The Influence of Prostate Volume on Prostate Cancer Detection

Objectives: The influence of prostate volume on the positive yield of the systematic sector biopsy is logical and has been demonstrated in numerous reports.Methods: Literature on prostate biopsy was reviewed and a selection of articles made. Keywords used for the Medline search included: Prostate cancer, Biopsy, Diagnosis.Results: Sextant biopsies have the highest positive biopsy rate (≤40 g) in small prostates (<20 g), whereas in large prostate (80–90 cc) it drops to 10% only.Conclusions: The present paper reviews the influence of total and peripheral zone volumes of the prostate on prostate cancer detection rates.     

Value of transrectal power Doppler sonography in the detection of low-risk prostate cancers

PurposeTo evaluate the risk of low-risk prostate cancer or prostate cancer that may benefit from surveillance in patients with a PSA level less than 10 ng/ml, a normal digital rectal examination (DRE) and a transrectal power Doppler sonography (PDS) without anomaly.Patients and methodsTwo hundred and forty-three consecutive patients with a PSA level less than 10 ng/ml and a DRE without anomaly had PDS-guided biopsies: 12 to 15 samples were systematically taken and echo-guided in the suspect areas. The PDS results were rated from 1 to 4: 1: normal, 2: slightly hypoechogenic avascular area in which the hypo-echogenicity disappears after compression by probe, 3: hypoechogenic avascular area, 4: hypoechogenic vascularised area with power Doppler sonography. Patients rated 3 or 4 were considered to be pathological. D’Amico's criteria were used to assess the risk of a biological recurrence after treatment and those of Dall’Era were used to select the patients that could benefit from active surveillance (AS). The PDS was considered to be a true positive if at least one biopsy was positive in the same sextant as the suspect image.ResultsIn a prospective manner, 106 cancers were diagnosed that could be qualified as low-risk in 84% of the cases (89% with a normal PDS and 79% with an abnormal PDS). Sixty-nine percent of the cases could be subject to AS (86% of the normal PDS cases and 47% of the abnormal PDS cases; P < 0.001). The PDS was normal in 159 of the 243 patients (65%). With a normal PDS, there was a 96% probability of not having a high-risk cancer. With an abnormal PDS, at least one biopsy was positive in 57% of the cases and the probability of having a significant cancer was 30% according to the Dall’Era criteria. A significant reduction was noted with a normal PDS, to 36% and 5%, respectively (VPN = 95%) (P = 0.015).ConclusionA normal PDS in patients presenting a PSA level less than 10 ng/ml and a DRE without anomaly may be used to put off the indication for a biopsy in order to reduce their number as well as the risks of overtreatment for a latent cancer.     

Valor de la PET en la recurrencia del cáncer de próstata con PSA < 5 ng/ml

Introduction and objectivesWe intend to evaluate the usefulness of PET scans in diagnosing recurrent prostate cancer after a curative attempt using radical treatment.Material and methods92 consecutive prostate cancer patients in biochemical progression following radical surgery (63) or radiation treatment (29) were studied with positron emission tomography (PET). In all cases two scans were performed in the same day (¹¹C-choline and ¹⁸F-FDG). PET efficacy was evaluated both globally (by employing the results achieved with both ¹¹C-choline and ¹⁸F-FDG) and using both radiotracers independently to detect recurrence in patients with biochemical progression. For this purpose, we used comparison of means for k-independent samples, 2 × 2 and 2 × X contingency tables and ROC curves.Results1. Global PET: there is evidence of PET alteration regarding the PSA level (P=.003): the clinical stage (P=.01). There are no statistically significant PET alterations regarding the affected biopsy (uni or bilateral), surgical margins, pathological stage and time to progression. ROC curve PET-PSA is statistically significant (P<.0001) permitting calculation of different cut-off points, with a specificity of 91% (highest) for a PSA of 4.3 ng/ml. 2. PET ¹⁸FDG: the area under the ROC curve is statistically significant (P<.0001) with a specificity of 91% for a PSA of 6.51 ng/ml. 3. PET ¹¹choline: the area under the ROC curve is statistically significant (P<.0001) with a specificity of 91% for a PSA of 5.15 ng/ml.ConclusionsPET is a useful tool for diagnosing prostate cancer recurrence after a curative attempt using radical treatment.     

