A case of double-negative prostate cancer with BRCA2 mutation and high tumor mutation burden treated sequentially with olaparib and pembrolizumab.

Introduction: Double-negative prostate cancer, an androgen receptor-independent prostate cancer without features of neuroendocrine tumors, is refractory to treatment but could be an ideal candidate for individualized treatment. Case presentation: An 85-year-old patient with metastatic castration-resistant prostate cancer without prostate-specific antigen progression presented with local recurrence and liver and lung metastases 6 months after orchiectomy and apalutamide. A liver tumor biopsy led to a diagnosis of double-negative prostate cancer. FoundationOne® CDx showed BRCA2 mutation and high tumor mutation burden. Olaparib and pembrolizumab were administered sequentially, and the patient responded to each treatment for 5 months until radiographic progression. Conclusion: Sequential use of olaparib and pembrolizumab may be effective for double-negative prostate cancer with BRCA2 mutations and high tumor mutation burden.

Serum Androgens as Predictive Biomarkers: Results From a Randomized Clinical Trial Comparing Enzalutamide and Abiraterone Acetate in Men With Metastatic Castration-Resistant Prostate Cancer.

INTRODUCTION: The purpose of this study was to investigate the association between baseline androgen concentrations and outcomes in men with metastatic castration-resistant prostate cancer (mCRPC) treated with first-line enzalutamide or abiraterone acetate plus prednisone (AAP). MATERIALS AND METHODS: We previously randomized men with mCRPC to enzalutamide or AAP to compare side-effects and measured androgen concentrations. In this post-hoc analysis, patients were grouped in quartiles (Q) based on their serum androgen values. Kaplan-Meier and Cox regression were used to analyze progression-free and overall survival for baseline androgen groups, treatment subgroups and their interaction. The trial was registered at clinicaltrialsregister.eu (2017-000099-27). RESULTS: Eighty-four patients received enzalutamide and 85 AAP. Overall, higher (Q4) compared with lower (Q1) baseline serum testosterone was associated with longer progression-free survival (24.8 vs. 10.7 months, hazard ratio [HR] 0.52, 95% confidence interval [CI] 0.33; 0.84) and overall survival (52.8 vs. 31.5 months, HR 0.49, 95% CI 0.28; 0.85). The risk reduction in death seemed to be treatment dependent (treatment subgroup interaction P = .04). For men in the AAP subgroup, the Q4 compared with Q1 group had a significant lower risk of death (HR 0.30, 95% CI 0.13; 0.73), while no difference was found for enzalutamide (HR 0.77, 95% CI 0.35; 1.69). Similar results were found for the other androgens. CONCLUSION: Pre-treatment serum testosterone levels may be a clinically useful biomarker for predicting mCRPC treatment responses and guiding treatment selection.

Effect of Preoperative Nursing Visit on Anxiety and Postoperative Complications in Patients Undergoing Radical Prostatectomy: A Retrospective Study.

OBJECTIVE: This study aimed to explore the effect of preoperative nursing visit on anxiety and postoperative complications in patients undergoing radical prostatectomy and to provide a better perioperative management plan for patients with prostate cancer (PCa) undergoing surgical treatment. METHODS: The medical records of 199 patients who underwent PCa treatment in our hospital from June 2021 to June 2023 were retrospectively analysed. The reference group received preoperative routine nursing, whereas the observation group implemented preoperative nursing visit. The stress indexes, quality of life, negative emotion level and incidence of complications were compared between the two groups. RESULTS: Before management, no significant difference in the levels of epinephrine, norepinephrine and cortisol was found between the two groups (p > 0.05). After management, the levels of the abovementioned stress indicators in the observation group were lower than those in the reference group (p < 0.001). Before management, no significant difference in Short-Form-36 Health Survey (SF-36) scores was observed between the two groups (p > 0.05). After management, the observation group had higher SF-36 score than the reference group (p < 0.001). Before management, no significant difference in Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD) scores was found between the two groups (p > 0.05). After management, the observation group had lower HAMA and HAMD scores than the reference group (p < 0.001). Furthermore, no significant difference in the incidence of complications was found between the two groups (p > 0.05). CONCLUSIONS: Preoperative nursing visit can reduce the anxiety of patients with PCa to a certain extent. This scheme can promote the postoperative recovery of patients, and it has certain clinical application and promoting values.

The Impact of Radical Prostatectomy Versus Radiation Therapy on Cancer-Specific Mortality for Nonmetastatic Prostate Cancer: Analysis of an Other-Cause Mortality Matched Cohort.

