Incidence and follow‐up of patients with focal prostate carcinoma in 2 screening rounds after an interval of 4 years

Abstract

BACKGROUND Focal carcinoma detected by needle biopsy has been a common finding since prostate‐specific antigen (PSA)‐based screening was introduced. Clinicopathologic features in patients with focal prostate carcinoma who underwent radical prostatectomy (RP) or who were treated with watchful waiting (WW) were analyzed to detect clinical predictors for disease progression during follow‐up. METHODS Patients were selected from the European Randomized Screening study for Prostate Cancer. Focal carcinoma on sextant biopsy was defined as ≤ 3.0 mm involvement by tumor in 1 biopsy core lacking Gleason pattern 4 or 5. PSA doubling time was used in the WW group as a marker of disease progression. RESULTS The proportion of patients with focal prostate carcinoma increased significantly from 16% in the first screening round to 29% in the second screening round. One hundred eighteen men underwent RP, and 108 men were treated with WW. The median tumor volume was 0.13 mL. PSA level and prostate volume were predictive for tumor volume in a multivariate regression analysis. A PSA density cut‐off level of ≤ 0.1 ng/mL/cm3 predicted organ‐confined tumor (< 0.5 mL) in 94% of patients. Positive surgical margins were predictive for PSA recurrence. Four patients in the RP group had PSA recurrence at follow‐up. PSA doubling times < 2 years, < 3 years, and < 4 years were noted in 4.9%, 14.6%, and 22.0% of patients in the WW group, respectively. CONCLUSIONS The median tumor volume was small (0.13 mL). A comparison between PSA recurrence in the RP group and PSA doubling time in the WW group showed a significantly more favorable outcome after RP if a PSA doubling time of < 3 years or < 4 years was chosen as a marker for disease progression in the WW group. A WW policy with delayed curative intent may be recommended in patients ages 55–75 years with focal carcinoma and PSA density < 0.1 ng/mL/cm3. Cancer 2005. © 2005 American Cancer Society.

The clinical management of patients with a small volume of prostatic cancer on biopsy: What are the risks of progression?

“…The origin of the articles and clinical characteristics of the subgroups of patients with microfocal carcinoma are given in Table 1. Four studies reported on men who were diagnosed in the context of the European Randomized Trial for Screening of Prostate Cancer either in the Netherlands 11,21,47 or in Sweden. 44 Details of patient selection are provided in Table 2.…”

“…Thirty-four articles 11,[15][16][17][18][19][20][21][22][23][24][25][26] addressed the specific question of the correlation between small-volume (''microfocal'') cancer on biopsy and pathologic findings, biochemical or clinical progression, or mortality, and 32 of those articles provided original data. 11,[15][16][17][18][19][20][21][22][23][24][25][26] Three of those articles were unique: One referred to the number of positive biopsy sites rather than cores, 42 another examined the relation between the number of positive cores on each side (right or left) and the incidence of extraprostatic spread on that side, 48 and the final article took into account both biopsy cancer volume and presenting PSA density in the presentation of results. 46 Those 3 articles were not considered further, because they did not provide data that were comparable with data from the other 29 articles.…”

“…With the rise of PSA-detected prostate cancer in asymptomatic men, this is an increasingly common clinical situation that affects up to 29% of men. 11 The objective of this review was to systematically evaluate the literature regarding the outcomes of men diagnosed on the basis of a small volume of cancer in prostatic biopsies. Biochemical or clinical recurrence or progression and prostate cancer-specific mortality clearly are the most relevant outcome measures.…”

Detection rates of high‐grade prostate cancer during subsequent screening visits. Results of the European Randomized Screening Study for Prostate Cancer

“…small foci of <3 mm Gleason score 6 or lower prostatic adenocarcinoma in 1 biopsy (or in G€ oteborg teborg up to 2 adjacent biopsies 16 ), may be considered as an indirect parameter for the occurrence of small-sized low Gleason score prostate cancers in the screened population. 17 As this information is not recorded in the central database, the frequency of focal cancers was only available for the Rotterdam series, the reviewed Finnish cases and the previously published G€ oteborg cases. In Table III, the proportion of focal cancers during the 1st and 2nd screening in Finland, Rotterdam 17 and G€ oteborg 16 is shown.…”

International Society of Urological Pathology (ISUP) Consensus Conference on Handling and Staging of Radical Prostatectomy Specimens. Working group 2: T2 substaging and prostate cancer volume

“…For patients with clinically insignificant cancers, defined as organ-confined (pT2), no more than 10 mm in diameter and no more than Gleason score 6, 57 the option was discussed to include a separate comment in the report in order to point out that these tumors are rarely, if at all, associated with biochemical failure, provided that the surgical margins of the prostatectomy specimen are negative. 58 Consensus was obtained that, as a minimum requirement for the reporting of prostate cancer in radical prostatectomy specimens, some quantitative estimate of cancer volume should be undertaken, the nature of which being dependent on routine practice within the pathology laboratory (Table 3). It was recommended that each laboratory should adopt a well-defined and standardized protocol and that this be used by all pathologists within the institution who report radical prostatectomy specimens.…”