Have You Read? February 2022

By: Craig Niederberger, MD, FACS | Posted on: 01 Feb 2022

Hope TA, Eiber M, Armstrong WR et al: Diagnostic accuracy of 68Ga-PSMA-11 PET for pelvic nodal metastasis detection prior to radical prostatectomy and pelvic lymph node dissection: a multicenter prospective phase 3 imaging trial. JAMA Oncol 2021; 7: 1635–1642.

Special thanks to Drs. Hari Vigneswaran and Daniel Moreira at the University of Illinois at Chicago.

Positron emission tomography (PET) in prostate cancer helps urologists diagnose patients with biochemical recurrence after local therapy. Choline and fluciclovine PET were conventionally used, but prostate specific membrane antigen (PSMA) PET has shown promising results and appears to be replacing the more conventional imaging modalities.

The authors of this multicenter prospective phase 3 imaging trial evaluated the role of PSMA PET in the initial staging of localized prostate cancer to identify those with pelvic nodal metastasis. Patients with either intermediate- or high-risk prostate cancer were studied. In total 764 men were recruited from 2015 to 2019 and underwent 68Ga-PSMA-11 PET scans. The primary end points of the study evaluated the accuracy of PSMA PET compared to the pathological specimen at time of surgery.

Of the 764 who underwent PET imaging, 277 underwent surgery, and the others underwent radiation, systemic therapy, surveillance or were lost to followup. In the surgical group, 40 (14%) had regional pelvic node metastasis on PSMA PET, and 75 (27%) had metastases by pathological evaluation. The sensitivity of PSMA PET was modest at 40% but with a high specificity of 95%. The positive predictive value was 75%, and the negative predictive value was 81%. These results were used for U.S. Food and Drug Administration application of PSMA PET for initial prostate cancer staging. If approved, urologists may soon use this evidence when considering PET evaluation in their own patients for initial staging of prostate cancer.

Punjani N, Flannigan R, Kang C et al: Quantifying heterogeneity of testicular histopathology in men with nonobstructive azoospermia. J Urol 2021; 206: 1268–1275.

Special thanks to Drs. Kareim Khalafalla and Samuel Ohlander at the University of Illinois at Chicago.

Urologists who treat men with azoospermia due to spermatogenic dysfunction are keenly interested in predictors of successful surgical sperm retrieval. Many studies have tried, but few have succeeded in, identifying clear factors that forecast success. In this study, the authors evaluated the correlation between testicular histopathological heterogenicity and surgical sperm retrieval rate (SRR) in patients undergoing microdissection testicular sperm extraction over a 10-year period ending in 2020.

A total of 918 men with microdissection testicular sperm extraction were included. The median testis volume was 8 cc and the median follicle stimulating hormone was 21 miU/ml. Of these, 391 men (43%) had 1 pathology, 388 men (42%) had 2, 108 (12%) had 3 and 31 (3.4%) had 4 different pathologies. Sertoli cell-only was the most common histopathology detected, followed by maturation arrest. The overall SRR was 42% with a clinical intrauterine gestation rate of 30%. Increasing histopathological variety was associated with higher SRRs: SRR of 33% was observed when 1 histopathological subtype was present, 41% with 2 subtypes, 64% with 3 subtypes and 94% with 4 subtypes. Men with any foci of spermatogenesis had higher SRRs.

The authors concluded that the presence of multiple heterogenic histopathology specimens correlated with higher surgical sperm retrieval rates in men with azoospermia due to spermatogenic dysfunction. Proper uniform reporting of histopathology pattern and percent is thus critical for patient management and followup. Despite how small an area with spermatogenesis is, it truly makes a difference in a patient’s hope in fathering children.

Daskivich TJ, Gale R, Luu M et al: Patient preferences for communication of life expectancy in prostate cancer treatment consultations. JAMA Surg 2021; https://doi.org/10.1001/jamasurg.2021.5803.

Special thanks to Drs. Susan Talamini and Omer Acar at the University of Illinois at Chicago.

The diagnosis of cancer is life changing. Life expectancy is a vital component in determining which men will obtain the most benefit from treatment and aids in selecting therapy. These investigators assessed the patient perspective in the communication of life expectancy in prostate cancer.

A total of 26 men were interviewed after consultation for prostate cancer treatment. The importance of life expectancy, if or how it had been discussed, barriers to discussing life expectancy, and ideal modes of communication were assessed. Of the participants, 19 (73%) recalled discussing life expectancy. Of these men, three-quarters recalled the discussion as a generalization such as “long” or “short” or a numerical survival probability, and the remainder discussed life expectancy as number of years. The majority of men (6 of 7) who did not discuss life expectancy felt that it would have been helpful.

Regarding preferences for life expectancy discussion, men preferred either number of years as it was easily understandable and concrete, or survival probability as it provided hope. Generalizations were felt to reduce patient involvement in shared decision making. The main barrier to discussing life expectancy was anxiety (15 of 26, or 58%), which could be ameliorated by using life expectancy ranges, depersonalizing language and assessing patient’s desire to know life expectancy.

This article demonstrates evidence that patients diagnosed with prostate cancer want to be informed about their life expectancy and would like specifics rather than generalizations. The authors also provide a framework for conducting life expectancy conversations using patient-centered language in a way that enhances shared decision making in the treatment of prostate cancer.

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