Pretreatment nomogram for prostate-specific antigen recurrence after radical prostatectomy or external-beam radiation therapy for clinically localized prostate cancer

Baseline Ga-68 PSMA PET-Derived Primary Tumor Parameters in Patients with Prostate Cancer and Their Association with Clinical Risk Stratification and Clinicopathologic Features

Aim  This article evaluates whether parameters derived from the gallium-68-labeled prostate-specific membrane antigen ( 68 Ga-PSMA) positron emission tomography/computed tomography (PET/CT) imaging studies of primary prostate cancer (PCa) lesions were associated with Gleason score (GS), D'Amico risk class, Candiolo nomograms, and the metastatic status of the disease. Methods  We retrospectively evaluated newly diagnosed PCa patients who underwent 68 Ga-PSMA PET/CT before therapy. Age, baseline serum prostate-specific antigen (PSA), and metastatic status were recorded. Maximal standardized uptake value (SUVmax), mean SUV (SUVmean), total lesion PSMA (TL-PSMA), and PSMA-derived tumor volume (PSMA-TV) were analyzed. The patients were grouped according to GS (GS ≤ 7 and GS ≥ 8), D'Amico risk classes (low intermediate and high-risk), and also based on their results with the Candiolo nomogram which normally creates five risk classes. For Candiolo classes, very-low risk and low-risk patients were pooled into the low-risk Candiolo (LRC) group, high and very high-risk patients were pooled into the high-risk Candiolo (HRC) group. The intermediate-risk Candiolo group was utilized as-is (IRC). Results  Mean age was 67 ± 8 years, median PSA value was 14.3 (3-211). There were 82 patients with GS ≤ 7 and 38 patients with GS ≥ 8; intermediate D'Amico class comprised 32 patients, while the high D'Amico class comprised 88 patients. For Candiolo, there were 23 LRC, 40 IRC, and 57 HRC patients. PSMA-positive metastases were detected in 44 (36.7%) patients. The SUVmean, SUVmax, PSMA-TV, and TL-PSMA values of the primary tumor demonstrated significant differences when compared according to classifications for GS, D'Amico, LRC versus HRC, and metastatic versus nonmetastatic patients. Of note, TL-PSMA was the only parameter that varied significantly among all risk groups. Conclusion  Primary tumor parameters obtained from baseline 68 Ga-PSMA PET/CT are useful to distinguish PCa patients in terms of GS, D'Amico, Candiolo nomogram, and metastatic states. TL-PSMA appears to be the best parameter as it is the only parameter that can distinguish all risk groups from each other.

Association between smoking and prostate cancer survivors' long-term quality of life and function: an analysis of the CEASAR (Comparative Effectiveness Analysis of Surgery and Radiation) study

PURPOSE

There is limited evidence of tobacco smoking's effect on cancer survivors' quality of life (QOL) and function. As the natural history of localized prostate cancer (PCa) is protracted, there is a need to identify modifiable risk factors that can influence PCa survivorship, such as tobacco smoking.

MATERIAL AND METHODS

We used up to 10-year survey data from the CEASAR (Comparative Effectiveness Analysis of Surgery and Radiation) study, a prospective, population-based, observational study of patients diagnosed with localized PCa in 2011-2012. Survivors were categorized as never, former, and current smokers during survivorship. Adjusted multivariable linear regression models were used to assess the association between smoking and 5-year and 10-year scores on the 26-Item Expanded Prostate Index Composite (EPIC-26; PCa-specific domains) and 5-year scores on the Medical Outcomes Study 36-Item Short Form Survey (SF-36; general health domains).

RESULTS

We included 2426 patients of whom 142 (6%) were current smokers, 1039 (43%) were former smokers, and 1245 (51%) were never smokers. Current smokers were more likely to be Black, low-income, and less formally educated (all p < 0.01). After adjustments, there was no association between smoking history with disease-specific functional outcomes (EPIC-26) at 5 years or 10 years (all p > 0.05). However, in adjusted analyses assessing general health domains (SF-36), compared to participants who never smoked, current smokers during survivorship had worse physical function (- 10.96, 95% CI - 16.37 to - 5.55, p < 0.01) at 5 years.

CONCLUSION

PCa survivors who continue to smoke experience worse physical functioning though there is no significant independent effect on PCa-specific functional domains.

IMPLICATIONS FOR CANCER SURVIVORS

Prostate cancer survivors who continue to smoke experience worse physical functioning though there is no significant independent effect on PCa-specific functional domains. Smoking cessation may improve prostate cancer survivorship.

The impact of surgical technique on very early functional outcomes after radical prostatectomy

INTRODUCTION

To determine the very early functional as well as oncological outcomes after robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP) at a single institution.

METHODS

We identified patients who underwent RARP or ORP at our institution between August 2021 and July 2023. The main criterion for surgical technique selection was patient preference. Primary endpoints included anastomosis leakage rate, very early continence rate reported by standardized pad-test, and positive surgical margin rate. Furthermore, we analyzed operation time, hospital stay, postoperative analgesia, and complication rates.

RESULTS

In this prospective study, we analyzed data from 222 radical prostatectomies (111 RARP and 111 ORP). There were no significant differences in preoperative age, prostate size, and risk stratification among the groups. Patients who underwent RARP had lower anastomosis leakage rates (8.1% vs. 18.9%) and slightly lower early continence rates (76.6% vs. 78.4%) when compared to patients who underwent ORP. Positive surgical margin rates were similar, and complication rates were also comparable. Operation time was similar for both techniques, but the hospital stay was significantly shorter in the RARP group (6.3 vs. 9.1 days, p=0.03). The ORP group experienced significantly higher opioid administration postoperatively (p<0.001).

CONCLUSIONS

From a functional and oncological point of view, both techniques are safe and provide excellent outcomes when performed by experienced surgeons. Nevertheless, patients are likely to benefit from a shortened hospital stay and reduced postoperative pain after RARP.

The accuracy and intra- and interobserver variability of PSMA PET/CT for the local staging of primary prostate cancer

PURPOSE

Prostate-specific membrane antigen (PSMA) positron emission tomography/ computed tomography (PET/CT) is recognized as the most accurate imaging modality for detection of metastatic high-risk prostate cancer (PCa). Its role in the local staging of disease is yet unclear. We assessed the intra- and interobserver variability, as well as the diagnostic accuracy of the PSMA PET/CT based molecular imaging local tumour stage (miT-stage) for the local tumour stage assessment in a large, multicentre cohort of patients with intermediate and high-risk primary PCa, with the radical prostatectomy specimen (pT-stage) serving as the reference standard.

METHODS

A total of 600 patients who underwent staging PSMA PET/CT before robot-assisted radical prostatectomy was studied. In 579 PSMA positive primary prostate tumours a comparison was made between miT-stage as assessed by four nuclear physicians and the pT-stage according to ISUP protocol. Sensitivity, specificity and diagnostic accuracy were determined. In a representative subset of 100 patients, the intra-and interobserver variability were assessed using Kappa-estimates.

RESULTS

The sensitivity and specificity of the PSMA PET/CT based miT-stage were 58% and 59% for pT3a-stage, 30% and 97% for ≥ pT3b-stage, and 68% and 61% for overall ≥ pT3-stage, respectively. No statistically significant differences in diagnostic accuracy were found between tracers. We found a substantial intra-observer agreement for PSMA PET/CT assessment of ≥ T3-stage (k 0.70) and ≥ T3b-stage (k 0.75), whereas the interobserver agreement for the assessment of ≥ T3-stage (k 0.47) and ≥ T3b-stage (k 0.41) were moderate.

CONCLUSION

In a large, multicentre study evaluating 600 patients with newly diagnosed intermediate and high-risk PCa, we showed that PSMA PET/CT may have a value in local tumour staging when pathological tumour stage in the radical prostatectomy specimen was used as the reference standard. The intra-observer and interobserver variability of assessment of tumour extent on PSMA PET/CT was moderate to substantial.

The influence of Gleason score ≤ 6 histology on the outcome of high-risk localized prostate cancer after modern radiotherapy

We aimed to retrospectively review outcomes in patients with high-risk prostate cancer and a Gleason score ≤ 6 following modern radiotherapy. We analyzed the outcomes of 1374 patients who had undergone modern radiotherapy, comprising a high-risk low grade [HRLG] group (Gleason score ≤ 6; n = 94) and a high-risk high grade [HRHG] group (Gleason score ≥ 7, n = 1125). We included 955 patients who received brachytherapy with or without external beam radio-therapy (EBRT) and 264 who received modern EBRT (intensity-modulated radiotherapy [IMRT] or stereotactic body radiotherapy [SBRT]). At a median follow-up of 60 (2-177) months, actuarial 5-year biochemical failure-free survival rates were 97.8 and 91.8% (p = 0.017), respectively. The frequency of clinical failure in the HRLG group was less than that in the HRHG group (0% vs 5.4%, p = 0.012). The HRLG group had a better 5-year distant metastasis-free survival than the HRHG group (100% vs 96.0%, p = 0.035). As the HRLG group exhibited no clinical failure and better outcomes than the HRHG group, the HRLG group might potentially be classified as a lower-risk group.

