Predicting recurrence after radical prostatectomy for patients with high risk prostate cancer

PURPOSE: Previous studies have shown that patients with clinical stage T2c-T3 prostate cancer, serum prostate specific antigen (PSA) at diagnosis greater than 20 ng./ml. or a biopsy Gleason score of 8 to 10 are at high risk for disease recurrence after radical prostatectomy. We determined the most important pretreatment predictors of disease recurrence in this high risk population. MATERIALS AND METHODS: We identified 547 patients with high risk prostate cancer who underwent radical prostatectomy at University of California, San Francisco or as part of the Cancer of the Prostate Strategic Urological Research Endeavor data base, a longitudinal disease registry of patients with prostate cancer. High risk disease was defined as 1992 American Joint Committee on Cancer clinical stage T2c-T3 disease in 411 patients, serum PSA at diagnosis greater than 20 ng./ml. in 124 and/or biopsy Gleason score 8 to 10 in 114. Disease recurrence was defined as PSA 0.2 ng./ml. or greater on 2 consecutive occasions after radical prostatectomy or second cancer treatment more than 6 months after surgery. The Cox proportional hazards analysis was performed to determine significant independent predictors of disease recurrence. The likelihood of disease recurrence for clinically relevant patient groups was determined using the Kaplan-Meier method and compared using the log rank test. RESULTS: Median followup after surgery was 3.1 years. Disease recurred in 177 patients (32%). Multivariate analysis demonstrated that serum PSA at diagnosis, biopsy Gleason score, ethnicity and the percent of positive prostate biopsies were significant independent predictors of disease recurrence, while patient age and clinical tumor stage were not. Patients with a Gleason score 8 to 10 tumor and a serum PSA of 10 ng./ml. or less had a significantly higher likelihood of remaining disease-free 5 years after surgery than those with PSA greater than 10 ng./ml. (47% versus 19%, p <0.05). Patients with a serum PSA at diagnosis of greater than 20 ng./ml. and a Gleason score of less than 8 had a significantly higher likelihood of remaining disease-free 5 years after surgery than similar patients with a Gleason score of 8 or greater (45% versus 0%, p <0.05). CONCLUSIONS: PSA, Gleason score, ethnicity and the percent of positive prostate biopsies appear to be the most important pretreatment predictors of disease recurrence in men with high risk prostate cancer. Patients with high grade disease may continue to be appropriate candidates for local therapy if PSA is less than 10 ng./ml. at diagnosis or there are fewer than 66% positive prostate biopsies.     

The percent of cores positive for cancer in prostate needle biopsy specimens is strongly predictive of tumor stage and volume at radical prostatectomy

PURPOSE: Pretreatment clinical staging of prostatic adenocarcinoma is important due to the increasing use of nonsurgical treatment options. Using multivariate analysis we assessed the predictive value of biopsy cores positive for cancer as a percent of all cores obtained as well as the percent surface area of needle cores involved with tumor for determining tumor volume and pathological stage at radical prostatectomy. Candidate variables for the multivariate model included patient age, clinical disease stage, serum prostate specific antigen (PSA) and Gleason score of cancer in the needle biopsy. MATERIALS AND METHODS: We reviewed prostate needle biopsy findings in 207 consecutive patients who subsequently underwent radical retropubic prostatectomy. Each biopsy specimen was assessed for tumor involvement by calculating the percent of cores positive for cancer, percent surface area involved in all cores and Gleason score. Initial serum PSA and preoperative clinical disease stage were incorporated with biopsy results into a multivariate model to determine the parameters most predictive of pathological stage and tumor volume at radical retropubic prostatectomy. RESULTS: Of the 207 patients 152 (73.4%) had organ confined cancer and 55 (26.6%) had extraprostatic extension (pathological stages T2 and T3 or greater, respectively). Preoperative clinical staging information was available in 195 cases, in which disease was clinically confined and not confined in 184 (94.4%) and 11 (5.6%), respectively. Needle biopsy revealed a surface area of cancer ranging from less than 5% in 69 patients (33.3%) to 90% (mean 16, median 10). Univariate analysis demonstrated that the risk of extraprostatic extension was predicted by preoperative serum PSA (p = 0.027), the percent of cores and percent of surface area positive for cancer (p <0.0001), and Gleason score (p = 0.0009). Clinical stage approached significance (p = 0.071). Multivariate analysis showed that the percent of positive cores (p = 0.0003), initial serum PSA (p = 0.005) and Gleason score of cancer in the needle biopsy (p = 0.03) were the only parameters that jointly predicted pathological stage (T2 versus T3). Percent of tumor surface area involvement in the needle biopsies did not add any more information after the percent of positive cores was known. Univariate analysis revealed that the percent of cores positive for cancer (Spearman r = 0.52, p <0.0001), Gleason score (Spearman r = 0.34, p <0.0001) and initial serum PSA (Spearman r = 0.24, p = 0.003) were predictive of log tumor volume at radical prostatectomy, while clinical stage was not (rank sum test p = 0.14). On multivariate analysis the percent of positive cores (p <0.0001), Gleason score (p <0.0001) and initial serum PSA (0.0033) were the only variables that jointly were predictive of tumor volume. CONCLUSIONS: The percent of needle biopsy cores and surface area positive for cancer are the strongest predictors of pathological stage and tumor volume on multivariate analysis incorporating preoperative serum PSA and Gleason score.     