Caracterización clínica del cáncer de próstata potencialmente insignificante en la biopsia prostática

ObjectiveThe aim of this study was to identify the rate of clinical significant disease (Gleason score > 6 or tumor volume > 0.5 cc in the RP specimen) among patients who had an insignificant prostate cancer on biopsy, evaluating the presence of prognostic factors.Patients and methodsPatients who fulfilled the following criteria were included: PSA ≤ 10 ng/ml, T1c disease, biopsy Gleason Score ≤ 6 affecting <5% of only 1 core and who had undergone a radical prostatectomy. The following variables were studied: Age, PSA, dPSA, free/total PSA ratio and prostatic volume assessed by transrectal ultrasound.ResultsIn a series of 2424 biopsies, 77 patients completely fulfilled the inclusion criteria, with 66.23% (n = 51) of clinical significant disease in the prostatectomy specimen. No differences were observed between these patients and those with insignificant disease in age, PSA, free/total PSA ratio. However, prostatic volume was significantly greater and PSA density significantly lower in those patients with an insignificant disease. Statistical analysis using a logistical regression showed that dPSA was the only prognostic factor (OR: 25067.10, CI 95%: 26.79–2.34 × 10⁷, P = .004).ConclusionsThese findings suggest that a high rate of patients who have a suspected insignificant prostate cancer on biopsy have a clinical significant disease, being dPSA the only independent prognostic factor.     

Usefulness and predictive value of PSA density, adjusted by transition zone volume, in men with PSA levels between 2 and 4 ng/ml

ObjectiveTo assess the diagnostic significance of prostate-specific antigen (PSA), density (PSAD) accuracy, and PSAD adjusted by transition zone volume (PSATZD) in men with PSA levels between 2.0 and 4.0 ng/ml.Material and methodsBetween 2000 and 2010, 138 men with PSA levels between 2 and 4.0 ng/ml underwent transrectal ultrasonography (TRUS) and 12-core prostate biopsy. Diagnostic accuracies for various cut-offs of PSAD and PSATZD were investigated according to subdivided PSA levels of 2.0 to 3.0 ng/ml and 3.1 to 4.0 ng/ml.ResultsThe detection rate of prostate cancer was 23,8% (32/134). The percentage of patients with extracapsular disease was 28.1% (10/32) and primary Gleason grade 4 or 5 was obtained in 8/32 (25%) patients. The transition zone volume and PSATZD in cancer cases were significantly different in comparison with those in non-cancer cases. The area under the receiver operating characteristic curve for PSATZD was significantly higher in comparison with that for PSAD in the same subdivided PSA ranges. The diagnostic efficiency for PSATZD was higher than that for PSAD. The diagnostic efficiency showed the highest value at the cut-off level for PSATZD of 0.23 and 0.28 in men with PSA levels of 2.0 to 3.0 ng/ml and 3.1 to 4.0 ng/ml, respectively.ConclusionsThe use of PSATZD cut-offs as a biopsy indication may reduce many unnecessary biopsies without missing most prostate cancer cases in the PSA range of 2.0 to 4.0 ng/ml.     

Prostate cancer in deceased organ donors: A review

Objective: To estimate the risk of prostate cancer transmission in relation with organ procurement. Methods: A literature search from the Medline database using the following keywords—transplantation, prostate cancer, organ procurement, donor transmitted malignancies, disease transmission, staging, evaluation, and PSA—was conducted to select 16 articles written in English and French over the last 15 years. Results: The incidence of prostate cancer in deceased organ donors (DOD) has been estimated to be between 3% and 18.5%. There were more than 120 solid-organ transplantations performed with organs coming from DOD with a proven prostate cancer without any case of cancer transmission or death related to malignancy and only 1 case of transmission by the donor after a heart transplant has been described. Conclusion: Transmission of prostate cancer by a transplanted organ seems incidental. When PSA is measured, it should be suspected only if the value is beyond 20 ng/ml and in all cases, should be interpreted taking digital rectal examination (DRE) into account. Organs from a DOD with a DRE proving a T3–T4 prostate cancer should not be procured. Suspect iliac lymph nodes during the preparation of the vessels for cannulation must lead to the discontinuation of the procurement or a histological analysis.     

