The role of nephrectomy in metastatic renal cell carcinoma in the immuno-oncology era

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Accuracy of standardized 12-core template biopsies versus non-standardized biopsies for detection of Epstein Grade 5 prostate cancer regarding the histology of the prostatectomy specimen

OBJECTIVE: To evaluate the effectiveness of EAU Guideline compliant transrectal ultrasound-guided 12-core prostate biopsies for detection of highly aggressive Epstein Grade 5 (Gleason Score 9-10) prostate cancer. METHODS: Two hundred ninety-nine patients, treated by radical prostatectomy for prostate cancer, have been prospectively recorded in a database and were evaluated for this study. Pre-operatively, all patients received transrectal ultrasound-guided biopsies according to inhomogeneous templates chosen by the referring urologist. We evaluated the outcomes according to a stratified group-analysis: Group 1 received less than 12 biopsies, Group 2 received more than 12 biopsies, and Group 3 received exactly 12 biopsies, according to the EAU Guidelines template. After surgical removal of the prostate, 12 EAU Guideline-templated biopsies were performed in all prostatectomy specimens, directly after the surgery. Pre-operative and post-operative Epstein Grade 5 biopsy detection rates were thereafter correlated with these prostatectomy specimens. RESULTS: In prostatectomy specimens, the histology of 12 patients (4.0%) were Epstein Grade 1, 31 patients (10.5%) were Epstein Grade 2, 190 patients (63.5%) were Epstein Grade 3, 27 patients (9%) were Epstein Grade 4, and 39 patients (13%) were Epstein Grade 5. The detection rate of Epstein Grade 5 compared to the radical prostatectomy specimen was: Group 1: 23.0% pre-operatively and 61.5% post-operatively, Group 2: 33.3% pre-operatively and 58.3% post-operatively; and Group 3: 57.1% pre-operatively and 64.2% post-operatively. CONCLUSION: Detection rates of highly aggressive Epstein Grade 5 prostate cancer vary considerably according to the biopsy technique. EAU Guideline compliant 12-core template biopsies increase the detection rates of Epstein Grade 5 prostate cancer. © 2018 Wiley Periodicals, Inc

Accuracy of standardized 12-core template biopsies versus non-standardized biopsies for detection of Epstein Grade 5 prostate cancer regarding the histology of the prostatectomy specimen

OBJECTIVE: To evaluate the effectiveness of EAU Guideline compliant transrectal ultrasound-guided 12-core prostate biopsies for detection of highly aggressive Epstein Grade 5 (Gleason Score 9-10) prostate cancer. METHODS: Two hundred ninety-nine patients, treated by radical prostatectomy for prostate cancer, have been prospectively recorded in a database and were evaluated for this study. Pre-operatively, all patients received transrectal ultrasound-guided biopsies according to inhomogeneous templates chosen by the referring urologist. We evaluated the outcomes according to a stratified group-analysis: Group 1 received less than 12 biopsies, Group 2 received more than 12 biopsies, and Group 3 received exactly 12 biopsies, according to the EAU Guidelines template. After surgical removal of the prostate, 12 EAU Guideline-templated biopsies were performed in all prostatectomy specimens, directly after the surgery. Pre-operative and post-operative Epstein Grade 5 biopsy detection rates were thereafter correlated with these prostatectomy specimens. RESULTS: In prostatectomy specimens, the histology of 12 patients (4.0%) were Epstein Grade 1, 31 patients (10.5%) were Epstein Grade 2, 190 patients (63.5%) were Epstein Grade 3, 27 patients (9%) were Epstein Grade 4, and 39 patients (13%) were Epstein Grade 5. The detection rate of Epstein Grade 5 compared to the radical prostatectomy specimen was: Group 1: 23.0% pre-operatively and 61.5% post-operatively, Group 2: 33.3% pre-operatively and 58.3% post-operatively; and Group 3: 57.1% pre-operatively and 64.2% post-operatively. CONCLUSION: Detection rates of highly aggressive Epstein Grade 5 prostate cancer vary considerably according to the biopsy technique. EAU Guideline compliant 12-core template biopsies increase the detection rates of Epstein Grade 5 prostate cancer. © 2018 Wiley Periodicals, Inc

MRI as a screening tool for prostate cancer: current evidence and future challenges

