International Society of Urological Pathology (ISUP) Consensus Conference on Handling and Staging of Radical Prostatectomy Specimens. Working group 2: T2 substaging and prostate cancer volume

Predicting Gleason score using the initial serum total prostate-specific antigen in Black men with symptomatic prostate adenocarcinoma in Nigeria

Background

Men of Black African descent are known to have the highest incidence of prostate cancer. The disease is also more aggressive in this group possibly due to biologically more aggressive tumor or late presentation. Currently, serum prostate-specific antigen (PSA) assay plays a significant role in making the diagnosis of prostate cancer. However, the obtained value of serum PSA may not directly relate with the Gleason score (GS), a measure of tumor aggression in prostate cancer. This study explores the relationship between serum total PSA at presentation (iPSA) and GS.

Patients and methods

The iPSA of patients with histologically confirmed prostate cancer was compared with the obtained GS of the prostate biopsy specimens. The age of the patients at presentation and the prostate volumes were also analyzed with respect to the iPSA and GS. The data were analyzed retrospectively using IBM SPSS Version 20. Pearson correlation was used for numeric variables, whereas Fisher’s exact test was used for categorical variables. Significance was set at P≤0.05.

Results

There were 205 patients from January 2010 to November 2013 who satisfied the inclusion criteria. iPSA as well as age at presentation and prostate volume were not found to significantly correlate with the primary Gleason grade, the secondary Gleason grade, or the GS. However, the presence of distant metastasis was identified to significantly correlate positively with GS.

Conclusion

GS may not be confidently predicted by the iPSA. Higher iPSA does not correlate with higher GS and vice versa.

Staging of prostatic carcinoma at 1.5-T MRI: correlation of a simplified MRI exam with whole-mount radical prostatectomy specimens

OBJECTIVE

To retrospectively analyze the accuracy of simplified multiparametric MRI at 1.5 T for local staging by using whole-mount-section histopathological analysis as the standard of reference.

METHODS

123 consecutive patients underwent T2 weighted, T1 weighted and diffusion-weighted MRI without endorectal coil prior to radical prostatectomy. The accuracy of predicting extracapsular extension (ECE) (T3a) was assessed using direct signs or the combination of direct and indirect signs of extraprostatic extension. The accuracy of predicting seminal vesicle invasion (T3b) was evaluated, taking into account different routes of seminal vesicle involvement. Finally, adjacent organ invasion (T4) was evaluated in this patient population.

RESULTS

Histopathology showed T3a, T3b and T4 in 61, 28 and 9 cases, respectively. The use of direct signs of extraprostatic extension showed a sensitivity of 57.4% and specificity of 91.9%. The combination of direct signs and indirect signs improved sensitivity (85.2%) at the expense of moderate loss of specificity (83.9%). MR sensitivity for the detection of seminal vesicle invasion was low (53.6%); however, it was dependent on the route of seminal vesicle tumour infiltration. MR sensitivity and specificity for adjacent organ invasion were 88.9% and 99.1%.

CONCLUSION

Simplified MRI study at 1.5 T provides a relatively high sensitivity for detecting ECE (T3a) when using the combination of indirect and direct signs. However, this high sensitivity reading is at the cost of a moderate loss of specificity. Invasion of the seminal vesicles (T3b) occurs most often along the ejaculatory duct complex with low MR sensitivity.

ADVANCES IN KNOWLEDGE

Simplified MRI study at 1.5 T without endorectal coil could be used for the local T staging of prostate cancer.

Ablative therapy for people with localised prostate cancer: a systematic review and economic evaluation

BACKGROUND

For people with localised prostate cancer, active treatments are effective but have significant side effects. Minimally invasive treatments that destroy (or ablate) either the entire gland or the part of the prostate with cancer may be as effective and cause less side effects at an acceptable cost. Such therapies include cryotherapy, high-intensity focused ultrasound (HIFU) and brachytherapy, among others.

OBJECTIVES

This study aimed to determine the relative clinical effectiveness and cost-effectiveness of ablative therapies compared with radical prostatectomy (RP), external beam radiotherapy (EBRT) and active surveillance (AS) for primary treatment of localised prostate cancer, and compared with RP for salvage treatment of localised prostate cancer which has recurred after initial treatment with EBRT.

DATA SOURCES

MEDLINE (1946 to March week 3, 2013), MEDLINE In-Process & Other Non-Indexed Citations (29 March 2013), EMBASE (1974 to week 13, 2013), Bioscience Information Service (BIOSIS) (1956 to 1 April 2013), Science Citation Index (1970 to 1 April 2013), Cochrane Central Register of Controlled Trials (CENTRAL) (issue 3, 2013), Cochrane Database of Systematic Reviews (CDSR) (issue 3, 2013), Database of Abstracts of Reviews of Effects (DARE) (inception to March 2013) and Health Technology Assessment (HTA) (inception to March 2013) databases were searched. Costs were obtained from NHS sources.

REVIEW METHODS

Evidence was drawn from randomised controlled trials (RCTs) and non-RCTs, and from case series for the ablative procedures only, in people with localised prostate cancer. For primary therapy, the ablative therapies were cryotherapy, HIFU, brachytherapy and other ablative therapies. The comparators were AS, RP and EBRT. For salvage therapy, the ablative therapies were cryotherapy and HIFU. The comparator was RP. Outcomes were cancer related, adverse effects (functional and procedural) and quality of life. Two reviewers extracted data and carried out quality assessment. Meta-analysis used a Bayesian indirect mixed-treatment comparison. Data were incorporated into an individual simulation Markov model to estimate cost-effectiveness.

RESULTS

The searches identified 121 studies for inclusion in the review of patients undergoing primary treatment and nine studies for the review of salvage treatment. Cryotherapy [3995 patients; 14 case series, 1 RCT and 4 non-randomised comparative studies (NRCSs)], HIFU (4000 patients; 20 case series, 1 NRCS) and brachytherapy (26,129 patients; 2 RCTs, 38 NRCSs) studies provided limited data for meta-analyses. All studies were considered at high risk of bias. There was no robust evidence that mortality (4-year survival 93% for cryotherapy, 99% for HIFU, 91% for EBRT) or other cancer-specific outcomes differed between treatments. For functional and quality-of-life outcomes, the paucity of data prevented any definitive conclusions from being made, although data on incontinence rates and erectile dysfunction for all ablative procedures were generally numerically lower than for non-ablative procedures. The safety profiles were comparable with existing treatments. Studies reporting the use of focal cryotherapy suggested that incontinence rates may be better than for whole-gland treatment. Data on AS, salvage treatment and other ablative therapies were too limited. The cost-effectiveness analysis confirmed the uncertainty from the clinical review and that there is no technology which appears superior, on the basis of current evidence, in terms of average cost-effectiveness. The probabilistic sensitivity analyses suggest that a number of ablative techniques are worthy of further research.

