Pathologic Findings in Radical Prostatectomy Specimens From Patients Eligible for Active Surveillance With Highly Selective Criteria: A Multicenter Study

Single Positive Core Prostate Cancer at Biopsy: Clinicopathological Implications and Risk Factors for Adverse Pathological Outcomes

BACKGROUND

Whether one positive core prostate cancer (PCa) is a low-risk disease remains to be determined. We investigated the pathological results of radical prostatectomy specimens diagnosed on single core positive prostate biopsy.

METHODS

Between January 2013 and December 2019, A total of 3441 consecutive patients treated with radical prostatectomy in our institution were examined. Among them, 293 patients were diagnosed with single positive core PCa on biopsy, and the clinical parameters and pathological findings of their radical prostatectomy specimens were analyzed.

RESULTS

Of the 293 patients, 108 (36.9%) had undergraded Gleason Scores (GS) based on the biopsy. Positive surgical margins (PSMs), perineural invasion (PNI), extracapsular extension (ECE, pT3a) and seminal vesicle invasion (SVI, pT3b) were found in 16.4%, 15.0%, 3.4% and 2.4% of patients, respectively. In the multivariate analysis, we found that preoperative PSA level predict a significant increased risk of upgraded GS and PSMs, and biopsy GS was is a strong predictor of PNI, upgraded GS, tumor stage pT3 at radical prostatectomy.

CONCLUSIONS

Single positive core PCa have clinically significance in the radical prostatectomy specimens, with considerable rates of undergrading for the GS, PNI, PSMs, ECE and SVI. For patients with single positive core PCa, other prognostic factors must be considered in the treatment plan.

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

INTRODUCTION & OBJECTIVES

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

MATERIALS & METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION AND OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Prostate Cancer Biomarker Development: National Cancer Institute's Early Detection Research Network Prostate Cancer Collaborative Group Review

Prostate cancer remains the most common non-skin cancer and second leading cause of death among men in the United States. Although progress has been made in diagnosis and risk assessment, many clinical questions remain regarding early identification of prostate cancer and management. The early detection of aggressive disease continues to provide high curative rates if diagnosed in a localized state. Unfortunately, prostate cancer displays significant heterogeneity within the prostate organ and between individual patients making detection and treatment strategies complex. Although prostate cancer is common among men, the majority will not die from prostate cancer, introducing the issue of overtreatment as a major concern in clinical management of the disease. The focus of the future is to identify those at highest risk for aggressive prostate cancer and to develop prevention and screening strategies, as well as discerning the difference in malignant potential of diagnosed tumors. The Prostate Cancer Research Group of the National Cancer Institute's Early Detection Research Network has contributed to the progress in addressing these concerns. This summary is an overview of the activities of the group.See all articles in this CEBP Focus section, "NCI Early Detection Research Network: Making Cancer Detection Possible."

Preoperative prostate health index predicts adverse pathology and Gleason score upgrading after radical prostatectomy for prostate cancer

BACKGROUND

We aimed to explore the utility of prostate specific antigen (PSA) isoform [- 2] proPSA and its derivatives for prediction of pathological outcome after radical prostatectomy (RP).

METHODS

Preoperative blood samples were prospectively and consecutivelyanalyzed from 472 patients treated with RP for clinically localized prostate cancerat four medical centers. Measured parameters were PSA, free PSA (fPSA), fPSA/PSA ratio, [- 2] proPSA (p2PSA), p2PSA/fPSA ratio and Prostate Health Index (PHI)(p2PSA/fPSA)*√PSA]. Logistic regression models were fitted to determine the accuracy of markers for prediction of pathological Gleason score (GS) ≥7, Gleason score upgrading, extracapsular extension of the tumor (pT3) and the presence of positive surgical margin (PSM). The accuracy of predictive models was compared using area under the receiver operating curve (AUC).

RESULTS

Of 472 patients undergoing RP, 339 (72%) were found to have pathologic GS ≥ 7, out of them 178 (53%) experienced an upgrade from their preoperative GS = 6. The findings of pT3 and PSM were present in 132 (28%) and 133 (28%) cases, respectively. At univariable analysis of all the preoperative parameters, PHI was the most accurate predictor of pathological GS ≥7 (OR 1.02, 95% CI 1.01-1.03, p<0.001), GS upgrading (OR 1.02, 95% CI 1.01-1.03, p<0.003), pT3 disease (OR 1.01, 95% CI 1.00-1.02, p<0.007) and the presence of PSM (OR 1.01, 95% CI 1.00-1.02, p<0.002). Adding of PHI into the base multivariable model increased significantly the accuracy for prediction of pathological GS by 4.4% to AUC = 66.6 (p = 0.015) and GS upgrading by 5.0% to AUC = 65.9 (p = 0.025), respectively.

CONCLUSIONS

Preoperative PHI levels may contribute significantly to prediction of prostate cancer aggressiveness and expansion of the tumor detected at final pathology.

The Impact of Prostate Cancer Upgrading and Upstaging on Biochemical Recurrence and Cancer-Specific Survival

Background and Objectives: Significant numbers of prostate cancer (PCa) patients experience tumour upgrading and upstaging between prostate biopsy and radical prostatectomy (RP) specimens. The aim of our study was to investigate the role of grade and stage increase on surgical and oncological outcomes. Materials and Methods: Upgrading and upstaging rates were analysed in 676 treatment-naïve PCa patients who underwent RP with subsequent follow-up. Positive surgical margin (PSM), biochemical recurrence (BCR), metastasis-free survival (MFS), overall (OS) and cancer specific survival (CSS) were analysed according to upgrading and upstaging. Results: Upgrading was observed in 29% and upstaging in 22% of PCa patients. Patients undergoing upgrading or upstaging were 1.5 times more likely to have a PSM on RP pathology. Both upgrading and upstaging were associated with increased risk for BCR: 1.8 and 2.1 times, respectively. Mean time to BCR after RP was 2.1 years in upgraded cases and 2.7 years in patients with no upgrading (p < 0.001), while mean time to BCR was 1.9 years in upstaged and 2.8 years in non-upstaged cases (p < 0.001). Grade and stage increase after RP were associated with inferior MFS rates and ten-year CSS: 89% vs. 98% for upgrading (p = 0.039) and 87% vs. 98% for upstaging (p = 0.008). Conclusions: Currently used risk stratification models are associated with substantial misdiagnosis. Pathological upgrading and upstaging have been associated with inferior surgical results, substantial higher risk of BCR and inferior rates of important oncological outcomes, which should be considered when counselling PCa patients at the time of diagnosis or after definitive therapy.

