Is there more to prostate cancer aggressiveness than Gleason score?
Should we require more information from our pathologist, beyond the current International Collaboration on Cancer Reporting ICCR recommendations?
Introduction
The commonly used risk stratification models such as the D’Amico classification, prognostication models such as the Kattan nomogram and predictors of indolence such as Epstein’s criteria do not take into account evidence of local infiltration on biopsy. In our cohort of histologically proven prostate cancer at a tertiary centre over a period of 5 years, the majority of our patients had high grade disease at presentation, and more than half had evidence of perineural infiltration.
Objectives
To determine if other histological features other than the Gleason score, which indicate increased aggression and advancement of prostate cancer deserve greater recognition and should be included in risk stratification and prognostication models?
Methods
The histological reports of all prostate cancers at a tertiary centre over 5 years were reviewed for the following parameters:
- Completeness of reporting based on the ICCR guidelines
- PSA level
- Gleason grade
- Evidence of local infiltration
Results
726 specimens were available for review, of which 664 were from core needle biopsies with the rest obtained from radical prostatectomies, open prostatectomies, channel TURP’s, TURP’s and radical cystoprostatectomies.
We found the following:
- Completeness of reporting based on the ICCR guidelines: 63% of the core needle biopsies met the criteria for reporting of the required criteria. Evidence of local infiltration which is only recommended was reported in 84% of the specimens.
- PSA level: 70% of patients had PSA >20 ng/ml. The median PSA was 1148.35 ng/ml (0.7 – 22,978 ng/ml), 10% of the cohort had PSA > 1000 ng/ml.
- Gleason grade: 61% of all specimens had high grade disease at presentation. A further 14% had intermediate grade disease.
- Evidence of local infiltration: Local infiltration on biopsy can be in the form of perineural, lymphovascular, extra- capsular or seminal vesicle invasion. Of the total 609 specimens in which local infiltration was commented on, only 3 had no evidence of any form of invasion.
Conclusion
The majority of our patients had high grade disease at presentation with evidence of local infiltration on biopsy.
Should we be adding local infiltration as a parameter to risk stratification and prognostication models?
