The maximum tumour length in biopsy cores as a predictor of outcome after radical prostatectomy

OBJECTIVES

To evaluate maximum tumour length (MTL) in biopsy cores as a predictor of prostate‐specific antigen (PSA)‐failure, systemic failure, and death from prostate cancer after radical prostatectomy (RP).

PATIENTS AND METHODS

We assessed 209 men with clinically localized prostate cancer treated with RP; preoperative variables were correlated with unfavourable pathological characteristics in the RP specimens and with outcome after surgery, using univariate and multivariate analysis.

RESULTS

The median (range) MTL was 4 (0.2–19) mm and correlated with adverse pathological findings, including specimen Gleason score (P = 0.003), pT3 (P < 0.001), seminal vesicle invasion (P < 0.001) and lymph node involvement (P = 0.019) in multivariate analysis. Preoperative PSA (P < 0.001), biopsy Gleason score (P = 0.002), and MTL (P = 0.045) were independent predictors of PSA failure, whereas only MTL remained a predictor of systemic‐failure (P < 0.001) and death from prostate cancer (P = 0.004). The median (range) follow‐up after surgery was 90 (17–152) months, during which 83 patients had PSA failure, 20 developed systemic failure and 15 died from prostate cancer.

CONCLUSIONS

The MTL correlates well with adverse pathological findings and appears to be an independent predictor of outcome after RP. Patients with a greater MTL might have cancer with an aggressive phenotype and therefore be candidates for more aggressive therapies.     

Accuracy of transrectal ultrasound guided prostate biopsy: Histopathological correlation to matched prostatectomy specimens

BACKGROUND: The Gleason grading system is currently the world's most commonly used histological system for prostate cancer. It provides significant information about the prognosis. Therefore, Gleason score is accepted as an important factor in therapeutic decision-making for prostate cancer. This retrospective study assessed the correlation of transrectal ultrasound (TRUS) guided biopsy and radical prostatectomy specimens in terms of Gleason scores. METHODS: We reviewed the records of 103 patients who underwent radical prostatectomy due to clinically localized prostate cancer. The Gleason scores of the TRUS biopsies were compared with the respective Gleason scores of surgical specimen. RESULTS: In 28.7% of cases, the TRUS biopsy score was the same as that of the radical prostatectomy specimen. The most significant discordance was the upgrading of well-differentiated tumors after surgery in 71.7% of cases. However, in 81.8% of cases with high Gleason score on TRUS, biopsy was correlated with poorly differentiated tumor after surgery. CONCLUSIONS: Well-differentiated tumors on TRUS biopsy did not correlate with the grades of final pathology in the majority of cases; however, a high Gleason score on TRUS biopsy usually indicated a poorly differentiated tumor on prostatectomy specimen. Therefore, the treatment algorithms for particularly well-differentiated tumors should not be deduced from biopsy histology alone.     

The total percentage of biopsy cores with cancer improves the prediction of pathological stage after radical prostatectomy

OBJECTIVE: To examine whether the simple variable 'percentage of cancer-positive biopsy cores' is a significant predictor of true pathological stage after radical prostatectomy and can be used to improve pathological stage prediction by simple means. PATIENTS AND METHODS: In all, 375 patients had a radical prostatectomy for localized prostate cancer in two UK centres; 260 had complete preoperative staging information. Logistic regression was used and predicted probability graphs constructed to assess predictors of pathological stage. RESULTS: In this study, only PSA (P = 0.004) and percentage cancer-positive biopsy cores (P < 0.001) were significant predictors of pathological stage. The final model was an acceptable classifier for pathological stage (area under the receiver operating characteristic curve 0.76, specificity 85%, sensitivity 47%). A patient with a PSA of 10 ng/mL and one of six cores positive for cancer would have a predicted probability of extraprostatic disease of 20%, whereas the same patient with all six biopsy cores positive would have a predicted probability of extraprostatic disease of 80%. CONCLUSIONS: The percentage of cancer-positive biopsy cores significantly predicts the disease stage after radical prostatectomy. This variable is easy to obtain by the clinician and avoids the need to estimate the percentage of biopsy tissue infiltrated by cancer. This readily available information can easily be computed and may help to counsel patients about realistic expectations of organ-confined disease in relation to surgery as a treatment option.     