Clinical Significance of Multiparametric Magnetic Resonance Imaging as a Preoperative Predictor of Oncologic Outcome in Very Low-Risk Prostate Cancer

Currently, multiparametric magnetic resonance imaging (mpMRI) is not an indication for patients with very low-risk prostate cancer. In this study, we aimed to evaluate the usefulness of mpMRI as a diagnostic tool in these patients. We retrospectively analyzed the clinical and pathological data of individuals with very low-risk prostate cancer, according to the NCCN guidelines, who underwent mpMRI before radical prostatectomy at our institution between 2010 and 2016. Patients who did not undergo pre-evaluation with mpMRI were excluded. We analyzed the factors associated with biochemical recurrence (BCR) using Cox regression model, logistic regression analysis, and Kaplan–Meier curve. Of 253 very low-risk prostate cancer patients, we observed 26 (10.3%) with BCR during the follow-up period in this study. The median follow-up from radical prostatectomy was 53 months (IQR 33–74). The multivariate Cox regression analyses demonstrated that the only factor associated with BCR in very low-risk patients was increase in the pathologic Gleason score (GS) (HR: 2.185, p-value 0.048). In addition, multivariate logistic analyses identified prostate specific antigen (PSA) (OR: 1.353, p-value 0.010), PSA density (OR: 1.160, p-value 0.013), and suspicious lesion on mpMRI (OR: 1.995, p-value 0.019) as the independent preoperative predictors associated with the pathologic GS upgrade. In our study, the pathologic GS upgrade after radical prostatectomy in very low-risk prostate cancer patients demonstrated a negative impact on BCR and mpMRI is a good prognostic tool to predict the pathologic GS upgrade. We believe that the implementation of mpMRI would be beneficial to determine the treatment strategy for these patients.

[Active surveillance of prostate cancer : An update]

Prostate cancer is a heterogeneous disease. In cases of low-risk prostate cancer, active surveillance represents an attractive alternative treatment. Significant complications of a definitive treatment can therefore be delayed or completely avoided. Despite strict inclusion criteria for active surveillance, the diagnosis of low-risk prostate cancer can be inaccurate and there is therefore a risk of missing the optimal point in time for definitive treatment. Multimodal diagnostics and continuous aftercare are therefore crucial.

Predictors of adverse pathologic features after radical prostatectomy in low-risk prostate cancer

BACKGROUND

Prostate-specific antigen (PSA) screening more frequently detects early stage prostate cancer (PC). However, adverse pathologic features (APFs) after radical prostatectomy (RP) in low-risk PC occur. Previous related studies had utilized outdated staging criteria or small sample cohorts. In this study, we analyzed predictors of APFs after RP in low-risk PC using classification under the current criteria.

MATERIALS AND METHODS

We retrospectively reviewed medical records of 546 low-risk PC patients who had undergone RP. Low-risk PC was defined as PC with clinical T1-T2a, Gleason score ≤ 6, and PSA levels < 10 ng/mL. Clinical and pathological parameters were analyzed to predict APFs. APFs were defined as extracapsular extension (ECE), seminal vesicle invasion (SVI), or positive surgical margins (PSM). We analyzed our data using univariable and multivariable logistic regression analyses, as well as receiver operator characteristics to predict APFs.

RESULTS

Among 546 patients, ECE, SVI, and PSM were present in 199 (36.4%), 8 (1.5%), and 179 cases (32.8%), respectively. PSM had a significant correlation with preoperative high PSA levels and number of positive cores obtained. ECE/SVI was also significantly correlated with PSA levels and number of positive cores. As a result, presence of APFs after RP was associated with high PSA levels and large number of positive cores. PSA > 4.5 ng/mL and number of positive cores > 2 in low-risk PC were significantly associated with APFs, and suggested as cut-off values for predicting APFs.

CONCLUSIONS

PSA > 4.5 ng/mL and number of positive cores > 2 in low-risk PC were associated with presence of APFs and patients with such records should be considered carefully to provide active surveillance.

Comparison of Pathological and Oncologic Outcomes of Favorable Risk Gleason Score 3 + 4 and Low Risk Gleason Score 6 Prostate Cancer: Considerations for Active Surveillance

PURPOSE

Recent NCCN^® (National Comprehensive Cancer Network®) Guidelines® show that patients with biopsy Gleason score 3 + 4/Grade Group 2 but otherwise favorable features are active surveillance candidates. However, little is known about the long-term outcomes compared to that in men in the low risk Gleason score 6/Grade Group 1 group. We sought to clarify the risk of adverse features and oncologic outcomes in surgically treated, favorable Grade Group 2 vs 1 cases.

MATERIALS AND METHODS

We queried our prospectively maintained radical prostatectomy database for all 8,095 patients with biopsy Grade Group 1 or 2 prostate cancer who otherwise fulfilled the NCCN low risk definition of prostate specific antigen less than 10 ng/ml and cT2a or less, and who underwent radical prostatectomy from 1987 to 2014. Multivariable logistic regression and Kaplan-Meier methods were used to compare pathological and oncologic outcomes.

RESULTS

Organ confined disease was present in 93.9% and 82.6% of Grade Group 1 and favorable intermediate risk Grade Group 2 cases while seminal vesicle invasion was noted in 1.7% and 4.7%, and nodal disease was noted in 0.3% and 1.8%, respectively (all p <0.0001). On multivariable logistic regression biopsy proven Grade Group 2 disease was associated with a threefold greater risk of nonorgan confined disease (OR 3.1, 95% CI 1.7-5.7, p <0.001). The incidence of late treatment (more than 90 days from surgery) in Grade Group 1 vs 2 was 3.1% vs 8.5% for hormonal therapy and 6.0% vs 12.2% for radiation (p <0.001). In the Grade Group 1 vs 2 cohorts the 10-year biochemical recurrence-free survival rate was 88.9% vs 81.2% and the 10-year systemic progression-free survival rate was 99% vs 96.5% (each p <0.001).

CONCLUSIONS

Men at favorable risk with Grade Group 2 disease who are considering active surveillance should be informed of the risks of harboring adverse pathological features which impact secondary therapies and an increased risk of cancer progression.

Low-risk Prostate Cancer: Identification, Management, and Outcomes

CONTEXT

The incidence of low-risk prostate cancer (PCa) has increased as a consequence of prostate-specific antigen testing.

