Assessment of anatomic extent and biologic hazard of prostatic adenocarcinoma

Bone histology at autopsy and matched bone scintigraphy findings in patients with hormone refractory prostate cancer: the effect of bisphosphonate therapy on bone scintigraphy results

Bisphosphonates (BisP) are non-metabolized compounds with high bone affinity used in bone metastasis diagnosis and treatment. Currently, BisP are used to treat hypercalcemia of malignancy as well as to prevent, minimize, or delay skeletal morbidity. These compounds have a long half-life in bone. Thus long-term BisP treatment might saturate bone and interfere with a single-dose scanning agent used for bone scintigraphy when visualizing bone metastases. In an effort to answer this question, this study evaluated the concordance of histology and Technetium99 methylene diophosphonate (Tc99 MDP) bone scintigraphy in the diagnosis of bone metastases in prostate cancer patients. We assessed the concordance of findings between bone scintigraphy and histology using 188 bone biopsies from 11 autopsied patients who died with metastatic prostate cancer, 5 of whom were treated with pamidronate for 2 to 13 months before death. Overall agreement between histology and bone scintigraphy was 84%, 86% in non-pamidronate-treated patients and 82% in pamidronate-treated patients. Scintigraphic bone metastases without histological metastasis (false negatives = 12.7%) were observed in 24 anatomic locations; half of these were in one patient who had been treated with pamidronate and had no histological bone response to the carcinoma. There were only 4 sites where a positive bone scan was not associated with histologic metastasis (false positives = 2.21%). There was no statistical difference between the treated and non-treated group for concordance, specificity, sensitivity, positive and negative predictive values of bone scintigraphy and prevalence of histological abnormality. Long-term pamidronate treatment of prostate cancer bone metastases does not generally affect the ability to detect bone metastases with Tc99 MDP bone scintigraphy.

Correlação entre a graduação histológica de biópsias e do espécimen cirúrgico em câncer da prostata

Foram estudados, retrospectivamente, os prontuários de 120 pacientes com câncer localizado da próstata nos estádios clínicos T1, T2 e T3a e que foram submetidos a 1infadenectomia ilíaca e a cirurgia radical da próstata. Todos haviam sido graduados pela escala de Gleason através de biópsias da próstata guiadas pela ultra-sonografia transretal. Correlacionamos a graduação histo1ógica destas biópsias da próstata com a graduação final obtida no exame da peça cirúrgica correspondente e obtivemos exata concordância em 39 pacientes (32,50%). Ao considerarmos a concordância de ± 1unidade, observamos concordância de resultado em 81 pacientes (67,50%). A subgraduação histológica das biópsias prostáticas foi encontrada em 75 pacientes (62,50%) dos casos.

Preoperative prediction of pathological tumor volume and stage in clinically localized prostate cancer: comparison of digital rectal examination, transrectal ultrasonography and magnetic resonance imaging

Accurate preoperative staging is important for proper selection of patients for radical retropubic prostatectomy. Preoperative staging by digital rectal examination, transrectal ultrasound, magnetic resonance imaging (MRI), Gleason grade and prostate specific antigen was compared to pathological stage for 25 patients who underwent radical retropubic prostatectomy. The predictive value for tumor confinement was 36% by rectal examination, 37% by ultrasound and 30% by MRI. The predictive value for extracapsular disease was 100% by rectal examination, 83% by ultrasound and 66% by MRI. Preoperative determinations of tumor volume by any modality did not correlate with pathological tumor volume. Digital rectal examination, ultrasound and MRI clinically understage the disease in most patients but they may be reliable to predict extracapsular disease.

