Armando Stabile

Radical Prostatectomy in Men with Oligometastatic Prostate Cancer: Results of a Single-institution Series with Long-term Follow-up

In the absence of data from randomized trials, the role of local treatment in metastatic prostate cancer (PCa) is gaining interest. Our study aimed to assess perioperative and long-term oncologic outcomes of radical prostatectomy (RP) in a selected cohort of 11 patients with oligometastatic disease treated with RP and extended pelvic lymph node dissection between 2006 and 2011. Oligometastatic disease was defined as the presence of five or fewer bone lesions at bone scan with or without suspicious pelvic or retroperitoneal nodal involvement at preoperative imaging. The minimum follow-up for survivors was 5 yr. Perioperative outcomes, clinical progression, and cancer-specific mortality (CSM) were evaluated. Median age was 72 yr. Median operative time, blood loss, and length of hospitalization were 170min, 750ml, and 13 d, respectively. Overall, two patients (18%) experienced grade 3 complications in the postoperative period, and eight (73%) received blood transfusions. Overall, 10 (91%) and 8 (73%) patients had lymph node invasion and positive surgical margins, respectively. Adjuvant androgen deprivation therapy was administered to 10 patients (91%). Median follow-up for survivors was 63 mo. The 7-yr clinical progression- and CSM-free survival rates were 45% and 82%, respectively. Our findings support the safety and effectiveness of RP in a highly selected cohort of PCa patients with bone metastases and long-term follow-up. PATIENT SUMMARY We evaluated the outcomes of patients with oligometastatic prostate cancer treated with radical prostatectomy with a minimum of 5-yr follow-up. This surgical procedure performed with a multimodal approach might represent a safe and feasible option in selected men and provide acceptable oncologic outcomes at long-term follow-up.

Orgasmic Dysfunction After Robot-assisted Versus Open Radical Prostatectomy.

UNLABELLED Several alterations of orgasmic function that occur after radical prostatectomy (RP) have never been assessed in robot-assisted RP (RARP) series. We sought to assess the prevalence and predictors of recovery from orgasm-associated incontinence (climacturia) and painful orgasm (PO) after RARP and open RP (ORP). Following surgery, sexually active patients who had undergone either RARP or ORP prospectively completed a 28-item questionnaire including sensitive issues regarding sexual function (eg, climacturia and PO). Rates of postoperative climacturia and PO were compared for RARP and ORP patients. Kaplan-Meier analysis was applied to assess estimated rates of recovery from either climacturia or PO after both procedures. Cox regression models tested predictors of recovery from those conditions. Overall, 221 (29.5%) of 749 patients reported climacturia, without differences between RARP and ORP. Conversely, PO was significantly more frequently reported after ORP than after RARP (46 [11.6%] vs 25 [7.1%] patients, respectively; p=0.04). At Kaplan-Meier analysis, recovery from climacturia over time was faster and greater after RARP than after ORP (8.5% vs 5%, respectively, at 24-mo assessment and 48% vs 15%, respectively, at 84-mo assessment; p<0.01). Conversely, no differences were found between groups in terms of postoperative recovery from PO. At multivariable analysis, only RARP achieved independent predictor status for recovery from climacturia after adjusting for other functional outcomes. Conversely, no variables were significantly associated with recovery from postoperative PO. PATIENT SUMMARY Orgasmic modifications such as climacturia and painful orgasm (PO) are frequently reported after radical prostatectomy. Robotic surgery was associated with a lower rate of postoperative PO and with greater and faster recovery from climacturia.

The New Prostate Cancer Grading System Does Not Improve Prediction of Clinical Recurrence After Radical Prostatectomy: Results of a Large, Two-Center Validation Study

A new prostate cancer (PCa) grading system (namely, Gleason score‐GS‐ ≤6 vs. 3 + 4 vs. 4 + 3 vs. 8 vs. ≥9) was recently proposed and assessed on biochemical recurrence (BCR) showing improved predictive abilities compared to the commonly used three‐tier system (GS ≤6 vs. 7 vs. ≥8). We assessed the predictive ability of the five‐tier grade group (GG) system on harder clinical endpoint, namely clinical recurrence (CR).

Identifying the candidate for super extended staging pelvic lymph node dissection among patients with high-risk prostate cancer

To assess if the preoperative lymph node invasion (LNI) risk could be used to tailor the extent of pelvic lymph node dissection (PLND) according to individual profile in patients with prostate cancer (PCa) undergoing radical prostatectomy (RP), and to identify those who would benefit from the removal of the common iliac and pre‐sacral nodes.

Contemporary Incidence and Cancer Control Outcomes of Primary Neuroendocrine Prostate Cancer: A SEER Database Analysis

