Rectal examination in volume determination of carcinoma of the prostate: clinical and anatomical correlations

The Added Value of [18F]Choline PET/CT in Low-Risk Prostate Cancer Staging: A Case Report

In the management of prostate cancer (PCa), correct staging is crucial in order to assess the right therapeutic approach. [18F]Choline PET/CT has been shown to provide more accurate staging information than conventional imaging approaches. The aim of this paper is to provide a real practice demonstration of the impact of [18F]Choline PET/CT on low-risk prostate cancer staging and clinical management. We report a 64-year-old man with biochemical PCa recurrence diagnosis after transurethral resection of the prostate. The patient, after the detection of an increased level of PSA, underwent multi-parametric prostate magnetic resonance imaging (mpMRI) that did not show evidence of disease. The patient was admitted to perform [18F]Choline PET/CT that showed a macroscopic prostate recurrence. Patient underwent photon external beam radiation therapy (EBRT) treatment, and [18F]Choline PET/CT was also used to define treatment volumes. At 3- and 6-month clinical follow-up evaluations, no late toxicity was detected and a significant reduction in PSA value was shown. Therefore, our case highlights the potential usefulness of [18F]Choline PET/CT for the staging of low-risk prostate cancer and its impact on the management and quality of life of such patients. The presented case should urge the scientific community to enhance larger and multicentric studies, assessing more extensively the potential impact of [18F]Choline PET/CT in this clinical scenario.

Role of MRI in planning radical prostatectomy: what is the added value?

INTRODUCTION

The goal of radical prostatectomy is to eradicate oncological disease while achieving the best possible functional outcomes. In this regard, nerve sparing offers a greater chance of recovering potency after surgery. Accurately locating prostate cancer foci is instrumental for identifying good candidates for this approach whilst maintaining safe oncological margins. In addition to this, the length of membranous urethra is an independent predictor of time to, and extent of, continence recovery. The introduction of Mp-MRI allows visualising malignant tissue within the prostate gland, which could lead to image-directed surgery planning as with other solid-organ cancers such as kidney, pancreas, breast or testes.

METHODS

A narrative review of the available literature was performed.

RESULTS

Mp-MRI demonstrated moderate sensitivity and high specificity to detect extra-capsular extension, seminal vesicle involvement or T3 stage. Measurements of membranous urethral length have shown to be useful in predicting probability of achieving continence after surgery. Furthermore, image-guided surgery has shown to be accurate to determine surgical planes to safely preserve neurovascular bundles.

CONCLUSION

The use of Mp-MRI for pre-surgical planning introduces a new scenario where the previously homogeneous radical prostatectomy can be tailored to suit patient and tumour features. This has the potential to improve functional outcomes whilst not compromising on surgical margins. Moreover, the introduction of Mp-MRI increases the ability to predict functional outcomes after surgery and allows for a more accurate local staging. This in turn provides more information to both patients and clinicians in the decision-making process regarding treatment.

Impact of multiparametric magnetic resonance imaging on risk group assessment of patients with prostate cancer addressed to external beam radiation therapy

PURPOSE

To investigate the impact of multiparametric magnetic resonance imaging (mpMRI) on risk group assessment of patients with prostate cancer (PCa) initially addressed to external beam radiation therapy (EBRT).

MATERIALS AND METHODS

We prospectively performed mpMRI (3.0Tsystem) in 44 patients addressed to EBRT, using a multiparametric protocol (high-resolution multiplanar T2-weighted, diffusion-weighted and dynamic contrast-enhanced imaging). Risk group was assessed in accordance with the National comprehensive cancer network (NCCN) categories, by combining prostate-specific-antigen level, Gleason score and the T-stage as established by digital rectal examination (clinical risk assessment; c-RA) versus mpMRI (mpMRI-risk assessment; mpMRI-RA). The agreement between c-RA and mpMRI-RA was investigated using Cohen's kappa.

RESULTS

Patients were included in very low/low risk, intermediate risk, high risk, very high risk and metastatic NCCN categories in 10 (22.7%), 18 (40.9%), 15 (34.1%), 1 (2.3%) and 0 cases using c-RA vs. 8 (18.2%), 14 (31.8%), 14 (31.8%), 4 (9.1%) and 4 (9.1%) cases using mpMRI-RA, respectively, with only moderate agreement (k=0.43). mpMRI-RA determined risk downgrading in 2/44 patients (4.5%), and risk upgrading in 16/44 patients (36.3%). After mpMRI, EBRT remained indicated in all patients.

CONCLUSION

mpMRI changed clinical risk stratification in about 41% of patients with PCa, with potential impact on EBRT planning.

Role of 3.0 T multiparametric MRI in local staging in prostate cancer and clinical implications for radiation oncology

PURPOSE

To evaluate the accuracy of preoperative 3T multiparametric magnetic resonance imaging (3TmMRI) for local staging of prostate cancer and its influence on the decision to change the clinical target volume (CTV), total dose and hormonal therapy when treating prostate cancer patients with radiotherapy.

METHODS

From 2009 to 2013, 150 patients, who had confirmed prostate cancer and underwent a 3TmMRI before treatment with radical prostatectomy or radical radiation therapy, were included. Radiation therapy treatment (CTV, total dose and hormonal therapy) was initially determined on the basis of the clinical information, and radiation therapy plan was reevaluated after 3TmMRI review. The value of preoperative 3TmMRI in local staging and in the decision of radiotherapy treatment according to NCCN risk classification was analyzed.

