Management of high-risk localized prostate cancer

Effect of Neoadjuvant Hormone Therapy on Resection Margin and Survival Prognoses in Locally Advanced Prostate Cancer after Prostatectomy Using Propensity-Score Matching

This study aimed to investigate the effect of neoadjuvant hormone therapy (NHT) on resection margin positivity, biochemical-recurrence- (BCR-) free survival, and overall survival (OS) in 176 patients with locally advanced prostate cancer (LAPC) treated with radical prostatectomy using propensity-score matching, including 79 (44.9%) patients treated with the NHT. Fifty pairs of one-to-one propensity-score matching were matched to investigate the pure effect of NHT on resection margin positivity, BCR, and OS with a statistical significance of p<0.050. Before matching, NHT, tumor volume percentage, and extracapsular extension were significant factors for resection margin positivity (p≤0.001); however, after matching, NHT became insignificant in the multivariate analysis (p=0.084). In the survival analysis, NHT was not associated with BCR or OS before and after matching (BCR: hazard ratio, 1.35 and 0.84, respectively; OS: hazard ratio, 1.05 and 0.77, respectively; p≥0.539 for all). Conversely, PSA level (HR, 2.23), extracapsular extension (HR, 2.10), and lymphovascular invasion (HR, 1.85) were significant factors for BCR (p≤0.001 for all), but none were significant factors for OS in the propensity-score matching analysis (p≥0.948). Therefore, NHT was not a significant factor for resection margin positivity, BCR-free survival, and OS before and after propensity-score matching in patients with LAPC.

Prostate stem cell antigen mRNA in blood is a predictor of survival after radical prostatectomy in patients with high-risk prostate cancer

Objectives

To investigate whether the preoperative detection of prostate stem cell antigen (PSCA) mRNA in blood has predictive value for biochemical recurrence, overall survival, and cancer-specific survival after radical prostatectomy in patients with high-risk prostate cancer.

Results

Median age was 67 years (interquartile range: 63-71), and median follow-up was 41 months (interquartile range: 25–65). PSCA mRNA was detected in 151 patients (51.1%). Biochemical recurrence was developed in 101 patients (34.2%), and all-cause mortality and prostate cancer-specific mortality occurred in 17 (5.7%) and 8 (2.7%) patients, respectively. Kaplan–Meier analysis revealed significant differences in biochemical recurrence, overall survival, and cancer-specific survival according to PSCA mRNA positivity. Cox regression hazards model analysis showed that PSCA mRNA positivity was an independent predictor of biochemical recurrence, overall survival, and cancer-specific survival.

Conclusions

PSCA mRNA in the peripheral blood was related to poor prognosis. Detection of PSCA mRNA by polymerase chain reaction in peripheral blood can be used to predict survival after radical prostatectomy in patients with high-risk prostate cancer. Future study with larger cohort and long-term follow-up is required to confirm this finding.

Materials and methods

A total of 295 patients with high-risk prostate cancer scheduled to undergo radical prostatectomy were prospectively enrolled from 2008 to 2016. Nested reverse transcription polymerase chain reaction was used to detect cells with PSCA mRNA in peripheral blood. The predicting ability of PSCA mRNA positivity for biochemical recurrence, overall survival, and cancer-specific survival after radical prostatectomy was evaluated.

Antiproliferative effect of a synthetic aptamer mimicking androgen response elements in the LNCaP cell line

