Early carcinoma of the prostate: comparison of stages A and B

Expression of prostatic acid phosphatase (PSAP) in transurethral resection specimens of the prostate is predictive of histopathologic tumor stage in subsequent radical prostatectomies

Clinical management of incidental prostate cancer (IPC) remains challenging since its clinical course cannot be predicted by conventional histopathology. Aiming to define predictive factors in IPC, we correlated the immunohistochemically detected expression of prostate-specific antigen (PSA), prostatic acid phosphatase (PSAP), alpha-methylacyl-CoA racemase (AMACR, p504s), and androgen receptor in transurethral resection specimens with Gleason scores and histologic staging on the corresponding radicals in a cohort of 54 patients (mean age, 65.9 years; range, 49-80 years). PSAP expression showed a significant correlation with tumor staging (rho = -0.37; p = 0.02) but not with Gleason scores (rho = -0.06; p = 0.69). K-statistics revealed a highly significant moderate interobserver agreement concerning the evaluation of PSAP staining (K = 0.47; p < 0.001). In contrast, the other markers assessed failed to correlate with conventional histopathology. Therefore, PSAP might be predictive of tumor stage in IPC and represent a valuable adjunct for clinical decisions in terms of individual therapeutic management.

Adenocarcinoma of the prostate in Iceland: a population-based study of stage, Gleason grade, treatment and long-term survival in males diagnosed between 1983 and 1987

OBJECTIVE

To investigate adenocarcinoma of the prostate in a single population with an extended follow-up period.

MATERIAL AND METHODS

Using the Icelandic Cancer Registry, we identified all Icelandic men diagnosed with prostate cancer between 1983 and 1987. Disease stage, initial treatment and follow-up information were obtained from hospital records and death certificates. A critical evaluation was made of the accuracy of the death certificates regarding prostate cancer. All available histology information was reviewed and graded according to the Gleason grading system.

RESULTS

A total of 414 men were diagnosed with adenocarcinoma of the prostate. Of these, 370 were alive at the time of diagnosis and stage could be determined. Four stage groups were defined: focal incidental (n=50); localized (n=164); local advanced (n=32); and metastatic disease (n=124). The mean age at diagnosis was 74.4 years (range 53-94 years). The combined Gleason score was 2-5 in 89, 6-7 in 117, 8-10 in 117 and unknown in 47 cases. The median follow-up period for the group was 6.15 years (range 0.3-19.8 years). Thirty men received treatment with curative intent: radiation therapy, n=20; and radical prostatectomy, n=10. A total of 334 patients died during the follow-up period, of whom 168 (50%) died of prostate cancer. Prostate cancer-specific survival at 10 and 15 years was 100% and 90.6%, respectively for focal incidental cancer; 73.1% and 60.8% for men with localized disease; 23.4% and 11.7% for local advanced disease; and 6.81% and 5.45% for metastatic disease. A Cox multivariate analysis showed age, stage and Gleason score to be independent predictors of prostate cancer death. A total of 104 patients with localized disease and a Gleason score of <or=7 received deferred treatment. The cause-specific survival for this group was 95.6%, 86.5% and 79.2% at 5, 10 and 15 years, respectively. Death certificates were judged to be accurate with regard to prostate cancer in nearly all instances (96%).

CONCLUSIONS

During an extended follow-up period, half of all patients with prostate cancer died from the disease. Males with localized disease and a favorable tumor grade fared well with deferred treatment. However, a higher stage and grade were associated with substantial prostate cancer mortality. Death certificates were accurate as far as prostate cancer was concerned.

Active surveillance with selective delayed intervention for favorable risk prostate cancer

Good risk prostate cancer, defined as a Gleason score of < or = 6, prostate-specific antigen (PSA) <10, and T1c-T2a, now constitutes 50% of newly diagnosed prostate cancer. Recent data from the Prostate Cancer Prevention Trial, Stamey data set on PSA-prostate cancer correlations, and the Surveillance, Epidemiology, and End Results database make it very clear that a policy of PSA screening with biopsy for those patients in whom PSA is increased results in the diagnosis, and radical treatment, of a very large proportion of men who do not have life-threatening prostate cancer. Most men with good risk prostate cancer have indolent and slow growing disease. The challenge is to identify those patients who are unlikely to have significant progression, while offering radical therapy to those who are at risk. The approach to favorable risk prostate cancer described in this article uses estimation of PSA doubling time (DT) and repeat biopsy to stratify patients according to the risk of progression. Patients who select this approach are treated initially with active surveillance. Those patients who have a PSA DT of < or = 3 years (based on a minimum of 3 determinations over 6 months) are offered radical intervention. The remaining patients are closely monitored with serial PSA and periodic prostate repeat biopsy at 1, 4, 7, and 10 years. In one series of 299 patients treated in this way, 65% remained free of treatment at 8 years. The prostate cancer specific survival using this approach was 99.3% at 8 years. The majority of patients in this study remain on surveillance. Active surveillance with selective delayed intervention based on PSA DT is a practical middle ground between radical therapy for all, which results in over-treatment of patients with indolent disease, and watchful waiting with palliative therapy only, which results in under-treatment of those with aggressive disease.

Characteristics of patients with stage T1b incidental prostate cancer

OBJECTIVE

To study the characteristics of patients with incidental prostate cancer.

