Application of a Prognostic Gleason Grade Grouping System to Assess Distant Prostate Cancer Outcomes

A preoperative scoring system for predicting the extraprostatic extension of prostate cancer following radical prostatectomy using magnetic resonance imaging and clinical factors

PURPOSE

We aimed to develop a preoperative prediction model for extraprostatic extension (EPE) in prostate cancer (PCa) patients following radical prostatectomy (RP) using MRI and clinical factors.

METHODS

This retrospective study enrolled 266 consecutive patients who underwent RP for PCa in 2022. These patients were divided into a training set (n = 187) and a test set (n = 79) through random assignment. The evaluated variables included age, prostate-specific antigen (PSA) level, prostate volume, PSA density (PSAD), index tumor length on MRI, Prostate Imaging-Reporting and Data System (PI-RADS) category, and EPE-related MRI features as defined by PI-RADS v2.1. A predictive model was constructed through multivariable logistic regression and subsequently translated into a scoring system. The performance of this scoring system in terms of prediction and calibration was assessed using C statistics and the Hosmer‒Lemeshow test.

RESULTS

Among patients in the training and test cohorts, 74 (39.6%) and 25 (31.6%), respectively, exhibited EPE after RP. The formulated scoring system incorporated the following factors: PSAD, index tumor length, bulging prostatic contour, and tumor-capsule interface > 10 mm as identified on MRI. This scoring system demonstrated strong prediction performance for EPE in both the training (C statistic, 0.87 [95% confidence interval, 0.86-0.87]) and test cohorts (C statistic, 0.85 [0.83-0.89]). Furthermore, the scoring system exhibited good calibration in both cohorts (P = 0.988 and 0.402, respectively).

CONCLUSION

Our scoring system, built upon MRI features defined by the PI-RADS, offers valuable assistance in assessing the likelihood of EPE after RP.

Imaging features of the PI-RADS for predicting extraprostatic extension of prostate cancer: systematic review and meta-analysis

OBJECTIVES

To systematically determine the diagnostic performance of each MRI feature of the PI-RADS for predicting extraprostatic extension (EPE) in prostate cancer.

METHODS

A literature search in the MEDLINE and EMBASE databases was conducted to identify original studies reporting the accuracy of each feature on MRI for the dichotomous diagnosis of EPE. The meta-analytic pooled diagnostic odds ratio (DOR), sensitivity, specificity, and their 95% confidence intervals (CIs) were obtained using a bivariate random-effects model.

RESULTS

After screening 1955 studies, 17 studies with a total of 3062 men were included. All six imaging features, i.e., bulging prostatic contour, irregular or spiculated margin, asymmetry or invasion of neurovascular bundle, obliteration of rectoprostatic angle, tumor-capsule interface > 10 mm, and breach of the capsule with evidence of direct tumor extension, were significantly associated with EPE. Breach of the capsule with direct tumor extension demonstrated the highest pooled DOR (15.6, 95% CI [7.7-31.5]) followed by tumor-capsule interface > 10 mm (10.5 [5.4-20.2]), asymmetry or invasion of neurovascular bundle (7.6 [3.8-15.2]), and obliteration of rectoprostatic angle (6.1 [3.8-9.8]). Irregular or spiculated margin showed the lowest pooled DOR (2.3 [1.3-4.2]). Breach of the capsule with direct tumor extension and tumor-capsule interface > 10 mm showed the highest pooled specificity (98.0% [96.2-99.0]) and sensitivity (86.3% [70.0-94.4]), respectively.

CONCLUSIONS

Among the six MRI features of prostate cancer, breach of the capsule with direct tumor extension and tumor-capsule interface > 10 mm were the most predictive of EPE with the highest specificity and sensitivity, respectively.

Ultrasonographic pathological grading of prostate cancer using automatic region-based Gleason grading network

The Gleason scoring system is a reliable method for quantifying the aggressiveness of prostate cancer, which provides an important reference value for clinical assessment on therapeutic strategies. However, to the best of our knowledge, no study has been done on the pathological grading of prostate cancer from single ultrasound images. In this work, a novel Automatic Region-based Gleason Grading (ARGG) network for prostate cancer based on deep learning is proposed. ARGG consists of two stages: (1) a region labeling object detection (RLOD) network is designed to label the prostate cancer lesion region; (2) a Gleason grading network (GNet) is proposed for pathological grading of prostate ultrasound images. In RLOD, a new feature fusion structure Skip-connected Feature Pyramid Network (CFPN) is proposed as an auxiliary branch for extracting features and enhancing the fusion of high-level features and low-level features, which helps to detect the small lesion and extract the image detail information. In GNet, we designed a synchronized pulse enhancement module (SPEM) based on pulse-coupled neural networks for enhancing the results of RLOD detection and used as training samples, and then fed the enhanced results and the original ones into the channel attention classification network (CACN), which introduces an attention mechanism to benefit the prediction of cancer grading. Experimental performance on the dataset of prostate ultrasound images collected from hospitals shows that the proposed Gleason grading model outperforms the manual diagnosis by physicians with a precision of 0.830. In addition, we have evaluated the lesions detection performance of RLOD, which achieves a mean Dice metric of 0.815.

