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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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Akcay K, Kibar A, Sahin OE, Demirbilek M, Beydagi G, Asa S, Aghazada F, Toklu T, Selcuk NA, Onal B, Kabasakal L. Prediction of clinically significant prostate cancer by [ 68 Ga]Ga-PSMA-11 PET/CT: a potential tool for selecting patients for active surveillance. Eur J Nucl Med Mol Imaging 2024; 51:1467-1475. [PMID: 38112777 DOI: 10.1007/s00259-023-06556-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 11/30/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE In our study, our aim was to investigate the role of [68 Ga]Ga-PSMA-11 PET /CT imaging in the diagnosis of clinically significant prostate cancer (csPCa) (ISUP GG 2 and higher) in patients initially diagnosed with ISUP GG 1 and 2 after prostate biopsy. MATERIALS AND METHODS We retrospectively reviewed 147 patient records in whom [68 Ga]Ga-PSMA-11 PET/CT imaging was performed preoperatively. All patients were initially diagnosed with ISUP GG 1 and 2 PCa by biopsy. Final pathology reports were obtained after radical prostatectomy. The [68 Ga]Ga-PSMA-11 PET/CT images were evaluated to determine the PRIMARY score. Patients' mpMRI-PIRADS scores were also recorded when available and analyzed in correlation with the pathology results. RESULTS For the 114 patients scored using PRIMARY, 19 out of 37 patients with scores of 1 and 2 (51%) were diagnosed with csPCa. Of the 77 patients with PRIMARY scores between 3 and 5, 64 (83%) had csPCa. Notably, every patient with a PRIMARY score of 5 had csPCa. PRIMARY scoring had a sensitivity of 77% and specificity of 58%, with a positive predictive value of 83%. A moderate correlation was observed between PRIMARY scores and ISUP GG (Rho = 0.54, p < 0.001). In contrast, the PIRADS score displayed a sensitivity and specificity of 86% and 25% respectively, with a positive predictive value of 68%. No substantial correlation was found between PIRADS and ISUP GG. Statistical analysis revealed a significant correlation between PRIMARY and ISUP GG (p < 0.001), but not between PIRADS and ISUP GG (p = 0.281). Comparatively, PRIMARY scoring was significantly more reliable than PIRADS scoring in identifying csPCa. CONCLUSION [68 Ga]Ga-PSMA-11 PET/CT imaging is promising for distinguishing high-risk prostate cancer patients from those apt for active surveillance, potentially aiding in the identification of csPCa.
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Affiliation(s)
- Kaan Akcay
- Department of Nuclear Medicine, Yeditepe University Medical Faculty, Koşuyolu Mah. Koşuyolu Cad. No: 168, 34718, Kadıköy/Istanbul, Turkey
| | - Ali Kibar
- Department of Nuclear Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Fatih, Istanbul, 34098, Turkey
| | - Onur Erdem Sahin
- Department of Nuclear Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Fatih, Istanbul, 34098, Turkey
| | - Muhammet Demirbilek
- Department of Urology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Fatih, Istanbul, 34098, Turkey
| | - Gamze Beydagi
- Department of Nuclear Medicine, Yeditepe University Medical Faculty, Koşuyolu Mah. Koşuyolu Cad. No: 168, 34718, Kadıköy/Istanbul, Turkey
| | - Sertac Asa
- Department of Nuclear Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Fatih, Istanbul, 34098, Turkey
| | - Fuad Aghazada
- Department of Nuclear Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Fatih, Istanbul, 34098, Turkey
| | - Turkay Toklu
- Department of Nuclear Medicine, Yeditepe University Medical Faculty, Koşuyolu Mah. Koşuyolu Cad. No: 168, 34718, Kadıköy/Istanbul, Turkey
| | - Nalan Alan Selcuk
- Department of Nuclear Medicine, Yeditepe University Medical Faculty, Koşuyolu Mah. Koşuyolu Cad. No: 168, 34718, Kadıköy/Istanbul, Turkey
| | - Bulent Onal
- Department of Urology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Fatih, Istanbul, 34098, Turkey
| | - Levent Kabasakal
- Department of Nuclear Medicine, Yeditepe University Medical Faculty, Koşuyolu Mah. Koşuyolu Cad. No: 168, 34718, Kadıköy/Istanbul, Turkey.
- Department of Nuclear Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Fatih, Istanbul, 34098, Turkey.
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Nasri J, Barthe F, Parekh S, Ratnani P, Pedraza AM, Wagaskar VG, Olivier J, Villers A, Tewari A. Nomogram predicting adverse pathology outcome on radical prostatectomy in low-risk prostate cancer men. Urology 2022; 166:189-195. [DOI: 10.1016/j.urology.2022.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/08/2022] [Accepted: 02/21/2022] [Indexed: 10/18/2022]
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Roscigno M, Stabile A, Lughezzani G, Pepe P, Dell’Atti L, Naselli A, Naspro R, Nicolai M, La Croce G, Muhannad A, Perugini G, Guazzoni G, Montorsi F, Balzarini L, Sironi S, Da Pozzo LF. Multiparametric magnetic resonance imaging and clinical variables: Which is the best combination to predict reclassification in active surveillance patients? Prostate Int 2020; 8:167-172. [PMID: 33425794 PMCID: PMC7767935 DOI: 10.1016/j.prnil.2020.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 04/25/2020] [Accepted: 05/14/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction & objectives We tested the role of multiparametric magnetic resonance imaging (mpMRI) in disease reclassification and whether the combination of mpMRI and clinicopathological variables could represent the most accurate approach to predict the risk of reclassification during active surveillance. Materials & methods Three-hundred eighty-nine patients (pts) underwent mpMRI and subsequent confirmatory or follow-up biopsy according to the Prostate Cancer Research International Active Surveillance (PRIAS) protocol. Pts with negative (−) mpMRI underwent systematic random biopsy. Pts with positive (+) mpMRI [Prostate Imaging Reporting and Data System, version 2 (PI-RADS-V2) score ≥3] underwent targeted + systematic random biopsies. Multivariate analyses were used to create three models predicting the probability of reclassification [International Society of Urological Pathology ≥ Grade Group 2 (GG2)]: a basic model including only clinical variables (age, prostate-specific antigen density, and number of positive cores at baseline), an Magnetic resonance imaging (MRI) model including only the PI-RADS score, and a full model including both the previous ones. The predictive accuracy (PA) of each model was quantified using the area under the curve. Results mpMRI negative (−) was recorded in 127 (32.6%) pts; mpMRI positive (+) was recorded in 262 pts: 72 (18.5%) had PI-RADS 3, 150 (38.6%) PI-RADS 4, and 40 (10.3%) PI-RADS 5 lesions. At a median follow-up of 12 months, 125 pts (32%) were reclassified to GG2 prostate cancer. The rate of reclassification to GG2 prostate cancer was 17%, 35%, 38%, and 52% for mpMRI (−), PI-RADS 3, 4, and 5, respectively (P < 0.001). The PA was 69% and 64% in the basic and MRI models, respectively. The full model had the best PA of 74%: older age (P = 0.023; Odds ratio (OR) = 1.040), prostate-specific antigen density (P = 0.037; OR = 1.324), number of positive cores at baseline (P = 0.001; OR = 1.441), and PI-RADS 3, 4, and 5 (overall P = 0.001; OR = 2.458, 3.007, and 3.898, respectively) were independent predictors of reclassification. Conclusions Disease reclassification increased according to the PI-RADS score increase, at confirmatory or follow-up biopsy. However, a no-negligible rate of reclassification was found also in cases of mpMRI (−). The combination of mpMRI and clinicopathological variables still represents the most accurate approach to pts on active surveillance.
