Obligatory information that a patient diagnosed of prostate cancer and candidate for an active surveillance protocol must know

OBJECTIVES

To know the necessary information to reproduce the results found in the literature on active surveillance (AS) in prostate cancer (PCa) in our own center so that the information would be objective and correctly given to the patients. We have aimed to study the percentage of candidates for AS chosen in our setting, and the data on infrastaging, subgrading and prediction of insignificant PCa, debugging the predictive value of clinical variables to improve our selection criteria and finally to analyze the results of our patients enrolled in AS.

MATERIALS AND METHODS

A retro- and prospective review of our data bases was performed. A one-year period was analyzed to know AS candidates. Analysis of our radical prostatectomy specimens for infrastaging, subgrading and prediction of insignificant PCa (Epstein's criteria) was made as well as a uni/multivariate analysis of clinical variables in patients with insignificant PCa in the specimen. A prospective validation was performed with overall survival and survival free of active treatment (SFAT) as endpoints in patients enrolled in AS.

RESULTS

Between October-2010/October-2011, 44.7% of our PCa were candidates for AS, but only 11.2% choose it. The percentages found for infrastaging, subgrading and prediction of insignificant PCa were 14%, 31.4% and 55.7%, respectively. However, only just 6 patients (6.97%) had≥pT3a+Gleason≥7+volume>0.5cc PCa. The multivariate analysis showed that PSA density and number of affected cores were independent predictors of insignificant PCa. With a mean follow-up of 36±39months, 63 out of 232 patients enrolled in AS went on to active treatment (27.1%), with only 13 due to anxiety without pathologic progression. Median time of SFAT was 72.7 months (CI 95% 30.9-114.4). SFAT at 24 months was 76.4% (69.7-83.1%) and at 48 months 58.1% (48.8-67.4%). Only 10 patients died (4.3%), 9 due to causes different of PCa. Estimated overall survival at 5 years was 92.8% (CI 95% 86.7-98.9%).

CONCLUSIONS

It should be mandatory to have the exact knowledge of the local data of each Center in order to objectively inform patients about prostate biopsy efficiency, and if percentages of infrastaging, subgrading and prediction of insignificant PCa are in accordance with the literature. At 3 years, we reproduced the results of the longest series of AS, so we have ascertained that our AS protocol can be implemented with increasingly more patients.

Preliminary results of the Spanish Association of Urology National Registry in Active Surveillance for prostate cancer

OBJECTIVES

To present a National Registry of patients with prostate cancer as monitored through active surveillance, with the intention of testing the hypothesis that cancer-specific mortality in very low-risk and low-risk patients is less than 5% at 15 years.

MATERIAL AND METHODS

A multicentre observational study (AEU-PIEM/2014/0001) sponsored by the Spanish Association of Urology was conducted using their platform for multicentre studies. The clinical-pathological inclusion criteria were as follows: cT1a-cT3a, PSA ≤ 20 ng/ml, initial minimum biopsy of 10 cores, number of affected cores ≤ 3, 1st Gleason score of 3 and 2nd Gleason score ≤ 4 and a known prostate volume (in cc). A unified follow-up was not established for all recruiting centres; however, a survey was conducted that reflects the follow-up characteristics based on a number of tangible parameters that allow for their comparison. With the same philosophy of flexibility, the use of certain biomarkers and multiparametric MRI was not considered necessary for inclusion.

RESULTS

We describe the Registry's characteristics and possibilities, as well as the preliminary results from the 324 patients included in its first 5 months of operation in the 15 recruiting centres. We also report the clinical-pathological variables, biomarkers, radiodiagnosis technique and quality-of-life questionnaires considered for the database, as well as the possibilities for indefinite follow-up, remaining open to any active treatment recognized in clinical guidelines.

CONCLUSIONS

The AEU-PIEM/2014/0001 represents an extremely useful tool for all Spanish urologists for multicentre clinical research. The registry will undoubtedly enable the dissemination of active surveillance of our patients in a more coordinated manner, thus maintaining the advantages of optimised opportunistic screening for prostate cancer without resulting in overtreatment.

Active surveillance for small renal masses diagnosed in elderly or comorbid patients: looking for the best treatment strategy

INTRODUCTION

Aim of this study is to provide our results after long-term active surveillance (AS) protocol for small renal masses (SRMs), and to report the outcomes of patients who remained in AS compared to those who underwent delayed surgical intervention.

PATIENTS AND METHODS

We retrospectively reviewed our database of 58 patients diagnosed with 60 contrast enhancing SRMs suspicious for renal cell carcinoma (RCC). All patients had clinical and radiological follow-up every 6 months. We evaluated the differences between patients who remained on AS and those who underwent surgical delayed intervention.

