Partin Tables cannot accurately predict the pathological stage at radical prostatectomy
Introduction
Several nomograms and other statistical models were recently devised to predict pathological stage prior to definitive therapy.1, 2, 3, 4, 5, 6, 7, 8, 9, 10 These tools offer the possibility of using their predictions for the most evidence-based and individualized selection of available treatment alternatives. Among different models, the Partin Tables represent one of the most fundamental stepping stones that led to the development of the field of prognostics in urologic oncology.11, 12, 13, 14 The Partin Tables rely on pretreatment prostate specific antigen (PSA), clinical stage, and biopsy Gleason score to predict the probability of extracapsular extension (ECE), seminal vesicle invasion (SVI) and lymph node invasion (LNI). The Partin Tables help urologists, radiation oncologists, medical oncologists and general practitioners to predict what stage of the disease might be expected, if the prostate were surgically removed. The Table's predictions represent the most widely used guide towards the selection for definitive therapy in Europe and North America. For example, the Partin Tables' predictions of ECE guide urological surgeons with respect to the safety of neurovascular bundle preservation. Patients at low risk of ECE may be considered for neurovascular bundle sparing-radical prostatectomy.15, 16 Conversely, those at high risk should not. The Partin Tables' predictions of SVI can help identifying those at low risk of SVI, in whom the seminal vesicles may be spared. This may improve post-operative erectile and urinary function.4 Finally, the Partin Tables are widely used to identify patients at risk of LNI who should be staged with a pelvic lymphadenectomy.17, 18
The original Partin Tables were developed in 1993 and were subsequently updated in 1997.11, 12 The 1997 Tables have become the most widely used staging tool in urologic oncology. Due to prostate cancer stage migration, the Tables were updated in 2001 (n = 5079).13, 14 The validity of the 2001 Tables was confirmed in several populations from North America,19 Canada,20 and Europe.21 The discrimination and calibration properties were compared to the 1997 Tables and showed equally good results.22 The ongoing stage migration prompted Partin and associates to update their series again and the authors included men treated with radical prostatectomy (RP) between 2000 and 2005, which resulted in the 2007 update of the Tables (n = 5730).14 The updated 2007 version of the Tables represents an important contribution for the urologic community in North America. However, the rate and the type of stage migration that occurred in Europe during the same time period (2000–2005) did not necessarily perfectly replicate the stage and grade migration that occurred in North America. Recent reports suggest that important differences in stage, grade and PSA at presentation may exist between men in the United States and those in Europe.2 These differences were shown to result in equally important differences in the pathological stage at RP.2, 23 These differences might undermine the performance characteristics and/or the accuracy of the Partin Tables in European patients, especially since the Partin Tables were developed in men from the United States. Important differences in patient's characteristics may therefore lead to inaccurate predictions. Inaccurate predictions may in turn mislead the clinicians with respect to the safety of neurovascular bundle preservation or the need for seminal vesicle resection or lymphadenectomy. Therefore, prior to the clinical implementation of the 2007 Partin Tables, we decided to assess their accuracy and performance characteristics in patients treated with RP at one tertiary academic centre in Europe.
Section snippets
Patients
To comply with the temporal characteristics of the original Partin Tables' cohort, we relied on 3288 consecutive patients treated with radical prostatectomy for localized prostate cancer at the University of Eppendorf in Hamburg, Germany between January 2000 and December 2005. Of those, 61 were excluded due to missing PSA values, 16 for missing clinical stage information, and 87 for missing biopsy Gleason scores. Men with clinical stages T1a (n = 6), T1b (n = 3), and T3 (n = 10) were also excluded to
Results
Clinical and pathological characteristics of the current study cohort and those of the Partin 2001 and 2007 cohorts are displayed in Table 1. For all three cohorts the data are strikingly similar with respect to clinical stage distribution. Serum PSA distribution of the German cohort and of the 2001 Partin Table cohorts are equally comparable. Conversely, relative to the German cohort, a higher proportion of low serum PSA values were reported in the 2007 Partin cohort. The German cohort
Discussion
The pathologic stage of the disease represents the determinant of treatment choice. For example, patients with a high likelihood of extra prostatic disease (ECE, SVI, or LNI) are not good candidates for observation (active surveillance) or for less definitive treatment modalities, such as brachytherapy or high intensity focused ultrasound.25, 26, 27, 28 The consequence of incorrect staging leads to inappropriate preservation of the neurovascular bundle in patients with ECE or of lack of staging
Conclusion
The Partin Tables guide clinicians with respect to the safety of nerve bundle preservation at RP or with respect to the need for seminal vesicle resection or lymphadenectomy. The use of Partin Tables predictions may significantly affect the type and/or the extent of the surgery that is performed. In their present format the Partin Tables are not accurate enough to warrant their use in pre-operative decision making.
Conflict of interest
The authors have no conflict of interest.
Acknowledgments
Pierre I. Karakiewicz is partially supported by the University of Montreal Health Center Urology Associated, Fonds de la Recherche en Santè du Quebec, the University of Montreal Department Of Surgery and the University of Montreal Health Center (CHUM) Foundation.
Dr. François Péloquin and Dr. Daniel Pharand both contributed to the critical revision of this manuscript.
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2013, Expert Systems with ApplicationsCitation Excerpt :Augustin, Sun, Isbarn, Pummer, and Karakiewicz (2012) compared the three versions and did not identify the best one. The Partin tables represent the most widely used guide towards the selection of definitive therapies in Europe and North America (Bhojani et al., 2009). The European Association of Urology (EAU) guidelines recommend the use of Partin tables and Kattan nomogram for prostate cancer staging (Briganti, Karakiewicz, Joniau, & Van Poppel, 2009).
Development and validation of a UK-specific prostate cancer staging predictive model: UK prostate cancer tables
2012, British Journal of Medical and Surgical UrologyDecision curve analysis to compare 3 versions of Partin Tables to predict final pathologic stage
2012, Urologic Oncology: Seminars and Original InvestigationsCitation Excerpt :However, recently certain limitations were recorded in European patient cohorts. For example, in men from Germany, France, and Italy, the 2007 version of the Partin Tables showed suboptimal performance characteristics [8,9]. This observation prompted us to examine the 1997 and 2001 versions of the Partin Tables with the intent of comparing them with the 2007 version.
Machine learning for improved pathological staging of prostate cancer: A performance comparison on a range of classifiers
2012, Artificial Intelligence in MedicineCitation Excerpt :Using the British data and the approach described in [8], we build new lookup tables and assess the methodology itself. The results are compared against the previous validation studies [9–19] and provide additional understanding on Partin tables performances. Second, we propose alternative classifying techniques to build lookup tables for prostate cancer staging.
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Equal contribution.