Postoperative Prostate-specific Antigen Research Articles

An analysis of the time course of postoperative prostate-specific antigen failure in patients with positive surgical margins: Implications on the use of adjuvant therapy

The role of adjuvant therapy in the postprostatectomy setting for positive margin patients is an unresolved issue. The purpose of this study is to provide the rationale for patient selection in Phase III trials that test the impact of adjuvant therapy on survival in positive margin prostate cancer patients. Early (12 months or less) and delayed (more than 12 months) postoperative prostate-specific antigen (PSA) failure have been correlated with distant and local failure, respectively, as the site of first failure. In this study, a Cox regression multivariate analysis was used to determine the significant independent clinical and pathologic predictors of early and delayed postoperative PSA failure in 143 margin-positive prostate cancer patients. Margin-positive patients with positive pelvic lymph nodes, seminal vesicle invasion, or prostatectomy Gleason sum 8 or higher were excluded. For the remaining patients, a prostatectomy Gleason sum of 7, preoperative PSA more than 20 ng/mL, and an endorectal coil magnetic resonance imaging (erMRI) scan showing extensive disease were significant independent predictors of early postoperative PSA failure. Conversely, a prostatectomy Gleason sum of 6 or less, preoperative PSA 20 ng/mL or less, and an erMRI showing limited disease predicted delayed PSA failure. Preliminary data suggest that the pattern of first failure can be predicted by the time course of rise in the postoperative PSA. The preliminary results of this study suggest that patient selection for clinical trials examining the efficacy of postoperative adjuvant therapy in the positive margin patient may be determined on the basis of the clinical and pathologic characteristics that predict early versus delayed postoperative PSA failure.

Preoperative Prediction of Tumor Heterogeneity and Recurrence After Radical Prostatectomy for Localized Prostatic Carcinoma with Digital Rectal Examination, Prostate Specific Antigen and the Results of 6 Systematic Biopsies

Purpose Digital rectal examination, preoperative serum prostate specific antigen (PSA) concentration and results of 6 ultrasound guided systematic sextant biopsies in 257 consecutive patients with clinical stages T2 and T1c prostatic carcinoma were evaluated for their use in predicting pathological stage and tumor recurrence. Materials and Methods Each of the 257 consecutive specimens was examined using the 3 mm. step section technique. Results of preoperative digital rectal examination, PSA and 6 systematic sextant biopsies were correlated with pathological stage, margin status and postoperative PSA during a mean followup of 2 years. Patients were considered to have disease progression based on an elevated PSA level by a supersensitive assay. Results Digital rectal examination could not predict pathological stage and tumor recurrence. Preoperative PSA concentration, number of positive biopsies and tumor grade in the biopsy specimens correlated well with pathological stage. The best predictor of tumor recurrence was the biopsy result. However, a precise prediction of outcome (87 percent probability of being PSA negative versus 0 percent) was possible only in a third of the patients if the biopsy results were used. Use of preoperative PSA concentration did not improve this probability. Conclusions Preoperative PSA concentration and/or biopsy results correlate significantly with pathological stage and margin status. Precise prediction of tumor recurrence is possible in only approximately a third of the patients with clinical stage T2 prostatic carcinoma.

Reference range of prostate-specific antigen after transurethral resection of the prostate

The aim of the present study was to investigate how transurethral resection of the prostate (TURP) affected the serum levels of prostate-specific antigen (PSA) and to establish reference ranges of PSA in patients who have undergone TURP. PSA was determined preoperatively and 3 months postoperatively in 190 patients who underwent TURP because of benign prostatic hyperplasia (BPH). Mean PSA levels were reduced by 70%, from 6.0 to 1.9 ng/mL. Prostate volume was reduced by 58% from 63.3 to 26.5 cc, which is close to the reported normal volume in men without BPH. Ninety percent of the patients had a postoperative PSA value of less than 4 ng/mL and 98% less than 10 ng/mL. After a complete TURP with a benign histopathologic specimen, PSA should be expected to be within the normal reference range, that is, less than 4 ng/mL.

The use of 'ultrasensitive' prostate-specific antigen assays in the detection of biochemical recurrence after radical prostatectomy.

