Percentages of positive cores, cancer length and Gleason grade 4/5 cancer in systematic sextant biopsy are all predictive of adverse pathology and biochemical failure after radical prostatectomy

AIM: We investigated whether the quantitative parameters of systematic sextant biopsies were predictive of either adverse pathological findings or disease recurrence after radical prostatectomy (RP). METHODS: We retrospectively evaluated a total of 117 men with untreated prostate cancer whose needle biopsies were matched with RP specimens. The pretreatment parameters of the serum prostate-specific antigen (PSA), the PSA density, the percentage of positive biopsy cores, the percentage of cancer length and the percentage of Gleason grade 4/5 cancer in the biopsy were determined and compared with the pathological features of prostate cancer in RP specimens. These pretreatment parameters and pathological factors in the RP specimens, including the cancer volume, the percentage of Gleason grade 4/5 cancer, the positive surgical margin and the seminal vesicle invasion were evaluated for their ability to predict the disease recurrence. RESULTS: The percentages of positive biopsy cores, the Gleason grade 4/5 cancer in the biopsy and the cancer length in the biopsy had a weak correlation with the cancer volume in RP specimens (r = 0.373, 0.345, 0.408, respectively). All quantitative biopsy parameters were strongly predictive of the non-organ-confined status, the positive surgical margin and the seminal vesicle invasion in the logistic regression analysis. The percentage of positive biopsy cores and the percentage of Gleason grade 4/5 cancer in the biopsy predicted biochemical failure after RP. CONCLUSION: These results indicate that quantitative biopsy parameters are independent predictors of the adverse pathology of prostate cancers and disease recurrence after RP.     

Is seminal vesicle ablation mandatory for all patients undergoing radical prostatectomy? A multivariate analysis on 1283 patients

OBJECTIVE: With a shift in prostate cancer stage and a majority of patients operated nowadays with PSA levels <10 ng/ml, rates of seminal vesicle (SV) invasion found on radical prostatectomy specimens have decreased as compared to historical data. Since SV-sparing surgery may possibly have an influence on post-operative erectile dysfunction and urinary recovery, we tried to determine which patients could be safely spared SV excision during radical prostatectomy. MATERIAL AND METHODS: We used preoperative data from 1283 patients operated by radical retropubic prostatectomy--777 with serum PSA <10.0 ng/ml--to predict SV invasion on final pathological examination. Variables analyzed included age, digital rectal examination, serum PSA, biopsy Gleason score and percentage of biopsy cores invaded by prostate cancer. Statistical analysis included univariate, multivariate logistic regression analysis and receiver operating characteristic (ROC) curves. RESULTS: Out of 1283 patients, 137 (10.6%) had SV involvement, 41/777 (5.2%) with PSA <10.0 ng/ml, 16.1% in the 10-20 ng/ml range and 26.2% when PSA was >20 ng/ml. Percentage of biopsies affected by prostate cancer and biopsy Gleason score were significant predictors of SV invasion in multivariate analysis, both in the entire population and in the subset of patients with PSA <10.0 ng/ml (p < 0.0001). Probability graphs created for patients with PSA <10 ng/ml indicate a risk of seminal invasion <5% when Gleason score on biopsy is <7 or when the percentage of biopsies affected by cancer is <50%. CONCLUSIONS: Resection of SV might not be "oncologically" necessary in all patients undergoing RP when PSA levels are below 10 ng/ml except when biopsy Gleason score is > or =7 or when more than 50% of prostate biopsy cores show cancer involvement. SV-sparing surgery could be prospectively compared to standard retropubic prostatectomy in selected individuals analyzing potential benefits on erectile function and urinary continence.     

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.     