LIMITATIONS

The main limitations were the quantity and quality of the data available on cancer-related outcomes and dysfunction.

CONCLUSIONS

The findings indicate that there is insufficient evidence to form any clear recommendations on the use of ablative therapies in order to influence current clinical practice. Research efforts in the use of ablative therapies in the management of prostate cancer should now be concentrated on the performance of RCTs and the generation of standardised outcomes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002461.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Assessment of the circumferential margins, extraprostatic extension and Gleason score in radical prostatectomy specimens: Comparison of a partial embedding method with supplemental total inclusion of peripheral tissues

BACKGROUND

Recent data suggest that up to 21% of positive circumferential margins (PCM) and 47% of extraprostatic extension (EPE) samples may be missed when partial embedding methods are employed. Kim and colleagues (2009) suggested that total inclusion of the periphery (3mm rim) of the prostate prevented the failure to detect PCM and EPE.

DESIGN

Radical prostatectomy specimen (n=148) slides were reviewed after adoption of a protocol that included a ∼3 mm rim of peripheral tissues. We evaluated whether the analysis of supplemental slides of prostate periphery changed margin status, presence of EPE, Gleason score and extent of PCM and EPE.

RESULTS

Partial sampling resulted in missing 29% of PCM and 20% of EPE without using data from the supplemental slides of prostate periphery. Changes from focal to extensive disease were found in 11/21 (52%) cases of positive circumferential margins and in 5/13 (38%) cases of extraprostatic extension. Changes in the Gleason score were uncommon.

CONCLUSIONS

These results indicate the importance of including all the prostate peripheral tissue for microscopic analysis when partial embedding methods are adopted.

[Analysis and prognostic factors of the specimen of radical prostatectomy in prostate cancer]

OBJECTIVES

Handling and pathologic analysis of radical prostatectomy specimens are crucial to confirm the diagnosis of prostate cancer and evaluate prognostic criteria.

MATERIAL AND METHODS

A systematic review of the scientific literature was performed in the Medline database (PubMed), using different associations of the following keywords: prostate cancer; prostatectomy; specimen; handling; pathology; tumor staging; Gleason score; surgical margin; prognosis; frozen section; lymph node; biomarkers. A particular search was done on specimen management and characterization of tissue prognostic factors.

RESULTS

Handling of both radical prostatectomy specimen and lymph node dissection is standardized according to international criteria. Although the main histoprognostic factors are still Gleason score, pathologic staging and margin status, these criteria have been refined these last 10 years, allowing to improve the prediction of relapse after surgical treatment.

CONCLUSION

The standardization of handling and pathology reporting of radical prostatectomy specimens will be mandatory for treatment uniformization according to risk stratification in prostate cancer and personalization of therapeutic approaches.

Size-adjusted Quantitative Gleason Score as a Predictor of Biochemical Recurrence after Radical Prostatectomy

BACKGROUND

The risk of biochemical recurrence (BCR) following radical prostatectomy for pathologic Gleason 7 prostate cancer varies according to the proportion of Gleason 4 component.

OBJECTIVE

We sought to explore the value of several novel quantitative metrics of Gleason 4 disease for the prediction of BCR in men with Gleason 7 disease.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed a cohort of 2630 radical prostatectomy cases from 1990-2007. All pathologic Gleason 7 cases were identified and assessed for quantity of Gleason pattern 4. Three methods were used to quantify the extent of Gleason 4: a quantitative Gleason score (qGS) based on the proportion of tumor composed of Gleason pattern 4, a size-weighted score (swGS) incorporating the overall quantity of Gleason 4, and a size index (siGS) incorporating the quantity of Gleason 4 based on the index lesion.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Associations between the above metrics and BCR were evaluated using Cox proportional hazards regression analysis.

RESULTS AND LIMITATIONS

qGS, swGS, and siGS were significantly associated with BCR on multivariate analysis when adjusted for traditional Gleason score, age, prostate specific antigen, surgical margin, and stage. Using Harrell's c-index to compare the scoring systems, qGS (0.83), swGS (0.84), and siGS (0.84) all performed better than the traditional Gleason score (0.82).

CONCLUSIONS

Quantitative measures of Gleason pattern 4 predict BCR better than the traditional Gleason score.

PATIENT SUMMARY

In men with Gleason 7 prostate cancer, quantitative analysis of the proportion of Gleason pattern 4 (quantitative Gleason score), as well as size-weighted measurement of Gleason 4 (size-weighted Gleason score), and a size-weighted measurement of Gleason 4 based on the largest tumor nodule significantly improve the predicted risk of biochemical recurrence compared with the traditional Gleason score.

In-parallel comparative evaluation between multiparametric magnetic resonance imaging, prostate cancer antigen 3 and the prostate health index in predicting pathologically confirmed significant prostate cancer in men eligible for active surveillance

OBJECTIVE

To assess the performance capabilities of multiparametric magnetic resonance imaging (mpMRI), the prostate health index (PHI) and prostate cancer antigen 3 (PCA3) in predicting the presence of pathologically confirmed significant prostate cancer (PCSPCa), according to the European Randomized Study of Screening Prostate Cancer definition, in a single cohort of patients who underwent radical prostatectomy (RP) but who were eligible for active surveillance (AS).

MATERIALS AND METHODS

An observational retrospective study was performed in 120 patients with prostate cancer (PCa), treated with robot-assisted RP but eligible for AS according to Prostate Cancer Research International: Active Surveillance criteria. Blood and urine specimens were collected before initial prostate biopsy for PHI and PCA3 measurements, respectively. In addition, all patients underwent mpMRI, preoperatively and 6-8 weeks after biopsy, with a 1.5T scanner using a four-to-five-channel phase array coil combined with an endorectal coin. mpMRI images were assessed and diagrams showing the prostate sextants were used to designate regions of abnormality within the prostate. Prostate findings were assigned to one of five categories according to Prostate Imaging-Reporting and Data System guidelines (PI-RADS) and considered positive for PCa if final PI-RADS score was >3 and negative if ≤3.

