PERINEURAL INVASION AND SEMINAL VESICLE INVOLVEMENT PREDICT PELVIC LYMPH NODE METASTASIS IN MEN WITH LOCALIZED CARCINOMA OF THE PROSTATE

Clinical impact of perineural invasion encircled completely vs. incompletely by prostate cancer on needle core biopsy

The clinical significance of the pattern or degree of perineural invasion (PNI) by prostate cancer remains largely unknown. We herein assessed radical prostatectomy findings and postoperative oncologic outcomes in 125 patients who had undergone systematic sextant prostate biopsy exhibiting only a single focus of PNI encircled completely (n = 57; 46 %) vs. incompletely (n = 68; 54 %) by cancer. Between these two cohorts, there were no significant differences in clinicopathological features on biopsy or prostatectomy, including tumor grade, stage, and length or volume, and surgical margin status, as well as the need for adjuvant therapy immediately after prostatectomy. Similarly, survival analysis demonstrated no significant difference in the risk of disease progression following prostatectomy in patients with encircled vs. non-encircled PNI on biopsy (P = 0.679). When the non-encircled cases were further divided into four groups [i.e. 1-25 % enclosed (n = 12; 18 %), 26-50 % enclosed (n = 18; 26 %), 51-75 % enclosed (n = 10; 15 %), 76-99 % enclosed (n = 28; 41 %)], the rates of progression-free survival were comparable among the five groups (P = 0.954). In prostate biopsy specimens exhibiting PNI at only one focus, the degree of nerve involvement thus appears to have little clinical impact. Accordingly, PNI detected on prostate biopsy may need to be similarly taken into consideration irrespective of the degree of nerve involvement.

Clinical Significance of Perineural Invasion by Prostate Cancer Detected on Needle Core Biopsy

OBJECTIVES

The clinical impact of the laterality of perineural invasion (PNI) by prostate cancer remains poorly understood. We herein compared radical prostatectomy (RP) findings and long-term oncologic outcomes in patients with prostate cancer with PNI in two prostate biopsy (PBx) sites.

METHODS

We retrospectively assessed 170 consecutive patients undergoing systematic sextant PBx where PNI had been detected in two of six PBx sites, followed by RP.

RESULTS

PNI occurred unilaterally in 140 (82.4%) cases and bilaterally in 30 (17.6%) cases. Compared with unilateral PNI, bilateral PNI was significantly associated with a higher number of cancer-positive sites and longer total tumor length on PBx. However, there were no significant differences in RP findings, including tumor grade/stage and tumor volume, between unilateral and bilateral PNI cohorts. Kaplan-Meier analysis revealed that patients with bilateral PNI had a significantly higher risk of disease progression after RP than those with unilateral PNI (P = .038). In multivariate analysis, bilateral PNI (vs unilateral PNI) showed significance for progression (hazard ratio, 2.281; P = .023).

CONCLUSIONS

In PBx specimens exhibiting PNI in two sextant sites, bilateral PNI was found to be associated with poorer prognosis as an independent predictor but not worse histopathologic features in RP specimens compared with unilateral PNI.

The Clinical Significance of Perineural Invasion by Prostate Cancer on Needle Core Biopsy

CONTEXT.—

Perineural invasion (PNI) by prostate cancer has been associated with adverse pathology, including extraprostatic extension. However, the significance of PNI quantification on prostate biopsy (PBx) remains unclear.

OBJECTIVE.—

To compare radical prostatectomy (RP) findings and long-term outcomes in patients whose PBx had exhibited PNI.

DESIGN.—

We assessed 497 consecutive patients undergoing sextant (6-site/≥12-core) PBx showing conventional adenocarcinoma followed by RP.

RESULTS.—

PNI was found in 1 (n = 290)/2 (n = 132)/3 (n = 47)/4 (n = 19)/5 (n = 5)/6 (n = 4) of the sites/regions of PBx. Compared with a single PNI site, multiple PNIs were significantly associated with higher preoperative prostate-specific antigen, higher Grade Group (GG) on PBx or RP, higher pT or pN category, positive surgical margin, and larger estimated tumor volume. When compared in subgroups of patients based on PBx GG, significant differences in RP GG (GG1-3), pT (GG1-2/GG1-3/GG2/GG3), surgical margin status (GG1-3/GG3/GG5), or tumor volume (GG1-2/GG1-3/GG2/GG3) between 1 versus multiple PNIs were observed. Moreover, there were significant differences in prostate-specific antigen (PNI sites: 1-2 versus 3-6/1-3 versus 4-6/1-4 versus 5-6), RP GG (1-3 versus 4-6/1-4 versus 5-6), pT (1-2 versus 3-6/1-3 versus 4-6), pN (1-3 versus 4-6), or tumor volume (1-2 versus 3-6/1-4 versus 5-6). Outcome analysis revealed significantly higher risks of disease progression in the entire cohort or PBx GG1-2/GG1-3/GG2/GG3/GG5 cases showing 2 to 6 PNIs, compared with respective controls with 1-site PNI. In multivariate analysis, multisite PNI was an independent predictor for progression (hazard ratio = 1.556, P = .03).

CONCLUSIONS.—

Multiple sites of PNI on PBx were associated with worse histopathologic features in RP specimens and poorer prognosis. PNI may thus need to be specified, if present, in every sextant site on PBx, especially those showing GG1-3 cancer.

Impact of biopsy perineural invasion on younger prostate cancer patients after radical prostatectomy

OBJECTIVES

To identify the potential indicators for higher-risk disease and poor outcome in younger prostate cancer (PCa) patients (age ≤ 50) who had undergone radical prostatectomy (RP) in the prostate-specific antigen (PSA) era.

MATERIALS AND METHODS

A total of 186 PCa cases of age ≤ 50 who underwent RP between 2003 and 2010 at our center were included for study. High-risk disease after RP was defined as cases with pre-PSA ≥ 20 ng/ml and/or Gleason score (GS) ≥ 4 + 3 and/or pT stage ≥ 3. The poor outcome group was defined as cases with biochemical recurrence (BCR) and/or metastasis (Mets) and/or all-cause death. Multivariate logistic regression models were performed to identify independent risk factors for both high-risk disease and poor outcome.

RESULTS

Among 186 younger PCa patients aged ≤ 50, 36 cases (19.5%) had high-risk disease and 24 cases (12.9%) had poor outcome. The presence of biopsy perineural invasion (BxPNI) was significantly associated with high-risk disease and showed a trend to correlate with worse outcome in univariate analysis. On multivariate logistic regression analysis, BxPNI was shown to be a significant independent risk factor with covariate of D'Amico for poor outcome (p = 0.047) and an independent risk factor with covariate of BxGPC for high-risk PCa excepting the variables to define high-risk disease (p = 0.013). Prognostically, cases with BxPNI showed a poor BCR-free survival in univariate analysis but did not reach significance (p = 0.063).

CONCLUSION

Our results show that BxPNI could be considered as a risk classification factor to identify the best candidates among younger PCa patients for further treatment and may also be used for developing active surveillance (AS) selection criteria for younger PCa patients.

