Should Gleason score 7 prostate cancer be considered a unique grade category?

Significance of tertiary Gleason pattern 5 in patients with Gleason score 7 after radical prostatectomy: a retrospective cohort study

PURPOSE

To evaluate the association between tertiary Gleason pattern 5 (TGP5) and biochemical recurrence (BCR) in patients with prostate cancer (PCa) with a Gleason score (GS) of 7 after radical prostatectomy (RP).

PATIENTS AND METHODS

This retrospective study identified 350 patients who received RP and were graded as GS 7 (3+4 or 4+3) at the West China Hospital from January 2009 to December 2017. Initially, the patients were divided into two groups, TGP5 absence and TGP5 presence, independent of Gleason score. We further stratified the patients by adding the Gleason score into four groups: GS 3+4, GS 3+4/TGP5, GS 4+3, and GS 4+3/TGP5. Cox proportional-hazards models were used to evaluate the association between the status of TGP5 and BCR after adjusting for the confounding factors.

RESULTS

The risk of BCR was significantly higher in patients with TGP5 when compared to patients without TGP5 (P=0.04, HR=2.17 95%, Cl: 1.03-4.59). For patients with primary Gleason pattern 4, the risk of BCR for patients with Gleason 4+3/TGP5 was statistically significantly higher than Gleason 4+3 (P=0.04, HR=2.45, 95% Cl: 1.04-5.76).

CONCLUSION

The TGP5 in patients with GS 7 had strong association with the risk of BCR and was an independent predictor for BCR. Further research on larger data sets is needed to confirm these findings.

Machine learning classifiers can predict Gleason pattern 4 prostate cancer with greater accuracy than experienced radiologists

OBJECTIVE

The purpose of this study was: To test whether machine learning classifiers for transition zone (TZ) and peripheral zone (PZ) can correctly classify prostate tumors into those with/without a Gleason 4 component, and to compare the performance of the best performing classifiers against the opinion of three board-certified radiologists.

METHODS

A retrospective analysis of prospectively acquired data was performed at a single center between 2012 and 2015. Inclusion criteria were (i) 3-T mp-MRI compliant with international guidelines, (ii) Likert ≥ 3/5 lesion, (iii) transperineal template ± targeted index lesion biopsy confirming cancer ≥ Gleason 3 + 3. Index lesions from 164 men were analyzed (119 PZ, 45 TZ). Quantitative MRI and clinical features were used and zone-specific machine learning classifiers were constructed. Models were validated using a fivefold cross-validation and a temporally separated patient cohort. Classifier performance was compared against the opinion of three board-certified radiologists.

RESULTS

The best PZ classifier trained with prostate-specific antigen density, apparent diffusion coefficient (ADC), and maximum enhancement (ME) on DCE-MRI obtained a ROC area under the curve (AUC) of 0.83 following fivefold cross-validation. Diagnostic sensitivity at 50% threshold of specificity was higher for the best PZ model (0.93) when compared with the mean sensitivity of the three radiologists (0.72). The best TZ model used ADC and ME to obtain an AUC of 0.75 following fivefold cross-validation. This achieved higher diagnostic sensitivity at 50% threshold of specificity (0.88) than the mean sensitivity of the three radiologists (0.82).

CONCLUSIONS

Machine learning classifiers predict Gleason pattern 4 in prostate tumors better than radiologists.

KEY POINTS

• Predictive models developed from quantitative multiparametric magnetic resonance imaging regarding the characterization of prostate cancer grade should be zone-specific. • Classifiers trained differently for peripheral and transition zone can predict a Gleason 4 component with a higher performance than the subjective opinion of experienced radiologists. • Classifiers would be particularly useful in the context of active surveillance, whereby decisions regarding whether to biopsy are necessitated.

Increased HSF1 expression predicts shorter disease-specific survival of prostate cancer patients following radical prostatectomy

Prostate cancer is a highly heterogeneous disease and the clinical outcome is varying. While current prognostic tools are regarded insufficient, there is a critical need for markers that would aid prognostication and patient risk-stratification. Heat shock transcription factor 1 (HSF1) is crucial for cellular homeostasis, but also a driver of oncogenesis. The clinical relevance of HSF1 in prostate cancer is, however, unknown. Here, we identified HSF1 as a potential biomarker in mRNA expression datasets on prostate cancer. Clinical validation was performed on tissue microarrays from independent cohorts: one constructed from radical prostatectomies from 478 patients with long term follow-up, and another comprising of regionally advanced to distant metastatic samples. Associations with clinical variables and disease outcomes were investigated. Increased nuclear HSF1 expression correlated with disease advancement and aggressiveness and was, independently from established clinicopathological variables, predictive of both early initiation of secondary therapy and poor disease-specific survival. In a joint model with the clinical Cancer of the Prostate Risk Assessment post-Surgical (CAPRA-S) score, nuclear HSF1 remained a predictive factor of shortened disease-specific survival. The results suggest that nuclear HSF1 expression could serve as a novel prognostic marker for patient risk-stratification on disease progression and survival after radical prostatectomy.

Marital status independently predicts prostate cancer survival in men who underwent radical prostatectomy: An analysis of 95,846 individuals

Marital status is an independent prognostic factor for survival in several types of cancer, but has not been fully studied in prostate cancer (PCa). A total of 95,846 men diagnosed with PCa were treated with radical prostatectomy (RP) between 2004 and 2009 within 18 Surveillance, Epidemiology and End Results registries. Survival curves were generated using Kaplan-Meier estimates and differences in survival were assessed using the log-rank test. Cox regression models were used to assess the impact of marital status on survival outcomes. The results demonstrated that the 8-year cancer-cause specific survival (CSS) rate of married men was higher than unmarried individuals. Further analyses revealed that divorced/separated men had a higher proportion of high Gleason scores (GS) PCa at diagnosis [hazard ratio (HR), 1.12; P=0.007] and those patients had the worst survival outcomes independent of age, ethnicity, grade, stage and sequence number [HR, 1.61; 95% confidence interval (CI), 1.34-1.93]. Interestingly, it was observed that CSS among divorced/separated men decreased as the GS increased (GS≤6: HR, 2.5; GS=7: HR, 1.71; GS≥8: HR, 1.50; all P<0.05). Apart from that, no significant differences in CSS were observed in those who had never been married (HR, 1.20) or were widowed (HR, 1.13) relative to the married group. The results of the present study support the hypothesis that marital status is an independent prognostic factor among men with PCa who underwent RP. It was demonstrated that the mortality rates of divorced or separated men with PCa were significantly greater compared with the other groups. A further understanding of the potential associations among marital status, psychosocial factors and survival outcomes may help in developing novel, more effective methods of treating different groups of patients with PCa.

Whole-lesion apparent diffusion coefficient metrics as a marker of percentage Gleason 4 component within Gleason 7 prostate cancer at radical prostatectomy

PURPOSE

To retrospectively assess the utility of whole-lesion apparent diffusion coefficient (ADC) metrics in characterizing the Gleason 4 component of Gleason 7 prostate cancer (PCa) at radical prostatectomy.

MATERIALS AND METHODS

Seventy patients underwent phased-array coil 3T-magnetic resonance imaging (MRI) before prostatectomy. A uropathologist mapped locations and Gleason 4 percentage (G4%) of Gleason 7 tumors. Two radiologists independently reviewed ADC maps, aware of tumor locations but not G4%, and placed a volume-of-interest (VOI) on all slices including each lesion on the ADC map to obtain whole-lesion mean ADC and ADC entropy. Entropy reflects textural variation and increases with greater macroscopic heterogeneity. Performance for characterizing Gleason 7 tumors was assessed with mixed-model analysis of variance (ANOVA) and logistic regression.

RESULTS

Among 84 Gleason 7 tumors (G4% 5%-85%, median 30%; 59 Gleason 3+4, 25 Gleason 4+3), ADC entropy was significantly higher in Gleason 4+3 than Gleason 3+4 tumors (R1: 5.27 ± 0.61 vs. 4.62 ± 0.78, P = 0.001; R2: 5.91 ± 0.32 vs. 5.57 ± 0.56, P = 0.004); mean ADC was not significantly different between these groups (R1: 0.90 ± 0.15*10(-3) cm(2) /s vs. 0.98 ± 0.21*10(-3) cm(2) /s, P = 0.075; R2: 1.06 ± 0.19*10(-3) cm(2) /s vs. 1.14 ± 0.16*10(-3) cm(2) /s, P = 0.083). The area under the receiver operating characteristic (ROC) curve (AUC) for differentiating groups was significantly higher with ADC entropy than mean ADC for one observer (R1: 0.74 vs. 0.57, P = 0.027; R2: 0.69 vs. 0.61, P = 0.329). For R1, correlation with G4% was moderate for ADC entropy (r = 0.45) and weak for mean ADC (r = -0.25). For R2, correlation with G4% was moderate for ADC entropy (r = 0.41) and mean ADC (r = -0.32). For both readers, ADC entropy (P = 0.028-0.003), but not mean ADC (P = 0.384-0.854), was a significant independent predictor of G4%.

