Systematic biopsies and digital rectal examination to identify the nerve-sparing side for radical prostatectomy without risk of positive margin in patients with clinical stage T2, N0 prostatic carcinoma

Use of PIRADS 2.1 to predict capsular invasion in patients with radiologic T3a prostate cancer

Objective

Using multi-parametric magnetic resonance imaging (mpMRI) to identify patients with clinical T3a (cT3a) who were overestimated on mpMRI with final pathological T2 (pT2). To suggest that the neurovascular bundle (NVB) can be preserved by evaluating the characteristics of patients according to their pathological grade among cT3a prostate cancer (PCa) patients using mpMRI.

Materials and methods

Patients who underwent robot-assisted laparoscopic radical prostatectomy (RALP) were retrospectively analyzed and those patients with clinical T3aN0M0 were enrolled. These enrolled patients were divided into a localized cancer group with pT2 PCa and a locally advanced group with pT3a or higher. Factors affecting the diagnosis of localized PCa after RALP in patients with cT3a PCa were evaluated.

Results

Among the preoperative parameters of patients with cT3a PCa, the prostate specific antigen density (PSAD) (OR: 3.76, 95% CI: 1.85-7.64, p<0.001), international society of urological pathology (ISUP) grade (p<0.05), and index lesion size (OR: 1.44, 95% CI: 1.85-7.64, p<0.001) were significantly associated with pathological locally advanced PCa. Optimal cut-off values for prediction of pT3a or higher were 0.36 ng/mL2 for PSAD (sensitivity: 55.7%, specificity: 70.8%), 1.77 cm for index lesion size (sensitivity: 54.3%, specificity: 66.0%), and 2.5 for ISUP grading (sensitivity: 67.6%, specificity: 53.2%). For prediction of pT3a or higher among patients with cT3a PCa, a nomogram was developed using ISUP grade, index lesion size, and PSAD on prostate biopsy (area under the curve: 0.71, 95% CI: 0.670-0.754, p<0.001). PSAD less than 0.36 index lesion size less than 1.77 cm, and biopsy ISUP grade 1-2 are highly likely to indicate that there is no actual extracapsular extension in cT3a PCa patients.

Conclusions

PSAD, ISUP, and index lesion size showed significant associations with the classification of pathologic localized and locally advanced PCa in patients with cT3a PCa. A nomogram including these features can predict the diagnosis of locally advanced PCa in patients with cT3a PCa.

Tumor focality in prostate cancer: implications for focal therapy

In recent years, there has been a growing interest in focal treatment for prostate cancer. Although widely used for the treatment of tumors of the breast and kidney, focal treatment for prostate cancer remains a controversial area. Criticism of focal prostate therapy has been based on the fact that prostate cancer is a multifocal disease. Until now, little attention has been paid to distinguishing between men with unifocal and those with multifocal disease because such information has little clinical relevance when treatment is aimed at the whole gland irrespective of the volume or number of cancers in the prostate. In this Review, we summarize existing knowledge and examine the issue of prostate cancer focality in the context of focal treatment.

Evaluation of a Contralateral Biopsy Specimen in Prostate Cancer Patients with Unilateral Suspicious Lesions

INTRODUCTION

In patients with a clinically unilateral palpable and/or visible lesion confined to the prostate on digital rectal examination and transrectal ultrasonography, the findings of biopsy specimens of a clinically unsuspicious lobe do not reflect TNM staging results (2002 classification). In patients with such a unilateral lesion, we compared the biopsy results of a clinically unsuspicious lobe with the pathological assessment of the radical prostatectomy specimen and evaluated the importance of the results of biopsy specimens in an unsuspicious lobe.

PATIENTS AND METHODS

Between April 2000 and August 2004, 97 prostatic cancer patients without neoadjuvant therapy underwent a radical retropubic prostatectomy. In the patients with a unilateral lesion on digital rectal examination and/or transrectal ultrasound, the preoperative prostate-specific antigen levels, the results of contralateral biopsy specimens, and contralateral cancer foci in radical prostatectomy specimens were examined.

