Prostate Rebiopsy Research Articles

Patients with metabolic syndrome and widespread high grade prostatic intraepithelial neoplasia are at a higher risk factor of prostate cancer on re-biopsy: A prospective single cohort study

ObjectivesTo test the hypothesis that patients with widespread high grade prostatic intra epithelial neoplasia (wHGPIN) and metabolic syndrome (MetS) are at a higher risk of prostate cancer (PCa) at a repeat biopsy. Methods and MaterialsWe prospectively evaluated 161 patients submitted from December 2004 to December 2011 to prostate rebiopsy after a initial diagnosis of HGPIN in a tertiary academic center. A 12 core biopsy template was used for all the biopsies. Rebiopsy was performed six months after the initial biopsy independently from PSA level and the DRE finding. wHGPIN was defined as≥4 biopsy cores involved. MetS was defined according to the National Cholesterol Education Program’s Adult Treatment Panel III criteria. ResultsOverall, 64 patients (39.7%) presented wHGPIN and 97 isolated HGPIN (60.3%). MetS was found in 63 patients, 39.1% of the whole population. Out of them 16 (25.3%) and 47 (74.7%) patients had a diagnosis of isolated and wHGPIN (P = 0.001). PCa detection rate at repeat biopsy was significantly higher in patients with MetS and wHGPIN than in those with wHGPIN and no MetS (57.4% Vs 23.5%; P = 0.016). A logistic regression model confirmed that wHGPIN and MetS are independent risk factors of prostate cancer diagnosis (respectively: Odds ratio (OR) = 4.187, 95%CI: 1.65–10.57 p = 0.002 and OR=3.603, 95%CI: 1.41-9.19, p = 0.007). ConclusionPatients with MetS and wHGPIN are at a higher risk of PCa, therefore performing a new prostate biopsy in those patients should be recommended.

P1-127 - Repeat Biopsy Outcomes and Change in QOL Status at 1 Year after Active Surveillance: Results from a Japanese Multicenter Prospective Study and the Prias-Japan

ABSTRACT Backgrounds and objectives In Japan, two prospective multicenter active surveillance (AS) studies are under investigation. The first is a prospective Japanese AS study that has been carried out in favorable risk prostate cancer since 2002. The second is the PRIAS-JAPAN; 30 institutions in Japan have been participating into the Prostate cancer Research International: Active Surveillance (PRIAS) study as the PRIAS-JAPAN since 2010.The objective of this study is to evaluate the outcomes of 1 year after AS including prostate re-biopsy and the change in QOL status using the two Japanese prospective cohorts. Patients and methods Thirteen institutions participated in the Japanese AS study. One hundred and thirty-four patients with biopsy proven favorable risk prostate cancer were enrolled into study between January 2002 and December 2003. AS remaining rate in 33.2%. On the other hand, the PRIAS-JAPAN study was started since January 2010. Until December 2011, 189 patients were enrolled. One year after rebiopsy was recommended to all participants, and QOL was assessed at enrollment and at 1 year after AS in both studies. Results In the Japanese AS study, 64 patients who underwent re-biopsy, 42 met the pathological selection criteria again. The reclassification rate was 34.4%. In PRIAS-JAPAN, the reclassification rate was 28% (P = 0.467). There was no predictive parameter for reclassification in the Japanese AS study. On the other hand, number of positive cores was a significant predictive parameter for reclassification in PRIAS-Japan. Almost all domains of QOL at enrollment revealed better QOL than norm-based scoring (NBS). At 1 year after AS, there was no significant change. Conclusions Instead of the time difference between the two studies was ∼10 years, the reclassification rate for the current AS cohort (PRIAS-J) was comparable or even lower than the former cohort. Health-related QOL of the Japanese patients who opted AS as an initial treatment was better than NBS and it has been maintained 1 year after AS.

Repeat biopsy outcomes and change in QOL status at 1 year after active surveillance: Results from a Japanese multicenter prospective study and the PRIAS-JAPAN.

