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MP51-11 LOWERING THE RATE OF POSITIVE SURGICAL MARGIN AND BIOCHEMICAL FAILURE BY INTRAOPERATIVE FROZEN SECTION ANALYSIS DURING LAPAROSCOPIC RADICAL PROSTATECTOMY
THE JOURNAL OF UROLOGYâ
Vol. 191, No. 4S, Supplement, Monday, May 19, 2014
MP51-10 PREDICTORS OF FAVORABLE URINARY OUTCOMES AFTER PROSTATE CANCER TREATMENT Peter Chang*, Meredith Regan, Boston, MA; John Wei, Ann Arbor, MI; Larry Hembroff, East Lansing, MI; Jeff Michalski, St. Louis, MO; Christopher Saigal, Mark S. Litwin, Los Angeles, CA; Daniel Hamstra, Ann Arbor, MI; Irving Kaplan, Boston, MA; Jay Ciezki, Eric Klein, Cleveland, OH; Adam Kibel, Boston, MA; Louis Pisters, Deborah Kuban, Houston, TX; David Wood, Grosse Pointe, MI; Howard Sandler, West Hollywood, CA; Rodney Dunn, Ann Arbor, MI; Martin Sanda, Atlanta, GA INTRODUCTION AND OBJECTIVES: While prostate cancer (PCa) treatment can result in bothersome urinary side effects, a subset of patients may actually perceive an improvement in their urination after PCa treatment. However, information on what factors may predict favorable urinary outcome is sparse. METHODS: We analyzed the 1,021 men in a multicenter prospective cohort of 522 radical prostatectomy (RP), 239 external radiotherapy (XRT), and 260 brachytherapy (BT) PCa patients who had complete pre- and 2-year post-treatment urinary quality-of-life follow-up. We categorized pre- to post-treatment change in EPIC-26 overall urinary bother (5-point scale from no problem to big problem) into a fiveitem ordinal scale: “-2”: major worsening, “-1”: minor worsening, “0”: no change, “1”: minor improvement, and “2”: major improvement, where “minor” ¼ 1 point and “major” ¼ 2 or greater point change. We used ordinal logistic regression to identify factors that predicted a higher ordinal score across all levels of urinary bother change (i.e., a “better” or “less bad” urinary outcome). We then assessed how the effect of treatment group interacted with the most powerful predictor. RESULTS: Patients with moderate to severe pre-treatment LUTS (AUA-SI 8) were most likely to have a good urinary outcome after PCa treatment (45% improved and 25% worsened; Table), and after controlling for other covariates, had an approximately 3 times higher odds of a favorable outcome (OR 2.8; p <0.0001). This effect varied significantly by treatment group, and was especially strong in RP compared to XRT and BT patients (OR 4.29 vs 1.89 and 1.86, respectively); of the RP patients with baseline LUTS, 52% had improved and 22% had worsened urinary bother. Pre-treatment urinary medications use also predicted better outcome (OR 1.41; p ¼ 0.04), while pretreatment urinary incontinence was not a significant predictor. CONCLUSIONS: The presence of pre-treatment LUTS is the most powerful predictor of a favorable (or less unfavorable) change in overall urinary bother after PCa treatment. RP patients with pre-treatment LUTS generally preferred post-operative urinary incontinence over their pre-treatment symptoms. These results highlight the oft-overlooked importance of LUTS in PCa patients’ urinary health, and should be used to guide patients with pre-treatment LUTS towards radical prostatectomy. Ordinal Distribution of Urinary Bother Change across Significant Factors on Multivariable Logistic Regression
Treatment group RP XRT BT Pre-treatment LUTS (AUA-SI) Mild (0-7) Mod to Severe (8) Pre-treatment urinary medications No Yes
e601
Source of Funding: National Institutes of Health (R01 CA95662, RC1 CA146596). This work was supported in part by a grant from the UrologyCare Foundation Research Scholars Program and Dornier Medtech titled “Measuring Prostate Cancer Patient Reported Outcomes at the Point of Care”.
