Urinary bother, Urinalysis, and Two-Year Efficacy Follow-Up Results of Phase I Trial of Intravesical Bacillus Calmette-Guérin Combined with Intravenous Pembrolizumab in Recurrent or Persistent High-Grade Non-Muscle-Invasive Bladder Cancer after Previous Bacillus Calmette-Guérin Treatment

OBJECTIVE

To report urinary bother, urinalysis changes, disease-free survival (DFS), and overall survival (OS) over 2 years for subjects enrolled in a phase I dose-escalation trial (NCT02324582) of intravesical Bacillus Calmette-Guérin (BCG) in combination with systemic pembrolizumab for recurrent or persistent high-grade non-muscle invasive bladder cancer (HGNMIBC).

METHODS

Eighteen patients consented to the study. Five were screen failures. Clinical activity was determined using cystoscopy and cytology with a biopsy of suspicious lesions. Urinalysis and International Prostate symptom score were assessed at pre-treatment, Week 10 (during combined BCG and pembrolizumab treatment), and 3 and 6 months from treatment completion. IPSS was analyzed using a mixed-model repeated measures analysis. A Chi-square test was used to compare urinalysis results at each interval.

RESULTS

The pathologic disease stage after restaging transurethral resection and before treatment was pTa in 6 (46.2%), CIS in 6 (46.2%), and pT1 in 1 (7.7%). There was no increase in reported urinary bother throughout treatment. Quality of life measurements demonstrated no change in subjective burden. On urinalysis, we did not observe significant differences at 3 months compared to baseline evaluation. At 12 months, the DFS and OS were 69.23% and 92.31%, respectively. At 24 months, the DFS and OS were 38.46% and 92.31%, respectively.

CONCLUSIONS

Treatment with BCG combined with intravenous pembrolizumab is not showing increased urinary bother or adverse urinalysis changes. Two-year response data is promising and await confirmation in the phase III study (Keynote 676).

Complications of single-port robot-assisted radical prostatectomy: multi-institutional analysis from the Single-Port Advanced Research Consortium (SPARC)

OBJECTIVE

To evaluate the perioperative complications of single-port robot-assisted radical prostatectomy (SP-RARP).

PATIENTS AND METHODS

A retrospective review was performed on the prospectively maintained, Institutional Review Board-approved, multi-institutional Single-Port Advanced Research Consortium (SPARC) database. A total of 1103 patients were identified who underwent three different approaches of SP-RARP between 2019 and 2022 using the purpose-built SP robotic platform. In addition to baseline clinical, perioperative outcomes, this study comprehensively analysed for any evidence of intraoperative complication, as well as postoperative complication and readmission within 90 days of the respective surgery.

RESULTS

Of the 244, 712, and 147 patients who underwent transperitoneal, extraperitoneal, and transvesical SP-RARP, respectively, intraoperative complications were noted in five patients (0.4%), all of which occurred during the transperitoneal approach. Two patients had bowel serosal tears, two had posterior button-holing of the bladder necessitating repair, and one patient had an obturator nerve injury. Postoperative complications were noted in 143 patients (13%) with major complications (Clavien-Dindo Grade ≥III) only identified in 3.7% of the total cohort. The most common complications were lymphocele (3.9%), acute urinary retention (2%), and urinary tract infection (1.9%). The 90-day re-admission rate was 3.9%.

CONCLUSION

The SP-RARP is a safe and effective procedure with low complication and readmission rates regardless of the approach. These results are comparable to current multi-port RARP literature.

Low Risk of Postoperative Hernia Following Single-port Robot-assisted Radical Prostatectomy: A Report From the Single-port Advanced Research Consortium (SPARC)

OBJECTIVE

To evaluate the risk of postoperative hernia following different approaches of single-port robot-assisted radical prostatectomy (SP-RARP).

METHODS

A retrospective review was performed on patients who underwent SP-RARP between February 2019 and December 2022. Demographic and clinical information was collected from the multi-institutional, prospectively-maintained Single-Port Advanced Research Consortium (SPARC) database. Data were analyzed using IBM Statistical Packaging for Social Sciences (SPSS) version 29.0 with descriptive statistics as presented.

RESULTS

A total of 1103 patients were identified, consisting of 244 (22.1%), 712 (64.6%), and 147 (13.3%) cases performed via transperitoneal, extraperitoneal (EP), and transvesical (TV) approaches, respectively. During a median follow-up time of 11 months (interquartile range 5.7-17.1 months), only two cases of incisional hernia were reported. Both cases occurred following transperitoneal SP-RARP with one patient requiring surgical repair. There remains no evidence of postoperative hernia following EP and TV SP-RARP at the completion of our review.

CONCLUSION

SP-RARP was associated with low risk for postoperative hernia. The risk was lower following TV and EP SP-RARP where the peritoneum is preserved.

Building a Roadmap for Surveillance of Renal Masses Using a Modified Delphi Method to Help Achieve Consensus

OBJECTIVE

To establish a consensus for initial evaluation and follow-up of patients on active surveillance (AS) for T1 renal masses (T1RM).

METHODS

A modified Delphi method was used to gather information about AS of T1RM, with a focus on patient selection, timing/type of imaging modality, and triggers for intervention. A consensus panel of Michigan Urological Surgery Improvement Collaborative-affiliated urologists who routinely manage renal masses was formed. Areas of consensus (defined >80% agreement) about T1RM AS were established iteratively via 3 rounds of online questionnaires.

RESULTS

Twenty-six Michigan Urological Surgery Improvement Collaborative urologists formed the panel. Consensus was achieved for 321/587 scenarios (54.7%) administered through 124 questions. Life expectancy, age, comorbidity, and renal function were most important for patient selection, with life expectancy ranking first. All tumors <3 cm and all patients with life expectancy <1 year were considered appropriate for AS. Appropriateness also increased with elevated perioperative risk, increasing tumor complexity, and/or declining renal function. Consensus was for multiphasic axial imaging initially (contrast CT for GFR >60 or MRI for GFR >30) with first repeat imaging at 3-6 months and subsequent imaging timing determined by tumor size. Consensus was for chest imaging for tumors >3 cm initially and >5 cm at follow up. Renal biopsy was not felt to be a requirement for entering AS, but useful in several scenarios. Consensus indicated rapid tumor growth as an appropriate trigger for intervention.

CONCLUSION

Our consensus panel was able to achieve areas of consensus to help define a clinically useful and specific roadmap for AS of T1RM and areas for further discussion where consensus was not achieved.

