Correlation of clinical stage, serum prostatic acid phosphatase and preoperative Gleason grade with final pathological stage in 275 patients with clinically localized adenocarcinoma of the prostate

Roach's Mathematical Equations in Predicting Pathological Stage in Men with Clinically Localized Prostate Cancer

Aims and Background

The therapeutic choice in patients with clinically localized prostate cancer depends on preoperative clinical stage. Diagnostic instruments currently available for such an evaluation – considered separately – have not shown enough efficacy. Roach has recently introduced three simple mathematical equations that – on the basis of prostate-specific antigen and the biopsy Gleason score – are aimed at calculating the definitive pathological stage. We retrospectively analyzed our radical prostatectomy data base to assess the accuracy of the equations in predicting the final stage in patients with clinically localized prostate cancer.

Methods Study Design

The study included 173 patients who had undergone radical retropubic prostatectomy at our Institution. Patients were divided into 25 groups, depending on preoperative PSA and the biopsy Gleason score. The risk of extracapsular neoplastic growth, seminal vesicle involvement and lymph node involvement was calculated for each group by means of Roach's equations. On the basis of definitive histological examinations, we compared the expected risk to the observed risk.

Results

The observed risk fell within the interval of expected risk in I6 of 17 groups (94%) regarding the evaluation of extracapsular growth, in I5 of 17 (88%) regarding the analysis of seminal vesicle involvement, and in 14 of 17 (82%) regarding the evaluation of lymph node involvement. Therefore, the observed event was in agreement with the expected event in 45 of 51 groups (88%).

Conclusions

The equations represent a practical and effective instrument for preoperative clinical staging in patients with localized prostate cancer. By means of these mathematical formulas, one can assess the correct prognosis and – above all – plan the best therapeutic approach.

A Deep Belief Network and Dempster-Shafer-Based Multiclassifier for the Pathology Stage of Prostate Cancer

Object

Pathologic prediction of prostate cancer can be made by predicting the patient's prostate metastasis prior to surgery based on biopsy information. Because biopsy variables associated with pathology have uncertainty regarding individual patient differences, a method for classification according to these variables is needed.

Method

We propose a deep belief network and Dempster-Shafer- (DBN-DS-) based multiclassifier for the pathologic prediction of prostate cancer. The DBN-DS learns prostate-specific antigen (PSA), Gleason score, and clinical T stage variable information using three DBNs. Uncertainty regarding the predicted output was removed from the DBN and combined with information from DS to make a correct decision.

Result

The new method was validated on pathology data from 6342 patients with prostate cancer. The pathology stages consisted of organ-confined disease (OCD; 3892 patients) and non-organ-confined disease (NOCD; 2453 patients). The results showed that the accuracy of the proposed DBN-DS was 81.27%, which is higher than the 64.14% of the Partin table.

Conclusion

The proposed DBN-DS is more effective than other methods in predicting pathology stage. The performance is high because of the linear combination using the results of pathology-related features. The proposed method may be effective in decision support for prostate cancer treatment.

Improved Prediction of the Pathologic Stage of Patient With Prostate Cancer Using the CART–PSO Optimization Analysis in the Korean Population

Objective:

In current practice, medical experts use the pathological stage predictions provided in the Partin tables to support their decisions. Hence, the Partin tables are based on logistic regression built from the US data. In the present study, we developed a data-mining model to predict the pathologic stage of prostate cancer. In this newly developed model, using the classification and regression tree-particle swarm optimization analysis of the Korean population data, we aim to improve the prediction accuracy of the pathologic state of prostate cancer.

Method:

A total of 467 patients from the smart prostate cancer database were evaluated. The results were intended to predict the pathologic stage of prostate cancer: organ-confined disease and non–organ-confined disease. The accuracy of 4 classification and regression tree-particle swarm optimization models was compared; furthermore, the models were validated with the Partin tables using the receiver operating characteristic curve.

Results:

Among the 467 evaluated patients, 235 patients had organ-confined disease and 232 patients had non–organ-confined disease. The area under the receiver operating characteristic curve of the proposed classification and regression tree-particle swarm optimization model (0.858 ± 0.034) was larger than the 1 in the Partin tables (0.666 ± 0.046).

Conclusion:

The proposed classification and regression tree-particle swarm optimization model was superior to the Partin tables in terms of predicting the risk of prostate cancer. Compared to the validation of the Partin tables for the Korean population, the classification and regression tree-particle swarm optimization model resulted in a larger receiver operating characteristic curve and a more accurate prediction of the pathologic stage of prostate cancer in the Korean population.

Prostate cancer markers: An update

As the most common noncutaneous malignancy in American men, prostate cancer currently accounts for 29% of all diagnosed cancers, and ranks second as the cause of cancer fatality in American men. Prostatic cancer is rarely symptomatic early in its course and therefore disease presentation often implies local extension or even metastatic disease. Thus, it is extremely critical to detect and diagnose prostate cancer in its earliest stages, often prior to the presentation of symptoms. Three of the most common techniques used to detect prostate cancer are the digital rectal exam, the transrectal ultrasound, and the use of biomarkers. This review presents an update regarding the field of prostate cancer biomarkers and comments on future biomarkers. Although there is not a lack of research in the field of prostate cancer biomarkers, the discovery of a novel biomarker that may have the advantage of being more specific and effective warrants future scientific inquiry.

Review by urological pathologists improves the accuracy of Gleason grading by general pathologists

Backgrounds

Urologists use biopsy Gleason scores for patient counseling, prognosis prediction, and decision making. The accuracy of Gleason grading is very important. However, the variability of Gleason grading between general pathologists cannot be overlooked. Here we evaluate the discrepancy in the Gleason grading between 2 urologic pathologists and general pathologists as well as improvement in the accuracy of Gleason grading by general pathologists as a result of review by urologic pathologists.

