Final Gleason Score Research Articles

Does the presence of robotic surgery affect demographics in patients choosing to undergo radical prostatectomy? A multi-center contemporary analysis.

We report on differences in patient demographics in those men choosing to undergo radical prostatectomy in a UK center where there is no influence of robotic surgery and in those choosing radical prostatectomy in a US center where there is a strong robotic influence. Demographic and pathologic data were prospectively recorded in parallel for 78 consecutive men undergoing robot-assisted radical prostatectomy in a tertiary care academic US center and 69 consecutive men concurrently undergoing open radical prostatectomy in a similar UK center. Although average patient age was significantly younger in the US cohort (58.8years, range 43.1-77.6 vs. 62.2years, range 51.7-70.5; P=0.002), the US cohort encompassed a wider age range and older patients than the UK cohort. Average preoperative prostate-specific antigen (PSA) was significantly lower in the US group (6.0, range 2.0-6.0 vs. 8.60, range 4.6-12.6; P<0.01). Biopsy Gleason score, clinical stage, final pathology Gleason score, pathologic staging and positive margin rate were not significantly different between the two groups. Blood loss and transfusion rate were significantly lower in the US group. 16.7% of men in the US cohort had overall positive surgical margins compared to 29% in the UK group (P=0.07). This data confirms our belief that patient age ranges are different in a setting influenced by robotic surgery. Although pathologic parameters were similar, the age distribution of robotic surgery patients was much wider, suggesting robotics attracts men previously reluctant to undergo surgery in the open setting or to pursue active surveillance protocols. Larger studies are needed to verify this finding.

The Value of Mandatory Second Opinion Pathology Review of Prostate Needle Biopsy Interpretation Before Radical Prostatectomy

We determined the value of mandatory second opinion pathology review to interpret prostate needle biopsy before radical prostatectomy. In all cases referred to our institution for radical prostatectomy in 1 year we compared pathological parameters in original and reviewed pathology reports, including benign, atypical or malignant diagnosis, final Gleason score, positive core number, core highest cancer percent and perineural invasion or extraprostatic extension. A major Gleason score discrepancy was defined as a change to a different risk category (6, 7 and 8-10). We defined a significant difference in the highest percent of cancer in a core as 30% or greater. Of the 855 cases originally diagnosed as prostatic adenocarcinoma cancer was confirmed in 844 (98.8%) by needle biopsy and prostatectomy, of which 9 (1%) were atypical and 2 (0.2%) were benign upon review. A major discrepancy in Gleason score was present in 124 cases (14.7%), of which 57 (46.0%) were upgraded and 67 (54%) were downgraded. Of cases with a final Gleason score of 6, 8.4% were originally diagnosed as 7 (7.8%) or 8-10 (0.6%), 21% with a final score of 7 had an original score of 6 (13.2%) or 8-10 (7.8%) and 21 of 61 (34%) with a score of 8-10 were originally diagnosed as 7 or less. There were 80 cases (64.5%) of disagreement between scores 6 and 7. Of the 777 cases with the positive core number in each report 71 (9.1%) had discrepancies. After review the positive core number was higher in 45 cases (63.4%) and lower in 26 (36.6%). We noted a significant difference in the highest cancer percent in a core in 76 of 844 evaluable cases (9%) in which cancer was originally underestimated. In 60 of 76 cases (78.9%) cancer discontinuously involved the core on review. Review revealed perineural invasion in 138 of 844 cases (16.3%) that was not originally reported in 37 of 138 (26.8%). In 4 cases review showed extraprostatic extension on needle biopsy. Compared to a smaller study more than 10 years ago at our institution the rate of unconfirmed cancer was identical (1.2%). To our knowledge this is the first study to analyze concordance upon review of the number of positive cores and maximum percent positive in a core (each discrepancy 9%). In a few cases mandatory second opinion on prostate needle biopsy results in significant differences that may affect therapy.

Oncologic Outcome after Extraperitoneal Laparoscopic Radical Prostatectomy: Midterm Follow-up of 1115 Procedures

