Apical soft tissue biopsies predict biochemical failure in radical perineal prostatectomy patients with apical cancer involvement

Can a nomogram predict apical prostate cancer pathology upgrade from fusion biopsy to final pathology? A multicenter study

BACKGROUND

This study evaluates the efficacy of a nomogram for predicting the pathology upgrade of apical prostate cancer (PCa).

METHODS

A total of 754 eligible patients were diagnosed with apical PCa through combined systematic and magnetic resonance imaging (MRI)-targeted prostate biopsy followed by radical prostatectomy (RP) were retrospectively identified from two hospitals (training: 754, internal validation: 182, internal-external validation: 148). A nomogram for the identification of apical tumors in high-risk pathology upgrades through comparing the results of biopsy and RP was established incorporating statistically significant risk factors based on univariable and multivariable logistic regression. The nomogram's performance was assessed via the receiver operating characteristic (ROC) curve, calibration plots, and decision curve analysis (DCA).

RESULTS

Univariable and multivariable analysis identified age, targeted biopsy, number of targeted cores, TNM stage, and the prostate imaging-reporting and data system score as significant predictors of apical tumor pathological progression. Our nomogram, based on these variables, demonstrated ROC curves for pathology upgrade with values of 0.883 (95% CI, 0.847-0.929), 0.865 (95% CI, 0.790-0.945), and 0.840 (95% CI, 0.742-0.904) for the training, internal validation and internal-external validation cohorts respectively. Calibration curves showed good consistency between the predicted and actual outcomes. The validation groups also showed great generalizability with the calibration curves. DCA results also demonstrated excellent performance for our nomogram with positive benefit across a threshold probability range of 0-0.9 for the training and internal validation group, and 0-0.6 for the internal-external validation group.

CONCLUSION

The nomogram, integrating clinical, radiological, and pathological data, effectively predicts the risk of pathology upgrade in apical PCa tumors. It holds significant potential to guide clinicians in optimizing the surgical management of these patients.

Open radical retropubic prostatectomy 2007: the true minimally invasive surgery for localized prostate cancer?

The introduction of robotic laparoscopic assisted prostatectomy at our institution and nationwide has been a great advancement and has caused us to focus and fine-tune our goal for improvements in prostate cancer outcomes whether the patient elects for robotic laparoscopic assisted prostatectomy or open minimally invasive radical retropubic prostatectomy. While these authors favor the open technique performed by highly skilled urologic surgical oncologists, the lessons we have learned to date suggest that it is the skill of the surgeon that determines outcome, regardless of whether or not the operation is performed by an open or robotic laparoscopic technique. The concepts we have articulated here are related to resection and avoidance of positive margins, limited intraoperative blood loss and pain control, which allow equivalence in these outcome areas, regardless of technique.

Impiego Dell'esame Estemporaneo al Congelatore per la Valutazione dei Margini Chirurgici in Corso di Prostatectomia Radicale

Introduction

At present there is no consensus on the use of frozen sections (FS) during radical prostatectomy. Several groups have proposed the benefit of FS although the studies differ widely in sampling methods and sites where FS were taken. This study aims to evaluate the usefulness and reliability of standard assessment of FS in multiple sites during radical prostatectomy.

Methods

During open radical prostatectomy in all patients we sampled tissue from the urethral stump, the neurovascular bundles, the Denonvillier fascia and the bladder neck after removing the prostate. Where FS showed positive margins, further periprostatic tissue was resected from the prostatic bed until negative margins were achieved. The results of FS were compared with margin status of final pathology.

Results

From 1998 to 2004 we performed FS during 250 consecutive open radical prostatectomies (104 nerve sparing procedures). 66 patients had positive FS (26.4%) and 53 patients had positive surgical margins at final pathology (21.2%). All patients with positive FS had negative margins when further tissue was resected in the prostatic bed. During nerve sparing procedures positive FS were found in 14 patients. In these cases the procedure was converted into standard prostatectomy by resecting the neurovascular bundles. Sensibility and specificity were both 90%. Positive and negative predictive values were respectively 72% and 97%.

Conclusions

Standard assessment of FS in multiple sites during radical prostatectomy achieved sensibility and specificity as high as 90%. Although the resection of urethral stump and tissue close to the neurovascular bundles could compromise functional results, standard assessment of FS in multiple sites could help the surgeon to reduce the positive surgical margins, to monitor the oncological safety of a nerve sparing procedure and to improve the pathological staging.

Intraoperative frozen section analysis of urethral margin biopsies during radical prostatectomy

OBJECTIVES

To evaluate the accuracy and potential clinical value of intraoperative frozen section analysis (FSA) on urethral margin (UM) tissue during radical prostatectomy. Positive surgical margins increase the risk of post-operative cancer recurrence. Positive surgical margins are frequently found at the apex. The utility of intraoperative FSA of the margins is controversial.

METHODS

We reviewed a consecutive series of radical prostatectomy cases (n = 1669) performed at our institution, in which UMs were routinely evaluated by intraoperative FSA.

RESULTS

The submitted UM tissue contained cancer glands in 111 cases (6.7%). On FSA, the pathologists detected cancer in 55 cases (3.3%), missed cancer in 38 (2.3%), and reported atypical glands in 18 (1.1%). FSA of the UMs had a sensitivity of 59.1%, specificity of 99.8%, and positive and negative predictive value of 94.8% and 97.6%, respectively. The low sensitivity resulted from a substantial false-negative rate (n = 38), which was largely attributed to limited sampling on FSA (n = 31). Of the 55 patients (3.3%) whose positive UMs were detected by FSA, 20 (1.2%) had cancer-free margins after tissue re-excision. A positive final UM was associated with greater biochemical recurrence (P = .0073). However, the few patients limited the statistical analysis of the benefit of margin conversion through tissue re-excision (P = .35).

CONCLUSIONS

Although experienced pathologists can evaluate the UMs on FSA with good accuracy, FSA has a relatively low sensitivity. Our data have indicated a low yield and a questionable value of routine FSA during radical prostatectomy.

Is the apical soft tissue margin a better predictor of biochemical recurrence than the surgical specimen?

PURPOSE

To identify predictors of apical surgical margin (ASM) and apical soft tissue margin (ASTM), determine if the ASTM is a better predictor of biochemical recurrence (BR) than the ASM, and ascertain the impact of apical biopsies on BR rates.

MATERIALS AND METHODS

One thousand three hundred eight consecutive men underwent open radical retropubic prostatectomy (RP) between October 2000 and December 2006. Circumferential biopsies of the ASTM were obtained intraoperatively and submitted for frozen section analysis. Logistic regression models were utilized to identify the factors associated with the presence of positive ASMs and ASTMs. The estimated 5-year risk of BR was calculated by the Kaplan-Meier method.

RESULTS

Overall, 43 (3.3%) and 86 (6.6%) of cases exhibited positive ASM and ASTM, respectively. ASM was significantly associated with higher mean serum prostate-specific antigen levels, presence of perineural invasion, and greater volume of tumor in the biopsy specimen. None of these factors were observed to be associated with the presence of cancer in the ASTMs. In the multivariate analysis, only the presence of perineural invasion was a significant independent predictor of ASMs. The estimated 5-year BR rates in the positive ASMs only, ASTMs only, and both positive ASMs and ASTMs groups were 48.6%, 4.7%, and 38.8%, respectively.

CONCLUSIONS

A positive ASM was associated with a significantly greater risk of BR compared with a positive ASTM. The very low estimated risk of BR at 5 years in cases with ASTM suggests that performing the ASTM biopsies may increase the cure rates achieved with RP.