Shifting the paradigm in the management of early prostate cancer

Outcomes from active surveillance have clearly shown that it is the optimal method of managing many early prostate cancers. Yet, clinician training and healthcare systems are still primarily focused on the "need to treat". This comment explores the challenges and resource issues in future implementation of high-quality surveillance programmes.

Prostate cancer nomograms and their application in Asian men: a review

Nomograms help to predict outcomes in individual patients rather than whole populations and are an important part of evaluation and treatment decision making. Various nomograms have been developed in malignancies to predict and prognosticate clinical outcomes such as severity of disease, overall survival, and recurrence-free survival. In prostate cancer, nomograms were developed for determining need for biopsy, disease course, need for adjuvant therapy, and outcomes. Most of these predictive nomograms were based on Caucasian populations. Prostate cancer is significantly affected by race, and Asian men have a significantly different racial and genetic susceptibility compared to Caucasians, raising the concern in generalizability of these nomograms. We reviewed the existing literature for nomograms in prostate cancer and their application in Asian men. There are very few studies that have evaluated the applicability and validity of the existing nomograms in these men. Most have found significant differences in the performance in this population. Thus, more studies evaluating the existing nomograms in Asian men or suggesting modifications for this population are required.

Novel Approaches in the Systemic Management of High-Risk Prostate Cancer

Locally advanced prostate cancer comprises approximately 20% of new prostate cancer diagnoses. For these patients, international guidelines recommend treatment with radiotherapy (RT) to the prostate in combination with long-term (2-3 years) androgen deprivation therapy (ADT), or radical prostatectomy in combination with extended pelvic lymph node dissection (PLND) as another treatment option for selected patients as part of multimodal therapy. Improvements in overall survival with docetaxel or an androgen receptor signaling inhibitor have been achieved in patients with metastatic castration sensitive or castration resistant prostate cancer. However, the role of systemic therapy combinations for high risk and/or unfavorable prostate cancer is unclear. In this context, the aim of this review is to assess the current evidence for systemic treatment combinations as part of primary definitive therapy in patients with high-risk localized prostate cancer.

Functional outcome after radical prostatectomy in 1313 patients: A single-center study

OBJECTIVES

To assess the impact of urinary continence and erectile function on the quality of life in men undergoing radical prostatectomy (RP) for prostate cancer (PC), we analyzed the preoperative and 1-year postoperative outcomes of five functional domains and their influencing factors.

PATIENTS AND METHODS

In this prospective study, all patients undergoing open or robot-assisted RP between Febuary 2017 and March 2020 in a single academic center were included. Patient-reported outcomes were assessed pre- and 12 months postoperatively using the Expanded Prostate Index Composite (EPIC-26) survey, evaluating continence, irritative/obstructive micturition, gastrointestinal symptoms, sexuality, and overall vitality. We examined the impact of RP on sexual function and urinary continence using multivariable logistic regression models, accounting for patient and tumor characteristics.

RESULTS

Overall, 1313 consecutive patients gave consent for study participation and completed both surveys. The median age was 66 years (IQR: 60-70). The majority of patients (n = 601, 46%) had an intermediate risk PC. Robotic RP was performed in 71.6% and nerve-sparing technique in 81% of the cases. The median pre- versus postoperative scores were the following: urinary continence 100 (IQR: 91.8-100) versus 85.5 (64.8-100), irritative micturition 87.5 (IQR: 75-100) versus 93.8 (IQR: 87.5-100), gastrointestinal symptoms the same with 100 (IQR: 95.8-100), vitality 95 (IQR: 80-100) versus 90 (IQR: 75-100), and erectile function 65.3 (IQR: 38.8-87.5) versus 22.2 (IQR: 12.5-48.7), respectively. Age (p < 0.001), risk classification (p = 0.002), and nerve-sparing surgery (p = 0.016) were associated with good sexual function (EPIC-26 score ≥60), while only age (p = 0.001) was statistically significantly associated with good urinary continence (EPIC-26 score ≥80).

CONCLUSION

Non-modifiable factors such as age and PC risk classification impact urinary continence and sexual function after RP. Nevertheless, urologic surgeons should further focus on improving nerve-sparing techniques, the only modifiable variable, to reduce the surgery's negative impact on urinary continence and sexual function.

Prostate cancer risk, screening and management in patients with germline BRCA1/2 mutations

Mutations in the BRCA1 and BRCA2 tumour suppressor genes are associated with prostate cancer risk; however, optimal screening protocols for individuals with these mutations have been a subject of debate. Several prospective studies of prostate cancer incidence and screening among BRCA1/2 mutation carriers have indicated at least a twofold to fourfold increase in prostate cancer risk among carriers of BRCA2 mutations compared with the general population. Moreover, BRCA2 mutations are associated with more aggressive, high-grade disease characteristics at diagnosis, more aggressive clinical behaviour and greater prostate cancer-specific mortality. The risk for BRCA1 mutations seems to be attenuated compared with BRCA2. Prostate-specific antigen (PSA) measurement or prostate magnetic resonance imaging (MRI) alone is an imperfect indicator of clinically significant prostate cancer; therefore, BRCA1/2 mutation carriers might benefit from refined risk stratification strategies. However, the long-term impact of prostate cancer screening is unknown, and the optimal management of BRCA1/2 carriers with prostate cancer has not been defined. Whether timely localized therapy can improve overall survival in the screened population is uncertain. Long-term results of prospective studies are awaited to confirm the optimal screening strategies and benefits of prostate cancer screening among BRCA1/2 mutation carriers, and whether these approaches ultimately have a positive impact on survival and quality of life in these patients.

The role of matrix metalloproteinases in pathogenesis, diagnostics, and treatment of human prostate cancer

The prostate gland is highly susceptible to oncogenic transformation, many times more than other sex tissues, such as seminal vesicles. In fact, prostate cancer (PCa) will be diagnosed in one in seven lifetime patients, making PCa the subject of intense research aimed at clarifying its biology and providing adequate treatment. PCa is the fourth most common cancer in the world in terms of the overall population and the second most common cancer for the male population. It is postulated that the development of PCa may be influenced by dietary factors, physical and sexual activity, androgens, obesity, and inflammation, but their role in the development of prostate cancer still remains unclear. Extracellular matrix metalloproteinases (MMPs) and tissue metalloproteinase inhibitors (TIMPs) play an important role in many physiological and pathological processes, including proliferation, migration, invasion, cell differentiation, participation in inflammatory processes and angiogenesis. Numerous studies point to a direct relationship between MMPs and both local tumor invasion and the formation of distant metastases. High activity of MMPs is observed in solid tumors of various origins, which positively correlates with a poor overall survival rate. Although biochemical diagnostic markers of PCa are currently available, from the point of view of clinical practice, it seems particularly important to develop new and more sensitive markers allowing for early diagnosis and long-term monitoring of patients after PCa treatment, and the assessment of MMP activity in urine and serum of patients are potential factors that could play such a role.

ACR-ABS-ASTRO Practice Parameter for Transperineal Permanent Brachytherapy of Prostate Cancer

AIM/OBJECTIVES/BACKGROUND

The American College of Radiology (ACR), American Brachytherapy Society (ABS), and American Society for Radiation Oncology (ASTRO) have jointly developed the following practice parameter for transperineal permanent brachytherapy of prostate cancer. Transperineal permanent brachytherapy of prostate cancer is the interstitial implantation of low-dose rate radioactive seeds into the prostate gland for the purpose of treating localized prostate cancer.

METHODS

This practice parameter was developed according to the process described under the heading The Process for Developing ACR Practice Parameters and Technical Standards on the ACR website (https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards) by the Committee on Practice Parameters-Radiation Oncology of the Commission on Radiation Oncology, in collaboration with ABS and ASTRO.

RESULTS

This practice parameter provides a framework for the appropriate use of low-dose rate brachytherapy in the treatment of prostate cancer either as monotherapy or as part of a treatment regimen combined with external-beam radiation therapy. The practice parameter defines the qualifications and responsibilities of all involved radiation oncology personnel, including the radiation oncologist, medical physicist, dosimetrist, radiation therapist, and nursing staff. Patient selection criteria and the utilization of supplemental therapies such as external-beam radiation therapy and androgen deprivation therapy are discussed. The logistics of the implant procedure, postimplant dosimetry assessment, and best practices with regard to safety and quality control are presented.

CONCLUSIONS

Adherence to established standards can help to ensure that permanent prostate brachytherapy is delivered in a safe and efficacious manner.

