0:00

I want to take a summary of anatomic

0:02

stage and prognosis from the

0:04

American Cancer Society Committee.

0:07

And I want to make a point.

0:09

You've got several groups on the left here.

0:12

And each of these groups have a series of

0:15

divisions that depend on the T stage,

0:17

the N stage, the M stage, the PSA, and the Gleason.

0:20

So what if the PSA and or the

0:22

Gleason are not available?

0:24

Then you completely go by T staging alone.

0:28

Now I'm not going to read this entire chart

0:30

off to you because that would put you to sleep.

0:33

But this chart will be available in the

0:35

video notes in this section of MRI online.

0:40

But look at what is determining

0:43

the overall prognosis factors.

0:45

It's the T stage, which

0:47

includes the N and M stages.

0:49

For regional nodal metastases and for

0:52

distant nodal, bony, and other organ

0:55

metastases, the PSA, and the Gleason score.

1:00

Now, this seems very obvious, intuitively

1:02

obvious, but this is how we're going to tier

1:06

prognostic groups into Tier 1, Tier 2, and Tier 3.

1:10

To determine who's a candidate for

1:13

MRI surveillance and who is not.

1:17

So let's talk about those tiers, which

1:19

we have discussed in prior vignettes.

1:21

In Tier 1, the PSA level is less than

1:24

10 nanograms per ml, and the Gleason

1:28

score has never been greater than 6.

1:32

So it's 6 or less.

1:33

The clinical T category is T1C or T2A.

1:37

If you want to learn more about those

1:39

categories, go to the prior vignette.

1:42

Tier two intermediate risk.

1:44

The PSA level is between

1:46

10 and 20 nanograms per ml.

1:49

The Gleason score is seven, and the

1:51

clinical T category is T2B, Tier three.

1:57

The PSA is greater than 20 nanograms per ml.

2:01

The Gleason score is eight to 10, and

2:05

the clinical T category is T2C.

2:10

So we would stratify these as low

2:12

risk, intermediate, and high risk.

2:15

Now, a couple of comments.

2:17

The Gleason 6 is kind of like the tipping point.

2:21

You're going to see Gleason scores of 6,

2:26

7, 8, 9, a lot more frequently than you're

2:30

ever going to encounter Gleason, say, 4 or 5.

2:34

Usually those lower Gleason scores

2:36

are incidentally detected, often within

2:38

the transitional zone of the prostate.

2:41

So it's not very common.

2:42

In fact, it's going to be rare when you

2:44

see Gleason scores in that category.

2:46

So 6 is a pretty critical cutoff.

2:48

You're going to see a lot of 6s.

2:50

And 6s is in the category of lower

2:54

grade, low-tier, lower risk disease.

2:57

As soon as you hit seven, you've

2:58

jumped into another level.

3:00

A word about PSA.

3:03

PSA is a glycoprotein.

3:05

It's elevated in BPH, in

3:07

infarcts, in inflammation.

3:09

After a digital exam, after cystoscopy. After a

3:12

biopsy, so you have to view PSA in the framework

3:17

of the patient's age and these other factors.

3:20

PSA drops with oral or topical medicines.

3:24

In fact, if you put minoxidil on your hair and

3:26

you take it by mouth, you can drop the PSA.

3:29

The PCA3, or the PSA PCA3, is

3:34

not part of clinical practice yet.

3:36

That is a special, that's a special test.

3:40

So, we usually break the PSA down

3:42

into greater than 4 and less than 4.

3:46

If it's greater than 4, then the

3:50

odds of the patient having extra

3:51

capsular spread start to go up.

3:53

So if it's less than 4, first of all, there's

3:56

a 10 percent chance of carcinoma in the right

4:01

age group and population that's being evaluated.

4:04

And 90 percent of cancers with total PSA of

4:08

less than 4 nanograms per mL are going to

4:12

have, uh, cancer confined to the prostate.

4:15

So what if you have a total PSA

4:17

of 4 to 10 nanograms per ml?

4:21

Well, 70 percent now of tumors are confined

4:24

to the prostate, so it's dropped by 20%,

4:27

and the cancer probability in the right

4:30

age group category of patients being

4:31

evaluated is 25 percent probability.

4:36

If the total PSA is greater than 10 nanograms

4:39

per ml, another, another critical area.

4:42

So less than 4 and greater than 10.

4:44

These have real significant meaning.

4:47

The probability of cancer goes up to 50

4:49

percent and the probability that the cancer

4:52

is confined to the gland is only 50%.

4:56

So while PSA can be very valuable in these

4:59

less than 4, greater than 10 categories,

5:02

It has to be taken with a grain of salt.

5:04

If the patient, uh, is being delivered anti

5:07

estrogen therapy, the PSA can potentially go down.

5:11

If they're taking minoxidil,

5:13

the PSA can potentially go down.

5:15

And the Gleason 6 and below and 7 and

5:20

above are a critical cutoff point.

5:23

We'll stop right there.

5:24

Remember, this is going to be

5:25

available in your notes for MRI online.