Clinicopathologic Features of Prostate Adenocarcinoma Incidentally Discovered at the Time of Radical Cystectomy: An Evidence-Based Analysis

Clinicopathologic characteristics and outcomes of prostate cancer incidentally discovered at the time of radical cystoprostatectomy: a population-based cohort study

OBJECTIVE

This study aimed to comprehensively analyze the clinical characteristics and prognosis of patients with concomitant bladder cancer (BCa) and prostate cancer (PCa) using a large population-based database.

METHODS

Within the Surveillance, Epidemiology, and End Results (SEER) database (2000-2019), the authors identified patient with concomitant PCa at the time of radical cystoprostatectomy (RCP). Logistic regression and propensity score matching (PSM) analyses were employed to identify risk factors and mitigate confounders, respectively. Kaplan-Meier survival curves were used to estimate cancer-specific survival (CSS).

RESULTS

A total of 14 199 BCa patients undergoing RCP were identified, with 28.8% incidentally discovered to have concurrent PCa. Among them, 89.9% exhibited organ-confined (T1-2) PCa. An increased risk of concomitant tumors was observed among older age, white race, and high tumor grade of BCa. Survival analysis revealed no significant difference in CSS between patients with BCa alone and those with concurrent PCa (5-year CSS rate: 71.3 vs. 67.2%, P =0.076). Subgroup analysis and multivariable analysis, however, indicated that concurrent high-risk PCa adversely impacted survival (5-year CSS rate: 71.3 vs. 63.4%, HR 1.27, 95% CI: 1.01-1.58, P =0.038) compared to solitary BCa. Notably, the presence of low/intermediate-risk PCa did not affect survival outcomes ( P =0.584).

CONCLUSION

In conclusion, incidentally discovered PCa in RCP specimens is frequent and characterized by organ-confined presentation, lower PSA levels, and Gleason scores. Patients with concurrent high-risk PCa have a worse prognosis compared to those with solitary BCa, while the presence of low/intermediate-risk PCa does not influence oncological prognosis.

The role of single-nucleotide polymorphisms of the 8q24 chromosome region in patients with concomitant bladder and prostate cancer

OBJECTIVE

To assess whether single-nucleotide polymorphisms (SNPs) of the 8q24 chromosome region are associated with recurrence-free survival (RFS) after radical cystoprostatectomy (RC) in patients with concomitant bladder (BC) and prostate cancer (PC).

MATERIALS AND METHODS

A cohort of thirty-six patients treated with RC and pelvic lymph node dissection and histologically exhibited invasive BC and incidental PC. Using Sanger sequencing, a total of seven SNPs in the androgen-responsive element of the promoter region of the following genes were assessed in tumor-free lymph nodes and correlated with oncological outcomes: PSCA (rs2294008, rs2978974, rs1045531, rs3736001), MYC (rs6983267), FXBO32 (rs7830622), and MIR151A (rs14974929). The median follow-up was 26 months (range: 4-68).

RESULTS

In a dominant model, patients exhibiting rs2978974 as a minor allelic variant of the PSCA gene had worse RFS (32 vs. 75%, p = 0.015). No associations were found for the other SNPs.

CONCLUSIONS

These data suggest that the rs2978974 of the PSCA gene correlates with inferior BC-specific RFS after RC and should be further evaluated in larger studies.

Incidental prostate cancer in patients who underwent radical cystectomy for high risk non muscle invasive bladder cancer: Is it clinically significant?

INTRODUCTION AND OBJECTIVE

Non muscle invasive, high-risk, bladder cancer is an entity which is usually treated with radical cystectomy. Incidental prostate cancer refers to prostate cancer detected in radical cystectomy specimens in patients with no signs of the disease. Objective of this study is to report the prevalence, characteristics, and clinical significance of incidental prostate cancer in non-muscle invasive bladder cancer patients treated with radical cystectomy in our department.

MATERIAL AND METHODS

We retrospectively reviewed data from 41 patients who underwent radical cystectomy for non-muscle invasive, high risk, bladder cancer during the years 2016-2020 in our department. Prostate cancer was described as clinically significant when there were positive surgical margins, extraprostatic extension, Gleason score >6, or tumor volume ⩾0.5 cm³. Two groups of patients were formed according to the presence or absence of clinically significant prostate cancer.

RESULTS

Incidental prostate cancer in the cystectomy specimens was detected in 21 of the 35 patients investigated. Clinically significant prostate cancer was detected in five patients. Positive surgical margins and extraprostatic extension were present in one patient, respectively. Gleason score was more than six in four of the five patients and PCa tumor volume was above 0.5 cm³ in three patients. Two patients with clinically significant prostate cancer were diagnosed with biochemical recurrence during their follow up.

CONCLUSIONS

In non-muscle invasive, high-risk patients undergoing radical cystectomy, clinically significant incidental PCa is an important issue as it may affect prognosis, quality of life, metastasis free survival, and overall survival.

Overdiagnosis in urologic cancer : For World Journal of Urology Symposium on active surveillance in prostate and renal cancer

BACKGROUND

Cancer, which historically was diagnosed at late and incurable stages, has expanded to a heterogeneous group of conditions that vary from clinically insignificant to rapidly aggressive and lethal. This evolution is due to the widespread use of screening tests for early detection of cancer, both directed (i.e., PSA, mammography, colonoscopy) and undirected (abdominal imaging). The use of these tests has resulted in both benefits and harms. The benefits are a reduction in survival and mortality, due to significant cancers being diagnosed at a more curable stage. The harms are an increase, in some cases dramatic, in the diagnosis of clinically insignificant disease. These are called 'cancer' but not destined to affect the patient's life, even in the absence of treatment.

