Adenocarcinoma of the prostate in cystoprostatectomy specimens removed for bladder cancer

Characteristics of incidental prostatic adenocarcinoma in contemporary radical cystoprostatectomy specimens

OBJECTIVES

To investigate the relationship between prostate-specific antigen (PSA) level and tumour volume for incidental adenocarcinoma of the prostate found in cystoprostatectomy (CP) specimens, and to analyse the incidence of clinically significant prostate cancers in CP specimens and the biochemical recurrence of incidental prostate cancers on short-term follow up.

PATIENTS AND METHODS

Complete data from 97 of 105 prostates from CP specimens were available. Prostates were thoroughly analysed and sectioned at 2 mm intervals. PSA levels and the findings at digital rectal examination before surgery were obtained prospectively. None of the patients had any evidence of prostate cancer before CP.

RESULTS

Incidental prostate cancer was detected in 58 of 97 (60%) of the CP specimens; of these, 31 (53%) were significant according to the definition of Stamey et al. There was a weak correlation between tumour volume and PSA level, weighted solely by the four larger-volume cancers. The median PSA level for patients with and without prostate cancer was not significantly different (3.1 vs 1.1 ng/mL, P = 0.06). The follow-up of the 35 patients alive with prostate cancer showed four PSA recurrences (PSA >0.02 ng/mL) with one distant metastasis after a median follow-up of 3 years. None of the patients with insignificant tumours developed biochemical recurrence.

CONCLUSIONS

The weak correlation between PSA level and tumour volume in these patients supports the argument that PSA is largely produced by benign prostatic hyperplasia and is therefore a poor screening tool for asymptomatic healthy men. Most incidental prostate cancers in CP specimens are significant, contrary to previous analyses, but have little practical importance in terms of oncological outcome.

Specificity of serum prostate-specific antigen determination in the Finnish prostate cancer screening trial

Specificity constitutes a component of validity for a screening test. The number of false-positive (FP) results has been regarded as one of major shortcomings in prostate cancer screening. We estimated the specificity of serum prostate-specific antigen (PSA) determination in prostate cancer screening using data from a randomised, controlled screening trial conducted in Finland with 32 000 men in the screening arm. We calculated the specificity as the proportion of men with negative findings (screen negatives, SN) relative to those with negative and FP results (SN/(SN+FP)). A SN finding was defined as either PSA</=4 ng ml(-1) or PSA 3.0-3.9 ng ml(-1) combined with a negative ancillary test (digital rectal examination, DRE or free/total, F/T PSA ratio). False positives were those with positive screening test followed by a negative diagnostic examination. Of the 30 194 eligible men, 20 794 (69%) attended the first screening round and 1968 (9.5%) had a screen-positive finding. A total of 508 prostate cancers were detected at screening (2.4%). Hence, the number of SN findings was 18 825 and the number of FP results 1358. Specificity was estimated as 0.933 (18 825 out of 20 183) with 95% confidence interval (CI) 0.929-0.936. Specificity decreased with age. Digital rectal examination as ancillary examination had similar or higher specificity than F/T PSA. In the second screening round, specificity was slightly lower (0.912, 95% CI 0.908-0.916). The specificity of PSA screening in the Finnish screening trial is acceptable. Further improvement in specificity could, however, improve acceptability of screening and decrease screening costs.

Clinically significant prostate cancer found incidentally in radical cystoprostatectomy specimens

OBJECTIVE

To review the incidence, histopathological features and clinical outcomes of patients with incidental prostate cancer found in radical cystoprostatectomy (RCP) specimens excised for bladder cancer, to determine if these cancers affected the follow-up strategy and if prostate-sparing cystectomy would be appropriate for these patients.

PATIENTS AND METHODS

We retrospectively reviewed the charts of men who had a RCP for transitional cell carcinoma (TCC) of the bladder, at our institution between 1987 and 2003. Patients with a preoperative diagnosis or clinical suspicion of prostate cancer were excluded from further analysis. We identified those men with incidental prostate cancer in the RCP specimens. The patients' demographic, histopathological and clinical outcome data were collected.

RESULTS

In all, 217 men had RCP for TCC between 1987 and 2003; 13 were excluded from the study due to a preoperative diagnosis or clinical suspicion of prostate cancer, and 58 (28%) were found to have incidental prostate cancer. The mean (range) follow-up was 47 (6-157) months. Of these prostate cancers, 20% were of Gleason score > or = 7 and two patients developed local and metastatic prostate cancer recurrences.

CONCLUSION

Incidental prostate cancer is a relatively common finding in RCP specimens, with a significant proportion having the characteristics of clinically relevant prostate cancer. The follow-up for prostate cancer should be incorporated with that for TCC and adapted according to the grade and stage of the prostate cancer. Preserving the prostate in an attempt to decrease the morbidity after RCP carries a high risk of significant prostate cancer in the residual prostatic tissue, suggesting that prostate-sparing cystectomy should only be reserved for a highly selected group of patients.

Should prostate cancer status be determined in patients undergoing radical cystoprostatectomy?

INTRODUCTION

We estimate the frequency of prostate cancers detected incidentally in radical cystoprostatectomy specimens and discuss whether the prostate cancer status should be determined in patients undergoing radical cystoprostatectomy.

MATERIALS AND METHODS

A total of 97 radical cystoprostatectomies without evidence of prostate cancer on digital rectal examination were performed for transitional cell carcinomas of the bladder between January 2001 and May 2004. The mean patient age at the time of surgery was 66.9 +/- 9.52 (range 49-75) years.

RESULTS

The overall incidence of prostate cancer detected in radical cystoprostatectomy specimens was 21.6% (21/97 specimens). The mean tumor volume was found to be 0.93 +/- 0.81 ml. The tumor volume was >0.5 ml in 12 cases (57.1%). The surgical margin was negative in all cases, and the disease was organ confined in 20 patients (95.2%). Capsular invasion was evident in 2 patients (9.5%), 1 of whom had lymph-node-positive disease.

CONCLUSIONS

Despite the high prevalence of incidental prostate carcinomas among patients with bladder cancer undergoing cystoprostatectomy, the vast majority of the cancers are organ confined. However, the prostate cancer status should be determined on the basis of digital rectal examination and prostate-specific antigen in patients undergoing radical cystoprostatectomy - especially if prostate-sparing cystectomy is planned.

