The Continuing Importance of Transrectal Ultrasound Identification of Prostatic Lesions

PURPOSE

In light of a recent tendency toward systematic nontargeted biopsy we reassessed whether identification and biopsy of ultrasonographically suspicious lesions contribute to the detection of prostate cancer.

MATERIALS AND METHODS

We reviewed prospectively gathered data on 7,426 transrectal ultrasound directed prostatic biopsies performed at our institution between June 16, 2000 and September 1, 2005. Patients underwent systematic biopsy (6 to 10 cores on initial biopsy and 13 to 15 on rebiopsy) with additional sampling of visible suspicious lesions. The RR for finding cancer in transrectal ultrasound positive and negative patients was calculated for likely independent prognostic variables.

RESULTS

A total of 3,828 biopsies (51.5%) were transrectal ultrasound negative and 3,598 (48.5%) were transrectal ultrasound positive. Prostate cancer was detected in 3,258 biopsies (43.9%). For each independent variable the RR for prostate cancer was higher if a sonographic lesion was present. A lesion increased the likelihood of cancer detection (57.8% vs 30.8%, RR 1.8). Biopsies from lesions identified by transrectal ultrasound had a greater median percent of the core involved with cancer (50% vs 10%, p <0.001) and they were more likely to have Gleason score 7 or greater (69.3% vs 28.3%, p <0.001).

CONCLUSIONS

Biopsies taken when a prostatic lesion is identified by transrectal ultrasound are almost twice as likely to show cancer than when no lesion is visible. These cancers are of higher grade and volume and, therefore, they are more clinically significant. The search for and targeted biopsy of suspicious lesions seen on transrectal ultrasound remains important for prostate cancer diagnosis.

Does year of radical prostatectomy independently predict outcome in prostate cancer?

OBJECTIVES

To examine how the biochemical outcomes after radical prostatectomy (RP) have changed in the prostate-specific antigen (PSA) era when controlling for the effects of other prognostic variables. Since the beginning of the PSA era, the presentation, treatment, and therapeutic outcomes of prostate cancer have evolved.

METHODS

We reviewed the Columbia University Comprehensive Urologic Oncology Database and identified 1319 patients who had undergone RP without adjuvant therapy, performed by three surgeons, between 1988 and 2003 (minimal follow-up of 12 months). Univariate Cox proportional hazards models were used to determine which variables affect the hazard of biochemical failure (BCF), defined as a PSA level of 0.2 ng/mL or greater on at least two occasions, after RP. Multivariate analysis, controlling for the effects of other prognostic variables, was used to determine the effect that the year of surgery had on hazard of BCF.

RESULTS

Univariate analysis confirmed the importance of the year of surgery, preoperative PSA level, pathologic stage, Gleason sum, and surgical margin status in estimating the hazard of BCF (P <0.001). Age at surgery did not have a statistically significant effect. A multivariate Cox model showed that the year of surgery had a highly significant impact on the hazard of BCF even when controlling for PSA, stage, Gleason sum, and surgical margin status.

CONCLUSIONS

Patients undergoing RP in more recent years are at significantly less risk of BCF compared with patients who underwent surgery earlier in the PSA era, even when controlling for the effects of other prognostic variables. The factors that account for this change in outcomes over time have yet to be identified.

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.

Do younger men have better biochemical outcomes after radical prostatectomy?

OBJECTIVES

To examine the relationship between age and biochemical failure after radical prostatectomy (RP), controlling for the year of surgery. Prior studies have suggested that younger men have lower prostate-specific antigen recurrence rates after RP, although none of the prior studies had controlled for the year of surgery.

METHODS

We examined the data from 1753 men treated with RP between 1988 and 2002 at five equal access medical centers. We compared age, as a categorical variable according to decade of life (50 years old or younger, 51 to 60, 61 to 70, and older than 70 years), with the clinical and pathologic variables at RP, as well as the time to biochemical recurrence, using a multivariate Cox proportional hazards model.

RESULTS

Age was significantly related to the year of surgery, with the more recently treated patients being younger than less recently treated patients (P <0.001). After controlling for the year of surgery, the younger men had smaller prostates, fewer high-grade tumors on biopsy, and less lymph node metastasis, but a greater percentage of cores with cancer. On multivariate analysis, men 50 years old or younger had significantly lower recurrence rates than did the older men. Moreover, men older than 70 years had significantly greater prostate-specific antigen failure rates than men aged 51 to 70 years or men aged 50 years or younger.

CONCLUSIONS

The average age of men undergoing RP has decreased with time. Independent of this, young men have more favorable outcomes after RP than older men. Continued screening to detect prostate cancer among younger men when it is most curable appears warranted.

Time trends in pathologic features of radical prostatectomy—impact of family history

We investigated whether the clinical or pathological features of patients with a family history of prostate cancer treated by radical prostatectomy differ from patients without a family history. A retrospective analysis of patients treated by radical prostatectomy between 1989 through 2000 was performed. The clinical and pathologic features of patients with a family history (defined as at least one first-degree relative with prostate cancer, N = 103) were compared with those with no family history (N = 456). In addition, the patients were stratified into two groups, those treated from 1989 through 1992 and those treated after 1992. In the entire cohort from 1989 through 2000, patients with a family history had a greater proportion of well-differentiated tumors than the NFH group (26.2% vs. 17.8%; P = 0.05). From 1989 to 1992 there was no statistical difference between patients with a family history (FH) and those without a family history (NFH) with respect to age, prostate specific antigen (PSA), PSA density, clinical or pathologic stage, Gleason grade, or total tumor volume. However, after 1992 the FH group tended to be younger than the NFH group (61.1 vs. 63.4; P = 0.02) and have a lower PSA (6.8 vs. 7.9; P = 0.01) at the time of diagnosis. We believe these differences are predominantly driven by more aggressive screening in patients with a family history of prostate cancer rather than any true genetic differences.

Extended peripheral zone biopsy schemes increase cancer detection rates and minimize variance in prostate specific antigen and age related cancer rates: results of a community multi-practice study

PURPOSE

We assessed the impact of age and prostate specific antigen (PSA) on extended systematic biopsy schemes for detecting prostate carcinoma and better characterized these tumors as a function of patient age and PSA.

MATERIALS AND METHODS

We retrospectively reviewed the records of 2,299 consecutive patients who underwent initial systematic biopsy performed by 167 community based urologists. A total of 12 systematic biopsies of the peripheral zone were obtained in all patients. Various biopsy schemes were then created and cancer detection rates were calculated. Data analyses were stratified by patient age and PSA.

RESULTS

On biopsy 1,020 patients (44.4%) had cancer. Detection rates increased with increasing patient age. Increasing age and PSA were associated with larger, higher grade tumors. Overall and unique site specific cancer detection rates were highest for laterally directed biopsies and the apical biopsy of the standard sextant scheme. The 12 site biopsy scheme outperformed all other schemes in patients with PSA 7 ng./ml. or less and in those 60 years or younger. The variation in age related and PSA related detection rates was greatest for the standard sextant scheme and this variability decreased for extended biopsy schemes.

CONCLUSIONS

This multi-practice community based study confirms the inadequacy of sextant biopsies and emphasizes the need for extended peripheral zone sampling of the lateral aspect of the prostate. Generally increasing patient age and PSA were associated with larger, higher grade tumors. Extended biopsy schemes minimize PSA and age related detection rates.