Importance of early treatment of transitional cell carcinoma of prostatic ducts

Utility of D2-40, Cytokeratin 5/6, and High-Molecular-weight Cytokeratin (Clone 34βE12) in Distinguishing Intraductal Spread of Urothelial Carcinoma From Prostatic Stromal Invasion

Intraductal spread of urothelial carcinoma (UC) is not an uncommon finding in bladder cancer that requires appropriate clinical management. The presence of prostatic stromal invasion in non-muscle-invasive bladder cancer upstages the disease, necessitating cisplatin-based neoadjuvant chemotherapy and subsequent cystroprostatectomy. However, the identification of prostatic stromal invasion can be challenging, especially in biopsy and transurethral resection specimens. We assess the utility of D2-40, CK5/6, and high-molecular-weight cytokeratin (HMWCK) immunohistochemistry as an ancillary tool to differentiate prostatic stromal invasion from intraductal UC spread. We reviewed 13 cystoprostatectomies performed for UC with prostatic involvement. The presence of stromal invasion was histologically determined by the presence of circumferential retraction artifact, paradoxical differentiation, complex architecture, and desmoplastic reaction. The areas of interest were subsequently stained with D2-40, CK5/6, and HMWCK (clone 34βE12). Four bladder biopsies were used as a control to assess labeling in the benign urothelium. Nine cases had histologic evidence of prostatic stromal invasion (4 transmurally through bladder wall). D2-40 highlighted basal cells in all benign prostatic ducts and was consistently negative in UC, benign urothelium, prostatic adenocarcinoma, and benign luminal prostatic epithelium. D2-40 and CK5/6 performed similarly for intraductal UC, labeling only the basal cell layer with the exception of 1 case with squamous differentiation where CK5/6 exhibited full thickness staining. HMWCK diffusely stained 9 of 10 intraductal UCs without squamous differentiation and 1 intraductal UC with squamous differentiation. All 8 cases of invasive UC without squamous differentiation were negative for D2-40. Seven of these cases had focal CK5/6 and diffuse HMWCK staining. In 1 case of invasive UC with squamous differentiation, all stains were positive. D2-40 is expressed in prostatic basal cells, but it is not expressed in the benign or neoplastic urothelium. D2-40 and CK5/6 effectively highlight the intraductal spread of UC. While invasive UC is negative for D2-40, CK5/6 is usually patchy and localized to the periphery of the tumor nests. HMWCK often demonstrates diffuse staining in both scenarios. However, these stains do not perform well in cases of UC with squamous differentiation. Thus, D2-40 can be used as an ancillary tool to rule out prostatic stromal invasion.

Prostatic urethra recurrence after transurethral resection of bladder tumor (TURBT) for non-muscle-invasive bladder cancer (NMIBC)

Urinary bladder cancer is frequently multifocal and has a high incidence of recurrence. Although the prostatic urethra is a frequent site of tumor relapse in patients with non-muscle-invasive bladder cancer treated with TURBT, such tumors are often underdiagnosed. Here we present two cases having urethral recurrence after TURBT.

The occult urothelial cancer

Transitional cell carcinoma (TCC) is the tumor that most frequently affects the urinary tract. The most common location is in the bladder; the diagnosis, as the follow-up, is based on urine cytology, endoscopic, and radiological examinations. Urinary cytology is an important non invasive tool used in the diagnosis and follow-up of patients with TCC. A positive urine cytology result is highly predictive of the presence of TCC, even in the presence of normal cystoscopy, because malignant cells may appear in the urine long time before any cystoscopically visible lesion becomes apparent. The presence of a positive urinary cytology, in the absence of clinical or endoscopic evidence of a TCC, can identify an occult urothelial cancer, located in any site of the urinary tract (upper urinary tract, bladder, prostatic urethra). Most of the urothelial tumors of the renal pelvis and ureters are diagnosed by radiological examinations, but we can observe a high rate of false negatives. In order to improve the diagnostic role of urinary cytology and other conventional examinations, numerous molecular markers have been identified; however, the real clinical application remains unclear. Photodynamic diagnosis and narrow band imaging (NBI) cystoscopy increase the diagnostic accuracy of endoscopic examinations in the presence of lesions not easily detectable. The aim of this review is to analyze the current diagnostic standards in the presence of occult urothelial cancer.

