Can pT0 Stage of Prostate Cancer be Predicted before Radical Prostatectomy?

Nondetectable Prostate Carcinoma (pT0) after Radical Prostatectomy: A Narrative Review

(1) Background: Following radical prostatectomy (RP), the absence of a demonstrable tumor on the specimen of a previously histologically proven malignancy is known as the pT0 stage. The aim of our present study is to perform a narrative review of current literature in order to determine the frequency and oncological outcomes in patients with pT0 disease. (2) Methods: A narrative review of all available literature was performed. (3) Results: The incidence of pT0 ranges between 0.07% and 1.3%. Predictors of the pT0 stage are only a single biopsy core with low-grade cancer, a cancer length not exceeding 2 mm and a high prostate volume. Biochemical recurrence ranges between 0 and 11%. (4) Conclusions: The absence of malignancy in the RP specimen despite a previous positive biopsy is a rare and unpredictable finding. Although the prognosis is considered to be excellent in most of the cases, a continued close follow-up is warranted.

Contemporary clinicopathological characteristics of pT0 prostate cancer at radical prostatectomy: A population-based study

BACKGROUND

The incidence of pT0 prostate cancer (CaP) at radical prostatectomy (RP) is extremely rare. We performed the first population-based analysis of pT0 CaP at RP.

METHODS

Within the Surveillance, Epidemiology, and End Results database (2004-2015), we tested for clinical and pathological characteristics according to pT0 vs. non-pT0 CaP and included a multivariable logistic regression model.

RESULTS

pT0 was identified in 358 (0.2%) out of 160,532 clinically localized RP patients. The majority of pT0 patients presented with initial prostate-specific antigen (PSA) <10 ng/ml (82.4%), harboured biopsy Gleason score (GS) 6 (69.8%) and cT1 disease (78.1%). Nonetheless, pT0 was identified in 13 (3.6%) patients with PSA ≥20 ng/ml, in 69 (19.3%) patients with biopsy GS ≥7 and in 78 (21.8%) patients with ≥cT2 disease. In a subset of patients with available number of biopsy cores, pT0 was identified in 34 (33.3%) patients with ≥2 positive biopsy cores. Age, race, marital status, hospital region, population density, PSA, as well as number of biopsy cores did not discriminate between pT0 and non-pT0 cases. Analyses according to annual rates (2004-2015) of pT0 did not vary between the years (0.2%-1.6%, estimated annual percent change: -1.6%, P = 0.3). Neither did the rates vary according to geographic region.

CONCLUSIONS

pT0 at RP is very rare. Even though, most pT0 patients have low PSA, low clinical stage, low biopsy GS, and only one positive biopsy core, those with more aggressive characteristics can still harbour pT0 at RP.

[Oncological outcomes of prostate cancer surgery]

OBJECTIVE

Review of the oncological results of the radical prostatectomy as initial treatment of prostate cancer, according to the surgical approach and the risk stratification using D'Amico risk groups.

MATERIALS AND METHODS

Review of literature using Medline databases and MedScience based on scientific relevance. Research focused on the oncological results of the radical prostatectomy in series and meta-analysis published since 10 years, taking into consideration the surgical approach if mentioned.

RESULTS

The characteristics of the operated tumor highly impact the local control authenticated by the pathologic stage and the rates of positive surgical margins (PSM), in addition to the survival and the biochemical recurrence. Surgical technique adapted according to the tumor treated, was a constant challenge to the urologist, who counter balance between the oncological control and the conservation of urinary and sexual function by conditioning the type of radical prostatectomy. Results of radical prostatectomy acceptable in terms of PSM and survival are not influenced by the surgical approach but by the degree of surgical experience.

CONCLUSION

Results of radical prostatectomy show the efficient local control of prostate cancer, taking into consideration the oncological rules and indications validated by multidisciplinary meetings, based on the national (CCAFU) and European oncological guidelines. Tendency is going toward considering radical prostatectomy indicated for patients with higher risk of disease progression, so integrating surgery in a multidisciplinary personalized approach.

Evaluation of pT0 prostate cancer in patients undergoing radical prostatectomy

OBJECTIVE

To evaluate the incidence, predictors and oncological outcomes of pT0 prostate cancer (PCa).

