The percentage of prostate needle biopsy cores with carcinoma from the more involved side of the biopsy as a predictor of prostate specific antigen recurrence after radical prostatectomy

Unexpectedly high variability in determining tumour extent in prostatic biopsies: implications for active surveillance

AIMS

Tumour content in prostatic biopsies is an important indicator of prostate cancer volume and patient prognosis. Consequently, guidelines typically recommend reporting it as a percentage or linear length (mm). This study aimed to determine the current practices for reporting tumour content in prostatic biopsies and evaluated the consistency among pathologists in diagnosing 10 standard biopsy cases of prostate cancer to assess interobserver variability.

METHODS AND RESULTS

A web-based survey gathered data on demographics, experience and attitudes regarding the reporting of prostate cancer and its extent in biopsies. Virtual microscopy allowed analysis of 10 biopsy cases, each consisting of a single slide of prostate cancer. Self-reports from 304 participants recruited via the International Society of Urological Pathology and the German Society of Pathology were analysed. Most participants (43.4%) reported tumour extent as percentage of the biopsy core, 37.6% reported percentages and mm and 18.3% reported mm exclusively. The methods used to determine percentages showed an unexpected spread of choices, leading to considerable variability in results. Additionally, 40.8% of participants took part in the practical segment of the survey. The reported measures of tumour extent confirmed a notable interobserver variability, which was significantly higher for reported percentages.

CONCLUSION

A high rate of interobserver variability in reporting tumour content in prostatic biopsies was found. This matter is especially critical for patients who are candidates for active surveillance. Reporting absolute measures of tumour content has the advantage of lower variability in comparison to percentages.

Prediction of Postprostatectomy Biochemical Recurrence Using Quantitative Ultrasound Shear Wave Elastography Imaging

Objectives: To determine the prognostic significance of tissue stiffness measurement using transrectal ultrasound shear wave elastography in predicting biochemical recurrence following radical prostatectomy for clinically localized prostate cancer.

Patients and Methods: Eligible male patients with clinically localized prostate cancer and extraperitoneal laparoscopic radical prostatectomy between November 2013 and August 2017 were retrospectively selected. Information of potential biochemical recurrence predictors, including imaging (ultrasound shear wave elastography and magnetic resonance imaging), clinicopathological characteristics, and preoperative prostate specific antigen (PSA) levels were obtained. Recurrence-free survival (Kaplan–Meier curve) and a multivariate model were constructed using Cox regression analysis to evaluate the impact of shear wave elastography as a prognostic marker for biochemical recurrence.

Results: Patients experienced biochemical recurrence in an average of 26.3 ± 16.3 months during their follow-up. A cutoff of 144.85 kPa for tissue stiffness measurement was estimated for recurrence status at follow-up with a sensitivity of 74.4% and a specificity of 61.7%, respectively (p < 0.05). In univariate analysis, shear wave elastography performed well in all preoperative factors compared to biopsy Gleason Score, PSA and magnetic resonance imaging; in multivariate analysis with postoperative pathological factors, shear wave elastography was statistically significant in predicting postoperative biochemical recurrence, which improved the C-index of predictive nomogram significantly (0.74 vs. 0.70, p < 0.05).

Conclusions: The study revealed that quantitative ultrasound shear wave elastography-measured tissue stiffness was a significant imaging marker that enhanced the predictive ability with other clinical and histopathological factors in prognosticating postoperative biochemical recurrence following radical prostatectomy for clinically localized prostate cancer.

Performance characteristics of prostate-specific antigen density and biopsy core details to predict oncological outcome in patients with intermediate to high-risk prostate cancer underwent robot-assisted radical prostatectomy

Background

Many urologic surgeons refer to biopsy core details for decision making in cases of localized prostate cancer (PCa) to determine whether an extended resection and/or lymph node dissection should be performed. Furthermore, recent reports emphasize the predictive value of prostate-specific antigen density (PSAD) for further risk stratification, not only for low-risk PCa, but also for intermediate- and high-risk PCa. This study focused on these parameters and compared respective predictive impact on oncologic outcomes in Japanese PCa patients.

