Extraprostatic Extension In Patients Research Articles

Evaluation of Extra-Prostatic Extension on Deep Learning-Reconstructed High-Resolution Thin-Slice T2-Weighted Images in Patients with Prostate Cancer.

The aim of this study was to compare diagnostic performance for extra-prostatic extension (EPE) and image quality among three image datasets: conventional T2-weighted images (T2WIconv, slice thickness, 3 mm) and high-resolution thin-slice T2WI (T2WIHR, 2 mm), with and without deep learning reconstruction (DLR) in patients with prostatic cancer (PCa). A total of 88 consecutive patients (28 EPE-positive and 60 negative) diagnosed with PCa via radical prostatectomy who had undergone 3T-MRI were included. Two independent reviewers performed a crossover review in three sessions, in which each reviewer recorded five-point confidence scores for the presence of EPE and image quality using a five-point Likert scale. Pathologic topographic maps served as the reference standard. For both reviewers, T2WIconv showed better diagnostic performance than T2WIHR with and without DLR (AUCs, in order, for reviewer 1, 0.883, 0.806, and 0.772, p = 0.0006; for reviewer 2, 0.803, 0.762, and 0.745, p = 0.022). The image quality was also the best in T2WIconv, followed by T2WIHR with DLR and T2WIHR without DLR for both reviewers (median, in order, 3, 4, and 5, p < 0.0001). In conclusion, T2WIconv was optimal in regard to image quality and diagnostic performance for the evaluation of EPE in patients with PCa.

The Development and External Validation of Artificial Intelligence-Driven MRI-Based Models to Improve Prediction of Lesion-Specific Extraprostatic Extension in Patients with Prostate Cancer.

Adequate detection of the histopathological extraprostatic extension (EPE) of prostate cancer (PCa) remains a challenge using conventional radiomics on 3 Tesla multiparametric magnetic resonance imaging (3T mpMRI). This study focuses on the assessment of artificial intelligence (AI)-driven models with innovative MRI radiomics in predicting EPE of prostate cancer (PCa) at a lesion-specific level. With a dataset encompassing 994 lesions from 794 PCa patients who underwent robot-assisted radical prostatectomy (RARP) at two Dutch hospitals, the study establishes and validates three classification models. The models were validated on an internal validation cohort of 162 lesions and an external validation cohort of 189 lesions in terms of discrimination, calibration, net benefit, and comparison to radiology reporting. Notably, the achieved AUCs ranged from 0.86 to 0.91 at the lesion-specific level, demonstrating the superior accuracy of the random forest model over conventional radiological reporting. At the external test cohort, the random forest model was the best-calibrated model and demonstrated a significantly higher accuracy compared to radiological reporting (83% vs. 67%, p = 0.02). In conclusion, an AI-powered model that includes both existing and novel MRI radiomics improves the detection of lesion-specific EPE in prostate cancer.

Predictors of Extraprostatic Extension in Patients with Prostate Cancer.

To identify effective factors predicting extraprostatic extension (EPE) in patients with prostate cancer (PCa). This retrospective cohort study recruited 898 consecutive patients with PCa treated with robot-assisted laparoscopic radical prostatectomy. The patients were divided into EPE and non-EPE groups based on the analysis of whole-mount histopathologic sections. Histopathological analysis (ISUP biopsy grade group) and magnetic resonance imaging (MRI) (PI-RADS v2.1 scores [1-5] and the Mehralivand EPE grade [0-3]) were used to assess the prediction of EPE. We also assessed the clinical usefulness of the prediction model based on decision-curve analysis. Of 800 included patients, 235 (29.3%) had EPE, and 565 patients (70.7%) did not (non-EPE). Multivariable logistic regression analysis showed that the biopsy ISUP grade, PI-RADS v2.1 score, and Mehralivand EPE grade were independent risk factors for EPE. In the regression assessment of the models, the best discrimination (area under the curve of 0.879) was obtained using the basic model (age, serum PSA, prostate volume at MRI, positive biopsy core, clinical T stage, and D'Amico risk group) and Mehralivand EPE grade 3. Decision-curve analysis showed that combining Mehralivand EPE grade 3 with the basic model resulted in superior net benefits for predicting EPE. Mehralivand EPE grades and PI-RADS v2.1 scores, in addition to basic clinical and demographic information, are potentially useful for predicting EPE in patients with PCa.

