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PurposeTo test discontinuation rates during Active Surveillance (AS) in patients diagnosed with incidental prostate cancers (IPCa) vs. tumors diagnosed at prostate biopsies (BxPCa).MethodsRetrospective single center analysis of 961 vs. 121 BxPCa vs. IPCa patients (2008–2020). Kaplan–Meier plots and multivariable Cox regression models tested four different outcomes: (1) any-cause discontinuation; (2) discontinuation due to ISUP GG upgrading; (3) biopsy discontinuation due to ISUP GG upgrading or > 3 positive cores; (4) biopsy discontinuation or suspicious extraprostatic extension at surveillance mpMRI. Then, multivariable logistic regression models tested rates of clinically significant PCa (csPCa) (ISUP GG ≥ 3 or pT ≥ 3a or pN1) after radical prostatectomy (RP).ResultsMedian time follow-up was 35 (19–64) months. IPCa patients were at lower risk of any-cause (3-year survival: 79.3 vs. 66%; HR: 0.5, p = 0.001) and biopsy/MRI AS discontinuation (3-year survival: 82.3 vs. 72.7%; HR: 0.5, p = 0.001), compared to BxPCa patients. Conversely, IPCa patients exhibited same rates of biopsy discontinuation and ISUP GG upgrading over time, relative to BxPCa. In multivariable logistic regression models, IPCa patients were associated with higher rates of csPCa at RP (OR: 1.4, p = 0.03), relative to their BxPCa counterparts.ConclusionAS represents a safe management strategy for IPCa. Compared to BxPCa, IPCa patients are less prone to experience any-cause and biopsy/MRI AS discontinuation. However, the two mentioned groups present similar rates of biopsy discontinuation and ISUP GG upgrading over time. In consequence, tailored AS protocols with scheduled repeated surveillance biopsies should be offered to all newly diagnosed IPCa patients.

This report presents our experience with T therapy in a cohort of T-deficient men on active surveillance （AS） for Gleason 3 ＋ 3 and Gleason 3 ＋ 4 prostate cancer （PCa）. A retrospective chart review identified 28 men with T deficiency who underwent T therapy （T group） for at least 6 months while on AS for PCa. A comparison group of 96 men on AS for PCa with untreated T deficiency （no-T group） was identified at the same institution. The AS protocol followed a modified Epstein criteria and allowed inclusion of men with a single core of low-volume Gleason 3 ＋ 4 PCa. Mean age was 59.5 and 61.3 years, and mean follow-up was 38.9 and 42.4 months for the T and no-T groups, respectively. Of all 28 men in the T group, 3 （10.7%） men developed an increase in Gleason score while on AS. Of 22 men in the T group with Gleason 3 ＋ 3 disease, 7 （31.8%） men developed biopsy progression including 3 men （13.6%） who developed Gleason 3 ＋ 4 PCa. Of 6 men with Gleason 3 ＋ 4 disease at baseline, 2 （33.3%） men developed an increase in tumor volume, and none developed upgrading beyond Gleason 3 ＋ 4. All 96 men in the no-T group had Gleason 3 ＋ 3 disease at baseline and, 43 （44.7%） developed biopsy progression, including 9 men （9.38%） with upgrading to Gleason 7 （3 ＋ 4）. Biopsy progression rates were similar for both groups and historical controls. Biopsy progression in men on AS appears unaffected by T therapy over 3 years. Prospective placebo-controlled trials of T therapy in T-deficient men on AS should be considered given the symptomatic benefits experienced by treated men.

To reduce treatment-related side effects in low-risk prostate cancer (PCa), both focal therapy and deferred treatments, including active surveillance (AS) and watchful waiting (WW), are worth considering over radical prostatectomy (RP). Therefore, this study aimed to compare long-term survival outcomes between focal therapy and AS/WW. Data were obtained and analyzed from the Surveillance, Epidemiology, and End Results (SEER) database. Patients with low-risk PCa who received focal therapy or AS/WW from 2010 to 2016 were included. Focal therapy included cryotherapy and laser ablation. Multivariate Cox proportional hazards models were used to compare overall mortality (OM) and cancer-specific mortality (CSM) between AS/WW and focal therapy, and propensity score matching (PSM) was performed to reduce the influence of bias and unmeasured confounders. A total of 19 292 patients with low-risk PCa were included in this study. In multivariate Cox proportional hazards model analysis, the risk of OM was higher in patients receiving focal therapy than those receiving AS/WW (hazard ratio [HR] = 1.35, 95% confidence interval [CI]: 1.02-1.79, P = 0.037), whereas no significant difference was found in CSM (HR = 0.98, 95% CI: 0.23-4.11, P = 0.977). After PSM, the OM and CSM of focal therapy and AS/WW showed no significant differences (HR = 1.26, 95% CI: 0.92-1.74, P = 0.149; and HR = 1.26, 95% CI: 0.24-6.51, P = 0.782, respectively). For patients with low-risk PCa, focal therapy was no match for AS/WW in decreasing OM, suggesting that AS/WW could bring more overall survival benefits.

