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Fan Y, Mulati Y, Zhai L, Chen Y, Wang Y, Feng J, Yu W, Zhang Q. Diagnostic Accuracy of Contemporary Selection Criteria in Prostate Cancer Patients Eligible for Active Surveillance: A Bayesian Network Meta-Analysis. Front Oncol 2022; 11:810736. [PMID: 35083157 PMCID: PMC8785217 DOI: 10.3389/fonc.2021.810736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 12/10/2021] [Indexed: 12/24/2022] Open
Abstract
Background Several active surveillance (AS) criteria have been established to screen insignificant prostate cancer (insigPCa, defined as organ confined, low grade and small volume tumors confirmed by postoperative pathology). However, their comparative diagnostic performance varies. The aim of this study was to compare the diagnostic accuracy of contemporary AS criteria and validate the absolute diagnostic odds ratio (DOR) of optimal AS criteria. Methods First, we searched Pubmed and performed a Bayesian network meta-analysis (NMA) to compare the diagnostic accuracy of contemporary AS criteria and obtained a relative ranking. Then, we searched Pubmed again to perform another meta-analysis to validate the absolute DOR of the top-ranked AS criteria derived from the NMA with two endpoints: insigPCa and favorable disease (defined as organ confined, low grade tumors). Subgroup and meta-regression analyses were conducted to identify any potential heterogeneity in the results. Publication bias was evaluated. Results Seven eligible retrospective studies with 3,336 participants were identified for the NMA. The diagnostic accuracy of AS criteria ranked from best to worst, was as follows: Epstein Criteria (EC), Yonsei criteria, Prostate Cancer Research International: Active Surveillance (PRIAS), University of Miami (UM), University of California-San Francisco (UCSF), Memorial Sloan-Kettering Cancer Center (MSKCC), and University of Toronto (UT). I2 = 50.5%, and sensitivity analysis with different insigPCa definitions supported the robustness of the results. In the subsequent meta-analysis of DOR of EC, insigPCa and favorable disease were identified as endpoints in ten and twenty-two studies, respectively. The pooled DOR for insigPCa and favorable disease were 0.44 (95%CI, 0.31–0.58) and 0.66 (95%CI, 0.61–0.71), respectively. According to a subgroup analysis, the DOR for favorable disease was significantly higher in US institutions than that in other regions. No significant heterogeneity or evidence of publication bias was identified. Conclusions Among the seven AS criteria evaluated in this study, EC was optimal for positively identifying insigPCa patients. The pooled diagnostic accuracy of EC was 0.44 for insigPCa and 0.66 when a more liberal endpoint, favorable disease, was used. Systematic Review Registration [https://www.crd.york.ac.uk/prospero/], PROSPERO [CRD42020157048].
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Affiliation(s)
- Yu Fan
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Department of Urology, Tibet Autonomous Region People's Hospital, Lhasa, China
| | - Yelin Mulati
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
| | - Lingyun Zhai
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuke Chen
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
| | - Yu Wang
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
| | - Juefei Feng
- Department of Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Wei Yu
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
| | - Qian Zhang
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Peking University Binhai Hospital, Tianjin, China
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Survey on the practice of active surveillance for prostate cancer from the Middle East. Prostate Int 2020; 8:41-48. [PMID: 32257977 PMCID: PMC7125368 DOI: 10.1016/j.prnil.2019.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/10/2019] [Accepted: 11/14/2019] [Indexed: 11/29/2022] Open
Abstract
Background Prostate cancer is the most common cancer among Lebanese men. Management of prostate cancer includes medical, radiological, and surgical intervention. In addition, active surveillance (AS) is proven as a valid option in patients with low-risk prostate cancer. Currently, data from the Middle East about AS are scarce. The aim of this study is to assess the rate of implementation of AS by physicians, determine the selection and follow-up criteria used by physicians, and identify potential barriers to its widespread adoption. Methods After receiving ethical approval, a LimeSurvey electronic questionnaire was mailed to 206 eligible urologists, oncologists, and radiation oncologists registered in the order of physicians in Lebanon. The questionnaire included dichotomous, multiple choice questions, and multiple answer questions. The 23 questions tackled sociodemographic information, physician's attitude toward AS, and their current practices. Predictors of AS use were identified using the chi-squared and Fisher's exact test. Then, multivariate logistic regression model for the predictors of AS practice was conducted. Results The response rate was 25%, and the analysis was run on 52 respondents. Although most of the respondents agreed that AS is a valid modality for low-risk prostate cancer, only 34 (65.4%) of them had patients on active surveillance. The rate of patients on AS was also very low. Urologists, physicians with >15 years of experience, and those who practiced in a university hospital were all predictors of AS usage (p = 0.005; p = 0.002; p = 0.025, respectively). However, physicians with fear of patient noncompliance had the odds of resorting to this modality [odds ratio (OR) = 0.07 (0.01 – 0.76)]. Conclusion The main obstacles to implementing AS were fear of patient noncompliance and lack of national awareness as well as acceptance among the Lebanese uro-oncological body. Efforts to decentralize knowledge and expertize to new health-care practitioners and community hospitals would encourage its implementation.