INTRODUCTION: Studies comparing radical prostatectomy (RP) to radiation therapy (RT) have consistently shown that patients undergoing RT have a higher risk of other-cause mortality (OCM) compared to RP, signifying poor health status of the former patients. We aimed to evaluate the impact of RP versus RT on cancer-specific mortality (CSM) over a cohort with equivalent OCM risk. PATIENTS AND METHODS: The SEER database was queried to identify patients with nonmetastatic PCa between 2004 and 2009. Patients were matched based on their calculated 10-year OCM risk and further stratified for D'Amico Risk Score and Gleason Grade. A Cox-regression model was used to calculate the 10-year OCM risk. Propensity-score based on the calculated OCM risk were used to match RP and RT patients. Cumulative incidence curves and Competing-risk regression analyses were used to examine the impact of treatment on CSM in the matched cohort. RESULTS: We identified 55,106 PCa patients treated with RP and 36,674 treated with RT. After match, 6,506 patients were equally distributed for RT versus RP, with no difference in OCM rates (P = .2). The 10-year CSM rates were 8.8% versus 0.6% (P = .01) for RT versus RP in patients with unfavorable-intermediate-risk (Gleason Score 4 + 3) and 7.9% versus 3.9% (P = .003) for high-risk disease. There was no difference in CSM among RT and RP patients for favorable-intermediate-risk (Gleason Score 3 + 4) and low-risk disease. CONCLUSIONS: In a matched cohort of PCa patients with comparable OCM between the 2 arms, RP yielded a more favorable CSM rate compared to RT only for unfavorable-intermediate- and high-risk groups.

Impact of the COVID-19 pandemic on cancer mortality in Brazil.

BACKGROUND: In the first year of the COVID-19 pandemic, data projections indicated an increase in cancer mortality for the following years due to the overload of health services and the replacement of health priorities. The first studies published with data from mortality records have not confirmed these projections. However, cancer mortality is not an outcome that occurs immediately, and analyses with more extended follow-up periods are necessary. This study aims to analyze the impact of the COVID-19 pandemic on the mortality from all types and the five most common types of cancer in Brazil and investigate the relationship between the density of hospital beds and mortality from COVID-19 in cancer patients in Brazil's Intermediate Geographic Regions (RGIs). METHODS: The Brazilian Mortality Information System provided data on the deaths from trachea, bronchus, and lung, colorectal, stomach, female breast, and prostate cancer and all types of cancer, and from COVID-19 in individuals who had cancer as a contributing cause of death. Predicted rates for 2020-2022 were compared with the observed ones, through a rate ratio (RR). An association analysis, through multivariate linear regression, was carried out between mortality from COVID-19 in cancer patients, the rate of hospital beds per 100,000 inhabitants, and the Human Development Index of the 133 RGIs of Brazil. RESULTS: In 2020, 2021, and 2022, mortality from all cancers in Brazil was lower than expected, with an RR of 0.95, 0.94, and 0.95, respectively, between the observed and predicted rates. Stomach cancer showed the largest difference between observed and expected rates: RR = 0.89 in 2020 and 2021; RR = 0.88 in 2022. Mortality from COVID-19 in cancer patients, which reached its peak in 2021 (6.0/100,000), was negatively associated with the density of hospital beds in the public health system. CONCLUSIONS: The lower-than-expected cancer mortality during 2020-2022 seems to be partly explained by mortality from COVID-19 in cancer patients, which was probably underestimated in Brazil. The findings suggested a protective role of the availability of hospital care concerning deaths due to COVID-19 in this population. More extensive follow-up is needed to understand the impact of the COVID-19 pandemic on cancer mortality.

PSMA PET/CT in the Brazilian Unified Healthcare System reduces costs with futile salvage therapies in the management of cases of biochemical recurrence of prostate cancer.

