Cancer detected incidental to simple prostatectomy (stage A1)

Incidence and mortality of incidental prostate cancer: a Swedish register-based study

In a national register-based study of incidence trends and mortality of incidental prostate cancer in Sweden, we found that a significant proportion (26.6%) of affected men diagnosed died of their disease, which challenges earlier descriptions of incidental prostate cancer as a non-lethal disease.

Did the rate of incidental prostate cancer change in the era of PSA testing? A retrospective study of 1127 patients

OBJECTIVES

To evaluate, in a retrospective study, the impact of routine prostate-specific antigen (PSA) testing on the rate of incidental prostate cancer in patients undergoing surgery for obstructive symptoms caused by presumed benign prostatic enlargement (BPE) and to investigate the indication of a routine biopsy before alternative treatment procedures for BPE. In the pre-PSA era, the diagnosis of incidental carcinoma was exclusively based on normal digital rectal examination (DRE) findings.

METHODS

Since January 1993, 2422 operations (2283 transurethral resection of the prostate, 139 retropubic adenoma enucleations) for BPE were performed at our institution. The preoperative DRE findings and PSA level were evaluated, and patients with any suspicion for cancer were excluded. The pathologic reports of all patients were reviewed. A diagnosis of incidental carcinoma of the prostate required histologic evidence of cancer and negative DRE findings and a PSA level within age-specific reference ranges preoperatively.

RESULTS

Of 2422 patients, 1127 (46.5%) had both negative DRE findings and an age-specific PSA level and were evaluated for our study. Overall, prostate cancer was diagnosed by surgery in 314 (13%) of 2422 patients. The rate of incidental prostate cancer in patients with both negative age-specific PSA levels and negative DRE findings was 6.4% (72 of 1127).

CONCLUSIONS

In our series, the likelihood of detecting incidental prostate cancer by surgery was 6.4%. In the PSA era, the rate of incidental prostate cancer has been decreased by more than 50%. Today, the low rate of incidental carcinoma does not warrant routine histologic evaluation of the prostate if PSA testing and DRE are negative when alternative treatment modalities without tissue sampling are offered for the treatment of BPE.

Concurrent assessment of obstructive/irritative urinary symptoms and incontinence after radical prostatectomy

OBJECTIVES

To concurrently evaluate urinary obstructive symptoms and incontinence in men after radical prostatectomy and to determine the effects of these components on urinary impairment and satisfaction.

METHODS

Two hundred twenty-eight men after radical prostatectomy were age-matched and zip code-matched to a random sample of 228 men without prostate cancer. Urinary incontinence was assessed by the urinary function domain of the Prostate Cancer Index, and obstructive symptoms were assessed by the American Urological Association Symptom Index. Regression models were constructed to evaluate the impact of obstructive and incontinence symptoms on urinary impairment and satisfaction.

RESULTS

The control group reported greater urinary continence (P <0.0001) and less impairment (P <0.0001) than the prostatectomy group, but a difference was not observed for obstructive symptoms. Obstructive urinary symptoms were associated with impairment for both the prostatectomy and the control groups (P <0.0001), and incontinence symptoms were more strongly associated with impairment in the prostatectomy group than in the control group (P = 0.01). Greater obstructive/irritative and incontinence symptoms were associated with lower satisfaction (P <0.0001).

CONCLUSIONS

Urinary incontinence was more common in the radical prostatectomy group, but differences were not seen for obstructive symptoms. In addition to incontinence symptoms, obstructive symptoms were associated with urinary impairment and dissatisfaction in the prostatectomy group, suggesting that these symptoms should also be assessed after radical prostatectomy.

Evaluating early-stage prostate cancer. What pretreatment criteria best guide therapeutic decision making?

Although much has been learned about clinically localized PCa, no single prognostic parameter has been identified that is uniquely reliable in assessing prognosis. The best approach to the newly diagnosed PCa patient remains unchanged: to review all the clinical, radiologic, and histopathologic findings together. In combination, the serum PSA level and the histologic features of a tumor on biopsy can be used to predict the likelihood that a tumor is organ-confined or has spread beyond the gland. By this approach, some patients may be placed into a low-risk category for which "watchful waiting" may be a reasonable option. For other patients, the benefit from this approach is in making more informed decisions concerning definitive therapy and/or the use of adjuvant therapy. The role of the surgical pathologist is to provide as much information as possible regarding the amount, location, and differentiation of tumor present in biopsy and TUR specimens. Prognostic interpretation of these histopathologic findings depends on good communication between pathologists and urologists, oncologists, and radiation oncologists, which remains a cornerstone in therapeutic decision making.