e15127 Background: In Japan, two prospective multicenter active surveillance (AS) studies are under investigation. The 1st is a prospective Japanese AS study that has been carried out in favorable risk prostate cancer since 2002. The 2nd is the PRIAS-JAPAN; 30 institutions in Japan have been participating into the Prostate cancer Research International: Active Surveillance (PRIAS) study as the PRIAS-JAPAN since 2010. The objective of this study is to evaluate the outcomes of 1-year after AS including prostate re-biopsy and the change in QOL status using the two Japanese prospective cohorts. Methods: 134 patients with biopsy proven favorable risk prostate cancer were enrolled into study between January 2002 and December 2003. Triggers to start curable treatment were PSADT of 2 years or shorter or pathological progression at 1-year re-biopsy. AS remaining rate in 33.2% (median observation period: 78 months). On the other hand, PRIAS-JAPAN study was started since January 2010. Until December 2011, 189 patients were enrolled. 1-year after re-biopsy was recommended to all participants and QOL was assessed at enrollment and at 1-year after AS in both studies with Japanese version SF-36 and SF-8 respectively. Results: In the Japanese AS study, 64 patients who underwent re-biopsy, 42 met the pathological selection criteria again. Reclassification rate was 34.4%. In PRIAS-JAPAN, reclassification rate was 28% (p=0.467). There was no predictive parameter for reclassification in the Japanese AS study. On the other hand, number of positive cores was a significant predictive parameter for reclassification in PRIAS-Japan. Almost all domains of QOL at enrollment revealed better QOL than Norm-based Scoring (NBS). At 1-year after AS, there was no significant change and favorable QOL was maintained in both study. Conclusions: Instead of the time difference between the 2 studies was approximately 10 years, reclassification rate for the current AS cohort (PRIAS-J) was comparable or even lower than the former cohort. Health-related QOL of the Japanese patients who opted AS as an initial treatment was better than NBS and it has been maintained 1-year after AS.

1470 PROSTATE RE-BIOPSY OUTCOMES AND CHANGE IN QOL STATUS AT 1-YEAR AFTER ACTIVE SURVEILLANCE IN JAPANESE PROSTATE CANCER PATIENTS-FROM A JAPANESE AS STUDY AND THE PRIAS-JAPAN-

You have accessJournal of UrologyProstate Cancer: Localized VII1 Apr 20121470 PROSTATE RE-BIOPSY OUTCOMES AND CHANGE IN QOL STATUS AT 1-YEAR AFTER ACTIVE SURVEILLANCE IN JAPANESE PROSTATE CANCER PATIENTS-FROM A JAPANESE AS STUDY AND THE PRIAS-JAPAN- Mikio Sugimoto, Hiromi Hirama, and Yoshiyuki Kakehi Mikio SugimotoMikio Sugimoto Kagawa, Japan More articles by this author , Hiromi HiramaHiromi Hirama Kagawa, Japan More articles by this author , and Yoshiyuki KakehiYoshiyuki Kakehi Kagawa, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1991AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In Japan, two prospective multicentre active surveillance (AS) studies are under investigation. The 1st is a prospective Japanese multi-center AS study that has been carried out in favorable risk prostate cancer since 2002. The 2nd is the PRIAS-JAPAN; 30 institutions in Japan have been participating into the Prostate cancer Research International: Active Surveillance (PRIAS) study as the PRIAS-JAPAN since 2010. The objective of this study is to evaluate the outcomes of one-year after AS including prostate re-biopsy and the change in QOL status using the two Japanese prospective cohorts. METHODS 13 institutions participated in the Japanese multi-center AS study. 134 patients with biopsy proven prostate cancer that met the following criteria were enrolled into study between January 2002 and December 2003. The selection criteria included (1) stage T1cN0M0, (2) age 50-80, (3) serum prostate specific antigen (PSA) <20 ng/ml, (4) one or two positive cores per 6-12 systematic biopsy cores, (5) Gleason score <6, and (6) maximum cancer involvement in positive core <50%. Triggers to start curable treatment were PSADT of 2 years or shorter or pathological progression at 1-year re-biopsy.AS remaining rate in 33.2% (median observation period: 78 months). On the other hand, PRIAS-JAPAN study was started since January 2010. Until August 2011, 150 patients were enrolled. 1-year after re-biopsy was recommended to all participants and QOL was assessed at enrollment and at 1-year after AS in both studies with Japanese version SF-36 and SF-8 respectively. RESULTS In the Japanese multi-center AS study, although 99 patients were eligible for re-biopsy, only 66 out of 99 patients underwent. In 66 patients who underwent re-biopsy, 44 met the pathological selection criteria again, including 25 patients in whom biopsy turned negative. Reclassification rate was 33.3%. In PRIAS-JAPAN, reclassification rate was 20% (p=0.214). Almost all domains of QOL at enrollment revealed better QOL than that of general population with comparable ages. At 1-year after AS, there was no significant change and favorable QOL was maintained in both study. CONCLUSIONS Instead of the time difference between the 2 studies was approximately 10 years, reclassification rate for the current AS cohort (PRIAS-J) was comparable or even lower than the former cohort. Health-related QOL of the Japanese patients who opted AS as an initial treatment was favorable as compared to the age-matched Japanese population and it has been maintained 1-year after AS. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e596 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mikio Sugimoto Kagawa, Japan More articles by this author Hiromi Hirama Kagawa, Japan More articles by this author Yoshiyuki Kakehi Kagawa, Japan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1821 GLEASON UPGRADING AND INCREASED CANCER VOLUME ON REPEAT PROSTATE BIOPSY IN PATIENTS ON ACTIVE SURVEILLANCE

