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2035 NON- SURGICAL MANAGEMENT OF LOCALIZED PROSTATE CANCER. IS ACTIVE SURVEILLANCE A SAFE OPTION?
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THE JOURNAL OF UROLOGY姞
months follow-up (n⫽198), 86% of patients had recovered potency and 95% were continent. PSM occurred in 7.6%. BCR occurred in 1.1% at a median follow-up of 13 months. CONCLUSIONS: Patients with low-risk prostate cancer, and especially those who would qualify for AS, have very favorable options available to them. Those who desire curative therapy have a high likelihood of achieving excellent functional and oncologic outcomes following RALP. With only 3% upstaging, those who elect AS can be reassured that the majority of AS candidates had favorable tumor characteristics at the time of surgery. Although we found a 43% rate of upgrading, the vast majority were upgraded to the more benign 3⫹4⫽7. Only 3% were upgraded to 4⫹3⫽7, and none to Gleason 8 or higher. This cohort of patients will likely do well regardless of whether they choose AS or surgical extirpation. Source of Funding: None
2035 NON- SURGICAL MANAGEMENT OF LOCALIZED PROSTATE CANCER. IS ACTIVE SURVEILLANCE A SAFE OPTION? M Z Aslam*, Ferhad Kheradmund, Gareth Turner, S F Brewster, Oxford, United Kingdom INTRODUCTION AND OBJECTIVES: Active Surveillance for localized prostate cancer is a management option which is becoming an area of growing interest.We studied histopathological reports of 314 radical prostatectomies (RP) performed for D’Amico’s low risk (LR) and intermediate risk (IR) disease in a UK cancer centre to assess the safety of this practice. METHODS: 150 LR and 164 IR cases were included. Pathological features studied in RP specimens included Gleason score upgrading to ⱖ7, pT3 upstaging, the presence of tumour multifocality / bilaterality and for the presence of clinically significant tumours(CST) (by Epstein’s criteria, including tumour volume ⬎0.5cc). RESULTS: LR group (n⫽150): On final RP histopathological analysis, 115 (75%) and 123(82%) cases exhibited multifocal and bilateral disease respectively. 57 (38%) were upgraded while 29 (19%) had pT3 cancer. 93(62%) cases harboured at least one CST. IR group (n⫽164): 126 (77%) and 143(87%) exhibited multifocal and bilateral disease respectively. 25(15%) were upgraded while 68(42%) had pT3 cancer. 131(80%) cases harboured at least one CST. CONCLUSIONS: One-fifth of LR cases and two-fifths of IR cases had locally-advanced cancer, and many more exhibited aggressive features. Caution should be taken when recommending AS to the patients suitable for radical treatment, as in the absence of long term outcomes of large randomised trials, this could be an unsafe management option. Source of Funding: None
2036 GLEASON SCORE UPGRADING IN PATIENTS WITH UNILATERAL PROSTATE CANCER: IMPLICATIONS FOR SELECTION INTO ACTIVE SURVEILLANCE REGIMEN. Sonal Grover*, Abhishek Srivastava, Gerald Tan, David Peters, Kumaran Mudaliar, Youssef El-Douaihy, Robert Leung, Ashutosh Tewari, New York, NY INTRODUCTION AND OBJECTIVES: Clinicians often rely heavily on biopsy Gleason score when selecting patients for active surveillance, focal or curative (prostatectomy or radiation) therapy. Unfortunately, discordance between the biopsy and true pathological Gleason score has been well documented. We sort to identify possible predictors for Gleason upgrading, where the Gleason Sum was higher on final histopathology when compared to that found on biopsy, based on pre operative clinico-pathologic characters METHODS: Data were prospectively gathered using our IRB approved protocol. From June 2005 to July 2009, there were 1114
Vol. 183, No. 4, Supplement, Wednesday, June 2, 2010
