Prognostic indicators in patients with seminal vesicle involvement following radical prostatectomy for clinically localized prostate cancer

Senescent Tumor Cells Are Frequently Present at the Invasion Front: Implications for Improving Disease Control in Patients with Locally Advanced Prostate Cancer

INTRODUCTION

Local tumor invasion is a critical factor for the outcome of men with prostate cancer. In particular, seminal vesicle invasion (SVI) has been reported to be associated with a more unfavorable prognosis. A better understanding of the functional state of invading prostate cancer cells is crucial to develop novel therapeutic strategies for patients with locally advanced disease.

METHODS

The prognostic impact of local tumor progression was ascertained in over 1,000 men with prostate cancer. Prostate cancer specimens were stained by double-immunohistochemistry for the proliferation marker Ki-67 and the senescence marker p16INK4A. The migratory properties of senescent prostate cancer cells were analyzed in vitro using a wound healing assay and immunofluorescence microscopy for p16INK4A.

RESULTS

We confirm the notion that patients with SVI have a more unfavorable prognosis than patients with extraprostatic extension alone. Surprisingly, we found that the tumor invasion front frequently harbors p16INK4A-positive and Ki-67-negative, i.e., senescent, tumor cells. While the intraprostatic tumor periphery was a hotspot for both proliferation and expression of p16INK4A, the area of SVI showed less proliferative activity but was at the same time a hotspot of cells with increased nuclear p16INK4A expression. Senescence was associated with an accelerated migration of prostate cancer cells in vitro.

CONCLUSION

This proof-of-concept study shows that invading prostate cancer cells frequently show signs of cellular senescence. This finding may open new avenues for neoadjuvant and adjuvant treatment concepts in men with locally advanced prostate cancer.

Retrospective Cohort Analysis from a High-Volume Center of Prognostic Factors Affecting Biochemical Relapse in Patients with Encapsulated, Margin-Negative, Isolated Seminal Vesicle Invasion After Robot-Assisted Laparoscopic Prostatectomy: A Novel Study

Purpose: Specimen pathology findings collectively impact the long-term outcomes of robot-assisted laparoscopic prostatectomy. Since seminal vesicle invasion (SVI) is an important independent predictor of biochemical recurrence (BCR), this study was designed to evaluate the influence of isolated SVI in the absence of capsular/margin invasion on BCR. Material and Methods: Pathology reports of 2009 robot-assisted laparoscopic prostatectomy specimens were analyzed retrospectively excluding capsular breach and/or margin-positive cases to include 1409 patients in the study. Factors predicting SVI and BCR in this select group of patients were assessed and statistically analyzed. Survival analysis for PSA (prostate-specific antigen) failure probability and binomial regressions for variable predictability were performed. Results: The African American race was associated with SVI (p < 0.05). PSA had a directly proportional correlation with the occurrence of SVI and BCR. SVI was found to be an independent predictor of BCR, leading to higher odds of BCR at 5 years (odds ratio [OR] 8.2, 95% confidence interval [CI] 4.5-14.6, p < 0.0001). When the seminal vesicle was invaded, the specimen Gleason grade group (SGGG; OR 1.9, 95% CI 1.02-3.7, p = 0.04), PSA (OR 1.2, 95% CI 1.01-1.4, p = 0.03), and BMI (body mass index) (OR 1.2, 95% CI 1.04-1.5, p = 0.01) predicted BCR. Seminal vesicle involvement was not found in SGGG 1. Risk stratification of significant predictors of BCR with isolated SVI identified a subgroup with BMI ≤27.9 kg/m², PSA ≤8.6 ng/mL, and SGGG 2, which had a significantly better prognosis (p = 0.029, log-rank test). Conclusions: Seminal vesicles are infrequently involved with SGGG 1. Select groups of patients with isolated SVI who have low-grade disease with relatively lower PSA and BMI do not have an aggressive biological behavior and are unlikely to have a BCR, thereby circumventing unnecessary adjuvant therapy with its attendant side effects. The BMI significantly predicted PSA failures and should be considered as an additional risk assessment tool.

Benefit on Biochemical Control of Adjuvant Radiation Therapy in Patients with Pathologically Involved Seminal Vesicles after Radical Prostatectomy

Aims and Background

To determine whether there is a benefit for biochemical control with adjuvant radiation therapy to the surgical bed following radical prostatectomy in patients with seminal vesicle invasion and pathologically negative pelvic lymph nodes (pT3b-pT4 pN0).

Methods

We retrospectively reviewed the clinical records of radical prostatectomy patients treated between 1995 and 2002. A total of 66 patients with seminal vesicle invasion were identified: 45 of these patients received adjuvant radiation therapy and 21 were observed. Radiation therapy was initiated within 4 months of prostatectomy. Median dose was 66 Gy (range, 60–70 Gy). Median follow-up from the day of surgery was 40.6 months (mean, 41.5; range, 12–99). Biochemical recurrence was defined as the first value ≥0.2 ng/ml.

Results

At two years, the proportion of patients free from biochemical recurrence was 80% in patients who received adjuvant radiation therapy versus 54% for those not given radiation therapy (P = 0.036). Actuarial biochemical recurrence at 5 years was 59% vs 41% for the radiation therapy and no radiation therapy groups, respectively. On univariate Cox regression model, the hazard of biochemical failure was also associated with a detectable (≥0.2 ng/ml) postsurgical prostate-specific antigen (P = 0.02) prior to radiation therapy. Pathological T stage (pT3b vs pT4), Gleason score, primary Gleason pattern and positive surgical margins were not significantly associated with biochemical recurrence. The hazard of biochemical failure was around 85% lower in the radiation therapy group than in the observation group (P = 0.002).

Conclusions

Data from the present series suggest that adjuvant radiation therapy for patients with seminal vesicle invasion and undetectable (≤0.2 ng/ml) postoperative prostate-specific antigen significantly reduces the likelihood of biochemical failure.

Prostate cancer reporting and staging: needle biopsy and radical prostatectomy specimens

Prostatic adenocarcinoma remains the most common cancer affecting men. A substantial majority of patients have the diagnosis made on thin needle biopsies, most often in the absence of a palpable abnormality. Treatment choices ranging from surveillance to radical prostatectomy or radiation therapy are largely driven by the pathologic findings in the biopsy specimen. The first part of this review focuses on important morphologic parameters in needle biopsy specimens that are not covered in the accompanying articles. This includes tumor quantification as well as other parameters such a extraprostatic extension, seminal vesicle invasion, perineural invasion, and lymphovascular invasion. For those men who undergo radical prostatectomy, pathologic stage and other parameters are critical in prognostication and in determining the appropriateness of adjuvant therapy. Staging parameters, including extraprostatic extension, seminal vesicle invasion, and lymph node status are discussed here. Surgical margin status is also an important parameter and definitions and reporting of this feature are detailed. Throughout the article the current reporting guidelines published by the College of American Pathologists and the International Collaboration on Cancer Reporting are highlighted.

