Variabilidad de la práctica clínica urológica en cáncer de próstata en España

ObjectivesStudy the opinion of the Spanish urologists regarding the main points in the diagnosis, prevention, quality of life and treatment of prostate cancer.Material and methodsAn anonymous questionnaire was administered to 290 specialists who represented the urological professional group involved in the management of prostate cancer in Spain. The following were considered in their definition: grade of professional experience, work setting, contractual relation with patient and academic character of the center. The statistical analysis was based on the study of relative frequencies for qualitative variables. The results were interpreted in 2009-10 and the final report of them was done in 2011.ResultsResponse rate collected and correctly transcribed from the forms was 96.9% (n = 281). This accounts for 10-15% of the national group. Median age was 47.7 (29-69) years and 92% were men. Mean years of professional experience were 19.1 (1-43). Responses collected regarding 153 questions were analyzed. These dealt with: a) How the diagnosis of the disease was carried out in the setting of the surveyed; b) The opinions given on the disease prevention; c) Treatment of the localized treatment; d) Treatment of the advanced disease; and e) The definition of the fields of interest for the professional.ConclusionThis survey showed important variability in some points of clinical practice in regards to the recommendations of the experts. It also shows the principal concerns of the professional, defines opportunities for training improvements and detects needs in the national urological group.     

Ganglio centinela en la metástasis ganglionar por cáncer papilar de tiroides: validez diagnóstica y aplicación en la práctica clínica

IntroductionThe presence of lymph nodes metastasis in papillary thyroid cancer modifies the type of surgical resection as well as the indication of the treatment with ¹³¹I in the postoperative period. This therapeutic approach is based on the results of the diagnostic tests, like the cervical ultrasonography. Currently other methods of diagnostic are tested as selective sentinel lymph node biopsy (SLNB). It can complement to the ultrasound results. The aim was to validate the SLNB for use in the diagnosis of lymph node metastasis by papillary thyroid cancer.MethodsObservational prospective cohort study of 55 patients who underwent papillary thyroid cancer without suspicion of lymph node involvement clinical or radiological, since February 2012 through February 2015, with a follow-up between 6 and 8 years. It was used ⁹⁹Tc with intratumoral nanocoloid and a portable tube of the gamma camera for the detection of the sentinel node. Variables: age, gender, histological, analytical and preoperative and postoperative staging. The sensitivity, specificity and predictive values of technique was calculated. The validation was determined by calculating the detectability and the false negative results of the test.ResultsIn 53 of the 55 patients (96.36%) there was the sentinel node detection. The false negative were 4 patients (7.5%). Of the rest, after applying the SLNB, 24 (48.9%) were kept as N0, 14 (28.5%) became N1a and 11 (22.4%) were classified as N1b. The differences observed in the study were significant (P < .05). The sensitivity was 86.21%, the specificity of 100%, the PPV was 100% and the NPV of 85.71%. The diagnostic accuracy was 92.45%.ConclusionsThe SLNB is a valid technique for use in patients suffering from papillary thyroid cancer with a high diagnostic accuracy.     

Asesoramiento genético en cáncer de próstata: ¿cómo implementarlo en la práctica clínica diaria?

Prostate cancer plays an undeniably prominent role in public health in our days and health systems. Its epidemiological impact is quantitatively very close to that of other tumors such as colon cancer and breast cancer, in which genetic counseling is part of their routine clinical practice, both in the initial evaluation and in the selection of therapeutic strategies. Hereditary cancer syndromes, breast/ovarian and Lynch syndrome are part of genetic counseling in these tumors. Currently, we also know that they can be associated to prostate cancer.The time has come to implement genetic counseling in prostate cancer from the earliest stages of its approach, from initial suspicion to the most advanced tumors. We present an updated review carried out by our interdisciplinary working group on scientific literature, clinical practice guidelines and consensus documents, aimed at the creation and drafting of a’Protocol for genetic counseling in prostate cancer’ for the study of germline, with easy application in different healthcare settings. This protocol is currently being implemented in our routine practice and provides answers to 3 specific questions: Who should receive genetic counseling for prostate cancer? Which gene panel should be analyzed? How should counseling be done according to the results obtained? Other aspects about who should perform genetic counseling, ethical considerations and regulations are also collected.     