To determine the gain in lead time obtained when using ultrasensitive prostate-specific antigen (PSA) assays in the diagnosis of biochemical progression after radical prostatectomy. The post-operative PSA serum concentrations of 137 patients who had undergone radical prostatectomy were evaluated retrospectively. From these patients, 12 were selected who showed biochemical recurrence, as measured by the Hybritech Tandem-E Singlepoint PSA assay. Samples of the serum frozen at the time of the initial analysis were thawed and PSA values were remeasured by the Abbott IMx PSA assay and the Tandem-E Multipoint PSA assay. Analytical thresholds (zero-dose + 3 SD) for the Tandem-E Singlepoint, IMx and Tandem-E Multipoint assay were 1.0, 0.04 and 0.04 ng/mL, respectively. The lead time to the detection of a recurrence obtained when using the IMx and the Tandem-E Multipoint PSA assay was compared with that attained using the Tandem-E Singlepoint PSA assay. As a control, PSA values were determined in 58 serum specimens of nine patients having no evidence of recurrence after radical prostatectomy. All 58 control specimens had PSA levels below the analytical thresholds of the three assays, except one which had a PSA serum concentration of 0.08 ng/mL, estimated by the IMx assay. When compared with the lead time obtained with the Tandem-E Singlepoint assay, the 12 patients with a biochemical recurrence had a median gain in lead time of 327 days (range 60-627) with the IMx assay and of 369 days (range 60-639) with the Tandem-E Multipoint assay. A PSA value > 0.04 ng/mL after radical prostatectomy heralds further biochemical progression. The use of the ultrasensitive IMx and the Tandem-E Multipoint assays provided more lead time, but there is no clear evidence that this gain is necessarily of benefit to the patient.

Postoperative prostate-specific antigen as a prognostic indicator in patients with margin-positive prostate cancer, undergoing adjuvant radiotherapy after radical prostatectomy

Objectives To identify a population of patients within the group with positive surgical margins after radical prostatectomy who would benefit in terms of improved local control of disease by the administration of adju- vant radiation therapy to the prostate bed. Methods Postoperative prostate-specific antigen (PSA) values were evaluated in 45 patients with margin-pos- itive (MP) disease who underwent adjuvant radiotherapy within 6 months of surgery. All patients were clini- cally T1 -2 MO, and pNO. A cutoff of 0.5 ng/mL or less was used as the level below which PSA was considered undetectable. The mean follow-up time from date of radiation was 33 months. Results In 30 of 45 (67%) patients, PSA levels did drop to undetectable levels postoperatively. In 15 of 45 (33%) patients postoperative PSA levels did not drop to undetectable levels. In the group with detectable post- operative PSA, 12 of 15 (80%) failed adjuvant radiotherapy as determined by a progressive increase in PSA levels in a mean time of 0.95 years (range, 4 months to 2.02 years; median, 0.92 years). When postoperative PSA reached undetectable levels, only 10 of 30 (33%) failed treatment, with a mean time to failure of 2.1 years (range, 4 months to 7.8 years; median, 3.31 years). Conclusions The data would suggest that patients who are MP, but attain an undetectable PSA level post-operatively accompanied by a progressive delayed increase in PSA, probably represent a group with local disease recurrence in the prostate fossa, whereas patients whose PSA levels are detectable postoperatively may represent a group with microscopic metastatic disease or a combination of local recurrence and distant disease or large volume local persistent disease. It is in the group of patients in whom the postoperative PSA decreased to undetectable levels that adjuvant radiotherapy may be effective in controlling local progression of prostate cancer through improved local control, as indicated by a durable decrease in PSA values to undetectable levels in roughly two thirds of these patients. Longer follow-up of these patients will be required to determine whether this improved local control will translate into improved survival.

