Small Volume Prostate Cancer Research Articles

Small volume (

INTRODUCTION. It is not well known how many Small Volume Prostate Cancers (SVPC) may host high grade (Gleason pattern 4/5) or have extraprostatic extension in particular in the national setting. Features of SVPC are very interesting since they raise controversies in diagnosis and have important clinical implications in treatment strategies. The diagnosis may be difficult and the treatment ranges from active surveillance to radical surgery. AIM. We evaluate clinical and pathological features of SVPC in surgical specimens of patients who underwent biopsy and radical prostatectomy. METHODS. We analysed a consecutive series of 849 radical prostatectomies performed between 2005 and 2008. Inclusion criteria were: biopsy specimen available, pathological tumor volume analysis according to standard criteria, whole-mount section 3 mm step analysis according to Stanford protocol, clinical parameters (PSA, DRE, number of core biopsy taken). any hormonal manipulation before surgery and cT1A/B stage. Data were analysed using SPSS for statistical comparison. RESULTS. 238 patients were evaluated. SVPC<0.5 cc was observed in 58 (24.3%). Overall in 17/58 (29.3%) a clinical/pathological relevant disease was observed. In 16/58 (27.5%) pathological Gleason Score (GS) was 7-8, in 5/58 (9%) pathological stage was T3. The number of tumor foci was >1 in 78.3%, tumor-involving in both lobes in 55%. Unifocal disease was observed in 22%. Clinically relevant disease is significantly associated with total cancer volume (0.20 versus 0.31, p 0.007), but not to tumor foci (2.5 versus 2.0). PSA, age, no. of positive cores, DRE were not predictive of clinical relevant disease. Six of 17 (35%) cases with SVPC - who were in the low risk category (PSA <10, biopsy Gleason score <7 and negative DRE), had clinical relevant disease. CONCLUSION. SVPC are clinically relevant in 29.3% since they have a Gleason pattern 4 (27.5%) or have only pathological T3 (9%). Early diagnosis techniques and treatments have to consider that SVPC prostate cancer may contain high risk disease in 1/4 of cases. Clinical parameters are not useful to accurately detect high risk SVPC.

Validating multiparametric MRI for diagnosis and monitoring of prostate cancer in patients for active surveillance

To compare multiparametric magnetic resonance imaging (mpMRI) with transrectal ultrasound-guided prostate biopsy (TRUS-bx) for the diagnosis and monitoring of small-volume prostate cancer (PCa) in patients on active surveillance (AS). In a retrospective cross-sectional validation study, 100 patients on AS for PCa underwent a systematic 12-core TRUS-bx (the gold standard) as well as mpMRI, on either a 1.5 or 3 Tesla scanner (32 and 68 patients, respectively). Three pathologists reported biopsy histology separately. A single, experienced radiologist scored mpMRI scans using the PI-RADS system. We compared left- and right-sided PI-RADS scores of the peripheral zone with TRUS-bx results of the relevant prostate lobe. We then estimated the specificity and sensitivity of mpMRI in diagnosing low-grade low-risk PCa in our AS cohort. The sensitivity of mpMRI was 37% (95% CI 28-47%) and specificity was 85% (CI 76-92%) for cancer. The negative predictive value was 51% (CI 44-60%), and the positive predictive value was 76% (CI 62-87%). The positive and negative likelihood ratios were 2.5 and 0.7, respectively. Because of its low specificity and low negative predictive value, mpMRI is not suitable for diagnosing low-grade small-volume PCa. However, because of a specificity of 85% and a negative likelihood ratio of 0.7, mpMRI may be useful for follow-up of previously TRUS-bx diagnosed patients who are on AS.

Optimal method for measuring tumor extent in needle biopsy specimens to identify small-volume prostate cancer.

