Is Unilateral Lymphadenectomy an Option in Selected Patients with Prostate Cancer?

Background: Evidence regarding the relationship between the laterality of lymph node invasion (LNI) and the prostatic lobe affected is limited. Our aim was to review our records of patients with exclusively unilateral localised prostate cancer (PCa) with metastatic LN involvement. Methods: Between 2006 and 2023, after radical prostatectomy and extended pelvic lymphadenectomy at our centre, thirty patients with intermediate-high risk unilateral PCa and pN1 disease were identified. To perform a retrospective study, data were obtained from a prospective collected database approved by the ethical committee at the Valencian Oncology Institute Foundation. Descriptive and comparative statistical analysis was made using software R. The Fisher’s Exact test was employed to analyse the categorical variables. In terms of continuous variables, both tumour volume and number of nodes retrieved exhibited normality; Hence Student’s T-test was employed. Mann-Whitney U test was utilized for the number of positive nodes. Results: The median age and prostate specific antigen (PSA) at diagnosis were 66 years old (interquartile range (IQR): 63.3–70.9) and 14.6 ng/mL (IQR: 7.4–21.5), respectively. Median follow-up time was 67 months (IQR: 35.9–92.9). Nineteen patients (63%) had a Gleason score of 7, and the rest had a Gleason score of 8–10. Most patients (73%) had locally advanced disease. Baseline characteristics were comparable between groups (p-value > 0.05). Twenty-two patients (73%) had concordance between the laterality of the PCa lesion and the LNI. All the patients with right prostatic cancer had exclusive ipsilateral LNI. Conclusions: In our experience, the majority of patients with unilateral PCa had exclusively ipsilateral LNI. However, sparing contralateral LN dissection in unilateral PCa should not be an option... (AU)

Personalised indocyanine-guided lymphadenectomy for prostate cancer: a randomised clinical trial.

OBJECTIVES: To study the safety and efficacy of a personalised indocyanine-guided pelvic lymph node dissection (PLND) against extended PLND (ePLND) during radical prostatectomy (RP). PATIENTS AND METHODS: Patients who were candidates for RP and lymphadenectomy, with intermediate- or high-risk prostate cancer (PCa) according to the National Comprehensive Cancer Network guidelines, were enrolled in this randomised clinical trial. Randomisation was made 1:1 to indocyanine green (ICG)-PLND (only ICG-stained LNs) or ePLND (obturator fossa, external, internal, and common iliac and presacral LNs). The primary endpoint was the complication rate within 3 months after RP. Secondary endpoints included: rate of major complications (Clavien-Dindo Grade III-IV), time to drainage removal, length of stay, percentage of patients classified as pN1, number of LNs removed, number of metastatic LNs, rate of patients with undetectable prostate-specific antigen (PSA), biochemical recurrence (BCR)-free survival, and rate of patients with androgen-deprivation therapy at 24 months. RESULTS: A total of 108 patients were included with a median follow-up of 16 months. In all, 54 were randomised to ICG-PLND and 54 to ePLND. The postoperative complication rate was higher in the ePLND (70%) vs the ICG-PLND group (32%) (P < 0.001). Differences between major complications in both groups were not statically significant (P = 0.7). The pN1 detection rate was higher in the ICG-PLND group (28%) vs the ePLND group (22%); however, this difference was not statistically significant (P = 0.7). The rate of undetectable PSA at 12 months was 83% in the ICG-PLND vs 76% in the ePLND group, which was not statistically significant. Additionally, there were no statistically significant differences in BCR-free survival between groups at the end of the analysis. CONCLUSIONS: Personalised ICG-guided PLND is a promising technique to stage patients with intermediate- and high-risk PCa properly. It has shown a lower complication rate than ePLND with similar oncological outcomes at short-term follow-up.

Free-indocyanine green-guided pelvic lymph node dissection during radical prostatectomy.

