RADICAL PROSTATECTOMY FOR IMPALPABLE PROSTATE CANCER: ‘THE JOHNS HOPKINS EXPERIENCE WITH TUMORS FOUND ON ‘TRANSURETHRAL RESECTION (STAGES T1A AND T1B) AND ON NEEDLE BIOPSY (STAGE T1C) JONATHAN I. EPSTEIN,’ PATRICK C. WALSH axo CHARLES 8. BRENDLER ‘rom he Depart of Pty od Ural, The Jn Hophne Unity Sl of Mone nd James Buchanan Brody lg! nat, The bas Hopns Hop, Botimars Manne ‘We review the pathological findings of impalpable prostate cancer detected by transurethral resection (stages Tla and TID) and needle bigpsy (stage THe). The short-term (4 years) and Tong-term (8 to 10 years) natural histories oPuntoeated stage TLa prostate cancer are examined, sane options to follow patients expectant. The findings on radical prostatectomy for stages TIa fand Tb diseaso are reviewed and compared, Of the 64 cases of stage Tia dissase 13 20%) Showed substantial tamer, ineading 7 with more tha Lee of tumor 5 with capsular penetration find with a Gleason grade + 5 ~9 tumor, Based on preoperative pathological parameters, one ‘could not predict which eases had minimal versus substantial tamor. In a sod” from oor institution that undertook eomplte histological examination of 39 radial prostatectomy specs mens of stage Tib carcinoma, we found tha all prostates contained residil carciroma, 20% had ‘capsular penetration and 10% had invasion of the seminal vesicles, When comparing morgho- tetrically determined vokumes of careinoma with similar data from 56 patients sith stage T2 ‘carcinoma, stage Til tumars Were much more heterogeneous in grade, location and volume than ‘were stage T2 lesions. Unless all 3 variables (grada, volume and location) were kxown, the final pathological stage af Tb cancers coud not be predicted with confidence “Finally, we examined preoperative clinical and pathological parameters in 157 men with clinical stage Te diveaae undergoing radical prostatectomy, and correlated these findings wi pathological ‘extent of disease in the eargeal specimen in an attempt to identify a subaet of patents ith potentially biologically snsignfcan tumor who might be flowed conservatively. Ofte urs 16% ‘ver insigiffeant (ess than 0.2 ce, organ confined and Gleason gradeless than 7), 10% were minimal (0210 0.8 e, organ confined and Gleason grade lese than 7), 31% wre moderate (more than 0.5 cc ‘oreapssar penetration with Gleason som les than 7) and 37% were advanced espsular penetration With Gleason sum 7 or more or positive margin, postive seminal vesicles or positive lymph nodes) ‘These findings ate intermediate between those found in cincal stages Tn an T2 disease. The best model predicting insgnfeant tumor was @ prostate specie antigen (PSA) density af les thar 0.1 {nd ne adverse pathological finding on needle bopay ora PSA density of 0. to 0.15 with less than ‘Stim Tow to intermediate grado cancer on aly 1 needle biopsy ere. The postive predictive value of the model was 95% vith a nogative predictive value of 66%. Using this model, we accurately predicted 75% of eases with insiifcant tumor. Although most impalpable prostais cancers diag- hosed by needle biopsy ave sgnfeant tumors that warrant deinive therapy, ie maybe ressonable to fallow same patente whose tumors are met Hikely insignificant with seal PSA measurements tnd repeat biopsies. Ky Won: rsa opens proetatemy ope, nade: pation [An increasing number of tumors ae being diagnosed and teeated when the are impalpable on digital rectal examina tions A third of men older Gan 0 gents Rave neon Cirinoma food a aotopey, yet linia prostate canoer de ‘elope i oly 10% of men during the hfe. When cancer {found intently on tranmurethral resection or need Biopay tie goesien aries nr toric pronate cancers Tin be" Slowed. sonstevaiely without imedate CCurrenty, fewer ancors age inedentaly detected rane: swrethrl revoeton compared taf ears ago. Tae pe ‘pomenon reuls frome combination of factors. Urdoget na Bop Baklooe: Megane Barston” er are asing varios modi thorapios for the trtment of ‘benign prostate hyperplasia PTD ina inceasing numer men, Also, llernaive surges eatment options, such as Ineo eryowurgery, alos latatin, sents and microwave therapy, donot provide soos for hitlogel examination Finally inthe dugnoste evaluation of men wilh unary stsrucve jmptons, serum prostate spi etigen (PSA) {ested ulmanund ates ey elt im cance detected on redle biopey Noneelc trnmarthral rections wi sinoe tobe performed ether as en nl ino therapy in ‘ne inen or en who fal alteative trestsat options, Tn pe studies apprazimately 19% (range 13 to 22) of transurethral resestione performed for presomed. BUH re ‘ened indents sdenearinomn ofthe prostate Teen: {al adenocactnome of the prostate i divided nto tumors that ar of elalively ow stme ad low grade etage Ts) utame igh volume, hh grade (tage Tb). The definition of stage ‘Tin dlosane te controversial: Tornoe volume tay be te {hzed as number of trncurathal resection shipe with amor (Glo fewer chips, +3 ower chip) per cet of the spe ten involved by tor ea) pr eat of eanzurea ‘eacctio dip wih tamor or etal Cum lume Gas than Tey Some surgeon require that tage Ta tseae conse “nly of aw grado tumor Gleason our ores), whe ars {lw the tumor to be of low or intermediate grade, Further: tuor, the defition of intermedito grado tumor ie conte. ‘erst fn tho pac, Gioacon sum 7 tumor was indaded sth this eatery. However, more event ladies have Guggeated that Cleacon sum 7 tumor fares Worse than ‘Gleasn sum 8 o 6 tumor and preboblychould be considered. Se high grade tomor fn 1981 Cantrell et al sutied the tural Rotor of unteanted sage Ta prota cancer ‘When a tumor occupied 6% or lee of the cpecimon and eae otf high grade, only 2 ofthe men hod progression at ‘ear Im cntrast when te tamer asepiod more than 5 of the specinen or was of high grade 80% had progression a 4 years, Based on these finding, stage Tia was defined a5 mer oesnying fo lows of the specimen and soto igh (rae, with higher valame or high grade tumor dened ae Stage is Sulsequcnt to thi study, there have been several lvls on the longterm progression rte of untreatod cage ‘Tianna! The progreaon rates ia than stdies Rave Tange from 8 to 2, wilh te esis fallow ranging From 8 o 10 yrs able 1" In general, the studies thst showed higher progression rales wore tage wit longer falowup. Sine the mean inter ‘alo prorenon in these sues ranged fom to 10 year Studie wth shorter followup are probably wnderestinating thor of progression Its san hnportant to recngniae tha io 7% of te men in thevestuhen did of tae crc, Patients werent followed cooly ate the dagnosiso tage td many died of eaoer Data fom thes longterm sacs Shea ome light on the question of whether low ele Ine termediate grad tno should be considered tage Tis or ‘Tih nour data, as lng asthe tor ocmpied 3 oles {Be specimen there nas dference i the progression rae Tilowing diagnos whether the Gleason sn wos oro6. re several options when following patients with stage Tis diseave, Dagital rectal examination cannot be ‘Sted on to detect praresion in Stage Ta diseabe, since Stage Tis tomor in pattie with sigoeant tomor solos La impaipable! Trapsrectal ulfmound har relatively Tow sensitivity and specifiy in detsting prostate cancer, Which is even Tower {n mon who have undergone prior tone: Uthyal resection Tpeat transurethral resection has ls bem proposed ax a staging procedure for tage Tia disease 2 Fowevee, mart. of the studies have demon Seated that in Tess thar 108 of pationte with stage Ta {iseaat who undergo repeat tranrorthral romction Uh can fer ts upstaged wo stage Tih, Furthermore, those with no Fesidul tumor at repeat ansuretral resection sill may Ihave progression *™ “Taue .Long som progrnin rate of tage Tia dase PROSTATECTOMY FOR IMPALPABLE PROSTATE CANCER. ‘The newest modality that hae buen proposed for flowing patients wit