Methods

Two-hundred and fifty patients with intermediate- and high-risk PCa according to the National Comprehensive Cancer Network (NCCN) classification, that underwent robot-assisted radical prostatectomy at a single institution, and with observation periods of longer than 6 months were enrolled. None of the patients received hormonal treatments including antiandrogens, luteinizing hormone-releasing hormone analogues, or 5-alpha reductase inhibitors preoperatively. PSAD and biopsy core details, including the percentage of positive cores and the maximum percentage of cancer extent in each positive core, were analyzed in association with unfavorable pathologic results of prostatectomy specimens, and further with biochemical recurrence. The cut-off values of potential predictive factors were set through receiver-operating characteristic curve analyses.

Results

In the entire cohort, a higher PSAD, the percentage of positive cores, and maximum percentage of cancer extent in each positive core were independently associated with advanced tumor stage ≥ pT3 and an increased index tumor volume > 0.718 ml. NCCN classification showed an association with a tumor stage ≥ pT3 and a Gleason score ≥8, and the attribution of biochemical recurrence was also sustained. In each NCCN risk group, these preoperative factors showed various associations with unfavorable pathological results. In the intermediate-risk group, the percentage of positive cores showed an independent predictive value for biochemical recurrence. In the high-risk group, PSAD showed an independent predictive value.

Conclusions

PSAD and biopsy core details have different performance characteristics for the prediction of oncologic outcomes in each NCCN risk group. Despite the need for further confirmation of the results with a larger cohort and longer observation, these factors are important as preoperative predictors in addition to the NCCN classification for a urologic surgeon to choose a surgical strategy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12894-017-0238-y) contains supplementary material, which is available to authorized users.

A narrowing range of bone scan in newly diagnosed prostate cancer patients: A retrospective comparative study

OBJECTIVES

The objective of the following study is to clarify a suitable group whereby a bone scan could be spared at the initial staging of prostate cancer, we wished to identify the possible relationship between bone metastasis and clinical and pathological parameters including serum total prostate specific antigen (PSA) concentration, alkaline phosphatase (ALP), biopsy Gleason Score (GS), and percentage of pathological cores.

MATERIALS AND METHODS

We reviewed the results of 220 bone scintigraphies, which were done between January 1, 2011 and June 30, 2013 in patients with newly diagnosed prostate cancer. These parameters were evaluated together with standard clinicopathological data to determine the prediction ability of the bone scan by univariate and multivariate analyses.

RESULTS

Bone metastases were seen in 44 patients of all 220 patients (20%, 95% confidence interval, 17-24%). In univariate analysis, PSA and biopsy GS were useful in predicting the bone scan result, but ALP and percentage of pathological cores was not. In multivariate analysis, the single most useful parameter in predicting the bone scan result was PSA (P < 0.001).

CONCLUSIONS

A bone scan seems to be impractical in newly diagnosed prostate cancer patients with serum PSA level <20 ng/ml and GS up to seven and pre-treatment PSA is the best predictor of the need for the bone scan according to results of this study.

Prognostic histopathological and molecular markers on prostate cancer needle-biopsies: a review

Prostate cancer is diverse in clinical presentation, histopathological tumor growth patterns, and survival. Therefore, individual assessment of a tumor's aggressive potential is crucial for clinical decision-making in men with prostate cancer. To date a large number of prognostic markers for prostate cancer have been described, most of them based on radical prostatectomy specimens. However, in order to affect clinical decision-making, validation of respective markers in pretreatment diagnostic needle-biopsies is essential. Here, we discuss established and promising histopathological and molecular parameters in diagnostic needle-biopsies.

Allelic loss of the loci containing the androgen synthesis gene, StAR, is prognostic for relapse in intermediate-risk prostate cancer

BACKGROUND

Androgen deprivation therapy (ADT) and novel agents targeting the androgen synthesis axis (e.g., abiraterone acetate) are adjuvant therapies that are currently, or may in the future be, combined with radiotherapy to reduce the chance of disease relapse. Little is known about allelic loss or gain pertaining to genes associated with the androgen synthesis axis and whether this is prognostic in patients who receive localized radiotherapy. In this hypothesis generating study, we conducted an array comparative genomic hybridization (aCGH) analysis of 33 androgen synthesis genes to identify potential prognostic factors for radiotherapy outcome.

