Abstract Objective To evaluate the effectiveness of extended (e-PLND) and super-extended pelvic lymph node dissection (se-PLND) during robot-assisted radical prostatectomy (RARP) by examining lymph node (LN) yield, complications, LN metastasis, and biochemical recurrence (BCR) incidence. Methods Between January 2016 and January 2020, 354 consecutive patients with > 5% risk of lymph node involvement (LNI), as predicted by the Memorial Sloan Kettering Cancer Center nomogram, underwent RARP with (s)e-PLND at a high-volume center. The e-PLND involved removing fibrofatty lymphatic tissue around the obturator fossa, internal iliac region, and external iliac vessels. The se-PLND, performed at the discretion of the surgeons, also included lymph nodes from the pre-sacral and common iliac regions. Outcomes included histopathological findings by anatomical region; complications; and BCR incidence during follow-up. Results The median LNI risk was 18% (IQR 9–31%). A median of 22 LN (IQR 16–28) were removed, with se-PLND yielding a higher number: 25 (IQR 20–32) compared to e-PLND: 17 (IQR 13–24) ( p < 0.001). pN1 disease was detected in 22% of patients overall, higher in se-PLND (29%) than e-PLND (14%) ( p < 0.001). Of metastatic LNs, 14% were situated outside the e-PLND template. Operation time was longer for se-PLND, but perioperative complications were similar between both groups. After a median follow-up of 24 months (IQR 7–33), BCR incidence was comparable between the two groups. Conclusion Compared to standard extended pelvic lymph node dissection (PLND), super extended PLND increases lymph node yield and removal of metastatic deposits but does not contribute to progression free survival at mid-term.
Abstract Purpose To assess if PSMA PET quantitative parameters are associated with pathologic ISUP grade group (GG) and upgrading/downgrading. Methods PCa patients undergoing radical prostatectomy with or without pelvic lymph node dissection staged with preoperative PSMA PET at seven referral centres worldwide were evaluated. PSMA PET parameters which included SUV max , PSMA volume , and total PSMA accumulation (PSMA total ) were collected. Multivariable logistic regression evaluated the association between PSMA PET quantified parameters and surgical ISUP GG. Decision-tree analysis was performed to identify discriminative thresholds for all three parameters related to the five ISUP GGs The ROC-derived AUC was used to determine whether the inclusion of PSMA quantified parameters improved the ability of multivariable models to predict ISUP GG ≥ 4. Results A total of 605 patients were included. Overall, 2%, 37%, 37%, 10% and 13% patients had pathologic ISUP GG1, 2, 3, 4, and 5, respectively. At multivariable analyses, all three parameters SUV max , PSMA volume and PSMA total were associated with GG ≥ 4 at surgical pathology after accounting for PSA and clinical T stage based on DRE, hospital and radioligand (all p < 0.05). Addition of all three parameters significantly improved the discrimination of clinical models in predicting GG ≥ 4 from 68% (95%CI 63 – 74) to 74% (95%CI 69 – 79) for SUV max , 72% (95%CI 67 – 76) for PSMA volume , 74% (70 – 79) for PSMA total and 75% (95%CI 71 – 80) when all parameters were included (all p < 0.05). Decision-tree analysis resulted in thresholds that discriminate between GG (SUV max 0–6.5, 6.5–15, 15–28, > 28, PSMA vol 0–2, 2–9, 9–20 and > 20 and PSMA total 0–12, 12–98 and > 98). PSMA volume was significantly associated with GG upgrading (OR 1.03 95%CI 1.01 – 1.05). In patients with biopsy GG1-3, PSMA volume ≥ 2 was significantly associated with higher odds for upgrading to ISUP GG ≥ 4, compared to PSMA volume < 2 (OR 6.36, 95%CI 1.47 – 27.6). Conclusion Quantitative PSMA PET parameters are associated with surgical ISUP GG and upgrading. We propose clinically relevant thresholds of these parameters which can improve in PCa risk stratification in daily clinical practice.
