Clinical Stage T1c Disease Research Articles

Use of Natural Language Understanding to Facilitate Surgical De-Escalation of Axillary Staging in Patients With Breast Cancer.

Natural language understanding (NLU) may be particularly well equipped for enhanced data capture from the electronic health record given its examination of both content-driven and context-driven extraction. We developed and applied a NLU model to examine rates of pathological node positivity (pN+) and rates of lymphedema to determine whether omission of routine axillary staging could be extended to younger patients with estrogen receptor-positive (ER+)/cN0 disease. We found that rates of pN+ and arm lymphedema were similar between patients age 55-69 years and ≥70 years, with rates of lymphedema exceeding rates of pN+ for clinical stage T1c and smaller disease. Data from our NLU model suggest that omission of sentinel lymph node biopsy might be extended beyond Choosing Wisely recommendations, limited to those older than 70 years and to all postmenopausal women with early-stage ER+/cN0 disease. These data support the recently reported SOUND trial results and provide additional granularity to facilitate surgical de-escalation.

Optimal Monitoring of Prostate-Specific Antigen Detects Prostate Cancer at the Localized Stage after Photoselective Vaporization for Benign Prostatic Hyperplasia

Introduction: Photoselective vaporization of the prostate (PVP) does not provide prostate tissue for pathologic analysis. Here, we carried out early monitoring for prostate cancer by measuring prostate-specific antigen (PSA) levels and assessing clinicopathological features after PVP. Materials and Methods: Patients (n = 800) who underwent PVP and were followed-up for more than 12 months were analyzed retrospectively. After PVP, PSA levels were measured at 3 and 12 months and each year thereafter. Prostate biopsies were performed when PSA levels increased continuously. We assessed the characteristics of patients diagnosed with prostate cancer. Results: The mean follow-up period was 49 months. After PVP, 54 patients underwent biopsies, and 23 patients were diagnosed with prostate cancer. Overall, 10, 10, and 3 patients had clinical stage T1c, T2a, and T2b disease, respectively, and there were no cases of stage T2c disease or greater. Conclusions: We found that it was possible to diagnose prostate cancer at a localized stage under our optimal PSA monitoring schedule before and after PVP.

Complications, Recovery, and Early Functional Outcomes and Oncologic Control Following In-bore Focal Laser Ablation of Prostate Cancer

From April 2013 to July 2014, 25 consecutive men participated in a longitudinal outcomes study following in-bore magnetic resonance imaging (MRI)-guided focal laser ablation (FLA) of prostate cancer (PCa). Eligibility criteria were clinical stage T1c and T2a disease; prostate-specific antigen (PSA) <10 ng/ml; Gleason score <8; and cancer-suspicious regions (CSRs) on multiparametric MRI harboring PCa. CSRs harboring PCa were ablated using a Visualase cooled laser applicator system. Tissue temperature was monitored throughout the ablation cycle by proton resonance frequency shift magnetic resonance thermometry from phase-sensitive images. There were no significant differences between baseline and 3-mo mean American Urological Association Symptom Score or Sexual Health Inventory in Men scores. No man required pads at any time. Overall, the mean PSA decrease between baseline and 3 mo was 2.3 ng/ml (44.2%). Of 28 sites subjected to target biopsy after FLA, 26 (96%) showed no evidence of PCa. Our study provides encouraging evidence that excellent early oncologic control of significant PCa can be achieved following FLA, with virtually no complications or adverse impact on quality of life. Longer follow-up is required to show that oncologic control is durable. Patient summaryEarly results for focal laser ablation of prostate cancer are very encouraging. Until long-term oncologic control is demonstrated, focal laser ablation must be considered an investigational treatment option.

PD14-02 PERCENTAGE OF CANCER INVOLVEMENT IN POSITIVE CORES CAN PREDICT UNFAVOURABLE DISEASE IN MEN WITH LOW-RISK PROSTATE CANCER BUT ELIGIBLE FOR THE PROSTATE CANCER INTERNATIONAL: ACTIVE SURVEILLANCE CRITERIA