Objective: To compare costs between treatment strategies employed prior to and after prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) via the Brazilian Unified Health Care System and their impact on the therapeutic management of biochemical recurrence of prostate cancer. Materials and Methods: The referring physicians were surveyed on their treatment intentions (strategies) at two different time points: prior to and after PSMA PET/CT. Cost comparison results are presented as median (IQR) for each of the two strategies. The shift in therapeutic management after PSMA PET/CT was also analyzed. Results: The study sample included 59 patients (mean age: 65.9 years). The PSMA PET/CT result was considered positive in 38 patients (64.4%) and was found to have an impact on the treatment strategy in for 36 patients (61.0%). Prior to PSMA PET/CT, salvage therapy (i.e., treatment with curative intent) was the intended treatment for most patients, and that was significantly less so after the examination (76.3% vs. 45.8%; p < 0.001). Conversely, a strategy involving systemic (i.e., palliative) therapy became more common after PSMA PET/CT (23.7% vs. 54.2%; p < 0.001). The after-PSMA PET/CT strategy presented higher overall costs than did the before-PSMA PET/CT strategy, in all scenarios evaluated. In all scenarios, nearly half of this cost difference was related to the cost of the PSMA PET/CT itself, the remainder being related to the new treatment choices that stemmed from knowledge of the PSMA PET/CT findings. Conclusion: For patients treated within the Brazilian Unified Health Care System, PSMA PET/CT presented higher costs in comparison with conventional imaging methods. Adding PSMA PET/CT to the workflow had an impact on therapeutic management, mainly representing a shift from futile curative treatments to systemic palliative ones. The amount of funds that could potentially be saved by not providing such futile treatments would suffice to evaluate roughly two patients with PSMA PET/CT scans for each futile treatment strategy avoided.

Objetivo: Comparar custos entre estratégias antes e após o exame de PET/CT-PSMA da perspectiva do Sistema Único de Saúde e seu impacto no manejo terapêutico para pacientes com recidiva bioquímica de câncer de próstata. Materiais e Métodos: Os médicos solicitantes informaram a intenção terapêutica em dois momentos: antes e após o exame. Os resultados de comparação de custo estão apresentados como medianas de custo (p25; p75). A mudança na intenção terapêutica também foi analisada. Resultados: O estudo envolveu 59 pacientes (idade média: 65,9 anos). A PET/CT-PSMA foi considerada positiva em 38 dos 59 pacientes (64.4%). O exame impactou a estratégia de tratamento para 36 pacientes (61%). Antes da obtenção das informações da PET/CT-PSMA, a terapia de resgate (i.e., com intenção curativa) era o tratamento sugerido para a maioria dos pacientes, e após o exame, reduziu significativamente (76,3% vs 45,8%; p < 0,001). Em contrapartida, a terapia sistêmica (i.e., paliativa) aumentou como intenção de tratamento após o exame (23,7% vs 54,2%; p < 0,001). A estratégia "após PET/CT-PSMA" apresentou maiores custos em relação à estratégia "antes da PET/CT-PSMA" nos cenários comparados. Cerca de metade da diferença de custos entre as duas estratégias foi relacionada aos custos do exame propriamente ditos, enquanto a outra metade foi relacionada às novas escolhas de tratamento a partir do exame. Conclusão: Oferecer a PET/CT-PSMA no Sistema Único de Saúde apresentou maiores custos em relação à estratégia com métodos de imagem convencionais e impactou o manejo terapêutico, pelo favorecimento de tratamentos sistêmicos paliativos no lugar de tratamentos curativos fúteis. A quantidade de recursos que poderiam ser poupados ao evitar tratamentos fúteis seria suficiente para avaliar aproximadamente dois pacientes com exames de PET/CT-PSMA para cada estratégia de tratamento fútil evitada.

Does sexual rehabilitation work for gay and bisexual prostate cancer patients? Acceptability, feasibility, and efficacy results from the Restore-2 randomized controlled trial.

PURPOSE: Sexual minority prostate cancer patients have worse health-related quality of life outcomes than heterosexual patients. We conducted the first study to test whether sexual and urinary rehabilitation tailored for sexual minority patients was acceptable, feasible, and efficacious at improving their sexual and urinary function. METHODS: Restore-2 was a 24-month randomized controlled trial of an online biopsychobehavioral rehabilitation study for sexual minority men treated for prostate cancer experiencing sexual and/or urinary problems. Participants were 401 US sexual minority men treated for prostate cancer and experiencing sexual and/or urinary problems at baseline. Intervention components included phosphodiesterase-5 inhibitors, sexual aids, a pelvic floor exercise regimen and video, a guide to good gay sex following treatment, and coaching. Quality of life assessments were completed at baseline, 3, 6, 12, 18, and 24 months. RESULTS: We confirmed good acceptability and feasibility, but only minimal improvement was observed over time and no differences were found between treatment and control arms. CONCLUSIONS: We found no evidence that the intervention improved sexual or urinary outcomes for participants. However, we confirmed excellent acceptability and feasibility for a sexual rehabilitation program tailored to sexual minority participants. In addition, participants reported enduring usage and acceptability of sexual aids (including vacuum pump, anal dilators, and penile constriction rings) as well as masturbation and pelvic floor exercises to accommodate their sexual challenges. IMPLICATIONS FOR CANCER SURVIVORS: Sexual "accommodation," rather than "rehabilitation," may be a more accurate and realistic goal for this population. Patients should be provided sexual aids to help accommodate their sexual and urinary challenges. TRIAL REGISTRATION: This study was retrospectively registered with ClinicalTrials.gov, study number: NCT03923582; date: 22/04/2019.