Candidates to salvage therapy after external-beam radiotherapy of prostate cancer: Predictors of local recurrence volume and metastasis-free survival

PurposeThe purpose of this study was to assess the predictors of metastasis-free survival (MFS) and of the volume of the local recurrence in patients with rising prostate-specific antigen (PSA) serum level after radiotherapy for prostate cancer and referred for prostate magnetic resonance imaging (MRI) and biopsy in view of salvage treatment.Materials and methodsA total of 132 consecutive men (median age, 70 years; IQR, 66–77 years) with rising PSA after prostate radiotherapy who underwent prostate MRI and biopsy in view of salvage treatment between January 2010 and July 2017 were retrospectively evaluated at a single center. MFS predictors were assessed with Cox models. Predictors of the volume of the local recurrence (number of invaded prostate sectors at biopsy) were assessed using Poisson regression among variables available at PSA relapse.ResultsAt multivariate analysis, an initial Gleason score ≥ 8 (OR = 7 [95% confidence interval (CI): 1.2–40]; P = 0.03), a recent radiotherapy (OR = 17 [95% CI: 3.9–72]; P < 0.0001), the use of androgen deprivation therapy at PSA relapse (OR = 12.5 [95% CI: 2.8–57]; P = 0.001) and the number of invaded prostate sectors (OR = 1.5 [95% CI: 1.1–2]; P = 0.007) and maximum cancer core length (OR = 0.7 [95%CI: 0.6–0.9]; P = 0.002) at biopsy performed at PSA relapse were significant MFS predictors. The PSA level at relapse was significant independent predictor of the volume of local recurrence only when used as a continuous variable (P = 0.0002) but not when dichotomized using the nadir + 2 threshold (P = 0.41).ConclusionPathological and clinical factors can help predict MFS in patients with rising PSA after prostate radiotherapy and candidates to salvage treatment. The PSA level at relapse has strong influence on the local recurrence volume when used as a continuous variable.     

Eficacia diagnóstica del índice de inmunidad-inflamación sistémica en la biopsia de próstata por fusión

ObjectiveTo investigate the diagnostic efficiency of systemic immune response (SII) in prostate cancer (PCa) in patients with PSA < 10 ng/ml undergoing fusion prostate biopsy.MethodsThe prospective study included patients who were planned for fusion prostate biopsy and had PSA < 10 ng/ml and a PI-RADS ≥ 3. All the patients underwent 12-core standard transrectal prostate biopsy followed targeted biopsy (combined biopsy). Based on preoperative complete blood count parameters, SII was calculated using the following formula: SII = platelet × neutrophil-to-lymphocyte ratio. Correlations between PI-RADS score, platelet, neutrophil-to-lymphocyte ratio, PSA, PSA density, SII and PCa were determined using ROC curve analysis. Optimal cut-off values were determined using the maximum Youden Index (defined as: sensitivity + specificity ? 1).ResultsThe study included 508 patients with a mean age of 62.49 ± 6.86 years and a median PSA level of 7.28 (5.69-8.70) ng/ml. The overall clinically significant PCa rate was 39.4%. Although SII had no significant diagnostic value in PCa patients with low ISUP grades (grade 1 and 2) (AUC = 0.487, P = .622), it was revealed as a significant marker in PCa patients with an ISUP grade ≥ 3 (AUC = 0.811, P < .001). The cut-off value of SII was 533.0. While the combination of SII with PI-RADS score is the most effective marker, neutrophil-to-lymphocyte ratio and platelet were also revealed as effective markers in predicting ISUP grade 3-5 PCa, though not as effective as SII.ConclusionSII and SII combination with PI-RADS score appear to be a significant diagnostic marker in patients with high-grade PCa (ISUP grade 3-5). These values were found to be higher compared to those of patients with a benign pathology and patients with lower ISUP scores.     

Do racial disparities exist in the use of prostate cancer screening and detection tools in veterans?