Radical prostatectomy for clinical stage T1-2N0M0 prostatic adenocarcinoma: long-term results

A total of 441 stage T1-2N0M0 and 11 stage T1-2N0M0 cancer patients with an elevated acid phosphatase level only, and 18 stage T1-2N+M0 cancer patients underwent radical prostatectomy. Analysis of the 441 stage T1-2N0M0 cancer patients demonstrated that failure and survival were a function of the disease being organ-confined, specimen-confined or margin-positive, with 10-year failure rates of 12, 30 and 60%, respectively. Of the patients with positive margins 44 were and 79 were not irradiated postoperatively. Postoperative radiation produced no survival advantage. No difference in interval to failure or of survival could be identified between 105 patients whose disease was diagnosed by transurethral resection and 328 who had a palpable abnormality. Eleven patients had negative bone and node findings but they had an elevated acid phosphatase level. All 8 patients not treated with immediate androgen deprivation failed within 36 months.

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

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

The value of computed tomography and ultrasound in assessment of pelvic lymph node metastases in patients with clinically locally confined carcinoma of the prostate

With the aim of detecting any metastases in pelvic lymph nodes, computed tomography (CT) was performed in 42 patients with clinically localized prostatic carcinoma, and ultrasound (US) examination in 35 of them, prior to pelvic lymphadenectomy. CT was positive in only one patient, and US was negative in all examined patients. At lymph node dissection macrometastases were found in four patients and histopathologic examination revealed micrometastases in a further ten patients. It is concluded that in clinically locally confined prostatic carcinoma CT and US are insensitive in diagnosing pelvic lymph node metastases, and that lymph node dissection remains the only method for staging of the regional lymph nodes.

Prognostic factors in localized prostatic carcinoma

Serial histological sections were performed in 54 radical prostatectomy specimens in an attempt to identify prognostic factors responsible for dissemination of prostatic cancer. Factors considered in the study included clinical versus pathological staging, histological grading of the biopsy specimen compared to the final pathological result, intraprostatic tumor distribution and deoxyribonucleic acid analysis of the tumor by flow cytometry in the last 33 cases. In patients with clinical stages A2 and B1 disease pathological findings were in accord in 78 per cent (11 of 14). However, only 3 of 40 patients with clinical stage B2 tumor had pathological stage B2 disease. Histologically, 72 per cent of the tumors were bilateral. Microscopic involvement of the capsule per se did not appear to influence lymph node invasion, since only 1 of 27 patients with microscopic capsular involvement had pelvic lymph node metastasis. However, 9 of 13 patients with seminal vesicle involvement had pelvic lymph node metastasis. The addition of flow cytometry to the Gleason score improves the predictive value of histological grade in higher stage lesions.

External beam radiation salvage for residual or recurrent local tumor following radical prostatectomy

External beam radiation therapy was used as a means of salvage in 32 patients with either incomplete excision or palpable local recurrence following radical prostatectomy. Patients were divided into 2 groups consisting of 13 patients who were referred within 4 months of incomplete excision (group 1) and 19 who were referred only after palpable local recurrence had developed (group 2). The 5 and 10-year actuarial survival free of disease in group 1 was 57 per cent, compared to 40 and 20 per cent for group 2 (p equals 0.05). Fourteen patients with an elevated pre-radiation therapy serum acid phosphatase level and/or bladder invasion had an especially poor prognosis, with a median survival free of disease of only 2.4 years. Ten complications were recorded in 5 patients (16 per cent), which were slightly higher than experienced in irradiated patients without a previous radical operation. The data support the contention that external beam radiation therapy may offer a means of post-radical prostatectomy salvage for selected patients with incomplete excision or palpable local recurrence. The best results were obtained in patients who were referred within 4 months of prostatectomy because of incomplete excision rather than waiting for palpable local recurrence to develop.

Accuracy of transcutaneous aspiration biopsy in the definitive assessment of nodal involvement in prostatic carcinoma

The inaccuracy of lymphangiography in predicting nodal involvement and the complications of pelvic lymphadenectomy prompted us to evaluate other methods of staging prostatic cancer. On the basis of the results obtained in 24 patients with carcinoma of the prostate, the authors suggest transcutaneous fluoroscopy-guided fine needle aspiration biopsy as a satisfactory alternative to lymphadenectomy. In 95-8% of patients pelvic lymphadenectomy confirmed the cytological findings of transcutaneous aspiration biopsy of pelvic lymph nodes using a "long-bevelled, side-holed" thin needle. It is considered essential to perform aspiration biopsy on most of the pelvic lymph node chains opacified, regardless of lymphographic diagnosis.

