Prognostic significance of PI-RADS 5 lesions in patients treated by radical prostatectomy.

PURPOSE: To analyse the pathological features and survival of patients with a PI-RADS 5 lesion on pre-biopsy MRI. METHODS: We extracted from a European multicentre prospectively gathered database the data of patients with a PI-RADS 5 lesion on pre-biopsy MRI, diagnosed using both systematic and targeted biopsies and subsequently treated by radical prostatectomy. The Kaplan-Meier model was used to assess the biochemical-free survival of the whole cohort and univariable and multivariable Cox models were set up to study factors associated with survival. RESULTS: Between 2013 and 2019, 539 consecutive patients with a PI-RADS 5 lesion on pre-biopsy MRI were treated by radical prostatectomy and included in the analysis. Follow-up data were available for 448 patients. Radical prostatectomy and lymph node dissection specimens showed non-organ confined disease in 297/539 (55%), (including 2 patients with a locally staged pT2 lesion and lymph node involvement (LNI)). With a median follow-up of 25 months (12-39), the median biochemical recurrence-free survival was 54% at 2 years (95% CI 45-61) and 28% at 5 years (95% CI 18-39). Among the factors studied, MRI T stage [T3a vs T2 HR 3.57 (95%CI 1.78-7.16); T3b vs T2 HR 6.17 (95% CI 2.99-12.72)] and PSA density (HR 4.47 95% CI 1.55-12.89) were significantly associated with a higher risk of biochemical recurrence in multivariable analysis. CONCLUSION: Patients with a PI-RADS 5 lesion on pre-biopsy MRI have a high risk of early biochemical recurrence after radical prostatectomy. MRI T stage and PSA density can be used to improve patient selection and counselling.

The impact of postoperative inflammatory biomarkers on oncologic outcomes of bladder cancer.

INTRODUCTION: The clinical impact of inflammatory biomarkers has been evaluated in urothelial bladder cancer. However, data are limited to preoperative values and there is paucity of evidence of the role of postoperative measurement of those biomarkers. The aim of the current study was to determine the association of inflammatory biomarkers as neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), hemoglobin to platelet ratio (HPR) and C-reactive protein (CRP), before and after radical cystectomy, with recurrence and survival of bladder cancer. MATERIAL AND METHODS: We prospectively evaluated 134 patients undergoing radical cystectomy for invasive bladder cancer between January 2013 and January 2018. The inflammatory biomarkers were measured 10days before surgery and at 1, 6 and 12months postoperatively. Kaplan-Meier curves and Cox proportional hazards and logistic regression models were used to evaluate the association between the different inflammatory biomarkers and recurrence free survival (RFS), cancer specific survival (CSS) and overall survival (OS). RESULTS: The median follow-up time was 21.1months (5-37 mo). On multivariate analysis, preoperative NLR>3.88 was associated to locally-advanced disease (>pT3) and NLR>3.88 and HPR<0.039 were significantly associated to node positive disease. Postoperative NLR at 3months>4.68 (HR: 2.37, 95% CI: 1.08-4.47, P=0.03) was associated with a reduced RFS. A postoperative NLR at 3months>4.68 (P=0.04) and a postoperative HPR at 3months<0.029 (P=0.001) were associated with a significant reduction in CSS and OS. CONCLUSION: Postoperative NLR and HPR at 3months appear to be closely associated with RFS, CSS and OS. Further studies are needed on these postoperative markers to establish the potential impact of these inflammatory biomarkers on a tailored therapeutic approach for each patient. LEVEL OF EVIDENCE: 3.

A systematic review of contemporary management of oligometastatic prostate cancer: fighting a challenge or tilting at windmills?

PURPOSE: Amongst the unanswered questions regarding prostate cancer (PCa), the optimal management of oligometastatic disease remains one of the major concerns of the scientific community. The very existence of this category is still subject to controversy. Aim of this systematic review is to summarize current available data on the most appropriate management of oligometastatic PCa. EVIDENCE ACQUISITION: All relevant studies published in English up to November the 1st were identified through systematic searches in PubMed, EMBASE, Cochrane Library, CINAHL, Google Scholar and Ovid database. A search was performed including the combination of following words: (prostate cancer) and (metastatic) and [(oligo) or (PSMA) or (cytoreductive) or (stereotaxic radiotherapy) or (prostatectomy)]. 3335 articles were reviewed. After title screening and abstract reading, 118 papers were considered for full reading, leaving a total of 36 articles for the systematic review. EVIDENCE SYNTHESIS: There is still no consensus on the definition of oligometastatic disease, nor on the imaging modalities used for its detection. While retrospective studies suggest an added benefit with the treatment the primitive tumor by cytoreductive prostatectomy (55% survival rate vs 21%, p < 0.001), prospective studies do not validate the same outcome. Nonetheless, most studies have reported a reduction in local complications after cytoreductive prostatectomy (< 10%) compared to the best systemic treatment (25-30%). Concerning radiotherapy, an overall survival benefit for patients with a low metastatic burden was found in STAMPEDE (HR 0.68, 95% CI 0.52-0.90; p = 0.007) and suggested in subgroup analysis of the HORRAD trial. Regarding the impact of metastases-directed therapy (MDT), the STOMP and ORIOLE trials suggested that metastatic disease control might improve androgen deprivation therapy-free survival (in STOMP: 21 vs 13 months for MDT vs standard of care). Nonetheless, the impact of MDT on long-term oncologic results remains unclear. Finally, oligometastatic disease appears to be a biologically different entity compared to high-burden metastatic disease. New findings on exosomes appear to make them intriguing biomarkers in the early phases of oligometastatic PCa. CONCLUSION: Oligometastatic PCa is today a poorly understood disease. The implementation of new imaging techniques as whole-body MRI and PSMA PET/CT has increased exponentially the number of oligometastatic patients detected. Data of available trials suggest a benefit from cytoreductive prostatectomy to reduce local complication, though its impact on survival remains unknown. Radiotherapy may be beneficial for patients with low-burden metastatic PCa, while MDT may delay the need for androgen deprivation therapy. Results from ongoing trials data are eagerly awaited to draw reliable recommendations.