Important preoperative prognostic factors for extracapsular extension,seminal vesicle invasion and lymph node involvement in cases with radical retropubic prostatectomy

Introduction: Initial diagnostic evaluation may provide information about the extent of disease after radical retropubic prostatectomy (RRP). The aim of this study was to investigate the predictive value of preoperative serum prostate specific antigen (PSA) level, local disease extension identified by transrectal ultrasound (TRUS), total number of positive biopsies and percentage of positive cores for cancer, as well as TRUS Biopsy Gleason score in determining the extent of disease in radical retropubic prostatectomy specimens. Materials and methods: A retrospective analysis was performed on 171 patients who underwent RRP from March 1993 to February 2003 for organ confined prostate cancer and whose follow-up data was accessible. The correlation of preoperative serum PSA level, local disease extension in TRUS, the total number of positive sextant biopsies and the percent of cores positive for cancer and Gleason score at TRUS biopsy specimen with the extent of disease at final pathology (Extra-capsular extension (ECE), seminal vesicle invasion (SVI), lymph node involvement (LNI) and surgical margin (SM) status on RRP specimens) were analyzed. Results: The median age of the patients was 65 years. The mean preoperative serum PSA level of all patients was 11.6 ± 1.2 (median 8.6) ng/ml. Histopathological evaluation of RRP specimens revealed 60 (35%) patients with ECE, 38 (22.2%) with SVI, 7 (0.04%) with LNI, and 58 (33.9%) had positive SM. Comparing the preoperative TRUS findings and postoperative evaluation of RRP specimens, the sensitivity of TRUS in predicting the ECE was 11.8% and specificity was 96%. Sensitivity of TRUS in predicting SVI was 9.8% and its specificity was 99%. With univariate analysis (sample t-test), Gleason score, percent of cores positive for cancer, and DRE were found to be predictive factors for extra-prostatic disease in RRP specimens. But with multivariate analysis (logistic regression test) Gleason score appears to be the most important and independent predictive factor for extra-prostatic disease in RRP specimens. Serum PSA levels and percentages of cores positive for cancer were also significant predictors of non organ-confined disease found at final pathology. Conclusion: Gleason score is the most important and independent predictive factor for extra-prostatic disease. Serum PSA levels and percentages of cores positive for cancer are the other important but non-independent predictive factors.     

Ultrasound-guided seminal vesicle biopsies in prostate cancer

Invasion of prostatic adenocarcinoma into the seminal vesicles (SV) is generally accepted as an index of poor prognosis. The pre-operative identification of SV invasion is an important element in staging since it may alter subsequent treatment decisions. We studied the possibility of diagnosing SV invasion with two biopsies from the junction between the prostate and seminal vesicles. Also we studied the correlation of several prognostic factors with the risk of clinical stage T(1,2,3) prostate cancer patients of having cancer growth into the seminal vesicles. Consecutive patients referred for transrectal ultrasound (TRUS) and biopsy because of clinical suspicion of prostate cancer were examined. This staging procedure was evaluated in patients who underwent a pelvic lymphadenectomy and radical retropubic prostatectomy (RRP). In 83 out of 138 patients prostate cancer was detected whereas 55 patients had benign disease. In 44% of prostate cancer patients a positive SV biopsy was found. The accuracy of the biopsies adjacent to the junction of the SV and the prostate was 91%. The best predictors for SV invasion were tumor grade of the biopsy sample (P<0.001), serum prostate-specific antigen (PSA) (P<0.0005), PSA density (P<0.0005) and clinical stage (P<0.0005). No significance was found in the relation to seminal vesicle involvement with free/total (f/t) PSA ratio (P=0.588) for the prostate cancer group (SV+ and SV-). In a receiver operating characteristic curves analysis, PSA density was significantly more accurate for prediction of SV invasion than PSA or f/t PSA ratio. In five prostatectomized patients (and negative SV biopsy) no SV invasion was found in the final pathologic examination either. SV biopsy at the junction of the SV and prostate is accurate for staging with high efficacy and low morbidity. To predict SV invasion in prostate cancer patients, PSA density was more accurate than PSA or f/t PSA ratio. The determination of the f/t PSA ratio in patients with low and intermediate PSA levels (eg <15 &mgr;g/L) is not useful to estimation of the risk of seminal vesicle involvement. The combination of serum PSA concentration, PSA density, tumor grade from the biopsy specimens ad clinical stage provides the best prediction of SV invasion. These parameters are identical to the conventional predictors of pathology after RRP. SV biopsies may provide additional information; if one or both basal biopsies are positive, a clinical T(1,2) disease is altered to T(3). Hence SV biopsy is useful for selection of patients who might obtain good results from RRP for prostate cancer. Prostate Cancer and Prostatic Diseases (2000) 3, 100-106     

