Predictive criteria of insignificant prostate cancer: what is the correspondence of linear extent to percentage of cancer in a single core?

Objective The aim of active surveillance of early prostate cancer is to individualize therapy by selecting for curative treatment only patients with significant cancer. Epstein’s criteria for prediction of clinically insignificant cancer in surgical specimens are widely used. Epstein’s criterion “no single core with >50% cancer” has no correspondence in linear extent. The aim of this study is to find a possible correspondence. Materials and Methods From a total of 401 consecutive patients submitted to radical prostatectomy, 17 (4.2%) met criteria for insignificant cancer in the surgical specimen. The clinicopathologic findings in the correspondent biopsies were compared with Epstein’s criteria for insignificant cancer. Cancer in a single core was evaluated in percentage as well as linear extent in mm. Results Comparing the clinicopathologic findings with Epstein’s criteria predictive of insignificant cancer, there was 100% concordance for clinical stage T1c, no Gleason pattern 4 or 5, ≤2 cores with cancer, and no single core with >50% cancer. However, only 25% had density ≤0.15. The mean, median and range of the maximum length of cancer in a single core in mm were 1.19, 1, and 0.5-2.5, respectively. Additionally, the mean, median, and range of length of cancer in all cores in mm were 1.47, 1.5, and 0.5-3, respectively. Conclusion To pathologists that use Epstein’s criteria predictive of insignificant cancer and measure linear extent in mm, our study favors that “no single core with >50% cancer” may correspond to >2.5 mm in linear extent. .

Controversial predictors of biochemical recurrence after radical prostatectomy: a study from a Latin American (Brazilian) Institution

Purpose To analyze controversial clinicopathologic predictors of biochemical recurrence after surgery: age, race, tumor extent on surgical specimen, tumor extent on needle biopsy, Gleason score 3 + 4 vs 4 + 3, and amount of extent of extraprostatic extension and positive surgical margins. Materials and Methods The needle biopsies and the correspondent surgical specimens were analyzed from 400 patients. Time to recurrence was analyzed with the Kaplan-Meier curves and risk of shorter time to recurrence using Cox univariate and multivariate analysis. Results Except for age, race, maximum percentage of cancer per core, and number of cores with cancer, all other variables studied were significantly predictive of time to biochemical recurrence using the Kaplan-Meier curves. In univariate analysis, except for focal extraprostatic extension, age, race, focal positive surgical margins, and maximum extent and percentage of cancer per core, all other variables were significantly predictive of shorter time to recurrence. On multivariate analysis, diffuse positive surgical margins and preoperative PSA were independent predictors. Conclusions Young patients and non-whites were not significantly associated with time to biochemical recurrence. The time consuming tumor extent evaluation in surgical specimens seems not to add additional information to other well established predictive findings. The higher predictive value of Gleason score 4 + 3 = 7 vs 3 + 4 = 7 discloses the importance of grade 4 as the predominant pattern. Extent and not simply presence or absent of extraprostatic extension should be informed. Most tumor extent evaluations on needle biopsies are predictive of time to biochemical recurrence, however, maximum percentage of cancer in all cores was the strongest predictor. .

Does tumor extent on needle prostatic biopsies influence the value of perineural invasion to predict pathologic stage > T2 in radical prostatectomies?

