Search

The impact of germline mutations associated with hereditary cancer syndromes in patients on active surveillance (AS) for prostate cancer is poorly defined. We examined the association between family history of prostate cancer (FHP) or family history of cancer (FHC) and risk of progression or adverse pathology at radical prostatectomy (RP) in patients on AS.Patients on AS at a single tertiary-care center between 2000-2019 were categorized by family history. Disease progression was defined as an increase in Gleason grade on biopsy. Adverse pathology was defined as upgrading/upstaging at RP. Multivariable Cox and logistic regression models were used to assess association between family history and time to progression or adverse pathology, respectively.Among 3,211 evaluable patients, 669 (21%) had FHP, 34 (1%) had FHC and 95 (3%) had both; 753 progressed on AS and 481 underwent RP. FHP was associated with increased risk of progression (HR 1.31; 95% CI, 1.11-1.55; p=0.002) but FHC (HR 0.67; 95% CI, 0.30-1.50; p=0.3) or family history of both (HR 1.22; 95% CI, 0.81-1.85; p=0.3) were not. FHP, FHC or both were not associated with adverse pathology at RP (p0.4).While FHP was associated with an increased risk of progression on AS, wide confidence intervals render this outcome of unclear clinical significance. FHC was not associated with risk of progression on AS. In the absence of known genetically defined hereditary cancer syndrome, we suggest FHP and/or FHC should not be used as a sole trigger to preclude patients from enrolling on AS.

PURPOSE: Many patients will experience symptoms in the initial days after radical prostatectomy (RP), but early patient-reported symptoms have not been well-characterized. Our objective was to illustrate the pattern of symptoms experienced after RP and the relation of severe symptoms to postoperative complications. METHODS: In 2016, electronic patient-reported symptom monitoring began at our institution’s ambulatory surgery center. We retrospectively reviewed patients treated with minimally-invasive RP, who were sent a daily questionnaire completed using a web-interface until postoperative day 10. Severe symptoms automatically generate a “yellow alert,” which messages the clinic, while very severe symptoms generate a “red alert,” additionally prompting the patient to call. We summarized rates of moderate-to-very severe symptoms and fit local polynomial regressions. We compared rates of 30- or 90-d complications (≥grade 2) based on the presence of alert symptoms. RESULTS: Of 2266 men undergoing RP, 1942 (86%) completed surveys. Among moderate-to-very severe symptom levels, pain (72%) and dyspnea (11%) were most common. Pain, nausea, and dyspnea consistently decreased over time; fever and vomiting had a flat pattern. In patients experiencing red-alert symptoms, we observed a higher risk of 30-d complications, but rates were low and differences between groups were non-significant (2.9% vs 1.9%; difference 1.1%; 95% CI -1.3%−3.5%; p = 0.3). Results were similar examining 90-d complications. CONCLUSIONS: While symptoms are common after RP, substantial improvements occur over the first 10 d. Severe or very severe symptoms conferred at most a small absolute increase in complication risk, which should be reassuring to patients and clinicians.

BACKGROUND AND OBJECTIVE: Prophylactic antibiotics are routinely given at the time of catheter removal post radical prostatectomy (RP). The low rate of infectious complications entails that large sample sizes are required for randomized controlled trials (RCTs), a challenge given the cost of standard RCTs. We evaluated infectious complications associated with 1 vs 3 days of prophylactic antibiotics at the time of catheter removal post RP using a novel, clinically-integrated trial with randomization at the surgeon level. METHODS: Surgeons were cluster randomized for periods of 3 months to prescribe 1-day versus 3-day regimen of prophylactic antibiotics at the time of catheter removal. The primary endpoint was an infectious complication as routinely captured by nursing phone call within 10 days of catheter removal and defined as: positive urine cultures (≥10(5) CFU) and at least 1 of the following symptoms: fever (>38C), urgency, frequency, dysuria or suprapubic tenderness. RESULTS: A total of 824 patients were consented and underwent RP, with respectively, 389 and 435 allocated to 1-and 3-day antibiotics, predominately ciprofloxacin. Accrual was achieved within 3 years: 95% and 88% of patients received the allocated 3-day or 1-day antibiotic regimen, respectively. There was 0 UTI (0%) in the 1-day regimen and 3 UTIs (0.7%) in the 3-day regimen, meeting our prespecified criterion for declaring the 1-day regimen to be non-inferior. CONCLUSION: A clinically integrated trial using cluster randomization accrued rapidly with no important logistical problems and negligible burden on surgeons. If surgeons choose to prescribe empiric prophylactic antibiotics after catheter removal following RP, then the duration should not exceed 1 day.

