Tumor volume as a predictor of adverse pathologic features and biochemical recurrence (BCR) in radical prostatectomy specimens: a tale of two methods

MRI-derived tumor volume as a predictor of biochemical recurrence and adverse pathology in patients after radical prostatectomy: a propensity score matching study

PURPOSE

To investigate the predictive value of MRI-derived tumor volume (TV) of biochemical recurrence (BCR) and adverse pathology (AP) in patients following radical prostatectomy (RP).

METHODS

The data of 565 patients receiving RP in a single institution between 2010 and 2021 were retrospectively analyzed. All suspicious tumor foci were delineated manually using ITK-SNAP software as the regions of interest (ROIs). The sum of the TV of all lesions was calculated automatically based on the voxel in the ROIs to acquire the final TV parameter. TV was categorized as low-volume (≤ 6.5 cm³) and high-volume (> 6.5 cm³) based on the cut-off value. Univariate and multivariate Cox and logistic regression analyses were performed to identify independent predictors of BCR and AP. The Kaplan-Meier with the log-rank test was conducted to compare the BCR-free survival (BFS) between the low and high-volume groups.

RESULTS

All the included patients were divided into the low-volume group (n = 337) and the high-volume group (n = 228). The TV was an independent predictor of BFS in the multivariate Cox regression analysis (Hazard Ratio (HR) [95% CI]: 1.550 [1.066-2.256], P = 0.022). The Kaplan-Meier analysis demonstrated that low volume was associated with a better BFS than high volume before propensity score matching (PSM) (P < 0.001). One hundred and fifty-eight pairs were obtained by 1:1 PSM to balance the baseline parameters between the two groups. After the PSM, low-volume remained to be associated with a better BFS than high-volume (P = 0.006). TV as a categorical variable was an independent factor of AP in multivariate logistic regression analysis (Odd ratio (OR) [95% CI]: 1.821 [1.064-3.115], P = 0.029). After balancing the potential factors influencing AP by 1:1 PSM, 162 new pairs were identified. The high-volume group had a higher AP rate than the low-volume group after PSM (75.9 vs. 64.8%, P = 0.029).

CONCLUSION

We adopted a novel approach to acquiring the TV on preoperative MRI. TV was significantly associated with BFS and AP of patients undergoing RP, which was further illustrated by PSM analysis. MRI-derived TV may serve as a predictive marker for assessing BFS and AP in further studies, which will facilitate clinical decision-making and patient counseling.

Tumor Location and a Tumor Volume over 2.8 cc Predict the Prognosis for Japanese Localized Prostate Cancer

(1) Objective: Our study investigated the prognostic value of tumor volume and location in prostate cancer patients who received radical prostatectomy (RP). (2) Methods: The prognostic significance of tumor volume and location, together with other clinical factors, was studied using 557 patients who received RP. (3) Results: The receiver operating characteristic (ROC) curve identified the optimal cutoff value of tumor volume as 2.8 cc for predicting biochemical recurrence (BCR). Cox regression analysis revealed that a tumor in the posterior area (p = 0.031), peripheral zone (p = 0.0472), and tumor volume ≥ 2.8 cc (p < 0.0001) were predictive factors in univariate analysis. After multivariate analysis, tumor volume ≥ 2.8 cc (p = 0.0225) was an independent predictive factor for BCR. Among them, a novel risk model was established using tumor volume and location in the posterior area and peripheral zone. The progression-free survival (PFS) of patients who met the three criteria (unfavorable group) was significantly worse than other groups (p ≤ 0.001). Furthermore, multivariate analysis showed that the unfavorable risk was an independent prognostic factor for BCR. The prognostic significance of our risk model was observed in low- to intermediate-risk patients, although it was not observed in high-risk patients. (4) Conclusion: Tumor volume (≥2.8 cc) and localization (posterior/peripheral zone) may be a novel prognostic factor in patients undergoing RP.

