Robotic prostatectomy findings in patients with a single microfocus (5% or Less) of Gleason 6 Prostate Cancer at Biopsy

A Single Microfocus (5% or Less) of Gleason 6 Prostate Cancer at Biopsy-Can We Predict Adverse Pathological Outcomes?
Source: Urotoday

While a microfocus of Gleason score 6 prostate cancer on biopsy is commonly considered low risk disease, there was a greater than 1/5  risk of pathological upgrading and/or up staging. Patients with Gleason score 6 microfocal prostate cancer should be counseled that they may harbor more aggressive disease, especially when pretreatment clinical risk factors are present, such as advanced age or high clinical prostate specific antigen density.

The team at the University of Chicago looked at patients with only 1 small focus of cancer that was the lower grade (6) on biopsy. Overall 42 patients (22%) had adverse pathological outcomes, including upgrading in 35 [higher gleason score] (18%) and upstaging [cancer outside the prostate] in 16 (8%). I performed a similar study almost 2 years ago that also found the amount and type of cancer is underestimated on biopsy.

Surgeon and hospital volume linked to radical prostatectomy outcomes

Source: MedWire News

“Briefly, higher hospital and surgeon volumes are associated with a decreased risk of most in-hospital complications after RP,” the team concludes.

They add: “These associations are statistically significant and likely to be clinically important, especially if doubling hospital or surgical volume can lead to an 8% to 9% decrease in the rate of any complication.”

Another study, this one from Canada, showing that hospital and surgeon volume are both related to lower rates of complications for prostate cancer surgery.

I am pleased to say that I am close to 500 robotic prostatectomies and my partner and I have combined for over 600.

UroToday – Percent Tumor Involvement and Risk of Biochemical Progression After Radical Prostatectomy

From UroToday:

We examined the association between percent tumor involvement in the radical prostatectomy specimen and the outcome measures of pathological stage and biochemical progression using multivariate logistic regression and Cox proportional hazards analysis, respectively, in 2,220 patients from the Duke Prostate Center radical prostatectomy database.

This was a study that showed that if you had more cancer in the prostate, you had a higher risk of the cancer coming back after surgery. Although this is obvious, it is important to show these type of things with studies.

Would I would like to see is if patients with the same gleason score and stage (meaning the extent of cancer spread) have different rates of recurrences.

For example, 2 men with organ confined prostate cancer that both have gleason 6 cancers. If 1 man has 1% of tumor volume in his prostate and the other 30%, I would imagine the man with 30% would be more likely to have a recurrence. I am not aware of any studies that have looked at this.

Determinants of Long-Term Retention of Prostate Cancer Patients in Active Surveillance Management Programs

From Urotoday and the AUA

Of the 2134 PCa cases, 169 (7.9%) had AS as their initial management. Of the 169 AS cases, 89 (53%) remained untreated throughout follow-up (mean 7.1 years) and the remaining 47% received treatment an average of 3.1 years post-diagnosis. Significant predictors of eventual active treatment in multivariate models included younger age at diagnosis (60-69 vs. 70+ years), higher Gleason score (>6 vs. <6), and higher prostate cancer aggressiveness/risk. The researchers observed similar rates for development of clinical metastases and PCa death in both AS and immediate treatment groups, respectively (metastases: N=8 and N=92, 6.5 vs. 6.7 events per 1,000 person-years, p=1.0; PCa death: N=4 and N=51, 2.4 vs. 2.7 deaths per 1,000 person-yrs, p=1.0).

This one study shows that men that did active surveillance, needed therapy about half of the time. The results seemed similar for both groups. My main concern is that we do not know the cancer characteristics of the patients. It is possible that the active surveillance patients had less cancer than the treated patients and should have done better.
I also think that waiting 3 years to treat someone may later the treatment approach and possibly lead to more side effects after therapy.

Active Surveillance for Prostate Cancer Patients

From Medscape

May 12, 2008 — The urine test for the PCA3 gene, already marketed for use in diagnosing prostate cancer, could also be useful in prognostication. It might have clinical application in selecting men with low-grade and low-volume tumors who would be suitable candidates for active surveillance, say researchers writing in the May issue of the Journal of Urology.
The PCA3 urine test, marketed in Europe by Gen-Probe, has been shown in previous studies to be more accurate in diagnosing early prostate cancer than serum levels of prostate-specific antigen (PSA).

I usually use the PCA 3 test for men who have had a negative biopsy and we are considering performing a second one. I usualy use it for men with high grade PIN after one biopsy. If the PCA 3 is positive, I usually perform a second biopsy. I have not looked at my data to see if the above correlation exists, but that would be interesting.
I also am not sure if you can use PCA 3 tests that are taken a few months apart to mean anything. For example, would a rise in PCA 3 be expected if a man develops cancer or the cancer is growing?

