OBJECTIVE: To investigate the post-prostatectomy and long-term outcomes of men presenting with an elevated pretreatment PSA (>10 ng/mL) but otherwise low risk features (biopsy Gleason score ≤ 6 and clinical stage ≤ T2a).
PATIENTS AND METHODS: PSA-incongruent intermediate risk (Pii) cases were defined as those patients with preoperative PSA >10 and ≤ 20 ng/mL but otherwise low risk features, and PSA-incongruent high risk (Pih) cases were defined as men with PSA >20 ng/mL but otherwise low risk features. The Institutional Radical Prostatectomy Database (1992-2012) was queried and stratified into D'Amico low risk, D'Amico intermediate risk, D'Amico high risk, PSA-incongruent intermediate risk, and PSA-incongruent high risk cases. Prostate cancer (PCa) features and outcomes were evaluated using appropriate comparative tests. Multivariable analyses were adjusted for age, race, and year of surgery.
RESULTS: Of the total 17,608 men, 1,132 (6.4%) had Pii risk disease and 183 (1.0%) had Pih risk disease. Compared to low risk men, the odds of upgrading at RP were 2.20 (95% CI 1.93-2.52, p< 0.001) for Pii men and 3.58 (95% CI 2.64-4.85, p< 0.001) for Pih men, the odds of extra-prostatic disease at RP were 2.35 (95% CI 2.05-2.68, p< 0.001) for Pii men and 6.68 (95% CI 4.89-9.15, p< 0.001) for Pih men, and the odds of positive surgical margins were 1.97 (95% CI 1.67-2.33, p< 0.001) for Pii men and 3.54 (95% CI 2.50-4.95, p< 0.001) for Pih men. Compared to low risk disease, Pii risk disease was associated with a 2.85-, 2.99-, and 3.32-fold greater risk of biochemical recurrence (BCR), metastasis, and prostate cancer-specific mortality (PCSM) respectively, and Pih risk disease was associated with a 5.32-, 6.14-, and 7.07-fold greater risk of BCR, metastasis, and PCSM respectively (p≤ 0.001 for all comparisons). For Pii men, the increased risks for positive surgical margins, upgrading, upstaging and, BCR were dependent on PSA density (PSAD): Pii men who had a PSAD < 0.15 ng/mL/g were not at elevated risk compared to low risk disease. Pii men with PSAD ≥0.15 ng/mL/g and Pih men were more likely to have an anterior component of the dominant tumor (59% and 64%, respectively) compared to low (35%), intermediate (39%), and Pii men with PSAD < 0.15 ng/mL/g (29%).
CONCLUSIONS: Men with PSA >20 ng/mL or men with PSA >10 and ≤ 20 ng/mL with PSAD ≥0.15 ng/mL/g, but otherwise low risk prostate cancer, are at increased risk of adverse pathologic and oncologic outcomes and may be inappropriate candidates for active surveillance. These men are at increased risk of having anterior tumors that are undersampled at biopsy, so if treatment is deferred, ancillary testing such as anterior zone sampling or MRI should be strongly encouraged. Men with elevated PSA >10 and ≤ 20 ng/mL but low PSAD have outcomes comparable to low risk men, and consideration of surveillance is appropriate in these cases.
Written by:
Faisal FA, Sundi D, Pierorazio PM, Ball MW, Humphreys EB, Han M, Epstein JI, Partin AW, Carter HB, Bivalacqua TJ, Schaeffer EM, Ross AE. Are you the author?
Johns Hopkins University, Brady Urological Institute, Baltimore, MD.
Reference: BJU Int. 2014 Apr 15. Epub ahead of print.
doi: 10.1111/bju.12771
PubMed Abstract
PMID: 24731026
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