Thus,
these Gleason scores were subgrouped as 2 to 4, 5 to 6, or 8 to
10. Likewise, previous data have also demonstrated that Gleason
sums of 3 +4=7 and 4 +3 =7 behave differently and warrant substratification.8
TABLE
I. Clinical Stage T1c (nonpalpable, PSA elevated)
|
PSA
Range (ng/mL) |
Pathologic
Stage |
Gleason
Score
|
2-4
|
5-6
|
3+4=7
|
4+3=7
|
8-10
|
0-2.5
|
Organ
confined |
95
(89-99)
|
90
(88-93)
|
79
(74-85)
|
71
(62-79)
|
66
(54-76)
|
Extraprostatic
extension |
5
(1-11)
|
9
(7-12)
|
17
(13-23)
|
25
(18-34)
|
28
(20-38)
|
Seminal
vesicle (+) |
|
0
(0-1)
|
2 (1-5)
|
2
(1-5)
|
4
(1-10)
|
Lymph
node (+) |
|
|
1
(0-2)
|
1
(0-4)
|
1
(0-4)
|
2.6-4.0
|
Organ confined |
92
(82-98)
|
84
(81-86)
|
68
(62-74)
|
58
(48-67)
|
52
(41-63)
|
Extraprostatic
extension |
8
(2-18)
|
15
(13-18)
|
27
(22-33)
|
37
(29-46)
|
40
(31-50)
|
Seminal
vesicle (+) |
|
1
(0-1)
|
4
(2-7)
|
4
(1-7)
|
6
(3-12)
|
Lymph node
(+) |
|
|
1
(0-2)
|
1
(0-3)
|
1
(0-4)
|
4.1-6.0
|
Organ
confined |
90
(78-98)
|
80
(78-83)
|
63
(58-68)
|
52
(43-60)
|
46
(36-56)
|
Extraprostatic
extension |
10
(2-22)
|
19
(16-21)
|
32
(27-36)
|
42
(35-50)
|
45
(36-54)
|
Seminal
vesicle (+) |
|
1 (0-1)
|
3 (2-5)
|
3
(1-6)
|
5
(3-9)
|
Lymph
node (+) |
|
0 (0-1)
|
2
(1-3)
|
3
(1-5)
|
3 (1-6)
|
6.1-10.0
|
Organ
confined |
87
(73-97)
|
75
(72-77)
|
54
(49-59)
|
43
(35-51)
|
37
(28-46)
|
Extraprostatic
extension |
13
(3-27)
|
23
(21-25)
|
36
(32-40)
|
47
(40-54)
|
48
(39-57)
|
Seminal
vesicle (+) |
|
2 (2-3)
|
8
(6-11)
|
8
(4-12)
|
13
(8-19)
|
Lymph
node (+) |
|
0
(0-1)
|
2
(1-3)
|
2 (1-4)
|
3
(1-5)
|
>10.0
|
Organ
confined |
80
(61-95)
|
62 (58-64)
|
37
(32-42)
|
27
(21-34)
|
22
(16-30)
|
Extraprostatic
extension |
20
(5-39)
|
33
(30-36)
|
43
(38-48)
|
51
(44-59)
|
50
(42-59)
|
Seminal
vesicle (+) |
|
4
(3-5)
|
12
(9-17)
|
11
(6-17)
|
17
(10-25)
|
Lymph
node (+) |
|
2
(1-3)
|
8
(5-11)
|
10
(5-17)
|
11
(5-18)
|
KEY:
PSA = prostate-specific antigen. |
TABLE
II. Clinical Stage T2a (palpable < 1 .2 of one lobe))
|
PSA
Range (ng/mL) |
Pathologic
Stage |
Gleason
Score
|
2-4
|
5-6
|
3+4=7
|
4+3=7
|
8-10
|
0-2.5
|
Organ
confined |
91
(79-98)
|
81
(77-85)
|
64
(56-71)
|
53
(43-63)
|
47
(35-59)
|
Extraprostatic
extension |
9
(2-21)
|
17
(13-21)
|
29
(23-36)
|
40
(30-49
|
42
(32-53)
|
Seminal
vesicle (+) |
7 (2-16)
|
1 (0-2)
|
5 (1-9)
|
4
(1-9)
|
7
(2-16)
|
Lymph
node (+) |
|
0
(0-1)
|
2 (0-5)
|
3 (0-8)
|
3
(0-9)
|
2.6-4.0
|
Organ confined |
85
(69-96))
|
71 (66-75)
|
50
(43-57)
|
39
(30-48)
|
33 (24-44