Prostate cancer risk among users of finasteride and alpha-blockers - a population based case-control study

Finasteride has been reported to reduce prostate cancer risk in asymptomatic men. However, in clinical practice finasteride and alpha-blockers are used to treat benign prostatic hyperplasia (BPH). We evaluated prostate cancer risk among users of BPH pharmacotherapy at the population level. Comprehensive Finnish national registries provided information on 24723 prostate cancer cases and controls. Overall, prostate cancer risk was elevated among users of both drug categories compared to non-users (odds ratio, OR=1.41; 95% confidence interval, CI 1.31-1.51 for finasteride and OR=1.79; 95% CI 1.67-1.91 for alpha-blockers). However, the risk was lower among finasteride users when compared with alpha-blocker users (OR=0.80; 95% CI 0.64-1.00). Regular finasteride users had the lowest risk. The increased risk is probably due to enhanced diagnostics of prostate cancer in men with BPH. Finasteride use does not decrease prostate cancer incidence compared with non-users. Nevertheless, the risk is lower when compared with alpha-blocker users.

Predictive value of prostatic adenocarcinoma after a negative prostate biopsy

OBJECTIVE

To investigate the predictive value (PV) for all prostate cancers and for clinically significant cancer undiagnosed after a 10-core biopsy protocol, as the 10-core transrectal ultrasonography-guided biopsy is considered the standard technique of prostatic biopsy due to its high rate of detection of prostatic adenocarcinoma.

PATIENTS AND METHODS

In all, 132 consecutive radical prostatectomy (RP) specimens, with their corresponding 10-core biopsies, were reviewed. Cases with unilateral core involvement by prostate cancer were retained for study. Morphometric analysis was conducted on the biopsy-negative hemi-prostates to determine the PV of the biopsy protocol with respect to the size, position and clinical significance of the lesion.

RESULTS

In all, 70 resected prostates (RP) had unilateral core involvement by prostate cancer. In 38 cases, there was cancer in the biopsy-negative hemi-prostates (group 1); in the remaining 32 the hemi-prostates were free of cancer (group 2). Group 1 was categorized by morphometric criteria. Specifically, 23 cases had one to eight foci of prostate cancer in the posterior nontransitional zone (NTZ) (group 1a), while 15 had two to six foci of prostate cancer in the transitional zone (TZ), or the anterior horn (AH) of the peripheral zone or the TZ and AH (group 1b). There were two cases with clinically significant prostate cancer in group 1a, and six in group 1b.

CONCLUSIONS

The PV of a negative five-core biopsy protocol on a hemi-prostate is 54% for prostate cancer and 11% for clinically significant prostate cancer. Most clinically significant prostate cancers were in the AH/TZ of the prostate.

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.

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.

Allelotyping analysis at chromosome arm 8p of high-grade prostatic intraepithelial neoplasia and incidental, latent, and clinical prostate cancers

In this study, we used 7 informative microsatellite markers at 8p22, 23.1, and 23.2 in Japanese patients to compare frequency of loss of heterozygosity (LOH) in 53 lesions of high-grade prostatic intraepithelial neoplasia (HGPIN), 38 cases (38 lesions) of incidental prostate cancer (IPC), 31 cases (41 lesions) of latent prostate cancer (LPC), and 102 cases (168 lesions) of clinical prostate cancer (CPC). The frequency of LOH at 8p22-23.2 with at least 1 marker was 0%, 33%, 57%, and 51% in the HGPIN, IPC, LPC, and CPC cases, respectively. No statistically significant difference was found at 8p22-23.2 between the types of prostate cancer. However, the frequency of 8p22 deletion was significantly higher in CPC and LPC cases than in IPC cases (P = 0.0003) or lesions (P = 0.0017). The frequency of LOH at 8p22 and 8p23.1 loci in high-grade tumors was significantly higher than in low-grade tumors in both the LPCs/IPCs and CPCs (P < 0.05). Allelic loss at 8p22 was significantly more frequent in CPC than in IPC (P = 0.002) and in pT4 CPC than in earlier-stage CPC (P = 0.038). These findings suggest that deletion of 8p is an important event in both the initiation and metastasis of prostate cancer. The extremely high frequency of LOH at 8p22-23.1 in high-grade tumors suggests the existence of a novel putative tumor-suppressor gene associated with the progression of prostate cancer. These results should be useful in identifying the target gene of deletion at 8p.

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.

Synchronous primary carcinomas of the bladder and prostate

AIM

To determine the incidence of adenocarcinoma of the prostate for patients undergoing radical cystoprostatectomy for bladder cancer in Taiwan.

METHODS

A total of 248 patients in Taiwan who were histologically confirmed for transitional cell carcinoma of the bladder underwent cystoprostatectomy. Histopathologic evaluation of the prostate specimens sectioned at 5 mm intervals was performed.

RESULTS

Of the 248 patients, 10 (4.03%) were found to have prostate cancer. Of the 10 cases of unsuspected prostate cancer, eight proved to be at stage T1 or T2, and two at T3 and T4, respectively. This rate of incidentally found prostate cancer amongst our bladder cancer patients appeared to be lower than that found in bladder cancer patients in similar studies in USA.

CONCLUSION

Although the incidence of incidental prostate cancer in patients in Taiwan with bladder cancer is not high compared with that in Western countries, we suggest that digital rectal examination and prostate-specific antigen (PSA) are important screening tools for men with bladder cancer, especially for those aged 60 years and older in Taiwan.

Allelotyping analysis at chromosome 13q of high-grade prostatic intraepithelial neoplasia and clinically insignificant and significant prostate cancers

BACKGROUND

Loss of heterozygosity (LOH) at 13q is one of the most common chromosomal alterations in high-stage prostate cancer, yet little is known about genetic changes in earlier-stage prostate cancer.

METHODS

We used five microsatellite markers at 13q14, 21, and 33 to compare LOH frequencies in 51 lesions of high-grade prostatic intraepithelial neoplasia (HGPIN), 21 cases of incidental prostate cancers (IPCs), 31 cases of latent prostate cancers (LPCs), and 102 cases of clinical prostate cancers (CPCs).

RESULTS

The frequency of LOH at 13q with at least 1 marker was 0%, 38%, 56%, and 49% in HGPIN, IPCs, LPCs, and CPCs, respectively. No statistically significant difference was found between the types of prostate cancer. Allelic loss at 13q14 was significantly more frequent in pT4 tumors than in earlier-stage tumors (P=0.011).

CONCLUSIONS

Allelic loss at 13q is not only an important event in the metastasis of prostate cancer, but also associated with the initiation of the tumor.

Outcome of Patients with Fortuitous Prostate Cancer after Radical Cystoprostatectomy for Bladder Cancer

OBJECTIVES

To analyze the outcome of patients after fortuitous diagnosis of prostate cancer (PCa) on cystoprostatectomy (CPT) specimen.

METHODS

The medical charts of 141 male patients who underwent radical CPT for urothelial cell carcinoma of the bladder between january 1995 and april 2000 were retrospectively reviewed. None of the patients had preoperative clinical or biological suspicion of PCa.