Association of adenosine signaling gene signature with estrogen receptor-positive breast and prostate cancer bone metastasis

Bone metastasis is a common and devastating consequence of several major cancer types, including breast and prostate. Osteocytes are the predominant bone cell, and through connexin (Cx) 43 hemichannels release ATP to the bone microenvironment that can be hydrolyzed to adenosine. Here, we investigated how genes related to ATP paracrine signaling are involved in two common bone-metastasizing malignancies, estrogen receptor positive (ER⁺) breast and prostate cancers. Compared to other sites, bone metastases of both cancer types expressed higher levels of ENTPD1 and NT5E, which encode CD39 and CD73, respectively, and hydrolyze ATP to adenosine. ADORA3, encoding the adenosine A3 receptor, had a similar expression pattern. In primary ER⁺ breast cancer, high levels of the triplet ENTPD1/NT5E/ADORA3 expression signature was correlated with lower overall, distant metastasis-free, and progression-free survival. In ER⁺ bone metastasis biopsies, this expression signature is associated with lower survival. This expression signature was also higher in bone-metastasizing primary prostate cancers than in those that caused other tumor events or did not lead to progressive disease. In 3D culture, a non-hydrolyzable ATP analog inhibited the growth of breast and prostate cancer cell lines more than ATP did. A3 inhibition also reduced spheroid growth. Large-scale screens by the Drug Repurposing Hub found ER⁺ breast cancer cell lines were uniquely sensitive to adenosine receptor antagonists. Together, these data suggest a vital role for extracellular ATP degradation and adenosine receptor signaling in cancer bone metastasis, and this study provides potential diagnostic means for bone metastasis and specific targets for treatment and prevention.

Prognostic Utility of the Gleason Grading System Revisions and Histopathological Factors Beyond Gleason Grade

Background

The International Society of Urological Pathology (ISUP) revised the Gleason system in 2005 and 2014. The impact of these changes on prostate cancer (PCa) prognostication remains unclear.

Objective

To evaluate if the ISUP 2014 Gleason score (GS) predicts PCa death better than the pre-2005 GS, and if additional histopathological information can further improve PCa death prediction.

Patients and Methods

We conducted a case–control study nested among men in the National Prostate Cancer Register of Sweden diagnosed with non-metastatic PCa 1998–2015. We included 369 men who died from PCa (cases) and 369 men who did not (controls). Two uro-pathologists centrally re-reviewed biopsy ISUP 2014 Gleason grading, poorly formed glands, cribriform pattern, comedonecrosis, perineural invasion, intraductal, ductal and mucinous carcinoma, percentage Gleason 4, inflammation, high-grade prostatic intraepithelial neoplasia (HGPIN) and post-atrophic hyperplasia. Pre-2005 GS was back-transformed using i) information on cribriform pattern and/or poorly formed glands and ii) the diagnostic GS from the registry. Models were developed using Firth logistic regression and compared in terms of discrimination (AUC).

Results

The ISUP 2014 GS (AUC = 0.808) performed better than the pre-2005 GS when back-transformed using only cribriform pattern (AUC = 0.785) or both cribriform and poorly formed glands (AUC = 0.792), but not when back-transformed using only poorly formed glands (AUC = 0.800). Similarly, the ISUP 2014 GS performed better than the diagnostic GS (AUC = 0.808 vs 0.781). Comedonecrosis (AUC = 0.811), HGPIN (AUC = 0.810) and number of cores with ≥50% cancer (AUC = 0.810) predicted PCa death independently of the ISUP 2014 GS.

Conclusion

The Gleason Grading revisions have improved PCa death prediction, likely due to classifying cribriform patterns, rather than poorly formed glands, as Gleason 4. Comedonecrosis, HGPIN and number of cores with ≥50% cancer further improve PCa death discrimination slightly.

Presence of biopsy Gleason pattern 5 + 3 is associated with higher mortality after radical prostatectomy but not after external beam radiotherapy compared to other Gleason Grade Group IV patterns

BACKGROUND

We hypothesized that Gleason Grade Group (GGG) IV patients treated with radical prostatectomy (RP) or external beam radiotherapy (EBRT) exhibit different cancer-specific mortality (CSM) rates according to underlying Gleason patterns (GP): 4 + 4 versus 3 + 5 versus 5 + 3.

MATERIALS AND METHODS

We identified all GGG IV patients treated with either RP or EBRT within the Surveillance, Epidemiology, and End Results 2004-2016 database. The effect of biopsy GP on CSM (3 + 5 vs. 4 + 4 vs. 5 + 3) was tested in Kaplan-Meier and multivariable competing risks regression models (adjusted for PSA, age at diagnosis, cT-, and cN-stage).

RESULTS

Of 26,458 GGG IV patients, 14,203 (53.7%) were treated with EBRT and 12,255 (46.3%) with RP. Of RP patients, 15.3 versus 81.2 versus 3.4% exhibited biopsy GP 3 + 5 versus 4 + 4 versus 5 + 3 and respective 10-year CSM rates were 6.5 versus 6.2 versus 12.6% (p < .001). In multivariable analyses addressing RP patients, GP 5 + 3 was associated with two-fold higher CSM rate than GP 4 + 4 (p < .001), but not GP 3 + 5 (p = .1). Of EBRT patients, 7.6 versus 89.8 versus 2.6% exhibited biopsy GP 3 + 5 versus 4 + 4 versus 5 + 3 and respective 10-year CSM rates were 12.2 versus 13.8 versus 17.8% (p < .001). In multivariable analyses addressing EBRT patients, no CSM differences according to GP were observed (all p ≥ .4).