OBJECTIVE

In this collaborative review article, we examine recent literature regarding low-risk PCa and the available prognostic and therapeutic options.

EVIDENCE ACQUISITION

We performed a literature review of the Medline, Embase, and Web of Science databases. The search strategy included the terms: prostate cancer, low risk, active surveillance, focal therapy, radical prostatectomy, watchful waiting, biomarker, magnetic resonance imaging, alone or in combination.

EVIDENCE SYNTHESIS

Prospective randomized trials have failed to show an impact of radical treatments on cancer-specific survival in low-risk PCa patients. Several series have reported the risk of adverse pathologic outcomes at radical prostatectomy. However, it is not clear if these patients are at higher risk of death from PCa. Long-term follow-up indicates the feasibility of active surveillance in low-risk PCa patients, although approximately 30% of men starting active surveillance undergo treatment within 5 yr. Considering focal therapies, robust data investigating its impact on long-term survival outcomes are still required and therefore should be considered experimental. Magnetic resonance imaging and tissue biomarkers may help to predict clinically significant PCa in men initially diagnosed with low-risk disease.

CONCLUSIONS

The incidence of low-risk PCa has increased in recent years. Only a small proportion of men with low-risk PCa progress to clinical symptoms, metastases, or death and prospective trials have not shown a benefit for immediate radical treatments. Tissue biomarkers, magnetic resonance imaging, and ongoing surveillance may help to identify those men with low-risk PCa who harbor more clinically significant disease.

PATIENT SUMMARY

Low-risk prostate cancer is very common. Active surveillance has excellent long-term results, while randomized trials have failed to show a beneficial impact of immediate radical treatments on survival. Biomarkers and magnetic resonance imaging may help to identify which men may benefit from early treatment.

[Oncological results of active surveillance in prostate cancer: A retrospective multicentric cohort]

PURPOSE

To report oncological outcomes of patients with prostate cancer undergoing active surveillance according to SURACAP criteria.

METHODS

This multicentric study included patients who were initially treated with active surveillance for localized prostate cancer according to the SURACAP criteria. The duration of active surveillance as well as the causes of discontinuing the protocol and the definitive pathological results of patients who further underwent radical prostatectomy were retrospectively evaluated. The predictors of discontinuing active surveillance were assessed using a univariable Cox Model. In addition, the predictive value of initial MRI was assessed for patients who performed such imagery.

RESULTS

Between 2007 and 2013, 80 patients were included, with a median age of 64 years [47-74]. Median follow-up was 52.9 months [24-108]. At 5 years follow-up, 43.4% patients were still under surveillance. Among patients that underwent surgery, 17.8% had an extra-capsular extension. The risk of discontinuing was not significantly greater for patients with tumor size of 2 or 3mm versus 1mm (HR=0.9 [0.46-1.75], P=0.763), 2 positives cores versus 1 (HR=0.98 [0.48-2.02], P=0.967), T2a vs. T1c stage (HR=2.18 [0.77-6.18], P=0.133), increased PSA level (HR=1 [0.96-1.15], P=0.975) or the patient's age (HR=1 [0.93-1.16], P=0.966). Among the 50 patients who performed initial MRI, the results of such imagery was not significantly associated to the risk of discontinuing active surveillance MRI (HR=1.49 [0.63-3.52], P=0.36).

CONCLUSION

Although this study reveals a high rate of release from active surveillance at 5 years, the rate of extra-capsular tumors reported in the group of patients that underwent surgery is among the lowest in literature.

LEVEL OF EVIDENCE

4.

Confirmatory biopsy for the assessment of prostate cancer in men considering active surveillance: reference centre experience

OBJECTIVES

To evaluate how accurate a 12-core transrectal biopsy derived low-risk prostate cancer diagnosis is for an active surveillance programme by comparing the histological outcome with that from confirmatory transperineal sector biopsy.

SUBJECTS AND METHODS

The cohort included 166 men diagnosed with low volume Gleason score 3+3 prostate cancer on initial transrectal biopsy who also underwent a confirmatory biopsy. Both biopsy techniques were performed according to standard protocols and samples were taken for histopathology analysis. Subgroup analysis was performed according to disease severity at baseline to determine possible disease parameters of upgrading at confirmatory biopsy.

RESULTS

After confirmatory biopsy, 34% demonstrated Gleason score upgrade, out of which 25% were Gleason score 3+4 and 8.5% primary Gleason pattern 4. Results remained consistent for the subgroup analysis and a weak positive association, but not statistically significant, between prostate specific antigen (PSA), age, and percentage of positive cores, and PCa upgrading at confirmatory biopsy was found.

CONCLUSION

In our single centre study, we found that one-third of patients had higher Gleason score at confirmatory biopsy. Furthermore 8.5% of these upgraders had a primary Gleason pattern 4. Our results together with previously published evidence highlight the need for the revision of current guidelines in prostate cancer diagnosis for the selection of men for active surveillance.

[Oncological outcomes of prostate cancer surgery]

OBJECTIVE

Review of the oncological results of the radical prostatectomy as initial treatment of prostate cancer, according to the surgical approach and the risk stratification using D'Amico risk groups.

MATERIALS AND METHODS

Review of literature using Medline databases and MedScience based on scientific relevance. Research focused on the oncological results of the radical prostatectomy in series and meta-analysis published since 10 years, taking into consideration the surgical approach if mentioned.

RESULTS

The characteristics of the operated tumor highly impact the local control authenticated by the pathologic stage and the rates of positive surgical margins (PSM), in addition to the survival and the biochemical recurrence. Surgical technique adapted according to the tumor treated, was a constant challenge to the urologist, who counter balance between the oncological control and the conservation of urinary and sexual function by conditioning the type of radical prostatectomy. Results of radical prostatectomy acceptable in terms of PSM and survival are not influenced by the surgical approach but by the degree of surgical experience.

CONCLUSION

Results of radical prostatectomy show the efficient local control of prostate cancer, taking into consideration the oncological rules and indications validated by multidisciplinary meetings, based on the national (CCAFU) and European oncological guidelines. Tendency is going toward considering radical prostatectomy indicated for patients with higher risk of disease progression, so integrating surgery in a multidisciplinary personalized approach.