stage Te dlsese ee seam PSA ove. Iehas Eten mgmt that in patients who have ndergane tans srethral resection the confounding Iactorf BPH can be moved so that serum PSA levele will move acral re- ‘oe tho tamer volume. Tha recent report from our inst fon, 22 men who andereat radia prostatoctosy fr sage ‘Tin promat cancer were studied to correlate the ressdal {amar volume withthe post tanaurotral resection serum PSA Ive. tm man with serum PSA levee of lowe than 1 Dm tere were oaly small residual tumor volumes, 3 Strut Yochefow wen who Hed seruth PSA Tevla of ore {an 10 anahigher tumor volumes!" However slmost alfat fhe men hed ndstorminate serum PSA lowls of 1 to 10 pin with varying eatent of reaidal tumor volume. Anal ‘Sivaf aml group of men rom our ineituton who under ‘een delayed radical prostetoctomy following the diagnosis at ‘Rage Tia ucts revealed that 5 hnd serum PA levels fos ihe 4 ogi at radial poestany, Alhioogh of Une 8 ‘men had alow grade tumor confined to the prota, the Femaining Shad ethor a high grade tame, postive margins, tv inal vsilen or pote mp ode metastases ‘The mall group of men demonstrates Dat following po tents with stage Ta disease until the serum PSA level erates ta more than normal does ot engre detection af femor at acral seage’ However, srl PSA levels these ‘on Were oot eblinedfllowing dlagnoss bat aly at prow {reson reer ear ae agnosis by transurethral rece En Te erred recommendation forthe uae of cram PSA, levies a ean of flowing men wide tage Ta date 2 tonal srl PSA measurements Monitoring the change In PSA ett me i eed facts: 1 PSA eres wh Ineroming lamor volume, 2) the cntbution of canccr to ‘umm PEA level fe 10 Moen tht of BPH and prostate fener has «more rapid zat af growth than BPEL In reont aay fom our nsf i man demonrerced hat sera PSA levee in men wilh BPH incensed only slighty with tin, wherse those who eventually hed: prostate Cancer hoe & more rapid increase in the PSA lovel™ Cane ‘aunty, vas Beloved that one could monitor the rate of thange af scrum PSA levels patients digried with sage ‘a prostate cancer An nceate in serum PSA level, even to evo nora cul trigger an evatuaton fr progres: ‘ano dite Filly, we stud large group oftoaly embedded ead seal postatetomy specimens performed for stage Tla ‘ose Of these ctags 65 showed no redual tamoe appron: {Ettely 742 thowed minimal residual tomor snd Ft had stantial residual tomor, defined as ether relatively umer lume, tage nas ohh rad mo {Siew rluoe wa deed amore ti Ne fal one ‘elume, wich wes base ont the nding that this wae the ‘olin tune volume fo sage Ti disease Of co ISeases of ‘Stan tsmae 7 ad more than Taf tmor 8 sowed ‘Speck pecetratnn and 1 had Geasn graded Dao (Oe couldn preci, using properative paola para ‘or, whid cases had minal vetsus stantial tumor ‘The pathos! parameters wert resection per cnt (Unt 1% vena 4) ransuretheal resection tar bar volume oe transurethral resection Glzason grade hati lesson co 2 vere 8 In mummary, most authorities ommend a conservative approach inthe management of elder men wih stage Ths ‘daeane, However, the definition of older men ie controversial Snd range fom age 0 to 70 ears This conservative 4p rose i ated to Use Mh incidence af inital caer and at asapsy and the inereased lod of death fos ter esses teaue Ths a of progressive prostate cae ‘The management of younger man with stage Ta tumor fs fenteovarail One opion te aleo 4 conservative appraich ‘sth ffowap unt Progeession. Argument n avo of hissporoach are that 1) most radial pratatectmiee dove for ‘fie Pia disease show minima ume, 2) followup with a Combination o gal rectal examination, ara PEA Tevele ‘nd tapaecaaltrascund wil ently progesion of eome Stage Tia cancer patients al atime when they ate sti fate i'r sve may be any ee ‘The ober apn forthe management of young men with stage Ta disease ative therapy, sch a taal pro {atecomy. Arguments n suppor. oft appreath