Quality assessment of prostate MRI by PI-QUAL score: Inter-reader agreement and impact on prostate cancer local staging at 3 Tesla

PurposeTo evaluate whether the Prostate Imaging Quality (PI-QUAL) score impacts prostate cancer (PCa) staging on MRI. The secondary goal was to test inter-reader agreement among radiologists experienced in prostate imaging. MethodA retrospective, single-center study with patients who underwent 3 Tesla prostate MRI scans and were submitted to radical prostatectomy (RP) between January 2018 and November 2021 and were eligible for our study. Extraprostatic extension (EPE) data were collected from original MR reports (EPEm) and pathological reports of RP specimens (EPEp). Three expert prostate radiologists (ESUR/ESUI criteria R1, R2, R3) independently evaluated all MRI exams according to PI-QUAL score for image quality (1 to 5; 1: poor, 5: excellent), blinded to original imaging reports and clinical data. We studied the diagnostic performance of MRI using pooled data from PI-QUAL scores (≤3 vs. ≥4). We also performed univariate and multivariate analyses to assess the PI-QUAL score impact on local PCa staging. Cohen’s K and Tau-b Kendall tests were used to assess the inter-reader agreement for PI-QUAL score, T2WI, DWI, and DCE. ResultsOur final cohort included 146 patients, of which 27.4% presented EPE on pathology. We observed no impact of imaging quality on accuracy for EPE prediction: AUC of 0.750 (95% CI 0.26-1) for PI-QUAL ≤ 3 and 0.705 (95% CI 0.618–0.793) for PI-QUAL ≥ 4. The multivariate analysis demonstrated a correlation of EPEm (OR 3.25, p 0.001) and ISUP grade group (OR 1.89, p 0.012) to predict EPEp. The inter-reader agreement was moderate to substantial (0.539 for R1-R2, 0.522 for R2-R3, and 0.694 for R1-R3). ConclusionOur clinical impact evaluation showed no direct correlation between MRI quality by PI-QUAL score and accuracy in detecting EPE in patients undergoing RP. Additionally, we had moderate to a substantial inter-reader agreement for the PI-QUAL score.

PI-RADS v2 Findings of MRI and Positive Biopsy Core Percentage would Predict Pathological Extraprostatic Extension in Patients who Underwent Robot Assisted Radical Prostatectomy: A Retrospective Study.

This study aimed to examine whether preoperative Prostate Imaging Reporting and Data System v2 (PI-RADS v2) can predict pathological extracapsular extension (EPE) after radical prostatectomy. We also studied the preoperative factors which can predict EPE. In our institute, 294 patients underwent robot assisted radical prostatectomy (RARP) between December 2012 and August 2016. In this era, we performed MRI after biopsy to determine clinical stage before surgery. PI-RADS v2 scores were retrospectively reviewed using biparametric MRI and EPE in pathological mapping of resected specimens for each lobe. In the excised specimen, EPE was observed in 73 lobes (12%). The percentage of EPE by PI-RADS v2 score was score '1': 6% (17/297 lobes), '2': 3% (1/33 lobes), '3': 12% (8/67 lobes), '4': 19% (27/139 lobes), and '5': 38% (20/52 lobes). The higher the PI-RADS score, the higher the percentage of EPE (P <0.01). When classified as PI-RADS score ≥4 and <4, the positive predictive value (PPV) was 24.6% (47/191 lobes, 95%CI: 0.187 - 0.313) and negative predictive value (NPV) was 93.5% (371/397 lobes, 95%CI: 0.906 - 0.957). By multivariate analysis, positive biopsy core percentage ≥60%, and PI-RADS score ≥4 were independent factors for predicting EPE. The positive rate of EPE in lobes with zero, one and two factors (PI-RADS ≥4 and positive biopsy core percentage ≥60%) was 4%, 19%, and 38%, respectively. PPV and NPV of PI-RADS ≥4 for predicting pathologic EPE were 24.6% and 93.5%, respectively. PI-RADS ≥4 and positive biopsy core percentage ≥60% were independent risk factors for predicting EPE. The positive rate of EPE in lobes with zero, one and two factors (PI-RADS ≥4 and positive biopsy core percentage ≥60%) was 4%, 19%, and 38%, respectively.

