Clinical Stage T1c Prostate Cancer Research Articles

Focal bipolar radiofrequency ablation for localized prostate cancer: Safety and feasibility.

To evaluate the safety and feasibility of focal bipolar radiofrequency ablation in men with localized prostate cancer. A review of 10 patients treated with a novel bipolar radiofrequency ablation probe integrated in a coil design (Encage; Trod Medical, Bradenton, FL, USA) between 2011 and 2017 in two prospective pilot trials. All men had clinical stage T1c prostate cancer, prostate-specific antigen <10ng/mL and Gleason score ≤7. Ablation was carried out under general anesthesia, and bipolar probes were inserted transperineally under transrectal ultrasound guidance. Treatment-related adverse events, quality of life and negative biopsy rate were evaluated at 6months after ablation. The Wilcoxon signed-rank test was used to compare baseline and post-treatment symptom scores. The median age was 58years (range 50-64years) and the median prostate volume was 49.65cc (range 21-68cc). Prostate cancer with a Gleason score of 6 (3+3) and 7 (3+4) was noted in seven and three patients, respectively. The median number of radiofrequency ablation cycles was 2.5 (range 2-5). All patients were catheter-free and able to void the day of surgery. Within 6months after ablation, all adverse events were low grade, with the exception of one grade3 hematuria that required cystoscopy without coagulation. Six months after ablation bowel, urinary and hormonal functions, and overall satisfaction remained stable. Erectile dysfunction occurred in two out of four patients who had normal sexual function before the procedure. Neither urinary incontinence nor urinary infection was noted. This first report on focal bipolar radiofrequency ablation documents a safe and feasible treatment option for selected patients with localized prostate cancer.

Background factors and short-term health-related quality of life in patients who initially underwent radical prostatectomy or androgen deprivation therapy for localized prostate cancer in a Japanese prospective observational study (J-CaP Innovative Study-1).

BackgroundThis prospective observational study elucidated the usefulness of hormonal therapy for localized prostate cancer. Background factors and the health-related quality of life in patients who initially underwent radical prostatectomy (RP) or primary androgen deprivation therapy (PADT) for localized prostate cancer are summarized.Materials and methodsPatients aged 67–76 years with clinical stage T1c or T2 localized prostate cancer treated with PADT or RP, a prostate-specific antigen concentration of <20 ng/mL, and Gleason score of ≤7 were included. Health-related quality of life results estimated by the Medical Outcomes Study 8-Item Short-Form Health Survey (SF-8) and the Expanded Prostate Cancer Index Composite (EPIC) were investigated.ResultsIn total, 850 patients who underwent RP and 370 patients who underwent PADT were enrolled. The proportion of patients with comorbidities of hypertension, cardiovascular disease, and/or cerebrovascular disease was greater in the PADT group than in the RP group. The proportion of patients deciding on treatment was significantly higher in the PADT group than in the RP group. In the RP group, the scores of many SF-8 and EPIC domains decreased at 3 months following surgery and returned to baseline levels at 1 year. In the PADT group, several domains gradually decreased during the year after treatment initiation. The proportion of patients with decreased satisfaction scores at 1 year compared with baseline was lower in the PADT group than that in the RP group.ConclusionTreatment risk influenced decisions on primary treatment for localized prostate cancer. Although there was a selection bias, short-term overall satisfaction in the PADT group was superior to that in the RP group in this clinical study.

Can perineural invasion detected in prostate needle biopsy specimens predict surgical margin positivity in D'Amico low risk patients?

