Socioeconomic status is an independent predictor of biochemical recurrence among patients with prostate cancer who undergo radical prostatectomy.

PURPOSE: Socioeconomic status (SES) may influence cancer characteristics and behavior in several aspects. We analyzed PCa characteristics and behavior among low income uninsured men, and compare them to high income patients with health insurance in a developing country. MATERIALS AND METHODS: A retrospective case-control study was performed on 934 patients with clinically localized PCa who underwent radical prostatectomy between March, 1999 and July, 2009. Patients were divided in two groups, according to their SES. In group 1 (n =380), all had low income, low educational levels and couldn ' t afford medical insurance. In group 2 (n =554), all had higher income, higher education and had medical insurance. RESULTS: Patients from group 1 were older, had higher Gleason scores, higher rates of seminal vesicle and bladder neck involvement. The Kaplan Meier disease-free survival curve demonstrated that after a follow-up of four years, about 50% of uninsured patients had biochemical recurrence, versus 21% of insured patients (Log rank test: p < 0.001). A multivariate Cox regression analysis for the risk of disease recurrence demonstrated that only PSA levels, Gleason score, seminal vesicle involvement and SES were statistically significant variables. Patients with a low SES presented 1.8 times the risk of recurrence as compared to patients with a high SES. CONCLUSIONS: Patients with low SES were older, presented more aggressive PCa characteristics and a high rate of disease recurrence. A low SES constituted an independent predictor for disease recurrence.

The beginning of the 21st century: a paradigm shift in the surgical management of renal cell carcinoma in South America.

PURPOSE: The incidence of renal cell carcinoma (RCC) has been rising by 2.3 to 4.3% every year over the past three decades. Previously, RCC has been known as the internist's tumor; however, it is now being called the radiologist's tumor because 2÷3 are now detected incidentally on abdominal imaging. We compared patients who were treated toward the end of the 20th century to those treated during the beginning of the 21st century with regard to RCC size and type of surgical treatment. MATERIALS AND METHODS: The study included 226 patients. For analysis of tumor size, we considered a cut point of <4 cm and>4 cm. For analysis of type of surgery performed, we considered radical and partial nephrectomy. RESULTS: After the turn of the century, there was a reduction of 1.57±0.48 cm in the size of the RCC that was operated on. Nephron sparing surgeries were performed in 17% of the cases until the year 2000, and 39% of the tumors were <4 cm. From 2001, 64% of the tumors measured<4 cm and 42% of the surgeries were performed using nephron sparing techniques. Mean tumor size was 5.95 cm (±3.58) for the cases diagnosed before year 2000, and cases treated after the beginning of 21st century had a mean tumor size of 4.38 cm (±3.27). CONCLUSIONS: Compared with the end of the 20th century, at the beginning of the 21st century due to a reduction in tumor size it was possible to increase the number of nephron sparing surgeries.

Tumor banks: the cornerstone of basic research in urology.

PURPOSE: Tumor banks have the primary responsibility for collecting, cataloging, storing and disseminating samples of tissues, cells and fluids, which are used by researchers to identify diagnostic molecular markers, prognostic indicators and therapeutic targets. The objective of this review was to describe a simple, reliable and reproducible protocol for obtaining and storing samples of urological tumors. MATERIALS AND METHODS: Urogenital tumor tissues were collected by the surgeons from the Urology Division of University of Sao Paulo Medical School. The obtained surgical specimens were immediately placed in liquid nitrogen, dry ice or in a tube containing RNAlater, and then stored by cryopreservation (-80 degrees C). A mirror fragment was fixed in 10% formalin processed routinely and embedded in Paraplast. RESULTS: We developed a protocol for the collection, cataloging, storage, conservation and use of tumor samples. During a period of one year the Urological Tumor Bank of the Urology Division stored 274 samples of prostate, bladder, kidney, penis and testicle tumors of different histological types, 74 urine and 271 serum samples. CONCLUSIONS: Having biological materials characterized and available along with the clinical patient information provides an integrated portrait of the patients and their diseases facilitating advances in molecular biology. It also promotes the development of translational research improving methods of diagnosis and cancer treatment.

Role of Genetic Polymorphisms in the Development and Prognosis of Sporadic and Familial Prostate Cancer.