METHODS

aCGH analysis of tumor DNA prospectively derived from frozen needle biopsies of 126 men with intermediate-risk disease who underwent image-guided radiotherapy (IGRT) to a mean dose of 76.4 Gy was conducted. Statistical analyses were conducted for allelic loss or gain in genes as potential prognostic factors relative to prostate specific antigen, Gleason-score, and T-category.

RESULTS

We observed that allelic losses of loci containing the genes StAR and HSD17B2 were associated with increased genetic instability (as determined by percentage genome alteration). On multivariate analyses these loci were prognostic for biochemical disease-free relapse (StAR: HR = 2.84, 95% CI: 1.44-5.61, P = 0.00269; HSD17B2: HR = 1.97, 95% CI: 1.06-3.64, P = 0.031). The results were validated in a surgical cohort of 131 intermediate-risk patients.

CONCLUSIONS

Allelic losses of the loci containing StAR and HSD17B2 have significant prognostic value for intermediate-risk prostate cancer. With this hypothesis generating information future studies should test StAR and HSD17B2 losses as biomarkers of androgen response in combined modality protocols.

NKX3.1 haploinsufficiency is prognostic for prostate cancer relapse following surgery or image-guided radiotherapy

BACKGROUND

Despite the use of prostate specific antigen (PSA), Gleason-score, and T-category as prognostic factors, up to 40% of patients with intermediate-risk prostate cancer will fail radical prostatectomy or precision image-guided radiotherapy (IGRT). Additional genetic prognosticators are needed to triage these patients toward intensified combination therapy with novel targeted therapeutics. We tested the role of the NKX3.1 gene as a determinant of treatment outcome given its reported roles in tumor initiating cell (TIC) renewal, the DNA damage response, and cooperation with c-MYC during prostate cancer progression.

METHODS

Using high-resolution array comparative genomic hybridization (aCGH), we profiled the copy number alterations in TIC genes using tumor DNA from frozen needle biopsies derived from 126 intermediate-risk patients who underwent IGRT. These data were correlated to biochemical relapse-free rate (bRFR) by the Kaplan-Meier method and Cox proportional hazards models.

RESULTS

A screen of the aCGH-IGRT data for TIC genes showed frequent copy number alterations for NKX3.1, PSCA, and c-MYC. NKX3.1 haploinsufficiency was associated with increased genomic instability independent of PSA, T-category, and Gleason-score. After adjusting for clinical factors in a multivariate model, NKX3.1 haploinsufficiency was associated with bRFR when tested alone (HR = 3.05, 95% CI: 1.46-6.39, P = 0.0030) or when combined with c-MYC gain (HR = 3.88, 95% CI: 1.78-8.49, P = 0.00067). A similar association was observed for patients following radical prostatectomy with a public aCGH database. NKX3.1 status was associated with positive biopsies post-IGRT and increased clonogen radioresistance in vitro.

CONCLUSIONS

Our results support the use of genomic predictors, such as NKX3.1 status, in needle biopsies for personalized approaches to prostate cancer management.

Are prostate needle biopsies predictive of the laterality of significant cancer and positive surgical margins?

OBJECTIVE

To determine whether data obtained from preoperative prostate needle biopsy can predict the laterality of significant cancer and positive surgical margins on final-specimen pathology after laparoscopic radical prostatectomy (LRP).

PATIENTS AND METHODS

Data from 490 patients undergoing LRP by one surgeon were reviewed retrospectively. The demographic characteristics, intraoperative data and pathological results were analysed. Univariate and multivariate analyses were used to determine which factors before and during LRP influenced the positive surgical margin status.

RESULTS

There was only minor agreement between the laterality of positive needle biopsies and laterality of any cancer and significant cancer on final-specimen pathology (kappa = 0.135 and 0.151, respectively). This was irrespective of the number of needle cores obtained or final-specimen Gleason grade. Similarly, the laterality of dominant cancer on needle biopsy had only a minor agreement with the location of positive surgical margins (kappa = 0.050) and fair agreement with the location of extracapsular extension on final-specimen pathology (kappa = 0.235).

