Phillip D Stricker

University of New South Wales, Kensington, New South Wales, Australia

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Publications (63)346.77 Total impact

  • James Edward Thompson, Sam Egger, Phillip D Stricker
    European Urology 01/2014; · 10.48 Impact Factor
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    ABSTRACT: Purpose: MpMRI appears to improve PCa detection, but prospective studies are lacking. Our objective was to determine the accuracy of mpMRI for detecting significant PCa prior to diagnostic biopsy in men with abnormal PSA/ DRE. Materials and methods: Single center, prospective study. Men with age >40, abnormal PSA/DRE and no previous mpMRI, underwent T2WI, DWI and DCEI without endorectal coil, allocated alternately to 1.5T/ 3.0T. MpMRIs were double-reported independently using PIRADS, by specialist radiologists. Transperineal grid-directed 30-core biopsy was performed, with additional MRI-directed cores for ROIs outside template locations. Four significant cancer definitions were tested. Chi-square and logistic regression analysis were performed. Men undergoing prostatectomy were analyzed. Results 165 men were enrolled, 150 analyzed (median age 62.4 years, PSA 5.6, 29% abnormal DRE, 88% first biopsy). 66% had positive mpMRI (PIRADS 3-5). 61% had PCa, 30-41% had significant PCa (definitions 1-4). Sensitivity, specificity, NPV & PPV for significant cancer was 93-96%, 47-53%, 92-96% and 43-57% respectively (definitions 1-4). RP results in 48 men were similar. Aggregate PIRADS (4-20) performed similarly to overall PIRADS (1-5). NPV (100%) and PPV (71%) were similar in higher risk men (PSA>10/ abnormal DRE). On multivariate analysis, PIRADS score was associated with significant PCa (p<0.001); magnet strength was not. Adding PIRADS to the multivariate model improved AUC from 0.810 to 0.913 (p = 0.002, 95%CI 0.038-0.166; see figure 3). Radiologist agreement was substantial (weighted kappa = 0.626). Conclusions MpMRI reported by expert radiologists achieved an excellent NPV and moderate PPV for significant PCa, at both 1.5T and 3.0T.
    The Journal of urology 01/2014; · 4.02 Impact Factor
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    ABSTRACT: Positive surgical margins (PSMs) are a known risk factor for biochemical recurrence in patients with prostate cancer (PCa) and are potentially affected by surgical technique and volume. To investigate whether radical prostatectomy (RP) modality and volume affect PSM rates. Fourteen institutions in Europe, the United States, and Australia were invited to participate in this study, all of which retrospectively provided margins data on 9778 open RP, 4918 laparoscopic RP, and 7697 robotic RP patients operated on between January 2000 and October 2011. The outcome measure was PSM rate. Multivariable logistic regression analyses and propensity score methods identified odds ratios for risk of a PSM for one modality compared with another, after adjustment for age, preoperative prostate-specific antigen, postoperative Gleason score, pathologic stage, and year of surgery. Classic adjustment using standard covariates was also implemented to compare PSM rates based on center volume for each minimally invasive surgical cohort. Open RP patients had higher-risk PCa at time of surgery on average and were operated on earlier in the study time period on average, compared with minimally invasive cohorts. Crude margin rates were lowest for robotic RP (13.8%), intermediate for laparoscopic RP (16.3%), and highest for open RP (22.8%); significant differences persisted, although were ameliorated, after statistical adjustments. Lower-volume centers had increased risks of PSM compared with the highest-volume center for both laparoscopic RP and robotic RP. The study is limited by its nonrandomized nature; missing data across covariates, especially year of surgery in many of the open cohort cases; lack of standardized histologic processing and central pathology review; and lack of information regarding potential confounders such as patient comorbidity, nerve-sparing status, lymph node status, tumor volume, and individual surgeon caseload. This multinational, multi-institutional study of 22 393 patients after RP suggests that PSM rates might be lower after minimally invasive techniques than after open RP and that PSM rates are affected by center volume in laparoscopic and robotic cases. In this study, we compared the effectiveness of different types of surgery for prostate cancer by looking at the rates of cancer cells left at the margins of what was removed in the operations. We compared open, keyhole, and robotic surgery from many centers across the globe and found that robotic and keyhole operations appeared to have lower margin rates than open surgeries. How many cases a center and surgeon do seems to affect this rate for both robotic and keyhole procedures.