CONCLUSION

In GGG IV RP candidates, the presence of biopsy GP 5 + 3 purports a significantly higher CSM than in GP 4 + 4 or 3 + 5. In GGG IV EBRT candidates, no significant CSM differences according to GP were recorded.

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.

Detection and localisation of primary prostate cancer using 68 gallium prostate-specific membrane antigen positron emission tomography/computed tomography compared with multiparametric magnetic resonance imaging and radical prostatectomy specimen pathology

OBJECTIVE

To compare the accuracy of ⁶⁸ gallium prostate-specific membrane antigen positron emission tomography/computed tomography (⁶⁸ Ga-PSMA PET/CT) with multiparametric MRI (mpMRI) in detecting and localising primary prostate cancer when compared with radical prostatectomy (RP) specimen pathology.

PATIENTS AND METHODS

Retrospective review of men who underwent ⁶⁸ Ga-PSMA PET/CT and mpMRI for primary prostate cancer before RP across four centres between 2015 and 2018. Patients undergoing imaging for recurrent disease or before non-surgical treatment were excluded. We defined pathological index tumour as the lesion with highest International Society of Urological Pathology Grade Group (GG) on RP specimen pathology. Our primary outcomes were rates of accurate detection and localisation of RP specimen pathology index tumour using ⁶⁸ Ga-PSMA PET/CT or mpMRI. We defined tumour detection as imaging lesion corresponding with RP specimen tumour on any imaging plane, and localisation as imaging lesion matching RP specimen index tumour in all sagittal, axial, and coronal planes. Secondary outcomes included localisation of clinically significant and transition zone (TZ) index tumours. We defined clinically significant disease as GG 3-5. We used descriptive statistics and the Mann-Whitney U-test to define and compare demographic and pathological characteristics between detected, missed and localised tumours using either imaging modality. We used the McNemar test to compare detection and localisation rates using ⁶⁸ Ga-PSMA PET/CT and mpMRI.

RESULTS

In all, 205 men were included in our analysis, including 133 with clinically significant disease. There was no significant difference between ⁶⁸ Ga-PSMA PET/CT and mpMRI in the detection of any tumour (94% vs 95%, P > 0.9). There was also no significant difference between localisation of all index tumours (91% vs 89%, P = 0.47), clinically significant index tumours (96% vs 91%, P = 0.15) or TZ tumours (85% vs 80%, P > 0.9) using ⁶⁸ Ga-PSMA PET/CT and mpMRI. Limitations include retrospective study design and non-central review of imaging and pathology.

CONCLUSION

We found no significant difference in the detection or localisation of primary prostate cancer between ⁶⁸ Ga-PSMA PET/CT and mpMRI. Further prospective studies are required to evaluate a combined PET/MRI model in minimising tumours missed by either modality.

Photoacoustic spectral analysis at ultraviolet wavelengths for characterizing the Gleason grades of prostate cancer

The diagnosis of aggressive prostate cancer (PCa) has relied on microscopic architectures, namely Gleason patterns, of tissues extracted through core biopsies. Technology capable of assessing the tissue architecture without tissue extraction will reduce the invasiveness of PCa diagnosis and improve diagnostic accuracy by allowing for more sampling locations. Our recently developed photoacoustic spectral analysis (PASA) has achieved quantification of tissue architectural heterogeneity interstitially. Taking advantage of the unique optical absorption of cell nuclei at ultraviolet (UV) wavelengths, this study investigated PASA at 266 nm for quantifying the tissue architecture heterogeneity in prostates. The results have shown significant differences among the normal, early cancer, and late cancer stages in mouse prostates ex vivo and in vivo (n=20, p<0.05). The study with human samples ex vivo has shown a correlation of 0.80 (n=11, p<0.05) between PASA quantification and pathologic diagnosis.

Prostate Cancer, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology

The NCCN Guidelines for Prostate Cancer include recommendations regarding diagnosis, risk stratification and workup, treatment options for localized disease, and management of recurrent and advanced disease for clinicians who treat patients with prostate cancer. The portions of the guidelines included herein focus on the roles of germline and somatic genetic testing, risk stratification with nomograms and tumor multigene molecular testing, androgen deprivation therapy, secondary hormonal therapy, chemotherapy, and immunotherapy in patients with prostate cancer.

Updates in Histologic Grading of Urologic Neoplasms

CONTEXT.—

Tumor histology offers a composite view of the genetic, epigenetic, proteomic, and microenvironmental determinants of tumor biology. As a marker of tumor histology, histologic grading has persisted as a highly relevant factor in risk stratification and management of urologic neoplasms (ie, renal cell carcinoma, prostatic adenocarcinoma, and urothelial carcinoma). Ongoing research and consensus meetings have attempted to improve the accuracy, consistency, and biologic relevance of histologic grading, as well as provide guidance for many challenging scenarios.

OBJECTIVE.—

To review the most recent updates to the grading system of urologic neoplasms, including those in the 2016 4th edition of the World Health Organization (WHO) Bluebook, with emphasis on issues encountered in routine practice.

DATA SOURCES.—

Peer-reviewed publications and the 4th edition of the WHO Bluebook on the pathology and genetics of the urinary system and male genital organs.

CONCLUSIONS.—

This article summarizes the recently updated grading schemes for renal cell carcinoma, prostate adenocarcinomas, and bladder neoplasms of the genitourinary tract.

