Preoperative parameters to predict tumor volume in Japanese patients with nonpalpable prostate cancer

Methods. In 40 patients with T1c cancers treated with radical prostatectomy, the pretreatment parameters of serum PSA, PSA density, biopsy Gleason score, and number of cancer-positive cores were determined and compared with the histological features in the surgical specimens. Pretreatment parameters were also determined in patients whose biopsy Gleason score was 6 or less, and whose biopsy specimen contained one or two cancer-positive cores, with 50% or less cancer involvement in any cancer-positive cores. Results. At the time of radical prostatectomy, 73% of patients had organ-confined disease. When insignificant cancer was defined as a volume of less than 0.5 cm³ and a Gleason score of 6 or less, in 9 of the 40 (23%) patients with clinical T1c disease, the cancer was clinically insignificant. Multiple regression analysis of the pretreatment variables, including pretreatment PSA level, PSA density, and number of cancer-positive cores demonstrated that the pretreatment PSA level and number of cancer-positive cores were independent factors that predicted tumor volume. From the biopsy features, 19 patients were assessed as having clinically insignificant disease. Nine (47%) of them had tumors of less than 0.5 cm³, whereas 2 (11%) had tumors of more than 2 cm³. The values for pretreatment PSA density and PSA density adjusted for the transition zone volume for those with a cancer volume of 0.5 cm³ or more were significantly higher than the values for those patients with a cancer volume of less than 0.5 cm³. Conclusion. T1c cancers in Japanese patients included various cancers, from clinically insignificant to locally advanced ones. Pretreatment PSA level and the number of cancer-positive cores are useful parameters with which to predict cancer volume in the surgical specimen. Received: September 14, 2001 / Accepted: January 7, 2002     

Preoperative prediction of extracapsular tumor extension at radical retropubic prostatectomy in Taiwanese patients with T1c prostate cancer

BACKGROUND: To find a predictor for extracapsular tumor extension at radical retropubic prostatectomy (RRP) in Taiwanese patients with stage T1c prostate cancer (PC), preoperative transrectal sonoguiding prostate biopsy outcomes and clinicopathological data obtained from these patients were reviewed. METHODS: Fifty-five consecutive men who underwent radical retropubic prostatectomy for stage T1c PC were included. Preoperative sextant needle biopsies of the prostate were performed and whole-mount prostatectomy specimens were processed. The pathological end point was tumor capsular perforation extending entirely through the prostate capsule. Preoperative prostate-specific antigen (PSA), free-to-total PSA ratio, prostate volume, PSA density, Gleason score, number of positive biopsy cores, percentage cancer of sextant biopsies, percentage cancer of one lobe and percentage cancer of one core were analyzed for their ability to predict extracapsular tumor extension at RRP. RESULTS: Eighteen of the 55 specimens showed evidence of tumor capsular perforation. Those with extracapsular tumor extension (ECE) had higher PSA than organ-confined disease (OCD) (18.4 vs 8.3 ng/ml, P < 0.01). The ECE had a higher PSA density than OCD (0.556 vs 0.226, P < 0.01). The percentage of cancer in biopsies, percentage cancer of one lobe and percentage cancer of one core were all higher in ECE than OCD (P < 0.05). The ECE had a higher biopsy Gleason score than OCD (5.6 vs 4.5, P < 0.01). CONCLUSIONS: The four strongest predictors for extracapsular tumor extension of patients with T1c PC were PSA density >or=0.35, biopsy Gleason score >or=6, >or=20% cancer in biopsies and PSA >or=10 ng/ml.     

Single Positive Core Prostate Cancer at Biopsy: Clinicopathological Implications and Risk Factors for Adverse Pathological Outcomes

BackgroundWhether one positive core prostate cancer (PCa) is a low-risk disease remains to be determined. We investigated the pathological results of radical prostatectomy specimens diagnosed on single core positive prostate biopsy.MethodsBetween January 2013 and December 2019, A total of 3441 consecutive patients treated with radical prostatectomy in our institution were examined. Among them, 293 patients were diagnosed with single positive core PCa on biopsy, and the clinical parameters and pathological findings of their radical prostatectomy specimens were analyzed.ResultsOf the 293 patients, 108 (36.9%) had undergraded Gleason Scores (GS) based on the biopsy. Positive surgical margins (PSMs), perineural invasion (PNI), extracapsular extension (ECE, pT3a) and seminal vesicle invasion (SVI, pT3b) were found in 16.4%, 15.0%, 3.4% and 2.4% of patients, respectively. In the multivariate analysis, we found that preoperative PSA level predict a significant increased risk of upgraded GS and PSMs, and biopsy GS was is a strong predictor of PNI, upgraded GS, tumor stage pT3 at radical prostatectomy.ConclusionsSingle positive core PCa have clinically significance in the radical prostatectomy specimens, with considerable rates of undergrading for the GS, PNI, PSMs, ECE and SVI. For patients with single positive core PCa, other prognostic factors must be considered in the treatment plan.     

