OBJECTIVETo assess the predictive value of biopsy-identified cribriform carcinoma and/or intraductal carcinoma (CR/IDC) within the Briganti and MSKCC nomograms predicting lymph node metastasis (LNM) ...in patients with primary prostate cancer (PCa). METHODSWe retrospectively included 393 PCa patients who underwent radical prostatectomy with extended pelvic lymph node dissection at 3 tertiary referral centers. We externally validated 2 prediction tools: the Briganti 2012 nomogram and the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram. Both nomograms were augmented with CR/IDC. The original model was compared with the CR/IDC-updated model using the likelihood ratio test. The performance of the prediction tools was assessed using calibration, discrimination, and clinical utility. RESULTSOverall, 109 (28%) men were diagnosed with LNM. Calibration plots of the Briganti and MSKCC nomograms demonstrated an underestimation of the LNM risk across clinically relevant thresholds (≤15%). The addition of CR/IDC to the Briganti nomogram increased the fit of the data (χ2(1) = 4.30, P = .04), but did not improve the area under the curve (AUC) (0.69, 95% CI 0.63-0.75 vs 0.69, 95% CI 0.64-0.75). Incorporation of CR/IDC in the MSKCC nomogram resulted in an increased fit on the data (χ2(1) = 10.04, P <.01), but did not increase the AUC (0.66, 95% CI 0.60-0.72 vs 0.68, 95% CI 0.62-0.74). The addition of CR/IDC to the Briganti and MSKCC nomograms did not improve the clinical risk prediction. CONCLUSIONIncorporation of CR/IDC into the 2 clinically most used pre-radical prostatectomy nomograms does not improve LNM prediction in a multinational, contemporary PCa cohort.
We sought to identify a subset of patients in whom an extended pelvic lymph node dissection during robot-assisted laparoscopic radical prostatectomy for localized prostate cancer could be omitted ...when preoperative prostate specific membrane antigen positron emission tomography showed no lymph node metastatic prostate cancer.
A total of 434 patients who underwent prostate specific membrane antigen positron emission tomography prior to robot-assisted laparoscopic radical prostatectomy and extended pelvic lymph node dissection were retrospectively analyzed. Patients were excluded from analysis when the prostate specific membrane antigen positron emission tomography showed evidence of distant metastases. The primary outcome was whether a negative for metastases prostate specific membrane antigen positron emission tomography was able to correctly rule out pelvic lymp node metastases after extended pelvic lymph node dissection, ie its negative predictive value.
Overall sensitivity, specificity, positive predictive value and negative predictive value of prostate specific membrane antigen positron emission tomography for the detection of pelvic lymp node metastases were 37.9%, 94.1%, 64.3% and 84.4%, respectively. The negative predictive value of prostate specific membrane antigen positron emission tomography in patients with intermediate risk prostate cancer was 91.6% (95% CI 86-97), compared to 81.4% (95% CI 77-86) in patients with high risk prostate cancer. When only assessing patients with <rT3 disease on multiparametric magnetic resonance imaging, 51/52 patients with intermediate risk prostate cancer had a true negative prostate specific membrane antigen positron emission tomography (negative predictive value=98.1%; 95% CI 94-100).
In patients with high risk prostate cancer, extended pelvic lymph node dissection remains the gold standard staging method, as pelvic lymph node metastases are frequently missed in those with no lymph node metastatic prostate cancer on prostate specific membrane antigen positron emission tomography. Patients with intermediate risk prostate cancer and a radiological T-stage <rT3 on multiparametric magnetic resonance imaging are potential candidates to withhold an extended pelvic lymph node dissection in the presence of a "negative for lymph node metastases" prostate specific membrane antigen positron emission tomography.
The aim of this study was to estimate and subsequently measure the occupational radiation exposure for all personnel involved in producing, administering, or performing imaging or surgery with
...TcTc-PSMA-I&S, which has been introduced for identification of tumor-positive lymph nodes during salvage prostate cancer surgery.
The effective dose was estimated and subsequently measured with electronic personal dosimeters for the following procedures and personnel: labeling and quality control by the radiopharmacy technologist, syringe preparation by the nuclear medicine laboratory technologist, patient administration by the nuclear medicine physician, patient imaging by the nuclear medicine imaging technologist, and robot-assisted laparoscopic salvage lymph node dissection attended by an anesthesiology technologist, scrub nurse, surgical nurse, and surgeon. The dose rate of the patient was measured immediately after administration of
TcTc-PSMA-I&S, after imaging, and after surgery.