RESULTS

Pathologically confirmed reclassification was observed in 55 patients (45.8%). mpMRI showed good specificity and negative predictive value (0.61 and 0.73, respectively) for excluding PCSPCa compared with the PHI and PCA3. On multivariate analyses and after 1 000 bootstrapping resampling, the inclusion of both mpMRI and the PHI significantly increased the accuracy of the base model in predicting PCSPCa. For the prediction of PCSPCa, in particular, the base model had an area under the curve (AUC) of 0.71 which significantly increased by 4% with the addition of the PHI (AUC = 0.75; P < 0.01) and by 7% with the addition of mpMRI (AUC = 0.78; P < 0.01). Decision-curve analysis showed that the multivariable model with mpMRI had the highest net benefit.

CONCLUSION

In a single cohort of patients who underwent RP but who were eligible for AS, mpMRI and, to a lesser extent, the PHI, had an important role in discriminating the presence of PCSPCa; both measures could therefore be useful in the selection and monitoring of patients undergoing AS.

Predicting Pathological Features at Radical Prostatectomy in Patients with Prostate Cancer Eligible for Active Surveillance by Multiparametric Magnetic Resonance Imaging

PURPOSE

The aim of this study was to investigate the prognostic performance of multiparametric magnetic resonance imaging (mpMRI) and Prostate Imaging Reporting and Data System (PIRADS) score in predicting pathologic features in a cohort of patients eligible for active surveillance who underwent radical prostatectomy.

METHODS

A total of 223 patients who fulfilled the criteria for "Prostate Cancer Research International: Active Surveillance", were included. Mp-1.5 Tesla MRI examination staging with endorectal coil was performed at least 6-8 weeks after TRUS-guided biopsy. In all patients, the likelihood of the presence of cancer was assigned using PIRADS score between 1 and 5. Outcomes of interest were: Gleason score upgrading, extra capsular extension (ECE), unfavorable prognosis (occurrence of both upgrading and ECE), large tumor volume (≥ 0.5 ml), and seminal vesicle invasion (SVI). Receiver Operating Characteristic (ROC) curves and Decision Curve Analyses (DCA) were performed for models with and without inclusion of PIRADS score.

RESULTS

Multivariate analysis demonstrated the association of PIRADS score with upgrading (P < 0.0001), ECE (P < 0.0001), unfavorable prognosis (P < 0.0001), and large tumor volume (P = 0.002). ROC curves and DCA showed that models including PIRADS score resulted in greater net benefit for almost all the outcomes of interest, with the only exception of SVI.

CONCLUSIONS

mpMRI and PIRADS scoring are feasible tools in clinical setting and could be used as decision-support systems for a more accurate selection of patients eligible for AS.

Preoperative erectile function and the pathologic features of prostate cancer

Purpose

We evaluated whether preoperative erectile function is associated with pathologic features in the patients who underwent radical prostatectomy (RP).

Materials and Methods

We reviewed medical records of 1,743 men who underwent RP from November 2003 through May 2012. Of these, 50 patients who had prior hormone therapy and 272 patients who had lacking data of International Index of Erectile Function-5 (IIEF-5) were excluded. Men whose IIEF-5 was in the lower 25 percentile were assigned as Low Erectile Function group and the others were assigned as Control group. We compared pathologic features using univariable and multivariable logistic regression analysis between two groups.

Results

A total of 1,421 patients were included in the analysis. Patients’ age was 65.8 ± 6.7 years and prostate-specific antigen (PSA) was 12.8±16.1 ng/mL. Median and low 25 percentile of IIEF-5 were 14 and 8, respectively. Low Erectile Function group (IIEF-5<8) had higher risk to have high Gleason score (≥7(4+3), odds ratio (OR) 1.642, p<0.001) and large tumor volume (≥5 mL, OR 1.292, p=0.042). Even after adjusting age, year of surgery, body mass index, Charlson comorbidity index, PSA, clinical stage and biopsy Gleason score, Low Erectile Function group still had higher risk of high Gleason score (OR 1.910, p<0.001) and large tumor volume (OR 1.390, p=0.04) by multivariable logistic regressions.

Conclusions

Lower erectile function before RP was associated with higher Gleason’s score and larger tumor volume in final pathology. Thus, erectile function could be a surrogate barometer for prostate cancer aggressiveness.

PI-RADS Prostate Imaging - Reporting and Data System: 2015, Version 2

The Prostate Imaging - Reporting and Data System Version 2 (PI-RADS™ v2) is the product of an international collaboration of the American College of Radiology (ACR), European Society of Uroradiology (ESUR), and AdMetech Foundation. It is designed to promote global standardization and diminish variation in the acquisition, interpretation, and reporting of prostate multiparametric magnetic resonance imaging (mpMRI) examination, and it is based on the best available evidence and expert consensus opinion. It establishes minimum acceptable technical parameters for prostate mpMRI, simplifies and standardizes terminology and content of reports, and provides assessment categories that summarize levels of suspicion or risk of clinically significant prostate cancer that can be used to assist selection of patients for biopsies and management. It is intended to be used in routine clinical practice and also to facilitate data collection and outcome monitoring for research.

PHI and PCA3 improve the prognostic performance of PRIAS and Epstein criteria in predicting insignificant prostate cancer in men eligible for active surveillance

PURPOSE

To assess the performance of prostate health index (PHI) and prostate cancer antigen 3 (PCA3) when added to the PRIAS or Epstein criteria in predicting the presence of pathologically insignificant prostate cancer (IPCa) in patients who underwent radical prostatectomy (RP) but eligible for active surveillance (AS).

METHODS

An observational retrospective study was performed in 188 PCa patients treated with laparoscopic or robot-assisted RP but eligible for AS according to Epstein or PRIAS criteria. Blood and urinary specimens were collected before initial prostate biopsy for PHI and PCA3 measurements. Multivariate logistic regression analyses and decision curve analysis were carried out to identify predictors of IPCa using the updated ERSPC definition.

RESULTS

At the multivariate analyses, the inclusion of both PCA3 and PHI significantly increased the accuracy of the Epstein multivariate model in predicting IPCa with an increase of 17 % (AUC = 0.77) and of 32 % (AUC = 0.92), respectively. The inclusion of both PCA3 and PHI also increased the predictive accuracy of the PRIAS multivariate model with an increase of 29 % (AUC = 0.87) and of 39 % (AUC = 0.97), respectively. DCA revealed that the multivariable models with the addition of PHI or PCA3 showed a greater net benefit and performed better than the reference models. In a direct comparison, PHI outperformed PCA3 performance resulting in higher net benefit.

