Impact of the primary Gleason pattern on biochemical recurrence-free survival after radical prostatectomy: a single-center cohort of 1,248 patients with Gleason 7 tumors

Gleason score 3+3=6 prostatic adenocarcinoma is not benign and the current debate is unhelpful to clinicians and patients

Prostate adenocarcinoma is a common malignancy associated with a significant morbidity and mortality. In both prostate biopsies and radical prostatectomy specimens Gleason scoring informs both treatment and outcome prediction. The current convention is that in needle biopsies, Gleason patterns 3, 4 and 5 are considered to be malignant. Despite this there is debate as to whether or not Gleason score (GS) 3+3=6 should be diagnosed as cancer due to potential over-treatment and the psychological impact on patients. It is apparent that GS 3+3=6 is indolent disease with a low risk of metastasis. However, it does have the histological features of malignancy and is capable of infiltrating the prostate gland, extraprostatic extension, and metastatic spread. Furthermore GS 3+3=6 carcinoma has immunohistochemical and molecular genetic features similar to those of higher grade prostatic carcinoma. If GS 3+3=6 tumour is considered benign, the question arises should a benign label be given to the Gleason pattern 3 component of tumour that includes Gleason patterns of higher grade? This would seem a logical step as GS 3+3=6 cancers and the pattern 3 component in cancers with multiple patterns are morphologically identical. If pattern 3 is considered to be benign, then Gleason scoring would be limited to 4+4=8, 4+5=9, 5+4=9 and 5+5=10 which is clearly inappropriate. The correct strategy to address potential over-treatment of patients with low-grade cancer is clinician and patient education, not the recalibration of Gleason grading to reclassify malignant tumours as benign.

The Impact of Gleason Grade 3 as a Predictive Factor for Biochemical Recurrence after Robot-Assisted Radical Prostatectomy: A Retrospective Multicenter Cohort Study in Japan (The MSUG94 Group)

Background and Objectives: This study’s objective was to examine patients treated with robot-assisted radical prostatectomy (RARP) for intermediate-risk prostate cancer (IR-PCa), and to identify preoperative risk factors for biochemical recurrence (BCR) in these patients in Japan. Materials and Methods: We conducted a retrospective multicenter cohort study of patients with PCa who underwent RARP at 10 institutions in Japan. A total of 3195 patients were enrolled in this study. We focused on patients with IR-PCa who underwent RARP. We obtained data on pre- and postoperative covariates from the enrolled patients. Biochemical recurrence-free survival was the primary endpoint of this study. We also identified useful preoperative predictive factors for BCR in patients with IR-PCa after RARP. Results: A total of 1144 patients with IR-PCa were enrolled in this study. The median follow-up period was 23.7 months. At the end of the follow-up period, 94 (8.2%) patients developed BCR. The 2 and 3 year biochemical recurrence-free survival (BRFS) rates were 92.2% and 90.2%, respectively. Using the Kaplan–Meier method, Gleason grade (GG) 3 was significantly associated with poor BRFS compared with ≤GG 2. In multivariate analysis, GG 3 was a significant predictive factor for BCR in patients with IR-PCa. Conclusions: The results of the study indicated a significant relationship between GG 3 and post-RARP BCR in patients with IR-PCa.

Factors affecting biochemical recurrence of prostate cancer after radical prostatectomy in patients with positive and negative surgical margin

Purpose

To investigate the clinical and pathological predictive factors affecting biochemical recurrence (BCR) after radical prostatectomy (RP) in patients with positive and negative surgical margin (SM).

Methods

Patients who underwent RP were retrospectively reviewed for the study. Demographic, clinical, pathological and oncological data were evaluated. All data were compared between patients with positive SM and negative SM to detect factors associated with SM status. Later, patients were divided into two groups as BCR-negative and BCR-positive groups. Data were separately compared between BCR groups for all patients, SM-negative and SM-positive patients, respectively.

Results

A total of 254 patients with a mean age of 63.5 years and the mean prostate-specific antigen of 10.9 ng/ml were evaluated in the study. SM positivity was found to be an independent prognostic factor for BCR (p = 0.013, Odds Ratio (OR): 0.267, 95% Confidence Interval (CI): 0.094-0.755). In SM-positive patients, biopsy Gleason Score and International Society of Urological Pathology grade were found to be independent predictive factors for BCR (p < 0.05). However, only tumor to SM distance (TSMD) was found to be an independent risk factor for BCR (p = 0.024) in SM-negative patients. The predictive cutoff value of the TSMD was found to be 75 μm for BCR (100% sensitivity and 63.9% specificity) (AUC = 0.803, p = 0.024). Although all of 46 patients with >75 μm TSMD were recurrence free, 5 of 31 patients with <75 μm TSMD had BCR (p = 0.009; OR: 0.839 CI: 0.719-0.979).

Conclusion

High Gleason Score and International Society of Urological Pathology grade of biopsy were found to be associated with BCR in SM-positive patients. For SM-negative patients, only TSMD was found to be associated with BCR after RP.

Nomograms Predict Survival Advantages of Gleason Score 3+4 Over 4+3 for Prostate Cancer: A SEER-Based Study

Background: Different proportions of Gleason pattern 3 and Gleason pattern 4 lead to various prognosis of prostate cancer with Gleason score 7. The objective of this study was to compare the survival outcomes of Gleason score 3+4 and 4+3 based on data from the Surveillance, Epidemiology, and End Results cancer registry database, and to investigate independent prognosis-associated factors and develop nomograms for predicting survival in Gleason score 7 prostate cancer patients.

