Metastatic patterns of prostatic cancer. Correlation between sites and number of organs involved

Prostatic cancer in 1885 autopsy cases was classified according to the number of organs involved in metastasis, and a comparison was made concerning the frequency of metastasis to the various organs. The frequencies of metastasis to the lungs and para-aortic lymph nodes were low in cases with single-organ involvement (4.6% and 2.3%, respectively), but increased rectilinearly in accordance with the number of organs involved and became high in cases with metastasis to three or more organs (49.1% and 21.8% in total, respectively). On the other hand, the frequencies of local extension to the bladder and invasion of the pelvic lymph nodes were high even in cases with single-organ involvement (34.5% and 9.2%, respectively) and were not significantly changed regardless of the number of organs involved. No significant correlation was seen between pelvic and para-aortic lymph node involvement. In cases with single-organ involvement, metastasis to the lumbar spine occurred frequently, but those to the ribs, sternum, and ilium occurred less frequently. There may be multiple metastases in cases with metastases to the para-aortic lymph nodes, sternum, and ilium. The number of metastatically involved organs is useful in analyzing the mode of metastasis.

Histologic variants of urothelial carcinoma: differential diagnosis and clinical implications

An increasing number of histologic variants of urothelial carcinoma have been recognized in recent years. It is important for surgical pathologists to be aware of these morphological variants that, on occasion, may lead to misinterpretation as benign. Some also require a specific therapeutic approach. In this article, we review the most common histologic variants of urothelial carcinoma of the bladder. Emphasis is placed on clinical significance and differential diagnosis.

Secondary neoplasms of the bladder are histological mimics of nontransitional cell primary tumours: clinicopathological and histological features of 282 cases

AIMS

The incidence, anatomical localization and histological appearances of secondary neoplasms of the urinary bladder are described, with emphasis on the points of distinction from primary tumours.

METHODS AND RESULTS

A retrospective study of cases at the Royal Hospitals Trust yielded a total of 282 secondary bladder neoplasms, representing 2.3% of all malignant bladder tumours in surgical specimens. The commonest primary sites were the colon (21% of secondary neoplasms), prostate (19%), rectum (12%) and cervix (11%). Most tumours from these sites reached the bladder by direct spread. The most common sites of origin of tumours metastatic to the bladder were stomach (4.3% of all secondary bladder neoplasms), skin (3.9%), lung (2.8%), and breast (2.5%). Secondary tumour deposits were almost always solitary (96.7%), and 54% were located in the bladder neck or trigone. Histologically, 54% of secondary tumours were adenocarcinomas. Immunohistochemical staining patterns with prostate-specific acid phosphatase, prostate-specific antigen, carcinoembryonic antigen, chromogranin and neurone-specific enolase were similar in primary vesical and urachal adenocarcinomas and secondary adenocarcinomas from the gastrointestinal tract.

CONCLUSIONS

The incidence of secondary bladder tumours is comparable to that of nontransitional cell primary tumours. Few secondary tumours have distinctive histological features, hence knowledge of the history and clinical investigations are particularly important in their diagnosis.

Risk factors for subsequent development of bladder cancer after primary transitional cell carcinoma of the upper urinary tract

OBJECTIVES

To determine the independent risk factors for intravesical tumor recurrence in patients with primary transitional cell carcinoma of the upper urinary tract, and to develop a risk-stratification model to allow more accurate prediction of recurrence risk.

METHODS

Of 141 patients who underwent total nephroureterectomy for clinically localized transitional cell carcinoma of the upper urinary tract, the data from 89 patients were retrospectively reviewed. Patients with a previous history or concomitance of bladder cancer and/or a follow-up period of less than 1 year were excluded from this study. Multivariate analysis by Cox's proportional hazards model was used to determine independent risk factors for intravesical tumor recurrence.

RESULTS

Of 89 patients, 37 (41.6%) experienced subsequent intravesical tumor recurrence during a median follow-up period of 39.7 months (range 12.0 to 186.6). On multivariate analysis, tumor multiplicity, pathologic stage, tumor size, and surgical modality had a statistically significant impact on the risk of intravesical tumor recurrence (P = 0.0075, P = 0.0221, P = 0.0377, and P = 0.0413, respectively). Pathologic stage and tumor size were inversely correlated to the risk. A scoring system for the risk of intravesical recurrence was developed from the proposed prognostic factors, and the patients were stratified into three groups according to their scores, with statistically significant prognostic differences between them (P = 0.0018).