You have accessJournal of UrologyProstate Cancer: Localized II1 Apr 2014PD14-02 PERCENTAGE OF CANCER INVOLVEMENT IN POSITIVE CORES CAN PREDICT UNFAVOURABLE DISEASE IN MEN WITH LOW-RISK PROSTATE CANCER BUT ELIGIBLE FOR THE PROSTATE CANCER INTERNATIONAL: ACTIVE SURVEILLANCE CRITERIA Giorgio Ivan Russo, Sebastiano Cimino, Vincenzo Favilla, Eugenia Fragalà, Tommaso Castelli, Daniele Urzì, Massimo Madonia, and Giuseppe Morgia Giorgio Ivan RussoGiorgio Ivan Russo More articles by this author , Sebastiano CiminoSebastiano Cimino More articles by this author , Vincenzo FavillaVincenzo Favilla More articles by this author , Eugenia FragalàEugenia Fragalà More articles by this author , Tommaso CastelliTommaso Castelli More articles by this author , Daniele UrzìDaniele Urzì More articles by this author , Massimo MadoniaMassimo Madonia More articles by this author , and Giuseppe MorgiaGiuseppe Morgia More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1279AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Active surveillance has reached an important popularity with the intention to avoid or postpone surgery in patients with prostate cancer at low risk. Unfortunately, some doubts persist about the ability of the different criteria to predict an organ-confined prostate cancer. The aim of this study was to identify predictive factors of unfavourable disease and of biochemical failure in patients treated with radical prostatectomy (RP) but eligible for AS according to PRIAS criteria. We aimed to introduce and validate the percentage of cancer involvement in positive cores (CIPC) as potential worse predictive factor. METHODS From January 2002 to December 2007, 750 consecutive subjects underwent RP at a single institution. We identified 147 (19.05%) patients who were eligible for AS based on PRIAS criteria: clinical stage T1c or T2 disease, PSA level of ≤10 ng/ml, Gleason score ≤6, PSA-D of <0.2 ng/ml2 and fewer than three positive biopsy cores. We incorporated a new detailed histological parameter, the percentage of cancer involvement in positive cores (CIPC), calculated by dividing the cumulative cancer length (CCL) to the cumulative length of positive cores (CLPC). CCL was defined as the sum of the length of all cancerous lesions in mm while CLPC as sum of the length of all positive cores in mm. Unfavourable disease was considered as non-organ confined disease (pathological stage >pT2) and/or upgraded disease (Gleason score >6). RESULTS Of the 147 patients, 95 (66.43%) patients had favourable while 48 (33.57%) had unfavourable disease. In multivariate logistic regression, maximum cancer length (OR 12.52, p<0.01) and CIPC (OR 1.70, p<0.01) represented independent predictors of unfavourable PCa. The AUC analysis revealed significantly higher performance after including CIPC to the PRIAS criteria (0.61 vs. 0.94, p<0.01). A cutoff of 0.4 mm of CIPC was set to predict unfavourable disease with 93% specificity, 76% sensibility and 87% accuracy based on the ROC curve analysis. Finally, the 3- and 5-years BFS were significantly lower in subjects with CIPC ≥0.4 mm, 88.4 % and 81.0% vs. 97.8% and 95.7% respectively (p<0.01). CONCLUSIONS We showed that including CIPC to the pathological parameters of prostate biopsy is possible to estimate the presence of organ-confined disease in 93% of cases. Our findings suggest that the inclusion of CIPC to the prostate biopsy features could be helpful to avoid misclassification in patients eligible for AS according to the PRIAS criteria. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e411 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Giorgio Ivan Russo More articles by this author Sebastiano Cimino More articles by this author Vincenzo Favilla More articles by this author Eugenia Fragalà More articles by this author Tommaso Castelli More articles by this author Daniele Urzì More articles by this author Massimo Madonia More articles by this author Giuseppe Morgia More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Percentage of cancer involvement in positive cores can predict unfavorable disease in men with low-risk prostate cancer but eligible for the prostate cancer international: Active surveillance criteria

ObjectivesTo identify predictive factors of unfavorable disease and of biochemical failure in patients treated with radical prostatectomy but eligible for active surveillance (AS) according to Prostate Cancer Research International: Active Surveillance (PRIAS) criteria. We aimed to introduce and validate the percentage of cancer involvement in positive cores (CIPC) as potential worse predictive factor. MethodsFrom January 2002 to December 2007, 750 consecutive subjects underwent radical prostatectomy at a single institution. We identified 147 (19.05%) patients who were eligible for AS based on PRIAS criteria: clinical stage T1c or T2 disease, prostate-specific antigen level of≤10ng/ml, Gleason score≤6, prostate-specific antigen-D of<0.2ng/ml2, and fewer than 3 positive biopsy cores. CIPC was included in the analysis. ResultsOf the 147 patients, 95 (66.43%) patients had favorable disease, whereas 48 (33.57%) had unfavorable disease. In multivariate logistic regression, maximum cancer length (odds ratio 12.52, P<0.01) and CIPC (odds ratio 1.70, P<0.01) represented independent predictors of unfavorable prostate cancer. The area under the receiver operating characteristics curve analysis revealed significantly higher performance after including CIPC to the PRIAS criteria (0.61 vs. 0.94, P<0.01). A cutoff of 0.4mm of CIPC was set to predict unfavorable disease with 93% specificity, 76% sensibility, and 87% accuracy based on the receiver operating characteristics curve analysis. Finally, the 3- and 5-years biochemical recurrence (BCR)-free survival were significantly lower in subjects with CIPC≥0.4mm, 88.4 % and 81.0% vs. 97.8% and 95.7%, respectively (P< 0.01). ConclusionsOur findings suggest that the inclusion of CIPC to the prostate biopsy features could be helpful to avoid misclassification in patients eligible for AS according to the PRIAS criteria.