RESULTS

Of 39 patients with a unilateral palpable and/or visible lesion, 15 had contralateral positive biopsy findings, while 24 had contralateral negative biopsy findings. In a pathological analysis of prostatectomy specimens, a significantly higher rate of clinically significant cancer foci and a larger cancer volume in a clinically unsuspicious lobe have been observed in patients with contralateral positive biopsy findings than in patients with contralateral negative biopsy findings (p < 0.001). Moreover, contralateral cancer foci in patients with a contralateral positive biopsy specimen exhibited a more ominous state, such as seminal vesicle invasion, extraprostatic extension, and a positive surgical margin, than those in patients with a contralateral negative biopsy specimen (40.0 vs. 8.3%, p = 0.017). However, in a pathological analysis of both ipsilateral and contralateral cancer foci, the proportion of ominous pathological findings did not differ between the patients with a contralateral positive biopsy and those with a contralateral negative biopsy.

CONCLUSIONS

In patients with clinically unilateral palpable and/or visible tumors confined to the prostate, the results of a bilateral biopsy need not be used to determine the clinical stage. However, in patients with positive biopsy results for an unsuspicious lobe, urologists should perform an extended surgical resection.

Efficacy of unilateral nerve sparing in radical perineal prostatectomy

AIM

We determine the efficacy of unilateral nerve-sparing radical perineal prostatectomy in preserving the sexual function.

PATIENTS AND METHODS

Ninety-two patients with histologically confirmed unilateral prostate cancer were scheduled for contralateral nerve preservation. The perioperative morbidity was assessed using the patients' chart reviews. Postoperative health-related quality of life, urinary continence, and potency were evaluated prospectively with questionnaires provided before surgery and then after 6, 12, and 24 months.

RESULTS

Unilateral nerve preservation was performed in 88 of the 92 patients. Due to extensive scarring or prostatic size, the procedure was terminated as regular radical prostatectomy in 4 other patients. The perioperative complication rate was low and of minor significance, except in 1 patient who experienced a significant myoglobulinuria due to a prolonged procedure. Blood transfusions were necessary in 5 (5.4%) patients. Ureteral reimplantation was performed in 1 patient because of ureteral stricture. Positive surgical margins were present in 12 (18%) of 67 pT2 patients and in 8 (35%) of 23 pT3 patients. A proportion of 48% (15/31) of the patients followed for more than 24 months and who had a good erectile function prior to surgery reported unassisted sexual intercourse. However, only 4 of these patients were completely satisfied with all aspects of sexual performance, as asked in a short version of the International Index of Erectile Function questionnaire.

CONCLUSIONS

Unilateral nerve-sparing radical perineal prostatectomy is technically feasible and yields excellent results in terms of potency preservation for prostates <60 ml. However, the quality of erections is decreased, even in patients with erections sufficient for intercourse. Hence, appropriate sexual counseling in conjunction with medical therapy should be offered to all patients.

Influence of nerve-sparing (NS) procedure during radical prostatectomy (RP) on margin status and biochemical failure

PURPOSE

To evaluate whether nerve-sparing procedure itself is a risk factor for biochemical recurrence in carefully selected patients.

MATERIAL AND METHODS

We compared patients of our historical series who in retrospect were candidates for nerve-sparing (NS) procedure with a contemporary cohort of patients. With respect to stage migration and selection bias between these two groups we performed a multivariate analysis adjusting for all explanatory variables in the model. NS was performed in n = 723 patients (bilateral n = 359, unilateral n = 364) in comparison to n = 620 patients undergoing non-NS RP, comprising n = 756 patients within the favorable pT2 category. We examined the association of clinical and histopathological parameters in relation to PSA recurrence in uni- and multivariate analyses including NS as a variable. Furthermore, for each prostate lobe separately we determined whether surgical procedure (nerve-sparing vs. non-nerve-sparing RP) resulted in a positive margin.

RESULTS

In univariate analysis there was no difference in pT2 (log rank p = 0.091), pT3a (log rank p = 0.171) and pT3b (log rank p = 0.110) cancers between patients treated with NS compared to non-NS surgery. The 3- and 5-year recurrence free survival rate for patients with pT2, pT3a and pT3b cancers treated by NS vs. non-NS were 96.3/94.9 vs. 94.9/90.8, 75.0/61.8 vs. 73.4/55.0 and 46/30 vs. 38/23. Multivariate regression analysis showed no association with PSA failure (p = 0.798) for patients who underwent NS. Capsular penetration (p < 0.001), lymph-node status (p < 0.001), seminal vesicle invasion (p < 0.001), surgical margin status (p = 0.0130), Gleason score (p < 0.001) and preoperative PSA (p = 0.005) were significantly associated with risk of failure. The positive margin rate per each prostate lobe in pT2 cancers was 6.5% vs. 5.1% in NS and non-NS cases, 10.3% vs. 17.3% in patients with extracapsular extension and 15.0% vs. 25.1% in cases with seminal vesicle invasion respectively.

