Racial/ethnic differences in receipt of pelvic lymph node dissection among men with localized/regional prostate cancer

BACKGROUND:

Black and Hispanic men have a lower prostate cancer (PCa) survival rate than white men. This racial/ethnic survival gap has been explained in part by differences in tumor characteristics, stage at diagnosis, and disparities in receipt of definitive treatment. Another potential contributing factor is racial/ethnic differences in the timely and accurate detection of lymph node metastases. The current study was conducted to examine the association between race/ethnicity and the receipt of pelvic lymph node dissection (PLND) among men with localized/regional PCa.

METHODS:

Logistic regression was used to estimate the adjusted odds of undergoing PLND among men who were diagnosed during 2000 to 2002 with PCa, who underwent radical prostatectomy or PLND without radical prostatectomy, and who were diagnosed in regions covered by the Surveillance, Epidemiology, and End Results database (n = 40,848).

RESULTS:

Black men were less likely to undergo PLND than white men (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.84‐0.98). When the analysis was stratified by PCa grade, black men with well differentiated PCa (OR, 0.48; 95% CI, 0.27‐0.84) and poorly differentiated PCa (OR, 0.73; 95% CI, 0.60‐0.89) were less likely to undergo PLND than their white counterparts, but racial differences were not observed among men with moderately differentiated PCa (OR, 0.96; 95% CI, 0.88‐1.05).

CONCLUSIONS:

Among men with poorly differentiated PCa, failure to undergo PLND was associated with worse survival. Racial disparities in the receipt of PLND, especially among men with poorly differentiated PCa, may contribute to racial differences in prostate cancer survival. Cancer 2011;. © 2011 American Cancer Society.     

Analysis of pathologic extent of disease for clinically localized prostate cancer after radical prostatectomy and subsequent use of adjuvant radiation in a national cohort

BACKGROUND:

The Surveillance, Epidemiology, and End Results database was analyzed to explore the pathologic extent of disease for clinically localized prostate cancer after radical prostatectomy as well as the use of adjuvant radiation in this population.

METHODS:

Identified were patients from 2004 to 2006 with clinically staged T1c‐2cNx‐0M0 prostate adenocarcinoma who underwent radical prostatectomy. All patients had complete clinical and pathologic data. The use of postoperative radiation was recorded. Logistic regression analysis was performed to identify unadjusted and adjusted predictors for extraprostatic disease or positive surgical margins and for adjuvant radiation use.

RESULTS:

A total of 35,642 patients were identified. For those patients with Gleason 7 (4 + 3) and a prostate‐specific antigen (PSA) level of ≥10.1 ng/mL or Gleason 8 to 10 with any PSA level, the rate of organ‐confined disease with negative surgical margins was found to be <50%. Of those with indications for adjuvant radiation, 11.1% received the treatment.

CONCLUSIONS:

This large population‐based study detailed the risk of extraprostatic extension and positive surgical margins in a broad setting across multiple regions and communities, as well as the use of adjuvant radiation for these patients. As of 2006, 11.1% of patients who had indications for adjuvant radiation received this treatment, providing a useful baseline for future patterns of care studies. Cancer 2010. © 2010 American Cancer Society.     

Phase 2 study of neoadjuvant docetaxel plus bevacizumab in patients with high-risk localized prostate cancer : A Prostate Cancer Clinical Trials Consortium trial

BACKGROUND:

Treatment of high‐risk localized prostate cancer remains inadequate. The authors performed a phase 2 multicenter trial of neoadjuvant docetaxel plus bevacizumab before radical prostatectomy.

METHODS:

Eligibility included any of the following: prostate‐specific antigen (PSA) >20 ng/mL or PSA velocity >2 ng/mL/y, cT3 disease, any biopsy Gleason score 8 to 10, and Gleason score 7 with T3 disease by endorectal magnetic resonance imaging (MRI) at 1.5 T. Also, those with ≥50% biopsy cores involved and either Gleason score 7, PSA >10, or cT2 disease were eligible. Patients were treated with docetaxel 70 mg/m² every 3 weeks for 6 cycles and bevacizumab 15 mg/m² every 3 weeks for 5 cycles. The primary endpoint was partial response by endorectal MRI.

