Clinical experiences of incidental prostate cancer after transurethral resection of prostate (TURP) according to initial treatment: a study of a Korean high volume center

Current Trends in Incidence and Management of T1a and T1b Prostate Cancer

Prostate cancer (PCa) identified incidentally (iPCa) after surgical treatment for symptomatic benign prostatic hyperplasia (BPH) causing lower urinary tract symptoms (LUTS) is considered low risk by the most current guidelines. Management protocols for iPCa are conservative and are identical to other prostate cancers classified as having favorable prognoses. The objectives of this paper are to discuss the incidence of iPCa stratified by BPH procedure, to highlight predictors of cancer progression, and to propose potential modifications to mainstream guidelines for the optimal management of iPCa. The correlation between the rate of iPCa detection and the method of BPH surgery is not clearly defined. Old age, small prostate volume, and high pre-operative prostate-specific antigen (PSA) are associated with an increased likelihood of detecting iPCa. PSA and tumor grade are strong predictors of cancer progression and can be used along with magnetic resonance imaging (MRI) and potential confirmatory biopsies to determine disease management. In instances that iPCa requires treatment, radical prostatectomy (RP), radiation therapy, and androgen deprivation therapy all have oncologic benefits but may be associated with increased risk after the BPH surgery. It is advised that patients with low to favorable intermediate-risk prostate cancer undergo post-operative PSA measurement and prostate MRI imaging before electing to choose between observation, surveillance without confirmatory biopsy, immediate confirmatory biopsy, or active treatment. Subdividing the binary T1a/b cancer staging into more categories with ranging percentages of malignant tissue would be a helpful first step in tailoring the management of iPCa.

Incidence of incidental cancer in transurethral resection of prostate specimens: a 10-year retrospective analysis

Background

Prostate cancer can be detected incidentally in patients undergoing transurethral resection of the prostate for benign prostatic hyperplasia. Therefore, it is very important that the transurethral resection of the prostate specimen is evaluated carefully for accurate grading and staging. The aim of this study was to investigate the frequency of incidental prostate cancer and its relationship with clinicopathological findings.

Methods

The study included a total of 900 patients, who underwent transurethral resection of the prostate for benign prostatic hyperplasia treatment between June 2010 and June 2020. Patient age, prostate-specific antigen (PSA) levels and resected prostate weight were assessed, and the tumor stage, Gleason grade group, lymphovascular and perineural invasion status were also evaluated in the incidental prostate cancer group. The association between these parameters and prostate cancer detection was analyzed.

Results

Incidental detection of prostate cancer was determined at the rate of 13.3%. The incidental prostate cancer group had a significantly higher mean age and PSA levels compared to the benign prostatic hyperplasia group. The weight of the resected specimen had no impact on the incidence of incidental prostate cancer. Of the total 120 incidental prostate cancer cases, 59 (49.2%) were stage T1a and 61 (50.8%) were stage T1b. No significant difference was determined between the T1 stages and age distribution, but a statistically significant difference was determined in the other clinicopathological parameters.

Conclusions

The results of this study demonstrated that the incidence of incidental prostate cancer detection was related to age and PSA levels and increased, especially in those aged ≥ 60 years and/or PSA level ≥ 4 ng/mL. To avoid overlooking incidental prostate cancer in these patients, it can be recommended that material is sufficiently sampled and carefully evaluated, and when necessary, all resected specimens are examined. Although no significant correlation was determined between specimen weight and the incidence of incidental prostate cancer, as a significant difference was determined in T1 stages, this suggests that the amount of material evaluated could change the sub-stage.

Incidental Prostatic Adenocarcinoma in Open Prostatectomy Specimens: An Institutional Experience

Background

Prostatic diseases cause significant morbidity and mortality in African men. Most Nigerian patients presenting with huge prostate enlargement are availed open prostatectomy to relieve symptoms of prostatism. Some prostates removed for benign enlargement have indolent cancers that are only discovered after histopathological examination. The incidence of these incidental adenocarcinomas of the prostate varies widely.

Methodology

We carried out a 10-year retrospective review of open prostatectomy specimens received in the Department of Pathology, from January 2009 to December 2018. At grossing, a minimum of 6 cassettes were used depending on size, and tissue was taken from representative areas for microscopic examination. The data was analysed for the presence of, and the relationship between, incidental adenocarcinoma of the prostate and clinicopathological parameters in each case using relevant statistical tools in the SPSS version 23.