Quantification of perineural invasion focus after radical prostatectomy could improve predictive power of recurrence

Perineural invasion (PNI) after radical prostatectomy (RP) is a common feature of prostate cancer (PCa) and has been associated with unfavorable tumor characteristics. However, its prognostic relevance is controversial. In this study, we evaluated the impact of both PNI status (PNI+ versus PNI-) and quantified number of PNI focus on the long-term prognosis of biochemical recurrence (BCR) after RP. After reevaluating PNI of a total of 721 patients with localized PCa who underwent RP at our institution between 2000 and 2002, we examined associations between PNI status or PNI focus number and clinicopathological factors including tumor stage, Gleason score, margin status, tumor location, preoperative prostate specific antigen, age, prostate weight as well as BCR outcome. PNI was present in 530 of 721 cases (73.5%) of the RP specimens and was associated with more aggressive disease. BCR occurred in 19.4% of all patients within a median follow-up period of 8.5 years. PNI+ status was associated with poor BCR prognosis in univariate analysis but lost in multivariate analysis. Based on the number of PNI focus, PNI was further divided into 2 distinct group: PNI+ a (≤3) and PNI+ b (>3). In a multivariate Cox regression model, PNI+ b (>3) was identified as an independent BCR prognostic factor. Quantification of PNI focus number beside the dichotomized status recording will not only provide more detailed information but also be a novel prognostic indicator for risk stratification. Further external validation will be needed for an optimal cut-off value of the PNI focus number. Our findings will help further research on the relevance of PNI in the pretreatment setting and support ongoing efforts to understand its role of cancer progression.

Impact of biopsy perineural invasion on the outcomes of patients who underwent radical prostatectomy: a systematic review and meta-analysis

Objectives: To investigate the association between biopsy perineural invasion (PNI) and oncological outcomes of prostate cancer (PCa) after radical prostatectomy (RP).Materials and methods: A systematic literature search was performed using PubMed, EMBASE and Web of Science up to December 2018 to identify the eligible studies that included localized PCa patients who underwent biopsy and subsequently RP as well as follow-up information. Meta-analyses were conducted using available hazard ratios (HRs) of biopsy PNI from both univariate and multivariate analyses.Results: Eighteen studies including 14,855 patients with treatment follow-up information were included in the current systematic review. The rate of biopsy PNI varied between 7.0% and 33.0%. Seven out of the 18 studies that demonstrated biopsy PNI were associated with adverse pathologic features. Thirteen out of the 18 studies showed biopsy PNI correlated significantly with higher rates of biochemical recurrence (BCR)/cancer progression status or worse prognostic outcomes. With pooled data based on four studies with available univariate analysis results and four studies with multivariate analysis, statistically significant associations were found between biopsy PNI and BCR with univariate analysis (HR = 2.05; 95% CI = 1.57-2.68; p < 0.001) and with multivariate analysis (HR = 1.57; 95% CI = 1.28-1.93; p < 0.001).Conclusion: Evidence from the included observational studies indicated that biopsy PNI was not only correlated with adverse pathologic characteristics but also with worse BCR prognosis of local PCa after RP. The status of biopsy PNI could serve as a promising risk-stratification factor to help the decision-making process, considering active surveillance (AS) or further treatment for PCa patients.

Constructing Bayesian networks by integrating gene expression and copy number data identifies NLGN4Y as a novel regulator of prostate cancer progression

To understand the heterogeneity of prostate cancer (PCa) and identify novel underlying drivers, we constructed integrative molecular Bayesian networks (IMBNs) for PCa by integrating gene expression and copy number alteration data from published datasets. After demonstrating such IMBNs with superior network accuracy, we identified multiple sub-networks within IMBNs related to biochemical recurrence (BCR) of PCa and inferred the corresponding key drivers. The key drivers regulated a set of common effectors including genes preferentially expressed in neuronal cells. NLGN4Y—a protein involved in synaptic adhesion in neurons—was ranked as the top gene closely linked to key drivers of myogenesis subnetworks. Lower expression of NLGN4Y was associated with higher grade PCa and an increased risk of BCR. We show that restoration of the protein expression of NLGN4Y in PC-3 cells leads to decreased cell proliferation, migration and inflammatory cytokine expression. Our results suggest that NLGN4Y is an important negative regulator in prostate cancer progression. More importantly, it highlights the value of IMBNs in generating biologically and clinically relevant hypotheses about prostate cancer that can be validated by independent studies.

Diagnostic performance of 68Gallium-PSMA-11 PET/CT to detect significant prostate cancer and comparison with 18FEC PET/CT

Background

Radiolabeled prostate-specific membrane antigen (PSMA) has proven to be a highly accurate method to detect recurrence and metastases of prostate cancer, but only sparse data is available about its performance in the diagnosis of clinically significant primary prostate cancer.

Methods

We compared ⁶⁸Ga-PSMA-11 PET/CT in 25 patients with ¹⁸FEC PET/CT in 40 patients with suspected prostate carcinoma based on an increased PSA level.The PET/CT results were compared with the histopathologic Gleason Score (GS) of biopsies.

Results

The ⁶⁸Ga-PSMA-11 PET/CT revealed highly suspect prostatic lesions (maximum standardized uptake value/SUV_max >2.5) in 21/25 patients (84%), associated with GS≥6 (low-grade/high-grade carcinoma). Two histopathologic non-malignancy-relevant cases (GS<6) had PSMA-SUV_max ≤2.5; all histopathologic high-grade cases (GS≥7b) showed PSMA-SUV_max >12.0 which further increased with rising GS. There were 2 false positives and no false negative findings for high-grade prostate cancer using a cut off-level for SUV_max of 2.5.In contrast, the ¹⁸FEC PET/CT showed suspected malignant lesions in 38/40 patients (95%), which included 3 lesions with GS<6. The mean SUV_max values did not differ with different GS. There were 11 false positives and 1 false negative for detection of high-grade prostate cancer (cut off 2.5).By means of ROC analysis a SUV_max of 5.4 was found to be an optimal cut off-level to distinguish between low- and high-grade carcinoma in ⁶⁸Ga-PSMA-11 PET/CT (AUC=0.9692; 95% CI 0.9086;1.0000;SD(AUC)=0.0309)). Choosing a cut off-level of SUV_max5.4, ⁶⁸Ga-PSMA-11 PET/CT was able to distinguish between GS ≤7a/≥7b with a sensitivity of 84%, a specificity of 100%, a negative predictive value (NPV) of 67%, and an efficiency of 88% (p<0.001).The ROC analysis revealed a SUV_max 6.5 as an optimal cut off-level to distinguish between low- and high-grade carcinoma in ¹⁸FEC PET/CT (AUC=0.7470; 95% CI 0.5919;0.9020;SD(AUC)=0.0791) with a sensitivity of 61% and a specificity of 92%; but the efficiency was only 70% and the NPV 50% (p=0.01).

Conclusion

⁶⁸Ga-PSMA-11 PET/CT guided biopsy of the prostate increases diagnostic precision and is likely to help to reduce overtreatment of low-grade malignant disease as well as detect the foci of the highest Gleason pattern. Both methods (⁶⁸Ga-PSMA-11,¹⁸FEC) were suitable to detect primary prostate cancer, but the excellent image quality, the higher specificity and the good correlation of positive scans with GS are advantages of ⁶⁸Ga-PSMA-11.

Perineural invasion in prostate biopsy specimens is associated with increased bone metastasis in prostate cancer

BACKGROUND

We aimed to evaluate the relationship between perineural invasion (PNI) and bone metastasis in prostate cancer (PCa).