INTRODUCTION AND OBJECTIVES: Extended Pelvic Lymph Node Dissection (ePLND) remains the most accurate technique for the detection of occult lymph node metastases (LNMs) in prostate cancer (CaP) patients. Here we aim to examine whether free-Indocyanine Green (F-ICG) could accurately assess the pathological nodal (pN) status in CaP patients during real-time lymphangiography as a potential replacement for ePLND. MATERIALS AND METHODS: 219 consecutive patients undergoing F-ICG-guided PLND, ePLND and radical prostatectomy (RP) for clinical-localized CaPwere included in this prospective single-center study. The pathological outcomes of F-ICG-guided PLND were compared to confirmatory ePLND. Parameters of a binary diagnostic test for the proper classification of the pN status of patients ('per-patient' analysis) and for the probability of detecting all the metastatic LNs ('per-node' analysis) were calculated. Outcome measures were prevalence, accuracy (Acc), sensitivity (Se), negative predictive value (NPV), and likelihood ratio of a negative F-ICG-guided PLND test result [LR(-)]. RESULTS: F-ICG-guided PLND successfully visualized LNs in all procedures with no adverse events. The overall per-patient F-ICG staging Acc was 97.7%, Se was 91.4%, with a NPV of 97.0%, and LR(-) of 8.6%. At the overall per-node level, 4,780 LNs were removed and 1,535 (32.1%) were fluorescent in vivo. F-ICG-guided PLND identified LNMs with a Se of 63.4%. CONCLUSIONS: This study confirms that F-ICG-guided lymphangiography correctly staged almost 98% of patients. The high per-patient NPV suggested that avoiding ePLND is safe for most patients when F-ICG stained nodes were pN0. Thus, more conservative approaches might minimise perioperative morbidity during LNMs diagnosis in selected patients.

Bilateral Seminal Vesicle Invasion Is Not Associated with Worse Outcomes in Locally Advanced Prostate Carcinoma.

Background and Objectives: Patients with seminal vesicle invasion (SVI) are a highly heterogeneous group. Prognosis can be affected by many clinical and pathological characteristics. Our aim was to study whether bilateral SVI (bi-SVI) is associated with worse oncological outcomes. Materials and Methods: This is an observational retrospective study that included 146 pT3b patients treated with radical prostatectomy (RP). We compared the results between unilateral SVI (uni-SVI) and bi-SVI. The log-rank test and Kaplan-Meier curves were used to compare biochemical recurrence-free survival (BCR), metastasis-free survival (MFS), and additional treatment-free survival. Cox proportional hazard models were used to identify predictors of BCR-free survival, MFS, and additional treatment-free survival. Results: 34.93% of patients had bi-SVI. The median follow-up was 46.84 months. No significant differences were seen between the uni-SVI and bi-SVI groups. BCR-free survival at 5 years was 33.31% and 25.65% (p = 0.44) for uni-SVI and bi-SVI. MFS at 5 years was 86.03% vs. 75.63% (p = 0.1), and additional treatment-free survival was 36.85% vs. 21.93% (p = 0.09), respectively. In the multivariate analysis, PSA was related to the development of BCR [HR 1.34 (95%CI: 1.01-1.77); p = 0.03] and metastasis [HR 1.83 (95%CI: 1.13-2.98); p = 0.02]. BCR was also influenced by lymph node infiltration [HR 2.74 (95%CI: 1.41-5.32); p = 0.003]. Additional treatment was performed more frequently in patients with positive margins [HR: 3.50 (95%CI: 1.65-7.44); p = 0.001]. Conclusions: SVI invasion is an adverse pathology feature, with a widely variable prognosis. In our study, bilateral seminal vesicle invasion did not predict worse outcomes in pT3b patients despite being associated with more undifferentiated tumors.

Deep learning for fully automatic detection, segmentation, and Gleason grade estimation of prostate cancer in multiparametric magnetic resonance images.

Although the emergence of multi-parametric magnetic resonance imaging (mpMRI) has had a profound impact on the diagnosis of prostate cancers (PCa), analyzing these images remains still complex even for experts. This paper proposes a fully automatic system based on Deep Learning that performs localization, segmentation and Gleason grade group (GGG) estimation of PCa lesions from prostate mpMRIs. It uses 490 mpMRIs for training/validation and 75 for testing from two different datasets: ProstateX and Valencian Oncology Institute Foundation. In the test set, it achieves an excellent lesion-level AUC/sensitivity/specificity for the GGG[Formula: see text]2 significance criterion of 0.96/1.00/0.79 for the ProstateX dataset, and 0.95/1.00/0.80 for the IVO dataset. At a patient level, the results are 0.87/1.00/0.375 in ProstateX, and 0.91/1.00/0.762 in IVO. Furthermore, on the online ProstateX grand challenge, the model obtained an AUC of 0.85 (0.87 when trained only on the ProstateX data, tying up with the original winner of the challenge). For expert comparison, IVO radiologist's PI-RADS 4 sensitivity/specificity were 0.88/0.56 at a lesion level, and 0.85/0.58 at a patient level. The full code for the ProstateX-trained model is openly available at https://github.com/OscarPellicer/prostate_lesion_detection . We hope that this will represent a landmark for future research to use, compare and improve upon.

