ERA SPECIFIC BIOCHEMICAL RECURRENCE-FREE SURVIVAL FOLLOWING RADICAL PROSTATECTOMY FOR CLINICALLY LOCALIZED PROSTATE CANCER

A contemporary analysis of outcomes of adenocarcinoma of the prostate with seminal vesicle invasion (pT3b) after radical prostatectomy

PURPOSE

Despite earlier detection and stage migration, seminal vesicle invasion is still reported in the prostate specific antigen era and remains a poor prognostic indicator. We investigated outcomes in men with pT3b disease in the contemporary era.

MATERIALS AND METHODS

The institutional radical prostatectomy database (1982 to 2010) of 18,505 men was queried and 989 with pT3b tumors were identified. The cohort was split into pre-prostate specific antigen (1982 to 1992), and early (1993 to 2000) and contemporary (2001 to present) prostate specific antigen eras. Of the 732 men identified in the prostate specific antigen era 140 had lymph node involvement and were excluded from study. The Kaplan-Meier method was used to determine biochemical recurrence-free, metastasis-free and prostate cancer specific survival. Proportional hazard models were used to determine predictors of biochemical recurrence-free, metastasis-free and cancer specific survival.

RESULTS

In the pre-prostate specific antigen, and early and contemporary prostate specific antigen eras, 7.7%, 4.3% and 3.3% of patients, respectively, had pT3bN0 disease (p >0.001). In pT3bN0 cases, the 10-year biochemical recurrence-free survival rate was 25.8%, 28.6% and 19.6% (p = 0.8), and the cancer specific survival rate was 79.9%, 79.6% and 83.8% (p = 0.6) among the eras, respectively. In pT3bN0 cases in the prostate specific antigen era, prostate specific antigen, clinical stage T2b or greater, pathological Gleason sum 7 and 8-10, and positive surgical margins were significant predictors of biochemical recurrence-free survival on multivariate analysis while clinical stage T2c or greater and Gleason 8-10 were predictors of metastasis-free and cancer specific survival.

CONCLUSIONS

Despite a decreased frequency of pT3b disease, and lower rates of positive surgical margins and lymph nodes, patients with seminal vesicle invasion continue to have low biochemical recurrence-free survival. Advanced clinical stage, intermediate or high risk Gleason sum at pathological evaluation and positive surgical margins predict biochemical recurrence. High risk clinical stage and Gleason sum predict metastasis-free and cancer specific survival.

Weight gain is associated with an increased risk of prostate cancer recurrence after prostatectomy in the PSA era

Although obesity at the time of prostatectomy has been associated with prostate cancer recurrence, it is unknown whether obesity before or after surgery, or weight change from the years prior to surgery to after surgery is associated with recurrence. Thus, we examined the influence of obesity and weight change on recurrence after prostatectomy. We conducted a retrospective cohort study of 1,337 men with clinically localized prostate cancer who underwent prostatectomy performed during 1993-2006 by the same surgeon. Men self-reported weight and physical activity at 5 years before and 1 year after surgery on a survey during follow-up. Mean follow-up was 7.3 years. We estimated multivariable-adjusted HRs of prostate cancer recurrence comparing obesity at 5 years before and at 1 year after surgery with normal weight, and a gain of more than 2.2 kg from 5 years before to 1 year after surgery with stable weight. During 9,797 person years of follow-up, 102 men recurred. Compared with men who had stable weight, those whose weight increased by more than 2.2 kg had twice the recurrence risk (HR = 1.94; 95% CI, 1.14-3.32) after taking into account age, pathologic stage and grade, and other characteristics. The HR of recurrence was 1.20 (95% CI, 0.64-2.23) and 1.72 (95% CI, 0.94-3.14) comparing obesity at 5 years before and at 1 year after surgery, respectively, with normal weight. Physical activity (≥ 5 h/wk) did not attenuate risk in men who gained more than 2.2 kg. By avoiding weight gain, men with prostate cancer may both prevent recurrence and improve overall well-being.

Conventional prostatic adenocarcinoma arising in a multilocular prostatic cystadenoma

Multilocular prostatic cystadenoma is a rare benign neoplasm located between the bladder and the rectum. These are prostatic tissue and have been shown to harbor high-grade intraepithelial neoplasia and likely susceptible to the same disease processes seen in the prostate gland. We report the first case of conventional prostatic adenocarcinoma involving a multilocular cystadenoma. Distinction from cystadenocarcinoma is also made.

Long-term survival after radical prostatectomy for men with high Gleason sum in pathologic specimen

OBJECTIVES

To evaluate the long-term outcomes of patients with high Gleason sum 8-10 at radical prostatectomy (RP) and to identify the predictors of prostate cancer-specific survival (CSS) in this cohort.

METHODS

The institutional RP database was queried. A total of 9381 patients with complete follow-up underwent RP from 1982 to 2008. Of these 9381 patients, 1061 had pathologic Gleason sum 8-10 cancer. The patient and prostate cancer characteristics were evaluated. Survival analyses were performed using the Kaplan-Meier method. Univariate and multivariate proportional hazard regression models were created to evaluate the pertinent predictors of CSS (death from, or attributed to, prostate cancer).

RESULTS

The median preoperative prostate-specific antigen level was 7.6 ng/mL; 435 men had clinical Stage T1 tumor, 568 had Stage T2, and 36 had Stage T3. The biopsy Gleason sum was <7, 7, and >7 in 244 (22.3%), 406 (37.2%), and 425 (38.9%) patients, respectively. The median follow-up was 5 years (range 1-23). The actuarial 15-year recurrence-free survival, CSS, and overall survival rate was 20.7%, 57.4%, and 45.4%, respectively. On multivariate analysis, the predictors of poor CSS were pathologic Gleason sum 9-10 and seminal vesicle and lymph node involvement. Patients with pathologic Gleason sum 8 and organ-confined disease had a CSS rate of 89.9% at 15 years.

CONCLUSIONS

The results of our study have shown that 80% of the men with Gleason sum 8-10 who undergo RP will have experienced biochemical recurrence by 15 years. However, the CSS rate approached 90% for men with pathologic organ-confined disease. Higher pathologic Gleason sum 9-10 and seminal vesicle and lymph node involvement were independent predictors of worse CSS.

The significance of a positive bladder neck margin after radical prostatectomy: the American Joint Committee on Cancer Pathological Stage T4 designation is not warranted

PURPOSE

The American Joint Committee on Cancer currently designates invasion of the bladder neck as a pT4 lesion. However, retrospective analyses have not demonstrated biochemical recurrence-free survival after radical prostatectomy to be consistent with other T4 lesions. We examined biochemical recurrence-free survival and cancer specific survival in men with a positive bladder neck margin.

MATERIALS AND METHODS

Of nearly 17,000 patients in the Johns Hopkins Institutional radical prostatectomy database (1982 to 2008) 198 (1.2%) were identified with a positive bladder neck margin. Kaplan-Meier analyses were used to evaluate biochemical recurrence-free survival and cancer specific survival. A multivariate proportional hazards model predicting biochemical recurrence-free survival and cancer specific survival was fit with prostate specific antigen, Gleason sum and pathological stage to determine the significance of a positive bladder neck margin.

RESULTS

Of the 198 men with a positive bladder neck margin 79 had an isolated bladder neck margin without seminal vesicle or lymph node involvement. The 12-year biochemical recurrence-free survival of men with organ confined disease, extraprostatic extension, seminal vesicle invasion and lymph node involvement without a positive bladder neck margin was 91.1%, 61.1%, 24.5% and 8.1%, respectively. For men with a positive bladder neck margin and those with an isolated positive bladder neck margin biochemical recurrence-free survival was 16.8% and 37.1%, respectively. The 12-year cancer specific survival for men with organ confined disease, extraprostatic extension, seminal vesicle invasion and lymph node involvement without a positive bladder neck margin was 93.5%, 89.0%, 77.0% and 66.8%, respectively. For men with a positive bladder neck margin and those with an isolated positive bladder neck margin cancer specific survival was 78.2% and 92.5%, respectively. A positive bladder neck margin was not a significant predictor of outcome (p = 0.4) on multivariable analysis.