CONCLUSIONS

Preoperative needle biopsy data have only a minor correlation with the laterality of significant cancer and positive surgical margins at final pathology of LRP specimens. Recognition of this fact, and the frequent bilaterality of significant cancer, with its potential for contralateral positive surgical margins even when the biopsies are positive only unilaterally, is an important consideration when planning nerve-sparing, and potentially for focal therapy.

Percentages of positive cores, cancer length and Gleason grade 4/5 cancer in systematic sextant biopsy are all predictive of adverse pathology and biochemical failure after radical prostatectomy

AIM

We investigated whether the quantitative parameters of systematic sextant biopsies were predictive of either adverse pathological findings or disease recurrence after radical prostatectomy (RP).

METHODS

We retrospectively evaluated a total of 117 men with untreated prostate cancer whose needle biopsies were matched with RP specimens. The pretreatment parameters of the serum prostate-specific antigen (PSA), the PSA density, the percentage of positive biopsy cores, the percentage of cancer length and the percentage of Gleason grade 4/5 cancer in the biopsy were determined and compared with the pathological features of prostate cancer in RP specimens. These pretreatment parameters and pathological factors in the RP specimens, including the cancer volume, the percentage of Gleason grade 4/5 cancer, the positive surgical margin and the seminal vesicle invasion were evaluated for their ability to predict the disease recurrence.

RESULTS

The percentages of positive biopsy cores, the Gleason grade 4/5 cancer in the biopsy and the cancer length in the biopsy had a weak correlation with the cancer volume in RP specimens (r = 0.373, 0.345, 0.408, respectively). All quantitative biopsy parameters were strongly predictive of the non-organ-confined status, the positive surgical margin and the seminal vesicle invasion in the logistic regression analysis. The percentage of positive biopsy cores and the percentage of Gleason grade 4/5 cancer in the biopsy predicted biochemical failure after RP.

CONCLUSION

These results indicate that quantitative biopsy parameters are independent predictors of the adverse pathology of prostate cancers and disease recurrence after RP.

Appropriate patient selection in the focal treatment of prostate cancer: the role of transperineal 3-dimensional pathologic mapping of the prostate--a 4-year experience

This study was undertaken to evaluate the usefulness of transperineal mapping biopsy of the prostate as a staging procedure in the appropriate selection of patients for treatment with focal cryoablation. Between October 2001 and January 2006, a total of 80 patients underwent extensive template-guided transperineal pathologic mapping of the prostate (3-DPM), in conjunction with repeat transrectal ultrasound (TRUS)-guided biopsies. Before 3-DPM was performed, the following clinical variables were recorded: age, prostate-specific antigen (PSA), percent free PSA, total prostate volume, transition zone volume, Gleason score, TNM stage, number of positive cores, and maximum percent of positive cores. Results of 3-DPM were compared with those of TRUS-guided biopsies to determine patient suitability for focal cryoablation; this served as the study end point. Of 80 study patients, 43 (54%) were deemed unsuitable for focal cryoablation. When compared with 3-DPM in assessing patient suitability for focal cryoablation repeat TRUS-guided biopsies yielded a false-negative rate of 47%, a sensitivity of 54%, and a negative predictive value of 49%. None of the pre-3-DPM variables correlated significantly with patient suitability for focal ablation. Treatment selected by the 80 study patients included total gland cryoablation (30%), expectant management (23%), radical prostatectomy (18%), focal cryoablation (11%), external irradiation (10%), brachytherapy (6%), and combined external irradiation and brachytherapy (1%); 1% were undecided about treatment selection. In this study, we demonstrated that 3-DPM (1) effectively excluded patients with clinically significant unsuspected cancer outside the area destined to be ablated, (2) appeared to do so more effectively than repeat TRUS-guided biopsies, and (3) was able to precisely locate the site of the cancer to be selectively ablated.