穿刺标本Gleason评分预测前列腺癌病理分级准确性的研究

目的 分析前列腺癌患者穿刺标本与根治术标本Gleason评分的相关性,探讨影响穿刺标本Gleason评分准确性的可能因素.方法 回顾性分析86例接受根治性前列腺切除术的前列腺癌患者资料,比较穿刺标本与根治术标本Gleason评分的符合情况,应用二分类Logistic回归分析筛选影响穿刺标本Gleason评分准确性的可能因素.结果 86例患者穿刺标本平均Gleason评分为6.1,根治术标本平均Gleason评分为6.5,穿刺标本与根治术标本Gleason评分相比,评分相符42例(48.8%),评分偏低32例(37.2%),评分偏高1 2例(14.0%),差异具有统计学意义(P＜0.05),偏差与患者年龄、血清PSA、前列腺体积、临床分期无显著相关性(P＞0.05),与穿刺针数(OR=2.905)及穿刺阳性率(OR=4.225)有显著相关(P＜0.05).结论 穿刺针数与穿刺阳性针数百分比是影响穿刺标本Gleason评分准确性的可能因素,增加前列腺穿刺活检针数将可能有助于提高穿刺标本预测前列腺癌病理分级的准确性.     

Is ethnicity an independent predictor of prostate cancer recurrence after radical prostatectomy?

PURPOSE: Prostate cancer incidence and mortality are higher in black than in white American men. We determined whether ethnicity is an independent predictor of disease recurrence in men undergoing radical prostatectomy. MATERIALS AND METHODS: We studied 1,468 patients who underwent radical prostatectomy at the University of California, San Francisco or as part of the Cancer of the Prostate Strategic Urological Research Endeavor database, a longitudinal disease registry of patients with prostate cancer. Preoperative characteristics, including age, race, prostate specific antigen (PSA) at diagnosis, clinical T stage, biopsy Gleason score and percent positive prostate biopsies at diagnosis were determined in each patient. Disease recurrence was defined as PSA 0.2 ng./ml. or greater on 2 consecutive occasions after radical prostatectomy or second cancer treatment at least 6 months after surgery. Cox proportional hazards analysis was performed to determine independent predictors of time to disease recurrence. To control for pretreatment disease characteristics simultaneously patients were assigned to previously described risk groups based on clinical tumor stage, PSA at diagnosis and biopsy Gleason score. The likelihood of disease recurrence per risk group stratified according to ethnicity was determined using the Kaplan-Meier method and compared using the log rank test. Additional multivariate analysis was performed in the subset of patients enrolled in Cancer of the Prostate Strategic Urological Research Endeavor on whom education and income information was available. RESULTS: Disease recurred in 304 of the 1,468 patients (21%). Black ethnicity, serum PSA at diagnosis, biopsy Gleason score and percent positive prostate biopsies were independent predictors of recurrence on multivariate analysis. Black ethnicity remained an independent predictor of disease recurrence in the multivariate model after stratifying patients into risk groups (p = 0.0007). Ethnicity was most important in patients at high risk, in whom estimated 5-year disease-free survival was 65% and 28% in white and black men, respectively. Education, income and ethnicity correlated highly. When education and income were entered into the multivariate model, ethnicity was no longer an independent predictor of outcome after prostatectomy. CONCLUSIONS: Ethnicity appears to be an independent predictor of disease recurrence after adjusting for pretreatment measures of disease extent in patients undergoing radical prostatectomy. It appears to be particularly important in those with high risk disease characteristics. However, black ethnicity, education and income are highly correlated variables, suggesting that sociodemographic factors may contribute to the poorer outcomes in black patients even after adjusting for differences in pretreatment disease characteristics.     

