Local Staging Of Prostate Cancer Research Articles

MR imaging in local staging of prostate cancer

Clinical staging to differentiate between localized and advanced disease stage appear to be unreliable. Curative therapy can only be performed in patients with localized prostate cancer. Accurate staging is therefore especially important for proper disease management. Since 1984, magnetic resonance (MR) imaging has been applied for this purpose. However, the role of MR imaging of the prostate is debated extensively in the literature. Initially, MR imaging was performed using a conventional body coil with subsequent limited anatomical detail due to insufficient spatial resolution.

11C]Choline uptake with PET/CT for the initial diagnosis of prostate cancer: relation to PSA levels, tumour stage and anti-androgenic therapy

The accuracy of positron emission tomography (PET)/CT with [(11)C]choline for the detection of prostate cancer is not well established. We assessed the dependence of [(11)C]choline maximum standardized uptake values (SUV(max)) in the prostate gland on cell malignancy, prostate-specific antigen (PSA) levels, Gleason score, tumour stage and anti-androgenic hormonal therapy. In this prospective study, PET/CT with [(11)C]choline was performed in 19 prostate cancer patients who subsequently underwent prostatectomy with histologic sextant analysis (group A) and in six prostate cancer patients before and after anti-androgenic hormonal therapy (bicalutamide 150 mg/day; median treatment of 4 months; group B). In group A, based on a sextant analysis with a [(11)C]choline SUV(max) cutoff of 2.5 (as derived from a receiver-operating characteristic analysis), PET/CT showed sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 72, 43, 64, 51 and 60%, respectively. In the patient-by-patient analysis, no significant correlation was detected between SUV(max) and PSA levels, Gleason score or pathological stage. On the contrary, a significant (P < 0.05) negative correlation was detected between SUV(max) and anti-androgenic therapy both in univariate (r (2) = 0.24) and multivariate (r (2) = 0.48) analyses. Prostate [(11)C]choline uptake after bicalutamide therapy significantly (P < 0.05) decreased compared to baseline (6.4 +/- 4.6 and 11.8 +/- 5.3, respectively; group B). PET/CT with [(11)C]choline is not suitable for the initial diagnosis and local staging of prostate cancer. PET/CT with [(11)C]choline could be used to monitor the response to anti-androgenic therapy.

Local Experience of Endorectal Magnetic Resonance Imaging of Prostate with Correlation to Radical Prostatectomy Specimens

We evaluated the accuracy of endorectal magnetic resonance imaging (MRI) in the staging of prostate cancer. We retrospectively reviewed 32 patients who underwent endorectal MR prostate prior to radical prostatectomy. The tumour stage based on MR imaging was compared with the pathologic stage. The sensitivity and specificity of endorectal MR prostate in the evaluation of extracapsular extension (ECE) of the tumour were then determined. MR correctly diagnosed 17 cases of organ-confined prostate carcinoma and 2 cases of locally advanced disease. In the evaluation of ECE, endorectal MR achieved a high specificity of 94.4%, low sensitivity of 14.3% and moderate accuracy of 59.4%. Endorectal MR prostate has high specificity for the detection of ECE. It is useful in the local staging of prostate cancer in patients with intermediate risk as this helps to ensure that few patients will be deprived of potentially curative surgery.

Prostatakarzinom - Diagnostik und Staging

Prostate cancer is the most common malignancy of men in Germany. Transrectal ultrasound (TRUS) is the primary used imaging modality. Patients with elevated PSA levels undergo systematic TRUS-guided transrectal biopsy of the prostate for histologic confirmation of prostate cancer. Magnetic resonance imaging (MRI) using the combined endorectal body phased-array coil may be indicated in men with one or more negative prostate biopsies. The detection of prostate cancer by conventional MRI can be improved by an additional dynamic contrast-enhanced MR study and proton MR spectroscopy. Local staging of prostate cancer by MRI is more accurate compared with digital rectal examination and transrectal ultrasound. However, accuracies reported in the literature for these procedures vary widely. Bone scintigraphy with 99m Tc-bisphosphonate is currently the method of choice for the detection of bone metastases. However, more recent techniques such as whole-body MRI and PET using 18 F-FDG, 11 C-choline or 11 C-acetate as tracers were found to have higher sensitivities.