The Significance of Primary Biopsy Gleason 5 in Patients with Grade Group 5 Prostate Cancer

The five-tier grade group (GG) classification for prostate cancer (PCa) does not differentiate between primary (5+4) or secondary (4+5) histological Gleason 5 pattern in GG 5. We addressed the prognostic value of primary versus secondary biopsy Gleason 5 for GG 5 among 18 555 PCa patients treated with radical prostatectomy (RP) between 1992 and 2014. Of these, 922 patients had GG 5 PCa with primary (n=295) or secondary (n=627) Gleason 5 on biopsy. Prediction of biochemical recurrence (BCR), metastasis, and cancer-specific mortality (CSM) was assessed using Kaplan-Meier curves and univariable/multivariable Cox regression controlling for known prognosticators. Median follow-up was 74.8 mo (interquartile range [IQR] 49.2-120.2). BCR developed in 24.3% of patients (n=4508) at a median of 23.6 mo (IQR 7.1-48.6). Metastasis developed in 4.5% (n=827) and 2.0% (n=370) died of PCa. When stratifying GG 5 by primary versus secondary Gleason 5, the estimated 5-yr metastasis-free survival was 80.4% (95% confidence interval [CI] 76.1-85.0%) versus 86.9% (95% CI 84.2-89.7%; p= 0.002) and cancer-specific survival was 90.9% (95% CI 87.5-94.4%) versus 96.3% (95% CI 94.7-98.0%; p< 0.001). On multivariable analysis, the negative impact of primary biopsy Gleason 5 among GG 5 patients remained significant for metastasis (hazard ratio [HR] 1.58; p< 0.001) and CSM (HR 2.44; p< 0.001). Therefore, stratifying GG 5 into primary (5 + 4, 5 + 5) and secondary (4 + 5) Gleason 5 may be warranted. PATIENT SUMMARY: We recorded worse oncological outcomes for patients with a primary histological Gleason 5 pattern on prostate biopsy compared to patients with a secondary biopsy Gleason 5 pattern.

Prognostic significance of the presence of intraductal carcinoma of the prostate and bone metastasis in needle biopsy for prostate carcinoma patients with Grade Group 5

Intraductal carcinoma of the prostate (IDC-P) and bone metastasis have been both identified to associate with unfavorable clinical outcome of the prostate carcinoma (PCa). Our objective is to examine whether IDC-P or bone metastasis at diagnostic biopsies was associated with each other and whether they were linked with overall survival (OS) and cancer specific survival (CSS) of Grade Group 5 patients. We retrospectively selected the prostate biopsy specimens of 120 PCa patients with Grade Group 5 from Qilu Hospital of Shandong University between 2012 and 2016. There were 12 patients with IDC-P only, 52 patients with bone metastasis only and 10 patients with both IDC-P and bone metastasis. Overall, there was a significant correlation between the presences of the IDC-P and bone metastasis (P = 0.003). Kaplan-Meier survival analysis demonstrated that the presence of IDC-P and bone metastasis in diagnostic needle biopsy both conferred unfavorable CSS of Grade Group 5 patients. In addition, the presence of bone metastasis was a poor predictor of OS. Univariate and multivariate analysis revealed that bone metastasis was an independent prognostic factor for OS of Grade Group 5 patients, but IDC-P failed to be significant for either OS or CSS. Collectively, our study suggested that bone metastasis is an important prognostic factor and superior than the presence of the IDC-P for PCa patients with Grade Group 5.

Polyploid giant cancer cells: Unrecognized actuators of tumorigenesis, metastasis, and resistance

Cancer led to the deaths of more than 9 million people worldwide in 2018, and most of these deaths were due to metastatic tumor burden. While in most cases, we still do not know why cancer is lethal, we know that a total tumor burden of 1 kg-equivalent to one trillion cells-is not compatible with life. While localized disease is curable through surgical removal or radiation, once cancer has spread, it is largely incurable. The inability to cure metastatic cancer lies, at least in part, to the fact that cancer is resistant to all known compounds and anticancer drugs. The source of this resistance remains undefined. In fact, the vast majority of metastatic cancers are resistant to all currently available anticancer therapies, including chemotherapy, hormone therapy, immunotherapy, and systemic radiation. Thus, despite decades-even centuries-of research, metastatic cancer remains lethal and incurable. We present historical and contemporary evidence that the key actuators of this process-of tumorigenesis, metastasis, and therapy resistance-are polyploid giant cancer cells.

[Grading of prostate cancer. For a more precise prognosis]

The simplification of the Gleason grading system, together with the reclassification of some of its patterns, has improved correlation with the clinical reality of prostate cancer, whilst maintaining the basic principles established fifty years ago. The subsequent grouping of the patterns into five degrees has allowed a more rational unification and enhanced the physician/patient communication. However, a greater precision in the assessment of the prognosis for each patient is still necessary and, to this end, elements that allow greater discrimination are continually being sought. The purpose of this brief review is to discuss the value and possible future incorporation in international recommendations of the percentage of pattern 4, the quantification of the cribriform pattern, the detection of intraductal carcinoma, the regrouping of some 'scores' and the possible stratification of the grade group 1.

DNA damage repair alterations are frequent in prostatic adenocarcinomas with focal pleomorphic giant-cell features

AIMS

Prostatic adenocarcinomas with focal pleomorphic giant-cell features constitute a rare tumour subtype with abysmal clinical outcomes. More than one-third of patients with this histology die within a year of the initial diagnosis of prostate cancer. We aimed to perform molecular profiling of these tumors to identify potential therapeutic targets.

