Bladder Neck Invasion Research Articles

Probability of extraprostatic disease according to the percentage of positive biopsy cores in clinically localized prostate cancer.

ABSTRACTObjectivePrediction of extraprostatic disease in clinically localized prostate cancer is relevant for treatment planning of the disease. The purpose of this study was to explore the usefulness of the percentage of positive biopsy cores to predict the chance of extraprostatic cancer.Materials and MethodsWe evaluated 1787 patients with localized prostate cancer submitted to radical prostatectomy. The percentage of positive cores in prostate biopsy was correlated with the pathologic outcome of the surgical specimen. In the final analysis, a correlation was made between categorical ranges of positive cores (10% intervals) and the risk of extraprostatic extension and/or bladder neck invasion, seminal vesicles involvement or metastasis to iliac lymph nodes. Student's t test was used for statistical analysis.ResultsFor each 10% of positive cores we observed a progressive higher prevalence of extraprostatic disease. The risk of cancer beyond the prostate capsule for <10% positive biopsy cores was 7.4% and it increased to 76.2% at the category 90-100% positive cores. In patients with Gleason grade 4 or 5, the risk of extraprostatic cancer prostate was higher than in those without any component 4 or 5.ConclusionThe percentage of positive cores in prostate biopsy can predict the risk of cancer outside the prostate. Our study shows that the percentage of positive prostate biopsy fragments helps predict the chance of extraprostatic cancer and may have a relevant role in the patient's management.

Prostate cancer collaborative stage data items--their definitions, quality, usage, and clinical implications: a review of SEER data for 2004-2010.

Version 2 of the Collaborative Stage Data Collection System (CSv2) became effective with cases diagnosed in 2010. This report focuses on the CSv2 components required to derive the American Joint Committee on Cancer (AJCC) stage for prostate cancer and on the site-specific factors for prostate cancer captured in CSv2. The report also highlights differences between the AJCC 6th and 7th editions for classifying prostate cancer stage. Data from 18 Surveillance, Epidemiology, and End Results (SEER) Program population-based registries (SEER-18) were analyzed for the years 2004-2010, which included 400,591 prostate cancer cases. CSv2 provides specificity with regard to the Gleason grading system by distinguishing between clinical and pathologic patterns and scores. The AJCC 7th edition incorporates prostate-specific antigen values into staging, subdivides stage II into IIA and IIB, and reclassifies extraprostatic invasion with microscopic bladder neck invasion from T4 in the 6th edition to T3a; this latter change affected the AJCC stage of 283 cases in 2010. Of the 44,578 prostate cancer cases diagnosed in 2010 that would have been classified as stage II in the AJCC 6th edition, 32.7%, 27.5%, and 39.8% are classified as stages I, IIA, and IIB, respectively, in the 7th edition. CSv2 provides more information than was previously available to researchers using SEER prostate data. The absence of a clearly defined clinical stage for each prostate case is the overriding limitation that researchers face in relying on Collaborative Stage information to analyze prostate cancer data.

A retrospective study of prostate cancer cases mimicking urothelial cell carcinoma of the bladder

BackgroundProstate cancer (PCa) originating from the prostate base may intrude into the urinary bladder and may be misdiagnosed as bladder cancer. In this retrospective study, we reviewed the clinic data on PCa cases which were initially misdiagnosed as bladder cancer in order to identify diagnostic methods that would allow a better differential diagnosis for PCa.MethodsOut of a total of 455 patients treated for PCa at our hospital between April 2003 and June 2011, 14 patients (3.1%) had been initially misdiagnosed as urinary bladder urothelial cell carcinoma. The clinical data on these 14 cases was retrieved and analyzed.ResultsOf the 14 patients, 11 patients were eventually diagnosed with PCa after MRI examination, and seven out of these had PCa with bladder neck invasion. Prostate needle biopsy or transurethral resection of prostate (TURP) revealed that all 14 patients had adenocarcinoma of prostate with Gleason scores ranging from 7 to 9. Nine patients received TURP for hematuria or lower urinary tract blockage. The mean follow-up was 37 months, during which six patients survived.ConclusionsAs clinical presentation and in emergency settings, prostate cancer originating from the prostate base can be confused with bladder cancer originating from the neck or the triangle region of the urinary bladder. Serum prostate specific antigen (PSA) levels and digital rectal examination, in combination with transrectal ultrasound (TRUS), MRI, and prostate needle biopsy are valuable tools for definitive differential diagnosis of the basal prostate cancer.