ObjectiveTo determine whether racial disparities exist in the use of prostate cancer screening and detection tools in veterans.Methods and materialsAdministrative data were obtained from the Corporate Data Warehouse on a national cohort of 275,831 veterans (21% African American [AA]) between the ages of 40 and 70 years who were free of heart disease, did not have an elevated prostate specific antigen (PSA) level (>4 ng/ml), did not have other clinical signs of prostate cancer, had not been diagnosed with prostate cancer, and had not received treatment for prostate cancer between January 10, 1998 and September 30, 2000. Subjects were followed up until September 30, 2007. Regular users were defined as those with at least 1 annual visit to the Veterans Healthcare Administration (VHA) between October 1, 1998 and September 30, 2000. We sought to determine if race was significantly associated with PSA testing, the time to elevated PSA detection, the time to prostate biopsy, and the time to diagnosis of prostate cancer. Chi-square tests, logistic regression, and Cox proportional hazard models were used to test for associations between race and prostate cancer variables.ResultsEighty-four percent of the veterans between the ages 40 and 70 years undergo PSA testing. AA veterans are as likely as white veterans to undergo PSA testing. Screened AA veterans are more likely to have a PSA>4 ng/ml, undergo prostate biopsy, and be diagnosed with prostate cancer than screened white veterans. The time intervals between undergoing a prostate biopsy and being diagnosed with prostate cancer were statistically significantly shorter (although unlikely of clinical significance) for AA veterans with a PSA level>4 ng/ml than that for white veterans with a PSA level>4 ng/ml. When routine care in regular VHA users was compared with that of participants in major screening trials such as Prostate, Lung, Ovarian and Colon Cancer Trial and European Study of Screening for Prostate Cancer, prostate biopsy rates were lower (30% vs. 40%–86%), prostate cancer detection rates/person biopsied were higher (49% vs. 31%–45%), and incidence of prostate cancer was 1.1% vs. 4.9% to 8.3%.ConclusionsAmong regular users of the VHA for healthcare, no disparities toward AA veterans exist in the use of prostate cancer screening and detection tools. Any differences in prostate cancer treatment outcomes are not likely because of inequalities in the use of prostate cancer screening or detection tools.     

Prostate cancer detection: The impact of obesity on Asian men

ObjectiveTo evaluate the impact of body mass index (BMI) on prostate cancer detection in biopsy-naive men presenting to a single tertiary hospital in Singapore.Materials and methodsWe retrospectively examined 458 men who underwent initial prostate biopsies between January 2012 and April 2014. Indications for biopsy were serum prostate-specific antigen level≥4.0 ng/ml, or digital rectal examination findings suspicious for malignancy, or both. Only men with serum prostate-specific antigen level <20 ng/ml were included. BMI categories were based on the World Health Organization recommendations (normal:<25.0, overweight: 25.0–29.9, and obese: ≥30).ResultsOf the 458 men included in our cohort, 125 (27.3%) men were positive for prostate cancer on biopsy, with 69 (15.1%) being clinically significant (Gleason≥7). Men with BMI≥25 kg/m² (41.7%) were younger (67.2 vs. 68.8 y, P = 0.030), had larger prostates (45.5 vs. 40.1 g, P = 0.014), and were more likely to have a positive biopsy finding (34.6% vs. 22.1%, P = 0.003). On multivariate analysis, being overweight or obese was associated with increased risk of having prostate cancer on biopsy (odds ratio [OR] = 2.61, 95% CI: 1.58–4.30, P<0.001 and OR = 3.26, 95% CI: 1.37–7.73 P = 0.007, respectively). The same trend was observed for clinically significant cancers but not for clinically insignificant cancers (OR = 3.57, 95% CI: 1.87–6.82, P<0.001 and OR = 3.86, 95% CI: 1.33–11.21, P = 0.013 for being overweight and obese, respectively).ConclusionAsian men with BMI≥25 kg/m² are at greater risk of having a positive initial biopsy result. The BMI threshold (BMI≥25 kg/m²) for Asian men to be at increased risk of prostate cancer detection on initial biopsy is lower than that of Western populations (BMI≥30 kg/m²).     

¿Evita la antibioterapia biopsias de próstata en pacientes con valores elevados de PSA?