Purpose To study whether probabilistic selection by the use of a nomogram could improve patient selection for active surveillance (AS) compared to the various sets of rule-based AS inclusion criteria currently used. Methods We studied Dutch and Swedish patients participating in the European Randomized study of Screening for Prostate Cancer (ERSPC). We explored which men who were initially diagnosed with cT1-2, Gleason 6 (Gleason pattern ≤3 + 3) had histopathological indolent PCa at RP [defined as pT2, Gleason pattern ≤3 and tumour volume (TV) ≤0.5 or TV ≤ 1.3 ml, and TV no part of criteria (NoTV)]. Rule-based selection was according to the Prostate cancer Research International: Active Surveillance (PRIAS), Klotz, and Johns Hopkins criteria. An existing nomogram to define probability-based selection for AS was refitted for the TV1.3 and NoTV indolent PCa definitions. Results 619 of 864 men undergoing RP had cT1-2, Gleason 6 disease at diagnosis and were analysed. Median follow-up was 8.9 years. 229 (37 %), 356 (58 %), and 410 (66 %) fulfilled the TV0.5, TV1.3, and NoTV indolent PCa criteria at RP. Discriminating between indolent and significant disease according to area under the curve (AUC) was: TV0.5: 0.658 (PRIAS), 0.523 (Klotz), 0.642 (Hopkins), 0.685 (nomogram). TV1.3: 0.630 (PRIAS), 0.550 (Klotz), 0.615 (Hopkins), 0.646 (nomogram). NoTV: 0.603 (PRIAS), 0.530 (Klotz), 0.589 (Hopkins), 0.608 (nomogram). Conclusions The performance of a nomogram, the Johns Hopkins, and PRIAS rule-based criteria are comparable. Because the nomogram allows individual trade-offs, it could be a good alternative to rigid rule-based criteria.

Objective：The optimal management strategy for prostate cancer （PCa） remains controversial.We performed a systemic review of current progress and controversies regarding the diagnosis and treatment of PCa.Data Sources：We searched PubMed for recently published articles up to July 2017 using the following key words：＂prostate cancer,＂ ＂progress,＂ ＂controversy,＂ ＂immunotherapy,＂ and ＂prevention.＂ Study Selection：Articles were obtained and reviewed to provide a systematic review of the current progress and controversies regarding PCa management.Results：The value of serum prostate-specific antigen （PSA） screening remains controversial,but PSA screening is recommended to facilitate the early diagnosis of PCa in high-risk groups.Prostate biopsy via the transrectal or perineal approach has both advantages and disadvantages.There was a significant correlation between testosterone levels and PCa prognosis.The current research is focused on the mechanisms responsible for PCa.Active surveillance has been proposed as a management strategy for low-risk,localized PCa,but there is an urgent need for further clinical studies to establish the criteria for recommending this approach.The main complications of radical resection for PCa are urinary incontinence and erectile dysfunction,though three-dimensional laparoscopic and robot-assisted laparoscopic techniques have obvious advantages over radical surgery.Radiotherapy is also a therapeutic option for PCa,while immunotherapies may alter the prostate tumor microenvironment.Ongoing studies aim to provide guidance on effective sequential and combination strategies.Prevention remains an important strategy for reducing PCa morbidity and mortality.Conclusions：The diagnosis,treatment,and prevention of PCa are complex issues,worthy of intensive study.Further studies are needed to improve the management of PCa.

Abstract Objectives This study aims to investigate the consequences of comedonecrosis omission as an exclusion criterion of the Comparison of Operative vs Monitoring and Endocrine Therapy (COMET) trial. Methods The clinical inclusion criteria of the COMET trial were applied on women who were mammographically screened between 2007 and 2017 and had a diagnosis of low- or intermediate-grade ductal carcinoma in situ (DCIS). The percentage of ductal diameter occupied by necrosis was calculated. Results Twenty-six of 129 (20.2%) cases were upgraded. Larger calcification span correlated with upgrade (P = .02), with the best cutoff of 1.1 cm, and negative predictive value of 86%. When solely analyzing cases with no comedonecrosis (n = 76), none of the variables correlated with upgrade. Comedonecrosis was significantly correlated with upgrade to invasive carcinoma (P = .041), with the best cutoff of 53% of ductal diameter occupied by necrosis. Conclusions Results indicate that comedonecrosis and span of mammographic calcifications could be risk factors in women managed with active surveillance.

Objective：To review the natural history and growth kinetics of small renal masses （SRMs）.Data Sources：The literature concerning natural history and growth kinetics of SRMs was collected from PubMed published from 1990 to 2014.Study Selection：We included all the relevant articles on the active surveillance （AS） or delayed treatment for SRMs in English,with no limitation of study design.Results：SRMs under AS have a slow growth potential in general.The mean linear growth rate is 0.33 cm/year,the mean volumetric growth rate is 9.48 cm3/year.The rate of metastasis during AS is below 2％.Some factors are associated with the growth rate of SRMs,including tumor grade,histological subtype,initial tumor size,age,radiographic characteristics,and molecular markers.No definite predictor of growth rate of SRMs is defined at present.SRMs with high tumor grade and the subtype of clear cell renal cell carcinoma may have aggressive growth potential.Conclusions：AS is a reasonable choice for elderly patients with SRMs,who are at high risk from surgery.Progression during observation is the biggest concern while performing AS.There is no definite predictor of progression for SRMs under AS.Percutaneous renal biopsy providing immunohistological and genic biomarkers may improve the understanding of natural history of SRMs.