A phase I clinical trial of oncolytic adenovirus mediated suicide and interleukin-12 gene therapy in patients with recurrent localized prostate adenocarcinoma

In a phase I dose escalation and safety study (NCT02555397), a replication-competent oncolytic adenovirus expressing yCD, TK and hIL-12 (Ad5-yCD/mutTKSR39rep-hIL-12) was administered in 15 subjects with localized recurrent prostate cancer (T1c-T2) at increasing doses (1 × 1010, to 1 × 1012 viral particles) followed by 7-day treatment of 5-fluorocytosine (5-FC) and valganciclovir (vGCV). The primary endpoint was toxicity through day 30 while the secondary and exploratory endpoints were quantitation of IL-12, IFNγ, CXCL10 and peripheral blood mononuclear cells (PBMC). The study maximum tolerated dose (MTD) was not reached indicating 1012 viral particles was safe. Total 115 adverse events were observed, most of which (92%) were grade 1/2 that did not require any treatment. Adenoviral DNA was detected only in two patients. Increase in IL-12, IFNγ, and CXCL10 was observed in 57%, 93%, and 79% patients, respectively. Serum cytokines demonstrated viral dose dependency, especially apparent in the highest-dose cohorts. PBMC analysis revealed immune system activation after gene therapy in cohort 5. The PSA doubling time (PSADT) pre and post treatment has a median of 1.55 years vs 1.18 years. This trial confirmed that replication-competent Ad5-IL-12 adenovirus (Ad5-yCD/mutTKSR39rep-hIL-12) was well tolerated when administered locally to prostate tumors.

Abstract 747: Racial differences in clinical outcome in patients treated for clinically localized prostate cancer by radical prostatectomy

Introduction: African Americans (AA) had a higher mortality from prostate cancer than Caucasian Americans (CA). The racial disparity in the outcome of prostate cancer is explained by socioeconomic factors. However, if equally accessible to standard care, whether AA with prostate cancer have an inferior outcome than CAs remains unknown. To understand the biochemical recurrence free survival (RFS) after radical prostatectomy in a racial disparity perspective, we analyzed a large cohort of patients and made important observations.

Method: AA (n=1020) and CA (n=1263) who received prostatectomy for prostate cancer were included. Their demographic and clinicopathologic characteristics were compared using the Chi-squared test and the Wilcox-rank test. RFS between AA and CA was compared using Kaplan-Meier curves with stratified log-rank test and cox-ph models. The Gleason grade across multiple biopsies was summarized by spaghetti plot and compared by linear mixed models.

Results: Compared with CA, AA were younger at the time of prostatectomy (60.5 vs 62 years), had higher pre-operative PSA levels (5.7 vs 5.3 ng/mL), were fewer with Gleason grade of 5 (7.9% vs 13.3%) and lymph node metastasis (6.1% vs 9.5%), and waited longer from biopsy to prostatectomy (3 vs 2.3 months)(all p &lt;.05). Of note, longer RFS (16 vs 15.6 years, p=0.005) and higher 5-year RFS rate (0.82 vs 0.71) were observed in AA than CA. AA had a better RFS than CA (Hazard Ratio=1.25, p=0.05) after adjusting known prognostic factors (Table 1). For those who had multiple biopsies before prostatectomy, Gleason grade increased with time for AA (0.15 per year, p=0.005), but not for CA (-0.11 per year, p=0.06).

Conclusion: Our data showed that contrary to common belief, AA had a better RFS than CA after receiving prostatectomy. This study further supported the underlying biological difference of prostate cancer between AA and CA that requires future studies to elucidate.

RFS Summary HR Race African American 1020 (44.7) - Caucasian 1263 (55.3) 1.25 (1.00-1.58, p=0.05) Pre-operative PSA (ng/mL) Mean (SD) 7.5 (9.0) 1.01 (1.01-1.02, p&lt;0.001) Tumor volume (%) Mean (SD) 14.9 (14.5) 1.01 (1.00-1.02, p=0.02) Gleason Grade Group 1 375 (16.7) - 2 1060 (47.2) 1.84 (1.05-3.22, p=0.03) 3 435 (19.4) 3.91 (2.20-6.94, p&lt;0.001) 4 129 (5.7) 4.10 (2.25-7.47, p&lt;0.001) 5 249 (11.1) 3.82 (2.10-6.96, p&lt;0.001) Tumor margins Positive 730 (32.0) 1.78 (1.43-2.13, p&lt;0.001) Lymph vascular invasion Present 274 (12.0) 1.50 (1.10-2.05, p=0.01)

Citation Format: Pin Li, Wei Zhao, Shannon Carskadon, Craig Rogers, James Peabody, Mani Menon, Dhananjay Chitale, Sean Williamson, Nilesh Gupta, Nallasivam Palanisamy. Racial differences in clinical outcome in patients treated for clinically localized prostate cancer by radical prostatectomy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 747.

Abstract 5762: New perspective on racial disparities in prostate cancer: identification of new molecular subsets using whole-mount radical prostatectomy

Introduction: Prostate cancer is a heterogenous multifocal disease. We hypothesize that different tumor foci may harbor distinct driver molecular aberrations, making it a more complex disease and difficult to manage. To avoid overlooking smaller tumor foci with clinical and biological significance, we used an innovative approach to understand the genetic underpinnings of each tumor foci based on the molecular analysis of whole-mount radical prostatectomy specimens rather than a systematic sampling of dominant nodules alone. Our study aimed to identify distinct molecular subsets of prostate cancer, if any, and correlate them with clinical outcomes in Caucasians (CA) and African Americans (AA).

Method: We randomly selected 834 whole-mount radical prostatectomy tissues including 463 (56%) CA and 371 (44%) AA. We used combined dual immunohistochemistry (IHC) for ERG and SPINK1 and dual RNA in-situ hybridization (ISH) for ETV1 and ETV4. The racial disparity in aberrant oncogene expression was analyzed by the Chi-squared test. The recurrence-free survival (RFS) of patients with distinct molecular subsets of prostate cancer was examined by the Kaplan-Meier method and cox-ph models. The Gleason’s grades of prostate biopsies were summarized by spaghetti plot and compared by linear mixed models.

Results: Patients with localized prostate cancer expressing none, one, two, and three of four oncogenes were 16.4%, 58.4%, 21.7%, and 3.5%, respectively. The expression of ERG and SPINK1 was negatively correlated (odds ratio (OR)=0.38, 95% CI 0.29-0.51, p&lt;.001). Compared with CA, AA had a lower incidence of ERG (38.8% vs 60.3%), a higher incidence of SPINK1 (63.3% vs 35.6%), and similar incidences of ETV1 (9.4% vs 9.3%) and ETV4 (4.6% vs 3.9%). Importantly, ETV1 expression was associated with a worse RFS in CAs (hazard ratio (HR)=2.49, 95% CI 1.15-5.38, p=.02). ETV4 expression was associated with a worse RFS in AA (HR=3.11, 95% CI 1.32-8.04, p=.01). In addition, ETV4 expression was associated with lymph node metastasis in AA (OR=4.0, 95% CI 1.06-12.44, p=.02) but not in CA (OR=0.56, 95% CI 0.03-2.85, p=.57). For those who had multiple biopsies before radical prostatectomy, Gleason’s grade increased with time in AA (0.23 per year, p&lt;.001) but was unchanged in CA. ERG expression was associated with a lower Gleason grade (-0.20, p=.03). ETV4 was associated with a higher Gleason grade (0.50, p=.02).