Methods

The subjects enrolled in the study were 755 patients who underwent prostate needle biopsy at affiliate hospitals of Nara Medical University over a period of 2 years. The biopsy samples were diagnosed by general pathologists. All biopsy samples were sent to Nara Medical University where they were diagnosed by 2 urologic pathologists. The results were then returned to the general pathologists. We compared the diagnostic accuracy of the general pathologists with that of the urologic pathologists for the parameters of no malignancy, atypical small acinar proliferation, high grade prostatic intraepithelial neoplasia and Gleason score (6, 3 + 4, 4 + 3 and 8–10). We then evaluated the concordance rate between the general and urologic pathologists for each of four consecutive 6-month periods.

Results

The overall concordance rate of urologic pathologists and general pathologists in the first, second, third and last 6-month periods was 71.8 % (140/198), 79.8 % (168/225), 89.7 % (166/185) and 89.9 % (133/148), respectively. The concordance rate of the Gleason score between urologic pathologists and general pathologists in the first, second, third and last 6-month periods was 47.5 %(38/80), 62.6 %(57/91),76.9 %(50/65) and 78.7 %(48/61), respectively, and the kappa value was 0.55, 0.68, 0.81 and 0.84, respectively. The concordance rate improved significantly over the course of each period (P = 0.04).

Conclusion

The concordance rate of the Gleason grading between the general pathologists and the urologic pathologists was 47.5 %. However, improvement of the concordance rate as a result of review by the urological pathologist could be seen.

Immunotherapy for prostate cancer: lessons from responses to tumor-associated antigens

Prostate cancer (PCa) is the most common cancer in men and the second most common cause of cancer-related death in men. In recent years, novel therapeutic options for PCa have been developed and studied extensively in clinical trials. Sipuleucel-T is the first cell-based immunotherapeutic vaccine for treatment of cancer. This vaccine consists of autologous mononuclear cells stimulated and loaded with an immunostimulatory fusion protein containing the prostate tumor antigen prostate acid posphatase. The choice of antigen might be key for the efficiency of cell-based immunotherapy. Depending on the treatment strategy, target antigens should be immunogenic, abundantly expressed by tumor cells, and preferably functionally important for the tumor to prevent loss of antigen expression. Autoimmune responses have been reported against several antigens expressed in the prostate, indicating that PCa is a suitable target for immunotherapy. In this review, we will discuss PCa antigens that exhibit immunogenic features and/or have been targeted in immunotherapeutic settings with promising results, and we highlight the hurdles and opportunities for cancer immunotherapy.

Clinical and pathological variables that predict changes in tumour grade after radical prostatectomy in patients with prostate cancer

INTRODUCTION

Preoperative Gleason score is crucial, in combination with other preoperative parameters, in selecting the appropriate treatment for patients with clinically localized prostate cancer. The aim of the present study is to determine the clinical and pathological variables that can predict differences in Gleason score between biopsy and radical prostatectomy.

METHODS

We retrospectively analyzed the medical records of 302 patients who had a radical prostatectomy between January 2005 and September 2010. The association between grade changes and preoperative Gleason score, age, prostate volume, prostate-specific antigen (PSA), PSA density, number of biopsy cores, presence of prostatitis and high-grade prostatic intraepithelial neoplasia was analyzed. We also conducted a secondary analysis of the factors that influence upgrading in patients with preoperative Gleason score ≤6 (group 1) and downgrading in patients with Gleason score ≤7 (group 2).

RESULTS

No difference in Gleason score was noted in 44.3% of patients, while a downgrade was noted in 13.7% and upgrade in 42.1%. About 2/3 of patients with a Gleason score of ≤6 upgraded after radical prostatectomy. PSA density (p = 0.008) and prostate volume (p = 0.032) were significantly correlated with upgrade. No significant predictors were found for patients with Gleason score ≤7 who downgraded postoperatively.

CONCLUSION

Smaller prostate volume and higher values of PSA density are predictors for upgrade in patients with biopsy Gleason score ≤6 and this should be considered when deferred treatment modalities are planned.

Smaller prostate gland size and older age predict Gleason score upgrading

OBJECTIVES

Gleason score is important for prostate cancer (CaP) risk stratification and prognostication but has a significant rate of upgrading. We examined the effect of prostate size and age on upgrading of Gleason 6 CaP.

MATERIALS AND METHODS

A retrospective review was performed of patients with Gleason 6 CaP who underwent radical prostatectomy from 2001 through 2010. Preoperative clinical and pathologic variables were assessed to determine association with risk of upgrading at prostatectomy.

RESULTS

A total of 1,836 patients were identified with Gleason 6 on prostate biopsy. Upgrading was observed in 543 (29.6%) patients with a final Gleason score of 3+4 in 463 (25.2%), 4+3 in 49 (2.7%), and 8-10 in 31 (1.7%). On univariate logistic regression, age, prostate weight, and PSA were significant predictors of Gleason score upgrading and remained significant on multiple logistic regression. Prostate weight was inversely related to risk of upgrading. To further explore this effect, we performed multiple logistic regression to examine risk of Gleason 6, 7, or 8-10 disease in 2,493 patients with Gleason 6-10 at prostatectomy. After controlling for age and PSA, there was a progressively increased risk of Gleason 6, 7, and 8-10 disease with decreasing prostate weight.

CONCLUSIONS

Older age, higher PSA, and smaller prostate gland size are associated with increased risk of Gleason score upgrading. The inverse relationship of prostate weight to risk of Gleason upgrading may be related to increased high-grade disease in smaller glands.

