A Multivariate Analysis of Clinical and Pathological Factors that Predict for Prostate Specific Antigen Failure after Radical Prostatectomy for Prostate Cancer

Abstract

A Cox regression multivariate analysis was done to determine the clinical and pathological indicators that predict for prostate specific antigen (PSA) failure in 347 patients who underwent radical prostatectomy for clinically localized prostate cancer between 1989 and 1993. In the patient subgroups (PSA less than 20 ng./ml. and biopsy Gleason sum 5 to 7 or PSA more than 10 to 20 ng./ml. and biopsy Gleason sum 2 to 4) not classifiable into those at high and low risk for postoperative PSA failure using PSA and biopsy Gleason sum, the status of the seminal vesicles and prostatic capsule on endo-rectal coil magnetic resonance imaging (MRI) allowed for this categorization. Specifically, 2-year actuarial PSA failure rates were 84% versus 23% in patients with and without seminal vesicle invasion, respectively, on MRI (p < 0.0001) and 58% versus 21% in those with and without extracapsular extension, respectively (p = 0.0001). In patients with extracapsular extension but without pathological involvement of the seminal vesicle(s) or poorly differentiated tumors (pathological Gleason sum 8 to 10), the 2-year actuarial PSA failure rates were 50% (margin positive), 28% (margin negative with established extracapsular disease) and 9% (margin negative with focal microscopic extracapsular disease). Therefore, endo-rectal coil MRI showing seminal vesicle invasion or extracapsular extension when the PSA level is less than 20 ng./ml. and the biopsy Gleason sum is 5 to 7 or the PSA level is more than 10 but less than 20 ng./ml. and the biopsy Gleason sum is 2 to 4 predicted for PSA failure. In patients with extracapsular extension who had pathological Gleason sum less than 8 disease with uninvolved seminal vesicles, the margin status and extent of extracapsular disease predicted for PSA failure.

The role of radical prostatectomy in patients with clinically localized prostate cancer and a prostate-specific antigen level >20 ng/ml

“…However, the rate of positive lymph node was 31%. A similar low 2-year bRFS of 24% was observed in 64 patients with PSApt 420 ng/ml after RP by D'Amico et al 18 In a more recent study, D'Amico et al 5 reported an estimated 2-and 10-year bRFS of 58 and 29%, respectively, after RP in 414 patients classified in the high-risk group (PSApt 420 ng/ml or biopsy Gleason score 47 or stage T2c). The difference observed between these D'Amico's studies is likely owing to group size and prognostic variations within the high-risk group.…”

“…ECE rates of 50-85% have been reported in patients with PSApt 420 ng/ml. 2,9,18,19,21 However, in most studies, the rates reported were over 70%.…”

International Society of Urological Pathology (ISUP) Consensus Conference on Handling and Staging of Radical Prostatectomy Specimens. Working group 4: seminal vesicles and lymph nodes

“…Seminal vesicle invasion by prostatic adenocarcinoma (pT3b) has generally been shown to be a predictor of poor prognosis after radical prostatectomy, [18][19][20][21] and is commonly associated with other forms of extraprostatic extension such as infiltration into surrounding adipose tissue. Despite this, the literature relating to seminal vesicle infiltration by tumor was greatly distorted by differences in how the seminal vesicles are sampled and assessed.…”

“…This issue was considered in a comprehensive literature review 22 that revealed large differences in major series, in both the percentages of cases with seminal vesicle invasion and in the 5-year recurrence-free survival that ranged from 5 to 60%. [19][20][21][23][24][25][26][27] The main conclusions from the literature search were that conformity to one definition and a uniform approach to seminal vesicle invasion is essential for the analysis and comparison of future radical prostatectomy series, in order to derive staging information that provides meaningful data for survival analysis and prognostic tables.…”

Formalized prediction of clinically significant prostate cancer: is it possible?

“…Because of these advantages, nomograms tend to predict outcomes more accurately than other methods of risk estimation, including risk groupings. [17][18][19][20][21][22][23][24] There are a number of published nomograms based on pre-treatment data that predict clinical end points related to the aggressiveness of prostate cancer and which may be useful in determining eligibility for surveillance ( Table 2). Kattan and colleagues 25 developed a nomogram to predict the probability of indolent prostate cancer, defined as a tumor volume ,0.5 cc, pathological Gleason score f6 and confined to the prostate (Figure 1).…”