PATHOLOGY

Updated Nomogram to Predict Pathologic Stage of Prostate Cancer Given Prostate-Specific Antigen Level, Clinical Stage, and Biopsy Gleason Score (Partin Tables) Based on Cases from 2000 to 2005
Makarov DV, Trock BJ, Humphreys EB, Mangold LA, Walsh PC, Epstein JI, Partin AW
Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
Urology. 2007 69:1095-101

• Objectives: To update the 2001 “Partin tables” with a contemporary patient cohort and revised variable categorization, correcting for the effects of stage migration.
• Methods: We analyzed 5730 men treated with prostatectomy (without neoadjuvant therapy) between 2000 and 2005 at the Johns Hopkins Hospital. Average age was 57 years. Multivariable logistic regression was used to estimate the probability of organ-confined disease, extraprostatic extension, seminal vesicle involvement, or lymph node involvement. Predictor variables included preoperative prostate-specific antigen (PSA) level (0 to 2.5, 2.6 to 4.0, 4.1 to 6.0, 6.1 to 10.0, and greater than 10.0 ng/mL), clinical stage (T1c, T2a, and T2b/T2c), and biopsy Gleason score (5 to 6, 3 + 4 = 7, 4 + 3 = 7, or 8 to 10). Bootstrap resampling was used to generate 95% confidence intervals for predicted probabilities.
• Results: Seventy-seven percent of patients had T1c, 76% had Gleason score 5 to 6, 80% had a PSA level between 2.5 and 10.0 ng/mL, and 73% had organ-confined disease. Nomograms were developed for the predicted probability of pathologically organ-confined disease, extraprostatic extension, seminal vesicle invasion, or lymph node involvement. The risk of non-organ-confined disease increased with increases in any individual prognostic factor. The dramatic decrease in clinical stage T2c compared with the patient series used in the previous models resulted in T2b and T2c being combined as a single predictor in the nomogram.
• Conclusions: These updated “Partin tables” were generated to reflect trends in presentation and pathologic stage for men diagnosed with clinically localized prostate cancer at our institution. Clinicians and patients can use these nomograms to help make important decisions regarding management of prostate cancer.
  
  
• Editorial Comment
  It is worth noting in this updated nomogram that Gleason score 7 has been stratified to 3+4=7 and 4+3=7. Tumors with a Gleason score of 7 have a significantly worse prognosis than those with a Gleason score of 6. Given the adverse prognosis associated with Gleason pattern 4, one would expect that whether a tumor is Gleason score 3+4 or 4+3 would influence prognosis (1). This issue has been controversial in the literature, however, most of the studies have shown that Gleason score 4+3 has a worse prognosis than Gleason score 3+4 (2,3). Recently we evaluated the biochemical (PSA) progression following radical prostatectomy in 300 patients according to Gleason score 3+4 and 4+3 in the surgical specimens. Of the total of 300 patients, 140/300 (46.6%) patients were Gleason score 3+4=7 and 37/300 (12.3%) patients Gleason score 4+3=7. The 4-year biochemical (PSA) progression-free survival rate with Gleason score 3+4 and Gleason score 4+3 was 60% and 30%, respectively (log-rank, p=0.046).
  Another topic in the updated nomogram relates to clinical stage. According to the authors the dramatic decrease in clinical stage T2c compared with the present series used in the previous models resulted in T2b and T2c being combined as a single predictor in the nomogram. According to the 2002 TNM classification of malignant tumors, T2b involves more than half of one lobe, but not both lobes. Some studies did not found this stage in surgical specimens. Eichelberger & Cheng (4) question the existence of a true pathologic stage pT2b tumor. They studied 369 prostate cancer patients treated by radical prostatectomy. Prostate cancers were multifocal in 312 cases (85%). The majority of the specimens were pathologic stage pT2 (276, or 75%). Using the 2002 TNM staging criteria, 54 (15%) of the tumors were stage pT2a, 222 (60%) were pT2c, 75 (20%) were pT3a, and 18 (5%) were pT3b. No pathologic stage pT2b tumors were identified. The findings of Quintal et al. (5) using a point-count method for evaluating tumor extension, are in accordance with Eichelberger and Cheng (3). No tumor pathologic stage pT2b was found and the frequency of the stages in Quintal’s series is very similar to theirs: stage pT2a, 28 (12.50%); pT2c, 138 (61.61%); pT3a, 30 (13.39%); and, pT3b 28 (12.50%).

References
1. Epstein JI, Amin M, Boccon-Gibod L, Egevad L, Humphrey PA, Mikuz G, et al.: Prognostic factors and reporting of prostate carcinoma in radical prostatectomy and pelvic lymphadenectomy specimens. Scand J Urol Nephrol Suppl 2005;216:34-63.
2. Han M, Partin AW, Pound CR, Epstein JI, Walsh PC: Long-term biochemical disease-free and cancer-specific survival following anatomic radicl retropubic prostatectomy. The 15-year Johns Hopkins experience. Urol Clin North Am 2001;28:555-65.
3. Chan TY, Partin AW, Walsh PC, Epstein JI: Prognostic significance of Gleason score 4+3 tumor at radical prostatectomy. Urology 2000;56:823-7.
4. Eichelberger LE, Cheng L: Does pT2b cancer exist? Critical appraisal of the 2002 TNM classification of prostate cancer. Cancer. 2004; 100: 2573-6.
5. Quintal MM, Magna LA, Guimaraes MS, Ruano T, Ferreira U, Billis A: Prostate cancer pathologic pT2b (2002 TNM staging system): does it exist? Int Braz J Urol 2006;32:43-7.

Dr. Athanase Billis
Full-Professor of Pathology
State University of Campinas, Unicamp
Campinas, São Paulo, Brazil
E-mail: athanase@fcm.unicamp.br