What is prostate cancer staging

By staging your cancer, your doctor is trying to assess, based on your prostate biopsy results, your physical examination, your PSA, and other tests and X-rays (if obtained), whether your prostate cancer is confined to the prostate, and if it is not, to what extent it has spread. Studies of large numbers of men who have undergone radical prostatectomy and pelvic lymph node dissections have provided for the development of nomograms predicting the pathologic stage of CaP based on clinical stage (TNM), PSA, and Gleason score (Table 5). It was initially thought that magnetic resonance imaging (MRI) would be very helpful in determining whether capsular penetration and extracapsular disease were present; however, it has only proved to be useful in centers that perform large numbers of MRIs. Similarly, the use of computed tomographic (CT) scanning in assessing whether or not the cancer has spread to the pelvic lymph nodes has been disappointing.

Knowing the stage (the size and the extent of spread) of the prostate cancer helps the doctor counsel you on treatment options. Your doctor may tell you a clinical stage (Figure 8), based on your rectal examination, prostate biopsies, and radiographic/nuclear medicine studies (CT scan, bone scan, MRI). Pathological staging is performed when a pathologist examines the prostate, seminal vesicles, and pelvic lymph nodes (if removed) at the time of radical prostatectomy. The most common staging system used is called the TNM System. In this system, T refers to the size of the tumor in the prostate, N refers to the extent of cancerous involvement of the lymph nodes, and M refers to the presence or absence of metastases (deposits of prostate cancer outside of the

Table 5 Nomograms Predicting Pathologic Stage of CaP Based on Clinical Stage (TNM), PSA, and Gleason Score

Clinical Stage Tic (nonpalpable, PSA elevated) N = 4419

Table 5 Nomograms Predicting Pathologic Stage of CaP Based on Clinical Stage (TNM), PSA, and Gleason Score

Clinical Stage Tic (nonpalpable, PSA elevated) N = 4419

PSA

Biopsy Gleason Score

Range (ng/mL)

Pathologic Stage

5-6

3 + 4 = 7

4 + 3 = 7

8-10

0-2.5

Organ confined (N = 226)

93 (91-95)

82 (76-87)

73 (64-80)

77 (65-85)

Extraprostatic extension (N = 19)

6 (5-8)

14 (10-18)

20 (14-28)

16 (11-24)

Seminal vesicle (+) (N = 1)

0 (0-1)

2(0-5)

2 (0-5)

3 (0-8)

Lymph node (+) (N = 3)

0 (0-1)

2 (0-6)

4 (1-12)

3 (1-12)

2.6-4.0

Organ confined (N = 619)

88 (86-90)

72 (67-76)

61 (54-68)

66 (57-74)

(N = 92)

11 (10-13)

23 (19-27)

33 (27-39)

26 (19-34)

Seminal vesicle (+) (N = 8)

1 (0-1)

4 (2-7)

5 (2-8)

7 (3-13)

Lymph node (+) (N = 1)

0 (0-0)

1 (0-1)

1 (0-3)

1 (0-3)

4.1-6.0

Organ confined (N = 1266)

83 (81-85)

63 (59-67)

51 (45-56)

55 (46-64)

(N = 297)

16 (14-17)

30 (26-33)

40 (34-45)

32 (25-40)

Seminal vesicle (+) (N = 37)

1 (1-1)

6 (4-8)

7 (4-10)

10 (6-15)

Lymph node (+) (N = 12)

0 (0-0)

2(1-3)

3 (1-6)

3 (1-6)

6.1-10.0

Organ confined (N = 989)

81 (79-83)

59 (54-64)

47 (41-53)

51 (41-59)

Extraprostatic extension (N = 281)

18 (16-19)

32 (27-36)

42 (36-47)

34 (26-42)

Seminal vesicle (+) (N = 36)

1 (1-2)

8 (6-11)

8 (5-12)

12 (8-19)

Lymph node (+) (N = 5)

0 (0-0)

1 (1-3)

3 (1-5)

3 (1-5)

>10.0

Organ confined (N = 324)

70 (66-74)

42 (37-48)

30 (25-36)

34 (26-42)

(N = 165)

27 (23-30)

40 (35-45)

48 (40-55)

39 (31-48)

Seminal vesicle (+) (N = 25)

2 (2-3)

12 (8-16)

11 (7-17)

17(10-25)

Lymph node (+) (N = 13)

1 (0-1)