Prostate cancer usually develops to a hormone-refractory state that is irresponsive to conventional therapeutic approaches. Therefore, new methods for treating aggressive prostate cancer are under development. Because of the importance of androgen receptors (ARs) in the development of the hormone-refractory state and AR mechanism of action, this study was designed. A single-stranded DNA as an aptamer was designed that could mimic the hormone response element (HRE). The LNCaP cells as an AR-rich model were divided into three sets of triplicate groups: the test group was transfected with Aptamer Mimicking HRE (AMH), Mock received only transfection reagents (mock) and a negative control. All three sets received 0, 10 and 100 nM of dehydroepiandrosterone (DHEA) separately. Data analysis showed hormone dependency of LNCaP cells in the negative control group upon treatment with 10 and 100 nM DHEA (compared with cells left untreated (P=0.001)). Transfection of AMH resulted in significant reduction of proliferation in the test group when compared with the negative control group with 10 (P=0.001) or 100 nM DHEA (P=0.02). AMH can form a hairpin structure at 37 °C and mimic the genomic HRE. Hence, it is capable of effectively competing with genomic HRE and interrupting the androgen signaling pathway in a prostate cancer cell line (LNCaP).

Treatment trends for clinically localised prostate cancer. National population analysis: GESCAP group

OBJECTIVES

To describe the established therapies for localised prostate cancer (PC) in Spain and to assess compliance with the 2010 UAE guidelines.

PATIENTS AND METHODS

This was an epidemiological, observational, prospective and multicentre study. Of the 3,918 patients diagnosed with PC during 2010, only those patients with localised PC were included. Follow-up was ultimately conducted for a minimum of one year from the diagnosis for 3,713 patients (94.77%). The treatment groups assessed were as follows: radical prostatectomy, radiation therapy, hormone therapy, brachytherapy, active surveillance or observation and experimental local treatment (cryotherapy or other treatment). Compliance with the recommendations of the EAU guidelines was studied, describing the treatment groups according to D'Amico risk stratification criteria (localised [low, intermediate and high risk] and locally advanced), age, PSA and Gleason score.

RESULTS

By applying the D'Amico criteria, we included 3,641 (92.93%) patients. Based on the UAE recommendations: 1) 68.87% of the patients at low-intermediate risk aged≤65 years underwent radical prostatectomy; 2) 34.51% of the patients>65 years at high risk with locally advanced disease were administered radiation therapy and hormone therapy; 3) 30.36% of the patients at high risk with locally advanced disease were only treated with hormone therapy; 4) 15.20% of the patients at low risk were only treated with brachytherapy; 5) active surveillance or observation was selected for 2.44% of the patients aged≤65 years and for 10.63% of the patients at low-intermediate risk who were>65 years. Lastly, 86.5% of the patients at low risk underwent a single treatment, and 43.62% of the patients at high risk with locally advanced disease underwent combined treatments.

CONCLUSIONS

This is the first national European study to evaluate the therapeutic management of localised PC based on the risk group to which the patient belonged. Most young patients (≤65 years) with low-intermediate risk localised PC were treated with surgery, which adheres to the recommendations of the 2010 UAE guidelines. Various therapeutic combinations have been employed for patients with high-risk, locally advanced localised tumours, revealing the need for a multidisciplinary approach (Controlled-trials.com number: ISRCTN19893319).

Individualization of Adjuvant Therapy After Radical Prostatectomy for Clinically Localized Prostate Cancer: Current Status and Future Directions

Radiation therapy indications in the postprostatectomy setting are evolving. Several retrospective series have identified a number of "high-risk" pathologic features associated with an elevated risk of disease recurrence after radical prostatectomy. More recently, several randomized phase III trials demonstrated superior biochemical relapse-free survival for adjuvant radiation therapy after prostatectomy for patients with these high-risk pathologic features, including positive margin status, extraprostatic extension, and/or seminal vesicle invasion. These series further suggested improvement in distant metastasis control and overall survival after 15 years. However, not all patients with high-risk features experience disease recurrence after surgery alone, and some subsets of patients experience suboptimal disease control and survival despite immediate postoperative radiotherapy. Furthermore, some patients without high-risk features will develop recurrence. The present review discusses the current data and potential future directions to improve individualization of therapy after prostatectomy.

Diffusion-weighted MRI in early assessment of tumour response to radiotherapy in high-risk prostate cancer

OBJECTIVE

The objective of this study was to assess the efficacy of diffusion-weighted MRI (DWI) in monitoring response to radiotherapy in high-risk prostate cancer (PC).

