Can stage A1 tumor extent be predicted by transurethral resection tumor volume, per cent or grade? A study of 64 stage A1 radical prostatectomies with comparison to prostates removed for stages A2 and B disease

Overview of benign and malignant prostatic disease in Pakistani patients: a clinical and histopathological perspective

BACKGROUND

To present the overall clinical and histological perspective of benign and malignant prostatic disease as seen in our practice in the Section of Histopathology, Department of Pathology and Microbiology, Aga Khan University Hospital, Karachi, Pakistan.

MATERIALS AND METHODS

All consecutive prostate specimens (transurethral resection or TUR, enucleation, needle biopsies) received between July 1, 2012 and December 31, 2012 were included in the study.

RESULTS

Of the total of 785 cases, 621 (79.1%) were TUR specimens, 80 (10.2%) enucleation specimens, and 84 (10.7%) needle biopsies. Some 595 (75.8%) were benign, while 190 (24.2%) were malignant. Mean weight of BPH specimens was 19 grams and 43 grams for TUR and enucleation specimens respectively. Almost 67% of adenocarcinomas were detected on TUR or enucleation specimens. Of the above cases, 41.7% were clinically benign while 58.3% were clinically malignant. The average volume of carcinoma in all cases ranged between 60 to 65%. The average number of cores involved in needle biopsies was 5. In general, higher Gleason scores were seen in TUR/enucleation specimens than in needle biopsies. Overall, in all types of specimens, commonest Gleason score was 7, seen in 74 (38.9%) cases, followed by Gleason score 9 seen in 47 (24.7%) cases. Out of the 63 needle biopsies with carcinoma, radical prostatectomy was performed in 16 cases (25.4%).

CONCLUSIONS

Benign prostatic hyperplasia (BPH) is extremely common and constitutes the bulk of prostate specimens. TMajority of prostatic carcinomas are still diagnosed on TUR or enucleation specimens. These included both clinically benign and clinically malignant cases. The volume of carcinoma in these specimens was quite high indicating extensive disease. Gleason scores were also generally high compared with scores from needle biopsies. Commonest Gleason score in all type of specimens was 7. Pathologic staging was possible in very few cases since radical prostatectomies are rarely performed.

Outcome of radical prostatectomy for incidental carcinoma of the prostate

OBJECTIVE To evaluate a contemporary series of patients with incidental prostate cancer detected by transurethral resection of the prostate (TURP) and undergoing radical prostatectomy (RP). PATIENTS AND METHODS Between 1998 and 2004, 1931 patients had TURP for obstructive voiding symptoms and suspected BPH. Incidental prostate cancer was found in 104 (5.4%); 26 of these patients had a RP. The pathological staging and treatment of these patients were reviewed retrospectively and the follow-up results obtained. RESULTS Of the 26 patients who had RP, 17 had T1a and nine had T1b carcinoma of the prostate. After RP, six (35%) in the T1a group had no residual tumour (pT0) and 11 (65%) had pT2 cancer; the respective incidence in those with T1b was two and seven, with no pT3 disease in either group. The preoperative Gleason grading did not correspond well with that after RP; 30% of the patients had upgraded Gleason scores and 42% showed either downgrading or no residual tumour, with 81% having Gleason scores of <7. After a median follow-up of 47 months, one patient is receiving hormonal therapy because of biochemical relapse. Conclusion Subsequent to stringent PSA testing and prostate biopsy when indicated, the rate of incidental prostate cancer is low. Furthermore, substantially many patients will harbour either no residual cancer or tumours with favourable characteristics in their RP specimens. However, there is currently no possibility to reliably predict the absence of aggressive prostate cancer after TURP, and thus safely recommend observation instead of further therapy. Therefore, patients with incidental prostate cancer need to be counselled individually. The decision 'treatment or no treatment' should be determined by the patients' age and life-expectancy, tumour aggressiveness in the TURP specimen and the prostate-specific antigen level after TURP.