METHODS

Non-explicit summary of the literature on overdiagnosis of cancer.

RESULTS

The phenomenon of overdiagnosis requires two factors: the presence of a common reservoir of microfocal disease and a screening test to find it. These factors exist for breast, prostate, skin, renal, and thyroid cancers, and to a lesser degree for lung cancer. The problem of cancer overdiagnosis and overtreatment is complex, with numerous etiologies and many tradeoffs. It is a particular problem in prostate cancer but is a major issue in many other cancer sites. Screening for prostate cancer based on the best data from prospective randomized trials significantly reduces cancer mortality. However, reducing overtreatment in patients diagnosed with indolent disease is critical to the success of screening.

CONCLUSION

Active surveillance, the focus of this series of articles, is an important strategy to reduce overtreatment. This article reviews the pathological, clinical, social, and psychological aspects of overdiagnosis in cancer.

Long-term outcomes of incidental prostate cancer at radical cystectomy

OBJECTIVE

We evaluated the natural history and long-term outcomes of incidentally detected prostate cancer (PCa) at radical cystectomy (RC) for bladder cancer (BCa).

PATIENTS AND METHODS

We identified 1,640 male patients who underwent RC between 1992 and 2012. Patients were stratified as clinically insignificant and clinically significant PCa, based on Grade Group (GG) 1 and ≥2, respectively. Survival was assessed using the Kaplan-Meier method.

RESULTS

There were 329 (20%) patients with incidentally detected PCa at RC: 245 (15%) GG1, 52 (3.2%) GG2, 20 (1.2%) GG3, 6 (0.4%) GG4, and 6 (0.4%) GG5. Median follow-up among survivors was 9.6 years (interquartile range 7.5-13.3), during which time 253 patients died, of whom 127 died of BCa and 1 died of PCa. Nine patients experienced biochemical recurrence (BCR), 4 underwent salvage PCa therapies, and 2 developed PCa metastases. Patients with clinically significant PCa were significantly more likely to experience BCR (6% vs. 1.6%; P = 0.04) and had shorter median time to BCR (1.8 vs. 10.4 years; P = 0.01) than those with clinically insignificant PCa. No patients with BCR had greater than pT2N0 BCa or positive BCa margins. Ten-year PCa-specific survival, BCa-specific survival, other cause-specific survival, and overall survival were 99%, 57%, 63%, and 35%, respectively.

CONCLUSIONS

In a large RC series, we note a 20% rate of incidental PCa, the majority of which are clinically insignificant. On long-term follow-up, we determined that BCR and PCa mortality are extremely rare events among these patients. Pending validation, future guidelines may consider omission of PCa surveillance for some patients with incidental PCa at RC.

The diagnostic value of prostate cancer between holmium laser enucleation of the prostate and transurethral resection of the prostate for benign prostatic hyperplasia: A retrospective comparative study

BACKGROUND

To compare the diagnostic value of prostate cancer (PCa) between holmium laser enucleation of the prostate (HoLEP) and transurethral resection of the prostate (TURP).

METHODS

We retrospectively analyzed the clinical data of 2909 patients who underwent surgery for benign prostatic hyperplasia (BPH) from January 2008 to June 2018. A total of 1362 patients received HoLEP, and 1547 patients received TURP. The baseline patient characteristics were collected. We then compared the perioperative outcomes of these patients who diagnosed with incidentally diagnosed prostatic carcinoma (IDPC) or PCa after BPH surgeries.

RESULTS

The total detection rate of PCa in HoLEP group was higher than that in TURP group (85/6.24% vs. 61/3.94%, p = 0.005). Specifically, 55(4.6%) patients were diagnosed with IDPC in HoLEP group with prostate-specific antigen (PSA) less than 4 ng/ml, and 37(2.7%) patients in TURP group (p = 0.014). For the patients with PSA between 4 and 10 ng/ml, 15(13.9%) patients were diagnosed with PCa after HoLEP, and 6(5.0%) patients after TURP (p = 0.023). But the detection rate of PCa was not significantly different between the two groups when PSA was over 10 ng/ml. On the other hand, 57 in 1215 patients with no prostate biopsy preoperatively were diagnosed with PCa after HoLEP, while 42 in 1370 patients after TURP (4.7% vs. 3.1%, p = 0.040), respectively. Twenty-six patients received once biopsy and diagnosed with PCa in HoLEP group, while 15 patients in TURP group (18.4% vs. 8.9%, p = 0.018), respectively. However, no significant difference was observed for patients who received twice prostate biopsy in the two groups.

CONCLUSIONS

The present study showed that HoLEP can provide a higher total detection rate of PCa when compared with TURP. Besides, this superiority was especially embodied in patients with PSA less than 10 ng/ml.

Oncologic outcomes of patients with incidental prostate cancer who underwent RARC: a comparison between nerve sparing and non-nerve sparing approach

BACKGROUND

Incidental Prostate cancer (iPCa) is a relatively common finding during histopathological evaluation of radical cystectomy (RC) specimens. To reduce the high impact of RC on erectile function, several sexual-preserving techniques have been proposed. The aim of this study was to evaluate and compare the oncologic outcomes of patients with iPCa who underwent nerve spring and no-nerve sparing robot-assisted radical cystectomy (RARC).

