Transitional cell carcinoma of the prostate following intravesical therapy for transitional cell carcinoma of the bladder

Primary high-grade urothelial carcinoma of prostate with prostatic hyperplasia: a rare case report and review of the literature

BACKGROUND

Primary urothelial carcinoma in the prostate (UCP) is extremely rare and occurs most frequently in the bladder. There are only dozens of primary cases reported in the literature. Here, we describe a rare case of primary UCP and review the literature.

CASE PRESENTATION

A 67-year-old widowed male, was referred to our hospital due to the frequency, and urgency of dysuria. Magnetic resonance imaging (MRI) examination revealed prostate size was about 57 mm × 50 mm × 54 mm, increased prostatic transitional zone, and surrounding of prostatic duct indicate bar isointense T1, short T2, hyperintense DWI, and hyposignal ADC (PI-RADS 3); posterior of peripheral zone indicate patchy isointense T1, short T2, hyperintense DWI, and hyposignal ADC (PI-RADS 5). Subsequently, the patient underwent a transrectal prostate biopsy. Histopathological and immunohistochemical (IHC) assessments showed prostatic high-grade urothelial carcinoma with benign prostatic hyperplasia. Finally, the patient underwent laparoscopic radical prostatectomy. Four months after surgery, CT plain and enhanced scan revealed thickening of the bladder wall. On further workup, cystoscopy revealed lymphoid follicular changes in the cut edge of the radical prostatectomy, and cystoscopic biopsies showed the malignant tumor.

CONCLUSIONS

Prostatic urothelial carcinoma should always be considered if the patient with severe lower urinary tract symptoms or hematuria, PSA, and digital rectal examination without abnormalities, without a personal history of urothelial cancer, but contrast-enhanced MRI showed the lesion located in the prostate. As of right now, radical surgical resections remain the most effective treatment. The effectiveness of neoadjuvant or adjuvant chemotherapy is still controversial.

Imaging of hematuria

Hematuria may have a number of causes, of which the more common are urinary tract calculi, urinary tract infection, urinary tract neoplasms (including renal cell carcinoma and urothelial tumors), trauma to the urinary tract, and renal parenchymal disease. This article discusses the current status of imaging of patients suspected of having urologic causes of hematuria. The role of all modalities, including plain radiography, intravenous urography or excretory urography, retrograde pyelography, ultrasonography, and multidetector computed tomography (MDCT) in evaluation of these patients is discussed. The article highlights the current status of MDCT urography in imaging of patients with hematuria, and discusses various-often controversial-issues, such as optimal protocol design, accuracy of the technique in imaging of the urothelium, and the significant issue of radiation dose associated with MDCT urography.

Prostatic transitional cell carcinoma: pathologic features and clinical management

Prostatic involvement by transitional cell carcinoma (pTCC) in patients with bladder cancer is a frequent finding, particularly in patients with high-grade invasive tumor and urothelial carcinoma in situ. Various patterns and levels of prostatic involvement have been described, and their impact in patients' management and their prognosis recognized. The role of prostatic urethral biopsy and intraoperative frozen section in the management of bladder cancer, tailoring to the bladder tumor stage is still not well defined and universally accepted. This review discusses the current understanding of the biology and histological patterns of pTCC and their clinical significance and management options. A rational approach for management of pTCC in patients with bladder cancer will be proposed on the basis of our experience and our review of literature.

Multidetector-row computed tomography (MDCT) in patients with a history of previous urothelial cancer or painless macroscopic haematuria

The sensitivity and specificity of MDCT for depiction and localization of urothelial carcinoma (UC) was determined retrospectively. Axial and coronal four-row MDCT of the urinary tract (unenhanced, contrast-enhanced nephrographic, CT urography) was independently reviewed for UC by a radiologist (R1) and a urologist (R2), without other patient information, in 27 patients (22 male, five female; age, 72 +/- 11 years) with previous UC and/or painless macroscopic haematuria. Urinary tract segments included bladder, right and left upper, middle, and lower caliceal groups, renal pelvis, uretero-pelvic junction, upper, middle, and lower ureter. MDCT findings were corroborated by surgery, other invasive procedures, and 1-year follow-up, including MDCT, intravenous urography, and cystoscopy. Receiver-operating characteristic analysis was undertaken and the the area under the curve (AUC) calculated. Eighteen of 27 patients had evidence of UC (pTa, n = 3; pT1-pT3, n = 15; TNM 2002). Tumor was correctly located by both R1 and R2 in 17 patients (sensitivity, 94%; 95% confidence interval, 84-100%) and ruled out in seven (specificity, 78%; 95% confidence interval, 51-100%), with complete agreement. Each detected ten of 11 upper urinary tracts affected by UC. For 35 urinary tract segments with UC and 308 without, the AUC was 0.910 +/- 0.035 (R1) and 0.74 +/- 0.055 (R2), z = 2.4772, Bonferroni-corrected P = 0.022. MDCT depicts urinary tracts affected by UC with high sensitivity and substantial agreement between readers with different training.

