were applied: (1) unifocal MRI lesion with Prostate Imaging-Reporting and Data System score of 3-5; (2) prostate-specific antigen (PSA) ≤20 ng/ml; (3) cT2-3a stage on MRI; and (4) International Society of Urological Pathology grade group (GG) 1 and ≥6 mm or GG 2-3. A total of 334 patients were included in the final analysis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was unfavorable disease at RP, defined as GG ≥4, and/or lymph node invasion, and/or seminal vesicle invasion, and/or contralateral clinically significant PCa. Logistic regression was used to assess predictors of unfavorable disease. The performance of the models including clinical, MRI, and biopsy information was evaluated using the area under the receiver operating characteristic curve (AUC), calibration plots, and decision curve analysis. A coefficient-based nomogram was developed and internally validated. RESULTS AND LIMITATIONS Overall, 43 patients (13%) had unfavorable disease on RP pathology. The model including PSA, clinical stage on digital rectal examination, and maximum lesion diameter on MRI had an AUC of 73% on internal validation and formed the basis of the nomogram. Addition of other MRI or biopsy information did not significantly improve the model performance. Using a cutoff of 25%, the proportion of patients eligible for FT was 89% at the cost of missing 30 patients (10%) with unfavorable disease. External validation is required before the nomogram can be used in clinical practice. CONCLUSIONS We report the first nomogram that improves selection criteria for FT and limits the risk of undertreatment. PATIENT SUMMARY We conducted a study to develop a better way of selecting patients for focal therapy for localized prostate cancer. A novel predictive tool was developed using the prostate-specific antigen (PSA) level measured before biopsy, tumor stage assessed via digital rectal examination, and lesion size on magnetic resonance imaging (MRI) scans. This tool improves the prediction of unfavorable disease and may reduce the risk of undertreatment of localized prostate cancer when using focal therapy.
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Affiliation(s)
- Georges Mjaess
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium.
| | - Alexandre Peltier
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Elena Lievore
- Department of Urology, Clinique Saint-Augustin, Bordeaux, France; Department of Urology, IRCCS Istituto Europeo di Oncologia, Milan, Italy
| | - Vito Lacetera
- Department of Urology, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Giuseppe Chiacchio
- Department of Urology, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Valerio Beatrici
- Department of Urology, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Riccardo Mastroianni
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giuseppe Simone
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Olivier Windisch
- Department of Urology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Daniel Benamran
- Department of Urology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Alexandre Fourcade
- Department of Urology, Hôpital Cavale Blanche, CHRU Brest, Brest, France
| | - Truong An Nguyen
- Department of Urology, Hôpital Cavale Blanche, CHRU Brest, Brest, France
| | - Georges Fournier
- Department of Urology, Hôpital Cavale Blanche, CHRU Brest, Brest, France
| | - Gaelle Fiard
- Department of Urology, Grenoble Alpes University Hospital, Université Grenoble Alpes, Grenoble, France
| | | | - Thierry Roumeguère
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Simone Albisinni
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Romain Diamand
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
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9
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Gandaglia G, Leni R, Plagakis S, Stabile A, Montorsi F, Briganti A. Active surveillance should not be routinely considered in ISUP grade group 2 prostate cancer. BMC Urol 2023; 23:153. [PMID: 37777767 PMCID: PMC10542696 DOI: 10.1186/s12894-023-01315-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/03/2023] [Indexed: 10/02/2023] Open
Abstract
Active surveillance has been proposed as a therapeutic option in selected intermediate risk patients with biopsy grade group 2 prostate cancer. However, its oncologic safety in this setting is debated. Therefore, we conducted a non-systematic literature research of contemporary surveillance protocols including patients with grade group 2 disease to collect the most recent evidence in this setting. Although no randomized controlled trial compared curative-intent treatments, namely radical prostatectomy and radiotherapy vs. active surveillance in patients with grade group 2 disease, surgery is associated with a benefit in terms of disease control and survival when compared to expectant management in the intermediate risk setting. Patients with grade group 2 on active surveillance were at higher risk of disease progression and treatment compared to their grade group 1 counterparts. Up to 50% of those patients were eventually treated at 5 years, and the metastases-free survival rate was as low as 85% at 15-years. When considering low- and intermediate risk patients treated with radical prostatectomy, grade group 2 was one of the strongest predictors of grade upgrading and adverse features. Available data is insufficient to support the oncologic safety of active surveillance in all men with grade group 2 prostate cancer. Therefore, those patients should be counselled regarding the oncologic efficacy of upfront active treatment modalities and the lack of robust long-term data supporting the safety of active surveillance in this setting.
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Affiliation(s)
- Giorgio Gandaglia
- Unit of Urology/Division of Oncology; URI, IRCCS Ospedale San Raffaele, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
| | - Riccardo Leni
- Unit of Urology/Division of Oncology; URI, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | | | - Armando Stabile
- Unit of Urology/Division of Oncology; URI, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Montorsi
- Unit of Urology/Division of Oncology; URI, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Briganti
- Unit of Urology/Division of Oncology; URI, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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10
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Tan GH, Deniffel D, Finelli A, Wettstein M, Ahmad A, Zlotta A, Fleshner N, Hamilton R, Kulkarni G, Nason G, Ajib K, Herrera-Caceres J, Chandrasekar T, Perlis N. Validating the total cancer location density metric for stratifying patients with low-risk localized prostate cancer at higher risk of grade group reclassification while on active surveillance. Urol Oncol 2023; 41:146.e23-146.e28. [PMID: 36639336 DOI: 10.1016/j.urolonc.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 11/07/2022] [Accepted: 12/08/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE To validate a previously proposed prognostic metric, Total Cancer Location (TCLo) density, in a contemporary cohort of men with grade group (GG) 1 prostate cancer (PCa) on active surveillance (AS). METHODS We evaluated 123 patients who entered AS with maximum GG1 PCa at diagnostic and/or confirmatory biopsy. TCLo was defined as the total number of PCa locations identified on both biopsy sessions. TCLo density was calculated as TCLo / prostate volume [ml]. Primary endpoint was progression-free survival (PFS), defined as time from confirmatory biopsy to grade group reclassification (GGR) on repeat biopsy or prostatectomy. Optimal cut-point for TCLo density was predefined in a previously reported cohort and applied to this contemporary cohort. Kaplan-Meier and multivariable Cox regression analysis were used to estimate the association of predictors with PFS. RESULTS During median follow-up of 7.8 years, (IQR 7.3-8.2) 34 men had GGR. Using previously defined cut-points, PFS at 5-years was 60% (95% CI: 44%-81%) vs. 89% (95% CI: 83%-96%) in men with high (≥0.06 ml-1) vs. low (<0.06 ml-1) TCLo density, and 63% (95% CI: 48%-82%) vs. 90% (95% CI: 83%-96%) in men with high (≥3) vs. low (≤2) TCLo (log-rank test: P < 0.0001, respectively). Adjusting for age, prostate volume, percent of positive cores and PSA, both higher TCLo density (HR [per 0.01 ml-1 increase]: 1.18, 95% CI: 1.05-1.33, P = 0.005) and TCLo (HR: 1.69, 95% CI: 1.20-2.38, P = 0.002) were associated with shorter PFS. CONCLUSION The previously suggested prognostic value of TCLo density was confirmed in this validation cohort. TCLo alone performed similarly well. Patients with high TCLo density (≥0.06 ml-1) or TCLo (>2) were at greater risk of GGR while on AS. With external validation, these metric may help guide risk-adapted surveillance protocols.