BACKGROUNDS: Our aim was to evaluate the role of 20 genetic polymorphisms in the development and prognosis of sporadic and familial PC. A case-control study of 185 patients who underwent radical prostatectomy from 1997 to 2011. These patients were divided into two groups based on their family history. Gleason grade, PSA value and pathological TNM 2002 stage were used as prognostic factors. Blood samples from 70 men without PC were used as controls. The SNPs were genotyped using a TaqMan® SNP Genotyping Assay Kit. RESULTS: Considering susceptibility, the polymorphic allele in the SNP rs2660753 on chromosome 3 was significantly more prevalent in controls (p = 0.01). For familial clustering, the polymorphic homozygote genotype of the SNP rs7931342 was five times more frequent in patients with familial PC compared to sporadic PC (p = 0.01). Regarding the SNP 1447295, the polymorphic homozygote genotype was more prevalent in patients with organ-confined PC (p = 0.05), and most importantly, the polymorphic allele occurred more frequently in patients without biochemical recurrence (p = 0.01). Kaplan-Meier analysis showed a median biochemical recurrence free survival of 124.2 compared to 85.6 months for patients with the wild-type allele (p = 0.007). CONCLUSION: Our findings provide the evidence for the association of 20 recently highlighted SNPs and their susceptibility, familial clustering, staging, Gleason score and biochemical recurrence of PC. We believe that the association between these SNPs and PC may contribute to the development of alternative tools that can facilitate the early detection and prognosis of this disease.

[Well differentiated localized prostate carcinoma: prognostic relevance of tertiary Gleason pattern 4 and tumor volume]. / O padrão 4 de Gleason e o volume tumoral no prognóstico do carcinoma da próstata.

INTRODUCTION: Early introduction of adjuvant radiation or hormone therapy after radical prostatectomy has been advocated in recent literature aiming to improve survival rates in high risk prostate cancer. Traditional prognostic parameters such as serum PSA, Gleason score and clinical stage have been used to identify these cases however accuracy is far from ideal. Recently, tumor volume and presence and percentage of a tertiary less differentiated Gleason pattern have been considered better indicators of prostate cancer behavior. The purpose of this study was to evaluate the importance of presence and percentage of a Gleason pattern 4 and of tumor volume in the outcome of patients treated for well-differentiated prostate adenocarcinoma. METHODS: Seventy seven patients submitted to radical prostatectomy for well-differentiated prostate carcinoma, Gleason score 6 or less, and followed up for at least 5 years were selected. Thirty seven experienced biochemical recurrence while 40 did not. The percentage of Gleason pattern 4, the percentage of the gland involvement (considered as "tumor volume"), capsular invasion and extraprostatic extension were submitted to univariate and multivariate analyses for the evaluation of possible associations with biochemical recurrence. RESULTS: Tumor volume was the most important parameter to predict biochemical recurrence by univariate and multivariate analysis. The median of tumor volume was 25.0% for patients who suffered recurrence, and 11.5% for those with no recurrence (p=0.003). The percentage of Gleason pattern 4 was predictive of recurrence in univariate analysis only. The median percentage of Gleason pattern 4 was 7.5% for patients without recurrence and 19.0% for those who presented recurrence (p=0.046). CONCLUSION: Tumor volume is very objective, easy to evaluate and the most important parameter to predict biochemical recurrence in well-differentiated adenocarcinoma of the prostate. On the other hand, presence and percentage of a tertiary less differentiated Gleason pattern correlated with systemic relapse. Both parameters should be included in future studies to evaluate the role of adjuvant therapy in high risk prostate cancer.

Perineural invasion detection in prostate biopsy is related to recurrence-free survival in patients submitted to radical prostatectomy.

