Prostate Cancer and Prostatic Diseases最新文献

Background: Clinical guidelines favor MRI before prostate biopsy due to proven benefits. However, adoption patterns across the US are unclear.

Methods: This study used the Merative™ Marketscan® Commercial & Medicare Databases to analyze 872,829 prostate biopsies in 726,663 men from 2007-2022. Pre-biopsy pelvic MRI within 90 days was the primary outcome. Descriptive statistics and generalized estimating equations assessed changes over time, urban-rural differences, and state-level variation.

Results: Pre-biopsy MRI utilization increased significantly from 0.5% in 2007 to 35.5% in 2022, with faster adoption in urban areas (36.1% in 2022) versus rural areas (28.3% in 2022). Geographic disparities were notable, with higher utilization in California, New York, and Minnesota, and lower rates in the Southeast and Mountain West.

Conclusions: The study reveals a paradigm shift in prostate cancer diagnostics towards MRI-guided approaches, influenced by evolving guidelines and clinical evidence. Disparities in access, particularly in rural areas and specific regions, highlight the need for targeted interventions to ensure equitable access to advanced diagnostic techniques.

Background

Staging patients with high-risk prostate cancer (HRPCa) with conventional imaging of computed tomography (CT) and bone scintigraphy (BS) is suboptimal. Therefore, we aimed to compare the accuracy of whole-body magnetic resonance imaging (WBMRI) with conventional imaging to stage patients with HRPCa.

Methods

We prospectively enrolled patients with newly diagnosed HRPCa (prostate‐specific antigen ≥20 ng/ml and/or Grade Group ≥4). Patients underwent BS, CT of the abdomen and pelvis, and WBMRI within 30 days of evaluation. The primary endpoint was the diagnostic performances of detecting metastatic disease to the lymph nodes and bone for WBMRI and conventional imaging. The reference standard was defined by histopathology or by all available clinical information at 6 months of follow-up. To compare diagnostic tests, Exact McNemar’s test and area under the curve (AUC) of the receiver operating characteristics curves were utilized.

Results

Among 92 patients enrolled, 15 (16.3%) and 8 (8.7%) patients were found to have lymphatic and bone metastases, respectively. The sensitivity, specificity, and accuracy of WBMRI in detecting lymphatic metastases were 0.60 (95% confidence interval 0.32–0.84), 0.84 (0.74–0.92), and 0.80 (0.71–0.88), respectively, while CT were 0.20 (0.04–0.48), 0.92 (0.84–0.97), and 0.80 (0.71–0.88). The sensitivity, specificity, and accuracy of WBMRI to detect bone metastases were 0.25 (0.03–0.65), 0.94 (0.87–0.98), and 0.88 (0.80–0.94), respectively, while CT and BS were 0.12 (0–0.53), 0.94 (0.87–0.98), and 0.87 (0.78–0.93). For evaluating lymphatic metastases, WBMRI demonstrated a higher sensitivity (p = 0.031) and discrimination compared to CT (0.72 versus 0.56, p = 0.019).

Conclusions

For staging patients with HRPCa, WBMRI outperforms CT in the detection of lymphatic metastases and performs as well as CT and BS in the detection of bone metastases. Further studies are needed to assess the cost effectiveness of WBMRI and the utility of combined PSMA PET and WBMRI.

Background

Scant data exists on the impacts of prostate radiation on ejaculatory function. We performed a systematic review and meta-analysis to assess ejaculatory outcomes in men after prostate radiation.

Methods

We queried PubMed, Embase, and Web of Science to identify 17 articles assessing ejaculatory function post-radiation. The primary outcome was anejaculation rate and secondary outcomes included ejaculatory volume (EV), ejaculatory discomfort, and mean decline in ejaculatory function scores (EFS). We assessed study quality with the Newcastle-Ottawa scale. We calculated pooled proportions using inverse variance and random effects models.

Results

We identified 17 observational studies with 2156 patients reporting ejaculatory profiles post-radiation. Seven studies utilized external beam radiation therapy, 7 brachytherapy, 1 stereotactic RT and 2 utilized either external or brachytherapy. Ten studies reported an anejaculation rate. Pooled proportion of patients having anejaculation, decreased EV and EjD were 18% (95% CI, 11–36%), 85% (95% CI, 81–89%) and 24% (95% CI, 16–35%), respectively. Five studies reported decline in EFS post-radiation.

Conclusions

Patients receiving radiation treatment may experience significant changes in their ejaculation, such as the absence of ejaculation, reduced EV, and EjD. It is important to counsel them about these potential side effects.

