Stage T1c Research Articles

Qualidade de vida em pacientes submetidos à prostatectomia radical

A cross-sectional study with a descriptive analysis of 81 patients submitted to radical prostatectomy (RP). Our objective was to correlate quality of life (QL) according to the EORTC-QLQ C30 with age group and time after surgery. Mean age was 65.7 years. Most sought the care of urology, asymptomatic. Some referred former smoking (49.9%) and high blood pressure (53.1%). Mean preoperative SBP was 8.4 ng/ml. Most participants were in stages T2c to T3, Gleason ?6 and over a year after surgery. Erectile dysfunction presented in 90.1%, and urinary incontinence in 33.3%. Functional and overall health scales presented high QL indexes, and symptomatology, with low ones. Older adults presented higher QL regarding emotional functioning, financial difficulties and overall health, as well as those with over a year after surgery, regarding cognitive functioning and fatigue. Although QL was not greatly affected, there were differences between age groups and time after surgery. doi: 10.5216/ree.v16i3.21589.

External beam radiotherapy plus single-fraction high dose rate brachytherapy in the treatment of locally advanced prostate cancer

PurposeTo evaluate the efficacy and toxicity of external beam radiation therapy (EBRT) plus high-dose-rate brachytherapy (HDRB) as a boost in patients (pts) with intermediate or high-risk prostate cancer. Methods and materialsFrom 2002 to July 2012, 377pts with a diagnosis of intermediate or high-risk prostate cancer were treated with EBRT plus HDRB. Median patient age was 66years (range, 41–86). Most patients (347pts; 92%) were classified as high-risk (stage T2c–T3, or PSA>20ng/mL, or GS⩾8), with 30 patients (8%) considered intermediate risk. All patients underwent EBRT at a prescribed dose of 60.0Gy (range, 45–70Gy) to the prostate and seminal vesicles. A total of 120pts (31%) received a dose of 46Gy (45–50Gy) to the true pelvis. All pts received a single-fraction 9Gy (9–15Gy) HDR boost. Most patients (353; 94%) were prescribed complete androgen deprivation therapy (ADT). Overall survival (OS), cause-specific survival (CSS), and biochemical relapse-free survival (BRFS) rates were calculated. In the case of BRFS, patients with <26months of follow-up (n=106) were excluded to minimize the impact of ADT. ResultsThe median follow-up for the entire sample was 50months (range, 12–126), with 5-year actuarial OS and CSS, respectively, of 88% (95% confidence interval [CI]: 84–92) and 98% (95% CI: 97–99). The 5-year BRFS was 91% (95% CI: 87–95) in the 271pts with ⩾26months (median, 60months) of follow-up. Late toxicity included grade 2 and 3 gastrointestinal toxicity in 17 (4.6%) and 6pts (1.6%), respectively, as well as grades 2 and 3 genitourinary toxicity in 46 (12.2%) and 3pts (0.8%), respectively. ConclusionThese long-term outcomes confirm that EBRT plus a single-fraction HDRB boost provides good results in treatment-related toxicity and biochemical control. In addition to the excellent clinical results, this fractionation schedule reduces physician workload, treatment-related expenses, patient discomfort and risks associated with anaesthesia. We believe these findings support the use of single-fractionation boost techniques.

Evolución de las características del paciente candidato a prostatectomía radical y de los resultados obtenidos con la técnica

ObjectivesTo evaluate the oncological profile and risk of biochemical recurrence of patients with prostate cancer who underwent radical prostatectomy based on the time period in which the patients were operated. To evaluate the differences in prostate-specific antigen (PSA) at diagnosis of patients with or without biochemical recurrence based on these time periods. Material and methodsObservation carried forward study of a cohort of 972 radical prostatectomies performed during 3 time periods (1994-2000, 2001-2006, 2007-2011). The importance of PSA at diagnosis on the time periods and on biochemical recurrence was assessed using a generalized linear model. The independent predictive behavior of biochemical recurrence was analyzed using Cox regression. ResultsThe median follow-up was 38 (16-76) months. PSA levels at diagnosis were higher in the period 1994-2000 (12.97ng/mL, P<.001). Seventy-two percent of the patients from the period 2007-2011 were diagnosed as clinical stage T1c (P<.001), compared with 55% from the period 1994-2000. The percentage of extracapsular extension in the specimen decreased from 27% to 18% from the period 1994-2000 to the period 2007-2011 (p<.001). The percentage of patients with biochemical recurrence went from 38% to 14% from the first to the third period (P>.001). The difference between PSA levels at diagnosis for the patients with or without biochemical recurrence was independent of the period (P=.84). The period during which surgery was performed was not an independent predictive factor for biochemical recurrence (P=.09). ConclusionsPatients from the 2007-2011 period had less extracapsular disease in the radical prostatectomy. The period was not an independent predictive factor for biochemical recurrence.

Long-acting testosterone injections for treatment of testosterone deficiency after brachytherapy for prostate cancer.