CONCLUSIONS

Tumor multiplicity, pathologic stage, tumor size, and surgical modality all had a significant impact on the incidence of intravesical tumor recurrence. A risk stratification model constructed from tumor biologic factors may be useful in the follow-up of patients with transitional cell carcinoma of the upper urinary tract.

FDG-PET for preoperative staging of bladder cancer

PURPOSE

The presence of lymph node involvement (N) and distant metastasis (M) in patients with invasive bladder carcinoma is a major determinant of survival and, therefore, a pivotal element in the therapeutic management. The aim of this prospective study was to evaluate the use of( 18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in this indication.

METHODS

Whole-body FDG-PET and computed tomography (CT) were performed in 55 patients with non-metastatic invasive bladder cancer for preoperative staging. Correlative imaging of PET with CT was performed, leading to a PET(CT) result. The imaging results were compared with the gold standard, consisting of histopathology (lymphadenectomy, guided biopsy) or clinical follow-up for 12 months, and related to overall survival using the Kaplan-Meier method.

RESULTS

The gold standard was available in 40 patients and indicated NM-positive disease in 15 patients (12 N lesions, 8 M lesions), and NM-negative disease in 25 patients. For the diagnosis of NM-positive disease, the sensitivity, specificity and accuracy of PET(CT) were 60%, 88% and 78%, respectively. Diagnostic discordances between PET(CT) and CT alone were found in 9/40 patients, among whom PET was correct in six (15%): three with true-positive and one with true-negative distant metastases, and two with true-negative lymph nodes. Median survival time of patients in whom PET(CT) indicated NM-positive disease was 13.5 months, compared with 32.0 months in the patients with a NM-negative PET(CT) (p=0.003).

CONCLUSION

Addition of metabolism-based information provided by FDG-PET to CT in the preoperative staging of invasive bladder carcinoma yields a high diagnostic and prognostic accuracy.

Impact of body mass index on radical cystectomy

PURPOSE

Radical cystectomy has a significant rate of morbidity and it is important to elucidate the factors that contribute to this risk. Obesity is a major problem in the United States and is associated with increased health hazard. Morbid obesity may even preclude definitive surgical treatment. This study examines the impact of body mass index (BMI) on radical cystectomy.

MATERIALS AND METHODS

Retrospective analysis was performed on 498 patients who underwent radical cystectomy primarily for bladder cancer from July 1, 1990 to May 10, 2002. Patient BMI was defined as normal (less than 25 in 151), overweight (25 to 29.9 in 198), obese (30 to 34.9 in 98) and morbidly obese (35 or greater in 51). The bivariate relationships among BMI categories and clinical parameters were assessed using the chi-square test, the analysis of variance and the log rank test. Multivariate analyses were performed using Cox regression models.

RESULTS

Median followup for the cohort was 3.3 years. Mean BMI was 28 and 70 of the study group was above normal weight. Compared to normal BMI, upper weight BMI groups were younger (p <0.0001), and had increased estimated blood loss (p = 0.01) and operative time (p = 0.001). Complication number (p = 0.0004) was increased in these groups but complication severity was similar (p = 0.54). Morbidly obese patients underwent incontinent diversion more often (p = 0.03). In multivariate models increased BMI was independently associated with increased estimated blood loss (p = 0.004), prolonged operative time (p = 0.006) and increased complication rate (p = 0.01).

CONCLUSIONS

Increased BMI independently poses a greater perioperative risk to the patient and contributes to the technical challenge of the cystectomy. This is most appreciated in the morbidly obese population and likely contributes to a greater use of incontinent diversion in this group. The increased perioperative risk associated with elevated BMI is significant but not prohibitive and should not preclude cystectomy as definitive treatment.