|
Extraprostatic
extension |
15
(4-31)
|
27
(23-31)
|
41
(35-48)
|
52
(43-61)
|
53 (44-63)
|
Seminal
vesicle (+) |
|
2
(1-3)
|
7
(3-12)
|
6
(2-12)
|
10
(4-18)
|
Lymph node
(+) |
|
0
(0-1)
|
2
(0-4)
|
2
(0-6)
|
3
(0-8)
|
4.1-6.0
|
Organ
confined |
81
(63-95)
|
66
(62-70)
|
44 (39-50)
|
33
(25-41)
|
28
(20-37)
|
Extraprostatic
extension |
19
(5-37)
|
32
(28-36)
|
46 (40-52)
|
56 (48-64)
|
58 (49-66)
|
Seminal
vesicle (+) |
|
1
(1-2)
|
5 (3-8)
|
5
(2-8)
|
8
(4-13)
|
Lymph
node (+) |
|
1
(0-2)
|
4
(2-7)
|
6 (3-11)
|
6 (2-12)
|
6.1-10.0
|
Organ
confined |
76
(56-94)
|
58
(54-61)
|
35 (30-40)
|
25
(19-32)
|
21
(15-28)
|
Extraprostatic
extension |
24
(6-44)
|
37
(34-41)
|
49
(43-54)
|
58 (51-66)
|
57
(48-65)
|
Seminal
vesicle (+) |
|
4
(3-5)
|
13 (9-18)
|
11
(6-17)
|
17
(11-26)
|
Lymph
node (+) |
|
1
(0-2)
|
3 (2-6)
|
5 (2-8)
|
5
(2-10)
|
>10.0
|
Organ
confined |
65
(43-89)
|
42 (38-46)
|
20
(17-24)
|
14
(10-18)
|
11 (7-15)
|
Extraprostatic
extension |
35
(11-57)
|
47
(43-52)
|
49
(43-55)
|
55
(46-64)
|
52
(41-62)
|
Seminal
vesicle (+) |
|
6
(4-8)
|
16
(11-22)
|
13
(7-20)
|
19
(12-29)
|
Lymph
node (+) |
|
4 (3-7)
|
14
(9-21)
|
18
(10-27)
|
17
(9-29)
|
KEY:
PSA = prostate-specific antigen. |
TABLE
III. Clinical Stage T2b (palpable > 1 .2 of one lobe, not
on both lobes)
|
PSA
Range (ng/mL) |
Pathologic
Stage |
Gleason
Score
|
2-4
|
5-6
|
3+4=7
|
4+3=7
|
8-10
|
0-2.5
|
Organ
confined |
88
(73-97)
|
75 (69-81)
|
54
(46-63)
|
43
(33-54)
|
37
(26-49)
|
Extraprostatic
extension |
12
(3-27)
|
22 (17-28)
|
35
(28-43)
|
45
(35-56)
|
46
(35-58)
|
Seminal
vesicle (+) |
|
2 (0-3)
|
6
(2-12)
|
5 (1-11)
|
9
(2-20)
|
Lymph
node (+) |
|
1
(0-2)
|
4
(0-10)
|
6
(0-14)
|
6
(0-16)
|
2.6-4.0
|
Organ confined |
80
(61-95)
|
63
(57-69)
|
41
(33-48)
|
30
(22-39)
|
25
(17-34)
|
Extraprostatic
extension |
20
(5-39)
|
34
(28-40)
|
47
(40-55)
|
57
(47-67)
|
57
(46-68)
|
Seminal
vesicle (+) |
|
2
(1-4)
|
9 (4-15)
|
7
(3-14)
|
12
(5-22)
|
Lymph node
(+) |
|
1
(0-2)
|
3
(0-8)
|
4 (0-12)
|
5
(0-14)
|
4.1-6.0
|
Organ
confined |
75
(55-93)
|
57 (52-63)
|
35
(29-40)
|
25
(18-32)
|
21
(14-29)
|
Extraprostatic
extension |
25
(7-45)
|
39
(33-44)
|
51
(44-57)
|
60
(50-68)
|
59
(49-69)
|
Seminal
vesicle (+) |
|
2
(1-3)
|
7 (4-11)
|
5
(3-9)
|
9
(4-16)
|
Lymph
node (+) |
|
2
(1-3)
|
7 (4-13)
|
10 (5-18)
|
10 (4-20)
|
6.1-10.0
|
Organ
confined |
69
(47-91)
|
49
(43-54)
|
26
(22-31)
|
19
(14-25)
|
15
(10-21)
|
Extraprostatic
extension |
31
(9-53)
|
44
(39-49)
|
52 (46-58)
|
60
