Prognostic significance of primary Gleason pattern in Japanese men with Gleason score 7 prostate cancer treated with radical prostatectomy

Does the Gleason Score 7 Upgrading Always Predict Worse Prognosis?

OBJECTIVE

To determine the clinical significance of Gleason score(GS) 7 upgraded on radical prostatectomy(RP) and its impact on the prognosis of patients.

PATIENTS AND METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) database to study 8832 men diagnosed with M0 GS 3+4/4+3 prostate cancer (PCa) from 2010 to 2015 treated by RP. Logistic regression was used to analyze the effect of clinicopathological characteristics on the Gleason sore upgraded. Cox hazards regression analysis was performed to find significant factors of overall survival (OS).

RESULTS

A total of 6237 (70.6%) biopsy GS 3+4 patients and 2595(29.4%) biopsy GS 4+3 patients were included in the study. Univariate and multivariate logistic regression analysis found that prostate-specific antigen (PSA)>20ng/ml, T stage 3-4, lymph node metastasis are independent risk factors in predicting the incidence of GS upgraded after RP (all P<0.05). Through multivariate analysis, we found that black race, GS upgraded, chemotherapy played significant roles in predicting poor OS (all P<0.05). It was surprising to find that the biopsy GS upgraded in patients with PSA 0-4ng/ml and 4.1-10ng/ml had a significant association with poor OS (all P<0.05). Multivariate analysis showed that only in patients with PSA 4-10ng/ml, biopsy GS upgrade had a statistically important relationship with poor OS (P=0.046).

CONCLUSIONS

Not all patients with GS 7 upgraded had a worse prognosis than those without GS upgraded. Only in patients with PSA 4.1-10ng/ml, biopsy GS 7 upgraded was an independent risk factor affecting OS.

A critical evaluation of visual proportion of Gleason 4 and maximum cancer core length quantified by histopathologists

Gleason score 7 prostate cancer with a higher proportion of pattern 4 (G4) has been linked to genomic heterogeneity and poorer patient outcome. The current assessment of G4 proportion uses estimation by a pathologist, with a higher proportion of G4 more likely to trigger additional imaging and treatment over active surveillance. This estimation method has been shown to have inter-observer variability. Fifteen patients with Prostate Grade Group (GG) 2 (Gleason 3 + 4) and fifteen patients with GG3 (Gleason 4 + 3) disease were selected from the PROMIS study with 192 haematoxylin and eosin-stained slides scanned. Two experienced uropathologists assessed the maximum cancer core length (MCCL) and G4 proportion using the current standard method (visual estimation) followed by detailed digital manual annotation of each G4 area and measurement of MCCL (planimetric estimation) using freely available software by the same two experts. We aimed to compare visual estimation of G4 and MCCL to a pathologist-driven digital measurement. We show that the visual and digital MCCL measurement differs up to 2 mm in 76.6% (23/30) with a high degree of agreement between the two measurements; Visual gave a median MCCL of 10 ± 2.70 mm (IQR 4, range 5–15 mm) compared to digital of 9.88 ± 3.09 mm (IQR 3.82, range 5.01–15.7 mm) (p = 0.64) The visual method for assessing G4 proportion over-estimates in all patients, compared to digital measurements [median 11.2% (IQR 38.75, range 4.7–17.9%) vs 30.4% (IQR 18.37, range 12.9–50.76%)]. The discordance was higher as the amount of G4 increased (Bias 18.71, CI 33.87–48.75, r 0.7, p < 0.0001). Further work on assessing actual G4 burden calibrated to clinical outcomes might lead to the use of differing G4 thresholds of significance if the visual estimation is used or by incorporating semi-automated methods for G4 burden measurement.

Discrimination between clinical significant and insignificant prostate cancer with apparent diffusion coefficient - a systematic review and meta analysis

Background

Prostate MRI has become a corner stone in diagnosis of prostate cancer (PC). Diffusion weighted imaging and the apparent diffusion coefficient (ADC) can be used to reflect tumor microstructure. The present analysis sought to compare ADC values of clinically insignificant with clinical significant PC based upon a large patient sample.

Methods

MEDLINE library and SCOPUS databases were screened for the associations between ADC and Gleason score (GS) in PC up to May 2019. The primary endpoint of the systematic review was the ADC value of PC groups according to Gleason score. In total 26 studies were suitable for the analysis and included into the present study. The included studies comprised a total of 1633 lesions.

Results

Clinically significant PCs (GS ≥ 7) were diagnosed in 1078 cases (66.0%) and insignificant PCs (GS 5 and 6) in 555 cases (34.0%). The pooled mean ADC value derived from monoexponenantially fitted ADC_mean of the clinically significant PC was 0.86 × 10^− 3 mm²/s [95% CI 0.83–0.90] and the pooled mean value of insignificant PC was 1.1 × 10^− 3 mm²/s [95% CI 1.03–1.18]. Clinical significant PC showed lower ADC values compared to non-significant PC. The pooled ADC values of clinically insignificant PCs were no lower than 0.75 × 10^− 3 mm²/s.

