No abstract

No abstract

Introduction: A proportion of prostate cancer (PCa) patients initially managed with active surveillance (AS) are upgraded to a higher Gleason score (GS) at the time of radical prostatectomy (RP). Our objective was to determine predictors of upgrading on RP specimens using a national database. Methods: The Surveillance, Epidemiology, and End Results Prostate with Watchful Waiting database was used to identify AS patients diagnosed with very low- or low-risk PCa who underwent delayed RP between 2010 and 2015. The primary outcome was upgrading to GS 7 disease or worse. Logistic regression analyses were used to evaluate demographic and oncological predictors of upgrading on final specimen. Results: A total of 3775 men underwent RP after a period of AS, 3541 (93.8%) of whom were cT2a; 792 (21.0%) patients were upgraded on RP specimen, with 85.4%, 10.6%, and 3.4% upgraded to GS 7(3+4), 7(4+3), and 8 diseases, respectively. On multivariable analysis, higher prostate-specific antigen (PSA) at diagnosis (5–10 vs. 0–2 ng/ml, odd ratio [OR] 2.59, p<0.001) and percent core involvement (80–100% vs. 0–20%, OR 2.52, p=0.003) were significant predictors of upgrading on final RP specimen, whereas higher socioeconomic status predicted lower odds of upgrading (highest vs. lowest quartile OR 0.75, p=0.013). Conclusions: Higher baseline PSA and percent positive cores involvement are associated with significantly increased risk of upgrading on RP after AS, whereas higher socioeconomic status predicts lower odds of such events. These results may help identify patients at increased risk of adverse pathology on final specimen who may benefit from earlier definitive treatment.

INTRODUCTION AND OBJECTIVE: The ability to accurately determine the location and extent of lymph node involvement has significant implications in the management of prostate cancer (PCa). Radioguided surgery has emerged as a promising means of assisting the detection of lymph node metastases at the time of radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND) in men with high-risk PCa due to the recent development of prostatespecific membrane antigen (PSMA) labelled with gamma-emitting radionuclides such as technetium-99m ( 99m Tc). The DETECT trial is a prospective, international, multi-institutional study that aims to evaluate the feasibility and effectiveness of radioguided surgery in this setting using 99m Tc-labelled PSMA targeting.METHODS: Men over the age of 18 with !cT3a or Gleason score !4þ3[7 PCa, with suspected (Briganti nomogram risk >10%) or known lymph node metastasis, who have undergone a pre-operative PSMA PET scan were consented to undergo a pre-operative intravenous administration of 99m Tc-labelled PSMA (500 MBq). Patients then underwent a robot-assisted RP with ePLND and had intraoperative measurements taken with a drop-in, in vivo gamma probe at template lymph node sites, the prostate, prostate bed and other sites suspected of harbouring prostate cancer. All patients underwent an ePLND as standard of care. Histopathological concordance with intraoperative gamma probe findings was evaluated to establish the accuracy of the probe in detecting prostate cancer metastases. This clinical trial has received institutional ethics approval.RESULTS: A total of 10 patients were included in the study with a median age of 68 years (IQR, 63.3-69) and pre-operative PSA of 9.15 ng/ml (IQR 6.9-14). The majority of patients harboured ISUP Grade Group 5 disease (70%) and had avid lymph nodes on pre-operative PSMA PET (80%). In total, 61 extraprostatic tissue specimens were resected, of which 16 (26.2%) had histological evidence of prostate cancer. The sensitivity, specificity, negative and positive predictive values of the gamma probe in the intraoperative detection of extraprostatic prostate cancer was 68.8% (95% CI 41.3 -89%), 82.2% (95% CI, 68 -92%), 57.9% (95% CI 40.3 -73.7%) and 88.1% (95% CI 77.9 -93.9%) respectively. The intraoperative use of the drop-in gamma probe in conjunction with CT-guided hookwire localisation was notably effective in the surgically challenging dissection of PSMA-avid mesorectal lymph nodes in 2 patients. In 1 patient, the gamma probe identified residual disease at the prostate bed which was confirmed on histological analysis. Only 1 minor postoperative complication was observed with no complications greater than Clavien-Dindo Grade I seen in the immediate 8-week follow-up period.CONCLUSIONS: Interim results from the DETECT trial show that the use of the 99m Tc-PSMA targeting as valuable and safe in the detection of lymph node metastases and suspected residual disease.