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Hurez V, Padrón ÁS, Svatek RS, Curiel TJ. Considerations for successful cancer immunotherapy in aged hosts. Clin Exp Immunol 2016; 187:53-63. [PMID: 27690272 DOI: 10.1111/cei.12875] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2016] [Indexed: 12/22/2022] Open
Abstract
Immunotherapy is now experiencing unprecedented successes in treating various cancers based on new understandings of cancer immunopathogenesis. Nonetheless, although ageing is the biggest risk factor for cancer, the majority of cancer immunotherapy preclinical studies are conducted in young hosts. This review will explore age-related changes in immunity as they relate to cancer immune surveillance, immunopathogenesis and responses to immunotherapy. Although it is recognized that declining T cell function with age poses a great challenge to developing effective age-related cancer immunotherapies, examples of successful approaches to overcome this hurdle have been developed. Further, it is now recognized that immune functions do not simply decline with age, but rather change in ways than can be detrimental. For example, with age, specific immune cell populations with detrimental functions can become predominant (such as cells producing proinflammatory cytokines), suppressive cells can become more numerous or more suppressive (such as myeloid-derived suppressor cells), drugs can affect aged immune cells distinctly and the aged microenvironment is becoming recognized as a significant barrier to address. Key developments in these and other areas will be surveyed as they relate to cancer immunotherapy in aged hosts, and areas in need of more study will be assessed with some speculations for the future. We propose the term 'age-related immune dysfunction' (ARID) as best representative of age-associated changes in immunity.
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Affiliation(s)
- V Hurez
- Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Á S Padrón
- Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - R S Svatek
- Department of Urology, University of Texas Health Science Center, San Antonio, TX, USA.,Cancer Therapy and Research Center, University of Texas Health Science Center, San Antonio, TX, USA
| | - T J Curiel
- Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA.,Cancer Therapy and Research Center, University of Texas Health Science Center, San Antonio, TX, USA.,Department of Microbiology and Immunology, University of Texas Health Science Center, San Antonio, TX, USA.,The Barshop Institute for Ageing and Longevity Studies, University of Texas Health Science Center, San Antonio, TX, USA
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Kim SP, Gross CP, Smaldone MC, Han LC, Van Houten H, Lotan Y, Svatek RS, Thompson RH, Karnes RJ, Trinh QD, Kutikov A, Shah ND. Perioperative outcomes and hospital reimbursement by type of radical prostatectomy: results from a privately insured patient population. Prostate Cancer Prostatic Dis 2014; 18:13-7. [PMID: 25311766 DOI: 10.1038/pcan.2014.38] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 08/12/2014] [Accepted: 08/18/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND With the increasing use of robotic surgery in the United States, the comparative effectiveness and differences in reimbursement of minimally invasive radical prostatectomy (MIRP) and open prostatectomy (ORP) in privately insured patients are unknown. Therefore, we sought to assess the differences in perioperative outcomes and hospital reimbursement in a privately insured patient population who were surgically treated for prostate cancer. METHODS Using a large private insurance database, we identified 17,610 prostate cancer patients who underwent either MIRP or ORP from 2003 to 2010. The primary outcomes were length of stay (LOS), perioperative complications, 90-day readmissions rates and hospital reimbursement. Multivariable regression analyses were used to evaluate for differences in primary outcomes across surgical approaches. RESULTS Overall, 8981 (51.0%) and 8629 (49.0%) surgically treated prostate cancer patients underwent MIRP and ORP, respectively. The proportion of patients undergoing MIRP markedly rose from 11.9% in 2003 to 72.5% in 2010 (P<0.001 for trend). Relative to ORP, MIRP was associated with a shorter median LOS (1.0 day vs 3.0 days; P<0.001) and lower adjusted odds ratio of perioperative complications (OR: 0.82; P<0.001). However, the 90-day readmission rates of MIRP and ORP were similar (OR: 0.99; P=0.76). MIRP provided higher adjusted mean hospital reimbursement compared with ORP (US $19,292 vs. US $17,347; P<0.001). CONCLUSIONS Among privately insured patients diagnosed with prostate cancer, robotic surgery rapidly disseminated with over 70% of patients undergoing MIRP by 2009-2010. Although MIRP was associated with shorter LOS and modestly better perioperative outcomes, hospitals received higher reimbursement for MIRP compared with ORP.