Radical prostatectomy for incidental (stage T1a-T1b) prostate cancer: analysis of predictors for residual disease and biochemical recurrence

BACKGROUND

Controversies exist about the most appropriate management for patients with incidental prostate cancer after surgery for benign prostatic hyperplasia (BPH).

OBJECTIVES

To test the accuracy of preoperative clinical variables in predicting the presence of residual disease and biochemical recurrence in patients with incidental prostate cancer treated with radical retropubic prostatectomy.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed 126 T1a-T1b prostate cancers diagnosed at surgery for BPH between 1995 and 2007.

INTERVENTION

All patients underwent radical retropubic prostatectomy within 6 mo of surgery for BPH.

MEASUREMENTS

Univariate and multivariate logistic regression models addressed the association between the predictors (age, prostate-specific antigen [PSA] before and after surgery for BPH, T1a-T1b stage, prostate volume, and Gleason score at surgery for BPH) and the presence of residual cancer at radical retropubic prostatectomy. Cox proportional hazards regression analyses tested the relationship between the same predictors and the rate of biochemical recurrence after radical retropubic prostatectomy.

RESULTS AND LIMITATIONS

Seventy-five (59.5%) patients were stage T1a and 51 (40.5%) were stage T1b. At radical retropubic prostatectomy, 21 (16.7%) patients were pT0 and seven (5.6%) patients had extraprostatic disease (pT3). PSA before and after surgery for BPH and Gleason score at surgery for BPH were the only independent predictors of residual cancer at radical retropubic prostatectomy (all p<0.04). Stage (T1a vs T1b) did not predict residual cancer or the rate of biochemical recurrence. With a mean follow-up of 57 mo, the 5- and 10-yr biochemical recurrence-free survival rates were 92% and 87%, respectively. PSA after surgery for BPH and Gleason score at surgery for BPH were the only significant multivariate predictors of biochemical recurrence (all p<0.04). The main limitation of this study is the requirement of an external validation before implementation of the clinical recommendations.

CONCLUSION

PSA measured before and after surgery for BPH and Gleason score at surgery for BPH were the only significant predictors of the presence of residual cancer at radical retropubic prostatectomy. PSA measured after surgery for BPH and Gleason score at surgery for BPH were the only independent predictors of biochemical recurrence after radical retropubic prostatectomy.

Predictive Factors for Progression in Patients with Clinical Stage T1a Prostate Cancer in the PSA Era

OBJECTIVE

In the literature, most data regarding the outcome of patients with clinical stage T1a prostate cancer were established before the prostate-specific antigen (PSA) era. The aim of our study was to determine the predictive factors of progression in patients with T1a prostate cancer diagnosed in the PSA era.

METHODS

Consecutive patients (n=144) with newly diagnosed T1a prostate cancer (tumor involving < or =5% of the resected prostatic tissue) were included. None of them was treated before evidence of tumor progression confirmed by prostate needle biopsies. The associations between tumor characteristics and time to cancer progression were assessed using Cox regression analysis.

RESULTS

With a mean follow-up of 5.1 yr, 30 patients (21%) experienced cancer progression. Five adverse parameters were significantly associated with cancer progression: preoperative PSA> or =10 ng/ml, postoperative PSA> or =2 ng/ml, prostate weight > or =60 g, weight of resected tissue > or =40 g, and Gleason score> or =6. The 5-yr progression rate was 12% if fewer than two of these parameters were present, whereas it was 47% if two or more parameters were present (p<0.001).

CONCLUSION

In the PSA era the risk of progression associated with T1a prostate cancer can be predicted using five criteria, and two groups of patients can be defined. The patients at low risk of progression may be good candidates for surveillance. In those with a high risk of progression, a more aggressive treatment should be discussed.

Subclassification of clinical stage T1 prostate cancer: impact on biochemical recurrence following radical prostatectomy

PURPOSE

We investigated biochemical outcomes following radical prostatectomy across subclassifications of clinical stage T1 prostate cancer.