To evaluate the clinical and biochemical effects of long-acting testosterone undecanoate injections in men with prostate cancer treated with brachytherapy, as the use of testosterone therapy (TTh) in men with prostate cancer is highly controversial, with limited published safety data, particularly after brachytherapy treatment. In all, 20 men treated with brachytherapy for prostate cancer received TTh for symptoms of testosterone deficiency from February 2005 to August 2013. Symptoms of testosterone deficiency included low libido, erectile dysfunction, and fatigue. The mode of TTh was long-acting testosterone undecanoate injections in all cases. Sexual function was assessed by Sexual Health Inventory for Men (SHIM) questionnaire. Serum PSA and testosterone concentrations were recorded monthly for 3 months, then every 3 months for the first year, every 6 months for the second year, and annually then after. The mean (range) age was 62 (49-74) years and the mean (range) serum PSA level at the time of prostate cancer diagnosis was 6.2 (2-11.5) ng/mL. The Gleason score was 2 + 3 in one patient, 3 + 3 in 15 patients, 3 + 4 in three patients and 4 + 4 in one patient. In all, 15 men were stage T1c and five were T2a. The mean (range) baseline total testosterone concentration was 343 (200-592) ng/dL, and 6.9 (2.1-9.7) ng/dL for free testosterone. The mean SHIM scores improved with treatment from 16.1 at baseline to 22.1 with TTh (P = 0.002). There was a decrease in mean PSA level from baseline of 0.7 ng/mL before initiation of TTh to 0.1 ng/mL at last follow-up (P < 0.001), with a median (range) follow-up of 31 (12-48) months. There were no cases of prostate cancer progression or recurrence. With a median of 31-months follow-up, long-acting testosterone injections in men with prostate cancer treated with brachytherapy produced significant clinical benefits. There were no cases of rising serum PSA, prostate cancer progression or recurrence.

PD14-02 PERCENTAGE OF CANCER INVOLVEMENT IN POSITIVE CORES CAN PREDICT UNFAVOURABLE DISEASE IN MEN WITH LOW-RISK PROSTATE CANCER BUT ELIGIBLE FOR THE PROSTATE CANCER INTERNATIONAL: ACTIVE SURVEILLANCE CRITERIA

You have accessJournal of UrologyProstate Cancer: Localized II1 Apr 2014PD14-02 PERCENTAGE OF CANCER INVOLVEMENT IN POSITIVE CORES CAN PREDICT UNFAVOURABLE DISEASE IN MEN WITH LOW-RISK PROSTATE CANCER BUT ELIGIBLE FOR THE PROSTATE CANCER INTERNATIONAL: ACTIVE SURVEILLANCE CRITERIA Giorgio Ivan Russo, Sebastiano Cimino, Vincenzo Favilla, Eugenia Fragalà, Tommaso Castelli, Daniele Urzì, Massimo Madonia, and Giuseppe Morgia Giorgio Ivan RussoGiorgio Ivan Russo More articles by this author , Sebastiano CiminoSebastiano Cimino More articles by this author , Vincenzo FavillaVincenzo Favilla More articles by this author , Eugenia FragalàEugenia Fragalà More articles by this author , Tommaso CastelliTommaso Castelli More articles by this author , Daniele UrzìDaniele Urzì More articles by this author , Massimo MadoniaMassimo Madonia More articles by this author , and Giuseppe MorgiaGiuseppe Morgia More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1279AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Active surveillance has reached an important popularity with the intention to avoid or postpone surgery in patients with prostate cancer at low risk. Unfortunately, some doubts persist about the ability of the different criteria to predict an organ-confined prostate cancer. The aim of this study was to identify predictive factors of unfavourable disease and of biochemical failure in patients treated with radical prostatectomy (RP) but eligible for AS according to PRIAS criteria. We aimed to introduce and validate the percentage of cancer involvement in positive cores (CIPC) as potential worse predictive factor. METHODS From January 2002 to December 2007, 750 consecutive subjects underwent RP at a single institution. We identified 147 (19.05%) patients who were eligible for AS based on PRIAS criteria: clinical stage T1c or T2 disease, PSA level of ≤10 ng/ml, Gleason score ≤6, PSA-D of <0.2 ng/ml2 and fewer than three positive biopsy cores. We incorporated a new detailed histological parameter, the percentage of cancer involvement in positive cores (CIPC), calculated by dividing the cumulative cancer length (CCL) to the cumulative length of positive cores (CLPC). CCL was defined as the sum of the length of all cancerous lesions in mm while CLPC as sum of the length of all positive cores in mm. Unfavourable disease was considered as non-organ confined disease (pathological stage >pT2) and/or upgraded disease (Gleason score >6). RESULTS Of the 147 patients, 95 (66.43%) patients had favourable while 48 (33.57%) had unfavourable disease. In multivariate logistic regression, maximum cancer length (OR 12.52, p<0.01) and CIPC (OR 1.70, p<0.01) represented independent predictors of unfavourable PCa. The AUC analysis revealed significantly higher performance after including CIPC to the PRIAS criteria (0.61 vs. 0.94, p<0.01). A cutoff of 0.4 mm of CIPC was set to predict unfavourable disease with 93% specificity, 76% sensibility and 87% accuracy based on the ROC curve analysis. Finally, the 3- and 5-years BFS were significantly lower in subjects with CIPC ≥0.4 mm, 88.4 % and 81.0% vs. 97.8% and 95.7% respectively (p<0.01). CONCLUSIONS We showed that including CIPC to the pathological parameters of prostate biopsy is possible to estimate the presence of organ-confined disease in 93% of cases. Our findings suggest that the inclusion of CIPC to the prostate biopsy features could be helpful to avoid misclassification in patients eligible for AS according to the PRIAS criteria. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e411 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Giorgio Ivan Russo More articles by this author Sebastiano Cimino More articles by this author Vincenzo Favilla More articles by this author Eugenia Fragalà More articles by this author Tommaso Castelli More articles by this author Daniele Urzì More articles by this author Massimo Madonia More articles by this author Giuseppe Morgia More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP74-14 EXTREMELY HIGH LEVELS OF PCA-3 IS ASSOCIATED WITH PROSTATIC INFLAMMATION

