ISUP版Gleason评分在前列腺癌根治术后评分升级的影响因素分析

目的:探讨前列腺癌根治术后标本较前列腺穿刺活检标本Gleason评分升级的影响因素。方法:回顾性分析2012年1月至2015年6月接受前列腺穿刺活检确诊为前列腺癌并行根治性切除的235例患者年龄、术前PSA、前列腺体积、PSA密度(PSAD)、穿刺至手术间隔时间、穿刺阳性针数、切缘情况、精囊侵犯、淋巴转移等指标,统计其穿刺和术后Gleason评分的差异。运用Logistic回归分析引起术后Gleason评分升级的危险因素。结果:164例患者纳入分析,其中术前穿刺与根治术后标本Gleason评分相符有95例(57.93%),术后上升55例(33.54%),下降14例(8.52%)。前列腺体积(P0.01)和穿刺评分(P0.05)是影响根治术后标本Gleason评分升级的独立预测因子,其中前列腺体积≤25 ml组其术后Gleason评分升高的风险是体积60 ml组的27倍(P0.05),前列腺体积25~40 ml组术后Gleason评分升高的风险是体积60 ml组的9倍(P0.05)。结论:穿刺Gleason评分≤6、小体积前列腺(≤40 ml),术后Gleason评分升级可能性大。     

低危型前列腺癌患者术前穿刺病理Gleason评分发生术后病理升级的相关因素分析

目的:探讨引起低危型前列腺癌(PCa)患者术前穿刺病理Gleason评分发生术后病理升级的独立危险因素。方法:收集我院收治的150例低危型PCa患者的临床资料,包括年龄、体质指数、TPSA、PSAD、F/T、前列腺体积、阳性穿刺百分比和术前临床分期,比较各相关因素中术后大体病理未升级者与术后大体病理升级者之间的差异,将差异有统计学意义的变量代入多因素Logistic回归分析,找出发生术后病理升级的独立危险因素。结果:(1)术后大体病理Gleason评分较术前穿刺病理Gleason评分发生升级者55例,占36.67%。(2)前列腺体积、阳性穿刺百分比和术前临床分期等因素的术后大体病理未升级例数与术后大体病理升级例数比较差异有统计学意义(P0.05)。(3)多因素Logistic回归分析显示,前列腺体积与阳性穿刺百分比为低危型PCa患者术后病理升级的独立危险因素(P0.05)。结论:前列腺体积较小与穿刺阳性百分比较低可能是低危型PCa患者术后Gleason评分升高的独立危险因素。     

前列腺体积对腹腔镜下前列腺根治性切除术后组织病理学预后的影响

目的 探讨术前前列腺体积对于腹腔镜下前列腺根治性切除术后组织病理学预后的影响. 方法 回顾性分析2006年10月至2011年3月216例经前列腺穿刺括检诊断为前列腺腺癌并行腹腔镜下前列腺根治性切除术患者的资料,根据术前经直肠前列腺超声检查测定的前列腺体积将患者分为较小前列腺组( ＜30 ml)103例(47.7％)、中等前列腺组(30 ～60 ml)71例(32.9％)和较大前列腺组( ＞60ml)42例(19.4％).术前资料包括患者确诊时年龄、体质指数(BMI)、PSA、前列腺体积、穿刺阳性百分数、临床分期、穿刺Gleason评分等,术后组织病理学参数包括患者大体病理Gleason评分、是否存在术后病理升级、病理分期、切缘情况等.比较3组患者临床资料和术后组织病理学参数并进行统计学分析. 结果 3组患者术前PSA值随前列腺体积增大而升高,组间差异有统计学意义(P＜0.01),年龄、BMI、穿刺Gleason评分、穿刺阳性百分数及临床分期等对比较差异均无统计学意义(P＞0.05).小体积前列腺与较差的组织病理学预后相关,小体积前列腺痛患者术后Gleason评分较高(P =0.034),更容易出现大体病理升级现象(P=0.037),术后病理分期晚(P=0.025),特别是包膜侵犯的发生率增高(P =0.013).前列腺体积由小至大3组标本切缘阳性率分别为35.0％、33.8％和19.0％,差异无统计学意义(P =0.152). 结论 前列腺体积较小的前列腺癌患者行腹腔镜下前列腺根治性切除术后的组织病理学预后较差,肿瘤恶性程度高、病理分期晚,在临床工作中应予以重视.     