Conclusion: Our findings showed the molecular heterogeneity between CA and AA who had localized prostate cancer, and supported ETV1 and ETV4 as prognostic markers that can be incorporated into clinical practice to better predict prostate cancer recurrence after radical prostatectomy in CA and AA, respectively.

Citation Format: Wei Zhao, Pin Li, Shannon Carskadon, Craig Rogers, James Peabody, Mani Menon, Dhananjay Chitale, Sean Williamson, Nilesh Gupta, Nallasivam Palanisamy. New perspective on racial disparities in prostate cancer: identification of new molecular subsets using whole-mount radical prostatectomy. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5762.

Strengthening personalized norm feedback interventions: The ambivalent-attitude effect

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Personalized norm feedback effectively reduces heavy drinking in college students.

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Inducing ambivalence makes norms a stronger predictor of behavior.

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We predicted that ambivalence before the PNF would lower alcohol intentions.

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Ambivalent Ps intended to drink less re compared to those low in ambivalence.

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Ambivalence should be included in personalized norm feedback interventions.

This study investigated the effect of induced attitude ambivalence on the relationship between the personalized norm feedback (PNF) intervention and heavy drinking by college students. College students consume more alcohol and engage in binge drinking at greater rates than most segments of the population. Given the harmful effects of binge drinking and other risky drinking behaviors, it is important to implement effective interventions to reduce alcohol consumption. PNF is an effective intervention for reducing heavy drinking where students compare their drinking and perceptions of normative drinking with actual drinking norms. Past research suggests that inducing ambivalence makes norms a stronger predictor of behavior. We hypothesized that induced attitudinal ambivalence before the PNF intervention would lower intentions to consume alcohol. This study was a one-way design with ambivalence about drinking (high vs low) as the independent variable and intentions to drink alcohol in the future as the dependent variable (N = 338, 76 % female, M_age = 19.76, SD = 2.61). All participants received the PNF intervention after the ambivalence manipulation and before the intentions to drink alcohol measure. Results from the generalized linear model revealed a significant effect for ambivalence, p =.028. As predicted, participants in the high ambivalence condition intended to drink fewer drinks in one sitting in the future compared to those in the low ambivalence condition. These results suggest that ambivalence may play an important role in make PNF interventions more effective, though more research is necessary to untangle the relationship between ambivalence and norms.

Association of request for opioid medications refill after hospital discharge with race in patients with prostate cancer treated with robotic-assisted laparoscopic radical prostatectomy

BACKGROUND AND OBJECTIVE

Request for refills of opioids is one of the indicators of possible misuse. We aimed to investigate racial variations in request for refills of opioids after hospital discharge from robotic-assisted laparoscopic radical prostatectomy (RALP).

METHODS

We conducted a retrospective study of a contemporary cohort of patients treated with RALP for prostate cancer and post-operative standardized pain control that employed nonopioid medications. Patients' request for refills of opioids (within 30 days) after discharge was examined, accounting for race, age, pain control after surgery, alcohol intake, marijuana consumption, pre-existing behavioral health diagnoses, and pre-existing chronic pain disorders using multivariate analysis. p-Value of < 0.05 was considered significant.

RESULTS

We included a total of 282 adult patients in this study. African Americans (AA) patients comprised 24.5 percent of our post-prostatectomy individuals. Of the total cohort, 94.3 percent of patients reported adequate pain control in the hospital after surgery, and only 5.7 percent requested refills of opioid medications after discharge. No racial variations in request of refills were identified. Only pre-existing chronic pain disorders were found to be a significant predictor of requesting an opioid medication refill for pain control after discharge from the hospital.

CONCLUSIONS

A combination of minimally invasive surgery and nonopioid heavy pain management leads to low level of post-hospital discharge request for refills of opioid medication in patients treated with RALP across racial groups. Awareness and better control of chronic pain perioperatively are needed to ensure better postdischarge pain control.

Development and Validation of Dynamic Multivariate Prediction Models of Sexual Function Recovery in Patients with Prostate Cancer Undergoing Radical Prostatectomy: Results from the MUSIC Statewide Collaborative

Background

Radical prostatectomy (RP) is the most common definitive treatment for men with intermediate-risk prostate cancer and is frequently complicated by erectile dysfunction.

Objective

To develop and validate models to predict 12- and 24-month post-RP sexual function.

Design, setting, and participants

Using Michigan Urological Surgery Improvement Collaborative (MUSIC) registry data from 2016 to 2021, we developed dynamic, multivariate, random-forest models to predict sexual function recovery following RP. Model factors (established a priori) included baseline patient characteristics and repeated assessments of sexual satisfaction, and Expanded Prostate Cancer Index Composite 26 (EPIC-26) overall scores and sexual domain questions.

Outcome measurements and statistical analysis

We evaluated three outcomes related to sexual function: (1) the EPIC-26 sexual domain score (range 0–100); (2) the EPIC-26 sexual domain score dichotomized at ≥73 for “good” function; and (3) a dichotomized variable for erection quality at 12 and 24 months after RP. A gradient-boosting decision tree was used for the prediction models, which combines many decision trees into a single model. We evaluated the performance of our model using the root mean squared error (RMSE) and mean absolute error (MAE) for the EPIC-26 score as a continuous variable, and the area under the receiver operating characteristic curve (AUC) for the dichotomized EPIC-26 sexual domain score (SDS) and erection quality. All analyses were conducted using R v3.6.3.

Results and limitations

We identified 3983 patients at 12 months and 2494 patients at 24 months who were randomized to the derivation cohort at 12 and 24 months, respectively. Using baseline information only, our model predicted the 12-month EPIC-26 SDS with RMSE of 24 and MAE of 20. The AUC for predicting EPIC-26 SDS ≥73 (a previously published threshold) was 0.82. Our model predicted 24-month EPIC-26 SDS with RMSE of 26 and MAE of 21, and AUC for SDS ≥73 of 0.81. Inclusion of post-RP data improved the AUC to 0.91 and 0.94 at 12 and 24 months, respectively. A web tool has also been developed and is available at https://ml4lhs.shinyapps.io/askmusic_prostate_pro/.

Conclusions

Our model provides a valid way to predict sexual function recovery at 12 and 24 months after RP. With this dynamic, multivariate (multiple outcomes) model, accurate predictions can be made for decision-making and during survivorship, which may reduce decision regret.

Patient summary

Our prediction model allows patients considering prostate cancer surgery to understand their probability before and after surgery of recovering their erectile function and may reduce decision regret.