Percent of prostate needle biopsy cores with cancer is significant independent predictor of prostate specific antigen recurrence following radical prostatectomy: results from SEARCH database

PURPOSE: Recent studies have suggested that the percent of positive cores in the prostate needle biopsy is a significant predictor of outcome among men undergoing radical prostatectomy or radiation therapy for prostate cancer. We evaluate whether either percent of cores with cancer or percent of cores positive from the most and least involved side of the prostate needle biopsy was associated with a worse outcome among men treated with radical prostatectomy. MATERIALS AND METHODS: A retrospective survey of 1,094 patients from the SEARCH Database treated with radical prostatectomy at 4 different equal access medical centers in California between 1988 and 2002 was undertaken. We used multivariate analysis to examine whether total percent of prostate needle biopsy cores with cancer, percent of cores positive from each side of the prostate and other clinical variables were significant predictors of adverse pathology and time to prostate specific antigen (PSA) recurrence following radical prostatectomy. RESULTS: On multivariate analysis serum PSA and percent of positive cores were significant predictors of positive surgical margins, nonorgan confined disease and seminal vesicle invasion. Percent of positive cores (p <0.001), serum PSA (p = 0.008) and biopsy Gleason score (p = 0.014) were significant independent predictors of time to biochemical recurrence. On a separate multivariate analysis that included the variables of total percent of positive cores, percent of positive cores from the most involved side of the biopsy, percent of positive cores from the least involved side of the biopsy and whether the biopsy was positive unilaterally or bilaterally, only the percent of positive cores from the most involved side of the biopsy was a significant independent predictor of PSA failure following radical prostatectomy. Percent of positive cores was used to separate patients into a low risk (less than 34%), intermediate risk (34% to 50%) and high risk (greater than 50%) groups, which provided significant preoperative risk stratification for PSA recurrence following radical prostatectomy (p <0.001). Percent of positive cores cut points were able to further risk stratify men who were at low (p = 0.001) or intermediate (p = 0.036) but not high (p = 0.674) risk for biochemical failure based on serum PSA and biopsy Gleason score. CONCLUSIONS: Percent of positive cores in the prostate needle biopsy was a significant predictor of adverse pathology and biochemical failure following radical prostatectomy, and the cut points of less than 34%, 34% to 50% and greater than 50% can be used to risk stratify patients preoperatively. The finding that percent of positive cores from the most involved side of the biopsy was a stronger predictor of PSA failure than the total percent of cores involved suggests that multiple positive biopsies from a single side might be a better predictor of a larger total cancer volume and thus correlate with clinical outcome.     

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.     

Preoperative Predictors for Organ-Confined Disease in Japanese Patients with Stage T1c Prostate Cancer

Background : In order to define the characteristics of patients with clinical stage T1c prostate cancer in Japan, clinicopathologic data obtained from patients treated by radical prostatectomy were reviewed.
Methods : Fifty-four stage T1 c cancers were evaluated for tumor volume, Cleason grade, tumor location and pathologic stage from prostatectomy specimens in association with preoperative clinical parameters.
Results : The mean tumor volume was 3.94 mL (range, 0.07 to 33.4 mL), and 11 of the 54 tumors had a tumor volume of less than 0.5 mL. Thirty-two tumors (59%) were organ-confined, while 7(13%) involved the seminal vesicle and/or regional lymph nodes. Multivariate logistic regression analysis of the pretreatment variables, including age, pretreatment PSA level, prostate volume, biopsy grade, and number of cancer-positive cores revealed that the serum PSA level and the number of cancer-positive biopsy cores were independent factors to predict organ-confined tumors ( P = 0.036 and 0.044, respectively). For T1c cancer with less than 4 cancer-positive biopsy cores, the sensitivity and specificity for predicting organ-confined tumors were 90% and 70%, with a cut-off value of 17 ng/mL for the serum PSA level. Conclusion: The clinicopathologic features of Tic prostate cancer in Japanese patients were similar to those of whites reported elsewhere. Both serum PSA levels and the number of positive biopsy cores may be useful as pretreatment parameters to identify patients with the potential to benefit from radical treatment.     