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Affiliation(s)
- Marco Roscigno
- Department of Urology, ASST Papa Giovanni XXIII, Bergamo, Italy
- Corresponding author. Dept. of Urology, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy.
| | - Armando Stabile
- Department of Urology and Division of Experimental Oncology, URI, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Lughezzani
- Department of Urology, Istituto Clinico Humanitas IRCCS-Clinical and Research Hospital, Rozzano, Italy
| | - Pietro Pepe
- Urology Unit, Cannizzaro Hospital, Catania, Italy
| | - Lucio Dell’Atti
- Department of Urology, University Hospital “Ospedali Riuniti” and Polythecnic University of Marche Region, Ancona, Italy
| | - Angelo Naselli
- Urology Department, Ospedale San Giuseppe, Gruppo Multimedica, Milan, Italy
| | - Richard Naspro
- Department of Urology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Maria Nicolai
- Department of Urology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | | | | | - Giorgio Guazzoni
- Department of Urology, Istituto Clinico Humanitas IRCCS-Clinical and Research Hospital, Rozzano, Italy
- Department of Biomedical Science, Humanitas University, Milan, Rozzano, Italy
| | - Francesco Montorsi
- Department of Urology and Division of Experimental Oncology, URI, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Balzarini
- Dept. of Radiology, Humanitas Clinical and Research Center, Humanitas University, Rozzano, Italy
| | - Sandro Sironi
- Department of Radiology, ASST Papa Giovanni XXIII, Bergamo, Italy
- University of Milano-Bicocca, School of Medicine and Surgery, Monza, Italy
| | - Luigi F. Da Pozzo
- Department of Urology, ASST Papa Giovanni XXIII, Bergamo, Italy
- University of Milano-Bicocca, School of Medicine and Surgery, Monza, Italy
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Roscigno M, Stabile A, Lughezzani G, Pepe P, Galosi AB, Naselli A, Naspro R, Nicolai M, La Croce G, Aljoulani M, Perugini G, Guazzoni G, Montorsi F, Balzarini L, Sironi S, Da Pozzo LF. The Use of Multiparametric Magnetic Resonance Imaging for Follow-up of Patients Included in Active Surveillance Protocol. Can PSA Density Discriminate Patients at Different Risk of Reclassification? Clin Genitourin Cancer 2020; 18:e698-e704. [PMID: 32493676 DOI: 10.1016/j.clgc.2020.04.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The objective of this study was to test Prostate Imaging Reporting and Data System (PI-RADS) classification on multiparametric magnetic resonance imaging (mpMRI) and MRI-derived prostate-specific antigen density (PSAD) in predicting the risk of reclassification in men in active surveillance (AS), who underwent confirmatory or per-protocol follow-up biopsy. MATERIALS AND METHODS Three hundred eighty-nine patients in AS underwent mpMRI before confirmatory or follow-up biopsy. Patients with negative (-) mpMRI underwent systematic random biopsy. Patients with positive (+) mpMRI underwent targeted fusion prostate biopsies + systematic random biopsies. Different PSAD cutoff values were tested (< 0.10, 0.10-0.20, ≥ 0.20). Multivariable analyses assessed the risk of reclassification, defined as clinically significant prostate cancer of grade group 2 or more, during follow-up according to PSAD, after adjusting for covariates. RESULTS One hundred twenty-seven (32.6%) patients had mpMRI(-); 72 (18.5%) had PI-RADS 3, 150 (38.6%) PI-RADS 4, and 40 (10.3%) PI-RADS 5 lesions. The rate of reclassification to grade group 2 PCa was 16%, 22%, 31%, and 39% for mpMRI(-) and PI-RADS 3, 4, and 5, respectively, in case of PSAD < 0.10 ng/mL2; 16%, 25%, 36%, and 44%, in case of PSAD 0.10 to 0.19 ng/mL2; and 25%, 42%, 55%, and 67% in case of PSAD ≥ 0.20 ng/mL2. PSAD ≥ 0.20 ng/mL2 (odds ratio [OR], 2.45; P = .007), PI-RADS 3 (OR, 2.47; P = .013), PI-RADS 4 (OR, 2.94; P < .001), and PI-RADS 5 (OR, 3.41; P = .004) were associated with a higher risk of reclassification. CONCLUSION PSAD ≥ 0.20 ng/mL2 may improve predictive accuracy of mpMRI results for reclassification of patients in AS, whereas PSAD < 0.10 ng/mL2 may help selection of patients at lower risk of harboring clinically significant prostate cancer. However, the risk of reclassification is not negligible at any PSAD cutoff value, also in the case of mpMRI(-).
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Affiliation(s)
- Marco Roscigno
- Department of Urology, ASST Papa Giovanni XXIII, Bergamo, Italy.