MP51-11 LOWERING THE RATE OF POSITIVE SURGICAL MARGIN AND BIOCHEMICAL FAILURE BY INTRAOPERATIVE FROZEN SECTION ANALYSIS DURING LAPAROSCOPIC RADICAL PROSTATECTOMY Bela Kovacs*, Imre Bode, Andras Magyar, Aniko Hajdu, Tunde Mezei, Peter Tenke, Budapest, Hungary INTRODUCTION AND OBJECTIVES: Positive surgical margin (PSM) is an independent risk factor of prostate cancer progression (biochemical recurrence (BCR), local relapse and mortality) after radical prostatectomy. Intraoperative frozen section (IFS) reduces the rate of PSM in cases with biopsy Gleason score 7 or higher tumors, while provides a more secure approach for the nerve sparing technique. We analyzed the impact of IFS on PSM and BCR in pT2 and pT3 tumors after laparoscopic radical prostatectomy (LRP) in the era of “operate high risk patients”. METHODS: PSM, positive IFS and BCR of 234 consecutive patients were determined after LRP. False negative IFSs gave the number of cases, where further intraoperative resection could not be performed to reduce the risk of final PSM. The positive IFS and false negative IFS patients were sub-grouped into T2 and T3 stages and the reduction effect of IFS on each sub-group was counted. RESULTS: Operations were performed between March 2010 and July 2013. Average PSA was 12,15ng/ml, 137 patients had postoperative Gleason score 7, 59 patients had Gleason score 8 or worse, average follow-up was two years. PSM was 97 (32 T2 (28 T2c), 64 T3)), 61 of them showed positive IFS. In 45 cases, further resection was performed, 29 were tumor positive. In 36 cases the IFS was false negative, 14 T2 (13 T2c) and 22 T3, 6% and 9,4% of the total operation count, respectively. BCR occurred in 7 (3%) and 21 (9%) patients, in the PSM and in total. CONCLUSIONS: Although the PSM was high in this rather high risk group of patients, the IFS revealed the two-third of it, and gave the opportunity to reduce the margin positive T2 and T3 cases from 13,6% to 6% and from 27,3% to 9,4%, respectively, with a relatively low BCR. Meanwhile, a better nerve preservation could be performed for the sake of early continence and better erectile function recovery. Source of Funding: None
-2
-1
0
1
2
N (col %)
9% 7% 16%
16% 17% 21%
47% 51% 50%
15% 18% 9%
13% 7% 3%
522 (51) 239 (23) 260 (25)
MP51-12
12% 7%
18% 17%
59% 31%
8% 25%
3% 20%
648 (63) 373 (37)
Adam Reese*, Philadelphia, PA; Zhaoyong Feng, Patricia Landis, Bruce Trock, Jonathan Epstein, Ballentine Carter, Baltimore, MD
10% 13%
18% 15%
52% 31%
13% 19%
7% 23%
870 (85) 151 (15)
“-2” indicates major worsening, “-1” indicates minor worsening, “0” indicates no change, “1” indicates minor improvement, and “2” indicates major improvement in overall urinary bother after PCa treatment, where “minor” ¼ 1 point and “major” ¼ 2 or greater point change
PREDICTORS OF ADVERSE PATHOLOGY IN MEN UNDERGOING RADICAL PROSTATECTOMY FOLLOWING INITIAL ACTIVE SURVEILLANCE
INTRODUCTION AND OBJECTIVES: The Epstein criteria can be used to identify men with low-risk prostate cancer who may be candidates for active surveillance (AS). At our institution, men enrolled in active surveillance (AS) are reclassified if they no longer meet Epstein criteria during follow-up. We report pathological outcomes and predictors of adverse pathology in men undergoing radical prostatectomy (RP) after initial AS.
Vol. 191, No. 4S, Supplement, Monday, May 19, 2014
MP51-10 PREDICTORS OF FAVORABLE URINARY OUTCOMES AFTER PROSTATE CANCER TREATMENT Peter Chang*, Meredith Regan, Boston, MA; John Wei, Ann Arbor, MI; Larry Hembroff, East Lansing, MI; Jeff Michalski, St. Louis, MO; Christopher Saigal, Mark S. Litwin, Los Angeles, CA; Daniel Hamstra, Ann Arbor, MI; Irving Kaplan, Boston, MA; Jay Ciezki, Eric Klein, Cleveland, OH; Adam Kibel, Boston, MA; Louis Pisters, Deborah Kuban, Houston, TX; David Wood, Grosse Pointe, MI; Howard Sandler, West Hollywood, CA; Rodney Dunn, Ann Arbor, MI; Martin Sanda, Atlanta, GA INTRODUCTION AND OBJECTIVES: While prostate cancer (PCa) treatment can result in bothersome urinary side effects, a subset of patients may actually perceive an improvement in their urination after PCa treatment. However, information on what factors may predict favorable urinary outcome is sparse. METHODS: We analyzed the 1,021 men in a multicenter prospective cohort of 522 radical prostatectomy (RP), 239 external radiotherapy (XRT), and 260 brachytherapy (BT) PCa patients who had complete pre- and 2-year post-treatment urinary quality-of-life follow-up. We categorized pre- to post-treatment change in EPIC-26 overall urinary bother (5-point scale from no problem to big problem) into a fiveitem ordinal scale: “-2”: major worsening, “-1”: minor worsening, “0”: no change, “1”: minor improvement, and “2”: major improvement, where “minor” ¼ 1 point and “major” ¼ 2 or greater point change. We used ordinal logistic regression to identify factors that predicted a higher ordinal score across all levels of urinary bother change (i.e., a “better” or “less bad” urinary outcome). We then assessed how the effect of treatment group interacted with the most powerful predictor. RESULTS: Patients with moderate to severe pre-treatment LUTS (AUA-SI 8) were most likely to have a good urinary outcome after PCa treatment (45% improved and 25% worsened; Table), and after controlling for other covariates, had an approximately 3 times higher odds of a favorable outcome (OR 2.8; p <0.0001). This effect varied significantly by treatment group, and was especially strong in RP compared to XRT and BT patients (OR 4.29 vs 1.89 and 1.86, respectively); of the RP patients with baseline LUTS, 52% had improved and 22% had worsened urinary bother. Pre-treatment urinary medications use also predicted better outcome (OR 1.41; p ¼ 0.04), while pretreatment urinary incontinence was not a significant predictor. CONCLUSIONS: The presence of pre-treatment LUTS is the most powerful predictor of a favorable (or less unfavorable) change in overall urinary bother after PCa treatment. RP patients with pre-treatment LUTS generally preferred post-operative urinary incontinence over their pre-treatment symptoms. These results highlight the oft-overlooked importance of LUTS in PCa patients’ urinary health, and should be used to guide patients with pre-treatment LUTS towards radical prostatectomy. Ordinal Distribution of Urinary Bother Change across Significant Factors on Multivariable Logistic Regression
Treatment group RP XRT BT Pre-treatment LUTS (AUA-SI) Mild (0-7) Mod to Severe (8) Pre-treatment urinary medications No Yes
e601
Source of Funding: National Institutes of Health (R01 CA95662, RC1 CA146596). This work was supported in part by a grant from the UrologyCare Foundation Research Scholars Program and Dornier Medtech titled “Measuring Prostate Cancer Patient Reported Outcomes at the Point of Care”.