Transition zone biopsy and prediction of extraprostatic extension at radical prostatectomy

BACKGROUND: There is limited data in the literature that suggests that transition zone (TZ) biopsy might be useful for the prediction of extraprostatic extension (EPE) in clinically localized prostate cancer. We studied the role of TZ biopsy in the prediction of EPE. METHODS: Transition zone biopsies were performed in addition to systematic peripheral zone (PZ) biopsies between November 1995 and December 1999. During this period, 59 patients underwent radical prostatectomy for clinically localized disease. Final pathological results were compared with preoperative clinical and biopsy findings. RESULTS: Of the 59 patients who underwent radical prostatectomy, 46 had cancer only in the PZ cores and 13 had cancer both in the PZ and the TZ cores at the biopsy. Final histopathological results revealed EPE in 19 (32%) patients and positive surgical margins in 22 (37%). In univariate analysis of age, prostate-specific antigen (PSA), mean percentage of positive PZ cores, mean biopsy Gleason score and positive TZ biopsy, there was a significant difference for serum PSA levels (P = 0.021), presence of positive TZ cores (P = 0.018) and percentage of positive PZ cores in patients with and without EPE (P < 0.001). In multivariate analysis, the single independent predictor of EPE was the percentage of positive PZ biopsy cores (P = 0.0227). There was agreement between the side of positive TZ biopsy and EPE in seven of eight patients. CONCLUSION: Taking two TZ cores in addition to peripheral sextant biopsy did not result in better prediction of EPE. The relationship between TZ involvement and the presence of EPE can be investigated further in radical prostatectomy specimens.     

The extent of biopsy involvement as an independent predictor of extraprostatic extension and surgical margin status in low risk prostate cancer: implications for treatment selection

PURPOSE: We identify predictors of extraprostatic extension and positive surgical margins in patients with low risk prostate cancer (prostate specific antigen [PSA] 10 ng./ml. or less, biopsy Gleason score 7 or less and clinical stage T1c-2b). MATERIALS AND METHODS: From August 1997 to January 1999, 143 previously untreated patients underwent radical retropubic prostatectomy for clinically localized prostate cancer. A total of 62 patients were low risk, with PSA 10 ng./ml. or less, biopsy Gleason score 7 or less and clinical stage T1c-2b, and had sextant biopsy with separate pathological evaluation of each sextant cores. PSA, clinical stage, biopsy Gleason score, average percentage of cancer in the entire biopsy specimen, maximum percentage of cancer on the most involved core, number of cores involved and bilaterality were evaluated for association with extraprostatic extension, seminal vesicle involvement and positive surgical margins. RESULTS: Of the 62 patients 13 (21%) had extraprostatic extension, 6 (10%) seminal vesicle involvement and 20 (32%) positive surgical margins. Average percentage greater than 10% and maximum percentage greater than 25% were associated with extraprostatic extension (p = 0.01 and 0.004, respectively). Average percentage greater than 10%, maximum percentage greater than 25%, more than 2 cores involved and bilaterality were associated with positive surgical margins (p = 0.007, 0.01, 0.002 and 0.03, respectively). On multivariate analysis maximum percentage remained the only independent predictor of extraprostatic extension (p = 0.03), and the number of cores involved remained an independent predictor of positive surgical margins (p = 0.01). Biopsy Gleason score, PSA and clinical stage did not correlate with extraprostatic extension or positive surgical margins in this patient population. CONCLUSIONS: In low risk prostate cancer the extent of biopsy involvement significantly correlates with the risk of extraprostatic extension and positive surgical margins. Biopsy information should be considered when selecting and modifying treatment modalities.     

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.     

