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Prostate Cancer Treatment (Professional) (cont.)

Stage Information for Prostate Cancer

Detection of asymptomatic metastatic disease in prostate cancer is greatly affected by the staging tests performed. Radionuclide bone scans are currently the most widely used tests for metastases to the bone, which is the most common site of distant tumor spread. Magnetic resonance imaging (MRI) is more sensitive than radionuclide bone scans but is impractical for evaluating the entire skeletal system. Some evidence suggests that serum prostate-specific antigen (PSA) levels can predict the results of radionuclide bone scan in newly diagnosed patients. In one series, only 2 of 852 patients (0.23%) with a PSA of less than 20 g/L had a positive bone scan in the absence of bone pain.[1] In another series of 265 prostate cancer patients, 0 of 23 patients with a PSA of less than 4 g/L had a positive bone scan, and 2 of 114 patients with a PSA of less than 10 g/L had a positive bone scan.[2] Prognosis is worse in patients with pelvic lymph node involvement.

Whether to subject all patients to a pelvic lymph node dissection (PLND) is debatable, but in patients undergoing a radical retropubic prostatectomy, the nodal status is ascertained as a matter of course. In patients who are undergoing a radical perineal prostatectomy in whom the PSA value is less than 20 and the Gleason sum is low, however, evidence is mounting that a PLND is probably unnecessary, especially in patients whose malignancy was not palpable but detected on ultrasound.[3,4] A PLND remains the most accurate method to assess metastases to pelvic nodes, and laparoscopic PLND has been shown to accurately assess pelvic nodes as effectively as an open procedure.[5] The exact role of PLND in diagnosis and subsequent treatment is being evaluated, though it has already been determined that the length of hospital stay following laparoscopic PLND is shorter than that following an open procedure. The determining factor when deciding if any type of PLND is indicated is whether definitive therapy may be altered. Likewise, preoperative seminal vesicle biopsy may be useful in patients with palpable nodules who are being considered for radical prostatectomy (unless they have a low Gleason score) because seminal vesicle involvement could affect choice of primary therapy and predicts for pelvic lymph node metastasis.[6]

In patients with clinically localized (stage I or stage II) prostate cancer, Gleason pathologic grade and enzymatic serum prostatic acid phosphatase values (even within normal range) predict the likelihood of capsular penetration, seminal vesicle invasion, or regional lymph node involvement.[3] Analysis of a series of 166 patients with clinical stage I and stage II prostate cancer undergoing radical prostatectomy revealed an association between Gleason biopsy score and the risk of lymph node metastasis found at surgery. The risks of node metastasis for patients grouped according to their Gleason biopsy score was 2%, 13%, and 23% for Gleason scores of 5, 6, and 8, respectively.[7]

Transrectal ultrasound (TRUS) may facilitate diagnosis by directing needle biopsy; however, ultrasound is operator dependent and does not assess lymph node size. Moreover, a prospective multi-institutional study of preoperative TRUS in men with clinically localized prostate cancer felt to be eligible for radical prostatectomy showed that TRUS was no better than digital rectal examination in predicting extracapsular tumor extension or seminal vesicle involvement.[8] Computed tomography (CT) can detect grossly enlarged nodes but poorly defines intraprostatic features;[9] therefore, it is not reliable for the staging of pelvic node disease when compared to surgical staging.[10] Although MRI has been used to detect extracapsular extension of prostate cancer, a positive-predictive value of about 70% and considerable interobserver variation are problems that make its routine use in staging uncertain.[11] Ultrasound and MRI, however, can reduce clinical understaging and thereby improve patient selection for local therapy. Preliminary data with the endorectal MRI coil for prostate imaging report the highest sensitivity and specificity for identification of organ-confined and extracapsular disease.[3,12,13] MRI is a poor tool for evaluating nodal disease.

Two systems are in common use for the staging of prostate cancer. The Jewett system (stages A through D) was described in 1975 and has since been modified.[14] In 1997, the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer adopted a revised tumor, nodes, metastasis (TNM) system that employs the same broad T stage categories as the Jewett system but includes subcategories of T stage, such as a stage to describe patients diagnosed through PSA screening. This revised TNM system is clinically useful and more precisely stratifies newly diagnosed patients. The AJCC further revised the TNM classification system in 2002 and, most recently, in 2010.[15] Both staging systems are shown below, and both are used in this summary to discuss treatment options. A thorough review of the controversies of staging in prostate cancer has been published.[16]

Definitions of TNM

The AJCC has designated staging by TNM classification to define prostate cancer.[15]

Table 1. Primary Tumor (T)a

a Reprinted with permission from AJCC: Prostate. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 457-68.
b Tumor found in one or both lobes by needle biopsy, but not palpable or reliably visible by imaging, is classified as T1c.
c Invasion into the prostatic apex or into (but not beyond) the prostatic capsule is classified not as T3 but as T2.
Clinical
TXPrimary tumor cannot be assessed.
T0No evidence of primary tumor.
T1Clinically inapparent tumor neither palpable nor visible by imaging.
T1aTumor incidental histologic finding in =5% of tissue resected.
T1bTumor incidental histologic finding in >5% of tissue resected.
T1cTumor identified by needle biopsy (e.g., because of elevated PSA).
T2Tumor confined within prostate.b
T2aTumor involves =one-half of one lobe.
T2bTumor involves >one-half of one lobe but not both lobes.
T2cTumor involves both lobes.
T3Tumor extends through the prostate capsule.c
T3aExtracapsular extension (unilateral or bilateral).
T3bTumor invades seminal vesicle(s).
T4Tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall.