RESULTS

3TmMRI performed correct, over- and under staging in 78.7 % (37/47), 6.3 % (3/47), 14.8 % patients (7/47), respectively. 3TmMRI identified 6 cT2a, 7 cT2b, 28 cT2c, 3 cT3a, 3 cT3b tumors. At final pathology, 5 tumors were classified as pT2a, 5 as pT2b, 30 as pT2c, 4 as pT3a, 3 as pT3b. After reviewing the MRI reports, the initial radiotherapy and hormonal therapy plan was changed in 33.9 % patients (35/103).

CONCLUSIONS

In our group of patients, 3TmMRI has been a reliable technique providing an optimal staging for prostate cancer. Its routine use could induce important changes in radiation therapy treatments in a significant number of such patients. However, more additional studies are needed to clarify this issue.

Is there a role for routine pelvic magnetic resonance imaging in intermediate risk prostate cancer?

Objectives

To determine the role of staging pelvic magnetic resonance imaging (MRI) in men with intermediate risk prostate cancer.

Patients and methods

We identified all patients diagnosed with intermediate risk (NICE definition: PSA 10-20 ng/ml, or Gleason score 7, or clinical stage T2b/T2c) prostate cancer between 1st January 2007 and 31st December 2008. Through retrospective case note review, we determined the number of patients who had undergone a pelvic MRI and whether such an investigation had altered the patient's management by increasing tumour stage.

Results

A total of 222 men (mean age 66 years; range: 48-88) were diagnosed with intermediate risk prostate cancer during our study period. The mean PSA was 11.8 ng/ml (range: 3-20 ng/ml). Of these, 112 (50.5%) underwent an MRI. Overall, in 25/112 (22.3%) patients, pelvic MRI findings impacted significantly upon patient treatment by demonstrating either extra-prostatic extension of cancer, lymph node involvement or bone metastases.

Conclusions

Our retrospective study has demonstrated that a pelvic MRI in men diagnosed with intermediate risk prostate cancer may influence treatment decision in approximately a quarter of patients. Routine pelvic MRI is indicated in men with intermediate risk prostate cancer where radical treatment is contemplated.

Defining prostate cancer risk before prostate biopsy

Prostate cancer is the most commonly diagnosed cancer in men. At present, patients are selected for prostate biopsy on the basis of age, serum prostate specific antigen (PSA), and prostatic digital rectal examination (DRE) findings. However, due to limitations in the use of PSA and DRE, many patients undergo unnecessary prostate biopsy. A further problem arises as many patients are diagnosed and treated for indolent disease. This review of the literature highlights the strengths and weaknesses of existing methods of prebiopsy risk stratification and evaluates promising serum, urine, and radiologic prostate cancer biomarkers, which may improve risk stratification for prostate biopsy in the future.

Is a digital rectal examination necessary in the diagnosis and clinical staging of early prostate cancer?

OBJECTIVE

To assess the role of a digital rectal examination (DRE) in the clinical diagnosis of prostate cancer and in predicting the pathological stage, as the diagnosis of early prostate cancer usually comprises prostate-specific antigen (PSA) testing, a DRE and transrectal ultrasonography (TRUS)-guided biopsies.

PATIENTS AND METHODS

Over the 4 years between 2000 and 2004, 408 consecutive patients (mean age 63.8 years) referred with age-specific PSA levels of 2.5-10.0 ng/mL and who had a TRUS-guided 12-core prostate biopsy were included in the study. They had a DRE by either of two experienced consultant urologists. The results of the DRE and core biopsy histology were compared with the histology and the radical prostatectomy specimen in a subset (82 men) of the study population.

RESULTS

Cancer was detected on biopsy in 152 patients; of the 196 with an abnormal DRE, 47% had cancer on biopsy. In the patients with a normal DRE, 59 cancers were detected. Men with cancer were older and had a higher median PSA level. There was no correlation between the DRE and biopsy findings, and none between an abnormal DRE and histological diagnosis of cancer. Of the patients who had a radical prostatectomy, 38% had a normal DRE.

CONCLUSION

There was no correlation between the DRE, biopsy findings and pathological staging. The DRE did not contribute to managing patients with prostate cancer, but this does not mean that there is no longer a place for the DRE in assessing the urological patient. If patients are appropriately counselled before PSA testing, a DRE may not be essential for patients with a PSA level of 2.5-10 ng/mL.

Prediction of pathological tumor volume in clinically localized prostate cancer: value of endorectal coil magnetic resonance imaging

The purpose of this study was to determine whether endorectal coil magnetic resonance imaging (MRI) enables accurate assessment of pathologic tumor volume in patients with clinically localized prostate carcinoma. Twenty-four patients with biopsy-proved prostate carcinoma underwent MRI at 0.5 T before radical prostatectomy. Tumor volumes were determined independently on axial fast-spin-echo (SE) T2-weighted MR images and whole-mount pathology slides of the surgical specimens. At pathology, tumor volumes ranged from 0.17 to 9.42 cm3 (mean +/- SD, 3.11 +/- 2.99 cm3). A strong correlation (r = .944) was found between measurements of tumor volume based on MR images and pathological specimens. The error was less than 0.5 cm3 in 14 cases, in the range of 0.5-1 cm3 in 7 cases, and more than 1 cm3 in 3 cases. By using an MR tumor volume of 2 cm3 as cutoff value, extracapsular tumor spread could be predicted with a sensitivity of 81.2%, a specificity of 100%, and an accuracy of 87.5%. Tumor volume determinations based on MR images seem to be accurate enough to be helpful in clinical decision-making.