Urothelial Carcinoma of the Prostate

This study was conducted to explore the diagnosis and management of urothelial carcinoma of the prostate in superficial disease and carcinoma in situ, stromal invasion, primary urothelial carcinoma, and urethral recurrence after radical surgery. A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d'Urologie (SIU) reviewed the diagnosis and management of urothelial carcinoma of the bladder. English-language literature about urothelial carcinoma of the prostate was identified and reviewed. Evidence-based recommendations for the diagnosis and management of urothelial carcinoma were made. Many recommendations were level 3 or 4 citations involving the diagnosis and management of superficial urothelial carcinoma; a few were level 2 citations. Level 1 citations related only to chemotherapy and radiotherapy in patients with stromal invasion, although these were not related specifically to invasive prostatic involvement. More than 130 reviewed citations are summarized in this review. Published reports on the diagnosis and treatment of superficial urothelial disease of the prostate primarily consist of short case series from individual centers. Prospective and multicenter trials are needed to identify the real incidence and the best management of these patients. In invasive disease of the prostate, the only large series were designed to investigate invasive bladder cancer.

Intravesical Instillations with Bacillus Calmette-Guérin for the Treatment of Carcinoma In Situ Involving Prostatic Ducts

OBJECTIVES

Bacillus Calmette-Guérin (BCG) has proven its efficacy in the treatment of carcinoma in situ (CIS) of the prostatic urethra. We performed a retrospective study to evaluate the use of intravesical instillations of BCG in patients with carcinoma in situ involving prostatic ducts after complete transurethral resection (TUR).

MATERIAL AND METHODS

Eligibility for the study was CIS of the prostatic urethra involving prostatic ducts. Previous instillation with BCG was an exclusion criterion. Patients were treated with intravesical BCG Connaught (81 mg) administered once a week, over a 6-wk period. TUR loop biopsies of the prostate were performed only when a macroscopic tumor was present.

RESULTS

In this retrospective study of 11 patients, 8 (73%) presented with macroscopic tumor in the prostatic urethra. Ten patients (91%) had a simultaneous superficial bladder carcinoma. Eight patients (73%) had tumoral involvement of the bladder neck region. After a median follow-up of 27 mo (n=10 patients), the response in the prostatic urethra was 82%, and the response in the bladder due to superficial tumor recurrence was 64%. Two patients with residual ductal disease in the prostatic urethra were subsequently treated with cystoprostatectomy and are currently free of disease. In one of those patients, the cystoprostatectomy specimen did show prostatic stromal invasion. Another patient developed distant metastatic disease and died a few months after diagnosis. Thus, progression was encountered in two patients (18%). Currently, 90% of patients are alive without evidence of disease and 72.7% have benefitted from this bladder preservation strategy.

CONCLUSION

Intravesical BCG is a feasible treatment option for patients with CIS involving prostatic ducts. In this retrospective study, bladder preservation was successful in 8 of 11 patients (70%) and there was only one oncologic death. Obviously, these patients need a careful follow-up with cystoscopy and cytology to detect either recurrence or progression and in those with persistent disease after the initial BCG induction therapy, prompt cystectomy is indicated.

Conservative Management of Mucosal Prostatic Urethral Involvement in Patients with Superficial Transitional Cell Carcinoma of the Bladder

OBJECTIVE

Treatment of patients with mucosal prostatic urethral transitional cell carcinoma (TCC) is controversial. In this study, we evaluated the outcome of patients with mucosal prostatic urethral TCC who were managed conservatively.

METHODS

The data of 290 consecutive male patients with superficial TCC of the bladder who were treated at our institution were reviewed. Median age was 63 years and median follow-up was 63 months. Initially, all patients with mucosal PU involvement without evidence of ductal and/or stromal involvement underwent intravesical BCG or Epirubicin therapy.

RESULTS

Nineteen patients (6.6%) had mucosal involvement of the prostatic urethra (PU) and concomitant multifocal TCC of the bladder. Of those, 12 patients (12/19, 4.2%) had macroscopic mucosal involvement of the PU, while the other 7 patients (7/19, 2.4%) had microscopic PU tumor. Seven of 12 patients who were treated with BCG and 2 of 7 patients who were treated with Epirubicin achieved complete response. Progression occurred in 3 patients who received BCG and no patients progressed in the Epirubicin group.