Optimizing patient selection for prostate monotherapy

PURPOSE: Patients at low risk for prostate-specific antigen (PSA) failure following definitive local therapy are those with PSA of 10 or less, biopsy Gleason Score of 6 or less, and 1992 American Joint Committee on Cancer (AJCC) clinical Stage T1c or T2a. However, low-risk patients managed with radical prostatectomy and found to have prostatectomy Gleason score > or = 3+4 have a less favorable PSA outcome when compared to patients with prostatectomy Gleason score < or = 3+3. This study was performed to determine whether the percentage of positive prostate biopsy cores could predict upgrading from a biopsy Gleason score of 6 or less to a prostatectomy Gleason score > or = 3+4 in low-risk patients to optimize selection for prostate only radiation therapy. METHODS AND MATERIALS: Concordance testing of the biopsy Gleason score and the primary and secondary prostatectomy Gleason grades was performed in 427 prostate cancer patients treated with radical prostatectomy and at low risk for PSA failure. Logistic regression multivariable analysis was performed to test the ability of the established prognostic factors and the percentage of positive prostate biopsies (<34%, 34-50%, >50%) to predict for upgrading from biopsy Gleason score of 6 or less prostatectomy Gleason score > or = 3+4. PSA failure-free survival was reported using the actuarial method of Kaplan and Meier and comparisons were made using a log-rank test. RESULTS: Twenty-nine percent of the 427 study patients were upgraded from a biopsy Gleason score of 6 or less to a prostatectomy Gleason score > or = 3+4. The presence of greater than 50% positive biopsies was the only significant factor for predicting the upgrading from biopsy Gleason score of 6 or less to prostatectomy Gleason score > or = 3+4 on logistic regression multivariable analysis with the variables treated as continuous and categorical. Specifically, upgrading occurred in 26% vs. 59% of patients with 50% or less vs. greater than 50% positive biopsies, respectively. This translated into a 5-year PSA failure-free survival which was significantly higher (92% vs. 62%, p = 0.00001) for men with 50% or less vs. greater than 50% positive prostate biopsies, respectively. CONCLUSION: The presence of greater than 50% positive biopsies was associated with higher rates of pathologic upgrading which translated into lower 5-year PSA failure-free survival following radical prostatectomy (RP). Therefore, the percentage of positive biopsies may be useful in optimizing the selection of low-risk patients for prostate only radiation therapy such as external beam radiation or implant monotherapy.     

No residual tumor in a radical prostatectomy specimen after neoadjuvant hormonal therapy for localized prostate cancer

The role of neoadjuvant hormonal therapy (NHT) before radical prostatectomy for localized prostate cancer remains controversial because many argue that apparent downstaging results in difficulties with the pathological evaluation of the neoadjuvant treated prostatectomy specimen. Furthermore, the downstaging to pT0 (no residual tumor), as reported by several institutions, remains questionable and is not yet confirmed by clinical or experimental evidence. To examine this issue and to assess the influence of NHT on downstaging, we investigated the stage pT0 status in radical prostatectomy specimens after NHT. We retrospectively reviewed 31 patients with histologically confirmed clinical stage T1c, T2 or T3 prostate cancer. All patients had received NHT for a mean duration of 5.2 months (range 2-19). We compared the pretreatment parameters (PSA, clinical stage, biopsy Gleason grade, number of positive cores, total length of cancer on each sextant biopsy or duration of NHT) to the pathological findings in the specimen sectioned at 3-mm thick after NHT. Five (16%) of 31 patients had no residual cancer (pT0) after radical prostatectomy, 8 (26%) had organ-confined disease (stage pT2), 6 (19%) had specimen confined disease, 10 (33%) had non-specimen confined disease and only 2 (6%) had lymph node metastasis. The histologic changes, including glandular atrophy and cytoplasmic vacuolation were stronger in specimens with a long duration (4 or more months) of NHT than those of a short duration (3 or less months). Multiple logistic regression analysis showed that only a longer duration of NHT was an independent predictor of a stage pT0 status in radical prostatectomy specimens after NHT (p=0.04, Odds ratio; 1.92, 95% CI; 1.03-3.56). Downstaging to pT0 occurs after duration of NHT of longer than 3 months. Further investigation of the optimal duration of NHT for downstaging and for improving patients' survival should be accomplished in randomized trials.     