In this study, our aim was to estimate the value of perineural invasion (PNI) in prostate needle biopsy (PNB) specimens in the prediction of surgical margin positivity (SMP) and its prognostic significance (upgrade Gleason Score) in patients who had undergone radical retropubic prostatectomy (RRP) with low risk prostate cancer according to D'Amico risk assessment. We retrospectively analyzed the data of 65 patients who were diagnosed as clinical stage T1c prostate cancer (PC) and underwent RRP between January 2010 and June 2013. Pathological specimens of PNB and RRP were separately examined for the parameters of PNI, vascular invasion (VI), Gleason Score (GS) and SMP. The patients' mean age was 63.65 ± 4.93 (range 47- 75) years. PNI in PNB specimens were identified in 12 of 65 patients and 11 of 12 patients showed SMP on RRP specimens. While 53 of 65 patients had not PNI on PNB, only 11 of them demonstrated SMP on RRP specimens. SMP was 30.64-fold more frequently encountered in PNB specimens obtained from PNI-positive patients relative to PNI-negative patients. In our study, PNI detected in PNB specimens was statistically significantly associated with SMP on RRP specimens (P = 0.0001). It is well known that higher PSA values and GS were independent predictors of SMP in clinically localized prostate cancer (CLPC). We think that PNI in PNB specimens may be a useful prognostic factor for predicting SMP in cases with CLPC.

Multiparametric 3T Prostate Magnetic Resonance Imaging to Detect Cancer: Histopathological Correlation Using Prostatectomy Specimens Processed in Customized Magnetic Resonance Imaging Based Molds

We determined the prostate cancer detection rate of multiparametric magnetic resonance imaging at 3T. Precise one-to-one histopathological correlation with magnetic resonance imaging was possible using prostate magnetic resonance imaging based custom printed specimen molds after radical prostatectomy. This institutional review board approved prospective study included 45 patients (mean age 60.2 years, range 49 to 75) with a mean prostate specific antigen of 6.37 ng/ml (range 2.3 to 23.7) who had biopsy proven prostate cancer (mean Gleason score of 6.7, range 6 to 9). Before prostatectomy all patients underwent prostate magnetic resonance imaging using endorectal and surface coils on a 3T scanner, which included triplane T2-weighted magnetic resonance imaging, apparent diffusion coefficient maps of diffusion weighted magnetic resonance imaging, dynamic contrast enhanced magnetic resonance imaging and spectroscopy. The prostate specimen was whole mount sectioned in a customized mold, allowing geometric alignment to magnetic resonance imaging. Tumors were mapped on magnetic resonance imaging and histopathology. Sensitivity, specificity, positive predictive value and negative predictive value of magnetic resonance imaging for cancer detection were calculated. In addition, the effects of tumor size and Gleason score on the sensitivity of multiparametric magnetic resonance imaging were evaluated. The positive predictive value of multiparametric magnetic resonance imaging to detect prostate cancer was 98%, 98% and 100% in the overall prostate, peripheral zone and central gland, respectively. The sensitivity of magnetic resonance imaging sequences was higher for tumors larger than 5 mm in diameter as well as for those with higher Gleason scores (greater than 7, p <0.05). Prostate magnetic resonance imaging at 3T allows for the detection of prostate cancer. A multiparametric approach increases the predictive power of magnetic resonance imaging for diagnosis. In this study accurate correlation between multiparametric magnetic resonance imaging and histopathology was obtained by the patient specific, magnetic resonance imaging based mold technique.

123 GENETIC VARIANTS SIGNIFICANTLY IMPROVE DETECTION OF PROSTATE CANCER AND ARE ASSOCIATED WITH AGGRESSIVE FEATURES IN PATIENTS WITH A “NORMAL” PSA AND DRE