(52-68)
|
57
(48-67)
|
Seminal
vesicle (+) |
|
5
(3-8)
|
16
(10-22)
|
13 (7-20)
|
19
(11-29)
|
Lymph
node (+) |
|
2
(1-3)
|
6
(4-10)
|
8 (5-14)
|
8
(4-16)
|
>10.0
|
Organ
confined |
57
(35-86)
|
33 (28-38)
|
14
(11-17)
|
9 (6-13)
|
7
(4-10)
|
Extraprostatic
extension |
43
(14-65)
|
52
(46-56)
|
47
(40-53)
|
50
(40-60)
|
46
(36-59)
|
Seminal
vesicle (+) |
|
8
(5-11)
|
17 (12-24)
|
13
(8-21)
|
19
(12-29)
|
Lymph
node (+) |
|
8
(5-12)
|
22
(15-30)
|
27
(16-39)
|
27
(14-40)
|
KEY:
PSA = prostate-specific antigen. |
TABLE
IV. Clinical Stage T2c (palpable on both lobes)
|
PSA
Range (ng/mL) |
Pathologic
Stage |
Gleason
Score
|
2-4
|
5-6
|
3+4=7
|
4+3=7
|
8-10
|
0-2.5
|
Organ
confined |
86
(71-97)
|
73
(63-81)
|
51 (38-63)
|
39
(26-54)
|
34
(21-48)
|
Extraprostatic
extension |
14
(3-29)
|
24 (17-33)
|
36 (26-48)
|
45 (32-59)
|
47 (33-61)
|
Seminal
vesicle (+) |
|
1
(0-4)
|
5
(1-13)
|
5
(1-12)
|
8 (2-19)
|
Lymph
node (+) |
|
1
(0-4)
|
6
(0-18)
|
9 (0-26)
|
10
(0-27)
|
2.6-4.0
|
Organ confined |
78
(58-94)
|
61
(50-70)
|
38
(27-50)
|
27
(18-40)
|
23
(14-34)
|
Extraprostatic
extension |
22
(6-42)
|
36
(27-45)
|
48
(37-59)
|
57
(44-70)
|
57
(44-70)
|
Seminal
vesicle (+) |
|
2 (1-5)
|
8
(2-17)
|
6
(2-16)
|
10
(3-22)
|
Lymph node
(+) |
|
1 (0-4)
|
5
(0-15)
|
7 (0-21)
|
8 (0-22)
|
4.1-6.0
|
Organ
confined |
73
(52-93)
|
55
(44-64)
|
31
(23-41)
|
21
(14-31)
|
18
(11-28)
|
Extraprostatic
extension |
27
(7-48)
|
40
(32-50)
|
50
(40-60)
|
57
(43-68)
|
57
(43-70)
|
Seminal
vesicle (+) |
|
2
(1-4)
|
6
(2-11)
|
4 (1-10)
|
7
(2-15)
|
Lymph
node (+) |
|
3
(1-7)
|
12
(5-23)
|
16
(6-32)
|
16
(6-33)
|
6.1-10.0
|
Organ
confined |
67
(45-91)
|
46
(36-56)
|
24
(17-32)
|
16
(10-24)
|
13
(8-20)
|
Extraprostatic
extension |
33
(9-55)
|
46 (37-55)
|
52 (42-61)
|
58 (46-69)
|
56
(43-69)
|
Seminal
vesicle (+) |
|
5
(2-9)
|
13
(6-23)
|
11
(4-21)
|
16 (6-29)
|
Lymph
node (+) |
|
3
(1-6)
|
10
(5-18)
|
13
(6-25)
|
13
(5-26)
|
>10.0
|
Organ
confined |
54
(32-85)
|
30 (21-38)
|
11 (7-17)
|
7
(4-12)
|
6
(3-10)
|
Extraprostatic
extension |
46
(15-68)
|
51
(42-60)
|
42
(30-55)
|
43
(29-59)
|
41
(27-57)
|
Seminal
vesicle (+) |
|
6 (2-12)
|
13 (6-24)
|
10
(3-20)
|
15
(5-28)
|
Lymph
node (+) |
|
13 (6-22)
|
33
(18-49)
|
38
(20-58)
|
38
(20-59)
|
KEY:
PSA = prostate-specific antigen. |
Like
our previous nomograms, PSA, Gleason score (biopsy), and clinical
stage contributed significantly to the prediction of pathologic
stage in the multinomial log-linear progression (P < 0.001).