前列腺穿刺单针阳性的临床特点

目的通过对前列腺穿刺单针阳性并行腹腔镜前列腺癌根治术患者的临床资料进行分析,了解其临床特点及意义。方法收集我院2013年1月至2017年12月进行的1091例前列腺穿刺中穿刺单针阳性确诊为前列腺癌并行腹腔镜前列腺癌根治术的44例患者的临床、病理及随访资料进行分析,并对Gleason评分升级的相关因素进行分析。结果 44例单针穿刺阳性前列腺癌的根治标本中,以前列腺根治标本Gleason为标准,穿刺标本Gleason与其一致的有25例(56.8%),评分升高的有17例(38.6%),评分降低的有2例(4.5%),手术切缘阳性13例(29.5%);统计分析显示患者年龄、PSA、f PSA/TPSA、PSAD、前列腺体积与前列腺根治术后Gleason评分升级无明显相关。术后行内分泌治疗者均未发现生化复发,其余患者术后PSA均未升高。结论前列腺单针穿刺阳性者Gleason评分以低危为主,但根治术后Gleason评分升高的风险较高,肿瘤负荷存在被低估的可能,需引起临床重视,目前尚无有效的指标用于预测Gleason评分升级。     

磁共振波谱成像联合血清PSA在前列腺癌诊断中的价值

目的初步探讨磁共振波谱成像(MRS)与血清前列腺特异抗原(PSA)在前列腺癌诊断中的应用。方法选取血清PSA异常40例男性患者行前列腺MRS并与病理结果对照。再分析MRS联合不同水平PSA(低危组4ng/mlPSA10ng/ml,高危组PSA≥10ng/ml)穿刺活检的阳性率。结果病理证实前列腺癌19例、非前列腺癌21例(良性前列腺增生,20例,前列腺炎症1例)。单独MRS前列腺穿刺活检阳性率为60%,低危组前列腺活检阳性率为31.25%,高危组前列腺活检阳性率为58.3%,MRS联合PSA低危组前列腺活检阳性率为42.8%,MRS同时联合PSA高危组活检阳性率为66.7%,各组差异有统计学意义(P0.05)。结论 MRS诊断前列腺癌具有无创和简便优点,其联合PSA有助于提高诊断的准确性。     

前列腺癌根治术后Gleason评分升级相关危险因素分析

目的探讨前列腺癌根治术后Gleason评分升级的相关危险因素。方法回顾性分析2014年8月至2016年9月175例行前列腺癌根治术患者的年龄、前列腺特异性抗原PSA、前列腺体积、穿刺阳性针数和穿刺癌组织最大占比等指标,统计穿刺与根治术后Gleason评分差异,并应用Logistic回归分析前列腺癌根治术后Gleason评分升级的危险因素。结果 175例患者中,44例(25.1%)出现术后病理Gleason评分较穿刺前升高。前列腺体积是前列腺癌根治术后Gleason评分升级的独立预测因素。结论前列腺体积较小的前列腺癌患者,术后Gleason评分发生升级的可能性较大。     

前列腺癌术后病理较穿刺病理Gleason评分升高的相关因素

目的探讨影响前列腺癌术后病理Gleason评分较穿刺病理Gleason评分升高的相关因素。方法回顾性选择第二军医大学附属长海医院自2014年1月至2015年6月的102例前列腺癌根治术患者,收集可能影响Gleason评分升高的相关因素资料,采用单因素和多因素Logistic回归筛选影响Gleason评分升高的因素。结果单因素Logistic回归分析显示年龄、体质量指数(BMI)、前列腺特异性抗原(PSA)、前列腺体积、PSA密度(PSAD)与直肠指诊(DRE)等相关指标无显著统计学意义(P0.05);多因素logistic回归分析结果显示前列腺体积对于前列腺癌术后病理Gleason评分升级具有重要相关性(OR=0.981)。结论通过测量前列腺体积可预测前列腺癌术后病理Gleason评分较穿刺病理Gleason评分升高的可能,从而准确估算前列腺癌患者的实际Gleason评分,以便做出更有利的医疗决策。     