MATERIAL AND METHODS

The proportion of incidentally diagnosed prostate cancer was investigated in patients who underwent transurethral resection of the prostate (TURP) at our clinic over a 5-year period. "True" incidental prostate cancer was defined as cases where the preoperative digital rectal examination (DRE) and the prostate-specific antigen (PSA) value were normal. Patients with known malignancy of the prostate were excluded, together with those with PSA >4 ng/ml and/or a positive DRE. The characteristics of these patients were compared to those of benign prostatic hyperplasia patients and the group as a whole.

RESULTS

Of the 786 patients operated on between 1999 and 2003, 34 (4.3%) had a positive pathology report for "true" incidental prostate cancer. An increased frequency of poorly differentiated tumors (32.3%) was noted. Of the 34 patients, 17 were stage T1a and 17 T1b; 11 patients had a Gleason sum of 7-10, all of them in the T1b group. In the T1b group the mean age was 74 years, the mean PSA level 2.9 ng/ml and the mean weight of tissue resected 11.1 g. Corresponding values in the T1a patients were 70.1 years, 3.32 ng/ml and 18.2 g.

CONCLUSIONS

Compared to previous studies, we noticed a low incidence of "true" incidental prostatic carcinoma but a high ratio of poorly differentiated tumors (all stage T1b). Compared to the group as a whole, patients with incidental prostate cancer were older and had smaller prostate and transition zone volumes. Further research is needed to identify parameters that may aid in the earlier identification of incidental prostate cancer, as patients may benefit from curative treatment.

Active Surveillance for Prostate Cancer: For Whom?

Prostate-specific antigen (PSA) –based prostate cancer screening results in the diagnosis of prostate cancer in many men who are not destined to have clinical progression during their lifetime. Good-risk prostate cancer, defined as a Gleason score of 6 or less, PSA < 10, and T1c to T2a, now constitutes 50% of newly diagnosed prostate cancer. In most of these patients, the disease is indolent and slow growing. The challenge is to identify those patients who are unlikely to experience significant progression while offering radical therapy to those who are at risk. The approach to favorable-risk prostate cancer described in this article uses estimation of PSA doubling time (PSA DT) to stratify patients according to the risk of progression. Patients who select this approach are managed initially with active surveillance. Those who have a PSA DT of 3 years or less (based on a minimum of three determinations over 6 months) are offered radical intervention. The remainder are closely monitored with serial PSA and periodic prostate rebiopsies (at 2, 5, and 10 years). In this series of 299 patients, the median DT was 7 years. Forty-two percent had a PSA DT > 10 years, and 20% had a PSA DT > 100 years. The majority of patients on this study remain under surveillance. The approach of active surveillance with selective delayed intervention based on PSA DT represents a practical compromise between radical therapy for all (which results in overtreatment for patients with indolent disease) and watchful waiting with palliative therapy only (which results in undertreatment for those with aggressive disease).

Active Surveillance with Selective Delayed Intervention: A Biologically Nuanced Approach to Favorable-Risk Prostate Cancer

Prostate cancer is an indolent, slow-growing disease in many patients and may not pose a threat during a patient's lifetime. The challenge is to identify those patients who are not likely to experience significant progression while offering radical therapy to those who are at risk. To date, molecular markers have failed to provide sufficiently reliable predictive information to influence decision-making. The approach to favorable-risk prostate cancer described in this article uses estimation of prostate-specific antigen doubling time (PSA DT) to stratify patients according to the risk of progression. Patients who select this approach initially undergo management with active surveillance; those who have a PSA DT <or=3 years (based on a minimum of 3 determinations over a period of 6 months) are offered radical intervention. The remainder are closely monitored. In a series of 231 patients in a study by our group, the median doubling time was 7.0 years; 42% had a PSA DT > 10 years and 20% had a PSA DT > 100 years. The majority of patients in this study continue to undergo surveillance. The approach of active surveillance with selective delayed intervention based on PSA DT represents a practical compromise between radical therapy for all (which results in overtreatment of patients with indolent disease) and watchful waiting with palliative therapy only (which results in undertreatment of patients with aggressive disease).

Expectant management with selective delayed intervention for favorable risk prostate cancer

Management options for favorable risk prostate cancer are diverse, varying from a conservative approach (expectant management) to definitive treatment (radical prostatectomy or radiotherapy.) Several studies have suggested that expectant management provides similar 10-year survival rates and quality-adjusted life years compared with radical prostatectomy or radiotherapy. Expectant management alone clearly deprives some patients with potentially curable life-threatening disease of the opportunity for curative therapy. However, every series of conservative management contains a substantial subset of long-term survivors, particularly in the group with favorable clinical parameters. We have conducted a clinical study to evaluate a novel approach in which the choice between a definitive therapy and conservative policy is determined by the rate of PSA increase or the development of early, rapid clinical and/or histologic progression. This strategy, which has never been previously evaluated, offers the powerful attraction of individualizing therapy according to the biological behavior of the cancer. This would mean that patients with slowly growing malignancy would be spared the side effects of radical treatment, while those with more rapidly progressive cancer would still benefit from curative therapy. Doubling time varied widely. In this series of 200 patients, neither grade, stage, nor baseline PSA predicted the PSA doubling time. Thirty-three percent of patients had a PSA doubling time (T(D)) > 10 years. Doubling time appears to be a useful tool to guide treatment intervention for patients managed initially with expectant management. A doubling time of less than 2 years appears to identify patients at high risk for local progression in spite of otherwise favorable prognostic factors. Fifteen to 20% of patients will fall into this category. The remainder have a high chance of remaining free of recurrence and progression for many years. Watchful waiting is clearly appropriate for patients who are elderly, have significant co-morbidity, and have favorable clinical parameters. The use of co-morbidity indices like the Index of Co-existent Disease (ICED) facilitate the identification of patients whose life-expectancy is diminished relative to the natural history of their prostate cancer. The likelihood of a prostate cancer death in these patients is low. Furthermore, many healthy patients fall into a grey zone where the benefits of treatment are unclear. In these patients, a policy of close monitoring with selective intervention for the 15-20% who progress rapidly is appealing. This approach is currently the focus of several clinical trials.

