RISK ASSESSMENT AND ALGORITHMS

The Narayan Tables

The second paper that has expanded on the approach of Partin et al is that of Narayan et al.³ In this study, 6 medical centers pooled their data on 813 men with clinically localized PC. They found a superior prediction of pathological diagnosis when the clinical stage (based on the digital rectal exam) was replaced by the transrectal ultrasound of the prostate (TRUSP) biopsy stage. The biopsy stage was simply broken down into two stages. Stage B1 indicated that the biopsies only showed PC in one side of the prostate while B2 showed cancer in both sides. These results were presented by Narayan et al as plots on a graph. We have translated these plots into tables for ease of use, and called them the Narayan Tables.

To simply our analysis and its presentation to the patient, we have combined the two predictive approaches into a set of four tables. In the hypothetical patient described above with a T1c lesion, if the biopsies showed cancer in one side only the patient would be a stage B-1. In the Partin/Narayan Tables all Narayan output is in bold. The patient with the T1c, GS 6 and PSA 7 has an OCD prediction of 81%. A lighter shading in all 4 tables indicates his results.

The Narayan predictions are more optimistic for this particular patient than those of Partin for OCD and extra-capsular penetration. Review the tables on the following pages.

Table 1: Comparison of PSA, Gleason’s Score & Clinical Stage per Partin¹ Vs PSA, GS, TRUSP stage per Narayan³

Prediction of Organ-Confined Disease

GS	Clinical stage according to Partin et al & Narayan et al
	T1a	T1b	T1c	T2a	T2b	B1*	T2c	B2*	T3a
2-4	90	80	89	81	72	90	77	86	-
5	82	66	81	68	57	87	62	82	40
6	78	61	78	64	52	84	57	69	35
7	-	43	63	47	34	78	38	67	19
8-10	-	31	52	36	24	72	27	60	-
For PSA values up to 4.0 use table section above
2-4	84	70	83	71	61	89	66	82	43
5	72	53	71	55	43	85	49	78	27
6	67	47	67	51	38	81	43	66	23
7	49	29	49	33	22	75	25	61	11
8-10	35	18	37	23	14	69	15	55	6
For PSA values 4.1-10 use table section above
2-4	76	58	75	60	48	82	53	78	-
5	61	40	60	43	32	77	36	68	18
6	-	33	55	38	26	70	31	53	14
7	33	17	35	22	13	63	15	49	6
8-10	-	9	23	14	7	60	8	41	3
For PSA values 10.1-20 use table section above
2-4	-	38	58	41	29	75	-	64	-
5	-	23	40	36	17	65	19	56	8
6	-	17	35	22	13	59	15	41	6
7	-	-	18	10	5	45	6	20	2
8-10	-	3	10	5	3	42	3	13	1
For PSA values greater than 20 use table section above
* B1 = TRUSP biopsy + in one lobe of the prostate, B2 = biopsy + both lobes
All numbers in bold are from Narayan; remainder are from Partin
Narayan numbers from 4.1-10, 10.1-20 are approximated from graph

Table 2: Comparison of PSA, Gleason’s Score & Clinical Stage per Partin¹ Vs³

Prediction of Extra-Capsular Extension (Narayan) & Capsular Penetration (Partin)

GS	Clinical stage according to Partin et al & Narayan et al
	T1a	T1b	T1c	T2a	T2b	B1	T2c	B2	T3a
2-4	9	19	10	18	25	10	21	14	-
5	17	32	18	30	40	13	34	17	51
6	19	35	21	34	43	16	37	21	53
7	-	44	31	45	51	20	45	27	52
8-10	-	43	34	47	48	24	42	33	-
For PSA values up to 4.0 use table section above
2-4	14	27	15	26	35	11	29	15	44
5	25	42	27	41	50	14	43	20	57
6	27	44	30	44	52	17	46	25	57
7	36	48	40	52	50	22	48	31	48
8-10	34	42	40	49	46	26	40	36	34
For PSA values 4.1-10 use table section above
2-4	20	36	22	35	43	14	37	37	-
5	33	50	35	50	57	18	51	45	59
6	-	49	38	52	57	22	50	53	54
7	38	46	45	55	51	27	45	60	40
8-10	-	33	40	46	38	32	33	66	26
For PSA values 10.1-20 use table section above
2-4	-	47	34	48	52	20	-	37	-
5	-	57	48	60	61	24	55	45	54
6	-	51	49	60	57	28	51	53	46
7	-	-	46	51	43	35	37	60	29
8-10	-	29	34	37	28	41	23	66	17
For PSA values greater than 20 use table section above
See legend at bottom of Table 1

Table 3: Comparison of PSA, Gleason’s Score & Clinical Stage per Partin¹ Vs PSA, GS, TRUSP stage per Narayan³

