Predictors of Gleason pattern 4/5 prostate cancer on prostatectomy specimens: can high grade tumor be predicted preoperatively?

PURPOSE: Radical prostatectomy provides excellent cancer control in men with clinically localized prostate carcinoma. However, to our knowledge preoperative parameters for distinguishing indolent from clinically significant cancer are not well characterized. In fact, recent evidence suggests that the percent of Gleason pattern 4/5 carcinoma in the complete radical prostatectomy specimen is one of the strongest predictors of prostate cancer progression and a valid measure of cancer severity. However, it is unclear whether preoperative parameters, including biopsy Gleason pattern 4/5 carcinoma, may predict radical prostatectomy Gleason pattern 4/5 disease and, thereby, distinguish indolent from clinically significant cancer. MATERIALS AND METHODS: We prospectively obtained 101 consecutive radical prostatectomy specimens and processed them in whole mount fashion. In addition to total tumor volume, we determined tumor volume for each Gleason pattern. Biopsy tumor area was measured in a similar fashion. Univariate and multivariate analyses were performed to identify preoperative clinical and pathology parameters for predicting Gleason pattern 4/5 carcinoma on prostatectomy specimens. RESULTS: Biopsy Gleason score 7 or greater, Gleason pattern 4/5 carcinoma, perineural invasion and biopsy tumor area had statistically significant associations for identifying Gleason pattern 4/5 carcinoma on prostatectomy specimens. Logistic regression models for predicting any or greater than 10% Gleason pattern 4/5 carcinoma on prostatectomy specimens revealed that an area of pattern 4/5 disease of greater than 0.01 cm.2 on biopsy was the best single predictor with odds ratios of 15.0 (95% confidence interval 3.3 to 69.0, p = 0.0005) and 3.9 (95% confidence interval 1. 4 to 10.9, p = 0.009), respectively. For predicting any pattern 4/5 carcinoma on prostatectomy specimens a biopsy area of pattern 4/5 disease of greater than 0.01 cm.2 had only 38% sensitivity but 96% specificity. Similarly for predicting significant pattern 4/5 disease on prostatectomy specimens, defined as 10% or greater pattern 4/5, sensitivity and specificity for a biopsy area of greater than 0.01 cm.2 were 34% and 88%, respectively. Therefore, due to high false-negative rates these models had limited predictive value on an individual basis. CONCLUSIONS: Biopsy parameters such as Gleason pattern 4/5 carcinoma may provide adequate specificity for predicting clinically significant cancer, as defined by high grade Gleason patterns in the corresponding radical prostatectomy specimen. However, the accuracy of these parameters for predicting indolent cancer is limited by a prohibitive rate of false-negative findings.

Benign prostatic glands at surgical margins of radical prostatectomy specimens: frequency and associated risk factors.

OBJECTIVES: Elevation of serum prostate-specific antigen (PSA) after radical prostatectomy for prostate cancer is considered a surrogate marker of therapeutic failure. The most likely explanation for early PSA failure is considered to be due to local recurrent disease, provided the patient had a nondetectable PSA level after radical prostatectomy. Others have recently suggested that benign prostatic glands located on the surgical margins may often lead to detectable PSA levels. We examined the frequency of benign prostatic glands at the surgical margins of radical prostatectomy specimens and the factors associated with this finding. METHODS: One hundred nineteen consecutive radical prostatectomies were performed by two experienced oncologic surgeons. Whole-mount sectioning of the prostatectomy specimens was performed at 3-mm intervals. Bivariate and multivariate analyses were used to determine which clinical and pathologic factors were associated with benign glands on inked surgical margins. RESULTS: Of the 119 cases, 13 (11%) had benign glands on the inked surgical margins. Four of these 13 had tumor on the inked margins. The remaining 9 cases (8%) were organ confined (pT2), with negative surgical margins. Benign glands were most often seen to involve the apex focally (7 of 9 cases). On bivariate and multivariate analyses, a high Gleason score and prostate gland volume were significantly associated with finding benign glands on the surgical margins. Only 2 of 86 patients with follow-up had PSA recurrence at 59 and 67 days and neither had benign glands on the inked surgical margins. CONCLUSIONS: The presence of benign prostatic glands identified on inked surgical margins was an infrequent occurrence in this consecutive series of 119 whole-mount prostatectomy specimens. When benign glands were identified, they most often consisted of 1 to 3 glands at the apex margin. These findings suggest that benign glands on surgical margins are an unusual cause of postoperative detectable PSA.

