RISK ASSESSMENT AND ALGORITHMS

The Bluestein Tables and other papers

Predicting lymph node involvement

There are tables specifically used to analyze the risk of lymph node involvement as well as papers focused on predicting high vs low risk for nodal involvement using other approaches. This is important to direct the patient either toward additional staging studies if the risk is high or away from them if the risk is negligible. The Bluestein Tables use a combination of clinical stage, Gleason grade (not score) and analyze this information vs the highest PSA level that would allow for negligible lymph node involvement.

This sounds awkward but a discussion of Gleason’s grade vs score and an example should clarify this. Gleason’s score or sum is comprised of two numbers as in [3+4]. The Gleason’s score is 7 but the first number in the score is the primary Gleason’s grade or 3. The primary grade represents the preponderant histologic pattern seen on microscopic review of the pathology slides. The next most prominent pattern is the second number or secondary grade. It must comprise at least 5% of that which is seen by the pathologist.

Let us go to the Bluestein Table. Our hypothetical patient that we used in the Partin and Narayan Tables had a clinical stage of T1c, a Gleason’s score of [3+3] or 6 and a PSA of 7. We would find the clinical stage in the first column and in the second column next to it chose the row with the primary Gleason’s grade of 3.

For this patient, a PSA of 8 would be the threshold for very little probability of lymph node involvement (< 3%). Negligible is defined as a false negative error of no more than 3%. Our hypothetical man had a PSA of 7. He therefore has a < 3% prediction for nodal involvement. If his PSA had been 10 then this would not be the case. Interestingly, the Partin Table for lymph node involvement would have him at only 1% chance and the Narayan at 3%. These results are incredibly close.

Such a patient could forego a lymph node dissection; his risk of having metastatic prostate cancer to the lymph nodes is low enough for us to reasonably counsel him that he does not need sampling of these tissues. The potential morbidity of either laparoscopy or lymph node sampling at the time of RP as well as the cost of analyzing nodes in time and money are avoided. Other studies such as CT (computerized tomography) of the abdomen and pelvis are avoided as well. Additional studies, such as the ProstaScint scan, would also not be indicated.

 

Table 5: The Bluestein Tables: Combinations of local clinical stage, primary Gleason grade and serum PSA to yield a false-negative rate of 3% for positive lymph nodes

Clinical Stage	Primary Gleason Grade	Serum PSA (ng/ml)
T1a-T2b (A1-B1) (includes T1c)	1 and 2 3 4 and 5	17.1 8.0 4.2
T2c (B2)	1 and 2 3 4 and 5	4.1 2.0 1.0
T3a (C1)	1 and 2 3 4 and 5	1.4 0.7 0.3

 

For our man with a clinical stage of T2c, PSA of 18 and Gleason’s score of (3+3), he would have to have had a PSA no greater than 2 for negligible risk for lymph node involvement. Our hypothetical patient with a PSA of 18 is therefore at significant risk. The Partin prediction for such a patient would be 22% and the Narayan prediction would be 16%. Check the tables to confirm that you understand this.

The use of the Partin and Narayan Tables may also enable us to bypass neoadjuvant hormone blockade (NHB in patients who have favorable Gleason scores (2-4), with low PSA readings (< 4) and in clinical stages T1a to T2a. In such a cohort of patients, predictions of organ-confinement are 81 to 90%; predictions for capsular penetration are 10% (T1c group). Since the preponderant clinical stage has become T1c, the low risk group for non-organ confined disease now extends also extends to patients with T1c, GS 5 and PSA < 4 and to T1c, GS 2-4 and PSA of 4.1-10. Multiple paper are now confirming that a GS of 5 or less and a PSA of less than 10 are highly correlated with fredom from PSA relapse after RP or RT.^6,7

 

Prostate Cancer Research Institute (PCRI)
 

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