血清PSA值与穿刺标本Gleason评分预测前列腺癌病理分级

目的 探讨准确有效预测前列腺癌病理分级的方法.方法 分析75例前列腺癌患者术前血清PSA水平、穿刺活检标本和前列腺癌根治术后标本Gleason评分资料,对血清PSA水平与根治术后标本Gleason评分进行等级相关分析,对穿刺活检标本与根治术后标本Gleason评分进行配对秩和检验.结果 75例患者术前血清PSA值4～230 ng/ml,平均33.5 ng/ml;穿刺活检标本Gleason评分2～9分,平均(4.4±2.3)分;根治术后标本Gleason评分2～10分,平均(4.8±2.5)分.术前血清PSA水平与根治术后标本Gleason评分呈正相关(rs=0.279,P=0.015),穿刺活检标本与根治术后标本Gleason评分差异有统计学意义(P=0.011).结论 前列腺癌患者术前血清PSA水平越高,根治术后标本Gleason评分也越高;穿刺标本Gleason评分有低估的缺点,必要时应行病理分级后再评估.     

前列腺癌根治术后Gleason评分升级与术前多参数MRI PI-RADS评分的关系

目的探讨前列腺癌根治术后Gleason评分升级与术前多参数MRI(mpMRI)前列腺影像报告数据系统(PIRADS)评分的关系。方法回顾性分析198例前列腺癌根治术后患者的资料。根据PI-RADS评分分为低分(1~2分),中分(3分),高分(≥4分)3组。通过单因素和多因素Logistic回归分析探讨PI-RADS评分与Gleason评分的关系。结果单因素分析显示,前列腺特异性抗原密度、前列腺体积、术前穿刺病理Gleason评分、精囊侵犯、穿刺阳性针数、PI-RADS评分是术后Gleason评分升级的影响因子(P均0.05)。多因素分析显示,前列腺体积(P0.01)与术前PI-RADS评分(P0.01)是前列腺癌根治术后Gleason评分升级的独立预测因素。术前PI-RADS评分低分组及中分组术前与术后Gleason评分差异无统计学意义(P均0.05);而高分组术后Gleason评分高于术前,差异有统计学意义(P0.05)。结论术前Gleason评分较低(≤6分)而PI-RADS评分较高(≥4分)的小体积前列腺癌患者,术后Gleason评分升级的可能大。     

诊断性前列腺电切术对血清PSA异常患者的应用研究

目的:探讨诊断性前列腺电切(TURP)在前列腺增生合并血清PSA异常患者中的应用价值及意义,为临床处理前列腺增生合并血清PSA异常的患者提供一种新的手段。方法:收集符合入组标准的患者71例,总结病理为前列腺癌患者的Gleason评分及预后。对所有患者进行术后随访,检测其TURP术后6个月、1年的PSA值及IPSS评分,分析术后血清PSA值、IPSS的变化,评估TURP在前列腺增生伴血清PSA异常患者中的诊疗效果。结果:①40例前列腺穿刺活检阴性而血清PSA持续异常的患者中,2例术后病理示前列腺腺癌(2/40),Gleason评分为6分,另1例电切后病理示前列腺增生组织,但术后血清PSA持续异常(18μg/L),行2次活检,病理诊断为前列腺癌,Gleason评分6分,3例均行前列腺根治性切除术,术后随访恢复好。31例拒绝活检患者中术后病理示前列腺腺癌9例(9/31)。Gleason评分7⁹分,平均8分,1例行前列腺根治性切除术,8例行内分泌治疗。②59例病理诊断为良性前列腺增生(BPH),其中血清PSA恢复正常者56例,显著降低者3例,IPSS评分有明显改善53例,6例尿道狭窄经过尿扩处理后评分亦有改善。结论:诊断性TURP可提高前列腺癌的早期检出率,改善患者的下尿路症状,且有利于患者血清PSA持续正常化。对血清PSA异常(>4μg/L),伴有下尿路梗阻状态、前列腺穿刺活检阴性的患者可考虑行诊断性TURP。     

A low incidence of positive surgical margins in prostate cancer at high risk of extracapsular extension after a modified anterograde radical prostatectomy