| | - Armando Stabile
- Department of Urology and Division of Experimental Oncology, URI, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Lughezzani
- Department of Urology, Istituto Clinico Humanitas IRCCS-Clinical and Research Hospital, Rozzano, Italy
| | - Pietro Pepe
- Urology Unit, Cannizzaro Hospital, Catania, Italy
| | - Andrea Benedetto Galosi
- Department of Urology, University Hospital "Ospedali Riuniti" and Polytechnic University of Marche Region, Ancona, Italy
| | - Angelo Naselli
- Urology Department, Ospedale San Giuseppe, Gruppo Multimedica, Milan, Italy
| | - Richard Naspro
- Department of Urology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Maria Nicolai
- Department of Urology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | | | | | - Giorgio Guazzoni
- Department of Urology, Istituto Clinico Humanitas IRCCS-Clinical and Research Hospital, Rozzano, Italy; Department of Biomedical Science, Humanitas University, Milan, Rozzano, Italy
| | - Francesco Montorsi
- Department of Urology and Division of Experimental Oncology, URI, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Balzarini
- Department of Radiology, Humanitas Clinical and Research Center, Humanitas University, Rozzano, Italy
| | - Sandro Sironi
- Department of Radiology, ASST Papa Giovanni XXIII, Bergamo, Italy; University of Milano-Bicocca, School of Medicine and Surgery, Monza, Italy
| | - Luigi Filippo Da Pozzo
- Department of Urology, ASST Papa Giovanni XXIII, Bergamo, Italy; University of Milano-Bicocca, School of Medicine and Surgery, Monza, Italy
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Höffkes F, Arthanareeswaran VKA, Stolzenburg JU, Ganzer R. Rate of misclassification in patients undergoing radical prostatectomy but fulfilling active surveillance criteria according to the European Association of Urology guidelines on prostate cancer: a high-volume center experience. MINERVA UROL NEFROL 2018; 70:588-593. [DOI: 10.23736/s0393-2249.18.03126-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Galgano SJ, Glaser ZA, Porter KK, Rais-Bahrami S. Role of Prostate MRI in the Setting of Active Surveillance for Prostate Cancer. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1096:49-67. [DOI: 10.1007/978-3-319-99286-0_3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Moody TE, Spraitzar CL, Eisenhart E, Tully S. The american urological association's prostate cancer screening guideline: Which cancers will be missed in average-risk men aged 40 to 54 years? Rev Urol 2017; 19:106-112. [PMID: 28959147 DOI: 10.3909/riu0748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
To determine the impact of the American Urological Association's (AUA) guideline for early detection of prostate cancer that recommends against routine screening in men aged 40 to 54 years at average risk (eg, white men without a family history of prostate cancer), we undertook a study of 973 men who previously underwent a prostate biopsy at Urology Centers of Alabama (UCA) over the 5-year period from 2010 to 2014. We retrospectively reviewed the results of the prostate biopsies performed by urologists at UCA-and, where applicable, the final surgical pathology results and compared the results by race and family history. In white men with a family history of prostate cancer, 47% had cancer and 30% had Gleason score (GS) ≥ 7 disease. In white men without a family history of prostate cancer, 32% had cancer and 23% had GS ≥ 7 disease. By comparison, in African American men with a family history of prostate cancer, 56% had cancer and 42% had GS ≥ 7 disease. In African American men without a family history, 42% had cancer and 29% had GS ≥ 7 disease. In our study, 144 of 456 (32%) of the group of average-risk men had cancer and 105 of 456 (23%) had GS ≥ 7 cancer. Had the AUA guidelines been followed, these cancers would have been missed or the diagnoses delayed.
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Loeb S, Folkvaljon Y, Robinson D, Makarov DV, Bratt O, Garmo H, Stattin P. Immediate versus delayed prostatectomy: Nationwide population-based study (.). Scand J Urol 2016; 50:246-54. [PMID: 27067998 PMCID: PMC4979613 DOI: 10.3109/21681805.2016.1166153] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 03/11/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The aim of this study was to compare the outcome of immediate versus delayed radical prostatectomy (RP) in men with low-grade prostate cancer. MATERIALS AND METHODS The study included a nationwide population-based cohort in the National Prostate Cancer Register of Sweden, of 7608 men with clinically localized, biopsy Gleason score 6 prostate cancer who underwent immediate or delayed RP in 1997-2007. Multivariable models compared RP pathology, use of salvage radiotherapy and prostate cancer mortality based on timing of RP (< 1, 1-2 or >2 years after diagnosis). Median follow-up was 8.1 years. RESULTS Men undergoing RP more than 2 years after diagnosis had a higher risk of Gleason upgrading [odds ratio 2.93, 95% confidence interval (CI) 2.34-3.68] and an increased risk of salvage radiotherapy [hazard ratio (HR) 1.90, 95% CI 1.41-2.55], but no significant increase in prostate cancer-specific mortality (HR 1.85, 95% CI 0.57-5.99). In competing risk analysis, 7 year prostate cancer-specific cumulative mortality was similar, at less than 1%, for immediate RP and active surveillance regardless of later intervention. Limitations of this study include the lack of data on follow-up biopsies and the limited follow-up time. CONCLUSION Men undergoing RP more than 2 years after diagnosis had more adverse pathological features and second line therapy, highlighting the trade-off in deferring immediate curative therapy. However, men with delayed RP constitute a minority with higher risk cancer among the much larger group of low-risk men initially surveilled, and the overall risk of prostate cancer mortality at 7 years was similarly low with immediate RP or active surveillance.
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Affiliation(s)
- Stacy Loeb
- a New York University and Manhattan Veterans Affairs Medical Center , New York , NY , USA
| | - Yasin Folkvaljon
- b Regional Cancer Centre Uppsala Örebro, Uppsala University Hospital , Uppsala , Sweden
| | - David Robinson
- c Department of Surgery and Perioperative Sciences, Urology and Andrology , Umeå University Hospital , Umeå , Sweden
- d Department of Urology , Ryhov County Hospital , Jönköping , Sweden
| | - Danil V Makarov
- a New York University and Manhattan Veterans Affairs Medical Center , New York , NY , USA
| | - Ola Bratt
- e Department of Urology, CamPARI Clinic , Addenbrooke's Hospital , Cambridge , UK
- f Department of Translational Sciences , Lund University , Lund , Sweden
| | - Hans Garmo
- g Faculty of Life Sciences and Medicine, Division of Cancer Studies , King's College London , London , UK
| | - Pär Stattin
- c Department of Surgery and Perioperative Sciences, Urology and Andrology , Umeå University Hospital , Umeå , Sweden
- h Department of Surgical Sciences , Uppsala University , Uppsala , Sweden
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Komisarenko M, Timilshina N, Richard PO, Alibhai SMH, Hamilton R, Kulkarni G, Zlotta A, Fleshner N, Finelli A. Stricter Active Surveillance Criteria for Prostate Cancer do Not Result in Significantly Better Outcomes: A Comparison of Contemporary Protocols. J Urol 2016; 196:1645-1650. [PMID: 27350077 DOI: 10.1016/j.juro.2016.06.083] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE We reviewed various existing active surveillance criteria and determined the competing trade-offs of the stricter vs more inclusive active surveillance criteria. MATERIALS AND METHODS Men enrolled in an active surveillance program at Princess Margaret Cancer Centre between 1998 and 2014 were identified through a prospectively maintained database. All patients were assessed for entry eligibility into the Prostate Cancer Research International: Active Surveillance, Johns Hopkins, University of Miami, University of California San Francisco, Memorial Sloan Kettering Cancer Center, University of Toronto-Sunnybrook and Royal Marsden protocols. The 2-sided t-test, ANOVA, Wilcoxon rank sum or chi-square tests were used for comparison as appropriate. RESULTS Of the 1,365 men identified 1,085 met the Princess Margaret Cancer Centre inclusion criteria. When the Johns Hopkins, Prostate Cancer Research International: Active Surveillance and University of Miami criteria were applied 15.2%, 11.5% and 11.3% of these patients were excluded from active surveillance, respectively. No significant differences were noted between men who met the Princess Margaret Cancer Centre criteria and those who were excluded based on more stringent criteria when grade or volume reclassification was compared. No significant differences in prostate specific antigen velocity or the number of patients who proceeded to seek treatment were noted (p >0.1). Rates of biochemical recurrence among patients who chose to undergo radical prostatectomy after initial active surveillance were not different between men who met the more inclusive vs more exclusive active surveillance protocols. CONCLUSIONS More selective criteria do not significantly improve short-term outcomes when considering the relative risk of grade reclassification or biochemical failure after treatment. In an era of increased awareness regarding the over diagnosis and overtreatment of prostate cancer, we believe that stricter entry criteria should be reconsidered.