Prediction of Seminal Vesicle Involvement

GS	Clinical stages according to Partin et al & Narayan et al
	T1a	T1b	T1c	T2a	T2b	B1	T2c	B2	T3a
2-4	0	1	1	1	2	1	2	3	-
5	1	2	1	2	3	1	3	4	7
6	1	2	1	2	3	2	4	6	7
7	-	6	4	6	10	4	12	9	19
8-10	-	11	9	12	17	5	21	12	-
For PSA values up to 4.0 use table section above
2-4	1	2	1	2	4	1	5	4	10
5	2	3	2	3	5	1	6	5	12
6	2	3	2	3	5	3	6	8	11
7	6	9	8	10	15	5	18	11	26
8-10	10	15	15	19	24	7	28	15	35
For PSA values 4.1-10 use table section above
2-4	2	4	2	4	7	2	8	9	-
5	3	5	3	5	8	4	9	11	15
6	-	4	4	5	7	6	9	16	14
7	8	11	12	14	18	10	22	21	28
8-10	-	15	20	22	25	15	30	29	34
For PSA values 10.1-20 use table section above
2-4	-	9	7	10	14	8	-	20	-
5	-	10	9	11	15	12	19	28	25
6	-	8	8	10	13	18	17	35	21
7	-	-	22	24	27	27	32	45	36
8-10	-	20	31	33	33	38	38	55	40
For PSA values greater than 20 use table section above
See legend at bottom of Table 1

Table 4: Comparison of PSA, Gleason’s Score & Clinical Stage per Partin¹ Vs PSA, GS, TRUSP stage per Narayan

Prediction of Lymph Node Involvement

GS	Clinical stages according to Partin et al & Narayan et al
	T1a	T1b	T1c	T2a	T2b	B1	T2c	B2	T3a
2-4	0	0	0	0	0	1	0	2	-
5	0	1	0	0	1	2	1	2	2
6	1	2	0	1	2	2	2	2	5
7	-	6	1	2	5	2	5	10	9
8-10	-	14	4	5	10	3	10	16	-
For PSA values up to 4.0 use table section above
2-4	0	1	0	0	1	1	1	1	1
5	1	2	0	1	2	1	2	1	3
6	3	5	1	2	4	3	4	1	9
7	8	12	3	4	9	3	9	12	15
8-10	18	23	8	9	16	4	17	20	24
For PSA values 4.1-10 use table section above
2-4	0	2	0	1	1	3	1	6	-
5	3	5	1	2	6	4	4	10	7
6	-	13	3	4	10	6	10	16	18
7	18	24	8	9	17	8	18	25	26
8-10	-	40	16	17	29	11	29	37	37
For PSA values 10.1-20 use table section above
2-4	-	4	1	1	3	10	-	15	-
5	-	10	3	3	7	13	7	24	11
6	-	23	7	8	16	17	17	36	26
7	-	-	14	14	25	22	25	50	32
8-10	-	51	24	24	36	28	35	65	42
For PSA values greater than 20 use table section above
See legend at bottom of Table 1

PAP (Prostatic Acid Phosphatase):

A valuable indicator of extra-prostatic spread

Serum PAP elevations noted at the time of diagnosis of prostate cancer are usually associated with extra-prostatic spread. In a study at the Johns Hopkins University School of Medicine,⁴ 21 of 460 men or 4.6% had elevations of PAP. Of those men fully evaluated, evidence of extra-prostatic disease was documented in all. Positive bone scans, extra-prostatic extension of disease, PSA > 100, positive lymph nodes and positive seminal vesicles were found. Most of the above patients with increased PAP's (17 of 21) had abnormal digital rectal exams (DRE's) consistent with disease outside of the prostate or had PSA levels > 100.

Therefore, in these patients the PAP was not that helpful. (But remember all doctors do not have the same ability to perform a DRE as Pat Walsh or Charles Brendler at Johns Hopkins). In the remaining 4 patients, the PAP was helpful in directing treatment towards systemic therapy as opposed to local therapy. A PAP determination as part of the initial staging evaluation is still reasonable. The PAP methodology used in such studies is the enzymatic method of Roy. We suggest that a baseline PAP test be performed and that if elevated further evaluation of the patient to exclude systemic or regionally advanced disease be done. This is discussed further in the section "Suggestions for Staging."

1. Partin AW, Yoo J, Carter HB, et al: The use of prostate specific antigen, clinical stage, and Gleason Score to predict pathological stage in men with localized prostate cancer. J Urol 150:110-14, 1993.
   
   
2. Narayan P, Gajendran V, Taylor SP, et al: The role of transrectal ultrasound-guided biopsy-based staging, pre-operative serum prostate-specific antigen, and biopsy Gleason score in prediction of final pathologic diagnosis in prostate cancer. Urology 46:205-12, 1995.

    

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