INTRODUCTION AND OBJECTIVES: AS is gaining acceptance as a management strategy for men with low-risk prostate cancer and/or limited life expectancy. PSA has been shown to be an unreliable marker for important pathological changes on surveillance biopsy, and the success of AS requires periodic prostate biopsy. In the elevated PSA population, conflicting evidence exists between uPCA3 levels and the volume and grade of prostate cancer. uPCA3 may be a useful adjunct to biopsy among AS patients but its utility remains to be determined. METHODS: From a prospective biopsy database, clinical information and follow-up data was obtained of patients on AS managed at Cleveland Clinic from 2005 and 2013. The study was restricted to AS patients who had undergone surveillance uPCA3 testing after diagnosis of prostate cancer and committing to AS. Using Cox regression analysis, the association of surveillance uPCA3 levels (as a continuous variable and using cut-point of 25) with Gleason up-grading (increase in Gleason Score), volume progression (>50% of positive cores), and treatment was performed. RESULTS: uPCA3 levels were available for 104 AS patients, of whom 75 patients had received a subsequent biopsy. Mean age was 65.2 7.9 years, with mean PSA 6.1 4.9 ng/mL and mean PCA3 value 50.1 40.6. At diagnosis, 88% of patients were Stage T1c and 88% were Gleason grade 6. A total of 12 patients (12%) in the cohort underwent treatment. Mean PCA3 levels were not significantly different between patients that experienced grade/volume progression (63.8 29) and those who did not (47.2 49, P1⁄40.2). Similarly, the proportion of patients with level >25 was not significantly different among those who did and did not experience progression (p1⁄4.10). A positive PCA3 test during the AS period was not associated with increased odds of undergoing treatment (OR 0.875, 95% confidence interval (CI) 0.24-3.1. Using Cox regression modeling, uPCA3 was not associated with biopsy progression (HR 1.01; 95% CI: 0.99-1.02; P 1⁄4 0.16) or treatment (HR 0.99; 95% CI: 0.98-1.01; P 1⁄4 0.9); similar results were observed when modeled as a categorical variable (P > 0.05 for both). CONCLUSIONS: Among men with favorable clinical features on AS, uPCA3 was not associated with important disease reclassification (by change in Gleason score or percentage of positive cores) or the receipt of deferred therapy. As such, uPCA3 can not be used in lieu of other surveillance tests such as prostate biopsy and/or MRI. Prospective studies based on large cohorts with mature follow-up are needed to properly assess the utility of uPCA3 in the AS population.

MP74-13 URINARY (U)PCA3 AS A TEST TO MONITOR PATIENTS FOR DISEASE RECLASSIFICATION ON ACTIVE SURVEILLANCE (AS)

INTRODUCTION AND OBJECTIVES: AS is gaining acceptance as a management strategy for men with low-risk prostate cancer and/or limited life expectancy. PSA has been shown to be an unreliable marker for important pathological changes on surveillance biopsy, and the success of AS requires periodic prostate biopsy. In the elevated PSA population, conflicting evidence exists between uPCA3 levels and the volume and grade of prostate cancer. uPCA3 may be a useful adjunct to biopsy among AS patients but its utility remains to be determined. METHODS: From a prospective biopsy database, clinical information and follow-up data was obtained of patients on AS managed at Cleveland Clinic from 2005 and 2013. The study was restricted to AS patients who had undergone surveillance uPCA3 testing after diagnosis of prostate cancer and committing to AS. Using Cox regression analysis, the association of surveillance uPCA3 levels (as a continuous variable and using cut-point of 25) with Gleason up-grading (increase in Gleason Score), volume progression (>50% of positive cores), and treatment was performed. RESULTS: uPCA3 levels were available for 104 AS patients, of whom 75 patients had received a subsequent biopsy. Mean age was 65.2 7.9 years, with mean PSA 6.1 4.9 ng/mL and mean PCA3 value 50.1 40.6. At diagnosis, 88% of patients were Stage T1c and 88% were Gleason grade 6. A total of 12 patients (12%) in the cohort underwent treatment. Mean PCA3 levels were not significantly different between patients that experienced grade/volume progression (63.8 29) and those who did not (47.2 49, P1⁄40.2). Similarly, the proportion of patients with level >25 was not significantly different among those who did and did not experience progression (p1⁄4.10). A positive PCA3 test during the AS period was not associated with increased odds of undergoing treatment (OR 0.875, 95% confidence interval (CI) 0.24-3.1. Using Cox regression modeling, uPCA3 was not associated with biopsy progression (HR 1.01; 95% CI: 0.99-1.02; P 1⁄4 0.16) or treatment (HR 0.99; 95% CI: 0.98-1.01; P 1⁄4 0.9); similar results were observed when modeled as a categorical variable (P > 0.05 for both). CONCLUSIONS: Among men with favorable clinical features on AS, uPCA3 was not associated with important disease reclassification (by change in Gleason score or percentage of positive cores) or the receipt of deferred therapy. As such, uPCA3 can not be used in lieu of other surveillance tests such as prostate biopsy and/or MRI. Prospective studies based on large cohorts with mature follow-up are needed to properly assess the utility of uPCA3 in the AS population.

