Current Opinion in Urology最新文献

Purpose of review: The variety of prostate cancer aggressiveness in patients with biochemical recurrence (BCR) leads to the unmet need of accurate risk stratification. This review examined the recently published risk stratification tool using prostate-specific membrane antigen positron-emission tomography (PSMA-PET) compared to the risk categories by European Association of Urology (EAU).

Recent findings: The risk stratification by EAU was proposed for patients with BCR, including the doubling time of the prostate-specific-antigen and Gleason score as predictors for survival. Although stratification into low- vs. high-risk groups reached significant differences in the external validation, C-indices determined moderate discriminative ability and the need to improve the EAU risk categories. PSMA-PET was recently validated as prognostic biomarker and PSMA-PET standardized by Prostate Cancer Molecular Imaging Standardized Evaluation (PROMISE) metrics were combined to create a visual and a quantitative nomogram to predict overall survival.

Summary: The unmet need to improve risk stratification for prostate cancer patients experiencing BCR was addressed with PSMA-PET PROMISE (PPP) nomograms. Although PPP nomograms are not applied for individual patient counselling yet, they can be used additionally to EAU risk categories.

Purpose of review: The aim of this review is to assess contemporary studies on ultra-hypofractionated local salvage therapies - stereotactic body radiation therapy (SBRT) and brachytherapy - for macroscopic prostate bed recurrence after radical prostatectomy, with or without prior external beam radiotherapy (EBRT), and to highlight knowledge gaps guiding current trials.

Recent findings: Recent studies, primarily retrospective, report 1-year biochemical control rates of 56-88% for SBRT and up to 87% for high-dose-rate brachytherapy, with low to moderate rates of severe genitourinary toxicity. Higher biologically effective doses and limited tumour volume predict improved outcomes, yet focal-only strategies carry some risk of out-of-field relapse within the prostate bed. The role of concomitant androgen deprivation therapy remains unclear. Several phase II trials (e.g. STARR, PROSTARE, REPAIR, and HypoFocal SRT) are underway.

Summary: Ultra-hypofractionated salvage radiotherapy offers effective disease control with manageable toxicity for selected patients and may defer systemic therapy. Further studies are needed to standardize imaging, biopsy confirmation, dose escalation, and systemic treatment integration. Prospective, randomized studies are crucial to define optimal modality, target volume, and patient selection criteria before widespread adoption.

Purpose of review: To summarize recent evidence on the role of radiotherapy in managing pelvic lymph node (PLN) recurrence following curative-intent primary therapy for prostate cancer (PCa), focusing on radiotherapy strategies, novel medical imaging, and oncological outcomes.

Recent findings: Prostate-specific membrane antigen PET (PSMA-PET) has improved accuracy of staging in patients with PCa; however, more often than not, it fails to correctly identify PLN metastases, and the impact on clinical outcomes of the patients is uncertain. Metastasis-directed therapies (MDT) combined with short-term androgen-deprivation therapy (ADT) in patients with PLN recurrence are associated with a significantly higher risk of recurrence compared to more comprehensive approaches. Emerging data support the role of elective nodal radiotherapy (ENRT) combined with short-term androgen deprivation therapy (ADT) and radiotherapy boost to the PLN metastases to enhance disease control. Notably, despite treating a more extensive pelvic region than MDT, ENRT does not appear to significantly increase acute toxicity or negatively impact quality of life (QoL). Recent evidence suggests a role for androgen receptor pathway inhibitors (ARPI), such as enzalutamide, in patients with high-risk biochemical recurrence, introducing a new treatment paradigm for patients ineligible for salvage radiotherapy. Ongoing prospective studies are refining the role of radiotherapy in combination with systemic treatments.

Summary: Despite PSMA-PET allowing for improved staging and better patient-tailored decisions, patients with PLN recurrence continue to benefit from comprehensive multimodal treatment approach. Elective PLN irradiation combined with radiotherapy boost and ADT lead to improved disease control, without compromising safety and toxicity. ARPI+ADT and ARPI-monotherapy emerge as alternatives for select patients.

Purpose of review: The natural history of biochemical recurrence (BCR) is highly variable, complicating the distinction between BCR and metastasis. A targeted approach to risk stratifying disease progression is needed. This review proposes a 'framework,' that categorizes disease progression into five distinct groups: low-risk BCR, high-risk BCR, oligometastatic disease, low-volume metastatic disease, and high-volume metastatic disease. Each group is defined by clinicopathological and molecular features, along with targeted treatment strategies to tailor therapy and optimize disease management.

Recent findings: Recent clinical trials and updates to guidelines have focused on treatment intensification and early identification of patients at risk for recurrence. In addition, the utilization of molecular imaging and implementation of metastasis directed therapy has led to a change in the conventions of recurrence and metastasis. Therefore, the patients with BCR or metastatic disease require a more individualized and multimodal treatment for their prostate cancer.

Summary: Distinguishing BCR from metastatic disease has important implications. It offers ways to avoid unnecessary treatment in patients who are less likely to progress and helps identify those who are more likely to benefit from earlier or more aggressive interventions.

Purpose of review: The Phoenix criteria, which define biochemical recurrence (BCR) after radiotherapy as a prostate specific antigen (PSA) rise of at least 2 ng/ml above nadir, were developed to improve consistency in outcome reporting and distinguish genuine cancer recurrence from transient, noncancerous PSA fluctuations, commonly referred to as PSA "bounces". However, in the current era of advanced imaging and precision oncology, this definition is increasingly viewed as inadequate. This review critically examines recent evidence challenging the clinical utility of the Phoenix definition and explores potential alternatives that better reflect disease biology and patient outcomes.