CONCLUSIONS

Prostatic urethral sampling should be considered necessary in intermediate and high risk patients with superficial TCC of the bladder. Intravesical therapy, especially with BCG seems to be an effective treatment alternative in the management of mucosal PU involvement.

Carcinoma transicional primario puro de próstata. revisión de nuestra serie

Primary prostate transitional cell carcinoma is a very uncommon tumor, that represents about 1% of all prostate tumours. In our institution, only six patients have been diagnosed with pure transitional cell prostate carcinoma until 2002. Bladder origin of the neplasic was ruled out in all cases. We report a study about the progression and survival of prostate transitional cell carcinoma. These prostatic tumours carry a poor prognostic (median survival is 4.6 months) with a strong tendency to metastatic spread. Therefore, we suggest a radical prostatectomy (without cystectomy) when it rules out bladder origin tumour.

A clinicopathologic analysis of urothelial carcinomas diagnosed on prostate needle biopsy

No data exist on urothelial carcinoma diagnosed on prostatic needle biopsy. We reviewed 21 cases (19 consultations) of urothelial carcinoma diagnosed on prostate needle biopsy from 1991 to 1998. In 13 of 21 (62%) cases, urothelial carcinoma showed in situ urothelial carcinoma involving prostatic ducts and acini (DCIS) only; 6 of 21 (29%) cases showed both DCIS and invasive carcinoma and 2 of 21 (9%) cases showed widespread stromal invasion without DCIS. In contrast to prostatic adenocarcinoma, cases exhibited greater nuclear pleomorphism, variably prominent nucleoli, increased mitoses, and necrosis. Immunostains for PSA and PSAP were negative in all 18 cases studied. CK7 was positive in 14 of 16 cases, CK20 was positive in 13 of 16 cases, and 34betaE12 was positive in 11 of 17 cases. A total of 7 of 17 (41%) men had no prior or subsequent history of urothelial carcinoma outside the prostate, 6 of 17 (35%) had concurrent urothelial cell carcinomas of the bladder (1 with extensive carcinoma in situ [CIS] at cystoprostatectomy), 2 of 17 (12%) had a prior urothelial cell carcinoma, and 2 of 17 (12%) developed urothelial cell carcinomas outside the prostate subsequent to the needle biopsy diagnosis. A total of 14 of 18 (78%) men had an elevated prostate specific antigen (PSA), abnormal digital rectal examination, or abnormal ultrasound suggestive of prostatic adenocarcinoma. Follow-up information was available in 17 cases. Six of nine (67%) patients with DCIS eventually died of disease (DOD) (2 with prior urothelial cell carcinoma, 1 with no prior or subsequent history, 3 without information), and 3 of 9 (33%) patients with DCIS were alive with residual disease (AWD). Of the patients with invasive carcinomas, 4 of 8 (50%) were DOD, 2 of 8 (25%) were AWD, and 2 of 8 (25%) were alive without evidence of disease. All men who are alive were treated aggressively with surgery and often adjuvant chemotherapy-radiation. Overall, 10 of 17 (59%) men were DOD with a mean survival after diagnosis of 23.2 months (2-72 months). The diagnosis of urothelial carcinoma on prostate needle biopsy is difficult because it is rare and clinically can mimic prostatic adenocarcinoma; often there is no history of urothelial carcinoma elsewhere. Although the prognosis is poor even with only apparent DCIS, histologic recognition is essential because the only opportunity for improved outcome is early and aggressive treatment.

[Primary transitional carcinoma of the prostatic ductus]

Primary prostate transitional cell carcinoma is a very rare tumour originating in the transitional epithelial cells of the intraprostate periurethral ductus. Only 17 of 829 patients diagnosed with prostate carcinoma were found to have the transitional cell variety. Eight (8) of those had pure transitional cell carcinoma and 9 a mixed presentation of acinar adenocarcinoma and transitional cell ductal carcinoma. Bladder origin of the tumour was ruled out in all cases. We report a retrospective study on the clinical behaviour of prostate transitional cell carcinoma. Compared to acinar carcinomas, few differences were found when age, symptoms, physical findings and imaging diagnosis were evaluated. Clinical presentation, DRE, PSA, metastatic spread and presence of supravesical obstructive uropathy where also studied to establish a diagnosis. Radiotherapy was the most frequently used therapeutical approach. Mean survival is 26.6 months (4-60 months) and there has been 11 death up to now. Compared to acinar forms, this tumour shows a hormone-resistant, aggressive biological behaviour with poor prognosis. Early diagnosis and radical surgery are the only options available to increase life expectancy for these patients.