RESULTS:

Forty‐one patients were treated. Median age was 55 years (range, 40‐66 years). Baseline characteristics included: median PSA, 10.1 ng/mL; cT2, 49%, cT3, 32%; and Gleason score 8 to 10, 73%. Thirty‐eight of 41 (93%) patients completed all 6 cycles. Grade ≥3 adverse events were rare, although 3 of 41 (7%) experienced febrile neutropenia. Twelve patients (29%; 95% confidence interval [CI], 16%‐45%) achieved a >50% reduction in tumor volume, and 9 patients (22%; 95% CI, 11%‐38%) achieved a >50% post‐treatment decline in PSA. Thirty‐seven of the 41 patients underwent radical prostatectomy; there were no complete pathologic responses.

CONCLUSIONS:

Neoadjuvant docetaxel and bevacizumab is safe, and results in reductions in both tumor volume and serum PSA, in men with high‐risk localized prostate cancer. The role of neoadjuvant chemotherapy in prostate cancer, and perioperative antiangiogenic therapy in general, requires further elucidation through ongoing and planned trials. Cancer 2012. © 2012 American Cancer Society.     

The impact of robot-assisted radical prostatectomy on the use and extent of pelvic lymph node dissection in the “post-dissemination” period

Introduction

Previous series during the dissemination era of minimally invasive techniques for treatment of prostate cancer (PCa) showed a declining use of pelvic lymph node dissection (PLND). The aim of our study was to re-assess the impact of robot-assisted radical prostatectomy (RARP) on the utilization rate of PLND and its extent in the post-dissemination period.

Methods

Relying on the Surveillance Epidemiology and End Results (SEER) Medicare-linked database, 5804 patients with non-metastatic PCa undergoing open radical prostatectomy (ORP) or RARP between years 2008 and 2009 were identified. Uni- and multivariable logistic regression analyses tested the relationship between surgical approach (RARP vs. ORP) and: 1 – the rate of PLND (pNx vs. pN0-1); and 2 – the extent of PLND (limited vs. extended).

Results

Overall, 3357 (57.8%) patients underwent a PLND. The proportion of patients treated with PLND was significantly higher among ORP vs. RARP patients: 71.2 vs. 48.6%, respectively (P < 0.001). In addition, the median number of lymph nodes removed was significantly higher for patients treated with ORP vs. RARP: 5 vs. 4, respectively (P < 0.001). In multivariable analyses, ORP was associated with 2.7- and 1.3-fold higher odds of undergoing PLND and of receiving an extended PLND compared to RARP, respectively (both P ≤ 0.001). Stratified analyses according to disease risk classifications revealed similar trends.

Conclusions

In the post-dissemination era, RARP remains associated with a decreased use of PLND and suboptimum extent. Efforts should be made to improve guideline adherence in performing a PLND whenever indicated according to tumor aggressiveness, despite surgical approach.     

Costs of medical care after open or minimally invasive prostate cancer surgery: a population-based analysis

BACKGROUND:

Evidence suggests that minimally invasive radical prostatectomy (MRP) and open radical prostatectomy (ORP) have similar short‐term clinical and functional outcomes. MRP with robotic assistance is generally more expensive than ORP, but it is not clear whether subsequent costs of care vary by approach.

METHODS:

In the Surveillance, Epidemiology, and End Results (SEER) cancer registry linked with Medicare claims, men aged 66 years or older who received MRP or ORP in 2003 through 2006 for prostate cancer were identified. Total cost of care was estimated as the sum of Medicare payments from all claims for hospital care, outpatient care, physician services, home health and hospice care, and durable medical equipment in the first year from the date of surgical admission. The impact of surgical approach on costs was estimated, controlling for patient and disease characteristics.

RESULTS:

Of 5445 surgically treated prostate cancer patients, 4454 (82%) had ORP and 991 (18%) had MRP. Mean total first‐year costs were more than $1200 greater for MRP compared with ORP ($16,919 vs $15,692; P = .08). Controlling for patient and disease characteristics, MRP was associated with 2% greater mean total payments, but this difference was not statistically significant. First‐year costs were greater for men who were older, black, lived in the Northeast, had lymph node involvement, more advanced tumor stage, or greater comorbidity.

CONCLUSIONS:

In this population‐based cohort of older men, MRP and ORP had similar economic outcomes. From a payer's perspective, any benefits associated with MRP may not translate to net savings compared with ORP in the first year after surgery. Cancer 2012;118: 3079–86. © 2011 American Cancer Society.     

