Role of dynamic contrast-enhanced magnetic resonance (MR) imaging and proton MR spectroscopic imaging in the detection of local recurrence after radical prostatectomy for prostate cancer

OBJECTIVES: To assess the accuracy of magnetic resonance (MR) spectroscopic imaging (1H-MRSI) and dynamic contrast-enhanced MR (DCEMR) in the depiction of local prostate cancer recurrence in patients with biochemical progression after radical prostatectomy (RP). MATERIALS AND METHODS: 1H-MRSI and DCEMR were performed in 70 patients at high risk of local recurrence after RP. The population was divided on the basis of the clinical validation of MR results with the use of a transrectal ultrasound biopsy examination in a group of 50 patients (group A) and the prostate-specific antigen (PSA) serum level restitution after external beam radiotherapy, in a group of 20 patients (group B). RESULTS: In group A, 1H-MRSI analysis alone showed a sensitivity of 84% and a specificity of 88%; the DCEMR analysis alone, a sensitivity of 71% and a specificity of 94%; combined 1HMRSI-DCEMR, a sensitivity of 87% and specificity of 94%. Areas under the receiver operating characteristic (ROC) curve for 1HMRSI, DCEMR, and combined 1HMRSI /DCEMR were 0.942, 0.93,1 and 0.964, respectively. In group B, 1HMRSI alone showed a sensitivity of 71% and a specificity of 83%; DCEMR, a sensitivity of 79% and a specificity of 100%; combined 1HMRSI and DCEMR, a sensitivity of 86% and a specificity of 100%. Areas under the ROC curve for each of these groups were 0.81, 0.923, and 0.94, respectively. CONCLUSION: Our results show that combined 1H-MRSI and DCMRE is an accurate method to identify local prostate cancer recurrence in patients with biochemical progression after RP.     

Magnetic resonance imaging in the prediction of biochemical recurrence of prostate cancer after radical prostatectomy

OBJECTIVE

To investigate whether magnetic resonance imaging (MRI) findings, when converted into a scoring system, can predict the biochemical recurrence of prostate cancer after radical prostatectomy (RP).

PATIENTS AND METHODS

Between January 2000 and October 2004, 610 patients with biopsy‐confirmed prostate cancer had MRI before RP, with whole‐mount step‐sectioning of the pathology sample. MRI findings were retrospectively scored on a seven‐point scale based on Tumour‐Node‐Mestastasis staging (1, no tumour seen, to 7, lymph node metastasis). MRI scores were added to published 5‐ and 10‐year clinical preoperative nomograms for predicting recurrence. The predictive accuracy of MRI was quantified as the differences in bootstrap‐corrected concordance indices of the models with and without MRI.

RESULTS

As of August 2007, 64 (10.5%) patients had a biochemical recurrence. MRI scores were associated with recurrence (P < 0.001) with hazard ratios of 1.76 and 1.81 in the 5‐ and 10‐year models, respectively. Actual recurrence rates by MRI score were: 1, 0%; 2, 4.5%; 3, 9%; 4, 24.1%; 5, 33.3%; 6, 69.2%; 7, 100%. When MRI was added, the concordance indices of the 5‐ and 10‐year models increased, from 0.762 to 0.776 (P = 0.081) and 0.773 to 0.788 (P = 0.107), respectively; the improvement was not significant.

CONCLUSION

The MRI scoring system devised was a strong predictor of biochemical recurrence after RP. Although MRI did not provide added prognostic value to standard clinical nomograms, in centres where MRI is used routinely, it might increase the confidence of the clinician in assessing the risk of recurrence by contributing supporting data.     

Long-term risk of clinical progression after biochemical recurrence following radical prostatectomy: the impact of time from surgery to recurrence

Background

The natural history of biochemical recurrence (BCR) after radical retropubic prostatectomy (RRP) is variable and does not always translate into systemic progression or prostate cancer (PCa) death.

Objective

To evaluate long-term clinical outcomes of patients with BCR and to determine predictors of disease progression and mortality in these men.