METHODS

The clinicopathologic data of male patients who underwent RARC at our institution between 2006 and 2016 were retrospectively analysed. Patients with iPCa at definitive pathological examinations were stratified in two groups, according to the preservation of the neurovascular bundles (nerve sparing vs no nerve sparing). Significant PCa was defined as any Gleason score ≥ 3 + 4. Biochemical recurrence (BR) was defined as a sustained PSA level > 0.2 ng/mL on two or more consecutive appraisals. BR rate was assessed only in patients with incidental prostate cancer and at least 2 years of follow-up. Differences in categorical and continuous variables were analysed using the chi-squared test and the Mann-Withney U test, respectively. Biochemical recurrence curves were generated using the Kaplan-Meier method and compared with the Log-rank test.

RESULTS

Overall, 343 male patients underwent RARC for bladder cancer within the study period. Nerve-sparing surgery was performed in 143 patients (41%), of these 110 had at least 2 years of follow up after surgery. Patients who underwent nerve-sparing surgery were significantly younger (p < 0.001). Clinically significant PCa was found in 24% of patients. No significant differences regarding preoperative PSA value (p = 0.3), PCa pathological stage (p = 0.5), Gleason score (p = 0.3) and positive surgical margin rates (p = 0.3) were found between the two groups. After a median follow-up of 51 months only one patient, in the no-nerve-sparing group had developed a biochemical recurrence (p = 0.4).

CONCLUSIONS

In our series most of the iPca detected in RC specimens can be considered as insignificant with a low rate of BR (0.9%). Nerve-sparing RARC is a safe procedure which did not affect oncological outcomes of patients with iPCa.

Defining clinically significant prostate cancer on the basis of pathological findings

The definition of clinically significant prostate cancer is a dynamic process that was initiated many decades ago, when there was already evidence that a great proportion of patients with prostate cancer diagnosed at autopsy never had any clinical symptoms. Autopsy studies led to examinations of radical prostatectomy (RP) specimens and the establishment of the definition of significant cancer at RP: tumour volume of 0.5 cm³ , Gleason grade 6 [Grade Group (GrG) 1], and organ-confined disease. RP studies were then used to develop prediction models for significant cancer by the use of needle biopsies. The first such model was used to delineate the first active surveillance (AS) criteria, known as the 'Epstein' criteria, in which patients with a cancer Gleason score of 3 + 3 = 6 (GrG1) involving fewer than two cores, and <50% of any given core, and a prostate-specific antigen density of <0.15 ng/ml per cm³ had a minimal risk of significant cancer at RP. These were adopted as components of the 'very-low-risk category' of the National Comprehensive Cancer Network guidelines, in which AS is supported as a management option. With the increase in the popularity of AS, much research has been carried out to better define significant/insignificant cancer, in order to be able to safely offer AS to a larger proportion of patients without the risk of undertreatment. Research has focused on allowing higher volume tumours, focal extraprostatic extension, and a limited amount of Gleason pattern 4, and the significance of different morphological patterns of Gleason 4. Other areas of research that will probably impact on the field but that are not covered in this review include the molecular classification of tumours and imaging techniques.

The prognostic impact of incidental prostate cancer following radical cystoprostatectomy: a nationwide analysis

BACKGROUND

To determine the prevalence and prognostic impact of incidental prostate cancer in patients undergoing radical cystoprostatectomy.

METHODS

A nationwide population-based study of incidental prostate cancer diagnosed following radical cystoprostatectomy. Information on vital status, Gleason score, positive and negative tumor margins, pT-category and subsequent prostate cancer therapies were obtained from the Danish Prostate Cancer Registry and by manual chart review.

RESULTS

A total of 1,450 men who underwent radical cystoprostatectomy in Denmark from 1995-2011 were identified. Forty-six men were excluded from analysis, thus 1,404 patients were eligible. The median follow-up was 7.8 years. A total of 466 (33.2%) had incidental prostate cancer diagnosed. No statistical differences in 10- and 15-year cumulative overall mortality were observed when comparing men with, or without, incidental prostate cancer. In men diagnosed with incidental prostate cancer, neither Gleason score, positive surgical margins or locally advanced prostate cancer (pT3-4) was associated with mortality. Only 0.9% received post-operative prostate cancer-related treatment.

CONCLUSION

In this population-based cohort of patients with incidental prostate cancer diagnosed at radical cystoprostatectomy, we found no impact of incidental prostate cancer on overall mortality, regardless of Gleason score, surgical margin status and pathological T-category. Patients diagnosed with incidental prostate cancer following radical cystoprostatectomy are unlikely to benefit from additional follow-up.

Clinical Significance of Incidental Prostatic Carcinoma on Radical Cystectomy Histology Specimens: a Clinicopathological and Survival Analysis

Incidental prostatic carcinoma on radical cystectomy histology specimens is not an uncommon entity and managing such cases is still controversial. Classification into clinically significant and insignificant cancers by Epstein based on the assumption that one is more likely to affect the survival than the other is not universally accepted. We conducted this retrospective analysis with the aim to find out the role of dichotomization of incidental prostatic cancer into such classification. Patient's data were retrospectively reviewed from January 2013 to December 2014. A total of 175 patients underwent radical cystectomy during the study duration and amongst them, 38 specimens showed incidental prostatic cancer. Their data pertaining to demographic profile, clinicopathological details, treatment received, complications and follow-up data was recorded. On comparative analysis, the disease-free survival in csPCa (clinically significant prostatic cancer) group was 60.82% and cisPCa (clinically insignificant prostatic cancer) 62.68% at 2.3 years (p 0.566), while OS was 55.68% for csPCa and 87.5% for cisPCa respectively (p 0.814). The mean duration to recurrence was also comparable (19.4 months csPCa and 17 months cisPCa). None of the patients developed PSA elevation on follow-up and none of the recurrence or death were attributed to prostatic cancer. The stage of bladder cancer was the only factor, which had a significant impact on overall survival. The distinction between clinically significant and insignificant is not relevant according to our analysis.