Spectroscopie par résonance magnétique de la prostate

MRI spectroscopy is a non invasive method for detecting active metabolites used as markers. Chorine and citrate are used for analyzing prostate cancer. MRI spectroscopy combines morphologic imaging and metabolic cartography. This combination allows a new approach for the diagnosis of prostate cancer in patients with negative biopsy and high levels of PSA. With MRI spectroscopy the local staging of prostate cancer has a better accuracy than with MRI alone. It can also be used for the diagnosis of residual disease and recurrence in patients treated with conservative therapy.

Long-Term Survival in Men With High Grade Prostate Cancer: A Comparison Between Conservative Treatment, Radiation Therapy and Radical Prostatectomy—A Propensity Scoring Approach

We performed a retrospective cohort study using propensity score analysis to calculate long-term survival in patients with prostate cancer with Gleason score 8 or greater who were treated with conservative therapy, radiation therapy and radical prostatectomy. Between January 1, 1980 and December 31, 1997, 3,159 patients in the Henry Ford Health System were diagnosed with clinically localized prostate cancer. Of these patients 453 had a Gleason score of 8 or greater in the biopsy specimen and they were the cohort. The end points were overall and prostate cancer specific survival. Propensity score analysis was used to more precisely compare the 3 treatments of observation, radiation and radical prostatectomy. Median patient followup was longer in the radical prostatectomy arm than in the conservative treatment and radiation therapy arms (68 months vs 52 and 54, respectively). Of the 453 patients 197 (44%) were treated conservatively, 137 (30%) received radiation therapy and 119 (26%) underwent radical prostatectomy. Using propensity scoring analysis median overall survival for conservative therapy, radiation and radical prostatectomy was 5.2, 6.7 and 9.7 years, respectively. Median cancer specific survival was 7.8 years for conservative therapy and more than 14 years for radiation therapy and radical prostatectomy. The risk of cancer specific death following radical prostatectomy was 68% lower than for conservative treatment and 49% lower than for radiation therapy (p<0.001 and 0.053, respectively). Survival of men with high grade prostate cancer can be improved by radical prostatectomy or radiation therapy.

Sentinel Lymph Node Dissection for Prostate Cancer: Experience With More Than 1,000 Patients

We determined the incidence of positive pelvic lymph nodes in men undergoing radical retropubic prostatectomy and describe the correlation with prostate specific antigen, histological grade and stage. We examined whether tumor cells are localized in the sentinel nodes only or also in other nonsentinel lymph nodes. A total of 1,055 men with prostate cancer underwent radio guided pelvic lymph node dissection and radical retropubic prostatectomy. In men with prostate specific antigen 20 ng/ml or less and biopsy Gleason score 7 or less only sentinel nodes were removed. In men with prostate specific antigen more than 20 ng/ml or Gleason score greater than 7 extended pelvic lymph node dissection was also performed. Positive lymph nodes were found in 207 men (19.6%). In 63.3% of the men these lymph nodes were detected outside of the region of standard lymphadenectomy. The percent of patients with positive nodes was greater than predicted by currently used nomograms. The higher the preoperative prostate specific antigen, pathological stage and grade, the greater the percent of men with positive sentinel and nonsentinel lymph nodes (p<0.001). When deciding on pelvic lymph node dissection, sentinel or extended lymphadenectomy should be performed since more than half of patients have positive nodes outside of the region of standard lymphadenectomy. In cases of positive sentinel nodes extended lymph node dissection should be performed since tumor cells are also detectable in nonsentinel lymph nodes.