RESULTS

The mean age was 75 years, the mean follow-up was 88.5 months. The median initial tumor size at presentation was 2.6cm, and the median estimated tumor volume was 8.7cm(3). The median linear growth rate of the cohort was 0.7cm/year, and the median volumetric growth rate was 8.8 cm(3)/year. Death for metastatic disease occurred in 2 patients (3.4%). No correlation was found between initial tumor size and size growth rate. The mean linear and volumetric growth rates of the group of patients who underwent surgery was higher than in those who remained on surveillance (1.9 vs. 0.4cm/year and 16.1 vs. 4.6 cm(3)/year, respectively; P<.001).

CONCLUSIONS

Most of SRMs demonstrate to have an indolent course and low metastatic potential. Malignant disease could have faster linear and volumetric growth rates, thus suggesting the need for a delayed surgical intervention. In properly selected patients with low life-expectancy, AS could be a reasonable option in the management of SRMs.

Active surveillance in low-risk prostate cancer. Patient acceptance and results

OBJECTIVES

To evaluate the acceptance of active monitoring by patients treated in our healthcare community and to report the clinical results of an active surveillance program in patients with low-risk prostate cancer.

MATERIAL AND METHODS

Prospective study of patients enrolled in an active surveillance programme at our centre between 2004 and 2012. The inclusion criteria were PSA <10 ng/ml, Gleason score ≤6, clinical stage T1c/T2a, ≤2 positive cores, and no more than 50% of the core being affected. Curative treatment was proposed when faced with pathological progression over the course of the monitoring.

RESULTS

In 2011, only 17% of the total number of potential candidate patients rejected their inclusion in a surveillance programme and were treated actively. We analysed a series of 144 patients included in our active surveillance protocol. The mean follow-up time was 3.22 years (SD 2.08). A total of 110 patients (76.3%) remained under active monitoring, with an estimated median treatment-free survival after diagnosis of 6.9 years (95% CI: 6.2-7.6). The percentage of patients who remained free of treatment at 2 and 5 years was 96.3% (95% CI: 92.8%-99.8%) and 70.9% (95% CI: 59.3%-85.5%), respectively. Thirty four patients (23.6%) required curative treatment. The mean time to treatment was 4.6 years (SD 2.3).

CONCLUSIONS

Active surveillance of highly selected patients with low-risk prostate cancer is a valid alternative therapy that is accepted by patients in our community.

Variability in the multicentre National Registry in Active Surveillance; a questionnaire for urologists

BACKGROUND

Our main objective was to report the current use of active surveillance in Spain and to identify areas for potential improvement.

METHODS

A questionnaire generated by the Platform for Multicentre Studies of the Spanish Urology Association (AEU/PIEM/2014/0001, NCT02865330) was sent to all associate researchers from January to March 2016. The questionnaire included 7 domains covering various aspects of active surveillance.

RESULTS

Thirty-three of the 41 associate researchers responded to the questionnaire. Active surveillance is mainly controlled by the urology departments (87.9%). There was considerable heterogeneity in the classical clinical-pathological variables as selection criteria. Only 36.4% of the associate researchers used prostate-specific antigen density (PSAd). Multiparametric magnetic resonance imaging (mpMRI) was clearly underused as initial staging (6%). Only 27.3% of the researchers stated that their radiology colleagues had a high level of experience in mpMRI. In terms of the confirmation biopsy, most of the centres used the transrectal pathway, and only 2 out of 33 used the transperineal pathway or fusion software. Half of the researchers interviewed applied active treatment when faced with disease progression to Gleason 7 (3+4). There was no consensus on when to transition to an observation strategy.

CONCLUSIONS

The study showed the underutilisation of informed consent and quality-of-life questionnaires. PSAd was not included as a decisive element in the initial strategy for most researchers. There was a lack of confidence in the urologists' mpMRI experience and an underutilisation of the transperineal pathway. There was also no consensus on the follow-up protocols and active treatment criteria, confirming the need for prospective studies to analyse the role of mpMRI and biomarkers.

Utility of the RENAL index -Radius; Exophytic/endophytic; Nearness to sinus; Anterior/posterior; Location relative to polar lines- in the management of renal masses

CONTEXT

The growing incidence of renal masses and the wide range of available treatments require predictive tools that support the decision making process. The RENAL index -Radius; Exophytic/endophytic; Nearness to sinus; Anterior/posterior; Location relative to polar lines- helps standardise the anatomy of a renal mass by differentiating 3 groups of complexity. Since the introduction of the index, there have been a growing number of studies, some of which have been conflicting, that have evaluated the clinical utility of its implementation.

OBJECTIVE

To analyse the scientific evidence on the relationship between the RENAL index and the main strategies for managing renal masses.

ACQUISITION OF THE EVIDENCE

A search was conducted in the Medline database, which found 576 references on the RENAL index. In keeping with the PRISM Declaration, we selected 100 abstracts and ultimately reviewed 96 articles.