METHODS

We conducted a retrospective analysis of 20 222 patients undergoing radical prostatectomy (RP) for PCa at the Mayo Clinic between 1987 and 2012. Disease recurrence was defined as follow-up PSA >0.4 ng/mL or biopsy-proven local recurrence. Systemic progression was defined as development of metastatic disease on imaging. Comparisons of baseline characteristics between pT0 and non-pT0 groups were carried out using chi-squared tests. Recurrence-free survival was estimated using the Kaplan-Meier method and compared using the log-rank test.

RESULTS

A total of 62 patients (0.3%) had pT0 disease according to the RP specimen. In univariable analysis, pT0 disease was significantly associated with older age (P = 0.045), lower prostate-specific antigen (PSA; P = 0.002), lower clinical stage (P < 0.001), lower biopsy Gleason score (P = 0.042), and receipt of preoperative transurethral resection, hormonal and radiation therapies (all P < 0.001). In multivariable analysis, lower PSA levels, lower Gleason score, and receipt of preoperative treatment were independently associated with pT0 (all P < 0.05). Seven patients (11%) with pT0 PCa developed disease recurrence over a median follow-up of 10.9 years. All seven patients had preoperative treatment(s) and three had recurrence with a PSA doubling time of <9 months. Compared with non-pT0 disease, pT0 disease was associated with longer recurrence-free survival (P < 0.05). Only one (1.6%) patient with pT0 disease developed systemic progression.

CONCLUSIONS

pT0 stage PCa is a rare phenomenon and is associated with receipt of preoperative treatment and features of low-risk PCa. Although pT0 has a very favourable prognosis, some men, especially those who received preoperative treatment, experience a small but non-negligible risk of disease recurrence and systemic progression.

The prevalence and outcomes of pT0 disease after neoadjuvant hormonal therapy and radical prostatectomy in high-risk prostate cancer

Background

To identify the prevalence and clinical outcomes of pT0 disease following neoadjuvant hormonal therapy (NHT) and radical prostatectomy (RP) in high-risk prostate cancer.

Methods

We retrospectively included 111 patients who had received NHT and RP for the treatment of high-risk prostate cancer. We classified the patients into two groups, the pT0 group and the non-pT0 group, depending on whether a residual tumor was observed.

Results

We identified 6 cases (5.4 %) with pT0 disease after reviewing the slides of all patients. There was no recurrence of disease in the pT0 group during a median follow-up of 59 months. Among the 105 patients in the non-pT0 group, biochemical recurrence (BCR) developed in 60 patients (57.1 %), with the median time to BCR being 14 months.

Conclusions

Among the 111 patients with high-risk prostate cancer, we found 6 cases that showed a complete pathological response after NHT and no recurrence of disease during the follow-up, meaning that the androgen deprivation therapy could potentially eradicate high-risk prostate cancer. This is one of the largest studies demonstrating the prevalence of pT0 disease and its outcomes after NHT among patients with high-risk prostate cancer.

DNA comparison between operative and biopsy specimens to investigate stage pT0 after radical prostatectomy

PURPOSE

The aim was to eliminate, by DNA comparison, any identity mismatch between operative and biopsy specimens and to analyse the determinants of all pT0 prostate cancers occurred in a single institution.

METHODS

All prostate pT0 cases in a single institution over 20 years were investigated. None of the patients had been diagnosed after a transurethral resection of the prostate nor had they received neoadjuvant hormonal treatment. The biopsies performed in other centres had been referred for a centralized pathologic re-analysis. DNA analysis was performed in samples from operative and biopsy specimens, and pairs of tissues were blindly constituted. Correct matching was verified in each pair and compared to the original database in order to comment on the occurrence of identity mismatches in the series.

RESULTS

Nineteen patients (0.77 %) had been diagnosed as having pT0 prostate cancer among the 2,462 RP procedures performed over 19 years. The biopsy re-analysis invalidated the initial diagnosis of prostate cancer in one biopsy set performed elsewhere. Among 12 entirely processed cases, the biochemistry procedure evaluated as "very unlikely" the occurrence of an error in tissue identification in the biopsy setting, during the surgical procedure or the pathological analysis. No identification error of tissue samples was established in this first verified pT0 series.