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Tsang CF, Lai TCT, Lam W, Ho BSH, Ng ATL, Ma WK, Yiu MK, Tsu JHL. Is prostate specific antigen (PSA) density necessary in selecting prostate cancer patients for active surveillance and what should be the cutoff in the Asian population? Prostate Int 2018; 7:73-77. [PMID: 31384609 PMCID: PMC6664316 DOI: 10.1016/j.prnil.2018.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/02/2018] [Accepted: 03/06/2018] [Indexed: 01/15/2023] Open
Abstract
Background To investigate the role of Prostate Specific Antigen density (PSAD) in selecting prostate cancer patients for active surveillance (AS) and to determine a cutoff PSAD in identifying adverse pathological outcomes. Methods Data from 287 patients who underwent radical prostatectomy for prostate cancer were retrospectively reviewed. Six different AS protocols, the University of Toronto; Royal Marsden; John Hopkins; University of California San Francisco (UCSF); Memorial Sloan Kettering Cancer Center (MSKCC) and Prostate Cancer Research International: Active Surveillance (PRIAS), were applied to the cohort. Pre-operative demographics and pathological outcomes were analysed. Statistical analyses on the predictive factors of adverse pathological outcomes and significance of PSAD were performed. A cutoff PSAD with best balance between sensitivity and specificity in identifying adverse pathological outcome was determined. Results PSAD predicted adverse pathological outcomes better than Prostate Specific Antigen (PSA) level alone. The PSAD was significantly lower (0.12-0.13 ng/dl/ml) in protocols including PSAD (the John Hopkins and PRIAS) compared with the other four protocols not including PSAD as a selection criteria (0.21-0.25 ng/dl/dl, P = 0.00). PSAD predicted adverse pathological outcomes in all protocols not incorporating PSAD as an inclusion criteria (P = 0.00-0.02). By the receiver operator characteristics curve analysis, it was found that a PSAD level of 0.19 ng/ml/ml had the best balance between sensitivity and specificity in predicting pathological adverse disease (Area under curve = 0.63, P = 0.004). Conclusion PSAD is necessary in selecting prostate cancer patients for active surveillance. It predicts adverse pathological outcomes in patients eligible for active surveillance better than PSA level alone. A PSAD cutoff at 0.19 ng/ml/ml has the best balance between sensitivity and specificity in predicting pathological adverse disease. We recommend using AS protocol incorporating PSAD as a selection criteria (in particular the PRIAS protocol with a cutoff PSAD at 0.2 ng/ml/ml) when recruiting prostate cancer patients for AS.