Results

Incidental adenocarcinoma of the prostate was found in 5.7% of 158 open prostatectomy specimens seen during the study period. High-grade prostatic intraepithelial neoplasm (HGPIN) was present in 1.9% of cases. Patients in the 7th and 8th decade accounted for 88.8% of all incidental adenocarcinomas. The mean weight of the excised glands was 89.8g (range10-500g). The weight of the prostate did not predict diagnosis of incidental adenocarcinoma. In-hospital consultation accounted for 66.9% of open prostatectomy samples received in the department but the majority (72.7%) of incidental adenocarcinomas were seen in specimens form external consultations. The tumours were mostly ISUP grade group one tumours.

Conclusion

The rate of diagnosis of occult prostate cancer is low with majority of the tumours being well differentiated. Organ weight had no relationship with histological diagnosis. Cases managed outside the teaching hospital were more likely to have incidental prostate cancer.

Active surveillance for prostate cancer: comparison between incidental tumors vs. tumors diagnosed at prostate biopsies

PURPOSE

To test discontinuation rates during Active Surveillance (AS) in patients diagnosed with incidental prostate cancers (IPCa) vs. tumors diagnosed at prostate biopsies (BxPCa).

METHODS

Retrospective single center analysis of 961 vs. 121 BxPCa vs. IPCa patients (2008-2020). Kaplan-Meier plots and multivariable Cox regression models tested four different outcomes: (1) any-cause discontinuation; (2) discontinuation due to ISUP GG upgrading; (3) biopsy discontinuation due to ISUP GG upgrading or > 3 positive cores; (4) biopsy discontinuation or suspicious extraprostatic extension at surveillance mpMRI. Then, multivariable logistic regression models tested rates of clinically significant PCa (csPCa) (ISUP GG ≥ 3 or pT ≥ 3a or pN1) after radical prostatectomy (RP).

RESULTS

Median time follow-up was 35 (19-64) months. IPCa patients were at lower risk of any-cause (3-year survival: 79.3 vs. 66%; HR: 0.5, p = 0.001) and biopsy/MRI AS discontinuation (3-year survival: 82.3 vs. 72.7%; HR: 0.5, p = 0.001), compared to BxPCa patients. Conversely, IPCa patients exhibited same rates of biopsy discontinuation and ISUP GG upgrading over time, relative to BxPCa. In multivariable logistic regression models, IPCa patients were associated with higher rates of csPCa at RP (OR: 1.4, p = 0.03), relative to their BxPCa counterparts.

CONCLUSION

AS represents a safe management strategy for IPCa. Compared to BxPCa, IPCa patients are less prone to experience any-cause and biopsy/MRI AS discontinuation. However, the two mentioned groups present similar rates of biopsy discontinuation and ISUP GG upgrading over time. In consequence, tailored AS protocols with scheduled repeated surveillance biopsies should be offered to all newly diagnosed IPCa patients.

Exploration on Gleason score variation trend of patients with prostate carcinoma from 1996 to 2019: a retrospective single center study

Background

Gleason score (GS) is one of the stronger prognostic factors and is integral to the management of prostate carcinoma. Subsequent modifications, recommended by the International Society of Urological Pathology in 2005 and 2014, enabled accurate prediction of prognosis. The present study investigated GS variation trend of patients with prostate carcinoma from 1996 to 2019 and offered an overview of GS changes with age, specimen type, histopathological type and serum prostate specific antigen (PSA).

Methods

One thousand three hundred and seventy-six patients, admitted to Peking University People's Hospital in 1996 to 2019, were divided into 1996 to 2006, 2007 to 2015 and 2016 to 2019 groups. Data, including demographic characteristics, GS, primary and secondary grade and percentage of primary and secondary grade of each group, were collected and analyzed. The population distribution and average of GS was evaluated, after segmented and stratified by age, type of specimen, histopathological type and PSA.

Results

The average of age and PSA of each cohort had no obvious change. The average of total GS fluctuated among three cohorts with statistically significant differences. The distribution of age and PSA did not differ among cohorts. The distribution of total and primary GS shifted, with more patients detected as total GS higher than 6 (86.1%), and more primary grade higher than 3 (56.7%) in 2016-2019. After segmented and stratified by age, specimen type, histological type and PSA, the population percentage of GS over 6 was significantly higher in 2016-2019 than 1996-2006 and 2007-2015 in patients aged younger than 80 years (age <60, 89.6%, age 60-69, 82.0%, age 70-79, 87.7%). Patients, aged below 80 years in 2016-2019, were detected with higher total GS.