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Affiliation(s)
- Maria Komisarenko
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Narhari Timilshina
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Patrick O Richard
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Shabbir M H Alibhai
- Department of Medicine, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Robert Hamilton
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Girish Kulkarni
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Alexandre Zlotta
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Neil Fleshner
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Antonio Finelli
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada.
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Tonttila PP, Lantto J, Pääkkö E, Piippo U, Kauppila S, Lammentausta E, Ohtonen P, Vaarala MH. Prebiopsy Multiparametric Magnetic Resonance Imaging for Prostate Cancer Diagnosis in Biopsy-naive Men with Suspected Prostate Cancer Based on Elevated Prostate-specific Antigen Values: Results from a Randomized Prospective Blinded Controlled Trial. Eur Urol 2016; 69:419-25. [DOI: 10.1016/j.eururo.2015.05.024] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 05/14/2015] [Indexed: 10/23/2022]
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Peltier A, Aoun F, Albisinni S, Marcelis Q, Ledinh D, Paesmans M, Lemort M, van Velthoven R. Results of a comparative analysis of magnetic resonance imaging-targeted versus three-dimensional transrectal ultrasound prostate biopsies: Size does matter. Scand J Urol 2016; 50:144-8. [DOI: 10.3109/21681805.2015.1118408] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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13
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Kim SJ, Jeong TY, Yoo DS, Park J, Cho S, Kang SH, Lee SH, Jeon SH, Lee TY, Park SY. Can Prostate-Specific Antigen Kinetics before Prostate Biopsy Predict the Malignant Potential of Prostate Cancer? Yonsei Med J 2015; 56:1492-6. [PMID: 26446628 PMCID: PMC4630034 DOI: 10.3349/ymj.2015.56.6.1492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 11/26/2014] [Accepted: 12/30/2014] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To predict the malignant potential of prostate cancer (PCa) according to prostate-specific antigen velocity (PSAV), PSA density (PSAD), free/total PSA ratio (%fPSA), and digital rectal examination (DRE). MATERIALS AND METHODS From January 2009 to December 2012, 548 adult male patients were diagnosed with PCa by prostate biopsy at four hospitals in Korea. We retrospectively analyzed 155 adult male patients with an initial PSA level≤10 ng/mL and whose PSA levels had been checked more than two times at least 6 months before they had been diagnosed with PCa, with test intervals of more than 3 months. Patients with a urinary tract infection, and patients who had previously undergone cystoscopy or surgery of the prostate were excluded. We separated patients into two groups according to Gleason sum [Gleason sum≤7 (n=134) or Gleason sum≥8 (n=21)] and the presence of extracapsular invasion [organ confined (n=129) or extracapsular invasion (n=26)]. Differences between the groups were compared. RESULTS The group with a Gleason sum≥8 or extracapsular invasion of PCa showed high PSAV and significantly lower %fPSA. There were no significant differences in PSAD and the presence of an abnormality on DRE between two groups. CONCLUSION In PCa patients treated with other therapies besides prostatectomy, a high PSA velocity and a low %fPSA may predict high grade PCa with a Gleason sum≥8 or the presence of extracapsular invasion.
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Affiliation(s)
- Sang Jin Kim
- Department of Urology, Myongji Hospital, Goyang, Korea
| | | | - Dae Seon Yoo
- Department of Urology, Eulji University College of Medicine, Daejeon, Korea
| | - Jinsung Park
- Department of Urology, Eulji University College of Medicine, Daejeon, Korea
| | - Seok Cho
- Department of Urology, Korea University College of Medicine, Seoul, Korea
| | - Seok Ho Kang
- Department of Urology, Korea University College of Medicine, Seoul, Korea
| | - Sang Hyub Lee
- Department of Urology, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seung Hyun Jeon
- Department of Urology, Kyung Hee University School of Medicine, Seoul, Korea
| | - Tchun Yong Lee
- Department of Urology, Hanyang University College of Medicine, Seoul, Korea
| | - Sung Yul Park
- Department of Urology, Hanyang University College of Medicine, Seoul, Korea.
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Zhu G, Liu Z, Epstein JI, Davis C, Christudass CS, Carter HB, Landis P, Zhang H, Chung JY, Hewitt SM, Miller MC, Veltri RW. A Novel Quantitative Multiplex Tissue Immunoblotting for Biomarkers Predicts a Prostate Cancer Aggressive Phenotype. Cancer Epidemiol Biomarkers Prev 2015; 24:1864-72. [PMID: 26404961 DOI: 10.1158/1055-9965.epi-15-0496] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 08/28/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Early prediction of disease progression in men with very low-risk (VLR) prostate cancer who selected active surveillance (AS) rather than immediate treatment could reduce morbidity associated with overtreatment. METHODS We evaluated the association of six biomarkers [Periostin, (-5, -7) proPSA, CACNA1D, HER2/neu, EZH2, and Ki-67] with different Gleason scores and biochemical recurrence (BCR) on prostate cancer TMAs of 80 radical prostatectomy (RP) cases. Multiplex tissue immunoblotting (MTI) was used to assess these biomarkers in cancer and adjacent benign areas of 5 μm sections. Multivariate logistic regression (MLR) was applied to model our results. RESULTS In the RP cases, CACNA1D, HER2/neu, and Periostin expression were significantly correlated with aggressive phenotype in cancer areas. An MLR model in the cancer area yielded a ROC-AUC = 0.98, whereas in cancer-adjacent benign areas, yielded a ROC-AUC = 0.94. CACNA1D and HER2/neu expression combined with Gleason score in a MLR model yielded a ROC-AUC = 0.79 for BCR prediction. In the small biopsies from an AS cohort of 61 VLR cases, an MLR model for prediction of progressors at diagnosis retained (-5, -7) proPSA and CACNA1D, yielding a ROC-AUC of 0.78, which was improved to 0.82 after adding tPSA into the model. CONCLUSIONS The molecular profile of biomarkers is capable of accurately predicting aggressive prostate cancer on retrospective RP cases and identifying potential aggressive prostate cancer requiring immediate treatment on the AS diagnostic biopsy but limited in BCR prediction. IMPACT Comprehensive profiling of biomarkers using MTI predicts prostate cancer aggressive phenotype in RP and AS biopsies.