6 (3-9)

10 (5-17)

(continued)

Table 5 Nomograms Predicting Pathologic Stage of CaP Based on Clinical Stage (TNM), PSA, and Gleason Score (Continued)

Clinical Stage T2a (palpable < V2 of one lobe) N = 998

Table 5 Nomograms Predicting Pathologic Stage of CaP Based on Clinical Stage (TNM), PSA, and Gleason Score (Continued)

Clinical Stage T2a (palpable < V2 of one lobe) N = 998

PSA

Biopsy Gleason Score

Range (ng/mL)

Pathologic Stage

5-6

3 + 4 = 7

4 + 3 = 7

8-10

0-2.5

Organ confined (N = 156)

88 (84-90)

70 (63-77)

58 (48-67)

63 (51-74)

(N = 18)

12 (9-15)

24 (18-30)

32 (24-41)

26 (18-36)

Seminal vesicle (+) (N = 2)

0 (0-1)

2 (0-6)

3 (0-7)

4 (0-10)

Lymph node (+) (N = 1)

0 (0-1)

3 (1-9)

7 (1-17)

6 (1-16)

2.6-4.0

Organ confined (N = 124)

79(75-82)

57 (51-63)

45 (38-52)

50 (40-59)

(N = 49)

20 (17-24)

37 (31-42)

48 (40-55)

40 (30-50)

Seminal vesicle (+) (N = 5)

1 (0-1)

5 (3-9)

5 (3-10)

8 (4-15)

Lymph node (+) (N = 0)

0 (0-0)

1(0-2)

2 (0-5)

2 (0-4)

4.1-6.0

Organ confined (N = 171)

71(67-75)

47 (41-52)

34 (28-41)

39 (31-48)

Extraprostatic extension (N = 101)

27 (23-31)

44 (39-49)

54 (47-60)

46 (37-54)

Seminal vesicle (+) (N = 10)

1 (1-2)

7 (4-10)

7 (4-11)

11 (6-17)

Lymph node (+) (N = 3)

0 (0-1)

2 (1-4)

5 (2-8)

4 (2-9)

6.1-10.0

Organ confined (N = 142)

68(64-72)

43 (38-48)

31 (26-37)

36 (27-44)

Extraprostatic extension (N = 99)

29 (26-33)

46 (41-51)

56 (49-62)

47 (37-56)

Seminal vesicle (+) (N = 12)

2 (1-3)

9(6-13)

9 (5-14)

13 (8-20)

Lymph node (+) (N = 6)

0 (1-0)

2 (1-4)

4 (2-8)

4 (1-8)

>10.0

Organ confined (N = 36)

54 (49-60)

28 (23-33)

18 (14-23)

21 (15-28)

(N = 47)

41 (35-46)

52 (46-59)

57 (48-66)

49 (39-59)

Seminal vesicle (+) (N = 9)

3 (2-5)

12 (7-18)

11 (6-17)

17 (9-25)

Lymph node (+) (N = 7)

1 (0-3)

7 (3-14)

13 (6-24)

12 (5-22)

Table 5 Nomograms Predicting Pathologic Stage of CaP Based on Clinical Stage (TNM), PSA, and Gleason Score (Continued)

Clinical Stage T2b (palpable > V2 of lobe) or T2c (palpable both lobes) N = 313

Table 5 Nomograms Predicting Pathologic Stage of CaP Based on Clinical Stage (TNM), PSA, and Gleason Score (Continued)

Clinical Stage T2b (palpable > V2 of lobe) or T2c (palpable both lobes) N = 313

PSA

Biopsy Gleason Score

Range (ng/mL)

Pathologic Stage

5-6

3 + 4 = 7

4 + 3 = 7

8-10

0-2.5

Organ confined N = 16

84 (78-89)

59 (47-70)

44 (31-58)

49 (32-65)

Extraprostatic extension (N = 10)

14 (9-19)

24 (16-33)

29 (19-42)

24 (14-36)

Seminal vesicle (+) (N = 0)

1 (0-3)

6 (0-14)

6 (014)

8 (0-21)

Lymph node (+) (N = 0)

1 (0-3)

10 (2-25)

19 (4-40)

17 (3-42)

2.6-4.0

Organ confined (N = 28)

74 (68-80)

47 (39-56)

36 (27-45)

39 (28-50)

(N = 15)

23 (18-29)

37 (28-45)