Evaluation of the 7th American Joint Committee on Cancer TNM Staging System for Prostate Cancer in Point of Classification of Bladder Neck Invasion

To assess the validity of the 7th edition of the American Joint Committee on Cancer TNM staging system for prostate cancer, paying special attention to bladder neck invasion, in an Asian population. Clinicopathologic data of 368 men who underwent radical prostatectomy between 2003 and 2011 at our institution were reviewed. The main interest of this study was to confirm that both isolated positive bladder neck margin and positive bladder neck margin associated with other surgical margin have more favorable biochemical outcomes than seminal vesicle invasion (pT3b). The 3-year biochemical recurrence-free survival for men with organ confined disease, extraprostatic extension, isolated positive bladder neck margin, positive bladder neck margin with other surgical margin and seminal vesicle invasion was 88.9, 74.8, 51.2, 19.4 and 18.8%, respectively. On multivariate analysis, the increased risk of progression associated with an isolated positive bladder neck margin (hazard ratio 4.34, 95% confidence interval 1.40-13.46, P = 0.011) was less than that of seminal vesicle invasion (hazard ratio 9.67, 95% confidence interval 3.70-25.25, P < 0.001). As for the positive bladder neck margin with other surgical margin, the increased risk of progression (hazard ratio 9.32, 95% confidence interval 3.50-24.82, P < 0.001) was similar to that of men with seminal vesicle invasion. In our study, men with isolated positive bladder neck margin and positive bladder neck margin plus other surgical margin had no worse biochemical outcomes than those with seminal vesicle invasion (pT3b). It is reasonable to classify prostate cancer with bladder neck invasion (the 6th American Joint Committee on Cancer edition pT4 category) into the 7th edition pT3 category.

Clear cell carcinoma of female urethral diverticulum—A case report

Primary malignancies of female urethral diverticulum are rare. A well-documented female patient with primary clear cell carcinoma of the urethral diverticulum is presented here. A65-year-old woman presented with frequency and voiding difficulty for 2 months. Physical examination showed a 4-cm mass protruding from anterior vaginal wall. Intravenous urography, magnetic resonance imaging, and cystoscopy showed a polypoid mass in urethral diverticulum. She then underwent anterior exenteration with ileal conduit diversion and urethrectomy. Pathology confirmed the diagnosis of clear cell adenocarcinoma with bladder neck invasion. She had no disease recurrence at 2-year follow-up. Careful clinical examination and image studies are helpful in making the preoperative diagnosis for the rare disease. Early radical surgery can achieve better survival.

Practical issues and pitfalls in staging tumors of the genitourinary tract

Accurate staging of tumors involving the genitourinary tract is critical to determine appropriate management options and subsequent clinical outcome for patients. The staging protocols, however, continue to evolve and are under constant revision and change. The new 2010 American Joint Committee on Cancer/Tumor Nodes and Metastasis (AJCC/TNM) staging system of the prostate, bladder, kidney, and testis is now recommended. Although the protocols are relatively straightforward, this article focuses on some practical issues and occasional pitfalls that may be encountered when staging cancers of the genitourinary tract. Specific issues that will be addressed include issues and pitfalls in radical prostatectomy specimens (substaging of pT2 tumors, extraprostatic extension, bladder neck invasion, positive surgical margins, seminal vesicle involvement, no residual tumor identified), cystectomy/cystoprostatectomy specimens (extravesicular extension and prostatic stromal invasion), nephrectomy specimens (renal sinus invasion, ipsilateral adrenal gland invasion, renal vein involvement, multifocal tumors), and orchiectomy specimens (pseudoangiolymphatic invasion of friable tumors, rete testis invasion, and spermatic cord invasion/metastasis). In addition, pitfalls in both prostate (extraprostatic extension, seminal vesicle/ejaculatory duct involvement in needle core biopsies, and quantification of tumor volume in transurethral resection specimens) and bladder (tumors with inverted growth pattern, muscularis propria invasion, extravesicular extension) biopsy interpretations that may have an impact on staging are also addressed.

