Prostatic involvement by transitional cell carcinoma: pathogenesis, patterns and prognosis

Characteristics and survival of primary urothelial carcinoma of the prostate: A multi-center retrospective study of 18 cases

OBJECTIVES

To explore the features, treatment, and outcomes of primary urothelial carcinoma of the prostate (PUCP) in a multicenter study.

METHODS

The clinical and imaging features, pathological findings, treatment, and outcomes of patients diagnosed with PUCP from January 2011 to April 2022 at three institutions were collected and analyzed. The Kaplan-Meier method and log-rank test were used to assess survival rates of the overall group and survival differences between groups according to TNM stage.

RESULTS

The study cohort comprised 18 patients with PUCP of mean age 72.4±7.8 years. Dysuria and urinary frequency were the most common symptoms (77.8 %). Sixteen (88.9 %) patients had normal serum total PSA concentrations. Most patients showed abnormalities on urinalysis. MRI was the most accurate diagnostic imaging method (88.9 %). As to immunohistochemistry findings, GATA-3 (81.8 %) and P63 (84.6 %) were positive in most examined patients; however, no lesions were positive for PSA. Three (17.6 %) patients with T1N0M0 and T2N0M0 tumors underwent radical cystectomy. Eleven (64.7 %) patients which almost all had T4 tumors received systematic therapy, most of them receiving chemotherapy with gemcitabine and cisplatin, and radiotherapy. The median overall survival was 42 months, and the median progression-free survival 25 months, the latter being significantly longer in patients with T1-2 than in those with T3-4 disease (p=0.035).

CONCLUSION

PUCP, a rare but highly aggressive type of prostate cancer, should be considered in men with abnormalities on MRI and normal serum PSA concentrations. Positive GATA-3, P63, and negative PSA are typical immunohistochemistry features. Radical cystectomy and systematic therapies can be effective.

Double cocktail immunostains with high molecular weight cytokeratin and GATA-3: useful stain to discriminate in situ involvement of prostatic ducts or acini from stromal invasion by urothelial carcinoma in the prostate

BACKGROUND

Distinguishing prostatic stromal invasion (PSI) by urothelial carcinoma (UC) from in situ UC involving prostatic ducts or acini with no stromal invasion (in situ involvement) may be challenging on hematoxylin and eosin stained sections. However, the distinction between them is important because cases with PSI show worse prognosis. This study was performed to assess the utility of double cocktail immunostains with high molecular weight cytokeratin (HMWCK) and GATA-3 to discriminate PSI by UC from in situ UC involvement of prostatic ducts or acini in the prostate.

METHODS

Among 117 radical cystoprostatectomy specimens for bladder UCs, 25 cases showed secondary involvement of bladder UC in prostatic ducts/acini only or associated stromal invasion and of these 25 cases, seven cases revealed equivocal PSI. In these seven cases with equivocal PSI, HMWCK, and GATA-3 double immunohistochemical stains were performed to identify whether this cocktail stain is useful to identify the stromal invasion.

RESULTS

In all cases, basal cells of prostate glands showed strong cytoplasmic staining for HMWCK and UC cells showed strong nuclear staining for GATA-3. In cases with stromal invasion of UC, GATA-3-positive tumor cells in the prostatic stroma without surrounding HMWCK-positive basal cells were highlighted and easily recognized. Among seven equivocal cases, two cases showed PSI and five in situ UC in the prostate. In two cases, the original diagnoses were revised.

CONCLUSIONS

Our study suggested that HMWCK and GATA-3 double stains could be utilized as an adjunct method in the distinction between PSI by UC from in situ UC involving prostatic ducts or acini.

Morphological and Immunohistochemical Biomarkers in Distinguishing Prostate Carcinoma and Urothelial Carcinoma: A Comprehensive Review

The differential diagnosis between high-grade prostate carcinoma and infiltrating urothelial carcinoma (UC) in transurethral resection prostate specimens as well as cystoprostatectomy specimens may often be challenging due to morphologic and clinical overlap of the 2 entities. Such distinction has critical therapeutic and staging consequences, yet it is hampered by both issues in morphology and by the low accuracy rates of single immunohistochemical markers, as reported in literature. This review aims to provide a comprehensive analysis of the available morphological and immunohistochemical parameters, which may allow to discriminate between prostate carcinoma and urothelial carcinoma in the proper clinical context and to discuss their diagnostic applications in daily practice.