Background

The natural history of biochemical recurrence (BCR) managed with delayed hormonal therapy is well documented by data from Johns Hopkins. However, as many patients receive treatment prior to metastasis, we evaluated the natural history and role of prostate-specific antigen doubling time (PSADT) in a more contemporary cohort of BCR patients with nonmetastatic castration-sensitive prostate cancer (nmCSPC).

Methods

Patients in the Veterans Health Administration (VHA; 01/01/06 to 06/22/20) with nmCSPC and BCR were divided into rapid ( ≤9 months) and less rapid ( >9 to ≤15 months) PSADT cohorts. Patients with PSADT >15 months were excluded as outcomes, even with delayed treatment, are excellent. Outcomes included time to first antineoplastic therapy after BCR, metastasis, metastasis-free survival (MFS), and overall survival (OS). Cox models adjusted for baseline demographics and clinical characteristics.

Results

Overall, 781 patients with BCR were identified (502 rapid; 279 less rapid PSADT). Rapid PSADT was associated with shorter time to first systemic antineoplastic therapy (median 11.4 vs. 28.3 months, adjusted hazard ratio [95% confidence interval] 2.17 [1.83–2.57]), metastasis (102.4 months vs. not reached, 1.79 [1.33–2.40]), MFS (76.1 vs. 106.3 months, 1.73 [1.33–2.24]), and OS (120.5 vs. 140.5 months, 1.76 [1.22–2.54]) versus less rapid PSADT.

Conclusion

Most patients with rapid PSADT underwent secondary treatment within 1 year after BCR. More contemporary patients treated with early secondary treatment had better outcomes than historical data from patients who had delayed treatment. Whether these results reflect the benefits of early secondary treatment or overall improvements in prostate cancer outcomes over time requires further study.

Purpose

Recent advancements in the management of biochemical recurrence (BCR) following local treatment for prostate cancer (PCa), including the use of androgen receptor signaling inhibitors (ARSIs), have broadened the spectrum of therapeutic options. We aimed to compare salvage therapies in patients with BCR after definitive local treatment for clinically non-metastatic PCa with curative intent.

Methods

In October 2023, we queried PubMed, Scopus, and Web of Science databases to identify randomized controlled trials (RCTs) and prospective studies reporting data on the efficacy of salvage therapies in PCa patients with BCR after radical prostatectomy (RP) or radiation therapy (RT). The primary endpoint was metastatic-free survival (MFS), and secondary endpoints included progression-free survival (PFS) and overall survival (OS).

Results

We included 19 studies (n = 9117); six trials analyzed RT-based strategies following RP, ten trials analyzed hormone-based strategies following RP ± RT or RT alone, and three trials analyzed other agents. In a pairwise meta-analysis, adding hormone therapy to salvage RT significantly improved MFS (HR: 0.69, 95% CI: 0.57–0.84, p < 0.001) compared to RT alone. Based on treatment ranking analysis, among RT-based strategies, the addition of elective nodal RT and androgen deprivation therapy (ADT) was found to be the most effective in terms of MFS. On the other hand, among hormone-based strategies, enzalutamide + ADT showed the greatest benefit for both MFS and OS.

Conclusions

The combination of prostate bed RT, elective pelvic irradiation, and ADT is the preferred treatment for eligible patients with post-RP BCR based on our analysis. In remaining patients, or in case of post-RT recurrence, especially for those with high-risk BCR, the combination of ADT and ARSI should be considered.

Background

Prednisolone/prednisone coadministration with abiraterone may explain abiraterone-related increase in cardiovascular risk. We explored this postulation and glucocorticoid’s association with cardiovascular risk.

Methods

Patients with prostate cancer on androgen deprivation therapy and enzalutamide, or abiraterone with 5 mg (ABI + P5) or 10 mg (ABI + P10) daily total prednisolone/prednisone were followed up for major adverse cardiovascular events (MACE).

Results

We analyzed 933 patients. ABI + P10, but not enzalutamide, had higher risk of MACE than ABI + P5. Cumulative glucocorticoid dose before enzalutamide/abiraterone initiation was associated with MACE.

Conclusions

Prednisolone/prednisone coadministration with abiraterone likely contributed to abiraterone-related increased cardiovascular risk. Prevalent cumulative glucocorticoid dose was associated with cardiovascular risk.

Background/Objectives

Endorsing the principles of minimal invasiveness in benign-prostatic hyperplasia (BPH) surgery, we conducted the first evaluation of transurethral intraprostatic anesthesia (TUIA) using Schelin catheter® (SC) prior to iTIND positioning.

Subjects/Methods

Of 23 patients enrolled, 11 (48%) received TUIA via SC whereas the remaining underwent standard anesthesia protocol. Pain was assessed using visual analogue scale (VAS).