Contemporary Pathological Stage Distribution After Radical Prostatectomy in North American High-Risk Prostate Cancer Patients

PurposeTo investigate pathological stage at radical prostatectomy (RP) using the “Partin tables” approach in NCCN high-risk (HR) prostate cancer (PCa) patients.Materials and MethodsWithin the SEER 2010 to 2016 database, we identified 7,718 NCCN HR PCa patients. Cross-tabulation was used to illustrate the distribution of organ confined disease (OC, pT2), extra-prostatic extension (EPE, pT3a), seminal vesicles invasion (SVI, pT3b), lymph node invasion (LNI, pT2N1), extra-prostatic and lymph node invasion (EPE + LNI, pT3aN1), and seminal vescicale and lymph node invasion (SVI + LNI, pT3bN1), according to preoperative criteria, which consisted in PSA, clinical T stage, biopsy Gleason Score (GS). Binomial 95%CI was constructed for the reported proportions.ResultsMedian (IQR) PSA levels was 9 (6-20) ng/ml. The majority of patient harbored cT1c (51%) followed by cT2 (35%) and cT3 (14%) stage. Most patients exhibited GS 4+4 (43%). Overall, 87 vs. 15 vs. 2% of patients harbored only 1 vs. 2 vs. all 3 HR criteria. At RP, OC, EPE, SVI, and LNI rates were respectively 36%, 27%, 17%, and 19%.Highest levels of OC were recorded for cT1c, PSA <10 ng/mL and biopsy GS4+4. Conversely, EPE, SVI and LNI were the highest in patients with cT3, PSA ≥20 ng/mL and GS 5+5. After stratification according to clinical stages, OC rates decreased with increasing PSA levels and GS. Conversely, EPE, SVI and LNI rates increased with increasing PSA and GS.ConclusionWe provide a lookup table to illustrate the relationship between clinical and pathological characteristics in NCCN HR PCa patients.     

Prognostic value of surgical margin status for biochemical recurrence following radical prostatectomy

OBJECTIVE: We evaluated the preoperative parameters to predict a positive surgical margin (SM) at radical prostatectomy for patients with prostate cancer. In addition, the prognostic factors for biochemical recurrence were determined in patients with positive SMs. METHODS: We retrospectively analysed 238 patients with prostate cancer who underwent retropubic radical prostatectomy and bilateral pelvic lymph node dissection from May 1985 to July 2005 in our hospital. Biochemical recurrence was defined as an increase of undetectable prostate-specific antigen (PSA) to 0.2 ng/ml or greater. RESULTS: Of the 238, 82 patients (34.4%) had positive SMs. On multivariate analysis, preoperative PSA (>/=10 ng/ml), clinical T stage (>/=T2a) and the positive core rate (>/=35%) were parameters that could predict a positive SM. During the median follow-up of 31.2 months, 48 patients (20.2%) developed biochemical recurrence. The 5-year biochemical progression-free survival rates were 81.7% and 62.6% in patients with negative and positive SMs, respectively (P < 0.001). In the Cox proportional hazards model, preoperative PSA of >/=20 ng/ml and a pathological T stage of pT3a/pT3b were significant risk factors for biochemical recurrence in patients with positive SMs. CONCLUSIONS: SM status at radical prostatectomy depends on preoperative PSA, clinical stage and the positive core rate. Patients with a positive SM had a higher risk for biochemical recurrence than those with a negative one. Patients with a positive margin had a higher risk for biochemical recurrence if they exhibited preoperative PSA of >/=20 ng/ml and/or pathological T stage of pT3a/pT3b.     