BackgroundAlthough the first laparoscopic radical prostatectomy was performed in 1997, few midterm oncologic data have been published for the extraperitoneal procedure. ObjectiveTo determine the oncologic outcome of extraperitoneal laparoscopic radical prostatectomy (ELRP). Design, setting, and participantsFrom 2000 to 2007, 1115 consecutive patients underwent ELRP for a localized prostate cancer at our department. Follow-up was scheduled and standardized for all patients and recorded into a prospective database. Median postoperative follow-up was 35.6 mo. InterventionAll ELRP were performed by three surgeons at the Department of Urology, Hospital Henri Mondor, Créteil, France. MeasurementsBiochemical recurrence was defined by prostate-specific antigen level ≥0.2 ng/ml. Results and limitationsIn pN0/pNx cancers, postoperative stage was pT2 in 664 patients (59.5%), pT3 in 350 patients (31.4%), and pT4 in 77 patients (6.9%). Positive lymph nodes were reported in 24 patients (2.2%). Margins were positive in 16.1% and 34.6% of pT2 and pT3 cancers, respectively. Final Gleason score was <7 in 288 men (25.8%), =7 in 701 men (62.9%), and >7 in 126 men (11.3%). Overall prostate-specific antigen (PSA) recurrence-free survival was 83% at 5 yr. The 5-yr progression-free survival rates were 93.4% for pT2, 74.5% for pT3a, and 55.0% for pT3b tumors, respectively. Multivariate Cox model showed that PSA, Gleason score, pT category, nodal status, and surgical margins were significant independent predictors of biochemical recurrence-free survival. ConclusionsThis assessment of oncologic results demonstrates that ELRP is a safe and effective procedure. On the basis of midterm follow-up data, the prognostic factors of PSA after ELRP failure are the same as those described previously in transperitoneal or open retropubic approaches. The oncologic results of ELRP also are in line with those reported with the use of the retropubic or the transperitoneal laparoscopic approaches.

Predicting the long-term risk of prostate cancer-specific mortality after radical prostatectomy

5007 Background: Nomograms that predict prostate-specific antigen (PSA) defined biochemical recurrence (BCR) of prostate cancer after radical prostatectomy are the most widely used prediction tools in oncology for treatment decision making and counseling. While BCR universally antedates prostate cancer-specific mortality (PCSM), it is a limited surrogate endpoint due to its variable natural history. Nomograms that accurately predict the risk of PCSM are needed. Methods: Using Fine and Gray competing risk regression analysis, the clinical data and follow-up information of 11,521 patients treated with radical prostatectomy at four academic centers from 1987 to 2005 were modeled to predict PCSM. The model was externally validated on 12,893 patients treated at a separate institution during the same period. Results: The 15-year PCSM and all-cause mortality was 7% and 33%, respectively. The 15-year PCSM for patients with final pathological Gleason score 2–6, 3+4, 4+3, and 8–10 was 1%, 7%, 8%, and 49%, respectively. By pathologic stage, the risks were 2%, 7%, 29%, and 23% for organ-confined, extraprostatic extension, seminal vesicle invasion, and lymph node-positive prostate cancer. Of 3756 patients with organ-confined and Gleason 2–6 cancer, only 1 (0.03%) died from prostate cancer. Primary and secondary Gleason grade (p &lt; 0.001 for both), seminal vesicle invasion (p &lt; 0.001), and year of surgery (p = 0.002) were significant predictors of PCSM. A nomogram predicting 15-year PCSM based on pathologic parameters was accurate and discriminating with an externally-validated concordance index of 0.92. Conclusions: A nomogram has been constructed that predicts the long-term risk of PCSM after radical prostatectomy based on the pathologic grade and stage of the cancer. The presence of poorly differentiated cancer and seminal vesicle invasion are the prime determinants of PCSM. Our study suggests that biomarkers may have limited empiric prognostic utility as PCSM can be accurately predicted once the pathologic features of prostate cancer are known. No significant financial relationships to disclose.

Saturation biopsies on autopsied prostates for detecting and characterizing prostate cancer

To evaluate a 36-core saturation biopsy scheme on autopsied prostate glands to estimate the detection rate based on the true cancer prevalence, and to compare the cancer features on biopsy with whole-mount pathological analysis, as saturation biopsies have been proposed as a tool to increase the prostate cancer detection rate, and as a staging tool to identify potentially insignificant cancers before surgery. We took 36-core needle biopsies in 48 autopsied prostates from men who had no history of prostate cancer. The first 18 cores corresponded to an extended biopsy protocol including six cores each in the mid peripheral zone (PZ), lateral PZ and central zone. Six additional cores were then taken in each of these three locations. We compared the histological characteristics of step-sectioned prostates with the biopsy findings. Tumours were considered clinically insignificant if they were organ-confined with an index tumour volume of <0.5 mL and Gleason score of <or=6. The pathological evaluation identified 12 (25%) cases of prostate cancer and 22 tumour foci; seven prostate cancers were significant. Of the 22 tumour foci, 16 (73%) were in the PZ. The first 18 cores detected seven cancers (58%), of which five were clinically significant. The last 18 cores detected four cancers, all of which were already detected by the first 18 cores. Of the five cancers remaining undetected by biopsies, two were clinically significant and three were insignificant. Comparison of the histological characteristics between biopsies and step-sectioned prostates showed an overestimation of Gleason score by saturation biopsies in three of seven cases. The evaluation of saturation biopsies based on the true prevalence of prostate cancer showed no increase in detection rate over a less extensive 18-core biopsy. Also, saturation biopsies might overestimate the final Gleason score on whole-mount analysis.