patients with unilateral disease on preoperative biopsy who eventually opted for radical prostatectomy at our institute. We reviewed biopsy, operative and clinical data to record age, BMI, preoperative prostate specific antigen (PSA), clinical stage, biopsy Gleason score, presence of high grade intraepithelial neoplasm (HGPIN), perineural invasion (PNI), prostate volume, number of positive cores and maximum percentage of positive cores. Clinical and biopsy variables were correlated against final surgical pathology. Logistic regression and Backward Wald analysis were performed to identify possible predictors of Gleason upgrading. Odd ratios (OR) were also determined. RESULTS: Of 1114 patients with unilateral disease on biopsy, Gleason upgrading was found in 376 (33.75%) patients. Preoperative PSA (P⫽ 0.016; OR⫽1.037) and biopsy Gleason score of ⱖ 7 (P⫽0.00; OR⫽0.111) were only significant predictors of Gleason upgrading on univariate analysis. Age (P⫽0.021; OR⫽ 1.032), BMI (P⫽0.075; OR⫽ 1.037), preoperative PSA(log) (P⫽0.001; OR⫽ 1.077), total positive cores (P⫽0.001; OR⫽ 1.321), maximum percentage of positive cores (P⫽0.044; OR⫽ 1.011), biopsy Gleason score of ⱖ 7 (P⫽0.000; OR⫽0.045), Prostate volume (log) (P⫽0.049; OR⫽ 0.993) were significant predictors of Gleason upgrading on multivariate analysis. CONCLUSIONS: There is little correlation between biopsy and the final surgical pathology which makes patient selection for active surveillance challenging. The risk for Gleason upgrading is influenced by preoperative PSA, biopsy Gleason of ⱖ 7, total number of positive cores, maximum percentage of cancer on biopsy and prostate volume. These variables should be taken in account while making management decisions. Source of Funding: None
2037 PREDICTORS FOR GLEASON SUM UPGRADING IN POTENTIAL CANDIDATES FOR ACTIVE SURVEILLANCE OF PRESUMED LOW-RISK PROSTATE CANCER Gerald Tan*, Casey Ng, Phil Dorsey, David Peters, Abhishek Srivastava, Sonal Grover, Youssef El Douaihy, Kumaran Mudaliar, DaWei Ye, Jason Fung, Amanda Lawlor, Robert Leung, Majnu John, Ashutosh Tewari, New York, NY INTRODUCTION AND OBJECTIVES: Active surveillance (AS) is becoming increasingly popular as a treatment option for men with indolent prostate cancer. One of the primary selection criteria for AS is a low Gleason score. Underestimation of disease severity could be detrimental, and patients at risk for Gleason upgrading would therefore be unsuitable for AS. We sought to identify risk factors that could more accurately predict Gleason upgrading in AS-eligible men. METHODS: A retrospective cohort study of 413 AS-eligible patients from a prospective database of 1535 men who underwent robotic-assisted radical prostatectomy by a single surgeon from January 2005 to January 2009. These 413 patients were eligible for AS ¨ 6, based stringent selection criteria consisting of Gleason sum ¡U ¨ T2a disease, PSA ¡U ¨ 10ng/ml, ¡U ¨ 3 positive cores and clinical stage ¡U ¨ 50% cancer present in a single core. Clinicopathologic parameters, ¡U including number of cores at initial biopsy, biopsy cancer volume, preoperative PSA, number of cancer-positive cores, body mass index, and prostate volume were recorded prospectively. Data were evaluated using chi-square and multivariate logistic regression analyses. Receiver operator characteristic curves (ROC) were constructed to determine the optimal cutoff values. RESULTS: 169 of 413 AS-eligible patients (40.9%) had Gleason upgrading at final pathology following radical prostatectomy. On univariate analysis, BMI, PSA density, preoperative PSA, lower prostate volume and maximum percentage of cancer in biopsy cores were predictors for Gleason upgrading. On multivariate analysis, all variables, except for BMI and PSA density, fell out of significance. PSA density ⬎ 0.1ng/ml/cm3 and BMI ⬎29kg/m2 are the optimal cutoff values based on ROC analysis.