1121 INTRADUCTAL CARCINOMA OF THE PROSTATE CAN BE A STRONG PREDICTOR OF PROSTATE CANCER DEATH

You have accessJournal of UrologyProstate Cancer: Localized V1 Apr 20121121 INTRADUCTAL CARCINOMA OF THE PROSTATE CAN BE A STRONG PREDICTOR OF PROSTATE CANCER DEATH Masashi Kato, Kyosuke Kimura, Toyonori Tsuzuki, Ryohei Hattori, and Momokazu Gotoh Masashi KatoMasashi Kato Nagoya, Japan More articles by this author , Kyosuke KimuraKyosuke Kimura Nagoya, Japan More articles by this author , Toyonori TsuzukiToyonori Tsuzuki Nagoya, Japan More articles by this author , Ryohei HattoriRyohei Hattori Nagoya, Japan More articles by this author , and Momokazu GotohMomokazu Gotoh Nagoya, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1230AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Inclusion of intraductal carcinoma of the prostate (iIDCP) is rarely seen in the absence of invasive prostate cancer. The prognostic value independent of high-grade invasive prostate cancer has been reported with only the endpoint of biochemical recurrence. To date no paper has shown IDCP to be a positive predictor of clinical failure or prostate cancer-specific death. Here we show the efficacy of IDCP as a predictor of clinical recurrence and cancer specific-death from prostate cancer for the first time. METHODS We retrospectively evaluated high-risk prostate cancer patients treated with radical prostatectomy between 1991 and 2005 in our three related hospitals and reviewed slides of prostatectomy specimens. Presence of IDCP was defined using previously published diagnostic criteria by a single urologic pathologist. Finally, a total of 206 patients with high-risk prostate cancer were entered in our retrospective clinicopathological analysis. Multivariate Cox proportional hazard regression models were developed to predict clinical recurrence and cancer-specific death from prostate cancer. RESULTS Baseline characteristics included iPSA 20≤ ng/ml at diagnosis in 59%, clinical stage T3≤ in 41.7%, and Gleason score 8≤ in 78.7% of all patients. Follow-up period was 86 months on average. Prostatectomy specimens showed positive surgical margin in 40.8%, extraprostatic extension in 53%, seminal vesicle invasion in 30.1%, bladder neck invasion in 5.8%, pelvic lymph node metastasis in 14.6% and IDCP in 50.5%. Clinical metastases were found in 44 cases (21.4%) and time to progression was a median 41 months. Progression-free rate was 84.8% at 5 years and 68.9% at 10 years. Cancer death was observed in 20 cases (9.7%) and time to cancer death was 56 months on average. Prostate cancer-specific survival was 93.8% at 5 years and 78.9% at 10 years. The multivariate analysis identified clinical T stage and presence of IDCP as predictors of clinical recurrence, and presence of IDCP and seminal vesicle invasion as predictors of prostate cancer-specific death (P<0.05). A higher Gleason score by definition of international society of urological pathology (ISUP) 2005 was not associated here. CONCLUSIONS Presence of IDCP can be a significant predictor of clinical recurrence and cancer-specific death from prostate cancer when analyzing factors of prostatectomy specimens in high risk prostate cancer. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e454-e455 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Masashi Kato Nagoya, Japan More articles by this author Kyosuke Kimura Nagoya, Japan More articles by this author Toyonori Tsuzuki Nagoya, Japan More articles by this author Ryohei Hattori Nagoya, Japan More articles by this author Momokazu Gotoh Nagoya, Japan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1559 PROSTATE CANCER ARISING IN THE TRANSITION ZONE: CHARACTERIZATION OF THE INCIDENCE, ANATOMICAL EXTENSION PATTERN AND PROGNOSTIC FACTORS

You have accessJournal of UrologyProstate Cancer: Localized VI1 Apr 20101559 PROSTATE CANCER ARISING IN THE TRANSITION ZONE: CHARACTERIZATION OF THE INCIDENCE, ANATOMICAL EXTENSION PATTERN AND PROGNOSTIC FACTORS Go Kimura, Ichiro Matsuzawa, Yuka Saito, Yasutomo Suzuki, Tsutomu Hamasaki, and Yukihiro Kondo Go KimuraGo Kimura More articles by this author , Ichiro MatsuzawaIchiro Matsuzawa More articles by this author , Yuka SaitoYuka Saito More articles by this author , Yasutomo SuzukiYasutomo Suzuki More articles by this author , Tsutomu HamasakiTsutomu Hamasaki More articles by this author , and Yukihiro KondoYukihiro Kondo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1324AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The transition zone cancer (TZC) has been reported to comprise 24% of prostate cancer (McNeal JE et al., Am J Surg Pathol, 1988) and the progosis is controversial. The aim of this study is to characrerize the incidence, anatomical extension pattern and prognostic factors of TZC in the era of PSA and extended biopsy. METHODS From 2000 to 2007, radical prostatectomy with no neoadjuvant therapy was performed in 358 cases in our hospital. Serial whole mount sections were reviewed to determine the incidense of TZC. The TZ was devided into four sub-zones, T1 (anteromedian), T2 (anterolateral), T3 (posterolateral) and T4 (posteromedian) (Fig 1). The sub-zonal incidence of the tumor in the TZ was also determined. The correlation between cancer occupation of each TZ subzone and clinicopathological factors including PSA and bladder neck invasion (b+) was studied by the Spearman's rank correlation. PSA failure-free survival was compared between TZC and non-TZC in all cases and subgroups inclluding the group A (PSA≤10), group B (10-20) and group C (>20) by Kaplan-Meier analysis using the logrank test. Cox proportional hazards models were used to assess prognostic factors. RESULTS The zonal origin of prostate cancer was 2% in the CZ, 68% in the PZ and 30% in the TZ. The sub-zonal tumor incidence devided by all cases was 53% in T1, 51% in T2, 29% in T3, and 23% in T4. Both PSA and b+ were significantly correlated with each of sub-zonal tumor occupation (Spearman's rho: T4>T3>T2>T1). A 5-year PSA failure-free surviaval of TZC was significantly better than that of non-TZC in the group B (91% vs. 49%) and the group C (78% vs. 40%). In PSA>20 cases positive surgical margin (PSM: HR=25.361) and TZC (HR=0.152) were the independent prognostic factors. In TZC cases only PSM was the independent prognostic factor (HR=19.608). CONCLUSIONS The TZC accounted for 30% of all prostate cancer in our RP cases. The TZC tends to arise from anterior portion of the TZ and extend toward both lower portion of the TZ and bladder neck along the urethra during progression. Since even in the cases with high PSA values TZC showed good prognosis in case of negtive surgical margin, a wide excision of bladder neck is recommended in high PSA value cases. Tokyo, Japan© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e602 Peer Review Report Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Go Kimura More articles by this author Ichiro Matsuzawa More articles by this author Yuka Saito More articles by this author Yasutomo Suzuki More articles by this author Tsutomu Hamasaki More articles by this author Yukihiro Kondo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Radical retropubic prostatectomy for prostate cancer with microscopic bladder neck involvement: survival and prognostic implications