Brachytherapy focal dose escalation using ultrasound based tissue characterization by patients with non-metastatic prostate cancer: Five-year results from single-center phase 2 trial

PURPOSE

This prospective trial investigates side effects and efficacy of focal dose escalation with brachytherapy for patients with prostate cancer.

METHODS AND MATERIALS

In the Phase II, monocentric prospective trial 101 patients with low-/intermediate- and high-risk prostate cancer were enrolled between 2011 and 2013. Patients received either PDR-/HDR-brachytherapy alone with 86-90 Gy (EQD2, α/β = 3 Gy) or PDR-/HDR-brachytherapy as boost after external beam radiation therapy up to a total dose of 91-96 Gy (EQD2, α/β = 3 Gy). Taking place brachytherapy all patients received the simultaneous integrated focal boost to the intra-prostatic tumor lesions visible in computer-aided ultrasonography (HistoScanning™) - up to a total dose of 108-119 Gy (EQD2, α/β = 3 Gy). The primary endpoint was toxicity. Secondary endpoints were cumulative freedom from local recurrence, PSA-free survival, distant metastases-free survival, and overall survival. This trial is registered with ClinicalTrials.gov, number NCT01409876.

RESULTS

Median follow-up was 65 months. Late toxicity was generally low with only four patients scoring urinary grade 3 toxicity (4/101, 4%). Occurrence of any grade of late rectal toxicities was very low. We did not register any grade ≥2 of late rectal toxicities. The cumulative 5 years local recurrence rate (LRR) for all patients was 1%. Five years- biochemical disease-free survival estimates according Kaplan-Meier were 98,1% and 81,3% for low-/intermediate-risk and high-risk patients, respectively. Five years metastases-free survival estimates according Kaplan-Meier were 98,0% and 83,3% for all patients, low-/intermediate-risk and high-risk patients, respectively.

CONCLUSIONS

The 5 years-results from this Phase II Trial show that focal dose escalation with computer-aided ultrasonography and brachytherapy for patients with non-metastatic prostate cancer is safe and effective.

Robot-assisted radical prostatectomy in the treatment of patients with clinically high-risk localized and locally advanced prostate cancer: single surgeons functional and oncologic outcomes

BACKGROUND

Optimal treatment approaches for high-risk localized and locally advanced prostate cancer remain controversial and there are currently no standard treatments. These patients with high-risk localized and locally advanced prostate cancer are usually offered radiotherapy in combination with hormonal therapy. We report functional and oncologic outcomes of patients who underwent primary robot-assisted radical prostatectomy (RARP) and assess the role of RARP in patients with high-risk localized and locally advanced prostate cancer.

METHODS

This study included 188 patients with high-risk localized (clinical stage T2c or a pretreatment prostate-specific antigen level > 20 ng/mL or a biopsy Gleason score ≥ 8) and/or locally advanced (any PSA, cT3-4 or cN+) prostate cancer who underwent RARP between July 2013 and May 2020. Functional outcomes including postoperative continence and potency were assessed at 1, 3, 6, and 12 months after RARP. Oncologic outcomes comprised positive surgical margins (PSMs), biochemical recurrence (BCR), BCR-free survival, and clinical recurrence (CR)-free survival rates at 1 and 3 years.

RESULTS

The median operative time was 185 (interquartile range [IQR] 130-260) minutes. Based on postoperative pathology, the rates of PSMs in the entire cohort and in those with stage pT2 disease were 26.6% and 8.5%, respectively. The continence and potency rates at 12 months were 88.3% and 56.4%, respectively. The BCR rate was 22.3%, and the median time to BCR was 10.5 (IQR 3.5-26.9) months. The 1- and 3-year BCR-free survival rates were 87.6% and 78.7%, respectively, and the 1- and 3-year CR-free survival rates were 97.5% and 90.8%, respectively.

CONCLUSIONS

Most patients with clinically high-risk localized and locally advanced prostate cancer treated with primary RARP remained BCR-free and CR-free during the 1- and 3-year follow-up, demonstrating the good functional outcomes with RARP. RARP was a safe and feasible minimally invasive surgical alternative to radiotherapy or hormonal therapy in select patients with high-risk localized and locally advanced prostate cancer. These results should be validated to assure the reproducibility of measurements in prospective randomized-controlled studies on primary RARP.

Comparison of Different Machine Learning Models in Prediction of Postirradiation Recurrence in Prostate Carcinoma Patients

After primary treatment of localized prostate carcinoma (PC), up to a third of patients have disease recurrence. Different predictive models have already been used either for initial stratification of PC patients or to predict disease recurrence. Recently, artificial intelligence has been introduced in the diagnosis and management of PC with a potential to revolutionize this field. The aim of this study was to analyze machine learning (ML) classifiers in order to predict disease progression in the moment of prostate-specific antigen (PSA) elevation during follow-up. The study cohort consisted of 109 PC patients treated with external beam radiotherapy alone or in combination with androgen deprivation therapy. We developed and evaluated the performance of two ML algorithms based on artificial neural networks (ANN) and naïve Bayes (NB). Of all patients, 72.5% was randomly selected for a training set while the remaining patients were used for testing of the models. The presence/absence of disease progression was defined as the output variable. The input variables for models were conducted from the univariate analysis preformed among two groups of patients in the training set. They included two pretreatment variables (UICC stage and Gleason's score risk group) and five posttreatment variables (nadir PSA, time to nadir PSA, PSA doubling time, PSA velocity, and PSA in the moment of disease reevaluation). The area under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value, and predictive accuracy was calculated to test the models' performance. The results showed that specificity was similar for both models, while NB achieved better sensitivity then ANN (100.0% versus 94.4%). The ANN showed an accuracy of 93.3%, and the matching for NB model was 96.7%. In this study, ML classifiers have shown potential for application in routine clinical practice during follow-up when disease progression was suspected.

Practice Patterns of Korean Urologists Regarding Positive Surgical Margins after Radical Prostatectomy: a Survey and Narrative Review

BACKGROUND

There is no clear consensus on the optimal treatment with curative intent for patients with positive surgical margins (PSMs) following radical prostatectomy (RP). The aim of this study was to investigate the perceptions and treatment patterns of Korean urologists regarding the resection margin after RP.

METHODS

A preliminary questionnaire was prepared by analyzing various studies on resection margins after RP. Eight experienced urologists finalized the 10-item questionnaire. In July 2019, the final questionnaire was delivered via e-mail to 105 urologists in Korea who specialize in urinary cancers.

RESULTS

We received replies from 91 of the 105 urologists (86.7%) in our sample population. Among them, 41 respondents (45.1%) had performed more than 300 RPs and 22 (24.2%) had completed 500 or more RPs. In the question about whether they usually performed an additional biopsy beyond the main specimen, to get information about surgical margin invasion during surgery, the main opinion was that if no residual cancer was suspected, it was not performed (74.7%). For PSMs, the Gleason score of the positive site (49.5%) was judged to be a more important prognostic factor than the margin location (18.7%), multifocality (14.3%), or margin length (17.6%). In cases with PSMs after surgery, the prevailing opinion on follow-up was to measure and monitor prostate-specific antigen (PSA) levels rather than to begin immediate treatment (68.1%). Many respondents said that they considered postoperative radiologic examinations when PSA was elevated (72.2%), rather than regularly (24.4%). When patients had PSMs without extracapsular extension (pT2R1) or a negative surgical margin with extracapsular extension (pT3aR0), the response 'does not make a difference in treatment policy' prevailed at 65.9%. Even in patients at high risk of PSMs on preoperative radiologic screening, 84.6% of the respondents said that they did not perform neoadjuvant androgen deprivation therapy. Most respondents (75.8%) indicated that they avoided nerve-sparing RP in cases with a high risk of PSMs, but 25.7% said that they had tried nerve-sparing surgery. Additional analyses showed that urologists who had performed 300 or more prostatectomies tended to attempt more nerve-sparing procedures in patients with a high risk of PSMs than less experienced surgeons (36.6% vs. 14.0%; P = 0.012).

CONCLUSION

The most common response was to monitor PSA levels without recommending any additional treatment when PSMs were found after RP. Through this questionnaire, we found that the perceptions and treatment patterns of Korean urologists differed considerably according to RP resection margin status. Refined research and standard practice guidelines are needed.