SYNTHESIS OF THE EVIDENCE

The RENAL index has a high degree of interobserver correlation and has been validated as a predictive nomogram of histological results. In active surveillance, the index has been related to the tumour growth rate and probability of nephrectomy. In ablative therapy, the index has been associated with therapeutic efficacy, complications and tumour recurrence. In partial nephrectomy, the index has been related to the rate of complications, conversion to radical surgery, ischaemia time, function preservation and tumour recurrence, a finding also observed in radical nephrectomy.

CONCLUSIONS

The RENAL index is an objective, reproducible and useful system as a predictive tool of highly relevant clinical parameters such as the rate of complications, ischaemia time, renal function and oncological results in the various currently accepted treatments for the management of renal masses.

Update and optimization of active surveillance in prostate cancer in 2021

INTRODUCTION AND OBJECTIVES

Within the paradigm shift of the last decade in the management of prostate cancer (PCa), perhaps the most relevant event has been the emergence of active surveillance (AS) as a mandatory strategy in low-risk disease. We carry out a critical review of the clinical, pathological and radiological improvements that allow optimizing AS in 2021.

MATERIAL AND METHODS

Critical narrative review of the literature on improvement issues and controversial aspects of AS.

RESULTS

Adequate use of traditional criteria, optimized by enhanced biopsy and calculation of the prostate volume technique thanks to multiparametric magnetic resonance imaging (mpMRI) allow a better selection of patients for AS. This management should not be limited to patients under 60years of age, and patients with intermediate-risk PCa should be carefully selected to be included. Biopsies are still required in the follow-up, which can be personalized according to risk patterns. The pathologist must identify the cribriform or intraductal histology on biopsies in order to exclude these patients from AS, in the same way as with patients with alterations in DNA repair genes.

CONCLUSIONS

Controversial indications such as the inclusion of patients from intermediate-risk groups, or the transition to active treatment due to exclusive progression in tumor volume, should be further optimized. It is possible that the future competition of tissue biomarkers, the refinement of objective parameters of mpMRI and the validation of PSA kinetics calculators may sub-stratify risk groups.

Changes in Gleason score grading on serial follow-up biopsies in prostate cancer patients undergoing active surveillance

INTRODUCTION

Active surveillance for prostate cancer has grown systematically in the recent years with more robust mid-term outcomes. However, changes in Gleason score during serial biopsies are not detailed in many of these reports.

OBJECTIVES

To evaluate changes in Gleason score on follow-up biopsies in low-risk prostate cancer in patients undergoing AS program in our center.

MATERIAL AND METHODS

Series of patients diagnosed of prostate cancer between 2004 and 2013 have been analyzed. The inclusion criteria were: PSA ≤ 10 ng/ml + Gleason ≤ 6 + T1c/T2a + ≤ 2 positive cores, and no more than 50% of affected core. The pathology of each of the biopsies was analyzed.

RESULTS

We studied a series of 175 patients undergoing AS. Mean follow-up was 3.96 years (SD 2.4). Follow-up biopsies with Gleason scores ≥ 7 were: 5.72% in the first biopsy, 7.39% and 7.41% in subsequent biopsies. By contrast, in 42.03% of cases did not show evident tumor involvement in the first biopsy, 40.74% and 51.85% in the second and third biopsies respectively. Median stay in the AS program was: 90.99 months (95% CI: 53.53-128.46) in patients with first positive biopsy vs. 96.66 months (95% CI: 63.19-130.13) in those without evidence of tumor.

CONCLUSIONS

In our series the pathological data of the first 3 biopsies remain stable in terms of the positive biopsy rate, Gleason score, or indication of active treatment proportions. Those patients who do not show evidence of malignancy in the first follow-up biopsy are less likely to need active treatment than the other patients in the series.

Our experience in the management of prostate cancer in renal transplant recipients

INTRODUCTION AND OBJECTIVES

The management of Prostate cancer (PCa) in renal transplant recipients (RTR) is challenging and remain controversial. Currently there is no consensus about this condition. The aim of the study was to analyse our experience in the diagnosis and management of PCa in RTR.

METHOD

Retrospective monocentric study of a prospective and consecutive database from 2003-2017. Inclusion of RTR diagnosed of PCa. Staging and treatment in agreement with the contemporary guidelines. The main outcome measures included clinical staging, type of treatment, oncological outcomes and follow-up.

RESULTS

1,330 renal transplants were performed (787 males), diagnosed of PCa in 33 RTR (4.2%), mean age 66years±6.3 (51-78). Median PSA was 8.8ng/ml and PSA ratio 0.19. Mean time between renal transplantation and PCa diagnosis 130months±90 (2-236).

TREATMENTS

Radical prostatectomy (RP) (n=22; 66.7%), Radiation therapy (RT) with Androgen deprivation therapy (ADT) (n=7; 21.2%), Active surveillance (n=3; 9.1%), ADT (n=1; 3%). No graft loss neither impaired renal function due to PCa treatment was reported. After RP two patients (9.1%) presented biochemical recurrence treated with RT. Remission of the 100%. Mean follow-up was 61months±37 (6-132).