To compare various methods for measuring tumor extent in prostate biopsy specimens to identify small-volume prostate cancer. A total of 100 radical prostatectomy specimens were retrospectively analyzed. Receiver operating characteristic analysis was used to compare the abilities of prostate-specific antigen density, and four measures of tumor extent in prostate biopsy specimens - positive core number, greatest percentage of cancer in a single core, greatest length of cancer in cores and total length of cancer in cores - to identify small volume prostate cancer. Four definitions of insignificant cancer volume were used in this analysis: index and total tumor volume <0.5 mL, index tumor volume <1.3 mL and total tumor volume <2.5 mL. Multivariate analysis was also used to evaluate variables for predicting small-volume prostate cancer. Total length of cancer in cores had the highest areas under the curve of all the measures defining small-volume prostate cancer: index tumor volume <0.5 mL (0.855), total tumor volume <0.5 mL (0.877), index tumor volume <1.3 mL (0.784) and total tumor volume <2.5 mL (0.818). On multivariate analysis total length of cancer in cores was an independent predictive factor for prostate cancers with index tumor volume <0.5 mL (P < 0.001), <1.3 mL (P < 0.001) and total tumor volume <0.5 mL (P < 0.001), respectively. Our data suggest that total length of cancer in cores is the optimal measure of tumor extent in prostate biopsy specimens for identifying small-volume prostate cancer.

A17 Session 5: General Urology : Role of focal therapy prostate cancer

New forms of thermal ablation have emerged over the past few decades to eradicate solid organ cancers. Much of this is due to the propagation of companies and technologies aimed at providing minimally invasive procedures that can be performed in an out-patient setting. In addition, we have learned more about the biology of some of these cancers, and research has demonstrated that the low metastatic rate for many of these indolent tumors make them amenable to ablation. At the end of the last century the introduction of third generation, gas-driven cryotherapy based on the Joule–Thompson effect has completely revolutionized the technique of cryosurgical ablation of the prostate. Recent improvements have allowed a simpler and quicker freeze–thaw process inside the prostate gland that has significantly shortened the operative time. Secondly, the use of ultra thin 17-gauge needles has become a truly minimally invasive procedure with direct transperineal skin penetration and precise insertion of the cryoprobes into the prostate through a conventional brachytherapy-type grid template. Despite these advances, whole-gland prostate cancer treatments can damage intimate anatomical structures (bladder, erectile nerves, rhabdosphincter and rectum) that contribute to a high quality of life. While the incidence of such damage has decreased as techniques to deliver both radiation and surgical extirpation have improved, morbidity remain significant in both frequency and personal impact. The role of organ-preserving therapy—most commonly termed “focal therapy”—has been suggested as a way to eliminate small-volume prostate cancer. The hypothetical premise of focal therapy is that while clinically insignificant smaller tumors may coexist elsewhere in the prostate gland, a dominant tumor drives the biology of the disease; thus, destroying the dominant tumor may alter the natural history of the disease for the individual patient. If focal therapy can destroy the dominant tumor in a way that limits collateral damage to urinary, bowel, and erectile functions associated with other prostate cancer therapies, this form of management may be desirable for well-selected patients who may be willing to accept potential oncological concessions in order to limit these risks. The concept of focal therapy for prostate cancer follows the same treatment paradigm used for almost all other solid tumors, where careful study has revealed that functional outcomes are improved by minimizing the excised or destroyed tissue with no resulting loss of oncologic efficacy. The use of focal therapy to treat kidney and bladder malignancies is well established in the literature. The focus of this lecture will discuss the clinical outcomes of focal therapy in the management of prostate cancer and selecting the proper patients for the procedure. In addition, post-operative management of these patients will be discussed, including functional as well as oncological outcomes.

Biochemical outcome of small volume or insignificant prostate cancer treated with radical prostatectomy.

279 Background: We examined biochemical outcome of small volume prostate cancers (&lt;0.5 cc, SVCa), and insignificant prostate cancers (&lt;0.5 cc and Gleason scores &lt;7, InsigCa) treated with radical prostatectomy. Methods: Between April 2000 and May 2011, 609 patients with prostate cancer were treated with radical prostatectomy in Hirosaki University Graduate School of Medicine. Of these, 237 were excluded from analysis because of pre-operative adjuvant treatment. The remaining 372 patients were eligible in the present study. Along with the routine pathological assessment, tumor volume (TV) was assessed in all patients. Biochemical recurrence (BCR) was defined as prostate-specific antigen (PSA) levels of greater than 0.2ng/ml. Results: The median age was 68 (48 to 78) and median pre-treatment PSA was 7.50 ng/ml.Average follow up period was 45.9 month. Mean tumor volume (TV) was 2.16 cc. We investigated 372 patients and found SVCa (&lt;0.5 cc) in 60 patients (16.3%), and InsigCa in 14 patients (3.7%). The five year BCR-free survival rate for TV greater than or equal to 0.5 group and SVCa was 67.3% and 87.1% respectively. A significant difference was seen in the log-rank test between the two groups ( p=0.008). We could not identify BCR in InsigCa patients. Conclusions: Despite the limited number of cases, in our study InsigCa were clinically insignificant but in SVCa group 12.9% patients developed PSA failure after radical prostatectomy. SVCa is not identical to InsigCa. Therefore new biomarker is needed to examine what the prognostic relevance is of SVCa.