Pathological Assessment of Men with Grade Group 2 Prostate Cancer.

PURPOSE: A variety of treatment options are now available for men with localized prostate cancer (PC); however, there is still debate in determining how and when to intervene for Grade Group (GG) 2 disease. Our study aims to formulate strategies to identify men at risk of upgrading and having adverse pathological outcomes. MATERIALS AND METHODS: This retrospective study includes 243 patients with GG2 PC that were treated with radical prostatectomy between 2015 and 2021. Patients on active surveillance, previous history of prostate biopsy, hormonal and/or radiation therapy prior to surgery were excluded from this study. A retrospective analysis was conducted using clinicopathological data obtained from medical records. RESULTS: Prostate-specific antigen (PSA) and Prostate Imaging Reporting and Data System (PI-RADS) score were statistically significant variables for risk of upgrading. In men who had presence of composite poor outcomes, PSA, PI-RADS score, presence of extraprostatic extension and seminal vesical invasion on MRI, number of positive cores, percentage of high grade (pattern 4/5) on prostate biopsy and Gleason pattern 4 volume on biopsy were all statistically significant variables. Strategy 8 (PI-RADS 5 lesion or percentage high grade [Gleason pattern 4] on prostate biopsy grade >10% or >3 cores positive on prostate biopsy) had significant association to identifying the highest number of men with upgrading and composite poor outcomes. CONCLUSIONS: Our study supports the use of strategy 8 in treatment decision making of men with GG2 PC. Further validation of the use of this strategy is warranted.

Predicting Survival in Patients with Neuroendocrine Prostate Cancer: A SEER-Based Comprehensive Study.

PURPOSE: Neuroendocrine prostate cancer (NEPC) represents a particularly aggressive subtype of prostate cancer with a challenging prognosis. The purpose of this investigation is to craft and confirm the reliability of nomograms that can accurately forecast the 1-, 3-, and 5-year overall survival (OS) and cancer-specific survival (CSS) rates for individuals afflicted with NEPC. MATERIALS AND METHODS: Data pertaining to patients diagnosed with NEPC within the timeframe of 2010 to 2020 was meticulously gathered and examined from the Surveillance, Epidemiology, and End Results Program (SEER). To predict OS and CSS, we devised and authenticated two distinct nomograms, utilizing predictive variables pinpointed through both univariate and multivariate Cox regression analyses. RESULTS: The study encompassed 393 of NEPC patients, who were systematically divided into training and validation cohorts at a 2:1 ratio. Key prognostic factors were isolated, verified, and integrated into the respective nomograms for OS and CSS. The performance metrics, denoted by C-indices, stood at 0.730, 0.735 for the training set, and 0.784, 0.756 for the validation set. The precision and clinical relevance of the nomograms were further corroborated by the analysis of receiver operating characteristic curves, calibration plots, and decision curve analyses. CONCLUSIONS: The constructed nomograms have demonstrated impressive efficacy in forecasting the 1-, 3-, and 5-year OS and rates for patients with NEPC. Implementing these predictive tools in clinical settings is anticipated to considerably enhance the care and treatment planning for individuals diagnosed with this aggressive form of prostate cancer, thus providing tailored and more precise prognostic assessments.

Long Term Cardiovascular Safety of Testosterone Therapy: A Review of the TRAVERSE Study.

TRAVERSE (TheRapy for Assessment of long-term Vascular events and Efficacy ResponSE in hypogonadal men) is multicentre randomized, double-blind, placebo-controlled, noninferiority trial of testosterone therapy, enrolling 5,246 men 45 to 80 years of age who had pre-existing or a high risk of cardiovascular disease and who reported symptoms of hypogonadism. Subjects required two fasting testosterone levels of less than 10.4 nmol/L. Patients were randomly assigned to receive daily transdermal 1.62% testosterone gel (dose adjusted to maintain testosterone levels between 12 nmol/L and 26 nmol/L) or placebo gel for a mean 27.1 months. The primary cardiovascular safety end point was the first occurrence of any component of a composite of death from cardiovascular causes, non-fatal myocardial infarction, or non-fatal stroke, assessed in a time-to-event analysis. TRAVERSE found no increase in major adverse cardiac events or prostate related events, including prostate cancer, effectively addressing the concerns raised by the United States Food and Drug Administration.