Does prostate biopsy Gleason score accurately express the biologic features of prostate cancer?

Purpose To correlate Gleason grading in prostate biopsies with the final Gleason score in radical prostatectomy specimens, and to investigate predictors for concordance and preoperative undergrading. Materials and methods The charts of 303 patients who underwent radical retropubic prostatectomy between 1992 and 2002 were retrospectively reviewed. Prostate biopsy and surgical specimen Gleason scores and correlative clinical data were recorded, and a multivariate analysis model was applied. Results Data were available in 293 cases (97%). The preoperative biopsy predicted the prostatectomy Gleason score accurately in 51% and undergraded them in 41% of the patients. Accuracy rates were significantly higher for Gleason scores 7–10 compared to low Gleason scores (2–4), concordance 90% and 6%, respectively ( P < 0.01). Moreover, accuracy rates were higher in patients with prostate-specific antigen (PSA) higher than 10 ng/ml (85% vs. 40%; P < 0.01) and prostate glands smaller than 55 g (68% vs. 38%; P < 0.01). In 233 patients, the biopsy Gleason score did not include 4 or 5 components. Upgrading to 4 or 5 in 1 of the components was noted in 32 patients (14%). Multivariate analysis revealed that upgrading is associated with preoperative serum PSA (odds ratio 1.05; P < 0.05) and the percentage of positive cores in the biopsy (odds ratio 1.47; P < 0.001). Conclusions Biopsy Gleason scores of 2–4, low PSA, and a low percentage of positive cores in the biopsy can predict the biopsy driven biologically significant undergrading of 1 of the components of the Gleason score that may adversely affect therapeutic decisions.

Minimal Tumor Volume May Provide Additional Prognostic Information in Good Performance Patients After Radical Prostatectomy

The significance of tumor volume (TV) as a predictor of biochemical failure after radical prostatectomy (RP) remains debatable. TV determinants can also entail significant time and cost. Estimating TVs using an asymmetric categorical classification system provides an economical alternative to determining this parameter. We evaluated the prognostic value of an estimated TV in patients undergoing RP in predicting for prostate-specific antigen (PSA) failure. We retrospectively reviewed the clinical and pathologic features of 865 patients who underwent RP at our institution from 1991 to 1999. The TV, PSA level, final Gleason score, percentage of positive biopsy cores, and clinical stage were evaluated using univariate and multivariate analysis to determine their association with biochemical failure. Patients were also stratified according to PSA level (less than versus greater than 10 ng/mL), Gleason score (less than versus greater than 7), and clinical T stage (Stage T1c or better versus worse than Stage T1c) to analyze the prognostic significance of TV in this subpopulation of patients. Of our 865 evaluable patients, 124 (14.3%) had progression to biochemical failure at a mean follow-up of 60 months. The TV was significantly associated with biochemical failure on univariate analysis (P = 0.024). In the low-risk patients (PSA level less than 10 ng/mL, Gleason score less than 7, and clinical Stage T1c or better), a minimal TV was associated with a lower risk of biochemical failure on multivariate analysis (hazard ratio 2.0, 95% confidence interval 1.09 to 3.68, P = 0.025). In RP patients with favorable clinical and pathologic characteristics, a minimal TV was associated with a decreased risk of biochemical failure. In carefully selected patients, the estimated TV might provide additional prognostic information for risk stratification for PSA progression and biochemical failure.

