Prostate Cancer: Diagnosis and evaluation: Difference between revisions
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*#***#*#'''<span style="color:#ff0000">Melanoma</span>''' | *#***#*#'''<span style="color:#ff0000">Melanoma</span>''' | ||
*#***#*'''<span style="color:#ff0000">Lynch syndrome</span>''' | *#***#*'''<span style="color:#ff0000">Lynch syndrome</span>''' | ||
*#***#**'''<span style="color:#ff0000">Associated cancers ( | *#***#**'''<span style="color:#ff0000">Associated cancers (11)</span>[https://www.ncbi.nlm.nih.gov/books/NBK431096/]''' | ||
*#***#**#'''<span style="color:#ff0000">Colorectal</span>''' | *#***#**#'''<span style="color:#ff0000">Colorectal (20-80%) (most common)</span>''' | ||
*#***#**#'''<span style="color:#ff0000"> | *#***#**#'''<span style="color:#ff0000">Gynecologic</span>''' | ||
*#***#**#'''<span style="color:#ff0000">Ovarian</span>''' | *#***#**## '''<span style="color:#ff0000">Endometrial (15-60%) in females (second most common)</span>''' | ||
*#***#**#'''<span style="color:#ff0000"> | *#***#**##'''<span style="color:#ff0000">Ovarian cancer (1-38%) in females</span>''' | ||
*#***#**#'''<span style="color:#ff0000"> | *#***#**#'''<span style="color:#ff0000">Urologic</span>''' | ||
*#***#**#'''<span style="color:#ff0000"> | *#***#**##'''<span style="color:#ff0000">Urothelial (1-18%), includes upper urinary tract and bladder</span>''' | ||
*#***#**# '''<span style="color:#ff0000"> | *#***#**##'''<span style="color:#ff0000">Prostate</span>''' | ||
*#***#**#'''<span style="color:#ff0000"> | *#***#**##'''<span style="color:#ff0000">Adrenal[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3739861/ §]</span>''' | ||
*#***#**#'''<span style="color:#ff0000">Sebaceous | *#***#**#'''<span style="color:#ff0000">Other gastrointestinal</span>''' | ||
*#***#**#'''<span style="color:#ff0000"> | *#***#**##'''<span style="color:#ff0000">Gastric cancers (1-13%)</span>''' | ||
*#***#**##'''<span style="color:#ff0000">Hepatobiliary</span>''' | |||
*#***#**##'''<span style="color:#ff0000">Small bowel</span>''' | |||
*#***#**#'''<span style="color:#ff0000">Skin</span>''' | |||
*#***#**#*'''<span style="color:#ff0000">Sebaceous adenoma, sebaceous epithelioma, sebaceous adenocarcinoma, keratoacanthoma, and squamous cell carcinoma[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3423888/]</span>''' | |||
*#***#**# '''<span style="color:#ff0000">Brain</span>''' | |||
*#***#**#'''<span style="color:#ff0000">Inconsistent: Pancreas, breast, (prostate)</span>''' | |||
*#**'''<span style="color:#ff0000">Patients with a "strong" family history should ideally be genotyped</span>[https://pubmed.ncbi.nlm.nih.gov/37096582/]''' | *#**'''<span style="color:#ff0000">Patients with a "strong" family history should ideally be genotyped</span>[https://pubmed.ncbi.nlm.nih.gov/37096582/]''' | ||
*#***'''Genotype is to ascertain whether there is presence of a pathogenic variant (e.g., BRCA1/2, Lynch Syndrome, ATM, CHEK2) or one or more of a growing set of identified germline DNA damage-repair mutations found in patients with metastatic prostate cancer diagnoses.''' | *#***'''Genotype is to ascertain whether there is presence of a pathogenic variant (e.g., BRCA1/2, Lynch Syndrome, ATM, CHEK2) or one or more of a growing set of identified germline DNA damage-repair mutations found in patients with metastatic prostate cancer diagnoses.''' | ||
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**Authors' interpretation: Among patients with MRI-visible lesions, combined biopsy led to more detection of all prostate cancers. However, MRI-targeted biopsy alone underestimated the histologic grade of some tumors. After radical prostatectomy, upgrades to grade group 3 or higher on histopathological analysis were substantially lower after combined biopsy. | **Authors' interpretation: Among patients with MRI-visible lesions, combined biopsy led to more detection of all prostate cancers. However, MRI-targeted biopsy alone underestimated the histologic grade of some tumors. After radical prostatectomy, upgrades to grade group 3 or higher on histopathological analysis were substantially lower after combined biopsy. | ||