Development and External Validation of a Novel Nomogram to Predict Side-specific Extraprostatic Extension in Patients with Prostate Cancer Undergoing Radical Prostatectomy

BackgroundPrediction of side-specific extraprostatic extension (EPE) is crucial in selecting patients for nerve-sparing radical prostatectomy (RP). ObjectiveTo develop and externally validate nomograms including multiparametric magnetic resonance imaging (mpMRI) information to predict side-specific EPE. Design, setting, and participantsA retrospective analysis of 1870 consecutive prostate cancer patients who underwent robot-assisted RP from 2014 to 2018 at three institutions. Outcome measurements and statistical analysisFour multivariable logistic regression models were established, including combinations of patient-based and side-specific variables: prostate-specific antigen (PSA) density, highest ipsilateral International Society of Urological Pathology (ISUP) biopsy grade, ipsilateral percentage of positive cores on systematic biopsy, and side-specific clinical stage assessed by both digital rectal examination and mpMRI. Discrimination (area under the curve [AUC]), calibration, and net benefit of these models were assessed in the development cohort and two external validation cohorts. Results and limitationsOn external validation, AUCs of the four models ranged from 0.80 (95% confidence interval [CI] 0.68–0.88) to 0.83 (95% CI 0.72–0.90) in cohort 1 and from 0.77 (95% CI 0.62–0.87) to 0.78 (95% CI 0.64–0.88) in cohort 2. The three models including mpMRI staging information resulted in relatively higher AUCs compared with the model without mpMRI information. No major differences between the four models regarding net benefit were established. The model based on PSA density, ISUP grade, and mpMRI T stage was superior in terms of calibration. Using this model with a cut-off of 20%, 1980/2908 (68%) prostatic lobes without EPE would be found eligible for nerve sparing, whereas non–nerve sparing would be advised in 642/832 (77%) lobes with EPE. ConclusionsOur analysis resulted in a simple and robust nomogram for the prediction of side-specific EPE, which should be used to select patients for nerve-sparing RP. Patient summaryWe developed a prediction model that can be used to assess accurately the likelihood of tumour extension outside the prostate. This tool can guide patient selection for safe nerve-sparing surgery.

Tumour-capsule interface measured on 18F-DCFPyL PSMA positron emission tomography/CT imaging comparable to multi-parametric MRI in predicting extra-prostatic extension of prostate cancer at initial staging.

Nerve-sparing prostatectomy is recommended in cases of organ-confined prostate cancer but is generally contraindicated in patients with suspected extra-prostatic extension (EPE). PSMA ligand imaging has been shown to be valuable in predicting EPE when performed on a hybrid PET/MRI scanner; however, the majority of PSMA PET imaging is performed using PSMA-PET. To our knowledge, there are no established PET/CT criteria for assessing EPE. In this study, we aim to provide a reproducible method for evaluating EPE on PSMA-PET/CT imaging and assess its utility compared with MRI. Imaging findings and histopathology were reviewed for 100 consecutive patients who underwent a radical prostatectomy after imaging with MRI and 18F-DCFPyL PSMA-PET/CT. A broad tumour-capsule interface measured using a standardised technique on fused PSMA-PET/CT imaging is associated with a higher risk for established EPE (P<0.001). In our cohort, applying the criteria of tumour-capsule contact≥10mm measured on PET/CT was as sensitive as applying PI-RADS version 2 criteria to mpMRI imaging for predicting EPE (74% and 79%, respectively, P=0.11) and had superior specificity (86% and 61%, respectively, P=0.035). 93% of MRI-occult lesions were visualised on PSMA-PET/CT. Applying the proposed PET/CT criteria for EPE to this subgroup of 14 patients yielded a sensitivity of 67% and specificity of 92%. Our results suggest that tumour-capsule interface measured on fused F18-DCFPyL PSMA-PET/CT imaging is comparable to MRI criteria for predicting the presence of EPE. Applying PET/CT criteria may be of particular benefit in predicting EPE in patients with MRI-occult prostate cancer.

