Perineural invasion as a predictor of biochemical outcome following radical prostatectomy for select men with clinically localized prostate cancer

Perineural invasion detected in prostate biopsy is a predictor of positive surgical margin of radical prostatectomy specimen: A meta-analysis

The role of perineural invasion detected by puncture biopsy of prostate cancer remains controversial. We performed a meta-analysis to assess the relationship between positive perineural invasion at prostate biopsy and positive surgical margins (PSM) after radical prostatectomy. We searched a number of relevant electronic databases including Web of Science, Medline, PubMed, Embase, and the Cochrane Library until 31 March 2021. STATA 15.1 software was used to analyse all data for this article. The quality of these studies was assessed by the Newcastle-Ottawa Scale (ranged from 0 to 9 stars). Finally, we selected 13 high-quality studies in our meta-analysis, which contain 8283 patients. Overall pooled analysis proposed that biopsy perineural invasion was related to a higher risk of the positive surgical margins after radical prostatectomy in prostate cancer (RR: 1.73; 95% CI: 1.56-1.92; z = 10.30, p = 0.000). Moreover, the outcomes of the publication bias checkout testified that without significant bias arose (Egger's test: 0.086 > 0.05; Begg's test: 0.59 > 0.05). The existing evidence indicates that higher incidence of positive surgical margins in patients who had perineural invasion was detected in prostate biopsy.

Interobserver reproducibility of perineural invasion of prostatic adenocarcinoma in needle biopsies

Numerous studies have shown a correlation between perineural invasion (PNI) in prostate biopsies and outcome. The reporting of PNI varies widely in the literature. While the interobserver variability of prostate cancer grading has been studied extensively, less is known regarding the reproducibility of PNI. A total of 212 biopsy cores from a population-based screening trial were included in this study (106 with and 106 without PNI according to the original pathology reports). The glass slides were scanned and circulated among four pathologists with a special interest in urological pathology for assessment of PNI. Discordant cases were stained by immunohistochemistry for S-100 protein. PNI was diagnosed by all four observers in 34.0% of cases, while 41.5% were considered to be negative for PNI. In 24.5% of cases, there was a disagreement between the observers. The kappa for interobserver variability was 0.67–0.75 (mean 0.73). The observations from one participant were compared with data from the original reports, and a kappa for intraobserver variability of 0.87 was achieved. Based on immunohistochemical findings among discordant cases, 88.6% had PNI while 11.4% did not. The most common diagnostic pitfall was the presence of bundles of stroma or smooth muscle. It was noted in a few cases that collagenous micronodules could be mistaken for a nerve. The distance between cancer and nerve was another cause of disagreement. Although the results suggest that the reproducibility of PNI may be greater than that of prostate cancer grading, there is still a need for improvement and standardization.

Perineural invasion in prostate needle biopsy: Prognostic value on radical prostatectomy and active surveillance

PURPOSE

The aim of this study was to evaluate the clinical impact of perineural invasion (PNI) in prostate biopsy in patients submitted to radical prostatectomy and on active surveillance (AS).

MATERIALS AND METHODS

We performed a single center, retrospective, cohort study on patients diagnosed with clinically localized prostate cancer and submitted to radical prostatectomy between January 2010 and December 2016. We evaluated clinical and anatomopathological characteristics from the biopsy and radical prostatectomy specimen and correlated with biochemical recurrence (BCR) using a survival analysis. We also evaluated the impact of PNI in patients with criteria for active surveillance.

RESULTS

The cohort analyzed consists of 107 patients, with a mean age of 63.1 years and a mean PSA prior to biopsy of 7.8 ng/ml. In prostate biopsy, 66.4% of the patients had a Gleason score of 6, 30.9% had a Gleason score of 7, and 2.7% had a Gleason score of 8 or higher, with PNI being detected in 57 (53.3%) of the patients. Regarding the anatomopathological characteristics of the surgical specimen, invasion of the seminal vesicles was observed in 6.5%, lymph nodes involvement in 9.3% and positive surgical margins in 27.1% of the cases. During follow-up, BCR was recorded in 24.3% of cases. Clinicopathological features were stratified according to the presence or absence of PNI, with statistical significance in relation to the Gleason Score (p = 0.001), pathologic T stage (p = 0.001), D'Amico risk (p = 0.002) and upstaging of the Gleason score (p = 0.045). The survival analysis revealed a relationship between PNI and BCR (hazard ratio = 2.98; 95% CI: 1.36-6.58; p = 0.007). Regarding the men potentially eligible for AS, the presence of PNI on the biopsy presented a significant relation with Gleason upgrade (p = 0.004) and extraprostatic extension (p = 0.017).

CONCLUSIONS

The presence of PNI in prostate biopsy is related to adverse anatomopathological factors, being a potential predictor of BCR and have a possible role in the selection of patients for AS.

Perineural invasion on biopsy specimen as predictor of tumor progression in aging male treated with radical prostatectomy. Could we use it for pre-surgical screening?

We aimed to analyze the correlation of perineural invasion on transrectal ultrasound guided prostate biopsy with predictors of biochemical cancer recurrence, as well as its impact on clinical outcomes, for non-metastatic prostate cancer. For the study, patients with perineural invasion (N = 86) were recruited into group I and underwent open retropubic prostatectomy, regardless of clinical stage; cases with prostate cancer but without perineural invasion on biopsy, who received radical prostatectomy as the treatment modality, were placed into group II (n = 90). Perineural invasion was detected preoperatively in 43% of cases that revealed surgical margin positivity postoperatively, while 85% of the remaining cases (group II) had negative surgical margins. There was no correlation on prostate biopsy between perineural invasion and Gleason score or PSA, based on Sperman's rank-order correlation analysis. However, there was strong positive correlation of perineural invasion with clinical stage and patients age. Additionaly, we demonstrated that perineural invasion on biopsy is a non-independent risk factor for metastatic occurrence, although the correlation was significant in univariate analysis. Nevertheless, we found strong correlation between invasion on initial biopsy specimen with biochemical cancer recurrence, suggesting that perineural invasion on prostate biopsy is a significant predictor of worse prognostic outcome.

Predictors of prostate bed recurrence on magnetic resonance imaging in patients with rising prostate-specific antigen after radical prostatectomy

INTRODUCTION

Radical prostatectomy (RP) is a standard treatment modality for localized prostate cancer. Biochemical failure after RP is usually evaluated with whole-body imaging to exclude distant metastatic disease, and pelvic magnetic resonance imaging (MRI) to detect local recurrence in the prostatectomy bed. The goal of this study is to correlate disease characteristics and demographic data in patients with rising prostate-specific antigen (PSA) after RP to determine association with MRI-detected cancer recurrence.

METHODS

Sixty-four patients who underwent pelvic MRI for rising PSA after RP and had complete clinical and pathological data available were included. Using Chi-squared testing, we analyzed PSA levels, pathological disease characteristics (prostate cancer risk group, Gleason score, extracapsular extension, positive surgical margin, seminal vesicle involvement, perineural invasion, lymphovascular invasion, and PSA level before MRI), time from surgery to biochemical failure, and patient demographic characteristics as potential predictors of MRI-detected local recurrence.

RESULTS

Definite MRI-detected local recurrence was observed in 17/64 patients (27%). Eleven (17%) patients had a suspicious lesion with the differential of scarring, retained seminal vesicle, or recurrent cancer. Thirty-six (56%) patients had no evidence of tumor in the prostate bed or pelvis on MRI. Patient race was associated with likelihood of detecting a prostate nodule on MRI (p=0.04), with African American patients having 82% lower odds of MRI-detected tumor recurrence compared with white patients (p=0.045). No other tumor or patient characteristic was significantly associated with MRI-detected recurrence.

CONCLUSIONS

African American patients with biochemical failure after RP are less likely to have MRI-detectable recurrence in the prostate bed compared with white patients.

Quantification of perineural invasion focus after radical prostatectomy could improve predictive power of recurrence

Perineural invasion (PNI) after radical prostatectomy (RP) is a common feature of prostate cancer (PCa) and has been associated with unfavorable tumor characteristics. However, its prognostic relevance is controversial. In this study, we evaluated the impact of both PNI status (PNI+ versus PNI-) and quantified number of PNI focus on the long-term prognosis of biochemical recurrence (BCR) after RP. After reevaluating PNI of a total of 721 patients with localized PCa who underwent RP at our institution between 2000 and 2002, we examined associations between PNI status or PNI focus number and clinicopathological factors including tumor stage, Gleason score, margin status, tumor location, preoperative prostate specific antigen, age, prostate weight as well as BCR outcome. PNI was present in 530 of 721 cases (73.5%) of the RP specimens and was associated with more aggressive disease. BCR occurred in 19.4% of all patients within a median follow-up period of 8.5 years. PNI+ status was associated with poor BCR prognosis in univariate analysis but lost in multivariate analysis. Based on the number of PNI focus, PNI was further divided into 2 distinct group: PNI+ a (≤3) and PNI+ b (>3). In a multivariate Cox regression model, PNI+ b (>3) was identified as an independent BCR prognostic factor. Quantification of PNI focus number beside the dichotomized status recording will not only provide more detailed information but also be a novel prognostic indicator for risk stratification. Further external validation will be needed for an optimal cut-off value of the PNI focus number. Our findings will help further research on the relevance of PNI in the pretreatment setting and support ongoing efforts to understand its role of cancer progression.