Prostate Cancer Characteristics in a Multiracial Community

ObjectivesTo investigate the hypothesis that Northern Africans differ from Caucasians with regard to their PCa characteristics, using our 1988–2006 database we retrospectively reviewed the preoperative and pathological features of consecutive patients subjected to radical prostatectomy (RP) for localized prostate cancer (PCa) and stratified according to their ethnic origin. MethodsIn 727 consecutive patients (616 Caucasians; 61 Blacks originating from Central Africa and the French West Indies; 50 Northern Africans from Morocco, Algeria, Tunisia), we preoperatively analyzed and compared age, clinical stage of the tumour, prostate-specific antigen (PSA), transrectal ultrasound prostate volume, PSA density (PSAD), biopsy Gleason score, number of positive cores (NPC), and percentage of tissue core invaded by cancer (PTIC); postoperatively, we determined the status of the capsule, seminal vesicles, and margins of the RP specimen, as well as Gleason score and prostate weight. Statistical analyses (chi-square test and ANOVA) were performed to compare the results between the three groups of patients. A multivariate analysis was carried out to test the independence of variables. ResultsBlack patients were the youngest at the time of surgery (by 3–4 yr) and had the highest rates of final Gleason score≥8. The Northern Africans had more favourable features than did Caucasian and Black patients: mean PTIC was 7.1% versus 14.6% and 12.5%, respectively (p=0.005), mean NPC was 26.4% versus 34.7% and 36.4%, respectively (p=0.034), rates of biopsy and final Gleason score≥8 were significantly lower (p=0.02 and p=0.028, respectively), and there were positive margins in 26% versus 36% and 35.6%, respectively (p>0.05). ConclusionsThis study showed that a French Black population is the most likely of those studied to have unfavourable PCa characteristics at the time of RP. Albeit in a limited series, we show for the first time that Northern Africans have significantly better features in this regard than Caucasians and Blacks. Although Northern Africans did not have a better pathological stage outcome, they did have a more favourable Gleason score.

The Role of Early Adopter Bias for New Technologies in Robot Assisted Laparoscopic Prostatectomy

We determined the potential influence of an early adopter bias in patients undergoing robot assisted laparoscopic prostatectomy. We compared baseline demographic, clinical and health related quality of life characteristics of patients undergoing 3 different surgical procedures for clinically localized prostate cancer following the introduction of robot assisted laparoscopic prostatectomy at our institution. Patients included in this analysis were participating in a prospective health related quality of life study using the SF-12(R) and Expanded Prostate Cancer Index Composite validated questionnaires. Of 402 patients 159 (39%) underwent robot assisted laparoscopic, 144 (36%) underwent radical perineal and 99 (25%) underwent radical retropubic prostatectomy. There were no statistically significant associations between procedure type and patient age (p = 0.267), race (p = 0.725), number of medical comorbidities (p = 0.490), income (p = 0.056) and level of education (p = 0.495). Mean prostate specific antigen was 5.9 +/- 3.3, 7.3 +/- 5.5 and 5.7 +/- 5.0 ng/ml for robot assisted laparoscopic, radical perineal and radical retropubic prostatectomy, respectively (p = 0.030). The proportion of robot assisted laparoscopic, radical perineal and radical retropubic prostatectomy patients with a final Gleason score of 4-6 was 55%, 45% and 39%, respectively (p = 0.037). The proportion of robot assisted laparoscopic, radical perineal and radical retropubic prostatectomy patients with stage T2 disease was 91%, 68% and 80%, respectively (p = 0.001). Statistically significant associations of higher income and education with higher baseline health related quality of life scores were seen in the sexual and physical domains (each p <0.01). We failed to find evidence of an early adopter bias for patients undergoing robot assisted laparoscopic prostatectomy. Nevertheless, observational studies comparing robot assisted laparoscopic prostatectomy to radical perineal and radical retropubic prostatectomy should account carefully for patient baseline characteristics to allow meaningful comparisons of surgical outcomes.

Poorly Differentiated Prostate Cancer Treated With Radical Prostatectomy: Long-Term Outcome and Incidence of Pathological Downgrading

Patients with high grade (Gleason score 8 to 10) prostate cancer on biopsy are at high risk for cancer recurrence after local treatment, such as radiation therapy and radical prostatectomy. We examined long-term outcomes in patients with high grade prostate cancer on biopsy who were treated with radical prostatectomy alone. We also investigated the impact on outcomes of changes in the radical prostatectomy Gleason score. Of 5,662 patients who underwent radical prostatectomy during 20 years 238 had a biopsy Gleason score of 8 to 10. We analyzed the rate of biochemical recurrence in this subgroup according to the Gleason grade of cancer in the radical prostatectomy specimen. Ten-year biochemical recurrence-free probability in the cohort was 39%. However, 45% of patients (95% CI 38 to 51%) with Gleason score 8 to 10 cancer on biopsy had a Gleason score of 7 or less in the radical prostatectomy specimen. These patients had a 10-year biochemical recurrence-free probability of 56% compared to 27% in those with a final Gleason score that remained 8 to 10 (p = 0.0004). On multivariate analysis neither prostate specific antigen nor biopsy features, including total number of cores, number of cores with cancer and percent of cancer in the cores, was a significant predictor of downgrading. However, clinical stage and biopsy Gleason score were significant with 58% of cT1c and 51% of biopsy Gleason score 8 cancers downgraded. Almost 65% of cT1c Gleason score 8 cancers were downgraded compared to 11% of cT3 Gleason score 9 cancers. Patients diagnosed with poorly differentiated prostate cancer (Gleason score 8 to 10) on biopsy do not uniformly have a poor prognosis. Of the patients 39% remain free of cancer recurrence 10 years after radical prostatectomy. Of these cancers 45% have a lower Gleason score in the radical prostatectomy specimen and a correspondingly more favorable long-term outcome. Predictors of downgrading are lower clinical stage (cT1c) and Gleason score 8 in the biopsy specimen.

