Correlation of pretherapy prostate cancer characteristics with histologic findings from pelvic lymphadenectomy specimens

Differences in survival of prostate cancer Gleason 8-10 disease and the establishment of a new Gleason survival grading system

Background

Although the latest Gleason grading system in 2014 has distinguished between Gleason 3 + 4 and 4 + 3, Gleason 8 and Gleason 9–10 are remained systemically classified.

Methods

A total of 261,125 patients diagnosed with prostate cancer (PCa) were selected between 2005 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. We used propensity score matching to balance clinical variables and then compared overall survival (OS) and cancer‐specific survival (CSS) between Gleason score subgroups. We further establish a new Gleason survival grading system based on the hazard ratio (HR) values of each Gleason subgroup. Cox proportional hazards models and Kaplan–Meier curves were used to compare patient survival.

Results

Among PCa patients with Gleason score 8 disease, patients with Gleason 5 + 3 had significantly worse OS and CSS than those with Gleason 3 + 5 (OS: HR = 1.26, p = 0.042; CSS: HR = 1.42, p = 0.005) and 4 + 4 (HR = 1.50 for OS and HR = 1.69 for CSS, p < 0.001 for all). PCa patients with Gleason 5 + 3 and Gleason 4 + 5 may have the similar OS and CSS (reference Gleason score <=6, 5 + 3: OS HR = 2.44, CSS HR = 7.63; 4 + 5: OS HR = 2.40, CSS HR = 8.92; p < 0.001 for all). The new Gleason survival grading system reclassified the grades 4 and 5 of the 2014 updated Gleason grading system into three hierarchical grades, which makes the classification of grades more detailed and accurate.

Conclusion

PCa patients with Gleason 8–10 may have three different survival subgroups, Gleason 3 + 5 and 4 + 4, Gleason 5 + 3 and 4 + 5, and Gleason 5 + 4 and 5 + 5. Our results maximize risk stratification for PCa patients, provide guidance for clinicians to assess their survival and clinical management, and make a recommendation for the next Gleason grading system update.

Clinical predictors and recommendations for staging computed tomography scan among men with prostate cancer

OBJECTIVE

To identify clinical variables associated with a positive computed tomography (CT) scan and estimate the performance of imaging recommendations in patients from a diverse sample of urology practices.

MATERIALS AND METHODS

This study comprised 2380 men with newly diagnosed prostate cancer seen at 28 practices in the Michigan Urological Surgery Improvement Collaborative from March 2012 through September 2013. Data included age, prostate-specific antigen (PSA) level, Gleason score (GS), clinical T stage, total number of positive biopsy cores, whether or not the patient received a staging abdominal and/or pelvic CT scan, and CT scan result. We fit a multivariate logistic regression model to identify clinical variables associated with metastases detected by CT scan. We estimated the sensitivity and specificity of existing imaging recommendations.

RESULTS

Among 643 men (27.4%) who underwent a staging CT scan, 62 men (9.6%) had a positive study. In the multivariate analysis, PSA, GS, and clinical T stage were independently associated with the occurrence of a positive CT scan (all P values <.05). The American Urological Association's Best Practice Statements' recommendations for imaging when PSA level >20 ng/mL or GS ≥ 8 or locally advanced cancer had a sensitivity of 87.3% and specificity of 82.6%. Compared with current practice, implementing this recommendation in the Michigan Urological Surgery Improvement Collaborative population was estimated to result in approximately 0.5% of positive study results being missed, and 26.1% of fewer study results overall.

CONCLUSION

Successful implementation of CT imaging criterion of PSA level >20, GS ≥ 8, or clinical stage ≥ T3 would ensure that CT scans are performed for almost all men who would have positive study results while reducing the number of negative study results.

Pre-treatment risk stratification of prostate cancer patients: A critical review

INTRODUCTION

The use of accepted prostate cancer risk stratification groups based on prostate-specific antigen, T stage and Gleason score assists in therapeutic treatment decision-making, clinical trial design and outcome reporting. The utility of integrating novel prognostic factors into an updated risk stratification schema is an area of current debate. The purpose of this work is to critically review the available literature on novel pre-treatment prognostic factors and alternative prostate cancer risk stratification schema to assess the feasibility and need for changes to existing risk stratification systems.

