Preoperative serum prostate-specific antigen and gleason grade as predictors of pathologic stage in clinically organ confined prostate cancer: Implications for the choice of primary treatment

Purpose: Despite careful preoperative staging, approximately 50% of patients who undergo radical prostatectomy for clinical stage A2 (T1b-c) and B (T2) prostate cancer are found to have pathologic stage C (T3-4) or D (N1) disease. This study investigates whether preoperative serum prostate specific antigen (PSA) and Gleason grade predict pathologic stage among patients with clinically organ confined prostate cancer. Methods: The records of all 63 patients who underwent attempted pelvic lymphadenectomy and radical prostatectomy for adenocarcinoma of the prostate at our institution in 1990-1991 were retrospectively reviewed. Results: Patients with a preoperative serum PSA of 12.5 ng/mL or greater had an 81% incidence of pathologic upstaging to stage C (T3-4) or D (N1) compared with 38% for patients with a PSA less than 12.5 (p = 0.0015). The incidence of various pathologic findings for prostate specific antigen ≥ 12.5 vs. prostate specific antigen < 12.5 was as follows: seminal vesicle involvement 29% vs. 5% (p = 0.0186), lymph node metastases 24% vs. 0% (p = 0.0029), capsular penetration 71% vs. 38% (p = 0.0424), and positive margins 47% vs. 36% (p = 0.56). None ( 0 3) of the patients with Gleason grade 4 or less were pathologically upstaged compared with 49% ( 24 49) of patients with grade 5-7 tumors (p = 0.15) and 82% ( 9 11) of patients with grade 8 or higher cancers (p = 0.0474, grade 5-7 vs. 8-10). Within the group of patients with Gleason grade 5-7, a prostate specific antigen of 12.5 ng/ mL or greater predicted an 79% rate of upstaging compared with 37% for patients with prostate specific antigen less than 12.5 (p = 0.0098). Conclusion: Patients with clinical Stage A2 (T1b-c) or B (T2) prostate cancer who have Gleason grade 8-10 tumors and those patients with Gleason grade 5-7 tumors with a preoperative serum prostate specific antigen of 12.5 ng/ mL or higher have a high incidence of pathologic upstaging. These patients should be preferentially treated with external beam radiation in most cases.