Can screening for early-stage prostate cancer be rationalized?

Prostate-specific antigen (PSA)-based screening identifies prostate cancer at an earlier stage than digital rectal examination alone. The widespread use of PSA as a screening tool has led to a marked increase in the incidence of prostate cancer and an apparent shift toward the diagnosis of earlier stage disease. Proof that PSA-based screening results in a reduction in prostate cancer-related mortality is lacking currently. Therefore, insufficient data are available to determine whether a general screening strategy should be adopted for detecting early-stage prostate cancer. Patients at average risk should be educated about the value of PSA testing. Patient groups at high risk should be the targets of aggressive screening initiatives.

Optimization of prostate carcinoma staging: comparison of imaging and clinical methods

PURPOSE

The diagnostic value of endorectal coil MRI, body coil MRI, transrectal ultrasound, digital rectal examination and PSA levels were prospectively analysed in order to define the most accurate preoperative staging method.

METHODS

33 patients with prostate carcinoma, who underwent subsequent prostatectomy, were enrolled in the study and examined on a 1.5T system using the body coil as well as the endorectal surface coil before and after the administration of contrast material. The results were compared to digital rectal examination, prostate specific antigen levels and endorectal ultrasound.

RESULTS

Staging accuracy of endorectal coil MRI was 87.9% with a sensitivity of 88.9% and specificity of 86.7%. For body coil MRI, the staging accuracy was 75.7%, the sensitivity 66.7% and the specificity 87.9%, for transrectal ultrasound 69.6%, 41.7% and 100% and for the digital rectal examination 56.6%, 33.3% and 100%, respectively. Prediction was improved by combining results of endorectal coil MRI with PSA values.

CONCLUSION

Endorectal ultrasound and digital rectal examination both had a tendency to underestimate the extent of the lesion. Endorectal coil MRI proved to be the best preoperative staging method. In combination with PSA values, diagnostic accuracy could be further improved. Therefore, local staging of prostate cancer could be based on these two parameters alone.

Computer simulation of the probability of detecting low volume carcinoma of the prostate with six random systematic core biopsies

OBJECTIVES

Six random systematic core biopsies (SRSCB) of the prostate (biopsies from apex, middle, and base of each lobe) have been commonly used in detection of prostate carcinoma. The objective of this study was to verify the validity of the SRSCB technique in detecting cancer in prostates with low-volume tumor (less than 6 cc).

METHODS

We developed a computer model of the prostate to simulate the SRSCB technique. The data for development of this model were taken from 159 radical prostatectomy specimens in which 112 patients had tumor volumes measured and in which 91 prostates had tumors with volumes less than 6 cc (by whole-mount sectioning).

RESULTS

The simulation shows that only 20.3% of the simulated prostates, with total aggregate tumor volume between 0.034 and 5.1 cc, had a tumor distribution for which the SRSCB technique has a 95% probability of detecting the tumor. In fact, 26.8% had a tumor distribution that was completely disjointed from the six recommended biopsy regions. To compare these results with other possible occurrence, various biases for the angle of biopsy and the distribution of cancer foci were incorporated into the model. Study results should be viewed with the understanding that any simulated model has its limitations. In our simulated model, the shape of the simulated tumor foci (spherical) does not represent all the possible shapes of prostate cancer. However, these results indicate that detection of cancer with biopsies taken from the apex, middle, and base of each lobe of a prostate with tumor volumes of less than 6 cc may not be as effective as it is in prostates with larger tumor volumes or patients with an abnormal digital rectal examination. The study of bias models suggests that the distributional pattern of cancerous foci can have a significant impact on the effectiveness of a given biopsy strategy.

CONCLUSIONS

We concluded that future attempts to improve systematic biopsy strategies for detection of low-volume cancer should include biomechanical characteristics of prostate cancer, including gland volume and tumor distribution. Driven by the conclusions from this idealized model, we have developed a three-dimensional model of the prostate gland from its whole-mount histologic maps. It is anticipated that this continuing investigation will lead to realistic guidelines for improving biopsy techniques.

Prediction of prostate cancer volume using prostate-specific antigen levels, transrectal ultrasound, and systematic sextant biopsies

OBJECTIVES

Prostate-specific antigen (PSA) levels, transrectal ultrasound, and systematic sextant biopsies have each shown limited ability to predict prostate cancer volume. In combination, these studies may allow more accurate estimation of volume and prognosis.

METHODS

One hundred twenty-four patients were evaluated prior to radical prostatectomy. Interactive stepwise multiple regression and separate logistic regression analysis were performed for prediction of prostate cancer volume and volume range.

RESULTS

The cancer volumes calculated correlated with the volumes in the radical prostatectomy specimens with R2 of 0.76. Cancers were predicted to be in the volume range associated with poor prognosis (more than 12 cc) or clinically insignificant cancer (less than 1.0 cc) with bias corrected error rates of 5.3% and 10%, respectively.