METHODS

A systematic literature search was conducted to identify original research publications and review articles on prognostic factors and risk stratification in prostate cancer. Search terms included risk stratification, risk assessment, prostate cancer or neoplasms, and prognostic factors. Abstracted information was assessed to draw conclusions regarding the potential utility of changes to existing risk stratification schema.

RESULTS

The critical review identified three specific clinically relevant potential changes to the most commonly used three-group risk stratification system: (1) the creation of a very-low risk category; (2) the splitting of intermediate-risk into a low- and high-intermediate risk groups; and (3) the clarification of the interface between intermediate- and high-risk disease. Novel pathological factors regarding high-grade cancer, subtypes of Gleason score 7 and percentage biopsy cores positive were also identified as potentially important risk-stratification factors.

CONCLUSIONS

Multiple studies of prognostic factors have been performed to create currently utilized prostate cancer risk stratification systems. We propose potential changes to existing systems.

Clinical characteristics and primary treatment of prostate cancer in Sweden between 1996 and 2005

OBJECTIVE

The incidence of prostate cancer is rising rapidly in Sweden and there is a need to better understand the pattern of diagnosis, tumor characteristics and treatment.

MATERIAL AND METHODS

Between 1996 and 2005, all new cases of adenocarcinoma of the prostate gland were intended to be registered in the National Prostate Cancer Register (NPCR). This register contains information on diagnosing unit, date of diagnosis, cause of diagnosis, tumor grade, tumor stage according to the TNM classification in force, serum prostate-specific antigen (PSA) levels at diagnosis and primary treatment given within the first 6 months after diagnosis.

RESULTS

In total, 72,028 patients were registered, comprising >97% of all pertinent incident cases of prostate cancer in the Swedish Cancer Register (SCR). During the study period there was a considerable decrease in median age at the time of diagnosis, a stage migration towards smaller tumors, a decrease in median serum PSA values at diagnosis, a decrease in the age-standardized incidence rate of men diagnosed with distant metastases or with a PSA level of > 100 ng/ml at diagnosis and an increase in the proportion of tumors with Gleason score <6. Relatively large geographical differences in the median age at diagnosis and the age-standardized incidence of cases with category T1c tumors were observed. Treatment with curative intent increased dramatically and treatment patterns varied according to geographical region. In men with localized tumors and a PSA level of <20 ng/ml at diagnosis, expectant treatment was more commonly used in those aged > or =75 years than in those aged <75 years. Also, the pattern of endocrine treatment varied in different parts of Sweden.

CONCLUSIONS

All changes in the register seen over time are consistent with increased diagnostic activity, especially PSA testing, resulting in an increased number of cases with early disease, predominantly tumors in category T1c. The patterns of diagnosis and treatment of prostate cancer vary considerably in different parts of Sweden. The NPCR continues to be an important source for research, epidemiological surveillance of the incidence, diagnosis and treatment of prostate cancer.

[Incidence of locally invasive prostate cancer in patients with intermediate values of prostate-specific antigen]

BACKGROUND/AIM

Feasibility of radical prostatectomy (RP) in patients with locally invasive prostate cancer (PC) is assessed by the standard parameters such as the stage of the disease, serum prostate-specific antigen (PSA) and bioptic Gleason grade (GG). Intermediate values of PSA are important in predicting the local confines of the tumor, but can also be detected in more than 30% of patients with locally advanced PC. The aim of this study was to find out the incidence of locally advanced PC in the patients with intermediate serum PSA in whom RP had been performed.

METHODS

We used the biopsy cores and the tissue obtained after RP from 46 patients who had intermidiate PSA values which were defined as PSA from 2.6-10 ng/ml. In all the patients classical regional lymphadenectomy was performed. In all the patients, preoperative stage was determined according to the Partin tables (PT) from 2001.