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.

p53 expression, proliferation marker Ki-S5, DNA content and serum PSA: possible biopotential markers in human prostatic cancer

OBJECTIVES

The biology of prostate cancer is poorly understood. Despite established prognostic criteria, a confident prediction of the clinical outcome is not always possible. Therefore, additional and more precise information is highly desirable. In the present study, we compared potential biologic markers with the laboratory, clinical, and histopathologic parameters of prostate-specific antigen (PSA) level, tumor stage, and tumor grade.

METHODS

Paraffin-embedded material from 62 radical prostatectomies for prostate carcinoma was examined immunohistochemically using monoclonal antibody Ki-S5 to determine the tumor growth fraction and antibody DO-1 to assess p53 protein overexpression. Deoxyribonucleic acid-ploidy was analyzed by flow and image cytometry. Preoperative PSA levels were assessed by standard method. The tumors were categorized according to the Gleason grading system and staged postsurgery after the TNM classification.

RESULTS

The p53 expression, proliferation rate (Ki-S5), and rate of aneuploidy correlated closely with stage (P < 0.05) and Gleason score (P < 0.01). However, divergences were occasionally observed. The ploidy status correlated closely with proliferative activity and p53 expression. Conversely, no correlation was seen between these parameters and serum PSA content, the latter being significantly associated with the tumor stage alone.

CONCLUSIONS

The results characterize proliferation marker Ki-S5, p53 expression, and ploidy status as tumor biopotential markers, whereas PSA provides diagnostic information. Use of these investigative methods promises to provide additional information relevant in prognosis and therapy selection. Nonetheless, their precise prognostic value will have to be established in further studies.

Anatomy of the prostate and distribution of early prostate cancer

Many of the difficulties in understanding diseases of the prostate have arisen through poor understanding of the anatomy of the prostate. The recent description of histologically separate zones in the prostate has been an important advance, allowing evaluation of separate cancers arising in the transition and peripheral zones of the prostate. While the majority of cancers sampled at transurethral resection of the prostate (TURP) are of transition zone origin, most of these prostates contain separate cancers in the peripheral zone. The peripheral zone cancers have a higher grade-to-volume ratio and are more frequently associated with histological features of progression (extracapsular extension, seminal vesicle invasion) than transition zone cancers. Furthermore, peripheral zone cancers are frequently associated with prostatic intraepithelial neoplasia, in contrast to transition zone cancers. These findings suggest a greater biological activity for cancers arising in the peripheral zone. The majority of cancers detected by digital rectal examination are of peripheral zone origin. While associated transition zone cancers are less frequently present than in TURP sampled prostates, a similarly high association of peripheral zone cancers with histological indicators of biological activity is seen. DNA ploidy analysis of separate foci in radical prostatectomy specimens confirms a significantly higher rate of non-diploidy in cancers of peripheral zone origin, some of very small volume, which further suggests a greater biological activity compared to transition zone cancers.

Observation alone in the management of localized prostate cancer: the natural history of untreated disease

OBJECTIVE

To review the data from a series of patients with localized prostate cancer managed with observation alone. When available, cancer-specific survival was analyzed. Predictive factors for disease outcome were reviewed.

METHODS

Series of patients with localized prostate cancer managed with observation alone were reviewed. When available, cancer-specific survival was analyzed. Predictive factors for disease outcome are reviewed.

RESULTS

In published trials of observation alone, ten-year cancer-specific survivals of 80-90 percent are realized. Adverse predictors of outcome include higher stage and grade as well as aneuploid tumors. Although tumor progression is more common in patients with adverse predictive factors, adverse outcomes can occur in the larger group of patients with intermediate grade, stage, or tumor volume.

CONCLUSIONS

Based on a small number of studies of patients with localized prostate cancer managed with observation alone, it appears that this option is reasonable for patients with good predictive factors and for patients with shorter life expectancies. The principal advantage of observation is the avoidance of treatment-related morbidity, but for the patient whose disease progresses during follow-up, disease-related morbidity can occasionally occur.