MATERIAL AND METHODS

Of 8,658 men who underwent radical prostatectomy for clinical stage T1 prostate cancer 85, 156 and 8,417 had clinical stage T1a, T1b and T1c disease, respectively. Age, race, prostate specific antigen, year of surgery and preoperative Gleason scores were compared across clinical stage T1 subcategories. Time to prostate specific antigen recurrence was compared among groups using Kaplan-Meier and Cox hazards modeling.

RESULTS

Patients with clinical stage T1a prostate cancer had more favorable postoperative pathological features, including lower prostatectomy Gleason scores (p <0.001), rates of extraprostatic extension (p <0.001), lymph node invasion (p <0.001) and positive surgical margins (p = 0.006). Patients with T1a cancer also showed significantly lower rates of biochemical recurrence on Kaplan-Meier analysis than men with T1b and T1c disease (log rank 0.006). Cox regression analysis adjusted for known predictors of biochemical recurrence demonstrated that clinical tumor stage in the subgroup of patients with T1 disease was not an independent predictor of biochemical recurrence (p = 0.321).

CONCLUSIONS

Men with clinical stage T1a prostate cancer who undergo radical prostatectomy have significantly lower biochemical recurrence rates than men with stage T1b or T1c disease. However, subclassification of tumors in this group of patients was not an independent prognostic factor for biochemical recurrence after accounting for preoperative variables, including prostate specific antigen and Gleason score.

[Incidental carcinoma of the prostate: can we and should we recommend radical prostatectomy?]

INTRODUCTION

There is controversy regarding tumor control of incidental prostate cancer (PC). We evaluated in a large cohort if we can recommend radical prostatectomy after TURP.

MATERIAL AND METHOD

In 52 (4.3%) from a total of 1207 patients undergoing radical prostatectomy the diagnosis had been made by TURP. In a retrospective analysis we evaluated morbidity, histopathological results, and tumor control of pT1a/b tumors.

RESULTS

The number of incidentally detected PC decreased with time. In 5.8% in the TURP group and in 0.5% of the needle biopsy group, there was no residual tumor found (p<0.001). Morbidity was similar +/- TURP with the exception of operation time (206 vs 188 min) and catheter duration (19.3 vs 17.3 days). Postoperative continence was identical. There was no difference in tumor control for local recurrence-free survival and PSA-free survival with and without TURP.

CONCLUSIONS

The rate of incidentally detected PC by TURP decreases over time, but in almost all cases we found clinically relevant cancer. TURP is not an adverse prognostic factor and morbidity is similar compared with patients who were diagnosed by needle biopsy. Our data confirm that we should recommend radical prostatectomy to patients who are candidates for further curative therapy.

Predictors of cancer progression in T1a prostate adenocarcinoma

BACKGROUND

The biologic behavior of T1a prostate adenocarcinoma is variable. A critical issue in the management of patients with T1a prostate adenocarcinoma is to distinguish those who will develop cancer progression from those who will not. Predictive factors that identify those at high risk of cancer progression are needed to stratify patients for treatment. In the current study the authors attempted to identify such predictors of cancer progression in a large series of untreated patients with lengthy follow-up.

METHODS

The authors studied 102 patients who were diagnosed with T1a prostate adenocarcinoma (incidental tumor involving < or = 5% of the resected prostatic tissue) at the time they underwent transurethral resection of the prostate (TURP) at the Mayo Clinic between 1960-1970. None of these patients were treated. Patient ages ranged from 48-91 years (mean +/- standard deviation, 69 +/- 7 years). The average weight of the resected prostate tissue was 24 +/- 18 g (range, 3-115 g; median, 18 g). Tumor volume was measured by the grid method. Cox proportional hazards models were used to identify factors associated with cancer progression. Survival curves were estimated using the Kaplan-Meier method.

