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What is clinically important in the pathology specimen for radical radiotherapy in prostate cancer?
Wojciech Majewski, Poland
PO-1368

Abstract

What is clinically important in the pathology specimen for radical radiotherapy in prostate cancer?
Authors:

Wojciech Majewski1, Dariusz Lange2, Agata Stanek-Widera2, Bartosz Itrych3, Tomasz Krzysztofiak4, Michal Jarzab5, Malgorzata Oczko-Wojciechowska6, Rafal Tarnawski7

1Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Radiotherapy Department, Gliwice, Poland; 2Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Department of Pathology, Gliwice, Poland; 3Centre of Postgraduate Medical Education, Department of Breast Cancer, Warsaw, Poland; 4Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Department of Brachytherapy, Gliwice, Poland; 5Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Breast Unit, Gliwice, Poland; 6Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Department of Genetic and Molecular Diagnostics of Cancer, Gliwice, Poland; 7Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, III Clinic of Radiotherapy and Chemotherapy, Gliwice, Poland

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Purpose or Objective

Although the WHO 2016 grading classification in prostate cancer indicates large differences between Grading Groups, we assumed that in patients treated with radiation therapy (RT) +/- hormonal treatment (HT) some differences might not be so pronounced, especially between Gleason 3+4 and 4+3 (Grading Group 2 and 3). Other pathology details like nerve invasion, cribriform pattern and number of involved cores may be of importance. Hence, we re-evaluated pathology specimens in patients with Gleason score 7 who underwent a radical RT and had a long-term follow-up.

Material and Methods

The study group consist of 139 patients with prostate cancer and initial Gleason score 7 (3+4 or 4+3) treated with 3DCRT or IMRT between 2008 and 2013. Patients were treated with conventionally fractionated RT to the total dose of 76 Gy with 2 Gy per fraction, in 45% of patients pelvic lymph nodes were irradiated. HT was implemented in 88% patients before referral to RT. There were 45% and 55% patients in the intermediate and high-risk group, respectively. The original pathology specimen was re-evaluated, according to the contemporary experience. The clinical outcome was assessed with respect to the biochemical control. The importance of selected factors from the re-evaluated pathology report was assessed.  

Results

The median follow-up was 53 months. The 5-year biochemical control was 89%. After re-evaluation majority of patients (96 pts-69%) were up-graded from Gleason 7 to higher scores.  Finally, there were 4 patients (3%) Gleason 3+3, 12 patients (9%) Gleason 3+4, 27 patients (19%) Gleason 4+3, 51 patients (37%) Gleason 4+4 and 45 patients (32%) with higher Gleason sum. In 42 patients (30%) a cribriform pattern was observed, in 38 patients (27%) neuro-invasion was noted. The median number of involved cores was 3 and the median percentage of involved cores was 40%.

Among the analyzed factors only the Gleason score (p=0.011) was important for biochemical control and a cribriform pattern was of borderline importance (p=0.05). We observed no biochemical recurrences in patients in patients with Gleason score ≤4+3, 14% of patients with Gleason score 4+4 experienced biochemical recurrences and 13% of patients with Gleason score 4+5, 5+4, 5+5. The 5-year biochemical control was 100% if Gleason score was ≤4+3 vs 84% for others. If the cribriform pattern was present there were 17% biochemical recurrences as compared to 6% of recurrences if no cribriform pattern was revealed. The 5-year biochemical control was 93% and 81%, respectively. 

Conclusion

Re-evaluation and verification of pathology specimen according to the contemporary rules up-graded the Gleason score in majority of patients. The aggressive behavior of prostate cancer starts to occur from Gleason score 4+4. The cribriform pattern almost tripled the biochemical failure rate.