RESULTS

Pathological examination of the CPT specimens showed PCa in 20 patients (14.2%). Of these, 6 had a microfocal PCa, 10 had a pT2a tumour, 2 had a pT2b tumour, and 2 had a pT3a tumour. The Gleason score was < or =5 in 5 cases, 6 in 13 cases, and 7 in 2 cases. Two patients were lost to follow-up. Ten patients died of bladder cancer after a median follow-up of 13 months. Eight patients remained free of disease after a median follow-up of 64.5 months. None of the 20 patients experienced PCa recurrence during follow-up.

CONCLUSIONS

In our experience, the rate of unsuspected PCa on cystoprostatectomy specimens was 14.2%. The majority of these PCas were organ-confined, and there was no PCa recurrence during follow-up.

Risk assessment for occult malignancy in the prostate before radical cystectomy

OBJECTIVES

To assess our clinical ability to predict prostate involvement by transitional cell carcinoma (PI-TCC) or occult prostate cancer (CAP) in patients undergoing radical cystectomy (RCx).

METHODS

We retrospectively analyzed 70 male patients undergoing RCx for TCC of the bladder between 1995 and 2003, focusing on preoperative factors to predict PI-TCC or CAP.

RESULTS

Of 70 RCx patients, 30 (43%) had PI-TCC (14) or CAP (16). Risk factors for PI-TCC included carcinoma in situ, multifocal TCC, and bladder neck involvement (P <0.05 for all three analyses). All 14 patients with PI-TCC had one or more risk factors, and none of 40 patients without these risk factors had PI-TCC (P <0.001). Risk factors for CAP included elevated prostate-specific antigen level, abnormal results on digital rectal examination, and age more than 65 years. Of 16 patients with CAP, 14 had one or more of these risk factors (P <0.05). Sixteen of the seventy patients in this series (22.9%) had no risk factors for PI-TCC or CAP, and none of these had prostatic involvement with either malignancy (P <0.05).

CONCLUSIONS

Our findings suggest that a well-defined subset of patients undergoing RCx might be at low risk for malignancy in the prostate. However, further evaluation of these risk factors in a prospective setting will be required to substantiate these findings and guide clinical decision making in this controversial field.

Prostate-specific antigen levels in the United States: implications of various definitions for abnormal

BACKGROUND

The finding that some men with a normal prostate-specific antigen (PSA) level (i.e., less than 4 ng/mL) nonetheless have microscopic evidence of prostate cancer has led to some suggestions that the threshold defining abnormal should be lowered to 2.5 ng/mL. We examined the effect of this lower threshold on the number of American men who would be labeled abnormal by a single PSA test.

METHODS

We obtained PSA data on a nationally representative sample of American men 40 years of age and older with no history of prostate cancer and no current inflammation or infection of the prostate gland (n = 1308) from the 2001-2002 National Health and Nutrition Examination Survey. We obtained data on the 10-year risk of prostate cancer death in the pre-PSA era from DevCan, the National Cancer Institute's software to calculate the probability of dying of cancer.

RESULTS

Based on NHANES data, approximately 1.5 million American men aged 40 to 69 years have a PSA level over 4.0 ng/mL. Lowering the threshold to 2.5 ng/mL would label an additional 1.8 million men as abnormal, if all men were screened. For men aged 70 years or older, the corresponding numbers are 1.5 and 1.2 million. The proportion of the population affected by different thresholds would vary with age. Among men in their 60s, for example, 17% have a PSA level over 2.5 ng/mL, 5.7% have a PSA level over 4.0 ng/mL, and 1.7% have a PSA level over 10.0 ng/mL. For context, only 0.9% of men in their 60s are expected to die from prostate cancer in the next 10 years.

CONCLUSION

Lowering the PSA threshold to 2.5 ng/mL would double the number of men defined as abnormal, to up to 6 million. Until there is evidence that screening is effective, increasing the number of men recommended for prostate biopsy--and the number potentially diagnosed and treated unnecessarily--would be a mistake.

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

There are limited data regarding the pathological features of incidentally detected prostate cancer. Examination of cystoprostatectomy specimens obtained during bladder cancer treatment affords a unique opportunity to examine incidentally detected prostate cancer and determine its relationship with clinically detected prostate cancer obtained during radical prostatectomy. We compared the pathological findings of incidentally detected prostate cancer in 132 consecutive cystoprostatectomy specimens from patients treated for bladder cancer with a consecutive series of 228 radical prostatectomy specimens from patients treated for prostate cancer. All specimens were totally embedded and whole-mounted. Karyometry was evaluated in select subsets of patients from the study groups. Incidentally detected cancer was found in 42% of cystoprostatectomy specimens, and the cancers were of lower Gleason score and lower pathological stage with fewer positive surgical margins than in clinically detected cancers in age-matched radical prostatectomies. High-grade prostatic intraepithelial neoplasia (PIN) was present in 82% of radical prostatectomy specimens, in 70% of cystoprostatectomies with incidentally detected prostate cancer, and in 54% of cystoprostatectomies without prostate cancer. Mean nuclear and nucleolar area was lower in incidentally detected cancer and PIN when compared with clinically detected cancer and PIN, respectively, similar to the results with proliferative indices. We conclude that incidentally detected cancer is less aggressive than clinically detected cancer.

HIGHER THAN EXPECTED ASSOCIATION OF CLINICAL PROSTATE AND BLADDER CANCERS

PURPOSE

In this study we evaluated the risk of a second malignancy of the bladder or prostate in patients with a previous diagnosis of prostate cancer (PCa) or urothelial cancer (TCC).

MATERIALS AND METHODS

We retrospectively analyzed all cases of PCa and TCC diagnosed between January 1996 and June 2003. Only PCa diagnosed due to abnormal digital rectal examination or increased prostate specific antigen were included. All patients with TCC presented with hematuria or irritative voiding symptoms and the diagnoses were confirmed with a tissue diagnosis. The incidence of lung, colon and renal cancers was also analyzed.

RESULTS

A total of 816 men were diagnosed with PCa and/or TCC. Of 673 men initially diagnosed with PCa 21 had TCC. Of 149 men initially diagnosed with TCC 18 had PCa. Average age at PCa and TCC diagnosis +/- SD was 68.2 +/- 7.9 and 68.2 +/- 10.4 years, respectively. The standardized incidence ratio (SIR) of TCC in patients with PCa (SIR 4.31, 95% CI 2.411 to 7.110) and of PCa in patients with TCC (SIR 3.83, 95% CI 1.911 to 6.858) was significantly increased. There was no statistical significant difference in SIR for TCC in men with or without radiotherapy. SIR for lung, renal or colon cancer was not significantly different from what was expected.

CONCLUSIONS

Patients with PCa have higher incidence of bladder cancer and those with bladder cancer have a higher incidence of PCa. This study has clinical implications in the care of these patients and it may stimulate research interest that may identify common pathways of carcinogenesis.