Performance Characteristics of Prostate-specific Antigen in Patients Undergoing Radical Prostatectomy

To assess the performance characteristics of prostate-specific antigen (PSA) for predicting the volume of total or high-grade cancer in men undergoing radical prostatectomy. It is known that the performance characteristics of PSA are improved for predicting the presence of high-grade prostate cancer. We identified 1459 patients from the Stanford Radical Prostatectomy Database with clinical Stage T1c (n = 783) and T2 (n = 676) disease who underwent surgery from 1988 to 2003 with detailed morphometric mapping. We generated receiver operating characteristic curves for PSA levels according to the total and high-grade (Gleason score 4 or 5) cancer volume and compared the areas under the curve (AUC) for the various total and high-grade cancer volumes. For patients with Stage T1c disease, the AUC for the PSA ROC curve increased in a stepwise fashion as both the total cancer volume and the high-grade cancer volume increased. Significant differences between the AUCs for low and high volumes of total and high-grade disease were observed. For T2 disease, the AUCs for predicting high-grade cancer volume were generally greater than the corresponding AUCs for T1c disease, although no incremental increase was observed. In patients with Stage T1c disease, in whom the PSA level was the driving force for biopsy, the PSA performance improved in a stepwise fashion with greater total and high-grade cancer volumes as evidenced by improved ROC. Previous studies have shown that PSA performs better for detecting the presence of high-grade disease. We have shown that PSA performs better in predicting greater volumes of high-grade disease in radical prostatectomy specimens.

Performance characteristics of PSA in patients undergoing radical prostatectomy.

199 Background: The Prostate Cancer Prevention Trial demonstrated that the performance characteristics of PSA are improved for diagnosis of high grade disease. We assessed the performance of PSA for determining total and high grade cancer volume in a radical prostatectomy series. Methods: We identified 1307 patients from the Stanford Radical Prostatectomy Database with clinical stage T1c (n=658) and T2 (n=549) disease who had surgery between 1988 and 2002 and detailed morphometric mapping by a single pathologist. Patients with T1c and T2 disease were analyzed separately as the indication for biopsy was different in these two populations (elevated PSA versus abnormal DRE). We generated receiver operating characteristic (ROC) curves for PSA based on total tumor volume and volume of Gleason 4 or 5 disease and compared the areas under the curve (AUC) for different cut points of total and high grade cancer volume. Results: For patients with clinical stage T1c disease, as total and high grade cancer volumes increased, so did the AUC for PSA performance. There was a significant difference in AUC for PSA for total cancer volumes greater than 0.5 cc (AUC=0.62) compared to greater than 2 cc (AUC=0.72, p=0.02), and also between volumes greater than 2 cc (AUC=0.72) and 5 cc (AUC=0.79, p=0.0003, Fig.1). The AUC for PSA performance for volume of high grade disease increased from 0.66, to 0.68, to 0.76 for Gleason 4 or 5 volumes of 0, 0.5, and 3 cc, respectively (Fig. 2). For patients with clinical stage T2 disease, the AUCs for total or high grade cancer volume were not different across cut points, but were overall higher compared to the T1c group. Conclusions: In T1c patients, PSA performance improved in a stepwise fashion with higher total and high grade cancer volumes as evidenced by improved receiver operating characteristics. In T2 patients, no similar trend was observed, although overall PSA performance was improved compared to T1c patients. Prior studies show that PSA performs better for the detection of high grade disease; here, we show that PSA performs better in predicting volume of high grade disease in radical prostatectomy specimens.

Small Prostate Size and High Grade Disease—Biology or Artifact?

