Prostate volume and biopsy tumor length are significant predictors for classical and redefined insignificant cancer on prostatectomy specimens in Japanese men with favorable pathologic features on biopsy

Limited Adenocarcinoma of the Prostate on Needle Core Biopsy

CONTEXT.—

Grading small foci of prostate cancer on a needle biopsy is often difficult, yet the clinical significance of accurate grading remains uncertain.

OBJECTIVE.—

To assess if grading of limited adenocarcinoma on prostate biopsy specimen is critical.

DESIGN.—

We studied 295 consecutive patients undergoing extended-sextant biopsy with only 1-core involvement of adenocarcinoma, followed by radical prostatectomy.

RESULTS.—

The linear tumor lengths on these biopsy specimens were: less than 1 mm (n = 114); 1 mm or more or less than 2 mm (n = 82); 2 mm or more or less than 3 mm (n = 35); and 3 mm or more (n = 64). Longer length was strongly associated with higher Grade Group (GG) on biopsy or prostatectomy specimen, higher risk of extraprostatic extension/seminal vesicle invasion and positive surgical margin, and larger estimated tumor volume. When cases were compared based on biopsy specimen GG, higher grade was strongly associated with higher prostatectomy specimen GG, higher incidence of pT3/pT3b disease, and larger tumor volume. Outcome analysis further showed significantly higher risks for biochemical recurrence after radical prostatectomy in patients with 1 mm or more, 2 mm or more, 3 mm or more, GG2-4, GG3-4, GG4, less than 1 mm/GG2-4, less than 1 mm/GG3-4, less than 2 mm/GG3-4, 3 mm or more/GG2-4, or 3 mm or more/GG3-4 tumor on biopsy specimens, compared with respective control subgroups. In particular, 3 mm or more, GG3, and GG4 on biopsy specimens showed significance as independent prognosticators by multivariate analysis. Meanwhile, there were no significant differences in the rate of upgrading or downgrading after radical prostatectomy among those subgrouped by biopsy specimen tumor length (eg, <1 mm [44.7%] versus ≥1/<2 mm [41.5%] versus ≥2/<3 mm [45.7%] versus ≥3 mm [46.9%]).

CONCLUSIONS.—

These results indicate that pathologists still need to make maximum efforts to grade relatively small prostate cancer on biopsy specimens.

Clonal evaluation of prostate cancer molecular heterogeneity in biopsy samples by dual immunohistochemistry and dual RNA in situ hybridization

Prostate cancer is frequently multifocal. Although there may be morphological variation, the genetic underpinnings of each tumor are not clearly understood. To assess the inter and intra tumor molecular heterogeneity in prostate biopsy samples, we developed a combined immunohistochemistry and RNA in situ hybridization method for the simultaneous evaluation of ERG, SPINK1, ETV1, and ETV4. Screening of 601 biopsy cores from 120 consecutive patients revealed multiple alterations in a mutually exclusive manner in 37% of patients, suggesting multifocal tumors with considerable genetic differences. Furthermore, the incidence of molecular heterogeneity was higher in African Americans patients compared with Caucasian American patients. About 47% of the biopsy cores with discontinuous tumor foci showed clonal differences with distinct molecular aberrations. ERG positivity occurred in low-grade cancer, whereas ETV4 expression was observed mostly in high-grade cancer. Further studies revealed correlation between the incidence of molecular markers and clinical and pathologic findings, suggesting potential implications for diagnostic pathology practice, such as defining dominant tumor nodules and discriminating juxtaposed but molecularly different tumors of different grade patterns.

Elevated Serum Sialic Acid Levels Predict Prostate Cancer As Well As Bone Metastases

Objective: To evaluate the value of serum sialic acid (SA) in diagnosis of benign prostatic hyperplasia (BPH), prostate cancer (PCa), and bone metastases in PCa patients. Materials and Methods: Data from 540 patients who were newly diagnosed with PCa or BPH between November 2014 and March 2018 were retrospectively collected and analyzed. Pretreatment SA levels were compared across various groups, then, associations between SA levels and clinic parameters of patients were analyzed as well. Univariate and multivariate logistic regression analyses were further used to identify independent associations. Results: The mean SA levels in patients with PCa were significantly higher than with BPH (p = 0.013). Furthermore, PCa patients with bone metastases showed elevated SA levels compared with PCa without bone metastases (p < 0.001). A multivariate logistic regression model showed that: SA level > 52.35 mg/dL was identified to be independently associated with the diagnosis of PCa (HR = 1.645, p = 0.036), and SA level > 59 mg/dL was identified to be independent association with the presence of bone metastases in PCa patients (HR = 6.421, p = 0.012). Conclusions: Elevated SA level is an independent predictor of prostate cancer as well as its bone metastases. Therefore, SA level may be a promising diagnostic and prognostic biomarker for prostate cancer and bone metastases.