To report the oncological outcome of 106 patients who had locally advanced prostate cancer with microscopic bladder neck invasion, identified in a series of 1129 patients surgically treated with retropubic radical prostatectomy over a 12-year period. All specimens were reviewed. Microscopic bladder neck invasion was defined as the presence of neoplastic cells within the smooth muscle bundles of the bladder neck, with no accompanying prostatic glandular tissue on the corresponding slide. Survival was analysed for different subgroups in relation to several variables. The follow-up (median 7.2 years, mean 6.68, range 0.3-14) was available for 106 patients with microscopic bladder neck invasion. Seminal vesicle invasion was present in 69.8% of the cases, lymph node involvement in 29.2%, apex infiltration in 31.8%, and positive surgical margins in 23.6%. Biochemical progression occurred in 61 (57.5%) patients, and 25 of them died from cancer. The mean (sd) biochemical progression-free survival was 0.68 (0.05), 0.59 (0.05), 0.40 (0.05) and 0.38 (0.05) at 1, 2, 5 and 10 years, respectively. Age, Gleason score and lymph node invasion were independent prognostic factors on multivariate analysis. Overall and cancer-specific survival rates were 0.75 (0.04) and 0.80 (0.04) at 5 years and 0.57 (0.04) and 0.75 (0.04) at 10 years, respectively. Univariate analysis showed that seminal vesicle invasion, lymph node involvement and surgical Gleason score > or =8 significantly increased the risk of death. On multivariate analysis only the surgical Gleason score had an independent prognostic role with regard to overall survival (P = 0.01; odds ratio 2.82, 95% confidence interval 1.2-6.4) and cancer-specific survival (P < 0.001; 8.6, 2.5-28.8). In this series, overall and cancer-specific survival rates were comparable to those reported for surgically treated cT3 prostate cancers. The lack of need for external urinary diversion during the entire follow-up significantly contributed to the patients' quality of life.

The prognostic significance of bladder neck invasion in prostate cancer: is microscopic involvement truly a T4 disease?

Since the widespread of prostate-specific antigen-based screening, prostate cancer at clinical stage T4 has become rare. Most bladder invasion is actually detected on radical prostatectomy specimens as a microscopic bladder neck involvement (BNI). The 2002 Tumour-Node-Metastasis (TNM) classification system classified prostate cancer with BNI within a unified pT4 category and rendered it equivalent to invasion into the pelvic wall musculature or external sphincter; this decision is controversial. Various series have assessed the clinical relevance and the effect of BNI on prognosis. This evidence-based review provides evidence that BNI should be assigned within the subset of pT3 stage, and that further improvement of the actual TNM staging system should be considered. However, BNI remains strongly associated with adverse pathology and should be regarded as a factor that worsens the prognosis of the underlying tumour stage.