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Affiliation(s)
- Guangjing Zhu
- The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Zhi Liu
- The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan I Epstein
- Department of Pathology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christine Davis
- The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christhunesa S Christudass
- The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - H Ballentine Carter
- The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Patricia Landis
- The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hui Zhang
- Department of Pathology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Joon-Yong Chung
- Experimental Pathology Laboratory, Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland
| | - Stephen M Hewitt
- Experimental Pathology Laboratory, Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland
| | | | - Robert W Veltri
- The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Thomsen FB, Berg KD, Iversen P, Brasso K. Poor association between the progression criteria in active surveillance and subsequent histopathological findings following radical prostatectomy. Scand J Urol 2015; 49:354-9. [DOI: 10.3109/21681805.2015.1040448] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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16
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Active Surveillance is an Appropriate Management Strategy for a Proportion of Men Diagnosed with Prostate Cancer by Prostate Specific Antigen Testing. J Urol 2015; 194:680-4. [PMID: 25636657 DOI: 10.1016/j.juro.2015.01.089] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to determine the fraction of men who would qualify for active surveillance in a population based cohort diagnosed with prostate cancer. In those who qualified and subsequently underwent primary treatment with radical prostatectomy, we assessed the rate of upgrading and up staging. MATERIALS AND METHODS SABOR is a Clinical and Epidemiologic Center of the EDRN (Early Detection Research Network), NCI (National Cancer Institute), with 3,828 men enrolled at the time of review. Of these men 320 were diagnosed with prostate cancer, of whom 281 had sufficient data for review. These 281 cases were reviewed to determine suitability for active surveillance using 2 sets of criteria. Criteria 1 were prostate specific antigen density less than 15%, 2 or fewer cores involved with cancer, Gleason score 6 or less and cancer involving 50% or less of biopsy volume. Criteria 2 were 4 or fewer cores with Gleason 3 + 3 cancer and only 1 core of Gleason 3 + 4 cancer with up to 15% of core involved with Gleason 3 + 4 disease. For those undergoing radical prostatectomy, we examined rates of up staging and upgrading. RESULTS Of the 281 patients, 187 (67%) qualified for active surveillance under criteria 1 and/or 2. Treatment data were available on 178 patients, and 74 underwent radical prostatectomy. Using the initial biopsy, 14 men (33.1%) who met criteria 1 and 9 (25%) who met criteria 2 were upgraded and/or up staged on final pathological review. By comparison, 38% of those who did not qualify for active surveillance were upgraded and/or up staged. CONCLUSIONS In a population based cohort, two-thirds of men diagnosed with prostate cancer qualify for active surveillance. Less restricted criteria for surveillance may be appropriate based on similar rates of upgrading/up staging at radical prostatectomy.
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Predictors of Unfavorable Disease after Radical Prostatectomy in Patients at Low Risk by D'Amico Criteria: Role of Multiparametric Magnetic Resonance Imaging. J Urol 2014; 192:402-8. [DOI: 10.1016/j.juro.2014.02.2568] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2014] [Indexed: 11/19/2022]
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Russo GI, Cimino S, Castelli T, Favilla V, Urzì D, Veroux M, Madonia M, Morgia G. Percentage of cancer involvement in positive cores can predict unfavorable disease in men with low-risk prostate cancer but eligible for the prostate cancer international: Active surveillance criteria. Urol Oncol 2014; 32:291-6. [DOI: 10.1016/j.urolonc.2013.07.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 07/03/2013] [Accepted: 07/03/2013] [Indexed: 11/29/2022]
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19
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D'Amico AV. Stereotactic body radiation therapy versus intensity-modulated radiation therapy for prostate cancer: less cost at the expense of more genitourinary toxicity is a concerning but testable hypothesis. J Clin Oncol 2014; 32:1183-5. [PMID: 24616317 DOI: 10.1200/jco.2014.55.2380] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Anthony V D'Amico
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA
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20
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van den Bergh RC, van der Poel HG. Reply from Authors re: Stacy Loeb. Does Delaying Prostate Cancer Treatment Miss the Window of Curability? Eur Urol 2013;64:216–7. Eur Urol 2013. [DOI: 10.1016/j.eururo.2013.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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21
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Abdollah F, Suardi N, Capitanio U, Gallina A, Sun M, Villa L, Scattoni V, Bianchi M, Tutolo M, Fossati N, Karakiewicz P, Rigatti P, Montorsi F, Briganti A. Spatial distribution of positive cores improves the selection of patients with low-risk prostate cancer as candidates for active surveillance. BJU Int 2013; 112:E234-42. [DOI: 10.1111/bju.12152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Firas Abdollah
- Department of Urology; Vita-Salute San Raffaele University; Milan; Italy
| | - Nazareno Suardi
- Department of Urology; Vita-Salute San Raffaele University; Milan; Italy
| | - Umberto Capitanio
- Department of Urology; Vita-Salute San Raffaele University; Milan; Italy
| | - Andrea Gallina
- Department of Urology; Vita-Salute San Raffaele University; Milan; Italy
| | - Maxine Sun
- Cancer Prognostics and Health Outcomes Unit; University of Montreal Health Centre; Montreal; Quebec; Canada
| | - Luca Villa
- Department of Urology; Vita-Salute San Raffaele University; Milan; Italy
| | - Vincenzo Scattoni
- Department of Urology; Vita-Salute San Raffaele University; Milan; Italy
| | - Marco Bianchi
- Department of Urology; Vita-Salute San Raffaele University; Milan; Italy
| | - Manuela Tutolo
- Department of Urology; Vita-Salute San Raffaele University; Milan; Italy
| | - Nicola Fossati
- Department of Urology; Vita-Salute San Raffaele University; Milan; Italy
| | - Pierre Karakiewicz
- Cancer Prognostics and Health Outcomes Unit; University of Montreal Health Centre; Montreal; Quebec; Canada
| | - Patrizio Rigatti
- Department of Urology; Vita-Salute San Raffaele University; Milan; Italy
| | - Francesco Montorsi
- Department of Urology; Vita-Salute San Raffaele University; Milan; Italy
| | - Alberto Briganti
- Department of Urology; Vita-Salute San Raffaele University; Milan; Italy
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El Hajj A, Ploussard G, de la Taille A, Allory Y, Vordos D, Hoznek A, Abbou CC, Salomon L. Patient selection and pathological outcomes using currently available active surveillance criteria. BJU Int 2013; 112:471-7. [DOI: 10.1111/bju.12154] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Albert El Hajj
- Department of Urology; APHP, CHU Henri Mondor; Créteil; France
| | | | | | - Yves Allory
- Department of Pathology; APHP, CHU Henri Mondor; Créteil; France
| | - Dimitri Vordos
- Department of Urology; APHP, CHU Henri Mondor; Créteil; France
| | - Andras Hoznek
- Department of Urology; APHP, CHU Henri Mondor; Créteil; France
| | | | - Laurent Salomon
- Department of Urology; APHP, CHU Henri Mondor; Créteil; France
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Potential Consequences of Low Biopsy Core Number in Selection of Patients With Prostate Cancer for Current Active Surveillance Protocols. Urology 2013; 81:837-42. [DOI: 10.1016/j.urology.2012.10.068] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 09/24/2012] [Accepted: 10/15/2012] [Indexed: 11/24/2022]