Conclusions

We evaluated the published literature comparing clinical insignificant with clinically prostate cancer in regard of the Apparent diffusion coefficient values derived from magnetic resonance imaging. We identified that the clinically insignificant prostate cancer have lower ADC values than clinically significant, which may aid in tumor noninvasive tumor characterization in clinical routine.

Nomograms Predict Survival Advantages of Gleason Score 3+4 Over 4+3 for Prostate Cancer: A SEER-Based Study

Background: Different proportions of Gleason pattern 3 and Gleason pattern 4 lead to various prognosis of prostate cancer with Gleason score 7. The objective of this study was to compare the survival outcomes of Gleason score 3+4 and 4+3 based on data from the Surveillance, Epidemiology, and End Results cancer registry database, and to investigate independent prognosis-associated factors and develop nomograms for predicting survival in Gleason score 7 prostate cancer patients.

Methods: A retrospective study was conducted on 69,116 cases diagnosed as prostate adenocarcinoma with Gleason score 7 between 2004 and 2009. Prognosis-associated factors were evaluated using univariate and multivariate Cox regression analysis, and a 1:1 ratio paired cohort by propensity score matching with the statistical software IBM SPSS, to evaluate prognostic differences between Gleason score 3+4 and 4+3. The primary cohort was randomly divided into training set (n = 48,384) and validation set (n = 20,732). Based on the independent factors of prognosis, nomograms for prognosis were established by the training group and validated by the validation group using R version 3.5.0.

Results: After propensity score matching, Cox regression analysis showed that Gleason 4+3 had an increased mortality risk both for overall survival (HR: 1.235, 95% CI: 1.179–1.294, P < 0.001) and cancer-specific survival (HR: 1.606, 95% CI: 1.468–1.762, P < 0.001). Nomograms for overall survival and cancer-specific survival were established with C-index 0.786 and 0.842, respectively. The calibration plot indicated an optimal agreement between the actual observation and nomogram prediction for overall survival and cancer-specific survival probability at 5 or 10 year.

Conclusions: Prostate cancer with Gleason score 4+3 had worse overall survival and cancer-specific survival than Gleason score 3+4. Nomograms were formulated to predict 5-year and 10-year OS and CSS in patients with prostate cancer of Gleason score 7.

Evolution in Prostate Cancer Staging: Pathology Updates From AJCC 8th Edition and Opportunities That Remain

The Tumor-Nodes-Metastasis system at the core of prognostic staging has been recently updated in the American Joint Committee on Cancer (AJCC) 8th edition, published in 2016. For prostate cancer, significant changes in staging of organ-confined disease, inclusion of a new grade grouping, and provision of levels of evidence for these modifications are part of what differentiates the 8th edition AJCC from prior iterations. Herein, the rationale underlying these changes is detailed. In addition, data elements not well represented in the present system are highlighted as opportunities for fresh study that may impact future AJCC classifications.

Prognostic significance of six clinicopathological features for biochemical recurrence after radical prostatectomy: a systematic review and meta-analysis

Identifying patients with high risk of biochemical recurrence after radical prostatectomy is of immense value in clinical practice. Assessment of prognostic significance of specific clinicopathological features plays an important role in surgical management after prostatectomy. The purpose of our meta-analysis was to investigate the association between the six pathological characteristics and the prognosis of prostate cancer. We carried out a systematic document retrieval in electronic databases to sort out appropriate studies. Outcomes of interest were gathered from studies comparing biochemical recurrence-free survival (BCFS) in patients with the six pathological traits. Studies results were pooled, and hazard ratios (HRs) combined with corresponding 95% confidence intervals (CIs) for survival were used to estimate the effect size. 29 studies (21,683 patients) were enrolled in our meta-analysis. All the six predictors were statistically significant for BCFS with regard to seminal vesicle invasion (HR = 1.97, 95% CI = 1.79–2.18, p < 0.00001), positive surgical margin (HR = 1.79, 95% CI = 1.56–2.06, p < 0.00001), extracapsular extension (HR = 2.03, 95% CI = 1.65–2.50, p < 0.0001), lymphovascular invasion (HR = 1.85, 95% CI = 1.54–2.22, p < 0.00001), lymph node involvement (HR = 1.88, 95% CI = 1.37–2.60, p = 0.0001) and perineural invasion (HR = 1.59, 95% CI = 1.33–1.91, p < 0.00001). Subgroup analysis showed that all the six predictors had significantly relationship with poor BCFS. The pooled results demonstrated that the six clinical findings indicated a worse prognosis in patients with prostate cancer. In conclusion, our results show several clinicopathological characteristics can predict the risk of biochemical recurrence after radical prostatectomy. Prospective studies are needed to further confirm the predictive value of these features for the prognosis of prostate cancer patients after radical prostatectomy.

The effect of Rapid Access Prostate Clinics on the outcomes of Gleason 7 prostate cancer: does earlier diagnosis lead to better outcomes?