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Affiliation(s)
- Chiu-Fung Tsang
- Division of Urology, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Terence C T Lai
- Division of Urology, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Wayne Lam
- Division of Urology, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Brian S H Ho
- Division of Urology, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Ada T L Ng
- Division of Urology, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Wai-Kit Ma
- Division of Urology, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Ming-Kwong Yiu
- Division of Urology, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - James H L Tsu
- Division of Urology, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
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Prostate Imaging Reporting and Data System, Version 2, Assessment Categories and Pathologic Outcomes in Patients With Gleason Score 3 + 4 = 7 Prostate Cancer Diagnosed at Biopsy. AJR Am J Roentgenol 2017; 208:1037-1044. [PMID: 28267359 DOI: 10.2214/ajr.16.16843] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to assess associations between Prostate Imaging Reporting and Data System, version 2 (PI-RADSv2), categories and the presence of a tumor with a Gleason score (GS) of 4 + 3 = 7 or greater or the presence of extraprostatic extension (EPE) at radical prostatectomy (RP) in patients with a GS 3 + 4 = 7 tumor at biopsy. MATERIALS AND METHODS A total of 81 men with GS 3 + 4 = 7 prostate cancer diagnosed by transrectal ultrasound-guided biopsy underwent multiparametric MRI and RP between 2012 and 2015. Two blinded radiologists assessed multiparametric MR images and assigned PI-RADSv2 assessment categories (categories 1-5) with the use of sector maps, which were compared with regard to the location of the tumor, the GS, and the presence of EPE at RP. Comparisons were performed between groups with the use of chi-square and multivariate analysis. Diagnostic accuracy was assessed using ROC curve analysis, and localization was compared using the Fisher exact test. RESULTS A total of 53.1% of men (43/81) had EPE, and 21.0% (17/81) had GS 4 + 3 = 7 prostate cancer after RP, whereas 2.5% of men (2/81) had their tumors downgraded to GS 3 + 3 = 6. No statistically significant difference in patient age, prostate specific antigen level, or clinical stage existed between groups (p > 0.05). PI-RADSv2 assessment categories were significantly higher for GS 4 + 3 = 7 tumors (p = 0.03). PI-RADSv2 showed moderate accuracy for the diagnosis of GS 4 + 3 = 7 tumors (AUC, 0.65; 95% CI, 0.54-0.77), with a category of 4 or higher having a sensitivity and specificity for diagnosis of 94.1% and 23.4%, respectively. No patient with a PI-RADSv2 category lower than 3 had a GS 4 + 3 = 7 tumor. Accuracy of tumor localization ranged from 86.4% to 92.6%, with 88.2% of errors (15/17) occurring in GS 3 + 3 = 6 or GS 3 + 4 = 7 tumors (p = 0.30). PI-RADSv2 categories were noted to be higher when EPE was present (p < 0.001). Interobserver agreement was moderate (κ = 0.43). CONCLUSION For GS 3 + 4 = 7 cancers detected at transrectal ultrasound-guided biopsy, higher PI-RADSv2 assessment categories are associated with upgrading to GS 4 + 3 = 7 cancer and with the presence of EPE after RP. A PI-RADSv2 score of 3 or higher was 100% sensitive for diagnosing GS 4 + 3 = 7 tumors.
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Prognostic Significance of the Disparity Between Biopsy and Pathologic Gleason Score After Radical Prostatectomy in Clinical Candidates for Active Surveillance According to the Royal Marsden Criteria. Clin Genitourin Cancer 2016; 14:e329-33. [DOI: 10.1016/j.clgc.2016.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 12/29/2015] [Accepted: 01/16/2016] [Indexed: 11/21/2022]
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Bosco C, Cozzi G, Kinsella J, Bianchi R, Acher P, Challacombe B, Popert R, Brown C, George G, Van Hemelrijck M, Cahill D. Confirmatory biopsy for the assessment of prostate cancer in men considering active surveillance: reference centre experience. Ecancermedicalscience 2016; 10:633. [PMID: 27170833 PMCID: PMC4854226 DOI: 10.3332/ecancer.2016.633] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Cecilia Bosco
- King’s College London, Division of Cancer Studies, Cancer Epidemiology Group, London SE1 9RT, UK
| | - Gabriele Cozzi
- European Institute of Urology, Division of Urology, Milan, Italy
| | - Janette Kinsella
- Guy’s and St Thomas’ Hospital NHS Foundation Trust, London SE1 9RT, UK
| | - Roberto Bianchi
- Guy’s and St Thomas’ Hospital NHS Foundation Trust, London SE1 9RT, UK
| | - Peter Acher
- Southend University Hospital NHS Foundation Trust, Southend SS0 0RY, UK
| | | | - Rick Popert
- Guy’s and St Thomas’ Hospital NHS Foundation Trust, London SE1 9RT, UK