PurposeProstate cancer (PCa) screening, which relies on prostate-specific antigen (PSA) testing, is a contentious topic that received negative attention due to the low sensitivity and specificity of PSA to detect clinically significant PCa. In this context, due to the higher sensitivity and specificity of magnetic resonance imaging (MRI), several trials investigate the feasibility of "MRI-only" screening approaches, and question if PSA testing may be replaced within prostate cancer screening programs.MethodsThis narrative review discusses the current literature and the outlook on the potential of MRI-based PCa screening.ResultsSeveral prospective randomized population-based trials are ongoing. Preliminary study results appear to favor the "MRI-only" approach. However, MRI-based PCa screening programs face a variety of obstacles that have yet to be fully addressed. These include the increased cost of MRI, lack of broad availability, differences in MRI acquisition and interpretation protocols, and lack of long-term impact on cancer-specific mortality. Partly, these issues are being addressed by shorter and simpler MRI approaches (5-20 min bi-parametric MRI), novel quality indicators (PI-QUAL) and the implementation of radiomics (deep learning, machine learning).ConclusionAlthough promising preliminary results were reported, MRI-based PCa screening still lack long-term data on crucial endpoints such as the impact of MRI screening on mortality. Furthermore, the issues of availability, cost-effectiveness, and differences in MRI acquisition and interpretation still need to be addressed

Prospective randomized trial comparing titanium clips to bipolar coagulation in sealing lymphatic vessels during pelvic lymph node dissection at the time of robot-assisted radical prostatectomy

Lymphocele is the most common complication after pelvic lymph node dissection (PLND). Over the years, various techniques have been introduced to prevent lymphocele, but no final conclusion can be drawn regarding the superiority of one technique over another. In this prospective study, 220 patients undergoing robot-assisted radical prostatectomy between 2012 and 2015 were randomized to receive titanium clips (group A, n=110) or bipolar coagulation (group B, n=110) to seal lymphatic vessels at the level of the femoral canal during extended PLND (ePLND). Ultrasound examination was used to detect lymphoceles at 10 and 90 d after surgery. Lymphocele was defined as any clearly definable fluid collection and was considered clinically significant when requiring treatment. There were no statistically significant differences between groups A and B regarding overall lymphocele incidence (47% vs 48%; difference -0.91%, 95% confidence interval [CI] -2.6 to 0.7; p=0.9) and the rate of clinically significant lymphocele [5% vs 4%; difference 0.75%, 95% CI, 0.1-3.2; p=0.7]. The two groups were comparable regarding mean (±SD) lymphocele volume (30±32 vs 35±39ml; p=0.6), lymphocele location (unilateral, 37% vs 35%, p=0.7; bilateral, 13% vs 14%, p=0.9), and time to lymphocele diagnosis (95% vs 98% on postoperative day 10; p=0.5). In conclusion, this trial failed to identify a difference in lymphocele occurrence between clipping and coagulation of the lymphatic vessels at the level of the femoral canal during robot-assisted ePLND for prostate cancer. PATIENT SUMMARY: In this study we compared the frequency of postoperative complications after sealing lymphatic vessels from the leg to the abdomen using metallic clips or electrical coagulation during robot-assisted surgery for prostate cancer. We found no difference in postoperative complications between the two methods

Cystatin C predicts renal function impairment after partial or radical tumor nephrectomy

Purpose: To test the value of preoperative and postoperative cystatin C (CysC) as a predictor on kidney function after partial (PN) or radical nephrectomy (RN) in renal cell carcinoma (RCC) patients with normal preoperative renal function. Methods: From 01/2011 to 12/2014, 195 consecutive RCC patients with a preoperative estimated glomerular filtration rate (eGFR) > 60 ml/min/1.73m2 underwent surgical RCC treatment with either PN or RN. Logistic and linear regression models tested for the effect of CysC as a predictor of new-onset chronic kidney disease in follow-up (eGFR < 60 ml/min/1.73m2). Moreover, postoperative CysC and creatinine values were compared for kidney function estimation. Results: Of 195 patients, 129 (66.2%) underwent PN. In postoperative and in follow-up setting (median 14 months, IQR 10–20), rates of eGFR < 60 ml/min/1.73m2 were 55.9 and 30.2%. In multivariable logistic regression models, preoperative CysC [odds ratio (OR): 18.3] and RN (OR: 13.5) were independent predictors for a reduced eGFR < 60 ml/min/1.73m2 in follow-up (both p < 0.01), while creatinine was not. In multivariable linear regression models, a difference of the preoperative CysC level of 0.1 mg/dl estimated an eGFR decline in follow-up of about 5.8 ml/min/1.73m2. Finally, we observed a plateau of postoperative creatinine values in the range of 1.2–1.3 mg/dl, when graphically depicted vs. postoperative CysC values (‘creatinine blind area’). Conclusion: Preoperative CysC predicts renal function impairment following RCC surgery. Furthermore, CysC might be superior to creatinine for renal function monitoring in the early postoperative setting