Mucinous and secondary tumors of the prostate

Primary mucinous tumors and secondary tumors involving the prostate gland are relatively uncommon, however they have important diagnostic, therapeutic, and prognostic implications. The primary mucinous tumors of the prostate include mucinous (colloid) adenocarcinoma of the prostate, prostatic adenocarcinoma with mucinous features, and mucinous adenocarcinoma of the prostatic urethra (mucin-producing urothelial-type adenocarcinoma of the prostate). Mucinous adenocarcinoma of the prostate is defined as a primary prostatic acinar tumor characterized by the presence of at least 25% of the tumor composed of glands with extraluminal mucin. This diagnosis can only be made in radical prostatectomy specimens. Recent studies have shown that these tumors have a similar or in some cases better prognosis than conventional prostatic adenocarcinoma treated by radical prostatectomy. The preferred terminology for tumors that are composed of <25% extraluminal mucinous component in radical prostatectomy specimens is 'prostatic adenocarcinoma with mucinous features.' All cases of prostatic adenocarcinoma with extraluminal mucinous components in prostate needle core biopsies or transurethral resection of the prostate specimens are also referred to as 'prostatic adenocarcinoma with mucinous features.' Mucinous adenocarcinoma of the prostatic urethra (mucin-producing urothelial-type adenocarcinoma of the prostate) as the name implies, does not arise from prostatic acini or ducts, and is a distinct entity that arises from the prostatic urethra usually from urethritis glandularis or glandular metaplasia with malignant transformation, and is analogous to adenocarcinoma with mucinous differentiation arising from the urinary bladder. This tumor is aggressive and has a relatively poor prognosis. The most common secondary tumors that arise from adjacent organs and spread (direct extension or metastasis) to the prostate gland, include urothelial carcinoma of the bladder and colorectal adenocarcinoma. Other secondary tumors that may involve the prostate include metastatic epithelial tumors from several other sites, malignant melanoma and soft tissue tumors.

Transurethral biopsy of the prostatic urethra is associated with final apical margin status at radical cystoprostatectomy

PURPOSE

Biopsy of the prostatic urethra is an integral part of clinical staging in patients prior to radical cystoprostatectomy (RC) and urinary diversion. We examined whether preoperative transurethral resection (TUR) biopsy was associated with final apical urethral margin status and hypothesized that a negative biopsy could replace intraoperative frozen section for decision making regarding the feasibility of orthotopic neobladder reconstruction.

METHODS

TUR biopsy, frozen section, urethrectomy, and final apical urethral margin pathologic data were extracted from the charts of men who had undergone RC at the Houston Methodist Hospital between 1987 and 2013. TUR biopsies were performed at five and seven o'clock adjacent to the verumontanum. A positive biopsy was defined as the presence of in situ or invasive urothelial carcinoma. Clinical and perioperative variables were analyzed using descriptive and inferential statistics.

RESULTS

We reviewed the medical records of 272 men. Preoperative TUR biopsies of the prostatic urethra were negative in 74% (200/272) and positive in 26% (72/272) of men. The overall incidence of apical urethral margin positivity on final pathology was 2.2% (six of 272). Four men underwent primary or secondary urethrectomy. TUR biopsy negative and positive predictive values for apical urethral margin positivity were 99.5% (95% confidence interval (CI): 97.2 to 99.9) and 6.9% (95% CI: 2.3 to 15.5), respectively.

CONCLUSIONS

The incidence of a positive apical urethral margin was low in patients undergoing RC. A negative preoperative TUR biopsy of the prostatic urethra was reliably associated with a negative final margin, obviating the need for intraoperative frozen section. Furthermore, a positive biopsy was not reliably associated with final margin status. These data will aid in the counseling of patients regarding the feasibility of neobladder reconstruction.

Usefulness of transurethral biopsy for staging the prostatic urethra before radical cystectomy

PURPOSE

We determined the likelihood that transurethral resection biopsy of the prostatic urethra adjacent to the verumontanum would detect prostatic involvement of urothelial carcinoma in patients with bladder carcinoma.

MATERIALS AND METHODS

We compared precystectomy transurethral resection biopsy specimens of the prostatic urethra with those of the matched radical cystoprostatectomy in 272 patients with urothelial carcinoma of the bladder. All prostates were evaluated by whole mount step sections.

RESULTS

Prostatic involvement by urothelial carcinoma was detected by transurethral resection biopsy or radical cystoprostatectomy in 101 patients (37.1%). Transurethral resection biopsy detected urothelial carcinoma in 72 cases with 71.3% sensitivity and 100% specificity. The overall accuracy of transurethral resection biopsy to detect urothelial carcinoma of the prostate was 89% (positive and negative predictive values 100% and 86%, respectively). Invasive prostatic urothelial carcinoma arising from the prostatic urethra was detected by transurethral resection biopsy in 21 of 26 patients (81%) while prostatic carcinoma in situ was detected in 39 of 52 (75%). Transurethral resection biopsy detected prostatic invasive urothelial carcinoma resulting from transmural invasion of a bladder tumor in 4 of 15 patients.

CONCLUSIONS

Prostatic involvement by urothelial carcinoma of the bladder was found in 37.1% of patients. Transurethral resection biopsy missed most tumors resulting from transmural invasion of the bladder primary lesion. Carcinoma in situ and invasive urothelial carcinoma arising from the prostatic urethra were detected in most cases. Transurethral resection biopsy of the prostatic urethra can complement staging and support clinical decision making with respect to neoadjuvant chemotherapy and planning for an orthotopic neobladder.

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.

[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.

