Extended prostate needle biopsy improves concordance of Gleason grading between prostate needle biopsy and radical prostatectomy

PURPOSE: We examined the concordance of Gleason scores in prostate needle biopsy specimens and the corresponding radical retropubic prostatectomy specimens in a cohort of patients grouped according to the number of cores obtained during diagnostic needle biopsy. MATERIALS AND METHODS: We reviewed clinical and pathological data on a cohort of 466 men diagnosed with localized prostate cancer by needle biopsies who underwent radical retropubic prostatectomy between January 1, 1990 and July 31, 2001. Two study groups were identified, including 126 patients diagnosed with prostate cancer by extended needle biopsies (10 or more cores) and 340 diagnosed with cancer by nonextended needle biopsies (9 or fewer cores). Mean age was 60 years and median prostate specific antigen was 5.8 ng./ml. The median number of cores in the extended and nonextended biopsy groups was 12 and 6, respectively. The concordance of Gleason score in the needle biopsy and prostatectomy specimens was compared and correlated with the number of cores on needle biopsy. RESULTS: In the whole cohort 311 patients (67%) had identical Gleason scores on the needle biopsy and prostatectomy specimens, while 53 (11%) were over graded and 102 (22%) were under graded on needle biopsy. In patients who underwent extended needle biopsies the accuracy rate for Gleason scoring was 76% with 10% over and 14% under graded. The highest accuracy rates were in patients with 13, 14 and 16 cores (89%, 87% and 100%, respectively). No patients in the extended needle biopsy group had a discrepancy of more than 2 Gleason units in grade in the biopsy and surgical specimens. In those who underwent nonextended needle biopsies the accuracy rate for Gleason scoring was 63% with 12% over and 25% under graded. There were significantly different rates of accuracy (p = 0.008) and under grading (p = 0.01) in the 2 needle biopsy groups. Patients with a needle biopsy Gleason score of less than 7 had significantly higher concordance with the prostatectomy Gleason score when extended biopsies were done compared with nonextended biopsies (p = 0.001). CONCLUSIONS: Prostate cancer grading by extended needle biopsy is a better predictor of the final Gleason score than nonextended needle biopsy, as determined by radical prostatectomy histological evaluation. Therefore, extended prostate needle biopsy provides better guidance to determine the appropriate treatment in patients with prostate cancer.     

前列腺穿刺活检单针阳性患者行前列腺根治性切除术后的病理特征

目的 研究前列腺穿刺活检单针阳性患者行前列腺根治性切除术(RP)后的病理特征。方法 选择本院于2017年9月至2018年10月收入的前列腺癌(PCa)患者85例,均为前列腺穿刺活检单针阳性,对相关临床资料进行分析,根据术前因素进行分组,观察临床病理差异。结果 不同年龄段患者术后各项病理特征差异无统计学意义,在不同前列腺特异抗原（PSA）上pT0期、切缘阳性、病理分期＞T2比较,差异无统计学意义（P＞0.05）,在不同临床分期上pT0期、切缘阳性、病理分期＞T2比较,差异无统计学意义（P＞0.05）;PSA≥10 ng/mL患者在Gleason≥7分比例上明显多于PSA＜10 ng/mL患者,临床分期cT1患者在pT0期上多于cT2患者,差异有统计学意义（P＜0.05）。在穿刺Gleason评分上pT0期、切缘阳性、Gleason≥7分比较,差异无统计学意义（P＞0.05）;但Gleason 4+3分患者病理分期＞T2高于6分、3+4分、≥8分患者,差异有统计学意义（P＜0.05）。 结论 前列腺穿刺活检单针阳性不可作为PCa低风险筛查指标,大多数单针阳性患者需要积极进行治疗。     

Brachytherapy versus radical prostatectomy in patients with clinically localized prostate cancer

