Low-intermediate Risk Prostate Cancer Research Articles

Late Toxicity Following SABR with Multi-modality Imaging and Flattening Filter Free for Low–Intermediate Risk Prostate Cancer

Late Toxicity Following SABR with Multi-modality Imaging and Flattening Filter Free for Low–Intermediate Risk Prostate Cancer

Magnetic resonance guided focused high frequency ultrasound ablation for focal therapy in prostate cancer - phase 1 trial.

To evaluate the feasibility and safety of focal therapy for low-intermediate risk prostate cancer (PCa) with magnetic resonance-guided high frequency focused ultrasound (MRgFUS) METHODS: This IRB-approved phase 1 prospective study enrolled eight patients with prostate specific antigen (PSA) ≤ 10 ng/ml, ≤ cT2a and Gleason score ≤ 7 (4 + 3) disease following informed consent. Under MRI guidance, focused high frequency ultrasound energy was delivered to ablate the target tissue. Treatment-related adverse events were recorded. Oncologic outcomes were evaluated with multiparametric MRI, PSA and TRUS biopsy at 6 months following treatment. Ten target lesions [six Gleason 6 lesions, two Gleason 7 (3 + 4) and two Gleason 7 (4 + 3)] were treated in eight men (prostate volume range, 25-50 cc; mean MRI time, 248 min per patient; mean sonication duration, 65 min). Mean target volume was 2.7 cc and mean post-treatment non-perfused volume was 4.3 cc. Quality of life parameters were similar between baseline and 6 months in 6/8 patients. All treated regions were negative on MRI; 4/8 patients and 6/10 target lesions (60%) were clear of disease on biopsy. One patient with 2-mm Gleason 8 disease in one of five cores from treatment site (4 + 3 disease at baseline) subsequently underwent prostatectomy with negative surgical margins. Three patients with low volume (5-15%) Gleason 6 residual disease were offered active surveillance. Mean PSA decreased from 5.06 at baseline to 3.4 ng/ml at 6 months. MRgFUS is a feasible and safe method of noninvasively ablating low-intermediate risk PCa with acceptable short-term oncologic outcomes. • Focal therapy selectively ablates locally confined, clinically significant index lesion with a margin while sparing rest of gland and adjacent vital structures. • Magnetic resonance-guided focused high frequency ultrasound surgery (MRgFUS) combines MRI with HIFU. • MRgFUS provides ability to monitor treatments in real time and allows a targeted approach for focal ablation. • MRgFUS is a feasible, safe method of noninvasively ablating low-intermediate risk PCa. • MRgFUS providesacceptable oncologic outcomes at 6 months.

The Patient-Reported Information Multidimensional Exploration (PRIME) Framework for Investigating Emotions and Other Factors of Prostate Cancer Patients with Low Intermediate Risk Based on Online Cancer Support Group Discussions.

This study aimed to use the Patient Reported Information Multidimensional Exploration (PRIME) framework, a novel ensemble of machine-learning and deep-learning algorithms, to extract, analyze, and correlate self-reported information from Online Cancer Support Groups (OCSG) by patients (and partners of patients) with low intermediate-risk prostate cancer (PCa) undergoing radical prostatectomy (RP), external beam radiotherapy (EBRT), and active surveillance (AS), and to investigate its efficacy in quality-of-life (QoL) and emotion measures. From patient-reported information on 10 OCSG, the PRIME framework automatically filtered and extracted conversations on low intermediate-risk PCa with active user participation. Side effects as well as emotional and QoL outcomes for 6084 patients were analyzed. Side-effect profiles differed between the methods analyzed, with men after RP having more urinary and sexual side effects and men after EBRT having more bowel symptoms. Key findings from the analysis of emotional expressions showed that PCa patients younger than 40years expressed significantly high positive and negative emotions compared with other age groups, that partners of patients expressed more negative emotions than the patients, and that selected cohorts (<40years, >70years, partners of patients) have frequently used the same terms to express their emotions, which is indicative of QoL issues specific to those cohorts. Despite recent advances in patient-centerd care, patient emotions are largely overlooked, especially in younger men with a diagnosis of PCa and their partners. The authors present a novel approach, the PRIME framework, to extract, analyze, and correlate key patient factors. This framework improves understanding of QoL and identifies low intermediate-risk PCa patients who require additional support.

Safety and feasibility of prostate stereotactic ablative radiotherapy using multimodality imaging and flattening filter free.