Pathologic Outcomes in Men with Low-risk Prostate Cancer Who Are Potential Candidates for Contemporary, Active Surveillance Protocols

The purpose of this study was to determine whether contemporary active surveillance (AS) protocols could sufficiently discriminate significant from indolent tumors in men with low-risk prostate cancer. We retrospectively analyzed 312 patients with low-risk prostate cancer treated with radical prostatectomy. After exclusion of patients with fewer than 10 cores taken at biopsy and those who received neo-adjuvant treatment, 205 subjects satisfied the final inclusion criteria. Five widely accepted AS protocols were employed in this study. A total of 82.0% of the patients met the inclusion criteria of at least one protocol, and 18% did not meet any criteria of published AS protocols. A significant proportion of patients had non-organ-confined disease (8.6% to 10.6%) or a Gleason score of 7 or greater (18.6% to 23.9%) between the different AS criteria. Among patients who did not meet any AS criteria, 32.4% of patients had a pathologically insignificant cancer. Our results indicated a significant adverse pathology in patients who met the contemporary AS protocols. On the other hand, some patients in whom expectant management would be appropriate did not meet any criteria of published AS protocols. None of the clinical or histological criteria reported to date is able to sufficiently discriminate aggressive tumors from indolent ones.

Heterogeneity in D'Amico classification-based low-risk prostate cancer: Differences in upgrading and upstaging according to active surveillance eligibility

BACKGROUND

To date, no study has examined clinical, pathological, and surgical characteristics of D׳Amico low-risk patients according to active surveillance (AS) eligibility.

MATERIAL AND METHODS

We relied on patients with low-risk prostate cancer, who were classified based on the D׳Amico classification, treated with radical prostatectomy (RP) between 2008 and 2013 at the Martini-Clinic Prostate Cancer Center. We assessed differences in clinical, pathological, and surgical characteristics in D׳Amico low-risk patients according to AS eligibility (prostate-specific antigen [PSA]≤ 10 ng/ml, Gleason score ≤ 3 + 3, ≤ 2 positive cores,≤5 0% tumor content per core, and ≤ cT1-2a). Multivariable logistic regression analyses targeted 2 end points: (1) presence of either intermediate- or high-risk characteristics (Gleason score ≥ 3+4 or ≥ pT3 or pN1) or (2) exclusive presence of high-risk characteristics (Gleason score ≥ 4+4 or ≥ pT3 or pN1) at RP.

RESULTS

Of 1,331 patients low-risk prostate cancer classified based on the D׳Amico classification, 825 (62%) men were eligible for AS. AS candidates were less frequently either upgraded (55% vs. 78%, P<0.001) or upstaged (8% vs. 15%, P<0.001). Similarly, at final pathology, AS candidates less frequently harbored either intermediate- or high-risk (56% vs. 78%, P<0.001), or exclusive high-risk characteristics (9% vs. 16%, P<0.001). Tumor involvement per core (>50%) (most powerful), number of positive cores, PSA values, and age were independent predictors for either intermediate- or high-risk characteristics at RP. Tumor involvement per core and PSA values were independent predictors for exclusive high-risk characteristics at RP.

CONCLUSIONS

D׳Amico low-risk patients did not have a homogeneous histology at RP. Especially, non-AS candidates were at a higher risk of either upgrading or upstaging at final pathology. Tumor involvement greater than 50% per core was the most powerful indicator of adverse pathology. Therefore, D'Amico low-risk criteria are not safe enough to identify AS candidates.

Adverse Pathologic Features at Radical Prostatectomy: Effect of Preoperative Risk on Oncologic Outcomes

BACKGROUND

Up to 30% of patients with low-risk prostate cancer (PCa) are found to have features of aggressive disease at radical prostatectomy (RP). Several predictive nomograms and novel genomic markers have been developed to estimate the risk of adverse pathology in men eligible for active surveillance (AS). However, oncologic risk associated with these findings remains unknown.

OBJECTIVE

To determine if the presence of adverse pathologic features at RP in patients eligible for AS is prognostic of poor oncologic outcome independent of pretreatment risk status.

DESIGN, SETTING, AND PARTICIPANTS

A total of 2660 patients underwent immediate RP at our institution between 1998 and 2008. Patients were stratified as low, intermediate, or high risk according to the D'Amico clinical risk criteria.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The rates of adverse pathology were reported, and the 5-yr risk of biochemical recurrence (BCR) was calculated in the presence of aggressive disease.

RESULTS AND LIMITATIONS

The 5-yr risk of BCR in patients with extracapsular extension (n=937) was 43% (95% confidence interval [CI], 40-46) overall but only 15% (95% CI, 11-22) for those who met the criteria for low risk (n=181). For the 473 patients with pathologic Gleason score 4+3, the risk of recurrence at 5 yr was 41% (95% CI, 37-46) overall, 13% (95% CI, 5-27) for low-risk men (n=41), 41% (95% CI, 35-47) for intermediate-risk men (n=287), and 51% (95% CI, 43-60) for high-risk men (n=145). Limitations include use of BCR as the study end point and surrogate for oncologic outcome in men who received curative treatment.

CONCLUSIONS

The presence of pathologically unfavorable disease in patients eligible for AS is not informative as to the safety of this treatment modality. We question the relevance of adverse pathology as the end point for predictive tools designed to guide treatment decisions in low-risk PCa.

PATIENT SUMMARY

The risk of biochemical recurrence associated with adverse pathologic findings at prostatectomy is reduced by approximately 50% in men with clinically low-risk prostate cancer.

Clinical value of core length in contemporary multicore prostate biopsy

Objectives

There is little data about the clinical value of core length for prostate biopsy (PBx). We investigated the clinical values of various clinicopathological biopsy-related parameters, including core length, in the contemporary multi-core PBx.

Patients and Methods

Medical records of 5,243 consecutive patients who received PBx at our institution were reviewed. Among them, 3,479 patients with prostate-specific antigen (PSA) ≤10ng/ml level who received transrectal ultrasound (TRUS)-guided multi (≥12)-core PBx at our institution were analyzed for prostate cancer (PCa). Gleason score upgrading (GSU) was analyzed in 339 patients who were diagnosed with low-risk PCa and received radical prostatectomy. Multivariate logistic regression analyses for PCa detection and prediction of GSU were performed.