Improving postoperative radiotherapy following radical prostatectomy

INTRODUCTION

Prostate cancer has one of the highest incidences in the world, with good curative treatment options like radiotherapy and radical prostatectomy. Unfortunately, about 30% of the patients initially treated with curative intent will develop a recurrence and need adjuvant treatment. Five randomized trials covered the role of postoperative radiotherapy after radical prostatectomy, but there is still a lot of debate about which patients should receive postoperative radiotherapy. Areas covered: This review will give an overview on the available literature concerning post-operative radiotherapy following radical prostatectomy with an emphasis on the five randomized trials. Also, new imaging techniques like prostate-specific membrane antigen positron emission tomography (PSMA-PET) and multiparametric magnetic resonance imaging (mp-MRI) and the development of biomarkers like genomic classifiers will be discussed in the search for an improved selection of patients who will benefit from postoperative radiotherapy following radical prostatectomy. With new treatment techniques like Intensity Modulated Radiotherapy, toxicity profiles will be kept low. Expert commentary: Patients with biochemical recurrence following radical prostatectomy with an early rise in prostate-specific antigen (PSA) will benefit most from postoperative radiotherapy. In this way, patients with only high risk pathological features can avoid unnecessary treatment and toxicity, and early intervention in progressing patients would not compromise the outcome.

Association between Seminal Vesicle Invasion and Prostate Cancer Detection Location after Transrectal Systemic Biopsy among Men Who Underwent Radical Prostatectomy

Background

Our hypothesis is that the location of the seminal vesicles near the base of the prostate, the more positive cores are detected in the base, the greater the risk of seminal vesicle invasion. Therefore we investigate the clinical outcomes of base dominant prostate cancer (BDPC) in transrectal ultrasound (TRUS) -guided biopsies compared with anteromiddle dominant prostate cancer (AMPC).

Methods

From November 2003 to June 2014, a total of 990 intermediate and high risk prostate cancer (PCa) patients who underwent radical prostatectomy (RP) were enrolled and stratified into two groups according to proportion of positive cores–BDPC group had ≥ 33.3% ratio of positive cores from the prostate base among all positive cores and AMPC group < 33.3% in systemic biopsy. Between two groups, we compared the rate of pathologic outcomes and biochemical recurrence (BCR). We performed multivariate logistic regression model to confirm the significance of BDPC to seminal vesicle invasion (SVI) and Cox proportional hazard analysis to BCR.

Results

Among these 990 PCa patients, the 487 patients in BDPC group had more advanced clinical stage (p<0.001), a higher biopsy GS (p = 0.002), and a higher rate of extracapsular extension (ECE), SVI and BCR (all p<0.001) than AMPC group. The patients in BDPC group had poor BCR free survival rate via Kaplan-meier analysis (p<0.001). The ratio of the base positive cores was a significant predictor to SVI in multivariate analysis (p < 0.001) and significant predictor of BCR in multivariate Cox proportional analysis (hazard ratio: 1.466, p = 0.004).

Conclusions

BDPC in TRUS-guided prostate biopsies was significantly associated with SVI and BCR after adjusting for other clinical factors. Therefore, BDPC should be considered to be a more aggressive tumor despite an otherwise similar cancer profile.

Prognostic value of seminal vesicle involvement due to prostate cancer in radical prostatectomy specimens

OBJECTIVE

To study the influence, in terms of prognosis, of the finding of seminal vesicle involvement in patients with prostate adenocarcinoma treated with radical prostatectomy.

MATERIAL AND METHOD

We reviewed a series of patients with seminal vesicle involvement with clinically localized prostate adenocarcinoma who underwent radical prostatectomy between 1989 and 2009, focusing on their clinical-pathological characteristics, biochemical progression-free survival (BPFS) and specific survival (SS). We assessed the variables that influenced BPFS and designed a risk model.

RESULTS

A total of 127 out of 1,132 patients who underwent surgery (11%) presented seminal vesicle invasion (i.e., pT3b). In the multivariate study of the entire series (Cox model), pT3b affects the BPFS (HR: 2; 95% CI: 1.4-3.3; P=.001). Other influential factors were the affected borders, initial prostate-specific antigen levels, pathological Gleason score and the presence of palpated tumor. The pT3b tumors have poorer clinical-pathological variables when compared with pT2 and pT3a tumors. Sixty-five percent of the patients evidenced biochemical progression. The BPFS was significantly poorer for pT3b (40 ± 4% and 28 ± 4% at 5 and 10 years, respectively) than for pT2 and pT3a (P<.0001). The SS was also poorer in patients with pT3b tumors (91 ± 2% and 76 ± 4% at 5 and 10 years, respectively) (P<.0001). The predictors within the pT3b patient group were: PSA levels >10 ng/mL (HR: 1.9; 95% CI: 1.04-3.6; P=.04) and pathological Gleason score 8-10 (HR: 2.1; 95% CI: 1.2-3.5; P=.03). We designed a risk model that accounts for the variables involved, which entails 2 groups with different BPFS (P=.004): Group 1 (0-1 variable), with a BPFS of 46 ± 7% and 27 ± 8% at 5 and 10 years, respectively; and Group 2 (2 variables), with a BPFS of 14 ± 7% and 5 ± 5% at 5 and 10 years, respectively.

CONCLUSION

Seminal vesicle involvement severely and negatively affects the BPFS and SS. We designed a risk model with the independent influential variables in BPFS (pathological Gleason score 8-10 and PSA levels >10 ng/mL). This model confirms that pT3b tumors are a heterogeneous group, which includes an important group with better prognosis when surgical treatment is performed.

Morphological Analysis of Radical Prostatectomy Specimens: Recent Topics Relevant to Prognosis

The pathology report should include clinically relevant information as well as provide clinically useful information derived from the macroscopic examination and microscopic evaluation of the radical prostatectomy (RP) specimens. The reporting pathologist should pay particular attention to the evaluation of the prognostic factors proven to be of prognostic importance and useful in clinical patient management, including histological type, grade and volume of cancer, the extent of local invasion and stage of cancer as well as the surgical margins status.