RESULTS

In 52, 17% of the patients biopsy GG was < or = 6, while it was 7 in 47.83% of the patients. Clinically localized disease (cT2b) was found in 86.96% of patients; other 13.04% of the patients had locally advanced PC. After RP, the incidence of localized PC was 47.83%, while the advanced disease was found in 52.17%. Metastasis in one or two regional lymph nodes (N1) was found in 10.87% of the patients with the advanced PC. According to PT, the expected incidence of positive lymph nodes should have been 8% for pT3 stage. Positive correlation between the assumed N1 stage according to PT and N1 stage in our radical prostatectomies was statistically significant (p = 0.012).

CONCLUSION

In more than 50% of patients with intermediate values of PSA locally advanced disease can be expected after RP. The use of the Partin tables have an important predictive value in assessing the local confines of the cancer and metastasis in regional lymph nodes.

Radiotherapy after prostatectomy: improved biochemical relapse-free survival with whole pelvic compared with prostate bed only for high-risk patients

PURPOSE

To compare the biochemical relapse-free survival (bRFS) among patients receiving whole pelvic radiotherapy (WPRT) vs. prostate bed RT (PBRT) after radical prostatectomy.

METHODS AND MATERIALS

Between 1985 and 2005, 160 patients underwent adjuvant or salvage RT after radical prostatectomy. A short course of total androgen suppression was also given concurrently to 87 patients. Of the 160 patients, 114 were considered at high risk of lymph node involvement because they had a pathologic Gleason score of >/=8, a preoperative prostate-specific antigen level >20 ng/mL, seminal vesicle or prostate capsule involvement, or pathologic lymph node involvement. Of this group, 72 underwent WPRT and 42 underwent PBRT. The median follow-up was >5 years for all patient subsets. Kaplan-Meier and Cox proportional hazards multivariate analyses were performed for all clinical, pathologic, and treatment factors predicting for bRFS.

RESULTS

Whole pelvic RT resulted in superior bRFS compared with PBRT (p = 0.03). The advantage of WPRT was limited to high-risk patients, with a 5-year bRFS rate of 47% (95% confidence interval, 35-59%) after WPRT vs. 21% (95% confidence interval, 8-35%) after PBRT (p = 0.008). For low-risk patients, no difference (p = 0.9) was found. On multivariate analysis, only WPRT (p = 0.02) and a preoperative prostate-specific antigen level <1.0 ng/mL (p = 0.002) were significantly associated with bRFS. The benefit from total androgen suppression with postoperative RT was only observed when given concurrently with WPRT (p = 0.04) and not with PBRT (p = 0.4).

CONCLUSION

The results of our study have indicated that WPRT confers superior bRFS compared with PBRT for high-risk patients receiving adjuvant or salvage RT after radical prostatectomy. This advantage was observed only with concurrent TAS. These results are analogous to the benefit from WPRT seen in the Radiation Therapy Oncology Group 94-13 study.

When should the seminal vesicles be included in the target volume in prostate radiotherapy?

External beam radiotherapy to the prostate and seminal vesicles as a radical treatment for prostate cancer can result in a significant dose being delivered to the rectum. This can be reduced if the target volume includes the prostate only. Using a Medline search, published studies are reviewed to show that the risk of seminal vesicle involvement can be accurately predicted using readily available pre-treatment parameters. We recommend when to exclude the seminal vesicles from a target volume, and the proportion of seminal vesicles that should be included in a target volume in higher risk patients.

Permanent prostate brachytherapy: pathologic implications as assessed on radical prostatectomy specimens of broadening selection criteria for monotherapy

OBJECTIVES

To assess the impact of clinical selection criteria on pathologic features among patients treated by radical retropubic prostatectomy and to evaluate the implications of broadening eligibility for permanent prostate brachytherapy monotherapy.

METHODS

A consecutive series of 423 patients with prostate cancer, who underwent diagnostic biopsy and subsequent radical retropubic prostatectomy, were selected for this study. Four subgroups were defined using the American Brachytherapy Society selection criteria, including prostate size limits (group 1), no prostate size limits (group 2A), a modified set of criteria (group 2B), and clinical Stage T1-T2 (group 3). The rates of extraprostatic extension, seminal vesicle invasion, and lymph node involvement were compared.