Understaging and undergrading of prostate cancer. Argument for postoperative radiation as adjuvant therapy

This report reviews the staging and grading errors that occurred in a consecutive series of 14 patients treated for prostate cancer by radical prostatectomy and of 58 patients treated by both radical prostatectomy and pelvic lymphadenectomy. Almost half of the patients who were in Stages A2, B1, or B2 by clinical criteria were in pathologic Stage C when both capsular perforation and seminal vesicle invasion were used as the criteria for Stage C disease. Seminal vesicle invasion was the more important prognostic factor. Moreover, the pathologic grade of cancer, as determined by needle or transurethral biopsy, was underestimated in 39 per cent of the cases; when the grade was corrected, the patient often was in a worse prognostic group than the one originally assigned. Thus, in this series, more than 40 per cent of the patients were at high risk of persistent or recurrent disease after radical prostatectomy. Radiation was given after operation to 22 such high-risk patients and was well tolerated.

Staging errors in clinically localized prostatic cancer

The interrelationships among tumor grade, local tumor extension, lymph node involvement and early treatment failure were examined in 96 consecutive patients with clinical stage A (11 patients) or B (85 patients) prostatic cancer who were considered potential candidates for radical prostatectomy. In this series 20 of the 82 patients (24 per cent) who underwent radical prostatectomy had local tumor extension beyond the prostatic capsule and 27 of the 88 patients (31 per cent) who had lymph node dissections had nodal involvement. Of the entire group of 96 patients 38 (40 per cent) had either local extension and/or nodal involvement. A direct correlation was observed between clinical stage and the incidence of local tumor extension but not between clinical stage and nodal involvement. However, there was a striking correlation between surgical stage and lymph node involvement in patients who underwent radical prostatectomy. A direct correlation also was observed between tumor grade, and local extension and nodal involvement. Analysis of multiple parameters revealed that clinical grade of tumor considered together were more predictive of nodal involvement than either parameter alone. Early treatment failures occurred in 5 patients, all of whom were understaged clinically.

Some questions raised by histologic study of RTOG protocols 75-06 and 77-06 as illustrated by selected samples

Histologic study of about 700 biopsy specimens from patients with prostate cancers collected by the Radiation Therapy Oncology Group (RTOG) reemphasized the difficulty in accurately predicting biologic behavior of the carcinoma in individual cases. Some well-differentiated carcinomas metastasized to regional lymph nodes. Histologic proof of lymph node metastases may be difficult to detect. Some duct carcinomas do not readily fit a Gleason pattern. A variety of histologic grades may be seen either in a single sample or after the passage of time in the same case. Some prostatic epithelial proliferations may closely simulate carcinomas by routine light microscopy, but are biologically benign. Some of these prostate lesions have histologic similarities to breast lesions.

Whither pelvic lymphadenectomy in prostatic cancer?

In the last decade pelvic lymphadenectomy has gained in popularity as a staging maneuver designed to improve the selection of patients with localized prostatic cancer for curative treatment, by uncovering lymph node metastases. The presence of tumor in the regional nodes portends substantial risk for the later appearance of distant metastases. With rare exceptions, lymphadenectomy is widely regarded as a staging procedure without therapeutic benefits. Unfortunately, the operation as routinely performed carries a significant complication rate. The survival results of total prostatectomy for well-selected nodules of prostatic cancer are excellent without preliminary lymphadenectomy. The morbidity of lymphadenectomy is compounded by superimposed external irradiation. Because of the low complication rate from external radiation alone, it is suggested that patients selected for pelvic radiation be spared the discomfort of lymphadenectomy. Clinical trials of adjuvant chemotherapy in patients with minimal nodal disease may answer the question of whether pelvic lymphadenectomy should ever be performed. It is predicted that noninvasive imaging will improve to the point that staging lymphadenectomy may be relegated to the surgical archives.