Gleason grading: past, present and future

In 1966 Donald Gleason developed his grading and scoring system for prostatic adenocarcinoma. This classification was refined in 1974 and gained almost universal acceptance, being classified as a category 1 prognostic parameter by the College of American Pathologists. Modifications to the classification were recommended at a conference convened by the International Society of Urological Pathology (ISUP) in 2005. This modified classification has resulted in a significant upgrading of tumours, although some studies have shown a greater concordance between needle biopsy and radical prostatectomy scores when compared to classical Gleason (CG) grading. The ISUP consensus conference recommended that for needle biopsies higher tertiary patterns should be incorporated into the final Gleason score, and this has been correlated with biochemical failure, tumour volume and mortality. Recently the validity of including cribriform glands as a component of Gleason pattern 3 has been questioned and it has been recommended that all tumours showing cribriform architecture should be classified as Gleason pattern 4. The recommendations arising from the 2005 Consensus Conference were largely unsupported by validating data, yet this new grading system has achieved widespread usage. It is unfortunate that recent suggestions for further modification are similarly lacking in supporting evidence. In view of this it is recommended that the Modified Gleason Scoring Classification should continue to be utilized in its original (2005) format and that any future alterations should be implemented only when mandated by tumour-related outcome studies.

Pathology in prostate research: optimizing the pathological data

Pathology remains the gold standard for the diagnosis and local staging and grading of prostate cancer. However, as in any discipline, there are variations in national standards and protocols leading to possible significant intra-observer variations. This can significantly impact on the data supplied to clinical trials. Diagnostic and grading criteria. Error rates in the diagnosis of prostate cancer have improved but the possibility that diagnostic error may be discovered has to be addressed in any research series. Major changes in Gleason grading have occurred in the past 40 years and this may lead to suboptimal application of grades in research cohorts, falsely raising the prognostic power of new biomarkers. Tumor measurements and staging criteria. Further information that may provide additional prognostic information include various measures of tumor extent and peri-neural invasion in biopsy specimens. Standardization of measures of tumor extent is necessary to give more useful assessments of prognosis. In radical prostatectomy specimens there are a number of other staging measurements which might be applied, including tumor volume, margin status, extra-capsular extension and nodal positivity though many of these variables are interdependent. Conclusion. Appropriate utilization of such pathological material will produce improved cohorts in which it will be possible to test new biomarkers with increased rigor.

A contemporary analysis of outcomes of adenocarcinoma of the prostate with seminal vesicle invasion (pT3b) after radical prostatectomy

PURPOSE

Despite earlier detection and stage migration, seminal vesicle invasion is still reported in the prostate specific antigen era and remains a poor prognostic indicator. We investigated outcomes in men with pT3b disease in the contemporary era.

MATERIALS AND METHODS

The institutional radical prostatectomy database (1982 to 2010) of 18,505 men was queried and 989 with pT3b tumors were identified. The cohort was split into pre-prostate specific antigen (1982 to 1992), and early (1993 to 2000) and contemporary (2001 to present) prostate specific antigen eras. Of the 732 men identified in the prostate specific antigen era 140 had lymph node involvement and were excluded from study. The Kaplan-Meier method was used to determine biochemical recurrence-free, metastasis-free and prostate cancer specific survival. Proportional hazard models were used to determine predictors of biochemical recurrence-free, metastasis-free and cancer specific survival.

RESULTS

In the pre-prostate specific antigen, and early and contemporary prostate specific antigen eras, 7.7%, 4.3% and 3.3% of patients, respectively, had pT3bN0 disease (p >0.001). In pT3bN0 cases, the 10-year biochemical recurrence-free survival rate was 25.8%, 28.6% and 19.6% (p = 0.8), and the cancer specific survival rate was 79.9%, 79.6% and 83.8% (p = 0.6) among the eras, respectively. In pT3bN0 cases in the prostate specific antigen era, prostate specific antigen, clinical stage T2b or greater, pathological Gleason sum 7 and 8-10, and positive surgical margins were significant predictors of biochemical recurrence-free survival on multivariate analysis while clinical stage T2c or greater and Gleason 8-10 were predictors of metastasis-free and cancer specific survival.

CONCLUSIONS

Despite a decreased frequency of pT3b disease, and lower rates of positive surgical margins and lymph nodes, patients with seminal vesicle invasion continue to have low biochemical recurrence-free survival. Advanced clinical stage, intermediate or high risk Gleason sum at pathological evaluation and positive surgical margins predict biochemical recurrence. High risk clinical stage and Gleason sum predict metastasis-free and cancer specific survival.

International Society of Urological Pathology (ISUP) Consensus Conference on Handling and Staging of Radical Prostatectomy Specimens. Working group 4: seminal vesicles and lymph nodes

The 2009 International Society of Urological Pathology Consensus Conference in Boston made recommendations regarding the standardization of pathology reporting of radical prostatectomy specimens. Issues relating to the infiltration of tumor into the seminal vesicles and regional lymph nodes were coordinated by working group 4. There was a consensus that complete blocking of the seminal vesicles was not necessary, although sampling of the junction of the seminal vesicles and prostate was mandatory. There was consensus that sampling of the vas deferens margins was not obligatory. There was also consensus that muscular wall invasion of the extraprostatic seminal vesicle only should be regarded as seminal vesicle invasion. Categorization into types of seminal vesicle spread was agreed by consensus to be not necessary. For examination of lymph nodes, there was consensus that special techniques such as frozen sectioning were of use only in high-risk cases. There was no consensus on the optimal sampling method for pelvic lymph node dissection specimens, although there was consensus that all lymph nodes should be completely blocked as a minimum. There was also a consensus that a count of the number of lymph nodes harvested should be attempted. In view of recent evidence, there was consensus that the diameter of the largest lymph node metastasis should be measured. These consensus decisions will hopefully clarify the difficult areas of pathological assessment in radical prostatectomy evaluation and improve the concordance of research series to allow more accurate assessment of patient prognosis.

The prognostic impact of seminal vesicle involvement found at prostatectomy and the effects of adjuvant radiation: data from Southwest Oncology Group 8794

PURPOSE

From the randomized study Southwest Oncology Group 8794 we evaluated the effect of seminal vesicle involvement on outcomes and whether those patients benefited from post-prostatectomy adjuvant radiation therapy.

MATERIALS AND METHODS

Southwest Oncology Group study 8794 randomized high risk patients (with seminal vesicle positive disease and/or capsular penetration and/or positive margins) to radiation vs observation after prostatectomy. A total of 431 subjects with pathologically advanced prostate cancer were randomized.

