Reducing the demand for magnetic resonance imaging scans and prostate biopsies during the early detection of clinically significant prostate cancer: Applying the Barcelona risk-stratified pathway in Catalonia

PURPOSE

To analyze the reduction in multiparametric magnetic resonance imaging (mpMRI) demand and prostate biopsies after the hypothetical implementation of the Barcelona risk-stratified pathway (BCN-RSP) in a population of the clinically significant prostate cancer (csCaP) early detection program in Catalonia.

MATERIALS AND METHODS

A retrospective comparation between the hypothetical application of the BCN-RSP and the current pathway, which relied on pre-biopsy mpMRI and targeted and/or systematic biopsies, was conducted. The BCN-RSP stratify men with suspected CaP based on a prostate specific antigen (PSA) level >10 ng/ml and a suspicious rectal examination (DRE), and the Barcelona-risk calculator 1 (BCN-RC1) to avoid mpMRI scans. Subsequently, candidates for prostate biopsy following mpMRI are selected based on the BCN-RC2. This comparison involved 3,557 men with serum PSA levels > 3.0 ng/ml and/or suspicious DRE. The population was recruited prospectively in 10 centers from January 2021 and December 2022. CsCaP was defined when grade group ≥ 2.

RESULTS

CsCaP was detected in 1,249 men (35.1%) and insignificant CaP was overdeteced in 498 (14%). The BCN-RSP would have avoid 705 mpMRI scans (19.8%), and 697 prostate biopsies (19.6%), while 61 csCaP (4.9%) would have been undetected. The overdetection of insignificant CaP would have decrease in 130 cases (26.1%), and the performance of prostate biopsy for csCaP detection would have increase to 41.5%.

CONCLUSION

The application of the BCN-RSP would reduce the demand for mpMRI scans and prostate biopsies by one fifth while less than 5% of csCaP would remain undetected. The overdetection of insignificant CaP would decrease by more than one quarter and the performance of prostate biopsy for csCaP detection would increase to higher than 40%.

Prostatic cyst: A rare entity with differential diagnostic challenges in urology - A case report

A 62-year-old man presented with a Prostate Specific Antigen (PSA) level of 9.89 ng/mL during routine screening. The clinical examination revealed lower urinary tract symptoms, along with a soft, bulging, painless mass in the left lobe of the prostate during digital rectal examination. Imaging confirmed the presence of a left latero-prostatic cystic formation with a low level of malignancy. A prostate biopsy indicated a benign prostatic parenchyma with no signs of malignancy. Medical treatment with alpha-blockers resulted in improved urinary symptoms, and follow-up monitored PSA levels at 3 and 6 months, recording 8.05 ng/mL and 6.87 ng/mL, respectively.

Novel hormone therapy and coordination of care in high-risk biochemically recurrent prostate cancer

Biochemical recurrence (BCR) occurs in 20-50% of patients with prostate cancer (PCa) undergoing primary definitive treatment. Patients with high-risk BCR have an increased risk of metastatic progression and subsequent PCa-specific mortality, and thus could benefit from treatment intensification. Given the increasing complexity of diagnostic and therapeutic modalities, multidisciplinary care (MDC) can play a crucial role in the individualized management of this patient population. This review explores the role for MDC when evaluating the clinical evidence for the evolving definition of high-risk BCR and the emerging therapeutic strategies, especially with novel hormone therapies (NHTs), for patients with either high-risk BCR or oligometastatic PCa. Clinical studies have used different characteristics to define high-risk BCR and there is no consensus regarding the definition of high-risk BCR nor for management strategies. Next-generation imaging and multigene panels offer potential enhanced patient identification and precision-based decision-making, respectively. Treatment intensification with NHTs, either alone or combined with radiotherapy or metastasis-directed therapy, has been promising in clinical trials in patients with high-risk BCR or oligometastases. As novel risk-stratification and treatment options as well as evidence-based literature evolve, it is important to involve a multidisciplinary team to identify patients with high-risk features at an earlier stage, and make informed decisions on the treatments that could optimize their care and long-term outcomes. Nevertheless, MDC data are scarce in the BCR or oligometastatic setting. Efforts to integrate MDC into the standard management of this patient population are needed, and will likely improve outcomes across this heterogeneous PCa patient population.

[Predictive model of early urinary continence recovery based on prostate gland MRI parameters after laparoscopic radical prostatectomy]

OBJECTIVE

Constructing a predictive model for urinary incontinence after laparoscopic radical prostatectomy (LRP) based on prostatic gland related MRI parameters.

METHODS

In this study, 202 cases were included. All the patients were diagnosed with prostate cancer by prostate biopsy and underwent LRP surgery in Peking University Third Hospital. The preoperative MRI examination of all the patients was completed within 1 week before the prostate biopsy. Prostatic gland related parameters included prostate length, width, height, prostatic volume, intravesical prostatic protrusion length (IPPL), prostate apex shape, etc. From the first month after the operation, the recovery of urinary continence was followed up every month, and the recovery of urinary continence was based on the need not to use the urine pad all day long. Logistic multivariate regression analysis was used to analyze the influence of early postoperative recovery of urinary continence. Risk factors were used to draw the receiver operator characteristic (ROC) curves of each model to predict the recovery of postoperative urinary continence, and the difference of the area under the curve (AUC) was compared by DeLong test, and the clinical net benefit of the model was evaluated by decision curve analysis (DCA).

RESULTS

The average age of 202 patients was 69.0 (64.0, 75.5) years, the average prostate specific antigen (PSA) before puncture was 12.12 (7.36, 20.06) μg/L, and the Gleason score < 7 points and ≥ 7 points were 73 cases (36.2%) and 129 cases (63.9%) respectively, with 100 cases (49.5%) at T1/T2 clinical stage, and 102 cases (50.5%) at T3 stage. The prostatic volume measured by preoperative MRI was 35.4 (26.2, 51.1) mL, the ratio of the height to the width was 0.91 (0.77, 1.07), the membranous urethral length (MUL) was 15 (11, 16) mm, and the IPPL was 2 (0, 6) mm. The prostatic apex A-D subtypes were 67 cases (33.2%), 80 cases (39.6%), 24 cases (11.9%) and 31 cases (15.3%), respectively. The training set and validation set were 141 cases and 61 cases, respectively. The operations of all the patients were successfully completed, and the urinary continence rate was 59.4% (120/202) in the 3 months follow-up. The results of multivariate analysis of the training set showed that the MUL (P < 0.001), IPPL (P=0.017) and clinical stage (P=0.022) were independent risk factors for urinary incontinence in the early postoperative period (3 months). The nomogram and clinical decision curve were made according to the results of multivariate analysis. The AUC value of the training set was 0.885 (0.826, 0.944), and the AUC value of the validation set was 0.854 (0.757, 0.950). In the verification set, the Hosmer-Lemeshow goodness-of-fit test was performed on the model, and the Chi-square value was 5.426 (P=0.711).

CONCLUSION

Preoperative MUL, IPPL, and clinical stage are indepen-dent risk factors for incontinence after LRP. The nomogram developed based on the relevant parameters of MRI glands can effectively predict the recovery of early urinary continence after LRP. The results of this study require further large-scale clinical research to confirm.

Global and regional quality of care index for prostate cancer: an analysis from the Global Burden of Disease study 1990-2019

BACKGROUND

Prostate cancer (PCa) is one of the most prevalent cancers worldwide, with a significant burden on societies and healthcare providers. We aimed to develop a metric for PCa quality of care that could demonstrate the disease's status in different countries and regions (e.g., socio-demographic index (SDI) quintiles) and assist in improving healthcare policies.

METHODS

Basic burden of disease indicators for various regions and age-groups were retrieved from Global Burden of Disease Study 1990-2019, which then were used to calculate four secondary indices: mortality to incidence ratio, DALYs to prevalence ratio, prevalence to incidence ratio, and YLLs to YLDs ratio. These four indices were combined through a principal component analysis (PCA), producing the quality of care index (QCI).

RESULTS

PCa's age-standardized incidence rate increased from 34.1 in 1990 to 38.6 in 2019, while the age-standardized death rate decreased in the same period (18.1 to 15.3). From 1990 to 2019, global QCI increased from 74 to 84. Developed regions (high SDI) had the highest PCa QCIs in 2019 (95.99), while the lowest QCIs belonged to low SDI countries (28.67), mainly from Africa. QCI peaked in age groups 50 to 54, 55 to 59, or 65 to 69, depending on the socio-demographic index.

CONCLUSIONS

Global PCa QCI stands at a relatively high value (84 in 2019). Low SDI countries are affected the most by PCa, mainly due to the lack of effective preventive and treatment methods in those regions. In many developed countries, QCI decreased or stopped rising after recommendations against routine PCa screening in the 2010-2012 period, highlighting the role of screening in reducing PCa burden.

[The interoperability of IIEF-5 with EPIC-26 : Sexual function after radical prostatectomy]

BACKGROUND

In the past, the IIEF‑5 (International Index of Erectile Function 5 ) was predominantly used to measure erectile function in prostate cancer patients. Following international developments, the domain "sexuality" of the EPIC-26 (Expanded Prostate Cancer Index Composite 26) is increasingly used in Germany.

OBJECTIVE

The aim of this work is to create a practicable comparison of the domain "sexuality" of the EPIC-26 with the IIEF‑5 for treatment in Germany. This is particularly necessary for the evaluation of historical patient collectives.

MATERIALS AND METHODS

For the evaluation, 2123 patients with prostate cancer confirmed by biopsy from 2014-2017 who completed both the IIEF‑5 and the EPIC-26 were considered. Linear regression analyses are calculated to convert IIEF‑5 sum scores to EPIC-26 sexuality domain scores.

RESULTS

The correlation between IIEF‑5 and the EPIC-26 domain score "sexuality" was 0.74, suggesting a high degree of content convergence between the constructs measured. While the standard error of the predicted values is relatively small, the prediction intervals are very wide. For example, for the critical IIEF‑5 value of 22, the predicted value is 78.88 with a 95% prediction interval of 55.09 to 102.66.