CONCLUSIONS

In a same cohort of patients eligible for AS, the addition of PHI and PCA3 to Epstein or PRIAS models improved their prognostic performance. PHI resulted in greater net benefit in predicting IPCa compared to PCA3.

Influence of pathological factors on oncological outcomes after robot-assisted radical prostatectomy for localized prostate cancer: Results of a prospective study

PURPOSE

To assess the prognostic significance of lymphovascular invasion (LVI), maximum tumor diameter (MTD), high-grade prostatic intraepithelial neoplasia, perineural invasion, and length of positive surgical margins after robot-assisted radical prostatectomy (RARP).

METHODS

A single-institution prospective analysis of all patients who underwent RARP for localized prostate cancer was performed between January 2005 and June 2013. The primary end point was biochemical recurrence-free survival (BRFS). BRFS was estimated using the Kaplan-Meier method and compared to that from the log-rank test. Cox׳s proportional hazards regression univariate and multivariate analyses were performed to define the prognostic factors.

RESULTS

Overall, 742 men were included. After a median follow-up of 31.4 months, biochemical recurrence occurred in 80 patients (10.8%). BRFS was 93%, 87%, and 80.7% at 1, 3, and 5 years, respectively. Progression to local recurrence occurred in 49 patients (6.6%). During the follow-up period, 3 patients experienced progression to metastatic disease and were treated with hormonotherapy. No patient died of disease during the study period. In multivariate analyses, Gleason score was the strongest predictor of BRFS (hazard ratio [HR] = 3.4; P<0.001). There were 3 other predictive factors of BRFS were LVI (HR = 7.64; P = 0.005), MTD (HR = 4.04; P =0.009), and margin length ≥ 3 mm (HR = 1.25; P = 0.04).

CONCLUSION

In the era of serum prostate-specific antigen testing maturity in conjunction with a single approach to extirpation of the prostate gland by RARP, LVI, MTD, and positive surgical margins ≥ 3 mm are prognostic factors associated with BRFS after RARP. Consideration could be given to incorporate them in the pathology report of the radical prostatectomy specimens and they could assist physicians in clinical decision making.

A Randomized Controlled Trial To Assess and Compare the Outcomes of Two-core Prostate Biopsy Guided by Fused Magnetic Resonance and Transrectal Ultrasound Images and Traditional 12-core Systematic Biopsy

BACKGROUND

Prostate biopsy guided by computer-assisted fusion of magnetic resonance imaging (MRI) and transrectal ultrasound (TRUS) images (MRI group) has not yet been compared with 12-core random biopsy (RB; control group) in a randomized controlled trial (RCT).

OBJECTIVE

To compare the rate of detection of clinically significant prostate cancer (csPCa) between the two groups.

DESIGN, SETTING, AND PARTICIPANTS

This RCT included 175 biopsy-naïve patients with suspicion for prostate cancer, randomized to an MRI group (n=86) and a control group (n=89) between September 2011 and June 2013.

INTERVENTION

In the MRI group, two-core targeted biopsy (TB) guided by computer-assisted fusion of MRI/TRUS images of MRI-suspicious lesions was followed by 12-core RB. In the control group, both two-core TB for abnormal digital rectal examination (DRE) and/or TRUS-suspicious lesions and 12-core RB were performed. In patients with normal MRI or DRE/TRUS, only 12-core RB was performed.

OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS

The detection rates for any cancer and csPCa were compared between the two groups and between TB and RB.

RESULTS AND LIMITATIONS

Detection rates for any cancer (MRI group 51/86, 59%; control group 48/89, 54%; p=0.4) and csPCa (38/86, 44% vs 44/89, 49%; p=0.5) did not significantly differ between the groups. Detection of csPCa was comparable between two-core MRI/TRUS-TB (33/86, 38%) and 12-core RB in the control group (44/89, 49%; p=0.2). In a subset analysis of patients with normal DRE, csPCa detection was similar between two-core MRI/TRUS-TB (14/66, 21%) and 12-core RB in the control group (15/60, 25%; p=0.7). Among biopsy-proven csPCas in MRI group, 87% (33/38) were detected by MRI/TRUS-TB. The definition of csPCa was only based on biopsy outcomes.

CONCLUSION

Overall csPCa detection was similar between the MRI and control groups. Two-core MRI/TRUS-TB was comparable to 12-core RB for csPCa detection.

PATIENT SUMMARY

Our randomized controlled trial revealed a similar rate of prostate cancer detection between targeted biopsy guided by magnetic resonance imaging (MRI) and transrectal ultrasound (TRUS) and 12-core random biopsy. The traditional 12-core random biopsy may be replaced by two-core MRI/TRUS targeted biopsy for detection of clinically significant prostate cancer.

1.5-T multiparametric MRI using PI-RADS: a region by region analysis to localize the index-tumor of prostate cancer in patients undergoing prostatectomy

BACKGROUND

The use of multiparametric magnetic resonance imaging (mpMRI) to detect and localize prostate cancer has increased in recent years. In 2010, the European Society of Urogenital Radiology (ESUR) published guidelines for mpMRI and introduced the Prostate Imaging Reporting and Data System (PI-RADS) for scoring the different parameters.

PURPOSE

To evaluate the reliability and diagnostic performance of endorectal 1.5-T mpMRI using the PI-RADS to localize the index tumor of prostate cancer in patients undergoing prostatectomy.

MATERIAL AND METHODS

This institutional review board IRB-approved, retrospective study included 63 patients (mean age, 60.7 years, median PSA, 8.0). Three observers read mpMRI parameters (T2W, DWI, and DCE) using the PI-RADS, which were compared with the results from whole-mount histopathology that analyzed 27 regions of interest. Inter-observer agreement was calculated as well as sensitivity, specificity, positive predictive value (PPV), and negative predicted value (NPV) by dichotomizing the PI-RADS criteria scores ≥3. A receiver-operating curve (ROC) analysis was performed for the different MR parameters and overall score.

RESULTS

Inter-observer agreement on the overall score was 0.41. The overall score in the peripheral zone achieved sensitivities of 0.41, 0.60, and 0.55 with an NPV of 0.80, 0.84, and 0.83, and in the transitional zone, sensitivities of 0.26, 0.15, and 0.19 with an NPV of 0.92, 0.91, and 0.92 for Observers 1, 2, and 3, respectively. The ROC analysis showed a significantly increased area under the curve (AUC) for the overall score when compared to T2W alone for two of the three observers.