In an effort to help physicians offer their patients unbiased advice on the best alternatives for treatment of localized prostate cancer, we present a retrospective comparison of the effectiveness of brachytherapy and radical retropubic prostatectomy in 1305 men with stage T1 and T2 adenocarcinoma of the prostate. Data from 1305 patients treated in our community-based private practice urology group from 1993 to 2002 were reviewed, and patients were classified by initial prostate-specific antigen (PSA) level and risk grouping. Risk grouping was defined by preoperative PSA levels and Gleason scores. We used time to PSA-indicated recurrence as the measure of efficacy. Brachytherapy and radical prostatectomy provided similar responses to treatment (no significant differences given the sample size, length of follow-up, and numerical differences observed) for localized prostate cancers. A prospective study is presently underway to evaluate the respective outcome of these procedures (including incidence of incontinence and impotence), and assess their impact on patient quality of life. The results presented here fail to show any superiority of prostatectomy over brachytherapy with palladium-103 (TheraSeed; Theregenics Corp., Buford, GA) with respect to time until relapse indicated by PSA level increase (> 0.2 ng/mL for prostatectomy and >1.5 ng/mL and rising for brachytherapy). In fact, any differences between treatments favor brachytherapy, particularly for intermediate- and high-risk groups. We conclude that both brachytherapy and prostatectomy should be offered, equally and without bias, to men with stage T1 or T2 organ-confined prostate cancer.     

Micro-focal prostate cancer: a comparison of biopsy and radical prostatectomy specimen features

OBJECTIVES: To study the pathologic features of radical prostatectomy (RP) specimens of patients operated on the basis of a potentially "Insignificant" prostate cancer (Ca P) characterized by one single focus (less than 3mm) of moderately differentiated adenocarcinoma - Gleason score < or =6, out of 6-10 biopsies and to determine which characteristics, if any, are predictive of the presence of a "non significant" prostate cancer in the specimen characterized by a low volume (<0.5 ml) moderately differentiated organ confined, cancer (Gleason score less than 6). PATIENTS AND METHODS: PSA, biopsy features, and surgical specimens of a series of 56 patients submitted to RP for "insignificant Ca P" on TRUS prostate biopsies between 1988 and 2004 were compared regarding the number of tumor foci, Gleason grade and score, tumor volume determined by the cylinder method, as well as extraprostatic extension (EPE) and positive surgical margins (P.SM.). RESULTS: 70% of the patients had multifocal microfocal cancer apart from the index tumor. The presence of grade 4 was ignored by the biopsy in 50% of the cases, however the primary grade was correctly evaluated in more than 70% of the biopsy sets. 42% of the patients had a cancer volume less than 0.5 ml and 29% met the definition of insignificant/unimportant cancer characterized by a moderately differentiated (Gleason score < or =6) of low volume (less than 0.5 ml) however no feature accurately predictive of insignificant cancer could be individualized. In this whole series, only 8% of the patients had EPE. When the pre-operative PSA was <10 ng/ml, 98% of the patients had an organ confined tumor. CONCLUSION: Patients diagnosed with prostate cancer on the basis of one single focus less than 3 mm of moderately differentiated (Gleason < or =6) prostate cancer have 30% of chances of harboring an insignificant tumor in their prostate and are therefore, at risk of being overtreated, however there is at this time no specific feature able to identify these patients pre operatively.     

肥胖对临床局限性前列腺癌患者临床病理特征的影响

本研究旨在探讨不同肥胖测量指标对中国临床局限性前列腺癌患者临床病理特征的影响。本研究共入组734例在我院接受根治性前列腺切除术治疗的临床局限性前列腺癌患者,我们回顾性收集了全组患者的临床病理资料。BMI的计算即体重公斤数除以身高米数的平方。本组共413例患者术前在我院行盆腔增强核磁共振（magnetic resonance imaging,MRI）扫描。在MRJ扫描T2加权、矢状位图像上测量413例患者的腹部肥胖测量指标。利用方差分析或卡方检验比较不同BMI组患者的临床病理特征。利用Logistic回归模型分析术前血清睾酮水平和各肥胖测量指标对术后病理结果的影响。在多因素分析中,我们并未发现BMI与患者术后病理结果存在相关性。然而,多因素分析结果显示,内脏脂肪比例为术后病理Gleason评分≥8分（P〈O．001）,包膜外侵犯（P=0．002）和精囊腺侵犯（P=0．007）的独立预后因素。此外,我们还发现术前血清睾酮水平与内脏脂肪比例呈负相关（R=-0．485,P〈0．001）而与皮下脂肪厚度成正相关（R=0．413,P〈0．001）。综上所述,本研究结果显示,腹部脂肪的分布,尤其是内脏脂肪比例,是进展性前列腺癌的危险因素。而且,内脏脂肪比例与血清睾酮水平呈负相关。内脏肥胖影响进展性前列腺癌的分子生物学机制仍需进一步研究。     

