Rate Of Extracapsular Extension Research Articles

The tumor volume after radical prostatectomy and its clinical impact on the prognosis of patients with localized prostate cancer

We evaluated the contribution of tumor volume (TV) to localized prostate cancer (PCa) patients’ prognosis. We retrospectively analyzed the data of 2394 patients who underwent radical prostatectomy (RP) for localized PCa. The effect of TV and tumor prostate ratio (TV/PV) on PCa patients' prognosis was analyzed through Kaplan–Meier and Cox-proportional analysis. The mean prostate volume for all patients was 36.5 ± 15.4 cc, and the mean TV was 5.9 ± 8.3 cc. A significant positive relationship was observed between the classification by risk group in D’ Amico risk classification and the National Comprehensive Cancer Network risk group (P < 0.001). The high TV showed significantly worse pathologic outcomes than the low TV in terms of high rates of extra-capsular extension, seminal vesicle invasion, and positive surgical margin (P < 0.05). The patients with high TV and TV/PV had significantly shorter biochemical recurrence-free survivals than those with low TV and TV/PV (P < 0.001). Finally, based on multivariate Cox-proportional analyses, TV and TV/PV was an independent predictor to predict shorter biochemical recurrence-free survival as both a TV (HR: 1.04, 95% CI 1.04–1.05, P < 0.001) and TV/PV (HR: 1.42, 95% CI 1.13–1.78, P = 0.003). TV was revealed to be an independent prognostic factor in the postoperative biochemical recurrence. Patients with a high number of positive core and longer tumor length were significantly related to higher TV.

Intra-mammary lymph nodes, an overlooked breast cancer prognostic tool?

BackgroundDue to the high variability of incidence and prevalence of intra-mammary lymph nodes (IMLNs), they might be overlooked during clinical and radiological examinations. Properly characterizing pathological IMLNs and detecting the factors that might influence their prevalence in different stages of breast cancer might aid in proper therapeutic decision-making and could be of possible prognostic value.MethodsMedical records were reviewed for all breast cancer patients treated at the National Cancer Institute of Cairo University between 2013 and 2019. Radiological, pathological, and surgical data were studied.ResultsIntra-mammary lymph nodes were described in the final pathology reports of 100 patients. Five cases had benign breast lesion. Three cases had phyllodes tumors and two cases had ductal carcinoma in situ (DCIS). All ten cases were excluded. The remaining 90 cases all had invasive breast cancer and were divided into two groups: one group for patients with malignant IMLNs (48) and another for patients with benign IMLNs (42). Pathological features of the malignant IMLN group included larger mean tumor size in pathology (4.7 cm), larger mean size of the IMLN in pathology (1.7 cm), higher incidence of lympho-vascular invasion (65.9%), and higher rate of extracapsular extension in axillary lymph nodes (57.4%). In addition, the pathological N stage was significantly higher in the malignant IMLN group.ConclusionClinicians frequently overlook intra-mammary lymph nodes. More effort should be performed to detect them during preoperative imaging and during pathological processing of specimens. A suspicious IMLN should undergo a percutaneous biopsy. Malignant IMLNs are associated with advanced pathological features and should be removed during surgery.

The impact of perivesical lymph node metastasis on clinical outcomes of bladder cancer patients undergoing radical cystectomy

BackgroundPerivesical lymph nodes (PVLNs) are occasionally isolated during grossing of cystectomy specimens. However, the prognostic implications of the involvement of PVLNs in bladder cancer patients, especially those with comparisons to pN0 disease, remain poorly understood.MethodsA retrospective review identified 115 radical cystectomy cases where PVLNs had been histologically assessed. These cases were then divided into 4 groups – Group 1 (n = 76): PVLN-negative/other pelvic lymph node (non-PVLN)-negative; Group 2 (n = 5): PVLN-positive/non-PVLN-negative; Group 3 (n = 17): PVLN-negative/non-PVLN-positive; and Group 4 (n = 17): PVLN-positive/non-PVLN-positive.ResultspT stage at cystectomy was significantly higher in Group 3 (P = 0.013), Group 4 (P < 0.001), Groups 2 and 4 (P < 0.001), or Groups 2–4 (P < 0.001) than in Group 1. However, the number of positive PVLNs (mean: 1.8 vs. 2.1; P = 0.718) or the rate of extracapsular extension in the PVLNs (40% vs. 65%, P = 0.609) was not significantly different between Group 2 and Group 4. Kaplan-Meier analysis and log-rank test revealed significantly (P < 0.05) higher risks of disease progression (Group 3/Group 4), cancer-specific mortality (Group 2/Group 3/Group 4), and overall mortality (Group 4), compared with Group 1. Multivariate analysis further showed metastasis to both PVLN and non-PVLN (Group 4), PVLN (Groups 2 and 4), or PVLN and/or non-PVLN (Groups 2–4) as an independent prognosticator for cancer-specific mortality and overall survival. There were also insignificant (P = 0.096) and significant (P = 0.036) differences in cancer-specific survival and overall survival, respectively, between Group 3 versus Group 4, and the trend of the latter was confirmed by subset multivariate analysis (hazard ratio = 3.769; P = 0.099).ConclusionsWorse prognosis was observed in bladder cancer patients with isolated PVLN metastasis (vs. pN0 disease especially for cancer-specific survival), PVLN metastasis with or without non-PVLN metastasis (vs. pN0 disease), and concurrent PVLN and non-PVLN metastases (vs. PVLN-negative/non-PVLN-positive disease especially for overall survival). These findings indicate the importance of thorough histopathological assessment of PVLNs in radical cystectomy specimens.