Are PSA density and PSA density of the transition zone more accurate than PSA in predicting the pathological stage of clinically localized prostate cancer?

PURPOSE: To assess whether PSA density (PSAD) and PSA density of the transition zone (PSADTZ) are more accurate than PSA alone in predicting the pathological stage of prostate cancer. MATERIALS AND METHODS: One hundred and nine consecutive patients with clinically localized prostate cancer and preoperative PSA values over the whole range, treated with radical retropubic prostatectomy and limited pelvic lymph node dissection were included in this prospective study. Total prostate and transition zone volumes were measured by transrectal ultrasound using the prolate ellipsoid method. PSA, PSAD, and PSADTZ were compared to percentage of positive biopsy cores (% PC), biopsy and surgical Gleason score, and pathological stage, using univariate and multivariate analysis. RESULTS: Pathological stage was pT2a, pT2b, pT3a, and pT3b in 25.6%, 37.7%, 25.6%, and 11.1% of patients, respectively. Lymph node metastases were found in 4.6% of patients. PSA, PSAD, and PSADTZ were significantly related to % PC, biopsy, and surgical Gleason score and pathological stage (P < 0.001), and were equally able to predict higher pathological stage, i.e., seminal vesicle invasion and lymph node metastases. Only by adding % PC in multivariate analysis was it possible to discriminate intra- from extracapsular tumors. CONCLUSIONS: The results of the present study demonstrate that PSAD and PSADTZ failed to outperform PSA in preoperative stage prediction of prostate cancer, possibly because the formula used to calculate them does not eliminate the contribution to total PSA of the nonmalignant portion of the gland.     

前列腺癌体积的临床预测及其意义

目的　研究以术前前列腺活检资料来推断前列腺癌体积及病理的价值。方法　以 3 3例因前列腺癌而行根治术的患者作为研究对象 ,将术前PSA、PSAD及前列腺 8点活检的结果与前列腺癌体积及病理进行相关分析研究。结果　 (1)前列腺癌体积与术前PSA、PSAD及前列腺活检的结果呈显著正相关 ,而与年龄、术前前列腺体积以及摘除标本的体积无明显相关关系 ;(2 )前列腺活检中阳性点数联合PSA与前列腺癌体积的回归模型预测前列腺癌体积最好 ;(3 )前列腺活检中阳性点数≤ 3点组的癌体积及精囊浸润率低于阳性点数≥ 4点组 ,两者有显著性差异。结论　前列腺 8点活检中阳性点数是预测前列腺癌体积及病理的一个重要参考指标 ,尤其是联合检测PSA ,更增加其预测前列腺癌体积的准确性     

The percent of cores positive for cancer in prostate needle biopsy specimens is strongly predictive of tumor stage and volume at radical prostatectomy