Local recurrence of prostate cancer in rectal submucosa after transrectal needle biopsy and radical prostatectomy

A 69-year-old man with clinical Stage T1cN0M0 prostate cancer underwent radical prostatectomy, revealing negative surgical margins, focal capsular penetration, and negative lymph nodes and seminal vesicles. Five years later, his prostate-specific antigen level had increased to 0.2 ng/mL, and digital rectal examination revealed a palpable submucosal mass in the rectum that was confirmed by colonoscopy and transrectal ultrasonography. Excisional biopsy revealed prostatic adenocarcinoma similar in appearance and grade to the initial needle biopsy. This case report illustrates an extremely rare needle tract adenocarcinoma implantation after needle biopsy of the prostate.     

Androgen deprivation in combination with radical prostatectomy for localized prostate cancer

Radical prostatectomy is the only potential modality for cure in patients with localized prostate cancer. However, the lack of reliable and accurate clinical staging frequently leads to incomplete excision of tumor, with the consequences of early local recurrence or distant metastasis. Thus, the role of neoadjuvant or adjuvant hormonal treatment has been investigated in improving disease-free or cause-specific survival. This review reports the current status and problems of such androgen deprivation in combination with radical prostatectomy for localized prostate cancer.     

Ductal adenocarcinoma of the prostate diagnosed on needle biopsy: correlation with clinical and radical prostatectomy findings and progression

Ductal adenocarcinoma of the prostate, previously referred to as endometrioid cancer, is typically diagnosed on transurethral resection. When treated by radical prostatectomy (RP), it pursues a more aggressive clinical course than usual acinar prostate cancer does. The significance of prostate cancer with ductal features found on needle biopsies from the peripheral zone is unknown. We reviewed 58 prostate needle biopsy cases with ductal adenocarcinoma for which we were able to obtain clinical information. Patients had a mean age of 69 years (range, 50-89 years) and had a wide range of levels of serum prostate-specific antigen (median, 7.9 ng/mL) and clinical stages. Six (10%) had metastases at the time of diagnosis. Cribriform or papillary structures or a mixture of the two patterns were seen in 86% of cases, whereas in the remaining cases, discrete glands composed of tall columnar cells were present. Stromal fibrosis accompanied the ductal carcinoma in 67% of the cases. A coexisting acinar carcinoma component was identified in 48% of the biopsy specimens. On biopsy, the ductal component composed a mean of 82% of the tumor. Of the 20 tumors treated by RP, 63% had extraprostatic spread of tumor and 20% had positive margins. Two (10%) cases showed seminal vesicle invasion, but none had lymph node metastases. The number of positive needle cores correlated with RP margin status (p<0.004) and with likelihood of clinical progression (p<0.02), but not with organ-confined status. Tumor volume calculated on the 11 extensively sampled RPs ranged from 0.15 cm3 to 20.3 mL (mean, 2.8 cm3). Two years after therapy, the actuarial risk of progression was between 34% (RP patients) and 42% (all patients). A shortened average time to progression was observed relative to a previous study group of men with acinar carcinoma. Serum prostate-specific antigen levels correlated with neither RP organ-confined status nor tumor volume. We conclude that prostatic ductal adenocarcinoma seen on needle biopsy implies more advanced cancer with a shortened time to progression.     

Correlation between Gleason score of needle biopsy and radical prostatectomy tissue

Gleason score has been identified as an important variable to predict disease extent and biologic behaviour of prostate cancer. However, the correlation between Gleason score of needle biopsy and surgical specimen is often poor. We studied 72 patients who underwent needle biopsy and radical prostatectomy to correlate Gleason score with PSA, clinical and pathological tumour stage. Only 47.2% of Gleason scores were identical in the biopsy and specimens, 37.5% were undergraded and 15.2% were overgraded. Correlations between clinical and pathological stage were identical in 30.5% of patients, 61.1% of patients were understaged and 8.3% overstaged. In conclusion, accuracy of clinical staging and grading of prostate cancer is low. Although the Gleason score on needle biopsy might be useful to predict the final stage and grade, correlation with surgical specimen is poor.     