Malignant lymphoma of the bladder: evidence from 36 cases that low-grade lymphoma of the MALT-type is the most common primary bladder lymphoma

Patients with malignant lymphoma of the bladder were studied, and three clinical groups were defined: those with primary lymphoma localized in the bladder, lymphoma presenting in the bladder as the first sign of disseminated disease (nonlocalized lymphoma), and recurrent bladder involvement by lymphoma in patients with a history of malignant lymphoma (secondary lymphoma). The differences in these groups regarding lymphoma type, clinical presentation, and clinical outcome were studied. Mayo Clinic Tissue Registry records from 1940 to 1996 were searched to identify patients with lymphomas involving the bladder. The lymphomas were classified based on review of the histology and immunophenotype performed by immunoperoxidase methods. Clinical records were reviewed. Presenting symptoms included urinary frequency, dysuria, hematuria, and lower abdominal and back pain. Primary lymphoma was present in six patients. All were B-cell lineage low-grade lymphomas of the mucosa-associated lymphoid tissue (MALT) type. No patient had recurrent lymphoma or died of lymphoma. Nonlocalized bladder lymphoma occurred in 17 patients; one with low-grade lymphoma of the MALT type, four with follicle center lymphomas, and 12 with large cell lymphomas. Excluding two patients who died postoperatively, median survival was 9 years. Six patients died of lymphoma in the follow-up period. Secondary bladder lymphoma occurred in 13 patients: two with low-grade lymphoma of the MALT type, one with follicle center lymphoma, one with mantle cell lymphoma, and nine with diffuse large cell lymphomas. Median survival in this group was 0.6 years. Low-grade lymphoma of the MALT type was the most frequent type of primary bladder lymphoma and was associated with an excellent prognosis. The bladder can be the presenting site of lymphomatous involvement in patients with more widespread disease. Survival in this group is quite favorable and is presumably dependent on lymphoma histologic type, stage of disease, and other prognostic factors. Bladder involvement by recurrent lymphoma is a sign of widely disseminated disease and is associated with a very poor prognosis.

Risk factors for the development of bladder cancer after upper tract urothelial cancer

OBJECTIVES

To determine the clinical and pathologic risk factors for initial intravesical recurrence in patients with primary renal pelvic and/or ureteral cancer and to examine the progression in the bladder in patients having high risk factors for intravesical recurrence.

METHODS

This study included 69 patients with renal pelvic and/or ureteral cancer. We excluded patients with distant metastases, those with a short period of follow-up, and those having a previous history or concomitance of bladder cancer. The exclusion criteria were chosen to avoid contamination by patients with a poor prognosis who might die of the primary cancer before bladder cancer development. Multivariate analysis by Cox's proportional hazards model was used to determine what clinical and pathologic variables significantly affected the initial intravesical recurrence of cancer. We also studied the stage progression of cancer that recurred in the bladder.

RESULTS

Initial intravesical recurrence of the cancer was found in 22 patients during a median follow-up period of 53 months (range 12 to 225). The intravesical disease-free rate after upper tract urothelial cancer was 65% (rate of disease recurrence in bladder 35%) at 5 years by the Kaplan-Meier method. The extent (multifocality) of the upper urinary cancer (P = 0.0038) and pathologic stage (P = 0.0409) independently influenced intravesical recurrence. Age, sex, adjuvant chemotherapy, configuration of the primary tumor, primary cancer size, and pathologic grade did not affect recurrence. The rate of stage progression also was not influenced by the extent of the disease in the upper urinary tract.

CONCLUSIONS

The extent and pathologic stage of cancer in the upper urinary tract were significant and independent factors for initial intravesical recurrence of cancer. However, no difference was found in clinical outcome in terms of stage progression between patients having high risk factors for intravesical recurrence and those without them.

Relation between cyclooxygenase-2 expression and tumor invasiveness and patient survival in transitional cell carcinoma of the urinary bladder

BACKGROUND

Expression of the inducible form of cyclooxygenase (COX)-2 is known to correlate with development of transitional cell carcinoma (TCC) of the human urinary bladder. However, the clinical significance of COX-2 expression with respect to clinicopathologic findings and patient survival is unknown.

METHODS

COX-2 expression was examined immunohistochemically in tumor tissues obtained from 108 patients who underwent radical cystectomy for TCCs, without knowledge of clinicopathologic findings. Correlation between COX-2 expression and clinicopathologic findings and patient survival was determined.

RESULTS

COX-2 expression was detected in 34 of 108 (31%) tumors but in none of 10 normal uroepithelial samples. Univariate logistic regression analysis showed a significant correlation between COX-2 expression and local invasion, infiltration pattern, lymphatic invasion, and venous invasion. However, multivariate logistic regression analysis revealed that only local invasion correlated significantly with COX-2 expression (P = 0.047). Cox proportional hazards regression analysis showed that both local invasion (P = 0.008) and lymph node metastasis (P = 0.001) were independent prognostic factors; however, COX-2 expression (P = 0.16) was not.