Conclusions

In the present study, GS in patients with prostate carcinoma showed a upward trend. Primary grade, age, serum PSA and specimen type were the main reasons for GS changing while secondary grade, tissue types and diagnostic criteria influenced less.

Active Surveillance for Incidental (cT1a/b) Prostate Cancer: Long-Term Outcomes of the Prospective Noninterventional HAROW Study

INTRODUCTION

Optimal treatment for incidental prostate cancer (IPC) after surgical treatment for benign prostate obstruction is still debatable. We report on long-term outcomes of IPC patients managed with active surveillance (AS) in a German multicenter study.

METHODS

HAROW (2008-2013) was designed as a noninterventional, prospective, health-service research study for patients with localized prostate cancer (≤cT2), including patients with IPC (cT1a/b). A follow-up examination of all patients treated with AS was carried out. Overall, cancer-specific, and metastasis-free survival and discontinuation rates were determined.

RESULTS

Of 210 IPC patients, 68 opted for AS and were available for evaluation. Fifty-four patients had cT1a category and 14 cT1b category. Median follow-up was 7.7 years (IQR: 5.7-9.1). Eight patients died of which 6 were still under AS or watchful waiting (WW). No PCa-specific death could be observed. One patient developed metastasis. Twenty-three patients (33.8%) discontinued AS changing to invasive treatment: 12 chose radical prostatectomy, 7 radiotherapy, and 4 hormonal treatment. Another 19 patients switched to WW. The Kaplan-Meier estimated 10-year overall, cancer-specific, metastasis-free, and intervention-free survival was 83.8% (95% CI: 72.2-95.3), 100%, 98.4% (95% CI: 95.3-99.9), and 61.0% (95% CI: 47.7-74.3), respectively. In multivariable analysis, age (RR: 0.97; p < 0.001), PSA density ≥0.2 ng/mL2 (RR: 13.23; p < 0.001), and PSA ≥1.0 ng/mL after surgery (RR: 5.19; p = 0.016) were significantly predictive for receiving an invasive treatment.

CONCLUSION

In comparison with other AS series with a general low-risk prostate cancer population, our study confirmed the promising survival outcomes for IPC patients, whereas discontinuation rates seem to be lower for IPC. Thus, IPC patients at low risk of progression may be good candidates for AS.

Clinical experience with active surveillance protocol using regular magnetic resonance imaging instead of regular repeat biopsy for monitoring: A study at a high-volume center in Korea

Background

Here, we report the experience of a multiparameter magnetic resonance imaging (MRI)–based active surveillance (AS) protocol that did not include performing a repeat biopsy after the diagnosis of prostate cancer by prostate biopsy or transurethral resection of prostate.

Methods

From January 2010 to December 2017, we reviewed 193 patients with newly diagnosed prostate cancer who were eligible for AS. The patients were divided into AS group (n = 122) and definitive treatment group (n = 71) based on initial treatment. Disease progression was defined as a remarkable change in MRI findings. To confirm the stability of protocol, we compared the clinicopathological characteristics of patients who initially underwent radical prostatectomy (RP) (n = 58) and RP after termination of AS (n = 20).

Results

Among patients who initially selected AS (median adherence duration = 31.4 months), 70 (57.3%) subsequently changed their treatment options. Disease progression (n = 30) was the main cause for termination. No significant differences were found in the clinicopathologic characteristics at initial diagnosis and pathologic outcomes between patients who initially underwent RP and those who chose RP after termination of AS. In a comparative analysis of diagnostic methods, the patients with incidental prostate cancer by transurethral resection of prostate had higher age, lower prostate-specific antigen level and density, as well as longer AS adherence duration and follow-up duration compared with those diagnosed by prostate biopsy.

Conclusions

Our AS monitoring protocol, which depends on MRI instead of regular repeat biopsy, was feasible. Patients with incidental prostate cancer continued AS more compared with patients diagnosed by prostate biopsy.

Interval from transurethral resection of prostate to laparoscopic radical prostatectomy does not affect outcomes for incidental prostate cancer

Introduction

Laparoscopic radical prostatectomy (LRP) has become a common option for the treatment of prostate cancer. The aim of our study was to examine whether LRP performed within 12 weeks of transurethral resection of the prostate (TURP) is associated with surgical difficulty or outcomes.

Material and methods

A single-institutional retrospective analysis was performed on patients who underwent LRP for incidental prostate cancer after TURP between July 2009 and December 2017. The interval between TURP and LRP was determined and patients with intervals of ≤ 12 weeks were compared to those with intervals of > 12 weeks. Patient characteristics, perioperative, pathological, and postoperative functional outcomes were analyzed to determine statistically significant differences between the 2 groups. Multivariable analyses were performed to determine whether the interval between TURP and LRP was a significant independent predictor of these outcomes.