Also, as seen in our previous nomograms, similar results were seen
when PSA was used as a continuous variable and all two-way and three-way
interactions were tested and added little to the statistical significance
of the final model (P > 0.05). The final model contained only
the main effects, and the combination of the three variables predicted
better than any single variable. The medians (95% confidence intervals
[CIs]) of the predicted probabilities from the multinomial log-linear
regression analysis of 1000 bootstrap samples from the original
study group are presented in the nomograms (Tables I to IV). The
numbers within each cell of the nomogram represent the percentage
of likelihood of a given pathologic stage based on the regression
of all three variables combined. For example, a man with a preoperative
serum PSA level of 2.7 ng/mL and a biopsy Gleason score of levels
less than 10.0 ng/mL, and nonpalpable (Stage T1c) disease. This
dramatic change in presentation, which may be due to PSA and better
screening strategies, has nonetheless caused a major stage migration
for prostate cancer, with nearly 60% of newly diagnosed cases presenting
with localized or regional disease.1 Our methods for
predicting the pathologic stage, which were primarily developed
from data collected from men treated before this stage migration,2-4
must also evolve to allow us to make accurate predictions for men
newly diagnosed with prostate cancer. For this reason, we have updated
our nomograms ("Partin Tables") to better represent the demographic,
clinical, and biochemical data of men presenting with prostate cancer
in 2001. Like our previous tables, simple, easily obtainable variables
were used (se-rum PSA, biopsy Gleason score, and clinical stage
[AJCC TNM-1992]) and combined into simple-to-use tables.
Several patients and physicians who used the previous
nomograms 2 suggested that an individual with a serum
PSA level of 4.1 ng/mL must have a higher probability of organ-confined
disease than an individual with a PSA of 10.1 ng/mL with the same
stage and Gleason score (eg, T2c and 3 +4 = 7). Intuitively, this
seemed obvious; however, the previous tables "lumped" these men
into the same group and provided limited differentiation with respect
to the likelihood of the various pathologic stages. In the previous
(1997) nomograms, both men would have had a likelihood of organ-confined
disease of 25%; the new (2001) nomograms provide the first man with
a likelihood of organ-confined disease of 31% (95% CI 23% to 41%).
The second would have only an 11% (95% CI 7% to 17%) chance of organ-confined
disease and no overlap in the confidence intervals. Additionally,
two men with similar PSA levels (eg, 5.2 ng/mL) and similar digital
rectal examination results (eg, T2a) might have a biopsy Gleason
score of 3 +4 = 7 (44% chance of organ-confined disease, 95% CI
39% to 50%) compared with a man with a biopsy Gleason score of 4
+ 3 = 7 who has only a 33% chance of organ-confined disease, 95%
CI 25% to 41% (little overlap in confidence intervals). The further
stratification of the Gleason groups and the PSA groups are provided
to better capture the actual probabilities of the various pathologic
stages for the individual patient.
Since we presented our 1997 updated nomograms, investigators
at the Mayo Clinic have independently evaluated this method of stage
prediction on their cohort of patients and provided excellent validation
of this method.9 Others have suggested the incorporation
of race,10 biopsy information such as the number of cores
or the percentage of cores involved,11 or use of transrectal
ultrasound staging,12 or nuclear chromatin texture characteristics
13 into similar staging models. Although these suggestions may improve
the prediction of the pathologic stage, they make the use of simple
tables more cumbersome because of the increased number of variables
and have yet to be validated in large cohorts of patients. Large
numbers of variables (greater than three or four) will require
the use of neural networks for stage prediction and are presently
being evaluated for this purpose. 14 Additionally, within
this contemporary cohort, the numbers of biopsies with Gleason scores
2 to 4 are very limited and the probabilities should be interpreted
with caution. At our institution, a Gleason score of 2 to 4 on prostate
biopsy is no longer given.15 With only 6% African-American
men in this cohort, the utility of these tables for African-American
men is questionable. Within the only subgroup of African-American
men with enough numbers for statistical analysis (T1c, 3+3=6, PSA
6.0 to 10.0 ng/mL, n =38), the rate of organ-confined cancer was
81% for all men, 81% for white men, and 80% for African-American
men. Thus, we continue to caution use of these tables for African-American
men until they can be validated in other cohorts with larger numbers
of African-American men.