Impact of biopsy perineural invasion on the outcomes of patients who underwent radical prostatectomy: a systematic review and meta-analysis

Objectives: To investigate the association between biopsy perineural invasion (PNI) and oncological outcomes of prostate cancer (PCa) after radical prostatectomy (RP).Materials and methods: A systematic literature search was performed using PubMed, EMBASE and Web of Science up to December 2018 to identify the eligible studies that included localized PCa patients who underwent biopsy and subsequently RP as well as follow-up information. Meta-analyses were conducted using available hazard ratios (HRs) of biopsy PNI from both univariate and multivariate analyses.Results: Eighteen studies including 14,855 patients with treatment follow-up information were included in the current systematic review. The rate of biopsy PNI varied between 7.0% and 33.0%. Seven out of the 18 studies that demonstrated biopsy PNI were associated with adverse pathologic features. Thirteen out of the 18 studies showed biopsy PNI correlated significantly with higher rates of biochemical recurrence (BCR)/cancer progression status or worse prognostic outcomes. With pooled data based on four studies with available univariate analysis results and four studies with multivariate analysis, statistically significant associations were found between biopsy PNI and BCR with univariate analysis (HR = 2.05; 95% CI = 1.57-2.68; p < 0.001) and with multivariate analysis (HR = 1.57; 95% CI = 1.28-1.93; p < 0.001).Conclusion: Evidence from the included observational studies indicated that biopsy PNI was not only correlated with adverse pathologic characteristics but also with worse BCR prognosis of local PCa after RP. The status of biopsy PNI could serve as a promising risk-stratification factor to help the decision-making process, considering active surveillance (AS) or further treatment for PCa patients.

Intraductal/ductal histology and lymphovascular invasion are associated with germline DNA-repair gene mutations in prostate cancer

BACKGROUND

Germline mutations in genes mediating DNA repair are common in men with recurrent and advanced prostate cancer, and their presence may alter prognosis and management. We aimed to define pathological and clinical characteristics associated with germline DNA-repair gene mutations, to facilitate selection of patients for germline testing.

METHODS

We retrospectively evaluated 150 unselected patients with recurrent or metastatic prostate cancer who were offered germline genetic testing by a single oncologist using a clinical-grade assay (Color Genomics). This platform utilizes next-generation sequencing from saliva to interrogate 30 cancer-susceptibility genes. Presence or absence of a deleterious germline mutation was correlated with histological and clinical characteristics, and with family history of cancer. All patients with DNA-sequence alterations (pathogenic or variants) were offered genetic counseling.

RESULTS

Between July 2016 and July 2017, 150 consecutive patients underwent germline testing; pathogenic mutations were identified in 21 men (14%). Among those with germline mutations, 9 (43%) were in BRCA2, 3 (14%) were in ATM, 3 (14%) were in CHEK2, and 2 (9%) were in BRCA1. While there were no associations between germline mutations and age, tumor stage, Gleason sum or family history; mutation-positive patients had lower median PSA levels at diagnosis (5.5 vs 8.6 ng/mL, P = 0.01) and unique pathologic features. Namely, men with germline mutations were more likely to harbor intraductal/ductal histology (48% vs 12%, P < 0.01) and lymphovascular invasion (52% vs 14%, P < 0.01). Finally, 44% of patients with a positive germline test would not have been offered genetic screening according to current National Comprehensive Cancer Network (NCCN) guidelines.

CONCLUSIONS

Presence of intraductal/ductal histology and lymphovascular invasion appear to be associated with pathogenic germline DNA-repair gene mutations in men with prostate cancer, and identification of these features may help to select patients for germline testing. NCCN guidelines may be inadequate in predicting which prostate cancer patients should undergo genetic screening.

Perineural invasion status, Gleason score and number of positive cores in biopsy pathology are predictors of positive surgical margin following laparoscopic radical prostatectomy

This study was designed to define possible preoperative predictors of positive surgical margin after laparoscopic radical prostatectomy. We retrospectively analyzed the records of 296 patients with prostate cancer diagnosed by prostate biopsy, and eventually treated with laparoscopic radical prostatectomy. The prognostic impact of age, prostate volume, preoperative prostate-specific antigen, biopsy Gleason score, maximum percentage tumor per core, number of positive cores, biopsy perineural invasion, capsule invasion on imaging, and tumor laterality on surgical margin was assessed. The overall positive surgical margin rate was 29.1%. Gleason score, number of positive cores, perineural invasion, tumor laterality in the biopsy specimen, and prostate volume significantly correlated with risk of positive surgical margin by univariate analysis (P < 0.05). Gleason score (odds ratio [OR] = 2.286, 95% confidence interval [95% CI] = 1.431–3.653, P = 0.001), perineural invasion (OR = 4.961, 95% CI = 2.656–9.270, P < 0.001), and number of positive cores (OR = 4.403, 95% CI = 1.878–10.325, P = 0.001) were independent predictors of positive surgical margin at the multivariable logistic regression analysis. Patients with perineural invasion, higher biopsy Gleason scores and/or a large number of positive cores in biopsy pathology had more possibility of capsule invasion. The positive surgical margin rate in patients with capsule invasion (49.5%) was much higher than that with localized disease (17.8%). In contrast, prostate volume showed a protective effect against positive surgical margin (OR = 0.572, 95% CI = 0.346–0.945, P = 0.029). Gleason score, perineural invasion, and number of positive cores in the biopsy specimen were preoperative independent predictors of positive surgical margin after laparoscopic radical prostatectomy while prostate volume was a protective factor against positive surgical margin.

Effects of perineural invasion on biochemical recurrence and prostate cancer-specific survival in patients treated with definitive external beam radiotherapy

OBJECTIVES

Perineural invasion (PNI) has not yet gained universal acceptance as an independent predictor of adverse outcomes for prostate cancer treated with external beam radiotherapy (EBRT). We analyzed the prognostic influence of PNI for a large institutional cohort of prostate cancer patients who underwent EBRT with and without androgen deprivation therapy (ADT).

MATERIAL AND METHODS

We, retrospectively, reviewed prostate cancer patients treated with EBRT from 1993 to 2007 at our institution. The primary endpoint was biochemical failure-free survival (BFFS), with secondary endpoints of metastasis-free survival (MFS), prostate cancer-specific survival (PCSS), and overall survival (OS). Univariate and multivariable Cox proportional hazards models were constructed for all survival endpoints. Hazard ratios for PNI were analyzed for the entire cohort and for subsets defined by NCCN risk level. Additionally, Kaplan-Meier survival curves were generated for all survival endpoints after stratification by PNI status, with significant differences computed using the log-rank test.

RESULTS

Of 888 men included for analysis, PNI was present on biopsy specimens in 187 (21.1%). PNI was associated with clinical stage, pretreatment PSA level, biopsy Gleason score, and use of ADT (all P<0.01). Men with PNI experienced significantly inferior 10-year BFFS (40.0% vs. 57.8%, P = 0.002), 10-year MFS (79.7% vs. 89.0%, P = 0.001), and 10-year PCSS (90.9% vs. 95.9%, P = 0.009), but not 10-year OS (67.5% vs. 77.5%, P = 0.07). On multivariate analysis, PNI was independently associated with inferior BFFS (P<0.001), but not MFS, PCSS, or OS. In subset analysis, PNI was associated with inferior BFFS (P = 0.04) for high-risk patients and with both inferior BFFS (P = 0.01) and PCSS (P = 0.05) for low-risk patients. Biochemical failure occurred in 33% of low-risk men with PNI who did not receive ADT compared to 8% for low-risk men with PNI treated with ADT (P = 0.01).

CONCLUSION

PNI was an independently significant predictor of adverse survival outcomes in this large institutional cohort, particularly for patients with NCCN low-risk disease. PNI should be carefully considered along with other standard prognostic factors when treating these patients with EBRT. Supplementing EBRT with ADT may be beneficial for select low-risk patients with PNI though independent validation with prospective studies is recommended.

The impact of multifocal perineural invasion on biochemical recurrence and timing of adjuvant androgen-deprivation therapy in high-risk prostate cancer following radical prostatectomy

BACKGROUND

Perineural invasion (PNI) is a distinct pathologic entity and a recognized source of tumor spread. However, the role of PNI in high-risk prostate cancer (PCa) has not been explored. The aims of the study were to investigate the impact of PNI on biochemical recurrence (BCR) and optimal timing of adjuvant androgen-deprivation therapy (ADT) after radical prostatectomy (RP).

METHODS

A total of 265 prostatectomies, median follow-up 45 months, were assessed for the presence and intensity of PNI (unifocal and multifocal) in RP specimens. Kaplan-Meier curves were used to estimate BCR probabilities. Cox proportional hazard models were used to address predictors of BCR. Harrell's C-index was conducted to further validate prognostic value of multi-PNI.