CK5, CK5/6, and double-stains CK7/CK5 and p53/CK5 discriminate in situ vs invasive urothelial cancer in the prostate

For primary bladder tumors, distinguishing urothelial carcinoma (UC) invading the fibromuscular stroma of the prostate (pT4a) from in situ UC involving prostatic ducts can be difficult. Immunohistochemical markers (cytokeratin [CK]5/6, CK5, CK7, CK20, p53, p63, high-molecular-weight keratin [HMWK], androgen receptor, prostate-specific antigen [PSA], prostate specific acid phosphatase [PSAP], laminin, CD44s, CD141) were assessed for their usefulness in determining depth of UC invasion in the prostate. In cystoprostatectomy specimens containing in situ UC in prostatic ducts, both CK5/6 and CK5 clearly differentiated prostatic basal cells from in situ UC. The remaining markers were not effective in determining depth of tumor invasion. Double-stain combinations CK7/CK5 and p53/CK5 were performed and robustly color contrasted in situ tumor from surrounding basal cells. The use of CK5/6, CK5, CK7/CK5, or p53/CK5 is recommended to assist in determining the depth of UC invasion in the prostate when histologic findings are equivocal.

Utility of p63 and high molecular weight cytokeratin in the distinction between urothelial carcinoma with prostatic stromal invasion and urothelial carcinoma with colonisation of prostatic ducts and acini

AIMS

To evaluate the utility of p63 and high molecular weight cytokeratin in the distinction between urothelial carcinoma with prostatic stromal invasion and urothelial carcinoma with colonisation of prostatic ducts and acini which may be challenging on H&E, especially for general pathologists who may occasionally encounter these cases.

METHODS

A search of surgical pathology and consultation files was made for cystoprostatectomy specimens with confirmed urothelial carcinoma with prostatic stromal invasion. Intensity for both p63 and high molecular weight cytokeratin within the tumour cells were scored as negative/weak or strong.

RESULTS

A total of 34 cases were identified, 23 (68%) of which had associated foci of urothelial carcinoma with colonisation of prostatic ducts and acini. Mean patient age was 68.5 years (range 44-88 years). In all cases, basal cells of benign prostatic glands showed strong staining for both p63 and high molecular weight cytokeratin. Seventeen of 34 cases (50%) of urothelial carcinoma showed no or weak expression of high molecular weight cytokeratin in the tumour cells. The other 17 cases (50%) of urothelial carcinoma showed strong expression of high molecular weight cytokeratin in the tumour cells. Fourteen of 34 cases (41%) showed negative or weak expression of p63 in tumour cells. Twenty of 34 cases (59%) showed strong expression of p63 in tumour cells. In the 14 of 34 cases (41%) and 17 of 34 cases (50%) which showed negative/weak expression of p63 and high molecular weight cytokeratin, respectively, in the tumour cells, the positive staining of the basal cells by p63 and high molecular weight cytokeratin in the benign prostatic glands and acini or those colonised by urothelial carcinoma, aided in the distinction from urothelial carcinoma with prostatic stromal invasion. In the remaining 20 of 34 cases (59%) and 17 of 34 cases (50%) in which the tumour cells showed strong expression of p63 and high molecular weight cytokeratin, respectively, larger malignant tumour cells and smaller benign basal cells of the prostatic glands and acini were highlighted with these markers, and were easily distinguishable.

CONCLUSION

Our study suggests that p63 and high molecular weight cytokeratin may be utilised in the distinction between urothelial carcinoma with prostatic stromal invasion and urothelial carcinoma with colonisation of prostatic ducts and acini.

Depth and origin of prostatic involvement by urothelial carcinoma: prognostic significance and staging interpretation

OBJECTIVE

To investigate the prognostic significance of prostatic involvement by bladder urothelial carcinoma using the new 2009 TNM staging system.

METHODS

From 1993 to 2008, 77 consecutive men who were clinically and/or pathologically diagnosed with bladder cancer underwent radical cystectomy. Patients were classified into several groups, according to the presence, extent and invading pathway of prostatic involvement by urothelial carcinoma, whether there was stromal or non-stromal involvement, and whether there was contiguous or non-contiguous involvement. Cause-specific survivals were calculated in each group and they were compared.

RESULTS

Prostatic involvement was observed in 23 (30%) patients: 10 had non-contiguous non-stromal involvement, 5 had non-contiguous stromal involvement and 8 had contiguous stromal involvement. Patients with stromal involvement (both contiguous and non-contiguous) showed significantly shorter cause-specific survival compared with those without prostatic stromal involvement (P= 0.002). The survival of patients with contiguous prostatic stromal involvement was similar to that of patients with non-contiguous prostatic stromal involvement (P= 0.79). Multivariate analysis showed that prostatic stromal involvement (both contiguous and non-contiguous) (hazard ratio, 8.4; P< 0.001), lymph node involvement (hazard ratio, 4.4; P= 0.016) and perivesical fat involvement (hazard ratio, 3.8; P= 0.029) were predictive of cause-specific survival.

CONCLUSIONS

The depth of prostatic involvement has a significant impact on survival for patients with bladder urothelial carcinoma; however, whether its origin is contiguous or non-contiguous does not appear to be important.

Prospective study of transitional cell carcinoma in the prostatic urethra and prostate in the cystoprostatectomy specimen

OBJECTIVES

To prospectively evaluate the incidence of transitional cell carcinoma (TCC) in the prostatic urethra and prostate in the cystoprostatectomy specimen, investigate characteristics of bladder tumours in relation to the risk of involvement of the prostatic urethra and prostate and examine the sensitivity of preoperative loop biopsies from the prostatic urethra.