Results

The mean age and PSA of the entire cohort were 63.5 years and 5.4ng/ml, respectively. The overall cancer detection rate was 28.5%. There was no statistical difference in core length between patients diagnosed with PCa and those without PCa (16.1 ± 1.8 vs 16.1 ± 1.9mm, P = 0.945). The core length was also not significantly different (16.4 ± 1.7 vs 16.4 ± 1.6mm, P = 0.889) between the GSU group and non-GSU group. Multivariate logistic regression analyses demonstrated that the core length of PBx did not affect PCa detection in TRUS-guided multi-core PBx (P = 0.923) and was not prognostic for GSU in patients with low-risk PCa (P = 0.356).

Conclusions

In patients undergoing contemporary multi-core PBx, core length may not have significant impact on PCa detection and also GSU following radical prostatectomy among low-risk PCa group.

Active surveillance for localized prostate cancer: an analysis of patient contacts and utilization of healthcare resources

OBJECTIVE

Evidence supports active surveillance (AS) as a means to reduce overtreatment of low-risk prostate cancer (PCa). The consequences of close and long-standing follow-up with regard to outpatient visits, tests and repeated biopsies are widely unknown. This study investigated the trajectory and costs of AS in patients with localized PCa.

MATERIALS AND METHODS

In total, 317 PCa patients were followed in a prospective, single-arm AS cohort. The primary outcomes were number of patient contacts, prostate-specific antigen (PSA) tests, biopsies, hospital admissions due to biopsy complications and patients eventually undergoing curative treatment. The secondary outcome was cost.

RESULTS

The 5 year cumulative incidence of discontinued AS in a competing-risk model was 40%. During the first 5 years of AS patients underwent a median of two biopsy sets, and patients were seen in an outpatient clinic including PSA testing three to four times annually. In total, 38 of the 406 biopsy sessions led to hospital admission and 87 of the 317 patients required treatment for bladder outlet obstruction (BOO). With a median of 3.7 years' follow-up, the total cost of AS was euro (€) 1,240,286. Assuming all patients had otherwise undergone primary radical prostatectomy, the cost difference favoured AS with a net benefit of €662,661 (35% reduction).

CONCLUSIONS

AS entails a close clinical follow-up with a considerable risk of rebiopsy complication, treatment of BOO and subsequent delayed definitive therapy. This risk should be weighed against a potential economic benefit and reduction in the risk of overtreatment compared to immediate radical treatment.

Analysis of different tumor volume thresholds of insignificant prostate cancer and their implications for active surveillance patient selection and monitoring

Purpose:

We compared oncological outcomes according to tumor volume (TV) thresholds defining both classical and updated insignificant prostate cancer (IPC), since the TV threshold can be used as clinical parameter for active surveillance.

Methods:

Between 2001 and 2012, we retrospectively analyzed 331 organ-confined prostate cancer patients who had preoperative Gleason score 6, preoperative PSA under 10 ng/mL and pathologic TV less than 1.3 mL. Among them, 81 of 331 (24.5%) had Gleason grade 4/5 disease postoperatively. Patients were stratified into two groups: (1) TV less than 0.5 mL, using the classical definition; and (2) TV between 0.5 mL and 1.3 mL, using the range of updated definition. We compared biochemical recurrence (BCR)-free survival and identified independent predictors of BCR in each group.

Results:

Group 2 had more Gleason grade 4/5 disease than group 1 (P<0.001). On multivariate analysis, Gleason grade 4/5 disease was not associated with BCR in group 1 (P=0.132). However, it was an independent predictor for BCR in group 2 (P=0.042). BCR-free survival were not significantly different according to the presence of Gleason grade 4/5 disease in group 1 (P=0.115). However, in group 2, it was significantly different according to the presence of Gleason grade 4/5 disease (P=0.041).

Conclusions:

Although the TV thresholds of the two definitions of IPC vary only slightly, this difference was enough to result in different clinical course if Gleason grade 4/5 disease was present. Therefore, the updated IPC TV threshold should be carefully applied as clinical parameter for active surveillance.

Focal therapy for prostate cancer. Rationale, indications and selection

CONTEXT

The great controversy surrounding the treatment of localized prostate cancer is related with its possibilities of radical treatment or active surveillance. The objective of this paper is to analyze the rationale selection among current focal therapy modalities regarding tumor and patient selection.

EVIDENCE ACQUISITION

Current articles about advantages and disadvantages on the treatment of localized prostate cancer as well as information about focal therapy regarding tumour selection, characteristics and indications cited in MEDLINE search were reviewed.

SUMMARY OF EVIDENCE

Focal therapy standardized criteria must be: low risk tumors, PSA<10-15, Gleason score ≤ 6, and unilateral presentation all supported by image-guided biopsy and nuclear magnetic resonance (NMR). There are doubts about the suitability of focal therapy in cases of bilateralism or in those with Gleason score 3+4 or PSA>15.

CONCLUSIONS

Focal therapy is an alternative for localized prostate cancer treatment. However, some aspects of their diagnosis and selection criteria should be defined by prospective studies which should provide knowledge about the indication for focal therapy.

Predictive factors of unfavorable prostate cancer in patients who underwent prostatectomy but eligible for active surveillance

PURPOSE

To investigate the predictive factors of unfavorable prostate cancer in Korean men who underwent radical prostatectomy but eligible for active surveillance according to Epstein criteria.

METHODS

We retrospectively reviewed the medical records of 2,036 patients who underwent radical prostatectomy for prostate cancer between 1994 and 2011. Among these, 233 patients were eligible for active surveillance based on Epstein criteria. Unfavorable prostate cancer was defined as pathologic Gleason sum ≥7 or non-organ-confined disease. We investigated pathologic outcomes and predictive factors for unfavorable prostate cancer.

RESULTS

Of 233 cases, 91 patients (39.1%) were pathologic Gleason sum ≥7, 11 (4.7%) had extracapsular extension, and three (1.3%) had seminal vesicle invasion. Ninety-eight patients (42.1%) had unfavorable prostate cancer. When comparing clinically insignificant and significant prostate cancer, there were significant differences in mean age (P=0.007), prostate volume (P=0.021), prostate-specific antigen (PSA) density (P=0.03), maximum tumor volume in biopsy core (P<0.001), and rate of two positive cores (P=0.001). On multivariate analysis, age (P=0.015), PSA density (P=0.017) and two positive cores (P=0.001) were independent predictive factors for unfavorable prostate cancer.

CONCLUSIONS

A significant proportion of patients who were candidates for active surveillance had unfavorable prostate cancer. Age, PSA density, and two positive cores were independent significant predictive factors for unfavorable prostate cancer. These factors should be considered when performing active surveillance.

