Seminal vesicle biopsy: accuracy and implications for staging of prostate cancer.

OBJECTIVES: Seminal vesicle biopsy (SVB) is a new technique for detecting the spread of prostate cancer to the seminal vesicles. A comparison of findings following SVB in patients undergoing radiation therapy with pathologic findings following radical retropubic prostatectomy (RRP) was made to evaluate the accuracy of this test and its use in the staging of prostate cancer. METHODS: Four hundred nine patients with clinically localized adenocarcinoma of the prostate gland were evaluated for treatment: 222 patients underwent SVB prior to radiation therapy and 187 patients underwent RRP. Clinical stages in patients undergoing SVB included T1a (1 patient), T1b (4), T1c (35), T2a (49), T2b (96), and T2c (37); RRP clinical stages included T1b (3 patients), T1c (48), T2a (57), T2b (66), and T2c (13). The Gleason scores in patients undergoing SVB were 2 to 4 in 50 men, 5 to 6 in 110 men, and 7 and greater in 62 men; the Gleason scores in patients undergoing RRP were 2 to 4 in 53 men, 5 to 6 in 94 men, and 7 and greater in 40 men. Prostate-specific antigen (PSA) values ranged from 1.3 to 190 ng/mL (median 10.75) in men undergoing SVB and ranged from 0.5 to 140.6 ng/mL (median 9.0) in men undergoing RRP. RESULTS: The overall incidence of seminal vesicle involvement as determined by the two techniques was the same. Seminal vesicle involvement was found in 33 of 222 patients (15%) undergoing SVB and in 27 of 187 (14%), of the RRP specimens (P = 0.9). When the two groups were further divided by three prognostic categories (clinical stage, PSA level, and grade), there was no difference in the incidence of seminal vesicle involvement between the two methods, except in the patients with Gleason score of 4 or less. In these patients, 5 of 53 (9%) had seminal vesicle involvement in the RRP group, compared with none of the 50 men in the SVB group (P = 0.02). Disease that was not organ confined was found in 69 of 187 prostatectomy specimens (37%). Of these patients, 27 of 69 (39%) had seminal vesicle involvement. CONCLUSIONS: SVB is an accurate method of detecting seminal vesicle invasion based on comparisons with radical prostatectomy findings. Its importance lies in its ability to detect a large percentage of patients with non-organ-confined disease and in its use in modifying treatment planning accordingly.

Seminal vesicle biopsy and laparoscopic pelvic lymph node dissection: implications for patient selection in the radiotherapeutic management of prostate cancer.

PURPOSE: Seminal vesicle biopsies (SVB) and laparoscopic pelvic lymph node dissection (LPLND) are safe surgical staging procedures for prostate cancer that can yield more accurate information than can be obtained by routine clinical means. This information is critical in patient and treatment selection when planning definitive prostate irradiation. An analysis of the procedural findings was undertaken to better define those patients who might benefit from these procedures. METHODS AND MATERIALS: From June 1990 to February 1994, 120 patients with clinical Stage T1b to T2c prostate cancer with negative bone scan and pelvic computerized tomography (CT) scans underwent transrectal ultrasound guided SVB (three from each side). Of these patients, 99 also underwent LPLND. Twelve patients were excluded from analysis of LPLND findings because they were treated with 3 months of hormonal therapy prior to LPLND. During LPLND, 0 to 18 nodes were removed (median-five nodes) from the right side and 0 to 20 nodes (median-five nodes) were removed from the left side. Prostate specific antigen (PSA) values ranged from 1.6 to 190 ng/ml, with a median value of 11.5. Combined Gleason grades ranged from 2 to 9, with a median of 6. RESULTS: A positive SVB was found in 18 patients (15%). A logistic regression analysis was performed to test the effect of grade, PSA, and stage on SVB results. Combined grade and PSA were significant predictors of a positive SVB (p < 0.001 and p = 0.024, respectively). Patients with combined grades of 7 or greater had a higher positive SVB rate of 37.5% (12 out of 32) compared to 7% (6 out of 88) for patients with a lower grade (p < 0.0001). Patients with PSA values greater than 10 had a positive SVB rate of 21% (15 out of 70) compared to 6% (3 out of 50) for patients with values up to 10. There was no morbidity associated with SVB. Laparoscopic pelvic lymph node disection detected positive pelvic nodes in nine patients (10%). The effect of a positive SVB, combined Gleason grade, PSA, and stage on the detection of positive nodes were tested using a stepwise logistic regression analysis. Seminal vesicle biopsy was the most significant predictor of positive nodes (p < 0.0001), while combined grade and PSA were also significant predictors (p = 0.0006 and p = 0.005, respectively). Positive nodes were found in 50% (9 out of 18) of patients with positive SVB compared to 0% (0 out of 69) of patients with a negative SVB (p < 0.0001). Positive nodes were found in 35% (8 out of 23) of patients with a combined grade of 7 or greater compared to 2% (1 out of 64) of patients with a combined grade less than 7 (p < 0.0001). Laparoscopic pelvic lymph node dissection revealed positive nodes in 3% (2 out of 58) of patients with PSA levels < = 20 compared to 24% (7 out of 29) of patients with PSA levels greater than 20 (p = 0.003). Laparoscopic pelvic lymph node dissection was associated with a hospital stay of one night and a minor complication rate of 4%. There were no major complications. CONCLUSIONS: Seminal vesicle biopsy should be performed before treatment in all patients, except those with low risk factors, undergoing radiation therapy for prostate cancer, due to its ability to upstage patients, select patients for LPLND, and alter radiotherapeutic management. Laparoscopic pelvic lymph node dissection should be considered in patients with high risk features, especially in patients with positive SVB where the likelihood of encountering positive nodes is 50%.