Indocyanine green guidance improves the efficiency of extended pelvic lymph node dissection during laparoscopic radical prostatectomy.

OBJECTIVES: To evaluate whether indocyanine green guidance can improve the quality of extended pelvic lymph node dissection in patients undergoing radical prostatectomy. METHODS: A total of 214 patients underwent laparoscopic radical prostatectomy with indocyanine green-guided lymph node dissection plus extended pelvic lymph node dissection. These patients (group A) were matched 1:1 for clinical risk groups according to the National Comprehensive Cancer Network classification with patients who underwent the same procedure without fluorescence guidance (group B). Biochemical recurrence was defined as two consecutive prostate-specific antigen rises of at least 0.2 ng/mL. The Kaplan-Meier method and Cox regression models were used to identify predictors of biochemical recurrence. RESULTS: The median number of retrieved nodes was significantly higher in group A (22 vs 14, P < 0.001). The rate of lymph node metastases was higher in group A (65.9% vs 34.1%, P = 0.01). Increasing the yield of lymph node dissection was independently and negatively correlated with the biochemical recurrence risk in both overall and pN-positive patients (hazard ratio 0.97, P = 0.03; and hazard ratio 0.95, P = 0.02). The 5-year biochemical recurrence-free survival rates were (75.8% vs 65.9, P = 0.09) and (54.1% vs 24.9%, P = 0.023) for group A and group B in the overall cohort and pN-positive cohort, respectively. CONCLUSION: Indocyanine green-guided lymph node dissection plus extended pelvic lymph node dissection improves identification of lymphatic drainage, resulting in a higher number of lymph nodes and retrieved lymph node metastases, and allowing a more accurate local staging and a prolonged biochemical recurrence-free survival.

Ablación Focal con Láser y Terapia Vascular Fotodinámica con TOOKAD® soluble, en el tratamiento del cáncer de próstata de bajo riesgo / Focal Laser Ablation and Photodynamic Vascular Therapy with soluble TOOKAD® in the treatment of low risk prostate cancer

El incremento en el diagnóstico de Cáncer de Próstata (CaP) de bajo riesgo se traducen una nueva entidad clínica, para la cual, la vigilancia activa puede no ser siempre suficiente y para la que las terapias convencionales suponen un claro sobre-tratamiento. Ante la necesidad de dar una respuesta terapéutica a estos pacientes, y facilitado por los avances tecnológicos en el campo de la imagen y nuevas fuentes de energía, el interés se centra ahora en el desarrollo clínico de las terapias focales, como una alternativa de mínima comorbilidad y oncológicamente segura. Como parte de la revisión llevada a cabo por este monográfico, este artículo se centrará en aspectos referentes al desarrollo pre-clínico y clínico de la terapia ablativa con láser y de la novedosa terapia vascular fotodinámica con TOOKAD® Soluble. Con esta finalidad, se realizó una exhaustiva búsqueda bibliográfica, actualizada en Febrero de 2016, de las mayores bases reprográficas, incluyendo publicaciones originales y revisiones referentes al objeto de esta revisión, sin restricciones por año de publicación. Este artículo revisa el desarrollo pre- y clínico de estas novedosas técnicas ablativas en el campo de la terapia focal del CaP de bajo riesgo

The increase of the diagnosis of low risk prostate cancer translates into a new clinical entity, for which active surveillance may not be always enough and conventional therapies are clearly overtreatment. Faced with the necessity of giving a therapeutic answer to these patients, and facilitated by the technological advances in the imaging field and new energy sources, the interest is centered in the clinical development of focal therapies as an alternative with minimal morbidity and oncologically safe. As a part of the review carried out in this monographic issue, this article focus on the features relative to the preclinical and clinical development of laser ablative therapy and the innovative photodynamic vascular therapy with soluble TOOKAD®. With this aim we performed an exhaustive bibliographic search, updated to February 2016, in the greater databases, including original articles and reviews in reference to the object of this review, without restrictions for year of publication. This article reviews the preclinical and clinical development of these innovative ablative techniques in the field of focal therapy for low risk prostate cáncer

An update on imaging techniques to optimize active surveillance in prostate cancer.