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.     

Estudio genético de RNASEL en cáncer de próstata y su relación con la estadificación clínica

ObjectivesThis study has aimed to find a possible genetic relationship between sporadic prostate cancers. An attempt is made to establish population subgroups in patients based on the genotype found and the aggressiveness of the cancer.Material and methodsA total of 231 patients with sporadic prostate cancer and 68 controls were selected. The subjects were selected by an urologist using clinical parameters such as PSA level and Gleason score. Both groups (patients and controls) were genotyped in RNASEL gene by sequencing the exons 1 and 3.ResultsStatistically significant differences were found between controls and patients in some of the genotyped regions of the RNASEL gene (I97L, D541E and R462Q).ConclusionsThanks to the genetic profile in some regions of the genoma, such as the RNASEL gene, together with the combination of the clinical and environmental parameters, we can suggest a care and more personalized follow-up of each patient.     

Factores clínicos determinantes para la realización de pruebas de imagen en cáncer de próstata resistente a la castración no metastásico en la práctica clínica: resultados del estudio IDENTIFICA

IntroductionThe aim of the study was to describe the clinical drivers that lead physicians to perform imaging tests in search of metastasis in non-metastasic castration prostate resistant cancer (nmCRPC) patients.MethodsObservational, cross-sectional study conducted at the Departments of Urology of 38 Spanish hospitals. The study included 188 patients diagnosed with nmCRPC who underwent an imaging test for the assessment of metástasis. In one study visit, physicians were requested to specify the clinical factors that led them to perform these tests. The results of the imaging tests and the clinical characteristics of the patients since the time of prostate cancer (PC) diagnosis, were reported. Regression analyses were used to determine predictors of imaging test results.ResultsProstate-specific antigen (PSA) level was the most important driver to order imaging tests (57.1%), followed by regular follow-up (16.5%) and PSA doubling time (PSADT) (12.0%). Although these drivers were not associated to detection of metastasis, patients with PSA levels ≥20 ng/mL had a greater risk of metastasis than patients with PSA levels < 4ng/mL (P=.004) and CRPC patients diagnosed with metastasis (mCRPC) had higher median PSA levels (20.9; interquartile range [IQR]: 6.7-38.6) than nmCRPC (9.1; IQR: 5.0-18.0) (P=.005). Sixty-six percent of the patients did not undergo any imaging test after CRPC diagnosis until the study visit (10.6, IQR: 4.0-19.5 months). Curative-intent treatment at PC diagnosis and Gleason score predicted longer time from PC to CRPC diagnosis.ConclusionsPhysicians based their decisions to order imaging tests for metastasis detection in nmCRPC patients mainly on PSA and PSA kinetics, including the regular follow-up stated by guideline recommendations.     

Evaluación de la utilidad clínica de un cuestionario de calidad de vida relacionado con la salud en pacientes con cáncer de próstata

ObjectivesThe PROSQoLI questionnaire evaluates health related quality of life in patients with advanced prostate cancer. Although its utility in different clinical settings has never been assessed, its brevity and good measurement properties make its use recommendable in clinical practice. The objective is to evaluate the clinical usefulness of PROSQoLI in clinical treatment decision-making in patients with prostate cancer.Materials and methodsAn observational, prospective longitudinal and multi-center study conducted in different Spanish centers. Sociodemographic and clinical data of patients and researchers were collected. Each patient fulfilled PROSQoLI questionnaire in each visit. Besides, physicians answered a survey about clinical usefulness of PROSQoLI questionnaire.ResultsThe mean age of patients was 74.7 (7.4) years (standard deviation) and of researchers 51.8 (9.7) years. The usefulness in clinical decision-making was considered high by 66.1% of physicians; regarding questionnaire characteristics 71.3% of physicians considered it highly useful and 73.4% of them regarding doctor-patient communication.ConclusionsThe use of health-related quality of life questionnaires improves doctor-patient communication. It is demonstrated that PROSQoLI can be an additional tool in clinical decision-making as well as a means of facilitating doctor-patient communication     