Inguinal hernia after a radical prostatectomy for localized prostate cancer

Since prostate-specific antigen (PSA) screening began in the 1980s in Taiwan, there has been a significant increase in the detection of prostate cancers (PCs) at an earlier stage. For clinically localized PC, a radical prostatectomy (RP) remains the gold standard treatment. However, patients undergoing a RP for PC are at risk of onset or worsening of inguinal hernias (IHs). We reviewed the current status of IHs after a RP. We reviewed literature published from PubMed using the key words of “inguinal hernia”, “prostatectomy”, and “prostate cancer”. The postprostatectomy mechanism was illustrated. The incidences of various prostatectomies were recorded. The prediction and prevention of postprostatectomy IHs were analyzed. Disruption of the transversalis fascia caused by surgical procedures was proposed as contributing to postprostatectomy-related IH formation because it assaults the anatomic-physiological balance in the abdominal wall. The myopectineal orifice is traversed by the spermatic cord and femoral vessels, and its inner surface is sealed by the transversalis fascia. A body mass index of <23 kg/m² and a history of previous IH repair were significant risk factors for postoperative IH. The incidence of IHs after surgery was reported to range from 12.4% to 23.9%, and most IHs occur within 6–24 months postprostatectomy. The incidence of IHs is greater with the extraperitoneal approach than with the transperitoneal approach. A preoperative abdominal computed tomography (CT)-scan might identify asymptomatic IHs, but the test lacks sensitivity and is inferior to a simple physical examination (PE). A PE of the groin should be performed before a RP, and careful surgical manipulation is essential to prevent postoperative IHs. The concurrent repair of any detectable IHs at the time of a prostatectomy could significantly reduce the incidence of postoperative IHs.     

Immunological evaluation of neoadjuvant peptide vaccination before radical prostatectomy for patients with localized prostate cancer

BACKGROUND: The purpose of this study was to determine the safety and immune responses of pre-operative personalized peptide vaccine for patients with localized prostate cancer. METHOD: Ten human leukocyte antigen (HLA)-A24(+) patients with localized prostate cancer received weekly personalized peptide vaccine for six times with positive peptides (up to four kinds of peptides) from 16 kinds of vaccine candidates, followed by a retropubic radical prostatectomy (RRP). Eight patients with localized prostate cancer receiving RRP served as the control group. The serum prostate-specific antigen (PSA) level, and peptide-specific cytotoxic T lymphocyte (CTL) precursor analysis by interferon-gamma production, and peptide-reactive immunoglobulin G (IgG) using an enzyme-linked immunosorbent assay were monitored during the treatment. Distributions of CD45RO(+) cells, CD8(+) T cells, and CD20(+) B cells in tissue microarray samples were studied using an immunohistochemical technique. RESULT: The peptide vaccination was safe and well tolerated with no major adverse effects. Increased CTL response and the anti-peptide IgG titer were observed in the post-vaccination samples in 8 of 10 or 8 of 10 patients, respectively. The intensity of CD45RO(+) infiltrating cells in the vaccination group was significantly larger than that in the control group. CD8(+) T cell infiltration was seen only in the vaccinated group. CONCLUSION: Increased immune responses, at both the circulation and tumor sites in the vaccinated group, support the further development of personalized peptide vaccines for patients with localized prostate cancer.     