RESULTS

Median followup was 12.2 years. Of the patients 139 had seminal vesicle involvement with or without capsular penetration and/or positive margins. Compared to the 286 patients with seminal vesicle negative disease there was poorer 10-year biochemical failure-free survival (33% for seminal vesicle negative and 22% for seminal vesicle positive, p = 0.04), metastasis-free survival (70% and 56%, respectively, p = 0.005) and overall survival (10-year overall survival 74% and 61%, respectively, p = 0.02) for those with seminal vesicle positive disease. Patients with seminal vesicle positive disease who received adjuvant radiation compared to observation realized an improvement in 10-year biochemical failure-free survival from 12% to 36% (p = 0.001), in 10-year overall survival from 51% to 71% (p = 0.08) and in metastasis-free survival from 47% to 66% (p = 0.09), respectively.

CONCLUSIONS

Although seminal vesicle involvement is a negative prognostic factor, long-term control is possible especially if patients are given adjuvant radiation therapy. This therapy appears to be effective in patients with seminal vesicle involvement.

Marges après prostatectomie totale : aspects techniques et valeur pronostique

The status of surgical margins after radical prostatectomy is a major prognostic factor. The role of several technical aspects of radical prostatectomy, such have surgical access, bladder neck preservation or neurovascular bundle sparing, in generating supplementary positive margins has been controversial for many years. Positive margins along with other poor prognostic factors are important elements in the decision to perform adjuvant therapy after radical prostatectomy. This review of the literature, based on a Medline search, was designed to update these various issues encountered by urologists in their everyday practice.

Cancer-specific survival and predictors of prostate-specific antigen recurrence and survival in patients with seminal vesicle invasion after radical prostatectomy

BACKGROUND

The objectives of the current study were to determine the long-term biochemical recurrence (BCR) and cancer-specific survival (CSS) rates for men with seminal vesicle invasion (SVI) and to identify risk factors for freedom from BCR and CSS in patients who received treatment in the prostate-specific antigen era and who had SVI identified at the time of radical prostatectomy (RP).

METHODS

Prospective clinical, pathologic, and outcome data were collected for 5377 men who underwent RP between June 1983 and August 2004. There were 936 patients who were excluded because they received treatment before RP. Multivariable analysis was used to identify the factors that predicted BCR and CSS.

RESULTS

Among 4441 eligible patients, 387 patients (8.7%) had SVI, and 91 of those 387 patients (24%) had lymph node involvement (LNI). In total, 210 patients experienced BCR. For patients without LNI, the 10-year and 15-year freedom from BCR rates were 36% and 32%, respectively, and the corresponding CSS rates were 89% and 81%, respectively. For the 91 men who had SVI and LNI, the 10-year BCR-free probability was 10%, but the 10-year CSS probability was 74%. By 10 years, patients with LNI were 3 times more likely to die from cancer than from other causes; nonetheless, 66% of patients were alive despite their advanced stage. The preoperative prostate-specific antigen level, extracapsular extension, LNI, and Gleason grade were associated independently with BCR. Gleason scores of 8 to 10 and LNI were significant predictors of CSS.

CONCLUSIONS

SVI does not invariably signal BCR or death from cancer in patients who undergo RP and pelvic lymph node dissection. Fifteen years later, approximately 33% of men with SVI and negative lymph nodes are expected remain free of BCR, and CSS was surprisingly good.

Key issues in handling and reporting radical prostatectomy specimens

CONTEXT

Patients with prostatic adenocarcinoma commonly undergo radical prostatectomy, and it is often difficult and time consuming to handle the resulting specimens and to report the findings. Pathologic information derived from the radical prostatectomy specimen is used for selecting adjuvant therapy, such as radiotherapy and hormone therapy, and for determining a patient's prognosis. The prostate specimen must be handled in a systematic fashion to derive the appropriate prognostic parameters.

OBJECTIVE

To review the prognostic factors of relevance in classifying radical prostatectomy specimens, using the College of American Pathologists categorization system, including a detailed survey of the morphologic-based factors but excluding other factors such as DNA ploidy and novel phenotypic and genotypic markers.

CONCLUSIONS

Gleason score, pathologic stage, and margin status are considered category 1 prognostic factors, which are of proven prognostic significance and are useful in patient management. Factors such as tumor volume (intraglandular extent) and tumor subtype are considered category 2 prognostic factors, which show significant promise but require validation in multivariate analysis. Lymphovascular space invasion is a promising category 3 prognostic factor that needs additional study. Perineural invasion is an almost ubiquitous finding in radical prostatectomy specimens and is considered a category 3 prognostic factor. After prognostic factors have been analyzed at the histologic level, it is critical to report the findings in a clear and unambiguous fashion. The synoptic style of reporting is ideal for describing complex cancer resection specimens. A synoptic report based on an evidence-based checklist, such as the one developed by the College of American Pathologists, effectively communicates complex cancer-related data, such as radical prostatectomy specimen findings. This information is used not only for individual case management with respect to treatment and prognostication but also for purposes such as education, research, quality monitoring, and system planning.

Prognostic factors and reporting of prostate carcinoma in radical prostatectomy and pelvic lymphadenectomy specimens

This paper, based on the activity of the Morphology-Based Prognostic Factors Committee of the 2004 World Health Organization-sponsored International Consultation, describes various methods of handling radical prostatectomy specimens for both routine clinical use and research purposes. The correlation between radical prostatectomy findings and postoperative failure is discussed in detail. This includes issues relating to pelvic lymph node involvement, detected both at the time of frozen section and in permanent sections. Issues of seminal vesicle invasion, including its definition, routes of invasion and relationship to prognosis, are covered in detail. The definition, terminology and incidence of extra-prostatic extension are elucidated, along with its prognostic significance relating to location and extent. Margins of resection are covered in terms of their definition, the etiology, incidence and sites of positive margins, the use of frozen sections to assess the margins and the relationship between margin positivity and prognosis. Issues relating to grade within the radical prostatectomy specimen are covered in depth, including novel ways of reporting Gleason grade and the concept of tertiary Gleason patterns. Tumor volume, tumor location, vascular invasion and perineural invasion are the final variables discussed relating to the prognosis of radical prostatectomy specimens. The use of multivariate analysis to predict progression is discussed, together with proposed modifications to the TNM system. Finally, biomarkers to predict progression following radical prostatectomy are described, including DNA ploidy, microvessel density, Ki-67, neuroendocrine differentiation, p53, p21, p27, Bcl-2, Her-2/neu, E-cadherin, CD44, retinoblastoma proteins, apoptotic index, androgen receptor status, expression of prostate-specific antigen and prostatic-specific acid phosphatase and nuclear morphometry.