PURPOSE: Pretreatment clinical staging of prostatic adenocarcinoma is important due to the increasing use of nonsurgical treatment options. Using multivariate analysis we assessed the predictive value of biopsy cores positive for cancer as a percent of all cores obtained as well as the percent surface area of needle cores involved with tumor for determining tumor volume and pathological stage at radical prostatectomy. Candidate variables for the multivariate model included patient age, clinical disease stage, serum prostate specific antigen (PSA) and Gleason score of cancer in the needle biopsy. MATERIALS AND METHODS: We reviewed prostate needle biopsy findings in 207 consecutive patients who subsequently underwent radical retropubic prostatectomy. Each biopsy specimen was assessed for tumor involvement by calculating the percent of cores positive for cancer, percent surface area involved in all cores and Gleason score. Initial serum PSA and preoperative clinical disease stage were incorporated with biopsy results into a multivariate model to determine the parameters most predictive of pathological stage and tumor volume at radical retropubic prostatectomy. RESULTS: Of the 207 patients 152 (73.4%) had organ confined cancer and 55 (26.6%) had extraprostatic extension (pathological stages T2 and T3 or greater, respectively). Preoperative clinical staging information was available in 195 cases, in which disease was clinically confined and not confined in 184 (94.4%) and 11 (5.6%), respectively. Needle biopsy revealed a surface area of cancer ranging from less than 5% in 69 patients (33.3%) to 90% (mean 16, median 10). Univariate analysis demonstrated that the risk of extraprostatic extension was predicted by preoperative serum PSA (p = 0.027), the percent of cores and percent of surface area positive for cancer (p <0.0001), and Gleason score (p = 0.0009). Clinical stage approached significance (p = 0.071). Multivariate analysis showed that the percent of positive cores (p = 0.0003), initial serum PSA (p = 0.005) and Gleason score of cancer in the needle biopsy (p = 0.03) were the only parameters that jointly predicted pathological stage (T2 versus T3). Percent of tumor surface area involvement in the needle biopsies did not add any more information after the percent of positive cores was known. Univariate analysis revealed that the percent of cores positive for cancer (Spearman r = 0.52, p <0.0001), Gleason score (Spearman r = 0.34, p <0.0001) and initial serum PSA (Spearman r = 0.24, p = 0.003) were predictive of log tumor volume at radical prostatectomy, while clinical stage was not (rank sum test p = 0.14). On multivariate analysis the percent of positive cores (p <0.0001), Gleason score (p <0.0001) and initial serum PSA (0.0033) were the only variables that jointly were predictive of tumor volume. CONCLUSIONS: The percent of needle biopsy cores and surface area positive for cancer are the strongest predictors of pathological stage and tumor volume on multivariate analysis incorporating preoperative serum PSA and Gleason score.     

Clinicopathological study of prostate cancer patients who had a serum PSA level of more than 20 ng/ml and were treated by a radical prostatectomy

PURPOSE: In order to assess the validity of radical prostatectomy for the prostate cancer with PSA greater than 20 ng/ml, we reviewed the clinicopathological characteristics and prognoses of radical prostatectomy cases with PSA greater than 20 ng/ml. MATERIAL AND METHODS: Twenty-one radical prostatectomy cases who had a serum PSA level greater than 20 ng/ml were reviewed regarding their clinicopathological characteristics. Step-sectioned specimens were used for pathological evaluation. RESULT: The serum PSA level ranged from 21 to 65 ng/ml (median : 27 ng/ml). As for the clinical stage, there were 8 T1c cases, 5 T2b cases, 5 T2c cases, and 3 T3a cases (2001. TNM classification). According to the tumor location, 10 cases were diagnosed as peripheral zone (PZ) cancer, and 10 cases were diagnosed as transition zone (TZ) cancer. One case had several small cancer foci both in PZ area and TZ area. In 10 PZ cancer cases, 2 cases had lymph node metastasis, and 8 had seminal vesicle invasion. All of 10 PZ cancer cases showed extraprostatic extension, and 7 showed positive surgical margin. On the other hands in 10 TZ cancer cases, no cases had lymph node metastasis and seminal vesicle invasion. Five TZ cancer cases showed extraprostatic extension, and 6 showed positive surgical margin. The findings of digital rectal examination (DRE) and transrectal ultrasonography (TRUS) were positive in all PZ cancer cases, but these findings were unclear in TZ cancer cases. In addition, no significant difference were observed between the PZ cancer cases and the TZ cancer cases regarding age, PSA, prostate volume, PSA density, cancer volume, and Gleason scores. PSA failure was observed in 9 PZ cancer cases, and 2 TZ cancer cases. CONCLUSION: Based on our findings, the prognosis of TZ cancer cases was better than that of PZ cancer cases among the radical prostatectomy cases with PSA greater than 20 ng/ml. Radical prostatectomy might be one of the effective treatment option for TZ cancer even if the PSA shows greater than 20 ng/ml. It seems to be important to detect TZ cancer properly based on DRE and TRUS findings.     

