Diagnosis/Treatment Prostate Ailments Conventional Treatments

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Subject: PCa Staging

Date: Tues, 14 Apr 1998 07:24:00 -0600

From: "Larry Clapp" lclapp@prostate90.com

I am often asked about staging. This post by Dr. Strum really lays it out.

Because the Gleason score is such a critical item, I would want to have an expert pathology opinion. This should be obtained from a prostate cancer pathology expert. The ones that I am most familiar with include: David Bostwick (Mayo), Jon Epstein (Hopkins), John McNeal (Stanford), Gary Miller (Colorado), Jon Oppenheimer (Oklahoma). The full addresses for these pathologists is listed under PCAB (Prostate Cancer Address Book) on our homepage. A second opinion on the pathology is usually covered by insurance but if not, runs about $150. A copy of the original pathology report with the actual slides or re cuts from the tissue block are sent to the outside reviewer. A copy of the insurance information is usually sent along with this. Your primary care doctor or specialist can initiate such a 2nd opinion.

You need to do your predictive algorithms to give you a sense of risk. This too I have said a number of times before...

At this point we tell you to download the free software programs from our homepage or to print out the paper on Predictive and Prognostic Testing in the Counseling of Newly Diagnosed Patients with PC. Within that paper are the new Partin and Narayan tables, as well as the Bluestein table. You can use these for generating predictions as to the likelihood of organ confined disease and the risks for capsular penetration, seminal vesicle and lymph node involvement. This is the foundation for any logical thought as to how to approach further staging and therapy. At least it is in my opinion.

With a GS of 5-6, CS T2a, bPSA 14.1, TRUSP stage of Narayan of B2, neg Bone scan, you can figure out your risks for nodal, seminal vesicle, capsular penetration and the probability of organ confined disease. Your new Partin is 38,52,5,4. That is using a GS of 6 based on the GG of 3. If it really is a GS of 5 then: 43,50,5,2. That is for organ confined disease, capsular penetration, seminal vesicle and nodal involvement. Suggest you download the paper above and do the rest for yourself and include those stats in your PCD. You had a normal PAP which is good. If your Bluestein prediction shows significant risk for nodal disease (it does), you should have a ProstaScint scan. If that is negative for nodal disease, we would next advise an endorectal MRI with spectroscopy at UCSF.

We don't hardly ever bother with CT scans as they now exist.

AGAIN, the CT scan as it is currently used is a blatant waste of money. It is way too insensitive to be of value in the initial staging of PC. The exception to this is when the PSA is high and there is bulky disease. Often, in such cases, the bone scan will also be positive, but not always. Otherwise, the CT scans are of miniscule value.

Lastly, you could also do a BioStage evaluation if you have good findings on the ProstaScint. Here is some info on BioStage.

Have your doc order a BioStage analysis. This assesses the degree of ANGIOGENESIS in the diagnostic biopsy material showing PC. It then uses this micro vessel density along with GS and PSA to give % organ confined result. You can read about biostage on the Internet at barddiagnostics.com. You can call and speak with the people at BioStage at 206 814-1507. The people who have written about this include notables such as David Bostwick from the Mayo Clinic and Peter Scardino from Baylor.

Here is additional input re: risk assessment

Let me state that the fundamental NECESSARY step before making treatment decisions must be the determination of organ confined disease status.

THE FIRST CROSSROAD THAT A PATIENT-DOCTOR MUST CROSS IS THE DETERMINATION OF ORGAN CONFINED DISEASE.

ORGAN CONFINED DISEASE
ORGAN CONFINED DISEASE
ORGAN CONFINED DISEASE

This is not a computer virus. Over and over and over again I see the same stupid, lazy, ignorant mistake made in the initial evaluation of the man with PC.

Guys, learn one thing here. Before entering the arena of how do I treat PC, ask and answer the first question: Do I have organ confined disease?

#1: Obtain the basic data that allows for a risk assessment of organ confined disease. This includes PSA (the highest value in your clinical history), the Gleason score (with confirmation by an prostate pathology expert),a clinical stage (usually based on the DRE but in the hands of a good ultrasonagrapher the TRUSP is part of this as is any non-invasive study), the TRUSP stage of Narayan(are the biopsies positive on one side only or B1 or both sides B2), the number of cores taken and the number involved, the gland volume as per TRUSP, the BioStage.

#2: use as much of this data as possible and run it through the predictive algorithms that have been published in the urologic literature. The ones that I have found useful are obtainable free from our homepage. They include the new Partin, Narayan, Bluestein, and D'Amico. Eventually we will also include Kleer and others.

The BioStage is a test that requires additional work.

With what you have so far determined you then focus your efforts on confirming or refuting those areas at risk.

We routinely do all of these. We send our patients to a center of excellence for the endorectal MRI. My favorite site is UCSF with John Kurhanewicz. I find this gentleman and his associates to be of the highest caliber. John uses endorectal MRI imaging and spectroscopy. If the results of both modes of imaging are CONCORDANT then the accuracy rate is at 95%. Spectroscopy utilizes the finding that normal prostate tissue is rich in citrate vs prostate cancer that is rich in choline. It determines a choline/citrate ratio that is most or more indicative of malignancy. Kurhanewicz's phone number is in the PCAB on our homepage.

The missing information i.e. prostate volume, cores positive/cores taken also generate further information.

We use the prostate volume to decide how much the gland size needs to come down before implantation. We also use it to crudely guesstimate the PC volume using the formula of gland volume x 0.12 = expected PSA. Actual PSA - expected PSA = excess PSA. Excess PSA/1.8 = tumor volume. This is crude but not too bad. If in your case your gland volume per TRUSP was 40 cc's you would have a crude tumor volume guesstimate of 0.4 cc's. This crude volume is helpful since we can use it as another risk factor. For example:

The relationship of cancer volume in the RP specimen to cure was analyzed

RP Cancer Vol # Patients	# Patients Cured	Percentage cure
<.5 cc's	17	16	94
.5-2 cc	91	73	80
2-6	129	65	50
6-12	49	11	22
>12	32	2	6
			Total 318

The above is from Tom Stamey's data (Stanford).

We are generous with our use of hormone blockade. We feel that it is a fundamental first step in reducing tumor volume and decreasing angiogenesis in preparation for any local therapy. Hormone blockade is synergistic with all forms of radiation therapy. It also reduces IGF-1, VEGF (vascular endothelial growth factor) and decreases the degree of RT PCR PSA/PSM positivity after RP.

We do not know the optimum duration or hormone blockade prior to or after local therapy. I personally aim at a gland volume of ~ 15 cc's prior to seed implantation,or cryosurgery and a hormone blockade duration of at least 6 months prior to RP. There is published data that the 3 month PSA level will determine accurately the likelihood of organ confined disease at RP. So, to summarize, yes we absolutely use CHB prior to SI, and we use the gland volume to guide us. However, we do our homework first and make sure we are dealing with organ confined disease, to the best of our ability.

End of Dr. Strums post