CONCLUSIONS

PCa in renal transplant patients can be managed with the same therapeutic options as in the general population. Active surveillance should also be provided in RTR despite being under immunosuppressive therapy.

Clinical performance of transperineal template guided mapping biopsy for therapeutic decision making in low risk prostate cancer

OBJECTIVES

To evaluate the role of Transperineal Template guided Mapping Biopsy (TTMB) in determining the management strategy in patients with low risk prostate cancer (PCa).

METHODS

We retroscpectively evaluated 169 patients who underwent TTMB at our institution from February 2008 to June 2011. Ninety eight of them harbored indolent PCa defined as: Prostate Specific Antigen<10ng/ml, Gleason score 6 or less, clinical stage T2a or less, unilateral disease and a maximum of one third positive cores at first biopsy and<50% of the core involved. TTMB results were analyzed for Gleason score upgrading and upstaging as compared to initial TransRectal UltraSound (TRUS) biopsies and its influence on the change in the treatment decisions.

RESULTS

TTMB detected cancer in 64 (65%) patients. The upgrade, upstage and both were noted in 33% (n=21), 12% (n=8) and 7% (n=5) respectively of the detected cancers. The disease characteristics was similar to initial TRUS in 30 (48%) patients and TTMB was negative in 34 (35%) patients. Prostate volume was significantly smaller in patients with upgrade and/or upstage noted at TTMB (45.4 vs 37.9; P=.03). TTMB results influenced 73.5% of upgraded and/or upstaged patients to receive radical treatment while 81% of the patients with unmodified stage and/or grade continued active surveillance or focal therapy.

CONCLUSIONS

In patients with low risk PCa diagnosed by TRUS, subsequent TTMB demonstrated cancer upgrade and/or upstage in about one-third of the patients and resulted in eventual change in treatment decision.

The role of multiparametric magnetic resonance imaging in the selection and follow-up of patients undergoing active surveillance for prostate cancer. An European Section of Uro-Technology (ESUT) review

INTRODUCTION

In recent years, active surveillance (AS) has gained popularity as a safe and reasonable option for patients with low-risk, clinically localized prostate cancer.

OBJECTIVE

To summarize the latest information regarding the use of mpMRI in the setting of active surveillance (AS) for the management of prostate cancer (PCa).

EVIDENCE ACQUISITION

A PubMed-based, English literature search was conducted through February 2020. We selected the most relevant original articles, meta-analyses and systematic reviews that could provide important information.

EVIDENCE SYNTHESIS

The great importance of mpMRI of the prostate in the setting of PCa diagnosis is its ability to visualize primarily high-grade cancerous lesions potentially missed on systematic biopsies. In several studies, mpMRI has shown an improved performance over clinically based models for identifying candidates which will benefit the most from AS. Although data on prostate mpMRI during follow-up of men under AS is sparse, it holds the probability to improve significantly AS programs by a more precise selection of optimal candidates, a more accurate identification of disease progression and a reduction in number of biopsies. The goal of reassessment of patients undergoing AS is to find the most effective moment to change attitude to active treatment.

CONCLUSION

The value of mpMRI has been recognized due to its high negative predictive value (NPV) for lesion upgrading in low-risk PCa patients. The improvement in imaging detection, and precise diagnosis with mpMRI could reduce misclassifications at initial diagnosis and during follow-up, reducing the number of biopsies.

3+4 = 6? Implications of the stratification of localised Gleason 7 prostate cancer by number and percentage of positive biopsy cores in selecting patients for active surveillance

OBJECTIVE

To determine whether the number and percentage of positive biopsy cores identify a Gleason 3+4 prostate cancer (PC) subgroup of similar biologic behaviour to Gleason 3+3.

MATERIAL AND METHOD

An observational post-radical prostatectomy study was conducted of a cohort of 799 patients with localised low-risk (n=582, Gleason 6, PSA <10ng/ml and cT1c-2a) and favourable intermediate PC (n=217, Gleason 3+4, PSA ≤10 ng/ml and pT2abc). The Gleason 3+4 tumours were stratified by number (≤3 vs.>3) and by percentage of positive cores (≤33% vs. >33%). We analysed the tumours' association with the biochemical recurrence risk (BRR) and cancer-specific mortality (CSM). We conducted various predictive models using Cox regression and estimated (C-index) and compared their predictive capacity.

RESULTS

With a median follow-up of 71 months, the BRR and CSM of the patient group with Gleason 3+4 tumours and a low number (≤3) and percentage (≤33%) of positive cores were not significantly different from those of the patients with Gleason 6 tumours. At 5 and 10 years, there were no significant differences in the number of biochemical recurrences, the probability of remaining free of biochemical recurrences, the number of deaths by PC or the probability of death by PC between the 2 groups. In contrast, the patients with Gleason 3+4 tumours and more than 33% of positive cores presented more deaths by PC than the patients with Gleason 6 tumours. At 10 years, the probability of CSM was significantly greater. This subgroup of tumours showed a significantly greater BRR (RR, 1.6; P=.02) and CSM (RR, 5.8, P≤.01) compared with the Gleason 6 tumours. The model with Gleason 3+4 stratified by the percentage of positive cores significantly improved the predictive capacity of BRR and CSM.

