Extraprostatic Extension in Core Biopsies Epitomizes High-risk but Locally Treatable Prostate Cancer

Myeloid differentiation factor-2/LY96, a potential predictive biomarker of metastasis and poor outcomes in prostate cancer: clinical implications as a potential therapeutic target

Prostate cancer (CaP) is the most diagnosed cancer in males and the second leading cause of cancer deaths. Patients with localized tumors are generally curable. However, no curative treatment exists for patients with advanced and metastatic disease. Therefore, identifying critical proteins involved in the metastatic process would help to develop new therapeutic options for patients with advanced and aggressive CaP. We provide strong evidence that Myeloid differentiation factor-2 (MD2) plays a critical role in metastasis and CaP progression. Analysis of tumor genomic data showed that amplifications of MD2 and increased expression are associated with poor outcomes in patients. Immunohistochemistry analysis of tumor tissues showed a correlation between the expression of MD2 and cancer progression. The Decipher-genomic test validated the potential of MD2 in predicting metastasis. In vitro studies demonstrated that MD2 confers invasiveness by activating MAPK and NF-kB signaling pathways and inducing epithelial-mesenchymal transition. Furthermore, we show that metastatic cells release MD2 (sMD2). We measured serum-sMD2 in patients and found that the level is correlated to disease extent. We determined the significance of MD2 in metastasis in vivo and as a therapeutic target, showing that the molecular and pharmacological targeting of MD2 significantly inhibited metastasis in murine models. We conclude that MD2 predicts metastatic behavior, and serum-MD2 could be studied as a potential non-invasive biomarker for metastasis, whereas MD2 presence on prostate biopsy predicts adverse disease outcome. We suggest MD2-targeted therapies could be developed as potential treatments for aggressive metastatic disease.

Detection of extraprostatic extension by transperineal multiparametric magnetic resonance imaging-ultrasound fusion targeted combined with systemic template prostate biopsy

BACKGROUND

Extraprostatic extension (EPE) of prostate cancer (PCa) on transrectal (TR) needle core biopsy (Bx) is a rare histopathological finding that can help in clinical decision-making. The detection efficiency of the transperineal (TP) approach is yet to be explored.

METHODS

We retrospectively reviewed 2848 PCa cases using concomitant systemic template biopsy (SBx) and multiparametric magnetic resonance imaging (MRI)-ultrasound fusion-targeted biopsy (TBx) using the TR (n = 1917) or TP (n = 931) approach at our institution between January 2015 and July 2022. We assessed and compared clinical, MRI, and biopsy characteristics using different approaches (TP and TR) and methods (SBx and TBx).

RESULTS

In total, 40 EPE cases were identified (40/2848, 1.4%). TP showed a significantly higher EPE detection rate compared to TR in SBx (TR:0.7% vs. TP:1.6%; p = 0.028) and TBx (TR:0.5% vs. TP:1.2%; p = 0.033), as well as the combined methods (2.1% vs. 1.1%, p = 0.019). A significantly higher incidence of EPEs was found at non-base sites in TP than in TR (76.7% vs. 50%, p = 0.038). SBx showed a higher EPE detection rate than TBx; however, the difference was not statistically significant. TP showed higher prostate-specific antigen density (0.35 vs. 0.17, p = 0.005), higher frequency of GG4-5 in the cores with EPE (65.0% vs. 50.0%, p = 0.020), and more PCa-positive SBx cores (10 vs. 8, p = 0.023) compared to the TR.

CONCLUSIONS

TP may improve EPE detection compared with TR and should be applied to patients with adverse pre-biopsy features.

Myeloid differentiation factor-2/LY96, a new predictive biomarker of metastasis in prostate cancer: Clinical implications as a potential therapeutic target

Relapsed prostate cancer (CaP), usually treated with androgen deprivation therapy, acquires resistance to develop into lethal metastatic castration-resistant CaP. The cause of resistance remains elusive, and the lack of biomarkers predictive of castration-resistance emergence is a stumbling block in managing the disease. We provide strong evidence that Myeloid differentiation factor-2 (MD2) plays a critical role in metastasis and CaP progression. Analysis of tumor genomic data and IHC of tumors showed a high frequency of MD2 amplification and association with poor overall survival in patients. The Decipher-genomic test validated the potential of MD2 in predicting metastasis. In vitro studies demonstrated that MD2 confers invasiveness by activating MAPK and NF-kB signaling pathways. Furthermore, we show that metastatic cells release MD2 (sMD2). We measured serum-sMD2 in patients and found that the level is correlated to disease extent. We determined the significance of MD2 as a therapeutic target and found that targeting MD2 significantly inhibited metastasis in a murine model. We conclude that MD2 predicts metastatic behavior and serum-MD2 is a non-invasive biomarker for tumor burden, whereas MD2 presence on prostate biopsy predicts adverse disease outcome. We suggest MD2-targeted therapies could be developed as potential treatments for aggressive metastatic disease.

