Pathology

doi:10.1590/S1677-55382004000200018

UROLOGICAL SURVEY

Pathology

Vascular invasion is an independent prognostic factor in prostatic adenocarcinoma

Carr MD, Koch MO, Eble JN, Zeng G, Daggy J, Cheng L

Indiana University School of Medicine, Indianapolis, Indiana, USA

Mod Pathol. 2004; 17 (suppl.1): 144A

BACKGROUND: Prostate cancer is a significant cause of cancer morbidity and mortality in North American men. Tumor grade and stage are well-accepted prognostic factors. Histologic demonstration of tumor in vascular spaces has been associated with poor prognosis in many tumor types. Whether vascular invasion represents an independent prognostic factor for disease progression is uncertain in prostate cancer.

DESIGN: 504 cases of prostatic adenocarcinoma from patients undergoing radical prostatectomy were reviewed for the presence of vascular invasion. Clinical followup data was available for 459 cases.

RESULTS: Vascular invasion was identified in 106 (21%) of the cases. Univariate analysis showed a significant association between vascular invasion and PSA recurrence, tumor stage, Gleason grade, extraprostatic extension, seminal vesicle invasion, lymph node metastasis, surgical margins, perineural invasion, and preoperative serum PSA level (all p < 0.001). No association was observed between vascular invasion and age at surgery, prostate weight, or the presence of high grade prostatic intraepithelial neoplasia. Vascular invasion is an independent predictor of PSA recurrence after controlling for tumor stage and Gleason grade in the multivariate analysis.

CONCLUSIONS: Vascular invasion can be seen in approximately 20% of prostate cancers. Vascular invasion is an independent risk factor for PSA recurrence.

Editorial Comment

This paper emphasizes the importance of vascular invasion in radical prostatectomies. Most of the pathologists do not report this finding because it does not alter staging of the tumor. The same occurs in kidney and urinary bladder tumors except in testicular neoplasias. Since the 1997 edition of the TNM system for classification of malignant tumors, testicular neoplasms limited to the testis but with vascular invasion are classified as pT2 tumors.

The study from the Indiana University showed that vascular invasion seen in approximately 20% of prostate cancers is an independent predictor of PSA recurrence after controlling for tumor stage and Gleason grade in the multivariate analysis. It was shown that vascular invasion is important and should be reported by pathologists. We hope that this finding is confirmed by other studies and considered in future staging systems.

Dr. Athanase Billis

Full-Professor of Pathology

State University of Campinas, Unicamp

Campinas, São Paulo, Brazil

The combined percentage of Gleason 4 and 5 is the best predictor of cancer progression after radical prostatectomy

Cheng L, Koch MO, Daggy J

Indiana University School of Medicine, Indianapolis, Indianapolis, USA

Mod Pathol. 2004; 17 (suppl.1): 145A

BACKGROUND: Clinical outcome is variable in prostate cancer patients treated by radical prostatectomy. The Gleason histologic grade of prostatic adenocarcinoma is one of the strongest predictors of biological aggressiveness of prostate cancer. We evaluate the significance of relative proportion of high grade cancer (Gleason pattern 4 and/or 5) in predicting cancer progression in prostate cancer patients treated by radical prostatectomy.

DESIGN: Radical prostatectomy specimens from 364 consecutive prostate cancer patients were totally embedded and whole mounted. Various clinical and pathologic characteristics were analyzed. All the data were collected prospectively.

RESULTS: The primary Gleason grade, secondary Gleason grade, Gleason score sum, the presence of Gleason grade 4, % of Gleason grade 4, the presence of Gleason grade 5, % of Gleason grade 5, and the combined % of Gleason grade 4 and 5 were all predictive of PSA recurrence (all P value <0.001). However, based on the Likelihood Ratio Test statistic the combined % of Gleason grade 4/5 is the best predictor of PSA recurrence. In a multivariate analysis that included the combined % of Gleason grade 4/5, Gleason score sum, tumor stage (T2 vs. T3), and surgical margins, only the combined % of Gleason grade 4/5 (P = 0.005) and surgical margins (P=0.01) were independent predictors of PSA recurrence.

CONCLUSIONS: The combined percentage of Gleason 4 and 5 is one of the most powerful predictors of patient outcome. We recommend that the combined percentage of Gleason 4 and 5 be evaluated in radical prostatectomy specimens.

Editorial Comment

As a measure of intrinsic biologic aggressiveness, Gleason grading may be enhanced by both structural (morphologic and morphometric) and functional means (by using gene expression profiling, for example). One proposed morphologic approach is quantitation of the amount of high-grade (percentage Gleason grade 4/5) carcinoma.

This paper clearly showed that the combined percentage of Gleason 4 and 5 is one of the most powerful predictors of patient outcome. We have recently evaluated in our Department 88 patients submitted to radical prostatectomy with a follow-up period of 12 to 63 (median = 26 months).Our data showed that comparing Gleason score (< 7 vs. = 7) and Gleason predominant grade (< 4 vs. 4/5) in the surgical specimen, only Gleason grade 4/5 was a statistically significant predictor of progression (recurrence and/or metastases) following radical prostatectomy.

Urologists should differentiate high-grade Gleason score 4 + 3 = 7 from 3 + 4 = 7. They have different biological significance. Pathologists should always report grade 4/5 in radical prostatectomy specimens even if it corresponds to a tertiary grade.