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seminal vesicles: bladder neck, external sphincter,
rectum, levator muscles, and/or pelvic wall.
Stage Grouping for Prostate Cancer, 2002 AJCC
Criteria
Stage I T1a N0 M0 G1*
Stage II T1a N0 M0 G2, 3-4
N0 M0 Any G
N0 M0 Any G
N0 M0 Any G
N0 M0 Any G
Stage T3 N0 M0 Any G
III
Stage T4 N0 M0 Any G
IV
Any T N1 M0 Any G
Any T Any N M1 Any G
*
Grade: tumor grade is assessed as follows:
Grade 1: Well differentiated (slight anaplasia), Gleason
score 2-4
Grade 2: Moderately differentiated (moderate anaplasia)
Gleason score 5-6
Grade 3-4: Poorly differentiated/undifferentiated (marked
anaplasia) Gleason score 7-10
A. Tumor histology (Gleason score). Analysis of
the tumor histology provides an index of prognosis
and may guide local therapy. Gleason score of
one represents the most well-differentiated
appearance, and Gleason score ten represents
the most poorly differentiated.
B. Clinical staging
1. Serum PSA. This value is not used for staging,
but may help to predict the local extent of
disease in men with prostate cancer. There is
a higher likelihood of finding organ-confined
disease when the serum PSA concentration is
less than 4.0 ng/mL. A serum PSA
concentration of 4.1 to 10.0 ng/mL increases
the likelihood of finding an organ-confined
tumor larger than 0.5 mL, but also increases
the odds of finding extracapsular extension by
5.1-fold. A serum PSA concentration higher
than 10.0 ng/mL increases the likelihood of
finding extraprostatic extension by 24 to 50
fold.
2. Radionuclide bone scan. A positive
radionuclide bone scan indicates extraprostatic
spread and eliminates the potential for curative
surgery. Bone scan need not be performed in
a patient with clinical stage T1 or T2 cancer on
physical examination, a Gleason score of six or
less, and a serum PSA value less than 10
ng/mL.
3. CT scan should be considered in men who are
going to be treated with external beam
radiation therapy, and in men who have a PSA
>10 to 15 ng/mL or a Gleason score greater
than six. These men have an increased
likelihood of pelvic lymph node metastasis.
4. Endorectal coil magnetic resonance
imaging (MRI) of the prostate gland utilizing an
endorectal probe can determine the likelihood
of either seminal vesicle involvement or
extracapsular extension in patients who are
thought to have clinically localized prostate
cancer. The likelihood of cure with either
radiation therapy or radical prostatectomy is
low in these locally advanced patients, and
surgery is usually not recommended.
V. Treatment for early prostate cancer (organ-
confined)
A. The three standard therapies for men with early
stage (organ-confined) prostate cancer are radical
prostatectomy (RP), radiotherapy (RT), and
watchful waiting. Hormone therapy is reserved for
patients with locally advanced or metastatic
prostate cancer.
B. Radical prostatectomy
1. RP involves excising the entire prostate from
the urethra and bladder, which are then
reconnected. This treatment offers the best
chance of long-term survival. The retropubic
approach to RP permits pelvic lymph node
sampling prior to prostate removal to confirm
the presence or absence of metastases. The
prostate is removed if the lymph nodes are free
of disease.
2. Fifteen-year progression-free survival rates
have been reported to be 80 to 85 percent for
men with organ-confined disease.
3. Complications
a. Incontinence. About 1.6 percent report no
urinary control, 7 percent report frequent
leakage, and 42 percent report occasional
leakage.
b.Impotence. The potency rate after surgery is
100 percent in men in their 40s, 55 percent
for men in their 50s, 43 percent for men in
their 60s, and 0 percent for men in their 70s.
4. Perineal prostatectomy can be considered for
men with lower grade and low volume tumors,
such as those with Gleason score
serum PSA less than 10 ng/mL. The likelihood
of extraprostatic disease is less than 5 percent
in such patients, making pelvic lymph node
dissection unnecessary.
C. Radiation therapy
1. Radiation therapy (RT) does not require
hospitalization and normal activity can usually
be maintained during the course of treatment.
Cure rates with RT appear to be comparable to
those with RP for clinically localized disease for
the first five years. Late recurrences following
RT ten years or more after treatment occur
more frequently than with RP.
D. Watchful waiting
1. Watchful waiting describes patients who forego
treatment. Such patients are followed with
serum PSA measurements and digital rectal
examination every three months for the first
year, and then less frequently. Definitive or
palliative therapy is initiated if a significant
change in the serum PSA concentration or
DRE occurs.
2. Men with early stage disease (T0 to T2, NX,
MO) were followed for ten years, and only 9
percent died of prostate cancer. The survival
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