Evaluating radical prostatectomy specimens: therapeutic and prognostic importance

Incidence and Pitfalls of Adipose Tissue Encountered in Prostatic Transurethral Resections and Related Specimens

While the presence of adipose tissue and its involvement by prostatic cancer (extraprostatic extension) is well-recognized in prostate biopsies, adipose tissue in transurethral resections of the prostate (TURP) is largely unexplored. Herein, 200 consecutive TURPs and related specimens were reviewed, including a separate 3-year analysis of specimens containing prostatic cancer, with the following data collected: presence of fat, presence of cancer within fat, and quantity of fat. For specimens with both fat and prostatic cancer, specimen weight and tumor volume were recorded. Within the 200 consecutive TURPs and related specimens, adipose tissue was identified in 20%; 55% had 2.5 mm of adipose tissue; the number of fragments with adipose tissue ranged from 1 to 14. No correlation between specimen weight and measured extent of adipose tissue or number of fragments with adipose tissue was identified. Of all the specimens with prostatic cancer, 15/56 (27%) involved adipose tissue, with two specimens with large cancer volume (>90%) demonstrating extensive involvement of adipose tissue. Adipose tissue is frequently present within TURP and related specimens with variability in extent. The etiology behind encountering adipose tissue is uncertain, and it could represent resection into peri-prostatic fat, intraprostatic fat, or bladder neck fat sampling. Although encountering adipose tissue involved by cancer in TURP and related specimens may imply extraprostatic extension (pT3a), further studies are needed to corroborate these findings as well as to determine if these should be included in reported synoptics.

Quantifying Tumor Heterogeneity from Multiparametric Magnetic Resonance Imaging of Prostate Using Texture Analysis

Simple Summary

Prostate cancer (PCa) occurs in males at a rate of 21.8%, predominantly at the customary primary site. High cure rates are possible through early detection and therapy when the tumor is still restricted to the prostate. These tumors do not grow rapidly, allowing for periods of up to 20 years between diagnosis and death. Multiparametric MRI (mp-MRI) is used as a non-invasive approach to diagnose PCa in subjects. This imaging method uses MR imaging with at least one functional MRI sequence to detect and characterize PCa. The use of multiparametric magnetic resonance imaging has refined the diagnosis of prostate cancer in radiology. Malignancy-modified critical features in tissue composition, such as heterogeneity, are associated with adverse tumor biology. Heterogeneity can be quantified through texture analysis, an effective technique for reviewing tumor images acquired in routine clinical practice. This study focused on identifying and quantifying tumor heterogeneity from prostate mp-MRI utilizing texture analysis.

Abstract

(1) Background: Multiparametric MRI (mp-MRI) is used to manage patients with PCa. Tumor identification via irregular sampling or biopsy is problematic and does not allow the comprehensive detection of the phenotypic and genetic alterations in a tumor. A non-invasive technique to clinically assess tumor heterogeneity is also in demand. We aimed to identify tumor heterogeneity from multiparametric magnetic resonance images using texture analysis (TA). (2) Methods: Eighteen patients with prostate cancer underwent mp-MRI scans before prostatectomy. A single radiologist matched the histopathology report to single axial slices that best depicted tumor and non-tumor regions to generate regions of interest (ROIs). First-order statistics based on the histogram analysis, including skewness, kurtosis, and entropy, were used to quantify tumor heterogeneity. We compared non-tumor regions with significant tumors, employing the two-tailed Mann–Whitney U test. Analysis of the area under the receiver operating characteristic curve (ROC-AUC) was used to determine diagnostic accuracy. (3) Results: ADC skewness for a 6 × 6 px filter was significantly lower with an ROC-AUC of 0.82 (p = 0.001). The skewness of the ADC for a 9 × 9 px filter had the second-highest result, with an ROC-AUC of 0.66; however, this was not statistically significant (p = 0.08). Furthermore, there were no substantial distinctions between pixel filter size groups from the histogram analysis, including entropy and kurtosis. (4) Conclusions: For all filter sizes, there was poor performance in terms of entropy and kurtosis histogram analyses for cancer diagnosis. Significant prostate cancer may be distinguished using a textural feature derived from ADC skewness with a 6 × 6 px filter size.

Preoperative Prediction of Extracapsular Extension: Radiomics Signature Based on Magnetic Resonance Imaging to Stage Prostate Cancer

PURPOSE

To investigate and validate the potential role of a radiomics signature in predicting the side-specific probability of extracapsular extension (ECE) of prostate cancer (PCa).

PROCEDURES

The preoperative magnetic resonance imaging data of 238 prostatic samples from 119 enrolled PCa patients were retrospectively assessed. The samples with were randomized in a two-to-one ratio into training (n = 74) and validation (n = 45) datasets. The radiomics features were derived from T2-weighted images (T2WIs). The optimal radiomics features were identified from the least absolute shrinkage and selection operator (LASSO) logistic regression model and were used to construct a predictive radiomics signature via dimension reduction and selection approaches. The association between the radiomics signatures and pathological ECE status was explored. Receiver operating characteristic (ROC) analysis was used to assess the discriminatory ability of the signature. The calibration performance and clinical usefulness of the radiomics signature were subsequently assessed by calibration curve and decision curve analyses.

RESULTS

The proposed radiomics signature that incorporated 17 selected radiomics features was significantly associated with pathological ECE outcomes (P < 0.001) in both the training and validation datasets. The constructed model displayed good discrimination, with areas under the curve (AUC) of 0.906 (95 % confidence interval (CI), 0.847, 0.948) and 0.821 (95 % CI, 0.726, 0.894) for the training and validation datasets, respectively, and had a good calibration performance. The clinical utility of this model was confirmed through decision curve analysis.

CONCLUSIONS

The radiomics signature based on T2WIs showed the potential to predict the side-specific probability of pathological ECE status and can facilitate the preoperative individualized predictions for PCa patients.

