Multiple Positive Cores Research Articles

MP05-16 WHAT IS THE DEFINITION OF MISCLASSIFICATION IN PATIENTS WITH GRADE GROUP 2 PROSTATE CANCER ELIGIBLE FOR ACTIVE SURVEILLANCE AND DIAGNOSED WITH MRI TARGETED BIOPSY? A MULTI-INSTITUTIONAL ANALYSIS WITH PATHOLOGICAL CONFIRMATION

MP05-16 WHAT IS THE DEFINITION OF MISCLASSIFICATION IN PATIENTS WITH GRADE GROUP 2 PROSTATE CANCER ELIGIBLE FOR ACTIVE SURVEILLANCE AND DIAGNOSED WITH MRI TARGETED BIOPSY? A MULTI-INSTITUTIONAL ANALYSIS WITH PATHOLOGICAL CONFIRMATION

Proportion of cores with the highest Gleason grade group among positive cores on prostate biopsy: does this affect the probability of upgrading or downgrading?

Purpose: This study assessed the ability to predict the probability of pathologic upgrading or downgrading based on the proportion of cores with the highest Gleason grade on prostate biopsy.Materials and methods: From 2002–2017, 494 patients with multiple positive cores on prostate biopsy who underwent radical prostatectomy were included for the analysis. The proportion of cores with the highest Gleason grade group among positive cores was calculated and patients were divided into three groups based on the proportion (≤33% vs >33% and ≤67% vs >67%).Results: Tumor characteristics, including PSA level, biopsy Gleason grade, preoperative MR imaging, pathologic grade, pathologic stage and tumor volume, were worse in patients with a highest Gleason grade proportion, ≤33%. Upgrading (5.6% vs 15.0% vs 39.4%, p < 0.001) was more common in patients with a higher highest Gleason grade proportion, while downgrading (51.7% vs 35.3% vs 7.2, p < 0.001) was more common in patients with a lower highest Gleason grade proportion. On multivariate analysis, the highest Gleason grade proportion was a significant predictor for upgrading and downgrading in addition to other clinical variables. The areas under the curve for models predicting upgrading (0.784 vs 0.768, p = 0.009) and downgrading (0.746 vs 0.717, p = 0.017), which incorporating the highest Gleason grade proportion, were significantly higher than models without the highest Gleason grade proportion.Conclusions: The proportion of cores with the highest Gleason grade is a readily available novel parameter for calculating the probability of upgrading or downgrading.

MP03-04 DOES THE INCLUSION OF NON-INDEX LESIONS AT BIOPSY IMPROVE OUR ABILITY TO PREDICT ADVERSE PATHOLOGIC OUTCOMES AT RADICAL PROSTATECTOMY? IMPLICATIONS FOR TARGETED PLUS SYSTEMATIC BIOPSY SCHEMES