    European Urology 11/2013; · 10.48 Impact Factor
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    ABSTRACT: Comparative studies suggest functional and perioperative superiority of robot-assisted radical prostatectomy (RARP) over open radical prostatectomy (ORP). To determine whether high-volume experienced open surgeons can improve their functional and oncologic outcomes with RARP and, if so, how many cases are required to surpass ORP outcomes and reach the learning curve plateau. A prospective observational study compared two surgical techniques: 1552 consecutive men underwent RARP (866) or ORP (686) at a single Australian hospital from 2006 to 2012, by one surgeon with 3000 prior ORPs. Demographic and clinicopathologic data were collected prospectively. The Expanded Prostate Cancer Index Composite quality of life (QoL) questionnaire was administered at baseline, 1.5, 3, 6, 12, and 24 mo. Multivariate linear and logistic regression modelled the difference in QoL domains and positive surgical margin (PSM) odds ratio (OR), respectively, against case number. A total of 1511 men were included in the PSM and 609 in the QoL analysis. RARP sexual function scores surpassed ORP scores after 99 RARPs and increased to a mean difference at 861st case of 11.0 points (95% confidence interval [CI], 5.9-16.1), plateauing around 600-700 RARPs. Early urinary incontinence scores for RARP surpassed ORP after 182 RARPs and increased to a mean difference of 8.4 points (95% CI, 2.1-14.7), plateauing around 700-800 RARPs. The odds of a pT2 PSM were initially higher for RARP but became lower after 108 RARPs and were 55% lower (OR: 0.45; 95% CI, 0.22-0.92) by the 866th RARP. The odds of a pT3/4 PSM were initially higher for RARP but decreased, plateauing around 200-300 RARPs with an OR of 1.15 (0.68-1.95) at the 866th RARP. Limitations include single-surgeon data and residual confounding. RARP had a long learning curve with inferior outcomes initially, and then showed progressively superior sexual, early urinary, and pT2 PSM outcomes and similar pT3 PSM and late urinary outcomes. Learning RARP was worthwhile for this high-volume surgeon, but the learning curve may not be justifiable for late-career/low-volume surgeons; further studies are needed.
    European Urology 10/2013; · 10.48 Impact Factor
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    ABSTRACT: Background:Circulating microRNAs (miRNAs) are emerging as promising biomarkers for prostate cancer. Here, we investigated the potential of these molecules to assist in prognosis and treatment decision-making.Methods:MicroRNAs in the serum of patients who had experienced rapid biochemical recurrence (BCR) (n=8) or no recurrence (n=8) following radical prostatectomy (RP) were profiled using high-throughput qRT-PCR. Recurrence-associated miRNAs were subsequently quantitated by qRT-PCR in a validation cohort comprised of 70 patients with Gleason 7 cancers treated by RP, 31 of whom had undergone disease progression following surgery. The expression of recurrence-associated miRNAs was also examined in tumour tissue cohorts.Results:Three miRNAs - miR-141, miR-146b-3p and miR-194 - were elevated in patients who subsequently experienced BCR in the screening study. MiR-146b-3p and miR-194 were also associated with disease progression in the validation cohort, as determined by log-rank tests and Cox proportional hazards regression. Multivariate analysis revealed that miR-146b-3p possessed prognostic information beyond standard clinicopathological parameters. Analysis of tissue cohorts revealed that miR-194 was robustly expressed in the prostate, elevated in metastases, and its expression in primary tumours was associated with a poor prognosis.Conclusion:Our study suggests that circulating miRNAs, measured at the time of RP, could be combined with current prognostic tools to predict future disease progression in men with intermediate risk prostate cancers.British Journal of Cancer advance online publication 11 July 2013; doi:10.1038/bjc.2013.369 www.bjcancer.com.