Isolated seminal vesicle invasion imparts better outcomes after radical retropubic prostatectomy for clinically localized prostate cancer: Prognostic stratification of pt3b disease by nodal and margin status

OBJECTIVES

To examine the survival differences in men with seminal vesicle invasion (SVI) according to surgical margin (SM) and nodal (N) status to characterize the influence of isolated SVI on disease progression after radical retropubic prostatectomy for clinically localized prostate cancer.

METHODS

We reviewed the records of 941 men who underwent radical retropubic prostatectomy for clinically localized prostate cancer between 1984 and 2002. Three groups with evidence of SVI (SM-/N-, SM+/N-, and N+) were analyzed to identify differences in age, preoperative prostate-specific antigen (PSA) level, biopsy Gleason score, surgical Gleason score, time to PSA progression, follow-up time, and cancer-specific and overall survival. Kaplan-Meier estimates and univariate and multivariate calculations were generated to examine differences in biochemical-free survival.

RESULTS

Of 941 patients, 87 were identified with SVI; of these, 28 (32.2%) were SM-/N-, 35 (40.2%) were SM+/N-, and 24 (27.6%) were N+. The median follow-up for all patients was 70 months. The 5-year biochemical progression-free rate for SM-/N-, SM+/N-, and N+ patients was 71.9%, 36.6%, and 25.9%, respectively. The median time to PSA progression for SM-/N-, SM+/N-, and N+ patients was 26, 16, and 6 months, respectively. The clinical stage, pretreatment PSA level, and margin and node status were statistically predictive (P < 0.05) on univariate analyses; however, only positive margin status approached statistical significance on multivariate analysis (P = 0.06). The overall and cancer-specific 5-year survival rates for SM-/N-, SM+/N-, and N+ patients were 89% and 100%, 79% and 97%, and 78% and 86%, respectively.

CONCLUSIONS

Isolated SVI is associated with lower rates of, and longer intervals to, biochemical failure compared with SVI with positive margins and/or regional lymph node involvement.

Contemporary survival results and the role of radiation therapy in patients with node negative seminal vesicle invasion following radical prostatectomy

PURPOSE

Seminal vesicle invasion (SVI) in a radical prostatectomy (RRP) specimen is associated with a guarded prognosis. We evaluated patients with SVI treated in the pre-prostate specific antigen (PSA) (1983 to 1991) and PSA (1992 to 2003) eras.

MATERIALS AND METHODS

Of patients with prostate cancer treated with RRP from January 1983 through March 2002, 220 with SVI were evaluated, including 67 in the pre-PSA era and 153 in the PSA era. Postoperative PSA greater than 0.2 ng/ml was considered biochemical evidence of cancer progression. Survival rates were compared using Kaplan-Meier estimates to calculate progression-free, cancer specific and all cause survival. Multivariate Cox proportional hazard models were used to correlate variables with disease progression.

RESULTS

The incidence of SVI in the PSA era was lower than in the pre-PSA era (6.0% vs 10.2%, p = 0.001). To date 124 patients (56%) have had evidence of cancer progression. The 4 and 7-year progression-free, cancer specific and all cause survival rates were significantly higher in men with SVI in the PSA era (p = 0.02). PSA at diagnosis, cancerous surgical margins and higher Gleason score were significantly associated with progression. Neither adjuvant nor salvage radiotherapy appeared to confer a significant progression-free survival benefit.

CONCLUSIONS

The incidence of SVI has decreased in the PSA era. Progression-free, cancer specific and all cause survival rates following RRP in patients with SVI have improved in the PSA era. This may reflect earlier detection in this pathological tumor stage and more favorable prognostic factors associated with PSA screening. Adjuvant radiotherapy does not appear to confer any therapeutic benefit. Salvage radiotherapy can lead to durable PSA regressions in a small percent of men, although no long-term survival advantage can be proved.

Surgical management of prostate cancer: Advances based on a rational approach to the data

The management of localised prostate cancer has undergone important changes in the past two decades, with major improvements in surgical technique, a greater emphasis on structured assessment of quality of life, and a greater attempt to tailor treatment to biological risk. Disease diagnosis is predicated on identification of demographic risk factors, serum levels of prostate-specific antigen and its derivatives, and extended biopsy techniques. Surgical removal of the prostate may be accomplished by open or minimally invasive techniques and in experienced hands results in good functional outcomes a high rate of cure for those with organ confined disease. Radical prostatectomy is also appropriate in selected patients with locally advanced disease and after failed radiation therapy.

Improved biochemical outcome with adjuvant radiotherapy after radical prostatectomy for prostate cancer with poor pathologic features

PURPOSE

The indications for adjuvant external beam radiotherapy (EBRT) after radical prostatectomy (RP) are poorly defined. We performed a retrospective comparison of our institution's experience treating prostate cancer with RP vs. RP followed by adjuvant EBRT.

METHODS AND MATERIALS

Between 1987 and 1998, 617 patients with clinical Stage T1-T2N0M0 prostate cancer underwent RP. Patients who underwent preoperative androgen deprivation and those with positive lymph nodes were excluded. Of the 617 patients, 34 (5.5%) with an undetectable postoperative prostate-specific antigen (PSA) level underwent adjuvant prostatic fossa RT at a median of 0.25 year (range, 0.1-0.6) postoperatively because of poor pathologic features. The median total dose was 59.4 Gy (range, 50.4-66.6 Gy) in 1.8-2.0-Gy fractions. These 34 RP+RT patients were compared with the remaining 583 RP patients. Biochemical failure was defined as any postoperative PSA level > or =0.1 ng/mL and any postoperative PSA level > or =0.3 ng/mL (at least 30 days after surgery). Administration of androgen deprivation was also scored as biochemical failure when applying either definition. The median clinical follow-up was 8.2 years (range, 0.1-11.2 years) for RP and 8.4 years (range, 0.3-13.8 years) for RP+RT.