CONCLUSIONS

Although it must be suspected, specimen identification error was not a cause for pT0 prostate cancer. Only after a full pathological and DNA verification, the pT0 stage remains a sole entity, unexplained in most cases.

pT0 Prostate Cancer: Predictive Clinicopathologic Features in an American Population

INTRODUCTION

The pT0 stage of prostate cancer describes the radical prostatectomy (RP) specimen where no cancer can be identified. Given known racial and geographic differences in prostate cancer incidence and survival, we reviewed our experience with pT0 disease to determine applicability of these predictive features in an American population.

MATERIALS AND METHODS

A retrospective chart review was conducted for all RPs at one state tertiary care institution during a 20-year period (1991-2011). Clinicopathologic features of pT0 patients were collected and their relevant pathologic material re-reviewed.

RESULTS

Of a total of 1,635 RPs performed, 4 (0.2%) not receiving neoadjuvant therapy or other prior prostate surgeries were stage pT0. Biopsies from 3 of 4 patients were re-evaluated and confirmed a small focus, <1% of tissue, of Gleason score 3+3 adenocarcinoma; a fourth was not available for re-review. Our re-review of the RP slides identified small foci of cancer in two of the four, thus yielding a final true pT0 incidence of 0.1%. Preoperative prostate specific antigen ranged from 4.4 to 7.4 ng/ml, clinical stages were all T1c, and there was no evidence of recurrence at 3 months to 10 years of follow-up.

CONCLUSIONS

Stage pT0 prostate cancer is very uncommon, occurring with an incidence of 0.1%, and in our experience occurs only in clinical T1c patients with pre-biopsy prostate specific antigen < 7.5 ng/ml, with Gleason score 3 + 3 adenocarcinoma comprising < 1%, 1 mm of a single core biopsy, a stricter threshold than that seen in non-American populations.

[Status and medicolegal implications in France pT0 stage of prostate cancer: a study by the CC-AFU]

OBJECTIVE

To assess the frequency, circumstances, and possible medico-legal consequences of the pT0 prostate cancer, defined by the absence of tumor in a radical prostatectomy specimen.

METHODS

Six centers retrospectively identified all cases of pT0 and selectionned those that occurred without prior hormone therapy or prostate resection. Preoperative data, histological report and clinical and biological outcome were analyzed. The lawsuits' registry in pathology were consulted at insurance companies.

RESULTS

Thirty cases of pT0 prostate cancer (0.4%) were reported on 7693 patients. The median age was 63years, PSA 7.4ng/mL. The number of positive preoperative biopsies ranged from one to four for a median tumor length of 1mm (0.3 to 18mm). The biopsy Gleason score was 3+3 for 23 patients, less than 5 for six others and included a contingent of grade 4 in two patients. With a median follow-up of 82months, no clinical or biochemical recurrence was observed. One patient complaint for pT0 prostate was found in the insurances registry.

CONCLUSION

The occurrence of a prostate pT0 called into question all the diagnostic procedures and surgical indication. To avoid a forensic procedure, urologists should inform patients of the possibility of this situation before radical prostatectomy.

Trends in prostatic adenocarcinoma tumor volume by visual estimation in prostatectomy specimens

We retrospectively reviewed 1792 consecutive radical prostatectomies (RP) from 2003 to 2006 at a single institution to establish tumor volume reference values, to determine current trends in visually estimated prostate adenocarcinoma tumor volume, and to characterize cases with no residual cancer on RP. Tumor volumes were recorded and subsequently stratified as very low, 0-1%; low, 1.1-10%; intermediate, 10.1-20%; high, 20.1-50%; and very high, >50%, with incidences of 11.7%, 52.1%, 21.5%, 13.2%, and 1.5%, respectively. The incidence of very low volume tumors increased within the time period (p=0.04). Seminal vesicle involvement was detected in 5.0% of cases and lymph node metastasis occurred in 1.4%. Volume categories statistically correlated with seminal vesicle invasion (p=0) and lymph nodes metastases (p=0). Eleven cases of no residual cancer (0.6%) were identified with a non-statically significant increase during the study (p=0.07). The rising incidence of very low volume tumors should be considered by clinicians when discussing treatment options with patients. A discrete tumor volume should be provided for RP specimens as it may be an important prognostic factor.