METHODS

We retrospectively reviewed the data of 633 PCas who had whole-body bone scan (WBBS) between 2008 and 2014. We recorded the age, clinical T-stage, total PSA (tPSA) prior to biopsy, Gleason sum (GS), and PNI in transrectal ultrasound guided biopsy (TRUS-Bx) and digital rectal examination findings. Bone metastases were assessed with WBBS and magnetic resonance image if WBBS was suspicious. We divided the patients into two groups according to NCCN criteria: (Group 1) bone scan not indicated, (Group 2) bone scan indicated.

RESULTS

There were 262 patients in Group 1 and 371 in 2. There is not significant relationship between PNI and bone metastasis in Group 1. However, there is very limited number of metastatic patients (n = 12) in this group. There is a strong relationship between PNI and bone metastasis in Group 2 (P = 0.001). Sensitivity, specificity and positive predictive value of PNI for bone metastasis were 72.4%, 81.7%, and 77.7%, respectively. In this group, tPSA, GS, positive DRE, and PNI were significant covariates for prediction of bone metastasis in univariate and multivariate analysis (except age). The most powerful predictor was PNI, and it increased the risk of bone metastasis 11-fold.

CONCLUSIONS

PNI in the TRUS-Bx specimens is the most powerful predictive histopathological feature for bone metastasis, by increasing the risk of bone metastasis 11-fold in NCCN bone scan indicated patients (Group 2).

Perineural spread of pelvic malignancies to the lumbosacral plexus and beyond: clinical and imaging patterns

OBJECT

Perineural spread along pelvic autonomie nerves has emerged as a logical, anatomical explanation for selected cases of neoplastic lumbosacral plexopathy (LSP) in patients with prostate, bladder, rectal, and cervical cancer. The authors wondered whether common radiological and clinical patterns shared by various types of pelvic cancer exist.

METHODS

The authors retrospectively reviewed their institutional series of 17 cases concluded as perineural tumor spread. All available history, physical examination, electrodiagnostic studies, biopsy data and imaging studies, evidence of other metastatic disease, and follow-up were recorded in detail. The series was divided into 2 groups: cases with neoplastic lumbosacral plexopathy confirmed by biopsy (Group A) and cases included based on imaging characteristics despite the lack of biopsy or negative biopsy results (Group B).

RESULTS

Group A comprised 10 patients (mean age 69 years); 9 patients were symptomatic and 1 was asymptomatic. The L5–S1 spinal nerves and sciatic nerve were most frequently involved. Three patients had intradural extension. Seven patients were alive at last follow-up. Group B consisted of 7 patients (mean age 64 years); 4 patients were symptomatic, 2 were asymptomatic, and 1 had only imaging available. The L5–S1 spinal nerves and the sciatic nerve were most frequently involved. No patients had intradural extension. Four patients were alive at last follow-up.

CONCLUSIONS

The authors provide a unifying theory to explain lumbosacral plexopathy in select cases of various pelvic neoplasms. The tumor cells can use splanchnic nerves as conduits and spread from the end organ to the lumbosacral plexus. Tumor can continue to spread along osseous and muscle nerve branches, resulting in muscle and bone “metastases.” Radiological studies show a reproducible, although nonspecific pattern, and the same applies to clinical presentation.

Prediction of perineural invasion and its prognostic value in patients with prostate cancer

Purpose

The prognostic significance of perineural invasion by prostate cancer is debated. We investigated the association between perineural invasion and clinicopathological factors and the effect of perineural invasion on survival in patients with prostate cancer.

Materials and Methods

A total of 361 patients with prostate cancer without any neoadjuvant therapies prior to surgery from 1999 to 2010 were analyzed retrospectively. Whole-mount sections of surgical specimens from all patients who underwent radical prostatectomy were evaluated. Positive perineural invasion was defined as infiltration of cancer cells in the perineurium or neural fascicles. The relationship of perineural invasion with clinicopathological features and prognosis of prostate cancer was studied. We also researched preoperative factors that were associated with perineural invasion.

Results

Perineural invasion in a prostatectomy specimen (PNIp) was positive in 188 of 361 patients (52.1%). In the multivariate analysis of the preoperative variables, PNIp was related to the primary Gleason grade (p=0.020), the number of positive cores (p=0.008), and the percentage of tumor cells in positive cores (p=0.021), but not to perineural invasion of a prostate biopsy. In the evaluation between PNIp and pathologic findings of the prostatectomy specimen, PNIp was related to the Gleason score (p=0.010), T-stage (p=0.015), and lymphovascular invasion (p=0.019). However, by multivariate analysis, the PNIp was not an independent prognostic factor of biochemical serum recurrence (p=0.364) or cancer-specific survival (p=0.726).

Conclusions

PNIp was significantly related to biologically aggressive tumor patterns but was not a prognostic factor for biochemical serum PSA recurrence or cancer-specific survival in patients with prostate cancer.

The impact of perineural invasion on biochemical outcome after permanent prostate iodine-125 brachytherapy

PURPOSE

Perineural invasion (PNI) in prostate biopsies is associated with increased risk of higher Gleason score and worse pathologic stage. We report the influence of PNI in biochemical no evidence of disease (bNED) survival after (125)I prostate brachytherapy (BT).

METHODS AND MATERIALS

Pathology reports of 700 men with localized prostate cancer who underwent (125)I prostate BT in 1999-2008 were reviewed. The presence or absence of PNI in the biopsy was documented in 339 men. Clinical, treatment, and dosimetric parameters, along with PNI status, were evaluated for bNED survival, defined by "nadir+2" definition.

RESULTS

Of the 339 patients, 87% had favorable risk and 13% intermediate risk. PNI was present in 89 patients (26%). After a median followup of 32 months, there were five biochemical failures (4: +PNI and 1: -PNI), of which one was local failure (+PNI). Actuarial 5-year bNED survival for the entire group was 97.0% (92.9% for +PNI; 99.2% for -PNI). In univariate analysis age, pretreatment prostate-specific antigen, Gleason score 7, and intermediate risk group predicted for worse biochemical outcome, whereas the presence of PNI showed a trend toward significance (p=0.06). Some of the regression algorithms failed to converge because of low event rates.

CONCLUSIONS

We report excellent biochemical control in 339 men treated with (125)I prostate BT. The presence of PNI showed a trend toward significance in predicting 5-year bNED survival but did not impact on local control and should not influence the decision to recommend BT for localized prostate cancer.

Parameters of perineural invasion in radical prostatectomy specimens lack prognostic significance

The prognostic significance of perineural invasion by prostate cancer is debated. We have evaluated the association between biochemical failure and measurements of perineural invasion in radical prostatectomy specimens. Perineural invasion was identified in sections using S-100 protein immunostaining. For nerves showing invasion, the involved nerve closest to the edge of the prostate and to the surgical excision margin, as well as the diameter of these nerves, the largest nerve showing perineural invasion and its proximity to the excision margin, and the percentage of nerves showing perineural invasion up to 1.75 mm from the excision margin was determined and tested against time to prostate-specific antigen failure, along with preoperative prostate-specific antigen levels, highest Gleason primary grade, Gleason score and TNM T category. Perineural invasion was present in 90% of cases, with extraprostatic perineural invasion in 25% of tumors. Diameter of nerves showing perineural invasion ranged from 11 to 680 microm and the shortest distance to the surgical excision margin ranged from 33 to 2.57 mm. Perineural invasion density ranged from 6 to 96%. Gleason scores were six in 58 cases, seven in 43 cases, eight in three cases and nine in one case. Clinical T categories were T1c in 75 cases, T2a in 22 cases, T2b in five cases, T2c in two cases, T3 in one case. During a follow-up period of 11 to 55 months (median 26 months), 27 patients showed prostate-specific antigen failure. On univariate analysis only presence of extraprostatic perineural invasion, among parameters of perineural invasion, showed a weak correlation with outcome, while on multivariate analysis this lost significance and preoperative prostate-specific antigen levels, Gleason score and excision margin status were independently associated with biochemical failure. We conclude that the investigated parameters of perineural invasion do not predict prostate-specific antigen recurrence in radical prostatectomy specimens.

