STAGING OF PROSTATE CANCER USING 3-DIMENSIONAL TRANSRECTAL ULTRASOUND IMAGES: A PILOT STUDY

PURPOSE: We used conventional transrectal ultrasound images for 3-dimensional (D) reconstruction of the prostate, and determined its value in staging clinically localized prostate cancer. MATERIALS AND METHODS: A total of 36 patients with newly diagnosed clinically localized prostate cancer were studied. All patients underwent conventional transrectal ultrasonography with 3-D reconstruction. Images were examined and analyzed blindly, and findings were compared to histopathological staging following radical prostatectomy. RESULTS: Pathological staging of specimens revealed 15 sites of extracapsular extension in 10 patients, of whom 8 had positive margins and 2 had seminal vesicle invasion. The 3-D imaging identified 12 sites of extracapsular extension in 9 patients with 80% sensitivity, 96% specificity and 90% positive predictive value. Of the 2 patients with seminal vesicle invasion 1 was identified correctly on 3-D images. Overall staging accuracy of 3-D imaging was 94%. CONCLUSIONS: The 3-D reconstruction of conventional transrectal ultrasonography imaging is superior to 2-D imaging for staging localized prostate cancer. However, this advantage relies entirely on the visibility of prostate cancer lesions on conventional ultrasonography. Further studies are warranted to evaluate this technology for the management of prostate cancer.     

Prediction of Capsular Perforation and Seminal Vesicle Invasion in Prostate Cancer

Purpose

Capsular perforation and seminal vesicle invasion are unfavorable, prognostic factors in prostate cancer. Accurate preoperative prediction of these factors would be clinically useful for planning treatment, especially in patients being considered for radiation therapy, nerve sparing radical prostatectomy and watchful waiting. However, current methods are imprecise at predicting the presence and extent of these factors. We determined which combination of commonly available preoperative variables provides the best prediction of capsular perforation and seminal vesicle invasion in patients with clinically localized prostate cancer.

Materials and Methods

We reviewed the preoperative medical records and biopsy findings from 314 patients with clinical stages T1cN0M0 to T2cN0M0 cancer who underwent radical retropubic prostatectomy and bilateral pelvic lymphadenectomy between September 1991 and June 1993. Radical prostatectomy specimens were embedded and evaluated by whole mount sections.

Results

Capsular perforation was observed in 104 patients (33.1 percent) and seminal vesicle invasion was noted in 46 (14.6 percent). Preoperative variables predictive of capsular perforation and seminal vesicle invasion on univariate analysis were serum prostate specific antigen (PSA) concentration, clinical stage, Gleason primary and secondary patterns, Gleason score, nuclear grade, perineural invasion and percent cancer in the biopsy specimens. On multivariate analysis independent prognostic factors for capsular perforation and seminal vesicle invasion were PSA, Gleason score and percent cancer in the biopsy specimens.

Conclusions

The combination of serum PSA concentration, Gleason score and percent cancer in the biopsy specimens provides the best prediction of capsular perforation and seminal vesicle invasion. Models based on this combination of factors may be clinically useful to stratify patients for nonoperative treatment.     

Sonographic and pathological staging of patients with clinically localized prostate cancer

We evaluated 64 patients with clinically localized prostate cancer (on the basis of rectal examination, serum acid phosphatase, bone scan and pelvic computerized tomography scan) by transrectal sonography before radical prostatectomy. Of the 48 patients with histologically proved localized prostate cancer sonography overstaged the disease in 5 (10%) and correctly staged it in 43 (90%). All overstaged cancer patients were scanned after either prostatic biopsy (4) or transurethral prostatectomy (1) established the diagnosis of prostate cancer. Of the 16 patients with histologically proved, locally advanced prostate cancer (that is extracapsular extension and/or seminal vesicle invasion) sonography understaged the disease in 10 (62%) and correctly staged the disease in 6 (38%). These data suggest that sonography is associated with considerable staging errors when used to evaluate men with clinically localized prostate cancer.     

MAGNETIC RESONANCE IMAGING OF CLINICALLY LOCALIZED PROSTATIC CANCER

Purpose

We assess the accuracy of endorectal coil magnetic resonance imaging (MRI) for detecting tumor localization, capsular penetration and seminal vesicle invasion in clinically organ confined prostate cancer. We also evaluate intra-observer and interobserver agreement in interpreting MRI studies.