Neobladder with Prostatic Capsule and Seminal-sparing Cystectomy for Bladder Cancer: A Step in the Wrong Direction

A laudable trend in urologic surgical oncology is to minimize operative morbidity by anatomic and functional organ preservation without compromising radicality. An increasing number of authors have taken advantage of the sexual-function-preserving cystectomy for bladder cancer. The modified procedure includes cystectomy with sparing of prostate, vasa deferens, seminal vesicles, and resection of a prostatic adenoma to avoid bladder outlet obstruction and bladder reconstruction with an orthotopic reservoir. This article focuses on studies from the last 15 years and includes the results from 13 centers worldwide. Many of them report a pattern of failure (local versus distant) that is highly unusual. Although a local recurrence rate of 7 of 252 patients is to be expected in this combined series the distant failure rate of 34 of 252 patients is at least twice as high as expected for the given series of superficial or organ-confined TCC. The observed distant failure rate of sexuality-preserving cystectomy in this potentially lethal disease is more than 5% higher as compared with standard radical cystectomy. The precise underlying mechanism of this unexpected pattern of failure following sexuality-sparing cystectomy is not fully understood. Furthermore, surgeons considering procedures that preserve a portion of the prostatic urethra, the prostatic capsule, or the entire prostate should recognize a 6% risk of significant prostatic cancer in any residual tissue, and the potential risk of urethral tumor involvement with TCC. Daytime continence following radical versus sexuality-sparing cystectomy is identical. Data on nighttime continence of sexuality-sparing cystectomy are inconclusive. The continuous intermittent catheterization rate following sexuality-sparing cystectomy, however, seems to be higher than after standard cystectomy. The only advantage sexuality-preserving cystectomy has is indeed preservation of these functions in a much higher percentage than following standard or nerve-sparing cystectomy. This is at the cost of radicality, however, and results in a 10% to 15% higher oncologic failure rate. Consequently, sexuality-sparing cystectomy for bladder cancer is a step in the wrong direction and should be abandoned.

CLINICAL OUTCOMES AFTER SEXUALITY PRESERVING CYSTECTOMY AND NEOBLADDER (PROSTATE SPARING CYSTECTOMY) IN 44 PATIENTS

PURPOSE

We describe the functional outcome on erectile function, continence and voiding, and local and distant cancer recurrence rates in 44 patients after sexuality preserving cystectomy and neobladder (prostate sparing cystectomy).

MATERIALS AND METHODS

A total of 44 males underwent cystectomy with preservation of the prostate, seminal vesicles and vasa deferentia, after which a Studer type neobladder was anastomosed to the prostate. Oncological outcome (disease specific survival, distant and local recurrence rates) and functional results (continence, voiding, erectile function) were determined.

RESULTS

At a median followup of 42 months, 13 (30%) patients died of cancer. All 13 experienced widespread disease, which was combined with a pelvic recurrence (pelvic recurrence rate 6.9%) in 3. The 3-year survival according to pathological stage was 86% for pT 2N0 or lower, 63% pT3N0 and 39% for node positive tumors (anyT Npos). Prostate cancer was diagnosed in 1 patient 5 years after treatment, and recurrent carcinoma in situ in the prostatic urethra in another patient. Complete daytime and nighttime continence was achieved in 95.3% and 74.4%, respectively. Incontinence during day and night could be managed by 1 pad per day/night in 4.7% and 20.9%, respectively, while 4.7% needed more than 1 pad per night. Erectile function could be determined in 40 patients, and potency was maintained in 77.5%, impaired in 12.5% and absent in 10%.

CONCLUSIONS

Functional results with regard to erectile function and urinary continence after prostate sparing cystectomy are good. Oncological results have been promising, but need to be confirmed after longer followup and in larger trials.

Preservation of prostate during radical cystectomy: Evaluation of prevalence of prostate cancer associated with bladder cancer

OBJECTIVES

To estimate the frequency and characteristics of prostatic lesions discovered incidentally in radical cystoprostatectomy specimens and to determine whether any factors would allow for the detection of prostate cancer preoperatively.

METHODS

A total of 100 radical cystoprostatectomy specimens with orthotopic bladder reconstruction were performed for malignant bladder disease between 1990 and 2000. The mean patient age at surgery was 62 +/- 8 years (range 32 to 75). Digital rectal examination and prostate-specific antigen (PSA) assay were done routinely before surgery. During the 10-year study period, the same pathologist examined the prostatic tissues from radical cystoprostatectomy specimens using McNeal's technique on fine slices every 2.5 mm.

RESULTS

The overall incidence of prostate cancer discovered incidentally in radical cystoprostatectomy specimens was 51%, of which 29% were microcancers (volume less than 0.5 cm3) and 22% were significantly larger (volume 0.5 cm3 or more). The mean Gleason score was 6. Of the tumors, 24% could be considered "clinically nonsignificant" (less than 0.5 cm3 and Gleason score less than 7). The mean preoperative PSA level was 4.13 +/- 1.36 ng/mL. Of 66 patients with a PSA level of less than 4 ng/mL (mean PSA 1.5 +/- 0.8) and a normal digital rectal examination before surgery, 50% had prostate cancer, of which 69% were microcancers.

CONCLUSIONS

The prevalence of prostate cancer (51%) in our series is among the highest in published reports. Furthermore, our results stress that currently no factors are available to enable the detection of "clinically significant" prostate cancer preoperatively.

Prevalence and characteristics of screen-detected prostate carcinomas at low prostate-specific antigen levels: aggressive or insignificant?

Screening for prostate cancer at low prostate-specific antigen (PSA) levels (<or=4.0 ng/mL) risks detecting clinically insignificant cancers, which are of no threat to the man. In this review we evaluate the prevalence and tumour characteristics of prostate cancer detected at low PSA levels, comparing screening studies, cystoprostatectomy series and autopsy data. The favourable characteristics of tumours detectable at very low PSA levels seem to justify the conclusion that an unknown but sizeable proportion of the cancers found at biopsy are clinically insignificant.

Microenvironmental regulators of tissue structure and function also regulate tumor induction and progression: the role of extracellular matrix and its degrading enzymes

It is now widely accepted that elements of the cellular and tissue microenvironment are crucial regulators of cell behavior in culture and homeostasis in vivo, and that many of the same factors influence the course of tumor progression. Less well established is the extent to which extracellular factors actually cause cancer, and the circumstances under which this may occur. Using physiologically relevant three-dimensional culture assays and transgenic animals, we have explored how the environmental and architectural context of cells, tissues, and organs controls mammary-specific gene expression, growth regulation, apoptosis, and drug resistance and have found that loss of tissue structure is a prerequisite for cancer progression. Here we summarize this evidence and highlight two of our recent studies. Using mouse mammary epithelial cells, we show that exposure to matrix metalloproteinase-3 (MMP-3) stimulates production of reactive oxygen species (ROS) that destabilize the genome and induce epithelial-mesenchymal transition, causing malignant transformation. Using a human breast cancer progression series, we find that ADAM-dependent growth factor shedding plays a crucial role in acquisition of the malignant phenotype. These findings illustrate how normal tissue structure controls the response to extracellular signals so as to preserve tissue specificity and growth status.