CONCLUSIONS

The authors showed that COX-2 overexpression plays a role in development and invasion of TCCs, but not prognosis of patients with TCC. COX-2 inhibitors may be useful for chemoprevention of TCCs and treatment of invasive disease.

Multivisceral resections in colorectal cancer

From 1969 to 1983 a total of 1918 patients with colorectal cancer were treated by curative resection. One hundred twenty one patients in this group had multivisceral organ involvement, necessitating extended multivisceral radical resection. Tumor infiltration was proven histologically in 55 percent, while 45 percent had inflammatory adherence to the attached organ only. Postoperative mortality was 12 percent. Dukes' A and B stages were present in 57 percent. The five-year survival rate (postoperative mortality included) was 54 percent for patients with inflammatory adherence, 49 percent for patients with tumor infiltration resected en bloc without tumor tears of rupture, and 17 percent when the surgeon inadvertently had torn or cut into tumor tissue during resection.

Health-related quality-of-life parameters as independent prognostic factors in advanced or metastatic bladder cancer

PURPOSE

This retrospective analysis examined prognostic significance of health-related quality-of-life (HRQoL) parameters combined with baseline clinical factors on outcomes (overall survival, time to progressive disease, and time to treatment failure) in bladder cancer.

PATIENTS AND METHODS

Outcome and HRQoL (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30) data were collected prospectively in a phase III study assessing gemcitabine and cisplatin versus methotrexate, vinblastine, doxorubicin, and cisplatin in locally advanced or metastatic bladder cancer. Prespecified baseline clinical factors (performance status, tumor-node-metastasis staging, visceral metastases [VM], alkaline phosphatase [AP] level, number of metastatic sites, prior radiotherapy, disease measurability, sex, time from diagnosis, and sites of disease) and selected HRQoL parameters (global QoL; all functional scales; symptoms: pain, fatigue, insomnia, dyspnea, anorexia) were evaluated using Cox's proportional hazards model. Factors with individual prognostic value (P <.05) on outcomes in univariate models were assessed for joint prognostic value in a multivariate model. A final model was developed using a backward selection strategy.

RESULTS

Patients with baseline HRQoL were included (364 of 405, 90%). The final model predicted longer survival with low/normal AP levels, no VM, high physical functioning, low role functioning, and no anorexia. Positive prognostic factors for time to progressive disease were good performance status, low/normal AP levels, no VM, and minimal fatigue; for time to treatment failure, they were low/normal AP levels, minimal fatigue, and no anorexia. Global QoL was a significant predictor of outcome in univariate analyses but was not retained in the multivariate model.

CONCLUSION

HRQoL parameters are independent prognostic factors for outcome in advanced bladder cancer; their prognostic importance needs further evaluation.

Immunohistochemical distinction between primary adenocarcinoma of the bladder and secondary colorectal adenocarcinoma

Primary adenocarcinoma of the urinary bladder sometimes causes a diagnostic dilemma because it can be indistinguishable morphologically from adenocarcinoma of colorectal origin secondarily involving the bladder by metastasis or direct extension. It is much less well studied than conventional urothelial carcinoma and colorectal adenocarcinoma because of its rarity. The current study was specifically designed to investigate whether an important mechanism involved in the pathogenesis of colorectal adenocarcinoma, beta-catenin dysregulation, was also important for the development of primary bladder adenocarcinoma and whether these two morphologically similar tumors could be distinguished immunohistochemically. Formalin-fixed, paraffin-embedded tissues from 17 primary adenocarcinomas of the urinary bladder, 16 colorectal adenocarcinomas involving the bladder, and 10 conventional urothelial (transitional) carcinomas were included in this study. Thirteen of the primary bladder adenocarcinomas were moderately to well differentiated (enteric type) and morphologically indistinguishable from colorectal cancers. The remaining four primary tumors were poorly differentiated (two cases) or of clear cell type (two cases). Immunohistochemical studies using a panel of monoclonal antibodies demonstrated positive nuclear staining for beta-catenin expression in 13 of the 16 (81%) colorectal adenocarcinomas secondarily involving the bladder but in none of the primary adenocarcinomas or the urothelial carcinomas. Instead, positive membranous (and some cytoplasmic) staining was present in all primary bladder tumors with the exception of two poorly differentiated adenocarcinomas where no beta-catenin staining was detected. All secondary colorectal adenocarcinomas stained negatively for CK7 and thrombomodulin (TM), whereas positivity for CK20 was observed in 15 (94%) cases. All urothelial carcinomas stained positively for CK7 and TM, and four of them also for CK20. Primary adenocarcinomas of the bladder showed mixed staining patterns for CK7, CK20, and TM with a positive rate of 65%, 53%, and 59%, respectively. These data indicate that dysregulation of beta-catenin, an important aberration seen in colorectal carcinogenesis, does not appear to play a role in the pathogenesis of the bladder adenocarcinoma. In addition, our data demonstrate that a panel of immunostains, including CK7, CK20, TM, and beta-catenin, is of diagnostic value in differentiating primary bladder adenocarcinoma from secondary adenocarcinoma of colorectal origin.