Prior radical prostatectomy series have shown an inverse association between prostate size and high grade cancer. It has been suggested that smaller size prostates arise in a low androgen environment, enabling development of more aggressive cancer. We propose that this observation is the result of ascertainment bias driven by prostate specific antigen performance. We identified 1,404 patients from the Stanford Radical Prostatectomy Database with clinical stage T1c (723) and T2 (681) disease who underwent surgery between 1988 and 2002, and underwent detailed morphometric mapping by a single pathologist. Multivariate linear regression was performed to assess for the effects of age, prostate weight and prostate specific antigen on total and high grade (Gleason grade 4/5) cancer volume and percentage of high grade disease. In patients who underwent biopsy due to abnormal prostate specific antigen (stage T1c), prostate weight was negatively associated (p = 0.0002) with total cancer volume, volume of high grade disease and percentage of high grade disease. For patients who underwent biopsy based on abnormal digital rectal examination (stage T2) these associations were not observed. Improved prostate specific antigen performance for high grade disease results in ascertainment bias in patients with T1c disease. Thus, the association between prostate size and high grade disease may be a consequence of grade dependent performance of prostate specific antigen rather than true tumor biology.

285 True recurrences and new primary tumours have different clinical features in invasive breast cancer patients with ipsilateral breast tumour relapse after breast-conserving treatment

We review the pathological findings of impalpable prostate cancer detected by transurethral resection (stages T1a and T1b) and needle biopsy (stage T1c). The short-term (4 years) and long-term (8 to 10 years) natural histories of untreated stage T1a prostate cancer are examined, as are options to follow patients expectantly. The findings on radical prostatectomy for stages T1a and T1b disease are reviewed and compared. Of the 64 cases of stage T1a disease 13 (20%) showed substantial tumor, including 7 with more than 1 cc of tumor, 5 with capsular penetration and 1 with a Gleason grade 4 + 5 = 9 tumor. Based on preoperative pathological parameters, one could not predict which cases had minimal versus substantial tumor. In a study from our institution that undertook complete histological examination of 39 radical prostatectomy specimens of stage T1b carcinoma, we found that all prostates contained residual carcinoma, 26% had capsular penetration and 10% had invasion of the seminal vesicles. When comparing morpho-metrically determined volumes of carcinoma with similar data from 56 patients with stage T2 carcinoma, stage T1b tumors were much more heterogeneous in grade, location and volume than were stage T2 lesions. Unless all 3 variables (grade, volume and location) were known, the final pathological stage of T1b cancers could not be predicted with confidence.Finally, we examined preoperative clinical and pathological parameters in 157 men with clinical stage T1c disease undergoing radical prostatectomy, and correlated these findings with pathological extent of disease in the surgical specimen in an attempt to identify a subset of patients with potentially biologically insignificant tumor who might be followed conservatively. Of the tumors 16% were insignificant (less than 0.2 cc, organ confined and Gleason grade less than 7), 10% were minimal (0.2 to 0.5 cc, organ confined and Gleason grade less than 7), 37% were moderate (more than 0.5 cc or capsular penetration with Gleason sum less than 7) and 37% were advanced (capsular penetration with Gleason sum 7 or more, or positive margins, positive seminal vesicles or positive lymph nodes). These findings are intermediate between those found in clinical stages T1a and T2 disease. The best model predicting insignificant tumor was a prostate specific antigen (PSA) density of less than 0.1 and no adverse pathological finding on needle biopsy or a PSA density of 0.1 to 0.15 with less than 3 mm. low to intermediate grade cancer on only 1 needle biopsy core. The positive predictive value of the model was 95% with a negative predictive value of 66%. Using this model, we accurately predicted 73% of cases with insignificant tumor. Although most impalpable prostate cancers diagnosed by needle biopsy are significant tumors that warrant definitive therapy, it may be reasonable to follow some patients whose tumors are most likely insignificant with serial PSA measurements and repeat biopsies.

Is High-Grade Prostate Cancer Easier to Find in Smaller Prostates Because There Is More High-Grade Disease to Find? – Response