Methods: A retrospective study was conducted on 69,116 cases diagnosed as prostate adenocarcinoma with Gleason score 7 between 2004 and 2009. Prognosis-associated factors were evaluated using univariate and multivariate Cox regression analysis, and a 1:1 ratio paired cohort by propensity score matching with the statistical software IBM SPSS, to evaluate prognostic differences between Gleason score 3+4 and 4+3. The primary cohort was randomly divided into training set (n = 48,384) and validation set (n = 20,732). Based on the independent factors of prognosis, nomograms for prognosis were established by the training group and validated by the validation group using R version 3.5.0.

Results: After propensity score matching, Cox regression analysis showed that Gleason 4+3 had an increased mortality risk both for overall survival (HR: 1.235, 95% CI: 1.179–1.294, P < 0.001) and cancer-specific survival (HR: 1.606, 95% CI: 1.468–1.762, P < 0.001). Nomograms for overall survival and cancer-specific survival were established with C-index 0.786 and 0.842, respectively. The calibration plot indicated an optimal agreement between the actual observation and nomogram prediction for overall survival and cancer-specific survival probability at 5 or 10 year.

Conclusions: Prostate cancer with Gleason score 4+3 had worse overall survival and cancer-specific survival than Gleason score 3+4. Nomograms were formulated to predict 5-year and 10-year OS and CSS in patients with prostate cancer of Gleason score 7.

The new ISUP 2014/WHO 2016 prostate cancer grade group system: first résumé 5 years after introduction and systemic review of the literature

PURPOSE

To systematically and comprehensively review and summarize the most recent literature assessing the value of the new grading system introduced by the International Society of Urological Pathology (ISUP) in 2014 and accepted by the World Health Organization (WHO) in 2016.

METHODS

A systematic literature search in the PubMed database was performed up to November 2018. Overall, 15 studies in the period from 2016 to 2018 evaluating the new grading system have been selected for evidence synthesis.

RESULTS

The main goals of the new ISUP 2014/WHO 2016 grading system were to establish (I) a more accurate and simplified grade stratification, (II) less overtreatment of indolent prostate cancer as well as (III) an improved patient communication. The majority of the studies chose biochemical recurrence as an endpoint for evaluation and statistically assigns the new ISUP 2014/WHO 2016 grading system a higher prognostic accuracy than the former Gleason grading. However, in only a subset of studies it was clearly evident that the historical samples were not only re-grouped according to the new grade groups but also re-graded according to the new histomorphological 2014 ISUP criteria.

CONCLUSIONS

The vast majority of the studies support an improved prognostic accuracy of the ISUP 2014/WHO 2016 grade groups and endorse its worldwide application.

Performance characteristics of prostate-specific antigen density and biopsy primary Gleason score to predict biochemical failure in patients with intermediate prostate cancer who underwent radical prostatectomy

Background

Prognosis for intermediate-risk prostate cancer (PCa) remains variable; therefore, we aimed to investigate high-risk factors for biochemical recurrence (BCR), and intermediate-risk PCa using radical prostatectomy to identify patients having equivalent BCR-free survival rates when compared to high-risk PCa.

Patients and methods

A total of 441 medical records were analyzed, including those of 169 intermediate-risk and 272 high-risk PCa patients. Risk factors for time to BCR were tested and analyzed using Kaplan–Meier survival analysis, log-rank tests, and Cox proportion hazards models.

Results

In the intermediate-risk group, prostate-specific antigen density (PSAD) and primary Gleason pattern were significant preoperative risk factors for BCR. Moreover, BCR-free survival of patients in the intermediate-risk group with a higher PSAD (>0.5 ng/mL/cm³) was comparable with that of patients in the high-risk group (P=0.735). When combining primary Gleason pattern 4 and 3 with PSAD cut-offs 0.3–0.7 ng/mL/cm³, we found that BCR-free survival of patients in the intermediate-risk group with a primary Gleason pattern 4 and PSAD >0.3 ng/mL/cm³ was comparable with that of patients in the high-risk group (P=0.463).

Conclusion

PSAD and primary Gleason pattern are potential risk factors associated with biochemical failure in intermediate-risk PCa patients after radical prostatectomy. Regarding significant differences in prognosis according to PSAD as well as primary Gleason pattern on biopsy, a subset of the intermediate-risk patients could be identified with outcomes that were equivalent to that of high-risk patients.

Positive surgical margin is associated with biochemical recurrence risk following radical prostatectomy: a meta-analysis from high-quality retrospective cohort studies

Background and purpose

Although numerous studies have shown that positive surgical margin (PSM) is linked to biochemical recurrence (BCR) in prostate cancer (PCa), the research results have been inconsistent. This study aimed to explore the association between PSM and BCR in patients with PCa following radical prostatectomy (RP).

Materials and methods

In accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), PubMed, EMBASE and Wan Fang databases were searched for eligible studies from inception to November 2017. The Newcastle–Ottawa Scale was used to assess the risk of bias of the included studies. Meta-analysis was performed by using Stata 12.0. Combined hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs) were calculated using random-effects or fixed-effects models.

Results

Ultimately, 41 retrospective cohort studies of high quality that met the eligibility criteria, comprising 37,928 patients (94–3294 per study), were included in this meta-analysis. The results showed that PSM was associated with higher BCR risk in both univariate analysis (pooled HR = 1.56; 95% CI 1.46, 1.66; p < 0.001) and multivariate analysis (pooled HR = 1.35; 95% CI 1.27, 1.43; p < 0.001). Moreover, no potential publication bias was observed among the included studies in univariate analysis (p-Begg = 0.971) and multivariate analysis (p-Begg = 0.401).

Conclusions

Our meta-analysis demonstrated that PSM is associated with a higher risk of BCR in PCa following RP and could serve as an independent prognostic factor in patients with PCa.

Electronic supplementary material

The online version of this article (10.1186/s12957-018-1433-3) contains supplementary material, which is available to authorized users.