Experiencia inicial del uso de SelectMDx® en el diagnóstico de cáncer de próstata en un entorno de práctica clínica habitual «real-world evidence»

IntroductionThe use of biomarkers in the detection of prostate cancer (PC) can decrease overdiagnosis and overtreatment of non-significant PC. We analyze the usefulness and applicability of the SelectMDx® marker in a routine clinical practice setting.Material and methodsRetrospective study of 48 patients evaluated by the SelectMDx® test between July 2017 and April 2019. Patients were stratified into two groups according to the risk estimated by the clinically significant CP test (CS-PC): < 2% or ‘very low risk’, and > 2%. Results were expressed based on previous prostate biopsy (PB) and multi-parametric magnetic resonance imaging (mpMRI) outcomes.ResultsPatients with negative PB and normal/doubtful mpMRI had < 2% risk in 7/9 cases. Patients without PB and normal/doubtful mpMRI had < 2% risk in 12/18 cases, and 2/6 cases with a > 2% risk presented CS-PC. Of the 14 patients with no previous PB or mpMRI, 9 had < 2% risk, and 2 cases were diagnosed with PC from the group of patients (5) with risk > 2%. The number of patients in the remaining subgroups is too small to draw any conclusions. In all cases with pathological digital rectal examination, the test showed a > 2% PC risk.ConclusionSelectMDx® is a promising test for detecting patients with a very low risk of CS-PC, especially in patients with suspected PC, with or without negative PB, with normal/doubtful mpMRI. The presence of a pathological digital rectal examination may condition the result of the test.     

Actualización y optimización de la vigilancia activa en cáncer de próstata en 2021

Introduction and objectivesWithin the paradigm shift of the last decade in the management of prostate cancer (PCa), perhaps the most relevant event has been the emergence of active surveillance (AS) as a mandatory strategy in low-risk disease. We carry out a critical review of the clinical, pathological and radiological improvements that allow optimizing AS in 2021.Material and methodsCritical narrative review of the literature on improvement issues and controversial aspects of AS.ResultsAdequate use of traditional criteria, optimized by enhanced biopsy and calculation of the prostate volume technique thanks to multiparametric magnetic resonance imaging (mpMRI) allow a better selection of patients for AS. This management should not be limited to patients under 60 years of age, and patients with intermediate-risk PCa should be carefully selected to be included. Biopsies are still required in the follow-up, which can be personalized according to risk patterns. The pathologist must identify the cribriform or intraductal histology on biopsies in order to exclude these patients from AS, in the same way as with patients with alterations in DNA repair genes.ConclusionsControversial indications such as the inclusion of patients from intermediate-risk groups, or the transition to active treatment due to exclusive progression in tumor volume, should be further optimized. It is possible that the future competition of tissue biomarkers, the refinement of objective parameters of mpMRI and the validation of PSA kinetics calculators may sub-stratify risk groups.     