RESULTS

Adverse pathologic features at radical retropubic prostatectomy were noted in 8 (9.3%) of 86 patients in group 1, 11 (5.6%) of 195 patients in group 2A, 35 (12.0%) of 292 patients in group 2B, and 90 (21.8%) of 413 patients in group 3. The rates of extraprostatic extension, seminal vesicle invasion, and lymph node involvement appeared comparable among groups 1 (5.8%, 3.5%, and 0.0%, respectively), 2A (3.6%, 2.1%, and 0.0%, respectively), and 2B (6.9%, 3.8%, and 1.4%, respectively), but were greater in group 3 (9.7%, 7.8%, and 4.4%, respectively).

CONCLUSIONS

Judicious broadening of the clinical selection criteria may allow a greater number of patients to be eligible for permanent prostate brachytherapy monotherapy by including patients whose risk of having adverse pathologic features is comparable to that of patients currently deemed suitable for permanent prostate brachytherapy monotherapy. Prospective assessment of oncologic outcomes of such an approach is required.

Current status of lymph node-positive prostate cancer: Incidence and predictors of outcome

In early surgical series, the incidence of positive lymph nodes in patients with prostate cancer was approximately 40%. In the modern era of screening and improved patient selection, the incidence is now <10%, although most series excluded patients with higher risk disease. The risk of having positive lymph nodes is influenced by disease stage, prostate-specific antigen level, and tumor grade and by the aggressiveness of lymph node dissection. Many of the same factors predict the outcome of these patients. Although the percentage of patients with positive lymph nodes has declined, there remain significant numbers of patients with lymph node-positive prostate cancer, and it remains a therapeutic dilemma.

External beam radiotherapy as curative treatment of prostate cancer

External beam radiotherapy (RT) has been used as a curative treatment of prostate cancer for more than 5 decades, with the "modern" era emerging more than 3 decades ago. Its history is marked by gradual improvements punctuated by several quantum leaps that are increasingly driven by advancements in the computer and imaging sciences and by its integration with complementary forms of treatment. Consequently, the contemporary use of external beam RT barely resembles its earliest form, and this must be appreciated in the context of current patient care. The influence of predictive factors on the use and outcomes of external beam RT is presented, as is a selected review of the methods and outcomes of external beam RT as a single therapeutic intervention, in association with androgen suppression, or as a postoperative adjunct. Thus, the "state of the (radiotherapeutic) art" is presented to enhance the understanding of this treatment approach with the hope that this information will serve as a useful resource to physicians as they care for patients with prostate cancer.

Limited pelvic lymphadenectomy using the sentinel lymph node procedure in patients with localised prostate carcinoma: a pilot study

PURPOSE

The purpose of this study was to determine the potential role of the sentinel lymph node (SLN) procedure in limited lymph node dissection in patients with apparently localised prostate carcinoma.

METHODS

In 27 patients with organ-confined prostate cancer, a single injection of 0.3 ml/30 MBq( 99m)Tc-rhenium sulphur colloid was injected transrectally into the peripheral zone of each lobe of the prostate (total 0.6 ml/60 MBq) under ultrasound guidance. Two hours after injection, scintigraphy was performed. The first step in surgery was the detection and dissection of lymph nodes identified as SLNs. Then, standard lymphadenectomy was performed, consisting in a limited dissection that included all lymph nodes from the obturator fossa and along the external iliac vein. Lymphatic tissue along the hypogastric artery was not systematically removed, except in the presence of SLNs.

RESULTS

Mean patient age was 66 years (48-77); the mean serum prostate-specific antigen value was 10.6 ng/ml. In a high proportion of patients (21/27, 77.8%) an SLN was located along the initial centimetres of the hypogastric artery. The second most frequent site of SLNs was in the obturator fossa (11/27 patients, 40.7%), followed by the external iliac area (5/27 patients, 18.5%). Four patients had lymph node metastases, all in SLNs: two in the hypogastric area and two in the obturator fossa.

