Incidentally detected prostate cancer in cystoprostatectomies: pathological and morphometric comparison with clinically detected cancer in totally embedded specimens

Long exposure to a mixture of endocrine disruptors prediposes the ventral prostate of rats to preneoplastic lesions

Endocrine disruptors (ED) are compounds dispersed in the environment that modify hormone biosynthesis, affecting hormone-dependent organs such as the prostate. Studies have only focused on evaluating the effects of ED alone or in small groups and short intervals and have not adequately portrayed human exposure. Therefore, we characterized the prostate histoarchitecture of rats exposed to an ED mixture (ED Mix) mimicking human exposure. Pregnant females of the Sprague-Dawley strain were randomly distributed into two experimental groups: Control group (vehicle: corn oil, by gavage) and ED Mix group: received 32.11 mg/kg/day of the ED mixture diluted in corn oil (2 ml/kg), by gavage, from gestational day 7 (DG7) to post-natal day 21 (DPN21). After weaning at DPN22, the male pups continued to receive the complete DE mixture until they were 220 days old when they were euthanized. The ED Mix decreased the epithelial compartment, increased the fractal dimension, and decreased glandular dilation. In addition, low-grade prostatic intraepithelial neoplasia was observed in addition to regions of epithelial atrophy in the group exposed to the ED Mix. Exposure to the mixture decreased both types I and III collagen area in the stroma. We concluded that the ED Mix was able to cause alterations in the prostatic histoarchitecture and induce the appearance of preneoplastic lesions.

Using hospital medical record data to assess the accuracy of the SEER Los Angeles Cancer Surveillance Program for initial treatment of prostate cancer: a small pilot study

PURPOSE

Treatment information from the Surveillance, Epidemiology, and End Result Program (SEER) cancer registries is increasingly being used for population-based cancer research; however, it may be incomplete for outpatient procedures and is not quality controlled. We sought to validate SEER information on initial treatment of prostate cancer by comparison to electronic medical record (EMR) review.

METHODS

Patients diagnosed with prostate cancer between 1 January 2010 and 31 December 2014 in Los Angeles County who received treatment at our institution within 6 months of diagnosis were identified from the SEER registry. We reviewed the hospital EMR for these patients and identified initial treatment received within 6 months of diagnosis. We compared data reported to SEER data to our re-abstracted hospital EMR data (defined as the gold standard) to identify the completeness of SEER treatment data (sensitivity) and the accuracy of the SEER information (positive predictive value).

RESULTS

Based on 266 eligible patients, SEER's sensitivity in capturing initial treatment was 95.9% (118/123) for prostatectomy, 95.8% (69/72) for no treatment, 87.5% (21/24) for radiation therapy, 68.3% (28/41) for active surveillance or watchful waiting, and 50.0% (2/4) for cryosurgery. The SEER positive predictive value was 100% for radiation therapy and cryosurgery, 97.5% (118/121) for radical prostatectomy, 82.3% (28/34) for active surveillance or watchful waiting, and 78.4% (69/88) for no treatment.

CONCLUSION

The SEER data were highly sensitive and has a high positive predictive value for surgery and radiation therapy but underreported use of active surveillance. These results may assist researchers in understanding the strengths and weaknesses of using SEER prostate cancer treatment data.

Three-dimensional proton magnetic resonance spectroscopy and diffusion-weighted imaging in the differentiation of incidental prostate carcinoma from benign prostate hyperplasia

The present study evaluated three-dimensional proton magnetic resonance spectroscopy (MRS) and diffusion-weighted imaging (DWI) features in differentiating incidental prostate carcinoma (IPCa) and benign prostate hyperplasia (BPH) in the central gland of the prostate. The clinical and imaging data of 9 patients with IPCa, 118 patients with BPH [including those with glandular hyperplasia (GH), stromal hyperplasia (SH) and mixed hyperplasia (MH)], were retrospectively analyzed. The mean (choline + creatine)/citrate (CC/C) value of 3D MRS, the apparent diffusion coefficient (ADC) value and the minimal ADC value of DWI were compared between carcinoma and non-carcinoma tissues. The mean CC/C values were 1.04±0.28, and 1.09±0.58 in IPCa and BPH, respectively (t=-0.205, P=0.838). No significant difference in CC/C values (χ²=2.595, P=0.458) could be detected between IPCa, GH, SH and MH groups. The ADC values of the central gland only differed between IPCa (1.48±0.18) ×10^-3 and GH (1.60±0.16) ×10^-3 mm²/sec (P=0.037). The minimal ADC values were similar between IPCa (1.15±0.10) ×10^-3 and BPH (1.14±0.11) ×10^-3 mm²/sec, no significant differences could be detected between IPCa and GH (P=0.930), IPCa and SH (P=0.192), and IPCa and MH (P=0.544). Although the ADC values of the central gland of the prostate differed between IPCa and GH, the findings of the present study therefore indicate that combining 3D MRS with DWI cannot potentially improve the detection of IPCa.

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.

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.

Synchronous primary malignancies of the male urogenital tract

The finding of prostate cancer after a cystoprostatectomy for a bladder tumour can occur in up to 70% of cases. The incidence of prostate cancer in patients with a bladder tumour is 18 times higher than in the general population; moreover, the incidence of bladder cancer in patients with prostate cancer is 19 times higher than in the general population. This association can be explained by the common embryological origin of these organs, with molecular similarities. Other similarities between these two cancers are noted. They are multifocal and may be secondary to urinary stasis. However, this association does not seem responsible for an increased risk of progression of both diseases. The prognosis is related to the extension of each cancer. The stage and grade of bladder cancer are, in terms of prognosis, greater than those of prostate cancer. Most often, this is insignificant prostate cancer. Despite this, the prostate-specific antigen test should be administered to monitor patients after cystoprostatectomy.

Basal cell hyperplasia (BCH) versus high grade prostatic intraepithelial neoplasia (HGPIN) in tiny prostatic needle biopsies: Unusual diagnostic dilemma

BACKGROUND

Histopathological differentiation between BCH and HGPIN in prostatic needle biopsies is a diagnostic challenge. The gold standard for detection of HGPIN and BCH is histopathological examination; however subjectivity in interpretation and tiny volume of obtained tissue hamper reliable diagnosis.

AIMS

The aim of this study was to assess usefulness of using the p63 and p504s to solve this problem. Although the use of p63 and p504s is now well established in differentiation between preneoplastic and neoplastic prostatic lesions, their usefulness in tiny tissue material is, however, not fully studied.

METHODS

The study included a spectrum of 30 prostatic needle biopsies (5 BCH, 10 HGPIN, 10 indefinite luminal proliferations where BCH and HGPIN could not be distinguished from each other and 5 adenocarcinomas). H&E stained sections were examined for histopathological features. Other sections were stained immunohistochemically with p63 and p504s.

RESULTS

The mean age of patients was 69 (SD=7.6) years. PSA range was 1.3-2.7 ng/ml. Ultrasongraphic findings were unremarkable. All BCH showed p504s-/p63+ pattern, All HGPIN had p504s+/p63+ pattern while carcinomas were p504s+/p63-. After immunostaining combined with histopathological features; the 10 indefinite specimens could be diagnosed as 4 BCH and 6 HGPIN. The article explains how applying this staining pattern on the challenging specimens, combined with histopathological features, can be helpful in proper identification of prostatic proliferations.

[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.

Pulmonary embolus as a first presentation of occult metastatic prostate cancer

A 65-year-old gentleman with a previous history of pulmonary embolus presented with a subacute onset of shortness of breath, haemoptysis and chest pain associated with a swollen left leg. Ultrasound Doppler scanning of the leg revealed no deep-vein thrombosis. Thereafter, a CT scan of the pulmonary vasculature revealed a large right-sided pulmonary embolus. CT scanning of the abdomen and pelvis was performed to look for evidence of an intra-abdominal source of thrombus and revealed evidence of a moderate sized pelvic mass causing obstructive uropathy. Urological review of the patient revealed a hard prostate and raised prostate specific antigen, consistent with a diagnosis of primary prostatic carcinoma, which after investigation with a radioisotope bone scan was found to have metastasised to the bony pelvis.

Determination of optical coefficients and fractal dimensional parameters of cancerous and normal prostate tissues

Optical extinction and diffuse reflection spectra of cancerous and normal prostate tissues in the 750 to 860 nm spectral range were measured. Optical extinction measurements using thin ex vivo prostate tissue samples were used to determine the scattering coefficient (μ(s)), while diffuse reflection measurements using thick prostate tissue samples were used to extract the absorption coefficient (μ(a)) and the reduced scattering coefficient (μ'(s)). The anisotropy factor (g) was obtained using the extracted values of μ(s) and μ'(s). The values of fractal dimension (D(f)) of cancerous and normal prostate tissues were obtained by fitting to the wavelength dependence of μ'(s). The number of scattering particles contributing to μ(s) as a function of particle size and the cutoff diameter d(max) as a function of g were investigated using the fractal soft tissue model and Mie theory. Results show that d(max) of the normal tissue is larger than that of the cancerous tissue. The cutoff diameter d(max) is observed to agree with the nuclear size for the normal tissues and the nucleolar size for the cancerous tissues. Transmission spectral polarization imaging measurements were performed that could distinguish the cancerous prostate tissue samples from the normal tissue samples based on the differences between their absorption and scattering parameters.