Percent of prostate needle biopsy cores with cancer is significant independent predictor of prostate specific antigen recurrence following radical prostatectomy: results from SEARCH database

PURPOSE: Recent studies have suggested that the percent of positive cores in the prostate needle biopsy is a significant predictor of outcome among men undergoing radical prostatectomy or radiation therapy for prostate cancer. We evaluate whether either percent of cores with cancer or percent of cores positive from the most and least involved side of the prostate needle biopsy was associated with a worse outcome among men treated with radical prostatectomy. MATERIALS AND METHODS: A retrospective survey of 1,094 patients from the SEARCH Database treated with radical prostatectomy at 4 different equal access medical centers in California between 1988 and 2002 was undertaken. We used multivariate analysis to examine whether total percent of prostate needle biopsy cores with cancer, percent of cores positive from each side of the prostate and other clinical variables were significant predictors of adverse pathology and time to prostate specific antigen (PSA) recurrence following radical prostatectomy. RESULTS: On multivariate analysis serum PSA and percent of positive cores were significant predictors of positive surgical margins, nonorgan confined disease and seminal vesicle invasion. Percent of positive cores (p <0.001), serum PSA (p = 0.008) and biopsy Gleason score (p = 0.014) were significant independent predictors of time to biochemical recurrence. On a separate multivariate analysis that included the variables of total percent of positive cores, percent of positive cores from the most involved side of the biopsy, percent of positive cores from the least involved side of the biopsy and whether the biopsy was positive unilaterally or bilaterally, only the percent of positive cores from the most involved side of the biopsy was a significant independent predictor of PSA failure following radical prostatectomy. Percent of positive cores was used to separate patients into a low risk (less than 34%), intermediate risk (34% to 50%) and high risk (greater than 50%) groups, which provided significant preoperative risk stratification for PSA recurrence following radical prostatectomy (p <0.001). Percent of positive cores cut points were able to further risk stratify men who were at low (p = 0.001) or intermediate (p = 0.036) but not high (p = 0.674) risk for biochemical failure based on serum PSA and biopsy Gleason score. CONCLUSIONS: Percent of positive cores in the prostate needle biopsy was a significant predictor of adverse pathology and biochemical failure following radical prostatectomy, and the cut points of less than 34%, 34% to 50% and greater than 50% can be used to risk stratify patients preoperatively. The finding that percent of positive cores from the most involved side of the biopsy was a stronger predictor of PSA failure than the total percent of cores involved suggests that multiple positive biopsies from a single side might be a better predictor of a larger total cancer volume and thus correlate with clinical outcome.     

Comparison of Gleason scores from sextant prostate biopsies and radical prostatectomy specimens.

OBJECTIVES: We compared the Gleason scores obtained from sextant prostate biopsy and radical prostatectomy (RP) specimens in patients with localized prostate cancer. PATIENTS AND METHODS: Sixty-one patients having a clinical diagnosis of localized prostate cancer underwent needle biopsy under transrectal ultrasonography (TRUS) and RP. Grading and staging were assigned based on Gleason scores and the TNM system, respectively. RESULTS: Mean patient age was 65.5 +/- 13.43 years and mean PSA level was 14.69 +/- 3.95. Mean Gleason score for prostate biopsy and RP specimen were 5.85 +/- 0.7 and 6.34 +/- 1.44, respectively. With respect to clinical stage, there were 20 patients in stage 1 and 41 patients in stage 2 prostate cancer. Comparing the Gleason scores, the biopsy score was lower in 26 (42.26%) and higher than RP specimens in 7 (11.84%) cases, and there was agreement between the biopsy and RP specimens in 28 (45.9%) patients. The difference between the two Gleason scores was +/- 1 for 18 patients (29.5%) and +/- 2 or more for 17 patients (27.86%). CONCLUSION: In our study, high Gleason score biopsies with elevated PSA level (>10 ng/ml) were risk factors for extraprostatic extension, and we demonstrated that Gleason scores were significantly correlated with seminal vesicle and lymph node invasion (p < 0.05). The Gleason scores of biopsy and RP specimens agreed with 45.9% of TRUS-guided sextant prostate biopsies, and this ratio was 91.1% in moderately differentiated tumors Copyright 2001 S. Karger AG, Basel     