Prostate volume and biopsy tumor length are significant predictors for classical and redefined insignificant cancer on prostatectomy specimens in Japanese men with favorable pathologic features on biopsy

Background

Gleason pattern 3 less often has molecular abnormalities and often behaves indolent. It is controversial whether low grade small foci of prostate cancer (PCa) on biopsy could avoid immediate treatment or not, because substantial cases harbor unfavorable pathologic results on prostatectomy specimens. This study was designed to identify clinical predictors for classical and redefined insignificant cancer on prostatectomy specimens in Japanese men with favorable pathologic features on biopsy.

Methods

Retrospective review of 1040 PCa Japanese patients underwent radical prostatectomy between 2006 and 2013. Of those, 170 patients (16.3%) met the inclusion criteria of clinical stage ≤ cT2a, Gleason score (GS) ≤ 6, up to two positive biopsies, and no more than 50% of cancer involvement in any core. The associations between preoperative data and unfavorable pathologic results of prostatectomy specimens, and oncological outcome were analyzed. The definition of insignificant cancer consisted of pathologic stage ≤ pT2, GS ≤ 6, and an index tumor volume < 0.5 mL (classical) or 1.3 mL (redefined).

Results

Pathologic stage ≥ pT3, upgraded GS, index tumor volume ≥ 0.5 mL, and ≥ 1.3 mL were detected in 25 (14.7%), 77 (45.3%), 83 (48.8%), and 53 patients (31.2%), respectively. Less than half of cases had classical (41.2%) and redefined (47.6%) insignificant cancer. The 5-year recurrence-free survival was 86.8%, and the insignificant cancers essentially did not relapse regardless of the surgical margin status. MRI-estimated prostate volume, tumor length on biopsy, prostate-specific antigen density (PSAD), and findings of magnetic resonance imaging were associated with the presence of classical and redefined insignificant cancer. Large prostate volume and short tumor length on biopsy remained as independent predictors in multivariate analysis.

Conclusions

Favorable features of biopsy often are followed by adverse pathologic findings on prostatectomy specimens despite fulfilling the established criteria. The finding that prostate volume is important does not simply mirror many other studies showing PSAD is important, and the clinical criteria for risk assessment before definitive therapy or active surveillance should incorporate these significant factors other than clinical T-staging or PSAD to minimize under-estimation of cancer in Japanese patients with low-risk PCa.

Is active surveillance a safe alternative in the management of localized prostate cancer? Pathological features of radical prostatectomy specimens in potential candidates for active surveillance

INTRODUCTION AND OBJECTIVE

Active surveillance (AS) has become an accepted alternative for patients with low risk prostate cancer. The purpose of AS is to defer definitive therapy in these patients to avoid treatment-related complications. Our aim was to determine the pathological features of the surgical specimen from potential AS candidates that underwent radical prostatectomy (RP).

MATERIALS AND METHODS

We retrospectively reviewed a group of patients submitted to RP who met criteria for AS: Gleason score (GS) ≤ 3+3 = 6, PSA ≤ 10ng/mL, T1c - T2a,< 1/3 of positive cores, < 50% of involvement in any core and PSA density < 0.15. We determined the concordance between GS in biopsy and RP specimen (RPS). Other pathological features of the RPS were also analyzed, including surgical margins, extracapsular extension, seminal vesicles and lymph node involvement.

RESULTS

We identified 167 patients subjected to RP that met the criteria for AS. Fifty two patients (31.1%) had a GS > 6 in the RPS (GS 7 n = 49; GS 8 n = 3). Extracapsular extension, seminal vesicle and lymph node involvement was found in 6.1%, 3.1% and 1.2% of the specimens, respectively.

CONCLUSION

In this study a significant proportion of potential candidates for AS showed features of aggressive and/or high-risk tumors in the RPS. Therefore, before considering a patient for an AS protocol, a proper and strict selection must be performed, and informed consent is crucial for these patients.

[The significance of PSA density as predictive factor in Afro-Caribbean patients eligible for active surveillance by the French protocol criteria]

OBJECTIVES

Study the interest of addition of PSA density (PSAD), to the selection criteria of the French protocol for inclusion patients Afro-Caribbean on active surveillance prostate cancer.

METHODS

A retrospective analysis of 1505 patients who had, in turn, a radical prostatectomy for cancer between 2000 and 2012, in a single reference center. One hundred and forty-one patients was eligible, at the time of their diagnosis, for active surveillance by the criteria of the French protocol. This population was divided into 2 groups according to the histological analysis of the prostatectomy specimen confirmed indolent cancer or overturned. The median PSAD of each group was calculated to be compared. Secondarily, the most discriminating PSAD was investigated by the method of ROC after constitution tables intrinsic validity in this population. This threshold has secondary conducting a comparative analysis of the underestimation of cancer in terms of aggressiveness and/or extension between patients selected according to the criteria of the French protocol and "on-selected" patients according to these criteria and their PSAD.

RESULTS

Of the 141 patients identified for analysis, histological examination of the prostatectomy specimen has to show that 42 patients (29.7 %) were actually more aggressive cancer (20.6 % of Gleason ≥ 7), wider (4.2 % ≥ pT3) or larger and more aggressive (4.9 %) than foreshadowed criteria French protocol. The median PSAD these 42 patients were significantly higher than the median PSAD patients correctly estimated (0.18 vs. 0.14, p-value=0.046). The application of the most discriminating threshold: 0.15 ng/ml/cm(3) in this population allowed to significantly improve the selection of candidates of the 79 "on-selected" patients, six (20.2 %) were actually more aggressive cancer (13.9 % of Gleason ≥ 7), wider (2.5 % ≥ pT3) or larger and more aggressive (3.8 %).

CONCLUSION

The criteria for the French protocol for active surveillance, applied to the Caribbean population underestimate 29 % of non-latent cancers. Adjuvants criteria that must be inexpensive, sensitive and specific seem necessary in this population. A PSAD<0.15 ng/ml/cm(3) could be one of these criteria.

Active surveillance for clinically localized prostate cancer--a systematic review

Active surveillance (AS) has been introduced as an observational strategy to delay or avoid curative treatment without compromising long-term cancer-specific survival. The 10 studies included in this review, published between 2008 and 2013, generally agreed upon patients selection for the AS strategy and how they should be managed within the program. However, uncertainties persists concerning optimal patient selection and reliable progression criteria, as well as the long-term safety of AS.

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.

