Endogenous testosterone density as ratio of endogenous testosterone levels on prostate volume predicts tumor upgrading in low-risk prostate cancer

The role of endogenous testosterone in relationship with low- and intermediate-risk prostate cancer: a systematic review

ABSTRACT

An enduring debate in research revolves around the association between elevated endogenous testosterone levels and prostate cancer. This systematic review is intended to assess the present understanding of the role of endogenous testosterone in the diagnosis and treatment of low- and intermediate-risk prostate cancer. Our search strategy was the following: (endogenous testosterone) AND (((low risk) OR (intermediate risk)) AND ((diagnosis) OR (treatment))) AND (prostate cancer); that was applied to PubMed, Web of Science, and Scopus databases to identify pertinent articles. Two investigators performed an independent selection following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The preliminary investigation detected 105 records, and 81 records remained after eliminating duplicates. Following the review of titles and abstracts, 71 articles were excluded. A comprehensive examination of the full text was conducted for 10 articles, excluding 3 of them. After revising the references of eligible articles, other 3 articles were included. We finally identified 10 suitable studies, including three main topics: (1) association between endogenous testosterone and European Association of Urology (EAU) risk classes; (2) association between endogenous testosterone density and the tumor load; and (3) association of endogenous testosterone with tumor upgrading and tumor upstaging. Actual literature about the impact of endogenous testosterone on low- and intermediate-risk prostate cancer is not numerous, but appears to be still conflicting. More investigations are needed to increase the consistency of the literature's results.

Positive independent association between preoperative endogenous testosterone density and tumor load density in surgical specimen of patients undergoing radical prostatectomy

OBJECTIVE

To evaluate the influence of endogenous testosterone density (ETD) and tumor load density (TLD) in the surgical specimen of prostate cancer (PCa) patients.

METHODS

ETD was assessed as the ratio of endogenous testosterone (ET) to prostate volume (PV). TLD was calculated as the ratio of tumor load (TL) to prostate weight. Preoperative prostate-specific antigen relative densities (PSAD) and percentage of biopsy-positive cores (BPCD) were also assessed. The association of high TLD (above the first quartile) with clinical and pathological factors was assessed by the logistic regression model (univariate and multivariate analysis).

RESULTS

Between November 2014 and December 2019, ET was measured in 805 cases treated with radical prostatectomy (RP). Median (IQR) of ET and ETD was 412 (321.4-519 ng/dL) and 9.8 (6.8-14.4 ng/(dLxmL)) as well as for TL and TLD was 20 (10-30%) and 0.33 (0.17-0.58%/gr), respectively. As a result, high TLD was detected in 75% of cases. A positive independent association was found between high TLD and ETD. Accordingly, as ETD levels increased, the risk of detecting high TLD in the surgical specimen increased, regardless of PSAD and BPCD.

CONCLUSIONS

At diagnosis of PCa, a positive independent association was found between ETD and risk of high TLD. Subjects with increasing ETD levels were more likely to have high TLD, associated with unfavorable pathology features. The positive association between ETD and TLD in the prostate microenvironment might adversely influence PCa's natural history.

Validation of Epstein criteria and development of a nomogram for active surveillance in a contemporary Chinese population

PURPOSE

To evaluate the Epstein criteria for insignificant prostate cancer (CaP) prediction in a contemporary Chinese population, and to develop a risk model with combined clinical and systematic biopsy and targeted biopsy parameters for active surveillance.

METHODS

A total of 249 CaP patients with biopsy Gleason score (GS) of 6 were included. One hundred and one patients were eligible for insignificant CaP on final pathology (GS ≤6 and organ-confined). Diagnostic tests were used to validate the ability of the 2 Epstein criteria. Univariate and multivariate regression analyses were performed to identify predictors of insignificant CaP for the development of predictive models. Receiver operating characteristics analysis was used to select the best model, followed by risk nomogram construction and internal validation.

RESULTS

There were 47 patients met EC1 and 61 met EC2, with pathological upgrading rates of 36% and 41%, respectively, and 70% (71/101) and 64% (65/101) were missed, with areas under the curve of 0.591 and 0.594, respectively. Four prediction models were developed using regression analysis, and model 2 incorporating age, prostate-specific antigen density, maximum percentage of core involvement at systematic biopsy, and percentage of positive cores at targeted biopsy showed the best diagnostic value (area under the curve = 0.731, sensitivity 62.4%, specificity 77.0%) and was used to construct the nomogram. Calibration curves and decision curve analysis demonstrated favorable calibration (mean absolute error 0.048) and clinical benefits of the novel nomogram.

CONCLUSION

The Epstein criteria need to be revised by incorporating targeted biopsy parameters to improve diagnostic performance, and a novel nomogram was developed with better prediction of insignificant CaP.

Preoperative endogenous testosterone density predicts disease progression from localized impalpable prostate cancer presenting with PSA levels elevated up to 10 ng/mL

OBJECTIVE

To investigate endogenous testosterone density (ETD) predicting disease progression from clinically localized impalpable prostate cancer (PCa) presenting with prostate-specific antigen (PSA) levels elevated up to 10 ng/mL and treated with radical prostatectomy.

MATERIALS AND METHODS

In a period ranging from November 2014 to December 2019, 805 consecutive PCa patients who were not under androgen blockade had endogenous testosterone (ET, ng/dL) measured before surgery. ETD was evaluated as the ratio of ET on prostate volume (PV). Unfavorable disease was defined as including ISUP ≥ 3 and/or seminal vesicle invasion in the surgical specimen. The risk of disease progression was evaluated by statistical methods.

RESULTS

Overall, the study selected 433 patients, of whom 353 (81.5%) had available follow-up. Unfavorable disease occurred in 46.7% of cases and was predicted by tumor quantitation features that were positively associated with ETD. Disease progression, which occurred for 46 (13%) cases, was independently predicted only by ETD (hazard ratio, HR = 1.037; 95% CI 1.004-1.072; p = 0.030) after adjusting for unfavorable disease. According to a multivariate model, ETD above the third quartile was confirmed to be an independent predictor for PCa progression (HR = 2.479; 95% CI 1.355-4.534; p = 0.003) after adjusting for unfavorable disease. The same ETD measurements, ET mean levels were significantly lower in progressing cancers.

CONCLUSIONS

In this particular subset of patients, increased ETD with low ET levels, indicating androgen independence, resulted in a more aggressive disease with poorer prognosis.