Whole mounted radical prostatectomy specimens do not increase detection of adverse pathological features.

PURPOSE: The optimal method to process radical prostatectomy specimens to maximize the detection of adverse pathological features is unclear and accurate staging is critical. We compare the ability of whole mounted sections to detect these features compared to partially submitted radical prostatectomy specimens. MATERIALS AND METHODS: A total of 93 consecutive radical prostatectomy specimens were processed as whole mounts. Tissue sections were analyzed and the pathological outcomes measured included Gleason score, surgical margin status, and presence or absence of extraprostatic tumor extension and/or seminal vesicle invasion. The pathological outcomes of the preceding cohort were compared to those of a similar cohort consisting of 554 men whose radical prostatectomy specimens were processed as partially submitted glands. RESULTS: A multivariate logistic regression analysis was performed to determine the effect of the method of tissue processing on the pathological outcomes. When considered alone or adjusted for various preoperative patient characteristics (prostate specific antigen, biopsy Gleason score and clinical stage), there were no significant differences in the ability of whole mounted specimens to detect the various outcomes compared to partially submitted specimens (all p >0.4). CONCLUSIONS: Whole mounted sampling of the radical prostatectomy specimen does not improve detection of adverse pathological features.

Coordinate expression of cytokeratins 7 and 20 in prostate adenocarcinoma and bladder urothelial carcinoma.

We studied the expression of cytokeratin (CK)-7 and CK-20 in prostate adenocarcinoma and urothelial carcinoma and evaluated their usefulness for distinguishing high-grade forms of these tumors. We examined prostate adenocarcinoma in 59 radical prostatectomy specimens and in 10 autopsy specimens showing metastatic disease, and urothelial carcinoma of the bladder in 28 cystectomy specimens. Immunohistochemical staining for CK-7, CK-20, and prostate-specific antigen (PSA) was performed on paraffin sections. For prostate adenocarcinoma, 5 cases had only CK-7 positivity, 5 had only CK-20 focal positivity, 1 stained for both markers, and 48 were negative for both. PSA was positive in all but 1 poorly differentiated prostatic carcinoma. In the autopsy cases, PSA was expressed in the prostate and the metastatic tumors in most cases; few cases were focally positive for CK-7 or CK-20, but none was positive for both markers. For the urothelial tumors, CK-7 was the sole positive marker in 6 cases, and CK-20 in 1 case; 17 cases were positive for both, and 4 were negative for both. All urothelial carcinomas were PSA negative. Although PSA is useful for differentiating prostatic from urothelial carcinoma, CK-7 and CK-20 are helpful when both are positive, supporting the diagnosis of urothelial carcinoma. However, if only 1 marker is positive or both are negative, these markers have limited usefulness for distinguishing these carcinomas.

Relationship and significance of greatest percentage of tumor and perineural invasion on needle biopsy in prostatic adenocarcinoma.