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Affiliation(s)
- Guan Hee Tan
- University Health Network, Sprott Department of Surgery, Division of Urology, University of Toronto, Toronto, Canada; Sunway Medical Centre, Bandar Sunway, Selangor, Malaysia
| | - Dominik Deniffel
- Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Germany; Joint Department of Medical Imaging, University Health Network, Sinai Health System and University of Toronto, ON, Canada
| | - Antonio Finelli
- University Health Network, Sprott Department of Surgery, Division of Urology, University of Toronto, Toronto, Canada
| | - Marian Wettstein
- University Health Network, Sprott Department of Surgery, Division of Urology, University of Toronto, Toronto, Canada
| | - Ardalan Ahmad
- University Health Network, Sprott Department of Surgery, Division of Urology, University of Toronto, Toronto, Canada
| | - Alexandre Zlotta
- University Health Network, Sprott Department of Surgery, Division of Urology, University of Toronto, Toronto, Canada; Division of Urology, Sinai Health System, Toronto, Canada
| | - Neil Fleshner
- University Health Network, Sprott Department of Surgery, Division of Urology, University of Toronto, Toronto, Canada
| | - Robert Hamilton
- University Health Network, Sprott Department of Surgery, Division of Urology, University of Toronto, Toronto, Canada
| | - Girish Kulkarni
- University Health Network, Sprott Department of Surgery, Division of Urology, University of Toronto, Toronto, Canada
| | - Gregory Nason
- University Health Network, Sprott Department of Surgery, Division of Urology, University of Toronto, Toronto, Canada
| | - Khaled Ajib
- University Health Network, Sprott Department of Surgery, Division of Urology, University of Toronto, Toronto, Canada
| | - Jaime Herrera-Caceres
- University Health Network, Sprott Department of Surgery, Division of Urology, University of Toronto, Toronto, Canada
| | | | - Nathan Perlis
- University Health Network, Sprott Department of Surgery, Division of Urology, University of Toronto, Toronto, Canada.
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11
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Heidegger I, Hamdy FC, van den Bergh RCN, Heidenreich A, Sedelaar M, Roupret M. Intermediate-risk Prostate Cancer-A Sheep in Wolf's Clothing? Eur Urol Oncol 2023; 6:103-109. [PMID: 34305038 DOI: 10.1016/j.euo.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/23/2021] [Accepted: 07/07/2021] [Indexed: 11/16/2022]
Abstract
This case-based discussion describes a 65-year-old man newly diagnosed with International Society of Urological Pathology (ISUP) grade 2 prostate cancer (PCa). According to the European Association of Urology classification system, the patient harbors an intermediate-risk cancer. In step-by step discussion, we elaborate guideline-based treatment modalities for intermediate-risk PCa focused on debating active surveillance versus active treatment. Thereby, we discuss the importance of patient characteristics, including age, hereditary factors, life expectancy and comorbidity status, findings of multiparametric magnetic resonance imaging, as well as prostate-specific antigen (PSA) density and PSA kinetics, in predicting the clinical course of the disease. In addition, we focus on cribriform pathology as a predictor of adverse outcomes and critically discuss its relevance in patient management. Lastly, we outline genomic stratification in ISUP 2 cancer as a future tool to predict PCa aggressiveness. PATIENT SUMMARY: Based on current guidelines, patients with intermediate-risk prostate cancer are treated actively or can alternatively undergo an active surveillance approach when favorable risk factors are present. One major issue is to discriminate between patients who benefit from an active therapy approach and those who benefit from a deferred treatment. Therefore, reliable biomarkers and early predictors of disease progression are needed urgently.
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Affiliation(s)
- Isabel Heidegger
- Department of Urology, Medical University Innsbruck, Innsbruck, Austria.
| | - Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - Axel Heidenreich
- Department of Urology, Uro-Oncology, Robot Assisted and Reconstructive Urologic Surgery, University Hospital Cologne, Cologne, Germany; Department of Urology, Medical University Vienna, Vienna, Austria
| | - Michiel Sedelaar
- Department of Urology, Radboud University, Medical Center, Nijmegen, The Netherlands
| | - Morgan Roupret
- Sorbonne Université, Urology Department, Hôpital Pitié-Salpêtrière, Paris, France
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12
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Kesch C, Pantea V, Soeterik T, Marquis A, la Bombarda G, Morlacco A, Barletta F, Radtke JP, Darr C, Preisser F, Zattoni F, Marra G, van den Bergh RCN, Hadaschik B, Gandaglia G. Risk and predictors of adverse pathology after radical prostatectomy in patients diagnosed with IUSP 1-2 prostate cancer at MRI-targeted biopsy: a multicenter analysis. World J Urol 2023; 41:427-434. [PMID: 36534151 PMCID: PMC9947075 DOI: 10.1007/s00345-022-04236-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 11/25/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Although active surveillance (AS) is recommended for low- to favorable intermediate-risk prostate cancer (PCa), risk of upgrading at radical prostatectomy (RP) is not negligible. Available studies based on systematic transrectal ultrasound biopsy might not be applicable to contemporary cohorts diagnosed with MRI-targeted biopsy (TB). The aim of the present study is to explore rates and risk factors for adverse outcomes (AO) at RP in patients with ISUP ≤ 2 PCa detected at TB with concomitant systematic biopsy (SB). METHODS Multicenter, retrospective analysis of 475 consecutive patients with ISUP ≤ 2 PCa at MRI-TB + SB is treated with RP. AO were defined as ISUP upgrading, adverse pathology (upgrading to ISUP ≥ 3 and/or ≥ pT3 at RP, and/or pN1) (AP) or biochemical recurrence (BCR) in men with follow-up (n = 327). RESULTS The rate of ISUP upgrading, upgrading ≥ 3, and AP were 39%, 21%, and 43%. Compared to ISUP2, men with ISUP1 PCa had a higher rate of overall upgrading (27 vs. 67%, p < 0.001), but less upgrading to ≥ 3 (27 vs. 10%, p < 0.001). AP was more common when ISUP2 was detected with a combined MRI-TB + SB approach compared to considering TB (p = 0.02) or SB (p = 0.01) alone. PSA, PSA density, PI-RADS, ISUP at TB, overall biopsy ISUP and EAU classification were predictors of upgrading to ISUP ≥ 3 and AP. The 1 year BCR-free survival was 94% with no differences in BCR rates between subgroups. CONCLUSION Upgrading in ISUP ≤ 2 PCa remains prevalent even in men diagnosed in the MRI era. The use of MRI-TB with concomitant SB allows for the accurate identification of ISUP2 PCa and predicts the risk of AO at RP.