Patterns of Local Failure Following Prostate Brachytherapy

PURPOSE

We describe biopsy results in patients with prostate cancer treated with brachytherapy.

MATERIALS AND METHODS

A total of 1,562 men with localized prostate cancer were treated with permanent prostate brachytherapy, of whom 508 agreed to ultrasound guided biopsies 2 years after the completion of all therapy. Median followup was 6.7 years (range 2 to 14.6) and median prostate specific antigen was 7.4 ng/ml (range 0.3 to 300). Disease was categorized as Gleason score less than 7 in 74.8% of patients, stage T2a or less in 64.2%, low risk in 43.1%, intermediate risk in 24.2% and high risk in 32.7%. Of the 508 men 315 (62%) received (125)I, 110 (21.7%) received (103)Pd and 83 (16.3%) received (103)Pd and external beam radiotherapy. A total of 237 men (46.7%) received a short course of hormonal therapy (3 to 9 months). Subsequent biopsies were performed after 2 years if initial biopsy was positive or prostate specific antigen increased. Post-implantation dosimetry results were grouped into low, normal and high dose. Associations were tested by chi-square analysis. Survival functions were calculated with Kaplan-Meier analysis and Cox regression.

RESULTS

A total of 643 biopsies were performed in 508 men between 2 and 11 years after implantation. Of the 508 men 39 (7.7%) had a final positive biopsy. Positive biopsy was associated with high prostate specific antigen (p=0.035), stage (p=0.003), risk (p=0.024), no hormonal therapy (p=0.002) and low dose (p<0.0001). On multivariate analysis only dose and hormonal therapy were significant (p<0.0001 and p=0.004, respectively). Of the patients 80% were free of PSA failure at 10 years if final biopsy was negative compared to 27.3% with a positive biopsy (p<0.0001). Death from prostate cancer was associated with a positive biopsy (OR 18.5, 95% CI 2.3-143, p<0.0001). Of the 52 men with a positive biopsy at year 2, 23 (44.2%) had negative results on subsequent biopsy, while 10 of the 456 (2.2%) with negative 2-year biopsies showed positive results. Positive biopsy occurred in the prostate only in 31 of 39 men (79.5%), in the prostate and seminal vesicles in 3 (7.7%), and in the seminal vesicles only in 5 (12.8%).

CONCLUSIONS

Patients undergoing prostate brachytherapy must receive an adequate radiation dose to eradicate local disease. Hormonal therapy may benefit local control in patients with intermediate to high risk disease. Extraprostatic biopsies should be performed in patients with local failure who are considering salvage therapy to rule out seminal vesicle involvement.

Perineural invasion on prostate needle biopsy does not predict biochemical failure following brachytherapy for prostate cancer

PURPOSE

To determine if the presence of perineural invasion (PNI) predicts biochemical recurrence in patients who underwent low-dose-rate brachytherapy for the treatment of localized prostate cancer.

METHODS AND MATERIALS

A retrospective case control matching study was performed. The records of 651 patients treated with brachytherapy between 1996 and 2003 were reviewed. Sixty-three of these patients developed biochemical failure. These sixty-three patients were then matched in a one-to-one ratio to patients without biochemical failure, controlling for biopsy Gleason score, clinical stage, initial prostate-specific antigen, age, and the use of androgen deprivation. The pathology of the entire cohort was then reviewed for evidence of perineural invasion on initial prostate biopsy specimens. The biochemical relapse free survival rates for these two groups were compared.

RESULTS

Cases and controls were well matched, and there were no significant differences between the two groups in age, Gleason grade, clinical stage, initial prostate-specific antigen, and the use of androgen deprivation. PNI was found in 19 (17%) patients. There was no significant difference in the rates of PNI between cases and controls, 19.6% and 14.3% respectively (p = 0.45). PNI did not correlate with biochemical relapse free survival (p = 0.40).

CONCLUSION

Perineural invasion is not a significant predictor of biochemical recurrence in patients undergoing brachytherapy for prostate cancer.

Prognostic Parameters Other Than Gleason Score for the Daily Evaluation of Prostate Cancer in Needle Biopsy

OBJECTIVE

To evaluate in prostate needle biopsies the usefulness and the efficacy of not time-consuming morphologic parameters in order to predict whether prostate cancer is organ-confined or it is not, that could contribute additional information to pre-surgical serum PSA and Gleason score, both of them parameters already accepted as clinically significant.

METHODS

Three hundred and two consecutive patients were evaluated, of whom a diagnostic needle biopsy and the radical prostatectomy specimen with no pre-surgical hormone therapy were available. Bilateral or unilateral extension, number of positive cores, percentage of positive cores, intraprostatic perineural invasion (IPNI) and the presence of high-grade prostatic intraepithelial neoplasia (HGPIN) in any of the biopsy cores were evaluated in the needle biopsy.

RESULTS

The median of cores is 6. The IPNI, the presence of bilateral tumour, and the percentage of positive cores, higher than 37.5% (ROC curve), show significant crude OR (4.0, 2.8, 6.9 respectively). The regression model discloses that only the percentage of positive cores shows a significant OR (5.8) adjusting for bilaterality, IPNI, HGPIN and age.

CONCLUSIONS

The percentage of cores with cancer and the bilateral involvement are another two parameters predictive of cancer with extraprostatic extension. (p<0.0005 in both). IPNI has statistical significance too (p<0.002), but it is related to the tumour volume expressed through the two mentioned parameters.

Prostate Cancer: Incremental Value of Endorectal MR Imaging Findings for Prediction of Extracapsular Extension

PURPOSE

To assess the incremental value of endorectal magnetic resonance (MR) imaging findings in addition to clinical variables for prediction of extracapsular extension (ECE) in patients with prostate cancer.

MATERIALS AND METHODS

In this cohort study, 344 consecutive patients with biopsy-proved prostate cancer underwent endorectal MR imaging prior to surgery; 216 of these patients also underwent MR spectroscopic imaging. MR images were interpreted by 10 attending radiologists. The likelihood of ECE was scored retrospectively on the basis of MR imaging reports. Clinical variables included serum prostate-specific antigen (PSA) level, Gleason score, clinical stage of tumor, greatest percentage of cancer in all core biopsy specimens, percentage of cancer-positive core specimens in all core biopsy specimens, and presence of perineural invasion. For data analysis, receiver operating characteristic (ROC) curves and univariate and multivariate logistic regression analyses were used. Jackknife analysis was used for prediction of probability from a model that included clinical variables as tested comparatively with a model that included the clinical variables plus endorectal MR imaging findings. A difference with P <.05 was considered significant.

