A UK-based investigation of inter- and intra-observer reproducibility of Gleason grading of prostatic biopsies

AIMS

The frequency of prostatic core biopsies to detect cancer has been increasing with more widespread prostate specific antigen (PSA) testing. Gleason score has important implications for patient management but morphological reproducibility data for British practice are limited. Using literature-based criteria nine uropathologists took part in a reproducibility study.

METHODS

Each of the nine participants submitted slides from consecutive cases of biopsy-diagnosed cancer assigned to the Gleason score groups 2-4, 5-6, 7 and 8-10 in the original report. A random selection of slides was taken within each group and examined by all pathologists, who were blind to the original score. Over six circulations, new slides were mixed with previously read slides, resulting in a total of 47 of 81 slides being read more than once.

RESULTS

For the first readings of the 81 slides, the agreement with the consensus score was 78% and overall interobserver agreement was kappa 0.54 for Gleason score groups 2-4, 5-6, 7, 8-10. Kappa values for each category were 0.33, 0.56, 0.44 and 0.68, respectively. For the 47 slides read more than once, intra-observer agreement was 77%, kappa 0.66. The study identified problems in core biopsy interpretation of Gleason score at levels 2-4 and 7. Patterns illustrated by Gleason as 2 tended to be categorized as 3 because of the variable acinar size and unassessable lesional margin. In slides with consensus Gleason score 7, 13% of readings were scored 6 and in slides with consensus 6, 18% of readings were scored 7.

CONCLUSIONS

Recommendations include the need to increase objectivity of the Gleason criteria but limits of descriptive morphology may have to be accepted.

A study of Gleason score interpretation in different groups of UK pathologists; techniques for improving reproducibility

AIMS

To test the effectiveness of a teaching resource (a decision tree with diagnostic criteria based on published literature) in improving the proficiency of Gleason grading of prostatic cancer by general pathologists.

METHODS

A decision tree with diagnostic criteria was developed by a panel of urological pathologists during a reproducibility study. Twenty-four general histopathologists tested this teaching resource. Twenty slides were selected to include a range of Gleason score groups 2-4, 5-6, 7 and 8-10. Interobserver agreement was studied before and after a presentation of the decision tree and criteria. The results were compared with those of the panel of urological pathologists.

RESULTS

Before the teaching session, 83% of readings agreed within +/- 1 of the panel's consensus scores. Interobserver agreement was low (kappa = 0.33) compared with that for the panel (kappa = 0.62). After the presentation, 90% of readings agreed within +/- 1 of the panel's consensus scores and interobserver agreement amongst the pathologists increased to kappa = 0.41. Most improvement in agreement was seen for the Gleason score group 5-6.

CONCLUSIONS

The lower level of agreement among general pathologists highlights the need to improve observer reproducibility. Improvement associated with a single training session is likely to be limited. Additional strategies include external quality assurance and second opinion within cancer networks.

The feasibility and results of a population-based approach to evaluating prostate-specific antigen screening for prostate cancer in men with a raised familial risk

The feasibility of a population-based evaluation of screening for prostate cancer in men with a raised familial risk was investigated by studying reasons for non-participation and uptake rates according to postal recruitment and clinic contact. The levels of prostate-specific antigen (PSA) and the positive predictive values (PPV) for cancer in men referred with a raised PSA and in those biopsied were analysed. First-degree male relatives (FDRs) were identified through index cases (ICs): patients living in two regions of England and diagnosed with prostate cancer at age ⩽65 years from 1998 to 2004. First-degree relatives were eligible if they were aged 45–69 years, living in the UK and had no prior diagnosis of prostate cancer. Postal recruitment was low (45 of 1687 ICs agreed to their FDR being contacted: 2.7%) but this was partly due to ICs not having eligible FDRs. A third of ICs in clinic had eligible FDRs and 49% (192 out of 389) agreed to their FDR(s) being contacted. Of 220 eligible FDRs who initially consented, 170 (77.3%) had a new PSA test taken and 32 (14.5%) provided a previous PSA result. Among the 170 PSA tests, 10% (17) were ⩾4 ng ml⁻¹ and 13.5% (23) tests above the age-related cutoffs. In 21 men referred, five were diagnosed with prostate cancer (PPV 24%; 95% CI 8, 47). To study further the effects of screening, patients with a raised familial risk should be counselled in clinic about screening of relatives and data routinely recorded so that the effects of screening on high-risk groups can be studied.

Allelic imbalance and biochemical outcome after radical prostatectomy

OBJECTIVE

To compare the incidence of allelic imbalance (AI) in men with rapid disease progression with those who remained disease free after radical prostatectomy, with the aim of identifying genetic markers to predict prognosis and guide further treatment.

PATIENTS AND METHODS

Tumour and normal DNA were extracted from two matched groups of 31 men with extracapsular node-negative (pT3N0) prostate cancer who had undergone radical prostatectomy. One group comprised men who developed biochemical recurrence within 2 years of surgery and one group were prostate-specific antigen (PSA) free for at least 3 years. Men were matched for Gleason grade, preoperative PSA and pathological stage. Analysis was performed by genotyping.