You have accessJournal of UrologyProstate Cancer: Epidemiology and Natural History I1 Apr 2010123 GENETIC VARIANTS SIGNIFICANTLY IMPROVE DETECTION OF PROSTATE CANCER AND ARE ASSOCIATED WITH AGGRESSIVE FEATURES IN PATIENTS WITH A “NORMAL” PSA AND DRE Brian T. Helfand, Stacy Loeb, Matthias D. Hofer, Ronald Kim, Phillip R. Cooper, Donghui Kan, and William J. Catalona Brian T. HelfandBrian T. Helfand Chicago, IL More articles by this author , Stacy LoebStacy Loeb Baltimore, MD More articles by this author , Matthias D. HoferMatthias D. Hofer Chicago, IL More articles by this author , Ronald KimRonald Kim Chicago, IL More articles by this author , Phillip R. CooperPhillip R. Cooper Chicago, IL More articles by this author , Donghui KanDonghui Kan Chicago, IL More articles by this author , and William J. CatalonaWilliam J. Catalona Chicago, IL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.174AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Several reports suggest that a combination of genetic prostate cancer (CaP) susceptibility variants may independently predict CaP risk and tumor features. However, the ability to detect CaP in patients with a “normal” PSA and non-suspicious digital rectal examination (DRE) remains to be determined. Therefore, the present study examined the performance of genetic variants in prediction models for CaP risk and aggressiveness. METHODS From June 2002-May 2008, we examined 79 Caucasian men with clinical stage T1c prostate cancer diagnosed at a PSA <4.0 ng/mL and 595 controls with negative DRE and PSA <4.0 ng/mL. The genotypes for 14 CaP risk alleles (on chromosomes 2p15, 3q21, 5p15, 8q24, 10q11, 11q13, 17q12, 17q24, 19q13, and Xp11) were compared between CaP cases and controls. Additional analyses were used to compare the pathologic features between carriers and non-carriers of the variants. RESULTS 12 of the variants were over-represented in CaP patients with “normal” PSA values compared to controls. Among Caucasian men with “normal” PSA values, carriers of an increasing number of genetic variants were at a significantly increased risk of CaP (p-trend<0.001). Men with ≥9 genetic variants had an OR of 6.7 (95% CI 2.0-23.7) compared to men with ≤4 variants (Table 1). On multivariate analysis with age, the genetic variants remained significant predictors of CaP risk in this population (OR 2.3, 95% CI 1.5-3.8, p=0.0005). There also was an increase in the frequency of high Gleason grade (≥7) disease in carriers of 11 variants. Specifically, a statistically significant difference was observed for the frequency of both high-grade cancer (p=0.03) and seminal vesicle invasion (p=0.02) in carriers of the 8q24 rs16901979 variant. Table 1. Cumulative Model Comparing Frequency of Genetic Variants in Patients with “Normal” PSA and DRE Carrier of Variants # Case N=(%) Control N=(%) OR (95% C.I.) p-value 0-4 9(11.4) 145(24.4) — — 5 19(24.0) 158(26.5) 1.9(0.8-4.4) 0.12 6 14(17.8) 129(21.7) 1.7(0.7-4.2) 0.21 7 19(24.0) 108(18.2) 2.8(1.2-6.5) 0.14 8 13(16.5) 43(7.2) 4.9(2.0-12.2) 0.0007 ≥9 5(6.3) 12(2.0) 6.7(1.9-23.2) 0.0026 CONCLUSIONS A substantial proportion of biopsy-detectable CaP occurs in men with PSA levels >4 ng/mL and negative DRE. In this population, genetic risk variants are significantly associated with CaP risk and may guide in the prediction of aggressive disease. Future studies are warranted to determine the utility of incorporating genetic risk alleles into CaP screening programs. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e50 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brian T. Helfand Chicago, IL More articles by this author Stacy Loeb Baltimore, MD More articles by this author Matthias D. Hofer Chicago, IL More articles by this author Ronald Kim Chicago, IL More articles by this author Phillip R. Cooper Chicago, IL More articles by this author Donghui Kan Chicago, IL More articles by this author William J. Catalona Chicago, IL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Clinical stage T1c prostate cancer: evaluation with endorectal MR imaging and MR spectroscopic imaging

Clinical stage T1c prostate cancer: evaluation with endorectal MR imaging and MR spectroscopic imaging