Clinical utility of endorectal MRI in determining PSA outcome for patients with biopsy Gleason score 7, PSA <or=10, and clinically localized prostate cancer

PURPOSE: Although the optimal management for patients with high-grade clinically localized prostate cancer is undefined, radical prostatectomy (RP) or external beam radiotherapy (EBRT) is performed. The clinical utility of the pretreatment prostrate-specific antigen (PSA) level (10 ng/mL) and endorectal MRI (erMRI) stage (T3 vs. T2) to stratify PSA outcome after RP in these patients was evaluated. METHODS AND MATERIALS: erMRI was performed in 147 men with biopsy Gleason score >or=7 and 1992 AJCC clinical Stage T1c or T2a disease before RP. Enumerations of the biopsy and prostatectomy Gleason scores, pathologic stage, and margin status were performed for each pretreatment group on the basis of erMRI findings and PSA level. Comparisons were made using a chi-square metric. The median follow-up was 4.5 years (range 1-10 years). Comparisons of the actuarial freedom from PSA failure (bNED) were made using the log-rank test. RESULTS: erMRI Stage T2 and T3 disease was found in 132 and 15 patients, respectively. On stratification by PSA level, patients with erMRI T3 disease had similar bNED outcomes (p = 0.46), regardless of the PSA level. The 3-year bNED rate was 82%, 64%, and 25% (p <0.0001) for Group 1 (erMRI T2 and PSA 10 ng/mL), and Group 3 (erMRI T3 with any PSA level), respectively. The rates of prostatectomy T3 disease, biopsy and prostatectomy Gleason score 8-10, and positive surgical margins were significantly higher (p or=7, PSA 相似文献   

Percent free prostate-specific antigen (PSA) is an accurate predictor of prostate cancer risk in men with serum PSA 2.5 ng/mL and lower

BACKGROUND: Up to 17% of men with a prostate-specific antigen (PSA) level below the accepted prostate biopsy cutoff of 2.5 ng/mL may have prostate cancer. Because identification of these patients represents a difficult task, we assessed the ability of percent free PSA to discriminate between benign and malignant prostate biopsy outcomes in men with PSA < or =2.5 ng/mL. METHODS: Between 1999 and 2006, 543 men with a PSA < or =2.5 ng/mL were referred for initial prostate biopsy. Age, total PSA, percent free PSA, and digital rectal examination findings represented predictors of prostate cancer at biopsy in logistic regression models. The area under the receiver operating characteristics curve (AUC) quantified the discriminative ability of the predictors. The pathological characteristics of the detected cancers were assessed in individuals treated with radical prostatectomy. RESULTS: Of all, 23% had prostate cancer on biopsy, 16.5% of patients treated with radical prostatectomy had pT3 stage, and 35.6% had a pathological Gleason score of 3 + 4 or higher. The most accurate predictor of prostate cancer on biopsy was percent free PSA (0.68) versus age (0.50), total PSA (0.57), or rectal examination findings (0.58). Of patients with percent free PSA below 14%, 59% had prostate cancer. In multivariate models, percent free PSA (P < .001) and rectal examination findings (P = .001) were the only independent predictors of prostate cancer. The combined AUC of all predictors (0.69) was not significantly (P = .7) higher than that of percentage of free PSA alone (0.68). CONCLUSIONS: The risk of prostate cancer is clearly non-negligible in patients with PSA < or =2.5 ng/mL. The percent free PSA can accurately predict the prevalence of prostate cancer at prostate biopsy in these individuals.     

Tumour growth fraction measured by immunohistochemical staining of Ki67 is an independent prognostic factor in preoperative prostate biopsies with small‐volume or low‐grade prostate cancer

Accurate prognostic parameters in prostate biopsies are needed to better counsel individual patients with prostate cancer. We evaluated the prognostic impact of morphologic and immunohistochemical parameters in preoperative prostate cancer biopsies. A consecutive series of prostate biopsies of 279 men (72% with clinical stage T1c and 23% with T2) who subsequently underwent radical prostatectomy was prospectively analysed for Gleason score, number and percentage of positive cores (NPC, PPC), total percentage of biopsy tissue with tumour (TPT), maximum tumour percentage per core (MTP), and expression of Ki67, Bcl‐2 and p53. All biopsy features were significantly associated with at least one feature of the radical prostatectomy specimen. pT stage was independently predicted by PSA, seminal vesicle invasion by Ki67 LI, positive margins by PSA and MTP, large tumour diameter by PSA and PPC, and Gleason score by biopsy Gleason score, MTP, and Ki67 LI, respectively. Biopsy Gleason score, NPC (1 vs. >1), TPT (<7 vs. ≥7%), and Ki67 LI (<10 vs. ≥10%) were significant predictors of biochemical recurrence after radical prostatectomy (p < 0.01, each). KI67 LI was the only independent prognostic factor in case of a low TPT (<7%) or low Gleason score (<7), the hazard ratio being 6.76 and 6.44, respectively. In summary, preoperative Gleason score, NPC, TPT and Ki67 LI significantly predict the risk of recurrence after radical prostatectomy, and Ki67 is an independent prognosticator in biopsies with low‐volume or low‐grade prostate cancer. Analysis of Ki67 LI in these biopsies may help to better identify patients with clinically insignificant prostate cancer. © 2008 Wiley‐Liss, Inc.     

