Prostate Workup

International Prostate Symptom Score (IPSS)

A symptom index for benign prostatic hyperplasia (BPH) was developed and validated by a multidisciplinary measurement committee of the American Urological Association (AUA). Validation studies were conducted involving a total of 210 BPH patients and 108 control subjects.
Erectile Function
1. had a sensation of not emptying your bladder completely after urinating?
2. had to urinate again less than two hours after you have urinated?
3. how often have you stopped and started, serveral times when you urinated?
4. found it difficult to postpone urination?
5. had a weak urinary stream?
6. had to push or stain to urinate?
7. how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

Gleason Score

  • The Gleason score, by strict definition, only includes the two most common Gleason patterns of the tumor (the primary and secondary patterns).
  • When a tumor is essentially all one pattern (e.g. Gleason score 3+3=6) but there is a very focal (<5%) component of pattern 4 or 5, this latter component is also referred to as "tertiary" and it, too, has not been included in the standard Gleason score.
  • However, it has been demonstrated that a tertiary Gleason pattern 4 or 5 has an adverse impact on prognosis after total prostatectomy.
  • Gleason score 5-6 and 7 tumors with tertiary higher pattern grades progressed more often than tumors without such tertiary patterns.

== Johns Hopkins Pathology ==

Risk Groups

D’Amico (Use 1992 AJCC classification)

Low risk psa < 10, gleason < 7, and T1-T2a
High risk psa > 20, gleason > 7 and T2c, T3 or T4

Other Prognostic Factors

Perineural Invasion (PNI)
low-risk patients with evidence of PNI on biopsy are pathologically similar to intermediate risk patients (23% risk of extraprostatic extension on radical prostatectomy specimen).
low-risk men with PNI “may benefit” from treatment typically reserved for men with higher risk disease (i.e. androgen deprivation and pelvic lymph node irradiation).
Possible Treatment include:
1) brachytherapy deliver higher radiobiologic doses this way, but the small amount of data on PNI in brachytherapy patients fails to show an improvements.
2) short-term (6 months) androgen deprivation to external beam radiotherapy is a consideration

Patterns of Spread

  • Direct extension to the anterior rectal wall is rare because Denovilliers’ fascia acts as a protective barrier.
  • Lymphatic drainage is primarily to the obturator and internal and external iliac LN and presacral LN.
  • Hematogenous spread to bone.

Risk of Spread (Nomograms)

  • Partin Table (risk based on PE, PSA and Gleason)
  • ROACH FORMULA:
    • ECE = 3/2 PSA + 10 (GS-3)
    • SV = PSA + 10 (GS-6)
    • LN = 2/3 PSA + 10 (GS-6)
  • Generally
    • High risk 30-50% LN(+)
    • Intermediate 10-30% LN(+)
    • Low risk < 10% LN(+)
    • PSA < 6 and GS < 7 have < 1% LN(+)

Anatomy

Retrograde urethrography

  • Technique: 60 cc of dilute contrast is placed in the bladder and catheter is pulled bac, and then retrograde urethrography was performed and the penis was clamped.
  • identifies inferior most location of the prostatic sphincter; therfor "beak" must lie beneath the pelvic floor.
  • average distance between the prostate apex and "beak" is 11 mm

MR results

anatomy
  • mean distance from bulb-peak was 2.4 mm.
  • median distance from bulb-peak was 3.0 mm.
  • prostatic apex to bulb averages 1.45 cm.

CT based

Swanson.jpg
  • average distance from the inferior pubic symphasis and urethra was 1.6 cm
  • Swanson's line, drawing through the sagittal pubis, delineates where urethra passes through the pelvic floor.
  • Prostatic apex will be above where Swanson's line crosses the urethra and 1-8 mm above the line.
Bibliography
1. Lee IH, Roberts R, Shah RB, WOJNO KJ, Wei JT, Sandler HM. Perineural invasion is a marker for pathologically advanced disease in localized prostate cancer. Int J Radiat Oncol Biol Phys. 2007 Jul 15;68(4): 1059-64. PMID: 17398032
2. Yu HH, Song DY, Tsai YY, Thompson T, Frassica DA, DeWeese TL. Perineural invasion affects biochemical recurrence-free survival in patients with prostate cancer treated with definitive external beam radiotherapy. Urology. 2007 Jul;70(1): 111-6. PMID: 17656219
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