[Transitional carcinoma of the prostate]

Case report of prostate transitional carcinoma diagnosed by transurethral resection, an infrequent tumour with incidence ranging from 1% to 4% of all prostate neoplasias which appears in 2.8% of all radical cystoprostatectomies specimens carried out at the Mayo Clinic. Most commonly, when it appears in the prostate this tumour is simultaneous or subsequent to other transitional carcinoma arisen in other organs mostly the bladder. Very rarely it occurs as an early form within the ducts and even less often within the prostate acinus. Review of the neoplasia histology, signs and symptoms, diagnostic procedures and management, emphasising the aggressiveness of its behaviour (such as in our case report) when the prostate gland stroma is infiltrated by the tumour.

Intravesical bacillus Calmette-Guerin for the treatment of superficial transitional cell carcinoma of the prostatic urethra in association with carcinoma of the bladder

Between 1981 and 1989, 83 male patients with stages Ta, Tis and T1 transitional cell carcinoma were treated with bacillus Calmette-Guerin (BCG). Of 17 patients with carcinoma in situ of the prostatic urothelium 13 had identifiable prostatic ducts and periurethral ductal transitional cell carcinoma was identified in 7. At a median followup of 64 months (range 29 to 90) 12 of 17 patients (70%) had a complete response in the prostatic urethra. Among the 10 patients with mucosal carcinoma without ductal involvement 8 responded as did 4 of the 7 with mucosal and ductal involvement. A total of 9 patients had persistent tumor or recurrence in the bladder or prostate. Two men had recurrence in the prostatic urethra and, due to age and co-morbidity, both were treated by transurethral resection and fulguration. Cystectomy was performed in the remaining 7 patients. Three of 31 patients (10%) whose prostate urethral biopsies were negative before BCG therapy had a positive biopsy afterwards. After treatment with BCG, the actuarial curves for cancer specific, progression-free and overall survivals showed no statistical difference between male patients with an initially positive or initially negative prostatic urethral biopsy. BCG is a reliable agent for initial therapy of superficial prostatic transitional cell carcinoma. Careful followup can identify persistent tumor, recurrences or progression that identifies patients for whom cystectomy is appropriate.

Bladder cancer following prostate cancer--an analysis of risk factors

Between 1969 and 1988, 1421 men had been treated for primary adenocarcinoma of the prostate. In 14 cases subsequent primary bladder cancer was observed, as compared to 5.98 cases to be expected, thus constituting a relative risk of 2.34. Seven of these cases developed synchronously (within 6 months), with a range of up to 10 years. Aetiologically, cigarette smoking was detected as the single most important denominator, whereas family history was positive for malignancy in only two cases.

An adequate sampling of the prostate to identify prostatic involvement by urothelial carcinoma in bladder cancer patients

The distribution of any involved prostatic urethra, ducts and acini by urothelial carcinoma was studied to determine an adequate sampling method for detecting prostatic involvement using the maps of 38 cystoprostatectomy specimens. A total of 31 patients had prostatic duct and acini involvement, while 7 had prostatic urethral involvement alone. However, the distribution of the involved prostatic urethra, ducts and acini varied. In 29 of the 31 patients (93.5%) with prostatic duct and acini involvement, urethral carcinoma in situ and/or superficial gland involvement (an involvement of the afferent ducts within a few millimeters of the urethral mucosa) at the 5 and/or 7 o'clock position of the verumontanum portion was identified. In 7 patients with prostatic urethral involvement alone 2 had carcinoma foci at the 5 and/or 7 o'clock position of the verumontanum portion. Furthermore, the frequency of deeper gland involvement (an involvement of true prostatic acini except for superficial glands) was higher in patients with superficial gland involvement at the 5 and/or 7 o'clock position of the verumontanum portion (57.7%) than in patients without such involvement (20.0%). Therefore, this study emphasizes that a transurethral resection biopsy containing prostatic tissue at the 5 and/or 7 o'clock position of the verumontanum portion substantially improves the detection of prostatic duct and acini involvement in bladder cancer patients. Moreover, if the prostatic superficial glands are involved at the 5 and/or 7 o'clock position of the verumontanum portion, the potential involvement of the deeper glands should also be suspected.