46 (36-55)

37 (27-48)

Seminal vesicle (+) (N = 3)

2(1-5)

13 (7-21)

13 (7-22)

19 (9-32)

Lymph node (+) (N = 2)

0 (0-1)

3 (0-7)

5 (0-14)

4 (0-13)

4.1-6.0

Organ confined (N = 46)

66 (59-72)

36 (29-43)

25 (19-32)

27 (19-37)

Extraprostatic extension (M = 40)

30 (24-36)

41 (33-47)

47 (38-55)

38 (28-48)

Seminal vesicle (+) (N = 7)

4 (2-6)

16 (10-23)

15 (9-23)

22 (13-33)

Lymph node (+) (N = 4)

1 (0-2)

7 (3-12)

13 (6-21)

11 (4-23)

6.1-10.0

Organ confined (N = 53)

62 (55-68)

32 (26-38)

22 (17-29)

24 (17-33)

(N = 28)

32 (26-38)

41 (33-49)

47 (38-56)

38 (29-48)

Seminal vesicle (+) (N = 15)

5 (3-8)

20 (13-28)

19 (11-28)

27 (16-39)

Lymph node (+) (N = 5)

1 (0-2)

6 (3-11)

11 (5-19)

10 (3-20)

>10.0

Organ confined (N = 8)

46 (39-53)

18 (13-24)

11 (7-15)

12 (7-18)

(N = 15)

41 (34-50)

40 (31-51)

40 (30-52)

33 (22-46)

Seminal vesicle (+) (N = 10)

7 (4-12)

23 (15-33)

19 (10-29)

28 (16-42)

Lymph node (+) (N = 8)

5 (2-8)

18 (9-30)

29 (15-44)

26 (12-44)

Makarov DV, Trock BJ, Humphreys EB, Mangold LA, Walsh PC, Epstein JI, Partin AW. Updated nomogram to predict pathologic stage of prostate cancer given prostate-specific antigen level, clinical stage, and biopsy gleason score (partin tables) based on cases from 2000 to 2005. Urology 2007; 69: 1095-1101.

Makarov DV, Trock BJ, Humphreys EB, Mangold LA, Walsh PC, Epstein JI, Partin AW. Updated nomogram to predict pathologic stage of prostate cancer given prostate-specific antigen level, clinical stage, and biopsy gleason score (partin tables) based on cases from 2000 to 2005. Urology 2007; 69: 1095-1101.

Stage B2 Stage C

Figure 8 The prostate gland showing the different stages of cancer.

prostate and lymph nodes). Another staging system is the Whitmore Jewett System (Table 6).

In individuals in whom there is a concern about metastases to the bone, such as those with high PSAs and pain localized to a bone, a bone scan may be obtained to determined if there are bone metastases.

A bone scan is a study performed in the nuclear medicine department that involves injecting a small amount of a radioactive chemical through a vein into your bloodstream. The chemical circulates through your body and is picked up by areas of fast bone growth that may be associated with cancer. The bone scan is the most sensitive technique currently available for identifying prostate cancer that has spread to the bones. Other problems of

In individuals in whom there is a concern about metastases to the bone, such as those with high PSAs and pain localized to a bone, a bone scan may be obtained to determined if there are bone metastases.

Bone scan

A specialized nuclear medicine study that allows one to detect changes in the bone that may be related to metastatic prostate cancer.

TN M

Description

Whitmore-Jewett

Description

TX

Primary tumor cannot be assessed

None*

None

TO

No evidence of primary tumor

None

None

T1

Clinically unapparent tumor—not palpable or visible by imaging

A

Same as TNM

Tla

Tumor found incidentally in tissue removed at TUR; 5% or less of tissue is cancerous

A1

Same as TNM

Tlb

Tumor found incidentally at TUR; more than 5% of tissue is cancerous

A2

Same as TNM

Tic

Tumor identified by prostate needle biopsy because of PSA elevation

None

None

T2

Palpable tumor confined within the prostate

B

Same as TNM

T2a

Tumor involves half of a lobe or less

BIN

Tumor involves half of a lobe or less; surrounded by normal tissue

T2b

Tumor involves more than half of a lobe, but not both lobes

B1

Tumor involves less than one lobe

T2c

Tumor involves both lobes

B2

Tumor involves one entire lobe or more

T3

Palpable tumor extending through prostate capsule and/or involving seminal vesicle(s)