Prevalence and clonality of synchronous primary carcinomas in the bladder and prostate

Incidental prostate adenocarcinoma (IPCa) has been frequently discovered during postoperative histopathological evaluation of radical cystoprostatectomy specimens in patients with bladder cancer (BCa). However, there is currently no conclusive study addressing the clinical significance of IPCa and the clonal relatedness of IPCa and BCa. Here, we performed a retrospective single-center review of 919 BCa cases and an additional meta-analysis including a total of 19 868 individuals who underwent radical cystectomy for bladder cancer. IPCa, mostly clinically insignificant, was detected in 67 of 919 BCa patients (7.3%) and was significantly associated with greater age. In the meta-analysis, a lower prevalence was observed in Asian than in non-Asian countries (19% versus 32%), presumably due to their different rates of prostate cancer occurrence. Whole-exome sequencing on matched BCa and IPCa samples unambiguously revealed independent clonal origins of the synchronous tumors. BCa and IPCa lesions from each patient displayed distinctive genomic abnormalities and largely unrelated mutational signatures of single nucleotide variations, indicating disparate mutational processes underlying bladder and prostate oncogenesis. These findings provide important insights into the incidental nature of prostate adenocarcinoma in patients with bladder cancer, and suggest that the two concurrent diseases can be managed separately. Copyright © 2017 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Impact of the Level of Urothelial Carcinoma Involvement of the Prostate on Survival after Radical Cystectomy

Objective:

Urothelial prostatic involvement (UPI) at the time of radical cystoprostatectomy (RCP) was found associated with worse survival outcomes by several previous reports. Our aim is to evaluate the impact of different levels of UPI on survival outcomes using a large series of male patients treated with RCP.

Methods:

Whole step section specimens from 995 male BCa patients were assessed for UPI defined as: no involvement vs. prostatic urethral carcinoma in situ (CIS) vs. lamina propria involvement vs. ductal CIS vs. prostate stromal involvement. Primary end point of the study was predictors of prostatic involvement at RCP and its impact on overall survival after surgery.

Results:

Prostatic involvement was recorded in 307 (30.9%) patients: 28% with prostatic urethral CIS, 12% with lamina propria involvement, 13% with ductal CIS and 47% with stromal involvement. Median follow-up was 70 months. Patients with stromal involvement had a worse 5-year survival (12%) than those with prostatic urethra CIS (40%), lamina propria involvement (36%), and ductal CIS (35%). Considering predictors of prostatic involvement, multifocal tumor (Odds Ratio [OR]: 6.60, p < 0.001), lymphovascular invasion (OR: 2.61, p < 0.001), lymph node metastases (OR: 2.02, p < 0.001) and CIS (OR: 2.02, p < 0.001) were found associated. Similar predictors were found assessing stromal involvement.

Conclusions

Approximately one third of RCP patients harbor prostatic involvement of urothelial carcinoma. While all UPI are associated with worse overall survival, stromal involvement confers the worst outcome supporting its classification as T4 in the TNM staging.

Is survival after radical cystectomy for bladder cancer in Saudi patients different from that of Western patients?

BACKGROUND

Although radical cystectomy (RC) is considered the gold standard treatment of muscle invasive bladder cancer, nearly half of patients develop metastases and ultimately die within 2 years.

OBJECTIVE

To assess survival, evaluate different prognostic factors that may affect disease-free survival (DFS) in Saudi patients after RC for carcinoma of the bladder and to compare our results with those of Western countries.

DESIGN

Retrospective chart review.

SETTING

A tertiary care center in Saudi Arabia.

PATIENTS AND METHODS

We collected data on patients who underwent RC for bladder cancer in the period between 1979 and 2014. Demographic, clinical and pathological variables and the application of perioperative chemotherapy were reviewed. Univariate and multivariate analyses were done with DFS as the end point.

MAIN OUTCOME MEASURE

Disease-specific survival.

RESULTS

On 328 patients for whom data was available, the median follow up was 23 months (range, 2 month-28 years) and median age was 58 years (range, 21-90). Of these patients, 268 were males (81.7%), 235 (71.7%) had urothelial carcinoma (UC), 79 (24.1%) had squamous cell carcinoma (SCC), and 208 (63.4%) had pathological tumor stage 3 or more. The 5-year overall survival (OS) and DFS were 52% and 48%, respectively. There was no statistically significant difference in DFS of patients with UC and pure SCC. On univariate analysis, lymph node status and pathological tumor stage were significant predictors of DFS. Both variables sustained statistical significance in a multivariate analysis.

CONCLUSION

Survival following RC is almost the same as others. Moreover, pathological tumor stage and lymph node metastasis were the only independent predictors for survival following RC. Future cooperative prospective studies are required to gain data on our region.

LIMITATIONS

Relatively small sample size and retrospective.

Incidental Prostate Adenocarcinoma in Cystoprostatectomy Specimens: Partial Versus Complete Prostate Sampling

BACKGROUND

The rate of incidental prostate adenocarcinoma (PCa) detection in radical cystoprostatectomy (RCP) varies widely, ranging from 15% to 54%. Such variability may be explained by institutional differences in prostate grossing protocols. Either partial or complete submission of the prostate gland in RCP may result in detection of clinically insignificant or significant incidental PCa. The aim of the study was to compare the clinical significance of PCa in RCP specimens in partial versus complete sampling.