PE30 - Development and external validation of a new nomogram to predict side-specific extraprostatic extension in patients with prostate cancer undergoing robot assisted radical prostatectomy (RARP)

PE30 - Development and external validation of a new nomogram to predict side-specific extraprostatic extension in patients with prostate cancer undergoing robot assisted radical prostatectomy (RARP)

Endothelin-1 expression in prostate needle biopsy specimens correlated with aggressiveness of prostatic cancer

As the prostate adenocarcinoma is one of the most common malignant tumors in males, looking for a marker to effectively predict aggressiveness and metastatic potential in an apparently localized cancer in initial needle biopsy specimens can help the clinicians to make more appropriate decision for treatment, planning, and choosing appropriate targeted therapy. The present study assessed the value of Endothelin-1 expression to predict prognosis of prostatic cancer. In a cross sectional study, 83 patients who underwent radical prostatectomy in Hasheminejad Kidney Center in 2008 through 2012 were assigned to two groups including 43 with and 40 without extra-prostatic extension (EPE). Endothelin-1 staining was performed on Paraffin Embedded blocks of preoperative needle biopsies. The expression of Endothelin-1 increased in 72% of patients in the group with EPE (P<0.001). The group with Endothelin-1 positivity showed higher serum level of prostate specific antigen (PSA) (p = 0.039). Endothelin-1 expression was positive in 67% of patients with perineurial invasion (P<0.001). Adjusting the baseline variables of PSA and PN in a multivariable logistic regression model, the Endothelin-1 positivity could effectively predict EPE in patients with prostatic cancer (OR: 5.46, p = 0.010). Correlation of Endothelin-1 expression in needle biopsy specimens in expected with extra-prostatic extension of tumor in radical prostatectomy specimens, perineurial invasion and serum PSA level at the time of diagnosis.

Multiparametric magnetic resonance imaging and frozen-section analysis efficiently predict upgrading, upstaging, and extraprostatic extension in patients undergoing nerve-sparing robotic-assisted radical prostatectomy.

To evaluate the role of multiparametric magnetic resonance imaging (mpMRI) in predicting upgrading, upstaging, and extraprostatic extension in patients with low-risk prostate cancer (PCa). MpMRI may reduce positive surgical margins (PSM) and improve nerve-sparing during robotic-assisted radical prostatectomy (RARP) for localized prostate cancer PCa.This was a retrospective, monocentric, observational study. We retrieved the records of patients undergoing RARP from January 2012 to December 2013 at our Institution. Inclusion criteria were: PSA <10 ng/mL; clinical stage <T3a; biopsy Gleason score <7; prostate mpMRI performed preoperatively at our Institution; intraoperative FSA of the posterolateral aspects of the specimen.All the identified lesions were scored according to the Prostate Imaging Reporting and Data System (PIRADS). We considered the lesion with the highest PIRADS score as index lesion. All the included patients underwent nerve-sparing RARP. During surgery, the specimen was sent for FSA of the posterolateral aspects. The surgeon, according to the localization scheme provided by the mpMRI, inked the region of the posterolateral aspect of the prostate that had to be submitted to FSA.We evaluated association between clinical features and PSM, upgrading, upstaging, and presence of unfavorable disease.Two hundred fifty-four patients who underwent nerve-sparing RARP were included. PSM rate was 29.13% and 15.75% at FSA and final pathology respectively. Interestingly, the use of FSA reduced PSM rate in pT3 disease (25.81%). Higher PIRADS scores demonstrated to be related to high probability of upgrading and upstaging. This significativity remains even when considering PIRADS 2–3 versus 4 versus 5 and PIRADS 2–3 versus 4–5. Also PSM at FSA were associated with higher probability of upgrading and upstaging.PIRADS score and FSA resulted to be strictly related to grading and staging, thus being able to predict upgrading and/or upstaging at final pathology.

ERG rearrangement as a novel marker for predicting the extra-prostatic extension of clinically localised prostate cancer.

Currently, there are no well-established preoperative clinicopathological parameters for predicting extra-prostatic extension (EPE) in patients with clinically localised prostate cancer (PCa). The transmembrane protease serine 2 (TMPRSS2)-ETS-related gene (ERG) fusion gene is a specific biomarker of PCa and is considered a prognostic predictor. The aim of the present study was to assess the value of this marker for predicting EPE in patients with clinically localised PCa. In total, 306 PCa patients with clinically localised disease, including 220 patients (71.9%) with organ-confined disease and 86 EPE cases (28.1%), were included in the study. Receiver operating characteristic curves and logistic regression were employed to establish the optimal cut-off value and to investigate whether ERG rearrangement was an independent predictor for the EPE of clinically localised PCa. A leave-one-out cross-validation (LOOCV) model was implemented to validate the predictive power of ERG rearrangement. An increase in ERG rearrangements was identified to be associate'd with EPE, and the optimal cut-off for predicting EPE was determined to be 2.25%, with a sensitivity of 70.24% [95% confidence interval (CI), 62.6-78.9%], a specificity of 80.43% (95% CI, 75.4-85.1%), and an area under the curve (AUC) of 0.781 (95% CI, 0.730-0.826). In the LOOCV model, ERG rearrangement also demonstrated good performance for predicting EPE (sensitivity, 76.923%; specificity, 71.429%; 95% CI for AUC, 0.724-0.958). In addition, a high Gleason score (≥7) and a cT2c classification upon biopsy were independent factors for EPE.

