Incidental adenocarcinoma of the prostate: the role of repeat transurethral resection in staging

Expectant management of stage A-1 (T1a) prostate cancer utilizing serum PSA levels: a preliminary report

BACKGROUND AND OBJECTIVES

The natural history of stage A-1 (Tla) prostate cancer remains unpredictable. Although stage A-1 (Tla) was traditionally considered an indolent lesion, recent reports have documented the potential progression of stage A-1 (Tla) cancer.

METHODS

Eight men aged 65 to 76 years at the time of diagnosis with stage A-1 (Tla) prostate cancer received no therapy. These men have been followed from 3 to 9.5 years (mean, 6.25 years). During this period, the patients have been followed with periodic rectal examinations and prostate-specific antigen (PSA) levels.

RESULTS

The PSA levels of five of the eight patients remain in the normal range and no patient has had a change in his rectal examination. In the three patients who had elevated PSA levels, there was no evidence of metastatic disease. No patient has died from prostate cancer; one patient died from cerebrovascular causes.

CONCLUSIONS

Patients with stage A-1 (Tla) prostate cancer have an unpredictable natural history. PSA levels can be used to monitor disease progression and identify those patients where observation is no longer appropriate.

Radical prostatectomy for impalpable prostate cancer: the Johns Hopkins experience with tumors found on transurethral resection (stages T1A and T1B) and on needle biopsy (stage T1C)

We review the pathological findings of impalpable prostate cancer detected by transurethral resection (stages T1a and T1b) and needle biopsy (stage T1c). The short-term (4 years) and long-term (8 to 10 years) natural histories of untreated stage T1a prostate cancer are examined, as are options to follow patients expectantly. The findings on radical prostatectomy for stages T1a and T1b disease are reviewed and compared. Of the 64 cases of stage T1a disease 13 (20%) showed substantial tumor, including 7 with more than 1 cc of tumor, 5 with capsular penetration and 1 with a Gleason grade 4 + 5 = 9 tumor. Based on preoperative pathological parameters, one could not predict which cases had minimal versus substantial tumor. In a study from our institution that undertook complete histological examination of 39 radical prostatectomy specimens of stage T1b carcinoma, we found that all prostates contained residual carcinoma, 26% had capsular penetration and 10% had invasion of the seminal vesicles. When comparing morphometrically determined volumes of carcinoma with similar data from 56 patients with stage T2 carcinoma, stage T1b tumors were much more heterogeneous in grade, location and volume than were stage T2 lesions. Unless all 3 variables (grade, volume and location) were known, the final pathological stage of T1b cancers could not be predicted with confidence. Finally, we examined preoperative clinical and pathological parameters in 157 men with clinical stage T1c disease undergoing radical prostatectomy, and correlated these findings with pathological extent of disease in the surgical specimen in an attempt to identify a subset of patients with potentially biologically insignificant tumor who might be followed conservatively. Of the tumors 16% were insignificant (less than 0.2 cc, organ confined and Gleason grade less than 7), 10% were minimal (0.2 to 0.5 cc, organ confined and Gleason grade less than 7), 37% were moderate (more than 0.5 cc or capsular penetration with Gleason sum less than 7) and 37% were advanced (capsular penetration with Gleason sum 7 or more, or positive margins, positive seminal vesicles or positive lymph nodes). These findings are intermediate between those found in clinical stages T1a and T2 disease. The best model predicting insignificant tumor was a prostate specific antigen (PSA) density of less than 0.1 and no adverse pathological finding on needle biopsy or PSA density of 0.1 to 0.15 with less than 3 mm. low to intermediate grade cancer on only 1 needle biopsy core. The positive predictive value of the model was 95% with a negative predictive value of 66%.(ABSTRACT TRUNCATED AT 400 WORDS)