Primary Circulating Prostate Cells Are Not Detected in Men with Low Grade Small Volume Prostate Cancer

Objective. To determine if primary circulating prostate cells (CPCs) are found in all men with prostate cancer. Methods and Patients. A prospective study, to analyze all men with an elevated PSA between 4.0 and 10.0 ng/mL undergoing initial biopsy. Primary CPCs were obtained by differential gel centrifugation and detected using standard immunocytochemistry using anti-PSA; positive samples underwent a second process with anti-P504S. A malignant primary CPC was defined as PSA (+) P504S (+) and a test positive if 1 cell/4 mL was detected. Biopsy results were registered as cancer/no-cancer, number of cores positive, and percent infiltration of the cores. Results. 328/1123 (29.2%) of the study population had prostate cancer diagnosed on initial biopsy, and 42/328 (12.8%) were negative for primary CPCs. CPC negative men were significantly older, and had lower PSA levels, lower Gleason scores, and fewer positive cores and with infiltration by the cancer. 38/42 (91%) of CPC negative men complied with the criteria for active surveillance in comparison with 34/286 (12%) of CPC positive men. Conclusions. Using primary CPC detection as a sequential test to select men with an elevated PSA for biopsy, the risk of missing clinically significant prostate cancer is minimal when the patient is primary CPC negative; less than 0.5% of all primary CPC negative men had a clinically significant prostate cancer.

There is no way to identify patients who will harbor small volume, unilateral prostate cancer at final pathology. Implications for focal therapies

The aim of this study was to assess the clinical characteristics of the potentially ideal candidates for focal therapy, that is, patients with unilateral, small volume (namely, pT2a) prostate cancer (PCa) at radical prostatectomy (RP). We evaluated 2,503 consecutive pT2 PCa patients treated with RP between 2002 and 2009 at a single center. Within this population, the clinical characteristics of patients with pT2a and pT2b/c disease were compared. Univariable and multivariable logistic regression models were fitted to assess clinical predictors of pT2a at RP. Overall, 349 patients (14%) had pT2a PCa, while the remaining patients had either pT2b (n = 334; 15.5%) or pT2c disease (n = 1,820 patients; 84.5%). Patients with pT2a PCa had a significantly lower mean PSA value, lower mean percentage of positive biopsy cores and lower biopsy Gleason score distribution (all P ≤ 0.03). However, at multivariable analyses, only percentage of positive cores maintained an independent predictor status (P = 0.01). Even when considering only patients sharing all the most favorable PCa characteristics (namely, clinical stage T1, PSA ≤ 4, Gleason score ≤6 and percentage of positive cores ≤25%), the rate of pT2a disease was only 24%. The rate of small volume, unilateral PCa even among patients with extremely favourable PCa characteristics was remarkably low (roughly 25%). This suggests that: (1) Three quarters of the best candidates for focal therapy would ultimately show adverse pathological features; (2) At present, accurate identification of the ideal candidate for focal therapy is not possible with current clinical-pathologic parameters.

Biochemical outcome of small-volume or insignificant prostate cancer treated with radical prostatectomy in Japanese population