We appreciate Dr. Walsh's comments about our article and acknowledge that our study provides only one possible explanation for the findings from the Prostate Cancer Prevention Trial. We are also familiar with the literature that he has cited. It is important to emphasize that the difference in the detection of high-grade cancer between finasteride and placebo during the Prostate Cancer Prevention Trial was only seen in the “for cause biopsies,” driven by prostate-specific antigen (PSA) or an abnormal prostate examination. There was no difference in the detection of high-grade cancers at the end of the study biopsy, in which no “trigger” for biopsy was used other than the rules of the protocol. If small prostates are biologically more likely to harbor high-grade disease, why would not the smaller prostates at the end of study in the finasteride arm be more likely to have high-grade disease? We appreciate his suggestion about analyzing the data from Stanford that was meticulously characterized by John McNeal. These data were recently accepted for presentation at the American Urological Association Meeting in San Francisco this year (1). We identified 1,404 patients from the Stanford Radical Prostatectomy Database with clinical stage T1c ( n = 723) and T2 ( n = 681) disease who underwent surgery and had detailed morphometric mapping by Dr. McNeal. Multivariate linear regression was done to assess for the effects of prostate weight (a surrogate for prostate volume) and PSA, on the volume and percentage of high-grade disease (Gleason grade 4 and 5). Among patients with T1c disease, a multivariate model including PSA and prostate weight showed that only PSA was significantly associated with the volume of high-grade disease ( P = 0.0015). Among patients with T2 disease, a similar multivariate model including PSA and prostate weight showed that only PSA was significantly associated with volume of high-grade disease ( P < 0.0001). There was a significantly greater volume of high-grade disease in the T2 patients compared with T1c patients ( P = 0.026). As we and others have shown, the performance of PSA is better for the detection of high-grade disease (2). In a radical prostatectomy series in which PSA is the driving force for biopsy (stage T1c), smaller prostates will have a higher PSA density (PSA/prostate weight) and are thus more likely to harbor high-grade disease. In patients with palpable disease (T2) in which PSA is not the only indication for biopsy, the effect of PSA exceeds the effect of prostate size in predicting high-volume and high-grade disease. These data suggest that the association between prostate size and high-grade disease seen in radical prostatectomy series may be related to ascertainment bias rather than cancer biology. The additional data we present here further supports a PSA performance bias in the observations from Prostate Cancer Prevention Trial. Disclosure of Potential Conflicts of Interest No potential conflicts of interest were disclosed.

Clinical Stage T1c Prostate Cancer: Evaluation with Endorectal MR Imaging and MR Spectroscopic Imaging

To assess the diagnostic accuracy of endorectal magnetic resonance (MR) imaging and MR spectroscopic imaging for prediction of the pathologic stage of prostate cancer and the presence of clinically nonimportant disease in patients with clinical stage T1c prostate cancer. The institutional review board approved-and waived the informed patient consent requirement for-this HIPAA-compliant study involving 158 patients (median age, 58 years; age range, 40-76 years) who had clinical stage T1c prostate cancer, had not been treated preoperatively, and underwent combined 1.5-T endorectal MR imaging-MR spectroscopic imaging between January 2003 and March 2004 before undergoing radical prostatectomy. On the MR images and combined endorectal MR-MR spectroscopic images, two radiologists retrospectively and independently rated the likelihood of cancer in 12 prostate regions and the likelihoods of extracapsular extension (ECE), seminal vesicle invasion (SVI), and adjacent organ invasion by using a five-point scale, and they determined the probability of clinically nonimportant prostate cancer by using a four-point scale. Whole-mount step-section pathology maps were used for imaging-pathologic analysis correlation. Receiver operating characteristic curves were constructed and areas under the curves (AUCs) were estimated nonparametrically for assessment of reader accuracy. At surgical-pathologic analysis, one (0.6%) patient had no cancer; 124 (78%) patients, organ-confined (stage pT2) disease; 29 (18%) patients, ECE (stage pT3a); two (1%) patients, SVI (stage pT3b); and two (1%) patients, bladder neck invasion (stage pT4). Forty-six (29%) patients had a total tumor volume of less than 0.5 cm(3). With combined MR imaging-MR spectroscopic imaging, the two readers achieved 80% accuracy in disease staging and AUCs of 0.62 and 0.71 for the prediction of clinically nonimportant cancer. Clinical stage T1c prostate cancers are heterogeneous in pathologic stage and volume. MR imaging may help to stratify patients with clinical stage T1c disease for appropriate clinical management.

Outcomes of radical prostatectomy for patients with clinical stage T1a and T1b disease

To compare the outcomes between patients with stage T1a/b with those of patients with T1c cancer of the prostate treated with radical retropubic prostatectomy (RRP), as the appropriate management of clinical stage T1a/b prostate cancer is subject to debate; although many patients are managed expectantly, some have adverse pathological features suggesting that more active treatment might be beneficial. From 1983 to 2003, 3478 men had RRP by one surgeon. From this group, we retrospectively identified 29 men with clinical stage T1a and 83 with clinical stage T1b disease. Using statistical analysis we compared the treatment outcomes of these patients with those of 1774 men with clinical stage T1c disease. Men with T1a/b disease had a significantly lower preoperative prostate-specific antigen (PSA) level, a greater proportion with organ-confined disease, and a lower mean/median prostatectomy Gleason score than those with T1c disease. Also, men with T1a/b disease were less likely to be potent before surgery, although the frequency of recovery of potency was similar among all groups. On multivariate analysis with age, year of surgery, PSA level and Gleason score, there was no statistical difference in the rates of biochemical recurrence and the 10-year overall survival rates. However, patients with T1b disease had a significantly lower cancer-specific survival. T1a and T1b prostate cancer can be associated with aggressive pathological features and have a similar rate of progression as clinical stage T1c disease. That notwithstanding, most patients in the study were cured with RRP and had favourable long-term functional outcomes.