The value of prostate-specific antigen density in the prediction of extraprostatic extension in patients with clinically organ-confined prostate cancer

Objective To evaluate the role of PSA density with prostate volume determined by MR images in the prediction of extraprostatic extension in patients with clinically organ-confined prostate cancer. Method A total of 71 patients with clinically organ-confined prostate cancer who underwent radical prostatectomy from January 2009 to December 2013 were included in the study.MRI PSAD, preoperative total serum PSA (tPSA), free PSA/total PSA(fPSA/tPSA), biopsy Gleason score, prostate volume, age, body mass index in patients with extraprostatic extension were compared with those in patients with organ-confined disease.The receiver operating characteristic (ROC)curve was used to analyze the performance of each of the above parameters to predict the extraprostatic extension.Multivariate logistic regression analysis was used to select the independent influencing factors for extraprostatic extension. Results Pathologic examination revealed 32 patients were positive for extraprostatic extension and 39 patients had organ-confined disease.MRI PSAD(P<0.001), tPSA(P<0.001) and biopsy Gleason score levels(P=0.006) were higher in patients with extraprostatic extension than that in patients with organ-confined disease, and prostate volume was lower(P=0.009). MRI PSAD showed the largest area under ROC curve(AUC) among those parameter(AUC=0.852, P<0.001), and tPSA was the second(AUC=0.764). Multivariate logistic regression analyses showed that MRI PSAD was an independent predictor of extraprostatic extension. Conclusions MRI PSAD was better than tPSA in predicting pathological stage of extraprostatic extension.The value of PSAD should not be ignored in the prediction of pathological stage. Key words: Prostatic neoplasms; Prostate specific antigen; Prostate specific antigen density; Pathological stage; Extraprostatic extension.

Prediction of Extraprostatic Extension in Patients with Clinically Organ-Confined Prostate Cancer

Introduction: Preoperative parameters for predicting extraprostatic extension (ECE) in clinically organ-confined prostate cancer patients are not well defined. Our aim was to evaluate the roles of the biopsy Gleason score, prostate-specific antigen (PSA)-based parameters, volume, and clinical T classification in prediction of ECE. Materials and Methods: A total of 188 patients with clinically organ-confined prostate cancer who underwent radical prostatectomy from January 1998 to December 2007 were included in the study. Age, prostate volume, preoperative total serum PSA (tPSA), free PSA, PSA density (PSAD), biopsy Gleason score, and clinical T classification were analyzed by univariate and multivariate analyses to predict ECE. Results: Pathologic examination revealed 130 patients had organ-confined disease and 58 patients were positive for ECE. Multivariate logistic regression analyses showed that tPSA was an independent predictor of ECE. Gleason score ≥8 had a trend for predicting ECE. Receiver operating characteristic (ROC) curves suggested that tPSA and PSAD had a similar diagnosis performance in the whole cohort. For patients with Gleason score of 7, PSAD was found to be statistically better than tPSA for predicting ECE. Conclusions: tPSA remains one of the most important factors for predicting ECE in prostate cancer patients. PSAD may be more helpful than tPSA for predicting ECE in the patients with Gleason score of 7.

This Month in Adult Urology

No AccessJournal of UrologyThis Month in Adult Urology1 Nov 2013This Month in Adult Urology William D. Steers William D. SteersWilliam D. Steers More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.08.001AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "This Month in Adult Urology." The Journal of Urology, 190(5), pp. 1629–1630 References 1 : Risk of urinary incontinence following post-brachytherapy transurethral resection of the prostate and correlation with clinical and treatment parameters. J Urol2013; 190: 1805. Link, Google Scholar 2 : Testosterone supplementation does not worsen lower urinary tract symptoms. J Urol2013; 190: 1828. Link, Google Scholar 3 : Population based study of use and determinants of active surveillance and watchful waiting for low and intermediate risk prostate cancer. J Urol2013; 190: 1742. Link, Google Scholar 4 : The predictive value of endorectal 3 Tesla multiparametric magnetic resonance imaging for extraprostatic extension in patients with low, intermediate and high risk prostate cancer. J Urol2013; 190: 1728. Link, Google Scholar 5 : Automated analysis of urinary stone composition using Raman spectroscopy: pilot study for the development of a compact portable system for immediate postoperative ex vivo application. J Urol2013; 190: 1895. Link, Google Scholar 6 : Male breast cancer and 5α-reductase inhibitors finasteride and dutasteride. J Urol2013; 190: 1811. Link, Google Scholar © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 190Issue 5November 2013Page: 1629-1630 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information William D. Steers More articles by this author Expand All Advertisement PDF downloadLoading ...

