NY Prostate Cancer Conference - K. Touijer - Session 4: Predicting clinical and biochemical endpoints before surgery
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NY Prostate Cancer Conference - K. Touijer - Session 4: Predicting clinical and biochemical endpoints before surgery
- 1. Predicting Clinical and Biochemical Endpoints Before Surgery Karim Touijer, MD Department of Surgery, Urology Service Memorial Sloan-Kettering Cancer Center
- 3. Determinism Pierre Simon Laplace “ Given for one instant an intelligence which could comprehend all the forces by which nature is animated and the respective situation of the beings who compose it – an intelligence sufficiently vast to submit these data to analysis- it would embrace in the same formula the movements of the greatest bodies of the universe and those of the lightest atom; for it, nothing would be uncertain and the future, as the past, would be present to its eyes”
- 6. NOMOGRAM FOR PREDICTING PATHOLOGIC STAGE PSA 4.1- 10 PSA 10.1-20 Gleason Sum Clinical Stage Clinical Stage 5 69 38 23 57 28 16 (63-74) (32-45) (13-38) (50-64) (22-34) (8-28) T1c T2b T3a T1c T2b T3a Organ-Confined Johns Hopkins, Baylor, U. Michigan SPOREs 7 48 21 11 36 14 7.2 (42-53) (17-25) (5.8-20) (30-42) (11-18) (4-14) Modified from Partin AW, Kattan MW, Subong ENP, Walsh PC, Wojno KJ, Oesterling JE, Scardino PT, Pearson JD. JAMA 1997; 277:1445.
- 8. Progression-free probability by risk group * p < 0.05 Mod. From D’Amico et al JAMA 280:969-74, 1998 * * * High risk Intermediate risk Low risk T1c/T2a, Gl 2-6, PSA <10 T2b or Gl 7 or PSA 10-20 T2c or Gl 8-10 or PSA >20
- 9. Improving prediction of stage means better design of the surgical treatment strategy
- 10. When and to what anatomical extent should we perform a pelvic lymph node dissection?
- 12. J Urol. 2010 Jul; 184(1): 143-8.
- 13. MSK data
- 14. What is the risk of EPE and to what extent can we safely preserve the NVB?
- 17. NVB Resection - Extrafascial
- 18. Should the established prognostic indicators be updated ?
- 20. Tradeoff: avoiding PLND in selected patients misses a proportion of nodal metastases (n=5510) Nomogram LND Avoided % of +LN Prediction % no PLND TN FN undetected NPV < 1% 2.3 125 2 0.97 .984 < 2% 43.8 2386 25 12.1 .990 < 3% 66.8 3623 56 27.2 .985 < 4% 76.0 4110 77 37.4 .982 < 5% 82.8 4466 94 45.6 .979 TN = true negative NPV = negative predictive value FN = false positive
- 23. Which standard are the manufacturers using? MANUFACTURER: Instrument/Assay CALIBRATION Abbott IMx / AxSYM/ AxSYM Plus / ARCHITECT WHO Biomerieux VIDAS WHO Roche Elecsys / Cobas / Modular Analytics WHO Siemens Dimension / ADVIA Centaur / Immulite WHO Immulite 3 rd gen Hybritech TOSOH AIA Hybritech Ortho Clinical Diagnostics VITROS Hybritech Beckman Coulter Access / UniCel Both
- 24. Age (1) (2) (3) (4) (5) (6) (7)=(3)x(5)x(6) (8)=(4)x(5)x(6) (9)=(7)-(8) No. of men with PSA > 4.0 ng/ml No. of men in (1) and (2) with biopsy-detectable cancer Proportion with PSA test in past year (%) Proportion complied with biopsy (%) No. of biopsy detectable cancers No. of cancers missed Hybritech WHO Hybritech WHO Hybritech WHO 40-44 46490 15980 20010 8250 7 60 820 340 480 45-49 148380 77250 68860 41950 9 60 3900 2380 1520 50-54 340130 167450 157940 88490 16 55 13970 7830 6140 55-59 292050 171870 134600 86790 24 55 17610 11360 6250 60-64 434690 227440 186960 108230 31 50 28980 16780 12200 65-69 430440 289260 202720 149090 34 40 27270 20060 7210 70-74 660540 459840 309660 233920 33 30 30310 22890 7420 75-79 533720 245660 232430 125020 35 20 16380 8810 7570 80-84 646130 435780 312140 231260 39 15 18080 13400 4680 Total 3532570 2090530 1625320 1073000 20% 36% 157320 103850 34%
- 25. Shift in Stage at Diagnosis after Introduction of PSA (SEER Data) 90 5 5 Local Regional Distant 1995 Percent Percent 68 13 19 0 20 40 60 80 100 Local Regional Distant 1983 0 20 40 60 80 100
- 27. Minimal Impact of Clinical Stage on Prostate Cancer Prognosis Among Contemporary Patients with Clinically Localized Disease Reese et al. J Urol. 2010; 184:114 AIC unchanged whether the model included clinical stage or not Clinical Stage EPE Positive margins cT1c reference reference cT2a 1.09 (0.89-1.33) 0.89 (0.74-1.08) cT2b 1.55 (1.17-2.06)* 1.16 (0.88-1.53) cT2c 1.37 (1.12-1.68)* 1.05 (0.86-1.27) Clinical Stage p Value cT1c reference reference cT2a 1.05 (0.84-1.23) 0.66 cT2b 1.24 (0.95-1.62) 0.11 cT2c 0.9 (0.72-1.13) 0.36
- 30. Endorectal Magnetic Resonance Imaging (erMRI) Axial MRI Whole-mount prostate cancer cancer Normal Peripheral Zone
Editor's Notes
- WE DEVELOPED A TOOL FOR THE PALM PILOT. WRITTEN BY PAUL FEARN, A MEMBER OF OUR GROUP, THIS APPLICATION COMPUTES THE NOMOGRAM PREDICTIONS OF OUR PREOPERATIVE, POSTOPERATIVE, AND PATHOLOGIC STAGING TABLES. THE USER SELECTS OR WRITES IN VALUES AND PRESSES A BUTTOM TO COMPUTE THE PREDICTIONS, WHICH ARE RETURNED AS CONFIDENCE INTERVALS. THIS APPLICATION IS IN USE AT SEVERAL ACADEMIC UROLOGIC CENTERS THROUGHOUT THE COUNTRY. WE PLAN TO ADD OTHER TREATMENT MODALITIES TO IT SOON, SUCH AS BRACHYTHERAPY AND RADIATION THERAPY.
- 34% of the cancers will be missed if the PSA calibration is ignored
- 2