are at 3) theae men have a longer ie expectancy nth relatively ‘gh rk prostate cancer ropesion eth dies hen {in co loyear ollowup demotseratingsppronmatly 18 to 20% rik of prgresion, Younger men can be expected to fave’ higher Rak of posession dure the hte 2) as Alacssed previo, tere tac of means of ensure: {ocr ats crsle Sage with emcee flowy thet Sowing ser serum PSA levels wil provide ths ye mains unproved and 3 aprons 20% of adel pra ‘Gaicsdne fr iage'Ti eas she spicata aod ‘lel prtatecon proves care i's al paints ‘io mori ‘As withthe definitive treatment ofall early carcinomas, te tlm fruses onthe potential overtreatment ofthe Ijury of patents while guaranecing care, or pont der trestaent ofthe minore of patents who may abe ‘tuantty have progrmman and ie ofthe daca In sty fom oar institution of 30 completely abated adie protatctomics for stage Tb cardio, e fd ‘hat all prostates contained rial earenoma, 265 had Eaeolar penetration and 10% had invasion ofthe Seminal Seicen"When comparing morphometscally determined ‘Volume of careima with smiler deta fom 56 patients ‘nth stage T2cseinoma, stage Tb tumors mere math more Ietergencousnsradelecation and wlume than were stage ‘To cansnomas™" Ot the stage THb amore 41% were lw 13 rad Gleason sore ess than 4), compared tony 5% af the age 72 tumors “The cation of stage TH carcoma alo difeed fom stage T2enteinama. Stage TIh eae werecentral in 38% of {heeaces and centralasientr im 27% mang them unde teciale by rectal examination, Te average vlome cf amr ‘Soctiy csneurchral ecto was obs ange’ 20) ‘Fhe total tumor a Felleson ofthe central Toston of the Sage Tib carcinoma. Oaly 20% a stage TID tumors were ‘mote vluminous inthe pstrior Felon the prostate The fervelation af mor volume and plbalogeal stage also di fered between stages Tih and T2 dcase Stage T2 tmore ‘with capeular penetration wer usualy tow volume ‘Because thos tumuars clcly appeaced the prostate ap ule when they atained aeocain ea, capsular penetration eure, In eatrart, sano rage Tb esos that were on tral focoted auamed argor volume bore capsular pene {tation rare fg) Despite he strong correlation be eon tenor grade, per eet and volume fn tansanetva soction specimens a Saal paabyieal wage ar ra estate, che predictive vale forthe ida pe ome was snuatintatory” OF the 8 higher volume caenrt tithoot capelar penetation, et transurethral reecsion Tome were low grade aconnding fr the favorable stage) ‘Gthey were high grade snd high volume a transuratal ‘ecco, yet were central Ieated wth minimal residual ner at adil prostaecemny.Conrersly there were ow ‘ine earcoocaa at tanaurtheal rection wit capeclar Penetration. In each of then canes there as substantial ‘sida enrinoms af varying gradein th anterior or poste ‘or eglns: Beeause of the perio for sampling rer {ntrodaced by Como locaton, transurethral escton tamer ‘lume did not alvays scratly rfc the total volume of ‘acinoma, Unet all 3 varablee (rede, volume and los {on were known, che il pathol stage af Tb ances eal not be predicted with conideree Defiasve treatment forall stage Tis tury, rogardloas the postopartie PSA levee recommended stace 12 race ie ® 2 Go» 8 8 as ; nf t ee eons ol Bs ct se 26 uALaMLLNAO o10n9 t cme Fo. 1, Tumor volume cole mith van o organ cn eae in cna TH age AD a inal T tae tien aam We recently studied 167 totally embed radial poste testy spectnens removed for ipalpale prostate cancer Alggnate by needle Bopay (stage The)" To place stage Te Alarase into perspective, we compared these ease to 4 pre iowa stoded specimens from radial prstatectomy pee Famed fr chincl ste Ta disease relatively idol to ‘ors and to 488 radial prostatectomy specimens removed forctinial stage 72 (palpabo prostate caner * Tpalpe bl mors nee cttied ater Deo ato loge ings nthe reba prostatectmy specimen able BI insignificant, 2) minimel, 3) Moderato and 4) ad vanced Insignificant tumors fere not of