    British Journal of Cancer 07/2013; · 5.08 Impact Factor
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    ABSTRACT: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: With an aging population and routine use of PSA testing, there is an increase in men undergoing biopsy to assess for prostate cancer. The most common route for accessing the prostate is through the rectum, which potentially exposes the patient to otherwise innocuous Enterobacteriaceae. The rising incidence of extended-spectrum beta-lactamase has been linked to a rise in post-TRUS biopsy infection rates internationally. The study describes an alternative route for biopsy of the prostate that is associated with a very low infection rate, whilst still maintaining a good tumour detection rate. OBJECTIVE: To present the template-guided transperineal prostate biopsy (TPB) outcomes for patients of two urologists from a single institution. PATIENTS AND METHODS: We conducted a prospective study of 409 consecutive men who underwent TPB between December 2006 and June 2008 in a tertiary referral centre using a standardized 14-region technique. The procedure was performed as day surgery under general anaesthesia with fluoroquinolone antibiotic cover. Follow-up took place within 2 weeks, during which time men were interviewed using a standardized template. Results were compared with those of the Australian national prostate biopsy audits performed by the Urological Society of Australia and New Zealand (USANZ). RESULTS: Indications for biopsy included elevated prostate-specific antigen (PSA) level (75%), with a median PSA level of 6.5 ng/mL, abnormal digital rectal examination (8%) and active surveillance (AS) re-staging (18%). The mean patient age was 63 years and two-thirds of patients were undergoing their first biopsy. A positive biopsy was found in 232 men, 74% of whom had a Gleason score of ≥7. The overall cancer detection rate was 56.7% (USANZ 2005 national audit = 56.5%). Stratified between those having their first TPB or a repeat procedure (after a previous negative biopsy), the detection rates were 64.4 and 35.6%, respectively. Significantly higher detection rates were found in prostates <50 mL in volume than in larger prostates (65.2 vs 38.3%, respectively, P < 0.001). Haematuria was the most common side effect (51.7%). Others included dysuria (16.4%), acute urinary retention (4.2%) and fever (3.2%). One patient (0.2%) had septicaemia requiring i.v. antibiotics. Repeat biopsy was not associated with increased complication rates. CONCLUSIONS: TPB is a safe and efficacious technique, with a cancer detection rate of 56.7% in the present series, and a low incidence of major side effects. Stratified by prostate volume, the detection rate of TPB was higher in smaller glands. Given the relatively low rate of serious complications, clinicians could consider increasing the number of TPB biopsy cores in larger prostates as a strategy to improve cancer detection within this group. Conversely, in patients on AS programmes, a staging TPB may be a superior approach for patients undergoing repeat biopsy so as to minimize their risk of serious infection.
    BJU International 04/2013; · 3.05 Impact Factor
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    ABSTRACT: Objective •  To compare long-term biochemical control of high-risk prostate cancer in those men receiving high-dose rate brachytherapy (HDRB) and radical prostatectomy (RP). Patients and methods •  The 10-year biochemical freedom from relapse (BFR) was calculated for 243 patients who underwent either RP or combined therapy with HDRB + external beam radiotherapy + androgen deprivation between 1998 and 2000. •  Inclusion criteria: clinical stage ≥ T2b, or Gleason sum ≥ 8, or PSA level of > 20 ng/mL. Groups were appraised using the Kattan nomogram for surgery to calculate progression-free probability (PFP). Results •  For the RP group (153 patients) the median PSA level was 8.1 ng/mL and the median age was 62.2 years. The median 5- and 10-year predicted PFP for RP was 64% and 56 %, respectively. The 5- and 10-year BFR was 65.5% and 55.4%. There was no significant difference between the predicted and the actual PFP for the RP group (P= 0.525). •  For HDRB group (90 patients). The median PSA level was 14.2 ng/mL and the median age was 67.6 years. The median 5- and 10-year predicted PFP for HDRB was 46% and 35%, respectively. The 5- and 10-year BFR was 79.6% and 53.6%. There was a significant improvement between the actual and the predicted PFP for the HDRB group (P= 0.002). Conclusions •  Amongst a high-risk cohort, patients undergoing RP performed as predicted by the pre-treatment surgical nomogram, whereas the patients undergoing HDRB performed significantly better than was predicted by the surgical nomogram at 10 years.