Machine learning-based prediction of upgrading on magnetic resonance imaging targeted biopsy in patients eligible for active surveillance

OBJECTIVE

To examine the ability of machine learning methods to predict upgrading of Gleason score on confirmatory magnetic resonance imaging-guided targeted biopsy (MRI-TB) of the prostate in candidates for active surveillance.

SUBJECTS AND METHODS

Our database included 592 patients who received prostate multiparametric magnetic resonance imaging in the evaluation for active surveillance. Upgrading to significant prostate cancer on MRI-TB was defined as upgrading to G 3+4 (definition 1 - DF1) and 4+3 (DF2). Machine learning classifiers were applied on both classification problems DF1 and DF2.

RESULTS

Univariate analysis showed that older age and the number of positive cores on pre-MRI-TB were positively correlated with upgrading by DF1 (P-value ≤ 0.05). Upgrading by DF2 was positively correlated with age and the number of positive cores and negatively correlated with body mass index. For upgrading prediction, the AdaBoost model was highly predictive of upgrading by DF1 (AUC 0.952), while for prediction of upgrading by DF2, the Random Forest model had a lower but excellent prediction performance (AUC 0.947).

CONCLUSION

We show that machine learning has the potential to be integrated in future diagnostic assessments for patients eligible for AS. Training our models on larger multi-institutional databases is needed to confirm our results and improve the accuracy of these models' prediction.

Prostate Cancer with Peritoneal Carcinomatosis: A robotic-assisted radical prostatectomy-based Case Series

OBJECTIVE

To aid in the diagnosis and treatment of patients with metastatic tumor seeding, an exceedingly phenomenon following minimally invasive urological surgery, additional case reports are needed.

MATERIALS AND METHODS

We report our experience with patients determined to have peritoneal carcinomatosis following robotic-assisted radical prostatectomy (RARP) and provide a descriptive summary of these unique cases.

RESULTS

Five cases of peritoneal carcinomatosis were identified, all of which occurred relatively late - between 8-13 years - following RARP. Four of the five cases had T3 disease at the time of prostatectomy. ⁶⁸Ga-PSMA PET identified peritoneal carcinomatosis in three of five cases.

CONCLUSIONS

Certain clinical factors, such as advanced pathologic stage at the time of prostatectomy, may predict risk for carcinomatosis following RARP. Additionally, next generation imaging modalities, such as PSMA PET, may aid in identifying these metastases and are likely to identify increasing numbers of these patients as next generation imaging becomes more widely available. Continued documentation and classification of this atypical presentation are needed to improve our understanding and management of this phenomenon.

Utilizing lesion diameter and prostate specific antigen density to decide on magnetic resonance imaging guided confirmatory biopsy of prostate imaging reporting and data system score three lesions in African American prostate cancer patients managed with active surveillance

OBJECTIVE

The objective of the study is to identify the rate of significant prostate cancer (PCa) detection in PI-RADS3 lesions in AA patients stratified by PSAD threshold of < 0.15 vs. ≥ 0.15 ng/ml² and lesion diameter of < 1 cm vs ≥ 1 cm.

METHODS

We analyzed our institutional database of MRI-TB to identify the rate of significant prostate cancer (PCa) detection in PI-RADS3 lesions in AA patients stratified by PSAD threshold of < 0.15 vs. ≥ 0.15 ng/ml² and lesion diameter of < 1 cm vs ≥ 1 cm. Significant prostate cancer was defined as Gleason grade group 2 or higher on MRI-TB of the PI-RADS 3 lesion.

RESULTS

Of 768 patients included in the database, 211 (27.5%) patients identified themselves as AAs. Mean age of AA patients was 63 years and mean PSAD was 0.21. Sixty nine (32.7%) AA patients were found to have PI-RADS 3 lesions. Mean PSAD of AA patients with PI-RADS 3 lesions was 0.21 ng/ml² as well. Fifty percent of AA patients with PI-RADS 3 lesions had PSAD ≥ 0.15 ng/ml². Significant PCa detection rate for AA patients with PI-RADS 3 lesions was 9% for PSAD of ≥ 0.15 vs. 0.03% percent for AA patients with PSAD < 0.15 ng/ml² (OR 7.056, CI 1.017-167.9, P = 0.04). Stratification by lesion diameter (< 1 cm vs. > 1 cm) resulted in missing 0% of significant PCa when only AA patients with PSAD ≥ 0.15 ng/ml² and lesion diameter ≥ 1 cm received MRI-TB.

CONCLUSIONS

We report on the performance of a reported PSAD density threshold in detecting significant PCa in one of the largest series of AA patients receiving MRI-TB of the prostate. Our results have direct clinical implications when counseling AA patients with PI-RADS 3 lesion on whether they should undergo MRI-TB of such lesions.

Impact of neoadjuvant chemotherapy on survival and recurrence patterns after robot-assisted radical cystectomy for muscle-invasive bladder cancer: Results from the International Robotic Cystectomy Consortium

OBJECTIVES

To analyze the impact of neoadjuvant chemotherapy on survival and recurrence patterns in muscle-invasive bladder cancer after robot-assisted radical cystectomy.

MATERIALS AND METHODS

The International Robotic Cystectomy Consortium database was reviewed to identify patients who underwent robot-assisted radical cystectomy for muscle-invasive bladder cancer between 2002 and 2019. Survival outcomes, response rates, and recurrence patterns were compared between patients who received neoadjuvant chemotherapy and those who did not. Survival distributions were estimated using Kaplan-Meier analyses and compared using the log-rank test.

RESULTS

A total of 1370 patients with muscle-invasive bladder cancer were identified, of whom 353 (26%) received neoadjuvant chemotherapy. After a median follow-up of 27 months, neoadjuvant chemotherapy recipients had higher 3-year overall survival (74% vs 57%; log-rank P < 0.01), 3-year cancer-specific survival (83% vs 73%; log-rank P = 0.03), and 3-year relapse-free survival (64% vs 48%; log-rank P < 0.01). Neoadjuvant chemotherapy was a predictor of higher overall survival, cancer-specific survival, and relapse-free survival in univariate but not multivariate analysis. Pathological downstaging (46% vs 23%; P < 0.01), complete responses (24% vs 8%; P < 0.01), and margin negativity (95% vs 91%; P < 0.01) at robot-assisted radical cystectomy were more common in the neoadjuvant chemotherapy group. Neoadjuvant chemotherapy recipients had lower distant (15% vs 22%; P < 0.01) but similar locoregional (12% vs 13%; P = 0.93) recurrence rates.

CONCLUSIONS

In this analysis from a large international database, patients with muscle-invasive bladder cancer who received neoadjuvant chemotherapy before robot-assisted radical cystectomy had higher rates of survival, pathological downstaging, and margin-negative resections. They also experienced fewer distant recurrences.