The Predictive Value of Endorectal 3 Tesla Multiparametric Magnetic Resonance Imaging for Extraprostatic Extension in Patients with Low, Intermediate and High Risk Prostate Cancer

We determined the positive and negative predictive values of multiparametric magnetic resonance imaging for extraprostatic extension at radical prostatectomy for different prostate cancer risk groups. We evaluated a cohort of 183 patients who underwent 3Tesla multiparametric magnetic resonance imaging, including T2-weighted, diffusion weighted magnetic resonance imaging and dynamic contrast enhanced sequences, with an endorectal coil before radical prostatectomy. Pathological stage at radical prostatectomy was used as standard reference for extraprostatic extension. The cohort was classified into low, intermediate and high risk groups according to the D'Amico criteria. We recorded prevalence of extraprostatic extension at radical prostatectomy and determined sensitivity, specificity, positive predictive value and negative predictive value of multiparametric magnetic resonance imaging for extraprostatic extension in each group. Univariate and multivariate analyses were performed to identify predictors of extraprostatic extension at radical prostatectomy. The overall prevalence of extraprostatic extension at radical prostatectomy was 49.7% ranging from 24.7% to 77.1% between low and high risk categories. Overall staging accuracy of multiparametric magnetic resonance imaging for extraprostatic extension was 73.8%, with sensitivity, specificity, positive predictive value and negative predictive value of 58.2%, 89.1%, 84.1% and 68.3%, respectively. Positive predictive value of multiparametric magnetic resonance imaging for extraprostatic extension was best in the high risk cohort with 88.8%. Negative predictive value was highest in the low risk cohort with 87.7%. With anodds ratio of 10.3 multiparametric magnetic resonance imaging is by far the best preoperative predictor of extraprostatic extension at radical prostatectomy. For adequate patient counseling, knowledge of predictive values of multiparametric magnetic resonance imaging for extraprostatic extension is of utmost importance. High negative predictive value, important for decisions on nerve sparing strategies at radical prostatectomy, is only reached in low risk subjects.

Partial Sampling of Radical Prostatectomy Specimens

Currently there is no global agreement as to how extensively a radical prostatectomy specimen should be sectioned and histologically examined. We analyzed the ability of different methods of partial sampling in detecting positive margin (PM) and extraprostatic extension (EPE)-2 pathologic features of prostate cancer that are most easily missed by partial sampling of the prostate. Radical prostatectomy specimens from 617 patients treated with open radical prostatectomy between 1992 and 2011 were analyzed. Examination of the entirely submitted prostate detected only PM in 370 (60%), only EPE in 100 (16%), and both in 147 (24%) specimens. We determined whether these pathologic features would have been diagnosed had the examination of the specimen been limited only to alternate sections (method 1), alternate sections representing the posterior aspect of the gland in addition to one of the mid-anterior aspects (method 2), and every section representing the posterior aspect of the gland in addition to one of the mid-anterior aspects, supplemented by the remaining ipsilateral anterior sections if a sizeable tumor is seen (method 3). Methods 1 and 2 missed 13% and 21% of PMs and 28% and 47% of EPEs, respectively. Method 3 demonstrated better results missing only 5% of PMs and 7% of EPEs. Partial sampling techniques missed slightly more PMs and EPEs in patients with low-risk to intermediate-risk prostate cancer, although even in high-risk cases none of the methods detected all of the studied aggressive pathologic features.