INTRODUCTION AND OBJECTIVES: The choice to terminate active surveillance (AS) for localized prostate cancer in favor of initiating definitive treatment is based on a variety of factors. These may include pathologic change on re-biopsy, progression in PSA or DRE, or patient preference. The relative extent to which each of these factors plays a role in the termination of AS is not clearly established. Our objective was to determine the prevalence of prostate re-biopsy and subsequent pathologic change in an AS cohort. METHODS: Under IRB approved protocol, a historical cohort study of men diagnosed with prostate cancer was performed at a single tertiary-care center between 1991 and 2011. Although AS had been practiced throughout this period, in 2008 our group agreed upon a protocol for repeat biopsy at 12-18 months after diagnosis. Subsequent biopsy was left to the discretion of the treating physician. Only men with active surveillance as the initial management option were included. RESULTS: The median follow-up was 4.5 years for the 623 patients included in the study. Median PSA at diagnosis was 5.1 ng/mL. 96.2% (600/623) of patients were Gleason 6, 3.7% (23/623) were Gleason 7 and 89.9% (561/623) were stage T1c. 378 (60.1%) patients underwent re-biopsy. The number of re-biopsies ranged from 1 – 7 with 125 (33.1%) patients having more than one re-biopsy. Findings on initial re-biopsy revealed prostate cancer in 70.9% (268/378), benign tissue in 21.2% (80/378), PIN in 6.4% (24/378), and atypia in 1.6% (6/378). The Gleason sum increased in 17.9% of patients whose re-biopsy revealed cancer. Cancer volume increased (expressed as percentage of positive cores in quartiles) in 25.7% of patients on re-biopsy. Of 149 patients who required active treatment, 45.0% (67/ 149) was due to pathologic progression. CONCLUSIONS: We identified a significant proportion of Gleason upgrading and volume progression on repeat biopsy in this cohort. Repeat biopsy often resulted in a significant change in management of our AS population. These findings support the critical role of repeat biopsy in an AS protocol.

Diagnosis of isolated high‐grade prostatic intra‐epithelial neoplasia: proposal of a nomogram for the prediction of cancer detection at saturation re‐biopsy

Study Type--Diagnostic (case series). Level of Evidence 4. What's known on the subject? And what does the study add? Multifocality, age, PSA values, and biopsy protocols regarding the predictive value of high grade PIN have been discussed extensively in the literature. Our study developed for the first time a predictive nomogram that could be helpful for patient counselling and to guide the urologist to perform rPBX after an initial diagnosis of isolated HGPIN. • To evaluate factors that may predict prostate cancer (PCa) detection after the initial diagnosis of high-grade prostatic intra-epithelial neoplasia (HGPIN) on prostate biopsy (PBx) with six to 24 random cores. • We retrospectively evaluated 262 patients submitted from 1998 to 2007 to prostate re-biopsy (rPBx) after an initial HGPIN diagnosis in tertiary academic centres. • HGPIN diagnosis was obtained on initial systematic PBx with six to 24 random cores. • All patients were re-biopsied with a 'saturation' rPBx with 20-26 cores, with a median time to rPBx of 12 months. • All slides were reviewed by expert uropathologists. • Plurifocal HGPIN (pHGPIN) was found in 115 patients and monofocal HGPIN (mHGPIN) was found in 147 patients. • In total, 108 and 154 patients, respectively, were submitted to >12-core initial PBx and ≤12-core initial PBx. • Overall PCa detection at rPBx was 31.7%. PSA level (7.7 vs 6.6 ng/mL; P= 0.031) and age (68 vs 64 years; P= 0.001) were significantly higher in patients with PCa at rPBx. • PCa detection was significantly higher in patients with a ≤12-core initial PBx than in those with a >12-core initial PBx (37.6% vs 23.1%; P= 0.01), as well as in patients with pHGPIN than in those with mHGPIN (40% vs 25.1%; P= 0.013). • At multivariable analysis, PSA level (P= 0.041; hazards ratio, HR, 1.08), age (P < 0.001; HR, 1.09), pHGPIN (P= 0.031; HR, 1.97) and ≤12-core initial PBx (P= 0.012; HR, 1.95) were independent predictors of PCa detection. • A nomogram including these four variables achieved 72% accuracy for predicting PCa detection after an initial HGPIN diagnosis. • PCa detection on saturation rPBx after an initial diagnosis of HGPIN is significantly higher in patients with a ≤12-core initial PBx than those with a >12-core initial PBx and in patients with pHGPIN than in those with mHGPIN. • We developed a simple prognostic tool for the prediction of PCa detection in patients with initial HGPIN diagnosis who were undergoing saturation rPBx.