Patient- and Surgeon-Level Variation in Patient-Reported Sexual Function Outcomes Following Radical Prostatectomy Over 2 Years: Results From a Statewide Surgical Improvement Collaborativep

Importance

Of patient-reported outcomes for individuals undergoing radical prostatectomy, sexual function outcomes are among the most reported and the most detrimental to quality of life. Understanding variations at the patient and surgeon level may inform collaborative quality improvement.

Objective

To describe patient- and surgeon-level sexual function outcomes for patients undergoing radical prostatectomy in the Michigan Urological Surgery Improvement Collaborative (MUSIC) and to examine the correlation between surgeon case volume and sexual function outcomes.

Design, Setting, and Participants

This is a prospective cohort study using the MUSIC registry and patient-reported sexual function outcome data. Patient- and surgeon-level variation in sexual function outcomes were examined among patients undergoing radical prostatectomy from May 2014 to August 2019. Sexual function outcome data were collected using validated questionnaires, which were completed before surgery and at 3, 6, 12, and 24 months' follow-up following surgery. All participants were male. Race and ethnicity data were self-reported and were included to examine potential variation in outcomes by race and/or ethnicity. Data were analyzed from January 2021 to March 2021.

Main Outcomes and Measures

There were 4 outcomes in this study, including the 26-item Expanded Prostate Cancer Index Composite (EPIC-26) sexual function scores at 3, 6, 12, and 24 months' follow-up; patient-level sexual function recovery at 12- and 24-month follow-up; surgeon-level variation in sexual function outcomes at 12- and 24-month follow-up; and correlation between surgeon case volume and sexual function outcomes.

Results

A total of 1426 male patients met inclusion criteria for this study. The median (IQR) age was 64 (58-68) years. A total of 115 participants (8%) were Black, 1197 (84%) were White, 25 (2%) were of another race or ethnicity (consolidated owing to low numbers), and 89 (6%) were of unknown race or ethnicity. Among patients undergoing bilateral nerve-sparing radical prostatectomy, mean (SD) EPIC-26 sexual function scores at 12- and 24-month follow-up (12 months, 39 [28]; 24 months, 63 [29]) did not return to baseline levels. There was wide variation in EPIC-26 sexual function scores at both 12-month follow-up (range, 23-69; P < .001) and 24-month follow-up (range, 27-64; P < .001). Similar variations were found in EPIC-26 sexual function scores and recovery of sexual function by surgeon. Recovery rates ranged from 0% to 40% of patients at 12-month follow-up (18 surgeons; P < .001) and 3% to 44% of patients at 24-month follow-up (12 surgeons; P < .001). Surgeon case volume and sexual function outcomes were not significantly correlated. On multivariable analysis, the following variables were associated with better recovery at 24-month follow-up: younger age (P < .001), lower baseline EPIC-26 sexual function score (P < .001), lower Gleason score (P = .05), and nonobesity (P = .03).

Conclusions and Relevance

In this study, there was significant patient- and surgeon-level variation in sexual function recovery over 2 years following radical prostatectomy. Variation in surgeon-level sexual function outcomes presents an opportunity and model for surgical collaborative quality improvement.

Evaluation of Patient- and Surgeon-Specific Variations in Patient-Reported Urinary Outcomes 3 Months After Radical Prostatectomy From a Statewide Improvement Collaborative

Importance

Understanding variation in patient-reported outcomes following radical prostatectomy may inform efforts to reduce morbidity after this procedure.

Objective

To describe patient-reported urinary outcomes following radical prostatectomy in the diverse practice settings of a statewide quality improvement program and to explore whether surgeon-specific variations in observed outcomes persist after accounting for patient-level factors.

Design, Setting, and Participants

This prospective population-based cohort study included 4582 men in the Michigan Urological Surgery Improvement Collaborative who underwent radical prostatectomy as primary management of localized prostate cancer between April 2014 and July 2018 and who agreed to complete validated questionnaires prior to surgery and at 3, 6, and 12 months after surgery. Data were analyzed from 2019 to June 2019.

Exposures

Radical prostatectomy.

Main Outcomes and Measures

Patient- and surgeon-level analyses of patient-reported urinary function 3 months after radical prostatectomy. Outcomes were measured using validated questionnaires with results standardized using previously published methods. Urinary function survey scores are reported on a scale from 0 to 100 with good function established as a score of 74 or higher.

Results

For the 4582 men undergoing radical prostatectomy within the Michigan Urological Surgery Improvement Collaborative who agreed to complete surveys, mean (SD) age was 63.3 (7.1) years. Survey response rates varied: 3791 of 4582 (83%) responded at baseline, 3282 of 4137 (79%) at 3 months, 2975 of 3770 (79%) at 6 months, and 2213 of 2882 (77%) at 12 months. Mean (SD) urinary function scores were 88.5 (14.3) at baseline, 53.6 (27.5) at 3 months, 68.0 (25.1) at 6 months, and 73.7 (23.0) at 12 months. Regression analysis demonstrated that older age, lower baseline urinary function score, body mass index (calculated as weight in kilograms divided by height in meters squared) of 30 or higher, clinical stage T2 or higher, and lack of bilateral nerve-sparing surgery were associated with a lower probability of reporting good urinary function 3 months after surgery. When evaluating patients with good baseline function, the rate at which individual surgeons' patients reported good urinary function 3 months after surgery varied broadly (0% to 54.5%; P < .001). Patients receiving surgery from top-performing surgeons were more likely to report good 3-month function. This finding persisted after accounting for patient risk factors.

Conclusions and Relevance

In this study, patient- and surgeon-level urinary outcomes following prostatectomy varied substantially. Documenting surgeon-specific variations after accounting for patient factors may facilitate identification of surgical factors associated with superior outcomes.

Evaluation of lymphovascular invasion as a prognostic predictor of overall survival after radical prostatectomy

OBJECTIVE

To assess the prognostic ability of lymphovascular invasion (LVI) as a predictor of overall survival (OS).

MATERIALS AND METHODS

We included 126,682 prostate cancer (CaP) cM0 patients who underwent radical prostatectomy with lymph node dissection between 2010 and 2015, within the National Cancer Database. Patients who received androgen deprivation therapy were included. Patients were divided into four sub-cohorts based on LVI and lymph node invasion (LNI) status: pL₀N₀, pL₁N₀, pL₀N₁, and pL₁N₁. Kaplan-Meier curves estimated OS and Cox-regression analysis tested the relationship between LVI and OS.