Ecografía tridimensional de próstata

To present the examination technique of grayscale tridimensional transrectal prostatic ultrasound and its clinical viability. To define the ultrasonographic patterns and to report the clinical experience of our group.We analyze selected exams from a database of more than 600 digitally stored tridimensional transrectal prostatic ultrasounds performed with a robotic probe. We collect the opinion and observations of the examiners, all of them experts on prostatic ultrasound. Each case has been completed with pathologic and clinical data.The time spent for each test was less than three minutes, achieving good quality, reproducible exams. The analysis of the front view offers the greatest contribution in comparison to the conventional technique, allowing a more clear detection of structures such as the junction with the seminal vesicles, the capsular contour, and urethra.Tridimensional transrectal prostatic ultrasound is an imaging test applicable in the clinical practice which offers quality images and may provide great benefits for the diagnosis and local staging of prostate cancer, by means of the analysis of the front view.

Evidence to Support a Continued Stage Migration and Decrease in Prostate Cancer Specific Mortality

We evaluated whether the proportion of patients with a postoperative PSA-DT less than 3 months, a surrogate for PCSM, decreased significantly during the PSA era. Between July 1988 and July 2002, 3,719 men with clinically localized prostate cancer treated with RP comprised the study cohort. A chi-square metric was used to compare the preoperative and postoperative characteristics, 5-year actual PSA failure rates, and PSA-DTs for patients treated during the 2 equally divided eras of the early PSA era, July 1988 to July 1995 and the late PSA era, August 1995 to July 2002. Patients presenting in the more recent PSA era were of younger age (p < 0.0001), with earlier stage (p < 0.0001) and lower grade disease (p = 0.01). Similarly, patients had lower grade (p < 0.001), stage (p < 0.0001), and positive margin (p < 0.0001) and lymph node rates (p = 0.0002) at RP. The 5-year actual PSA failure rates decreased from 14.3% in the early PSA era to 2.5% in the later PSA era (p < 0.0001). There was a 37% reduction in the proportion of patients with a PSA-DT less than 3 months, corresponding to a decrease in absolute magnitude from 9% to 5.7% between the 2 eras. Absolute reductions of 3.1% and 9% were also noted for the proportion of PSA-DTs of 3 to 5.99 months and 6 to 11.99 months, respectively, whereas PSA-DTs of 12 months or greater increased by 15.3%. During the recent PSA era, postoperative PSA failure has significantly decreased and PSA-DTs have increased, suggesting that PCSM will continue to decrease.

Classification of pathological stage of prostate cancer patients using penalized splines

We propose a penalized splines (P-splines) based method to predict the pathological stage of localized prostate cancer. A combination of prostate-specific antigen, Gleason histological score, and clinical stage from a cohort study of 834 prostate cancer patients are used to build the P-splines model. It turns out that the proposed methodology results in improved prediction of pathological stage compared to usual logistic regression after removing a few outliers. The improvement is shown to be statistically significant. Receiver-operating characteristic (ROC) curve is drawn and we show that the increase in area under the ROC curve over the commonly used logistic regression based classification method is also statistically significant.

LOW SERUM TESTOSTERONE LEVELS ARE ASSOCIATED WITH POSITIVE SURGICAL MARGINS IN RADICAL RETROPUBIC PROSTATECTOMY: HYPOGONADISM REPRESENTS BAD PROGNOSIS IN PROSTATE CANCER

It has been reported that more aggressive prostate cancer (PC) can be associated with low serum testosterone levels. The relationship between serum androgens and PC is still not completely understood. In this study we examined the association of prognostic factors in men who underwent radical retropubic (RRP) prostatectomy with low or normal total testosterone. We retrospectively evaluated 64 consecutive patients with localized PC treated with RRP between July 2002 and November 2003. PC was diagnosed by transrectal ultrasonography guided biopsy performed for either a suspicious digital rectal examination or serum prostate specific antigen greater than 4.0 ng/ml. Gleason score was determined in prostatic biopsies. Pathological TNM staging (1997), capsular perforation, seminal vesicle involvement and surgical margin status were determined in all surgical specimens. The threshold for serum total testosterone was 270 ng/dl. In all analyses p <0.05 was considered statistically significant. There were no statistically significant differences among prostate specific antigen, Gleason score (biopsy or specimen), pathological stage, capsular perforation and seminal vesicle involvement. However, patients with low total testosterone had increased positive surgical margins (p = 0.026). Patients with low total testosterone more frequently present with positive surgical margins in RRP specimens. The true association between low testosterone and poor clinical outcome in the long term needs validation in large prospective studies.