RESULTS

Five-year and 10-year progression free survival rates were 93% and 87%, respectively. During the mean follow-up of 9.5 +/- 6.8 years (range, 0.3-31 years; median, 9.0 years), 14 patients developed clinical cancer progression, including 5 patients with systemic progression (1 with distant metastases and 4 who died of prostate adenocarcinoma). The interval from diagnosis to clinical cancer progression ranged from 1-23 years (mean, 7.3 years). The amount of resected prostate tissue (TURP weight) was associated with progression (P = 0.04). Patients with a TURP weight > or = 30 g had 100% progression free survival at 10 years compared with a progression free survival rate of 73% in patients with a TURP weight < 12 g. Gleason score, tumor volume, number of chips involved by tumor, number of tumor foci, and the presence of high grade prostatic intraepithelial neoplasia were not significant in predicting cancer progression. There was a trend toward a worse prognosis with the increasing number of chips involved by cancer (P = 0.16). Patients with < 3 chips involved by cancer had a 88% 10-year progression free survival rate compared with 73% in patients with > or = 3 chips involved by cancer.

CONCLUSIONS

The clinical course of T1a prostate adenocarcinoma is variable. If left untreated, a small but significant proportion of patients are at risk for disease progression and death. However, the current study found that patients with a TURP weight > or = 30 g have an excellent prognosis and can be managed conservatively.

Follow-up of localized prostate cancer, with emphasis on previous undiagnosed incidental cancer

OBJECTIVE

To determine the natural course of incidental untreated transition zone prostate cancer and thus help to identify criteria to predict the prognosis and to determine treatment for individual patients.

MATERIALS AND METHODS

A total of 1135 unselected surgical specimens of the prostate, examined during 1974 and 1975, were reviewed while unaware of case by two experienced pathologists. The patients from which the samples were obtained were followed for up to 20 years or death by The Cancer Registry of Norway and the outcome compared with the histological review.

RESULTS

The histology review revealed a total of 311 cancers, of which 73 had not been initially recorded; these patients had received no treatment. The kappa coefficient for interobserver reproducibility was 0.86 for carcinoma. The follow-up showed that patient age was the strongest predictor of survival, followed by histological grade and percentage of tumour involvement. Only two of the 73 patients with untreated transition zone cancer died from prostate cancer during the follow-up, compared with 78 of 144 patients with standard management of transition zone tumours. The 5- and 10-year relative survival rates for the 144 patients with standard management of transitional zone tumours and for the 53 patients with peripheral zone tumours were 56% and 26%, and 45% and 33%, respectively. Metastasis (+ or -) was the only individual prognostic factor in the multivariate analysis.

CONCLUSION

This study shows that patients with incidental low-grade tumours have a low probability of dying from prostate cancer and may thus be followed expectantly. The biological distinction between atypical hyperplasia and stage T1a cancer is unclear. The survival of men with prostate cancer is significantly reduced with loss of differentiation and with increasing tumour volvement.

Expectant management of stage A-1 (T1a) prostate cancer utilizing serum PSA levels: a preliminary report

BACKGROUND AND OBJECTIVES

The natural history of stage A-1 (Tla) prostate cancer remains unpredictable. Although stage A-1 (Tla) was traditionally considered an indolent lesion, recent reports have documented the potential progression of stage A-1 (Tla) cancer.

METHODS

Eight men aged 65 to 76 years at the time of diagnosis with stage A-1 (Tla) prostate cancer received no therapy. These men have been followed from 3 to 9.5 years (mean, 6.25 years). During this period, the patients have been followed with periodic rectal examinations and prostate-specific antigen (PSA) levels.

RESULTS

The PSA levels of five of the eight patients remain in the normal range and no patient has had a change in his rectal examination. In the three patients who had elevated PSA levels, there was no evidence of metastatic disease. No patient has died from prostate cancer; one patient died from cerebrovascular causes.

CONCLUSIONS

Patients with stage A-1 (Tla) prostate cancer have an unpredictable natural history. PSA levels can be used to monitor disease progression and identify those patients where observation is no longer appropriate.

Evaluating early-stage prostate cancer. What pretreatment criteria best guide therapeutic decision making?