RESULTS

Median (IQR) age and PSA at diagnosis were 62 (57-66) years and 5.7 (4.5-8.9) ng/ml, respectively. Most patients had pT2 stage (68.5%), and pathological Gleason 3+4 (46.7%). 10.0% and 4.0% patients had LVI and LNI, respectively. Median follow-up was 42 months (27-58). At 5-years, OS was 96.5% in pL₀N₀ patients vs 93.1% pL₁N₀ patients vs 93.3% in pL₀N₁ patients vs 86.6% pL₁N₁ patients. LVI was an independent predictor of OS (hazard ratio [HR]:1.28). LVI showed interaction with LNI, as LVI was associated with a higher overall-mortality in patients with LNI (HR:1.66), than in patients without LNI (HR:1.22). (all P<0.0001) CONCLUSIONS: Our report highlights the detrimental impact of LVI on OS. Patients with LVI alone fared similarly to patients with LNI alone. Patients with both LVI and LNI had worse OS than those with only LVI or LNI, implying a synergetic detrimental interaction. Our findings demonstrate an important utility that LVI can provide in deciding patients' prognoses.

Post Prostatectomy Pathologic Findings of Patients With Clinically Significant Prostate Cancer and no Significant PI-RADS Lesions on Preoperative Magnetic Resonance Imaging

OBJECTIVES

We present postprostatectomy pathology results from a series of prostate cancer (Pca) Gleason grade group ≥2 patients who did not have findings suggestive of cancer on preoperative pelvic magnetic resonance imaging (MRI).

METHODS

We performed an institutional retrospective study of prostate magnetic resonance imaging (MRI) examinations done from October 2015 to February 2018. We identified patients who underwent prostatectomy for Pca Gleason ≥3 + 4 diagnosed on prostate biopsy with no associated MRI findings suggestive of malignancy and analyzed their postprostatectomy pathologic findings and MRI imaging results.

RESULTS

At our institution, 850 men with Pca received MRI between 2015 and 2018, and 156/850 patients received robotic-assisted radical prostatectomy. Thirty-three patients (33/156 = 21%) had negative MRI for PIRAD 3 or greater but had a biopsy showing significant Pca. Their mean (range) age was 62.7 (50-86) years. Their median (interquartile range) PSA, and PSA density were, 4.6 (3.7) ng/mL and 0.12 (0.05) ng/mL/cm², respectively; all not significantly different from patients with visible lesions on MRI who underwent surgery. On post prostatectomy pathology, 27/33 (82%) men had Pca Gleason score 7 or greater. The most common pattern was infiltrative growth with cancer glands intermingling between benign glands.

CONCLUSION

We describe the pathologic and imaging findings in an extensive series of men with clinically significant Pca with no significant lesions on preoperative MRI. Our results support the importance of patient counseling on the risk of missing significant Pca on MRI in isolation from other clinical variables.

Abstract A113: Comprehensive molecular mapping of prostate cancer- Approaching health disparities in molecular tumor heterogeneity perspective

Prostate cancer (PCa) is a heterogeneous disease and the diverse clinical outcomes may be associated with hitherto unidentified tumor molecular heterogeneity. In the era of precision medicine, new approaches to identify distinct molecular subsets of tumors may lead to the development of targeted treatment options. Given the disparity in the disease progression between African American (AA) and Caucasian American (CA) patients, understanding the existence of distinct molecular subtypes between the two racial groups may facilitate effective cancer management. Therefore, we carried out a comprehensive molecular analysis using prostate cancer-specific molecular markers, including ERG, ETV1, ETV4, ETV4, ETV5 and SPINK1, to study tumor molecular heterogeneity in a large cohort of AA and CA PCa patients. A total of 1,117 PCa cases comprising 575 (52%) CA and 453 (41%) AA patients were included in this study. Dual IHC for ERG/SPINK1 and RNA ISH for ETV1, ETV4 and ETV5 were carried out on whole mount prostatectomy specimens. Incidence of markers in each tumor foci, difference between the two racial groups, and the association of the markers with the clinical and pathologic findings in each racial group were analyzed. Independent clonal origin of tumor foci in patients with multifocal disease were observed with the presence of dual and triple marker positivity in dominant and/or secondary tumor foci. ERG was more frequently overexpressed among CA patients (P=0.0000) while SPINK1 was more prevalent among AA patients (P=0.0000). The incidence of dual marker positive cases for ERG+/SPINK1+ and SPINK1+/ETV1+ were more prevalent among AA patients than CA patients (P=0.0124 and P=0.0417, respectively). In both CA and AA patients, ERG overexpression is associated with young men age lower than 50 and a positive perineural invasion,(CA; P=0.0037 and P=0.0199, respectively; AA; P= 0.0338 and P=0.0309, respectively). Among CA patients, ERG overexpression also associated with a lower Gleason grade group (group 1 and 2, P=0.0483). SPINK1 overexpression associated with grade group lower than 5 and a negative family history among AA patients (P=0.0003 and P=0.0063). In CA patients, SPINK1 overexpression associated with grade group higher than 1, pT3 stage and tumor volume larger than 10% (P= 0.0036, P=0.0426 and P=0.0377, respectively). ETV1 overexpression is associated with positive family history (P=0.0043) and ETV4 overexpression associated with a tumor volume of 1-10% (P=0.0385) in CA patients. In AA patients, ETV4 expression associated with an age higher than 70 (P=0.0212). ERG/SPINK1 overexpression associated with grade group 2, tumor volume of 10-20%, and an age lower than 70 among CA patients (P=0.0013, P=0.0316, and P=0.0191, respectively). AA patients, on the other hand, showed an association between ERG/SPINK1 and age group lower than 40 (P=0.0092). We will discuss the details on the identification of new molecular subsets of PCa with clonal molecular heterogeneity in racial disparity perspective.

Citation Format: Shannon Carskadon, Mireya Diaz-Insua, Nilesh Gupta, Sean Williamson, Craig Rogers, James Peabody, Mani Menon, Nallasivam Palanisamy. Comprehensive molecular mapping of prostate cancer- Approaching health disparities in molecular tumor heterogeneity perspective [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A113.

Managing Urology Consultations During COVID-19 Pandemic: Application of a Structured Care Pathway

Objective

To describe and evaluate a risk-stratified triage pathway for inpatient urology consultations during the SARS-CoV-2 (COVID-19) pandemic. This pathway seeks to outline a urology patient care strategy that reduces the transmission risk to both healthcare providers and patients, reduces the healthcare burden, and maintains appropriate patient care.

Materials and Methods

Consultations to the urology service during a 3-week period (March 16 to April 2, 2020) were triaged and managed via one of 3 pathways: Standard, Telemedicine, or High-Risk. Standard consults were in-person consults with non COVID-19 patients, High-Risk consults were in-person consults with COVID-19 positive/suspected patients, and Telemedicine consults were telephonic consults for low-acuity urologic issues in either group of patients. Patient demographics, consultation parameters and consultation outcomes were compared to consultations from the month of March 2019. Categorical variables were compared using Chi-square test and continuous variables using Mann-Whitney U test. A P value <.05 was considered significant.