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Affiliation(s)
- Claudia Kesch
- Department of Urology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany.
| | - Vlad Pantea
- Department of Urology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Timo Soeterik
- Department of Urology, St. Antonius Hospital, Nieuwegein-Utrecht, The Netherlands
| | - Alessandro Marquis
- Department of Urology, San Giovanni Battista Hospital, Città della Salute e della Scienza and University of Turin, Turin, Italy
| | - Giulia la Bombarda
- Department of Surgery, Oncology and Gastroenterology, Urology Clinic, University of Padova, Padua, Italy
| | - Allesandro Morlacco
- Department of Surgery, Oncology and Gastroenterology, Urology Clinic, University of Padova, Padua, Italy
| | - Francesco Barletta
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Jan Philipp Radtke
- Department of Urology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Christopher Darr
- Department of Urology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Felix Preisser
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Fabio Zattoni
- Department of Surgery, Oncology and Gastroenterology, Urology Clinic, University of Padova, Padua, Italy
| | - Giancarlo Marra
- Department of Urology, San Giovanni Battista Hospital, Città della Salute e della Scienza and University of Turin, Turin, Italy
| | | | - Boris Hadaschik
- Department of Urology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Giorgio Gandaglia
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
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Porcaro AB, Panunzio A, Bianchi A, Sebben M, Gallina S, De Michele M, Orlando R, Serafin E, Mazzucato G, Vidiri S, D'Aietti D, Princiotta A, Montanaro F, Marafioti Patuzzo G, De Marco V, Brunelli M, Pagliarulo V, Cerruto MA, Tafuri A, Antonelli A. Prognostic Impact and Clinical Implications of Unfavorable Upgrading in Low-Risk Prostate Cancer after Robot-Assisted Radical Prostatectomy: Results of a Single Tertiary Referral Center. Cancers (Basel) 2022; 14:cancers14246055. [PMID: 36551541 PMCID: PMC9776665 DOI: 10.3390/cancers14246055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022] Open
Abstract
Objective: to evaluate predictors and the prognostic impact of favorable vs. unfavorable tumor upgrading among low-risk prostate cancer (LR PCa) patients treated with robot-assisted radical prostatectomy (RARP). Methods: From January 2013 to October 2020, LR PCa patients treated with RARP at our institution were identified. Unfavorable tumor upgrading was defined as the presence of an International Society of Urological Pathology (ISUP) grade group at final pathology > 2. Disease relapse was coded as biochemical recurrence and/or local recurrence and/or presence of distant metastases. Regression analyses tested the association between clinical and pathological features and the risk of unfavorable tumor upgrading and disease relapse. Results: Of the 237 total LR PCa patients, 60 (25.3%) harbored unfavorable tumor upgrading. Disease relapse occurred in 20 (8.4%) patients. Unfavorable upgrading represented an independent predictor of disease relapse, even after adjustment for other clinical and pathological variables. Conversely, favorable tumor upgrading did not show any statistically significant association with PCa relapse. Unfavorable tumor upgrading was associated with tumors being larger (OR: 1.03; p = 0.031), tumors extending beyond the gland (OR: 8.54, p < 0.001), age (OR: 1.07, p = 0.009), and PSA density (PSAD) ≥ 0.15 ng/mL/cc (OR: 1.07, p = 0.009). Conclusions: LR PCa patients with unfavorable upgrading at final pathology were more likely to be older, to have PSAD ≥ 0.15 ng/mL/cc, and to experience disease relapse. Unfavorable tumor upgrading is an issue to consider when counseling these patients to avoid delayed treatments, which may impair cancer-specific survival.
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Affiliation(s)
- Antonio Benito Porcaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | - Andrea Panunzio
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | - Alberto Bianchi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | - Marco Sebben
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
- Department of Urology, IRCCS Ospedale Sacro Cuore Don Calabria, 37024 Negrar, Italy
| | - Sebastian Gallina
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | - Mario De Michele
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | - Rossella Orlando
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | - Emanuele Serafin
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | - Giovanni Mazzucato
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | - Stefano Vidiri
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | - Damiano D'Aietti
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | - Alessandro Princiotta
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | - Francesca Montanaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | - Giulia Marafioti Patuzzo
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | - Vincenzo De Marco
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | - Matteo Brunelli
- Department of Pathology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | | | - Maria Angela Cerruto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | | | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
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Fallara G, Fankhauser CD, Martini A. Comment on: "Improving the stratification of intermediate risk prostate cancer". Minerva Urol Nephrol 2022; 74:819-821. [PMID: 36629816 DOI: 10.23736/s2724-6051.22.05209-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Giuseppe Fallara
- Unit of Urology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy.,Department of Urology, University College London Hospital, London, UK
| | | | - Alberto Martini
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA -
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15
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Tsaur I, van den Bergh RCN, Soeterik T, Thomas A, Brandt MP, Zattoni F, Dal Moro F, Morlacco A, Collavino J, Ploussard G, Surcel C, Mirvald C, Carmona O, Rosenzweig B, Ruckes C, Heisinger T, Heidegger I, Gandaglia G, Dotzauer R. Predictors of Unfavorable Pathology in Patients with Incidental (pT1a-T1b) Prostate Cancer. Eur Urol Focus 2022; 8:1599-1606. [PMID: 35317972 DOI: 10.1016/j.euf.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/23/2022] [Accepted: 03/08/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Incidental prostate cancer (IPCa) is encountered in 10% of surgical procedures for benign prostatic obstruction (BPO). Identification of patients with underlying detrimental prostate cancer is paramount for tailored treatment decision-making, but guideline recommendations for this setting are lacking. OBJECTIVE To highlight clinical and histological characteristics related to BPO surgery that may predict IPCa with unfavorable pathology. DESIGN, SETTING, AND PARTICIPANTS We included men with IPCa who underwent radical prostatectomy (RP) in the short term after IPCa diagnosis. Two cohorts were built according to final pathology for the RP specimen: unfavorable pathology (International Society of Urological Pathology [ISUP] grade group [GG] ≥3 and/or ≥pT3a and/or pN1) versus favorable pathology. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We performed multivariate regression analysis for the endpoint, which was unfavorable pathology for the RP specimen. Using the model estimates for prostate-specific antigen (PSA), ISUP GG, age, and prostate volume, we established a model for estimating the risk of unfavorable histopathology. RESULTS AND LIMITATIONS Overall, 112 patients were included in the final assessment. On multivariate analysis, PSA (odds ratio [OR] 1.083, 95% confidence interval [CI] 1.003-1.170; p = 0.042), ISUP GG for the specimen from BPO surgery (OR 3.090; 95% CI 1.129-8.457; p = 0.028), and age (OR 1.121, 95% CI 1.026-1.225; p = 0.012) were independent predictors for unfavorable histopathology. On receiver operating characteristic analysis, the area under the curve was 0.751. A novel calculator was developed to predict adverse pathology for men with IPCa. The study is limited by its retrospective design. CONCLUSIONS For men with IPCa, PSA before surgery for BPO, ISUP GG, and age are independent predictors of unfavorable disease. Our results might improve preoperative risk assessment for patient counseling. PATIENT SUMMARY We developed a novel calculator to estimate the risk of underlying detrimental disease in men diagnosed with prostate cancer at surgery for benign prostatic obstruction.