**[https://pubmed.ncbi.nlm.nih.gov/32130814/ Ahdoot, Michael, et al.] "MRI-targeted, systematic, and combined biopsy for prostate cancer diagnosis." ''New England Journal of Medicine'' 382.10 (2020): 917-928. | **[https://pubmed.ncbi.nlm.nih.gov/32130814/ Ahdoot, Michael, et al.] "MRI-targeted, systematic, and combined biopsy for prostate cancer diagnosis." ''New England Journal of Medicine'' 382.10 (2020): 917-928. | ||
*'''<span style="color:#ff00ff">GOTEBORG-2 (2022)</span>''' | *'''<span style="color:#ff00ff">GOTEBORG-2 (2022/2024)</span>''' | ||
**Objective: Determine whether targeted-biopsy only (and avoid systematic) is adequate in patients with elevated PSA and prostate MRI | **Objective: Determine whether targeted-biopsy only (and avoid systematic) is adequate in patients with elevated PSA (3-10 ng/ml) and prostate MRI | ||
**Population: Swedish males aged 50-60 living in Gothenburg, Sweden, without previous diagnosis of prostate cancer | **Population: Swedish males aged 50-60 living in Gothenburg, Sweden, without previous diagnosis of prostate cancer | ||
**Randomized to invited screening with PSA test vs. no invitation | **Randomized to invited screening with PSA test vs. no invitation | ||
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***Secondary outcome: detection of clinically significant prostate cancer, defined as a Gleason score of 3+4 or higher | ***Secondary outcome: detection of clinically significant prostate cancer, defined as a Gleason score of 3+4 or higher | ||
**Results: | **Results: | ||
*** | ***19,733 (52%) of those randomized to invitation to screening underwent PSA testing | ||
****7% had PSA > 3 ng/mL | ****1371 (7%) had PSA > 3 ng/mL | ||
*****95% of patients with PSA > 3 ng/mL underwent MRI | *****95% of patients with PSA > 3 ng/mL underwent MRI | ||
*** | ***Risk of clinically insignificant prostate cancer at screening or at interval: significantly more common in patients undergoing systematic +/- targeted biopsy compared to targeted biopsy only (2.4% vs. 1.0%) | ||
*** | ***Risk of clinically significant prostate cancer at screening or at interval: no significant difference (2.1% systematic +/- targeted vs. 1.8% targeted biopsy only) | ||
***10 patients in reference group found to have clinically significant prostate cancer on systematic only | ***(2022 publication) 10 patients in reference group found to have clinically significant prostate cancer on systematic only | ||
****9 with negative MRI, 1 with false-positive MRI | ****9 with negative MRI, 1 with false-positive MRI | ||
*****All GG2, GG4 <5% in 6 patients | *****All GG2, GG4 <5% in 6 patients | ||
******6 managed with AS | ******6 managed with AS | ||
***128 patients in experimental group with PSA <10 diagnosed with cancer by targeted biopsy only | ***(2022 publication) 128 patients in experimental group with PSA <10 diagnosed with cancer by targeted biopsy only | ||
****72/128 (56%) had GG1 | ****72/128 (56%) had GG1 | ||
*****86% underwent systematic biopsy | *****86% underwent systematic biopsy | ||
*****26% upgraded (all GG2 except 1 to 3+5) | *****26% upgraded (all GG2 except 1 to 3+5) | ||
****Gleason 3+3 lesions that had been detected by systematic biopsy differed only in tumor extension from those that had been detected by targeted biopsy of suspicious lesions shown on MRI, with greater volume measured in tumors that were visible on MRI | ****Gleason 3+3 lesions that had been detected by systematic biopsy differed only in tumor extension from those that had been detected by targeted biopsy of suspicious lesions shown on MRI, with greater volume measured in tumors that were visible on MRI | ||
**Author's interpretation: | **Author's interpretation: omitting prostate biopsy in men with negative MRI results, and thereby delaying a potential