MRI of Prostate Cancer at 1.5 and 3.0 T: Comparison of Image Quality in Tumor Detection and Staging

This prospective study was performed to compare the image quality, tumor delineation, and depiction of staging criteria on MRI of prostate cancer at 1.5 and 3.0 T. Twenty-four patients with prostate cancer underwent MRI at 1.5 T using the combined endorectal-body phased-array coil and at 3.0 T using the torso phased-array coil, among them 22 before undergoing radical prostatectomy. The prostate was imaged with T2-weighted sequences in axial and coronal orientations at both field strengths and, in addition, with an axial T1-weighted sequence at 1.5 T. Preoperative analysis of all MR images taken together was compared with the histologic findings to determine the accuracy of MRI for the local staging of prostate cancer. In a retroanalysis, the image quality, tumor delineation, and conspicuity of staging criteria were determined separately for both field strengths and compared. Statistical analysis was performed using Wilcoxon's and the McNemar tests. In the preoperative analysis, MRI (at both 1.5 and 3.0 T) had an accuracy of 73% for the local staging of prostate cancer. The retroanalysis yielded significantly better results for 1.5-T MRI with the endorectal-body phased-array coil in terms of image quality (p < 0.001) and tumor delineation (p = 0.012) than for 3.0-T MRI with the torso phased-array coil. Analysis of the individual staging criteria for extracapsular disease did not reveal a superiority of either of the two field strengths in the depiction of any of the criteria. Intraindividual comparison shows that image quality and delineation of prostate cancer at 1.5 T with the use of an endorectal coil in a pelvic phased-array is superior to the higher field strength of 3.0 T with a torso phased-array coil alone. As long as no endorectal coil is available for 3-T imaging, imaging at 1.5 T using the combined endorectal-body phased-array coil will continue to be the gold standard for prostate imaging.

DETECTION OF EARLY LYMPH NODE METASTASES IN PROSTATE CANCER BY LAPAROSCOPIC RADIOISOTOPE GUIDED SENTINEL LYMPH NODE DISSECTION

Radioisotope guided sentinel lymph node (SLN) dissection (SLND) for prostate cancer has been shown to increase the sensitivity of detecting early metastases in open pelvic lymph node dissection. We developed a technique that allows SLND to be performed by laparoscopy in conjunction with laparoscopic radical prostatectomy. In 71 consecutive patients SLND was performed by 1 surgeon preceding laparoscopic radical prostatectomy. Mean preoperative prostate specific antigen was 8.88 ng/ml (range 2.1 to 25.4). At 24 hours prior to surgery 3 ml (200 MBq) Tc labeled human albumin colloid were injected into the prostate gland under transrectal ultrasound guidance. An especially designed laparoscopic gamma probe was used to measure radioactivity during surgery. SLNs were identified and removed. If frozen section analysis showed metastases, extended pelvic lymph node dissection was performed. Radioactivity was detected on 2, 1 and no sides in 50 (70.4%), 19 (26.7%) and 2 patients (2.8%), respectively. In 81 of the 142 pelvic side walls (54.7%) SLNs were exclusively outside of the obturator fossa. Histopathological examination showed metastases to SLNs in 9 patients (12.9%). Eight of the 11 detected metastases (72.7%) were outside of the obturator fossa. Lymph node metastases were exclusively found in Tc marked lymph nodes. Mean tumor size was 1.7 mm (range 0.2 to 3.9). SLND is feasible by laparoscopy. It detects micrometastases outside of the obturator fossa in a significant number of patients. We noted that the transperitoneal approach allowing wide exposure and a gamma probe with a 90-degree lateral energy window is the most important factor to enable successful laparoscopic SLND.