OBJECTIVES: To evaluate the incidence of positive surgical margins (and associated risk factors) in patients with localized prostate cancer at high preoperative risk of extracapsular disease treated using a modified anterograde radical retropubic prostatectomy technique. Positive surgical margins are an important risk factor for disease recurrence after radical prostatectomy, particularly in patients with extracapsular disease. PATIENTS AND METHODS: In total, 84 patients with clinically localized prostate cancer and a preoperative prostate-specific antigen (PSA) level > 10 ng/mL and/or a biopsy Gleason score > or = 7 were evaluated. The surgical technique allows easy, wide resection of the posterolateral prostatic pedicles, and good mobilization and exposure of the apex before the urethra transection. Prostatectomy specimens were examined for extracapsular tumour spread and positive surgical margins. Differences in putative risk factors (Gleason score, preoperative PSA level, prostate weight) between the positive- and negative-margin groups were evaluated using the Mann-Whitney test. RESULTS: Overall, 11 of the 84 (13%) patients had positive surgical margins and of these a single site was involved in six. In total, 15 positive-margin sites were identified (five apical, four basal, three posterolateral, two anterior and one posterior). All patients with positive margins had histological extracapsular disease. The preoperative PSA level and Gleason score were significantly higher in the positive- than in the negative-margin group (P = 0.025 and 0.035, respectively). CONCLUSIONS: The anterograde radical prostatectomy minimizes the incidence of positive surgical margins in patients at high risk of extracapsular disease.     

一项基于单中心腹腔镜前列腺癌手术难度的多重影响因素分析

目的寻找有效的围术期相关术前数据预测前列腺癌患者行腹腔镜根治性前列腺切除术的手术难度和风险。方法回顾性分析2013年8月至2017年4月接受腹腔镜前列腺根治性切除术的125例前列腺癌患者的围术期资料,分为3组:A组为早期进行的48例腹膜外前列腺癌根治术患者、B组为后期进行的48例腹膜外前列腺癌根治术患者、C组为29例经腹腔前列腺癌根治术患者。将3组中符合体质指数≥25、前列腺体积≥30 mL、术前PSA水平≥10 ng/mL、有中叶突出这4个条件中的3~4个的患者划为高危组,0~2个的患者划为低危组。分别在A、B、C 3组患者中比较高危组与低危组之间在手术切缘阳性率、手术时长及术中出血量等可以直观体现手术难度数据上的差异。结果A、B、C 3组中,高危组的手术切缘阳性率、手术时长及术中出血量均显著高于低危组,差异具有统计学意义(P<0.05)。结论体质指数、前列腺体积、术前PSA水平、中叶突出4个因素与手术难度密切相关,术前准确识别影响因素的数目和程度,有助于外科医师预断手术难度。     

Upgrading and upstaging of low-risk prostate cancer among Korean patients: a multicenter study

Only 54% of prostate cancer cases in Korea are localized compared with 82% of cases in the US. Furthermore, half of Korean patients are upgraded after radical prostatectomy (41.6%–50.6%). We investigated the risk factors for upgrading and/or upstaging of low-risk prostate cancer after radical prostatectomy. We retrospectively reviewed the medical records of 1159 patients who underwent radical prostatectomy at five hospitals in Honam Province. Preoperative data on standard clinicopathological parameters were collected. The radical prostatectomy specimens were graded and staged and we defined a “worsening prognosis” as a Gleason score ≥ 7 or upstaging to ≥ pT3. Multivariate logistic regression models were used to assess factors associated with postoperative pathological upstaging. Among the 1159 patients, 324 were classified into the clinically low-risk group, and 154 (47.5%) patients were either upgraded or upstaged. The multivariable analysis revealed that the preoperative serum prostate-specific antigen level (odds ratio [OR], 1.131; 95% confidence interval [CI], 1.007–1.271; P= 0.037), percent positive biopsy core (OR: 1.018; 95% CI: 1.002–1.035; P= 0.032), and small prostate volume (≤30 ml) (OR: 2.280; 95% CI: 1.351–3.848; P= 0.002) were predictive of a worsening prognosis. Overall, 47.5% of patients with low-risk disease were upstaged postoperatively. The current risk stratification criteria may be too relaxed for our study cohort.     

Improved risk stratification for biochemical recurrence after radical prostatectomy using a novel risk group system based on prostate specific antigen density and biopsy Gleason score