A validated strategy for side specific prediction of organ confined prostate cancer: a tool to select for nerve sparing radical prostatectomy

PURPOSE: Nerve sparing radical prostatectomy for prostate cancer should be restricted to patients who harbor tumors without capsular penetration. To our knowledge the selection criteria for nerve sparing radical prostatectomy are not clearly defined. We investigated a panel of preoperative tumor characteristics with respect to their ability to predict organ confined tumor growth for each lobe of the prostate to indicate unilateral or bilateral nerve sparing radical prostatectomy. MATERIALS AND METHODS: Nine preoperative tumor characteristics in 278 patients with clinically localized prostate cancer were included in retrospective univariate and multivariate tree structured regression analysis. The association of clinical stage, serum prostate specific antigen (PSA), PSA density, and results of transrectal ultrasound and systematic sextant biopsy, including a quantitative assessment of cancer in the biopsies with organ confined tumor growth, was statistically evaluated. Except for serum PSA and PSA density preoperative characteristics were considered separately for each prostate lobe. Multivariate analysis results were validated prospectively in 353 patients. RESULTS: On univariate analysis the number of positive biopsies was the most useful single parameter with a positive predictive value of 83% in 274 lobes and a negative predictive value of 55%, followed by mm. of tumor in the biopsy. Of all characteristics included in multivariate analysis only the number of biopsies with high grade cancer, the number of positive biopsies and serum PSA were independent for predicting organ confined cancer. When PSA was less than 10 ng./ml. and not more than 1 biopsy with high grade cancer was identified in a lobe, organ confined tumor growth was present in 86.1% of cases. On prospective validation the same criteria led to an 88.5% incidence of organ confined prostate cancer. Pooling the 2 most favorable groups led to 391 prostate lobes (70.8% of those investigated) with a positive predictive value of 82.1% (95% confidence interval 77.9% to 85.8%). Using the multivariate approach more prostate lobes were assigned to a favorable risk group than on univariate analysis. Clinical stage and simple Gleason grade did not contribute independent information for predicting organ confined disease. CONCLUSIONS: Quantifying cancer and high grade cancer by systematic biopsy and serum PSA concentration are useful preoperative characteristics for predicting organ confined prostate cancer. Side specific analysis of these parameters is a flexible and reliable tool for selecting patients for nerve sparing radical prostatectomy.     

穿刺标本Gleason评分预测前列腺癌病理分级准确性的研究

目的 分析前列腺癌患者穿刺标本与根治术标本Gleason评分的相关性,探讨影响穿刺标本Gleason评分准确性的可能因素.方法 回顾性分析86例接受根治性前列腺切除术的前列腺癌患者资料,比较穿刺标本与根治术标本Gleason评分的符合情况,应用二分类Logistic回归分析筛选影响穿刺标本Gleason评分准确性的可能因素.结果 86例患者穿刺标本平均Gleason评分为6.1,根治术标本平均Gleason评分为6.5,穿刺标本与根治术标本Gleason评分相比,评分相符42例(48.8%),评分偏低32例(37.2%),评分偏高1 2例(14.0%),差异具有统计学意义(P＜0.05),偏差与患者年龄、血清PSA、前列腺体积、临床分期无显著相关性(P＞0.05),与穿刺针数(OR=2.905)及穿刺阳性率(OR=4.225)有显著相关(P＜0.05).结论 穿刺针数与穿刺阳性针数百分比是影响穿刺标本Gleason评分准确性的可能因素,增加前列腺穿刺活检针数将可能有助于提高穿刺标本预测前列腺癌病理分级的准确性.     

Use of Systematic Biopsy Results to Predict Pathologic Stage in Patients with Clinically Localized Prostate Cancer: A Preliminary Report

Background : The purpose of this study was to determine the ability of clinical tests to predict advanced pathologic stage (seminal vesicle invasion, pT3c, or pelvic lymph node metastases, pN+).
Methods : T stage, PSA, PSA density, and pathologic features in systematic biopsy specimens were correlated with pathologic stage in 190 consecutive patients with clinically localized (T1-3) prostate cancer detected by systematic needle biopsies and treated with radical prostatectomies.
Results : Thirty-three patients (17%) had an advanced pathologic stage cancer (pT3c or pN+). In logistic regression analysis, the total length of cancer in all biopsy cores ( P < 0.0005), the percent of poorly-differentiated cancer in each specimen (P < 0.021), and serum PSA (P < 0.028) were the only significant predictors of advanced stage. A model was constructed to predict advanced stage: if the PSA was 6 ng/mL and 4 or more biopsy cores were positive and the total length of cancer in all cores was 20 mm and at least 10% of the cancer was poorly-differentiated, then 14 (93%) of 15 patients had an advanced pathologic stage cancer compared to 11% of the remaining 175 patients (P < 0.0005). Conclusion: The pathologic features of cancer in systematic needle biopsy specimens more accurately predicts which patients have advanced stage cancer than standard clinical tests alone.     