    BJU International 12/2012; 110 Suppl 4:71-6. · 3.05 Impact Factor
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    ABSTRACT: Anterior tumors are estimated to constitute 20% of prostate cancers. Current data indicate that transperineal biopsy is more reliable than transrectal biopsy in identifying these tumors. If correct, this superior reliability should result in an increased proportion of anterior tumors identified by transperineal biopsy. We investigated this hypothesis with reference to prostatectomy specimens. Radical prostatectomy histopathology records were retrospectively examined. Patients were grouped based on primary transperineal or transrectal biopsy as the modality used to identify the initial cancer. After grouping, tumor location and size were recorded and, thus, the proportion of anterior tumors was determined. A total of 1,132 (414 transperineal and 718 transrectal) prostatectomy specimens were examined. Overall mean tumor size (1.8 and 2.0 cm(3)), stage (pT2 63.3% and 61%) and significance (5.1% and 5.1%) for the transperineal and transrectal methods were similar. However, the transperineal method was associated with proportionally more anterior tumors (16.2% vs 12%, p = 0.046), and identified them at a smaller size (1.4 vs 2.1 cm(3), p = 0.03) and lower stage (extracapsular extension 13% vs 28%, p = 0.03) compared to the transrectal method. The pT3 positive surgical margin rate for anterior vs other tumors was 69% vs 34.9%, respectively. Overall transrectal and transperineal biopsy identify cancers that are similar in size, stage and significance. However, transperineal biopsy detected proportionally more anterior tumors (16.2% vs 12%), and identified them at a smaller size (1.4 vs 2.1 cm(3)) and stage (extracapsular extension 13% vs 28%) compared to transrectal biopsy. Identifying anterior tumors early is important because the positive surgical margin rate for anterior pT3 lesions is significantly higher.
    The Journal of urology 07/2012; 188(3):781-5. · 4.02 Impact Factor
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    ABSTRACT: We determined whether systematic template guided transperineal biopsies can accurately locate and sensitively detect prostate cancer. In addition, we reported discrepancies between diagnostic and pathological Gleason scores, and investigated whether prostate size had an effect on the cancer detection rate. This retrospective diagnostic accuracy study compares the results of primary transperineal biopsies with the radical prostatectomy pathology of 414 consecutive patients treated at a single institution between November 2002 and August 2010. The average sensitivity and specificity for the detection of cancer in all prostates across all biopsy zones was 48% (95% CI 42.6-53.4) and 84.1% (95% CI 80-88.2), respectively. There was a statistically significant decrease in the sensitivity of transperineal biopsy in larger prostates (t11=4.687, p=0.001). The overall Kappa value was 0.255 (95% CI 0.212-0.298). Grading concordance between biopsy and pathology specimens was achieved in 65.7% of patients. Upgrading of Gleason scores occurred in 25.6% of patients and downgrading occurred in 8.8%. Our current transperineal biopsy method has only demonstrated fair agreement with the histopathology findings of the corresponding radical prostatectomy specimens. This finding is most likely due to the small, multifocal nature of prostate cancer in the patient series. The cancer detection rate was lower in larger prostates. Thus, clinicians may consider increasing the number of cores in larger prostates as a strategy to improve cancer detection.
    The Journal of urology 04/2012; 187(6):2044-9. · 4.02 Impact Factor
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    ABSTRACT: The introduction of robotics into a surgical team should be imagined as an ambitious team project able to ensure the transfer and the integration of a proficiency acquired in a reference centre. In this article, we present the robot-assisted laparoscopic prostatectomy technique which we use, directly inspired fromVR. Patel and in the light of one year of fellowship for the surgeon dedicated to this technique. This surgical technique has characteristics such as the retrograde neurovascular bundles sparing dissection, the urethral suspension stitch and the posterior reconstruction. We insist particularly on the assistant and scrub nurse part, knowing that their performance impact directly patients outcomes. A technique inspired from reference centre, standardized for the surgeon and his assistant, is essential to introduce safely and ambitiously a robotic program.
    Progrès en Urologie - FMC. 12/2011; 21(4).