Materials and Methods

MRI studies of 51 consecutive patients a mean of 61 years old with biopsy proved prostate cancer were retrospectively read twice by 2 radiologists in random order. Both radiologists marked tumor localization, capsular penetration and seminal vesicle invasion on standard tumor maps. These findings were compared with the histopathological results of radical prostatectomy specimens.

Results

The overall accuracy of detecting cancer localization was 61%. The detection rate for cancer foci less than 5 mm. was only 5% but for lesions greater than 10 mm. it was 89%. There was 91 and 80% accuracy for detecting capsular penetration and seminal vesicle invasion, respectively. Sensitivity and specificity were 60 and 63, 13 and 97, and 59 and 84% for localization, capsular penetration and seminal vesicle invasion, respectively. Intra-observer and interobserver agreement ranged from fair to good (kappa coefficient 0.240 to 0.647).

Conclusions

Endorectal MRI seems to be better than previously reported for detecting seminal vesicle invasion and tumor foci in the anterior half of the prostate. Sensitivity in detecting minor capsular penetration of the tumor was low, which can probably be improved by methodological development. MRI may be useful for locating cancer foci in patients with high prostate specific antigen values but repeatedly negative biopsy findings.     

Predictive ability of partin tables 2001 in a Welsh population

OBJECTIVES: Partin tables are widely used to select and counsel patients prior to radical surgery for prostate cancer. However, Partin tables have been developed in the USA which has a different ethnic mixture from that of North Wales. We aimed to assess Partin tables' predictive ability in a Welsh population. MATERIALS AND METHODS: 193 patients underwent radical retropubic prostatectomy for clinically localized carcinoma of the prostate between April 1993 and July 2004 in a single institution in North Wales. Complete preoperative clinical staging information was available in 177 patients. Receiver operating characteristic curve analysis was used. RESULTS: The mean patient age was 64 (48-73) years. Preoperative clinical staging distribution was: T1c 46.6% and T2 53.4%. 75% had organ-confined disease (TNM 1992). Extracapsular extension without seminal vesicle or lymph node involvement was seen in 13.5%. Nine percent had seminal vesicle invasion without lymph node involvement. Lymph node metastasis was found in 2.2%. The predictive effectiveness of the Partin table was high with an area under ROC curve of 0.733 for organ confinement, 0.738 for seminal vesicle invasion and 0.780 for lymph node involvement (CI 95%). CONCLUSION: Our study demonstrated that the predictive ability of Partin tables for prostate cancer is also applicable to a Welsh population.     

Bladder neck involvement in pathological stage pT4 radical prostatectomy specimens is not an independent prognostic factor

PURPOSE: Bladder neck invasion by prostate cancer in radical prostatectomy specimens is uncommon and, thus, its influence on disease recurrence has not been well defined. Consequently the classification of bladder neck invasion in the TNM staging system is controversial. We studied our cohort of patients with stage pT4 disease and bladder neck invasion to clarify the true clinical behavior and prognostic significance of bladder neck invasion in radical prostatectomy specimens. MATERIALS AND METHODS: The study group consisted of 4,090 consecutive patients treated with radical prostatectomy at one of our institutions between 1983 and 2001. Median followup was 53.1 months (range 1 to 189). After excluding from analysis patients treated with neoadjuvant androgen withdrawal or preoperative irradiation 72 of the remaining 2,571 (2.8%) with bladder neck invasion were classified with stage pT4 disease and their specimens were reviewed. Progression-free probability was determined by Kaplan-Meier analysis. Using the Cox proportional hazards model the independent prognostic significance of bladder neck invasion was assessed after controlling for pretreatment prostate specific antigen, final Gleason sum, extracapsular extension, surgical margins status, seminal vesicle invasion and lymph node involvement. RESULTS: Of the 72 patients categorized with stage pT4 disease 14 (19%) had poorly differentiated Gleason sum 8 to 10 cancer, 38 (53%) had established extracapsular extension, 24 (33%) had seminal vesicle invasion and 8 (11%) had lymph node involvement. However, 26 patients (36%) had cancer confined to the prostate and 28 (39%) had negative surgical margins except for the bladder neck site. The mean 5-year progression-free probability plus or minus SD in all stage pT4 cases was 68% +/- 7%, which was better than in cases of seminal vesicle invasion (52% +/- 5%, log rank test p = 0.0156) but worse than in those of extracapsular extension (84% +/- 4.1%). Univariate analysis of the stage pT4 cohort revealed that higher prostatectomy Gleason sum, more extensive extracapsular extension and seminal vesicle invasion were significantly associated with an adverse prognosis. However, in a multivariate model that included all radical prostatectomy cases the finding of bladder neck invasion or stage pT4 disease did not independently predict prostate specific antigen recurrence. CONCLUSIONS: Stage pT4 disease comprises a heterogeneous group of tumors with various pathological features and inconsistent outcomes. Assigning the pT4 stage to cases of microscopic bladder neck invasion provides no independent ability for predicting disease progression after adjusting for other adverse disease features. Due to this and previously reported data the definition of stage pT4 disease should be modified in the next version of the TNM staging system.     