Design, setting, and participants

We reviewed our institutional registry of 14 632 patients who underwent RRP between 1990 and 2006 to identify 2426 men with BCR (prostate-specific antigen [PSA] levels ≥0.4 ng/ml) who did not receive neoadjuvant or adjuvant therapy. Median follow-up was 11.5 yr after RRP and 6.6 yr after BCR.

Intervention

RRP.

Measurements

Patients were grouped into quartiles according to time from RRP to BCR. Survival after BCR was estimated using the Kaplan-Meier method and compared using the log-rank test. Cox proportional hazard regression models were used to analyze clinicopathologic variables associated with systemic progression and death from PCa.

Results and limitations

Median systemic progression-free survival (PFS) and cancer-specific survival (CSS) had not been reached after 15 yr of follow-up after BCR. Cancer-specific mortality 10 yr after BCR was 9.9%, 9.3%, 7.8%, and 4.7% for patients who experienced BCR <1.2 yr, 1.2–3.1 yr, 3.1–5.9 yr, and >5.9 yr after RRP, respectively (p = 0.10). On multivariate analysis, time from RRP to BCR was not significantly associated with the risk of systemic progression (p = 0.50) or cancer-specific mortality (p = 0.81). Older patient age, increased pathologic Gleason score, advanced tumor stage, and rapid PSA doubling time (DT) predicted systemic progression and death from PCa. Limitations included retrospective design, varied utilization of salvage therapies, and the inclusion of few patients with positive lymph nodes.

Conclusions

Only a minority of men experience systemic progression and death from PCa following BCR. The decision to institute secondary therapies must balance the risk of disease progression with the cost and morbidity of treatment, independent of time from RRP to BCR.     

Obesity is associated with biochemical recurrence after radical prostatectomy: A multi-institutional extended validation study

Background

There are no clear data regarding the association between body mass index (BMI) and outcomes after radical prostatectomy (RP). This study aimed to investigate the association between BMI and biochemical recurrence (BCR) after RP in a large international contemporary cohort of patients with prostate cancer.

Robotic-assisted radical prostatectomy by a single surgeon in Taiwan: experience with the initial 30 cases

Robotic-assisted laparoscopic radical prostatectomy (RALP) is an established trend in surgical treatment for localized prostate cancer in the USA; however, RALP is still in its infancy in Taiwan. We have tracked various indicators of proficiency as a single Taiwanese surgeon became familiar with the procedure through experience with 30 initial RALP surgeries using the da Vinci system between December 2005 and April 2007. Here, we report the changes in these proficiency indicators, and the short-term outcomes for the patients. Thirty consecutive patients were classified into group 1 (cases 1–15) and group 2 (cases 16–30). Preoperative clinical characteristics, including age, body mass index (BMI), American Society of Anesthesiologists anesthetic surgical risks class (ASA), prostate-specific antigen levels (PSA), and Gleason scores were similar between the groups. The clinical stage (T1/T2) was significantly higher in group 2 than in group 1 (p = 0.028). Group 1 needed more frequent insertion of a double-J stent (60% versus 0%) before surgery and evaluation by cystogram before removal of urethral catheter (80% versus 6.7%) than group 2; these differences were statistically significant. Blood loss and transfusion rates were lower in group 2, but complication and conversion rates were higher in group 1. These differences were not statistically significant. Positive surgical margins, continence rates, potency, and intercourse rates at 12 months were similar between the groups. Console time was 262 min in group 1 and 190 min in group 2 (p = 0.033); this appeared to be the best indicator of proficiency. Establishing proficiency as determined by functional outcomes required about 30 cases, but the positive surgical margin rates indicate that experience with more than 30 cases was needed to ascend the learning curve with respect to oncological outcomes.     