Thanks to the higher diagnostic accuracy and safety, new imaging techniques provide future prospects in terms of patient management and follow-up in active surveillance (AS) protocols. Two of the aims of developing new imaging techniques are improving patient selection criteria and to improve follow-up with non-invasive tests. Another objective is to improve the diagnostic performance of biopsies; this would enable physicians to switch from blind systematic TRUS-guided biopsies to targeted biopsies to reduce the amount of biopsies required and reduce the diagnostic rate of clinically insignificant cancers. The notable advances of multi-parametric or functional prostatic imaging (mpMRI) have led to perceptible diagnostic improvements as it they does do not only provide information regarding size and location but also tumor aggressiveness. MRI has proven to be the most reliable non-invasive technique to be able to exclude patients with clinically significant cancer and thus gain acceptance in AS protocols during selection, confirmation and follow-up of AS patients. This chapter reviews the notable impact of multiparametric prostate MRI (mpMRI) on improving both diagnostic accuracy and follow-up. The second point describes the technical advances in the field of transrectal ultrasound imaging, aiming at improving the diagnostic accuracy of biopsies given their increased accessibility and real-time use.

Actualización en las técnicas de imagen para optimizar la vigilancia activa en cáncer de próstata / An update on imaging techniques to optimize active surveillance in prostate cancer

Las nuevas técnicas de imagen, gracias a su mayor precisión diagnóstica y seguridad, tienen un gran potencial en el manejo de los pacientes considerados para vigilancia activa (VA).Entre los objetivos de las técnicas de imagen se encuentran mejorar los criterios de selección de los pacientes y optimizar el seguimiento mediante pruebas no invasivas. Asimismo, pretenden mejorar el rendimiento diagnóstico de la biopsia pasando de la biopsia ecodirigida sistemática "a ciegas" a la biopsia dirigida focalizada, con la finalidad de poder reducir el número de biopsias y permitiendo disminuir el diagnóstico de cánceres clínicamente insignificantes. Los notables avances en la RM multiparamétrica o funcional de próstata (RMmp) han permitido una mejora en el diagnóstico, ya que no sólo aporta información de la localización y el tamaño, sino también sobre la agresividad tumoral. La RMmp ha demostrado ser la técnica no invasiva más fiable para poder excluir a aquellos pacientes con cáncer clínicamente significativo, obteniendo así cada vez más protagonismo en los protocolos de VA tanto en los periodos de selección como durante su confirmación y el seguimiento. Este capítulo pretende detallar el notable impacto que está teniendo la incorporación de la RMmp en mejorar el diagnóstico y facilitar el seguimiento de estos pacientes. En segundo lugar se detallan los avances técnicos en el campo de la ecografía transrectal en su intento de mejorar el rendimiento diagnóstico de la biopsia, gracias a su mayor accesibildad y su realización en tiempo real

Thanks to the higher diagnostic accuracy and safety, new imaging techniques provide future prospects in terms of patient management and follow-up in active surveillance (AS) protocols. Two of the aims of developing new imaging techniques are improving patient selection criteria and to improve follow-up with non-invasive tests. Another objective is to improve the diagnostic performance of biopsies; this would enable physicians to switch from blind systematic TRUS-guided biopsies to targeted biopsies to reduce the amount of biopsies required and reduce the diagnostic rate of clinically insignificant cancers. The notable advances of multi-parametric or functional prostatic imaging (mpMRI) have led to perceptible diagnostic improvements as it they does do not only provide information regarding size and location but also tumor aggressiveness. MRI has proven to be the most reliable non-invasive technique to be able to exclude patients with clinically significant cancer and thus gain acceptance in AS protocols during selection, confirmation and follow-up of AS patients. This chapter reviews the notable impact of multiparametric prostate MRI (mpMRI) on improving both diagnostic accuracy and follow-up. The second point describes the technical advances in the field of transrectal ultrasound imaging, aiming at improving the diagnostic accuracy of biopsies given their increased accessibility and real- time use

High-intensity focused ultrasound in small renal masses.

High-intensity focused ultrasound (HIFU) competes with radiofrequency and cryotherapy for the treatment of small renal masses as a third option among ablative approaches. As an emerging technique, its possible percutaneous or laparoscopic application, low discomfort to the patient and the absence of complications make this technology attractive for the management of small renal masses. This manuscript will focus on the principles, basic research and clinical applications of HIFU in small renal masses, reviewing the present literature. Therapeutic results are controversial and from an clinical view, HIFU must be considered a technique under investigation at present time. Further research is needed to settle its real indications in the management of small renal masses; maybe technical improvements will certainly facilitate its use in the management of small renal masses in the near future.