Prostate-specific antigen velocity and prostate cancer gleason grade and stage

BACKGROUND: Increased preoperative prostate-specific antigen (PSA) velocity (PSAV) has been associated with increased prostate cancer mortality and higher Gleason scores. The authors evaluated the relation between PSAV, biopsy Gleason score, and pathologic stage in men who were enrolled in a prostate cancer screening trial. METHODS: Data were analyzed from 1441 men who were enrolled in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial who received > or =2 PSA screens and were diagnosed with prostate cancer within 1 year of the last screen. PSAV was estimated by using all screening PSA values within 6 years prediagnosis. RESULTS: Both PSA and PSAV were related to biopsy Gleason score. The multivariable odds ratios (OR), controlling for PSA and demographics, for having a Gleason score of 7 to 10 were 1.3 (95% confidence interval [95% CI], 0.9-1.9), 2.2 (95% CI, 1.5-3.3), and 2.3 (95% CI, 1.4-3.9) for men with PSAV values from 0.5 to 1 ng/mL per year, from 1 to 2 ng/mL per year, and >2 ng/mL per year, respectively, compared with men who had PSAV values <0.5 ng/mL per year. The median PSAV was 0.60 ng/mL per year for men with Gleason scores from 2 to 6 versus 0.84 ng/mL per year for men with Gleason scores from 7 to 10 (P < .0001). Among 658 men who underwent prostatectomy, both PSA and PSAV were associated with advanced pathologic stage in univariate analyses; however, when the analysis controlled for clinical stage and biopsy Gleason score, the associations of PSA and PSAV were no longer statistically significant. CONCLUSIONS: PSAV and PSA levels were associated independently with biopsy Gleason score. Among men who underwent prostatectomy, PSAV and PSA were not predictive of advanced pathologic stage when the analysis was controlled for biopsy Gleason score and clinical stage. It cannot be determined yet whether PSAV is predictive of long-term prostate cancer outcome in this cohort.     

Preoperative prediction of extracapsular tumor extension at radical retropubic prostatectomy in Taiwanese patients with T1c prostate cancer

BACKGROUND: To find a predictor for extracapsular tumor extension at radical retropubic prostatectomy (RRP) in Taiwanese patients with stage T1c prostate cancer (PC), preoperative transrectal sonoguiding prostate biopsy outcomes and clinicopathological data obtained from these patients were reviewed. METHODS: Fifty-five consecutive men who underwent radical retropubic prostatectomy for stage T1c PC were included. Preoperative sextant needle biopsies of the prostate were performed and whole-mount prostatectomy specimens were processed. The pathological end point was tumor capsular perforation extending entirely through the prostate capsule. Preoperative prostate-specific antigen (PSA), free-to-total PSA ratio, prostate volume, PSA density, Gleason score, number of positive biopsy cores, percentage cancer of sextant biopsies, percentage cancer of one lobe and percentage cancer of one core were analyzed for their ability to predict extracapsular tumor extension at RRP. RESULTS: Eighteen of the 55 specimens showed evidence of tumor capsular perforation. Those with extracapsular tumor extension (ECE) had higher PSA than organ-confined disease (OCD) (18.4 vs 8.3 ng/ml, P < 0.01). The ECE had a higher PSA density than OCD (0.556 vs 0.226, P < 0.01). The percentage of cancer in biopsies, percentage cancer of one lobe and percentage cancer of one core were all higher in ECE than OCD (P < 0.05). The ECE had a higher biopsy Gleason score than OCD (5.6 vs 4.5, P < 0.01). CONCLUSIONS: The four strongest predictors for extracapsular tumor extension of patients with T1c PC were PSA density >or=0.35, biopsy Gleason score >or=6, >or=20% cancer in biopsies and PSA >or=10 ng/ml.     

Biochemical recurrence after radical prostatectomy for prevalent versus incident cases of prostate cancer : implications for management

BACKGROUND.

Among screened populations, it is unknown whether men with prostate cancer (PC) diagnosed at the initial screening (prevalent cases) have a different outcome than men who are diagnosed at subsequent screenings (incident cases) after adjusting for known prognostic factors.

METHODS.

The current study cohort was comprised of 1923 men from a prospective PC screening study who underwent radical prostatectomy (RP) between September 19, 1989 and May 22, 2002. Cox regression multivariate analysis was used to determine whether having prevalent PC versus incident PC was associated with the time to prostate‐specific antigen (PSA) failure after RP after adjusting for PSA level, Gleason score, clinical tumor (T) classification, and year of RP.

RESULTS.