A Multivariate Analysis of Clinical and Pathological Factors that Predict for Prostate Specific Antigen Failure after Radical Prostatectomy for Prostate Cancer

A Cox regression multivariate analysis was done to determine the clinical and pathological indicators that predict for prostate specific antigen (PSA) failure in 347 patients who underwent radical prostatectomy for clinically localized prostate cancer between 1989 and 1993. In the patient subgroups (PSA less than 20 ng./ml. and biopsy Gleason sum 5 to 7 or PSA more than 10 to 20 ng./ml. and biopsy Gleason sum 2 to 4) not classifiable into those at high and low risk for postoperative PSA failure using PSA and biopsy Gleason sum, the status of the seminal vesicles and prostatic capsule on endo-rectal coil magnetic resonance imaging (MRI) allowed for this categorization. Specifically, 2-year actuarial PSA failure rates were 84 percent versus 23 percent in patients with and without seminal vesicle invasion, respectively, on MRI (p less than 0.0001) and 58 percent versus 21 percent in those with and without extracapsular extension, respectively (p = 0.0001). In patients with extracapsular extension but without pathological involvement of the seminal vesicle(s) or poorly differentiated tumors (pathological gleason sum 8 to 10), the 2-year actuarial PSA failure rates were 50 percent (margin positive), 28 percent (margin negative with established extracapsular disease) and 9 percent (margin negative with focal microscopic extracapsular disease). Therefore, endo-rectal coil MRI showing seminal vesicle invasion or extracapsular extension when the PSA level is less than 20 ng./ml. and the biopsy Gleason sum is 5 to 7 or the PSA level is more than 10 but less than 20 ng./ml. and the biopsy Gleason sum is 2 to 4 predicted for PSA failure. In patients with extracapsular extension who had pathological Gleason sum less than 8 disease with uninvolved seminal vesicles, the margin status and extent of extracapsular disease predicted for PSA failure.

Clearance of serum PSA after open surgery for benign prostatic hypertrophy, radical cystectomy, and radical prostatectomy

To study the clearance of serum prostate-specific antigen (PSA) after several types of prostatic tissue ablation. Serum PSA levels were measured (YANG Proscheck ultrasensitive assay) just before surgery, immediately after specimen removal, then twice weekly for 5 weeks or until it was undetectable (< 0.05 ng/ml) in patients undergoing radical cystoprostatectomy for bladder cancer (n = 10), or radical prostatectomy for T1 T2 prostate cancer (n = 18) and daily for 6 days after open surgery for benign prostatic hypertrophy (BPH) (n = 10). Open enucleation for BPH: the immediately postoperative PSA level was 6 times its preoperative value. It decreased following a monoexponential curve with a very short half-life of 0.55 +/- 0.39 days, range (0.14-1.3), reaching a value lower than the preoperative level in all cases, except one by day 3. After radical cystoprostatectomy: the decrease of serum PSA is monoexponential with a half life of 1.92 +/- 1.2 days (0.57-4.24) reaching undetectable level (< 0.05 ng/ml) in all patients by day 21. After radical prostatectomy: 11/18 patients (61%) showed a one-component exponential decrease in PSA with a half-life of 2.5 +/- 1.33 days (range 0.97-4.6 days), and 7/18 showed a two-component exponential decrease with a first half-life of 0.94 +/- 0.8 days and a second of 7.62 +/- 6.35 days); 100% of the patients reached undetectable serum PSA by day 28 in the first group compared to 14.2% of the patients with a two component exponential decrease (P < 0.01). There was no difference between these groups as far as preoperative PSA levels and specimen pathology were concerned. Serum clearance of PSA after extirpative prostatic surgery is closely related to the type and indication of procedure used. Radical cystoprostatectomy is probably the best model in which to study the pharmacokinetics of PSA.

Patterns of Positive Specimen Margins and Detectable Prostate Specific Antigen After Radical Perineal Prostatectomy

Positive specimen margins and detectable postoperative prostate specific antigen (PSA) levels were analyzed after 200 consecutive radical perineal prostatectomies for clinical stages T1 and T2 adenocarcinoma of the prostate. Clinical parameters that correlated with lymph node metastases in concomitant pelvic lymphadenectomies were also noted. At a mean followup of 35 months 79 percent of the patients had undetectable PSA levels. Step-section pathological analysis of specimens obtained by either nerve sparing or extended radical modifications revealed that 41 percent of the tumors were organ confined and 56 percent had negative margins. Selective sacrifice of the posterolateral periprostatic fascia and the enclosed neurovascular bundle achieved negative margins and undetectable PSA levels despite capsular penetration in 15 percent of all patients. Of all positive margins with the perineal approach, solitary positive apical and posterolateral margins were infrequent (7 percent and 16 percent, respectively) but solitary positive anterior margins were more so (25 percent). Of those positive anterior margins 41 percent appeared to be artifactual and 45 percent might have been eliminated by avoiding avulsion of the puboprostatic ligaments. Pelvic lymphadenectomy could have been eliminated in 58 percent of the patients (clinical stage T2b or less, biopsy Gleason score 6 or less and PSA level 11 or less, for a node negative predictive value of 99 percent).