PURPOSE: Previous studies have suggested that prostate specific antigen (PSA) density is a significant independent predictor of biochemical failure after primary therapy. We determined whether pathological PSA density using surgical weight of the radical prostatectomy specimen was an independent predictor of adverse pathological features or biochemical recurrence after radical prostatectomy. We also examined whether combining pathological PSA density with biopsy Gleason score improved risk stratification compared with serum PSA and biopsy Gleason score for predicting PSA recurrence after prostatectomy. MATERIALS AND METHODS: Multivariate analysis was used to determine whether pathological PSA density was an independent predictor of adverse pathology or PSA recurrence after radical prostatectomy in 325 patients treated at a Veterans Affairs medical center. Cutoff points of pathological PSA density were generated to identify patients at various risks for biochemical recurrence. These cutoffs were combined with biopsy Gleason cutoff points 2 to 6, 7 and 8 to 10 to generate a risk stratification system that was compared with a previous risk stratification system using PSA and biopsy Gleason score cutoff points. The validity of the risk stratification system using pathological PSA density and biopsy Gleason score was evaluated in another cohort of 490 patients treated with radical prostatectomy at a tertiary care medical center. RESULTS: Pathological PSA density was an independent predictor of positive surgical margins (p <0.001), nonorgan confined disease (p <0.001), seminal vesicle invasion (p = 0.003) and biochemical recurrence after radical prostatectomy (p <0.001). The cutoff points for pathological PSA density of less than 0.3, 0.3 to 0.7 and greater than 0.7 ng./ml./gm. separated patients into 3 distinct groups at increasing risk for biochemical failure after radical prostatectomy (p <0.001). Pathological PSA density cutoffs combined with biopsy Gleason score cutoffs 2 to 6, 7 and 8 to 10 provided better risk stratification for biochemical failure than cutoffs based on a combination of PSA and biopsy Gleason score in patients treated at the Veterans Affairs (hazards ratio 3.04, confidence interval 2.25 to 4.11, p <0.001) and tertiary care (hazards ratio 2.38, confidence interval 1.78 to 3.18, p <0.001) medical centers. CONCLUSIONS: Pathological PSA density was a strong predictor of advanced pathology and biochemical failure after radical prostatectomy. Pathological PSA density combined with biopsy Gleason score defined a novel risk group system that improved risk stratification compared with a combination of PSA and biopsy Gleason score. These results were validated in another cohort of patients treated with radical prostatectomy at a tertiary care medical center. Further studies are required using PSA density values calculated from preoperative transrectal ultrasound measurements to determine whether a combination of PSA density and biopsy Gleason score provides significant pretreatment risk stratification.     

Bevorzugte Behandlungsoptionen des lokalisierten Prostatakarzinoms von deutschen Urologen und Radioonkologen bei eigener Erkrankung

Introduction

We evaluated the currently preferred primary treatment options among German urologists and radio-oncologists if personally diagnosed with localized prostate cancer, taking into consideration the different prognostic risk groups.

Materials and methods

A questionnaire was mailed to 3,217 urologists and 598 radio-oncologists. They were asked to choose their preferred primary treatment option if they were personally diagnosed with prostate cancer, taking into consideration the different prognostic risk groups: low risk [Gleason score ≤6, prostate-specific antigen (PSA) ≤10 μg/l, T1c], intermediate risk (Gleason score 7, PSA 11–19 μg/l, T2), and high risk (Gleason score ≥8, PSA≥20 μg/l, T3). Surgical options were further subdivided according to technique (retropubic, laparoscopic, perineal).

Results

The questionnaire return rate was 49% for urologists and 41% for radio-oncologists. The mean age was 48 years (28–86) for urologists and 47 years (29–68) for radio-oncologists. Primary surgical treatment was selected by 62% of urologists for low-risk prostate cancer, 90% for intermediate-risk prostate cancer, and 77% for high-risk prostate cancer. Radiotherapy as a primary treatment option was elected by 71% of radio-oncologists for low-risk prostate cancer, 84% for intermediate-risk prostate cancer, and 89% for high-risk prostate cancer. Retropubic, laparoscopic, and perineal prostatectomy would be chosen by 61%, 28%, and 10% of urologists, respectively, for low-risk prostate cancer; by 70%, 24%, and 6%, respectively, for intermediate-risk prostate cancer, and by 80%, 15%, and 5%, respectively for high-risk prostate cancer.

Conclusion

Urologists prefer surgery and radio-oncologists radiotherapy for primary treatment of prostate cancer, irrespective of the prognostic risk group. Particularly for high-risk prostate cancer, the majority of radiooncologists would still choose radiotherapy as a primary treatment option. In the age of minimally invasive surgery, radical retropubic prostatectomy is still the preferred surgical treatment option among urologists for any prognostic risk group.     

