Substratification of stage T1C prostate cancer based on the probability of biochemical recurrence

Comparison of Tumor Volume Parameters on Prostate Cancer Biopsies

CONTEXT.—

Prostate biopsy reports require an indication of prostate cancer volume. No consensus exists on the methodology of tumor volume reporting.

OBJECTIVE.—

To compare the prognostic value of different biopsy prostate cancer volume parameters.

DESIGN.—

Prostate biopsies of the European Randomized Study of Screening for Prostate Cancer were reviewed (n = 1031). Tumor volume was quantified in 6 ways: average estimated tumor percentage, measured total tumor length, average calculated tumor percentage, greatest tumor length, greatest tumor percentage, and average tumor percentage of all biopsies. Their prognostic value was determined by using either logistic regression for extraprostatic expansion (EPE) and surgical margin status after radical prostatectomy (RP), or Cox regression for biochemical recurrence-free survival (BCRFS) and disease-specific survival (DSS) after RP (n = 406) and radiation therapy (RT) (n = 508).

RESULTS.—

All tumor volume parameters were significantly mutually correlated (R2 > 0.500, P < .001). None were predictive for EPE, surgical margin, or BCRFS after RP in multivariable analysis, including age, prostate-specific antigen, number of positive biopsies, and grade group. In contrast, all tumor volume parameters were significant predictors for BCRFS (all P < .05) and DSS (all P < .05) after RT, except greatest tumor length. In multivariable analysis including only all tumor volume parameters as covariates, calculated tumor length was the only predictor for EPE after RP (P = .02) and DSS after RT (P = .02).

CONCLUSIONS.—

All tumor volume parameters had comparable prognostic value and could be used in clinical practice. If tumor volume quantification is a threshold for treatment decision, calculated tumor length seems preferential, slightly outperforming the other parameters.

Biochemical failure after radical prostatectomy in intermediate-risk group men increases with the number of risk factors

Introduction:

We aimed to determine whether the number and type of risk factors are associated with biochemical recurrence-free survival after radical prostatectomy in men with D’Amico intermediate-risk prostate cancer.

Materials and Methods:

Between August 1998 and May 2013, 481 Japanese patients underwent antegrade radical prostatectomy. The relationships between the rate of PSA failure after radical prostatectomy and the number and type of risk factors were examined in the intermediate-risk group.

Results:

According to the D’Amico criteria, the low-, intermediate-, and high-risk groups comprised 107, 222, and 152 patients, respectively. The median follow-up period after surgery was 54.1 months. The 5-year PSA failure-free rates in the low-, intermediate-, and high-risk groups were 96.5%, 88.9%, and 72.6%, respectively (P < 0.001). The 5-year PSA failure-free rate in the intermediate-risk group with one, two, and three intermediate risk factors was 94.9%, 88.4%, and 49.0%, respectively (P < 0.001). The difference between the high- and intermediate-risk group with three intermediate risk factors was statistically significant based on the log-rank test (P = 0.039).

Conclusion:

The number of intermediate risk factors is significantly associated with the PSA failure-free survival rate after radical prostatectomy in the intermediate-risk group. Patients classified into the intermediate-risk group based on all three intermediate risk factors are less likely to achieve a complete cure through surgery alone.

Long-term outcomes of nonpalpable prostate cancer (T1c) patients treated with radical prostatectomy

PURPOSE

Various strategies have been used to treat patients with nonpalpable prostate cancer (T1c). As one of the treatments for this stage, a radical prostatectomy was performed and the outcomes were evaluated.

METHODS

Between 1993 and 2002, 117 patients with T1c received a radical prostatectomy and their follow-up were examined by the end of 2013. Patients were classified according to risk groups using prostate-specific antigen (PSA) and Gleasson score, and outcomes of respective groups were compared.

