Are high-risk prostate cancer patients being treated equally? The impact of PSA.

BACKGROUND: Patients with high-risk (HR) prostate cancer (PCa) represent a heterogeneous group, however, current treatment guidelines do not consider their specific features. The objective of this study was to evaluate treatment trends and outcomes in HR patients defined by PSA alone and otherwise low-risk features. METHODS: Using the National Cancer Database, we identified patients diagnosed with HR PCa between 2010 and 2016. A study group of patients defined by PSA >20 ng/ml alone and otherwise low-risk features, was compared to a group of HR patients defined by Gleason score or stage. We compared treatment rates over time, the use of concomitant androgen deprivation therapy (ADT), and overall survival (OS). Examination of treatment trends was done using a Z-test analysis. A Kaplan-Meier survival analysis was used to determine 5-year OS with the Log-rank test for comparison. Statistical analyses were completed using R Version 3.5.2. RESULTS: We identified 5,652 patients in the study group and 71,922 in the comparison group. Only 6.8% of the study group had disease ≥cT2, compared to 43.7% in the comparison group. In the study group, 12.5% (709), underwent active surveillance (AS), 36.4% (2,055) radiation therapy (EBRT) and 51.1% (2,888) radical prostatectomy (RP), while the rate of AS, EBRT, and RP in the comparison group were 0.3% (191), 43.0% (30,928), and 56.7% (40,803), respectively. Over the study period, adoption of AS increased from 6.2% in 2010 to 25.0% in 2016 in the study group (P< 0.001), but not in the comparison group. In patients undergoing EBRT, ADT treatment increased from 2010 to 2016 in both groups, though by 2016 only 45.3% of patients in the study group and 86.3% in the comparison group received ADT. The 5-year OS was 93.7% (95% CI 92.8-94.6) in the study group and 89.7% (95% CI 89.2-90.1) in the comparison group (P< 0.001). CONCLUSIONS: Men with HR PCa defined by PSA with otherwise low risk features present at an earlier stage and receive less aggressive therapy than other HR patients. Despite increased rates of AS and decreased use of ADT, these patients appear to have improved survival when compared to other HR patients. These findings suggest that not all HR patients will benefit from aggressive definitive treatment.

Prospective Long-term Health-related Quality of Life Outcomes After Surgery, Radiotherapy, or Active Surveillance for Localized Prostate Cancer.

Background: Localized prostate cancer (PCa) treatment is associated with reduced health-related quality of life (HRQoL). Current literature is limited by short-term follow-up. Objective: To prospectively evaluate the 5-yr HRQoL outcomes in men undergoing radical prostatectomy (RP), external beam radiotherapy (EBRT), or active surveillance (AS). Design setting and participants: We prospectively evaluated HRQoL in patients with low-risk/favorable intermediate-risk PCa enrolled in the Center for Prostate Disease Research multicenter database between 2007 and 2017. Intervention: Of 1012 patients included in the study, 252 (24.9%) underwent AS, 557 (55.0%) RP, and 203 (20.0%) EBRT. Patients complete the Expanded Prostate Cancer Index Composite and the 36-item Medical Outcomes Study Short Form at baseline and thereafter each year up to 5 yr after treatment. Outcome measurements and statistical analysis: Temporal changes in HRQoL were compared between treatments and were modeled using linear regression models adjusted for baseline HRQoL, demographic, and clinical characteristics. Results and limitations: RP showed the least irritative symptoms and worse incontinence in comparison with AS (p < 0.001 for both subdomains) or EBRT (p < 0.001 for both subdomains) at all time points. RP sexual domain score was worse than the scores of AS (mean difference 22.3 points, 95% confidence interval [CI] 10.5-27.8, p < 0.001) and EBRT (mean difference 16.9 points, 95% CI 12.5-20.3, p < 0.001) during years 1-3 and not different from that of EBRT (mean difference 2.9 points, 95% CI -4.8 to 8.3, p = 0.3) at years 4 and 5. Bowel function and bother were worse for EBRT than for AS (p < 0.001 for both subdomains) and RP (p < 0.001 for both subdomains) at all time points. During the 3-5-yr period, AS demonstrated the worst decline in all mental health domains (p < 0.001 in comparison with both EBRT and RP). Conclusions: RP results in worse long-term urinary function and incontinence, but in less irritative and obstructive symptoms than EBRT and AS. Sexual domain scores were least affected by AS, while RP shows similar scores to EBRT at long term. Long-term HRQoL changes are critical for advising patients. Patient summary: We evaluated long-term health-related quality of life (HRQoL) in a large US population treated for localized prostate cancer. HRQoL outcomes varied according to treatment modality and time. These changes should inform patients about their expected outcomes following treatment.

The role of multiparametric ultrasound in the detection of clinically significant prostate cancer.