MATERIAL

Seventy-two out of 158 RCP cases showed incidental PCa. The pathologic features, including Gleason score, margin status, extraprostatic extension (EPE), seminal vesicle invasion (SVI), PCa stage, and tumor volume, were assessed.

RESULTS

The 72 cases were divided into partial (n = 21, 29.1%) and complete sampling (n = 51, 70.8%) groups. EPE was detected in 13/72 (18.1%) with 11/13 (84.6%) cases in the complete group. Positive margins were present in 11/72 (15.3%) with 9/11 (81.8%) in the complete group. SVI was detected in 4/72 (5.6%) with 3/4 (75.0%) in the complete group. Overall, 4/72 (5.6%) had a Gleason score >7, all of which were in the complete group.

CONCLUSION

Our data suggest that complete sampling of the prostate may be the ideal approach to grossing RCP specimens, allowing for greater detection of clinically significant incidental PCa.

Identifying aggressive prostate cancer foci using a DNA methylation classifier

BACKGROUND

Slow-growing prostate cancer (PC) can be aggressive in a subset of cases. Therefore, prognostic tools to guide clinical decision-making and avoid overtreatment of indolent PC and undertreatment of aggressive disease are urgently needed. PC has a propensity to be multifocal with several different cancerous foci per gland.

RESULTS

Here, we have taken advantage of the multifocal propensity of PC and categorized aggressiveness of individual PC foci based on DNA methylation patterns in primary PC foci and matched lymph node metastases. In a set of 14 patients, we demonstrate that over half of the cases have multiple epigenetically distinct subclones and determine the primary subclone from which the metastatic lesion(s) originated. Furthermore, we develop an aggressiveness classifier consisting of 25 DNA methylation probes to determine aggressive and non-aggressive subclones. Upon validation of the classifier in an independent cohort, the predicted aggressive tumors are significantly associated with the presence of lymph node metastases and invasive tumor stages.

CONCLUSIONS

Overall, this study provides molecular-based support for determining PC aggressiveness with the potential to impact clinical decision-making, such as targeted biopsy approaches for early diagnosis and active surveillance, in addition to focal therapy.

Radical cystectomy: do we need standardization?

INTRODUCTION

The first series of radical cystectomy with a definition of surgical landmarks was published in 1949 and was characterized by a high perioperative mortality and a 5-year survival rate around 50%. Decades later, nevertheless many surgical progresses were made and the perioperative mortality dropped to 2,5%, this had not lead to an improvement of long term survival rates, also because a standardization of the procedure is still missing. Areas covered: Radical cystectomy is performed with different surgical techniques obmitting a standardization. The comparability of many studies is therefore difficult or havely compromised. A paragon with other diciplines was made emphazing that there high surgical quality is defined, measured and controlled. A systematic literature search was made selecting finally 76 article adressing this issue. Expert commentary: Surgical guidelines in uro-oncology are vague and a definition of surgical quality is missing. A view outside of the box could be very helpful. This is a plea for a change.

Occult Metastases in Pelvic Lymphadenectomy Specimens From Patients With Urothelial Carcinoma of the Bladder

OBJECTIVE

To identify occult metastases within lymph nodes (LNs) reported as negative by routine histologic evaluation. In patients with high-grade, muscle-invasive urothelial carcinoma (UC) of the bladder, pelvic lymphadenectomy during radical cystectomy demonstrates a survival advantage, increasing with the number of LNs removed, even if negative for metastatic disease. This finding may potentially be explained by the presence of occult metastases.

MATERIALS AND METHODS

Radical cystectomy specimens with high-grade UC invading the perivesical tissue and negative LNs (pT3N0) between 2000 and 2014 were reviewed. Five levels were cut for each LN block. Two sections were cut per level: 1 stained for hematoxylin and eosin and 1 for AE1/AE3. Micrometastases were defined as tumor deposits >0.2 mm but <2 mm. Isolated tumor cells were defined as ≤0.2 mm. Medical records and survival data were reviewed.

RESULTS

We identified 21 cases, consisting of 370 lymph nodes. Six of 21 patients (29%) had occult metastases, including 5 occult metastatic UC and 1 occult metastatic prostate adenocarcinoma. There were 10 positive LNs; 2 macrometastases, 2 micrometastases, and 6 with ITCs. Two of 6 patients (33%) had lymphovascular invasion identified in the primary tumor. Kaplan-Meier analysis showed no significant difference in overall survival between the group of patients who remained N0 versus those upstaged due to discovery of occult metastases (P-value = .42).

CONCLUSION

In patients with pT3 UC undergoing cystectomy, we demonstrated the presence of occult metastases in 29% of patients. The high percentage of occult metastases present in these cases possibly explains the proven survival advantage of removing "negative" LNs. This finding might also have implications in the histologic evaluation of LNs.

Incidental prostate cancer diagnosed at radical cystoprostatectomy for bladder cancer: disease-specific outcomes and survival

Background

The current standard of care for men with muscle-invasive bladder cancer is radical cystoprostatectomy (RCP). One-third of RCP specimens demonstrate incidental prostate cancer, primarily reported in small series with limited follow-up. The aim of this study is to report mature outcomes, including patterns of failure and disease-specific recurrence rates, and survival, for a large cohort of men with incidental prostate cancer at RCP performed at a tertiary referral center.

Methods

This retrospective study describes cancer control and survival rates for men who underwent RCP for bladder cancer and were found incidentally to have prostate cancer. Analysis of patient-, tumor-, and treatment-specific factors were analyzed for association with disease control and survival endpoints.