Artificial intelligence in multiparametric prostate cancer imaging with focus on deep-learning methods

Prostate cancer represents today the most typical example of a pathology whose diagnosis requires multiparametric imaging, a strategy where multiple imaging techniques are combined to reach an acceptable diagnostic performance. However, the reviewing, weighing and coupling of multiple images not only places additional burden on the radiologist, it also complicates the reviewing process. Prostate cancer imaging has therefore been an important target for the development of computer-aided diagnostic (CAD) tools. In this survey, we discuss the advances in CAD for prostate cancer over the last decades with special attention to the deep-learning techniques that have been designed in the last few years. Moreover, we elaborate and compare the methods employed to deliver the CAD output to the operator for further medical decision making.

Preliminary study on ultrasound-guided prostate biopsy specimen scores

Prostate cancer (PCa) is the second most frequently diagnosed cancer in males worldwide and resulted in ~258,000 cases of cancer-associated mortality in 2008. The present study visually determined the pathology scores of PCa specimens by taking into account five characteristics, including the hardness, color, plumpness, transparency and uniformity of specimens. The current study also aimed to identify the association between pathology scores and prostate specific antigen (PSA) levels, in order to reduce the complications caused by punctures and elevate the specimen positive rates. A total of 1,608 specimens from 268 patients were analyzed by one sonographer, one urologist and one pathologist. A standard pathological examination was performed on the PCa biopsy specimens and specimen scores were recorded under double-blinded conditions. A receiver operator characteristic curve identified a linear correlation between the visually determined score and PSA levels (r=0.255; P<0.001). Furthermore, logistic regression analysis indicated that the visually determined score and PSA were correlated with the diagnosis of PCa. Additionally, the authenticity of the visually determined score was higher than PSA in the diagnosis of PCa, with the best sensitivity and specificity of the visually determined scores used to predict PCa being 0.817 and 0.931, respectively.

Discrimination of prostate carcinoma from benign prostate tissue fragments in vitro by estimating the gross biochemical alterations through Raman spectroscopy

Raman spectroscopy has been proposed for detecting biochemical alterations in prostate cancer (PrCa) compared to benign prostate tissue in in vitro fragments from surgery for diagnostic purposes. Freezer-stored fragments of human prostate tissues were unfrozen and submitted to Raman spectroscopy with a dispersive spectrometer (830-nm and 200-mW laser parameters, 30-s exposure time). Fragments were fixed and submitted to histopathology to grade PrCa according to Gleason score. A total of 160 spectra were taken from 32 samples (16 benign tissues and 16 PrCa tissues). The relative concentrations of selected biochemicals were estimated using a least-squares fitting model applied to the spectra of pure compounds and the tissue spectrum. A discrimination model was developed employing the most statistically relevant compounds with capability of separating PrCa from benign tissues. The fitting model revealed that actin, hemoglobin, elastin, phosphatidylcholine, and water are the most important biochemicals to discriminate prostate depending on the Gleason score. A discrimination based on Euclidean distance using the relative concentrations of phosphatidylcholine and water showed the higher accuracy of 74 % to discriminate PrCa from benign tissue. Raman spectroscopy is an analytical technique with possibility for identifying biochemical constitution of prostate and could be used for diagnostic purposes.

Margin status of the vas deferens in radical prostatectomy specimens: relevant or waste of time?

AIMS

Positive surgical margins (PSM) after radical prostatectomy are of great interest, but investigation of the vas deferens (VD) is not recommended. This study examined the VD margins in radical prostatectomy patients to report the incidence of PSM and their clinical staging.

METHODS AND RESULTS

A total of 2701 consecutive specimens (1995-2009) were reviewed for tumour infiltration of the VD margin and correlated with clinicopathological data. Forty-one of 2701 cases (1.5%) had a positive VD margin. Thirteen cases had bilateral infiltration. All tumours were locally advanced [pT3a (n = 1), pT3b (n = 34), pT4 (n = 6)]; 15 (37%) had lymph node metastases. While Gleason scores ranged from 7 to 9, mean PSA was 22.3 ng/ml (1.68-127 ng/ml). In all cases with seminal vesicle infiltration (40 of 41) the PSM of the VD was seen ipsilaterally. In 11 of 15 patients (73%) with pN1 status, seminal vesicle infiltration and PSM of the VD were seen on the same side. In 16 cases (39%) the VD was the only PSM.

CONCLUSIONS

A PSM of the VD is an infrequent finding, but might appear as the only PSM. Histological evaluation of the VD therefore seems reasonable, especially as biochemical recurrence has been reported with positive VD margins, and awareness of them might assist in making clinical decisions for adjuvant therapy.

A new method to provide a fresh frozen prostate slice suitable for gene expression study and MR spectroscopy

BACKGROUND

Fresh frozen tissue from radical prostatectomy specimens is highly valuable material for research on gene expression and cellular metabolites. The purpose of this study was to develop a standardized method to provide a representative high quality research sample from radical prostatectomy specimens without interfering with the routine histopathological procedure.

METHODS

A complete transversal slice is collected and snap-frozen before formalin fixation and routine processing of the remaining gland. The freezing preserves the original geometric shape, thus allowing subsampling of specific cell populations without thawing. RNA was extracted from 53 cylindrical subsamples (diameter 3 mm, thickness 2 mm) from 16 consecutive frozen slices. The histological pattern was evaluated by microscopy of a cryosection from sample before further analysis.

RESULTS

Using this novel harvesting method close to 400 slices have been collected. Whenever tumor was present in both adjacent surrounding hematoxylin-eosin sections, we found cancer in 88% of the frozen slices. The extracted RNA showed very high quality with a mean RNA integrity number of 9.16 (SD 0.53). The MR spectra showed metabolic profiles containing several resonances, which deserve further evaluation as possible biomarkers for prostate cancer. After MR analysis the RNA was still highly intact with a mean RNA integrity number of 8.40 (SD 1.53), which makes it possible to correlate transcriptomic and metabolomic profiles of the extracted samples.

