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Morselli S, Sebastianelli A, Campi R, Liaci A, Gabellini L, Tasso G, Fantechi R, Venturini S, Spatafora P, Cito G, Vignolini G, Raspollini MR, Gacci M, Serni S. Adverse pathology after radical prostatectomy: the prognostic role of cumulative cancer length >6-mm threshold in prostate cancer-positive biopsies. Prostate Int 2019; 7:143-149. [PMID: 31970139 PMCID: PMC6962732 DOI: 10.1016/j.prnil.2019.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/17/2019] [Accepted: 09/24/2019] [Indexed: 12/19/2022] Open
Abstract
Background To investigate the role of Cumulative Cancer Length (CCL) and PCa positive core number (PCapcn) in random prostate biopsies as predictors of Adverse Pathology (AP) at definitive pathology. Methods We prospectively enrolled patients submitted to random ultrasound guided prostate biopsies for suspect PCa in our center since 2016. Inclusion criteria were PSA <20 ng/ml or >3 ng/ml and age<71 years. Data on CCL and Grade Group (GG) at biopsy and pathology after Radical Prostatectomy (RP) were collected. AP was defined as pT3 or higher TNM, Positive Surgical Margin (>2mm) or PCa Positive Lymph Node. ROC curve was used to establish an appropriate CCL and PCapcn thresholds that were then investigated as predictors of AP at definitive pathology. Results Among 882 eligible biopsies, 344 had PCa and underwent RP. Mean age was 64 years (SD 5). Mean PSA was 7.75 (SD: 3.66). At definitive pathology there were AP features in 196 (56.9%) RP. PCapcn and CCL were statistically significantly associated with AP (p<0.0001). At multivariate age-adjusted logistic regression only PCapcn had an OR of 1.513 (CI95% 1.140-2.007) p=0.004. Through ROC curve a CCL>6mm and PCapcn >3 thresholds for AP were established (Area: 0.769; p<0.0001 CI 95% 0.698-0.840 and Area: 0.767; p<0.0001 CI 95% 0.696-0.837). When considering CCL>6mm AP had OR 5.462 (CI 95% 2.717-10.978) p<0.0001 and PCapcn >3 had OR 7.127 (CI 95% 3.366-15.090) p<0.0001. In particular, for GG 1 and 2, CCL>6mm had OR 3.989 (CI 95% 1.839-8.652) p<0.0001, while PCapcn >3 had OR 5.541 (CI 95% 2.390-12.849) p<0.0001. Conclusions At present time, random prostate biopsies might carry useful information regarding tumor extension and aggressiveness. A CCL>6mm or PCapcn >3 might be associated with AP features, in particular for low and favorable intermediate risk PCa.
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Affiliation(s)
- Simone Morselli
- Department of Urology, Careggi University Hospital, Florence, Italy
| | | | - Riccardo Campi
- Department of Urology, Careggi University Hospital, Florence, Italy
| | - Andrea Liaci
- Department of Urology, Careggi University Hospital, Florence, Italy
| | - Linda Gabellini
- Department of Urology, Careggi University Hospital, Florence, Italy
| | - Giovanni Tasso
- Department of Urology, Careggi University Hospital, Florence, Italy
| | | | | | - Pietro Spatafora
- 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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Decision models for distinguishing between clinically insignificant and significant tumors in prostate cancer biopsies: an application of Bayes' Theorem to reduce costs and improve outcomes. Health Care Manag Sci 2019; 23:102-116. [PMID: 30880374 DOI: 10.1007/s10729-019-09480-6] [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: 08/29/2018] [Accepted: 02/19/2019] [Indexed: 10/27/2022]
Abstract
Prostate cancer is the second leading cause of death from cancer, behind lung cancer, for men in the U. S, with nearly 30,000 deaths per year. A key problem is the difficulty in distinguishing, after biopsy, between significant cancers that should be treated immediately and clinically insignificant tumors that should be monitored by active surveillance. Prostate cancer has been over-treated; a recent European randomized screening trial shows overtreatment rates of 40%. Overtreatment of insignificant tumors reduces quality of life, while delayed treatment of significant cancers increases the incidence of metastatic disease and death. We develop a decision analysis approach based on simulation and probability modeling. For a given prostate volume and number of biopsy needles, our rule is to treat if total length of cancer in needle cores exceeds c, the cutoff value, with active surveillance otherwise, provided pathology is favorable. We determine the optimal cutoff value, c*. There are two misclassification costs: treating a minimal tumor and not treating a small or medium tumor (large tumors were never misclassified in our simulations). Bayes' Theorem is used to predict the probabilities of minimal, small, medium, and large cancers given the total length of cancer found in biopsy cores. A 20 needle biopsy in conjunction with our new decision analysis approach significantly reduces the expected loss associated with a patient in our target population about to undergo a biopsy. Longer needles reduce expected loss. Increasing the number of biopsy cores from the current norm of 10-12 to about 20, in conjunction with our new decision model, should substantially improve the ability to distinguish minimal from significant prostate cancer by minimizing the expected loss from over-treating minimal tumors and delaying treatment of significant cancers.
