Densidad de APE en pacientes PI-RADS 3: un parámetro clínico útil para su manejo / PSA density as a new approach for PIRADS 3 patient's management

Resumen: Objetivo: Analizar las biopsias realizadas en paciente categorizados PIRADS 3 en nuestra institución desde el segundo semestre del año 2016 al primer semestre del año 2018 y describir la correlación de la densidad de PSA con la incidencia de cáncer de próstata. Evaluar el rol de la densidad de PSA en la indicación de estudio histológico en pacientes PIRADS 3. Método: Trabajo autorizado por el comité de ética de nuestra institución. Se realizó búsqueda en el PACs, de todos los informes de RM multiparamétricas de próstata que incluyeran la categoría ¨PIRADS 3¨ en el periodo señalado. De ellos se calculó la densidad de PSA, con el último valor de PSA registrado en la ficha clínica previo a RM y volumen prostático en RM. Se procedió a buscar los pacientes con estudio histológico. Se correlacionó los resultados de biopsias con el valor de densidad de PSA. Realizamos análisis uni y multivariados, análisis estadísticos con sensibilidad, especificidad y uso de curva ROC. Resultados: De las 2416 RMmp de próstata realizadas en nuestra institución en las fechas ya descritas, se encontraron 424 informes catalogados con score PIRADS 3, y 267 de esos pacientes tenían estudio y seguimiento institucional, de los cuales 134 contaban con biopsia. La muestra tenía un promedio de edad de 60 años, y una mediana de densidad de PSA de 0,10 (RIC 0,07-0,14). Se encontraron 36 biopsias con cáncer clínicamente significativo (Gleason > 6), lo que corresponde a 26,8% de la muestra, valor similar al encontrado en la literuatua. En estos pacientes se obtuvo un punto de corte óptimo de densidad de PSA de 0,11, con una sensibilidad y especificidad de 67% y un AUC de 0,68. Una densidad de PSA de 0,11 presenta un OR de 4,1, con una probabilidad de 4 veces más de encontrar un cáncer de próstata por sobre este valor (IC 95% 1,3-9,8), lo cuál es estadísticamente significativo con un p igual a 0,01. Conclusión: La DAPE sobre 0,11 ng/ml/cc puede considerarse como una herramienta adicional para indicar biopsia en pacientes con RMmp PI-RADS 3, aumentando la precisión para la detección de cáncer de próstata clínicamente significativos ayudando a disminuir estudios histológicos innecesarios.

Abstract: Objective: To analyze the biopsies performed in patients categorized PIRADS 3 in our institution from the second half of 2016 to the first half of 2018 and describe the correlation of PSA density with the incidence of prostate cancer. To evaluate the role of PSA density in the indication of histological study in PIRADS 3 patients. Method: Work authorized by the ethics committee of our institution. The PACs were searched for all multiparameter prostate MRI reports that included the category "PIRADS 3" in the period indicated. The PSA density was calculated, with the last PSA value recorded in the clinical record before MRI and prostate volume in MRI. We proceeded to look for patients with the histological study. The biopsy results were correlated with the PSA density value. We perform uni and multivariate analyzes, statistical analyzes with sensitivity, specificity and use of the ROC curve. Results: Of the 2416 RMmp of the prostate performed in our institution on the dates already described, 424 reports catalogued with PIRADS 3 score were found, and 267 of those patients had study and institutional follow-up, of which 134 had a biopsy. The sample had an average age of 60 years and a median PSA density of 0.10 (RIC 0.075-0.146). We found 36 biopsies with clinically significant cancer (Gleason> 6), which corresponds to 26.8% of the sample, a value similar to that found in the literature. In these patients, an optimal cut-off point of PSA density of 0.11 was obtained, with a sensitivity and specificity of 67% and an AUC of 0.68. A PSA density of 0.11 has an OR of 4.1, with a 4-fold probability of finding prostate cancer above this value (95% CI 1.3-9.8), which It is statistically significant with a p equal to 0.01. Conclusion: DAPE over 0.11 ng/ml/cc can be considered as an additional tool to indicate biopsy in patients with RMmp PI-RADS 3, increasing the accuracy for the detection of clinically significant prostate cancer helping to reduce unnecessary histological studies.