Nuclear grading versus Gleason grading in small samples containing prostate cancer: a tissue microarray study

In this study we addressed the question whether nuclear grading in very small samples of prostate cancer would provide additional prognostic information as compared to Gleason grading. Therefore, a tissue microarray (TMA) was constructed comprising a total number of 3,261 prostate cancers. Blinded for all clinical and pathological data, the TMA spots (diameter 0.6 mm) containing cancer were graded with two systems: First, for nuclear features according to a modified Fuhrman grading system, and second, by using a simplified Gleason system. The results were compared with tumour stage, tumour grade and follow-up data. Although nuclear grading could easily be performed on the TMA spots, no correlation was found with tumour stage, grade or PSA recurrence after prostatectomy. However, Gleason grading, even when performed on the small TMA spots, provided significant prognostic information. Correlation with Gleason scores determined in the complete prostatectomy specimens showed moderate agreement in low-grade (score ≤ 6) or intermediate (score = 7) tumours, but poor agreement with high-grade (score ≥ 8) tumours. In conclusion, the Fuhrman grading of prostate cancer does not appear to be of any prognostic importance so the Gleason grading remains the system of choice, even in tumour specimens smaller than 1 mm.

The relationship between preoperative prostate-specific antigen and biopsy Gleason sum in men undergoing radical retropubic prostatectomy: a novel assessment of traditional predictors of outcome

OBJECTIVE

To investigate the relationship between prostate-specific antigen (PSA) level and Gleason sum, and its impact on biochemical failure (persistent PSA level of >0.2 ng/mL) after radical prostatectomy (RP), as the PSA, Gleason sum and clinical stage are commonly used preoperative predictors of outcome in men with localized prostate cancer.

PATIENTS AND METHODS

The Columbia Urologic Oncology Database was reviewed (1988-2006); 3460 had undergone RP. Patients who received neoadjuvant/adjuvant therapy or had incomplete data were excluded, yielding 1932 in the analysed sample. Analysis of variance (ANOVA) methods were used to assess differences in PSA level (on a log scale) among three different groups of patients, categorized by their Gleason sum scores, as <7, 7 and >7. To account for full penetrance of PSA screening, surgery before 1998 was considered as a potential confounder. ANOVA was used to determine whether the association of Gleason score and PSA levels differed before and after 1998. The effect of PSA level on biochemical failure was examined for variance among the three Gleason score groups using a Cox proportional hazards model with time to biochemical failure as the outcome, logPSA, Gleason sum (<7, 7 and >7), their interaction, and clinical stage as the predictors. Concordance indices (c-index) were calculated for the model with and without the interaction term between PSA and Gleason sum to determine its significance.

RESULTS

Of 1932 patients, 1190 (61.6%) had a Gleason sum of <7, 595 (30.8%) of 7 and 146 (7.6%) of >7. The median PSA level was 5.9, 6.1 and 7.8 ng/mL, respectively (P < 0.001). After adjusting for clinical stage, there was no significant interaction effect (P = 0.34) between Gleason sum and time of surgery on PSA level, implying that the relationship between Gleason sum and PSA levels has not changed over these two periods, despite changes in PSA screening. Results from the Cox model showed that PSA level, Gleason sum, their interaction term and clinical stage were significant predictors of biochemical failure. The c-index for the model without the interaction term was 0.70 and increased to 0.72 when including it, indicating an increase in the predictive ability of the model when including the interaction term.

CONCLUSION

PSA level and Gleason sum are highly interrelated variables, although they each carry additional information that significantly contributes to the prediction of biochemical failure. This study shows that, for an individual patient, the higher the initial PSA level the higher the risk of having poorly differentiated prostate cancer. Also, predictive models of biochemical failure can be improved by considering the interaction between PSA and Gleason sum.

Interobserver reproducibility of Gleason grading: evaluation using prostate cancer tissue microarrays

OBJECTIVES

Due to PSA screening and increased awareness, prostate cancer (PCa) is identified earlier resulting in smaller diagnostic samples on prostate needle biopsy. Because Gleason grading plays a critical role in treatment planning, we undertook a controlled study to evaluate interobserver variability among German pathologists to grade small PCas using a series of tissue microarray (TMA) images.

METHODS

We have previously demonstrated excellent agreement in Gleason grading using TMAs among expert genitourinary pathologists. In the current study, we identified 331 TMA images (95% PCa and 5% benign) to be evaluated by an expert PCa pathologist and subsequently by practicing pathologists throughout Germany. The images were presented using the Bacus Webslide Browser on a CD-ROM. Evaluations were kept anonymous and participant's scoring was compared to the expert's results.

RESULTS

A total of 29 German pathologists analysed an average of 278 images. Mean percentage of TMA images which had been assigned the same Gleason score (GS) as done by the expert was 45.7%. GSs differed by no more than one point (+/-1) in 83.5% of the TMA samples evaluated. The respondents were able to correctly assign a GS into clinically relevant categories (i.e. <7, 7, >7) in 68.3% of cases. A total of 75.9% respondents under-graded the TMA images. Gleason grading agreement with the expert reviewer correlated with the number of biopsies evaluated by the pathologist per week. Years of diagnostic experience, self-description as a urologic pathologist or affiliation with a university hospital did not correlate with the pathologist's performance.

CONCLUSION

The vast majority of participants under-graded the small tumors. Clinically relevant GS categories were correctly assigned in 68% of cases. This raises a potentially significant problem for pathologists, who have not had as much experience evaluating small PCas.

The use of body mass index to predict pathological stage in patients with clinically localized prostate cancer

BACKGROUND

To investigate whether body mass index (BMI) is an independent risk factor for nonorgan-confined disease in patients with clinically localized prostate cancer.

PATIENTS AND METHODS

Overall, 735 patients undergoing radical prostatectomy formed the study cohort. Pathological and clinical factors with special emphasis to BMI were used to determine a model for the prediction of nonorgan-confined disease.

RESULTS

359 patients had pathologically nonorgan-confined prostate cancer. These patients showed a significantly higher BMI than those with organ-confined disease (26.7 vs. 26.2; p = 0.0012). In multivariate analysis, age (p = 0.049), prostate-specific antigen (PSA) (p < 0.001), clinical stage (p < 0.001), prostatectomy grade (p < 0.001), and BMI (p = 0.004) were independent risk factors for nonorgan-confined disease. In patients with a serum PSA between 10.1 and 20 ng/ml only prostatectomy grade (p < 0.001) and BMI (p = 0.005) remained independent predictors.