We investigated the biochemical outcome of small-volume prostate cancers [tumor volume (TV) < 0.5 mL, SVCa] and insignificant prostate cancers (TV <0.5 mL without any Gleason pattern 4/5 elements, InsigCa) treated with radical prostatectomy. Between April 2000 and May 2010, 609 patients with prostate cancer underwent radical prostatectomy at Hirosaki University Graduate School of Medicine. Of these, 237 were excluded from the study because of preoperative adjuvant therapy. The remaining 372 patients underwent routine histopathological and TV evaluations. Biochemical recurrence (BCR) was defined as the presence of prostate-specific antigen (PSA) levels greater than 0.2 ng/mL after prostatectomy. The median patient age was 68 years (range 48-78 years) and the median preoperative PSA level was 7.50 ng/mL. The mean follow-up period was 45.9 months and the mean TV was 2.16 mL. Sixty patients (16.3%) had SVCa and 14 (3.7%) had InsigCa. The 5-year BCR-free survival rate for patients with SVCa was 67.3% and that for patients with a TV of 0.5 or greater was 87.1%. A significant difference was seen between the groups using the log-rank test (P = 0.008). We could not identify any BCR in patients with InsigCa. Despite the limited number of cases, patients with InsigCa did not develop BCR whereas 12.9% of those with SVCa developed BCR after radical prostatectomy within 5 years. Accurate prediction of the biochemical outcome of SVCa remains difficult and further studies are needed.

Small Volume (&lt;0.5 cc) Prostate Cancer: Characteristics and Clinical Implications

Introduction It is not well known how many Small Volume Prostate Cancers (SVPC) may host high grade (Gleason pattern 4/5) or have extraprostatic extension in particular in the national setting. Features of SVPC are very interesting since they raise controversies in diagnosis and have important clinical implications in treatment strategies. The diagnosis may be difficult and the treatment ranges from active surveillance to radical surgery. AIM. We evaluate clinical and pathological features of SVPC in surgical specimens of patients who underwent biopsy and radical prostatectomy. Methods We analysed a consecutive series of 849 radical prostatectomies performed between 2005 and 2008. Inclusion criteria were: biopsy specimen available, pathological tumor volume analysis according to standard criteria, whole-mount section 3 mm step analysis according to Stanford protocol, clinical parameters (PSA, DRE, number of core biopsy taken). Exclusion criteria: any hormonal manipulation before surgery and cT1A/B stage. Data were analysed using SPSS for statistical comparison. Results 238 patients were evaluated. SVPC&lt;0.5 cc was observed in 58 (24.3%). Overall in 17/58 (29.3%) a clinical/pathological relevant disease was observed. In 16/58 (27.5%) pathological Gleason Score (GS) was 7–8, in 5/58 (9%) pathological stage was T3. The number of tumor foci was &gt;1 in 78.3%, tumor-involving in both lobes in 55%. Unifocal disease was observed in 22%. Clinically relevant disease is significantly associated with total cancer volume (0.20 versus 0.31, p 0.007), but not to tumor foci (2.5 versus 2.0). PSA, age, no. of positive cores, DRE were not predictive of clinical relevant disease. Six of 17 (35%) cases with SVPC - who were in the low risk category (PSA &lt;10, biopsy Gleason score &lt;7 and negative DRE), had clinical relevant disease. Conclusion SVPC are clinically relevant in 29.3% since they have a Gleason pattern 4 (27.5%) or have only pathological T3 (9%). Early diagnosis techniques and treatments have to consider that SVPC prostate cancer may contain high risk disease in 1/4 of cases. Clinical parameters are not useful to accurately detect high risk SVPC.

Preoperative prediction of unifocal, unilateral, margin-negative, and small volume prostate cancer: Iczkowski KA, Hossain D, Torkko KC, Qian J, Lucia MS, Wheeler TM, Rewcastle JC, Bostwick DG, Department of Pathology, University of Colorado Health Science Center, Denver, Colorado

Contemporary prostate carcinoma is frequently of small volume and early stage. Subtotal gland ablation by minimally invasive therapies such as cryotherapy demands preoperative prediction of unifocal, unilateral, margin-negative, and small volume (less than 0.5 ml) cancer. We examined matched biopsy and prostatectomy and clinical data from 393 patients at 2 institutions who underwent surgery in 2000 through 2003. Radical prostatectomy specimens were uniformly sectioned at 5-mm intervals and completely embedded. Numerous clinical and biopsy variables were correlated by regression analysis with unifocal, unilateral, margin-negative, and 0.5 ml or less volume cancer in the prostatectomy specimen. Odds ratios (OR) were determined. At prostatectomy, 92 (23%) had unifocal cancer, 90 (23%) had unilateral cancer, 348 (89%) had organ-confined cancer, and 106 (31%) had small volume cancer. Unilateral cancer occurred in 71% to 76% of cases of unilateral cancer in the biopsy (OR, 4.30; if 9 or more cores were sampled, OR rose to 6.83), and was predicted by unifocality in the biopsy (OR, 2.63). Unifocal cancer was predicted by unilateral (OR, 2.66) but not unifocal, cancer present in the biopsy. Negative surgical margins were predicted by unilateral (OR, 2.53; positive predictive value, 82%) cancer in the biopsy and by serum prostate specific antigen (OR, 5.33). Small volume cancer was predicted by unilateral (OR, 5.50) and unifocal (OR, 7.98) cancer in the biopsy; Gleason score greater than 7 predicted a non-small volume cancer (OR, 7.52). Unilateral or unifocal cancer on biopsy are among the strongest predictors of unilateral, unifocal, and small volume prostate cancer in contemporary practice.