Watchful waiting versus active surveillance: Appropriate patient selection

The prostate-specific antigen (PSA) screening era has seen dramatic stage and age migration in patients with newly diagnosed prostate cancer. The average serum PSA level of newly diagnosed patients is about 6 ng/dL, and 60% of patients are diagnosed with clinical stage T1c disease. There is evidence that many low-grade and low-stage prostate cancers have a slow growth rate and protracted clinical course, with a very low threat of metastasis or death over a prolonged interval. Many men are also appropriately concerned about the impact of prostate cancer treatment on sexual and urinary function. Therefore, delaying therapy in favor of careful surveillance, with the expectation of delivering curative treatment upon evidence of progression, is an attractive concept. In this review, we discuss active surveillance, contrast it to watchful waiting, and define common inclusion criteria. We compare follow-up regimens and discuss indications and intervention outcomes after active surveillance. Finally, we support well-designed prospective clinical trials that evaluate active surveillance compared with immediate definitive treatment.

The Effect of Race/Ethnicity on the Accuracy of the 2001 Partin Tables for Predicting Pathologic Stage of Localized Prostate Cancer

To test the accuracy of the 2001 Partin Tables in African American men who underwent radical prostatectomy at multiple centers throughout the United States. We compiled a large multiethnic cohort of men (n = 3748) treated with radical prostatectomy at multiple sites, including all of the sites of the Department of Veterans Affairs-based Shared Equal Access Regional Cancer Hospital (SEARCH) database (n = 1524), Wayne State University (n = 1305), the University of Texas Health Science Center (n = 522), and the Henry Ford Hospital (n = 397). We evaluated the accuracy of the 2001 Partin Tables using area under the receiver operator characteristic curve (AUC) separately among African American and white men. African American men (n = 1188, 32%), despite being more likely to have clinical Stage T1c disease (56% versus 47%, chi-square P <0.001), had higher preoperative PSA values (9.1 versus 7.7 ng/mL, rank-sum P <0.001) and were more likely to have higher-grade disease on diagnostic biopsy (chi-square P = 0.005). Despite these differences in baseline clinical characteristics, the 2001 Partin Tables performed equally well in both racial groups. Specifically, there were no differences in the AUC for African American and white men for predicting organ-confined disease (AUC 0.73 versus 0.72; P = 0.56), extraprostatic extension (AUC 0.62 versus 0.62; P = 0.99), or seminal vesicle invasion (AUC 0.77 versus 0.79; P = 0.53). These data lend further support to the idea that although baseline differences between the races existed that may underlie an overall more aggressive disease among African American men, for the individual patient, race is not valuable for prognostication.

PSA in the New Millennium: A Powerful Predictor of Prostate Cancer Prognosis and Radical Prostatectomy Outcomes — Results from the SEARCH Database

ObjectivesAs a result of prostate-specific antigen (PSA) screening, most men today with prostate cancer present with localized disease and serum PSA values < 10ng/ml. Within this context, it is debated whether PSA remains an important prognostic variable in more recently treated patients. We examined the prognostic significance of preoperative PSA to predict pathologic stage and biochemical progression among men undergoing radical prostatectomy in the new millennium (2000–2006). MethodsWe performed a review of 925 men with prostate cancer treated by radical prostatectomy since 2000 within the Shared Equal Access Regional Cancer Hospital (SEARCH) database. We examined the association between preoperative PSA and risk of adverse pathologic features and biochemical progression using logistic regression and Cox proportional hazards analysis. ResultsAfter adjusting for multiple clinical preoperative characteristics, higher preoperative PSA values were associated with increased odds of extracapsular extension (p<0.001), positive surgical margins (p<0.001), and seminal vesicle invasion (p<0.001) and increased risk of biochemical progression (p=0.009). When the analyses were limited to the 690 men with a preoperative PSA<10ng/ml and after adjusting for multiple clinical characteristics, higher preoperative PSA values remained associated with increased risk of biochemical progression (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.06–1.28, p=0.002). Even among the 448 men with a PSA<10ng/ml and clinical stage T1c disease, preoperative PSA was associated with increased risk of biochemical progression (HR 1.14, 95%CI 1.00–1.31, p=0.047). ConclusionsPSA remains an important prognostic marker among men diagnosed with prostate cancer in the new millennium treated with radical prostatectomy and remains an important predictor of outcome even among men with preoperative PSA level < 10ng/ml.