CONCLUSIONS

The formula for prediction of cancer volume correlates well with actual cancer volume in 92 patients but is not adequate to predict volume for an individual patient. The formulas for prediction of volume range show promising predictive ability and may be useful if the extent of disease is unclear.

Pretreatment of metastatic disease. Prostate cancer in the older male

Prostate cancer is a disease of older men, with more than 80% of cases being diagnosed in men 65 years of age and older. Broader participation in screening and early detection programs has resulted in many diagnoses being made earlier in the course of the disease. However, an estimated 25-30% of cases among older men will be diagnosed as metastatic disease. These will be men initially diagnosed with metastatic disease as well as men previously treated for localized disease that has progressed to metastatic disease. The treatment of metastatic prostate cancer has been straightforward. Objective prognostic factors are assessed, and recommendations for the most suitable hormonal therapy are made. Androgen withdrawal, androgen blockade, or combination therapy are current first-line treatment modalities. Patients with good prognostic factors will generally do well for a long time, even experiencing a time-limited remission. Patients with a poor prognosis will die of their disease, with median survival being 18 months. Pretreatment assessment of men diagnosed with metastatic prostate cancer should include prognostic factors (tumor volume, histologic grade, DNA ploidy, and prostate specific antigen), health status (comorbidity and performance status), quality of life factors (as a baseline against which to evaluate subjective response and to predict subjective progression), and psychosocial dimensions (sexuality and sexual function, self image, sociability, and social support). Each of these assessment areas will provide important predictors for suitable treatment, response and progression, and survival. The challenge presented is the time and difficulty involved in weighing all these areas and in making an informed physician-patient decision on the most appropriate treatment plan. The physician must direct a health care team to treat metastatic prostate cancer effectively. This team includes oncology nurses, dietitians, social workers, spouses, significant others, and the patient himself.

Detection of microscopic extracapsular extension prior to radical prostatectomy for clinically localized prostate cancer

OBJECTIVE

To assess better techniques of clinical staging to identify the presence and location of extracapsular extension (ECE) and assist the surgeon in the selection of candidates for resection or preservation of neurovascular bundles during radical prostatectomy.

PATIENTS AND METHODS

In a retrospective review of the records of 117 patients with clinically localized (31 T1 and 86 T2) prostate cancer treated with radical prostatectomy the results of digital rectal examination (DRE), real-time transrectal ultrasound (TRUS) and a retrospective review of static films were compared to assess their accuracy in the detection of ECE. The ultrasonic criterion for ECE was bulging or irregularity of the boundary echo adjacent to a hypoechoic lesion. On DRE, the criterion for ECE was palpable bulging of a nodule beyond the normal contour of the prostate. The reference standard was the presence and location of ECE in the whole-mount, serially sectioned radical prostatectomy specimens.

RESULTS

Microscopic ECE was present in 64 of the specimens (55%). There was no significant difference between DRE, prospective TRUS and retrospective TRUS in the overall accuracy of detection of ECE. However, when the results of DRE and TRUS were combined (if either was positive the result was considered positive), the positive predictive value (PPV) was 79% and the sensitivity (91%), with the overall accuracy increased significantly (P < 0.05).

CONCLUSION

The presence and precise location of microscopic ECE can be determined pre-operatively with reasonable accuracy using real-time ultrasound combined with the results of DRE.

The role of radical surgery in the treatment of prostatic cancer

At present, prostatic cancer is the most common malignancy in men in many Western countries and its incidence is continuously increasing. Radical prostatectomy has been used for over 80 years, but there is still controversy about its role in the treatment of localized prostatic cancer. Because of insufficient knowledge of the natural history of prostatic cancer and a lack of accurate prognostic factors there are possibilities for both over- and undertreatment. Better staging methods are also required to discriminate between intra- and extracapsular tumours, which is essential for curative treatment. On the basis of the facts mentioned above and because of the poor sensitivity and specificity of transrectal palpation, ultrasound examination and prostate-specific antigen, which are used in screening, diagnosing and staging of prostatic cancer, screening is not yet recommended for the detection of early prostatic cancer.

Observations on the doubling time of prostate cancer. The use of serial prostate-specific antigen in patients with untreated disease as a measure of increasing cancer volume

BACKGROUND

The serum marker prostate-specific antigen (PSA) has been shown to be proportional to the volume of prostate cancer (Yang polyclonal assay). One gram of cancer on average produces 3.5 ng/ml of PSA elevation. Thus, changes in PSA in untreated patients should reflect tumor growth rate and the shape of the growth curve.

METHODS

Forty-three patients with previously untreated prostate cancer had serial PSA determinations during a period of at least 12 months (mean, 30 months; range, 12-63 months). There was no treatment between the initial and final PSA. PSA was measured five or more times in half of these patients. Log-PSA values were plotted versus time, tested for linearity, and compared between different clinical stages and histologic grades.

RESULTS

PSA values increased with time in 86% of patients but remained stable in 14%. The increase of PSA was exponential (log-linear) throughout the measured interval. Doubling times were faster in patients with higher disease stages and grades. Seventy-nine percent of all patients had a doubling time of more than 24 months. Twenty of 28 cancers thought to be clinically organ confined doubled at rates exceeding 48 months. Tumor doubling times were overestimated in patients with large-volume benign prostatic hyperplasia because hyperplasia increases serum PSA at an average rate of 0.3 ng/ml.