Results

No differences between cohorts were observed for pain during the device implantation and removal. Conversely, significantly lower median VAS scores were reported at 24- (1.0 vs. 3.0) and 48- (1.0 vs. 2.5) hour follow-up favoring TUIA.

Conclusions

SC TUIA offers effective pain control during iTIND procedures, supporting its use in outpatient settings.

Background

Prostate cancer remains the most frequently diagnosed cancer among men. High-Intensity Focused Ultrasound (HIFU) has emerged as a thermal ablative technique for partial-gland-ablation (PGA), aiming to minimize collateral damage while maximizing tumor control. Monitoring after HIFU PGA relies on serial PSA testing, multiparametric-MRI, and biopsies. The diagnostic accuracy of MRI for clinically-significant cancer(csPCa) recurrence is challenging.

Objective

This systematic review and meta-analysis aim to evaluate the accuracy of MRI in detecting early recurrence of localized prostate cancer following HIFU PGA.

Methods

Adhering to PRISMA guidelines, a comprehensive literature search was conducted until May 8^th 2024 using MEDLINE and Scopus. The inclusion criteria encompassed randomized controlled trials and cohort studies involving men diagnosed with localized prostate cancer who had as primary treatment HIFU PGA. The primary outcome measures included the sensitivity, specificity, positive-predictive value (PPV), and negative-predictive value (NPV) of MRI for csPCa(ISUP ≥ 2) based on biopsy results. We pooled data from studies with sufficient csPCa and csPCa-free patients (≥5) post HIFU for statistical analysis.

Results

Fifteen studies meet the inclusion criteria, encompassing 1093 patients and 12 studies were eligible for meta-analysis. MRI sensitivity in detecting clinically-significant prostate cancer (csPCa) recurrence post HIFU PGA varied widely (0–89%), with a pooled sensitivity of 0.52 (95% CI:0.36–0.68). Specificity ranged from 44% to 100%, with a pooled specificity of 0.81 (95% CI:0.68–0.91). The pooled NPV was 0.82 (95% CI:0.72–0.90), and the pooled PPV was 0.50 (95% CI:0.35–0.65). Three studies reported in-field diagnostic performance with sensitivities ranging from 0.42 to 0.80 and specificities from 0.45 to 0.97.

Conclusion

MRI accuracy for clinically-significant recurrence after partial gland ablation with HIFU for localized prostate cancer shows low diagnostic performance in the treated lobe with pooled sensitivity of 0.52 (95% CI:0.36–0.68) and specificity of 0.81 (95% CI:0.68–0.91). Limits of this review include the low number of studies reporting about site of recurrence in or out of the treated lobe.

Background: Androgen-receptor pathway inhibitors (ARPIs) have dramatically changed the management of advanced/metastatic prostate cancer (PCa). However, their cardiovascular toxicity remains to be clarified.

Objective: To analyze and compare the risks of cardiovascular events secondary to treatment of PCa patients with different ARPIs.

Methods: In August 2023, we queried PubMed, Scopus, and Web of Science databases to identify randomized controlled studies (RCTs) that analyze PCa patients treated with abiraterone, apalutamide, darolutamide, and enzalutamide. The primary outcomes of interest were the incidence of cardiac disorder, heart failure, ischemic heart disease (IHD), atrial fibrillation (AF), and hypertension. Network meta-analyses (NMAs) were conducted to compare the differential outcomes of each ARPI plus androgen deprivation therapy (ADT) compared to standard of care (SOC).

Results: Overall, 26 RCTs were included. ARPIs were associated with an increased risk of cardiac disorders (RR: 1.74, 95% CI: 1.13-2.68, p = 0.01), heart failure (RR: 2.49, 95% CI: 1.05-5.91, p = 0.04), AF (RR: 2.15, 95% CI: 1.14-4.07, p = 0.02), and hypertension (RR: 2.06, 95% CI: 1.67-2.54, p < 0.01) at grade ≥3. Based on NMAs, abiraterone increased the risk of grade ≥3 cardiac disorder (RR:2.40, 95% CI: 1.42-4.06) and hypertension (RR:2.19, 95% CI: 1.77-2.70). Enzalutamide was associated with the increase of grade ≥3 AF(RR: 3.17, 95% CI: 1.05-9.58) and hypertension (RR:2.30, 95% CI: 1.82-2.92).

Conclusions: The addition of ARPIs to ADT increases the risk of cardiac disorders, including IHD and AF, as well as hypertension. Each ARPI exhibits a distinct cardiovascular event profile. Selecting patients carefully and vigilant monitoring for cardiovascular issues is imperative for those undergoing ARPI + ADT treatment.