METHODS

This retrospective study included 78 patients with high-risk PC undergoing 3.0-T MRI (supplemented by DWI) before and after intensity-modulated radiotherapy (IMRT). Based on follow-up clinical examinations, patients were divided into two groups: the recurrence group (patients who suffered biochemical/clinical recurrence within 3 years, n = 13) and the non-recurrence group (patients who were recurrence free for over 3 years, n = 65). The apparent diffusion coefficient (ADC) values before and after IMRT were compared between these two groups. The receiver-operating characteristics (ROC) analysis was carried out to investigate the discriminatory capability for pre- and post-IMRT ADC values.

RESULTS

The overall ADC values were 1.04 ± 0.18 × 10(-3) mm(2) s(-1) for PCs before IMRT and 1.45 ± 0.15 × 10(-3) mm(2) s(-1) after IMRT (p < 0.001). A statistically significant difference in post-IMRT ADC values was noted between patients with and without recurrence (1.27 ± 0.14 × 10(-3) mm(2) s(-1) vs 1.49 ± 0.12 × 10(-3)mm(2) s(-1); p < 0.001), although there was no statistical difference between them in pre-IMRT ADC values (1.00 ± 0.17 × 10(-3) mm(2) s(-1) vs 1.05 ± 0.18 × 10(-3) mm(2) s(-1); p = 0.31). The ROC curve analysis revealed that the post-IMRT ADC values could help identify patients suffering recurrences (area under the curve, 0.88; p < 0.001).

CONCLUSION

Marked increase in ADC values was observed in PC after radiotherapy, especially in good responders. DWI is a valuable tool for monitoring the response to radiotherapy.

ADVANCES IN KNOWLEDGE

This study examined the relationship between ADC changes and tumour response to treatment of PC.

Systemic GLIPR1-ΔTM protein as a novel therapeutic approach for prostate cancer

GLIPR1 is a p53 target gene known to be downregulated in prostate cancer, and increased endogenous GLIPR1 expression has been associated with increased production of reactive oxygen species, increased apoptosis, decreased c-Myc protein levels and increased cell cycle arrest. Recently, we found that upregulation of GLIPR1 in prostate cancer cells increases mitotic catastrophe through interaction with heat shock cognate protein 70 (Hsc70) and downregulation of Aurora kinase A and TPX2. In this study, we evaluated the mechanisms of recombinant GLIPR1 protein (glioma pathogenesis-related protein 1-transmembrane domain deleted [GLIPR1-ΔTM]) uptake by prostate cancer cells and the efficacy of systemic GLIPR1-ΔTM administration in a prostate cancer xenograft mouse model. GLIPR1-ΔTM was selectively internalized by prostate cancer cells, leading to increased apoptosis through reactive oxygen species production and to decreased c-Myc protein levels. Interestingly, GLIPR1-ΔTM was internalized through clathrin-mediated endocytosis in association with Hsc70. Systemic administration of GLIPR1-ΔTM significantly inhibited VCaP xenograft growth. GLIPR1-ΔTM showed no evidence of toxicity following elimination from mouse models 8 hr after injection. Our results demonstrate that GLIPR1-ΔTM is selectively endocytosed by prostate cancer cells, leading to increased reactive oxygen species production and apoptosis, and that systemic GLIPR1-ΔTM significantly inhibits growth of VCaP xenografts without substantial toxicity.

The potential impact of adding genetic markers to clinical parameters in managing high-risk prostate cancer patients

Purpose

High-risk prostate cancer is a potentially lethal disease that is increasing in the diagnosis of prostate cancer patients. Compared to other prostate cancer patients (medium or low risk), management, diagnosis and treatment are not as successful among high-risk patients. Because the genetic characterization of prostate cancer patients is increasing, we aimed to determine whether genetic information in one of the primary associated genes, such as RNASEL (2', 5'-oligoadenylate-dependent RNase L), could be used as a biomarker to improve the quality of life and treatment among high-risk patients. The main objective is to identify genetic variants of RNASEL that could be associated with high-risk prostate cancer to improve the clinical managing of these patients.

