UROLOGICAL SURVEY
Pathology
Radical prostatectomy findings in patients in whom active surveillance of prostate cancer fails
Duffield AS, Lee TK, Miyamoto H, Carter HB, Epstein JI
Department of Pathology, The Johns Hopkins Hospital, Baltimore, Maryland 21231, USA
J Urol. 2009; 182: 2274-8
PURPOSE: Little data are available on radical prostatectomy findings in men who experience disease progression following active surveillance.
MATHERIAL AND METHODS: A total of 470 men in our active surveillance program underwent annual repeat needle biopsies to look for progression defined as any Gleason pattern grade 4/5, more than 50% cancer on any core or cancer in more than 2 cores. Slides were available for review in 48 of 51 radical prostatectomies with progression.
RESULTS: The average time between the first prostate biopsy and radical prostatectomy was 29.5 months (range 13 to 70), with 44% and 75% of the patients showing progression by the second and third biopsy, respectively. There were 31 (65%) organ confined cases, of which 25 (52%) were Gleason score 6. Of 48 cases 17 (35%) had extraprostatic extension, 3 had seminal vesicle/lymph node involvement and 7 (15%) had positive margins. Mean total tumor volume was 1.3 cm(3) (range 0.02 to 10.8). Of the 48 tumors 13 (27%) were potentially clinically insignificant (organ confined, dominant nodule less than 0.5 cm(3), no Gleason pattern 4/5) and 19% (5 of 26) of the radical prostatectomies with a dominant tumor nodule less than 0.5 cm(3) demonstrated extraprostatic extension, 4 with Gleason pattern 4. All 10 tumors with a dominant nodule greater than 1 cm(3) were located predominantly anteriorly.
CONCLUSIONS: Most progression after active surveillance occurs 1 to 2 years after diagnosis suggesting undersampling of more aggressive tumor rather than progression of indolent tumor. Even with progression most tumors have favorable pathology (27% potentially insignificant). A small percentage of men have advanced stage disease (pT3b or N1). The anterior region should be sampled in men on active surveillance.
Editorial Comment
The criteria for insignificant prostate cancer in the present study were absence Gleason pattern grade 4 or 5, less than 50% cancer on any core or cancer in no more than 2 cores (1,2). It is better to consider these criteria as probabilistic predictors of small volume cancer with favorable pathologic findings. The term insignificant may be interpreted as the latent carcinoma of the prostate. Unfortunately, there is no marker so far to predict the biologic behavior of the prostate cancer. Even small volume cancers with favorable pathologic findings at the time of diagnosis may progress as clinically significant cancers.
The study showed that most progression after active surveillance occurred 1 to 2 years after diagnosis and even with progression most tumors had favorable pathology (27% potentially insignificant). The authors suggest that occurred under sampling in the needle biopsy of more aggressive tumors by the time of diagnosis rather than progression of indolent tumor.
This is an important observation. The pathologist must be aware and inform if a sample is representative of the region biopsied. The criteria for insignificant prostate cancer (or small volume cancer with pathologic findings) should be applied only in well representative needle biopsies otherwise a rebiopsy should be performed.
Dr. Athanase Billis
Full-Professor of Pathology
State University of Campinas, Unicamp
Campinas, São Paulo, Brazil
E-mail: athanase@fcm.unicamp.br
- 1. Epstein JI, Walsh PC, Carmichael M, Brendler CB: Pathologic and clinical findings to predict tumor extent of nonpalpable (stage T1c) prostate cancer. JAMA. 1994; 271: 368-74.
- 2. Bastian PJ, Mangold LA, Epstein JI, Partin AW: Characteristics of insignificant clinical T1c prostate tumors. A contemporary analysis. Cancer. 2004; 101: 2001-5.
Publication Dates
-
Publication in this collection
15 Jan 2010 -
Date of issue
Dec 2009