RESULTS

A total of 123 patients (46.4%) were PNI positive, among which, 91 (74%) and 32 (26%) had unifocal PNI (uni-PNI) and multifocal PNI (multi-PNI), respectively. The presence of multi-PNI was strongly associated with increasing incidence of BCR (HR = 3.87, 95%CI: 1.66-9.01, P = 0.002). Patients with uni-PNI had a similar BCR rate to those without PNI after adjuvant ADT. For men with multi-PNI, immediate ADT was superior to delayed ADT in decreasing biochemical failure.

CONCLUSIONS

Our findings suggest that detection of multi-PNI in high-risk RP specimens could be a prognosticator for early biochemical relapse post-surgery. Initiation of adjuvant therapy may be appropriate in patients with multi-PNI as soon as possible after surgery.

Perineural Invasion and Risk of Lethal Prostate Cancer

Background: Prostate cancer has a propensity to invade and grow along nerves, a phenomenon called perineural invasion (PNI). Recent studies suggest that the presence of PNI in prostate cancer has been associated with cancer aggressiveness.Methods: We investigated the association between PNI and lethal prostate cancer in untreated and treated prostate cancer cohorts: the Swedish Watchful Waiting Cohort of 615 men who underwent watchful waiting, and the U.S. Health Professionals Follow-Up Study of 849 men treated with radical prostatectomy. One pathologist performed a standardized histopathologic review assessing PNI and Gleason grade. Patients were followed from diagnosis until metastasis or death.Results: The prevalence of PNI was 7% and 44% in the untreated and treated cohorts, respectively. PNI was more common in high Gleason grade tumors in both cohorts. PNI was associated with enhanced tumor angiogenesis, but not tumor proliferation or apoptosis. In the Swedish study, PNI was associated with lethal prostate cancer [OR 7.4; 95% confidence interval (CI), 3.6-16.6; P < 0.001]. A positive, although not statistically significant, association persisted after adjustment for age, Gleason grade, and tumor volume (OR 1.9; 95% CI, 0.8-5.1; P = 0.17). In the U.S. study, PNI predicted lethal prostate cancer independent of clinical factors (HR 1.8; 95% CI, 1.0, 3.3; P =0.04).Conclusions: These data support the hypothesis that perineural invasion creates a microenvironment that promotes cancer aggressiveness.Impact: Our findings suggest that PNI should be a standardized component of histopathologic review, and highlights a mechanism underlying prostate cancer metastasis. Cancer Epidemiol Biomarkers Prev; 26(5); 719-26. ©2017 AACR.

Relationship Between Perineural Invasion in Prostate Needle Biopsy Specimens and Pathologic Staging After Radical Prostatectomy

Background

Prostate cancer is the second most common malignancy among men worldwide and the sixth cause of cancer-related death. Some authors have reported a relationship between perineural invasion (PNI), Gleason score, and the invasion of peripheral organs during prostatectomy. However, it is not yet clear whether pathological evidence of PNI is necessary for risk stratification in selecting treatment type.

Objectives

The clinical and pathological stages of prostate cancer are compared in patients under radical prostatectomy and in patients without perineural invasion.

Patients and Methods

This cross-sectional study was conducted using a sample of 109 patients who attended a tertiary health care center from 2008 to 2013. The selection criteria were PNI in prostate biopsy with Gleason scores less than six, seven, and eight to ten. The participants were enrolled in a census manner, and they underwent clinical staging. After radical prostatectomy, the rates of pathological staging were compared. The under-staging and over-staging rates among those with and without perineural invasion in biopsy samples were compared.

Results

The concordance between Gleason scores according to biopsy and pathology was 36.7% (40 subjects). The concordance rate was 46.4% and 33.3% among those with and without PNI, respectively. The concordance rates were significantly varied in different subclasses of Gleason scores in patients without PNI (P = 0.003); the highest concordance rate was a Gleason score of 7 (63.6%) and the lowest was a Gleason score of eight to ten (25%). However, there were no significant differences in patients with PNI (P > 0.05).

Conclusions

Although the presence of PNI in prostate biopsy is accompanied by higher surgical stages, PNI is not an appropriate independent factor in risk stratification.

Predictive factors for biochemical recurrence in radical prostatectomy patients

Introduction

Radical prostatectomy (RP) is considered the best treatment for the management of localized prostate cancer in patients with life expectancy over 10 years. However, a complete recovery is not guaranteed for all patients who received/underwent RP treatment. Biochemical recurrence is frequently observed during the post-operative follow-up period. The main objective in this study is to evaluate the predictive factors of biochemical recurrence in localized prostate cancer patients who underwent RP surgery

Material and methods

The study included 352 patients with prostate cancer treated by RP at a single institution between February 2004 and June 2014. Detailed pathological and follow-up data of all patients were obtained and analyzed to determine the results.

Results

Mean follow-up duration was 39.7 months. 83 patients (23%) experienced biochemical recurrence (BCR) during the follow-up period. Mean BCR duration range was 6.56 (1–41) months. In multivariate logistic regression analysis, Gleason score (GS), PSA and extra-capsular tumour spread (ECS) variables were found to be statistically significant as BCR predictive factors.

Conclusions

According to our study results, it is thought that PSA, GS and ECS can all be used for guidance in choosing a treatment modality for post-RP biochemical recurrence and metastatic disease as predictive factors. However, there is no consensus in this matter and it is still debated.

Factors determining biochemical recurrence in low-risk prostate cancer patients who underwent radical prostatectomy

OBJECTIVE

This study was conducted to research the factors determining biochemical recurrence (BCR) in low-risk localized prostate cancer patients who underwent radical prostatectomy (RP).

MATERIALS AND METHODS

We retrospectively analyzed the data of 504 patients who had undergone RP between 2003 and 2013 at our clinic. One hundred and fifty-two patients who underwent RP for low-risk prostate cancer were included in the study.

RESULTS

The mean follow-up period for patients was 58.7 (21-229) months. The mean age of the patients was 63.7±7.2 years (49-79). The mean prostate specific antigen (PSA) value was 5.25±4.22 ng/mL (3.58-9.45). The BCR rate after the operation was 25% (38/152). In the univariate analysis, recurrence determining factors were shown to include extracapsular involvement (ECI) (p=0.004), capsular invasion (CI) (p=0.001), age (p=0.014), and tumor size (p=0.006). However, only CI was found to be significant in multivariate analysis (p=0.001).

CONCLUSION

Capsular invasion is an independent risk factor in low-risk prostate cancer patients who underwent RP for BCR.

Disease-specific outcomes of radical prostatectomies in Northern Norway; a case for the impact of perineural infiltration and postoperative PSA-doubling time

Background

Prostate cancer is the most common male malignancy and a mayor cause of mortality in the western world. The impact of clinicopathological variables on disease related outcomes have mainly been reported from a few large US series, most of them not reporting on perineural infiltration. We therefore wanted to investigate relevant cancer outcomes in patients undergoing radical prostatectomy in two Norwegian health regions with an emphasis on the impact of perineural infiltration (PNI) and prostate specific antigen- doubling time (PSA-DT).

Methods

We conducted a retrospective analysis of 535 prostatectomy patients at three hospitals between 1995 and 2005 estimating biochemical failure- (BFFS), clinical failure- (CFFS) and prostate cancer death-free survival (PCDFS) with the Kaplan-Meier method. We investigated clinicopathological factors influencing risk of events using cox proportional hazard regression.

Results

After a median follow-up of 89 months, 170 patients (32%) experienced biochemical failure (BF), 36 (7%) experienced clinical failure and 15 (3%) had died of prostate cancer. pT-Stage (p = 0.001), preoperative PSA (p = 0.047), Gleason Score (p = 0.032), non-apical positive surgical margins (PSM) (p = 0.003) and apical PSM (p = 0.031) were all independently associated to BFFS. Gleason score (p = 0.019), PNI (p = 0.012) and non-apical PSM (p = 0.002) were all independently associated to CFFS while only PNI (P = 0.047) and subgroups of Gleason score were independently associated to PCDFS. After BF, patients with a shorter PSA-DT had independent and significant worse event-free survivals than patients with PSA-DT > 15 months (PSA-DT = 3-9 months, CFFS HR = 6.44, p < 0.001, PCDFS HR = 13.7, p = 0.020; PSA-DT < 3 months, CFFS HR = 11.2, p < 0.001, PCDFS HR = 27.5, p = 0.006).

Conclusions

After prostatectomy, CFFS and PCDFS are variable, but both are strongly associated to Gleason score and PNI. In patients with BF, PSA-DT was most strongly associated to CF and PCD. Our study adds weight to the importance of PSA-DT and re-launches PNI as a strong prognosticator for clinically relevant endpoints.