RESULTS

Allelic imbalance was analysed using 30 markers, and was seen in at least one marker in 57 (92%) of the cases. Deletion at marker D10S211 (10p12.1) was significantly more common in the relapse group than the non-relapse group (35 vs 5%, P=0.03).

CONCLUSIONS

This study demonstrates significant association between AI on chromosome 10 and biochemical progression after radical prostatectomy.

Handling and Reporting of Biopsy and Surgical Specimens of Testicular Cancer

This paper is the result of a meeting of the European Association of Pathologists, Uropathology Division in Florence 2003. The aims of this meeting were to establish: guidelines for specimen handling by urologists and minimum requirements for data accompanying testicular specimens submitted to pathologists; a consensus on techniques for processing specimens by pathologists; the essential information required from pathology reports; areas where our standard practice is traditional rather than evidence based and where further studies are required. The general aims of histopathology are to give or confirm a diagnosis; assess established prognostic markers; identify changes associated with treatment; provide information for audit (i.e. imaging, urology and pathology) and maintain a permanent record (slides/blocks).

A large prostate at radical retropubic prostatectomy does not adversely affect cancer control, continence or potency rates

OBJECTIVES

To determine the effect of a large prostate at radical retropubic prostatectomy (RRP) on the pathological outcome, biochemical recurrence rates, potency and continence.

PATIENTS AND METHODS

From a database of 440 patients treated with RRP, retrospective information was obtained on prostate weights, patient and tumour characteristics, and follow-up. Potency and continence after RRP was obtained using a self-reported validated questionnaire. Patients with prostates of > 75 or < or = 75 g were compared.

RESULTS

The median (range) prostate size was 87 (76-182) and 42 (4.1-75) g in the two groups. The response rate to the questionnaire was 78% (344 men). Patients with prostates of > 75 g were older, with a median (range) age of 65 (51-74) years, than the other group, at 61 (40-76) years (P = 0.01), and had higher initial prostate-specific antigen (PSA) levels, at 9.6 (3.4-37.8) and 7.6 (0.1-30.0) ng/mL, respectively (P = 0.001). Tumours within larger prostates were of a lower stage (P = 0.035), lower Gleason grade (median 6 and 7, P = 0.015), of smaller volume (median 1.0, 0.1-12.4; and 1.5, 0.1-21.1 mL; P = 0.04) and more often 'clinically insignificant' (23% and 6%, P = 0.001). There was no difference in the number or distribution of positive surgical margins. For a limited median follow-up of 20-25 months, patients with prostates of > 75 g were less likely to have biochemical recurrence (5% vs 24%, P < 0.001). Potency and continence rates were similar between the groups.

CONCLUSIONS

Prostate size at RRP does not affect the risk of impotence or incontinence afterward. A prostate of > 75 g is associated with a lower likelihood of PSA-relapse, potentially as a result of lead-time bias. While an enlarged prostate may contraindicate other potentially curative cancer treatments, the outcomes of RRP appear to be unaffected.

Incidental findings in pelvic lymph nodes at radical prostatectomy

AIMS

To assess the frequency and cause of incidental (non-metastatic) lymph node pathology discovered before or at radical prostatectomy.

METHODS

Eight hundred and fifty four consecutive lymphadenectomies received between 1988 and 2001 were reviewed. All had been processed and stained routinely. Additional techniques, indicated by morphology, were then performed.

RESULTS

Incidental pathology was found in 15 cases: florid sinus histiocytosis following prosthetic joint replacement (eight), non-caseating granulomas (three), small lymphocytic cell lymphoma (two), follicular lymphoma (one), and foreign body reaction (one). Incidental pathology was present in 1.8% of 854 patients who underwent pelvic lymphadenectomy during radical prostatectomy.

CONCLUSION

Awareness of possible non-metastatic lymph node pathology aids histological diagnosis and may be clinically relevant.

Screening for prostatic cancer and its evolution within Britain

The arguments for and against screening for prostatic cancer are frequently discussed (Albertsen PC. Screening for prostate cancer is neither appropriate nor cost-effective. Urol Clin North Am 1996; 23: 521-530; Schroder FH, Alexander FE, Bangma CH, Hugosson J, Smith DS. Screening and early detection of prostate cancer. Prostate 2000; 44: 255-263). In contrast, this paper outlines how screening became possible, why the decision was made not to initiate a national screening programme in Britain, the other pathways being pursued, and the current problems, in particular the issue of histopathology workload.

Anterior prostate cancer: is it more difficult to diagnose?

OBJECTIVE; To determine whether anterior prostatic tumours are adequately sampled using the Stamey sextant protocol, as a fifth of prostate cancers are anterior in distribution at radical prostatectomy.

MATERIALS AND METHODS

All tumours (62) with an anterior distribution (>or=75% of the tumour anterior to the urethra) on radical prostatectomy whole-mounts, and in which the number and results of the sextant biopsies were available, were extracted from a prostate cancer database. Sixty-one posterior tumours (>or=75% of the malignant tissue posterior to the urethra) and their corresponding sextant biopsies were also retrieved for comparison. The number of biopsy sessions, the number of cores involved and the summated tumour length were recorded, together with the prostate gland weight, the tumour volume and the site of >or=75% of tumour in the superior-inferior axis.

