Faculty Bibliography
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521
The impact of anatomical radical retropubic prostatectomy on cancer control: the 30-year anniversary
PURPOSE: Radical prostatectomy has decreased prostate cancer specific mortality in men with clinically localized prostate cancer. We report oncological outcomes of the longest running series of nerve sparing radical retropubic prostatectomy on the 30th anniversary of the inaugural operation. MATERIALS AND METHODS: A total of 4,478 men underwent anatomical radical retropubic prostatectomy, as performed by a single surgeon (PCW), at the Johns Hopkins Medical Institutions from 1982 to 2011, without neoadjuvant or adjuvant therapy. During a median followup of 10 years (range 1 to 29), we examined progression-free, metastasis-free and cancer specific survival. RESULTS: The overall 25-year progression-free, metastasis-free and cancer specific survival rates were 68%, 84% and 86%, respectively, although there were significant differences in treatment outcomes between men treated in the pre-PSA and PSA eras. In each era, there were significant differences in progression-free, metastasis-free and cancer specific survival by D'Amico risk groups. In multivariable models considering prostatectomy features, pathological stage and grade were significantly associated with the risk of metastatic progression and disease specific mortality. CONCLUSIONS: Excellent prostate cancer specific survival was demonstrated up to 30 years after surgery. Clinical risk categories and pathological tumor features were significant predictors of long-term disease specific outcomes, supporting their ongoing use in risk stratification and management decisions. Anatomical radical retropubic prostatectomy continues to represent the gold standard in the surgical management of clinically localized prostate cancer to which alternate treatment options should be compared.
PMID: 23083655
ISSN: 0022-5347
CID: 250512
Association of [-2]proPSA with biopsy reclassification during active surveillance for prostate cancer
PURPOSE: Previous studies have suggested an association between [-2]proPSA expression and prostate cancer detection. Less is known about the usefulness of this marker in following patients with prostate cancer on active surveillance. Thus, we examined the relationship between [-2]proPSA and biopsy results in men enrolled in an active surveillance program. MATERIALS AND METHODS: In 167 men from our institutional active surveillance program we used Cox proportional hazards models to examine the relationship between [-2]proPSA and annual surveillance biopsy results. The outcome of interest was biopsy reclassification (Gleason score 7 or greater, more than 2 positive biopsy cores or more than 50% involvement of any core with cancer). We also examined the association of biopsy results with total prostate specific antigen, %fPSA, [-2]proPSA/%fPSA and the Beckman Coulter Prostate Health Index phi ([-2]proPSA/free prostate specific antigen) x (total prostate specific antigen)((1/2))). RESULTS: While on active surveillance (median time from diagnosis 4.3 years), 63 (37.7%) men demonstrated biopsy reclassification based on the previously mentioned criteria, including 28 (16.7%) of whom had reclassification based on Gleason score upgrading (Gleason score 7 or greater). Baseline and longitudinal %fPSA, %[-2]proPSA, [-2]proPSA/%fPSA and phi measurements were significantly associated with biopsy reclassification, and %[-2]proPSA and phi provided the greatest predictive accuracy for high grade cancer. CONCLUSIONS: In men on active surveillance, measures based on [-2]proPSA such as phi appear to provide improved prediction of biopsy reclassification during followup. Additional validation is warranted to determine whether clinically useful thresholds can be defined, and to better characterize the role of %[-2]proPSA and phi in conjunction with other markers in monitoring patients enrolled in active surveillance.