经腹途径与经腹膜外途径机器人辅助腹腔镜下根治性前列腺切除术临床疗效的Meta分析

目的:采用Meta分析的方法比较经腹途径机器人辅助腹腔镜下根治性前列腺切除术(Tp-RALRP)与经腹膜外途径机器人辅助腹腔镜下根治性前列腺切除术(Ep-RALRP)治疗局限性前列腺癌的临床疗效。方法:通过计算机检索Pubmed,EMBASE,Web of science,EBSCO,Cochrane library,万方,中国知网(CNKI),中国生物医学数据库(CBM)(2000年1月~2016年11月),入选文献必须对比Tp-RALRP与Ep-RALRP的疗效,包含手术时间、术中出血量、术后留置导尿时间、术后卧床时间、围手术期并发症发生率、切缘阳性率、与肠道有关的并发症发生率、术后尿道吻合口瘘发生率、术后控尿率等指标中的至少一项,运用Meta分析方法比较两种手术方式在治疗局限性前列腺癌疗效上的差异。统计学软件采用Rev Man 5.3软件。结果:经仔细筛选后共有8篇文献纳入该研究,其中Tp-RALRP组451例,Ep-RALRP组676例。与Tp-RALRP相比,Ep-RALRP具有手术时间短(WMD=21.39,95%CI 7.54~35.24,P=0.002),术后卧床时间短(WMD=0.85,95%CI 0.61~1.09,P0.001)、与肠道有关的并发症发生率低(RR=9.74,95%CI 3.26~29.07,P0.001)等优势,差异均有统计学意义(P0.05)。两种手术方式的术中出血量(WMD=-8.12,95%CI-27.86~11.63,P=0.42)、术后留置导尿时间(WMD=-0.17,95%CI-0.55~0.21,P=0.38)、围手术期并发症发生率(RR=1.34,95%CI-0.97~1.87,P=0.08)、切缘阳性率(RR=1.24,95%CI 0.95~1.61,P=0.12)、术后尿道吻合口瘘发生率(RR=0.98,95%CI 0.46~2.10,P=0.95)、术后3个月控尿率(RR=0.96,95%CI 0.91~1.00,P=0.05)及术后6个月控尿率(RR=1.00,95%CI 0.97~1.02,P=0.82)等方面差异均无统计学意义(P0.05)。结论:与Tp-RALRP相比,Ep-RALRP具有手术时间短、术后卧床时间短、与肠道有关的并发症发生率低等优点,因此,Ep-RLRP可能是治疗局限性前列腺癌更好的方法。但未来仍然需要开展更多多中心、大样本的随机对照研究进而更好地评估两种手术方式的优劣。     

Perioperative complications of radical retropubic prostatectomy in patients with locally advanced prostate cancer: a comparison with clinically localized prostate cancer

Radical prostatectomy (RP) continues to be an effective surgical therapy for prostate carcinoma, particularly for organ-confined prostate cancer (PCa). Recently, RP has also been used in the treatment of locally advanced prostate cancer. However, little research has been performed to elucidate the perioperative complications associated with RP in patients with clinically localized or locally advanced PCa. We sought to analyse the incidence of complications in these two groups after radical retropubic prostatectomy (RRP). From June 2002 to July 2010, we reviewed 379 PCa patients who underwent RRP in our hospital. Among these cases, 196 had clinically localized PCa (T_1a–T_2c: group 1), and 183 had locally advanced PCa (≥T_3a: group 2). The overall complication incidence was 21.9%, which was lower than other studies have reported. Perioperative complications in patients with locally advanced PCa mirror those in patients with clinically localized PCa (26.2% vs. 17.8%, P=0.91). Our results showed that perioperative complications could not be regarded as a factor to consider in regarding RP in patients with cT₃ or greater.     

Androgen replacement therapy in patients with age-related hypogonadism after radical retropubic prostatectomy for localized prostate cancer

BackgroundThe aim was to estimate the efficacy and safety of androgen replacement therapy (ART) in a retrospective cohort study of a group of patients with signs and symptoms of hypogonadism who had undergone radical retropubic prostatectomy (RRP) for localized prostate cancer (PCa).MethodsThe results of treatment in 16 patients who had undergone RRP for localized PCa at stage pT2N0M0 during the years 2001–2005 were analyzed. Both prior to and following the ART, serum total testosterone (T), and prostate-specific antigen (PSA) levels were evaluated, and signs and symptoms were assessed using the Aging Male Symptoms (AMS) Scale.ResultsWith a mean ART duration of 15 months, the mean test level increased from 6.5 ± 1.98 nmol/l to 19.2 ± 5.1 nmol/l (from 188 ± 57 ng/dl to 555 ± 198 ng/dl) (p < 0.01), while the AMS symptom score decreased from 40.4 ± 5.4 to 20.8 ± 3.8 points. None of the patients had evidence indicative of biochemical or clinical progression of localized PCa.ConclusionOur experience of the treatment of 16 patients and the relevant literature data suggest that in the carefully selected patients with the signs and symptoms of hypogonadism following RRP, the safe use of ART with a good clinical effect is feasible. To formulate the clinical guidelines on ART in patients who have been surgically cured of PCa, prospective, multicenter studies with large numbers of patients are required.