CONCLUSIONS

Fewer than 3 cores and a percentage <33% of positive cores identifies a subgroup of Gleason 3+4 tumours with biological behaviour similar to Gleason 6 tumours. At 10 years, there were no differences in BRR and CSM between the 2 groups. These results provide evidence supporting active surveillance as an alternative for Gleason 3+4 tumours and low tumour extension in biopsy.

Current management of small renal masses

One of the consequences of the growing use of diagnostic imaging techniques is the notable growth in the detection of small renal masses presumably corresponding to localized tumors that are potentially curable with surgical treatment. When faced with the finding of a small renal mass, radiologists must determine whether it is benign or malignant, and if it is malignant, what subtype it belong to, and whether it should be managed with surgical treatment, with ablative techniques, or with watchful waiting with active surveillance. Small renal masses are now a clinical entity that require management different from the approaches used for classical renal cell carcinomas. In this scenario, radiologists are key because they are involved in all aspects of the management of these tumors, including in their diagnosis, treatment, and follow-up.

Role of PCA3 and SelectMDx in the optimization of active surveillance in prostate cancer

INTRODUCTION & OBJECTIVES

A not negligible percentage of patients included in active surveillance (AS) for low and very low risk prostate cancer (PCa) are reclassified in the confirmatory biopsy or have disease progression during follow-up. Our aim is to evaluate the role of PCA3 and SelectMDx, in an individual and combined way, in the prediction of pathological progression (PP) in a standard AS program.

MATERIALS & METHODS

Prospective and observational study comprised of 86 patients enrolled in an AS program from 2009 to 2019, with results for PCA3 and SelectMDx previous to PCa diagnosis or during their confirmatory period. Univariate and multivariate analysis were performed to correlate PCA3 and SelectMDx scores as well as clinical and pathological variables with PP-free survival (PPFS). The most reliable cut-offs for both biomarkers in the context of AS were defined.

RESULTS

SelectMDx showed statistically significant differences related to PPFS (HR 1.035, 95%CI: 1.012-1.057) (p = 0.002) with a C-index of 0.670 (95%CI: 0.529-0.810) and AUC of 0.714 (95%CI: 0.603-0.825) at 5 years. In our series, the most reliable cut-off point for SelectMDx was 5, with a sensitivity and specificity for PP of 69.8% and 67.4%, respectively. Same figure for PCA3 was 65, with a sensitivity and specificity for PP of 51.16% and 74.42%, respectively. The combination of both biomarkers did not improve the prediction of PP, C-index 0.630 (95%CI: 0.455-0.805).

CONCLUSIONS

In the context of low or very low risk PCa, SelectMDx > 5 predicted 5 years PP free survival with a moderate discrimination ability outperforming PCA3. The combination of both tests did not improved outcomes.

Role of PCA3 and SelectMDx in the optimization of active surveillance in prostate cancer

INTRODUCTION AND OBJECTIVES

A not negligible percentage of patients included in active surveillance (AS) for low and very low risk prostate cancer (PCa) are reclassified in the confirmatory biopsy or have disease progression during follow-up. Our aim is to evaluate the role of PCA3 and SelectMDx, in an individual and combined way, in the prediction of pathological progression (PP) in a standard AS program.

MATERIALS AND METHODS

Prospective and observational study comprised of 86 patients enrolled in an AS program from 2009 to 2019, with results for PCA3 and SelectMDx previous to PCa diagnosis or during their confirmatory period. Univariate and multivariate analysis were performed to correlate PCA3 and SelectMDx scores as well as clinical and pathological variables with PP-free survival (PPFS). The most reliable cut-offs for both biomarkers in the context of AS were defined.

RESULTS

SelectMDx showed statistically significant differences related to PPFS (HR: 1.035; 95%CI: 1.012-1.057) (P=.002) with a C-index of 0.670 (95%CI: 0.529-0.810) and AUC of 0.714 (95%CI: 0.603-0.825) at 5years. In our series, the most reliable cut-off point for SelectMDx was 5, with a sensitivity and specificity for PP of 69.8% and 67.4%, respectively. Same figure for PCA3 was 65, with a sensitivity and specificity for PP of 51.16% and 74.42%, respectively. The combination of both biomarkers did not improve the prediction of PP, C-index 0.630 (95%CI: 0.455-0.805).

CONCLUSIONS

In the context of low or very low risk PCa, SelectMDx >5 predicted 5years PP free survival with a moderate discrimination ability outperforming PCA3. The combination of both tests did not improved outcomes.

Immediate versus delayed prostatectomy and the fate of patients who progress to a higher risk disease on active surveillance

INTRODUCTION

Oncological outcomes of radical prostatectomy (RP) in patients progressing on active surveillance (AS) are debated. We compared outcomes of AS eligible patients undergoing RP immediately after diagnosis with those doing so after delay or disease progression on AS.