CONCLUSION

Whole-lesion ADC entropy outperformed mean ADC in characterizing Gleason 7 tumors and may help refine prognosis for this heterogeneous PCa subset.

Prognostic value of stromal and epithelial periostin expression in human prostate cancer: correlation with clinical pathological features and the risk of biochemical relapse or death

BACKGROUND

The purpose of the present study was to evaluate the prognostic value of POSTN expression following prostatectomy.

METHODS

Periostin (POSTN) expression in prostate cancer (PCa) and in normal specimens was evaluated in 90 patients by an immuno-reactive score(IRS) based on the intensity of immunostaining and on the quantity of stained cells. The t-test was applied to compare IRS values in cancer specimens to values in normal specimens. Pearson's test was used to correlate POSTN expression to clinical pathologic features. PSA progression-free and survival curves were constructed by the Kaplan-Meier method and compared using the log-rank test. Multi-parametric models were constructed according to the Cox technique adding all the covariates predicting for either PSA progression or death into the models after univariate analysis.

RESULTS

Both stromal and epithelial POSTN expression were significantly increased in tumor tissues. In particular, we found stromal expression to be significantly higher than epithelial expression as compared to normal tissues (p<0.000 and p=0.001).A significant correlation between POSTN epithelial expression and extra-prostatic extension was found (p=0.03). While high stromal expression was significantly associated with shorter survival (p=0.008), a low epithelial score significantly correlated with shorter PSA-free survival (p=0.04), suggesting that POSTN plays an apparently opposing biological role depending on its compartmentalization.Regardless of the mechanism that is involved, patients showing both high stromal and low epithelial expression made up a subgroup with a very bleak prognosis.

CONCLUSIONS

Although requiring further validation through larger studies, our findings show that POSTN might represent a novel prognostic marker for PCa.

Biochemical recurrence in Gleason score 7 prostate cancer in korean men: significance of the primary Gleason grade

Purpose

To evaluate the impact of primary Gleason grade in Gleason score (GS) 7 prostate cancer on biochemical recurrence (BCR) after radical prostatectomy in Korean men.

Materials and Methods

We retrospectively reviewed records of 1,026 patients who underwent radical prostatectomy at Seoul National University Bundang Hospital between November 2003 and June 2009. We excluded patients who had received neoadjuvant therapy and had positive resection margins. Finally, 295 and 113 patients with GS 3+4 and GS 4+3, respectively, were included in this study. All patients were followed for at least 2 years.

Results

Of the 408 GS 7 patients, 295 (72.3%) were 3+4 and 113 (27.7%) were 4+3. Mean serum prostate specific antigen level in primary Gleason 3 was 8.99 ng/ml and primary Gleason 4 was 11.11 ng/ml. Patients with GS 4+3 were more likely to have extracapsular extension (30.1% vs. 17.6%, p<0.010) and lymphatic invasion (16.8% vs. 7.1%, p<0.005). After 2 years follow up BCR was detected in a total of 40 patients. In GS 7 with primary Gleason 3, BCR occurred in 15 (5.08%) patients while 20 (17.70%) showed BCR in GS 7 with primary Gleason 4.

Conclusions

In this study of a large, single center cohort of Korean men with GS 7 prostate cancer a noticeable difference in BCR was seen. Primary Gleason grade 4 have a higher risk of BCR compared to primary Gleason grade 3. This information may be useful when counseling patients on their prognosis and further management options.

Associations of serum sex steroid hormone and 5α-androstane-3α,17β-diol glucuronide concentrations with prostate cancer risk among men treated with finasteride

BACKGROUND

Finasteride, an inhibitor of 5α-reductase (type II), lowers intraprostatic dihydrotestosterone (DHT), which is reflected in serum as reduced 5α-androstane-3α,17β-diol glucuronide (3α-dG). It also modestly increases serum testosterone (T), estrone (E(1)), and estradiol (E(2)). In this altered hormonal milieu, it is unknown whether serum concentrations of these hormones are associated with prostate cancer risk.

METHODS

In this nested case-control study of men in the finasteride arm of the Prostate Cancer Prevention Trial, sex steroid hormones and sex hormone binding globulin were measured at baseline and approximately 3-year posttreatment in 553 prostate cancer cases and 694 controls.

RESULTS

Median posttreatment changes in concentrations of 3α-dG, T, E(1), and E(2) were -73.8%, +10.1%, +11.2%, and +7.5% (all P < 0.001), respectively. Neither the pre- nor posttreatment concentrations of 3α-dG, nor its change, were associated with risk. Pretreatment, high concentrations of E(1) and low concentrations of T were associated with increased cancer risk [OR; 95% confidence interval (CI) quartile 4 vs. 1: 1.38 (0.99-1.93) P(trend) = 0.03; 0.64 (0.43-0.93) P(trend) = 0.07, respectively]. Posttreatment, high concentrations of both E(1) and E(2) were associated with increased cancer risk [OR; 95% CI quartile 4 vs. 1: 1.54 (1.09-2.17) P(trend) = 0.03; 1.49 (1.07-2.07) P(trend) = 0.02, respectively].

CONCLUSIONS

Among finasteride-treated men, concentrations of 3α-dG were not associated with total or Gleason grades 2 to 6, 7 to 10, or 8 to 10 cancer. High serum estrogens may increase cancer risk when intraprostatic DHT is pharmacologically lowered.

IMPACT

Low posttreatment serum estrogens may identify men more likely to benefit from use of finasteride to prevent prostate cancer.

Prognostic value of nuclear matrix protein expression in localized prostate cancer

PURPOSE

The aim of the study was to correlate nuclear matrix (NM) protein expression profiles with the risk of PSA progression or death in early prostate cancer (PCa).

METHODS

High-resolution two-dimensional gel electrophoresis (2D-PAGE) was used to identify tumor-associated NM proteins in the PCa specimens obtained from 94 patients. The association between the expression of each protein and the probability of PSA progression or death was studied through univariate analysis. Unsupervised hierarchical clustering analysis was then used to generate patient clusters showing comparable outcomes by including the proteins that were predictive at univariate analysis. PSA-free and overall survival curves relative to each cluster were constructed by means of the Kaplan-Meier method and curves compared by the log-rank test. Multi-parametric models were constructed according to Cox proportional hazard technique.

RESULTS

After a median follow-up of 11.7 years (range, 6.5-16.2), 50 patients progressed and 22 died. Of the eight NM proteins identified through 2D-PAGE, proteins NM-6, NM-7 and NM-8 were confirmed to be individually associated with a higher risk of PSA progression at univariate analysis. Proteins NM-6 and NM-8 were also predictive of survival probability. Hierarchical clustering analysis of these proteins allowed to identify one cluster of tumors co-expressing the three proteins or proteins NM-6 and NM-8, characterized by a very poor outcome, suggesting a specific role for these proteins in PCa progression. The predictive value of this mini-signature in respect to PSA-free survival was confirmed by multivariate analysis.

CONCLUSIONS

Changes in NM scaffolding are strongly associated with the clinical outcome of patients following radical prostatectomy.

Association of tissue promoter methylation levels of APC, TGFβ2, HOXD3 and RASSF1A with prostate cancer progression

Aberrant promoter methylation is known to silence tumor-suppressor genes in prostate cancer (PCa). We correlated quantitative promoter methylation levels of APC, TGFβ2 and RASSF1A in 219 radical prostatectomies diagnosed between 1998 and 2001 with clinicopathological follow-up data available including Gleason Pattern (GP), Gleason Score (GS) and pathological stage and explored their potential in predicting biochemical recurrence using univariate and multivariate analyses. We observed that the average methylation levels of APC increased significantly from GS ≤ 6 to GS7, and pT2 to pT3a, and that of TGFβ2 increased from GS ≤ 6 to GS7, but not for RASSF1A. PCa samples were also stratified into high methylation (HM) and low methylation (LM) groups based on the PMR scores of all cases analyzed for each marker. The HM frequency of APC was greater in pT3a than pT2, and in GS ≥ 8 than GS ≤ 6. The HM frequency also increased significantly from GP3 to GP4 for APC, TGFβ2 and RASSF1A. APC methylation level was a significant predictor of biochemical recurrence in univariate analysis (p-value = 0.028). Finally, we combined methylation data of these three genes with the previously reported novel methylation biomarker HOXD3. Quantitative methylation assessment of a multiplex panel of markers, consisting of APC, HOXD3 and TGFβ2, outperforms any single marker for the prediction of biochemical recurrence (p-value = 0.017). Our study demonstrated that quantitative increase in promoter methylation levels of APC, HOXD3 and TGFβ2 are associated with PCa progression.

Predictive value of PCA3 in urinary sediments in determining clinico-pathological characteristics of prostate cancer

PURPOSE

PCA3 urine tests have shown to improve the specificity in prostate cancer (PCa) diagnosis, and have thus the potential to reduce the number of unnecessary prostate biopsies and to predict repeat biopsy outcomes. In this study, PCA3 was correlated with clinical stage, biopsy Gleason score (GS), radical prostatectomy GS, tumor volume, and pathological stage to assess its potential as predictor of PCa aggressiveness.