CONCLUSION

IIEF‑5 and the Sexuality scale of the EPIC-26 measure a similar construct. The analysis shows that conversion of individual values is associated with great uncertainty. However, at the group level, the observed EPIC-26 "sexuality" score could be predicted quite accurately. This opens up the possibility of comparing the erectile function of cohorts of patients/test persons, even if this was collected with different measuring instruments.

Cerebellar Metastases from Prostate Cancer Detected by PET/CT with 18F-Choline

A 76-year-old male, previously submitted enucleation renal-cell carcinoma (pT1) and prostatectomy for prostate cancer (Gleason score 3+5, pT3b pN0 pMx), was submitted to positron emission/computed tomography (PET/CT) with ¹⁸F-choline for restaging due to raised levels of prostate-specific antigen. PET/CT scan showed increased tracer incorporation corresponding to bone metastases in the left ischio-pubic ramus, also revealing 2 areas of increased tracer uptake in the cerebellum, subsequently confirmed by brain magnetic resonance imaging. The patient was urgently submitted to neurosurgery. Post-operative histology was positive for brain metastases from prostate cancer.

Dynamic evaluation of MRI-targeted, systematic and combined biopsy for prostate cancer diagnosis through 10 years of practice in a single institution

PURPOSE

To perform a dynamic evaluation of the prostate cancer (PCa) detection rate according to the biopsy strategy over 10 years of practice in a single institution that pioneered MRI-targeted fusion biopsy (MRI-TB).

METHODS

This stage 4 IDEAL study prospectively included all consecutive patients who underwent transrectal prostate biopsy for clinically suspected PCa between January 2010 and November 2020. Patients with positive MRI (PIRADS score ≥ 3) underwent both MRI-TB and systematic biopsy (SB) while those with negative MRI (PIRADS score < 3) underwent SB only. The main outcome was the evolution of the detection rate of clinically relevant PCa (csPCa; grade ≥ 2). The secondary outcome was the change in PCa detection rate according to the biopsy method.

RESULTS

A total of 2942 men underwent prostate MRI and a prostate biopsy: 2322 underwent MRI-TB and 620 had SB only. The detection rate of csPCa increased 2.5-fold from 23 to 58%. The detection rate of PCa and csPCa was significantly higher in patients who underwent MRI-TB compared to those who underwent SB only (67% vs. 52% and 40% vs. 32%, respectively (P < 0.001 for both comparisons)). The number of csPCa diagnosed by MRI-TB increased linearly over the study period and represented the majority of PCa diagnoses after 2016.

CONCLUSION

Implementation of MRI-TB in patients with positive MRI led to improved detection of csPCa.

Transperineal Prostate Biopsy Is the New Black: What Are the Next Targets?

Transperineal biopsy is recommended as the first-choice technique for diagnosis of prostate cancer owing to lower rates of postprocedural sepsis. However, unresolved issues such as biopsy quality, lack of a systematic biopsy template, cost-effectiveness, and the risk of acute urine retention are yet to be resolved by the urological community.

Urethra-sparing surgery for a prostate cancer lesion in the anterior urethral zone with magnetic resonance-guided focused ultrasound: a case report

Prostate cancer (PCa) is the most common malignancy among men worldwide. High-intensity focused ultrasound (HIFU) is a focal therapeutic strategy for low- to intermediate-risk PCa with a low risk of complications. However, lesions located in the anterior urethral zone are challenging to treat with this approach because it is difficult to avoid urethral injury during HIFU therapy, which might further cause urethral stricture and symptoms related to bladder outlet obstruction (BOO). Here, we present the case of a 79-year-old male with elevated prostate-specific antigen (PSA) levels for over 1 year. Multiparametric magnetic resonance imaging revealed a 1.8 cm × 1.0 cm mass covering an area of the anterior urethral zone. Histopathological examination revealed an International Society of Urological Pathology grade group 3 acinar adenocarcinoma. Given the patient’s request for functional preservation, a magnetic resonance-guided focused ultrasound surgery was performed. During the operation, a urethra-sparing approach was utilized by administering proper energy and adjusting the sequence of the sonications. The patient developed urinary retention after catheter removal less than 48 h after the treatment, which resolved after removal of the second catheter a week later. On a follow-up visit 3 months after the treatment, evaluation by the level of PSA and multiparametric magnetic resonance imaging showed no recurrence of PCa. No significant changes in the International Prostate Symptom Score and Quality of Life score were found compared to baseline scores. With proper adjustment, magnetic resonance-guided focused ultrasound surgery could be safely used for urethra-sparing surgeries for PCa lesions in the anterior urethral zone, without influencing post-treatment urination. The indwelling time of the catheter should be extended appropriately for full recovery from treatment-related prostatic edema around the prostatic urethra to avoid urinary retention.

Randomised controlled trial to investigate the effectiveness of the symptom management after radiotherapy (SMaRT) group intervention to ameliorate lower urinary tract symptoms in men treated for prostate cancer

PURPOSE

To evaluate the effectiveness of the symptom management after radiotherapy (SMaRT) group intervention to improve urinary symptoms in men with prostate cancer.

METHODS

The randomised controlled trial (RCT) recruited men from one radiotherapy centre in the UK after curative radiotherapy or brachytherapy and with moderate to severe urinary symptoms defined as scores ≥ 8 on the International Prostate Symptom Score (IPSS) questionnaire. Sixty-three men were randomised either; to SMaRT, a 10-week symptom-management intervention including group support, education, pelvic floor muscle exercises, or a care-as-usual group. The primary outcome was the IPSS at 6 months from baseline assessment. Secondary outcomes were IPSS at 3 months, and International Continence Society Male Short Form (ICS), European Organisation for Research and Treatment of Cancer Quality of Life prostate scale (EORTC QLQ-PR25), EORTC QLQ-30 and Self-Efficacy for Symptom Control Inventory (SESCI) at 3 and 6 months from baseline. Analysis of covariance (ANCOVA) was used to analyse the effect of the intervention.

RESULTS

SMaRT group intervention did not improve urinary symptoms as measured by IPSS at 6-months. The adjusted difference was - 2.5 [95%CI - 5.0 to 0.0], p = 0.054. Significant differences were detected at 3 months in ICS voiding symptoms (- 1.1 [- 2.0 to - 0.2], p = 0.017), ICS urinary incontinence (- 1.0 [- 1.8 to - 0.1], p = 0.029) and SESCI managing symptoms domain (13.5 [2.5 to 24.4], p = 0.017). No differences were observed at 6 months.

CONCLUSIONS

SMaRT group intervention provided short-term benefit in urinary voiding and continence and helped men manage symptoms but was not effective long term.

[Combination radiotherapy-immunotherapy in genitourinary cancer]

Immunotherapy occupies a growing place in urologic oncology, mainly for kidney and bladder cancers. On the basis of encouraging preclinical work, the combination of immunotherapy with radiotherapy aims to increase the tumor response, including in metastatic tumors, which raises many hopes, which this article reviews.

Prospective assessment of two-gene urinary test with multiparametric magnetic resonance imaging of the prostate for men undergoing primary prostate biopsy

PURPOSE

To evaluate the diagnostic accuracy of SelectMDx and its association with multiparametric magnetic resonance (mpMRI) in predicting prostate cancer (PCa) and clinically significant PCa (csPCa) on prostate biopsies among men scheduled for initial prostate biopsy.

METHODS

In this single-center prospective study, 52 men scheduled for initial prostate biopsy, based on elevated total PSA level (> 3 ng/ml) or abnormal digital rectal examination, were consecutively included. All subjects underwent SelectMDx, PSA determination and mpMRI.

RESULTS

SelectMDx score was positive in 94.1 and 100% of PCa and csPCa, respectively, and in only 8.6% of negative cases at biopsy. The probability for a csPCa at the SelectMDx score was significantly (p = 0.002) higher in csPCa (median value 52.0%) than in all PCa (median value 30.0%). SelectMDx showed slightly lower sensitivity (94.1 versus 100.0%) but higher specificity (91.4%) than total PSA (17.1%), and the same sensitivity but higher specificity than mpMRI (80.0%) in predicting PCa at biopsy. The association of SelectMDx plus mpMRI rather than PSA density (PSAD) plus mpMRI showed higher specificity (both 91.4%) compared to the association of PSA plus mpMRI (85.7%). In terms of csPCa predictive value, SelectMDx showed higher specificity (73.3%) than PSA (13.3%) and mpMRI (64.4%); as for the association of SelectMDx plus mpMRI (75.6%) versus PSA plus mpMRI (68.9%), the association of PSAD plus mpMRI showed the highest specificity (80.0%).

CONCLUSION

Our results of SelectMDx can be confirmed as significant but their impact on clinical practice together with a cost-effectiveness evaluation should be investigated in a larger prospective multicenter analysis.

Artificial intelligence is a promising prospect for the detection of prostate cancer extracapsular extension with mpMRI: a two-center comparative study

PURPOSE

A balance between preserving urinary continence as well as sexual potency and achieving negative surgical margins is of clinical relevance while implementary difficulty. Accurate detection of extracapsular extension (ECE) of prostate cancer (PCa) is thus crucial for determining appropriate treatment options. We aimed to develop and validate an artificial intelligence (AI)-based tool for detecting ECE of PCa using multiparametric magnetic resonance imaging (mpMRI).

METHODS

Eight hundred and forty nine consecutive PCa patients who underwent mpMRI and prostatectomy without previous radio- or hormonal therapy from two medical centers were retrospectively included. The AI tool was built on a ResNeXt network embedded with a spatial attention map of experts' prior knowledge (PAGNet) from 596 training patients. Model validation was performed in 150 internal and 103 external patients. Performance comparison was made between AI, two experts using a criteria-based ECE grading system, and expert-AI interaction.