The presence of prostate cancer on saturation biopsy can be accurately predicted

Study Type – Diagnostic (non‐consecutive)
Level of Evidence 3b

OBJECTIVE

To improve the ability of our previously reported saturation biopsy nomogram quantifying the risk of prostate cancer, as the use of office‐based saturation biopsy has increased.

PATIENTS AND METHODS

Saturation biopsies of 540 men with one or more previously negative 6–12 core biopsies were used to develop a multivariable logistic regression model‐based nomogram, predicting the probability of prostate cancer. Candidate predictors were used in their original or stratified format, and consisted of age, total prostate‐specific antigen (PSA) level, percentage free PSA (%fPSA), gland volume, findings on a digital rectal examination, cumulative number of previous biopsy sessions, presence of high‐grade prostatic intraepithelial neoplasia on any previous biopsy, and presence of atypical small acinar proliferation (ASAP) on any previous biopsy. Two hundred bootstraps re‐samples were used to adjust for overfit bias.

RESULTS

Prostate cancer was diagnosed in 39.4% of saturation biopsies. Age, total PSA, %fPSA, gland volume, number of previous biopsies, and presence of ASAP at any previous biopsy were independent predictors for prostate cancer (all P < 0.05). The nomogram was 77.2% accurate and had a virtually perfect correlation between predicted and observed rates of prostate cancer.

CONCLUSIONS

We improved the accuracy of the saturation biopsy nomogram from 72% to 77%; it relies on three previously included variables, i.e. age, %fPSA and prostate volume, and on three previously excluded variables, i.e. PSA, the number of previous biopsy sessions, and evidence of ASAP on previous biopsy. Our study represents the largest series of saturation biopsies to date.     

Cancer ablation with regional templates applied to prostatectomy specimens from men who were eligible for focal therapy

OBJECTIVE

To assess the totality of prostate cancer eradication in radical prostatectomy (RP) specimens from men with a unilaterally positive prostate biopsy, and who would currently qualify for subtotal prostate ablation with controlled thermal energy such as cryoablation or high‐intensity focused ultrasound.

MATERIALS AND METHODS

Therapies for prostate cancer hold the promise of individualized treatment that selectively ablates the tumour while minimizing treatment‐associated morbidity, but as prostate cancer is multifocal there are concerns about untreated residual disease. RP specimens (180) from men with a unilaterally positive prostate biopsy were examined to characterize the location, volume and grade of each tumour focus. Two treatment templates (hemiprostate and ‘hockey‐stick’) were applied to every prostate cross‐section. The nature of the in‐field and out‐of‐field tumours was assessed and described for each treatment template.

RESULTS

A single focus of cancer was the only tumour in 31 (17%) of the patients (contralateral cancer was present in 149, 83%, of specimens despite a unilateral positive biopsy). Hemiprostate and hockey‐stick treatment templates covered all tumour foci in 17% and 47% of men, respectively. Most out‐of‐field cancers were clinically insignificant tumours not identified by prostate biopsy (low‐volume, 0.5 mL; and low grade, Gleason score ≤6). Regional ablation would have successfully treated all clinically significant prostate tumours in 64% and 81% of patients using the hemiprostate or hockey‐stick template, respectively. The hockey‐stick template encompassed all dominant tumours (largest volume).

CONCLUSIONS

Regionally targeted prostate ablation is capable of eradicating all dominant tumours and the vast majority of clinically significant tumours in men with unilateral disease by biopsy. The study of focally ablative therapy should proceed under the auspices of an approved protocol.     

Gleason score and tumor laterality in radical prostatectomy and transrectal ultrasound-guided biopsy of the prostate: a comparative study

We aimed to compare Gleason score and tumor laterality between transrectal ultrasound-guided biopsy of the prostate (TRUSBX) and radical prostatectomy (RP). Some factors that could cause a discrepancy in results between these two procedures were also evaluated. Among the 318 cases reviewed, 191 cases were selected for inclusion in this comparative study. We divided the patients into two groups using the Gleason score: an intermediate/high-grade group (≥7) and a low-grade group (<6). Exploratory analyses were conducted for comparisons between groups. We also performed comparisons between TRUSBX and RP for tumor laterality. TRUSBX overestimated 6% and underestimated 24% cases in comparison with RP for Gleason score, and overestimated 2.6% and underestimated 46% cases compared with RP for tumor laterality. Biopsy specimens were slightly smaller in TRUSBX cases with underestimated tumor laterality (P < 0.05), and no relationship between the biopsy specimen size and underestimated Gleason score in TRUSBX was found. Prostatic volume showed no statistical correlation with the likelihood of under or overestimation (P > 0.05). Thus, our study showed that TRUSBX has a high likelihood of underestimating both the Gleason score and tumor laterality in prostate cancer (PCa). The size of the fragment appears to be an important factor influencing the likelihood of laterality underestimation and Gleason score overestimation via TRUSBX. Due to the high likelihood of underestimation of the Gleason score and tumor laterality by 12-core prostate biopsy, we conclude that this type of biopsy should not be used alone to guide therapy in PCa.     