IntroductionWe investigated if antibiotherapy has any role on total PSA (tPSA), free PSA (fPSA) and fPSA/tPSA ratio in patients with tPSA higher than 2.5 ng/ml. We also analyzed if it has any relation with prostate cancer diagnosis rate.Material and MethodsA total 108 patients older than 50 years of age with lower urinary system sypmtoms and tPSA >2.5 ng/ml were included in this study. Antibiotherapy was given to all the cases for three weeks. After that, transrectal ultrasound-guided prostate biopsies were taken from all the patients. Before and after antibiotherapy, “The International Prostate Symptom Score” (IPSS) and “National Institutes of Health Chronic Prostatitis Symptom Index” (NIH-CPSI) questinories are performed and serum tPSA, fPSA and fPSA/tPSA values were obtained.ResultsTPSA, fPSA and fPSA/tPSA ratio alterations prior to and after antibiotherapy did not show any statistically significant difference (p > 0.05). When prostate adenocarcinoma was excluded, an statistically significant decrease was found in IPSS and NIH-CPSI scores for all cases.ConclusionsAntibiotherapy given to patients with PSA levels higher than threshold value has not led to significant change in prostate needle biopsy decision. Prostate biopsy should be considered without trying antibiotherapy in patients with high PSA values if a suspicion of prostatitis does not exist.     

¿Impacta el criterio para indicar la biopsia prostática sobre su exactitud? Estudio prospectivo llevado a cabo sobre una población de pacientes ambulantes

IntroductionProstate specific antigen (PSA) and digital rectal examination (DRE) are the main tests for initial prostate investigation; there is no consensus about the best criterion for prostate biopsies. We aim to check the accuracy of different criteria in this context including PSA derivatives to detect prostate cancer.Material and methodsFour different criteria for indication of prostate biopsy were compared: (A) PSA-density (>15 ng/ ml/ cc); (B) PSA > 2,5ng/ml; (C) PSA-velocity (> 0.7 ng/ ml/ year); (D) free/total PSA ratio (<15%). All biopsies and histopathological examinations were performed by the same urologist and pathologist, respectively.ResultsThe study was performed on 180 consecutive biopsies with 37.7% overall cancer detection rate: 29 (16.1%) performed following criterion A, 42 (23.3%) criterion B, 65 (36.1%) criterion C and 44 (24.4%) criterion D. Based on PSA criteria alone, the predictive positive value (PPV) was 37.9% for criterion A, 33.3% for B, 32.3% for C and 50.0% for criterion D, respectively, (p > 0.05). Associating positive DRE with changed PSA, the PPV increased to 50%, 50%, 43.9% and 68.2% for criteria A, B, C and D, respectively (p > 0.05). In univariate analysis, DRE (positive versus negative), PSA level (>10 ng/ ml versus <4.0 ng/ ml), free/total PSA ratio (<10% versus >15%) and age were associated with PC. In multivariate analysis only positive DRE was associated with prostate cancer.ConclusionsAll the criteria of PSA derivatives are complementary and useful predictors of cancer risk. However, a positive DRE increased the PPV of PSA derivatives. New tools are needed to improve the accuracy of prostate cancer detection.     

Factores influyentes en la respuesta al rescate con radioterapia tras prostatectomía radical

ObjectiveTo analyze the influential factors in the response in prostatectomized patients with subsequent biochemical relapse (BCR) and treated with salvage radiotherapy (RTP).Material and methodsWe analyzed 313 patients with pT2/pT3 prostate cancer who were receiving salvage therapy due to biochemical relapse (from a series of 1,310 radical prostatectomies between 1989-2012). Of the 313 patients; 159 (50.8%) only received androgen deprivation (AD), 63 (20.1%) Radiotherapy (RTP) plus concomitant AD and 91 (29.1%) only RTP. Of these, 57 (62.6%) have maintained complete response and 34 (37.4%) had failure response with post-RTP BCR.ResultsStudy of the group treated exclusively with salvage RTP. Ninety-one patients were treated with salvage RTP. Median follow-up was 6.4 years and median to recurrence 11 months. Post-RTP biochemical relapse-free survival (PRBRFS) was 68 ± 7% and 30 ± 10% in 5 to 10 years. Median PRBRFS was 7.3 years (6.3-8.3). Initial PSA (HR: 1.08; 95% CI: 1.01-1.1 P = .02) with best PSA cut-off point PSA > 20 ng/ml (HR: 13.6; 95% CI: 2.1-86 P = .005) and PSA pre-RTP (HR: 1.9; 95% CI: 1.2-3.3; P = .009), best PSA cut-off point PSA preRTP 0.92 ng/ml (HR: 4.5; 95% CI: 1.3-15.6; P = .01) showed independent influence in the response in the multivariate study. PRBRFS at 5 years, 81 ± 9% versus 58 ± 9% with initial PSA < 20 or > 20 ng/ml (P = .03). PRBRFS at 5 years, 93 ± 5% versus 53 ± 10% according to PSA pre-RTP < 0.9 or > 0.9 ng/ml (P = .02).ConclusionsIn patients treated with salvage RTP after radical prostatectomy, the preoperative PSA > 20 ng/ml and PSA preRTP > 0.92 ng/ml shows an independent influence on the response.     

