A single-center long-term experience of active surveillance for prostate cancer: 15 years of follow-up

Clinical utility of transperineal template-guided mapping prostate biopsy in a selection of patients under active surveillance and confirmation of patients with negative biopsy for prostate cancer

Purpose

We investigated the change to definitive treatment in patients under active surveillance (AS) and cancer diagnosis in non-cancerous patients for prostate cancer after confirmatory transperineal template-guided mapping biopsy (TTMB).

Materials and methods

A total of 336 patients who underwent TTMB between March 2017 and March 2023 were retrospectively reviewed, with 134 AS patients and 202 non-cancerous patients. All patients were routinely followed up via prostate-specific antigen (PSA) and multiparametric magnetic resonance imaging (mpMRI), and follow-up biopsy was performed when deemed clinically appropriate. Treatment changes in the AS and cancer detection in the non-cancerous group were analyzed. Descriptive statistics were used to analyze the retrospective data, and the Kaplan-Meier analysis was performed to indicate conversion to radical treatment in the AS group, as well as cancer detection in the previously benign non-cancerous group.

Results

One hundred thirty-four patients under the AS protocol were analyzed, of whom 110 (82.1%) maintained AS for 33 months. Nine patients (6.7%) had significant findings in mpMRI [Prostate Imaging-Reporting and Data System (PI-RADS) ≥3] and received radical treatment following target biopsy via transrectal ultrasonography. A total of 115 patients (83.3%) with insignificant findings in mpMRI (PI-RADS 1 or 2 lesions) were followed up via transrectal ultrasound-guided prostate biopsy (17.4%, N = 20), repeat TTMB (6.1%, N = 7), or no additional biopsy (76.5%, N = 88), and from each group, five (25.0%), two (28.5%), and eight (9.1%) patients converted to radical treatment. In the non-cancerous group, five patients (2.5%) were diagnosed with prostate cancer, with PI-RADS ≥ 3 findings via mpMRI, and were confirmed by target biopsy during a mean follow-up period of 25 months, subsequently receiving radical treatment.

Conclusions

TTMB is effective in selecting patients for AS treatment and confirming benign patients and can be used as an effective follow-up modality.

Germline DNA-Repair Genes and HOXB13 Mutations in Korean Men with Metastatic Prostate Cancer: Data from a Large Korean Cohort

PURPOSE

Germline mutations in DNA damage repair (DDR) genes such as BRCA2 have been associated with prostate cancer (PC) risk but has not been thoroughly evaluated for metastatic prostate cancer (mPC) in Asian men. This study attempts to evaluate frequency of DDR mutations in the largest cohort of Koreans.

MATERIALS AND METHODS

We recruited 340 patients with mPC unselected for family history of cancer and compared to 495 controls. Whole genome sequencing was applied to assess germline pathogenic/likely pathogenic variants (PV/LPVs) in 26 DDR genes and HOXB13, including 7 genes (ATM, BRCA1/2, CHEK2, BRIP1, PALB2, and NBN) associated with hereditary PC. Comparisons to published Caucasian and Japanese cohorts were performed.

RESULTS

Total of 28 PV/LPVs were identified in 30 (8.8%) patients; mutations were found in 13 genes, including BRCA2 (15 men [4.41%]), ATM (2 men [0.59%]), NBN (2 men [0.59%], and BRIP1 (2 men [0.59%]). Only one patient had HOXB13 mutation (0.29%). A lower rate of overall germline variant frequency was observed in Korean mPC compared to Caucasians (8.8% vs. 11.8%), but individual variants notably differed from Caucasian and geographically similar Japanese cohorts. PV/LPVs in DDR genes tended to increase gradually with higher Gleason scores (GS 7, 7.1%; GS 8, 7.5%; GS 9-10, 9.9%).

CONCLUSIONS

BRCA2 was the most frequently mutated gene common to different cohorts supporting its importance, but differences in variant distribution in Korean mPC underscore the need for ethnic-specific genetic models. Future ethnic-specific analyses are warranted to verify our findings.

Polygenic risk score for tumor aggressiveness and early-onset prostate cancer in Asians

We attempted to assess the performance of an ethnic-specific polygenic risk score (PRS) designed from a Korean population to predict aggressive prostate cancer (PCa) and early-onset (age < 60). A PRS score comprised of 22 SNPs was computed in 3695 patients gathered from one of 4 tertiary centers in Korea. Males with biopsy or radical prostatectomy-proven PCa were included for analysis, collecting additional clinical parameters such as age, BMI, PSA, Gleason Group (GG), and staging. Patients were divided into 4 groups of PRS quartiles. Intergroup differences were assessed, as well as risk ratio and predictive performance based on GG using logistic regression analysis and AUC. No significant intergroup differences were observed for BMI, PSA, and rate of ≥ T3a tumors on pathology. Rate of GG ≥ 2, GG ≥ 3, and GG ≥ 4 showed a significant pattern of increase by PRS quartile (p < 0.001, < 0.001, and 0.039, respectively). With the lowest PRS quartile as reference, higher PRS groups showed sequentially escalating risk for GG ≥ 2 and GG ≥ 3 pathology, with a 4.6-fold rise in GG ≥ 2 (p < 0.001) and 2.0-fold rise in GG ≥ 3 (p < 0.001) for the highest PRS quartiles. Combining PRS with PSA improved prediction of early onset csPCa (AUC 0.759) compared to PRS (AUC 0.627) and PSA alone (AUC 0.736). To conclude, an ethnic-specific PRS was found to predict susceptibility of aggressive PCa in addition to improving detection of csPCa when combined with PSA in early onset populations. PRS may have a role as a risk-stratification model in actual practice. Large scale, multi-ethnic trials are required to validate our results.

Temporal changes of PIRADS scoring by radiologists and correlation to radical prostatectomy pathological outcomes

Purpose

To assess temporal improvement of prostate image reporting and data system (PIRADS) 3-5 lesion correlation to histopathologic findings from radical prostatectomy (RP) in prostate cancer (PCa).

Materials and methods

A total of 1481 patients who underwent RP for biopsy-proven PCa between 2015 and 2019 were divided into 14 groups of 100 sequential readings for the evaluation of histopathological correlation with PIRADS readings. Temporal trends of PIRADS distribution and predictive performance for RP pathology were evaluated to assess underlying changes in prostate magnetic resonance imaging (MRI) interpretation by radiologists.

Results

PIRADS 4-5 lesions were significantly correlated with the increasing rates of Gleason Group (GG) upgrade (p = 0.044) and decreasing rate of GG downgrade (p = 0.016) over time. PIRADS ≥3 lesions read after median 2 years of experience were shown to independently predict intermediate-high-risk (GG ≥ 3) PCa (odds ratio 2.93, 95% confidence interval 1.00-8.54; P= 0.049) in RP pathology. Preoperative GG ≥ 3 biopsy lesions with PIRADS 4-5 lesions were significantly more susceptible to GG upgrade (P= 0.035) and GG ≥ 4 RP pathology (p = 0.003) in experienced reads, in contrast to insignificant findings in early readings (p = 0.588 and 0.248, respectively).

Conclusion

Preoperative MRI reports matched with RP pathology suggest an improved prediction of adverse pathology in PIRADS 3-5 lesions over time, suggesting a temporal change in PIRADS interpretation and predictive accuracy. Institutions with low volume experience should use caution in solely relying on MRI for predicting tumor characteristics. Future prospective trials and larger scale assessments are required to further validate our results.