RESULTS

Anterior tumours required significantly more biopsy sessions to diagnose prostate cancer than posterior neoplasms (anterior, one set 47; > one set 15; posterior, one set 57; > one set, four, P=0.007). Anterior tumours had fewer cores with tumour involvement and less summated tumour length than had posterior cancers. The mean (sd) number of positive cores was; anterior 1.8 (1.01), posterior 2.50 (1.30) (P=0.001); the summated tumour length was; anterior 5.05 (4.10) mm, posterior 9.25 (7.80) mm (P<0.001). There was no significant difference in gland weight (mean anterior 43.8 g; posterior 48.3 g, P=0.3) or tumour volume (mean anterior 1.85 mL; posterior 1.49 mL, P=0.11) between the groups. There was no significant difference between the incidence of anterior and posterior neoplasms with respect to their position in the superior-inferior axis (P=0.96).

CONCLUSIONS

Anterior prostate tumours account for 21% of all prostate cancers. They more often require multiple sets of sextant biopsies for diagnosis, and yield smaller areas of cancer on core biopsies than do posterior tumours in glands of similar weight and tumour volume. If prostate cancer is suspected clinically but biopsies are negative, targeting the anterior gland at subsequent prostatic biopsy should be considered.

The role of the histopathologist in the management of testicular germ cell tumour in adults

In the last 20--30 years the availability of effective chemotherapy and more accurate clinical staging has greatly improved the prognosis for patients with testicular germ cell tumours. Initially, such treatment appeared to diminish the role of histopathology to the distinction between seminoma and nonseminomatous germ cell tumour (NSGCT) in the primary specimen. However, histopathology has evolved as a prognostic tool indicating the risk of relapse in various defined clinical contexts thereby facilitating therapeutic decisions. The clinical emphasis has been on quality of life and reduction of therapy both in terms of the number of patients treated and the number of chemotherapy courses given to each patient. The treatment of adult testicular germ cell tumours may differ between countries but protocols are established. Therefore it is appropriate to discuss the role of histopathology during this era of relative therapeutic stability.

Treating the human bladder with capsaicin: is it safe?

OBJECTIVES

Although human contact with capsaicin has occurred over thousands of years, some uncertainty surrounds its status as a possible carcinogen. This is the first report of bladder biopsies from patients who have been treated with capsaicin over a 5-year period.

METHODS

Between 1991 and 1996, 20 patients (9 males, 11 females; mean age 52.5 years, range 40-70 years) with intractable detrusor hyperreflexia have had repeated instillations of intravesical capsaicin (1-2 mmol/l). The number of treatments per patient varied between 1 and 17 (total = 82; average 6/patient). The surveillance programme involved repeated flexible cystoscopy and bladder biopsies before and after capsaicin. Cryostat sections were stained with haematoxylin-eosin and examined by light microscopy.

RESULTS

None of the bladder biopsies have shown metaplasia, dysplasia, flat carcinoma in situ, papillary or solid invasive cancer.

CONCLUSIONS

No pre-malignant of malignant change has been found in biopsies of patients who had repeated capsaicin instillations for up to 5 years. However, as the morphological effects of chemical carcinogens may not be apparent for 10 years, further surveillance is being continued.

Accuracy and cost of intraoperative lymph node frozen sections at radical prostatectomy

AIM

To assess the value of intraoperative diagnostic examination of frozen sections of lymph nodes removed during radical prostatectomy.

METHODS

Pelvic lymph nodes from patients with prostatic carcinoma were obtained (1) as frozen sections during radical prostatectomy, to exclude patients from non-curative surgery, and (2) as paraffin sections postoperatively from lymphadenectomy performed at radical prostatectomy, to stage the tumour and assess need for adjuvant treatment. Findings from the two approaches were used to assess the accuracy and cost of frozen section diagnosis, and to judge the results of omitting intraoperative diagnosis.

RESULTS

In 82 patients frozen section revealed metastasis in six (7.3%), and metastases were found in a further four (4.9%) on paraffin sections (false negatives). Of the 195 patients undergoing staging lymphadenectomy (without frozen section), metastatic cancer was seen in nine cases (4.6%). The frozen section cost of metastatic cancer detection per patient was calculated as 7516 Pounds (550 Pounds x 82/6), with an associated false negative rate of 33%.

CONCLUSIONS

Frozen section diagnosis of metastatic carcinoma in pelvic lymph nodes before radical prostatectomy has a high false negative rate and is costly. It may not be justified with the observed low incidence of lymph node metastasis.

Prognostic markers in clinically localised prostate cancer

The prognostic value of immunohistochemical staining of P53, BCL-2, p27kip1, PSA, AR and MIB-1 was compared with that of established prognostic variables (Gleason score, surgical margins, tumour volume) following radical prostatectomy. Five groups were selected: negative margins with stable serum PSA (n=11), negative margins with rising serum PSA (n=7), positive margins with stable serum PSA (n=7), positive margins with rising serum PSA (6) and patients with micrometastatic disease diagnosed in lymph nodes removed during radical prostatectomy (n=8). Gleason score and tumour volume were of prognostic significance and immunohistochemical staining for MIB-1 and BCL-2 showed added independent prognostic significance in multivariate analysis.