Diagnosis of local recurrence after radical prostatectomy

In the long-term there is biochemical evidence of recurrent prostate carcinoma in approximately 40% of patients after radical prostatectomy (RP). Detecting the site of recurrence (local vs distant) is critical for defining the optimum treatment. Pathological and clinical variables, e.g. Gleason score, involvement of seminal vesicles or lymph nodes, margin status at surgery, and especially the timing and pattern of prostate-specific antigen (PSA) recurrence, may help to predict the site of relapse. Transrectal ultrasonography (TRUS) of the prostatic fossa in association with TRUS-guided needle biopsy is considered more sensitive than a digital rectal examination for detecting local recurrence, especially if PSA levels are low. Although it cannot detect minimal tumour mass at very low PSA levels (< 1 ng/mL) TRUS biopsy is presently the most sensitive method for detecting local recurrence. Nevertheless, the conclusive role of biopsy of the vesico-urethral anastomosis remains unclear. However, 111In-capromab pendetide scintigraphy and [11C]-choline tomography (which are better than conventional imaging for detecting metastatic tumour), have low detection rates for local disease and are considered complementary to TRUS in this setting. Patients with a high PSA after RP may be managed with external beam salvage radiotherapy. An initial PSA of < 1 ng/mL, Gleason score < 8 and radiation dose of 66-70 Gy seem to be key factors in determining success. Although a positive TRUS anastomotic biopsy may predict a better outcome after radiation therapy, the need to take a biopsy in the event of PSA failure remains under investigation. The value of salvage radiation to the prostatic bed for PSA-only progression after RP remains in question.     

Adjuvant vs. salvage radiotherapy for patients at high risk for recurrence after radical prostatectomy

Prostate cancer patients with adverse pathologic factors (i.e., positive surgical margin, pT3 disease) after radical prostatectomy are more likely not cured (>60%) than cured by surgery alone. Adjuvant radiotherapy compared with observation reduces recurrence by 49% to 57%, may improve overall survival, and improves long-term quality of life without increased long-term patient-reported urinary or gastrointestinal tract symptoms. Despite these results, adjuvant radiotherapy is uncommonly received by patients with these adverse factors.We discuss the rationale for adjuvant therapy as part of oncologic treatment and potential reasons why patients do not receive adjuvant radiotherapy in prostate cancer. We conclude that patients need a thorough discussion regarding the potential benefits and harms of both approaches (watch and wait vs. adjuvant radiotherapy) to make an informed decision.     

Urinary continence after radical retropubic prostatectomy: relationship with membranous urethral length on preoperative endorectal magnetic resonance imaging

PURPOSE: We determined whether membranous urethral length on preoperative magnetic resonance imaging (MRI) is predictive of urinary continence after radical retropubic prostatectomy. MATERIALS AND METHODS: Membranous urethral length was measured on preoperative endorectal MRI in 211 consecutive patients with newly diagnosed prostate cancer before radical retropubic prostatectomy performed by a single surgeon. Neurovascular bundle resection was done in 60 cases. After surgery the time to stable postoperative continence was recorded in 180 cases and the level of stable continence was graded on a 5-point scale of 1-complete continence to 5-complete incontinence. RESULTS: After controlling for age and surgical technique multivariate analysis showed that membranous urethral length was related to time to stable postoperative continence (p = 0.02), such that a longer membranous urethra was associated with a shorter time to stable continence. For example, 1 year after surgery 120 of the 134 patients (89%) with a preoperative membranous urethral length of greater than 12 mm. were completely continent compared with 35 of the 46 (77%) with a preoperative length of 12 mm. or less. CONCLUSIONS: On endorectal MRI before radical prostatectomy a longer membranous urethra is associated with significantly more rapid return of urinary continence after surgery.     

前列腺癌根治术后勃起功能障碍的相关问题

前列腺癌根治术后的勃起功能障碍一直是困扰泌尿外科医师的难题,并严重影响患者的生活质量.术中海绵体神经的损伤是造成术后勃起功能障碍的主要原因.随着保留神经血管束或重建海绵体神经的前列腺癌根治术的开展及腹腔镜技术、机器人辅助腹腔镜技术与治疗药物的应用,前列腺癌根治术后勃起功能障碍的发生率已逐渐下降.本文拟就前列腺癌根治术后勃起功能障碍的相关问题进行讨论,以促进前列腺癌根治术后勃起功能障碍防治措施的推广应用.     