RESULTS

Approximately 60% of patients were in low risk group, and the remaining patients were grouped into the intermediate or high risks in half. In 22% insignificant cancer was detected. Biochemical failure occurred in 14%. One patient exhibited bone metastasis, but no deaths from prostate cancer ware observed. The five and ten year overall survival rates were 92% and 75%, respectively, and the biochemical failure-free survival rates were 92% and 89%, respectively. No different outcomes were observed for the different risk groups in the overall and biochemical failure-free survival rates. T1c tumors contain a certain range of various stages of tumors, but most patients experienced favorable outcomes.

CONCLUSION

Radical prostatectomy as monotherapy is one of the treatment option for T1c prostate cancer patients, who have a long life span and belong to intermediate or high risk groups.

Positive resection margins may not reflect the true margin in patients undergoing radical prostatectomy

The aim of the present study was to evaluate the hypothesis that a positive resection margin (RM1) of an excised specimen may not reflect the true margin in patients that have undergone radical prostatectomy (RP). Between September 2003 and March 2011, 370 Japanese patients underwent an antegrade RP at the National Kyushu Cancer Center (Fukuoka, Japan), however, 95 of these patients were excluded from the study due to a history of receiving hormonal therapy or insufficient preoperative clinical data. The incidence of biochemical failure (BCF) was evaluated using multivariate analysis, which revealed that the preoperative prostate-specific antigen (PSA) level, pathological tumor stage, RP Gleason score and a PSA nadir <0.008 ng/ml were significant predictors (P=0.0065, 0.0006, 0.0002 and <0.0001, respectively). By contrast, an RM1 was not found to be a significant predictor of BCF, while the parameter with the highest hazard ratio (HR) was a PSA nadir <0.008 ng/ml (HR, 10.055; 95% confidence interval, 5.005–20.200). From the 56 cases that were RM1, 41 cases (73.2%) exhibited a PSA nadir <0.008 ng/ml. There were 42 cases (75.0%) in which only one site was identified to be RM1; among these cases, no significant difference was observed between a PSA level <0.008 ng/ml and a PSA level ≥0.008 ng/ml at the RM1 site (apex, P=0.1460; base, P=0.1384; anterior, P=0.3870; and posterolateral, P=0.5040). There were 14 cases (25.0%) in which multiple sites were RM1; these cases were classified by the number of sites that were RM1 (one vs. multiple) and no significant difference was observed between a PSA level <0.008 ng/ml and a PSA level ≥0.008 ng/ml (P=0.6090). Based on these results, an RM1 of an excised specimen may not reflect the true margin in patients that are treated with RP, specifically in cases where the PSA level is identified to decrease to below the postoperative measurement threshold value (PSA nadir <0.008 ng/ml).

Early versus delayed hormonal treatment in locally advanced or asymptomatic metastatic prostatic cancer patient dilemma

INTRODUCTION

The objective of this work is to compare the effectiveness of hormonal treatment (luteinizing hormone-releasing hormone agonists and/or antiandrogens) as an early or as a deferred intervention for patients with locally advanced prostate cancer (LAPC) and/or asymptomatic metastasis.

MATERIALS AND METHODS

Systematic review of trials published in 1950-2007. Sources included MEDLINE and bibliographies of retrieved articles. Eligible trials included adults with a history of LAPC who are not suitable for curative local treatment of prostate cancer. We retrieved 22 articles for detailed review, of which 8 met inclusion criteria. The Veterans Administration Cooperative Urological Research Group suggested that delaying hormonal therapy did not compromise overall survival and that many of the patients died of causes other than prostate cancer. In European Organisation for Research and Treatment of Cancer (EORTC) 30846 trial, the median survival for delayed endocrine treatment was 6.1 year, and for immediate treatment 7.6 year, the HR for survival on delayed versus immediate treatment was 1.23 (95 % CI 0.88-1.71), indicating a 23 % nonsignificant trend in favour of early treatment. In EORTC 30891, the immediate androgen deprivation resulted in a modest but statistically significant increase in overall survival. The protocol SAKK 08/88 showed the lack of any major advantage of immediate compared with deferred hormonal treatment regarding quality of life or overall survival.

CONCLUSIONS

The early intervention with hormonal treatment for patients with LAPC provides important reductions in all-cause mortality, prostate cancer-specific mortality, overall progression, and distant progression compared with deferring their use until standard care has failed to halt the disease.