Stage T1A carcinoma of prostate

When presented with a post-TURP patient with pathologically confirmed Stage T1a disease, several points should be considered (Fig. 1). Is the patient's anticipated longevity and quality-of-life likely to be affected by the confirmed diagnosis? From current knowledge, men over the age of seventy or with co-morbid risk factors probably will not be adversely affected, and no treatment is required apart from expectant follow-up with semiannual DRE and serum PSA determinations. The group at risk seems to be the young patient with a Stage T1a tumor who is likely to survive more than ten years after the diagnosis. Data showing progression rates without treatment as high as 16-25 percent at eight to ten years seem to indicate the need for additional therapy. If the patient belongs to this category and is ready to pursue more aggressive treatment, reestablishing the diagnosis might be suggested, as well as an evaluation of the pre- and post-TUR PSA levels. This can be done by TRUS-guided biopsies of the prostate (or repeat TURP, which we regard as less preferable). If residual tumor is not found, we would counsel a "wait and see" approach. If subsequent tissue sampling identifies other than well-differentiated cancer or indicates the likelihood of more extensive cancer than the T1a staging, treatment would be suggested. If the restaging reveals some residual well-differentiated disease that would not alter the initial staging of T1a, the patient should be offered the alternatives of close monitoring, radical prostatectomy, or radiation therapy. Until prognostic factors such as DNA ploidy and nuclear roundness are better studied, we are unable to counsel the patient on the biologic significance/aggressiveness of his Stage T1a disease.

Negative repeat transurethral resection of prostate fails to identify patients with stage A1 prostatic carcinoma at lower risk of progression: a long-term study

Stage A1 (low-grade and low-volume) adenocarcinoma is associated with a low likelihood of progression. Repeat transurethral resection has been used to identify patients at increased risk (residual cancer noted) as well as those at low risk of progression (no residual cancer noted). We recently evaluated the ability of this technique to define a low-risk patient population. We reviewed the records of 24 patients who underwent repeat transurethral resection after they were identified as having Stage A1 prostatic cancer on initial resection (Gleason score < 5, tumor volume comprising < 5% of the resection specimen). Despite no evidence of residual carcinoma on repeat resection, 3 patients (13%) progressed at a mean follow-up of seven years (2 locally, 1 locally and distantly). We conclude that repeat resection does not effectively evaluate the risk of progression and that other techniques including transrectal ultrasonography and serial prostate-specific antigen measurements should be similarly evaluated.

Value of transrectal prostate ultrasonography pre-transurethral prostatectomy in screening for occult prostate carcinoma

A total of 311 patients who underwent consecutive transurethral resection of prostate (TURP) for obstructive voiding symptoms were reviewed. All patients had benign prostate glands by digital rectal examination. Results of preoperative ultrasound screening of the prostate in 65 of 311 patients showed 41 with nonmalignant prostate, but pathologic examination showed cancer in 11 and benign hyperplasia in 30. Of seven ultrasounds interpreted as suspicious for cancer, pathologic examination revealed benign hyperplasia in all seven. Of 17 patients with ultrasound interpretations consistent with prostate cancer, 14 had transrectal ultrasound-guided prostate biopsies prior to TURP. Biopsy specimens revealed benign hyperplasia without carcinoma in all 14 patients. Two of 17 patients refused biopsies, and 1 underwent TURP without biopsy for urinary retention and did have cancer. Sensitivity of prostate ultrasound in evaluation of occult prostate carcinoma in this group of patients was 8.3 percent and specificity was 56.6 percent. Our results indicate that transrectal prostate ultrasound performed on men with obstructive voiding symptoms and benign glands as evidenced by digital rectal palpation has little value in predicting the presence or absence of occult prostate cancer.