Serum prostate-specific antigen (PSA) levels and the biopsy Gleason sum are used along with clinical staging to predict prostatectomy pathology results for men with localized prostate cancer. The additional predictive value of perineural invasion (PNI) in pretreatment prostate needle biopsies for evaluating tumor stage in this setting is controversial. The current study evaluates the independent predictive value of PNI for tumor staging in a cohort of 632 men who underwent radical retropubic prostatectomies for clinically localized adenocarcinoma of the prostate between the years 1994 and 1998. None of these men received hormonal or radiation therapy before surgery. In addition to the Gleason sum, biopsy results contained detailed information regarding tumor burden: 1) total number of biopsy cores involved by adenocarcinoma, 2) greatest percentage of any single biopsy involved by prostate carcinoma (GPC), and 3) total percentage of cancer added over all cores (TPC). The presence or absence of any PNI was recorded. Pretreatment factors were analyzed in a univariate and multivariate fashion to determine their predictive value using the TNM tumor stage (pT2 vs pT3) and the modified tumor staging system, which includes surgical margin status (pT2 vs pT3 or positive surgical margin) as end points. Univariate analysis revealed a significant association between pT3 disease and several preoperative factors including age, Gleason sum, serum PSA, digital rectal examination, PNI, GPC, TPC, and the total number of positive cores (p <0.01). Multivariate analysis indicated that serum PSA, Gleason sum, age, and GPC contributed significantly to predicting pT3 disease with odds ratios of 2.7 (95% CI, 1.7-4.3), 2.3 (95% CI, 1.7-3.1), 1.7 (95% CI, 1.1-2.7), and 1.7 (95% CI, 1.4-2.1) respectively. PNI was significant in multivariate analysis only when GPC and TPC were not considered, due to a significant interaction between GPC and PNI (p <0.0001, Wilcoxon's rank sum test). These predictive factors showed a similar relationship to adverse pathology when an alternative definition of adverse pathology was used that included positive surgical margins (pT3 or any positive margin). In the interaction between GPC and PNI, GPC was more significant than PNI in predicting pT3 disease. However, PNI added additional information when adverse pathology was defined more broadly as pT3 or any positive margin.

Study of chromosome 12 copy number in breast cancer using fluorescence in situ hybridization.

Trisomy 12 is the most frequent numerical chromosomal abnormality reported in chronic lymphocytic leukemia (CLL). Its significance in other cancers, however, has not been extensively investigated until recently. Less than 20 cases of polysomy for chromosome 12 have been studied thus far. The most recent data in the literature suggest that gain of chromosome 12 may be a recurrent and sometimes early event in breast carcinogenesis. To test the hypothesis that a subset of breast cancer may be characterized by chromosome 12 trisomy, we conducted a retrospective study of 40 specimens. Of these, ten were stage I, ten were stage II, ten were stage III, and ten were stage IV. Out of the total sample, 12 cases (30%) were found to be presumably trisomic, if a conservative cutoff point of greater than or equal to 15% cells with three signals is adopted. Furthermore, some, but not all, of the 12 cases were found to be likely triploid, when data from a control chromosome 17 probe were taken into account. Thus, our data support the hypothesis that a subset of breast cancer exists which is characterized by an abnormal copy of chromosome 12, in either a diploid or a triploid background.

HER-2/neu gene amplification in stages I-IV breast cancer detected by fluorescent in situ hybridization.