METHODS

In this study, 351 men admitted for prostate biopsies based on serum PSA levels >3 ng/ml, an abnormal DRE, and/or a family history of PCa were included. Post-DRE urinary sediments from 336 men were tested using a transcription-mediated amplification-based PCA3 test, and assay results were correlated with clinical stage and biopsy GS. In a sub-cohort of 70 men who underwent radical prostatectomy, the PCA3 values were correlated to their radical prostatectomy GS, tumor volume, and pathological stage.

RESULTS

In this patient cohort we could not find a correlation between clinical stage, biopsy GS, radical prostatectomy GS, tumor volume, and pathological stage.

CONCLUSIONS

The predictive value of PCA3 for PCa aggressiveness features as reported in earlier studies cannot be confirmed in our study. Experimental differences (urine sediments vs. whole urine) and cohort may explain this. The exact place of PCA3 as prognostic test for PCa remains the subject of investigation.

Saturation biopsy improves preoperative Gleason scoring of prostate cancer

We evaluated the differences between conventional needle biopsy (CB) and saturation biopsy (SB) techniques with regard to the prediction of Gleason score, tumor stage, and insignificant prostate cancer. Data from a total number of 240 patients were analyzed. The main group, consisting of 185 patients, was diagnosed according to a saturation prostate needle biopsy protocol (SB), by which more than 12 cores were taken per biopsy. The control group was diagnosed using CB, by which 12 or less than 12 cores were taken per biopsy (n=55). In the main group, the Gleason score of the biopsy was confirmed in 19.5%, in the control group in 23.5% according to the prostatectomy specimen (p=0.50). Upgrading after the operation was found in 56.7% in the main group and in 60% in the control group (p=0.24). Downgrading after the operation was found in 23.9% in the main group and in 16.3% in the control group (p=0.24). If the Gleason score of the postoperative specimens differed by only one point from the biopsy, we considered this a minor deviation. In the main group, 59% of the carcinomas were preoperatively classified correctly or revealed minor deviation in Gleason scores. In contrast, only 47% of the carcinomas in the control group were assessed correctly or with minor deviation in Gleason scores. Thus, the main group demonstrated a better rate of preoperative prediction in tumor grading assessed by Gleason score (p=0.05). In addition, the Gleason scores of both protocols were assigned to three groups (Gleason <7; Gleason 7; Gleason >7), and the group changes from the biopsy to the prostatectomy specimen were found to be significantly more frequent in the CB group (p=0.04). There was no significant difference between the two types of biopsy techniques regarding tumor stage or the detection of insignificant carcinomas. The advantage of the extensive prostate needle biopsy technique (SB) is a better preoperative prediction of the Gleason score as well as the risk groups with Gleason scores <7, equal to 7, or >7. Both techniques fail to detect insignificant prostate cancer.

Overcoming challenges in designing and implementing a phase II randomized controlled trial using a presurgical model to test a dietary intervention in prostate cancer

BACKGROUND

The time between the diagnosis of cancer and a planned definitive surgical procedure offers a strong and direct approach for assessing the impact of interventions (including lifestyle interventions) on the biology of the target tissue and the tumor. Despite the many strengths of presurgical models, there are practical issues and challenges that arise when using this approach.

PURPOSE/METHODS

We recently completed an NIH-funded phase II trial that utilized a presurgical model in testing the comparative effects of flaxseed supplementation and/or dietary fat restriction on the biology and biomarkers associated with prostatic carcinoma. Herein, we report the rationale for our original design, discuss modifications in strategy, and relay experiences in implementing this trial related to the following topics: (1) subject accrual; (2) subject retention; (3) intervention delivery; and (4) retrieval and completion rates regarding the collection of paraffin-embedded and fresh frozen prostate tissue, blood, urine, ejaculate, anthropometric measures and survey data.

RESULTS

This trial achieved its accrual target, i.e., a racially-representative (70% white, 30% minority) sample of 161 participants, low rates of attrition (7%); and collection rates that exceeded 90% for almost all biospecimens and survey data. While the experience gained from pilot studies was invaluable in designing this trial, the complexity introduced by the collection of several biospecimens, inclusion of a team of pathologists (to provide validated readings), and shifts in practice patterns related to prostatectomy, made it necessary to revise our protocol; lessons from our experiences are offered within this article.

CONCLUSIONS

While our experience specifically relates to the implementation of a presurgical model-based trial in prostate cancer aimed at testing flaxseed-supplemented and fat-restricted diets, many of the lessons learned have broad application to trials that utilize a presurgical model or dietary modification within various cancer populations.

[(11)C]Choline positron emission tomography/computed tomography for staging and restaging of patients with advanced prostate cancer

INTRODUCTION

To evaluate [(11)C]Choline positron emission tomography (PET)/computed tomography (CT) for staging and restaging of patients with advanced prostate cancer and to compare the diagnostic performance of PET, CT and PET/CT.

METHODS

Forty-five consecutive patients with advanced prostate cancer underwent [(11)C]Choline-PET/CT between 5/2004 and 2/2006.

RESULTS

Overall, 295 lesions were detected: PET alone, 178 lesions; diagnostic CT, 221 lesions; PET/CT (low-dose CT), 272 lesions; PET/CT (diagnostic CT), 295 lesions. Two thirds of the lesions were located in the bone; one third in the prostate, lymph nodes, periprostatic tissue and soft tissue (lung, liver). The use of diagnostic CT did not result in a statistically significant difference with respect to lesion localization certainty and lesion characterization (P=.063, P=.063). PET-negative but PET/CT-positive lesions were mostly localized in the bone (78%, 91/117) as were PET-positive and CT-negative lesions (72%, 53/74). Of the latter, 91% (48/53) represented bone marrow and 9% (5/53) cortical involvement.

CONCLUSIONS

Staging and restaging with [(11)C]Choline PET/CT in patients with advanced prostate cancer improve the assessment of local and regional recurrent as well as metastatic disease including skeletal manifestations. [(11)C]Choline PET/CT (with a low-dose CT) results in improved localization and lesion characterization. [(11)C]Choline PET/CT provides an added value for skeletal manifestations. [(11)C]Choline PET/CT changed disease management in 11 (24%) of 45 patients with advanced prostate cancer.

Primary Gleason pattern does not impact survival after permanent interstitial brachytherapy for Gleason score 7 prostate cancer

BACKGROUND

The impact of primary Gleason pattern was determined on cause-specific (CSS), biochemical progression-free (bPFS), and overall survival (OS) after brachytherapy for Gleason score 7 prostate cancer.

METHODS

From April 1995 to October 2003, 530 patients underwent brachytherapy for Gleason score 3+4 (n = 300) or Gleason 4+3 (n = 230) prostate cancer. All patients underwent brachytherapy more than 3 years before analysis. The median follow-up was 5.7 years. Of the 530 patients, 412 (77.7%) received supplemental external beam radiation therapy (XRT) and 177 (33.4%) received androgen deprivation therapy. bPFS was defined by a prostate-specific antigen (PSA) </=0.40 ng/mL after nadir. Multiple parameters were evaluated as predictors of CSS, bPFS, and OS.

RESULTS

At 10 years, Gleason 3+4 versus 4+3 did not predict for CSS (96.7% vs 93.3%, P = .506), bPFS (97.0% vs 92.9%, P = .085), or OS (77.0% vs 78.0%, P = .933). Cox linear regression analysis demonstrated that clinical stage and radiation dose (D90) predicted for CSS, whereas pretreatment PSA, clinical stage, and prostate size predicted for bPFS. Patient age, diabetes, and tobacco were the strongest predictors for OS. To date, 57 patients have died, with 80.7% due to cardiovascular/pulmonary events or secondary malignancies. Five patients have died of prostate cancer.

CONCLUSIONS

The primary Gleason pattern did not impact CSS, bPFS, or OS in Gleason score 7 prostate cancer. Deaths from cardiovascular/pulmonary disease and second malignancies were 9.6 times more common than death from prostate cancer.

Should We Replace the Gleason Score with the Amount of High-Grade Prostate Cancer?

OBJECTIVES

The stage and grade shift of currently diagnosed prostate cancer has led to a diminished prognostic power of the Gleason score system. We investigated the predictive value of the amount of high-grade cancer (Gleason growth patterns 4/5) in the biopsy for prostate-specific antigen (PSA) and clinical relapse after radical prostatectomy.

METHODS

PSA-tested participants (N=281) of the European Randomized Study of Screening for Prostate Cancer (ERSPC) who underwent radical prostatectomy were analyzed. Besides clinical features, and serum-PSA, histopathologic features as determined in the diagnostic biopsy and matching radical prostatectomy specimen were related to patient outcome.