Transrectal Ultrasound Imaging and Ultrasound Guided Prostate Biopsies in the Detection of Residual Carcinoma in Clinical Stage A Carcinoma of the Prostate

Planning treatment for patients diagnosed with stage A prostate cancer by transurethral resection or open enucleation can be difficult. Inability to determine the presence or absence of significant residual disease can result in unnecessary treatment for some individuals and inadequate treatment in others. Transrectal ultrasound imaging and systematic prostate biopsies offer a potential means of evaluating these patients. To determine the rate of residual cancer detection 3 groups of stage A prostate cancer cases were evaluated. Group 1 consisted of 39 patients who underwent radical prostatectomy. Preoperative ultrasound imaging revealed residual cancer in only 24%. Transrectal ultrasound guided systematic biopsies were performed in group 2 (25 patients) and revealed cancer in only 28%. Based on prior morphometric studies of prostatectomy specimens from stage A cases, a modification of the systematic biopsy method, which included anteriorly directed biopsies, was developed and applied to group 3 (47 patients). Cancer was detected in 47% of the patients, and it was detected by additional anterior biopsies alone in 11%.

Cancer detected incidental to simple prostatectomy (stage A1)

The incidence of stage A (incidental) adenocarcinoma of the prostate in transurethral resection (TUR) specimens is approximately 16%. This paper discusses the criteria for differentiating stage A1 versus stage A2 tumor, based on tumor volume and grade. Both the short-term (4 year) and long-term (8-10 year) natural history of untreated stage A1 prostate cancer are examined. Options to follow patients expectantly are presented. These include digital rectal examination and transrectal ultrasound. Specific problems relating to analyzing transrectal ultrasounds in patients who have had a prior TUR are addressed. Also, the unique aspects of transrectal ultrasound for stage A1 disease as it relates to the location of the lesion are expanded upon. The third option in the management of stage A1 disease is to monitor serum prostate specific antigen (PSA) levels. Areas covered include the sensitivity and specificity of PSA in general, and, in specific, serum PSA levels following TUR for stage A1 disease as a predictor of residual tumor. New data on a small group of patients who underwent delayed radical prostatectomy following diagnosis of stage A1 disease, where PSA data was available, are presented. The rationale for following patients with stage A1 disease by monitoring their serum PSA levels is supported by data from a group of men with normally sized prostates, benign prostatic hyperplasia, or cancer where longitudinal serum PSA levels were available. Finally, the option of radical prostatectomy for stage A1 disease is put forth. Data include a study of a large group of radical prostatectomy specimens performed for stage A1 disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Can stage A1 tumor extent be predicted by transurethral resection tumor volume, per cent or grade? A study of 64 stage A1 radical prostatectomies with comparison to prostates removed for stages A2 and B disease

We studied 64 totally embedded radical prostatectomy specimens of stage A1 prostate cancer. The transurethral resection specimens were studied and compared to previously studied stages A2 and B cancer in which tumor volumes also were calculated. At radical prostatectomy 6% of the specimens had no residual cancer, 74% had minimal cancer and 20% had substantial cancer. Although most stages A2 and B tumors were larger, there was overlap among all stages. Transurethral resection tumor volume, per cent and grade were not statistically correlated with either radical prostatectomy residual tumor volume, or whether tumor was classified as minimal or substantial. Gleason sum 2 to 4 versus 5 to 7 tumor on transurethral resection showed no difference in predicting radical prostatectomy residual tumor or minimal versus substantial tumor status. Because 20% of all stage A1 cancers have substantial tumor at radical prostatectomy unpredictable by transurethral resection, radical prostatectomy remains an option for young men with stage A1 prostate cancer.