high grade and were so small tht i the extent could have been pedited proopers. {ely these patients might have heen candidates fr expects tnt therapy We chow asm eneifO acta, pry bee ‘re have not sen cape penetraion or rogreaon 5 years ‘fer tanger in tumors ih thse flames" Als, ia tories of ncldentaladenocarinnn ofthe prostate eried {in 159 qtoprestatecomy specmene removed for trans onal cll carcinoma of the bladder. shen patient were refi evaluated to eile ot palpable prostate caner B85 ‘the prostate tomers were lea than 0.2 cig. 2." Case of minimal tarnors ha paige ining dent cal to those wih insignificant tumors eeept at or Yolumes were 0.2 to 0.5 ce (able 2). These tumors were ‘Nese minimal rather than insignia, since 30023 linia stage'T2 tumors (18%) with volumes of 0.2 to 05 ce ‘emonstrated capsular peneaton. Retavspeetvely in spe por of this clatifestion was our eventual finding of fx falar penetration in 2 (9.6%) and established capsular Penetration n 214.8%) of 21 ctago Tie rumors with avlume [£022 100.5ee Weslo wished tallow fora cain aoa fia eae yr {ial temor Uke revue can be soalyed sending to coe oom a “Our eategry af moderato tomoe encompassed patients vith fw ees than 19% risk af propresdon 10 years afer Fadel prostaiectamy based on our prvous sud of sage {tamara table) Advanced tumors hed high kei nat ining cared by radial prostatectomy. These tamars Fae'a more than 40% risk of progression # to 10 years aier deal prostatectomy ‘lintel sage Tie radical prostatectomy findings (abe CCarinoma was organ confined only 31 of tea, le {58 demonstrated seminal vse asin ae had ple Tym made metastaen of the 10 patients wath seminal Vesile invasion Shad Iymph node metastases ws woll Sur (eal margins of Feection mere eallypsive i 1 of Uae PROSTATECTOMY FOR INPALPABLE PRCSTATE CANCER casex The distal margin was positive in 7 eases, pstralat- ‘al rgion 08, antenor marin in, and antes and ital ‘Sergio, Te ponarior, eral pranimal posterior aed ‘pnterlateral and posterior and lieral sites were involved Bit eae eth “the meta Gleason score and tamor vlumns within the radial pronatecomy apscinens were compared toa Prior ‘Sis of ralialprosatctomle performed for stagee Ta Sind T2dlwate (able 3). The Gleason sero was 90 4 In ‘ofthe canes, 8 toe In 65%, 7 n 32% and 80 9 in Oe ‘Tumor vale wes less than 02 ein 17% af the ease, 0.2 00.49 cess 19%, 0.5 v9 0.99 ce in 17%, 110 399 erin 42%, 2109.98 cin 5% and 10 or mare cen 3%. Tho only ease inthe radical prestatecomy iene of Glomeon 12 ‘Of the tanos Bi wee peripherally oe adjacent othe spe 61 of tae case were mons thas 0 where oe ‘hr have pected he tamors tobe palpable. Atala 5% the fr 2 ean) wa prednmsnandy con and an {avo in Teton, comparable to moet tumors digas by iransuredalresetion ofthe prostate. The mmaiing ee ‘Wee hetereeneons “Compara fo siage TTa and stage T2 lesions, Clinical stage Fe amore bad signicntly more advanced palag- {eal Bing tham nage Ti eso ll opect sted {able 3, exept for the ineidenee of op nce retains ‘Wen compared ical stage 2 tumor, stage Te stone ‘were sinifeanty less advaneed inal Rates hated in able Sreaept for the incidence af yap noe metastases ad Gheason sere In verms of Us overall clasaieation stage Tle lesions were intermediate in aggresiveness between sages Tiaand Te table 0 Toatns ‘or palpably. To determine whether gland shine call luo tusor palpi, we selected 6 ‘Seal stage Tie peripheral tumors with volumes of more than 08 cerwhich ne might have expected vo be palpable: ‘Minded mashed pair analjls was performed so that elirial tage Te Gmpapble) and cinta stage 72 paable) bie ors of sat Mente! eunor volumes wee compared The ‘lo of tumor lume over gland vlume for impelpable ‘ums (06) was aignieay amar than fr papal oe tor 0.07 p — 0.001) Becae taro volumes ee lost ‘lente bee the matched pais tho ference in these ‘tios could be attsbuted tothe relative inereace in ean a ‘men