Mortalidade em homens com câncer de próstata e sua associação com variáveis sociodemográficas e clínicas / Mortality among men bearing prostate cancer and its association with sociodemographic and clinical variables / Mortalidad en hombres con cáncer de próstata y su asociación con variables sociodemográficas y clínicas

Objective: The study's purpose has been to evaluate the association of socio-demographic and clinical variables with the general and specific mortality from prostate cancer. Methods: This is a retrospective study that was carried out through the analyses of medical records from 1,290 men diagnosed with prostate cancer over the period from 2000 to 2006. Results: Considering the 1,290 men, 758 were alive, 308 had died from prostate cancer, and 224 had died from other causes. Those that were associated with death from prostate cancer include: Gleason score > 9, Prostate Specific Antigen (PSA) > 20 and the presence of metastasis. Furthermore, there were those associated with death due to other causes, as follows: widowers, admission to the hospital without diagnosis and without treatment, and also PSA > 50. Conclusion: Clinical variables predominated with regards to prostate cancer-specific mortality. On the other hand, socio-demographic variables prevailed towards deaths originated from other causes

Objetivo: Avaliar a associação de variáveis sociodemográficas e clínicas com a mortalidade geral e específica por câncer de próstata. Método: Estudo retrospectivo de 1290 homens diagnosticados com câncer de próstata entre 2000 e 2006. Consultou-se prontuários, Sistema de Registro Hospitalar e Sistema de Informações sobre Mortalidade. Resultados: Dos 1290 homens, 758 estavam vivos, 308 morreram por câncer de próstata e 224 por outras causas. Associaram-se ao óbito por câncer de próstata: escore de Gleason > 9, PSA > 20 (entre 2,82 e 5,55 vezes) e presença de metástase. Associaram-se ao óbito por outras causas: estado civil viúvo, ingresso no hospital sem diagnóstico e sem tratamento e PSA > 50. Conclusão: Variáveis clínicas predominaram sobre a mortalidade específica por câncer de próstata, já variáveis sociodemográficas em óbitos por outras causas

Objetivo: Evaluar la asociación de las variables sociodemográficas y clínicas con la mortalidad general y específica por cáncer de próstata. Métodos:Estudio retrospectivo de 1.290 hombres con cáncer de próstata en el período del 1 de enero de 2000 al 31 de diciembre de 2006. Resultados: De los 1.290 hombres, 758 estaban vivos, 308 murieron por cáncer de próstata y 224 por otras causas. Se asociaron con la muerte por cáncer de próstata: Gleason puntuación >9, PSA>20 (entre 2,82 y 5,55 veces) y metástasis. Ellos se asociaron con muerte por otras causas: el estado civil viuda, la admisión al hospital diagnosticar y sin tratar y el PSA>50. Conclusión: Las variables clínicas predominaron sobre la mortalidad específica por cáncer de próstata, ya variables sociodemográficas en muertes por otras causas

Clinical and pathologic factors predicting reclassification in active surveillance cohorts

ABSTRACT The incidence of small, lower risk well-differentiated prostate cancer is increasing and almost half of the patients with this diagnosis are candidates for initial conservative management in an attempt to avoid overtreatment and morbidity associated with surgery or radiation. A proportion of patients labeled as low risk, candidates for Active Surveillance (AS), harbor aggressive disease and would benefit from definitive treatment. The focus of this review is to identify clinicopathologic features that may help identify these less optimal AS candidates. A systematic Medline/PubMed Review was performed in January 2017 according to PRISMA guidelines; 83 articles were selected for full text review according to their relevance and after applying limits described. For patients meeting AS criteria including Gleason Score 6, several factors can assist in predicting those patients that are at higher risk for reclassification including higher PSA density, bilateral cancer, African American race, small prostate volume and low testosterone. Nomograms combining these features improve risk stratification. Clinical and pathologic features provide a significant amount of information for risk stratification (>70%) for patients considering active surveillance. Higher risk patient subgroups can benefit from further evaluation or consideration of treatment. Recommendations will continue to evolve as data from longer term AS cohorts matures.