A single institution experience with biochemical recurrence after radical prostatectomy for tumors that on pathology are of small volume or “insignificant”

Objective Small volume prostate cancers (<0.5 cc, svPC), and insignificant prostate cancers (<0.5 cc and Gleason scores <7, InsigPC) are considered clinically insignificant by some investigators. The aim of this study is to determine the biochemical recurrence rate (BCR) of svPC and InsigPC in prostatectomy specimens. Methods In total, 502 patients with prostate cancer, treated with radical prostatectomy (RP) between 1992 and 2005 and with detailed pathological classification, were included in the present study. Patients were postoperatively followed for a median period of 39.5 months (0.6–150). A total of 82 specimens (16.3%) with svPC including 64 (12.8%) with InsigPC were identified. BCR was defined as 2 consecutive PSA levels >0.10 ng/ml. Results In the total group, the median age at the time of surgery was 62.7 years (42.4–73.4) and the median preoperative PSA level was 8.0 ng/ml. Patients with InsigPC had Gleason scores of 4 in 7%, 5 in 37%, and 6 in 56%. Positive surgical margins were identified in 13 (15.9%) svPC and in 8 (12.7%) InsigPC specimens. The 5-year risk of BCR for the svPC group and the insigPC group was 10% (95% CI 2–18%, 7 and 5 patients, respectively) vs. 35% (95% CI 29–41%) in the rest of the cohort (log rank P = 0.001). Conclusion Patients with svPC and patients with InsigPC have a significantly lower risk of BCR. However, even in this seemingly very favorable patient group, 1 in 10 patients will develop a BCR after RP. Therefore, new studies are needed to examine what the prognostic relevance is of small-volume tumors.

Pathologic stage T2a and T2b prostate cancer in the recent prostate‐specific antigen era: Implications for unilateral ablative therapy

Early detection of small volume prostate cancer (PCa) has led to the concept of focal therapy to treat in an organ-sparing manner. We evaluated trends in pathologic staging among patients with localized PCa undergoing radical prostatectomy (RP), defining the frequency of unilateral cancers during 1988-1995, 1996-2000 and 2001-2006. Data were abstracted from the Duke Prostate Cancer Outcome database selecting 3,676 men with available pathology treated with RP. Based on surgical pathology, trends in as pathological T (pT) stage, pathological Gleason Score (pGS), and percent tumor involvement (PTI) were evaluated. pT2a increased from 2.8% of men undergoing RP in 1988-1995 to 13.0% during 2001-2006 (P < 0.0005). PTI analysis shifted towards low volume disease, e.g. PTI <or= 5% increased from 10% during 1988-1995, to 37% in 2001-2006 (P < 0.005). Of all pT2a disease throughout 1988-2006, an increase in proportion of pT2a tumors from 10% during 1988-1995 to 69.4% during 2001-2006 was identified. Over three eras, pT2a had minimal (65% had PTI <or= 5%) or small volume (14% had PTI 5.01-10.00) disease, and 59% were low grade (pGS <or= 6). Using a Cox Hazard model, pT2a versus pT2b disease, surgical margins, PTI, and PSA statistically contributed to PSA disease-free survival in the contemporary era 2001-2006. The increasing prevalence of unilateral pT2a/T2b PCa characterizes a growing proportion of men recently electing RP. These tumors are associated with lower PTI, pGS <or= 7, and demonstrated better PSA-free survival in the 2001-2006 era. These low risk pathologic characteristics may allow for unilateral focal therapy in carefully selected patients.