RESULTS

Radical prostatectomy + radiation therapy patients had a greater pathologic Gleason score (mean, 7.3 vs. 6.5; p < 0.01) and pathologic T stage (median, T3a vs. T2c; p < 0.01). Age (median, 65.7 years) and pretreatment PSA level (median, 7.9 ng/mL) were similar between the treatment groups. Extracapsular extension was present in 72% of RP+RT patients vs. 27% of RP patients (p < 0.01). The RP+RT patients were more likely to have seminal vesicle invasion (29% vs. 9%, p < 0.01) and positive margins (73% vs. 36%, p < 0.01). Despite these poor pathologic features, the 5-year biochemical control (BC) rate (PSA <0.1 ng/mL) was 57% for RP+RT and 47% for RP (p = 0.28). For patients with extracapsular extension, the 5-year BC rate was 52% for RP+RT vs. 30% for RP (p < 0.01). The 5-year BC rate for patients with seminal vesicle invasion was 60% for RP+RT vs. 18% for RP (p < 0.01). For those with positive margins, the 5-year BC rate was 64% for RP+RT vs. 27% for RP (p < 0.01). The use of adjuvant RT remained statistically significant on multivariate analysis when applying either biochemical failure definition. Adjuvant RT also remained statistically significant when including the postoperative PSA level (>30 days after surgery) in the multivariate analyses. In addition, 99 (17%) of the 583 RP patients required salvage prostatic fossa RT (median dose, 59.4 Gy) at a median interval of 1.3 years after surgery (range, 0.1-8.4) for a palpable recurrence (n = 10) or a detectable/rising postoperative PSA level (n = 89). The median PSA level before salvage RT was 0.8 ng/mL (mean, 3.2 ng/mL). The 5-year and 8-year BC rate, using the PSA <0.1 ng/mL definition, from the date of salvage RT was 41% and 35%, respectively. The 5-year and 8-year BC rate, using the PSA <0.3 ng/mL definition, was 46% and 36%, respectively. The 8-year local recurrence rate after salvage RT was 4%.

CONCLUSION

Adjuvant RT demonstrated improved efficacy against prostate cancer. For patients with poor pathologic features (extracapsular extension, seminal vesicle invasion, positive margins), adjuvant RT improved the biochemical outcome independent of other prognostic factors.

What is the best postoperative treatment for patients with pT3bN0M0 adenocarcinoma of the prostate?

The purpose of this paper to identify the optimal therapy after radical prostatectomy (RP) for patients with adenocarcinoma of the prostate invading the seminal vesicles (pT3bN0M0 or SVI). A PubMed search using the keywords 'prostate', 'seminal vesicle', 'prostatectomy', 'radiotherapy', 'androgen blockade' was performed to identify literature regarding rates of disease failure in patients with SVI who are observed or treated with androgen blockade (AB), radiotherapy (RT) or RT + AB after RP. The outcome of 68 patients treated at Duke University with post-operative AB, RT or RT + AB for pT3bN0M0 is also presented. More than 70% of patients with SVI develop disease recurrence after surgery. For many, recurrence occurs within 2 y after RP. These patients have poor control rates with postoperative RT alone. While experience with AB and RT+AB is limited, control rates are generally superior to RT alone. At Duke University, after a median follow-up of nearly 4 y, patients treated with RT + AB or AB alone for pT3bN0M0 achieved better 5-y progression-free survival (PFS) compared with those who received RT alone (78 and 68 vs 30%, P = 0.03 and 0.046, respectively). There was no PFS difference between those who received AB alone or RT + AB (68 vs 78%, P=0.5). Seminal vesicle invasion confers a poor prognosis after RP. SVI is a consistent predictor of poor outcome after RT. The limited data available examining AB and RT + AB in pT3bN0M0 disease, including data from Duke University, are encouraging. Nonetheless, postoperative AB, RT and RT + AB for pT3bN0M0 disease require prospective evaluation, as RP alone is rarely curative.

Long-term outcome of patients with prostate cancer and pathologic seminal vesicle invasion (pT3b): effect of adjuvant radiotherapy

OBJECTIVES

To evaluate the long-term outcome of patients with prostate cancer who have pathologic seminal vesicle invasion without lymph node metastasis (pT3bN0M0) and compare management strategies.

METHODS

From October 1987 to August of 1997, 43 men underwent radical prostatectomy at Thomas Jefferson University Hospital, had pT3bN0M0 disease, complete preoperative and postoperative prostate-specific antigen (PSA) data, and a minimum of 2 years of follow-up. Eighteen patients with undetectable postoperative PSA levels received adjuvant radiotherapy (RT) within 6 months of surgery. Twelve patients with undetectable PSA levels postoperatively were considered for salvage treatment at biochemical progression. Thirteen patients with persistently elevated PSA levels postoperatively underwent immediate salvage RT. We evaluated the prognostic factors for freedom from biochemical failure (bNED), distant metastasis (DM), disease-specific survival, and overall survival.

RESULTS

The median follow-up time was 5.9 years (range 2 to 10). Patients who received adjuvant RT had significantly greater 5-year bNED survival than patients who did not (80% versus 8%, P <0.001) and increased freedom from DM that was of borderline significance (P = 0.05). The 5-year survival estimates for DM were 0% for the adjuvant RT versus 17% for the observed patient group. In patients with undetectable postoperative PSA levels, the preoperative PSA level was an independent prognostic factor for later disease progression. Patients with a preoperative PSA level of less than 20 ng/mL showed significantly greater 5-year bNED survival than those with a preoperative PSA level of 20 ng/mL or greater (56% versus 32%, P <0.05). The survival curves for risk of DM and death from prostate cancer for those two patient groups were not significantly different statistically.

CONCLUSIONS

Although pathologic seminal vesicle invasion has been associated with poor prognosis and high DM risk, adjuvant RT may result in improved bNED survival in patients with undetectable PSA levels after radical prostatectomy. The effect on clinical outcome awaits additional follow-up.

An analysis of risk factors for biochemical progression in patients with seminal vesicle invasion: validation of Kattan's nomogram in a pathological subgroup

OBJECTIVE

To assess the ability of a recently published nomogram to predict failure after radical retropubic prostatectomy (RRP) in a cohort of patients with seminal vesicle invasion (SVI) of the resected specimen, widely regarded as a very poor prognostic factor in patients with prostate cancer.

PATIENTS AND METHODS

Men with SVI after RRP were analysed retrospectively; patients with positive lymph nodes, adjuvant radiotherapy or hormone therapy were excluded. Age, race, baseline prostate specific antigen (PSA) level, clinical stage, Gleason score, margin status, perineural invasion, capsular invasion, laterality and route of invasion were recorded. Biochemical recurrence was defined as one PSA measurement of 0.4 ng/mL. Biochemical disease-free survival probability was plotted using the Kaplan-Meier method. Kattan's nomogram was applied to each patient and a receiver-operator characteristic (ROC) curve produced to assess the test's reliability.

RESULTS

In all, 67 patients with SVI were identified (mean age 64.6 years, sd 5.9; median follow-up 30.5 months). Biochemical disease-free survival was significantly better for men with negative margins, unilateral SVI and perineural invasion. No other significant factors were detected. The median (95% confidence limit) area under the ROC curve was 0.739 (0.604-0.847).