RESULTS

At a median follow-up of 7 yr, 39 (13.9%), 24 (8.5%), and 12 (4.3%) patients had PSA >/=0.1 ng/ml, PSA >/=1.0 ng/ml, and clinical relapse after radical prostatectomy, respectively. Using Cox proportional hazards, PSA level (p=0.002), length of tumour (p=0.040), and length of high-grade cancer (p=0.006) in the biopsy, but not Gleason score, were independent prognostic factors for biochemical relapse (PSA >/=0.1 ng/ml) when assessed as continuous variables. In radical prostatectomies, the proportion of high-grade cancer (p<0.001) was most predictive of relapse (PSA >/=0.1 ng/ml). For PSA >/=1.0 ng/ml and clinical relapse, the amount of high-grade cancer, both in the biopsy specimen (p=0.016 and p=0.004, respectively) and radical prostatectomy specimen (p=0.002 and p=0.005, respectively), but not Gleason score, was an independent predictor.

CONCLUSIONS

In biopsy and radical prostatectomy specimens of surgically treated prostate cancer, the amount of high-grade cancer is superior to the Gleason grading system in predicting patient outcome. We propose that, in addition to the Gleason score, the amount of Gleason growth patterns 4/5 in the biopsy (whether absolute length or proportion) should be mentioned in the pathology report.

Is it necessary to cure prostate cancer when it is possible? (Understanding the role of prostate inflammation resolution to prostate cancer evolution)

OBJECTIVE

Definitive therapy with radical prostatectomy, cryotherapy, or radiation therapy generally follows the initial diagnosis of prostate cancer, particularly when men have at least 10 additional years of life expectancy. There is growing concern regarding the optimal conservative treatment for patients who decline or do not otherwise qualify for such definitive curative treatment. For those patients who choose a watchful waiting approach, it would be beneficial to know what specific dietary and nutritional methods could potentially slow the progression of their disease. In this prospective study, it was our goal to analyze the efficacy and safety of treating prostate cancer conservatively using the principles of a Mediterranean diet in association with a specific prostate nutritional supplement.

METHOD

Twenty-three men aged 43-74 (median age: 64) with biopsy proven, organ-confined prostate cancer who had already declined immediate hormonal therapy and attempts at a curative cancer treatment agreed to participate in a Chronic Disease Management (CDM) protocol highlighted by diet with a specific prostate nutritional supplement. The diet recommended was a modified Mediterranean diet while a patented nutritional prostatitis formula (Peenuts) was the supplement common to all patients. Prostate specific antigen (PSA), a recognized marker of prostate disease and prostate cancer activity, was the primary indicator to validate exacerbation or suppression of disease. All men were followed with serial PSA testing, a digital rectal exam, an International Prostate Symptom Score index (IPSS-Index) and an expressed prostatic secretion (EPS) examination. The primary Gleason sum/score represented in this study was 6 (n = 11), while Gleason sum patterns 5, 5/6, 6/7, and 7 were also evaluated. Referencing the Partin Tables, organ confinement was predicted to be 66%.

RESULTS

Eighty-seven percent of men (n = 20) noted a 58% reduction (range of improvement: 13%-90%) in PSA over an average of 38.5 months (range: 13-84 months). The remaining 13% of men included three men who experienced a mild elevation in PSA of 0.3 ng/ml, 0.7 ng/ml, and 0.9 ng/ml over 14 months, 42 months, and 34 months, respectively. Fifteen men had completed an initial and secondary IPSS-Index while 14 men had undergone an initial and secondary EPS. The mean percentage reduction in IPSS-Index was 61% (range: 20%-100% with a median of 55%), while men evaluated with EPS examinations noted a mean percentage reduction in white blood cells of 77.5% (range: 33%-99% with a median of 82%). These results were evaluated using the t-test, Wilcoxon Analysis and the Null Hypothesis and found to be statistically significant.

CONCLUSION

Clearly there is a need to develop effective alternative conservative therapies for the increasing numbers of prostate cancer patients who will not tolerate definitive curative measures or simply choose a conservative approach. Although this prospective study had no control arm, was of limited duration and included only 23 participants, it did appear to show significant benefit to the majority of prostate cancer patients treated with selective nutritional and dietary therapy alone. Such treatments may provide a safe and effective long-term treatment alternative for some patients. Further study is encouraged.

Tertiary Gleason Pattern 5 is a Powerful Predictor of Biochemical Relapse in Patients With Gleason Score 7 Prostatic Adenocarcinoma

PURPOSE

In radical prostatectomy specimens Gleason score 7 is among the most commonly assigned scores for prostate carcinoma accounting for 30% to 50% of cases. Gleason score 7 is different from other more differentiated prostate carcinomas (tumors of Gleason scores 5 and 6) with a significantly worse outcome and higher rate of recurrence. Nonetheless, Gleason score 7 tumors are heterogeneous. In this study we examined the differences in clinical outcome between primary Gleason grade 3 and 4 tumors in patients who underwent radical prostatectomy, and determined the influence of tertiary Gleason pattern 5 on patient outcome.

MATERIALS AND METHODS

A total of 504 patients underwent radical prostatectomy for prostate cancer and 228 of the patients (45%) had a Gleason score of 7. Cases were analyzed for a variety of clinical and pathological parameters. The influence of primary Gleason pattern and tertiary Gleason pattern 5 on patient outcome was assessed in the Cox regression model.

RESULTS

Among 228 patients with Gleason score 7 prostatic adenocarcinoma, 91 (40%) had a primary Gleason pattern 4 and 137 (60%) had primary Gleason pattern 3. Patients of the former group were more likely to have a higher pathological stage (p = 0.003), more likely to have PSA recurrence (p = 0.02) and more likely to have a tertiary Gleason pattern 5 (p <0.0001). A total of 37 (41%) patients with primary Gleason 4 had a tertiary Gleason pattern 5, whereas only 13 (9%) patients with primary Gleason 3 had a tertiary Gleason pattern 5. In the Cox regression model controlling for tumor stage and surgical margin status, the primary Gleason pattern was not an independent predictor of PSA recurrence (p = 0.80), whereas the presence of tertiary Gleason pattern 5 was a significant predictor of PSA recurrence (hazard ratio 2.10, 95% CI 1.24-3.55, p = 0.006). Five-year PSA recurrence-free survival was 70% for patients without a tertiary Gleason pattern 5 compared to 19% for those patients with a tertiary Gleason pattern 5.

CONCLUSIONS

Among patients with Gleason score 7, primary Gleason grade 4 indicates a likelihood of higher tumor stage and higher probability of PSA recurrence than does primary pattern 3. However, it does not independently predict a worse outcome after controlling for other known prognostic parameters associated with disease progression. Regardless of whether the primary Gleason pattern is 3 or 4, a tertiary Gleason pattern 5 is the strongest predictor of a worse outcome in patients with Gleason grade 7 prostatic adenocarcinoma. Therefore, tertiary pattern 5 should be reported in radical prostatectomy specimens.

Prognostic factors and reporting of prostate carcinoma in radical prostatectomy and pelvic lymphadenectomy specimens

This paper, based on the activity of the Morphology-Based Prognostic Factors Committee of the 2004 World Health Organization-sponsored International Consultation, describes various methods of handling radical prostatectomy specimens for both routine clinical use and research purposes. The correlation between radical prostatectomy findings and postoperative failure is discussed in detail. This includes issues relating to pelvic lymph node involvement, detected both at the time of frozen section and in permanent sections. Issues of seminal vesicle invasion, including its definition, routes of invasion and relationship to prognosis, are covered in detail. The definition, terminology and incidence of extra-prostatic extension are elucidated, along with its prognostic significance relating to location and extent. Margins of resection are covered in terms of their definition, the etiology, incidence and sites of positive margins, the use of frozen sections to assess the margins and the relationship between margin positivity and prognosis. Issues relating to grade within the radical prostatectomy specimen are covered in depth, including novel ways of reporting Gleason grade and the concept of tertiary Gleason patterns. Tumor volume, tumor location, vascular invasion and perineural invasion are the final variables discussed relating to the prognosis of radical prostatectomy specimens. The use of multivariate analysis to predict progression is discussed, together with proposed modifications to the TNM system. Finally, biomarkers to predict progression following radical prostatectomy are described, including DNA ploidy, microvessel density, Ki-67, neuroendocrine differentiation, p53, p21, p27, Bcl-2, Her-2/neu, E-cadherin, CD44, retinoblastoma proteins, apoptotic index, androgen receptor status, expression of prostate-specific antigen and prostatic-specific acid phosphatase and nuclear morphometry.

Impact of the percentage of positive biopsy cores on the further stratification of primary grade 3 and grade 4 Gleason score 7 tumors in radical prostatectomy patients

OBJECTIVES

To examine whether the percentage of core biopsies positive can further stratify Gleason score 7 patients with primary Gleason grade into precise prognostic groups.

METHODS

Between 1991 and 1999, 379 radical prostatectomy patients were found to have pathologic Gleason 7 tumors. The patients were divided into primary grade 3 or 4. Percentage positive was calculated by dividing the number of positive core biopsies by the total number of cores.