Original Articles: Prostate Cancer: Measurement of Serum Prostate Specific Antigen Levels in Women and in Prostatectomized Men With an Ultrasensitive Immunoassay Technique

ABSTRACTSerum prostate specific antigen (PSA) was measured in 89 prostate cancer patients with no evidence of relapse after radical prostatectomy, in 387 hospitalized women with various diseases and in 674 apparently healthy female blood donors, using an ultrasensitive time resolved immunofluorometric assay with a biological detection limit of 0.01 micrograms./l. Of the prostatectomized cancer patients 50% had measurable PSA (0.010 micrograms./l. or greater) and 21% had levels of 0.050 micrograms./l. or greater. Postoperative PSA was not associated with year of surgery, preoperative PSA or histological grade of the tumors. The distribution of PSA in 1,064 female sera is also reported, of which 83% had no detectable serum PSA, and in 15% PSA was between 0.010 and 0.049 micrograms./l. Only 27 subjects (2.5%) had PSA levels of 0.050 micrograms./l. or greater, including 16 (1.5%) with PSA of 0.10 micrograms./l. or greater. High serum PSA in women was associated with age 50 years or older. Further studies are ...

Original Articles

Serum prostate specific antigen (PSA) was measured in 89 prostate cancer patients with no evidence of relapse after radical prostatectomy, in 387 hospitalized women with various diseases and in 674 apparently healthy female blood donors, using an ultrasensitive time resolved immunofluorometric assay with a biological detection limit of 0.01 microgram./l. Of the prostatectomized cancer patients 50% had measurable PSA (0.010 microgram./l. or greater) and 21% had levels of 0.050 microgram./l. or greater. Postoperative PSA was not associated with year of surgery, preoperative PSA or histological grade of the tumors. The distribution of PSA in 1,064 female sera is also reported, of which 83% had no detectable serum PSA, and in 15% PSA was between 0.010 and 0.049 microgram./l. Only 27 subjects (2.5%) had PSA levels of 0.050 microgram./l. or greater, including 16 (1.5%) with PSA of 0.10 microgram./l. or greater. High serum PSA in women was associated with age 50 years or older. Further studies are needed to examine if the difference in PSA levels between women and prostatectomized men is due to residual or recurrent tumor or to other reasons associated with gender.

Radical prostatectomy in men less than 50 years old

We studied the effect of age on tumor progression (defined as postoperative prostate specific antigen elevation) in 543 men who underwent radical prostatectomy for clinically localized prostate cancer. Patients were divided into two age groups: patients under 50 years (N = 85) and patients older than 50 years (N = 458). The mean follow-up for both groups was S.3 years. Clinical stage was similar in both groups, with only 3% in each group detected by screening techniques. By Kaplan-Meier analysis, men under 50 years showed slightly less progression than men older than 50 years ( p = 0.04), especially during the first 5 years following surgery. The key differentiating feature was a lower incidence of positive margins in the younger age group (18.8%) than the older age group (42.6%; p < 0.0001). There was a higher incidence of lymph node metastasis in the younger age group (14.1%) than the older age group (6.1%; p = 0.01); this adverse feature was present in only a small fraction of the patients and did not play a major role in the difference in progression between age groups. There was no statistically significant difference between the two age groups in tumor grade, capsular penetration, or seminal vesicle invasion. Gland volume was significantly higher in the older age group. Within the younger age group, progression was not affected by a family history of prostate cancer. We found that, despite the tendency in younger men to preserve the neurovascular bundles and cut closer to the prostate, this age group still has a lower incidence of positive surgical margins possibly due to greater ease of surgical removal of small glands. Young men who are candidates for radical prostatectomy do not have a worse prognosis following surgery than older men, and even fare better during the first five postoperative years.

