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PATHOLOGY
doi: 10.1590/S1677-553820100001000023
Does
perineural invasion on prostate biopsy predict adverse prostatectomy outcomes?
Loeb S, Epstein JI, Humphreys EB, Walsh PC
James Buchanan Brady Urological Institute and the Department of Urology,
Johns Hopkins Medical Institutions, Baltimore, MD, USA
BJU Int. 2009 Aug 19. [Epub ahead of print]
- Objective:
To determine the relationship between perineural invasion (PNI) on prostate
biopsy and radical prostatectomy (RP) outcomes in a contemporary RP
series, as there is conflicting evidence on the prognostic significance
of PNI in prostate needle biopsy specimens.
Patients and Methods: From 2002 to 2007, 1256 men had RP by one surgeon.
Multivariable logistic regression and Cox proportional hazards models
were used to examine the relationship of PNI with pathological tumour
features and biochemical progression, respectively, after adjusting
for prostate-specific antigen level, clinical stage and biopsy Gleason
score. Additional Cox models were used to examine the relationship between
nerve-sparing and biochemical progression among men with PNI.
Results: PNI was found in 188 (15%) patients, and was significantly
associated with aggressive pathology and biochemical progression. On
multivariate analysis, PNI was significantly associated with extraprostatic
extension and seminal vesicle invasion (P < 0.001). Biochemical progression
occurred in 10.5% of patients with PNI, vs 3.5% of those without PNI
(unadjusted hazard ratio 3.12, 95% confidence interval 1.77-5.52, P
< 0.001). However, PNI was not a significant independent predictor
of biochemical progression on multivariate analysis. Finally, nerve-sparing
did not adversely affect biochemical progression even among men with
PNI.
Conclusion: PNI is an independent risk factor for aggressive pathology
features and a non-independent risk factor for biochemical progression
after RP. However, bilateral nerve-sparing surgery did not compromise
the oncological outcomes for patients with PNI on biopsy.
- Editorial
Comment
Perineural invasion (PNI) on needle prostatic biopsies as a marker of
extraprostatic extension has been controversial. In almost all studies,
perineural invasion has been related to extraprostatic extension in
univariate analysis but in only a few studies in multivariate analysis.
The practical importance relates to the decision of whether to sacrifice
part or all of the neurovascular bundle on the side of the biopsy with
PNI in planning nerve-sparing radical prostatectomy.
Egan and Bostwick (1) found on univariate analysis that PNI on needle
biopsy was significantly associated to extraprostatic extension and
seminal vesicle invasion. On multivariate analysis, however, only preoperative
PSA, proportion of the biopsy involved by cancer, and Gleason score
were significant. Ukimura et al. (2) found that PNI on biopsy was a
good predictor among others studied for extraprostatic extension on
univariate analysis but not on multivariate analysis. In the study by
Vargas et al. (3) PNI was not an independent predictor of extraprostatic
extension when PSA was included.
D’Amico et al. (4) evaluated the clinical use of PNI at biopsy
for predicting time to PSA failure following radical prostatectomy of
750 men with clinically localized or PSA detected prostate cancer. The
presence of PNI on biopsy was not a significant predictor of PSA outcome
following RP for patients in the intermediate or high risk group. O’Malley
et al. (5) compared 78 biopsies with PNI with 78 matched controls without
PNI and were unable to show that PNI on needle biopsy influences long-term
tumor-free survival.
In the study surveyed, Loeb’s et al. found that PNI is an independent
risk factor for aggressive pathology features like extraprostatic extension
and seminal vesicle invasion, and a non-independent risk factor for
biochemical progression after radical prostatectomy. According to the
authors, the findings support the routine reporting of PNI in biopsy
pathology reports. They also concluded that nerve-sparing surgery did
not adversely affect biochemical progression even among men with PNI.
References
- Egan
AJM, Bostwick DG: Prediction of extraprostatic extension of prostate
cancer based on needle biopsy findings: Perineural invasion lacks significance
on multivariate analysis. Am J Surg Pathol. 1997; 21: 1496-500.
- Ukimura
O, Troncoso P, Ramirez EI, Babaian RJ: Prostate cancer staging: correlation
between ultrasound determined tumor contact length and pathologically
confirmed extraprostatic extension. J Urol. 1988; 159: 1251-9.
- Vargas
SO, Jiroutek M, Welch WR, Nucci MR, D’Amico AV, Renshaw AA: Perineural
invasion in prostate needle biopsy specimens. Correlation with extraprostatic
extension at resection. Am J Clin Pathol. 1999; 111: 223-8.
- D’Amico
AV, Wu Y, Chen MH, Nash M, Renshaw AA, Richie JP: Perineural invasion
as a predictor of biochemical outcome following radical prostatectomy
for select men with clinically localized prostate cancer. J Urol. 2001;
165: 126-9.
- O’Malley
KJ, Pound CR, Walsh PC, Epstein JI, Partin AW: Influence of biopsy perinerual
invasion on long-term biochemical disease-free survival after radical
prostatectomy. Urology. 2002; 59: 85-90.
Dr.
Athanase Billis
Full-Professor of Pathology
State University of Campinas, Unicamp
Campinas, São Paulo, Brazil
E-mail: athanase@fcm.unicamp.br
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