Multifocal Extraprostatic Extension of Prostate Cancer

Managing prostate cancer after proctocolectomy and ileal pouch-anal anastomosis: feasibility and outcomes of single-port transvesical robot-assisted radical prostatectomy

INTRODUCTION

Patients with proctocolectomy and ileal pouch-anal anastomosis (PC-IPAA) face unique challenges in managing prostate cancer due to their hostile abdomens and heightened small bowel mucosa radiosensitivity. In such cases, external beam radiation therapy (EBRT) is contraindicated, and while brachytherapy provides a safer option, its oncologic effectiveness is limited. The Single-Port Transvesical Robot-Assisted Radical Prostatectomy (SP TV-RARP) offers promise by avoiding the peritoneal cavity. Our study aims to evaluate its feasibility and outcomes in patients with PC-IPAA.

METHODS

A retrospective evaluation was done on patients with PC-IPAA who had undergone SP TV-RARP from June 2020 to June 2023 at a high-volume center. Outcomes and clinicopathologic variables were analyzed.

RESULTS

Eighteen patients underwent SP TV-RARP without experiencing any complications. The median hospital stay was 5.7 h, with 89% of cases discharged without opioids. Foley catheters were removed in an average of 5.5 days. Immediate urinary continence was seen in 39% of the patients, rising to 76 and 86% at 6- and 12-month follow-ups. Half of the cohort had non-organ confined disease on final pathology. Two patients with ISUP GG3 and GG4 exhibited detectable PSA post-surgery and required systemic therapy; both had SVI, multifocal ECE, and large cribriform pattern. Positive surgical margins were found in 44% of cases, mostly Gleason pattern 3, unifocal, and limited. After 11.1 months of follow-up, no pouch failure or additional BCR cases were found.

CONCLUSION

Patients with PC-IPAA often exhibit aggressive prostate cancer features and may derive the greatest benefit from surgical interventions, particularly given that radiation therapy is contraindicated. SP TV-RARP is a safe option for this group, reducing the risk of bowel complications and promoting faster recovery.

The absolute tumor-capsule contact length in the diagnosis of extraprostatic extension of prostate cancer

BACKGROUND

Extraprostatic extension (EPE) of prostate cancer is associated with a poor prognosis. The broad-based capsule-tumor interface has been recognized as one of the worrisome imaging features in multiparametric prostate MRI (mpMRI). However, there was significant heterogeneity among the measurement method used in prior studies.

OBJECTIVES

This study's objectives were to investigate and compare the accuracy between the curvilinear and linear measurement, find the optimal cut-off contact surface threshold for the diagnosis of EPE, and assess the benefit of the additional contact surface measurement versus visual assessment alone.

METHODS

The status of EPE in mpMRI and the overall PI-RADS were assessed. The tumor's dimensions, the actual tumor-capsule contact length (ACTCL), and the absolute tumor-capsule contact length (ABTCL) were measured. The parameters were analyzed and correlated with the EPE status from prostatectomy specimens.

RESULTS

Ninety-five patients who underwent mpMRI followed by prostatectomy were included in the study. High Gleason score (score 8-9), radiologist's impression of EPE, and PI-RADS 5 were significantly correlated with EPE in surgical specimens (p = 0.014, p < 0.001, and p < 0.001, respectively). Both ACTCL and ABTCL of patients with EPE were significantly higher than those without EPE in all imaging sequences (p < 0.001 to p = 0.003). The ABTCL has higher accuracy than the ACTCL. Dynamic contrast enhancement (DCE) was the most accurate sequence to measure the contact interface. The recommended cut-off value of ABTCL was 15.0 mm, which had a sensitivity and specificity of 75.86% and 72.09%. Multivariable analysis revealed that the ABTCL > 15 mm and the radiologist's impression on visual assessment were the only two independent predictors for the prediction of EPE (p = 0.048 and p = 0.016, respectively). Improvement of diagnostic performance was achieved when the two factors were combined.

CONCLUSION

The ABTCL has better accuracy than the curvilinear measurement in the prediction of EPE. The optimum sequence for the measurement of the contact surface is the DCE. We recommended using 15.0 mm as a cut-off point.

CLINICAL IMPACT

The addition of the ABTCL measurement showed an increase in diagnostic performance. We encourage radiologists to use the capsular contact measurement in addition to their visual assessment to detect EPE in pre-operative MRI.

Revisiting extraprostatic extension based on invasion depth and number for new algorithm for substaging of pT3a prostate cancer

Extraprostatic extension (EPE) is a factor in determining pT3a stage in prostate cancer. However, the only distinction in EPE is whether it is focal or non-focal, causing diagnostic and prognostic ambiguity. We substaged pT3a malignancies using classification of EPE to improve personalized prognostication. We evaluated 465 radical prostatectomy specimens with a digital image analyzer by measuring the number, radial distance and two-dimensional square area of the EPE. The most significant cut-off value was proposed as an algorithm for the pT3a substaging system to predict biochemical recurrence (BCR). A combination of the radial distance and the number of EPEs predicted BCR the most effectively. The optimal cut-off criteria were 0.75 mm and 2 mm in radial distance and multifocal EPE (hazard ratio: 2.526, C-index 0.656). The pT3a was subdivided into pT3a1, < 0.75 mm and any number of EPEs; pT3a2, 0.75–2 mm and one EPE; and pT3a3, > 2 mm and any number of EPEs or 0.75–2 mm and ≥ 2 EPEs. This combined tier was highly significant in the prediction of BCR-free survival. The combination of radial distance and number of EPEs could be used to subdivide pT3a prostate cancer and may aid in the prediction of BCR.

Similarities and Differences in the 2019 ISUP and GUPS Recommendations on Prostate Cancer Grading: A Guide for Practicing Pathologists

Contemporary subspecialization of practice in prostate pathology has seen a transition to complex, nuanced reporting, where a growing number of histopathologic parameters may signal differences in patient management. In this context, the International Society of Urological Pathology (ISUP) and the Genitourinary Pathology Society (GUPS) both published proceedings papers on the grading of prostate cancer in 2019. Overall, the 2 prostate cancer grading manuscripts reached many of the same conclusions and recommendations. Yet, each consensus was conducted somewhat differently, and in a couple of key areas, each reached different conclusions and recommendations. Herein, sourced from the experience and viewpoints of members of both societies, we provide the practicing pathologist a summary of the shared recommendations, and of the discordances. It is anticipated that these 2 documents will inform future iterations of recommendations and guidelines for reporting prostate cancer by organizations such as the College of American Pathologists, the Royal College of Pathologists, and the European Society of Pathology, which will promote best practices for their respective constituents. Our goal is to provide the practicing pathologist a useful catalog of the main points of both, allowing each practitioner to make informed decisions and understand any divergent opinions as may arise between observers for individual cases.