Although much has been learned about clinically localized PCa, no single prognostic parameter has been identified that is uniquely reliable in assessing prognosis. The best approach to the newly diagnosed PCa patient remains unchanged: to review all the clinical, radiologic, and histopathologic findings together. In combination, the serum PSA level and the histologic features of a tumor on biopsy can be used to predict the likelihood that a tumor is organ-confined or has spread beyond the gland. By this approach, some patients may be placed into a low-risk category for which "watchful waiting" may be a reasonable option. For other patients, the benefit from this approach is in making more informed decisions concerning definitive therapy and/or the use of adjuvant therapy. The role of the surgical pathologist is to provide as much information as possible regarding the amount, location, and differentiation of tumor present in biopsy and TUR specimens. Prognostic interpretation of these histopathologic findings depends on good communication between pathologists and urologists, oncologists, and radiation oncologists, which remains a cornerstone in therapeutic decision making.

Radical prostatectomy for impalpable prostate cancer: the Johns Hopkins experience with tumors found on transurethral resection (stages T1A and T1B) and on needle biopsy (stage T1C)

We review the pathological findings of impalpable prostate cancer detected by transurethral resection (stages T1a and T1b) and needle biopsy (stage T1c). The short-term (4 years) and long-term (8 to 10 years) natural histories of untreated stage T1a prostate cancer are examined, as are options to follow patients expectantly. The findings on radical prostatectomy for stages T1a and T1b disease are reviewed and compared. Of the 64 cases of stage T1a disease 13 (20%) showed substantial tumor, including 7 with more than 1 cc of tumor, 5 with capsular penetration and 1 with a Gleason grade 4 + 5 = 9 tumor. Based on preoperative pathological parameters, one could not predict which cases had minimal versus substantial tumor. In a study from our institution that undertook complete histological examination of 39 radical prostatectomy specimens of stage T1b carcinoma, we found that all prostates contained residual carcinoma, 26% had capsular penetration and 10% had invasion of the seminal vesicles. When comparing morphometrically determined volumes of carcinoma with similar data from 56 patients with stage T2 carcinoma, stage T1b tumors were much more heterogeneous in grade, location and volume than were stage T2 lesions. Unless all 3 variables (grade, volume and location) were known, the final pathological stage of T1b cancers could not be predicted with confidence. Finally, we examined preoperative clinical and pathological parameters in 157 men with clinical stage T1c disease undergoing radical prostatectomy, and correlated these findings with pathological extent of disease in the surgical specimen in an attempt to identify a subset of patients with potentially biologically insignificant tumor who might be followed conservatively. Of the tumors 16% were insignificant (less than 0.2 cc, organ confined and Gleason grade less than 7), 10% were minimal (0.2 to 0.5 cc, organ confined and Gleason grade less than 7), 37% were moderate (more than 0.5 cc or capsular penetration with Gleason sum less than 7) and 37% were advanced (capsular penetration with Gleason sum 7 or more, or positive margins, positive seminal vesicles or positive lymph nodes). These findings are intermediate between those found in clinical stages T1a and T2 disease. The best model predicting insignificant tumor was a prostate specific antigen (PSA) density of less than 0.1 and no adverse pathological finding on needle biopsy or PSA density of 0.1 to 0.15 with less than 3 mm. low to intermediate grade cancer on only 1 needle biopsy core. The positive predictive value of the model was 95% with a negative predictive value of 66%.(ABSTRACT TRUNCATED AT 400 WORDS)

Is submission of remaining tissue necessary when incidental carcinoma of the prostate is found on transurethral resection?

We examined 151 entirely submitted transurethral resection of the prostate (TURP) specimens that showed incidental prostate cancer. Fifty-one (34%) showed > 15% involvement of the specimen by tumor; these were not reviewed because submission of more tissue would not convert these cases from stage T1b (> or = 5% of tumor) to stage T1a ( < 5% of tumor). Sixty-six cases (44%) that were totally submitted in < or = nine cassettes also were excluded because most laboratories would totally submit these specimens from the outset. The remaining 34 cases (22%) had < or = 15% tumor and required 10 or more cassettes for total submission. The first eight slides were reviewed and percentage of tumor involvement and grade was calculated. The remaining slides were then reviewed to see if the overall tumor percentage or grade changed. Because in one case the tumor grade was significantly increased in the remaining slides and of the infrequency with which more than eight cassettes needs to be submitted, we recommended submission of all remaining tissue in stage T1a lesions. There is no need to submit additional tissue in stage T1b lesions because the percentage will not decrease with greater sampling.