Clinical assessment of carcinoma in situ of the human urinary bladder

Recent interest in intravesical instillation of bacillus Calmette-Guérin for the management of carcinoma in situ (CIS) of the bladder prompted us to review our results of total immediate cystourethrectomy. From 1975 to 1987, we surgically treated 302 patients with primary bladder tumours. Of these, 21 bladder tumours were histologically diagnosed as CIS, and total immediate cystourethrectomy was performed in all cases. The lesions were classified into three types: primary CIS accompanied by neither previous nor simultaneous tumours of the urinary tract (Type 1, 9 patients), concomitant CIS associated with superficial papillary tumour (Type 2, 6 patients), and secondary CIS detected during the follow-up period after treatment of the superficial papillary tumour (Type 3, 6 patients). Primary CIS was more often diagnosed according to subjective symptoms such as micturition pain than concomitant CIS. Secondary CIS was diagnosed in all patients by routine examinations including cytology and cystoscopy. There was no particular relationship between the time of recurrence of the tumour and the occurrence of secondary CIS. Within the same period, 60 patients with stage T1 bladder tumour were treated by total cystourethrectomy. The actuarial 5-year survival rate was 77% for T1 and 75% for CIS. The 5-year survival rate was 71% for Type 1, 83% for Type 2, and 67% for Type 3 CIS with no difference among the CIS types. Tumour invasion to the bladder, prostate, ureter, or lymph nodes was observed in 9 (42.9%) of the 21 patients, although cystourethrectomy was performed within 3 months of the diagnosis. Examination of ABH antigens did not allow prediction of invasion of CIS. Our findings suggest that the invasive potential of CIS may seriously limit the indications of conservative treatment against carcinoma in situ.

Prostatic occurrence of transitional cell carcinoma after intravesical chemotherapy

Thirteen patients with Stage Tis, Ta, or T1 transitional cell carcinoma (TCC) of the bladder treated by transurethral resections and intravesical chemotherapy developed TCC of the prostate. Among the 13 cases, cytology specimens were obtained from 10 at the time prostatic disease was diagnosed; 9 demonstrated TCC. One was treated successfully by transurethral resection of a Ta lesion involving the prostatic urethra only. One of 2 patients declining radical surgery is alive with residual disease at twenty-four months, and the other died of progressive disease at nineteen months. Of the 10 patients who underwent radical cystoprostatectomy, 7 are alive with no evidence of disease eight to forty-two months postoperatively, with 2 of these 7 having received 4 courses of systemic methotrexate, vincristine, Adriamycin, and cisplatinum (MVAC) for metastatic disease. Two of the 10 died of metastatic disease six and thirteen months postoperatively, and one frail patient died of surgical complications. When treating patients with intravesical chemotherapy for superficial TCC, biopsy of the prostate should be done during follow-up examinations, especially in the presence of cytologic or palpable prostatic abnormalities.

Urethral recurrence following radical cystectomy

We reviewed the clinical courses of 86 men after radical cystoprostatectomy for transitional cell carcinoma of the bladder to determine who were at highest risk for urethral recurrence. We assessed patients for prostatic involvement as well as tumor extent in the bladder and distal ureters. Of the 30 patients with tumor in the prostate 11 (37%) suffered urethral recurrences. Of the 56 patients with all other types of tumor involvement patterns exclusive of disease in the prostate only 2 (4%) had recurrence. We recommend rigorous screening for transitional cell carcinoma of the prostate before cystectomy. Prophylactic urethrectomy is indicated for patients with prostatic involvement, while those without such involvement may be considered at low risk for urethral recurrence.

Local bacillus Calmette-Guerin therapy for superficial bladder cancer: clinical, histological and ultrastructural patterns

The effectiveness of intravesical administration of bacillus Calmette-Guerin as a prophylaxis of superficial bladder cancer has been definitely demonstrated. On the other hand, therapeutic regimens, duration effects, efficacy of either maintenance cycles or repeated courses of therapy in case of failures are still controversial. We report the results achieved in 15 cases of carcinoma in situ of the bladder and in 48 cases of superficial bladder cancer (Ta-T1 stage of disease) with bacillus Calmette-Guerin immunotherapy. Our patients underwent an initial six week cycle and a following maintenance cycle with monthly administrations for one year. Median follow-up was 19 months (range 18-21 months). Patients with carcinoma in situ are now free of disease; on the contrary, patients with Ta-T1 tumors experienced 18 recurrences (28%). There was a marked decrease of recurrence rate when compared to previous local chemotherapy. We report in detail the adverse effects encountered and both histologic and ultrastructural findings observed after immunotherapy. Bacillus Calmette-Guerin therapy can influence positively the natural history of the disease but possible adverse effects should always be considered before starting the treatment.