CONCLUSION

Patients with nonorgan-confined disease showed a significantly higher BMI than those with organ-confined stages. Moreover, BMI was an independent predictor for nonorganconfined prostate cancer. This knowledge might be helpful in patient counseling to choose between various options for the treatment of clinically localized prostate cancer.

Tumour and target volumes in permanent prostate brachytherapy: A supplement to the ESTRO/EAU/EORTC recommendations on prostate brachytherapy

The aim of this paper is to supplement the GEC/ESTRO/EAU recommendations for permanent seed implantations in prostate cancer to develop consistency in target and volume definition for permanent seed prostate brachytherapy. Recommendations on target and organ at risk (OAR) definitions and dosimetry parameters to be reported on post implant planning are given.

A Correlation of FTIR Spectra Derived from Prostate Cancer Biopsies with Gleason Grade and Tumour Stage

OBJECTIVES

We introduce biochemistry as a second dimension to Gleason grading, using Fourier transform infrared (FTIR) microspectroscopy. For the first time, we correlate FTIR spectra derived from prostate cancer (pCA) tissue with Gleason score and the clinical stage of the tumour at time of biopsy.

METHODS

Serial sections from paraffin-embedded pCA tissue were collected. One was stained with hematoxylin and eosin and Gleason scored; FTIR spectra were collected from malignant locations using a second unstained section. FTIR spectra, representing different Gleason grades, were used to construct a diagnostic classifier for pCA using linear discriminant analysis (LDA). This model was blind tested using 383 IR spectra from 36 biopsies.

RESULTS

Using a three-band Gleason criteria, we obtained sensitivity of > or =70% for the FTIR-LDA model to predict Gleason <7,=7, and >7, with specificities of > or =81%. Using a threshold of Gleason/FTIR-LDA score of > or =8, we obtained a sensitivity and specificity of 71% and 67%, respectively, for the correlation with metastatic tumours using the FTIR-LDA system and 85% and 63%, respectively, for the correlation of metastatic tumours using the Gleason system.

CONCLUSIONS

There is a correlation between tissue architecture using Gleason score with tissue biochemistry using FTIR-LDA. Both systems are similar in their performance in predicting metastatic behaviour in tumours from individual patients.

Determinants for Prediction of Malignant Potential by Metalloproteinase:E-Cadherin Ratio in Prostate Core Needle Biopsy

According to a good correlation between in situ hybridization-based metalloproteinase-2/9:E-cadherin ratio (MER) and the pathological stage of prostate cancer, we set the cutoff line of MER at 6.0 (MER>6) to distinguish between organ-confined (pT2) and advanced diseases (pT3a-b/N1). In this study, we looked at the factors affecting MER and leading to a misprediction of the pathological stage. We examined MER in 39 paired specimens of prostate core needle biopsy and prostatectomy from the same patient and compared these MERs. In 34 (87%) of 39 cases, the MER of biopsy was correlated with the final pathological stage (pT2 vs. pT3a-b/N1). MER ranges in pT3a-b/N1 cancer were significantly wider than those in pT2 cancer (p < 0.01). The number of MER>6 fields in Gleason score 8-9 cancer was larger than that in Gleason score 7 cancer (p < 0.0001). In 5 cases where there was a failure to distinguish pT2 from pT3a-b/N1, the misdiagnosis was significantly associated with a small number of biopsies (4 or 6 specimens; p = 0.0469), a small amount of tumor tissue in biopsy specimens (less than 5 mm; p = 0.0492), and a wide MER range (more than 5.0; high intratumoral heterogeneity; p = 0.0202). Considering these factors increases the usefulness of preoperative prediction of the final pathological stage by MER in prostate cancer.

Comparison of Gleason grade and score between preoperative biopsy and prostatectomy specimens in prostate cancer

AIM

Although the histopathological findings obtained from biopsy specimens are important for choosing the appropriate management of prostate cancer, there have been some discrepancies in Gleason grade and consequently, score between biopsy and surgical specimens. A comparison of findings between these two kinds of specimens was performed.

METHODS

Radical prostatectomy was performed at Asahi General Hospital on 223 cases of T1b-T3 without previous cancer treatment, and the Gleason grade and score of the biopsy and surgical specimens were compared.

RESULTS

A 37% coincidence in Gleason score was obtained between biopsy and surgical specimens; coincidence including one digit difference in score was approximately 70%. Upgrading was more than downgrading. Disagreement in secondary grade was greater than that in primary grade. Disagreement in Gleason score was roughly similar among different score items and was not influenced by level of prostate-specific antigen, however, the small volume of the cancer tissues more affected the discrepancy in score.

CONCLUSION

The use of biopsy findings is required to be taken into account regarding the discrepancy.

Prognostic factors in prostate cancer

Prognostic factors in organ confined prostate cancer will reflect survival after surgical radical prostatectomy. Gleason score, tumour volume, surgical margins and Ki-67 index have the most significant prognosticators. Also the origins from the transitional zone, p53 status in cancer tissue, stage, and aneuploidy have shown prognostic significance. Progression-associated features include Gleason score, stage, and capsular invasion, but PSA is also highly significant. Progression can also be predicted with biological markers (E-cadherin, microvessel density, and aneuploidy) with high level of significance. Other prognostic features of clinical or PSA-associated progression include age, IGF-1, p27, and Ki-67. In patients who were treated with radiotherapy the survival was potentially predictable with age, race and p53, but available research on other markers is limited. The most significant published survival-associated prognosticators of prostate cancer with extension outside prostate are microvessel density and total blood PSA. However, survival can potentially be predicted by other markers like androgen receptor, and Ki-67-positive cell fraction. In advanced prostate cancer nuclear morphometry and Gleason score are the most highly significant progression-associated prognosticators. In conclusion, Gleason score, capsular invasion, blood PSA, stage, and aneuploidy are the best markers of progression in organ confined disease. Other biological markers are less important. In advanced disease Gleason score and nuclear morphometry can be used as predictors of progression. Compound prognostic factors based on combinations of single prognosticators, or on gene expression profiles (tested by DNA arrays) are promising, but clinically relevant data is still lacking.