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Aizer AA, Chen MH, Hattangadi J, D'Amico AV. Initial management of prostate-specific antigen-detected, low-risk prostate cancer and the risk of death from prostate cancer. BJU Int 2013; 113:43-50. [PMID: 23473327 DOI: 10.1111/j.1464-410x.2012.11789.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The recently published Prostate Cancer Intervention versus Observation Trial (PIVOT) did not identify differences in prostate cancer-specific mortality or all-cause mortality among patients with low-risk disease managed conservatively vs those managed definitively; however, recently published data suggest that older men may harbour more aggressive disease than is identified at biopsy owing to sampling error and undergrading. Whether older men with apparent low-risk disease are placed at risk of prostate cancer-specific mortality when managed conservatively remains unknown. The study used population-level data to show that non-curative approaches for older men with low-risk prostate cancer do result in an increased risk of prostate cancer-specific mortality. Differences between our study and the PIVOT trial include the fact that we included a larger sample size, analysed the data using an 'as-treated' approach, and included a healthier cohort of men as evinced by lower 4-year all-cause mortality estimates in our study than in the PIVOT. Our results suggest that older men with apparent low-risk prostate cancer are at risk of undergrading, which probably explains the differences in prostate cancer-specific mortality observed between men managed conservatively vs those managed definitively. Our study suggests that alternative approaches to excluding occult, high grade prostate cancer are needed in such men. OBJECTIVE To evaluate whether older age in men with low-risk prostate cancer increases the risk of prostate cancer-specific mortality (PCSM) when non-curative approaches are selected as initial management. PATIENTS AND METHODS The study cohort consisted of 27 969 men, with a median age of 67 years, with prostate-specific antigen (PSA)-detected, low-risk prostate cancer (clinical category T1c, Gleason score ≤6, and PSA ≤10) identified by the Surveillance, Epidemiology and End Results programme between 2004 and 2007. Fine and Gray's competing risk regression analysis was used to evaluate whether management with non-curative vs curative therapy was associated with an increased risk of PCSM after adjusting for PSA level, age at diagnosis and year of diagnosis. RESULTS After a median follow-up of 2.75 years, 1121 men died, 60 (5.4%) from prostate cancer. Both older age (adjusted hazard ratio [AHR] 1.05; 95% confidence interval (CI) 1.02-1.08; P < 0.001) and non-curative treatment (AHR 3.34; 95% CI 1.97-5.67; P < 0.001) were significantly associated with an increased risk of PCSM. Men > the median age experienced increased estimates of PCSM when treated with non-curative as opposed to curative intent (P < 0.001); this finding was not seen in men ≤ the median age (P = 0.17). CONCLUSION Pending prospective validation, our study suggests that non-curative approaches for older men with 'low-risk' prostate cancer result in an increased risk of PCSM, suggesting the need for alternative approaches to exclude occult, high grade prostate cancer in these men.
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Turkbey B, Mani H, Aras O, Ho J, Hoang A, Rastinehad AR, Agarwal H, Shah V, Bernardo M, Pang Y, Daar D, McKinney YL, Linehan WM, Kaushal A, Merino MJ, Wood BJ, Pinto PA, Choyke PL. Prostate cancer: can multiparametric MR imaging help identify patients who are candidates for active surveillance? Radiology 2013; 268:144-52. [PMID: 23468576 DOI: 10.1148/radiol.13121325] [Citation(s) in RCA: 176] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine whether multiparametric magnetic resonance (MR) imaging can help identify patients with prostate cancer who would most appropriately be candidates for active surveillance (AS) according to current guidelines and to compare the results with those of conventional clinical assessment scoring systems, including the D'Amico, Epstein, and Cancer of the Prostate Risk Assessment (CAPRA) systems, on the basis of findings at prostatectomy. MATERIALS AND METHODS This institutional review board-approved HIPAA-compliant retrospectively designed study included 133 patients (mean age, 59.3 years) with a mean prostate-specific antigen level of 6.73 ng/mL (median, 4.39 ng/mL) who underwent multiparametric MR imaging at 3.0 T before radical prostatectomy. Informed consent was obtained from all patients. Patients were then retrospectively classified as to whether they would have met AS eligibility criteria or were better served by surgery. AS eligibility criteria for prostatectomy specimens were a dominant tumor smaller than 0.5 mL without Gleason 4 or 5 patterns or extracapsular or seminal vesicle invasion. Conventional clinical assessment scores (the D'Amico, Epstein, and CAPRA scoring systems) were compared with multiparametric MR imaging findings for predicting AS candidates. The level of significance of difference between scoring systems was determined by using the χ(2) test for categoric variables with the level of significance set at P < .05. RESULTS Among 133 patients, 14 were eligible for AS on the basis of prostatectomy results. The sensitivity, positive predictive value (PPV), and overall accuracy, respectively, were 93%, 25%, and 70% for the D'Amico system, 64%, 45%, and 88% for the Epstein criteria, and 93%, 20%, and 59% for the CAPRA scoring system for predicting AS candidates (P < .005 for all, χ(2) test), while multiparametric MR imaging had a sensitivity of 93%, a PPV of 57%, and an overall accuracy of 92% (P < .005). CONCLUSION Multiparametric MR imaging provides useful additional information to existing clinicopathologic scoring systems of prostate cancer and improves the assignment of treatment (eg, AS or active treatment).
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Affiliation(s)
- Baris Turkbey
- Molecular Imaging Program, Laboratory of Pathology, Radiation Oncology Branch, and Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, 10 Center Dr, MSC 1182 Bldg 10, Room B3B69, Bethesda, MD 20892-1088, USA
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Dall’Era MA, Albertsen PC, Bangma C, Carroll PR, Carter HB, Cooperberg MR, Freedland SJ, Klotz LH, Parker C, Soloway MS. Active Surveillance for Prostate Cancer: A Systematic Review of the Literature. Eur Urol 2012; 62:976-83. [DOI: 10.1016/j.eururo.2012.05.072] [Citation(s) in RCA: 480] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 05/31/2012] [Indexed: 12/01/2022]
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Shapiro RH, Johnstone PAS. Risk of Gleason grade inaccuracies in prostate cancer patients eligible for active surveillance. Urology 2012; 80:661-6. [PMID: 22925240 DOI: 10.1016/j.urology.2012.06.022] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 06/05/2012] [Accepted: 06/12/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate increases in Gleason grade because of sample bias after immediate rebiopsy or prostatectomy for patients considered active surveillance candidates by institutional protocol. METHODS A contemporary medical literature search was performed using PubMed. Series were included if the patients had no more than Gleason 6 prostate cancer score on initial biopsy and underwent a prostatectomy or rebiopsy within 6 months. Patient sets using neoadjuvant hormonal therapy or focal prostate treatment were excluded. RESULTS In patients who would have fallen into the D'Amico low-risk prostate cancer group, 42% were found to have an increase in the Gleason score: 32% resulting in grade ≥ 7 disease and 3% grade ≥ 8. For series that limited patients to the Epstein criteria, Gleason upgrades were 34%, 29%, and 2%, respectively. Of the 139 patients whose second tissue specimens were from a rebiopsy, 17% were found to have grade ≥ 7 disease, whereas only 1 patient had grade ≥ 8. There were no consistent multivariate analysis variables among the series to predict for an increase in Gleason score. CONCLUSION More than one third of the patients were found to have been undergraded based on their initial prostate biopsy. Therefore, 1 biopsy alone may not be sufficient to offer active surveillance as an option. Further exploration is necessary to better ensure low-risk disease before active surveillance.
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Affiliation(s)
- Ronald H Shapiro
- Indiana University School of Medicine, Department of Radiation Oncology, Indianapolis, IN 46202, USA.