Six additional systematic lateral cores enhance sextant biopsy prediction of pathological features at radical prostatectomy

PURPOSE: We evaluated the contribution of 6 additional systematically obtained, laterally directed biopsy cores to traditional sextant biopsy for the prediction of final pathological findings in the radical prostatectomy specimen. MATERIALS AND METHODS: We studied 178 consecutive patients with no history of prostate biopsy in whom prostate cancer was diagnosed during an initial systematic 12 core biopsy and who subsequently underwent radical prostatectomy. Of the systematic 12 cores we compared the subset of the 6 traditional sextant cores (S6C), the set of 6 laterally directed cores (L6C) and the complete 12 core set, which included the 6 traditional sextant and the 6 laterally directed cores. Biopsy Gleason score, number of positive cores, total cancer length and percent of tumor in the biopsy sets were examined for their ability to predict extracapsular extension, total tumor volume and pathological Gleason score. RESULTS: On univariable analyses the biopsy parameters of the complete 12 core set correlated more strongly with extracapsular extension and total tumor volume than the biopsy parameters of S6C or L6C. On multivariable analyses S6C and L6C were independent predictors of pathological features at prostatectomy. CONCLUSIONS: The addition of 6 systematically obtained, laterally directed cores to traditional sextant biopsy improved the ability to predict pathological features at prostatectomy by a statistically and prognostically significant margin. Preoperative nomograms that use data from a full complement of 12 systematic cores, specifying sextant and laterally directed biopsy cores, should demonstrate improved performance in predicting prostatectomy pathology.     

The results of transperineal versus transrectal prostate biopsy: a systematic review and meta-analysis

This systematic review was performed to compare the efficacy and complications of transperineal (TP) vs. transrectal (TR) prostate biopsy. A systematic research of PUBMED, EMBASE and the Cochrane Library was performed to identify all clinical controlled trials on prostate cancer (PCa) detection rate and complications achieved by TP and TR biopsies. Prostate biopsies included sextant, extensive and saturation biopsy procedures. All patients were assigned to a TR group and a TP group. Subgroup analysis was performed according to prostate-specific antigen (PSA) levels and digital rectal examination (DRE) findings. The Cochrane Collaboration's RevMan 5.1 software was used for the meta-analysis. A total of seven trials, including three randomized controlled trials (RCTs) and four case-control studies (CCS), met our inclusion criteria. There was no significant difference in the cancer detection rate between the sextant TR and TP groups (risk difference (RD), -0.02; 95% confidence interval (CI), -0.08-0.03; P=0.34). Meta-analysis for RCTs combined with CCS showed that there was no difference in the cancer detection rate between the extensive TR and TP group (RD, -0.01; 95% CI, -0.05-0.04; P=0.81). There was no significant difference in PCa detection rate between the saturation TR and TP approaches (31.4% vs. 25.7%, respectively; P=0.3). There were also no significant differences in cancer detection between the TR and TP groups in each subgroup. Although the data on complications were not pooled for the meta-analysis, no significant difference was found when comparing TR and TP studies. TR and TP biopsies were equivalent in terms of efficiency and related complications. TP prostate biopsy should be an available and alternative procedure for use by urologists.     

Understanding the pathological features of focality, grade and tumour volume of early-stage prostate cancer as a foundation for parenchyma-sparing prostate cancer therapies: active surveillance and focal targeted therapy

What's known on the subject? and What does the study add? The recent shift of pathological stage migration towards earlier forms suggested great potential for the introduction of focal therapy into urological practice. A body of the literature showed increasing frequency of unilateral and unifocal lesions that can be efficiently treated with tumour ablative techniques. The internal panel of experts has done a comprehensive review of the largest mostly single institution studies and their own trials with the aim of evaluating a value of main pathological features of early stage prostate cancer as a background to developing a concept of focal therapy. Analysis data including latest developments will help to better understand the purpose, meaning and patient selection of different kinds of focal targeted ablation of prostate cancer.

