AUA 2006 - Prostate Cancer Staging II Podium Session

UroToday.com - This session on staging addressed several areas of interest. With the growing stage shift in prostate tumors during the PSA era, concerns for overdetection of insignificant have grown. Several nomograms have been developed to contend with this issue and Currlin et al [ABST 1645] compared 10 available nomograms for there operational characteristics against a cohort of 646 patients with available clinical and histological data. The best fit to the clinical data was the Kattan (medium) nomogram with an area under the curve of 0.766. In general these tools were constrained by the limited specificity in the majority of cases.

The cancer of the prostate risk assessment (CAPRA) index from the University of California San Francisco underwent a multi-institutional validation Cooperberg et al [ABST 1648]. Compared to standard multivariable hazard models or nomograms, this index was developed from a community-based data base and follows a 0-10 scoring. Median follow up of the patients was 34 months and 26% of patients experienced a recurrence. The hazard ratio for each increase in point score1.39 95% [CI1.31-1.46]. 5 year actuarial recurrence free survival was 86% for scores of 0-1 and 21% for scores of 7-10. The validation of this model suggests that it may have significant application given its straight forward nature.

A reevaluation of clinical parameters and the potential for a positive bone scan was performed by Abbot et al [ABST 1652] in 467 prostate cancer patients diagnosed from 2000- 2004. Twenty three of 467 patients had a positive scan (4.9%). Only 2 patients with gleason score 7 or less disease were positive yet 16.7 percent of gleason 8-10 patients had positive scans. Further analysis suggested that the potential for a positive bone scan in gleason 7 or less patients was high only if the PSA value was greater than 30 ng/ml, while those patients with high gleason scores are at risk for a positive scan if the PSA exceeds 10ng/ml.

An effort at preoperative stratification for positive outcomes was demonstrated by Pierorazio et al [ABST 1653]. A subset of a university data based was analyzed for general PSA failure risk stratification as well as for urinary continence and erectile function. A linear analysis of all of these parameters was performed allowing an estimate of obtaining all or most of these positive outcomes. In the author's series, 71.2% of the low risk patients 52.3 % of the intermediate group patients and 47.5% of the high risk patients had the potential of obtaining excellent outcomes in all three categories (the "trifecta" per the authors). The analysis was based on a subset of patients and there was no validation or comparison with other series, yet such analysis do provide patients with a better understanding of appropriate expectations with surgery.

Fine and associates [ABST 1656] performed an analysis on the impact of minute gleason score 8-10 cancer on prostate needle biopsy. Consultant files revealed 108 patients with foci of high grade disease: 37 had Gleason 8, 41 Gleason 9 and 31 Gleason 10. Of the 42 patients who could be pathologically staged, 28/42 (66.7%) were organ confined, 7/42 had extracapsular extension with negative margins 5(11.9%) had ECE with positive margins and 2 had positive seminal vesicle or lymph node positivity. The progression free survival for these patients in different subgroups were excellent over 2-5 years (90.2% overall at 2years and 78% at five and 10 years) and 83.4 percent of patients demonstrated organ confined or ECE with negative margins. Surgery is clearly an option in a subset of these patients.

By S.Bruce Malkowicz, MD

WC 590

Supported by an unrestrictional educational grant from Sanofi-Aventis

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