E-cadherin: a marker for differentiation and invasiveness in prostatic carcinoma

Considerable controversy exists concerning the value of histomorphological data in the assessment of the malignant potential of prostatic carcinomas. We investigated the expression pattern of E-cadherin in human prostate at the translational level. E-cadherin is a specific epithelial cell-cell adhesion molecule which has previously been found to be expressed in well-differentiated non-invasive carcinoma cell lines but is lost in many poorly differentiated invasive cell lines. The E-cadherin expression pattern in the prostate samples was correlated with histopathological findings in the same specimens. We found strong E-cadherin expression in normal prostate and benign prostatic hyperplasia. A decrease in or loss of E-cadherin was seen in 13 of 14 locally advanced and in 8 of 9 poorly differentiated prostatic carcinomas. We conclude that downregulation of E-cadherin expression plays a role in prostate carcinogenesis and invasiveness.

Conservative approaches to the management of localized prostatic cancer

BACKGROUND

The management of early stage prostatic cancer is controversial.

METHODS

Pertinent literature concerning the conservative management of early stage prostatic cancer by early endocrine therapy (EET) or by deferred treatment (DT) was reviewed.

RESULTS

EET has not been systematically studied. Available evidence suggests that early stage prostatic cancer often progresses slowly and that DT results in a cancer-specific mortality of approximately 80% at 10 years.

CONCLUSIONS

EET warrants clinical investigation. DT is a management option, at least in patients with a life expectancy of 10 years or less.

The natural history of adenocarcinoma of the prostate

All analyses of the efficacy of therapy for prostate cancer must control for the natural history of the disease. Over the past years, several long-term series involving several hundred patients have helped to describe the results of untreated disease. In general, most patients will not die of their disease, although approximately half of the patients will develop disease progression within 10 years. Predictors of progression include tumor stage, grade, and ploidy status.

A comparison of the morphological features of cancer arising in the transition zone and in the peripheral zone of the prostate

To determine the characteristics of transition zone and peripheral zone prostate cancer, we examined a series of 42 stage A and 54 stage B radical prostatectomy specimens with particular attention to the number of separate foci of cancer, zone of origin, volume and grade of each focus, and presence of severe intraductal dysplasia (high grade prostatic intraepithelial neoplasia), extra-capsular extension and seminal vesicle invasion associated with cancer in each zone. We found that there were fundamental differences between transition zone and peripheral zone cancers, and that the features that characterize these tumors were apparent in stages A and B disease. Although the total tumor burden was similar in stages A (3.98 cc) and B (4.56 cc) disease, stage A cancer tended to be multifocal (3.1 tumors per prostate) and more diffuse. While 81% of stage A prostate specimens contained a tumor of transition zone origin and 93% had cancer of peripheral zone origin, transurethral resection of the prostate sampled a transition zone cancer in 77% and a peripheral zone cancer in 31% (8% had both types). Stage B cancer tended to be more focal (2.3 cancers per prostate). All stage B prostate specimens contained a peripheral zone cancer and 43% had a transition zone cancer as well. In only 1 stage B cancer patient was the transition zone tumor the palpable or index cancer. In stages A and B disease, peripheral zone tumors were less well differentiated (median Gleason sum 6 and 7) than transition zone tumors (5 and 5, respectively) and more likely to extend through the capsule (44% versus 11%). Seminal vesicle invasion arose from 19% of the peripheral zone but none of the transition zone cancers. Peripheral zone tumors were almost always (93%) associated with high grade prostatic intraepithelial neoplasia, while none of the transition zone cancers was so associated. For peripheral zone disease there was a moderate correlation between volume and grade (tau = 0.46, p less than 0.001) so that the larger the tumor the higher the Gleason sum but within transition zone disease this correlation was poor (tau = 0.23) and not statistically significant (p greater than 0.05). Extracapsular extension occurred at a smaller volume with peripheral zone cancer (mean 3.86, minimum 0.06 cc) than transition zone cancer (mean 4.98, minimum 0.39 cc). Cancer that arises in the transition zone appears to have a different histogenesis, is associated with more favorable pathological features and may have less malignant potential than tumors that arise in the peripheral zone.

Long-term followup results after expectant management of stage A1 prostatic cancer

A total of 132 patients with stage A1 adenocarcinoma of the prostate was followed for 5 to 23 years (mean 8.2 years). Of these patients 52 underwent a second staging transurethral resection of the prostate between 1977 and 1986. Progressive disease developed in 3 of the 12 patients (25%) in whom residual foci of well differentiated cancer were detected by the second transurethral resection and who did not undergo further treatment. Of the 38 patients in whom the second transurethral resection did not detect residual cancer 3 (8%) also had progressive disease. From April 1989 to December 1989, 44 patients were re-evaluated by transrectal ultrasonography and ultrasonographically guided biopsies. Of these patients 3 had locally progressive disease. Progressive disease also developed in 4 more patients. Thus, 13 of the 132 patients (10%) had either locally or systemically progressive disease after long-term followup. The interval from diagnosis of stage A1 disease to detection of progression ranged from 6 months to 20 years (mean 7 years). Ten patients underwent definitive treatment for what was believed to be locally progressive disease, 2 underwent palliative therapy and 1 had no therapy due to poor physical condition. Of the 10 patients who underwent definitive therapy 6 are alive without evidence of disease, 2 died of unrelated causes without evidence of disease and 2 are alive with stage D1 disease. These data suggest that patients in whom a second staging transurethral resection of the prostate detects residual cancer have a high probability of progressive disease. Also, negative findings from a second staging transurethral resection may not exclude the possibility of disease progression. Expectant management of stage A1 disease is warranted but regular and long-term followup is mandatory.