A rare cause of testicular metastasis: upper tract urothelial carcinoma

Metastatic testicular cancers are rare. Primary tumor sources are prostate, lung, and gastrointestinal tract for metastatic testicular cancers. Metastasis of urothelial carcinoma (UC) to the testis is extremely rare. Two-thirds of upper tract urothelial carcinoma (UTUC) is of invasive stage at diagnosis and metastatic sites are the pelvic lymph nodes, liver, lung, and bone. We report a rare case of metastatic UTUC to the testis which has not been reported before, except one case in the literature. Testicular metastasis of UC should be considered in patients with hematuria and testicular swelling.

The conundrum of prostatic urethral involvement

The presence and depth of urothelial cancer involvement in the prostatic urethra can significantly affect the management of a patient with non-muscle invasive bladder cancer. This article presents an overview of the incidence, diagnosis, management, and follow-up of urothelial cancer.

Pathologic assessment and clinical significance of prostatic involvement by transitional cell carcinoma and prostate cancer

The prostate is commonly involved by transitional cell carcinoma (TCC) in patients with bladder cancer. A number of clinicopathologic factors including multifocal carcinoma in situ, tumor location, and tumor stage are associated with prostatic TCC (pTCC). In addition, the manner and extent of pathologic examination also makes a significant difference in the detection rate. Distinct patterns and extent of pTCC have been described and are associated with pathologic stage of the primary bladder tumor as well as prognosis. Preoperative transurethral biopsy of the prostatic urethra is a sensitive and accurate method to detect pTCC and is helpful for surgical planning. Given the high incidence of pTCC and prostatic adenocarcinoma, radical cystoprostatectomy is the treatment of choice for loco-regional control for patients with T4a disease. Further studies are necessary to establish the role of neoadjuvant and adjuvant therapy for patient with prostatic stroma invasion.

Prostatic transitional cell carcinoma: pathologic features and clinical management

Prostatic involvement by transitional cell carcinoma (pTCC) in patients with bladder cancer is a frequent finding, particularly in patients with high-grade invasive tumor and urothelial carcinoma in situ. Various patterns and levels of prostatic involvement have been described, and their impact in patients' management and their prognosis recognized. The role of prostatic urethral biopsy and intraoperative frozen section in the management of bladder cancer, tailoring to the bladder tumor stage is still not well defined and universally accepted. This review discusses the current understanding of the biology and histological patterns of pTCC and their clinical significance and management options. A rational approach for management of pTCC in patients with bladder cancer will be proposed on the basis of our experience and our review of literature.

Transitional Cell Carcinoma of the Prostate

Transitional cell carcinoma of the prostate (TCCP) has become a well recognized entity, showing an increasing incidence due to the growing research awareness. TCCP is part of the well known pan-urothelial disease: the urologist, therefore, is strongly recommended to consider the prostate at any time in the management of superficial and invasive bladder cancer. Several cases are diagnosed in association with bladder cancer (secondary TCCP): primary prostatic transitional cell carcinoma arises ‘de novo’ as first tumour of the prostate urothelium and is rare. Prognosis depends on the prostate invasion degree. No reliable staging systems are presently available. Non-invasive TCCP can be successfully treated with conservative means (TUR +/- BCG), whereas stromal invasive TCCP must be aggressively treated with radical cystectomy. TCCP can interphere with surgeon's decisions about urinary diversion in patients undergoing radical cystectomy for urothelial cancer. (Urologia 2007; 74: 15–21)

Testicular metastasis of transitional cell carcinoma of the urinary bladder: An unusual site

We present a 74-year-old man with a testicular metastasis originating from a transitional cell carcinoma of the urinary bladder. Initially, radical cystectomy and ileal-conduit urinary diversion were performed. Three years later, he presented with a tumor in the left testicle, proved to harbor transitional cell carcinoma.

Prostatic involvement by transitional cell carcinoma in patients with bladder cancer and its prognostic significance