Extended and saturation prostatic biopsy in the diagnosis and characterisation of prostate cancer: a critical analysis of the literature

OBJECTIVE

To review and critically analyse all the recent literature on the detection and characterisation of prostate cancer by means of extended and saturation protocols.

METHODS

A systematic review of the literature was performed by searching MedLine from January 1995 to April 2007. Electronic searches were limited to the English language, and the key words "prostate cancer," "diagnosis," "transrectal ultrasound (TRUS)," "prostate biopsy," and "prognosis" were used.

RESULTS

The prostate biopsy technique has changed significantly since the original Hodge sextant biopsy protocol. Several types of local anaesthesia are now available, but periprostatic nerve block (PPNB) has proved to be the most effective method to reduce pain during TRUS biopsy. It remains controversial whether PPNB should be associated with other medications. The optimal extended protocol (sextant template with at least four additional cores) should include six standard sextant biopsies, with additional biopsies (up to 12 cores) taken more laterally (anterior horn) to the base and medially to the apex. Repeat biopsies should be based on saturation biopsies (number of cores >/= 20) and should include the transition zone, especially in a patient with an initial negative biopsy. As a means of increasing accuracy of prostatic biopsy and reducing unnecessary prostate biopsy, colour and power Doppler imaging, with or without contrast enhancement, and elastography now can be successfully adopted, but their routine use is still controversial.

CONCLUSION

Extended and saturation biopsy schemes should be performed at first and repeat biopsy, respectively. The widespread use of local anaesthesia makes the procedures more comfortable.

Can biopsy be a reliable predictor of spatial distribution of prostate cancer? Comparison of a novel biopsy regimen with radical prostatectomy findings

OBJECTIVES

To obtain accurate spatial information on cancer distribution with a novel prostate biopsy regimen.

METHODS

From 2003 to 2005, 265 patients underwent a three fan-shaped biopsy (3FSB) technique of 12 to 14 cores and sextant biopsy (SB) simultaneously. When both techniques had positive findings, and radical prostatectomy was performed, the concordance among the positive biopsy locations of the SB, 3FSB, and the combination of both (the reference standard biopsy [RSB]), the proven locations of cancer, and the presence of extracapsular extension and positive surgical margins was calculated.

RESULTS

A total of 41 patients were selected, and 74 locations (left and right apex, left and right lobe) had cancer. Of these, 61 were confirmed by RSB, 58 by 3FSB, and 43 by SB with a sensitivity of 95%, 78%, and 58%, respectively. The sensitivity at the apical location was consistently greater for the 3FSB at 68% (19 of 28) compared with 40% (11 of 28) for all proven apical positive localizations and 100% (19 of 19) compared with 58% (11 of 19) for the RSB. The receiver operating characteristic analysis showed 78% accuracy for 3FSB and 68% accuracy for SB compared with the RSB. At the apex, the 3FSB and SB revealed positive surgical margins with a sensitivity of 1 and 0.4, specificity of 0.067 and 0.4, positive predictive value of 0.263 and 0.182, and negative predictive value of 1 and 0.667, respectively.

CONCLUSIONS

The 3FSB had a great ability to find cancer in the gland, especially at the apex.

Percentage of positive biopsy cores, preoperative prostate-specific antigen (PSA) level, pT and Gleason score as predictors of PSA recurrence after radical prostatectomy: a multi-institutional outcome study in Japan

OBJECTIVE

To evaluate the clinical outcome of radical prostatectomy (RP) in Japan, by retrospectively analysing the clinicopathological data in patients with clinical T1-T2 prostate cancer treated by RP, as there can be prostate-specific antigen (PSA) recurrence after RP in substantially many patients, and its character can differ according to ethnic group and/or country.

PATIENTS AND METHODS

We reviewed 1192 patients who had a RP from 1993 to 2002 with no neoadjuvant/adjuvant therapy and whose PSA level after RP decreased at least once to undetectable levels (<0.2 ng/mL). PSA recurrence was defined as > or = 0.20 ng/mL. The patient data were collected from the Urological Oncology Study Group, a subgroup of Japan Clinical Oncology Group.