Men with prevalent PC had higher PSA levels (P < .001) and more advanced clinical T classification (P < .001) than men with incident PC. After a median follow‐up of 6.1 years, factors that were associated with a significantly shorter time to PSA failure after RP were prevalent PC (adjusted hazard ratio [AHR], 1.8; 95% confidence interval [95% CI], 1.3‐2.6; P = .0005), baseline PSA (AHR, 1.07; 95%CI, 1.04‐1.09; P < .001), Gleason 7 disease (AHR, 2.5; 95% CI, 1.9‐3.3; P < .001), Gleason 8 to 10 disease (AHR, 2.3; 95%CI, 1.5‐3.5; P < .001), and the year of RP (AHR, 0.92; 95%CI, 0.86‐0.97; P = .003). Men with prevalent PC also had worse outcomes after adjusting for their more advanced pathologic features.

CONCLUSIONS.

After adjusting for known prognostic factors, men with prevalent PC had a poorer outcome after RP than men with incident PC. The authors believe that this finding should be taken into consideration when weighing the risk of recurrence and treatment options for men who are diagnosed with PC on their initial screening. Cancer 2008. © 2008 American Cancer Society.     

Radioisotope guided sentinel lymph node dissection in patients with localized prostate cancer: Results of the first 100 cases

Aims

The purpose of this prospective study was to assess the results and the relevance of radioisotope guided pelvic lymph node dissection (PLND) in loco-regional staging in patients with clinically localized prostate cancer.

Methods

A total of 100 patients with prostate cancer underwent radioisotope guided PLND. Eighty-seven patients were candidates for retropubic radical prostatectomy and 13 underwent radiotherapy. The 72 first patients received 2× 0.3 ml of 30 MBq-nanocolloid-^99mTc and the next 28 patients received 2× 0.3 ml of 100 MBq. Sentinel lymph nodes (SLNs) were detected intraoperatively with a gamma probe.

Results

A median number of three SLNs was removed per patient. SLNs were located outside obturator fossa in more than two thirds of patients. Lymph node involvement was observed in 12% of patients. Fifty percent of the LNM were outside obturator fossa;41.6% of lymph node metastases (LNM) were lying at the first centimeters of the hypogastric artery. Eleven of the 13 LNM were detected in the SLN. The two non-SLN (NSLN) involved nodes were found in two patients who failed the sentinel lymph node procedure. Each of 12 patients had pre-operative PSA above 10 ng/ml and Gleason score ≥7.

Conclusions

Limited PLND to obturator fossa is clearly insufficient for accurate lymph node staging in patients with prostate cancer. SLN procedure could be an alternative for pelvic lymph node staging with an excellent sensitivity in patients with unfavorable prognostic factors (PSA >10 ng/ml; biopsy Gleason score >6).     

Predicting prostate specific antigen failure after radical retropubic prostatectomy for T1c prostate cancer

PURPOSE: Clinicopathological data were reviewed to find a predictor of prostate specific antigen (PSA) failure in Taiwanese patients who had received radical retropubic prostatectomy (RRP) for stage T1c prostate cancer (PC). METHODS: Fifty-five consecutive men who underwent RRP for stage T1c PC were included. The clinical end point was PSA failure (PSA >0.2 ng/ml). Preoperative PSA, free-to-total PSA ratio, prostate volume, PSA density, transrectal sextant biopsy and whole mount of RRP parameters were analyzed for their ability to predict postoperative PSA failure. RESULTS: Fifteen of the 55 patients developed PSA failure during the follow-up period. Those with PSA failure had higher PSA, higher percentage of cancer in biopsies and higher biopsy Gleason score than the freedom from PSA failure group (all P < 0.05). The PSA failure group had higher pathology Gleason score and a higher incidence of extracapsular tumor extension than the freedom from PSA failure group (all P < 0.05). The PSA failure group had a larger tumor volume and higher incidence of combined peripheral lobe with transitional lobe involvement than the freedom from PSA failure group (all P < 0.05). Multivariate analysis revealed that the predictors for PSA failure after RRP were biopsy Gleason score > or =6, tumor volume > or =2.5 ml and PSA > or =10 ng/ml. CONCLUSION: The single most significant predictor for PSA failure in T1c PC patients after RRP was tumor volume > or =2.5 ml.     