| | - Christian Brown
- King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Gincy George
- King’s College London, Division of Cancer Studies, Cancer Epidemiology Group, London SE1 9RT, UK
- Guy’s and St Thomas’ Hospital NHS Foundation Trust, London SE1 9RT, UK
| | - Mieke Van Hemelrijck
- King’s College London, Division of Cancer Studies, Cancer Epidemiology Group, London SE1 9RT, UK
| | - Declan Cahill
- Guy’s and St Thomas’ Hospital NHS Foundation Trust, London SE1 9RT, UK
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Kang M, Song B, Lee I, Lee SE, Byun SS, Hong SK. Predictors of pathological upgrading in low-risk prostate cancer patients without hypointense lesions on an apparent diffusion coefficient map of multiparametric magnetic resonance imaging. World J Urol 2016; 34:1541-1546. [PMID: 27074937 DOI: 10.1007/s00345-016-1829-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 04/04/2016] [Indexed: 10/22/2022] Open
Abstract
PURPOSE To examine the clinicopathological features and identify the predictors of pathological upgrading in low-risk prostate cancer (PCa) patients without hypointense lesions on the apparent diffusion coefficient (ADC) map calculated from multiparametric magnetic resonance imaging. METHODS We reviewed the medical records of 1905 PCa patients who underwent radical prostatectomy between 2007 and 2015. All ADC images were graded using the five-grade Likert scale; the positive hypointense lesions were graded 4-5. We analyzed 256 patients with low-risk classifications according to D'Amico criteria. Patients were classified into two groups according to the pathologic upgrading in the surgical specimens. The predictive factors for pathologic upgrading were evaluated using a multivariate logistic regression analysis. RESULTS In 256 patients with low-risk PCa, the percentage of positive cores [odds ratio (OR) 1.09; 95 % confidence interval (CI) 1.02-1.16], the percentage of cancer in the positive cores (OR 1.07, 95 % CI 1.03-1.12), and the presence of hypointensity on an ADC map (OR 2.28; 95 % CI 1.23-4.22) were independent predictors of pathologic upgrading. Notably, 138 of low-risk patients (53.9 %) had no hypointense lesions on an ADC map. Of these 138 patients, the percentage of positive cores (OR 1.09; 95 % CI 1.01-1.18) and the percentage of cancer in the positive cores (OR 1.06; 95 % CI 1.01-1.12) remained independent predictors of pathologic upgrading. CONCLUSIONS In low-risk PCa patients without hypointense lesions on an ADC map, biopsy-related parameters such as the percentage of positive cores and the percentage of cancer in the positive cores were independent predictors of pathological upgrading following radical prostatectomy.
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Affiliation(s)
- Minyong Kang
- Department of Urology, Seoul National University Hospital, 101, Daehak-ro, Jongno-Gu, Seoul, Republic of Korea
| | - Byeongdo Song
- Department of Urology, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea
| | - Injae Lee
- Department of Urology, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea
| | - Sang Eun Lee
- Department of Urology, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea
| | - Seok-Soo Byun
- Department of Urology, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea
| | - Sung Kyu Hong
- Department of Urology, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea.
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Tosoian JJ, Carter HB, Lepor A, Loeb S. Active surveillance for prostate cancer: current evidence and contemporary state of practice. Nat Rev Urol 2016; 13:205-15. [PMID: 26954332 DOI: 10.1038/nrurol.2016.45] [Citation(s) in RCA: 166] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Prostate cancer remains one of the most commonly diagnosed malignancies worldwide. Early diagnosis and curative treatment seem to improve survival in men with unfavourable-risk cancers, but significant concerns exist regarding the overdiagnosis and overtreatment of men with lower-risk cancers. To this end, active surveillance (AS) has emerged as a primary management strategy in men with favourable-risk disease, and contemporary data suggest that use of AS has increased worldwide. Although published surveillance cohorts differ by protocol, reported rates of metastatic disease and prostate-cancer-specific mortality are exceedingly low in the intermediate term (5-10 years). Such outcomes seem to be closely associated with programme-specific criteria for selection, monitoring, and intervention, suggesting that AS--like other management strategies--could be individualized based on the level of risk acceptable to patients in light of their personal preferences. Additional data are needed to better establish the risks associated with AS and to identify patient-specific characteristics that could modify prognosis.