THE JOURNAL OF UROLOGY姞
months follow-up (n⫽198), 86% of patients had recovered potency and 95% were continent. PSM occurred in 7.6%. BCR occurred in 1.1% at a median follow-up of 13 months. CONCLUSIONS: Patients with low-risk prostate cancer, and especially those who would qualify for AS, have very favorable options available to them. Those who desire curative therapy have a high likelihood of achieving excellent functional and oncologic outcomes following RALP. With only 3% upstaging, those who elect AS can be reassured that the majority of AS candidates had favorable tumor characteristics at the time of surgery. Although we found a 43% rate of upgrading, the vast majority were upgraded to the more benign 3⫹4⫽7. Only 3% were upgraded to 4⫹3⫽7, and none to Gleason 8 or higher. This cohort of patients will likely do well regardless of whether they choose AS or surgical extirpation. Source of Funding: None
2035 NON- SURGICAL MANAGEMENT OF LOCALIZED PROSTATE CANCER. IS ACTIVE SURVEILLANCE A SAFE OPTION? M Z Aslam*, Ferhad Kheradmund, Gareth Turner, S F Brewster, Oxford, United Kingdom INTRODUCTION AND OBJECTIVES: Active Surveillance for localized prostate cancer is a management option which is becoming an area of growing interest.We studied histopathological reports of 314 radical prostatectomies (RP) performed for D’Amico’s low risk (LR) and intermediate risk (IR) disease in a UK cancer centre to assess the safety of this practice. METHODS: 150 LR and 164 IR cases were included. Pathological features studied in RP specimens included Gleason score upgrading to ⱖ7, pT3 upstaging, the presence of tumour multifocality / bilaterality and for the presence of clinically significant tumours(CST) (by Epstein’s criteria, including tumour volume ⬎0.5cc). RESULTS: LR group (n⫽150): On final RP histopathological analysis, 115 (75%) and 123(82%) cases exhibited multifocal and bilateral disease respectively. 57 (38%) were upgraded while 29 (19%) had pT3 cancer. 93(62%) cases harboured at least one CST. IR group (n⫽164): 126 (77%) and 143(87%) exhibited multifocal and bilateral disease respectively. 25(15%) were upgraded while 68(42%) had pT3 cancer. 131(80%) cases harboured at least one CST. CONCLUSIONS: One-fifth of LR cases and two-fifths of IR cases had locally-advanced cancer, and many more exhibited aggressive features. Caution should be taken when recommending AS to the patients suitable for radical treatment, as in the absence of long term outcomes of large randomised trials, this could be an unsafe management option. Source of Funding: None
2036 GLEASON SCORE UPGRADING IN PATIENTS WITH UNILATERAL PROSTATE CANCER: IMPLICATIONS FOR SELECTION INTO ACTIVE SURVEILLANCE REGIMEN. Sonal Grover*, Abhishek Srivastava, Gerald Tan, David Peters, Kumaran Mudaliar, Youssef El-Douaihy, Robert Leung, Ashutosh Tewari, New York, NY INTRODUCTION AND OBJECTIVES: Clinicians often rely heavily on biopsy Gleason score when selecting patients for active surveillance, focal or curative (prostatectomy or radiation) therapy. Unfortunately, discordance between the biopsy and true pathological Gleason score has been well documented. We sort to identify possible predictors for Gleason upgrading, where the Gleason Sum was higher on final histopathology when compared to that found on biopsy, based on pre operative clinico-pathologic characters METHODS: Data were prospectively gathered using our IRB approved protocol. From June 2005 to July 2009, there were 1114
Vol. 183, No. 4, Supplement, Wednesday, June 2, 2010