[Nondetectable prostate cancer in radical prostatectomy specimens]

Since the widespread use of prostate-specific antigen, early diagnosis of prostate cancer at an early stage has been increased. Consequently, a greater frequency of low-volume disease or no tumor has been found in radical prostatectomy specimen.

AIMS

In the present study authors analyzed patients classified as pT0 after radical prostatectomy at their center.

METHODS

1134 radical prostatectomies were evaluated retrospectively at the author's center between 1996 and 2010. If there was no evidence of prostate cancer in the specimen, patient was staged as pT0. Patients were divided into two groups: received neoadjuvant hormonal therapy or not.

RESULTS

Overall 32 (2.8%) patients were staged as pT0. The rate of pT0 staging was 9.3% and 1.2% in the hormonally treated group and non-hormonally treated group. False-positive prostate biopsy was found in 2 cases. The rate of pT0 staging was higher in patients with incidental prostate cancer, low Gleason score and enlarged prostate. Biochemical relapse was observed in 3 pT0 patients in the hormonally treated group, among them there was one clinical relapse. In non-hormonally treated group no recurrence was detected.

CONCLUSION

The rate of pT0 staging was higher in the hormonally treated group. Because of biochemical and clinical relapse despite vanishing prostate cancer phenomenon, these cases are considered not to be true pT0. On the basis of present study and other reports the rate of pT0 staging is about one percentage in non-hormonally treated patients. Prognosis of these patients is excellent.

Minimal or No Residual Prostatic Adenocarcinoma on Radical Prostatectomy: A 5-Year Experience With “Vanishing Carcinoma Phenomenon”

Context.—“Vanishing carcinoma phenomenon” (VC) has been defined as the finding of minute or no cancer on radical prostatectomy specimens after a positive biopsy.

Objective.—To discuss our experience with VC and to recommend guidelines for its detection.

Design.—One thousand seven hundred forty-one radical prostatectomy specimens (2004–2009) processed by whole-mount section procedure yielded 21 (1.2%) cases with VC and 6 (0.34%) cases with minimal carcinoma (≤2 mm) in the radical prostatectomy specimen. To find the eluding carcinoma in VC cases or more carcinoma in minimal carcinoma cases, the following was done: 3 levels of all the paraffin blocks were obtained; if negative, the paraffin blocks were melted, the tissue was flipped, and 3 levels were prepared. The tumor bank frozen tissue was also processed for routine examination.

Results.—Three deeper levels in the radical prostatectomy specimen of 21 VC cases failed to show malignancy; however, the flipping and recutting of the tissue yielded a focus of carcinoma (1–5 mm) in 16 of 21 cases and in 3 of 16 cases in the saved frozen tissue. In 1 of the 6 cases with minimal carcinoma, subsequent recuts of the flipped tissue displayed carcinoma (2 foci of tumor, &lt;1 mm each).

Conclusions.—In VC we recommend: embed and process any remaining prostatic tissue including any saved fresh-frozen tissue; obtain 3 levels of each paraffin block; if results are negative, melt and flip the tissue and obtain 3 more levels. Following the above guidelines, a hidden carcinoma may be detected in the majority of the cases of VC.

International Society of Urological Pathology (ISUP) Consensus Conference on Handling and Staging of Radical Prostatectomy Specimens. Working group 1: specimen handling

The 2009 International Society of Urological Pathology Consensus Conference in Boston made recommendations regarding the standardization of pathology reporting of radical prostatectomy specimens. Issues relating to the handling and processing of radical prostatectomy specimens were coordinated by working group 1. Most uropathologists followed similar procedures for fixation of radical prostatectomy specimens, with 51% of respondents transporting tissue in formalin. There was also consensus that the prostate weight without the seminal vesicles should be recorded. There was consensus that the surface of the prostate should be painted. It was agreed that both the prostate apex and base should be examined by the cone method with sagittal sectioning of the tissue sample. There was consensus that the gland should be fully fixed before sectioning. Both partial and complete embedding of prostates was considered to be acceptable as long as the method of partial embedding is stated. No consensus was determined regarding the necessity of weighing and measuring the length of the seminal vesicles, the preparation of whole mounts rather than standardized blocks and the methodology for sampling of fresh tissue for research purposes, and it was agreed that these should be left to the discretion of the working pathologist.