Endorectal coil magnetic resonance imaging and clinicopathologic findings in T1c adenocarcinoma of the prostate

Stage T1c prostate cancer has become the most commonly diagnosed clinical stage of localized prostate cancer. Endorectal coil magnetic resonance imaging (erMRI) can be used in the staging of such patients. The purpose of this study was to correlate the preoperative erMRI findings with the pathologic characteristics of the surgical specimens. A database review of 355 radical prostatectomy specimens revealed 130 patients with T1c disease. Of these patients, 124 were clinically staged with erMRI. Standard sensitivity analysis and multivariable analysis was then applied to determine the utility of erMRI in the staging of patients with T1c prostate cancer. The mean prostate specific antigen (PSA) value was 8.3 (1.0-33.6). Most patients had Gleason score of 5 or 6 (51.6%) or 7 (33.1%), with fewer patients having Gleason scores between 2 and 4 (7.2%) or 8 and 10 (8.1%). The positive predictive value of erMRI for extracapsular disease was 38.7%, negative predictive value was 75.3%, and accuracy was 79%. Multivariable regression analysis demonstrated that erMRI and preoperative PSA were predictive for seminal vesicle involvement. However, erMRI was not predictive in multivariable or univariable analysis for extracapsular extension or margin positivity. Previous investigators demonstrated the utility and independent significance of preoperative erMRI for a select subset of patients. However, it is not a useful staging modality for patients with T1c cancer as a whole. Further stratification of the T1c patients would be necessary to identify patients within this group who may benefit from staging with erMRI.     

11C-choline positron-emission tomography/computed tomography and transrectal ultrasonography for staging localized prostate cancer

OBJECTIVE: To evaluate and compare the role of (11)C-choline positron emission tomography (PET) and transrectal ultrasonography (TRUS) in the preoperative staging of clinically localized prostate cancer. PATIENTS AND METHODS: Fifty-five consecutive patients with biopsy-confirmed prostate cancer had TRUS and (11)C-choline PET as a part of their clinical staging programme before radical retropubic prostatectomy (RP). The PET images were prospectively interpreted by a consensus decision of two nuclear medicine physicians and one radiologist with special expertise in the field. The TRUS was done by one experienced urologist. The criteria evaluated prospectively in each patient were extracapsular extension (ECE), seminal vesicle invasion (SVI) and bladder neck invasion (BNI). The results were compared with the histopathological findings after RP. RESULTS: At pathology, 32 patients were classified pT2, 16 as pT3a and three had pT3b lesions. In four patients the histopathological examination showed pT4 with BNI. The overall accuracy of PET in defining local tumour stage (pT2 and pT3a-4) was 70%; the overall accuracy by TRUS was 26%. PET was more sensitive than TRUS for detecting ECE (pT3a) and SVI (pT3b) in advanced stages, and in pT4 stages. The sensitivity and positive predictive value (PPV) (95% confidence interval) in stages pT3a-pT4 for PET were 36 (17-59)% and 73 (39-89)%. The sensitivity and PPV in stages pT3a-pT4 for TRUS were 14 (3-35)% and 100 (29-100)%. CONCLUSIONS: (11)C-choline PET and TRUS tended to understage prostate cancer. This series shows the current limited value of TRUS and PET for making treatment decisions in patients with clinically localized prostate cancer, especially if a nerve-sparing RP is considered. Treatment decisions should not be based on TRUS and (11)C-choline PET findings alone. In future studies, the combination of metabolic and anatomical information of PET and endorectal magnetic resonance imaging should be evaluated, as this might optimize the preoperative staging in prostate cancer.     