Trans-rectal Versus Trans-Perineal Saturation Rebiopsy of the Prostate: Is There a Difference in Cancer Detection Rate?

To test the hypothesis that there is no significant difference in the rate of prostate cancer (PCa) detection rate between the transrectal and transperineal approach in men undergoing a saturation (24-core) prostate rebiopsy. We evaluated 472 consecutive men who underwent a 24-core prostate rebiopsy at 2 tertiary referral centers. Of these, 70% (332) underwent a transrectal biopsy, and 30% (140) underwent a transperineal biopsy. Propensity score was used to match 280 patients with homogeneous characteristics; those represented the final study cohort. Univariable and multivariable logistic regression analyses were used to address the relationship between biopsy approach and PCa detection rate. Covariates consisted of age at biopsy, prostate-specific antigen, total prostate volume, digital rectal examination findings, histologic findings on previous biopsy, and the number of previous negative biopsy sets. Overall, PCa detection rate was 28.6%. There was no statistically significant difference in PCa detection rate between the transrectal and transperineal approach (31.4% vs 25.7%, respectively; P = .3). The type of approach was not an independent predictor of PCa detection rate at multivariable analyses (odds ratio = 0.61, P = .1). Transrectal and transperineal prostate saturation biopsies have a similar PCa detection rate in men undergoing a saturation rebiopsy. Both approaches can be offered to men undergoing a prostate rebiopsy without undermining the rate of PCa detection.

Transperitoneal Laparoscopic Prostatectomy Does Not Increase Small Bowel Within the Target Volume for Postoperative Radiotherapy

Laparoscopic or robot assisted laparoscopic radical prostatectomy is often performed via a transperitoneal approach for prostate cancer, in contrast to open retropubic radical prostatectomy. Theoretically transgressing the peritoneum may introduce small bowel loops into the pelvis, increasing the risk of small bowel injury with adjuvant radiotherapy. We compared the incidence of small bowel within the planning target volume for radiotherapy to the prostate bed in patients who underwent open retropubic and laparoscopic radical prostatectomy. A total of 25 patients recently treated with laparoscopic radical prostatectomy prospectively provided consent to undergo radiotherapy planning computerized tomography simulation to assess the incidence of small bowel within the prostate bed planning target volume. These studies were compared to radiotherapy planning computerized tomography in 50 patients who underwent open retropubic radical prostatectomy and received adjuvant or salvage radiotherapy for prostate cancer. For all computerized tomography images 1 blinded observer delineated the distal small bowel loops and 1 blinded radiation oncologist delineated the superior extent of clinical and planning target volumes. The overlap rate between small bowel and planning target volume was 16% in the laparoscopic and open radical prostatectomy groups (p = 0.579). There is no difference between transperitoneal laparoscopic and open retropubic radical prostatectomy in the incidence of small bowel within the planning target volume for radiotherapy to the prostate bed. Thus, patients who undergo transperitoneal laparoscopic radical prostatectomy do not face a higher risk of toxicity or compromise due to adjuvant or salvage radiotherapy should they require it.

Eficacia clínica de la biopsia prostática. Experiencia en nuestro centro 1990-2002