METHODS AND RESULTS

Here, we performed next-generation sequencing with a highly validated targeted panel (UW-OncoPlex) on somatic tumour DNA extracted from eight cases of prostatic adenocarcinoma with focal pleomorphic giant-cell features, including cases with and without prior treatment for prostate cancer. We found that DNA damage repair mutations are common in this rare subset of prostate tumours, with two of eight having bi-allelic pathogenic mutations in homologous DNA repair genes (including BRCA2 and NBN) and two of eight having bi-allelic pathogenic mutations in mismatch repair genes (including MSH2 and MLH1).

CONCLUSION

These data are consistent with emerging data showing that DNA repair alterations are enriched among castration-resistant prostate cancer and aggressive subsets of primary tumours. Given that these patients are potential candidates for poly(ADP-ribose) polymerase inhibitor and/or immune checkpoint blockade, and have a poor prognosis with standard therapy, we recommend that tumour and germline DNA sequencing with or without mismatch repair protein immunohistochemistry be considered for all prostatic adenocarcinomas with focal pleomorphic giant-cell features.

Essential Updates in Grading, Morphotyping, Reporting, and Staging of Prostate Carcinoma for General Surgical Pathologists

CONTEXT.—

Within this decade, several important updates in prostate cancer have been presented through expert international consensus conferences and influential publications of tumor classification and staging.

OBJECTIVE.—

To present key updates in prostate carcinoma.

DATA SOURCES.—

The study comprised a review of literature and our experience from routine and consultation practices.

CONCLUSIONS.—

Grade groups, a compression of the Gleason system into clinically meaningful groups relevant in this era of active surveillance and multidisciplinary care management for prostate cancer, have been introduced. Refinements in the Gleason patterns notably result in the contemporarily defined Gleason score 6 cancers having a virtually indolent behavior. Grading of tertiary and minor higher-grade patterns in radical prostatectomy has been clarified. A new classification for prostatic neuroendocrine tumors has been promulgated, and intraductal, microcystic, and pleomorphic giant cell carcinomas have been officially recognized. Reporting the percentage of Gleason pattern 4 in Gleason score 7 cancers has been recommended, and data on the enhanced risk for worse prognosis of cribriform pattern are emerging. In reporting biopsies for active surveillance criteria-based protocols, we outline approaches in special situations, including variances in sampling or submission. The 8th American Joint Commission on Cancer TNM staging for prostate cancer has eliminated pT2 subcategorization and stresses the importance of nonanatomic factors in stage groupings and outcome prediction. As the clinical and pathology practices for prostate cancer continue to evolve, it is of utmost importance that surgical pathologists become fully aware of the new changes and challenges that impact their evaluation of prostatic specimens.

Three-year interim results of overall and progression-free survival in a cohort of patients with prostate cancer (GESCAP group)

AIMS

To describe the 3-year progression-free survival (PFS), overall survival (OS) and disease-specific mortality in the prospective prostate cancer GESCAP cohort, as well as the progression to castration resistance in patients on hormone therapy.

MATERIAL AND METHODS

Prospective, observational, epidemiological, multicentre study. Of the 4087 patients recruited, 3843 were evaluable. The variables analysed were the risk group (localized, locally advanced, lymph involvement, metastatic), age, prostate-specific antigen (PSA) levels, Gleason score and initial treatment. Kaplan Meier survival analysis, the log-rank test and the Cox model were used to evaluate the survival data.

RESULTS

Three-year PFS was 81.4% and OS was 92.4%. During the 3 years of follow-up, 303 patients died (7.9%), 110 of them (36.3%) due to disease-related causes. The probability of castration resistance for all patients on hormone therapy (n=715) was 14.2%: 5%, 9.9%, 26.1% and 44.4% in localized, locally advanced, lymph involvement and metastatic cancer, respectively (log-rank P<.0001). Patients with metastases had poorer outcomes with respect to PFS, OS, disease-specific mortality and castration resistance. In the multivariate analysis, the Gleason score, PSA and presence of metastases were associated with shorter OS and PFS.

CONCLUSIONS

Our study showed stratification of risk, with a more unfavourable prognosis for patients with metastases. Patients with locally advanced disease differed with respect to those with localized disease due to their higher risk as regards disease-specific mortality. (Controlled-trials.com ISRCTN19893319).

Urologic Pathology: Key Parameters from a Urologist's Perspective

Prostate cancer, bladder cancer, and kidney cancer represent the 3 most common urologic malignancies, and form a heterogenous group of disease processes, with a wide range of pathologic features. As a urologist, a strong understanding of the pathologic features of urologic malignancies is essential to prognosticate and counsel patients and to determine the most effective course of treatment. This review discusses the pathologic features of prostate, bladder, and kidney cancer, and examines how detailed pathologic reporting is critical to today's practicing urologist.

Optimization of the 2014 Gleason grade grouping in a Canadian cohort of patients with localized prostate cancer

OBJECTIVES

To evaluate the five-tier Gleason grade group (GG) scoring of prostate cancers adopted by the International Society of Urology Pathology (ISUP) in 2014, and to propose modifications to optimize its performance.

PATIENTS AND METHODS

Data were obtained from PROCURE, a prospective cohort of patients with localized prostate cancer undergoing radical prostatectomy in Québec, 2006-2013. Surgical specimens were evaluated by genitourinary pathologists using 2014 ISUP criteria. Treatment failure was defined as biochemical recurrence and/or initiation of secondary, non-adjuvant therapy. Analyses were conducted using Kaplan-Meier methods, log-rank tests, Cox proportional hazards models and Harrell's concordance indices.