Preoperative Clinical and Pathological Characteristics of pT0 Prostate Cancer in Radical Prostatectomy

Purpose

To analyze the preoperative clinical and pathological characteristics of patients with pT0 prostate cancer.

Materials and Methods

We retrospectively reviewed the records of 702 patients who underwent radical prostatectomy (RP) at our institution between January 2004 and July 2008 for clinically localized prostate cancer. If there was no evidence of residual tumor in the pathological specimen of the prostate, a patient was staged as pT0. Patients with pT0 disease were compared with a control group of patients who were operated on during the same period.

Results

Overall, 9 (1.3%) patients were staged as pT0 on the pathologic examination. Significant differences were observed between the pT0 group and the control patients in the biopsy Gleason score (p=0.004), the number of positive cores on biopsy (p=0.018), the tumor length of positive cores (p<0.001), and prostate volume (p=0.015). Cutoff values predictive of pT0 tumor status were defined as a biopsy Gleason score sum ≤6, 2 or fewer positive biopsy cores, tumor length on biopsy ≤2 mm, and prostate volume >30 cm³. Whereas 8 of the 9 (88.9%) pT0 patients showed all of these characteristics, only 55 of the 693 (7.9%) control patients fulfilled the criteria. The combination suggested above afforded a sensitivity of 88.8% and a specificity of 92.1% for the prediction of pT0 status.

Conclusions

The frequency of pT0 prostate cancer seen on RP was 1.3%. A combination of clinicopathological features, incorporating a biopsy Gleason score, the number of positive biopsy cores, tumor length on biopsy, and prostate volume, was useful to predict pT0 stage on RP.

Search for residual prostate cancer on pT0 radical prostatectomy after positive biopsy

Reported incidence of no residual prostate cancer (i.e. pathological stage pT0) on radical prostatectomy ranges from 0.07 to 4.2%. The incidence is higher after neoadjuvant endocrine treatment. The aim of this study was to search for residual cancer on radical prostatectomy (RP) specimens when an initial sampling failed to find the cancer in patients with positive biopsy. Our database of 1,328 consecutive patients whose biopsies and RP specimen were both examined at the Polytechnic University-United Hospitals of the Marche Region between March 1995 and June 2006 was reviewed. The radical prostatectomies were grossly completely sampled and examined with the whole mount technique. We identified eight patients (i.e. 0.6%; three untreated and five hormonally treated preoperatively, i.e. 0.3 and 0.8%, respectively, of the total number of RPs included in the study) with positive biopsy and with no residual cancer in the initial routine histological examination of the RP. The RP of this group of eight was subjected to additional sectioning and evaluation of the paraffin blocks of the prostatectomy, also after block-flipping, immunostaining with an antibody against CAM 5.2, p63, PSA, and alpha-methylacyl-CoA racemase, and DNA specimen identity analysis. There were no cases with a false positive biopsy diagnosis, and cancer was not overlooked or missed in the initial routine histological examination of any of the 8 pT0 RPs. A minute focus of cancer (the diameter was always below 2.0 mm) was found on the additional sections in five. In particular, cancer was found after block-flipping in one of them. In an additional case, cancer was eventually discovered after immunostaining tissue sections for cytokeratin CAM 5.2, for p63 and PSA. In the remaining two cases (one untreated and the other hormonally treated), cancer was not found (0.15% of the 1,328 RPs included in the study); the review of the description of the macroscopic appearance of the RP and of its slides revealed that part of the peripheral zone corresponding to the site of the positive biopsy was missing, i.e. not removed from the patient at the time of the operation at least in one of the two. DNA specimen analysis confirmed the identity of the biopsy and prostatectomy in both. An extensive search for residual cancer reduces the number of pT0 RPs after a positive biopsy from 0.6 to 0.15%. It is recommended to have the needle biopsy reviewed, carefully look again at the radical prostatectomy, do deeper sections and then flip certain paraffin blocks. In addition, atypical foci should be stained for basal cell markers and often AMACR, especially in hormone-treated cases. If a block is missing part of the peripheral zone (capsular incision), this should be commented on. DNA analysis for tissue identity should be performed when the other steps have been taken without finding cancer.