IntroductionThe prostate biopsy is the only valid tool to diagnose the existence of cancer of prostate. The indications of the biopsy, according with EAU, are the existence of high PSA, increased velocity PSA and a rectal suspicious tact Objectivesvalidation of the utility of the prostate biopsy, to know the value of the PSA as a marker of prostate cancer in our way and to value the indication and efficiency of repeated biopsies Matherial and methodswe practice a manual review of the biopsies in our hospital, between the years 1990 and 2002. We study the level of PSA before the biopsy, number of prostatic cores and histologic information of the biopsy. A statistical descriptive and inferencial study has been performed by SPSS 12.0 package ResultsThe total number of biopsies registered was a 1202, with 36.96 % of biopsy positive. The PSA before the biopsy (available in the biopsies realized between the year 1999 and 2002: 578 biopsies, 48.08 % of the whole) was> 10 ng/ml in 55,88 % of these patients, 4-10 ng/ml in 39.27 % and 0-4ng/ml in 4.84 %. The average and PSA’s median is of 19.09 (standard error: 1.87) and 10.6, respectively. The positividad of the biopsy increases with PSA’s level: 48,61 % with PSA> 10; 25.11 % with PSA 4-10 and 21,4 % in patients with PSA <4. There was realized prostate rebiopsy (2 ó more biopsies) in 132 patients (21,97 % positive) 88,36 % of the cancers was diagnosed in the first biopsy, and 6.62 % in the second one (94,98% of the diagnoses of cancer of prostate carried out with the first 2 biopsies) ConclusionsThe information obtained in the study by means of the descriptive analysis of our series meets in conformity the published in other studies and publications. There exists a need to increase the diagnostic profitability of the biopsy of prostate, for which we have introduced a protocol of biopsy under local anesthesia in order to be able to increase the number of obtained cylinders

4012 POSTER Preliminary results of the 2-year prostate re-biopsy in a phase II randomized study of conventional fractionation vs. hypofractionation on patients with high risk prostate cancer

4012 POSTER Preliminary results of the 2-year prostate re-biopsy in a phase II randomized study of conventional fractionation vs. hypofractionation on patients with high risk prostate cancer

Re-biopsy of the Prostate Using a Stereotactic Transperineal Technique

In this study we investigated the detection rate and morbidity of stereotactic transperineal prostate re-biopsy with 3-dimensional mapping for diagnosis of nonpalpable isoechoic occult prostate malignancy. A total of 180 consecutive patients with continued increasing total prostate specific antigen and at least 1 prior benign transrectal prostate biopsy underwent stereotactic transperineal prostate biopsy at a single outpatient institution between April 2004 and March 2006. Similar to a prostate brachytherapy procedure, patients were placed in the dorsal lithotomy position. With the patient under general anesthesia, and using transrectal ultrasound, a perineal brachytherapy template and stabilizing device, the prostate was positioned on the implant grid. It was equally divided into 8 sections (octants) according to x and y coordinates on the mid gland axial image. The midplanes of axial and sagittal prostate gland images for each patient determined the x, y and z coordinates that would occupy each octant. Tissue cores were initially obtained from the apical octants, followed by identical x and y coordinates of the basilar octants. Specimens from each specific octant were placed in 1 of 8 specimen jars and pathological review was reported accordingly. Stereotactic transperineal prostate biopsy yielded positive biopsies identifying adenocarcinoma in 68 of 180 (38%) patients. Acute urinary retention developed in 18 of 180 (10%) patients requiring an indwelling urinary catheter upon discharge home. In all patients estimated blood loss was less than 5 cc and median pain score was 1 of 10. Stereotactic transperineal prostate biopsy is extremely well tolerated and useful for diagnosis of nonpalpable isoechoic occult prostate malignancy. Additionally, stereotactic transperineal prostate biopsy provides comprehensive tissue sampling with accurate 3-dimensional mapping of malignancy in this select group of patients.

Active Surveillance for Prostate Cancer: For Whom?

Prostate-specific antigen (PSA) -based prostate cancer screening results in the diagnosis of prostate cancer in many men who are not destined to have clinical progression during their lifetime. Good-risk prostate cancer, defined as a Gleason score of 6 or less, PSA < 10, and T1c to T2a, now constitutes 50% of newly diagnosed prostate cancer. In most of these patients, the disease is indolent and slow growing. The challenge is to identify those patients who are unlikely to experience significant progression while offering radical therapy to those who are at risk. The approach to favorable-risk prostate cancer described in this article uses estimation of PSA doubling time (PSA DT) to stratify patients according to the risk of progression. Patients who select this approach are managed initially with active surveillance. Those who have a PSA DT of 3 years or less (based on a minimum of three determinations over 6 months) are offered radical intervention. The remainder are closely monitored with serial PSA and periodic prostate rebiopsies (at 2, 5, and 10 years). In this series of 299 patients, the median DT was 7 years. Forty-two percent had a PSA DT > 10 years, and 20% had a PSA DT > 100 years. The majority of patients on this study remain under surveillance. The approach of active surveillance with selective delayed intervention based on PSA DT represents a practical compromise between radical therapy for all (which results in overtreatment for patients with indolent disease) and watchful waiting with palliative therapy only (which results in undertreatment for those with aggressive disease).