PSAD预测前列腺癌根治术前后G1eason评分变化的临床应用价值

目的：探讨前列腺根治术前血清前列腺特异性抗原密度（PSAD）预测术后Gleason评分变化的应用价值。方法：对133例行前列腺癌根治术的患者资料进行回顾,将前列腺癌根治术前术后Gleason评分变化与患者年龄、术前Gleason评分、前列腺特异性抗原（PSA）、前列腺体积和PSAD的相关性进行分析,并进一步分析术前Gleason评分≤6患者中评分升高和Gleason评分≥7患者中评分下降与上述因素的关系。结果：133例患者中经直肠超声（TRUS）引导下前列腺穿刺活检Gleason评分与前列腺癌根治术后Gleason评分保持一致52例（39．1％）,评分下降13例（9．8％）,评分升高68例（51．1％）。PSAD（P=0．002）与Gleason评分升高明显相关,未发现Gleasbn评分≥7患者中评分下降与前列腺特异性抗原（PSA）、前列腺体积和PSAD有相关性。进一步应用受试者工作特征（receiver operating characteristic,ROC）曲线分析得出：TRUS穿刺活检Gleason评分≤6患者PSAD〉0．2435预示根治术后Gleason评分升高可能性较大。结论：TRUS引导下前列腺穿刺活检Gleason评分较低且PSAD较高的前列腺癌患者提示有可能实际Gleason评分升高,进而影响治疗选择和预后。     

PREDICTING PROSTATE SPECIFIC ANTIGEN OUTCOME PREOPERATIVELY IN THE PROSTATE SPECIFIC ANTIGEN ERA

PURPOSE: We evaluated the ability of previously defined risk groups to predict prostate specific antigen (PSA) outcome 10 years after radical prostatectomy in patients diagnosed with clinically localized prostate cancer during the PSA era. MATERIALS AND METHODS: Between 1989 and 2000, 2,127 men with clinically localized prostate cancer underwent radical prostatectomy, including 1,027 at Hospital of the University of Pennsylvania (study cohort) and 1,100 at Brigham and Women's Hospital (validation cohort). Cox regression analysis was done to calculate the relative risk of PSA failure with the 95% confidence interval (CI) in patients at intermediate and high versus low risk. The Kaplan-Meier actuarial method was used to estimate PSA outcome 10 years after radical prostatectomy. RESULTS: Compared with low risk patients (stages T1c to 2a disease, PSA 10 ng./ml. or less and Gleason score 6 or less) the relative risk of PSA failure in those at intermediate (stage T2b disease or PSA greater than 10 to 20 ng./ml. or less, or Gleason score 7) and high (stage T2c disease, or PSA greater than 20 ng./ml. or Gleason score 8 or greater) risk was 3.8 (95% CI 2.6 to 5.7) and 9.6 (95% CI 6.6 to 13.9) in the study cohort, and 3.3 (95% CI 2.3 to 4.8) and 6.3 (95% CI 4.3 to 9.4) in the validation cohort. The 10-year PSA failure-free survival rate in the 1,020 patients in the low, 693 in the intermediate and 414 in the high risk groups was 83%, 46% and 29%, respectively (p <0.0001). CONCLUSIONS: Based on 10-year actuarial estimates of PSA outcome after radical prostatectomy 3 groups of patients were identified using preoperative PSA, biopsy Gleason score and 1992 clinical T category.     

Extended pelvic lymphadenectomy in patients undergoing radical prostatectomy: high incidence of lymph node metastasis

PURPOSE: Lymphadenectomy for prostate cancer is limited to obturator and external iliac lymph nodes, although the internal lymph nodes represent the primary landing zone of lymphatic drainage. We performed anatomically adequate extended pelvic lymphadenectomy to assess the incidence of lymph node metastasis in cases of clinically localized prostate cancer. MATERIALS AND METHODS: A total of 103 consecutive patients underwent extended pelvic lymphadenectomy at radical retropubic prostatectomy comprising 9 selective fields, namely the external iliac, internal iliac, obturator and common iliac lymph nodes bilaterally, and the presacral lymph nodes. Histopathological findings were compared with serum prostate specific antigen (PSA), histopathological stage, preoperative biopsy and postoperative prostatectomy Gleason score. Extended pelvic lymphadenectomy was compared with radical retropubic prostatectomy and standard lymphadenectomy in 100 consecutive patients in terms of complications, the number of lymph nodes dissected and operative time. RESULTS: There were no significant differences in age, preoperative PSA or mean biopsy Gleason score in patients who underwent extended pelvic and standard lymphadenectomy. Metastases were diagnosed in 27 of the 103 patients (26.2%) who underwent the extended procedure. A mean of 28 lymph nodes (range 21 to 42) were dissected. Metastases were identified in the internal iliac and presacral regions despite negative obturator lymph nodes. Of the 27 patients 1 to 3 lymph nodes involved with metastasis were detected in 15, 9 and 1, respectively. In 26 of the 27 patients (95.8%) with lymph node metastasis PSA was greater than 10.5 ng./ml. and preoperative biopsy Gleason sum was 7 or greater. A low risk of 2% for lymph node disease was noted in patients with serum PSA less than 10.5 ng./ml. and biopsy Gleason sum less than 7. There were no significant differences in regard to intraoperative and postoperative complications, lymphocele formation or blood loss in the 2 groups. CONCLUSIONS: Extended pelvic lymphadenectomy is associated with a high rate of lymph node metastasis outside of the fields of standard lymphadenectomy in cases of clinically localized prostate cancer. Lymphadenectomy including the internal iliac lymph nodes should be performed in all patients with prostate cancer who are at high risk for lymph node involvement, as indicated by PSA greater than 10.5 ng./ml. and biopsy Gleason sum 7 or greater. In the low risk group pelvic lymphadenectomy can be omitted.     