Multi-Dimensional Scaling Analysis of Key Regulatory Genes in Prostate Cancer Using the TCGA Database

Prostate cancer (PC) is a polygenic disease with multiple gene interactions. Therefore, a detailed analysis of its epidemiology and evaluation of risk factors can help to identify more accurate predictors of aggressive disease. We used the transcriptome data from a cohort of 243 patients from the Cancer Genome Atlas (TCGA) database. Key regulatory genes involved in proliferation activity, in the regulation of stress, and in the regulation of inflammation processes of the tumor microenvironment were selected to test a priori multi-dimensional scaling (MDS) models and create a combined score to better predict the patients' survival and disease-free intervals. Survival was positively correlated with cortisol expression and negatively with Mini-Chromosome Maintenance 7 (MCM7) and Breast-Related Cancer Antigen2 (BRCA2) expression. The disease-free interval was negatively related to the expression of enhancer of zeste homolog 2 (EZH2), MCM7, BRCA2, and programmed cell death 1 ligand 1 (PD-L1). MDS suggested two separate pathways of activation in PC. Within these two dimensions three separate clusters emerged: (1) cortisol and brain-derived neurotrophic factor BDNF, (2) PD-L1 and cytotoxic-T-lymphocyte-associated protein 4 (CTL4); (3) and finally EZH2, MCM7, BRCA2, and c-Myc. We entered the three clusters of association shown in the MDS in several Kaplan-Meier analyses. It was found that only Cluster 3 was significantly related to the interval-disease free, indicating that patients with an overall higher activity of regulatory genes of proliferation and DNA repair had a lower probability to have a longer disease-free time. In conclusion, our data study provided initial evidence that selecting patients with a high grade of proliferation and DNA repair activity could lead to an early identification of an aggressive PC with a potentials for metastatic development.

Intraductal carcinoma of the prostate in prostate biopsy samples: correlation with aggressive pathological features after radical prostatectomy and prognostic value in high-risk prostate cancer

Intraductal carcinoma of the prostate (IDC-P) is an aggressive pathological pattern of prostate cancer (PCa). We investigated the association of IDC-P in prostate biopsy (PBx) with several pathological features after radical prostatectomy (RP) and its prognostic value in high-risk PCa. A total of 418 patients with high-risk PCa after RP were included in this study. IDC-P and its architectural patterns were identified according to the 2016 World Health Organization Classification. Chi-squared test and logistic regression were used to investigate the correlation between IDC-P and post-RP pathological features. Kaplan–Meier curves and Cox regression were applied to explore the prognostic value of IDC-P. IDC-P was identified in PBx in 36/418 (8.6%) patients. Logistic regression indicated that IDC-P in PBx was independently associated with several pathological features of RP, including Gleason score 8–10 (P < 0.001), seminal vesicular invasion (P < 0.001), and pathological T (pT) 3a (P = 0.043). Patients with IDC-P in PBx manifested poorer biochemical-free survival (BFS) than those without IDC-P (37.47 months vs not reached, P < 0.001). The addition of IDC-P in several prognostic nomograms could improve the predictive accuracy of these tools. We conclude that IDC-P in PBx is positively associated with several aggressive pathological features after RP in high-risk PCa. In addition, IDC-P in PBx could effectively predict the BFS of high-risk PCa patients after RP.

Transcriptome sequencing and multi-plex imaging of prostate cancer microenvironment reveals a dominant role for monocytic cells in progression

BACKGROUND

Prostate cancer is caused by genomic aberrations in normal epithelial cells, however clinical translation of findings from analyses of cancer cells alone has been very limited. A deeper understanding of the tumour microenvironment is needed to identify the key drivers of disease progression and reveal novel therapeutic opportunities.

RESULTS

In this study, the experimental enrichment of selected cell-types, the development of a Bayesian inference model for continuous differential transcript abundance, and multiplex immunohistochemistry permitted us to define the transcriptional landscape of the prostate cancer microenvironment along the disease progression axis. An important role of monocytes and macrophages in prostate cancer progression and disease recurrence was uncovered, supported by both transcriptional landscape findings and by differential tissue composition analyses. These findings were corroborated and validated by spatial analyses at the single-cell level using multiplex immunohistochemistry.

CONCLUSIONS

This study advances our knowledge concerning the role of monocyte-derived recruitment in primary prostate cancer, and supports their key role in disease progression, patient survival and prostate microenvironment immune modulation.

An external validation of the Candiolo nomogram in a cohort of prostate cancer patients treated by external-beam radiotherapy

Background

the aim of this study is to perform an external validation for the Candiolo nomogram, a predictive algorithm of biochemical and clinical recurrences in prostate cancer patients treated by radical Radiotherapy, published in 2016 on the journal “Radiation Oncology”.

Methods

561 patients, treated by Radiotherapy with curative intent between 2003 and 2012, were classified according to the five risk-classes of the Candiolo nomogram and the three risk-classes of the D’Amico classification for comparison. Patients were treated with a mean prostatic dose of 77.7 Gy and a combined treatment with Androgen-Deprivation-Therapy in 76% of cases. The end-points of the study were biochemical-progression-free-survival (bPFS) and clinical-Progression-Free-Survival (cPFS). With a median follow-up of 50 months, 56 patients (10%) had a biochemical relapse, and 30 patients (5.4%) a clinical progression. The cases were divided according to D’Amico in low-risk 21%, intermediate 40%, high-risk 39%; according to Candiolo very-low-risk 24%, low 37%, intermediate 24%, high 10%, very-high-risk 5%. Statistically, the Kaplan-Meier survival curves were processed and compared using Log-Rank tests and Harrell-C concordance index.

Results

The 5-year bPFS for the Candiolo risk-classes range between 98 and 38%, and the 5-year cPFS between 98 and 50% for very-low and very-high-risk, respectively. The Candiolo nomogram is highly significant for the stratification of both bPFS and cPFS (P < 0.0001), as well as the D’Amico classification (P = 0.004 and P = 0.001, respectively). For the Candiolo nomogram, the C indexes for bPFS and cPFS are 75 and 80%, respectively, while for D’Amico classification they are 64 and 69%, respectively. The Candiolo nomogram can identify a greater number of patients with low and very-low-risk prostate cancer (61% versus 21% according to D’Amico) and it better picks out patients with high and very-high-risk of recurrence, equal to only 15% of the total cases but subject to 48% (27/56) of biochemical relapses and 63% (19/30) of clinical progressions.

Conclusions

the external validation of the Candiolo nomogram was overall successful with C indexes approximately 10% higher than the D’Amico control classification for bPFS and cPFS. Therefore, its clinical use is justified in prostate cancer patients before radical Radiotherapy.

Trial registration Retrospectively registered.

Neoadjuvant Approaches Prior To Radical Prostatectomy

Patients with high-risk localized prostate cancer benefit from multimodality therapy of curative intent. Androgen-deprivation therapy (ADT) combined with radiation improves survival in this population. However, prior clinical trials of neoadjuvant ADT and surgery failed to consistently demonstrate a survival advantage. The development of novel, more potent hormonal agents presents an opportunity to revisit the potential for neoadjuvant therapy to improve long-term outcomes for patients with localized prostate cancer. We review recent advances in neoadjuvant approaches for prostate cancer and emerging clinical trials data supporting the use of neoadjuvant therapy prior to radical prostatectomy.

Characterizing Prostate-Specific Antigen Levels at Death in Patients with Metastatic Castration-Resistant Prostate Cancer: Are We Underutilizing Imaging?

BACKGROUND

Prostate-specific antigen (PSA) is a valuable prognostic and predictive biomarker in prostate cancer; however, the significance of PSA at or near the time of death is not well understood. This study aimed to characterize the significance of PSA at death in patients with metastatic castration-resistant prostate cancer (mCRPC).

PATIENTS AND METHODS

The Mount Sinai Genitourinary Cancer Biorepository, an institutional review board-approved, single-institution database containing all consented genitourinary cancer patients seen between 2010 and 2018, was used to identify and stratify patients into the following cohorts based on their PSA at or near death: <100 ng/mL, 100-1000 ng/mL, and >1000 ng/mL. Analyses were performed to assess clinical characteristics of disease, treatment response, and outcomes.

RESULTS

We identified 1097 patients with prostate cancer, and 101 were confirmed to be deceased following a diagnosis of mCRPC. In patients with mCRPC, cohorts of higher PSA level at death were associated with lower Gleason score at diagnosis and a trend toward longer time to mCRPC and longer time from diagnosis to death, despite a higher burden of disease at death. Conversely, subgroup analysis of PSA < 10 ng/mL at death was associated with lower rates of imaging within 6 months of death, lower treatment rate, and worse clinical outcomes.

CONCLUSIONS

Cohorts of different PSA levels at death in mCRPC patients showed distinct patterns of disease characteristics and clinical outcomes, likely due to the underlying molecular phenotype differences. Imaging for the patient population with very low PSA levels may be underutilized and should be considered more routinely.

Sudden PSA rise to ≥20 ng/ml and prostate cancer diagnosis in the United States: A population-based study

PURPOSE

While prostate-specific antigen (PSA) screening protocols vary, many clinicians have anecdotes of screened men with low PSA levels that rise significantly and are associated with high-risk prostate cancer (PC). We sought to better understand the frequency of high-risk cases that appear suddenly in a screened population.