Is there a role for prostate tumour overexpressed-1 in the diagnosis of HGPIN and of prostatic adenocarcinoma? A comparison with alpha-methylacyl CoA racemase

Prostate Tumour Overexpressed-1 (PTOV1) was recently identified as a novel gene and protein during a differential display screening for genes overexpressed in prostate cancer (PCa). Alpha-Methyl-CoA racemase (AMACR) mRNA was identified as being overexpressed in PCa. PTOV1 and racemase were immunohistochemically evaluated in PCa, high-grade prostatic intraepithelial neoplasia (HGPIN), atrophy and normal-looking epithelium (NEp) in 20 radical prostatectomies (RPs) with pT2a Gleason score 6 prostate cancer with the aim of analyzing the differences in marker expression between PTOV1 and AMACR. The level of expression of PTOV1 and AMACR increased from NEp and atrophy through HGPIN, away from and adjacent to prostate cancer, to PCa. With the ROC curve analysis the overall accuracy in distinguishing PCa vs HGPIN away from and adjacent to cancer was higher for AMACR than for PTOV1. In conclusion, AMACR can be considered a more accurate marker than PTOV1 in the identification of HGPIN and of PCa. However, PTOV1 may aid in the diagnosis of PCa, at least to supplement AMACR as another positive marker of carcinoma and to potentially increase diagnostic accuracy.

Comparison of incidentally detected prostate cancer with screen-detected prostate cancer treated by prostatectomy

BACKGROUND

The prostate may often harbor a prostate cancer (PC) which will not cause morbidity if left untreated. Screening for PC leads to increased detection of these insignificant cancers. Objective of this study is to compare PC detected by PSA screening at subsequent screening rounds and treated by radical prostatectomy (RP) with PC incidentally found in cystoprostatectomy specimens.

METHODS

Radical prostatectomy specimens of 617 screen-detected PC were compared with 123 PC identified in cystoprostatectomy specimens. Surgical specimens were systematically examined and stage, grade, tumor volume were recorded. Next, we classified PC as clinically significant or insignificant (i.e., tumor volume <0.5 cm(3), absence of Gleason pattern 4/5, organ confined). Pathological features of incidentally detected PC were compared with PC detected in subsequent screening rounds and with screen-detected T1c PC.

RESULTS

Screen-detected PC overall were more often multifocal, larger in volume, more advanced in tumor stage and of higher grade, while the frequency of insignificant PC was lower as compared to those in cystoprostatectomy specimens. This effect became more pronounced during subsequent screening rounds. Screen-detected T1c PC were also more often multifocal (73% vs. 37%) in average fivefold larger (0.85 cm(3) vs. 0.16 cm(3)), less often organ confined (81% vs. 94%), and less frequently clinically insignificant (33% vs. 81%).

CONCLUSIONS

Screen-detected (T1c) PC treated with RP shows more aggressive features than incidentally found PC. This PSA screening-related selection seems to be mainly driven by tumor volume and-in later screening rounds-by the preferential treatment by prostatectomy of more aggressive PC.

Immunohistochemical expression of prostate tumor overexpressed 1 in cystoprostatectomies with incidental and insignificant prostate cancer. Further evidence for field effect in prostatic carcinogenesis

Prostate tumor overexpressed 1 was recently identified as a novel gene and protein during a differential display screening for genes overexpressed in prostate cancer. It has been suggested that overexpression of prostate tumor overexpressed 1 can contribute to the proliferative status of prostate tumor cells and, thus, to their biologic behavior. Prostate tumor overexpressed 1 and Ki-67 were immunohistochemically evaluated in prostate cancer, high-grade prostatic intraepithelial neoplasia, and normal-looking epithelium in 20 cystoprostatectomies and 20 radical prostatectomies with pT2a Gleason score 6 prostate cancer. The aim was to see whether there were differences in marker expression between cystoprostatectomies and radical prostatectomies. The proportions of prostate tumor overexpressed 1- and Ki-67-positive cells in the cystoprostatectomies and radical prostatectomies increased from normal-looking epithelium through high-grade prostatic intraepithelial neoplasia, away from and adjacent to prostate cancer, to prostate cancer. Prostate tumor overexpressed 1 expression in prostate cancer in cystoprostatectomies was lower than in radical prostatectomies, the differences being significant; there were significant differences in Ki-67 indices. In conclusion, our findings related to prostate tumor overexpressed 1 expression in high-grade prostatic intraepithelial neoplasia, evaluated adjacent and away from prostate cancer, and in incidental and clinical cancers give further support to the concept of field effect in prostatic carcinogenesis as well as to differences in the process of prostatic carcinogenesis between cystoprostatectomies and radical prostatectomies.

[PSA--Quo vadis?]

Prostate cancer is the most frequent cancer in males. Because of the high cure rates, early detection of prostate cancer should identify organ-confined prostate cancers. An early detection examination should be performed annually starting at the age of 50 years and ending when life expectancy is less than 10 years. Digital rectal examination is supplemented by determination of prostate-specific antigen (PSA). Before the first PSA test, the patient must be informed of possible consequences such as biopsy recommendation and treatment options. A threshold of 4 ng/ml is defined as the indication for prostate biopsy. Imaging methods do not play a major role in early detection of prostate cancer today. Early detection identifies many latent prostate cancers, and patients may receive overtreatment. A possible solution is to change the early detection paradigm from detection of all prostate cancers to identification of aggressive ones. In this article, early detection is discussed based on the recent literature.