Results

Between March 16 and April 2, 2020, 53 inpatient consultations were performed. By following our triage pathway, a total of 19/53 consultations (35.8%) were performed via Telemedicine with no in-person exposure, 10/53 consultations (18.9%) were High-Risk, in which we strictly controlled the urology team member in-person contact, and the remainder, 24/53 consultations (45.2%), were performed as Standard in-person encounters. COVID-19 associated consultations represented 18/53 (34.0%) of all consultations during this period, and of these, 8/18 (44.4%) were managed successfully via Telemedicine alone. No team member developed COVID-19 infection.

Conclusion

During the COVID-19 pandemic, most urology consultations can be managed in a patient and physician safety-conscious manner, by implementing a novel triage pathway.

Abstract 915: Pseudogene-associated recurrent gene fusion in prostate cancer

Pseudogenes are a class of non-coding genes that are dysfunctional relatives of known functional genes. Often considered as junk DNA, pseudogenes have recently emerged as functional units in the form of non-coding RNA transcripts and micropeptides with regulatory roles in gene expression. Notably, association of some pseudogenes with oncogenes and tumor suppressor genes have been observed, indicating a possible role in cancer formation. Although many genetic aberrations in prostate cancer (PCa) have been identified, the expression of pseudogenes in PCa has not been well explored. We surveyed the transcriptional landscape of pseudogenes using next generation paired-end sequencing data and observed the formation of a recurrent gene fusion by trans-splicing event between a protein coding gene KLK4 and a noncoding pseudogene KLKP1 and its cognate fusion protein. RNA in situ analysis of 649 cases using tissue microarray identified high Gleason grade specific expression (&gt;6) in 24% of cases compared to benign, high grade prostate intraepithelial neoplasia and atypical lesions, confirming cancer specific expression and with significantly high expression in Caucasian American compared with African American PCa. Furthermore, KLK4-KLKP1 expression was seen to be associated with ERG+ and ETV1+ cases. However, no association was observed with SPINK1+, ETV4+ and ETV5+ tumors, suggesting mutually exclusive expression with distinct PCa markers. Using expression constructs transfected into RWPE, PrEc and HEK293 cells, we confirmed the expression of a ~15 KD KLK4-KLKP1 fusion protein. RT-PCR analysis of 33 PCa derived xenografts identified 15 with endogenous expression of KLK4-KLKP1 fusion transcript. We generated a polyclonal antibody using antigenic peptide from the pseudogene part of the fusion protein and confirmed its specificity by western blot analysis using cell lysates from RWPE, PrEc, HEK293 and PDX models with and without the fusion gene. Immunohistochemistry analysis also confirmed the specificity of the antibody to the fusion protein. To explore the oncogenic properties of KLK4-KLKP1, we analyzed the effects on cell proliferation and invasion using RWPE cells transfected with KLK4-KLKP1. Increased cell proliferation and invasion was observed and Chicken chorioallantoic membrane (CAM) assay also revealed increased cell migration to lower CAM suggesting a role for KLK4-KLKP1 in cancer development. Notably, KLK4-KLKP1 transcripts could be detected in urine samples obtained from PCa patients, indicating the potential for noninvasive detection for early diagnosis. Taken together, we showed the oncogenic role of a new recurrent gene fusion in prostate cancer. In conclusion, our study highlights the underexplored functional roles of pseudogenes and establishes KLK4-KLKP1 as a novel player in PCa development with potential uses as a biomarker and a therapeutic target.

Citation Format: Balabhadrapatruni V. S. K. Chakravarthi, Shanker Kalyana-Sundaram, Pavithra D. Arachchige, Shannon Carskadon, Satya S. Pathi, Mireya Diaz-Insua, Craig Rogers, James Peabody, Clara Hwang, Mani Menon, Sean Williamson, Gupta Nilesh, Sooryanarayana Varambally, Nallasivam Palanisamy. Pseudogene-associated recurrent gene fusion in prostate cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 915.

Abstract 4693: Evaluation of prostate tumor molecular heterogeneity using whole mount radical prostatectomy by dual immunohistochemistry and dual RNA in situ hybridization

Prostate cancer (PCa) remains the second most common cancer among American men. Morphological heterogeneity in prostate cancer is well recognized, however, recent investigations revealed molecular heterogeneity with the existence of unique molecular aberrations among patient sub groups. Molecular heterogeneity may be associated with distinct routes of disease progression, thereby, enabling the use of molecular profiling to facilitate targeted therapy. Importantly, African Americans (AA) are known to develop more aggressive forms of PCa compared to Caucasian Americans (CA). Therefore, the identification of distinct molecular profiles between the two groups may lead to more precise treatment options for PCa patients. Given that a comprehensive molecular mapping, encompassing both AA and CA patients is lacking, we carried out an extensive profiling of multiple molecular markers in a large cohort of AA and CA PCa patients. Whole-mounted post-prostatectomy tissues were obtained from 1117 patients who underwent radical prostatectomy surgery at our institute. The selected cases included 575 (52%) CA and 453 (41%) AA patients. The presence of ERG, SPINK1, ETV1, ETV4 and ETV5 was evaluated using dual IHC and dual RNA ISH. The racial disparity in the molecular marker incidence was analyzed. The incidence of ERG was observed in 52.0% (436/839) of cases while SPINK1 incidence occurred in 45.1% (378/838) cases. The incidence of other ERG family rearrangements, ETV1, ETV4 and ETV5 was low with 9.9% (78/791), 3.8 % (28/733) and 0.6% (2/350) cases respectively. A total of 260 cases showed the incidence of multiple markers on a single prostate. Of these, ERG+/SPINK1+ was prominent with an incidence of 18% (151/838), followed by ERG+/ETV1+ which occurred in 5.2% cases (41/790). In most cases, multiple marker incidence was detected in separate foci, supporting the independent clonal origin of tumor foci in patients with multi focal disease. In a subset of cases, the co-occurrence of ERG and SPINK1 in the same foci was observed, suggesting intra tumor heterogeneity, however, in majority of the cases mutually exclusive pattern of expression was observed, indicating the presence of unique driver molecular aberrations in each tumor foci.. Statistical analysis revealed significant incidence of ERG+ in CA (P=0.00) and SPINK1 in AA patients (P=0.00). Additionally, the incidence of ERG/SPINK1 and SPINK1/ETV1 were more frequent among AA patients compared to CA patients (P=0.0124 and P=0.0417). In conclusion, our study highlights the existence of significant molecular heterogeneity among PCa patients in a racially disparate perspective. Consequently, a thorough understanding of the clinical association between distinct molecular sub groups and disease progression in each racial group will significantly aid the treatment efforts in combatting PCa disease.