Double primary cancers of the prostate and bladder: a literature review

A number of studies report a high frequency of double primary cancers of the bladder and prostate. The coincidence was as high as 70% for prostate cancers in patients with bladder cancer, and 3.4% for bladder cancers in patients with prostate cancer. Two studies reviewing medical records reported a significant risk of bladder cancer after prostate cancer and of prostate cancer after bladder cancer. Only 1 of 3 cancer registry studies reported a significantly increased risk of prostate cancer after bladder cancer, and 3 of 11 studies reported a significantly increased risk in bladder cancer after prostate cancer. There was an association between DNA repair and N-acetyltransferase polymorphisms and risk of prostate and bladder cancer. These data suggest that these cancers may share a common carcinogenic process or that these patients are particularly susceptible to both cancers. Because of the association between these cancers, patients who are diagnosed with prostate or bladder cancer should be followed closely for the detection of the second urologic malignancy.

Coexistence of prostate neoplasia in patients undergoing radical cystoprostatectomy due to vesical neoplasia

OBJECTIVE

To assess the incidence of bladder carcinoma infiltrating the prostate and prostate adenocarcinoma in patients undergoing radical cystoprostatectomy due to bladder cancer, as well as to assess if the characteristics of the bladder neoplasia influence the prostatic involvement by this neoplasia.

MATERIALS AND METHODS

We retrospectively assessed 60 male patients, who underwent radical cystoprostatectomy between July 1997 and December 2003. Mean age was 66.7 years (40 and 93 years). The product of radical cystoprostatectomies was checked for involvement of urethra and prostate parenchyma by the primary neoplasia, and for the presence of associated prostate adenocarcinoma. Bladder neoplasia characteristics, such as localization, size, multifocality, association with in situ carcinoma and histological grade, were studied in order to assess the possibility of using such characteristics as predictive factors of prostate infiltration by bladder urothelial carcinoma.

RESULTS

We observed the presence of 20% of patients with bladder carcinoma infiltrating the prostatic urethra, 23.3% of patients with infiltration of the prostate parenchyma and 28.3% of patients with associate prostate adenocarcinoma, resulting in a total of 55% of patients with prostatic involvement (infiltrative bladder carcinoma and/or adenocarcinoma). We also observed a statistically significant correlation between tumor location in the trigone, the presence of in situ carcinoma and the histological grade of the bladder tumor with prostatic infiltration by the vesical neoplasia.

CONCLUSION

The coexistence of prostatic neoplasia in patients operated for bladder neoplasia was frequent in our sample (55%). We observed that the prostatic infiltration by bladder tumors occurs more frequently with tumors located in the trigone, with associated in situ carcinoma and with high histological grade. There was no correlation between neoplastic infiltration of prostate and multifocality or size of the bladder tumor in the studied sample.

Incidence of bladder cancer discovered by urethrocystoscopy at prostate biopsy: extraordinary high incidence of tiny bladder cancer in elderly males

In order to clarify the incidence of bladder cancer with and without prostate cancer, we investigated bladder cancer discovered incidentally by urethrocystoscopy at prostate biopsy. Between April 1997 and December 2003, 498 patients who were suspected prostate cancer were performed prostate biopsy and urethrocystoscopy simultaneously. We investigate possible invasion of prostate cancer into the urethra or bladder mucosa as well as bladder cancer, including other benign lesions of the bladder by urethrocystoscopy. Prostate cancer was confirmed in 175 (35.1%) of the 498 patients histologically, and bladder cancer was discovered incidentally in 12 patients (2.4 %). The incidence of bladder cancer in patients with prostate cancer of 2.3% (4/175) was not significantly different from that in patients without prostate cancer, which was 2.5% (8/323). Superficial and those with a size less than 1 cm were noted in 11 patients (92%) and 10 patients (83%) respectively. High incidence rate of bladder cancer with prostate cancer was reported previously, however, there was no study to compare the incidence rate of bladder cancer between cases with and without prostate cancer. The present study suggests that asymptomatic tiny bladder cancer may be present at an unexpectedly high incidence rate in elderly males.

Incidence and location of prostate and urothelial carcinoma in prostates from cystoprostatectomies: implications for possible apical sparing surgery

PURPOSE

Prostatic carcinoma (Pca) at cystoprostatectomy is usually an incidental finding with the majority thought to be clinically insignificant. Most studies have not specifically addressed the location of Pca or the incidence and location of in situ or invasive urothelial carcinoma (Uca) in prostates of cystoprostatectomy specimens. The frequency of involvement of the apex with these processes has clinical implications. Specifically urinary continence following orthotopic diversion may be enhanced by prostate apical sparing. In this study the pathological features of Pca and Uca, and the frequency of apical involvement were investigated in prostates from cystoprostatectomy specimens.

MATERIALS AND METHODS

Whole mounted prostates from 121 consecutive cystoprostatectomy specimens were analyzed. Pca location, tumor volume, grade, stage, surgical margin and pelvic lymph node status of Pcas were assessed. Clinically insignificant Pcas had a volume of less than 0.5 cc without Gleason pattern 4, extracapsular extension, seminal vesicle invasion, lymph node involvement or positive surgical margins. Prostate involvement by Uca or urothelial carcinoma in situ (CIS)/severe dysplasia and its location were assessed.

RESULTS

Of 121 prostates 50 (41%) had unsuspected Pca, of which 24 (48%) were clinically significant. Of Pcas 30 of 50 (60%) involved the apex, including 19 of 24 (79%) that were significant and 11 of 26 (42%) that were insignificant. Of 121 prostates 58 (48%) had Uca involving the prostatic stroma, noninvasive Uca or urothelial CIS/severe dysplasia in the prostatic urethra or periurethral ducts, of which 19 (33%) had apical involvement. Overall only 32 of 121 patients (26%) had no Pca or prostate Uca/CIS and only 45 (37%) had no clinically significant Pca or Uca/CIS in the prostate. However, 74 of the 121 patients (61%) had no prostatic apical involvement by Pca or Uca/CIS and 85 (70%) had no apical involvement by clinically significant Pca or Uca/CIS. Patients with prostatic apical involvement by invasive or in situ Uca uniformly had involvement of more proximal (toward the base) portions of the prostate.