Postchemotherapy residual masses in germ cell tumor patients: content, clinical features, and prognosis. Medical Research Council Testicular Tumour Working Party

BACKGROUND

In a retrospective study that included a detailed histopathologic review, the clinicopathologic features of patients with germ cell tumors (GCT) and resectable residual masses after chemotherapy were assessed.

METHODS

Histologic material from 153 patients was available for review. Recorded details included primary histologic diagnosis, location, size and number of metastases, marker levels before and after chemotherapy, and completeness of surgical excision. A median of seven histologic sections per resection were reviewed by two pathologists independently (and together when disagreement occurred). In each case, details were recorded regarding fibrosis, necrosis, hemorrhage, embryonal carcinoma (undifferentiated teratoma), yolk sac tumor, choriocarcinoma (trophoblastic tumor), differentiated teratoma (mature and immature), dysplasia in somatic tissues, and non- germ cell tumor (GCT) malignancies. The percentage of the sample that each of these components comprised was also estimated.

RESULTS

The median postchemotherapy follow-up time was 7 years, and 38 of 153 patients (25%) experienced disease progression. In a multivariate analysis, incomplete resection of all residual masses (in 38 patients) and the presence of malignant elements (in 23 patients) were independent risk factors for progression. In the subset of patients in whom all masses were completely resected, the presence of embryonal carcinoma (undifferentiated teratoma) was the single most significant risk factor for progression. Seven percent of patients had this factor, which was associated with a 2-year progression free survival rate of 12.5%, compared with 88.0% where this component was absent.

CONCLUSIONS

Progression free survival can be predicted well by the completeness of excision of residual masses and the presence of malignant germ cell elements. The latter confers a relatively poor prognosis even if all of these elements are completely resected.

Intratubular germ cell neoplasia of the contralateral testis in testicular cancer: defining a high risk group

PURPOSE

We define a group of testis cancer patients who are at high risk for carcinoma in situ of the contralateral testis and, therefore, a second germ cell tumor.

MATERIALS AND METHODS

The histology was reviewed in 186 testis cancer patients who underwent contralateral testicular biopsy either because of a history of testicular maldescent or an atrophic contralateral testis (defined as a volume of 12 ml. or less). Testicular volume, semen analysis, serum gonadotropin levels, serum testosterone and estradiol levels were assessed in the majority of patients.

RESULTS

Univariate analyses identified contralateral testicular atrophy, low sperm density, young age at presentation and low Johnsen score as factors associated with increased risk of a positive biopsy. A history of maldescent in the absence of atrophy was associated with carcinoma in situ prevalence of only 4%. Multivariate analysis identified only testicular atrophy and age at presentation as independent determinants of a positive biopsy. Testis cancer patients with a small contralateral testis had a 20% and those presenting at age 30 years or younger had a 34% prevalence, respectively, of carcinoma in situ on contralateral testis biopsy (95% confidence interval 20 and 46%, respectively).

CONCLUSIONS

Testis cancer patients with an atrophic contralateral testis who present before the age of 31 years are at high risk for carcinoma in situ of the contralateral testis and, therefore, a second germ cell tumor. It is estimated that this group comprises 6% of all testis cancer patients. We predict that a policy of performing contralateral testicular biopsy will produce positive results for carcinoma in situ in a third of these patients and will detect contralateral carcinoma in situ in approximately 40% of all testis cancer patients.

Clinical aspects associated with Sertoli-cell-only histology

OBJECTIVE

To assess the clinical features found in infertile men in whom the histological diagnosis of Sertoli-cell-only (SCO) was made on testicular biopsy.

PATIENTS AND METHODS

A retrospective review was carried out of the seminal fluid analysis, testis size and follicle-stimulating hormone (FSH) levels of 72 men who had bilateral testicular biopsies due to infertility when one (30) or both (42) of bilateral testicular biopsies showed tubules containing only Sertoli cells. In a subgroup of 15 men, the biopsies were re-examined to correlate the morphological features with the plasma FSH level.

RESULTS

When both biopsies showed bilateral SCO the patient had azoospermia (86%) or oligozoospermia (14%); the testicular size was normal in 36% and the FSH level was normal (43%), raised (21%) or grossly elevated (more than twice normal, 36%). When one biopsy showed SCO, the opposite testis showed appearances which varied from grossly impaired spermatogenesis to almost normal spermatogenesis. The clinical findings were also very variable.

CONCLUSIONS

The clinical features associated with the histological diagnosis of SCO are extremely variable. Biopsy evidence of bilateral SCO cannot be relied upon to indicate a total absence of spermatogenesis in the testes.

Histological changes associated with long-term urethral stents

OBJECTIVE

To assess the histological changes found in patients with long-term external sphincter, prostatic and urethral stents.