Percentage of cancer volume in biopsy cores is prognostic for prostate cancer death and overall survival in patients treated with dose-escalated external beam radiotherapy

PURPOSE

To investigate the prognostic utility of the percentage of cancer volume (PCV) in needle biopsy specimens for prostate cancer patients treated with dose-escalated external beam radiotherapy.

METHODS AND MATERIALS

The outcomes were analyzed for 599 men treated for localized prostate cancer with external beam radiotherapy to a minimal planning target volume dose of 75 Gy (range, 75-79.2). We assessed the effect of PCV and the pretreatment and treatment-related factors on the freedom from biochemical failure, freedom from metastasis, cause-specific survival, and overall survival.

RESULTS

The median number of biopsy cores was 7 (interquartile range, 6-12), median PCV was 10% (interquartile range, 2.5-25%), and median follow-up was 62 months. The PCV correlated with the National Comprehensive Cancer Network risk group and individual risk features, including T stage, prostate-specific antigen level, Gleason score, and percentage of positive biopsy cores. On log-rank analysis, the PCV stratified by quartile was prognostic for all endpoints, including overall survival. In addition, the PCV was a stronger prognostic factor than the percentage of positive biopsy cores when the two metrics were analyzed together. On multivariate analysis, the PCV predicted a worse outcome for all endpoints, including freedom from biochemical failure, (hazard ratio, 1.9; p = .0035), freedom from metastasis (hazard ratio, 1.7, p = .09), cause-specific survival (hazard ratio, 3.9, p = .014), and overall survival (hazard ratio, 1.8, p = .02).

CONCLUSIONS

For patients treated with dose-escalated external beam radiotherapy, the volume of cancer in the biopsy specimen adds prognostic value for clinically relevant endpoints, particularly in intermediate- and high-risk patients. Although the PCV determination is more arduous than the percentage of positive biopsy cores, it provides superior risk stratification.

Measurements of cancer extent in a conservatively treated prostate cancer biopsy cohort

The optimal method for measuring cancer extent in prostate biopsy specimens is unknown. Seven hundred forty-four patients diagnosed between 1990 and 1996 with prostate cancer and managed conservatively were identified. The clinical end point was death from prostate cancer. The extent of cancer was measured in terms of number of cancer cores (NCC), percentage of cores with cancer (PCC), total length of cancer (LCC) and percentage length of cancer in the cores (PLC). These were correlated with prostate cancer mortality, in univariate and multivariate analysis including Gleason score and prostate-specific antigen (PSA). All extent of cancer variables were significant predictors of prostate cancer death on univariate analysis: NCC, hazard ration (HR) = 1.15, 95% confidence interval (CI) = 1.04-1.28, P = 0.011; PPC, HR = 1.01, 95% CI = 1.01-1.02, P < 0.0001; LCC, HR = 1.02, 95% CI = 1.01-1.03, P = 0.002; PLC, HR = 1.01, 95% CI = 1.01-1.02, P = 0.0001. In multivariate analysis including Gleason score and baseline PSA, PCC and PLC were both independently significant P = 0.004 and P = 0.012, respectively, and added further information to that provided by PSA and Gleason score, whereas NNC and LCC were no longer significant (P = 0.5 and P = 0.3 respectively). In a final model, including both extent of cancer variables, PCC was the stronger, adding more value than PLC (χ² (1df) = 7.8, P = 0.005, χ² (1df) = 0.5, P = 0.48 respectively). Measurements of disease burden in needle biopsy specimens are significant predictors of prostate-cancer-related death. The percentage of positive cores appeared the strongest predictor and was stronger than percentage length of cancer in the cores.

Prostate specific antigen nadir determined using ultra-sensitive prostate specific antigen as a predictor of biochemical progression after radical prostatectomy in Japanese males

OBJECTIVES

We examined whether the prostate specific antigen (PSA) nadir is a good predictor of biochemical failure after radical prostatectomy.

