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PATHOLOGY
Application
of the Epstein criteria for prediction of clinically insignificant prostate
cancer in Korean men
Lee SE, Kim DS, Lee WK, Park HZ, Lee CJ, Doo SH, Jeong SJ, Yoon CY, Byun
SS, Choe G, Hwang SI, Lee HJ, Hong SK
Department of Urology, Seoul National Bundang Hospital, Seongnam, Korea
BJU Int. 2010; 105: 1526-30
- Objective:
To investigate the rate of pathologically confirmed unfavourable prostate
cancers among Korean men who fulfilled the contemporary Epstein criteria
for clinically insignificant prostate cancer.
Patients and Methods: This was a retrospective study of 131 Korean men
who underwent radical prostatectomy (RP) for clinically insignificant
prostate cancer as defined by contemporary Epstein criteria. We assessed
the percentage of unfavourable prostate cancer (pathological Gleason
sum > or = 7 and/or extraprostatic extension [EPE]) among these men
and tried to identify useful predictors for such unfavourable tumour
profiles using uni- and multivariate analyses.
Results: Among 131 men with clinically insignificant prostate cancer,
40 (30.5%) had pathological Gleason > or = 7 tumours after RP. Of
these 40 men, four (3.1%) also had EPE on examination of RP specimen.
All those who did not have Gleason score upgrading after RP had organ-confined
disease from examination of RP specimen. Overall, 40 (30.5%) of the
131 men who fulfilled the contemporary Epstein criteria for clinically
insignificant prostate cancer before RP had pathologically unfavourable
disease. Among our patients, no significant preoperative predictor of
pathologically unfavourable disease was identified using uni- and multivariate
analyses.
Conclusion: Our results showed that a significant proportion of contemporary
Korean patients who meet all the conditions of the contemporary Epstein
criteria for prediction of clinically insignificant prostate cancer
might actually harbour prostate cancer with unfavourable pathological
features. Such findings should be considered when treatment options
are contemplated based upon the Epstein criteria among Asian patients.
- Editorial
Comment
Watchful waiting (active surveillance) has gaining popularity as a management
strategy for newly diagnosed low-grade, limited cancer on needle biopsy
based on the large discrepancy between incidence and mortality rate
of prostate cancer. Data from the European Randomized Study of Screening
for Prostate Cancer Trial showed that PSA screening reduced the rate
of death from prostate cancer by 20% but was associated with a high
risk of overdiagnosis (1).
Epstein proposed a set of criteria based on PSA and preoperative biopsy
features that identify a high likelihood of organ-confined insignificant
cancers at radical prostatectomy (2). Insignificant cancers are defined
as cancers confined to the prostate (pT2), Gleason low-grade (score
= 6), and low-volume (= 0.5 cc). It is important to be aware that insignificant
cancer is not synonymous of latent (indolent) carcinoma. So far, there
is no single marker of biological behavior for prostate cancer.
The preoperative biopsy and clinical features of Epstein’s criteria
for insignificant cancer are: clinical stage T1c, preoperative PSA density
< 0.15, no Gleason pattern 4 or 5, no more than 2 cores with cancer,
and no more than 50% of involvement of cancer in a single core. According
to Bastian at Johns Hopkins, the predictive value using the Epstein’s
criteria for organ-confined disease and insignificant cancer is 92%
and 84%, respectively.
Several studies have applied Epstein’s criteria for prediction
of clinically insignificant prostate cancer with differing results.
In all studies, the criteria are predictive of a high frequency of organ-confined
disease but differ for insignificant cancer. In the study from Korea,
the frequency of organ-confined disease was 97% (vs. 92% from Johns
Hopkins) but 69% for insignificant cancer (vs. 84% from Johns Hopkins).
References
- Schröder
FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, et al.: Screening
and prostate-cancer mortality in a randomized European study. N Engl
J Med. 2009; 360: 1320-8.
- Bastian
PJ, Mangold LA, Epstein JI, Partin AW: Characteristics of insignificant
clinical T1c prostate tumors. A contemporary analysis. Cancer. 2004;
101: 2001-5.
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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