RESULTS

The patients' median (range) age was 67 (47-83) years and their PSA level before RP was 8.7 (1.0-153) ng/mL. During the median follow-up of 45.6 months, 302 of the 1192 patients (25.3%) developed PSA recurrence. The median time to recurrence was 369 (61-2128) days after RP. A log-rank test showed that five significant clinicopathological factors were associated with PSA recurrence after RP: the percentage of prostate needle-biopsy cores with cancer, the biopsy Gleason score, PSA level before RP, pathological stage, and the Gleason score of the RP specimen (P < 0.001 for all). In multivariate analyses, the percentage of positive biopsy cores, PSA level before RP, pT and the Gleason score of the RP specimen were all independent significant predictors of PSA recurrence after RP in Japanese men.

CONCLUSIONS

The frequency of PSA recurrence after RP was 25.3% in Japan and the percentage of positive biopsy cores, PSA level before RP, pT and the Gleason score of the RP specimen were independent significant factors for PSA recurrence.

Current practice of diagnosis and reporting of prostate cancer on needle biopsy among genitourinary pathologists

As there is a lack of hard data in the literature about many of the issues relating to diagnosing and reporting prostate cancer, we sought to survey current practices. A questionnaire was sent to 93 genitourinary pathologists with a response rate of 69%. Almost all respondents (95%) used formalin as fixative for needle biopsies. Unstained intervening sections were retained by 47%. Three levels of needle biopsies were used routinely by 63%. For verification of a diagnosis of cancer, high-molecular-weight cytokeratin was still the most commonly used immunohistochemical marker (91%), followed by p63 (58%) and alpha-methylacyl-CoA-racemase (50%). Features considered pathognomonic for cancer were glomeruloid bodies (58%), collagenous micronodules (64%), circumferential perineural invasion (84%), and growth in fat (36%). With none of these present, 39% required a minimum of 2 to 10 glands (median, 3) to diagnose cancer, whereas the others had no lower limit. A Gleason score was always given to even minute cancer foci by 86% and typically a Gleason score 6 was assigned (77%). Perineural invasion was mentioned by 86%. The extent of cancer on needle biopsies was quantified by all respondents with number of involved cores (80%) being the most commonly used measure. Linear extent was estimated by almost all, either as a percentage (80%) or millimeters of cancer length (41%) or both (22%). Measuring cancer from end to end or subtracting intervening benign tissue were almost equally common. For those general pathologists who would like to be in the mainstream of most urological pathologists, our survey data provide a guideline on how to diagnose and report prostate cancer.

Histopathology reporting of prostate needle biopsies. 2005 update

This report reviews the diagnostic and prognostic importance of the pathologic findings in prostate needle biopsies. The morphological findings of the needle biopsy may be placed into one of the following five categories: prostate cancer, atypical small acinar proliferation, high-grade prostatic intraepithelial neoplasia, inflammation, and benign prostatic tissue. While the prime goal of the biopsy is to diagnose prostatic adenocarcinoma, once carcinoma is detected, further descriptive information regarding the type, amount of cancer, and grade forms the cornerstone for contemporary management of the patient and for assessment of the potential for local cure and the risk for distant metastasis. The information provided in the needle biopsy report regarding the attributes of carcinoma is used depending on the individual patient's medical condition and preference and on the treating physician's evaluation to determine whether any form of treatment is indicated and, if so, the type of therapy.

Prostate Biopsy Tumor Extent but Not Location Predicts Recurrence After Radical Prostatectomy: Results From CaPSURE

PURPOSE

Prostate cancer biopsy information is important for patient risk assessment. Although the number and extent of positive biopsies have been used to predict recurrence, the impact of positive biopsy location and contiguity is less clear. We compared the ability of positive prostate biopsy location and pattern with number and percent positive biopsies to predict recurrence after RP.

MATERIALS AND METHODS

From CaPSURE we identified 2,037 men treated with RP from 1992 to 2002 for whom detailed biopsy information and 2 or more followup PSA values were available. Treatment failure was defined as 2 consecutive PSA values of 0.2 ng/ml or higher, or a second treatment delivered more than 6 months after RP. Biopsy tumor volume (number and percent positive sites), location of disease (anatomical site, laterality), and contiguity of positive biopsies were entered into Cox proportional hazards models to predict risk of disease recurrence while controlling for Gleason grade, PSA and T stage.