CONCLUSION

We present a safe and standardized method for procurement of a high quality fresh frozen prostate slice, suitable for gene expression analysis and MR spectroscopy.

International Society of Urological Pathology (ISUP) Consensus Conference on Handling and Staging of Radical Prostatectomy Specimens. Working group 2: T2 substaging and prostate cancer volume

The 2009 International Society of Urological Pathology consensus conference in Boston made recommendations regarding the standardization of pathology reporting of radical prostatectomy specimens. Issues relating to the substaging of pT2 prostate cancers according to the TNM 2002/2010 system, reporting of tumor size/volume and zonal location of prostate cancers were coordinated by working group 2. A survey circulated before the consensus conference demonstrated that 74% of the 157 participants considered pT2 substaging of prostate cancer to be of clinical and/or academic relevance. The survey also revealed a considerable variation in the frequency of reporting of pT2b substage prostate cancer, which was likely a consequence of the variable methodologies used to distinguish pT2a from pT2b tumors. Overview of the literature indicates that current pT2 substaging criteria lack clinical relevance and the majority (65.5%) of conference attendees wished to discontinue pT2 substaging. Therefore, the consensus was that reporting of pT2 substages should, at present, be optional. Several studies have shown that prostate cancer volume is significantly correlated with other clinicopathological features, including Gleason score and extraprostatic extension of tumor; however, most studies fail to demonstrate this to have prognostic significance on multivariate analysis. Consensus was reached with regard to the reporting of some quantitative measure of the volume of tumor in a prostatectomy specimen, without prescribing a specific methodology. Incorporation of the zonal and/or anterior location of the dominant/index tumor in the pathology report was accepted by most participants, but a formal definition of the identifying features of the dominant/index tumor remained undecided.

International Society of Urological Pathology (ISUP) Consensus Conference on Handling and Staging of Radical Prostatectomy Specimens. Working group 1: specimen handling

The 2009 International Society of Urological Pathology Consensus Conference in Boston made recommendations regarding the standardization of pathology reporting of radical prostatectomy specimens. Issues relating to the handling and processing of radical prostatectomy specimens were coordinated by working group 1. Most uropathologists followed similar procedures for fixation of radical prostatectomy specimens, with 51% of respondents transporting tissue in formalin. There was also consensus that the prostate weight without the seminal vesicles should be recorded. There was consensus that the surface of the prostate should be painted. It was agreed that both the prostate apex and base should be examined by the cone method with sagittal sectioning of the tissue sample. There was consensus that the gland should be fully fixed before sectioning. Both partial and complete embedding of prostates was considered to be acceptable as long as the method of partial embedding is stated. No consensus was determined regarding the necessity of weighing and measuring the length of the seminal vesicles, the preparation of whole mounts rather than standardized blocks and the methodology for sampling of fresh tissue for research purposes, and it was agreed that these should be left to the discretion of the working pathologist.

International Society of Urological Pathology (ISUP) Consensus Conference on Handling and Staging of Radical Prostatectomy Specimens. Working group 4: seminal vesicles and lymph nodes

The 2009 International Society of Urological Pathology Consensus Conference in Boston made recommendations regarding the standardization of pathology reporting of radical prostatectomy specimens. Issues relating to the infiltration of tumor into the seminal vesicles and regional lymph nodes were coordinated by working group 4. There was a consensus that complete blocking of the seminal vesicles was not necessary, although sampling of the junction of the seminal vesicles and prostate was mandatory. There was consensus that sampling of the vas deferens margins was not obligatory. There was also consensus that muscular wall invasion of the extraprostatic seminal vesicle only should be regarded as seminal vesicle invasion. Categorization into types of seminal vesicle spread was agreed by consensus to be not necessary. For examination of lymph nodes, there was consensus that special techniques such as frozen sectioning were of use only in high-risk cases. There was no consensus on the optimal sampling method for pelvic lymph node dissection specimens, although there was consensus that all lymph nodes should be completely blocked as a minimum. There was also a consensus that a count of the number of lymph nodes harvested should be attempted. In view of recent evidence, there was consensus that the diameter of the largest lymph node metastasis should be measured. These consensus decisions will hopefully clarify the difficult areas of pathological assessment in radical prostatectomy evaluation and improve the concordance of research series to allow more accurate assessment of patient prognosis.

Pathologic results of radical prostatectomies in patients with simultaneous atypical small acinar proliferation and prostate cancer

PURPOSE

The incidence of adenocarcinoma on a subsequent biopsy following a diagnosis of atypical small acinar proliferation (ASAP) ranges from 34% to 60%. We reexamined radical prostatectomy (RP) specimens of patients diagnosed as having synchronous ASAP with prostate cancer (PCa) to evaluate pathological entities and the clinical significance of ASAP.

MATERIALS AND METHODS

From January 2007 to December 2008, a total of 118 patients who had been diagnosed with adenocarcinoma on prostate needle biopsy underwent RP. Forty-six of the 118 patients (39%) were diagnosed as having synchronous ASAP with PCa on the prostate needle biopsy. Using whole-mount sections and prostate mapping, we evaluated the RP specimens that were close sections to the ASAP on prostate needle biopsy. All tissues were examined by immunohistochemistry with high molecular weight cytokeratin (34betaE12), p63, and AMACR/P504S added to initial H&E stains by one pathologist.

RESULTS

Thirty-six of the 46 patients (78%) were diagnosed as having adenocarcinoma at sites of ASAP on the initial prostate needle biopsies. The Gleason score was 5 to 6 in 22 patients (61%), 7 in 3 (8%), and unknown due to multifocal and microfocal lesions in 11 (31%). The tumor volume of 14 of the 36 patients (39%) was 0.5 cc or less and was unknown due to multifocal and microfocal lesions in 8 (22%).

CONCLUSIONS

Most ASAP on initial prostate needle biopsy was a true pathological entity, in other words, prostatic adenocarcinoma. Aggressive approaches including more extended repeat biopsy with additional biopsy of the site of the ASAP are needed to diagnose PCa in patients with ASAP.