You have accessJournal of UrologyProstate Cancer: Detection & Screening I1 Apr 2017MP03-04 DOES THE INCLUSION OF NON-INDEX LESIONS AT BIOPSY IMPROVE OUR ABILITY TO PREDICT ADVERSE PATHOLOGIC OUTCOMES AT RADICAL PROSTATECTOMY? IMPLICATIONS FOR TARGETED PLUS SYSTEMATIC BIOPSY SCHEMES Giorgio Gandaglia, Marco Bandini, Paolo Dell'Oglio, Nicola Fossati, Francesco Pellegrino, Giuseppe Fallara, Emanuele Zaffuto, Carlo Andrea Bravi, Luigi Nocera, Rocco Damiano, Massimo Freschi, Rodolfo Montironi, Francesco Montorsi, and Alberto Briganti Giorgio GandagliaGiorgio Gandaglia More articles by this author , Marco BandiniMarco Bandini More articles by this author , Paolo Dell'OglioPaolo Dell'Oglio More articles by this author , Nicola FossatiNicola Fossati More articles by this author , Francesco PellegrinoFrancesco Pellegrino More articles by this author , Giuseppe FallaraGiuseppe Fallara More articles by this author , Emanuele ZaffutoEmanuele Zaffuto More articles by this author , Carlo Andrea BraviCarlo Andrea Bravi More articles by this author , Luigi NoceraLuigi Nocera More articles by this author , Rocco DamianoRocco Damiano More articles by this author , Massimo FreschiMassimo Freschi More articles by this author , Rodolfo MontironiRodolfo Montironi More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , and Alberto BrigantiAlberto Briganti More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.121AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Although prostate biopsies targeted only to MRI detected lesions allow for the detection of clinically significant diseases, they would not result into a complete sampling of the entire prostate. Therefore, lower grade tumors (i.e., non-index lesions) in other areas would not be detected. We hypothesized that the presence of non-index lesions might impact on the risk of adverse outcomes at radical prostatectomy (RP). METHODS 761 PCa patients treated with RP between 2012 and 2016 were identified. All biopsy specimens were re-reviewed by two high-volume dedicated uro-pathologists. The index lesion was defined as the highest-grade core at biopsy. When multiple positive cores were present, the index lesion was defined as higher-grade disease or higher number of positive cores with higher-grade disease from the same location. Non-index lesions were defined as lower grade or lower number of positive cores in other areas. Multivariable logistic regression (MVA) analyses tested the impact of the non-index lesions and of the number of positive non-index lesion cores on the risk of extracapsular extension (ECE), seminal vesicle involvement (SVI), and positive surgical margins (PSM). AUC of the models without information on the presence of non-index lesions were compared with full models using the DeLong method. RESULTS Overall, 284 (37.5%), 83 (10.9%), and 145 (19.1%) patients had ECE, SVI, and PSM at final pathology. At MVA, the presence of non-index lesions was a predictor of ECE (Odds ratio [OR]: 2.12; P=0.001), SVI (OR: 2.75; P=0.02), and PSM (OR: 2.16; P=0.01). Similarly, the number of positive cores in the non-index lesion was associated with the risk of ECE (OR: 1.09; P=0.02), SVI (OR: 1.13; P<0.001), and PSM (OR: 1.07; P=0.01). The inclusion of information on non-index lesions improved the accuracy of the model predicting PSM (AUC: 67.0 vs. 69.4%; P=0.04). No differences in the AUCs of the base model and of the model including the presence of non-index lesions were observed for ECE (78.8 vs. 78.6%; P=0.7) and SVI (81.5 vs. 82.1%; P=0.3). CONCLUSIONS The presence of non-index lesions and the number of positive cores in the non-index lesion represent predictors of ECE, SVI, and PSM. The inclusion of these parameters improves our ability to identify patients at higher risk of PSM. A systematic sample of the prostate provides useful preoperative information on the risk of adverse pathologic outcomes and should be always considered in association with targeted biopsies. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e20 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Giorgio Gandaglia More articles by this author Marco Bandini More articles by this author Paolo Dell'Oglio More articles by this author Nicola Fossati More articles by this author Francesco Pellegrino More articles by this author Giuseppe Fallara More articles by this author Emanuele Zaffuto More articles by this author Carlo Andrea Bravi More articles by this author Luigi Nocera More articles by this author Rocco Damiano More articles by this author Massimo Freschi More articles by this author Rodolfo Montironi More articles by this author Francesco Montorsi More articles by this author Alberto Briganti More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Chronic Inflammation in Prostate Biopsy Cores is an Independent Factor that Lowers the Risk of Prostate Cancer Detection and is Inversely Associated with the Number of Positive Cores in Patients Elected to a First Biopsy

Objectives: To investigate associations of chronic inflammatory infiltrate (CII) with prostate cancer (PCa) risk and the number of positive cores in patients elected to a first set of biopsies. Materials and Methods: Excluding criteria were as follows: active surveillance, prostate specific antigen (PSA) ≥ 30 ng/l, re-biopsies, incidental PCa, less than 14 cores, metastases, or 5-alpha reductase inhibitors. The cohort study was classified as negative (control group) and positive cores between 1 and 2 or > 2. Results: The cohort included 421 cases who did not meet the exclusion criteria. PCa was detected in 192 cases (45.6%) of which the number of positive cores was between 1 and 2 in 77 (40.1%) cases. The median PSA was 6.05 ng/ml (range 0.3-29 ng/ml). Linear regression models showed that CII was an independent predictor inversely associated with the risk of PCa. Multinomial logistic regression models showed that CII was an independent factor that was inversely associated with PCa risk in cases with positive cores between 1 and 2 (OR = 0.338; p = 0.004) or more than 2 (OR = 0.076; p < 0.0001) when compared to the control group. Conclusion: In a cohort of men undergoing the first biopsy set after prostate assessment, the presence of CII in the biopsy core was an independent factor inversely associated with PCa risk as well as with the number of positive biopsy cores (tumor extension). Clinically, the detection of CII in negative biopsy cores might reduce the risk of PCa in repeat biopsies as well as the probability of detecting multiple positive cores.