Seminal vesicle biopsies in the preoperative staging of prostatic cancer.

Twenty-five patients with localized prostate cancer underwent seminal vesicle biopsies before radical prostatectomy. A transrectal probe of 7 MHz, a 18-gauge needle and a biopsy gun were used. The preoperative biopsy established the absence of seminal vesicle invasion in 89% of cases. When the seminal vesicles are positive at biopsy, capsular penetration is observed in 100% of the cases and lymph node positivity in 50%. When seminal vesicles are negative at biopsy and the prostate-specific antigen level is less than 20 ng/ml (n less than 2.5), capsular penetration of greater than 1 cm is absent in 100% of cases and lymph nodes are positive in only 7% of cases. Biopsy of the seminal vesicle, as an outpatient procedure, improves the preoperative staging of prostate cancer before radical prostatectomy: negative biopsies are good predictors of the absence of lymph node invasion.     

Limited value of endorectal magnetic resonance imaging and transrectal ultrasonography in the staging of clinically localized prostate cancer

OBJECTIVE: To examine the role of endorectal magnetic resonance imaging (eMRI) and transrectal ultrasonography (TRUS) for clinically localized prostate cancer and to assess interobserver agreement in interpreting MRI studies. PATIENTS AND METHODS: Fifty-four patients with biopsy-confirmed prostate cancer underwent TRUS and eMRI before radical retropubic prostatectomy. The MR images were prospectively interpreted by two radiologists with special expertise in this field. The criteria evaluated prospectively in each patient were extracapsular extension (ECE) and seminal vesicle invasion (SVI). The results were correlated with the histopathological findings after radical prostatectomy. RESULTS: At pathology, 27 patients had stage pT2, 15 had stage pT3a and 12 had stage pT3b lesions. The overall accuracy of eMRI in defining local tumour stage was 93% by radiologist A and 56% by radiologist B; the overall accuracy by TRUS was 63%. There was a poor correlation for the MRI studies between observers. The eMRI was more sensitive than TRUS for detecting ECE and SVI in organ-confined prostate cancer. TRUS had a relatively high specificity for ECE and SVI, and was better than eMRI in this regard. CONCLUSION: Whereas MRI tended to over-stage, TRUS under-staged prostate cancer. This series shows the current limited value of TRUS and eMRI for planning treatment in patients with clinically localized prostate cancer. Treatment decisions should not be altered based on TRUS or eMRI findings alone.     

Bedeutung von endorektaler Kernspintomographie und transrektaler Sonographie beim lokalen Staging des Prostatakarzinoms

METHODS: We assessed the staging accuracy of endorectal magnetic resonance imaging (eMRI) and transrectal ultrasonography (TRUS) for localized prostate cancer. 54 patients with biopsy proven prostate cancer underwent TRUS and eMRI prior to radical retropubic prostatectomy. The MR images were prospectively interpreted by two radiologists. These findings were compared with the histopathological results. RESULTS: Overall accuracy of eMRI in defining local tumor stage was 93% by radiologist A and 56% by radiologist B. Overall accuracy by TRUS was 63%. Analysis of interobserver agreement showed a poor correlation regarding MRI studies. Endorectal MRI was more sensitive than TRUS for detecting capsular penetration and seminal vesicle involvement. TRUS revealed a relatively high specificity and was superior to eMRI in this regard. CONCLUSION: This series shows the current limited value of TRUS and eMRI for planning treatment in patients with clinically localized prostate cancer.     