Preoperative Clinical and Pathological Characteristics of pT0 Prostate Cancer in Radical Prostatectomy

Purpose

To analyze the preoperative clinical and pathological characteristics of patients with pT0 prostate cancer.

Materials and Methods

We retrospectively reviewed the records of 702 patients who underwent radical prostatectomy (RP) at our institution between January 2004 and July 2008 for clinically localized prostate cancer. If there was no evidence of residual tumor in the pathological specimen of the prostate, a patient was staged as pT0. Patients with pT0 disease were compared with a control group of patients who were operated on during the same period.

Results

Overall, 9 (1.3%) patients were staged as pT0 on the pathologic examination. Significant differences were observed between the pT0 group and the control patients in the biopsy Gleason score (p=0.004), the number of positive cores on biopsy (p=0.018), the tumor length of positive cores (p<0.001), and prostate volume (p=0.015). Cutoff values predictive of pT0 tumor status were defined as a biopsy Gleason score sum ≤6, 2 or fewer positive biopsy cores, tumor length on biopsy ≤2 mm, and prostate volume >30 cm³. Whereas 8 of the 9 (88.9%) pT0 patients showed all of these characteristics, only 55 of the 693 (7.9%) control patients fulfilled the criteria. The combination suggested above afforded a sensitivity of 88.8% and a specificity of 92.1% for the prediction of pT0 status.

Conclusions

The frequency of pT0 prostate cancer seen on RP was 1.3%. A combination of clinicopathological features, incorporating a biopsy Gleason score, the number of positive biopsy cores, tumor length on biopsy, and prostate volume, was useful to predict pT0 stage on RP.

[Vanishing prostate cancer. Clinical presentation and histological review]

The impossibility to identify cancer in the final surgical specimen has been reported in some patients with prostate cancer undergoing radical prostatectomy. This has been attributed to either a wrong diagnosis or pathological technique, or to spontaneous or biopsy-induced cure of the tumor. This study assessed the incidence of vanishing prostate cancer in our department for 12 years, the clinical characteristics of patients, and their follow-up. The initial puncture biopsies were also re-evaluated using inmunohistochemical stains. Prostate cancer could not be confirmed in the surgical specimen in six out of 346 operated patients (1.73%) receiving no neoadjuvant therapy. When the initial biopsies were reviewed, cancer was only confirmed in three patients. Incidence of vanishing cancer at our department in the 12-year period considered was 0.86% (3/346). No tumor relapse occurred during 4.5 years of follow-up.

Comparison of proliferating cell nuclear antigen immunostaining in lymph node metastases and primary prostate adenocarcinoma after neoadjuvant androgen deprivation therapy

OBJECTIVE

To evaluate the effect of neoadjuvant androgen deprivation therapy (NADT) on the cellular proliferative activity in primary prostate cancer and lymph node metastases using proliferating cell nuclear antigen (PCNA) immunostaining.

MATERIAL AND METHODS

Metastatic pelvic lymph nodes and tumoral prostatic tissue were obtained from 21 patients after radical prostatectomy and pelvic lymphadenectomy. Sixteen patients received NADT for 3 months prior to surgery; five patients did not and were evaluated as a control group. Histopathologic analysis was performed using PCNA immunostaining. and histopathologic findings of primary tumors and lymph node metastases after NADT were reported. Clinical follow-up was performed for a mean of 43.7 months.

RESULTS

Evaluation of PCNA immunostaining of lymph node metastases in the 16 treated patients revealed a mean positivity for metastatic tumor of 4.5% (SD 3.1%); the corresponding value for the five patients who were not treated with NADT was 19.6% (SD 0.94%) (p < 0.05). In four of the treated cases the proliferative activity in the lymph node metastases was greater than that in the other 12 (9.3% and 3.0%, respectively) and no histopathologic regressive changes were observed in these four cases. The residual tumoral proliferative activity in lymph nodes was greater than that in primary tumors (4.5% and 1.3%, respectively).

CONCLUSIONS

This study shows that the nodal metastases were responsive to hormonal therapy, as assessed by PCNA staining, although a greater residual proliferative activity was observed after NADT in lymph node metastases in comparison with the primary prostatic tumor. This can be attributed to a metastatic phenotype less responsive to hormonal therapy compared to the primary tumor.

The quality of surgical pathology care for men undergoing radical prostatectomy in the U.S

BACKGROUND

The authors assessed adherence with the College of American Pathologists (CAP) radical prostatectomy (RP) practice protocol in a national sample of men who underwent RP for early-stage prostate cancer.

METHODS

Using the National Cancer Data Base, the authors identified a nationally representative sample of 1240 men (unweighted) who underwent RP. For each patient, local cancer registrars performed an explicit medical record review to assess patient-level compliance with surgical pathology report documentation of 7 morphologic criteria (ie, quality indicators). Applying the CAP prognostic factor classification framework, composite measures and all-or-none measures of quality indicator compliance were calculated for the following analytic categories: 1) a strict subset of CAP category I prognostic factors (3 indicators), 2) a broad subset of CAP category I factors (6 indicators), and 3) the full set of 7 indicators.

RESULTS

Among a weighted sample of 24,420 patients who underwent RP, compliance with documentation of the CAP category I factors varied from 54% (95% confidence interval [95% CI], 50-58%) for pathologic tumor, lymph node, metastases classification (according to the American Joint Committee on Cancer staging system) to 97% (95% CI, 96-99%) for Gleason score. In composite, RP pathology reports contained 83% (95% CI, 81-84%), 85% (95% CI, 84-87%), and 79% (95% CI, 78-80%) of the recommended data elements measured by the strict CAP category I subset, the broad CAP category I subset, and the full set of 7 indicators, respectively. In contrast to the generally higher composite scores, only 52% (95% CI, 48-56%) and 41% (95% CI, 37-45%) of men who underwent RP had complete documentation in their pathology reports for the strict and broad CAP category I subsets, respectively.