MATERIAL AND METHODS

Preoperatively, patients were investigated with cold cup biopsies from the bladder and transurethral loop biopsies from the bladder neck to the verumontanum. The prostate and bladder neck were submitted to sagittal whole-mount pathological analysis.

RESULTS

The incidence of TCC in the prostatic urethra and prostate in the cystoprostatectomy specimen was 29% (50/175 patients). Age, previous bacillus Calmette-Guérin treatment, carcinoma in situ (Cis) in the cold cup mapping biopsies and tumour grade were not associated with the risk of TCC in the prostatic urethra/prostate. Cis, multifocal Cis (> or = 2 locations) and tumour location in the trigone were significantly more common in cystectomy specimens with TCC in the prostatic urethra and prostate: 21/50 (42%) vs 32/125 (26%), p=0.045; 20/50 (40%) vs 27/125 (22%), p=0.023; and 20/50 (40%) vs 26/125 (21%), p=0.01, respectively. Preoperative resectional biopsies from the prostatic urethra in the 154 patients analysed identified 31/47 (66%) of patients with TCC in the prostatic urethra/prostate, with a specificity of 89%. The detection of stromal-invasive and non-stromal involvement was similar: 66% and 65%, respectively.

CONCLUSIONS

The incidence of TCC in the prostatic urethra and prostate was 29% (50/175) in the cystoprostatectomy specimen. Preoperative biopsies from the prostatic urethra identified 66% of patients with such tumour growth. Our findings suggest that preoperative cold cup mapping biopsies of the bladder for detection of Cis add little extra information with regard to the risk of TCC in the prostatic urethra and prostate.

Pathologic assessment and clinical significance of prostatic involvement by transitional cell carcinoma and prostate cancer

The prostate is commonly involved by transitional cell carcinoma (TCC) in patients with bladder cancer. A number of clinicopathologic factors including multifocal carcinoma in situ, tumor location, and tumor stage are associated with prostatic TCC (pTCC). In addition, the manner and extent of pathologic examination also makes a significant difference in the detection rate. Distinct patterns and extent of pTCC have been described and are associated with pathologic stage of the primary bladder tumor as well as prognosis. Preoperative transurethral biopsy of the prostatic urethra is a sensitive and accurate method to detect pTCC and is helpful for surgical planning. Given the high incidence of pTCC and prostatic adenocarcinoma, radical cystoprostatectomy is the treatment of choice for loco-regional control for patients with T4a disease. Further studies are necessary to establish the role of neoadjuvant and adjuvant therapy for patient with prostatic stroma invasion.

Dilemmas in the treatment of urothelial cancers of the prostate

OBJECTIVES

The objective of this paper is to examine the contemporary incidence, diagnosis, and treatment of prostatic urothelial carcinoma and make recommendations on the current dilemmas of treating urothelial cancer of the prostate.

METHODS

A review of English-language literature from 1990 to the present was performed utilizing the U.S. National Library of Medicine's Pub Med database. Keywords used were urothelial cell carcinoma, prostatic urethral involvement, prostatic duct/acini involvement, carcinoma in situ. Bibliographies of reviewed articles were also searched.

RESULTS

Transitional cell carcinoma of the bladder with involvement of the prostate has been reported in multiple studies with an incidence between 12% and 48%. Stromal invasion of the prostate has a reported incidence between 7% and 17%. The incidence of primary transitional cell carcinoma of the prostate has been estimated at 1% to 4% of prostatic malignancies. Degree and depth of prostatic invasion has prognostic significance with 5-year survival rates being 100% for those with urethral mucosal involvement, 50% with ductal/acinar involvement, and 40% with prostatic stromal invasion. The actual anatomic path that urothelial carcinoma invasion occurs also has prognostic significance. Those with contiguous malignant involvement had a 7% 5-year survival rate compared with those with noncontiguous involvement and a 46% 5-year survival rate.

CONCLUSIONS

Prostatic urothelial carcinoma is often under appreciated and not well understood. Malignant involvement of different anatomic locations of the prostate (i.e., mucosa, ducts, acini, and stroma) influence not only diagnosis but treatment of disease. Although debate exists regarding optimal therapy for mucosal involvement, if the prostatic stroma is involved, radical cystoprostatectomy is the treatment of choice.

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.

Prostatic involvement by urothelial carcinoma of the bladder: clinicopathological features and outcome after radical cystectomy

OBJECTIVES

To review the long-term outcome of prostatic involvement in patients with bladder cancer (BC) treated with radical cystectomy (RC), as urothelial carcinoma (UC) involving the prostate occurs in such patients, and prostatic invasion by UC is by transmural invasion (contiguous), or when UC develops from the epithelium of the prostatic urethra (not contiguous).

PATIENTS AND METHODS

Between 1992 and 2006, 351 men had RC for BC by one surgeon at our centre; they were stratified into those with contiguous or non-contiguous disease, based on prostatic stromal involvement. Relevant clinical and pathological data were collected and the survival analysed.

RESULTS

In all, 24% (78/320) of the patients who had RC had prostatic involvement; 29 (9%) and 49 (15%) had contiguous and non-contiguous involvement, respectively. In the non-contiguous group, there was stromal and non-stromal UC involvement in 18 (37%) and 31 (63%), respectively. The overall 5-year survival of contiguous, non-contiguous and no prostatic involvement was 6%, 57% and 66% (P < 0.001). The 5-year overall survival of stromal and non-stromal UC was 26% and 74% (P = 0.008). There was no statistical difference in survival between contiguous and non-contiguous stromal involvement (P = 0.58).