MP42-02 POTENTIAL OF ADDITIONAL MAGNETIC RESONANCE IMAGING (MRI)-TARGETED PROSTATE BIOPSY TO AVOID UNDERESTIMATION OF SYSTEMATIC 14-CORE BIOPSY

You have accessJournal of UrologyProstate Cancer: Staging II1 Apr 2014MP42-02 POTENTIAL OF ADDITIONAL MAGNETIC RESONANCE IMAGING (MRI)-TARGETED PROSTATE BIOPSY TO AVOID UNDERESTIMATION OF SYSTEMATIC 14-CORE BIOPSY Noboru Numao, Yoh Matsuoka, Masaya Ito, Soichiro Yoshida, Yudai Ishikawa, Yusuke Uchida, Masahiro Toide, Saori Higuchi, Takayuki Nakayama, Masaharu Inoue, Hideki Takeshita, Toshiki Kijima, Yasukazu Nakanishi, Junichiro Ishioka, Kazutaka Saito, Yasuhisa Fujii, and Kazunori Kihara Noboru NumaoNoboru Numao More articles by this author , Yoh MatsuokaYoh Matsuoka More articles by this author , Masaya ItoMasaya Ito More articles by this author , Soichiro YoshidaSoichiro Yoshida More articles by this author , Yudai IshikawaYudai Ishikawa More articles by this author , Yusuke UchidaYusuke Uchida More articles by this author , Masahiro ToideMasahiro Toide More articles by this author , Saori HiguchiSaori Higuchi More articles by this author , Takayuki NakayamaTakayuki Nakayama More articles by this author , Masaharu InoueMasaharu Inoue More articles by this author , Hideki TakeshitaHideki Takeshita More articles by this author , Toshiki KijimaToshiki Kijima More articles by this author , Yasukazu NakanishiYasukazu Nakanishi More articles by this author , Junichiro IshiokaJunichiro Ishioka More articles by this author , Kazutaka SaitoKazutaka Saito More articles by this author , Yasuhisa FujiiYasuhisa Fujii More articles by this author , and Kazunori KiharaKazunori Kihara More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1179AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives Even extended biopsy that includes anterior samplings, which meets biopsy criteria for selecting candidates for active surveillance, is reported to be associated with significant underestimation. Since 2011, we have performed MRI-targeted biopsy (MRBx) in addition to transrectal ultrasound (TRUS)-guided systematic 14-core biopsy with anterior samplings (S14Bx). We aimed to use the data to evaluate the potential of additional MRBx to avoid underestimation of S14Bx. Methods Between September 2011 and July 2013, we prospectively evaluated 216 consecutive men with cancerous lesions on prebiopsy 1.5T MRI and clinical stage T1-2 based on digital rectal examination. MRI protocol included T2-weighted, diffusion-weighted, and/or dynamic contrast-enhanced imaging. Biopsy protocol was a combination of MRBx and S14Bx. MRBx was performed using the free-hand technique or the MRI-TRUS fusion system. Four-core samplings for each suspected lesion on MRI were performed. Detected cancer was categorized into very low, low, intermediate, and high risk (NCCN criteria) based on information obtained by S14Bx only and by S14Bx plus MRBx. Very low risk criteria was modified to fit this study and was defined as prostate-specific antigen (PSA) < 10 ng/ml, clinical stage T1c, biopsy Gleason score of 3+3 or less, and maximum cancer length < 5 mm. We evaluated characteristics of cancers that were missed by S14Bx but detected by MRBx. We also analyzed risk category change by additional MRBx in cancers detected by both S14Bx and MRBx. Results The median PSA was 8.3 ng/ml. The number of suspected lesions on MRI was one/two/three in 192/23/1 cases, respectively. The mean number of sampling cores in MRBX was 4.5. The cancer detection rate of S14Bx plus MRBx was 72% (155/216). Based on the S14Bx plus MRBx information, the number of cancers in the very low-/low-/intermediate-/high-risk category was 11/10/77/57, respectively. S14Bx detected 143 cancers and missed 12 cancers. S14Bx-missed cancers included 2/2/6/2 in the very low-/low-/intermediate-/high-risk categories, respectively. Of the 143 S14Bx-detected cancers, the risk categories in 22 cancers changed to higher risk. Conclusions Additional MRBx avoided underestimation of S14Bx in 15% (32/216) of the overall cohort, including 10 additional cancer detections except for very low-risk cancer and 22 risk category changes to higher risk. These results suggest that additional MRBx has high potential to avoid underestimation of systematic biopsy. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e468 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Noboru Numao More articles by this author Yoh Matsuoka More articles by this author Masaya Ito More articles by this author Soichiro Yoshida More articles by this author Yudai Ishikawa More articles by this author Yusuke Uchida More articles by this author Masahiro Toide More articles by this author Saori Higuchi More articles by this author Takayuki Nakayama More articles by this author Masaharu Inoue More articles by this author Hideki Takeshita More articles by this author Toshiki Kijima More articles by this author Yasukazu Nakanishi More articles by this author Junichiro Ishioka More articles by this author Kazutaka Saito More articles by this author Yasuhisa Fujii More articles by this author Kazunori Kihara More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP46-09 INDICATIONS FOR INTERVENTION DURING ACTIVE SURVEILLANCE OF PROSTATE CANCER: A COMPARISON OF THE JOHNS HOPKINS AND PRIAS PROTOCOLS

You have accessJournal of UrologyProstate Cancer: Localized IV1 Apr 2014MP46-09 INDICATIONS FOR INTERVENTION DURING ACTIVE SURVEILLANCE OF PROSTATE CANCER: A COMPARISON OF THE JOHNS HOPKINS AND PRIAS PROTOCOLS Max Kates, Jeffrey Tosoian, Bruce Trock, Zhaoyong Feng, Ballentine Carter, and Alan Partin Max KatesMax Kates More articles by this author , Jeffrey TosoianJeffrey Tosoian More articles by this author , Bruce TrockBruce Trock More articles by this author , Zhaoyong FengZhaoyong Feng More articles by this author , Ballentine CarterBallentine Carter More articles by this author , and Alan PartinAlan Partin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1442AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives Active surveillance is an alternative to immediate intervention that may reduce overtreatment in men with low risk prostate cancer. The widespread acceptance of active surveillance, however, has been limited by a lack of consensus on criteria for monitoring and intervention. Two outstanding questions include the need for yearly biopsy and the use of PSA kinetics as a trigger for intervention. We analyzed how patients enrolled in our biopsy-based surveillance program would fare under the PRIAS protocol which utilizes PSA kinetics. Methods Since 1995, 1,125 men with favorable risk prostate cancer have enrolled in the AS program at Johns Hopkins Hospital. Entrance criteria include: clinical stage T1c, PSA density < 0.15 ng/mL, and prostate biopsy findings (Gleason score ¡Ü 6, ¡Ü 2 cores involved, ¡Ü 50% cancer involvement of any core). Surveillance protocol involves semi-annual PSA and annual biopsy, and pathological reclassification triggers definitive therapy. The PRIAS protocol obtains PSA measurement every 3 months and scheduled biopsies in years 1, 4, and 7. PSA doubling time triggers definitive therapy (if PSADT <3 yrs) or repeat biopsy (if PSADT 3-10 yrs). Patients enrolled in the JHH AS program were retrospectively reviewed to evaluate how the use of PRIAS protocol would alter the timing and identification for curative intervention. The primary outcome was pathological reclassification on prostate biopsy. Results Over follow-up time of 2.9 yrs, 427 (38%) men experienced biopsy reclassification. Of those, 260 (61%) were detected at biopsy intervals corresponding to PRIAS criteria (222 at 1 yr, 28 at 4 yrs, and 10 at 7 yrs). In 67 (16%) men, reclassification was detected between PRIAS biopsy years (55 at 2-3 yrs, 9 at 5-6 yrs, 3 after 7 yrs), with a median delay in detection of 1.9 yrs (range 0.1 ¨C 2.5 yrs). Of 204 men with >5 yrs of follow up without biopsy reclassification, 32 (16%) had PSADT <3 yrs that would have triggered immediate intervention under PRIAS, and 54 (26%) had PSADT 3-10 yrs that would have triggered biopsy. 22 (11%) men went on to be reclassified at a median of 4.7 yrs after their date of PSADT progression. Conclusions For patients enrolled in active surveillance, use of the PRIAS monitoring protocol would have delayed identification of biopsy reclassification in 16% of men with a median delay of 1.9 yrs as compared to an annual biopsy schedule. Progression based on PSA kinetics would result in over-treatment of 5% of men, while initiating earlier intervention (by median 4.7 yrs) in 11% of patients with eventual reclassification. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e513 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Max Kates More articles by this author Jeffrey Tosoian More articles by this author Bruce Trock More articles by this author Zhaoyong Feng More articles by this author Ballentine Carter More articles by this author Alan Partin More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP78-20 OVERALL SURVIVAL AMONG LOW-RISK PROSTATE CANCER PATIENTS TREATED IN THE VA HEALTH CARE SYSTEM

You have accessJournal of UrologyProstate Cancer: Epidemiology & Natural History III1 Apr 2014MP78-20 OVERALL SURVIVAL AMONG LOW-RISK PROSTATE CANCER PATIENTS TREATED IN THE VA HEALTH CARE SYSTEM Philip Barbosa, I-Chun Thomas, Benjamin Chung, Sandy Srinivas, Todd Wagner, James Brooks, and John Leppert Philip BarbosaPhilip Barbosa More articles by this author , I-Chun ThomasI-Chun Thomas More articles by this author , Benjamin ChungBenjamin Chung More articles by this author , Sandy SrinivasSandy Srinivas More articles by this author , Todd WagnerTodd Wagner More articles by this author , James BrooksJames Brooks More articles by this author , and John LeppertJohn Leppert More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2503AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Users of the VA health care system (VAHCS) tend to be older and often have comorbid conditions associated with lower baseline health. Studies evaluating outcomes among veterans with prostate cancer, such as the recently published PIVOT trial, demonstrate that veterans suffer from significant competing risks of mortality. A better understanding of overall survival among users of VA health care is critical to inform screening and treatment decisions. We sought to describe patterns of overall survival for all patients treated in the VAHCS with low risk prostate cancer. METHODS We created an analytic cohort of 36,160 patients with low risk prostate cancer, diagnosed at age 75 or less, from the VA Central Cancer Registry (VACCR) diagnosed from 1995-2001. We performed descriptive statistics of patient characteristics (age, race/ethnicity), and exposure history (Agent Orange, tobacco). We created Kaplan-Meier survival estimates to visualize overall survival. RESULTS Mean patient age was 66 years and mean follow-up time was 41 months. 44% of tumors were clinical stage t1c. 22% of patients underwent radical prostatectomy, 26% received primary radiation, and 24.5% were initially treated with androgen deprivation. 2.5% of the cohort had a history of agent orange exposure. Median overall survival of the entire cohort was 73 months. Among patients that received surgery, median overall survival was longer at 89 months (Fig 1a). Overall survival was strongly associated with patient age at diagnosis with a median survival of 87 months for patients diagnosed <50 years, 85 months for 50-60 years, 75 months for 60-70 years, 65 months for 70-80 years. (Fig1b). CONCLUSIONS Overall survival for all patients diagnosed with low risk prostate cancer in the VAHCS is less than general population and single institution reports. These data highlight the importance of population specific life-expectancy estimates in developing high-value prostate cancer screening and treatment decisions. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e929 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Philip Barbosa More articles by this author I-Chun Thomas More articles by this author Benjamin Chung More articles by this author Sandy Srinivas More articles by this author Todd Wagner More articles by this author James Brooks More articles by this author John Leppert More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Retrograde robotic radical prostatectomy: description of a new technique and early perioperative outcomes.

