Pathologic and clinical findings to predict tumor extent of nonpalpable (stage T1c) prostate cancer

J. I. Epstein, P. C. Walsh, M. Carmichael and C. B. Brendler
Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Md.

OBJECTIVES--We examined preoperative clinical and pathologic parameters in men with clinical stage T1c disease who underwent radical prostatectomy and correlated these findings with the pathologic extent of disease in the surgical specimen in an attempt to identify a subset of patients with potentially biologically insignificant tumor who might be followed up without immediate treatment. DESIGN AND PATIENTS--A case series of 157 consecutive men who underwent radical prostatectomy for clinical stage T1c disease compared with 64 similarly treated clinical stage T1a cancers (incidental minimal cancers found on transurethral resection of prostate) and 439 clinical stage T2 (palpable) cancers. MAIN OUTCOME MEASURES--Pathologic stage, grade, and margins; tumor volume; and tumor location. RESULTS--Sixteen percent of tumors were insignificant (< 0.2 cm3 and confined to the prostate, with a Gleason score < 7); 10% were minimal (0.2 to 0.5 cm3 and confined to the prostate, with a Gleason score < 7); 37% were moderate (> 0.5 cm3 or capsular penetration, with a Gleason score < 7); and 37% were advanced (capsular penetration, with a Gleason score > or = 7 or positive margins, seminal vesicles, or lymph nodes). These findings are intermediate between those found in clinical stage T1a and stage T2 disease. The following parameters were not predictive of tumor extent: age, reason for evaluation, method of detection, and transrectal ultrasound. The best model predicting insignificant tumor was prostate-specific antigen (PSA) density less than 0.1 ng/mL per gram and no adverse pathologic findings on needle biopsy, or PSA density of 0.1 to 0.15 ng/mL per gram, with a low- to intermediate-grade cancer smaller than 3 mm found in only one needle biopsy core specimen. The positive predictive value of the model was 95%, with a negative predictive value of 66%. We accurately predicted 73% of cases with insignificant tumor. CONCLUSIONS--Eighty-four percent of nonpalpable prostate cancers diagnosed by screening techniques are significant tumors and warrant definitive therapy. However, 16% are insignificant. Serum PSA level, PSA density, and needle biopsy pathologic findings are accurate predictors of tumor extent. It may be reasonable to follow up some patients whose tumors are most likely insignificant with serial PSA measurements and repeated biopsies.

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Do patients with low volume prostate cancer have prostate specific antigen recurrence following radical prostatectomy?
Furusato et al.
J. Clin. Pathol. 2008;61:1038-1040.
ABSTRACT | FULL TEXT  

Pathologic Characteristics of Cancers Detected in the Prostate Cancer Prevention Trial: Implications for Prostate Cancer Detection and Chemoprevention
Lucia et al.
Cancer Prevention Research 2008;1:167-173.
ABSTRACT | FULL TEXT  

Case 15-2008 -- A 55-Year-Old Man with an Elevated Prostate-Specific Antigen Level and Early-Stage Prostate Cancer
Barry et al.
NEJM 2008;358:2161-2168.
FULL TEXT  

What to Do with an Abnormal PSA Test
Loeb and Catalona
The Oncologist 2008;13:299-305.
ABSTRACT | FULL TEXT  

Prospective Evaluation of Selection Criteria for Active Surveillance in Japanese Patients with Stage T1cN0M0 Prostate Cancer
Kakehi et al.
Jpn J Clin Oncol 2008;0:hym161v1-7.
ABSTRACT | FULL TEXT  

Baseline Prostate-Specific Antigen Level and Risk of Prostate Cancer and Prostate-Specific Mortality: Diagnosis Is Dependent on the Intensity of Investigation
Connolly et al.
Cancer Epidemiol. Biomarkers Prev. 2008;17:271-278.
ABSTRACT | FULL TEXT  

Needle Biopsies on Autopsy Prostates: Sensitivity of Cancer Detection Based on True Prevalence
Haas et al.
JNCI J Natl Cancer Inst 2007;99:1484-1489.
ABSTRACT | FULL TEXT  

Outcomes of Treatment vs Observation of Localized Prostate Cancer in Elderly Men
Porter
JAMA 2007;297:1652-1652.
FULL TEXT  

Commentary: On the incidence of histological prostate cancer and the probable diagnosis of cases with tumours too small to produce symptoms or to attract attention on physical examination--the findings of Dr Arnold Rice Rich
Adolfsson
Int J Epidemiol 2007;0:dym053v1-3.
FULL TEXT  