The primary
value of these updated "Partin Tables" will be for counseling patients
regarding the probability of their tumor being a specific pathologic
stage, rather than a strict decision-making tool. The nomograms
may help patients and their treating physicians make informed decisions
based on the probability of a pathologic stage, the individual patient's
risk tolerance, and the values they place on the various potential
outcomes. In addition, the use of these nomograms may aid in the
rational selection of patients to undergo definitive therapy for
prostate cancer with the hope of further improving the numbers and
percentage of cancers that receive effective therapy that will cure
the disease.
Conclusion
We have updated our nomograms for predicting pathologic stage for
prostate cancer with a more contemporary cohort of men treated between
1994 and 2000. The new nomograms combine PSA, biopsy Gleason score,
and clinical stage with improved substratification of both Gleason
and PSA groups. The new "Partin Tables" may help us counsel our
patients regarding their likelihood of having various pathologic
stages and aid in important decision making.
References
-
Greenlee RT, Hill-Harmon MB, Murray T, et al: Cancer Statistics
2001. CA Cancer J Clin 51: 15-36, 2001.
- Partin
AW, Kattan MW, Subong MS, et al: Combination
of prostate-specific antigen, clinical stage and Gleason score
to predict pathological stage of localized prostate cancer: a
multi-institutional update. JAMA 277: 1445-1451, 1999.
- Kattan
MW, Eastham JA, Stapleton AMF, et al: A preoperative nomogram
for disease recurrence following radical prostatectomy for prostate
cancer. J Natl Cancer Inst 90: 766-771, 1998.
- Kattan
MW, Wheeler TM, and Scardino PT: Postoperative
nomogram for disease recurrence after radical prostatectomy for
prostate cancer. J Clin Oncol 17: 1499-1507, 1999.
- Agresti
A: Categorical Data Analysis. New York, John
Wiley & Sons, 1990, com pp 307-310.
- Elfron
B, and Tibshirani R: An Introduction to the Boot-strap. New York,
Chapman & Hall, 1993.
- Han
M, Partin AW, Pound CR, et al: Long-term bio-chemical
disease-free and cancer-specific survival following radical
retropubic prostatectomy: the 15-year Johns Hopkins experience.
Urol Clin North Am 28: 555-565, 2001.
- Han
M, Snow PB, Epstein JI, et al: A neural network
predicts progression for men with Gleason score 3 + 4 versus
4 + 3 tumors after radical prostatectomy. Urology 56: 994-999,
2000.
- Blute
ML, Bergsrtalh EJ, Partin AW, et al: Validation of
Partin tables for predicting pathological stage of clinically
localized prostate cancer. J Urol 165: 1591-1595, 2000.
- Bauer
JJ, Connelly RR, Sesterhenn IA, et al: Biostatistical modeling
using traditional variables and genetic biomarkers for predicting
the risk of prostate carcinoma recurrence after radical prostatectomy.
Cancer 79: 952-962, 1997.
- D'Amico
AV, Whittington R, Malkowiez SB, et al: Combination of the preoperative
PSA level, biopsy Gleason score, percentage of positive biopsies
and MRI T-stage to predict early PSA failure in men with clinically
localized prostate cancer.
Urology 55: 572-577, 2000.
- Narayan
P, Gajendran V, Taylor SP, et al: The role of
transrectal ultrasound-guided-biopsy based staging, preoperative
PSA and biopsy Gleason score in prediction of final pathological
diagnosis in prostate cancer. Urology 46: 205-212, 1995.
- Veltri
RW, Miller MC, Partin AW, et al: Prediction of
prostate carcinoma stage by quantitative biopsy pathology. Cancer
91: 2322-2328, 2001.
- Han
M, Snow PB, Brandt JM, et al: Evaluation of artificial neural
networks for the prediction of pathological stage in prostate
carcinoma. Cancer 91: 1661-1666, 2001.
- Epstein
JI: Gleason score 2-4 adenocarcinoma of the
prostate on needle biopsy: a diagnosis that should not be made.
Am J Surg Pathol 24: 477-478, 2000
|