CONCLUSIONS

The incidence of an isolated positive bladder neck margin is low. Men with an isolated positive bladder neck margin after radical prostatectomy experienced a 12-year biochemical recurrence-free survival of 37% and cancer specific survival of 92%, similar to patients with seminal vesicle invasion (pT3b) and extraprostatic extension (pT3a), respectively. The existing American Joint Committee on Cancer classification for prostate cancer should be reconsidered.

Peroxisome proliferator-activated receptor gamma coactivator-1alpha interacts with the androgen receptor (AR) and promotes prostate cancer cell growth by activating the AR

There are currently few successful therapies for castration-resistant prostate cancer (CRPC). CRPC is thought to result from augmented activation of the androgen/androgen receptor (AR) signaling pathway, which could be enhanced by AR cofactors. In this study, peroxisome proliferator-activated receptor gamma coactivator-1alpha (PGC-1alpha) was found to be an AR cofactor. PGC-1alpha interacted with the N-terminal domain of AR, was involved in the N- and C-terminal interaction of AR, and enhanced the DNA-binding ability of AR to androgen-responsive elements in the prostate-specific antigen enhancer and promoter regions to increase the transcription of AR target genes. Silencing of PGC-1alpha suppressed cell growth of AR-expressing prostate cancer (PCa) cells by inducing cell-cycle arrest at the G(1) phase, similar to inhibition of androgen/AR signaling. Furthermore, PGC-1alpha knock-down also suppressed cell growth in the castration-resistant LNCaP-derivatives. These findings indicate that PGC-1alpha is involved in the proliferation of AR-expressing PCa cells by acting as an AR coactivator. Modulation of PGC-1alpha expression or function may offer a useful strategy for developing novel therapeutics for PCa, including CRPC, which depends on AR signaling by overexpressing AR and its coactivators.

Overexpression of the potential kinase serine/ threonine/tyrosine kinase 1 (STYK 1) in castration-resistant prostate cancer

Despite high response rates and clinical benefits, androgen ablation often fails to cure advanced or relapsed prostate cancer because castration-resistant prostate cancer (CRPC) cells inevitably emerge. CRPC cells not only grow under castration, but also behave more aggressively, indicating that a number of malignant signaling pathways are activated in CRPC cells as well as androgen receptor signaling. Based on information from the gene expression profiles of clinical CRPC cells, we here identified one overexpressed gene, serine/threonine/tyrosine kinase 1 (STYK1), encoding a potential kinase, as a molecular target for CRPC. RNA and immunohistochemical analyses validated the overexpression of STYK1 in prostate cancer cells, and its expression was distinct in CRPC cells. Knockdown of STYK1 by siRNA resulted in drastic suppression of prostate cancer cell growth and, concordantly, enforced expression of STYK1 promoted cell proliferation, whereas ectopic expression of a kinase-dead mutant STYK1 did not. An in vitro kinase assay using recombinant STYK1 demonstrated that STYK1 could have some potential as a kinase, although its specific substrates are unknown. These findings suggest that STYK1 could be a possible molecular target for CRPC, and small molecules specifically inhibiting STYK1 kinase could be a possible approach for the development of novel CRPC therapies.

Histopathological findings in extended prostate biopsy with PSA < or = 4 ng/mL

OBJECTIVE

Cancer detection has been reported in up to 27% of patients when lowering the PSA cutoff to 2.5 ng/mL. Although this practice could increase the number of biopsies performed, it also could lead to more frequent detection of significant prostate cancers at an organ-confined stage and/or a less aggressive state. This study describes the incidence of malignancy and tumor characteristics in extended prostate biopsies with PSA <or= 4 ng/mL.

MATERIALS AND METHODS

Prostate biopsies from 1081 patients where examined, 275 (25.4%) patients had PSA level <or= 4 ng/mL.

RESULTS

Cancer was diagnosed in 32.0% and 35.7% of patients with PSA <or= 4 ng/mL and >4 ng/mL, respectively (p=0.906). The median Gleason score was 7 independent of PSA > or <or= 4 ng/mL (p=0.078). The median number of cores positive for tumor was 4 and 3, respectively, for PSA >4 ng/mL and PSA <or= 4 ng/mL (p=0.627). There was a difference in the total percent of tumors involving all cores, 11% and 7% for PSA > or <or= 4 ng/mL (p=0.042). Fifty-six patients underwent radical prostatectomy, 12 had PSA <or= 4 ng/mL. In both groups, a diagnosis of cancer was accurate with no differences in Gleason score, tumor volume or staging for both groups.

CONCLUSION

When PSA is below 4 ng/mL, cancer is detected in a proportion equal to the proportion diagnosed with a PSA >4 ng/mL, and tumor characteristics are similar between the two groups. Only clinically significant tumors were diagnosed following radical prostatectomy.

[Radical transurethral resection of the prostate. An alternative therapy for the treatment of prostate cancer]

The value of radical transurethral resection of prostate cancer (TURPC) as an alternative therapy was investigated in this prospective study. From January 1995 to July 2008, 533 patients with a median age of 67 years (range 40-89 years) and with clinically localized prostate cancer were resected by the corresponding author with curative intention. The tumor stages were as follows: pT1 8%; pT2 61%; pT3 31%; G1 2%; G2 80%; G3 18%. TURPC requires continuous low-pressure irrigation with the irrigator liquid level at 10 cm water above the pubic region. It also requires a suprapubic trocar, a resectoscope with a 28F sheath, an autoregulated electrosurgical unit, and video monitoring. The prostate is resected completely with peripheral capsule and seminal vesicles. The specimen is retrieved in fractions for correct histopathological staging. If indicated, laparoscopic staging lymphadenectomy is performed. A secondary session for control of positive margins follows after 8 weeks. The transfusion rate was 1.5%, revision for hemorrhage 2.4%, lung embolism 0.2%, bladder neck incision 14%, grade 2 incontinence 0.6% out of 314, and impotence 30% out of 136. The prostate-specific antigen (PSA) nadir was < or =0.2 ng/ml in 95% of 444 cases. PSA recurrence at 5 years was 6% for pT1, 18% for pT2, and 31% for pT3. Postoperative survival at 10 years was 96% for pT1, 91% for pT2, and 85% for pT3 patients. Prostate cancer can be resected transurethrally with reasonable oncological results. The outcome with respect to survival and PSA recurrence is comparable with the results of other published procedures. Low-pressure irrigation with a suprapubic trocar is mandatory for safe performance.

Perineural invasion is a prognostic factor for biochemical failure after radical prostatectomy

OBJECTIVES

To identify the prognostic significance of lymphovascular invasion (LVI) and perineural invasion (PNI) in patients undergoing radical prostatectomy for prostate cancer.

METHODS

Overall, 237 patients who had undergone radical prostatectomy for prostate cancer between 1995 and 2004 were analyzed for all clinical and pathological factors. The influence of these two pathological features on biochemical failure-free survival was evaluated by univariate and multivariate analysis.

RESULTS

Lymphovascular and perineural invasion were identified in 41 (17.2%) and 100 (42.0%) patients, respectively. LVI and PNI were significantly associated with the preoperative prostate-specific antigen (PSA) level, a higher PSA density, a higher pathological stage, a higher Gleason score, a higher frequency of extracapsular extension, a higher frequency of seminal vesicle invasion, and a higher frequency of a positive resection margin. Positive resection margins (P = 0.001) and perineural invasion (P = 0.011) were identified as independent factors associated with biochemical failure-free survival by the multivariate analysis.

CONCLUSIONS

In this series, PNI was associated with established parameters of biologically aggressive disease, and was an important prognostic factor for biochemical failure-free survival in patients undergoing radical prostatectomy. This finding supports routine evaluation of the PNI status in radical prostatectomy specimens and suggests that patients with PNI should be more closely followed after surgery.

Surveillance of urothelial carcinoma: stage and grade migration, 1993-2005 and survival trends, 1993-2000

BACKGROUND

Previous investigators have detected shifts to lower stages at diagnosis for renal cell carcinoma and prostate cancer. The authors investigated whether a similar pattern is seen for urothelial carcinomas of the bladder, ureter, and renal pelvis and sought to identify changes in cancer grade and survival trends from 1993 to 2005.