Transrectal ultrasonography in stage A prostate cancer: detection of residual tumor after transurethral resection of prostate

To evaluate the ability of transrectal ultrasonography to detect residual cancer in the prostate gland after transurethral resection in patients with stage A cancer, we studied 38 patients with stage A disease (11 stage A1 and 27 stage A2) in whom transrectal ultrasonography was done at least 3 weeks after resection. Each patient underwent radical prostatectomy, and residual cancer was present in 97% of the specimens (peripheral zone cancer in 95% and transition zone cancer in 61%). At sonography we identified hypoechoic areas suggestive of cancer in 10 patients (26%). In the pathological specimen residual cancer was present at the hypoechoic area in 8 of these cases (positive predictive value 80%). In a retrospective review of the sonograms we identified 25 hypoechoic lesions greater than 5 mm. in diameter, including 15 that corresponded to cancer in the radical prostatectomy specimens (positive predictive value 60%). Granulomas due to the transurethral resection were found in 92% of the radical prostatectomy specimens but none appeared hypoechoic on ultrasound. A total of 103 separate cancers was identified in the whole mount step sections of the radical prostatectomy specimens (2.7 cancers per patient). Of the 103 separate cancers 54 were less than 0.1 cc in volume and none of these could be identified in the retrospective review of the sonograms, 37 were 0.1 to 1.0 cc and 5 of these (14%) appeared hypoechoic, and 12 were greater than 1.0 cc and 10 of these (83%) appeared hypoechoic. Hypoechoic lesions greater than 5 mm. in diameter in the transition zone proved to be cancer in 47% of the cases, while 88% of similar lesions in the peripheral zone proved to be cancer. We conclude that suspicious-appearing hypoechoic lesions suggestive of cancer, whether in the peripheral zone or the transition zone, should be biopsied before expectant management of stage A prostate cancer is considered. Transrectal ultrasonography is useful for restaging after transurethral resection and for evaluating the extent of residual cancer in stages A1 and A2 prostate cancer.

Long-term followup results after expectant management of stage A1 prostatic cancer

A total of 132 patients with stage A1 adenocarcinoma of the prostate was followed for 5 to 23 years (mean 8.2 years). Of these patients 52 underwent a second staging transurethral resection of the prostate between 1977 and 1986. Progressive disease developed in 3 of the 12 patients (25%) in whom residual foci of well differentiated cancer were detected by the second transurethral resection and who did not undergo further treatment. Of the 38 patients in whom the second transurethral resection did not detect residual cancer 3 (8%) also had progressive disease. From April 1989 to December 1989, 44 patients were re-evaluated by transrectal ultrasonography and ultrasonographically guided biopsies. Of these patients 3 had locally progressive disease. Progressive disease also developed in 4 more patients. Thus, 13 of the 132 patients (10%) had either locally or systemically progressive disease after long-term followup. The interval from diagnosis of stage A1 disease to detection of progression ranged from 6 months to 20 years (mean 7 years). Ten patients underwent definitive treatment for what was believed to be locally progressive disease, 2 underwent palliative therapy and 1 had no therapy due to poor physical condition. Of the 10 patients who underwent definitive therapy 6 are alive without evidence of disease, 2 died of unrelated causes without evidence of disease and 2 are alive with stage D1 disease. These data suggest that patients in whom a second staging transurethral resection of the prostate detects residual cancer have a high probability of progressive disease. Also, negative findings from a second staging transurethral resection may not exclude the possibility of disease progression. Expectant management of stage A1 disease is warranted but regular and long-term followup is mandatory.

Prostate cancer

Prostate cancer is the most common malignancy in men and the second leading cause of cancer deaths. Although the mortality rate for prostate cancer has remained unchanged for 50 years, new advances have changed classic concepts in the diagnosis and management of patients with this disease. Our understanding of the anatomy and natural history of patients with prostate cancer has been enhanced. The ability to diagnose early stage prostate tumors has been improved by the introduction of prostate-specific antigen and transrectal ultrasound. Clinical staging of patients with prostate cancer has been refined, which has decreased adverse effects of inappropriate treatment. Modifications in the technique of radical prostatectomy have minimized the morbidity associated with this procedure, making it a more attractive therapeutic option. DNA ploidy analysis holds promise as a predictor of response to hormonal therapy. New agents are available to reduce adverse effects of hormonal therapy. In addition, traditional ideas about the timing of hormonal therapy and the use of total androgen blockade are being challenged. These changes may presage an improved quality of life and improve survival for patients with prostate cancer.