CONCLUSION

The SLN procedure revealed the individual variability in the lymphatic drainage of the prostate. The main site of SLNs was the hypogastric area, and two of the four metastatic nodes were located at this site. A limited standard pelvic lymphadenectomy, excluding the hypogastric lymph nodes, would have missed half of the lymph node metastases in this study. A radionuclide SLN procedure could assist in the correct staging of patients with early prostate cancer, especially when performing limited lymphadenectomy.

BASELINE STAGING OF NEWLY DIAGNOSED PROSTATE CANCER: A SUMMARY OF THE LITERATURE

PURPOSE

Staging for prostate cancer often includes bone scanning and computerized tomography (CT). We systematically reviewed the published evidence for these tests.

MATERIALS AND METHODS

We searched MEDLINE for articles on these investigations in newly diagnosed cases of prostate cancer. Data were pooled based on prostate specific antigen (PSA), grade and tumor stage.

RESULTS

Among 23 studies examining the role of bone scan metastases were detected in 2.3%, 5.3% and 16.2% of patients with PSA levels less than 10, 10.1 to 19.9 and 20 to 49.9 ng/ml, respectively. Scanning detected metastases in 6.4% of men with organ confined cancer and 49.5% with locally advanced disease. Detection rates were 5.6% and 29.9% for Gleason scores 7 or less and 8 or greater, respectively. Among 25 studies CT documented lymphadenopathy in 0 and 1.1% of patients with PSA less than 20 and 20 ng/ml or greater, respectively. CT detection rate was 0.7% and 19.6% in patients with localized and locally advanced disease, respectively. Detection rates in patients with Gleason scores 7 or less and 8 or greater were 1.2% and 12.5%, respectively. These risks were typically much greater on pathological evaluation.

CONCLUSIONS

Patients with low risk prostate cancer are unlikely to have metastatic disease documented by bone scan or CT. Therefore, these investigations should not be standard practice. However, patients with PSA 20 ng/ml or greater, locally advanced disease, or Gleason score 8 or greater are at higher risk for bone metastases and should be considered for bone scan. CT may be useful in patients with locally advanced disease or Gleason score 8 or greater but appears not to be of benefit in patients with increased PSA alone.

The relevance of prostatectomy findings for brachytherapy selection in patients with localized prostate carcinoma

BACKGROUND

The efficacy of brachytherapy for patients with localized prostate carcinoma depends on adequate radiotherapeutic coverage of the primary tumor and its subclinical extraprostatic extensions. Predictive models based on pretherapy factors may be useful to estimate the likelihood for clinically relevant extraprostatic disease and may be incorporated into selection criteria for this procedure.

METHODS

Multivariate logistic regression model building was performed using pretherapy factors in 2905 surgically staged patients with localized prostate carcinoma to estimate the probability of seminal vesicle and/or lymph node involvement. Bootstrap methods were employed to assess the stability of the final model parameters and to determine the sensitivity and specificity of the final model.

RESULTS

Clinical tumor classification, biopsy Gleason score groupings, and serum prostate specific antigen (PSA) levels were associated with seminal vesicle and/or pelvic lymph node involvement. These factors were incorporated into a multivariate model that predicted for these adverse histopathologic features. Allowing for up to a 10% likelihood for seminal vesicle and/or pelvic lymph node involvement, patients with tumors classified as T1c-T2a, Gleason scores of 2-6, and PSA < or = 16 ng/mL; or with tumors classified as T1c-T2a, Gleason scores of 7-10, and PSA < or = 4 ng/mL; or with tumors classified as T2b-T2c, Gleason scores of 2-6, and PSA < or = 6 ng/mL would be potential candidates for brachytherapy alone.

CONCLUSIONS

The predictive model presented may provide criteria whereby an adequately performed prostate brachytherapy procedure is expected to encompass the intraprostatic and adjacent extraprostatic disease. Prostate brachytherapy alone may be considered in these circumstances, whereas the addition of external beam radiotherapy may be reserved for patients with disease that is apt to extend beyond the brachytherapy target volume.