RESULTS

In the cohort, 290 tumors were primary grade 3, and 89 were primary grade 4. On univariate analysis patients with primary grade 3 tumors had a significant prostate-specific antigen (PSA) progression-free survival advantage over grade 4 patients. When separated according to percentage of core biopsies positive, statistical analysis revealed significantly better 60-month actuarial PSA progression-free survival for patients with grade 3 and grade 4 and less than 50% core biopsies positive as compared with grade 3 and grade 4 and 50% or more core biopsies positive (85%, 85%, 61%, and 33%, respectively). Furthermore, multivariate analysis demonstrated that primary grade did not have an independent impact on biochemical progression-free survival. However, on subset analysis, among patients with 50% or more biopsy cores positive, primary Gleason grade was indeed found to have a significant, independent impact.

CONCLUSIONS

In the present study Gleason 7 patients with primary grade 4 tumors and less than 50% of biopsy cores positive had an excellent prognosis after radical prostatectomy. Our data suggest that among Gleason 7 patients, the percentage of positive biopsies is a stronger predictor of biochemical progression-free survival than primary Gleason grade.

Interval from prostate biopsy to radical prostatectomy: Effect on PSA, Gleason sum, and risk of recurrence

OBJECTIVES

To determine whether the change in prostate-specific antigen (PSA), change in Gleason sum, and/or interval between prostate biopsy and radical prostatectomy have an association with biochemical recurrence.

METHODS

The relationship between biochemical recurrence and the interval between biopsy and surgery, as well as the rate and amount of change in PSA and Gleason sum from biopsy to surgery, was evaluated in 151 patients with prostate cancer treated with radical prostatectomy.

RESULTS

A statistically significant increase was found in PSA level and Gleason sum between biopsy and surgery (P = 0.01 and P < 0.0001, respectively). No significant association was found between prebiopsy PSA level (P = 0.27) or biopsy Gleason sum (P = 0.07) with biochemical recurrence as independent variables or in a combined model (P = 0.12). An association was also not found between recurrence and preprostatectomy PSA level (P = 0.15) or the rate of PSA change (P = 0.28) as independent variables. However, a significant association was found with the prostatectomy Gleason sum (P = 0.001). In a combined model, a significant association was noted between the preprostatectomy PSA level and prostatectomy specimen Gleason sum and biochemical recurrence (P = 0.003). No increased risk of biochemical recurrence was noted with increasing time from biopsy to prostatectomy (odds ratio 1.00) or the rate (odds ratio 1.03) and degree (odds ratio 1.30) of serum PSA or Gleason sum (odds ratio 1.07).

CONCLUSIONS

The interval between biopsy and radical prostatectomy is not a predictor of biochemical failure. An association was noted between an increased risk of biochemical failure and the amount of serum PSA and Gleason sum increase between biopsy and surgery.

Pathological extension of prostate cancer as defined by Gleason score on biopsy

INTRODUCTION

Based on the importance of the Gleason score on the behavior of prostate adenocarcinoma, this study attempts to predict the extension of prostate adenocarcinoma pre-operatively, as defined by the Gleason score on biopsy, in individuals who will undergo radical prostatectomy.

MATERIALS AND METHODS

We selected 899 individuals who underwent retropubic radical prostatectomy from 1988 to 2004. Clinical and pathological data obtained in the preoperative period were retrospectively analyzed through digital rectal examinations of the prostate, initial serum PSA levels and pathological data provided by biopsy. The Gleason score on biopsy was assessed and divided into 3 groups: 2 to 6, 7, and 8 to 10, and correlated with the possibility of the disease being confined to the prostate.

RESULTS

From the 899 selected patients, 654 (74%) showed Gleason scores of 2 to 6, 165 (18%) had a score of 7 and 80 (9%) had scores of 8 to 10 on biopsy. The likelihood of confined diseases, extraprostatic extensions, invasion of seminal vesicles and lymph nodal involvement were respectively: 74%, 18%, 8% and 0.8% for a Gleason score of 2 to 6, 47%, 30%, 19% and 4% for a Gleason score of 7, and 49%, 29%, 18% and 4% for a Gleason score of 8 to 10.

CONCLUSION

In patients who will undergo radical prostatectomy due to prostate adenocarcinoma, a Gleason score of 7 on biopsy shows the same behavior as a Gleason score of 8 to 10 in relation to extension of disease.

Gleason grading and volume estimation in prostate needle biopsy specimens: evolving issues

The Gleason grading system for prostate cancer is a powerful tool that can help choose therapy and predict outcome for patients. The clinical use and problem areas of the Gleason grading system are reviewed. The issues discussed include grade discrepancies between prostate biopsy and resection specimens, grading small foci of tumor, diagnosing and grading cribriform lesions, reporting the grade when 3 grades of cancer are present in a specimen, and assignment of grade when multiple cores of differing grades are present. Finally, differing ways of communicating tumor volume and the percentage of high-grade carcinoma in prostate biopsy cores are considered.

The Impact of Primary Gleason Grade on Biochemical Outcome Following Brachytherapy for Hormone-Naive Gleason Score 7 Prostate Cancer

PURPOSE

Although the perception exists that biochemical outcome in patients with a Gleason score of 7 with dominant pattern 4 histology is inferior to that of patients with a Gleason score of 7 with a primary Gleason grade of 3, conflicting conclusions have been reported for radical prostatectomy and brachytherapy. In this study, we evaluate the effect of the dominant histologic pattern in Gleason score 7 prostate cancer on biochemical progression-free survival after brachytherapy.

MATERIAL AND METHODS

Between April 1995 and October 2001, 273 consecutive patients underwent permanent interstitial brachytherapy without androgen deprivation therapy for clinical T1c-T3a NxM0 (2002 American Joint Committee on Cancer) prostate cancer. No patient underwent seminal vesicle biopsy or pathological lymph node staging. All patients underwent brachytherapy more than 3 years before analysis. Biochemical progression-free survival was defined by a prostate specific antigen (PSA) cut point < or = 0.4 ng/mL after nadir or by the American Society for Therapeutic Radiology and Oncology (ASTRO) consensus definition. The median follow-up was 4.7 years. Clinical, treatment, and dosimetric parameters evaluated for biochemical progression-free survival included primary Gleason grade; clinical T stage; pretreatment PSA level; risk group; percent positive biopsy results; perineural invasion; patient age; isotope; supplemental external-beam radiation therapy; prostate volume; brachytherapy planning volume; percent of the target volume receiving 100%, 150%, and 200% of the prescribed dose (V100/150/200); minimum percent of the prescribed dose covering 90% of the target volume (D90); tobacco consumption; hypertension; and diabetes.

RESULTS

For the entire cohort, the actuarial 8-year biochemical progression-free survival rate was 94.5% and 94.8% using a PSA cut point < or = 0.4 ng/mL after nadir and the ASTRO consensus definition, respectively. For biochemically disease free patients, the median posttreatment PSA level was < 0.1 ng/mL. When the group was stratified by the dominant histologic pattern, no statistical difference in outcome was noted for any of the evaluated parameters. In forward conditional Cox regression analysis, pretreatment PSA level and percent positive biopsy results were statistically significant predictors of biochemical outcome.

CONCLUSIONS

In hormone-naive patients with a Gleason score of 7, prostate brachytherapy results in a high probability of 8-year biochemical progression-free survival and is independent of Gleason 3 + 4 versus 4 + 3 histology.

Prognostic significance of Gleason pattern in patients with Gleason score 7 prostate carcinoma

BACKGROUND

In the current study, the authors sought to further stratify the prognosis of patients with Gleason score (GS) 7 prostate carcinoma. They assessed the influence on outcome of a predominant poorly differentiated Gleason pattern (primary Gleason pattern [GP] 4) and/or a coincident small focus of poorly differentiated tumor of higher grade (tertiary GP 5).

METHODS

The authors studied 412 patients (mean postoperative follow-up, 33 months) with GS 7 tumors treated with radical prostatectomy at a single Australian campus between November 1989 and December 2002. The chi-square test, Kaplan-Meier method, and Cox proportional hazards analyses were used to evaluate the correlation between primary GP 4 and tertiary GP 5 with the occurrence of adverse pathologic features and disease recurrence.

RESULTS

In this cohort, 307 patients (75%) had primary GP 3 tumors, 105 (25%) had primary GP 4 tumors, and 17 (2.3%) had a tertiary element of high-grade tumor (GP 5). Patients with primary GP 4 tumors displayed higher rates of seminal vesicle involvement and extraprostatic extension and, along with patients with tertiary GP 5, had significantly shorter times to disease recurrence. Univariate analysis demonstrated that primary GP 4 (P = 0.0003) and tertiary GP 5 (P < 0.0001) were strong predictors of disease recurrence. Primary GP 4 (P = 0.0122) remained an independent predictor of disease recurrence on stepwise multivariate analysis.

CONCLUSIONS

Primary GP 4 tumors represented an aggressive subset of GS 7 prostate carcinomas. Primary GP was an easily accessible and clinically relevant predictor of disease recurrence in patients with GS 7 prostate carcinoma.