Expectant management of localized prostatic cancer

Seventy-five patients with clinical Stage B histologically proven prostatic cancer accumulated over a 40-year period and receiving no therapy for at least 1 year after histologic diagnosis were retrospectively reviewed. Twenty-nine patients had Stage B1 lesions, 37 had B2, and nine had B3 lesions; median follow-up for these patients was 124, 120, and 96 months, respectively. Five ultimately received pelvic lymph node dissection with iodine-125 implantation, 23 had transurethral resection of the prostate, and 18 had endocrine therapy. Of those tumors which progressed, 18 of 19 (95%) B1, 26 of 29 (90%) B2, and four of four (100%) B3 lesions demonstrated local progression first. Six of 29 (21%) B1, 17 of 37 (46%) B2, and two of nine (22%) B3 tumors developed recognized distant metastasis. Actuarial survival at 15 years was 67%, 39%, and 63% for patients with B1, B2, and B3 lesions, respectively. These data indicate the varied and potentially protracted course of patients with clinical Stage B prostatic cancer.

Therapeutic options in the management of incidental carcinoma of the prostate

Incidental carcinoma of the prostate is a protean disease with a natural course which may be indolent or aggressive, with prognosis correlated with histologic grade and extent of disease. Treatment of this pathologic entity has varied over time and has been governed by institutional policy rather than randomized comparison of therapies. This report reviews the literature on incidental prostate cancer focusing on outcomes of patients as related to different therapeutic maneuvers. Observation alone with careful follow-up is appropriate therapy only for those patients with well differentiated disease of limited extent. Patients with diffuse or less differentiated disease required definitive therapy to prevent symptomatic progression. Hormonal manipulation alone has not been demonstrated to be of benefit. Radioactive implants have yielded poor disease-free survival. Radical prostatectomy by an experienced surgeon for patients with adequate health to tolerate the procedure has been associated with acceptable morbidity and excellent local control and survival. Radiation therapy has yielded similar excellent local control and survival and appears to be appropriate for a broader range of patients regardless of health or age.

Radical prostatectomy versus expectant primary treatment in stages I and II prostatic cancer. A fifteen-year follow-up

A fifteen-year follow-up of a prospective, randomized study comparing placebo with radical prostatectomy as the primary treatment of early prostatic cancer is presented. A total of 111 patients with clinical Stage I or II prostatic cancer, normal acid phosphatase levels, and negative findings on skeletal x-ray film were evaluable. Thirty Stage I patients and 20 Stage II patients received placebo only; 31 Stage I and 30 Stage II patients underwent radical prostatectomy. The survival status for 95 patients (86%) was established at the fifteen-year follow-up. No significant differences in crude survival occurred in either stage or in both stages combined. Moreover, the survival curves closely followed reference curves based on expected U.S. mortality for men of comparable ages and races. A statistically significant association between a high Gleason histologic score and poor survival was established. In this study, initial treatment with radical prostatectomy did not yield longer survival than initial placebo treatment alone. However, the findings should be interpreted with caution, since sample size was small and staging procedure was simplified.

Intraglandular tumor extent and prognosis in prostatic carcinoma: application of a grid method to prostatectomy specimens

The extent of tumor in prostatectomy specimens was determined by a grid method in 117 patients with prostatic adenocarcinoma. A plastic strip or ruler with squares of 3.0 mm was used, and the ratio of squares overlying carcinoma to the total number of squares overlying prostate tissue was calculated. This grid ratio, which represents an estimate of the percentage of the prostate involved by tumor, was a significant prognosticator closely tied to the likelihood of tumor progression and to survival time, as assessed by logistic regression analysis and a proportional hazard model. The grid ratio was better than histologic grade in predicting tumor progression and patient survival; also, the ratio was more objective than histologic grade as judged by interobserver agreement values. Only slight improvement in prognostication was obtained with concurrent use of both extent and grade. The grid ratio method was slightly better in predicting tumor progression and patient survival than a second method of assessing the percentage of prostatic tissue involved by tumor, the pathologist's percentage estimate. These results indicate that it is important to quantitate tumor extent within prostatectomy specimens; such quantitation need not require step-sectioning of the entire prostate and an expensive and time-consuming method such as computerized morphometrics but rather may be performed by a simple estimate of the percentage of the prostate involved by tumor. Reporting of histologic grade and tumor extent in the prostate gland is recommended as both appear to be important in identifying those patients at risk for a poor outcome after prostatectomy for prostatic carcinoma.

Incidental adenocarcinoma after open prostatic adenectomy

Adenocarcinoma of the prostate occasionally is discovered incidentally in the enucleated gland at open prostatic adenectomy for benign disease. Among 468 men who underwent open prostatic adenectomy, unsuspected adenocarcinoma of the prostate was found on pathological examination in 28 (6.0 per cent). The tumors were stage A1 in 14 patients and stage A2 in 14. Careful tissue review resulted in reassigning 5 cases from stage A1 to stage A2. At a mean followup of 10.6 years disease progression had occurred in 4 patients with stage A2 disease. When stage A adenocarcinoma is discovered after open prostatectomy we recommend careful review of the surgical specimen for accurate staging, and adjuvant therapy for all patients with stage A2 disease an for younger patients (less than 65 years old) with stage A1 disease who have favorable life expectancies.