Chemical disease-free survival in localized carcinoma of prostate treated with external beam irradiation: comparison of American Society of Therapeutic Radiology and Oncology Consensus or 1 ng/mL as endpoint

PURPOSE

To compare postirradiation biochemical disease-free survival using the American Society of Therapeutic Radiology and Oncology (ASTRO) Consensus or elevation of postirradiation prostate-specific antigen (PSA) level beyond 1 ng/mL as an endpoint and correlate chemical failure with subsequent appearance of clinically detected local recurrence or distant metastasis.

METHODS AND MATERIALS

Records of 466 patients with histologically confirmed adenocarcinoma of the prostate treated with irradiation alone between January 1987 and December 1995 were analyzed; 339 patients were treated with bilateral 120 degrees arc rotation and, starting in 1992, 117 with three-dimensional conformal irradiation. Doses were 68--77 Gy in 1.8 to 2 Gy daily fractions. Minimum follow-up is 4 years (mean, 5.5 years; maximum, 9.6 years). A chemical failure was recorded using the ASTRO Consensus or when postirradiation PSA level exceeded 1 ng/mL at any time. Clinical failures were determined by rectal examination, radiographic studies, and, when clinically indicated, biopsy.

RESULTS

Six-year chemical disease-free survival rates using the ASTRO Consensus according to pretreatment PSA level for T1 tumors were: < or = 4 ng/mL, 100%; 4.1--20 ng/mL, 80%; and > 20 ng/mL, 50%. For T2 tumors the rates were: < or = 4 ng/mL, 91%; 4.1--10 ng/mL, 81%; 10.1--20 ng/mL, 55%; 20.1--40 ng/mL, 63%; and > 40 ng/mL, 46%. When postirradiation PSA levels higher than 1 ng/mL were used, the corresponding 6-year chemical disease-free survival rates for T1 tumors were 92% for pretreatment PSA levels of < or = 4 ng/mL, 58--60% for levels of 4.1--20 ng/mL, and 30% for levels > 20 ng/mL. For T2 tumors, the 6-year chemical disease-free survival rates were 78% in patients with pretreatment PSA levels of 4--10 ng/mL, 45% for 10.1--40 ng/mL, and 25% for > 40 ng/mL. Of 167 patients with T1 tumors, 30 (18%) developed a chemical failure, 97% within 5 years from completion of radiation therapy; no patient has developed a local recurrence or distant metastasis. In patients with T2 tumors, overall 45 of 236 (19%) had chemical failure, 94% within 5 years of completion of radiation therapy; 4% have developed a local recurrence, and 10%, distant metastasis. In patients with T3 tumors, overall, 24 of 65 (37%) developed a chemical failure, 100% within 3.5 years from completion of radiation therapy; 4% of these patients developed a local recurrence within 2 years, and 12% developed distant metastasis within 4 years of completion of irradiation. The average time to clinical appearance of local recurrence or distant metastasis after a chemical failure was detected was 5 years and 3 years, respectively.

CONCLUSION

There was a close correlation between the postirradiation nadir PSA and subsequent development of a chemical failure. Except for patients with T1 tumors and pretreatment PSA of 4.1--20 ng/mL, there is good agreement in 6-year chemical disease-free survival using the ASTRO Consensus or PSA elevations above 1 ng/mL as an endpoint. Although the ASTRO Consensus tends to give a higher percentage of chemical disease-free survival in most groups, the differences with longer follow-up are not statistically significant (p > 0.05). It is important to follow these patients for at least 10 years to better assess the significance of and the relationship between chemical and clinical failures.

American Brachytherapy Society (ABS) recommendations for transperineal permanent brachytherapy of prostate cancer

PURPOSE/OBJECTIVE

To develop and disseminate the American Brachytherapy Society (ABS) recommendations for the clinical quality assurance and guidelines of permanent transperineal prostate brachytherapy with 125I or 103Pd.