Preoperative Prediction of Unifocal, Unilateral, Margin-Negative, and Small Volume Prostate Cancer

Contemporary prostate carcinoma is frequently of small volume and early stage. Subtotal gland ablation by minimally invasive therapies such as cryotherapy demands preoperative prediction of unifocal, unilateral, margin-negative, and small volume (less than 0.5 mL) cancer. We examined matched biopsy and prostatectomy and clinical data from 393 patients at two institutions who underwent surgery in 2000 through 2003. Radical prostatectomy specimens were uniformly sectioned at 5-mm intervals and completely embedded. Numerous clinical and biopsy variables were correlated by regression analysis with unifocal, unilateral, margin-negative, and 0.5 mL or less volume cancer in the prostatectomy specimen. Odds ratios (OR) were determined. At prostatectomy, 92 (23%) had unifocal cancer, 90 (23%) had unilateral cancer, 348 (89%) had organ-confined cancer, and 106 (31%) had small volume cancer. Unilateral cancer occurred in 71% to 76% of cases of unilateral cancer in the biopsy (OR, 4.30; if 9 or more cores were sampled, OR rose to 6.83), and was predicted by unifocality in the biopsy (OR, 2.63). Unifocal cancer was predicted by unilateral (OR, 2.66) but not unifocal, cancer present in the biopsy. Negative surgical margins were predicted by unilateral (OR, 2.53; positive predictive value, 82%) cancer in the biopsy and by serum prostate specific antigen (OR, 5.33). Small volume cancer was predicted by unilateral (OR, 5.50) and unifocal (OR, 7.98) cancer in the biopsy; Gleason score greater than 7 predicted a non-small volume cancer (OR, 7.52). Unilateral or unifocal cancer on biopsy are among the strongest predictors of unilateral, unifocal, and small volume prostate cancer in contemporary practice.

Preoperative Prediction of Unifocal, Unilateral, Margin-Negative, and Small Volume Prostate Cancer

Preoperative Prediction of Unifocal, Unilateral, Margin-Negative, and Small Volume Prostate Cancer

Expectant Management of Prostate Cancer With Curative Intent: An Update of The Johns Hopkins Experience

We updated our experience with a strategy of expectant treatment for men with stage T1c prostate cancer and evaluated predictors of disease intervention. A total of 407 men with a median age of 65.7 years (range 45.8 to 81.5) with stage T1c (99.8%) or T2a (0.2%) prostate cancer suspected of harboring small volume prostate cancer based on needle biopsy findings and prostate specific antigen density have been followed in a prospective, longitudinal surveillance program with a median followup of 2.8 years (range 0.4 to 12.5). A recommendation for treatment was made if disease progression was suggested by unfavorable followup needle biopsy findings (Gleason pattern 4 or 5, greater than 2 biopsy cores with cancer or greater than 50% involvement of any core with cancer). Cox proportional hazards regression was used to evaluate the affect of multiple covariates on the outcome of curative intervention. Of 407 men 239 (59%) men remained on active surveillance at a median followup of 3.4 years (range 0.43 to 12.5), 103 (25%) underwent curative intervention at a median of 2.2 years after diagnosis (range 0.96 to 7.39) and 65 (16%) were either lost to followup (12), withdrew from the program (45), or died of causes other than prostate cancer (8). Older age at diagnosis (p = 0.011) and an earlier date of diagnosis (p = 0.001) were significantly associated with curative intervention. Recognizing that over treatment of prostate cancer is prevalent, especially among elderly patients, a program of careful selection and monitoring of older men who are likely to harbor small volume, low grade disease may be a rational alternative to the active treatment of all.