Stage T1A carcinoma of prostate

When presented with a post-TURP patient with pathologically confirmed Stage T1a disease, several points should be considered (Fig. 1). Is the patient's anticipated longevity and quality-of-life likely to be affected by the confirmed diagnosis? From current knowledge, men over the age of seventy or with co-morbid risk factors probably will not be adversely affected, and no treatment is required apart from expectant follow-up with semiannual DRE and serum PSA determinations. The group at risk seems to be the young patient with a Stage T1a tumor who is likely to survive more than ten years after the diagnosis. Data showing progression rates without treatment as high as 16-25 percent at eight to ten years seem to indicate the need for additional therapy. If the patient belongs to this category and is ready to pursue more aggressive treatment, reestablishing the diagnosis might be suggested, as well as an evaluation of the pre- and post-TUR PSA levels. This can be done by TRUS-guided biopsies of the prostate (or repeat TURP, which we regard as less preferable). If residual tumor is not found, we would counsel a "wait and see" approach. If subsequent tissue sampling identifies other than well-differentiated cancer or indicates the likelihood of more extensive cancer than the T1a staging, treatment would be suggested. If the restaging reveals some residual well-differentiated disease that would not alter the initial staging of T1a, the patient should be offered the alternatives of close monitoring, radical prostatectomy, or radiation therapy. Until prognostic factors such as DNA ploidy and nuclear roundness are better studied, we are unable to counsel the patient on the biologic significance/aggressiveness of his Stage T1a disease.

Diagnosis, prognosis and management of incidentally found prostate cancer

Incidentally discovered cancer of the prostate may be divided into focal and diffuse disease. The focal tumour tends to be of low grade and low-volume and in the majority of patients runs a clinically benign course. In 10-15% of untreated patients, however, progression occurs by 10 years after diagnosis. At the same stage of follow-up 30-63% of the patients have died of other causes, with no evidence of recurrence. In patients with low-grade focal cancer of the prostate, radical prostatectomy may be curative. An alternative management option is to closely observe these patients. Digital rectal examination, prostatic specific antigen, transrectal prostatic ultrasound and repeated prostatic biopsies can all make contributions to the follow-up of these patients.

Cancer detected incidental to simple prostatectomy (stage A1)

The incidence of stage A (incidental) adenocarcinoma of the prostate in transurethral resection (TUR) specimens is approximately 16%. This paper discusses the criteria for differentiating stage A1 versus stage A2 tumor, based on tumor volume and grade. Both the short-term (4 year) and long-term (8-10 year) natural history of untreated stage A1 prostate cancer are examined. Options to follow patients expectantly are presented. These include digital rectal examination and transrectal ultrasound. Specific problems relating to analyzing transrectal ultrasounds in patients who have had a prior TUR are addressed. Also, the unique aspects of transrectal ultrasound for stage A1 disease as it relates to the location of the lesion are expanded upon. The third option in the management of stage A1 disease is to monitor serum prostate specific antigen (PSA) levels. Areas covered include the sensitivity and specificity of PSA in general, and, in specific, serum PSA levels following TUR for stage A1 disease as a predictor of residual tumor. New data on a small group of patients who underwent delayed radical prostatectomy following diagnosis of stage A1 disease, where PSA data was available, are presented. The rationale for following patients with stage A1 disease by monitoring their serum PSA levels is supported by data from a group of men with normally sized prostates, benign prostatic hyperplasia, or cancer where longitudinal serum PSA levels were available. Finally, the option of radical prostatectomy for stage A1 disease is put forth. Data include a study of a large group of radical prostatectomy specimens performed for stage A1 disease.(ABSTRACT TRUNCATED AT 250 WORDS)