RESULTS

An index PAGNet model using a single-slice image yielded the highest areas under the receiver operating characteristic curve (AUC) of 0.857 (95% confidence interval [CI], 0.827-0.884), 0.807 (95% CI, 0.735-0.867), and 0.728 (95% CI, 0.631-0.811) in training, internal, and external validation data, respectively. The performance of two experts (AUC, 0.632 to 0.741 vs 0.715 to 0.857) was lower (paired comparison, all p values < 0.05) than that of AI assessment. When experts' interpretations were adjusted by AI assessments, the performance of two experts was improved.

CONCLUSION

Our AI tool, showing improved accuracy, offers a promising alternative to human experts for ECE staging using mpMRI.

Radiation-induced haemorrhagic cystitis after prostate cancer radiotherapy: factors associated to hospitalization and treatment strategies

BACKGROUND

Late onset of radiation-induced haemorrhagic cystitis (RHC) after radiation therapy (RT) for prostate cancer (PCa) may present or evolve severely, requiring hospitalization with invasive interventions. In the present study, we have analysed the prevalence and risk factors associated with the onset of RHC.

METHODS

From January 2002 to May 2017, 1421 patients undertook RT for PCa as a primary, adjuvant, or salvage treatment option. RHC presented in 5.6% (n = 80) of the patients; the diagnosis was based on clinical and endoscopic characteristics. Variables in observation included patients, tumours, and RT-dosimetry characteristics. Patients with a previous history of bladder cancer were excluded. Univariate (Student t/Chi square) and uni-/multivariate Cox regression analysis were performed; the events and time-points were hospitalization and time-to-event, respectively.

RESULTS

There were 80 patients with a mean age at RT of 70.1 years (SD 6.4), mean time lag to RHC of 43.9 months (SD 37.5). Median Emergency attendance was two and three times for patients without/with hospitalization, respectively. There were in total 64 admissions with invasive treatment required in 26/36 (72.2%) of the patients hospitalised, including transurethral fulguration in 22 and radical cystectomy in 5. Patients at higher risk of hospitalization were those undertaking antiplatelet/anticoagulant treatment (HR:3.30; CI 95%:1.53-3.30; p = 0.002) and those treated with salvage RT with higher bladder volume receiving >70 Gy (bladder V70) (HR:1.03; CI 95%:1.01-1.05; p = 0.027). At receiving operating characteristic analysis, the cutoff for bladder V70 was 29%.

CONCLUSION

Nearly half of patients presenting RHC may require invasive treatment including cystectomy. Risk factors associated with hospitalization are patients undertaking antiplatelet/coagulant treatment and bladder V70 > 29% in salvage RT patients.

Identifying Prostate Cancer Among Men with Lower Urinary Tract Symptoms

Background

In men aged above 50 yr, lower urinary tract symptoms (LUTS), benign prostate hyperplasia, and prostate cancer are common urological conditions. Current guidelines for general practitioners frequently recommend prostate-specific antigen (PSA) testing in patients with LUTS for the detection of prostate cancer.

Objective

To assess the performance of PSA, PSA density, and the Stockholm3 blood test for identification of prostate cancer among men with LUTS.

Design, setting, and participants

In this post hoc analysis of a population-based diagnostic trial (STHLM3, n = 58 588), 4588 men aged 50–69 yr, without previous prostate cancer, with International Prostate Symptom Score (IPSS) data, and having PSA ≥ 3 ng/mL were identified. Men with at least moderate LUTS, defined as an IPSS score of ≥8, were included. PSA density and Stockholm3 scores were calculated.

Intervention

Participants underwent 10–12-core systematic prostate biopsies.

Outcome measurements and statistical analysis

The primary outcome was significant prostate cancer (sPCa) defined as International Society of Urological Pathology (ISUP) grade ≥2. Logistic regression analysis adjusted for age and previous biopsy status was performed. The area under the receiver operating characteristic curve (AUC) was calculated, and decision curve analysis was performed.

Results and limitations

Out of 4588 men, 1544 (34%) reported at least moderate LUTS. The median age was 64 yr, and 11% had undergone a previous prostate biopsy. The Stockholm3 test showed superior discrimination for sPCa to PSA density, which in turn showed superior discrimination to PSA (AUC 0.77 vs 0.70 vs 0.61, p <  0.02). Calibration of the Stockholm3 test was adequate. Performing biopsy only in men with PSA ≥5 ng/mL saved 64% of biopsies, but resulted in missing 52% of detectable sPCa. Recommending biopsy for men with PSA density ≥0.07 resulted in sparing 26% of biopsy procedures and delaying the diagnosis of 12% of sPCa cases, with a 6.1% risk of sPCa among unbiopsied men. Recommending men with Stockholm3 ≥ 0.11 for biopsy resulted in sparing 53% of biopsy procedures and delaying the diagnosis of 20% of sPCa cases, with a 5.1% risk of finding sPCa in unbiopsied men.

Conclusions

PSA density and the Stockholm3 blood test were superior to PSA for the identification of prostate cancer among men with LUTS.

Patient summary

In this analysis of a large Swedish study, we find that the use of prostate-specific antigen (PSA) density or the Stockholm3 blood test instead of only PSA might improve the detection of prostate cancer among men with lower urinary tract symptoms.

Proper 6-branch suburethral autologous sling tensioning during robotic assisted radical prostatectomy with the intraopeartive use of retrograde perfusion sphincterometry: the technique

The aim of this paper is to describe our surgical technique and results of proper 6-branch autologous sling tensioning during RALP employing intraoperatively the Retrograde Perfusion Sphincterometry (RPS). Between May 2016 and February 2020, 374 patients underwent RALP with the 6-branch suburethral autologous sling tensioned under intraoperative guidance of RPS. Surgical procedure: Retrograde Leak Point pressure (RLPP) was evaluated by means of RPS after pneumoperitoneum induction (RLPPp), after urethrovescical anastomosis (RLPPa) and during proper sling tensioning (RLPPs). The goal of the sling tensioning was to obtain at the end of the procedure similar pressures as after pneumoperitoneum induction (RLPPs ≅ RLPPp). Intraoperative variables, postoperative complications, and continence recovery outcomes were assessed. A descriptive statistical analysis was performed. Sling positioning and tensioning was feasible in all patients. Mean operative time was 215 min. Proper sling tensioning allowed for the possibility to restore sphincteric efficacy to preoperative value (RLPPs vs. RLPPp (42.5 vs. 42.6) cmH2O). Urinary continence was achieved, respectively, in 58%, 67%, 74%, 88% and 92% of patients after 24 h, 10 days, 1 month, 6 months and 1 year after catheter removal. In conclusion, RPS revealed a valid option for proper autologous 6-branch sling tensioning during RALP, offering the possibility to restore sphincteric apparatus efficiency to its preoperative status to improve EUC.

[The preliminary clinical study on radical prostatectomy without preoperative prostate biopsy]

Objective: To investigate the feasibility and safety of minimally invasive radical prostatectomy for prostate cancer patients without preoperative prostate biopsy in the new era of the continuous development of comprehensive new imaging diagnostic mode and minimally invasive surgery technology. Methods: From August 2018 to October 2019, 17 patients with prostate cancer were enrolled in this study in the Cancer Hospital, Chinese Academy of Medical Sciences. All patients were highly suspected of prostate cancer by PSMA-PET/CT-based imaging diagnostic techniques and underwent 3D laparoscopic radical prostatectomy without prostate biopsy. The perioperative data, postoperative pathology, postoperative complications and follow-up results were recorded and analyzed. Results: The average age of 17 patients with prostate cancer was (65±7) years. The body mass index (BMI) average was (24.4±3.0) kg/m(2). The American Society of Anesthesiologists (ASA) score was 1 (1-2) and the Charlson comorbidity index (CCI) score was 1 (0-4). The preoperative value of PSA was (19±11) μg/L. The PSMA PET/CT showed abnormally high expression foci and the great possibility of prostate cancer for all the 17 patients. Prostate puncture biopsy: the results of prostate biopsy were negative in 3 cases. The digital rectal examination found that the prostate volume was Ⅰ or Ⅱ degree large, 10 cases touched hard and the nodule was touched in two cases. Three patients had undergone a previous prostate biopsy, but prostate cancer was not found. All the 17 operations were successfully performed without conversion to open surgery. The surgery time was (85±21) (range from 45 to 120) min, the estimated blood loss was (25±18) (range from5 to 100) ml, the time of intake of liquid diet was (14.3±4.4) h, the intestinal recovery time was (23±10) h, the postoperative activity time was (22±7) h, the drainage duration was (3.7±0.8) d, the postoperative hospital stay was (4.9±1.2) days, and the catheter removal time was (7.4±1.5) days. In the early postoperative period (within 30 days after surgery), no obvious complications occurred. The postoperative final pathology confirmed that all the 17 specimens were prostate cancer. After a median follow-up of 6.5 months, the patient's urinary control rate reached 81.3% at postoperative 1 month, 92.3% at postoperative 3 months after surgery, and the urinary control rate reached 100% at postoperative 6 months. Postoperative PSA value was (0.08±0.08) μg/L, significantly lower than preoperative PSA level (P<0.001). There was significant difference between the preoperative and postoperative QOL (Quality of life) score (57±5 and 47±5 respectively, P<0.001) which indicated that the patients' postoperative quality of life was greatly improved. Conclusions: It is safe and feasible to perform minimally invasive radical prostatectomy without preoperative prostate biopsy for patients with highly suspected prostate cancer by comprehensive diagnostic mode based on modern new imaging technology.

Cellular density of low-grade transition zone prostate cancer: A limiting factor to correlate restricted diffusion with tumor aggressiveness

OBJECTIVE

To compare the mean apparent diffusion coefficient (ADCmean) and glandular density of Gleason score (GS) 3 + 3 transition zone prostate cancers (TZ-PCa) with those of the peripheral zone (PZ-PCa).

MATERIAL & METHODS

Seventy-nine men (mean age: 65 ± 6 [SD] years; range: 52-81 years) with 37 TZ-PCa (37/79; 53 %) and 42 PZ-PCa (42/79; 47 %) had prostate MRI before radical prostatectomy. Glandular cell density was semi-quantitatively evaluated in all tumors. ADCmean and glandular cell density of GS3 + 3 TZ-PCa were compared to those of PZ-PCa. ADCmean was correlated to GS in each zone.