METHODS

We retrospectively reviewed clinico-pathological data in 257 patients who underwent radical prostatectomy. Twenty-nine patients of whom PSA nadir did not reach 0.1 ng/mL and three patients in whom second line therapy was started before biochemical failure were excluded, and 225 patients were subject to this study. We evaluated the changes in PSA value at very low (from less than 0.01-0.10 ng/mL) levels using an ultra-sensitive PSA assay after radical prostatectomy. Biochemical failure was defined as three consecutive elevations of PSA to above 0.1 ng/mL.

RESULTS

Biochemical failure-free survival was attained by 89.9% of patients at 1 year, 83.0% at 2 years, and 81.0% at 5 years. PSA nadir more than 0.01 ng/mL was strongly associated with biochemical failure after radical prostatectomy (P < 0.0001). Mean time to reach PSA nadir was 3.1 months. Preoperative PSA > 20 ng/mL (P = 0.0013), clinical T stage = T2 (P = 0.0462), Gleason score 8-10 (P = 0.0243) were also independent predictors of biochemical progression.

CONCLUSIONS

Prostate specific antigen nadir determined by ultra-sensitive PSA assay is an important parameter that is objective, reliable, and easily measured, and useful for predicting the subgroups of patients both most likely and unlikely to exhibit biochemical progression.

Prediction by quantitative histology of pathological stage in prostate cancer

AIMS

To find a predictor of extraprostatic extension in clinically localized prostate cancer (PCa), pre-operative ultrasound-guided prostate needle biopsies and clinico-pathological data were reviewed.

METHODS

One hundred and eighty-three consecutive patients who underwent radical retropubic prostatectomy for clinical T1-T2 PCa and serum PSA <10 ng/ml were reviewed. Pre-operative biopsy was performed according to an extended protocol and whole-mount prostatectomy specimens were processed. The following biopsy variables were categorized to this analysis: Gleason score (< or =6, >6), TPC (< or =20%; >20%), GPC (< or =50%; >50%), cancer-positive cores (< or =2; >2), cancer-positive cores in both lateral portions (yes; no), PCa (monolateral; bilateral).

RESULTS

Only 60/183 specimens showed an organ-confined PCa; the remaining ones showed pT3a in 57 cases, pT3b in 11 and pT3 with positive surgical margins in 55. A locally advanced PCa was found in 60.2 and 76.8% of T1c and T2 clinical stage, respectively. The positive predictive value and negative predictive value of biopsy findings to predict a locally advanced PCa was 89.9 and 75%, respectively. All biopsy variables associations were statistically significant; however, among these variables (non-categorized), in multivariate logistic regression analysis, only GPC was significantly associated with pathologic stage (odds ratio estimate was 1.075, 95% CI: 1.053-1.098).

CONCLUSIONS

Quantitative histology, especially GPC, seems to be helpful for pre-operative staging of PCa in patients with T1c-T2 clinical stage and PSA < 10 ng/ml.

Evaluating the use of early hormonal therapy in patients with localised or locally advanced prostate cancer

This article evaluates the use of early hormonal therapy in patients with localised or locally advanced prostate cancer. In patients receiving radiotherapy, an overall survival benefit is proven for adjuvant goserelin ('Zoladex') in locally advanced disease. Adjuvant to radical prostatectomy, castration (goserelin or orchiectomy) has demonstrated an overall survival benefit in patients with lymph node metastases. Survival advantages have not yet been proven with nonsteroidal antiandrogens, but immediate or adjuvant bicalutamide ('Casodex') improves objective progression-free survival in patients with locally advanced disease, with certain quality-of-life advantages over castration.

CONTROVERSIES IN PROSTATE CANCER SCREENING

PURPOSE

Prostate cancer is the most common cancer in men and the second most common cause of cancer death in men, and yet controversy continues to surround the practice of prostate cancer screening. Despite recent studies that have cast doubt over the true efficacy of breast cancer screening programs, the National Cancer Institute continues to support breast cancer screening and it has withheld endorsement of widespread prostate cancer screening. Criticisms of prostate cancer screening include the financial burden of screening, the morbidity of prostate biopsy, the low positive predictive value of screening, the over treatment of an indolent disease and the lack of evidence demonstrating a mortality benefit due to screening.