CONCLUSION

NS RP is an oncologically safe procedure provided that appropriate preoperative selection of patients by means of a validated nomogram is performed. Moreover, evaluation of positive margins in patients undergoing NS and non-NS RP revealed no evidence that adequacy of tumor excision is compromised by NS procedure.

Prediction of extraprostatic extension in the neurovascular bundle based on prostate needle biopsy pathology, serum prostate specific antigen and digital rectal examination

PURPOSE

There are few studies on predictors of extraprostatic extension (EPE) in the region of the neurovascular bundle (NVB). We investigated whether clinical information and prostate biopsy data could predict EPE of clinical localized prostate cancer.

MATERIALS AND METHODS

Through a retrospective analysis of the pathology database we identified 2,660 cases of clinically localized prostate cancer treated with radical retropubic prostatectomy without preoperative adjuvant therapy at The Johns Hopkins Hospital. The study sample involved a total of 3,006 lobes with prostate cancer including 2,070 with organ confined disease, 620 with EPE in the NVB at the posterolateral edge of the prostate and 316 with EPE in a region other than the NVB (EPE elsewhere). Through univariate and multivariate logistic regression analysis we determined whether patient age, year of surgery, serum prostate specific antigen, digital rectal examination, biopsy highest Gleason score, perineural invasion, percent of side specific biopsy cores with cancer, percent of each core involved with cancer and the maximum percent of a core involved with cancer was predictive of EPE in the NVB.

RESULTS

Prostate specific antigen (10 or greater vs less than 10), biopsy Gleason score (7 or greater vs 6 or less), digital rectal examination (abnormal vs normal), percent of side specific cores with tumor (greater than 33.3% vs 33.3% or less) and average percent involvement of each positive core (greater than 20% vs 20% or less) were all found to be statistically significant independent predictors of NVB penetration in multivariate analysis. The generated model stratifies each of these variables into high and low risk. The probability of EPE in the NVB was less than 10% in cases with 1 or fewer of the higher risk variables and was 10% or greater in cases with more than 1 of the higher risk variables.

CONCLUSIONS

The model generated in this study allows for the preoperative identification of patients with 10% or greater probability of EPE in the NVB. Our algorithm will help provide objective parameters that aid in the decision to spare the NVB safely.

Nerve-sparing radical retropubic prostatectomy: techniques and clinical considerations

There are essentially two ways to accomplish nerve preservation during radical retropubic prostatectomy: the 'apical approach' described by Walsh and the so-called 'lateral approach', a simplified method where the dissection is initially conducted on the portion of the bundles that courses posterolateral to the prostate. Do the different techniques differ in the ability to preserve potency and in the positive surgical margins rate? No previous study has addressed this question. Above all, the preoperative and intraoperative indications to spare or not the nerves remain a matter of debate. The present review is an attempt to elucidate these questions in light of the current literature.

Tumor length and location of cancer on biopsy predict for side specific extraprostatic cancer extension

PURPOSE

We studied preoperative variables in a contemporary series of men who underwent nonnerve sparing radical prostatectomy in an effort to establish criteria that would predict side specific extraprostatic extension (EPE) of cancer.

MATERIALS AND METHODS

We reviewed the records of 430 patients who underwent radical prostatectomy for localized prostate cancer with no prior therapy between 1996 and 1998, and for whom we had at least sextant biopsy information. We evaluated biopsy data (Gleason score, maximum length of cancer in positive cores, percent of cancer per involved core, proportion of positive biopsy cores, tumor location and number of positive biopsy cores) and correlated these findings with EPE at the neurovascular bundle and posterior lateral (NVB/PL) region.

RESULTS

We found that a higher number of positive cores, a higher biopsy Gleason score on a side, a positive core at the basal region, 50% or greater tumor in the core or a maximum tumor length of 7 mm or greater increased the likelihood that EPE was present at the NVB/PL region on the corresponding side of the prostate. On multivariate analysis maximum tumor length 7 mm or greater and positive basal core location were the strongest independent predictors of EPE at the NVB/PL region on a given side (p <0.0001 and 0.002, respectively).

CONCLUSIONS

Excluding any patient with 1 positive biopsy core with a maximum tumor length of 7 mm or greater plus a positive basal core of any tumor length and grade can decrease the risk of EPE at the NVB/PL region to approximately 10%.