PSGR2, a novel G-protein coupled receptor, is overexpressed in human prostate cancer

The G-protein coupled receptors (GPCRs) recognize a large variety of extracellular molecules (such as hormones, neurotransmitters, growth and developmental factors) and several sensory messages (such as light, odors and pain). GPCRs and their signal transduction pathway represent important specific targets for a variety of human diseases. To investigate the potential roles of GPCRs in human normal prostate and prostate cancers, we identified and characterized a novel human G-protein coupled receptor, PSGR2, which is highly overexpressed in human prostate cancers. Although PSGR2 shares sequence homology with human olfactory G-protein coupled receptors, the expression of PSGR2 is highly restricted to human prostate tissue, and no expression was detected in 22 normal and 10 tumor tissues examined using Northern blot and PCR analysis. Furthermore, we investigated the expression levels of PSGR2 in 133 human prostate samples with real-time quantitative reverse transcription-PCR and in situ hybridization method. We demonstrated that PSGR2 expression increased significantly in human high grade prostate intraepithelial neoplasia (PIN) and prostate cancers (approximately 10-fold) as compared to normal and BPH (benign prostatic hyperplasia) tissues (p < 0.001), suggesting PSGR2 may play an important role in human prostate cancer development and progression. Together, our results suggest that PSGR2 is a novel prostate specific G-protein coupled receptor and may be useful as a tissue marker and molecular target for the early detection and treatment of human prostate cancers.

Diagnostic utility of alpha-methylacyl CoA racemase (P504S) on prostate needle biopsy

Alpha-methylacyl CoA racemase (AMACR), also known as P504S, was identified by the analysis of cDNA library subtraction in conjunction with high throughput microarray screening from prostate tissue and has been proven to be one of the very few biomarkers that can distinguish cancer from benign cells with high sensitivity and specificity for prostate carcinoma. It is a successful example of the translation of molecular findings into clinical practice. This review focuses on the study of AMACR (P504S) expression in small focal prostate cancer and atypical small acinar proliferation (ASAP) on needle biopsies and emphasizes the utility of AMACR (P504S) in routine surgical pathology practice. We also discuss the potential pitfalls and caveats in the interpretation of immunostaining results.

Cancer de la prostate. Épidémiologie. Facteurs de risques. Anatomopathologie

Prostate cancer (prostate adenocarcinoma) has become an important concern in terms of public health these past fifteen years; recent French epidemiological data revealed 10,104 deaths due to this disease in 2000. The two main factors involved are the serum prostatic specific antigen (PSA), routinely used since late 1980's and which allows early diagnosis (before symptom onset), and the lengthened duration of life. Such cancer is rare before the age of 50, but its frequency increases with age, making it the most frequent type of cancer in French men. Although the aetiology of this disease is unknown, the ethnic origin, and a familial history of prostate or breast cancer are known risk factors. Predisposing genes to such hereditary types remain to be identified. Other genetic factors (polymorphisms), combined with environmental factors such as nutrition, have been incriminated, which is likely to explain the geographical variations of this affection. At the molecular level, the mechanisms involved in the tumoral initiation and progression remain unclear. Various genetic alterations have been identified among the genome of cancerous cells, at various stages of the affection: intraepithelial neoplasia, localized, locally advanced, metastatic or hormone refractory stage -, hormonal escape). However, the precise sequence and nature of the complex molecular events remain to be determined prior to their routine utilisation in the determination of subjects at risk, or as prognostic factors, and even as therapeutic targets. The anatomopathology is a key for the diagnosis. Intraepithelial neoplasia is the pre-cancerous lesion observed in most adenocarcinomas; these are localized in the peripheral part of the prostate gland in 70% of the cases. Gleason's classification is the current gold standard for the determination of tumoral aggressiveness and categorisation of the adenocarcinomas which are basically heterogeneous (coexistence of tumors cells with different degrees of differenciation in the same tumor). This anatomopathological classification allows distinguishing the tumours in terms of potential progressiveness and prognosis, and hence, to orientate the therapeutic strategy in case of localised or locally advanced prostate cancer.

Preoperative serum acid phosphatase and alkaline phosphatase are not predictors of pathological stage and prostate-specific antigen failure after radical prostatectomy

OBJECTIVE

To examine the utility and prognostic significance of enzymatic serum acid phosphatase (total acid phosphatase, TAP, and prostatic fraction of acid phosphatase, PFAP) and alkaline phosphatase (ALP) for staging, grading and outcome of patients who underwent radical retropubic prostatectomy (RRP) after the introduction of prostate-specific antigen (PSA) testing.

PATIENTS AND METHODS

In all, 180 consecutive patients with clinically localized prostate cancer who underwent RRP with standard obturator lymph-node dissection between 1 January 1990 and 31 December 1995 were evaluated. Levels of TAP of > 5.4 IU/L, PFAP of > 1.2 IU/L and ALP of > 120 IU/L were classified as abnormally high. The relationship between abnormally high values and prostate cancer stage, grade and time to recurrence after RRP were calculated. The median follow-up was 86 months (approximately 7 years).

RESULTS

Of the 180 patients, information about preoperative TAP, PFAP and ALP were available in 164, 163 and 154, respectively; TAP was abnormal in seven (4%), PFAP in 33 (20%) and ALP in only 13 (8%). None of the markers examined was associated with any variables of disease severity, as measured by pathological stage, Gleason score, perineural invasion, capsular penetration, positive margins, seminal vesicle involvement, and lymph node involvement. Abnormal TAP, PFAP or ALP were not associated with recurrence (P = 0.96, 0.45 and 0.41, respectively). In contrast, a PSA level of > 4 ng/mL was predictive of recurrence after RRP (P < 0.001). In the sample overall, 25 (14%) of the patients had recurrence and only one died from prostate cancer.