MATERIALS AND METHODS

We formulated a comprehensive discussion addressing the criticisms of prostate cancer screening.

RESULTS

In an effort to highlight the importance of prostate cancer screening we noted how concerns regarding cost, morbidity and low positive predictive value are common to widely accepted screening programs for other common malignancies. We also draw attention to the danger of abandoning prostate cancer screening, a practice that is called into question by watchful waiting series and Markov modeling of prostate cancer treatment. Finally, we observed how the implementation of prostate cancer screening in the United States has led to the phenomenon of stage migration and paralleled the decrease in the prostate cancer mortality rate.

CONCLUSIONS

The prostate specific antigen era has brought great promise for improving the prognosis of prostate cancer. We must continue to seek support for widespread prostate cancer screening.

PREOPERATIVE MODEL FOR PREDICTING PROSTATE SPECIFIC ANTIGEN RECURRENCE AFTER RADICAL PROSTATECTOMY USING PERCENT OF BIOPSY TISSUE WITH CANCER, BIOPSY GLEASON GRADE AND SERUM PROSTATE SPECIFIC ANTIGEN

PURPOSE

We developed a preoperative model to risk stratify patients for prostate specific antigen (PSA) failure following radical prostatectomy (RP) and identify those at high risk who would be potential candidates for neoadjuvant clinical trials.

MATERIALS AND METHODS

A retrospective survey of 459 patients from the SEARCH Database treated with RP between 1990 and 2002 was done. Multivariate analysis was used to compare the preoperative variables of patient age, race, PSA, biopsy Gleason score, clinical stage and percent of prostate needle biopsy tissue with cancer for the ability to predict time to PSA recurrence following RP. Significant independent predictors were combined to create a novel risk grouping model.

RESULTS

On multivariate analysis biopsy Gleason score (p < 0.001), percent of biopsy tissue with cancer (p < 0.001) and serum PSA (p = 0.001) were the only significant independent predictors of PSA failure. Combining these 3 significant predictors of PSA failure using previously published cutoff points for each variable generated a 4 tier preoperative model for predicting biochemical failure following RP (HR 1.91 for each 1 risk category increase, CI 1.62 to 2.26, p < 0.001). The model further stratified patients who were already stratified into low, intermediate and high risk groups based on a previously described model using PSA, biopsy Gleason score and clinical stage. A simplified table was developed to predict the risk of biochemical recurrence within 2 years following surgery, as stratified by percent of tissue with cancer, PSA and biopsy Gleason score.

CONCLUSIONS

A combination of serum PSA, biopsy Gleason score and percent of prostate biopsy tissue with cancer define a new preoperative model for predicting PSA failure following RP. This model further stratified patients who were already stratified based on PSA, biopsy Gleason score and clinical stage, and it can be used preoperatively to identify patients at high risk who would be candidates for neoadjuvant clinical trials. Using this model an easy to use table was developed to predict preoperatively the 2-year risk of PSA recurrence following RP.

Preoperative Prediction of Pathological Stage by Quantitative Histology in 102 Patients with Prostate Cancer (PCa) and Serum PSA ≤10 ng/mL

Purpose. To find a predictor of extraprostatic extension in clinically localized prostate cancer (PCa), preoperative ultrasound-guided prostate needle biopsies and clinicopathological data were reviewed.

Materials and Methods

102 consecutive patients (median age 63 years) with serum PSA ≤10 ng/mL who underwent radical retropubic prostatectomy were included. Preoperative prostate biopsies according to an extended protocol were performed and whole-mount prostatectomy specimens were processed. One or more of the following biopsy variables were considered predictive of locally andvanced PCa: more than 2/12 cancer-positive cores, total percentage of cancer (TPC) >20%, greatest percentage of cancer (GPC) >50%, bilateral PCa, presence of cancer in both lateral portions, Gleason score >6.