ULTRASENSITIVE SERUM PROSTATE SPECIFIC ANTIGEN NADIR ACCURATELY PREDICTS THE RISK OF EARLY RELAPSE AFTER RADICAL PROSTATECTOMY

Ultrasensitive prostate specific antigen (PSA) assays allow a lower limit of detection (less than 0.01 ng/ml) than standard PSA assays. In this study we examined the ability of ultrasensitive PSA nadir to predict relapse after radical prostatectomy (RP). A total of 906 men treated with RP were followed with PSA measurements at 3, 6 and 12 months, and yearly thereafter. Of the 906 men 545 (60%) with a PSA nadir of less than 0.01 ng/ml or at least 3 followup ultrasensitive PSA measurements underwent analysis and stratification by PSA nadir. Biochemical relapse was defined as 2 consecutive increasing post-nadir PSA measurements of 0.1 ng/ml or greater. The ability of ultrasensitive PSA nadir to predict relapse was assessed by univariate and multivariate analysis. At a mean followup of 3.1 years 54 of 545 men (9.9%) experienced biochemical relapse with a mean time to relapse of 25.2 months. Relapse rates in men with a PSA nadir of less than 0.01 (423), 0.01 (75), 0.02 (19) and 0.04 or greater ng/ml (28) were 4%, 12%, 16% and 89%, respectively. Men with a nadir of less than 0.01 ng/ml had a significantly lower relapse rate than men with a nadir of 0.01 (p <0.01), 0.02 (p <0.025) or 0.04 or greater ng/ml (p <0.01). Multivariate logistic regression analysis showed that a nadir of 0.01 (p <0.05), 0.02 (p <0.05) and 0.04 or greater ng/ml (p <0.01) independently predicted an increased risk of biochemical relapse compared to a nadir of less than 0.01 ng/ml. Ultrasensitive PSA nadir accurately predicts the risk of early biochemical relapse following RP. Men who achieve a nadir of less than 0.01 ng/ml have a low likelihood of early relapse. Higher nadir points may identify candidates for early adjuvant or salvage therapies.

High-dose-rate intensity-modulated brachytherapy with external beam radiotherapy for prostate cancer: California endocurietherapy’s 10-year results

To present the long-term outcome and morbidity of high-dose-rate brachytherapy (HDR-BT) combined with external beam radiotherapy (EBRT) for localized prostate cancer. Between September 1991 and December 1998, 209 consecutive patients with no prior androgen suppression were treated with HDR-BT plus EBRT. The median follow-up was 7.25 years (range, 5-12 years). The patients were stratified into three risk groups: low (Stage T2a or less, Gleason score </=6, and prostate-specific antigen [PSA] level </=10 ng/mL), intermediate (Stage T2b,c, Gleason score 7, and PSA level 10-20 ng/mL), and high (Stage T3, Gleason score 8-10, and PSA level >20). Four definitions of PSA progression were compared with the general clinical failure outcome: the American Society for Therapeutic Radiology and Oncology (ASTRO) definition, nadir plus 2.0 ng/mL, two consecutive rises >/=0.5 ng/mL, and PSA level >0.2 ng/mL. Morbidity was scored using Radiation Therapy Oncology Group criteria. The general clinical control rate was 90% (188 of 209), and the general clinical failure rate was 10% (21 of 209). The overall survival rate was 79%, and the cause-specific survival rate was 97%. The PSA progression-free survival (ASTRO definition) rate was 90%, 87%, and 69% for the low-, intermediate-, and high-risk groups, respectively. The nadir plus 2 ng/mL and two rises >/=0.5 definitions correlated better with the actual clinical outcome than did the ASTRO and PSA >0.2 ng/mL definitions. The rate of Grade 3 and 4 late urinary morbidity was 6.7% and 1%, respectively, mostly occurring in patients who had undergone post-RT transurethral prostate resection. No late Grade 3 or 4 rectal morbidity developed. The sexual potency preservation rate was 67%. Our 10-year results have demonstrated HDR-BT plus EBRT is a proven treatment for all stages of localized prostate cancer. The morbidity was low, but post-RT transurethral resection should be avoided.