METHODS AND MATERIALS

The ABS formed a committee of experts in prostate brachytherapy to develop consensus guidelines through a critical analysis of published data supplemented by their clinical experience. The recommendations of the panels were reviewed and approved by the Board of Directors of the ABS.

RESULTS

Patients with high probability of organ-confined disease are appropriately treated with brachytherapy alone. Brachytherapy candidates with a significant risk of extraprostatic extension should be treated with supplemental external beam radiation therapy (EBRT). Patient selection guidelines were developed. Dosimetric planning of the implant should be carried out for all patients before seed insertion. A modified peripheral loading is preferred. The AAPM TG-43 recommendations requiring a change in prescription dose for 125I sources should be universally implemented. The recommended prescription doses for monotherapy are 145 Gy for 125I and 115-120 Gy for 103Pd. The corresponding boost doses (after 40-50 Gy EBRT) are 100-110 Gy and 80-90 Gy, respectively. Clinical evidence to guide selection of radionuclide (103Pd or 125I) is lacking. Post implant dosimetry and evaluation must be performed on all patients. It is suggested that the dose that covers 90% (D90) and 100% (D100) of the prostate volume and the percentage of the prostate volume receiving the prescribed dose (V100) be obtained from a dose-volume histogram (DVH) and reported.

CONCLUSION

Guidelines for appropriate patient selection, dose reporting, and improved quality of permanent prostate brachytherapy are presented. These broad recommendations are intended to be technical and advisory in nature, but the ultimate responsibility for the medical decisions rests with the treating physician. This is a constantly evolving field, and the recommendations are subject to modifications as new data becomes available.

Improved freedom from PSA failure with whole pelvic irradiation for high-risk prostate cancer

PURPOSE

To determine the impact of whole pelvic irradiation on the risk of PSA failure in prostate cancer patients, at high predicted risk for lymph node involvement, receiving definitive radiotherapy.

MATERIALS AND METHODS

Between October 1987 and December 1995, 506 patients with clinically localized prostate cancer were treated with definitive radiotherapy at UCSF and affiliated institutions. Treatment consisted of 4-field whole pelvic irradiation followed by a prostate-only boost, or prostate-only treatment (median follow-up was 35 months and 30 months, respectively). PSA failure was defined as: 1. a PSA value > or = 1 ng/ml; or 2. a PSA value that rose > or = 0.5 ng/ml in < or = 1 year posttreatment on two consecutive measurements, with the first rise defined as the time of failure. The calculated risk of lymph node positivity (%rLN+) was defined as 2/3(iPSA) + 10(GS-6), and high risk was defined as %rLN+ > or = 15%. Univariate and multivariate analyses were performed.

RESULTS

A total of 201 high-risk patients were identified. High-risk patients who received whole pelvic irradiation had significantly improved freedom from PSA failure compared to those who received prostate-only treatment (median PFS = 34.3 months vs. 21.0 months; p = 0.0001). Potential confounding variables, including initial PSA, Gleason score, T stage, radiation dose, year of treatment, use of three-dimensional (3D) conformal techniques, and use of hormone therapy, did not account for the observed difference in time to PSA failure. Multivariate analysis revealed type of radiation treatment to be the most significant independent predictor of outcome.

CONCLUSION

Whole pelvic radiotherapy significantly improves the PSA failure-free survival in patients with a high calculated risk of lymph node positivity.

An enhanced prognostic system for clinically localized carcinoma of the prostate

BACKGROUND

This investigation was conducted to develop an enhanced prognostic system based on readily available and independently predictive tumor-related factors for patients with clinically localized prostate carcinoma.

METHODS

The outcome of 500 patients treated solely with irradiation for clinical TNM classifications T1-4, NO or NX, MO prostate carcinoma was used to identify factors independently associated with disease relapse. Logistic regression constructed a risk score equation, and optimized cutoff points to characterize patient groups with low, intermediate, or high risks for relapse were established with receiver operating characteristic curve analysis.