To investigate feasibility and safety of stereotactic ablative radiotherapy in the management of prostate cancer while employing MR/CT fusion for delineation, fiducial marker seeds for positioning and Varian RapidArc with flattening filter free (FFF) delivery. 41 patients were treated for low-intermediate risk prostate cancer with initial prostate-specific antigen of ≤20 ng ml-1, Gleason score 6-7. Patients had MR/CT fusion for delineation of prostate ±seminal vesicles. CT/MR fusion images were used for delineation and planned using flattening filter free modality. Verification on treatment was cone beam CT imaging with fiducial markers for matching. Patients had Radiation Therapy Oncology Group scoring for genitourinary and gastointestinal symptoms at baseline, week 4, 10 and 18. Clinically acceptable plans were achieved for all patients, all plans achieved the objective clinical target volume D99% ≥ 95%, and for planning target volume D95% ≥ 95%. Rectum dose constraints were met for 95.1% for V18 Gy ≤ 35%, 80% V28 Gy ≤ 10%. A total of 32 (78.0%) plans achieved all rectum dose constraints. Grade 1 acute genitourinary symptoms were 53.7% of patients at baseline, 90.2% [95% CI (76.8-97.3%)] (p = 0.0005) at treatment 5, falling to 78.0% (62.4-89.4%) at week 4, and 75.0% (58.8-87.3%) by week 10 and 52.5% (36.1-68.5%) (p = 1.00) at week 18. Acute gastrointestinal symptoms were 5% at baseline, 46.3% [95% CI (30.7-62.6%)] at treatment 5, week 4 43.9% [95% CI (28.5-60.3%)], week 10 25.0% (11.1-42.3%), and declined slightly by week 18 [-20.095% CI (12.7-41.2)] p = 0.039. Overall 75.6% (31/41) of patients experienced Grade 1-2 toxicity during or after treatment. This planning and delivery technique is feasible, safe and efficient. A homogeneous dose can be delivered to prostate with confidence, whilst limiting high dose to nearby structures. The use of this technology can be applied safely within further randomized study protocols. Advances in knowledge: Multimodality imaging for delineation and linac-based image-guided RT with FFF for the treatment of prostate stereotactic ablative radiotherapy.

Functional Recovery, Oncologic Outcomes and Postoperative Complications after Robot-Assisted Radical Prostatectomy: An Evidence-Based Analysis Comparing the Retzius Sparing and Standard Approaches

We report a 1-year update of functional urinary and sexual recovery, oncologic outcomes and postoperative complications in patients who completed a randomized controlled trial comparing posterior (Retzius sparing) with anterior robot-assisted radical prostatectomy. A total of 120 patients with clinically low-intermediate risk prostate cancer were randomized to undergo robot-assisted radical prostatectomy via the posterior and anterior approach in 60 each. Surgery was performed by a single surgical team at an academic institution. An independent third party ascertained urinary and sexual function outcomes preoperatively, and 3, 6 and 12 months after surgery. Oncologic outcomes consisted of positive surgical margins and biochemical recurrence-free survival. Biochemical recurrence was defined as 2 postoperative prostate specific antigen values of 0.2 ng/ml or greater. Median age of the cohort was 61 years and median followup was 12 months. At 12 months in the anterior vs posterior prostatectomy groups there were no statistically significant differences in the urinary continence rate (0 to 1 security pad per day in 93.3% vs 98.3%, p = 0.09), 24-hour pad weight (median 12vs 7.5 gm, p = 0.3), erection sufficient for intercourse (69.2% vs 86.5%) or postoperative Sexual Health Inventory for Men score 17 or greater (44.6% vs 44.1%). In the posterior vs anterior prostatectomy groups a nonfocal positive surgical margin was found in 11.7% vs 8.3%, biochemical recurrence-free survival probability was 0.84 vs 0.93 and postoperative complications developed in 18.3% vs 11.7%. Among patients with clinically low-intermediate risk prostate cancer randomized to anterior (Menon) or posterior (Bocciardi) approach robot-assisted radical prostatectomy the differences in urinary continence seen at 3 months were muted at the 12-month followup. Sexual function recovery, postoperative complication and biochemical recurrence rates were comparable 1 year postoperatively.

Deferring Treatment in Men With Low and Low-Intermediate Risk Prostate Cancer Does Not Adversely Affect Outcome