CONCLUSIONS

The authors conclude that prostate cancer has a constant (log-linear) growth rate that is very slow. This extraordinarily slow doubling time has substantial consequences for therapeutic decisions and for screening programs.

Serum prostate specific antigen as pre-screening test for prostate cancer

Prostate cancer has become the most common cancer and the second cause of death due to cancer in men in North America. Since curative therapies are limited to early stages of the disease, the availability of an efficient, easy to perform, widely acceptable and cost-effective method of early detection of prostate cancer is particularly important. Thus, digital rectal examination, transrectal ultrasonography of the prostate as well as measurements of serum prostate specific antigen (PSA) were performed independently in a series of 1,002 men between 45 and 80 years old randomly selected from the electoral rolls of Quebec City and its vicinity as part of a screening program for prostate cancer. Using this population of randomly chosen men, various cutoff serum PSA values were selected in an attempt to find the optimal decision threshold that would indicate a much greater risk of having prostatic cancer. At a threshold value of 3.0 micrograms./l. the sensitivity and specificity of the test are 80.7 and 89.6%, respectively, while the area under the receiver operating characteristic curve reflecting the accuracy of the test is 87.8 +/- 3.3% (plus or minus standard deviation). Moreover, the negative predictive value was estimated at 98.6%, thus leaving only a 1.4% chance of missing cancer when the serum PSA value was 3.0 micrograms./l. or less. Most importantly, such a threshold level of serum PSA retains only 19% of the whole cohort as candidates for transrectal ultrasonography and expensive diagnostic procedures, thus leading to the finding of 1 prostate cancer of 4 such examinations. The present data indicate that simple measurement of serum PSA can be used efficiently as a pre-screening test for prostate cancer in the general population to identify, at a low cost, the subpopulation of men at a much greater risk of having prostate cancer, and who should then be submitted to the more elaborate and expensive diagnostic procedures.

Early detection of prostate cancer

Prostate cancer is unique among the potentially lethal human malignancies in the wide discrepancy between the high prevalence of histologic changes recognizable as cancer and the much lower prevalence of the clinical disease. Despite the availability of effective tests for early detection and of effective treatment for cancers so detected, the diagnosis usually is not established until the tumor is locally advanced or metastatic. Yet, physicians hesitate to use these tests for fear that many cancers found would be latent, of little threat to the life or health of the host, and treatment could introduce inappropriate morbidity. Latent or "clinically unimportant" cancers can be distinguished from those that are clinically important by the larger volume, higher grade, and greater invasiveness of the latter. The available tests can detect only those cancers large enough to be palpable, visible on ultrasound, or capable of elevating the serum level of prostate-specific antigen. Such cancers are clinically important and should be treated for cure if the life expectancy of the patient is sufficiently long and the morbidity rate of therapy is low. Early detection of prostate cancer using the tests that are available today may widen the window of opportunity so that treatment indeed becomes possible in those for whom it is necessary.

Correlation between side of palpable tumor and side of pelvic lymph node metastasis in clinically localized prostate cancer

Of 411 patients with palpable but clinically localized (Stages B or C) adenocarcinoma of the prostate, 100 (24.3%) were found at complete bilateral pelvic lymphadenectomy to have one or more lymph nodes positive for metastasis. These patients were divided into five subgroups on the basis of the location of the palpable tumor at digital rectal examination: left side only, left predominantly, both sides, right side predominantly, or right side only. Among 35 patients with positive nodes and a palpable tumor limited to one side of the prostate (clinically unilobar), metastases were found in the ipsilateral pelvic lymph nodes in 29 (83%). Only 6 (17%) of the patients had contralateral metastasis alone. A unilateral pelvic lymphadenectomy (ipsilateral to the side of the largest palpable tumor, or on either side if the tumor were bilateral) would have detected 80% of the patients with positive lymph nodes, with a positive predictive value of 100% and a negative predictive value of 94%. Lymph node metastases in patients with clinically localized palpable prostate cancer are most likely to be found on the same side as the palpable tumor and are considerably less likely to be found on the contralateral side alone. If frozen section examination of lymph nodes or laparoscopic lymph node dissection is planned before definitive therapy for prostate cancer, the pelvic lymph nodes ipsilateral to the side of the palpable tumor should be removed first.

Transrectal ultrasonography in the staging of localized prostatic carcinoma. A pilot study

Transrectal ultrasonography (TRUS) was evaluated as a staging procedure in ten patients with localized prostatic carcinoma. The ultrasound images were correlated to histopathological whole-mount step sections of the surgical specimens after radical prostatectomy. Nine of the patients had pathological stage T3 (pT3) and only one was pT2. TRUS gave a diagnostic accuracy of 60% compared to 10% both for digital rectal examination (DRE) and computer tomography (CT) in detecting extracapsular tumor spread. We conclude so far that TRUS is superior to DRE and CT in detecting extracapsular tumor spread. Further we state that whole-mount step section of the surgical specimens is mandatory in order to achieve a correct pathological staging (pT-stage).