RESULTS

ADCmean of GS 3 + 3 tumors was significantly lower in the TZ (728 × 10^-6±52 [SD] mm²/s; range: 670-1060mm²/s) than in the PZ (865 × 10^-6 ±121 [SD] mm²/s; range: 670-1120mm²/s) (p = 0.0007), related to a significantly higher glandular density involving more than 50 % of the tumor in 58 % (7/12) of patients in GS3 + 3 TZ-PCa versus 7.6 % (1/13) in PZ-PCa (p = 0.03). ADCmean of GS3 + 3 TZ-PCa was not significantly different from that of GS 3 + 4 (p = 0.14) or GS>3 + 4 Ca (p = 0.9), whatever the zone of origin. In the PZ, ADCmean of GS 3 + 3-PCa was higher than that of Gleason>3 + 4 PZ-PCa (p = 0.02) and similar to that of GS 3 + 4 PZ-PCa (p = 0.24). Correlation between ADCmean and GS was weak for TZ-PCa (ρ = 0.32; p = 0.04) and moderate for PZ-PCa (ρ = 0.45; p = 0.003).

CONCLUSION

ADCmean of GS 3 + 3 TZ-PCa is significantly lower than that of GS 3 + 3 PZ-PCa, related to a unique dense histological pattern and reaches that of higher-grade PCa, whatever the zone of origin.

Predictors of adverse pathology on radical prostatectomy specimen in men initially enrolled in active surveillance for low-risk prostate cancer

Purpose

To evaluate clinical variables, including magnetic resonance imaging (MRI) predictive of adverse pathology (AP) at radical prostatectomy (RP) in men initially enrolled in active surveillance (AS).

Methods

A population-based cohort study of men diagnosed with low-risk prostate cancer (PCa), in Stockholm County, Sweden, during 2008–2017 enrolled in AS their intended primary treatment followed by RP. AP was defined as ISUP grade group  ≥ 3 and/or pT-stage ≥ T3. Association between clinical variables at diagnosis and time to AP was evaluated using Cox regression and multivariate logistic regression to evaluate the association between AP and clinical variables at last biopsy before RP.

Results

In a cohort of 6021 patients with low-risk PCa, 3116 were selected for AS and 216 underwent RP. Follow-up was 10 years, with a median time on AS of 23 months. 37.7% of patients had AP at RP. Clinical T-stage [Hazard ratio (HR): 1.81, 95% confidence interval (CI) 1.04–3.18] and PSA (HR: 1.31, 95% CI 1.17–1.46) at diagnosis and age [Odds Ratio (OR): 1.09, 95% CI 1.02–1.18), PSA (OR: 1.22, 95% CI 1.07–1.41), and PI-RADS (OR 1.66, 95% CI 1.11–2.55)] at last re-biopsy were significantly associated with AP.

Conclusion

PI-RADS score is significantly associated with AP at RP and support current guidelines recommending MRI before enrollment in AS. Furthermore, age, cT-stage, and PSA are significantly associated with AP.

Electronic supplementary material

The online version of this article (10.1007/s00345-020-03394-7) contains supplementary material, which is available to authorized users.

A systematic scoping review of multidisciplinary cancer team and decision-making in the management of men with advanced prostate cancer

PURPOSE

The early diagnosis of prostate cancer and subsequent access to the treatment options helps to achieve optimal cancer outcomes. As the treatment options for patients with advanced prostate cancer continues to evolve, patients need to access a multidisciplinary team (MDT) meeting to receive best-practice care.

METHODS

In this paper a MEDLINE review was performed to assess clinical decision making in the context of MDT discussions for patients with advanced prostate cancer.

RESULTS

From 441 returned articles and abstracts, 50 articles were assessed for eligibility and 16 articles included for analysis. Sixteen articles were identified, 9 of the 16 articles used quantitative methodology including three retrospective analysis of clinical registry data, patient medical records and/or MDT meeting notes and three cross-sectional surveys. Other study designs included one observation study and one study using a combination of qualitative and quantitative methodologies and one mini-review. There were also four editorials included in the review and two consensus statements.

CONCLUSION

This paper highlights the important role the inter-disciplinary MDT has on shared decision making for men with advanced prostate cancer. The application of MDT care is a rapidly growing trend in uro-oncology and an efficient MDT service requires further research to assess its efficiency so that it may expand through all aspect of uro-oncology.

Effect of information on prostate biopsy history on biopsy outcomes in the era of MRI-targeted biopsies

Purpose

To describe the predictive value of information on previous benign biopsy for the outcome of MRI-targeted biopsies.

Methods

An exploratory analysis was conducted using data from a prospective, multicenter, paired diagnostic study of 532 men undergoing diagnostics for prostate cancer during 2016–2017. All men underwent 1.5 T MRI; systematic prostate biopsies; and MRI-targeted biopsies to MRI lesions with Prostate Imaging Reporting and Data System version 2, PI-RADS ≥ 3. The main outcome was numbers of detected prostate cancer characterized by grade group (GG) where GG ≥ 2 defined clinically significant cancer (csPCa).

Results

Men with previous biopsies had significantly more often negative MRI (26% vs. 17%, p < 0.05) compared to men without previous biopsies. Men with previous biopsies showed higher rates of benign biopsies (41% vs. 26%, p < 0.05) and lower rates of GG2 (17% vs. 30%, p < 0.05) and GG ≥ 3 (5% vs. 10%, p < 0.05) cancer. Biopsy-naïve men had higher proportions of highly suspicious MRI lesions (PIRADS 5; p < 0.05) and a higher proportion of significant cancer in those lesions (p = 0.05). In multivariate regression analysis, a previous benign prostate biopsy was associated with less than half the odds of csPCa (OR 0.38; 95% CI 0.20–0.71).

Conclusion

In this large prospective multicenter trial, we showed that men with a previous prostate biopsy had higher proportions of MRIs without lesions and lower proportion of highly suspicious lesions than biopsy-naïve men. Further, biopsy-naïve men showed higher detection of clinically significant cancer when using MRI-targeted biopsies. Also, in the era of MRI-targeted biopsy strategies, biopsy history should be carefully considered in biopsy decisions.

Trial registration

NCT02788825 (ClinicalTrials.gov). Date of registration June 2, 2016.

Electronic supplementary material

The online version of this article (10.1007/s00345-020-03277-x) contains supplementary material, which is available to authorized users.

Can natural killer cell activity help screen patients requiring a biopsy for the diagnosis of prostate cancer?

Purpose

To evaluate the usefulness of natural killer cell activity (NKA) in diagnosing prostate cancer (PC).

Materials and Methods

The medical records of patients who underwent transrectal prostate biopsy (TRBx) at Korea University Ansan Hospital between May 2017 and December 2017 were retrospectively reviewed. NKA levels were measured using NK Vue® Tubes (ATgen, Sungnam, Korea). All blood samples were obtained at 8 AM on the day of biopsy. Patients with other malignancies, chronic inflammatory conditions, high prostate-specific antigen (PSA) level (>20ng/mL), or history of taking 5-alpha-reductase inhibitor or testosterone replacement therapy were excluded.

Results

A total of 102 patients who underwent TRBx for PC diagnosis were enrolled. Among them, 50 were diagnosed with PC. Significant differences in age and NKA level were observed between the PC and no-PC groups. Receiver operating characteristic (ROC) curve analysis showed that the optimal cut-off of NKA level for the prediction of PC was 500pg/dL, with a sensitivity of 68.0% and a specificity of 73.1%. In addition, NKA level (0.630) had the greatest area under the ROC curve compared to those for the ratio of total PSA to free PSA (0.597) and PSA density (0.578).

Conclusions

The results of this pilot study revealed that low NKA and high PSA levels were likely to be associated with a positive TRBx outcome. NKA detection was easy and improved the diagnostic accuracy of PC.

Radiotherapy Plus GnRH Analogue Versus High Dose Bicalutamide: A Case Control Study

BACKGROUND/AIM

Radiotherapy (RT) with adjuvant hormone therapy (HT) improves prognosis in prostate cancer (PC) patients. Gonadotrophin-releasing hormone agonist (GnRHa) with luteinizing hormone-releasing hormone (LH-RH) analogues is the standard HT. High-dose antiandrogen therapy also improves survival in patients with locally advanced PC. The aim of this study was to compare the results of patients treated with RT plus GnRHa and patients treated with RT plus bicalutamide.

PATIENTS AND METHODS

Our institutional PC database was used to identify patients treated with definitive or postoperative RT +/- HT which were included in this study.

RESULTS

Three hundred and eighteen patients were retrospectively reviewed (median follow-up=56 months). Five-year biochemical relapse-free survival was 85.5% and 88.3% in patients treated with GnRHa and bicalutamide, respectively (p=0.712).

CONCLUSION

Bicalutamide may be offered as an adjuvant treatment to RT in patients who refuse GnRHa because of related side effects. Furthermore, our study justifies randomized trials comparing RT plus GnRHa and RT plus bicalutamide.

[Radon exposure and genitourinary cancer in miners]

OBJECTIVE

To assess the association between exposure to radon and genitourinary cancer in a mining population through a systematic review of the scientific literature.

METHOD

A systematic review of the scientific literature was carried out in MEDLINE (PubMed), combining MeSH (Medical Subject Heading) terms and free terms. We applied a specific scale to assess the quality of the included studies.

RESULTS

We included 17 studies; all were cohort studies with the exception of one which was a pooling of data. All studies included analysed the relationship between exposure to radon and genitourinary cancer. While some studies point towards an association between radon exposure and genitourinary cancer, especially kidney cancer, others do not find such association.

CONCLUSIONS

The included studies showed great heterogeneity. It cannot be concluded that there is an association between exposure to radon and genitourinary cancer. More research is needed on this topic, designing studies with higher statistical power, better control of confounders, and preferably prospective.