Transrectal ultrasonography for prostatic cancer: its value in staging and monitoring the response to radiotherapy and chemotherapy

Current methods to evaluate the size and local extent of prostatic cancer are imprecise. Quantitative assessments of changes after therapy are unreliable. We have used transrectal ultrasonography in 50 patients with clinically localized prostatic cancer to determine the value of this imaging technique in staging the local tumor and in monitoring the response of the tumor to therapy. Transverse images of the prostate were obtained at 5 mm. intervals, and were used to determine the size and shape of the prostate, irregularity or discontinuity of the capsule, extracapsular extension of tumor and invasion into the seminal vesicles. Ultrasonography proved highly accurate in staging. Among 18 previously untreated patients whose tumor appeared to be confined to the prostate by rectal examination 8 (44 per cent) had extension beyond the prostate by ultrasonography, which was confirmed by operative findings. Serial ultrasonograms were performed before and after definitive radiotherapy in 7 patients and chemotherapy in 6 patients. In response to therapy the prostate decreased in size and resumed a more normal, symmetrical shape, the capsule reformed and thickened, the degree of extracapsular extension diminished and the seminal vesicles became normal. Maximal reduction in the size of the prostate usually occurred by 9 months after radiotherapy and by 3 months after chemotherapy. In patients with prostatic cancer transrectal ultrasonography is highly accurate in staging and offers an objective monitor of the response to therapy.     

Local staging of prostate cancer by tumor volume, prostate-specific antigen, and transrectal ultrasound.

Conventional methods of staging prostate tumors are highly inaccurate. To improve clinical staging, prostate-specific antigen (PSA) levels (> 10 ng/mL), sonographic tumor volume (> 3 cc), maximum tumor diameter, length of capsular tumor abutment, and overall impression of capsular irregularity suggesting periprostatic tumor spread were assessed in 29 men prior to undergoing radical prostatectomy for clinically localized tumor. After surgery, 18 men had tumor confined to the prostate, while 11 men had histologic evidence of extracapsular disease. Analysis of the parameters measured showed these were the most helpful factors in predicting the presence of extracapsular disease. However, the positive and negative predictive values were only 70 to 90 percent. Therefore, the clinical usefulness of any one measurement alone in determining treatment for the individual patient is limited. However, combining these parameters yields an improved prediction of extracapsular disease. All 6 patients with PSA < 10 ng/mL, tumor volume < 3 cc, and no capsular irregularity on ultrasound had localized disease (neg. predictive value = 100%), while all 7 patients who had more than one of these parameters had extracapsular disease (pos. predictive value = 100%). Thus, using the factors in combination may provide more accurate staging and thereby help in counseling patients regarding therapy.     

Influence of Preoperative Vesicle Biopsy on the Decision for Radical Prostatectomy

Purpose: The presence of seminal vesicle invasion (SVI) by prostate cancer is difficult to detect clinically and is associated with poor prognosis. The aim of our study was to identify the efficacy of transrectal ultrasound-guided seminal vesicle biopsies in the detection of seminal vesicle invasion (SVI) in patients with prostate cancer. Materials and methods: One hundred transrectal ultrasound-guided seminal vesicle biopsies were performed in 50 patients with clinically localized prostate cancer. Every patient underwent two biopsies, one for a each seminal vesicle. Radical retropubic prostatectomy was performed in all cases and the specimens with the attached seminal vesicles were examined for the presence of prostate cancer invasion. Results: Of a total of 100 seminal vesical biopsies 87 were identified as seminal vesicle by characteristic epithelium. Cancer was found in 7 (8%) biopsies, confirmed in all cases by pathology in the surgical specimen. Eighty biopsies (40 patients) were normal. Pathological analysis of these 40 radical prostatectomy specimens revealed that 6 seminal vesicles (5 patients) were invaded by prostate cancer (6 false negative biopsies, 7.5%). Transrectal ultrasound images of 15 seminal vesicles were suspicious for invasion while 85 were normal. Of the 15 suspicious cases 11 were invaded by cancer (73.3%). Of the sonographically benign seminal vesicles 5 (5.88%) were invaded by cancer. Our data were analyzed by the ARCUS PRO-STAT statistical package. Conclusions: We suggest that transrectal ultrasound-guided seminal vesicle biopsy is useful and reliable for a more exact preoperative staging of prostate cancer, therefore helpful in correct decision making for radical prostatectomy.     