Bladder tumor staging: comparison of contrast-enhanced and gray-scale ultrasound

Editorial Comment Similar to other studies the authors showed that MR imaging findings might represent additional useful variables for predicting disease extent in patients with clinically localized prostate cancer. Combined endorectal MRI-MR spectroscopic imaging had 80% accuracy in the staging of disease in patients with clinical stage T1c prostate cancer. These combined techniques had a moderate accuracy, 62-72%, in the prediction of clinically non-important cancer in this group of patients. As the authors pointed out it would be of clinical interest in the future to investigate whether multiparametric examination which combination of conventional T2-w images, spectroscopy, diffusion-weighted image (DWI) and perfusion studies can yield superior diagnostic information for stratifying patients with T1 c prostate cancer. Since 2004, we have been using in our department this multiparametric evaluation in patients with organ-confined tumor, based on finding of conventional T2-weighted images. We have found that DWI and perfusion techniques, similarly to spectroscopy are very useful to detect tumor > 0.5 cm3 and with higher Gleason grades. All techniques have difficult to detect smaller and low grades tumor. In other words, when we find a lesion with imaging characteristics of a possible aggressive tumor on T2-w images and spectroscopy, but without concordant findings on DWI and perfusion studies, our tendency is to downgrade the lesion to a possible less important one. We have found that usually a large and aggressive tumor will present as an area with restricted diffusion (lower ADC values) and with abnormally elevated values of the pharmacokinetics parameters obtained with perfusion studies. On the other hand, patients with normal multiparametric prostate examination has a very high probability of have a clinically non-important cancer. Another important finding of this study is that from 158, 124 (78%) patients had organ-confined disease (stage pT2), 29 (18%) had extracapsular extension (stage pT3a), two (1%) had seminal vesicle invasion (stage pT3b), and two (1%) had bladder neck invasion (stage pT4). We have to remember that clinically T1 c patients typically are considered to have localized early-stage disease of relatively low risk. Additionally 30 (19%) of the patients met the criteria to be considered for active surveillance as a management strategy, 4(13%) had extraprostatic extension of disease at surgical-pathologic analysis. These findings further enhance the value of endorectal MRI examination in the pre-operative evaluation of patients with T1c prostate carcinoma.

Clinical Stage T1c Prostate Cancer: Evaluation with Endorectal MR Imaging and MR Spectroscopic Imaging

To assess the diagnostic accuracy of endorectal magnetic resonance (MR) imaging and MR spectroscopic imaging for prediction of the pathologic stage of prostate cancer and the presence of clinically nonimportant disease in patients with clinical stage T1c prostate cancer. The institutional review board approved-and waived the informed patient consent requirement for-this HIPAA-compliant study involving 158 patients (median age, 58 years; age range, 40-76 years) who had clinical stage T1c prostate cancer, had not been treated preoperatively, and underwent combined 1.5-T endorectal MR imaging-MR spectroscopic imaging between January 2003 and March 2004 before undergoing radical prostatectomy. On the MR images and combined endorectal MR-MR spectroscopic images, two radiologists retrospectively and independently rated the likelihood of cancer in 12 prostate regions and the likelihoods of extracapsular extension (ECE), seminal vesicle invasion (SVI), and adjacent organ invasion by using a five-point scale, and they determined the probability of clinically nonimportant prostate cancer by using a four-point scale. Whole-mount step-section pathology maps were used for imaging-pathologic analysis correlation. Receiver operating characteristic curves were constructed and areas under the curves (AUCs) were estimated nonparametrically for assessment of reader accuracy. At surgical-pathologic analysis, one (0.6%) patient had no cancer; 124 (78%) patients, organ-confined (stage pT2) disease; 29 (18%) patients, ECE (stage pT3a); two (1%) patients, SVI (stage pT3b); and two (1%) patients, bladder neck invasion (stage pT4). Forty-six (29%) patients had a total tumor volume of less than 0.5 cm(3). With combined MR imaging-MR spectroscopic imaging, the two readers achieved 80% accuracy in disease staging and AUCs of 0.62 and 0.71 for the prediction of clinically nonimportant cancer. Clinical stage T1c prostate cancers are heterogeneous in pathologic stage and volume. MR imaging may help to stratify patients with clinical stage T1c disease for appropriate clinical management.

Cystoprostatectomy as a Treatment of Prostate Cancer Involving the Bladder Neck

Objective: We evaluated the clinicopathological findings and short- and long-term outcomes of prostate cancer (PCa) patients with bladder neck invasion who underwent cystoprostatectomy. Patients and Methods: Between 1989 and 2005, we performed 17 cystoprostatectomies for PCa patients having bladder neck invasion without distant visceral or distant lymph node metastasis. Of the 17 patients, 11 were treated with neoadjuvant hormone therapy and all patients were treated with adjuvant hormone therapy immediately after surgery. Results: All 7 patients in whom pelvic lymph node swelling was identified by preoperative imaging studies had pathological lymph node metastasis. Of the 10 patients judged as cN0 preoperatively, 7 (70.0%) had lymph node metastasis. Although local recurrence was found in 2 (11.8%) patients, no additional urinary diversion or inconvenient urinary symptoms due to PCa progression were observed in any patients. The 5-year prostate-specific antigen recurrence-free survival rate was 62.2%. Cause-specific survival at 5 years after surgery was 87.1%. The 5-year cause-specific survival rate of node-positive patients was 92.3%. Conclusion: Cystoprostatectomy followed by immediate hormone therapy may be a feasible treatment option to achieve excellent local control for patients with previously untreated PCa, even in the presence of pelvic lymph node metastasis.