Molecular Hallmarks of Prostate-specific Membrane Antigen in Treatment-naïve Prostate Cancer.

BACKGROUND AND OBJECTIVE: We characterized tumor prostate-specific membrane antigen (PSMA) levels as a reflection of cancer biology and treatment sensitivities for treatment-naïve prostate cancer. METHODS: We first correlated PSMA positron emission tomography (PET) maximum standardized uptake values (SUVmax) in primary prostate cancer with tumor FOLH1 (PSMA RNA abundance) to establish RNA as a proxy (n = 55). We then discovered and validated molecular pathways associated with PSMA RNA levels in two large primary tumor cohorts. We validated those associations in independent cohorts (18 total; 5684 tumor samples) to characterize the pathways and treatment responses associated with PSMA. KEY FINDINGS AND LIMITATIONS: PSMA RNA abundance correlates moderately with SUVmax (ρ = 0.41). In independent cohorts, androgen receptor signaling is more active in tumors with high PSMA. Accordingly, patients with high PSMA tumors experienced longer cancer-specific survival when managed with androgen deprivation therapy for biochemical recurrence (adjusted hazard ratio [AHR] 0.54 [0.34-0.87]; n = 174). PSMA low tumors possess molecular markers of resistance to radiotherapy. Consistent with this, patients with high PSMA tumors experience longer time to recurrence following primary radiotherapy (AHR 0.50 [0.28-0.90]; n = 248). In the SAKK09/10 trial (n = 224), patients with high PSMA tumors who were managed with salvage radiotherapy experienced longer time to progression in the 64-Gy arm (restricted mean survival time [RMST] +7.60 [0.05-15.16]), but this effect was mitigated in the 70-Gy arm (RMST 3.52 [-3.30 to 10.33]). Limitations include using PSMA RNA as a surrogate for PET SUVmax. CONCLUSIONS AND CLINICAL IMPLICATIONS: PSMA levels in treatment-naïve prostate cancer differentiate tumor biology and treatment susceptibilities. These results warrant validation using PET metrics to substantiate management decisions based on imaging.

Changing times: trends in risk classification, tumor upstaging, and positive surgical margins after radical prostatectomy - results from a contemporary National Cancer Database study.

PURPOSE: Recent advancements in screening, prostate MRI, robotic surgery, and active surveillance have influenced the profile of patients undergoing radical prostatectomy (RP). We sought to examine their impact on trends in clinicodemographic, risk classification, and adverse pathology in men undergoing surgery. METHODS: We queried the National Cancer Database for clinicodemographic, risk group, and pathology data in men undergoing upfront RP between 2006 and 2020. Patients were categorized by NCCN risk groups, and trends were assessed among 2006-2010, 2011-2015, and 2016-2020 periods. Endpoints included rates of pT3, positive surgical margins (PSM), pathologic upstaging, and Gleason grade group (GG) upgrading. RESULTS: 610,762 patients were included. There were significant increases in African Americans (9.8-14.1%), comorbidities (2.1-5.2% with Charlson scores > 1), and robot-assisted RP (78-84%). Over the three time periods, high-risk cases increased from 15 to 20 to 27%, and intermediate-risk from 54 to 51 to 60%. Overall rates of pT3 rose from 20 to 38%, and PSM from 20 to 27% (p < 0.001). Pathologic upstaging increased in low (6-15%), intermediate (20-33%), and high-risk groups (42-58%) -p < 0.001. Gleason upgrading rose in low-risk (45-59%, p < 0.001), with slight reductions in the intermediate and high-risk groups. CONCLUSIONS: Recent trends in RP indicate a shift towards more advanced disease, evidenced by increasing rates of pT3, PSM, and pathologic upstaging across all NCCN risk groups. These findings emphasize the need for a careful balance in applying fascia and nerve-sparing techniques to avoid compromising oncological safety.

Connecting Gene Variation to Treatment Outcomes in Metastatic Castration-Resistant Prostate Adenocarcinoma: Insights into Second-Generation Androgen Receptor Axis-Targeted Therapies.