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Affiliation(s)
- Igor Tsaur
- Department of Urology and Pediatric Urology, University Medicine Mainz, Mainz, Germany.
| | | | - Timo Soeterik
- Department of Urology, St Antonius Hospital, Utrecht, The Netherlands
| | - Anita Thomas
- Department of Urology and Pediatric Urology, University Medicine Mainz, Mainz, Germany
| | - Maximilian P Brandt
- Department of Urology and Pediatric Urology, University Medicine Mainz, Mainz, Germany
| | - Fabio Zattoni
- Department Surgery, Oncology and Gastroenterology, Urologic Unit, University of Padua, Padua, Italy
| | - Fabrizio Dal Moro
- Department Surgery, Oncology and Gastroenterology, Urologic Unit, University of Padua, Padua, Italy
| | - Alessandro Morlacco
- Department Surgery, Oncology and Gastroenterology, Urologic Unit, University of Padua, Padua, Italy
| | - Jeanlou Collavino
- Department Surgery, Oncology and Gastroenterology, Urologic Unit, University of Padua, Padua, Italy
| | - Guillaume Ploussard
- Department of Urology, La Croix du Sud Hospital, Toulouse, France; Institut Universitaire du Cancer Toulouse-Oncopole, Toulouse, France
| | - Christian Surcel
- Center of Urologic Surgery, Dialysis and Renal Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Christian Mirvald
- Center of Urologic Surgery, Dialysis and Renal Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Orel Carmona
- Department of Urology, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Barak Rosenzweig
- Department of Urology, Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Christian Ruckes
- Interdisciplinary Centre for Clinical Trials, University Medical Centre, Johannes Gutenberg University, Mainz, Germany
| | - Tatjana Heisinger
- Department of Urology, Medical University Innsbruck, Innsbruck, Austria
| | - Isabel Heidegger
- Department of Urology, Medical University Innsbruck, Innsbruck, Austria
| | - Giorgio Gandaglia
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Robert Dotzauer
- Department of Urology and Pediatric Urology, University Medicine Mainz, Mainz, Germany
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16
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Nocera L, Collà Ruvolo C, Stolzenbach LF, Deuker M, Tian Z, Gandaglia G, Fossati N, Abdollah F, Suardi N, Mirone V, Graefen M, Chun FK, Saad F, Montorsi F, Briganti A, Karakiewicz PI. Improving the stratification of intermediate risk prostate cancer. Minerva Urol Nephrol 2022; 74:590-598. [PMID: 33887893 DOI: 10.23736/s2724-6051.21.04314-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Intermediate risk prostate cancer (IR PCa) may exhibit a wide array of phenotypes, from favorable to unfavorable. NCCN criteria help distinguishing between favorable versus unfavorable subgroups. We studied and attempted to improve this classification. METHODS Within the SEER database 2010-2016, we identified 19,193 IR PCa patients treated with radical prostatectomy. A multivariable logistic regression model predicting unfavorable IR PCa was developed and externally validated, in addition to a head-to-head comparison with NCCN IR PCa stratification. RESULTS Model development (development cohort N.=13,436: 3585 unfavorable versus 9851 favorable) rested on age, PSA, clinical T stage, biopsy Gleason Grade Group (GGG) and percentage of positive cores. All were independent predictors of unfavorable IR PCa. In external validation cohort (N.=5757: 1652 unfavorable versus 4105 favorable), NCCN stratification was 61.8% accurate in discriminating between favorable versus unfavorable, compared to 67.6% for nomogram, which exhibited excellent calibration, less pronounced departures from ideal prediction and greater net-benefit in decision curve analyses (DCA) than NCCN stratification. The optimal nomogram cutoff misclassified 312 of 1976 patients (15.8%) versus 598 of 2877 (20.8%) for NCCN stratification. Of NCCN misclassified patients, 90.0% harbored pT3-4 stages versus 84.6% of nomogram. CONCLUSIONS The newly developed, externally validated nomogram discriminates better between favorable versus unfavorable IR PCa, according to overall accuracy, calibration, DCA, and actual numbers and stage distribution of misclassified patients.
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Affiliation(s)
- Luigi Nocera
- Unit of Cancer Prognostics and Health Outcomes, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada - .,Division of Experimental Oncology, Unit of Urology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy -
| | - Claudia Collà Ruvolo
- Unit of Cancer Prognostics and Health Outcomes, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada.,Department of Urology, University of Naples Federico II, Naples, Italy
| | - Lara F Stolzenbach
- Unit of Cancer Prognostics and Health Outcomes, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada.,Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Marina Deuker
- Unit of Cancer Prognostics and Health Outcomes, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada.,Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Zhe Tian
- Unit of Cancer Prognostics and Health Outcomes, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
| | - Giorgio Gandaglia
- Division of Experimental Oncology, Unit of Urology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Fossati
- Division of Experimental Oncology, Unit of Urology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Firas Abdollah
- Center for Outcomes Research, Analytics, and Evaluation, Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA
| | - Nazareno Suardi
- Department of Urology, IRCCS San Martino University Hospital, University of Genoa, Genoa, Italy
| | - Vincenzo Mirone
- Department of Urology, University of Naples Federico II, Naples, Italy
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Felix K Chun
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Fred Saad
- Unit of Cancer Prognostics and Health Outcomes, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
| | - Francesco Montorsi
- Division of Experimental Oncology, Unit of Urology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Briganti
- Division of Experimental Oncology, Unit of Urology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pierre I Karakiewicz
- Unit of Cancer Prognostics and Health Outcomes, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
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17
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Expanding Active Surveillance Criteria for Low- and Intermediate-risk Prostate Cancer: Can We Accurately Predict the Risk of Misclassification for Patients Diagnosed by Multiparametric Magnetic Resonance Imaging–targeted Biopsy? Eur Urol Focus 2022; 9:298-302. [PMID: 36210296 DOI: 10.1016/j.euf.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/29/2022] [Accepted: 09/23/2022] [Indexed: 11/24/2022]
Abstract
Models predicting the risk of adverse pathology (ie, International Society of Urological Pathology [ISUP] grade group ≥3, pT3, and/or pN1) among patients operated by radical prostatectomy (RP) have been proposed to expand active surveillance (AS) inclusion criteria. We aimed to test these models in a set of 1062 low-risk and favorable intermediate-risk prostate cancer (PCa) patients diagnosed by multiparametric magnetic resonance imaging (MRI) and MRI-targeted biopsy. We hypothesized that the inclusion of radiological features into a novel model would improve patient selection. Performance was assessed using discrimination, calibration, and decision curve analysis (DCA). Available models were characterized by poor discrimination (areas under the receiver operating characteristic curve [AUCs] of 59% and 60%), underestimation of predicted risk on calibration plots, and a small amount of net benefit against a probability threshold of 40-50% at the DCA. The development of a novel model slightly improved discrimination (AUC of 63% vs 59%, p = 0.001, and 63% vs 60%, p = 0.07) and net benefit against threshold probabilities of ≥30%. This first multicenter study demonstrated the poor performance of models predicting adverse pathology and that implementation of MRI and MRI-targeted biopsy in this setting was not associated with a clear improvement in patient selection. Patients harboring low-risk or favorable intermediate-risk PCa and candidates for RP cannot be referred accurately to an AS program without a non-negligible risk of misclassification. PATIENT SUMMARY: We tested prediction models that could expand the selection of prostate cancer patients for active surveillance. Models were inaccurate and associated with a high risk of misclassification despite the implementation of multiparametric magnetic resonance imaging and targeted biopsies.