Can Tumour Volume Percentage in Radical Prostatectomy Predict Cancer Biochemical Recurrence? Determining a Cut-off Point and Composite Risk Factors Approach

BACKGROUND

Incidence of biochemical recurrence (BCR) after radical prostatectomy is relatively high and overall survival can be poor. Debate exists whether tumour volume predicts BCR and when treatments should be administered. In this study, we aimed to i) assess the impact of tumour volume percentage (TVP) as a predictor for BCR, ii) determine TVP cut-off point for BCR and iii) evaluate single and composite predictors of BCR.

METHODS

From March 2000 to December 2013, 1777 patients underwent laparoscopic radical prostatectomy for localized prostate cancer. None received neoadjuvant or adjuvant therapy. One hundred and forty-six patients experienced BCR (range 3 months-10 years). Using D'Amico classification, 146 matched controls without BCR were compared. Liu cut-point analysis was used to identify TVP with optimal sensitivity and specificity. Single and composite BCR risk predictors were analyzed using Cox hazards regression in cases and controls.

RESULTS

Median TVP was 10% (range 1-90%). Most of BCR peaked after 3 years of follow-up. TVP ≥8% was an independent predictor of BCR with HR 1.6 (p= 0.001, 95% CI= 1.11-2.48). TVP of 8% was associated with the highest accuracy: sensitivity 74% and specificity 53% (ROC curve= 0.7). At TVP ≥8%, pathological stage pT3 was associated with 1.7-fold higher risk of BCR compared to T2. Lymph node invasion was associated with 1.4-fold higher risk of BCR compared to no invasion. Combining TVP ≥8%, pT3 and lymph node invasion, HR jumped to 3.73 (p< 0.001, 95% CI= 2.27-6.14), whereas combining TVP ≥8%, positive surgical margin and lymph node invasion, HR was 2.68 (p= 001, 95% CI= 1.50-4.77).

CONCLUSION

TVP can be used as an independent predictor of BCR after radical prostatectomy for prostate cancer. TVP cut-point of ≥8% allows the best discrimination. TVP should be considered in combination with other clinico-pathological factors to improve prediction of long-term oncological outcomes and to stratify BCR risk.

Percent tumor volume vs American Joint Committee on Cancer staging system subclassification for predicting biochemical recurrence in patients with pathologic T2 prostate cancer

PURPOSE

Here, we re-checked the American Joint Committee on Cancer 7th edition subclassification and confirmed the possibility of percent tumor volume as a prognostic factor for biochemical recurrence in the 8th edition subclassification.

METHODS

A total of 1073 patients with pathologic T2 stage disease who underwent radical prostatectomy were included. Exclusion criteria were neoadjuvant therapy and pathologic T3 and N1 disease. Biochemical recurrence-free survival was estimated using the Kaplan-Meier method. Cox hazard regression was used to predict biochemical recurrence.

RESULTS

According to the 7th edition subclassification, 141 patients (13.1%) had T2a, 43 (4.0%) had T2b, and 889 (82.9%) had T2c disease. The 7th edition subclassification did not differ significantly on Kaplan-Meier analysis (p = 0.502). Mean percent tumor volume was 8.7 ± 8.0% (interquartile range, 5-10%). Percent tumor volume was positively correlated with initial prostate-specific antigen, grade group, surgical margin, and T2 subclassification (all p < 0.001). The 7th edition subclassification was not a significant factor, whereas percent tumor volume was (hazard ratio, 1.023; 95% confidence interval, 1.005-1.041; p = 0.0128) on multivariate analysis. On Kaplan-Meier analysis, percent tumor volume (> 7.5% vs ≤ 7.5%) differed significantly for biochemical recurrence-free survival (p < 0.001).

CONCLUSIONS

The 7th edition pathologic T2 subclassification had poor prognostic value for biochemical recurrence in our cohort. Elimination of the 8th edition subclassification was suitable. Percent tumor volume classified biochemical recurrence prognosis in pathologic T2 stage. Therefore, percent tumor volume can be a candidate factor for the next T2 subclassification.