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Wong LM, Neal DE, Johnston RB, Shah N, Sharma N, Warren AY, Hovens CM, Larry Goldenberg S, Gleave ME, Costello AJ, Corcoran NM. International multicentre study examining selection criteria for active surveillance in men undergoing radical prostatectomy. Br J Cancer 2012; 107:1467-73. [PMID: 23037714 PMCID: PMC3493756 DOI: 10.1038/bjc.2012.400] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: The controversies concerning possible overtreatment of prostate cancer, highlighted by debate over PSA screening, have highlighted active surveillance (AS) as an alternative management option for appropriate men. Regional differences in the underlying prevalence of PSA testing may alter the pre-test probability for high-risk disease, which can potentially interfere with the performance of selection criteria for AS. In a multicentre study from three different countries, we examine men who were initially suitable for AS according to the Toronto and Prostate Cancer Research International: Active Surveillance (PRIAS) criteria, that underwent radical prostatectomy (RP) in regards to:1.the proportion of pathological reclassification(Gleason score ⩾7, ⩾pT3 disease),2.predictors of high-risk disease,3.create a predictive model to assist with selection of men suitable for AS. Methods: From three centres in the United Kingdom, Canada and Australia, data on men who underwent RP were retrospectively reviewed (n=2329). Multivariable logistic regression was performed to identify predictors of high-risk disease. A nomogram was generated by logistic regression analysis, and performance characterised by receiver operating characteristic curves. Results: For men suitable for AS according to the Toronto (n=800) and PRIAS (410) criteria, the rates for upgrading were 50.6, 42.7%, and upstaging 17.6, 12.4%, respectively. Significant predictors of high-risk disease were:•Toronto criteria: increasing age, cT2 disease, centre of diagnosis and number of positive cores.•PRIAS criteria: increasing PSA and cT2 disease.Cambridge had a high pT3a rate (26 vs 12%). To assist selection of men in the United Kingdom for AS, from the Cambridge data, we generated a nomogram predicting high-risk features in patients who meet the Toronto criteria (AUC of 0.72). Conclusion: The proportion of pathological reclassification in our cohort was higher than previously reported. Care must be used when applying the AS criteria generated from one population to another. With more stringent selection criteria, there is less reclassification but also fewer men who may benefit from AS.
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Affiliation(s)
- L-M Wong
- Department of Urology, Addenbrooke's Hospital, Cambridge, UK.
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Iremashvili V, Manoharan M, Rosenberg DL, Acosta K, Soloway MS. Pathological findings at radical prostatectomy in patients initially managed by active surveillance: a comparative analysis. Prostate 2012; 72:1573-9. [PMID: 22415945 DOI: 10.1002/pros.22507] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 02/15/2012] [Indexed: 11/08/2022]
Abstract
BACKGROUND The purpose of our analysis was to determine if delays in treatment caused by active surveillance result in significant pathological changes when patients no longer meet the criteria on repeat biopsy and to study whether or not these changes may affect treatment outcomes. METHODS Out of 207 men who were on active surveillance, 47 (23%) no longer met the criteria after one of the repeat biopsies. Twenty-two underwent radical prostatectomy at our institution and formed the main group (Group 1) of this study. One hundred sixty-four patients met the criteria for active surveillance but underwent immediate surgery. Of these patients, we selected 38 (23%) with the lowest predicted biochemical recurrence-free survival. These patients formed the comparison group (Group 2). Pathological features as well as postoperative biochemical outcomes were compared between the groups. RESULTS Seven patients (32%) in Group 1 and four (11%) in Group 2 have predominantly high-grade cancer (i.e., ≥4/5 + 3) at pathology. The visually estimated percent of carcinoma was also higher in patients initially managed by active surveillance (median 12.5 vs. 5.0 in Groups 1 and 2, respectively, P = 0.009). Other pathological characteristics were similar in both groups. With limited duration of follow-up, postoperative biochemical recurrence-free survival did not differ significantly between the groups. CONCLUSIONS Our study has demonstrated that both tumor grade and volume may increase during active surveillance. However, the clinical significance of these changes with respect to the outcomes of delayed treatment remains to be established.
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Affiliation(s)
- Viacheslav Iremashvili
- Department of Urology, Miller School of Medicine, University of Miami, Miami, Florida 33101, USA.
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Pathologic Prostate Cancer Characteristics in Patients Eligible for Active Surveillance: A Head-to-Head Comparison of Contemporary Protocols. Eur Urol 2012; 62:462-8. [DOI: 10.1016/j.eururo.2012.03.011] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 03/09/2012] [Indexed: 11/22/2022]
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Drouin SJ, Comperat E, Cussenot O, Bitker MO, Haertig A, Rouprêt M. Clinical characteristics and pathologic findings in patients eligible for active surveillance who underwent radical prostatectomy. Urol Oncol 2012; 30:402-7. [DOI: 10.1016/j.urolonc.2010.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Revised: 04/09/2010] [Accepted: 04/12/2010] [Indexed: 10/19/2022]
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El Hajj A, Ploussard G, de la Taille A, Allory Y, Vordos D, Hoznek A, Abbou CC, Salomon L. Analysis of outcomes after radical prostatectomy in patients eligible for active surveillance (PRIAS). BJU Int 2012; 111:53-9. [DOI: 10.1111/j.1464-410x.2012.11276.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Albert El Hajj
- Department of Urology; APHP, CHU Henri Mondor; Créteil; France
| | | | | | - Yves Allory
- Department of Pathology; APHP, CHU Henri Mondor; Créteil; France
| | - Dimitri Vordos
- Department of Urology; APHP, CHU Henri Mondor; Créteil; France
| | - Andras Hoznek
- Department of Urology; APHP, CHU Henri Mondor; Créteil; France
| | | | - Laurent Salomon
- Department of Urology; APHP, CHU Henri Mondor; Créteil; France
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Iremashvili V, Manoharan M, Rosenberg DL, Soloway MS. Biopsy features associated with prostate cancer progression in active surveillance patients: comparison of three statistical models. BJU Int 2012; 111:574-9. [PMID: 22564446 DOI: 10.1111/j.1464-410x.2012.11127.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Active surveillance is an established management option for patients with favourable-risk prostate cancer. However, about 25-30% of active surveillance patients demonstrate biopsy progression within the first 3-5 years of follow-up. Although several factors, such as the results of the diagnostic and surveillance biopsies, are known to be associated with the risk of progression, our ability to accurately predict this risk remains limited. Our analysis demonstrated that the overall number of positive cores in the diagnostic and first surveillance biopsies is strongly associated with the risk of progression in active surveillance patients. Furthermore, combined results of diagnostic and first surveillance biopsies provide more information about the probability of progression than they do separately. The most important variable affecting the progression-free survival was the overall number of cores positive for cancer. By 3 years of active surveillance, most of the patients who had four positive cores in the diagnostic and surveillance biopsies progressed, while those who had only one positive core had an excellent prognosis. These findings could be used to improve the accuracy of assessments of the prognosis of patients with low-risk prostate cancer and to help them make informed decisions about their treatment. OBJECTIVE To analyse the prognostic importance of information provided by the diagnostic biopsy, the first surveillance biopsy and a combination thereof to identify active surveillance patients with a particularly high risk of progression. MATERIALS AND METHODS The present study included 161 active surveillance patients who had at least two surveillance biopsies. The first surveillance biopsy was performed within 1 year of the diagnosis. Further surveillance biopsies usually took place every 1-2 years. Progression on the surveillance biopsy was defined as the presence of Gleason 4/5 cancer, > two positive cores or >20% involvement of any core. Cox proportional hazards regression analysis was used to examine the relationship between biopsy characteristics and progression. Three distinct statistical models were built using characteristics of diagnostic biopsies, surveillance biopsies, and a combination thereof. Harrell's c-index was used to quantify the predictive accuracy of each multivariate Cox model. RESULTS The median follow-up was 3.6 years; 46 (28.6%) patients progressed. In multivariate analysis the major factor associated with progression was the number of positive cores. The model based on the combined results of diagnostic and first surveillance biopsies was significantly more predictive than the models based on the individual results of each biopsy. Patients with four positive cores in the diagnostic and first surveillance biopsies had estimated 5-year progression rate of 100%. CONCLUSION The total number of positive cores in the diagnostic and first surveillance biopsies provides important information about the risk of prostate cancer progression in active surveillance patients.