Combination of Diffusion-weighted Magnetic Resonance Imaging and Extended Prostate Biopsy Predicts Lobes Without Significant Cancer: Application in Patient Selection for Hemiablative Focal Therapy

Background

Significant cancer in contralateral sides of the prostate that was missed on prostate biopsy (PBx) is a concern in hemiablative focal therapy (FT) of prostate cancer (PCa). However, extended PBx, a common diagnostic procedure, has a limited predictive ability for lobes without significant cancer.

Objective

To identify prostate lobes without significant cancer using extended PBx combined with diffusion-weighted imaging (DWI), which has the potential to provide pathophysiologic information on pretreatment assessment.

Design, setting, and participants

We conducted a prebiopsy DWI study between 2007 and 2012 that included 270 prostate lobes in 135 patients who underwent radical prostatectomy (RP) for clinically localized PCa.

Intervention

Participants underwent DWI and 14-core PBx; those with PBx-proven PCa and who were treated with RP were analyzed.

Outcome measurements and statistical analysis

Imaging and pathology were assessed in each side. Based on RP pathology, lobes were classified into lobes with no cancer (LNC), lobes with indolent cancer (LIC), and lobes with significant cancer (LSC). Predictive performance of DWI, PBx, and their combination in identifying lobes without significant cancer was examined.

Results and limitations

LNC, LIC, and LSC were identified in 23 (8.5%), 64 (23.7%), and 183 sides (67.8%), respectively. The negative predictive values (NPV) of DWI, PBx, and their combination were 22.1%, 27.8%, and 43.5%, respectively, for lobes with any cancer (ie, either LIC or LSC), and 68.4%, 72.2%, and 95.7%, respectively, for LSC. The NPV of PBx for LSC was improved by the addition of DWI findings (p = 0.001), with no adverse influence on the positive predictive value. Limitations included a possible selection bias under which the decision to perform PBx might be affected by DWI findings.

Conclusions

The combination of DWI and extended PBx efficiently predicts lobes without significant cancer. This procedure is applicable to patient selection for hemiablative FT.     

经腹膜外腹腔镜前列腺癌根治术（附9例报告）

目的探讨经腹膜外腹腔镜前列腺癌根治术的手术方法和疗效。方法我科自2006年1月至2008年10月对9例前列腺癌患者行经腹膜外途径腹腔镜前列腺癌根治术,手术经腹膜外路径顺行切除前列腺,切开膀胱颈部前先以1-0可吸收线缝扎背血管复合体。结果9例手术均获得成功,无中转开放手术。手术时间180-510min,平均322min,术中出血量200-1500ml,平均433ml,术后48h内胃肠功能恢复,术后2～3d下床活动,无直肠损伤和吻合口尿漏出现。标本切缘阳性1例。1例患者术后半年仍有轻度尿失禁。其中7例患者随访5～33个月,未发现肿瘤局部和生化复发和远处转移;术后3个月前列腺特异性抗原0～0．1ng／ml。结论经腹膜外腹腔镜前列腺癌根治术是一种安全有效的手术方法,手术创伤小,患者恢复快,腹腔并发症少。但该手术难度较大,需要具有丰富腹腔镜操作经验的医生完成。     

