Metastatic Prostate Cancer in Men Initially Treated with Active Surveillance

Yamamoto, Toshihiro; Musunuru, Hima Bindu; Vesprini, Danny; Zhang, Liying; Ghanem, Gabriella; Loblaw, Andrew; Klotz, Laurence

doi:10.1016/j.juro.2015.11.075

Cited by 102 publications

(69 citation statements)

References 26 publications

(17 reference statements)

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…However, among men entering with elements of Gleason pattern 4 in programs at Sunnybrook and Royal Marsden and diagnosed with conventional biopsy, the risk of progressive disease was found to be increased 23,25 . In fact, a recent report documents the possibility of metastatic disease in men entering AS with secondary Gleason pattern 4 26 . The present data confirm and quantify that GS-related risk using MRI-guided biopsies (Kaplan-Meier curves): upgrading to unfavorable pathology over 3 years was found in 63% of men entering with GS3+4 vs. 18% of men entering with GS3+3 ( p <0.01).…”

Section: Discussionmentioning

confidence: 99%

Targeted Biopsy to Detect Gleason Score Upgrading during Active Surveillance for Men with Low versus Intermediate Risk Prostate Cancer

et al. 2017

View full text Add to dashboard Cite

Purpose To determine rate of upgrading to Gleason score (GS) ≥ 4+3, using targeted biopsy for diagnosis and monitoring, in men undergoing active surveillance (AS) of prostate cancer (CaP). Materials and Methods Subjects were all 259 men (196 with GS 3+3 and 63 with GS 3+4) who were diagnosed by MRI/US fusion-guided biopsy (2009–2015) and who underwent subsequent fusion biopsy for as long as 4 years of AS. Primary endpoint was discovery of GS ≥ 4+3 CaP. Follow-up biopsies included targeting of positive sites, which were tracked in an Artemis device. Kaplan-Meier curves were generated to determine rates of upgrading, stratified by initial GS and PSA density. Results Based on a Cox proportional hazard model, men with GS 3+4 were 4.65 more likely to have upgrading than men with initial GS 3+3 (3yr, p < 0.01). 63% of men with GS 3+4 had upgraded by the third surveillance year, compared with 18.0% of men starting with GS 3+3 (p < 0.01). 97% of all upgrades (32/33) occurred within an MRI-visible or a tracked site of tumor, rather than a previously-negative systematic site. Independent predictors of upgrading were GS 3+4, PSA density ≥ 0.15 ng/ml/cm3, and a grade 5 lesion on MRI. The incidence-rate ratio of upgrading (GS 3+4 vs. GS 3+3) was 4.25 per year of patient follow-up (p < 0.01). Conclusions During AS of CaP, targeting of tracked tumor foci by MRI/US fusion biopsy allows heightened detection of GS ≥ 4+3 cancers. Baseline variables directly related to important upgrading and warranting increased vigilance include GS 3+4, PSA density ≥ 0.15, and grade 5 lesions on MRI.

show abstract

Section: Discussionmentioning

confidence: 99%

Targeted Biopsy to Detect Gleason Score Upgrading during Active Surveillance for Men with Low versus Intermediate Risk Prostate Cancer

et al. 2017

View full text Add to dashboard Cite

show abstract

“…A PSA level between 10 and 20 ng/mL places a patient in the intermediate‐risk category; however, PSA in this range confers little increased risk of progression. In the Sunnybrook series, PSA >10 ng/mL in men with GG1 cancer, independent of PSA density (PSAD), had no significantly increased risk of metastasis .…”

Section: Risk Stratification: Which Patients Are Eligible?mentioning

confidence: 91%

“…PSA density, which accounts for prostate volume, has been assessed in numerous studies in the context of prostate cancer diagnosis. Higher PSAD is associated with a higher rate of reclassification to higher grade disease . Intuitively, this implies that men with PSA values higher than expected relative to their prostate volume may harbour higher grade disease that was not identified on initial biopsy.…”