METHODS

We utilized data from a Commercial and Medicare advantage claims database to identify all US men ages 50 and above undergoing PSA screening who then had a sudden interval rise in PSA (e.g., PSA ≥ 20) and diagnosis of PC. We determined associations with age, race, screening intensity, and baseline PSA levels.

RESULTS

In all, 526,120 men met entry criteria with an average age of 60.7 and follow-up of 5.6 years. As the baseline PSA increased, the rate of high-risk PC increased from 2/10,000 persons among men with the lowest baseline PSA (<1 ng/ml) to 14/10,000 person-years among men with a baseline PSA < 5 ng/ml. Moreover, as a man's age at baseline PSA increased, the rate of high-risk PC also increased. In contrast, the incidence of high-risk PC did not vary significantly by race/ethnicity. More screening PSAs and shorter intervals between PSA screenings were associated with a lower incidence of high-risk PC.

CONCLUSIONS

The incidence of high-risk PC in a screened population is low (<0.1%). Our findings suggest that systematic screening cannot eliminate all PC deaths and provide an estimate for the risk of the rapid development of high-risk cancers that is comparable to that observed in active surveillance populations.

Evaluation of the clinical use of PET/CT with 68Ga-PSMA for the assessment of biochemical recurrence of low or intermediate-risk prostate cancer

RATIONALE

⁶⁸Ga-prostate-specific membrane antigen positron emission tomography/computed tomography (PET-PSMA) has shown promising performance for the assessment of biochemical recurrence of prostate cancer in high-risk patients, defined by D´Amico et al. criteria. Little evidence for the impact of this diagnostic method for patients at low or intermediate risk, in terms of management and benefits of subsequent treatment, is available.

METHODS

Data from 57 patients with low and intermediate-risk prostate cancer and biochemical recurrence underwent PET-PSMA were examined retrospectively. Images were analyzed and findings were compared with clinical data. Indications for the PET-PSMA imaging, study positivity/negativity, lesion locations, Gleason (ISUP) score, prostate-specific antigen (PSA) level on the examination date, postexamination treatment, and management were evaluated.

RESULTS

PET-PSMA findings were negative for 28 (49.12%) patients, 11 of whom received salvage radiotherapy (S-RT; with or without HT; PSA levels declined significantly in 10 (90.9%) of these patients compared with levels in those not undergoing S-RT. Positive PET-PSMA findings enabled the accurate identification of patients who benefited from salvage pelvic RT for local disease control and those who responded satisfactorily to systemic treatment.

CONCLUSION

PET-PSMA is useful for the assessment of biochemical recurrence in prostate cancer patients with prostate cancer at low and intermediate-risk.

Detection of ctDNA in plasma of patients with clinically localised prostate cancer is associated with rapid disease progression

BACKGROUND

DNA originating from degenerate tumour cells can be detected in the circulation in many tumour types, where it can be used as a marker of disease burden as well as to monitor treatment response. Although circulating tumour DNA (ctDNA) measurement has prognostic/predictive value in metastatic prostate cancer, its utility in localised disease is unknown.

METHODS

We performed whole-genome sequencing of tumour-normal pairs in eight patients with clinically localised disease undergoing prostatectomy, identifying high confidence genomic aberrations. A bespoke DNA capture and amplification panel against the highest prevalence, highest confidence aberrations for each individual was designed and used to interrogate ctDNA isolated from plasma prospectively obtained pre- and post- (24 h and 6 weeks) surgery. In a separate cohort (n = 189), we identified the presence of ctDNA TP53 mutations in preoperative plasma in a retrospective cohort and determined its association with biochemical- and metastasis-free survival.

RESULTS

Tumour variants in ctDNA were positively identified pre-treatment in two of eight patients, which in both cases remained detectable postoperatively. Patients with tumour variants in ctDNA had extremely rapid disease recurrence and progression compared to those where variants could not be detected. In terms of aberrations targeted, single nucleotide and structural variants outperformed indels and copy number aberrations. Detection of ctDNA TP53 mutations was associated with a significantly shorter metastasis-free survival (6.2 vs. 9.5 years (HR 2.4; 95% CIs 1.2-4.8, p = 0.014).

CONCLUSIONS

CtDNA is uncommonly detected in localised prostate cancer, but its presence portends more rapidly progressive disease.

Prostate Cancer, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology

The NCCN Guidelines for Prostate Cancer include recommendations regarding diagnosis, risk stratification and workup, treatment options for localized disease, and management of recurrent and advanced disease for clinicians who treat patients with prostate cancer. The portions of the guidelines included herein focus on the roles of germline and somatic genetic testing, risk stratification with nomograms and tumor multigene molecular testing, androgen deprivation therapy, secondary hormonal therapy, chemotherapy, and immunotherapy in patients with prostate cancer.

Tumor characteristics, treatments, and survival outcomes in prostate cancer patients with a PSA level < 4 ng/ml: a population-based study

BACKGROUND

To examine the tumor characteristics, treatments and survival outcomes of prostate cancer (PCa) patients with a prostate-specific antigen (PSA) level < 4 ng/ml.

METHODS

Of 205,913 men with primary prostate adenocarcinoma in the Surveillance, Epidemiology and End Results (SEER) database (2010 to 2015), 24,054 (11.68%) patients were diagnosed with a PSA level < 4 ng/ml. Comparisons of categorical variables among different groups were performed by using the Chi square test. Multivariate Cox regression analysis was adjusted for age, ethnicity, marital status, insurance status, TNM stage, Gleason grade, treatment and survival. Kaplan-Meier survival curves were constructed for overall mortality and tested by the log-rank test.

RESULTS

PCa patients with a PSA level < 4 ng/ml generally had more favorable tumor characteristics: younger, lower T stage, lower Gleason grade and lower lymph node metastasis rate. However, there were more patients in stage M1 in the group of PSA level < 4 ng/ml than that in the groups of PSA level of 4-10 ng/ml, 10-20 ng/ml and > 20 ng/ml. The multivariate Cox regression model revealed that overall mortality was associated with age, marital status, race, Gleason grade, M stage and treatment approach.

CONCLUSIONS

In conclusion, PCa patients with a PSA level < 4 ng/ml have more favorable tumor characteristics at diagnosis and receive more benefit from active treatment. However, those patients with advanced TNM stage and high Gleason grade should be paid more attention in clinical application.

Interobserver agreement of [68Ga]Ga-PSMA-11 PET/CT images interpretation in men with newly diagnosed prostate cancer

Background

Prostate-specific membrane antigen (PSMA) ligand PET/CT has already provided promising results in prostate cancer (PC) imaging, yet simple and reproductible reporting criteria are still lacking. This study aimed at retrospectively evaluating interobserver agreement of [⁶⁸Ga]Ga-PSMA-11 PET/CT images interpretation according to PC molecular imaging standardized evaluation (PROMISE) criteria and reproducibility of PSMA reporting and data systems (RADS).

Methods

Forty-three patients with newly diagnosed, histologically proven intermediate- or high-risk PC, eligible for radical prostatectomy and who underwent [⁶⁸Ga]Ga-PSMA-11 PET/CT before surgery were retrospectively included. Three nuclear medicine physicians (2 experienced and 1 resident) independently reviewed PET/CT images. Interpretation of [⁶⁸Ga]Ga-PSMA-11 PET/CT images was based on PROMISE criteria including miTNM staging and lesions miPSMA expression score visual estimation and PSMA-RADS version 1.0 for a given scan. Readers’ agreement was measured using Krippendorff’s coefficients

Results

Agreement between observers was almost perfect (coefficient ≥ 0.81) for miM; it was substantial (coefficient ≥ 0.61) for the following criteria: miT, miN, PSMA-RADS, and miPSMA expression score of primary PC lesion and metastases. However, agreement was moderate (coefficient = 0.41–0.60) for miPSMA score of positive lymph nodes and for detection of PC primary lesion.

Conclusion

Visual interpretation of [⁶⁸Ga]Ga-PSMA-11 PET/CT images in patients with newly diagnosed PC in a clinical setting leads to at least substantial agreement for PROMISE criteria and PSMA-RADS classification except for PC primary lesion detection and for miPSMA expression scoring of positive lymph nodes that might have been hampered by the interindividual variability of reference organs PSMA expression.

Nodal recurrence patterns on PET/CT after RTOG-based nodal radiotherapy for prostate cancer

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Recurrence patterns on PET/CT after RT for PC_N+ were correlated with nodal fields.

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In-field nodal recurrences were uncommon.

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Out-field nodal recurrences occurred mostly just above the elective nodal field.

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Expanding elective fields to the aorta bifurcation may prolong disease-free survival.

Purpose

Biochemical failure after external beam radiotherapy (RT) for node-positive prostate cancer (PC_N+) frequently involves nodal recurrences, in most cases out of field. This raises the question if current RTOG-based elective nodal fields can still be considered optimal. Modern diagnostic tools like PSMA PET/CT and choline PET/CT can visualize nodal recurrences with unprecedented accuracy. We evaluated recurrence patterns on PET/CT after RT for PC_N+, with the aim to explore options for improved nodal target definition.