METHODS

Between 2000 and 2014, 961 patients were AS eligible as per EAU criteria. RP within 6 months of diagnosis (IRP) or beyond (DRP), RP without AS (DRPa) and AS patients progressing to RP (DRPb) were compared. Baseline PSA, clinical and biopsy characteristics were noted. Oncological outcomes included adverse pathology in RP specimen and biochemical recurrence (BCR). Matched pair analysis was done between DRPb and GS7 patients undergoing immediate RP (GS7IRP).

RESULTS

IRP, DRP, DRPa and DRPb had 820 (85%), 141 (15%), 118 (12.24%) and 23 (2.7%) patients respectively. IRP, DRPa and DRPb underwent RP at a median of 3, 9 and 19 months after diagnosis respectively. Baseline characteristics were comparable. DRP vs. IRP had earlier median time (31 vs. 43 months; p<.001) and higher rate of progression to BCR (7.6 vs. 3.9%;p=.045). DRPb showed higher BCR (19 vs. 5%;p=.021) with earlier median time to BCR, compared to IRP and DRPa (p=.038). There was no difference in adverse pathology and BCR rates, but time to BCR was significantly lesser in DRPb (49 vs. 6 months;p<.001), compared to GS7IRP.

CONCLUSIONS

Patients progressing on AS had worst oncological outcomes. RP for GS7 progression and matched pair of GS7 patients had similar outcomes. Worse oncological outcomes in AS progressors cannot be explained by a mere delay in RP.

Clinical and histological predictive factors of reclassification of prostate cancer patients on active surveillance

INTRODUCTION AND OBJECTIVE

Active surveillance (AS) has been established as a therapeutic strategy in patients with low-risk prostate cancer. Demographic and anatomopathological factors that increase the probability of reclassifying patients have been identified.

MATERIALS AND METHODS

Laboratory and histopathological data were collected from 116 patients included on AS since 2014. Univariate analysis was performed with Chi-square, t-student and Kendall's Tau, multivariate analysis according to logistic regression and Kaplan-Meier curves were calculated.

RESULTS

Of the 116 patients in AS, the median age at diagnosis was 66 years and the median follow-up was 13 months (2-72). Of these, 61 (52.6%) are still on surveillance, while 55 (47.4%) have left the program, mostly due to histological progression (52 patients (45.2%)); radical prostatectomy was performed in 27 (49.1%). Prostate volume (PV)≤60cc and the number of positive cylinders >1 in diagnostic biopsy (P=.05) were associated with higher reclassification rate in univariate analysis (P<.05). Multivariate analysis showed that these two variables significantly correlated with higher reclassification rate (PV 60 cc: OR 4.39, P=.04; >1 positive cylinder at diagnostic biopsy: OR 2.48, P=.03).

CONCLUSIONS

It has been shown that initial ultrasound volume and the number of positive cylinders in the diagnostic biopsy are independent risk factors for reclassification. Initial PSA, laterality of the affected cylinders and PSA density were not predictive factors of progression in our series.

Active surveillance protocol in prostate cancer in Portugal

OBJECTIVE

To examine clinical practice patterns in locally managing patients under an active surveillance protocol among Portuguese urologists.

INTRODUCTION

Prostate cancer (PCa) is a heterogeneous disease with many prostate adenocarcinomas being indolent and a low probability of ever causing symptoms or death. Active surveillance (AS) is a form of conservative management aimed to reduce over-treatment for low-risk PCa patients. Over the years, experience with AS has grown considerably and is now standard in some countries, however a universal protocol still does not exist.

METHODS

Nationwide anonymous e-survey concerning habits and practices on AS among Portuguese urologists, that consisted of twelve questions and was sent electronically to all 368 current members of the Portuguese Urological Association.

RESULTS

56 urologists were surveyed (15.21% answer rate), evenly distributed geographically and allocated according to years of experience as well as number of PCa patients managed monthly. The vast majority of respondents recommends AS to their patients, particularly ISUP grade 1 patients, whose PSA serum level is bellow 20 ng/mL. Observance of AS programs by patients was not in question but concerns exist over psychological morbidity while harboring disease. Majority believed that international guidelines surveillance protocols were adequate and sufficient, but there are some constraints concerning availability of periodic MRIs and re-biopsy needs.

CONCLUSIONS

AS seems to be sustained in urologist clinical practice, although patients still lag to adhere and choose for active treatment. AS may not be an easy choice for patients and clinicians due to uncertainty of disease progression, risk of loss to follow-up and repeated biopsies but is also a cause for anxiety, depression, uncertainty and a perception of danger.