CONCLUSIONS

RP surgical pathology reports contained most of the recommended data elements; however, the frequent absence of pathologic stage provides an opportunity for quality improvement.

Iatrogenic and non-iatrogenic positive margins: incidence, site, factors involved, and time to PSA progression following radical prostatectomy

INTRODUCTION

There are conflicting data regarding the incidence, site and prognostic significance of positive margins resulting from iatrogenic incision into the prostate (pT2+) or non-iatrogenic inability to excise extraprostatic extension (EPE) of tumor.

MATERIALS AND METHODS

The surgical specimens were whole-mount processed. Nerve-sparing, tumor extension and Gleason score were considered possible factors involved in positive margins. Time to PSA progression was studied using a Kaplan-Meier product-limit analysis.

RESULTS

Positive margins resulted from iatrogenic incision in 61/230 (26.52%) prostates and from EPE in 34/230 (14.78%) prostates. The site most frequently involved in pT2+ prostates was the posterolateral quadrants (40.98%); in cases with EPE both anterolateral and posterolateral quadrants (67.65%) were most frequently involved. Positive margins occurred equally in patients with and without nerve-sparing in both groups. Tumors were significantly more extensive and with higher Gleason score in patients with EPE. Time to PSA progression was similar in patients with pT2+ versus EPE and no invasion of the seminal vesicle, but was significantly shorter in patients with EPE and invasion of the seminal vesicle.

CONCLUSION

The frequency of positive margins in our institution was similar to others with large experience in performing radical prostatectomies. The higher frequency of posterolateral quadrants in iatrogenic positive margins is probably related to the preservation of adjacent vital structures and not to nerve-sparing surgery. A trend for a decreasing frequency of non-iatrogenic surgical margins may be explained by the marked increase of clinical stage T1c in recent years. More-extensive tumors and higher Gleason scores seem to influence only non-iatrogenic positive margins. Biochemical (PSA) progression in EPE must be studied by stratifying the patients into two groups: with and without seminal vesicle invasion.

Seminal vesicle invasion in radical prostatectomies: which is the most common route of invasion?

INTRODUCTION

Very few studies have been published on seminal vesicle invasion (SVI), and these have obtained conflicting results. The aim of the present investigation was to determine the most frequent of three possible routes of seminal vesicle invasion: (1) extraprostatic extension (EPE) into soft tissue adjacent to the seminal vesicle and then into the wall of the seminal vesicle, (2) invasion via the sheath of the ejaculatory duct, penetrating the muscular wall of the ejaculatory duct or extending up the ejaculatory duct into the seminal vesicle muscle wall, or (3) discontinuous metastases.

MATERIALS AND METHODS

The surgical specimens of 230 consecutive patients submitted to radical prostatectomy were histologically evaluated by complete embedding and whole-mount processing.

RESULTS

Of the surgical specimens obtained from 230 patients, 28 (12.17%) showed the presence of either unilateral or bilateral SVI. The routes of SVI in these 28 specimens were: (1) only via the sheath of the ejaculatory duct (0/28; 0%); (2) discontinuous metastases (3/28; 11%), (3) both EPE and via the sheath of the ejaculatory duct (6/28; 21%), and (4) only EPE (19/28; 68%). One-half (14/28; 50%) of the 28 seminal vesicles involved had unilateral invasion and, in most of these cases (42.85%), EPE was unilateral and ipsilateral.

CONCLUSION

Our results suggest that the most important and most frequent route of SVI is extraprostatic extension of prostate carcinoma into the soft tissue adjacent to the ipsilateral seminal vesicle and then into the wall of the seminal vesicle.

Activation of the Thromboxane A2 Pathway in Human Prostate Cancer Correlates with Tumor Gleason Score and Pathologic Stage

OBJECTIVE

We investigated the potential involvement of the thromboxane A(2) (TXA(2)) pathway in human prostate cancer (PCa).

METHODS

Expression of cyclooxygenase-2 (COX-2), TXA(2) synthase (TXS), and TXA(2) receptors (TPRs), the main actors of the TXA(2) pathway, was analyzed on serial tissue sections from 46 human PCa specimens.

RESULTS

The expression levels of COX-2, TXS, and TPRs were significantly higher in malignant than in corresponding nontumoral prostatic epithelial cells. Increased immunoreactivity for these antigens was also observed in high-grade prostate intraepithelial neoplasia (HGPIN) glands. COX-2, TXS, and TPR proteins usually displayed a coordinated overexpression pattern in PCa lesions, as assessed in serial tissue sections. Increased levels of these proteins in the tumors were all significantly associated with higher Gleason scores and pathologic stages.

CONCLUSIONS

Proteins specifically involved in the TXA(2) pathway are up-regulated in human PCa and their level of expression is associated with tumor extraprostatic extension and loss of differentiation. Our study is the first to examine simultaneously all key proteins involved in this pathway including TXA(2) receptors and results suggest that the TXA(2) pathway may be a potential target for PCa prevention/therapy.

Obesity and survival after radical prostatectomy: A 10-year prospective cohort study

BACKGROUND

Obesity and prostate cancer are among the most common health problems affecting American men today. The authors' goal was to assess the impact of obesity on clinical and pathologic features of prostate cancer and long-term outcomes.

METHODS

The authors performed a prospective cohort study on 5313 men who underwent radical prostatectomy between 1990 and 1999. Patient height and weight were measured at the time of surgery to calculate the body mass index (BMI). The patients were separated into 3 BMI groups: BMI <25, 25-29.9, and > or =30 kg/m2. The associations between BMI and age, prostate-specific antigen (PSA) level, and Gleason score were assessed with the Spearman rank correlation test. The associations between BMI and pathologic features were assessed with the Mantel-Haenszel chi 2 test. Fifteen-year biochemical progression-free survival, systemic progression-free survival, cancer-specific survival, and overall survival were estimated using the Kaplan-Meier method and evaluated using Cox models. RESULTS.: The median length of follow-up for the entire cohort was 10.1 years. Clinical and pathologic features appear worse in patients with a higher BMI. On univariate and multivariate analyses, it was found that BMI had no impact on biochemical progression, systemic progression, prostate cancer survival, or overall survival.

