VIGILÂNCIA ATIVA PAPEL DO PSA, DA RESSONÂNCIA E DA BIÓPSIA HUMBERTO LOPES -UFJF

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1 VIGILÂNCIA ATIVA PAPEL DO PSA, DA RESSONÂNCIA E DA BIÓPSIA HUMBERTO LOPES -UFJF

2 PSA Velocidade PSA e Tempo Duplicação ConclusionPostdiagnosticPSA kinetics do not reliably predict adverse pathology and should not be used to replace annual surveillance biopsy for monitoring men on active surveillance. J Clin Oncol,2010

3 Cinética PSA Controverso Eur Urol,2012 AdamyA et al Role of Prostate Specific Antigen and Immediate Confirmatory Biopsy in Predicting Progression During Active Surveillance for Low Risk Prostate Cancer J Urol, 2011 Fatores clínicos Obesidade Eur Urol,2014

4 PSA e Tempo Duplicação Long-term follow-up of a large active surveillance cohort of patients with prostate cancer. Klotz L 1,VespriniD 2,SethukavalanP 2,JethavaV 2,ZhangL 2,JainS 2,Yamamoto T 2,Mamedov A 2,LoblawA 2.J ClinOncol, 2014

5 Densidade PSA 0.15 Mudança grau 31 % x 10 % KotbAF, et al. Relationship between initial PSA density with future PSA kinetics and repeat biopsies in men with prostate cancer on active surveillance. Prostate Cancer Disease, Tumor alto risco Corcoran et al.the ability of prostate-specifi c antigen(psa) density to predict an upgrade in Gleason score between initial prostate biopsy and prostatectomy diminishes withincreasingtumourgrade dueto reducedpsa secretionper unittumourvolume BJU International, 2012

6 PSA kinetics may be helpful in defining the indications for prostate biopsy in AS patients who are followed with regular biopsies for more than 3-4 years. UROLOGY :,

7 RESSONÂNCIA MAGNÉTICA SERIADA SENSIBILIDADE 37% ESPECIFICIDADE 90% FelkerER, et al. Serial Magnetic Resonance Imaging in Active Surveillance of Prostate Cancer: Incremental Value J Urol, 2016

8 BIÓPSIA DIRIGIDA E RANDOMIZADA?

9 Rosenkrantz et al, Clinical Imaging, 2015

10 Rosenkrantz et al, Clinical Imaging, 2015

11 Eur Urol,2016

12 Eur Urol, 2016 In press

13 USG-TC TillmannLoch, Pat Fox Fulgham. Active Surveillance Challenges in Men with Prostate Cancer: Role of Imaging Today and Tomorrow Eur Urol, 2016

14 Re-biópsia BIÓPSIA Limitar erro primeira biópsia avaliar progressão patológica tumor-grau/volume Reclassificação (melhor amostra) Real progressão Intervalo? PRIAS Prostate Cancer Research International Active Surveillance 30% pacientes Compliance Rates with the Prostate Cancer Research International Active Surveillance(PRIAS) ProtocolandDiseaseReclassification in Noncompliers. Bokhorst, etal. EurUrol, 2015

15 Re-biópsia volume 555 pacientes 70 pac. aumento volume 42.3%-Gleason7 85%-18 meses 62%-optaram por tratamento 2ª/3ª BIÓPSIA Maria Komisarenkoetal. An increasein Gleason6 tumor volume while Active Surveillance Portends a Greater Risk of. Grade Reclassification with Further Followup J Urol, 195, 2016

16 Biópsia dirigida ou randomizada? FilsonCP et al. Prostate cancerdetectionwithmagnetic resonance-ultrasound fusion biopsy: The role of systematic and targeted biopsies. Cancer, 2016

17 RESULTS biopsies were taken in men. Infection was reported after 55 biopsies (2.5%), and one in five men reported any form of complication. At multivariable analysis, the number of previous biopsies was not a significant predictor of infection (odds ratio 1.04, 95% confidence interval ). The only significant predictor for infection was the type of prophylaxis used. Of all men with a complication at the diagnostic or first repeat biopsy, 21% did not have a repeat biopsy at the time a repeat biopsy was scheduled according to protocol, vs12% for men without a previous biopsy complication.

18 RE-BIÓPSIAS NÃO NECESSÁRIA -MENOS FREQUENTE -APÓS PRIMEIRA RE-BIÓPSIA? Of 251 patients without disease reclassification at ispbx, the 2-year rates of subsequent type I and II reclassification were 17% (95% CI:10-24) and 3% (95% CI:0.1-7), respectively. Kovac E, et al. Outcomes of Active Surveillance after Initial Surveillance Prostate Biopsy J Urol,2016, in press.

19 J Urol, 2016

20 Genomic Prostate Score mrna expression The Genomic Prostate score has been developed to help predict eventual adverse pathologic findings at surgery based on prostate biopsy tissue helping to identify men best suited for active surveillance. Martin, NE Current Opinion, 2016

21 PSA Ressonância Biópsia MENSAGEM Estabilização na ressonância magnética Densidade PSA menor 0.15ng/ml Tumor menor3 mm

22 OBRIGADO

23 Graphical representation of the Biopsy-Integrated Algorithm for Determining Gleason 6 Upgrading Risk (BADGR) TruangM et al Cancer,2013

24 Genomic Prostate Score mrna expression The Genomic Prostate score has been developed to help predict eventual adverse pathologic findings at surgery based on prostate biopsy tissue helping to identify men best suited for active surveillance. Martin, NE Current Opinion, 2016 %[2] propsa Prostate Health Index

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26 BehfarEhdaie, et al. The Impact of Repeat Biopsies on Infectious Complications in Men with Prostate Cancer on Active Surveillance. J Urol, 2014

27 Vigilância ativa NIH Volume GanzPA, AnnInter Med, 2012 EAU Gleason 7, ansiedade,psa DT MolherJL, J NatlComprCancNetw, 2013 NCCN Alteração no grupo de risco NealRD, BrJ GenPract,2008 NIHCE PSA e achados adversos biopsia Stamey TA,Cancer, 1993

28 Vigilância ativa Estadio-T PSA Densidade PSA Gleason Número fragmentos positivos/ % malignidade nos fragmentos Predictors of Pathologic Progression on Biopsy Among Men on Active Surveillance for Localized Prostate Cancer: The Value of the Pattern of SurveillanceBiopsies K. Clint Cary*, Janet E. Cowan, Melissa Sanford, KatsutoShinohara, Nannette Perez, June M. Chan, Maxwell V. Meng, Peter R. Carroll Eur Urol,66,2014

29 Vigilância ativa Necessidade melhores testes... Cinética PSA Ressonância Magnética Re-biópsia Gleason 7