CONCLUSIONS

The majority of prostates from cystoprostatectomies had no involvement of the prostatic apex by Uca or clinically significant Pca. Hence, most patients may be candidates for prostate apical sparing. However, involvement of the apex by Uca in any patient raises concern about procedures that leave portions of the prostate urethra after cystectomy in an effort to improve continence. In candidates for orthotopic neobladder reconstruction removing all of the prostatic urethra and sparing the remainder of the prostatic apex may allow improved preservation of urinary continence with an acceptable low risk of clinical Pca progression. Whether future strategies for preoperative exclusion of apical Pca and intraoperative assessment of more proximal prostate to help exclude apical urothelial disease may identify patients suitable for prostatic apical sparing remains to be determined. The impact on functional outcomes and cancer control also require additional study.

The pitfalls of lung cancer screening

Lung cancer screening has received extensive attention for a number of years. As yet the goal of such a screening programme, a reduction in lung cancer mortality proven by a large randomised controlled trial, has not been achieved. Instead we are left with a number of unanswered questions and practical problems. In addition to the basic requirements for an effective screening programme, this review will identify the main pitfalls in lung cancer screening, with particular reference to multislice computed tomography. The specific difficulties relating to the identification of unimportant disease, the failure to identify important disease successfully, the consequences of investigating and treating identified disease and the financial costs will all be discussed.

Comparative study on the prevalence of clinically detectable prostate cancer in patients with and without bladder cancer

OBJECTIVES

To investigate the prevalence of prostate cancer in patients with a past or present history of bladder cancer compared with age-matched control subjects in population-based screening for prostate cancer.

METHODS

Between 1998 and 2000, 106 patients who were followed up in the outpatient clinic for bladder cancer (case cohort) and 1060 age-matched men who participated in screening for prostate cancer (control cohort) were enrolled in this study. Serum prostate-specific antigen (PSA) levels were measured for all participants, and all participants underwent digital rectal examination (DRE). The PSA distribution and prevalence rate of prostate cancer were compared between these two cohorts.

RESULTS

The serum PSA levels were significantly greater in the case cohort than in the control cohort. The detection rate of prostate cancer was 12.3% (13 of 106) and 1.5% (16 of 1060) in the case and control cohorts, respectively. The biopsy compliance for those with abnormal PSA and/or DRE findings was significantly lower (31%) in the control cohort than in the case cohort (84%). If all those in the control cohort with abnormal PSA and/or DRE findings had undergone prostate biopsies, another 26 cases of prostate cancer might have been detected. The expected detection rate of prostate cancer in the control cohort was high at 4.0% (42 of 1060); however, this was still significantly lower than that in the case cohort.

CONCLUSIONS

Patients with a present or past history of bladder cancer could be a high-risk group for developing or having prostate cancer. Additional studies should be conducted to confirm this.

Pathologic evaluation of radical cystectomy specimens

BACKGROUND

The authors evaluated the pathology of radical cystectomy and pelvic lymph node specimens from patients with bladder carcinoma who were enrolled in a cooperative group trial. Their objective was to determine whether current practices conform to suggested pathology practice guidelines for reporting on radical cystectomy and pelvic lymph node specimens.

METHODS

Overall, 268 patients underwent radical cystectomy with pelvic lymph node dissection over 11 years in a total of 109 diverse geographic locations and types of institutions. Institutions included 50 community hospitals, 36 academic hospitals, and 23 Veterans Administration (VA)/military hospitals, which evaluated 84, 137, and 47 patients, respectively. The quality of pathology examination was assessed based on the original pathology reports of specimens that were submitted according to published practice guidelines.

RESULTS

Among all types of institutions, pathologic evaluation of radical cystectomy specimens generally was complete for tumor histology, grade, size, location, pathologic stage, lymph node status, prostate involvement, and associated mucosal abnormalities, including ureters and urethra. Perivesical fat (soft tissue) margins were not recorded in 10% of specimens, and 18% of patients did not mention either the presence or the number of lymph nodes. These deficiencies were observed primarily at community and VA hospitals.

CONCLUSIONS

The overall quality of pathologic examination of radical cystectomy specimens is high. Better reporting of soft tissue margin status and pelvic lymph node counts is needed to achieve compliance with the standards published by evolving practice protocols. Standardized pathologic evaluation and reporting of radical cystectomy specimens will optimize important prognostic information and foster better communication between the pathologist, surgeon, and interested oncologists to benefit patients.

The clinical significance of a small focus of well-differentiated carcinoma at prostate biopsy

OBJECTIVE

To compare a series of 121 sextant needle biopsy sets with their corresponding radical prostatectomy specimens in screened participants in the European Randomized study of Screening for Prostate Cancer (ERSPC), investigating the effect of screening for prostate cancer on disease-specific mortality and quality of life, as the clinical significance of a small focus of well-differentiated prostate cancer on biopsy is unclear.

PATIENTS AND METHODS

The expected clinical significance of the discovered tumours was estimated using an arbitrary model combining volume, grade, and stage characteristics.

RESULTS

Of 34 patients who had a small focus (< 3 mm on a single biopsy core) of well-differentiated carcinoma on biopsy, only 18 (53%) were found to have minimal carcinoma (a small focus of well-differentiated carcinoma) at radical prostatectomy, while 16 (47%) had moderately advanced or advanced carcinoma at radical prostatectomy. The preoperative prediction of minimal carcinoma improved when the amount of cancer in the sextant biopsy set was combined with the preoperative serum prostate specific antigen (PSA) level. Of 12 patients with a small focus of well-differentiated carcinoma on biopsy and a serum PSA of < 4 ng/mL, 11 had minimal carcinoma at radical prostatectomy, while there was minimal carcinoma in only seven of 22 (32%) patients with a small focus of well-differentiated carcinoma on biopsy and a serum PSA of > or = 4 ng/mL.

CONCLUSIONS

The predictive value of a small focus of well-differentiated cancer on systematic sextant biopsy for a small well-differentiated tumour in the prostate is limited. The predictive value improves when serum PSA levels are considered concurrently, but is still considered insufficient to support a base for selecting therapy for the individual patient.

Persistence of microscopic human cancers in mice: alterations in the angiogenic balance accompanies loss of tumor dormancy

Some human tumor lines do not form visible tumors when inoculated into immunosuppressed mice. The fate of these human tumor lines was followed by transfecting them with green fluorescence protein before inoculating them into mice. Although the tumor lines failed to grow progressively, they formed small dormant microscopic foci maintained at constant mass by balanced proliferation and apoptosis. Transfecting the cells with either VEGF165 or activated c-Ha-ras induced loss of dormancy, which correlated with a shift in the angiogenic balance toward increased vascularity with reduced tumor cell apoptosis. These results support a model in which loss of dormancy is controlled in part by a switch to an angiogenic phenotype. These tumor lines may serve as models for investigating the cellular mechanisms controlling dormancy and identifying those factors that promote the loss of balanced proliferation and apoptosis. Finally, these models may prove useful in the design and testing of therapies directed toward eradicating dormant tumors and preventing tumor recurrence.

