Clinical and pathologic staging of localized prostate cancer: an ...

A new review by Epstein, currently available on line in the Journal of Urology, provides a detailed analysis of the clinical significance of various factors in determining prognostic risk for newly diagnosed and recently treated patients with localized prostate cancer.

Epstein starts by pointing out that the 2010 update to the TNM classification system still divides clinical and pathologic T2 disease into three categories:

• T2a disease is cancer that is unilateral and found in less half of one lobe of the prostate.
• T2b disease is cancer that is unilateral and found in more than half of one lobe of the prostate.
• T2c disease is cancer that is bilateral (i.e.,? found in both lobes of the prostate).

In the case of clinical T2 disease, these categories are based on a combination of data from digital rectal examination, ultrasound examination, and actual biopsy. The clinical stages are therefore clearly estimates based on a physician?s clinical judgment. In the case of pathological T2 disease, the stage can be assessed with great accuracy based on pathological examination of the prostate post-surgery.

However, Epstein and others are now recommending that pathological T2 disease should no longer be subdivided into substages for the simple reason that this information lacks any definite prognostic significance, for a number of reasons:

• Only 1/7 careful studies of post-surgical prostate pathology has ever been shown to include a significant amount of pT2b disease.
• Only 1/10 prognostic studies has ever shown that there was a significant prognostic difference between substages of pT2 disease on univariate analysis ? and that study showed only that pT2a disease had a better prognosis than T2b/c disease.
• In all 10 of these prognostic studies, pT2 substages did not correlate with prognosis after the pathologic Gleason score and the status of the surgical margins had been taken into account.

So if we can no longer use pathologic and clinical substages of T2 disease for prognostic purposes, are there other clinical and/or pathologic data that can replace this traditional tool?

Epstein discusses two, in detail: the total tumor volume (TV) after radical prostatectomy (RP) and the quantification of tumor in biopsy cores. We don?t intend to provide a complete commentary on what is a complex discussion.

There are clearly some issues to be sorted out with respect to the value of tumor volume and according to the International Society of Urological Pathology (ISUP)? ?the independent value of [tumor volume] remains uncertain.? In the meantime, ISUP recommends that, ?some quantitative estimate of cancer volume should be undertaken, the nature of which being dependent on routine practice within the pathology laboratory.? (Dr. Epstein himself is clearly not comfortable with this interim recommendation.)

With respect to the quantification of tumor based on needle biopsies, there are some simple established processes and some areas with no consensus as yet:

• We can usually report the total number of biopsy cores sampled and the number of those cores that are positive for cancer to obtain a fraction of positive biopsy cores (e.g., 3/12).
• However, cores can fragment, and pathologists recommend that urologists submit 1, 2 or at most 3 prostate biopsy cores in each biopsy jar.
• There is no consensus about assessment of the ?length? of tumor in a specific biopsy core when the tumor is discontinuous.
• Some laboratories (John Hopkins included) will measure the length of an interrupted biopsy core as though it is an uninterrupted core.
• Others will measure the length of actual tumor in an interrupted biopsy core.
• This means that the same interrupted biopsy core, when assessed by two different laboratories, might be give as 5 percent of the core or 60 percent!

At present, the only thing that seem certain is that the TNM staging system, when next updated, will need to eliminate the clinical and pathologic substages of T2 disease. This will have implications for many prognostic nomograms that currently include information about these substages (e.g., the Kattan nomograms and others). Of course there can be no certainty that the TMN staging system (which is not overseen by ISUP) will in fact be updated in the way that Epstein and others are recommending.

Filed under: Diagnosis, Living with Prostate Cancer, Management, Risk Tagged: | biopsy, clinical, core, pathologic, prognosis, quantification, stage, T2, tumor, volume

Source: http://prostatecancerinfolink.net/2011/07/25/clinical-and-pathologic-staging-of-localized-prostate-cancer-an-update/

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