The ratio of prostate chips with cancer: a new measure of tumor extent and its relationship to grade and prognosis

The ratio of chips with cancer to the total number of chips was studied in 118 patients with prostate cancer who underwent transurethral prostatectomy. We found that this ratio is a prognosticator closely associated to the stage of tumor (local or extensive) and to the chance of death from prostate cancer. Stage, the ratio of positive chips and the Gleason histologic score are all closely tied one to another, and it is unclear from this initial study whether these variables provide independent or additive prognostic information. Nevertheless, the ratio of positive chips shows far better interobserver agreement than does the Gleason score, and in patients with the most common predominant score of three, it can separate most of those with localized disease from most of those with extensive disease. Thus the ratio shows promise as a reliable predictor of stage of disease and of long-term failure, and hence it may help in the choice of patients for curative surgery.

Prognosis of untreated stage A1 prostatic carcinoma: a study of 94 cases with extended followup

Previously we showed that in cases of stage A prostatic cancer, if the tumor involved 5 per cent or less of the tissue and was not high grade (stage A1), only 2 per cent of the tumors progressed at 4 years. The current study investigated a larger group of 94 men with stage A1 disease and extended followup. While 26 men (mean age 75 years) died of other causes less than 4 years after diagnosis, of the 50 men who remained at risk 8 years or longer from the time of diagnosis 8 (16 per cent) had progression of disease. The intervals from diagnosis to progression ranged from 3.5 to 8 years, with 6 of the 8 patients dying of the cancer. Neither volume nor grade predicted progression, since of the 8 tumors that progressed 4 involved less than 1 per cent of the tissue and 6 were low grade. Based on these findings we conclude that stage A1 tumors progress at longer intervals from diagnosis and at lower frequency than stage A2 tumors. However, patients with stage A1 disease are not entirely free of risk of progression, and because 16 per cent of the men in this study who were at risk 8 years or longer experienced progression this factor must be recognized in the management of young men with stage A1 tumors.

Efficacy of radical prostatectomy for stage A2 carcinoma of the prostate

Optimal management of men with diffuse incidental prostatic cancer (Stage A2) is an unresolved issue. Current forms of therapy include radical prostatectomy, external beam radiation therapy, and no treatment. Long-term results with curative therapy have been unreported because of the relatively recent substaging of Stage A into incidental and diffuse disease. The results of radical prostatectomy in 25 patients with Stage A2 prostatic cancer were reviewed. Incontinence was the most serious complication and occurred in four patients (16%). Pathologically, 24 patients (96%) had residual carcinoma present in the radical prostatectomy specimen. In 22 men (88%) the tumor was entirely confined to the prostate. Two patients (8%) demonstrated seminal vesicle invasion, and one (4%) had capsular penetration. In follow-up metastatic disease has developed in one patient, and another died without evidence of cancer. The remaining patients are alive without evidence of disease. Since 88% of men with Stage A2 disease have their tumor entirely confined to the prostate, radical prostatectomy offers an excellent chance of long-term cure, as in Stage B prostatic cancer.

Incidental carcinoma of the prostate: significance of staging transurethral resection

We compared the results of staging by a second circumferential transurethral resection and/or transperineal needle biopsy in 42 patients with stage A prostatic adenocarcinoma on initial transurethral resection (defined as tumor of low grade, Gleason sum 2 to 4, and low volume, less than 5 per cent of the specimen or less than 3 foci). Transurethral resection only was done in 16 patients, transperineal needle biopsy only in 2 and both procedures in 24. In the 24 patients who underwent both procedures residual carcinoma was identified by transurethral resection in 6 and confirmed by transperineal needle biopsy in only 1. Thirty-two patients (76 per cent) had no residual carcinoma. Of the 10 patients (24 per cent) with residual carcinoma 5 underwent radical prostatectomy with pelvic lymphadenectomy, 1 had interstitial irradiation with pelvic lymphadenectomy and 1 had pelvic lymphadenectomy only. No lymphatic metastases were detected; persistent carcinoma confined to the prostate was noted in all 5 patients who had undergone radical prostatectomy and 3 of these tumors were upstaged because of higher grade and/or volume. We conclude that residual carcinoma cannot be assessed accurately with transperineal needle biopsy, whereas transurethral resection staging enabled us to define a substantial number of our patients (24 per cent) with persistent disease. Importantly, upstaging by either low volume/high grade or high volume carcinoma was identified in 3 patients at the time of radical prostatectomy. However, the true stage and prognosis of those patients with persistent low volume and low grade prostatic carcinoma remain to be determined.