RESULTS

Clinical tumor stage (P < 0.00001), Gleason score (P = 0.0002), and pretherapy serum prostate specific antigen (P < 0.00001) were independently associated with clinical or biochemical relapse. These factors were included in a risk score equation that defined patient groups with a distinctly different outcome. For the low, intermediate, and high risk groups, the relapse-free probabilities at 5 years after irradiation were 92%, 67%, and 24%, respectively (P < 0.00001).

CONCLUSIONS

Readily available, pretherapy disease-related characteristics formed the basis of an enhanced prognostic system for patients with clinically localized prostate carcinoma. A multivariate prognostic system of this nature estimated patient prognosis in a more exacting fashion than a system exclusively based on anatomic factors.

Defining the ideal tumor marker for prostate cancer

The ideal tumor marker would function well for detection, screening, staging, prognosis, follow-up, and performance characteristics. Prostate-specific antigen is a remarkably good tool in this respect; however, the translation into improved patient outcomes is still uncertain.

A multiple prognostic index predictive of disease outcome after irradiation for clinically localized prostate carcinoma

BACKGROUND

This investigation was conducted to identify independent pretherapy disease-related factors associated with disease outcome in patients with clinically localized carcinoma of the prostate (CaP) and to develop models that incorporated relevant covariates for estimating the risk of disease relapse after irradiation (RT).

METHODS

The outcome of 500 patients treated only with RT between March 1987 and June 1993 for clinical Stages T1-4N0,XM0 CaP was evaluated. The risk of disease relapse as a function of individual prognostic variables, and combinations thereof, was determined using logistic regression.

RESULTS

With a median follow-up of 43 months (range, 4-103 months), 69 patients (14%) had clinical evidence of local recurrence (27 patients), regional lymph node relapse (4 patients), or metastatic relapse (38 patients) within 5 years of RT. Forty additional patients (8%) had biochemical relapse based solely on the post-RT serum prostate specific antigen (PSA) profile. Clinical tumor stage (P = 0.0006), Gleason score (P = 0.001) of the diagnostic biopsy specimen, and pretherapy PSA (P < 0.0001) were associated with disease relapse. The risk of any relapse within 5 years of RT was determined and graphically displayed as risk estimate plots for combinations of these pretherapy prognostic variables.

CONCLUSIONS

The combination of pretherapy clinical tumor (T) stage, Gleason score, and PSA level can be used to obtain improved estimates of the risk for disease relapse in patients treated solely with RT for clinically localized CaP. Risk estimate plots of this type may facilitate exchange of therapeutic outcome information, be instrumental in pretherapy decision-making for the new patient with this condition, and aid in the selection of patients for future studies.

Current prognostic factors for prostate carcinoma

BACKGROUND

Prostate carcinoma provides a wide spectrum for risk of death from the disease and clinicians have long sought methods to predict the outcome accurately in individual patients. Traditional prognostic factors, such as histologic grade and stage, remain valuable. Additional clinical and laboratory studies may add to the precision of predicting the natural history of the disease or response to therapy.

METHODS

A review of the literature on current, well accepted prognostic factors for prostate carcinoma and evolving methodology for the incorporation of new factors was conducted.

RESULTS

The most widely used current prognostic factors for survival of patients with prostate carcinoma include clinical and pathologic stage, histologic grade, prostate specific antigen (PSA) level, age, and comorbidity. DNA ploidy has been extensively studied on radical prostatectomy specimens and appears valuable, but is not widely employed. The utility of DNA ploidy on biopsy specimens is less certain because of both methodologic issues and heterogeneity within the tumor. The statistical tools used to identify and validate new prognostic factors are critical and new techniques are sought to incorporate several independent factors into a prognostic score or index for an individual patient.

CONCLUSIONS

Current prognostic factors for prostate carcinoma provide important information for patient care and research. However, new methods to define pretreatment prognosis and needed to assist clinicians and patients in making therapeutic choices for prostate carcinoma. The ideal method with which to incorporate the information attained from anatomic stage, histologic grade, PSA level, age, and comorbidity into a manageable prognostic score is uncertain and studies on this topic should be a high priority research objective.