The extent of biopsy involvement as an independent predictor of extraprostatic extension and surgical margin status in low risk prostate cancer: implications for treatment selection

PURPOSE: We identify predictors of extraprostatic extension and positive surgical margins in patients with low risk prostate cancer (prostate specific antigen [PSA] 10 ng./ml. or less, biopsy Gleason score 7 or less and clinical stage T1c-2b). MATERIALS AND METHODS: From August 1997 to January 1999, 143 previously untreated patients underwent radical retropubic prostatectomy for clinically localized prostate cancer. A total of 62 patients were low risk, with PSA 10 ng./ml. or less, biopsy Gleason score 7 or less and clinical stage T1c-2b, and had sextant biopsy with separate pathological evaluation of each sextant cores. PSA, clinical stage, biopsy Gleason score, average percentage of cancer in the entire biopsy specimen, maximum percentage of cancer on the most involved core, number of cores involved and bilaterality were evaluated for association with extraprostatic extension, seminal vesicle involvement and positive surgical margins. RESULTS: Of the 62 patients 13 (21%) had extraprostatic extension, 6 (10%) seminal vesicle involvement and 20 (32%) positive surgical margins. Average percentage greater than 10% and maximum percentage greater than 25% were associated with extraprostatic extension (p = 0.01 and 0.004, respectively). Average percentage greater than 10%, maximum percentage greater than 25%, more than 2 cores involved and bilaterality were associated with positive surgical margins (p = 0.007, 0.01, 0.002 and 0.03, respectively). On multivariate analysis maximum percentage remained the only independent predictor of extraprostatic extension (p = 0.03), and the number of cores involved remained an independent predictor of positive surgical margins (p = 0.01). Biopsy Gleason score, PSA and clinical stage did not correlate with extraprostatic extension or positive surgical margins in this patient population. CONCLUSIONS: In low risk prostate cancer the extent of biopsy involvement significantly correlates with the risk of extraprostatic extension and positive surgical margins. Biopsy information should be considered when selecting and modifying treatment modalities.     

Prediction of extraprostatic extension by prostate specific antigen velocity, endorectal MRI, and biopsy Gleason score in clinically localized prostate cancer

Objectives:   To investigate the clinical value of prostate specific antigen velocity (PSAV) in predicting the extraprostatic extension of clinically localized prostate cancer.
Methods:   One hundred and three patients who underwent radical prostatectomy for clinically localized prostate cancer were included in the analysis. The correlation between preoperative parameters, including PSA-based parameters, clinical stage, and histological biopsy findings, and the pathological findings were analyzed. Logistic regression analysis was performed to identify a significant set of independent predictors for the local extent of the disease.
Results:   Sixty-four (60.2%) patients had organ confined prostate cancer and 39 (39.8%) patients had extraprostatic cancer. The biopsy Gleason score, PSA, PSA density, PSA density of the transition zone, and PSAV were significantly higher in the patients with extraprostatic cancer than in those with organ confined cancer. Multivariate logistic regression analysis indicated that the biopsy Gleason score, endorectal magnetic resonance imaging findings, and PSAV were significant predictors of extraprostatic cancer ( P  < 0.01). Probability curves for extraprostatic cancer were generated using these three preoperative parameters.
Conclusions:   The combination of PSAV, endorectal magnetic resonance imaging findings, and biopsy Gleason score can provide additional information for selecting appropriate candidates for radical prostatectomy.     