<div>AbstractPurpose:<p>[<sup>177</sup>Lu]Lu-PSMA-617 radioligand therapy (<sup>177</sup>Lu-PSMA) is a novel treatment for metastatic castration-resistant prostate cancer (mCRPC), which could also be applied to patients with metastatic hormone-sensitive prostate cancer (mHSPC) with PSMA expression. In this prospective study (NCT03828838), we analyzed toxicity, radiation doses, and treatment effect of <sup>177</sup>Lu-PSMA in pateints with low-volume mHSPC.</p>Patients and Methods:<p>Ten progressive patients with mHSPC following local treatment, with a maximum of ten metastatic lesions on [<sup>68</sup>Ga]Ga-PSMA-11 PET/diagnostic-CT imaging (PSMA-PET) and serum PSA doubling time <6 months received two cycles of <sup>177</sup>Lu-PSMA. Whole-body single-photon emission CT/CT (SPECT/CT) and blood dosimetry was performed to calculate doses to the tumors and organs at risk (OAR). Adverse events (AE), laboratory values (monitoring response and toxicity), and quality of life were monitored until week 24 after cycle 2, the end of study (EOS). All patients underwent PSMA-PET at screening, 8 weeks after cycle 1, 12 weeks after cycle 2, and at EOS.</p>Results:<p>All patients received two cycles of <sup>177</sup>Lu-PSMA without complications. No treatment-related grade III–IV adverse events were observed. According to dosimetry, none of the OAR reached threshold doses for radiation-related toxicity. Moreover, all target lesions received a higher radiation dose than the OAR. All 10 patients showed altered PSA kinetics, postponed androgen deprivation therapy, and maintained good quality of life. Half of the patients showed a PSA response of more than 50%. One patient had a complete response on PSMA-PET imaging until EOS and two others had only minimal residual disease.</p>Conclusions:<p><sup>177</sup>Lu-PSMA appeared to be a feasible and safe treatment modality in patients with low-volume mHSPC.</p></div>
Samenvatting De behandeling bij gemetastaseerd hormoongevoelig prostaatcarcinoom (mHSPC) is volop in ontwikkeling. Hoewel androgeendeprivatietherapie (ADT) nog altijd de hoeksteen vormt van de behandeling van mHSPC, is de laatste jaren gebleken dat intensivering van de behandeling met chemotherapie of remmers van de androgeenreceptor- pathway significante verlenging van overleving geeft, met een acceptabele toxiciteit. Daarnaast wordt in studieverband de uitkomst onderzocht van veelbelovende aanvullende therapieën, zoals remmers van poly(-adenosinedifosfaat-ribose) polymerase (PARP) bij mHSPC-patiënten met een DNA-reparatiedeficiëntie (DRD). Dit artikel geeft de stand van zaken in diagnostiek en behandeling van mHSPC in de dagelijkse urologische praktijk en een overzicht van de belangrijkste ontwikkelingen. Daarnaast wordt aandacht besteed aan de cruciale rol van de uroloog bij de multidisciplinaire behandeling van mHSPC en de groeiende mogelijkheden voor gepersonaliseerde zorg.
<i>Objective:</i> The increasing incidence of both obesity and prostate cancer (PCa) detection will confront the urologist more often with obese men having PCa. It is unknown whether obesity affects the surgical and oncological outcomes following open radical retropubic prostatectomy (RRP). Knowledge concerning this issue is relevant when counselling obese patients with PCa for RRP. <i>Patients and Methods:</i> A single institution cohort study was performed including 252 men who underwent a RRP between 1992 and 2003. The surgical complications (perioperative complications, post-RRP urinary incontinence, urethral strictures) were compared between obese (BMI >30) and nonobese (BMI ≤30) men. <i>Results:</i> Compared to nonobese (n = 221), obese men (n = 31) developed more frequently wound infections (16.1 vs. 4.5%; p < 0.05), urinary incontinence (25.8 vs. 8.7%; p < 0.05) as well as vesico-urethral strictures (46.2 vs. 12.3%; p < 0.05). The pathology results and the 5-year cumulative risk of PSA recurrence were comparable among both groups. <i>Conclusions:</i> Compared to nonobese, obese men suffer more frequently from post-RRP urinary incontinence and vesicourethral strictures following open RRP.