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Affiliation(s)
- S P Kim
- 1] University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Urology Institute, Cleveland, OH, USA [2] Center for Reducing Racial Disparities, Case Western Reserve University, Cleveland, OH, USA
| | - C P Gross
- 1] Yale University, Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, New Haven, CT, USA [2] Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - M C Smaldone
- Fox Chase Cancer Center, Department of Surgery, Philadelphia, PA, USA
| | - L C Han
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | - H Van Houten
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | - Y Lotan
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - R S Svatek
- Department of Urology, UT Health Science Center San Antonio, San Antonio, TX, USA
| | - R H Thompson
- Mayo Clinic, Department of Urology, Rochester, MN, USA
| | - R J Karnes
- Mayo Clinic, Department of Urology, Rochester, MN, USA
| | - Q-D Trinh
- Harvard Medical School, Brigham and Women's Hospital, Dana Farber Cancer Institute, Division of Urologic Surgery, Boston, MA, USA
| | - A Kutikov
- Fox Chase Cancer Center, Department of Surgery, Philadelphia, PA, USA
| | - N D Shah
- 1] Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA [2] Mayo Clinic, Knowledge and Evaluation Research Unit, Rochester, MN, USA
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Xylinas E, Kent M, Kluth L, Pycha A, Comploj E, Svatek RS, Lotan Y, Trinh QD, Karakiewicz PI, Holmang S, Scherr DS, Zerbib M, Vickers AJ, Shariat SF. Accuracy of the EORTC risk tables and of the CUETO scoring model to predict outcomes in non-muscle-invasive urothelial carcinoma of the bladder. Br J Cancer 2013; 109:1460-6. [PMID: 23982601 PMCID: PMC3776972 DOI: 10.1038/bjc.2013.372] [Citation(s) in RCA: 168] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 06/13/2013] [Accepted: 06/22/2013] [Indexed: 11/24/2022] Open
Abstract
Background: The European Organization for Research and Treatment of Cancer (EORTC) risk tables and the Spanish Urological Club for Oncological Treatment (CUETO) scoring model are the two best-established predictive tools to help decision making for patients with non-muscle-invasive bladder cancer (NMIBC). The aim of the current study was to assess the performance of these predictive tools in a large multicentre cohort of NMIBC patients. Methods: We performed a retrospective analysis of 4689 patients with NMIBC. To evaluate the discrimination of the models, we created Cox proportional hazard regression models for time to disease recurrence and progression. We incorporated the patients calculated risk score as a predictor into both of these models and then calculated their discrimination (concordance indexes). We compared the concordance index of our models with the concordance index reported for the models. Results: With a median follow-up of 57 months, 2110 patients experienced disease recurrence and 591 patients experienced disease progression. Both tools exhibited a poor discrimination for disease recurrence and progression (0.597 and 0.662, and 0.523 and 0.616, respectively, for the EORTC and CUETO models). The EORTC tables overestimated the risk of disease recurrence and progression in high-risk patients. The discrimination of the EORTC tables was even lower in the subgroup of patients treated with BCG (0.554 and 0.576 for disease recurrence and progression, respectively). Conversely, the discrimination of the CUETO model increased in BCG-treated patients (0.597 and 0.645 for disease recurrence and progression, respectively). However, both models overestimated the risk of disease progression in high-risk patients. Conclusion: The EORTC risk tables and the CUETO scoring system exhibit a poor discrimination for both disease recurrence and progression in NMIBC patients. These models overestimated the risk of disease recurrence and progression in high-risk patients. These overestimations remained in BCG-treated patients, especially for the EORTC tables. These results underline the need for improving our current predictive tools. However, our study is limited by its retrospective and multi-institutional design.