Investigating the clinical utility of the percent of positive prostate biopsies in predicting PSA outcome following local therapy for patients with clinically localized prostate cancer

The clinical utility of the percent of positive prostate biopsies in predicting prostate-specific antigen (PSA) outcome following radical prostatectomy (RP), or external beam radiation therapy (RT), for men with PSA detected, or clinically palpable prostate cancer was investigated. After accounting for the established prognostic significance of the PSA level, biopsy Gleason score and the clinical T-stage, the percent of positive prostate biopsies added clinically significant information regarding time to PSA failure following RP. These findings were validated in the intermediate risk patients using an independent surgical and radiation data set. Prostate Cancer and Prostatic Diseases (2000) 3, 259-264     

Preoperative p27 status is an independent predictor of prostate specific antigen failure following radical prostatectomy

PURPOSE: p27 is an important cell cycle regulator, and decreased expression in radical prostatectomy specimens is associated with an increased risk of prostate specific antigen (PSA) failure. To our knowledge no prior study has shown that preoperative p27 status independently predicts recurrence after radical prostatectomy. MATERIALS AND METHODS: The prostate needle biopsy specimens of 161 men treated with radical prostatectomy were examined for p27 expression using immunohistochemistry. Various p27 cut points were examined for their ability to separate patients into groups with different risk for time to biochemical recurrence following radical prostatectomy. The best p27 cut point was compared to other clinical variables (PSA, clinical stage, age, biopsy Gleason score and percent of prostate needle biopsy with cancer) on multivariate analysis to determine which variables independently predicted biochemical failure. RESULTS: A p27 cut point of less than 45% positive staining cells resulted in significant preoperative risk stratification for time to PSA failure (HR 2.41, p = 0.010). On multivariate analysis serum PSA (HR 1.04, p = 0.011), biopsy Gleason score (HR 1.51, p = 0.011), percent of biopsy tissue with cancer (HR 10.01, p = 0.001) and less than 45% p27 positive cells (HR 2.44, p = 0.014) were all independent predictors of biochemical recurrence. CONCLUSIONS: Preoperative p27 expression is an independent predictor of time to biochemical recurrence following radical prostatectomy. Patients with less than 45% p27 positive cells in the prostate needle biopsy specimen have almost a 2.5-fold increased risk of biochemical recurrence. To our knowledge this study is the first to show that p27 status of the prostate needle biopsy specimen can be used before radical prostatectomy to predict biochemical failure.     

Does prostate biopsy Gleason score accurately express the biologic features of prostate cancer?

PURPOSE: To correlate Gleason grading in prostate biopsies with the final Gleason score in radical prostatectomy specimens, and to investigate predictors for concordance and preoperative undergrading. MATERIALS AND METHODS: The charts of 303 patients who underwent radical retropubic prostatectomy between 1992 and 2002 were retrospectively reviewed. Prostate biopsy and surgical specimen Gleason scores and correlative clinical data were recorded, and a multivariate analysis model was applied. RESULTS: Data were available in 293 cases (97%). The preoperative biopsy predicted the prostatectomy Gleason score accurately in 51% and undergraded them in 41% of the patients. Accuracy rates were significantly higher for Gleason scores 7-10 compared to low Gleason scores (2-4), concordance 90% and 6%, respectively (P < 0.01). Moreover, accuracy rates were higher in patients with prostate-specific antigen (PSA) higher than 10 ng/ml (85% vs. 40%; P < 0.01) and prostate glands smaller than 55 g (68% vs. 38%; P < 0.01). In 233 patients, the biopsy Gleason score did not include 4 or 5 components. Upgrading to 4 or 5 in 1 of the components was noted in 32 patients (14%). Multivariate analysis revealed that upgrading is associated with preoperative serum PSA (odds ratio 1.05; P < 0.05) and the percentage of positive cores in the biopsy (odds ratio 1.47; P < 0.001). CONCLUSIONS: Biopsy Gleason scores of 2-4, low PSA, and a low percentage of positive cores in the biopsy can predict the biopsy driven biologically significant undergrading of 1 of the components of the Gleason score that may adversely affect therapeutic decisions.     