Subclassification of Clinical Stage T1 Prostate Cancer: Impact on Biochemical Recurrence Following Radical Prostatectomy

We investigated biochemical outcomes following radical prostatectomy across subclassifications of clinical stage T1 prostate cancer. Of 8,658 men who underwent radical prostatectomy for clinical stage T1 prostate cancer 85, 156 and 8,417 had clinical stage T1a, T1b and T1c disease, respectively. Age, race, prostate specific antigen, year of surgery and preoperative Gleason scores were compared across clinical stage T1 subcategories. Time to prostate specific antigen recurrence was compared among groups using Kaplan-Meier and Cox hazards modeling. Patients with clinical stage T1a prostate cancer had more favorable postoperative pathological features, including lower prostatectomy Gleason scores (p <0.001), rates of extraprostatic extension (p <0.001), lymph node invasion (p <0.001) and positive surgical margins (p = 0.006). Patients with T1a cancer also showed significantly lower rates of biochemical recurrence on Kaplan-Meier analysis than men with T1b and T1c disease (log rank 0.006). Cox regression analysis adjusted for known predictors of biochemical recurrence demonstrated that clinical tumor stage in the subgroup of patients with T1 disease was not an independent predictor of biochemical recurrence (p = 0.321). Men with clinical stage T1a prostate cancer who undergo radical prostatectomy have significantly lower biochemical recurrence rates than men with stage T1b or T1c disease. However, subclassification of tumors in this group of patients was not an independent prognostic factor for biochemical recurrence after accounting for preoperative variables, including prostate specific antigen and Gleason score.

A Study on the Incidence and Preoperative Predicting Factors of Extraprostatic Extension in T1c Prostate Cancers

Purpose: To evaluate the incidence and identify the predicting factors of extraprostatic extension (EPE) in T1c prostate cancers. Materials and Methods: Of 267 consecutive men who underwent radical retropubic prostatectomy (RRP) as initial treatment for prostate cancers, 131 (49.1%) presented with a clinical stage T1c disease. Clinicopathological data were collected, and factors related to biopsy collected; i.e. the number of positive cores (No. (+) core); the percentage of positive cores (% (+) core); the maximal tumor length (Max. mm cancer); the sum of tumor length (Total mm cancer); the maximal ratio of tumor/core length (Max. % mm cancer) and the mean ratio of tumor/core length (Mean % mm cancer). A logistical regression analysis was performed after dividing the cases into organ-confined (OC) and EPE. Results: Of the T1c tumors, 107 (81.7%) and 24 (18.3%) were found to be OC and to have EPE after RRP, respectively. The preoperative factors that showed a significant difference between the two groups (OC vs. EPE) were %free prostate-specific antigen (17.7 vs. 11.1%), prostate volume (43.5 vs. 34.6ml), Gleason score (6.4 vs. 6.8), % (+) core (17.9 vs. 27%), Max. mm cancer (3.5 vs. 6.7mm) and Max. % mm cancer (24.0 vs. 41.6%). Of these factors, those significantly predicting EPE in the receiver operator characteristics curve were: the Gleason score, % (+) core, Max. mm cancer and Max. % mm cancer. Of these, only the % (+) core and Max. mm cancer were significant in predicting EPE in the multivariate logistical regression. When the cutoff of % (+) core was 19%, the risk of EPE increased 2.3 times, and when the cutoff of Max. mm cancer was 5mm the risk increased 3.6 times. Conclusions: Max. mm cancer and % (+) core during a biopsy are preoperative factors that predict the EPE of a clinical stage T1c disease, and should be considered for modifying the surgical technique and in establishing treatment plans. (Korean J Urol 2007;48:797-803) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Impact of surgical margin status on long‐term cancer control after radical prostatectomy