INTRODUCTION

Rapid Access Prostate Clinics (RAPC) were introduced in Ireland by the National Cancer Control Programme bringing about expedited referral pathways and increased detection rates of prostate cancer. Lower Gleason (G) grade at diagnosis due to RAPC has been previously reported but grade at prostatectomy has not been assessed. The aim of this study was to assess the impact of RAPC on the outcomes of patients with G7 disease on radical prostatectomy (RP).

METHODS

A retrospective analysis was carried out of all RPs performed over a 9-year period (2006-2014). Outcomes for G7 prostatectomies were compared before and after the introduction of the RAPC, with a further sub-analysis of G4 + 3 versus G3 + 4. The primary outcome was biochemical recurrence (BCR). Other outcomes were adjuvant/salvage radiotherapy, extra prostatic extension, positive surgical margins, seminal vesicle involvement and tumour stage.

RESULTS

In total, 240 RPs were performed with 167 cases graded G7 (70 graded G4 + 3 and 97 graded G3 + 4). Since the introduction of RAPC the proportion of G4 + 3 compared to G3 + 4 has increased from 37.9 to 42%. There was no statistical difference in outcomes for G4 + 3 treated before and after the introduction of RAPC. G4 + 3 was associated with higher rates of BCR (24.4 vs. 0%, p < 0.0001, radiotherapy (41.1 vs. 4.8%, p < 0.0001) and worse histological features than G3 + 4.

CONCLUSION

Despite the benefits in diagnosis of prostate cancer brought about by RAPC in Ireland, this has not translated to a lower grade for surgically treated patients. There has been no improvement in outcomes especially for higher grade G4 + 3 disease.

Permanent prostate brachytherapy and short-term androgen deprivation for intermediate-risk prostate cancer in Japanese men: outcome and toxicity

OBJECTIVES

To evaluate the interim outcomes of low-dose-rate permanent brachytherapy (PB) combined with short-term androgen deprivation therapy (ADT) in Japanese men with intermediate-risk prostate cancer excluding those with a Gleason score of 4+3.

METHODS

The Protocol-intermediate-risk group (Protocol-IRG) was defined as clinical stage T1c-T2c, Gleason score of 3+4, or lower and prostatic-specific antigen (PSA) level lower than 20 ng/mL. A total of 308 patients underwent brachytherapy in the protocol-IRG group (n=152) or in the low-risk group (n=156). Patients in Protocol-IRG had received at least 6 months of ADT before and after PB. Supplemental external beam radiotherapy was not used. Planned followup by PSA was carried out every 3 months for the first 2 years and every 6 months thereafter. The PSA failure was defined as nadir+2 ng/mL. Patients' Expanded Prostate Cancer Index Composite was recorded before and 3 years after treatment.

RESULTS

The median followup was 68 and 68 months for the protocol-IRG and the low-risk groups, respectively. The 5-year biological disease-free survival rates in the low-risk and protocol-IRG groups were 94.8 and 94.6%, respectively. As far as survival rates were concerned, there were no significant differences between the two groups. Overall satisfaction and sexual function at 3 years after PB had significantly improved compared with pretreatment (p=0.01 and p=0.01, respectively).

CONCLUSIONS

In intermediate-risk prostate patients, excluding those with a biopsy Gleason score of 4+3, brachytherapy with short-term ADT can be an effective treatment option for Japanese men.

Biochemical recurrence in Gleason score 7 prostate cancer in korean men: significance of the primary Gleason grade

Purpose

To evaluate the impact of primary Gleason grade in Gleason score (GS) 7 prostate cancer on biochemical recurrence (BCR) after radical prostatectomy in Korean men.

Materials and Methods

We retrospectively reviewed records of 1,026 patients who underwent radical prostatectomy at Seoul National University Bundang Hospital between November 2003 and June 2009. We excluded patients who had received neoadjuvant therapy and had positive resection margins. Finally, 295 and 113 patients with GS 3+4 and GS 4+3, respectively, were included in this study. All patients were followed for at least 2 years.

Results

Of the 408 GS 7 patients, 295 (72.3%) were 3+4 and 113 (27.7%) were 4+3. Mean serum prostate specific antigen level in primary Gleason 3 was 8.99 ng/ml and primary Gleason 4 was 11.11 ng/ml. Patients with GS 4+3 were more likely to have extracapsular extension (30.1% vs. 17.6%, p<0.010) and lymphatic invasion (16.8% vs. 7.1%, p<0.005). After 2 years follow up BCR was detected in a total of 40 patients. In GS 7 with primary Gleason 3, BCR occurred in 15 (5.08%) patients while 20 (17.70%) showed BCR in GS 7 with primary Gleason 4.

Conclusions

In this study of a large, single center cohort of Korean men with GS 7 prostate cancer a noticeable difference in BCR was seen. Primary Gleason grade 4 have a higher risk of BCR compared to primary Gleason grade 3. This information may be useful when counseling patients on their prognosis and further management options.