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Affiliation(s)
- Jeffrey J Tosoian
- Brady Urological Institute, Johns Hopkins Medical Institutions, 600 N. Wolfe Street, Baltimore, Maryland 21287-2101, USA
| | - H Ballentine Carter
- Brady Urological Institute, Johns Hopkins Medical Institutions, 600 N. Wolfe Street, Baltimore, Maryland 21287-2101, USA
| | - Abbey Lepor
- Department of Urology, New York University, 550 1st Avenue (VZ30 #612), New York, New York 10016, USA
| | - Stacy Loeb
- Department of Urology, New York University, 550 1st Avenue (VZ30 #612), New York, New York 10016, USA.,Depatment of Population Health, New York University. 550 1st Avenue (VZ30 #612), New York, New York 10016, USA.,The Laura &Isaac Perlmutter Cancer Center, New York University, 550 1st Avenue (VZ30 #612), New York, New York 10016, USA
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Abstract
PURPOSE OF REVIEW The clinical value of active surveillance may still be limited due to acceptance and considerable misclassification rates, and inadequate follow-up criteria. This review focuses on the most recent developments in the use of active surveillance and patient-specific factors that may be used to identify patients suitable for this strategy. RECENT FINDINGS The number of patients diagnosed with low-risk prostate cancer has risen. Active surveillance acceptance rates are increasing, but still limited and varying importantly (2-49%). Misclassification is inevitable in all currently used protocols, although most of these patients still have relatively favorable-risk prostate cancer. African-American race, obese, and older-aged patients show more unfavorable intermediate results in an active surveillance situation. These are unlikely to be explained by the small differences in preoperative characteristics only. Psychological profiling may also be added to the selection process. Most studies report intermediate endpoints only. SUMMARY Patient-specific factors may be incorporated when identifying patients for active surveillance. This does not imply that active surveillance is not justified in specific groups, but may suggest the need for an intensified and personalized selection, instead of a one-size-fits-all approach.
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Whole-Tumor Quantitative Apparent Diffusion Coefficient Histogram and Texture Analysis to Predict Gleason Score Upgrading in Intermediate-Risk 3 + 4 = 7 Prostate Cancer. AJR Am J Roentgenol 2016; 206:775-82. [PMID: 27003049 DOI: 10.2214/ajr.15.15462] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of our study was to evaluate whole-lesion quantitative apparent diffusion coefficient (ADC) for the prediction of Gleason score (GS) upgrading in 3 + 4 = 7 prostate cancer. MATERIALS AND METHODS Fifty-four patients with GS 3 + 4 = 7 prostate cancer diagnosed at systematic transrectal ultrasound (TRUS)-guided biopsy underwent 3-T MRI and radical prostatectomy (RP) between 2012 and 2014. A blinded radiologist contoured dominant tumors on ADC maps using histopathologic correlation. The whole-lesion mean ADC, ADC ratio (normalized to peripheral zone), ADC histogram, and texture analysis were compared between tumors with GS upgrading and those without GS upgrading using multivariate ROC analyses and logistic regression modeling. RESULTS Tumors were upgraded to GS 4 + 3 = 7 after RP in 26% (n = 14) of the 54 patients, and tumors were downgraded after RP in none of the patients. The mean ADC, ADC ratio, 10th-centile ADC, 25th-centile ADC, and 50th-centile ADC were similar between patients with GS 3 + 4 = 7 tumors (0.99 ± 0.22, 0.58 ± 0.15, 0.77 ± 0.31, 0.94 ± 0.28, and 1.15 ± 0.24, respectively) and patients with upgraded GS 4 + 3 = 7 tumors (1.02 ± 0.18, 0.55 ± 0.11, 0.71 ± 0.26, 0.89 ± 0.20, and 1.11 ± 0.16) (p > 0.05). Regression models combining texture features improved the prediction of GS upgrading. The combination of kurtosis, entropy, and skewness yielded an AUC of 0.76 (SE = 0.07) (p < 0.001), a sensitivity of 71%, and a specificity of 73%. The combination of kurtosis, heterogeneity, entropy, and skewness yielded an AUC of 0.77 (SE = 0.07) (p < 0.001), a sensitivity of 71%, and a specificity of 78%. CONCLUSION In this study, whole-lesion mean ADC, ADC ratio, and ADC histogram analysis were not predictive of pathologic upgrading of GS 3 + 4 = 7 prostate cancer after RP. ADC texture analysis improved accuracy.