To determine whether previously described technical modifications that significantly decreased the positive surgical margin (PSM) rate have translated into improved long-term cancer control, as SM status is generally recognized as an independent risk factor for biochemical recurrence (BR) after radical retropubic prostatectomy (RRP), and is the only factor that can be modified by surgical technique. Between March 1994 and December 2004, 996 consecutive patients had RRP as the sole treatment for clinically localized prostate cancer. The surgery was done by one surgeon (C.B.B.) and the data were prospectively reviewed. The overall PSM rate was 8.8%; the PSM rate by pathological stage was 1.7%, 24.2% and 27.1% for men with pT2, pT3a and pT3b disease, respectively (P < 0.001). In all, 968 of 996 (97.2%) patients were available for the follow-up (mean 6.4 years); 69 of 883 (7.8%) with negative SMs (NSMs) developed BR, vs 29 of 85 (34%) with PSMs (P < 0.001). The actuarial 5- and 10-year biochemical disease-free survival was 92.1% and 89.6%, and 70.6% and 59.9%, for patients with NSM and PSM, respectively (P < 0.001). On multivariate analysis, PSM, pathological stage and Gleason grade were the strongest predictors of BR (P < 0.001). The preoperative prostate-specific antigen level, and clinical stage T1c and T2a disease were not associated with recurrence. The hazard ratio (95% confidence interval) for BR in patients with PSMs was 3.27 (2.1-5.1). RRP including the previously described surgical modifications not only decreased the PSM rate but also resulted in excellent long-term cancer control. The importance of meticulous surgical technique in RRP cannot be overemphasised.

Results of a phase II trial of transrectal ultrasound-guided permanent radioactive implantation of the prostate for definitive management of localized adenocarcinoma of the prostate (Radiation Therapy Oncology Group 98-05)

To evaluate the effectiveness of transrectal ultrasound-guided permanent radioactive (125)I implantation of the prostate for organ-confined adenocarcinoma of the prostate compared with historical data of prostatectomy and external beam radiotherapy within a cooperative group setting. Patients accrued to this study had histologically confirmed, locally confined, adenocarcinoma of the prostate with clinical Stage T1b, T1c, or T2a, no nodal or metastatic disease, prostate-specific antigen level of < or =10 ng/mL, and Gleason score of < or =6. All patients underwent transrectal ultrasound-guided radioactive (125)I permanent seed implantation into the prostate. The prescribed dose was 145 Gy to the prostate planning target volume. A total of 27 institutions accrued a total of 101 patients to this protocol, with no institution accruing >8 patients. Six patients were ineligible, leaving 95 properly entered as eligible in the study. The median follow-up was 5.3 years (range, 0.4-6.5 years). At 5 years, 5 patients had local failure, 1 had evidence of distant failure, and 6 (6%) had biochemical failure. The overall survival rate at 5 years was 96.7%. At last follow-up, no patient had died of prostate cancer or related toxicities. Eight patients had a maximal acute toxicity level of 3, and no patient had Grade 4 or 5 acute toxicity. During follow-up, 2 patients had maximal Grade 3 toxicity, both related to bladder issues, and no patient experienced Grade 4 or 5 toxicity. The results of this clinical protocol (a multi-institutional trial of brachytherapy for localized adenocarcinoma of the prostate) have demonstrated that this type of trial can be successfully completed through the Radiation Therapy Oncology Group. Biochemical disease-free survival was comparable with other brachytherapy published series and with the results after surgery and external beam radiotherapy.

The Effect of Age on Prostate Implantation Results

The current study was undertaken to determine the effect of young age (60 years or younger) on the 5-year biochemical disease-free survival rate following ultrasound-guided transperineal prostate implantation. The radiation therapy charts of 330 patients who underwent ultrasound-guided transperineal prostate implantation who were treated from 1992 through 2004 were retrospectively reviewed. Follow-up ranged from 12 to 120 months, with a mean of 48 months. A total of 63 patients were 60 years of age or younger, and 267 patients were over 60 years of age. Prostate-specific antigen (PSA) recurrence was defined as three successive increases following ultrasound-guided transperineal prostate implantation. Biochemical disease-free survival was determined using the life-table method. There were no statistically significant differences in the 5-year biochemical disease-free survival rates for the younger versus the older group. On univariate analysis, age was not a statistically significant factor in predicting PSA failure. Univariate analysis revealed that Gleason score, PSA at diagnosis, and clinical T stage were significant in predicting for PSA failure. Patients with Gleason score<7, PSA<10, and clinical stage T1c disease had statistically significant lower PSA failure rates than patients with Gleason score>or=7, PSA>or=10, and clinical stage T2 disease, respectively. Patients who are 60 years of age or younger who are treated with ultrasound-guided transperineal prostate implantation can expect 5-year biochemical disease-free survival rates similar to those of older patients treated with ultrasound-guided transperineal prostate implantation therapy.