Which of the following factors has the greatest prognostic impact for this patient?

A firm, irregular prostatic nodule is discovered during annual physical examination of a 66-year-old patient. Biopsy reveals the presence of a moderately well-differentiated prostate carcinoma. Which of the following factors has the greatest prognostic impact for this patient?

(A) degree of cellular atypia
(B) histological grading
© initial prostate-specific antigen level
(D) pathological staging
(E) presence of mitotic figures


(D) Pathological staging of a tumor is important for the prognosis of almost all neoplasms, and in prostate carcinoma (CA), it has much greater prognostic impact than any other factor. Stage is determined by extent of tumor infiltration and metastasis. Although pathological staging criteria vary with different neoplasms, one attempt to standardize tumor staging is the TNM classification, which includes primary tumor size (T), lymph node involvement (N), and distant metastasis (M). Degree of cellular atypia (choice A) refers to the degree of differentiation of a tumor, and in concert with presence of mitotic figures (choice E), these two features comprise the histological grading criteria (choice B) of neoplasia. Although tumor grading is important, in general it has proved to be of less clinical significance than tumor staging. Most statistical data on cancer survival is related to tumor staging rather than tumor grading. Initial prostate-specific antigen (PSA) level (choice C) is not a reliable prognostic indicator for prostate CAas elevated PSAlevels (>3.9 ng/mL) occur in up to half of patients with benign prostatic hyperplasia, and a significant number of patients with prostate CAhave normal levels of PSA, regardless of clinical stage. PSAhas, however, demonstrated value as a marker for monitoring prostate CAtherapy (e.g., post-radical prostatectomy).