Importance of margin extent as a predictor of outcome after adjuvant radiotherapy for Gleason score 7 pT3N0 prostate cancer

PURPOSE: To evaluate, in Gleason score 7, pT3N0 prostate cancer patients with positive surgical margins, the predictors of progression-free survival and to identify a patient subgroup that would benefit from immediate adjuvant postoperative radiotherapy (ART). METHODS AND MATERIALS: Between November 1989 and August 1998, 76 men underwent radical prostatectomy and were found to have capsular penetration (pT3N0), surgical Gleason score 7, tumor present at the resection margin, and an undetectable postoperative prostate-specific antigen (PSA) level. All surgical specimens underwent whole-mount serial sectioning to determine the degree of margin positivity (focal vs. extensive). Of the 76 men, 45 underwent early ART (within 6 months with a median dose of 64.8 Gy), and 31 had no immediate treatment. We defined freedom from PSA failure (bNED) as the absence of two consecutive PSA rises >0.2 ng/mL. RESULTS: The median follow-up time was 5.1 years (range, 2-10 years). The ART and non-ART patients were similar with respect to preoperative PSA level, Gleason score (4 + 3 vs. 3 + 4), presence of seminal vesicle invasion, and margin extent. On univariate analysis, margin extent was predictive for improved bNED (5-year bNED rate of 92% vs. 58%, p = 0.010, for men with focal and extensive margins, respectively). Gleason score (4 + 3 vs. 3 + 4), seminal vesicle invasion, and ART were not statistically significant predictors. On multivariate analysis, the preoperative PSA level, margin extent, and ART were independent significant factors. In the group with extensive surgical margins, men receiving ART had a significantly greater 5-year bNED survival rate compared with the non-ART patients (73% vs. 31%, p = 0.004). CONCLUSION: These data suggest that the amount of microscopic residual tumor significantly affects bNED after radical prostatectomy for Gleason score 7, pT3N0 prostate cancer. In addition, men with pathologic evidence of microscopic local disease appear to benefit from early ART compared with untreated controls.     

Operative Therapie des lokal begrenzten Prostatakarzinoms

Background

Radical prostatectomy is the most frequently used therapy for localized prostate cancer. Staging measures are based on the preoperative parameters prostate-specific antigene (PSA) level, the Gleason score of biopsy material and the results of the digital rectal examination for diagnostics of the extent of tumor spread. For low risk cancers (PSA <?10 ng/ml, cT1c–cT2a and Gleason sum ≤?6) no further imaging diagnostics should be performed.

Results

Radical prostatectomy can be performed by open surgery (ORP), laparoscopically (LRP) or robot-assisted (RALP). In a prospective randomized trial radical prostatectomy significantly reduced local progression, distant metastases and prostate cancer mortality compared to watchful waiting. Progression-free survival after radical prostatectomy is >?80?% after 7 years and cancer-specific survival rates of >?90?% after 15 years have been reported. Perioperative complications are observed in 9?% of the patients. In recent retrospective studies incontinence rates between 8 and 11?% were reported. Depending on tumor stage a nerve sparing approach is possible and results in postoperative potency rates between 50 and 90?%.

Conclusions

Surgeons experience is of paramount importance for the outcome of radical prostatectomy. Furthermore, comparisons of retrospective data suggest that RALP improves a number of short-term outcomes. Two randomized studies showed concordantly significantly better continence and potency rates after RALP compared to conventional LRP.     

Long-term outcomes of radical prostatectomy with multimodal adjuvant therapy in men with a preoperative serum prostate-specific antigen level > or =50 ng/mL

BACKGROUND.

The authors evaluated the long‐term outcomes of men with prostate cancer and very high (≥50 ng/mL) preoperative serum prostate‐specific antigen (PSA) values that were treated with radical prostatectomy.

METHODS.

This study included 236 men with preoperative serum PSA values ≥50ng/mL who underwent radical retropubic prostatectomy between 1987 and 2004. For comparison, the study cohort was divided into 2 groups: patients with PSA levels between 50 and 99 ng/mL and patients with PSA levels ≥100 ng/mL. Biochemical recurrence was defined as a single postoperative serum PSA value of 0.4 ng/mL or greater. Systemic disease progression was defined as the development of a local recurrence or systemic metastases, and any death resulting from prostate cancer or its treatment was defined as a cancer‐specific mortality.

RESULTS.

Biochemical recurrence‐free survival rates in the groups of patients with a PSA level 50 to 99 ng/mL and ≥100 ng/mL were 43% and 36% at 10 years, respectively. Systemic progression‐free survival rates in the PSA 50 to 99 ng/mL and PSA ≥100 ng/mL groups were 83% and 74% at 10 years, respectively. Estimated overall cancer‐specific survival was 87% at 10 years.