Prognostic significance of microscopic bladder neck invasion in prostate cancer

To assess the prognostic significance of microscopic bladder neck invasion (BNI+) after radical prostatectomy (RP). From January 1988 to December 2006, 1480 patients with clinically localized prostate cancer were surgically treated at one tertiary university hospital. The risk of biochemical progression, defined as a prostate-specific antigen (PSA) level after RP of >0.2 ng/mL, was assessed with univariate and multivariate analyses for clinical and pathological variables. We compared the biochemical progression-free survival (bPFS) of patients with BNI+ vs stages pT2, pT3a, pT3b and positive lymph nodes (N+). In a second analysis, we evaluated the bPFS of patients in different stages associated with BNI+ and compared them with those in the same stages with no BNI. BNI+ was found in 132 (9%) patients; the 5-year bPFS was 86%, 54%, 26% and 10% for stages pT2, pT3a, pT3b and N+, respectively, while it was 30% for BNI+ (P < 0.001). There was no difference in the 5-year bPFS between stage pT2 and pT2 + BNI (P = 0.32). Stages pT3a and pT3b had a better 5-year bPFS than stage pT3a + BNI (P = 0.003) and pT3b + BNI (P = 0.001), respectively. In the univariate analysis all variables were associated with BP. In the multivariate analysis, only BNI+ had no association with BP (odds ratio 1.14, 95% confidence interval 0.70-1.85; P = 0.59). Microscopic BNI+ in prostate cancer is not an independent risk factor for biochemical progression and should be regarded as a factor that worsens the prognosis of the underlying tumour stage. A longer follow-up is necessary to confirm these findings.

Effects of Simultaneous Transurethral Resection of Non-Muscle-Invasive Bladder Cancer and Benign Prostatic Hyperplasia

Purpose: To evaluate the effects of simultaneous transurethral resection of bladder tumor (TURB) and transurethral resection of prostate (TURP) in patients with non-muscle-invasive bladder cancer and benign prostatic hyperplasia (BPH). Materials and Methods: From March 1995 to February 2007, TURB was performed for transitional cell carcinoma (TCC) of the bladder in 395 men by a single surgeon. Among these patients, 24 patients underwent TURB and TURP simultaneously for BPH as well as non-muscle-invasive TCC without bladder neck or prostatic urethral invasion and were followed up for at least 12 months (group 1). For purposes of comparison, the data from 165 men who underwent TURB alone for non-muscle-invasive TCC of the bladder (group 2) were also reviewed. Results: There were no significant differences in the clinicopathological variables of bladder cancer between the 2 groups. The 60-month overall recurrence-free, recurrence-free at bladder neck or prostatic urethra, and progression-free probability were 68.4%, 80.0%, and 89.4% in group 1 and 72.5%, 91.9%, and 94.5% in group 2, respectively. Kaplan-Meier curves showed that there were no significant differences in the overall recurrencefree rate (p=0.688), recurrence-free rate at bladder neck or prostatic urethra (p=0.867), or progression-free rate (p=0.885) between the 2 groups. Among the clinicopathological variables, no predictor of recurrence was identified in group 1. Conclusions: Simultaneous TURP during TURB does not increase the recurrence or progression rates of bladder cancer. TURP can be safely performed during TURB in patients with non-muscle-invasive bladder cancer and BPH. (Korean J Urol 2009;50:534-539) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Comparative expression of Hedgehog ligands at different stages of prostate carcinoma progression