Incidence of metastasis and prostate-specific antigen levels at diagnosis in Gleason 3+4 versus 4+3 prostate cancer

Aims:

The aim is to assess for a difference in the incidence of metastasis (IM) and prostate-specific antigen (PSA) levels at diagnosis in patients with Gleason score (GS) 3+4 versus 4+3 prostate cancer using a large veterans affairs database.

Subjects and Methods:

A retrospective review of 1402 medical records from 5 VA hospitals was conducted. The study period was from 2009 to 2014. Primary endpoints were IM and PSA levels at diagnosis. A secondary endpoint was overall survival.

Statistical Analysis Used:

Chi-square tests for categorical variables, Student's t-test for continuous, normally distributed variables, and rank sum tests for continuous nonnormally distributed variables.

Results:

There were 1050 patients with GS3+4 and 352 with GS4+3. There were no differences in sociodemographic and clinical characteristics of the study population. PSA at the time of diagnosis was significantly higher in the GS4+3 patients compared to GS3+4 (18.0 vs. 11.4, respectively; P < 0.001). The IM at diagnosis was higher in the GS4+3 patients (10/352) compared to GS3+4 (9/1041) (2.8% vs. 0.9%; P = 0.005). In an adjusted model, GS4+3 was associated with higher PSA, higher IM at diagnosis. There was no difference in overall survival between the 2 groups though a 23% reduction in overall survival in the GS4+3 was noted (P = 0.53).

Conclusions:

Our results indicate that patients with GS4+3 prostate cancers have higher PSA levels at diagnosis. GS4+3 is associated with 3-fold increased risk of IM at diagnosis than GS3+4 though the overall incidence is low. Further research is needed to assess whether GS4+3 patients need routine staging imaging investigations at the time of diagnosis similar to patients with higher Gleason scores (GS ≥8).

Oncological outcomes in an Australian cohort according to the new prostate cancer grading groupings

Background

A new 5-tiered grading grouping system has recently been endorsed for reporting of prostate cancer (PCa) grade to better reflect escalating risk of progression and cancer death. While several validations of the new grade groupings have been undertaken, most have involved centralised pathological review by specialist urological pathologists.

Methods

Participants included 4268 men with non-metastatic PCa diagnosed between 2006 and 2013 from the multi-institutional South Australia Prostate Cancer Clinical Outcomes Collaborative registry. PCa-specific survival and biochemical recurrence-free survival were compared across the five grade groups using multivariable competing risk regression.

Results

For the entire cohort, risk of PCa death increased with increasing grade groups (at biopsy) Adjusted subdistribution-hazard ratios [sHR] and 95% confidence intervals [95%CI] were: 2.2 (1.5–3.6); 2.5 (1.6–4.2); 4.1 (2.6–6.7) and 8.7 (4.5–14.0) for grade groups II (pattern 3 + 4), III (pattern 4 + 3), IV (total score 8) and V (total score 9–10) respectively, relative to grade group I (total score < =6). Clear gradients in risk of PCa death were observed for radical prostatectomy (RP), but were less clear for those who had radiotherapy (RT) with curative intent and those who were managed conservatively. Likewise, risk of biochemical recurrence increased across grade groups, with a strong and clear gradient for men undergoing RP [sHR (95%CI): 2.0 (1.4–2.8); 3.8 (2.9–5.9); 5.3 (3.5–8.0); 11.2 (6.5–19.2) for grade groups II, III, IV and V respectively, relative to grade group I], and a less clear gradient for men undergoing RT.

Conclusion

In general, the new five-tiered grade groupings distinguished PCa survival and recurrence outcomes for men with PCa. The absence of a clear gradient for RT may be due to heterogeneity in this patient group.

Prognostic Significance of Percentage and Architectural Types of Contemporary Gleason Pattern 4 Prostate Cancer in Radical Prostatectomy

The International Society of Urological Pathology (ISUP) 2014 consensus meeting recommended a novel grade grouping for prostate cancer that included dividing Gleason score (GS) 7 into grade groups 2 (GS 3+4) and 3 (GS 4+3). This division of GS 7, essentially determined by the percent of Gleason pattern (GP) 4 (< or >50%), raises the question of whether a more exact quantification of the percent GP 4 within GS 7 will yield additional prognostic information. Modifications were also made by ISUP regarding the definition of GP 4, now including 4 main architectural types: cribriform, glomeruloid, poorly formed, and fused glands. This study was conducted to analyze the prognostic significance of the percent GP 4 and main architectural types of GP 4 according to the 2014 ISUP grading criteria in radical prostatectomies (RPs). The cohort included 585 RP cases of GS 6 (40.2%), 3+4 (49.0%), and 4+3 (10.8%) prostate cancers. Significantly different 5-year biochemical recurrence (BCR)-free survival rates were observed among GS 6 (99%, 95% confidence interval [CI]: 97%-100%), 3+4 (81%, 95% CI: 76%-86%), and 4+3 (60%, 95% CI: 45%-71%) cancers (P<0.01). Dividing the GP 4 percent into quartiles showed a 5-year BCR-free survival of 84% (95% CI: 78%-89%) for 1% to 20%, 74% (95% CI: 62%-83%) for 21% to 50%, 66% (95% CI: 50%-78%) for 51% to 70%, and 32% (95% CI: 9%-59%) for >70% (P<0.001). Among the GP 4 architectures, cribriform was the most prevalent (43.7%), and combination of architectures with cribriform present was more frequently observed in GS 4+3 (60.3%). Glomeruloid was mostly (67.1%) seen combined with other GP 4 architectures. Unlike the other GP 4 architectures, glomeruloid as the sole GP 4 was observed only as a secondary pattern (ie, 3+4). Among patients with GS 7 cancer, the presence of cribriform architecture was associated with decreased 5-year BCR-free survival when compared with GS 7 cancers without this architecture (68% vs. 85%, P<0.01), whereas the presence of glomeruloid architecture was associated with improved 5-year BCR-free survival when compared with GS 7 cancers without this architecture (87% vs. 75%, P=0.01). However, GS 7 disease having only the glomeruloid architecture had significantly lower 5-year BCR-free survival than GS 6 cancers (86% vs. 99%, P<0.01). Multivariable Cox proportional hazards regression model for factors associated with BCR among GS 7 cancers identified age (hazard ratio [HR] 0.95, P<0.01), preoperative prostate-specific antigen (HR 1.07, P<0.01), positive surgical margin (HR 2.70, P<0.01), percent of GP 4 (21% to 50% [HR 2.21], 51% to 70% [HR 2.59], >70% [HR 6.57], all P<0.01), presence of cribriform glands (HR 1.78, P=0.02), and presence of glomeruloid glands (HR 0.43, P=0.03) as independent predictors. In conclusion, our study shows that increments in percent of GP 4 correlate with increased risk for BCR supporting the ISUP recommendation of recording the percent of GP 4 in GS 7 prostate cancers at RP. However, additional larger studies are needed to establish the optimal interval for reporting percent GP 4 in GS 7 cancers. Among the GP 4 architectures, cribriform independently predicts BCR, whereas glomeruloid reduces the risk of BCR. Distinction should be made between cribriform and glomeruloid architectures, despite glomeruloid being considered as an early stage of cribriform, as cribriform confers a higher risk for poorer outcome.