CONCLUSIONS

Obese patients appear to have worse pathologic features at the time of prostatectomy. Despite these features, long-term oncologic outcomes, including cancer-specific survival, remain the same regardless of BMI. BMI appears to influence prostate cancer outcomes at the time of prostatectomy, as evidenced by more aggressive pathologic features. However, after prostatectomy, BMI does not appear to be an independent predictor of recurrence or survival.

Invasion of fat justifies assignment of stage pT3a in prostatic adenocarcinoma

AIMS

The detection of invasive cancer cells within the adipose tissue of needle biopsies has been regarded as bona fide evidence of extraprostatic tumour extension, and as a consequence may influence subsequent patient management. However, the identification of rare intraprostatic fat from recent reports involving series of autopsies has challenged this practice principle. We examined totally embedded, whole-mounted radical prostatectomy specimens in order to determine the occurrence of intraprostatic fat in prostatic tissue, and further, to assess the importance of the identification of fat infiltration by neoplastic cells in needle biopsy specimens as a marker of extraprostatic infiltration by tumour.

METHODS

Between 2000 and 2003, 313 consecutive patients underwent radical prostatectomy for clinically localised prostate cancer in the Indiana University Hospital. All radical prostatectomy specimens were completely embedded and whole mounted for histological examination. All slides were reviewed and evaluated for the presence or absence of intraprostatic fat. Other pathological characteristics of prostate cancer were also assessed and clinical data were gathered by a review of patient charts.

RESULTS

The mean age of patients was 60 years. None of these 313 radical prostatectomy specimens revealed any adipose tissue components within the most peripheral boundary of normal prostatic acini in the prostate.

CONCLUSIONS

We found no evidence of intraprostatic fat and our findings suggest that, at best, the occurrence of fat within the prostate is of extreme rarity. Accordingly, the finding of carcinoma invading adipose tissue in needle biopsies should continue to be considered as extraprostatic extension and stage pT3a assigned.

Relationship of age to outcome and clinicopathologic findings in men submitted to radical prostatectomy

OBJECTIVE

It is controversial whether age is associated with higher grade and worse outcome. Some studies have not found age to be related to outcome nor younger age to be associated with better response to therapy.

MATERIALS AND METHODS

The study population consisted of 27 patients aged 55 years or younger and 173 patients 56 years or older submitted to radical prostatectomy. The variables studied were preoperative PSA, time to PSA progression following radical prostatectomy and pathologic findings in surgical specimens: Gleason score, Gleason predominant grade, positive surgical margins, tumor extent, extraprostatic extension (pT3a), and seminal vesicle invasion (pT3b).

RESULTS

Comparing patients aged 55 years or younger and 56 years or older, there was no statistically significant difference for all variables studied: preoperative PSA (p = 0.4417), Gleason score (p = 0.3934), Gleason predominant grade (p = 0.2653), tumor extent (p = 0.1190), positive surgical margins (p = 0.8335), extraprostatic extension (p = 0.3447) and seminal vesicle invasion (p > 0.9999). During the study period, 44 patients (22%) developed PSA progression. No difference was found in the time to biochemical progression between men aged 55 years or younger and 56 years or older.

CONCLUSIONS

Our findings suggest that age alone do not influence the biological aggressiveness of prostate cancer.

Radical prostatectomy for locally advanced prostate cancer: Results of a feasibility study (EORTC 30001)

The aim of this open, non-randomised, 2-stage feasibility study was to determine whether radical prostatectomy (RP) was safe and could provide cure for good prognosis patients with clinical T3 prostate cancer, in a multicentre setting. Cure was defined as a 3 months post-operative of undetectable serum PSA in combination with the presence of pathologically negative margins in the surgical specimen. Forty patients were enrolled of whom 38 were eligible. Six patients (5 pN+ and 1 pNx) did not meet the inclusion criteria and were excluded leaving 32 evaluable pN0 patients of whom 19 (59.4%, SE=4.26) achieved a complete response (CR) and in whom only two serious toxic events (STEs) were observed. The results of the first phase of the study passed the toxicity criteria (<3 STE's) but failed on the cure rate (>20 CRs). This resulted in discontinuation of the study after the first stage. The main reason for failure was the incidence of positive margins in the resected specimen. Although the study was stopped after the first phase, 28 of the 32 pN0 patients (87.5%) had undetectable serum PSA at 3 months. We continue to believe that RP with extensive resection can be beneficial as monotherapy for T3aN0M0 prostate cancer.

Are prostate carcinoma clinical stages T1C and T2 similar?

PURPOSE

A recent study has found that PSA recurrence rate for clinical T1c tumors is similar to T2 tumors, indicating a need for further refinement of clinical staging system. To test this finding we compared clinicopathologic characteristics and the time to PSA progression following radical retropubic prostatectomy of patients with clinical stage T1c tumors to those with stage T2, T2a or T2b tumors.

MATERIALS AND METHODS

From a total of 186 consecutive patients submitted to prostatectomy, 33.52% had clinical stage T1c tumors, 45.45% stage T2a tumors and 21.02% stage T2b tumors. The variables studied were age, preoperative PSA, prostate weight, Gleason score, tumor extent, positive surgical margins, extraprostatic extension (pT3a), seminal vesicle invasion (pT3b), and time to PSA progression. Tumor extent was evaluated by a point-count method.

RESULTS

Patients with clinical stage T1c were younger and had the lowest mean preoperative PSA. In the surgical specimen, they had higher frequency of Gleason score < 7 and more organ confined cancer. In 40.54% of the patients with clinical stage T2b tumors, there was extraprostatic extension (pT3a). During the study period, 54 patients (30.68%) developed a biochemical progression. Kaplan-Meier product-limit analysis revealed no significant difference in the time to PSA progression between men with clinical stage T1c versus clinical stage T2 (p = 0.7959), T2a (p = 0.6060) or T2b (p = 0.2941) as well as between men with clinical stage T2a versus stage T2b (p = 0.0994).

