UROLOGICAL ONCOLOGY

Prediction of pathological stage is inaccurate in men with PSA values above 20 ng/mL
Gallina A, Jeldres C, Chun FK, Shariat SF, Briganti A, Walz J, Roehrborn CG, Saad F, Huland H, Graefen M, Montorsi F, Karakiewicz PI
Cancer Prognostics and Health Outcomes Unit, University of Montreal, Montreal, Quebec, Canada
Eur Urol. 2007; 52: 1374-80

• Introduction: We hypothesized that either very low (0-2.5 ng/mL) or very high (>20 ng/mL) PSA values may limit the accuracy of pathological stage predictions. To test this hypothesis, we examined 5193 consecutive patients subjected to radical prostatectomy (RP) for localized prostate cancer (PCa).
• Material and Methods: Patients were divided into three cohorts according to their pre-treatment PSA value: </=2.5 (n=331), 2.51-20 (n=4545) and >20 ng/mL (n=317). Subsequently in each cohort, the ability of PSA, clinical stage and biopsy Gleason sum was tested in multivariable logistic regression models predicting three separate endpoints: extracapsular extension (ECE), seminal vesicle invasion (SVI) and lymph node invasion (LNI). Predictive accuracy represented the performance benchmark. All models were adjusted for year of surgery and subjected to 200 bootstrap resamples to reduce overfit bias.
• Results: For PSA </=2.5 ng/mL, predictive accuracy was 76.7%, 72.3% and 82.8% for respectively ECE, SVI and LNI. For PSA 2.51-20 ng/mL, the predictive accuracy for the same endpoints was 67.8%, 77.4% and 81.6%. Finally, for PSA > 20 ng/mL, predictive accuracy was 63.6%, 63.7% and 70.6%.
• Conclusions: The ability to predict pathological stage in patients with PSA values in excess of 20 ng/mL significantly decreased, compared to patients with lower PSA values. Therefore, accurate staging of these patients may require alternative markers or staging schemes.
  
  
• Editorial Comment
  The authors of this multi-institutional survey investigate whether the current prognosticators and tables (e.g. Partin) are useful in very low and very high PSA levels. They analyzed the radical prostatectomy results of 5193 patients.
  Altogether, the predictive accuracy was rather satisfactory even in the very low and the very high PSA ranges. In the latter, predictive accuracy declined.
  It may be allowed to shed a critical view on the figures in detail, which may decrease the enthusiasm for prognosticators somewhat. Overall, extracapsular extension (ECE) was found in 20.4% and seminal vesicle invasion (SVI) in 10.6%. In the PSA range > 20 ng/mL, ECE was found in 30.6 % and SVI in 33.4 %. Otherwise, still of patients 13% had ECE and 10% had SVI in the PSA range below 2.5.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany