Atypia in nonneoplastic prostate glands after radiotherapy for prostate cancer: duration of atypia and relation to type of radiotherapy

Prognostic and therapeutic potential of senescent stromal fibroblasts in prostate cancer

The stromal component of the tumour microenvironment in primary and metastatic prostate cancer can influence and promote disease progression. Within the prostatic stroma, fibroblasts are one of the most prevalent cell types associated with precancerous and cancerous lesions; they have a vital role in the structural composition, organization and integrity of the extracellular matrix. Fibroblasts within the tumour microenvironment can undergo cellular senescence, which is a stable arrest of cell growth and a phenomenon that is emerging as a recognized hallmark of cancer. Supporting the idea that cellular senescence has a pro-tumorigenic role, a subset of senescent cells exhibits a senescence-associated secretory phenotype (SASP), which, along with increased inflammation, can promote prostate cancer cell growth and survival. These cellular characteristics make targeting senescent cells and/or modulating SASP attractive as a potential preventive or therapeutic option for prostate cancer.

Prostate Cancer: Update on Grading and Reporting

The Gleason scoring system and Grade Group systems facilitate accurate grading and reporting of prostate cancer, which are essential tasks for surgical pathologists. Gleason Pattern 4 is critical to recognize because it signifies a risk for more aggressive behavior than Gleason Pattern 3 carcinoma. Prostatic adenocarcinoma with radiation or androgen therapy effect, with aberrant P63 expression, or with Paneth cell-like differentiation represent pitfalls in prostate cancer grading because although they display architecture associated with aggressive behavior in usual prostatic adenocarcinoma, they do not behave aggressively and using conventional Gleason scoring in these tumors would significantly overstate their biologic potential.

Oncologic Impact and Safety of Pre-Operative Radiotherapy in Localized Prostate and Bladder Cancer: A Comprehensive Review from the Cancerology Committee of the Association Française d'Urologie

Preoperative radiotherapy (RT) is commonly used for the treatment of various malignancies, including sarcomas, rectal, and gynaecological cancers, but it is preferentially used as a competitive treatment to radical surgery in uro-oncology or as a salvage procedure in cases of local recurrence. Nevertheless, preoperative RT represents an attractive strategy to prevent from intraoperative tumor seeding in the operative field, to sterilize microscopic extension outside the organ, and to enhance the pathological and/or imaging tumor response rate. Several clinical works support this research field in uro-oncology. In this review article, we summarized the oncologic impact and safety of preoperative RT in localized prostate and muscle-invasive bladder cancer. Preliminary studies suggest that both modalities can be complementary as initial primary tumor treatments and that a pre-operative radiotherapy strategy could be beneficial in a well-defined population of patients who are at a very high-risk of local relapse. Future prospective trials are warranted to evaluate the oncologic benefit of such a combination of local treatments in addition to new life-prolonging systemic therapies, such as immunotherapy, and new generation hormone therapies. Moreover, the safety and the feasibility of salvage surgical procedures due to non-response or local recurrence after pelvic RT remain poorly evaluated in that context.

A Cytological Study Enlightening the Unseen Effects of Concomitant Chemoradiotherapy in Contralateral Normal Buccal Mucosa of Oral Squamous Cell Carcinoma Patients

Background/objectives In patients receiving concomitant chemoradiotherapy (CCRT) as a treatment for oral squamous cell carcinoma (OSCC), cytological changes were seen not only in neoplastic epithelial cells but the non-neoplastic epithelial cells are also affected, resulting in cytopathological atypical changes. The present study was designed to observe oral epithelial atypical cytopathologic changes induced in contralateral normal buccal mucosa in OSCC patients receiving CCRT. Methods The study included 150 patients with OSCC treated by CCRT whose details were collected from the Institute of Nuclear Medicine and Oncology Lahore (INMOL) Hospital Lahore. Cytological smears were obtained from the contralateral normal buccal mucosa of OSCC patients. The serial scrape smears were taken before, immediately after, on the 17th day (mid of treatment), and at the end of CCRT, whereas 20 patients were taken as normal healthy controls and were not exposed to CCRT. The smears were stained with hematoxylin and eosin and Papanicolaou stain. SPSS version 20 (Armonk, NY: IBM Corp.) was used for statistical analysis and p > 0.05 was considered to be significant. Results CCRT-induced oral epithelial atypical cytological changes were predominantly noted at end of therapy (19.7%) in the contralateral normal buccal mucosa. Nuclear atypia features were higher on the 17th day and end of treatment; whereas, epithelial atypia was mainly observed on the 17th day of CCRT (40%). A highly significant association was observed between epithelial atypia and radio-chemotherapy dose (p = 0.045), between CCRT-induced epithelial atypical cytological changes and days of treatment (p = 0.001), and between days of CCRT and nuclear atypia (0.000) accordingly. Atypia was not observed in any control group. Conclusion Varying degrees of oral epithelial atypical cytological changes may occur in otherwise normal contralateral mucosa of the patients receiving CCRT.