1488: Risk of Disparity Between Needle Biopsy Gleason Score and Final Pathologic Gleason Score is not Correlated with Prostate Volume

1488: Risk of Disparity Between Needle Biopsy Gleason Score and Final Pathologic Gleason Score is not Correlated with Prostate Volume

Evaluation of concordance of Gleason score between prostatectomy and biopsies that show more than two different Gleason scores in positive cores

Objectives To evaluate variables that may predict the Gleason score of radical prostatectomy specimens in patients with more than two different Gleason scores in the positive cores of their biopsy specimens. Methods We reviewed the pathologic data of 98 patients who had more than two different Gleason scores in 12-site biopsy specimens. We assessed the following biopsy parameters: the greatest Gleason score on the biopsy specimen, the Gleason score of the greatest tumor percentage in the core, the Gleason score of the largest linear cancer length, and the greatest tumor ratio score (Gleason score of the greatest total tumor length of the same Gleason score/total core length of the same Gleason score). We also assessed the concordance in Gleason scores between biopsy specimens and prostatectomy specimens. Results The greatest tumor ratio score was associated with the greatest (67%) concordance rate. The concordance of the greatest Gleason score on biopsy specimens was only 49%. When stratified into categories of well-differentiated (Gleason score 6 or less), moderate (Gleason score 7), and poorly differentiated (Gleason score 8 or more), the grade concordance rate of the greatest tumor ratio score was 73%. The grade concordance rate of the Gleason scores of the greatest tumor percentage in the core, Gleason score core with maximal tumor length, and the greatest Gleason score was 64%, 62%, and 57%, respectively. Conclusions If biopsy specimen results in more than two different Gleason scores in the positive cores, the greatest tumor ratio score may be the most useful variable with regard to the prediction of the final Gleason score in the radical prostatectomy specimen.

Extended prostate needle biopsy improves concordance of Gleason grading between prostate needle biopsy and radical prostatectomy.

We examined the concordance of Gleason scores in prostate needle biopsy specimens and the corresponding radical retropubic prostatectomy specimens in a cohort of patients grouped according to the number of cores obtained during diagnostic needle biopsy. We reviewed clinical and pathological data on a cohort of 466 men diagnosed with localized prostate cancer by needle biopsies who underwent radical retropubic prostatectomy between January 1, 1990 and July 31, 2001. Two study groups were identified, including 126 patients diagnosed with prostate cancer by extended needle biopsies (10 or more cores) and 340 diagnosed with cancer by nonextended needle biopsies (9 or fewer cores). Mean age was 60 years and median prostate specific antigen was 5.8 ng./ml. The median number of cores in the extended and nonextended biopsy groups was 12 and 6, respectively. The concordance of Gleason score in the needle biopsy and prostatectomy specimens was compared and correlated with the number of cores on needle biopsy. In the whole cohort 311 patients (67%) had identical Gleason scores on the needle biopsy and prostatectomy specimens, while 53 (11%) were over graded and 102 (22%) were under graded on needle biopsy. In patients who underwent extended needle biopsies the accuracy rate for Gleason scoring was 76% with 10% over and 14% under graded. The highest accuracy rates were in patients with 13, 14 and 16 cores (89%, 87% and 100%, respectively). No patients in the extended needle biopsy group had a discrepancy of more than 2 Gleason units in grade in the biopsy and surgical specimens. In those who underwent nonextended needle biopsies the accuracy rate for Gleason scoring was 63% with 12% over and 25% under graded. There were significantly different rates of accuracy (p = 0.008) and under grading (p = 0.01) in the 2 needle biopsy groups. Patients with a needle biopsy Gleason score of less than 7 had significantly higher concordance with the prostatectomy Gleason score when extended biopsies were done compared with nonextended biopsies (p = 0.001). Prostate cancer grading by extended needle biopsy is a better predictor of the final Gleason score than nonextended needle biopsy, as determined by radical prostatectomy histological evaluation. Therefore, extended prostate needle biopsy provides better guidance to determine the appropriate treatment in patients with prostate cancer.