Pre-operative percent free PSA predicts clinical outcomes in patients treated with radical prostatectomy with total PSA levels below 10 ng/ml

INTRODUCTION: To evaluate the association of total prostate specific antigen (T-PSA) and percent free PSA (%F-PSA) with prostate cancer outcomes in patients treated with radical prostatectomy (RP). METHODS: Pre-operative serum levels of T-PSA and F-PSA were prospectively measured in 402 consecutive patients treated with RP for clinically localized prostate cancer who had T-PSA levels below 10 ng/ml. RESULTS: T-PSA was not associated with any prostate cancer characteristics or outcomes. Lower %F-PSA was significantly associated with higher percent positive biopsy cores, extracapsular extension, seminal vesicle involvement, lympho-vascular invasion, perineural invasion, positive surgical margins, and higher pathologic Gleason sum. When adjusted for the effects of standard pre-operative features, lower %F-PSA significantly predicted non-organ confined disease, seminal vesicle involvement, lympho-vascular invasion, and biochemical progression. %F-PSA did not retain its association with biochemical progression after adjusting for the effects of standard post-operative features. Based on data from 22 patients with biochemical progression, lower %F-PSA was correlated with shorter T-PSA doubling time after biochemical progression (rho = 0.681, p = 0.010). %F-PSA was lower in patients who failed salvage radiation therapy (p = 0.031) and in patients who developed distant cancer metastases compared to patients who did not (p < 0.001). CONCLUSIONS: Pre-operative T-PSA is not associated with prostate cancer outcomes after RP when levels are below 10 ng/ml. In contrast, pre-operative %F-PSA is associated with adverse pathologic features, biochemical progression, and features of aggressive disease progression in patients treated with RP and T-PSA levels below 10 ng/ml. %F-PSA may improve pre-operative predictive models for predicting clinical outcomes of patients diagnosed with prostate cancer nowadays.     

Usefulness of Preoperative MRI Diagnosis in Prostatic Adenocarcinoma

Background :
We examined the reliability of an MRI diagnosis prior to radical prostatectomy for prostate cancer.
Methods :
A radical prostatectomy was performed in 24 patients with prostate cancer. Resected specimens were fixed and 5 mm step sections vertical to the urethra were prepared to resemble MRI images. We compared this pathological map with the preoperative MRI diagnosis which included capsular or seminal vesicle invasion and tumor localization in the prostate. We defined a new criterion for the presence of capsular invasion as a chemical shift that occurred on the rectal side on T1 -weighted images 5 minutes after gadolinium (Gd) enhancement and the periprostatic venous plexus was not serial. We also examined 4 diagnostic factors of tumor localization including a low-signal intensity area detected in the peripheral zone on T2-weighted images, the presence of an enhanced area on Gd-enhanced T1-weighted images, and a low T2 with either Gd-enhanced or nonenhanced T1-weighted images.
Results :
The accuracy of a preoperative MRI diagnosis of capsular invasion was 16.7% using the conventional criteria, but 88.9% adding the new criterion. The accuracy of predicting seminal vesicle invasion was 63.2% in a group using a body surface coil compared to 75% in the group using an endorectal surface coil. The accuracy, positive predictive value, sensitivity and specificity of diagnosing tumor localization were 69%, 74.4%, 35.1%, and 91.8%, respectively.
Conclusion :
This new criterion proved superior for diagnosing capsular invasion in prostate cancer patients. Also, analysis of tumor localization in the peripheral zone demonstrated that cancer detection is increased if the low-signal intensity area is enhanced by Gd.     

Prostate cancer disease-free survival after radical retropubic prostatectomy in patients older than 70 years compared to younger cohorts

