Incidental prostate cancer management in patients treated for urinary tract symptoms

Mario Salvatore Mangano1, Claudio Lamon1, Alberto De Gobbi1, Francesco Beniamin1, Giandavide Cova1, Giuseppe Battistella2, Luigino Maccatrozzo1
  • 1 Ospedale Ca' Foncello, S. C. Urologia (Treviso)
  • 2 Ospedale Ca' Foncello, Servizio di Statistica ed Epidemiologia (Treviso)

Objective

Incidental prostate cancer (iPCa) is found in about 5% patients with lower urinary tract symptoms (LUTS). However, to establish how to manage this pathological condition could be an interesting therapeutic hint to emphasize.
The aim is to evaluate clinical features in patients with iPCa underwent surgical or endoscopic treatment. Then we describe therapeutic strategies implemented in our population.

Materials and Methods

We retrospectively analized 1002 consecutive patients affected by lower urinary tract symptoms (LUTS) and without prior diagnosis of prostate cancer underwent surgical (227 prostatic retropubic adenomectomy) or endoscopic (775 trans urethral resection of prostate) treatment between April, 2010 and December, 2015. The pathological stage and the cancer diagnosis of all BPH specimens were reviewed by pathologists who were unaware of the clinical details. When iPCa was found, we collected cTNM stages (T1a or T1b), clinical, pathological and biochemical patients’ data, as well as those regarding treatment, overall survival and disease free survival. We used t-test (p<0.05) and Fisher test for statistical analysis.

Results

In 1002 patients with LUTS we performed 227 prostatic adenomectomy and 775 trans urethral resection of prostate (TURP). In 60 patients (6%) iPCa: was found: in 30 cases it was cT1a and in the other 30 it was cT1b. In these two groups, comparing the characteristics regarding age, prostate volume (determined by transrectal ultrasound), PSA density, weight of prostatic adenoma removed and operative time, did not show statistically significant differences.
PSA was significantly higher in cT1b patients (p=0.03).
4 patients were lost at follow up; in the other 56 patients the mean time of follow up was 45 months.
In 27 patients the clinical iPCa stage was T1a: 20 underwent to Watchful Waiting approach and 7 were treated by Active Surveillance strategy.
Of the 29 patients with cT1b, 15 (51.7%) underwent conservative treatment (Watchful Waiting or Active Surveillance strategies), 4 patients (13.7%) radical prostatectomy, 6 (20.6%) radiotherapy, 4 (13.7%) androgen deprivation, mainly according to comorbities and clinical conditions.
Biochemical failure has occured in 4 patients (7%), of these 2 belonged to cT1a group and 2 to cT1b.
Only one patient died, for other causes.

Discussions

IPCa is still a clinical and pathological condition whose characteristics are not yet fully defined. TNM classification seems to have a role in stratifying patients as for their management. This study has confirmed that the value of PSA is the only statistically significant variable, like in the two groups of patients examined. The therapeutic strategies regarding the two groups of patients (cT1a and cT1b) were different: conservative in cT1a group, or conservative vs. curative in T1b group, depending on the stratification of clinical and pathological characteristics of patients. A longer follow-up could give us more informations about “oncological end-points” and in particular concerning disease free survival and overall survival.

Conclusion

The population of Italy is aging, and thus interest in prostate cancer is increasing. It is becoming increasingly important to establish appropriate treatment plans (including the choice of no treatment) that address factors related to patient quality of life, patient age, life expectancy, performance status, availability of medical care, and patient education. In addition to clinical stage (T1a vs. T1b), PSA value before and after disostructive approach represents the most informative variable for use in clinical decisions. In our experience Watchful Waiting and Active Surveillance strategies represent the choice in cT1a iPCa, while cT1b iPCa deserves to be treated or strictly followed-up.

References

1. Capitanio U. Contemporary management of patients with T1a and T1b prostate cancer. Curr Opin Urol. 2011 May;21(3):252-6.
2. Jones JS, Follis HW, Johnson JR. Probability of finding T1a and T1b (incidental) prostate cancer during TURP has decreased in the PSA era. Prostate Cancer Prostatic Dis. 2009;12(1):57-60.
3. Melchior S1, Hadaschik B, Thüroff S, Thomas C, Gillitzer R, Thüroff J. Outcome of radical prostatectomy for incidental carcinoma of the prostate. BJU Int. 2009 Jun;103(11):1478-81.

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