Significance of extraprostatic extension by Grade Groups 1-3 prostatic carcinoma on needle biopsy

BACKGROUND

It is rare for extraprostatic extension (EPE) on biopsy to be seen with Grade Groups (GG) 1-3 (Gleason scores 3 + 3 = 6; 3 + 4 = 7; 4 + 3 = 7) prostatic adenocarcinoma, and there is no data whether this finding should be a contraindication for performing radical prostatectomy (RP).

METHODS

Thirty eight cases with GG 1-3 prostatic adenocarcinoma as the highest grade in the case with EPE on biopsy were identified from our consultation files. Highly unfavorable findings at RP were those that if they could have been predicted preoperatively, might have factored into the decision of whether to proceed with surgery. For these purposes, highly unfavorable pathology at RP was defined as either the presence of seminal vesicle invasion or lymph node metastases or GG5 (Gleason score 9-10).

RESULTS

Among 37 patients with clinical follow-up data, 18 (49%) received radiation and/or hormonal therapy (RT/HT), 13 patients (35%) either underwent (n = 11) or are planning (n = 2) RP, and 6 patients (16%) received either ablation therapy or active surveillance. Based on the 11 RP pathology reports, 8 were GG2, one GG3 with tertiary pattern 5, and two GG3. Ten cases were reported to have EPE and six cases had positive margins. Only one had highly unfavorable pathology with pT3bN1 disease. The only difference between the RP and the RT/HT groups in their pretreatment parameters was the mean age of the RP patients was 61 compared with 69 for the RT/HT men (p = 0.02); the lack of many cases with highly unfavorable pathology at RP cannot be attributable to a selection bias of men with lower volume cancer on biopsy or lower serum prostate-specific antigen levels choosing RP over RT/HT.

CONCLUSIONS

Despite EPE on biopsy, most men do not have highly unfavorable pathology at RP, and this treatment should remain an option in this setting.

Perineural invasion on biopsy specimen as predictor of tumor progression in aging male treated with radical prostatectomy. Could we use it for pre-surgical screening?

We aimed to analyze the correlation of perineural invasion on transrectal ultrasound guided prostate biopsy with predictors of biochemical cancer recurrence, as well as its impact on clinical outcomes, for non-metastatic prostate cancer. For the study, patients with perineural invasion (N = 86) were recruited into group I and underwent open retropubic prostatectomy, regardless of clinical stage; cases with prostate cancer but without perineural invasion on biopsy, who received radical prostatectomy as the treatment modality, were placed into group II (n = 90). Perineural invasion was detected preoperatively in 43% of cases that revealed surgical margin positivity postoperatively, while 85% of the remaining cases (group II) had negative surgical margins. There was no correlation on prostate biopsy between perineural invasion and Gleason score or PSA, based on Sperman's rank-order correlation analysis. However, there was strong positive correlation of perineural invasion with clinical stage and patients age. Additionaly, we demonstrated that perineural invasion on biopsy is a non-independent risk factor for metastatic occurrence, although the correlation was significant in univariate analysis. Nevertheless, we found strong correlation between invasion on initial biopsy specimen with biochemical cancer recurrence, suggesting that perineural invasion on prostate biopsy is a significant predictor of worse prognostic outcome.

Added Clinical Value of Whole-mount Histopathology of Radical Prostatectomy Specimens: A Collaborative Review

CONTEXT

Whole-mount histopathology, that is, large format histology or whole-mount sectioning, refers to the histopathological examination of tissue sections from specimens processed with large tissue cassette. In some institutions, it is applied routinely to specimens with genitourinary cancers.

OBJECTIVE

To give an overview of the application of the large format histology to the morphological examination of the radical prostatectomy (RP) specimens.

EVIDENCE ACQUISITION

A comprehensive PubMed search was performed up to May 2020, using the keywords "prostate carcinoma," "radical prostatectomy specimens," "whole-mount histopathology," "whole mount sectioning," "large format histology," "macrosectioning," "diagnostic criteria," and "prognosis." The search, supplemented with a hand search, was restricted to articles published in the English language. No limitations were placed on the publication year. References in relevant articles were also reviewed.

EVIDENCE SYNTHESIS

Even though the whole-mount sections of RPs appear not to be superior to regular sections in detecting adverse pathological features, their use has the advantage of displaying the architecture of the prostate gland and identifying and locating tumor nodule(s) more clearly, with particular reference to the index tumor. Further, it is easier to compare the pathological features with clinical findings derived, for instance, from digital rectal examination, transrectal ultrasound, multiparametric magnetic resonance imaging, surgical operation, and prostate biopsies.

CONCLUSIONS

Urologists, radiologists, and oncologists are updated about the step forward made by pathologists when diagnostic and prognostic information is derived from an approach that closely resembles that used by the clinicians when dealing with imaging findings.

PATIENT SUMMARY

Adoption of the whole-mount histopathology adds clinical value in correlation with clinical/imaging findings of radical prostatectomy specimens.