Increasing the number of biopsy cores improves the concordance of biopsy Gleason score to prostatectomy Gleason score

To evaluate taking more biopsy cores for predicting the radical prostatectomy (RP) Gleason score compared with the biopsy Gleason score, as although random sextant biopsies are the standard for a tissue diagnosis of prostate cancer, and taking more biopsies increases the detection rate, it is uncertain whether taking more cores improves the prediction of the RP Gleason score. We analysed retrospectively 404 patients from three centres (Seattle 162, Washington 107 and Chicago 135) who had RP for prostate cancer. Six, eight or 10 biopsies were taken based on the physician's preference and the patient's characteristics. Before RP, 158 (39%) patients had six, 65 (16%) had eight and 181 (45%) had 10 biopsy cores taken. The accuracy of the Gleason sum of the three groups was 65/158 (41%), 26/65 (40%) and 104/181 (57.5%), respectively (P < 0.004, 10-core vs six-core). However, when comparing the Gleason score separately (i.e. 4 + 3 is not equal to 3 + 4), the accuracy of the three groups was 48/158 (30%), 20/65 (31%), and 95/181 (52.5%), respectively (P < 0.001, 10-core vs six core). Taking more biopsy cores improves the accuracy of the biopsy Gleason score in predicting the final Gleason score at RP; the predictive accuracy of the final Gleason score may be increased from 41% to 58% by increasing the number of biopsies from six to 10.

Preoperative prediction of Gleason grade in radical prostatectomy specimens: the influence of different Gleason grades from multiple positive biopsy sites

The Gleason score of prostate adenocarcinomas is an important preoperative predictor of cancer behavior, and is used to help guide treatment. In the setting of more than two positive biopsy sites, pathologists usually grade the tumor at each site separately, and the Gleason score may differ from each positive site. This study seeks to determine if the highest Gleason score in all biopsy sites, or the Gleason score in the site with the highest tumor volume on the needle biopsy is the best predictor of final Gleason score in the radical prostatectomy specimens. Various preoperative biopsy findings were analyzed. All 151 patients had at least two positive biopsy sites and underwent radical prostatectomy. Primary and secondary Gleason pattern grades were assigned for each positive biopsy site. The tumor volume in the needle biopsy site was defined by the percentage of areas of biopsy cores involved by cancer. The radical prostatectomy specimens were completely embedded and processed in the whole-mount method. The Gleason score from both the biopsy site with the highest Gleason score and the biopsy site with the highest tumor volume on the needle biopsy correlated equally well with final Gleason score at radical prostatectomy (Spearman correlation coefficient =0.54 for both, P<0.001). The Gleason score from both the biopsy site with the highest Gleason score and the biopsy site with the highest tumor volume on the needle biopsy also correlated with primary Gleason pattern grade at radical prostatectomy (Spearman correlation coefficient =0.53 for both, P<0.001). Secondary Gleason pattern grade from the biopsy site with the highest tumor volume on the needle biopsy correlated with secondary Gleason pattern grade at radical prostatectomy slightly better than those from the biopsy site with the highest Gleason score (Spearman correlation coefficient, 0.32 vs 0.24; both P<0.001). Our data indicate that the highest Gleason score from all sites and the Gleason score from the site with the highest tumor volume on the needle biopsy are equally and significantly predictive of final Gleason score on radical prostatectomy. Both methods of prediction are significantly predictive of primary and secondary Gleason pattern grade on radical prostatectomy. We recommend that the highest Gleason score from all positive biopsy sites should be used when assigning an initial score using needle biopsies.

Characterizing prostatic adenocarcinomas in men with a serum prostate specific antigen level of < 4.0 ng/mL.