Tumor Volume and Clinical Failure in High-Risk Prostate Cancer Patients Treated With Radical Prostatectomy

INTRODUCTION

To identify the most significant cut-off of tumor volume (TV) for prediction of clinical failure (CF) among high-risk prostate cancer (hPCa) patients.

METHODS

Within a multi-institutional cohort, 262 patients treated with radical prostatectomy (RP) for hPCa were identified. CF was defined as local recurrence or distant metastases. A time dependent ROC curve was used to evaluate the area under the curve (AUC) using TV as single marker to predict clinical failure at 10 years. We searched for the TV cut off value with the highest combined sensitivity and specificity predicting CF. Three multivariable Cox regression analyses (MVA) tested the predictors of CF after RP. Predictors of the model 1 were pre-operative PSA, pathologic stage (PT), pathologic Gleason sum (GS), surgical margin status, and lymph node invasion. Predictors of the models 2 and 3 were the same of model 1 plus TV as a continuous or dichotomous variable using the defined cutoff, respectively. Validation (leave-one-out-cross-validation-LOOCV) of each model was performed.

RESULTS

Overall, 46 (17.6%) patients experienced CF. The TV value was 6.29 ml. In MVA of models 2 and 3, PT and GS remained independent predictors of CF. Moreover, in model 2 TV (HR:1.07,) and in model 3 TV >6.29 ml (HR:2.99,) were independently associated with CF. In LOOCV, the C-index of models 1-3 were 65.53%, 71.75%, and 70.26%, respectively.

CONCLUSIONS

TV is an independent predictor of CF in hPCa patients. Patients with a TV exceeding the cut-off of 6.29 ml are more likely to develop CF. Prostate 77:3-9, 2017. © 2016 Wiley Periodicals, Inc.

Radical prostatectomy and positive surgical margins: relationship with prostate cancer outcome

INTRODUCTION

Positive surgical margins (PSMs) are an adverse factor that may predict a worse outcome in patients submitted to radical prostatectomy (RP). However, not all of these cases will evolve to biochemical (BCR) or clinical (CR) recurrence, therefore relationship between PSMs and these recurrent events has to be correlated with other clinical and pathologic findings to indicate complementary treatment for selected patients.

MATERIALS AND METHODS

Of 1250 patients submitted to open retropubic radical prostatectomy (RRP), between March 1991 and June 2008, the outcome of 161 patients with PSMs and of 67 without PSMs as a control group, comprising a total of 228 cases were retrospectively reviewed. A minimum follow-up time of 2 years after surgery was considered. BCR was determined when PSA ≥ 0.2 ng/mL. CR was determined whenever there was clinical evidence of tumor. Chi-square test was used to correlate clinical and pathologic variables with PSMs. Time interval to biochemical recurrence was analyzed by the Kaplan-Meier product limit analysis using the log-rank test for comparison between groups. Univariate and multivariate Cox stepwise logistic regression models were used to identify significant predictors of risk of shorter intervals to BCR.

RESULTS

Prostate circumference margin was the most common site with 78 cases (48.44%). Regarding the outcome of 228 cases from both groups, BCR occurred in 68 patients (29.82%), and CR in 10 (4.38%). Univariate analysis showed statistically significant associations (p < 0.001) between presence of PSMs with BCR, but not with CR (p = 0.05). At follow-up of the 161 patients with PSMs, only 61(37.8%) presented BCR, while 100 (62.8%) did not. BCR correlated with pathologic stage; Gleason score; preoperative PSA; tumor volume in the specimen; capsular and perineural invasion; presence and number of PSMs. CR correlated only with angiolymphatic invasion and Gleason score. Considering univariate analysis of clinical and pathologic factors predicting progression-free survival at 5 years, prostate weight; preoperative PSA; Gleason score; pathologic stage; tumor volume; PSMs; capsular and perineural invasion were correlated with BCR. At multivariate analysis, only Gleason score and percentage of tumor volume correlated as significant independent predictors of BCR.