Evaluating the size criterion for PI-RADSv2 category 5 upgrade: is 15 mm the best threshold?

PURPOSE

The purpose of the study was to determine if the ≥ 15 mm threshold currently used to define PIRADS 5 lesions is the optimal size threshold for predicting high likelihood of clinically significant (CS) cancers.

MATERIALS

Three hundred and fifty-eight lesions that may be changed from category 4 to 5 or vice versa on the basis of the size criterion (category 4: n = 288, category 5: n = 70) from 255 patients were evaluated. Kendall's tau-b statistic accounting for inter-lesion correlation, generalized estimation equation logistic regression, and receiver operating curve analysis evaluated two lesion size-metrics (lesion diameter and relative lesion diameter-defined as lesion diameter/prostate volume) for ability to identify CS (Gleason grade ≥ 3 + 4) cancer at targeted biopsy. Optimal cut-points were identified using the Youden index. Analyses were performed for the whole prostate (WP) and zone-specific sub-cohorts of lesions in the peripheral and transition zones (PZ and TZ).

RESULTS

Lesion diameter showed a modest correlation with Gleason grade (WP: τB = 0.21, p < 0.0001; PZ: τB = 0.13, p = 0.02; TZ: τB = 0.32, p = 0.001), and association with CS cancer detection (WP: AUC = 0.63, PZ: AUC = 0.59, TZ: AUC = 0.74). Empirically derived thresholds (WP: 14 mm, PZ: 13 mm, TZ: 16 mm) performed similarly to the current ≥ 15 mm standard. Lesion relative lesion diameter improved identification of CS cancers compared to lesion diameter alone (WP: τB = 0.30, PZ: τB = 0.24, TZ: τB = 0.42, all p < 0.0001). AUC also improved for WP and PZ lesions (WP: AUC = 0.70, PZ: AUC = 0.68, and TZ: AUC = 0.74).

CONCLUSIONS

The current ≥ 15 mm diameter threshold is a reasonable delineator of PI-RADS category 4 and category 5 lesions in the absence of extraprostatic extension to predict CS cancers. Additionally, relative lesion diameter can improve identification of CS cancers and may serve as another option for distinguishing category 4 and 5 lesions.

Correlation between body mass index (BMI) and the Gleason score of prostate biopsies in Chinese population

We assessed the correlation between BMI and Gleason score in prostate biopsies in Chinese Population. In this retrospective study, we collected the Gleason score, PSA, BMI, age, race, and other related clinical data on 290 patients who had undergone prostatic biopsy. We then compared the prostate cancer detection rates and Gleason scores between the high BMI group (BMI ≥ 25; 143 cases) and low BMI group (< 25; 147 cases). Among the 137 patients in whom prostate cancer detected, 70 had high BMIs and 67 had normal BMIs, making the detection rates 48.95% and 45.58% respectively. Seventeen prostate cancer patients had low Gleason scores (Gleason score < 7), while 120 had high Gleason scores (≥ 7). Within the high BMI group, 44.76% had high Gleason scores, which was significantly greater than the 38.10% in the low BMI group (P = 0.027). These results indicate that while there was no effect of BMI on the rate of positive prostate cancer biopsies, the rate of high Gleason scores was greater in the high BMI group than the normal BMI group.

Comparative rates of upstaging and upgrading in Caucasian and Korean prostate cancer patients eligible for active surveillance

Purpose

To investigate the impact of race on the risk of pathological upgrading and upstaging at radical prostatectomy (RP) in an Asian (Korean) and Western (Caucasian) cohort eligible for active surveillance (AS).

Materials and methods

We performed a retrospective cohort study of 854 patients eligible for AS who underwent RP in United States (n = 261) and Korea (n = 593) between 2006 and 2015. After adjusting for age, PSA level, and prostate volume, we utilized multivariate logistic regression analysis to assess the effect of race on upgrading or upstaging.