前列腺癌分期方法的临床评价

目的 :探讨临床参数对前列腺癌分期的临床意义。　方法 :通过病理诊断、MRI检查及全身骨扫描对 112例经前列腺活检病理证实的前列腺癌进行分期 ,结合血清前列腺特异抗原 (PSA)、穿刺后Gleason评分、穿刺阳性针数百分率评价其临床意义。　结果 :112例前列腺癌中 ,血清PSA、Gleason评分、穿刺阳性针数百分率对前列腺癌分期有显著相关性 (r=0 .6 98,r=0 .6 74 ,r=0 .6 71,P均 <0 .0 0 1) ,但对B期和C期前列腺癌的诊断差异无显著性 (χ2=2 .6 75 ,P =0 .0 96 ;χ2 =0 .70 4 ,P =0 .4 0 1) ,血清PSA较Gleason评分和穿刺阳性针数百分率对D期的诊断差异有显著性 (χ2 =5 .135 ,P =0 .0 2 3;χ2 =4 .5 93,P =0 .0 32 )。血清PSA、Gleason评分和穿刺阳性针数百分率的敏感性分别为 76 .7%、83.3%和 77.8% ,特异性为 5 0 %、77.3%和 5 4 .5 % ,准确性为 71.4 %、82 .1%和 73.2 %。　结论 :血清PSA、Gleason评分、穿刺阳性针数百分率可预测前列腺癌的分期 ,穿刺后Gleason评分对前列腺癌分期的预测较血清PSA和穿刺阳性针数百分率更准确。血清PSA对远处转移性前列腺癌的预测更有意义     

The Role of TRUS Prostate Biopsy Quantitative Histology in Predicting the Risk of Extraprostatic Disease

Objectives: In the era of prostate-specific antigen (PSA), extended core biopsy schemes are widely adopted with an increased detection rate of stage T1c prostate cancer. As regards extraprostatic disease, the low predictive value of traditional prognostic factors, such as Gleason score (Gs) and PSA levels in this group of patients means that prostate biopsy quantitative histology plays a major role in the risk assessment of extraprostatic involvement.Methods: Literature on prostate biopsy was reviewed and a selection of articles made. Keywords used for the Medline search included: prostate cancer, biopsy, staging and prognosis.Results: Over the last few years, an increasing number of investigators have shown that number and percentage of positive cores, percentage of tumor involvement, maximum percentage of tumor involvement on the cores most strongly involved and tumor location, are considered the most predictive pathological parameters for adverse final pathological results. However, they are somewhat limited in terms of predicting the pathological stage of the disease on an individual basis.Conclusions: Nowadays, several quantitative histological parameters have been evidenced as good indicators for an extraprostatic spread of the tumor and positive surgical margins after radical prostatectomy. However, it is difficult for a single parameter in systematic biopsies to predict pathological stage and final outcome. Only the inclusion of some measure of neoplastic extension on the biopsies in models for the preoperative prediction of pathological stage will tell us what the definitive role of quantitative prostate biopsy is in assessing the risk of extraprostatic extension.     

Prostate cancers scored as Gleason 6 on prostate biopsy are frequently Gleason 7 tumors at radical prostatectomy: implication on outcome

PURPOSE: Differentiation between Gleason score 6 and 7 in prostate biopsy is important for treatment decision making. Nevertheless, under grading errors compared with the actual pathological grade at radical prostatectomy are common. We compared the characteristics and outcomes of tumors that were scored 6 on prostate biopsy but were 7 on subsequent radical prostatectomy pathological evaluation to those in tumors with a consistent rating of Gleason score 6 or 7 at biopsy and surgery. MATERIALS AND METHODS: We performed a retrospective database analysis from our referral center (1989 to 2004). We compared pre-prostatectomy characteristics, radical prostatectomy pathological features and the post-radical prostatectomy prostate specific antigen failure rate, defined as any 2 consecutive detectable prostate specific antigen measurements, in 3 subgroups of patients, including 156 with matched Gleason score 6 in the prostate biopsy and radical prostatectomy, 205 with upgraded Gleason score 6/7, that is prostate biopsy Gleason score 6 and radical prostatectomy Gleason score 7, and 412 with matched Gleason score 7 in the prostate biopsy and radical prostatectomy. RESULTS: Radical prostatectomy Gleason score matched the prostate biopsy score in 38.2% of biopsy Gleason score 6 and 81.4% of biopsy Gleason score 7 cases. Higher prostate specific antigen was associated and an increased percent of cancer in the prostate biopsy was predictive of discordance between the prostate biopsy and radical prostatectomy Gleason scores (p <0.001). Margin (p = 0.0075) or seminal vesicle involvement (p = 0.0002), cancer volume (p <0.001) and the prostate specific antigen failures rate (p = 0.014) were significantly higher in under graded Gleason score 7 cancer compared to those in matched Gleason score 6 cases. However, they were comparable to those with a matched Gleason score 7 tumor grade (p = 0.66). CONCLUSIONS: Almost half of tumors graded Gleason score 6 at biopsy are Gleason score 7 at surgery. Upgraded Gleason score 6 to 7 tumors have outcomes similar to those of genuine Gleason score 7 cancer. For prostate biopsy Gleason score 6 tumors clinicians should consider the overall likelihood of tumor upgrading as well as specific patient characteristics, such as prostate specific antigen and the percent of tumor in the prostate biopsy, when contemplating treatments that are optimized for low grade tumors, including watchful waiting or brachytherapy.     