Pathologic features the urologist should expect on a prostate biopsy

In recent years, the pathological evaluation of prostate biopsy specimens has made great improvements in diagnostic accuracy and comprehensiveness. In this article, we review major pathological findings on prostate biopsy, their interpretation and reporting, as well as their clinical significance and utility. We discuss especially the clinically relevant histological features in either a positive or negative biopsy. We emphasize that both Gleason score and extent of cancer involvement in a needle core biopsy are important predictors of clinical outcome after either radical prostatectomy or radiation. Special issues regarding diagnosis and grading of minimal cancer on needle core biopsies are discussed. We also highlight the current standards on high-grade prostatic intraepithelial neoplasia and atypical small acinar proliferation on needle core biopsies. In summary, the pathology reports on needle biopsies are far beyond the simple presence or absence of cancer; they contain invaluable information to clinicians on patient management and counseling.

Reliability of preoperative values to determine the need for lymphadenectomy in patients with prostate cancer and meticulous lymph node dissection

INTRODUCTION

The only definite way to determine lymph node metastasis, an unfavorable prognostic factor in prostate cancer is lymphadenectomy. Due to increased morbidity and the increasing trend towards minimally invasive surgery, ways to avoid or at least limit lymphadenectomy are being sought. We routinely performed a meticulous lymphadenectomy in all patients and the goal of this study was to evaluate which of the previously proposed criteria determining who needs a lymphadenectomy can be applied in our patients.

PATIENTS AND METHODS

Patients with clinically localized prostate cancer confirmed by fine needle aspiration cytology, without neoadjuvant hormone therapy, negative pelvic and abdominal CT scans and negative bone scan underwent a radical prostatectomy with simultaneous bilateral extended lymphadenectomy.

RESULTS

Between 1989 and 1999, 463 patients were included in this study. The median age was 64 (range 44-76) years and the median PSA was 11.0 (range 0.42-172) ng/ml. A median of 21 nodes were removed per patient. One hundred and nine (24%) had lymph node metastasis: 17% of patients with a PSA value < or =20 ng/ml and 12% with a PSA value < or = 10 ng/ml. None of the patients with a preoperative grading of 1 and a PSA value < or =10 ng/ml and 10% of the "low-risk patients" with a PSA value < or = 10 ng/ml and a preoperative grading <3 had lymph node metastases. Seven percent with a PSA value < or = 10 ng/ml and a prostatectomy Gleason score under 7 were found to be node positive.

CONCLUSIONS

A significant number of patients would have been understaged and left with diseased nodes when applying preoperative PSA value < or = 10 ng/ml and grading <3/Gleason <7 as criteria for omitting lymphadenectomy. Therefore we consider meticulous lymphadenectomy a must for correct staging in all patients undergoing radical prostatectomy for prostate cancer, with the exception of patients with a grading of 1 and a PSA < or = 10 ng/ml.

Biochemical outcome for hormone-naive patients with Gleason score 3+4 versus 4+3 prostate cancer undergoing permanent prostate brachytherapy

OBJECTIVES

To determine the effect of the dominant pattern in Gleason score 7 histologic findings on biochemical no evidence of disease survival for hormone-naive patients undergoing permanent prostate brachytherapy.

METHODS

A total of 114 hormone-naive patients with Gleason score 7 histologic findings underwent transperineal ultrasound-guided permanent prostate brachytherapy for clinical T1c-T3a NxM0 adenocarcinoma of the prostate gland from April 1995 to October 1999. No patient was lost to follow-up. No patient underwent seminal vesicle biopsy or pathologic lymph node staging. Sixty-four patients were diagnosed with Gleason score 3+4 and 50 with Gleason score 4+3 prostate cancer. Twenty-one patients were implanted with either palladium 103 or iodine 125 monotherapy, and 93 patients received supplemental external beam radiotherapy with a brachytherapy boost. The median patient age was 69 years (range 49 to 79). The median follow-up was 46.4 months (range 20 to 80). The American Society for Therapeutic Radiology and Oncology consensus definition was used to determine the biochemical disease-free survival.

RESULTS

The actuarial 5-year biochemical disease-free survival rate was 90.3%. No statistically significant difference in outcome was found when stratified by the dominant pattern in Gleason score 7 histologic features (89.4% versus 91.5% for 3+4 and 4+3, respectively, P = 0.700). The biochemical no evidence of disease survival analysis in terms of the Gleason cohorts revealed no difference in terms of the choice of isotope, use of supplemental external beam radiotherapy, or preimplant prostate-specific antigen level. The median and mean postimplant prostate-specific antigen level was less than 0.1 ng/mL and 0.12 +/- 0.20 ng/mL, respectively, without a significant difference between Gleason score 3+4 and 4+3.

CONCLUSIONS

Our results indicate that the 5-year biochemical outcome with a hormone-naive prostate brachytherapy approach that uses multiple periprostatic seeds is not dependent on Gleason score 3+4 versus 4+3 histologic features.

Clinical significance of biopsy-derived primary Gleason score among radical prostatectomy candidates with Gleason 7 tumors

OBJECTIVES

To determine the clinical value of assessing primary Gleason scoring among patients with grade 7 tumors at needle biopsy with emphasis on its correlation with final pathologic stage and grade.

METHODS

A total of 108 contemporary cases of surgically treated prostate cancer graded as Gleason score 7 by needle biopsy were reviewed. The influence of primary Gleason pattern, as determined by needle biopsy, on pathologic outcomes, including positive surgical margins and extracapsular extension, was assessed. We also examined the positive predictive value of the assigned primary Gleason pattern.

RESULTS

Among the 108 cases, 79 (73.1%) and 29 (26.9%) demonstrated primary pattern 3 and 4, respectively. The positive predictive value of primary Gleason 3 and 4 was 46% and 35%, respectively. When stratified by the needle biopsy primary Gleason pattern, the incidence of extracapsular extension, positive surgical margins, and seminal vesicle involvement was not significantly different.

CONCLUSIONS

Pathologic features at radical prostatectomy among patients with biopsy-derived Gleason 7 tumors are not associated with the assigned primary pattern. These data call into question whether pathologists should issue a primary score among patients with Gleason 7 cancers at needle biopsy.

Proliferation of prostate cancer cells in the bone marrow predicts recurrence in patients with localized prostate cancer

BACKGROUND

Reverse-transcription polymerase chain reaction (RT-PCR) amplification of prostate specific antigen (PSA) mRNA has been used to detect the presence of prostate cancer cells in the peripheral blood and bone marrow of patients with clinically localized disease. Some studies have demonstrated a correlation between detection of PSA-mRNA and disease recurrence. However, many RT-PCR-positive patients remain disease-free. We propose that phenotypic characterization of individual micrometastatic cells may provide more prognostic information than mere detection of such cells.

METHODS

We studied 58 patients undergoing radical prostatectomy for clinically localized disease whose bone marrow had been found to contain PSA-mRNA by RT-PCR. Immunohistochemical detection and phenotypic characterization of micrometastatic cells was performed using a two-color technique: cytokeratin antibody for detection and the MIB-1 antibody for proliferation. The clinical endpoint was disease recurrence.

RESULTS

One or more micrometastatic cells were proliferating in 36.2% of the patients; the disease-free survival rate was 76.2% in this group. In contrast, in the patients with non-proliferating cells, 97.3% remained disease-free (P = 0.025). Multivariate analysis demonstrated that the presence of proliferating cells was the only preoperative variable that correlated with disease-free survival (P = 0.05).

CONCLUSIONS

Determination of the phenotype of individual micrometastatic cells can contribute prognostic information above and beyond the mere determination of their presence or absence. Phenotypic characterization of individual micrometastatic cells may ultimately be used to select patients for systemic therapy given either alone or in combination with local therapy.

Prognostic factors for survival of patients with pathological Gleason score 7 prostate cancer: differences in outcome between primary Gleason grades 3 and 4

PURPOSE

We evaluated differences in clinical and pathological outcomes between Gleason 3 + 4 and 4 + 3 prostate cancer.

MATERIALS AND METHODS

The radical prostatectomy whole mounted specimens from 263 men with pathological Gleason 7 tumors were identified. Gleason 3 + 4 and 4 + 3 tumors were compared in regard to pathological variables and outcome. Significance of clinical and pathological data on progression-free survival was analyzed.

RESULTS

Of the tumors 34% had a primary Gleason grade of 4, and were more likely than those with primary grade 3 to have seminal vesicle involvement (34% versus 18%, p = 0.006), a higher pathological stage (pT3 55% versus 42%, N+ 13% versus 3%, 0.001), extraprostatic extension (58% versus 38%, 0.001) and higher median preoperative prostate specific antigen (PSA) (13.5 versus 9.0 ng./ml., respectively <0.001). Mean followup plus or minus standard deviation was 6.8 +/- 1.9 years. The overall 10-year crude, cancer specific and progression-free survival rates were 83%, 99% and 58%, respectively. Primary Gleason grade was significantly associated with progression-free (risk ratio 1.6, 95% confidence interval 1.08 to 2.5, p = 0.02) but not crude and cancer-specific survival. Univariately, primary Gleason grade 4 was associated with progression-free survival, as were percent Gleason 4, seminal vesicle invasion, lymph node involvement, pT stage, margin status, DNA ploidy, preoperative PSA, cancer volume and extent of extraprostatic extension. Multivariately, only preoperative PSA (p <0.001), seminal vesicle invasion (<0.001) and DNA ploidy (0.002) were associated with progression-free survival. Primary Gleason grade and percent Gleason 4 were not identified as independently associated with progression-free survival.