The impact of the biopsy Gleason score on PSA outcome for prostate cancer patients with PSA < or = 10 ng/ml and T1c,2a: implications for patient selection for prostate-only therapy

PURPOSE: This study was performed to determine the ability of the biopsy Gleason score, prostate-specific antigen (PSA) level, and the 1992 American Joint Commission on Cancer (AJCC) clinical T-stage for predicting time to postoperative PSA failure for patients with a PSA < or =10 ng/ml and T1c or T2a disease. Specific attention is given to the patient subgroup with biopsy Gleason 3 + 4 vs. 4 + 3. METHODS AND MATERIALS: A concordance map of the biopsy and prostatectomy Gleason grades and a clinical-pathologic correlation of the PSA, biopsy Gleason score, and 1992 AJCC T-stage and pathologic stage were performed. A Cox regression multivariable analysis was used to evaluate the ability of the biopsy Gleason score, PSA, and 1992 AJCC T-stage to predict time to PSA failure for 457 men managed with a radical prostatectomy (RP). RESULTS: The absence of prostatectomy Gleason grade 4 or 5 disease was noted in 71%, 50%, and 11% of patients with biopsy Gleason score 2-6, 3 + 4, and > or =4 + 3 disease respectively while pathologic evidence of seminal vesicle invasion was noted in 2%, 4%, and 17% of these patients respectively. Estimates of 5-year PSA failure-free survival rates were not statistically different for patients with biopsy Gleason score 2-6 vs. 3 + 4 (79% vs. 81%; p = 0.93), but were significantly different for patients having biopsy Gleason score 2-6 vs. 4 + 3 (79% vs. 62%; p = 0.04) or 2-6 vs. 8-10 (79% vs. 18%; p = 0.0001) prostate cancer. CONCLUSION: Based on the pathologic stage and PSA control data following RP, patients with biopsy Gleason 3 + 4 disease and PSA < or =10 ng/ml and 1992 AJCC T1c or T2a disease may be suitable candidates for radiation therapy directed at the prostate only.     

Advancing Age and the Odds of Upgrading and Upstaging at Radical Prostatectomy in Men with Gleason Score 6 Prostate Cancer

PurposeTo identify a subset of men with Gleason score (GS) 6 prostate cancer who are at high risk for upgrading/upstaging who should be recommended for multiparametric magnetic resonance imaging.Patients and MethodsBetween 1992 and 2017, a total of 3571 men with GS6 prostate cancer were consecutively treated at a single institution with radical prostatectomy. Logistic regression multivariable analyses to determine the odds of upgrading and upstaging were performed, adjusting for age and year of diagnosis, clinical T category, prostate-specific antigen level, number of biopsy cores, and percentage of positive biopsy cores.ResultsOf 3571 men, the disease of 115 (3.22%), 245 (6.86%), and 254 (7.11%) was upgraded, was upstaged, or had positive surgical margins (R1), respectively. Older age at diagnosis was associated with an increased risk of upgrading disease to GS7 or higher, prostatectomy T3/T4, and R1 with adjusted odds ratios (95% confidence intervals) of 1.05 (1.01-1.08; P = .005), 1.02 (1.00-1.05; P = .048), and 1.02 (1.002-1.05; P = .03), respectively. Older age was associated with an increasing proportion of men with disease upgraded to GS7 or higher (T1c: P = .002; T2 or higher: P = .04) or upstaged to pT3/4 or pT2R1 (T1c: P = .02; T2 or higher: P = .02) among men with ≥ 33% but not < 33% positive biopsy cores.ConclusionBefore initiating active surveillance, performing multiparametric magnetic resonance imaging in otherwise healthy older men with GS6 prostate cancer and ≥ 33% positive biopsy cores should be considered.     