Abstract Context The dramatic rise in the incidence of thyroid cancer over the last 30 years is largely attributable to the increasing diagnosis of papillary microcarcinomas (mPTCs). Current guidelines endorse an observational management approach in properly selected cases. Objective To evaluate the feasibility of active surveillance in mPTC in Italy, its impact on real life, and to identify risk factors of progression. Design and setting In 2014 we started a prospective–observational study of active surveillance in mPTC patients. Patients Included patients demonstrated a single Thy4 or Thy5 thyroid nodule, with largest diameter ≤1.3 cm, and no suspicious laterocervical lymph nodes by neck ultrasonography. Of 185 eligible subjects, 50.3% (93/185) enrolled in the observational management protocol while the others opted for surgery and were excluded from this analysis. Intervention Enrolled patients were followed with neck ultrasound at 6- to 12-month intervals. Disease progression was defined as the appearance of abnormal lymph nodes or nodule enlargement during follow-up. In these cases, patients were directed to surgery. Results Three patients (3/93, 3%) showed clinical progression and required surgery. Another 19 patients (19/93, 20%) decided to transition to surgical intervention even though there was no evidence of disease progression. All operated patients had excellent response to initial treatment despite the delayed surgery. Conclusions Within an Italian medical context, active surveillance appears to be a feasible and safe alternative to immediate surgery in healthy mPTC patients. Only 3% of mPTC demonstrated disease progression during a median follow-up of 19 months (range 6–54) and importantly demonstrated excellent outcomes after surgical intervention in a short-term follow-up.

Background The incidence of thyroid cancer is increasing globally. This is mainly due to the increase in the detection of small papillary carcinomas, including papillary microcarcinomas (PMC) 1 cm or smaller. It was suggested recently that PMCs are overdiagnosed and overtreated. Methods In 1993, the author proposed a clinical trial to compare surgery and observation for low-risk PMC at doctors’ meeting in Kuma Hospital, which was approved and the trial started in the same year. Patients choose immediate surgery or observation. This paper shares our 22-year experience with the active surveillance of more than 2000 patients with low-risk PMC and compares the outcomes of immediate surgery with that of active observation. Results The oncological outcomes of these management groups were similarly excellent. In our active surveillance trial on 1235 patients, 8 % of patients showed tumor enlargement by 3 mm or more at 10 years of observation, and 3.8 % of the patients showed novel appearance of lymph node metastasis at 10 years. Patients 40 years or younger tended to show progression of the disease. Patients with these slight progressions of the disease were successfully treated with a rescue surgery. None of the patients in both study groups died of the disease. However, incidences of unfavorable events, such as temporary vocal cord paralysis (VCP) and temporary and permanent hypoparathyroidism, were significantly higher in the immediate surgery group than in the observation group (4.1 vs. 0.6 %, p  < 0.0001; 16.7 vs. 2.8 %, p  < 0.0001; and 1.6 vs. 0.08 %, p  < 0.0001, respectively). Permanent VCP occurred in two of the surgery group. Conclusions As a result, although we still offer two options, immediate surgery or observation, to patients with low-risk PMC at Kuma Hospital, we now strongly recommend observation as the best choice.

Abstract Context The long-term quality of life (QoL) in patients with low-risk papillary thyroid microcarcinoma (PTMC) underwent active surveillance (AS) and immediate surgery is unclear. Objective The aim of this study was to investigate the effect of initial treatment choice on 2-year QoL in patients with low-risk PTMC Design, Setting, and Participants We analyzed 2652 QoL surveys from 1055 subjects enrolled in ongoing multicenter prospective cohort study on active surveillance of PTMC, in which the median follow-up duration was 24.4 months. Major Outcome Measure We evaluated QoL of patients with low-risk PTMC according to their treatment modality using generalized estimating equation. Results Six hundred and seventy-four subjects (male = 161; mean age = 48.8 ± 11.9 years) with low-risk PTMC chose AS while 381 subjects (male = 75; mean age = 45.7 ± 10.4 years) chose immediate surgery, including lobectomy/isthmusectomy (L/I) and total thyroidectomy (TT). Among the 817 subjects who completed baseline QoL surveys, 2-year QoL was good in order of AS (n = 500), L/I (n = 238), and TT (n = 79) groups after adjustment for age, sex, baseline tumor size, and baseline QoL scores. Among the 101 subjects who changed their treatment from AS to surgery during the follow-up period, 35 subjects who changed treatment due to disease progression had better QoL than 66 subjects who had no disease progression. Conclusions This study identified QoL as a major issue in choosing an initial treatment of low-risk PTMC and highlighted the possibility of using AS as the primary treatment.