PATIENTS AND METHODS

Eighteen patients with long-term stents (mean time since insertion 3.5 years) were investigated. Three had external sphincter stents for detrusor-sphincter dyssynergia secondary to spinal injury, eight had prostatic stents for obstruction secondary to benign prostatic hyperplasia and seven had urethral stents for recurrent strictures. Nine stents were occluded at investigation, of which seven were entirely removed. The mucosae overlying the remaining two were biopsied, as were mucosae over the nine patent stents, at urethroscopy.

RESULTS

The changes observed included polypoid hyperplasia (11 of 18 patients) between and around the stent mesh wires, nonkeratinizing squamous metaplasia (two) or hyperkeratotic squamous metaplasia (seven), chronic inflammation (15) with prominent plasma cell infiltrates (11), variable foreign-body granuloma (two) and microabscess formation (five), usually associated with clefts formed around the stent wires (three of five).

CONCLUSION

Stents become incorporated into the urethral wall by a process of polypoid hyperplasia through the stent mesh, with at least focal covering of the stent in most cases, and with variable inflammatory infiltrates, most of which are rich in plasma cells. The urothelial and connective tissue proliferation resulted in obstruction of the stent lumen in nine of the patients studied. Further long-term study is necessary to exclude the development of carcinoma in patients with keratinizing squamous metaplasia, although no malignancy was seen in this study.

Prevalence of prostatic intra-epithelial neoplasia (PIN) in biopsies from hospital practice and pilot screening: clinical implications

As high grade PIN is commonly associated with concomitant cancer, current literature recommends re-biopsy of patients with high grade PIN. This paper describes the prevalence of high grade prostatic intra-epithelial neoplasia (PIN) from three independent clinical settings, reported by a single pathologist (MCP). High grade PIN was diagnosed in biopsies from 131 of the 1205 (11%) of patients in whom cancer was suspected in hospital practice, 42 of the 202 (20%) asymptomatic men screened for prostate cancer and 29 of the 118 (25%) patients presenting with prostatism in a case finding study. Re-biopsy on this scale has major clinical and cost implications. However, from a literature review, there is evidence to suggest that the risk of concomitant cancer with high grade PIN may be stratified according to serum PSA. This opinion should be tested prospectively.

Lesions produced by the extravasation of urine from the upper urinary tract

We present six cases which illustrate the spectrum of clinical features, macroscopic findings and light microscopic findings of urine extravasation from the upper urinary tract. The early lesions are characterized macroscopically by an oedematous, glistening or gelatinous appearance to the renal perihilar and peripelvic fat. Light microscopically there is lipolysis with associated foamy macrophages, multinucleate giant cells and lymphocytes. Immunohistochemical staining for Tamm-Horsfall protein is strongly positive in the extracellular space and in the foamy macrophages confirming urine extravazation. Later lesions are characterized by cicatrization of fibrous tissue around the renal pelvis and hydronephrosis. Microscopically there is relatively bland fibrosis with occasional lymphocytes and histiocytic cells. The late lesions are also characterized by extracellular deposits of weakly eosinophilic, granular or hyaline material, the so called 'urinary precipitates'. These deposits stain strongly with diastase PAS and weakly positive for Tamm-Horsfall protein. The staining of these urinary precipitates is analogous to renal tubular hyaline casts, thus supporting the theory that they are derived from uroproteins. We consider that these deposits are pathognomic of past urine extravasation.

Ki-67 expression in early prostate cancer and associated pathological lesions

AIM

To assess cell proliferation in early prostate cancer and associated pathological lesions.

METHODS

Using the Ki-67 antibody, the cell proliferation index was measured in early stage prostatic carcinoma in 37 incidental tumours diagnosed at transurethral prostatectomy (TURP) and in 20 low volume cancers treated by radical prostatectomy. Proliferation indexes have also been measured in areas of normal peripheral zone, transition zone hyperplasia, atrophic appearing lobules, and high grade prostatic intraepithelial neoplasia in the radical prostatectomy cases.

RESULTS

In the TURP series the proliferation index correlated with grade and stage. Logistic regression analysis, however, showed that Gleason grade was the most reliable predictor of biopsy proven residual disease and clinical progression. In the radical series transition zone carcinoma the proliferation index was half that of peripheral zone carcinoma. The atrophic lobules also showed a high proliferation index of the same order as seen in the peripheral zone carcinoma. Normal peripheral zone showed the lowest proliferation index and in hyperplastic transition zone it was also less than the other areas.

CONCLUSIONS

There is only limited support for the correlation of proliferation index with grade in early stage prostatic carcinoma. The findings do not suggest that proliferation index adds to the prognostic information given by grade and stage in pT1 disease. The significant difference in proliferation index in transition zone and peripheral zone carcinomas supports the morphological distinction of these tumour types and is consistent with differences in biological behaviour. The high proliferation index in lobules considered morphologically atrophic is reminiscent of previous observations in which carcinoma was spatially associated with atrophy.