An updated approach to incremental nerve sparing for robot-assisted radical prostatectomy.

To update the algorithm for performing incremental nerve sparing (NS) using our multiparametric magnetic resonance imaging (mpMRI)-based nomogram. We applied the coefficients of the nomogram to the observations extracted from our population of patients who underwent robot-assisted radical prostatectomy between February 2014 and October 2015 and who received preoperative mpMRI. The information considered were PSA level, highest side-specific biopsy Gleason grade group, highest ipsilateral percentage core involvement with the highest Gleason grade group, and extracapsular extension (ECE) on mpMRI. The nomogram-derived probability [P (%)], after internal validation, was used as the independent variable on a classification tree to identify the most significant thresholds for ECE prediction. Incremental NS was performed as follows: Grade 1 NS: intrafascial dissection between the peri-prostatic veins and the pseudocapsule of the prostate; Grade 2 NS: inter-fascial dissection along the peri-venous plane; Grade 3 NS: inter-fascial dissection through the outer compartment of the lateral prostatic fascia; Grade 4 NS: extrafascial dissection. Data from 561 patients were considered, and 829 prostatic lobes with biopsy-documented tumour were analysed. Overall, 142 lobes presented ECE that was focal in 27 (19%) cases. The classification tree identified four risk categories. In the low- [P (%) ≤10], intermediate- [P (%) 10-21], high [P (%) 21-73] and very-high-risk [P(%) >73] groups, the ECE rates were 3.3%, 16%, 61.6% and 90%, respectively. Amongst those, ECE was focal in 41.7%, 31.7%, 7.9% and 0%, respectively. We suggest that Grade 1 NS (intrafascial) should be performed in the low-risk group. The inter-fascial approach, namely grades 2 and 3 NS, should be performed in the intermediate- and high-risk categories, respectively. Grade 4 NS (extrafascial) should be performed in the very-high-risk group. The current algorithm yields a better accuracy than the previous one; however, prospective validation is warranted.

Outcomes of men aged ≤50 years treated with radical prostatectomy: a retrospective analysis.

Previous studies investigating prostate cancer (PCa) features in younger men have reported conflicting findings. This study aimed to investigate pathologic outcomes and biochemical recurrence (BCR) status in younger men who underwent radical prostatectomy (RP) for PCa. Records of 2057 patients who underwent RP at Seoul National University Bundang Hospital (Seongnam, Korea) between 2006 and 2015 were reviewed; patients were divided according to age into the younger and older groups (men aged ≤50 and >50 years, respectively). Postoperative BCR status and functional outcomes and clinicopathologic features were compared between both groups. All analyses were repeated after propensity score matching. Younger men were more likely to have low-risk disease (P < 0.001), lower pathologic Gleason score (P < 0.001) and pathologic stages (P < 0.001) than older men. The pathologic Gleason score (P = 0.002) and rates of extracapsular extension (P = 0.004) were lower in younger men after propensity score matching. In multivariate analysis, age at RP was not an independent predictor of BCR-free survival after RP (P = 0.669). Moreover, at 1 year after RP, younger men with preoperative 5-item International Index of Erectile Function score ≥22 (n = 228) showed more favorable results for urinary continence (defined as nonuse of pads daily) (99.4% vs 95%, P = 0.009) and erections sufficient for vaginal intercourse (81.8% vs 55.5%, P = 0.001). Younger men had more favorable clinicopathologic features at RP than their older counterparts. Although age was not an independent predictor of BCR status outcome, younger men had better functional outcomes following RP.

Elevated preoperative neutrophil-lymphocyte ratio predicts upgrading at radical prostatectomy.