Prostate-specific antigen cutoff of 2.6 ng/mL for prostate cancer screening is associated with favorable pathologic tumor features

OBJECTIVES

To evaluate the pathologic characteristics of clinical Stage T1c (nonpalpable, prostate-specific antigen [PSA]-detected) prostate cancers detected in the 2.6 to 4.0-ng/mL PSA range and compare them with Stage T1c cancers concurrently detected in the 4.1 to 10.0-ng/mL PSA range. All cancers were detected in a prostate cancer screening study.

METHODS

We studied 94 patients with clinical Stage T1c prostate cancer diagnosed by four or six-sector ultrasound-guided needle biopsy who underwent radical prostatectomy between June 1995 and December 1996. We included all men whose prostatectomy specimens were processed with complete embedding of all prostatic tissue. Of these, 42 had a PSA level of 2.6 to 4.0 ng/mL and 52 a PSA level 4.1 to 10.0 ng/mL at the time of cancer detection. We determined the tumor volume by complete embedding and grid morphometry, pathologic stage, Gleason sum, and surgical margin status and compared the cancer volume and pathologic tumor stages for each group.

RESULTS

Men with cancer detected at the 2.6 to 4.0 ng/mL PSA range had significantly smaller cancer volumes (1.1 +/- 1.1 cm(3) versus 1.8 +/- 1.5 cm(3), P = 0.02); however, no difference was found in the proportion (11.9% versus 11.5%, P = 0.9, and 23.8% versus 26.9%, P = 0.7, respectively) of tumors that met previously published criteria of "clinically insignificant" (organ confined, less than 0.2 cm(3) tumor volume, Gleason sum 6 or less) or "clinically unimportant" (organ confined, less than 0.5 cm(3) tumor volume, and Gleason sum 6 or less) tumors. Using the lower PSA cutoff point resulted in the detection of a significantly higher percentage of organ-confined tumors (88% versus 63%, P = 0.01).

CONCLUSIONS

The use of a 2.6-ng/mL PSA threshold for screening resulted in the more frequent detection of small, organ-confined tumors without overdetecting possibly clinically insignificant ones.

Usefulness of PSA screening in outpatients with bladder cancer: preliminary results

BACKGROUND

We performed prostate-specific antigen (PSA) screening and evaluated its usefulness in outpatients with bladder cancer who may have an elevated risk for prostate cancer.

METHODS

Sixty-one new or followed-up outpatients with bladder cancer were examined between September 1999 and December 2000 in the Department of Urology, Gunma University Hospital, Japan. PSA was measured after informed consent was obtained, and patients in whom the PSA level was 4.1 ng/mL or higher were selected for thorough examination. In the examination, one examiner performed DRE (digital rectal examination) and, based on DRE and TRUS (transrectal ultrasonography) findings, determined whether prostate biopsy was indicated.

RESULTS

The average age of the 61 cases was 69.1 +/- 8.6 years, and the average PSA level was 3.5 +/- 5.8 ng/mL. The PSA level was 4.1 ng/mL or higher in 11 (18.0%) patients, nine of whom underwent six-sextant biopsy under TRUS guidance. Of these nine cases, four (6.6%) were diagnosed as having prostate cancer. The Gleason score was 7 in three cases and 9 in one case. The clinical stage was T2N0M0 in three cases and T3N0M0 in one case.

CONCLUSIONS

On PSA screening in patients with bladder cancer and patients with a history of transurethral resection of the bladder tumor (TUR-BT), prostate cancer was found in 6.6%. This rate is higher than in the general population. These cancers were classified into intermediate to high-risk groups, and the prognosis of prostate cancers could be more important than those of the bladder cancers in two cases (50%). We conclude that PSA screening for inpatients with bladder cancer may be useful.

Heterogeneity of angiogenic activity in a human liposarcoma: a proposed mechanism for "no take" of human tumors in mice

BACKGROUND

Tumor cells are known to be heterogeneous with respect to their metastatic activity, proliferation rate, and activity of several enzymes. However, little is known about the heterogeneity of tumor angiogenic activity. We investigated whether heterogeneity of angiogenic activity could be responsible for the well-known observation of "no take" of human tumors transplanted into immunodeficient mice.

METHODS

Severe combined immunodeficient (SCID) mice were xenotransplanted subcutaneously with tumor tissue (n = 55) or cell suspension of a human liposarcoma cell line (SW-872) or subclones (n = 28), with varying cell proliferation rates. Xenograft tumor growth was recorded for up to 6 months. Tumor tissues were then removed and analyzed for tumor cell apoptosis, microvessel density, and cell proliferation. All statistical tests were two-sided.

RESULTS

Pieces of tumor derived from the parental cell line or its clones gave rise to three kinds of tumors: 1) highly angiogenic and fast-growing (aggressive) tumors, 2) weakly angiogenic and slow-growing tumors, and 3) nonangiogenic and stable tumors. Most tumors retained the original phenotype of their parental tumor. Tumor volume correlated positively with microvessel density (Spearman correlation coefficient [r] =.89; P< or =.0001) and inversely with tumor cell apoptosis (Spearman r = -.68; P =.002). Tumor volume was less strongly but still positively correlated with tumor cell proliferation in vivo (Spearman r =.55; P =.02).

CONCLUSIONS

Human liposarcoma cells appear to be heterogeneous in their angiogenic activity. When tumor cells with little or no angiogenic activity are transplanted into SCID mice, a microscopic, dormant tumor results that may not grow further. Because such tiny tumors are neither grossly visible nor palpable, they have previously been called "no take." The finding that an angiogenic tumor can contain subpopulations of tumor cells with little or no angiogenic activity may provide a novel mechanism for dormant micrometastases, late recurrence, and changes in rate of tumor progression.

Significance of high-grade prostatic intraepithelial neoplasia in needle biopsy specimens

OBJECTIVES

To examine the significance of high-grade prostatic intraepithelial neoplasia (HGPIN) in biopsy specimens.

METHODS

We performed sextant biopsies on a series of 83 cystoprostatectomy specimens removed for bladder cancer. For each case the number of foci and volume of both HGPIN and prostate cancer were assessed in the prostatectomy specimens and compared with the number of biopsy specimens involved by HGPIN.

RESULTS

We identified HGPIN in 82 (99%) of 83 prostatic glands, whereas prostate cancer was found in 41 cases (49%). Corresponding sextant biopsies harbored both HGPIN and prostate cancer in 6 cases (7%), whereas only HGPIN was diagnosed in 29 sextant biopsies (35%). There was a positive correlation between the number of biopsy specimens containing HGPIN and the volume and multifocality of HGPIN in the corresponding prostatic glands. Prostates with HGPIN on sextant biopsy contained prostate cancer significantly more often when compared to cases with no HGPIN on sextant biopsy. Frequency of concurrent prostate cancer was higher in cases with two or more biopsy specimens containing HGPIN than in cases with only one such biopsy specimen, but case numbers of these categories were too small to render this difference statistically significant.