Objectives. This research was conducted to describe a novel technique for performing robotic-assisted laparoscopic prostatectomy (RALP) using a retrograde approach that mimics the classic open surgical technique. Methods. From June 2009 to March 2011, we performed 18 nonconsecutive RALPs using a novel retrograde approach. Patients were initially selected with D'Amico low to intermediate risk disease. Pre-, intra-, and postoperative data were analyzed in all patients. Results. All 18 patients had successful surgery without any intraoperative complications. Mean preoperative PSA was 6.0 ng/mL. Nine patients had biopsy Gleason score (GS) 6, seven patients had GS 7, and two patients had GS 8. Fourteen patients had clinical stage T1c and four patients had stage T2a. Mean operative time was 198 minutes, with a mean robotic console time of 168 minutes. Fifteen patients had T2 disease on the final pathology and three had T3 disease. With a median follow-up of 11 months, 10 patients had an undetectable PSA. Conclusions. Our early experience with retrograde robotic-assisted laparoscopic prostatectomy demonstrates the feasibility of this approach with early outcomes comparable to the contemporary antegrade approach. Long-term study with a greater number of patients will be necessary to fully evaluate the oncologic and functional outcomes using this technique.

Snail as a potential marker for predicting the recurrence of prostate cancer in patients at stage T2 after radical prostatectomy

BackgroundWe retrospectively investigated the relationship between immunohistochemical staining of radical prostatectomy (RP) specimens for snail and cancer recurrence. MethodsSeventy-six patients with prostate cancer who underwent RP were enrolled, and 53 patients were ultimately collected whose cancer was pathologically defined as T2. We detected the expression of snail using tissue microarrays. The snail image score was determined by the intensity×tumor percentage, and a high score was defined as 8 (1–12 points). ResultsThe snail image scores and Gleason score sums were correlated with recurrence-free survival according to a log–rank test (p<0.05). In a Cox proportional hazard model, only a high snail image score (≥8) (hazard ratio (HR): 3.04, p=0.036) but not a high Gleason score sum (≥7) (HR: 1.33, p=0.215), and a more-advanced pathological T stage (T2c) (HR: 1.5, p=0.461) were significantly correlated with worse recurrence-free survival. The snail image score was determined to be an independent factor for predicting prostate cancer recurrence after RP. ConclusionIn patients with pathological localized prostate cancer and a high snail image score in cancer tissue, adjuvant therapy might be suggested to prevent early biochemical failure.

Is clinical stage T2C prostate cancer intermediate- or high-risk disease?

110 Background: Clinical stage T2c (cT2c) is an indeterminate factor in the algorithm for prostate cancer (CaP) risk stratification. According to the D’Amico risk stratification and the American Urological Association (AUA) guidelines, cT2c is high−risk, whereas the National Comprehensive Cancer Network (NCCN) and EUA classify cT2c as intermediate−risk. Since determining whether cT2c is intermediate- or high-risk has implications for treatment, it is important to define what exact risk cT2c portends. Thus, we sought to assess whether cT2c tumors, without associated other high−risk factors (cT2c not otherwise specified (cT2c−nos)), behave as intermediate− or high−risk by analyzing biochemical recurrence (BCR) after radical prostatectomy (RP). Methods: We retrospectively analyzed 2,759 men who underwent RP from 1988 to 2011 from the Shared Equal Access Regional Cancer Hospital (SEARCH) database. Comparisons in time to BCR between cT2c−nos patients and intermediate−risk (prostate-specific antigen [PSA] 10 to 20 ng/ml or Gleason sum (GS) =7 or cT2b), and high−risk (PSA greater than 20 ng/ml, GS 8 to 10, cT3) patients was performed using log−rank test and Cox proportional hazards analyses. Given changes in CaP, we adjusted for year of surgery (continuous) and to adjust for case mix among centers contributing to SEARCH we included a categorical term for center. Results: A total of 99 men (4%) were classified as cT2c−nos. During a median follow-up of 66 months (IQR: 34−101 months), cT2c−nos patients had similar BCR risk as intermediate-risk (p=0.27), but significantly lower BCR risk versus high-risk patients (p&lt;0.001, Figure). After adjusting for year and center and compared to low-risk disease, the HRs for cT2c−nos patients was similar to those with intermediate-risk (HR 1.90 vs. 2.28). When specifically compared to intermediate-and high-risk patients, and after adjusting for year and center, cT2c−nos patients had outcomes comparable to intermediate−risk (p=0.44), but significantly better than high-risk patients (HR 0.55; 95%CI 0.38,0.78; p=0.001). Conclusions: BCR risk for patients with clinical stage T2c was comparable to men who had intermediate-risk disease and significantly better than men with high-risk CaP. These findings suggest men with cT2c disease should be offered treatment options for intermediate-risk CaP.