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The impact of core length on prostate cancer diagnosis during a standard 14-core prostate biopsy scheme. Urologia 2016; 83:186-189. [PMID: 27716886 DOI: 10.5301/uro.5000199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2016] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Even if many studies in the literature purposed to evaluate the improvement of the prostate biopsy (PBx), few studies assessed the diagnostic value of core length in PBx. In this study, we evaluated the length of needle cores sampled during transrectal PBx (TRUSBx) and its impact on cancer diagnosis in a standard 14-core scheme. METHODS Medical records of 573 patients who underwent an initial TRUSBx with 14-cores scheme for suspicious prostate cancer (PCa) at our Department were reviewed. The PBx procedure and pathological evaluation were standardized. Cores lengths were compared in patients with versus without cancer, and were divided into group A and B, respectively. Statistical analysis was done to define an acceptable cut-off for biopsy length. RESULTS The mean age of the entire cohort was 62.1 ± 7.2 years, while median total prostate-specific antigen (PSA) and prostate volume were 4.2 ng/ml and 44.7 ml, respectively. PCa was showed in 33.3% of patients. Mean core length in group A versus B was 11.9 ± 3.9 versus 11.1 ± 3.2 mm (p = 0.016). Thus, core lengths were significantly longer in patients with cancer. There were no statistically significant differences when we considered the whole length of cores sampled from the right lobe (p = 0.58) and left lobe (p = 0.34). CONCLUSIONS The cancer detection rates in cores may be increased by core length in PCa patients during a TRUSBx. Our results suggest a core length of greater than 11.8 mm as a cut-off for quality warranty.
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Kang M, Song B, Lee I, Lee SE, Byun SS, Hong SK. Predictors of pathological upgrading in low-risk prostate cancer patients without hypointense lesions on an apparent diffusion coefficient map of multiparametric magnetic resonance imaging. World J Urol 2016; 34:1541-1546. [PMID: 27074937 DOI: 10.1007/s00345-016-1829-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 04/04/2016] [Indexed: 10/22/2022] Open
Abstract
PURPOSE To examine the clinicopathological features and identify the predictors of pathological upgrading in low-risk prostate cancer (PCa) patients without hypointense lesions on the apparent diffusion coefficient (ADC) map calculated from multiparametric magnetic resonance imaging. METHODS We reviewed the medical records of 1905 PCa patients who underwent radical prostatectomy between 2007 and 2015. All ADC images were graded using the five-grade Likert scale; the positive hypointense lesions were graded 4-5. We analyzed 256 patients with low-risk classifications according to D'Amico criteria. Patients were classified into two groups according to the pathologic upgrading in the surgical specimens. The predictive factors for pathologic upgrading were evaluated using a multivariate logistic regression analysis. RESULTS In 256 patients with low-risk PCa, the percentage of positive cores [odds ratio (OR) 1.09; 95 % confidence interval (CI) 1.02-1.16], the percentage of cancer in the positive cores (OR 1.07, 95 % CI 1.03-1.12), and the presence of hypointensity on an ADC map (OR 2.28; 95 % CI 1.23-4.22) were independent predictors of pathologic upgrading. Notably, 138 of low-risk patients (53.9 %) had no hypointense lesions on an ADC map. Of these 138 patients, the percentage of positive cores (OR 1.09; 95 % CI 1.01-1.18) and the percentage of cancer in the positive cores (OR 1.06; 95 % CI 1.01-1.12) remained independent predictors of pathologic upgrading. CONCLUSIONS In low-risk PCa patients without hypointense lesions on an ADC map, biopsy-related parameters such as the percentage of positive cores and the percentage of cancer in the positive cores were independent predictors of pathological upgrading following radical prostatectomy.
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Affiliation(s)
- Minyong Kang
- Department of Urology, Seoul National University Hospital, 101, Daehak-ro, Jongno-Gu, Seoul, Republic of Korea
| | - Byeongdo Song
- Department of Urology, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea
| | - Injae Lee
- Department of Urology, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea
| | - Sang Eun Lee
- Department of Urology, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea
| | - Seok-Soo Byun
- Department of Urology, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea
| | - Sung Kyu Hong
- Department of Urology, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea.