patients with unilateral disease on preoperative biopsy who eventually opted for radical prostatectomy at our institute. We reviewed biopsy, operative and clinical data to record age, BMI, preoperative prostate specific antigen (PSA), clinical stage, biopsy Gleason score, presence of high grade intraepithelial neoplasm (HGPIN), perineural invasion (PNI), prostate volume, number of positive cores and maximum percentage of positive cores. Clinical and biopsy variables were correlated against final surgical pathology. Logistic regression and Backward Wald analysis were performed to identify possible predictors of Gleason upgrading. Odd ratios (OR) were also determined. RESULTS: Of 1114 patients with unilateral disease on biopsy, Gleason upgrading was found in 376 (33.75%) patients. Preoperative PSA (P⫽ 0.016; OR⫽1.037) and biopsy Gleason score of ⱖ 7 (P⫽0.00; OR⫽0.111) were only significant predictors of Gleason upgrading on univariate analysis. Age (P⫽0.021; OR⫽ 1.032), BMI (P⫽0.075; OR⫽ 1.037), preoperative PSA(log) (P⫽0.001; OR⫽ 1.077), total positive cores (P⫽0.001; OR⫽ 1.321), maximum percentage of positive cores (P⫽0.044; OR⫽ 1.011), biopsy Gleason score of ⱖ 7 (P⫽0.000; OR⫽0.045), Prostate volume (log) (P⫽0.049; OR⫽ 0.993) were significant predictors of Gleason upgrading on multivariate analysis. CONCLUSIONS: There is little correlation between biopsy and the final surgical pathology which makes patient selection for active surveillance challenging. The risk for Gleason upgrading is influenced by preoperative PSA, biopsy Gleason of ⱖ 7, total number of positive cores, maximum percentage of cancer on biopsy and prostate volume. These variables should be taken in account while making management decisions. Source of Funding: None
2037 PREDICTORS FOR GLEASON SUM UPGRADING IN POTENTIAL CANDIDATES FOR ACTIVE SURVEILLANCE OF PRESUMED LOW-RISK PROSTATE CANCER Gerald Tan*, Casey Ng, Phil Dorsey, David Peters, Abhishek Srivastava, Sonal Grover, Youssef El Douaihy, Kumaran Mudaliar, DaWei Ye, Jason Fung, Amanda Lawlor, Robert Leung, Majnu John, Ashutosh Tewari, New York, NY INTRODUCTION AND OBJECTIVES: Active surveillance (AS) is becoming increasingly popular as a treatment option for men with indolent prostate cancer. One of the primary selection criteria for AS is a low Gleason score. Underestimation of disease severity could be detrimental, and patients at risk for Gleason upgrading would therefore be unsuitable for AS. We sought to identify risk factors that could more accurately predict Gleason upgrading in AS-eligible men. METHODS: A retrospective cohort study of 413 AS-eligible patients from a prospective database of 1535 men who underwent robotic-assisted radical prostatectomy by a single surgeon from January 2005 to January 2009. These 413 patients were eligible for AS ¨ 6, based stringent selection criteria consisting of Gleason sum ¡U ¨ T2a disease, PSA ¡U ¨ 10ng/ml, ¡U ¨ 3 positive cores and clinical stage ¡U ¨ 50% cancer present in a single core. Clinicopathologic parameters, ¡U including number of cores at initial biopsy, biopsy cancer volume, preoperative PSA, number of cancer-positive cores, body mass index, and prostate volume were recorded prospectively. Data were evaluated using chi-square and multivariate logistic regression analyses. Receiver operator characteristic curves (ROC) were constructed to determine the optimal cutoff values. RESULTS: 169 of 413 AS-eligible patients (40.9%) had Gleason upgrading at final pathology following radical prostatectomy. On univariate analysis, BMI, PSA density, preoperative PSA, lower prostate volume and maximum percentage of cancer in biopsy cores were predictors for Gleason upgrading. On multivariate analysis, all variables, except for BMI and PSA density, fell out of significance. PSA density ⬎ 0.1ng/ml/cm3 and BMI ⬎29kg/m2 are the optimal cutoff values based on ROC analysis.