Analysis of early failures after intravesical instillation therapy with bacille Calmette-Guérin for carcinoma in situ of the bladder

OBJECTIVE

To analyse the clinical and therapeutic consequences of early treatment failure after bacille Calmette-Guérin (BCG) instillation therapy for carcinoma in situ of the bladder.

PATIENTS AND METHODS

A total of 115 patients with carcinoma in situ (Tis) of the bladder were treated by intravesical instillation of living BCG vaccine (Immun BCG Pasteur F). Twenty five patients had primary Tis and 90 had secondary Tis with synchronous or prior superficial papillary tumours. All papillary tumours were resected before instillation of BCG. All patients completed one series of 6 weekly instillations of 120 mg BCG.

RESULTS

Twenty-two of 25 patients (88%) with primary Tis responded completely, with negative cytology and cystoscopy findings within a median follow-up period of 44 months. Three of the 25 (12%) had cytological evidence of disease within 9 months of therapy and were considered to be early treatment failures. One patient had muscle-invasive bladder cancer, one had Tis and invasive cancer of the prostatic urethra, and the last, in whom a second BCG course also failed, had Tis of both ureters. Seventy of 90 patients (78%) with secondary Tis had a complete response after treatment with BCG, with repeated negative cytology and cystoscopy examinations within a median follow-up time of 40 months. Twenty of the 90 (22%) with secondary Tis had positive cytology within 9 months after BCG therapy and were considered early treatment failures. Five of these 20 had a cystectomy, three for persistent Tis of the bladder and two for a solid urothelial carcinoma of the prostate. The remaining 15 early failures received a second course of BCG. Four of these 15 patients responded and the remaining 11 failed the second course. The 11 failures included two patients with multifocal T1 G3 bladder cancers. four with invasive bladder cancer, two with solid urothelial carcinomas of the prostatic urethra, and three with Tis of the upper urinary tract.

CONCLUSIONS

According to these data, early treatment failure after 6 weekly instillations of 120 mg Immun BCG Pasteur F is an alarming signal which requires immediate re-assessment of the patient to exclude a muscle-invasive bladder cancer or an extravesical carcinoma in situ, either in the upper urinary tract or in the prostatic urethra.

Monoclonal antibodies to six-transmembrane epithelial antigen of the prostate-1 inhibit intercellular communication in vitro and growth of human tumor xenografts in vivo

Six-transmembrane epithelial antigen of the prostate-1 (STEAP-1) is a novel cell surface protein highly expressed in primary prostate cancer, with restricted expression in normal tissues. In this report, we show STEAP-1 expression in prostate metastases to lymph node and bone and in the majority of human lung and bladder carcinomas. We identify STEAP-1 function in mediating the transfer of small molecules between adjacent cells in culture, indicating its potential role in tumor cell intercellular communication. The successful generation of two monoclonal antibodies (mAb) that bind to cell surface STEAP-1 epitopes provided the tools to study STEAP-1 susceptibility to naked antibody therapy. Both mAbs inhibited STEAP-1-induced intercellular communication in a dose-dependent manner. Furthermore, both mAbs significantly inhibited tumor growth in mouse models using patient-derived LAPC-9 prostate cancer xenografts and established UM-UC-3 bladder tumors. These studies validate STEAP-1 as an attractive target for antibody therapy in multiple solid tumors and provide a putative mechanism for mAb-induced tumor growth inhibition.