CONCLUSIONS

The presence of HGPIN in sextant biopsies is a significant predictor of concurrent prostate cancer. Multifocality of HGPIN is a useful parameter in assessing the extent of HGPIN in the corresponding prostates. Its value in predicting a significantly increased risk of concurrent prostate cancer needs to be further investigated in larger case studies.

Immunophenotype of high-grade prostatic adenocarcinoma and urothelial carcinoma

Morphologic features alone can usually be used to distinguish prostatic adenocarcinoma and urothelial carcinoma of the urinary bladder. Poorly differentiated tumors, however, can occasionally have features of both neoplasms, making determination of site of origin difficult. No study has provided a panel of antibodies to assist in the distinction of these two tumors. For this study, 73 examples of moderately and poorly differentiated prostatic adenocarcinoma and 46 examples of high-grade urothelial carcinoma were obtained from radical resection specimens. Immunohistochemical studies were performed using the following panel of antibodies: cytokeratin (CK) 7, CK 20, 34betaE12, Leu M1, carcinoembryonic antigen (CEA)m, CEAp, p53, Leu 7, prostate-specific acid phosphatase (PSAP), prostate-specific antigen (PSA), and B72.3. Mucicarmine was also performed. Intermediate and high-grade prostatic carcinoma were compared and then high-grade prostatic carcinoma was compared with high-grade urothelial carcinoma. PSA and PSAP each stained 94% of prostatic adenocarcinomas, but no urothelial carcinomas. Leu 7 stained 94% of prostate and 17% of urothelial carcinomas. Over half of the urothelial carcinomas showed positivity for 34betaE12 (65%), as did two cases of prostatic carcinoma (6%). Eighty-three percent of urothelial carcinomas and 12% of prostatic adenocarcinomas stained with CK 7. Forty-one percent of urothelial carcinomas and 12% of prostatic carcinomas were reactive for CEAm, and p53 stained 33% and 3% of urothelial and prostatic adenocarcinomas, respectively. No significant difference was seen in the expression of CEAp, CK 20, B72.3, Leu M1, or mucicarmine between prostate and urothelial carcinoma. We propose a panel of six antibodies to assist in the distinction of high-grade prostatic adenocarcinoma from high grade urothelial carcinoma: PSA, PSAP, 34betaE12, Leu 7, CK 7, and p53. The first three antibodies should be used initially; if results are negative, the remaining antibodies may be employed.

Evaluation of prostatic specific antigen and digital rectal examination as screening tests for prostate cancer

BACKGROUND

The 11,811 first visits and 46,751 annual follow-up visits performed since 1988 were analyzed in order to assess the efficacy of serum prostatic specific antigen (PSA) and digital rectal examination (DRE) for diagnosis of prostate cancer.

METHODS

At first visit, screening included DRE and measurement of PSA using 3.0 ng/ml as upper limit of normal, demonstrated as optimal value in the course of the study. Transrectal echography of the prostate (TRUS) was performed only if PSA and/or DRE was abnormal. For elevated PSA, biopsy was performed only if PSA was above the value predicted from prostatic volume measured by TRUS. At follow-up visits, it was decided during the course of the study to use PSA alone.

RESULTS

PSA was above 3.0 ng/ml in 16.6% and 15.6% of men at first and follow-up visits, respectively. Prostate cancer was found in 2.9% of men invited for screening at first visit and in only 0.4% of men at follow-up visits for a 7.1-fold decrease at follow-up visits done up to 11 years. PSA alone allowed to find 90.5% and 90. 0% of cancers at first and follow-up visits, respectively, compared to 41.1% and 25.0% by DRE alone. In the presence of normal PSA, 344 and 1,919 DREs are needed to find one prostate cancer at first and follow-up visits, respectively. A significant improvement in stage of the disease is found at follow-up (215 cancers) compared to first visits (337 cancers). Comparison made between men invited for screening and those who were not invited but screened showed no significant difference in terms of incidence and prevalence of prostate cancer as well as diagnosis of cancer as a function of age or as a function of PSA, DRE, and TRUS data. The cost for finding one case of prostate cancer is estimated at Can $2,420 and Can $7, 105 (first and follow-up visits, respectively, when PSA is used as prescreening).

CONCLUSIONS

PSA used as prescreening and followed by DRE and TRUS when PSA is abnormal is highly efficient in detecting prostate cancer at a localized (potentially curable) stage since 99% of the cancers diagnosed were at such a localized stage, thus practically eliminating the diagnosis of metastatic and noncurable prostate cancer. The approach used is highly reliable, sensitive, efficient, and acceptable by the general population. The detection of clinically nonsignificant cancer is an exception.

Teaching evidence-based medicine: caveats and challenges

Evidence-based medicine (EBM) is an important new paradigm of the medical profession. While the quantitative approach of EBM has its place, clinical medicine must take into account many subtleties that EBM fails to consider. In this article, the authors describe three caveats to this quantitative approach: (1) the detection of "maybe disease" (physiologic, anatomic, or histologic abnormalities that may not ever be overtly expressed in the patient's lifetime) inflates apparent diagnostic test performance; (2) probability revision is valuable primarily as an exercise to gain qualitative insights; and (3) patients are likely to be interested more than just central tendencies in making treatment decisions. They then consider some challenging questions facing clinician-educators: how do they prepare students for situations where there is an absence of rigorous evidence? Should they teach students that the burden of proof lies in demonstrating efficacy or in demonstrating ineffectiveness? And what should they tell students about when to seek evidence to aid diagnostic and treatment decisions?

Screening for prostate cancer

Screening for prostate cancer has shown great promise in its ability to detect prostate cancer at a curable stage; however, significant problems exist with respect to our knowledge of its impact on prostate cancer mortality. For the properly informed patient with at least a 10-year life expectancy, it would seem that early detection efforts utilizing digital rectal examination (DRE) and serum prostate-specific antigen (PSA) determination are beneficial. Considerable controversy abounds about early detection and screening and will continue until definitive proof of decreased prostate cancer mortality as a result of effective early detection and treatment regimens is demonstrated. Until then, all men with at least a 10-year life expectancy should be counseled as to the potential benefits and risks. The salient literature is reviewed and commentary made as to the benefits of screening methods that can be invoked as well as their limitations and potential liabilities.

Screening for prostate cancer. The challenge of promoting informed decision making in the absence of definitive evidence of effectiveness

Evidence demonstrating the burden of prostate cancer upon men in the United States is incontrovertible; less compelling, however, is proof of benefit from early detection efforts. Nevertheless, the absence of definitive evidence does not lessen the interest of men in prostate testing or the obligation of physicians to help interested men make well-informed decisions, which integrate personal circumstance and preference with the best available data. This article provides the counseling physician with the information required to frame the current prostate testing debate and an approach to support informed decision making by men who can benefit from their assistance.