PURPOSE: We implemented an advanced practice provider (APP)-led clinic to aid in managing the growing population of men on active surveillance (AS) for prostate cancer. Our objective was to evaluate the quality and safety of an established APP-led AS clinic by comparing outcomes with urologist-led biopsies, defined in terms of adherence to scheduled visits and biopsy complications. MATERIALS AND METHODS: We performed a retrospective review of 2341 consecutive patients treated in an AS clinic at a high-volume referral center between 2000–2019. We examined the rate of no-show or same-day cancellation of visits for APPs versus urologists and compared the risk of biopsy complications between these providers. Generalized estimating equations were used to account for repeated visits and biopsies. RESULTS: There were significantly more no-shows at APP visits (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.16–1.70, p

BACKGROUND: Active surveillance (AS) protocols rely on rectal examination, prostate-specific antigen, imaging, and biopsy to identify disease progression. OBJECTIVE: To evaluate whether an AS regimen based on magnetic resonance imaging (MRI) or clinical stage changes can detect reclassification to grade group (GG) ≥2 disease compared with scheduled systematic biopsies. DESIGN, SETTING, AND PARTICIPANTS: We identified a cohort of men initiated on AS between January 2013 and April 2016 at a single tertiary-care center. Patients completed confirmatory testing and prostate MRI prior to enrollment, then underwent laboratory and physical evaluation every 6 mo, MRI every 18 mo, and biopsy every 3 yr. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: MRI results were evaluated using composite Likert/Prostate Imaging Reporting and Data System v2 scoring. MRI and clinical changes were assessed for association with disease progression. Univariable and multivariable regression models were used to predict upgrading on 3-yr biopsy. RESULTS AND LIMITATIONS: At 3 yr, of 207 men, 66 (32%) had ≥GG2 at biopsy: 55 (83%) with GG2, 10 (15%) with GG3, and one (1.5%) with GG4. Among patients with a 3-yr MRI score of ≥3, 41% had ≥GG2 disease, compared with 15% with an MRI score of

OBJECTIVE To examine a set of proposed eligibility factors for hemi-ablative focal therapy in prostate cancer and to determine the likelihood of residual extensive disease. METHODS We retrospectively analyzed data from 98 patients with unilateral prostate cancer on biopsy with detailed tumor maps from whole-mount slides and preoperative magnetic resonance imaging data. These patients met the focal therapy consensus meeting inclusion criteria (prostate-specific antigen

Androgen deprivation therapy as single modality therapy was the standard management for oligometastatic prostate cancer (PCa). Current paradigm shifts toward a multimodality therapy approach, targeting all sites of disease, including treatment of the primary in the form of radical prostatectomy or radiation therapy. The objective of this article was to reveiw the literature regarding the role of surgery in oligometastatic PCa. PubMed and MEDLINE electronic databases were queried for English language articles from January 1, 1980 to March 31, 2019. Keywords use included oligometastatic PCa, metastatic prostate cancer (mPCa), radical prostatectomy, and cytoreductive prostatectomy. Preclinical, prospective, and retrospective studies were included. There is no published randomized controlled trials, evaluating the role of surgery in mPCa. Preclinical and retrospective data suggest benefit of primary tumor treatment in mPCa. Current literature supports the concept of cytoreductive surgery as it can prevent late symptomatic local progression, has acceptable complications, and may prolong survival in patients with mPCa. Surgery is a feasible procedure in mPCa which may improve outcome in mPCa. However, there is no Level 1 evidence, yet that support the role of surgery in mPCa. The results from well-organized prospective, randomized controlled trials are awaited before performing radical prostatectomy for mPCa in clinical practice. Keywords: Cytoreductive radical prostatectomy, Metastatic prostate cancer, Oligometastatic prostate cancer, Radical prostatectomy, Surgery in metastatic, Treatment of primary tumor

INTRODUCTION AND OBJECTIVE:Tumor sequencing is increasingly used for therapeutic selection in men with advanced prostate cancer (PC). If tumor-only sequencing is performed without matched germline,...