The estimated dose per procedure ranged from 1.59 × 10
μSv (imaging technologist) to 9.74 μSv (scrub nurse). The measured effective dose ranged from 0 to 5 μSv for all personnel during a single procedure with
TcTc-PSMA-I&S. The highest effective dose was received by the scrub nurse (3.2 ± 1.3 μSv), whereas the lowest dose was measured for the surgical nurse (0.2 ± 0.5 μSv). If a single scrub nurse were to perform as many as 100 procedures with
TcTc-PSMA-I&S in a year, the total effective dose would be 320 μSv/y. Immediately after administration, the dose rate at 50 cm from the patient was 18.5 ± 1.6 μSv/h, which dropped to 1.8 ± 0.3 μSv/h after imaging the following day, reducing even further to 0.56 ± 0.33 μSv/h after surgery.
The effective dose for personnel involved in handling
TcTc-PSMA-I&S is comparable to that of other
Tc-radiopharmaceuticals and therefore safe for imaging and radioguided surgery.
There is currently no consensus on the optimal treatment for patients with a primary diagnosis of clinically and pathologically node-positive (cN1M0 and pN1M0) hormone-sensitive prostate cancer ...(PCa). The treatment paradigm has shifted as research has shown that these patients could benefit from intensified treatment and are potentially curable. This scoping review provides an overview of available treatments for men with primary-diagnosed cN1M0 and pN1M0 PCa. A search was conducted on Medline for studies published between 2002 and 2022 that reported on treatment and outcomes among patients with cN1M0 and pN1M0 PCa. In total, twenty-seven eligible articles were included in this analysis: six randomised controlled trials, one systematic review, and twenty retrospective/observational studies. For cN1M0 PCa patients, the best-established treatment option is a combination of androgen deprivation therapy (ADT) and external beam radiotherapy (EBRT) applied to both the prostate and lymph nodes. Based on most recent studies, treatment intensification can be beneficial, but more randomised studies are needed. For pN1M0 PCa patients, adjuvant or early salvage treatments based on risk stratification determined by factors such as Gleason score, tumour stage, number of positive lymph nodes, and surgical margins appear to be the best-established treatment options. These treatments include close monitoring and adjuvant treatment with ADT and/or EBRT.
In clinically localized high-risk prostate cancer patients, sentinel lymph node biopsy–based selection of men with occult nodal metastases for whole pelvis radiotherapy is associated with favorable ...oncological outcomes as compared with imaging-based prostate-only radiotherapy.
Accurate identification of men who harbor nodal metastases is necessary to select patients who most likely benefit from whole pelvis radiotherapy (WPRT). Limited sensitivity of diagnostic imaging approaches for the detection of nodal micrometastases has led to the exploration of the sentinel lymph node biopsy (SLNB).
To evaluate whether SLNB can be used as a tool to select pathologically node-positive patients who likely benefit from WPRT.
We included 528 clinically node-negative primary prostate cancer (PCa) patients with an estimated nodal risk of >5% treated between 2007 and 2018.
A total of 267 patients were directly treated with prostate-only radiotherapy (PORT; non-SLNB group), while 261 patients underwent SLNB to remove lymph nodes directly draining from the primary tumor prior to radiotherapy (SLNB group); pN0 patients were treated with PORT, while pN1 patients were offered WPRT.
Biochemical recurrence–free survival (BCRFS) and radiological recurrence-free survival (RRFS) were compared using propensity score weighted (PSW) Cox proportional hazard models.
The median follow-up was 71 mo. Occult nodal metastases were found in 97 (37%) SLNB patients (median metastasis size: 2 mm). Adjusted 7-yr BCRFS rates were 81% (95% confidence interval CI 77–86%) in the SLNB group and 49% (95% CI 43–56%) in the non-SLNB group. The corresponding adjusted 7-yr RRFS rates were 83% (95% CI 78–87%) and 52% (95% CI 46–59%), respectively. In the PSW multivariable Cox regression analysis, SLNB was associated with improved BCRFS (hazard ratio HR 0.38, 95% CI 0.25–0.59, p < 0.001) and RRFS (HR 0.44, 95% CI 0.28–0.69, p < 0.001). Limitations include the bias inherent to the study’s retrospective nature.
SLNB-based selection of pN1 PCa patients for WPRT was associated with significantly improved BCRFS and RRFS compared with (conventional) imaging-based PORT.
Sentinel node biopsy can be used to select patients who will benefit from the addition of pelvis radiotherapy. This strategy results in a longer duration of prostate-specific antigen control and a lower risk of radiological recurrence.
We reviewed the treatment of patients with prostate cancer that has spread to lymph nodes outside the pelvis without further systemic spread. There is evidence that treatment of the primary prostate ...tumor improves outcomes in these patients and that treatment targeting distant lymph node metastases can delay the start of systemic treatment.