Heterogeneous oncologic outcomes according to surgical pathology in high-risk prostate cancer: implications for better risk stratification and preoperative prediction of oncologic outcomes

PURPOSE

To evaluate the better risk stratification based on surgical pathology, and to predict oncologic outcomes after radical prostatectomy (RP) with a better scoring system in high-risk prostate cancer (PCa) patients.

METHODS

We evaluated high-risk PCa patients (PSA >20 ng/ml, ≥cT3a, or Gleason score 8-10) who underwent RP between 2007 and 2013 at our institute. We classified patients into three groups according to their pathologic outcomes: favorable (pT2, Gleason score ≤7, and node negative), intermediate (specimen-confined disease (pT2-3a, node negative PCa with negative surgical margins) but not in the favorable group), and unfavorable (the remaining patients). We developed a risk stratification scoring system to predict prognostic outcomes after RP and validated our scoring system to estimate its predictive accuracy.

RESULTS

Among a total of 356 patients, 95 (26.7%), 115 (32.3%), and 146 (41%) were in the favorable, intermediate, and unfavorable prognostic groups, respectively. The 5-year biochemical recurrence-free survival rates of the patients in each group were 87.8, 64.6, and 41.4%, respectively. We developed a scoring system based on preoperative PSA, clinical stage, percentage of tumor positive core, and percentage of cores with a Gleason score 8-10. This demonstrated internally and externally validated concordance indices of 0.733 and 0.772, respectively.

CONCLUSIONS

Using our scoring system, we can predict which patients with high-risk PCa would benefit more from RP. Thus, this system can be used in patient counseling to determine an optimal treatment strategy for high-risk PCa.

PET and PET/CT with radiolabeled choline in prostate cancer: a critical reappraisal of 20 years of clinical studies

We here aim to provide a comprehensive and critical review of the literature concerning the clinical applications of positron emission tomography/computed tomography (PET/CT) with radiolabeled choline in patients with prostate cancer (PCa). We will initially briefly summarize the historical context that brought to the synthesis of [¹¹C]choline, which occurred exactly 20 years ago. We have arbitrarily grouped the clinical studies in three different periods, according to the year in which they were published and according to their relation with their applications in urology, radiotherapy and oncology. Studies at initial staging and, more extensively, studies in patients with biochemical failure, as well as factors predicting positive PET/CT will be reviewed. The capability of PET/CT with radiolabeled choline to provide prognostic information on PCa-specific survival will also be examined. The last sections will be devoted to the use of radiolabeled choline for monitoring the response to androgen deprivation therapy, radiotherapy, and chemotherapy. The accuracy and the limits of the technique will be discussed according to the information available from standard validation processes, including biopsy or histology. The clinical impact of the technique will be discussed on the basis of changes induced in the management of patients and in the evaluation of the response to therapy. Current indications to PET/CT, as officially endorsed by guidelines, or as routinely performed in the clinical practice will be illustrated. Emphasis will be made on methodological factors that might have influenced the results of the studies or their interpretation. Finally, we will briefly highlight the potential role of positron emission tomography/magnetic resonance and of new radiotracers for PCa imaging.

The effect of Rapid Access Prostate Clinics on the outcomes of Gleason 7 prostate cancer: does earlier diagnosis lead to better outcomes?

INTRODUCTION

Rapid Access Prostate Clinics (RAPC) were introduced in Ireland by the National Cancer Control Programme bringing about expedited referral pathways and increased detection rates of prostate cancer. Lower Gleason (G) grade at diagnosis due to RAPC has been previously reported but grade at prostatectomy has not been assessed. The aim of this study was to assess the impact of RAPC on the outcomes of patients with G7 disease on radical prostatectomy (RP).

METHODS

A retrospective analysis was carried out of all RPs performed over a 9-year period (2006-2014). Outcomes for G7 prostatectomies were compared before and after the introduction of the RAPC, with a further sub-analysis of G4 + 3 versus G3 + 4. The primary outcome was biochemical recurrence (BCR). Other outcomes were adjuvant/salvage radiotherapy, extra prostatic extension, positive surgical margins, seminal vesicle involvement and tumour stage.

RESULTS

In total, 240 RPs were performed with 167 cases graded G7 (70 graded G4 + 3 and 97 graded G3 + 4). Since the introduction of RAPC the proportion of G4 + 3 compared to G3 + 4 has increased from 37.9 to 42%. There was no statistical difference in outcomes for G4 + 3 treated before and after the introduction of RAPC. G4 + 3 was associated with higher rates of BCR (24.4 vs. 0%, p < 0.0001, radiotherapy (41.1 vs. 4.8%, p < 0.0001) and worse histological features than G3 + 4.