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    ABSTRACT: Study Type - Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Only 30-35% of patients with positive surgical margins after radical prostatectomy develop recurrent disease. Adjuvant radiotherapy reduces the rate of biochemical relapse or metastasis and improves overall survival after radical prostatectomy. Various pathological factors, such as location and extent of positive margins, have been proposed as possible prognostic factors in men with margin-positive prostate cancer, however, the recent International Society of Urological Pathology consensus meeting in Boston noted that there is limited data on the significance of Gleason grade of the carcinoma at a positive margin. The present study shows that the presence of high grade prostate cancer, i.e. Gleason pattern 4 or 5, at a positive surgical margin is an independent predictor of biochemical recurrence after radical prostatectomy. Moreover, patients with lower grade carcinoma at the margin have a similar prognosis to men with negative margins. Hence, assessment of Gleason grade at the site of positive margin may aid optimal selection of patients for adjuvant radiotherapy. • To establish predictors of biochemical recurrence by analysing the pathological characteristics of positive surgical margins (PSMs), including Gleason grade of the carcinoma at the involved margin. • Clinicopathological and outcome data on 940 patients who underwent radical prostatectomy (RP) between 1997 and 2003 were collected. • Of these, 285 (30.3%) patients with PSMs were identified for pathological review, including assessment of location of margin, linear extent, number of PSMs, plane of margin and Gleason grade (3 vs 4 or 5) at the margin. • At a median follow-up of 82 months, the biochemical recurrence rate of the PSM cohort was 29%. • On univariate analysis, the presence of Gleason grade 4 or 5 at the margin (34.4% of cases) was significantly associated with biochemical recurrence (hazard ratio [HR] 2.80, 95% confidence interval [CI]= 1.82-4.32, P < 0.001) compared with the presence of Gleason grade 3. • Linear extent of margin involvement was also associated with recurrence (P= 0.009). • Single vs multiple margin involvement, location, and plane of the involved margin were not significant predictors of recurrence. • On multivariate analysis, Gleason grade 4 or 5 at the margin remained an independent predictor of recurrence (HR 2.14, 95% CI = 1.29-4.03, P= 0.003). • The Gleason grade at the site of a PSM identifies patients at increased risk of biochemical recurrence and should aid stratification of patients for adjuvant radiation therapy.
    BJU International 10/2011; 109(12):1794-800. · 3.05 Impact Factor
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    ABSTRACT: •  To examine whether nerve-sparing surgery (NSS) is a risk factor for positive surgical margins (PSMs) in patients with either organ-confined prostate cancer or extracapsular extension (ECE). •  Clinicopathological outcome data on 945 consecutive patients treated with radical prostatectomy (RP) were prospectively collected. •  All patients underwent RP (bilateral, unilateral or non-NSS) by one surgeon between 2002 and 2007. •  Risk of PSMs and their locations with respect to NSS was determined by multivariate logistic regression analysis adjusting for preoperative risk factors for PSMs within pT2, pT3a and pT3b tumours. •  Overall a PSM was identified in 19.6% of patients in an unscreened population with mean prostate-specific antigen (PSA) level of 8.1 ng/mL. •  There was no significant difference in rates of PSMs between NSS groups on multivariate analysis (P= 0.147). •  There was no significant difference in pT2 (P= 0.880), pT3a (P= 0.175) or pT3b (P= 0.354) tumours. •  The only significant predictor of PSMs was preoperative PSA level (risk ratio 1.289, P= 0.006). •  There was no significant difference in the location of PSMs except for the pT3a group, where the patients that had bilateral NSS were at higher risk of a posterolateral PSM (P= 0.028). •  With appropriate selection of patients, NSS does not increase the risk of PSMs, whether the cancer is organ confined or ECE is present. •  The adverse impact of the NSS procedure in the hands of an experienced surgeon is minimal and is a realistic compromise to obtain the increase in health-related quality of life offered by NSS.