Identification of insignificantprostate cancers: Analysis of preoperative parameters

Objectives. Analyzing preoperative parameters to help determine the risk of a random or systematic prostate needle biopsy specimen detecting an incidental microscopic prostate cancer. Methods. We reviewed the charts of 28 patients who had ≤ 3 mm of Gleason grade (Glgr) ≤2 (score ≤4) prostate cancer in their prostate biopsy specimen and subsequently underwent a radical retropubic prostatectomy (RRP). Histopathologic review of the RRP specimen was carefully performed to determine the respective tumor volume, number of tumor foci, pathologic stage, Glgr, and score. Prostate-specific antigen (PSA) levels and the calculated PSA density (PSAD) were recorded for each case. Results. Sixteen of the 28 (57%) RRP specimens contained a very small well-differentiatedtumor (≤0.2 cc); 7 (25%) tumors were minimally larger (0.2 to 0.5 cc); and 2 specimens (7%) contained a large tumor (4 and 6 cc) only sampled by the biopsy specimen. Mean PSA levels and PSAD values both significantly differentiated tumors ≤0.5 cc from those > 0.5 cc (p < 0.005). PSA ≤4 Vs PSAD ≤0.1 correctly identified 12 of 23 (52%) vs 22 of 23 (96%) tumors 50.5 cc, and 10 of 16 (63%) vs 15 of 16 (94%) tumors ≤0.2 cc, respectively; both parameters excluded 4 of 5 (80%) tumors > 0.5 cc. PSA ≤4 vs PSAD ≤0.1 identified 13 of 25 (52%) vs 24 of 25 (96%) organ-confined tumors, respectively, and both parameters excluded the 2 specimen-confined and 1 margin-positive tumors. Thus, PSAD had an excellent ability to differentiate the tumors based on their volumes. All tumors ≤0.5 cc in the RRP specimen were organ-confined and postoperative serial PSA levels remained < 0.4 in these patients at a mean follow-up of 24 months. Conclusions. Our data indicate that a patient who has a random or systematic prostate biopsy specimen that contains ≤3 mm of Glgr ≤2 prostate cancer and a PSAD ≤0.1 is at a substantial risk (82%) of being diagnosed with an incidental, organ-confined, and probably insignificant, microscopic prostate cancer.

Comparison of Prostate Specific Antigen with Prostate Specific Antigen Density for 3 Clinical Applications

We compared prostate specific antigen (PSA) to PSA density for 3 clinical uses: detection of nonpalpable prostate cancer, staging of clinically localized prostate cancer and prediction of PSA detectability following radical prostatectomy. Of 153 men with normal digital rectal examinations undergoing prostate biopsy 25% had prostate cancer. Analysis of receiver operator characteristic curves demonstrated that PSA density predicted the outcome of biopsy significantly better than did PSA (p = 0.0013). Pathological examination of 155 radical prostatectomy specimens revealed that 56% had pathologically uncontained disease. There was no difference between the ability of PSA and PSA density to predict the pathological findings (p = 0.2379). PSA data more than 1 year postoperatively were available in 96 of the 155 prostatectomy patients. Of these men 41% had postoperative PSA levels of 0.1ng./ml. or more. Preoperative PSA and PSA density values were almost identical in the ability to identify these patients (p = 0.6776). While PSA density is superior to PSA for the detection of prostate cancer in patients with a palpably normal prostate, it does not offer any improvement over PSA for staging of prostate cancer or for the prediction of PSA detectability after radical prostatectomy.