CONCLUSION

Despite the benefits in diagnosis of prostate cancer brought about by RAPC in Ireland, this has not translated to a lower grade for surgically treated patients. There has been no improvement in outcomes especially for higher grade G4 + 3 disease.

Prediction of prostate cancer recurrence using quantitative phase imaging: Validation on a general population

Prediction of biochemical recurrence risk of prostate cancer following radical prostatectomy is critical for determining whether the patient would benefit from adjuvant treatments. Various nomograms exist today for identifying individuals at higher risk for recurrence; however, an optimistic under-estimation of recurrence risk is a common problem associated with these methods. We previously showed that anisotropy of light scattering measured using quantitative phase imaging, in the stromal layer adjacent to cancerous glands, is predictive of recurrence. That nested-case controlled study consisted of specimens specifically chosen such that the current prognostic methods fail. Here we report on validating the utility of optical anisotropy for prediction of prostate cancer recurrence in a general population of 192 patients, with 17% probability of recurrence. Our results show that our method can identify recurrent cases with 73% sensitivity and 72% specificity, which is comparable to that of CAPRA-S, a current state of the art method, in the same population. However, our results show that optical anisotropy outperforms CAPRA-S for patients with Gleason grades 7-10. In essence, we demonstrate that anisotropy is a better biomarker for identifying high-risk cases, while Gleason grade is better suited for selecting non-recurrence. Therefore, we propose that anisotropy and current techniques be used together to maximize prediction accuracy.

Predictive efficacy of the 2014 International Society of Urological Pathology Gleason grading system in initially diagnosed metastatic prostate cancer

We compared the predictive ability of the 2014 and 2005 Gleason grading systems in 568 patients initially diagnosed with metastatic prostate cancer (PCa). Outcomes included the duration of castration-resistant prostate cancer-free survival (CFS) and overall survival (OS). Univariate analyses and log-rank tests were used to identify prognosis indicators and assess univariable differences in CFS and OS in Gleason score (GS) groups. Cox proportional hazards and area under the curves of receiver operator characteristics methods were used to evaluate the predictive efficacy of the 2005 and 2014 ISUP grading systems. Univariate analyses showed that the 2005 and 2014 grading systems were prognosticators for CFS and OS; both systems could distinguish the clinical outcome of patients with GS 6, GS 7, and GS 8–10. Using the 2014 criteria, no statistical differences in patient survival were observed between GS 3 + 4 and GS 4 + 3 or GS 8 and GS 9–10. The predictive ability of the 2014 and 2005 grading systems was comparable for CFS and OS (P = 0.321). However, the 2014 grading system did not exhibit superior predictive efficacy in patients initially diagnosed with PCa and bone metastasis; trials using larger cohorts are required to confirm its predictive value. To the best of our knowledge, ours is the first study to compare the 2005 and 2014 grading systems in initially diagnosed PCa with bone metastasis. At present, we recommend that both systems should be used to predict the prognosis of patients with metastatic PCa.

Validation of International Society of Urological Pathology (ISUP) grading for prostatic adenocarcinoma in thin core biopsies using TROG 03.04 'RADAR' trial clinical data

In 2014 a consensus conference convened by the International Society of Urological Pathology (ISUP) adopted amendments to the criteria for Gleason grading and scoring (GS) for prostatic adenocarcinoma. The meeting defined a modified grading system based on 5 grading categories (grade 1, GS 3+3; grade 2, GS 3+4; grade 3, GS 4+3; grade 4, GS 8; grade 5, GS 9-10). In this study we have evaluated the prognostic significance of ISUP grading in 496 patients enrolled in the TROG 03.04 RADAR Trial. There were 19 grade 1, 118 grade 2, 193 grade 3, 88 grade 4 and 79 grade 5 tumours in the series, with follow-up for a minimum of 6.5 years. On follow-up 76 patients experienced distant progression of disease, 171 prostate specific antigen (PSA) progression and 39 prostate cancer deaths. In contrast to the 2005 modified Gleason system (MGS), the hazards of the distant and PSA progression endpoints, relative to grade 2, were significantly greater for grades 3, 4 and 5 of the 2014 ISUP grading scheme. Comparison of predictive ability utilising Harrell's concordance index, showed 2014 ISUP grading to significantly out-perform 2005 MGS grading for each of the three clinical endpoints.

Predictors of time to biochemical recurrence in a radical prostatectomy cohort within the PSA-era

INTRODUCTION

We sought to determine predictors for early and late biochemical recurrence following radical prostatectomy among localized prostate cancer patients.

METHODS

The study included localized prostate cancer patients treated with radical prostatectomy (RP) at the University of Southern California from 1988 to 2008. Competing risks regression models were used to determine risk factors associated with earlier or late biochemical recurrence, defined using the median time to biochemical recurrence in this population (2.9 years after radical prostatectomy).

RESULTS

The cohort for this study included 2262 localized prostate cancer (pT2-3N0M0) patients who did not receive neoadjuvant or adjuvant therapies. Of these patients, 188 experienced biochemical recurrence and a subset continued to clinical recurrence, either within (n=19, 10%) or following (n=13, 7%) 2.9 years after RP. Multivariable stepwise competing risks analysis showed Gleason score ≥7, positive surgical margin status, and ≥pT3a stage to be associated with biochemical recurrence within 2.9 years following surgery. Predictors of biochemical recurrence after 2.9 years were Gleason score 7 (4+3), preoperative prostate-specific antigen (PSA) level, and ≥pT3a stage.

CONCLUSIONS

Higher stage was associated with biochemical recurrence at any time following radical prostatectomy. Particular attention may need to be made to patients with stage ≥pT3a, higher preoperative PSA, and Gleason 7 prostate cancer with primary high-grade patterns when considering longer followup after RP.

Increased prostate cancer specific mortality following radical prostatectomy in men presenting with voiding symptoms-A whole of population study

BACKGROUND

Whole of population studies reporting long-term outcomes following radical prostatectomy (RP) are scarce. We aimed to evaluate the long-term outcomes in men with prostate cancer (PC) treated with RP in a whole of population cohort. A secondary objective was to evaluate the influence of mode of presentation on PC specific mortality (PCSM).

METHODS

A prospective database of all cases of RP performed in Victoria, Australia between 1995 and 2000 was established within the Victorian Cancer Registry. Specimen histopathology reports and prostate-specific antigen (PSA) values were obtained by record linkage to pathology laboratories. Mode of presentation was recorded as either PSA screened (PSA testing offered in absence of voiding symptoms) or symptomatic (diagnosis of PC following presentation with voiding symptoms). Multivariate Cox and competing risk regression models were fitted to analyze all-cause mortality, biochemical recurrence, and PCSM.

RESULTS

Between 1995 and 2000, 2,154 men underwent RP in Victoria. During median follow up of 10.2 years (range 0.26-13.5 years), 74 men died from PC. In addition to Gleason score and pathological stage, symptomatic presentation was associated with PCSM. After adjusting for stage and PSA, no difference in PCSM was found between men with Gleason score ≤ 6 and Gleason score 3 + 4 = 7. Men with Gleason score 4 + 3 had significantly greater cumulative incidence of PCSM compared with men with Gleason score 3 + 4.

CONCLUSIONS

Primary Gleason pattern in Gleason 7 PC is an important prognosticator of survival. Our findings suggest that concomitant voiding symptoms should be considered in the work-up and treatment of PC.

Manganese superoxide dismutase (SOD2/MnSOD)/catalase and SOD2/GPx1 ratios as biomarkers for tumor progression and metastasis in prostate, colon, and lung cancer

The role of manganese-dependent superoxide dismutase (SOD2/MnSOD) during tumor progression has been studied for several decades with controversial results. While SOD2 downregulation was initially associated with tumor initiation and was proposed as a tumor suppressor gene, recent studies have reported that SOD2 might favor tumor progression and dissemination. To our knowledge this is the first time that changes in SOD2 expression in three different types of tumors, i.e., prostate, lung, and colon cancer, are studied by analyzing both SOD2 mRNA and protein levels in a total of 246 patients' samples. In prostate samples, SOD2 protein levels were also increased, especially in middle stage tumors. In the case of colon and lung tumors both mRNA and protein SOD2 levels were increased in malignant tissues compared to those in nontumor samples. More importantly, all metastases analyzed showed increased levels of SOD2 when compared to those of normal primary tissue and healthy adjacent tissue. Together, these results suggest that a common redox imbalance in these three types of tumor occurs at intermediate stages which then might favor migration and invasion, leading to a more aggressive cancer type. Consequently, the ratios SOD2/catalase and SOD2/Gpx1 could be considered as potential markers during progression from tumor growth to metastasis.

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.

Primary Gleason pattern in biopsy Gleason score 7 is predictive of adverse histopathological features and biochemical failure following radical prostatectomy

OBJECTIVE

The aim of this study was to analyse whether primary Gleason pattern in biopsy Gleason score (GS) 7 predicted adverse histopathological features and had an impact on the risk of biochemical failure in a consecutive series of patients undergoing radical prostatectomy (RP).

MATERIAL AND METHODS

Between 2006 and 2010, 441 patients with biopsy GS 7 underwent RP at Rigshospitalet, Copenhagen, Denmark. Favourable histopathological features were defined as pT2 margin-negative cancer, RP specimen GS ≤ 3+4 and no lymph-node metastasis. Adverse histopathological features were defined as advanced pT3/4 cancer or pT2 margin-positive cancer and/or RP specimen GS ≥ 4+3 and/or positive lymph nodes. Biochemical failure was defined as the first prostate-specific antigen (PSA) ≥ 0.2 ng/ml.

RESULTS

A total of 344 patients (78.0%) had GS 3+4 in biopsies, while 97 patients (22.0%) had GS 4+3. No difference in age, PSA, percentage of biopsies with cancer, clinical tumour stage or volume on transrectal ultrasonography was found. Primary Gleason pattern 4 was associated with worse pathological stage (p = 0.049). On multivariate analysis, primary Gleason pattern 4 (p < 0.0001), cT stage (p = 0.024), PSA (p < 0.0001) and age (p = 0.009) predicted adverse histopathological features. In univariate analysis, Gleason score 3+4 had a significantly lower biochemical failure rate compared with Gleason score 4+3 (p = 0.0035). PSA (p < 0.0001), primary Gleason pattern 4 (p = 0.001) and percentage of biopsies with cancer (p = 0.02) were independently associated with risk of biochemical failure.

CONCLUSIONS

In biopsies with GS 7, a primary Gleason pattern 4 was associated with significantly elevated risk of adverse histopathological features and biochemical failure compared to pattern 3 in patients undergoing RP. This study underlines the heterogeneity of biopsy GS 7.

Prognostic Gleason grade grouping: data based on the modified Gleason scoring system

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The Gleason scoring system is a well-established predictor of pathological stage and oncological outcomes for men with prostate cancer. Modifications throughout the last few decades - most recently by the International Society of Urological Pathology (ISUP) in 2005 - have attempted to improve the correlation between biopsy and radical prostatectomy Gleason sum and better stratify patients to predict clinical outcomes. Based on these clinical outcomes and the excellent prognosis for patients with low Gleason scores, we recommend Gleason grades incorporating a prognostic grade grouping which accurately reflect prognosis and are clearly understood by physicians and patients alike.