CONCLUSIONS

Preoperative enzymatic serum TAP, PFAP and ALP levels are not predictors of the severity of disease or PSA disease-free recurrence after RRP.

The free-to-total serum prostatic specific antigen ratio as a predictor of the pathological features of prostate cancer

OBJECTIVES

Curative therapy and extended period of disease free survival for patients with prostate cancer is possible only if the radical prostatectomy is performed when the disease is organ confined. It has been shown that combined use of local clinical stage, Gleason score of transrectal needle biopsy and serum PSA can accurately predict the final pathological stage in men undergoing radical prostatectomy. Recently the free/total PSA (F/T PSA) has been shown to improve the specificity of serum PSA level in early detection prostate cancer. In this study the utility of F/T PSA ratio in prediction the final pathological features of the prostate cancer was investigated.

METHODS

52 patients who had undergone radical prostatectomy were included in this study with mean age of 63 (ranging from 49 to 73). According to the pathologic features of the tumors, patients were classified as organ confined in 37 (%71), specimen-confined in 39 (%75) and as with favorable pathology which was defined as organ confined or specimen confined with Gleason score lower than 7, 39 (%75) patients.

RESULTS

Neither total PSA levels nor F/T PSA values correlate significantly with the pathological characteristics of the tumor. The logistic regression analysis showed that the biopsy Gleason score was the only variable that was able to predict the pathology of the tumor (p < 0,05).

CONCLUSION

As a conclusion Gleason score of the needle biopsy specimen is the most predictive factor of the final pathological outcome. F/T PSA ratio did not provide additional information about predicting pathological stage.

Contemporary preoperative parameters predict cancer-free survival after radical prostatectomy: a tool to facilitate treatment decisions

Prostate specific antigen (PSA) screening has heralded stage migration in prostate cancer toward cancers that may be readily eliminated by primary intervention. We sought to identify contemporary, preprostatectomy measures of cancer severity useful and significant for predicting postprostatectomy, recurrence-free survival. The association of baseline variables clinical variables (age, clinical stage, serum PSA, and race) and prostate biopsy parameters (Gleason score, presence of perineural invasion, number of biopsy cores with cancer, and the greatest percentage of a biopsy core occupied by cancer--GPC) with recurrence-free survival was evaluated by multivariate Cox proportional hazards regression among consecutive patients that underwent radical prostatectomy as primary therapy between 1994 and 2002. Tables were generated depicting expected 5-year recurrence-free survival after prostatectomy. From 1414 patients, 183 developed biochemical recurrence, 8 died from prostate cancer, and 31 died of all causes. Multivariable Cox regression found that clinical stage, PSA, Gleason score, and the greatest percentage of a biopsy core involved by cancer (GPC), were each significant determinants of post-prostatectomy, PSA recurrence-free survival (P < 0.05 for each). Gleason score and GPC were also significantly associated with clinical recurrence-free survival and cancer death, whereas other biopsy parameters and PSA were not. The amount of cancer in a biopsy core is a significant predictor of recurrence-free survival after prostatectomy, and is a simple clinical measure that complements baseline PSA, and Gleason score in predicting outcome. Tabulated 5-year PSA-free survival outcomes, stratified by these preoperative parameters, provide a basis for preoperative counseling of patients regarding postprostatectomy cancer control expectations.

Intraoperative lymph node staging of prostate cancer: the case against

BACKGROUND

Intraoperative frozen section analysis of obturator nodes is an accepted screening procedure, excluding from prostatectomy that group of node-positive patients who are presumed to almost always have disseminated cancer. The overall efficacy of this procedure depends not only on the near inevitability of cancer progression in these patients, but also the procedure morbidity (previously estimated at 8.4%), the additional costs (currently estimated at A$1200) and the infrequency of positive nodes. We evaluate the efficacy of lymph node staging for prostate cancer.

METHODS

We have evaluated the efficacy of intraoperative screening by node dissection in 123 prostatectomy cases. These cases were prescreened from a series of 261 radical prostatectomies by evaluating preoperative serum PSA and Gleason grade.

RESULTS

Three patients were identified with nodal disease, representing a detection rate of 2.4%. The present study confirms that current trends in prostate cancer identification and selection of individuals for radical surgery very rarely identify node-positive disease even after preselection with accepted 'high-risk' markers.

CONCLUSION

Considering the attendant cost and morbidity, there appears to be no justification for lymph node dissection as a routine preliminary to prostatectomy.

Biochemical staging of prostate cancer

PSA continues to be one of the most effective and widely used cancer screening tools available. Its popularity in prostate cancer screening, however, has eroded its usefulness in the staging of this disease. As more men are screened every year on a routine basis with DRE and PSA, the average PSA at diagnosis has drifted down to well below 10 ng/mL in many centers, including ours. This trend is likely to accelerate, as a PSA cut off for prompting biopsy of the prostate of 2.5 ng/mL gains more widespread acceptance. The recent realization that, at these levels, serum PSA is more reflective of the presence of BPH than of the extent of cancer and, therefore, does not provide additional staging information, has renewed the search for new biochemical markers that are capable of predicting prostate cancer stage and prognosis. Because of the heterogeneity of this disease, it is unlikely that a single biochemical marker that is capable of accurately staging all prostate cancer patients will be found. For this reason, nomograms that are capable of integrating various parameters to predict stage and prognosis will remain indispensable. As new biochemical markers that provide independent predictive information about stage or prognosis are identified, they can be incorporated into currently available nomograms. Of the biochemical markers discussed in this article, IL-6sR and TGF-beta1 are the most promising. By incorporating them into a preoperative nomogram designed to predict PSA recurrence, we found that they improved the ability to predict biochemical recurrence by a statistically and clinically significant margin. The ability to stage prostate cancer and predict response to therapy has improved dramatically over the last 3 decades. Nevertheless, there is still a need for new biochemical markers that will improve the ability to predict an individual patient's stage and response to therapy. Incorporating these new markers into nomograms will enhance the ability to provide optimal care for each prostate cancer patient.