Results

Between 2002 and 2010, 94 patients with incidental discovery of prostate cancer postRCP were identified for inclusion in this study. Forty-five patients (45%) underwent RCP for recurrent (rather than initial presentation of) bladder carcinoma. At a median follow-up of 40.3 months (71.2 months for survivors; range, 8.9–155.5 months), 42 patients were alive without recurrence and 52 patients had died (25 associated with disease). The estimated 5-year bladder cancer disease-free, urinary tract malignancy disease-free, and prostate specific antigen (PSA) relapse-free survivals were 76% [95% confidence interval (CI), 65–84%], 64% (52–74%), and 97% (79–100%), respectively. The estimated 5-year urinary tract malignancy-specific and overall survivals were 61% (49–71%) and 52% (41–62%), respectively. Univariate analysis demonstrated associations between pathologic T/N-stage and nodal ratio with bladder cancer disease-free, urinary tract malignancy disease-specific, and overall survivals, with patient age at diagnosis as an additional adverse factor associated with overall survival. Multivariate analysis confirmed pN-stage and age as independently associated with worse survival.

Conclusion

For men undergoing RCP for bladder cancer, the present study suggests that incidentally discovered prostate cancers, irrespective of pathologic stage, Gleason score, or clinical significance, do not impact 5-year disease control or survival outcomes.

Laparoscopic radical cystectomy with prostate capsule sparing. Initial experience

INTRODUCTION

In 2008, our department introduced a modified technique of laparoscopic radical cystectomy in which the prostatic capsule is spared in selected patients with bladder cancer. The different series published are mostly using the standard open procedure. The aim of this study is to describe this technique using the laparoscopic approach and present our preliminary results.

MATERIAL AND METHODS

This study includes 20 patients selected by clinical analysis and imaging criteria operated using laparoscopic radical cystectomy with prostate capsule sparing at our department in the period between 2008 and 2012.

RESULTS

Patient mean age was 58 years. Mean operative time was 390 minutes. Median follow-up was 36 months. No patient had bladder cancer recurrence. Only one patient died of disease progression, as the pathological findings was a pT3 pN1 Mx. Mean PSA before surgery: 1.3 ng/ml (03-2), mean PSA after surgery 1.0 ng/ml (0.08-1.7). No patients had prostate cancer recurrence. Satisfactory daytime and night-time continence was achieved. 90% of patients have sexual function preserved.

CONCLUSIONS

Prostate-sparing radical cystectomy remains one of the most controversial topics in urology today. The laparoscopic approach could be an alternative to conventional radical cystoprostatectomy in well selected patients, done in experienced institutions in order to find better functional results, with a low disease progression and recurrence rate.

Clinical Relevance of Incidental Prostatic Lesions on FDG-Positron Emission Tomography/Computerized Tomography-Should Patients Receive Further Evaluation?

PURPOSE

FDG ((18)F-fluoro-2-deoxy-D-glucose)-PET/CT (positron emission tomography)/(computerized tomography) is a widely used diagnostic tool for whole body imaging. Incidental prostatic uptake is often found on FDG-PET/CT. The objective of this study was to determine the clinical relevance of incidental prostatic uptake on FDG-PET/CT.

MATERIALS AND METHODS

We analyzed 108 consecutive male patients with bladder cancer who underwent FDG-PET/CT and subsequently radical cystoprostatectomy between May 2009 and November 2014. PET/CT scans were blindly reviewed by a dedicated nuclear medicine physician for incidental prostatic FDG uptake. If present, the maximum standardized uptake value was determined. Subsequently incidental prostatic uptake was categorized as suspect, indeterminate or nonsuspect for prostate cancer.

RESULTS

Incidental prostatic uptake was present in 43 of 108 patients (40%). Of these 43 patients 13 (30%) had occult prostate cancer in cystoprostatectomy specimens. Overall prostate cancer was found in 25 of 108 specimens (23%). If all incidental prostatic uptake was regarded as prostate cancer, the sensitivity and specificity of FDG-PET/CT for prostate cancer detection were 52% and 64%, respectively. Positive and negative predictive values were 30% and 82%, respectively. If only lesions labeled suspect or indeterminate were regarded as prostate cancer, sensitivity, specificity, and positive and negative predictive values were 32%, 76%, 29% and 79%, respectively. Categorizing indeterminate lesions as nonprostate cancer did not improve diagnostic accuracy. Gleason score did not correlate with maximum standardized uptake value or serum prostate specific antigen.

CONCLUSIONS

Incidental prostatic uptake on FDG-PET/CT has a low positive predictive value for prostate cancer. An attempt to classify lesions as suspect or nonsuspect did not increase diagnostic accuracy. Based on these results physicians should be cautious about applying invasive diagnostic methods to detect prostate cancer in case of incidental prostatic uptake on FDG-PET/CT.

Incidental prostate cancer in Asian men: high prevalence of incidental prostatic adenocarcinoma in Chinese patients undergoing radical cystoprostatectomy for treatment of bladder cancer and selection of candidates for prostate-sparing cystectomy

BACKGROUND

Previous studies report a low prevalence of incidental prostate cancer in Chinese patients (3-7%). We evaluated incidental prostatic adenocarcinoma (PCa) and urothelial carcinoma (UCa) involvement of the prostate in cystoprostatectomy specimens.

METHODS

We analyzed 340 cystoprostatectomy specimens from patients who underwent radical cystoprostatectomy for the treatment of bladder cancer in China from 2004 to 2014. None of the patients had known prostate cancer prior to cystoprostatectomy.