Circadian chemotherapy for gynecological and genitourinary cancers

The circadian timing of surgery, anticancer drugs, radiation therapy, and biologic agents can result in improved toxicity profiles, tumor control, and host survival. Optimally timed cancer chemotherapy with doxorubicin or pirarubicin (06:00h) and cisplatin (18:00h) enhanced the control of advanced ovarian cancer while minimizing side effects, and increased the response rate in metastatic endometrial cancer. Therapy of metastatic bladder cancer with doxorubicin-cisplatin was made more tolerable by this same circadian approach resulting in a 57% objective response rate. This optimally timed therapy is also effective in the adjuvant setting, decreasing the expected frequency of metastasis from locally advanced bladder cancer. Circadian fluorodeoxyuridine (FUDR) continuous infusion (70% of the daily dose given between 15:00h and 21:00h) has been shown effective for metastatic renal cell carcinoma resulting in 29% objective response and stable disease of more than 1 yr duration in the majority of patients. Toxicity is reduced markedly when FUDR infusion is modulated to circadian rhythms. In a multicenter trial in patients with metastatic renal cell cancer, patients were randomized to a flat or a circadian-modified FUDR infusion. This study confirmed a significant difference in toxicity and dose intensity, favoring the circadian-modified group. Hormone refractory metastatic prostate cancer has been treated with circadian-timed FUDR chemotherapy; however, without objective response. Biological agents such as interferon-alpha and IL-2 have shown low but effective disease control in metastatic renal cell cancer, however, with much toxicity. Each of these cytokines shows circadian stage dependent toxicity and efficacy in model systems. In summary, the timing of anthracycline, platinum, and fluoropyrimidine-based drug therapies during the 24h is relevant to the toxic therapeutic ratio of these agents in the treatment of gynecologic and genitourinary cancers.

Frequent loss of heterozygosity on chromosome 10q in muscle-invasive transitional cell carcinomas of the bladder

Loss of heterozygosity (LOH) on chromosome 10 has been observed in several human cancers including glioblastomas, meningiomas, melanomas and endometrial and prostate carcinomas. We have investigated the incidence of LOH on chromosome 10 in 36 human transitional cell carcinomas (TCCs) of the bladder, three upper urinary tract TCCs and one lymph node metastasis, using a panel of 27 highly polymorphic markers spanning 10p (short arm) and 10q (long arm). Fourteen bladder tumours (39%), the three upper urinary tract tumours and the lymph node metastasis showed LOH for at least one locus on chromosome 10. Remarkably, LOH on chromosome 10 was observed mainly in muscle-invasive (P = 0.01) and high grade tumours (P = 0.03). For five tumours and the lymph node metastasis, LOH was found at all informative loci, indicating monosomy or isodisomy of chromosome 10. The deletion mapping of the tumours with partial loss delineated two minimal regions of loss on chromosome 10q. One region, the most telomeric, was bounded by markers D10S214 and D10S169 and the other, the most proximal, was bounded by markers D10S222 and D10S531. Our results demonstrate that chromosome 10q LOH is common in muscle-invasive bladder cancers and that two potential tumour suppressor loci, at 10q24.1-q24.3 and 10q26.1-q26.2, may contribute to the malignant progression of these tumours. Localization of the smallest common regions of loss in bladder tumours provides a starting point for the identification of the genes involved.

Value of a panel of antibodies to identify the primary origin of adenocarcinomas presenting as bladder carcinoma

AIMS

Adenocarcinomas may arise primarily from the urinary bladder, but secondary involvement from adenocarcinomas arising in adjacent organs is more common. In the present study we tried to differentiate primary urinary bladder adenocarcinomas from adenocarcinomas arising from the surrounding organs, based on their antigen profiles in routinely processed, paraffin-embedded tissue specimens. We analysed the staining results using stepwise linear discriminant analysis.

METHODS AND RESULTS

We investigated the usefulness of a panel of antibodies against cytokeratin 7, E48, cytokeratin 20, PSA, PSAP, CEA, vimentin, OC125 and HER-2/neu, to discriminate primary bladder adenocarcinoma from adenocarcinomas arising from the prostate, urachus, colon, cervix, ovary and endometrium. In the differential diagnosis with urinary bladder adenocarcinoma, an overall correct classification was reached for 77% and 81% of urachal and colonic carcinomas, respectively, using CEA, for 93% of prostatic adenocarcinomas using PSA, for 82% and 70% of cervical and ovarian adenocarcinomas, respectively, using OC125, and for 91% of endometrial adenocarcinomas using vimentin. Adding other antibodies did not improve the classification results for any of these differential diagnoses.

CONCLUSIONS

For the surgical pathologist, a panel of antibodies consisting of CEA, PSA, OC125 and vimentin is helpful to differentiate primary urinary bladder adenocarcinomas from adenocarcinomas originating from prostate and endometrium, less helpful in differentiation with urachal carcinoma, and not helpful in differentiation with colonic, cervical and ovarian carcinoma.

Transitional cell carcinoma of renal pelvis

Sixty-eight patients with transitional cell carcinoma of the renal pelvis were studied with respect to clinical presentation, tumor grade, stage and location, subsequent development of other urothelial tumors, and patient survival. Of the 66 patients with adjacent mucosa available for evaluation, 63 (95 per cent) had abnormal findings with severe dysplasia and CIS common in the high-grade, high-stage tumors. Twenty-eight patients (41 per cent) had transitional cell carcinoma previously, concomitantly, and/or subsequently, and in 14 patients (21 per cent) subsequent bladder tumors developed. Because of the relatively high tumor recurrence rate in the ureter (16 per cent) in patients who underwent subtotal ureterectomies, nephrectomy and complete ureterectomy including a bladder cuff should be the operation of choice in patients with carcinoma of the renal pelvis.

Immune checkpoint inhibitors for metastatic bladder cancer

Chemotherapy has represented the standard therapy for unresectable or metastatic urothelial carcinoma for more than 20 years. The growing knowledge of the interaction between tumour and immune system has led to the advent of new classes of drugs, the immune-checkpoints inhibitors, which are intended to change the current scenario. To date, immunotherapy is able to improve the overall responses and survival. Moreover, thanks to its safety profile immune-checkpoint inhibitors could be proposed also to patients unfit for standard chemotherapy. No doubts that these agents have started a revolution expected for years, but despite this encouraging results it appears clear that not all subjects respond to these agents and requiring the development of reliable predictive response factors able to isolate patients who can more benefit from these treatments as well as new strategies aimed to improve immunotherapy clinical outcome. In this review we describe the active or ongoing clinical trials involving Programmed Death Ligand 1 (PD-L1), Programmed Death receptor 1 (PD-1) and Cytotoxic-T Lymphocyte Antigen 4 (CTLA 4) inhibitors in urothelial carcinoma focusing our attention on the developing new immune-agents and combination strategies with immune-checkpoint inhibitors.

Immunocytochemical localisation of prostate-specific antigen: specificity and application to clinical practice

An immunocytochemical method to localise prostate-specific antigen (PSA) in paraffin sections was used to establish the prostatic origin of both primary and metastatic tumours. The specificity of the technique was confirmed in 65 known primary (63 PSA-positive) and 17 metastatic prostatic carcinomas (16 PSA-positive). Thirteen non-prostatic primary carcinomas and a series of benign proliferative and malignant conditions which might be considered in the morphological differential diagnosis of prostatic adenocarcinoma were PSA-negative. The technique has now been applied diagnostically to tumour tissue resected from 21 patients. These neoplasms of the base and neck of the bladder could not be categorised as prostatic or urothelial in origin by clinical and endoscopic assessment or by conventional histopathology. In 11 patients such tumours were PSA-positive, indicating a prostatic origin. In two further patients, the prostatic origin of lymph node secondaries was confirmed in the absence of a clinically apparent primary. The technique is a valuable adjunct to conventional histopathology.

Immunohistochemical profile of high-grade urothelial bladder carcinoma and prostate adenocarcinoma

The differential diagnosis between poorly differentiated prostate adenocarcinoma (PAC) involving the bladder and high-grade urothelial bladder cancer (UC) with prostate extension can be very challenging. The aim of this study is to evaluate the use of a panel of antibodies to distinguish the poorly differentiated forms of these two tumors. We evaluated a series of 40 PAC cases (Gleason's grade >/= 8) and 45 (G3) UC cases obtained from transurethral endoscopic resection material. Immunohistochemical analysis was performed using the following antibodies: prostate acid phosphatase (PAP), prostate-specific antigen (PSA), uroplakin III (UP), thrombomodulin (TM), cytokeratin (CK) 7, and CK20. PAC expressed PSA and PAP in 34 and 38 cases, respectively. The sensitivity and specificity of expressing at least 1 marker (PSA+ or PAP+) is 95% and 100%, respectively. All UC cases were negative for both markers. UC expressed UP and TM in 27 and 22 cases, respectively. In addition, 36 of 45 cases stained positively for at least 1 marker (UP + or TM +) with specificity and sensitivity of 80% and 100%, respectively. All cases of PAC were negative for both markers. Twenty-eight UC cases were CK7+/CK20 +, and 4 PAC cases stained positively for both markers. On the other hand, 29 PAC cases and 4 UC cases were CK7-/CK20-. We concluded that PSA, PAP, UP, and TM are very useful markers in differentiating poorly differentiated UC from PAC. Finally, when all 4 markers (PAP, PSA, UP, and TM) were negative, CK7 and CK20 appeared of no major use in making the differential diagnosis.