PMCID:3976250
PMID: 22901577
ISSN: 0022-5347
CID: 250542
External validation of the cancer of the prostate risk assessment (CAPRA) score in a single-surgeon radical prostatectomy series
OBJECTIVES: Prostate cancer clinical staging has significant limitations in the ability to accurately risk-stratify patients for prompt treatment or expectant management. The University of California San Francisco Cancer of the Prostate Risk Assessment (UCSF CAPRA) was recently described as a straightforward staging system that uses clinical variables to generate a score ranging from 0 to 10. Our objective was to perform an external validation of the CAPRA score as a predictor of 5-year progression-free survival (PFS) in a single-surgeon radical retropubic prostatectomy (RRP) series. MATERIALS AND METHODS: We examined the performance characteristics of the preoperative CAPRA score (0-10) to predict biochemical progression-free survival (PFS) in 990 men who underwent RRP by a single surgeon from 2003 to 2009. RESULTS: CAPRA scores were significantly associated with the risk of early biochemical progression in our series. For example, 5-year PFS was markedly different for scores at the extremes of 0 to 1 vs. >/=7 (95% vs. 40%, respectively). The concordance index was 0.764 for the prediction of biochemical progression using CAPRA scores in this cohort, which compares favorably with the concordance index of 0.66 in the original CaPSURE dataset. CONCLUSIONS: Our results validate the UCSF-CAPRA score as a significant predictor of 5-year PFS in a single surgeon series. The CAPRA score is a simple preoperative tool that can be readily applied in clinical practice to help risk-stratify prostate cancer patients.
PMCID:3137684
PMID: 20822930
ISSN: 1078-1439
CID: 160313
AN EXAMINATION OF THE DYNAMIC CHANGES IN PROSTATE-SPECIFIC ANTIGEN OCCURRING IN A POPULATION-BASED COHORT OF MEN OVER TIME
PMID: 22313542
ISSN: 1464-4096
CID: 160278
Novel technique for fragment removal after percutaneous management of large-volume neobladder calculi
OBJECTIVE: To describe a novel method for fragment evacuation after percutaneous lithotripsy of neobladder calculi. METHODS: The technique was developed using a Urovac bladder evacuator, which was attached to a standard 30F Amplatz working sheath. RESULTS: The attachment of the Urovac evacuator to the Amplatz sheath rapidly evacuated large quantities of stone material. Careful attention should be paid to maintaining low-pressure irrigation by ensuring the bladder is not overly full and the Urovac device is not vigorously manipulated, to minimize the likelihood of bladder injury. CONCLUSION: Percutaneous ultrasonic/hydraulic lithotripsy for large-volume neobladder calculi often results in a substantial burden of stone fragments that can be difficult to clear using standard techniques. Attaching a Urovac bladder evacuator to the 30F Amplatz sheath can simplify the management of this task.
PMID: 22857764
ISSN: 0090-4295
CID: 250552
Infectious Complications and Hospital Admissions After Prostate Biopsy in a European Randomized Trial
BACKGROUND: The complications of prostate needle biopsy (PNB) are important when considering the benefits and harms of prostate cancer screening. Studies from the United States and Canada have recently reported increasing numbers of hospitalizations for infectious complications after PNB. OBJECTIVE: Examine the risk of infectious complications and hospital admissions after PNB in a European screening trial. DESIGN, SETTING, AND PARTICIPANTS: From 1993 to 2011, 10 474 PNBs were performed in the European Randomized Study of Screening for Prostate Cancer (Rotterdam section). Prophylaxis originally consisted of trimethoprim-sulfamethoxazole. Beginning in 2008, it was changed to ciprofloxacin. MEASUREMENTS: Febrile complications and hospital admissions were assessed by questionnaires 2 wk after PNB. Logistic regression was used to identify risk factors for biopsy-related fever and hospital admission. RESULTS AND LIMITATIONS: Fever and hospital admission were reported on 392 of 9241 questionnaires (4.2%) and 78 of 9198 questionnaires (0.8%), respectively. Although most fevers were managed on an outpatient basis, 81% of hospital admissions were for infection. Of the 56 available blood cultures, 34 were positive with Escherichia coli as the predominant organism. On multivariable analysis, prostate enlargement and diabetes were significantly associated with an increased risk of fever after PNB, whereas later year of biopsy was the only factor significantly associated with an increased risk of hospital admission. CONCLUSIONS: In a European screening trial, <5% PNBs resulted in febrile complications. Significant risk factors included diabetes and prostatic enlargement. Although most fevers were managed on an outpatient basis, infection remained the leading cause of hospital admission after PNB. Consistent with prior international reports, the frequency of hospital admissions after PNB significantly increased over time. Nevertheless, the absolute frequency of hospital admissions related to PNB was low and should not dissuade healthy men who would benefit from early prostate cancer diagnosis from undergoing biopsy when clinically indicated.