Immunohistochemical Expression of Prostate Stem Cell Antigen in Cystoprostatectomies with Incidental Prostate Cancer

High expression of Prostate Stem Cell Antigen (PSCA) has been shown to be associated with adverse prognostic features in clinically-diagnosed prostate cancer. The aim of this study is to analyze PSCA expression in cystoprostatectomies with incidental prostate carcinoma (PCa). PSCA expression was evaluated immunohistochemically in normal-looking epithelium (NEp), high-grade prostatic intraepithelial neoplasia (HGPIN) and pT2a Gleason score 6 acinar adenocarcinoma. The evaluation was carried out on 20 cystoprostatectomies (CyPs) with incidental PCa from men with bladder urothelial carcinoma (UC), and 20 radical prostatectomies (RPs) with hormonally untreated PCa from men with clinically detected PCa. Ki-67 was also investigated. The percentages of PSCA positive cells in HGPIN were significantly higher than in NEp (NEp: CyP, mean 2.92% ± standard deviation 6.26%; RP, 3.5% ± 6.46%. HGPIN: CyP, 13.67% ± 12.78%; RP, 14.67% ± 11.34%) (p<0.001). The proportions of positive cells in PCa were greater than in HGPIN (CyP, 20.25% ± 15.96%; RP, 22.58% ± 13.67%) (p0.001). For Ki-67 labeling, the proportions of positive nuclei in the CyPs significantly increased from NEp through HGPIN to PCa. A similar trend was seen in the RPs. In the CyPs the percentages of PSCA and Ki67 positive cells were lower than in the RPs, the differences between the CyP and RP compartments being not statistically significant. Our findings suggest that PSCA is a marker associated with neoplastic transformation of prostate cells, both in CyPs and RPs. However, there are no significant differences between CyPs with incidental prostate carcinoma and RPs with clinically diagnosed cancer.

Is incidentally detected prostate cancer in patients undergoing radical cystoprostatectomy clinically significant?

Cystoprostatectomy specimens obtained from patients with bladder cancer provide a unique opportunity to assess the features of silent prostate adenocarcinoma (PCa). The whole-mount prostate sections of 248 totally embedded and consecutively examined radical cystoprostatectomy (RCP) specimens were reviewed to determine the incidence and features of incidentally detected PCa. PCa was considered clinically significant if any of the following criteria were present: total tumor volume, 0.5 cc or more; Gleason grade, 4 or more; extraprostatic extension; seminal vesicle invasion; lymph node metastasis (of PCa); or positive surgical margins. PCa was present in 123 (49.6%) of 248 specimens. Features were as follows: acinar adenocarcinoma, 123 (100.0%); peripheral zone location, 98 (79.7%); pT2a, 96 (78.0%); pT2b, 11 (8.9%); pT2c, 9 (7.3%); pT3a, 5 (4.1%); pT3b, 2 (1.6%); pT4, 0 (0.0%); Gleason score 6 or less, 107 (87.0%); negative margins, 119 (96.7%); pN0 for PCa, 123 (100.0%); and tumor volume less than 0.5 cc, 116 (94.3%). Of the 123 incidentally detected cases of PCa, 100 (81.3%) were considered clinically insignificant. Incidentally detected PCa is frequently observed in RCP. The majority are clinically insignificant.

Prevalence of incidental prostate cancer in patients undergoing radical cystoprostatectomy: data from China and other Asian countries

The purpose of this study is to investigate the frequency of prostate cancer (Pca) discovered incidentally in radical cystoprostatectomy specimens in Asia and to determine the feasibility of prostate-sparing cystectomy (PSC) for Asian patients. Ninety-two male bladder cancer patients who underwent radical cystoprostatectomy at our center between January 2003 and January 2008 were included in this study. The mean age of patients was 67.1 years (range: 32-75 years). Prostate-specific antigen (PSA) levels and digital rectal examination (DRE) results before surgery were obtained retrospectively. Prostates of all patients were embedded and sectioned at 5-mm intervals. The same pathologist examined the prostatic tissues from radical cystoprostatectomy specimens. Finally, a structured literature review was performed using MEDLINE and PUBMED to estimate the occurrence of incidental Pca in Asia. Of the 92 patients, 3 (3.3%) were found to have Pca; in one out of three (33.3%) patients the disease was clinically significant due to a Gleason grade 4 carcinoma. Eight articles were included in our review. The overall incidence of Pca discovered incidentally in radical cystoprostatectomy specimens in Asia was 9.9% (64/642). When age was restricted to < 60 years, only 7 out of 222 (3.2%) patients were found to have synchronous Pca, and none of the cases was clinically significant. The occurrence of Pca in radical cystoprostatectomy specimens in Asia is much lower than that in Western countries. PSC might be feasible for Asian patients under a strict preoperative selection.