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The biopsy Gleason score 3+4 in a single core does not necessarily reflect an unfavourable pathological disease after radical prostatectomy in comparison with biopsy Gleason score 3+3: looking for larger selection criteria for active surveillance candidates. Prostate Cancer Prostatic Dis 2015; 18:270-5. [DOI: 10.1038/pcan.2015.21] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 03/15/2015] [Accepted: 04/12/2015] [Indexed: 12/23/2022]
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Chen DJ, Falzarano SM, McKenney JK, Przybycin CG, Reynolds JP, Roma A, Jones JS, Stephenson A, Klein E, Magi-Galluzzi C. Does cumulative prostate cancer length (CCL) in prostate biopsies improve prediction of clinically insignificant cancer at radical prostatectomy in patients eligible for active surveillance? BJU Int 2014; 116:220-9. [PMID: 25060664 DOI: 10.1111/bju.12880] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To evaluate if cumulative prostate cancer length (CCL) on prostate needle biopsy divided by the number of biopsy cores (CCL/core) could improve prediction of insignificant cancer on radical prostatectomy (RP) in patients with prostate cancer eligible for active surveillance (AS). PATIENTS AND METHODS Patients diagnosed with prostate cancer on extended (≥10 cores) biopsy with an initial prostate-specific antigen (iPSA) level of <15 ng/mL, clinical stage (cT) ≤ 2a, and highest biopsy Gleason score 3 + 3 = 6 or 3 + 4 = 7 with <3 positive cores who underwent RP were included in the study. The CCL/core and presence of insignificant cancer (organ-confined, volume <0.5 mL, Gleason score at RP ≤6) were recorded. pT2 prostate cancer with RP Gleason score ≤3 + 4 = 7 and volume <0.5 mL were categorised as low-tumour-volume organ-confined disease (LV-OCD). RESULTS In all, 221 patients met the inclusion criteria: the mean age was 59 years and the median iPSA level was 4.5 ng/mL. The clinical stage was cT1 in 86% of patients; biopsy Gleason score was 3 + 3 = 6 in 67% (group 1) and 3 + 4 = 7 in 33% of patients (group 2). The maximum percentage of biopsy core involvement was <50 in 85%; the median CCL/core was 0.15 mm. Insignificant cancer was found in 27% and LV-OCD in 44% of patients. Group 2 was associated with higher number of positive cores, maximum percentage core involvement, total prostate cancer length, and CCL/core. Group 1 was more likely to have insignificant cancer (39%) or LV-OCD (54%) than group 2 (3% and 23%, respectively). Group 2 had significantly higher RP Gleason score and pathological stage. Univariate analysis of group 1 showed that the iPSA level, maximum percentage core involvement, prostate cancer length, and CCL/core were all significantly associated with insignificant cancer and LV-OCD. For group 2, the number of positive cores (1 vs 2) was also significantly associated with LV-OCD. On multivariate logistic regression analysis, maximum percentage core involvement of <50, and number of positive cores (1 vs 2) were independent predictors of insignificant cancer in group 1; biopsy Gleason score, maximum percentage core involvement of <50 and prostate cancer length of <3 mm or CCL/core of <0.2 mm were all independent predictors of LV-OCD in the whole population. The maximum percentage of core involvement of <50 and prostate cancer length of <3 mm or CCL/core of <0.2 mm were also independent predictors of LV-OCD in group 1 patients. CONCLUSION In patients eligible for AS, a CCL/core of <0.20 mm was significantly associated with insignificant cancer and LV-OCD. However, when parameters of cancer burden were considered, CCL/core did not independently add any additional value for predicting insignificant cancer in patients with biopsy Gleason score 6. The CCL/core was an independent predictor of LV-OCD in the whole population and in group 1 patients, although the model including prostate cancer length showed slightly higher area under the receiver operating characteristic curve.
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Affiliation(s)
- Derrick J Chen
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sara M Falzarano
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jesse K McKenney
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA.,Glickman Urological and Kidney Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Chris G Przybycin
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA.,Glickman Urological and Kidney Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jordan P Reynolds
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andres Roma
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - J Stephen Jones
- Glickman Urological and Kidney Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andrew Stephenson
- Glickman Urological and Kidney Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eric Klein
- Glickman Urological and Kidney Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Cristina Magi-Galluzzi
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA.,Glickman Urological and Kidney Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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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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The Percentage of Core Involved by Cancer Is the Best Predictor of Insignificant Prostate Cancer, According to an Updated Definition (Tumor Volume up to 2.5 cm3): Analysis of a Cohort of 210 Consecutive Patients With Low-risk Disease. Urology 2014; 83:28-32. [DOI: 10.1016/j.urology.2013.07.056] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 07/07/2013] [Accepted: 07/10/2013] [Indexed: 11/19/2022]
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