MP51-11 LOWERING THE RATE OF POSITIVE SURGICAL MARGIN AND BIOCHEMICAL FAILURE BY INTRAOPERATIVE FROZEN SECTION ANALYSIS DURING LAPAROSCOPIC RADICAL PROSTATECTOMY Bela Kovacs*, Imre Bode, Andras Magyar, Aniko Hajdu, Tunde Mezei, Peter Tenke, Budapest, Hungary INTRODUCTION AND OBJECTIVES: Positive surgical margin (PSM) is an independent risk factor of prostate cancer progression (biochemical recurrence (BCR), local relapse and mortality) after radical prostatectomy. Intraoperative frozen section (IFS) reduces the rate of PSM in cases with biopsy Gleason score 7 or higher tumors, while provides a more secure approach for the nerve sparing technique. We analyzed the impact of IFS on PSM and BCR in pT2 and pT3 tumors after laparoscopic radical prostatectomy (LRP) in the era of “operate high risk patients”. METHODS: PSM, positive IFS and BCR of 234 consecutive patients were determined after LRP. False negative IFSs gave the number of cases, where further intraoperative resection could not be performed to reduce the risk of final PSM. The positive IFS and false negative IFS patients were sub-grouped into T2 and T3 stages and the reduction effect of IFS on each sub-group was counted. RESULTS: Operations were performed between March 2010 and July 2013. Average PSA was 12,15ng/ml, 137 patients had postoperative Gleason score 7, 59 patients had Gleason score 8 or worse, average follow-up was two years. PSM was 97 (32 T2 (28 T2c), 64 T3)), 61 of them showed positive IFS. In 45 cases, further resection was performed, 29 were tumor positive. In 36 cases the IFS was false negative, 14 T2 (13 T2c) and 22 T3, 6% and 9,4% of the total operation count, respectively. BCR occurred in 7 (3%) and 21 (9%) patients, in the PSM and in total. CONCLUSIONS: Although the PSM was high in this rather high risk group of patients, the IFS revealed the two-third of it, and gave the opportunity to reduce the margin positive T2 and T3 cases from 13,6% to 6% and from 27,3% to 9,4%, respectively, with a relatively low BCR. Meanwhile, a better nerve preservation could be performed for the sake of early continence and better erectile function recovery. Source of Funding: None
-2
-1
0
1
2
N (col %)
9% 7% 16%
16% 17% 21%
47% 51% 50%
15% 18% 9%
13% 7% 3%
522 (51) 239 (23) 260 (25)
MP51-12
12% 7%
18% 17%
59% 31%
8% 25%
3% 20%
648 (63) 373 (37)
Adam Reese*, Philadelphia, PA; Zhaoyong Feng, Patricia Landis, Bruce Trock, Jonathan Epstein, Ballentine Carter, Baltimore, MD
10% 13%
18% 15%
52% 31%
13% 19%
7% 23%
870 (85) 151 (15)
“-2” indicates major worsening, “-1” indicates minor worsening, “0” indicates no change, “1” indicates minor improvement, and “2” indicates major improvement in overall urinary bother after PCa treatment, where “minor” ¼ 1 point and “major” ¼ 2 or greater point change
PREDICTORS OF ADVERSE PATHOLOGY IN MEN UNDERGOING RADICAL PROSTATECTOMY FOLLOWING INITIAL ACTIVE SURVEILLANCE
INTRODUCTION AND OBJECTIVES: The Epstein criteria can be used to identify men with low-risk prostate cancer who may be candidates for active surveillance (AS). At our institution, men enrolled in active surveillance (AS) are reclassified if they no longer meet Epstein criteria during follow-up. We report pathological outcomes and predictors of adverse pathology in men undergoing radical prostatectomy (RP) after initial AS.