PURPOSE: Approximately 25-30% of breast and ovarian carcinomas have amplification of the HER-2/neu oncogene. The aim of the present study was to focus on HER-2/neu gene amplification in different clinical stages of breast cancer in order to (1) determine if fluorescent in situ hybridization (FISH) can be used to detect HER-2/neu gene amplification in different clinical stages of breast cancer, (2) establish whether HER-2/neu gene amplification characterizes a subset of breast cancer in each of these stages, and (3) determine whether a trend for correlation of amplification with the clinical stage of the disease can be detected using the FISH technology. METHODS: A total of 40 specimens of formalin-fixed, paraffin-embedded breast cancer tissues were analyzed cytogenetically, in a blinded fashion, for HER-2/neu gene amplification using FISH and the Vysis LSI HER-2/neu Orange and CEP 17 Green DNA dual color probe. The criterion for "high amplification" was an amplification ratio of >4.0, that for "moderate amplification" a ratio between 2.1 and 4.0, and that for "low amplification" a ratio of 1.5-2.0. RESULTS: Using a cutoff point of > or =1.5, the overall frequency of HER-2/neu gene amplification among stage I tumors was 30% (3 out of 10). Of these, one-third (1 out of 3) showed low amplification, one-third (1 out of 3) were moderately amplified, and one-third (1 out of 3) were highly amplified. The overall frequency of HER-2/neu gene amplification among stage II tumors was 0% (0 out of 10). The overall frequency of HER-2/neu gene amplification among stage III tumors was 10% (1 out of 10). The sole tumor found positive was classified as moderately amplified by our criteria. The overall frequency of HER-2/neu gene amplification among stage IV tumors was 50% (5 out of 10). Four of the 5 tumors found positive were highly amplified. The overall frequency of gene amplification in the 40 cases studied was 22.5% (9 out of 40 tumors studied). CONCLUSION: Although a linear correlation between HER-2/neu amplification and clinical stage cannot be established at this time, it is interesting to note that when stages I and II, and when stages III and IV are combined, respectively, the latter category has a higher amplification frequency than the former. Furthermore, stage IV has the highest frequency (5 out of 10) of HER-2/neu gene amplification than all three lower stages combined (4 out of 30). This is no doubt due to the high frequency of gene amplification observed in stage IV tumors, which, interestingly, also demonstrate high level amplification of HER-2/neu gene copy numbers. Although the biologic and clinical basis for gene amplification is not clear, given the observation that the most aggressive disease stage is associated with the highest frequency of gene amplification and the most high level amplification, further exploration of HER-2/neu as a prognostic marker of poor outcome using FISH is warranted.

Expression of a highly conserved oncofetal gene, TA1/E16, in human colon carcinoma and other primary cancers: homology to Schistosoma mansoni amino acid permease and Caenorhabditis elegans gene products.

The peptides encoded by the rat liver oncofetal cDNA TA1 and the human lymphocyte activation gene E16 display a high degree of homology with coding regions recently identified in Schistosoma mansoni and Caenorhabditis elegans. Previous studies showed that up-regulation of TA1/ E16 expression was associated with rat hepatocarcinogenesis and human tumor cell lines; therefore, we analyzed several primary human tumors including a panel of 20 colon carcinomas to evaluate the relationship of TA1/E16 RNA and protein expression to neoplasia. A 4.0-kb transcript was detected in all but one colorectal carcinoma but not in normal colon or specimens of inflammatory bowel disease. Steady-state TA1/E16 mRNA levels varied considerably between carcinomas and did not correlate simply with mitotic index, modified Dukes' stage, or tumor size. TA1/E16 message also was detected in adenocarcinomas from breast, endometrium, salivary gland, and esophagus. Western blot analysis using antibodies against TA1/E16-deduced peptides identified major reactive bands of approximately 35 and 19 kDa in neoplasms but not in normal tissue. Immunoperoxidase staining localized the protein primarily to the supranuclear region of colon carcinoma cells, whereas normal epithelial cells were negative. Heterogeneous staining was found in villous adenomas with focal intramucosal adenocarcinoma but was negative in tubular adenomas, suggesting that expression of TA1/E16 may correlate with neoplastic progression in the colon. Up-regulation of this gene in various human cancers suggests a common role in the carcinogenic process and possible application as a tumor marker.

Intratubular spermatic granulomas of the canine efferent ductules.

Spermatic granulomas are inflammatory lesions that occur in the efferent ductule and epididymis of humans, goats, rats, and bulls. Three clinically normal dogs from a control group had histologic lesions of the initial segment of the caput epididymis consisting of intratubular spermatic granulomas. The granulomas were located within the efferent ductules, and the inflammatory response consisted primarily of aggregates of spermiophagic macrophages in the ductules. Sperm stasis of the affected ductules was evident by the dilation and accumulation of large numbers of spermatozoa in adjacent cross-sections of efferent ductules. Blind-ending efferent ductules were demonstrated by serially sectioning the initial segment of the epididymis. The intratubular granulomas did not completely occlude the outflow tract because spermatozoa were present in the cauda epididymis. While spermatic granulomas can be induced by trauma, infection, or toxins, spontaneous granulomas due to blind-ending ductules should be considered as a differential. Clinical history, location of the granuloma, and serial sectioning can help determine the most likely etiology in early cases.