Perineural invasion as a predictor of biochemical outcome following radical prostatectomy for select men with clinically localized prostate cancer

PURPOSE: The presence of perineural invasion on the prostate needle biopsy specimen has been suggested to be an independent predictor of prostate specific antigen (PSA) outcome following radical prostatectomy. We evaluated the clinical use of perineural invasion at biopsy for predicting time to PSA failure following radical prostatectomy after controlling for established prognostic factors. MATERIALS AND METHODS: A prospective evaluation using a Cox regression multivariate analysis of 750 men with clinically localized or PSA detected prostate cancer was performed to evaluate the ability of PSA, biopsy Gleason score, perineural invasion on the needle biopsy specimen and the percent of positive prostate biopsies to predict PSA outcome following radical prostatectomy. RESULTS: Multivariate analysis demonstrated that the presence of perineural invasion on the needle biopsy specimen provided additional information regarding 5-year PSA outcome (82% versus 95%, p = 0.04) for patients who were in the low risk group. This difference in PSA outcome could be explained by higher rates of positive surgical margins (25% versus 17%, p = 0.07). Patients whose prostate needle biopsy contained perineural invasion and who had the corresponding neurovascular bundle resected had a significantly lower positive margin rate (11% versus 100%, p = 0.001) compared to those who had the neurovascular bundle spared. The presence of perineural invasion on biopsy was not a significant predictor of PSA outcome following radical prostatectomy for patients in the intermediate or high risk group. CONCLUSIONS: Resection of the neurovascular bundle on the side corresponding to location of perineural invasion on the biopsy may decrease the positive surgical margin rate and improve outcome for low risk patients.     

The role of imaging studies and molecular markers for selecting candidates for radical prostatectomy

For the typical patient who has newly diagnosed prostate cancer, clinically organ-confined disease of moderate grade, and a PSA less than 10 ng/mL, the current role of imaging studies and molecular biomarkers is limited. Bone scans are not necessary for newly diagnosed men with a PSA less than 10 ng/mL in the absence of bone pain. Similarly, abdominal and pelvic CT scanning rarely provides any useful diagnostic or staging information when the PSA is less the 20 ng/mL and is indicated rarely. Endorectal coil MR imaging adds staging information for patients with a PSA between 10 and 20 ng/mL, a Gleason score of 7 or less, and 50% or more positive biopsies on a sextant sampling. Indium 111 capromab pendetide scanning (ProstaScint) is FDA-approved to evaluate newly diagnosed patients at high risk for metastases. These patients have a Gleason score of 7 or greater and a PSA greater than 20 ng/mL, a Gleason score of 8 to 10 regardless of the PSA value, or clinical stage T3 disease and a Gleason score of 6 or greater. RT-PCR testing of blood or bone marrow for prostate-specific or prostate cancer-specific gene expression, or "molecular staging," is a promising technique whose current use is still investigational. Much useful information may be gained by careful study of prostate needle biopsy material. Aside from current Gleason grading and the number or percentage of cores involved with cancer, no molecular biomarker is approved for clinical use. p27, p53, bcl-2, Ki-67 (MIB-1), and the assessment of neovascularity hold promise, but prospective multicenter studies are needed. In the long-term, multiple gene expression profiling of biopsy material using gene chips may revolutionize the care of patients with prostate cancer and those who elect radical prostatectomy.     