RESULTS

At univariate analysis, all variables were associated with ECE. At ROC univariate analysis, endorectal MR imaging findings had the largest area under the ROC curve. At multivariate analysis, serum PSA level, percentage of cancer in all core biopsy specimens, and endorectal MR imaging findings (P =.001, P =.001, and P <.001, respectively) were predictors of ECE. Areas under ROC curve for two models, with and without endorectal MR imaging findings, were 0.838 and 0.772, respectively (P =.022).

CONCLUSION

A model containing endorectal MR imaging findings has a significantly larger area under the ROC curve than a model containing only clinical variables; thus, endorectal MR imaging findings add incremental value in the prediction of ECE.

The reporting of prostate cancer on needle biopsy: prognostic and therapeutic implications and the utility of diagnostic markers

Prostate needle biopsy remains the gold standard for diagnosing prostate cancer. Prostate cancer on needle biopsy can be evaluated by numerous techniques of quantifying tumour extent, Gleason score, and the presence of perineural invasion (PNI). These modalities can help clinicians in assessing the risk of extraprostatic disease, progression likelihood, and in helping men with prostate cancer choose among therapeutic options. This review details the information that should be included in the routine pathology report. Recent advances in molecular biology of prostate carcinogenesis have identified many molecular markers for prostate cancer. While several are extremely promising as diagnostic immunohistochemical markers, other prognostic markers are not yet ready to be used in routine practice until they are validated by large prospective studies.

Myths and fallacies in permanent prostate brachytherapy

Because there are competing modalities to treat early-stage prostate cancer, the constraints or deficiencies of one modality may be erroneously applied to others. Some valid concerns arising from surgery and external beam therapy, which have been falsely transferred to brachytherapy, are constraints based on patient age, clinical and pathological parameters, patient weight, and size of prostate. Although the constraints have a valid basis in one modality, knowledge of the origin and mechanism of the constraint has provided a means to circumvent or overcome it in brachytherapy. Failures as measured by biochemical no-evidence of disease (bNED) survival may be attributed to extracapsular disease extension. Such extension often expresses itself in surrogate parameters such as a high percentage of positive biopsies, perineural invasion, or the dominant pattern in Gleason score histology. Failures due to such factors may be prevented by implanting with consistent extracapsular dosimetric margins. Some presumed limitations on prostate brachytherapy originated from data on patients implanted in the first few years the procedure was being developed. Most of the urinary morbidity and a significant part of the decrease in sexual function observed may be avoided by controlling the dosimetry along the prostatic and membranous urethra and at the penile bulb.

Permanent interstitial brachytherapy for the management of carcinoma of the prostate gland

PURPOSE

We summarize the permanent prostate brachytherapy literature, including biochemical outcomes, quality of life parameters and areas of controversy.

MATERIALS AND METHODS

The permanent prostate brachytherapy literature was reviewed using MEDLINE searches to ensure completeness.

RESULTS

Using various planning and intraoperative techniques the majority of the brachytherapy literature demonstrates durable biochemical outcomes for patients with low, intermediate and high risk features. For low risk patients there is no advantage to combining supplemental external beam radiation therapy with brachytherapy. In addition, supplemental external beam radiation therapy may not improve biochemical outcomes for patients at intermediate and high risk if the target volume consists of the prostate with a generous periprostatic margin. There is no defined role for adjuvant hormonal manipulation. Although a reliable set of pretreatment criteria to predict implant related morbidity is not available, severe urinary and rectal morbidity is rare. The incidence of brachytherapy induced erectile dysfunction is significantly greater than initially reported but the majority of patients respond favorably to sildenafil.

CONCLUSIONS

Continued refinements in brachytherapy planning and implementation techniques, postimplantation evaluation and continued elucidation of the etiology of urinary, bowel and sexual dysfunction should result in further improvements in biochemical and quality of life outcomes.

Practical considerations in permanent brachytherapy for localized adenocarcinoma of the prostate

Prostate brachytherapy has become an accepted treatment modality for localized prostate cancer. Long-term biochemical and biopsy data confirm the early positive impressions that brachytherapy is as valid a treatment option as radical prostatectomy or EBRT. Quality-of-life data also look promising, but more follow-up data are needed. Is brachytherapy as good as or perhaps better than radical prostatectomy? This question cannot be answered yet. Well-controlled, randomized studies are needed. In the meantime, the clinician will have to rely on the available published data.

Clinical interpretation of the prostate biopsy

Pathologic evaluation of the prostate biopsy provides the clinician with a wealth of information. Identifying needle biopsy parameters predictive of pathological stage and tumor volume at radical prostatectomy has become a major focus in the field of prostate pathology. From a review of the literature, the following factors are strongly predictive of extraprostatic disease; tumor involvement of greater than 25%, greater than two positive cores, cancer involvement greater than 3 mm, and perineural invasion. Such information could prove useful in patient counseling and identifying high-risk patients who may be good candidates for adjuvant therapy trials.

Prospective assessment of patient-reported long-term urinary morbidity and associated quality of life changes after 125I prostate brachytherapy

PURPOSE

Prostate brachytherapy has been reported to have less morbidity for patients than radical prostatectomy or external beam irradiation. However, to date there have been no long-term data to support these claims. With radiation doses in excess of 140 Gy required to control the tumor, disabling chronic urinary symptoms and associated quality of life (QOL) changes might be expected to occur. This study prospectively assessed the long-term effects of (125)I prostate brachytherapy on urinary morbidity.

METHODS AND MATERIALS

A total of 248 patients with a median age of 67 years (range, 43-83 years) who presented with T1-T2 prostate cancer were treated with (125)I seed implantation and followed up for a minimum of 18 months after treatment (range, 18 to 108 months; median, 31 months). There were 177 T1b-T2a cases and 41 patients with prostate-specific antigen >10 ng/ml; 20.2% were treated with hormonal therapy. All patients prospectively reported their urinary symptoms and QOL assessment on American Urological Association symptom score records before treatment and at each follow-up visit. Urinary symptoms at last follow-up were compared with pretreatment scores. Radiation doses to the prostate (dose delivered to 90% of the gland; D(90)) and urethra (D(30)) were determined by CT-based dosimetry.

RESULTS

The median prostate D(90) was 165 Gy (range, 16.5-260 Gy), and the median urethra D(30) was 192 Gy (range, 23.5-306 Gy). Mean individual scores and QOL ranged from 0.31 to 1.65 before implantation and 0.39 to 1.73 afterward. There were no significant differences between pretreatment and last mean scores for any of the categories except for a small but significant increase in urgency (p=0.01) and weak stream (p=0.03). The cohort of patients who initially presented with marked urinary symptoms (initial score >or=3) had improvement in individual scores by 31.4% to 58.2%, total score by 31.1% (p=0.0005), and QOL by 40.6% (p<0.0001).

CONCLUSIONS

This study suggests that prostate brachytherapy is associated with minimal long-term urinary morbidity. The subgroup of patients who present with marked urinary symptoms before implantation has improvement in symptoms and QOL after implantation. These data substantiate the favorable long-term QOL outcomes associated with modern brachytherapy techniques.