CONCLUSION

There were significant prognostic differences for three of the factors assessed. Although components of the Kattan nomogram were not significant in this group its predictive value approached that found originally, suggesting that it can be applied to patients with SVI in helping to direct adjuvant therapy and guide postoperative counselling.

Prognostic indicators for long term outcome following radical retropubic prostatectomy for prostate cancer involving the seminal vesicles

Seminal vesicle involvement at the time of radical prostatectomy (RP) for prostate cancer has been equated with metastatic disease. We review our biochemical freedom from disease results following RP in patients with seminal vesicle involvement with particular attention to identifying variables that may be predictive of disease recurrence. We retrospectively reviewed our surgical database and identified patients with pT3b (2002 AJCC) prostate cancer at RP [corrected]. There were 70 cases without lymph node involvement and with available clinical follow-up identified. Any patient receiving androgen deprivation therapy, radiation therapy, or with a sustained PSA elevation greater than 0.2 ng/mL was considered a biochemical failure. Results were calculated using the Kaplan-Meier method. Mean age was 63.4 (range 45.7-79.5) years, mean preoperative PSA was 11.3 ng/mL (range 2-60), mean biopsy Gleason score was 7.2 (range 4-9), mean RP Gleason score was 7.5 (range 5-9), and median follow-up time was 61.5 months (range 2.3-160.6). Overall, 33/70 (47%) patients were without evidence of disease without further therapy. For patients with pT3bN0Mx prostate cancer, margin status, capsular invasion, and PSA were not statistically significant risk factors for disease progression. Gleason score and major Gleason grade were the only statistically significant variables that predicted disease progression. A specimen Gleason score of greater than 7 and major Gleason grades greater than 3 were associated with an increased rate of disease progression in this patient group.

Importance of margin extent as a predictor of outcome after adjuvant radiotherapy for Gleason score 7 pT3N0 prostate cancer

PURPOSE

To evaluate, in Gleason score 7, pT3N0 prostate cancer patients with positive surgical margins, the predictors of progression-free survival and to identify a patient subgroup that would benefit from immediate adjuvant postoperative radiotherapy (ART).

METHODS AND MATERIALS

Between November 1989 and August 1998, 76 men underwent radical prostatectomy and were found to have capsular penetration (pT3N0), surgical Gleason score 7, tumor present at the resection margin, and an undetectable postoperative prostate-specific antigen (PSA) level. All surgical specimens underwent whole-mount serial sectioning to determine the degree of margin positivity (focal vs. extensive). Of the 76 men, 45 underwent early ART (within 6 months with a median dose of 64.8 Gy), and 31 had no immediate treatment. We defined freedom from PSA failure (bNED) as the absence of two consecutive PSA rises >0.2 ng/mL.

RESULTS

The median follow-up time was 5.1 years (range, 2-10 years). The ART and non-ART patients were similar with respect to preoperative PSA level, Gleason score (4 + 3 vs. 3 + 4), presence of seminal vesicle invasion, and margin extent. On univariate analysis, margin extent was predictive for improved bNED (5-year bNED rate of 92% vs. 58%, p = 0.010, for men with focal and extensive margins, respectively). Gleason score (4 + 3 vs. 3 + 4), seminal vesicle invasion, and ART were not statistically significant predictors. On multivariate analysis, the preoperative PSA level, margin extent, and ART were independent significant factors. In the group with extensive surgical margins, men receiving ART had a significantly greater 5-year bNED survival rate compared with the non-ART patients (73% vs. 31%, p = 0.004).

CONCLUSION

These data suggest that the amount of microscopic residual tumor significantly affects bNED after radical prostatectomy for Gleason score 7, pT3N0 prostate cancer. In addition, men with pathologic evidence of microscopic local disease appear to benefit from early ART compared with untreated controls.

Invasion of seminal vesicles by adenocarcinoma of the prostate: PSA outcome determined by preoperative and postoperative factors

OBJECTIVES

To determine which preoperative and postoperative factors were predictive of the time to prostate-specific antigen (PSA) failure after radical retropubic prostatectomy (RRP) for patients with seminal vesicle invasion (SVI). SVI by prostate cancer is associated with high PSA failure rates after RRP and subsequent distant metastases.

METHODS

Between 1988 and 2002, 1697 patients with prostate cancer underwent RRP at Brigham and Women's Hospital, of whom 103 (6%) had SVI. Cox regression multivariable analysis was used to determine whether the preoperative PSA level, prostatectomy Gleason score, margin status, or presence of extraprostatic extension was predictive of the time to postoperative PSA failure. Estimates of PSA outcome were made using the actuarial method of Kaplan and Meier for patients who had none, all, or at least one of the factors that predicted for the time to postoperative PSA failure.

RESULTS

The statistically significant categorical predictors of the time to PSA failure after RRP in patients with SVI included prostatectomy Gleason score of 4+3 or greater (P = 0.009), preoperative PSA level greater than 20 ng/dL when evaluated as a categorical or as a continuous variable (P = 0.002 and P = 0.001, respectively), and margin positivity (P = 0.075) which was of borderline significance. The 3-year estimate of PSA control was 52% to 100%, 28%, and 0% for patients with negative margins, preoperative PSA less than 20 ng/dL, and prostatectomy Gleason score of 3+4 or less versus having one to two or all three predictors of the time to postoperative PSA failure.

CONCLUSIONS

The PSA outcome after RRP for patients with SVI varies depending on the preoperative PSA level, prostatectomy Gleason score, and margin status.

Predictors of prostate-specific antigen progression among men with seminal vesicle invasion at the time of radical prostatectomy

BACKGROUND

Seminal vesicle (SV) invasion at the time of radical prostatectomy (RP) generally is considered to be indicative of poor outcome. The authors examined whether there was a subset of men with SV invasion who had long-term prostate-specific antigen (PSA) progression-free survival.

METHODS

Data were examined from 1687 men who underwent RP between 1988 and 2002 at 5 equal-access medical centers. Patients were grouped based on the presence or absence of SV invasion at the time of RP. Clinical and pathologic variables as well as biochemical outcome data were compared across the groups using rank-sum, chi-square, and log-rank tests. Multivariate Cox proportional hazards analysis was used to determine the significant predictors of time to PSA failure among men with SV invasion.