OBJECTIVE: Perineural invasion (PNI) is detected in almost 20% of prostate biopsies and has been related to worse prognostic factors in radical prostatectomy (RP) specimens and lower disease-free survival rates. The aim of this study was to evaluate the importance of PNI during periods of extended prostate biopsies and to determine the value of this preoperative parameter as a predictor of pathologic findings in surgical specimens and in biochemical recurrence. MATERIALS AND METHODS: Between 2001 and 2009, 599 prostate biopsies and their respective RP specimens were examined in our laboratory. The RP specimens were always examined completely. The mean age of the patients was 61 years, and the mean PSA was 6.4 ng/mL. The mean and median number of biopsy cores obtained was 14.4 and 14, respectively. PNI was identified in 105 biopsies (17.5%). We studied the ability of PNI in prostate biopsies to determine the tumor stage in surgical specimens and the relationship of PNI with biochemical recurrence during a mean follow-up time of 51.4 months. RESULTS: The presence of PNI in prostate biopsies was observed in older patients (63 vs. 61 years old, P = 0.008). All of the prognostic factors determined for the RP specimens were significantly worse in patients with PNI compared with those without PNI. PNI was strongly associated with a higher pathologic stage (87% specificity, 40% sensitivity, odds ratio 4.8). Stage pT3 prostatic cancer was determined in 46 (43.8%) of 105 patients with PNI on biopsy compared to 69 (14%) of 494 patients without PNI (P = 0.01). Fifty-six (19.6%) patients had a biochemical recurrence, and PNI correlated significantly with PSA recurrence. A Kaplan-Meier analysis revealed a significant difference in recurrence-free survival between patients with and without PNI (45% vs. 53%, respectively, P = 0.021, log-rank test = 0.19). CONCLUSION: PNI is an important morphologic preoperative predictor of the pathologic stage as well as biochemical recurrence and must always be mentioned when adenocarcinoma is diagnosed on prostate biopsies.

Are we able to correctly identify prostate cancer patients who could be adequately treated by focal therapy?

INTRODUCTION AND OBJECTIVE: Because of the improvements on detection of early stage prostate cancer over the last decade, focal therapy for localized prostate cancer (PC) has been proposed for patients with low-risk disease. Such treatment would allow the control of cancer, thereby diminishing side effects, such as urinary incontinence and sexual dysfunction, which have an enormous impact on quality of life. The critical issue is whether it is possible to preoperatively predict clinically significant unifocal or unilateral prostate cancer with sufficient accuracy. Our aim is to determine whether there is any preoperative feature that can help select the ideal patient for focal therapy. MATERIAL AND METHODS: A total of 599 patients who underwent transrectal ultrasound (TRUS)-guided prostate biopsy followed by radical prostatectomy to treat PC were examined in our laboratory between 2001 and 2009. We established very restricted criteria to select patients with very-low-risk disease for whom focal therapy would be suitable (only 1 biopsy core positive, tumor no larger than 80% of a single core, no perineural invasion, PSA serum level < 10 ng/ml, Gleason score < 7 and clinical stage T1c, T2a-b). We defined 2 groups of patients who would be either adequately treated or not treated by focal therapy. The primary endpoint was the evaluation of preoperative features in order to identify which parameters should be considered when choosing good candidates for focal therapy. RESULTS: Fifty-six out of 599 patients met our criteria. The mean age was 59 years, and the mean number of biopsy cores was 14.4. Forty-seven (83.9%) were staged T1c, and 9 (16.1%) were staged T2a-b. Forty-four (78.6%) patients could be considered to have been adequately treated by focal therapy, and 12 (21.4%) could not. There was no statistical difference between the 2 groups considering age, clinical stage, PSA levels, Gleason score, and tumor volume in the biopsy. All 12 patients who could be considered inadequately treated had a bilateral, significant secondary tumor, 58.3% had Gleason ≥ 7, and 25% were staged pT3. CONCLUSION: Although focal therapy might be a good option for patients with localized prostate cancer, we are so far unable to select which of them would benefit from it based on preoperative data, even using very restricted criteria, and a considerable proportion of men would still be left undertreated.

Long-term outcomes of radical cystectomy with preservation of prostatic capsule.

