The prognostic significance of perineural invasion and race in men considering active surveillance

Abstract

Objective• To determine the importance of perineural invasion (PNI) on diagnostic biopsy in men enrolled in active surveillance (AS). Patients and Methods• Eligibility criteria for AS included clinical stage ≤ T2a and Gleason score ≤6, ≤3 cores positive, maximum single core involvement <50%, and total tumour volume ≤5% on diagnostic biopsy.• All men received 12-core confirmation biopsy at ≤6 months.• AS 'failure' on confirmatory biopsy was defined as failure to meet one or more eligibility criteria.• Risk of AS failure was compared in men with and without PNI. Results• For the 165 men comprising the study population, the mean (SD) age was 66.9 (6.5) years and the median (interquartile, IQR) PSA level of men at study entry was 4.4 (3.2-6.0) ng/mL. The median (IQR) follow-up was 5.5 (1.1-9.9) months.• In all, 8.5% (14/165 men) had PNI on diagnostic biopsy.• Compared with those without PNI, men with PNI tended to have more cores involved with cancer, at a mean (SD) of 2.0 (0.7) vs 1.6 (0.8) cores (P = 0.08) but did not have significantly a greater mean (SD) total tumour length on diagnostic biopsy, at 3.0 (2.1) vs 2.3 (3.6) mm (P = 0.27).• Men with PNI on diagnostic biopsy were significantly more likely to meet criteria for disease progression on confirmatory biopsy (57% [8/14] vs 21% [32/151]; P = 0.006).• PNI remained a significant predictor for AS failure after adjustment for number of positive cores, maximum percentage core involvement, and total tumour length (odds ratio 4.4, 95% confidence interval 1.4-14.2). Conclusions• PNI on diagnostic biopsy is associated with disease progression on confirmatory biopsy.• The presence of PNI should factor into appropriate patient selection and counselling in AS.

Can perineural invasion detected in prostate needle biopsy specimens predict surgical margin positivity in D’Amico low risk patients?

“…PNI in PNB was considered as an important criterion in the decisionmaking of active surveillance in several studies. Still, in these studies, PNI was associated with higher tumor volume, which did not indicate a poor prognosis (9)(10)(11). In an investigation performed by Walsh and Epstein in 1993, the authors reported that knowledge about the presence and extent of PNI in needle biopsy specimens might provide information about capsular penetration and aid in the decision-making process for nerve-sparing surgery (12).…”

Active Surveillance for Prostate Cancer: A Systematic Review of Clinicopathologic Variables and Biomarkers for Risk Stratification

“…They concluded that, if the goal of AS is to monitor men with low grade disease, AA men may require alternative selection criteria. Cohn et al (11) similarly showed that AA race was a significant predictor of reclassification confirmation biopsy, along with perineural invasion, body mass index (BMI), PSA density and number of positive cores at diagnostic biopsy. However, in other studies race was not a significant predictor of surveillance biopsy outcome or conversion to active treatment (10, 13–18).…”

“…Only a few studies included BMI as a potential predictor of reclassification (10, 11), PSA growth (38), or time to active treatment (17), of which one found a significant association (11). Similarly, Iremashvili et al (9) did not find a significant relationship between metabolic syndrome components with increases in grade or extent of cancer on surveillance biopsy.…”

“…The extent of cancer on biopsy such as number of positive cores, cancer length and/or percentage of core involvement were also shown in the majority of studies to be important predictors of disease progression or the probability of remaining on AS (5, 9, 11, 14, 19, 21, 24, 25, 27, 32, 35, 40, 45–47). Bul et al (19) showed that the strongest predictors for short-term biopsy reclassification (> 2 positive cores or GS >6 at repeat biopsy) were PSA density and the number of positive cores (2 versus 1).…”

Prostate cancer with perineural spread and dural extension causing bilateral lumbosacral plexopathy: case report

“…4,13 Its prognostic value is still controversial, but in more recent studies primarily focused on PNI, it appears to be an independent prognostic factor associated with decreased survival and increased recurrence rate. 1,6,7,11 PNI is the major mechanism of prostate cancer spread outside the prostate gland. 24 Nerves not only harbor cancer cells, but they appear to actively promote cancer cell penetration 19 and survival and decrease apoptosis of the invading cells.…”