Preoperative prediction of pathological tumor volume and stage in clinically localized prostate cancer: comparison of digital rectal examination, transrectal ultrasonography and magnetic resonance imaging

Accurate preoperative staging is important for proper selection of patients for radical retropubic prostatectomy. Preoperative staging by digital rectal examination, transrectal ultrasound, magnetic resonance imaging (MRI), Gleason grade and prostate specific antigen was compared to pathological stage for 25 patients who underwent radical retropubic prostatectomy. The predictive value for tumor confinement was 36% by rectal examination, 37% by ultrasound and 30% by MRI. The predictive value for extracapsular disease was 100% by rectal examination, 83% by ultrasound and 66% by MRI. Preoperative determinations of tumor volume by any modality did not correlate with pathological tumor volume. Digital rectal examination, ultrasound and MRI clinically understage the disease in most patients but they may be reliable to predict extracapsular disease.

Case-control study of screening for prostatic cancer by digital rectal examinations

Although commonly thought to be an effective method of screening for prostatic cancer, digital rectal examinations have yet to be shown by controlled study to help prevent advanced forms of this disease. 139 men with metastatic (stage D) prostatic cancer (cases) were compared with an equal number of matched men free of this condition (controls), with respect to rectal examinations recorded in the medical records up to, on average, 23 years before the cases' initial diagnosis of prostatic cancer. Cases and controls were members of a large health maintenance organisation in northern California. In the 10 years before initial diagnosis (excluding the last three months) the average number of examinations for routine screening (2.45 vs 2.52) or to evaluate intestinal or rectal symptoms (0.44 in both) were similar in cases and controls, respectively. After adjustment for racial differences, the relative risk of metastatic prostatic cancer for men with one or more screening rectal examinations compared with men with none was 0.9 with a 95% confidence interval of 0.5-1.7. Screening by routine digital rectal examination appears to have little if any effect in preventing metastatic prostatic cancer. If there is a small benefit, it will be difficult to demonstrate by conventional epidemiological study.

Comparison of transrectal ultrasound and magnetic resonance imaging in the staging of prostate cancer

A group of 32 patients with a histological diagnosis of prostate cancer underwent transrectal ultrasound (TRUS) and magnetic resonance imaging (MRI) to stage the disease. TRUS was more sensitive in the detection of tumour and in the detection of direct extracapsular spread. MRI was more sensitive in the detection of tumour involvement of the seminal vesicles and bladder base. MRI allowed the detection of lymphadenopathy and bone metastases in the lumbosacral spine and pelvis. During MRI the short tau inversion recovery (STIR) sequence was found to be particularly useful for the detection of tumour spread. TRUS and MRI are complementary investigations and for the accurate staging of prostatic malignancy both investigations should be used.

Prostate cancer: transrectal ultrasound and pathology comparison. A preliminary study of outer gland (peripheral and central zones) and inner gland (transition zone) cancer

A study was conducted to compare results of transrectal ultrasound with pathologic findings on 116 patients who underwent radical prostatectomy for treatment of prostate cancer. In 96% (111 of 116), transrectal ultrasound guided biopsies of a hypoechoic lesion proved cancer; seven patients had known Stage A cancer; one patient had cancer detected by palpation and not detected by ultrasound. Cancers in the outer gland (peripheral and central zones) were compared with cancers in the inner gland (transition zone) by both ultrasound and pathology. Forty-eight percent (52 of 108) of cancers originating in the outer gland showed extraprostatic extension (Stage C disease). The primary sites of tumor escape from the outer gland were the prostatic capsule (38%), anterior fibromuscular stroma (5%), seminal vesicle (18%), the base of the gland at the neurovascular bundle (21%), and the apex (31%). Twenty-two percent (17 of 54) of cancers originating in the inner gland (transition zone) showed extraprostatic extension (Stage C disease). The primary sites of tumor escape from the inner gland were the anterior fibromuscular stroma (6%) and apex (11%). Both histologic and biologic differences between outer and inner gland cancers were found when tumor size was controlled. Gleason scores were significantly different for inner and outer gland cancers, with mean scores of 6.2 +/- 1.6 and 7.4 +/- 0.9, respectively. An odds ratio of 8.6 confirmed the increased risk of extraprostatic extension for outer gland cancer. Outer gland cancers showed increased aggressive behavior of both histologic and biologic nature. The difference in biologic aggressiveness of outer and inner gland cancers has definite implications for treatment options. Use of other diagnostic parameters, such as DNA ploidy, may help to determine which cancers to treat and when to treat them; this may have more relevance for cancers originating in the inner gland. Strategic transrectal ultrasound guided biopsy affords accurate tumor mapping and staging when modes of internal spread and escape of cancer from both outer and inner gland are known. Thus, transrectal ultrasound may be our "window of observation" through which additional research may explain the histologic and biologic discrepancies between outer and inner gland cancers.