Deferring treatment in men who present with low and low intermediate risk prostate cancer is actively championed as a appropriate care for this group of patients. However it is often difficult for a patient to reconcile the idea of doing nothing when told they have cancer and advertisements for safe noninvasive treatment assail them on every front. This study attempts to provide data on long term follow up of a group who did not immediately choose treatment. Between 2000 and 2015, 2437 men were diagnosed with prostate cancer in a VA Healthcare facility. Eleven percent or 274 patients elected a course of watchful waiting or active surveillance. Thirty three percent or 89 of these men deferred treatment for more than 12 months and then elected to pursue treatment. We reviewed the reasons for selecting treatment and as well as the results of treatment. The majority of patients (95.5%). were Gleason’s 6 (70%) or 7 (25%) The median duration for deferring treatment in the Gleason 6 cohort was 31 months and for the Gleason 7 group it was 19 months. Eighty men (94%) eventually received curative therapy; surgery or radiation +/-hormonal therapy or hormonal therapy alone.Five men consistently refused treatment and ultimately started hormonal therapy when diagnosed with bone mets and survived between 9.5 and 14 years. The reasons why patients chose to start treatment in the Gleason 6 group were: increasing Gleason’s score on rebiopsy (22), increasing PSA (16), physician’s advice (16) personal choice (6) metastatic disease (4) and other(4). Three of the 4 men starting for mets had PSA values >100ng/ml. In the Gleason 7 group the reasons were similar: Increased PSA (9), increasing Gleasons score on rebiopsy (5), physician’s advice (4) personal choice (3) metastatic disease (1). The patients treated for curative intent have a median follow up of 50 months (3-84 months) in the Gleason 6 group and 60 months (7-166 months) in the Gleason 7 group. The survival since diagnosis ranges from 26 to 273 months for the Gleason 6 patients ( median 67 months) and 29 to 180 months for the Gleason 7 patients, (median 78 months). Of the 80 patients, 54 are bNED, 17 are cNED, 6 are AWD, 2 DWD and I DOD. Among men who elected only hormonal therapy the median follow since diagnosis up is 154 months for Gleason 6 and 94 months for Gleason 7. Also only 4 patients actually died of disease and 3 of these were in the group who chose no treatment until they developed bone mets. With only 4 relapses and 1 death among the 85 Gleason 6 and 7 tumors, a 100% survival would fall within the 95% confidence interval. Men with Gleason score 6 tumors and low-intermediate risk Gleason 7 tumors may defer treatment with active surveillance and follow-up biopsies without compromising their prostate cancer specific survival. This has important implications for assessing the risks vs. benefits of prostate cancer screening programs.

Comparison of Toxicities in High Dose Rate Versus Low Dose Rate Brachytherapy as Monotherapy in Patients with Low to Favorable Intermediate Risk Prostate Cancer

The purpose of our study was to compare acute and late toxicities of high dose rate (HDR) brachytherapy and low dose rate (LDR) permanent iodine or palladium seeds as monotherapy in patients with low and favorable intermediate risk prostate cancer. We retrospectively examined patients with biopsy proven, low to favorable intermediate risk prostate cancer treated with interstitial brachytherapy monotherapy from 1998-2016 at a single institution. Patients selected were restricted to T stage ≤ T2c, Gleason score ≤7, and prostate specific antigen (PSA) less than 20 ng/ml. For each case of prostate brachytherapy, needles/seeds were implanted transperineally via trans-rectal ultrasound guidance. Dose for LDR was 145 Gy and HDR was 27 Gy in 2 fractions. The Common Toxicity Criteria scale, version 2.0 and 3.0 were used to score the acute (<12 months after brachytherapy) and late (≥ 12 months after brachytherapy) toxicities. Chi square analysis tested for associations between toxicity and treatment technique. Logistic regression was used in multivariable analyses (MVA). A total of 572 patients were included, including 97 treated with HDR using 192iridium (192Ir), and 475 treated with LDR using 125iodine (125I) or 103palladium (103Pd). The median follow up time was 9.2months (range 3.1-145.3) for HDR patients and 53.1 months (range 0.2-198.6) for LDR patients. The two treatment groups were well-balanced with respect to age, T stage, ethnicity, and implanted prostate gland volume. A majority of patients had T1c disease and pretreatment PSA less than 10 ng/ml. 69% of HDR patients had Gleason score of 7 while 2.5% of LDR patients had Gleason score of 7. On univariate analysis, HDR brachytherapy was associated with lower rate of grade 2+ acute GU toxicity (14% vs 38%, p <0.0001) and grade 2+ late GU toxicity (10% vs 31%, p< 0.0001). Acute GI toxicity was low at 3% for both HDR and LDR; late GI toxicity were 6% and 7% (p= 0.63) for HDR and LDR, respectively. In MVA, only LDR was independently associated with increased risk of grade 2+ acute GU toxicity (OR 2.4, 95% CI 1.1-5.3), but it was no longer associated with increased risk of grade 2+ late GU toxicity (OR 1.0, 95% CI 0.5-2.3). MVA demonstrated no difference between the two treatment methods with regard to acute or late GI toxicity. Acute and late GI toxicity was rare in patients treated with brachytherapy. The use of HDR brachytherapy as monotherapy was associated with a significantly lower risk of grade 2+ acute GU toxicity but similar grade 2+ late GU toxicity compared to LDR. Our results suggest HDR may be the preferred brachytherapy option in patients with clinically localized prostate cancer due to the better acute safety profile.