OBJECTIVE: We report our results of orthotopic ileal neobladder after radical cystectomy with prostatic adenomectomy with regard to urinary continence, sexual outcome and disease control. METHODS: Between March 2003 and July 2004, 22 men with bladder transitional cell carcinoma (mean age 65.0) were analyzed. They underwent radical cystectomy with prostatic adenomectomy with preservation of the prostatic capsule, seminal vesicles and orthotopic ileal neobladder. Urinary continence was assessed after 2 days, 2 months, 6 months and 1 year. Preservation of sexual function was defined as the ability to have sexual intercourse and was assessed after 2-, 6-, and 12-months postoperatively. Overall survival and cancer-specific survival were assessed. RESULTS: Median postoperative follow-up was 60 months. Daytime and nighttime urinary continence after 48 h was 47 and 14%, respectively. After 2, 6 and 12 months, these rates were 74 and 16%, 85 and 26%, and 94 and 31%, respectively. Sexual intercourse was achieved in 69% of patients. Overall survival rate was 68%, and cancer-specific survival rate was 73%. Overall survival rates according to pathologic stage for pT0, pT1, pT2 and pT3 were 100, 60, 71 and 57%, and cancer-specific survival were 100, 80, 71 and 57%, respectively. CONCLUSIONS: Urinary continence and sexual function achieved by radical cystectomy with prostatic adenomectomy with orthotopic ileal neobladder seem to be similar to those achieved by the conventional technique with satisfactory oncologic results.

Perineural invasion by transitional cell carcinoma of the bladder in patients submitted to radical cystectomy: what is the prognostic value?

OBJECTIVE: Determine the prognostic value of perineural invasion (PNI) in patients with transitional cell carcinoma (TCC) of the bladder treated with radical cystectomy. MATERIALS AND METHODS: From January 1993 to January 2005, 113 people were selected from 153 patients with TCC of the bladder treated with radical cystectomy. The association between the presence of PNI and other pathologic characteristics were analyzed through Fisher exact test. The Kaplan-Meier method was utilized to assess the survival curve and the statistical significance was determined by the Breslow test. The multivariate analysis was performed through the Cox regression model. RESULTS: The PNI was identified in 10 (8.8%) of the 113 patients. This variable significantly related to the microvascular invasion and to tumor staging. The mean segment after surgery was 31.7 +/- 28.5 months. Recurrence occurred in 5 (50%) and in 41 (39.8%) patients (p=0.363) and mortality occurred in 2 (20%) and 22 (21.9%) patients (p=0.606) with or without PNI respectively. In Cox regression analysis, patients with PNI presented with 1.53 times (IC 95% 0.60 to 3.91; p=0.371) and 1.60 times (IC 95% 0.37 to 6.95; p=0.532) the risk of recurrence and mortality when compared to patients without PNI. CONCLUSIONS: The PNI does not constitute an independent variable of disease-free and cancer specific survival in patients with TCC of the bladder treated with radical cystectomy.

Preoperative determination of prostate cancer tumor volume: analysis through biopsy fragments.

OBJECTIVE: Preoperative determination of prostate cancer (PCa) tumor volume (TV) is still a big challenge. We have assessed variables obtained in prostatic biopsy aiming at determining which is the best method to predict the TV in radical prostatectomy (RP) specimens. MATERIALS AND METHODS: Biopsy findings of 162 men with PCa submitted to radical prostatectomy were revised. Preoperative characteristics, such as PSA, the percentage of positive fragments (PPF), the total percentage of cancer in the biopsy (TPC), the maximum percentage of cancer in a fragment (MPC), the presence of perineural invasion (PNI) and the Gleason score were correlated with postoperative surgical findings through an univariate analysis of a linear regression model. RESULTS: The TV correlated significantly to the PPF, TPC, MPC, PSA and to the presence of PNI (p < 0.001). However, the Pearson correlation analysis test showed an R2 of only 24%, 12%, 17% and 9% for the PPF, TPC, MPC, and PSA respectively. The combination of the PPF with the PSA and the PNI analysis showed to be a better model to predict the TV (R2 of 32.3%). The TV could be determined through the formula: Volume = 1.108 + 0.203 x PSA + 0.066 x PPF + 2.193 x PNI. CONCLUSIONS: The PPF seems to be better than the TPC and the MPC to predict the TV in the surgical specimen. Due to the weak correlation between those variables and the TV, the PSA and the presence of PNI should be used together.