Final outcomes of patients with low‐risk prostate cancer suitable for active surveillance but treated surgically

OBJECTIVE

To study the outcomes of a contemporary cohort of patients referred from around the UK with low‐risk prostate cancer consistent with the UK National Institute for Health and Clinical Excellence guidelines for active surveillance but who were treated with laparoscopic radical prostatectomy (LRP) in a single surgeon series.

PATIENTS AND METHODS

From 1080 consecutive patients who underwent LRP between March 2000 and April 2008, 549 patients (51%) had low preoperative risk disease (PSA level <10 ng/mL, clinical stage ≤T2a and biopsy Gleason score ≤6). The pathological outcomes of these 549 patients as well as a subgroup of 74 patients with preoperative prediction of ‘insignificant’ disease were assessed.

RESULTS

The mean age of the patients was 61 years, the mean (range) PSA level was 6.1 (1–9) ng/mL; 38% of patients were staged as cT2a. In all, 126 patients (23%) were upgraded on final pathology to Gleason score ≥7. In all, 29 patients (5%) had extraprostatic extension with seminal vesicle invasion in five (0.9%). Of the 74 patients with preoperative prediction of insignificant disease, 61% had significant disease with 16% upgraded to an intermediate‐risk group. Overall, there were positive margins in 44 patients (8.0%) and biochemical failure occurred in six patients (1.1%) with a median follow‐up of 28 months.

CONCLUSION

In this contemporary UK cohort of patients with apparently low‐ or favourable‐risk prostate cancer, 23% will have higher grade disease than preoperatively predicted. Even though active surveillance is increasingly being recommended for managing low‐risk localized prostate cancer, patients and their physicians need to be aware of the potential for harbouring more significant disease.     

Prediction of Gleason score upgrading in low-risk prostate cancers diagnosed via multi (≥12)-core prostate biopsy

Objectives  A paucity of data exists on actual pathology of the contemporary patients strictly categorized as having low-risk prostate cancer. We tried to identify useful preoperative predictors of Gleason score upgrading in patients who underwent radical retropubic prostatectomy (RRP) for low-risk prostate cancer diagnosed via multi-core prostate biopsy. Methods  A total of 203 patients who underwent radical RRP for low-risk prostate cancer, as defined by D’Amico et al.'s classification (clinical stage ≤T2a, biopsy Gleason sum ≤6, and PSA ≤10 ng/ml), detected via multi (≥12)-core prostate biopsy were enrolled. We reviewed patients preoperative and pathological data. Results  Among all subjects, 81 (39.9%) were upgraded to Gleason score ≥7 after RRP, whereas no downgrading was observed. In multivariate analysis, only preoperative PSA level (P = 0.024) and number of positive cores (P = 0.027) were observed to be independent predictors of Gleason score upgrading following RRP. Also, Gleason core upgrading was observed to be significantly associated with extraprostatic extension of tumor (P < 0.001) and positive surgical margin (P = 0.002). Conclusions  A significant proportion of patients with low-risk prostate cancer as defined by D’Amico et al.’s classification diagnosed via multi-core prostate biopsy in contemporary period may have Gleason score upgrading following RRP. For patients with low-risk prostate cancer, preoperative PSA level and number of positive cores may be useful predictors of Gleason score upgrading, which was observed to significantly associated with other adverse pathologic features.