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Affiliation(s)
- Viacheslav Iremashvili
- Department of Urology, Miller School of Medicine, University of Miami, Miami, FL 33101, USA.
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Marberger M, Barentsz J, Emberton M, Hugosson J, Loeb S, Klotz L, Koch M, Shariat SF, Vickers A. Novel approaches to improve prostate cancer diagnosis and management in early-stage disease. BJU Int 2012; 109 Suppl 2:1-7. [DOI: 10.1111/j.1464-410x.2011.10870.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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McGuire BB, Helfand BT, Kundu S, Hu Q, Banks JA, Cooper P, Catalona WJ. Association of prostate cancer risk alleles with unfavourable pathological characteristics in potential candidates for active surveillance. BJU Int 2011; 110:338-343. [PMID: 22077888 DOI: 10.1111/j.1464-410x.2011.10750.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE • To assess whether the carrier status of 35 risk alleles for prostate cancer (CaP) is associated with having unfavourable pathological features in the radical prostatectomy specimen in men with clinically low risk CaP who fulfil commonly accepted criteria as candidates for active surveillance. PATIENTS AND METHODS • We studied men of European ancestry with CaP who fulfilled the commonly accepted clinical criteria for active surveillance (T1c, prostate-specific antigen <10 ng/mL, biopsy Gleason ≤6, three or fewer positive cores, ≤50% tumour involvement/core) but instead underwent early radical prostatectomy. • We genotyped these men for 35 CaP risk alleles. We defined 'unfavourable' pathological characteristics to be Gleason ≥7 and/or ≥ pT2b in their radical prostatectomy specimen. RESULTS • In all, 263 men (median age 60 [46-72] years) fulfilled our selection criteria for active surveillance, and 58 of 263 (22.1%) were found to have 'unfavourable' pathological characteristics. • The frequencies of three CaP risk alleles (rs1447295 [8q24], P= 0.004; rs1571801 [9q33.2], P= 0.03; rs11228565 [11q13], P= 0.02) were significantly higher in men with 'unfavourable' pathological characteristics. • Two other risk alleles were proportionately more frequent (rs10934853 [3q21], P= 0.06; rs1859962 [17q24], P= 0.07) but did not achieve nominal statistical significance. • Carriers of any one of the significantly over-represented risk alleles had twice the likelihood of unfavourable tumour features (P= 0.03), and carriers of any two had a sevenfold increased likelihood (P= 0.001). • Receiver-operator curve analysis demonstrated an area under the curve of 0.66, suggesting that the number of single nucleotide polymorphisms carried provided discrimination between men with 'favourable' and 'unfavourable' tumour features in their prostatectomy specimen. CONCLUSION • In potential candidates for active surveillance, certain CaP risk alleles are more prevalent in patients with 'unfavourable' pathological characteristics in their radical prostatectomy specimen.
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Affiliation(s)
- Barry B McGuire
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brian T Helfand
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Shilajit Kundu
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Qiaoyan Hu
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jessica A Banks
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Phillip Cooper
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - William J Catalona
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Hegarty J, Bailey DE. Active Surveillance as a Treatment Option for Prostate Cancer. Semin Oncol Nurs 2011; 27:260-6. [DOI: 10.1016/j.soncn.2011.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Ayres BE, Montgomery BS, Barber NJ, Pereira N, Langley SE, Denham P, Bott SR. The role of transperineal template prostate biopsies in restaging men with prostate cancer managed by active surveillance. BJU Int 2011; 109:1170-6. [DOI: 10.1111/j.1464-410x.2011.10480.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Suardi N, Gallina A, Capitanio U, Salonia A, Lughezzani G, Freschi M, Mottrie A, Rigatti P, Montorsi F, Briganti A. Age-adjusted validation of the most stringent criteria for active surveillance in low-risk prostate cancer patients. Cancer 2011; 118:973-80. [DOI: 10.1002/cncr.26234] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 03/30/2011] [Accepted: 04/11/2011] [Indexed: 11/06/2022]
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D'Amico AV. Future of Treatment for Low-Risk Prostate Cancer: For All, for Some, or for None? J Clin Oncol 2011; 29:1940-3. [DOI: 10.1200/jco.2010.34.2006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Anthony V. D'Amico
- Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA
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Xylinas E, Durand X, Campeggi A, Ploussard G, Allory Y, Vordos D, Hoznek A, De La Taille A, Abbou CC, Salomon L. Surveillance active du cancer de prostate ayant des critères de latence : les critères SURACAP sont-ils suffisants ? Prog Urol 2011; 21:264-9. [DOI: 10.1016/j.purol.2010.09.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 07/28/2010] [Accepted: 09/29/2010] [Indexed: 10/18/2022]
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Gorin MA, Soloway CT, Eldefrawy A, Soloway MS. Factors That Influence Patient Enrollment in Active Surveillance for Low-risk Prostate Cancer. Urology 2011; 77:588-91. [DOI: 10.1016/j.urology.2010.10.039] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 10/03/2010] [Accepted: 10/20/2010] [Indexed: 10/18/2022]
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Brookman-May S, May M, Wieland WF, Lebentrau S, Gunia S, Koch S, Gilfrich C, Roigas J, Hoschke B, Burger M. Should we abstain from Gleason score 2–4 in the diagnosis of prostate cancer? Results of a German multicentre study. World J Urol 2010; 30:97-103. [DOI: 10.1007/s00345-010-0632-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 12/08/2010] [Indexed: 10/18/2022] Open
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Editorial Comment. Urology 2010; 76:692-3; discussion 693-4. [DOI: 10.1016/j.urology.2010.01.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Revised: 01/05/2010] [Accepted: 01/07/2010] [Indexed: 11/19/2022]
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