Hypothesis: Partial Nephrectomy is oncological safe in patients with pT3a RCC. Purpose: To compare the oncological and functional outcomes of patients with pT3a RCC scheduled for PN and RN. Materials and Methods: We retrospectively reviewed patients with pT3a N0 M0 RCC who underwent partial or radical nephrectomy from 2005 to 2016. Perioperative characteristics, including estimated glomerular filtration rate, tumor size, pathological histology, and RENAL nephrometry score, were compared between patients scheduled for partial or radical nephrectomy. We used multivariable Cox proportional hazards regression models to compare overall survival, cancer-specific survival, and recurrence-free survival between planned procedure type. Results: Of the 589 patients, 369 (63%) and 220 (37%) were scheduled for radical and partial nephrectomy, respectively; 26 (12%) of the scheduled partial nephrectomy cases were intraoperatively converted to radical nephrectomy. After adjusting for tumor size and histology, there were no statistically significant differences in overall survival (hazard ratio 0.66; 95% CI, 0.38–1.13), cancer-specific survival (hazard ratio 0.53; 95% CI, 0.16–1.75), or recurrence-free survival (hazard ratio 0.66; 95% CI, 0.34–1.28) between patients scheduled for partial or radical nephrectomy. Fewer patients scheduled for partial nephrectomy had estimated glomerular filtration rate reductions 3 to 9 months after surgery than patients scheduled for radical nephrectomy. Conclusion: We found no evidence that patients scheduled to undergo partial nephrectomy had poorer oncologic outcomes than patients scheduled to undergo radical nephrectomy. In select patients with pT3a renal cell carcinoma in whom partial nephrectomy is deemed feasible by the surgeon, partial nephrectomy should not be discouraged.

Although important advances have been achieved in the development of radiolabeled prostate-specific membrane antigen (PSMA)-targeting ligand constructs for both diagnosis and therapy of prostate cancer (PCa) over the past decade, challenges related to off-target effects and limited treatment responses persist. In this study, which builds upon the successful clinical translation of a series of ultrasmall, dye-encapsulating core-shell silica nanoparticles, or Cornell Prime Dots (C′ dots), for cancer management, we sought to address these limitations by designing a dual-modality, PSMA-targeting platform that evades undesirable accumulations in the salivary glands, kidneys, and reticuloendothelial system, while exhibiting bulk renal clearance. This versatile PCa-targeted particle imaging probe offers significant clinical potential to improve future theranostic applications in a variety of patient care settings.

Background Pelvic lymph node dissection (PLND) is the most reliable procedure for lymph node staging. However, the therapeutic benefit remains unproven; although most radical prostatectomies at academic centers are accompanied by PLND, there is no consensus regarding the optimal anatomical extent of PLND. Objective To evaluate whether extended PLND results in a lower biochemical recurrence rate. Design, setting, and participants We conducted a single-center randomized trial. Patients, enrolled between October 2011 and March 2017, were scheduled to undergo radical prostatectomy and PLND. Patients were assigned to limited or extended PLND by cluster randomization. Specifically, surgeons were randomized to perform limited or extended PLND for 3-mo periods. Intervention Randomization to limited (external iliac nodes) or extended (external iliac, obturator fossa and hypogastric nodes) PLND. Outcome measurements and statistical analysis The primary endpoint was the rate of biochemical recurrence. Results and limitations Of 1440 patients included in the final analysis, 700 were randomized to limited PLND and 740 to extended PLND. The median number of nodes retrieved was 12 (interquartile range [IQR] 8–17) for limited PLND and 14 (IQR 10–20) extended PLND; the corresponding rate of positive nodes was 12% and 14% (difference −1.9%, 95% confidence interval [CI] −5.4% to 1.5%; p = 0.3). With median follow-up of 3.1 yr, there was no significant difference in the rate of biochemical recurrence between the groups (hazard ratio 1.04, 95% CI 0.93–1.15; p = 0.5). Rates for grade 2 and 3 complications were similar at 7.3% for limited versus 6.4% for extended PLND; there were no grade 4 or 5 complications. Conclusions Extended PLND did not improve freedom from biochemical recurrence over limited PLND for men with clinically localized prostate cancer. However, there were smaller than expected differences in nodal count and the rate of positive nodes between the two templates. A randomized trial comparing PLND to no node dissection is warranted. Patient summary In this clinical trial we did not find a difference in the rate of biochemical recurrence of prostate cancer between limited and extended dissection of lymph nodes in the pelvis. This study is registered on ClinicalTrials.gov as NCT01407263.