CONCLUSIONS

In patients with Gleason 7 score prostate cancer primary Gleason grade 3 and 4 cancers are different in pathological parameters and prognosis. However, primary Gleason grade does not provide any additional information than other known prognostic factors, such as preoperative PSA, seminal vesicle invasion and DNA ploidy.

How accurately does prostate biopsy Gleason score predict pathologic findings and disease free survival?

OBJECTIVE

Due to the significant impact on prognosis by subgrouping of prostatectomy Gleason scores < 7, 7, and > 7, we undertook this study to answer whether the biopsy Gleason score was as predictive of disease free survival and assess the correlation with the prostatectomy Gleason score in a modern prostatectomy series.

METHODS

An analysis of 1,031 patients who underwent radical prostatectomy for clinically localized prostate cancer was performed. All data was prospectively collected. The Gleason score was categorized into 3 different groups (< 7, 7, and > 7) for biopsy and prostatectomy specimens. Disease free survival was then analyzed for each group. Discrepancies between scores and outcomes were evaluated.

RESULTS

Accurate correlation was noted in 54.8, 66.8, and 47.4% of Gleason scores < 7, 7, and > 7, respectively. Overall accuracy was 58.3%. Both, biopsy and prostatectomy Gleason score correlated significantly with disease free survival (P = 0.001), furthermore the classification (Gleason scores < 7, 7 and > 7) was highly significant (P = 0.001). Patients with prostatectomy Gleason < 7 tumors had significant survival advantage over those with biopsy Gleason < 7, (P = 0.001). However, disease free survival was superior for patients with biopsy Gleason > 7 than those with prostatectomy Gleason > 7, (P = 0.02). The overall disease free survival was similar among the patients with Gleason score of 7 (P = 0.12).

CONCLUSIONS

It appears that biopsy Gleason score, although oftentimes not correlating strongly with the prostatectomy Gleason score, is an important prognostic factor in prostate cancer. There are significant differences in disease free survival between biopsy and prostatectomy Gleason score categories.

Factors that influence the measurement of prostate cancer DNA ploidy and proliferation in paraffin embedded tissue evaluated by flow cytometry

DNA ploidy and proliferation have been shown in several studies to be prognostic markers for prostate cancer. Flow cytometry (FCM) is often used in the determination of ploidy and proliferation. However, FCM cannot readily distinguish among benign epithelium, stromal and inflammatory cells, high grade prostatic intraepithelial neoplasia (HGPIN), and cancer cells. In this study, we evaluated H&E histologic features of 322 radical prostatectomy formalin-fixed, paraffin-embedded tissue blocks used for determining DNA ploidy, percent S-phase (%S), and %S + %G2M by FCM. The microscopic findings included Gleason score, extent of cancer and HGPIN in the tissue block, and presence of a needle track. The amount of cancer in the block was expressed as a percentage of the total tissue surface area in quartiles: < or =25%, 26-50%, 51-75%, and > or =76%. The extent of HGPIN was recorded in rough 5% intervals. Needle track effect was defined as a combination of fibrohistiocytic reaction, fibrin clot, granuloma formation, and chronic inflammation. The associations between these histologic features and DNA ploidy and proliferation (%S and %S + %G2M) were assessed. In multivariate analyses, Gleason score, the amount of tumor in the tissue block, and the extent of HGPIN were significantly associated with ploidy. Gleason score was the only parameter significantly associated with the proliferation measure of %S. If we included %G2M as part of the proliferative fraction of the histogram, however, both Gleason score and the amount of tumor in the block were significantly associated with this measure of proliferation. The presence of a needle track was not significantly associated with DNA ploidy, %S, or %S + %G2M. In summary, prostate cancer DNA ploidy and proliferation results assessed by FCM in paraffin-embedded tissue blocks were associated with the Gleason score, amount of cancer in the tissue block, and extent of HGPIN. However, the presence of a needle track was not associated with the FCM results.

Prognostic significance of pathologic features in localized prostate cancer treated with radical prostatectomy: implications for staging systems and predictive models

PURPOSE

Although predicting outcome for men with clinically localized prostate cancer (PC) has improved, the staging system and nomograms used to do this are based on results from the North American health system. To be internationally applicable, these models require testing in cohorts from a variety of different health systems based on the predominant PC case identification methods used.

PATIENTS AND METHODS

We studied 732 men with localized PC treated with radical prostatectomy and no preoperative therapy between 1986 and 1999 at one Australian institution to determine the effect of clinicopathologic features on disease-free survival.

RESULTS

Preoperative serum prostate-specific antigen (PSA) concentration, Gleason score, pathologic stage, and year of surgery were independent predictors of outcome. Although margin status demonstrated only a trend toward significance in multivariate modeling overall, it proved to be independent in subgroups based on later year of surgery (1986 to 1994 v 1995 to 1998), preoperative PSA of less than 10 ng/mL, and Gleason score > or = 7. Adjuvant radiation therapy improved disease-free survival rates in patients with multiple surgical margin involvement.

CONCLUSION

This work confirms the prognostic significance of pathologic stage, Gleason score, and preoperative serum PSA. In the context of a contemporaneous screening effect in Australia, these findings may have implications for methods that predict outcome following surgery as screening becomes more prevalent in a population. The independent prognostic effect of margin status may alter with an increase in the proportion of screening-identified PCs. Staging systems and nomograms that predict outcome following surgery require validation in cohorts with different health practices before being universally applied.

Pathologic assessment of the surgical specimen

Despite the wealth of information obtained by conventional histology, long-term studies are needed to provide novel information on the correlation of pathologic findings with prognosis. Findings need to be correlated not only with PSA progression but with the more clinically important parameters of distant metastases and survival. Although conventional histology still will have a role in the evaluation of prostate cancer at radical prostatectomy and its correlation with outcome, it undoubtedly will be augmented by newer techniques. These developments must be approached critically and rationally to determine whether they provide additional prognostic information beyond that currently available using more conventional parameters.

Prognostic significance of histologic grading in patients with prostate carcinoma who are assessed by the Gleason and World Health Organization grading systems in needle biopsies obtained prior to radiotherapy

BACKGROUND

The current study was conducted to evaluate and compare the impact of two major histologic grading systems on failure-free survival in patients with prostate carcinoma who are treated with definitive radiation.

METHODS

Eligible patients for the current study had localized adenocarcinoma of the prostate (T1-4pN0M0, T3/4: 67%, median observation time: 69 months) and were treated with intent-to-cure external radiotherapy between 1989 and 1995. The specimens from 178 patients, obtained by needle biopsies, were reviewed simultaneously by two pathologists assigning World Health Organization (WHO) and Gleason grades. Three-tiered Gleason grouping distributed patients into three groups (those with a score < 7, those with a score of 7, and those with a score of 8--10), whereas two-tiered Gleason categorization distributed patients into two groups (those with a Gleason score of 7A, major 3 + minor 4 patients were added to the group of patients with a Gleason score < 7 and patients with a Gleason score of 7B, major 4 + minor 3 were added to the group of patients with a Gleason score of 8--10). Univariate and multivariate analyses were performed. A P value < 0.05 was considered to be statistically significant.

RESULTS

Three-tiered Gleason grouping resulted in a relatively even distribution of the patients (44 patients had a Gleason score < 7, 58 patients had a Gleason score of 7, and 76 patients had a Gleason score of 8--10) whereas 130 patients were determined to have Grade 2 tumors based on WHO criteria. Separating those patients with a Gleason score of 7 (score 3+4 vs. score 4+3) led to the two-tiered Gleason grouping (88 patients in the favorable group and 90 patients in the unfavorable group). The two-tiered Gleason grouping displayed differences with regard to failure-free survival with the lowest P values for all patients and separately for T1/2 versus T3/4 tumors. Together with T category and pretreatment prostate specific antigen, WHO grading, three-tiered Gleason grouping, and two-tiered Gleason grouping resulted in independent parameters in the Cox regression model. The proportional variance estimate confirmed the superior discrimination for survival of two-tiered Gleason grouping.

CONCLUSIONS

The equal allocation of patients to subgroups based on the Gleason system helps the clinician to overcome the dilemma of overrepresentation of Grade 2 patients as occurs with WHO grading. The Gleason grading system and, most likely, the two-tiered Gleason grouping appear to result in better prognostic separation of patients referred to radiotherapy for relatively advanced primary tumors. Therefore the authors recommend the routine use of Gleason grading for these patients.

Pilot study of dietary fat restriction and flaxseed supplementation in men with prostate cancer before surgery: exploring the effects on hormonal levels, prostate-specific antigen, and histopathologic features

OBJECTIVES

Dietary fat and fiber affect hormonal levels and may influence cancer progression. Flaxseed is a rich source of lignan and omega-3 fatty acids and may thwart prostate cancer. The potential effects of flaxseed may be enhanced with concomitant fat restriction. We undertook a pilot study to explore whether a flaxseed-supplemented, fat-restricted diet could affect the biomarkers of prostatic neoplasia.

