Prediction of prostatic involvement by urothelial carcinoma in radical cystoprostatectomy for bladder cancer

Prostatic urethra recurrence after transurethral resection of bladder tumor (TURBT) for non-muscle-invasive bladder cancer (NMIBC)

Urinary bladder cancer is frequently multifocal and has a high incidence of recurrence. Although the prostatic urethra is a frequent site of tumor relapse in patients with non-muscle-invasive bladder cancer treated with TURBT, such tumors are often underdiagnosed. Here we present two cases having urethral recurrence after TURBT.

Impact of the Level of Urothelial Carcinoma Involvement of the Prostate on Survival after Radical Cystectomy

Objective:

Urothelial prostatic involvement (UPI) at the time of radical cystoprostatectomy (RCP) was found associated with worse survival outcomes by several previous reports. Our aim is to evaluate the impact of different levels of UPI on survival outcomes using a large series of male patients treated with RCP.

Methods:

Whole step section specimens from 995 male BCa patients were assessed for UPI defined as: no involvement vs. prostatic urethral carcinoma in situ (CIS) vs. lamina propria involvement vs. ductal CIS vs. prostate stromal involvement. Primary end point of the study was predictors of prostatic involvement at RCP and its impact on overall survival after surgery.

Results:

Prostatic involvement was recorded in 307 (30.9%) patients: 28% with prostatic urethral CIS, 12% with lamina propria involvement, 13% with ductal CIS and 47% with stromal involvement. Median follow-up was 70 months. Patients with stromal involvement had a worse 5-year survival (12%) than those with prostatic urethra CIS (40%), lamina propria involvement (36%), and ductal CIS (35%). Considering predictors of prostatic involvement, multifocal tumor (Odds Ratio [OR]: 6.60, p < 0.001), lymphovascular invasion (OR: 2.61, p < 0.001), lymph node metastases (OR: 2.02, p < 0.001) and CIS (OR: 2.02, p < 0.001) were found associated. Similar predictors were found assessing stromal involvement.

Conclusions

Approximately one third of RCP patients harbor prostatic involvement of urothelial carcinoma. While all UPI are associated with worse overall survival, stromal involvement confers the worst outcome supporting its classification as T4 in the TNM staging.

Systematic Review on the Fate of the Remnant Urothelium after Radical Cystectomy

CONTEXT

Urothelial carcinoma is considered a pan-urothelial disease. As such, the remnant urothelium in the upper urinary tract and urethra following radical cystectomy (RC) remains at risk for secondary urothelial tumors (SUTs).

OBJECTIVE

To describe the incidence, diagnosis, treatment, and outcomes of patients with SUTs after RC.

EVIDENCE ACQUISITION

A systematic search was conducted using PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify studies between 1970 and 2016 reporting on malignant diseases of the urothelium after RC for bladder cancer. The search strategy separated between upper and lower tract urothelial tumors.

EVIDENCE SYNTHESIS

Of a total of 1069 studies, 57 were considered for evidence synthesis. SUTs occured in approximately 4-10% of patients after RC. Carcinoma in situ of the bladder, a history of nonmuscle invasive bladder cancer, and tumor involvement of the distal ureter are the strongest risk factors for secondary upper tract tumors. Risk factors for secondary urethral tumors represent urothelial malignancy in the prostatic urethra/prostate and bladder neck (in women), nonorthotopic diversions, and positive findings on permanent sections. The majority of patients (84%) with SUTs, presented with urothelial recurrence without evidence of metastasis. Of those, 84.0% were treated with surgery, 10.5% with systemic chemotherapy and/or radiotherapy, and 5.6% with topical chemotherapy and/or immunotherapy. After a median follow-up of 91 mo (range: 26-155), 65.9% of patients died of disease and 21.5% died of other causes. Detection and treatment of SUTs at an asymptomatic stage can reduce the risks of cancer-specfific and overall mortality by 30%. A limitation of the study is that the available data were retrospective.

CONCLUSIONS

SUTs are rare oncological events and most patients have an adverse prognosis despite absence of distant disease at diagnosis. Therefore, surveillance of the remnant urothelium should be implemented for patients with histological features of panurothelial disease as it may improve timely detection and treatment.