RESULTS

Men with SV invasion had significantly higher PSA values, higher clinical stage, higher grade tumors, and were more likely to have concomitant extracapsular extension or a positive surgical margin. The 5-year PSA progression-free rates for men who had SV invasion was 36%, compared with 70% among men who had no SV invasion. Among men who had SV invasion, using multivariate analysis, only age (P = 0.023), pathologic Gleason score (P = 0.041), and surgical margin status (P = 0.019) were found to be independent predictors of PSA failure. By combining significant prognostic variables, the authors identified a subset of men with SV invasion, low-grade tumors (Gleason score 2-6), and negative surgical margins who had a 5-year PSA progression-free rate of 69%. Men with SV invasion, Gleason scores 2-6 tumors, negative surgical margins, and age > or = 60 years (n = 11; 8%) had a 5-year PSA progression-free rate of 100%.

CONCLUSIONS

Although the majority of men with SV invasion have high-grade disease and a short time to biochemical failure, the authors identified a subset of men with low-grade disease, negative surgical margins, and older age who, despite SV invasion, had an extremely favorable clinical course. Thus, SV invasion does not uniformly suggest an unfavorable prognosis. prognosis.

Seminal vesicle involvement after radical prostatectomy: predicting risk factors for progression

OBJECTIVES

To evaluate and study the factors for progression after radical prostatectomy with seminal vesicle invasion in a cohort of European and American patients.

METHODS

The data of 137 patients with isolated seminal vesicle invasion who underwent radical retropubic prostatectomy between 1988 and 2001 were analyzed. The Gleason score of the specimen, presence of capsular invasion, and surgical margin status were noted. Follow-up data were obtained through routine serum prostate-specific antigen (PSA) assays and digital rectal examinations. A defining criterion for progression was a postoperative serum PSA level greater than 0.2 ng/mL or any postoperative radiotherapy or hormonal treatment. Kaplan-Meier analysis was used to determine the actuarial biochemical recurrence-free likelihood, and the log-rank test was used to compare these results. Differences were considered statistically significant when the P value was less than 0.05.

RESULTS

After a mean follow-up of 4.9 years (range 0.9 to 13.4), 70 patients (51.9%) had progression. The biochemical 5-year progression-free survival rate was 33.8%. In univariate and multivariate analyses, only preoperative PSA level (P = 0.001) and Gleason score of the specimen (P = 0.01) were independent predictors of progression. Neither capsular invasion nor positive surgical margins predicted progression. When an analysis was performed according to the major Gleason grade of the radical prostatectomy specimen, Gleason grade 5 was associated with a worse prognosis compared with Gleason grade 3 and 4 (P = 0.01). The mean time to progression was 20.5, 17.1, and 10.1 months for Gleason grade 3, 4, and 5, respectively.

CONCLUSIONS

Seminal vesicle invasion after radical prostatectomy has historically been associated with a poor prognosis. However, in the present study, seminal vesicle invasion was associated with a 34% rate of freedom from progression at 5 years after surgery alone. Preoperative PSA and Gleason score of the radical prostatectomy specimen were independent factors for progression in the present study, which described the largest patient group to date. The Gleason grade of the radical prostatectomy specimen distinguished among different times to progression.

Pathologic features the urologist should expect on a prostate biopsy

In recent years, the pathological evaluation of prostate biopsy specimens has made great improvements in diagnostic accuracy and comprehensiveness. In this article, we review major pathological findings on prostate biopsy, their interpretation and reporting, as well as their clinical significance and utility. We discuss especially the clinically relevant histological features in either a positive or negative biopsy. We emphasize that both Gleason score and extent of cancer involvement in a needle core biopsy are important predictors of clinical outcome after either radical prostatectomy or radiation. Special issues regarding diagnosis and grading of minimal cancer on needle core biopsies are discussed. We also highlight the current standards on high-grade prostatic intraepithelial neoplasia and atypical small acinar proliferation on needle core biopsies. In summary, the pathology reports on needle biopsies are far beyond the simple presence or absence of cancer; they contain invaluable information to clinicians on patient management and counseling.

Biochemical and pathological predictors of the recurrence of prostatic adenocarcinoma with seminal vesicle invasion

PURPOSE

We assessed biochemical and pathological factors as predictors of recurrence in men with seminal vesicle invasion.

MATERIALS AND METHODS

A consecutive series of 812 men who underwent radical retropubic prostatectomy between 1992 and 2000 included 106 (13%) with seminal vesicle invasion. Disease recurrence was defined as prostate specific antigen (PSA) 0.4 ng./ml. or greater. Patients with less than 12 months of followup, salvage radical retropubic prostatectomy, lymph node metastases and adjuvant therapy were excluded from study. Data on the remaining 66 cases were analyzed using the chi-square test, bivariate logistic regression, Kaplan-Meier analyses and Cox proportional regression. Variables included demographics, recurrence, time from surgery to recurrence, positive margins, capsular invasion, extracapsular extension, Gleason score (2 to 6, 7 and 8 to 10), and dichotomized values of preoperative PSA (10 or less versus 10 ng./ml.) and tumor volume (20% or less versus greater than 20%).

RESULTS

Mean patient age was 62 years (range 48 to 74). At an average followup of 47.7 months (range 13 to 109) 53% of the patients were free of biochemical recurrence. Mean time to recurrence was 18.6 months (range 1.7 to 51.6). Univariate analyses revealed a statistical significant increased risk of recurrence in patients with PSA greater than 10 ng./ml. (p <0.0001), capsular invasion (p = 0.01) and age (p = 0.036). When adjusting for potential covariates, Cox proportional regression analysis indicated that higher PSA (hazard ratio 7.33, 95% CI 2.57 to 20.95), larger tumor volume (hazard ratio 5.64, 95% CI 1.97 to 16.19) and higher age (hazard ratio 1.13, 95% CI 1.04 to 1.22) were significantly associated with shorter time to recurrence.

CONCLUSIONS

PSA greater than 10 ng./ml., tumor volume greater than 20% and age are significant predictors of recurrence after radical retropubic prostatectomy in patients with prostate cancer and seminal vesicle invasion. Hopefully future randomized trials may show a survival benefit of adjuvant therapy in patients at high risk.

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.

Pathologic assessment of the surgical specimen

Despite the wealth of information obtained by conventional histology, long-term studies are needed to provide novel information on the correlation of pathologic findings with prognosis. Findings need to be correlated not only with PSA progression but with the more clinically important parameters of distant metastases and survival. Although conventional histology still will have a role in the evaluation of prostate cancer at radical prostatectomy and its correlation with outcome, it undoubtedly will be augmented by newer techniques. These developments must be approached critically and rationally to determine whether they provide additional prognostic information beyond that currently available using more conventional parameters.