前列腺癌根治术后tPSA异常的影响因素

目的分析前列腺癌根治术后tPSA异常的影响因素,为前列腺癌患者个体化后续治疗提供依据。方法回顾性分析2004年1月至2013年10月在广西医科大学第一附属医院及附属肿瘤医院行前列腺癌根治术的72例前列腺癌患者的临床资料。单因素分析研究各参数对根治术后1个月tPSA异常的影响,多因素Logistic回归分析影响根治术后tPSA异常的独立因素。结果单因素分析显示年龄、前列腺体积、直肠指检、影像学表现、术前Gleason评分及临床分期对评估术后tPSA值异常无统计学意义（P〉0.05）。新辅助治疗、术前tPSA水平、病理分期、术后Gleason评分、淋巴结转移及切缘情况对评估术后tPSA值异常有统计学意义（P〈0.05）。多因素分析显示术后Gleason评分、淋巴结转移及切缘情况是术后tPSA异常的独立影响因素。结论术后Gleason评分、淋巴结转移、切缘情况是影响前列腺根治术后患者tPSA异常的独立因素。     

Positive margins after laparoscopic radical prostatectomy: a prospective study of 100 cases performed by 4 different surgeons

OBJECTIVE: Laparoscopic radical prostatectomy (LRP) has been refined by experienced surgeons into a competitive treatment alternative for localized prostate cancer. Less is known, however, about the outcomes of "learning curve" cases from newly trained surgeons. We prospectively studied 100 cases of LRP performed by 2 senior and 2 junior surgeons and addressed the rates of positive margins-an important early endpoint of oncologic efficacy. METHODS: 100 consecutive cases of LRP were performed by two senior (n=62) and two junior surgeons (n=38) by a 5-port transperitoneal route. Whole-mount step-section prostate specimens were examined by Stanford protocol. RESULTS: Positive margins occured in 25% of cases: 18% for pT2a (2/11), 18% for pT2b (11/61), 45% for pT3a (10/22), and 50% for pT3b (2/4) (p=0.002 pT2 vs. pT3). By surgeon experience, the rates were 19% (12/62) for senior and 34% (13/38) for junior (p=0.04). However, in a multiple logistic regression analysis, only pathologic stage (p=0.083) and Gleason sum (p=0.0133) reached statistical significance, while surgeon experience did not (p=0.0992). CONCLUSION: Positive margin rates after laparoscopic radical prostatectomy are significantly influenced by pathologic stage and Gleason score, and are within the range reported from open series. The higher positive margin rate from junior surgeons, although not statistically significant, suggests the need for further study and continued mentoring during surgery and/or video review of cases to improve oncologic results.     

PSA in the new millennium: a powerful predictor of prostate cancer prognosis and radical prostatectomy outcomes--results from the SEARCH database

OBJECTIVES: As a result of prostate-specific antigen (PSA) screening, most men today with prostate cancer present with localized disease and serum PSA values < 10 ng/ml. Within this context, it is debated whether PSA remains an important prognostic variable in more recently treated patients. We examined the prognostic significance of preoperative PSA to predict pathologic stage and biochemical progression among men undergoing radical prostatectomy in the new millennium (2000-2006). METHODS: We performed a review of 925 men with prostate cancer treated by radical prostatectomy since 2000 within the Shared Equal Access Regional Cancer Hospital (SEARCH) database. We examined the association between preoperative PSA and risk of adverse pathologic features and biochemical progression using logistic regression and Cox proportional hazards analysis. RESULTS: After adjusting for multiple clinical preoperative characteristics, higher preoperative PSA values were associated with increased odds of extracapsular extension (p<0.001), positive surgical margins (p<0.001), and seminal vesicle invasion (p<0.001) and increased risk of biochemical progression (p=0.009). When the analyses were limited to the 690 men with a preoperative PSA<10 ng/ml and after adjusting for multiple clinical characteristics, higher preoperative PSA values remained associated with increased risk of biochemical progression (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.06-1.28, p=0.002). Even among the 448 men with a PSA<10 ng/ml and clinical stage T1c disease, preoperative PSA was associated with increased risk of biochemical progression (HR 1.14, 95%CI 1.00-1.31, p=0.047). CONCLUSIONS: PSA remains an important prognostic marker among men diagnosed with prostate cancer in the new millennium treated with radical prostatectomy and remains an important predictor of outcome even among men with preoperative PSA level < 10 ng/ml.