CI

Tumor < 6 cm in diameter

T3a

Unilateral extracapsular extension

CI

Same as TNM

('Continued)

('Continued)

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TNM

Description

Whitmore-Jewett

Description

T3b

Bilateral extracapsular extension

CI

Same as TNM

T3c

Tumor invades seminal vesicle(s)

CI

Same as TNM

T4

Tumor is fixed or invades adjacent structures other than seminal vesicles

C2

Tumor <6 cm in diameter

T4a

Tumor invades bladder neck and/or external sphincter and/or rectum

C2

Same as TNM

T4b

Tumor invades levator muscle and/or is fixed to pelvic wall

C2

Same as TNM

N+

Involvement of regional lymph nodes

D1

Same as TNM

None

None

DO

Elevation of prostatic acid phosphatase only (enzymatic assay)

NX

Regional lymph nodes cannot be assessed

None

None

NO

No regional lymph node metastasis

None

None

N1

Metastasis in a single regional lymph node, < 2 cm in greatest dimension

D1

Same as TNM

N2

Metastasis in a single regional lymph node, > 2 cm but not > 5 cm in greatest dimension, or multiple regional lymph nodes, none > 5 cm in greatest dimension

D1

Same as TNM

N3

Metastasis in a regional lymph node > 5 cm in greatest dimension

D1

Same as TNM

M+

Distant metastatic spread

D2

Same as TNM

TNM

Description

Whitmore-Jewett

Description

MX

Presence of distant metastases cannot be assessed

None

None

MO

No distant metastases

None

None

Ml

Distant metastases

D2

Same as TNM

Mia

Involvement of nonregional lymph nodes

D2

Same as TNM

Mlb

Involvement of bone(s)

D2

Same as TNM

Mlc

Involvement of other distant sites

D2

Same as TNM

None

None

D3

Hormone refractory disease

*None, No comparable category; TUR, Transurethral resection; PSA, prostate-specific antigen.

Source: Loughlin, P. 100 Questions and Answers About Prostate Disease. Jones and Bartlett Publishers, LLC, 2007.

Problems of the bones, such as a history of a broken bone, arthritis, and Pagets disease, may cause an increase in uptake of the radioactive chemical.

Osteoblastic lesion

Pertaining to plain X-ray of a bone, increased density of bone seen on X-ray when there is extensive new bone formation due to cancerous destruction of the bone.

Osteolytic lesion

Pertaining to plain X-ray of a bone, refers to decreased density of bone seen on X-ray when there is destruction and loss of bone by cancer.

Hydronephrosis

Dilation of the kidneys, usually due to obstruction.

the bones, such as a history of a broken bone, arthritis, and Paget's disease, may cause an increase in uptake of the radioactive chemical. Often, your history, the location of the bone, and possible additional studies, such as a plain X-ray study or an MRI, will help determine whether the area of increased uptake indicates the presence of cancer.

The bone scan is quite sensitive, but it does not identify small numbers of cancer cells in the bones. In a small number of men (8%), the bone scan may be normal when bone metastases are present. Prostate cancer is not the only cancer that spreads to the bone, but prostate cancer tends to cause the bone to look different than that of involvement with other cancers, such as breast, colon, and bladder. Prostate cancer metastases are typically osteoblastic, whereas those of other cancers tend to be osteolytic. Osteoblastic lesions look as if there is an increase in the amount of bone present on a plain X-ray, whereas osteolytic lesions look like there is a loss of bone. The bone scan may also show obstruction of the urinary tract, leading to hydronephrosis.

The bone scan is often obtained as part of the staging work-up in men with prostate cancer and is helpful in men with a rising PSA (either after primary treatment, such as radical prostatectomy, or during watchful waiting) with or without bone pain to identify new areas of uptake that may indicate new bone involvement. The bone scan is usually obtained as part of the staging evaluation in men with newly diagnosed clinically localized prostate cancer who have a PSA > 20 ng/mL. Because the risk of bone metastases in men with newly diagnosed clinically localized prostate cancer who have a PSA < 20 ng/mL is so low, a bone scan is not routinely obtained in these men. Although the chemical used for the study is radioactive, the amount used is small, and it will not put you or your family at-risk.

Arthritis Joint Pain

Arthritis Joint Pain

Arthritis is a general term which is commonly associated with a number of painful conditions affecting the joints and bones. The term arthritis literally translates to joint inflammation.

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