Cost-Effectiveness of Single-Fraction High-Dose Rate Brachytherapy versus Intensity Modulated Radiation Therapy for the Treatment of Low-Intermediate Risk Prostate Cancer

Cost-Effectiveness of Single-Fraction High-Dose Rate Brachytherapy versus Intensity Modulated Radiation Therapy for the Treatment of Low-Intermediate Risk Prostate Cancer

Preclinical studies for implementing flattening filter-free beams in hypofractionated volumetric-modulated arc therapy (VMAT) for prostate cancer radiotherapy

AbstractBackgroundVolumetric-modulated arc therapy (VMAT) has emerged as one of the most favourable techniques for radiotherapy treatment in recent years because of its conformal dose distribution to the planning target volume (PTV), lower doses to adjacent normal organs at risk (OARs) and faster and easier dose delivery. A typical conventional VMAT protocol for low-intermediate risk prostate cancer uses a flattened 6 MV photon beam to deliver 78 Gy in 39 fractions, however, a recent Radiation Therapy Oncology Group study investigated prostate cancer radiotherapy with a hypofractionated dose scheme of 36·25 Gy in 5 fractions. One advantage of flattening filter-free (FFF) beams in radiotherapy is the higher doses in the central region on the dose profile and much higher dose delivery rates.Methods and materialsThis paper reports the investigation of preclinical studies for implementing FFF beams in hypofractionated VMAT for prostate cancer radiotherapy. All treatment planning were accomplished using Varian EclipseTM treatment planning system version 11 and delivered on Varian Truebeam linear accelerators. The studies compared the biological-effective dose–volume histograms and dose–volume histograms of PTV and OARs for 20 patients using conventional and hypofractionated dose schemes. The study also evaluated the 6 and 10 MV FFF by comparing 6 and 10 MV VMAT plans with the FFF beams. The treatment time was investigated using plans with 6 MV beams and doses of 2, 4, 5, 6, 7·25 Gy/fraction and plans with 10 MV FFF with a dose of 7·25 Gy/fraction. We also investigated an angular monitor unit (MU) quantity (MU/deg) and its threshold value for RapidArcTM plans, beyond which FFF beams can be considered superior to flattened beams in terms of treatment time increased caused by higher dose per fraction.ResultsThe results show that the hypofractionated plans resulted in greater biological equivalent doses to PTV and lower doses to OARs. The 10 MV FFF plans have statistically lower mean doses to all the OARs, whereas PTV homogeneity index remains the same compared with other beam energies. The mean body integral dose for the 20 patients is 8·7% lower using 10 MV FFF compared with 6 MV FFF mainly because of the higher energy and less required MUs with the 10 MV FFF beam. The hypofractionated scheme with 10 MV FFF plan has the same treatment time as that of the 6 MV plan at 2 Gy/fraction, as the higher dose delivery rates at 10 MV FFF can compensate for the higher prescribed dose per fraction without the need of extra treatment time.ConclusionIn this study, we observed that the 10 MV FFF beam is better for hypofractionated prostate cancer VMAT plan delivery. The threshold value of MU/deg is found to be 2·083 MU/deg based on our machine configurations.

Brachytherapy for prostate cancer: Present and future

Based on recent, important publications on the impact of brachytherapy in the management of prostate cancer, we analysed already validated indications and the “under investigations” use of brachytherapy. Published studies (MEDLINE), randomized trials and recommendations were reviewed, as well as Delphi consensus when available. While low-dose rate brachytherapy remains a standard of care for low-risk eligible patients, three randomized trials are now available to consider that combination of external beam radiation therapy with brachytherapy boost (low- or high-dose rate) appears as a recommended treatment for intermediate and high-risk patients. Other indications of prostate brachytherapy (monotherapy and salvage) remain under evaluation. For low-risk patients with good urinary status, low-dose rate brachytherapy alone should be offered. For low-intermediate risk prostate cancer, low-dose rate brachytherapy alone may be offered as monotherapy, while for high-intermediate risk prostate cancer, a combination of external beam radiation therapy (with or without androgen deprivation therapy) plus brachytherapy boost (low- or high-dose rate) should be offered to eligible patients. For patients with high-risk prostate cancer receiving external beam radiation therapy and androgen deprivation therapy, brachytherapy boost (low- or high-dose rate) should be offered to eligible patients. High-dose rate brachytherapy as monotherapy (single dose for low-risk/multifractionated for intermediate and high-risk) must be explored under clinical investigations, as well as salvage brachytherapy for local recurrence.

Active surveillance for low-risk prostate cancer.

The approach of active surveillance for low-risk prostate cancer has evolved in many ways since its introduction 20 years ago. There is a great deal of ongoing research addressing the molecular genetics and clinical outcome of low-risk disease, the use of MRI and biomarkers, and the role of lifestyle and dietary modifications. The major developments in the field are reviewed in this article. Low risk and many cases of low-intermediate risk prostate cancer are indolent, have little or no metastatic potential, and do not pose a threat to the patient in his lifetime. These are termed clinically insignificant. Studies over the last 20 years have advanced our understanding of who these patients are, and promoted the use of conservative management in such individuals. A key component of this approach is the early identification of those patients who have been misattributed as having low-risk disease, who in fact harbor higher risk disease and are likely to benefit from definitive therapy. This represents about 30% of newly diagnosed low-risk patients. A further small proportion of patients with low-risk disease demonstrate biological progression to higher grade disease. Extent of Gleason 6 on biopsy, Prostate Specific Antigen density, and race are predictors for the likelihood of coexistent higher grade cancer. The results of active surveillance, embodying conservative management with selective, delayed intervention for the subset who are reclassified as higher risk over time based on repeat biopsy, imaging, or biomarker results, have shown that this approach is safe in the intermediate to long term, with a 0.5-3% cancer-specific mortality at 10-15 years. Further refinement incorporating MRI and targeted biopsies is the subject of intensive research at the moment, and promises to improve the safety and precision of conservative management.