Bladder tumor staging: comparison of contrast-enhanced and gray-scale ultrasound

Editorial Comment Similar to other studies the authors showed that MR imaging findings might represent additional useful variables for predicting disease extent in patients with clinically localized prostate cancer. Combined endorectal MRI-MR spectroscopic imaging had 80% accuracy in the staging of disease in patients with clinical stage T1c prostate cancer. These combined techniques had a moderate accuracy, 62-72%, in the prediction of clinically non-important cancer in this group of patients. As the authors pointed out it would be of clinical interest in the future to investigate whether multiparametric examination which combination of conventional T2-w images, spectroscopy, diffusion-weighted image (DWI) and perfusion studies can yield superior diagnostic information for stratifying patients with T1 c prostate cancer. Since 2004, we have been using in our department this multiparametric evaluation in patients with organ-confined tumor, based on finding of conventional T2-weighted images. We have found that DWI and perfusion techniques, similarly to spectroscopy are very useful to detect tumor > 0.5 cm3 and with higher Gleason grades. All techniques have difficult to detect smaller and low grades tumor. In other words, when we find a lesion with imaging characteristics of a possible aggressive tumor on T2-w images and spectroscopy, but without concordant findings on DWI and perfusion studies, our tendency is to downgrade the lesion to a possible less important one. We have found that usually a large and aggressive tumor will present as an area with restricted diffusion (lower ADC values) and with abnormally elevated values of the pharmacokinetics parameters obtained with perfusion studies. On the other hand, patients with normal multiparametric prostate examination has a very high probability of have a clinically non-important cancer. Another important finding of this study is that from 158, 124 (78%) patients had organ-confined disease (stage pT2), 29 (18%) had extracapsular extension (stage pT3a), two (1%) had seminal vesicle invasion (stage pT3b), and two (1%) had bladder neck invasion (stage pT4). We have to remember that clinically T1 c patients typically are considered to have localized early-stage disease of relatively low risk. Additionally 30 (19%) of the patients met the criteria to be considered for active surveillance as a management strategy, 4(13%) had extraprostatic extension of disease at surgical-pathologic analysis. These findings further enhance the value of endorectal MRI examination in the pre-operative evaluation of patients with T1c prostate carcinoma.

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.

Oncological Outcome following Radical Prostatectomy in Japanese Men with Clinical Stage T1c Prostate Cancer

Background: The objective of this study was to retrospectively review oncological outcome following radical prostatectomy (RP) in patients with T1c prostate cancer. Patients and Methods: This study included 135 patients who were diagnosed as having T1c prostate cancer and subsequently underwent RP without any neoadjuvant therapies. In this series, biochemical recurrence (BR) was defined as a serum prostate specific antigen 0.2 ng/ml or greater on 2 consecutive measurements. Results: The pathological stage was pT2, pT3a and pT3b in 113, 18 and 4 patients, respectively, and a positive surgical margin was detected in 30; however, there was no patient with lymph node metastasis. During the mean observation period of 45.8 months, despite none of the patients dying of cancer progression, BR occurred in 17 patients, and the 5-year BR-free survival rate was 87.0%. Of several factors examined, BR was significantly associated with preoperative serum prostate specific antigen, pathological stage, seminal vesicle invasion and surgical margin status, among which only surgical margin status appeared to be an independent predictor of BR. Conclusions: Oncological outcome of RP as monotherapy for Japanese men with T1c prostate cancer would be favorable; however, RP alone may not be sufficient for cancer control in patients with a positive surgical margin.

Nephroureteral Stent on Suction for Urethrovesical Anastomotic Leak After Robot-assisted Laparoscopic Radical Prostatectomy

Delayed urinary anastomotic leak after transperitoneal robot-assisted radical prostatectomy (RALP) is an uncommon complication. After failure of conventional measures, we successfully managed this problem using a nephroureteral stent placed on intermittent suction. A 62-year-old man with clinical stage T1c prostate cancer (Gleason 3 + 3) developed a persistent urinary anastomotic leak after RALP. Conventional measures, including catheter traction, passive drainage, and needle vented Foley catheter suction, failed. On postoperative day 6 a unilateral nephroureteral stent was placed on intermittent suction. Placement of one nephroureteral stent on suction device immediately stopped the urinary anastomotic leakage into the peritoneal cavity. In case of a persistent urinary leak after RALP that fails conservative management, a nephroureteral stent on suction may aid to stop the anastomotic leak.

Case Report: Severe Bleeding after Laparoscopic Radical Prostatectomy: Successful Management with Transarterial Embolization

We present the first report of postoperative bleeding after laparoscopic radical prostatectomy (LRP) managed by transarterial embolization (TAE). A 54-year-old man underwent an uneventful LRP for clinical stage T(1c) prostate cancer. His blood pressure, however, was 83 over 55 mm Hg, and the hematocrit dropped to 20.4% from a baseline of 26.9% 5 hours postoperatively. Active bleeding from a capsular artery was diagnosed by CT angiography and managed by superselective embolization.