Escala patológica de Gleason para el cáncer de próstata y sus modificaciones / Pathological scale of Gleason for prostate cancer and its modifications

Resumen:El sistema de puntuación o escala de Gleason es una herramienta ampliamente utilizada en la actualidad debido a su adecuada orientación pronóstica y de tratamiento en la evaluación del adenocarcinoma prostático. Dicha escala ha sufrido diversas modificaciones desde sus inicios en los años sesenta así como en los últimos años, las cuales buscan facilitar y homogenizar los criterios patológicos de cada una de sus categorías.

Summary:The Gleason scoring system is a tool widely used today due to its adequate prognostic and treatment orientation in the evaluation of prostatic adenocarcinoma. This scale has suffered several modifications since its beginnings in the sixties as well as in recent years, which seek to facilitate and homogenize the pathological criteria of each of its categories.

What is new in Genitourinary Pathology? Recent developments and highlights of the new 2016 World Health Organization classification of tumors of the urinary system and male genital organs

The recently published 2016 World Health Organization (WHO) Classification of Tumors of the Urinary System and Male Genital Organs stems from the accumulated knowledge and data collected during the last 12 years, since the previous edition of the WHO "blue book" 2004. The major changes in prostate pathology include the introduction of a novel grading system for prostate cancer (Grade Groups/International Society of Urological Pathology (ISUP) grades 1­5), the recognition of intraductal carcinoma as a new entity, and the terminological changes regarding the neuroendocrine prostatic neoplasms. In bladder and urothelial tract, within the spectrum of flat and non-invasive lesions, a newly introduced term "urothelial proliferation of uncertain malignant potential" replaced the term "urothelial hyperplasia", and the term "urothelial dysplasia" was better defined. A category of "invasive urothelial carcinoma with divergent differentiation" was introduced for tumors showing a component of "usual type" urothelial carcinoma combined with other morphologies. A new WHO/ISUP renal tumor grading system was recommended (Grade 1­4). The definition of renal papillary adenoma was modified and expanded to include papillary neoplasms measuring up to 1.5 cm. Several new epithelial renal tumors were recognized as new entities including: hereditary leiomyomatosis and renal cell carcinoma (RCC) syndrome­associated RCC, succinate dehydrogenase­deficient RCC, tubulocystic RCC, acquired cystic disease­associated RCC, and clear cell papillary RCC. In testis pathology, intratubular proliferations of testicular germ cell tumors were renamed as "germ cell neoplasia in-situ" (GCNIS), and the testicular neoplasms were divided into two main groups: derived from or unrelated to GCNIS. A major change in penile pathology was the introduction of a new classification of penile squamous cell carcinoma, based on the presence of human papillomavirus (HPV), which characterizes penile tumor subtypes as HPV-related or non-HPV-related. A similar distinction was introduced for the preneoplastic penile intraepithelial precursor lesion (PeIN) into non-HPV related (differentiated PeIN) and HPV-related types (undifferentiated PeIN). In this review, we provide a summary and highlight the changes in the genitourinary pathology introduced by the 2016 WHO blue book, and we also discuss some recent developments that may impact the practice of genitourinary pathology in the near future (AU)

Adverse reactions to docetaxel: an active survey

The rates of breast cancer mortality remain high in Brazil. Docetaxel is a semi-synthetic taxane used to treat various tumors, particularly tumors of the breast, lung and prostate. In this study ADR that occurred in 45 docetaxel users with breast cancer were surveyed. They were identified by type, causality (Naranjo algorithm and World Health Organization categories) and, if considered probable or defined, rated for severity according to SOBRAFO proposal (2007). A total of 325 ADR were observed: 165 in the first, 137 in the second and 23 in the third cycle. Fifty seven ADR were immediate and the others, late. Fatigue and exhaustion for more than five days, classified as Grade 3 by SOBRAFO (2007), were reported as the primary late RAM. There was no significant difference in the occurrence of immediate and late ADR between cycles (p=1 and p=0.3577, respectively). The presence of a pharmacist gave the patients a better understanding of the occurrence of RAM, especially those that occur outside the hospital, between chemotherapy cycles and are often not reported to the healthcare team, creating institutional demands and reaching the goal to track, observe and correlate the RAM for each user.