Prostatic Biopsy after Radiotherapy: When and How

Objectives: External beam radiotherapy and seed implantation are treatment options for clinically localized prostate cancer. Post-radiation biopsies may assess the efficacy of radiation in locally eradicating prostate cancer cells. Aim of this overview was to analyze the role of prostate rebiopsies after radiation to evaluate treatment success. Methods: A Medline search was performed from 1980 to 2001 for articles in English. Results: Based on the available data a positive prostate rebiopsy can be found in 18–90% for patients with stage T1–T3. Pretreatment PSA, pretreatment Gleason score, clinical stage and digital rectal examination (DRE) after radiotherapy correlate with biopsy results. A positive post-treatment biopsy is associated with a higher nadir PSA serum level and a higher rate of local recurrence compared to patients with negative biopsies. However, systematic prostate biopsies after radiation therapy are not necessary in the standard follow-up because a rising PSA after radiation therapy is a more rigorous end-point for evaluation of treatment efficacy. However, patients with rising PSA after irradiation without evidence of systematic disease and positive prostate biopsies may be candidates for salvage treatment. Conclusions: Prostate biopsies after radiation therapy are not necessary as a standard procedure for follow-up. Prostate rebiopsies may be an important research tool to evaluate histological changes within the prostate and may indicate local recurrence.

When and How a Prostatic Re-Biopsy Should be Performed?

Objectives: What should be done when a first set of prostate biopsies was negative is still a matter of debate. Methods: Literature on prostate re-biopsy was reviewed and a selection of articles made. Keywords used for the Medline search included: Prostate cancer, Biopsy, Diagnosis. Results: Several studies including data from the multicenter European Prostate Cancer Detection Study (EPCDS) have shown that at least 10% of patients with negative sextant biopsies had prostate cancer found on repeat biopsy. Re-biopsy can be performed 6 weeks after an intial set of biopsies without significant increase in pain or morbidity. Conclusions: The current review critically evaluated the indications, timing, number of cores and location of repeat biopsies focussing on the available literature.

How does histologic grade change over time on repeat biopsy in untreated, favorable grade, localized prostate cancer

Purpose: To examine the change of histologic grade of untreated, favorable grade, prostate adenocarcinoma over time on repeat prostate biopsy. Materials and Methods: A prospective single-arm cohort study has been in progress since November 1995, to assess the feasibility of a watchful observation protocol with selective delayed intervention using clinical, histologic, and/or PSA progression as treatment indication in untreated, favorable grade, localized prostate adenocarcinoma. Patients are initially managed with watchful observation alone. When a patient meets the pre-defined criteria of disease progression, appropriate treatment is implemented according to his age, disease extent, co-morbidity, and preference. Eligible subjects must have clinical stage T1b-T2b N0M0, Gleason score (GS) ≤7, and PSA ≤15 ng/ml. Patients are followed every 3 months for the first 2 years and then every 6 months thereafter. At each visit, medical history, physical examination and blood tests including PSA are obtained. Transrectal ultrasound (TRUS) of the prostate and bone scan are performed every 6 and 12 months respectively. TRUS guided prostate biopsy is repeated at 12-18 months after enrolment to evaluate the change in the histologic grade of malignancy. Most initial and subsequent biopsies were centrally reviewed by one pathologist. Possible associations of the change in histologic grade with PSA doubling time (PSAdt), and the baseline clinical parameters of the patients are explored with correlation analysis. PSAdt is estimated from a linear regression of ln(PSA) on time, assuming a simple exponential growth model. Results: As of April 2001, 67(42%) of a total of 161 eligible patients underwent rebiopsy of prostate, and formed the basis of this analysis. None received any treatment prior to rebiopsy. 94 declined or were not subjected to the rebiopsy at the discretion of an attending physician. Median time to rebiopsy was 18 months (range: 9-58). Median age was 70 years (range: 58-81). The distribution of clinical stage, PSA at entry and initial GS was as follows: T1: T2 = 40:27, initial PSA < 5: 5-9.9:10-14.9 = 23:34:10, initial GS 4:5:6:7:GX = 2:13:37:14:1. Median follow-up was 29 months (range: 13-59). GS was unchanged in 21(31%), upgraded in 22(33%) and downgraded in 24(36%) on repeat biopsy (see Table). In 19(28%), there was no malignancy on rebiopsy. The higher initial GS did not predict a higher probability of GS upgrade. There was no statistically significant correlation between the change in histologic grade and PSAdt, or the baseline variables including age, initial PSA, and clinical stage. Conclusion: The histologic grade of malignancy can change over time as the biology of malignancy evolves. In our cohort, 19(28%) did not have malignancy on rebiopsy. This was most likely related to sampling error. Furthermore, there was no consistent upgrade of histologic grade on repeat biopsy at a median of 18 months. This may be due to a short interval between the two biopsies, and/or the favorable clinical and pathological parameters of our cohort which predict very slow biological evolution over time. Also, this observation is subject to the adequacy of biopsy sampling as well as intra- and inter-observer variability of GS. It remains to be seen whether or not upgrade of histologic grade is a useful predictor of disease progression requiring therapeutic intervention in patients managed with watchful observation. Tabled 1Initial GS →GX (n=1)GS 4 (n=2)GS 5 (n=13)GS 6 (n=37)GS 7 (n=14)Histological unchanged002136Histological upgraded116140Histological downgraded01 (no malignancy)5 (no malignancy)10 (no malignancy)8 (3: no malignancy) Open table in a new tab