Site-specific positive margins at radical prostatectomy: assessing cancer-control benefits of wide excision of the neurovascular bundle on a side with cancer on biopsy

OBJECTIVE

To determine the potential risk of biopsy-selected nerve-sparing surgery based on the findings of site-specific extracapsular extension (ECE) and positive surgical margins (PSMs) in the area of the neurovascular bundle in radical prostatectomy specimens.

PATIENTS AND METHODS

Controlling for surgical technique and pathological interpretation, 221 consecutive patients had their neurovascular bundles removed on the side with a positive biopsy. The surgical specimens were reviewed for ECE and PSM status, specifically in the area of the neurovascular bundle, from apex to base.

RESULTS

Of the 221 patients, 38% had ECE and 43 (20%) had a PSM in the area of the neurovascular bundle. This equates to a ratio of 51% for PSM/ECE. An additional 42 men (18%) had ECE with negative margins, but would have been at potential risk for PSMs if the neurovascular bundle had been preserved.

CONCLUSION

Preserving the neurovascular bundle on the side with a positive biopsy could result in a significantly greater incidence of PSM than with wide excision. Optimizing cancer control may require excision of the neurovascular bundle on a side known to have cancer on biopsy. In future site-specific analyses, the PSM/ECE ratio could be used as a marker comparing cancer-control outcomes from studies with differing technical approaches and indications for nerve-sparing surgery.

Can predictive models for prostate cancer patients derived in the United States of America be utilized in European patients? A validation study of the Partin tables

OBJECTIVES

Prostate cancer patients in the US and Europe differ due to selection and treatment differences. Accuracy of predictive tools derived in the US might therefore suffer when applied to European patients. We tested the validity of the widely accepted Partin tables for their ability to predict pathologic stage in German patients.

METHODS

Clinical and pathological characteristics were obtained from 1,298 consecutive men with clinically localized prostate cancer undergoing radical prostatectomy at the University Hospital Hamburg between January 1992 and February 2000. Receiver operating characteristic (ROC) curve analysis was performed to compare observed and predicted Partin rates for each pathologic stage.

RESULTS

The rate for organ confinement was 56% in Hamburg patients compared to 48% in the Partin study. The rates of Hamburg patients for extracapsular extension without seminal vesicle or lymph node involvement were 25%, for seminal vesicle without lymph node involvement 14% and for lymph node metastases 5%. The corresponding rates of the Partin study were 40, 7 and 5%, respectively. The accuracy of Partin table derived probability was high with an area under the ROC curve of 0.817 (95% CI, 0.757-0.876) for organ confinement and 0.807 (95% CI, 0.781-0.833) for lymph node involvement.

CONCLUSION

Our study demonstrated that predictive tools for prostate cancer developed in the US could be applied to European patients with comparable accuracy to that reported for validation studies performed with US patients.

Patient-reported sexual function after nerve-sparing radical retropubic prostatectomy

OBJECTIVE

Improved selection criteria have lead to an increasing number of nerve-sparing radical retropubic prostatectomies (RRP) in patients with clinically localised prostate cancer (PCA). Patient questionnaire based outcome analysis on post-operative erectile function after uni- or bilateral nerve-sparing RRP is described.

METHODS

Between January 1992 and March 1999, 366 patients (mean age 62.5 years) underwent uni- or bilateral nerve-sparing RRP at our institution. Indication for nerve-sparing procedure was based on the results of a multivariate classification and regression tree analysis (CART). For evaluation of post-operative patient-reported rates of sexual and erectile function non-validated and validated questionnaires (IIEF 5) were administered after a follow-up of 12 months. Data of five operation periods were analysed.

RESULTS

The unilateral procedure resulted in rates of 13-29% of erections sufficient for unassisted intercourse. Some degree of tumescence was reported by 37-73% of the remaining patients. Bilateral nerve-sparing procedures were almost exclusively performed in periods 3-5, only four patients of period 2 received the bilateral procedure. Here, rates of erections sufficient for intercourse were 25% (period 2), 61% (period 3), 50% (period 4), and 52% (period 5), respectively. Patients with grades 4 and 5 erections had IIEF scores of 19.2 and 20.2 and patients without rigidity or tumescence had scores of 5.7 and 7.0 after uni- and bilateral nerve-sparing procedure, respectively. Patients <60 years of age had better erections than those > or =60 (unilateral: 19% versus 13%, bilateral 45% versus 38%).

CONCLUSION

Compared to a unilateral nerve-sparing procedure, the bilateral nerve-sparing technique revealed much better results inasmuch as about 50% of the patients reported recovery of erections sufficient for sexual intercourse without use of sexual aids.