Accelerated Middle Half Body Radiotherapy in Bone Metastases from Prostate Cancer: A Phase I Study (SHARON Project)

BACKGROUND/AIM

The primary endpoint of this phase I study was the maximum tolerated dose (MTD) of middle half body (MHB) accelerated radiotherapy (RT) in multiple bone metastatic (BM) prostate cancer (PCa) patients.

PATIENTS AND METHODS

Three step dose escalation [13 Gy (3.25 Gy/fraction), 14 Gy (3.5 Gy/fraction), and 15 Gy (3.75 Gy/fraction)] in three consecutive patient cohorts were planned. RT was delivered in two consecutive days and two daily fractions. Six patients were enrolled in the first two cohorts and 12 in the third cohort. Grade ≥3 toxicity was considered as a dose-limiting toxicity (DLT).

RESULTS

Twenty-five patients (median age=71 years, median follow-up=7.4 months) were enrolled. Defined MTD dose was 15 Gy. Overall pain response rate was 76%: 9 patients (36%) showed complete and 10 patients (40%) reported partial response of pain.

CONCLUSION

MHB accelerated RT (total dose: 15 Gy) delivered in two consecutive days and two daily fractions is well tolerated.

Novel Poly(Adenosine Diphosphate-Ribose) Polymerase (PARP) Inhibitor, AZD2461, Down-Regulates VEGF and Induces Apoptosis in Prostate Cancer Cells

Background

Prostate cancer (Pca) is a heterogeneous disease, and current treatments are not based on molecular stratification. Poly(adenosine diphosphate [ADP]-ribose) polymerase (PARP) inhibitors have recently been found to be remarkably toxic to cells with defects in homologous recombination, particularly cells with BRCA-mutated backgrounds. Therefore, this preliminary study was designed to evaluate whether PTEN expression status could have an impact on the sensitivity of invasive Pca cells to the PARP inhibitor, AZD2461.

Methods

MTT viability test, Annexin V‐FITC/propidium iodide double staining, and caspase3 activity assay were used to evaluate the apoptosis and relative expression of PTEN and VEGF in PC-3 and DU145 cell lines using real-time PCR.

Results

MTT results showed that the inhibitory effects of AZD2461 were higher in PC-3 than DU145 cells (with IC50 of 36.48 and 59.03 µM at 48 hours of treatment, respectively). Flow cytometric analysis also showed the same results. When exposed to 40 µM of AZD2461, PC-3 (38.8%) and DU145 (28%) cells underwent apoptosis (p < 0.05). Treatment of cells by AZD2461 also caused a significant increase in apoptosis through caspase3 activation in both cell lines. VEGF mRNA levels in PC-3 cells significantly decreased compared to adjusted untreated cells (p < 0.05) in all measured times while displaying different alteration patterns in DU145 cells (p < 0.05).

Conclusion

AZD2461 suppresses the growth of prostate tumor cells since AZD2461 monotherapy could prove to be efficacious, especially against cells not expressing PTEN besides activating the possible apoptosis-independent cell death pathways.

Is there any association between prostate-specific antigen screening frequency and uptake of active surveillance in men with low or very low risk prostate cancer?

BACKGROUND

Patient-related factors such as concern about cancer are believed to influence both men's decisions to undergo prostate specific antigen (PSA) testing and to have definitive treatment if diagnosed with low risk prostate cancer (PCa). The potential link between screening frequency and choice of active surveillance (AS) for low risk disease has not been studied previously. Our aim was to investigate whether there is any association between PCa screening frequency or previous negative prostate biopsy and uptake of AS among men with low risk PCa.

METHODS

This register-based study included all men ≤75 years from Stockholm who were diagnosed with low risk PCa from 2008 to 2014 (n = 4336). Pre-diagnostic PSA testing and biopsy histories were obtained from the Stockholm PSA and Biopsy Register, a population-based register for the Stockholm country. The association between previous screening/biopsy history and AS uptake (based on primary treatment recorded in the National Prostate Cancer Register) was examined using multivariable logistic regression.

RESULTS

Forty seven percent of men with low risk PCa underwent AS. Uptake was associated with older age, very low risk disease, more recent diagnosis and absence of family history. None of the screening/biopsy measures (testing frequency, mean interval, PSA velocity, highest pre-diagnostic PSA or prior negative biopsy) were associated with uptake of AS among men with low risk PCa. Generalisability to settings with different policies and practices may be limited.

CONCLUSION

We found no evidence that screening frequency and negative biopsy influence uptake of AS among Swedish men with low risk PCa. Further research is required to determine factors that still present barriers for men taking up AS.

[Diagnostic and therapeutic management in a series of 1156 patients with the diagnosis of prostate cancer in Castilla y Leon during 2014.]

OBJECTIVES

To evaluate the current clinical practice for patients with Prostate Cancer (CP) in the Health Areas of Castilla y León (CyL) in 2014. METHODS: A retrospective multicenter study was designed to provide data on the diagnosis and treatment of PC in CyL: 87.8% of patients were screened. Descriptive statistics on variables related to characteristics of the patient, the tumor and the treatment modality of the first line to which it was submitted are provided. RESULTS: A total of 1156 new cases of PC were analyzed with a mean age of 68.2 years and a mean PSA of 8.40 ng/ml. The Gleason score (GS) showed 538 (46.2%), 418 (35.9 %) and 200 (17.1%) patients for GS ≤ 6, 7 and  ≥ 8 respectively. 91% of patients (1053 patients) are diagnosed at a localized stage. 56 (4.8%) patients received treatment with active surveillance/ watchful waiting, 423 (36.6%) radical prostatectomy (PR), 348 (30.1%) radiotherapy (RT), 98 (8.4%) brachytherapy (BT) and 170 (14.7%) hormone therapy (HT) respectively.

CONCLUSIONS

Differed strategies still accounted for a small percentage of treatments. PR and RT/BT were of choice in patients with localized stages of the disease and younger than 70 years. More advanced stages and older patients were treated with HT mainly. Age is postulated as the main factor involved in therapeutic decision making.

Dominant intraprostatic lesion boosting in sexual-sparing radiotherapy of prostate cancer: A planning feasibility study

AIM

Radical radiotherapy of prostate cancer requires a relatively high dose to achieve an optimal tumor control probability and a reduced dose to the critical structures related to the sexual function (S_OARs) in order to avoid erectile dysfunction. The aim of this study was to perform a planning feasibility analysis of a 3-level dose prescription with Simultaneous Integrated Boost (SIB) on the dominant intraprostatic lesion (DIL) and with S_OARs sparing.

MATERIAL AND METHODS

Twelve patients with clinically localized intermediate risk prostate cancer were included. The prostate, seminal vescicles, and DIL Clinical Target Volumes were delineated on rigid fused MRI-CT simulation images using mp-MRI as a separate guide. A 5 mm margin was added to define the PTVs. Penile bulb (PB), corpora cavernosa (CC), internal pudendal arteries (IPAs) and neurovascular bundles were contoured as S_OARs. The following doses were prescribed in 25 fractions: 56.25 Gy to PTVsv, 67.50 Gy to PTVp, and 75 Gy to PTVdil. Standard plans (SD-VMAT) were created to fulfil targets coverage and Quantec constraints for conventional OARs (SD_OARs: rectum, bladder, and femoral heads). For each patient, a new "sexual-sparing" plan (SS-VMAT) was created adding new objectives for S_OARs with priority to minimize mean doses to IPAs, CC, and PB. Dose-volume histogram end points were compared between the 2 plans using Wilcoxon test.

RESULTS

D_98% were >95% of prescribed doses for all targets and techniques. No significant differences were found in sparing SD_OARs for considered metrics. Regarding S_OARs, SS_VMAT plans provided a significant reduction of the dose. Mean dose reduction for IPAs, CC, PB, and neurovascular bundles was 32.4% (11.2 Gy, p = 0.002), 22.5% (4.1 Gy, p = 0.006), 10.0% (4.6 Gy, p = 0.010), and 2.6% (1.8 Gy, p = 0.020), respectively.

CONCLUSIONS

We showed that a significant dose sparing for S_OARs using VMAT-SIB strategy is feasible allowing "sexual-sparing" and highly conformal plans with dose escalation to the DIL.

Screening: Actual trends on PSA marker. When, who, how?

Prostate cancer (PCa) is the most common non-skin malignancy among men world-wide. PCa incidence is higher among African American (AA) menin comparison to the white population. Men with a previous history of PCa in first-line relatives carry also an increased risk for this disease. The incidence of PCa diminished in United States (US) since the publication in 2012 of US Preventive Service Task Force (USPSTF), in which PCa screening was bestowed with a grade D of recommendation. Nonetheless, locally advanced andmetastatic disease rates increased notably. In 2018, the USPSTF drop back in their statement against PCa screening and recommended this to be a shared-decision between men 55-69 years old and their physicians.A side-by-side evaluation methodology of the three trials included in USPSTF review was performed. The high intensity screening modality and the lower contamination rate in the control arm found in the ERSPC trial justify theearlier splitting in the cumulative mortality curves between the screening and control arm when contrasted with the CAP and PCLO trials presented. We aim to perform an objective and critical review of the current practice on prostate cancer screening, regarding its limitations and when the physician should offer a shared-decision process screening based on PSA.The controversy over PSA screening has not ended despite unequivocal evidence that it saves lives. Although the USPSTF's 2017 new draft is a step in the right direction, there is more progress to be made concerning the identification of patients harboring high-risk tumors and, consequently, die of PCa. PSA baseline may lead us to differentiate properly patients at high-risk from those under risk of overdiagnosis and overtreatment. It is well established that mpMRI has come to help us in the diagnosis of PCa and in the identification of clinically significanttumors. Finally, studies ongoing on biomarkers may assist us to improve our understanding about this frequent malignancy.

Outcomes after salvage radical prostatectomy and first-line radiation therapy or HIFU for recurrent localized prostate cancer: results from a multicenter study

INTRODUCTION

Despite no consensus on the optimal management of recurrent prostate cancer after primary radiation or HIFU therapy, salvage prostatectomy (sRP) is reserved for only 3% of patients because of technical challenges and frequent post-operative complications. We assessed outcomes after sRP in a series of patients with localized PCa and that had received radiation therapy or HIFU as a first-line treatment.