Yttrium-90 Radioembolization to the Prostate Gland: Proof of Concept in a Canine Model and Clinical Translation

PURPOSE

To investigate the feasibility, safety, and absorbed-dose distribution of prostatic artery radioembolization (RE) in a canine model.

MATERIALS AND METHODS

Fourteen male castrated beagles received dihydroandrosterone/estradiol to induce prostatic hyperplasia for the duration of the study. Each dog underwent fluoroscopic prostatic artery catheterization. Yttrium-90 (⁹⁰Y) microspheres (TheraSphere; Boston Scientific, Marlborough, Massachusetts) were delivered to 1 prostatic hemigland (dose escalation from 60 to 200 Gy), with the contralateral side serving as a control. Assessments for adverse events were performed throughout the follow-up (Common Terminology Criteria for Adverse Events v5.0). Positron emission tomography/magnetic resonance (MR) imaging provided a confirmation after the delivery of absorbed-dose distribution. MR imaging was performed before and 3, 20, and 40 days after RE. Tissue harvest of the prostate, rectum, bladder, urethra, penis, and neurovascular bundles was performed 60 days after RE.

RESULTS

All the animals successfully underwent RE. Positron emission tomography/MR imaging demonstrated localization to and good coverage of only the treated hemigland. No adverse events occurred. The MR imaging showed a significant dose-dependent decrease in the treated hemigland size at 40 days (25%-60%, P < .001). No extraprostatic radiographic changes were observed. Necropsy demonstrated no gross rectal, urethral, penile, or bladder changes. Histology revealed RE-induced changes in the treated prostatic tissues of the highest dose group, with gland atrophy and focal necrosis. No extraprostatic RE-related histologic findings were observed.

CONCLUSIONS

Prostate ⁹⁰Y RE is safe and feasible in a canine model and leads to focal dose-dependent changes in the gland without inducing unwanted extraprostatic effects. These results suggest that an investigation of nonoperative prostate cancer is warranted.

Evaluation of the residual prostate cancer rate on cystoprostatectomy specimen in patients treated with radiotherapy for prostate cancer

PURPOSE

To evaluate the residual cancer rate after cystoprostatectomy (CPT) in patients with a history of radiation therapy for prostate cancer and the postoperative complication rates.

MATERIAL AND METHODS

We conducted a retrospective study involving 21 patients who had a CPT over 7 years and who had a history of radiotherapy for prostate cancer. To compare results, two additional groups were created: a group of patients without a history of radiotherapy in whom a CPT was performed, and a group without a history of radiotherapy and in whom was accidentally discovered a prostate cancer after CPT on histology specimens.

RESULTS

The median age at the time of radiotherapy was 69 years. The median age at the time of cystoprostatectomy was 78 years. The median PSA at the time of the intervention was 0.6 ng/ml in the group with a history of radiotherapy. The residual cancer rate was 24%. No patients had criteria for biological recurrence. There were no additional surgical complications in the radiotherapy group (p = 0.2). The rate of cutaneous ureterostomy was higher (p = 0.0006) due to increased surgical difficulties (p = 0.0009).

CONCLUSION

The residual cancer rate was 24% after radiotherapy for prostate cancer. PSA alone does not appear to be sufficient to detect the persistence of residual prostate cancer after radiotherapy. There were no more surgical complications after prostate radiotherapy.

Changes in lower urinary tract symptoms after iodine-125 brachytherapy for prostate cancer

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Patients who received BT experienced acute urinary morbidity 3 months after BT of the prostate.