palpable tumors compared to palpi cto, “nada a enizn enlargement of ee prostate masking the palpabiity oa tamor, sme of the tumors wee pal ple because ofthe ited ize. Others were not detected on Fecal examination dae te the anterior andor central nen tion Tha 1 of mpeipabe tamors were mare than 03 od aduacet tothe rotate capa recs poorly onthe fli age ie mare oho toa mt napPROSTATECTOMY FOR IMPALPABLE PROSTATE CANCER io) Tumor Volume (cc) ge 38 H eepeyerin Tocderio! Stage Sto Stoge toner Te) Tie T2 (ee) (64) 2B) 306) 5a ie ype ntl are pre: 2S eo ly aznatsty of digital rectal examination in detecting Prostate cance. "Poston of eosrall mor eategory dosed on preoperative clinical parameter. Ago, thr as &eanuaus oe diholo- tt hn er tan pal rae was fot predictive of tumor eaogoy. Neer Camis nae roves of well syinpms wan protien, ‘Tranerecal sltewsound realte were aio het predictive of 1725 "Tae 3 Pht! finding a raed pratt of leat thas Tis tort compre col mages Tan Taras Tate 7 3 ‘Tome 4, Onl compari of links THe nor overall tumor category demonstrated by the hw positive and ‘egative predictive vals san in tale 6. Poative predictive ‘alue defies how oh, when a promperatve chine param ‘er prditedsigntennt tamar Gmnimal, moderate ord ‘anced tumors there was actualy gait utor with {head protect spimen Te sega pete ‘alue defines how ae, when 4 presperatve clini param: ‘ler predicted insignificant tor, here ea fet ig ‘cant tumor preznt ‘PEA and SA density (using either. 0.15, wor individually highly statisti signet Final tomar category (p 00001). The PRA and PSA deny to overall tune cago Intable and jn gure 3 Prado of ural tar category Base on ewe Biopsy pathological resuie The prenoe of Gleasan patiern 4a 8 {greater than ove with amor or my ore ith mae than S00 tumor invnfemsent war highly praicive of igtant tamer inthe radia prosscctoty ej (@ 0 O01, tle 6) Bilateral tumor on ewe bopyy was no prediive of {Umer category” OF 8 pints with Gleason sm 2204 on ele bopry 3 ad madera and 2 anced tumor inthe ‘adil prttatecony specimen. Of SD patients wih Lae {han S mm. fencer 0a tote 19 33% ted moderate and 3 (83) advanced tumor inthe rade prostatectomy. spec tment. "Thos, limited tamor ora lw Gleason sum un nels ‘pay by self dd nat pede fverable tumor within the prostatectomy Prediction of overall tuo Based n combined anal of prsoperatiee clinical and potelgie! porate. The com [ination of PSA density mare than O1 ran aero patho. Toga variable on poole hopey coeciy Monte 111 of 116 moderate ot advaned tamors (8°), 11 of 15 nial {more 738) and 21 of 28 agree tamer (2, tle {The overall postive pred Vlue of this combination {or identifying nen mare woe 82% snd the negate Drodesiv aloe was 6 Cnsideringencer ofa PSA enaty oF 1 to 015 when there was les than S tm. fle oF128 PROSTATECTOMY FOR IMPALPABLE PROSTATE CANCER. {ae &. Caren of tno parame with radial pretty i Praent Tames Sal Hara Aas Ne PSA (ng/td ‘8 A, aint Of PSA tm at aoa PA {ntermediate grade cancer on only core minimum a Scores mpled) also a2 favorable preoperative nding increased the postive predictive valu fn Of and negative prodiesee ‘alee ts 66% Ourentera for posing insgsicnt tomar [He suntavized i gure ‘four ces 124 had PSA values of more than 4 mean PSA, 11.8) In this group 11% ofthe eases Wer insignificant, 8% ‘were animal SO were toderste end 49% were advanced ing'a PSA denaiyof Tae than 0.1 and good pathologies findings on nowdle Biopsy to predict insignificant tumor, we i- an: t E — ty PSAD tum ext, Reprinted with permis” ‘ure dete only 5 of 15 (3) wth insgicant ta ton, Conslering cages of « PSA dena of 0.1 0 048 wit Teer than 3mm of cancer on 1 ene alo se a favorable Dprovperative finding, we ore identified 9 of 15 tsi. Concerns buen eased that sereening for prostate cancer wil although increas the Tat of cancer detection, deny{DALE Conran fn op iho rade prs as Ne Bae Paige ro ee ‘tats 1. Carlton