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Affiliation(s)
- E Xylinas
- 1] Department of Urology, Weill Cornell Medical College, New York, NY, USA [2] Department of Urology, Cochin Hospital, APHP, Paris Descartes University, Paris, France
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Xylinas E, Cha EK, Sun M, Rink M, Trinh QD, Novara G, Green DA, Pycha A, Fradet Y, Daneshmand S, Svatek RS, Fritsche HM, Kassouf W, Scherr DS, Faison T, Crivelli JJ, Tagawa ST, Zerbib M, Karakiewicz PI, Shariat SF. Risk stratification of pT1-3N0 patients after radical cystectomy for adjuvant chemotherapy counselling. Br J Cancer 2013; 107:1826-32. [PMID: 23169335 PMCID: PMC3504939 DOI: 10.1038/bjc.2012.464] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND In pT1-T3N0 urothelial carcinoma of the bladder (UCB) patients, multi-modal therapy is inconsistently recommended. The aim of the study was to develop a prognostic tool to help decision-making regarding adjuvant therapy. METHODS We included 2145 patients with pT1-3N0 UCB after radical cystectomy (RC), naive of neoadjuvant or adjuvant therapy. The cohort was randomly split into development cohort based on the US patients (n=1067) and validation cohort based on the Europe patients (n=1078). Predictive accuracy was quantified using the concordance index. RESULTS With a median follow-up of 45 months, 5-year recurrence-free and cancer-specific survival estimates were 68% and 73%, respectively. pT-stage, ge, lymphovascular invasion, and positive margin were significantly associated with both disease recurrence and cancer-specific mortality (P-values ≤ 0.005). The accuracies of the multivariable models at 2, 5, and 7 years for predicting disease recurrence were 67.4%, 65%, and 64.4%, respectively. Accuracies at 2, 5, and 7 years for predicting cancer-specific mortality were 69.3%, 66.4%, and 65.5%, respectively. We developed competing-risk, conditional probability nomograms. External validation revealed minor overestimation. CONCLUSION Despite RC, a significant number of patients with pT1-3N0 UCB experience disease recurrence and ultimately die of UCB. We developed and externally validated competing-risk, conditional probability post-RC nomograms for prediction of disease recurrence and cancer-specific mortality.
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Affiliation(s)
- E Xylinas
- Department of Urology, Weill Cornell Medical College, Starr 900, 525 East 68th Street, Box 94, New York, NY 10065, USA
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Choi W, Shah JB, Tran M, Svatek RS, Marquis L, Lee IC, Yu D, Adam L, Bondaruk JE, Wen S, Shen Y, Dinney CPN, Czerniak B, McConkey DJ, Siefker-Radtke AO. Use of P63 expression to define a lethal subset of muscle-invasive bladder cancers. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.4653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Chromecki TF, Svatek RS, Holmäng S, Karakiewicz PI, Mazumdar M, Dunning A, Kamat AM, Tagawa ST, Scherr D, Shariat SF. Prognostic factors of cancer recurrence and progression in non-muscle-invasive urothelial carcinoma: A multicenter study of over 4,300 patients. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.7_suppl.249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
249 Background: The outcomes of patients with non-muscle-invasive urothelial carcinoma of the bladder (NMIUCB) remain poorly understood. The aim of our study was to identify prognostic factors of cancer recurrence and progression in patients with primary UCB. Methods: We performed a combined analysis on individual data from 4,325 patients with primary NMIUCB. Results: Within a median follow-up of 64 months, 1,960 patients (45.4%) experienced disease recurrence, 498 (11.5%) experienced progression to muscle-invasive stage, 1,155 (26.7%) died of any cause, and 310 (7.2%) died of their cancer. In multivariable Cox regression analysis, advanced age, higher grade, larger tumor size, higher number of tumors, number of prior recurrences, and type of intravesical therapy were independent predictors of disease recurrence and progression. While treatment intravesical chemotherapy was only associated with decreased/delayed cancer recurrence, intravesical BCG therapy was associated with decreased/delayed cancer recurrence and progression. The predictive accuracies of the models for recurrence and progression were 63.5% and 71.3%, respectively. Conclusions: Even in a heterogenous patient population, BCG therapy appears to decrease frequency and delay time to cancer recurrence and progression in patients with NMIUCB. Predictive tools based on combination of multiple clinical variables which capture the biological and clinical potential of nonmuscle-invasive disease could help with patient counseling and individualized risk assessment for adjuvant intravesical therapy and clinical trial design. [Table: see text] No significant financial relationships to disclose.