Nomograms for the Prediction of Pathologic Stage of Clinically Localized Prostate Cancer in Korean Men

We analyzed the prostate cancer data of 317 Korean men with clinically localized prostate cancer who underwent radical prostatectomy at Asan Medical Center between June 1990 and November 2003 to construct nomograms predicting the pathologic stage of these tumors, and compared the outcome with preexisting nomograms. Multinomial log-linear regression was performed for the simultaneous prediction of organ-confined disease (OCD), extracapsular extension (ECE), seminal vesicle invasion (SVI) and lymph node metastasis (LNM) using serum prostate-specific antigen (PSA), Gleason score and clinical stage. Nomograms representing percent probabilities were constructed and compared with those presented by Partin et al. by calculating areas under the receiver operating characteristics (ROC) curves. Median serum PSA at surgery was 10.8 ng/mL, and median biopsy Gleason score was 7. Overall OCD, ECE, SVI and LNM rates were 59.6%, 20.5%, 11.7% and 8.2%, respectively, and areas under the curves were 0.724, 0.626, 0.662, and 0.794, respectively. Pathologic stage of localized prostate cancer in Korean men may be predicted using the Partin table, with acceptable accuracy for OCD and LNM, but less so for ECE and SVI.

ACCURACY OF PROSTATE WEIGHT ESTIMATION BY DIGITAL RECTAL EXAMINATION VERSUS TRANSRECTAL ULTRASONOGRAPHY

The ability to estimate prostate weight is useful. Two commonly used methods for estimating prostate weight are digital rectal examination (DRE) and transrectal ultrasonography (TRUS). We evaluated the relative accuracy of these weight estimates by comparing them to prostate weight following radical retropubic prostatectomy (RRP). Between 1989 and 2001 more than 36,000 community men participated in a large prostate cancer screening study. Of these men 2,238 underwent RRP. In this subset we examined the correlation between documented preoperative DRE and TRUS estimates of prostate weight with actual gland weight. DRE estimates of prostate weight by multiple examiners correlated poorly with RRP specimen weight (r = 0.2743). However, TRUS estimates correlated moderately well (r = 0.6493). TRUS provided more accurate estimates of prostate weight for smaller glands, although it generally underestimated gland weight compared to the weight of the surgical specimen. In a large, community based prostate cancer screening study prostate weight estimated by DRE was shown to correlate poorly with actual prostate weight. Compared with DRE, TRUS provides a better estimate of prostate weight. In addition, TRUS measurements were more accurate in smaller prostate glands.

Three dimensional ultrasound and prostate cancer

Three-dimensional ultrasound (3-D US) is a non-invasive method of producing whole volume images of solid structures. Early work on prostate imaging identified several advantages over 2-D imaging with a good ability to detect intraprostatic lesions. Several 3-D transrectal ultrasound (3-D TRUS) systems are now available for prostate imaging. Initial work using gray scale ultrasound appears promising with reported overall staging accuracies of up to 94%. These results were favourable when compared to other modalities for local staging of prostate cancer. Several adjuncts to 3-D gray scale TRUS have been investigated. A greater sensitivity for cancer detection has been achieved with the addition of power colour Doppler and contrast agents. Further clinical applications for 3-D TRUS include assessing placement of brachytherapy seeds and for cyroablation techniques. Computer enhancement with image registration has shown that 3-D US images can be manipulated to derive more information. Although the results of gray scale imaging alone or with adjuncts and post processing appear promising, these techniques remain largely experimental.

Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer--a multi-institutional update

Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer--a multi-institutional update

Local staging of prostate cancer with endorectal surface coil MR imaging in a mid-field magnetic system

To investigate the accuracy of endorectal surface coil magnetic resonance imaging (ecMRI) in a 1.0-T magnetic field for the local staging of prostate cancer, 25 patients were studied. In 14 Stages T1 and T2 tumors, 11 were correctly identified and 3 were overstaged. In 11 Stage T3 neoplasms, ecMRI was accurate in 7 cases, and the other 4 were understaged. The overall accuracy of ecMRI in 1.0 T was 72% and that was comparable to the reported accuracy of this technique in high-field systems.