Histopathology of prostate carcinoma. Diagnosis and differential diagnosis

The prognosis of prostate cancer depends largely on the degree of differentiation. Therefore the pathologist plays an important part in diagnosis and therapeutic decisions. There are three different growth patterns: glandular, cribriform, and solid-undifferentiated. In the glandular pattern, well and poorly differentiated forms are to be distinguished. Well differentiated adenocarcinomas are observed predominantly in benign nodular hyperplasia as incidental carcinomas. In case of differentiation from benign proliferations, the behaviour of the cellular nucleus--size, form, and characteristics of nucleolus--is decisive. Inflammatory stromal reaction is always absent. The growth pattern and degree of nuclear atypia determine the degree of malignancy to be demonstrated in a score. In clinically manifest carcinomas, pluriform patterns are prevailing. The lowest degree of differentiation of each case counts for the grading. In incidental carcinomas, the extension of the carcinoma has to be determined by the resection material. Here the nodular carcinoma represents a special form primarily located in the centre and obviously developing from a nodular hyperplasia. The differential diagnosis of prostatic cancer may cause great problems. Primary and secondary--postatrophic--hyperplasias may be similar to a glandular and cribriform carcinoma. Atypical hyperplasias of irregular nuclear pattern are present. Carcinoma in situ is not the proper term for such proliferations. Concerning rare types of prostate carcinomas, the urothelial carcinoma, the carcinoma with argentaffine cells, so-called endometrioid carcinomas, and squamous cell carcinomas are of importance. Following conservative, antiandrogen and radio-therapy characteristic regressive alterations can be observed in the prostate carcinoma. Response and resistance to therapy of the local tumor growth may be assessed during follow-up. A grading system is proposed for this purpose. Among all markers immunohistochemically demonstrable, only the presence of acid prostate phosphatase and prostate-specific antigen is of practical diagnostic importance in prostate cancer up to now.

Incidental adenocarcinoma of the prostate: the role of repeat transurethral resection in staging

Accurate staging of patients with incidental prostatic adenocarcinoma (A1 vs A2) is crucial to the selection of appropriate treatment. To evaluate the potential sampling error in specimens obtained by transurethral resection, repeat resection was performed on 31 patients pathologically staged as A1 (five or less chips with tumor). Second specimens showed no tumor in 22 (71%), stage A1 in six (20%), and stage A2 in three (9%). The weight of tissue removed at reresection was greater in patients found to have more extensive involvement (P less than 0.005). No patient with initial Gleason score 2, 3, or 4 had stage A2 at reresection. Repeat resection is not routinely necessary, but may be helpful when the tumor is high grade but of minimal extent, in an anxious younger patient who may wish therapy if disease persists, or where some suspicion of an incomplete resection exists.

Combined bipedal lymphangiography, CT scanning and transabdominal lymph node aspiration cytology for node staging in carcinoma of the prostate

Forty-two patients with carcinoma of the prostate have been studied by bipedal lymphangiography, abdominal CT scanning and percutaneous transabdominal lymph node aspiration cytology to try to increase the accuracy of lymph node staging. The use of two independent radiologists to report the lymphangiograms did not improve the accuracy of reporting. CT scanning was of value only in patients in whom the lymph nodes were not opacified on lymphangiography. Aspiration cytology was positive in 8 of the 40 patients who were studied. There was no morbidity. Six of these 8 patients had MO disease, three had TO tumours and were not on treatment. A poor correlation was found between the presence of lymph node metastases and the Gleason score. Percutaneous transabdominal lymph node aspiration cytology is a safe procedure. When positive, it avoids the need for a staging lymphadenectomy and so helps to identify those patients for whom local treatment is not applicable.

Accuracy of staging in A1 carcinoma of the prostate

The classification of patients with incidental carcinoma of the prostate into focal (Stage A1) or diffuse (Stage A2) subgroups depends primarily on the microscopic findings on tissue removed from transurethral resection (TUR) or open enucleation. However, these procedures sample only a portion of the entire prostate, and some patients staged A1 may have residual diffuse cancer that should properly be classified as Stage A2. This study is a review of 86 patients with Stage A1 cancer of the prostate in whom additional prostatic tissue was available because of repeat transurethral resection or radical prostatectomy. Only six patients (7%) were found to have diffuse cancer in the remaining prostatic tissue. Therefore, it appears that the classification of patients into Stage A1 or Stage A2 is generally accurate when based on the findings from initial TUR alone and that the incidence of understaging in this group is low. Repeat transurethral resection does not appear to contribute significantly to the accuracy of staging.

Surgical treatment of stage A2 prostatic carcinoma: significance of tumor grade and extent

Patients with stage A2 carcinoma of the prostate are a heterogeneous population and not all of them progress to clinically manifest disease. We found a similar variability in terms of the pathological findings in a group of 34 patients with stage A2 disease undergoing pelvic lymphadenectomy and radical prostatectomy. While 8 patients (24 per cent) had metastatic disease on staging lymphadenectomy, 9 patients (27 per cent) had negative lymphadenectomy, with minimal or no residual tumor in the radical specimen. The histologic grade and extent of tumor on transurethral resection did not predict reliably patients with stage A2 disease and minimally invasive cancer at radical prostatectomy. It appears that present criteria for separating stage A tumors into focal and diffuse categories are adequate for selecting therapy for patients with incidental carcinoma of the prostate.

Prognostic significance of tumor grade and stage in the patient with carcinoma of the prostate

Available English language articles relating the grade, stage, and grade-stage of carcinoma of the prostate to evidence of tumor progression and survival in untreated and treated patients have been reviewed. Observations of the extremes of the spectrum of biological behavior of carcinoma of the prostate have been emphasized; for example, tumor progression, never or always; survival, never or always. The reported experiences indicated the following; namely, 1) reproducible biologically meaningful grading is achievable; however, grade cannot be utilized as a reliable indicator of stage; 2) accurate staging provides information that correlates with tumor progression and survival in groups of patients. However, unexpectedly prolonged or abbreviated progression-free survivals occur frequently enough in every stage, except perhaps patients with clinically unsuspected focal carcinoma, to indicate that the natural history and treatment response of individuals grouped by stage is far from homogeneous; 3) appropriate use of carefully obtained grade and stage information together maximizes the accuracy of prognostic attempts and is necessary to evaluate treatment results. At the present time, assessment and consideration of the grade and stage of carcinoma of the prostate is essential to formulate prognosis and advise and evaluate treatment in patients with this disease.