Short-course adjuvant chemotherapy in high-risk stage I nonseminomatous germ cell tumors of the testis: a Medical Research Council report

PURPOSE

This United Kingdom Medical Research Council (UK-MRC) study prospectively evaluated efficacy and long-term toxicity of adjuvant chemotherapy in high-risk stage I nonseminomatous germ cell tumors of the testis (NSGCTT).

PATIENTS AND METHODS

Eligible patients were those identified by the local histopathologist as having features confirmed in MRC surveillance studies to indicate an approximate 50% risk of relapse. Central histopathology review was undertaken. Chemotherapy consisted of two courses of cisplatin 100 mg/m2, bleomycin 30 mg weekly x 3, and etoposide 120 mg/m2 x 3, every 21 days (BEP).

RESULTS

One hundred fourteen eligible cases were enrolled. Median time of follow-up was 4 years, with 93 patients followed-up for at least 2 years. There have been two relapses, including one patient who did not have a germ cell tumor (GCT), according to the reference histopathologist. This patient is alive with active disease, the other has died. There was one death after a cerebrovascular accident during treatment. Assessment of fertility, lung function, and audiometry pretreatment and more than 9 months posttreatment indicated no clinically significant changes. A mean decrease in transfer factor coefficient (KCO) of 15% of the predicted value was noted, but no patient had symptomatic respiratory dysfunction.

CONCLUSION

There have been only two relapses among 114 cases of high-risk stage I NSGCTT treated with two courses of adjuvant BEP chemotherapy. The 95% confidence interval (CI) excludes a true relapse rate of more than 5%. Of 104 patients confirmed on histopathology review to have GCT, there has been only one relapse. Adjuvant chemotherapy is free from significant long-term toxicity, offering an effective alternative to surveillance or retroperitoneal lymph node dissection (RPLND) followed by surveillance, and may be preferred by some patients.

Paratesticular sarcomas revisited: a review of cases in the British Testicular Tumour Panel and Registry

OBJECTIVE

To assess differences in the histopathological diagnoses of a series of paratesticular sarcomas following changes in the morphological classification of these tumours and the availability of investigations to define their immunophenotype, and to consider the impact of these changes on clinical management.

MATERIALS AND METHODS

Thirty-six soft tissue tumours of the paratesticular region, originally submitted to the British Testicular Tumour Panel and Registry between 1958 and 1967 were re-examined histologically using modern diagnostic criteria, including immunohistochemical features. Where possible, follow-up was brought up to date.

RESULTS

Thirteen (35%) of the diagnoses made in 1967 were changed; of these, seven changes were attributable to the results of immunohistochemical tests and one involved the identification of an entity not recognized in 1967 (spindle cell rhabdomyosarcoma).

CONCLUSION

The changes in diagnoses of major clinical relevance involved three neoplasms (8%) in which the recent opinion was rhabdomyosarcoma, a tumour for which successful treatment protocols are currently available.

Pre-neoplastic lesions of the prostate

Acinar carcinoma of the prostate is the third most frequently registered cancer and its incidence is expected to increase as life expectancy increases. Consequently, there have been attempts to introduce possible screening programmes for early detection of prostatic carcinoma. In this context the histopathologist has a role in that potential pre-neoplastic lesions have to be recognized. Two such pre-neoplastic lesions in the prostate are adenomatous hyperplasia and prostatic intraepithelial neoplasia. In this article the histological features of these lesions, their differential diagnosis and their pre-malignant potential are reviewed.

ACP Broadsheet No 146: August 1995. Macroscopic examination of prostatic specimens

Images

Vesical clear cell adenocarcinoma. V. Nephrogenic adenoma: a diagnostic problem

Following the diagnosis of nephrogenic adenoma in a bladder lesion, which was later interpreted as early clear cell adenocarcinoma, the morphological and immunocytochemical features of these two lesions were reviewed to see if differences could be established for future diagnostic application. The architecture, extent, cell type, nuclear pleomorphism, presence of mitotic figures and glycogen content were recorded in 28 nephrogenic adenomas and the clear cell carcinoma. Similarly, the immunoreactivity for CAM 5.2, LP34, EMA and CEA of 10 nephrogenic adenomas and the clear cell carcinoma were compared. Proliferation rate in five nephrogenic adenomas and the carcinoma was assessed by antibody M1B1. Many of the features showed differences in degree or extent (clear cell change, nuclear pleomorphism, CAM 5.2 and CEA positivity). The only features distinct to clear cell carcinoma were the presence of solid islands, mitoses greater than 1/10 HPF (HPF area = 0.4 mm2) and M1B1 counts in excess of 29/200 in clear cell carcinoma (range 30/200-83/200). Only the high M1B1 count was present in the first biopsy of the clear cell carcinoma.

Carcinoma in situ in boys with cryptorchidism: when can it be detected?

OBJECTIVE

To investigate the possibility of a pre-invasive phase of adult germ cell tumours being detectable in childhood.

PATIENTS AND METHODS

Seventy testicular biopsies were examined which had been taken at orchidopexies from 57 patients aged 1 to 16 years during the period 1951-1973, and for whom follow-up data on cancers and deaths up to 1989 were available.