As taxas de mortalidade por câncer de mama no Brasil permanecem altas. O docetaxel é um taxano semi-sintético usado para tratar vários tumores, particularmente tumores da mama, pulmão e próstata. Neste estudo, as Reações Adversas (RAM) ocorridas em 45 pacientes com câncer de mama foram monitoradas. Elas foram classificadas pelo tipo e causalidade (Algoritmo de Naranjo e categorias propostas pela Organização Mundial da Saúde) e, se consideradas prováveis ou definidas, foram classificadas também pela severidade, de acordo com a proposta da SOBRAFO (2007). Um total de 325 RAM foram observadas: 165 no primeiro, 137 no segundo e 23 no terceiro ciclo. Cinquenta e sete RAM foram imediatas e as demais tardias. Fadiga e exaustão por mais de 5 dias, classificadas como grau 3 pela SOBRAFO (2007), foram as principais RAM encontradas. Não houve diferença significativa na ocorrência de RAM imediatas ou tardias entre os ciclos (p=1 e p=0,3577, respectivamente). A presença de um farmacêutico proporcionou aos pacientes um melhor entendimento sobre a ocorrência de RAM, especialmente sobre aquelas que ocorrem fora do ambiente hospitalar, entre os ciclos da terapia, não sendo usualmente relatadas aos profissionais de saúde. Isto gerou uma demanda na instituição e permitiu alcançar a meta de acompanhar, observar e correlacionar as RAM de cada paciente.

Genetic classifiers for prostate cancer: A new era on the horizon?

No abstract available.

Gleason score and laterality concordance between prostate biopsy and prostatectomy specimens

Objectives: Prostate biopsy involvement and Gleason score guide treatment decisions in prostate cancer. We evaluated concordance in Gleason score and laterality between biopsy and radical retropubic prostatectomy (RRP) specimens and factors that influenced this relationship. Material and Methods: We reviewed 538 prostate cancer diagnoses at a Veterans Affairs medical center (2000-2005) to identify men with prostate biopsy and RRP specimens. During this time there was a move from limited (6 core) to extended (12 core) biopsy schemes. Discordance in Gleason score was defined as any change in Gleason score. Results: 152 men underwent RRP with biopsy showing Gleason < 7 in 56 percent, 7 in 36 percent, and > 7 in 8 percent. Biopsy involvement was unilateral in 59 percent and bilateral in 41 percent. Compared to the biopsy, RRP Gleason score was concordant in 76 (50 percent), higher in 51 (34 percent), and lower in 25 (16 percent). Bilateral involvement was concordant in 97 percent, while unilateral involvement was concordant in only 20 percent. Both Gleason score and laterality were concordant in only 26 percent. Gleason concordance was higher in those with 8 or more cores compared to < 8 cores taken (54 percent vs. 34 percent, p = 0.046), but concordance was not affected by age, PSA, prostate volume, or length of time from biopsy to RRP. During later years, concordance did not improve despite taking more cores. Conclusions: Prostate biopsy underestimated prostatectomy Gleason score in 34 percent of men and bilateral involvement in 80 percent of those with unilateral disease on biopsy. Taking at least eight cores improves the accuracy of the prostate biopsy.

Classification of Focal Prostatic Lesions on Transrectal Ultrasound (TRUS) and the Accuracy of TRUS to Diagnose Prostate Cancer

OBJECTIVE: To improve the diagnostic efficacy of transrectal ultrasound (TRUS)-guided targeted prostatic biopsies, we have suggested the use of a new scoring system for the prediction of malignancies regarding the characteristics of focal suspicious lesions as depicted on TRUS. MATERIALS AND METHODS: A total of 350 consecutive patients with or without prostate cancer who underwent targeted biopsies for 358 lesions were included in the study. The data obtained from participants were randomized into two groups; the training set (n = 240) and the test set (n = 118). The characteristics of focal suspicious lesions were evaluated for the training set and the correlation between TRUS findings and the presence of a malignancy was analyzed. Multiple logistic regression analysis was used to identify variables capable of predicting prostatic cancer. A scoring system that used a 5-point scale for better malignancy prediction was determined from the training set. Positive predictive values for malignancy prediction and the diagnostic accuracy of the scored components with the use of receiver operating characteristic curve analysis were evaluated by test set analyses. RESULTS: Subsequent multiple logistic regression analysis determined that shape, margin irregularity, and vascularity were factors significantly and independently associated with the presence of a malignancy. Based on the use of the scoring system for malignancy prediction derived from the significant TRUS findings and the interactions of characteristics, a positive predictive value of 80% was achieved for a score of 4 when applied to the test set. The area under the receiver operating characteristic curve (AUC) for the overall lesion score was 0.81. CONCLUSION: We have demonstrated that a scoring system for malignancy prediction developed for the characteristics of focal suspicious lesions as depicted on TRUS can help predict the outcome of TRUS-guided biopsies.