Socioeconomic status is an independent predictor of biochemical recurrence among patients with prostate cancer who undergo radical prostatectomy

PURPOSE: Socioeconomic status (SES) may influence cancer characteristics and behavior in several aspects. We analyzed PCa characteristics and behavior among low income uninsured men, and compare them to high income patients with health insurance in a developing country. MATERIALS AND METHODS: A retrospective case-control study was performed on 934 patients with clinically localized PCa who underwent radical prostatectomy between March, 1999 and July, 2009. Patients were divided in two groups, according to their SES. In group 1 (n=380), all had low income, low educational levels and couldn't afford medical insurance. In group 2 (n=554), all had higher income, higher education and had medical insurance. RESULTS: Patients from group 1 were older, had higher Gleason scores, higher rates of seminal vesicle and bladder neck involvement. The Kaplan Meier disease-free survival curve demonstrated that after a follow-up of four years, about 50 percent of uninsured patients had biochemical recurrence, versus 21 percent of insured patients (Log rank test: p < 0.001). A multivariate Cox regression analysis for the risk of disease recurrence demonstrated that only PSA levels, Gleason score, seminal vesicle involvement and SES were statistically significant variables. Patients with a low SES presented 1.8 times the risk of recurrence as compared to patients with a high SES. CONCLUSIONS: Patients with low SES were older, presented more aggressive PCa characteristics and a high rate of disease recurrence. A low SES constituted an independent predictor for disease recurrence.

The beginning of the 21st century: a paradigm shift in the surgical management of renal cell carcinoma in South America

PURPOSE: The incidence of renal cell carcinoma (RCC) has been rising by 2.3 to 4.3 percent every year over the past three decades. Previously, RCC has been known as the internist’s tumor; however, it is now being called the radiologist’s tumor because 2/3 are now detected incidentally on abdominal imaging. We compared patients who were treated toward the end of the 20th century to those treated during the beginning of the 21st century with regard to RCC size and type of surgical treatment. MATERIALS AND METHODS: The study included 226 patients. For analysis of tumor size, we considered a cut point of < 4 cm and > 4 cm. For analysis of type of surgery performed, we considered radical and partial nephrectomy. RESULTS: After the turn of the century, there was a reduction of 1.57 ± 0.48 cm in the size of the RCC that was operated on. Nephron sparing surgeries were performed in 17 percent of the cases until the year 2000, and 39 percent of the tumors were < 4 cm. From 2001, 64 percent of the tumors measured < 4 cm and 42 percent of the surgeries were performed using nephron sparing techniques. Mean tumor size was 5.95 cm (± 3.58) for the cases diagnosed before year 2000, and cases treated after the beginning of 21st century had a mean tumor size of 4.38 cm (± 3.27). CONCLUSIONS: Compared with the end of the 20th century, at the beginning of the 21st century due to a reduction in tumor size it was possible to increase the number of nephron sparing surgeries.

Tumor banks: the cornerstone of basic research in urology

PURPOSE: Tumor banks have the primary responsibility for collecting, cataloging, storing and disseminating samples of tissues, cells and fluids, which are used by researchers to identify diagnostic molecular markers, prognostic indicators and therapeutic targets. The objective of this review was to describe a simple, reliable and reproducible protocol for obtaining and storing samples of urological tumors. MATERIALS AND METHODS: Urogenital tumor tissues were collected by the surgeons from the Urology Division of University of Sao Paulo Medical School. The obtained surgical specimens were immediately placed in liquid nitrogen, dry ice or in a tube containing RNAlater ®, and then stored by cryopreservation (-80°C). A mirror fragment was fixed in 10 percent formalin processed routinely and embedded in Paraplast®. RESULTS: We developed a protocol for the collection, cataloging, storage, conservation and use of tumor samples. During a period of one year the Urological Tumor Bank of the Urology Division stored 274 samples of prostate, bladder, kidney, penis and testicle tumors of different histological types, 74 urine and 271 serum samples. CONCLUSIONS: Having biological materials characterized and available along with the clinical patient information provides an integrated portrait of the patients and their diseases facilitating advances in molecular biology. It also promotes the development of translational research improving methods of diagnosis and cancer treatment.

Value of various PSA parameters for diagnosing prostate cancer in men with normal digital rectal examination.