Asymptomatic prostatic inflammation in men with clinical BPH and erectile dysfunction affects the positive predictive value of prostate-specific antigen

ObjectiveTo test the hypothesis that sexual dysfunction in elderly men with benign prostatic hyperplasia leads to prostatic inflammation, diagnosed by prostatic fluid interleukin-8 (IL-8), which lowers the positive predictive value of prostate-specific antigen (PSA).MethodsOverall, 160 men with lower urinary tract symptoms between 50 and 75 years of age with an elevated PSA level of more than 4 ng/ml with normal digital rectal examination and 50 age-matched controls with normal PSA level were prospectively evaluated for prostatic fluid IL-8 levels. Erectile dysfunction was measured by self-administered questionnaire of the Sexual Health Inventory for Men. Total and free serum PSA levels and IL-8 in prostatic fluid were measured 6 to 8 weeks after a course of 400 mg of ofloxacin and 20 mg of piroxicam given daily for 2 weeks. Transrectal ultrasonography–guided biopsy was done only when PSA level did not decrease less than 4 ng/ml.ResultsMean ages of patients and controls were 63.18 (standard deviation [SD]±7.10) and 60.18 (SD+6.02) years, respectively. Mean concentration of IL-8 in prostatic fluid of the patients was significantly higher, i.e., 6678 pg/ml (SD±1985.7) than in control, i.e., 1543 pg/ml (SD±375.7) (P<0.001). Following anti-inflammatory treatment, there was a significant decrease in the mean level of IL-8 from baseline to 5622 pg/ml (SD±1870.66) (P<0.001). Corresponding to this, a significant decrease was noted in total PSA levels to less than 4 ng/ml in 105 (65.62%) patients. Men with the highest levels of IL-8 had a greater degree of erectile dysfunction.ConclusionMen with symptomatic benign prostatic hyperplasia and erectile dysfunction had significant inflammation of the prostate to cause spurious rise in PSA level resulting in an unnecessary biopsy.     

Cryosurgery for Prostate Cancer—Experience with Third-Generation Cryosurgery and Novel Developments in the Field

ObjectivesTo analyse and present the data of our cryosurgery experience for the treatment of prostate cancer.MethodsBetween August 2003 and November 2006, a total of 91 patients were treated with cryosurgery for prostate cancer as either primary treatment (n = 49) or salvage treatment (n = 42). The mean follow-up was 19.16 mo (range: 6 wk to 6 mo). Data were collected prospectively.ResultsThe prostate-specific antigen (PSA) level dropped to <0.5 ng/ml in 67% of all primary treatments and in 59% of all salvage treatments at the first 6-wk postoperative evaluation. At 1 yr, a PSA level below 0.5 ng/ml was found in 59% of primary treatments and 61% of salvage treatments. Three rectourethral fistulas were found (all in the salvage group). Twenty-seven percent (9 of 33) of patients were sexually potent in the primary group and 4.37% (1 of 23) in the salvage group.ConclusionsOur data show that prostate cryosurgery is a safe and effective treatment option in the management of prostate cancer. The complication rate in the salvage group was higher than in the primary group. With the advent of newer temperature-monitoring systems, we envisage that the serious complication of rectourethral fistulas would reduce even further.     