    BJU International 06/2011; 109(4):533-8. · 3.05 Impact Factor
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    ABSTRACT: Men with positive margins after radical prostatectomy (RP) for localized prostate cancer (PC) have a 40-50% biochemical relapse rate at 5 years. Adjuvant radiotherapy improves biochemical progression-free and overall survival in men with positive margins, but is associated with increased toxicity. There is an urgent need to identify new prognostic markers to define the group of patients who would benefit from multimodality therapy. Nuclear β-catenin, membranous secreted frizzled-related protein 4 (sFRP4), zinc-alpha 2-glycoprotein (AZGP1), and macrophage inhibitory cytokine-1 (MIC-1) have previously been identified as molecular markers of outcome in localized PC. From these published studies, we identified a subset of patients with positive margins. The aim of this study was to assess the association between these four molecular markers and outcome in men with margin-positive, localized PC. We identified 186 men with positive margins from 330 men with localized PC; 53% had preoperative PSA >10 ng/ml, 72% extraprostatic extension (EPE), 24% seminal vesicles involvement (SVI), and 57% RP Gleason score ≥ 7. AZGP1 (P = 0.009), membranous sFRP4 (P = 0.03) and MIC-1 (P = 0.04) expression predicted for biochemical relapse on univariate analysis. Only absent/low AZGP1 expression (P = 0.01) was an independent predictor of recurrence in margin-positive, localized PC when modeled with preoperative PSA (P = 0.2), EPE (P = 0.2), SVI (P = 0.4), Gleason score ≥ 7 (P = 0.5) and adjuvant treatment (P = 0.4). Furthermore, there was an association between absent/low AZGP1 expression and clinical recurrence (P = 0.007). AZGP1 is a potential molecular marker for biochemical relapse in men with margin-positive, localized PC. Routine assessment of this biomarker may lead to better selection of patients who will benefit from post-RP radiotherapy.
    The Prostate 03/2011; 71(15):1638-45. · 3.84 Impact Factor
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    ABSTRACT: Accurate estimates of recurrence risk are needed for optimal treatment of patients with clinically localized prostate cancer. We combined an established nomogram and what to our knowledge are novel molecular predictors into a new prognostic model of prostate specific antigen recurrence. We analyzed gene expression profiles from formalin fixed, paraffin embedded, localized prostate cancer tissues to identify genes associated with prostate specific antigen recurrence. Profiles of the identified markers were reproduced by reverse transcriptase-polymerase chain reaction. We used the profiles of 3 of these genes along with output from the Kattan postoperative nomogram to produce a predictive model of prostate specific antigen recurrence. After variable selection we built a model of prostate specific antigen recurrence combining expression values of 3 genes and the postoperative nomogram. The 3-gene plus nomogram model predicted 5-year prostate specific antigen recurrence with a concordance index of 0.77 in a validation set compared to a concordance index of 0.67 for the nomogram. This model identified a subgroup of patients at high risk for recurrence that was not identified by the nomogram. This new gene based classifier has superior predictive power compared to that of the 5-year nomogram to assess the risk of prostate specific antigen recurrence in patients with organ confined prostate cancer. Our classifier should provide more accurate stratification of patients into high and low risk groups for treatment decisions and adjuvant clinical trials.
    The Journal of urology 10/2010; 184(4):1521-8. · 4.02 Impact Factor
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    ABSTRACT: Epigenetic alterations are common in prostate cancer, yet how these modifications contribute to carcinogenesis is poorly understood. We investigated whether specific histone modifications are prognostic for prostate cancer relapse, and whether the expression of epigenetic genes is altered in prostate tumorigenesis. Global levels of histone H3 lysine-18 acetylation (H3K18Ac) and histone H3 lysine-4 dimethylation (H3K4diMe) were assessed immunohistochemically in a prostate cancer cohort of 279 cases. Epigenetic gene expression was investigated in silico by analysis of microarray data from 23 primary prostate cancers (8 with biochemical recurrence and 15 without) and 7 metastatic lesions. H3K18Ac and H3K4diMe are independent predictors of relapse-free survival, with high global levels associated with a 1.71-fold (P < 0.0001) and 1.80-fold (P = 0.006) increased risk of tumor recurrence, respectively. High levels of both histone modifications were associated with a 3-fold increased risk of relapse (P < 0.0001). Epigenetic gene expression profiling identified a candidate gene signature (DNMT3A, MBD4, MLL2, MLL3, NSD1, and SRCAP), which significantly discriminated nonmalignant from prostate tumor tissue (P = 0.0063) in an independent cohort. This study has established the importance of histone modifications in predicting prostate cancer relapse and has identified an epigenetic gene signature associated with prostate tumorigenesis. Impact: Our findings suggest that targeting the epigenetic enzymes specifically involved in a particular solid tumor may be a more effective approach. Moreover, testing for aberrant expression of epigenetic genes such as those identified in this study may be beneficial in predicting individual patient response to epigenetic therapies.