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Affiliation(s)
- T. F. Chromecki
- Weill Cornell Medical College, New York, NY; University of Texas M. D. Anderson Cancer Center, Houston, TX; Sahlgrenska University Hospital, Goteborg, Sweden; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada
| | - R. S. Svatek
- Weill Cornell Medical College, New York, NY; University of Texas M. D. Anderson Cancer Center, Houston, TX; Sahlgrenska University Hospital, Goteborg, Sweden; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada
| | - S. Holmäng
- Weill Cornell Medical College, New York, NY; University of Texas M. D. Anderson Cancer Center, Houston, TX; Sahlgrenska University Hospital, Goteborg, Sweden; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada
| | - P. I. Karakiewicz
- Weill Cornell Medical College, New York, NY; University of Texas M. D. Anderson Cancer Center, Houston, TX; Sahlgrenska University Hospital, Goteborg, Sweden; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada
| | - M. Mazumdar
- Weill Cornell Medical College, New York, NY; University of Texas M. D. Anderson Cancer Center, Houston, TX; Sahlgrenska University Hospital, Goteborg, Sweden; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada
| | - A. Dunning
- Weill Cornell Medical College, New York, NY; University of Texas M. D. Anderson Cancer Center, Houston, TX; Sahlgrenska University Hospital, Goteborg, Sweden; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada
| | - A. M. Kamat
- Weill Cornell Medical College, New York, NY; University of Texas M. D. Anderson Cancer Center, Houston, TX; Sahlgrenska University Hospital, Goteborg, Sweden; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada
| | - S. T. Tagawa
- Weill Cornell Medical College, New York, NY; University of Texas M. D. Anderson Cancer Center, Houston, TX; Sahlgrenska University Hospital, Goteborg, Sweden; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada
| | - D. Scherr
- Weill Cornell Medical College, New York, NY; University of Texas M. D. Anderson Cancer Center, Houston, TX; Sahlgrenska University Hospital, Goteborg, Sweden; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada
| | - S. F. Shariat
- Weill Cornell Medical College, New York, NY; University of Texas M. D. Anderson Cancer Center, Houston, TX; Sahlgrenska University Hospital, Goteborg, Sweden; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada
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Sonpavde G, Khan MM, Lerner SP, Svatek RS, Skinner EC, Karakiewicz PI, Kassouf W, Dinney CP, Fradet Y, Shariat SF. Correlation of disease-free survival at 2 to 3 years and 5-year overall survival in patients with muscle-invasive bladder cancer undergoing radical cystectomy. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.4576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Svatek RS, Lotan Y, Karakiewizc PI, Shariat SF. Screening for bladder cancer using urine-based tumor markers. MINERVA UROL NEFROL 2008; 60:247-253. [PMID: 18923361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Bladder cancer screening differs from routine detection of bladder cancer in patients with symptoms, such as hematuria, or a history of bladder cancer. The ultimate goal of cancer screening is to decrease cancer-related mortality by detecting disease prior to the time that the disease would normally prompt evaluation from symptoms. There are several features of urothelial carcinoma of the bladder which make screening for this disease an attractive alternative to the current approach to this disease. The disease targets a defined population and survival for patients with this disease is strongly associated with disease stage at presentation. In addition, quick, easy, and painless screening tests are theoretically possible using tumor-related markers because of the direct exposure of cancer cells to urine. Indeed, recent insights into the biology of bladder cancer initiation and progression have resulted in the identification of several urine-based markers which have promise for detecting the presence of bladder cancer. Nevertheless, adoption of screening programs prior to establishing evidence of effectiveness and large-scale financial considerations has substantial damaging consequences. This article reviews the current literature regarding screening for bladder cancer using urine-based markers.