PATIENT SUMMARY

Secondary tumors of the renal pelvis, ureters, and urethra occur in approximately 4-10% of patients after radical removal of the bladder for bladder cancer. These patients' prognoses are reduced, likely due to delayed diagnosis. Therefore, routine surveillance might be important to detect tumors at an early stage.

Undiagnosed prostatic malignancy at the time of radical cystoprostatectomy after prior prostatic radiation therapy

Purpose:

We determined the prevalence of prostatic malignancy in patients undergoing radical cystoprostatectomy (RC) for urothelial carcinoma (UC) with a history of radiation therapy (XRT) treatment for prostatic adenocarcinoma (PCa).

Materials and Methods:

Fifty-three men who underwent a RC for UC that were previously treated for PCa with XRT were retrospectively identified. Pathology reports were reviewed to assess for residual PCa or prostatic UC at the time of surgery.

Results:

Thirteen (25%) patients had residual PCa, 16 (30%) had prostatic UC, and 8 (15%) had both. Sixteen (30%) patients had no evidence of prostatic disease. Patients with PCa had median tumor volume of 2.2 cc (interquartile range: 1.2–2.5 cc) and one-third had high-risk features (Gleason score >8 or pT3-T4 disease). Sixteen of 24 patients (67%) with prostatic UC had a stromal invasion, 5 (21%) had a ductal invasion, and 3 (13%) had carcinoma in situ. Tumors at bladder neck or trigone during transurethral resection were predictive of prostatic UC (odds ratio: 4.32, 95% confidence interval: 1.2–15.5, P = 0.025).

Conclusions:

Despite prior XRT for PCa, less than one-third of patients had no prostatic disease at the time of RC. Routine prostatic sampling should be considered in these patients especially if considering the orthotopic diversion.

Challenges in the pathological reporting of urothelial carcinoma involving prostatic transurethral resection specimens within a single institution

AIM

Primary bladder urothelial carcinoma (UC) may involve the prostate with differing management depending on whether tumour is in situ or invades the prostatic subepithelium or fibromuscular stroma. We aim to understand challenges in reporting UC within prostate transurethral resection (TUR).

METHODS

A retrospective review from 2007 to 2010 identified prostate TUR performed for primary bladder UC.

RESULTS

25.1% of cystoprostatectomy patients (60/239) had a prior prostate TUR; 129 patients had a prostate TUR for UC and 50.4% (65/129) were given a neoplastic diagnosis. Prostatic fibromuscular stroma was present in 84.6% of cases, with a comparable rate among surgeons. Diagnostic concordance of UC versus a non-neoplastic diagnosis was 96.7%, with rare cases initially diagnosed as non-neoplastic having in situ UC on review. Of reports with invasive tumour, 19.4% did not specify extent of invasion (e.g., bladder muscularis propria, prostate fibromuscular stroma) and 13.9% had discordant extent of invasion on review. Terminology typically used for bladder (lamina propria/muscularis propria) was found in 23.1% of reports without explicit reference to the bladder or prostate.

CONCLUSION

This study reveals difficulties in reporting UC within prostatic TUR specimens. We recommend documenting tumour extent and referencing the organ of origin if ambiguous anatomical terms are used.

A retrospective study of prostate cancer cases mimicking urothelial cell carcinoma of the bladder

BACKGROUND

Prostate cancer (PCa) originating from the prostate base may intrude into the urinary bladder and may be misdiagnosed as bladder cancer. In this retrospective study, we reviewed the clinic data on PCa cases which were initially misdiagnosed as bladder cancer in order to identify diagnostic methods that would allow a better differential diagnosis for PCa.

METHODS

Out of a total of 455 patients treated for PCa at our hospital between April 2003 and June 2011, 14 patients (3.1%) had been initially misdiagnosed as urinary bladder urothelial cell carcinoma. The clinical data on these 14 cases was retrieved and analyzed.

RESULTS

Of the 14 patients, 11 patients were eventually diagnosed with PCa after MRI examination, and seven out of these had PCa with bladder neck invasion. Prostate needle biopsy or transurethral resection of prostate (TURP) revealed that all 14 patients had adenocarcinoma of prostate with Gleason scores ranging from 7 to 9. Nine patients received TURP for hematuria or lower urinary tract blockage. The mean follow-up was 37 months, during which six patients survived.