African-American men with nonpalpable prostate cancer exhibit greater tumor volume than matched white men

BACKGROUND: Although prostate cancer (PC) mortality disproportionately affects African-American (AA) men, limited data exist comparing the pathologic characteristics of white and AA patients with nonpalpable PC (clinical stage T1c). METHODS: The authors reviewed the radical prostatectomy (RP) specimens from 37 consecutive AA men with clinical stage T1c PC and 35 white men who were matched for age, clinical stage, serum prostate-specific antigen (PSA) level, year of surgery, prostate weight, and prostate biopsy strategy. Pathologic characteristics were compared after mapping tumor foci and calculating tumor volumes by using computer software. RESULTS: For AA men, the median age (57.7 years), mean serum PSA level (9.3 ng/mL), mean prostate weight (43 g), and biopsy strategy (73% sextant) were matched with the cohort of 35 white men (median age, 57.1 years; mean PSA, 9.3 ng/mL;, mean prostate weight, 43 g; biopsy strategy, 66% sextant). Despite similar biopsy characteristics between the 2 groups (Gleason score > or =7 in 43% of AA men vs. 37% of white men), AA men exhibited significantly higher prostatectomy Gleason scores (> or =7 in 76% of AA men vs. 34% of white men; P = .01). AA men also had a higher mean tumor volume (1.82 cm3 vs. 0.72 cm3; P = .001) and had 2.8 times more tumor per ng/mL of serum PSA (0.22 cm3 per ng/mL vs. 0.079 cm3 per ng/mL; P = .001). CONCLUSIONS: Compared with a cohort of white men with similar clinical features at the time of biopsy, AA men with nonpalpable PC had higher prostatectomy Gleason scores, greater cancer volume, and greater tumor volume per ng/mL of serum PSA. These data provide additional support for the concept of early PC detection using a serum PSA threshold of 2.5 ng/mL for biopsy among AA men.     

Place de la prostatectomie radicale dans le traitement curatif du cancer de la prostate: à propos de 91 cas

Objective

To study the role of radical prostatectomy in the treatment of prostate cancer.

Patients and methods

It was a retrospective multicenter study of 5 years on 91 radical prostatectomies performed at Medico-Surgical Center le Bois of Chaumont in France and at Notre-Dame-de-la-Paix in Burkina Faso.

Results

In 5 years, 91 patients underwent radical prostatectomy with curative intent, 85 at Medico-Surgical Center le Bois in France and 6 at Notre-Dame-de-la-Paix in Burkina Faso. Their average age was 66.52 years. Clinically, the patients were classified as stage A (2.2%) or B (98.8%) of Whitemore-Jewett. The average PSA (prostatic specific antigen) was 9.25 ng/ml. Endorectal ultrasound, CTabdominopelvic bone scan, magnetic resonance imaging, and histology of biopsy pieces were able to classify all patients as T1a to T2b N0M0. It was adenocarcinoma, and the average Gleason score was 6. Surgical treatment was radical prostatectomy. After pathologic study of surgical specimens, 2.2% were classified as pT1, 76.92% pT2, 21.92% pT3, and 1.10% pT4. The rate of PSA, six months after radical prostatectomy, was undetectable in 81.32%. In addition to radical prostatectomy, patients received hormone therapy (4 cases), radiation therapy (9 cases), and radiotherapy-hormone therapy (2 cases). The operative mortality was zero. The average length of hospital stay was 8 days. Complications such as seromas (6.60% patients), erectile dysfunction (47.25%), urinary incontinence (32.97%), and acute retention (2.2%) were noted. The 3-year survival rate was 78.33% after radical prostatectomy alone and 100% after radical prostatectomy associated with radiotherapy and/or hormone therapy.

Conclusion

Radical prostatectomy allowed to control prostate cancer, and it requires early diagnosis. The addition of radiotherapy and/or hormone therapy optimizes the prognosis.     

Patient selection for hemiablative focal therapy of prostate cancer

BACKGROUND:

The application of focal therapy for low‐risk prostate cancer (PCa) depended on appropriate patient selection. No definitive criteria existed to characterize patients who may potentially benefit from an organ‐sparing approach. We evaluated pretreatment clinical parameters that may predict unilateral PCa amenable to hemigland thermoablation.

METHODS:

In total, 538 patients with complete data from the Duke Prostate Center (DPC) Outcomes database with low‐ to low‐intermediate–risk PCa (prostate‐specific antigen<10 ng/mL, biopsy Gleason score ≤7, and clinical stage T1c‐T2b) treated with radical prostatectomy (RP) were included in the dataset. Patients underwent diagnostic prostate biopsy (PBx) at Duke or community hospitals from 1996 to 2006. Clinical and biopsy parameters were assessed as to the ability to predict PCa unilaterality verified by RP pathology.