Treatment of prostate cancer with radiotherapy: should the entire seminal vesicles be included in the clinical target volume?

PURPOSE

When treating high-risk prostate cancer with radiation therapy, inclusion of the seminal vesicles (SVs) within the clinical target volume (CTV) can dramatically increase the volume of radiated normal tissues and hinder dose escalation. Because cancer may involve only the proximal portion of the frequently lengthy SVs, we performed a complete pathology review of prostatectomy specimens to determine the appropriate length of SV to include within the CTV when SV treatment is indicated.

METHODS AND MATERIALS

A detailed pathologic analysis was performed for 344 radical prostatectomy specimens (1987-2000). All slides from each case were reviewed by a single pathologist (N.S.G.). Factors recorded for each case included length of each SV (cm), length of cancer involvement in each SV (cm) measured from the prostate-SV junction, and percentage of SV length involved.

RESULTS

Fifty-one patients (15%) demonstrated SV involvement in 81 SVs (21 unilateral, 30 bilateral SV involvement). The median SV length was 3.5 cm (range: 0.7-8.5 cm). Factors associated with SV involvement included the pretreatment PSA level, biopsy Gleason score, and clinical T classification. The commonly used risk group stratification was very effective at predicting SV positivity. Only 1% of low-risk patients (PSA <10 ng/mL, Gleason <or=6, and clinical stage <or=T2a) demonstrated SV involvement vs. 27% of high-risk patients. Patients with only one high-risk feature still demonstrated a 15% risk of SV involvement, whereas 58% of patients with all three high-risk features had positive SVs. The median length of SV involvement was 1.0 cm (90th percentile: 2.0 cm, range: 0.2-3.8 cm). A median of 25% of each SV was involved with adenocarcinoma (90th percentile: 54%, range: 4%-75%). For the 81 positive SVs, no factor was associated with a greater length or percentage of SV involvement. In the entire population, 7% had SV involvement beyond 1.0 cm. There was an approximate 1% risk of SV involvement beyond 2.0 cm or 60% of the SV. In addition, this risk was less than 4% for all subgroups, including high-risk patients.

CONCLUSIONS

A portion of the SV should be included in the CTV only for higher-risk patients (PSA >or=10 ng/mL, biopsy Gleason >or=7, or clinical T stage >or=T2b). When treating the SV for prostate cancer, only the proximal 2.0-2.5 cm (approximately 60%) of the SV should be included within the CTV.

P504S: a new molecular marker for the detection of prostate carcinoma

The ability to diagnose prostate carcinoma would be improved by the detection of a tumor-associated antigen. P504S, a cytoplasmic protein, was recently identified by cDNA library subtraction in conjunction with high throughput microarray screening from prostate carcinoma. The aim of this study was to establish the pattern of expression of P504S in prostate carcinoma and benign prostatic tissue. A total of 207 cases, including 137 cases of prostate carcinoma and 70 cases of benign prostate, from prostatectomies (n = 77), prostate needle biopsies (n = 112), and transurethral prostate resections (n = 18) were examined by immunocytochemistry for P504S. P504S showed strong cytoplasmic granular staining in 100% of prostate carcinomas regardless of Gleason scores and diffuse (>75% of tumor) staining in 92% of cases. In contrast, 171 of 194 (88%) of benign prostates, including 56 of 67 (84%) benign prostate cases and 115 of 127 (91%) cases of benign glands adjacent to cancers were negative for P504S. The remainders of benign prostates were focally and weakly positive for P504S. The staining pattern of these normal glands was different and easily distinguishable from that observed in prostate carcinoma. Expression of P504S was not found in basal cell hyperplasia, urothelial cells/metaplasia and small atrophic glands that may mimic prostate carcinoma. Our findings indicate that P504S is a highly sensitive and specific positive marker for prostate carcinoma.

Indications and contraindications for nerve-sparing radical prostatectomy

Nerve-sparing radical prostatectomy can be performed safely in most men undergoing radical prostatectomy. As is true in many aspects of prostate cancer diagnosis and therapy, the key element is patient selection. With many prostate tumors diagnosed at an earlier stage, the authors have seen a shift toward more favorable pathologic findings at the time of surgery. Concomitant with the success of early detection of prostate cancer is the realization that men are younger at the time of diagnosis and more interested in preserving sexual function. This article has described factors associated with an increased risk for extraprostatic tumor and, subsequently, an increased possibility of postprostatectomy cancer recurrence. Except for the previously mentioned absolute contraindications, none of these factors, by themselves, should be used to exclude a patient from nerve-sparing prostatectomy. Instead, meticulous attention must be given to the surgical dissection. If any doubt remains regarding residual tumor, the surgeon should err on the side of caution and remove the neurovascular bundle. The use of standardized intraoperative frozen-section analysis can help guide these decisions. The patient must be informed before surgery regarding the risks of nerve-sparing surgery, the potency rates of the surgeon, and the possibility that, to ensure adequate cancer control, the nerves may be sacrificed despite any preoperative optimism favoring the potential for their salvage.

Serum acid phosphatase level and biochemical recurrence following radical prostatectomy for men with clinically localized prostate cancer

OBJECTIVES

Serum acid phosphatase (ACP) was once used as the marker for advanced prostate cancer. However, with the development of assays for prostate-specific antigen (PSA), a more sensitive and specific tumor marker, the use of ACP has diminished. We investigated the prognostic value of preoperative serum ACP in predicting prognosis for men with localized prostate cancer following radical retropubic prostatectomy (RRP).

METHODS

Of 2293 men treated from 1982 to 1998, 1681 men had a preoperative ACP measurement using an enzymatic assay. We analyzed the actuarial freedom from biochemical (PSA) progression following RRP according to ACP levels. We used multivariate logistic regression and proportional hazards models to determine the independent prognostic value of ACP level with respect of pathologic stage and biochemical recurrence.