MATERIALS AND METHODS

Data from nine French referral centers on patients treated with sRP between 2005 and 2017 were collected. Pre- and post-operative data, including oncological and functional outcomes after first treatment and sRP, were analyzed to determine the predictors for biochemical recurrence (BCR) and cancer-specific survival (CSS) after sRP.

RESULTS

First-line treatments were external beam-radiation therapy (EBRT) for 30 (55%), brachytherapy (BT) for 10 (18%), and high-intensity focused ultrasound (HIFU) for 15 (27%). Median (IQR) PSA at diagnosis was 6.4 (4.9-9.5) ng/mL, median PSA at nadir was 1.9 (0.7-3.0) ng/mL, and median (IQR) to first BCR was 13 (6-20) months. Of the 55 patients, 44 (80%) received robot-assisted salvage radical prostatectomy and 11 (20%) received salvage retropubic radical prostatectomy. Restoration of continence was achieved in 90% of preoperatively continent patients; 24% that had received nerve-sparing (NS) procedures were potent after surgery. Prolonged catheterization due to anastomotic leakage was the most common complication. Age, preoperative clinical stage, NS procedure, and a pathological Gleason score were predictors for BCR.

CONCLUSIONS

sRP was safe, feasible, and effective using either an open or robot-assisted approach, in experienced hands. Age, preoperative clinical stage, NS procedure, and pathological GS were linked with BCR after sRP.

Correlation of Androgen Deprivation Therapy with Cognitive Dysfunction in Patients with Prostate Cancer: A Nationwide Population-Based Study Using the National Health Insurance Service Database

Purpose

The purpose of this study was to evaluate the association of androgen deprivation therapy (ADT) with cognitive dysfunction.

Materials and Methods

Using the National Health Insurance Service database of the entire Korean adult prostate cancer population (n=236,391), data on ADT and cognitive dysfunction between 2008 and 2015 were analyzed. We excluded patients previously diagnosed with cognitive dysfunction, dementia, or a cerebral event history. We tested the effect of ADT on the risk of cognitive dysfunction using propensity score–matched Cox proportional hazards regression models and Kaplan-Meier survival analysis. Our final cohort comprised of 35,401 individuals with prostate cancer, including 24,567 men (70.6%) who underwent ADT.

Results

During a mean follow-up period of 4.1 years, 4,741 patients were newly diagnosed with cognitive dysfunction. A statistically significant association was found between ADT and the risk of cognitive dysfunction (hazard ratio, 1.169; p=0.002). Meanwhile, age (≥ 70 years), diabetes, hypertension, cardiovascular history, and peripheral vascular disease were identified as factors that contribute to the increased risk of cognitive dysfunction. In contrast, the use of statins and aspirin was associated with a lower risk of cognitive dysfunction. Kaplan-Meier analysis demonstrated that patients aged 70 years or older who underwent ADT had the lowest cumulative probability of remaining cognitive dysfunction-free (log-rank p < 0.001).

Conclusion

Our results revealed an association between the use of ADT for the treatment of prostate cancer and an increased risk of cognitive dysfunction in a nationwide population-based study. This finding should be further evaluated in prospective studies.

Prostate Cancer Diagnostics Using a Combination of the Stockholm3 Blood Test and Multiparametric Magnetic Resonance Imaging

BACKGROUND

More specific diagnostic for prostate cancer is needed to decrease overdetection and number of diagnostic procedures.

OBJECTIVE

To assess the performance of combining a blood-based biomarker panel and magnetic resonance imaging (MRI)-targeted biopsies for prostate cancer detection.

DESIGN, SETTING, AND PARTICIPANTS

We used a prospective, multicenter, paired diagnostic study design. A total of 532 men aged 45-74 yr referred for prostate cancer workup were included during 2016-2017.

INTERVENTION

Participants underwent blood sampling for analysis of the Stockholm3 test including protein biomarkers, genetic polymorphisms, and clinical variables; 1.5 T MRI; systematic prostate biopsies; and MRI-targeted biopsies to lesions with Prostate Imaging Reporting and Data System version 2 ≥3.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The main outcome was numbers of detected prostate cancer characterized by grade group (GG) and the number of performed biopsies using relative sensitivity (RS).

RESULTS AND LIMITATIONS

Median prostate-specific antigen was 6.3 ng/ml, and mean age was 63.9 yr. Targeted and systematic biopsies detected 170 and 162 GG ≥2 tumors, respectively (RS 1.05; 95% confidence interval [CI] 0.96-1.14). Compared with performing systematic biopsies on all men, performing targeted and systematic biopsies only on men with >10% risk of GG ≥2 cancer, as predicted by the Stockholm3 test, required 62% (95% CI 58-66) of the biopsy procedures and detected 58% (95% CI 48-70) of GG 1 disease, with increased sensitivity for GG ≥2 detection (RS 1.10; 95% CI 1.02-1.17). Performing only targeted biopsies in men with elevated Stockholm3 test altered these results only slightly. Compared with performing systematic and targeted biopsies on all men, performing this only for men with an elevated Stockholm3 test decreased detection of GG ≥2 cancer slightly (RS 0.92; 95% CI 0.88-0.95). Limitations include lacking knowledge of true disease prevalence.

CONCLUSIONS

These findings provide evidence that strategies combining the blood-based Stockholm3 test and MRI-targeted biopsies can be used to inform biopsy decision making.

PATIENT SUMMARY

In this study, 532 men coming for prostate cancer workup underwent blood sampling, and both traditional and magnetic resonance imaging/fusion-guided prostate biopsies. We report that performing targeted biopsies only in men with an elevated risk as assessed by the Stockholm3 test saved biopsies, decreased overdetection, and maintained the number of detected high-grade cancers.

Crowdsourced versus expert evaluations of the vesico-urethral anastomosis in the robotic radical prostatectomy: is one superior at discriminating differences in automated performance metrics?

Crowdsourcing from the general population is an efficient, inexpensive method of surgical performance evaluation. In this study, we compared the discriminatory ability of experts and crowdsourced evaluators (the Crowd) to detect differences in robotic automated performance metrics (APMs). APMs (instrument motion tracking and events data directly from the robot system) of anterior vesico-urethral anastomoses (VUAs) of robotic radical prostatectomies were captured by the dVLogger (Intuitive Surgical). Crowdsourced evaluators and four expert surgeons evaluated video footage using the Global Evaluative Assessment of Robotic Skills (GEARS) (individual domains and total score). Cases were then stratified into performance groups (high versus low quality) for each evaluator based on GEARS. APMs from each group were compared using the Mann-Whitney U test. 25 VUAs performed by 11 surgeons were evaluated. The Crowd displayed moderate correlation with averaged expert scores for all GEARS domains (r > 0.58, p < 0.01). Bland-Altman analysis showed a narrower total GEARS score distribution by the Crowd compared to experts. APMs compared amongst performance groups for each evaluator showed that through GEARS scoring, the most common differentiated metric by evaluators was the velocity of the dominant instrument arm. The Crowd outperformed two out of four expert evaluators by discriminating differences in three APMs using total GEARS scores. The Crowd assigns a narrower range of GEARS scores compared to experts but maintains overall agreement with experts. The discriminatory ability of the Crowd at discerning differences in robotic movements (via APMs) through GEARS scoring is quite refined, rivaling that of expert evaluators.

Psychological and functional effect of different primary treatments for prostate cancer: A comparative prospective analysis

OBJECTIVES

The aim of the study was to comparatively evaluate the psychological and functional effect of different primary treatments in patients with prostate cancer.

METHODS AND MATERIALS

We conducted a single-center prospective non randomized study in a real-life setting using functional and psychological questionnaires in prostate cancer cases submitted to radical prostatectomy, external radiotherapy, or active surveillance. Totally, 220 cases were evaluated at baseline and during the follow-up at 1-, 3-, 6-, and 12-month interval after therapy. Patients self-completed questionnaires on urinary symptoms and incontinence, erectile and bowel function, psychological distress (PD), anxiety, and depression.

RESULTS

Several significant differences among the three groups of treatment were found regarding the total score of the functional questionnaires. Regarding PD, cases submitted to radical prostatectomy showed stable scores during all the 12 months of follow-up whereas cases submitted to radiotherapy showed a rapid significant worsening of scores at 1-month interval and persistent also at 6- and 12-month interval. Cases submitted to active surveillance showed a slight and slow worsening of scores only at 12-month interval. PD and depression resulted to be more associated with urinary symptoms than sexual function worsening whereas anxiety resulted to be associated either with urinary symptoms or sexual function worsening.

CONCLUSIONS

The results of our comparative and prospective analysis could be used to better inform treatment decision-making. Patients and their teams might wish to know how functional and psychological aspects may differently be influenced by treatment choice.

Improved Recovery of Erectile Function in Younger Men after Radical Prostatectomy: Does it Justify Immediate Surgery in Low-risk Patients?

BACKGROUND

Although active surveillance is increasingly used for the management of low-risk prostate cancer, many eligible patients are still nonetheless subject to curative treatment. One argument for considering surgery rather than active surveillance is that the probability of postoperative recovery of erectile function is age dependent, that is, patients who delay surgery may lose the window of opportunity to recover erectile function after surgery.

OBJECTIVE

To model erectile function over a 10-yr period for immediate surgery versus active surveillance.

DESIGN, SETTING, AND PARTICIPANTS

Data from 1103 men who underwent radical prostatectomy at a tertiary referral center were used.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Patients completed the International Index of Erectile Function (IIEF-6) pre- and postoperatively as a routine part of clinical care. Preoperative IIEF-6 scores were plotted against age to assess the natural rate of functional decline due to aging. Reported erectile scores in the 2-yr period following surgery were used to assess post-surgical recovery.