Results

A total of 56 incidental prostate cancer patients detected by TURP were included in this study. No significant differences were detected in estimated blood loss, operative duration, postoperative length of stay, and rate of positive margin, Gleason score upgrading, major complications, incontinence and prostate-specific antigen (PSA) recurrence in patients with a TURP to LRP interval above and below 12 weeks. The TURP to LRP interval was not an independent predictor of outcomes during or after LRP.

Conclusions

Our results showed that performing LRP within 12 weeks after TURP does not adversely influence surgical difficulty or outcomes.

Favorable long-term oncological and urinary outcomes of incidental prostate cancer following holmium laser enucleation of the prostate

The aim of the present study was to investigate the impact of incidental prostate cancer (IPCa), which was diagnosed by holmium laser enucleation of the prostate (HoLEP), on long-term oncological and functional outcomes. A total of 482 patients who underwent HoLEP for benign prostatic hyperplasia (BPH) between 2008 and 2016 at our institution were retrospectively reviewed. We defined IPCa as prostate cancer (PCa) according to the enucleated tissue of transitional zone. Therefore, 64 patients were excluded for the following reasons: Prostate-specific antigen (PSA) ≥4.0 ng/ml and no prostate biopsy (n=46); and PSA ≥4.0 ng/ml and diagnosed with PCa by prostate biopsy performed during HoLEP (n=18). Notably, 418 patients were included in the study and divided into two groups: The BPH group and the IPCa group. For 5 years, postoperative PSA and functional outcomes were evaluated. Of 418 patients, 25 (6%) were diagnosed with IPCa by HoLEP, 21 patients (84%) had a Gleason score ≤6 and 5 patients (20%) received adjuvant therapy for PCa following HoLEP. No significant differences were observed between groups for preoperative PSA, PSA density, or urinary and sexual function outcomes; however, age at the time of HoLEP significantly differed between groups (71.7 vs. 75.5 years, P=0.026). Long-term (5-year) urinary outcomes demonstrated sustained improvement. Postoperative PSA increased gradually in the IPCa group (3-year, P=0.033; 4-year, P=0.037); International Index of Erectile Function 5 conversely decreased (5-year, P=0.068). According to the present results, if standard PSA screening and prostate biopsy are performed, watchful waiting for IPCa is feasible, and IPCa does not impact on 5-year urinary outcomes.

Incidental prostate cancer: a 10-year review of a tertiary center, Tehran, Iran

Objective

Incidental prostate cancer (IPCa) is defined as a symptom-free cancer unexpectedly discovered upon microscopic examination of resected tissue. The aim of this study was to report the correlation between some specific clinical criteria in patients incidentally diagnosed with prostate cancer (PCa) during transurethral resection of the prostate (TURP) or open prostatectomy (OP) after clinically suspected benign prostatic hyperplasia.

Patients and methods

This was a cross-sectional, retrospective study. Data were collected from Shohada-e-Tajrish Hospital database during November 2006 to October 2016. Four hundred and twenty three men suffering from symptomatic benign prostatic hyperplasia who underwent either TURP or OP that provided a prostate specimen were evaluated. The data analysis was performed using Pearson correlation test and independent t-test using SPSS version 20 software.

Results

The mean age of subjects was 68.74±9.87 years old (45-93 years). The mean prostate specific antigen (PSA) level was 21.47±13.44 ng/mL (0.6-47.1 ng/mL). Results showed that 84 patients (19.9%) had PCa (40 patients who underwent TURP [12.6%] and 44 patients who underwent OP [40.7%] groups). Cut-off point of PSA for detecting IPCa was 3.8 ng/mL in our study, and this showed sensitivity, specificity, negative predictive value, and positive predictive value of 26.08%, 100%, 100%, and 29.79%, respectively. Twenty two patients with cancer had a positive family history for PCa; thus, a significant relationship between familial history of PCa and its occurrence was shown (p=0.0001).

Conclusion

According to the results of this study, the cut-off point for PSA levels in detecting PCa was 3.8 ng/mL, which is similar to that reported by other studies. Familial history of PCa and PSA levels were two predictors in determining the PCa.