Methods and materials

Data of all patients treated with curative intent EBRT for PC_N+ in NKI-AVL from 2008 to 2018 were retrospectively reviewed. EBRT comprised 70 Gy to the prostate or 66–70 Gy to the prostate bed, 60 Gy to involved nodes, and 52,5–56 Gy (46 Gy EQD2) to RTOG-based elective nodal fields, in 35 fractions. Locations of recurrences on PET/CT were noted, and nodal locations were correlated with the applied EBRT fields.

Results

42 patients received PSMA (28) or choline (14) PET/CT at biochemical recurrence. 35 patients (83%) had a positive scan. At their first positive scan 17 patients had nodal metastasis, in some cases together with a local recurrence or distant disease. In-field nodal recurrences were uncommon (n = 3). Out-field nodal recurrences occurred more frequently (n = 14), with the majority (n = 12) just above the elective nodal field. These nodes were the single area of detectable failure in 6 patients (14%).

Conclusions

Current RT with RTOG-based nodal fields for PC_N+ provides good in-field tumour control, but frequent out-field nodal recurrences suggest missed microscopic locations. Expanding elective fields to include the aorta bifurcation may prolong recurrence-free survival. Future research must address whether the potential benefits of this strategy outbalance additional toxicity.

Development and Internal Validation of a Web-based Tool to Predict Sexual, Urinary, and Bowel Function Longitudinally After Radiation Therapy, Surgery, or Observation

BACKGROUND

Shared decision making to guide treatment of localized prostate cancer requires delivery of the anticipated quality of life (QOL) outcomes of contemporary treatment options (including radical prostatectomy [RP], intensity-modulated radiation therapy [RT], and active surveillance [AS]). Predicting these QOL outcomes based on personalized features is necessary.

OBJECTIVE

To create an easy-to-use tool to predict personalized sexual, urinary, bowel, and hormonal function outcomes after RP, RT, and AS.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, population-based cohort study was conducted utilizing US cancer registries of 2563 men diagnosed with localized prostate cancer in 2011-2012.

INTERVENTION

Patient-reported urinary, sexual, and bowel function up to 5 yr after treatment.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Patient-reported urinary, sexual, bowel, and hormonal function through 5 yr after treatment were collected using the 26-item Expanded Prostate Index Composite (EPIC-26) questionnaire. Comprehensive models to predict domain scores were fit, which included age, race, D'Amico classification, body mass index, EPIC-26 baseline function, treatment, and standardized scores measuring comorbidity, general QOL, and psychosocial health. We reduced these models by removing the instrument scores and replacing D'Amico classification with prostate-specific antigen (PSA) and Gleason score. For the final model, we performed bootstrap internal validation to assess model calibration from which an easy-to-use web-based tool was developed.

RESULTS AND LIMITATIONS

The prediction models achieved bias-corrected R-squared values of 0.386, 0.232, 0.183, 0.214, and 0.309 for sexual function, urinary incontinence, urinary irritative, bowel, and hormonal domains, respectively. Differences in R-squared values between the comprehensive and parsimonious models were small in magnitude. Calibration was excellent. The web-based tool is available at https://statez.shinyapps.io/PCDSPred/.

CONCLUSIONS

Functional outcomes after treatment for localized prostate cancer can be predicted at the time of diagnosis based on age, race, PSA, biopsy grade, baseline function, and a general question regarding overall health. Providers and patients can use this prediction tool to inform shared decision making.

PATIENT SUMMARY

In this report, we studied patient-reported sexual, urinary, hormonal, and bowel function through 5 yr after treatment with radical prostatectomy, radiation therapy, or active surveillance for localized prostate cancer. We developed a web-based predictive tool that can be used to predict one's outcomes after treatment based on age, race, prostate-specific antigen, biopsy grade, pretreatment baseline function, and a general question regarding overall health. We hope both patients and providers can use this tool to better understand expected outcomes after treatment, further enhancing shared decision making between providers and patients.

Clinical and oncological outcomes of robot-assisted radical prostatectomy with nerve sparing vs. non-nerve sparing for high-risk prostate cancer cases

Robot-assisted radical prostatectomy (RARP) is one of the most widely used procedures for localized prostate cancer (PCa). In the present study, the clinical and oncological outcomes of RARP with bilateral or unilateral nerve sparing (NS) for D'Amico high-risk PCa cases were assessed. Among the 767 cases who received RARP at Fujita Health University Hospital between August 2009 and December 2016, 230 high-risk PCa cases who were observed for >6 months comprised the retrospective study cohort. Bilateral NS was performed with the bilateral neurovascular bundle in eight, unilateral in 125 and none in 97 cases. Perioperative parameters [surgery time, console time, estimated blood loss, pathological stage, positive lymph node metastases [pN (+)], and surgical margin positivity] did not exhibit significant differences between the NS and non-NS cohorts. During a median follow-up time of 25 months, the 1- and 3-year biochemical recurrence (BCR)-free survival rates in the NS/non-NS cohorts were 84.4/86.0 and 72.7/75.0%, respectively. There were no significant differences identified between the two groups at each time period. According to multivariate analysis, the resection margin was an important factor for time to BCR, regardless of the NS technique used. The numbers of pads used daily at 3 and 6 months after RARP between the NS/non-NS cohorts were 1.1/1.5 and 0.6/1.0, respectively (P=0.045 and P=0.009), suggesting that the NS technique resulted in significantly improved outcomes regarding urinary continence recovery. In selected high-risk PCa cases, the NS technique resulted in equivalent oncological outcomes and improved urinary continence compared with the non-NS RARP group.

Moving Beyond Gleason Scoring

Context.—

The combination of grading and staging is the basis of current standard of care for prediction for most cancers. D. F. Gleason created the current prostate cancer (PCa) grading system. This system has been modified several times. Molecular data have been added. Currently, all grading systems are cancer-cell based.

Objective.—

To review the literature available on host response measures as reactive stroma grading and stromogenic carcinoma, and their predictive ability for PCa biochemical recurrence and PCa-specific death.

Data Sources.—

Our own experience has shown that reactive stroma grading and the subsequently binarized system (stromogenic carcinoma) can independently predict biochemical recurrence and/or PCa-specific death, particularly in patients with a Gleason score of 6 or 7. Stromogenic carcinoma has been validated by 4 other independent groups in at least 3 continents.

Conclusions.—

Broders grading and Dukes staging have been combined to form the most powerful prognostic tools in standard of care. The time has come for us to incorporate measures of host response (stromogenic carcinoma) into the arsenal of elements we use to predict cancer survival, without abandoning what we know works. These data also suggest that our current definition of PCa might need some revision.

Circulating miRNAs in localized/locally advanced prostate cancer patients after radical prostatectomy and radiotherapy

BACKGROUND

Overtreatment is a well-known clinical challenge in local prostate cancer (PCa). Although risk assessment models have contributed to a better stratification of patients with local PCa, a tailored management is still in its infancy. Over the last few decades, microRNAs (miRNAs) have shown promising results as biomarkers in PCa. The aim of this study was to investigate circulating miRNAs after management of local PCa.

METHODS

The relative expression of four miRNAs (miRNA-21, -93, -125b, and miRNA-221) was assessed in plasma from 149 newly diagnosed patients with local or locally advanced PCa. Real-time polymerase chain reaction was used for analysis. A baseline sample at time of diagnosis and a follow-up sample after 6 months were assessed. The patients were grouped in an interventional cohort (radical prostatectomy, curative intent radiotherapy, or androgen-deprivation therapy alone) and an observational cohort (watchful waiting or active surveillance).

RESULTS

In the interventional cohort, levels of both miRNA-93 and miRNA-221 were significantly lower in the follow-up samples compared to baseline z = -2.738, P = 0.006, and z = -4.498, P < 0.001, respectively. The same observation was recorded for miRNA-125b in the observational cohort (z = -2.656, P = 0.008). Both miRNA-125b and miRNA-221 were correlated with risk assessment r = 0.23, P = 0.015, and r = 0.203, P = 0.016 respectively, while miRNA-93 showed tendency to significant correlation with the prostatectomy Gleason score (r = 0.276, P = 0.0576).

CONCLUSIONS

The current results indicate a possible role of miRNA-93 and miRNA-221 in disease monitoring in localized and locally advanced PCa. Larger studies are warranted to assess the clinical impact of these biomarkers.

A national survey of radiation oncologists and urologists on prediction tools and nomograms for localized prostate cancer

PURPOSE

Although prediction tools for prostate cancer (PCa) are essential for high-quality treatment decision-making, little is known about the degree of confidence in existing tools and whether they are used in clinical practice from radiation oncologists (RO) and urologists (URO). Herein, we performed a national survey of specialists about perceived attitudes and use of prediction tools.