Citation Format: Pavithra D. Arachchige, Shannon Carskadon, Gaury Dhamdhere, Mireya Diaz-Insua, Hans Stricker, Craig Rogers, James Peabody, Mani Menon, Sean Williamson, Nilesh Gupta, Nallasivam Palanisamy. Evaluation of prostate tumor molecular heterogeneity using whole mount radical prostatectomy by dual immunohistochemistry and dual RNA in situ hybridization [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4693.

Abstract 4688: Evaluation of tumor heterogeneity in prostate biopsy samples

Prostate cancer (PCa) is the second most common cancer among men with more than 25,000 deaths each year. A significant number of PCa patients are known to present with multifocal disease characterized by the presence of more than one tumor nodule. Currently, management decisions for active surveillance are made based on the Gleason grade, tumor stage and volume on initial prostate biopsies. Although morphological heterogeneity has been well recognized, recent studies have revealed that PCa is a heterogeneous disease at the molecular level as well. Importantly, some molecular aberrations have been associated with aggressive disease and clinical outcomes, suggesting that tumor heterogeneity may be a determining factor in the success of active surveillance and other PCa management options. Therefore, we evaluated the incidence of several molecular markers on prostate biopsy samples to understand tumor molecular heterogeneity among PCa cases. A total of 626 biopsy cores were collected from 130 consecutive patients undergoing either standard or double sextant biopsies from July to October 2016 at our institute. Selected cores included benign (n=13), high grade intraepithelial neoplasia (HGPIN, n=124), atypical/ASAP (n=33) and Gleason grade 6-9 tissues (n=447). Of the 626, 119 cores included discontinuous (intervening benign tissue) tumor foci. The presence of the molecular markers, ERG, SPINK1, ETV1 and ETV4 was simultaneously evaluated using a novel, combined approach by dual Immunohistochemistry and RNA in situ hybridization. A total of 281 cores (44.9%) were positive for at least one molecular marker. Of these, ERG+ was more prominent (22.0%), followed by SPINK1+ (14.1%). The incidence of ETV1+ and ETV4+ was low (4.5% and 2.1%, respectively). 253 biopsy cores (56.6%) with Gleason 6-9 cancer were positive for at least one marker. Notably, only 12 cores (9.7%) of HGPIN were positive for any one of the markers while all benign cores were negative. Of note, 13 atypical/ASAP cores (39.4%) were positive for at least one marker, suggesting the potential use of molecular analysis to eliminate ambiguities associated with the diagnosis of cancer in atypical lesions. Of the 119 cores with discontinuous tumor foci, 14 (11.7%) dual marker positive with discordant marker status in each foci. Additionally, 99 cores (83.2%) showed the presence of a single marker either in one or both foci, further emphasizing the independent clonal origin and the presence of distinct driver molecular aberrations in different tumor foci in a subset of PCa cases. Finally, 345 of the 626 cores (55.1%) were negative for all the tested molecular markers indicating hitherto unidentified driver molecular aberrations. In conclusion, our study highlights the presence of significant tumor molecular heterogeneity identified in biopsy samples and emphasizes the importance of considering all tumor nodules in multi focal disease in making clinical decision on active surveillance.

Citation Format: Pavithra D. Arachchige, Shannon Carskadon, Gaury Dhamdhere, Mireya Diaz-Insua, Rogers Craig, James Peabody, Mani Menon, Sean Williamson, Nilseh Gupta, Nallasivam Palanisamy. Evaluation of tumor heterogeneity in prostate biopsy samples [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4688.

Validity of the Patient-Reported Outcome Measurement Information System (PROMIS) Sexual Interest and Satisfaction Measures in Men Following Radical Prostatectomy

PURPOSE

Patient-reported outcomes after radical prostatectomy have focused on erectile function. To date, no studies have validated the Patient-Reported Outcome Measurement Information System (PROMIS) Sexual Interest and Satisfaction single item measures in patients with prostate cancer, nor have studies examined how these measures relate to erectile function. In addition, data are lacking with regard to the clinical responsiveness of these measures to treatment. We sought to validate and examine the clinical utility of these measures in men after radical prostatectomy.

PATIENTS AND METHODS

We identified men who underwent a robotic radical prostatectomy from May 2014 to January 2016 in the Michigan Urological Surgery Improvement Collaborative. A single item from the PROMIS Global Satisfaction With Sex Life subdomain and a single item from the PROMIS Interest in Sexual Activity subdomain were administered. Erectile function was also assessed. Differences between baseline and 24-month T-scores for both PROMIS interest and satisfaction were examined. Multilevel models were constructed to examine change over time.

RESULTS

A total of 1,604 patients were included in the analysis. Convergent and discriminant validity of the PROMIS measures was supported. The mean PROMIS interest T-score decreased significantly from baseline to 3 months (P = .001) and significantly increased from 3 months to 24 months in this cohort, with 24-month scores exceeding baseline scores (P < .001). The mean PROMIS satisfaction T-score declined from baseline to 3 months and increased from 3 months to 24 months (P < .002).

CONCLUSION

PROMIS Global Satisfaction With Sex Life and Interest in Sexual Activity single-item measures are fundamental measures in prostate cancer survivorship. Patients are interested in sex despite functional losses and can salvage satisfaction, thereby giving insight into attainable patient-centered survivorship goals for sexual recovery after radical prostatectomy.

Modular Training for Robot-Assisted Radical Prostatectomy: Where to Begin?

OBJECTIVE

Effective training is paramount for patient safety. Modular training entails advancing through surgical steps of increasing difficulty. This study aimed to construct a modular training pathway for use in robot-assisted radical prostatectomy (RARP). It aims to identify the sequence of procedural steps that are learnt before surgeons are able to perform a full procedure without an intervention from mentor.

DESIGN

This is a multi-institutional, prospective, observational, longitudinal study. We used a validated training tool (RARP Score). Data regarding surgeons' stage of training and progress were collected for analysis. A modular training pathway was constructed with consensus on the level of difficulty and evaluation of individual steps. We identified and recorded the sequence of steps performed by fellows during their learning curves.

SETTING AND PARTICIPANTS

We included 15 urology fellows from UK, Europe, and Australia.

RESULTS

A total of 15 surgeons were assessed by mentors in 425 RARP cases over 8 months (range: 7-79) across 15 international centers. There were substantial differences in the sequence of RARP steps according to the chronology of the procedure, difficulty level, and the order in which surgeons actually learned steps. Steps were not attempted in chronological order. The greater the difficulty, the later the cohort first undertook the step (p = 0.021). The cohort undertook steps of difficulty level I at median case number 1. Steps of difficulty levels II, III, and IV showed more variation in median case number of the first attempt. We recommend that, in the operating theater, steps be learned in order of increasing difficulty. A new modular training route has been designed. This incorporates the steps of RARP with the following order of priority: difficulty level > median case number of first attempt > most frequently undertaken in surgical training.

CONCLUSIONS

An evidence-based modular training pathway has been developed that facilitates a safe introduction to RARP for novice surgeons.