CONCLUSIONS

As clinical presentation and in emergency settings, prostate cancer originating from the prostate base can be confused with bladder cancer originating from the neck or the triangle region of the urinary bladder. Serum prostate specific antigen (PSA) levels and digital rectal examination, in combination with transrectal ultrasound (TRUS), MRI, and prostate needle biopsy are valuable tools for definitive differential diagnosis of the basal prostate cancer.

The conundrum of prostatic urethral involvement

The presence and depth of urothelial cancer involvement in the prostatic urethra can significantly affect the management of a patient with non-muscle invasive bladder cancer. This article presents an overview of the incidence, diagnosis, management, and follow-up of urothelial cancer.

[Prognostic influence of prostate gland invasion by bladder tumour and/or prostate cancer in cystoprostatectomy specimen: a review]

INTRODUCTION

Cystoprostatectomy (CPT) is the gold standard surgical treatment for muscle invasive bladder cancer (MIBC). In certain cases, MIBC can invade the prostate gland and/or a prostate cancer (PCa) can be discovered fortuitously on the pathologic specimen. The aim of the current study was to report the prognostic influence of PCa in patients who underwent a CPT for MIBC.

MATERIALS AND METHODS

A systematic review of the scientific literature was achieved in the Pubmed database, using the following keywords: prostatic neoplasm; urinary bladder neoplasm; cystectomy; surgery; recurrence; prognosis; survival. Clinical cases and series of less than five cases were deliberately excluded herein.

RESULTS

Overall, ten studies published between 2004 and 2011 and involving 2196 patients were selected. Only retrospective studies of low level of evidence (NP 4) were available. The incidence of neoplastic invasion of the prostate gland by MIBC ranged from 25 to 48%. Preoperative predictors were multiple BC, recurrent, location in the trigone and existence of CIS. Overall survival at 3 years was significantly affected by the invasion of the prostate gland (pT4a) in these patients. The incidence of PCa discovered incidentally pathologic specimen CPT ranged from 14 to 49%. Only age was found as a positive predictor. The diagnosis of PCa did not influence survival of patients with MIBC and no specific PCa adjuvant treatment was systematically advocated.

CONCLUSION

Fortuitous diagnosis of PCa and/or neoplastic invasion of the prostatic gland by BC on CPT specimen is not uncommon but this is variable across studies, depending on the quality of the pathological analysis. The invasion of the prostate gland by MIBC is a serious situation (pT4a) and linked with a poor prognosis. In case of concomitant PCa and MIBC, the prognosis is much more related to the natural history of the bladder tumour.

[Prostatic involvement by urothelial carcinoma in patients with bladder cancer and their implications in the clinical practice]

OBJECTIVES

Urothelial carcinoma (UC) is a multifocal disease that may develop in any location of the urinary tract, including the prostate. We analyze the types of prostate involvement due to UC, their diagnosis, risk factors and the clinical implications of this entity.

MATERIAL AND METHODS

Analysis of original, review articles and publications related to prostate involvement due to UC. The study included works published in the period of 1985-2011, most of which were obtained from the search in PubMed.

RESULTS

Prostate involvement due to UC has been observed frequently in both non-muscle invasive bladder cancer (NMIBC) series and prolonged follow-up (39%) as in radical cystectomy series (15-48%). Prostatic involvement may occur in the mucosa and ducts (superficial involvement) or prostate stroma (invasive involvement), a fact that has prognostic and therapeutic implications. Stromal involvement may have both a bladder and intraurethral origin. Carcinoma in situ, multifocality, bladder neck/trigone cancer, and previous history of tumor recurrence are the factors that have been m ore consistently associated to prostate involvement due to UC. The incidence of prostatic involvement by UC in patients with NMIBC increases over time when risk factors exist. In these cases, a prostatic urethral biopsy should be performed during the follow-up. Conservative treatment with transurethral resection and BCG is possible in case of superficial involvement of the prostatic urethra, assuming its risk of progression. Patients subjects to cystectomy and with prostate involvement due to UC have a greater risk of urethral recurrence. The elevated incidence of prostatic adenocarcinoma and prostatic involvement by UC in cystectomy specimens makes it necessary to be very selective when indicating prostate-sparing cystectomy. Chemotherapy may be an option in an attempt to improve survival of patients with prostatic stromal involvement.