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18
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Adverse upgrading and/or upstaging in contemporary low-risk prostate cancer patients. Int Urol Nephrol 2022; 54:2521-2528. [PMID: 35838831 PMCID: PMC9463257 DOI: 10.1007/s11255-022-03250-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/08/2022] [Indexed: 11/06/2022]
Abstract
Background Upgrading and/or upstaging in low-risk prostate cancer (PCa) patients may represent an indication for active treatment instead of active surveillance (AS). We addressed contemporary upgrading and/or upstaging rates in a large population based-cohort of low-risk PCa patients. Materials and methods Whitin the SEER database (2010–2015), NCCN low-risk PCa patients were identified across management modalities: radical prostatectomy (RP), radiotherapy (RT) and non-local treatment (NLT). In RP patients, upgrading and/or upstaging rates were assessed in logistic regression models. Results Overall, of 27,901 low-risk PCa patients, 38% underwent RP vs 28% RT vs 34% NLT. RP patients were the youngest and harbored the highest percentage of positive cores and a higher rate of cT2a than NLT. At RP, 46.2% were upgraded to GGG ≥ 2, 6.0% to GGG ≥ 3 and 10.5% harbored nonorgan-confined stage (NOC, pT3-4 or pN1). Of NOC patients, 1.6% harbored GGG ≥ 3, 6.3% harbored GGG2 and 2.6% harbored GGG1. Of pT2 patients, 4.4% harbored GGG ≥ 3, 33.9% harbored GGG2 and 51.3% harbored GGG1. Age, PSA, percentage of positive cores and number of positive cores independently predicted the presence of NOC and/or GGG ≥ 3, but with low accuracy (63.9%). Conclusions In low-risk PCa, critical changes between tumor grade and stage at biopsy vs RP may be expected in very few patients: NOC with GGG ≥ 3 in 1.6% and NOC with GGG2 in 6.3%. Other patients with upgrading and/or upstaging combinations will invariably harbor either pT2 or GGG1 that far less critically affect PCa prognosis.
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19
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Active surveillance for intermediate-risk prostate cancer. World J Urol 2022; 40:79-86. [PMID: 35044491 DOI: 10.1007/s00345-021-03893-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/15/2021] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Active surveillance (AS) is an established approach in the management of low-risk, localized prostate cancer. While the use of AS to manage intermediate-risk (IR) disease has gradually increased over time, there remains uncertainty with regards to its safety, with only a minority of IR patients currently being managed with this approach. MATERIALS AND METHODS We conducted a narrative review based on an analysis of the literature focusing on articles describing AS for IR prostate cancer. We focus on the uncertainty surrounding AS in IR disease by discussing variations in the definitions and guideline recommendations associated with IR disease, and describing the limitations of the evidence from observational studies and randomized trials. CONCLUSION The safety of AS for IR disease remains unknown, given the lack of randomized trials and the limitations of the current observational studies. Further research is needed to identify select patients with IR prostate cancer that can be managed safely with AS.
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20
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Brinkley GJ, Fang AM, Rais-Bahrami S. Integration of magnetic resonance imaging into prostate cancer nomograms. Ther Adv Urol 2022; 14:17562872221096386. [PMID: 35586139 PMCID: PMC9109484 DOI: 10.1177/17562872221096386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/05/2022] [Indexed: 11/16/2022] Open
Abstract
The decision whether to undergo prostate biopsy must be carefully weighed. Nomograms have widely been utilized as risk calculators to improve the identification of prostate cancer by weighing several clinical factors. The recent inclusion of multiparametric magnetic resonance imaging (mpMRI) findings into nomograms has drastically improved their nomogram's accuracy at identifying clinically significant prostate cancer. Several novel nomograms have incorporated mpMRI to aid in the decision-making process in proceeding with a prostate biopsy in patients who are biopsy-naïve, have a prior negative biopsy, or are on active surveillance. Furthermore, novel nomograms have incorporated mpMRI to aid in treatment planning of definitive therapy. This literature review highlights how the inclusion of mpMRI into prostate cancer nomograms has improved upon their performance, potentially reduce unnecessary procedures, and enhance the individual risk assessment by improving confidence in clinical decision-making by both patients and their care providers.