Prostate cancer (PC) is one of the most commonly diagnosed tumours among men. Second-generation androgen receptor axis-targeted (ARAT) agents, namely abiraterone acetate (AbA) and enzalutamide (ENZ), are currently used in the management of metastatic castration-resistant PC (mCRPC). However, the treatment is challenging due to the lack of prognostic biomarkers. Meanwhile, single-nucleotide polymorphisms (SNPs) have emerged as potential prognostic indicators of mCRPC. Thus, this study evaluated the impact of relevant SNPs on the treatment outcomes of 123 mCRPC patients enrolled in a hospital-based cohort study. The CYP17A1 rs2486758 C allele was associated with a 50% reduction in the risk of developing castration resistance (hazard ratio (HR) = 0.55; p = 0.003). Among patients without metastasis at tumour diagnosis and under AbA, a marginal association between YBX1 rs10493112 and progression-free survival was detected (log-rank test, p = 0.056). In the same subgroup, significant associations of HSD3B1 rs1047303 (CC/CA vs. AA; HR = 3.41; p = 0.025), YBX1 rs12030724 (AT vs. AA; HR = 3.54; p = 0.039) and YBX1 rs10493112 (log-rank test, p = 0.041; CC vs. AA/AC; HR = 3.22; p = 0.053) with overall survival were also observed, which were confirmed by multivariate Cox analyses. Although validation with larger cohorts is required, these findings suggest that SNPs could enhance the prognosis assessment of mCRPC patients, leading to a more personalised treatment.

Feasibility and Outcomes of Same-Day Discharge after Multiport Robot-Assisted Radical Prostatectomy.

Introduction: Robot-assisted radical prostatectomy (RARP) provides much quicker recovery for men than open prostatectomy. In most centers, discharge is planned the morning after operation. However, after several years, we observed that no routine intervention was required for a majority of men over the first evening. Here, we detail our institution's outcomes for multiport RARP (MP-RARP) with same-day discharge (SDD). Methods: After excluding patients with single-port RARP (n = 25) and overnight stays (n = 30), data from 224 patients (n = 224/279, 88.2%) who underwent MP-RARP from May 2021 to September 2023 were collected. All patients were placed on an Enhanced Recovery After Surgery protocol and were given instructions regarding SDD. Patients were considered as SDD if they were discharged on the day of operation. Data regarding messages and phone calls to health care providers, urology clinic, and emergency department visits were recorded for analysis in the week postoperation. Results: The mean (±standard deviation [SD]) operative time was 142.5 ± 25.2 minutes, with a mean (±SD) console time of 95.1 ± 25.6 minutes. The median (interquartile range [IQR]) estimated blood loss was 50 (50-100) mL, and the mean (±SD) length of hospitalization was 163.2 ± 64.6 minutes. No intraoperative complications occurred in this cohort. The median (IQR) patient-reported pain score at 1 hour after operation was 3.5 (0-7), compared with 2 (0-4) at discharge. Of the 145 (64.7%) patients who reported their postoperative pain management, only 50 (34.4%) endorsed using opioids, and of those, 8 (16%) were known chronic opioid users. In the week after operation, 14 (6.3%) patients had unplanned visits to the health care facility. Additionally, 56 (25%) of patients contacted the clinic regarding the postoperative course during the same time frame. Conclusions: SDD after RARP is predictable and safe. SDD helps reduce the costs associated with inpatient stays without compromising surgical outcomes for patients.

Salvage lymphadenectomy or radiation therapy in prostate cancer patients with biochemical recurrence and PET positive lymph nodes after radical prostatectomy: A systematic review and pooled analysis.

OBJECTIVE: To analyze the oncologic outcomes of biochemical recurrence (BCR) patients who received salvage treatment of lymph node dissection (LND) or radiation therapy (RT) for positron emission tomography (PET)-positive lymph node recurrences following radical prostatectomy (RP). METHODS: Research using the MEDLINE, Cochrane, and Web of Science databases was conducted until June 2023. Inclusion criteria were BCR patients that received salvage LND or RT for PET-positive lymph node recurrence following primary RP for prostate cancer. Studies with a follow-up period of less than 12 months were excluded. RESULTS: This study included 2476 patients (995 LND, 1481 RT) from 19 publications. The pooled incidences were 51.1 % and 74.3 % in PSA response, 69.8 % and 26.9 % in PSA progression, 41.5 % and 26.9 % in image progression, 41.5 % and 32.0 % in systemic progression, 0.9 % and 0.5 % in overall mortality, and 6.5 % and 1.3 % in cancer-specific mortality in LND and RT, respectively. Limitations include high heterogeneity. CONCLUSION: Although heterogeneity is high across all studies, the pooled rates of PSA, image, and systemic progressions are higher in LND than in RT concerning BCR patients with PET-positive lymph nodes. For future trial designs in BCR, assessing the optimal timing of PSMA PET scans, concurrent systemic therapy, and salvage therapy type is imperative.