Predicting Unilateral Prostate Cancer Based on Biopsy Features: Implications for Focal Ablative Therapy—Results From the SEARCH Database

For men with low risk prostate cancer it was recently proposed that ablative treatment to the affected side may decrease morbidity, while maintaining good oncological outcomes. However, few studies have assessed the correlation between biopsy parameters and pathological outcome (unilateral vs bilateral disease). Using the Shared Equal Access Regional Cancer Hospital Database of men treated with radical prostatectomy at multiple equal access medical centers we retrospectively examined the records of 261 men with clinical stage T1c or T2a prostate cancer, prostate specific antigen less than 10 ng/ml, Gleason sum 6 or less and only 1 or 2 ipsilateral positive cores on at least sextant biopsy. We compared clinical characteristics between men with pathologically unilateral disease or less (pT2b or less) and men with pathologically bilateral disease or extraprostatic extension (pT2c or greater). To determine the significant predictors of pT2c or greater disease we used a multivariate logistic regression model. Of the cohort of 261 men with low risk prostate cancer only 93 (35.1%) had unilateral or no evidence of disease following examination of radical prostatectomy specimens. Men with pathologically unilateral or less disease did not differ from those with bilateral or more advanced disease by age, prostate specific antigen, clinical stage, body mass index or number of positive biopsy cores (1 vs 2). On multivariate analysis no clinical feature was significantly related to pathologically unilateral or less vs bilateral or greater disease. The majority of men with low risk prostate cancer and 1 or 2 ipsilateral positive biopsy cores have pathologically bilateral disease. Therefore, strategies for unilateral treatment of prostate cancer are unlikely to be curative for these men.

Under Diagnosis and Over Diagnosis of Prostate Cancer

We quantified the rates of over and under diagnosis of prostate cancer in 2 large patient cohorts during the last 15 years. A total of 2,126 men with clinical stage T1c prostate cancer were treated with radical prostatectomy during 1 of the 3 periods 1989 to 1995, 1995 to 2001 and 2001 to 2005. The respective proportions of men with a tumor that met our criteria for over diagnosis (0.5 cm3 or less, confined to the prostate with clear surgical margins and no Gleason pattern 4 or 5) and under diagnosis (nonorgan confined, pathological stage T3 or greater, or positive surgical margins) were examined. The proportion of men with an over diagnosed tumor was 1.3% to 7.1%. The proportion with prostate cancer that was under diagnosed was 25% to 30%. An ancillary finding was that decreasing the prostate specific antigen threshold for biopsy from 4.0 to 2.5 ng/ml in the screened population resulted in a lower rate of under diagnosis from 30% to 26%, a higher rate of over diagnosis from 1.3% to 7.1% and an increase in the 5-year progression-free survival rate from 85% to 92%. Men who were 55 years or younger were significantly more likely to meet our criteria for over diagnosed cancer. Under diagnosis of prostate cancer continues to occur more frequently than over diagnosis. Lowering the prostate specific antigen threshold for recommending biopsy to 2.5 ng/ml resulted in a lower rate of under diagnosis and a higher progression-free survival rate.