Interobserver agreement of gleason score and modified gleason score in needle biopsy and in surgical specimen of prostate cancer

INTRODUCTION: Gleason score, which has a high interobserver variability, is used to classify prostate cancer. The most recent consensus valued the tertiary Gleason pattern and recommended its use in the final score of needle biopsies (modified Gleason score). This pattern is considered to be of high prognostic value in surgical specimens. This study emphasized the evaluation of the modified score agreement in needle biopsies and in surgical specimen, as well as the interobserver variability of this score MATERIALS AND METHODS: Three pathologists evaluated the slides of needle biopsies and surgical specimens of 110 patients, reporting primary, secondary and tertiary Gleason patterns and after that, traditional and modified Gleason scores were calculated. Kappa test (K) assessed the interobserver agreement and the agreement between the traditional and modified scores of the biopsy and of the surgical specimen RESULTS: Interobserver agreement in the biopsy was K = 0.36 and K = 0.35, and in the surgical specimen it was K = 0.46 and K = 0.36, for the traditional and modified scores, respectively. The tertiary Gleason grade was found in 8 percent, 0 percent and 2 percent of the biopsies and in 8 percent, 0 percent and 13 percent of the surgical specimens, according to observers 1, 2 and 3, respectively. When evaluating the agreement of the traditional and modified Gleason scores in needle biopsy with both scores of the surgical specimen, a similar agreement was found through Kappa CONCLUSION: Contrary to what was expected, the modified Gleason score was not superior in the agreement between the biopsy score and the specimen, or in interobserver reproducibility, in this study.

Measurement of plasma levels of vascular endothelial growth factor in prostate cancer patients: relationship with clinical stage, Gleason score, prostate volume, and serum prostate-specific antigen

PURPOSE: This study focused on circulating levels of vascular endothelial growth factor in patients with prostate cancer compared to a normal population. METHODS: We analyzed 26 normal individuals and 80 patients with prostate cancer. Blood was drawn from all subjects, and plasma was extracted to determine the concentration of vascular endothelial growth factor using a quantitative immunoassay technique (ELISA-enzyme-linked immunosorbent assay). RESULTS: The median plasma level of vascular endothelial growth factor was significantly elevated in patients with metastatic disease compared to patients with localized disease and with healthy controls. Patients with serum prostate-specific antigen > 20 ng/mL had significantly higher levels of plasma vascular endothelial growth factor than patients with serum prostate-specific antigen < 20 ng/mL. There was a trend for patients with a Gleason score of 8 to 10 to have higher levels of plasma vascular endothelial growth factor when compared to patients with lower Gleason scores. No relationship was found between plasma vascular endothelial growth factor and clinical staging, or between plasma vascular endothelial growth factor and prostate volume, in patients with localized prostate cancer. CONCLUSION: This study indicates that patients with metastatic prostate cancer have higher plasma vascular endothelial growth factor levels than patients with localized disease or in healthy controls.