CONCLUSIONS.

Patients with prostate cancer and a serum PSA level ≥50 ng/mL have very high‐risk prostate cancer that carries a high likelihood of being pathologically advanced. Although the probability of realizing long‐term survival in these high‐risk patients is less than in patients with more favorable disease, 10‐year survival outcomes remain excellent and argue for aggressive management of these cases. Cancer 2008. © 2008 American Cancer Society.     

Impact of recent screening on predicting the outcome of prostate cancer biopsy in men with elevated prostate‐specific antigen

BACKGROUND:

Risk models to predict prostate cancer on biopsy, whether they include only prostate‐specific antigen (PSA) or other markers, are intended for use in all men of screening age. However, the association between PSA and cancer probably depends on a man's recent screening history.

METHODS:

The authors examined the effect of prior screening on the ability to predict the risk of prostate cancer by using a previously reported, 4‐kallikrein panel that included total PSA, free PSA, intact PSA, and human kallikrein‐related peptidase 2 (hK2). The study cohort comprised 1241 men in Gothenburg, Sweden who underwent biopsy for elevated PSA during their second or later visit for the European Randomized Study of Screening for Prostate Cancer. The predictive accuracy of the 4‐kallikrein panel was calculated.

RESULTS:

Total PSA was not predictive of prostate cancer. The previously published 4‐kallikrein model increased predictive accuracy compared with total PSA and age alone (area under the curve [AUC], 0.66 vs 0.51; P < .001) but was poorly calibrated and missed many cancers. A model that was developed with recently screened men provided important improvements in discrimination (AUC, 0.67 vs 0.56; P < .001). Using this model reduced the number of biopsies by 413 per 1000 men with elevated PSA, missed 60 of 216 low‐grade cancers (Gleason score ≤6), but missed only 1 of 43 high‐grade cancers.

CONCLUSIONS:

Previous participation in PSA screening dramatically changed the performance of statistical models that were designed to predict biopsy outcome. A 4‐kallikrein panel was able to predict prostate cancer in men who had a recent screening history and provided independent confirmation that multiple kallikrein forms contribute important diagnostic information for men with elevated PSA. Cancer 2010. © 2010 American Cancer Society.     

Association between percentage of tumor involvement and Gleason score upgrading in low-risk prostate cancer

To find the predictors of Gleason score upgrading in a cohort of low-risk prostate cancer patients, data were analyzed comprising 1,632 consecutive men with low-risk prostate cancer who underwent radical prostatectomy between 1993 and 2009. Assessment focused on preoperative parameters including patient age, race, diagnostic prostate-specific antigen (PSA) levels, clinical stage and biopsy Gleason score, along with pathological parameters including percentage of tumor involvement (PTI), tumor laterality, pathological stage, extra-capsular extension, seminal vesicle invasion, and surgical margins. These parameters were analyzed using univariate and multivariate methods. Kaplan?CMeier curves compared differences in biochemical disease-free survival in men having cancers with and without Gleason score upgrading. Cases involving pathological Gleason score upgrading were identified in 723 (44.3?%) of 1,632 patients. Kaplan?CMeier PSA recurrence-free survival curves showed a difference in outcome between men with and without Gleason score upgrading (p?<?0.001). Of Gleason score upgraded patients, 35 (4.8?%) men had PTI of <5?%, 237 (32.8?%) had PTI of 5?C9.9?%, 177 (24.5?%) had PTI of 10?C14.9?%, and 274 (37.9?%) had PTI????15?% (p?<?0.001). PTI (p?<?0.001) along with diagnostic PSA, patient age, diagnostic biopsy Gleason score, pathologic stage, and surgical margin status were independent predictors of pathological Gleason score upgrading on multivariate logistic regression. PTI correlates closely with Gleason score upgrading in a low-risk prostate cancer cohort. Low-risk prostate cancer patients with clinical findings suggestive of high PTI or large volume cancers should not benefit from active surveillance strategies.     

Long‐term adverse effects after retropubic and robot‐assisted radical prostatectomy. Nationwide,population‐based study

Background and Objectives

Surgery for prostate cancer is associated with adverse effects. We studied long‐term risk of adverse effects after retropubic (RRP) and robot‐assisted radical prostatectomy (RARP).