Percent prostate needle biopsy tissue with cancer is more predictive of biochemical failure or adverse pathology after radical prostatectomy than prostate specific antigen or Gleason score

PURPOSE

Biopsy Gleason score, serum prostate specific antigen (PSA) levels, and clinical stage are known to be independent predictors of adverse pathological features and biochemical failure after radical prostatectomy. We determine whether various prostate needle biopsy parameters were predictive of either adverse pathological findings or disease recurrence after radical prostatectomy.

MATERIALS AND METHODS

A single pathologist reviewed the prostate needle biopsy specimens of 190 men who underwent radical prostatectomy between 1991 and 2000. Biopsy specimens were examined for Gleason score, perineural invasion, number and percent of cores with cancer, and percent of total biopsy tissue with cancer and Gleason grade 4 or 5 cancer. Multivariate analysis was used to determine the prostate needle biopsy parameters and preoperative clinical variables, including serum PSA, clinical stage, patient age and race, that were most significant for predicting positive surgical margins, nonorgan confined disease, seminal vesicle invasion and biochemical failure after radical prostatectomy.

RESULTS

Of the prostate needle biopsy parameters examined percent of tissue with cancer was the strongest predictor of biochemical recurrence in the multivariate analysis (p <0.001). Percent of tissue with cancer was a stronger predictor of biochemical recurrence than either PSA (p = 0.048) or biopsy Gleason score (p = 0.053). It was also a strong independent predictor of seminal vesicle invasion (p = 0.015) and nonorgan confined disease (p = 0.024). Perineural invasion, percent and number of cores with cancer, and percent of tissue with Gleason grade 4 or 5 were not independent predictors of either adverse pathology or biochemical failure.

CONCLUSIONS

Of all the preoperative variables examined, including the standard clinical variables of serum PSA, Gleason score and clinical stage, percent of biopsy tissue with cancer was the strongest predictor of biochemical recurrence, seminal vesicle invasion and nonorgan confined disease. Consideration should be given to reporting percent of total biopsy tissue with cancer in all prostate biopsy results.

Influence of biopsy perineural invasion on long-term biochemical disease-free survival after radical prostatectomy

OBJECTIVES

To investigate the influence of biopsy perineural invasion (PNI) on long-term prostate-specific antigen recurrence rates, final pathologic stage, and surgical margin status of men treated with radical prostatectomy. Radical prostatectomy offers the best chance for surgical cure when performed for organ-confined disease. However, the histologic identification of PNI on prostate biopsy has been associated with a decreased likelihood of pathologically organ-confined disease.

METHODS

Seventy-eight men with histologic evidence of PNI on biopsy underwent radical prostatectomy by a single surgeon between April 1984 and February 1995 and were compared with 78 contemporary matched (biopsy Gleason score, prostate-specific antigen level, clinical stage, age) controls without PNI. Biochemical disease-free survival and pathologic findings were compared.

RESULTS

After a mean follow-up of 7.05 +/- 2.2 years and 7.88 +/- 2.7 years (P = 0.04) for patients with biopsy PNI and controls, respectively, no significant difference in the long-term prostate-specific antigen recurrence rates was observed (P = 0.13). The final Gleason score and pathologic staging were also similar in this matched cohort. Although the numbers of neurovascular bundles resected were comparable between the groups, no difference was found in the rate of positive surgical margins identified (13% versus 10%, P = 0.62).

CONCLUSIONS

We were unable to show that PNI on needle biopsy influences long-term tumor-free survival.

Prognostic factors for survival of patients with pathological Gleason score 7 prostate cancer: differences in outcome between primary Gleason grades 3 and 4

PURPOSE

We evaluated differences in clinical and pathological outcomes between Gleason 3 + 4 and 4 + 3 prostate cancer.

MATERIALS AND METHODS

The radical prostatectomy whole mounted specimens from 263 men with pathological Gleason 7 tumors were identified. Gleason 3 + 4 and 4 + 3 tumors were compared in regard to pathological variables and outcome. Significance of clinical and pathological data on progression-free survival was analyzed.

RESULTS

Of the tumors 34% had a primary Gleason grade of 4, and were more likely than those with primary grade 3 to have seminal vesicle involvement (34% versus 18%, p = 0.006), a higher pathological stage (pT3 55% versus 42%, N+ 13% versus 3%, 0.001), extraprostatic extension (58% versus 38%, 0.001) and higher median preoperative prostate specific antigen (PSA) (13.5 versus 9.0 ng./ml., respectively <0.001). Mean followup plus or minus standard deviation was 6.8 +/- 1.9 years. The overall 10-year crude, cancer specific and progression-free survival rates were 83%, 99% and 58%, respectively. Primary Gleason grade was significantly associated with progression-free (risk ratio 1.6, 95% confidence interval 1.08 to 2.5, p = 0.02) but not crude and cancer-specific survival. Univariately, primary Gleason grade 4 was associated with progression-free survival, as were percent Gleason 4, seminal vesicle invasion, lymph node involvement, pT stage, margin status, DNA ploidy, preoperative PSA, cancer volume and extent of extraprostatic extension. Multivariately, only preoperative PSA (p <0.001), seminal vesicle invasion (<0.001) and DNA ploidy (0.002) were associated with progression-free survival. Primary Gleason grade and percent Gleason 4 were not identified as independently associated with progression-free survival.

CONCLUSIONS

In patients with Gleason 7 score prostate cancer primary Gleason grade 3 and 4 cancers are different in pathological parameters and prognosis. However, primary Gleason grade does not provide any additional information than other known prognostic factors, such as preoperative PSA, seminal vesicle invasion and DNA ploidy.

[Prostate cancer]

Radiation therapy of prostate carcinoma with a curative intent implies to treat the whole prostate at high dose (at least 66 Gy). According to clinical stage, PSA level, Gleason's score, the clinical target volume may include seminal vesicles and less often pelvic lymph nodes. Microscopic extracapsular extension is found in 15 to 60% of T1-T2 operated on, specially in apex tumors. On contrary, cancers developing from the transitional zone may stay limited to the prostate even with a big volume and with a high PSA level. Zonal anatomy of the prostate identifies internal prostate, including the transitional zone (5% of the prostate in young people). External prostate includes central and peripheral zones. The inferior limit of the prostate is not lower than the inferior border of the pubic symphysis. Clinical and radiological examination: ultrasonography, nuclear magnetic resonance (NMR), CT-scan identify prognostic factors as tumor volume, capsule effraction, seminal vesicles invasion and lymph node extension. The identification of the clinical target volume is now done mainly by CT-Scan which identifies prostate and seminal vesicles. NMR could be helpful to identify more precisely prostate apex. The definition of margins around the clinical target volume has to take in account daily reproducibility and organ motion and of course the maximum tolerable dose for organs at risk.

Atypical ductal hyperplasia and ductal carcinoma in situ of the breast associated with perineural invasion

Perineural invasion is a histologic feature usually diagnostic of invasion in malignancies. In the breast, however, it has been associated with benign lesions such as sclerosing adenosis (SA), complex sclerosing lesion/radial scar (CSL/RS), and ductal carcinoma in situ (DCIS). This article describes perineural invasion associated with atypical ductal hyperplasia (ADH), florid hyperplasia without atypia (FH), and DCIS. All cases with a diagnosis of perineural invasion were selected from a series of 10,000 breast consult cases. Invasive mammary carcinomas were excluded. Fourteen cases of perineural invasion were found and associated with the following diagnoses: ADH (5), DCIS (3), FH (5), and ductal adenoma (1). Nine cases developed in CSL/RS, 4 cases in SA, and 1 case in a previous biopsy site of ductal adenoma; lesions were all less than 3 mm. The glands involving nerves showed cytologic and architectural features of the adjacent ADH, DCIS, and FH. Immunostaining for protein gene product (PGP) 9.5 marked nerves, and smooth muscle actin antibody highlighted the myoepithelial cells around glands. Perineural invasion seen in association with DCIS and ADH, in a background of CSL/RS and SA, may pose difficulty in diagnosis, especially in small biopsy specimens. It should be assessed with care to avoid misinterpretation as invasive mammary carcinoma.