Effect of Radiation Therapy on Detectable Serum Prostate Specific Antigen Levels Following Radical Prostatectomy: Early Versus Delayed Treatment

Radiation therapy may be beneficial after radical prostatectomy in some patients with pathological stage C prostate cancer and in those with detectable postoperative prostate specific antigen (PSA) levels. A total of 64 men underwent postoperative radiation therapy following radical prostatectomy for pathological stage C disease (27), a detectable serum PSA level (11) or both conditions (26). Of the 27 men treated prophylactically for pathological stage C disease 18 (67%) had no evidence of recurrence after radiation within the first 6 months postoperatively (median followup 40 months, range 17 to 97). Of 22 men treated for delayed PSA elevation 15 (68%) currently are disease-free (median followup 27.5 months, range 15 to 47). Of 15 men treated within the first 6 months after radical prostatectomy for persistently detectable PSA levels 8 (53%) had an initial decrease in PSA to undetectable levels but only 5 (33%) had a durable complete response (median followup 36 months, range 8 to 56). We conclude that patients with pathological stage C disease who are most likely to benefit from postoperative radiation therapy are those with initially undetectable postoperative PSA levels. We observed no striking difference in treatment outcome between early and delayed adjuvant radiation therapy.

Predictive value of prostate-specific antigen density for the presence of micrometastatic carcinoma of the prostate

Objective. To examine the efficacy of prostate-specific antigen (PSA) density (PSAD; serum PSA/prostate volume) as a predictor of clinical outcome of patients undergoing radical retropubic prostatectomy for clinically confined prostate cancer, and its ability to determine the presence of micrometastatic disease. Methods. A retrospective analysis of patient outcome as reflected by surgical stage and postoperative PSA was performed with respect to PSAD as determined by preoperative PSA and pathologic prostate gland volume. The findings for 107 consecutive patients who underwent radical prostatectomy are reported. Results. PSAD at low values was found to be 90 percent accurate in predicting operative success or absence of micrometastatic disease. PSAD at high values was shown to be 70 percent accurate in predicting failure. Conclusions. PSAD appears to be useful in selecting patients for radical prostatectomy and may be capable of identifying patients with micrometastatic disease.

Prostate-specific antigen levels after radical prostatectomy and immediate adjuvant hormonal treatment for stage D1 prostate cancer are predictive of early disease outcome.

Detectable prostate-specific antigen (PSA) levels (> or = 0.1 ng/ml) after radical prostatectomy (RPx) for prostate cancer are consistent with residual disease. Conversely, androgen deprivation therapy that produces 'negative' PSA values may not reflect actual disease status. One hundred forty-four patients with stage D1 prostate cancer treated with RPx and immediate adjuvant hormonal therapy (IAHT) had preoperative PSA tests and serial PSA evaluation up to 5.5 years postoperatively. Initial postoperative PSA levels (Hybritech method), performed a median of 3.7 months postoperatively, were undetectable (< 0.1 ng/ml) in 72% of patients, 0.1 ng/ml in 10%, 0.2 ng/ml in 8%, and > or = 0.3 ng/ml in 10%. Among patients whose initial PSA levels were detectable, 84% attained an undetectable level at a median time of 14.4 months postoperatively. The 3-year clinical progression rate after the initial postoperative (3.7 months) PSA determination was higher (20%) for those patients with a detectable PSA level compared with those with an undetectable level (7%; p = 0.09). Mean time to last PSA determination was 2.6 years (range 0.2-5.2 years). The course of the follow-up PSA values was classified for 126 patients as (a) negative (all PSA levels undetectable or decreasing), (b) solitary spikes (a one-time increase in PSA level), (c) positive (two or more increasing PSA levels), or (d) indeterminate. For the 74 patients (59%) with a negative course, only 1 progressed clinically. Similarly, no clinical progression has been observed in the 21 patients with solitary spikes, and only one progression has been noted in the 12 patients with an indeterminate course.(ABSTRACT TRUNCATED AT 250 WORDS)

Adjuvant irradiation after radical prostatectomy for adenocarcinoma of prostate: Analysis of freedom from psa failure