Prediction models in urology

Predicting risk is an inherent feature of clinical practice. How likely is a man with a given PSA level to have prostate cancer? Can lymph node dissection be safely avoided in a patient with testicular cancer? Should chemotherapy be given after cystectomy for bladder cancer? Traditionally, physicians use clinical judgment to estimate risks, relying on rules of thumb (heuristics) or assigning patients to simple risk groups. In the March issue of Nature Clinical Practice Urology, Novara et al. described a series of nomograms (or models) that can be used to predict whether a man with penile cancer has lymph node metastases and the likelihood that he will survive his cancer for 5 years (Novara et al. [2007] Nat Clin Pract Urol 4: 140–146). Risk stratification schemes have already been published that classify such patients into risk groups, and guidelines are available for the management of men with penile cancer. So why do we need nomograms? Nomograms are graphical representations of mathematical algorithms that incorporate multiple prognostic factors into optimized statistical models to predict a particular outcome. Since the first report of a nomogram for a urological disease (Kattan MW et al. [1998] J Natl Cancer Inst 90: 766–771), these models have come into widespread use, made easier to use in digital formats (www.nomograms.org). Despite their complexity, nomograms routinely provide more accurate predictions than risk group assignment or expert judgment (Kattan MW [2005] Nat Clin Pract Urol 2: 183–190). Risk groups are popular but their accuracy is limited, in that they combine individuals with similar but not identical risk factors into a single group and categorize variables, such as PSA (0–4 ng/ml, 4.1–10 ng/ml, etc.), which give more information when analyzed as continuous variables. D’Amico’s ‘low-risk’ prognostic group of prostate cancer patients (Stage T1c or T2a, Gleason score <7, PSA level <10 ng/ml) includes patients with a uniformly favorable prognosis, but many patients in his intermediate-risk and high-risk groups actually have an excellent prognosis as well (Kattan MW [2003] Curr Opin Urol 12: 111–116). Erroneous assignment to a high-risk group might lead to an inappropriate treatment decision, such as the pessimistic recommendation to avoid radical prostatectomy in a patient with a Gleason score 8, clinical stage T1c prostate cancer, whose PSA level is 4.5 ng/ml. This ‘high-risk’ patient actually has a 65% probability of freedom from biochemical recurrence 10 years after surgery alone (Stephenson et al. [2005] J Clin Oncol 23: 7005–7012). Nomograms sometimes seem counterintuitive, especially when they include prognostic factors that have not been found to be statistically significant as independent predictors of outcome in multivariable analyses or if they weigh the values of a risk factor nonlinearly. Nevertheless, the prediction is usually more accurate than if fewer factors are included or the results are weighted linearly. Novara et al. have made a valuable contribution by refining the accuracy of predicting nodal stage and survival in men with penile cancer. These nomograms, which incorporate standard, readily available, clinical and pathological variables are remarkably accurate (Ficarra V et al. [2006] J Urol 175: 1700–1705; Kattan MW et al. [2006] J Urol 175: 2103–2108). Before nomograms can be accepted in practice, or used to stratify patients in clinical trials, they should be validated in large, independent cohorts. Such nomograms provide patients with what they surely wish for: to know their own prognosis, not that of a risk group to which they might be assigned.

African‐American men with nonpalpable prostate cancer exhibit greater tumor volume than matched white men

Although prostate cancer (PC) mortality disproportionately affects African-American (AA) men, limited data exist comparing the pathologic characteristics of white and AA patients with nonpalpable PC (clinical stage T1c). The authors reviewed the radical prostatectomy (RP) specimens from 37 consecutive AA men with clinical stage T1c PC and 35 white men who were matched for age, clinical stage, serum prostate-specific antigen (PSA) level, year of surgery, prostate weight, and prostate biopsy strategy. Pathologic characteristics were compared after mapping tumor foci and calculating tumor volumes by using computer software. For AA men, the median age (57.7 years), mean serum PSA level (9.3 ng/mL), mean prostate weight (43 g), and biopsy strategy (73% sextant) were matched with the cohort of 35 white men (median age, 57.1 years; mean PSA, 9.3 ng/mL;, mean prostate weight, 43 g; biopsy strategy, 66% sextant). Despite similar biopsy characteristics between the 2 groups (Gleason score > or =7 in 43% of AA men vs. 37% of white men), AA men exhibited significantly higher prostatectomy Gleason scores (> or =7 in 76% of AA men vs. 34% of white men; P = .01). AA men also had a higher mean tumor volume (1.82 cm3 vs. 0.72 cm3; P = .001) and had 2.8 times more tumor per ng/mL of serum PSA (0.22 cm3 per ng/mL vs. 0.079 cm3 per ng/mL; P = .001). Compared with a cohort of white men with similar clinical features at the time of biopsy, AA men with nonpalpable PC had higher prostatectomy Gleason scores, greater cancer volume, and greater tumor volume per ng/mL of serum PSA. These data provide additional support for the concept of early PC detection using a serum PSA threshold of 2.5 ng/mL for biopsy among AA men.