Multiple cores of Gleason score 6 correlate with favourable findings at radical prostatectomy

To establish whether the good prognosis of Gleason score 6 (GS6) is maintained in the setting of multiple involved cores. In total, 6156 men (from 1 April 2000 to 30 April 2007) with GS6 on biopsy underwent radical prostatectomy (RP) at our institution. The number of positive cores was correlated with the outcome at RP. More positive cores correlated with less organ-confined disease (P < 0.001), positive margins (P < 0.012), increasing RP grade (P < 0.001) and increased seminal vesicles/lymph node involvement (P = 0.012). For men with data available, the actuarial risk of being biochemically free of disease at 5 years was 93.2% when ≤6 cores were positive (812 men followed to 5 years) vs 89.1% if >6 cores were positive (41 men followed to 2 years) (P = 0.6). Although the predicted 'cure rate' of >75% probability of a tumour showing no evidence of biochemical recurrence at 10 years after RP was statistically different between cases with ≤6 vs >6 positive cores (P < 0.0001), the outcome in both groups was still favourable (90.5% vs 84%). Partin-like tables were generated factoring in the number of positive cores to predict organ-confined disease as a guide for urologists to perform nerve-sparing surgery. For example, with T1c disease, there was a ≥75% probability of organ-confined disease with one to three positive cores regardless of prostate-specific antigen (PSA) level, and the same probability was present with four to six positive cores and a PSA level of 0-4 ng/mL. A low Gleason score on biopsy is a powerful prognostic finding, such that this favourable outcome is maintained even in the setting of multiple positive cores with GS6.

Prediction of pathological and oncological outcomes based on extended prostate biopsy results in patients with prostate cancer receiving radical prostatectomy: a single institution study

BackgroundThe prediction of pathological outcomes prior to surgery remains a challenging problem for the appropriate surgical indication of prostate cancer. This study was performed to identify preoperative values predictive of pathological and oncological outcomes based on standardized extended prostate biopsies with core histological results diagrammed/mapped in patients receiving radical prostatectomy for prostate cancer clinically diagnosed as localized or locally advanced disease.MethodsIn 124 patients with clinically localized or locally advanced prostate cancer (cT1c–cT3a) without prior treatment, pathological outcomes on the surgical specimen including seminal vesicle involvement (SVI), positive surgical margin (PSM), and perineural invasion (PNI) were studied in comparison with clinical parameters based on the results of 14-core prostate biopsies comprising sextant, laterally-directed sextant, and bilateral transition zone (TZ) sampling.ResultsConcerning the association of pathological outcomes with oncological outcomes, patients with PSM and PNI on surgical specimens had poorer biochemical-progression-free survival than those without PSM (logrank p = 0.002) and PNI (p = 0.003); it was also poorer concerning SVI, although the difference was not significant (p = 0.120). Concerning the impact of clinical parameters on these pathological outcomes, positive TZ and multiple positive biopsy cores in the prostatic middle were independent values predictive of SVI with multivariate analyses (p = 0.020 and p = 0.025, respectively); both positive TZ and multiple positive prostatic middle biopsies were associated with larger tumor volume (p < 0.001 in both). The percentage of positive biopsy cores (%positive cores) and biopsy Gleason score were independent values predictive of PSM (p = 0.001) and PNI (p = 0.001), respectively. Multiple positive cores in the prostatic base were associated with proximal/bladder-side PSM (p < 0.001), and also linked to poorer biochemical-progression-free survival (p = 0.004). Clinical T stage had no association with these pathological outcomes.Conclusions%positive cores and Gleason score in extended biopsies were independent values predictive of PSM and PNI in prostate cancer clinically diagnosed as localized or locally advanced disease, respectively, which were associated with poorer oncological outcomes. When diagramming biopsy-core results, extended biopsy may provide additional information for predicting oncological and pathological outcomes including SVI in patients clinically diagnosed as having localized or locally advanced disease.Virtual slidesThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/8790262771042628

