PATHOLOGIC OUTCOMES IN PATIENTS AFFECTED BY VERY LOW RISK AND LOW RISK PROSTATE CANCER AND ELIGIBLE FOR ACTIVE SURVEILLANCE
Objective
To evaluate pathologic outcomes in patients affected by very low risk (VLR) and low risk (LR) prostate cancer and eligible for Active Surveillance.
Materials and Methods
We conducted a retrospective analysis in patients with low risk prostate cancer who underwent Laparoscopic Radical Prostatectomy (LRP) at our institution from 2005 to 2016. We identified patients with low risk (LR) PCa defined as cT1c-T2a, Gleason score <7, PSA ≤10 ng/ml and patients with very low risk (VLR) PCa as defined by Italian PRIAS (cT1c-T2a, Gleason score <7, PSA ≤10 ng/ml, PSAD ≤0,20 ng/ml/cc, ≤2 positive cores). Complete information on PSA, PSA density (PSAD), clinical stage, Gleason score, percentage of positive cores, number of nodes removed, and pathological outcomes were available. We evaluate GS upgrading (to primary pattern 4), non-organ confined disease and unfavorable disease (≥pT3, GS ≥4+3, pN1) in LR and VLR patients. Prognostic factors of unfavorable disease were analyzed by logistic regression analysis (SPSS 24).
Results
We identified 103 patients with LR Prostate cancer. Of these, 58 patients have VLR cancer according with PRIAS criteria. Baseline characteristic of patients are described in table 1. There were no significant differences between LR and VLR patients. Pathological outcomes revealed upstaging in 9% and 1.7%, upgrading in 24.7% and 22.8% in LR and VLR patients, respectively. Unfavorable disease occurred in 28.2% and 22.4% of LR and VLR patients, respectively [table 2]. At multivariate analysis, PSAD was the only prognostic factor of unfavorable disease in LR patients [table 3].
Discussions
Active surveillance (AS) has emerged as a valid option for the conservative management of low risk prostate cancer (PCa). The D’Amico classification is commonly used criterion for identification of low risk patients. However upgrading and upstaging at radical prostatectomy occurred in 20-54% and 6-26% of patients, respectively. Therefore more restrictive criteria are adopted in several AS protocols. Italian arm (SIURO) of Prostate Cancer Research International Active Surveillance (PRIAS) inclusion criteria are stage cT1c/T2a, Gleason score <7, PSA ≤10 ng/ml, PSA density (PSAD) ≤0.20 ng/ml/cc, ≤ 2 positive cores. In our experience, a retrospective analysis on LR and VLR patients revelead no significant differences in terms of adverse pathology between LR and VLR patients (28.2 vs 22.4%). This results is probably due to clinical stage of LR patients (≤cT2a) and to percentage of positive cores. However this results seems to affirm need of mpMRI for more accurate selection of patients candidates for AS.
Conclusion
In our experience, upstaging and upgrading at laparoscopic radical prostatectomy occurred in 9% and 25% of low risk patients and in 2% and 23% of very low risk patients. About a quarter of the patients presented unfavorable disease (non organ confined, primary Gleason 4). PSA density was the only prognostic factor of unfavorable disease.
Reference
Eur Urol 2016; 69: 576-81
Eur urol 2015; 68: 458-63