Ten systematic transrectal-guided prostate re-biopsies in patients with a negative prostatic biopsy.

Ten systematic transrectal-guided prostate re-biopsies in patients with a negative prostatic biopsy.

TOTAL CRYOSURGERY OF THE PROSTATE VERSUS STANDARD CRYOSURGERY VERSUS RADICAL PROSTATECTOMY: COMPARISON OF EARLY RESULTS AND THE ROLE OF TRANSURETHRAL RESECTION IN CRYOSURGERY

Results of standard cryosurgery of the prostate for prostate cancer in 49 patients were compared to those of destruction of the urethra during or after cryosurgery with subsequent transurethral resection or total freezing of the prostate (total cryosurgery) in 27. These results were compared to those of radical surgery in 83 patients with similar age, stage and grade of disease, and prostate specific antigen (PSA). The 76 cryosurgery cases included all of those treated by 1 surgeon (R. S. G.) for localized prostate cancer after July 1, 1995. The 83 radical perineal prostatectomy cases consisted of all of those treated by another surgeon during the study period and by R. S. G. before cryosurgery use. Success was defined as a PSA of 0.2 or less 6 months after the procedure and a stricter standard, 0.0 PSA, was also assessed. The success rate was 96% for total cryosurgery, 48.9% for standard cryosurgery and 73.4% for radical surgery. Using 0.0 PSA as a criterion, 66.7% of total cryosurgery, 16.3% of standard cryosurgery and 48.2% of radical surgery cases were successfully treated. Total cryosurgical destruction of the prostate may offer new opportunities for cancer treatment heretofore unrecognized and should undergo more investigational analysis.

Repeat transrectal ultrasound-guided prostate biopsy: a strategy to improve the reliability of needle biopsy grading in patients with well-differentiated prostate cancer

Objectives. Gleason grade from prostate needle biopsy (PNB) specimens is important in guiding therapeutic decision making in patients with localized prostate cancer. Recent data from our institution suggest a significant discordance between Gleason grading from PNB versus the actual pathologic grade at radical prostatectomy (RRP). Of most concern is that a substantial proportion of patients with Gleason score of 6 or less from PNB actually have Gleason score of 7 or more at RRP. Under classic measurement theory, one useful way to improve the reliability of an inherently unreliable test is to repeat it. We investigated this strategy in an effort to reduce undergrading errors. Methods. The control group of patients (n = 51) from our neoadjuvant androgen deprivation protocol was used as the test (two-biopsy) group in this study. These patients underwent two separate PNBs before RRP. We used the highest Gleason score from the two biopsies in these patients and compared the error rates with a concurrent group of patients treated at our institution (n = 226) who had only one set (single-biopsy group) of prostate biopsies. All pathologic slides were reviewed at our institution. Any PNB grade of 6 or less that was scored as 7 or more on final pathology was considered significant. Results. Mean age, prostate-specific antigen levels, and stage distribution were not significantly different between these two groups. In the single-biopsy group, 165 patients had PNB Gleason score of 6 or less. Of these patients, 63 (38%) had final pathologic grade of 7 or more. In the two-biopsy group, 37 patients had PNB Gleason score of 6 or less. Of these patients, only 7 (19%) had final pathologic grade of 7 or more ( P = 0.04). Conclusions. Prostate rebiopsy minimizes the inherent unreliability of PNB derived grade and should be considered for patients in whom watchful waiting or nomogram-based therapy has been selected.