OBJETIVO: Analisar os níveis circulantes do fator de crescimento do endotélio vascular em pacientes com câncer prostático comparados com uma população de indivíduos eutróficos. MÉTODOS: Vinte e seis indivíduos eutróficos e oitenta pacientes com câncer de próstata foram analisados nesse estudo. A coleta sangüínea foi realizada da mesma maneira em todos os pacientes e o plasma foi extraído para a determinação dos níveis do fator de crescimento do endotélio vascular, utilizando-se o método quantitativo ELISA (enzyme-linked immunosorbent assay). RESULTADOS: Os níveis de fator de crescimento do endotélio vascular plasmático encontraram-se significativamente elevados nos pacientes com doença metastática quando comparados com pacientes com doença localizada e com indivíduos sadios. Pacientes com PSA sérico maior que 20 ng/ml apresentaram níveis maiores de fator de crescimento do endotélio vascular plasmático quando comparados com pacientes com PSA menor que 20 ng/ml. Houve uma tendência dos pacientes com escore de Gleason de 8 a 10 apresentarem níveis maiores do fator de crescimento do endotélio vascular plasmático em relação a pacientes com escores de Gleason menores que 8. Não houve relação entre fator de crescimento do endotélio vascular plasmático e estado clínico, ou entre fator de crescimento do endotélio vascular e volume prostático em pacientes com câncer de próstata localizado. CONCLUSÃO: Os dados indicam que pacientes com câncer de próstata metastático apresentam níveis significativamente mais elevados de fator de crescimento do endotélio vascular plasmático quando comparados com pacientes com câncer localizado e com indivíduos normais.

Grading prostatic malignancy on cytologic smears. A feasible proposition

Gleason's tumour grade has been accepted as a benchmark protocol in qualifying prostate cancer on histology. Since cyto-evaluation of suspected prostatic malignancy is being increasingly accepted, we have attempted a correlation between cytologic smear pattern categories and Gleason's grade, accorded on cytologic and histologic material and obtained from the same patient, simultaneously in 60 patients. The cytologic smears were classified as 1 well differentiated, corresponding to combined Gleason score 2-4, II moderately differentiated, Gleason 5-7, and III poorly differentiated, corresponding to Gleason 8-10. An overall concordance of 89% was observed between grading on cytologic and histologic material. The incidence of metastases and progression of clinical stage were also found to be clearly influenced by the cytologically accorded grade

Complicaciones de la prostatectomía radical retropúbica: nuestra experiencia en 62 pacientes / Complications of radical retropubic prostatectomy: our experience with 62 patients

El propósito de este trabajo es evaluar los resultados de la prostatetectomía radical por vía retropúbica como tratamiento electivo de pacientes con adenocarcinoma de próstata clínicamente localizado. Material y métodos: Se examinaron 62 prostatectomías radicales realizadas entre febrero de 1989 y marzo de 1998. Resultados: De los 62 pacientes operados, 2 fallecidos (3,33 por ciento).1 dentro de las 48 horas y el otro a los 45 días. La unica complicación intraoperatoria fue la hemorragia, que ascendió al 16,66 por ciento . Se observaron complicaciones postoperatoria tempranas en el 11,66 por ciento de los pacientes (angina de pecho 3,33 por ciento, infarto agudo de miocardio 1,66 por ciento, linfocele pelviano 3,33 por ciento, anemia aguda 1,66 por ciento y tromboembolismo pulmonar 1,66 por ciento). Las complicaciones tardías afectaron al 93,33 por ciento de los pacientes. De éstas, las más importantes fueron impotencia (66,66 por ciento) e incontinencia (20 por ciento más allá de los 6 meses de la intervención: 3,33 por ciento tenía incontinencia total, 3,33 por ciento incontinencia severa y 13,33 incontinencia leve); se observó asimismo estrechez uretral (3,33 por ciento), estenosis de la anastomosis uretrovesical (1,66 por ciento) y litiasis de la anastomosis uretrovesical (1,66 por ciento). Conclusiones: La prostatectomía radical implica una baja mortalidad y resultados aceptables en lo quie resdpecta a la calidad de vida en pacientes seleccionados con adenocarcinoma de próstata localizado y expectativa de vida mayor de 10 años. La incontinencia y la impotencia son las principales complicaciones derivadas de esta intervención

Neoplasia intraepitelial prostatica: interpretación diagnóstica / Prostatic intraepithelial neoplasia: dianostic interpretation

De las lesiones conocidad como premalignas la neoplasia intraepitelial prostática (PIN), es la que adquiere mayor relevancia, debido a su estrecha asociación con el cáncer invasor de proóstata. Su incidencia en hombres menores de 60 años ha sido probada y justifica las punciones repetidas en aquellos pacientes que la presenten. En este trabajo se realiza un análisis de 937 biopsias de próstata, y se correlaciona el hallazgo de PIN en sus diferentes grados con el comportamiento del antígeno prostático específico (PSA), la edad del paciente y la existencia de cáncer de próstata