Recent findings: Modern imaging techniques, particularly prostate-specific membrane antigen (PSMA) PET/computed tomography (CT), have demonstrated the ability to detect recurrent prostate cancer at PSA levels well below the Phoenix threshold, allowing for earlier salvage interventions. Additionally, PSA kinetics such as nadir levels and doubling time provide superior prognostic information compared to static PSA thresholds. Multiparametric risk models that also incorporate PSMA PET/CT findings, PSA kinetics and clinical features may enable more accurate stratification of patients into low-risk and high-risk BCR categories. This evolving approach supports the notion that early, risk-adapted treatment can improve outcomes in high-risk patients, while reducing overtreatment in those at low risk.

Summary: The Phoenix criteria no longer align with the capabilities of current diagnostic and prognostic tools. Redefining BCR using dynamic PSA metrics and advanced imaging could facilitate timely salvage treatment in patients at a high risk and allow surveillance strategies in those unlikely to progress. Prospective validation is warranted to inform future clinical guidelines.

Purpose of review: This review aims to synthesize emerging evidence on the role of adjuvant radiotherapy (RT) following radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC).

Recent findings: A randomized trial comparing adjuvant chemoradiotherapy to chemotherapy alone in 125 MIBC patients demonstrated a significant improvement in 2-year local recurrence- free survival (LRFS) (96% vs. 69%; P  < 0.01). Three studies have evaluated adjuvant RT alone. A single-arm study reported a 5-year local control rate of 79% among 72 patients, with 17% experiencing serious gastrointestinal (GI) adverse events (AEs). A randomized controlled trial (RCT) involving 122 patients found improved 3-year LRFS in the RT arm (81% vs. 71% at three years; P  = 0.046), with low rate of severe GI AEs (3%); however, the survival difference was not statistically significant. Another RCT with 153 patients showed similar rates of acute severe AEs between RT and observation groups (1.6% vs. 4.2%; P  = 0.34). Key limitations across studies include heterogeneity in design, lack of statistical power to detect survival differences, limited patient-reported outcome data, and absence of direct comparisons with immune checkpoint inhibitors - the current standard of care in the adjuvant setting.

Summary: Modern adjuvant RT appears to be associated with acceptable toxicity, likely due to improved delivery techniques. Although data suggest a benefit in local-regional control, an overall survival advantage has not been demonstrated. Adjuvant RT may be considered in selected high-risk patients, particularly in settings where access to salvage therapies or immunotherapy is limited.

Purpose of review: Muscle-invasive bladder cancer (MIBC) represents an aggressive malignancy with significant morbidity and mortality. Recent advances in artificial intelligence (AI) offer promising opportunities to enhance patient care across the entire MIBC management spectrum. This comprehensive review examines the current state and future potential of AI applications in MIBC, from diagnosis through treatment to response assessment.

Recent findings: In the diagnostic domain, AI systems demonstrate superior accuracy in cystoscopic cancer detection and staging, with deep learning models achieving high performance in differentiating muscle-invasive from noninvasive disease. For treatment planning, AI facilitates precise tumor delineation for radiotherapy, automates adaptive planning, and supports surgical decision-making through predictive lymph node involvement models. In treatment response evaluation, machine learning algorithms show encouraging results in predicting neoadjuvant chemotherapy outcomes, while radiomics and quantitative imaging biomarkers enable early response assessment. Despite these advances, significant challenges persist, including methodological limitations, dataset heterogeneity, workflow integration barriers, and regulatory uncertainties. Future directions should prioritize prospective clinical validation, federated learning approaches to address data scarcity, development of interpretable AI models, and interdisciplinary collaboration.

Summary: The integration of AI in MIBC management represents a paradigm shift toward personalized medicine, with the potential to improve diagnostic accuracy, optimize treatment selection, and enhance response prediction.

Purpose of review: Prostate cancer is the most common cancer in men. In the high-risk group, carbon ion radiotherapy (CIRT) is being developed as a state-of-the-art alternative for treatment.

Recent findings: Data conducted from studies in Japan, as published by the J-CROS group, suggest that CIRT provides a tool to deliver a treatment for high-risk prostate cancer that delivers tumour control similar to a brachytherapy boost, but without the associated increase in toxicity.

Summary: While a considerable number of patients has been treated with CIRT, a randomized controlled trial showing the benefits of low toxicity while maintaining excellent tumour control has not yet been published and is highly warranted.

Purpose of review: Biochemical recurrence (BCR) after radical prostatectomy exhibits heterogeneous prognostic implications. Recent advancements in imaging and biomarkers have high potential for personalizing care.

Recent findings: Prostate-specific membrane antigen imaging (PSMA)-PET/CT has revolutionized the BCR management in prostate cancer by detecting microscopic lesions earlier than conventional staging, leading to improved cancer control outcomes and changes in treatment plans in approximately two-thirds of cases. Salvage radiotherapy, often combined with androgen deprivation therapy, remains the standard treatment for high-risk BCR postprostatectomy, with PSMA-PET/CT guiding treatment adjustments, such as the radiation field, and improving progression-free survival. Advancements in biomarkers, genomic classifiers, and artificial intelligence-based models have enhanced risk stratification and personalized treatment planning, resulting in both treatment intensification and de-escalation.

Summary: While conventional risk grouping relying on Gleason score and PSA level and kinetics remain the foundation for BCR management, PSMA-PET/CT, novel biomarkers, and artificial intelligence may enable more personalized treatment strategies.