Introduction & Objectives: multifocal synchronous renal cancer on a solitary kidney represent a challenging clinical scenario. The complexity of imperative nephron-sparring surgery in this setting resides in ensuring complete excision of cancer with the maximal preservation of renal function. We aim to present a case of multiple partial nephrectomy (MPN) for multifocal synchronous renal cancer in a patient with a solitary kidney and discuss our experience of imperative partial in this setting. Materials & Methods: We present a case of a 76 years old man with a past medical history of hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, left radical nephrectomy for renal mass (2006) and a right renal artery stent placement for renal artery stenosis. During his surveillance, computerized axial tomography (CAT) scan showed 3 enhancing renal masses (2.2cm, 1.5cm and 1cm, respectively). Biopsy of the largest mass was consistent in clear cell renal cell carcinoma (ccRCC). Preoperative level of creatinine was 1.4mg/dL and estimated glomerular filtration rate (eGFR) 50ml/min/1,73m2. After ablative therapy was deemed unsafe, a MPN was planned.

Our purpose was to evaluate the performance of (11)C-choline PET/CT in detecting biochemically recurrent prostate cancer (PCa) in a large non-European cohort (in the context of emerging evidence for prostate-specific membrane antigen PET in this setting) and to map patterns of PCa recurrence. Methods: We retrospectively analyzed (11)C-choline PET/CT scans from 287 patients who were enrolled in an imaging protocol based on rising prostate-specific antigen (PSA) levels (mean, 3.43 ng/mL; median, 0.94 ng/mL; range, 0.15–89.91 ng/mL) and suspected recurrent PCa. A total of 187 patients had undergone primary radical prostatectomy (RP) (79/187 had secondary radiotherapy), 30 had undergone primary radiotherapy, and 70 had a persistent PSA elevation after receiving initial treatment (69 after RP, 1 after radiotherapy). The level of suspicion for recurrence on (11)C-choline PET/CT was scored (0, negative; 1, equivocal; 2, positive) by 2 readers. The correlation between (11)C-choline PET/CT positivity and initial treatment, Gleason score, National Comprehensive Cancer Network stage, PSA level, PSA doubling time, PSA velocity, and time between initial treatment and PET imaging was evaluated. Prostate Cancer Molecular Imaging Standardized Evaluation (PROMISE) criteria were used to map (11)C-choline recurrence patterns. Results: Considering scores 1 and 2 as positives, consensus between the 2 readers deemed 66% of the (11)C-choline PET/CT scans as positive. When sorted by PSA level, 45% of patients with a PSA of less than 0.5 ng/mL, 56% of patients with a PSA of 0.5–0.99 ng/mL, 70% of patients with a PSA of 1.0–1.99 ng/mL, and 90% of patients with a PSA of at least 2.0 ng/mL scored either 1 or 2 on (11)C-choline PET/CT scans. When considering scores of 2 only, (11)C-choline PET/CT positivity was 54% (28%, 46%, 62%, and 81%, respectively, for patients with PSA < 0.5 ng/mL, 0.5–0.99 ng/mL, 1.0–1.99 ng/mL, and ≥ 2.0 ng/mL). In multivariate analysis, only PSA level was significantly associated with scan positivity. Pattern analysis showed that pelvic lymph nodes were the most common site of recurrence, and 28% of patients had (11)C-choline–positive suspected recurrences outside the initial treatment field. Conclusion: (11)C-choline PET/CT can detect PCa recurrence even among patients with low PSA levels when interpretation accounts for the clinical context, providing a certain pretest probability. Until prostate-specific membrane antigen agents are fully approved for PCa, choline PET/CT may provide clinical utility.

INTRODUCTION AND OBJECTIVE:Pelvic lymph node dissection (PLND) in prostate cancer is controversial. Although it represents the most reliable procedure for lymph node staging, the extended PLND was ...

INTRODUCTION AND OBJECTIVE:Located below the inguinal ligament and anterior to Cooper’s ligament, Cloquet’s node is easily accessible and commonly dissected during pelvic lymph node dissection for ...

INTRODUCTION AND OBJECTIVE:Hereditary germline mutations (HGM) in prostate cancer (PCa) patients are associated with aggressive disease, with some mutations having therapeutic and prognostic implic...