Biopsia líquida y cáncer de próstata. Evidencia actual aplicada a la clínica

ContextDespite being a validated source of biomarkers, liquid biopsy has not yet succeeded in becoming part of the standard clinical practice in prostate cancer patients. Few biomarkers undergo adequate validation, prospective and independent, of their predictive and/or prognostic value, which results in a lack of the different available tests in the clinical practice.ObjectiveTo carry out a pragmatic synthesis of current scientific evidence on liquid biopsy for prostate cancer patients.Evidence acquisitionNon-systematic literature review, narrowing the search to papers on liquid biopsy from blood samples in prostate cancer patients. We mainly selected works evaluating clinical endpoints in prostate cancer.Evidence synthesisThe most clinically advanced forms of liquid biopsy are circulating tumor cells (CTCs) and circulating tumor DNA (ctDNA). Both CTCs and ctDNA have demonstrated their prognostic value in metastatic disease. ARV7 determination is the first predictive biomarker of the disease. Its implementation into routine clinical practice requires methodological standardization and adequate clinical validation of the different available ways to detect it. The detection of CTCs in the early stages of the disease still depends on the optimization of the diagnostic methods and on the development of the biological characterization of these cells. The biological information provided by CTCs and ctDNA is different; therefore, the study of its adequate combination is the object of cutting-edge research.ConclusionsThe absence of protocols and methodological standards is the limiting factor when aiming to reach conclusions that could have a potential impact on clinical practice. Therefore, the real short-term challenge for liquid biopsy is the establishment of consensus and common criteria.     

Manejo de la ginecomastia en pacientes con cáncer de próstata y deprivación androgénica

ContextGynecomastia, defined as benign proliferation of glandular breast tissue has a prevalence of 32% to 72% in the male. In the urology setting, it is associated to patients with prostate cancer and hormone treatment with a prevalence of 15% in the case of complete hormone blockage and 75% in monotherapy. The different options of treatment in prostate cancer have changed in recent decades. Thus, we have focused on this subject to evaluate the different therapy options of hormone manipulation induced gynecomastia in prostate cancer patients.ObjectiveTo synthesize the available evidence on the different therapeutic options in prostate cancer patients who develop gynecomastia due to the use of nonsteroidal antiandrogens and to generate a diagnostic algorithm and treatment.Acquisition of evidenceUsing the PICO type structured search strategy (Patient or problem, Intervention, Comparison, Outcome or result) in the data bases of PubMed-Medline and Cochrane, identification was made of the relevant studies related to the treatment of gynecomastia in Prostate Cancer patients treated with nonsteroidal antiandrogens.Synthesis of evidenceWe have found 3 possible therapeutic options for the treatment of gynecomastia and mastodynia in patients with hormone deprivation therapy for prostate cancer. The 10 Gy radiotherapy would be an option for the treatment of gynecomastia, although not all the patients need prophylactic treatment since only 50% report moderate-severe discomfort. Another option is the use of drugs such as tamoxifen 20 mg/day that lead to a significant decrease in the mammary effects.ConclusionsGynecomastia and mastodynia, given their high incidence, make the physical examination a fundamental tool for all patients before initiating treatment with antiandrogens. The use of tamoxifen 20 mg/day is the best treatment and prevention option against gynecomastia and mastodynia, while in the case of long-course established gynecomastia, surgery is the gold standard.     

Eficacia y seguridad de distintas cepas de BCG en el tratamiento del tumor vesical en práctica clínica habitual

Background

The natural progression of bladder tumours (nonmuscle-invasive bladder cancer [NMIBC]) is recurrence with a high rate of progression. Bacille Calmette-Guérin (BCG) has been shown effective in reducing these rates, but there are few comparative studies between strains.

Valor pronóstico de la ploidía del adn en el cáncer de próstata

ObjetiveTo asses the prognostic value of deoxyribonucleic acid (DNA) ploidy in a group of patients with prostate cancer treated with adrogenic blockadeMaterial and methodA retrospective study on 136 patients with prostatic cancer having undergone androgenic blockade was carried out. The prognostic influence of age, T and M categories, Gleason score and flow cytometry-determined DNA ploidy from survival analyses. Univariate survival analysis was carried out following Kaplan-Meier’s method, while for multivariate survival analysis Cox’s proportional hazard model was usedResultsThe univariante analysis showed that T and M categories, Gleason score and DNA ploidy have prognostic value. The Cox’s regression analysis identified DNA ploidy, metastasis and Gleason score as independent variables having prognostic potentialConclusionsDNA ploidy has independent prognostic value in prostate cancer treated with androgenic blockade and improves the predictive potential of classical prognostic factors     

