PATHOLOGICAL OUTCOMES IN PATIENTS CANDIDABLE FOR ACTIVE
SURVEILLANCE TREATED WITH RADICAL PROSTATECTOMY. ARE THEY REALLY
LOW RISK PATIENTS?
Authors: Elisa
CONTEGGIO CARATTERI: 2634 ok
AIM OF THE STUDY
Over-diagnosis and subsequent over-treatment are potential side effects of early detection
of prostate cancer (PCa). Active surveillance (AS) has evolved as an alternative to radical
treatment of patients affected by low-risk PCa, avoiding surgery-related complications.
Several protocols of AS has been proposed, based on standardized clinical parameters
such as Prostate Cancer Research International Active Survelliance (PRIAS) criteria.
Nevertheless in patients in AS the real pathological stage remains unknown.
The aim of our study is to retrospectively make out the pathological stage in a multicenter
cohort of patients who had undergone radical prostatectomy (RP) meeting the
preoperative PRIAS criteria.
MATERIALS AND METHODS
Out of 1604 patients recruited for minimally invasive RP between December 2009 and
February 2013 in nine Italian urological centers, 144 would have met the PRIAS criteria
(clinical stage T1c/T2, PSA <or= 10 ng/ml, one or two positive biopsy cores and Gleason
score < or =6, PSA density <0.2 ng/ml per milliliter). The pathological features of these low
risk patients have been investigated.
RESULTS
The preoperative patients’ characteristics are shown in table 1.
Of 144 patients included, 89 (61.8%) underwent laparoscopic RP and 55 (38.2%) robotassisted RP.
At pathological evaluation, 47 (32.6%), 11 (7.6%), 1 (0.7%) patients showed RP Gleason
sum =7, =8 and =9, respectively.
Eighty-three (57.6%), 15 (10.4%) and 4 (2.7%) patients had T2c, T3a and T3b pathological
stage respectively. One patient showed lymph node invasion.
Thirty-one patients (20.9%) had positive surgical margins, of these 11 (35.5%) were
multifocal.
The positive surgical margin rate for pT2 and pT3 disease was 16.8% and 52.6%,
respectively.
DISCUSSION
AS is a well established standard approach for low risk localized prostate cancer. However,
probably due to the poor reproducibility of the clinical tools, significant diseases can be
under-diagnosed or missed. Analysing the pathological features on definitive specimens,
some of these low risk patients demonstrated a migration in to intermediate or high risk
groups according to D’Amico classification. Despite the preoperative estimated low risk
of these patients, the rate of positive surgical margins was not negligible, particularly in
pT3 stage.
CONCLUSIONS
Despite some preoperative criteria can define patients affected by PCa as low risk patients,
at the pathological evaluation some of these patients revealed a non organ confined
disease. So, based on our data, in low risk patients the AS represents an option of
treatment that should be carefully considered evaluating age and comorbidities of every
single patient.
Table 1. Preoperative characteristics of patients.
CHARACTERISTICS ( n=144)
Age, yr, median (IQR)
Preoperative PSA level, ng/ml, median (IQR)
Biopsy Gleason score, %
65 (60-69)
5.3 (3.95-6.87)
<6
17.4
=6
Clinical stage, %
82.6
T1c
70.1
T2a
13.2
T2b
11.1
T2c
Positive cores, no. (%)
5.6
1
45.1
2
Number of patients recruited in each centre, median (IQR)*
54.9
28 (22-44)
*Patients who met PRIAS criteria were recruited from 5 urologic centre