Utility of diffusional kurtosis imaging as a marker of adverse pathologic outcomes among prostate cancer active surveillance candidates undergoing radical prostatectomy

OBJECTIVE

The purpose of this study was to compare findings at nongaussian diffusional kurtosis imaging and conventional diffusion-weighted MRI as markers of adverse pathologic outcomes among prostate cancer patients who are active surveillance candidates and choose to undergo prostatectomy.

MATERIALS AND METHODS

Fifty-eight active surveillance candidates (prostate-specific antigen concentration, < 10 ng/mL; clinical tumor category less than T2a; Gleason score, 3 + 3; ≤ 25% of biopsy cores positive for tumor; ≤ 50% tumor involvement of any individual core; ≤ 20% tumor involvement across all cores) who underwent prostatectomy and preoperative 3-T MRI including diffusional kurtosis imaging (b values, 0, 500, 1000, 1500, and 2000 s/mm(2)) were included. Adverse pathologic features at prostatectomy were defined using two schemes of varying stringency. One scheme (less stringent) was presence of a Gleason score greater than 6 or extracapsular extension (n = 19). The other scheme (more stringent) was presence of a Gleason score greater than 6, extracapsular extension, or an index tumor 10 mm or larger (n = 35). Parametric maps displaying standard apparent diffusion coefficient (ADC), kurtosis (K) representing nongaussian diffusion behavior, and diffusion (D) representing a diffusion coefficient adjusted for nongaussian (kurtosis) behavior were reviewed, and the most abnormal region was recorded for each metric. Associations between these metrics and the presence of adverse final pathologic findings were assessed with unpaired Student t tests and receiver operating characteristic analyses.

RESULTS

For both schemes, only D was significantly lower in patients with adverse final pathologic findings (p = 0.006, p = 0.025). K tended to be greater in patients with adverse final pathologic findings for the more stringent scheme (p = 0.072). ADC was not significantly different in the presence of adverse final pathologic findings for either scheme (p = 0.357, p = 0.383). With either scheme, D had a larger area under the receiver operating characteristics curve (AUC) for predicting adverse final pathologic results (AUC, 0.691 and 0.743) than did ADC (AUC, 0.569 and 0.655) or K (AUC, 0.617 and 0.714), but the difference was not significant (p = 0.183, p = 0.734).

CONCLUSION

Preliminary results suggest that diffusional kurtosis imaging findings may have more value than findings at conventional diffusion-weighted MRI as a marker of adverse final pathologic outcome among active surveillance candidates.

Prostate-specific antigen doubling time as a progression criterion in an active surveillance programme for patients with localized prostate cancer

OBJECTIVES

To elucidate the role of prostate-specific antigen (PSA) doubling time (PSAdt) as a progression criterion in patients with low-risk prostate cancer managed by active surveillance (AS). To assess the correlation between PSAdt during AS and final histopathology after radical prostatectomy (RP) in patients meeting predefined progression criteria.

PATIENTS AND METHODS

A total of 258 consecutive patients on an AS programme were included in the study. The PSAdt was calculated in patients with two or more PSA values, and 95% confidence intervals (CIs) were calculated in patients with four or more PSA values. Progression risk groups were defined as follows: high-risk: PSAdt <3 years, rebiopsy Gleason score (GS) ≥4 + 3, more than three positive biopsy cores, and/or bilateral tumour or cT ≥2c disease; intermediate-risk: PSAdt 3-5 years, GS = 3 + 4 or cT2b disease; and low-risk: PSAdt >5 years, without histopathological or clinical progression. Definitive treatment was recommended for patients in the high-risk group and treatment options were discussed with those in the intermediate-risk group.

RESULTS

A total of 2291 PSA values obtained during AS were available, of which 2071 were considered valid in the 258 patients. PSAdt values with 95% CIs were calculated in 221 patients based on a median of 8 PSA values. The 95% CIs for PSAdt overlapped considerably and in up to 91% of the patients, the 95% CIs overlapped among the risk group definitions. A total of 26% (68/258 patients) underwent RP after meeting the progression criteria. There was no association between preoperative PSAdt and final histopathology (P = 0.87).

CONCLUSION

The uncertainty of calculated PSAdt during AS leads to a significant risk of patients being misclassified in terms of risk of progression, which limits the use of PSAdt in the management of patients on AS.

Histology core-specific evaluation of the European Society of Urogenital Radiology (ESUR) standardised scoring system of multiparametric magnetic resonance imaging (mpMRI) of the prostate

OBJECTIVES

To evaluate the Prostate Imaging Reporting and Data System (PIRADS) in multiparametric magnetic resonance imaging (mpMRI) based on single cores and single-core histology. To calculate positive (PPV) and negative predictive values (NPV) of different modalities of mpMRI.

PATIENTS AND METHODS

We performed MRI-targeted transrectal ultrasound-guided perineal prostate biopsies on 50 patients (mean age 66 years, mean PSA level of 9.9 ng/mL) with suspicion of prostate cancer. The biopsy trajectories of every core taken were documented in three dimensions (3D) in a 3D-prostate model. Every core was evaluated separately for prostate cancer and the performed biopsy trajectories were projected on mpMRI images. PIRADS scores of 1177 cores were then assessed by a histology 'blinded' uro-radiologist in T2-weighted (T2W), dynamic contrast-enhanced (DCE), diffusion-weighted imaging (DWI) and magnetic resonance spectroscopy (MRS).

RESULTS

The PIRADS score was significantly higher in cores positive for cancer than in negative cores. There was a significant correlation between the PIRADS score and histopathology for every modality. Receiver operating characteristic (ROC) analysis showed excellent specificity for T2W (90% peripheral zone/97% transition zone) and DWI (98%/97%) images regardless of the prostate region observed. These numbers decreased for DCE (80%/93%) and MRS (76%/83%). All modalities had NPVs of 99%, if a PIRADS score threshold of 2 (for T2W, DCE, and MRS) or 3 (for DWI) was used. However, PPVs were low.

CONCLUSIONS

Our results show that PIRADS scoring is feasible for clinical routine and allows standardised reporting. PIRADS can be used as a decision-support system for targeting of suspicious lesions. mpMRI has a high NPV for prostate cancer and, thus, might be a valuable tool in the initial diagnostic evaluation.

Oncologic outcomes following radical prostatectomy in the active surveillance era

OBJECTIVE

In this study, we examine the oncologic outcomes of men with low, intermediate and high preoperative risk for prostate cancer treated with radical prostatectomy prior to and during the active surveillance era.