Determinants of pregnancy outcome and newborn behavior of a semirural Egyptian population.

Several potential determinants of birth weight and neonatal behavioral organization, ie, maternal anthropometry, food intake (energy, protein, and plant- and animal-source foods), morbidity, and household socioeconomic status, were followed systematically in a semirural Egyptian population during greater than or equal to 6 mo of pregnancy. In early pregnancy mothers were generally normal weight to moderately overweight. Their mean energy intake, largely from plant sources, was approximately 8.37 MJ/d (2000 kcal/d) during trimesters 2 and 3. Early (3 mo) pregnancy weight and weight gain during trimesters 2 and 3 were significantly positively related to birth weight Z scores. The best predictor model examined for birth weight included early pregnancy weight, weight gain, and length of gestation (R2 = 0.45). Early pregnancy weight and maternal intake of animal-source foods were significant positive predictors of the newborn's orientation and habituation behavior, respectively. Habituation and orientation measures assess the infant's early ability to process information.

Vitamin B-6 status of Egyptian mothers: relation to infant behavior and maternal-infant interactions.

Functional consequences of marginal maternal vitamin B-6 status for behavior of the neonate and for mother-infant interactions at age 3-6 mo were assessed by a double-blind procedure. In 27 of 70 Egyptian village women studied, vitamin B-6 concentration of their milk was considered indicative of poor maternal vitamin B-6 nutriture. Neonatal behavior, quantified by the Brazelton Neonatal Behavioral Assessment Scale, showed that consolability, appropriate build-up to a crying state, and response to aversive stimuli were significantly correlated with maternal vitamin B-6 nutriture. Naturalistic observational procedures, used twice monthly with infants aged 3-6 mo, indicated that mothers assessed as having marginal vitamin B-6 status were less responsive to their infants' vocalizations, showed less effective intervention to infant distress, and were more likely to use older siblings as care-givers than were mothers of better vitamin status. We conclude that vitamin B-6 was a factor influencing both the behavior of the mother and her infant.

The response of adult rats to varying combinations of dietary lysine and threonine.

The response of adult rats fed diets containing amino acid mixtures with varying combinations of lysine and threonine was studied by estimating the change in body weights, organ weights, total nitrogen content of organs and the concentration of free plasma lysine and threonine. Analysis of variance indicates a significant effect of threonine, lysine and a significant interaction due to feeding the two amino acids on the body weights, organ weights and total nitrogen content of various organs. Significant effect on the level of the plasma free amino acid was also shown as a result of feeding the particular amino acid. Results show that in deficient animals the rates of building body protein are low but are higher in the lysine deficient animals than in the threonine deficient and protein deficient animals. The varying rates of exchanging protein between the various organs in response to changing the levels of amino acids in the diet would mean that total change in body protein or total nitrogen balance may not be satisfactory way to determine the protein or amino acid requirements for maintenance. It seems to be necessary to focus down on protein turnover rates in specific tissues.

Response of adult rats to lysine supplementation.

The response of adult rats to wheat flour protein fortified by addition of lysine was studied by utilizing the relative protein value (RPV) compared to non-fortified wheat flour. Lactalbumin was used as a standard protein. Fortification of wheat flour by 0.3% lysine resulted in better growth of rats when fed at 6% protein level. However, no significant difference was observed in the growth of rats fed non-fortified or fortified wheat flour at 4% or 2% protein level. The relative nutritive value (RNV) of supplemented wheat flour protein is higher than that of the non-supplemented when change in body weight or change in body water are used as response parameters. When the dietary protein is provided at maintenance or below maintenance levels, lysine is not limiting. Therefore, supplementation of wheat flour protein with lysine did not result in any better growth response. When protein is provided at levels above maintenance requirements lysine is limiting and better growth was achieved by lysine supplementation to wheat flour protein.

Zinc, calcium, and magnesium concentrations in milk from American and Egyptian women throughout the first 6 months of lactation.

