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Pathologic findings after radical prostatectomy in patients with clinically low volume, low risk prostate cancer
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Pathologic findings after radical prostatectomy in patients with clinically low volume, low risk prostate cancer
Patrick A. Kenney, MD, Jessica A. Mandeville, MD, Alireza Moinzadeh, MD, John A. Libertino, MD.
Lahey Clinic Medical Center, Burlington, MA, USA.
Background: Active surveillance is a treatment option for localized adenocarcinoma of the prostate. Efforts are underway to define the patient population for whom active surveillance is an appropriate alternative. While there is no consensus, proposed criteria include low volume, low grade, clinical stage T1C or T2a, and PSA <10. To determine the incidence of upgrading or upstaging, we evaluted the post radical prostatectomy pathology specimen in patients who would have been candidates for active surveillance.
Methods: We retrospectively reviewed our database of patients who underwent radical prostatectomy between 2002-2006. We identified patients who had a standard sextant or extended core biopsy, low volume disease (disease in no more than one sextant), Gleason sum ≤ 6, PSA <10, and clinical stage T1C or T2a. Patients with non-diagnostic atypical cells in a second area were considered as having multi-focal disease and were not included. Of the 1,494 patients who underwent radical prostatectomy, 296 met the inclusion criteria. Patients were excluded if the tumor was too small to be graded on biopsy (n=7), if biopsy slides were not reviewed at our institution by a genitourinary pathologist (n=50), or if there was incomplete information about the number of cores obtained (n=11).
Results: Among the 228 study patients, median age was 59 (±6.4, 40-74) with a median preoperative PSA of 5 (±1.9, 5-9.9). 186 men (82%) were classified as clinical stage T1c. The median number of cores obtained from the gland was 12 (±2.5, 6-24). The median number of cores obtained from the positive sextant was 2 (±0.6, 1-4). 169 (74%) patients had disease in only one core. The median number of negative cores was 11 (±2.6).
72 (32%) patients were upgraded to Gleason ≥ 7 on final pathology. 4 patients (2%) had Gleason ≥ 8 disease. 142 (62%) patients had bilateral disease. 17 patients (7%) had extracapsular cancer extension and 34 (15%) patients had positive surgical margins.
Conclusions: A significant number of patients with unfavorable pathologic features may be included in active surveillance protocols. Current inclusion criteria will need to be altered to better stratify patients who may benefit from active surveillance.
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