Prostate Cancer Staging

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Prostate Cancer Staging

• Amy Opperer, D.O.
• Michigan State University
• January 21, 2004

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Objectives

• Know the reason for staging prostate cancer
• Know the elements of clinical and pathological
  staging
• Know the tools available for staging

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Outline

• Introduction
• History
• AJCC Staging
• Digital Rectal Exam
• Serum Tumor Markers
• Histologic Grade
• Imaging
• Lymph Node Evaluation
• Conclusion

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Introduction

• Goal of staging
• Assess prognosis and aid in planning management
• Identify clinically localized v. locally advanced
  v. metastatic disease
• Pathologic stage
• Best predictor of outcome
• Local extent (DRE)
• Serum PSA
• Tumor grade

Correlate well with pathologic grade
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Introduction

• More information
• Tumor volume
• Surgical margin status
• Extracapsular spread
• Seminal vesicle involvement
• Lymph node status

These plus tumor grade are most important for
prognosis
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Introduction

• Staging tools
• Digital rectal exam
• Serum tumor markers
• Histologic grade
• Radiographic imaging
• Pelvic lymphadenectomy

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History

• Whitmore (1956) first staging system
• Jewett (1975) revised
• American Joint Committee for Cancer Staging and
  End Results Reporting (AJCC)
• TNM adopted (1975)
• Modified (1992, 1997)

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1997 AJCC Staging

• Primary tumor
• Tx Primary tumor cannot be assessed
• T0 No evidence of primary tumor
• T1 Tumor not palpable or visible by imaging
• a ?5 resected tissue
• b gt5 resected tissue
• c needle biopsy specimen due to ?PSA

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1997 AJCC Staging

• T2 Palpable tumor confined to prostate
• a one lobe
• b both lobes
• T3 Extends through prostate capsule
• a unilateral or bilateral extracapsular
  extension
• b invades seminal vesicle

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1997 AJCC Staging

• T4 Fixed or invades adjacent structures other
  than seminal vesicles
• Bladder neck, external sphincter, rectum, levator
  muscles, pelvic wall

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1997 AJCC Staging

• Pathologic primary tumor
• pT2 Organ confined
• a unilateral
• b bilateral
• pT3 Extraprostatic extension
• a extracapsular
• b seminal vesicle invasion
• pT4 Invasion of bladder or rectum

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1997 AJCC Staging

• Regional Lymph Nodes
• Nx Cannot be assessed
• N0 No lymph node metastasis
• N1 Metastasis in regional lymph node(s)

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1997 AJCC Staging

• Distant Metastasis
• Mx Cannot be assessed
• M0 No distant metastasis
• M1 Distant metastasis
• a nonregional lymph nodes
• b bone
• c other site

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Digital Rectal Exam

• Significantly understages
• Increases with increased clinical stage
• Partin et al (1993) 52 sensitive, 81 specific
• 565 organ confined on DRE
• 52 organ confined
• 31 capsular penetration
• 17 seminal vesicle or LN invasion
• 36 non-organ confined on DRE
• 19 organ confined
• 36 capsular penetration
• 45 seminal vesicle or LN invasion

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Serum tumor markers

• Prostatic Acid Phosphatase
• Pre-PSA era
• Directly correlate with disease stage
• gt80 with abnormal (upper ½ normal) have
  extraprostatic disease
• Not specific

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Serum tumor markers

• Prostate-Specific Antigen (PSA)
• Not sufficient for staging alone
• Confounding factors
• Volume of BPH
• Tumor grade
• Stage overlap
• lt4ng/mL?80 organ confined
• 4-10ng/mL?66 organ confined
• gt10ng/mL?lt50 organ confined
• gt20ng/mL?20 LN involvement
• gt50ng/mL?75 LN involvement, 90 SV invasion

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Serum tumor markers

• Other
• Alkaline phosphatase
• Not specific
• Reverse Transcriptase-Polymerase Chain Reaction
  PSA
• Specific
• No additional value

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Histologic grade

• Strong predictor of biologic behavior
• Invasiveness
• Metastatic potential
• Perineural invasion indicates higher risk of
  non-organ confined disease
• 75 have capsular penetration
• Biopsy of seminal vesicles
• Consider for large palpable tumors