CONCLUSION

Clinicopathological features are not similar considering clinical stage T1c versus clinical stages T2, T2a or T2b.

Key issues in handling and reporting radical prostatectomy specimens

CONTEXT

Patients with prostatic adenocarcinoma commonly undergo radical prostatectomy, and it is often difficult and time consuming to handle the resulting specimens and to report the findings. Pathologic information derived from the radical prostatectomy specimen is used for selecting adjuvant therapy, such as radiotherapy and hormone therapy, and for determining a patient's prognosis. The prostate specimen must be handled in a systematic fashion to derive the appropriate prognostic parameters.

OBJECTIVE

To review the prognostic factors of relevance in classifying radical prostatectomy specimens, using the College of American Pathologists categorization system, including a detailed survey of the morphologic-based factors but excluding other factors such as DNA ploidy and novel phenotypic and genotypic markers.

CONCLUSIONS

Gleason score, pathologic stage, and margin status are considered category 1 prognostic factors, which are of proven prognostic significance and are useful in patient management. Factors such as tumor volume (intraglandular extent) and tumor subtype are considered category 2 prognostic factors, which show significant promise but require validation in multivariate analysis. Lymphovascular space invasion is a promising category 3 prognostic factor that needs additional study. Perineural invasion is an almost ubiquitous finding in radical prostatectomy specimens and is considered a category 3 prognostic factor. After prognostic factors have been analyzed at the histologic level, it is critical to report the findings in a clear and unambiguous fashion. The synoptic style of reporting is ideal for describing complex cancer resection specimens. A synoptic report based on an evidence-based checklist, such as the one developed by the College of American Pathologists, effectively communicates complex cancer-related data, such as radical prostatectomy specimen findings. This information is used not only for individual case management with respect to treatment and prognostication but also for purposes such as education, research, quality monitoring, and system planning.

Prostate cancer pathologic stage pT2b (2002 TNM staging system): does it exist?

OBJECTIVE

In the 1997 TNM staging system, tumors were classified into a single subdivision: T2a, and bilateral tumor involvement (T2b). In the 2002 TNM staging system, tumors are subclassified as T2a (less than one half of one lobe involvement), T2b (more than one half of one lobe involvement), and T2c (bilateral involvement). A recent study questioned the existence of a true pathologic pT2b tumor. The aim of our study is to verify this question.

MATERIALS AND METHODS

The study population consisted of 224 men submitted to radical retropubic prostatectomy. The surgical specimens were histologically evaluated by complete embedding and whole-mount processing. Tumor extent was evaluated by a point-count method. The surgical specimens were staged according to the 2002 TNM staging system.

RESULTS

Using the 2002 TNM criteria, the surgical specimens were classified as pT2a, 28 (12.50%); pT2b, 0 (0%); pT2c, 138 (61.61%); pT3a, 30 (13.39%); and, pT3b, 28 (12.50%). Using the point-count method for tumor extent evaluation, the minimum and maximum total points obtained in unilateral tumors were 192 and 368 points, respectively; the most extensive unilateral tumor showed 68 positive points (less than half the minimum total point-count).

CONCLUSIONS

Using the point-count method for tumor extent, our study questions a real existence for pathologic stage pT2b tumors (unilateral tumors involving greater than one-half of one lobe).

[Prognostic factors in prostate cancer]

Since several therapeutic options are currently available for clinically organ-confined prostate cancer, morphological parameters have rapidly emerged as prognostic factors to stratify patients into different therapeutic modalities. In addition to the PSA value, pathologic stage, as defined by the TNM system, Gleason grade and the surgical margin status, other markers have prognostic implications. This includes the percent pattern 4/5 cancer, tumor volume, intraductal spread, large volume perineural invasion and molecular markers. This review discusses the methods of sampling and reporting in prostate pathology with an emphasis on well established and new prognostic factors.

Validation of 2001 Partin tables in Turkey: a multicenter study

OBJECTIVE

Although Partin tables were developed in United States to predict the stage of prostate cancer preoperatively, they are used by many clinics throughout the world assuming that these figures apply to their population as well. However the predictive value of current Partin tables, which was updated in 2001, has not been validated in most of the countries as well as in Turkey. Therefore, we evaluated the validity of 2001 Partin tables, for the ability to predict the pathological stage in Turkish patients.

PATIENTS AND METHODS

The clinical and pathological findings of 1043 patients who have had radical prostatectomy were assessed. Serum PSA values, clinical stage, biopsy Gleason score and the pathological features of the radical prostatectomy specimens were collected from each clinic and evaluated. The predictive value of Partin nomogram and pathological findings of prostatectomy specimens were compared and analyzed according to Receiver Operating Characteristics (ROC) analysis.

RESULTS

Median age of the patients was 60 (45-74). In the presented study, percentage of patients with clinical stage T1c was 43%. Patients with Gleason score of 2-4 in biopsy constituted 23.4% of the study group. In the present study, the ratio of the patients with serum PSA higher than 10 ng/ml was 39.6%. Organ confined disease, seminal vesicle involvement, lymph node metastases ratios were 64.7%, 10.3%, 1.8% respectively. Area Under Curve (AUC) values for organ confined disease, seminal vesicle involvement and lymph node involvement were calculated as 0.665, 0.733 and 0.759 respectively.

CONCLUSION

It appears that Partin tables have a reasonable predictive value for the final pathological features like organ confined disease, seminal vesicle and lymph node involvement in Turkish patients. This multicenter study showed that current Partin tables could also be used in Turkish patients with comparable accuracy.

'Vanishing' prostate cancer in radical prostatectomy specimens: incidence and long-term follow-up in 38 cases

OBJECTIVE

To determine the incidence and long-term follow-up of the 'vanishing cancer' phenomenon, as complete sampling of some radical prostatectomy (RP) specimens reveals no residual cancer.