Results

There were significant differences between Caucasian and Korean patients in terms of age at surgery (60.2 yr. vs. 64.1 yr.), PSA density (0.115 ng/mL/mL vs. 0.165 ng/mL/mL) and mean number of positive cores (3.5 vs. 2.4), but not in preoperative PSA values (5.11 ng/mL vs. 5.05 ng/mL). The rate of upstaging from cT1 or cT2 to pT3 or higher was not significantly different between the two cohorts (8.8% vs. 11.0%, P = 0.341). However, there were higher rates of upgrading to high-grade cancer (Gleason 4+3 or higher) in Korean patients (9.1%) when compared to Caucasian counterparts (2.7%) (P = 0.003). Multivariate logistic regression analysis showed that age (OR 1.07, P < 0.001) and smaller prostate volume (OR 0.97, P < 0.001), but not race, were significantly associated with upstaging or upgrading.

Conclusions

There were no differences in rates of upgrading or upstaging between Caucasian and Korean men eligible for active surveillance.

Performance characteristics of prostate-specific antigen density and biopsy core details to predict oncological outcome in patients with intermediate to high-risk prostate cancer underwent robot-assisted radical prostatectomy

Background

Many urologic surgeons refer to biopsy core details for decision making in cases of localized prostate cancer (PCa) to determine whether an extended resection and/or lymph node dissection should be performed. Furthermore, recent reports emphasize the predictive value of prostate-specific antigen density (PSAD) for further risk stratification, not only for low-risk PCa, but also for intermediate- and high-risk PCa. This study focused on these parameters and compared respective predictive impact on oncologic outcomes in Japanese PCa patients.

Methods

Two-hundred and fifty patients with intermediate- and high-risk PCa according to the National Comprehensive Cancer Network (NCCN) classification, that underwent robot-assisted radical prostatectomy at a single institution, and with observation periods of longer than 6 months were enrolled. None of the patients received hormonal treatments including antiandrogens, luteinizing hormone-releasing hormone analogues, or 5-alpha reductase inhibitors preoperatively. PSAD and biopsy core details, including the percentage of positive cores and the maximum percentage of cancer extent in each positive core, were analyzed in association with unfavorable pathologic results of prostatectomy specimens, and further with biochemical recurrence. The cut-off values of potential predictive factors were set through receiver-operating characteristic curve analyses.

Results

In the entire cohort, a higher PSAD, the percentage of positive cores, and maximum percentage of cancer extent in each positive core were independently associated with advanced tumor stage ≥ pT3 and an increased index tumor volume > 0.718 ml. NCCN classification showed an association with a tumor stage ≥ pT3 and a Gleason score ≥8, and the attribution of biochemical recurrence was also sustained. In each NCCN risk group, these preoperative factors showed various associations with unfavorable pathological results. In the intermediate-risk group, the percentage of positive cores showed an independent predictive value for biochemical recurrence. In the high-risk group, PSAD showed an independent predictive value.

Conclusions

PSAD and biopsy core details have different performance characteristics for the prediction of oncologic outcomes in each NCCN risk group. Despite the need for further confirmation of the results with a larger cohort and longer observation, these factors are important as preoperative predictors in addition to the NCCN classification for a urologic surgeon to choose a surgical strategy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12894-017-0238-y) contains supplementary material, which is available to authorized users.

Tumor Volume and Clinical Failure in High-Risk Prostate Cancer Patients Treated With Radical Prostatectomy

INTRODUCTION

To identify the most significant cut-off of tumor volume (TV) for prediction of clinical failure (CF) among high-risk prostate cancer (hPCa) patients.

METHODS

Within a multi-institutional cohort, 262 patients treated with radical prostatectomy (RP) for hPCa were identified. CF was defined as local recurrence or distant metastases. A time dependent ROC curve was used to evaluate the area under the curve (AUC) using TV as single marker to predict clinical failure at 10 years. We searched for the TV cut off value with the highest combined sensitivity and specificity predicting CF. Three multivariable Cox regression analyses (MVA) tested the predictors of CF after RP. Predictors of the model 1 were pre-operative PSA, pathologic stage (PT), pathologic Gleason sum (GS), surgical margin status, and lymph node invasion. Predictors of the models 2 and 3 were the same of model 1 plus TV as a continuous or dichotomous variable using the defined cutoff, respectively. Validation (leave-one-out-cross-validation-LOOCV) of each model was performed.