RESULTS

A total of 1 917 patients were included, with a median follow-up of 69 months. The 5-year treatment failure rates were 9.6%, 23.5%, 43.1%, 52.6% and 84.3% in GG1-5, respectively (P < 0.001 when comparing GG2 with GG3). Treatment failure rates for patients in GG2 and GG3 with tertiary Gleason 5 pattern were higher than patients in the same group without a tertiary pattern (P < 0.001), but were similar to rates for patients in GGs 3 or 4 without a tertiary pattern (P > 0.3). Primary Gleason pattern (4/5) predicted treatment failure in GG5 (5-year failure rates 82.3% vs 97.1%, respectively; P = 0.001). The five-tier GG system had greater accuracy as a prognostic indicator compared with the four-tier system (Harrell's concordance index 0.716 vs 0.676). When upgrading patients in GG2/3 with tertiary Gleason 5 pattern to patients in GG3/4, and separating patients in GG5 by primary Gleason pattern, the Harrell's concordance index increased to 0.730.

CONCLUSION

The five-tier GG system increased accuracy for predicting treatment failure compared with the previous grading systems, but can be further improved.

Unfavorable Pathology, Tissue Biomarkers and Genomic Tests With Clinical Implications in Prostate Cancer Management

Prostate cancer management has traditionally relied upon risk stratification of patients based on Gleason score, pretreatment prostate-specific antigen and clinical tumor stage. However, these factors alone do not adequately reflect the inherent complexity and heterogeneity of prostate cancer. Accurate and individualized risk stratification at the time of diagnosis is instrumental to facilitate clinical decision-making and treatment selection tailored to each patient. The incorporation of tissue and genetic biomarkers into current prostate cancer prediction models may optimize decision-making and improve patient outcomes. In this review we discuss the clinical significance of unfavorable morphologic features such as cribriform architecture and intraductal carcinoma of the prostate, tissue biomarkers and genomic tests and assess their potential use in prostate cancer risk assessment and treatment selection.

RNAs as Candidate Diagnostic and Prognostic Markers of Prostate Cancer-From Cell Line Models to Liquid Biopsies

The treatment landscape of prostate cancer has evolved rapidly over the past five years. The explosion in treatment advances has been witnessed in parallel with significant progress in the field of molecular biomarkers. The advent of next-generation sequencing has enabled the molecular profiling of the genomic and transcriptomic architecture of prostate and other cancers. Coupled with this, is a renewed interest in the role of non-coding RNA (ncRNA) in prostate cancer biology. ncRNA consists of several different classes including small non-coding RNA (sncRNA), long non-coding RNA (lncRNA), and circular RNA (circRNA). These families are under active investigation, given their essential roles in cancer initiation, development and progression. This review focuses on the evidence for the role of RNAs in prostate cancer, and their use as diagnostic and prognostic markers, and targets for treatment in this disease.

How Are Gleason Scores Categorized in the Current Literature: An Analysis and Comparison of Articles Published in 2016-2017

BACKGROUND

A new prostate cancer grading system was proposed in 2013 and endorsed by major journals and societies in 2014, in part because of anecdotal evidence that Gleason scores (GSs) were incorrectly combined in the literature.

OBJECTIVE

To examine how published studies categorized GSs in current practice.

DESIGN, SETTING, AND PARTICIPANTS

A PubMed search was conducted on articles published in 2016-2017 using the search terms "Gleason" and "prostate". This literature review included 1576 articles after exclusions.

RESULTS

(1) Separating GS 7: pathology journals were more likely than non-pathology journals to grade GS 7 separately (56.9% vs 40.0%, p<0.05). Articles co-authored by a pathologist separated GS 7 more than those without a pathologist (53.2% vs 32.9%, p<0.001). North American and European studies separated GS 7 more than Asian studies (47.6% and 44.1% vs 24.1%, p<0.001). Clinical articles separated GS 7 more than research articles (43.7% vs 32.9%, p<0.001). (2) Separating GS 8 from GS 9-10: pathology journals separated GS 8 from GS 9-10 more than non-pathology journals (55.2% vs 34.4%, p=0.001). Articles co-authored by a pathologist separated GS 8 from GS 9-10 more often than those without a pathologist (44.9% vs 29.5%, p<0.001). (3) Using grade groups as "ideal" with all other groupings "non-ideal": pathology journals used ideal more than non-pathology journals (32.2% vs 15.9%, p<0.001). Ideal grouping is more likely in articles co-authored by a pathologist than in those without a pathologist (20.6% vs 11.0%, p<0.001). North American and European studies used ideal grouping more than Asian studies (17.6% and 14.0% vs 9.1%, p<0.05). (4) Arranging groupings in decreasing order from ideal to non-ideal: pathology journals were closer to ideal than non-pathology journals (p=0.002). Articles co-authored by a pathologist were classified closer to ideal than those without a pathologist (p<0.001). North American (p<0.001) and European (p=0.02) studies were closer to ideal than Asian studies.

CONCLUSIONS

There is still wide variation in how GSs are grouped world-wide. Only a minority of published articles group GSs accurately.

PATIENT SUMMARY

In this report, we looked at how GSs were grouped world-wide. We found that only a minority of published articles on prostate cancer were grouping GSs accurately, which could lead to inaccurate results and affect patient care with different prostate cancer grades. Our study calls for more widespread adoption of the new prostate cancer grading system composed of five grade groups to minimize incorrect grouping for future studies.