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Affiliation(s)
- Garrett J Brinkley
- Heersink School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew M Fang
- Department of Urology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Soroush Rais-Bahrami
- Department of Urology, The University of Alabama at Birmingham, Faculty Office Tower 1107, 510 20th Street South, Birmingham, AL 35294, USA
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21
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Lantz A, Falagario UG, Ratnani P, Jambor I, Dovey Z, Martini A, Lewis S, Lundon D, Nair S, Phillip D, Haines K, Cormio L, Carrieri G, Kryprianou N, Tewari A. Expanding Active Surveillance Inclusion Criteria: A Novel Nomogram Including Preoperative Clinical Parameters and Magnetic Resonance Imaging Findings. Eur Urol Oncol 2020; 5:187-194. [DOI: 10.1016/j.euo.2020.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/20/2020] [Accepted: 08/10/2020] [Indexed: 01/01/2023]
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22
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Luzzago S, de Cobelli O, Cozzi G, Peveri G, Bagnardi V, Catellani M, Di Trapani E, Mistretta FA, Pricolo P, Conti A, Alessi S, Marvaso G, Ferro M, Matei DV, Renne G, Jereczek-Fossa BA, Petralia G, Musi G. A novel nomogram to identify candidates for active surveillance amongst patients with International Society of Urological Pathology (ISUP) Grade Group (GG) 1 or ISUP GG2 prostate cancer, according to multiparametric magnetic resonance imaging findings. BJU Int 2020; 126:104-113. [PMID: 32150328 DOI: 10.1111/bju.15048] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To develop a novel nomogram to identify candidates for active surveillance (AS) that combines clinical, biopsy and multiparametric magnetic resonance imaging (mpMRI) findings; and to compare its predictive accuracy to, respectively: (i) Prostate Cancer Research International: Active Surveillance (PRIAS) criteria, (ii) Johns Hopkins (JH) criteria, (iii) European Association of Urology (EAU) low-risk classification, and (iv) EAU low-risk or low-volume with International Society of Urological Pathology (ISUP) Grade Group (GG) 2 classification. PATIENTS AND METHODS We selected 1837 patients with ISUP GG1 or GG2 prostate cancer (PCa), treated with radical prostatectomy (RP) between 2012 and 2018. The outcome of interest was the presence of unfavourable disease (i.e., clinically significant PCa [csPCa]) at RP, defined as: ISUP GG ≥ 3 and/or pathological T stage (pT) ≥3a and/or pathological N stage (pN) 1. First, logistic regression models including PRIAS, JH, EAU low-risk, and EAU low-risk or low-volume ISUP GG2 binary classifications (not eligible vs eligible) were used. Second, a multivariable logistic regression model including age, prostate-specific antigen density (PSA-D), ISUP GG, and the percentage of positive cores (Model 1) was fitted. Third, Prostate Imaging-Reporting and Data System (PI-RADS) score (Model 2), extracapsular extension (ECE) score (Model 3) and PI-RADS + ECE score (Model 4) were added to Model 1. Only variables associated with higher csPCa rates in Model 4 were retained in the final simplified Model 5. The area under the receiver operating characteristic curve (AUC), calibration plots and decision curve analyses were used. RESULTS Of the 1837 patients, 775 (42.2%) had csPCa at RP. Overall, 837 (47.5%), 986 (53.7%), 348 (18.9%), and 209 (11.4%) patients were eligible for AS according to, respectively, the EAU low-risk, EAU low-risk or low-volume ISUP GG2, PRIAS, and JH criteria. The proportion of csPCa amongst the EAU low-risk, EAU low-risk or low-volume ISUP GG2, PRIAS and JH candidates was, respectively 28.5%, 29.3%, 25.6% and 17.2%. Model 4 and Model 5 (in which only PSA-D, ISUP GG, PI-RADS and ECE score were retained) had a greater AUC (0.84), compared to the four proposed AS criteria (all P < 0.001). The adoption of a 25% nomogram threshold increased the proportion of AS-eligible patients from 18.9% (PRIAS) and 11.4% (JH) to 44.4%. Moreover, the same 25% nomogram threshold resulted in significantly lower estimated risks of csPCa (11.3%), compared to PRIAS (Δ: -14.3%), JH (Δ: -5.9%), EAU low-risk (Δ: -17.2%), and EAU low-risk or low-volume ISUP GG2 classifications (Δ: -18.0%). CONCLUSION The novel nomogram combining clinical, biopsy and mpMRI findings was able to increase by ~25% and 35% the absolute frequency of patients suitable for AS, compared to, respectively, the PRIAS or JH criteria. Moreover, this nomogram significantly reduced the estimated frequency of csPCa that would be recommended for AS compared to, respectively, the PRIAS, JH, EAU low-risk, and EAU low-risk or low-volume ISUP GG2 classifications.
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Affiliation(s)
- Stefano Luzzago
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy.,Università degli Studi di Milano, Milan, Italy
| | - Ottavio de Cobelli
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy.,Department of Oncology and Hematology-Oncology, Università degli Studi di Milano, Milan, Italy
| | - Gabriele Cozzi
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Giulia Peveri
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Michele Catellani
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Ettore Di Trapani
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Francesco A Mistretta
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy.,Università degli Studi di Milano, Milan, Italy
| | - Paola Pricolo
- Department of Radiology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Andrea Conti
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy.,Università degli Studi di Milano, Milan, Italy
| | - Sarah Alessi
- Department of Radiology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Giulia Marvaso
- Department of Oncology and Hematology-Oncology, Università degli Studi di Milano, Milan, Italy.,Department of Radiation Oncology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Matteo Ferro
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Deliu-Victor Matei
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Giuseppe Renne
- Department of Pathology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Department of Oncology and Hematology-Oncology, Università degli Studi di Milano, Milan, Italy.,Department of Radiation Oncology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Giuseppe Petralia
- Department of Oncology and Hematology-Oncology, Università degli Studi di Milano, Milan, Italy.,Precision Imaging and Research Unit, Department of Medical Imaging and Radiation Sciences, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Gennaro Musi
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy
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23
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Sanguedolce F, Falagario UG, Castellan P, Di Nauta M, Silecchia G, Bruno SM, Russo D, Treacy PJ, Tewari AK, Montironi R, Carrieri G, Cormio L. Bioptic intraprostatic chronic inflammation predicts adverse pathology at radical prostatectomy in patients with low-grade prostate cancer. Urol Oncol 2020; 38:793.e19-793.e25. [PMID: 32220548 DOI: 10.1016/j.urolonc.2020.02.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 02/02/2020] [Accepted: 02/22/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE To determine the potential role of bioptic inflammation (Irani score) in predicting adverse pathology (AP) at radical prostatectomy (RP) in patients with low-grade (ISUP Gleason Group [ISUP GG] 1 and 2) prostate cancer (CaP). METHODS After institutional review board-approval, we identified patients who underwent prostate biopsy, had bioptic Irani score assessment, were diagnosed with low-grade CaP (ISUP GG 1-2, prostate-specific antigen [PSA] <20 ng/ml), and underwent RP. The impact of standard clinicopathological variables and bioptic Irani Score (G = grade and A = aggressiveness) on AP at RP, defined as stage ≥T3 and/or ISUP GG ≥3, was assessed by univariate and multivariate logistic regression analysis. RESULTS A total of 282 patients were eligible for this study. AP at RP occurred in 37 of 214 (17.3%) patients with ISUP GG 1, and 26 of 68 (38.2%) with ISUP GG 2. At univariate analysis, serum PSA, PSA density, bioptic ISUP GG, number of positive cores, total percentage of core involvement and Irani G score emerged as significant risk factors of AP. At multivariate analysis, however, only PSA density, bioptic ISUP GG, total percentage of core, and Irani G score kept statistical significance. The area under the curve for the resulting model was 0.75. CONCLUSIONS This is the first study demonstrating that low-grade inflammation is associated with a significantly increased risk of AP at RP. These findings would support the concept of prostatic inflammation being inversely correlated with presence and aggressiveness of CaP. Further studies are needed to externally validate the role of this readily available parameter in the decision-making process of patients with low-grade CaP.