Recent studies have revealed the potential involvement of Hedgehog (Hh) signalling in proliferation and invasive behaviour of prostate carcinoma (PCa). The aim of this study was to specify the role of Sonic Hh (Shh), Desert Hh (Dhh) and Indian Hh (Ihh) in the natural history of PCa. Hh ligands expression was compared in primary hormone-naive PCa (HNPC), hormone-treated PCa (HTPC) and hormone-refractory PCa (HRPC), using immunohistochemistry. Shh and Dhh were expressed by both epithelial and stromal cells of prostate tissues. Ihh was only expressed by stromal cells. For the three ligands, mRNA and immunostaining were not correlated. In HNPC, Shh epithelial expression was significantly associated with high Gleason scores (p = 0.03), metastatic lymph nodes (p = 0.004) and Dhh epithelial staining was associated with high pT stages (p = 0.003), seminal vesicle invasion (p = 0.03) and bladder neck invasion (p = 0.0008). Negative Shh staining in stromal cells was associated with high Gleason scores (p = 0.015), high pT stages (p = 0.01) and bladder neck invasion (p = 0.04). Concomitant absence of Shh and Dhh expression in stromal cells was an independent prognostic parameter for biological recurrence on multivariate analysis (p = 0.01). Epithelial expression of Shh and Dhh was increased in HTPC compared to HNPC (p = 0.02 and p = 0.04). Interestingly, in vitro, transcript analysis also showed increased expression of these 2 Hh ligands when androgen-sensitive LNCaP cells were maintained in androgen-free medium mimicking hormonal therapy. Epithelial expression of Dhh was increased (p < 0.0001) in HRPC compared to HNPC, while stromal expression of Shh and Dhh was decreased (p < 0.0001). In conclusion, the Hh signalling pathway is associated with pejorative pathological parameters in HNPC and is up-regulated in epithelial cells of HTPC and HRPC. Moreover, the lack of Hh molecules in stromal cells seems to be associated with invasive and hormone-refractory behaviours and suggests specific changes in stromal-epithelial crosstalks during PCa progression.

The significance of microscopic bladder neck invasion in radical prostatectomies: pT4 disease?

It is controversial whether microscopic invasion of the bladder neck (BN) has a high risk for biochemical progression following radical prostatectomy (RP). The tumor, node, and metastasis (TNM) classification for prostate cancer considers BN involvement to be pT4 disease, equivalent to rectal or external sphincter invasion, however, it does not specify whether the invasion is macroscopic or microscopic. Clinicopathological findings were studied from 290 patients submitted to RP. The time to biochemical (prostate-specific antigen, PSA) progression-free outcome for patients with BN invasion was compared to patients with extraprostatic extension (EPE) or seminal vesicle invasion (SVI). A univariate Cox proportional hazards model was created and a final multivariate Cox proportional hazards model was developed to assess the influence of several variables simultaneously. BN invasion was present in 55/290 (18.96%) surgical specimens and 18/290 (6.2%) also showed positive surgical margins. Patients with microscopic BN invasion had significantly higher preoperative PSA, higher Gleason score, higher apical and circumferential positive surgical margins, more advanced pathological stage, and more extensive tumors. At 5 years 42%, 40%, and 27% of the patients with BN invasion, extraprostatic extension (EPE), and seminal vesicle invasion (SVI), respectively, were free of biochemical recurrence following RP. In multivariate analysis, BN invasion did not contribute for a higher relative hazard of PSA recurrence when added to EPE or SVI. BN invasion is associated with adverse clinicopathological findings. However, the biochemical-free outcome following RP is similar to patients with EPE but significantly better than patients with SVI. The findings of this study do not favor considering microscopic bladder neck invasion as stage pT4 but, probably, stage pT3a.

Invasion of bladder neck after radical prostatectomy: one definition for different outcomes

The aim of the study was to evaluate factors of progression after radical prostatectomy in patients with bladder neck invasion (BNI). From 1988 to 2006, 1395 patients underwent radical prostatectomy, 120 (8.6%) had microscopic BNI (pT4 N0, TNM 2002). Group 1 was defined as BNI alone, group 2 as BNI plus extracapsular extension and group 3 as BNI plus seminal vesicle invasion (SVI). Postoperative follow-up data were obtained through routine serum prostate-specific antigen (PSA) and digital rectal examination. Biochemical progression was defined as a single detectable PSA level postoperatively (>0.2 ng ml(-1)). Groups 1, 2 and 3 included 38 (31%), 35 (30%) and 47 (39%) patients, respectively. Preoperative PSA (11.1 vs 24.7 and 23.3 ng ml(-1), P=0.01), biopsy Gleason score (5 vs 6 and 6, P=0.003) and specimen Gleason score (6 vs 7 and 7, P=0.02) were statistically different between three groups. None of the patients had a specimen Gleason score >or=8 in group 1. After a mean follow-up of 27 months, 51 (42.5%) patients had biochemical progression. The 5-year progression-free survival was 87, 53 and 17% for groups 1, 2 and 3, respectively (P<0.001). Within pT4 prostate cancer, those tumors with isolated microscopic BNI appear to have better prognosis than those with associated extracapsular extension and/or seminal vesicle invasion, and should be distinguished in TNM classification.