Table 2. Pathologic (pT)a,b

a Reprinted with permission from AJCC: Prostate. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 457-68.
b There is no pathologic T1 classification.
c Positive surgical margin should be indicated by an R1 descriptor (residual microscopic disease).
pT2Organ confined.
pT2aUnilateral, =one-half of one side.
pT2bUnilateral, involving >one-half of side but not both sides.
pT2cBilateral disease.
pT3Extraprostatic extension.
pT3aExtraprostatic extension or microscopic invasion of bladder neck.c
pT3bSeminal vesicle invasion.
pT4Invasion of rectum, levator muscles, and/or pelvic wall.

Table 3. Regional Lymph Nodes (N)a

a Reprinted with permission from AJCC: Prostate. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 457-68.
Clinical
NXRegional lymph nodes were not assessed.
N0No regional lymph node metastasis.
N1Metastases in regional lymph node(s).
Pathologic
pNXRegional nodes not sampled.
pN0No positive regional nodes.
pN1Metastases in regional node(s).

Table 4. Distant Metastasis (M)a,b

a Reprinted with permission from AJCC: Prostate. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 457-68.
b When more than one site of metastasis is present, the most advanced category is used. pM1c is most advanced.
M0No distant metastasis.
M1Distant metastasis.
M1aNonregional lymph node(s).
M1bBone(s).
M1cOther site(s) with or without bone disease.

Table 5. Anatomic Stage/Prognostic Groupsab

PSA = prostate-specific antigen.
a Reprinted with permission from AJCC: Prostate. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 457-68.
b When either PSA or Gleason is not available, grouping should be determined by T stage and/or either PSA or Gleason as available.
GroupTNMPSAGleason
IT1a–cN0M0PSA <10Gleason =6
T2aN0M0PSA <10Gleason =6
T1–2aN0M0PSA XGleason X
IIAT1a–cN0M0PSA <20Gleason 7
T1a–cN0M0PSA =10 <20Gleason =6
T2aN0M0PSA =10 <20Gleason =6
T2aN0M0PSA <20 Gleason 7
T2bN0M0PSA <20Gleason =7
T2bN0M0PSA XGleason X
IIBT2cN0M0Any PSAAny Gleason
T1–2N0M0PSA =20Any Gleason
T1–2N0M0Any PSAGleason =8
IIIT3a–bN0M0Any PSAAny Gleason
IVT4N0M0Any PSAAny Gleason
Any T N1M0Any PSAAny Gleason
Any TAny NM1Any PSAAny Gleason

References:

  1. Oesterling JE, Martin SK, Bergstralh EJ, et al.: The use of prostate-specific antigen in staging patients with newly diagnosed prostate cancer. JAMA 269 (1): 57-60, 1993.
  2. Huncharek M, Muscat J: Serum prostate-specific antigen as a predictor of radiographic staging studies in newly diagnosed prostate cancer. Cancer Invest 13 (1): 31-5, 1995.
  3. Oesterling JE, Brendler CB, Epstein JI, et al.: Correlation of clinical stage, serum prostatic acid phosphatase and preoperative Gleason grade with final pathological stage in 275 patients with clinically localized adenocarcinoma of the prostate. J Urol 138 (1): 92-8, 1987.
  4. Daniels GF Jr, McNeal JE, Stamey TA: Predictive value of contralateral biopsies in unilaterally palpable prostate cancer. J Urol 147 (3 Pt 2): 870-4, 1992.
  5. Schuessler WW, Pharand D, Vancaillie TG: Laparoscopic standard pelvic node dissection for carcinoma of the prostate: is it accurate? J Urol 150 (3): 898-901, 1993.
  6. Stone NN, Stock RG, Unger P: Indications for seminal vesicle biopsy and laparoscopic pelvic lymph node dissection in men with localized carcinoma of the prostate. J Urol 154 (4): 1392-6, 1995.
  7. Fournier GR Jr, Narayan P: Re-evaluation of the need for pelvic lymphadenectomy in low grade prostate cancer. Br J Urol 72 (4): 484-8, 1993.
  8. Smith JA Jr, Scardino PT, Resnick MI, et al.: Transrectal ultrasound versus digital rectal examination for the staging of carcinoma of the prostate: results of a prospective, multi-institutional trial. J Urol 157 (3): 902-6, 1997.
  9. Gerber GS, Goldberg R, Chodak GW: Local staging of prostate cancer by tumor volume, prostate-specific antigen, and transrectal ultrasound. Urology 40 (4): 311-6, 1992.
  10. Hanks GE, Krall JM, Pilepich MV, et al.: Comparison of pathologic and clinical evaluation of lymph nodes in prostate cancer: implications of RTOG data for patient management and trial design and stratification. Int J Radiat Oncol Biol Phys 23 (2): 293-8, 1992.
  11. Schiebler ML, Yankaskas BC, Tempany C, et al.: MR imaging in adenocarcinoma of the prostate: interobserver variation and efficacy for determining stage C disease. AJR Am J Roentgenol 158 (3): 559-62; discussion 563-4, 1992.
  12. Consensus conference. The management of clinically localized prostate cancer. JAMA 258 (19): 2727-30, 1987.
  13. Schiebler ML, Schnall MD, Pollack HM, et al.: Current role of MR imaging in the staging of adenocarcinoma of the prostate. Radiology 189 (2): 339-52, 1993.
  14. Jewett HJ: The present status of radical prostatectomy for stages A and B prostatic cancer. Urol Clin North Am 2 (1): 105-24, 1975.
  15. Prostate. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 457-68.
  16. Montie JE: Staging of prostate cancer: current TNM classification and future prospects for prognostic factors. Cancer 75 (7 Suppl): 1814-1818, 1995.
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