It remains unclear whether men with hormone-sensitive prostate cancer (PCa) metastasized to nonregional lymph nodes (M1a) benefit from prostate-directed therapy (PDT) and/or metastasis-directed therapy (MDT).
To systematically summarize the literature regarding oncological outcomes of de novo and recurrent M1a PCa patients treated with PDT and/or MDT.
We searched Medline (Ovid), Embase, and Scopus according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for reports on oncological outcomes of de novo or recurrent hormone-sensitive M1a PCa patients treated with PDT (radical prostatectomy or radiotherapy) and/or MDT (nodal radiotherapy or salvage lymph node dissection) with or without androgen deprivation therapy. A descriptive data synthesis and a methodological quality assessment were performed to evaluate the impact of PDT and/or MDT on survival in M1a PCa patients.
A total of 6136 articles were screened and 24 studies were included in this systematic review. In de novo M1a PCa patients, PDT was associated with improved oncological outcomes compared with no PDT. In recurrent M1a PCa, MDT could delay the need for systemic treatment in a selection of patients, but high-level evidence from prospective phase III randomized controlled trials is still awaited.
This systematic review summarized the limited literature data on the management of M1a PCa. Subgroup analyses suggest a role for PDT plus systemic therapy in de novo M1a PCa. MDT to distant nodal metastases delayed the need for systemic therapy in recurrent disease, but robust data are lacking. The predominantly retrospective nature of the included studies and significant heterogeneity in study designs limit the strength of evidence.
We reviewed the treatment of patients with prostate cancer that has spread to lymph nodes outside the pelvis without metastases in other organ systems. There is evidence that treatment of the primary prostate tumor improves outcomes in well-selected patients and that treatment targeting distant lymph node metastases can delay the start of systemic treatment.
Robot‐Assisted Surgery
Image guidance technologies such as radiotracers and the DROP‐IN gamma probe alter the surgeon‐robot‐patient interaction during urologic interventions. To truly understand how ...these technologies impact surgical decision making, it is necessary to define how perception reflects into action. Artificial intelligence‐supported probe tracking allowed us to directly relate the DROP‐IN sensory feedback to the kinematics of surgical use. For further details, see article number 2300192 by Fijs W. B. van Leeuwen and co‐workers.
Objectives
To determine the consensus of a Dutch multidisciplinary expert panel on the diagnostic evaluation and treatment of de novo and recurrent metastatic prostate cancer (PCa) limited to ...non‐regional lymph nodes (M1a) in daily clinical practice.
Materials and methods
The panel consisted of 37 Dutch specialists from disciplines involved in the management of M1a PCa (urology, medical and radiation oncology, radiology, and nuclear medicine). We used a modified Delphi method consisting of two voting rounds and a consensus meeting (video conference). Consensus (good agreement) was defined as the situation in which ≥ 75% of the panelists chose the same option.
Results
Consensus existed for 57% of the items. The panel agreed that prostate‐specific membrane antigen positron emission tomography/computed tomography (PSMA‐PET/CT) is the most appropriate standard imaging modality to identify de novo (100%) and recurrent (97%) M1a PCa. Androgen deprivation therapy (ADT) combined with radiotherapy to the prostate ± the M1a lesion(s) was most frequently considered an option for de novo M1a PCa. For M1a as recurrent disease, ADT alone, deferring treatment, or local radiotherapy to the M1a lesion(s) were judged to be the most important treatment options. However, no specific indications for treatment choice in relation to disease characteristics could be formulated.
Conclusions
The Dutch consensus panel preferred PSMA‐PET/CT as the standard diagnostic modality to detect M1a PCa. Although potential treatment options were identified, explicit recommendations could not be formulated. This might (partly) be explained by the absence of high‐level clinical evidence in this subset of patients. Further research is, therefore, strongly encouraged.
Samenvatting
Een progressieve zwelling op de glans penis is verdacht voor een maligniteit. Differentiaaldiagnostisch kan er ook gedacht worden aan benigne afwijkingen, zoals een fibro-epitheliale ...poliep (FEP). Een FEP is een tumor die zelden voorkomt op de glans penis. Hieraan lijken chronische lokale druk, inflammatie of eerdere peniele chirurgie ten grondslag te liggen. Klinisch kan het lastig zijn een FEP te diagnosticeren en daarom is het verkrijgen van histologie noodzakelijk. Behandeling bestaat uit excisie. Hier beschrijven wij een zwelling op de glans penis bij een 75-jarige man die een buitenwaarts draagurinaal gebruikt. Hoewel wij aanvankelijk dachten aan een maligniteit, toonde histologisch onderzoek een FEP aan.
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