Basal Cell Carcinoma of the Prostate: A Clinicopathologic Study of 29 Cases

We studied 29 cases of basal cell carcinoma of the prostate including what others call adenoid cystic carcinoma of the prostate. Patients' age ranged from 42 to 89 (mean 69) years. The most common methods of diagnosis was transurethral resection (TURP) (n=29) and needle biopsy (n=9). In 28/29 cases, slides were reviewed and 24 (86%) cases showed more than 1 pattern: adenoid cysticlike (AC-P) pattern and small solid nests with peripheral palisading were the most predominant patterns, each seen in 18 cases (64%). Other patterns included: basal cell hyperplasialike in 9 cases (32%); small tubules occasionally lined by a hyaline rim in 9 cases (32%), with 4 of these cases also demonstrating intermingling cords of cells; and large solid nests in 8 cases (28.5%), 5 of which had central necrosis. Fourteen cases of small nests and tubules were centrally lined by eosinophilic cells. Desmoplasia was noted in 20 (71%) cases. Infiltration around benign glands was seen in 10 (36%) cases, with predominantly small nests and AC-P. Invasion of thick muscle bundles of the bladder neck was seen in 10 of 21 TURP cases. Perineural invasion was noted in 3 cases with AC-P and 1 case of small basaloid nests. Perineural and vascular invasion was seen in 2 basal cell carcinomas with large basaloid nests. Mitoses ranged from 0 to 60/10 hpf (mean=4). bcl2 was diffusely positive in 22/24 (92%) cases. Ki67 ranged from 2% to 80% (mean=23%). Ki67 > or =20% was seen in 13 (56.5%) cases, including all patterns except small solid nests. Basal cell markers (HMWCK, p63) either: (1) highlighted multiple layers of cells in 15/25 (60%) cases with sparing of the inner most luminal layer; (2) labeled just the outermost layers in 6/25 (24%) cases; or (3) reacted with only a few scattered cells in 4/25 (16%) cases (3 with large solid nests with central necrosis, 1 with tubules and cords). Seven patients had RP with: 5/7 showing extraprostatic extension with 1/5 also showing seminal vesicle involvement and 2/5 also with a positive margin; 1/7 having organ confined disease; and 1/7 showing no residual disease. An additional 11 cases showed extraprostatic extension on TURP with bladder neck invasion (n=10) or periprostatic adipose tissue invasion (n=1). Of 29 (65.5%) cases, 19 had follow-up > 1 year with a mean of 4.3 years (1 to 19 y). Of 19 (77%) cases, 14 had no evidence of disease after 1 to 19 (mean 5.8) years. Of 19 patients, 4 locally recurred with 2 after TURP, 1 after enucleation, and 1 after RP. Metastases developed in 4/29 patients: 1 in lung, 1 in lung and liver, 1 in lung, bone and liver, 1 in penile urethra. Basal cell carcinomas are rare tumors with a broad morphologic spectrum. These tumors predominantly show an indolent course with local infiltrative behavior. A small subset behaves aggressively with local recurrences and distant metastases. The most common morphology among those with an aggressive behavior is large solid nests more often with central necrosis, high Ki67%, and less staining with basal cell markers.

11C‐Choline positron‐emission tomography/computed tomography and transrectal ultrasonography for staging localized prostate cancer

To evaluate and compare the role of (11)C-choline positron emission tomography (PET) and transrectal ultrasonography (TRUS) in the preoperative staging of clinically localized prostate cancer. Fifty-five consecutive patients with biopsy-confirmed prostate cancer had TRUS and (11)C-choline PET as a part of their clinical staging programme before radical retropubic prostatectomy (RP). The PET images were prospectively interpreted by a consensus decision of two nuclear medicine physicians and one radiologist with special expertise in the field. The TRUS was done by one experienced urologist. The criteria evaluated prospectively in each patient were extracapsular extension (ECE), seminal vesicle invasion (SVI) and bladder neck invasion (BNI). The results were compared with the histopathological findings after RP. At pathology, 32 patients were classified pT2, 16 as pT3a and three had pT3b lesions. In four patients the histopathological examination showed pT4 with BNI. The overall accuracy of PET in defining local tumour stage (pT2 and pT3a-4) was 70%; the overall accuracy by TRUS was 26%. PET was more sensitive than TRUS for detecting ECE (pT3a) and SVI (pT3b) in advanced stages, and in pT4 stages. The sensitivity and positive predictive value (PPV) (95% confidence interval) in stages pT3a-pT4 for PET were 36 (17-59)% and 73 (39-89)%. The sensitivity and PPV in stages pT3a-pT4 for TRUS were 14 (3-35)% and 100 (29-100)%. (11)C-choline PET and TRUS tended to understage prostate cancer. This series shows the current limited value of TRUS and PET for making treatment decisions in patients with clinically localized prostate cancer, especially if a nerve-sparing RP is considered. Treatment decisions should not be based on TRUS and (11)C-choline PET findings alone. In future studies, the combination of metabolic and anatomical information of PET and endorectal magnetic resonance imaging should be evaluated, as this might optimize the preoperative staging in prostate cancer.