METHODS

We analyzed records from patients who underwent radical prostatectomy at our Canadian tertiary care facility from 2000 to 2012. Patients were stratified by D'Amico preoperative risk category and by year of treatment. Biochemical recurrence-free survival was estimated using the Kaplan-Meier method.

RESULTS

We included 2643 consecutive patients in our analysis. The proportion of men with low-risk disease undergoing radical prostatectomy decreased from 2007 onwards coincident with the implementation of an active surveillance strategy in our institution. Men with low-risk and high-risk disease showed significantly worse biochemical outcomes from 2007 to 2012 compared to 2000 to 2006 (p < 0.05), while men with intermediate-risk prostate cancer showed no significant differences (p = 0.27). Within the low-risk cohort, the later treatment group displayed significantly lower age, pre-treatment prostate specific antigen and tumour volume and significantly higher testosterone and body mass index.

CONCLUSIONS

The time period corresponding with the implementation of active surveillance at our institution corresponded with significant deterioration of biochemical outcomes in the low- and high-risk groups. This suggests that the men with most favourable disease deferred treatment, whereas men with worse preoperative disease characteristics were increasingly treated with radical prostatectomy in the past 6 years perhaps to their benefit.

Expanded criteria to identify men eligible for active surveillance of low risk prostate cancer at Johns Hopkins: a preliminary analysis

PURPOSE

At our institution the eligibility criteria used to enroll patients in active surveillance are clinical stage T1, prostate specific antigen density less than 0.15 ng/ml, biopsy Gleason score 6 or less, 2 or fewer positive biopsy cores and 50% or less involvement of any biopsy core. We hypothesized that these criteria may be excessively strict, precluding many men from active surveillance.

MATERIALS AND METHODS

We studied pathological outcomes in men treated with radical prostatectomy between 1995 and 2012 who met 4 or more of the 5 active surveillance criteria. Outcomes included a definition of significant tumor (pathological Gleason 7 or greater, or nonorgan confined). We compared adverse pathology rates between men who met all 5 vs 4 of 5 active surveillance criteria.

RESULTS

Of 8,261 men 1,890 (22.9%) met all active surveillance eligibility criteria and 2,133 (25.8%) met 4. Men with values exceeding prostate specific antigen density and biopsy Gleason criteria were at increased risk for adverse pathological outcomes. Clinical stage greater than T1 was not associated with adverse pathological findings. The risk of significant tumors in men with clinical stage T2 lesions, 3 or fewer positive biopsy cores and less than 60% core involvement was comparable to that of men who met all active surveillance criteria.

CONCLUSIONS

Prostate specific antigen density greater than 0.15 ng/ml and biopsy Gleason score 7 or greater are strongly associated with adverse pathological findings at radical prostatectomy. Our findings suggest that active surveillance criteria should be expanded to include men with clinical stage T2 lesions and a greater number of positive biopsy cores of low grade. Based on these preliminary findings, we are in the process of reassessing active surveillance eligibility criteria using more detailed pathological analysis.

Comparison of oncologic outcomes after radical prostatectomy in men diagnosed with prostate cancer with PSA levels below and above 4 ng/mL

PURPOSE

To assess whether the PSA level (threshold 4 ng/mL) is a prognostic factor in biochemical recurrence-free survival in men with prostate cancer (PCa) with an initial PSA level <10 ng/mL who underwent robotic-assisted laparoscopic radical prostatectomy (RARLP).

METHODS

We prospectively recruited data for consecutive patients treated by RARLP for PCa with an initial PSA level below 10 ng/mL between 2003 and 2011 at our institution. We divided the population into two groups: patients with a PSA level below 4 ng/mL (G1; n = 53) and patients with a PSA level between 4 and 10 ng/mL (G2; n = 371). Biochemical recurrence was defined as a single increase in PSA greater than 0.2 ng/mL after surgery. Multivariate analysis was used to assess prognostic factors of recurrence-free survival.

RESULTS

Overall, 424 patients were included, and the median age was 62 (58-67) years. The median PSA was 5.8 ng/mL (4.8-7.7 ng/mL). Overall, 6 patients from G1 and 34 patients from G2 experienced a biochemical recurrence. Overall, the 5-year recurrence-free survival rate was 86.6 %. The PSA level at diagnosis (under or over 4 ng/mL) was not significantly linked to recurrence-free survival (HR = 0.59, p = 0.25). However, positive margins and a Gleason score >7 on the specimen were significantly linked to recurrence-free survival with respective hazard ratios of 4.30 (p < 0.0001) and 6.18 (p < 0.0001), respectively.

CONCLUSION

A PSA level <4 ng/mL alone appears to be obsolete as a cut-off to define a population of men likely to have indolent disease.

Pathological outcomes of Japanese men eligible for active surveillance after radical prostatectomy

BACKGROUND

The aim of this study was to analyze the pathological features of prostatectomy specimens from patients with low-risk prostate cancer eligible for active surveillance (AS) and evaluate preoperative data suitable for predicting upstaged (≥pT3) or upgraded disease (Gleason score of ≥7), defined as 'reclassification'.

METHODS

A retrospective analysis of 521 consecutive radical prostatectomy procedures (January 2005 through to December 2011) performed at our institution without neoadjuvant hormonal therapy was performed. Eighty-four patients fulfilled the following criteria-clinical T1 or T2 disease, prostate-specific antigen (PSA) level of ≤10 ng/ml, one or two positive biopsies, and Gleason score of <7. Clinicopathological features at diagnosis were compared between patients with and without reclassification after radical prostatectomy.

RESULTS

Forty of 84 patients (47.6 %) had a Gleason score of ≥7, and 8 (9.5 %) had upstaged disease (≥pT3). Seven patients with upstaged disease also showed upgraded reclassification. Two patients with reclassification showed biochemical recurrence at 59 and 89 months after surgery, respectively. Preoperative parameters evaluated included age, PSA level, PSA density (PSAD), clinical T stage, and number and percentage of positive prostate cores. Among 82 patients with complete data, univariate analysis showed that PSAD (ng/ml(2)) was a significant parameter to discriminate patients with reclassified disease and those without reclassified disease (p < 0.001). Multivariate analysis revealed that PSAD was the only independent variable to predict disease with reclassification (p = 0.006).

CONCLUSIONS

Preoperative PSAD may be a good indicator for selecting patients eligible for AS in the Japanese population.