Association of Free-to-Total PSA Ratio and 18F-DCFPyL Prostate-Specific Membrane Antigen PET/CT Findings in Patients with Biochemical Recurrence After Radical Prostatectomy: A Prospective Single-Center Study.

In Canada and across the globe, access to PSMA PET/CT is limited and expensive. For patients with biochemical recurrence (BCR) after treatment for prostate cancer, novel strategies are needed to better stratify patients who may or may not benefit from a PSMA PET scan. The role of the free-to-total prostate-specific antigen (PSA) ratio (FPSAR) in posttreatment prostate cancer, specifically in the PSMA PET/CT era, remains unknown. Our aim in this study was to determine the association of FPSAR in patients referred for 18F-DCFPyL PSMA PET/CT in the BCR setting and assess the correlation between FPSAR and 18F-DCFPyL PSMA PET/CT positivity (local recurrence or distant metastases). Methods: This prospective study included 137 patients who were referred for 18F-DCFPyL PSMA PET/CT and had BCR with a total PSA of less than 1 ng/mL after radical prostatectomy (RP) (including adjuvant or salvage radiotherapy). Blood samples were collected on the day of 18F-DCFPyL PSMA PET/CT. FPSAR was categorized as less than 0.10 or as 0.10 or more. A positive 18F-DCFPyL PSMA PET/CT scan was defined by a PROMISE classification lesion score of 2 or 3, irrespective of the site of increased tracer uptake (e.g., prostate, pelvic nodes, bone, or viscera). Results: Overall, 137 blood samples of patients with BCR after RP were analyzed to calculate FPSAR. The median age at 18F-DCFPyL PSMA PET/CT was 68.6 y (interquartile range, 63.0-72.4 y), and the median PSA at 18F-DCFPyL PSMA PET/CT was 0.3 ng/mL (interquartile range, 0.3-0.6 ng/mL). Eighty-six patients (62.8%) had an FPSAR of less than 0.10, whereas 51 patients (37.2%) had an FPSAR of 10 or more. An FPSAR of 10 or more was identified as an independent predictor of a positive 18F-DCFPyL PSMA PET/CT scan, with an odds ratio of 6.99 (95% CI, 2.96-16.51; P < 0.001). Conclusion: An FPSAR of 10 or more after RP independently correlated with increased odds of a positive 18F-DCFPyL PSMA PET/CT scan among BCR post-RP patients. These findings may offer an inexpensive method by which to triage access to 18F-DCFPyL PSMA PET/CT in jurisdictions where availability is not replete.

MRI characteristics predict risk of pathological upgrade in patients with ISUP grade group 1 prostate cancer.

OBJECTIVE: This study aims to analyse multiparametric MRI (mpMRI) characteristics of patients diagnosed with ISUP grade group (GG) 1 prostate cancer (PC) on initial target plus systematic MRI/TRUS fusion-guided biopsy and investigate histopathological progression during follow-up. METHODS: A retrospective single-centre cohort analysis was conducted on consecutive patients with mpMRI visible lesions (PI-RADS ≥ 3) and detection of ISUP-1-PC at the time of initial biopsy. The study assessed clinical, mpMRI, and histopathological parameters. Subcohorts were analysed with (1) patients who had confirmed ISUP-1-PC and (2) patients who experienced histopathological upgrading to ISUP ≥ 2 PC during follow-up either at re-biopsy or radical prostatectomy (RP). RESULTS: A total of 156 patients (median age 65 years) between March 2014 and August 2021 were included. Histopathological upgrading to ISUP ≥ 2 was detected in 55% of patients during a median follow-up of 9.5 months (IQR 2.2-16.4). When comparing subgroups with an ISUP upgrade and sustained ISUP 1 PC, they differed significantly in contact length of the index lesion to the pseudocapsule, ADC value, PI-RADS category, and the MRI grading group (mGG) (p < 0.05). In the ISUP GG ≥ 2 subgroup, 91% of men had PI-RADS category 4 or 5 and 82% exhibited the highest mGG (mGG3). In multivariate analysis, mGG was the only independent parameter for predicting ISUP ≥ 2-PC in these patients. CONCLUSIONS: MRI reveals important information about PC aggressiveness and should be incorporated into clinical decision-making when ISUP-1-PC is diagnosed. In cases of specific MRI characteristics adverse to the histopathology, early re-biopsy might be considered. CLINICAL RELEVANCE STATEMENT: In cases with clear MRI characteristics for clinically significant prostate cancer (e.g., mGG 3 and/or PI-RADS 5, cT3, or clear focal PI-RADS 4 lesions on MRI) and ISUP GG 1 PC diagnosed on initial prostate biopsy, MRI findings should be incorporated into clinical decision-making and early re-biopsy (e.g., within 6 months) might be considered. KEY POINTS: MRI reveals important information about prostate cancer (PC) aggressiveness. MRI should be incorporated into clinical decision-making when ISUP GG 1 PC is diagnosed on initial prostate biopsy. In cases of specific MRI characteristics adverse to the histopathology, early re-biopsy might be considered.