Two-years Postradiotherapy Biopsies: Lessons from MRC RT01 Trial

Background

The importance of 2-yr postradiotherapy prostate biopsy status remains uncertain.

The presence of positive surgical margins in patients with organ-confined prostate cancer results in biochemical recurrence at a similar rate to that in patients with extracapsular extension and PSA≤10 ng/ml

PurposesWe investigated whether patients with organ-confined prostate cancer (PCa) and positive surgical margins (SMs) had a similar biochemical recurrence (BCR) risk compared with patients with pT3a and preoperative prostate-specific antigen (PSA) levels≤10 ng/ml. Furthermore, we examined the effects of incorporating SM status, Gleason score (Gls), and preoperative PSA level into the discrimination accuracy of the current tumor node metastasis-staging system.Materials and methodsWe analyzed 863 PCa patients treated with radical prostatectomy from 1999 to 2008. Only individuals with pT2N0 or pT3N0, without neoadjuvant or adjuvant therapy, were included. We performed chi-square automatic interaction detection analysis to generate a classification model for predicting BCR by analyzing interactions between age at surgery, SM status, Gls, PSA, and tumor stage, tumor volume and relative tumor volume. Cox regression analyses tested the relationship between SM status and BCR rate after stratification according to T-stage and the novel classification. The predictive and discrimination accuracy of the current T-stage and of the classification model was quantified with time-dependent receiver operating characteristics and integrated discrimination improvement. The topographical association between extracapsular extension of PCa and positive SM was analyzed in patients with pT3aR1 using a computational reconstruction diagram of the prostate.ResultsThe chi-square automatic interaction detection analysis found interactions among pT Stage, SM status, PSA and Gls and generated a classification model for BCR prediction: pT2R0, pT2R1, pT3a PSA≤10 ng/ml, pT3a PSA>10 ng/ml and pT3b. Men with pT2R1 had a shorter time to BCR compared with men with pT3a-PSA≤10 ng/ml (P<0.0001). Gls≥7a was correlated with a poorer BCR rate than Gls≤7a in men with pT2R1 or pT3a PSA≤10 ng/ml (P = 0.012). The rank order (highest to lowest) for the risk of developing BCR was pT3b>pT2R1/pT3a-PSA>10 ng/ml>pT2R1/pT3a PSA≤10 ng/ml>pT2R0 (P<0.0001). Discrimination accuracy gains were observed when PCa was stratified according to the novel classification (P<0.0001). A topographical association between extracapsular extension and positive SM was found in patients with pT3aR1 (P = 0.01).ConclusionPatients with pT2R1 develop a similar BCR risk to that of patients with pT3a PSA≤10 ng/ml. Gls≥7b is associated with a high BCR risk in these patient groups. Including SM status, PSA, and Gls in pT stage appears to improve prognostic stratification in patients with PCa.     

Optimización de un programa de cribado oportunista de cáncer de próstata; ensayo aleatorizado prospectivo del papel del PSA y del PCA3 en uso secuencial

ObjectivesTo reduce unnecessary biopsies (Bx) in an opportunistic screening programme of prostate cancerMaterial and methodsWe perform a prospective evaluation of PCA3 as a second line biomarker in an opportunistic screening for prostate cancer (PCa). From September-2010 until September-2012, 2,366 men, aged 40-74 years and with > 10 years life expectancy, were initially screened with PSA/digital rectal examination (DRE). Men with previous Bx or with recent urine infections were excluded. Men with abnormal DRE and/or PSA > 3 ng/ml were submitted for PCA3. All men with PCA3 ≥ 35 underwent an initial biopsy (IBx) —12cores—. Men with PCA3 < 35 were randomized 1:1 to either IBx or observation. Re-biopsy(16-18 cores) criteria were PSA increase > .5 ng/ml at 4-6months or PSAv > .75 ng/ml/year.ResultsWith median follow-up (FU) of 10.1 months, PCA3 was performed in 321/2366 men (13.57%), 289 at first visit and 32 during FU. All 110 PCA3+ men (34.3%) were biopsied and PCa was identified in 43 men in IBx (39.1%). In the randomized arm, 110 were observed and 101 underwent biopsy, finding 12 PCa (11.9%), showing a statistically significant reduction of PCa detection rate in this cohort (P < .001). Global PCa detection rates were 40.9% and 9.5% for the PCA3+ and PCA3– branches, respectively (P < .001). Area under the curve for PSA and PCA3 were .601 and .74, respectively. This is an ongoing prospective study limited by its short follow-up period and still limited enrolment.ConclusionsPCA3 as a second line biomarker within an opportunistic dual screening protocol, can potentially avoid 65.7% and 50.1% biopsies at first round and at median FU of 10.1 months, respectively, just missing around 3.2% of high grade PCa.     