OBJECTIVES: The risks of identifying prostate cancer (PCa) in patients with serum total PSA (tPSA) between 4 and 10 ng/dl are between 25 and 35%. There are no data in Brazil showing the incidence of disease when all variables for PSA assessment are considered altogether, specifically tPSA, free fraction, PSA velocity and PSA stratified by age. The objective in this work was to define the incidence of disease in a population of men with abnormal values of PSA variables and normal digital rectal examination. MATERIALS AND METHODS: Between 1998 and 2003, 273 prostate biopsies were performed by the same radiologist and analyzed by the same pathologist. All patients had a normal digital rectal examination and biopsy had been indicated due to tPSA above 4 ng/dl or free-to-total PSA ratio (F/T PSA) below 15% or PSA velocity higher than 25% per year or a PSA level regarded as high for the age range. The relationship between these parameters and the positivity for prostate caner was determined. RESULTS: Patients' mean age was 63.8 years, and PCa was identified in 135 cases (49.5%). The incidence of PCa, related to unitary variations in tPSA, ranged from the limits of 33 to 80%, respectively, in tPSA < 3 and PSA between 15.1 to 20. When the other PSA parameters were assessed (free PSA, PSA according to age, rise velocity) PCa was detected in more than 25.3% of cases. CONCLUSION: When patients with normal digital rectal examination are selected for prostate biopsy due to tPSA levels above 4 or F/T PSA ratio lower than 15% or PSA velocity higher than 25% per year or high PSA for the age range, the incidence of PCa is quite higher than that observed in a population selected exclusively with basis on total PSA value.

Preoperative determination of prostate cancer tumor volume: analysis through biopsy fragments

OBJECTIVE: Preoperative determination of prostate cancer (PCa) tumor volume (TV) is still a big challenge. We have assessed variables obtained in prostatic biopsy aiming at determining which is the best method to predict the TV in radical prostatectomy (RP) specimens. MATERIALS AND METHODS: Biopsy findings of 162 men with PCa submitted to radical prostatectomy were revised. Preoperative characteristics, such as PSA, the percentage of positive fragments (PPF), the total percentage of cancer in the biopsy (TPC), the maximum percentage of cancer in a fragment (MPC), the presence of perineural invasion (PNI) and the Gleason score were correlated with postoperative surgical findings through an univariate analysis of a linear regression model. RESULTS: The TV correlated significantly to the PPF, TPC, MPC, PSA and to the presence of PNI (p < 0.001). However, the Pearson correlation analysis test showed an R2 of only 24 percent, 12 percent, 17 percent and 9 percent for the PPF, TPC, MPC, and PSA respectively. The combination of the PPF with the PSA and the PNI analysis showed to be a better model to predict the TV (R2 of 32.3 percent). The TV could be determined through the formula: Volume = 1.108 + 0.203 x PSA + 0.066 x PPF + 2.193 x PNI. CONCLUSIONS: The PPF seems to be better than the TPC and the MPC to predict the TV in the surgical specimen. Due to the weak correlation between those variables and the TV, the PSA and the presence of PNI should be used together.

Perineural invasion by transitional cell carcinoma of the bladder in patients submitted to radical cystectomy: what is the prognostic value?

OBJECTIVE: Determine the prognostic value of perineural invasion (PNI) in patients with transitional cell carcinoma (TCC) of the bladder treated with radical cystectomy. MATERIALS AND METHODS: From January 1993 to January 2005, 113 people were selected from 153 patients with TCC of the bladder treated with radical cystectomy. The association between the presence of PNI and other pathologic characteristics were analyzed through Fisher exact test. The Kaplan-Meier method was utilized to assess the survival curve and the statistical significance was determined by the Breslow test. The multivariate analysis was performed through the Cox regression model. RESULTS: The PNI was identified in 10 (8.8 percent) of the 113 patients. This variable significantly related to the microvascular invasion and to tumor staging. The mean segment after surgery was 31.7 ± 28.5 months. Recurrence occurred in 5 (50 percent) and in 41 (39.8 percent) patients (p = 0.363) and mortality occurred in 2 (20 percent) and 22 (21.9 percent) patients (p = 0.606) with or without PNI respectively. In Cox regression analysis, patients with PNI presented with 1.53 times (IC 95 percent 0.60 to 3.91; p = 0.371) and 1.60 times (IC 95 percent 0.37 to 6.95; p = 0.532) the risk of recurrence and mortality when compared to patients without PNI. CONCLUSIONS: The PNI does not constitute an independent variable of disease-free and cancer specific survival in patients with TCC of the bladder treated with radical cystectomy.