To characterize prostate cancer in men undergoing radical prostatectomy who have a prostate-specific antigen (PSA) level of < 4.0 ng/mL, hypothesizing that a low PSA is not caused by diminished tumour production of PSA, nor does it signify clinically insignificant disease. Seventy-nine men (mean age 59.3 years, range 43-77) with a PSA level of < 4.0 ng/mL were identified from 702 who had a radical prostatectomy between 1994 and 2000. Demographic and clinical data were analysed; pathological specimens were evaluated by routine haematoxylin and eosin staining and immunohistochemistry with anti-PSA antibody, for both pathological staging and grading, and for the presence of PSA production. Tumours were classified as 'clinically insignificant' if the tumour volume was < 0.5 mL and the Gleason score < 7. The mean (SD, range) preoperative PSA level was 3.04 (0.85, 0.8-3.8) ng/mL Indications for biopsy included an abnormal digital rectal examination (61%), a PSA velocity of > 0.75 ng/mL/year (12%), a strong family history of prostate cancer (3%), obstructive urinary symptoms (2%), or no obvious indication (23%). Thirty-eight (48%) tumours were clinically insignificant. Of 41 clinically significant cancers, 13 had a final Gleason score of > or = 7, 20 had extraprostatic extension and 11 had a tumour volume of > or = 10 mL Of the 79 prostate cancer specimens 78 stained strongly for PSA; the exception was a Gleason 9 tumour. With a mean (range) follow-up of 3.5 (0.18-6) years only one patient had a biochemical recurrence (PSA > or = 0.1 ng/mL). Most prostate cancers in men with a PSA level of < 4.0 ng/mL are clinically significant and PSA-producing. Many of these tumours are high-grade, high-volume and extraprostatic. We are currently exploring factors to explain why serum PSA is not elevated in these men, including tumour location, pattern of invasion and microvessel density.

Location of positive surgical margins after retropubic, perineal, and laparoscopic radical prostatectomy for organ-confined prostate cancer: Salomon L, Anastasiadis AG, Levrel O, Katz R, Saint F, de la Taille A, Cicco A, Vordos D, Hoznek A, Chopin D, Abbou CC, Department of Urology, Henri Mondor Hospital, Creteil, France. Urology 2003;61:386–390

Objectives To evaluate and compare the location of positive surgical margins after retropubic, perineal, and laparoscopic radical prostatectomy for organ-confined prostate cancer (pT2). Methods From 1988 to 2001, 538 patients underwent radical prostatectomy for clinically localized prostate cancer. Patient age at surgery, clinical stage, preoperative prostate-specific antigen, and Gleason score of positive biopsies were noted. Postoperatively, specimen weight, final Gleason score, and capsular, seminal vesicle, and lymph node status, as well as tumor volume, were studied. The incidence and location of positive margins and the pathologic stage were noted according to the surgical approach. Results A total of 371 patients (69.5%) had organ-confined tumors. Of the 371 patients, 116 underwent the retropubic, 86 the perineal, and 169 the laparoscopic approach, and positive surgical margins were noted in 22 (18.9%), 12 (13.9%), and 32 (18.9%) patients, respectively. Positive surgical margins were reported in 72 specimen locations, 32 (44.4%) at the apex, 17 (23.6%) at the bladder neck, and 29 (31.9%) posterolaterally. The distribution for the retropubic, perineal, and laparoscopic approaches was apex in 50%, 33.3%, and 44.4%, bladder neck in 29.1%, 41.7%, and 13.9%, and posterolaterally in 20.8%, 25%, and 41.6%, respectively. Conclusions In our series, each approach had a specific high-risk location of positive margins: the apex for the retropubic, the bladder neck for the perineal, and posterolaterally for the laparoscopic approach. Improvements in the surgical techniques should take these specific locations under consideration to decrease the incidence of positive surgical margins.

Should each core with prostate cancer be assigned a separate gleason score?

If multiple biopsy cores contain prostate cancer with differing Gleason scores, should an overall Gleason score be assigned, or should each core be graded separately? We obtained data on 127 men with prostate cancer on needle biopsy who underwent subsequent radical prostatectomy at our institution. We compared the Gleason scores found on needle biopsy with the grade and stage (organ-confined, extra-prostatic extension, positive seminal vesicles or lymph nodes) at radical prostatectomy. On biopsy, 40 men had a pure Gleason score of 4 + 3 = 7, 25 men had a Gleason score of 4 + 3 = 7 with a Gleason score of 3 + 3 = 6 on a separate core of the biopsy specimen, 27 men had a pure Gleason score of 4 + 4 = 8, and 35 men had a Gleason score of 4 + 4 = 8 with separate cores containing Gleason pattern grade 3. A Gleason score of 4 + 4 = 8 with pattern grade 3 in other cores had a more advanced stage than a pure Gleason score of 4 + 3 = 7 ( P = 0.008). There was no clear pattern analyzing pathological stage of men with a pure Gleason score of 4 + 3 = 7 in comparison with those with Gleason scores of 4 + 3 = 7 and 3 + 3 = 6 in other cores. The group with a Gleason score of 4 + 4 = 8 and Gleason pattern grade 3 on other cores had a higher overall grade on radical prostatectomy than the group with a pure Gleason score of 4 + 3 = 7 ( P = 0.001). If one had assigned an overall Gleason score, then a biopsy with Gleason score 4 + 4 = 8 on 1 or more cores and some pattern grade 3 in other cores, would be designated as a Gleason score of 4 + 3 = 7. Based on our findings, patients with a Gleason score of 4 + 4 = 8 on one or more cores with pattern grade 3 in other cores should be given a final Gleason score of 4 + 4 = 8 instead of 4 + 3 = 7, because these patients are more likely to have higher stage and grade on radical prostatectomy, comparable to a pure Gleason score of 4 + 4 = 8. Each core should be assigned a separate Gleason score, especially in cases with high Gleason score cancer on at least 1 core.