Factores predictivos del síndrome de retirada de abiraterona

Introduction and objectiveAbiraterone withdrawal syndrome (AWS) is characterized by a transient decrease in the PSA after abiraterone acetate (AA) treatment discontinuation in patients diagnosed with metastatic castration-resistant prostate cancer (mCRPC). The aim of our study is to identify the possible predictive factors of AWS at diagnosis.Materials and methodsWe performed a retrospective study of 70 patients treated with AA at the Institut Català d’Oncologia – L’Hospitalet between 2015 and 2017.Results11 patients presented AWS. The mean age at diagnosis was 65.73 years and the mean age of presentation was 74.18 years. Patients were in the ninth treatment cycle. The median PSA was: 30.5 ng/ml at diagnosis, 33.24 ng/ml in the AWS, and 15.78 ng/ml before starting another treatment. The median follow-up period after AWS was 8.2 months. The predictive factors of AWS would be: high PSA (p = .002), ISUP ≥ 4 (p = .002) and stage IV at diagnosis (p < .001). Patients with a T stage present high risk, but without statistical significance. An AUC of 0.84 was obtained, with a 95% CI between 0.77 and 0.92 (p < .001).ConclusionsThe incidence of AWS is not negligible, describing prolonged responses after AA withdrawal, including the possibility of increased overall survival. These results could entail new treatment schemes for mCRPC.     

Can redesigning a laboratory request form reduce the number of inappropriate PSA requests without compromising clinical outcome

IntroductionUnnecessary laboratory utilization due to inappropriate test-ordering behaviour among hospital clinicians and community general practitioners is an ongoing problem in many hospitals and primary care trusts throughout the UK and abroad. In January 2007, our hospital removed the ‘tick box’ for PSA from its laboratory tests request form, in a managed way, with the intention of reducing unnecessary requests for this test. Here we address the impact this action had on the number of PSA tests being requested and its downstream effects on prostate cancer diagnosis.MethodsUsing our laboratory database we compared the number of hospital and local GP requests for PSA, before and after modification of our laboratory form (requests from 2004 to 2006 were compared to 2007). We then correlated this data with the number of fast-track target referrals (2 week wait) from primary care for suspected prostate cancer, the results of prostate biopsies, and the number of prostate cancers being diagnosed, over the same time period.ResultsMann–Whitney non-parametric testing demonstrated a 17% reduction in the median number of PSA requests since the change was introduced (p = 0.001). Subset analysis revealed an 18% reduction in GP requests (p = 0.002). However no change was found in the number of prostate cancer diagnoses being made (p = 0.86) and the number of target referrals for suspected prostate cancer (p = 0.59) in the months of April, May, June, July, August and September of 2004–2006 as compared to the same months in 2007. The rate of patients undergoing biopsy increased in the post intervention period from 15.5 to 18.5 patients per month. The rate of negative biopsies remained stable, changing from 7.2 to 7.3 per month, and the rate of positive biopsies increased from 8.3 to 11.2 per month. This change reduced the false negative rate (suspected cancer, negative biopsy) from 46% to 40% in the period following the intervention. The rate of target referrals leading on to cancer showed a small increase after the intervention from 2.9 to 3.3 per month.ConclusionsOur study shows that with this simple modification to the design of our laboratory request form, whereby the doctor must make an active written decision to order a PSA test, there was a significant reduction in the number of PSA requests, both in the hospital and in the community, without patient safety being compromised as measured by maintaining the number of fast-track target referrals for suspected prostate cancer and the number of prostate cancers diagnosed.