METHODS

The National Cancer Data Base (NCDB) collects data on approximately 75% of all newly diagnosed cancer cases annually. The authors queried the database for cases of urothelial carcinomas diagnosed in 1993-2005 in patients aged 18 years and older. All cancer stage data were forward converted to the sixth edition of the American Joint Committee on Cancer staging definitions.

RESULTS

A total of 334,480 bladder cancer cases, 15,105 renal pelvis cancer cases, and 10,128 ureteral carcinoma cases were identified. Stage data were available for 84% of bladder cases, 83% of renal pelvis cases, and 82% of ureter cases. With the classification of early stage tumors as stage 0a, 0is, and I and late stage tumors as II, III, and IV, the percentage of early stage renal pelvis and ureter tumors increased slightly from 1993 to 2005, whereas no stage migration was seen in bladder tumors. In looking specifically at early stage tumors, a significant increase in the proportion of stage 0a and a significant decrease in the proportion of stage I tumors for each cancer site was seen between 1993 and 2005. The proportion of high grade tumors in each disease site significantly increased from 1993 to 2005. For cases diagnosed in 1993-1996 and 1997-2000, a significant decrease in 5-year relative survival was observed for patients with stage I and stage II bladder cancer. The absolute change, however, was relatively small, and for bladder cases was not significantly different when adjusted for low or high grade tumors.

CONCLUSIONS

When differentiating between early and late stage tumors, a slight stage migration was seen in renal pelvis and ureteral carcinomas, whereas no stage migration was seen in bladder tumors. Within early stage tumors of all sites, a stage shift was seen, most notably with the proportion of stage 0a tumors increasing and stage I tumors decreasing. The proportion of high grade tumors in all sites increased. No change in overall survival was observed, underscoring the need for new therapeutic advances.

Stanniocalcin 2 overexpression in castration-resistant prostate cancer and aggressive prostate cancer

Prostate cancer is usually androgen-dependent and responds well to androgen ablation therapy based on castration. However, at a certain stage some prostate cancers eventually acquire a castration-resistant phenotype where they progress aggressively and show very poor response to any anticancer therapies. To characterize the molecular features of these clinical castration-resistant prostate cancers, we previously analyzed gene expression profiles by genome-wide cDNA microarrays combined with microdissection and found dozens of trans-activated genes in clinical castration-resistant prostate cancers. Among them, we report the identification of a new biomarker, stanniocalcin 2, as an overexpressed gene in castration-resistant prostate cancer cells. Real-time polymerase chain reaction and immunohistochemical analysis confirmed overexpression of stanniocalcin 2, a 302-amino-acid glycoprotein hormone, specifically in castration-resistant prostate cancer cells and aggressive castration-naïve prostate cancers with high Gleason scores (8-10). The gene was not expressed in normal prostate, nor in most indolent castration-naïve prostate cancers. Knockdown of stanniocalcin 2 expression by short interfering RNA in a prostate cancer cell line resulted in drastic attenuation of prostate cancer cell growth. Concordantly, stanniocalcin 2 overexpression in a prostate cancer cell line promoted prostate cancer cell growth, indicating its oncogenic property. These findings suggest that stanniocalcin 2 could be involved in aggressive phenotyping of prostate cancers, including castration-resistant prostate cancers, and that it should be a potential molecular target for development of new therapeutics and a diagnostic biomarker for aggressive prostate cancers.

A double-blind randomized crossover study of oral thalidomide versus placebo for androgen dependent prostate cancer treated with intermittent androgen ablation

PURPOSE

We determined whether thalidomide can prolong progression-free survival in men with biochemically recurrent prostate cancer treated with limited androgen deprivation therapy.

MATERIALS AND METHODS

A total of 159 patients were enrolled in a double-blind randomized trial to determine if thalidomide can improve the efficacy of a gonadotropin-releasing hormone agonist in hormone responsive patients with an increasing prostate specific antigen after primary definitive therapy for prostate cancer. Patients were randomized to 6 months of gonadotropin-releasing hormone agonist followed by 200 mg per day oral thalidomide or placebo (oral phase A). At the time of prostate specific antigen progression gonadotropin-releasing hormone agonist was restarted for 6 additional months. Patients were then crossed over to the opposite drug and were treated until prostate specific antigen progression (oral phase B). Testosterone and dihydroxytestosterone were likewise monitored throughout the study.

RESULTS

During oral phase A the median time to prostate specific antigen progression was 15 months for the thalidomide group compared to 9.6 months on placebo (p = 0.21). The median time to prostate specific antigen progression during oral phase B for the thalidomide group was 17.1 vs 6.6 months on placebo (p = 0.0002). No differences in time to serum testosterone normalization between the thalidomide and placebo arms were documented during oral phase A and oral phase B. Thalidomide was tolerable although dose reductions occurred in 47% (58 of 124) of patients.

CONCLUSIONS

Despite thalidomide having no effect on testosterone normalization, there was a clear effect on prostate specific antigen progression during oral phase B. This is the first study to our knowledge to demonstrate the effects of thalidomide using intermittent hormonal therapy.

Biochemical recurrence after radical prostatectomy for prevalent versus incident cases of prostate cancer : implications for management

BACKGROUND

Among screened populations, it is unknown whether men with prostate cancer (PC) diagnosed at the initial screening (prevalent cases) have a different outcome than men who are diagnosed at subsequent screenings (incident cases) after adjusting for known prognostic factors.

METHODS

The current study cohort was comprised of 1923 men from a prospective PC screening study who underwent radical prostatectomy (RP) between September 19, 1989 and May 22, 2002. Cox regression multivariate analysis was used to determine whether having prevalent PC versus incident PC was associated with the time to prostate-specific antigen (PSA) failure after RP after adjusting for PSA level, Gleason score, clinical tumor (T) classification, and year of RP.

RESULTS

Men with prevalent PC had higher PSA levels (P < .001) and more advanced clinical T classification (P < .001) than men with incident PC. After a median follow-up of 6.1 years, factors that were associated with a significantly shorter time to PSA failure after RP were prevalent PC (adjusted hazard ratio [AHR], 1.8; 95% confidence interval [95% CI], 1.3-2.6; P = .0005), baseline PSA (AHR, 1.07; 95%CI, 1.04-1.09; P < .001), Gleason 7 disease (AHR, 2.5; 95% CI, 1.9-3.3; P < .001), Gleason 8 to 10 disease (AHR, 2.3; 95%CI, 1.5-3.5; P < .001), and the year of RP (AHR, 0.92; 95%CI, 0.86-0.97; P = .003). Men with prevalent PC also had worse outcomes after adjusting for their more advanced pathologic features.

CONCLUSIONS

After adjusting for known prognostic factors, men with prevalent PC had a poorer outcome after RP than men with incident PC. The authors believe that this finding should be taken into consideration when weighing the risk of recurrence and treatment options for men who are diagnosed with PC on their initial screening.

Multivariate gene expression analysis reveals functional connectivity changes between normal/tumoral prostates

BACKGROUND

Prostate cancer is a leading cause of death in the male population, therefore, a comprehensive study about the genes and the molecular networks involved in the tumoral prostate process becomes necessary. In order to understand the biological process behind potential biomarkers, we have analyzed a set of 57 cDNA microarrays containing approximately 25,000 genes.

RESULTS

Principal Component Analysis (PCA) combined with the Maximum-entropy Linear Discriminant Analysis (MLDA) were applied in order to identify genes with the most discriminative information between normal and tumoral prostatic tissues. Data analysis was carried out using three different approaches, namely: (i) differences in gene expression levels between normal and tumoral conditions from an univariate point of view; (ii) in a multivariate fashion using MLDA; and (iii) with a dependence network approach. Our results show that malignant transformation in the prostatic tissue is more related to functional connectivity changes in their dependence networks than to differential gene expression. The MYLK, KLK2, KLK3, HAN11, LTF, CSRP1 and TGM4 genes presented significant changes in their functional connectivity between normal and tumoral conditions and were also classified as the top seven most informative genes for the prostate cancer genesis process by our discriminant analysis. Moreover, among the identified genes we found classically known biomarkers and genes which are closely related to tumoral prostate, such as KLK3 and KLK2 and several other potential ones.

CONCLUSION

We have demonstrated that changes in functional connectivity may be implicit in the biological process which renders some genes more informative to discriminate between normal and tumoral conditions. Using the proposed method, namely, MLDA, in order to analyze the multivariate characteristic of genes, it was possible to capture the changes in dependence networks which are related to cell transformation.