CONCLUSION

At univariate analysis, presence, number and location of PSMs have consistent correlation with BCR after RRP, but at follow-up BCR occurred only in 37.8% of patients with PSMs. However at multivariate analysis, the significant risk factors for BCR were percentage of tumor volume (p = 0.022) and Gleason score (p < 0.005) in the surgical specimen. Angiolymphatic invasion and Gleason score were significantly correlated with CR.

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.

Matrix-metalloproteinases in head and neck carcinoma-cancer genome atlas analysis and fluorescence imaging in mice

OBJECTIVE

(1) Obtain matrix-metalloproteinase (MMP) expression profiles for head and neck squamous cell carcinoma (HNSCC) specimens from the Cancer Genomic Atlas (TCGA). (2) Demonstrate HNSCC imaging using MMP-cleavable, fluorescently labeled ratiometric activatable cell-penetrating peptide (RACPP).

STUDY DESIGN

Retrospective human cohort study; prospective animal study.

SETTING

Translational research laboratory.

SUBJECTS AND METHODS

Patient clinical data and mRNA expression levels of MMP genes were downloaded from TCGA data portal. RACPP provides complementary ratiometric fluorescent contrast (increased Cy5 and decreased Cy7 intensities) when cleaved by MMP2/9. HNSCC-tumor bearing mice were imaged in vivo after RACPP injection. Histology was evaluated by a pathologist blinded to experimental conditions. Zymography confirmed MMP-2/9 activity in xenografts. RACPP was applied to homogenized human HNSCC specimens, and ratiometric fluorescent signal was measured on a microplate reader for ex vivo analysis.

RESULTS

Expression of multiple MMPs including MMP2/9 is greater in patient HNSCC tumors than matched control tissue. In patients with human papilloma virus positive (HPV+) tumors, higher MMP2 and MMP14 expression correlates with worse 5-year survival. Orthotopic tongue HNSCC xenografts showed excellent ratiometric fluorescent labeling with MMP2/9-cleavable RACPP (sensitivity = 95.4%, specificity = 95.0%). Fluorescence ratios were greater in areas of higher tumor burden (P < .03), which is useful for intraoperative margin assessment. Ex vivo, human HNSCC specimens showed greater cleavage of RACPP when compared to control tissue (P = .009).

CONCLUSIONS

Human HNSCC tumors show increased mRNA expression of multiple MMPs including MMP2/9. We used RACPP, a ratiometric fluorescence assay of MMP2/9 activity, to show improved occult tumor identification and margin clearance. Ex vivo assays using RACPP in biopsy specimens may identify patients who will benefit from intraoperative RACPP use.

Understanding the relationship between tumor size, gland size, and disease aggressiveness in men with prostate cancer

OBJECTIVE

To determine the relationship between prostate gland and tumor volume in men undergoing radical prostatectomy (RP) for prostate cancer. We hypothesized that larger tumors within smaller prostate glands are associated with more aggressive disease characteristics.

METHODS

Records of patients undergoing RP from 2000-2008 at a single institution were reviewed retrospectively. The dominant nodule was considered to be the largest focus of cancer within the prostate, and the dominant nodule-to-prostate volume ratio (DNVR) was calculated according to the ratio of the dominant nodule volume to the gland weight. Cox regression was performed to assess the relationship between DNVR and both pathologic outcomes (Cancer of the Prostate Risk Assessment post-Surgical score) and biochemical recurrence (BCR).

RESULTS

At a median follow-up of 3.7 years, 174 patients (7.2%) suffered BCR. There was no linear correlation between tumor volume and gland size (R = -0.09). DNVR above the median (≥0.033 cc/gm) was closely associated with high clinicopathologic risk as measured by Cancer of the Prostate Risk Assessment post-Surgical score (hazard ratio, 35.53; 95% confidence interval, 14.42-87.55 for high- vs low-risk groups). In the univariable analysis, both tumor diameter and DNVR were associated with increased risk of BCR. However, in the multivariable model, only tumor diameter remained a significant predictor of BCR (hazard ratio, 2.02; 95% confidence interval, 1.04-3.91).

