Do Clinically Insignificant Tumors of the Prostate Exist?

Abstract

Background: The discrepancy between minimal disease on biopsy and disease found in the subsequent prostatectomy specimen, in terms of the size and grade of tumor, extracapsular extension or positive margins, led several authors to dispute the existence of clinically insignificant impalpable tumors of the prostate. However, considering that prostate-specific antigen (PSA) is an indicator of prostate malignancy and since many impalpable prostatic carcinomas (PCs) are detected by a combination of PSA, transurethral ultrasound and needle biopsy (T1c), in the era of PSA screening, it is expected that most of the impalpable tumors found incidentally at transurethral resection of the prostate (stage T1a/b), could be clinically insignificant. Aim: The aim of this study was to identify the characteristics of latent, impalpable PCs and to analyze the incidence of clinically insignificant PCs among hypothetical stage T1 prostate cancers in tumors found incidentally at postmortem examination. Methods: We examined 40 cases of impalpable PCs found in 212 prostate autopsy specimens of men between 30 and 98 years of age who died of diseases other than carcinoma of the prostate and related conditions. Results: Most of T1 histological PCs (57.5%) had a Gleason score between 2 and 4, while 30% had Gleason score between 5 and 6. Only 5 (12.5%) had a Gleason score above 7. Twenty-nine of 40 stage T1 histological cancers (67.5%) had volume of <1 cm³. The highest volume tumors were those of intermediate and high grade (Gleason sums 5–8). Among tumors with volumes of <1 cm³, 96.55% were confined within the prostatic capsule. Conclusions: The majority of impalpable PCs were low-volume, well-differentiated tumors corresponding to clinically insignificant neoplasms. Similar characteristics could be attributed to most of the impalpable carcinomas detected after prostatectomy in clinical practice.

The Impact of Technology Diffusion on Treatment for Prostate Cancer

“…7 Second, many men diagnosed with prostate cancer have a low risk of dying from the disease and thus are appropriate candidates for observation. 8,9 Third, while the evidence is mixed, robotic prostatectomy and IMRT are thought to reduce side-effects affecting urinary, sexual, and gastrointestinal quality of life while also having the potential to improve cancer control when compared to their more traditional counterparts, i.e., open radical prostatectomy and three dimensional radiotherapy. 10–12 However, both of these advanced treatments are associated with higher incremental costs compared to traditional treatments.…”

“…This would further spur overall spending for prostate cancer care and, even more important, could lead to expansion of treatment among patients who have little to gain from local therapy (e.g., those with low-risk disease or advanced age) while being exposed to treatment related morbidity. 8,9 …”

Diagnostic and prognostic molecular biomarkers for prostate cancer

“…However, these current concepts of insignificant prostate cancer, derived mainly from analyses of US cohorts, are unsatisfying and might not be applicable to European patients 139,140 . Among contemporary urologists, a lively controversy surrounds the definition of insignificant prostate cancer and whether this term is really helpful, 141,142 or if an insignificant prostate cancer exists at all 143 . Therefore, we clearly need molecular markers to help define prostate cancer aggressiveness.…”

“…139,140 Among contemporary urologists, a lively controversy surrounds the definition of insignificant prostate cancer and whether this term is really helpful, 141,142 or if an insignificant prostate cancer exists at all. 143 Therefore, we clearly need molecular markers to help define prostate cancer aggressiveness. It is desirable to identify lethal, curable and insignificant cancer cases at the time of the diagnostic biopsy.…”

DNA-cytometric grading of prostate cancer Systematic review with descriptive data analysis

“…As the probability of patients with "clinically insignificant microcarcinomas" of the prostate [5] to die from their cancer is very low: 89% overall survival after 8 years [6], 81% overall survival after 10 years [7], the strategy of AS has been designed. About 45% of all screening-detected cancers can be managed with AS [7].…”