RESULTS

Overall, 180 (53%) patients had either PCa or UCa in the prostate. We found that 95 (28%) had PCa and 115 (34%) had UCa involvement of prostate. The rate of incidental prostate cancer was 21% and 31%, respectively, from two study periods (2004-2008 and 2009-2014). Among the 95 patients with PCa, 19 (20%) had Gleason score of ≥7, nine (10%) had PCa tumor volume >0.5 cc, and eight (8.4%) had extracapsular extension. Of the 115 with prostatic UCa, 61 had prostatic urethra and/or periurethral prostatic duct involvement only, while 54 had prostatic stromal invasion. Age (odds ratio [OR] = 1.04, P = 0.001), increasing stage of bladder tumor (OR = 1.28, P = 0.005), multifocal tumors of bladder (OR = 3.22, P < 0.001), carcinoma in situ (CIS) in the bladder (OR = 5.52, P < 0.001), and bladder neck involvement (OR = 6.12, P < 0.001) were strongly associated with prostatic UCa.

CONCLUSIONS

The rate of incidental PCa in cystoprostatectomy specimens in China has increased over the last decade. Patients with advanced age, elevated serum PSA level, advanced bladder tumor stage, multifocal bladder tumors, CIS in the bladder, and tumor location at the bladder neck should be excluded as candidates for prostate-sparing cystectomy.

Incidental prostate cancer at the time of cystectomy: the incidence and clinicopathological features in Chinese patients

OBJECTIVES

To evaluate the incidence and the clinicopathological features of incidental prostate cancer detected in radical cystoprostatectomy (RCP) specimens in Chinese men and to estimate the oncological risk of prostate apex-sparing surgery for such patients.

METHODS

The clinical data and pathological feature of 504 patients who underwent RCP for bladder cancer from January 1999 to March 2013 were retrospectively reviewed. Whole mount serial section of the RCP specimens were cut transversely at 3-4 mm intervals and examined in same pathological institution.

RESULTS

Thirty-four out of 504 patients (6.8%) had incidental prostate cancer with a mean age of 70.3 years. 12 cases (35.2%) were diagnosed as significant disease. 4 cases were found to have apex involvement of adenocarcinoma of the prostate while in 5 cases the prostate stroma invasion by urothelial carcinoma were identified (one involved prostate apex). The mean follow-up time was 46.4±33.8 months. Biochemical recurrence occurred in 3 patients but no prostate cancer-related death during the follow-up. There was no statistical significance in cancer specific survival between the clinically significant and insignificant cancer group.

CONCLUSIONS

The prevalence of incidental prostate cancer in RCP specimens in Chinese patients was remarkably lower than in western people. Most of the incidental prostate cancer was clinically insignificant and patient's prognosis was mainly related to the bladder cancer. Sparing the prostate apex was potentially associated with a 1.0% risk of leaving significant cancer of the prostate or urothelial carcinoma.

Prostate cancer overdiagnosis and overtreatment

PURPOSE OF REVIEW

To summarize the evidence, now extensive, that efforts to reduce prostate cancer mortality by screening and early detection result in overdiagnosis of disease that is clinically insignificant, and would never have been diagnosed in the patient's lifetime in the absence of screening. Overdiagnosis may result in overtreatment, which in the case of prostate cancer often carries significant, long-term quality-of-life effects. The review also addresses the solutions to the problem of overdiagnosis and overtreatment, and summarizes the outcomes of these approaches.

RECENT FINDINGS

Screening for prostate cancer has been demonstrated to reduce mortality, although with a high number needed to treat. One approach to this problem is to offer patients with favorable risk disease an initial conservative approach, with close monitoring and treatment for those patients who are reclassified as higher risk over time. Much preclinical data indicates that Gleason 6 prostate cancer does not carry the hallmarks of malignancy. However, a number of recent studies have demonstrated that in patients diagnosed with favorable risk prostate cancer (Gleason 6 or less, prostate-specific antigen <10), about 30% will harbor higher grade cancer and benefit from treatment. These patients are identifiable by a combination of repeat biopsy, serial prostate-specific antigen, and in borderline cases, multiparametric MRI.

SUMMARY

Active surveillance is a powerful solution to the problem of overdiagnosis and overtreatment associated with screening for prostate cancer. For the 40-50% of patients with favorable risk prostate cancer, it offers the benefit of personalized medicine, avoiding treatment and related quality-of-life effects altogether in the majority, and providing definitive management for the minority who are reclassified with higher risk disease over time.

[Prognostic influence of prostate gland invasion by bladder tumour and/or prostate cancer in cystoprostatectomy specimen: a review]

INTRODUCTION

Cystoprostatectomy (CPT) is the gold standard surgical treatment for muscle invasive bladder cancer (MIBC). In certain cases, MIBC can invade the prostate gland and/or a prostate cancer (PCa) can be discovered fortuitously on the pathologic specimen. The aim of the current study was to report the prognostic influence of PCa in patients who underwent a CPT for MIBC.

MATERIALS AND METHODS

A systematic review of the scientific literature was achieved in the Pubmed database, using the following keywords: prostatic neoplasm; urinary bladder neoplasm; cystectomy; surgery; recurrence; prognosis; survival. Clinical cases and series of less than five cases were deliberately excluded herein.

RESULTS

Overall, ten studies published between 2004 and 2011 and involving 2196 patients were selected. Only retrospective studies of low level of evidence (NP 4) were available. The incidence of neoplastic invasion of the prostate gland by MIBC ranged from 25 to 48%. Preoperative predictors were multiple BC, recurrent, location in the trigone and existence of CIS. Overall survival at 3 years was significantly affected by the invasion of the prostate gland (pT4a) in these patients. The incidence of PCa discovered incidentally pathologic specimen CPT ranged from 14 to 49%. Only age was found as a positive predictor. The diagnosis of PCa did not influence survival of patients with MIBC and no specific PCa adjuvant treatment was systematically advocated.

