Faculty Bibliography

OBJECTIVES: To examine the treatment outcomes of men who would have been eligible for active surveillance (AS) but underwent immediate radical retropubic prostatectomy (RRP). AS protocols are designed to spare the potential morbidity of treatment to patients with low-risk prostate cancer (PCa). METHODS: From a prospective RRP database, we evaluated the tumor features and treatment outcomes for men who would have met 1 of 3 published AS criteria: (1) clinically localized disease, Gleason < or = 7, and no significant comorbidities (Patel et al, J Urol. 2004;171:1520-1524) (2) T1b-T2b N0M0 disease, Gleason < or = 7, and prostate-specific antigen < or = 15 ng/mL (Choo R et al. J Urol. 2002;167:1664-1669), or (3) T1c PCa (Mohler JL et al. World J Urol. 1997;15:364-368.). RESULTS: 3959, 3536, and 2330 RRP patients, respectively, would have met these AS criteria. At surgery, 3%-4% had a Gleason score of 8-10, 16%-19% had positive surgical margins, 15%-18% had extracapsular tumor extension, 3%-5% had seminal vesicle invasion, and 0.4%-1% had lymph node metastasis. The 5-year progression-free survival rate ranged from 84%-89%. Metastasis occurred in 0.1%-1.2%, and 0.1%-0.9% died of PCa. On multivariate analysis, Gleason score > 6 was the strongest predictor of biochemical progression. CONCLUSIONS: A substantial proportion of men who might have been considered potential AS candidates had aggressive tumor features at RRP and/or progression. Biopsy Gleason score > 6 was the strongest predictor of adverse outcomes, highlighting the importance of limiting AS to patients with Gleason < or = 6. Overall, the accurate identification of patients with truly indolent PCa at the time of diagnosis remains challenging.

PURPOSE: A controversy of current prostate specific antigen based prostate cancer screening is the over detection of potentially insignificant prostate cancer. Because PSA kinetics were previously linked to prostate cancer specific mortality, we determined whether prostate specific antigen velocity is associated with clinically significant prostate cancer. MATERIALS AND METHODS: A total of 1,073 men underwent radical prostatectomy from 1992 to 2008 with data available on prostate specific antigen velocity and tumor volume. Insignificant cancer was defined by the Ohori criteria as organ confined, tumor volume 0.5 cc or less and no primary or secondary Gleason pattern 4 or 5. We calculated the proportion of men with pathologically insignificant prostate cancer stratified by prostate specific antigen velocity. RESULTS: Preoperative prostate specific antigen velocity greater than 0.4 ng/ml per year was significantly associated with high grade disease (p = 0.008), positive surgical margins (p = 0.003) and seminal vesicle invasion (p = 0.007) at radical prostatectomy. Median tumor volume was also significantly higher in men with preoperative prostate specific antigen velocity greater than 0.4 ng/ml per year (3.1 vs 2.4 cc, p = 0.0001). Overall 69 men (6%) met the Ohori criteria for insignificant cancer. Patients with preoperative prostate specific antigen velocity greater than 0.4 ng/ml per year were 50% less likely to have insignificant disease (10% vs 5%, p = 0.003). CONCLUSIONS: A prostate specific antigen velocity threshold of 0.4 ng/ml per year was associated with the likelihood of insignificant prostate cancer. This suggests that prostate specific antigen velocity may be a useful adjunct in prostate cancer screening to increase specificity for identifying patients with clinically significant disease.

The American Urological Association Best Practice Policy states that although pelvic lymph node dissection (PLND) is commonly done with radical prostatectomy, its morbidity must be considered, particularly in cases in which it offers little additional information. The benefits of PLND include more accurate staging and reassurance for the patient. In addition, PLND may be therapeutic for men with lymph node metastases and may result in long-term biochemical cure for selected node-positive patients. However, the incidence of node positivity is declining, and accordingly a greater number of lymphadenectomies must be performed to benefit 1 patient. In addition to the associated cost, PLND has the potential for morbidity, including lymphoceles, thromboembolic events, ureteral injury, and neurovascular injury. Patients and physicians should therefore assess the risk/benefit ratio associated with PLND on an individual basis to permit informed treatment decisions.

BACKGROUND: Radical cystoprostatectomy (RCP) remains the gold standard for the treatment of muscle-invasive bladder cancer. There are limited data regarding the clinical impact and detection of PSA following complete prostatectomy or the need to monitor serum PSA in patients with benign prostate pathology at time of RCP. The purpose of our study was to analyze the postoperative PSA characteristics of men without prostate cancer who underwent a RCP for bladder cancer. METHODS: The demographic, clinical and pathologic data were reviewed on 138 men who underwent RCP for bladder cancer from 1994 to 2008. Patients with known or incidentally discovered prostate cancer on final pathology were excluded from this study, and postoperative serum PSA values were reviewed in the remaining men. RESULTS: The median age of the study population was 64 years (range 40-84). At a mean follow-up of 40.7 months, 137 (99.3%) of patients had an undetectable serum PSA. The one (0.7%) case in which serum PSA was not undetectable underwent an apex-sparing prostatectomy at the time of cystectomy. CONCLUSIONS: Serum PSA should remain undetectable for men with benign prostate pathology undergoing complete prostatectomy at the time of RCP. Elevated serum PSA following complete RCP in men with bladder cancer and pathologically confirmed benign prostate findings is rare. If the serum PSA is undetectable 3 months after RCP with benign prostate pathology, there is no need for continued PSA monitoring. These data support the notion that potential nonprostatic sources of PSA are clinically insignificant following complete removal of the prostate.

PURPOSE: Obesity may be associated with lower prostate specific antigen through hemodilution. We examined the relationship between body mass index and prostate specific antigen by age in men without prostate cancer in a longitudinal aging study to determine whether prostate specific antigen must be adjusted for body mass index. MATERIALS AND METHODS: The study population included 994 men (4,937 observations) without prostate cancer in the Baltimore Longitudinal Study of Aging. Mixed effects models were used to examine the relationship between prostate specific antigen and body mass index in kg/m(2) by age. Separate models were explored in men with prostate cancer censored at diagnosis, for percent body fat measurements, for weight changes with time and adjusting for initial prostate size in 483 men (2,523 observations) with pelvic magnetic resonance imaging measurements. RESULTS: In men without prostate cancer body mass index was not significantly associated with prostate specific antigen after adjusting for age (p = 0.06). A 10-point body mass index increase was associated with a prostate specific antigen difference of -0.03 ng/ml (95% CI -0.40-0.49). Results were similar when men with prostate cancer were included, when percent body fat was substituted for body mass index, and after adjusting for prostate volume. Longitudinal weight changes also had no significant association with prostate specific antigen. CONCLUSIONS: Consistent with prior studies, we found an inverse relationship between obesity and serum prostate specific antigen. However, the magnitude of the difference was small. Thus, adjusting prostate specific antigen for body mass index does not appear warranted.