Evaluation of Gleason Grade Group 5 in a Contemporary Prostate Cancer Grading System and Literature Review

Association of Lymphovascular Invasion with Biochemical Recurrence and Adverse Pathological Characteristics of Prostate Cancer: A Systematic Review and Meta-analysis

Background and objective

Lymphovascular invasion (LVI) is a significant histopathological feature in prostate cancer (PCa) associated with higher risk of biochemical recurrence (BCR) and other adverse outcomes. Our aim was to assess the association of LVI found in radical prostatectomy (RP) specimens with BCR and adverse clinicopathological findings.

Methods

A systematic literature search was conducted using the PubMed, Embase, and Web of Science databases in July 2023, with an additional search in May 2024. We included 94 prospective and retrospective studies reporting on LVI in RP specimens and its association with the specified outcomes.

Key findings and limitations

Meta-analyses revealed that LVI is significantly associated with higher BCR risk (hazard ratio 1.96, 95% confidence interval [CI] 1.73-2.21), higher pathological tumour stage (odds ratio [OR] 5.77; 95% CI 3.96-8.40), higher Gleason score (OR 5.19, 95% CI 4.12-6.54), lymph node metastasis (OR 11.52, 95% CI 7.65-17.34), distant metastasis (OR 9.10, 95% CI 5.46-15.17), positive surgical margins (OR 2.38, 95% CI 1.83-3.09), extraprostatic extension (OR 5.01, 95% CI 3.11-8.06), seminal vesicle invasion (OR 7.50, 95% CI 3.47-16.23), and perineural invasion (OR 133.71, 95% CI 65.93-271.15). Major limitations of this study include high heterogeneity of the data and the reliance on nonrandomised studies.

Conclusions and clinical implications

Our findings reveal that LVI is associated with nearly twofold higher risk of BCR, highlighting its potential role as a critical prognostic marker.

Patient summary

We analysed data from multiple studies to understand the impact of the spread of prostate cancer into the lymph or blood vessels, called lymphovascular invasion (LVI). We found that LVI is linked to a higher risk of cancer recurrence after surgery and other negative outcomes. Our findings highlight the importance of considering LVI in treatment decisions for better management of prostate cancer.

Prognostic factors among patients with pathological Grade Group 5 prostate cancer based on robot-associated radical prostatectomy specimens from a large Japanese cohort (MSUG94)

PURPOSE

There are no definitive prognostic factors for patients with pathological Grade Group 5 (pGG 5) prostate cancer (PCa) undergoing robot-associated radical prostatectomy (RARP). This study aimed to explore the prognostic factors among patients with pGG 5 PCa in a large Japanese cohort (MSUG94).

METHODS

This retrospective, multi-institutional cohort study was conducted between 2012 and 2021 at ten centers in Japan and included 3195 patients. Patients with clinically metastatic PCa (cN1 or cM1) and those receiving neoadjuvant and/or adjuvant therapy were excluded. Finally, 217 patients with pGG5 PCa were analyzed.

RESULTS

The median follow-up period was 28.0 months. The 3- and 5-year biochemical recurrence-free survival (BCRFS) rates of the overall population were 66.1% and 57.7%, respectively. The optimal threshold value (47.2%) for the percentage of positive cancer cores (PPCC) with any GG by systematic biopsy was chosen based on receiver operating characteristic curve analysis. Univariate analysis revealed that the prostate-specific antigen level at diagnosis, pT, pN, positive surgical margins (PSMs), lymphovascular invasion, and PPCC were independent prognostic factors for BCRFS. A multivariate analysis revealed that PSMs and PPCC were independent prognostic factors for BCRFS. Using these two predictors, we stratified BCRFS, metastasis-free survival (MFS), and castration-resistant PCa-free survival (CRPC-FS) among patients with pGG 5 PCa.

CONCLUSION

The combination of PSMs and PPCC may be an important predictor of BCRFS, MFS, and CRPC-FS in patients with pGG 5 PCa undergoing RARP.

Peritumoral Radiomics Strategy Based on Ensemble Learning for the Prediction of Gleason Grade Group of Prostate Cancer

RATIONALE AND OBJECTIVES

To develop and evaluate a peritumoral radiomic-based machine learning model to differentiate low-Gleason grade group (L-GGG) and high-GGG (H-GGG) prostate lesions.

MATERIALS AND METHODS

In this retrospective study, a total of 175 patients with prostate cancer (PCa) confirmed by puncture biopsy were recruited and included 59 patients with L-GGG and 116 patients with H-GGG. The original PCa regions of interest (ROIs) were delineated on T2-weighted (T2WI), diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) maps, and then centra-tumoral and peritumoral ROIs were defined. Features were meticulously extracted from each ROI to establish radiomics models, employing distinct sequence datasets. Peritumoral radiomics models were specifically developed for both the peripheral zone (PZ) and transitional zone (TZ), utilizing dedicated PZ and TZ datasets, respectively. The performances of the models were evaluated by using the receiver operating characteristic (ROC) curve and precision-recall curve.