Variation in reporting of cancer extent and benign histology in prostate biopsies among European pathologists

It is not known how uropathologists currently report histopathological features of prostate biopsies such as core length, tumor extent, perineural invasion, and non-tumor-associated features such as inflammation and hyperplasia in needle biopsies. A web-based survey was distributed among 661 members of the European Network of Uropathology. Complete replies were received from 266 pathologists in 22 European countries. Total core lengths were reported by 64 %. The numbers of cores positive for cancer was given by 79 %. Linear cancer extent was reported by 81 %, most often given in millimeters for each core (53 %) followed by the estimation of percentage of cancer in each core (40 %). A gap of benign tissue between separate cancer foci in a single core would always be subtracted by 48 % and by 63 % if cancer foci were minute and widely separated. Perineural invasion was reported by 97 %. Fat invasion by tumor was interpreted as extraprostatic extension by 81 %. Chronic and active/acute inflammation was always reported by 32 and 56 % but only if pronounced by 54 and 39 %, respectively. While most (79 %) would never diagnose benign prostatic hyperplasia on needle biopsy, 21 % would attempt to make this diagnosis. Reporting practices for prostate biopsies are variable among European pathologists. The great variation in some methodologies used suggests a need for further international consensus, in order for retrospective data to be comparable between different institutions.

Prostate cancer at the peripheral end of prostate biopsy specimen predicts increased risk of positive resection margin after radical prostatectomy: results of a prospective multi-institutional study

PURPOSE

To test a novel technique of processing prostate biopsy specimen by marking the peripheral end (PE) as a predictive tool for positive resection margin after radical prostatectomy (RP) or for locally advanced carcinoma of the prostate (PC).

METHODS

Prospective, multi-institutional study of a consecutive cohort of men who underwent prostate biopsy with marking the peripheral biopsy end and subsequent RP at the same institution.

RESULTS

The study cohort comprised 445 men with a mean age of 63 years (40-77 years). Overall, PE-positive cores were found in 174 men (39.1 %) and R1 status was diagnosed in 132 men after RP (29.7 %). In the multivariate analysis, the presence of at least one PE-positive core was correlated with an increased risk of R1 status (OR 2.29, 95 % CI 1.31-4.00, p = 0.003) and was the strongest predictor followed by Gleason score, PSA and percentage of positive cores. Including all predictive parameters, a nomogram with a concordance index of 72.1 % was calculated. In the pT3/pT4 subgroup, PE positivity was the only predictive factor for R1 status (OR 3.03, 95 % CI 1.36-6.75, p = 0.006). In pT2 stage, no single factor was predictive for R1 status. PE-positive biopsies were not predictive for pT3/pT4 stages.

CONCLUSIONS

PC at the peripheral end of prostate biopsy specimen predicts an increased risk of R1 status in subsequent RP. This simple and cheap technique may contribute to an increased accuracy of risk stratification for curative treatment for PC.

Age and Racial Differences among PSA-Detected (AJCC Stage T1cN0M0) Prostate Cancer in the U.S.: A Population-Based Study of 70,345 Men

Purpose: Few studies have evaluated the risk profile of prostate-specific antigen (PSA)-detected T1cN0M0 prostate cancer, defined as tumors diagnosed by needle biopsy because of elevated PSA levels without other clinical signs of disease. However, some men with stage T1cN0M0 prostate cancer may have high-risk disease (HRD), thus experiencing inferior outcomes as predicted by a risk group stratification model.

Methods: We identified men diagnosed with stage T1cN0M0 prostate cancer from 2004 to 2008 reported to the surveillance, epidemiology, and end results (SEER) program. Multivariate logistic regression was used to model the probability of intermediate-risk-disease (IRD) (PSA ≥ 10 ng/ml but <20 ng/ml and/or GS 7), and high-risk-disease (HDR) (PSA ≥ 20 ng/ml, and/or GS ≥ 8), relative to low-risk disease (LRD) (PSA < 10 ng/ml and GS ≤ 6), adjusting for age, race, marital status, median household income, and area of residence.

Results: A total of 70,345 men with PSA-detected T1cN0M0 prostate cancer were identified. Of these, 47.6, 35.9, and 16.5% presented with low-, intermediate-, and high-risk disease, respectively. At baseline (50 years of age), risk was higher for black men than for whites for HRD (OR 3.31, 95% CI 2.85–3.84). The ORs for age (per year) for HRD relative to LRD were 1.09 (95% CI 1.09–1.10) for white men, and as 1.06 (95% CI 1.05–1.07) for black men. Further, among a subgroup of men with low PSA (<10 ng/ml) T1cN0M0 prostate cancer, risk was also higher for black man than for white men at baseline (50 years of age) (OR 2.70, 95% CI 2.09–3.48). The ORs for age (per year) for HRD relative to LRD were 1.09 (95% CI 1.09–1.10) for white men, and as 1.06 (95% CI 1.05–1.07) for black men.

Conclusion: A substantial proportion of men with PSA-detected prostate cancer as reported to the SEER program had HRD. Black race and older age were associated with a greater likelihood of HRD.

Prostate specific antigen and Gleason score in men with prostate cancer at a private diagnostic radiology centre in Western Jamaica

BACKGROUND

Prostate cancer is the most common malignant tumour in men and the second most common cause of male cancer death. The study examines the clinicopathological features of patients with prostate cancer consecutively diagnosed at a private Diagnostic Radiology Centre in Western Jamaica over a 6-year period.

METHOD

The medical records, including the pathology reports of 423 consecutive patients who had transrectal ultrasonography (TRUS) - guided prostate biopsy between January 2006 and December 2011 were reviewed.

RESULTS

The mean age at diagnosis of the 191 men with prostate adenocarcinoma was 68.5 ± 0.59 years with the majority in the 70 - 79 year age group (43.5%). Moderately differentiated carcinomas (Gleason score of 6) comprised the largest group with 72 cases (37.9%); poorly differentiated cancers with Gleason scores of 8 - 10 comprised 49 cases (25.8%). The PSA levels increased with Gleason score. The mean PSA levels for men with Gleason score of 6 was 50.1 ± 30.0 ng/mL compared with 136.5 ± 59.9 ng/mL in patients with Gleason score of 8 and 140.5 ± 31.8 ng/mL in patients with Gleason score of 9. Perineural invasion was present in 7.85% of the cases overall; high-grade prostatic intraepithelial neoplasia (HGPIN) was present in 4.71% of the biopsies.

CONCLUSION

Although the majority of patients had moderate, and moderate to poor differentiated carcinomas, the number with poorly differentiated carcinoma was high. This is a reflection of the patients' late clinical presentation at the time of diagnosis.

Findings in 12-core transrectal ultrasound-guided prostate needle biopsy that predict more advanced cancer at prostatectomy: analysis of 388 biopsy-prostatectomy pairs

We analyzed 5 features on 12-core transrectal ultrasound-guided prostate needle biopsy (TRUS) to predict the extent of cancer at radical prostatectomy (RP). In 388 TRUS-RP pairs, number of positive cores (NPC), percentage of each core involved (%PC), perineural invasion (PNI), Gleason score (GS), distribution of positive cores (DPC), and preoperative prostate-specific antigen (PSA) were correlated with extraprostatic extension (EPE), seminal vesicle invasion (SVI), positive surgical margin (R1), positive lymph nodes (N1), and tumor volume. All features predicted EPE and SVI. NPC, GS, %PC, and PNI strongly predicted R1 status. RP tumor volume was directly proportional to the NPC and %PC. PSA alone and with selected biopsy findings correlated with tumor volume, stage, SVI, and N1 (P < .0001). Contiguous DPC was a significant risk for EPE and SVI (P < .0001) compared with isolated positive cores. Findings at 12-core TRUS along with preoperative PSA reliably predict advanced local disease and have practical value as guides to effective planning for surgical resections.

Twelve-month prostate-specific antigen values and perineural invasion as strong independent prognostic variables of long-term biochemical outcome after prostate seed brachytherapy

PURPOSE

To determine whether post-treatment prostate-specific antigen (ptPSA) values at 12 months and other clinical parameters predict long-term PSA relapse-free survival (PRFS) following prostate seed brachytherapy.

METHODS AND MATERIALS

Records of 204 hormone-naïve patients with localized adenocarcinoma of the prostate treated at St. Mary's Regional Medical Center in Reno, NV, and at Carson Tahoe Regional Medical Center in Carson City, NV, between 1998 and 2003, using I-125 or Pd-103 seed brachytherapy, were retrospectively analyzed. Treatment planning was done using a preplanned, modified peripheral loading technique. A total of 185 of 204 patients had PSA records at 12 months after implant. Variables included were age, initial pretreatment PSA, Gleason score, T stage, National Comprehensive Cancer Network (NCCN) risk group (RG), perineural invasion (PNI), external beam boost, dose, and ptPSA levels at 12 months with cutpoints at ≤1, 1.01 to 2.00, 2.01 to 3.00, and >3.00 ng/ml.