Thyroid cancer

In recent decades, the diagnosis of thyroid cancer, especially the papillary type, has increased significantly due to the use of imaging techniques such as ultrasound. For this reason, it is essential to rationalize diagnosis and treatment, since the behavior of thyroid cancer varies from slow-progressing tumors to highly aggressive ones. The application of risk assessment systems for ultrasound images and the optimization of cytology incorporating molecular studies allows cases to be stratified in order to select therapy on an individual basis. Currently, attempts are being made to avoid overtreatment in low-risk tumors, with active surveillance or minimally invasive techniques. The administration of radioiodine is indicated according to risk, with lower doses, and in advanced cases, oncospecific systemic treatments are being incorporated. The management of thyroid cancer requires a multidisciplinary team and population studies and quality clinical trials are necessary to update treatment guidelines.

Does active surveillance avoid overtreatment in prostate cancer? Lessons learned from salvage radical prostatectomies

OBJECTIVE

Determine whether our institution's active surveillance (AS) protocol is a suitable strategy to minimise prostate cancer overtreatment.

MATERIAL AND METHODS

Retrospective analysis of 516 patients on AS after prostate cancer diagnosis. Population divided into «per-protocol» vs «induced» AS depending on fulfilment of protocol's inclusion criteria. Radical prostatectomies after AS were selected and stratified based on reclassification, progression or patient anxiety. Clinicopathological features and biochemical relapse-free survival were studied. Primary endpoint was overtreatment ratio based on the presence of insignificant prostate cancer and adverse pathological features in the surgical specimen. Kaplan-Meier curves were used to estimate the biochemical relapse-free survival and compared with log-rank test.

RESULTS

304 patients fulfilled inclusion criteria; 100 proceeded to radical prostatectomy (31% «induced», 69% «per-protocol» AS). Surgery indications were reclassification, progression and anxiety in 66%, 18% and 16% of patients, respectively. Rate of positive lymph nodes was higher in the progression group (11%) compared to reclassification and anxiety (5% and 0%, respectively; P=.002). Positive surgical margins were more frequently reported in the progression cohort compared to reclassification (28% vs 20%). Median follow-up from diagnosis until last radical prostatectomy was 48.3months (32.4-70). Three year biochemical relapse-free survival in the salvage radical prostatectomy was 85.4% (95%CI: 78.3-93.2). Insignificant cancer was noticed in 7% of patients (Epstein's vs 24% Wolters' criteria). Rate of patients with adverse pathological features was 36%.

CONCLUSIONS

The majority of patients who underwent salvage surgery after AS were not overtreated. Radical prostatectomy should be considered a safe rescue treatment.

Surveillance and office management of low-grade Ta bladder tumors

OBJECTIVE

Patients with low-grade (LG), grade 1-2, Ta bladder cancer (BC) will frequently have a "recurrence". However, they rarely progress in stage. Although current guidelines mention surveillance and office management for these new or recurrent tumors, transurethral resection (TURBT) is the most common treatment. The purpose of this study is to determine if surveillance and/or office cautery is safe.

MATERIALS AND METHODS

This study was conducted as a retrospective case series analysis of 45 patients who had recurrent LG Ta appearing bladder cancer (BC) and were managed primarily with surveillance and/or office cautery. Patients with carcinoma in-situ were excluded. The primary outcome was stage progression.

RESULTS

Median follow up was 62 months. 41 (91%) patients did not progress in stage. Three patients recurred with HG T1 BC; one is receiving systemic immunotherapy. One patient developed HG T2 BC and was treated with a bladder preservation protocol. 40 (89%) patients underwent office cauterization. Eleven received BCG and 26 received post-cautery intravesical chemotherapy. Five (11%) patients developed HG BC during follow up. No patients died. None of the 17 (38%) Hispanic patients had progression.

CONCLUSIONS

Active surveillance and/or office cautery for patients with small recurrent LG Ta bladder tumors is safe, reduces cost and improves quality of life by avoiding TURBTs.

Pathological findings in very low risk prostate cancer in surgical specimens

Perform a detailed anatomopathological analysis of consecutive surgical specimens in men with clinically very low risk prostate cancer according to National Comprehensive Cancer Network (NCCN) criteria.MATERIALS AND METHODS: The study included 799 prostate cancer patients who under went radical prostatectomy between January 2005 and December 2013. We identified 81 consecutive patients with clinically very low risk prostate cancer. The slides of the patients who fulfilled the inclusion criteria were re-reviewed. The parameters studied were: pathological stage, histological grade by Gleason score (GSS), margins involvement, tumor percentage (PT), and number of apparently independent tumor foci (FT). RESULTS: The patients had organ-confined tumors in almost all of them (pT2: 97.5%). Most of the cancers studied were bilateral (pT2c: 67.9%), multifocal (FT≥2:88.8%), with a low tumor percentage (PTand with a low Gleason Score (GSS≤6: 91,3%). Non-confined disease: 2.5%, all cases extra-prostatic extension (pT3a). GSS>6: 8,6%, all cases GSS7 (3+4). CONCLUSIONS: The NCCN criteria for very low risk prostate cancer help to make a good selection of non-aggressive tumors and are a useful tool for including patients in an active surveillance program.