增加穿刺活检针数提高前列腺癌分级准确性的临床研究

目的 探讨增加穿刺活检针数能否提高前列腺癌穿刺标本Gieason评分准确性.方法 接受根治性前列腺切除的前列腺癌患者86例.平均年龄63(55～72)岁.术前PSA值平均16.8(1.6～57.2)ng/ml,前列腺体积平均39.4(18.1～114.1)ml.患者术前均未接受新辅助内分泌治疗,按经直肠前列腺穿刺针数分为2组.A组46例行标准6针系统穿刺,B组40例行13针系统穿刺.统计学比较分析2组穿刺标本与根治术标本Gleason评分符合情况及影响因素. 结果 A组穿刺标本与根治术标本Gleason评分相符16例(34.8%),B组为26例(65.O%),B组评分符合率明显高于A组(P＜0.05).当穿刺标本Gleason评分≤6时,B组评分相符11例(68.8%),明显高于A组5例(25.0%),差异有统计学意义(P＜0.05).多因素Logistic回归分析结果提示前列腺穿刺活检针数及活检阳性率是影响穿刺标本与根治术标本Gieason评分符合率的主要相关因素(P＜0.05).结论 增加穿刺针数能够提高经直肠前列腺穿刺标本Gleason评分预测前列腺癌分级的准确性.     

Nomograms to predict the pathological stage of clinically localized prostate cancer in Korean men: Comparison with Western predictive tools using decision curve analysis

Objectives: To develop and evaluate nomograms to predict the pathological stage of clinically localized prostate cancer after radical prostatectomy in Korean men. Methods: We reviewed the medical records of 2041 patients who had clinical stages T1c–T3a prostate cancer and were treated solely with radical prostatectomy at two hospitals. Logistic regressions were carried out to predict organ‐confined disease, extraprostatic extension, seminal vesicle invasion, and lymph node metastasis using preoperative variables and resulting nomograms. Internal validations were assessed using the area under the receiver operating characteristic curve and calibration plot, and then external validations were carried out on 129 patients from another hospital. Head‐to‐head comparisons with 2007 Partin tables and Cancer of the Prostate Risk Assessment score were carried out using the area under the curve and decision curve analysis. Results: The significant predictors for organ‐confined disease and extraprostatic extension were clinical stage, prostate‐specific antigen, Gleason score and a percent positive core of biopsy. Significant predictors for seminal vesicle invasion were prostate‐specific antigen, Gleason score and percent positive core, and those for lymph node metastasis were prostate‐specific antigen and percent positive core. The area under the curve of established nomograms for organ‐confined disease, extraprostatic extension, seminal vesicle invasion and lymph node metastasis were 0.809, 0.804, 0.889 and 0.838, respectively. The nomograms were well calibrated and externally validated. These nomograms showed significantly higher accuracies and net benefits than two Western tools in Korean men. Conclusion: This is the first study to have developed and fully validated nomograms to predict the pathological stage of prostate cancer in an Asian population. These nomograms might be more accurate and useful for Korean men than other predictive models developed using Western populations.     

Prognostic role of perineural invasion in prostate biopsy

IntroductionDespite tumour cell dissemination through the intraprostatic nervous system being considered as a prostate cancer progression mechanism, the significance of perineural invasion in prostate biopsies to predict extraprostatic extension and its use as a potential prognosis factor is controversial.Materials and methodsRetrospective study carried out at an institution on 208 patients treated with radical prostatectomy (January 2007 - July 2010) in which the presence of perineural invasion and the Gleason score in the preoperative biopsy were determined, as well as the clinical stage and the pre-surgery PSA. We classified the patients in risk groups in accordance with the D’Amico classification. We performed bivariate and multivariate statistical analyses to establish the correlations between the different variables.ResultsWe objectified PNI in 18.3% of the prostate biopsies. 71% of the prostatectomy specimens with perineural invasion presented extraprostatic extension in the previous biopsy against 23.1% when this was not found (p < 0.0001) and 47% of the cases showed positive margins with PNI, against 18.3% without perineural invasion (p < 0.0001). In fact, in the multivariate analysis, perineural invasion proved to be an independent risk factor in the presentation of extraprostatic extension and positive margins in the prostatectomy specimen.ConclusionsThe presence of perineural invasion is a useful prognostic factor for predicting extraprostatic extension and the involvement of surgical margin in the radical prostatectomy specimen. We believe that determining it may be a useful tool for improving preoperative diagnosis and planning treatment.