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Jung JW, Lee JK, Hong SK, Byun SS, Lee SE. Stratification of patients with intermediate-risk prostate cancer. BJU Int 2015; 115:907-12. [PMID: 24612460 DOI: 10.1111/bju.12703] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To identify an appropriate risk stratification system for intermediate-risk prostate cancer (PCa). PATIENTS AND METHODS We reviewed the data on 1559 patients who were treated with radical prostatectomy (RP) at our institution between 2005 and 2013 and classified them according to National Comprehensive Cancer Network (NCCN) risk groups. For our analyses, intermediate-risk PCa was designated as unfavourable intermediate-risk PCa if it met at least one of the following two criteria: biopsy Gleason score 4 + 3 and/or presence of ≥ 2 intermediate-risk criteria. All other men with intermediate-risk PCa were designated as having favourable intermediate-risk disease. Postoperative outcomes, including biochemical recurrence (BCR)-free survival, were calculated and compared using the log-rank test and Cox proportional hazards model. RESULTS In multivariable analysis, biopsy Gleason score 4 + 3 and multiple (≥ 2) intermediate-risk criteria were observed to be independent predictors of BCR risk among men in the intermediate-risk group undergoing RP. The favourable intermediate-risk group had a significantly higher 5-year BCR-free survival compared with the unfavourable intermediate-risk group (87.5 vs 66.5%; P < 0.001). The unfavourable intermediate-risk group had significantly higher 5-year BCR-free survival than the high-risk group (66.5 vs 47.9%; P < 0.001) while the favourable intermediate-risk group had significantly lower 5-year BCR-free survival than the low-risk group (87.5 vs 93.5%; P = 0.002). CONCLUSIONS A marked heterogeneity exists in the biochemical outcomes of contemporary patients with intermediate-risk PCa who undergo definitive RP. According to biopsy Gleason score and number of intermediate-risk criteria present, the intermediate-risk group should be sub-divided into those with favourable and unfavourable intermediate-risk disease.
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Affiliation(s)
- Jin-Woo Jung
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Keun Lee
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung Kyu Hong
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seok-Soo Byun
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Eun Lee
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
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Chu WG, Kim BJ, Slezak J, Harrison TN, Gelfond J, Jacobsen SJ, Chien GW. The effect of urologist experience on choosing active surveillance for prostate cancer. World J Urol 2015; 33:1701-6. [PMID: 25761737 DOI: 10.1007/s00345-015-1528-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 03/03/2015] [Indexed: 10/23/2022] Open
Abstract
PURPOSE To evaluate the impact of the urologist's experience in selecting active surveillance (AS) versus immediate treatment (IT) for low-risk prostate cancer. METHODS Men with low-risk prostate cancer were enrolled from March 2011 to August 2013 at 13 medical centers in Kaiser Permanente Southern California. The AS cohort was defined as men who had cT1-T2a stage prostate cancer, prostate-specific antigen <10 ng/ml, a biopsy revealing Gleason grade ≤6, fewer than three biopsy cores positive, ≤50 % cancer in any core, and not undergone immediate therapy (surgery, radiation, other) within 6 months following diagnosis. The urologist's experience (age, number of years in practice, number of robotic surgeries performed, and fellowship experience in oncology and/or robotics) was then compared between AS and IT cohorts. RESULTS A total of 4754 men were diagnosed with prostate cancer, and 713 men satisfied with inclusion criteria; 433 (60.7 %) and 280 (39.3 %) chose AS and IT, respectively. A total of 87 urologists were included. Univariate and multivariate adjusted analyses revealed no differences in urologist's age or years in practice. Patients who saw urologists who had performed ≥50 robotic surgeries were less likely to choose AS (OR 0.40, 95 % CI 0.25-0.66). Patients who saw urologists with a fellowship in oncology and/or robotics were more than twice as likely to choose AS (OR 2.27, 95 % CI 1.38-3.75). CONCLUSION These data suggest that the decision to pursue AS may be influenced by the urologist's experience.