Overexpression of ELAV-like protein HuR is associated with increased COX-2 expression in atrophy, high-grade prostatic intraepithelial neoplasia, and incidental prostate cancer in cystoprostatectomies

BACKGROUND

The human ELAV-like protein HuR regulates the stability of several mRNA targets, including that of cyclooygenase-2 (COX-2). Their expression in prostatic carcinogenesis is uncertain.

OBJECTIVE

To analyze HuR and COX-2 expression in cystoprostatectomies (CyPs) with incidental prostate cancer and compare their expression with those in radical prostatectomies (RPs) with clinically detected cancer.

DESIGN, SETTING, AND PARTICIPANTS

HuR and COX-2 were immunohistochemically evaluated in normal-looking epithelium (NEp), atrophy, high-grade prostatic intraepithelial neoplasia (HGPIN), and prostate carcinoma (PCa) in 20 CyPs and 20 RPs, both types of specimens with pT2a Gleason score 6 PCa.

MEASUREMENTS

At least 1000 cells were counted in contiguous 400X microscopic fields in each case, separately for NEp, atrophy, HGPIN, and PCa.

RESULTS AND LIMITATIONS

There was an increase in the percentage of secretory cells with cytoplasmic HuR staining from NEp to atrophy, HGPIN, and PCa. The mean percentages in NEp, atrophy, and HGPIN adjacent to PCa were greater than away from cancer, both in the CyP and RPs. There was a trend towards a reduced nuclear HuR expression in atrophy, HGPIN, and PCa, compared to NEp. COX-2 staining was seen in the cytoplasm of the basal and secretory cells. There was a reduction in the mean proportion of positive basal cells and progressive increase in the percentage of positive secretory cells from atrophy to HGPIN and PCa, compared to NEp. Cytoplasmic HuR overexpression was correlated with COX-2 expression. There was no difference in HuR and COX-2 expression between cancers with tumour volume <0.5 ccm or >0.5 ccm. The limitations of this study were the small number of cases investigated and lack of a control group without cancer.

CONCLUSIONS

The secretory cells showed shift in HuR staining from nuclear in NEp to cytoplasmic in PCa. This is associated with a parallel shift in COX-2 expression from basal to secretory cells.

Risk Assessment of Prostatic Pathology in Patients Undergoing Radical Cystoprostatectomy

OBJECTIVES

To determine the incidence and location of prostate adenocarcinoma (PCa) and prostatic urothelial carcinoma (PUC) for patients undergoing radical cystoprostatectomy (RCP) for bladder cancer and to ascertain what preoperative information may be useful in predicting PUC or PCa in patients who may be candidates for prostate-sparing cystectomy.

METHODS

Between 2001 and 2004, 235 consecutive patients underwent RCP and had whole-mount sections of the prostate. We reviewed our prospective radical cystectomy database for preoperative clinicopathological information associated with each patient. The bladder and whole-mount prostate sections were re-reviewed to determine the location and depth of the bladder tumor as well as the presence of any associated PCa and PUC.

RESULTS

We identified 113 of 235 (48%) and 77 of 235 (33%) men with PCa and PUC, respectively. Among patients with PCa, 33 (29%) had Gleason score of > or = 7, 25 (22%) had PCa tumor volume > 0.5 cc, and 15 (13%) had extracapsular extension. On multivariable analysis, only increasing age was significantly associated with PCa (odds ratio=1.3, p=0.046). Of the 77 with PUC, 28 (36%) had in situ disease only, while 49 (64%) had prostatic stromal invasion. Bladder tumor location in the trigone/bladder neck (p<0.001) and bladder carcinoma in situ (p<0.001) was strongly associated with PUC in the final specimen. Overall, 158 (67%) had either PCa or PUC in the prostate.

CONCLUSIONS

PCa and/or PUC is present in a majority of RCP specimens. Current preoperative staging and tumor characteristics are not adequate for determining who can safely be selected for prostate-sparing cystectomy.

Immunohistochemical Expression of Endothelin-1 and Endothelin-A and Endothelin-B Receptors in High-Grade Prostatic Intraepithelial Neoplasia and Prostate Cancer

OBJECTIVES

To analyze the expression of endothelin-1 (ET-1), endothelin-A receptor (ET-A-R), and endothelin-B receptor (ET-B-R) in incidental prostate cancer in cystoprostatectomies (CyPs), clinically detected hormonally untreated and hormonally treated prostate cancer in radical prostatectomies (RPs), and hormone-independent prostate cancer in transurethral resections of the prostate (TURPs). High-grade prostatic intraepithelial neoplasia (HGPIN) was also investigated.

METHODS

Nineteen CyPs and 44 RPs (25 untreated, 19 treated) with pT2a Gleason score 6 cancer and HGPIN were examined. The study included 9 TURPs with hormone-independent cancer and 8 normal cases from CyPs without prostate cancer and HGPIN. ET-1, ET-A-R, ET-B-R, and the proliferation marker Ki67 were investigated immunohistochemically.