O padrão 4 de Gleason e o volume tumoral no prognóstico do carcinoma da próstata / Well differentiated localized prostate carcinoma: prognostic relevance of tertiary Gleason pattern 4 and tumor volume

OBJETIVOS: A introdução de terapia adjuvante pós-prostatectomia radical foi recentemente proposta na literatura na tentativa de se obter melhores taxas de sobrevida em pacientes com câncer de próstata com maior risco de recidiva da doença. Alguns parâmetros anatomopatológicos têm sido considerados bons determinantes dos riscos de recorrência local ou à distância desses tumores. Recentemente o volume tumoral e a presença de padrão terciário de Gleason menos diferenciado foram apresentados como os melhores indicadores do comportamento do carcinoma da próstata. A proposta deste estudo é avaliar a importância da presença e porcentagem do padrão 4 de Gleason e do volume tumoral na evolução de pacientes portadores da adenocarcinoma bem diferenciado de próstata, tratados com prostatectomia radical. MÉTODOS: Setenta e sete pacientes portadores de adenocarcinoma bem diferenciado da próstata, Gleason 6 ou menos, submetidos a prostatectomia radical entre 1995 e 1997 foram estudados. Trinta e sete pacientes sofreram recidiva bioquímica (PSA > 0,4 ng/ml), e 40 pacientes permaneceram livres de doença após seguimento mínimo de cinco anos. A presença e porcentagem do padrão 4 de Gleason, a porcentagem de tumor comprometendo a glândula (considerado como "volume tumoral"), a infiltração capsular e a invasão do tecido extraprostático foram submetidos a análise uni e multivariada para determinação da associação destes parâmetros com a recidiva bioquímica. RESULTADOS: O volume tumoral foi o parâmetro mais importante para determinação da recorrência bioquímica em análises uni e multivariadas. A mediana do volume foi de 25 por cento nos pacientes que sofreram recidiva e 11,5 por cento naqueles que permaneceram livres de doença (p=0,003). A porcentagem de padrão 4 de Gleason foi importante apenas em análise univariada. A mediana da porcentagem de Gleason 4 foi de 7,5 por cento para os pacientes que não sofreram recidiva e de 19 por cento naqueles que recidivaram (p=0,046). CONCLUSÃO: O volume do adenocarcinoma de próstata é um parâmetro objetivo, de fácil avaliação e importante na previsão da recidiva bioquímica no carcinoma bem diferenciado da próstata. Por outro lado, a porcentagem do padrão menos diferenciado de Gleason também serve para prever recidiva à distância. Ambos os parâmetros devem ser incorporados em estudos futuros de terapias adjuvantes para o carcinoma da próstata.

Value of various PSA parameters for diagnosing prostate cancer in men with normal digital rectal examination

OBJECTIVES: The risks of identifying prostate cancer (PCa) in patients with serum total PSA (tPSA) between 4 and 10 ng/dl are between 25 and 35 percent. There are no data in Brazil showing the incidence of disease when all variables for PSA assessment are considered altogether, specifically tPSA, free fraction, PSA velocity and PSA stratified by age. The objective in this work was to define the incidence of disease in a population of men with abnormal values of PSA variables and normal digital rectal examination. MATERIALS AND METHODS: Between 1998 and 2003, 273 prostate biopsies were performed by the same radiologist and analyzed by the same pathologist. All patients had a normal digital rectal examination and biopsy had been indicated due to tPSA above 4 ng/dl or free-to-total PSA ratio (F/T PSA) below 15 percent or PSA velocity higher than 25 percent per year or a PSA level regarded as high for the age range. The relationship between these parameters and the positivity for prostate caner was determined. RESULTS: Patients' mean age was 63.8 years, and PCa was identified in 135 cases (49.5 percent). The incidence of PCa, related to unitary variations in tPSA, ranged from the limits of 33 to 80 percent, respectively, in tPSA < 3 and PSA between 15.1 to 20. When the other PSA parameters were assessed (free PSA, PSA according to age, rise velocity) PCa was detected in more than 25.3 percent of cases. CONCLUSION: When patients with normal digital rectal examination are selected for prostate biopsy due to tPSA levels above 4 or F/T PSA ratio lower than 15 percent or PSA velocity higher than 25 percent per year or high PSA for the age range, the incidence of PCa is quite higher than that observed in a population selected exclusively with basis on total PSA value.