Predictors of Gleason score upgrading in a large African-American population

Purpose

Gleason score from biopsy specimens is important for prostate cancer (PCa) risk stratification and influences treatment decisions. Gleason score upgrading (GSU) between biopsy and surgical pathology specimens has been reported as high as 50 % and presents a challenge in counseling low-risk patients. While recent studies have investigated predictors of GSU, populations in these studies have been largely Caucasian. We report our analysis of predictors of GSU in a large urban African-American population.

Methods

A total of 959 patients with D’Amico low-risk prostate cancer underwent radical prostatectomy at Georgetown University or Washington Hospital Center between January 2005 and July 2012. Race, age, PSA, body mass index (BMI), cancer of the prostate risk assessment (CAPRA) score, and transrectal ultrasound (TRUS) biopsy characteristics (percent of biopsy cores showing adenocarcinoma, highest percent of biopsy core involved with cancer, and measured TRUS prostate volume) were analyzed with both univariate and multivariate analyses to identify significant predictors of GSU while controlling for clinical parameters.

Results

Of the 959 cases, 288 (30.0 %) were upgraded on final pathologic specimen with approximately 38 % (133/355) of African-American patients experiencing GSU. BMI (P = 0.02), percent positive biopsy cores (P < 0.01) and percent of core involved with cancer (P < 0.01), increasing CAPRA score, and serum PSA were independent predictors of GSU on both uni- and multivariate regression analyses. African Americans had a 73 % increase in the incidence of GSU over other races.

Conclusion

More than a quarter of low-risk prostate cancer patients were upgraded on final pathology in our series. Higher BMI, serum PSA, CAPRA score, percent of cores positive, and percent of cores involved were independent predictors of GSU. Individuals with those clinical parameters may harbor occult high-grade disease and should be carefully counseled on treatment decisions.     

Radical prostatectomy for adenocarcinoma of the prostate: The influence of preoperative and pathologic findings on biochemical disease-free outcome

Objective. This retrospective study evaluated the outcome for a cohort of men undergoing radical retropubic prostatectomy alone as primary treatment for clinical T1–2 prostate adenocarcinoma.Methods. Sixty-two patients treated at Boston University Medical Center between 1987 and 1992 underwent radical prostatectomy alone without adjuvant or neoadjuvant endocrine therapy. Actuarial and multivariate analyses were made of disease-free outcome according to preoperative tumor T stage, prostate-specific antigen (PSA), and biopsy grade, and according to the pathologic findings at surgery. Recurrence was defined as the persistence or recurrence of detectable serum PSA four or more weeks following surgery.Results. Of all patients judged clinically to have localized disease (T1–2), 52 percent proved to have pathologic T3 tumors. Of these, 81 percent had positive surgical margins. The strongest preoperative predictors of pT3 disease were the biopsy Gleason grade and the initial serum PSA value. Actuarial analysis showed the overall likelihood of remaining free from detectable PSA at four years to be 43 percent (75% for those with organ-confined disease and 27% for those who were pT3). The poorest prognosis was seen in those with seminal vesicle involvement. Biopsy Gleason grade and initial PSA were independent preoperative predictors of biochemical failure in a Cox regression analysis but clinical T stage was not.Conclusions. The biopsy Gleason grade and initial PSA were identified as strong preoperative predictors of disease-free outcome. We confirmed the favorable prognosis of men with organ-confined disease, but emphasize the high likelihood of relapse in those with positive surgical margins or seminal vesicle invasion.