Multimodal Imaging in Focal Therapy Planning and Assessment in Primary Prostate Cancer.

There is increasing interest in focal therapy (male lumpectomy) of localized low-intermediate risk prostate cancer. Focal therapy is typically associated with low morbidity and provides the possibility of retreatment. Imaging is pivotal in stratification of men with localized prostate cancer for active surveillance, focal therapy or radical intervention. This article provides a concise review of focal therapy and the evolving role of imaging in this clinical setting. We performed a narrative and critical literature review by searching PubMed/Medline database from January 1997 to January 2017 for articles in the English language and the use of search keywords "focal therapy", "prostate cancer", and "imaging". Most imaging studies are based on multiparametric magnetic resonance imaging. Transrectal ultrasound is inadequate independently but multiparametric ultrasound may provide new prospects. Positron emission tomography with radiotracers targeted to various underlying tumor biological features may provide unprecedented new opportunities. Multimodal Imaging appears most useful in localization of intraprostatic dominant index lesions amenable to focal therapy, in early assessment of therapeutic efficacy and potential need for additional focal treatments or transition to whole-gland therapy, and in predicting short-term and long-term outcomes. Multimodal imaging is anticipated to play an increasing role in the focal therapy planning and assessment of low-intermediate risk prostate cancer and thereby moving this form of treatment option forward in the clinic.

PD15-04 A RANDOMIZED CONTROLLED TRIAL EXAMINING THE IMPACT OF THE RETZIUS- SPARING APPROACH ON EARLY URINARY CONTINENCE RECOVERY AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy II1 Apr 2017PD15-04 A RANDOMIZED CONTROLLED TRIAL EXAMINING THE IMPACT OF THE RETZIUS- SPARING APPROACH ON EARLY URINARY CONTINENCE RECOVERY AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY Deepansh Dalela, Wooju Jeong, Madhu Ashni-Prasad, Akshay Sood, Firas Abdollah, Patrick Karabon, Mireya Diaz, Sriram Eleswarapu, Jesse Sammon, Brad Baize, Andrea Simone, and Mani Menon Deepansh DalelaDeepansh Dalela More articles by this author , Wooju JeongWooju Jeong More articles by this author , Madhu Ashni-PrasadMadhu Ashni-Prasad More articles by this author , Akshay SoodAkshay Sood More articles by this author , Firas AbdollahFiras Abdollah More articles by this author , Patrick KarabonPatrick Karabon More articles by this author , Mireya DiazMireya Diaz More articles by this author , Sriram EleswarapuSriram Eleswarapu More articles by this author , Jesse SammonJesse Sammon More articles by this author , Brad BaizeBrad Baize More articles by this author , Andrea SimoneAndrea Simone More articles by this author , and Mani MenonMani Menon More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.3286AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Retzius-sparing (posterior) robot-assisted radical prostatectomy (RARP) may expedite urinary continence (UC) recovery. We compared the short-term (≤3 months) UC, urinary function (UF) and UF-related bother outcomes of posterior RARP compared to standard approach (anterior) RARP in a randomized controlled trial (RCT). METHODS 120 patients aged 40-75 with low-intermediate risk prostate cancer (PCa) undergoing primary RARP by a single surgeon were randomized 1:1 to posterior (n=60) or anterior RARP (n=60). Primary outcome was UC (defined as 0 pad/one security liner per day and verified using 24-hour pad weights) 1 week after catheter removal. Secondary outcomes were time to UC recovery, UF and UF-related bother scores (measured by the International Prostatic Symptom Score (IPSS) and IPSS-Quality-of-Life scores respectively) assessed at 1 week, 2 weeks, 1 and 3 months following catheter removal. UC recovery was analyzed using Kaplan-Meier method and Cox proportional hazards regression. Linear generalized estimating equations (GEE) were used to compare UF and UF-related bother scores. RESULTS Median age of the cohort was 61 years. 75.8% harbored intermediate-risk PCa. 71.2% in the posterior vs. 48.3% in the anterior arm were continent 1-week post-catheter removal (p=0.01); corresponding median 24-hour pad weights were 5 and 25 gm respectively (p=0.001). Posterior RARP showed faster UC recovery (figure 1); 94.9% in posterior vs. 85.8% in anterior RARP arms were continent at 3 months (p=0.018), and findings were confirmed on multivariable regression analyses. Urinary bother scores were significantly lower in the posterior vs. anterior RARP group at 1,2 and 4 weeks on GEE analyses (figure 2). CONCLUSIONS This single-center RCT shows that in the hands of an experienced surgeon, Retzius-sparing approach of RARP resulted in earlier recovery of UC and lower UF-related bother than standard RARP in patients with low-intermediate risk PCa © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e283-e284 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Deepansh Dalela More articles by this author Wooju Jeong More articles by this author Madhu Ashni-Prasad More articles by this author Akshay Sood More articles by this author Firas Abdollah More articles by this author Patrick Karabon More articles by this author Mireya Diaz More articles by this author Sriram Eleswarapu More articles by this author Jesse Sammon More articles by this author Brad Baize More articles by this author Andrea Simone More articles by this author Mani Menon More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP97-04 URINARY CONTINENCE, SEXUAL FUNCTION AND BIOCHEMICAL RECURRENCE 12 MONTHS FOLLOWING ROBOT-ASSISTED RADICAL PROSTATECTOMY: A RANDOMIZED CONTROLLED STUDY COMPARING THE ‘BOCCIARDI’ AND ‘MENON’ TECHNIQUES

