Purpose:Bilateral extended pelvic lymph node dissection at the time of radical prostatectomy is the current standard of care if pelvic lymph node dissection is indicated; often, however, pelvic lymph node dissection is performed in pN0 disease. With the more accurate staging achieved with magnetic resonance imaging–targeted biopsies for prostate cancer diagnosis, the indication for bilateral extended pelvic lymph node dissection may be revised. We aimed to assess the feasibility of unilateral extended pelvic lymph node dissection in the era of modern prostate cancer imaging.Materials and Methods:We analyzed a multi-institutional data set of men with cN0 disease diagnosed by magnetic resonance imaging–targeted biopsy who underwent prostatectomy and bilateral extended pelvic lymph node dissection. The outcome of the study was lymph node invasion contralateral to the prostatic lobe with worse disease features, ie, dominant lobe. Logistic regression to predict lymph node invasion contralateral to the dominant lobe was generated and internally validated.Results:Overall, data from 2,253 patients were considered. Lymph node invasion was documented in 302 (13%) patients; 83 (4%) patients had lymph node invasion contralateral to the dominant prostatic lobe. A model including prostate-specific antigen, maximum diameter of the index lesion, seminal vesicle invasion on magnetic resonance imaging, International Society of Urological Pathology grade in the nondominant side, and percentage of positive cores in the nondominant side achieved an area under the curve of 84% after internal validation. With a cutoff of contralateral lymph node invasion of 1%, 602 (27%) contralateral pelvic lymph node dissections would be omitted with only 1 (1.2%) lymph node invasion missed.Conclusions:Pelvic lymph node dissection could be omitted contralateral to the prostate lobe with worse disease features in selected patients. We propose a model that can help avoid contralateral pelvic lymph node dissection in almost one-third of cases.
high Gleason score (GS) (92% in GS 8-10 vs 71% in 72% in GS 6-7, p <0.01). No difference of 18 F-DCFPyL positivity rate was observed in post-radiation patients with different PSAdt or GS. We identified 62 patients (28%) with a total of 109 possible extra-pelvic oligometastases. Among them, there are 60 osseous lesions (8 high, 16 moderate and 36 mild uptake), 40 lymph nodes (9 high, 13 moderate and 18 mild uptake) and 9 other lesions such as lung nodules (6 high, 2 moderate and 1 mild uptake). 27 out of the 62 patients (44%) received locally targeted therapy for these lesions (radiation therapy or surgery) with or without androgen deprivation therapy.CONCLUSIONS: 18 F-DCFPyL PET/CT holds great potential to be a "one-stop shop" diagnostic tool in the work-up of BCR prostate cancer to identify possible extra-pelvic oligometastases for locally targeted therapy.
Objectives: Localized very high-risk prostate cancer (VHR PCa) has long suffered from the inex-istence of good lymph node staging methods other than invasive surgery, as computed tomogra-phy has low sensitivity for nodal disease. With the rising use of positron emission tomography (PET), it is clinically meaningful to know its value for these patients. Our goal was to evaluate the real-life diagnostic accuracy of PET Choline in nodal staging, comparing it with the gold standard of extended pelvic lymph node dissection (ePLND).Materials and methods: We reviewed data from a high-volume center, including patients with VHR PCa according to current NCCN guidelines who underwent community 18F-fluorocholine PET/CT; followed by ro-botic assisted laparoscopic prostatectomy (RALP) and ePLND between 2010 and 2021. Results: We included 44 patients and 88 lymph node regions. Among those, 14/44 (31.8%) patients and 20/88 (22.7%) regions had nodal disease present on definitive pathology. In comparison with ePLND, we found a sensitivity of 64.3% (95% CI, 39.2-89.4%), specificity of 83.3% (95% CI, 70.0- 96.7%), PPV of 64.3% (95% CI, 39.2-89.4%), and NPV of 83.3% (95% CI, 70.0-96.7%) for nodal disease on a patient-based analysis; and sensitivity of 35.0% (95% CI, 14.1-60.0%), specificity of 88.2% (95% CI, 80.6-95.9%), PPV of 46.7% (95% CI, 21.4-71.9%), and NPV of 82.2% (95% CI, 73.4-91.0%) on a region-based analysis. Conclusions: In our view 18F-fluorocholine PET/CT doesn’t meet the criteria to be a standard exam for pre-operative staging for patients with VHR PCa, mostly due to its low sensitivity. However, other radiotracers should continue to be investigated in this setting.
BackgroundProstate cancer (PC) primarily affects elderly men. However, the specific features of cases diagnosed at younger ages (<65 years) suggest that they may represent a different clinical subtype. Our aim was to assess this suggestion by contrasting the geographical PC mortality and hospital admissions patterns in Spain for all ages to those in younger men.MethodsThe Spanish National Institute of Statistics supplied data on PC mortality, hospital admission, and population data. We estimated the expected town-specific number of deaths and calculated the standardized mortality ratios. Spatial autoregressive models of Besag-York-Mollié provided smoother municipal estimators of PC mortality risk (all ages; <65 years). We computed the provincial age-standardized rate ratios of PC hospital admissions (all men; <60 years) using Spanish rates as the reference.ResultsA total of 29,566 PC deaths (6% among those <65 years) were registered between 2010–2014, with three high-mortality risk zones: Northwest Spain; Southwest Andalusia & Granada; and a broad band extending from the Pyrenees Mountains to the north of Valencia. In younger men, the spatial patterns shared the high risk of mortality in the Northwest but not the central band. The PC hospital discharge rates confirmed a North-South gradient but also low mortality/high admission rates in Madrid and Barcelona and the opposite in Southwest Andalusia.ConclusionThe consistent high PC mortality/morbidity risk in the Northwest of Spain indicates an area with a real excess of risk. The different spatial pattern in younger men suggests that some factors associated with geographical risk might have differential effects by age. Finally, the regional divergences in mortality and morbidity hint at clinical variability as a source of inequity within Spain.
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Objectives: Focal therapies (FTs) are promising techniques for the treatment of localized prostate cancer. We assessed the medium-term oncological outcomes of intermediate-risk prostate cancer (PCa) treated with HIFU or cryotherapy. Materials and methods: One-hundred and fifty consecutive patients with intermediate-risk PCa, treated between 2009 and 2018 at a single center were included. Primary study outcome was failure-free survival (FFS), defined as absence of additional treatment, systemic progression or prostate cancer related death. Results: Thirty-seven (25%) patients underwent cryotherapy and 113 (75%) HIFU. Median age was 69 (IQR 62-72) years, with 36 (24%) presenting palpable disease on rectal examination, and median total PSA of 7.85 (IQR 5.75-10.62) ng/mL. Patients were followed for a median of 61 (IQR 48-82) months. FFS at 2 and 4 years was of 75.6% and 53.6%, respectively. Survival from whole gland or systematic treatment at 2 and 4 years was of 78.9% and 53.9%, respectively. Patients with FFS presented lower total PSA nadir (1.89 vs 3.25 ng/mL, p < 0.001), higher % PSA reduction at 3 months (66.1% vs 49.3%, p < 0.001), and at nadir (75.5% vs 55.8%, p < 0.001). Other characteristics such has the treatment modality, age, prostate size, initial total PSA, cT stage, International Society of Urological Pathology (ISUP), tumor location and biopsy results by region did not differ between patients failing and not failing FT. Complications were uncommon (13%), with only onr (1%) patient having Clavien-Dindo grade > II. No deaths due to treatment were registered. Conclusions: At medium-term, FTs for intermediate-risk PCa presented good oncological results, with an excellent safety profile.
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