Preoperative PSA and progression-free survival after radical prostatectomy for Stage T1c disease

Objectives To examine biochemical progression-free survival (PFS) rates as a function of preoperative prostate-specific antigen (PSA) in patients with clinical Stage T1c prostate cancer treated with radical prostatectomy. Controversy exists about whether performing prostate biopsies for PSA levels in the 2.6 to 4.0 ng/mL range provides a PFS advantage compared with detection at higher PSA ranges. Methods A total of 2804 men with clinical Stage T1c prostate cancer were treated with radical retropubic prostatectomy and monitored prospectively. The study parameters included preoperative PSA level, pathologic tumor stage, and Gleason grade. Patients were grouped into four clinically relevant strata according to their preoperative PSA level: 2.6 to 4.0, 4.1 to 7.0, 7.1 to 10.0, and greater than 10 ng/mL. The primary outcome was the 10-year actuarial biochemical PFS estimate generated using the Kaplan-Meier method. We compared the strata using the log-rank test. Cancer progression rates were compared using the Cochran Armitage test for trend. The chi-square test was used to compare the pathologic parameters among the PSA strata. Results Of the men with a preoperative PSA level of 2.6 to 4.0, 4.1 to 7.0, 7.1 to 10.0, and greater than 10.0 ng/mL, 81%, 74%, 72%, and 60%, respectively, had organ-confined disease ( P = 0.001) and 23%, 28%, 35%, and 47%, respectively, had a pathologic Gleason grade of 7 or greater ( P = 0.001). The corresponding 10-year PFS estimates were 88%, 80%, 76%, and 61% ( P = 0.0001, for trend). Conclusions Among men with clinical Stage T1c prostate cancer, those with a PSA level of 2.6 to 4.0 ng/mL had the greatest rate of organ-confined disease, lowest pathologic Gleason grade, and greatest 10-year PFS rate.

COMPARISON OF PREDICTIVE ACCURACY FOR PATHOLOGICALLY ORGAN CONFINED CLINICAL STAGE T1c PROSTATE CANCER USING HUMAN GLANDULAR KALLIKREIN 2 AND PROSTATE SPECIFIC ANTIGEN COMBINED WITH CLINICAL STAGE AND GLEASON GRADE

Previously human glandular kallikrein 2 (hK2) has been implicated to predict pathologically organ confined prostate cancer (PCa) in patients with stage T2 disease. Now we evaluated the usefulness of hK2, as measured by 2 entirely different immunoassay designs, to enhance the discrimination of pathologically organ from nonorgan confined clinical stage T1c PCa. A consecutive series of pretreatment serum from 148 men with clinical stage T1c PCa was used in 2 equally sensitive and specific methods to measure total hK2 with independent reagents and entirely different assay designs. Total prostate specific antigen (tPSA) and free PSA (fPSA) were measured and percent fPSA was calculated. We determined the algorithm, hK2*tPSA/fPSA, from data generated by each hK2 assay, calculated means, medians and ranges for each analyte and algorithm, and calculated the significance of differences on univariate analysis. Using pretreatment PSA, clinical stage and biopsy Gleason grade we then developed a multivariate logistic regression base model to predict organ confined cancer and we compared predictions of the base model supplemented by the different hK2 measurements. hK2 and hK2 based algorithms obtained by each hK2 assay were significantly different for pT2a/b vs pT3a or greater PCa (p = 0.034 to 0.0001) compared to tPSA (p = 0.06), fPSA (p = 0.90) or percent fPSA (p = 0.059). However, AUC (0.67 to 0.70) calculated by ROC analysis of the 4 models containing hK2 derived information was not significantly larger than that of the base model (AUC = 0.64, p = 0.52). The current data confirm that hK2 alone or hK2*tPSA/fPSA measured by 2 immunoassays is significantly lower in men with pT2a/b vs pT3a or greater PCa compared to tPSA, fPSA or percent fPSA on univariate analysis of a validation set of clinical stage T1c prostate cancer treated at an American center of excellence for prostate cancer surgery. However, the incorporation of preoperative hK2 into multiparameter predictive models for pT2 cancers did not increase predictive accuracy in this cohort of men.

Laparoscopic injury and repair of obturator nerve during radical prostatectomy

AbstractA 61-year-old man with bilateral Gleason score 7 (3+4) clinical Stage T1c prostate cancer was treated with laparoscopic bilateral pelvic lymphadenectomy and radical prostatectomy. The left obturator nerve was inadvertently transected during left obturator lymph node dissection and repaired by laparoscopic reapproximation.