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Affiliation(s)
- William G Chu
- Department of Urology, Los Angeles Medical Center, Kaiser Permanente Southern California, 4900 Sunset Blvd., 2nd Floor, Los Angeles, CA, 90027, USA
| | - Brian J Kim
- Department of Urology, Los Angeles Medical Center, Kaiser Permanente Southern California, 4900 Sunset Blvd., 2nd Floor, Los Angeles, CA, 90027, USA
| | - Jeff Slezak
- Research and Evaluation Department, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd Floor, Pasadena, CA, 91101, USA
| | - Teresa N Harrison
- Research and Evaluation Department, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd Floor, Pasadena, CA, 91101, USA
| | - Joy Gelfond
- Research and Evaluation Department, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd Floor, Pasadena, CA, 91101, USA
| | - Steven J Jacobsen
- Research and Evaluation Department, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd Floor, Pasadena, CA, 91101, USA
| | - Gary W Chien
- Department of Urology, Los Angeles Medical Center, Kaiser Permanente Southern California, 4900 Sunset Blvd., 2nd Floor, Los Angeles, CA, 90027, USA.
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13
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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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14
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Chen DJ, Falzarano SM, McKenney JK, Przybycin CG, Reynolds JP, Roma A, Jones JS, Stephenson A, Klein E, Magi-Galluzzi C. Does cumulative prostate cancer length (CCL) in prostate biopsies improve prediction of clinically insignificant cancer at radical prostatectomy in patients eligible for active surveillance? BJU Int 2014; 116:220-9. [PMID: 25060664 DOI: 10.1111/bju.12880] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To evaluate if cumulative prostate cancer length (CCL) on prostate needle biopsy divided by the number of biopsy cores (CCL/core) could improve prediction of insignificant cancer on radical prostatectomy (RP) in patients with prostate cancer eligible for active surveillance (AS). PATIENTS AND METHODS Patients diagnosed with prostate cancer on extended (≥10 cores) biopsy with an initial prostate-specific antigen (iPSA) level of <15 ng/mL, clinical stage (cT) ≤ 2a, and highest biopsy Gleason score 3 + 3 = 6 or 3 + 4 = 7 with <3 positive cores who underwent RP were included in the study. The CCL/core and presence of insignificant cancer (organ-confined, volume <0.5 mL, Gleason score at RP ≤6) were recorded. pT2 prostate cancer with RP Gleason score ≤3 + 4 = 7 and volume <0.5 mL were categorised as low-tumour-volume organ-confined disease (LV-OCD). RESULTS In all, 221 patients met the inclusion criteria: the mean age was 59 years and the median iPSA level was 4.5 ng/mL. The clinical stage was cT1 in 86% of patients; biopsy Gleason score was 3 + 3 = 6 in 67% (group 1) and 3 + 4 = 7 in 33% of patients (group 2). The maximum percentage of biopsy core involvement was <50 in 85%; the median CCL/core was 0.15 mm. Insignificant cancer was found in 27% and LV-OCD in 44% of patients. Group 2 was associated with higher number of positive cores, maximum percentage core involvement, total prostate cancer length, and CCL/core. Group 1 was more likely to have insignificant cancer (39%) or LV-OCD (54%) than group 2 (3% and 23%, respectively). Group 2 had significantly higher RP Gleason score and pathological stage. Univariate analysis of group 1 showed that the iPSA level, maximum percentage core involvement, prostate cancer length, and CCL/core were all significantly associated with insignificant cancer and LV-OCD. For group 2, the number of positive cores (1 vs 2) was also significantly associated with LV-OCD. On multivariate logistic regression analysis, maximum percentage core involvement of <50, and number of positive cores (1 vs 2) were independent predictors of insignificant cancer in group 1; biopsy Gleason score, maximum percentage core involvement of <50 and prostate cancer length of <3 mm or CCL/core of <0.2 mm were all independent predictors of LV-OCD in the whole population. The maximum percentage of core involvement of <50 and prostate cancer length of <3 mm or CCL/core of <0.2 mm were also independent predictors of LV-OCD in group 1 patients. CONCLUSION In patients eligible for AS, a CCL/core of <0.20 mm was significantly associated with insignificant cancer and LV-OCD. However, when parameters of cancer burden were considered, CCL/core did not independently add any additional value for predicting insignificant cancer in patients with biopsy Gleason score 6. The CCL/core was an independent predictor of LV-OCD in the whole population and in group 1 patients, although the model including prostate cancer length showed slightly higher area under the receiver operating characteristic curve.