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy VIII1 Apr 2017MP97-04 URINARY CONTINENCE, SEXUAL FUNCTION AND BIOCHEMICAL RECURRENCE 12 MONTHS FOLLOWING ROBOT-ASSISTED RADICAL PROSTATECTOMY: A RANDOMIZED CONTROLLED STUDY COMPARING THE ‘BOCCIARDI’ AND ‘MENON’ TECHNIQUES Mani Menon, Deepansh Dalela, Madhu Ashni-Prasad, Marcus Jamil, Firas Abdollah, Akshay Sood, Patrick Karabon, Mireya Diaz, Sriram Eleswarapu, Jesse Sammon, Brad Baize, Andrea Simone, and Wooju Jeong Mani MenonMani Menon More articles by this author , Deepansh DalelaDeepansh Dalela More articles by this author , Madhu Ashni-PrasadMadhu Ashni-Prasad More articles by this author , Marcus JamilMarcus Jamil More articles by this author , Firas AbdollahFiras Abdollah More articles by this author , Akshay SoodAkshay Sood More articles by this author , Patrick KarabonPatrick Karabon More articles by this author , Mireya DiazMireya Diaz More articles by this author , Sriram EleswarapuSriram Eleswarapu More articles by this author , Jesse SammonJesse Sammon More articles by this author , Brad BaizeBrad Baize More articles by this author , Andrea SimoneAndrea Simone More articles by this author , and Wooju JeongWooju Jeong More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.3048AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Retzius-sparing (posterior or ′Bocciardi′ approach) of robot-assisted radical prostatectomy (RARP) has been recently suggested as a feasible alternative to the standard (anterior or ′Menon′ approach) RARP. We compared urinary continence (UC), sexual function (SF), oncological outcomes, and postoperative complications over a short term (~1-year) follow up for patients undergoing posterior vs. anterior approach RARP in a randomized trial. METHODS 120 patients with low-intermediate risk prostate cancer (PCa) undergoing RARP by a single surgeon were randomized to posterior (n=60) or anterior RARP (n=60). Recovery of SF was defined as a) erections sufficient for penetrative intercourse (ESI), and b) Sexual Health Inventory for Men (SHIM) score≥ 17. UC recovery was defined as use of 0 pad/one security pad per day. Both UC and SF recovery data were collected by an independent third party (MUSIC registry) using validated patient-reported questionnaires. Oncologic outcomes consisted of positive surgical margins (PSM) and short term (~1 year) biochemical recurrence-free survival (BCRFS). RESULTS There were no significant differences in UC at 6- or 12-months post-RARP (98.4% in posterior vs. 95% in anterior RARP) or urinary function scores in the two arms (figure 1). Amongst preoperatively potent men (SHIM≥ 17), 72.4% in anterior and 83.7% in posterior RARP group were able to have ESI one year after surgery (p=0.6); 46.2% and 59.2% had regained SHIM≥ 17 by the same time point (figure 2). There were no significant differences in the incidence of PSM (25% in posterior vs. 13.3% in anterior RARP), BCRFS (91.5% vs. 94.4% respectively) or postoperative complications over a median follow-up of 13.5 months. CONCLUSIONS In this randomized trial of patients with low-intermediate risk PCa, UC, SF, postoperative complications, and BCR rates were comparable at 12 months in patients undergoing ′Bocciardi′ vs. ′Menon′ approach RARP. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1304 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Mani Menon More articles by this author Deepansh Dalela More articles by this author Madhu Ashni-Prasad More articles by this author Marcus Jamil More articles by this author Firas Abdollah More articles by this author Akshay Sood More articles by this author Patrick Karabon More articles by this author Mireya Diaz More articles by this author Sriram Eleswarapu More articles by this author Jesse Sammon More articles by this author Brad Baize More articles by this author Andrea Simone More articles by this author Wooju Jeong More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Brachytherapy for Patients With Prostate Cancer: American Society of Clinical Oncology/Cancer Care Ontario Joint Guideline Update.