Indicators of pathologic stage of prostate cancer and their use in clinical practice

Pathologic stage is the most reliable means of predicting the likelihood of curable prostate cancer at the time of definitive treatment. Its prediction is of the greatest importance to individuals with clinically localized disease, principally because of the therapeutic and prognostic implications. Multivariate models integrating variables that can be derived from clinical and pathologic assessment have been shown to be reliable and useful in urologic practice. Among these variables, the combination of clinical stage, serum PSA, and biopsy Gleason score provides reliable assessment of the risk for extraprostatic disease that can be used readily for counseling individual patients. Other biopsy-derived parameters may contribute additional information, but their value in multivariate analysis has not been validated in a multi-institutional setting. The development of new prognostic markers is a priority objective in current research to distinguish patients in whom cancer cannot be controlled by surgical treatment. For patients undergoing radical prostatectomy, definitive pathologic stage certainly will remain an important prognostic factor; therefore, clinical practice will continue to be determined by its accurate prediction.

Prevalence and location of peripheral nerve found on prostate needle biopsy

We examined 238 prostate biopsy cores from 40 sextant biopsies by routine H&E stain to determine the presence of prostatic adenocarcinoma (PCa), perineural invasion (PNI), and nerves. Step sections were immunostained for S-100 protein to confirm the presence of nerves. Nerves were distributed evenly in specimens from apex, mid gland, and base. No significant difference was observed in the number of nerves in these areas. Significantly more nerves were found using the S-100 stain than the H&E stain. There was no significant difference between cancerous and benign specimens. However, there was a significant reduction in the nerve density in cancerous compared with benign specimens. PNI was identified in 3 of 11 PCas. All foci of PNI were identified on H&E stain. The S-100 immunostain detected no additional foci of PNI. Nerves are distributed evenly in standard sextant biopsy specimens from prostatic apex, mid gland, and base. In addition, the specimens with PCa have nerve distribution similar to that of benign specimens, suggesting that finding no PNI may represent true absence of PNI in the specimens. Careful examination of routine H&E-stained specimens is sufficient to detect all important PNI.

Prognostic factors in prostate cancer. College of American Pathologists Consensus Statement 1999

BACKGROUND

Under the auspices of the College of American Pathologists, a multidisciplinary group of clinicians, pathologists, and statisticians considered prognostic and predictive factors in prostate cancer and stratified them into categories reflecting the strength of published evidence and taking into account the expert opinions of the Prostate Working Group members.

MATERIALS AND METHODS

Factors were ranked according to the previous College of American Pathologists categorical rankings: category I, factors proven to be of prognostic importance and useful in clinical patient management; category II, factors that have been extensively studied biologically and clinically but whose importance remains to be validated in statistically robust studies; and category III, all other factors not sufficiently studied to demonstrate their prognostic value. Factors in categories I and II were considered with respect to variations in methods of analysis, interpretation of findings, reporting of data, and statistical evaluation. For each factor, detailed recommendations for improvement were made. Recommendations were based on the following aims: (1) increasing uniformity and completeness of pathologic evaluation of tumor specimens, (2) enhancing the quality of data collected pertaining to existing prognostic factors, and (3) improving patient care.

RESULTS AND CONCLUSIONS

Factors ranked in category I included preoperative serum prostate-specific antigen level, TNM stage grouping, histologic grade as Gleason score, and surgical margin status. Category II factors included tumor volume, histologic type, and DNA ploidy. Factors in category III included perineural invasion, neuroendocrine differentiation, microvessel density, nuclear roundness, chromatin texture, other karyometric factors, proliferation markers, prostate-specific antigen derivatives, and other factors (oncogenes, tumor suppressor genes, apoptosis genes, etc).

Diagnosis of localized prostate cancer: 10 years of progress

Advances in the diagnosis of early stage disease, and particularly the introduction of prostate-specific antigen (PSA) testing, have had a dramatic effect on the presentation and clinical management of prostate cancer during the past ten years. As a result, there have been significant epidemiological changes in countries where early diagnosis is recommended. The importance of PSA testing for the diagnosis of localized prostate cancer has become well established in clinical practice and this is reflected by improved outcomes from definitive treatment. The contribution of PSA-related parameters and molecular forms of PSA both to cancer detection and prediction of pathological stage continue to be explored. Concerns about the reliability of the standard sextant biopsy technique for cancer detection relate to the need for re-biopsy in a growing number of patients with negative biopsies and an increasing proportion of patients with low volume, multifocal disease. In men with cancer, additional prognostic information can be derived from biopsy findings, with important therapeutic implications. This relates also to the need for reliable markers indicating pathological stage and risk of progression. The opportunities for the prevention of prostate cancer have grown with improved understanding of its biology and the genetic basis of the early steps associated with malignant transformation. In the future, the need for therapeutic intervention is likely to be most influenced by successful prevention strategies.

The use of artificial intelligence technology to predict lymph node spread in men with clinically localized prostate carcinoma

BACKGROUND

The current study assesses artificial intelligence methods to identify prostate carcinoma patients at low risk for lymph node spread. If patients can be assigned accurately to a low risk group, unnecessary lymph node dissections can be avoided, thereby reducing morbidity and costs.

METHODS

A rule-derivation technology for simple decision-tree analysis was trained and validated using patient data from a large database (4,133 patients) to derive low risk cutoff values for Gleason sum and prostate specific antigen (PSA) level. An empiric analysis was used to derive a low risk cutoff value for clinical TNM stage. These cutoff values then were applied to 2 additional, smaller databases (227 and 330 patients, respectively) from separate institutions.

RESULTS

The decision-tree protocol derived cutoff values of < or = 6 for Gleason sum and < or = 10.6 ng/mL for PSA. The empiric analysis yielded a clinical TNM stage low risk cutoff value of < or = T2a. When these cutoff values were applied to the larger database, 44% of patients were classified as being at low risk for lymph node metastases (0.8% false-negative rate). When the same cutoff values were applied to the smaller databases, between 11 and 43% of patients were classified as low risk with a false-negative rate of between 0.0 and 0.7%.

CONCLUSIONS

The results of the current study indicate that a population of prostate carcinoma patients at low risk for lymph node metastases can be identified accurately using a simple decision algorithm that considers preoperative PSA, Gleason sum, and clinical TNM stage. The risk of lymph node metastases in these patients is < or = 1%; therefore, pelvic lymph node dissection may be avoided safely. The implications of these findings in surgical and nonsurgical treatment are significant.

Perineural invasion on prostate needle biopsy: an independent predictor of final pathologic stage

OBJECTIVES

To examine the significance of perineural invasion (PNI) in predicting pathologic findings in patients treated by radical prostatectomy, because a recent study concluded that PNI on needle biopsy has no independent predictive value.