Section: Risk Stratification: Which Patients Are Eligible?mentioning

confidence: 99%

Active surveillance in intermediate‐risk prostate cancer

Klotz

2020

BJU International

Self Cite

View full text Add to dashboard Cite

Objectives Active surveillance (AS), now the standard of care for most men with favourable‐risk prostate cancer, is appealing for selected men with ‘favourable’ intermediate‐risk prostate cancer. Methods This is a review of the indications for conservative management in this population, the outcomes reported in prospective series, and the use of molecular biomarkers and imaging to identify optimal candidates. Results Candidates are those patients who are categorized as having intermediate‐risk disease either because of a prostate‐specific antigen level between 10 and 20 ng/mL, or by virtue of having Grade Group 2 disease, with a small percentage of Gleason 4 pattern, and a negative magnetic resonance imaging result or negative targeted biopsy of a region of interest. Confirmation with a favourable score on a tissue‐based genetic assay can provide further reassurance. A subset of patients with intermediate‐risk disease has indolent disease that may benefit from AS; at the same time, some patients with intermediate‐risk disease have an aggressive clinical course that requires early definitive therapy. This heterogeneity is not adequately captured with traditional histopathological staging. Clinical, genomic and radiological biomarkers are the key to appropriate risk stratification and patient selection. Conclusions The benefits of AS make it an appealing option for selected patients with intermediate‐risk disease.

show abstract

“…In the University of Toronto experience, which incorporates expanded surveillance criteria including some older men with intermediate-risk disease, 30 of 980 patients (3%) developed metastasis at a median follow up of 6.3 years despite reclassification and treatment. 27 These data highlight the heterogeneity of risk in patients who meet expanded surveillance criteria, which is significant as the opportunity for cure is lost upon metastatic progression. In the current study, the presence of biopsy perineural invasion in men who met expanded criteria for active surveillance was associated with a 2-fold increase in the likelihood of extracapsular extension at prostatectomy, and 63% of these men had pathological upgrading.…”

Section: Commentmentioning

confidence: 97%

Biopsy Perineural Invasion in Prostate Cancer Patients Who Are Candidates for Active Surveillance by Strict and Expanded Criteria

Turner

Yecies

Yabes

et al. 2017

Urology

View full text Add to dashboard Cite

Objective To evaluate the association of biopsy perineural invasion (PNI) with adverse pathological findings on radical prostatectomy in patients who would have been candidates for active surveillance (AS). Methods Using a prospectively populated database of 3084 men who underwent open radical prostatectomy, candidates for AS by strict (Johns Hopkins) and expanded (University of Toronto) criteria were identified. The presence of adverse pathologic features at radical prostatectomy was compared between those men with and without biopsy PNI. Results Of 596 men who met strict criteria for active surveillance, 16 (3%) had biopsy PNI. In the strict AS cohort, there were no differences in adverse pathologic features at radical prostatectomy between those with and without PNI. Of 1197 men who were candidates for AS by expanded criteria, 102 (9%) had biopsy PNI. Men with biopsy PNI in the expanded AS cohort were more likely to have extraprostatic extension (p < 0.001) and pathological upgrading (p = 0.01) at prostatectomy. In addition, those with PNI had larger dominant nodules (p < 0.001), and cancer comprised a greater percentage of their prostate glands (p < 0.001). There was no difference in the proportion with a positive margin between the two groups (p = 0.77). Conclusions Biopsy PNI was rare in patients who met strict criteria for AS. Among those men who met expanded criteria, PNI was associated with adverse pathologic findings upon prostatectomy. The presence of biopsy PNI may have a role in further risk stratifying patients who meet expanded criteria for AS.

show abstract

Metastatic Prostate Cancer in Men Initially Treated with Active Surveillance

Cited by 102 publications

References 26 publications

Targeted Biopsy to Detect Gleason Score Upgrading during Active Surveillance for Men with Low versus Intermediate Risk Prostate Cancer

Targeted Biopsy to Detect Gleason Score Upgrading during Active Surveillance for Men with Low versus Intermediate Risk Prostate Cancer

Active surveillance in intermediate‐risk prostate cancer

Biopsy Perineural Invasion in Prostate Cancer Patients Who Are Candidates for Active Surveillance by Strict and Expanded Criteria

Contact Info

Product

Resources

About