Radical radiotherapy in the management of carcinoma of the prostate

Reasons for the increased role of radical radiotherapy in the management of carcinoma of the prostate are presented. The results of a retrospective survey of 116 patients who received radical external beam radiotherapy to the primary tumour are reviewed. Local tumour control was obtained in 75% of patients with an overall morbidity of 14% mild and 9% severe side effects. The problems of accurate tumour staging, extended field radiotherapy and patient selection are discussed. In selected cases, treatment morbidity may be reduced by using interstitial implant techniques.

Incidental carcinoma of the prostate at the time of transurethral resection: importance of evaluating every chip

Incidental adenocarcinoma of the prostate has been divided into stage A1--less than 3 foci of well differentiated adenocarcinoma present and stage A2--3 or more foci of poorly differentiated tumor present. The clinical significance of these 2 stages has been well documented, with stage A1 lesions causing no increased mortality, while up to 30 per cent of patients with clinical stage A2 disease will have positive pelvic lymph nodes at exploration and, thus, will have surgical stage D1 tumor. Most pathology laboratories submit only a fraction of the transurethral resection chips for permanent blocks. In an effort to evaluate the over-all incidence and distribution of stages A1 and A2 lesions were began a prospective study in 1978 whereby all prostatic chips were submitted for permanent sections. A review of 500 consecutive cases of transurethral resection for clinically benign prostates before 1978 revealed 43 cases of adenocarcinoma: 10 (23 per cent) stage A1 and 33 (77 per cent) stage A2. A review of a similar series of 500 consecutive patients since 1978 revealed 71 cases of adenocarcinoma: 17 (24 per cent) clinical stage A1 and 54 (76 per cent) clinical stage A2. Thus, we found that since 178 incidental adenocarcinoma of the prostate has increased by 65 per cent and the distribution of stages A1 and A2 lesions has remained unchanged, 76 per cent of these lesions being clinical stage A2 with its much greater clinical significance. Evaluation of every chip does make a clinically significant difference in the subsequent management of patients with incidental adenocarcinoma of the prostate.

Early (stage A) prostatic cancer. VI. A critical look at the follow-up

The 4 year follow-up of an original series of 100 patients treated by subtotal prostatectomy and analysed on histopathological grounds is presented. 87 out of 100 were traced and were in the following groups: 37/45 A1, 27/29 A2, 10/12 A3, 13/14 benign prostatic hyperplasia. No therapy was performed. All three patients who died of prostatic carcinoma fitted into substage A3, all three patients living with metastases fitted into A1. The progression observed is significant when related to the brief interval of time, the size of the prostatic microcarcinoma and the histological grade (well differentiated tubular carcinomas in 5 out of 6 cases). Prostatectomy with capsulectomy is strongly recommended in order to prevent progression.

Radical perineal prostatectomy for clinical stage B2 carcinoma of the prostate

To refine the criteria for radical surgery in clinical stage B2 prostatic cancer a retrospective study was made of 53 patients who underwent radical perineal prostatectomy between 1951 and 1963. The 15-year survival free of tumor was 25 per cent, significantly less than the 51 per cent survival rate in a series of patients with clinical B1 disease undergoing radical perineal prostatectomy during the same period. Sixty-six per cent of the patients had extraprostatic extension of tumor on histological examination. The 15-year survival free of tumor in these patients was only 13 per cent, whereas those patients with tumor histologically confined to the prostate had a 15-year survival rate of 50 per cent, equal to an age-matched control population. Thus, although prolonged survival was demonstrated in patients without extraprostatic extension only a third of all clinical B2 cases were in this favorable category. Consequently, until improved reliable techniques for detection of extraprostatic extension become available it seems unwise to recommend radical prostatectomy as the treatment of choice for all men with clinical stage B2 disease.

Stage A prostate cancer from pathologist's viewpoint

Four hundred sixty-five departments of pathology in the United States were asked the following questions pertaining to Stage A prostatic cancer: (1) If a focus of adenocarcinoma is incidentally found in an enucleated specimen, what is the maximum diameter such a lesion may attain and still be considered an A-1 prostatic carcinoma? (2) If adenocarcinoma is incidentally found in a specimen resected transurethrally, how many chips may contain tumor and the lesion still be considered A-1 prostatic carcinoma? (3) What is your "routine pathologic examination" of a prostatic specimen? The majority of pathologists believe that the maximum diameter of a focal (A-1) lesion in an enucleated specimen is 5 mm., and the maximum number of transurethral chips containing tumor in a focal (A-1) lesion is three. The majority of pathologists section every chip when the specimen weighs less than 10 Gm. However, only 12 per cent of the pathologists section every chip when the specimen is greater than 10 Gm., while the others use a random section technique. There is a great diversity of techniques among pathologists in their methods of examining enucleated prostatic specimens.