Neutrophil-lymphocyte ratio (NLR) is a widely used, representative marker of systemic inflammatory response within the body. NLR can be calculated from simple, inexpensive peripheral blood samples. High NLR is a negative prognostic factor in a variety of malignancies including urological tumors. In this study, we aim to assess the prognostic value of preoperative neutrophil- lymphocyte ratio (NLR) in patients treated with radical prostatectomy (RP) for localized prostate cancer (PCa). Records of 7426 patients were retrospectively analyzed from prospectively collected datasets. A cut-off point of 3 was taken for NLR based on ROC analyses and previous literature. 23% (n = 1707) of patients had an NLR of ≥3. Patients with NLR ≥3 were more likely to harbor unfavorable pathological features such as higher biopsy Gleason score (GS), higher RP GS, higher rates of extra capsular extension, nodal involvement (all p < 0.001) and positive surgical margins (p = 0.002). On multivariable analyses, NLR ≥ 3 was associated with higher RP GS (OR 2.32; p < 0.001), seminal vesicle invasion (OR 1.60; p < 0.001) and nodal involvement (OR 1.43; p < 0.001). On multivariable analyses, NLR ≥ 3 was significantly associated with GS upgrading at RP (OR 1.39 p < 0.001). During a median follow up of 45 months, NLR ≥ 3 was associated with higher risk of BCR (p = 0.001). However, on multivariable Cox regression analysis such association was not shown (HR 0.86; p = 0.4). Preoperative NLR ≥ 3 was associated with aggressive PCa, such as upgrading at RP. Even though its effect on clinical-decision making seems to be limited when all clinical and pathological confounders are taken into account, preoperative NLR may still be useful in selected patients to identify aggressive PCa helping patient selection for active surveillance protocols. Conversely, it does not predict BCR when adjusted for the effect of pathological features.

Comparison of Clinical Outcomes of Different Radiation Strategies in Postoperative Radiation Therapy for Patients with Head and Neck Squamous Cell Carcinoma: A Propensity-Score Matched Analysis

Postoperative radiotherapy (PORT) may be useful for head and neck squamous cell carcinoma patients (HNSCC) with pathological risk factors. We previously reported an unfavorable loco-regional control rate (LRC) after limited field (LF)-PORT. Thus, we changed our strategy to cover the whole neck (WN-PORT) region and retrospectively analyzed the outcomes of HNSCC patients to compare the efficacy of the two different strategies. Before 2010, the clinical target volume covered the tumor bed without including the lymph node region for close/positive margin cases and only involved the neck region for multiple nodes and/or extracapsular extension (ECE). Since 2011, whole neck irradiation was planned with 3D conformal RT or intensity-modulated radiation therapy. Univariate analysis, multivariate analysis, and propensity-score matched analysis were performed. The study included 275 patients: 186 received LF-PORT and 89 received WN-PORT. The median follow-up for the entire cohort was 40.8 months (range, 2.3–172 months), 46.9 months for LF-PORT and 27.9 months for WN-PORT. Patient characteristics of the entire cohort were balanced in terms of age, sex, primary site, and pathological stage. However, the rates of ECE, positive surgical margin, and poor differentiation were significantly larger in the WN-PORT group. The 2-year overall survival rate (OS), progression-free survival rate (PFS), and LRC for the entire cohort were 66.8%, 49.7%, and 70.4%, respectively. In univariate analysis, favorable factors for OS were the tumor site, pTstage, pNstage, ECE, and pathological differentiation. Although the radiation strategy did not have a significant effect on either OS (P = .106) or PFS (P = .087), the WN-PORT group had a significantly better LRC (HR, 0.38; 95% CI, 0.21–0.67; P < .001). In multivariate analysis, unfavorable factors for OS were advanced pTstage and pNstage, high risk (ECE and/or close/positive margin), poorly differentiated tumor, having previous curative surgery, and LF-PORT; WN-PORT was a favorable factor for OS (HR, 0.49; 95% CI, 0.31–0.78; P = .003). Propensity-score matching resulted in a cohort consisting of 118 patients who were well matched and divided evenly between LF-PORT (n = 59) and WN-PORT (n = 59). The WN-PORT group had significantly better 2-year OS (56.4% vs 78.1%; HR, 0.410; 95% CI, 0.223-0.751; P = .003), 2-year PFS (34.7% vs 59.8%; HR, 0.523; 95% CI, 0.320-0.856; P = .009), and 2-year LRC (54.4% vs 83.2%; HR, 0.279; 95% CI, 0.136-0.573; P < .001). The WN-PORT group had a higher incidence of G3 late toxicity for any site (6.8% vs 17%), bone (3.4% vs 6.8%), and pharynx and esophagus (3.4% vs 6.8%) in the matched-pair cohort. WN-PORT is a more appropriate choice than LF-PORT for improving LRC, PFS, and OS, although it is associated with an acceptable increase in late toxicities of Grade 3 or greater. Thus, we recommend WN-PORT especially for HNSCC patients with ECE or a close/positive margin.