PURPOSE: To study the risk of metastatic prostate cancer development in men with Grade Group 2 disease being managed with active surveillance (AS) at Memorial Sloan Kettering Cancer Center. MATERIALS AND METHODS: 219 men with Grade Group 2 prostate cancer were managed with AS between 2000–2017. Biopsy was performed every 2–3 years or upon changes in magnetic resonance imaging, prostate-specific antigen (PSA) level, or digital rectal examination. The primary outcome was development of distant metastasis. The Kaplan-Meier method was used to estimate treatment-free survival. RESULTS: The median age at diagnosis was 67 years (IQR 61, 72), the median PSA was 5 ng/mL (IQR 4, 7), and most patients (69%) had non-palpable disease. During follow-up, 64 men received treatment: 36/64 (56%) radical prostatectomy; 20/64 (31%) radiotherapy; 3/64 (5%) hormone therapy; and 5/64 (8%) focal therapy. Of the 36 patients who underwent radical prostatectomy, 32/36 (89%) had Grade Group 2 disease on pathology and 4/36 (11%) had Grade Group 3. Treatment-free survival was 61% (95% CI 52%–70%) at 5 years and 49% (95% CI 37%–60%) at 10 years. Three men experienced biochemical recurrence, no men developed distant metastasis, and no men died of prostate cancer during the follow-up. The median follow-up was 3.1 years (IQR 1.9, 4.9). CONCLUSIONS: AS appears to be a safe initial management strategy in the short term for carefully selected and closely monitored men with Grade Group 2 prostate cancer managed at a tertiary cancer center. Definitive conclusions await further follow-up.

We report oncologic outcomes for men with Grade Group 1 prostate cancer managed with active surveillance at a tertiary cancer center.A total of 2,907 patients were managed with active surveillance between 2000 and 2017, of whom 2,664 had Grade Group 1 disease. Patients were recommended confirmatory biopsy to verify eligibility and were followed semiannually with prostate specific antigen, digital rectal examination and review of symptoms. Magnetic resonance imaging was increasingly used in recent years. Biopsy was repeated every 2 to 3 years or after a sustained prostate specific antigen increase or changes in magnetic resonance imaging/digital rectal examination. The Kaplan-Meier method was used to estimate probabilities of treatment, progression and development of metastasis.Median patient age at diagnosis was 62 years. For men with Grade Group 1 prostate cancer the treatment-free probability at 5, 10 and 15 years was 76% (95% CI 74-78), 64% (95% CI 61-68) and 58% (95% CI 51-64), respectively. At 5, 10 and 15 years there were 1,146, 220 and 25 men at risk for metastasis, respectively. Median followup for those without metastasis was 4.3 years (95% CI 2.3-6.9). Distant metastasis developed in 5 men. Upon case note review only 2 of these men were deemed to have disease that could have been cured on immediate treatment. The risk of distant metastasis was 0.6% (95% CI 0.2-2.0) at 10 years.Active surveillance is a safe strategy over longer followup for appropriately selected patients with Grade Group 1 disease following a well-defined monitoring plan.

PURPOSE: Active surveillance (AS) is often restricted to patients with low-risk prostate cancer (PCa) with three or fewer positive cores. We aimed to identify predictors of adverse pathology for low-risk PCa treated with radical prostatectomy (RP) and to determine if a threshold number of positive cores could help the decision process for AS. MATERIALS AND METHODS: A total of 3,359 men with low-risk PCa underwent RP between January 2000 and August 2016. We analyzed the relationship between biopsy core features and adverse pathology at RP, defined as grade group (GrdGrp) ≥3, seminal vesicle invasion (SVI), or lymph node involvement (LNI). RESULTS: Of the 171 (5.1%) patients with adverse pathology at RP, 144 (4.3%) were upgraded to GrdGrp ≥3, 31 (0.9%) had SVI, and 15 (0.4%) had LNI. Prostate-specific antigen and age were the only predictors of adverse pathology; there was no significant association with number of positive cores, total millimeters of cancer, or maximum percentage of cancer in any core. When we expanded the definition of adverse pathology to include GrdGrp 2 and extraprostatic extension, the association between core features and outcome, while statistically significant, was clinically weak, with no evidence of threshold effects. CONCLUSIONS: There is little basis for excluding patients with otherwise low-risk PCa on biopsy from AS based on criteria such as the number of positive cores or maximum cancer involvement of biopsy cores.