Focal Therapy in Prostate Cancer: International Multidisciplinary Consensus on Trial Design

BackgroundFocal therapy has been introduced for the treatment of localised prostate cancer (PCa). To provide the necessary data for consistent assessment, all focal therapy trials should be performed according to uniform, systematic pre- and post-treatment evaluation with well-defined end points and strict inclusion and exclusion criteria. ObjectiveTo obtain consensus on trial design for focal therapy in PCa. Design, setting, and participantsA four-staged consensus project based on a modified Delphi process was conducted in which 48 experts in focal therapy of PCa participated. According to this formal consensus-building method, participants were asked to fill out an iterative sequence of questionnaires to collect data on trial design. Subsequently, a consensus meeting was held in which 13 panellists discussed acquired data, clarified the results, and defined the conclusions. Outcome measurements and statistical analysisA multidisciplinary board from oncologic centres worldwide reached consensus on patient selection, pretreatment assessment, evaluation of outcome, and follow-up. Results and limitationsInclusion criteria for candidates in focal therapy trials are patients with prostate-specific antigen <15 ng/ml, clinical stage T1c–T2a, Gleason score 3+3 or 3+4, life expectancy of >10 yr, and any prostate volume. The optimal biopsy strategy includes transrectal ultrasound-guided biopsies to be taken between 6 mo and 12 mo after treatment. The primary objective should be focal ablation of clinically significant disease with negative biopsies at 12 mo after treatment as the primary end point. ConclusionsThis consensus report provides a standard for designing a feasible focal therapy trial. Patient summaryA variety of ablative technologies have been introduced and applied in a focal manner for the treatment of prostate cancer (PCa). In this consensus report, an international panel of experts in the field of PCa determined pre- and post-treatment work-up for focal therapy research.

Perspectives on the clinical management of localized prostate cancer

If cure is necessary, is it possible and if cure is possible, is it necessary?’-Willet F. Whitmore Defined broadly, prostate cancer has two states: An indolent histological manifestation of a locally proliferative and invasive process or a clinically relevant, potentially lethal disease. Likewise, the management of clinically localized prostate cancer must address two questions: what sort of disease is this and what needs to be done.

Localization of higher grade tumor foci in potential candidates for active surveillance who opt for radical prostatectomy

Purpose:To investigate actual intraprostatic location of higher graded tumor foci undetected via standard transrectal ultrasound-guided prostate biopsy amongst patients who would be clinically considered appropriate candidates for active surveillance (AS) but underwent radical prostatectomy (RP).Methods:We reviewed entirely-submitted and whole-mounted RP specimens from 169 men who were deemed appropriate for AS clinically, but opted for RP and were found to have higher grade tumors. For each case, tumor nodules were circled and color-coded in a grade-specific manner and digitally scanned to created tumor maps. The locations of tumor foci with Gleason grade ≥4 were stratified by specific sites: anterior, anterolateral, lateral only (not clearly anterior or posterior), posterior, and posterolateral area.Results:Of 169 patients, 86% had clinical stage T1c and 14% T2a. RP Gleason score 7 in all but two men. Higher-grade tumor foci were localized to: anterior (n=66, 39%), anterolateral (n=4, 2%), lateral only (not clearly anterior or posterior) (n=5, 3%), posterior (n=52, 31%), and posterolateral (n=42, 25%) prostate, respectively.Conclusions:Among patients deemed clinically appropriate for AS, higher-grade tumor foci missed by standard prostate biopsies were localized to both the anterior and posterior prostate, without predominance of a particular area. These findings lend additional support to performing repeat standard prostate biopsy in potential candidates for AS and should be considered in efforts to optimize current biopsy strategies for the selection of AS patients.

Percentage of cancer involvement in positive cores can predict unfavorable disease in men with low-risk prostate cancer but eligible for the prostate cancer international: Active surveillance criteria

ObjectivesTo identify predictive factors of unfavorable disease and of biochemical failure in patients treated with radical prostatectomy but eligible for active surveillance (AS) according to Prostate Cancer Research International: Active Surveillance (PRIAS) criteria. We aimed to introduce and validate the percentage of cancer involvement in positive cores (CIPC) as potential worse predictive factor. MethodsFrom January 2002 to December 2007, 750 consecutive subjects underwent radical prostatectomy at a single institution. We identified 147 (19.05%) patients who were eligible for AS based on PRIAS criteria: clinical stage T1c or T2 disease, prostate-specific antigen level of≤10ng/ml, Gleason score≤6, prostate-specific antigen-D of<0.2ng/ml2, and fewer than 3 positive biopsy cores. CIPC was included in the analysis. ResultsOf the 147 patients, 95 (66.43%) patients had favorable disease, whereas 48 (33.57%) had unfavorable disease. In multivariate logistic regression, maximum cancer length (odds ratio 12.52, P<0.01) and CIPC (odds ratio 1.70, P<0.01) represented independent predictors of unfavorable prostate cancer. The area under the receiver operating characteristics curve analysis revealed significantly higher performance after including CIPC to the PRIAS criteria (0.61 vs. 0.94, P<0.01). A cutoff of 0.4mm of CIPC was set to predict unfavorable disease with 93% specificity, 76% sensibility, and 87% accuracy based on the receiver operating characteristics curve analysis. Finally, the 3- and 5-years biochemical recurrence (BCR)-free survival were significantly lower in subjects with CIPC≥0.4mm, 88.4 % and 81.0% vs. 97.8% and 95.7%, respectively (P< 0.01). ConclusionsOur findings suggest that the inclusion of CIPC to the prostate biopsy features could be helpful to avoid misclassification in patients eligible for AS according to the PRIAS criteria.