MATERIALS AND METHODS

The Mayo Clinic prostate cancer RP database for 1966-1995 was searched for all cases in which there was no residual adenocarcinoma (pathological stage pT0). Each case was confirmed by a review of all tissue specimen slides. Various clinical and pathological features were evaluated, and the follow-up obtained for all patients.

RESULTS

Among 6843 RPs there were 38 in which no residual cancer was identified despite careful sampling. There was a 10-fold decline in the incidence of this finding, from 2.1% before 1980 to 0.2% in 1993-95; this decline appeared to be caused by a decrease in the frequency of diagnosis of cancer by transurethral resection from > 10% before 1990 to < 2% in 1993-95. The mean (range) age of the patients was 63 (38-75) years. All cancers on biopsy or transurethral resection were well or moderately differentiated; clinical stages included T1a (42% of cases), T1b (45%) and T2 (13%). Six patients had a nerve-sparing RP, all after 1990. The mean follow-up was 9.6 (1.0-28.5) years, and there were no recurrences of cancer; the serum prostate specific antigen concentration remained at < 0.2 ng/mL in surviving patients. Six patients (16%) died from intercurrent disease.

CONCLUSIONS

The incidence of 'vanishing cancer' declined between 1966 and 1995, probably as a result of the decline in the use of transurethral resection, occurring in 0.2% of RPs. The prognosis in such patients is excellent, indicating that there is no apparent clinical significance to microscopic foci of cancer that remain undetected after reasonably complete pathological sampling. The inability to identify cancer in a prostate removed for biopsy-confirmed carcinoma does not indicate technical failure.

Prostate cancer with bladder neck involvement: Pathologic findings with application of a new practical method for tumor extent evaluation and recurrence-free survival after radical prostatectomy

BACKGROUND

Recent studies have questioned the high risk for disease recurrence in cases of bladder neck involvement by prostate cancer (pT4 disease).

DESIGN

The study was based on 141 patients submitted to radical prostatectomy. PSA-recurrence was defined as 0.5 ng/ml or rising at three different examinations. Bladder neck invasion was correlated to Gleason score (<7 or > or =7), urethral or lateral positive surgical margins, tumor size (extensive or not extensive) using a new simple point-count method, race and preoperative PSA levels (<10 or > or =10 ng/ml). The mean and median follow-up periods were 17.2 and 15 months (range 3-55). Recurrence-free survival curves were constructed using the Kaplan-Meier survival method with tests of significant differences based on the log-rank statistic.

RESULTS

Bladder neck invasion was seen in 30/141 (21.27%) patients; 9 (6.38%) had also concomitant positive surgical margins in the sections. Extraprostatic extension was seen in 39/141 (27.65%) and seminal vesicle invasion in 18/141 (12.76%) patients. Patients with bladder neck invasion significantly correlated to Gleason score (P = 0.04), preoperative PSA (P < 0.001), and tumor extension (P= 0.04). No correlation was found to age (P = 0.44), race (P = 0.12) and positive urethral or lateral margins (P = 0.32). The PSA-recurrence relative risk in patients with bladder neck invasion was 0.17 (P = 0.68), with extraprostatic extension 0.53 (P = 0.47) and with seminal vesicle invasion 5.76 (P = 0.02).

CONCLUSIONS

Bladder neck involvement correlates with pathologic unfavorable findings on radical prostatectomy specimens as well as to preoperative PSA levels. However, the PSA-recurrence risk associated with bladder neck involvement (pT4) was similar to extraprostatic extension (pT3a) and substantially lower than seminal vesicle invasion (pT3b). The findings favor a need for downstaging of bladder neck involvement in the next version of the TNM system. The method proposed for tumor extent evaluation is simple and accessible to all pathologists working in routine pathology laboratories.

Handling and Pathology Reporting of Radical Prostatectomy Specimens

Proper examination of radical prostatectomy (RP) specimens by the pathologists is critical in accurately determining the prediction of patient outcome. The pathology report should include relevant clinical information as well as provide prognostically useful data derived from the evaluation of the RP specimen.

Production of serum-free and total prostate-specific antigen due to prostatic intraepithelial neoplasia

OBJECTIVE

High serum total prostate-specific antigen (PSA) levels have proven to be predictive of concurrent cancer but the role of prostatic intraepithelial neoplasia (PIN) in the production of total (t) and free (f) PSA is still the subject of research. In this study we wanted to discover whether variations in serum fPSA and tPSA levels are caused by PIN.

MATERIAL AND METHODS

We reviewed the medical records of 87 patients: in 32 of them the diagnosis of isolated PIN was made from surgical samples (simple prostatectomy, n = 19; radical cystectomy, n = 13); in 30 patients a diagnosis of benign prostatic hyperplasia (BPH) without PIN or prostatic carcinoma was made after simple prostatectomy (n = 20) or radical cystectomy (n = 10); and in 25 patients a clinically significant prostatic cancer was diagnosed and these patients underwent radical prostatectomy. All patients underwent a standard preoperative evaluation, including serum fPSA and tPSA determinations and PSA density.

RESULTS

The frequency of isolated PIN in simple prostatectomy specimens was 6.3%. The mean f/t PSA ratios were 17.66% in the 32 patients with PIN, 19.2% in the 8 patients with low-grade PIN, 17.6% in the 24 patients with high-grade PIN, 24.2% in patients with BPH and 13% in patients who underwent radical prostatectomy.

CONCLUSIONS

We believe that to make a definitive diagnosis of isolated PIN without carcinoma, study of the whole prostate gland is necessary, in order to definitively exclude the presence of concurrent neoplastic foci. Our data show that PIN does not contribute to tPSA levels and density; however, it may be responsible for a slight reduction in the f/t PSA ratio, with a significant reduction in cases with high-grade PIN (17.6%) compared to those with BPH (24.2%).