RESULTS

Median follow-up was 80 months, and median age was 69 years. The numbers of patients stratified by NCCN low, intermediate, and high RG were 110:65:10, respectively. Monotherapy and boost prescription doses were 145 Gy and 110 Gy for I-125, and 125 Gy and 100 Gy for Pd-103 seeds, respectively. The median dose (D90) was 95.4% of the prescribed dose. The 5-year PRFS at the 12-months ptPSA levels of ≤1, 1.01 to 2.00, 2.01 to 3.00, and >3.00 ng/ml were 98.5%, 85.7%, 61.5%, and 22.2%, respectively. The 10-year PRFS at the 12-months ptPSA levels of ≤1 and 1.01 to 2.00 ng/ml were 90.5% and 85.7%, respectively. In multivariate analysis, both ptPSA and PNI were significant independent predictors of PRFS. Hazard ratios (HR) for ptPSA levels at ≤1, 1.01 to 2.00, 2.01 to 3.00, and >3.00 ng/ml at 12 months were 1, 4.96, 27.57, and 65.10, respectively. PNI had an HR of 6.1 (p=0.009).

CONCLUSIONS

Presence of PNI and ptPSA values at 12 months are strong prognostic variables for long-term PRFS after definitive prostate brachytherapy seed implantation.

Perineural invasion detection in prostate biopsy is related to recurrence-free survival in patients submitted to radical prostatectomy

OBJECTIVE

Perineural invasion (PNI) is detected in almost 20% of prostate biopsies and has been related to worse prognostic factors in radical prostatectomy (RP) specimens and lower disease-free survival rates. The aim of this study was to evaluate the importance of PNI during periods of extended prostate biopsies and to determine the value of this preoperative parameter as a predictor of pathologic findings in surgical specimens and in biochemical recurrence.

MATERIALS AND METHODS

Between 2001 and 2009, 599 prostate biopsies and their respective RP specimens were examined in our laboratory. The RP specimens were always examined completely. The mean age of the patients was 61 years, and the mean PSA was 6.4 ng/mL. The mean and median number of biopsy cores obtained was 14.4 and 14, respectively. PNI was identified in 105 biopsies (17.5%). We studied the ability of PNI in prostate biopsies to determine the tumor stage in surgical specimens and the relationship of PNI with biochemical recurrence during a mean follow-up time of 51.4 months.

RESULTS

The presence of PNI in prostate biopsies was observed in older patients (63 vs. 61 years old, P = 0.008). All of the prognostic factors determined for the RP specimens were significantly worse in patients with PNI compared with those without PNI. PNI was strongly associated with a higher pathologic stage (87% specificity, 40% sensitivity, odds ratio 4.8). Stage pT3 prostatic cancer was determined in 46 (43.8%) of 105 patients with PNI on biopsy compared to 69 (14%) of 494 patients without PNI (P = 0.01). Fifty-six (19.6%) patients had a biochemical recurrence, and PNI correlated significantly with PSA recurrence. A Kaplan-Meier analysis revealed a significant difference in recurrence-free survival between patients with and without PNI (45% vs. 53%, respectively, P = 0.021, log-rank test = 0.19).

CONCLUSION

PNI is an important morphologic preoperative predictor of the pathologic stage as well as biochemical recurrence and must always be mentioned when adenocarcinoma is diagnosed on prostate biopsies.

Significance of perineural invasion, lymphovascular invasion, and high-grade prostatic intraepithelial neoplasia in robot-assisted laparoscopic radical prostatectomy

BACKGROUND

Recently, more detailed histopathological variables such as perineural invasion (PNI), lymphovascular invasion (LVI), and high-grade prostatic intraepithelial neoplasia (HGPIN) have been investigated as prognostic factors for adverse pathologic findings on the radical prostatectomy specimen. We aim to determine whether these pathological factors are associated with adverse pathologic features after robot-assisted laparoscopic radical prostatectomy (RALP).

METHODS

All 407 patients who underwent RALP with pelvic lymphadenectomy between July 2005 and December 2009 were analyzed, retrospectively. We investigated the association of these three pathological parameters with adverse pathological findings in RALP specimen and biochemical recurrence using Kaplan-Meier analysis with log-rank test and a multivariate Cox proportional hazard model.

RESULTS

The PNI and LVI were significantly associated with a higher pathological stage, a higher pathological Gleason score, a higher tumor volume in RALP specimen, a higher frequency of positive surgical margins, and a higher frequency of seminal vesicle invasion. In addition, PNI correlated with preoperative PSA, clinical stage, and Gleason score on needle biopsy. However, the HGPIN was not significantly associated with the clinicopathological characteristics studied. Using log-rank test, presence of PNI (P < 0.001) increases the probability of biochemical recurrence. On multivariate analysis, all three pathological parameters were not significantly correlated with biochemical recurrence.

CONCLUSION

Although presence of PNI and LVI in RALP specimen correlated with multiple adverse clinicopathological factors, it did not predict biochemical recurrence, thus limiting its clinical usefulness. HGPIN was not significantly associated with the clinicopathological characteristics studied.

[Prognostic role of perineural invasion in prostate biopsy]

INTRODUCTION

Despite tumour cell dissemination through the intraprostatic nervous system being considered as a prostate cancer progression mechanism, the significance of perineural invasion in prostate biopsies to predict extraprostatic extension and its use as a potential prognosis factor is controversial.

MATERIALS AND METHODS

Retrospective study carried out at an institution on 208 patients treated with radical prostatectomy (January 2007 - July 2010) in which the presence of perineural invasion and the Gleason score in the preoperative biopsy were determined, as well as the clinical stage and the pre-surgery PSA. We classified the patients in risk groups in accordance with the D'Amico classification. We performed bivariate and multivariate statistical analyses to establish the correlations between the different variables.

RESULTS

We objectified PNI in 18.3% of the prostate biopsies. 71% of the prostatectomy specimens with perineural invasion presented extraprostatic extension in the previous biopsy against 23.1% when this was not found (p<0.0001) and 47% of the cases showed positive margins with PNI, against 18.3% without perineural invasion (p<0.0001). In fact, in the multivariate analysis, perineural invasion proved to be an independent risk factor in the presentation of extraprostatic extension and positive margins in the prostatectomy specimen.

CONCLUSIONS

The presence of perineural invasion is a useful prognostic factor for predicting extraprostatic extension and the involvement of surgical margin in the radical prostatectomy specimen. We believe that determining it may be a useful tool for improving preoperative diagnosis and planning treatment.

Utilization and expense of adjuvant cancer therapies following radical prostatectomy

BACKGROUND

We sought to identify the costs of adjuvant therapies following radical prostatectomy (RP) and factors associated with their receipt.

METHODS

We used SEER-Medicare data from 2004-2006 to identify 4247 men who underwent RP, of whom 600 subsequently received adjuvant therapies. We used Cox regression to identify factors associated with receipt of adjuvant therapies. Health care expenditures within 12 months of diagnosis were compared for RP alone versus RP with adjuvant therapies.

RESULTS

Biopsy Gleason score, prostate-specific antigen, risk group, and SEER region were significantly associated with receipt of adjuvant treatments (all P<.001). Higher surgeon volume was associated with lower odds of receiving adjuvant therapies (hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.46-0.78 [P<.001]). Factors associated with increased receipt of adjuvant therapies were positive surgical margins (HR, 3.02; 95% CI, 2.55-3.57 [P<.001]), high-risk group versus low-risk group (HR, 7.65; 95% CI, 5.64-10.37 [P<.001]), lymph node-positive disease (HR, 5.36; 95% CI, 3.71-7.75 [P<.001]), and treatment in Iowa (HR, 1.93; 95% CI, 1.12-3.32 [P = .019]) and New Mexico/Georgia/Hawaii (HR, 1.92; 95% CI, 1.09-3.39 [P = .025]) versus San Francisco SEER regions (baseline). Age, race, comorbidities, and surgical approach were not associated with use of adjuvant therapies. The median expenditures attributable to postprostatectomy hormonal therapy, radiation therapy, and radiation with hormonal therapy versus were $1361, $12,040, and $23,487.

CONCLUSIONS

Men treated by high-volume surgeons were less likely to receive adjuvant therapies. Regional variation and high-risk disease characteristics were associated with increased receipt of adjuvant therapies, which increased health care expenditures by 2- to 3-fold when radiotherapy was administered.

Prognostic relevance of number and bilaterality of positive surgical margins after radical prostatectomy

Purpose

Positive surgical margin (PSM) status following radical prostatectomy (RP) is a well-established prognostic factor. The aim of the present study is to evaluate whether number of PSMs or bilaterality of PSMs might have prognostic significance for biochemical recurrence (BCR) in the population with a PSM status following RP.

Methods

We evaluated 1,395 RP pathology reports from our center between 1980 and 2006. All patients who underwent (neo)-adjuvant therapy were excluded, leaving a cohort of 1,009 patients, with 249 (24.7%) subjects having a PSM at RP of whom 29.4% had multiple PSMs (≥ 2 sites), while 13.6% had bilateral PSMs. Median follow-up was 40 months (range 0–258 months). We used BCR-free survival as the primary study outcome. BCR was defined as any rise in PSA above or equal to 0.2 ng/ml.