Prostate cancer laterality as a rationale of focal ablative therapy for the treatment of clinically localized prostate cancer

Early detection of small-volume prostate cancer (PCa) has led to the concept of focal therapy to treat PCa as an organ-sparing, minimally invasive procedure. The authors sought to determine the frequency of unilateral cancers in the contemporary prostate-specific antigen (PSA) era to determine the percentage of patients who would be candidates for hemiablation of the prostate by using focal therapy while preserving the contralateral lobe. Paraffin-embedded radical prostatectomy specimens (1184 specimens) from consecutive patients between 2002 and 2006 with pathologic organ confined PCa were analyzed. Pathologic assessment focused on tumor laterality and percentage of tumor involvement (PTI) along with other routine parameters such as pathological T-classification (pT), pathological Gleason Score (pGS), extracapsular extension (ECE), and surgical margins (SM). Clinical and pathologic parameters were analyzed by univariate and multivariate methods. Completely unilateral cancers were identified in 227 (19.2%) of 1184 patients. Of these patients, 164 (72.2%) had PTI of < or =5%, 40 (17.6%) had a PTI of 5.01%-10%, 9 (4.0%) had a PTI of 10.01%-15%, and 14 (6.2%) had a PTI of > 15%, respectively (P < .0005). African-American men had bilateral cancers more commonly that non-African-American men, eg, 90.8% versus 79.2%, respectively (P < .0005). Race, PTI, pGS, and SM were independent predictors by multivariate logistic regression (P < or = .05). This study suggests that 1 in 5 men diagnosed with PCa have small volume, completely unilateral cancers that may be amenable to hemiablation of the prostate. Further study is needed to develop predictive models to select candidates for focal therapy.

1877: Are Small-Volume Prostate Cancers Insignificant?

You have accessJournal of UrologyModerated Poster 59, Wednesday, May 23, 2007, 1:00 - 3:00 pm1 Apr 20071877: Are Small-Volume Prostate Cancers Insignificant? Inge M. van Oort, Dieuwertje E. Kok, Lambertus A. Kiemeney, Peter F. Mulders, Christina A. Hulsbergen-vandeKaa, and J. Alfred Witjes Inge M. van OortInge M. van Oort More articles by this author , Dieuwertje E. KokDieuwertje E. Kok More articles by this author , Lambertus A. KiemeneyLambertus A. Kiemeney More articles by this author , Peter F. MuldersPeter F. Mulders More articles by this author , Christina A. Hulsbergen-vandeKaaChristina A. Hulsbergen-vandeKaa More articles by this author , and J. Alfred WitjesJ. Alfred Witjes More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)32050-0AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "1877: Are Small-Volume Prostate Cancers Insignificant?." The Journal of Urology, 177(4S), pp. 623–624 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 177Issue 4SApril 2007Page: 623-624 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Inge M. van Oort More articles by this author Dieuwertje E. Kok More articles by this author Lambertus A. Kiemeney More articles by this author Peter F. Mulders More articles by this author Christina A. Hulsbergen-vandeKaa More articles by this author J. Alfred Witjes More articles by this author Expand All Advertisement Loading ...

7 Positive margin rates in patients with a single positive core on extended TRUS biopsy

Introduction: Extended TRUS biopsy (12 biopsies or more) is now a standard technique performed in many centres. The management of small volume prostate cancer (&lt;0.05cc) found in a single TRUS biopsy is controversial and may have implications in nerve‐sparing versus non‐nerve sparing radical prostatectomy. The aims of this study are:• To assess the incidence of prostate cancer in the unaffected contralateral prostate lobe on final histopathology• To assess the incidence of extracapsular extension and margin status in the ipsilateral and contralateral lobesPatients and methods: Of 897 radical prostatectomy specimens examined through Sullivan Nicolaides Pathology between 2002 and 2005, 78 had a single positive core in preoperative TRUS biopsy. Histopathalogy, PSA and Gleason sum were reviewed.Results: For patients with a Gleason sum of 6 on TRUS biopsy the mean PSA was 7.00 mcgm/dl. A majority (85%) of the positive cores had low volume disease with tumour occupying less than 30% of the core. Of those with Gleason 3 + 3 = 6 on TRUS biopsy, 34% had their Gleason sum upgraded on final histopathology. Ipsilateral positive margin was seen in 14% of cases. Contralateral positive margin was present in only 2.8% of cases despite tumour being found in 61% of cases in the contralateral lobe on final histopathology.Conclusion: This study shows that in patients with a single positive core of low volume disease, the incidence of contralateral margin involvement on final histopathology is very low. This data is useful in counselling patients who intend to undergo nerve sparing radical prostatectomy.