Results

Only 32/102 (31.4%) specimens showed an organ-confined PCa; the remaining were pT3a in 30 (29.4%) cases, pT3b in 6 (5.9%) and pT2–T3 with positive surgical margins in 34 (33.3%). Quantitative histology predicted an organ-confined PCa in 41.2% of patients. In all 102 patients and in 56 with T1c clinical stage, the positive predictive value (PPV) and negative predictive value (NPV) of biopsy findings, to predict an organ confined PCa, was 81.2 vs 92% and 91.6 vs 93.4%, respectively. The PPV and NPV to predict a locally advanced PCa was 92.8 and 86.5%, respectively.

Conclusions

Quantitative histology seems to be helpful for locally staging of PCa in patients with T1c clinical stage and PSA ≤10 ng/mL.

The percentage of prostate needle biopsy cores with carcinoma from the more involved side of the biopsy as a predictor of prostate specific antigen recurrence after radical prostatectomy

BACKGROUND

The authors previously found that, although the total percentage of prostate needle biopsy cores with carcinoma was a significant predictor of prostate specific antigen (PSA) failure among men undergoing radical prostatectomy (RP), there was a trend toward a lower risk of recurrence in patients with positive bilateral biopsies, suggesting that high-volume, unilateral disease was a worse predictor of outcome than an equivalent number of positive cores distributed over two lobes. In the current study, the authors sought to compare the total percentage of cores with carcinoma directly with the percentage of cores from the more involved or dominant side of the prostate with carcinoma for their ability to predict outcome among men who underwent RP.

METHODS

A retrospective survey of 535 patients from the Shared Equal Access Regional Cancer Hospital database who underwent RP at 4 different equal-access medical centers between 1988 and 2002 was undertaken. The total percentage of cores positive was compared with the percentage of cores positive from the dominant and nondominant sides for their ability to predict biochemical recurrence after RP. The best predictor then was compared with the standard clinical variables PSA, biopsy Gleason score, and clinical stage in terms of ability to predict time to PSA recurrence after RP using multivariate analysis.

RESULTS

The adverse pathologic features of positive surgical margins and extracapsular extension were significantly more likely to be ipsilateral to the dominant side on the prostate biopsy. The percentage of cores positive from the dominant side provided slightly better prediction (concordance index [C] = 0.636) for PSA failure than the total percentage of cores positive (C = 0.596) and markedly better than the percentage of cores from the nondominant side (C = 0.509). Cutoff points for percentage of cores positive from the dominant side were identified (< 34%, 34-67%, and > 67%) that provided significant risk stratification for PSA failure (P < 0.001). On multivariate analysis, the percentage of cores positive from the dominant side was the strongest independent predictor of PSA recurrence (P < 0.001). Biopsy Gleason score (P = 0.017) also was a significant, independent predictor of recurrence. There was a trend, which did not reach statistical significance, toward an association between greater PSA values and biochemical failure (P = 0.052). Combining the PSA level, biopsy Gleason score, and percentage of cores positive from the dominant side of the prostate resulted in a model that provided a high degree of prediction for PSA failure (C = 0.671).

CONCLUSIONS

The percentage of cores positive from the dominant side of the prostate was a slightly better predictor of PSA recurrence than was the total percentage of cores positive. Using the percentage of cores from the dominant side along with the PSA level and the biopsy Gleason score provided significant risk stratification for PSA failure.

PSA markers in prostate cancer detection

The PSA revolution that has occurred over the previous 2 decades has positively impacted the detection and treatment of men with prostate cancer. Although methods to improve specificity have shown promise (eg, PSAD, age-specific PSA, and PSA velocity), meaningful interpretation has yet to be uniformly accepted within clinical practice. The identification of other molecular forms of PSA within serum has led to a new era in PSA markers. Initial application employing %fPSA has provided improved discrimination between benign and malignant prostatic disease; however, questions remain regarding the ultimate threshold value. The discovery of various free forms of PSA--such as proPSA, BPSA, and iPSA--also have introduced the potential for improved specificity in detection. Although early results are encouraging, further evaluation is anticipated. The development of improved methods to detect and measure cPSA has demonstrated provocative results, and exhibits the potential to replace PSA as a standard diagnostic test in cancer screening.