PSMA-ligand uptake can serve as a novel biomarker in primary prostate cancer to predict outcome after radical prostatectomy

Background!#!The prostate-specific membrane antigen (PSMA) is a relevant target in prostate cancer, and immunohistochemistry studies showed associations with outcome. PSMA-ligand positron emission tomography (PET) is increasingly used for primary prostate cancer staging, and the molecular imaging TNM classification (miTNM) standardizes its reporting. We aimed to investigate the potential of PET-imaging to serve as a noninvasive imaging biomarker to predict disease outcome in primary prostate cancer after radical prostatectomy (RP).!##!Methods!#!In this retrospective analysis, 186 primary prostate cancer patients treated with RP who had undergone a !##!Results!#!At a median follow-up after RP of 38 months (interquartile range (IQR) 22-53), biochemical recurrence (BCR) was observed in 58 patients during the follow-up period. A significant association between a positive surgical margin and miN status (miN1 vs. miN0, odds ratio (OR): 5.428, p = 0.004) was detected. miT status (miT ≥ 3a vs. miT &amp;lt; 3, OR: 2.696, p = 0.003) was identified as an independent predictor for Gleason score (GS) ≥ 8. Multivariate Cox regression analysis indicated that PSA level (hazard ratio (HR): 1.024, p = 0.014), advanced GS (GS ≥ 8 vs. GS &amp;lt; 8, HR: 3.253, p &amp;lt; 0.001) and miT status (miT ≥ 3a vs. miT &amp;lt; 3, HR: 1.941, p = 0.035) were independent predictors for BCR. For stage I disease as determined by PET-imaging, a shorter BCR-free survival was observed in the patients with higher SUV!##!Conclusion!#!Preoperative miTNM classification fro

Non‐cancer mortality in elderly prostate cancer patients treated with combination of radical prostatectomy and external beam radiation therapy

Background: To test for rates of other cause mortality (OCM) and cancer-specific mortality (CSM) in elderly prostate cancer (PCa) patients treated with the combination of radical prostatectomy (RP) and external beam radiation therapy (EBRT) versus RP alone, since elderly PCa patients may be over-treated. Methods: Within the Surveillance, Epidemiology and End Results database (2004–2016), cumulative incidence plots, after propensity score matching for cT-stage, cN-stage, prostate specific antigen, age and biopsy Gleason score, and multivariable competing risks regression models (socioeconomic status, pathological Gleason score) addressed OCM and CSM in patients (70–79, 70–74, and 75–79 years) treated with RP and EBRT versus RP alone. Results: Of 18,126 eligible patients aged 70–79 years, 2520 (13.9%) underwent RP and EBRT versus 15,606 (86.1%) RP alone. After propensity score matching, 10-year OCM rates were respectively 27.9 versus 20.3% for RP and EBRT versus RP alone (p < .001), which resulted in a multivariable HR of 1.4 (p < .001). Moreover, 10-year CSM rates were respectively 13.4 versus 5.5% for RP and EBRT versus RP alone. In subgroup analyses separately addressing 70–74 year old and 75–79 years old PCa patients, 10-year OCM rates were 22.8 versus 16.2% and 39.5 versus 24.0% for respectively RP and EBRT versus RP alone patients (all p < .001). Conclusion: Elderly patients treated with RP and EBRT exhibited worrisome rates of OCM. These higher than expected OCM rates question the need for combination therapy (RP and EBRT) in elderly PCa patients and indicate the need for better patient selection, when combination therapy is contemplated