Background Salvage partial gland ablation (sPGA) has been proposed to treat some localized radiorecurrent prostate cancer. The role of prostate biopsy and magnetic resonance imaging (MRI) characteristics to identify patients eligible for sPGA is unknown. Objective To evaluate the ability of MRI and prostate biopsy characteristics to identify an index lesion suitable for sPGA and validate this selection using detailed tumor maps created from whole-mount slides from salvage radical prostatectomy (sRP) specimens. Design, setting, and participants Men who underwent sRP for recurrent prostate cancer following primary radiotherapy with external beam radiotherapy (EBRT) and/or brachytherapy between 2000 and 2014 at a single high-volume cancer center were eligible. Those with tumor maps, MRI and biopsy data were included in analysis. Outcome measurements and statistical analysis Primary outcome was the ability of clinicopathologic and imaging criteria to identify patients who may be eligible for sPGA based on detailed tumor map from whole-mount sRP slides. Results and limitations Of 216 men who underwent sRP following whole gland radiotherapy, tumor maps, MRI, and biopsy data were available for 77. Of these, 15 (19%) were determined to be eligible for sPGA based on biopsy-proven unilateral disease in contiguous sextant segments, a dominant lesion on MRI concordant with biopsy location or no focal region of interest, and no imaging evidence of extraprostatic disease. Review of tumor maps identified 6 additional men who would have met criteria for sPGA, resulting in sensitivity of 71% (95% C.I. 48%–89%) and specificity of 100% (lower bound of 95% C.I. 94%). None of the 15 men who met the criteria for sPGA on clinical data were identified incorrectly on tumor maps to require full gland surgery (upper bound of 95% C.I. 22%). Median tumor volume of the index lesion was 0.4 cc and recurrent cancer was noted in the apex, mid-gland, and base in 81%, 100%, and 29% of men. Conclusions In men with recurrent prostate cancer after radiotherapy, biopsy findings and MRI can be used to select index lesions potentially amenable for sPGA and can guide patient evaluation for inclusion in clinical trials of sPGA following radiation failure. Larger, prospective studies are required to evaluate both the role of MRI and clinical criteria in guiding focal salvage therapy and the effectiveness of this modality for radiorecurrent prostate cancer.

Resumen Introduccion Es necesaria una toma de imagenes precisa y fiable para mejorar el manejo del cancer de prostata. Durante los ultimos anos la PET/TC colina ha cambiado el manejo del cancer de prostata en Europa, y se utiliza comunmente para la estadificacion inicial o para diagnostico de la recurrencia bioquimica, aunque no carece de limitaciones. Otros marcadores estan a prueba, incluyendo el ligando del antigeno prostatico especifico de membrana (PSMA), que parece ofrecer perspectivas alentadoras. El objetivo de este trabajo fue revisar criticamente la actuacion de la colina y PSMA PET/TC en el cancer de prostata. Adquisicion de la evidencia Se realizo una revision sistematica de la literatura en la base de datos PUBMED/MEDLINE y EMBASE mediante la busqueda de articulos de texto completo en ingles publicados en el marcador PET en el cancer de prostata en la aplicacion clinica. Sintesis de la evidencia y Discusion Parece que 68Ga-PSMA PET/TC es mejor que PET/TC en el cancer de prostata para la deteccion de lesiones de prostata primarias, la deteccion inicial de metastasis en los ganglios linfaticos y la recurrencia. Sin embargo, se necesitan mas estudios para obtener pruebas de alto nivel. Ademas, en esta revision se analizan futuros otros marcadores de PET. Por otra parte, la aparicion de una nueva camara PET/RM puede cambiar el rendimiento de la toma de imagenes mediante PET.

Introduction There is a need for a precise and reliable imaging to improve the management of prostate cancer. In recent years the PET/CT with choline has changed the handling of prostate cancer in Europe, and it is commonly used for initial stratification or for the diagnosis of a biochemical recurrence, although it does not lack limitations. Other markers are being tested, including the ligand of prostate-specific membrane antigen (PSMA), that seems to offer encouraging prospects. The goal of this piece of work was to critically review the role of choline and PSMA PET/CT in prostate cancer. Evidence acquisition A systematic literature review of databases PUBMED/MEDLINE and EMBASE was conducted searching for articles fully published in English on the PET marker in prostate cancer and its clinical application. Evidence synthesis and discussion It seems as 68Ga-PSMA PET/CT is better than PET/CT in prostate cancer to detect primary prostate lesions, initial metastases in the lymph nodes and recurrence. However, further research is required to obtain high-level tests. Also, other PET markers are studied. Moreover, the emergence of a new PET/MR camera could change the performance of PET imaging.