Methods

In the National Prostate Cancer Register of Sweden, men who had undergone radical prostatectomy (RP) between 2004 and 2014 were identified. Diagnoses and procedures indicating adverse postoperative effects were retrieved from the National Patient Register. Relative risk (RR) of adverse effects after RARP versus RRP was calculated in multivariable analyses adjusting for year of surgery, hospital surgical volume, T stage, Gleason grade, PSA level at diagnosis, patient age, comorbidity, and educational level.

Results

A total of 11 212 men underwent RRP and 8500 RARP. Risk of anastomotic stricture was lower after RARP than RRP, RR for diagnoses 0.51 (95%CI = 0.42‐0.63) and RR for procedures 0.46 (95%CI = 0.38‐0.55). Risk of inguinal hernia was similar after RARP and RRP but risk of incisional hernia was higher after RARP, RR for diagnoses 1.48 (95%CI = 1.01‐2.16), and RR for procedures 1.52 (95%CI = 1.02‐2.26).

Conclusions

The postoperative risk profile for RARP and RRP was quite similar. However, risk of anastomotic stricture was lower and risk of incisional hernia higher after RARP.     

African-American men with nonpalpable prostate cancer exhibit greater tumor volume than matched white men

BACKGROUND: Although prostate cancer (PC) mortality disproportionately affects African-American (AA) men, limited data exist comparing the pathologic characteristics of white and AA patients with nonpalpable PC (clinical stage T1c). METHODS: The authors reviewed the radical prostatectomy (RP) specimens from 37 consecutive AA men with clinical stage T1c PC and 35 white men who were matched for age, clinical stage, serum prostate-specific antigen (PSA) level, year of surgery, prostate weight, and prostate biopsy strategy. Pathologic characteristics were compared after mapping tumor foci and calculating tumor volumes by using computer software. RESULTS: For AA men, the median age (57.7 years), mean serum PSA level (9.3 ng/mL), mean prostate weight (43 g), and biopsy strategy (73% sextant) were matched with the cohort of 35 white men (median age, 57.1 years; mean PSA, 9.3 ng/mL;, mean prostate weight, 43 g; biopsy strategy, 66% sextant). Despite similar biopsy characteristics between the 2 groups (Gleason score > or =7 in 43% of AA men vs. 37% of white men), AA men exhibited significantly higher prostatectomy Gleason scores (> or =7 in 76% of AA men vs. 34% of white men; P = .01). AA men also had a higher mean tumor volume (1.82 cm3 vs. 0.72 cm3; P = .001) and had 2.8 times more tumor per ng/mL of serum PSA (0.22 cm3 per ng/mL vs. 0.079 cm3 per ng/mL; P = .001). CONCLUSIONS: Compared with a cohort of white men with similar clinical features at the time of biopsy, AA men with nonpalpable PC had higher prostatectomy Gleason scores, greater cancer volume, and greater tumor volume per ng/mL of serum PSA. These data provide additional support for the concept of early PC detection using a serum PSA threshold of 2.5 ng/mL for biopsy among AA men.     

An immunohistochemical signature comprising PTEN,MYC, and Ki67 predicts progression in prostate cancer patients receiving adjuvant docetaxel after prostatectomy

BACKGROUND:

Loss of the tumor suppressor PTEN is common in prostate cancer and may have prognostic significance. The authors examined PTEN and additional protein markers in primary tumors from patients with high‐risk, localized prostate cancer who received adjuvant docetaxel in a prospective multicenter trial (TAX2501).

METHODS:

Fifty‐six of 77 patients enrolled in TAX2501 had primary prostatectomy specimens available for immunohistochemical analysis of PTEN, MYC, ERG, tumor protein p53 (p53), antigen KI‐67 (Ki67), and phosphorylated forms of Akt, mammalian target of rapamycin (mTOR), and S6 ribosomal protein. Protocol‐defined progression included a prostate‐specific antigen (PSA) level ≥0.4 ng/mL, radiologic/clinical recurrence, or death. Univariate and multivariable proportional hazards regression analyses were used to investigate the influence of PTEN status (and other protein markers) on progression‐free survival (PFS).