METHODS

In 2017, we invited 940 URO and 911 RO in a national survey to query their confidence in and use of the D'Amico criteria, Kattan Nomogram, and CAPRA score. The statistical analysis involved bivariate association and multivariable logistic regression analyses to identify physician characteristics (age, gender, race, practice affiliation, specialty, access to robotic surgery, ownership of linear accelerator and number of prostate cancer per week) associated with survey responses and use of active surveillance (AS) for low-risk PCa.

RESULTS

Overall, 691 (37.3%) specialists completed the surveys. Two-thirds (range 65.6-68.4%) of respondents reported being "somewhat confident", but only a fifth selected "very confident" for each prediction tool (18.0-20.1%). 19.1% of specialists in the survey reported not using any prediction tools in clinical practice, which was higher amongst URO than RO (23.9 vs. 13.4%; p < 0.001). Respondents who reported not using prediction tools were also associated with low utilization of AS in their low-risk PCa patients (adjusted OR 2.47; p = 0.01).

CONCLUSIONS

While a majority of RO and URO view existing prediction tools for localized PCa with some degree of confidence, a fifth of specialists reported not using any such tools in clinical practice. Lack of using such tools was associated with low utilization of AS for low-risk PCa.

Genomic Risk Predicts Molecular Imaging-detected Metastatic Nodal Disease in Prostate Cancer

BACKGROUND

The Decipher genomic classifier (GC) is increasingly being used to determine metastasis risk in men with localized prostate cancer (PCa). Whether GCs predict for the presence of occult metastatic disease at presentation or subsequent metastatic progression is unknown.

OBJECTIVE

To determine if GC scores predict extraprostatic ⁶⁸Ga prostate-specific membrane antigen (⁶⁸Ga-PSMA-11) positron emission tomography (PET) positivity at presentation.

DESIGN, SETTING, AND PARTICIPANTS

Between December 2015 and September 2018, 91 PCa patients with both GC scores and pretreatment ⁶⁸Ga-PSMA-11 PET scans were identified. Risk stratification was performed using the National Comprehensive Cancer Network (NCCN), Cancer of the Prostate Risk Assessment (CAPRA), and GC scores.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Logistic regression was used to identify factors correlated with PSMA-positive disease.

RESULTS AND LIMITATIONS

The NCCN criteria identified 23 (25.3%) and 68 patients (74.7%) as intermediate and high risk, while CAPRA scores revealed 28 (30.8%) and 63 (69.2%) as low/intermediate and high risk, respectively. By contrast, only 45 patients (49.4%) had high-risk GC scores. PSMA-avid pelvic nodal involvement was identified in 27 patients (29.7%). Higher GC score was significantly associated with pelvic nodal involvement (odds ratio [OR] 1.38 per 0.1 units; p=0.009) and any PSMA-avid nodal involvement (pelvic or distant; OR 1.40 per 0.1 units; p=0.007). However, higher GC score was not significantly associated with PSMA-avid osseous metastases (OR 1.11 per 0.1 units; p=0.50). Limitations include selection bias for patients able to receive both tests and the sample size.

CONCLUSIONS

Each 0.1-unit increase in GC score was associated with an approximate 40% increase in the odds of PSMA-avid lymph node involvement. These data suggest that patients with GC high risk might benefit from more nodal imaging and treatment intensification, potentially via pelvic nodal dissection, pelvic nodal irradiation, and/or the addition of chemohormonal agents.

PATIENT SUMMARY

Patients with higher genomic classifier scores were found to have more metastatic lymph node involvement on prostate-specific membrane antigen imaging.

Proton Beam Therapy Alone for Intermediate- or High-Risk Prostate Cancer: An Institutional Prospective Cohort Study

The role of proton beam therapy (PBT) as monotherapy for localized prostate cancer (PCa) remains unclear. The purpose of this study was to evaluate the efficacy and adverse events of PBT alone for these patients. Between January 2011 and July 2014, 218 patients with intermediate- and high-risk PCa who declined androgen deprivation therapy (ADT) were enrolled to the study and were treated with PBT following one of the following protocols: 74 Gray (GyE) with 37 fractions (fr) (74 GyE/37 fr), 78 GyE/39 fr, and 70 GyE/28 fr. The 5-year progression-free survival rate in the intermediate- and high-risk groups was 97% and 83%, respectively (p = 0.002). The rate of grade 2 or higher late gastrointestinal toxicity was 3.9%, and a significant increased incidence was noted in those who received the 78 GyE/39 fr protocol (p < 0.05). Grade 2 or higher acute and late genitourinary toxicities were observed in 23.5% and 3.4% of patients, respectively. Our results indicated that PBT monotherapy can be a beneficial treatment for localized PCa. Furthermore, it can preserve the quality of life of these patients. We believe that this study provides crucial hypotheses for further study and for establishing new treatment strategies.

Intraductal/ductal histology and lymphovascular invasion are associated with germline DNA-repair gene mutations in prostate cancer

BACKGROUND

Germline mutations in genes mediating DNA repair are common in men with recurrent and advanced prostate cancer, and their presence may alter prognosis and management. We aimed to define pathological and clinical characteristics associated with germline DNA-repair gene mutations, to facilitate selection of patients for germline testing.

METHODS

We retrospectively evaluated 150 unselected patients with recurrent or metastatic prostate cancer who were offered germline genetic testing by a single oncologist using a clinical-grade assay (Color Genomics). This platform utilizes next-generation sequencing from saliva to interrogate 30 cancer-susceptibility genes. Presence or absence of a deleterious germline mutation was correlated with histological and clinical characteristics, and with family history of cancer. All patients with DNA-sequence alterations (pathogenic or variants) were offered genetic counseling.

RESULTS

Between July 2016 and July 2017, 150 consecutive patients underwent germline testing; pathogenic mutations were identified in 21 men (14%). Among those with germline mutations, 9 (43%) were in BRCA2, 3 (14%) were in ATM, 3 (14%) were in CHEK2, and 2 (9%) were in BRCA1. While there were no associations between germline mutations and age, tumor stage, Gleason sum or family history; mutation-positive patients had lower median PSA levels at diagnosis (5.5 vs 8.6 ng/mL, P = 0.01) and unique pathologic features. Namely, men with germline mutations were more likely to harbor intraductal/ductal histology (48% vs 12%, P < 0.01) and lymphovascular invasion (52% vs 14%, P < 0.01). Finally, 44% of patients with a positive germline test would not have been offered genetic screening according to current National Comprehensive Cancer Network (NCCN) guidelines.

CONCLUSIONS

Presence of intraductal/ductal histology and lymphovascular invasion appear to be associated with pathogenic germline DNA-repair gene mutations in men with prostate cancer, and identification of these features may help to select patients for germline testing. NCCN guidelines may be inadequate in predicting which prostate cancer patients should undergo genetic screening.

The Cambridge Prognostic Groups for improved prediction of disease mortality at diagnosis in primary non-metastatic prostate cancer: a validation study

BACKGROUND

The purpose of this study is to validate a new five-tiered prognostic classification system to better discriminate cancer-specific mortality in men diagnosed with primary non-metastatic prostate cancer.

METHODS

We applied a recently described five-strata model, the Cambridge Prognostic Groups (CPGs 1-5), in two international cohorts and tested prognostic performance against the current standard three-strata classification of low-, intermediate- or high-risk disease. Diagnostic clinico-pathological data for men obtained from the Prostate Cancer data Base Sweden (PCBaSe) and the Singapore Health Study were used. The main outcome measure was prostate cancer mortality (PCM) stratified by age group and treatment modality.

RESULTS

The PCBaSe cohort included 72,337 men, of whom 7162 died of prostate cancer. The CPG model successfully classified men with different risks of PCM with competing risk regression confirming significant intergroup distinction (p < 0.0001). The CPGs were significantly better at stratified prediction of PCM compared to the current three-tiered system (concordance index (C-index) 0.81 vs. 0.77, p < 0.0001). This superiority was maintained for every age group division (p < 0.0001). Also in the ethnically different Singapore cohort of 2550 men with 142 prostate cancer deaths, the CPG model outperformed the three strata categories (C-index 0.79 vs. 0.76, p < 0.0001). The model also retained superior prognostic discrimination in the treatment sub-groups: radical prostatectomy (n = 20,586), C-index 0.77 vs. 074; radiotherapy (n = 11,872), C-index 0.73 vs. 0.69; and conservative management (n = 14,950), C-index 0.74 vs. 0.73. The CPG groups that sub-divided the old intermediate-risk (CPG2 vs. CPG3) and high-risk categories (CPG4 vs. CPG5) significantly discriminated PCM outcomes after radical therapy or conservative management (p < 0.0001).