CONCLUSIONS

Prostatic involvement by UC is not uncommon and it has important implications in the management of patients with NMIBC and in those who have an indication for or have undergone radical cystectomy.

Incidentally found prostate cancer and influence on overall survival after radical cystoprostatectomy

Objectives. To determine incidentally found prostate cancer frequency and impact on overall survival after RCP. Patients and Methods. The records of 81 men who underwent cystoprostatectomy from January 2000 to December 2009 were reviewed. The vital status of the study group was assessed as on September 1, 2009, by passive followup, using data from the population registry. Results. The 81 men underwent RCP. The incidental prostate cancer was found in the specimens of 27 (33.3%) patients. 13 (48.1%) of 27 prostate cancer cases were clinically significant. For 3 patients (11.1%) an extraprostatic extension was found. For 2 patients (7.4%)—positive margins, for 1 patient (3.7%)—Gleason sum 8, and for the rest 7 patients bigger than 0.5 cm³ volume tumor, and Gleason sum 7 was found. The mean follow-up time was 39.2 ± 33.8 months (varies from 0.8 to 131.2 months). The patients with bladder cancer and incidentally found prostate cancer lived shorter (28.1 ± 27.5 and 45.5 ± 35.40 months). Higher overall survival (P = 0.03) was found in the patient group with bladder cancer without incidentally diagnosed prostate cancer. Conclusion. There are indications that in this small study prostate cancer has influenced on patients' survival with bladder cancer after radical cystoprostatectomy.

Clinicopathologic features of incidental prostatic adenocarcinoma in radical cystoprostatectomy specimens

Background

The aim of this study is to review all features of incidentally discovered prostate adenocarcinoma in patients undergoing radical cystoprostatectomy for bladder cancer.

Methods

The medical charts of 300 male patients who underwent radical cystoprostatectomy for bladder cancer between 1997 and 2005 were retrospectively reviewed. The mean age of the patients was 62 (range 51-75) years.

Results

Prostate adenocarcinoma was present in 60 (20%) of 300 specimens. All were acinar adenocarcinoma. Of these, 40 (66.7%) were located in peripheral zone, 20 (33.3%) had pT2a tumor, 12 (20%) had pT2b tumor, 22(36.7%) had pT2c and, 6 (10%) had pT3a tumor. Gleason score was 6 or less in 48 (80%) patients. Surgical margins were negative in 54 (90%) patients, and tumor volume was less than 0.5 cc in 23 (38.3%) patients. Of the 60 incidentally detected cases of prostate adenocarcinoma 40 (66.7%) were considered clinically significant.

Conclusion

Incidentally detected prostate adenocarcinoma is frequently observed in radical cystoprostatectomy specimens. The majority are clinically significant.

Full analysis of the prostatic urethra at the time of radical cystoprostatectomy for bladder cancer: impact on final disease stage

Prostate involvement is a major prognostic element in urothelium carcinoma staging after radical cystoprostatectomy (RCP) for muscle invasive bladder cancer. While appropriate pTNM stage is necessary for adequate treatment, no standard procedure exists up to now for macroscopic sampling of the prostate in RCP in daily practice. We therefore propose a protocol where examination of the whole prostatic urethra (PU) is possible, without using whole mount sections. From 2008 to June 2009, RCP were sampled according to a macroscopic protocol permitting the whole length and the underlying stroma of PU to be visualized. Data were compared with our series or RCP from 2000-2007, when the PU was evaluated with a more simple protocol. One hundred and one specimens were examined between 2000-2007, 25 until June 2009. In the latter series, we found pT4 bladder cancer in 36% versus 21%, Cis in the PU in 28% versus 14%, and additional prostate cancer was seen in 44% compared with 13% (p = 0.0004) in the 2008-2009 group versus the 2000-2007 group, respectively. Our proposed protocol better detects prostate involvement by bladder cancer, therefore providing a better final stage of the patients. We propose a macroscopic protocol where the whole PU and the underlying stroma can be examined without the use of whole mount sections. Data are similar to those published in the recent literature, where whole mount sections were used. This protocol also permits better detection of concomitant prostate carcinomas.