Single Positive Core Prostate Cancer in a 12-Core Transrectal Biopsy Scheme: Clinicopathological Implications Compared with Multifocal Counterpart

PurposeThe incidence of single positive core prostate cancer at the time of biopsy appears to be increasing in the prostate-specific antigen (PSA) era. To determine the clinical implication of this disease, we analyzed surgical and pathological characteristics in comparison with multiple positive core disease.Materials and MethodsAmong 108 consecutive patients who underwent robotic radical prostatectomy following a diagnosis of prostate cancer based on a 12-core transrectal biopsy performed by the same method in a single institute, outcomes from 26 patients (Group 1) diagnosed on the basis of a single positive biopsy core and from 82 patients (Group 2) with multiple positive biopsy cores were analyzed.ResultsThe preoperative PSA value, Gleason score, prostate volume, and D'Amico's risk classification of each group were similar. The proportion of intermediate+highrisk patients was 69.2% in Group 1 and 77.9% in Group 2 (p=0.22). Total operative time and blood loss were similar. Based on prostatectomy specimens, only 3 patients (11.5%) in Group 1 met the criteria for an indolent tumor (7.31% in Group 2). Although similarities were observed during preoperative clinical staging (p=0.13), the final pathologic stage was significantly higher in Group 2 (p=0.001). The positive-margin rate was also higher in Group 2 (11.5% vs. 31.7%, p=0.043). Despite similarity in upstaging after prostatectomy in each group (p=0.86), upgrading occurred more frequently in Group 1 (p=0.014, 42.5% vs. 19.5%). No clinical parameters were valuable in predicting upgrading.ConclusionsMost single positive core prostate cancer diagnoses in 12-core biopsy were clinically significant with similar risk stratification to multiple positive core prostate cancers. Although the positive-margin rate was lower than in multiple positive core disease, an increase in Gleason score after radical prostatectomy occurred more frequently.

MP-21.05: Overall and the Highest-Core Gleason Score for Prostate Biopsy Specimens

For prostate biopsy specimens with multiple positive cores showing different Gleason grade, the 2005 International Society of Urological Pathology (ISUP) consensus recommended to assign individual Gleason score (GS) to each core for selecting the highest-core score with the option to give an overall score. We investigated the significance of biopsy GS, overall score (OGS) or the highest-core score (HGS), for distribution and prediction of pathological features of radical prostatectomy (RP) specimens.

Prostate Saturation Biopsy in the Reevaluation of Microfocal Prostate Cancer

We evaluated the ability of an extended, 32-core repeat transrectal ultrasound prostate biopsy protocol to improve the characterization of low volume, well differentiated disease in men with a diagnosis of potentially insignificant microfocal prostate cancer, as defined by 1 single focus positive core of 10 with less than 5 mm of Gleason score 6 or less tumor on primary biopsy. A total of 35 consecutive patients, who were 62 to 75 years old, had a median serum prostate specific antigen of 8 ng/ml (range 0.5 to 14) and a diagnosis of minimal prostate cancer, and were willing to consider observation with delayed treatment at progression, were offered repeat saturation prostate biopsy with a median of 32 cores (range 18 to 36) under local anesthesia. This biopsy was to determine whether more extensive prostate sampling would confirm or disprove the initial diagnosis of microfocal, well differentiated prostate cancer. The procedure was aborted in 1 patient because of massive rectal hemorrhage. Another patient had acute prostatitis with gram-negative sepsis. Of 34 evaluable biopsy sets 11 (32%) were negative for cancer, suggesting that tumor detected at the primary biopsy was probably of low volume and amenable to observation with delayed treatment. Of the biopsies 23 (68%) were positive, 17 were at multiple sites and 7 were upgraded to Gleason score 7 or greater. These patients were then considered to have significant tumors and were offered active treatment. This study is to our knowledge the first to describe the clinical use of prostate saturation biopsies for re-evaluating potentially insignificant prostate cancer. Of patients with minimal disease on standard 10-core biopsy, results show that this technique may be helpful for distinguishing the 30% who probably have minimal disease based on negative repeat saturation biopsy from the 70% who almost certainly have a significant tumor, as characterized by multiple positive cores, with or without an increased Gleason score. The latter patients should be offered active therapy.