1327 THE PRESENCE OF EXTRAPROSTATIC EXTENSION INCREASES THE RISK OF DEATH FROM PROSTATE CANCER AFTER RADICAL PROSTATECTOMY FOR PATIENTS WITH PT3B DISEASE

INTRODUCTION AND OBJECTIVES: Patients with pathologic T3b (seminal vesicle invasion) prostate cancer are at increased risk for disease recurrence and cancer-related mortality following radical prostatectomy (RP). Clinicopathologic features which stratify the risk of disease progression in these patients continue to be defined. We sought to determine the prognostic significance of extraprostatic extension (EPE) in patients with pT3b tumors with regard to the risks of subsequent biochemical recurrence (BCR), systemic progression (SP), and death from prostate cancer. METHODS: We reviewed 16,453 patients who underwent RP without prior therapy at our institution from 1987-2009 to identify patients noted to have pT3bN0 disease. Survival was estimated using the Kaplan Meier method and compared with the log rank test. The association of EPE with outcome was evaluated on Cox multivariate hazards regression models, controlling for Gleason score, preoperative PSA, tumor volume, and surgical margin status. RESULTS: A total of 1,132 patients with pT3b disease at RP were identified. Mean postoperative follow-up was 10.6 years (range 0-23.3). Of these, 693 (61%) also had pathologic evidence of EPE. Men with EPE, compared to those without, had a higher mean preoperative PSA (21.1 ng/ml vs 14.1 ng/ml; p 0.0001) and an increased rate of pathologic Gleason score 8-10 (28.1% vs 16.9%; p 0.0001). Overall, compared to patients without EPE, patients with EPE had an increased risk of BCR (63% vs 53%), SP (22% vs 14%), and death from prostate cancer (14% vs 8%) (p 0.0001 for all). Moreover, on multivariate analysis, the presence of EPE remained associated with significantly increased risks of BCR (HR 1.32, p 0.003), SP (HR 1.56, p 0.01), and death from prostate cancer (HR 1.7, p 0.03). In addition, increased Gleason score and higher tumor volume were significant predictors of death from prostate cancer (HR 2.31, p 0.0001; and HR 1.33, p 0.0006). On the other hand, administration of adjuvant hormonal therapy was associated with significantly lower risks of BCR (HR 0.32, p 0.0001), SP (HR 0.42, p 0.0001), and prostate cancer death (HR 0.49, p 0.009). CONCLUSIONS: The presence of EPE in patients with pT3b prostate cancer is significantly associated with increased risks of BCR, SP, and death from prostate cancer following RP. As the presence of EPE portends poorer outcomes in this patient population, consideration of adjuvant therapy should be given to pT3b patients with this pathologic finding.

The role of transrectal ultrasound-guided biopsy-based staging, preoperative serum prostate-specific antigen, and biopsy gleason score in prediction of final pathologic diagnosis in prostate cancer

Objectives To evaluate the role of ultrasound-guided systematic and lesion-directed biopsies, biopsy Gleason score, and preoperative serum prostate-specific antigen (PSA) as three objective and reproducible variables to provide a reliable combination in preoperative identification of risk of extraprostatic extension in patients with clinically localized prostate cancer. Methods The case records of 813 patients who underwent radical prostatectomy for clinically localized prostate cancer were analyzed. All had multiple systematic biopsies, two to three from each lobe, in addition to lesion-directed biopsies. Additionally, biopsies were done on seminal vesicles (SVs), if abnormal. Based on biopsy results, patients were classified as having Stage B1 (T2a–T2b) or B2 (T2c) disease, depending on whether biopsies from one or both lobes were positive and Stage C (T3) if there was evidence of SV involvement by biopsy or biopsies from areas of extracapsular extension as seen on transrectal ultrasound (TRUS) were positive. Logistic regression analyses with log likelihood chi-square test was used to define the correlation between individual as well as combination of preoperative variables and pathologic stage. Results On final pathologic examination, 473 (58%) patients had organ-confined disease, 188 (23%) had extracapsular extension (ECE), with or without positive surgical margins, and 72 (9%) had SV involvement. Eighty (10%) patients had pelvic lymph node metastases. Biopsy-based staging was superior to clinical staging in predicting final pathologic diagnosis. Logistic regression analyses revealed that the combination of biopsy-based stage, preoperative serum PSA, and biopsy Gleason score provided the best prediction of final pathologic stage. Probability plots constructed with these data can provide significant information on risk of extraprostatic extension in individual patients. Conclusions This study demonstrates that TRUS-guided systematic biopsy in combination with preoperative serum PSA and biopsy Gleason score may provide a cost-effective approach for management decisions and prognostication in patients with prostate cancer.