Background: Published data on prostate magnetic resonance imaging (MRI) during follow-up of men on active surveillance are lacking. Current guidelines for prostate MRI reporting concentrate on prostate cancer (PCa) detection and staging. A standardised approach to prostate MRI reporting for active surveillance will facilitate the robust collection of evidence in this newly developing area. Objective: To develop preliminary recommendations for reporting of individual MRI studies in men on active surveillance and for researchers reporting the outcomes of cohorts of men having MRI on active surveillance. Design, setting, and participants: The RAND/UCLA Appropriateness Method was used. Experts in urology, radiology, and radiation oncology developed a set of 394 statements relevant to prostate MRI reporting in men on active surveillance for PCa. Each statement was scored for agreement on a 9-point scale by each panellist prior to a panel meeting. Each statement was discussed and rescored at the meeting. Outcome measurements and statistical analysis: Measures of agreement and consensus were calculated for each statement. The most important statements, derived from both group discussion and scores of agreement and consensus, were used to create the Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) checklist and case report form. Results and limitations: Key recommendations include reporting the index lesion size using absolute values at baseline and at each subsequent MRI. Radiologists should assess the likelihood of true change over time (ie, change in size or change in lesion characteristics on one or more sequences) on a 1-5 scale. A checklist of items for reporting a cohort of men on active surveillance was developed. These items were developed based on expert consensus in many areas in which data are lacking, and they are expected to develop and change as evidence is accrued. Conclusions: The PRECISE recommendations are designed to facilitate the development of a robust evidence database for documenting changes in prostateMRI findings over time ofmen on active surveillance. If used, they will facilitate data collection to distinguish-measurement error and natural variability in MRI appearances from true radiologic progression. Patient summary: Few published reports are available on how to use and interpret magnetic resonance imaging for men on active surveillance for prostate cancer. The PRECISE panel recommends that data should be collected in a standardised manner so that natural variation in the appearance and measurement of cancer over time can be distinguished from changes indicating significant tumour progression. (C) 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

A significant number of patients with minimal lymph node disease at radical prostatectomy (RP) and pelvic lymph node dissection (PLND) have better than expected long-term outcomes. We explored whether stratification by number of positive nodes enhances our institutional prediction model for biochemical recurrence after RP. A total of 7789 patients underwent RP and pelvic lymph node dissection from 1995 to 2012 at a tertiary referral center. We compared two recurrence prediction models: one incorporated lymph node invasion and the other tracked the number of positive nodes. Existing and updated models' discrimination was assessed using Harrell's c-index and calibration. The 10-fold cross-validation was performed to correct for model overfitting. Of the 491 patients (6.3%) harboring nodal disease, 387 (5.0%) had 1-2 positive nodes and 104 (1.3%) had ⩾3 positive nodes. Data on number of positive nodes did not improve the c-index for the cohort as a whole. When we assessed discrimination for node-positive patients only, c-index for the model with number of positive nodes was 0.01 (95% confidence interval 0.001-0.024) higher than the model with lymph node invasion. Illustrative examples were provided by reclassification tables using number of positive lymph nodes. For instance, 40 of 7789 patients would be reclassified with a cutoff point of 50% for biochemical recurrence at 1 year, and 36 of 7789 patients would be reclassified with a cutoff point of 40% for biochemical recurrence at 10 years. Stratification by number of positive lymph nodes provided additional discriminative ability for evaluating risk in node-positive patients. Pending external validation, this model could be used for patient counseling and clinical trial stratification in this subpopulation.Prostate Cancer and Prostatic Diseases advance online publication, 13 December 2016; doi:10.1038/pcan.2016.60.

Summary Metabolic imaging using hyperpolarized magnetic resonance can increase the sensitivity of MRI, though its ability to inform on relevant changes to biochemistry in humans remains unclear. In this work, we image pyruvate metabolism in patients, assessing the reproducibility of delivery and conversion in the setting of primary prostate cancer. We show that the time to max of pyruvate does not vary significantly within patients undergoing two separate injections or across patients. Furthermore, we show that lactate increases with Gleason grade. RNA sequencing data demonstrate a significant increase in the predominant pyruvate uptake transporter, monocarboxylate transporter 1. Increased protein expression was also observed in regions of high lactate signal, implicating it as the driver of lactate signal in vivo. Targeted DNA sequencing for actionable mutations revealed the highest lactate occurred in patients with PTEN loss. This work identifies a potential link between actionable genomic alterations and metabolic information derived from hyperpolarized pyruvate MRI.

PURPOSE: To assess the impact of implementing the recommendations included in the 2014 American Urological Association (AUA) white paper on complications of transrectal prostate needle biopsy (PNB). METHODS: In the outpatient setting of a single tertiary-care institution, prophylactic antibiotic use and rate of infectious complications were compared before and after implementation by nursing of a standardized algorithm to select antibiotic prophylaxis (derived from the recommendations of the AUA white paper). The 584 patients in cohort A (January 2011–January 2012) received antimicrobial prophylaxis at the discretion of the treating physician; 654 patients in cohort B (January 2014–January 2015) received standardized risk-adapted antibiotic prophylaxis. Data on antibiotics administered and infectious complications were analyzed. RESULTS: Fluoroquinolone was the most common prophylactic regimen in both cohorts. In cohort A, 73% of men received a single-drug regimen, although 19 different regimens were utilized with duration of 72 hours. In cohort B, 97% received 1 of 4 standardized single-drug antibiotic regimens for duration of 24 hours. Infectious complications occurred in 19 men (3.3%) in cohort A, and in 18 men (2.8%) in cohort B (difference − 0.5%; one-sided 95% CI: 1.1%). No clinically relevant increase in infectious complication rates was found after implementing this quality improvement initiative. CONCLUSIONS: Use of a standardized risk-adapted approach to select antibiotic prophylaxis for PNB by nursing staff reduced the duration of antimicrobial prophylaxis and number of antibiotic regimens used, without increasing the rate of infectious complications. Our findings validate the current AUA recommendations for antibiotic prophylaxis.