Anatomic distribution and pathologic characterization of small-volume prostate cancer (

Some investigators consider small-volume prostate cancer (0.5 ml or less) without Gleason pattern 4/5 elements as clinically insignificant. The objective of this study was to characterize the anatomic distribution and pathologic features of small tumors (aggregate volume of 0.5 ml or less) in whole-mount prostatectomy specimens. Between 1999 and 2003, 371 consecutive patients underwent radical prostatectomy at the Indiana University Hospitals for localized prostate cancer. Patients who received hormonal or radiation therapy prior to the surgery were excluded from the study. A total of 62 specimens with total tumor volume of 0.5 ml or less were identified and included in this study. All specimens were embedded and whole-mounted. Tumor volume was measured using the grid method. The mean age at the time of surgery was 59 years (median, 61 years; range, 37–72 years). The mean preoperative prostate-specific antigen (PSA) was 6.5 ng/ml (range: 0.3–18 ng/ml). The mean prostate weight was 53 g (range: 16–132 g). The mean tumor volume was 0.29 ml (median, 0.35 ml; range, 0.02–0.48 ml). Tumor multifocality and bilaterality were present in 69 and 37% of cases, respectively. Three (5%) had positive surgical margins. The largest tumor was located in the peripheral zone, transitional zone, and central zone in 79, 16, and 5% of cases, respectively. The largest tumor was located in the anterior prostate in 10 cases (16%) and in the posterior prostate in 52 cases (84%). The distribution of Gleason scores was 5 (12 cases, 19 %), 6 (40 cases, 65 %), and 7 (10 cases, 16 %). One case had a primary Gleason pattern 4. None had extraprostatic extension, seminal vesicle invasion, or lymph node metastasis. Small-volume prostate cancers are often multifocal and bilateral, with predilection for the peripheral zone. Of these small-volume cases, 16% had Gleason pattern 4 and might, therefore, be clinically significant.

Can Prostate Specific Antigen Derivatives and Pathological Parameters Predict Significant Change in Expectant Management Criteria for Prostate Cancer?

A prior report established that pretreatment criteria based on clinical and biopsy pathology parameters can predict men who harbor small volume prostate cancer who might be followed expectantly. However, some of these men will exhibit disease progression with time and will need definitive therapy. To detect those in whom disease may progress, repeat prostate biopsies are performed at yearly intervals. Therefore, we determined whether biomarkers could be used to determine those in whom disease is likely to progress and thus those who require definitive therapy. Initial and repeat biopsy information along with transrectal ultrasound measurements of gland volume, total prostate specific antigen (PSA), %free PSA (%fPSA) and total PSA velocity were evaluated in 78 men, 45 from the prior study, in whom disease was being managed expectantly. Univariate and multivariate logistic regression analyses determined variables that predicted a favorable tumor burden based on biopsy pathology status at each subsequent repeat biopsy. A Cox proportional hazards model was produced using 67 of 78 evaluable cases having adequate temporal data to predict hazard ratios for conversion from favorable to unfavorable tumor burden status. At time zero for 78 patients %fPSA, total PSA, and gland volume univariately and multivariately differentiated unfavorable and favorable tumor burden groups (p <0.05). The receiver operator characteristic area under the curve (ROC-AUC) was 83%. At the first followup biopsy 17 of 67 (25.4%) men converted to unfavorable tumor burden status. The %fPSA, PSA velocity and gland volume univariately distinguished these 2 groups (p <0.05) with 82% ROC-AUC. At second repeat biopsy 6 of 36 (16.7%) men converted to unfavorable tumor burden status and the ROC-AUC was 76%. Of the 14 men who had a third repeat biopsy all demonstrated favorable tumor burden status. A Cox proportional hazards model stratified the 67 of 78 men into high (48) and low risk (19) groups based on %fPSA at a 20% cutoff (p <0.01). Classification and regression tree analysis using logistic regression multivariately selected variables predicted favorable tumor burden status with an accuracy that ranged from 75% to 84% during our study. PSA velocity, %fPSA and gland volume information improves the prediction of men undergoing expectant management who are more likely to have small volume disease based on a 12-core biopsy interpretation within the time of our observations. %fPSA proved to be a valuable marker to stratify the 2 risk groups. Therefore, based on these factors it may be possible to consider deferment of repeat prostate biopsy until adverse results are detected. This rational approach to the management of prostate cancer in older men with small volume cancer seems to be a reasonable strategy.