METHODS

Between 1993 and 1998, radical prostatectomy was performed in 319 consecutive patients. Prostate needle biopsies were reviewed in all cases. We compared PNI with other preoperative parameters, including digital rectal examination, PSA, and biopsy Gleason score, for the ability to predict tumor stage. Clinical records and pathologic findings were reviewed for all cases. Tumor stage was defined as either pT2 (organ confined) or pT3 (extraprostatic extension and/or seminal vesicle invasion).

RESULTS

The median age was 61.4 years (range 40 to 75.6). Seventy-two percent of the 95 men with nonpalpable disease and 67% of the 224 men with palpable disease had organ-confined prostate cancer on final pathologic staging. Of 205 men with a Gleason score on biopsy of 6 or less, 159 (78%) had organ-confined disease compared with 59 (52%) of 114 with a Gleason score of 7 to 9 (P <0.001, chi-square test). PNI was identified in 77 (24%) of 319 patients, with 83% specificity and 40% sensitivity for Stage pT3 disease (odds ratio 3.49). Of men with pT3 disease on final pathologic staging, 18%, 27%, and 56% had preoperative PSA levels of 0 to 4, more than 4 to 10, and greater than 10 ng/mL, respectively (P <0.001, Mantel-Haenszel chi-square test). On multivariate analysis, PNI (P = 0.0031), PSA (P = 0.0004), and Gleason score (P = 0.0003) independently predicted stage (pT3 disease).

CONCLUSIONS

PNI is an important preoperative predictor of pathologic stage and should be reported when adenocarcinoma is diagnosed on prostate needle biopsies.

Perineural invasion, mucinous fibroplasia, and glomerulations: diagnostic features of limited cancer on prostate needle biopsy

The diagnosis of prostate cancer on needle biopsy is based on a constellation of histologic features. There are, however, three histologic findings that are diagnostic of prostate carcinoma: perineural invasion (PNI), mucinous fibroplasia, and glomerulations. We prospectively identified core needle biopsies during a 5-month period in which one of these three entities was the key diagnostic feature of carcinoma within the biopsy specimen. Of 1480 consult cases reviewed, the following were key features to the diagnosis of very limited carcinoma: PNI (n = 9; 0.6%), mucinous fibroplasia (n = 2; 0.1%), and glomerulations (n = 0). To assess the incidence of PNI as the key feature, we also analyzed reports from Dianon during a 1-year period. Of approximately 16,300 Dianon needle biopsies with cancer, 12(0.07%) cases had PNI as the key diagnostic feature. Six of these 12 cases were also consult cases. Of the total of 15 cases with PNI, cancer was limited with 11 of the cases showing involvement of only one nerve. The median number of glands per nerve was five (range, 1-15). In addition to PNI, malignant cytologic features included amphophilic cytoplasm in 11 of 11 assessable cases and nuclear enlargement and hyperchromasia in 11 of 15 cases. Other malignant features were limited. Twelve cases showed rare to no visible nucleoli. Two cases had eosinophilic intraluminal debris. Blue mucin, crystalloids, and mitoses were absent in all cases. Nine of the 15 cases of PNI and the two cases of mucinous fibroplasia were verified as carcinoma with immunohistochemistry using high molecular weight cytokeratin. In rare cases, PNI is virtually the sole finding necessary to establish the diagnosis of carcinoma on needle biopsy. Although mucinous fibroplasia and glomerulations are also considered diagnostic of carcinoma, their occurrence alone without more conventional forms of carcinoma is even more rare.

Prostate cancer sampled on sextant needle biopsy: significance of cancer on multiple cores from different areas of the prostate

OBJECTIVES

To determine the relationship between the location of positive sites, when more than one sextant site shows prostate cancer in a given patient, and pathologic stage, tumor volume, and margin status if radical prostatectomy is performed.

METHODS

We performed biopsies using a spring-loaded biopsy gun on 343 Stage T1c (nonpalpable) radical prostatectomy specimens from each sextant site.

RESULTS

In 56 cases, carcinoma was identified in two separate sextant sites. In 38 cases, the sites were vertical to each other (ie, left apex, left mid); in 8 cases, the sites were diagonal (ie, left apex, right mid); in 5 cases, the sites were horizontal (ie, left apex, right apex); and in 5 cases, they were not contiguous but were separated by an uninvolved sextant site (ie, left apex, left base). Tumors were more likely to be multifocal in cases with diagonally positive biopsies (P <0.0001) and horizontally positive biopsies (P <0.0001) than in those with vertically positive biopsies. No significant differences were found in organ-confined status and margin positivity among cases with different positive biopsy locations. The dominant tumor nodule was larger (mean 2.76 cc) in cases with noncontiguously positive biopsies than in all other groups combined (mean 1.44 cc) (P = 0.017).

CONCLUSIONS

When more than one sextant site shows cancer, there are differences in terms of whether the tumors sampled are multifocal versus solitary depending on which sites are positive. However, no significant differences were found in predicting pathologic stage and margin positivity.

Prostate. Practice parameters, pathologic staging, and handling radical prostatectomy specimens

This article addresses the handling, processing, and reporting of radical prostatectomy specimens with the goal of providing general guidelines and practical suggestions for the surgical pathologist. During the last decade, pathologists in academic and community institutions have witnessed a surge in the number of radical prostatectomy specimens evaluated in their departments. Unlike the relative familiarity most pathologists have with other major oncologic resections, radical prostatectomy specimens present an interesting and occasionally frustrating challenge with respect to gross evaluation, sampling, and reporting.

Excision of the neurovascular bundle at radical prostatectomy in cases with perineural invasion on needle biopsy

OBJECTIVES

To assess, in a group of patients who had undergone radical prostatectomy and who were likely to have extraprostatic extension of their tumors based on the previous finding of perineural invasion on needle biopsy, how effective excision of the neurovascular bundle was in reducing the number of positive margins and increasing the potential cure rate.

METHODS

Eighty radical prostatectomy cases from our institution that had perineural invasion on prostate needle biopsy were retrospectively studied to determine the presence and location of extraprostatic extension, positive margins, and seminal vesicle or lymph node involvement, whether the neurovascular bundle had been excised, and whether tumor was present in the bundle region.

RESULTS

In 14 (17.5%) of 80 cases, excising the neurovascular bundle led to a situation in which there was tumor in the neurovascular bundle, all the surgical margins of resection were negative for tumor, and there was no seminal vesicle or lymph node involvement. The remaining cases were equally divided between (a) less aggressive tumors that were organ-confined or had only focal extraprostatic extension with no tumor in the neurovascular bundle and (b) more aggressive tumors that had positive margins or involvement of the seminal vesicles or lymph nodes. Within the latter group, however, there were 9 patients (11.3% of all 80 cases) with negative seminal vesicles and lymph nodes in whom excision of the neurovascular bundle at least reduced the extent of positive margins. Most of the positive margins in patients with tumor in the neurovascular bundle occurred outside the bundle region, and in this study, none of the cases with positive surgical margins were the sole result of failure to excise the neurovascular bundle.

CONCLUSIONS

When perineural invasion is seen on needle biopsy, the morbidity of resecting one or both neurovascular bundles, which in some cases could turn out to be unnecessary, must be weighed against the benefit of reducing the incidence of positive margins (17.5% of our cases) or decreasing the extent of positive margins (11.3% of our cases).