Biological selection criteria for radical prostatectomy

Tumors clinically confined to the prostate gland (T1-2) are heterogeneous with respect to pathological staging and outcome after definitive radical surgery (radical prostatectomy). The preoperative prognostic factors that could predict pathological stage and outcome of individual patients with clinically localized prostate cancer are reviewed. New preoperative factors have been identified by histological analysis of needle biopsy prostate specimens in addition to Gleason grading score, serum markers (PSA), and clinical staging. These factors are related to tumor volume, zonal origin of the tumor, and spread into the gland and surrounding tissues. Other biological factors are identified by molecular and immunohistochemical analysis (neuroendocrine differentiation, DNA content, microvessel density, and perineural invasion). Biomolecular factors can also be assessed preoperatively on serum samples (free/total PSA ratio, PSA RT-PCR). Although only a few of these factors have a role in predicting treatment failure and/or disease recurrence, the neural network analysis seems to be the most important tool for identifying patients with more aggressive disease. A combination of these new factors, also using neural networks, could be relevant in the preoperative management of patients with prostate cancer to identify those with confined disease and to select those suitable for a "nerve sparing radical prostatectomy" to preserve sexual function and to achieve definitive cancer control.

Preoperative predictors of cancerous involvement of the neurovascular bundles in patients with localized prostate cancer

BACKGROUND

The purpose of this study was to identify preoperative variables that would be useful in objectively selecting prostate cancer patients for nerve-sparing prostatectomy.

METHODS

Twenty-six patients with clinical T1c-T2c cancers were evaluated for cancerous involvement in the region of the neurovascular bundles (NVB) from prostatectomy specimens. Preoperative prostate-specific antigen (PSA) and pathologic features in systematic biopsy specimens also were reviewed.

RESULTS

A total of eight (31%) patients had cancerous involvement in the region of the NVB, including four on the right side, three on the left side and one on both sides. The percentage of each biopsy specimen occupied by the cancer was scored from zero to four and defined as the positive biopsy score. Preoperative PSA (P = 0.046), mean positive biopsy score (total sum of positive biopsy score divided by number of biopsy specimens; P = 0.001), number of cores containing cancer (P = 0.011), percentage of cores involved (P = 0.036) and maximum positive biopsy score (P < 0.001) were significant for predicting cancerous involvement in the NVB region using univariate analysis. However, only the mean positive biopsy score was independently significant according to multivariate analysis. To predict cancerous involvement in the region of each NVB, we found that ipsilateral mean positive biopsy score (total sum of corresponding positive biopsy score divided by number of ipsilateral biopsy specimens), number of cores involved on the ipsilateral side, percentage of cores involved on the ipsilateral side and maximum positive biopsy score on the ipsilateral side were significant predictive variables: the ipsilateral mean positive biopsy score being most appropriate for clinical practice.

CONCLUSION

Ipsilateral mean positive biopsy score in systematic biopsy specimens can be an appropriate variable for selecting patients with localized prostate cancer for nerve-sparing prostatectomy.

Clinical staging of prostate cancer: reproducibility and clarification of issues

The American Joint Committee on Cancer (AJCC) staging system for prostate cancer adopted in 1992 is based on tumor-node-metastasis (TNM) designations. It has been widely accepted for use in local and advanced disease. The purpose of this study was to assess reproducibility of staging among observers and to help clarify staging issues. Twelve prostate cancer cases were sent to 20 physicians with special expertise in prostate cancer including eight urologists, eight radiation oncologists, and four medical oncologists. Physicians were asked to assign a stage based on the 1992 AJCC clinical staging. The most frequently reported stage assigned to each case was taken to be the consensus. Agreement was the percentage of physicians who reported that particular stage. Seventy-five percent of the physicians responded. The overall agreement for assignment of T stage was 63.9%. Differences were found by specialty for inclusion of available information in designating a T stage. The overall agreement for N stage was 73.8%. The most common designation was Nx regardless of availability of a computed tomography scan. The overall agreement for M stage was 76.6%. Without a bone scan the most common designation was Mx regardless of Gleason grade or prostate-specific antigen (PSA). A frequent comment was that PSA was more indicative of disease extent than current clinical staging. The reproducibility of the 1992 clinical AJCC staging is poor even among experts in the field. This problem arises primarily from disagreement regarding which studies are included in assigning a stage. Some of these difficulties are addressed in the 1997 revision. However, the clinical staging does not address the true biological significance of disease in many instances.