cancer diagnosis, was associated with a substantial reduction in the detection of clinically insignificant cancer and a very low risk of detecting incurable cancers at repeat screening rounds or as interval cancers. | ||
**[https://pubmed.ncbi.nlm.nih.gov/39321360/ Hugosson, Jonas, et al.] "Results after Four Years of Screening for Prostate Cancer with PSA and MRI." ''New England Journal of Medicine'' 391.12 (2024): 1083-1095. | |||
**[https://pubmed.ncbi.nlm.nih.gov/36477032/ Hugosson, Jonas, et al.] "Prostate cancer screening with PSA and MRI followed by targeted biopsy only." ''New England Journal of Medicine'' 387.23 (2022): 2126-2137. | **[https://pubmed.ncbi.nlm.nih.gov/36477032/ Hugosson, Jonas, et al.] "Prostate cancer screening with PSA and MRI followed by targeted biopsy only." ''New England Journal of Medicine'' 387.23 (2022): 2126-2137. | ||
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====== Prostate cancer PET radiopharmaceutical tracers ====== | ====== Prostate cancer PET radiopharmaceutical tracers ====== | ||
* '''Not PSMA-specific radiopharmaceutical tracers''' | * '''<span style="color:#ff0000">Not PSMA-specific radiopharmaceutical tracers''' | ||
** Examples include 18F-fluciclovine (trade name Axumin), 18F-fluorodeoxyglucose (FDG), and 11C-choline | ** Examples include '''<span style="color:#ff0000">18F-fluciclovine (trade name Axumin)</span>''', 18F-fluorodeoxyglucose (FDG), and 11C-choline | ||
*** 18F-fluciclovine FDA approved in 2016 | *** 18F-fluciclovine FDA approved in 2016 | ||
** '''Replaced by PSMA-specific tracers''' | ** '''Replaced by PSMA-specific tracers''' | ||
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****** Castrate-resistance | ****** Castrate-resistance | ||
** '''<span style="color:#ff0000">PSMA-specific radiopharmaceutical tracers used in prostate cancer (2):</span>''' | ** '''<span style="color:#ff0000">PSMA-specific radiopharmaceutical tracers used in prostate cancer (2):</span>''' | ||
***'''<span style="color:#ff0000">Fluorine-18 (18F)-labeled PSMA-specific</span>''' (18F-DCFPyL (trade name '''Pylarify'''), 18F-PSMA-1007) | ***'''<span style="color:#ff0000">Fluorine-18 (18F)-labeled PSMA-specific</span>''' (18F-DCFPyL ('''piflufolastat''' F 18) (trade name '''<span style="color:#ff0000">Pylarify</span>'''), 18F-PSMA-1007) | ||
****'''Most commonly used radiotracer in the US and''' (18F-DCFPyL) '''Canada''' | ****'''Most commonly used radiotracer in the US and''' (18F-DCFPyL) '''Canada''' | ||
****18F-DCFPyL adverse reactions: headache, altered taste, fatigue[https://www.fda.gov/drugs/drug-safety-and-availability/fda-approves-second-psma-targeted-pet-imaging-drug-men-prostate-cancer] | ****18F-DCFPyL adverse reactions: headache, altered taste, fatigue[https://www.fda.gov/drugs/drug-safety-and-availability/fda-approves-second-psma-targeted-pet-imaging-drug-men-prostate-cancer] | ||
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===== Indications ===== | ===== Indications ===== | ||
====== AUA ====== | |||
* '''[https://pubmed.ncbi.nlm.nih.gov/35536144/ 2022 AUA Guidelines on Clinically Localized Prostate Cancer]''' | * '''[https://pubmed.ncbi.nlm.nih.gov/35536144/ 2022 AUA Guidelines on Clinically Localized Prostate Cancer]''' | ||
** '''<span style="color:#ff0000">Recommended (5):''' | ** '''<span style="color:#ff0000">Recommended (5):''' | ||
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**# '''<span style="color:#ff0000">Adverse tumor characteristics''' | **# '''<span style="color:#ff0000">Adverse tumor characteristics''' | ||
**#* '''Examples: High-risk disease; intermediate-risk disease with intraductal or cribriform morphology''' | **#* '''Examples: High-risk disease; intermediate-risk disease with intraductal or cribriform morphology''' | ||
====== NCCN ====== | |||
*'''NCCN (version 2.2021)''' | *'''NCCN (version 2.2021)''' | ||
** '''<span style="color:#ff0000">Recommended (5):''' | ** '''<span style="color:#ff0000">Recommended (5):''' | ||