To study the importance of prostatic involvement by transitional cell carcinoma (TCC) in patients with bladder cancer, we examined the entire prostates by whole-mount sections from 214 radical cystoprostatectomy specimens for detailed patterns of involvement by TCC and correlated the results with lymph node metastasis and patients' survival. Prostatic involvement by TCC was detected in 69 (32%) of 214 cases. Among them, 30 (43%) patients had carcinoma in situ (CIS) and the other 39 (57%) were invasive TCC. Carcinoma in situ occurred in either prostatic urethra (n = 6, 20%) or, more commonly, in prostatic ducts/acini (n = 14, 47%), and in a combination of prostatic urethra and ducts (n = 10, 33%). Ten (26%) of the invasive TCC resulted from direct penetration from the primary tumor in the bladder, and the remaining 29 (72%) cases arose from prostatic urethra/ducts, of which 11, 13, and 5 invaded the lamina propria, prostatic stroma, and periprostatic or seminal vesical tissue, respectively. Both prostatic TCC involvement and nodal metastasis were highly significant prognostic factors for patients' survival and the survival significance of prostatic TCC involvement still existed regardless of lymph node status. Furthermore, the presence of prostatic CIS and degrees of prostatic invasion are associated with nodal metastasis and survival. Patients with prostatic CIS or urethral lamina propria invasion had a similar, but higher incidence of lymph node metastasis and lower long-term and 5-year survival than those patients without prostatic involvement. Similarly, prostatic stromal invasion and periprostatic/seminal vesical invasion had a similar, but much higher nodal metastasis and worse survival than patients with only prostatic CIS or urethral lamina propria invasion. In summary, presence of prostatic TCC involvement and levels of involvement are significant prognostic factors in patients with bladder cancer.

Intravesical Instillations with Bacillus Calmette-Guérin for the Treatment of Carcinoma In Situ Involving Prostatic Ducts

OBJECTIVES

Bacillus Calmette-Guérin (BCG) has proven its efficacy in the treatment of carcinoma in situ (CIS) of the prostatic urethra. We performed a retrospective study to evaluate the use of intravesical instillations of BCG in patients with carcinoma in situ involving prostatic ducts after complete transurethral resection (TUR).

MATERIAL AND METHODS

Eligibility for the study was CIS of the prostatic urethra involving prostatic ducts. Previous instillation with BCG was an exclusion criterion. Patients were treated with intravesical BCG Connaught (81 mg) administered once a week, over a 6-wk period. TUR loop biopsies of the prostate were performed only when a macroscopic tumor was present.

RESULTS

In this retrospective study of 11 patients, 8 (73%) presented with macroscopic tumor in the prostatic urethra. Ten patients (91%) had a simultaneous superficial bladder carcinoma. Eight patients (73%) had tumoral involvement of the bladder neck region. After a median follow-up of 27 mo (n=10 patients), the response in the prostatic urethra was 82%, and the response in the bladder due to superficial tumor recurrence was 64%. Two patients with residual ductal disease in the prostatic urethra were subsequently treated with cystoprostatectomy and are currently free of disease. In one of those patients, the cystoprostatectomy specimen did show prostatic stromal invasion. Another patient developed distant metastatic disease and died a few months after diagnosis. Thus, progression was encountered in two patients (18%). Currently, 90% of patients are alive without evidence of disease and 72.7% have benefitted from this bladder preservation strategy.

CONCLUSION

Intravesical BCG is a feasible treatment option for patients with CIS involving prostatic ducts. In this retrospective study, bladder preservation was successful in 8 of 11 patients (70%) and there was only one oncologic death. Obviously, these patients need a careful follow-up with cystoscopy and cytology to detect either recurrence or progression and in those with persistent disease after the initial BCG induction therapy, prompt cystectomy is indicated.

[Primary transitional carcinoma of the prostatic ductus]

Primary prostate transitional cell carcinoma is a very rare tumour originating in the transitional epithelial cells of the intraprostate periurethral ductus. Only 17 of 829 patients diagnosed with prostate carcinoma were found to have the transitional cell variety. Eight (8) of those had pure transitional cell carcinoma and 9 a mixed presentation of acinar adenocarcinoma and transitional cell ductal carcinoma. Bladder origin of the tumour was ruled out in all cases. We report a retrospective study on the clinical behaviour of prostate transitional cell carcinoma. Compared to acinar carcinomas, few differences were found when age, symptoms, physical findings and imaging diagnosis were evaluated. Clinical presentation, DRE, PSA, metastatic spread and presence of supravesical obstructive uropathy where also studied to establish a diagnosis. Radiotherapy was the most frequently used therapeutical approach. Mean survival is 26.6 months (4-60 months) and there has been 11 death up to now. Compared to acinar forms, this tumour shows a hormone-resistant, aggressive biological behaviour with poor prognosis. Early diagnosis and radical surgery are the only options available to increase life expectancy for these patients.

Does prostate transitional cell carcinoma preclude orthotopic bladder reconstruction after radical cystoprostatectomy for bladder cancer?

PURPOSE

We determined if urethral preservation and orthotopic bladder replacement in patients with transitional cell carcinoma within the prostatic urethra or prostate placed these patients at risk for urethral recurrence or death.