Factors associated with variation in utility scores among patients with prostate cancer

OBJECTIVE

We aimed to assess the effects of age, comorbidity, and disease-specific functions on utility scores derived from three methods on prostate cancer.

METHODS

A total of 330 Japanese prostate cancer patients were asked to answer self-administered questionnaires. Community-weighted utility scores were derived from the EuroQoL-5D (EQ-5D) and the Short Form-36 (SF-36), while the patient's directly elicited utility score was derived from time trade-off technique. Univariate and multivariate analyses were performed to examine the relation between covariates and utility scores. We assigned age, the Index of Co-existent Disease, and disease-specific functions including sexual, urinary, bowel, and hormonal function as covariates.

RESULTS

Bowel and hormonal function were related to utility scores, while age and sexual function were not. Comorbidities were more closely related to utility scores derived from EQ-5D and SF-36.

CONCLUSIONS

These results contribute to an understanding of which factor has an impact on utility scores in patients with prostate cancer.

Apoptotic signaling in bufalin- and cinobufagin-treated androgen-dependent and -independent human prostate cancer cells

Prostate cancer has its highest incidence in the USA and is becoming a major concern in Asian countries. Bufadienolides are extracts of toxic glands from toads and are used as anticancer agents, mainly on leukemia cells. In the present study, the antiproliferative and apoptotic mechanisms of bufalin and cinobufagin on prostate cancer cells were investigated. Proliferation of LNCaP, DU145, and PC3 cells was measured by 3-(4,5-dimethylthiazol-2-yle)-2,5-diphenyltetrazolium bromide assay and the doubling time (tD) was calculated. Bufalin and cinobufagin caused changes in the tD of three prostate cancer cell lines, which were more significant than that of human mesangial cells. In addition, bufadienolides induced prostate cancer cell apoptosis more significantly than that in breast epithelial cell lines. After treatment, the caspase-3 activity and protein expression of caspase-3, -8, and -9 were elevated. The expression of other apoptotic modulators, including mitochondrial Bax and cytosolic cytochrome c, were also increased. However, expression of p53 was only enhanced in LNCaP cells. Downregulation of p53 by antisense TP53 restored the cell viability suppressed by bufalienolides. Furthermore, the increased expression of Fas was more significant in DU145 and PC3 cells with mutant p53 than in LNCaP cells. Transfection of Fas small interfering RNA restored cell viability in the bufadienolide-treated cells. These results suggest that bufalin and cinobufagin suppress cell proliferation and cause apoptosis in prostate cancer cells via a sequence of apoptotic modulators, including Bax, cytochrome c, and caspases. The upstream mediators might be p53 and Fas in androgen-dependent LNCaP cells and Fas in androgen-independent DU145 and PC3 cells.

Advances in MR spectroscopy of the prostate

Commercial MR imaging/magnetic resonance spectroscopic imaging (MRSI) packages for staging prostate cancer on 1.5-T MR scanners are now available. The technology is becoming mature enough to begin assessing its clinical utility in selecting, planning, and following prostate cancer therapy. Before therapy, 1.5-T MR imaging/MRSI has the potential to improve the local evaluation of prostate cancer presence and volume and has a significant incremental benefit in the prediction of pathologic stage when added to clinical nomograms. After therapy, two metabolic biomarkers of effective and ineffective therapy have been identified and are being validated with 10-year outcomes. Accuracy can be improved by performing MR imaging/MRSI at higher magnetic field strengths, using more sensitive hyperpolarized (13)C MRSI techniques and through the addition of other functional MR techniques.

An illustration of the potential for mapping MRI/MRS parameters with genetic over-expression profiles in human prostate cancer

INTRODUCTION

Magnetic resonance imaging (MRI) and MR spectroscopy can probe a variety of physiological (e.g. blood vessel permeability) and metabolic characteristics of prostate cancer. However, little is known about the changes in gene expression that underlie the spectral and imaging features observed in prostate cancer. Tumor induced changes in vascular permeability and angiogenesis are thought to contribute to patterns of dynamic contrast enhanced (DCE) MRI images of prostate cancer even though the genetic basis of tumor vasculogenesis is complex and the specific mechanisms underlying these DCEMRI features have not yet been determined.

MATERIALS AND METHODS

In order to identify the changes in gene expression that correspond to MRS and DCEMRI patterns in human prostate cancers, we have utilized tissue print micropeel techniques to generate "whole mount" molecular maps of radical prostatectomy specimens that correspond to pre-surgical MRI/MRS studies. These molecular maps include RNA expression profiles from both Affymetrix GeneChip microarrays and quantitative reverse transcriptase PCR (qrt-PCR) analysis, as well as immunohistochemical studies.

RESULTS

Using these methods on patients with prostate cancer, we found robust over-expression of choline kinase a in the majority of primary tumors. We also observed overexpression of neuropeptide Y (NPY), a newly identified angiogenic factor, in a subset of prostate cancers, visualized on DCEMRI.

CONCLUSION

These studies set the stage for establishing MRI/MRS parameters as validated biomarkers for human prostate cancer.

The influence of serial prostate-specific antigen (PSA) screening on the PSA velocity at diagnosis

BACKGROUND

A prostate-specific antigen (PSA) velocity (PSAV) >2 ng/mL during the year before diagnosis has been associated with an increased risk of prostate cancer-specific mortality (PCSM) after radical prostatectomy (RP) or radiation therapy. The objective of the current study was to examine whether the proportion of men with a PSAV >2 ng/mL per year has changed significantly during the PSA era.

METHODS

The authors evaluated 1095 men from a prospective prostate cancer screening study who underwent RP between 1989 and 2002. For the purposes of this analysis, clinicopathologic features were compared between men who were treated during the following 3 periods: before 1995, from 1995 to 1998, and after 1998. Logistic regression analysis was used to evaluate for an association between the year of diagnosis and the proportion of men with a PSAV >2 ng/mL per year.

RESULTS

Two hundred sixty-two of 1095 men (24%) had a PSAV >2 ng/mL per year. There was a statistically significant reduction in the proportion of men presenting with a PSAV >2 ng/mL per year over the study period. Specifically, 35% of men presented with a PSAV >2 ng/mL per year in the early period compared with only 22% and 12% in the middle and late periods, respectively (P < .001). Over the studied periods, there also was a significantly greater proportion of men with >2 PSA values obtained before diagnosis (P < .001).

CONCLUSIONS

Men who were screened serially with PSA were less likely to present with a PSAV >2 ng/mL per year. This association lends support to the hypothesis that serial PSA-based screening may lead to a decrease in PCSM.

Low risk prostate cancer in men under age 65: the case for definitive treatment

The management of low risk prostate cancer, defined as Gleason's sum <or=6, PSA <10 ng/ml, and clinical stage T1c to T2a, remains controversial. There is substantiating evidence to suggest that a subset of early stage, low risk cancers can cause significant patient morbidity and death in the long term. Studies have shown that the natural history of untreated prostate cancer is to progress, particularly after 15 years of followup. The majority of men seeking definitive surgical treatment in contemporary series fall within 55 to 65 years of age and are expected to enjoy an overall life expectancy ranging from about 15 to 30 years, placing these men at long-term risk for disease progression and prostate cancer-specific death if managed expectantly. During the past 2 decades, refinements in surgical technique and in the delivery of external beam radiation have resulted in excellent long-term cancer control and favorable quality of life outcomes following treatment. Active surveillance with selective delayed intervention assumes that an individual's cancer will not progress outside the window of curability during the surveillance period, that markers for disease progression are reliable, and that patients are compliant. Until we understand better the long-term natural history of untreated prostate cancer, have more reliable and accurate markers to detect disease progression with certainty, and can risk stratify more precisely the subgroup of men with low risk cancers who will eventually succumb to their disease, early definitive therapy seems prudent.

Contemporary evaluation of the D'amico risk classification of prostate cancer

OBJECTIVES

In 1998, D'Amico et al. suggested a model stratifying patients with prostate cancer into those with low, intermediate, or high-risk of biochemical recurrence after surgery according to the clinical TNM stage, biopsy Gleason score, and preoperative prostate-specific antigen level. We studied the performance and clinical relevance of this classification system over time, in the context of the stage migration seen in the contemporary era, using data from a high-volume, tertiary referral center.