RESULTS

ACP was not an independent predictor of organ confinement or lymph node involvement in the multivariate logistic regression models using preoperative variables. However, in the proportional hazards model, ACP was an independent predictor of tumor recurrence following RRP, and there was a statistically significant improvement in biochemical recurrence-free survival for men with lower levels of ACP (P <0.001). Furthermore, the normalized hazard ratios of ACP and PSA for predicting biochemical recurrence were similar.

CONCLUSIONS

Stratification of men according to their preoperative ACP levels was predictive of patient outcome after RRP. Proportional hazards modeling using preoperative variables demonstrated that the serum ACP level is an independent predictor of tumor recurrence following RRP.

Prostate Cancer - Old Problems and New Approaches. (Part II. Diagnostic and Prognostic Markers, Pathology and Biological Aspects)

Diagnostic and prognostic markers for prostatic cancer (PCa) include conventional protein markers (e.g., PAP, PSA, PSMA, PIP, OA-519, Ki-67, PCNA, TF, collagenase, and TIMP 1), angiogenesis indicator (e.g., factor VIII), neuroendocrine differentiation status, adhesion molecules (E-cadherin, integrin), bone matrix degrading products (e.g., ICPT), as well as molecular markers (e.g., PSA, PSMA, p53, 12-LOX, and MSI). Currently, only PSA is used clinically for early diagnosis and monitoring of PCa. The histological differential diagnosis of prostatic adenocarcinoma includes normal tissues such as Cowper's gland, paraganglion tissue and seminal vesicle or ejaculatory duct as well as pathological conditions such as atypical adenomatous hyperplasia, atrophy, basal cell hyperplasia and sclerosing adenosis. A common PCa is characterized by a remarkable heterogeneity in terms of its differentiation, microscopic growth patterns and biological aggressiveness. Most PCa are multifocal with signi ficant variations in tumor grade between anatomically separated tumor foci. The Gleason grading system which recognizes five major grades defined by patterns of neoplastic growth has gained almost uniform acceptance. In predicting the biologic behavior of PCa clinical and pathological stages are used as the major prognostic indicators. Among the cell proliferation and death regulators androgens are critical survival factors for normal prostate epithelial cells as well as for the androgen-dependent human prostatic cancer cells. The androgen ablation has been shown to increase the apoptotic index in prostatic cancer patients and castration also promotes apoptotic death of human prostate carcinoma grown in mice. The progression of PCa, similarly to other malignancies, is a multistep process, accompanied by genetic and epigenetic changes, involving phenomenons as adhesion, invasion and angiogenesis (without prostate specific features).

The prognostic significance of tertiary Gleason patterns of higher grade in radical prostatectomy specimens: a proposal to modify the Gleason grading system

The Gleason grading system of prostatic adenocarcinoma does not account for the existence of a tertiary (third most prevalent) pattern, and there are no studies concerning the latter's prognostic influence. The authors analyzed 114 radical prostatectomies with small tertiary components, which mostly occupied less than 5% of whole tumors. These specimens were compared with a prostatectomy database comprised of 2,276 cases without a tertiary component. The pathologic stages of "typical" Gleason score 5 to 6 tumors (Gleason scores 2 + 3 = 5, 3 + 2 = 5, 3 + 3 = 6), which contained tertiary patterns 4 or 5, were significantly higher than those of "typical" Gleason score 5 to 6 tumors without pattern 4 (p = 0.018) but lower than those of "typical" Gleason score 7 tumors (p = 0.021; Gleason scores, 3 + 4 = 7, 4 + 3 = 7). Typical Gleason score 7 tumors with a tertiary pattern 5 showed significantly worse pathologic stages than typical Gleason score 7 tumors (p = 0.008) without pattern 5 and were not different statistically from typical Gleason score 8 (Gleason score, 4 + 4 = 8) tumors. Both typical Gleason score 5 to 6 and 7 tumors with tertiary components revealed significantly higher progression rates than typical Gleason score 5 to 6 tumors (p <0.0001) and Gleason score 7 tumors (p = 0.003) without tertiary components, and progressed like typical Gleason score 7 and 8 tumors respectively. Tertiary high-grade components have an adverse impact on biologic behavior. The authors propose that the Gleason system for radical prostatectomy specimens be modified to take into account small volumes of patterns 4 and 5, which are important prognostically.

[Radical prostatectomy in prostate adenocarcinoma. Clinical factors influencing the pathological stage. Diagnostic model]

MATERIAL AND METHODS

Study on the efficacy of stage diagnosis, how to support it based on clinical objective data and description of a prognostic model. Analysis of 160 patients diagnosed with localized prostate adenocarcinoma undergoing radical prostatectomy in the Clínica Universitaria de Navarra between 1988-1997. The statistical study used Fisher's or Pearson's tests for the comparison of qualitative variables. A logistic regression multivariate analysis was run to avoid confounding factors in the pathological stage.

RESULTS

85/160 (53%) were correctly staged. Incorrect staging occurred in patients with higher clinical stage (T1-T2a: 25%; T2bc: 65%). The univariate study shows that the pathological stage is significantly correlated to: a) serum PSA levels (15 ng/mL in P2 vr. 25 ng/mL in P3-4), the most suitable cutoff value being 15 ng/mL. b) digital rectal examination and Gleason. Negatively influencing factors in the multivariate study were: PSA greater than 15 ng/mL, Gleason greater than 5 and a T2bc clinical stage. Risk groups: 4 risk groups are established based on the above factors (inclusion in group 1 involves an 8% risk of having P3, 30% in group 2, 56% in group 3 and 84% in group 4).

CONCLUSIONS

The clinical factors with influence in the pathological stage are PSA, Gleason and clinical stage. The reliability of the risk groups established based on these factors is remarkable.