CONCLUSION

Fortuitous diagnosis of PCa and/or neoplastic invasion of the prostatic gland by BC on CPT specimen is not uncommon but this is variable across studies, depending on the quality of the pathological analysis. The invasion of the prostate gland by MIBC is a serious situation (pT4a) and linked with a poor prognosis. In case of concomitant PCa and MIBC, the prognosis is much more related to the natural history of the bladder tumour.

[Treatment of bladder cancer. Value of radical prostate-sparing cystectomy]

In the management of muscle-invasive bladder cancer, prostate-sparing cystectomy represents a surgical alternative to radical cystoprostatectomy with equivalent oncological and improved functional results. Patient selection for prostate-sparing cystectomy is very critical and men with pT1 high-grade or solitary pT2 urothelial cancer without multifocal CIS and bladder neck involvement appear to be the most appropriate candidates. Stromal invasion of the prostate and accompanying clinically significant prostate cancer must be ruled out by appropriate diagnostic maneuvers. Considering the above-mentioned selection criteria, local and systemic relapse rates are around 3 and 13%, respectively, and do not differ from radical cystoprostatectomy. Daytime and nighttime continence is around 90-95% and erectile function can be preserved in 80-90% of the patients. Therefore, the functional results are much better than those achieved for nerve-sparing radical cystoprostatectomy. Especially young men might benefit from prostate-sparing cystectomy.

Incidentally found prostate cancer and influence on overall survival after radical cystoprostatectomy

Objectives. To determine incidentally found prostate cancer frequency and impact on overall survival after RCP. Patients and Methods. The records of 81 men who underwent cystoprostatectomy from January 2000 to December 2009 were reviewed. The vital status of the study group was assessed as on September 1, 2009, by passive followup, using data from the population registry. Results. The 81 men underwent RCP. The incidental prostate cancer was found in the specimens of 27 (33.3%) patients. 13 (48.1%) of 27 prostate cancer cases were clinically significant. For 3 patients (11.1%) an extraprostatic extension was found. For 2 patients (7.4%)—positive margins, for 1 patient (3.7%)—Gleason sum 8, and for the rest 7 patients bigger than 0.5 cm³ volume tumor, and Gleason sum 7 was found. The mean follow-up time was 39.2 ± 33.8 months (varies from 0.8 to 131.2 months). The patients with bladder cancer and incidentally found prostate cancer lived shorter (28.1 ± 27.5 and 45.5 ± 35.40 months). Higher overall survival (P = 0.03) was found in the patient group with bladder cancer without incidentally diagnosed prostate cancer. Conclusion. There are indications that in this small study prostate cancer has influenced on patients' survival with bladder cancer after radical cystoprostatectomy.

Defining and predicting indolent and low risk prostate cancer

The early detection of asymptomatic prostate cancer has led to the increased incidence of tumours that are unlikely to become symptomatic during life, so called indolent cancers. The prediction of low risk and indolent prostate cancer is needed to avoid overtreatment by unnecessary invasive therapies, and select men for active surveillance. Some of the currently available nomograms predicting these low risk tumours have been validated in independent populations. However, assessment to the compliance with their treatment advises based on the calculation of probability are scarce. The ultimate value of nomograms for the urologic practice can only be assessed by analysing their practical implementation.

Clinicopathologic features of incidental prostatic adenocarcinoma in radical cystoprostatectomy specimens

Background

The aim of this study is to review all features of incidentally discovered prostate adenocarcinoma in patients undergoing radical cystoprostatectomy for bladder cancer.

Methods

The medical charts of 300 male patients who underwent radical cystoprostatectomy for bladder cancer between 1997 and 2005 were retrospectively reviewed. The mean age of the patients was 62 (range 51-75) years.

Results

Prostate adenocarcinoma was present in 60 (20%) of 300 specimens. All were acinar adenocarcinoma. Of these, 40 (66.7%) were located in peripheral zone, 20 (33.3%) had pT2a tumor, 12 (20%) had pT2b tumor, 22(36.7%) had pT2c and, 6 (10%) had pT3a tumor. Gleason score was 6 or less in 48 (80%) patients. Surgical margins were negative in 54 (90%) patients, and tumor volume was less than 0.5 cc in 23 (38.3%) patients. Of the 60 incidentally detected cases of prostate adenocarcinoma 40 (66.7%) were considered clinically significant.

Conclusion

Incidentally detected prostate adenocarcinoma is frequently observed in radical cystoprostatectomy specimens. The majority are clinically significant.

Overdiagnosis in cancer

This article summarizes the phenomenon of cancer overdiagnosis-the diagnosis of a "cancer" that would otherwise not go on to cause symptoms or death. We describe the two prerequisites for cancer overdiagnosis to occur: the existence of a silent disease reservoir and activities leading to its detection (particularly cancer screening). We estimated the magnitude of overdiagnosis from randomized trials: about 25% of mammographically detected breast cancers, 50% of chest x-ray and/or sputum-detected lung cancers, and 60% of prostate-specific antigen-detected prostate cancers. We also review data from observational studies and population-based cancer statistics suggesting overdiagnosis in computed tomography-detected lung cancer, neuroblastoma, thyroid cancer, melanoma, and kidney cancer. To address the problem, patients must be adequately informed of the nature and the magnitude of the trade-off involved with early cancer detection. Equally important, researchers need to work to develop better estimates of the magnitude of overdiagnosis and develop clinical strategies to help minimize it.