Androgen Deprivation Benefits in Low-Dose-Rate Brachytherapy With Hydrogel Spacer.

INTRODUCTION: We aim to investigate the impact of rectal dose reduction of both androgen deprivation therapy (ADT) and concurrent hydrogel spacer placement (HSP) in patients treated with low-dose-rate (LDR) brachytherapy for prostate cancer and to determine whether there are variations in the degree of efficacy of dose reduction across different segments of the rectum. METHODS: This study involved 130 consecutive patients treated with I-125 LDR brachytherapy, with (ADT: n = 66) or without (nADT: n = 64) prior ADT, from June 2017 to April 2021. Among these, 13 ADT and 17 nADT patients underwent HSP following induction in May 2020, whereas the remaining patients (nHSP) included 53 ADT and 47 nADT individuals. In the post plan, a rectal dose assessment was made using the rectal volume (RV), divided by horizontal sections into three equal-length subparts (sRVs), such as high-, mid-, and low-RV. The mean sRV100 values were compared between the nADT and ADT patient groups, both with and without HSP. Similarly, mean sRV100 was compared between the nHSP and HSP patient groups, both with and without ADT. RESULTS: In nADT patients, HSP significantly reduced the mean RV100 of the high-RV (0.002 cc versus 0.086 cc, p < 0.05) and mid-RV (0.127 cc versus 0.377 cc, p < 0.05), but not of the low-RV (0.060 cc versus 0.150 cc, p = 0.06). In contrast, in ADT patients, HSP significantly reduced the RV100 at all three sites (0.002 cc versus 0.031 cc, p < 0.05; 0.034 cc versus 0.269 cc, p < 0.05; and 0.015 cc versus 0.151 cc, p < 0.05, respectively). No significant difference was observed when comparing mean sRV100 with or without ADT in both HSP and nHSP patients. CONCLUSION: The combination of ADT and HSP for LDR prostate brachytherapy showed the potential to significantly reduce RV100, especially in the lower rectum.

Real-World Treatment Patterns in Patients With Metastatic Castration-Resistant Prostate Cancer in Greece: The PROSPECT Study.

INTRODUCTION: Real-world data on management of metastatic castration resistant prostate cancer (mCRPC) with novel therapies is sparse. The aim of this study was to capture real-world management strategies in patients with mCRPC who initiated first line (1L) systemic therapy with chemotherapy or novel hormonal agents (NHAs) in Greece and describe the therapeutic sequencing strategy among patients who advanced to 2L and 3L treatment. PATIENTS AND METHODS: In this noninterventional, multicentre, retrospective study (PROSPECT), a medical chart review of 149 patients with mCRPC who initiated 1L systemic therapy with chemotherapy or NHAs in 7 major anticancer hospital clinics, from public, academic, and private sectors in Greece was conducted. All endpoints were descriptively analysed. Kaplan-Meier was used for time-to-event outcomes. RESULTS: At 1L (N = 149), most (78.5%) patients received NHAs; enzalutamide (52.3%), and abiraterone (26.2%). At 2L (N = 68), most (72.1%) patients received chemotherapy, most frequently docetaxel (50.0% of all patients). At 3L (N = 32), 56.3% and 31.3% of patients received chemotherapy and NHAs, respectively. Regarding treatment sequencing from 1L→2L (N = 68), most patients (55.9%) advanced from NHA→chemotherapy. Regarding treatment sequencing from 1L→2L→3L (N = 32), 34.4% advanced from NHAs→chemotherapy→chemotherapy and 31.3% from NHAs→chemotherapy→NHA. Estimated median times spent on treatment at 1L, 2L, and 3L were 9.8, 4.4, and 3.7 months, respectively. CONCLUSION: Most patients were treated with 1L NHAs, in accordance to established guidelines (which suggest both NHA and chemo as preferred 1st line options). There appeared to be a longer time on treatment of NHAs at 1L than chemotherapy, suggesting an unmet need for treatment optimisation/recommendations for 2L and 3L treatment in mCRPC.