Ultrasound findings are not useful for defining stage T1c prostate cancer

Endorectal color doppler sonography and endorectal MR imaging features of nonpalpable prostate cancer: correlation with radical prostatectomy findings

OBJECTIVE

The purpose of this study was to describe endorectal sonography and color Doppler sonography features of nonpalpable prostate cancer and to assess the value of endorectal MR imaging for the preoperative local staging of these tumors.

MATERIALS AND METHODS

Ninety-four patients with nonsuspicious findings on digital rectal examination and a mean prostate-specific antigen level of 16.3 +/-10 ng/mL (median, 13 ng/mL) underwent endorectal sonography, color Doppler sonography, sextant endorectal sonographically guided biopsy, and endorectal MR imaging before radical prostatectomy.

RESULTS

Tumors were visible in 48 cases and not visible in 46. The mean Gleason biopsy score, the frequency of tumors involving three sextants or more of the prostate gland at biopsies, and the frequency of stage pT3 tumors were significantly higher in patients with visible tumors (5.9+/-0.9, 42%, and 37.5%) than in those with invisible tumors (5.4+/-1.1, 17%, and 17%). The 42 hypervascular tumors were hypoechoic in every case and had a higher rate of Gleason tumor grades 4 and 5 at biopsy than did the 52 hypovascular tumors (33% versus 11.5%). Six hypovascular tumors (6/52, 11.5%, two visible) had an insignificant tumor volume. Established extraprostatic tumor spread was detected on MR imaging in six of 18 cases (sensitivity, 33%; specificity, 100%0, all of which had the following four features: hypervascularity, prostate-specific antigen level greater than 20 ng/mL, three or more sextants of the gland having positive findings at biopsy, and seminal vesicle invasion.

CONCLUSION

Endorectal sonography and color Doppler sonography are useful to differentiate low-risk invisible and hypovascular tumors from high-risk visible and hypervascular tumors. However, MR imaging has a poor sensitivity for the detection of extraprostatic spread and is accurate only in a minority of highly selected high-risk hypervascular tumors.

Prostate cancer in the elderly

The incidence of prostate cancer is age related and increased longevity increases the number of elderly men with the disease. Management of prostate cancer in the elderly requires a different approach. Screening and aggressive case finding to seek out early confined disease are contraindicated in those with a life expectation below 10 years. Early confined disease in the elderly is usually managed expectantly. Hormone treatment is more appropriate for locally advanced disease, and is a valuable non-surgical treatment for bladder outflow obstruction due to prostate cancer. A significant proportion of elderly men with prostate cancer still die from other diseases. Hormone refractory disease in the elderly should be managed by palliation of symptoms rather than toxic second-line therapies. The aim always is diagnosis where appropriate, treatment which will be of benefit, and quality rather than length of life.

Relationship of ultrasound staging and bilateral biopsy positivity to outcome in stage T1c prostate cancer treated with radiotherapy

OBJECTIVES

The strict definition of Stage T1c prostate cancer is that the tumor is not palpable on digital rectal examination (DRE) or seen on imaging studies such as ultrasound. The inclusion of ultrasound imaging was brought about without an understanding of the relationship between ultrasound upstaging and prognosis. We have also noticed that in clinical practice, treatment decisions are made on the basis of the finding of bilateral versus unilateral biopsy positivity. The objectives in this study were to determine the prognostic significance of upstaging by transrectal ultrasound (TRUS) to uT2 or uT3, and unilateral versus bilateral biopsy positivity in patients with Stage T1c cancer as determined by DRE (DRE-Stage T1c patients).

METHODS

Between 1987 and 1995 there were 643 patients with DRE-Stage T1-T2 prostate cancer treated with external beam radiotherapy; 24 had T1a, 76 had T1b, 183 had T1c, 133 had T2a, 168 had T2b, and 59 had T2c. Of these, 135 DRE-Stage T1c patients underwent ultrasound staging and 122 underwent bilateral prostate biopsies. All had pretreatment prostate-specific antigen values (PSAs) available and no patient received adjuvant androgen ablation. The median pretreatment PSA was 9.1 ng/mL, median radiotherapy dose was 66.0 Gy, and median follow-up was 41 months. Post-treatment failure was defined as disease recurrence and/or two elevations in PSA on consecutive follow-up visits.

RESULTS

The 5-year freedom from failure rate for DRE-Stage T1c patients (71%) was not significantly different from that of DRE-Stage T1b (65%) or DRE-Stage T2a (71%) patients. There was a trend (P = 0.1) toward a worse outcome for DRE-Stage T2b/T2c patients compared with DRE-Stage T1b/T1c/T2a patients. The distribution of DRE-Stage T1c patients by ultrasound staging was 29 with uT1c, 88 with uT2, and 18 with uT3 findings. Twenty percent of patients had bilateral positive biopsy specimens. In univariate and multivariate analyses, the only correlates of patient outcome were pretreatment PSA (P < or = 0.002) and isocenter dose (P = 0.03). TRUS upstaging had no effect on freedom from failure; uT1c patients had about the same risk of relapse or a rising PSA as uT2 or uT3 patients. Patients with bilateral positive prostate biopsy specimens had about the same prognosis as those with unilateral positive biopsy specimens.

CONCLUSIONS

For patients with DRE-Stage T1c prostate cancer, the data indicate that ultrasound staging and bilateral biopsy positivity are not predictive of outcome for patients treated with external beam radiotherapy and treatment decisions should not be based on these parameters.