CONCLUSION

1.5 T mpMRI using the PI-RADS to localize the index tumor achieved moderate reliability and diagnostic performance.

Is pilates as effective as conventional pelvic floor muscle exercises in the conservative treatment of post-prostatectomy urinary incontinence? A randomised controlled trial

AIMS

To verify the efficacy of a Pilates exercise program compared to conventional pelvic floor muscle exercise (PFME) protocol in the conservative treatment of post-prostatectomy urinary incontinence (PPUI).

METHODS

Baseline assessment was performed four weeks postoperatively and included 24 hr pad test, bladder diary, and the ICIQ-SF. Patients were randomised into three groups: Pilates (G1), PFME combined with anal electrical stimulation (G2), and a control group (G3). Both treatment groups had to perform 10 weekly treatment sessions. Primary outcomes were mean reduction of daily pads and mean reduction of ICIQ-SF score four months after surgery. The significance level was set at P < 0.05.

RESULTS

85 patients completed the study. Differences between treatment groups (G1 and G2) in terms of mean reduction in daily pad usage, 24 hr pad test, and ICIQ-SF scores were not statistically significant (P > 0.05). The control group differed from G1 in daily pad usage (P = 0.01) and ICIQ-SF score (P = 0.0073). Intergroup comparisons revealed that 57.7% of the volunteers in G1 and 50% of the individuals from G2 no longer used pads by the end of the treatment period (P = 0.57). In the control group, 22.6% were not using pads four months after surgery, with statistical difference compared to G1 (P < 0.05).

CONCLUSIONS

The Pilates exercise program proved to be as effective as conventional PFME to speed up continence recovery in PPUI. It also achieved a higher rate of fully continent patients when compared to the control group in the short-term. Neurourol. Urodynam. 35:615-621, 2016. © 2015 Wiley Periodicals, Inc.

Variation between specialist uropatholgists in reporting extraprostatic extension after radical prostatectomy

Aims

Extraprostatic extension of prostate cancer in radical prostatectomy specimens significantly affects patient management. We evaluated the degree of interobserver variation between uropathologists at a tertiary referral teaching hospital in assessing the extraprostatic extension of prostate cancer in radical prostatectomy specimens.

Methods

Histopathological data from a consecutive series of 293 radical prostatectomy specimens (January 2007–December 2012) were reviewed. A subset of 50 consecutive radical prostatectomy cases originally staged as tumours confined to the prostate (pT2) or tumours extending into periprostatic tissue (pT3a) during this period were reviewed by four specialist uropathologists.

Results

Five consultant histopathologists reported these specimens with significant differences in the reported stage (p=0.0164) between pathologists. Double-blind review by 4 uropathologists of 50 consecutive radical prostatectomy cases showed a lack of consensus in 16/50 (32%) cases (κ score 0.58, moderate agreement). A consensus meeting was held, but consensus could still not be reached in 9/16 cases.

Conclusions

Our findings highlight variability in the reporting of pT stage in radical prostatectomy specimens even by specialist uropathologists. Assessment of extraprostatic extension has important implications for patient management and there is a need for more precise guidance.

Detection of the index tumour and tumour volume in prostate cancer using T2-weighted and diffusion-weighted magnetic resonance imaging (MRI) alone

OBJECTIVE

To examine the performance of T2-weighted (T2W) and diffusion-weighted (DW) magnetic resonance imaging (MRI) for detecting the index tumour in patients with prostate cancer and to examine the agreement between MRI and histology when assessing tumour volume (TV) and overall tumour burden.

PATIENTS AND METHODS

The study included 199 consecutive patients with biopsy confirmed prostate cancer randomised to MRI before radical prostatectomy from December 2009 to July 2012. MRI-detected tumours (MRTs) were ranked from 1 to 3 according to decreasing volume and were compared with histologically detected tumours (HTs) ranked from 1 to 3, with HT 1 = index tumour. Whole-mount section histology was used as a reference standard. The TVs of true-positive MRTs (MRTVs 1-3) were compared with the TVs found by histology (HTVs 1-3). All tumours were registered on a 30-sector map and by classifying each sector as positive/negative, the rate of true-positive and -negative sectors was calculated.

RESULTS

The detection rate for the HT 1 (index tumour) was 92%; HT 2, 45%; and HT 3, 37%. The MRTV 1-3 vs the HTV 1-3 were 2.8 mL vs 4.0 mL (index tumour, P < 0.001), 1.0 mL vs 0.9 mL (tumour 2, P = 0.413), and 0.6 mL vs 0.5 mL (tumour 3, P = 0.492). The rate of true-positive and -negative sectors was 50% and 88%, κ = 0.39.

CONCLUSION

A combination of T2W and DW MRI detects the index tumour in 92% of cases, although MRI underestimates both TV and tumour burden compared with histology.

Current practice in handling and reporting prostate needle biopsies: results of a Turkish survey

BACKGROUND

In 2005 ISUP (International Society of Urological Pathology) consensus revised the Gleason grading system.

METHOD

We conducted a web based national survey of the members of Uropathology Working Group (WG) and general pathologists (NWP) to investigate the current practice in reporting prostate needle biopsies.

RESULTS

The revised system was well known and applied by the respondents. In pattern analysis major difference was detected in reporting medium sized, regular cribriform glands. In both group this pattern was reported as Gleason Pattern (GP) 3 by at least 50% of the repliers, the rest reported this pattern as GP 4. Gleason Score (GS) 2-4 was not reported by the WG. In NWP GS 2-4 was reported by 25% either frequently of infrequently. Any amount of secondary higher grade was included in GS by 92.5% of WG and 70% of NWP (p<0.05). Five percent cut off was requested for the lower secondary grade by 71.4% of WG but 64% of NWP. (p<0.05) Tertiary pattern was reported by 64.5% of WG and 34% of NWP (p<0.05). Individual GS was assigned for each core by 46.4% of WG and 26.5% of NWP (p<0.05). When measuring the extend of cancer, most included the benign tissue between cancer foci in the same core. Fat invasion was interpreted as extraprostatic invasion by 85.7% of WG and 55.9%of NWP (p<0.05).

CONCLUSION

This study showed the specific points where the educational efforts should be focused to have a better and standardized practice pattern of pathologists when reporting prostate biopsies.

Prognostic accuracy of Prostate Health Index and urinary Prostate Cancer Antigen 3 in predicting pathologic features after radical prostatectomy

OBJECTIVE

To compare the prognostic accuracy of Prostate Health Index (PHI) and Prostate Cancer Antigen 3 in predicting pathologic features in a cohort of patients who underwent radical prostatectomy (RP) for prostate cancer (PCa).