Purpose To jointly update the Cancer Care Ontario guideline on brachytherapy for patients with prostate cancer to account for new evidence. Methods An Update Panel conducted a targeted systematic literature review and identified more recent randomized controlled trials comparing dose-escalated external beam radiation therapy (EBRT) with brachytherapy in men with prostate cancer. Results Five randomized controlled trials provided the evidence for this update. Recommendations For patients with low-risk prostate cancer who require or choose active treatment, low-dose rate brachytherapy (LDR) alone, EBRT alone, and/or radical prostatectomy (RP) should be offered to eligible patients. For patients with intermediate-risk prostate cancer choosing EBRT with or without androgen-deprivation therapy, brachytherapy boost (LDR or high-dose rate [HDR]) should be offered to eligible patients. For low-intermediate risk prostate cancer (Gleason 7, prostate-specific antigen < 10 ng/mL or Gleason 6, prostate-specific antigen, 10 to 20 ng/mL), LDR brachytherapy alone may be offered as monotherapy. For patients with high-risk prostate cancer receiving EBRT and androgen-deprivation therapy, brachytherapy boost (LDR or HDR) should be offered to eligible patients. Iodine-125 and palladium-103 are each reasonable isotope options for patients receiving LDR brachytherapy; no recommendation can be made for or against using cesium-131 or HDR monotherapy. Patients should be encouraged to participate in clinical trials to test novel or targeted approaches to this disease. Additional information is available at www.asco.org/Brachytherapy-guideline and www.asco.org/guidelineswiki .

Association between Basal Total Testosterone Levels and Tumor Upgrading in Low and Intermediate Risk Prostate Cancer

Purpose: The study aimed to evaluate associations of basal levels of total testosterone (TT) with tumor upgrading to high risk disease in low-intermediate risk prostate cancer (PCA). Materials and Methods: We retrospectively evaluated the records of 135 patients undergoing radical prostatectomy. Evaluated factors included age, body mass index, prostate specific antigen (PSA), TT, prostate volume, PSA density (PSAD), proportion of biopsy positive cores (P+), clinical tumor stage, and biopsy grading system (1 or 2). Factors associating with tumor upgrading were investigated by the multivariate logistic regression analysis. Results: Tumor upgrading rate to high risk disease was 8.9%. TT, PSA, and PSAD were associated with tumor upgrading. On multivariate analysis, independent factors predicting tumor upgrading were PSA (OR 1.324; p = 0.001) and TT (OR 1.005; p = 0.015). Basal TT was dichotomized up to the third quartile (TT > q3) vs. TT ≤ q3 (426.0 ng/dL). The assessed tumor upgrading risk model showed that TT dichotomized to third quartile (TT > q3 vs. TT ≤ q3) stratified the risk of tumor upgrading (OR 6.577; p = 0.010) along increasing levels of PSA (OR 1.3; p < 0.0001). Conclusions: Low and intermediate risk PCA patients show a not negligible risk of tumor upgrading to high risk disease. In this particular subset of patients, basal levels of TT stratify the risk of tumor upgrading.

The Effect of Dutasteride on Magnetic Resonance Imaging Defined Prostate Cancer: MAPPED—A Randomized, Placebo Controlled, Double-Blind Clinical Trial

Dutasteride, which is licensed for symptomatic benign prostatic hyperplasia, has been associated with a lower progression rate of low risk prostate cancer. We evaluated the effect of dutasteride on prostate cancer volume as assessed by T2-weighted magnetic resonance imaging. In this randomized, double-blind, placebo controlled trial, men with biopsy proven, low-intermediate risk prostate cancer (up to Gleason 3 + 4 and PSA up to 15 ng/ml) who had visible lesion of 0.2 ml or greater on T2-weighted magnetic resonance imaging sequences were randomized to daily dutasteride 0.5 mg or placebo for 6 months. Lesion volume was assessed at baseline, and 3 and 6 months with image guided biopsy to the lesion at study exit. The primary end point was the percent reduction in lesion volume over 6 months. This trial was registered with the European Clinical Trials register (EudraCT 2009-102405-18). A total of 42 men were recruited between June 2010 and January 2012. In the dutasteride group, the average volumes at baseline and 6 months were 0.55 and 0.38 ml, respectively and the average reduction was 36%. In the placebo group, the average volumes at baseline and 6 months were 0.65 and 0.76 ml, respectively, and the average reduction was -12%. The difference in percent reductions between the groups was 48% (95% CI 27.4-68.3, p <0.0001). The most common adverse event was deterioration in erectile function, which was 25% in men randomized to dutasteride and 16% in men randomized to placebo. Dutasteride was associated with a significant reduction in prostate cancer volume on T2-weighted magnetic resonance imaging compared to placebo.