Micro‐Abstract Reports on neuroendocrine prostate cancer (NEPC) are scarce and mostly based on historical series or case reports. Importantly, incidence rates and survival figures of NEPC in contemporary patients are unknown. A retrospective analysis from a large administrative database was used to answer this question. NEPC is rare and mostly diagnosed at metastatic stage. Prognosis is poor regardless of histologic subtype. Introduction: Neuroendocrine carcinoma of the prostate (NEPC) is a rare entity. We aimed at providing contemporary data on incidence and survival figures of de‐novo NEPC. Materials and Methods: Within the Surveillance, Epidemiology, and End Results (SEER) database, we identified 309 individuals with de‐novo NEPC diagnosed between 2004 and 2013. We evaluated age‐adjusted incidence rates over the study. Kaplan‐Meier analyses assessed overall survival (OS) after stratification according to histologic subtype, metastatic status, and treatment. Cox regression analyses tested the predictors of overall mortality, after adjusting for confounders. Results: A total of 309 cases of NEPC were identified from 510,913 cases of prostate cancer. Metastatic disease was identified in 198 (64.1%) cases. The most common histologic subtype (n = 186; 60.2%) was small‐cell carcinoma (SCC). The age‐adjusted incidence of NEPC significantly increased over the study span. However, this increase only affected SCC (from 0.13/1,000,000 person‐years in 2004 to 0.30/1,000,000 person‐years in 2013; P = .001). Median survival for NEPC was 10 months. After stratification by metastatic status, no difference was observed according to SCC versus non‐SCC. Treatment with radical prostatectomy improved OS only among individuals with non‐metastatic disease, whereas radiation therapy did not affect OS rates. In multivariable Cox regression analyses predicting overall mortality, metastatic stage (hazard ratio, 1.52; 95% confidence interval, 1.12‐2.06; P < .01) and radical prostatectomy (hazard ratio, 0.38; 95% confidence interval, 0.20‐0.74; P < .01) achieved independent predictor status. Conclusion: De‐novo NEPC is extremely rare and will be encountered in clinical practice by few urologists. Most cases are metastatic at diagnosis. Prognosis is poor regardless of histologic type, especially in metastatic stage.

Preoperative multiparametric MRI of the prostate for the prediction of lymph node metastases in prostate cancer patients treated with extended pelvic lymph node dissection

AbstractObjectivesTo assess the role of preoperative multiparametric MRI (mpMRI) of the prostate in the prediction of nodal metastases in patients treated with radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND).MethodsWe retrospectively analyzed 101 patients who underwent both preoperative mpMRI of the prostate and RP with ePLND at our institution. For each patient, complete preoperative clinical data and tumour characteristics at mpMRI were recorded. Final histopathologic stage was considered the standard of reference. Univariate and multivariate logistic regression analyses were performed.ResultsNodal metastases were found in 23/101 (22.8%) patients. At univariate analyses, all clinical and radiological parameters were significantly associated to nodal invasion (all p<0.03); tumour volume at MRI (mrV), tumour ADC and tumour T-stage at MRI (mrT) were the most accurate predictors (AUC = 0.93, 0.86 and 0.84, respectively). A multivariate model including PSA levels, primary Gleason grade, mrT and mrV showed high predictive accuracy (AUC = 0.956). Observed prevalence of nodal metastases was very low among tumours with mrT2 stage and mrV<1cc (1.8%).ConclusionPreoperative mpMRI of the prostate can predict nodal metastases in prostate cancer patients, potentially allowing a better selection of candidates to ePLND.Key points• Multiparametric-MRI of the prostate can predict nodal metastases in prostate cancer • Tumour volume and stage at MRI are the most accurate predictors • Prevalence of nodal metastases is low for T2-stage and <1cc tumours • Preoperative mpMRI may allow a better selection of candidates to lymphadenectomy

New surgical approaches for clinically high-risk or metastatic prostate cancer

ABSTRACT Introduction: A considerable number of individuals with prostate cancer (PCa) still harbor locally-advanced and metastatic disease. Although such men were initially not considered eligible for local treatment, the role of radical prostatectomy (RP) has been recently reassessed. Areas covered: This review analyses currently published evidences regarding new surgical approaches for clinically high-risk PCa individuals, as well as the role of cytoreductive surgery in the metastatic setting. The role of robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection will be evaluated with regards to perioperative, oncologic, as well as functional outcomes. Expert commentary: RARP is a feasible approach in PCa patients regardless of the presence of high-risk disease features and can achieve optimal short-term oncologic outcomes and acceptable short/intermediate-term functional outcomes, that are comparable to those reported for open RP. Extended pelvic lymph node dissection can be performed in this setting and should be recommended for all high-risk PCa patients. The overall rate of complications in contemporary men treated with RARP for high-risk disease is not negligible. Cytoreduction in the oligo-metastatic setting is feasible and relatively safe, although evidence is scarce to recommend its widespread adoption. In consequence, longer follow-up data and, ideally, randomized controlled trials are needed.

Impact of multiparametric MRI and MRI-targeted biopsy on pre-therapeutic risk assessment in prostate cancer patients candidate for radical prostatectomy

PurposeTo assess the current status and future potential of multiparametric MRI (mpMRI) and MRI-targeted biopsy (MRI-TBx) on the pretherapeutic risk assessment in prostate cancer patients’ candidates for radical prostatectomy.MethodsA literature search of the MEDLINE/PubMed and Scopus database was performed. English-language original and review articles were analyzed and summarized after an interactive peer-review process of the panel.ResultsPretherapeutic risk assessment tools should be based on target plus systematic biopsies, where the addition of systematic biopsy (TRUS-Bx) to the mpMRI-target cores is associated with a lower rate of upgrading at final pathology. The combination of mpMRI findings with clinical parameters outperforms models based on clinical parameters alone in the prediction of adverse pathological outcomes and oncological results. This is particularly true when a specialized radiologist is present.ConclusionThe combination of mpMRI findings and clinical parameters should be considered to improve patient stratification in the pretherapeutic risk assessment. There is an urgent need to develop or include MRI data and MRI-TBx findings in available preoperative risk tools. This will allow improving the pretherapeutic risk assessment, providing important additional information for patient-tailored treatment planning and optimizing outcomes.

Adult prostatic sarcoma: A contemporary multicenter Rare Cancer Network study

Adult prostatic sarcoma (PS) is a rare disease. While surgery is considered the standard approach, the role of other therapies is not completely established. We report results of the largest multicentric contemporary cohort of PS patients.

Comment on ‘Validation of a contemporary prostate cancer grading system using prostate cancer death as outcome’

Comment on ‘Validation of a contemporary prostate cancer grading system using prostate cancer death as outcome’