Can MRI rule out bladder and rectal invasion in cervical cancer to help select patients for limited EUA?

OBJECTIVES

Although invasion of the bladder or rectum is rare in cervical carcinoma, endoscopic assessment of both organs is part of the standard FIGO clinical staging system, with associated increase in cost and risk of complications. Our objective was to evaluate whether MRI could be used to select patients who did not require invasive staging of the bladder or rectum.

METHODS

Two observers, blinded to the results of cystoscopy and endoscopic examination of the rectum, retrospectively reviewed the MR images of 112 patients with cervical carcinoma. A 5-point invasion score was used to determine bladder and rectal invasion (1 = no invasion, 5 = definite invasion). A confidence score of 3 or above was used to identify patients with possible bladder or rectal involvement. The results of cystoscopy and endoscopic examination of the rectum were recorded and correlated with the MR findings.

RESULTS

MRI was negative for both bladder and rectal invasion in 94/112 patients. Cystoscopy and endoscopic examination of the rectum were confirmed to be normal in all 94 cases. MRI identified 12 patients with possible rectal invasion, 2 confirmed at endoscopy. MRI identified 14 patients with possible bladder invasion, one confirmed at cystoscopy. Using a low threshold cut-off score of >3 to predict invasion resulted in a 100% negative predictive value (NPV) in detection of bladder and rectal invasion.

CONCLUSION

The absence of bladder or rectal invasion can be diagnosed with sufficient confidence using an MRI scoring system to safely obviate the need for invasive cystoscopic or endoscopic staging in the majority of patients with cervical cancer. This could potentially lead to a reduction in staging costs and morbidity.

Value of current chemotherapy and surgery in advanced and metastatic bladder cancer

The aim of the present paper was to review findings from the most relevant studies and to evaluate the value of current chemotherapy and surgery in advanced unresectable and metastatic bladder cancer. Studies were identified by searching the MEDLINE® and PubMed® databases up to 2011 using both medical subject heading (Mesh) and a free text strategy with the name of the known individual chemotherapeutic drug and the following key words: 'muscle-invasive bladder cancer', 'chemotherapeutics agents', and 'surgery in advanced bladder cancer'. At the end of our literature research we selected 141 articles complying with the aim of the review. The results showed that it has been many years since the MVAC (methotrexate, vinblastine, adriamycin, cisplatin) regimen was first developed. The use of cisplatin-based combination chemotherapy is associated with significant toxicity and produces long-term survival in only approximately 15-20% of patients. Gemcitabine + cisplatin represents the gold standard in the treatment of metastatic bladder cancer. In conclusion, the optimal approach in the management of advanced urothelial cancer continues to evolve. Further progress relies on the expansion of research into tumor biology and an understanding of the underlying molecular 'fingerprints' that can be used to enhance diagnostic and therapeutic strategies. Cisplatin-based therapy has had the best track record thus far.

Two different lymph node metastatic patterns of a prostatic cancer

Among 753 autopsy prostatic cancer cases with a metastasis, 476 (63%) had a lymph node metastasis, whereas 277 (37%) did not. Two different lymph node metastatic patterns were observed: Type 1, combined metastasis involving the pelvic and paraaortic lymph nodes; and Type 2, metastasis to the paraaortic lymph nodes, but not to the pelvic lymph nodes. Type 1 metastasis cases showed a significantly more frequent metastasis to the bladder and rectum, and a less frequent metastasis to the lungs and liver. Hydronephrosis occurred more frequently (P less than 0.01) in the Type 1. Furthermore, in the Type 1 cases the lymph node metastasis appeared to be continuously invasive, but in the Type 2 cases, metastasis appeared to be the skip type or some metastases may have spread via the vertebral vein bypass route and may have been associated with a hematogenous metastasis.