Intraglandular tumor extent and prognosis in prostatic carcinoma: application of a grid method to prostatectomy specimens

The extent of tumor in prostatectomy specimens was determined by a grid method in 117 patients with prostatic adenocarcinoma. A plastic strip or ruler with squares of 3.0 mm was used, and the ratio of squares overlying carcinoma to the total number of squares overlying prostate tissue was calculated. This grid ratio, which represents an estimate of the percentage of the prostate involved by tumor, was a significant prognosticator closely tied to the likelihood of tumor progression and to survival time, as assessed by logistic regression analysis and a proportional hazard model. The grid ratio was better than histologic grade in predicting tumor progression and patient survival; also, the ratio was more objective than histologic grade as judged by interobserver agreement values. Only slight improvement in prognostication was obtained with concurrent use of both extent and grade. The grid ratio method was slightly better in predicting tumor progression and patient survival than a second method of assessing the percentage of prostatic tissue involved by tumor, the pathologist's percentage estimate. These results indicate that it is important to quantitate tumor extent within prostatectomy specimens; such quantitation need not require step-sectioning of the entire prostate and an expensive and time-consuming method such as computerized morphometrics but rather may be performed by a simple estimate of the percentage of the prostate involved by tumor. Reporting of histologic grade and tumor extent in the prostate gland is recommended as both appear to be important in identifying those patients at risk for a poor outcome after prostatectomy for prostatic carcinoma.

Radical prostatectomy in stage A prostatic adenocarcinoma

A total of 76 patients (18 with stage A1 and 58 with stage A2 cancer) underwent radical perineal prostatectomy. No perioperative deaths occurred and no patient suffered rectal injury or was incontinent postoperatively. Five patients (3 with stage A1 and 2 with stage A2 disease) had negative surgical specimens, while 6 (4 with stage A1 and 2 with stage A2 cancer) had a single microscopic focus in the radical prostatectomy specimen. Outcome was assessed by first evidence of disease recurrence as a function of the Gleason sum and the local anatomical extent of disease. Of 41 patients 4 (9.7 per cent) with organ-confined disease failed at 2.5, 2.6, 4.3 and 11.9 years. None of 11 patients with specimen-confined disease failed, and 6 of 24 (25 per cent) with positive margins failed at 0.9, 1.2, 2.1, 3.1, 3.2 and 8.0 years. Radiation after an operation for margin-positive disease did not seem to alter the incidence of failure. The distribution frequency of the Gleason sum was noted to shift to a higher total sum as the extent of local disease increased. Kaplan-Meier analysis of the failure rate of patients with organ-confined and organ-nonconfined disease with a Gleason sum of 7 or less versus greater than 7 demonstrated an advantage for those with a sum of 7 or less (p less than or equal to 0.018).

The volume and anatomical location of residual tumor in radical prostatectomy specimens removed for stage A1 prostate cancer

A detailed histological analysis of 21 prostatectomy specimens for stage A1 disease was performed. Three cases (14 per cent) demonstrated no tumor, although all had foci of severe dysplasia. Of the prostates 18 (86 per cent) contained residual tumor: 13 (62 per cent) had minimal residual tumor and 5 (24 per cent) had substantial tumor. The residual carcinoma in the prostates with minimal tumor was predominantly in the apex of the gland or peripherally adjacent to the capsule such that complete removal by repeat transurethral resection would have been unlikely. Of the 5 specimens with substantial tumor, although some would have been upstaged by repeat transurethral resection, others would have remained stage A1 because of the peripheral location of the residual tumor. Within the definition of stage A1, using either the percentage of tumor involvement, weight of tumor or number of tumor foci in the transurethral resection specimen, one could not predict whether the prostatectomy specimen would have no, minimal or substantial residual tumor. Postoperatively, all patients are continent and 93 per cent are potent. Because some men with stage A1 carcinoma of the prostate will have substantial residual tumor not necessarily detected by repeat transurethral resection and the majority will have minimal residual tumor, which also appears to have an increased long-term risk of progression, radical prostatectomy should remain an option in the management of relatively young men with stage A1 disease.