RESULTS AND LIMITATIONS

Each year increase in patient age resulted in a 0.27 reduction in IIEF scores. In addition to IIEF reducing with increased age, the amount of erectile function that is recovered from presurgery to 12-mo postsurgery also decreases (-0.16 IIF points/yr, 95% confidence interval -0.27, -0.05, p=0.006). However, delayed radical prostatectomy increased the mean IIEF-6 score over a 10-yr period compared with immediate surgery (p=0.001), even under the assumption that all men placed on active surveillance are treated within 5 yr.

CONCLUSIONS

Small differences in erectile function recovery in younger men are offset by a longer period of time living with decreased postoperative function. Better erectile recovery in younger men should not be a factor used to recommend immediate surgery in patients suitable for active surveillance, even if crossover to surgery is predicted within a short period of time.

PATIENT SUMMARY

Younger men have better recovery of erectile function after surgery for prostate cancer. This has led to the suggestion that delaying surgery for low-risk disease may lead patients to miss a window of opportunity to recover erectile function postoperatively. We conducted a modeling study and found that predicted erectile recovery was far superior on delayed treatment because slightly better recovery in younger men is offset by a longer period of time living with poorer postoperative function in those choosing immediate surgery.

Effects of increasing the PSA cutoff to perform additional biomarker tests before prostate biopsy

Background

Multi-step testing might enhance performance of the prostate cancer diagnostic pipeline. Using PSA >1 ng/ml for first-line risk stratification and the Stockholm 3 Model (S3M) blood-test >10% risk of Gleason Score > 7 prostate cancer to inform biopsy decisions has been suggested. We aimed to determine the effects of changing the PSA cutoff to perform reflex testing with S3M and the subsequent S3M cutoff to recommend prostate biopsy while maintaining the sensitivity to detect Gleason Score ≥ 7 prostate cancer.

Methods

We used data from the prospective, population-based, paired, diagnostic Stockholm 3 (STHLM3) study with participants invited by date of birth from the Swedish Population Register during 2012–2014. All participants underwent testing with PSA and S3M (a combination of plasma protein biomarkers [PSA, free PSA, intact PSA, hK2, MSMB, MIC1], genetic polymorphisms, and clinical variables [age, family, history, previous prostate biopsy, prostate exam]). Of 47,688 men in the STHLM3 main study, we used data from 3133 men with S3M >10% and prostate biopsy data. Logistic regression models were used to calculate prostate cancer detection rates and proportion saved biopsies.

Results

44.2%, 62.5% and 67.9% of the participants had PSA <1, <1.5 and <1.7 ng/ml, respectively. Increasing the PSA cut-off for additional work-up from 1 ng/ml to 1.5 ng/ml would thus save 18.3% of the performed tests, 4.9% of the biopsies and 1.3% (10/765) of Gleason Grade ≥ 7 cancers would be un-detected. By lowering the S3M cutoff to recommend biopsy, sensitivity to high-grade prostate cancer can be restored, to the cost of increasing the number of performed biopsies modestly.

Conclusion

The sensitivity to detect prostate cancer can be maintained when using different PSA cutoffs to perform additional testing. Biomarker cut-offs have implications on number of tests and prostate biopsies performed. A PSA cutoff of 1.5 ng/ml to perform additional testing such as the S3M test might be considered.

Trial registration

ISRCTN84445406.

A randomized trial of early detection of clinically significant prostate cancer (ProScreen): study design and rationale

The current evidence of PSA-based prostate cancer screening shows a reduction in cause-specific mortality, but with substantial overdiagnosis. Recently, new developments in detection of clinically relevant prostate cancer include multiple kallikreins as biomarkers besides PSA, and multiparametric magnetic resonance imaging (mpMRI) for biopsy decision. They offer opportunities for improving the outcomes in screening, particularly reduction in overdiagnosis and higher specificity for potentially lethal cancer. A population-based randomized screening trial will be started, with 67,000 men aged 55-67 years at entry. A quarter of the men will be allocated to the intervention arm, and invited to screening. The control arm will receive no intervention. All men in the screening arm will be offered a serum PSA determination. Those with PSA of 3 ng/ml or higher will have an additional multi-kallikrein panel and those with indications of increased risk of clinically relevant prostate cancer will undergo mpMRI. Men with a malignancy-suspect finding in MRI are referred to targeted biopsies. Screening interval is 6 years for men with baseline PSA < 1.5 ng/ml, 4 years with PSA 1.5-3.0 and 2 years if initial PSA > 3. The main outcome of the trial is prostate cancer mortality, with analysis at 10 and 15 years. The statistical power is sufficient for detecting a 28% reduction at 10 years and 22% at 15 years. The proposed study has the potential to provide the evidence to justify screening as a public health policy if mortality benefit can be sustained with substantially reduced overdiagnosis.

A rare case of malignant solitary fibrous tumor in prostate with review of the literature

Background

Solitary fibrous tumor is an uncommon soft tissue neoplasm with intermediate biological behavior, which rarely metastasizes. Malignant solitary fibrous tumor, although not clearly defined, is rarely described in the prostate. The present case is characterized by some peculiarities if compared with previously reported cases of prostatic malignant solitary fibrous tumor. Firstly, it does not show a homogeneous morphology: part of the neoplasm (about 50%) showed the features of a conventional solitary fibrous tumor, while the remaining part showed the features of a malignant solitary fibrous tumor. In addition, the case is the first malignant solitary fibrous tumor reaching a huge diameter of 20 cm and replacing all prostatic parenchyma. Interestingly, normal prostatic parenchyma was observed on left-lobe trans-rectal needle-core biopsies, but was totally absent in surgical specimen. Since radical prostatectomy was carried out about 4 months after the biopsies, such discordant data may suggest exceedingly rapid growth of the neoplasm.

Case presentation

We report a case of a 62-year-old male, presented at medical observation for urinary retention, constipation and an enlarged prostate gland. A trans-rectal prostatic biopsy showed a low-grade spindle cell neoplasm. Histopathological examination of the prostatectomy specimen showed patternless architecture with hypocellular and hypercellular areas and hemangiopericytoma-like vessels. In some fields the neoplasm was characterized by a high mitotic index and evident cellular atypia. Immunohistochemically, neoplastic cells were positive for CD34, bcl2, CD99, STAT6 and partially for PgR. The neoplasm was diagnosed as a malignant solitary fibrous tumor.

Conclusions

The differential diagnosis of spindle cells tumors arising in the prostrate is broad and includes lesions of epithelial and mesenchymal origin, primary prostatic lesions such as stromal tumors of uncertain malignant potential and stromal sarcoma, as well as anatomically ubiquitous soft tissue neoplasms. Solitary fibrous tumors should be considered in cases of prostatic tumors with a spindled morphology, but malignancy in such tumors is extremely rare in the prostate. A review of literature showed only four additional cases. Because of the unpredictable biological behavior and the possibility of recurrence, a long-term clinical and instrumental follow-up is recommended.

Clinical efficacy of transrectal ultrasound-guided prostate biopsy in men younger than 50 years old with an elevated prostate-specific antigen concentration (>4.0 ng/mL)

BACKGROUND

Prostate cancer (PCa) is not commonly found in men younger than 50 years of age. However, serum prostate-specific antigen (PSA) concentration has been examined more frequently at a younger age in Asia partially due to an increased awareness of prostate cancer. The purpose of our study was to investigate the efficacy and complication of PSA-triggered transrectal ultrasonography-guided prostate (TRUSP) biopsies. We retrospectively reviewed TRUSP biopsies in young men with elevated PSA concentration in Taipei Veterans General Hospital.

METHODS

We reviewed the cases of patients younger than 50 years of age with elevated PSA concentration (>4.0 ng/mL), who received 12 cores TRUSP biopsies at TPEVGH from January 2008-December 2013. The age, family history, digital rectal examination (DRE) results, PSA concentration, free/total PSA ratio, total prostate volume, PSA density, lower urinary tract symptoms and complications after the procedure were reviewed. The pathologic findings of TRUSP biopsy and clinical follow-up were reviewed and analyzed according to the Epstein criteria.

RESULTS

A total of 77 patients were included and were divided into 2 groups: 1) the younger group consisted of 20 patients <40 years of age; and 2) the elder group had 57 patients who were 40-50 years of age. The overall detection rate of PCa was 11.69% (9/77), and all of the PCa cases were diagnosed in the elder group (group detection rate: 15.8%). There was a significant difference in the severity of lower urinary tract symptoms (LUTS) between these 2 groups. All PCa patients were clinically significant according to the Epstein criteria. Two patients experienced fever (2.60%) after TRUSP biopsy.

CONCLUSION

From our patient cohort, it appears that no benefit was apparent for patients younger than 40 years old who received TRUSP biopsy, even with elevated PSA. However, PCa detected in men between 40 and 50 years of age were all clinically significant. Overall, our results supported current major practice guidelines which recommend an initial PSA checkup at 40 years of age.

Institutional long-term outcomes at the first Canadian center performing intraoperatively planned low-dose-rate brachytherapy alone in low- and intermediate-risk prostate cancer

PURPOSE

The aim of this study is to report the long-term outcomes and toxicities from a large cohort of patients with localized prostate cancer treated with low-dose-rate intraoperatively planned brachytherapy.

METHODS AND MATERIALS

Prostate-specific antigen levels, urinary symptoms, and erectile function were recorded at baseline, and each followup visit was then entered into a prospective database. Urinary toxicity requiring procedural intervention was retrospectively verified using an integrated electronic medical system. A separate cross-sectional survey was performed to measure postimplant sexual function.

RESULTS

A total of 822 patients with low and favorable intermediate-risk prostate cancer were treated at our institution between 2003 and 2013. The Kaplan-Meier estimates for biochemical recurrence for our cohort were 95% and 87% at 5 and 10 years, respectively. Cystoscopy, transurethral resection of prostate, or dilatation was required for 7.1% of 720 patients with more than 2 years of followup. At a median followup of 3.7 years, 64.4% of patients retained adequate erectile function for intercourse, with 54% of patients who were no longer sexually active postimplant reporting social factors as the primary reason.

