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Gandaglia G, Ploussard G, Isbarn H, Suardi N, De Visschere PJL, Futterer JJ, Ghadjar P, Massard C, Ost P, Sooriakumaran P, Surcel CI, van der Bergh RCN, Montorsi F, Ficarra V, Giannarini G, Briganti A. What is the optimal definition of misclassification in patients with very low-risk prostate cancer eligible for active surveillance? Results from a multi-institutional series. Urol Oncol 2015; 33:164.e1-9. [PMID: 25620154 DOI: 10.1016/j.urolonc.2014.12.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 12/10/2014] [Accepted: 12/16/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The risk of unfavorable prostate cancer in active surveillance (AS) candidates is nonnegligible. However, what represents an adverse pathologic outcome in this setting is unknown. We aimed at assessing the optimal definition of misclassification and its effect on recurrence in AS candidates treated with radical prostatectomy (RP). MATERIALS AND METHODS Overall, 1,710 patients eligible for AS according to Prostate Cancer Research International: Active Surveillance criteria treated with RP between 2000 and 2013 at 3 centers were evaluated. Patients were stratified according to pathology results at RP: organ-confined disease and pathologic Gleason score ≤ 6 (group 1); organ-confined disease and Gleason score 3+4 (group 2); and non-organ-confined disease, Gleason score ≥ 4+3, and nodal invasion (group 3). Biochemical recurrence (BCR) was defined as 2 consecutive prostate-specific antigen (PSA) ≥ 0.2 ng/ml. Kaplan-Meier curves assessed time to BCR. Multivariable Cox regression analyses tested the association between pathologic features and BCR. Multivariable logistic regression analyses identified the predictors of adverse pathologic characteristics. RESULTS Overall, 926 (54.2%), 653 (33.0%), and 220 (12.9%) patients were categorized in groups 1, 2, and 3, respectively. Median follow-up was 32.2 months. The 5-year BCR-free survival rate was 94.2%. Patients in group 3 had lower BCR-free survival rates compared with those in group 1 (79.1% vs. 97.0%, P<0.001). No differences were observed between patients included in group 1 vs. group 2 (97.0% vs. 94.7%, P = 0.1). These results were confirmed at multivariable analyses and after stratification according to margin status. Older age and PSA density ≥ 10 ng/ml/ml were associated with higher risk of unfavorable pathologic characteristics (i.e., inclusion in group 3; all P<0.001). CONCLUSIONS Among patients eligible for AS treated with RP, only men with Gleason score ≥ 4+3 or non-organ-confined disease at final pathology were at increased risk of BCR. These individuals represent the real misclassified AS patients, who can be predicted based on older age and higher PSA density.
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Affiliation(s)
- Giorgio Gandaglia
- Unit of Urology/Division of Oncology; URI; IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Hendrik Isbarn
- Department of Urology, Regio Clinic Wedel, Wedel, Germany; Martini-Clinic, Prostate Cancer Center Hamburg-Eppendorf, Germany
| | - Nazareno Suardi
- Unit of Urology/Division of Oncology; URI; IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Jurgen J Futterer
- Department of Radiology, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Pirus Ghadjar
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Piet Ost
- Department of Radiation Oncology and Experimental Cancer Research, Ghent University Hospital, Ghent, Belgium
| | | | - Christian I Surcel
- Centre of Urological Surgery, Dialysis and Renal Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | | | - Francesco Montorsi
- Unit of Urology/Division of Oncology; URI; IRCCS Ospedale San Raffaele, Milan, Italy
| | - Vincenzo Ficarra
- Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
| | - Gianluca Giannarini
- Unit of Urology/Division of Oncology; URI; IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alberto Briganti
- Unit of Urology/Division of Oncology; URI; IRCCS Ospedale San Raffaele, Milan, Italy.
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