Prostate needle biopsy reporting: how are the surgical members of the Society of Urologic Oncology using pathology reports to guide treatment of prostate cancer patients?

Recent trends in prostate needle biopsy reporting have resulted in the inclusion of more information and new diagnostic categories. The goal of the current study was to survey surgical Members of the Society of Urologic Oncology to determine what information academic urologists consider important in the management of their prostate cancer (PCa) patients. A questionnaire was developed to investigate several areas of PCa biopsy reporting, which vary from institution to institution. Urologists were sent questionnaires and asked to return anonymous responses; 42 questionnaires were completely evaluated with a response rate of 76% (42 of 55). The urologists targeted for this survey were highly experienced with an average of 22 years in clinical practice (range, 6-35 years). On average, they performed 92 radical prostatectomies per year and 449 over the past 5 years (range, 60-1500) for a group total of 18,840 radical prostatectomies; 94% have their patient's biopsy reviewed prior to surgery. The primary and secondary Gleason pattern was required by 60% (25 of 42) of the respondents. In prostate needle biopsies containing only a single minute focus of PCa, only 41% (17 of 42) of respondents would request a Gleason score if not provided in the initial report. Interestingly, in biopsies with multiple positive cores from separate locations, 81% (34 of 42) use the highest Gleason score, regardless of the overall percentage involvement, to determine their treatment plan. Other pathology parameters requested by the respondents in descending order included: % involvement of the core by PCa (67%), the presence or absence of perineural invasion (38%), the number of cores with PCa (33%), and the length of core involvement (29%). Only 24% (10 of 42) of respondents use perineural invasion status to guide nerve-sparing surgery. The more radical prostatectomies performed by a surgeon, the greater the likelihood that they considered perineural invasion clinically important (Mann-Whitney, two-tailed, P = 0.015). The term atypical small acinar proliferation was uniformly considered sufficient to re-biopsy by 98% (41 of 42) of the urologists. This is the first study to survey urologists as to what information they require from prostate needle biopsy reports in their treatment planning of men with clinically localized PCa. With the exception of Gleason score, the use of detailed pathology information was variably used to guide treatment. PNI was not considered important by the majority of respondents. In contrast, atypical small acinar proliferation, a more recent diagnostic category, was recognized as important by nearly all respondents. Knowledge of how pathology biopsy reports are being used should help evaluate what data should be uniformly part of standard biopsy pathology report and help improve communication between pathologists and urologists.

Significance of preoperative parameters for predicting tumor volume in nonpalpable prostate cancer.

Preoperative parameters were assessed for their usefulness in predicting tumor volume in 26 cases of nonpalpable prostate cancer. The number of positive biopsy cores was found to be the parameter which predicted most accurately tumor volume in surgical specimens. All 14 patients with multiple positive cores had an index tumor of 0.5 cm3 or more in radical prostatectomy specimens. Only six tumors with a single positive core were substantial. Three of the patients showed a serum level of prostate specific antigen (PSA) of 4.0 ng/ml or more. The pathological stage and prostatectomy Gleason sum could not be predicted accurately by this variable (P>0.05). To predict index tumor volumes of 1.0 cm3 or greater, stepwise logistic regression analysis was conducted, and on the basis of the results it was possible to single out multiple positive biopsies as the only significant variable. The number of positive biopsies appeared reliable for predicting tumor volume of surgical specimens in cases of nonpalpable disease. The presence of significant tumors despite "normal" levels of PSA warrants further investigation of variables that can predict such prostate cancers. An adequate model for predicting significant tumors in oriental male populations should be established using samples of larger size.