RESULTS

The mean proportion of prostate cancer cells with strong ET-1, ET-A-R, and ET-B-R expression in CyPs was lower (18.5%, 28.0%, and 14.7%, respectively) than in the untreated group (40.7%, 39.7%, and 25.1%) and higher than in treated group (5.0%, 13.9%, and 11.3%). The highest values were in the hormone-independent cancer group (53.9%, 48.9%, 33.3%). The trend in the proportion of HGPIN cells overexpressing ET-1, ET-A-R, and ET-B-R was similar to that in the cancer groups. The values in HGPIN lesions were always slightly greater than those in the cancers. Ki67 expression in HGPIN and prostate cancer in CyPs was lower than in RPs and TURPs.

CONCLUSIONS

Our study showed for the first time that ET-1, ET-A-R, and ET-B-R expression is not limited to the late prostate cancer phases. It is also seen in HGPIN as well as in prostate cancers considered to be clinically insignificant, such as those seen in CyP specimens. Although the series of cases in each group was small, our data may have clinical significance.

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

OBJECTIVES

To review all relevant features of incidentally discovered prostate cancer (PCa) in patients undergoing radical cystectomy for bladder cancer: incidence, pathologic characteristics, clinical significance, and implications for its management.

METHODS

A structured literature review through a MEDLINE search was performed.

RESULTS

The frequency of incidentally discovered PCa in cystoprostatectomy specimens is extremely variable because of several factors, particularly the pathology sampling. The relationship among clinically, incidentally, and autopsy-detected cancer is uncertain. The definition of clinically significant cancer varies among published reports and remains inadequate for clinical application. High-grade prostatic intraepithelial neoplasia is a marker for concurrent PCa and the risk depends more on the volume than on its absolute presence. Outcome of patients with unsuspected PCa after cystoprostatectomy relies mostly on the bladder tumor.

CONCLUSIONS

Incidental PCa in patients with bladder cancer is highly variable and with an unclear clinical significance. For those who are candidates for prostate-sparing surgery, it seems reasonable to include a routine prostate biopsy in the standard preoperative work-up irrespective of prostate-specific antigen values. In the absence of sufficient data to make firm recommendations, when PCa is incidentally discovered, PCa surveillance should be part of the follow-up scheme after radical cystectomy.

Atypical small acinar proliferation: biopsy artefact or distinct pathological entity?

OBJECTIVE

To determine if atypical small acinar proliferation (ASAP) represents minimally sampled prostate cancer not fully evaluated on a biopsy or a distinct pathological entity, by examining prostates removed at radical cystectomy, as a finding of ASAP of the prostate on needle-core biopsy is closely associated with the detection of cancer on subsequent biopsy.

PATIENTS AND METHODS

In all, 65 consecutive cystoprostatectomy specimens taken from June 1990 to March 2004 had prostatic material reviewed by one genitourinary pathologist (S.E.M.). The presence of high-grade prostatic intraepithelial neoplasia (HGPIN), ASAP, and adenocarcinoma was recorded. Foci of ASAP found in the absence of cancer were assessed with additional sectioning, high-molecular weight keratin (CK903), and alpha-methylacyl coenzyme A racemase (AMACR) immunohistochemistry.

RESULTS

In all, 24 of 65 specimens (37%) had adenocarcinoma. Of the 41 without cancer, 18 (44%) had neither HGPIN nor ASAP, 14 (34%) had HGPIN alone, three (7%) had ASAP alone (four foci), and six had both HGPIN and ASAP (15%). Two foci of ASAP were not present on any further sectioning. The remaining eight foci all lacked CK903 stain, indicating disruption of the basal cell layer. Of these eight, only five were present for the AMACR stain, all of which were positive. Two of these five developed into a lesion considered cancer on further sectioning.

CONCLUSION

ASAP identified in incidental prostates represented marginally sampled cancer in at least two of 10 foci assessed. The remainder could not be resolved as benign on further evaluation, and remained suspicious for malignancy.

Incidence of Multiple Primary Bladder and Prostate Cancer in a Central Region of Italy. Umbria, 1994-2004

The aim of this study was to determine the incidence of multiple bladder-prostate cancers in the population of the Italian region of Umbria and to clarify some diagnostic aspects. Prostate and bladder cancer incidence data in Umbria were obtained from cancer registry records. In the period from 1994 to 2004, 3,470 new patients with bladder cancer and 5,430 new patients with prostate cancer were registered. Among these patients there were 238 who presented multiple bladder and prostate cancers.

Synchronous cancers were detected in 74 of these patients. Fifty-four of them had simultaneous tumors (diagnosed during the same hospitalization), while in 16 patients bladder cancer was detected earlier than prostate cancer and in 4 patients the opposite occurred. This study confirmed an increase in prostate cancer diagnoses in patients with bladder cancer. The increase was mainly accounted for by the detection of prostate cancers during cystectomies performed for bladder carcinoma.

