Outcome after radical prostatectomy with a pretreatment prostate biopsy Gleason score of ≥8
Authors: Manoharan M. , Bird V.G. , Kim S.S. , Civantos F. , Soloway M.S. 
Published: September 2003

The use of radical prostatectomy to treat patients with high‐grade prostate cancer is the subject of much discussion, and the authors from Miami present their considerable experience in this field. They show that patients with a pre‐treatment biopsy of Gleason score of ≥8 may benefit from radical prostatectomy, assuming a clinical stage of T1–T2, and particularly if their PSA level is <20 ng/mL.

Authors from Palermo present data on the long‐term outcome of antiandrogen monotherapy in advanced prostate cancer, with the 12‐year results of a phase II study. This is a very interesting evaluation, showing that patients with an early objective response have a prolonged progression‐free and overall survival.

In a large series of superficial bladder tumours, urologists from Tokyo identify a group of patients with tumours of low malignant potential with a high recurrence rate, but a very low invasive property. They suggest that those tumours should be referred to as having a low malignant potential, rather than being called superficial bladder carcinoma.

OBJECTIVE

To determine the outcome and predictors of recurrence in patients with a pretreatment prostate biopsy Gleason score (GS) of ≥ 8 and treated with radical prostatectomy (RP).

PATIENTS AND METHODS

We retrospectively reviewed 1048 consecutive patients who underwent RP by one surgeon (M.S.S.); patients who had a pretreatment biopsy GS of ≥ 8 were identified. Information was recorded on patient age, initial prostate specific antigen (PSA) level, clinical stage, biopsy GS, pathology GS, extraprostatic extension (EPE), tumour volume, surgical margin status, seminal vesicle invasion (SVI), and lymph node involvement. The results were assessed statistically using the Kaplan‐Meier method, univariate log‐rank tests and multivariate analysis using Cox's proportional hazards regression.

RESULTS

In all, 123 patients met the initial selection criteria; 44 were excluded from further analyses (five salvage RP, 23 < 1 year follow‐up and 16 adjuvant treatment). Thus 79 patients were included in the uni‐ and multivariate analyses; 25 (31%) patients had a GS of ≤ 7 in the RP specimen and 54 (69%) remained at GS ≥ 8. The mean follow‐up was 55 months, the age of the patients 63 years and the mean (sd) initial PSA level 13 (12) ng/mL. The overall biochemical failure rate was 38% (41% if the final GS was ≥ 8 and 32% if it was ≤ 7). For those with a GS of ≥ 8 in the RP specimen, 20% (11/54) were organ‐confined; two patients (2.5%) in this group developed local recurrence. If the final GS was ≤ 7, 52% (13/25) were organ‐confined. In the univariate analysis, significant risk factors for recurrence were PSA ≥ 20 ng/mL, EPE, SVI, a positive surgical margin and tumour volume. Cox's proportional regression indicated that a PSA of ≥ 20 ng/mL (hazard ratio 7.9, 95% confidence interval 2.6–24.2, P < 0.001), the presence of EPE (4.2, 1.6–10.9, P = 0.004) and a positive surgical margin (3.8, 1.5–9.7, P = 0.005) were significant independent predictors in a multivariate analysis.

CONCLUSION

RP is a reasonable treatment option for patients with a prostate biopsy GS of ≥8 and clinical stage T1–2. These patients have a high chance of remaining disease‐free if their PSA level is ≤ 20 ng/mL. Patients with a pretreatment biopsy GS of ≥ 8 should be counselled about the potential differences between the biopsy and the RP specimen GS.