A total of 84 consecutive men with extracapsular disease after radical prostatectomy who received postoperative irradiation and no adjuvant endocrine therapy were analyzed. Failure was defined as the development of clinical disease recurrence either locally or at a distant site, the development of detectable prostate-specific antigen (PSA) when postoperatively it had been undetectable, or any rise in PSA when postoperatively it still had been detectable. Sixteen of the 84 men had nodal disease. Overall, five-year actuarial freedom from relapse was 60 percent. For node-negative men, it was 64 percent and for node-positive men 43 percent. For the 68 men with pathologic Stage T3N0 disease, five-year freedom from relapse was 73 percent when seminal vesicles were negative and 43 percent when involved. Tumor grade also predicted the likelihood of recurrence. In a multivariate analysis the time interval from surgery to radiation and the level of postoperative PSA (detectable versus undetectable) did not influence the likelihood of relapse nor the median time to relapse. Fourteen separate patients treated with radiation alone for palpable tumor recurrence were also analyzed. Fewer than 40 percent were disease-free only two years after irradiation. We conclude that when treatment failure is defined in biochemical as well as clinical terms postoperative irradiation reduces the rate of relapse at five years relative to recently reported series in which adjuvant irradiation was not given. The additional morbidity is low. Whether or not this will translate into an overall cause-specific survival gain is currently unclear.

Is Prostate Specific Antigen of Clinical Importance in Evaluating Outcome after Radical Prostatectomy

Current bias would conclude that elevation of serum prostate specific antigen (PSA) after radical prostatectomy infers failure of the procedure. Since April 1987 preoperative and postoperative serum PSA levels have been obtained on 226 patients who underwent radical perineal prostatectomy for presumed organ confined prostate cancer (stage T1-2N0M0). Clinical failure as defined by elevation of serum acid phosphatase, biopsy proved local recurrence or evidence of malignant disease on bone scan has occurred in 3.9% of the patients with organ confined, 7.0% with specimen confined and 13.2% with margin positive disease. However, when a PSA elevation of greater than 0.5 ng./ ml. was used as an indicator of failure the failure rate became 9.8% for the organ confined group, 39.4% for the specimen confined group and 66.0% for margin positive group. Of the patients who failed clinically the interval from initial elevation of postoperative PSA to clinical detection of failure ranged from 2 to 28 months (median 16). Among the patients with an elevated postoperative PSA level but who have not clinically failed followup ranged from 4 to 46 months (median 23). A total of 11 patients had no evidence of failure at greater than 36 months despite the elevated postoperative serum PSA level.These PSA elevations in patients who undergo supposed curative therapy are distressing. However, at this time the majority of these patients have not failed. In the clinically cured patient biochemical evidence of failure may not be sufficient to change the treatment course.

Stratification of pathologic features in radical prostatectomy specimens that are predictive of elevated initial postoperative serum prostate-specific antigen levels.

Prostate-specific antigen (PSA) is an important marker for adenocarcinoma of the prostate and is of clinical utility in assessment of residual carcinoma after radical prostatectomy. Although elevated postoperative serum PSA levels have been linked to pathologic stage in radical prostatectomy specimens, limited data are available on the relationship of postoperative PSA levels to margin positivity, intraglandular tumor extent, and histologic grade. Initial postoperative serum PSA levels were related to pathologic features of 90 radical prostatectomy specimens with adenocarcinoma of the prostate. Logistic regression analysis was used to stratify pathologic stage, percentage intraglandular carcinoma, histologic grade, and margin positivity as predictors of elevated initial postoperative PSA levels. Pathologic stage, percentage carcinoma, and margin positivity were nearly equivalent in strength of prediction, whereas Gleason histologic grade was a significant but less reliable predictor of elevated initial postoperative PSA levels. Thirty-one of 51 (60.8%) patients with extension of carcinoma outside the prostate gland had an elevated initial postoperative PSA level, whereas only 5 of 39 (12.8%) patients with organ-confined carcinoma had an elevated postoperative PSA level. Intraglandular tumor extent greater than 10% was associated with a greater likelihood of an elevated postoperative PSA level. Additional predictive capacity was obtained with concurrent use of pathologic stage and percentage carcinoma or margin positivity in multivariate analysis. In radical prostatectomy specimens, pathologic stage, intraglandular carcinoma extent, and margin positivity are particularly important morphologic parameters because they are predictive of residual carcinoma that is detected early, as judged by an elevated initial postoperative serum PSA level.

Postoperative prostate specific antigen levels in pathologic stage C adenocarcinoma of the prostate in patients treated with radical prostatectomy alone

Postoperative prostate specific antigen levels in pathologic stage C adenocarcinoma of the prostate in patients treated with radical prostatectomy alone