Incidence of positive surgical margins after biopsy-selected nerve-sparing radical prostatectomy

OBJECTIVES

The selection criteria for a nerve-sparing radical prostatectomy (NSRP) are not thoroughly investigated and are based mainly on preoperative digital rectal examinations and intraoperative findings. At our institution NSRP is performed only on patients whose preoperative systematic sextant biopsy of the prostate showed only unilateral cancer. To prove the safety of these criteria, we analyzed the incidence of positive surgical margins and tumor progression rate in patients who were selected for an NSRP only by the result of the biopsy.

METHODS

Preoperative systematic sextant biopsies revealed unilateral cancer in 69 preoperatively potent men of 289 consecutive prostatic cancer patients (23.9%); contralateral NSRP was performed on these 69 patients. The prostate specimens were investigated by using a 3-mm step-section technique to identify positive surgical margins. Tumor progression was defined as a prostate-specific antigen (PSA) level greater than 0.4 ng/mL in the native and greater than 0.025 ng/mL in the suprasensitive postoperative blood test. Mean follow-up was 15 months (range 6 to 24).

RESULTS

In 69 patients who underwent NSRP, 11 positive margins (15.9%) were found. Only 3 patients (4.3%) had a positive margin on the nerve-sparing side. In 220 patients who underwent non-NSRP 59 positive margins (26.8%) were detected. PSA recurrence rate after 12 months was similar in patients with NSRP and non-NSRP. Analysis of systematic sextant biopsies gives safe selection criteria because in approximately 95% the surgical margin on the nerve-sparing side will be negative.

CONCLUSIONS

Basing the indication for an NSRP on the results of preoperative systematic biopsies was safe according to margin status and postoperative PSA, when all patients with tumor in one of the three biopsy cores of each side of the prostate were excluded from an NS technique on that side. Such a strict approach will exclude approximately 30% of patients from NSRP unnecessarily because of tumor findings on a prostate side where the cancer is still organ-confined. Less strict criteria, including patients with only well-differentiated cancer and a maximum of one positive biopsy on the evaluated side, seem to be as safe as the described selection. However, data on these patients need further evaluation.

Stage T1c prostate cancer: defining the appropriate staging evaluation and the role for pelvic lymphadenectomy

A good staging system should be able to accurately reflect the natural history of a malignant disease, to express the extent of the disease at the time of diagnosis, and stratify patients in prognostically distinctive groups. The staging system for prostate cancer, as it is today, fails to fulfill these requirements. Approximately one third of the patients who undergo surgery for complete excision of prostate cancer in fact do not have a localize disease. The incidence of tumor at the inked margin may reach 30% for T1 stage and up to 60% for clinical T2b prostate cancer according to comparison with pathologic examination of resected specimen. Several concepts have been recently proposed as a means of improving the accuracy of the available staging system. In this paper, we review current aspects of clinical and pathological staging of prostate cancer, and the importance of these new concepts on the early stages of prostate cancer.

Update on the appropriate staging evaluation for newly diagnosed prostate cancer

PURPOSE

Prostate cancer clinical staging methods and decision support tools were reviewed to assess their accuracy to predict pathological staging results and determine what comprises an appropriate clinical staging evaluation.

MATERIALS AND METHODS

The MEDLINE data base was searched and 238 abstracts were obtained. Data were extracted from 142 articles that evaluated the preoperative accuracy of digital rectal examination, prostate specific antigen, prostatic acid phosphatase, systematic biopsy parameters (including Gleason scoring), seminal vesicle biopsy, various imaging studies and pelvic lymphadenectomy versus pathological staging results. The sensitivity, specificity and accuracy rates were calculated and tabulated from the reported data on each method or decision support tools for organ confined, nonorgan confined and lymph node metastatic tumor.

RESULTS

Decision support tools based on logistic regression analysis, which combine several statistically independent staging parameters, had greater accuracy than any single clinical staging method alone. The most accurate decision support tools for clinical staging combined digital rectal examination (T stage), systematic biopsy parameters (including Gleason scoring) and prostate specific antigen.

CONCLUSIONS

The components that comprise the most accurate decision support tools for clinical staging represent an appropriate staging evaluation for the newly diagnosed prostate cancer patient in 1997. Limited use of radiographic imaging and seminal vesicle biopsy may be indicated in select patients to detect bone metastases, and plan pelvic lymphadenectomy and surgical therapy.