RESULTS

Overall, 46 (17.6%) patients experienced CF. The TV value was 6.29 ml. In MVA of models 2 and 3, PT and GS remained independent predictors of CF. Moreover, in model 2 TV (HR:1.07,) and in model 3 TV >6.29 ml (HR:2.99,) were independently associated with CF. In LOOCV, the C-index of models 1-3 were 65.53%, 71.75%, and 70.26%, respectively.

CONCLUSIONS

TV is an independent predictor of CF in hPCa patients. Patients with a TV exceeding the cut-off of 6.29 ml are more likely to develop CF. Prostate 77:3-9, 2017. © 2016 Wiley Periodicals, Inc.

Importance of prostate volume in the stratification of patients with intermediate-risk prostate cancer

OBJECTIVES

To evaluate the role of prostate volume assessed at final pathology in the risk of biochemical recurrence in patients with clinically localized prostate cancer treated with radical prostatectomy.

METHODS

Overall, 5637 patients treated with radical prostatectomy between January 1993 and August 2013 were identified. Multivariable Cox regression analyses tested the association between prostate volume and biochemical recurrence in the overall population and after stratifying patients according to the D'Amico risk groups.

RESULTS

Mean (median) prostate volume was 50.61 mL (46 mL). When patients were stratified according to D'Amico risk groups, mean (median) prostate volume was 51.7 mL (48 mL), 49.8 mL (45 mL) and 50.6 mL (46 mL) in low-, intermediate-, and high-risk prostate cancer, respectively (P = 0.04). Overall, the 5-year biochemical recurrence-free survival rate was 87.9%. In multivariable Cox regression analyses, prostate volume was associated with a lower risk of biochemical recurrence (hazard ratio 0.99, 95% confidence interval 0.99-1.00), after accounting for disease characteristics. However, when patients were stratified according to D'Amico risk groups, prostate volume represented an independent predictor of biochemical recurrence only in individuals with intermediate-risk disease (hazard ratio 0.99, 95% confidence interval 0.99-1.00). Conversely, prostate volume was not associated with the risk of experiencing biochemical recurrence in patients with low- and high-risk disease.

CONCLUSIONS

Smaller prostates are associated with increased risk of biochemical recurrence after surgery only in men with intermediate-risk disease. In this category, the preoperative assessment of prostate volume might be helpful in order to identify patients at higher risk of biochemical recurrence after surgery. Additionally, prostate volume might be used to individualize follow-up schedules after radical prostatectomy.

Can contemporary patients with biopsy Gleason score 3+4 be eligible for active surveillance?

INTRODUCTION

We analyzed whether expansion of existing active surveillance (AS) protocols to include men with biopsy Gleason score (GS) 3+4 prostate cancer (PCa) would significantly alter pathologic and biochemical outcomes of potential candidates of AS.

METHODS

Among patients who underwent radical prostatectomy at our center between 2006 and 2013, we identified 577 patients (group A) who preoperatively fulfilled at least one of 6 different AS criteria. Also, we identified 217 patients (group B) with biopsy GS 3+4 but fulfilled non-GS criteria from at least one of 6 AS criteria. Designating group C as expanded group incorporating all patients in group A and B, we compared risk of unfavorable disease (pathologic GS ≥ 4+3 and/or pathologic T stage ≥ pT3a) and biochemical recurrence (BCR)-free survival between groups.

RESULTS

Rates of unfavorable disease were not significantly different between patients of group A and C who met AS criteria from 5 institutions (all p>0.05), not including University of Toronto (p < 0.001). Also BCR-free survivals were not significantly different between patients in group A and C meeting each of 6 AS criteria (all p > 0.05). Among group B, PSAD > 0.15 ng/mL/cm3 (p = 0.011) and tumor length of biopsy GS 3+4 core > 4 mm (p = 0.007) were significant predictors of unfavorable disease. When these two criteria were newly applied in defining group B, rates of unfavorable disease in group A and B was 15.6% and 14.7%, respectively (p = 0.886).

CONCLUSION

Overall rate of pathologically aggressive PCa harbored by potential candidates for AS may not be increased significantly with expansion of criteria to biopsy GS 3+4 under most contemporary AS protocols. PSAD and tumor length of biopsy GS 3+4 core may be useful predictors of more aggressive disease among potential candidates for AS with biopsy GS 3+4.