Normal Central Zone of the Prostate and Central Zone Involvement by Prostate Cancer: Clinical and MR Imaging Implications

To describe the anatomic features of the central zone of the prostate on T2-weighted and diffusion-weighted (DW) magnetic resonance (MR) images and evaluate the diagnostic performance of MR imaging in detection of central zone involvement by prostate cancer. The institutional review board waived informed consent and approved this retrospective, HIPAA-compliant study of 211 patients who underwent T2-weighted and DW MR imaging of the prostate before radical prostatectomy. Whole-mount step-section pathologic findings were the reference standard. Two radiologists independently recorded the visibility, MR signal intensity, size, and symmetry of the central zone and scored the likelihood of central zone involvement by cancer on T2-weighted MR images and on T2-weighted MR images plus apparent diffusion coefficient (ADC) maps generated from the DW MR images. Descriptive summary statistics were calculated for central zone imaging features. Sensitivity, specificity, and area under the curve were used to evaluate reader performance in detecting central zone involvement. For readers 1 and 2, the central zone was visible, at least partially, in 177 (84%) and 170 (81%) of 211 patients, respectively. The most common imaging appearance of the central zone was symmetric, homogeneous low signal intensity. Cancers involving the central zone had higher prostate-specific antigen values, Gleason scores, and rates of extracapsular extension and seminal vesicle invasion compared with cancers not involving the central zone (P < .05). Area under the curve, sensitivity, and specificity in detecting central zone involvement were 0.70, 0.30, and 0.96 for reader 1 and 0.65, 0.35, and 0.93 for reader 2, and these values did not differ significantly between T2-weighted imaging and T2-weighted imaging plus ADC maps. The central zone was visualized in most patients. Cancers involving the central zone were associated with more aggressive disease than those without central zone involvement.

Robotic Radical Prostatectomy for Patients with Locally Advanced Prostate Cancer Is Feasible: Results of a Single-Institution Study

The aim of this study was to compare the outcomes of robotic prostatectomy (RP) in patients with clinically localized or locally advanced prostate cancer (PC). Between July 2005 and February 2008, we performed RP in 357 patients by using the da Vinci robot system and a transperitoneal approach. We defined locally advanced PC as cases with a clinical T-stage >/=T3a with any serum prostate-specific antigen (PSA) or Gleason score. Among the 321 men not treated with neoadjuvant hormonal therapy, 200 patients had clinically localized PC and 121 patients had locally advanced PC. We compared perioperative variables and early surgical outcomes between the two groups. Although advanced PC patients had significantly higher mean preoperative PSA levels, prostatectomy Gleason scores, and extracapsular extension rates, there were no significant differences in mean operation time, estimated blood loss, duration of bladder catheterization, hospital stay, or initiation of a regular postoperative diet between the two groups. Except for some early cases, a bilateral extended lymphadenectomy was performed without difficulty in both groups. Although both the frequency of lymph node invasion and the positive surgical margin rates were higher in the advanced PC patients, the positive surgical margin rate (48.8%) in the present study was similar to those of open radical retropubic prostatectomy in other studies. The overall complication rate did not differ between the two groups. Two intraoperative rectal injuries occurred in patients with locally advanced PC and were closed primarily without specific problems, except for 1 case. Our results suggest that RP may be performed safely on patients with locally advanced PC.

The effect of surgical volume on the rate of secondary therapy after radical prostatectomy

15620 Introduction and Objective: Some argue that prostate cancer (PCa) detection and treatment at a younger age may translate into higher rate of clinically insignificant PCa. We assessed the effect of patients age at diagnosis on the pathological stage at radical prostatectomy (RP). Methods: Clinical and pathological data were available for 11975 patients from 3 European and 3 North American tertiary care centers. All RPs were performed between 1987 and 2006. Univariable and multivariable logistic regression analyses addressed the effect of age at RP on the rate of extracapsular extension (ECE), seminal vesicle invasion (SVI) and lymph node invasion (LNI), after controlling for PSA, clinical stage, biopsy Gleason sum and year of surgery. Age at RP was coded as cubic spline to allow non-linear effects. Results: Mean age was 61.6 years (range 32–85) and mean PSA was 8.7 ng/mL (range 0.1–50.0). Biopsy Gleason sum was 2–6, 7 or 8–10 in 7510 (62.7%), 3656 (30.5%) and 809 (6.8%) patients, respectively. At RP, ECE, SVI and LNI were identified in 3383 (28.3%), 1309 (10.9%) and 469 (3.9%), respectively. In multivariable analyses, age was only an independent predictor of SVI (p&lt;0.001). Older men had a higher rate of SVI. Conclusions: Pathological age only affects the rate of SVI. However, only one in ten men harbored SVI and this percentage may decrease even further with ongoing stage migration. Nonetheless, these data suggest that the removal of seminal vesicles should not be omitted in older men. No significant financial relationships to disclose.