Improving quality through clinical registries in urology

PURPOSE OF REVIEW

In this review, we highlight the use of clinical registries for quality improvement and research purposes in urology. We focus on national and regional clinical database registries, such as the National Surgical Quality Improvement Programme, the Cancer of the Prostate Strategic Urologic Research Endeavor, the Michigan Urological Surgery Improvement collaborative and the American Urological Association Quality Registry programme.

RECENT FINDINGS

It is widely known that claims-based and institutional databases are limited in their capacity to provide granular, real-time data for quality improvement purposes. As a result, clinical registries have emerged as an attractive alternative given their ability to capture large amounts of data across networks of health records. Another added benefit of Federally Qualified Clinical Data Registries (QCDRs) is the ability to meet emerging Medicare quality reporting standards, such as Physician Quality Reporting System and Meaningful Use. Despite the enthusiasm for QCDRs in the field of urology, however, myriad challenges remain in their implementation and widespread adoption including integration of existing health-information technology infrastructure, the accurate measurement of quality measures and the availability of clinically relevant quality measures in subspecialty practices.

SUMMARY

Quality measurement and improvement have become important aspects of modern clinical practice. Advances in health information technology have ushered in new tools, such as clinical registries, which simultaneously improve the quality of scientific research and clinical care while assisting eligible professionals in meeting federally mandated reporting requirements.

The performance of the new prognostic grade and stage groups in conservatively treated prostate cancer

We evaluated the prognosis of the new grade groups and American Joint Committee on Cancer (AJCC) stage groups in men with prostate cancer (PCa) who were treated conservatively. A total of 13 798 eligible men were chosen from the Surveillance Epidemiology and End Results database. The new grade and AJCC stage groups were investigated on prostate biopsy specimens. Kaplan–Meier survival analysis and multivariable hazards models were applied to estimate the association of new grade and stage groups with overall survival (OS) and PCa-specific survival (CSS). Mean follow-up was 42.65 months (95% confidence interval: 42.47–42.84) in the entire cohort. The 3-year OS and CSS rates stepped down for grade groups 1–5 and AJCC stage groups I–IVB, respectively. After adjusting for clinical and pathological characteristics, all grade groups and AJCC stage groups were associated with higher all-cause and PCa-specific mortality compared to the reference group (all P ≤ 0.003). In conclusion, we evaluated the oncological outcome of the new grade and AJCC stage groups on biopsy specimens of conservatively treated PCa. These two novel clinically relevant classifications can assist physicians to determine different therapeutic strategies for PCa patients.

Prostate cancer grading: a decade after the 2005 modified system

This review article will cover the evolution of grading of prostate cancer from the original Gleason system in the 1960-1970s to a more patient-centric grading system proposed in 2013 from a group at Johns Hopkins Hospital, validated in 2014 by a large multi-institutional study, and subsequently accepted by the World Health Organization (WHO), College of American Pathology (CAP), and the AJCC TNM system. Covered topics include: (1) historical background; (2) 2005 and 2014 International Society of Urological Pathology Grading Conferences; (3) Description of Gleason patterns; (4) new approaches to display Gleason grades; (5) grading variants and variations of acinar adenocarcinoma; (6) reporting rules for Gleason grading reporting secondary patterns of higher grade when present to a limited extent; (7) reporting secondary patterns of lower grade when present to a limited extent; (8) reporting percentage pattern 4; (9) general applications of the Gleason grading system; (10) needle biopsy with different cores showing different grades; (11) radical prostatectomy specimens with separate tumor nodules; and (12) a new grading system for prostate cancer.

Optimizing androgen deprivation therapy with radiation therapy for aggressive localized and locally advanced prostate cancer

Radiation therapy with androgen deprivation therapy (ADT) has historically been one of the mainstays of treatment for intermediate- and high-risk prostate cancer. The benefit of ADT likely derives from both enhancing local control and inhibiting micrometastatic disease. While level 1 evidence has demonstrated the benefits of 4-6 months of ADT for all men with intermediate-risk disease, further stratification of intermediate-risk prostate cancer into favorable and unfavorable subgroups indicates that ADT may not be necessary for favorable intermediate-risk disease but likely still provides a survival advantage for unfavorable intermediate-risk disease, even in the dose escalation era. Long-course ADT, consisting of 2-3 years of treatment, is the standard of care for high-risk prostate cancer managed with RT based on phase III trials. However, emerging data from a randomized trial raises the possibility that 18 months of ADT could be sufficient for select high-risk patients. The desire to minimize exposure to ADT lies in its many adverse effects, including the potential for cardiovascular harm in certain patients with significant coexisting comorbidity, possibly increased risk for neurocognitive and psychiatric events, and the well-documented metabolic changes. Providers need to carefully weigh these potential risks with the known survival benefits of ADT in aggressive localized and locally advanced prostate cancer.

Whom to Treat: Postdiagnostic Risk Assessment with Gleason Score, Risk Models, and Genomic Classifier

Management of prostate cancer presents unique challenges because of the disease's variable natural history. Accurate risk stratification at the time of diagnosis in clinically localized disease is crucial in providing optimal counseling about management options. To accurately distinguish pathologically indolent tumors from aggressive disease, risk groups are no longer sufficient. Rather, multivariable prognostic models reflecting the complete information known at time of diagnosis offer improved accuracy and interpretability. After diagnosis, further testing with genomic assays or other biomarkers improves risk classification. These postdiagnostic risk assessment tools should not supplant shared decision making, but rather facilitate risk classification and enable more individualized care.