Diagnosis of adenocarcinoma in prostate needle biopsy tissue
Humphrey
J. Clin. Pathol. 2007;60:35-42.
ABSTRACT | FULL TEXT  

Incidence of initial local therapy among men with lower-risk prostate cancer in the United States.
Miller et al.
JNCI J Natl Cancer Inst 2006;98:1134-1141.
ABSTRACT | FULL TEXT  

Population-based screening for prostate cancer by measuring free and total serum prostate-specific antigen in Iran
Safarinejad
Ann Oncol 2006;17:1166-1171.
ABSTRACT | FULL TEXT  

The Natural History of Clinically Localized Prostate Cancer
Gann and Han
JAMA 2005;293:2149-2151.
FULL TEXT  

Prostate Cancers in Men with Low PSA Levels -- Must We Find Them?
Carter
NEJM 2004;350:2292-2294.
FULL TEXT  

Prostate Pathology of Genetically Engineered Mice: Definitions and Classification. The Consensus Report from the Bar Harbor Meeting of the Mouse Models of Human Cancer Consortium Prostate Pathology Committee
Shappell et al.
Cancer Res. 2004;64:2270-2305.
ABSTRACT | FULL TEXT  

Temporarily Deferred Therapy (watchful waiting) for Men Younger Than 70 Years and With Low-Risk Localized Prostate Cancer in the Prostate-Specific Antigen Era
Carter et al.
JCO 2003;21:4001-4008.
ABSTRACT | FULL TEXT  

Verification Bias in Screening for Prostate Cancer
Leiner et al.
NEJM 2003;349:1672-1673.
FULL TEXT  

Prognostic Significance of Visible Lesions on Transrectal Ultrasound in Impalpable Prostate Cancers: Implications for Staging
Augustin et al.
JCO 2003;21:2860-2868.
ABSTRACT | FULL TEXT  

Inherited Genotype and Prostate Cancer Outcomes
Rebbeck
Cancer Epidemiol. Biomarkers Prev. 2002;11:945-952.
ABSTRACT | FULL TEXT  

RESPONSE: Re: Pathologic Features of Prostate Cancer Found at Population-Based Screening With a Four-Year Interval
Hoedemaeker et al.
JNCI J Natl Cancer Inst 2002;94:228-229.
FULL TEXT  

Quantitation of GSTP1 Methylation in Non-neoplastic Prostatic Tissue and Organ-Confined Prostate Adenocarcinoma
Jeronimo et al.
JNCI J Natl Cancer Inst 2001;93:1747-1752.
ABSTRACT | FULL TEXT  

Molecular Cytogenetic Analysis of Prostatic Adenocarcinomas from Screening Studies : Early Cancers May Contain Aggressive Genetic Features
Alers et al.
Am. J. Pathol. 2001;158:399-406.
ABSTRACT | FULL TEXT  

Effect of 13-cis-Retinoic Acid on Serum Prostate-specific Antigen Levels in Patients with Recurrent Prostate Cancer after Radical Prostatectomy
Shalev et al.
Clin. Cancer Res. 2000;6:3845-3849.
ABSTRACT | FULL TEXT  

Clinical Utility of the Percentage of Positive Prostate Biopsies in Defining Biochemical Outcome After Radical Prostatectomy for Patients With Clinically Localized Prostate Cancer
D’Amico et al.
JCO 2000;18:1164-1172.
ABSTRACT | FULL TEXT  

Caveolin-1 Expression in Clinically Confined Human Prostate Cancer: A Novel Prognostic Marker
Yang et al.
Cancer Res. 1999;59:5719-5723.
ABSTRACT | FULL TEXT  

Predicting Tumor Failure in Prostate Carcinoma after Definitive Radiation Therapy: Limitations of Models Based on Prostate-specific Antigen, Clinical Stage, and Gleason Score
Vollmer and Montana
Clin. Cancer Res. 1999;5:2476-2484.
ABSTRACT | FULL TEXT  

CLAR1, a Novel Gene That Exhibits Enhanced Expression in Advanced Human Prostate Cancer
Rondinelli and Tricoli
Clin. Cancer Res. 1999;5:1595-1602.
ABSTRACT | FULL TEXT  

Oncodiagnosis Panel: 1997 : Prostatic Carcinoma
Lawton et al.
RadioGraphics 1999;19:185-203.
FULL TEXT  

Screening for Prostate Cancer with Prostate-Specific Antigen -- An Examination of the Evidence
Woolf
NEJM 1995;333:1401-1405.
FULL TEXT