Results

Of patients with a PSM status, 41% (95% CI: 33–49%) developed BCR within 5 years, compared to 12% (95% CI: 9–15%) in the population without a PSM. Multivariable analysis identified PSA at diagnosis and RP Gleason score as independent predictive factors for BCR. Increasing number and/or bilaterality of PSM did not lead to significant higher rates of BCR.

Conclusion

In patients with a PSM, the number of positive sites or bilaterality of PSM status does not add prognostic information for risk of BCR. Survival curve slopes were different for patients with bilateral PSM, showing a significant tendency to progress to BCR earlier during follow-up than patients with unilateral PSM.

PCA3 molecular urine assay for prostate cancer: association with pathologic features and impact of collection protocols

INTRODUCTION

PCA3 is a non-coding mRNA molecule that is overexpressed in prostate cancer. The purpose of this study is to evaluate the utility of the PCA3 molecular urine test scores to predict adverse pathologic features and catheterized specimen collection.

METHODS

Hundred men with clinically localized prostate cancer scheduled to undergo robotic prostatectomy were enrolled in the study following a standard consent process. The study protocol consisted of providing four urine samples. Voided urine obtained following digital rectal examination (DRE) pre-operatively (Vl), catheterized urine without DRE (V2), and l0-day and 6-week postoperative voided (V3 and V4) urine samples were collected and analyzed. These four urine specimens underwent target capture, transcription-mediated amplification, and hybridization in order to quantify both PCA3 and PSA mRNA. The PCA3 score was calculated as the ratio of PCA3 to PSA.

RESULTS

Informative rates (sufficient mRNA for analysis) for VI, V2, V3 and V4 were 91, 85, 0 and 2%, respectively. There was no significant associations with pathological stage, Gleason score >6. Higher PCA3 scores at V1 correlated with increased risk for perineural invasion (P = 0.0479).

CONCLUSIONS

Informative PCA3 scores can be obtained from post-DRE voided urine as well as catheterized urine without a DRE. The PCA3 test does not seem to predict adverse pathologic features, though, may have an association with perineural invasion. The ability of PCA3 score to predict clinical outcome remains to be determined.

Prediction of perineural invasion and its prognostic value in patients with prostate cancer

Purpose

The prognostic significance of perineural invasion by prostate cancer is debated. We investigated the association between perineural invasion and clinicopathological factors and the effect of perineural invasion on survival in patients with prostate cancer.

Materials and Methods

A total of 361 patients with prostate cancer without any neoadjuvant therapies prior to surgery from 1999 to 2010 were analyzed retrospectively. Whole-mount sections of surgical specimens from all patients who underwent radical prostatectomy were evaluated. Positive perineural invasion was defined as infiltration of cancer cells in the perineurium or neural fascicles. The relationship of perineural invasion with clinicopathological features and prognosis of prostate cancer was studied. We also researched preoperative factors that were associated with perineural invasion.

Results

Perineural invasion in a prostatectomy specimen (PNIp) was positive in 188 of 361 patients (52.1%). In the multivariate analysis of the preoperative variables, PNIp was related to the primary Gleason grade (p=0.020), the number of positive cores (p=0.008), and the percentage of tumor cells in positive cores (p=0.021), but not to perineural invasion of a prostate biopsy. In the evaluation between PNIp and pathologic findings of the prostatectomy specimen, PNIp was related to the Gleason score (p=0.010), T-stage (p=0.015), and lymphovascular invasion (p=0.019). However, by multivariate analysis, the PNIp was not an independent prognostic factor of biochemical serum recurrence (p=0.364) or cancer-specific survival (p=0.726).

Conclusions

PNIp was significantly related to biologically aggressive tumor patterns but was not a prognostic factor for biochemical serum PSA recurrence or cancer-specific survival in patients with prostate cancer.

Prostate cancer at the peripheral end of a prostate biopsy specimen as assessed by a novel marking technique may indicate increased risk of locally advanced disease

The objective of this study was to test a novel technique of processing a prostate biopsy (PB) specimen by marking its peripheral end (PE) as a predictive tool for locally advanced prostate cancer (PC) or margin-positive resection (R1) after radical prostatectomy (RP). Prospective evaluation of a consecutive cohort of men who underwent PB and subsequent RP was carried out. Transrectal ultrasound-guided 10-20 core PB was performed according to a standardized protocol. Each biopsy core was inked at the PE and classified as PE positive or negative. The study cohort comprised 100 men with a mean age of 62.3 years (41-75 years). Overall, PE-positive cores were found in 71 men, postoperative tumour (pT)3/pT4 stages were diagnosed in 33 men and R1 status in 45 men after RP. In univariate analysis, the presence of at least one PE-positive core was correlated to an increased risk for pT3/pT4 stage (relative risk (RR): 3.15; 95% confidence interval (95% CI): 1.1-9.9; P = 0.03) and R1 status (RR: 2.9; 95% CI: 1.1-7.5; P = 0.03). In multivariate analysis including Gleason score, total number of positive cores, PE positivity and PSA, PE positivity was correlated to pT3/pT4 stage (P = 0.04). In conclusion, PC at the PE of a PB specimen predicts non-organ-confined tumour stage in subsequent prostatectomy. This simple, new technique may contribute to increasing the accuracy of risk stratification for curative treatment of PC.

Does perineural invasion on prostate biopsy predict adverse prostatectomy outcomes?

OBJECTIVE

To determine the relationship between perineural invasion (PNI) on prostate biopsy and radical prostatectomy (RP) outcomes in a contemporary RP series, as there is conflicting evidence on the prognostic significance of PNI in prostate needle biopsy specimens.

PATIENTS AND METHODS

From 2002 to 2007, 1256 men had RP by one surgeon. Multivariable logistic regression and Cox proportional hazards models were used to examine the relationship of PNI with pathological tumour features and biochemical progression, respectively, after adjusting for prostate-specific antigen level, clinical stage and biopsy Gleason score. Additional Cox models were used to examine the relationship between nerve-sparing and biochemical progression among men with PNI.

RESULTS

PNI was found in 188 (15%) patients, and was significantly associated with aggressive pathology and biochemical progression. On multivariate analysis, PNI was significantly associated with extraprostatic extension and seminal vesicle invasion (P < 0.001). Biochemical progression occurred in 10.5% of patients with PNI, vs 3.5% of those without PNI (unadjusted hazard ratio 3.12, 95% confidence interval 1.77-5.52, P < 0.001). However, PNI was not a significant independent predictor of biochemical progression on multivariate analysis. Finally, nerve-sparing did not adversely affect biochemical progression even among men with PNI.

CONCLUSION

PNI is an independent risk factor for aggressive pathology features and a non-independent risk factor for biochemical progression after RP. However, bilateral nerve-sparing surgery did not compromise the oncological outcomes for patients with PNI on biopsy.

Perineural and lymphovascular invasion on prostatic biopsy: pathological assessment and significance

The importance of Gleason grade on prostatic needle biopsy specimens is widely accepted as a significant histopathological prognostic factor in the assessment of prostatic carcinoma. However, the value of other pathological variables used in the reporting of prostatic needle biopsies such as perineural or lymphovascular invasion is more controversial. This review examines the evidence for the utility of these pathological factors as prognostic indicators for prostatic carcinoma and the limitations in their assessment on needle biopsies.

Parameters of perineural invasion in radical prostatectomy specimens lack prognostic significance

The prognostic significance of perineural invasion by prostate cancer is debated. We have evaluated the association between biochemical failure and measurements of perineural invasion in radical prostatectomy specimens. Perineural invasion was identified in sections using S-100 protein immunostaining. For nerves showing invasion, the involved nerve closest to the edge of the prostate and to the surgical excision margin, as well as the diameter of these nerves, the largest nerve showing perineural invasion and its proximity to the excision margin, and the percentage of nerves showing perineural invasion up to 1.75 mm from the excision margin was determined and tested against time to prostate-specific antigen failure, along with preoperative prostate-specific antigen levels, highest Gleason primary grade, Gleason score and TNM T category. Perineural invasion was present in 90% of cases, with extraprostatic perineural invasion in 25% of tumors. Diameter of nerves showing perineural invasion ranged from 11 to 680 microm and the shortest distance to the surgical excision margin ranged from 33 to 2.57 mm. Perineural invasion density ranged from 6 to 96%. Gleason scores were six in 58 cases, seven in 43 cases, eight in three cases and nine in one case. Clinical T categories were T1c in 75 cases, T2a in 22 cases, T2b in five cases, T2c in two cases, T3 in one case. During a follow-up period of 11 to 55 months (median 26 months), 27 patients showed prostate-specific antigen failure. On univariate analysis only presence of extraprostatic perineural invasion, among parameters of perineural invasion, showed a weak correlation with outcome, while on multivariate analysis this lost significance and preoperative prostate-specific antigen levels, Gleason score and excision margin status were independently associated with biochemical failure. We conclude that the investigated parameters of perineural invasion do not predict prostate-specific antigen recurrence in radical prostatectomy specimens.

Perineural invasion affects biochemical recurrence-free survival in patients with prostate cancer treated with definitive external beam radiotherapy

OBJECTIVES

To assess the prognostic effect of perineural invasion (PNI) for patients undergoing external beam radiotherapy for prostate cancer.