f repeat clinical nd pate orem ith aden prvoeton Taal Posed Fane Shee Pop. Clnptl ge ‘njgiant— Mimal—Meee Aged Mpere Pe ce aa patton eae & a a s « “ LIMITED CANCER (SHINIMUMLS CORES SAMPLED) “<3 coRES PIVOLVED & & [NO CORE WET 0% INVOLVEMENT ‘VERY LIMITED CANCER (MINIMUMS CORES SAMPLED) nm CANCER ON ONE CORE & [NO GLEASON PATTERN or 5 IGNIFICANT-CANCER, LIMITED CANCER & PSA DENSIFY <0. VERY LIMITED CANCER PSA DENSITY <015 4, operetta ee te re ise ‘many ineldental tumor of tle bila significance that pone no heat to ie. Oue study demonarated that est EExpapable prostate cancers diagnosed hy sowesng tech ston at tan are han hi uty weal te freated dtivly Hf thy wero palpable oly 81% of the mors were organ confined, 34% demansirted established antler penetaton and 1% had postive surgical margin Our study demonstrted that, in grerl, stage THe tumore fare intermediate in extont compare to sages Ta and T2 Tesions, Of tho elinet stage THe lesions 20% wore inigni auto minimal compared to 68% of tage TlaTesions and tly 8% of stage T2 lesions, Simalry, 7% of stage Tle Tests were dvancod eompared to 58 of tag ond only "eo sage Tla tumors. Preoperative eines! and pathologalertria can be used to preties tamor extent PSA and FSA density corelatd ‘eo wih tr eategory, and bth tests ha high post tive predictive valuer PSA densi war anointed with "ght highor rosin preitve value than PSA. Esme oe am lovated PSA Level was probably the rel of prom: nent hypeplagia, which wan atorel ny the PSA deity “There wore stil aizable number ol patente wth minima smolrat or even advanced tnors and PSA value of fe ‘han dur PSA donity measurement {Jas than 0, Which has alo een demenstratd previusy.” Biopsies Were per form inthe men for vary of acon sions were ‘oualized en screening tramretal srapound 2) PSA on Inidal exinination was more than 4 yet the lait PSA level Sttined bear rdealprosatoctom Was less than 4 and) In ome caver 8 PSA level of moe thon 28 oink, at ‘oidered abnormal Somethat suresing in ou stay wat that tansrectl ultrasound findings were no predictive of tumor extent. The poor peeicabiiy of transocal ules ound may nary tchec variable persion expertise ad ‘equipment. Since the ulteaound tate were performed. Aeent ietitutions. Novetelss ow tay vet results ‘hat would be achieved in peeral medical practice Ferguson (c'a'endemoostvsted fat iere were no dfiernecs in ‘Sonor extent wether len was wae i vinualled on ‘ranartal utrasaond18 ‘PROSTATECTOMY FOR INPALPABLE PROSTATE CANCER ‘Tau 8, Tumor preoperatioy rdistedo hae iiifan ne yet th minimal madre oe ‘chaned tm ofa recon Ser fin pesty "WAC" rents Nemes Rede “Ee ‘hs I ll cases, adverse nese bopey pathological results predicted adverse pathologeal ndings within the radial prostatectomy’ specimen. However, favorable. pathologie! [Biting on ares bopay did ot para favorable pte: logieal reals inthe prostate de to sampling prdlems Ibrent ith needle bopses, which conte wih another stay. ‘By eumbining preoperative el and pathalogial Go ngs tumor extent wae predic with maxamum poate abd ‘gate proditive values able Using PSA less than & lind favorable pathologies! ndings on nedle siopes eco were men with munital tomer dod with moderate tumor ‘who would Rave been flelypredztod to have good Ingieal eles Ofthe men ths PSA deny a eer han OL (2A) teense petted pay hd ‘inimal ands modaravetumar tale 3) Tone wore sing these ertena to ‘dently patients who ugh be followed ‘expectant, theco patients may have remained wrested ‘Somtehevlog-vgeten st uno. Despite beng eategoraed ‘Shaving minal or moderate tumor most ofthese patients had rlatiely Io tumor ylumes, low Gleason grade end {ond pathlaea! stage: The 2 men with retry high ‘Sar volumes of Ls ctand 9:8 cea central and aseror ‘Using a combination of PSA tess than 4 and favorable patholascal rel on needle bopey to deny patents eho (Bight be followed conservatively 17 te 25 men (20) with