RESULTS

The classification model with combined peritumoral features based on T2 + DWI + ADC sequence dataset demonstrated superior performance compared to the original tumor and centra-tumoral classification models. It achieved an area under the ROC curve (AUC) of 0.850 [95% confidence interval, 0.849, 0.860] and an average accuracy of 0.950. The combined peritumoral model outperformed the regional peritumoral models with AUC of 0.85 versus 0.75 for PZ lesions and 0.88 versus 0.69 for TZ lesions, respectively. The peritumoral classification models exhibit greater efficacy in predicting PZ lesions as opposed to TZ lesions.

CONCLUSION

The peritumoral radiomics features showed excellent performance in predicting GGG in PCa patients and might be a valuable addition to the non-invasive assessment of PCa aggressiveness.

Recurrence rate after radical prostatectomy following primary staging of high-risk prostate cancer with 68Ga-PSMA PET/CT

BACKGROUND

Accurate primary staging is one of the most important issues for initial management of prostate cancer (PCa) patients to perform an optimal selection of patients for curative intended treatment. ⁶⁸Ga-Prostate-Specific-Membrane-Antigen (PSMA) PET/CT was found superior to conventional imaging both for detection of recurrence after curative intended treatment and for primary staging. We studied the recurrence rate after radical prostatectomy in high-risk PCa patients primary staged with ⁶⁸Ga-PSMA PET/CT compared with conventional imaging.

MATERIAL AND METHODS

The study included 247 D'Amico high-risk PCa patients treated with radical prostatectomy (RP) after primary staging with ⁶⁸Ga-PSMA PET/CT and a reference group of 137 high-risk patients with RP after conventional imaging (^99mTc bone scintigraphy and CT). Recurrence rates were assessed by Cox regression and Kaplan-Meier analysis.

RESULTS

The 5-year recurrence-free survival rate was 71.1% in the ⁶⁸Ga-PSMA PET/CT cohort compared with 56.4% in the conventional imaging cohort. Primary staging by ⁶⁸Ga-PSMA PET/CT reduced biochemical recurrence (BCR) risk by 42% (HR = 0.58 (0.41-0.83), p = .004).

CONCLUSION

The present data could indicate a lower recurrence rate after RP following primary staging with ⁶⁸Ga-PSMA PET/CT compared to conventional imaging, likely due to improved selection of patients for surgery.

Pattern of Biopsy Gleason Grade Group 5 (4 + 5 vs 5 + 4 vs 5 + 5) Predicts Survival After Radical Prostatectomy or External Beam Radiation Therapy

BACKGROUND

Previous cancer-specific mortality (CSM) analyses for different Gleason patterns in Gleason grade group (GGG) 5 cancer were limited by sample size.

OBJECTIVE

To test for differences in CSM according to biopsy GG 5 patterns (4 + 5 vs 5 + 4 vs 5 + 5) among patients undergoing radical prostatectomy (RP) or external beam radiation therapy (EBRT).

DESIGN, SETTING, AND PARTICIPANTS

Patients in the Surveillance, Epidemiology and End Results database treated with RP and EBRT (2004-2016) were identified and stratified according to Gleason 4 + 5 versus 5 + 4 versus 5 + 5.

INTERVENTION

RP or EBRT.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES

Kaplan-Meier and multivariable Cox regression models predicting CSM were constructed.

RESULTS AND LIMITATIONS

Of 17 263 eligible patients with GG 5 cancer at biopsy (RP: n = 7208; EBRT: n = 10 055), 12 705 had Gleason 4 + 5, 3302 had Gleason 5 + 4, and 1256 had Gleason 5 + 5 disease. Median age, prostate-specific antigen (PSA) at diagnosis, and advanced cT and cN stages significantly differed by Gleason pattern (Gleason 4 + 5 vs 5 + 4 vs 5 + 5; all p < 0.001). The 10-yr CSM rate was 18.2% for Gleason 4 + 5, 28.0% for Gleason 5 + 4, and 39.1% for Gleason 5 + 5 (p < 0.001). In multivariable analyses for the entire cohort adjusted for PSA, age at diagnosis, and cT and cN stage, Gleason 5 + 4 and Gleason 5 + 5 were associated with 1.6- and 2.2-fold higher CSM, respectively, relative to Gleason 4 + 5. In addition, Gleason 5 + 4 and Gleason 5 + 5 were associated with 1.6- and 2.5-fold, and 1.5- and 2.1-fold higher CSM rates in the RP and EBRT subgroups, respectively, relative to Gleason 4 + 5 (all p < 0.001).

CONCLUSIONS

For patients with biopsy GG 5 prostate cancer treated with RP or EBRT, there are important CSM differences by Gleason pattern (4 + 5 vs 5 + 4 vs 5 + 5). Ideally, the individual Gleason pattern should be considered in pretreatment risk stratification.

PATIENT SUMMARY

For patients with grade 5 prostate cancer, we found differences in cancer-specific death rates according to the pattern of abnormal cells in the prostate, called the Gleason score. The highest death rate was found for a Gleason pattern score of 5 + 5, followed by Gleason 5 + 4 and then Gleason 4 + 5. These differences were observed for both patients who were treated with prostate removal and patients who underwent radiotherapy.