METHODS AND MATERIALS

We evaluated 156 patients with biopsy-proven, clinically localized PCa who underwent RP between January 2013 and December 2013 at 2 tertiary care institutions. Blood and urinary specimens were collected before initial prostate biopsy for [-2] pro-prostate-specific antigen (PSA), its derivates, and PCA3 measurements. Univariate and multivariate logistic regression analyses were carried out to determine the variables that were potentially predictive of tumor volume > 0.5 ml, pathologic Gleason sum ≥ 7, pathologically confirmed significant PCa, extracapsular extension, and seminal vesicles invasions.

RESULTS

On multivariate analyses and after bootstrapping with 1,000 resampled data, the inclusion of PHI significantly increased the accuracy of a baseline multivariate model, which included patient age, total PSA, free PSA, rate of positive cores, clinical stage, prostate volume, body mass index, and biopsy Gleason score (GS), in predicting the study outcomes. Particularly, to predict tumor volume > 0.5, the addition of PHI to the baseline model significantly increased predictive accuracy by 7.9% (area under the receiver operating characteristics curve [AUC] = 89.3 vs. 97.2, P>0.05), whereas PCA3 did not lead to a significant increase. Although both PHI and PCA3 significantly improved predictive accuracy to predict extracapsular extension compared with the baseline model, achieving independent predictor status (all P's < 0.01), only PHI led to a significant improvement in the prediction of seminal vesicles invasions (AUC = 92.2, P < 0.05 with a gain of 3.6%). In the subset of patients with GS ≤ 6, PHI significantly improved predictive accuracy by 7.6% compared with the baseline model (AUC = 89.7 vs. 97.3) to predict pathologically confirmed significant PCa and by 5.9% compared with the baseline model (AUC = 83.1 vs. 89.0) to predict pathologic GS ≥ 7. For these outcomes, PCA3 did not add incremental predictive value.

CONCLUSIONS

In a cohort of patients who underwent RP, PHI is significantly better than PCA3 in the ability to predict the presence of both more aggressive and extended PCa.

The tumour hypoxia marker pimonidazole reflects a transcriptional programme associated with aggressive prostate cancer

Background:

The hypoxia marker pimonidazole is a candidate biomarker of cancer aggressiveness. We investigated the transcriptional programme associated with pimonidazole staining in prostate cancer.

Methods:

Index tumour biopsies were taken by image guidance from an investigation cohort of 52 patients, where 43 patients received pimonidazole before prostatectomy. Biopsy location within the index tumour was verified for 46 (88%) patients, who were included for gene expression profiling and immunohistochemistry. Two independent cohorts of 59 and 281 patients were used for validation.

Results:

Expression of genes in proliferation, DNA repair and hypoxia response was a major part of the transcriptional programme associated with pimonidazole staining. A signature of 32 essential genes was constructed and showed positive correlation to Ki67 staining, confirming the increased proliferation in hypoxic tumours as suggested from the gene data. Positive correlations were also found to tumour stage and lymph node status, but not to blood prostate-specific antigen level, consistent with the findings for pimonidazole staining. The association with aggressiveness was confirmed in validation cohorts, where the signature correlated with Gleason score and had independent prognostic impact, respectively.

Conclusions:

Pimonidazole staining reflects an aggressive hypoxic phenotype of prostate cancer characterised by upregulation of proliferation, DNA repair and hypoxia response genes.

Impact of barbed suture in controlling the dorsal vein complex during laparoscopic radical prostatectomy

OBJECTIVE

To compare applications of unidirectional knotless barbed suture and traditional two single polyglactin sutures for dorsal vein complex (DVC) control during laparoscopic radical prostatectomy (LRP).

MATERIAL AND METHODS

This was a non-randomized, prospective matched-pair pilot study. Thirty-one LRP cases with barbed suture (V-Loc®) were match-paired with 31 LRP cases in which traditional two single polyglactin stitches according to patient's prostate volume and body mass index (BMI) were used. Time needed for DVC ligation, DVC control and operation time were recorded. Peri- and postoperative parameters were noted. Statistical analyses were performed.

RESULTS

Mean age was 65.4±6.3 years. Mean follow-up was 20.2±3.3 months. Mean BMI and prostate volume were similar in both groups. Mean preoperative clinical stage, Gleason score, and PSA were comparable between both groups. Mean DVC ligature time and mean DVC controlling time in group 1 were statistically shorter than in group 2 (p=0.04, p<0.001). Continence rates were significantly higher in group 1 than in group 2 in early follow-up (p=0.005).

Are active surveillance criteria sufficient for predicting advanced stage prostate cancer patients?

OBJECTIVES

To examine the treatment outcomes of the prostate cancer (PCa) patients treated by radical prostatectomy (RP) who could be good candidates for active surveillance (AS) and test the confidence and reliability of the AS criterias for predicting advanced stage disease (RP Gleason score≥7 or Pathological stage T3).

METHODS

Between 2005 and 2012 the records of the 401 patients who underwent RP with a diagnosis of PCa were examined. Of these patients, 173 were found to be candidates of AS. The inclusion criteria were as follows; clinical stage T2a or less, PSA<10ng/ml, 2 or fewer cores involved with cancer, no single core with 50% or greater maximum involvement of cancer, and no Gleason grade greater than 3 in the specimen.

RESULTS

Univariate analyzes revealed that patients with advanced stage disease have higher prostate specific antigen density (PSAD), higher maximum percent (max%) in positive cores and higher RP tumor volumes. In multivariate analyzes PSAD, max% in positive cores and RP tumor volumes were statistically significant determinants for advanced stage disease. ROC analyzes revealed that the RP tumor volume is a good test on advanced stage disease.

CONCLUSIONS

Decreasing the cutoff values for PSAD and max% in positive cores should be considered for AS inclusion criteria. If we could calculate the tumor volume before RP, we can minimize the treatment failures (over or undertreatment) of PCa. Perhaps new biopsy protocols, tissue biomarkers, and molecular imaging technology may refine AS criteria.

A novel surgical technique for preserving the bladder neck during robot-assisted laparoscopic radical prostatectomy: preliminary results

PURPOSE

To describe our new surgical technique for preserving the bladder neck during robot-assisted laparoscopic prostatectomy (RALP) and to present the anatomy between the bladder neck and prostate.