PMID: 22244150
ISSN: 0302-2838
CID: 160281
Infection after Transrectal Ultrasonography-Guided Prostate Biopsy: Increased Relative Risks after Recent International Travel or Antibiotic Use
PMID: 22040375
ISSN: 1464-4096
CID: 160290
Outcomes in patients with Gleason score 8-10 prostate cancer: relation to preoperative PSA level
Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? High-grade prostate cancers are associated with poor disease-specific outcomes. A proportion of these tumours produce little PSA. This study demonstrates that among Gleason 8-10 prostate cancers, some of the worst survival outcomes are associated with the lowest PSA levels. OBJECTIVE: * To assess outcomes of patients with Gleason score 8-10 prostate cancer (CaP) with a low (10 ng/mL (n= 118). * We compared biochemical progression-free survival (PFS), metastasis-free survival (MFS), and cancer-specific survival (CSS) as a function of preoperative PSA level. RESULTS: * Patients with PSA level 10 ng/mL (32%, P= 0.02). * Gleason score 8-10 tumours with a PSA level 10 ng/mL, respectively, P= 0.2) and CSS (81, 100, 94 and 90% for PSA level 10 ng/mL, respectively, P= 0.3), although these differences were not statistically significant. * In the subset with palpable disease, Gleason grade 8-10 disease with PSA level
PMID: 22017732
ISSN: 1464-4096
CID: 160291
Use of Baseline Prostate-Specific Antigen Measurements to Personalize Prostate Cancer Screening
PMID: 22154726
ISSN: 0302-2838
CID: 160284
The relationship between prostate volume and prostate-specific antigen variability: data from the Baltimore Longitudinal Study of Aging and the Johns Hopkins Active Surveillance Program
Study Type - Prognostic (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Previous studies have attempted to characterize the normal biological variability in PSA among men without prostate cancer. These reports suggest that PSA variability is unrelated to age, but there are conflicting data on its association with the baseline PSA level. There are limited published data regarding the effects of prostate volume on PSA variability. A prior study assessing whether prostate volume changes would confound the use of PSA velocity in clinical practice reported that prostate volume changes were not significantly related to PSA changes. This study did not directly address the effect of baseline prostate volume on serial PSA variability. The objective of the current study was to further examine the relationship between prostate volume and PSA variability. Our hypothesis was that larger baseline prostate volume would be associated with increased PSA variability in men without known prostate cancer and in those with suspected small-volume disease. The results of the study suggest that baseline PSA, not prostate volume, is the primary driver of PSA variability in these populations. OBJECTIVE: * To clarify the relationship between serial prostate-specific antigen (PSA) variability and prostate volume in both cancer-free participants from the Baltimore Longitudinal Study of Aging (BLSA) and patients with low-risk prostate cancer from the Johns Hopkins Active Surveillance Program (AS). MATERIALS AND METHODS: * In all, 287 men from the BLSA and 131 patients from the AS were included in the analysis, all with at least two PSA measurements and concurrent prostate volume measurements. * PSA variability was calculated in ng/mL per year, and a linear mixed-effects model was used to determine the relative effects of prostate volume, baseline PSA and age on PSA change over time. RESULTS: * In a model with prostate volume, age and baseline PSA, there was no significant relationship between prostate volume and PSA variability (BLSA, P= 0.57; AS, P= 0.49). * Only baseline PSA showed a significant relationship to PSA yearly variability (PSAYV) (P < 0.001). Specifically, a one unit higher baseline PSA (ng/mL) corresponded on average to 0.09 and 0.06 ng/mL per year higher PSAYV in the BLSA and AS populations, respectively. CONCLUSIONS: * The results of the present study suggest that the primary driver of PSA variability is the baseline PSA level, rather than prostate volume. * Clinicians might consider the baseline PSA level to help predict the expected variability in serial PSA measurements.
PMCID:6124495
PMID: 22093443
ISSN: 1464-4096
CID: 160287