Prostate-specific antigen cutoff of 2.6 ng/mL for prostate cancer screening is associated with favorable pathologic tumor features

Objectives. To evaluate the pathologic characteristics of clinical Stage T1c (nonpalpable, prostate-specific antigen [PSA]-detected) prostate cancers detected in the 2.6 to 4.0-ng/mL PSA range and compare them with Stage T1c cancers concurrently detected in the 4.1 to 10.0-ng/mL PSA range. All cancers were detected in a prostate cancer screening study. Methods. We studied 94 patients with clinical Stage T1c prostate cancer diagnosed by four or six-sector ultrasound-guided needle biopsy who underwent radical prostatectomy between June 1995 and December 1996. We included all men whose prostatectomy specimens were processed with complete embedding of all prostatic tissue. Of these, 42 had a PSA level of 2.6 to 4.0 ng/mL and 52 a PSA level 4.1 to 10.0 ng/mL at the time of cancer detection. We determined the tumor volume by complete embedding and grid morphometry, pathologic stage, Gleason sum, and surgical margin status and compared the cancer volume and pathologic tumor stages for each group. Results. Men with cancer detected at the 2.6 to 4.0 ng/mL PSA range had significantly smaller cancer volumes (1.1 ± 1.1 cm 3 versus 1.8 ± 1.5 cm 3, P = 0.02); however, no difference was found in the proportion (11.9% versus 11.5%, P = 0.9, and 23.8% versus 26.9%, P = 0.7, respectively) of tumors that met previously published criteria of “clinically insignificant” (organ confined, less than 0.2 cm 3 tumor volume, Gleason sum 6 or less) or “clinically unimportant” (organ confined, less than 0.5 cm 3 tumor volume, and Gleason sum 6 or less) tumors. Using the lower PSA cutoff point resulted in the detection of a significantly higher percentage of organ-confined tumors (88% versus 63%, P = 0.01). Conclusions. The use of a 2.6-ng/mL PSA threshold for screening resulted in the more frequent detection of small, organ-confined tumors without overdetecting possibly clinically insignificant ones.

No residual tumor in a radical prostatectomy specimen after neoadjuvant hormonal therapy for localized prostate cancer

The role of neoadjuvant hormonal therapy (NHT) before radical prostatectomy for localized prostate cancer remains controversial because many argue that apparent downstaging results in difficulties with the pathological evaluation of the neoadjuvant treated prostatectomy specimen. Furthermore, the downstaging to pT0 (no residual tumor), as reported by several institutions, remains questionable and is not yet confirmed by clinical or experimental evidence. To examine this issue and to assess the influence of NHT on downstaging, we investigated the stage pT0 status in radical prostatectomy specimens after NHT. We retrospectively reviewed 31 patients with histologically confirmed clinical stage T1c, T2 or T3 prostate cancer. All patients had received NHT for a mean duration of 5.2 months (range 2-19). We compared the pretreatment parameters (PSA, clinical stage, biopsy Gleason grade, number of positive cores, total length of cancer on each sextant biopsy or duration of NHT) to the pathological findings in the specimen sectioned at 3-mm thick after NHT. Five (16%) of 31 patients had no residual cancer (pT0) after radical prostatectomy, 8 (26%) had organ-confined disease (stage pT2), 6 (19%) had specimen confined disease, 10 (33%) had non-specimen confined disease and only 2 (6%) had lymph node metastasis. The histologic changes, including glandular atrophy and cytoplasmic vacuolation were stronger in specimens with a long duration (4 or more months) of NHT than those of a short duration (3 or less months). Multiple logistic regression analysis showed that only a longer duration of NHT was an independent predictor of a stage pT0 status in radical prostatectomy specimens after NHT (p=0.04, Odds ratio; 1.92, 95% CI; 1.03-3.56). Downstaging to pT0 occurs after duration of NHT of longer than 3 months. Further investigation of the optimal duration of NHT for downstaging and for improving patients' survival should be accomplished in randomized trials.