DNA flow cytometry in carcinoma of the prostate for diagnosis, prognosis and study of tumor biology

Flow cytometry has been used to measure the cellular DNA content in fine-needle aspirates of a large number of patients with untreated prostate carcinomas. The tumors were subdivided into diploid, tetraploid aneuploid and non-tetraploid aneuploid with one or several aneuploid cell populations. The clinical relevance of this subdivision is supported by studies of the metastatic potential of the tumors and the outcome of the disease by follow-up of the patients. Changes were found in the proportion of the various ploidy classes with tumor stage. These were typical for the behavior of a 3-compartment system. Thus, the proportion of diploid tumors decreased exponentially with stage, that of the tetraploid-aneuploid tumors increased to maximum at intermediate stages, while the non-tetraploid aneuploid tumors increased exponentially after some delay. This strongly supports the concept of a continuous development of the prostate carcinoma from low grade to high grade connected with the doubling of the near-diploid genome of the tumor, and followed by successive loss of chromosomes from the near-tetraploid tumor. Further support of this concept is gained by the study of repeated fine-needle aspirates and the observation of coexisting diploid and aneuploid cell populations in the developing tumor. Clinical consequences of this concept are discussed.

Aspiration biopsy of the prostate gland: a brief review of collection, fixation, and pattern recognition with special attention to benign and malignant prostatic epithelium

The preparation and use of an alternate collection device for aspiration biopsy of the prostate is presented. The device is inexpensive and can be constructed from readily available office materials. Its use in conjunction with a liquid-phase collection of cellular products of aspiration biopsy by a backwash technique is described. Following this, a brief discussion of pattern recognition in cytological preparations of benign and malignant prostate epithelial aggregates is presented and illustrated.

Ultrasound guided transrectal core biopsies of the palpably abnormal prostate

Ultrasound imaging and ultrasound guided transrectal core biopsies were performed in 251 consecutive men with abnormal prostates on digital rectal examination. A hypoechoic defect on ultrasound was identified in 227 of 251 patients (90 per cent) corresponding to the area of palpable nodularity or abnormal firmness. A mean of 6.25 biopsies were obtained per patient using a commercially available spring-loaded gun. Biopsies were positive for cancer in 165 of the 251 prostates (66 per cent). Palpable nodules more often were hypoechoic and more often contained cancer than less distinct areas of abnormal firmness on digital examination. Among the clinical stages B1, B2 and B3 nodules 70, 76 and 88 per cent, respectively, were positive for cancer, as were 100 per cent of the clinical stage C prostates. Of 77 abnormally firm, nonnodular prostates 36 per cent were positive for cancer. Random biopsy of the contralateral normal lobe in 56 men with clinical stage B1 or B2 nodules showed cancer present contralaterally in 42 and 60 per cent, respectively; 20 per cent had positive biopsies despite a contralateral isoechoic ultrasound. In 78 patients with prior digitally guided biopsies, ultrasound guided biopsies confirmed previously diagnosed cancers in 94 per cent. However, in 23 of 43 patients (53 per cent) with previous negative digitally guided biopsies, ultrasound guided biopsies made the new diagnosis of cancer. Complications, including post-biopsy fever and bleeding, occurred in 6 of 251 patients (2.4 per cent). The combination of the new spring-loaded biopsy guns and transrectal ultrasound guidance of biopsies provides the urologist with a tool that allows multiple prostate cores to be obtained safely and painlessly, reducing the sampling error and increasing the accuracy in diagnosing prostate cancer in the man with a palpable abnormality of the prostate.

Prostate specific antigen in the diagnosis and treatment of adenocarcinoma of the prostate. II. Radical prostatectomy treated patients

Serum prostate specific antigen was determined (Yang polyclonal radioimmunoassay) in 102 men before hospitalization for radical prostatectomy. Prostate specimens were subjected to detailed histological and morphometric analysis. Levels of prostate specific antigen were significantly different between patients with and without a Gleason score of 7 or greater (p less than 0.001), capsular penetration greater than 1 cm. in linear extent (p less than 0.001), seminal vesicle invasion (p less than 0.001) and pelvic lymph node metastasis (p less than 0.005). Prostate specific antigen was strongly correlated with volume of prostate cancer (r equals 0.70). Bivariate and multivariate analyses indicate that cancer volume is the primary determinant of serum prostate specific antigen levels. Prostate specific antigen was elevated 3.5 ng. per ml. for every cc of cancer, a level at least 10 times that observed for benign prostatic hyperplasia. Prostate specific antigen is useful as a preoperative marker because no patient with lymph node metastasis had serum levels of less than 10 ng. per ml. (4 times the upper limit of normal range). Of the patients with greater than 50 ng. per ml. two-thirds had microscopic lymph node metastasis and 90 per cent had seminal vesicle invasion. Serum prostatic acid phosphatase levels showed a significantly weaker correlation with cancer volume (r equals 0.51) and every other pathological parameter. Of the patients 73 per cent had serum prostatic acid phosphatase levels in the normal range (0 to 2.1 ng. per ml.), including 7 per cent who had pelvic lymph node metastasis. Postoperative prostate specific antigen values were available in 97 of 102 patients, with a mean and maximum followup of 12 and 38 months. No patient with pelvic lymph node metastasis achieved an undetectable prostate specific antigen level without adjunctive therapy (hormonal or radiation). No difference in preoperative or postoperative prostate specific antigen levels, cancer volume, seminal vesicle invasion or incidence of pelvic lymph node metastasis was seen between patients with no capsular penetration and those with minimal capsular penetration (1 cm. or less total linear extent of full thickness penetration), providing the first quantitative evidence that small amounts of capsular penetration may not be of biological or prognostic significance.