METHOD

From 1984 to 2005, 6652 men underwent radical prostatectomy at our institution for clinically localized prostate cancer (clinical Stage T1c-T2c) with follow-up information available and no neoadjuvant or adjuvant therapy before biochemical recurrence. Biochemical recurrence-free survival (BRFS) was estimated using the Kaplan-Meier method, and the BRFS rates between the D'Amico risk groups and by era were compared using the log-rank statistic. Finally, the distribution of patients among the three groups was compared over time.

RESULTS

The 5-year BRFS rate was 84.6% overall and 94.5%, 76.6%, and 54.6% for the low, intermediate, and high-risk groups, respectively (P <0.0001). In the contemporary era, a very small fraction (4.9%) of patients undergoing radical prostatectomy at our institution were in the high-risk group, with most (67.7%) in the low-risk group (P <0.001).

CONCLUSIONS

The D'Amico classification system continues to stratify men into risk groups with statistically significant differences in BRFS. However, the major shift in the distribution of patients among the three risk groups over time suggests that the clinical relevance of this classification scheme may be limited and diminishing in the contemporary era.

Multiparametric magnetic resonance imaging in prostate cancer: present and future

PURPOSE OF REVIEW

The purpose of this article is to review the current status of advanced MRI techniques based on anatomic, metabolic and physiologic properties of prostate cancer with a focus on their impact in managing prostate cancer patients.

RECENT FINDINGS

Prostate cancer can be identified based on reduced T2 signal intensity on MRI, increased choline and decreased citrate and polyamines on magnetic resonance spectroscopic imaging (MRSI), decreased diffusivity on diffusion tensor imaging (DTI), and increased uptake on dynamic contrast enhanced (DCE) imaging. All can be obtained within a 60-min 3T magnetic resonance exam. Each complementary method has inherent advantages and disadvantages: T2 MRI has high sensitivity but poor specificity; magnetic resonance spectroscopic imaging has high specificity but poor sensitivity; diffusion tensor imaging has high spatial resolution, is the fastest, but sensitivity/specificity needs to be established; dynamic contrast enhanced imaging has high spatial resolution, but requires a gadolinium based contrast agent injection, and sensitivity/specificity needs to be established.

SUMMARY

The best characterization of prostate cancer in individual patients will most likely result from a multiparametric (MRI/MRSI/DTI/DCE) exam using 3T magnetic resonance scanners but questions remain as to how to analyze and display this large amount of imaging data, and how to optimally combine the data for the most accurate assessment of prostate cancer. Histological correlations or clinical outcomes are required to determine sensitivity/specificity for each method and optimal combinations of these approaches.

Identification of enhancer of zeste homolog 2 expression in peripheral circulating tumor cells in metastatic prostate cancer patients: a preliminary study

PURPOSE

Enhancer of zeste homolog 2 (EZH2), a kind of transcriptional repressor, is reportedly over-expressed in metastatic prostate cancer. In this study, we analyzed EZH2 mRNA in circulating tumor cells (CTCs) in peripheral blood as a biomarker in patients with metastatic prostate cancer.

PATIENTS AND METHODS

Ber-EP4 coated immunomagnetic beads were used to harvest CTCs, and mRNA was isolated by oligo- dT conjugated immunomagnetic beads. Reverse transcriptase- polymerase chain reaction for EZH2 mRNA was performed and the expression density was measured. The sensitivity of this test for detection of EZH2 mRNA was determined by serial dilutions of a human prostate cancer cell line. Blood samples were collected from 20 patients each with metastatic or localized prostate cancer and 10 healthy volunteers.

RESULTS

Sensitivity experiments showed that the test was highly sensitive as it could detect 10 tumor cells per 5 mL. EZH2 mRNA expression was obtained from peripheral blood samples of patients and control subjects. EZH2 mRNA expression density in the metastatic prostate cancer group was significantly higher than in the control (p=0.023) and localized prostate cancer groups (p=0.019). There was no difference between the control and localized prostate cancer groups (p > 0.05).

CONCLUSION

EZH2 mRNA expression in circulating epithelial cells represents a promising marker for detecting early metastasis in prostate cancer. However, more specific and sensitive techniques for detection of CTCs are needed to avoid mononuclear cell contamination.

[Incidence of locally invasive prostate cancer in patients with intermediate values of prostate-specific antigen]

BACKGROUND/AIM

Feasibility of radical prostatectomy (RP) in patients with locally invasive prostate cancer (PC) is assessed by the standard parameters such as the stage of the disease, serum prostate-specific antigen (PSA) and bioptic Gleason grade (GG). Intermediate values of PSA are important in predicting the local confines of the tumor, but can also be detected in more than 30% of patients with locally advanced PC. The aim of this study was to find out the incidence of locally advanced PC in the patients with intermediate serum PSA in whom RP had been performed.

METHODS

We used the biopsy cores and the tissue obtained after RP from 46 patients who had intermidiate PSA values which were defined as PSA from 2.6-10 ng/ml. In all the patients classical regional lymphadenectomy was performed. In all the patients, preoperative stage was determined according to the Partin tables (PT) from 2001.

RESULTS

In 52, 17% of the patients biopsy GG was < or = 6, while it was 7 in 47.83% of the patients. Clinically localized disease (cT2b) was found in 86.96% of patients; other 13.04% of the patients had locally advanced PC. After RP, the incidence of localized PC was 47.83%, while the advanced disease was found in 52.17%. Metastasis in one or two regional lymph nodes (N1) was found in 10.87% of the patients with the advanced PC. According to PT, the expected incidence of positive lymph nodes should have been 8% for pT3 stage. Positive correlation between the assumed N1 stage according to PT and N1 stage in our radical prostatectomies was statistically significant (p = 0.012).

CONCLUSION

In more than 50% of patients with intermediate values of PSA locally advanced disease can be expected after RP. The use of the Partin tables have an important predictive value in assessing the local confines of the cancer and metastasis in regional lymph nodes.

The detection and isolation of viable prostate-specific antigen positive epithelial cells by enrichment: a comparison to standard prostate-specific antigen reverse transcriptase polymerase chain reaction and its clinical relevance in prostate cancer

PURPOSE

To isolate prostate epithelial cells from the peripheral blood and bone marrow, and compare prostate-specific antigen (PSA) reverse transcriptase polymerase chain reaction (RT-PCR) performed on unenriched or epithelial enriched peripheral blood and bone marrow samples.

PATIENTS AND METHODS

Peripheral blood samples from 371 patients with prostate cancer and 141 controls, and bone marrow samples from 292 patients with prostate cancer and 43 controls were obtained. One aliquot was assessed with PSA RT-PCR. Another was enriched for epithelial cells with paramagnetic immune microbeads and assessed for: (1) PSA immunohistochemistry, (2) PSA RT-PCR, and (3) immunofluorescent detection of epithelial cells.

RESULTS

In the bone marrow (P < 0.01), but not the peripheral blood (P = 0.62), we observed significantly higher detection rates of disseminated PSA expressing epithelial cells after enrichment. The presence of epithelial cells with or without evidence of PSA production was uncommon among controls both in peripheral blood (1% and 0%) and bone marrow (11% and 0%). In patients with active prostate cancer, 46% to 74% had epithelial cells in peripheral blood, and 20% to 64% had PSA expressing epithelial cells. In bone marrow, 55% to 92% had epithelial cells, and 43% to 83% had PSA expressing epithelial cells. Particularly in bone marrow, circulating cells were frequently detected in men without evidence of disease after prostatectomy. With limited follow-up, the detection of epithelial cells or PSA expressing epithelial cells in peripheral blood or bone marrow before radical prostatectomy does not define a population of patients that will have biochemical failure.

CONCLUSIONS

Immunomagnetic enrichment frequently detects epithelial, presumably malignant, cells in the peripheral blood and, especially, the bone marrow of patients with prostate cancer. Viable cells can be acquired for gene expression and phenotyping studies.

Long-Term Outcome After Radical Prostatectomy for Patients With Lymph Node Positive Prostate Cancer in the Prostate Specific Antigen Era

PURPOSE

While the incidence of lymph node positive prostate cancer has decreased during the prostate specific antigen era, the optimal treatment of these patients remains in question. We examined the impact of lymph node metastases on the outcome of patients following radical prostatectomy and investigated prognostic factors that affect survival.