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Histologic grade

• Gleason grade
• Numbered score to identify histologic pattern
• ?4 has poorer prognosis
• Gleason score
• 2 most prominent patterns
• gt50 Have at least 3 patterns
• ? 7 has poorer prognosis
• Primary 4 (43)-more aggressive

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Histologic grade

• Gleason 1
• Atypical adenomatous hyperplasia
• Uncommon
• Rarely diagnosed

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Gleason Grade 1
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Histologic grade

• Gleason 2
• Similar to Gleason 1
• Well differentiated
• Less circumscribed
• ? variation of acinar size and shape
• Maintain round shapes

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Gleason Grade 2
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Histologic grade

• Gleason 3
• Most common
• 3 patterns
• Cribiform, small acinar, large acinar
• Prominent variation in size, shape, and spacing
  of acini
• Irregular arrangements
• Stromal fibrosis
• Infiltrative

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Gleason 3
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Histologic grade

• Gleason 4
• Poorly differentiated
• Fusion of acini
• Ragged infiltrating cords and nests
• Rigid network of epithelium
• Sheets of cells

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Gleason 4
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Gleason 4
30
Gleason 4
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Histologic grade

• Gleason 5
• Fused sheets and randomly arranged acini
• Displace other tissue
• Comedocarcinoma
• Luminal necrosis
• Signet cell carcinoma
• Distinct nuclear displacement by clear cytoplasm
• If gt25, then signet-ring cell carcinoma

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Gleason 5
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Gleason 5
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Imaging

• Bone surveys
• Not sensitive
• Follow up of radionuclide scan
• Bone scintigraphy
• Asymmetric areas with intense uptake
• Most sensitive
• PSA lt10 and no bone pain
• Baseline

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Imaging

• Magnetic Resonance Imaging
• Low sensitivity for local extension or LN mets
• Computed Tomography
• Low sensitivity for local extension or LN mets
• Transrectal Ultrasound
• 50 tumors gt1cm not visualized
• Most hypoechoic areas are benign
• No difference in prognosis if seen on TRUS

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Imaging

• ProstaScint Scan
• Indium 111 tagged antibody CYT-356
• Limited value in pretreatment staging
• Postitron Emission Tomography
• BPH and prostate tumors appear similar

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Lymph Node Evaluation

• 10 year progression of prostate cancer
• 31 in node negative
• 87 in node positive
• Pelvic lymph node metastasis
• T stage, PSA, Gleason score
• 5-12 localized disease (gt20 pre-PSA)

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Lymph Node Evaluation

• Pelvic lymph node dissection
• Relative indications
• Enlarged nodes on imaging
• PSA gt20ng/mL
• Gleason score 8-10
• Palpable locally advanced
• Lymphangiography
• Good visualization obturator nodes
• Poor visualization hypogastric chain (50)

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Conclusion

• Clinical and pathological staging estimate
  prognosis and guide treatment plans
• Digital rectal exam
• Serum tumor markers
• Histologic grade
• Radiographic imaging
• Pelvic lymphadenectomy

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References

• Bostwick, D.G., Quan, J. Schlesinger, C.
  (2003). Comtemporary pathology of prostate
  cancer. Urologic clinics of North America 30
  (2) 181-207.
• Carter, H.B. Partin, A.W. (2002). Diagnosis
  and staging of prostate cancer. In Walsh, Retik,
  Vaughan, Wein (ed.), Campbells Urology (pp.
  3055-3079). Philadelphia Saunders.
• Kozlowski, J.M. Grayhack, J.T. (2002).
  Carcinoma of the prostate. In Gillenwater, J.Y.,
  Grayhack, J.T., Howards, S.S. Mitchell, M.E.
  (ed.), Adult and Pediatric Urology (pp.
  1512-1526). Philadelphia Lippincott Williams
  Wilkins.
• Lloyd-Davies, R.W., Parkhouse, H., Gow, J.G.
  Davies, D.R. (1994). Color atlas of urology.
  London Mosby.