RESULTS

Higher number and percent of positive biopsy cores were associated with prostate cancer recurrence, risk stratification category and Gleason grade, p <0.0001, HR 1.09 (CI 1.02 to 1.16) and 1.01 (CI 1.00 to 1.01), respectively. Number of biopsy cores taken, laterality, contiguity and positive biopsy location were not associated with disease recurrence.

CONCLUSIONS

The number and the percentage of biopsies positive for cancer correlated with treatment failure after radical prostatectomy. Contiguity, laterality and location were not associated with recurrence.

Prognostic and predictive factors and reporting of prostate carcinoma in prostate needle biopsy specimens

The information provided in the surgical pathology report of a prostate needle biopsy of carcinoma has become critical in the subsequent management and prognostication of the cancer. The surgical pathology report should thus be comprehensive and yet succinct in providing relevant information consistently to urologists, radiation oncologists and oncologists and, thereby, to the patient. This paper reflects the current recommendations of the 2004 World Health Organization-sponsored International Consultation, which was co-sponsored by the College of American Pathologists. It builds on the existing work of several organizations, including the College of American Pathologists, the Association of Directors of Anatomic and Surgical Pathologists, the Royal Society of Pathologists, the European Society of Urologic Pathology and the European Randomized Study of Screening for Prostate Cancer.

The percentage of positive biopsy cores as a predictor of disease recurrence in patients with prostate cancer treated with radical prostatectomy

OBJECTIVE

To analyse the prognostic value of the percentage of positive biopsy cores (PPBC) in determining the pathological features and biochemical outcome of patients with prostate cancer treated by radical prostatectomy, as published data evaluating the prognostic value of PPBC in such patients have limitations.

PATIENTS AND METHODS

A group of 534 patients with clinically localized prostate cancer was selected. The PPBC was defined as the number of positive biopsy cores/total number of biopsy cores x 100, and grouped into categories of <25%, 25.1-50%, 50.1-75% and 75.1-100%. Patients were divided in low-, intermediate- and high-risk groups according to the usual variables.

RESULTS

The mean follow-up was 60.5 months. PPBC was associated with the preoperative serum prostate-specific antigen (PSA) level, biopsy Gleason score and clinical stage. On multivariate analysis, PPBC was a significant predictor of extraprostatic disease and seminal vesicle involvement. Of patients in the four PPBC categories, 16%, 27%, 33% and 60%, respectively, had biochemical recurrence (P < 0.001), and on Cox regression analysis, PPBC was an independent predictor of disease recurrence. After segregating patients into risk groups the PPBC further stratified patients using thresholds of 75% (P = 0.006), 25% (P = 0.026) and 50% (P = 0.011) for low-, intermediate- and high-risk groups, respectively.

CONCLUSIONS

We confirmed, with a longer follow-up, the clinical utility of the PPBC in determining the pathological features and biochemical outcome of patients with prostate cancer treated with radical prostatectomy, and established thresholds for use in patients in the three risk groups.

Prostate biopsy: is age important for determining the pathological features in prostate cancer?

INTRODUCTION

The influence of age on the aggressiveness of prostate cancer (PCa) is controversial. This study aims to assess the influence of age in determining the pathological features of biopsies from patients diagnosed with PCa.

PATIENTS AND METHODS

We selected 1422 patients with clinical suspicion of PCa; among them, 547 (38.5%) had received a diagnosis of adenocarcinoma. Patients were categorized into the following age groups: up to 50 years old, 51 to 60 years, 61 to 70 years, 71 to 80 years, and over 80 years. The evaluated variables were histological grade, presence of perineural invasion and estimate of tumor volume through measurement of the maximum percentage of tissue with cancer in one fragment and total percentage of tissue with cancer in the sample.