Effects of stage of lactation, nutrient intake, and cultural differences on the composition of human milk were examined during the first 6 mo of lactation in American and Egyptian women. In both population groups zinc levels in milk decreased from 1 to 6 months of lactation. American women supplemented with Zn had higher levels of Zn in their milk than did unsupplemented American or Egyptian women. Concentrations of calcium and magnesium were not significantly different in milk of American and Egyptian women except at month 6 of lactation. Ca levels in milk of both population groups increased from 1 to 2-3 mo of lactation and then decreased at 6 mo; Mg concentrations increased from 1 to 3 mo and then reached a plateau. Similarities in the longitudinal decrease observed in Zn levels of milk in Zn supplemented and unsupplemented subjects suggested physiological regulation.

Nutritive value of meat-soy mixture.

The protein value of meat soy blend was evaluated by utilizing the net protein ratio (NPR), the relative protein value (RPV) and the serum urea content methods. It was compared with that of meat. Casein was used as a reference protein. NPR values indicated that utilization of meat and meat soy proteins are comparable. The study of amino acid pattern shows that sulphur containing amino acids are limiting to almost the same degree in meat and meat soy blend. However, the RPV of meat soy bean blend is slightly higher than that of meat. The lowest serum urea content was that of rats fed meat soy blend. Therefore, the mixing of meat with soy bean did not reduce the nutritive value of meat, on the contrary there is tendency towards improvement.

Nutritive value of some common Egyptian meals.

The protein quality of two common Egyptian meals namely lentils and "Koshari" was evaluated on rats by utilizing the net protein ratio (NPR), the relative protein value (RPV) and the serum urea content methods. Casein was used as a reference protein. The macro nutrient contents of the two meals are almost similar. The NPR is higher with low dietary protein level. The estimated RNV of the "Koshari" was higher than that of lentils. Lower serum urea levels were found with the "Koshari" than with lentils meal indicating its better protein quality. This is most probably due to the effect of amino acid supplementation of cereals and legumes. Results obtained are in favour of utilizing the serum urea content method as a simple and reliable one for evaluating protein quality since a negative relationship exists between blood urea content and the biological value of dietary protein. Its validity in estimating dietary protein quality in man need to be investigated.

Availability of essential amino acids in corn flour and corn bread.

The availability of nitrogen, lysine and 9 essential amino acids was determined in corn before and after baking. Lysine availability was determined by the growth response method on weaning rats using regression analysis of body weight gain or moisture gain against lysine consumed from corn flour and corn bread. The results show a high correlation between lysine consumed and weight gain or moisture gain (r = 0.95) for rats fed the standard diets for 3 weeks. A good correlation was also obtained for corn bread. The results of lysine availability show that baking greatly improves availability by both ways of calculation. The availability of nitrogen and essential amino acids were also investigated by the balance trials with rats. Results show that availability values for nitrogen and all amino acids except threonine increased by baking. Data for food intake, weight gain, food efficiency, PER, NPR and true digestibility revealed that baking had little or no effect on nutritive value of corn tested in this investigation.

Detoxification and nutritional evaluation of solvent extracted Egyptian cottonseed meal.

Attempts for degossypolization of the solvent extracted Egyptian cottonseed meal (CSM) and evaluation of its nutritional value as a possible protein supplement for human feeding were undertaken. Three methods were applied for degossypolization: Steaming, addition of iron(II)-sulphate dihydrate, and steaming after addition of iron(II)-sulphate dihydrate. Steaming was done for varying periods of time. Nutritional evaluation was undertaken by chemical analysis and by feeding experiments. Chemically, the third method for degossypolization was the most effective. Feed efficiency and protein efficiency for diets containing 15 and 10% levels of CSM protein indicated that all treatments used for detoxification caused a decrease in diet and protein quality. Diets containing iron-supplemented CSM at the same level were the best of all. Mixing CSM with casein to form a diet containing 10% protein increases the protein quality of both casein and CSM.