RESULTS:

In this exploratory, post hoc analysis, PTEN protein loss (vs presence) was observed in 61% of patients and was associated with lower preoperative PSA levels, higher clinical stage, lower Ki67 expression, the presence of p53, and the presence of ERG. In univariate analysis, the factors associated with PFS included Gleason sum, seminal vesicle invasion, PTEN status, MYC expression, and Ki67 expression. In multivariable analysis, only 3 variables emerged as independent prognostic factors for PFS: PTEN status (P = .035), MYC expression (P = .001), and Ki67 expression (P < .001). A prognostic model was constructed that incorporated clinical covariates as well as information on PTEN, MYC, and Ki67.

CONCLUSIONS:

The current results indicated that PTEN status, MYC expression, and Ki67 expression in primary tumor samples may predict PFS more accurately than clinical factors alone in men with high‐risk prostate cancer who receive adjuvant docetaxel after prostatectomy. If validated, these hypothesis‐generating findings may have prognostic and therapeutic implications and may aid clinical trial design. Cancer 2012. © 2012 American Cancer Society.     

Ductal adenocarcinoma of the prostate

BACKGROUND:

Ductal or endometrioid adenocarcinoma of the prostate may be a subtype of prostate cancer that is amenable to aggressive local therapeutic strategies. The authors of this report investigated the clinical outcome of patients who had prostate ductal adenocarcinoma after primary radical prostatectomy or radiotherapy.

METHODS:

The clinical features of 108 patients with locally confined or advanced prostate ductal adenocarcinoma who had undergone primary radical prostatectomy (surgical group, n = 76 men) or no surgery (nonsurgical group, n = 32 men) were evaluated retrospectively. Clinical records were reviewed, and Gleason scores, clinical/pathologic stages, and preoperative prostate‐specific antigen levels were examined. The clinical features that were assessed included local recurrence, distant metastasis, and progression‐free and overall survival after primary therapy.

RESULTS:

In the surgical group, patients who had pure ductal prostate cancer survived longer (median, 13.8 years; 95% confidence interval [CI], from 13.8 years to not attained) than patients who had mixed ductal prostate cancer (median, 8.9 years; 95% CI, from 7.1 years to not attained; P = .05). In addition, the median time to local progression was shorter (2.8 years vs 4.9 years) and the median time to distant metastasis was longer (3.9 years vs 2.0 years) for patients who had pure ductal adenocarcinoma than for patients who had mixed ductal adenocarcinoma of the prostate after surgery, respectively.

CONCLUSIONS:

The results of this preliminary study suggested that pure ductal prostate adenocarcinoma tends to pursue an indolent clinical course and poses an increased risk for local recurrence. Local control (particularly prostatectomy) may improve the clinical outcome of patients with pure prostate ductal adenocarcinoma. These results need to be confirmed in prospective studies. Cancer 2009. © 2009 American Cancer Society.     

Tumour growth fraction measured by immunohistochemical staining of Ki67 is an independent prognostic factor in preoperative prostate biopsies with small‐volume or low‐grade prostate cancer

Accurate prognostic parameters in prostate biopsies are needed to better counsel individual patients with prostate cancer. We evaluated the prognostic impact of morphologic and immunohistochemical parameters in preoperative prostate cancer biopsies. A consecutive series of prostate biopsies of 279 men (72% with clinical stage T1c and 23% with T2) who subsequently underwent radical prostatectomy was prospectively analysed for Gleason score, number and percentage of positive cores (NPC, PPC), total percentage of biopsy tissue with tumour (TPT), maximum tumour percentage per core (MTP), and expression of Ki67, Bcl‐2 and p53. All biopsy features were significantly associated with at least one feature of the radical prostatectomy specimen. pT stage was independently predicted by PSA, seminal vesicle invasion by Ki67 LI, positive margins by PSA and MTP, large tumour diameter by PSA and PPC, and Gleason score by biopsy Gleason score, MTP, and Ki67 LI, respectively. Biopsy Gleason score, NPC (1 vs. >1), TPT (<7 vs. ≥7%), and Ki67 LI (<10 vs. ≥10%) were significant predictors of biochemical recurrence after radical prostatectomy (p < 0.01, each). KI67 LI was the only independent prognostic factor in case of a low TPT (<7%) or low Gleason score (<7), the hazard ratio being 6.76 and 6.44, respectively. In summary, preoperative Gleason score, NPC, TPT and Ki67 LI significantly predict the risk of recurrence after radical prostatectomy, and Ki67 is an independent prognosticator in biopsies with low‐volume or low‐grade prostate cancer. Analysis of Ki67 LI in these biopsies may help to better identify patients with clinically insignificant prostate cancer. © 2008 Wiley‐Liss, Inc.