METHODS

Between December 2012 and May 2014, 52 RALPs were performed at our institute. Demographic, perioperative, and postoperative data were recorded. Quality of life (QoL) scores were assessed before RALP, after urethral catheter removal, and at the first month after RALP. Fatty connective tissue between bladder neck and prostate was introduced, and circular muscle fibers of the internal sphincter were seen in all patients. Complications were classified according to the Clavien-Dindo classification. Statistical analyses were performed.

RESULTS

Mean follow-up was 9.6±5.2 months; mean age was 61.1±6.5 years. Our novel surgical technique for preserving the bladder neck was performed in 52 patients, and they were continent after catheter removal; mean duration of the catheter was 9.4±1.4 days. There was a significant difference in QoL before RALP and after catheter removal, however, but there was no statistical difference between before and 1 month after RALP (respectively; P<0.001, P=0.5). Furthermore, there was no complication related to the bladder neck such as bladder neck stricture, acute/chronic urinary retention, as well as no Clavien III, IV, and V complications. In addition, conventional laparoscopy and/or open surgery was not needed in any of the RALP cases.

CONCLUSION

Our novel technique provided very early continence at the time of catheter removal after RALP within short-term follow-up. This can help early recovery and develop QoL scores after RALP.

Impact of body mass index on outcomes of laparoscopic radical prostatectomy with long-term follow-up

OBJECTIVE

The aim of this study was to investigate the impact of body mass index (BMI) on the functional and oncological results of patients who had undergone laparoscopic radical prostatectomy (LRP).

MATERIAL AND METHODS

In total, 1224 patients with follow-up data (>24 months) were enrolled. Patients were divided into three groups according to BMI (kg/m(2)) as: group 1 (normal, BMI <25, n = 425), group 2 (overweight, 25 ≤ BMI <30, n = 594) and group 3 (obese, BMI ≥ 30, n = 205). Demographic, intraoperative and postoperative data with oncological outcomes were recorded. The impact of obesity on those parameters was evaluated and statistical analyses were performed.

RESULTS

Mean age was 63.8 ± 6.1 years and mean follow-up was 43.1 ± 25.1 months (mean ± SD). There were 425 (34.7%) patients in group 1, 594 (48.5%) in group 2 and 205 (16.8%) in group 3. Operation time, clinical stage and estimated blood loss were significantly higher in group 3 than in the other groups (p < 0.001, p = 0.001 and p = 0.001, respectively). Bilateral nerve-sparing rate and bladder neck-sparing rate were significantly decreased in group 3 compared with the other groups (p = 0.001 and p < 0.038, respectively). Statistically significantly higher pathological stage, tumour volume, positive surgical margin and Gleason scores were determined in group 3 compared with the other groups (p = 0.023, p = 0.018, p = 0.009 and p = 0.028, respectively). There were similar urinary continence rates among the groups. The rate of penetration with or without medication was significantly lower in group 3 than in the other groups (p = 0.593 and p = 0.007, respectively).

CONCLUSIONS

LRP seemed safe and effective in obese patients, with similar mean overall survival, cancer-specific survival, complication rates and continence rates to normal weight patients in the long term.

Maximum tumor diameter adjusted to the risk profile predicts biochemical recurrence after radical prostatectomy

Currently, no consensus exists on the best method for tumor quantification in prostate cancer (PCA), and its prognostic value remains controversial. We evaluated how a newly defined maximum tumor diameter (MTD) might contribute to the prediction of biochemical recurrence (BCR) in a consecutive series of PCA patients treated with radical prostatectomy (RP). Patients with PCA who underwent RP without neoadjuvant therapy at a single center were included for analysis. MTD was defined as the largest diameter of all identified tumors in all three dimensions (i.e., length, width, or depth) of the prostate ("Basel technique"). Cox regression models addressed the association of MTD with BCR in three risk groups (low risk-prostate-specific antigen (PSA) < 10 ng/ml, pT2, and Gleason score (GS) ≤ 6; intermediate risk-PSA ≥ 10 and <20 ng/ml and/or pT2 and GS = 7; high risk-PSA > 20 ng/ml or pT3 or GS ≥ 8) and whole cohort. Within a median follow-up of 44 months (interquartile range (IQR) 23-66), 48 patients (9.4 %) in the intermediate-risk and high-risk groups experienced BCR. In multivariate Cox regression analysis, PSA, pathological stage (pT stage), GS, positive surgical margins (PSMs), and MTD > 19.5 mm were independent predictors for BCR (p < 0.05). In subgroup analysis, MTD as a nominal variable (<24.5 and >24.5 mm) was the only independent predictor of BCR in the intermediate-risk group (hazard ratio (HR) 9.933, 95 % confidence interval (CI) 2.070-47.665; p < 0.05). MTD is an independent risk factor of BCR in PC patients after RP. The combination of the MTD with other well-known prognostic factors after RP may improve decision-making concerning follow-up intensity or adjuvant treatment.

Preoperative Prostate-specific Antigen Isoform p2PSA and Its Derivatives, %p2PSA and Prostate Health Index, Predict Pathologic Outcomes in Patients Undergoing Radical Prostatectomy for Prostate Cancer: Results from a Multicentric European Prospective Study

BACKGROUND

Currently available predictive models fail to assist clinical decision making in prostate cancer (PCa) patients who are potential candidates for radical prostatectomy (RP). New biomarkers would be welcome.

OBJECTIVE

To test the hypothesis that prostate-specific antigen (PSA) isoform p2PSA and its derivatives, percentage of p2PSA to free PSA (%p2PSA) and the Prostate Health Index (PHI), predict PCa characteristics at final pathology.

DESIGN, SETTING, AND PARTICIPANTS

An observational prospective multicentre European study was performed in 489 consecutive PCa patients treated with RP. Total PSA (tPSA), free PSA (fPSA), and p2PSA levels were determined. The %fPSA [(fPSA / tPSA) × 100], %p2PSA [(p2PSA pg/ml) / (fPSA ng/ml × 1000) × 100], and PHI [(p2PSA / fPSA) × √tPSA] were calculated.

INTERVENTION

Open or robot-assisted RP.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Logistic regression models were fitted to test the predictors of pT3 stage and/or pathologic Gleason score (GS) ≥7 and to determine their predictive accuracy. The base multivariable model included tPSA, digital rectal examination, biopsy GS, and percentage of positive biopsy cores. Decision curve analysis provided an estimate of the net benefit obtained using p2PSA, %p2PSA, or PHI.