MATERIALS AND METHODS

We identified 507 men treated with radical prostatectomy between 1988 and 2001 who had lymph node positive disease. Of the 507 patients 455 (89.7%) were treated with adjuvant hormonal therapy. Median followup was 10.3 years (IQR 6.1-13.5). Postoperative survival rates were estimated using the Kaplan-Meier method and the impact of various clinicopathological factors on outcome was analyzed using Cox proportional hazard regression models.

RESULTS

Ten-year cancer specific survival for patients with positive lymph nodes was 85.8% with 56% of the men free from biochemical recurrence at last followup. On multivariate analysis pathological Gleason score 8-10 (p = 0.004), positive surgical margins (p = 0.016), nondiploid tumor ploidy (p = 0.023) and 2 or greater positive nodes (p = 0.001) were adverse predictors of cancer specific survival. Tumor stage, year of surgery and total number of nodes removed did not significantly affect outcome. Adjuvant hormonal therapy decreased the risk of biochemical recurrence (p <0.001) and local recurrence (p = 0.004) but it was not associated with systemic progression (p = 0.4) or cancer specific survival (p = 0.4).

CONCLUSIONS

Radical prostatectomy may offer long-term survival to patients with lymph node positive prostate cancer. Gleason score, margin status, tumor ploidy and the number of involved nodes predict survival, while the role of adjuvant hormonal therapy continues to be defined.

Molecular features of hormone-refractory prostate cancer cells by genome-wide gene expression profiles

One of the most critical issues in prostate cancer clinic is emerging hormone-refractory prostate cancers (HRPCs) and their management. Prostate cancer is usually androgen dependent and responds well to androgen ablation therapy. However, at a certain stage, they eventually acquire androgen-independent and more aggressive phenotype and show poor response to any anticancer therapies. To characterize the molecular features of clinical HRPCs, we analyzed gene expression profiles of 25 clinical HRPCs and 10 hormone-sensitive prostate cancers (HSPCs) by genome-wide cDNA microarrays combining with laser microbeam microdissection. An unsupervised hierarchical clustering analysis clearly distinguished expression patterns of HRPC cells from those of HSPC cells. In addition, primary and metastatic HRPCs from three patients were closely clustered regardless of metastatic organs. A supervised analysis and permutation test identified 36 up-regulated genes and 70 down-regulated genes in HRPCs compared with HSPCs (average fold difference > 1.5; P < 0.0001). We observed overexpression of AR, ANLN, and SNRPE and down-regulation of NR4A1, CYP27A1, and HLA-A antigen in HRPC progression. AR overexpression is likely to play a central role of hormone-refractory phenotype, and other genes we identified were considered to be related to more aggressive phenotype of clinical HRPCs, and in fact, knockdown of these overexpressing genes by small interfering RNA resulted in drastic attenuation of prostate cancer cell viability. Our microarray analysis of HRPC cells should provide useful information to understand the molecular mechanism of HRPC progression and to identify molecular targets for development of HRPC treatment.

Surgery Versus Implant for Early Prostate Cancer: Results From a Single Institution, 1992–2005

PURPOSE

The aim of this study was to compare the biochemical disease-free survival rates for radical prostatectomy versus transperineal ultrasound-guided prostate implant for patients with early prostate cancer treated at a single institution from 1992 through 2005.

MATERIALS AND METHODS

The charts of 741 patients with early prostate cancer (350 implant and 391 surgery) treated from 1992 through 2005 were retrospectively reviewed. Surgery patients were treated by members of the academic Urology Section at Yale University School of Medicine. Implant patients were treated by a combined team from the Urology Section and the Department of Therapeutic Radiology at Yale Medical School. For the 350 implant patients, 35% were treated with iodine-125 and 65% with palladium-103. Of the implant patients 92% were treated with an implant alone and 8% with combined external beam radiation therapy plus an implant and 25% received short-term hormone therapy to downsize the prostate before the implant. Both surgery and implant patients were analyzed based on a group with favorable cancers (clinical stage T1c or T2, prostate-specific antigen <10, and Gleason score <7), an intermediate group (any 1 factor increased compared with the favorable group), and a poor group (any 2 factors increased compared with the favorable group). The follow-up time varied from 12 to 120 months with a mean/median follow-up time of 44 months/42 months for implant patients and 42 months/40 months for surgery patients. Prostate-specific antigen recurrence for surgery was defined as any detectable prostate-specific antigen after surgery. Prostate-specific antigen recurrence for implant was defined as the prostate-specific antigen nadir plus 2 ng/mL after implant. The biochemical disease-free survival rates were calculated using the life-table method.

RESULTS

The 5-year biochemical disease-free survival rates for radical prostatectomy versus implant were identical for the favorable group (93% versus 92%), intermediate group (70% versus 70%), and poor group (50% versus 52%) patients.

CONCLUSIONS

From 1992 through 2005, implant therapy produced equivalent 5-year biochemical disease-free survival rates compared with surgery in patients with early prostate cancer treated at a single institution.

Cost-Benefit and Outcome Analysis: Effect of Prostate Biopsy Undergrading

OBJECTIVES

Brachytherapy is a widely used treatment for localized prostate cancer (CaP) and is only appropriate as monotherapy for low-risk cancer. The predicted response to therapy is defined by the pretreatment parameters, of which the biopsy Gleason grade is central. However, the biopsy grade often misrepresents the true pathologic grade. We examined the impact of incorrect biopsy grading on brachytherapy outcomes.

METHODS

We constructed a decision analytic model to assess the theoretical performance of brachytherapy for a theoretical cohort of men with Gleason score 6 CaP who underwent radical prostatectomy. The variables regarding biopsy Gleason scores and the correlation with the surgical specimen findings were generated from the institutional data. The ranges for these variables, biochemical performance of brachytherapy, costs, and disease state utilities, were obtained from a data review.

RESULTS

For the base case, 67% of biopsy grades correlated with the pathologic grade. With this concordance, 8% of failures could be attributed, in part, to undergrading. On the basis of the model assumptions, as concordance worsened to 50%, the rate of undergraded failures increased to 12%. After adjusting for the quality of life associated with higher-grade disease and the risk of biochemical failure, the aggregate cost of treatment of biopsy grade 6 disease was increased by 8% because of undergrading ($75,700 versus $81,500 per case). The bulk of this effect was the cost of failure among patients with undergraded disease.

CONCLUSIONS

Brachytherapy for Gleason score 6 disease is reported to have excellent results. Undergrading of prostate biopsies can negatively affect clinical outcomes and increase treatment costs. Although the risk is low, it should be considered when counseling patients with CaP.

Efficiency of Ultrasensitive Prostate-specific Antigen Assay in Diagnosing Biochemical Failure After Radical Prostatectomy

BACKGROUND

Ultrasensitive prostate-specific antigen (PSA) is a significant serum biomarker for identifying the PSA nadir and early biochemical failure after radical prostatectomy (RP). We assessed the efficiency of ultrasensitive PSA assay in the follow-up after RP.

METHODS

We generated longitudinal ultrasensitive PSA data using a computer program assuming that patients experienced biochemical failure after RP. The simulation experiments, based on several different scenarios, were performed to assess the sensitivity and specificity in the diagnosis of biochemical failure using ultrasensitive PSA values and to estimate the lead time, which is the time advantage of detecting positivity for biochemical failure using the ultrasensitive PSA values compared with conventional PSA assay. We validated the sensitivity, specificity and lead time using actual follow-up data of 182 patients receiving RP.

RESULTS

It was suggested that the sensitivity obtained from the actual data was more similar to that obtained using ultrasensitive PSA with an exponential increase than with a linear increase in the simulation experiments. Diagnosing biochemical failure based on two consecutive increases in the ultrasensitive PSA values was not recommended. Of non-biochemical failure patients, 9.4% showed four consecutive increases in their ultrasensitive PSA values. Average lead time in the actual data was 11.2 months (SD: 10.1).

CONCLUSIONS

For an accurate diagnosis of biochemical failure, our findings suggest the importance of a certain duration of follow-up and exclusion of false-positive results afterwards.