RESULTS

Malignant germ cell tumours had developed in three testes from which biopsies were available: a right-sided teratoma and left-sided mixed germ cell tumour in one patient and a left-sided teratoma in a second patient. Carcinoma in situ was seen in only one of the 70 biopsies. This biopsy was taken from a patient aged 16 years and preceded the appearance of a teratoma by 4 years. Carcinoma in situ was not seen in a biopsy of this testis carried out 11 years before tumour diagnosis. Carcinoma in situ was also not seen in a biopsy of the contralateral testis in this patient carried out 22 years before tumour diagnosis in the testis, nor was it observed in a biopsy 17 years before the development of malignancy in the second patient.

CONCLUSION

These findings bring into question the extent to which the appearance of testicular biopsies taken during childhood orchidopexy can exclude the development of a tumour in adult life. No evidence has been found in this study for histological pre-malignant changes occurring before the onset of puberty.

Unilateral testicular obstruction: orchidectomy or reconstruction?

Unilateral testicular obstruction can cause infertility in man by reducing sperm output, or by stimulating antisperm antibody production. Amongst 125 subfertile men with unilateral blocks, the causes were defined as post-infective (n = 72), post-traumatic (n = 41) or congenital (n = 12) by surgical exploration. Of these, 50 had severe oligozoospermia or azoospermia, and another 30 had oligozoospermia; 67 had significantly raised serum antisperm antibody titres. The outflow tracts were reconstructed in 87 men, while in 24 the obstructed testis was removed and replaced with a prosthesis. Follow-up information is available in 104 men. Reconstruction produced significant improvement in sperm concentration in the ejaculate but little change in antisperm antibody titres. Orchidectomy lowered seminal plasma antibody titres and had no effect on sperm output. Orchidectomy plus prednisolone was most effective in terms of pregnancies produced in the female partners. Testicular biopsies showed that spermatogenesis was normal on the side of the block in 90% of cases, whereas it was impaired in the contralateral testis in 40% of men. Although sperm output can be improved by reconstruction, the stimulus to antibody production is more reliably eliminated by orchidectomy. Sperm concentration, antisperm antibody titres and bilateral testicular biopsy results should be taken into account before making a final therapeutic recommendation in men with unilateral testicular obstruction.

Cystic hamartoma of the renal pelvis

We describe three hitherto undocumented cases of renal lesion in the adult age group that share a similar site and histological features. They are three adult women, with a short clinical history of pain and an abdominal mass. A partial or complete nephrectomy resulted in clinical cure. All cases showed an intrarenal multicystic mass situated adjacent to the pelvicalyceal system. These vaguely circumscribed lesions had no true capsule and blended in with the adjacent renal parenchyma. The histological appearance was distinctive and characterised by disorderly biphasic proliferation of epithelial and mesenchymal elements. The epithelial component consisted of tubules and cysts lined by cuboidal and columnar epithelium showing focal oncocytic changes. The stroma was cellular and predominantly fibroblastic with scattered bundles of smooth muscle cells. Despite extensive sampling, blastemal cells were not identified. The tubular epithelium was positive for CAM 5.2, epithelial membrane antigen, carcinoembryonic staining, and vimentin immunostaining. The stroma stained positively for vimentin and smooth muscle bundles for alpa smooth muscle actin and desmin. The cytological appearances of these lesions were benign. We propose that these are benign hamartomatous lesions arising as a result of faulty focal embryogenesis. They are distinct from well recognised lesions such as multilocular cysts, partially differentiated nephroblastomas, mesoblastic nephromas, and nephrogenic adenofibromas.

Risk factors for carcinoma in situ of the contralateral testis in patients with testicular cancer. An interim report

In a study aimed at evaluating risk factors for carcinoma in situ (CIS) in the contralateral testis of selected patients with testicular cancer, information from 89 patients who have had contralateral testicular biopsies is available. The biopsies were performed because of the coexistence of the previously established risk factors - atrophy of the remaining testis, or a history of maldescent. CIS was diagnosed in 13% of patients, the prevalence being the same for both open and needle biopsies. Compared to its overall prevalence in the contralateral testis in testicular cancer an increased risk of CIS has been found in clinically atrophic testes but has not been found for maldescent. Patients found to have CIS were younger than those in whom it was not detected.

Prostatic 'capsule'--a comparative study of histological and ultrasonic appearances

The histological and transrectal ultrasound (TRUS) appearances at corresponding sites of the periphery of the prostate gland have been compared in 30 benign and 27 malignant glands taken at autopsy. In the benign series, the histological capsule was frequently absent and correlated poorly with the consistent TRUS findings of a regular, well-defined 'ultrasonic capsule'. It is concluded that 'the capsule' should be replaced as a tumour-staging landmark by a more realistic terminology. Carcinoma may be described as intra- or extra-prostatic, or confined or unconfined with respect to the gland. In the malignant glands, there was no correlation between morphologically unconfined cancers and irregular or absent ultrasound 'capsule' when corresponding areas were compared. This disparity must contribute to an underestimation of tumour extent with TRUS.