Location of positive surgical margins after retropubic, perineal, and laparoscopic radical prostatectomy for organ-confined prostate cancer

Objectives To evaluate and compare the location of positive surgical margins after retropubic, perineal, and laparoscopic radical prostatectomy for organ-confined prostate cancer (pT2). Methods From 1988 to 2001, 538 patients underwent radical prostatectomy for clinically localized prostate cancer. Patient age at surgery, clinical stage, preoperative prostate-specific antigen, and Gleason score of positive biopsies were noted. Postoperatively, specimen weight, final Gleason score, and capsular, seminal vesicle, and lymph node status, as well as tumor volume, were studied. The incidence and location of positive margins and the pathologic stage were noted according to the surgical approach. Results A total of 371 patients (69.5%) had organ-confined tumors. Of the 371 patients, 116 underwent the retropubic, 86 the perineal, and 169 the laparoscopic approach, and positive surgical margins were noted in 22 (18.9%), 12 (13.9%), and 32 (18.9%) patients, respectively. Positive surgical margins were reported in 72 specimen locations, 32 (44.4%) at the apex, 17 (23.6%) at the bladder neck, and 29 (31.9%) posterolaterally. The distribution for the retropubic, perineal, and laparoscopic approaches was apex in 50%, 33.3%, and 44.4%, bladder neck in 29.1%, 41.7%, and 13.9%, and posterolaterally in 20.8%, 25%, and 41.6%, respectively. Conclusions In our series, each approach had a specific high-risk location of positive margins: the apex for the retropubic, the bladder neck for the perineal, and posterolaterally for the laparoscopic approach. Improvements in the surgical techniques should take these specific locations under consideration to decrease the incidence of positive surgical margins.

Extended Prostate Needle Biopsy Improves Concordance Of Gleason Grading Between Prostate Needle Biopsy And Radical Prostatectomy

We examined the concordance of Gleason scores in prostate needle biopsy specimens and the corresponding radical retropubic prostatectomy specimens in a cohort of patients grouped according to the number of cores obtained during diagnostic needle biopsy. We reviewed clinical and pathological data on a cohort of 466 men diagnosed with localized prostate cancer by needle biopsies who underwent radical retropubic prostatectomy between January 1, 1990 and July 31, 2001. Two study groups were identified, including 126 patients diagnosed with prostate cancer by extended needle biopsies (10 or more cores) and 340 diagnosed with cancer by nonextended needle biopsies (9 or fewer cores). Mean age was 60 years and median prostate specific antigen was 5.8 ng./ml. The median number of cores in the extended and nonextended biopsy groups was 12 and 6, respectively. The concordance of Gleason score in the needle biopsy and prostatectomy specimens was compared and correlated with the number of cores on needle biopsy. In the whole cohort 311 patients (67%) had identical Gleason scores on the needle biopsy and prostatectomy specimens, while 53 (11%) were over graded and 102 (22%) were under graded on needle biopsy. In patients who underwent extended needle biopsies the accuracy rate for Gleason scoring was 76% with 10% over and 14% under graded. The highest accuracy rates were in patients with 13, 14 and 16 cores (89%, 87% and 100%, respectively). No patients in the extended needle biopsy group had a discrepancy of more than 2 Gleason units in grade in the biopsy and surgical specimens. In those who underwent nonextended needle biopsies the accuracy rate for Gleason scoring was 63% with 12% over and 25% under graded. There were significantly different rates of accuracy (p = 0.008) and under grading (p = 0.01) in the 2 needle biopsy groups. Patients with a needle biopsy Gleason score of less than 7 had significantly higher concordance with the prostatectomy Gleason score when extended biopsies were done compared with nonextended biopsies (p = 0.001). Prostate cancer grading by extended needle biopsy is a better predictor of the final Gleason score than nonextended needle biopsy, as determined by radical prostatectomy histological evaluation. Therefore, extended prostate needle biopsy provides better guidance to determine the appropriate treatment in patients with prostate cancer.