Utilidad de los nuevos esquemas de agrupación de los grados de Fuhrman en la práctica clínica para el tumor renal de células claras

ObjectiveTo evaluate if re-grading renal cell carcinoma (CRCC) in two or three-tiered grading schemes versus the traditional Fuhrman classification maintains the same prognostic value.Material and methodsA study of a cohort of 383 treated CRCC with radical or partial nephrectomy between 1990-2009 was made. We analyzed the demographic data, evolution and survival of these patients. An uropathologist reassigned the Fuhrman grades blindly to the first classification. In order to study if the prognostic value was maintained with the different classification, three Cox multivariate regression analysis were performed, classifying the variable of grade into four categories: (I-II-III-IV), into three (I + II-III-IV) and into two (I + II-III + IV). The explanatory variables were: age, gender, tumor size, study stage and grade. The response variables were progression-free survival (local-regional recurrence/metastasis) and cancer specific survival time.ResultsThe median overall survival was 125 months (95% CI: 92-159). In the three multivariate analyses carried out, the Fuhrman classification showed independent predictive value (p = :0.0001) compared to progression-free survival and cancer specific survival. The predictive power was maintained in the new classifications. In the three categories, the changing from grade I + II to III meant RR: 2.31 (p = 0.0001) and from grade III to IV RR: 2.47 (p = 0.0001) and in two-tiered classification an RR: 2.8 (p = 0.001) was found when changing from I + II to III + IV.ConclusionsOur results show that categorizing the Fuhrman grade into three or two-tiered grading schemes provide the same predictive accuracy on progressive free survival and cancer specific survival. Grades III and IV have different outcomes so that the three-tiered classification seems to be more appropriate to described the course of these patients.     

Afectación prostática por carcinoma urotelial en pacientes con tumor vesical y sus implicaciones en la práctica clínica

ObjectivesUrothelial carcinoma (UC) is a multifocal disease that may develop in any location of the urinary tract, including the prostate. We analyze the types of prostate involvement due to UC, their diagnosis, risk factors and the clinical implications of this entity.Material and methodsAnalysis of original, review articles and publications related to prostate involvement due to UC. The study included works published in the period of 1985-2011, most of which were obtained from the search in PubMed.ResultsProstate involvement due to UC has been observed frequently in both non-muscle invasive bladder cancer (NMIBC) series and prolonged follow-up (39%) as in radical cystectomy series (15-48%). Prostatic involvement may occur in the mucosa and ducts (superficial involvement) or prostate stroma (invasive involvement), a fact that has prognostic and therapeutic implications. Stromal involvement may have both a bladder and intraurethral origin. Carcinoma in situ, multifocality, bladder neck/trigone cancer, and previous history of tumor recurrence are the factors that have been m ore consistently associated to prostate involvement due to UC. The incidence of prostatic involvement by UC in patients with NMIBC increases over time when risk factors exist. In these cases, a prostatic urethral biopsy should be performed during the follow-up. Conservative treatment with transurethral resection and BCG is possible in case of superficial involvement of the prostatic urethra, assuming its risk of progression. Patients subjects to cystectomy and with prostate involvement due to UC have a greater risk of urethral recurrence. The elevated incidence of prostatic adenocarcinoma and prostatic involvement by UC in cystectomy specimens makes it necessary to be very selective when indicating prostate-sparing cystectomy. Chemotherapy may be an option in an attempt to improve survival of patients with prostatic stromal involvement.ConclusionsProstatic involvement by UC is not uncommon and it has important implications in the management of patients with NMIBC and in those who have an indication for or have undergone radical cystectomy.