CONCLUSIONS

Prostatic UC with no stromal involvement did not alter the survival predicted by the primary bladder stage. Stromal involvement of the prostate has a poor prognosis regardless of the mode of invasion.

Urothelial carcinoma in the prostatic urethra and prostate: current controversies

We reviewed the literature on urothelial carcinoma in the prostatic urethra and prostate. We concluded that the incidence of urothelial carcinoma in the prostatic urethra and prostate is probably underestimated. This fact warrants thorough follow-up of patients with high-risk bladder cancers and also whole-mount examination of the prostate after cystectomy to recognize the true incidence and extent of such tumor involvement. Resectoscope loop biopsy is the method of choice to detect urothelial carcinoma in the prostatic urethra/prostate and such biopsies should include the area around the verumontanum to ensure optimal sensitivity. Carcinoma in situ in the prostatic urethra should be treated with intravesical Bacillus Calmette-Guérin and a transurethral resection of the prostate prior to that treatment might increase the contact of Bacillus Calmette-Guérin with the prostatic urethra, improve staging and in itself treat the prostatic involvement. Conservative treatment of carcinoma in situ in the prostatic ducts is an option, although radical surgery is probably best for treating extensive intraductal involvement, since data on the former strategy are inconclusive. Patients with stromal invasion should undergo radical surgery. It is necessary to take the route of prostatic involvement into account when estimating prognosis in each individual patient, since contiguous growth into the prostate is associated with worse prognosis. Prospective studies using a whole-mount technique to investigate the prostate are needed to clarify both the role of different routes of prostate invasion and the prognostic significance of different degrees of prostate invasion. At cystectomy, when urothelial carcinoma is present in the prostatic urethra and/or prostate, it is necessary to balance the risk of urethral recurrence and decreased sexual function against opinion and expectations expressed by the patient during preoperative counseling regarding urinary diversion and primary urethrectomy.

Transitional Cell Carcinoma of the Prostate

Transitional cell carcinoma of the prostate (TCCP) has become a well recognized entity, showing an increasing incidence due to the growing research awareness. TCCP is part of the well known pan-urothelial disease: the urologist, therefore, is strongly recommended to consider the prostate at any time in the management of superficial and invasive bladder cancer. Several cases are diagnosed in association with bladder cancer (secondary TCCP): primary prostatic transitional cell carcinoma arises ‘de novo’ as first tumour of the prostate urothelium and is rare. Prognosis depends on the prostate invasion degree. No reliable staging systems are presently available. Non-invasive TCCP can be successfully treated with conservative means (TUR +/- BCG), whereas stromal invasive TCCP must be aggressively treated with radical cystectomy. TCCP can interphere with surgeon's decisions about urinary diversion in patients undergoing radical cystectomy for urothelial cancer. (Urologia 2007; 74: 15–21)

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.

Prostatic involvement by transitional cell carcinoma in patients with bladder cancer and its prognostic significance

To study the importance of prostatic involvement by transitional cell carcinoma (TCC) in patients with bladder cancer, we examined the entire prostates by whole-mount sections from 214 radical cystoprostatectomy specimens for detailed patterns of involvement by TCC and correlated the results with lymph node metastasis and patients' survival. Prostatic involvement by TCC was detected in 69 (32%) of 214 cases. Among them, 30 (43%) patients had carcinoma in situ (CIS) and the other 39 (57%) were invasive TCC. Carcinoma in situ occurred in either prostatic urethra (n = 6, 20%) or, more commonly, in prostatic ducts/acini (n = 14, 47%), and in a combination of prostatic urethra and ducts (n = 10, 33%). Ten (26%) of the invasive TCC resulted from direct penetration from the primary tumor in the bladder, and the remaining 29 (72%) cases arose from prostatic urethra/ducts, of which 11, 13, and 5 invaded the lamina propria, prostatic stroma, and periprostatic or seminal vesical tissue, respectively. Both prostatic TCC involvement and nodal metastasis were highly significant prognostic factors for patients' survival and the survival significance of prostatic TCC involvement still existed regardless of lymph node status. Furthermore, the presence of prostatic CIS and degrees of prostatic invasion are associated with nodal metastasis and survival. Patients with prostatic CIS or urethral lamina propria invasion had a similar, but higher incidence of lymph node metastasis and lower long-term and 5-year survival than those patients without prostatic involvement. Similarly, prostatic stromal invasion and periprostatic/seminal vesical invasion had a similar, but much higher nodal metastasis and worse survival than patients with only prostatic CIS or urethral lamina propria invasion. In summary, presence of prostatic TCC involvement and levels of involvement are significant prognostic factors in patients with 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.

Risk assessment for occult malignancy in the prostate before radical cystectomy

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

RISK GROUPS IN PATIENTS WITH BLADDER CANCER TREATED WITH RADICAL CYSTECTOMY: STATISTICAL AND CLINICAL MODEL IMPROVING HOMOGENEITY

PURPOSE

In this study we identified homogeneous risk groups, with no survival overlap among the subgroups that make up each risk group, in patients with transitional cell carcinoma of the bladder treated with radical cystectomy alone.

MATERIALS AND METHODS

Predictive factors for tumor death were analyzed with univariate and multivariate analysis among a group of 298 patients with transitional cell carcinoma of the bladder treated with radical cystectomy alone. Independent variables were progressively incorporated according to their statistical power in a stepwise process identifying a model with independent subgroups. The risk groups were identified according to different survival cutoff points including subgroups with similar survival. To search a clinical application and to check the strength of this model a new model was also set up using the weight score based on the size of hazard ratio from multivariate analysis.

RESULTS

Univariate analysis demonstrated that lymphatic invasion status, pathological stage (P), lymph node status (N) and prostatic stroma status (St) were predictive variables for tumor death, and the latter 3 were independent variables in the multivariate analysis. By taking the most powerful, N, as the reference variable, and progressively incorporating additional variables, a model was found including 7 independent subgroups. In this model only 2 subgroups, N1 and N2-3, included more than 1 category and their survival was also calculated. Three risk groups were identified establishing different survival cutoffs. The 5-year cancer specific survival rate was 86.4% for low risk (P1-2N0St-), 64.4% (range 60.9% to 65.3%) for intermediate risk (P1-2N1St-, P3N0St-, HR = 2.7) and 28.1% (range 0% to 47.7%) for high risk (N2-3, P4, St+, N1P3, HR = 8.7). This model was also reproduced using the weight score based on the size of the hazard ratio from the multivariate analysis

CONCLUSIONS

Three homogeneous risk groups were identified with high statistically significant survival differences among them and no survival overlap among subgroups that make up the risk groups.

Urinary bladder pathology 2004: An update

The field of urinary bladder pathology is advancing at a rapid rate, with generation of significant new knowledge on molecular pathogenesis and cell and tissue-based diagnosis. The aim of this presentation is to survey selected, recent advances in this broad field, with specific focus on histologic typing, grading, staging, molecular classification, and reporting on neoplasia of the urinary bladder.

Evaluation and follow-up strategies for superficial bladder cancer

Superficial bladder cancer comprises the majority of bladder tumors presenting today. Although the word "superficial" connotes a benign behaving curable disease, it is clear from long-term observations of the natural history of the disease that there are two discrete entities of superficial bladder cancer, one a low-grade innocuous tumor and the other a high-grade potentially lethal tumor. These two entities vary in their histologic appearance, risk of tumor recurrence, pattern of recurrence, and risk of tumor progression. Although work on prognostic markers is promising, currently none are sufficiently reliable; therefore, clinical factors are used to identify patients with a higher risk of tumor recurrence or progression. These include the tumor stage, tumor grade, number of tumors (multifocality), presence of associated carcinoma in situ, and initial response to therapy. Surveillance schedules are individualized based on the risks for recurrence and progression. High-risk patients who undergo successful treatment of their bladder tumor initially recur more commonly in the bladder, but have a progressive risk over time of extravesical recurrences necessitating lifelong surveillance of the bladder, urethra, prostate, and upper tracts. Patients who are refractory to conservative management with intravesical therapy and TUR should be apprised of the risks for further conservative treatment and consider early radical cystectomy in an attempt to improve long-term survival. The advent and long-term success of orthotopic continent diversions has made the decision for early radical cystectomy more palatable to both the patient and physician.

Transitional cell carcinoma involving the prostate: a clinicopathological retrospective study of 76 cases

PURPOSE

We reviewed the degree to which extension from transitional cell carcinoma into the prostate affects survival. We also compared whether prostatic stromal invasion occurring via direct extension through the bladder wall differs from stromal invasion arising intraurethrally.

MATERIALS AND METHODS

A total of 76 men who underwent radical cystectomy for transitional cell carcinoma also had prostate involvement. Patients were separated into group 1-18 with primary bladder tumor extending transmurally through the bladder wall to invade the prostate and group 2-58 with prostate involvement arising from within the prostatic urethra. In the latter group the degree of prostate invasion was classified as urethral mucosal involvement, ductal/acinar involvement and stromal invasion.

RESULTS

The 5-year overall survival and recurrence-free rate were 22% and 28% in group 1 versus 43% and 45% in group 2, respectively. In group 2 survival rates were similar in those with prostatic urethral and ductal tumors (without stromal invasion). Five-year overall survival rates without and with stromal invasion were 49% and 25%, respectively (p = 0.024). Prostate involvement decreased survival, which varied according to primary bladder stages (Pis, P1, P2a/b and P3a/b, p = 0.004) or superficial (Pis, Pa and P1) and muscle invasive (P2a/b and P3/b, p = 0.045), disease in 2 groups. Those with positive lymph nodes experienced poorer outcomes in each group. The 5-year overall survival rate in the 19 men with positive lymph nodes was 13% and it was 44% with negative lymph nodes (p = 0.034). The major prognostic factors were age, degree of prostate invasion and lymph node involvement.

CONCLUSIONS

The invasion pathways of prostate invasion in patients with transitional cell bladder carcinoma have a statistically significant prognostic role in survival. Transitional cell carcinoma of the bladder extending into the prostate through the bladder wall and bladder carcinoma that did not directly infiltrate the prostate through the bladder wall are 2 distinct clinicopathological entities that should not be included in the same staging grade.