MATERIALS AND METHODS

The clinical course of all patients undergoing urethral preservation and orthotopic bladder replacement was reviewed. The urethra was sacrificed only if the distal prostatic urethral margin was positive for transitional cell carcinoma. The pathological T stage and the grade of the primary malignancy, local recurrence, site of recurrence (urethral, pelvic, distant) and death were documented.

RESULTS

Of 81 patients 70 were evaluable (June 1996) with a mean followup of 35 months. Of the 70 patients 48 were alive without evidence of disease for a mean of 38 months (range 8 to 107) and 5 died without evidence of disease. Eight of these 53 patients (15%) had prostatic involvement (carcinoma in situ in 6, intraductal carcinoma in 1 and stromal invasive transitional cell carcinoma in 1). Of the 70 patients 17 had disease recurrence (13 died of disease and 4 are alive, 1 of whom had urethral recurrence without initial prostatic transitional cell carcinoma). Of the 17 patients (35%) 6 had transitional cell carcinoma prostatic involvement (carcinoma in situ in 4 and stromal invasion in 2), and 5 of these 6 died, none with or of urethral recurrence but of the primary bladder pathology. Of these 5 patients 1 had stromal invasive transitional cell carcinoma of the prostate and experienced a bulbar urethra recurrence at 1 month and a pelvic recurrence at 3 months, and died at 5 months. Death was not secondary to the urethral recurrence. Thus, of the 14 patients who had prostatic transitional cell carcinoma, only 1 had urethral recurrence (7%), and this recurrence did not present as the cause of death.

CONCLUSIONS

The guidelines for urethral resection can be relaxed, increasing the opportunities for orthotopic reconstruction, without placing the patients at increased risk for death of transitional cell carcinoma.

An adequate sampling of the prostate to identify prostatic involvement by urothelial carcinoma in bladder cancer patients

The distribution of any involved prostatic urethra, ducts and acini by urothelial carcinoma was studied to determine an adequate sampling method for detecting prostatic involvement using the maps of 38 cystoprostatectomy specimens. A total of 31 patients had prostatic duct and acini involvement, while 7 had prostatic urethral involvement alone. However, the distribution of the involved prostatic urethra, ducts and acini varied. In 29 of the 31 patients (93.5%) with prostatic duct and acini involvement, urethral carcinoma in situ and/or superficial gland involvement (an involvement of the afferent ducts within a few millimeters of the urethral mucosa) at the 5 and/or 7 o'clock position of the verumontanum portion was identified. In 7 patients with prostatic urethral involvement alone 2 had carcinoma foci at the 5 and/or 7 o'clock position of the verumontanum portion. Furthermore, the frequency of deeper gland involvement (an involvement of true prostatic acini except for superficial glands) was higher in patients with superficial gland involvement at the 5 and/or 7 o'clock position of the verumontanum portion (57.7%) than in patients without such involvement (20.0%). Therefore, this study emphasizes that a transurethral resection biopsy containing prostatic tissue at the 5 and/or 7 o'clock position of the verumontanum portion substantially improves the detection of prostatic duct and acini involvement in bladder cancer patients. Moreover, if the prostatic superficial glands are involved at the 5 and/or 7 o'clock position of the verumontanum portion, the potential involvement of the deeper glands should also be suspected.

Prostatic occurrence of transitional cell carcinoma after intravesical chemotherapy

Thirteen patients with Stage Tis, Ta, or T1 transitional cell carcinoma (TCC) of the bladder treated by transurethral resections and intravesical chemotherapy developed TCC of the prostate. Among the 13 cases, cytology specimens were obtained from 10 at the time prostatic disease was diagnosed; 9 demonstrated TCC. One was treated successfully by transurethral resection of a Ta lesion involving the prostatic urethra only. One of 2 patients declining radical surgery is alive with residual disease at twenty-four months, and the other died of progressive disease at nineteen months. Of the 10 patients who underwent radical cystoprostatectomy, 7 are alive with no evidence of disease eight to forty-two months postoperatively, with 2 of these 7 having received 4 courses of systemic methotrexate, vincristine, Adriamycin, and cisplatinum (MVAC) for metastatic disease. Two of the 10 died of metastatic disease six and thirteen months postoperatively, and one frail patient died of surgical complications. When treating patients with intravesical chemotherapy for superficial TCC, biopsy of the prostate should be done during follow-up examinations, especially in the presence of cytologic or palpable prostatic abnormalities.