    Cancer Epidemiology Biomarkers &amp Prevention 10/2010; 19(10):2611-22. · 4.56 Impact Factor
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    ABSTRACT: To critically analyse the learning curve for one experienced open surgeon converting to robotic surgery for radical prostatectomy (RP). From February 2006 to December 2008, 502 patients had retropubic RP (RRP) while concurrently 212 had robot-assisted laparoscopic RP (RALP) by one urologist. We prospectively compared the baseline patient and tumour characteristics, variables during and after RP, histopathological features and early urinary functional outcomes in the two groups. The patients in both groups were similar in age, preoperative prostate-specific antigen level, and prostatic volume. However, there were more high-stage (T2b and T3, P = 0.02) and -grade (Gleason 9, P = 0.01) tumours in the RRP group. The mean (range) operative duration was 147 (75-330) min for RRP and 192 (119-525) min for RALP (P < 0.001); 110 cases were required to achieve '3-h proficiency'. Major complication rates were 1.8% and 0.8% for RALP and RRP, respectively. The overall positive surgical margin (PSM) rate was 21.2% in the RALP and 16.7% in the RRP group (P = 0.18). PSM rates for pT2 were comparable (11.6% vs 10.1%, P = 0.74). pT3 PSM rates were higher for RALP than RRP (40.5% vs 28.8%, P = 0.004). The learning curve started to plateau in the overall PSM rate after 150 cases. For the pT2 and pT3 PSM rates, the learning curve tended to flatten after 140 and 170 cases, respectively. The early continence rates were comparable (P = 0.07) but showed a statistically significant improvement after 200 cases. Our analysis of the learning curve has shown that certain components of the curve for an experienced open surgeon transferring skills to the robotic platform take different times. We suggest that patient selection is guided by these milestones, to maximize oncological outcomes.
    BJU International 08/2010; 106(3):378-84. · 3.05 Impact Factor
  • Journal of Urology - J UROL. 01/2010; 183(4).
  • Journal of Urology - J UROL. 01/2010; 183(4).
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    ABSTRACT: To investigate the effect of prostate-specific antigen (PSA) testing on stage migration in an Australian population, and its consequences on the prognostic accuracy of the post-radical prostatectomy (RP) Kattan nomogram, as in North America widespread PSA testing has resulted in prostate cancer stage migration, questioning the utility of prognostic nomograms in this setting. The study comprised 1008 men who had consecutive RP for localized prostate cancer between 1991 and 2001 at one institution. Two groups were assessed, i.e. those treated in 1991-96 (group 1, the early PSA era), and 1997-2001 (group 2, the contemporary PSA era). Differences in clinicopathological features between the groups were analysed by chi-squared testing and survival modelling. Individual patient data were entered into the post-RP Kattan nomogram and the efficacy assessed by receiver- operating characteristic curve analysis. Patients in group 2 had lower pathological stage disease (P = 0.01) and fewer cancers with Gleason score > or =8 (P < 0.001) than group 1. Multivariate analysis identified preoperative serum PSA level (P < 0.01) and Gleason score (P < 0.01) as strong predictors of biochemical relapse in both groups. In group 2 pathological stage was not significant, but margin involvement became highly significant (P = 0.004). There was no difference in the predictive accuracy of the Kattan nomogram between the groups (P = 0.253). These findings show a downward stage migration towards organ-confined disease after the introduction of widespread PSA testing in an Australian cohort. Despite this, the Kattan nomogram remains a robust prognostic tool in clinical practice.
    BJU International 09/2009; 105(5):642-7. · 3.05 Impact Factor
  • Urology 01/2009; 74(4). · 2.42 Impact Factor

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1k Citations
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Institutions

  • 2013
    • University of New South Wales
      Kensington, New South Wales, Australia
  • 2000–2013
    • Garvan Institute of Medical Research
      • Cancer Research Program
      Darlinghurst, New South Wales, Australia
  • 2003–2012
    • Saint Vincent Hospital
      Worcester, Massachusetts, United States
  • 1997–2011
    • St. Vincent's Hospital Sydney
      • Department of Urology
      Sydney, New South Wales, Australia
  • 2010
    • St Vincent's Private Hospital
      Melbourne, Victoria, Australia
  • 2005
    • Sydney Cancer Centre
      Camperdown, New South Wales, Australia
  • 2002–2005
    • Memorial Sloan-Kettering Cancer Center
      New York City, New York, United States