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Acute urinary symptoms gradually improved with time and returned to BL at 36 months.

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Storage symptoms take longer to return to BL compared with voiding symptoms.

Purpose

To investigate chronological changes in lower urinary tract symptoms (LUTS) in patients who received iodine-125 brachytherapy (BT) for prostate cancer.

Methods

We enrolled 706 patients who received BT. Of these, 265 (38%) received BT combined with external beam radiation therapy (EBRT). An International Prostate Symptom Score (IPSS), IPSS quality of life (IPSS-QOL) score, and overactive bladder symptom score (OABSS) were recorded before BT (baseline, BL), and 1, 3, 6, 12, 24, 36, 48, and 60 months after BT. The sum of frequency (2), urgency (4) and nocturia (7) of the IPSS questionnaire was defined as the storage symptoms score, whereas the sum of emptying (1), intermittency (3), weak stream (5), and hesitancy (6) was defined as the voiding symptom score.

Results

Total IPSS significantly increased at 3 months following BT compared with BL (mean score: 17.1 vs. 7.99, P < 0.001) and returned to BL by 36 months. The storage symptom score did not return to BL 36 months after BT. Total OABSS significantly increased 3 months after BT compared with BL (mean score: 6.52 vs. 3.45, P < 0.001), and returned to BL 48 months after BT. The IPSS-QOL score was the highest score (mean score: 2.46 vs. 3.9, P < 0.001) 3 months after BT and returned to BL 48 months after BT, however the IPSS-QOL score was lower than BL (mean score: 2.01 vs 2.46, P < 0.001) at 60 months. The risk factors for LUTS within 1 year after BT were BL IPSS (P < 0.001) and PV (P < 0.001). Patients who received combined EBRT experienced transient storage symptoms 24 and 36 months after BT, whereas those who received BT alone did not. However, the storage symptom score of the patients who received combined EBRT was improving 48 months after BT and eventually showed no significant difference compared with those treated with BT alone.

Conclusion

Three months after BT, LUTS, including storage symptoms, deteriorated the most but improved with time. The urinary symptom in patients who received combined EBRT can potentially flare again in 24 and 36 months after BT. Knowledge of changes in LUTS associated with BT may influence treatment recommendations and enable patients to make better-informed decisions.

Focal Salvage High Dose-Rate Brachytherapy for Locally Recurrent Prostate Cancer After Primary Radiation Therapy Failure: Results From a Prospective Clinical Trial

PURPOSE

Although increasing data support whole-gland salvage therapy for recurrent prostate cancer, toxicity remains a significant concern. We hypothesized that focal therapy, treating only a portion of the prostate containing recurrent disease, might be equally effective and associated with less toxicity. The objectives of this prospective study were to explore the toxicities, quality of life, and efficacy of focal salvage high-dose-rate (HDR) brachytherapy in patients with multiparametric magnetic resonance imaging (MRI)-visible, biopsy-confirmed local recurrence after previous definitive external beam radiation therapy.

MATERIALS AND METHODS

Fifteen patients with locally recurrent prostate cancer after external beam radiation therapy were enrolled in this prospective study. Patients were treated with ultrasound-based HDR brachytherapy with a prescription dose of 27 Gy divided in 2 implants, separated by 1 week, to the clinical target volume, which was defined as the quadrant of the prostate where the MRI-visible recurrent lesion was located. Toxicity, quality of life, and biochemical outcomes were analyzed. Postsalvage MRI was performed to assess radiation therapy response.

RESULTS

Median follow-up was 36 months. The median size of the recurrence on MRI was 9 mm (range, 7-20 mm), and clinical target volume at the time of HDR was 6.1 mL (range, 2.2-16.1 mL). Only one grade 3 genitourinary toxicity event was observed. No urinary retention was observed. Three-year prostate-specific antigen failure-free rate was 61%. There was no significant change in Expanded Prostate Cancer Index Composite urinary or bowel domains over time. Of the 14 patients who had a post-HDR MRI, 12 had a treatment response.

CONCLUSIONS

Our results suggest that focal salvage HDR brachytherapy is well tolerated and promising. External validation is needed.