METHODS

We evaluated 657 consecutive patients who had undergone external beam radiotherapy for clinically localized prostate cancer. The clinical/treatment parameters used for analysis included PNI, clinical stage, biopsy Gleason score, pretreatment prostate-specific antigen, radiation dose, and androgen deprivation. The primary endpoint was biochemical recurrence defined by the Radiation Therapy Oncology Group-American Society for Therapeutic Radiology Oncology Phoenix consensus; the secondary endpoint was prostate cancer death.

RESULTS

Of 586 men with a minimum of 24 months of follow-up, 112 (19.1%) had PNI present in the biopsy specimen. When patients were stratified into risk groups using the National Comprehensive Cancer Network criteria, PNI was more prevalent in patients within higher risk groups (6.8% in low-risk versus 18.3% in intermediate-risk versus 30.1% in high-risk groups; P <0.001). The presence of PNI was associated with lower biochemical recurrence-free (P = 0.003) and cancer-specific (P = 0.040) survival rates by Kaplan-Meier analysis. Cox regression analysis showed that PNI was a statistically significant prognostic factor of biochemical recurrence on both univariate (hazard ratio [HR] 1.71, 95% confidence interval [CI] 1.19 to 2.46, P = 0.004) and multivariate (HR 1.57, 95% CI 1.06 to 2.32, P = 0.025) analyses. Regression analysis after stratification by risk group and adjustment for treatment covariates demonstrated a significant association between PNI and the risk of biochemical recurrence for low-risk (HR 4.14, 95% CI 1.55 to 11.02, P = 0.005) and intermediate/high-risk patients (HR 1.53, 95% CI 1.02 to 2.29, P = 0.040).

CONCLUSIONS

The results of our study have shown that the presence of PNI is an independent risk factor associated with an increased risk of biochemical recurrence in patients with prostate cancer undergoing external beam radiotherapy.

The prognostic significance of perineural invasion in prostatic cancer biopsies: a systematic review

Men with clinically localized prostate cancer are faced with a wide range of treatment options, and only Gleason grading is universally used as a histopathological prognostic factor for this disease. The significance of perineural invasion in diagnostic biopsies is controversial. Opinion about whether or not it should influence treatment decisions is currently almost equally divided. To address this, the authors performed a systematic review of studies that examine the association between perineural invasion and prostate cancer recurrence. MEDLINE, Embase, and the Web of Knowledge were searched from January 1990 to December 2005. Outcomes analyzed were the development of biochemical or clinical recurrence. Twenty-one articles on the association of perineural invasion in biopsies and prostate cancer recurrence after radical prostatectomy (n = 10) or radiotherapy (n = 11) were found but none on its significance in the context of watchful waiting. Structured data extraction was performed to allow comparisons between articles and to identify sources of heterogeneity to explain discrepancies in results. The considerable variation in study design, execution, and reporting precluded meta-analysis and quantitative risk estimation, but the weight of evidence suggested that perineural invasion in biopsies was a significant prognostic indicator, particularly in specific patient groups defined by presenting serum prostate-specific antigen levels and biopsy Gleason scores. Immediate treatment rather than watchful waiting may be more appropriate for patients with localized prostatic cancer and perineural invasion. However, the data are limited, and well-designed studies that use predefined stringent protocols are required to provide robust estimates of risk to aid in treatment planning.

Perineural invasion associated with increased cancer-specific mortality after external beam radiation therapy for men with low- and intermediate-risk prostate cancer

PURPOSE

To identify an association between perineural invasion (PNI) and cancer-specific survival in patients with prostate cancer after standard-dose external beam radiation therapy (RT).

METHODS AND MATERIALS

A total of 517 consecutive patients who underwent RT (median dose, 70.5 Gy) between 1989 and 2003 for low-risk or intermediate-risk prostate cancer were studied. A genitourinary pathologist (AAR) scored presence or absence of PNI on all prostate needle-biopsy specimens. A Cox regression multivariable analysis was performed to assess whether the presence of PNI was associated with risk of prostate cancer-specific mortality after RT when the recognized risk-group variables were factored into the model. Estimates of cancer-specific mortality were made using a cumulative incidence method. Comparisons of survival were made using a two-tailed log-rank test.

RESULTS

At a median follow-up of 4.5 years, 84 patients (16%) have died, 15 of 84 (18%) from prostate cancer. PNI was the only significant predictor of prostate cancer-specific mortality after RT (p=0.012). The estimated prostate cancer-specific mortality was 14% at 8 years for PNI+ patients vs. 5% for PNI- patients (p=0.0008).

CONCLUSIONS

Patients with low- or intermediate-risk prostate cancer who have PNI on prostate needle biopsy have a significantly higher rate of prostate cancer-specific mortality after standard-dose radiation therapy than patients without PNI. Although this analysis is retrospective, this association argues for consideration of the use of more aggressive therapy, such as hormonal therapy with RT or dose escalation, in these select patients.

Perineural invasion on prostate needle biopsy does not predict biochemical failure following brachytherapy for prostate cancer

PURPOSE

To determine if the presence of perineural invasion (PNI) predicts biochemical recurrence in patients who underwent low-dose-rate brachytherapy for the treatment of localized prostate cancer.

METHODS AND MATERIALS

A retrospective case control matching study was performed. The records of 651 patients treated with brachytherapy between 1996 and 2003 were reviewed. Sixty-three of these patients developed biochemical failure. These sixty-three patients were then matched in a one-to-one ratio to patients without biochemical failure, controlling for biopsy Gleason score, clinical stage, initial prostate-specific antigen, age, and the use of androgen deprivation. The pathology of the entire cohort was then reviewed for evidence of perineural invasion on initial prostate biopsy specimens. The biochemical relapse free survival rates for these two groups were compared.

RESULTS

Cases and controls were well matched, and there were no significant differences between the two groups in age, Gleason grade, clinical stage, initial prostate-specific antigen, and the use of androgen deprivation. PNI was found in 19 (17%) patients. There was no significant difference in the rates of PNI between cases and controls, 19.6% and 14.3% respectively (p = 0.45). PNI did not correlate with biochemical relapse free survival (p = 0.40).

CONCLUSION

Perineural invasion is not a significant predictor of biochemical recurrence in patients undergoing brachytherapy for prostate cancer.

Prognostic significance of perineural invasion on biochemical progression-free survival after prostate brachytherapy

OBJECTIVES

To evaluate the influence of perineural invasion (PNI) in the biopsy specimen on biochemical progression-free survival in hormone-naive patients with prostate cancer undergoing brachytherapy.

METHODS

A total of 512 consecutive hormone-naive patients (173 low risk, 212 intermediate risk, and 127 high risk) underwent brachytherapy for clinical Stage T1b-T2cNxM0 (2002 American Joint Committee on Cancer staging system) prostate cancer. No patient underwent seminal vesicle or pathologic lymph node staging. All patients had undergone brachytherapy at least 3 years before analysis. The median follow-up was 5.3 years. Biochemical progression-free survival was defined by a prostate-specific antigen (PSA) cutpoint of 0.4 ng/mL or less after nadir and by the American Society for Therapeutic Radiology and Oncology consensus definition. PNI was defined as carcinoma tracking along, or around, a nerve within the perineural space.

RESULTS

PNI was documented in 133 patients (26.0%). For both biochemical progression-free definitions, 94.0% and 94.9% of patients with and without PNI, respectively, remained free of biochemical progression. The median time to failure in patients with and without PNI was 17.2 and 17.9 months, respectively. For the biochemically disease-free cohort, the median posttreatment PSA level was less than 0.1 ng/mL. On univariate Cox regression analysis, the pretreatment PSA level, percentage of positive biopsies, prostate volume, and Gleason score predicted for biochemical outcome. PNI did not approach statistical significance (P = 0.671). On multivariate analysis, only pretreatment PSA (P < 0.001) and the percentage of positive biopsies (P < 0.001) maintained statistical significance.

CONCLUSIONS

In hormone-naive brachytherapy patients implanted with generous periprostatic treatment margins, the presence of PNI in the biopsy specimen did not adversely affect 8-year biochemical progression-free survival.

Tumor control outcomes of patients treated with trimodality therapy for locally advanced prostate cancer

OBJECTIVES

To evaluate, in a pilot study, the tumor control outcomes of our approach and define the pretreatment characteristics that predict a response to therapy. Patients with advanced clinically localized prostate cancer have a high likelihood of prostate-specific antigen (PSA) failure 3 to 5 years after initial treatment. We adopted trimodality therapy (neoadjuvant and adjuvant androgen ablation, external beam radiotherapy [RT], and a brachytherapy boost) to augment biochemical disease-free survival in this patient population.

METHODS

From 1997 to 2000, 93 patients with clinical Stage T2b or greater, or PSA level greater than 10 ng/mL, or Gleason score 7 or greater were treated with external beam RT followed by palladium-103 brachytherapy. Two to three months before external beam RT, an 8 to 9-month regimen of leuprolide and an oral antiandrogen was initiated. Patients were followed up at 3 to 4-month intervals with PSA determination and digital rectal examination. Perineural invasion, the percentage of cancer in biopsy cores, pretreatment PSA level, clinical T stage, and Gleason score were analyzed as prognostic factors for biochemical failure defined by both the American Society for Therapeutic Radiology and Oncology (ASTRO) criteria and PSA level greater than 0.2 ng/mL.

