AUA 2017: Journal of Urology 2016 Top Papers – Prostate and Testis Cancer
Stasivam and colleagues (J Urol. 2016;195:74-79) looked at 392 men on active surveillance (AS) with Gleason sum 6. The question was asked as to whether magnetic resonance imaging (MRI) can be used to avoid confirmatory biopsy. A decision model incorporating prostate-specific-antigen density, percentage of positive cores, MRI findings, and extent of cancer in the biopsy core was developed. Using this model, 76% of biopsies could be avoided if one accepts missing 2.3% of high-grade cancers. Using a more stringent “miss rate” of 1%, one can avoid 52.6% of biopsies.
O’Neil et al. (J Urol. 2016;195:321-329) considered differences in functional outcomes between patients undergoing open versus robotic prostatectomy. This retrospective review considered 1505 open and 933 robotic procedures. At 6 months, both urinary and erectile functions favored the robotic approach. While the difference in erectile function persisted at 12 months, there was no variation in continence at 12 months.
Phillips and associates looked at differences in adverse events for intermittent versus continuous androgen deprivation therapy in 9772 patients with metastatic PC. This population-based study found a lower risk for adverse events in the intermittent androgen deprivation therapy group. Specifically, there was a lower risk of serious cardiovascular events (hazard ratio [HR] 0.64), heart failure (HR 0.62), and fracture (HR 0.52).
Moore and colleagues (J Urol. 2017;197:1006-1013) considered the effect of dutasteride on MRI-visible PCas with a total of 42 men included in the analysis. The authors observed a 36% reduction in size of PCs in patients on dutasteride versus a 12% increase in those on placebo. The oncologic ramifications of this finding require further elucidation.
Rosenkrantz et al. (J Urol. 2016;196:1613-1618) provided a consensus statement on the use of MRI in patients with prior negative prostate biopsy. Prostate Imaging—Reporting and Data System or PI—RADS 3-5 lesions warrant repeat targeted biopsy. Cognitive fusion remains a reasonable approach in skilled hands. At least 2 targeted cores should be obtained. Systematic concurrent sampling should be determined on a case-specific basis. Other ancillary markers may be of value in identifying patients who warrant re-biopsy. Finally, measuring quality is critical to ensure that optimal results are obtained.
Truong and associates offered an interesting observation (J Urol. 2017 Feb 3) in a small series of men with initial negative biopsy who had a targeted biopsy on MRI followed by radical prostatectomy. Namely, a cribriform pattern on the radical prostatectomy specimen was not readily observed as a lesion on MRI. The authors suggested that this may be responsible for a portion of the negative outcomes in contemporary primary Gleason pattern 4 disease.
Thorstenson and colleagues (J Urol. 2017;197:61-66) performed a population-based study comparing survival outcomes in younger men (919 aged 35-49 years) with older men (45,098 aged 50-66 years). Stage for stage, young men were found to have worse survival outcomes relative to older men.
Muthigi et al. (J Urol. 2016;197:327-334) considered what causes us to “miss the mark” during MRI-targeted biopsies. Mechanisms for undergrading included reader oversight, error in technique, and intralesional heterogeneity.
Dr. Klotz highlighted a study performed in Toronto, Ontario, Canada, using his AS cohort. Musunuru and colleagues (J Urol. 2016;196:1651-1658) demonstrated that patients with secondary and primary Gleason pattern 4 PCa on AS have worse outcomes relative to those with Gleason 3+3=6 tumors.
The final PCa manuscript considered was related to focal therapy. Eggener and associates (J Urol. 2016;196:1670-1675) looked at MRI-guided focal laser ablation of PC and showed some promising short-term results. At 1 year, most individuals had a negative biopsy. The needs to define optimal patient populations and to acquire longer-term results may well prevent widespread adoption of this burgeoning technology.
Two papers on testis cancer were highlighted. Wymer and colleagues (J Urol. 2016;197:684-689) compared survival outcomes for patients managed according to National Comprehensive Cancer Network guidelines versus those who were not managed based on best-practice statements. Patients not managed by guideline statements have worse risk for relapse (HR 2.49, 95% confidence interval 1.61-3.85) relative to those managed appropriately.
Lastly, Banerji et al. (J Urol. 2016;196:1117-1122) queried the National Cancer Data Base for sex cord stromal (Leydig/Sertoli) tumors. While these represent only 0.4% of testis cancers, they are not inconsequential. Five-year survival was 91% for Leydig cell tumors and 77% for sertoli cell tumors. The authors cautioned against assuming a benign nature for sex cord stromal tumors, suggesting that more aggressive treatment may be needed for some of these patients.
Presented By: Laurence Klotz, MD, Chief of Urology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
Written By: Benjamin T. Ristau, MD, Fox Chase Cancer Center, Philadelphia, PA
at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA