Impact of pathology review of stage and margin status of radical prostatectomy specimens (EORTC trial 22911)

Does the extent of extraprostatic extension at radical prostatectomy predict outcome?-a systematic review and meta-analysis

Extraprostatic extension (EPE) of prostate cancer is usually reported as either focal (F-EPE) or established (E-EPE), but data on the implication for outcomes of this subdivision are conflicting and no systematic review (SR) evaluating this exists. This SR aims to address this gap in the literature, focusing on the impact of F-EPE and E-EPE on outcome in radical prostatectomy (RP) patients. Searches on Embase, Medline(R), and Pubmed databases were conducted. Studies were included if they investigated the extent of EPE in RP patients and correlated this with defined outcomes (biochemical recurrence [BCR], death, metastasis). Quality was assessed using the Newcastle-Ottawa Scale. A random effects model was used for studies reporting hazard ratios (EPE extent and biochemical recurrence). 24 studies, including 49,187 men, were included. Six studies were of high quality. 20 studies reported how they measured EPE. 13 studies reported that the extent of EPE was associated significantly with BCR. Meta-analysis showed there was a significant correlation between BCR and both F-EPE and E-EPE when compared to organ-confined disease; no significant difference was found between F-EPE and E-EPE. This is the only SR to investigate the extent of EPE on outcomes after RP. EPE alone predicts outcome, but the value of subdivision by extent could not be demonstrated. Comparisons are limited due to variability in EPE assessment and in the methods used to report outcomes in the literature. Further work to standardize EPE reporting methods, in larger cohorts, may be helpful to resolve remaining questions.

Positive Surgical Margins After Anterior Robot-assisted Radical Prostatectomy: Assessing the Learning Curve in a Multi-institutional Collaboration

BACKGROUND

The learning curve for robot-assisted radical prostatectomy (RARP) remains controversial, with prior studies showing that, in contrast with evidence on open and laparoscopic radical prostatectomy, biochemical recurrence rates of experienced versus inexperienced surgeons did not differ.

OBJECTIVE

To characterize the learning curve for positive surgical margins (PSMs) after RARP.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed the data of 13 090 patients with prostate cancer undergoing RARP by one of 74 surgeons from ten institutions in Europe and North America between 2003 and 2022.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Multivariable models were used to assess the association between surgeon experience at the time of each patient's operation and PSMs after surgery, with adjustment for preoperative prostate-specific antigen level, grade, stage, and year of surgery. Surgeon experience was coded as the number of robotic radical prostatectomies done by the surgeon before the index patient's operation.

RESULTS AND LIMITATIONS

Overall, 2838 (22%) men had PSMs on final pathology. After adjusting for case mix, we found a significant, nonlinear association between surgical experience and probability of PSMs after surgery, with a lower risk of PSMs for greater surgeon experience (p < 0.0001). The probabilities of PSMs for a patient treated by a surgeon with ten, 250, 500, and 2000 prior robotic procedures were 26%, 21%, 18%, and 14%, respectively (absolute risk difference between ten and 2000 procedures: 11%; 95% confidence interval: 9%, 14%). Similar results were found after stratifying patients according to extracapsular extension at final pathology. Results were also unaltered after excluding surgeons who had moved between institutions.

CONCLUSIONS

While we characterized the learning curve for PSMs after RARP, the relative contribution of surgical learning to the achievement of optimal outcomes remains controversial. Future investigations should focus on what experienced surgeons do to avoid positive margins and should explore the relationship between learning, margin rate, and biochemical recurrence. Understanding what margins affect recurrence and whether these margins are trainable or a result of other factors may shed light on where to focus future efforts in surgical education.

PATIENT SUMMARY

In patients receiving robotic radical prostatectomy for prostate cancer, we characterized the learning curve for positive margins. The risk of surgical margins decreased progressively with increasing experience, and plateaued around the 500th procedure. Understanding what margins affect recurrence and whether these margins are trainable or a result of other factors has implications for surgeons and patients, and it may shed light on where to focus future efforts in surgical education.

SARIFA as a new histopathological biomarker is associated with adverse clinicopathological characteristics, tumor-promoting fatty-acid metabolism, and might predict a metastatic pattern in pT3a prostate cancer

BACKGROUND

Recently, we introduced Stroma-AReactive-Invasion-Front-Areas (SARIFA) as a novel hematoxylin-eosin (H&E)-based histopathologic prognostic biomarker for various gastrointestinal cancers, closely related to lipid metabolism. To date, no studies on SARIFA, which is defined as direct tumor-adipocyte-interaction, beyond the alimentary tract exist. Hence, the objective of our current investigation was to study the significance of SARIFA in pT3a prostate cancer (PCa) and explore its association with lipid metabolism in PCa as lipid metabolism plays a key role in PCa development and progression.

METHODS

To this end, we evaluated SARIFA-status in 301 radical prostatectomy specimens and examined the relationship between SARIFA-status, clinicopathological characteristics, overall survival, and immunohistochemical expression of FABP4 and CD36 (proteins closely involved in fatty-acid metabolism). Additionally, we investigated the correlation between SARIFA and biochemical recurrence-free survival (BRFS) and PSMA-positive recurrences in PET/CT imaging in a patient subgroup. Moreover, a quantitative SARIFA cut-off was established to further understand the underlying tumor biology.

RESULTS

SARIFA positivity occurred in 59.1% (n = 178) of pT3a PCas. Our analysis demonstrated that SARIFA positivity is strongly associated with established high-risk features, such as R1 status, extraprostatic extension, and higher initial PSA values. Additionally, we observed an upregulation of immunohistochemical CD36 expression specifically at SARIFAs (p = 0.00014). Kaplan-Meier analyses revealed a trend toward poorer outcomes, particularly in terms of BRFS (p = 0.1). More extensive tumor-adipocyte interaction, assessed as quantity-dependent SARIFA-status on H&E slides, is also significantly associated with high-risk features, such as lymph node metastasis, and seems to be associated with worse survival outcomes (p = 0.16). Moreover, SARIFA positivity appeared to be linked to more distant lymph node and bone metastasis, although statistical significance was slightly not achieved (both p > 0.05).

CONCLUSIONS

This is the first study to introduce SARIFA as easy-and-fast-to-assess H&E-based biomarker in locally advanced PCa. SARIFA as the histopathologic correlate of a distinct tumor biology, closely related to lipid metabolism, could pave the way to a more detailed patient stratification and to the development of novel drugs targeting lipid metabolism in pT3a PCa. On the basis of this biomarker discovery study, further research efforts on the prognostic and predictive role of SARIFA in PCa can be designed.

The Surgical Learning Curve for Biochemical Recurrence After Robot-assisted Radical Prostatectomy

BACKGROUND

Improved cancer control with increasing surgical experience-the learning curve-was demonstrated for open and laparoscopic prostatectomy. In a prior single-center study, we found that this might not be the case for robot-assisted radical prostatectomy (RARP).

OBJECTIVE

To investigate the relationship between prior experience of a surgeon and biochemical recurrence (BCR) after RARP.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively analyzed the data of 8101 patients with prostate cancer treated with RARP by 46 surgeons at nine institutions between 2003 and 2021. Surgical experience was coded as the total number of robotic prostatectomies performed by the surgeon before the patient operation.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We evaluated the relationship of prior surgeon experience with the probability of BCR adjusting for preoperative prostate-specific antigen, pathologic stage, grade, lymph-node involvement, and year of surgery.

RESULTS AND LIMITATIONS

Overall, 1047 patients had BCR. The median follow-up for patients without BCR was 33 mo (interquartile range: 14, 61). After adjusting for case mix, the relationship between surgical experience and the risk of BCR after surgery was not statistically significant (p = 0.2). The 5-yr BCR-free survival rates for a patient treated by a surgeon with prior 10, 250, and 1000 procedures performed were, respectively, 82.0%, 82.7%, and 84.8% (absolute difference between 10 and 1000 prior procedures: 1.6% [95% confidence interval: 0.4%, 3.3%). Results were robust to a number of sensitivity analyses.

CONCLUSIONS

These findings suggest that, as opposed to open and laparoscopic radical prostatectomy, surgeons performing RARP achieve adequate cancer control in the early phase of their career. Further research should explore why the learning curve for robotic surgery differs from prior findings for open and laparoscopic radical prostatectomy. We hypothesize that surgical education, including simulation training and the adoption of objective performance metrics, is an important mechanism for flattening the learning curve.

PATIENT SUMMARY

We investigated the relationship between biochemical recurrence after robot-assisted radical prostatectomy and surgeon's experience. Surgeons at an early stage of their career had similar outcomes to those of more experienced surgeons, and we hypothesized that surgical education in robotics might be an important determinant of such a finding.

ACR Appropriateness Criteria® Pretreatment Detection, Surveillance, and Staging of Prostate Cancer: 2022 Update

Prostate cancer is second leading cause of death from malignancy after lung cancer in American men. The primary goal during pretreatment evaluation of prostate cancer is disease detection, localization, establishing disease extent (both local and distant), and evaluating aggressiveness, which are the driving factors of patient outcomes such as recurrence and survival. Prostate cancer is typically diagnosed after the recognizing elevated serum prostate-specific antigen level or abnormal digital rectal examination. Tissue diagnosis is obtained by transrectal ultrasound-guided biopsy or MRI-targeted biopsy, commonly with multiparametric MRI without or with intravenous contrast, which has recently been established as standard of care for detecting, localizing, and assessing local extent of prostate cancer. Although bone scintigraphy and CT are still typically used to detect bone and nodal metastases in patients with intermediate- or high-risk prostate cancer, novel advanced imaging modalities including prostatespecific membrane antigen PET/CT and whole-body MRI are being more frequently utilized for this purpose with improved detection rates. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The Clinical Significance of Either Extraprostatic Extension or Microscopic Bladder Neck Invasion Alone Versus Both in Men With pT3a Prostate Cancer Undergoing Radical Prostatectomy: A Proposal for a New pT3a Subclassification

The prognosis of prostate cancers exhibiting extraprostatic extension [other than bladder or seminal vesicle invasion (EPE)] and/or microscopic bladder neck invasion (mBNI) is variable, and further risk stratification is required. We herein assessed radical prostatectomy findings and long-term oncologic outcomes in consecutive 957 patients with pT3a disease. The patient cohort was divided into 4 groups, focal EPE (F-EPE) only (n=177; 18.5%), nonfocal/established (E-EPE) only (n=634; 66.2%), mBNI only (n=51; 5.3%). The rate of positive surgical margin and estimated volume of tumor were significantly higher in patients with both EPE and mBNI than in those with either. In addition, compared with F-EPE or mBNI only, E-EPE only was significantly associated with higher Grade Group, lymph node metastasis, and larger tumor volume. Kaplan-Meier analysis revealed a comparable prognosis after prostatectomy between those showing F-EPE only versus mBNI only ( P =0.986), and these 2 cohorts were combined for further analysis. Then, patients showing E-EPE only had a significantly higher or lower risk of progression compared with those showing F-EPE or mBNI only ( P <0.001) or both EPE and mBNI ( P <0.001), respectively. These significant differences in progression-free survival were also seen in subgroups, including those with or without undergoing adjuvant therapy before recurrence and those showing no lymph node metastasis. In multivariate analysis, F-EPE or mBNI only (hazard ratio=0.524, P =0.003) or both EPE and mBNI (hazard ratio=1.465, P =0.039) (vs. E-EPE only) showed significance for progression. Based on these findings, we propose a novel pT3a subclassification, pT3a1 (F-EPE or mBNI alone), pT3a2 (E-EPE alone), and pT3a3 (both EPE and mBNI).

Discriminatory Gleason grade group signatures of prostate cancer: An application of machine learning methods

One of the most precise methods to detect prostate cancer is by evaluation of a stained biopsy by a pathologist under a microscope. Regions of the tissue are assessed and graded according to the observed histological pattern. However, this is not only laborious, but also relies on the experience of the pathologist and tends to suffer from the lack of reproducibility of biopsy outcomes across pathologists. As a result, computational approaches are being sought and machine learning has been gaining momentum in the prediction of the Gleason grade group. To date, machine learning literature has addressed this problem by using features from magnetic resonance imaging images, whole slide images, tissue microarrays, gene expression data, and clinical features. However, there is a gap with regards to predicting the Gleason grade group using DNA sequences as the only input source to the machine learning models. In this work, using whole genome sequence data from South African prostate cancer patients, an application of machine learning and biological experiments were combined to understand the challenges that are associated with the prediction of the Gleason grade group. A series of machine learning binary classifiers (XGBoost, LSTM, GRU, LR, RF) were created only relying on DNA sequences input features. All the models were not able to adequately discriminate between the DNA sequences of the studied Gleason grade groups (Gleason grade group 1 and 5). However, the models were further evaluated in the prediction of tumor DNA sequences from matched-normal DNA sequences, given DNA sequences as the only input source. In this new problem, the models performed acceptably better than before with the XGBoost model achieving the highest accuracy of 74 ± 01, F1 score of 79 ± 01, recall of 99 ± 0.0, and precision of 66 ± 0.1.

The Clinical Impact of pT3a Lesions in Patients With pT3b Prostate Cancer Undergoing Radical Prostatectomy

CONTEXT.—

Seminal vesicle invasion (SVI) by prostate cancer (pT3b disease) has been considered as a key prognostic factor.

OBJECTIVE.—

To assess the clinical impact of T3a lesions (ie, extraprostatic extension other than bladder neck invasion [BNI] or SVI [EPE], microscopic bladder neck invasion [mBNI]) in pT3b disease.

DESIGN.—

We compared radical prostatectomy findings and long-term oncologic outcomes in 248 patients with pT3b disease, with versus without EPE/mBNI.

RESULTS.—

Extraprostatic extension/mBNI was found in 219 (88.3%)/48 (19.4%) cases, respectively. Extraprostatic extension was significantly associated with higher preoperative prostate-specific antigen (PSA) level, higher rates of positive surgical margin (pSM) and lymphovascular invasion (LVI), and larger tumor volume. Similarly, mBNI was significantly associated with higher PSA level, higher rates of Grade Group(s) 4-5 or 5, pSM, LVI, and pN1, and larger tumor volume. Significant differences in all of these clinicopathologic features (except lymph node metastasis) between EPE-/mBNI+ or EPE+/mBNI- and EPE+/mBNI+ cases were also observed. Outcome analysis revealed that patients with EPE (P < .001) or mBNI (P < .001) had a significantly higher risk of disease progression than respective controls. Notably, there were significant differences in progression-free survival between EPE-/mBNI+ or EPE+/mBNI- cases and EPE-/mBNI- (P = .001) or EPE+/mBNI+ (P < .001) cases. In multivariate analysis, EPE (hazard ratio [HR] = 6.53, P = .009) and mBNI (HR = 2.33, P = .003), as well as EPE-/mBNI+ or EPE+/mBNI- (HR = 11.7, P = .01) and EPE+/mBNI+ (HR = 25.9, P = .002) (versus EPE-/mBNI-), showed significance for progression.

CONCLUSIONS.—

From these significant findings, we propose a novel pT3b subclassification: pT3b1 (SVI alone without EPE or mBNI), pT3b2 (SVI with either EPE or mBNI), and pT3b3 (SVI with both EPE and mBNI).

Revisiting extraprostatic extension based on invasion depth and number for new algorithm for substaging of pT3a prostate cancer

Extraprostatic extension (EPE) is a factor in determining pT3a stage in prostate cancer. However, the only distinction in EPE is whether it is focal or non-focal, causing diagnostic and prognostic ambiguity. We substaged pT3a malignancies using classification of EPE to improve personalized prognostication. We evaluated 465 radical prostatectomy specimens with a digital image analyzer by measuring the number, radial distance and two-dimensional square area of the EPE. The most significant cut-off value was proposed as an algorithm for the pT3a substaging system to predict biochemical recurrence (BCR). A combination of the radial distance and the number of EPEs predicted BCR the most effectively. The optimal cut-off criteria were 0.75 mm and 2 mm in radial distance and multifocal EPE (hazard ratio: 2.526, C-index 0.656). The pT3a was subdivided into pT3a1, < 0.75 mm and any number of EPEs; pT3a2, 0.75–2 mm and one EPE; and pT3a3, > 2 mm and any number of EPEs or 0.75–2 mm and ≥ 2 EPEs. This combined tier was highly significant in the prediction of BCR-free survival. The combination of radial distance and number of EPEs could be used to subdivide pT3a prostate cancer and may aid in the prediction of BCR.

Predicting prostate cancer specific-mortality with artificial intelligence-based Gleason grading

Background

Gleason grading of prostate cancer is an important prognostic factor, but suffers from poor reproducibility, particularly among non-subspecialist pathologists. Although artificial intelligence (A.I.) tools have demonstrated Gleason grading on-par with expert pathologists, it remains an open question whether and to what extent A.I. grading translates to better prognostication.

Methods

In this study, we developed a system to predict prostate cancer-specific mortality via A.I.-based Gleason grading and subsequently evaluated its ability to risk-stratify patients on an independent retrospective cohort of 2807 prostatectomy cases from a single European center with 5–25 years of follow-up (median: 13, interquartile range 9–17).

Results

Here, we show that the A.I.’s risk scores produced a C-index of 0.84 (95% CI 0.80–0.87) for prostate cancer-specific mortality. Upon discretizing these risk scores into risk groups analogous to pathologist Grade Groups (GG), the A.I. has a C-index of 0.82 (95% CI 0.78–0.85). On the subset of cases with a GG provided in the original pathology report (n = 1517), the A.I.’s C-indices are 0.87 and 0.85 for continuous and discrete grading, respectively, compared to 0.79 (95% CI 0.71–0.86) for GG obtained from the reports. These represent improvements of 0.08 (95% CI 0.01–0.15) and 0.07 (95% CI 0.00–0.14), respectively.

Conclusions

Our results suggest that A.I.-based Gleason grading can lead to effective risk stratification, and warrants further evaluation for improving disease management.

Gleason grading is the process by which pathologists assess the morphology of prostate tumors. The assigned Grade Group tells us about the likely clinical course of people with prostate cancer and helps doctors to make decisions on treatment. The process is complex and subjective, with frequent disagreement amongst pathologists. In this study, we develop and evaluate an approach to Gleason grading based on artificial intelligence, rather than pathologists’ assessment, to predict risk of dying of prostate cancer. Looking back at tumors and data from 2,807 people diagnosed with prostate cancer, we find that our approach is better at predicting outcomes compared to grading by pathologists alone. These findings suggest that artificial intelligence might help doctors to accurately determine the probable clinical course of people with prostate cancer, which, in turn, will guide treatment.

Wulczyn et al. utilise a deep learning-based Gleason grading model to predict prostate cancer-specific mortality in a retrospective cohort of radical prostatectomy patients. Their model enables improved risk stratification compared to pathologists’ grading and demonstrates the potential for computational pathology in the management of prostate cancer.

Definition and Impact on Oncologic Outcomes of Persistently Elevated Prostate-specific Antigen After Salvage Lymph Node Dissection for Node-only Recurrent Prostate Cancer After Radical Prostatectomy: Clinical Implications for Multimodal Therapy

BACKGROUND

The optimal definition and prognostic significance of persistently elevated prostate-specific antigen (PSA) after salvage lymph node dissection (sLND) for node-only recurrent prostate cancer (PCa) remain unknown.

OBJECTIVE

To assess the definition and clinical implications of persistently elevated PSA after sLND for node-only recurrent PCa after radical prostatectomy.

DESIGN, SETTING, AND PARTICIPANTS

The study included 579 patients treated with sLND at 11 high-volume centers between 2000 and 2016.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We assessed the linear relationship between the first PSA after sLND and death from PCa. Different definitions of PSA persistence were included in a multivariable model predicting cancer-specific mortality (CSM) after surgery to identify the best cutoff value. We investigated the association between PSA persistence and oncologic outcomes using multivariable regression models. Moreover, the effect of early androgen deprivation therapy (ADT) after sLND was tested according to PSA persistence status and estimated risk of CSM.

RESULTS AND LIMITATIONS

We found an inverse relationship between the first PSA after sLND and the probability of cancer-specific survival. PSA persistence defined as first postoperative PSA ≥0.3 ng/ml provided the best discrimination accuracy (C index 0.757). According to this cutoff, 331 patients (57%) experienced PSA persistence. The median follow-up for survivors was 48 mo (interquartile range 27-74). After adjusting for confounders, men with persistently elevated PSA had higher risk of clinical recurrence (hazard ratio [HR] 1.61), overall mortality (HR 2.20), and CSM (HR 2.59; all p < 0.001) after sLND. Early ADT administration after sLND improved survival only for patients with PSA persistence after surgery (HR 0.49; p = 0.024). Similarly, when PSA persistence status was included in multivariable models accounting for pathologic features, early ADT use after sLND was beneficial only for patients with a predicted risk of CSM at 5 yr of >10%.

CONCLUSIONS

PSA persistence after sLND independently predicts adverse prognosis, with the best discrimination accuracy for CSM provided by a definition of PSA ≥ 0.3 ng/ml. We showed that when stratifying patients by final pathology results and PSA persistence status, early ADT use after sLND was beneficial only for patients with PSA persistence or with a calculated 5-yr risk of CSM of >10%, which could be useful as we await results from ongoing prospective trials.

PATIENT SUMMARY

We found that for patients with prostate cancer who had lymph nodes removed after their cancer recurred, persistently elevated prostate-specific antigen (PSA) levels predict poorer prognosis. We showed that a PSA level of ≥0.3 ng/ml provides the best accuracy in identifying patients with worse prognosis. This may help to improve risk stratification after lymph node removal and allow physicians to optimize treatment strategies after surgery.

The impact of positive surgical margins on salvage radiation or androgen deprivation therapy following radical prostatectomy - a nationwide study

BACKGROUND

The extent to which positive surgical margins (PSM) affect the risk of subsequent salvage radiation therapy (sRT) or androgen depletion therapy (ADT) following radical prostatectomy (RP) is not well described. Initiation of additional therapies after RP depend on patient preference, individual factors, local guidelines, and life expectancy. The aim of this study was to analyze differences between margin status in risk of subsequent treatment for PCa following RP in a retrospective population-based cohort from Denmark.

METHODS

Patients who underwent RP were identified in The Danish Prostate Cancer Registry (DaPCaR). Subsequent sRT and ADT were assessed in uni- and multivariate settings and validated with receiver operating characteristic (ROC).

RESULTS

PSM was associated with an increased risk of sRT (HR = 1.85, p < .001) and receiving ADT (HR:1.39, p = .007). Margin status only had a minor impact on the predictive ability for sRT (area under the curve (AUC): p < .001) and no significant impact for subsequent ADT (AUC: p = 1). Significant inter-institutional difference in the association between PSM with sRT or ADT was observed.

CONCLUSION

PSM is associated with the risk of sRT and initiation of ADT, however this association is weak. Our results underline that factors beyond tumor characteristics play a major role for initiation of sRT and ADT.

Development and Validation of a Deep Learning Algorithm for Gleason Grading of Prostate Cancer From Biopsy Specimens

Question

How does a deep learning system for assessing prostate biopsy specimens compare with interpretations determined by specialists in urologic pathology and by general pathologists?

Findings

In a validation data set of 752 biopsy specimens obtained from 2 independent medical laboratories and a tertiary teaching hospital, this study found that rate of agreement with subspecialists was significantly higher for the deep learning system than it was for a cohort of general pathologists.

Meaning

The deep learning system warrants evaluation as an assistive tool for improving prostate cancer diagnosis and treatment decisions, especially where subspecialist expertise is unavailable.

Importance

For prostate cancer, Gleason grading of the biopsy specimen plays a pivotal role in determining case management. However, Gleason grading is associated with substantial interobserver variability, resulting in a need for decision support tools to improve the reproducibility of Gleason grading in routine clinical practice.

Objective

To evaluate the ability of a deep learning system (DLS) to grade diagnostic prostate biopsy specimens.

Design, Setting, and Participants

The DLS was evaluated using 752 deidentified digitized images of formalin-fixed paraffin-embedded prostate needle core biopsy specimens obtained from 3 institutions in the United States, including 1 institution not used for DLS development. To obtain the Gleason grade group (GG), each specimen was first reviewed by 2 expert urologic subspecialists from a multi-institutional panel of 6 individuals (years of experience: mean, 25 years; range, 18-34 years). A third subspecialist reviewed discordant cases to arrive at a majority opinion. To reduce diagnostic uncertainty, all subspecialists had access to an immunohistochemical-stained section and 3 histologic sections for every biopsied specimen. Their review was conducted from December 2018 to June 2019.

Main Outcomes and Measures

The frequency of the exact agreement of the DLS with the majority opinion of the subspecialists in categorizing each tumor-containing specimen as 1 of 5 categories: nontumor, GG1, GG2, GG3, or GG4-5. For comparison, the rate of agreement of 19 general pathologists’ opinions with the subspecialists’ majority opinions was also evaluated.

Results

For grading tumor-containing biopsy specimens in the validation set (n = 498), the rate of agreement with subspecialists was significantly higher for the DLS (71.7%; 95% CI, 67.9%-75.3%) than for general pathologists (58.0%; 95% CI, 54.5%-61.4%) (P < .001). In subanalyses of biopsy specimens from an external validation set (n = 322), the Gleason grading performance of the DLS remained similar. For distinguishing nontumor from tumor-containing biopsy specimens (n = 752), the rate of agreement with subspecialists was 94.3% (95% CI, 92.4%-95.9%) for the DLS and similar at 94.7% (95% CI, 92.8%-96.3%) for general pathologists (P = .58).

Conclusions and Relevance

In this study, the DLS showed higher proficiency than general pathologists at Gleason grading prostate needle core biopsy specimens and generalized to an independent institution. Future research is necessary to evaluate the potential utility of using the DLS as a decision support tool in clinical workflows and to improve the quality of prostate cancer grading for therapy decisions.

Evaluation of the Use of Combined Artificial Intelligence and Pathologist Assessment to Review and Grade Prostate Biopsies

IMPORTANCE

Expert-level artificial intelligence (AI) algorithms for prostate biopsy grading have recently been developed. However, the potential impact of integrating such algorithms into pathologist workflows remains largely unexplored.

OBJECTIVE

To evaluate an expert-level AI-based assistive tool when used by pathologists for the grading of prostate biopsies.

DESIGN, SETTING, AND PARTICIPANTS

This diagnostic study used a fully crossed multiple-reader, multiple-case design to evaluate an AI-based assistive tool for prostate biopsy grading. Retrospective grading of prostate core needle biopsies from 2 independent medical laboratories in the US was performed between October 2019 and January 2020. A total of 20 general pathologists reviewed 240 prostate core needle biopsies from 240 patients. Each pathologist was randomized to 1 of 2 study cohorts. The 2 cohorts reviewed every case in the opposite modality (with AI assistance vs without AI assistance) to each other, with the modality switching after every 10 cases. After a minimum 4-week washout period for each batch, the pathologists reviewed the cases for a second time using the opposite modality. The pathologist-provided grade group for each biopsy was compared with the majority opinion of urologic pathology subspecialists.

EXPOSURE

An AI-based assistive tool for Gleason grading of prostate biopsies.

MAIN OUTCOMES AND MEASURES

Agreement between pathologists and subspecialists with and without the use of an AI-based assistive tool for the grading of all prostate biopsies and Gleason grade group 1 biopsies.

RESULTS

Biopsies from 240 patients (median age, 67 years; range, 39-91 years) with a median prostate-specific antigen level of 6.5 ng/mL (range, 0.6-97.0 ng/mL) were included in the analyses. Artificial intelligence-assisted review by pathologists was associated with a 5.6% increase (95% CI, 3.2%-7.9%; P < .001) in agreement with subspecialists (from 69.7% for unassisted reviews to 75.3% for assisted reviews) across all biopsies and a 6.2% increase (95% CI, 2.7%-9.8%; P = .001) in agreement with subspecialists (from 72.3% for unassisted reviews to 78.5% for assisted reviews) for grade group 1 biopsies. A secondary analysis indicated that AI assistance was also associated with improvements in tumor detection, mean review time, mean self-reported confidence, and interpathologist agreement.

CONCLUSIONS AND RELEVANCE

In this study, the use of an AI-based assistive tool for the review of prostate biopsies was associated with improvements in the quality, efficiency, and consistency of cancer detection and grading.

Inter-observer variability of cribriform architecture and percent Gleason pattern 4 in prostate cancer: relation to clinical outcome

The Grade group is an important parameter for clinical decision-making in prostate cancer. Recently, percent Gleason pattern 4 and presence of invasive cribriform and/or intraductal carcinoma (CR/IDC) have been recognized for their independent predictive value for prostate cancer outcome. There is sparse data on the inter-observer agreement for these pathologic features in practice. Our objectives were to investigate inter-observer variability of percent Gleason pattern and CR/IDC and to relate individual tumour scores to clinical outcome. Our cohort included 80 consecutive radical prostatectomies with a median follow-up 87.1 months (interquartile range 43.3-119.2), of which the slide with largest tumour volume was scored by six pathologists for Grade group (four tiers: 1, 2, 3 and 4/5), percent Gleason pattern 4 (four tiers: 0-25%, 26-50%, 51-75% and 76-100%) and presence of CR/IDC (two tiers: absent, present). The individual assignments were related to post-operative biochemical recurrence (20/80). Inter-observer agreement was substantial (Krippendorff's α 0.626) for assessment of Grade group and moderate for CR/IDC (α 0.507) and percent Gleason pattern 4 (α 0.551). For each individual pathologist, biochemical recurrence rates incremented by Grade group and presence of CR/IDC, although such relation was less clear for percent Gleason pattern 4. In conclusion, inter-observer agreement for CR/IDC and percent Gleason pattern 4 is lower than for Grade groups, indicating awareness of these features needs further improvement. Grade group and CR/IDC, but not percent Gleason pattern 4 was related to biochemical recurrence for each pathologist, indicating overall validity of individual grade assignments despite inter-observer variability.

Long-term Outcomes of Salvage Lymph Node Dissection for Nodal Recurrence of Prostate Cancer After Radical Prostatectomy: Not as Good as Previously Thought

BACKGROUND

Long-term outcomes of patients treated with salvage lymph node dissection (sLND) for nodal recurrence of prostate cancer (PCa) remain unknown.

OBJECTIVE

To investigate long-term oncological outcomes after sLND in a large multi-institutional series.

DESIGN, SETTING, AND PARTICIPANTS

The study included 189 patients who experienced prostate-specific antigen (PSA) rise and nodal-only recurrence after radical prostatectomy (RP) and underwent sLND at 11 tertiary referral centers between 2002 and 2011. Lymph node recurrence was documented by positron emission tomography/computed tomography (PET/CT) scan using either ¹¹C-choline or ⁶⁸Ga prostate-specific membrane antigen ligand.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome of the study was cancer-specific mortality (CSM). The secondary outcomes were overall mortality, clinical recurrence (CR), biochemical recurrence (BCR), and androgen deprivation therapy (ADT)-free survival after sLND. The probability of freedom from each outcome was calculated using Kaplan-Meier analyses. Cox regression analysis was used to predict the risk of prostate CSM after accounting for several parameters, including the use of additional treatments after sLND.

RESULTS AND LIMITATIONS

At long term, 110 and 163 patients experienced CR and BCR, respectively, with CR-free and BCR-free survival at 10 yr of 31% and 11%, respectively. After sLND, a total of 145 patients received ADT, with a median time to ADT of 41 mo. At a median (interquartile range) follow-up for survivors of 87 (51, 104) mo, 48 patients died. Of them, 45 died from PCa. The probabilities of freedom from cancer-specific and all-cause death at 10 yr were 66% and 64%, respectively. Similar results were obtained in sensitivity analyses in patients with pelvic-only positive PET/CT scan, as well as after excluding men on ADT at PET/CT scan and patients with PSA level at sLND higher than the 75th percentile. At multivariable analyses, patients who had PSA response after sLND (hazard ratio [HR]: 0.45; p = 0.001), and those receiving ADT within 6 mo from sLND (HR: 0.51; p = 0.010) had lower risk of death from PCa.

CONCLUSIONS

A third of men treated with sLND for PET-detected nodal recurrence of PCa died at long term, with PCa being the main cause of death. Salvage LND alone was associated with durable long-term outcomes in a minority of men who significantly benefited from additional treatments after surgery. Taken together, all these data argue against the use of metastasis-directed therapy alone for patients with node-only recurrent PCa. These men should instead be considered at high risk of systemic dissemination already at the time of sLND.

PATIENT SUMMARY

We assessed long-term outcomes of patients treated with salvage lymph node dissection (sLND) for node-recurrent prostate cancer (PCa). In contrast with prior evidence, we found that the majority of these men recurred after sLND and eventually died from PCa. A significant survival benefit associated with the administration of androgen deprivation therapy after sLND suggests that sLND should be considered part of a multimodal approach rather than an exclusive treatment strategy.

Prognostic Value of Gleason Score at Positive Surgical Margin in Prostate Cancer: A Systematic Review and Meta-analysis

The individual clinical significance of a positive surgical margin (PSM) after radical prostatectomy has remained controversial. Studies have suggested that the Gleason grade (GG) at the PSM could improve predictive accuracy and decision making. Our objective was to systematically review the reported data to determine the effect of the GG at the PSM on the prognosis after radical prostatectomy. A systematic review was conducted by searching MEDLINE/PubMed for studies reported by June 2019 in accordance with the Preferred Reporting Items for Systematic Review statement. The keywords used included prostate cancer, radical prostatectomy, positive surgical margin, Gleason score, and/or Gleason grade. After a systematic literature review, 10 studies were included, comprising 14,108 patients, of whom 2454 (17.4%) had a PSM and 428 (14%) eventually experienced biochemical recurrence (BCR) within a median follow-up of 18 to 156 months. Data on neoadjuvant or adjuvant therapy were not estimable. In a meta-analysis, GG4 at PSM was significantly associated with BCR compared with GG3 (pooled hazard ratio, 1.87; 95% confidence interval, 1.53-2.28; z = 6.16). The Cochrane Q test (χ² = 5.88; P = .318) and I² test (I² = 15.0%) showed that no significant heterogeneity was present. GG4 at a PSM is a feature of biologically and clinically aggressive prostate cancer that is associated with a significant increase risk of BCR. GG at PSM should be recorded in each pathological report. Given this adverse prognostic value patients with GG4 at the PSM should be considered for multimodal therapy such as radiotherapy.

On Being Sick and Tired

It is crucial that urologists keep abreast of the latest advances in medical research. This should include an awareness of the role of imaging techniques, collaboration in multidisciplinary teams, adherence to current guidelines, and ongoing documentation of postoperative complications and outcomes. Taken together, these key elements should facilitate optimisation of patient management in routine clinical practice.

"Real-time" Assessment of Surgical Margins During Radical Prostatectomy: State-of-the-Art

Histopathologic examination of the pathologic specimens using hematoxylin & eosin stains represents the backbone of the modern pathology. It is time-consuming; thus, "real-time" assessment of prostatic and periprostatic tissue has gained special interest in the diagnosis and management of prostate cancer. The current study focuses on the review of the different available techniques for "real-time" evaluation of surgical margins during radical prostatectomy (RP). We performed a comprehensive search of the Medline database to identify all the articles discussing "real-time" or intraoperative assessment of surgical margins during RP. Several filters were applied to the search to include only English articles performed on human subjects and published between January 2000 and March 2019. The search revealed several options for pathologic assessment of surgical margins including intraoperative frozen sections, confocal laser endomicroscopy, optical spectroscopy, photodynamic diagnosis, optical coherence tomography, multiphoton microscopy, structured illumination microscopy, 3D augmented reality, and ex vivo fluorescence confocal microscope. Frozen section represents the gold standard technique for real-time pathologic examinations of surgical margins during RP; however, several other options showed promising results in the initial clinical trials, and considering the rapid development in the field of molecular and cellular imaging, some of these options may serve as an alternative to frozen section.

Development and validation of a deep learning algorithm for improving Gleason scoring of prostate cancer

For prostate cancer patients, the Gleason score is one of the most important prognostic factors, potentially determining treatment independent of the stage. However, Gleason scoring is based on subjective microscopic examination of tumor morphology and suffers from poor reproducibility. Here we present a deep learning system (DLS) for Gleason scoring whole-slide images of prostatectomies. Our system was developed using 112 million pathologist-annotated image patches from 1226 slides, and evaluated on an independent validation dataset of 331 slides. Compared to a reference standard provided by genitourinary pathology experts, the mean accuracy among 29 general pathologists was 0.61 on the validation set. The DLS achieved a significantly higher diagnostic accuracy of 0.70 (p = 0.002) and trended towards better patient risk stratification in correlations to clinical follow-up data. Our approach could improve the accuracy of Gleason scoring and subsequent therapy decisions, particularly where specialist expertise is unavailable. The DLS also goes beyond the current Gleason system to more finely characterize and quantitate tumor morphology, providing opportunities for refinement of the Gleason system itself.

The use of digital pathology and image analysis in clinical trials

Digital pathology and image analysis potentially provide greater accuracy, reproducibility and standardisation of pathology-based trial entry criteria and endpoints, alongside extracting new insights from both existing and novel features. Image analysis has great potential to identify, extract and quantify features in greater detail in comparison to pathologist assessment, which may produce improved prediction models or perform tasks beyond manual capability. In this article, we provide an overview of the utility of such technologies in clinical trials and provide a discussion of the potential applications, current challenges, limitations and remaining unanswered questions that require addressing prior to routine adoption in such studies. We reiterate the value of central review of pathology in clinical trials, and discuss inherent logistical, cost and performance advantages of using a digital approach. The current and emerging regulatory landscape is outlined. The role of digital platforms and remote learning to improve the training and performance of clinical trial pathologists is discussed. The impact of image analysis on quantitative tissue morphometrics in key areas such as standardisation of immunohistochemical stain interpretation, assessment of tumour cellularity prior to molecular analytical applications and the assessment of novel histological features is described. The standardisation of digital image production, establishment of criteria for digital pathology use in pre-clinical and clinical studies, establishment of performance criteria for image analysis algorithms and liaison with regulatory bodies to facilitate incorporation of image analysis applications into clinical practice are key issues to be addressed to improve digital pathology incorporation into clinical trials.

Prognostic value of unifocal and multifocal positive surgical margins in a large series of robot-assisted radical prostatectomy for prostate cancer

PURPOSE

To evaluate the prognostic value of positive surgical margins (PSM) focality for the prediction of biochemical recurrence (BCR) in patients undergoing robotic-assisted radical prostatectomy (RARP) for prostate cancer.

METHODS

All men with clinically localized prostate cancer undergoing RARP in our tertiary referral centre between May 2005 and August 2016 were retrospectively identified. Patients with neoadjuvant therapy were excluded. Comparisons were made between cases with negative surgical margins (NSM), unifocal PSM (uPSM), and multifocal PSM (mPSM).

RESULTS

From a total of 973 patients available for analysis, 315 (32%) had a PSM. In these patients, 190 had uPSM and 125 had mPSM. Focality of PSM was significantly associated with tumour stage and grade, preoperative PSA, and postoperative PSA persistence (all p < 0.001), but not with nerve sparing (NS) (p = 0.15). PSA persistence was found in 120 (12%) patients, resulting in 853 patients available for survival analyses with a median follow-up of 52 months. Both uPSM and mPSM were found to be independent predictors of BCR, conferring a hazard ratio of 1.9 (95% CI 1.3-3.0; p = 0.002) and 3.4 (95% CI 2.1-5.6; p < 0.001), respectively, when compared to NSM. In subgroup analyses, PSM was particularly predictive for BCR when patients underwent unilateral or bilateral NS (p ≤ 0.003).

CONCLUSIONS

Based on a large case series of RARP, we found PSM focality to be an independent predictor of BCR, with a 1.9- and 3.4-fold risk increase for BCR in case of uPSM and mPSM, respectively. PSM seems to be of particular prognostic relevance when NS has been performed.

Harmonization in laboratory medicine: more than clinical chemistry?

The goal of harmonizing laboratory information is to contribute to quality in patient care, ultimately improving upon patient outcomes and safety. The main focus of harmonization and standardization initiatives has been on analytical processes within the laboratory walls, clinical chemistry tests in particular. However, two major evidences obtained in recent years show that harmonization should be promoted not only in the analytical phase but also in all steps of the testing process, encompassing the entire field of laboratory medicine, including innovative areas (e.g. “omics”) rather than just conventional clinical chemistry tests. A large body of evidence demonstrates the vulnerability of the extra-analytical phases of the testing cycle. Because only “good biological samples” can assure good analytical quality, a closer interconnection between the different phases of the cycle is needed. In order to provide reliable and accurate laboratory information, harmonization activities should cover all steps of the cycle from the “pre-pre-analytical” phase (right choice of test at right time for right patient) through the analytical steps (right results with right report) to the “post-post-analytical” steps (right and timely acknowledgment of laboratory information, right interpretation and utilization with any necessary advice as to what to do next with the information provided). In addition, modern clinical laboratories are performing a broad menu of hundreds of tests, covering both traditional and innovative subspecialties of the discipline. In addition, according to a centered viewpoint, harmonization initiatives should not be addressed exclusively to clinical chemistry tests but should also include all areas of laboratory medicine.

Endorectal MR imaging of prostate cancer: Evaluation of tumor capsular contact length as a sign of extracapsular extension

OBJECTIVE

To evaluate the length of contact between dominant tumor foci and the prostatic capsule as a sign of extracapsular extension at endorectal multiparametric MR imaging.

MATERIALS AND METHODS

We retrospectively identified 101 patients over a three-year interval who underwent endorectal multiparametric prostate MR imaging prior to radical prostatectomy for prostate cancer. Two readers identified the presence of dominant tumor focus (largest lesion with PI-RADS version 2 score of 4 or 5), and measured the length of tumor capsular contact and likelihood of extracapsular extension by standard criteria (1-5 Likert scale). Results were analyzed using histopathological review as reference standard.

RESULTS

Extracapsular extension was found at histopathological review in 27 patients. Reader 1 (2) identified dominant tumor in 79 (73) patients, with mean tumor capsular contact length of 18.2 (14.0) mm. The area under the receiver operating characteristic curve for identification of extracapsular extension by tumor capsular contact length was 0.76 for reader 1 and 0.77 for reader 2, with optimal discrimination at values of 18 mm and 21 mm, respectively. In the subset of patients without obvious extracapsular extension by standard criteria (Likert scores 1-3), corresponding values were 0.74 and 0.66 with optimal thresholds of 24 and 21 mm.

CONCLUSION

Length of contact between the dominant tumor focus and the capsule is a moderately useful sign of extracapsular extension at endorectal multiparametric prostate MR imaging, including the subset of patients without obvious extracapsular extension by standard criteria, with optimal discrimination at threshold values of 18 to 24 mm.

Lymph node yield during radical prostatectomy does not impact rate of biochemical recurrence in patients with seminal vesicle invasion and node-negative disease

OBJECTIVES

Seminal vesicle invasion (SVI) is a risk factor for poor oncologic outcome in patients with prostate cancer. Modifications to the pelvic lymph node dissection (PLND) during radical prostatectomy (RP) have been reported to have a therapeutic benefit. The present study is the first to determine if lymph node yield (LNY) is associated with a lower risk of biochemical recurrence (BCR) for men with SVI.

METHODS

A total of 220 patients from 2 high-volume institutions who underwent RP without adjuvant treatment between 1990 and 2015 and had prostate cancer with SVI (i.e., pT3b) were identified, and 21 patients did not undergo lymph node dissection. BCR was defined as a postoperative PSA>0.2ng/mL, or use of salvage androgen deprivation therapy (ADT) or radiation. Multivariable Cox proportional hazards models were used to determine whether LNY was predictive of BCR, controlling for PSA, pathologic Gleason Score, pathologic lymph node status, NCCN risk category, etc. The Kaplan-Meier method was used to determine 3-year freedom from BCR.

RESULTS

Median number of lymph nodes sampled were 7 (IQR: 3-12; range: 0-35) and 90.5% underwent PLND. The estimated 3-year BCR rate was 43.9%. Results from multivariable analysis demonstrated that LNY was not significantly associated with risk of BCR overall (HR = 1.00, 95% CI: 0.98-1.03; P = 0.848) for pN0 (HR = 0.99, 95% CI: 0.97-1.03; P = 0.916) or pN1 patients (HR = 0.96, 95% CI: 0.88-1.06; P = 0.468). Overall, PSA (HR = 1.02, P<0.001) and biopsy Gleason sum ≥ 8 (HR = 1.81, P = 0.001) were associated with an increased risk of BCR, and increasing LNY increased the likelihood of detecting>2 positive lymph nodes (OR = 1.27, 95% CI: 1.06-1.65, P = 0.023).

CONCLUSION

Seminal vesicle invasion is associated with an increased risk of BCR at 3 years, primarily due to pathologic Gleason score and PSA. Although greater lymph node yield is diagnostic and facilitates more accurate pathologic staging, our data do not show a therapeutic benefit in reducing BCR.

ACR Appropriateness Criteria® Prostate Cancer-Pretreatment Detection, Surveillance, and Staging

Despite the frequent statement that "most men die with prostate cancer, not of it," the reality is that prostate cancer is second only to lung cancer as a cause of death from malignancy in American men. The primary goal during baseline evaluation of prostate cancer is disease characterization, that is, establishing disease presence, extent (local and distant), and aggressiveness. Prostate cancer is usually diagnosed after the finding of a suspicious serum prostate-specific antigen level or digital rectal examination. Tissue diagnosis may be obtained by transrectal ultrasound-guided biopsy or MRI-targeted biopsy. The latter requires a preliminary multiparametric MRI, which has emerged as a powerful and relatively accurate tool for the local evaluation of prostate cancer over the last few decades. Bone scintigraphy and CT are primarily used to detect bone and nodal metastases in patients found to have intermediate- or high-risk disease at biopsy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Prostate cancer reporting and staging: needle biopsy and radical prostatectomy specimens

Prostatic adenocarcinoma remains the most common cancer affecting men. A substantial majority of patients have the diagnosis made on thin needle biopsies, most often in the absence of a palpable abnormality. Treatment choices ranging from surveillance to radical prostatectomy or radiation therapy are largely driven by the pathologic findings in the biopsy specimen. The first part of this review focuses on important morphologic parameters in needle biopsy specimens that are not covered in the accompanying articles. This includes tumor quantification as well as other parameters such a extraprostatic extension, seminal vesicle invasion, perineural invasion, and lymphovascular invasion. For those men who undergo radical prostatectomy, pathologic stage and other parameters are critical in prognostication and in determining the appropriateness of adjuvant therapy. Staging parameters, including extraprostatic extension, seminal vesicle invasion, and lymph node status are discussed here. Surgical margin status is also an important parameter and definitions and reporting of this feature are detailed. Throughout the article the current reporting guidelines published by the College of American Pathologists and the International Collaboration on Cancer Reporting are highlighted.

Improving postoperative radiotherapy following radical prostatectomy

INTRODUCTION

Prostate cancer has one of the highest incidences in the world, with good curative treatment options like radiotherapy and radical prostatectomy. Unfortunately, about 30% of the patients initially treated with curative intent will develop a recurrence and need adjuvant treatment. Five randomized trials covered the role of postoperative radiotherapy after radical prostatectomy, but there is still a lot of debate about which patients should receive postoperative radiotherapy. Areas covered: This review will give an overview on the available literature concerning post-operative radiotherapy following radical prostatectomy with an emphasis on the five randomized trials. Also, new imaging techniques like prostate-specific membrane antigen positron emission tomography (PSMA-PET) and multiparametric magnetic resonance imaging (mp-MRI) and the development of biomarkers like genomic classifiers will be discussed in the search for an improved selection of patients who will benefit from postoperative radiotherapy following radical prostatectomy. With new treatment techniques like Intensity Modulated Radiotherapy, toxicity profiles will be kept low. Expert commentary: Patients with biochemical recurrence following radical prostatectomy with an early rise in prostate-specific antigen (PSA) will benefit most from postoperative radiotherapy. In this way, patients with only high risk pathological features can avoid unnecessary treatment and toxicity, and early intervention in progressing patients would not compromise the outcome.

Influence of pathologist experience on positive surgical margins following radical prostatectomy

BACKGROUND

A positive surgical margin (PSM) following radical prostatectomy (RP) for prostate cancer is associated with increased risk of biochemical recurrence. We sought to examine whether the pathologist is an independent predictor of PSMs.

METHODS

We performed a retrospective review of 3,557 men who underwent RP for localized prostate cancer at our institution from 2003 to 2015. We evaluated 29 separate pathologists. Univariate and multivariable logistic regression were used to test variables previously shown to influence PSM rates.

RESULTS

Overall rate of PSM was 18.9%. Compared with patients without PSM, patients with PSM had higher body mass index (mean: 28.8 vs. 28.3), Gleason score≥7 (84% vs. 66%), extracapsular extension (51% vs. 20%), and median prostate-specific antigen (5.9 vs. 5.1ng/ml) (all P<0.05). Univariate logistic regression showed that surgeon experience, pathologist experience, and pathologist genitourinary fellowship training were all predictors of PSMs (all P<0.05). Multivariable regression analysis confirmed that decreased surgeon experience, increased pathologist experience, higher pathologic Gleason score, higher pathologic stage, and higher prostate-specific antigen were significant predictors of PSMs. Increasing surgeon experience was associated with decreased odds of PSM (odds ratio = 0.79 per 1 standard deviation increase, 95% CI [0.70-0.89]). In contrast, increasing pathologist experience was associated with increased odds of PSM (odds ratio = 1.11 per 1 standard deviation increase, 95% CI [1.03-1.19]). The relationship between pathologist experience and PSM appeared to be nonlinear (Fig. 2).

CONCLUSIONS

Greater pathologist experience appears to be associated with greater odds of PSMs following radical prostatectomy, even after controlling for case mix, pathologist fellowship training, and surgeon experience. Based on these findings, pathologists with less experience reviewing RP specimens may consider requesting rereview by a dedicated genitourinary pathologist.

Are you now a good surgeon? T2 positive margin status as a quality outcome measure following radical prostatectomy

Objective

To assess potential biases, such as the reporting pathologist, that may affect objectivity of T2 positive margin rates as a quality outcome measure following radical prostatectomy.

Patients and methods

Prospective data on 183 consecutive LRP patients with pT2 disease, operated on by a single surgeon (2003–2009), were studied. Outcomes were grouped as pre-, peri-, and post-operative and included: age, ethnicity, Gleason score, reporting pathologist, percentage of positive cores, operative time, blood loss, nerve-sparing status, hospital stay and prostate weight. Descriptive analysis and logistic regression analysis were carried out to compare these variables by positive margin status.

Results

A total of 30 (16.4 %) positive surgical margins (PSMs) were reported. Surgical stage, earlier date of surgery, and lower prostatic weight showed statistically significant associations with PSM status in both univariate and multivariate analysis. The reporting pathologist was not found to be predictive of PSMs (P = 0.855).

Conclusion

We showed that the reporting pathologist does not influence T2 positive margin status, in contrast to tumour characteristics and surgeon experience. T2 positive margin assessment therefore appears to be an objective quality outcome measure.

Interpretive Diagnostic Error Reduction in Surgical Pathology and Cytology: Guideline From the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology

CONTEXT

Additional reviews of diagnostic surgical and cytology cases have been shown to detect diagnostic discrepancies.

OBJECTIVE

To develop, through a systematic review of the literature, recommendations for the review of pathology cases to detect or prevent interpretive diagnostic errors.

DESIGN

The College of American Pathologists Pathology and Laboratory Quality Center in association with the Association of Directors of Anatomic and Surgical Pathology convened an expert panel to develop an evidence-based guideline to help define the role of case reviews in surgical pathology and cytology. A literature search was conducted to gather data on the review of cases in surgical pathology and cytology.

RESULTS

The panel drafted 5 recommendations, with strong agreement from open comment period participants ranging from 87% to 93%. The recommendations are: (1) anatomic pathologists should develop procedures for the review of selected pathology cases to detect disagreements and potential interpretive errors; (2) anatomic pathologists should perform case reviews in a timely manner to avoid having a negative impact on patient care; (3) anatomic pathologists should have documented case review procedures that are relevant to their practice setting; (4) anatomic pathologists should continuously monitor and document the results of case reviews; and (5) if pathology case reviews show poor agreement within a defined case type, anatomic pathologists should take steps to improve agreement.

CONCLUSIONS

Evidence exists that case reviews detect errors; therefore, the expert panel recommends that anatomic pathologists develop procedures for the review of pathology cases to detect disagreements and potential interpretive errors, in order to improve the quality of patient care.

Variation between specialist uropatholgists in reporting extraprostatic extension after radical prostatectomy

Aims

Extraprostatic extension of prostate cancer in radical prostatectomy specimens significantly affects patient management. We evaluated the degree of interobserver variation between uropathologists at a tertiary referral teaching hospital in assessing the extraprostatic extension of prostate cancer in radical prostatectomy specimens.

Methods

Histopathological data from a consecutive series of 293 radical prostatectomy specimens (January 2007–December 2012) were reviewed. A subset of 50 consecutive radical prostatectomy cases originally staged as tumours confined to the prostate (pT2) or tumours extending into periprostatic tissue (pT3a) during this period were reviewed by four specialist uropathologists.

Results

Five consultant histopathologists reported these specimens with significant differences in the reported stage (p=0.0164) between pathologists. Double-blind review by 4 uropathologists of 50 consecutive radical prostatectomy cases showed a lack of consensus in 16/50 (32%) cases (κ score 0.58, moderate agreement). A consensus meeting was held, but consensus could still not be reached in 9/16 cases.

Conclusions

Our findings highlight variability in the reporting of pT stage in radical prostatectomy specimens even by specialist uropathologists. Assessment of extraprostatic extension has important implications for patient management and there is a need for more precise guidance.

Significance and management of positive surgical margins at the time of radical prostatectomy

Positive surgical margins (PSM) at the time of radical prostatectomy (RP) result in an increased risk of biochemical recurrence (BCR) and secondary treatment. We review current literature with a focus on stratifying the characteristics of the PSM that may define its significance, the impact of modern imaging and surgical approaches in avoidance of PSM, and management strategies when PSM do occur. We performed a review of the available literature to identify factors associated with PSM and their management. PSM have been repeatedly demonstrated to be associated with an increased risk of BCR following RP. The specific characteristics (size, number, location, Gleason score at the margin) of the PSM may influence the risk of recurrence. Novel imaging and surgical approaches are being investigated and may allow for reductions of PSM in the future. The use of adjuvant treatment for a PSM remains controversial and should be decided on an individual basis after a discussion about the risks and benefits. The goal of RP is complete resection of the tumor. PSM are associated with increased risk of BCR and secondary treatments. Of the risk factors associated with BCR after RP, a PSM is directly influenced by surgical technique.

Salvage radiotherapy after robot-assisted laparoscopic radical prostatectomy

OBJECTIVE

To assess the incidence and efficacy of salvage radiotherapy (SRT) after robot-assisted radical prostatectomy (RARP). RARP has been linked to an increased use of adjuvant treatments. If RARP would result in an increased local recurrence rate, response rates to SRT could be expected to be better after RARP than after more conventional methods of prostatectomy. The incidence and efficacy of SRT in a RARP population were compared with nomogram prediction.

METHODS

Patient data were prospectively registered. Biochemical recurrence (BCR) was defined as a prostate-specific antigen (PSA) ≥0.1 ng/mL. SRT was offered to men with BCR after RARP. The Stephenson nomogram predictions were compared with outcome after SRT.

RESULTS

Of 1087 men, 157 (14.4%) received SRT for BCR or persistent PSA levels during a median follow-up of 1078 days after RARP. Median PSA level before SRT was 0.2 ng/mL. Three-year BCR-free rate was 64% for men after SRT. pN (pNx, pN0, pN1) and PSA level before SRT were independent predictors of the BCR interval after SRT. Men with more extensive fascia preservation were more likely to respond favorably to SRT. The Stephenson nomogram prediction showed a concordance rate of 0.66 in this RARP population. Limitations of the study are the retrospective design and limited follow-up duration.

CONCLUSION

In our RARP series, the use and efficacy of SRT were comparable with open prostatectomy series. The Stephenson nomogram reliably predicted outcome in patients with RARP with SRT, suggesting that similar characteristics predict response to SRT after RARP compared with open prostatectomy.

Interobserver variability in the pathological assessment of radical prostatectomy specimens: findings of the Laparoscopic Prostatectomy Robot Open (LAPPRO) study

OBJECTIVE

The aim of this study was to strengthen the validity of future findings in the Laparoscopic Prostatectomy Robot Open (LAPPRO) study by investigating the extent of interobserver variability between local pathologists and re-evaluating reference pathologists.

MATERIAL AND METHODS

LAPPRO is a Swedish prospective study comparing robot-assisted laparoscopic prostatectomy to open retropubic radical prostatectomy. Patients were recruited from 2008 to 2011. A random selection of 289 prostatectomy specimens was re-evaluated, in a blind fashion, by two reference pathologists from a University Hospital in Denmark and compared with original reports from local pathologists.

RESULTS

The exact concordance rate of Gleason score (GS) between local and reference pathologists was 56% (Spearman correlation coefficient 0.54). Exact concordance rates (κ value) for pathological tumour stage (pT), extraprostatic extension (EPE), surgical margin status (SMS) and seminal vesicle invasion (SVI) were 87% (0.63), 86% (0.59), 92% (0.76) and 98% (0.82), respectively. In subanalyses for surgical technique, exact concordance rates of GS, pT, EPE, SMS and SVI were 58%, 83%, 84%, 90% and 97%, respectively, for surgical technique 1 (ST1), compared to 55%, 88%, 87%, 93% and 98%, for surgical technique 2 (ST2). In ST1 specimens undergrading of GS by the local pathologists compared to central review was more common than overgrading (26% vs 16%). The inverse relationship was seen in ST2 specimens (14% vs 32%).

CONCLUSION

Re-evaluation of randomly selected prostatectomy specimens in the LAPPRO cohort showed comparable results compared to previous studies of this kind. A systematic variation in the assessment of GS exists, attributable to individual differences in judgement between pathologists. Dichotomising GS (≤ 7 vs ≥ 8) overcomes the systematic variation.