PROSTATE REBIOPSY IS A POOR SURROGATE OF TREATMENT EFFICACY IN LOCALIZED PROSTATE CANCER

Purpose Many investigators use prostate rebiopsy as an indicator of treatment efficacy and tumor response of localized prostate cancer for therapies in which the gland remains in situ. Because of the inherent sampling error of needle directed biopsies, however, some men will have a false-negative rebiopsy even if they have had no therapy or if the therapeutic intervention was unsuccessful in eradicating the malignancy. We evaluate the risk of a false-negative biopsy and the clinical factors that influence this risk. Materials and Methods A total of 90 patients undergoing radical prostatectomy for clinically localized disease underwent sextant biopsy of the prostate immediately after removal of the gland. Data collected included prostate specific antigen (PSA), hormonal status, age and biopsy core status. Results Of the total study population 67.8% received neoadjuvant hormonal therapy. While all patients had pathologically confirmed adenocarcinoma within the prostatectomy specimen, 45.6% demonstrated a false-negative rebiopsy. Within a combined predictive model, PSA and hormonal status demonstrated a statistically significant effect on the false-negative rebiopsy rate. Predictive power of this combined model was high across the spectrum of risk for a false-negative rebiopsy. Conclusions This series demonstrates that the risk of a false-negative sextant biopsy in the presence of documented prostate cancer is high and is affected by several factors, including PSA and hormonal status. These data suggest that prostate sextant rebiopsy is an inaccurate method of assessing the therapeutic efficacy of treatments for carcinoma of the prostate in which the gland remains in situ following therapy.

Advanced prostate cancer: The results of a randomized comparative trial of high dose irradiation boosting with conformal protons compared with conventional dose irradiation using photons alone

Purpose : Following a thorough Phase I II study, we evaluated by a Phase III trial high versus conventional dose external beam irradiation as mono-therapy for patients with Stage T3–T4 prostate cancer. Patient outcome following standard dose radiotherapy or following a 12.5% increase in total dose to 75.6 Cobalt Gray Equivalent (CGE) using a conformal perineal proton boost was compared for local tumor control, disease-free survival, and overall survival. Methods and Materials : Stage T3–T4, Nx, N0-2, M0 patients received 50.4 Gy by four-field photons and were randomized to receive either an additional 25.2 CGE by conformal protons (arm 1 — the high dose arm, 103 patients, total dose 75.6 CGE) or an additional 16.8 Gy by photons (arm 2 — the conventional dose arm, 99 patients, total dose 67.2 Gy). Actuarial overall survival (OS), disease-specific survival (DSS), total recurrence-free survival (TRFS), (clinically free, prostate specific antigen (PSA) less than 4ng/ml and a negative prostate rebiopsy, done in 38 patients without evidence of disease) and local control (digital rectal exam and rebiopsy negative) were evaluated. Results : The protocol completion rate was 90% for arm 1 and 97% for arm 2. With a median follow-up of 61 months (range 3 to 139 months) 135 patients are alive and 67 have died, 20 from causes other than prostate cancer. We found no significant differences in OS, DSS, TRFS or local control between the two arms. Among those completing randomized treatment (93 in arm 1 and 96 in arm 2), the local control at 5 and 8 years for arm 1 is 92% and 77%, respectively and is 80% and 60%, respectively for arm 2 ( p = .089) and there are no significant differences in OS, DSS, and TRFS. The local control for the 57 patients with poorly differentiated (Gleason 4 or 5 of 5) tumors at 5 and 8 years for arm 1 is 94% and 84% and is 64% and 19% on arm 2 ( p = 0.0014). In patients whose digital rectal exam had normalized following treatment and underwent prostate rebiopsy there was a lower positive rebiopsy rate for arm 1 versus arm 2 patients (28 vs. 45%) and also for those with well and moderately differentiated tumors versus poorly differentiated tumors (32 and 50%). These differences were not statistically significant. Grade 1 and 2 rectal bleeding is higher (32 vs. 12%, p = 0.002) as may be urethral stricture (19 vs. 8%, p = 0.07) in the arm 1 versus arm 2. Conclusions : An increase in prostate tumor dose by external beam of 12.5% to 75.6 CGE by a conformal proton boost compared to a conventional dose of 67.2 Gy by a photon boost significantly improved local control only in patients with poorly differentiated tumors. It has increased late radiation sequelae, and as yet, has not increased overall survival, disease-specific survival, or total recurrence-free survival in any subgroup. These results have led us to test by a subsequent Phase III trial the potential beneficial effect on local control and disease-specific survival of a 12.5% increase in total dose relative to conventional dose in patients with T1, T2a, and T2b tumors.