Rectal ulcer and pseudomalignant epithelial changes after prostate seed brachytherapy: A rare complication with a diagnostic pitfall

BACKGROUND

Implant brachytherapy (IBT) is a well-recognized treatment modality for early stage prostate cancer. Rectal ulcer and rectourethral fistula complicating IBT may cause an alteration of the normal anatomic landmarks. In this context, pseudomalignant radiation-induced changes within prostatic epithelium may be misinterpreted as a primary rectal malignancy. Such challenging and misleading findings have not been described, and may not be recognized as such.

MATERIALS AND METHODS

We present the clinical and pathologic aspects of two patients who underwent IBT for low stage prostate cancer that was complicated by deep rectal ulcer. Both patients underwent extensive palliative surgical resection for disease control.

RESULTS

The histologic changes in both cases were noteworthy for extensive necrosis and inflammation of the prostate, associated with loss of recto-prostatic anatomical landmarks. Prostatic glands showed striking radiation-induced atypia and pseudomalignant epithelial changes extending to the rectal ulcer bed, with no residual viable tumor. The first patient had undergone a biopsy of the rectal ulcer bed that was misinterpreted as a rectal adenocarcinoma prior to surgery. The similarity between atypical glands of the biopsy and the benign prostatic tissue with radiation-induced atypia in resection specimen confirmed their benign nature.

CONCLUSIONS

Deep rectal ulcer complicating IBT may lead to distortion of the normal recto-prostatic anatomical landmarks, resulting in detection of pseudo-malignant prostatic glands at the ulcer base. Such findings may be mistaken for a primary rectal malignancy in limited biopsy material if not familiar to the pathologist.

GATA3 Positivity in Benign Radiated Prostate Glands: A Potential Diagnostic Pitfall

Histologic changes following radiation therapy to the prostate include multilayering of glands, atrophy, squamous metaplasia, and often marked random nuclear atypia. We have seen multiple consultation cases where the differential diagnosis of these radiated prostate glands included urothelial carcinoma, with multilayered to solid-appearing proliferations that were positive by immunohistochemistry for GATA3. To formally investigate this issue, 30 cases of benign prostate tissue with radiation atypia, from 1990 to 2015, were obtained from our institution. Cases were evaluated by immunohistochemistry for the prostate-specific markers prostate-specific antigen (PSA), P501S (Prostein), and NKX3.1 and urothelial markers GATA3 and uroplakin 2. GATA3 was positive in 100% of cases, with 70% showing moderately strong to strong staining in a mostly patchy manner within a gland. PSA was positive in 93.3% of cases, with 89.2% showing moderately strong to strong staining in a mostly diffuse manner. P501S was positive in 96.7% of cases, with 93.1% showing moderately strong to strong staining in a mostly patchy manner. NKX3.1 was positive in 82.8% of cases, with 33.3% showing moderately strong to strong staining in a mostly patchy manner. Uroplakin 2 was negative in 100% of cases. Our findings highlight that GATA3 is often positive in benign prostate glands with radiation atypia, which along with the morphologic features present a pitfall for the misdiagnosis of urothelial carcinoma. A combination of PSA and P501S is the best prostate-specific panel for use in radiated prostate, with the caveat that they are often patchy and do not stain all radiated glands.

Prostate-specific antigen percentage: An early predictive tool after iodine-125 interstitial brachytherapy for prostate cancer

BACKGROUND

After interstitial prostate iodine-125 brachytherapy (BT), prostate-specific antigen (PSA) evolution in time could predict overall biochemical relapse, but, considering the single patient, it is influenced by the presentation PSA amount and by the prostatic volume. It is also challenging to differentiate a PSA bounce from a biochemical relapse.

PURPOSE

To determine the usefulness of PSA percentage (PP) defined as the rate between PSA presented by a patient at time "t" and the PSA that the same patient had presented at the time of diagnosis (t0) assumed as 100% in predicting biochemical relapse and in differentiating them from PSA Bounces.

METHODS AND MATERIALS

We included 721 patients from Milan S. Raffaele Turro (399) and Lucca Campo di Marte (then S. Luca) Hospital (322). The mean age of patients was 66.5 years (range, 50-79). Mean followup was 150 months (range, 24-180). For each patient, PSA was recorded before and after iodine-125 BT, and PPs were calculated. Cox regression model, relative operating characteristic curves, and Kaplan-Meier regression model were elaborated, and a cutoff of 20% was defined.