RESULTS:

The strongest predictor of pathologic unilaterality was PBx unilaterality. The sensitivity and specificity for biopsy unilaterality to predict pathologic unilaterality was 88.4% and 34%, with a positive predictive value of 28% and a negative predictive value of 91%. PBx unilaterality (odds ratio [OR] = 3.88; 95% confidence interval [CI], 2.14‐7.05; P < .0005) and negative family history of PCa (OR = 1.83; 95% CI, 1.09‐3.05; P = .21) was associated with a higher probability of unilateral disease by multivariate regression.

CONCLUSIONS:

Two pretreatment clinical variables were significantly predictive of unilateral PCa: negative family history of PCa and PBx unilaterality. These variables may be used to select men with low‐ to low‐moderate–risk PCa for hemiablation. Further work is necessary to decrease the false‐negative and false‐positive rates associated with PBx to improve predictability for PCa laterality. Cancer 2009. © 2009 American Cancer Society.     

The percentage of prostate needle biopsy cores with carcinoma from the more involved side of the biopsy as a predictor of prostate specific antigen recurrence after radical prostatectomy: results from the Shared Equal Access Regional Cancer Hospital (SEARCH) database

BACKGROUND: The authors previously found that, although the total percentage of prostate needle biopsy cores with carcinoma was a significant predictor of prostate specific antigen (PSA) failure among men undergoing radical prostatectomy (RP), there was a trend toward a lower risk of recurrence in patients with positive bilateral biopsies, suggesting that high-volume, unilateral disease was a worse predictor of outcome than an equivalent number of positive cores distributed over two lobes. In the current study, the authors sought to compare the total percentage of cores with carcinoma directly with the percentage of cores from the more involved or dominant side of the prostate with carcinoma for their ability to predict outcome among men who underwent RP. METHODS: A retrospective survey of 535 patients from the Shared Equal Access Regional Cancer Hospital database who underwent RP at 4 different equal-access medical centers between 1988 and 2002 was undertaken. The total percentage of cores positive was compared with the percentage of cores positive from the dominant and nondominant sides for their ability to predict biochemical recurrence after RP. The best predictor then was compared with the standard clinical variables PSA, biopsy Gleason score, and clinical stage in terms of ability to predict time to PSA recurrence after RP using multivariate analysis. RESULTS: The adverse pathologic features of positive surgical margins and extracapsular extension were significantly more likely to be ipsilateral to the dominant side on the prostate biopsy. The percentage of cores positive from the dominant side provided slightly better prediction (concordance index [C] = 0.636) for PSA failure than the total percentage of cores positive (C = 0.596) and markedly better than the percentage of cores from the nondominant side (C = 0.509). Cutoff points for percentage of cores positive from the dominant side were identified (< 34%, 34-67%, and > 67%) that provided significant risk stratification for PSA failure (P < 0.001). On multivariate analysis, the percentage of cores positive from the dominant side was the strongest independent predictor of PSA recurrence (P < 0.001). Biopsy Gleason score (P = 0.017) also was a significant, independent predictor of recurrence. There was a trend, which did not reach statistical significance, toward an association between greater PSA values and biochemical failure (P = 0.052). Combining the PSA level, biopsy Gleason score, and percentage of cores positive from the dominant side of the prostate resulted in a model that provided a high degree of prediction for PSA failure (C = 0.671). CONCLUSIONS: The percentage of cores positive from the dominant side of the prostate was a slightly better predictor of PSA recurrence than was the total percentage of cores positive. Using the percentage of cores from the dominant side along with the PSA level and the biopsy Gleason score provided significant risk stratification for PSA failure.     

Improving the Stratification of Patients With Intermediate-risk Prostate Cancer

BackgroundIntermediate-risk prostate cancer (IR PCa) phenotypes may vary from favorable to unfavorable. National Comprehensive Cancer Network (NCCN) criteria help distinguish between those groups. We studied and attempted to improve this stratification.Patients and MethodsA total of 4048 (NCCN favorable: 2015 [49.8%] vs. unfavorable 2033 [50.2%]) patients with IR PCa treated with radical prostatectomy were abstracted from an institutional database (2000-2018). Multivariable logistic regression models predicting upstaging and/or upgrading (Gleason Grade Group [GGG] IV-V and/or ≥ pT3 or pN1) in IR PCa were developed, validated, and directly compared with the NCCN IR PCa stratification.ResultsAll 4048 patients were randomly divided between development (n = 2024; 50.0%) and validation cohorts (n = 2024; 50.0%). The development cohort was used to fit basic (age, prostate-specific antigen, clinical T stage, biopsy GGG, and percentage of positive cores [all P < .001]) and extended models (age, prostate-specific antigen, clinical T stage, biopsy GGG, prostate volume, and percentage of tumor within all biopsy cores [all P < .001]). In the validation cohort, the basic and the extended models were, respectively, 71.4% and 74.7% accurate in predicting upstaging and/or upgrading versus 66.8% for the NCCN IR PCa stratification. Both models outperformed NCCN IR PCa stratification in calibration and decision curve analyses (DCA). Use of NCCN IR PCa stratification would have misclassified 20.1% of patients with ≥ pT3 or pN1 and/or GGG IV to V versus 18.3% and 16.4% who were misclassified using the basic or the extended model, respectively.ConclusionBoth newly developed and validated models better discriminate upstaging and/or upgrading risk than the NCCN IR PCa stratification.     