Transition from active surveillance to observation in prostate cancer patients older than 75 years. A long follow-up series

INTRODUCTION

The world population is ageing, and life expectancy is increasing. This situation will have a great impact on the management of patients with prostate cancer, especially in those of low risk, susceptible to a conservative management under active surveillance (AS). Regarding these patients' profile, it is necessary to answer the following questions: ¿for how long to continue with the AS scheme?, ¿which tests will be required?, ¿is it possible to carry out a transition to observation with oncological safety? The objective of this work is to analyse those patients with prostatic cancer who have been in AS with 75 years of age or more and assess the safety of the observation in an AS series with a long follow-up.

MATERIAL AND METHODS

We analysed our prospective cohort of AS patients between the years 1999 and 2018,including those who had been in follow-up with 75 years or more. They were offered treatment with curative intent when there were progression criteria and transition to observation under the urologist's decision. Some intermediate risk patients were included in the analysis. Comorbidity changes were analysed with the Charlson comorbidity index at entry and exit of AS. The progression and mortality of the patients were studied according to the management they received.

RESULTS

From 347 AS patients, 90 patients fulfilled the afore mentioned criteria and 15 (16.7%) were intermediate risk. The median follow-up was 6.4 years and 73 (81.1%) had low comorbidity (Charlson<2).There were 40 (44.4%) patients who left AS, 17 (18.9%) of them went to observationand the rest, 21 (23.3%), received curative treatment. There was a significant difference in comorbidity, measured by the Charlson index, at entry and exit of AS (P<.05) among patients receiving active treatment and the ones submitted to observation.No case of cancer-specific death or progression was observed in the observation group.

CONCLUSION

The transition from an active surveillance management to observation of prostate cancer elderly patients, as well as the decision to carry out a treatment with curative intent, seems controversial. In our series, this transition in patients older than 75 years does not increase the oncological risk.

Pathological outcomes and agressiveness of low-risk prostate cancer in Northern African men

BACKGROUND

Northern African (NAf) men show a high incidence of advanced prostate cancer (PCa) at diagnosis. Several studies suggested the existence of ethnic differences in the PCa aggressiveness and this has led to some concerns related to the inclusion of some ethnic groups into active surveillance protocols.

OBJECTIVE

To evaluate pathological outcomes and aggressiveness of low risk PCa treated by radical prostatectomy in a NAf ethnic group.

SUBJECTS AND METHODS

Data of 147 NAfs, who underwent radical prostatectomy for low risk PCa diagnosed via a 12-core biopsy in 2 academic centers between 2011 and 2015, were reviewed retrospectively to assess rates of worse pathological outcomes defined as: Gleason score upgrade to at least 3+4, upstage to pT3a or higher or pN1, and positive surgical margins.

RESULTS

Overall significant upstage and/or upgrade occurred in 20.2% and positive surgical margins occured in18.3%. In multivariate logistic regression analysis, independent variables that predicted for upstage and/or upgrade or positive surgical margins in the entire cohort were: NCCN risk group (low risk>very low risk), advanced age>60 years, PSA>6ng/ml, PSA density≥0.15, more than 2 positive cores in biopsy, more than 50% cancer involvement in positive cores, clinical stage (T2a>T1c) and UCSF-CAPRA-S score>3.

CONCLUSIONS

Our study found that, at least pathologically, NAf men do not have more aggressive disease than Caucasians and African Americans in both low and very low risk PCa. Thus, we think that active surveillance is a suitable approach for selected patients since there is no definitive data that show a more aggressive natural history of PCa in NAf men.

Optimization of PSA and its variants and other biomarkers for the follow-up of low-risk prostate cancer in active surveillance

INTRODUCTION AND OBJECTIVES

Active surveillance (AS) is currently a therapeuticstrategy recommended by all Clinical Guidelines forthe initial management of very low-risk, low-risk, andsome intermediate-risk prostate cancer (PCa). However,a high percentage of cases will present the need for active treatment and a quarter of them will presentunfavorable anatomopathological characteristics.

METHODS

review of the biomarkers' literature oncircumscribed to the inclusion and follow-up of patientsin AS.

RESULTS

PSA and its variants remain the most widelyused and most cost-effective biomarker in AS. Inparticular, the use of PSA density based on the prostatevolume detected by mpMRI has gained much weight.Different multipanel biomarkers in blood and urineare commercially available to predict progressionto PCa ≥3 + 4 (GG2), but they have not clearly beenprospectively tested in AS cohorts. Tissue biomarkersanalyze gene panels that offer predictive informationindependent of classical clinicopathological variablesand may play a role in controversial indications for AS.Lastly, risk calculators are cost-effective and validatedfor their care use in AS and are probably underused.

CONCLUSIONS

Although there is no specific biomarkerfor the optimization of AS, its rational use togetherwith mpMRI may in the future optimize the inclusionof patients in AS and follow-up differentiatedby risk groups.