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Affiliation(s)
| | - Ugo Giovanni Falagario
- Department of Urology and Organ Transplantation, University of Foggia, Foggia, Italy; Department of Urology, Icahn school of medicine at Mount Sinai, New York City, NY.
| | | | - Michele Di Nauta
- Department of Urology and Organ Transplantation, University of Foggia, Foggia, Italy
| | - Giovanni Silecchia
- Department of Urology and Organ Transplantation, University of Foggia, Foggia, Italy
| | - Salvatore M Bruno
- Department of Urology and Organ Transplantation, University of Foggia, Foggia, Italy
| | - Davide Russo
- Department of Pathology, University of Foggia, Foggia, Italy
| | | | - Ashutosh K Tewari
- Department of Urology, Icahn school of medicine at Mount Sinai, New York City, NY
| | - Rodolfo Montironi
- Institute of Pathological Anatomy and Histopathology, School of Medicine, Polytechnic University of the Marche Region (Ancona), United Hospitals, Ancona, Italy
| | - Giuseppe Carrieri
- Department of Urology and Organ Transplantation, University of Foggia, Foggia, Italy
| | - Luigi Cormio
- Department of Urology and Organ Transplantation, University of Foggia, Foggia, Italy
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24
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Herlemann A, Huang HC, Alam R, Tosoian JJ, Kim HL, Klein EA, Simko JP, Chan JM, Lane BR, Davis JW, Davicioni E, Feng FY, McCue P, Kim H, Den RB, Bismar TA, Carroll PR, Cooperberg MR. Decipher identifies men with otherwise clinically favorable-intermediate risk disease who may not be good candidates for active surveillance. Prostate Cancer Prostatic Dis 2020; 23:136-143. [PMID: 31455846 PMCID: PMC8076042 DOI: 10.1038/s41391-019-0167-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/17/2019] [Accepted: 07/22/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND We aimed to validate Decipher to predict adverse pathology (AP) at radical prostatectomy (RP) in men with National Comprehensive Cancer Network (NCCN) favorable-intermediate risk (F-IR) prostate cancer (PCa), and to better select F-IR candidates for active surveillance (AS). METHODS In all, 647 patients diagnosed with NCCN very low/low risk (VL/LR) or F-IR prostate cancer were identified from a multi-institutional PCa biopsy database; all underwent RP with complete postoperative clinicopathological information and Decipher genomic risk scores. The performance of all risk assessment tools was evaluated using logistic regression model for the endpoint of AP, defined as grade group 3-5, pT3b or higher, or lymph node invasion. RESULTS The median age was 61 years (interquartile range 56-66) for 220 patients with NCCN F-IR disease, 53% classified as low-risk by Cancer of the Prostate Risk Assessment (CAPRA 0-2) and 47% as intermediate-risk (CAPRA 3-5). Decipher classified 79%, 13% and 8% of men as low-, intermediate- and high-risk with 13%, 10%, and 41% rate of AP, respectively. Decipher was an independent predictor of AP with an odds ratio of 1.34 per 0.1 unit increased (p value = 0.002) and remained significant when adjusting by CAPRA. Notably, F-IR with Decipher low or intermediate score did not associate with significantly higher odds of AP compared to VL/LR. CONCLUSIONS NCCN risk groups, including F-IR, are highly heterogeneous and should be replaced with multivariable risk-stratification. In particular, incorporating Decipher may be useful for safely expanding the use of AS in this patient population.
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Affiliation(s)
- Annika Herlemann
- Department of Urology, University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- Department of Urology, Ludwig-Maximilians-University Munich, Munich, Germany
| | | | - Ridwan Alam
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | - Hyung L Kim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric A Klein
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jeffry P Simko
- Department of Urology, University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - June M Chan
- Department of Urology, University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Brian R Lane
- Urology, Spectrum Health Hospitals Prostate and Genitourinary Cancer Multispecialty Clinic, Grand Rapids, MI, USA
| | - John W Davis
- Department of Urology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Felix Y Feng
- Department of Urology, University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Peter McCue
- Department of Pathology, Anatomy and Cell, Thomas Jefferson University, Philadelphia, PA, USA
| | - Hyun Kim
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
- Department of Radiation Oncology, Washington University School of Medicine St. Louis, St. Louis, MO, USA
| | - Robert B Den
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Tarek A Bismar
- Departments of Pathology & Laboratory Medicine and Oncology, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Peter R Carroll
- Department of Urology, University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Matthew R Cooperberg
- Department of Urology, University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA.
- Department of Epidemiology and Biostatistics, University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA.
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25
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Confirmatory multiparametric magnetic resonance imaging at recruitment confers prolonged stay in active surveillance and decreases the rate of upgrading at follow-up. Prostate Cancer Prostatic Dis 2020; 23:94-101. [PMID: 31249386 DOI: 10.1038/s41391-019-0160-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/06/2019] [Accepted: 05/12/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND To understand the value of multiparametric magnetic resonance imaging (mpMRI) and targeted biopsies at recruitment on active surveillance (AS) outcomes. MATERIALS AND METHODS This retrospective single-center study enrolled two cohorts of 206 and 310 patients in AS. The latter group was submitted to mpMRI and targeted biopsies at recruitment. Kaplan-meier curves quantified progression-free survival (PFS) and Bioptic-PFS (B-PFS: no upgrading or >3 positive cores) in the two cohorts. Cox-regression analyses tested independent predictors of PFS and B-PFS. In patients submitted to radical prostatectomy (RP) after AS, significant cancer (csPCa) was defined as: GS ≥ 4 + 3 and/or pT ≥ 3a and/or pN+ . Logistic-regression analyses predicted csPCa at RP. RESULTS AND LIMITATIONS Median time follow-up and median time of persistence in AS were 46 (24-70) and 36 (23-58) months, respectively. Patients submitted to mpMRI at AS begin, showed greater PFS at 1- (98% vs. 91%), 3- (80% vs. 57%), and 5-years (70% vs. 35%) follow-up, respectively (all p < 0.01). At Cox-regression analysis only confirmatory mpMRI± targeted biopsy (HR: 0.3; 95% CI 0.2-0.5; p < 0.01) at AS begin was an independent predictor of PFS. Globally, 50 (16%) vs. 128 (62%) and 26 (8.5%) vs. 64 (31%) [all p < 0.01] men in the two groups experienced any-cause and bioptic AS discontinuation, respectively. Patients submitted to confirmatory mpMRI experienced greater 1-(98% vs. 93%), 3-(90% vs. 75%), and 5-years (83% vs. 56%) B-PFS, respectively (all p < 0.01). At Cox-regression analysis, mpMRI±-targeted biopsy at AS begin was associated with B-PFS (HR: 0.3; 95% CI 0.2-0.6; p < 0.01). No differences were recorded in csPCa rates between the two groups (22% vs. 28%; p = 0.47). Limitations of the study are the single-center retrospective nature and the absence of long-term follow-up. CONCLUSIONS Confirmatory mpMRI±-targeted biopsies are associated with higher PFS and B-PFS during AS. However, a non-negligible percentage of patients experience csPCa after switching to active treatment.