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Affiliation(s)
- R S Svatek
- Department of Urologic Oncology, MD Anderson Cancer Center, Houston, TX, USA
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Herman MP, Svatek RS, Lotan Y, Karakiewizc PI, Shariat SF. Urine-based biomarkers for the early detection and surveillance of non-muscle invasive bladder cancer. MINERVA UROL NEFROL 2008; 60:217-235. [PMID: 18923359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Bladder cancer has a very high frequency of recurrence and therefore requires lifelong surveillance, traditionally consisting of serial cystoscopy and cytology. These tests are both invasive and expensive, with considerable inter-user and inter-institutional variability. In addition, the sensitivity of cytology in detecting low-grade tumors is low. Therefore, there has been active investigation into urinary biomarkers that can either supplement or supplant these tests. At this point there are only six urine-based tests that are FDA-approved in bladder cancer surveillance, but a wide variety of other biomarkers are being studied. In this review, we examine the natural history of bladder cancer as well as the rationale and performance of an ideal urinary biomarker. The authors describe the FDA-approved biomarkers such as Bladder Tumor Antigen, ImmunoCyt, Nuclear Matrix Protein-22, and Fluorescent In Situ Hybridization, as well as the most promising investigational tests (i.e., Urinary bladder cancer test, BLCA-1, BLCA-4, hyaluronic acid, hyaluronidase, Lewis X antigen, microsatellite analysis, Quanticyt, soluble Fas, Survivin, and telomerase). The biological foundation, methodologies, and diagnostic performance of the biomarkers are discussed. The characteristics of the biomarkers are compared to urine cytology. At this time, urine biomarkers are utilized in a variety of clinical situations but their role is not well defined. The goal of identifying an optimal marker that will replace cystoscopy and/or cytology is still ongoing.
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Affiliation(s)
- M P Herman
- Weill Cornell Medical College, New York, NY, USA
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Svatek RS, Karam JA, Rogers TE, Shulman MJ, Margulis V, Benaim EA. Intraluminal crystalloids are highly associated with prostatic adenocarcinoma on concurrent biopsy specimens. Prostate Cancer Prostatic Dis 2007; 10:279-82. [PMID: 17325718 DOI: 10.1038/sj.pcan.4500954] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Prostatic crystalloids are intraluminal eosinophilic structures with variable size and shape. Their presence has been described in conjunction with the occurrence of prostatic adenocarcinoma (pCA). We herein report the association of crystalloids and pCA in a prospective trial utilizing an extended multi-site transrectal ultrasound-guided (TRUS) prostate biopsy protocol. Three hundred and forty-four consecutive patients were prospectively enrolled at the Dallas Veterans Administration Hospital from November 2002 to September 2003. Indications for biopsy included a prostate-specific antigen (PSA) > or =4 ng/ml and/or abnormal digital rectal exam. A single pathologist evaluated all biopsy cores and documented the presence or absence of significant histopathologic features. Univariate and multivariate logistic regression analysis were applied to test the association of these features with the presence of pCA on concurrent biopsy. Median number of core biopsies per patient was 12 (range 3-36). Overall cancer detection rate was 42.7%. pCA was diagnosed in 66 (81.5%) of 81 patients with crystalloids, 70 (69.3%) of 101 patients with high-grade prostatic intraepithelial neoplasia (HGPIN), and 32 (84.2%) of 38 patients with both HGPIN and crystalloids on biopsy. Multivariate analysis identified crystalloids (RR 4.53, 95% CI 2.30-8.88) and HGPIN (RR 3.20, 95% CI 1.84-5.57) as independent predictors of the presence of cancer on concurrent biopsy (P<0.001). In this prospective analysis, crystalloids were significantly associated with pCA on concurrent biopsy and more predictive of the presence of pCA than HGPIN. These findings suggest that the presence of crystalloids alone or in combination with HGPIN in prostate biopsies may be a more compelling indication for repeat biopsy than HGPIN alone.
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Affiliation(s)
- R S Svatek
- Department of Urology, Dallas Veterans Administration Hospital, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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