RESULTS

The mean age of patients was 66.4 years, with age range from 32 to 94 years. The estimate of tumor volume by maximum percentage of tissue with cancer in one fragment (p = 0.064), total percentage of tissue with cancer in the sample (p = 0.443), and Gleason score (p = 0.485) were not statistically different in relation to the age groups under study. The presence of perineural invasion occurred more frequently among the 50 years and 81 years age groups when compared with patients aged from 51 to 60 and from 61 to 80 years (p = 0.005).

CONCLUSIONS

Age did not represent a determining factor for pathological findings concerning Gleason score and estimate of tumor volume by the variables in use.

Gleason grading of prostate cancer in needle biopsies or radical prostatectomy specimens: contemporary approach, current clinical significance and sources of pathology discrepancies

The Gleason grading system is a powerful tool to prognosticate and aid in the treatment of men with prostate cancer. The needle biopsy Gleason score correlates with virtually all other pathological variables, including tumour volume and margin status in radical prostatectomy specimens, serum prostate-specific antigen levels and many molecular markers. The Gleason score assigned to the tumour at radical prostatectomy is the most powerful predictor of progression after radical prostatectomy. However, there are significant deficiencies in the practice of this grading system. Not only are there problems among practising pathologists but also a relative lack of interobserver reproducibility among experts.

Prognostic value of the percentage of positive fragments in biopsies from patients with localized prostate cancer

OBJECTIVE

To assess the prognostic value of the percentage of positive fragments (PPF) in biopsies from patients with localized prostate cancer (PCa) undergoing radical prostatectomy.

MATERIALS AND METHODS

During the period from March 1991 to November 2000, 440 patients were selected. Cases receiving neoadjuvant or adjuvant hormone therapy, or adjuvant radiotherapy, were excluded, as were cases presenting Gleason scores higher than 6 at biopsy. PPF was defined as the total number of fragments divided by the total number of biopsy fragments times 100. This variable was initially divided into categories from 0 to 25%, 25.1% to 50%, 50.1 to 75% and 75% to 100%. During the postoperative period, patients were assessed every 2 months for 1 year, then every 6 months for 5 years, and then yearly. Biochemical recurrence was defined as serum PSA higher than or equal to 0.4 ng/mL. Median follow-up was 60 months.

RESULTS

One hundred and nine (24.8%) of the 440 patients under study had biochemical recurrence. In the univariate analysis, PPF significantly influenced disease-free survival (log-rank, p < 0.001), and patients with PPF between 75 and 100% presented a risk of a biochemical recurrence of the disease 3 times higher than patients with PPF between 0 and 25% (p < 0.001). After the Cox regression analysis, both serum PSA (p = 0.001) and PPF (p < 0.001) showed to be independent predictive factors for disease-free survival following surgery.

CONCLUSION

PPF measurement in biopsy is a simple and practical method, which should be routinely used as a predictive factor for biochemical recurrence in patients with PCa presenting Gleason scores between 2 and 6.

Update of staging and risk assessment for prostate cancer patients

PURPOSE OF REVIEW

This paper will review the current staging system for prostate adenocarcinoma patients, and will also review new information that can be combined with clinical and pathological staging in order to assess a patient's risk of success or failure of treatment.

RECENT FINDINGS

There has been significant stage migration of prostate cancer patients in the past 15 years, such that patients are currently being diagnosed younger, with lower clinical stages and serum prostate-specific antigen levels, and a lower risk of metastatic disease than previously. The incorporation of the results of extended prostate biopsy schemes, with stage, grade and serum prostate-specific antigen levels, improves the risk assessment of newly diagnosed prostate cancer patients. New imaging techniques, such as transrectal ultrasound Doppler flow and magnetic resonance spectroscopy hold promise for improving risk assessment. Molecular biomarkers may improve risk assessment in the future, although none are currently approved by the US Food and Drug Administration for this indication. Gene chip arrays may further refine risk assessment and assist with the identification of therapeutic targets.

SUMMARY

There has been significant stage migration of prostate cancer patients in the prostate-specific antigen era. Incorporating biopsy information into nomograms and risk assessment equations improves upon clinical staging and risk assessment. New imaging techniques, molecular markers and gene chip arrays hold promise for future risk assessment.