PURPOSE: Perineural invasion (PNI) on needle prostatic biopsies (NPB) has been controversial as a marker of extraprostatic extension and consequently for planning of nerve-sparing radical prostatectomy (RP). The aim of this study was to find whether tumor extent on NPB influences the value of PNI to predict stage > pT2 on RP. MATERIALS AND METHODS: This retrospective study was based on 264 consecutive patients submitted to radical retropubic prostatectomy. Their NPB were matched with whole-mount processed and totally embedded surgical specimens. Tumor extent on NPB was evaluated as the percentage of linear tissue in mm containing carcinoma in all cores. Considering the median value, patients were stratified into 2 groups: harboring less or more extensive tumors on NPB. Univariate and multivariate logistic regression analyses were used to relate stage > pT2 to PNI and other clinical and pathological variables. RESULTS: In patients with more extensive tumors, PNI was predictive of stage > pT2 in univariate analysis but not in multivariate analysis. In less extensive tumors, PNI showed no association between any clinical or pathological variables studied; no difference in the time to biochemical progression-free status compared to patients without PNI; and, no predictive value for pathological stage > pT2 on both univariate and multivariate analyses. CONCLUSION: Tumor extent on NPB influences the predictive value of PNI for pathologic stage > pT2 on RP. With a higher number of small tumors currently detected, there is no evidence that perineural invasion should influence the decision on preservation of the nerve during radical prostatectomy.

Gleason score as predictor of clinicopathologic findings and biochemical (PSA) progression following radical prostatectomy

OBJECTIVE: There is evidence showing that Gleason grading of prostatic adenocarcinoma is one of the most powerful predictors of biological behavior and one of the most influential factors used to determine treatment for prostate cancer. The aim of the current study was to compare the Gleason score for needle biopsy to the Gleason score for the correspondent surgical specimen, find any possible difference in the biochemical (PSA) progression following surgery in upgraded cases, correlate Gleason score in the specimens to several clinicopathologic variables, and compare outcomes between patients with low-grade vs. high-grade Gleason and Gleason scores 3+4 vs. 4+3. MATERIALS AND METHODS: The study population consisted of 200 consecutive patients submitted to radical prostatectomy. Biochemical progression was defined as PSA > 0.2 ng/mL. Time to PSA progression was studied using the Kaplan-Meier product-limit analysis. RESULTS: In 47.1 percent of the cases, there was an exact correlation and 40.6 percent of cases were underestimated in the biopsies. Half of the tumors graded Gleason 6 at biopsy were Gleason score 7 at surgery. These upgraded tumors had outcomes similar to tumors with Gleason score 7 in both biopsy and surgery. There was a positive correlation of high-grade Gleason score in the surgical specimens to higher preoperative PSA, more extensive tumors, positive margins and more advanced pathologic staging. Tumors with a Gleason score > 7 have lower PSA progression-free survival vs. Gleason scores < 7. In this series, there was no significant difference when comparing Gleason scores of 3+4 vs. 4+3. CONCLUSIONS: The findings support the importance of Gleason grading for nomograms, which are used by clinicians to counsel individual patients and help them make important decisions regarding their disease.

Prostate cancer pathologic stage pT2b (2002 TNM staging system): does it exist?

OBJECTIVE: In the 1997 TNM staging system, tumors were classified into a single subdivision: T2a, and bilateral tumor involvement (T2b). In the 2002 TNM staging system, tumors are subclassified as T2a (less than one half of one lobe involvement), T2b (more than one half of one lobe involvement), and T2c (bilateral involvement). A recent study questioned the existence of a true pathologic pT2b tumor. The aim of our study is to verify this question. MATERIALS AND METHODS: The study population consisted of 224 men submitted to radical retropubic prostatectomy. The surgical specimens were histologically evaluated by complete embedding and whole-mount processing. Tumor extent was evaluated by a point-count method. The surgical specimens were staged according to the 2002 TNM staging system. RESULTS: Using the 2002 TNM criteria, the surgical specimens were classified as pT2a, 28 (12.50 percent); pT2b, 0 (0 percent); pT2c, 138 (61.61 percent); pT3a, 30 (13.39 percent); and, pT3b, 28 (12.50 percent). Using the point-count method for tumor extent evaluation, the minimum and maximum total points obtained in unilateral tumors were 192 and 368 points, respectively; the most extensive unilateral tumor showed 68 positive points (less than half the minimum total point-count). CONCLUSIONS: Using the point-count method for tumor extent, our study questions a real existence for pathologic stage pT2b tumors (unilateral tumors involving greater than one-half of one lobe).