Re: Urinary TMPRSS2:ERG and PCA3 in an Active Surveillance Cohort: Results from a Baseline Analysis in the Canary Prostate Active Surveillance Study

for this article http://dx.doi.org/10.1016/j.juro.2013.07.083 available at http://jurology.com/ Editorial Comment: A fundamental goal of repetitive sampling in men on active surveillance for low risk cancer is better assessment of disease volume and grade. In most patients observed to have greater disease volume on repeat biopsy this finding is presumed to be occult disease missed on initial sampling rather than true disease progression. In this study the authors report a correlation of urinary PCA3 and TMPRSS2:ERG levels and tumor volume among men on surveillance. In this case tumor volume was defined as number of positive cores found on repeat biopsy. In addition, biomarker levels correlated with Gleason score on repeat biopsy. The importance of this observation is twofold. First, if validated, urinary biomarker levels may allow individualization of the biopsy approach in men on surveillance. Frequency of biopsy and number of samples may be decreased in those with low levels, while those with high levels may need a more aggressive sampling to rule out occult high risk disease or may even require therapy. In addition, if truly a surrogate for tumor volume, then longitudinal measurement may allow noninvasive monitoring of these patients. My own experience with PCA3 in patients on surveillance has suggested that it is difficult to interpret. Variability in measured levels for the individual patient, perhaps owing to sampling technique, may limit the effectiveness of longitudinal measurement. Additionally image based tumor volume assessment does not appear to correlate well with PCA3. Further evaluations are warranted to validate the results of this provocative study. Samir S. Taneja, M.D. Re: Long-Term Functional Outcomes after Treatment for Localized Prostate Cancer M. J. Resnick, T. Koyama, K. H. Fan, P. C. Albertsen, M. Goodman, A. S. Hamilton, R. M. Hoffman, A. L. Potosky, J. L. Stanford, A. M. Stroup, R. L. Van Horn and D. F. Penson Department of Urologic Surgery, and Center for Surgical Quality and Outcomes Research, Vanderbilt University, Nashville, Tennessee N Engl J Med 2013; 368: 436e445. Abstract for this article http://dx.doi.org/10.1016/j.juro.2013.07.084 available at http://jurology.com/for this article http://dx.doi.org/10.1016/j.juro.2013.07.084 available at http://jurology.com/ Editorial Comment: It is well known to those of us who have been in practice for more than 15 years that patients with prostate cancer who undergo radiation manifest progressive toxicity from treatment. While new onset of hemorrhagic complications or pain is unusual beyond 10 years, urinary and sexual function may decline. It is difficult to know how often these findings are due to radiation PROSTATE CANCER 1765 and how often to age. In men who undergo surgery I have observed functional improvements in the early period followed by stability through time. The absence of a prostate may mean that these men are less likely to have age related worsening of urinary symptoms due to benign prostatic hyperplasia. This study evaluates functional outcomes among radiated and surgically treated patients at 15 years after treatment, demonstrating relative equivalence of urinary and sexual function at that point compared to worsened functional outcomes among surgical patients at the 2 and 5-year points. No interim points were evaluated, making it difficult to determine when the curves cross. It is my impression that equivalence of functional outcome seems to be earlier than 15 years—more in the range of 5 to 7 years—and this is how I have counseled patients. This finding may relate to improved quality of surgery, decreased quality of radiation and younger/healthier patient selection at baseline. Samir S. Taneja, M.D. Re: Prostate Cancer Diagnosis: Multiparametric MR-Targeted Biopsy with Cognitive and Transrectal US-MR Fusion Guidance versus Systematic Biopsy—Prospective Multicenter Study P. Puech, O. Rouvi ere, R. Renard-Penna, A. Villers, P. Devos, M. Colombel, M. O. Bitker, X. Leroy, F. M ege-Lechevallier, E. Comperat, A. Ouzzane and L. Lemaitre Departments of Radiology, Urology, Pathology and Biostatistics, CHRU Lille, Universit e Lille Nord de France, Lille, INSERM U703, CHRU Lille, Universit e Lille Nord de France, Loos, Hospices Civils de Lyon, Departments of Urinary and Vascular Radiology, Urology and Pathology, Hopital Edouard Herriot and Facult e de M edicine, Universit e Lyon 1, Lyon and Departments of Radiology, Urology and Pathology, La Piti e-Salpetri ere Hospital, Assistance Publique-Hopitaux de Paris, Facult e de M edicine Pierre and Marie Curie, University Paris VI, Paris, France Radiology 2013; 268: 461e469. Abstract for this article http://dx.doi.org/10.1016/j.juro.2013.07.085 available at http://jurology.com/for this article http://dx.doi.org/10.1016/j.juro.2013.07.085 available at http://jurology.com/ Editorial Comment: With growing interest in magnetic resonance (MR) targeted biopsy as a means of improving sampling efficiency, the question of how best to target an abnormality on MR imaging has arisen as highly relevant in clinical practice. This study compares the method of visually estimating the position of the abnormality on transrectal ultrasound guided biopsy using a computerized coregistration platform in which MR and ultrasound are directly fused to guide the transrectal ultrasound biopsy. The study is multicenter and prospective, and it shows no difference in the 2 techniques, suggesting that computerized coregistration does not improve sampling efficiency over visual estimation. The study suffers from a prolonged accrual (95 patients during 18 months), suggesting some patient selection, a small sample size and potential bias based on the fact that the operators were highly experienced in visual estimation. Only 68 of 95 patients actually underwent both biopsy strategies. It remains to be determined whether computerized coregistration can improve sampling efficiency and whether it can aid in the widespread adoption of MR targeted techniques. Samir S. Taneja, M.D.