Incremental value of 68-gallium-prostate-specific membrane antigen positron emission tomography/computed tomography in patients with abnormal prostate-specific antigen and benign transrectal ultrasound biopsy

Introduction:

Bladder outlet obstruction due to prostate enlargement is a common health problem in male and frequently investigated with prostate-specific antigen (PSA) and transrectal ultrasound (TRUS). TRUS-guided biopsy is critical to differentiate benign prostatic hyperplasia (BPH) or prostate cancer (PCa) even though it has been associated with false negative with reported 3%–16% incidence of PCa in BPH specimens. Prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT), a targeted molecular imaging for PCa, has showed promising results in recurrence and staging. We analyzed its role in patients with abnormal PSA and benign TRUS biopsy.

Material and Methods:

Of 558 ⁶⁸Ga-PSMA PET/CT performed from July 2014 to February 2017, we found six patients with abnormal PSA (range 8.2–24.2 ng/ml, median: 13.3 ng/ml) with benign 12 cores TRUS biopsy as indication. These cases were reanalyzed in detail. Spearman's rank test was used entire correlation using SPSS version 21.

Results:

⁶⁸Ga-PSMA PET/CT showed mild diffuse tracer uptake in prostate in all patients with no focality and maximum standard uptake value normalized to body weight (SUV_max) range was 3.2-5.8 (median: 3.9). Two patients with PSA <10 ng/ml had normal ⁶⁸Ga-PSMA PET/CT and underwent medical management. In other four patients with PSA >10 ng/ml, two showed metastatic disease in pelvic lymph node in both and in lung in one; hence, ⁶⁸Ga-PSMA PET/CT changed these patients' management. Spearman's rank test showed no correlation with baseline PSA and SUV_max of prostate (r_s −0.0287, P = 0.9571) while strong positive correlation was seen with baseline PSA and ⁶⁸Ga-PSMA PET/CT scan positivity for extraprostatic disease (r_s = 0.828, P = 0.042).

Conclusions:

⁶⁸Ga-PSMA whole-body PET/CT can provide useful incremental information in patient with high PSA and negative TRUS biopsy and has a potential to guide management in this subgroup of PCa patients.

Active surveillance in localized prostate cancer: comparison of incidental tumours (T1a/b) and tumours diagnosed by core needle biopsy (T1c/T2a): results from the HAROW study

OBJECTIVE

To conduct a comparative prospective analysis of patients with incidental T1a/T1b prostate cancer (IPCa) and those with prostate cancer (PCa) diagnosed by core needle biopsy, treated by active surveillance (AS), with regard to inclusion criteria, progression and switch to deferred treatment.

PATIENTS AND METHODS

The HAROW study is an observational outcomes research study on the management of localized PCa. Treating urologists reported clinical variables and information on therapy and clinical course of disease at 6-month intervals. With respect to therapy, only recommendations were made; the final decision on the therapeutic method rested with the treating physician.

RESULTS

Out of 2 957 patients included in the HAROW study, 447 chose AS. The median follow-up was 28.3 months. T1a, T1b, T1c and T2a disease were diagnosed in 81, 18, 292 and 56 patients, respectively. Patients in the IPCa group had lower prostate-specific antigen (PSA) levels (4.2 vs 6.1 ng/mL) and more comorbidities than those diagnosed by core needle biospy. The IPCa group also had fewer re-biopsies (25.3 vs 43.2%) and fewer changes to invasive treatment (12.1 vs 25.9%). No significant differences were found with respect to the criteria for discontinuation, subsequent therapies and histological findings after radical prostatectomy.

CONCLUSION

Urologists are highly inclined to use AS as a therapeutic option in IPCa. More patients with IPCa than those diagnosed after core needle biopsy continued on AS, which was also associated with the indication for a re-biopsy being less stringently observed.

Treatment of Incidental Prostate Cancer by Active Surveillance: Results of the HAROW Study

Objective: To report on a cohort of patients with incidental prostate cancer (IPC) that was treated by an active surveillance (AS) protocol in the HAROW study. Materials and Methods: The HAROW study is an observational study on the management of localized prostate cancer in Germany. Treating urologists were reporting clinical parameters, information on therapy and clinical course of disease at 6-month intervals. Results: In total, 3,169 patients were enrolled. In 224 patients were found an IPC and 104 (46%) of them were put on an AS protocol. The mean follow-up was 26.5 months. Tumor progression was noted in 16 patients. In 11 patients, AS was replaced by a definite intervention. In univariate and multivariate analyses, only PSA density correlated with progression. Conclusion: This is the first prospective description of an IPC patient cohort on AS as part of an outcomes research study. AS was selected as a therapeutic strategy in nearly half of the patients (46%). Only a minor proportion (16%) displayed progression. Of the clinical parameters, only PSA density correlated with progression.