Modeling Biochemical Relapse-Free Survival in Intraoperative Planned Low-Dose-Rate Prostate Brachytherapy: A Multicenter Cohort Analysis

To develop a model of biochemical relapse free survival (bRFS) outcomes in prostate cancer patients treated with intraoperatively planned low dose rate prostate brachytherapy using an automated delivery system (IO-LDRB). A total of 3286 patients with low or low-tier intermediate risk prostate cancer were treated with single modality IO-LDRB at 3 centers between December 1997 and August 2015. Data from 2 centers was used to develop a model for bRFS and data from the third center was used for external validation. Data was analyzed using R version 3.1.3, and is presented as medians (range; P value) unless otherwise indicated. After censuring for missing data, 2730 patients were analyzed: 1780 in the training and 950 in the comparison cohort. Median follow-ups were 52.9 (0.0-136.0) and 36.0 (0.0-114; <0.001) months, respectively. Ages were 64 (42-84) and 65 (44-80; <0.001) years. Pre-treatment PSAs were 5.6 (0.03-16.6) and 5.5 (0.2-18.5; 0.3) ng/mL. A total of 1,298 (73%) and 713 (75%; 0.7) were T1; the remainder were T2. A total of 1,380 (78%) and 651 (68.5; <0.001) patients had Gleason 6; 375 (21%) and 651 (30.5%; <0.001) had Gleason 7 disease. 307 (17.3%) and 7 (1%) received hormones for medians of 3.0 (0.5-32.1) and 4.5 (3-8; 0.1) months respectively. Median implant D90s were 190.6 (135.5-237.0) and 161.3 (97.0-273.0; <0.001) Gray. For the training cohort, median gland volume was 34.8 (10.9 – 66.9) cc. In the training cohort there were 85 (4.8%) biochemical failures as defined by the Phoenix definition. Median time to failure was 49.4 (6.3-132.3) months. In the validation cohort 26 (2.7%; <0.001) patients failed in a median of 48.1 (11.6 – 99.6; 1.0) months. Somer’s D was 0.44 after internal validation. Factors predicting bRFS were pre-treatment PSA, Gleason sum, stage, gland volume, D90 and hormone use. Predicted 5 and 10-year survival for patients with 34.8cc glands, PSA 5.6, T1 and Gleason 6 disease, treated to D90 = 190.6 and without hormones were 96% and 87%, respectively. Model prediction of survival estimates in the external validation cohort converged with Kaplan-Meier estimates confirming model validity. IO-LDRB is an effective treatment option for patients with low and low-tier intermediate risk prostate cancer. Despite low relapse rates, probability of relapse is predictable based on tumor and treatment characteristics. We present a comprehensive model for predicting bRFS in these patients.

Stereotactic Body Radiation Therapy for Low-Intermediate Risk Prostate Cancer—A Single-Institution Initial Analysis of Toxicity

Stereotactic Body Radiation Therapy for Low-Intermediate Risk Prostate Cancer—A Single-Institution Initial Analysis of Toxicity

Erratum to: A phase II experience evaluating quality of life and survival in linac-based SBRT for prostate cancer

This study aims to evaluate SBRT with volumetric modulated arc therapy (VMAT) and toxicity using five validated quality of life (QOL) instruments. An approved prospective NCI-designated phase II study (NCT01581749) was conducted. The inclusion criteria are the following: histologically proven prostate adenocarcinoma, Gleason score 6–7, clinical stage T1b-T2b, PSA ≤20 ng/ml, prostate volume ≤100 cm3, and no prior prostate radiotherapy. SBRT was delivered as 36.25 Gy in five fractions to PTV via VMAT. Patients self-reported on validated QOL measures including the American Urological Association (AUA) Index, Sexual Health Inventory for Men (SHIM), Utilization of Sexual Medications/Devices (USMD), and Expanded Prostate Cancer Index Composite Short Form (EPIC-26). In addition, PSA response and survival were evaluated. A total of 33 patients were entered into the study. Median time from treatment to last follow up was 30 months. Mean age was 67.5 years. Mean PSA was 6.1 and Gleason scores ranged from 6 to 7. Mean PSA declined by 42 % was observed at 1 month post-treatment and continued to decrease. Three patients (9.7 %) had PSA bounce, with one patient having disease progression (3.0 %). There were no transient side effects or sequelae noted on their QOL questionnaires over the follow-up period of 36 months. Some adverse effects to sexual health were noticed with the majority of these incidences occurring within 1 month after treatment and resolved within 3 months of symptom onset. SBRT with VMAT for low-intermediate risk prostate cancer is well tolerated. Acute toxicities showed no apparent impact on patient general sense of well-being. No adverse effects were observed over the 36 month period.