Additional Sampling of Dorsal Apex on Systematic Prostate Biopsy: Impact on Early Detection of Prostate Cancer

OBJECTIVES

To evaluate the significance of additional routine biopsies targeting the dorsal apex (DA) in men undergoing transrectal ultrasound (TRUS)-guided biopsies.

METHODS

This study included 429 patients undergoing TRUS-guided biopsy of the prostate. As a rule, 12 cores were taken from each patient, with 8 cores taken from the peripheral zones, 2 cores from the transition zones, and 2 additional cores from the DA.

RESULTS

Cancer was detected in 150 patients, of whom 97 had positive cores in the DA. Furthermore, cancer was detected only in the DA in 14 patients; that is, the increase in the cancer detection rate by additional sampling from the DA was 9.3%. Significant differences were found in the prostate-specific antigen level, prostate-specific antigen density, digital rectal examination findings, TRUS findings, clinical T stage, and percentage of positive biopsy cores among the 14 men with positive cores in the DA alone (group 1), 83 in the DA and other regions (group 2), and 53 in regions except for the DA (group 3). Of these, radical prostatectomy was performed in 6, 41, and 26 in groups 1, 2, and 3, respectively. No significant differences were found in the several pathologic factors among these groups, and 5 of the 6 patients in group 1 had a tumor volume greater than 0.5 cm3.

CONCLUSIONS

Additional sampling of biopsy cores from the DA significantly improved the cancer detection rate, particularly for early disease; however, this method does not appear to increase the detection of insignificant cancer. Accordingly, we recommend performing systematic biopsy routinely targeting the DA.

Lack of Progress in Early Diagnosis of Bladder Cancer

OBJECTIVES

The stage of presentation of prostate cancer has changed dramatically in the past two decades, largely because of prostate-specific antigen screening and increased public awareness regarding the disease. Recently, strides have been made in the validation, development, and approval of bladder cancer (BC) markers. We sought to evaluate whether any stage migration has occurred for patients with BC during the same period.

METHODS

A total of 351 and 1262 patients underwent radical cystectomy and radical retropubic prostatectomy, respectively, between 1992 and 2005 by one surgeon. The patients were divided into two consecutive groups: group 1 (1992 to 1998) and group 2 (1999 to 2005). The baseline and pathologic characteristics of the patients were compared.

RESULTS

No differences were found in the clinical or pathologic staging between the two groups of patients undergoing radical cystectomy. The 5-year overall and disease-specific survival also was not different between the two groups. For patients with prostate cancer, those in group 2 presented at a younger age, with a lower prostate-specific antigen level, and had a lower clinical stage. Group 2 patients had a decrease in the incidence of extracapsular extension, a decreased tumor volume, and a decrease in the incidence of Gleason 8 to 10 tumors.

CONCLUSIONS

During two consecutive periods, our patients with prostate cancer presented with the cancer at an earlier stage and had more favorable pathologic features after radical retropubic prostatectomy. However, our patients with BC did not demonstrate any stage migration. Physicians need to be more aggressive in diagnosing BC, especially in patients at high risk of the disease. Risk factors must be emphasized, urine markers should be used in a screening strategy, and the indications for radical cystectomy should be liberalized.

Identifying men diagnosed with clinically localized prostate cancer who are at high risk for death from prostate cancer

PURPOSE

We identified factors at diagnosis that are significantly associated with time to prostate cancer specific mortality following radical prostatectomy or external beam radiation therapy.

MATERIALS AND METHODS

The study cohort included 1,453 men treated with radical prostatectomy (1,095) or external beam radiation therapy (358) for localized prostate cancer between 1989 and 2002. Cox regression multivariate analysis was used to evaluate whether prostate specific antigen, prostate specific antigen velocity, biopsy Gleason score and clinical tumor category at diagnosis were significantly associated with time to prostate cancer specific mortality following radical prostatectomy or external beam radiation therapy.

RESULTS

In addition to increasing prostate specific antigen (p < or =0.04) and biopsy Gleason score 8 to 10 disease (p < or =0.02), prostate specific antigen velocity more than 2 ng/ml yearly was significantly associated with shorter time to prostate cancer specific mortality in patients treated with radical prostatectomy (adjusted HR 12, 95% CI 3 to 54) and external beam radiation therapy (adjusted HR 12, 95% CI 3 to 54) compared with that in men with prostate specific antigen velocity 2 ng/ml yearly or less (p < or =0.001). Despite low risk disease 7-year estimates of prostate cancer specific mortality were 5% to 19% in patients in whom prostate specific antigen increased by more than 2 ng/ml during the year before diagnosis compared with less than 1% in those with a prostate specific antigen increase of 2 ng/ml or less.

CONCLUSIONS

Despite prostate specific antigen level less than 10 ng/ml and Gleason score 6 cancer a prostate specific antigen increase of more than 2 ng/ml during the year before diagnosis places a man at high risk for prostate cancer death following radical prostatectomy or external beam radiation therapy.

Prostate-specific antigen-based serial screening may decrease prostate cancer-specific mortality

OBJECTIVES

To compare the preoperative characteristics, postoperative prostate-specific antigen (PSA) doubling time (DT), and prostate cancer-specific mortality (PCSM) estimates after PSA failure in men diagnosed during a screening study versus a community referral population. A PSA-DT of less than 3 months is a surrogate endpoint for PCSM.

METHODS

From 1988 to 2002, 1492 of 9637 patients with clinically localized prostate cancer underwent radical prostatectomy and experienced PSA failure. They were either participating in a screening study (n = 841) or attended 1 of 44 community-based practices (n = 611). The distributions of PSA, Gleason score, tumor stage, and PSA-DT were compared using chi-square metric. The estimates of PCSM after PSA failure were compared using Gray's P value.

RESULTS

Compared with the community population, the annually screened men experiencing PSA failure had a lower PSA level at diagnosis (5.1 versus 9.5 ng/mL, P <0.0001), were less likely to have Gleason score 7 to 10 cancer (25.1% versus 42.1%, P <0.0001), and were more likely to have low-risk disease (64.5% versus 23.8%, P <0.0001). Furthermore, the screened cohort had a reduction (P <0.0001) in the proportion with a PSA-DT of less than 3, 3 to 5.99, and 6 to 11.99 months and a significant increase in the proportion with a PSA-DT of 12 months or longer. After a median follow-up of 4.5 and 4.1 years after PSA failure in the screened and community cohorts, respectively, the PCSM estimates were lower (P = 0.0002) in the screened cohort (10-year estimate 3.6% [95% confidence interval 1.3 to 5.8] versus 11.3% [95% confidence interval 5.9 to 17.4]).

CONCLUSIONS

Patients diagnosed by annual prostate cancer screening appeared more likely to experience an indolent PSA recurrence and less likely to die of prostate cancer after PSA recurrence compared with patients referred from the community.

Expression of novel molecules, MICAL2-PV (MICAL2 prostate cancer variants), increases with high Gleason score and prostate cancer progression

PURPOSE

The aim of this study is to identify novel molecular targets for development of novel treatment or diagnostic markers of prostate cancer through genome-wide cDNA microarray analysis of prostate cancer cells purified by laser microdissection.

EXPERIMENTAL DESIGN AND RESULTS

Here, we identified molecule interacting with CasL-2 prostate cancer variants (MICAL2-PV), novel splicing variants of MICAL2, showing overexpression in prostate cancer cells. Immunohistochemical analysis using an antibody generated specific to MICAL2-PV revealed that MICAL2-PV was expressed in the cytoplasm of cancer cells with various staining patterns and intensities, whereas it was not or hardly detectable in adjacent normal prostate epithelium or prostatic intraepithelial neoplasia. Interestingly, immunohistochemical analysis of 105 prostate cancer specimens on the tissue microarray indicated that MICAL2-PV expression status was strongly correlated with Gleason scores (P < 0.0001) or tumor classification (P < 0.0001). Furthermore, the expression levels of MICAL2-PVs were also concordant to those of c-Met, a marker of tumor progression, with statistical significance (P = 0.0018). To investigate its potential of molecular therapeutic target for prostate cancers, we knocked down endogenous MICAL2-PVs in prostate cancer cells by small interfering RNA, which resulted in the significant reduction of prostate cancer cell viability.