CONCLUSIONS

This validation study of nearly 75,000 men confirms that the CPG five-tiered prognostic model has superior discrimination compared to the three-tiered model in predicting prostate cancer death across different age and treatment groups. Crucially, it identifies distinct sub-groups of men within the old intermediate-risk and high-risk criteria who have very different prognostic outcomes. We therefore propose adoption of the CPG model as a simple-to-use but more accurate prognostic stratification tool to help guide management for men with newly diagnosed prostate cancer.

Optimization of Risk Stratification in Localized Prostate Cancer

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors’ suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

A 67-year-old retired engineering professor was found to have a prostate-specific antigen (PSA) level of 11 ng/mL on a screening test at his annual physical examination. A digital rectal examination revealed a nodule on the right side. He underwent a transrectal ultrasound-guided prostate biopsy that was notable for prostate adenocarcinoma, Gleason 3 + 4 = 7 (Gleason grade group 2; 30% Gleason 4 component) involving two cores (60% and 20% core involvement). A bone scan and pelvic computed tomography scan were negative for evidence of metastatic disease. (Should he undergo prostate magnetic resonance imaging? That seems rather common these days.) He was diagnosed with cT2b intermediate-risk localized prostate cancer (PCa) by National Comprehensive Cancer Network (NCCN) risk group and was seen in the multidisciplinary clinic to discuss management options (Table 1).

Localized prostate cancer and robot-assisted laparoscopic radical prostatectomy: a retrospective, comparative study between pre- and post-operative Gleason scores

INTRODUCTION

To compare the pre- and post-operative Gleason scores (GS) in patients with localized prostate cancer treated with robot-assisted laparoscopic radical prostatectomy.

MATERIALS AND METHODS

A single center, retrospective comparison between pre- and post-operative GS. Age, prostate volume, PSA, number of biopsies, number of positive cores, biopsy GS, cTNM, final pathology GS and pTNM of 286 patients were retrieved. They were divided into risk groups.

RESULTS

A total of 286 patients with a mean age at surgery of 64.64 ± 7.81 y and mean PSA-value of 9.35 ± 8.38 ng/mL. Mean prostate volume was 55.09 ± 24.93 mL, mean number of biopsies was 11.90 ± 4.63. Mean percentage of positive cores was 36.90 ± 22.42%. A GS of <7 was seen in 23.4%, 66.8% had a GS of 7 and 9.7% of >7 in final pathology. Of the total, 38.1% were pre-operative low risk, 58.7% of them had an upgrade in GS on final pathology, 45.1% were in the intermediate risk group, 5.4% showed a downgrade, 64.3% remained stable and 30.2% had an upgrade in GS. Also, 16.8% were high risk patients of which 35.4% had a downgrade, 39.6% remained stable and 25% showed an upgrade of the GS.

CONCLUSIONS

We found a substantial underestimation of the GS in the pre-operative setting when compared to the GS in final pathology.

125I Brachytherapy for Localized Prostate Cancer: A Single Institution Experience

Aims and background

To evaluate the clinical outcome of a cohort of localized prostate cancer patients treated with 125I permanent brachytherapy at the University of Turin.

Methods and study design

A retrospective analysis was carried out on 167 consecutive patients with early stage prostate adenocarcinoma who underwent 125I brachytherapy between January 2003 and December 2010. A minimum follow-up of ≥12 months was mandatory for inclusion. Biochemical disease-free survival (defined on the basis of the ASTRO definition and the ASTRO-Phoenix definition) was chosen as the primary end point. Secondary end points were gastrointestinal and genitourinary toxicity (acute and late, defined according to the RTOG scale).

Results

With a median follow-up of 42 months (range, 13.5–90.7), biochemical disease-free survival at 3 and 5 years was respectively 91.1% and 85.7%, according to the ASTRO definition and 94.5% and 85.1% according to ASTRO-Phoenix definition (for statistical purposes, only the ASTRO definition was used). Hormone treatment and nadir PSA (cutoff of 0.35 ng/ml) were the only factors affecting biochemical disease-free survival both on univariate ( P = 0.02 and P = 0.001, respectively) and multivariate analysis (HR 0.024; P = 0.021 and HR 21.6; P = 0.006, respectively). Only 3.6% of patients experienced ≥grade 3 acute urinary toxicity and 5% ≥grade 3 late urinary toxicity. Prior transurethral prostate resection was the only independent predictor of grade 3 late urinary toxicity on multivariate analysis (HR 0.13; P = 0.009).

Conclusions

This mono-institutional series confirmed that brachytherapy is an effective and safe treatment modality for localized prostate cancer, with acceptable short- and long-term morbidity rates.

A retrospective analysis after low-dose-rate prostate brachytherapy with permanent 125I seed implant: clinical and dosimetric results in 70 patients

Aims and background

To evaluate the biochemical disease-free survival (bDFS) rate after 125I permanent-implant prostate brachytherapy.

Methods

Patients with a diagnosis of prostate adenocarcinoma and adequate PSA follow-up were selected for this retrospective study. Brachytherapy with permanent 125I seeds was performed as monotherapy, with a prescribed dose of 145 Gy to the prostate. Patients were stratified into recurrence risk groups according to the National Comprehensive Cancer Network (NCCN) guidelines. Biochemical failure was defined using the American Society of Therapeutic Radiology and Oncology (ASTRO) guidelines. The post-implant D90 (defined as the minimum dose covering 90% of the prostate) was obtained for each patient. Two cutoff points were used to test the correlation between D90 and bDFS results: 130 Gy and 140 Gy. bDFS was calculated from the implant date to the date of biochemical recurrence. Univariate and multivariate analysis were performed using the SPSS software and included clinical stage, pretreatment PSA, Gleason score (GS), androgen deprivation therapy, D90, and risk groups. In the univariate analysis we used a cutoff point of 5.89 ng/mL for PSA and 5 for GS.

Results

From June 2003 to April 2007, 70 patients were analyzed. The patients' distribution into recurrence risk groups was as follows: 39 patients (56%) in the low-risk group, 23 patients (33%) in the intermediate-risk group, and 8 patients (11%) in the high-risk group. At a median follow-up of 47 months (range, 19–70 months) bDFS was 88.4%, with a global actuarial 5-year bDFS of 86%. Disease-related factors including initial PSA level, GS and risk group were significant predictors of biochemical failure (P = 0.01, P = 0.01, P = 0.006, respectively). In multivariate analysis, risk group (P = 0.005) and GS (P = 0.03) were statistically significant.

Conclusion

Our data are in agreement with those in the literature and, despite the short follow-up, confirm the advantage of brachytherapy for patients at low and intermediate risk of recurrence.

Radiotherapy and Hormone Treatment in Prostate Cancer

BACKGROUND

Prostate cancer has the highest incidence of any type of cancer in Germany; an estimated 67 000 new diagnoses of prostate cancer will be made in 2016. In the current German S3 guideline for the treatment of prostate cancer, radiotherapy-sometimes in combination with androgen deprivation therapy (ADT)-is one of the two recommended options for treatment with curative intent (the other is radical prostatectomy). There have been many publications on this subject, yet it is still often unclear in routine practice how ADT should be administered, and for how long.

METHODS

This review is based on publications retrieved by a selective literature search, with special attention to controlled trials.

RESULTS

For low risk patients, radiotherapy without ADT is indicated (evidence level 1). Patients with localized prostate cancer and an intermediate risk benefit from radiotherapy combined with a four-to-six-month course of ADT. In this situation, a higher radiation dose might be an effective substitute for ADT (evidence level 1-2). For patients at high risk, radiotherapy combined with long-term hormonal treatment is the standard therapy, as it significantly improves all oncological end points (evidence level 1). For example, in the largest randomized and controlled trial, this form of treatment reduced cancer-specific mortality from 19% to 9% . Higher radiation doses of 66-74 Gy and longer ADT can improve local control at the cost of increased urethral toxicity.

CONCLUSION

Androgen deprivation combined with external beam radiotherapy is a curative standard option for patients with prostate cancer who are at high risk of recurrence. The modern radiotherapeutic techniques that are now available, such as intensity-modulated radiotherapy, enable a further improvement of the risk/benefit ratio.

Whom to Treat: Postdiagnostic Risk Assessment with Gleason Score, Risk Models, and Genomic Classifier

Management of prostate cancer presents unique challenges because of the disease's variable natural history. Accurate risk stratification at the time of diagnosis in clinically localized disease is crucial in providing optimal counseling about management options. To accurately distinguish pathologically indolent tumors from aggressive disease, risk groups are no longer sufficient. Rather, multivariable prognostic models reflecting the complete information known at time of diagnosis offer improved accuracy and interpretability. After diagnosis, further testing with genomic assays or other biomarkers improves risk classification. These postdiagnostic risk assessment tools should not supplant shared decision making, but rather facilitate risk classification and enable more individualized care.