OBJECTIVE

? To better understand the biology and incidence of the cancer foci within the prostate through a comprehensive literature review and a review of our own data, to establish the current level of knowledge regarding the pathological foundation for active surveillance (AS) or focal therapy (FT).

PATIENTS AND METHODS

? A systematic review of the literature was performed, searching PubMed® from January 1994 to July 2009. ? Electronic searches were limited to the English language using the keywords ‘prostate cancer’, ‘histopathology’, ‘radical prostatectomy’, ‘pathological stage’ and ‘focal therapy’. ? The authors’ own data were also analysed and are presented.

RESULTS

? Recent data have shown a significant pathological stage migration towards earlier disease comprising unilateral pT2a/b prostate cancer (PCa). ? The cancer volume of the clinically significant tumour (index lesion) has been proposed as a driving force of PCa progression and therefore should be identified and treated at an early stage. ? In general, most satellite lesions do not appear to be life‐threatening. ? Other pathological features, such as Gleason score, extraprostatic extension and the spatial distribution of PCa within the prostate, remain important selective criteria for AS or FT.

CONCLUSION

? The present study reviews the current knowledge of cancer focality, aggression and tumour volume. Further research is needed to better understand the biologic behaviour of each of the tumour foci within a cancerous prostate, and to employ this information to selected patients for no therapy (AS), parenchyma‐preserving approaches (FT) or whole gland radical therapy.     

经直肠前列腺穿刺活检中应用不同针径活检针的对比研究

目的:比较不同针径活检针在超声引导下经直肠前列腺穿刺活检中的应用价值。方法:选取2015年1月～2016年10月在我院泌尿外科行超声引导下经直肠前列腺穿刺活检患者100例,采用随机数表法将患者分为观察组与对照组,每组50例,观察组采用16G活检针,对照组采用常规18G活检针,两组均进行相同的系统12针+靶向穿刺方案,由同一名专职医师完成穿刺操作。比较两组间穿刺阳性率以及术后并发症发生率。结果:两组12针系统穿刺阳性率比较差异无统计学意义(36%vs.24%,P=0.190),而靶向穿刺阳性率比较观察组优于对照组(37.5%vs.15.0%,P=0.022)。观察组穿刺阳性率与血清总PSA水平、PSA密度有相关性。两组术后疼痛评分(P=0.629)、术后并发症发生率(P=0.648)比较差异无统计学意义。结论:16G活检针能显著提高前列腺靶向活检阳性率,且术后相关并发症风险并未增加。     

经会阴前列腺24针饱和穿刺活检与14针活检在PSA＜20μg/L患者中筛检前列腺癌的对比性研究

目的:探讨超声引导下经会阴前列腺24针饱和穿刺活检与14针穿刺活检方案对PSA<20μg/L可疑前列腺癌患者的筛检阳性率及其相关并发症。方法:选取116例可疑前列腺癌患者行经会阴超声引导下14针穿刺活检(14针组),另136例患者,行经会阴24针饱和前列腺穿刺活检(24针饱和组),比较两组前列腺癌筛检阳性率、标本阳性率及穿刺后肉眼血尿、泌尿系感染、尿潴留等并发症的发生率。结果:两组患者平均年龄、穿刺前PSA水平、平均前列腺体积等指标均无统计学差异(P>0.05)。24针饱和组及14针组前列腺癌筛检总体阳性率分别为48.53%和17.24%,存在显著性差异(P<0.001),标本阳性率分别为8.09%和2.83%(P=0.012);其中24针饱和组前列腺尖部肿瘤的检出率(11.76%)显著高于14针组(1.72%,P<0.05)。两组穿刺后尿潴留、泌尿系感染和肉眼血尿等发生率均无统计学差异(P>0.05)。结论:24针经会阴前列腺饱和穿刺活检方法显著提高PSA<20μg/L患者中前列腺癌的筛检阳性率,尤其是增加了前列腺尖部区域的肿瘤筛检阳性率,而并未增加相关并发症。