Insignificant fomore might hav been spared radial prosae tectomy. Using the sombinaton of PSA deny lem tan OT ited foiablefaolageal neadle opie” we forely Hear Uiied 15 o 2 patients (60%) wit nsgnennt tumors, Ue Ing our best model, PSA density Toss than 0.1 and ord pathogen rents on needle biopsy ar PSA density D1 9 BGs with Kisted ess thon nm) tomor an acedle psy ‘we correctly predicted 19 of 26 insignificant tamors (7, ‘nip 1 adeitonalexse, beyond those noted in table of ‘erate tumor was inconrolySdetied se having ii ‘fest amor This model was ler perorin ening Inaignifeant tumor in cases with a PSA of mate than ‘Serum PSA, PSA density and needle bopey pathologie! oral are securate predictor af tumorestentanditmay be ‘eatonble to follow those patients who moat hkely have ently insigaieant tumor with serial PSA measure: {nts to detec s change in shnlate PSA values ge well to ‘termine the raie of change of PSA volocty What re ‘hains unanswered is how many insignifieant o minioel {tumors when allowed expuctanlly wil progress beyond the ‘trae tge by the tine there eam irenne serum PSA, ‘ales For this reason, periodic bopsios may be ndisted. ‘Kerlin! fccr in deciding whether to fallow patients with gue glen cu may pan ge I ol {ely younger men with longer fe expetancie, i whom ‘tho rskoftomor growth and progression is greater more ‘Agronivetrentnen strategy ma be advsuble, Conver, ‘Sonmcretive aproseh may be warrated Sacer inv ‘als nh preoperative dings sugyst a high iklbood potently oegatensetmorFalyous daa will ave tobe validated prospectively as paients whose pedited have “insignia amor are flowed expects 1 Murr, W. Me, De, PJ, Braid Aan Tat, Ls ata anon he pre how mach emg 2 Nowm'A Friis Genlams Bi. Cay, Se and ‘Temas, Scat sarcoma tbe prostate it ‘eure opie rag ey Sates Top iia wih prenten oing reenl rpae i Ravan, JC, att, J tol Vai 1. ang tr fre rene seeded Urs, 135816, 181 6 hee ML, dnc ements Roe Acne rca 1p. Pas Gr Easton, J.C. and Wal, PC Pere reer ee 1 EE oa tt i Gag 7a ace ta le 10, Thompion, I. M. and Zeidman, B,J: Extended fellow up of sage 11. ang. seman NP SLR BL Reber. and ‘Redd, B, K= Long-term followup results iter expectant maa- 2 cecna 8, Bat kW. Wah Be asd pnd {Cis ln ro sd ston pags ag Ca 18 Rin, M.D. Zarbousi, R.A; Gatsons, © ., Quint LB RR Smee heh i ing ab ultrsowogrephy in lng early prostate cancerPROSRATECTOMY POR IMPALPABLE PROSTATE CANORRE ‘shah Sy Hamper Me Wala, B.C ad pst. 1 Stage “tiga of i Pate, ra OS ad es, Bia Wr tly Sand ack. ENP Agate panna stan an “Wlamas BD Incidental vl ft ete ai Sango sng anu ro. a, 48 Lane A. and Barry JM The pedis of tag ‘anal renin fh rsa unio ‘etal Mo age Aci of peat Uk San LP Gromman, HB. MacGregr, RS. aod Gita, ‘Ni iedentlognicariin the peat Te fle eee tonne enn gy Pete 88, Ingerman, A, Broderick, Witlams . god Coral "Sea wepetapcoreiral reno rst aot isi ates wit tge A pote xin a or canes 8 Para Ae Epa 3 1h DW sad Wa Ge mapa ce is Re ee eee et BW Rota Pac at a 8 Lac "amor extent be pede iy raat eectin ae ‘lume prs oe ade Amy’ Gt age At eee ngeAd and der) Ue Tag {2,190 ‘pane, AW Epstein 1, Obo. KR, Gitalooha. A Mond ed ratty nna prota ane tage “spp! od cel Eee TAA HS emo line a independ pect repress n Ingvar rote? muha of 18 tet aagefomscarnongs oe prt wiv years tote in: Cambell Urey, 6h Batol by PC. Walsh, TE chef Aste pean, e Plat edie fi ae “hos, nd Comer mH: wae epee st tei mean of dtrgug etn pte hyper. thy aed pat acer Ura 181 00) ‘Biguon MC, Whose TS. Otoem, A, Men... ad ‘ni iH roar eso “nines the te vo af eet ees erm brett priest 3: Ua pin, Wy Care HB, hy BW te, Jb “Setar ak €% Ward. Pand Was, # Prottospre an inthe sting hazed prostate ow item far Otel ad ‘gn parla J Ura, 47, 100 1 vee IE sini 2k a ‘Soracurie of lend von vere ive ser ‘rig ese ‘arte BW RIM, JB and She, T A: Dteton of “inc sgnent sate comer by wantetal re ‘undid retmate ops Url, la, 198 CEES Ret Bern AW ta JL and