Cystectomy with prostate sparing for bladder cancer in 100 patients: 10-year experience

PURPOSE

To minimize the risk of incontinence and impotence without compromising oncological outcome, we performed prostate sparing surgery during radical cystectomy for bladder cancer.

MATERIALS AND METHODS

Since 1992, 100 patients with a mean age of 64 years (range 48 to 82) underwent cystectomy for bladder transitional cell carcinoma with prostate sparing based on normal digital rectal examination of the prostate, normal prostate specific antigen (PSA), percent free PSA greater than 15 and normal transrectal ultrasound of the prostate. Prostate biopsies to exclude prostate cancer were performed on patients with an abnormal digital rectal examination, high PSA, percent free PSA less than 15 or hypoechoic lesions on ultrasound. Surgery consisted of transurethral resection of the prostate with analysis of frozen section of the prostatic urethra and transitional prostate and cystectomy with reconstruction by a Z ileal bladder anastomosed to the prostatic capsule after confirmation of the absence of prostate or bladder cancer on frozen sections of the surgical capsule specimens. Patients were followed closely with imaging and laboratory studies every 6 months and annually for 3 years thereafter.

RESULTS

Perioperative death occurred in 1 patient due to septicemia, 20 patients (20%) died of cancer and 6 (6%) died of nonrelated cancer causes. Mean followup 38 months (range 2 to 111). Postoperative pathological stage was PT0 in 2 cases, PtaT1 in 22, PT2 in 48, PT 3 in 28 and N+ in 13. The 5-year actuarial global survival according to pathological stage was pTaT1N0 in 96% of cases, pT2N0 in 83%, pT3N0 in 71% and N+ in 54% (p = 0.0001). The 5-year actuarial cancer specific survival was PT0, Ta T1 in 90% of cases, PT2 in 73%, PT3 in 63% and N- in 8%. The cancer specific survival according to pathological grade was 100% for well differentiated tumors (grade I), 76% for moderately differentiated tumors (grade II) and 47% for poorly differentiated tumors (grade III) (p = 0.003). Local recurrence was pTaT1N0 in 1 of 22 cases (4.5%), pT2N0 in 2 of 40 (5%), pT3N0 in 2 of 23 (8.5%) and N+ in 0 of 13 (0%). Prostate cancer was diagnosed in 3 patients (2 errors in the diagnosis and 1 cancer de novo within 5 years of followup). At 1-year followup 86 of 88 patients (97%) are fully continent (no pad) during the day, and 84 (95%) void 1 to 2 times a night to stay dry. Of 61 patients with previously adequate sexual function 50 (82%) maintained potency with retrograde ejaculation secondary to transurethral resection, 6 (10%) have partial potency and 5 (8.1%) are impotent.

CONCLUSIONS

Cystectomy with prostate sparing for bladder cancer is feasible and offers promising functional results with no additional oncological risk. Careful selection of patients is mandatory.

Prognostic impact of extensive parenchymal invasion pattern in pT3 renal pelvic transitional cell carcinoma

BACKGROUND

Pathologic T3 renal pelvic transitional cell carcinoma exhibits various patterns of invasion. The authors investigated the prognostic impact of three patterns of invasion of pT3 renal pelvic transitional cell carcinoma.

METHODS

Of 212 patients who underwent surgery for renal pelvic transitional cell carcinoma, 70 with pT3 disease were eligible for the main analyses. The candidate predictors of prognosis included patient age, gender, lesion laterality, tumor grade, perioperative cisplatin-based systemic chemotherapy, lymph node involvement, vascular involvement, and patterns of invasion. Invasion patterns were classified as fat invasion, ductal involvement, or parenchymal invasion.

RESULTS

Mean postoperative followup was 33.5 months (range, 1-136 months). On univariate analysis, gender, lymph node involvement, vascular involvement, and extensive parenchymal invasion each had a significant impact on the cause specific survival rate. A multivariate analysis using Cox stepwise regression revealed that extensive parenchymal involvement was the strongest prognostic predictor (P = 0.0004, hazard ratio = 5.59). Lymph node involvement (P = 0.0175, hazard ratio = 3.14) and gender (P = 0.0361, hazard ratio = 2.42) were other weaker predictors. Statistically, pT3 disease without extensive parenchymal invasion had a prognosis similar to that of lower stage disease, and pT3 disease with extensive parenchymal invasion had a prognosis similar to that of pT4 disease.

CONCLUSIONS

Extensive parenchymal invasion has a strong prognostic impact in renal pelvic transitional cell carcinoma. pT3 disease should be subclassified into two separate entities, that with and that without extensive parenchymal invasion, in view of prognosis.

Prognostic-factors-based risk-stratification model for invasive urothelial carcinoma of the urinary bladder in Taiwan

Objectives. To develop a prognostic-factors-based predictive model for invasive urothelial carcinoma of the urinary bladder derived from statistical comparison of clinical characteristics.Methods. The medical records for patients with invasive urinary bladder urothelial carcinoma were reviewed. Clinical data for age, sex, serum lactate dehydrogenase, creatinine, albumin, alkaline phosphatase, alanine aminotransferase, total bilirubin and hemoglobin levels, white blood cell and platelet counts, positive urine cytology, Eastern Cooperative Oncology Group performance status score, tumor size, histologic grading, T stage, presence of lymph node metastases, squamous differentiation, hydronephrosis, prostatic involvement, Charlson comorbidity index, surgical procedures, and adjuvant chemotherapy status were recorded. Univariate and multivariate analyses were performed to test independent factors for prediction of survival and disease recurrence.Results. After univariate and multivariate analyses, six independent prognostic factors were found: T stage, grading, prostatic involvement, Eastern Cooperative Oncology Group performance status score, and pretreatment serum creatinine and albumin levels. A scoring system was developed on the basis the relative risk associated with the proposed prognostic factors and patients were stratified into three groups according to their scores, with statistically significant prognostic differences revealed for each of the between-group comparisons. Independent factors affecting recurrence-free survival and best predicted disease recurrence were pretreatment serum creatinine, T stage, and surgical procedure.Conclusions. This prognostic-factors-based risk-stratification model for invasive urothelial carcinoma of the urinary bladder may help clinicians predict outcome and select the most appropriate therapeutic modalities. The incidence of recurrent disease is significantly higher for patients with poor renal function before treatment or advanced T stage and those undergoing transurethral tumor resection instead of radical cystectomy.

Carcinoma in situ and tumor multifocality predict the risk of prostatic urethral involvement at radical cystectomy in men with transitional cell carcinoma of the bladder

PURPOSE

Determining which patients are at risk for prostatic urethral involvement of urothelial carcinoma may alter assessment of the prostatic urethra before radical cystectomy and ultimately influence the choice of urinary diversion. We determined risk factors predictive of prostatic urethral involvement using preoperative bladder tumor characteristics in male patients who underwent radical cystoprostatectomy due to urothelial carcinoma of the bladder.

MATERIALS AND METHODS

We reviewed 192 consecutive radical cystectomy specimens from men with transitional cell carcinoma from June 1995 to June 2000. The prostatic urethra in each specimen was analyzed and urethral involvement was characterized as carcinoma in situ, intraductal invasion or prostatic stromal invasion. We then examined which clinical bladder tumor characteristics correlated with the incidence and extent of prostatic urethral involvement by performing multiple variable analysis.

RESULTS

Prostatic urethral involvement was evident in 30 of the 192 patients (15.6%). Of the 80 patients with carcinoma in situ in the bladder 25 (31.3%) had concomitant prostatic urethral involvement with carcinoma, whereas only 5 (4.5%) of the 112 with no evidence of carcinoma in situ had prostatic urethral involvement. Likewise 25 of the 72 patients (34.7%) with multifocal tumors had concomitant prostatic urethral involvement with carcinoma, whereas only 5 (4.2%) of the 120 with no evidence of multifocality had prostatic urethral involvement. In the multiple variable logistic regression model the odds of prostatic urethral involvement were 12 and 15-fold greater when carcinoma in situ and tumor multifocality were present, respectively.

CONCLUSIONS

Carcinoma in situ and/or tumor multifocality are valuable prognostic indicators of prostatic urethral involvement. However, in their absence prostatic urethral involvement was rare. Ultimately the extent of prostatic urethral involvement may influence decisions, such as the choice of urinary diversion and need for urethrectomy, in men undergoing radical cystectomy.

Clinical study of transitional cell carcinoma of the prostate associated with bladder transitional cell carcinoma

BACKGROUND

Transitional cell carcinoma of the prostate in patients with bladder cancer appears to influence the prognosis and affects the decision about therapeutic modality. Therefore, it is important to characterize transitional cell carcinoma associated with bladder cancer.

METHODS

From April 1980 to December 1998, 81 male patients underwent total cystoprostatectomies for transitional cell carcinoma of the bladder. The 81 cystoprostatectomy specimens were examined to clarify the characteristics of prostatic involvement by transitional cell carcinoma. The extent, origin, mode of spread and risk factor of prostatic involvement as well as the prognosis were investigated. In 13 of 15 patients with prostatic involvement the prostate was examined by sequential step sections.

RESULTS

Prostatic involvement was observed in 15 of 81 patients (18.5%). Prostatic urethral involvement, invasion to prostatic duct/acinus, prostatic stromal invasion and extraprostatic extension and/or seminal vesicle involvement were recognized in 12 (80%), 14 (93.3%), six (40%), and five (33.3%) of the 15 patients, respectively. Twelve of the 15 patients (80%) with prostatic involvement had papillary or non-papillary tumors (i.e. carcinoma in situ) both in the prostatic urethra and prostatic duct. In 10 of these 12 patients (88.3%), there was contiguity between prostatic urethral and ductal tumors. Seven of the 23 patients (30.4%) with carcinoma in situ of the bladder showed prostatic involvement, which increased to 50% in the presence of carcinoma in situ of the trigone or bladder neck.

CONCLUSIONS

Eighty per cent of the patients with prostatic involvement showed papillary or non-papillary tumors both in the prostatic urethra and prostatic duct. There was a high level of contiguity between both tumors. Patients with carcinoma in situ of the trigone or bladder neck revealed significantly higher incidence of prostatic involvement.

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.