Validation of the 2015 prostate cancer grade groups for predicting long-term oncologic outcomes in a shared equal-access health system

BACKGROUND

A 5-tier prognostic grade group (GG) system was enacted to simplify the risk stratification of patients with prostate cancer in which Gleason scores of ≤6, 3 + 4, 4 + 3, 8, and 9 or 10 are considered GG 1 through 5, respectively. The authors investigated the utility of biopsy GG for predicting long-term oncologic outcomes after radical prostatectomy in an equal-access health system.

METHODS

Men who underwent prostatectomy at 1 of 6 Veterans Affairs hospitals in the Shared Equal Access Regional Cancer Hospital database between 2005 and 2015 were reviewed. The prognostic ability of biopsy GG was examined using Cox models. Interactions between GG and race also were tested.

RESULTS

In total, 2509 men were identified who had data available on biopsy Gleason scores, covariates, and follow-up. The cohort included men with GG 1 (909 patients; 36.2%), GG 2 (813 patients; 32.4%), GG 3 (398 patients; 15.9%), GG 4 (279 patients; 11.1%), and GG 5 (110 patients; 4.4%) prostate cancer. The cohort included 1002 African American men (41%). The median follow-up was 60 months (interquartile range, 33-90 months). Higher GG was associated with higher clinical stage, older age, more recent surgery, and surgical center (P < .001) as well as increased biochemical recurrence, secondary therapy, castration-resistant prostate cancer, metastases, and prostate cancer-specific mortality (all P < .001). There were no significant interactions with race in predicting measured outcomes.

CONCLUSIONS

The 5-tier GG system predicted multiple long-term endpoints after radical prostatectomy in an equal-access health system. The predictive value was consistent across races. Cancer 2017;123:4122-4129. © 2017 American Cancer Society.

Biopsy Core Features are Poor Predictors of Adverse Pathology in Men with Grade Group 1 Prostate Cancer

PURPOSE

Active surveillance is often restricted to patients with low risk prostate cancer who have 3 or fewer positive cores. We aimed to identify predictors of adverse pathology results for low risk prostate cancer treated with radical prostatectomy and determine whether a threshold number of positive cores could help the decision process for active surveillance.

MATERIALS AND METHODS

A total of 3,359 men with low risk prostate cancer underwent radical prostatectomy between January 2000 and August 2016. We analyzed the relationship between biopsy core features and adverse pathology at radical prostatectomy, defined as Grade Group 3 or greater, seminal vesicle invasion or lymph node involvement.

RESULTS

Of the 171 cases (5.1%) with adverse pathology findings at radical prostatectomy 144 (4.3%) were upgraded to Grade Group 3 or greater, 31 (0.9%) had seminal vesicle invasion and 15 (0.4%) had lymph node involvement. Prostate specific antigen and patient age were the only predictors of adverse pathology results. There was no significant association with the number of positive cores, the total mm of cancer or the maximum percent of cancer in any core. When we expanded the definition of adverse pathology to include Grade Group 2 and extraprostatic extension, the association between core features and outcome was statistically significant but clinically weak, and with no evidence of threshold effects.

CONCLUSIONS

There is little basis for excluding patients with otherwise low risk prostate cancer on biopsy from active surveillance based on criteria such as the number of positive cores or the maximum cancer involvement of biopsy cores.

High levels of DEPDC1B predict shorter biochemical recurrence-free survival of patients with prostate cancer

DEP domain-containing protein 1B (DEPDC1B) has been reported to serve important functions in breast cancer and non-small cell lung cancer. However, its involvement in the development of prostate cancer (PCa) remains unclear. Therefore, the present study aimed to investigate the expression and clinical significance of DEPDC1B in tumor tissues from patients diagnosed with PCa. A total of 80 prostate tissue samples were collected following prostatectomy to generate a tissue microarray for immunohistochemical analysis of DEPDC1B protein expression. High throughput sequencing of mRNAs from 179 prostate tissue samples, either from patients with PCa or from healthy controls, was included in the Taylor dataset. The expression levels of DEPDC1B in tumor tissues from patients with PCa were revealed to be significantly increased compared with those in normal prostate tissues (P=0.039). Increased expression of DEPDC1B was significantly associated with advanced clinical stage (P=0.006), advanced T stage (P=0.012) and lymph node metastasis (P=0.004). Kaplan-Meier analysis demonstrated that patients with high levels of DEPDC1B mRNA had significantly shorter biochemical recurrence (BCR)-free survival times. Multivariate analysis using Cox proportional hazards model revealed that levels of DEPDC1B mRNA were significant independent predictors of BCR-free survival time of patients with PCa. Therefore, the expression of DEPDC1B may be used as an independent predictor of biochemical recurrence-free survival time of patients with PCa.

Contemporary grading of prostate cancer: 2017 update for pathologists and clinicians

The Gleason grading system for prostate cancer (PCa) was developed in the 1960s by DF Gleason. Due to changes in PCa detection and treatment, the application of the Gleason grading system has changed considerably in pathology routine practice. Two consensus conferences were held in 2005 and in 2014 to update PCa Gleason grading. This review provides a summary of the changes in the grading of PCa from the original Gleason grading system to the prognostic grade grouping, as well as a discussion of the clinical significance of the percentage of Gleason patterns 4 and 5.