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Affiliation(s)
- Derrick J Chen
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sara M Falzarano
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jesse K McKenney
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA.,Glickman Urological and Kidney Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Chris G Przybycin
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA.,Glickman Urological and Kidney Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jordan P Reynolds
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andres Roma
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - J Stephen Jones
- Glickman Urological and Kidney Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andrew Stephenson
- Glickman Urological and Kidney Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eric Klein
- Glickman Urological and Kidney Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Cristina Magi-Galluzzi
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA.,Glickman Urological and Kidney Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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15
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Ploussard G, Isbarn H, Briganti A, Sooriakumaran P, Surcel CI, Salomon L, Freschi M, Mirvald C, van der Poel HG, Jenkins A, Ost P, van Oort IM, Yossepowitch O, Giannarini G, van den Bergh RCN. Can we expand active surveillance criteria to include biopsy Gleason 3+4 prostate cancer? A multi-institutional study of 2,323 patients. Urol Oncol 2014; 33:71.e1-9. [PMID: 25131660 DOI: 10.1016/j.urolonc.2014.07.007] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 07/15/2014] [Accepted: 07/16/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To test the expandability of active surveillance (AS) to Gleason score 3+4 cancers by assessing the unfavorable disease risk in a large multi-institutional cohort. MATERIALS AND METHODS We performed a retrospective analysis including 2,323 patients with localized Gleason score 3+4 prostate cancer who underwent a radical prostatectomy between 2005 and 2013 from 6 academic centers. We analyzed the rates of biopsy downgrading/upgrading and advanced stage in the overall cohort by employing standardized AS criteria (using biopsy Gleason score 3+4). RESULTS The final pathologic Gleason score was 3+3 = 6 in 8%, 3+4 = 7 in 67%, 4+3 = 7 in 20%, and 8 to 10 in 5% cases. The overall rate of unfavorable disease (upgrading or advanced stage or both) was 46%. In multivariable analysis, prostate-specific antigen (PSA) level>10 ng/ml, PSA density (PSAD) >0.15 ng/ml/g, clinical stage >T1, and>2 positive cores were predictors of unfavorable disease. According to the AS criteria used, the risk of unfavorable disease ranged from 30% to 42%. In patients without any risk factor (PSA level≤ 10 ng/ml, PSAD ≤ 0.15 ng/ml/g, T1c, and ≤ 2 positive cores), the unfavorable disease rate was 19%. The main limitations of this study are the retrospective design and nonstandardization of pathologic assessment between centers. CONCLUSIONS Approximately half of patients with biopsy Gleason score 3+4 cancer have unfavorable disease at final pathology. Nevertheless, expanding AS eligibility to these patients may be acceptable provided adherence to strict selection criteria leading to a<20% risk of unfavorable disease. Future tools for selection such as magnetic resonance imaging, early rebiopsy, and serum markers may be especially beneficial in this group of patients.
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Affiliation(s)
- Guillaume Ploussard
- Department of Urology, Saint-Louis Hospital, Paris, France; Paris 7 University, Paris, France.
| | - Hendrik Isbarn
- Prostate Cancer Center Hamburg-Eppendorf, University Hospital Hamburg-Eppendorf and Martini-Clinic, Hamburg, Germany
| | - Alberto Briganti
- Department of Urology, San Raffaele Scientific Institute, Milan, Italy
| | - Prasanna Sooriakumaran
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Christian I Surcel
- Department of Uronephrology and Renal Transplantation, "Fundeni" Clinical Institute, Bucharest, Romania
| | | | - Massimo Freschi
- Department of Pathology, San Raffaele Scientific Institute, Milan, Italy
| | - Cristian Mirvald
- Department of Uronephrology and Renal Transplantation, "Fundeni" Clinical Institute, Bucharest, Romania
| | | | - Anna Jenkins
- Department of Pathology, Churchill Hospital, Oxford, UK
| | - Piet Ost
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Inge M van Oort
- Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Gianluca Giannarini
- Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
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