Focal cryoablation: a treatment option for unilateral low‐risk prostate cancer

To assess oncological (biochemical and histological recurrence) and functional (urinary and potency) outcomes in patients with unilateral low-risk organ-confined prostate cancer (PCa) treated with focal cryoablation (FC). From January 2009 to March 2012, patients with localized PCa who refused active surveillance were assigned to a FC protocol. This was a prospective, single-arm cohort study. Inclusion criteria were: unilateral disease, clinical stage T1c to T2a, prostate-specific antigen (PSA) concentration <10 ng/mL, low volume index lesion and Gleason score ≤6 (3+3). Hemi-ablation was carried out using the Precise(TM) cryoablation system (Galil Medical, Inc., Arden Hills, MN, USA). Oncological (PSA values) and functional (International Prostate Symptom Score and International Index of Erectile Function (IIEF)-5 score) outcomes were analysed at 3-, 6- and 12-month follow-up. The primary endpoint for oncological efficacy, no cancer in ipsilateral side, was based on the 12-month mandatory biopsy. A total of 48 consecutive patients with a mean age of 67 years were included. The median (interquartile range) follow-up was 13.2 (7.4-26.5) months. Follow-up prostate biopsies were negative for the treated lobe in 86% of patients. The mean PSA concentration dropped significantly at 3 months (by 55%) but did not correlate well with positive biopsy results. Urinary symptoms were unchanged. A slight decrease in the IIEF-5 score was present at 3 months, but did not differ significantly from baseline at 6-month follow-up. There were 15% grade 1 and 4% grade 2 complications (Clavien classification). Focal cryoablation is a low-morbidity option in selected patients with low-risk PCa. We showed PSA concentration to be an unreliable marker for monitoring FC and recommend a protocol of mandatory biopsies for follow-up. A multicentre randomized controlled trial is necessary to confirm the low-morbidity and the biopsy-proven PCa cure rates.

The value of the 2005 International Society of Urological Pathology (ISUP) modified Gleason grading system as a predictor of biochemical recurrence after radical prostatectomy

To compare time and risk to biochemical recurrence (BR) after radical prostatectomy of two chronologically different groups of patients using the standard and the modified Gleason system (MGS). Cohort 1 comprised biopsies of 197 patients graded according to the standard Gleason system (SGS) in the period 1997/2004, and cohort 2, 176 biopsies graded according to the modified system in the period 2005/2011. Time to BR was analyzed with the Kaplan-Meier product-limit analysis and prediction of shorter time to recurrence using univariate and multivariate Cox proportional hazards model. Patients in cohort 2 reflected time-related changes: striking increase in clinical stage T1c, systematic use of extended biopsies, and lower percentage of total length of cancer in millimeter in all cores. The MGS used in cohort 2 showed fewer biopsies with Gleason score ≤ 6 and more biopsies of the intermediate Gleason score 7. Time to BR using the Kaplan-Meier curves showed statistical significance using the MGS in cohort 2, but not the SGS in cohort 1. Only the MGS predicted shorter time to BR on univariate analysis and on multivariate analysis was an independent predictor. The results favor that the 2005 International Society of Urological Pathology modified system is a refinement of the Gleason grading and valuable for contemporary clinical practice.

Image-guided intensity-modulated radiotherapy for prostate cancer: Dose constraints for the anterior rectal wall to minimize rectal toxicity

Rectal adverse events (AEs) are a major concern with definitive radiotherapy (RT) treatment for prostate cancer. The anterior rectal wall is at the greatest risk of injury as it lies closest to the target volume and receives the highest dose of RT. This study evaluated the absolute volume of anterior rectal wall receiving a high dose to identify potential ideal dose constraints that can minimize rectal AEs. A total of 111 consecutive patients with Stage T1c to T3a N0 M0 prostate cancer who underwent image-guided intensity-modulated RT at our institution were included. AEs were graded according to the Common Terminology Criteria for Adverse Events, version 4.0. The volume of anterior rectal wall receiving 5 to 80Gy in 2.5-Gy increments was determined. Multivariable Cox regression models were used to identify cut points in these volumes that led to an increased risk of early and late rectal AEs. Early AEs occurred in most patients (88%); however, relatively few of them (13%) were grade ≥2. At 5 years, the cumulative incidence of late rectal AEs was 37%, with only 5% being grade ≥2. For almost all RT doses, we identified a threshold of irradiated absolute volume of anterior rectal wall above which there was at least a trend toward a significantly higher rate of AEs. Most strikingly, patients with more than 1.29, 0.73, or 0.45cm3 of anterior rectal wall exposed to radiation doses of 67.5, 70, or 72.5Gy, respectively, had a significantly increased risk of late AEs (relative risks [RR]: 2.18 to 2.72; p ≤ 0.041) and of grade ≥ 2 early AEs (RR: 6.36 to 6.48; p = 0.004). Our study provides evidence that definitive image-guided intensity-modulated radiotherapy (IG-IMRT) for prostate cancer is well tolerated and also identifies dose thresholds for the absolute volume of anterior rectal wall above which patients are at greater risk of early and late complications.