My approach to intraductal lesions of the prostate gland

The morphologically heterogeneous (intra)ductal lesions of the prostate frequently present a diagnostic challenge, particularly when found within prostate needle biopsies. By current convention, all high-grade intra-acinar and intraductal neoplastic lesions of prostatic origin fall under the diagnostic umbrella term: prostatic intraepithelial neoplasm (PIN). Although a long-standing contentious issue, some lesions currently adhering to the diagnostic criteria of PIN may actually represent the intraductal spread of (generally high grade) invasive cancer. Illustrating this fact, the well-described ductal subtype of prostatic adenocarcinoma is frequently associated with conventional-type acinar adenocarcinoma, and has a tendency to propagate within adjacent intact prostatic ducts. Clearly, the misdiagnosis of lesions representing invasive disease as preinvasive has the potential for unfavourable clinical sequelae. As yet, however, many of these lesions have escaped the establishment of reliable morphologic criteria or immunohistochemical differentiation for diagnosis. By defining stringent architectural and cytonuclear features specific for each of these lesions, it may be feasible to separate potentially sinister lesions from the subset of traditional (preinvasive) PIN lesions with limited clinical urgency. This review discusses the (intra)ductal lesions of the prostate, along with their differential diagnoses. Given the current state of knowledge, a pragmatic approach to their effective reporting is outlined, taking into consideration the clinical implications, as well as current guidelines for treatment and follow-up.

The role of prevalence in the diagnosis of prostate cancer

BACKGROUND

The worldwide incidence of prostate cancer has been rising rapidly, likely due to intensified effort in early detection and screening. Intense effort is also directed at novel schemas of chemoprevention and therapy. Incidence data are insufficient to identify the true magnitude of prostate cancer in a given population. The true prevalence of prostate cancer must be identified.

METHODS

We reviewed the latest worldwide epidemiologic data and clinical studies on prostate cancer studying the true prevalence of this disease.

RESULTS

The incidence of prostate cancer is increasing worldwide, with strong variation among regions. Prevalence studies based on autopsy data have confirmed a high frequency of latent prostate cancer in men of all ages. More aggressive screening measures using a lower prostate-specific antigen (PSA) threshold, together with an increasing number of biopsies, have escalated the detection of these latent cancers.

CONCLUSIONS

Recent improvements in prostate cancer detection narrow the gap between the incidence and true prevalence of prostate cancer. This, however, raises concerns about the risk of over detection of latent cancers and thus identifying a need for improvement in screening strategies to better identify clinically significant disease.

Tumour Features in the Control and Screening Arm of A Randomized Trial of Prostate Cancer

OBJECTIVE

To compare tumour characteristics at the time of diagnosis of cancers detected in the screening and control arm at the Rotterdam section of the European Randomized study of Screening for Prostate Cancer.

METHODS

Data were retrieved from the Rotterdam section of the ERSPC. Men were randomized to the screening arm (n=21,210) or the control arm (n=21,166). Men randomized to screening were offered PSA testing every 4 years. Through linkage with the cancer registry, men randomized to the control arm were detected. The biopsy Gleason score was determined in 1,591 and 373 patients in the screening and control arm, respectively. TURP, radical prostatectomy (RP) and cystoprostatectomy were evaluated for Gleason score, pathological (p)T stage and tumour volume.

RESULTS

More prostate cancers were detected in the screening arm (15.9 vs. 4.2 per 1000 man years, p<0.0001). Clinical stage distribution as well as biopsy and RP Gleason score distribution were significantly less favourable in the control arm. The incidence in man years of advanced disease (i.e. T4/N1/M1) was higher in the screening arm (6.0 per 100,000) as compared to the control arm (4.6 per 100,000). The 5-year PSA progression free survival after RP was 68% in the control arm and 89% in the screening arm (p<0.0001). The proportion of Incidental prostate cancers was 9.3% of all cancers detected in the control arm.

CONCLUSIONS

Although the number of men with advanced prostate cancer is slightly higher in the screening arm, the proportion of prostate cancers with favourable features is increased in the screening arm as compared to that in the control arm.

HER2 expression and gene amplification in pT2a Gleason score 6 prostate cancer incidentally detected in cystoprostatectomies: comparison with clinically detected androgen-dependent and androgen-independent cancer