Biochemical failure after radical prostatectomy in men with pathologic organ-confined disease: pT2a versus pT2b

BACKGROUND: The 1997 TNM staging system for prostate carcinoma defines a pT2a disease as a tumor histologically involving one lobe of the prostate and pT2b disease as a tumor histologically involving both prostatic lobes. Whether this distinction provides prognostic significance is unclear. The authors evaluated biochemical outcomes between men with pT2aN0 and pT2bN0 disease. METHODS: The authors identified 1606 men with organ-confined disease (pT2N0) who were treated with radical prostatectomy between 1982 and 2003 by one surgeon. Clinical characteristics were compared between men with pT2a and pT2b tumors using rank-sum analysis, and prostate-specific antigen (PSA) recurrence data were compared using log-rank analysis. The significant independent predictors of PSA recurrence were determined using a multivariate Cox proportional hazards model. RESULTS: There were no significant differences between men with pT2a and pT2b tumors at the time of surgery in terms of clinicopathologic characteristics (biopsy and pathologic Gleason score, serum PSA level, clinical stage, and age). Log-rank analysis revealed no significant differences in time to PSA recurrence between men with pT2a and pT2b tumors (P = 0.755). The 10-year PSA progression-free survival rate was 95% (confidence interval [CI], 92-97%) for men with pT2a tumors and 93% (CI, 90-95%) for men with pT2b tumors. Multivariate analysis showed that the significant predictors of PSA recurrence included serum PSA level, biopsy and pathologic Gleason score, and clinical stage. In the current cohort of men with organ-confined disease, pathologic stage (pT2a vs. pT2b) was not a significant predictor of PSA recurrence on multivariate analysis. CONCLUSIONS: There was no difference in PSA recurrence rates between men with pT2aN0 versus pT2bN0 tumors. In men with organ-confined disease, radical prostatectomy provided excellent 10-year PSA progression-free survival regardless of tumor burden (pT2a vs. pT2b). Consideration should be given to modifying the TNM staging system to eliminate substratification of pT2 tumors.     

The clinical utility of the percent of positive prostate biopsies in predicting biochemical outcome following external-beam radiation therapy for patients with clinically localized prostate cancer

PURPOSE: An investigation was performed of the clinical utility of the percent of positive prostate biopsies in predicting prostate-specific antigen (PSA) outcome following external-beam radiation therapy (RT) for men with PSA-detected or clinically palpable prostate cancer. METHODS AND MATERIALS: A Cox regression multivariable analysis was used to determine whether the percent of positive prostate biopsies provided clinically relevant information about PSA outcome following external beam RT in 473 men while accounting for the previously established risk groups based on the pretreatment PSA level, biopsy Gleason score, and the 1992 American Joint Commission on Cancer (AJCC) clinical T stage. RESULTS: Controlling for the known prognostic factors, the percent of positive prostate biopsies added clinically significant information (p = 0.02) regarding time to PSA failure following RT. Specifically, 76% of the patients in the intermediate risk group (1992 AJCC T(2b) or biopsy Gleason 7 or PSA > 10 ng/mL and < or = 20 ng/mL) could be classified into either an 30% or 85% 5-year PSA control cohort using the preoperative prostate biopsy data. CONCLUSION: The previously validated stratification of PSA outcome following radical prostatectomy (RP) using the percent of positive prostate biopsies in intermediate-risk patients is also clinically significant for men treated with external beam RT. The percent positive prostate biopsies should be considered in conjunction with the PSA level, biopsy Gleason score, and 1992 AJCC clinical T stage when counseling patients with newly diagnosed and clinically localized prostate cancer about PSA outcome following RP or external beam RT.