Newer Prostate Cancer Treatment Similar to Traditional Surgery

From Washington

“This reaffirms what many other manuscripts have shown, if you go to an individual who has experience, who does this on a consistent basis, your outcomes will be better,” said Dr. Ihor S. Sawczuk, chief of urologic oncology for the Cancer Center at Hackensack University Medical Center, in New Jersey. “If you go to someone who does 20 to 50 procedures a year, that’s better than somebody who only does two to three a year.

I agree with Dr. Sawczuk, a friend and colleague, that more experienced surgeons are more likely to have better results. The surgeon is important, probably more so than the technique. I think the best way to analyze this would have been to set up a study looking at high volume robotic vs. lap vs. open surgeons and having a 3rd party analyze the results. I do not think this is something that would ever be done.

My feeling after performing many open prostate cancer surgeries, a few laparoscopic ones, and over 400 robotic ones is that robotics gives me the ability to perform more accurate surgery, and the difference is more pronounced with more difficult cases.
Being able to remove the catheter within 3 days routinely without needing X-Rays would be difficult for me to achieve with open or laparoscopic surgery.

Upgrading after radical prostatectomy

UroToday – Prostate Cancer Volume at Biopsy Predicts Clinically Significant Upgrading – Abstract

Preoperative prostate specific antigen greater than 5.0 ng/ml (p = 0.036), prostate weight 60 gm or less (p = 0.004) and more cancer volume at biopsy, defined by cancer involving greater than 5% of the biopsy tissue (p = 0.002), greater than 1 biopsy core (p < 0.001) or greater than 10% of any core (p = 0.014), were associated with pathological upgrading. Upgraded patients were more likely to have extraprostatic extension and positive surgical margins at radical prostatectomy (p < 0.001 and 0.001, respectively).

This study gives some preoperative parameters that may be suggestive of a hogher gleason score after surgery. When prostates are removed, they are analyzed in more detail and a more accurate gleason score is obtained. In my series about 1/3 of gleason 6 prostate cancers are upgraded. I have noticed that tumor volume is related to upgrading similar to these authors.

Positive margins and their significance

UroToday – Prognostic Significance of Location of Positive Margins in Radical Prostatectomy Specimens

In the 201 men with a single positive SM, it was found in the apex in 75 men (37%), posterolateral in 70 men (35%), bladder neck in 20 men (10%), anterior in 25 men (12%), posterior in 11 men (5%), and in no men was a single positive SM found in the seminal vesicle. The positive SM rate decreased with time, from 18% in the early cohort versus 10% in the late cohort. Those with a positive SM had a 1.4 fold greater risk of progression than those with a negative SM (HR 1.39). In the multivariable analysis, significant differences were found between the effects of different sites of a positive SM on disease progression. A positive SM at the posterolateral or posterior regions significantly increased a patients’ risk of progression for a positive SM versus no SM at these sites. The authors attribute the posterolateral and posterior positive SM rates to neurovascular bundle preservation and an inherent risk of a nerve sparing operation.

This study out of Memorial Sloan Kettering reveals that there is a 40% increase in the recurrence rate of prostate cancer after surgery for a positive margin. The worst positive margins are in the area where the nerve bundles are.

New genetic tests to be developed for prostate cancer

Genetic test in three years to detect prostate cancer | Science | The Guardian:

“A genetic test that identifies men most at risk of prostate cancer could be available within three years, scientists said yesterday. British doctors will use the test in screening programmes to spot the disease in its earliest stages, before it has become dangerously advanced or has spread throughout the body.”

I had a patient in my office last week who was young, was done having children, and had a strong family history of prostate cancer. He was wondering if it would be reasonable to remove his prostate prophyllactically. I told him that I wasn’t ready to do that today, but in the near future I thought it would be reasonable. Breakthroughs like this will help diagnose prostate cancer earlier and more accurately than with prostate biopsies.

Robotic surgery summary- October/November 2007

In October and November I performed 46 robotic surgeries, including 35 dvPs, 4 partial nephrectomies, 2 nephrectomies, 2 radical cystectomies including a bladder replacement in a woman, 1 simple prostatectomy, a stone procedure to remove a large left kidney stone, and a removal of a piece of ureter and re-implant for ureteral cancer.
The most important operation was the anterior exenteration (removal of bladder) and bladder replacement in a female, the first operation to be done completely robotic for me of this type.

One nice trend I have been noticing is a significant improvement in the recovery of urinary control with the reconstruction sutures I have added to the robotic prostatectomy. Most patients are having decent control by 4-6 weeks. I will be looking at the data in more detail in a few months to see how much of an improvement the addition of these sutures has added.

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