Methods

A total of 231 prostate cancer patients were genotyped for 7 variants of RNASEL gene. Clinical information was obtained from medical examinations and genetic analysis (amplification and sequencing 7 variants of RNASEL gene) were performed by the researchers. Data were processed by statistical analysis (Chi square and logistic regression) using SPSS v.15.0.

Results

Comparisons between genotypes and clinical characteristics of patients revealed that individuals with GG in D541E, AA in R462Q and AG in I97L in RNASEL gene were high-risk patients according to the European Urology Guidelines.

Conclusions

Genotyping the RNASEL gene with routine diagnostic techniques could confer a more precise diagnosis of high-risk prostate cancer patients and increase the diagnostic accuracy above the current rate of 70% due to the relation between the genetic variants of RNASEL gene and the risk of this cancer.

Electronic supplementary material

The online version of this article (doi:10.1186/2193-1801-2-444) contains supplementary material, which is available to authorized users.

Unmet needs in the prediction and detection of metastases in prostate cancer

The therapeutic landscape for the treatment of advanced prostate cancer is rapidly evolving, especially for those patients with metastatic castration-resistant prostate cancer (CPRC). Despite advances in therapy options, the diagnostic landscape has remained relatively static, with few guidelines or reviews addressing the optimal timing or methodology for the radiographic detection of metastatic disease. Given recent reports indicating a substantial proportion of patients with CRPC thought to be nonmetastatic (M0) are in fact metastatic (M1), there is now a clear opportunity and need for improvement in detection practices. Herein, we discuss the current status of predicting the presence of metastatic disease, with a particular emphasis on the detection of the M0 to M1 transition. In addition, we review current data on newer imaging technologies that are changing the way metastases are detected. Whether earlier detection of metastatic disease will ultimately improve patient outcomes is unknown, but given that the therapeutic options for those with metastatic and nonmetastatic CPRC vary, there are considerable implications of how and when metastases are detected.

Impact of a genomic classifier of metastatic risk on postoperative treatment recommendations for prostate cancer patients: a report from the DECIDE study group

BACKGROUND

Only a minority of prostate cancer patients with adverse pathology and biochemical recurrence (BCR) post radical prostatectomy (RP) experience metastasis and die from prostate cancer. Improved risk prediction models using genomic information may enable clinicians to better weigh the risk of metastasis and the morbidity and costs of treatment in a clinically heterogeneous population.

PURPOSE

We present a clinical utility study that evaluates the influence on urologist treatment recommendations for patients at risk of metastasis using a genomic-based prediction model (DecipherTM).

METHODS

A prospective, pre-post design was used to assess urologist treatment recommendations following RP in both the adjuvant (without any evidence of PSA rise) and salvage (BCR) settings. Urologists were presented de-identified pathology reports and genomic classifier (GC) test results for 24 patients from a previously conducted GC validation study in high-risk post-RP men. Participants were fellowship trained, high-volume urologic oncologists (n=21) from 18 US institutions. Treatment recommendations for secondary therapy were made based solely on clinical information (pre-GC) and then with genomic biomarker information (post-GC). This study was approved by an independent IRB.

RESULTS

Treatment recommendations changed from pre-GC to post-GC in 43% of adjuvant, and in 53% of salvage setting case evaluations. In the adjuvant setting, urologists changed their treatment recommendations from treatment (i.e. radiation and/or hormones) to close observation post-GC in 27% of cases. For cases with low GC risk (more than 3% risk of metastasis), observation was recommended for 79% of the case evaluations post-GC. Consistent trends were observed in the salvage setting.

CONCLUSION

These results indicate that urologists across a range of practice settings are likely to change treatment decisions when presented with genomic biomarker information following RP. Implementation of genomic risk stratification into routine clinical practice may better direct treatment decision-making post-RP.