Transrectal ultrasound. A case report related to the natural history of prostate cancer

This is a case report of a man with prostate cancer diagnosed 10 years ago by digital rectal examination and prostatic biopsy. He was followed with serial transrectal ultrasound examinations for the last 22 months. Transrectal ultrasound enabled us to observe the natural history of his cancer. Because of accelerated tumor growth, a radical prostatectomy was performed. The tumor was confined within the prostate capsule and thus considered a "cure." Transrectal ultrasound is an invaluable tool for continuous monitoring of patients with prostate cancer.

Carcinoma of the prostate: pathology, staging, and treatment

Prostate cancer is the most common malignancy affecting American men over the age of 50. Its incidence increases with each decade. It is usually discovered by rectal examination performed during physical examination or incidentally found on histologic sections of a prostate removed to alleviate urinary obstructive symptoms. About 50% of patients have clinically localized disease at presentation. The majority of prostate cancers grow slowly, metastasize late, and are not the primary cause of death. Before recommending treatment to a patient with prostate cancer, the treating physician should assess the extent of malignancy and determine which therapy, if any, would favorably influence the course of disease with the least influence on the general quality of life. Patients with disease limited to the prostate are offered curative therapy with either radical prostatectomy or radiation therapy. Those with locally extensive disease are treated with external beam irradiation or with androgen ablation. Metastatic disease is treated by androgen ablation. Chemotherapy is reserved for those patients who fail hormonal treatment.

Urologic cancer

Cancer prevention and risk reduction in patients with carcinomas of the urinary tract are most easily identified by smoking cessation. Recent assessments of patients with bladder carcinomas show a high percentage of active smokers. Urologic surgeons and those dealing with cancers of the genitourinary tract should recognize such an important factor. In other lifestyle guidelines, the American Cancer Society suggests that those who significantly reduce the fat content of their diet with weight reduction will generally reduce risk factors in a number of cancers, including prostate cancer. Many new diagnostic tests have been introduced since the 1980 conference. Transrectal ultrasonography as a preoperative staging technique has been received with some enthusiasm. Currently, a national program for the testing of the detection of prostate cancer by ultrasound compared with other physical examinations and marker antigens, such as prostate antigen, is underway. The evaluation of renal masses continues to be improved by the use of ultrasonography and computed tomography (CT) scanning. Currently, magnetic resonance imaging (MRI) techniques are believed to have added some improved assessment for particularly large tumors and the question of their vascular extension. Occasionally observed lesions of the adrenal gland without hormonal expression in patients continue to be noticed during evaluations for frequently unrelated diagnoses. The management of such lesions less than 3.5 cm in diameter is believed to be conservative based on their size. Preoperative staging of the bladder has improved with transurethral ultrasonography use and the follow-up with patients has developed more frequently with the widely available urinary cytology. Fine needle aspiration of the prostate gland, lymph nodes, and other urinary tumor masses is increasing in diagnostic use. Flow cytometry has been applied to all lesions of the urinary tract and continues to be a field of clinical investigation. The field of biologic markers in diagnosis, detection, and follow-up evaluation of patients with carcinomas of the urinary tract is a most interesting and progressive one. Currently, the most widely accepted new innovation is the prostate antigen, which was developed by members of the National Prostatic Cancer Project between 1975 and 1986. Other markers offer potential added value in more accurate and earlier diagnosis and detection and correlation with prognostic factors concerning individual groups of patients. Progress in the detection, diagnosis, and management of genitourinary cancer is being achieved, and prevention, although perhaps simplistic in design, can be more readily applied.

Morphometric and clinical studies on 68 consecutive radical prostatectomies

Morphometric reconstructions of 68 consecutive radical prostatectomies were analyzed for cancer volume, extent of complete capsular penetration, microscopic seminal vesicle and lymph node invasion, and histological differentiation, all of which were strongly interrelated. At less than 3.0 cc cancer volume, only 6 of 34 prostates (18 per cent) showed capsular penetration compared to 27 of 34 (79 per cent) with tumors of greater than 3.0 cc. Seminal vesicle invasion occurred once in 34 tumors of less than 3.0 cc and 15 times in those greater than 3.0 cc. All 6 patients with metastases to lymph nodes, 2 with early postoperative development of bone metastases and 4 of 5 with reappearance of detectable prostate specific antigen postoperatively had cancer volumes of greater than 4.0 cc. Correlation of digital rectal examination with cancer volume showed that of 39 palpable nodules in prostates with a cancer volume of less than 4.0 cc 30 (77 per cent) occupied 50 per cent or less of the length of 1 lobe (clinical stage B1 in our classification). Of 22 palpable lesions in tumors of greater than 4.0 cc 21 (95 per cent) exceeded 50 per cent of 1 lobe in the longitudinal extension (stage B2) or they represented bilaterally palpable disease (stage B3). Capsular penetration into the periprostatic fat occurred most commonly in the dorsolateral area of the neurovascular bundle, including 10 of 12 tumors less than 4.0 cc in volume (stage B1) and 19 of 21 with greater than 4.0 cc in tumor volume (stages B2 and B3). All 10 of the stage B1 cancers were free of contralateral lobe capsular penetration while 1 of the 13 stage B2 nodules had minimal contralateral capsule penetration in the area of the neurovascular bundle. We believe that the modified nerve-sparing radical prostatectomy should be limited to the contralateral side in stage B disease.