Tumor volume versus percentage of specimen involved by tumor correlated with progression in stage A prostatic cancer

Previous studies from this institution have shown that in untreated stage A prostate cancer when 5 per cent of the specimen or less was involved by tumor (stage A1) only 2 per cent of the patients had progression at 4 years. Of the specimens with greater than 5 per cent cancer (stage A2) 33 per cent had progression at 4 years. More recently, we have shown that 16 per cent of the men with stage A1 disease who remained at risk for 8 years or longer after diagnosis had progression of disease despite a small percentage of the specimen involved by tumor. To address whether the actual volume of tumor resected may be a better predictor of progression than the percentage of the specimen involved by tumor the data from these studies were re-evaluated. We demonstrated that at 4 and 8 years of followup the percentage of the specimen and resected tumor volume were strongly associated with tumor progression, with the percentage of the specimen showing a stronger association especially at 4 years. Our study reaffirms the use of the percentage of resected tissue involved by tumor as a means to distinguish between stages A1 and A2 prostate cancer. Although at 8 years the distinction between stages A1 and A2 disease is blurred, this staging classification still is useful to identify those tumors with a relatively indolent course and a minimal short-term risk of progression from those that are more aggressive.

The ratio of prostate chips with cancer: a new measure of tumor extent and its relationship to grade and prognosis

The ratio of chips with cancer to the total number of chips was studied in 118 patients with prostate cancer who underwent transurethral prostatectomy. We found that this ratio is a prognosticator closely associated to the stage of tumor (local or extensive) and to the chance of death from prostate cancer. Stage, the ratio of positive chips and the Gleason histologic score are all closely tied one to another, and it is unclear from this initial study whether these variables provide independent or additive prognostic information. Nevertheless, the ratio of positive chips shows far better interobserver agreement than does the Gleason score, and in patients with the most common predominant score of three, it can separate most of those with localized disease from most of those with extensive disease. Thus the ratio shows promise as a reliable predictor of stage of disease and of long-term failure, and hence it may help in the choice of patients for curative surgery.

Incidental carcinoma of the prostate: significance of staging transurethral resection

We compared the results of staging by a second circumferential transurethral resection and/or transperineal needle biopsy in 42 patients with stage A prostatic adenocarcinoma on initial transurethral resection (defined as tumor of low grade, Gleason sum 2 to 4, and low volume, less than 5 per cent of the specimen or less than 3 foci). Transurethral resection only was done in 16 patients, transperineal needle biopsy only in 2 and both procedures in 24. In the 24 patients who underwent both procedures residual carcinoma was identified by transurethral resection in 6 and confirmed by transperineal needle biopsy in only 1. Thirty-two patients (76 per cent) had no residual carcinoma. Of the 10 patients (24 per cent) with residual carcinoma 5 underwent radical prostatectomy with pelvic lymphadenectomy, 1 had interstitial irradiation with pelvic lymphadenectomy and 1 had pelvic lymphadenectomy only. No lymphatic metastases were detected; persistent carcinoma confined to the prostate was noted in all 5 patients who had undergone radical prostatectomy and 3 of these tumors were upstaged because of higher grade and/or volume. We conclude that residual carcinoma cannot be assessed accurately with transperineal needle biopsy, whereas transurethral resection staging enabled us to define a substantial number of our patients (24 per cent) with persistent disease. Importantly, upstaging by either low volume/high grade or high volume carcinoma was identified in 3 patients at the time of radical prostatectomy. However, the true stage and prognosis of those patients with persistent low volume and low grade prostatic carcinoma remain to be determined.