Background Indications for partial nephrectomy (PN) have expanded to include larger tumors. Compared with radical nephrectomy (RN), PN reduces the risk of chronic kidney disease but is associated with higher morbidity. Objective To explore whether the benefit of PN (preservation of estimated glomerular filtration rate [eGFR] ≥60 ml/min/1.73 m2 1 yr postoperatively) over RN is offset by higher morbidity for cT2-cT3a tumors. Design, setting, and participants A total of 1921 patients with renal cortical tumors who underwent nephrectomy between 2000 and 2012 were analyzed, with 297 having clinical stage T2 or higher disease. Outcome measurements and statistical analysis Multivariable logistic regression models adjusted for age, tumor size, and comorbidities were used to calculate the risk of complications within 90 d and the risk of low eGFR across a range of tumor sizes. Models were created separately for RN and PN, and the difference between risk estimates was calculated. Results and limitations For tumors with diameters between 7 and 12 cm, the risk of eGFR downgrade associated with RN was higher than the risk of complications associated with PN. The magnitude of the risk of eGFR downgrade was similar to the magnitude of complications risk across all tumor sizes. Our analysis was performed at a single institution, and used only tumor size to compare the risk and benefits of surgery. Conclusions Our study suggests that PN is associated with higher eGFR preservation than RN for cT2 or greater renal tumors. The magnitude of this advantage offsets the higher morbidity observed with PN. Patient summary When treating a large kidney tumor, it is difficult to decide whether it is better to remove the whole kidney or remove just the tumor. The second option improves postoperative renal function but is more complex. We tried to find whether there is a tumor size at which one technique should be used over the other.

Objective To describe contemporary management and outcomes of patients experiencing postoperative hemorrhage after minimally invasive radical prostatectomy. Materials and Methods We retrospectively analyzed data from patients who underwent minimally invasive radical prostatectomy at our institution between January 2010 and January 2017. Clinically significant hemorrhage was defined as a decrease in hemoglobin of ≥30% or 4 g/dL from preoperative to 4 or 14 hours postoperative measurement, receiving a blood transfusion within 30 days, or undergoing a secondary procedure to control bleeding. Patients were analyzed in 3 groups: (1) serially monitored only, (2) received a blood transfusion, and (3) underwent a secondary procedure. Outcomes included imaging studies performed, length of stay, emergency room visits, hospital readmissions, complication rates, and functional outcomes. Results Of 3749 men, 4% (151/3749) had clinically significant hemorrhage, 1.6% (60/3749) received a transfusion; 0.32% (12/3749) underwent a secondary procedure to control bleeding. In a 30-day composite outcome, increased healthcare utilization (emergency room visit, readmission, or Grade ≥3 complications), was seen in 25% of the serial monitoring group, 65% of the transfusion group, and 100% in the secondary procedure group. This rate in 3598 men without hemorrhage was 12.5%. One-year erectile function was poorest in men who underwent a secondary procedure. Urinary functional outcomes were similar in the 3 groups. Conclusion Most patients experiencing clinically significant hemorrhage will stabilize without transfusion, and a very small fraction require secondary intervention. Patients experiencing milder bleeding events utilized additional healthcare resources at approximately twice the rate of those who did not, warranting appropriate counseling and postoperative monitoring.

INTRODUCTION AND OBJECTIVES:Among men with low risk prostate cancer (PCa) managed with active surveillance (AS), upgrade to Gleason Grade Group (GG) ≥2 has been used to trigger treatment. We aimed ...

INTRODUCTION AND OBJECTIVES:Pelvic lymph node dissection (PLND) in prostate cancer remains controversial. Although it represents the most reliable procedure for lymph node staging, a therapeutic be...

INTRODUCTION AND OBJECTIVES:Patients with intermediate-risk prostate cancer (IR-PC) belong to a heterogeneous group with highly variable prognoses.The objective was to determine the pre-operative p...