Medical Research Council prospective study of surveillance for stage I testicular teratoma. Medical Research Council Testicular Tumors Working Party

PURPOSE

A prospective study of surveillance after orchidectomy alone in patients with stage I nonseminomatous germ cell testicular tumor (NSGCT) was performed to determine the relapse-free rate and to identify the histologic criteria that predict for relapse.

PATIENTS AND METHODS

Three hundred ninety-six patients from 16 United Kingdom and one Norwegian centers were entered onto the study between January 1, 1984 and October 1, 1987 of whom 373 were eligible for analysis. In a previous retrospective study, we defined a prognostic index based on histologic criteria that identified a group of patients with a high risk of relapse. This index was based on the presence of venous and lymphatic invasion, undifferentiated cells, and the absence of yolk sac elements in the primary tumor.

RESULTS

The 2-year actuarial relapse-free rate after orchidectomy was 75% (95% confidence interval, 71% to 79%), and the rate at 5 years was 73%. Five patients died of tumor or treatment-related complications, which resulted in a 5-year survival of 98%. The relapse-free rate in patients with three or four risk factors was 54%.

CONCLUSIONS

This study confirms the safety of surveillance as a method of management and identifies a group of patients with a high risk of relapse. A prospective phase II study has been initiated to determine whether two courses of platinum-based adjuvant chemotherapy will prevent relapse in these high-risk patients.

Does DNA flow cytometry give useful prognostic information in renal parenchymal adenocarcinoma?

DNA ploidy and S-phase fraction (SPF) were measured by flow cytometry on 381 paraffin blocks from 93 unselected primary renal parenchymal adenocarcinomas (RPA). The results were compared with tumour grade and T category and patient survival, with a mean follow-up of 87 months. Only 21% of the tumours were uniformly diploid and ploidy was heterogeneous in 49% of cases. DNA ploidy and SPF were significantly associated with grade, but not T category of disease. Both flow cytometric parameters were significantly related to survival in a univariate analysis. However, when tumour grade was taken into account, both DNA ploidy and SPF lost their prognostic significance. Thus, neither of these parameters gave prognostic information additional to that provided by tumour grade in unselected cases of primary RPA.

Outcome in carcinoma in situ of bladder treated with intravesical bacille Calmette-Guérin

Fifty-three patients with carcinoma in situ of the bladder were treated with Evans strain BCG given intravesically. Complete remission was achieved after either one or two 6-weekly courses in 53% of patients. The median duration of remission was 32 months. Treatment-related bladder symptoms were minor during the first course, more severe during the second. There was no relation between severity of symptoms and likelihood of response. With a median follow-up of 32 months, disease progression has occurred in 10% of complete responders, whereas failure to respond on either cystoscopic, histological or cytological grounds was associated with a 48% progression rate. Although intravesical BCG produces impressive responses in carcinoma in situ of the bladder, managed conservatively the condition remains a dangerous one.

Treatment of advanced localised prostatic cancer by orchiectomy, radiotherapy, or combined treatment. A Medical Research Council Study. Urological Cancer Working Party--Subgroup on Prostatic Cancer

A total of 277 patients with apparently localised prostatic cancer (T2-T4 NXMO) were allocated at random to receive radiotherapy alone (88), orchiectomy alone (90) and combined therapy (99) between 1980 and 1985. The main outcome measures were survival, time to appearance of metastases and treatment of local disease progression by further transurethral resection. Orchiectomy, whether alone or with radiotherapy, produced a significant delay in detection of metastases when compared with radiotherapy alone. There were no statistically significant differences between the 3 treatment groups in local disease control or in overall survival.

The Second Medical Research Council study of prognostic factors in nonseminomatous germ cell tumors. Medical Research Council Testicular Tumour Working Party

PURPOSE

To assess prognostic factors in a large population of patients with metastatic nonseminomatous germ cell tumors (NSGCT) arising in gonadal or extragonadal sites.

PATIENTS AND METHODS

Data from 795 patients treated with chemotherapy between 1982 and 1986 in 13 centers were analyzed. Particular emphasis was placed on exact tumor measurements (eg, size of nodal masses, number of lung metastases), and the diagnostic pathology was also reviewed. Cox regression analysis was performed on these data. The patients were treated with a variety of cisplatin-containing chemotherapy regimens, 86% of which included etoposide.

RESULTS

With median follow-up of 45 months, overall 3-year survival is 85%. The independently adverse features proved to be (1) the presence of liver, bone, or brain metastases; (2) raised marker levels (alpha-fetoprotein [AFP] level greater than 1,000 kU/L or beta subunit of human chorionic gonadotropin [HCG] greater than 10,000 IU/L [corrected]); (3) the presence of a mediastinal mass greater than 5 cm in diameter; (4) the presence of 20 or more lung metastases; (5) increasing age; and (6) absence of undifferentiated teratoma (embryonal carcinoma) or fibrous tissue from the primary tumor.

CONCLUSIONS

The first four factors were used to define a simple prognostic classification. A good-prognosis group having none of these features comprised 67% of our patient population and had a 3-year survival of 93%. The remaining 33% of patients having at least one of these features had a 3-year survival rate of 68%. These patient groups are currently the subjects of international randomized clinical trials.