Previous studies have demonstrated HER2 protein overexpression and/or gene amplification in a subset of patients with clinically significant prostate cancer (PCa), especially in the androgen-independent phase of the disease. There are no studies on incidentally detected PCa. The aim of the study was to analyze HER2 expression and gene amplification in PCa incidentally detected in cystoprostatectomies. High-grade prostatic intraepithelial neoplasia (HGPIN) was also investigated. Comparison was made with clinically detected PCa, both untreated and hormonally treated, and with androgen-independent PCa. Nineteen cystoprostatectomy (CyP) and 44 radical prostatectomy specimens (25 untreated and 19 hormonally treated) with pT2a Gleason score 6 cancer and HGPIN were used in this study. It also included 9 specimens of transurethral resection of the prostate with hormone-independent cancer and 8 cases of normal prostate tissue from CyP specimens without PCa and prostatic intraepithelial neoplasia. HER2 protein and Ki-67 were investigated immunohistochemically. Patients with immunohistochemical scores of 2+ and 3+ were considered to have HER2 overexpression (HercepTest method). Dual-color fluorescence in situ hybridization analysis was performed using the CEP-17/HER dual probe combination. High-grade prostatic intraepithelial neoplasia showed HER2 overexpression in 26% of the CyP cases and in 40% and 83% of the untreated and treated cases, respectively. Prostate cancer showed HER2 overexpression in 16% of cases in the CyP group and in 36% and 47.5% in the untreated and treated groups, respectively. HER2 overexpression was present in 78% of androgen-independent cancers. HER2 gene amplification was seen in a small proportion of nuclei and some of the cases. In HGPIN, it ranged from 1.1% (in 5 cases) in the CyP group to 2.1% (in 10 cases) and 1.9% (in 6 cases) in the untreated and treated groups, respectively. In PCa, the proportion of nuclei with gene amplification was 0.7% (in 3 cases) in the CyP group, 2.6% (in 10 cases) and 2.5% (in 12 cases) in the untreated and treated groups, respectively, and 9% (in 6 cases) in the androgen-independent PCa. Ki-67 expression in HGPIN and PCa in CyP specimens was lower than in the radical prostatectomies and cases of transurethral resection of the prostate. Our findings in the current HER2-related study indicate that incidentally detected cancer has features of less aggressiveness than clinically detected cancer. This may contribute to a better understanding of the results obtained in screening programs where insignificant cancers are detected along with clinically significant cancers.

Should Men with Serum Prostate-Specific Antigen ≤4 ng/ml and Normal Digital Rectal Examination Undergo a Prostate Biopsy?

The clinical significance of a prostate cancer (PCa) cannot be determined solely by tumor volume (< or =0.5 cm(3)), as small tumors of higher Gleason grade and tumors occurring in younger men may become clinically significant even though the initial volume at diagnosis is small. A certain number of these minimal cancers are likely to remain clinically insignificant; however, it is unpredictable how many can progress beyond the curable stage by the time there is a rise in serum prostate-specific antigen (PSA) values. Compared to clinically detected PCa, PCa detected exclusively by PSA screening (clinical stage T1c) are less likely to be advanced but no more likely to be insignificant in terms of volume, pathologic stage, and Gleason pattern. Only 10-15% of PSA-detected cancers have the features of PCa found at autopsy or in cystoprostatectomy specimens. Actually, 25-30% of PCa are detected with PSA values between 2.5 and 4 ng/ml, and most of these cancers are clinically significant. Evidence from both retrospective and longitudinal studies has shown that the risk of a PCa is dependent on the patient's age and the initial serum PSA. This allows an individualized approach to PCa screening programs, and PSA cutoff values for biopsy indication may be lowered in selected patients.

Alteration of proliferation and apoptotic markers in normal and premalignant tissue associated with prostate cancer

Background

Molecular markers identifying alterations in proliferation and apoptotic pathways could be particularly important in characterizing high-risk normal or pre-neoplastic tissue. We evaluated the following markers: Ki67, Minichromosome Maintenance Protein-2 (Mcm-2), activated caspase-3 (a-casp3) and Bcl-2 to determine if they showed differential expression across progressive degrees of intraepithelial neoplasia and cancer in the prostate. To identify field effects, we also evaluated whether high-risk expression patterns in normal tissue were more common in prostates containing cancer compared to those without cancer (supernormal), and in histologically normal glands adjacent to a cancer focus as opposed to equivalent glands that were more distant.

Methods

The aforementioned markers were studied in 13 radical prostatectomy (RP) and 6 cystoprostatectomy (CP) specimens. Tissue compartments representing normal, low grade prostatic intraepithelial neoplasia (LGPIN), high grade prostatic intraepithelial neoplasia (HGPIN), as well as different grades of cancer were mapped on H&E slides and adjacent sections were analyzed using immunohistochemistry. Normal glands within 1 mm distance of a tumor focus and glands beyond 5 mm were considered "near" and "far", respectively. Randomly selected nuclei and 40 × fields were scored by a single observer; basal and luminal epithelial layers were scored separately.

Results

Both Ki-67 and Mcm-2 showed an upward trend from normal tissue through HGPIN and cancer with a shift in proliferation from basal to luminal compartment. Activated caspase-3 showed a significant decrease in HGPIN and cancer compartments. Supernormal glands had significantly lower proliferation indices and higher a-casp3 expression compared to normal glands. "Near" normal glands had higher Mcm-2 indices compared to "far" glands; however, they also had higher a-casp3 expression. Bcl-2, which varied minimally in normal tissue, did not show any trend across compartments or evidence for field effects.

Conclusion

These results demonstrate that proliferation and apoptosis are altered not only in preneoplastic lesions but also in apparently normal looking epithelium associated with cancer. Luminal cell expression of Mcm-2 appears to be particularly promising as a marker of high-risk normal epithelium. The role of apoptotic markers such as activated caspase-3 is more complex, and might depend on the proliferation status of the tissue in question.