METHODS

Twenty-five patients with prostate cancer who were awaiting prostatectomy were instructed on a low-fat (20% of kilocalories or less), flaxseed-supplemented (30 g/day) diet. The baseline and follow-up levels of prostate-specific antigen, testosterone, free androgen index, and total serum cholesterol were determined. The tumors of diet-treated patients were compared with those of historic cases (matched by age, race, prostate-specific antigen level at diagnosis, and biopsy Gleason sum) with respect to apoptosis (terminal deoxynucleotidyl transferase [TdT]-mediated dUTP-biotin nick end-labeling [TUNEL]) and proliferation (MIB-1).

RESULTS

The average duration on the diet was 34 days (range 21 to 77), during which time significant decreases were observed in total serum cholesterol (201 +/- 39 mg/dL to 174 +/- 42 mg/dL), total testosterone (422 +/- 122 ng/dL to 360 +/- 128 ng/dL), and free androgen index (36.3% +/- 18.9% to 29.3% +/- 16.8%) (all P <0.05). The baseline and follow-up levels of prostate-specific antigen were 8.1 +/- 5.2 ng/mL and 8.5 +/- 7.7 ng/mL, respectively, for the entire sample (P = 0.58); however, among men with Gleason sums of 6 or less (n = 19), the PSA values were 7.1 +/- 3.9 ng/mL and 6.4 +/- 4.1 ng/mL (P = 0.10). The mean proliferation index was 7.4 +/- 7.8 for the historic controls versus 5.0 +/- 4.9 for the diet-treated patients (P = 0.05). The distribution of the apoptotic indexes differed significantly (P = 0.01) between groups, with most historic controls exhibiting TUNEL categorical scores of 0; diet-treated patients largely exhibited scores of 1. Both the proliferation rate and apoptosis were significantly associated with the number of days on the diet (P = 0.049 and P = 0.017, respectively).

CONCLUSIONS

These pilot data suggest that a flaxseed-supplemented, fat-restricted diet may affect prostate cancer biology and associated biomarkers. Further study is needed to determine the benefit of this dietary regimen as either a complementary or preventive therapy.

Extended sector biopsy for detection of carcinoma of the prostate

Purpose: To determine whether an extended sector biopsy of the prostate will increase the detection of prostate cancer, without causing an increase in morbidity. Materials and Methods: A total of 74 men with a mean age of 62.3 years (46-98 years) who either had an elevated PSA or an abnormal digital rectal exam underwent a transrectal ultrasound guided needle biopsy. Beginning on 7/1/98, an extended sector biopsy technique was performed on 74 patients by one urologist (RRB). Each transrectal ultrasound guided needle biopsy included 12 total cores (normal sextant biopsy, 2 in each peripheral zone, and 2 in the transition zone). We retrospectively reviewed the biopsy results for the location of cancer. PSA data and morbidity of the procedures were reviewed. Results: Of 74 total patients, 40 (54.1%) were positive for adenocarcinoma of the prostate. There were 10 positive results detected only in the additional zones. If one looks at the total number of cancers detected (40), then 10/40 (25%) of the cancers detected were found in the additional regions only or in 13.5% of all patients biopsied. Of the 10 patients with sector only prostate cancer, 8 were detected in the peripheral zone, 1 in the transition zone and 1 in both zones. All 10 patients had a Gleason pattern score 3+3=6 or 4+3=7. There were no atypical or PIN cores found in the sector zones only. PSA ranged from 1.2-142 (median 6.0 ng/ml). The median PSA was 6.2 ng/ml in all patients found to have cancer, and 6.0 ng/ml in the cancers detected only in the additional zones. There was 1 (1.4%) complication of urinary retention and fever. Conclusion: Our study suggests that an extensive sector biopsy may increase the detection of prostate cancer by 13.5% over a routine sextant biopsy, without demonstrable serious morbidity.

The role of active treatment in early prostate cancer

The dramatic increase in the number of patients diagnosed with localized prostate cancer in the last decade presents a difficult challenge for physicians. Because the window of opportunity for cure is short it is vital to begin treatment before the cancer cells invade neighbouring tissues and organs or metastasise to other sites. This pressure of increased patient numbers provided clinicians with the opportunity to investigate other treatment options. New surgical techniques including laparoscopic radical prostatectomy, improving therapeutic radiation by the introduction of conformal radiotherapy, neutron radiation, cryosurgery, high intensity focussed ultrasound (HIF) and the revival of brachytherapy with or without external beam radiation are currently being investigated. The goal of these techniques is to treat localized prostate cancer based on the endpoints of disease specific mortality, no evidence of disease, absent or low levels of prostate-specific antigen (PSA), reduced side-effects, improved quality of life and importantly increased cost-efficacy. It is important to remember however, that watchful waiting and endocrine therapy are still valid therapy options in certain patient groups. The lack of randomized, prospective trials on local treatment of prostate cancer, makes it difficult to compare the efficacy of the different treatments, especially in terms of disease-specific survival. Trials are now in progress but it will be several years before results are available. In the meantime, we need to focus on surrogate endpoints, side effects, quality of life and the cost-efficacy of each treatment. It is also important to ensure that patients are kept informed and up-to-date with any new therapeutic developments.

Prognostic significance of Gleason score 3+4 versus Gleason score 4+3 tumor at radical prostatectomy

OBJECTIVES

To determine the clinical significance of Gleason score 3+4 versus 4+3 on radical prostatectomy.

METHODS

Of 2390 men who underwent radical prostatectomy by a single surgeon, 570 had Gleason score 7 tumors without lymph node metastasis, seminal vesicle invasion, or tertiary Gleason pattern 5. Patients were evaluated for biochemical recurrence (prostate-specific antigen progression) and distant metastases.

RESULTS

Eighty percent of patients had Gleason score 3+4, 20% had 4+3. The rate of established extraprostatic extension at radical prostatectomy for Gleason score 3+4 and 4+3 tumors was 38.2% and 52.7%, respectively (P = 0.008). With a mean follow-up of 4.6 years for men without progression, Gleason score 4+3 tumors had an increased risk of progression independent of stage and margin status (P <0.0001). The 5-year actuarial risk of progression was 15% and 40% for Gleason score 3+4 and 4+3 tumors, respectively. The mean time to progression was 4.4 years for Gleason score 3+4 tumors and 3.2 years for Gleason score 4+3 tumors. We stratified the patients into four prognostic groups on the basis of organ-confined status, margin status, and Gleason score (3+4 versus 4+3). The 5-year actuarial risk of progression was 10%, 35%, 45%, and 61%, with 10-year progression rates of 29%, 42%, 69%, and 84%, for the four groups. 3.9% of patients with Gleason score 3+4 and 10. 5% with Gleason score 4+3 tumors developed metastatic disease within a mean of 5.7 and 5.6 years, respectively. A Gleason score of 4+3 versus 3+4 was predictive of metastatic disease (P = 0.002) but not local recurrence.

CONCLUSIONS

Gleason score 7 tumors are heterogeneous in their biologic behavior. The differences in prognosis for patients with Gleason scores 3+4 and 4+3 tumors at radical prostatectomy are significant. Although the assessment of the percentage of pattern 4 at radical prostatectomy is not likely to be reproducible, the distinction between Gleason score 3+4 and 4+3 should be easier for pathologists to perform.

Gleason score 7 prostate cancer: a heterogeneous entity? Correlation with pathologic parameters and disease-free survival

OBJECTIVES

Gleason score 7, in different proportions of grades 3 and 4, is the score most frequently assigned to prostate cancer in our radical prostatectomy specimens (RPSs). We correlated the major grade component of score 7 tumors with clinicopathologic parameters and disease-free survival.

METHODS

All Gleason score 7 RPSs were classified as having a major grade of 3 or 4 carcinoma. The two groups were compared according to patient age, race, serum prostate-specific antigen (PSA) level, clinical and pathologic stage, tumor volume, and biochemical recurrence.

RESULTS

Of the 534 patients analyzed, 356 and 178 had major grade 3 or 4 tumors, respectively. Compared with patients with 3+4 tumors, those with 4+3 had significantly more advanced clinical and pathologic stages, larger tumor volume, higher preoperative PSA levels, and older age and a higher proportion were African American (P <0.05 for all above parameters). With a mean follow-up of 34.6 months, patients with 3+4 tumors experienced lower rates of PSA recurrence than did those with 4+3 tumors (P = 0.0021). Furthermore, for the subset of patients with organ-confined disease, multivariable analysis that included race, age, clinical stage, preoperative PSA level, tumor volume, and major grade component found only the latter to be a significant predictor of recurrence, with patients who had major grade 4 component tumors experiencing a higher incidence of PSA recurrence than those with major grade 3 tumors (P = 0.012).

CONCLUSIONS

The major grade 4 component in Gleason score 7 carcinoma indicates a higher likelihood of biochemical recurrence, particularly for the increasing proportion of patients with organ-confined disease after radical prostatectomy.