RESULTS AND LIMITATIONS

Overall, 344 patients (70%) were affected by pT3 disease or pathologic GS ≥7; pT3 disease and pathologic GS ≥7 were present in 126 patients (26%). At univariable analysis, p2PSA, %p2PSA, and PHI were significant predictors of pT3 disease and/or pathologic GS ≥7 (all p ≤ 0.001). The inclusion of PHI significantly increased the accuracy of the base multivariable model by 2.3% (p=0.003) and 2.4% (p=0.01) for the prediction of pT3 disease and/or pathologic GS ≥7, respectively. However, at decision curve analysis, models including PHI did not show evidence of a greater clinical net benefit.

CONCLUSIONS

Both %p2PSA and PHI are significant predictors of unfavourable PCa characteristics at final pathology; however, %p2PSA and PHI did not provide a greater net benefit for clinical decision making.

PATIENT SUMMARY

Prostate-specific antigen (PSA) isoform p2PSA and its derivatives, percentage of p2PSA to free PSA and the Prostate Health Index, are associated with adverse characteristics of prostate cancer; however, these biomarkers provided only a slight net benefit for clinical decision making.

Preoperative magnetic resonance imaging for detecting uni- and bilateral extraprostatic disease in patients with prostate cancer

Objective

The objective of the study was to evaluate the diagnostic accuracy of preoperative magnetic resonance imaging (MRI) for detecting uni- and bilateral extraprostatic disease (T3) in patients with prostate cancer (PCa).

Materials and methods

This prospective study included 199 patients with biopsy-proven PCa who underwent MRI prior to radical prostatectomy from December 2009 to July 2012. Extraprostatic extension and seminal vesicle invasion represented T3 disease, and was classified as uni- (right or left) or bilateral. MRI detection of T3 disease was assessed by descriptive statistics and odds ratio (OR). Whole-mount histopathology was used as the reference standard.

Results

The overall prevalence of pT3 was 105/199 (53 %), unilateral in 81/105 (77 %) and bilateral in 24/105 (23 %). The sensitivity of MRI for predicting pT3 was 76/105 (72 %), specificity 61/94 (65 %), accuracy 137/199 (69 %), and OR 4.8 (95 % CI 2.7–8.8). A complete match with respect to the laterality of pT3 was found in 52/105 (50 %), and the side-specific accuracy was 113/199 (57 %). When unilateral pT3 was found, MRI falsely suggested contralateral T3 in 4/81 (5 %) and bilateral in 8/81 (10 %). When bilateral pT3 was found, MRI falsely suggested unilateral T3 in 12/24 (50 %).

Conclusion

Magnetic resonance imaging (MRI) detected 72 % of all patients with T3 disease, and the accuracy dropped from 69 to 57 % when considering the laterality of T3. Thus far, the MRI technique is not yet adequate to meet the increasing demands of accurate diagnosis of locally advanced disease, and the contemporary MRI staging should be careful.

Optimizing prostate specimen handling for diagnosis and prognosis

Optimal processing, handling, and sampling of prostatic biopsies, transurethral resections, and radical prostatectomy specimens ensure accurate diagnosis and staging. Prognostic factors derived from careful examination of tissue samples are critical for patient management, including cancer volume, extraprostatic extension, surgical margins, vascular/lymphatic invasion, and perineural invasion. This chapter addresses these important issues, including recent recommendations of a consensus panel of the International Society of Urologic Pathologists.

Supporting prostate cancer focal therapy: a multidisciplinary International Consensus of Experts ("ICE")

Prostate cancer is a common malignancy among men, and the current screening, imaging and sampling approaches aim to detect early-stage, organ-confined disease. In such scenario, focal prostate cancer therapy currently relies on the index lesion concept as the dominant lesion that drives the disease natural history. Focal therapy demands the essential imaging and sampling techniques to strategically locate and qualify the disease, but, despite advances in technology, prostate imaging and biopsy have several limitations that need to be overcome if focal therapy is to be developed further. The I Prostate Cancer Focal Treatment International Symposium was convened to foster discussion on this topic that sits at the crossroads of multiple disciplines (Urology, Pathology, Radiology, Radiation Oncology and Medical Oncology) all of which were represented for this comprehensive multidisciplinary review of the current literature.

Identification of pathologically insignificant prostate cancer is not accurate in unscreened men

Background:

Identification of men harbouring insignificant prostate cancer (PC) is important in selecting patients for active surveillance. Tools have been developed in PSA-screened populations to identify such men based on clinical and biopsy parameters.

Methods:

Prospectively collected case series of 848 patients was treated with radical prostatectomy between July 2007 and October 2011 at an English tertiary care centre. Tumour volume was assessed by pathological examination. For each tool, receiver operator characteristics were calculated for predicting insignificant disease by three different criteria and the area under each curve compared. Comparison of accuracy in screened and unscreened populations was performed.

Results:

Of 848 patients, 415 had Gleason 3+3 disease on biopsy. Of these, 32.0% had extra-prostatic extension and 50.2% were upgraded. One had positive lymph nodes. Two hundred and six (24% of cohort) were D'Amico low risk. Of these, 143 had more than two biopsy cores involved. None of the tools evaluated has adequate discriminative power in predicting insignificant tumour burden. Accuracy is low in PSA-screened and -unscreened populations.

Conclusions:

In our unscreened population, tools designed to identify insignificant PC are inaccurate. Detection of a wider size range of prostate tumours in the unscreened may contribute to relative inaccuracy.

A modified point count method as a practical approach to assess the tumor volume and the percent gland involvement by prostate carcinoma

This study reports a modified point-count method for quantifying the extent of carcinoma in prostatectomy specimens (n=143), as adapted from Billis et al. (2003) [3]. The prostates were studied as follows: the basal/apical margins were sampled using the cone method. The remainder of the gland was divided into 12 quadrant-shaped regions that were sampled using two slices. Eight equidistant points were marked directly on the coverslip over each fragment. The points inside the tumoral areas were counted and expressed as both the percentage of prostate gland involvement by carcinoma (PGI) and the tumor volume (TV). A significant correlation between the preoperative PSA levels and each of the three quantitative estimations were observed, with improved correlations with the PGI and TV values obtained using the point-count method (viz. number of slices involved (NSI) (r=0.32), PGI (r=0.39) and TV (r=0.44)). With the data sets stratified into three categories, all three methods correlated with multiple parameters, including Gleason scores ≥7, primary Gleason scores ≥4, perineural/angiolymphatic invasion, extraprostatic extension, seminal vesicle invasion and positive margins. All three quantitative methods were associated with morphologic features of tumor progression. The results obtained using this modified point-count method correlate more strongly with preoperative PSA levels.