CONCLUSIONS

Our institutional experience with intraoperative low-dose-rate prostate brachytherapy yielded excellent long-term results with a low incidence of urinary and sexual toxicity.

Prostate-specific IL-6 transgene autonomously induce prostate neoplasm through amplifying inflammation in the prostate and peri-prostatic adipose tissue

Background

The causative role of the pro-inflammatory cytokine IL-6 in prostate cancer progression has been well established at molecular level. However, whether and how IL-6 may play a role in prostate cancer risk and development is not well defined. One limitation factor to acquiring this knowledge is the lack of appropriate animal models.

Methods

We generated a novel line of prostate-specific IL-6 transgenic mouse model. We compared the prostate pathology, tumorigenic signaling components, and prostate tumor microenvironment of the IL-6 transgenic mice with wild type littermates.

Results

With this model, we demonstrate that IL-6 induces prostate neoplasm autonomously. We further demonstrate that transgenic expression of IL-6 in the prostate activates oncogenic pathways, induces autocrine IL-6 secretion and steadily-state of STAT3 activation in the prostate tissue, upregulates paracrine insulin-like growth factor (IGF) signaling axis, reprograms prostate oncogenic gene expression, and more intriguingly, amplifies inflammation in the prostate and peri-prostatic adipose tissue.

Conclusions

The pro-inflammatory IL-6 is autonomous oncogene for the prostate. IL-6 induces prostate oncogenesis through amplifying local inflammation. We also presented a valuable animal model to study inflammation and prostate cancer development.

Electronic supplementary material

The online version of this article (doi:10.1186/s13045-016-0386-7) contains supplementary material, which is available to authorized users.

Prognostic value of inflammation in prostate cancer progression and response to therapeutic: a critical review

Prostate is an immune-competent organ normally populated by inflammatory cells. Prostatic inflammation origin can be multi-factorial and there are some emerging evidences on its possible role as a factor involved in prostate cancer (PC) pathogenesis and progression. This review critically analyzes the role of inflammation as a prognostic factor for progression and aggressiveness of PC. We verified the last 10 years literature data on the association between inflammation and PC aggressiveness, or PC response to therapies. Several studies tried to correlate different inflammatory factors with the aggressiveness and metastatization of PC; all data sustain the role of inflammation in PC progression but they also produce confusion to identify a reliable clinical prognostic marker. Data on patients submitted to radical prostatectomy (RP) showed that cases with marked intraprostatic tissue inflammation are associated with higher rate of biochemical progression; systemic inflammation markers appear to have a significant prognostic value. Analyzing data on patients submitted to radiotherapy (RT) emerges a significant association between high neuthrophil to lymphocyte ratio (NLR) and decreased progression free survival and overall survival; also plateled to lymphocyte ratio (PLR) and C-reactive protein (CRP) have been proposed as significant prognostic factors for progression and overall survival. In patients submitted to androgen deprivation therapy (ADT), inflammation may drive castration resistant PC (CRPC) development by activation of STAT3 in PC cells. NLR has been proposed as independent predictor of overall survival in CRPC submitted to chemotherapy. Most of data are focused on markers related to systemic inflammation such as NLR and CRP, more than specifically to chronic prostatic inflammation. The suggestion is that these inflammatory parameters, also if not specific for prostatic inflammation and possibly influenced by several factors other than PC, can integrate with established prognostic factors.

Technique and outcomes of bladder neck intussusception during robot-assisted laparoscopic prostatectomy: A parallel comparative trial

INTRODUCTION

Postprostatectomy incontinence significantly impairs quality of life. Although bladder neck intussusception has been reported to accelerate urinary recovery after open radical retropubic prostatectomy, its adaption to robotic surgery has not been assessed. Accordingly, we describe our technique and compare outcomes between men treated with and without bladder neck intussusception during robot-assisted laparoscopic prostatectomy.

MATERIALS AND METHODS

We performed a comparative trial of 48 men undergoing robot-assisted laparoscopic prostatectomy alternating between bladder neck intussusception (n = 24) and nonintussusception (n = 24). Intussusception was completed using 3-0 polyglycolic acid horizontal mattress sutures anterior and posterior to the bladder neck. We assessed baseline characteristics and clinicopathologic outcomes. Adjusting for age, body mass index, race, and D׳Amico risk classification, we prospectively compared urinary function at 2 days, 2 weeks, 2 months, and last follow-up using the urinary domain of the Expanded Prostate Cancer Index-Short Form.

RESULTS

Baseline patient characteristics and clinicopathologic outcomes were similar between treatment groups (P>0.05). Median catheter duration (8 vs. 8d, P = 0.125) and rates of major postoperative complications (4.2% vs. 4.2%, P = 1.000) did not differ. In adjusted analyses, Expanded Prostate Cancer Index-Short Form urinary scores were significantly higher for the intussusception arm at 2 weeks (65.4 vs. 46.6, P = 0.019) before converging at 2 months (69.1 vs. 68.3, P = 0.929) after catheter removal and at last follow-up (median = 7mo, 80.5 vs. 77.0; P = 0.665).

CONCLUSIONS

Bladder neck intussusception during robot-assisted laparoscopic prostatectomy is feasible and safe. Although the long-term effects appear limited, intussusception may improve urinary function during the early recovery period.

Factors associated with the omission of androgen deprivation therapy in radiation-managed high-risk prostate cancer

PURPOSE

Androgen deprivation therapy (ADT) has been shown to improve survival for men with unfavorable-risk prostate cancer (PCa). We investigated the utilization and factors associated with the omission of ADT in radiation-managed high-risk PCa.

METHODS AND MATERIALS

We used the National Cancer Database to identify men with National Comprehensive Cancer Network high-risk PCa treated with external beam radiation therapy (EBRT) with or without brachytherapy boost from 2004 to 2012. Multivariable logistic regression adjusting for clinical and sociodemographic factors was used to identify independent predictors for ADT use.

RESULTS

A total of 57,968 radiation-treated high-risk PCa men were included in our analysis. There were 49,363 patients (85.2%) treated with EBRT alone and 8605 patients (14.8%) treated with EBRT plus brachytherapy boost. Overall, 77% of men received ADT. In multivariable regression analysis, the use of brachytherapy boost was associated with a significantly lower utilization of ADT (70% vs. 78%; adjusted odds ratio [AOR]: 0.65; 95% CI: 0.62-0.69; p-Value <0.0001), as was treatment at an academic vs. nonacademic center (AOR: 0.90; 95% CI: 0.86-0.95; p-Value <0.0001) and treatment in 2010-2012 compared to 2004-2006 (AOR: 0.85; 95% CI: 0.81-0.90; p-Value <0.0001). Conversely, greater ADT use was seen with higher Gleason scores, PSA, and T-category (all p-Values <0.001).

CONCLUSIONS

Approximately one in four men with radiation-managed high-risk PCa do not receive ADT, which may reflect concerns about its toxicity profile despite known improvements in overall survival. Practice patterns suggest that some providers believe dose escalation through brachytherapy boost may obviate the need for ADT in some high-risk patients, but this hypothesis requires further testing.

[Prostate cancer microenvironment: Its structure, functions and therapeutic applications]

INTRODUCTION

In the field of prostate cancer there is a growing tendency for more and more studies to emphasise the predominant role of the zone situated between the tumour and the host: the tumour microenvironment. The aim of this article is to describe the structure and the functions of the prostate cancer microenvironment as well as the principal treatments that are being applied to it.

MATERIAL AND METHODS

PubMed and ScienceDirect databases have been interrogated using the association of keywords "tumour microenvironment" and "neoplasm therapy" along with "microenvironnement tumoral" and "traitements". Of the 593 articles initially found, 50 were finally included.

RESULTS

The tumour microenvironment principally includes host elements that are diverted from their primary functions and encourage the development of the tumour. In it we find immunity cells, support tissue as well as vascular and lymphatic neovascularization. Highlighting the major role played by this microenvironment has led to the development of specific treatments, notably antiangiogenic therapy and immunotherapy.

CONCLUSION

The tumour microenvironment, the tumour and the host influence themselves mutually and create a variable situation over time. Improvement of the knowledge of the prostate cancer microenvironment gradually enables us to pass from an approach centred on the tumour to a broader approach to the whole tumoral ecosystem. This enabled the emergence of new treatments whose place in the therapeutic arsenal still need to be found.

Atypical onset of bicalutamide-induced liver injury

Anti-androgen therapy is the leading treatment for advanced prostate cancer and is commonly used for neoadjuvant or adjuvant treatment. Bicalutamide is a non-steroidal anti-androgen, used during the initiation of androgen deprivation therapy along with a luteinizing hormone-releasing hormone agonist to reduce the symptoms of tumor-related flares in patients with advanced prostate cancer. As side effects, bicalutamide can cause fatigue, gynecomastia, and decreased libido through competitive androgen receptor blockade. Additionally, although not as common, drug-induced liver injury has also been reported. Herein, we report a case of hepatotoxicity secondary to bicalutamide use. Typically, bicalutamide-induced hepatotoxicity develops after a few days; however, in this case, hepatic injury occurred 5 mo after treatment initiation. Based on this rare case of delayed liver injury, we recommend careful monitoring of liver function throughout bicalutamide treatment for prostate cancer.

Is effective a prior multiparametric magnetic resonance scan in patients candidates to prostate biopsy? CAT Study

We carried out a critically appraised topic (CAT)-type study to determine whether the relevant scientific evidence supports the recommendation of doing a multiparametric magnetic resonance imaging study of the prostate in all patients who are candidates for prostate biopsy with the aim of improving the detection of clinically significant prostate cancer and stratifying patients to receive active surveillance or treatment. After a formal literature search and an analysis of the two most relevant articles it found, we reached the conclusion that, despite promising results that point to the potential usefulness of this approach, there is still not enough clear scientific evidence to endorse it categorically. Before this approach can be endorsed, we need evidence from well-designed prospective randomized trials using widely agreed upon criteria and including large numbers of patients at multiple centers.