PURPOSE: Transrectal ultrasound (US) imaging is paramount to the successful completion of prostate biopsies. Certain US features have been associated with prostate cancer (PCa), but their utility remains controversial. We explored the role of multiparametric US (mpUS) in the detection of clinically significant PCa. METHODS: We performed a retrospective cohort study to contrast the findings of prostate MRI and mpUS. Patients who underwent MRI, US and biopsy between 2015 and 2021 were included. Biopsies were performed using a systematic approach (12 cores), as well as with MRI (4 cores/lesion) and US (1 core/lesion) targeting. The US features analyzed consisted of: calcifications, hypoechoic lesions and power or color Doppler positivity. Gleason 3 + 4 or higher was used as to define true positives. Measures of diagnostic accuracy were calculated for the different imaging modalities. RESULTS: The final cohort included 74 patients, of which 24 (32.4%) had clinically significant PCa. The concordance between MRI and US was 63.5%. Seven individuals with discordant results had clinically significant PCa. MRI alone was more sensitive (87.5% vs 75%) but less specific (28% vs 32%) than US alone. An all-inclusive approach considering any suspicious US or MRI finding had a sensitivity of 95.8%. A more restrictive approach, targeting lesions noted in both US and MRI, yielded the highest specificity (50.0%) and accuracy (55.4%). CONCLUSION: Biopsy targeting based on US findings can provide additional diagnostic information that may increase sensitivity or specificity. Additional research into this topic could open the door to a more personalized approach to prostate biopsy.

Robotic level II inferior vena cava thrombectomy for metastatic melanoma.

We report on a case of a 38-year-old female who presented with metastatic malignant melanoma of her right kidney with Level II tumor thrombus. This is the first ever presented case of a renal melanoma IVC tumor thrombus. Furthermore, in an effort to expand the surgical scope of minimally invasive and robotic surgery, we report management of this lesion as the first case of non-renal cell carcinoma IVC tumor thrombus treated with a robotic thrombectomy.

Robotic inguinal lymph node dissection for melanoma: a novel approach to a complicated problem.

BACKGROUND: Indications for superficial inguinal lymph node (ILN) dissection in melanoma include fine needle aspiration or clinically positive ILN and sentinel lymph nodes (SLN). Open inguinal lymphadenectomy may be complicated by poor wound healing, deep vein thrombosis, and lymphedema. Technical considerations and case series of a novel surgical approach, robotic inguinal lymphadenectomy, are presented. METHODS: This is a case series of four robotic ILN dissections for melanoma at a tertiary care facility. Each patient had previously diagnosed melanoma by lymph node biopsy. Physician and patient jointly decided on robotic procedure after disclosure of this novel approach. Demographic, complication, pathological outcome, estimated blood loss (EBL), operative time, and length of stay (LOS) data were collected. RESULTS: No cases were aborted due to technical difficulty. The median patient age was 44.5 years (range 22-53 years) and median BMI was 27.5 (range 20.4-40.2). Operative time range was 120-231 min and EBL from 0 to 100 mL. Median nodal count was 5.5 (range 1-14 nodes). Patient LOS ranged from 0 (discharged from post anesthesia care unit) to 96 h. There was one complication of port site cellulitis, one seroma formation, and no instances of lymphedema. To date, there have been no deaths or melanoma recurrences in this population. CONCLUSION: Recent data suggest a minimum node count of six to seven for inguinal dissection. Of our four dissections, two were above this threshold and there were minimal postoperative complications. Given our limited sample size, future focus should be on increasing the data on this approach to optimize surgical outcomes and oncologic results.

Does Routine Pathology Analysis of Adult Circumcision Tissue Identify Penile Cancer?

OBJECTIVE: To assess the utility of foreskin pathology analysis, we evaluated the outcomes and the costs of this practice in patients for whom penile cancer was not suspected. Adult circumcision specimens are routinely sent for pathologic analysis even when penile cancer is not suspected, increasing costs with little benefit. MATERIALS AND METHODS: All adult patients who underwent circumcision between January 2000 and August 2013 at a single institution were evaluated by retrospective chart review. Cases of suspected penile cancer (n = 6) were excluded. We identified cases where foreskin specimens were sent for pathologic analysis and reviewed pathology reports. Our Department of Pathology estimated the cost for evaluation of specimens at $311 per case. RESULTS: A total of 147 circumcisions were performed in patients with no suspicious findings. Pathologic analysis was obtained in 69% (101 of 147) of the cases. Inflammation (58%) was the most common finding. One unsuspected instance of squamous cell carcinoma (Tis) was identified in a patient with human immunodeficiency virus (1 of 147 = 0.7%). The overall cost of pathologic analysis in this study was $31,411. CONCLUSION: In individuals without predisposing immunodeficiency and where cancer was not suspected, we found that pathologic analysis of circumcision specimens identified no additional malignancies. Our data suggest that in this normal risk population, pathologic analysis may not be required. Additionally, forgoing pathology on foreskin specimens in lower risk cases may reduce costs to the health care system.