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26
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Active surveillance eligibility of MRI-positive patients with grade group 2 prostate cancer: a pathological study. World J Urol 2019; 38:1735-1740. [DOI: 10.1007/s00345-019-02973-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 09/27/2019] [Indexed: 02/01/2023] Open
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27
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Ploussard G, Beauval JB, Lesourd M, Almeras C, Assoun J, Aziza R, Gautier JR, Loison G, Portalez D, Salin A, Tollon C, Soulié M, Malavaud B, Roumiguié M. Performance of systematic, MRI-targeted biopsies alone or in combination for the prediction of unfavourable disease in MRI-positive low-risk prostate cancer patients eligible for active surveillance. World J Urol 2019; 38:663-671. [PMID: 31197523 DOI: 10.1007/s00345-019-02848-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 06/07/2019] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To assess the upstaging/upgrading rates of low-risk prostate cancer (PCa) according to the biopsy scheme used (systematic (SB), targeted biopsies (TB), or both) in the setting of positive pre-biopsy MRI. PATIENTS AND METHODS We included 143 consecutive men fulfilling the Toronto University active surveillance (AS) criteria who underwent a pre-biopsy positive MRI, a combination of SB and software-based fusion TB, and a radical prostatectomy, in two expert centres. The primary endpoints were the pathological upgrading and upstaging rates. Overall unfavourable disease (OUD) was defined by any pT3-4 and/or pN1 and/or ≥ GG 3. RESULTS Using TB alone would have missed 21.7% of cancers including 16.7% of ≥ GG 3. The use of TB was significantly associated with a lower risk of ≥ Grade Group (GG) 3 disease (p < 0.006) in RP specimens. Combination of SB and TB lowered this risk by 39%, compared with TB alone. The biopsy scheme did not affect the upstaging rates which were substantial even in case of combination scheme (from 37 to 46%). OUD was detected in approximately 50% of cases. The presence of high grade on TB was the only independent predictive factor for both ≥ GG 2 (p = 0.015) and ≥ GG 3 (p = 0.023) in RP specimens. CONCLUSIONS High grade on TB biopsies represented the major predictor of upgrading. Combination of SB and TB better defined the sub-group of patients having the lowest risk of reclassification, compared with TB or SB alone. The risk of non-organ-confined disease remained high, and could not be accurately predicted by MRI or systematic/targeted biopsy features.
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Affiliation(s)
- Guillaume Ploussard
- Department of Urology, La Croix du Sud Hospital, IUCT-O, Toulouse, 52, chemin de Ribaute, 31130, Quint Fonsegrives, France. .,Department of Urology, Institut Universitaire du Cancer Toulouse, Oncopole, Toulouse, France.
| | | | - Marine Lesourd
- Department of Urology, Institut Universitaire du Cancer Toulouse, Oncopole, Toulouse, France.,Department of Urology, CHU Toulouse, Toulouse, France
| | - Christophe Almeras
- Department of Urology, La Croix du Sud Hospital, IUCT-O, Toulouse, 52, chemin de Ribaute, 31130, Quint Fonsegrives, France
| | - Jacques Assoun
- Department of Radiology, La Croix du Sud Hospital, Quint Fonsegrives, France
| | - Richard Aziza
- Department of Radiology, Institut Universitaire du Cancer Toulouse-Oncopole, Toulouse, France
| | - Jean-Romain Gautier
- Department of Urology, La Croix du Sud Hospital, IUCT-O, Toulouse, 52, chemin de Ribaute, 31130, Quint Fonsegrives, France
| | - Guillaume Loison
- Department of Urology, La Croix du Sud Hospital, IUCT-O, Toulouse, 52, chemin de Ribaute, 31130, Quint Fonsegrives, France
| | - Daniel Portalez
- Department of Radiology, Institut Universitaire du Cancer Toulouse-Oncopole, Toulouse, France
| | - Ambroise Salin
- Department of Urology, La Croix du Sud Hospital, IUCT-O, Toulouse, 52, chemin de Ribaute, 31130, Quint Fonsegrives, France
| | - Christophe Tollon
- Department of Urology, La Croix du Sud Hospital, IUCT-O, Toulouse, 52, chemin de Ribaute, 31130, Quint Fonsegrives, France
| | - Michel Soulié
- Department of Urology, CHU Toulouse, Toulouse, France
| | - Bernard Malavaud
- Department of Urology, Institut Universitaire du Cancer Toulouse, Oncopole, Toulouse, France.,Department of Urology, CHU Toulouse, Toulouse, France
| | - Mathieu Roumiguié
- Department of Urology, Institut Universitaire du Cancer Toulouse, Oncopole, Toulouse, France.,Department of Urology, CHU Toulouse, Toulouse, France
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28
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Roobol MJ. Active Surveillance for Low-risk Prostate Cancer: Will it Become Obsolete? Eur Urol 2019; 75:750-751. [DOI: 10.1016/j.eururo.2018.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/12/2018] [Indexed: 11/29/2022]
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29
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Sebastianelli A, Morselli S, Vitelli FD, Gabellini L, Tasso G, Venturini S, Cito G, Vignolini G, Raspollini MR, Gacci M, Serni S. The role of prostate-specific antigen density in men with low-risk prostate cancer suitable for active surveillance: results of a prospective observational study. Prostate Int 2019; 7:139-142. [PMID: 31970138 PMCID: PMC6962752 DOI: 10.1016/j.prnil.2019.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/10/2019] [Accepted: 02/14/2019] [Indexed: 01/29/2023] Open
Abstract
Background Low-risk prostate cancer (PCa) is currently managed also with active surveillance (AS). However, up to 40% of patients in AS may require radical treatment at a long-term follow-up. The aim of our study is to further investigate the role of prostate-specific antigen (PSA) density in AS. Methods A prospective observational study on PCa naïve patients with PSA<20 ng/ml submitted to prostate biopsy was conducted. Data on family history of PCa, PSA at biopsy, and digitorectal examination were collected. Prostate volume was calculated during TRUS. Bioptic cores number, Gleason Score, and International Society of Urological Pathology (ISUP) Grade Group were recorded. Patients who subsequently underwent radical prostatectomy (RP) were selected and stratified in low, intermediate, and high Risk based on the D'Amico risk classification at biopsy and after RP. Results A total of 746 patients were enrolled. PCa was found in 320 patients (42.9%), of whom 252 underwent RP (78.8% of positive biopsies). At biopsy, patients were stratified based on the D'Amico risk classification in low, intermediate, and high risk and were 20.6%, 66.7%, and 12.7%, respectively. Definitive pathology after RP showed PCa change in the risk group in 52.4% of patients (n = 132) and PCa upgrading in 46.8% of patients (n = 118). At Student t test and logistic regression, PSA density was significantly correlated with change in the risk group and upgrading in low-risk PCa (p = 0.024) with an age adjusted odds ratio of 10.01 and 7.53, respectively. Conclusion PSA density is a strong instrument in AS to decide whether to treat. However, further larger studies are needed to strongly assess this correlation.
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Affiliation(s)
| | - Simone Morselli
- Department of Urology, Careggi University Hospital, Florence, Italy
- Corresponding author. Largo Brambilla, 3, 50134 Florence, FI, Italy.
| | | | - Linda Gabellini
- Department of Urology, Careggi University Hospital, Florence, Italy
| | - Giovanni Tasso
- Department of Urology, Careggi University Hospital, Florence, Italy
| | | | - Gianmartin Cito
- Department of Urology, Careggi University Hospital, Florence, Italy
| | | | | | - Mauro Gacci
- Department of Urology, Careggi University Hospital, Florence, Italy
| | - Sergio Serni
- Department of Urology, Careggi University Hospital, Florence, Italy
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