RESULTS

The median length of follow-up was 45 months. The overall probability of biochemical failure using a PSA level greater than 0.2 ng/mL at 4 years was 79% (95% confidence interval 69% to 89%). With the ASTRO criteria, the overall failure rate at the same point was 77% (95% confidence interval 68% to 87%). Gleason score (P = 0.07) showed a trend toward predicting biochemical failure using the PSA level greater than 0.2 ng/mL criterion.

CONCLUSIONS

Trimodality RT offers excellent tumor control in patients with poor prognosis who often relapse early. Longer follow-up will be important to determine whether these results are durable over time.

Prognostic Parameters Other Than Gleason Score for the Daily Evaluation of Prostate Cancer in Needle Biopsy

OBJECTIVE

To evaluate in prostate needle biopsies the usefulness and the efficacy of not time-consuming morphologic parameters in order to predict whether prostate cancer is organ-confined or it is not, that could contribute additional information to pre-surgical serum PSA and Gleason score, both of them parameters already accepted as clinically significant.

METHODS

Three hundred and two consecutive patients were evaluated, of whom a diagnostic needle biopsy and the radical prostatectomy specimen with no pre-surgical hormone therapy were available. Bilateral or unilateral extension, number of positive cores, percentage of positive cores, intraprostatic perineural invasion (IPNI) and the presence of high-grade prostatic intraepithelial neoplasia (HGPIN) in any of the biopsy cores were evaluated in the needle biopsy.

RESULTS

The median of cores is 6. The IPNI, the presence of bilateral tumour, and the percentage of positive cores, higher than 37.5% (ROC curve), show significant crude OR (4.0, 2.8, 6.9 respectively). The regression model discloses that only the percentage of positive cores shows a significant OR (5.8) adjusting for bilaterality, IPNI, HGPIN and age.

CONCLUSIONS

The percentage of cores with cancer and the bilateral involvement are another two parameters predictive of cancer with extraprostatic extension. (p<0.0005 in both). IPNI has statistical significance too (p<0.002), but it is related to the tumour volume expressed through the two mentioned parameters.

Prostate biopsy: is age important for determining the pathological features in prostate cancer?

INTRODUCTION

The influence of age on the aggressiveness of prostate cancer (PCa) is controversial. This study aims to assess the influence of age in determining the pathological features of biopsies from patients diagnosed with PCa.

PATIENTS AND METHODS

We selected 1422 patients with clinical suspicion of PCa; among them, 547 (38.5%) had received a diagnosis of adenocarcinoma. Patients were categorized into the following age groups: up to 50 years old, 51 to 60 years, 61 to 70 years, 71 to 80 years, and over 80 years. The evaluated variables were histological grade, presence of perineural invasion and estimate of tumor volume through measurement of the maximum percentage of tissue with cancer in one fragment and total percentage of tissue with cancer in the sample.

RESULTS

The mean age of patients was 66.4 years, with age range from 32 to 94 years. The estimate of tumor volume by maximum percentage of tissue with cancer in one fragment (p = 0.064), total percentage of tissue with cancer in the sample (p = 0.443), and Gleason score (p = 0.485) were not statistically different in relation to the age groups under study. The presence of perineural invasion occurred more frequently among the 50 years and 81 years age groups when compared with patients aged from 51 to 60 and from 61 to 80 years (p = 0.005).

CONCLUSIONS

Age did not represent a determining factor for pathological findings concerning Gleason score and estimate of tumor volume by the variables in use.

Perineural invasion in prostate cancer biopsies is not associated with higher rates of positive surgical margins

PURPOSE

High rates of extracapsular tumor extension have been reported with biopsy perineural invasion (PNI), leading some to advocate routine resection of the ipsilateral neurovascular bundle (NVB) with radical retropubic prostatectomy (RRP) to assure negative surgical margins. The contemporary rates of extracapsular tumor extension (ECE) and margin status associated with biopsy PNI were investigated.

MATERIALS AND METHODS

The prostate needle biopsies, RRP specimens, and operative reports of 452 consecutive patients undergoing RRP by a single surgeon were reviewed to determine the presence of PNI invasion, presence of ECE, margin status, and preservation of NVB. Patients were excluded from the analysis if they underwent preoperative hormonal ablation or if their original biopsy was not reviewed by the pathologists at our institution. Both univariate and multivariate analyses were performed to determine the effect of PNI on extracapsular extension, the likelihood of performing a bilateral nerve-sparing technique, and the result of a positive surgical margin.

RESULTS

In the 402 evaluable cases, based on multivariate models PNI showed only a marginal association with positive surgical margin (+SM) (P = 0.10) and bilateral nerve-sparing (B-NS) (P = 0.07), but was significantly associated with organ confinement (P = 0.03). The odds ratio (OR) of PNI for +SM, although not statistically significant, was 0.36. Although showing a higher level of statistical significance, PNI for OC had an odds ratio of 0.50. Similarly, the odds ratio was 0.54 for B-NS.

CONCLUSIONS

Although biopsy PNI alone was associated with a higher probability of ECE, it is not predictive of bilateral nerve-sparing technique or a positive surgical margin in an individual patient.

Association of percent positive prostate biopsies and perineural invasion with biochemical outcome after external beam radiotherapy for localized prostate cancer

PURPOSE

Few studies have evaluated the significance of the percentage of positive biopsies (PPB) and perineural invasion (PNI) for patients treated with external beam radiotherapy (EBRT) for localized prostate cancer. Our goal was to investigate the value of these factors in predicting biochemical control (bNED) after EBRT.

METHODS AND MATERIALS

The study cohort consisted of 331 patients who received EBRT between 1993 and 1999 for clinically localized prostate cancer. The median follow-up was 4.4 years (range, 3 months to 9.6 years). The distribution by clinical T stage was as follows: T1 in 55 (17%), T2a in 94 (28%), T2b in 76 (23%), T2c in 74 (22%), T3a in 27 (8%), and T3b in 5 (2%). The pretreatment prostate-specific antigen (iPSA) level was < or =10 ng/mL in 224 patients, 10.1-20 ng/mL in 72 patients, and >20 ng/mL in 35 patients. The biopsy Gleason score was < or =6 in 216 patients and > or =7 in 115 patients. On the basis of the pathology report, the PPB was calculated for 239 patients and was < or =33% in 109, 34-66% in 72, and > or =67% in 58 patients. PNI was present in 30 patients. The median dose of EBRT was 68.4 Gy (range, 64-71 Gy). Patients were categorized into three risk groups: 142 patients were low risk (T1-T2, iPSA < or =10 ng/mL, and Gleason score < or =6), 137 were intermediate risk (increase in the value of one of the risk factors); and 52 patients were high risk (increase in value of two or more of the risk factors). Biochemical failure was defined as three consecutive rises in the PSA level.

RESULTS

The 5-year bNED rate for the entire cohort was 62%. The 5-year bNED rate for the low-, intermediate, and high-risk group was 79%, 51%, and 47%, respectively (p <0.0001). On univariate analysis (log-rank test), clinical stage (p = 0.0073), grade (p <0.0001), iPSA (p = 0.0043), risk group (p <0.0001), PPB (p = 0.0193), and presence of PNI (p = 0.0137) correlated with bNED. For T1-T2a, T2b-T2c, and T3 patients, the 5-year bNED rate was 71%, 59%, and 40%, respectively. The 5-year bNED rate was 68% for those with an iPSA level of < or =10 ng/mL and 49% for those with an iPSA level of >10 ng/mL. For patients with PPB < or =33%, 34-66%, and > or =67%, the 5-year bNED rate was 75%, 67%, and 51%, respectively. Within the intermediate-risk group, the PPB was significantly associated with the bNED rate: 67%, 52%, and 30% for those with PPB < or =33%, 34-66%, and > or =67%, respectively (p = 0.0046). This association was not seen in the low- or high-risk group. The 5-year bNED rate was 64% for patients without PNI and 48% for those with PNI. On multivariate analysis (Cox proportional hazards model), the statistically significant predictive factors for bNED were risk group (p = 0.0032) and PPB (p = 0.044). Using the chi-square test, statistically significant associations between T stage, PSA level, Gleason score, and risk group with PPB were found; PNI was significantly associated with T stage and PSA level only.

CONCLUSION

Our results showed that PPB and PNI have a statistically significant impact on the bNED rate in patients treated with conventional dose of EBRT (< or =71 Gy). Within the intermediate-risk group, the PPB was predictive of bNED, suggesting that patients with < or =33% PPB had a statistically significant better treatment outcome compared with those with a greater PPB. PNI was not significant for bNED in multivariate analysis. The effects of these two prognostic factors in patients who have been treated with higher doses of RT (> or =75.6 Gy) should be studied.