OBJECTIVE

To investigate pathological and short-term outcomes since the most recent Gleason system modifications by the International Society of Urological Pathology (ISUP) in an attempt to divide the current Gleason grading system into prognostically accurate Gleason grade groups.

PATIENTS AND METHODS

We queried the Johns Hopkins Radical Prostatectomy Database (1982-2011), approved by the institutional review board, for men undergoing radical prostatectomy (RP) without a tertiary pattern since 2004 and identified 7869 men. Multivariable models were created using preoperative and postoperative variables; prognostic grade group (Gleason grade ≤ 6; 3 + 4; 4 + 3; 8; 9-10) was among the strongest predictors of biochemical recurrence-free (BFS) survival.

RESULTS

Significant differences were noted among the Gleason grade groups at biopsy; differences were noted in the race, PSA level, clinical stage, number of positive cores at biopsy and the maximum percentage of positive cores among the Gleason grade groups at RP. With a median (range) follow-up of 2 (1-7) years, 5-year BFS rates for men with Gleason grade ≤ 6, 3 + 4, 4 + 3, 8 and 9-10 tumours at biopsy were 94.6, 82.7, 65.1, 63.1 and 34.5%, respectively (P < 0.001 for trend); and 96.6, 88.1, 69.7, 63.7 and 34.5%, respectively (P < 0.001), based on RP pathology.

CONCLUSIONS

The 2005 ISUP modifications to the Gleason grading system for prostate carcinoma accurately categorize patients by pathological findings and short-term biochemical outcomes but, while retaining the essence of the Gleason system, there is a need for a change in its reporting to more closely reflect tumour behaviour. We propose reporting Gleason grades, including prognostic grade groups which accurately reflect prognosis as follows: Gleason score ≤ 6 (prognostic grade group I); Gleason score 3+4=7 (prognostic grade group II); Gleason score 4+3=7 (prognostic grade group III); Gleason score 4+4=8 (prognostic grade group (IV); and Gleason score 9-10 (prognostic grade group (V).

Prognostication of prostate cancer based on TOP2A protein and gene assessment: TOP2A in prostate cancer

Background

TOP2A encodes for topoisomerase IIα, a nuclear enzyme that controls DNA topological structure and cell cycle progression. This enzyme is a marker of cell proliferation in normal and neoplastic tissues; however, little information is available about its expression in prostate cancer (PCa).

Methods

Immunohistochemistry (IHC) was automated using mouse monoclonal antibody against TOP2A (clone SWT3D1; DAKO, Carpenteria, CA, USA) at dilution 1:800 and Flex Plus detection system in autostainer 48Ultra (DAKO). FISH was performed using TOP2A (17q21)/ CEP17 probe kit (Kreateck Biotechnology, San Diego, CA, USA). Biochemical and pathological data from 193 patients with PCa were retrieved for the analysis, whose significance was considered when p < 0.05. Also, fractal analysis was performed in a subset of 20 randomly selected cases.

Results

TOP2A protein expression correlated with higher Gleason scores and higher levels of preoperative PSA (p = 0.018 and p = 0.011). Patients with higher levels of TOP2A presented shorter biochemical recurrence-free survival (BRFS) (p = 0.001). In multivariate analysis, we found that TOP2A remained an independent prognostic factor of BRFS, with a relative risk of 1.98 (p = 0.001; 95% CI, 1.338–2.93); thus, cases that expressed high levels of this enzyme had a shorter BRFS compared with TOP2A-negative or TOP2A-low cases. No alterations in TOP2A gene status nor correlation between FISH and IHC results were observed. Concerning fractal analysis, patients who expressed higher levels of TOP2A have angiolymphatic invasion and presented higher Gleason scores (p = 0.033 and p = 0.025, respectively). Also, patients with higher expression of TOP2A presented shorter BRFS (p = 0.001).

Conclusions

This is the first study to perform TOP2A protein and gene digital assessment and fractal analysis in association with BRFS in a large series of PCa. Also, we show that TOP2A gene copy number alterations are not observed in this type of tumor. So, higher protein expression of TOP2A is not related to gene amplification in PCa. Furthermore, TOP2A protein assessment has prognostic importance and, due to its relation with poor outcome, TOP2A IHC evaluation in the biopsy can represent an important tool for selecting the most suitable surgical and clinical approach for patients with PCa.

Biochemical recurrence in Gleason score 7 prostate cancer in korean men: significance of the primary Gleason grade

Purpose

To evaluate the impact of primary Gleason grade in Gleason score (GS) 7 prostate cancer on biochemical recurrence (BCR) after radical prostatectomy in Korean men.

Materials and Methods

We retrospectively reviewed records of 1,026 patients who underwent radical prostatectomy at Seoul National University Bundang Hospital between November 2003 and June 2009. We excluded patients who had received neoadjuvant therapy and had positive resection margins. Finally, 295 and 113 patients with GS 3+4 and GS 4+3, respectively, were included in this study. All patients were followed for at least 2 years.

Results

Of the 408 GS 7 patients, 295 (72.3%) were 3+4 and 113 (27.7%) were 4+3. Mean serum prostate specific antigen level in primary Gleason 3 was 8.99 ng/ml and primary Gleason 4 was 11.11 ng/ml. Patients with GS 4+3 were more likely to have extracapsular extension (30.1% vs. 17.6%, p<0.010) and lymphatic invasion (16.8% vs. 7.1%, p<0.005). After 2 years follow up BCR was detected in a total of 40 patients. In GS 7 with primary Gleason 3, BCR occurred in 15 (5.08%) patients while 20 (17.70%) showed BCR in GS 7 with primary Gleason 4.

Conclusions

In this study of a large, single center cohort of Korean men with GS 7 prostate cancer a noticeable difference in BCR was seen. Primary Gleason grade 4 have a higher risk of BCR compared to primary Gleason grade 3. This information may be useful when counseling patients on their prognosis and further management options.