CONCLUSIONS

Our findings suggest that MICAL2-PV is likely to be involved in cancer progression of prostate cancer and could be a candidate as a novel molecular marker and/or target for treatment of prostate cancers with high Gleason score.

The Effect of Age on Prostate Implantation Results

PURPOSE

The current study was undertaken to determine the effect of young age (60 years or younger) on the 5-year biochemical disease-free survival rate following ultrasound-guided transperineal prostate implantation.

PATIENTS AND METHODS

The radiation therapy charts of 330 patients who underwent ultrasound-guided transperineal prostate implantation who were treated from 1992 through 2004 were retrospectively reviewed. Follow-up ranged from 12 to 120 months, with a mean of 48 months. A total of 63 patients were 60 years of age or younger, and 267 patients were over 60 years of age. Prostate-specific antigen (PSA) recurrence was defined as three successive increases following ultrasound-guided transperineal prostate implantation. Biochemical disease-free survival was determined using the life-table method.

RESULTS

There were no statistically significant differences in the 5-year biochemical disease-free survival rates for the younger versus the older group. On univariate analysis, age was not a statistically significant factor in predicting PSA failure. Univariate analysis revealed that Gleason score, PSA at diagnosis, and clinical T stage were significant in predicting for PSA failure. Patients with Gleason score<7, PSA<10, and clinical stage T1c disease had statistically significant lower PSA failure rates than patients with Gleason score>or=7, PSA>or=10, and clinical stage T2 disease, respectively.

CONCLUSIONS

Patients who are 60 years of age or younger who are treated with ultrasound-guided transperineal prostate implantation can expect 5-year biochemical disease-free survival rates similar to those of older patients treated with ultrasound-guided transperineal prostate implantation therapy.

Predictive Ability of Partin Tables 2001 in a Welsh Population

OBJECTIVES

Partin tables are widely used to select and counsel patients prior to radical surgery for prostate cancer. However, Partin tables have been developed in the USA which has a different ethnic mixture from that of North Wales. We aimed to assess Partin tables' predictive ability in a Welsh population.

MATERIALS AND METHODS

193 patients underwent radical retropubic prostatectomy for clinically localized carcinoma of the prostate between April 1993 and July 2004 in a single institution in North Wales. Complete preoperative clinical staging information was available in 177 patients. Receiver operating characteristic curve analysis was used.

RESULTS

The mean patient age was 64 (48-73) years. Preoperative clinical staging distribution was: T1c 46.6% and T2 53.4%. 75% had organ-confined disease (TNM 1992). Extracapsular extension without seminal vesicle or lymph node involvement was seen in 13.5%. Nine percent had seminal vesicle invasion without lymph node involvement. Lymph node metastasis was found in 2.2%. The predictive effectiveness of the Partin table was high with an area under ROC curve of 0.733 for organ confinement, 0.738 for seminal vesicle invasion and 0.780 for lymph node involvement (CI 95%).

CONCLUSION

Our study demonstrated that the predictive ability of Partin tables for prostate cancer is also applicable to a Welsh population.

A new nomogram to predict pathologic outcome following radical prostatectomy

OBJECTIVE

To develop a preoperative nomogram to predict pathologic outcome in patients submitted to radical prostatectomy for clinical localized prostate cancer.

MATERIALS AND METHODS

Nine hundred and sixty patients with clinical stage T1 and T2 prostate cancer were evaluated following radical prostatectomy, and 898 were included in the study. Following a multivariate analysis, nomograms were developed incorporating serum PSA, biopsy Gleason score, and percentage of positive biopsy cores in order to predict the risks of extraprostatic tumor extension, and seminal vesicle involvement.

RESULTS

In univariate analysis there was a significant association between percentage of positive biopsy cores (p < 0.001), serum PSA (p = 0.001) and biopsy Gleason score (p < 0.001) with extraprostatic tumor extension. A similar pathologic outcome was seen among tumors with Gleason score 7, and Gleason score 8 to 10. In multivariate analysis, the 3 preoperative variables showed independent significance to predict tumor extension. This allowed the development of nomogram-1 (using Gleason scores in 3 categories - 2 to 6, 7 and 8 to 10) and nomogram-2 (using Gleason scores in 2 categories - 2 to 6 and 7 to 10) to predict disease extension based on these 3 parameters. In the validation analysis, 87% and 91.1% of the time the nomograms-1 and 2, correctly predicted the probability of a pathological stage to within 10% respectively.

CONCLUSION

Incorporating percent of positive biopsy cores to a nomogram that includes preoperative serum PSA and biopsy Gleason score, can accurately predict the presence of extraprostatic disease extension in patients with clinical localized prostate cancer.

Allelic imbalance and biochemical outcome after radical prostatectomy

OBJECTIVE

To compare the incidence of allelic imbalance (AI) in men with rapid disease progression with those who remained disease free after radical prostatectomy, with the aim of identifying genetic markers to predict prognosis and guide further treatment.

PATIENTS AND METHODS

Tumour and normal DNA were extracted from two matched groups of 31 men with extracapsular node-negative (pT3N0) prostate cancer who had undergone radical prostatectomy. One group comprised men who developed biochemical recurrence within 2 years of surgery and one group were prostate-specific antigen (PSA) free for at least 3 years. Men were matched for Gleason grade, preoperative PSA and pathological stage. Analysis was performed by genotyping.

RESULTS

Allelic imbalance was analysed using 30 markers, and was seen in at least one marker in 57 (92%) of the cases. Deletion at marker D10S211 (10p12.1) was significantly more common in the relapse group than the non-relapse group (35 vs 5%, P=0.03).

CONCLUSIONS

This study demonstrates significant association between AI on chromosome 10 and biochemical progression after radical prostatectomy.

Evidence to Support a Continued Stage Migration and Decrease in Prostate Cancer Specific Mortality

PURPOSE

We evaluated whether the proportion of patients with a postoperative PSA-DT less than 3 months, a surrogate for PCSM, decreased significantly during the PSA era.

MATERIALS AND METHODS

Between July 1988 and July 2002, 3,719 men with clinically localized prostate cancer treated with RP comprised the study cohort. A chi-square metric was used to compare the preoperative and postoperative characteristics, 5-year actual PSA failure rates, and PSA-DTs for patients treated during the 2 equally divided eras of the early PSA era, July 1988 to July 1995 and the late PSA era, August 1995 to July 2002.

RESULTS

Patients presenting in the more recent PSA era were of younger age (p < 0.0001), with earlier stage (p < 0.0001) and lower grade disease (p = 0.01). Similarly, patients had lower grade (p < 0.001), stage (p < 0.0001), and positive margin (p < 0.0001) and lymph node rates (p = 0.0002) at RP. The 5-year actual PSA failure rates decreased from 14.3% in the early PSA era to 2.5% in the later PSA era (p < 0.0001). There was a 37% reduction in the proportion of patients with a PSA-DT less than 3 months, corresponding to a decrease in absolute magnitude from 9% to 5.7% between the 2 eras. Absolute reductions of 3.1% and 9% were also noted for the proportion of PSA-DTs of 3 to 5.99 months and 6 to 11.99 months, respectively, whereas PSA-DTs of 12 months or greater increased by 15.3%.

CONCLUSIONS

During the recent PSA era, postoperative PSA failure has significantly decreased and PSA-DTs have increased, suggesting that PCSM will continue to decrease.

Chemotherapy for prostate cancer: implementing early systemic therapy to improve outcomes

Prostate cancer remains a significant health concern for men in the USA as it is a leading cancer diagnosis and a cause of death. With the use of prostate-specific antigen or screening, a stage migration has occurred with an increase in the number of men diagnosed with early-stage disease. The optimal primary management of these men is evolving, but despite adequate local treatment a significant percentage will develop either biochemical or clinical evidence of recurrent disease. Several criteria for risk stratification have been developed, thus, improving the ability to identify a high-risk population. Small studies have been reported demonstrating the feasibility of neoadjuvant or adjuvant chemotherapy in conjunction with either radiation or radical prostatectomy in this high-risk population, and large phase III studies are ongoing. With the advent of life-prolonging chemotherapy in the hormone-refractory setting, attention must now also be given to early-stage disease so as to develop multi-modality approaches with the hope of increasing survival and ultimately providing a cure.