OBJECTIVES: To evaluate the feasibility of radical retropubic prostatectomy (RRP) as an option for treating men older than 70 years with organ confined prostate cancer and to compare biochemical progression-free survival with younger cohorts. MATERIALS AND METHODS: A total of 689 consecutive patients who were treated with RRP from 1994 to 2002 for clinically localized prostate cancer were categorized into 3 different age groups: younger than 50 years (n = 49), 50-70 years (n = 601), and older than 70 years (n = 39). Patients older than 70 years were healthy individuals for their age. Preoperative and postoperative cancer-specific characteristics were compared among these 3 groups. RESULTS: There was no statistical significant difference among the 3 age strata in terms of clinical parameters (prostate-specific antigen, Gleason score, clinical stage, percent and number of positive biopsy cores) and pathologic findings (surgical margin, lymph node status, extracapsular extension, lymphovascular invasion, and pathologic Gleason score). The rate of seminal vesicle invasion and prostate volume increased with advancing age (P = 0.034 and P < 0.001). In multivariate logistic regression analysis, age was not associated with seminal vesicle invasion. The 5-year prostate-specific antigen progression-free estimates for patients younger than 50, 50-70, and older than 70 years were 82% (95% confidence interval [CI] 69% to 96%), 82% (95% CI 78% to 86%), and 65% (95% CI 43% to 86%), respectively (P = 0.349). The overall and cause-specific mortalities were not different. CONCLUSIONS: RRP could be considered a standard treatment option in men older than 70 years with localized prostate cancer. Further studies are necessary to assess the survival benefit and health-related quality of life after radical prostatectomy versus watchful waiting in patients older than 70 years.     

Innovative Diagnostik in der Früherkennung und beim Staging des lokalisierten Prostatakarzinoms

Prostate cancer is the most common malignancy in males. Men aged 50 years and older are recommended to undergo an annual digital rectal examination (DRE) and determination of prostate-specific antigen (PSA) in serum for early detection. Fortunately, disease-specific mortality continues to decline as a result of advances in screening, staging, and patient awareness. However, about 30% of men with a clinically organ-confined disease show evidence of extracapsular extension or seminal vesicle invasion on pathological analysis. Consequently, there is a need for more accurate diagnostic tools for planning tailored treatment. A variety of modern imaging techniques has been implemented in an attempt to obtain more precise staging, thereby allowing for more detailed counseling, and instituting optimum therapy. This review highlights developments in prostate cancer imaging that may improve staging and treatment planning for prostate cancer patients.     

Innovative concepts in early cancer detection and staging of localized prostate cancer

Prostate cancer is the most common malignancy in males. Men aged 50 years and older are recommended to undergo an annual digital rectal examination (DRE) and determination of prostate-specific antigen (PSA) in serum for early detection. Fortunately, disease-specific mortality continues to decline as a result of advances in screening, staging, and patient awareness. However, about 30% of men with a clinically organ-confined disease show evidence of extracapsular extension or seminal vesicle invasion on pathological analysis. Consequently, there is a need for more accurate diagnostic tools for planning tailored treatment. A variety of modern imaging techniques has been implemented in an attempt to obtain more precise staging, thereby allowing for more detailed counseling, and instituting optimum therapy. This review highlights developments in prostate cancer imaging that may improve staging and treatment planning for prostate cancer patients.     

THE USE OF PERCENT FREE PROSTATE SPECIFIC ANTIGEN FOR STAGING CLINICALLY LOCALIZED PROSTATE CANCER

Purpose

The free-to-total serum prostate specific antigen (PSA) ratio (percent free PSA) has been demonstrated to have clinical use for early detection of men with prostate cancer with total PSA levels between 4.0 and 10.0 ng./ml. Several studies evaluating the usefulness of percent free PSA for the staging of clinically localized prostate cancer have provided conflicting results. We further investigate the usefulness of percent free PSA for staging of clinically localized prostate cancer.

Materials and Methods

In 263 men with clinically localized prostate cancer who underwent radical prostatectomy total PSA and free PSA were measured preoperatively. Pathological stages were classified as organ confined in 134 cases, capsular penetration in 92, seminal vesicle involvement in 7, involvement of the surgical margins in 20 and lymph node involvement in 10.

Results

Percent free PSA was significantly different between men with organ confined versus nonorgan confined tumors (p <0.0001) and between those with favorable versus unfavorable pathology (p <0.0001). A cutoff of 12% free PSA provided a 72% positive predictive value and 52% negative predictive value for favorable pathology. A cutoff of 15% free PSA provided a 76% and 53% positive and negative predictive value, respectively, for organ confined disease.

Conclusions

These data demonstrate that the use of percent free PSA may be of additional value for the staging of clinically localized prostate cancer. The recommendations for cutoff levels of percent free PSA for detection and staging of localized prostate cancer are preliminary and can only be given for this particular assay. A large multicenter trial, controlling for age, stage and grade distribution, as well as for a uniform pathological evaluation and comparable total and free PSA assays, is required to elucidate this issue further.