CONCLUSION

Increased DNVR appears to be a characteristic of aggressive prostate tumors, although it did not predict BCR in the present study. However, these data support the association between tumor diameter and BCR after RP for prostate cancer independent of other key clinicopathologic features.

Defining prostate cancer risk after radical prostatectomy

Prostate cancer encompasses a wide spectrum of tumor phenotypes with differing prognoses and a part of these patients are at risk of experiencing tumor recurrence after initial treatment. This review discusses the parameters that determine PCa risk for failure after radical prostatectomy and also focuses on the ability of currently available post-treatment nomograms to predict treatment outcomes, and probability of treatment failure. The use of predictive nomograms may be therefore helpful in the complex decision making process.

High percent tumor volume predicts biochemical recurrence after radical prostatectomy in pathological stage T3a prostate cancer with a negative surgical margin

OBJECTIVES

To evaluate the impact of percent tumor volume and surgical margin status on biochemical recurrence in pT3-T4 prostate cancer.

METHODS

A total of 397 patients who had pT3-T4N0 diseases and did not receive neoadjuvant or adjuvant therapy were included for analysis.

RESULTS

In the entire cohort, prostate-specific antigen (per 1 ng/mL increase; hazard ratio 1.019; P = 0.002), pathological stage (T3b-T4 vs T3a; hazard ratio 2.283; P < 0.001), Gleason score (≥8 vs ≤6; hazard ratio 5.290; P = 0.005), surgical margin status (multiple positive vs negative; hazard ratio 1.839; P = 0.003) and lymphovascular invasion (present vs absent; hazard ratio 1.641; P = 0.008) were independent predictors of recurrence. Percent tumor volume was an independent predictor of recurrence in T3a diseases with negative surgical margins. In analysis using receiver operating characteristic curve, a threshold of 12% showed the best balance of sensitivity and specificity, 66% and 67%, respectively. The 5-year recurrence-free survival rates of pT3a diseases with negative surgical margin were 85.2% for percent tumor volume ≤12% and 57.7% for percent tumor volume >12% (P < 0.001). Patients with pT3a with negative surgical margins and percent tumor volume >12% showed comparable 5-year recurrence-free survival rate compared with those with pT3a with positive surgical margin (57.7% vs 57.6%; P = 0.763).

CONCLUSIONS

Despite having less impact on recurrence than other clinicopathological variables in pT3-T4 prostate cancer, percent tumor volume can further improve recurrence risk stratification in pT3a diseases with negative surgical margins.

Findings in 12-core transrectal ultrasound-guided prostate needle biopsy that predict more advanced cancer at prostatectomy: analysis of 388 biopsy-prostatectomy pairs

We analyzed 5 features on 12-core transrectal ultrasound-guided prostate needle biopsy (TRUS) to predict the extent of cancer at radical prostatectomy (RP). In 388 TRUS-RP pairs, number of positive cores (NPC), percentage of each core involved (%PC), perineural invasion (PNI), Gleason score (GS), distribution of positive cores (DPC), and preoperative prostate-specific antigen (PSA) were correlated with extraprostatic extension (EPE), seminal vesicle invasion (SVI), positive surgical margin (R1), positive lymph nodes (N1), and tumor volume. All features predicted EPE and SVI. NPC, GS, %PC, and PNI strongly predicted R1 status. RP tumor volume was directly proportional to the NPC and %PC. PSA alone and with selected biopsy findings correlated with tumor volume, stage, SVI, and N1 (P < .0001). Contiguous DPC was a significant risk for EPE and SVI (P < .0001) compared with isolated positive cores. Findings at 12-core TRUS along with preoperative PSA reliably predict advanced local disease and have practical value as guides to effective planning for surgical resections.