Prognostic importance of Gleason 7 disease among patients treated with external beam radiation therapy for prostate cancer: results of a detailed biopsy core analysis

PURPOSE

To analyze the effect of primary Gleason (pG) grade among a large cohort of Gleason 7 prostate cancer patients treated with external beam radiation therapy (EBRT).

METHODS AND MATERIALS

From May 1989 to January 2011, 1190 Gleason 7 patients with localized prostate cancer were treated with EBRT at a single institution. Of these patients, 613 had a Gleason 7 with a minimum of a sextant biopsy with nonfragmented cores and full biopsy core details available, including number of cores of cancer involved, percentage individual core involvement, location of disease, bilaterality, and presence of perineural invasion. Median follow-up was 6 years (range, 1-16 years). The prognostic implication for the following outcomes was analyzed: biochemical recurrence-free survival (bRFS), distant metastasis-free survival (DMFS), and prostate cancer-specific mortality (PCSM).

RESULTS

The 8-year bRFS rate for pG3 versus pG4 was 77.6% versus 61.3% (P<.0001), DMFS was 96.8% versus 84.3% (P<.0001), and PCSM was 3.7% versus 8.1% (P=.002). On multivariate analysis, pG4 predicted for significantly worse outcome in all parameters. Location of disease (apex, base, mid-gland), perineural involvement, maximum individual core involvement, and the number of Gleason 3+3, 3+4, or 4+3 cores did not predict for distant metastases.

CONCLUSIONS

Primary Gleason grade 4 independently predicts for worse bRFS, DMFS, and PCSM among Gleason 7 patients. Using complete core information can allow clinicians to utilize pG grade as a prognostic factor, despite not having the full pathologic details from a prostatectomy specimen. Future staging and risk grouping should investigate the incorporation of primary Gleason grade when complete biopsy core information is used.

Prognostic significance of primary Gleason pattern in Japanese men with Gleason score 7 prostate cancer treated with radical prostatectomy

OBJECTIVES

To evaluate the significance of the primary Gleason pattern in patients with Gleason score (GS) 7 prostate cancer treated with radical prostatectomy.

MATERIALS AND METHODS

This study included 959 consecutive Japanese men who underwent radical prostatectomy without neoadjuvant therapies and were subsequently diagnosed as having GS 7 prostate cancer based on the modified International Society of Urological Pathology (ISUP) 2005 Gleason grading system.

RESULTS

Of these 959 patients, 666 (69.4%) and 293 (30.6%) had GS 3+4 and GS 4+3 tumors, respectively. There were significant differences in the prostate-specific antigen (PSA) level, biopsy GS, pathologic T stage, lymphatic invasion, microvenous invasion, and perineural invasion between these 2 groups. During the mean observation of 48.9 months, biochemical recurrence occurred in 211 patients (22.0%), and there was a significant difference in the biochemical recurrence-free survival between patients with GS 3+4 tumors and those with GS 4+3 tumors. Of several factors examined, biochemical recurrence-free survival was significantly associated with the PSA level, biopsy Gleason score, capsular penetration, seminal vesicle invasion, surgical margin status, lymphatic invasion, microvenous invasion, perineural invasion, and primary Gleason pattern, among which the PSA level, capsular penetration, seminal vesicle invasion, and surgical margin status, but not primary Gleason pattern, appeared to be independent predictors of biochemical recurrence.

CONCLUSIONS

Despite the lack of an independent significance, primary Gleason pattern based on the modified ISUP 2005 Gleason grading system is shown to be significantly associated with the biochemical outcome of Japanese men with GS 7 prostate cancer.

Gleason 7 prostate cancer treated with low-dose-rate brachytherapy: lack of impact of primary Gleason pattern on biochemical failure

What's known on the subject? and What does the study add? There appears to be a clear difference in cancer control outcomes for patients with Gleason scores of 3+4 and those with scores of 4+3 after radical prostatectomy. It has been documented that patients with Gleason 4+3 prostate cancer have higher incidences of non-organ-confined disease than those with primary pattern 3. Higher rates of extracapsular extension, seminal vesicle invasion and positive margins have been found to be associated with primary pattern 4 over 3. These higher rates of non-organ-confined disease can lead to increased biochemical failure, which, in turn, can lead to higher mortality rates. This study provides information on the prognostic significance of primary Gleason pattern in the brachytherapy management of prostate cancer. Study Type - Prognosis (case series) Level of Evidence 4.

OBJECTIVES

• To report the biochemical outcomes for Gleason 7 prostate cancer treated with brachytherapy. • To analyse the impact of the primary Gleason pattern as well as other disease- and treatment-related factors on outcome.

PATIENTS AND METHODS

• A total of 560 patients with Gleason 7 prostate cancer were treated between 1990 and 2008 with brachytherapy, alone or in combination with hormonal therapy and/or external beam radiation therapy. • There were 352 patients with Gleason pattern 3+4 and 208 with Gleason pattern 4+3. • The mean (range) presenting PSA level was 11.2 (1-300) ng/mL, and the median was 7.8 ng/mL. • The presenting clinical stages were T1b in 1%, T1c in 33%, T2a in 16%, T2b in 32%, T2c in 16% and T3 in 2% of patients.

RESULTS

• The actuarial freedom from biochemical failure rate at 10 years was 82%. • There was no significant difference between 10-year freedom from biochemical failure rates for patients with Gleason scores of 3+4 (79%) and those with scores of 4+3 (82%). • Biologically effective dose and presenting PSA level were both significant predictors of biochemical failure in multivariate analysis.

CONCLUSIONS

• The primary Gleason pattern in Gleason 7 prostate cancer shows no significant effect on biochemical failure when treated with brachytherapy. • These results are different from those found after radical prostatectomy and are probably attributable to the enhanced local control afforded by a brachytherapy approach to this disease subset.