RESULTS

We observed that PP >20% is an independent variable highly associated with relapse risk (p < 0.0001) with a sensitivity of 79.7%, a specificity of 82%, and an hazard ratio of 12.1, since the 6 months of followup. A PSA increase above the nadir should be because of bounce (sensitivity and specificity of 81.4%, p < 0.0001) if patient had experienced at 6 months a PP <20%.

CONCLUSIONS

PP might represent an early and useful tool, predictive of clinical outcome in patients after BT for prostate cancer.

[Pathogenesis of urological complications after radiation therapy]

Radiation therapy is a treatment modality that is often used in the uro-oncological setting. The common indication for the radiation therapy in the urological sphere is prostate cancer, whether it is used primarily as a radical approach, or postoperatively as adjuvant or salvage therapy. All urological organs are sensitive to radiation injury with the urinary bladder being the most susceptible with a typical cascade including acute and late changes, arising in the dose-dependent manner. The common indication for radiation therapy in urology is prostate cancer, which collaterally affects the urinary bladder and rarely urethra (especially the bulbo-membranous urethra). Ureteral damage and stricture formation is almost always restricted to the cases of intraoperative therapy and external beam radiation therapy for other urological malignancies (gynecological organs, rectum, retroperitoneal soft tissue tumors) and should not be underestimated. Postradiotherapeutic tissue changes, especially of the prostate, can cause difficulties for pathologists and urologists with regard to diagnosis of prostate cancer recurrence and salvage therapy.

Predictive factors for urinary toxicity after iodine-125 prostate brachytherapy with or without supplemental external beam radiotherapy

PURPOSE

We examined the factors associated with urinary toxicities because of brachytherapy with iodine-125 with or without supplemental external beam radiotherapy (EBRT) for prostate cancer.

METHODS AND MATERIALS

We investigated 1313 patients with localized prostate cancer treated with iodine-125 brachytherapy with or without supplemental EBRT between 2003 and 2009. The International Prostate Symptom Score (IPSS) and Common Terminology Criteria for Adverse Events data were prospectively determined. Patients, treatment, and implant factors were investigated for their association with urinary toxicity or symptoms.

RESULTS

IPSS resolution was not associated with biologically effective dose (BED). Baseline IPSS, total needles, and the minimal dose received by 30% of the urethra had the greatest effect according to multivariate analysis (MVA). Urinary symptom flare was associated with baseline IPSS, age, BED, and EBRT on MVA. Urinary symptom flare and urinary Grade 2 or higher (G2+) toxicity occurred in 51%, 58%, and 67% (p = 0.025) and 16%, 22%, and 20% (p = 0.497) of the <180, 180-220, and >220 Gy BED groups, respectively. Urinary G2+ toxicity was associated with baseline IPSS, neoadjuvant androgen deprivation therapy (NADT), and seed density on MVA. When we divided patients into four groups according to prostate volume (<30 cc or ≥30 cc) and NADT use, urinary G2+ toxicity was most commonly observed in those patients with larger prostates who received NADT, and least in the patients with smaller prostates and no NADT.

CONCLUSIONS

NADT was associated with urinary G2+ toxicity. Higher dose and supplemental EBRT did not appear to increase moderate to severe urinary toxicities or time to IPSS resolution; however, it influenced urinary symptom flare.

The spectrum of morphology in non-neoplastic prostate including cancer mimics

The spectrum of morphology in non-neoplastic prostate includes lesions of prostatic epithelial origin, the most common being atrophy, including partial atrophy, adenosis (atypical adenomatous hyperplasia), basal cell hyperplasia and crowded benign glands, as well as those of non-prostatic origin, such as seminal vesicle epithelium. These lesions often mimic lower-grade prostatic adenocarcinoma whereas others, such as granulomatous prostatitis, for example, are in the differential diagnosis of adenocarcinoma, Gleason grades 4 or 5. Diagnostic awareness of the salient histomorphological and relevant immunohistochemical features of these prostatic pseudoneoplasms is critical to avoid rendering false positive diagnoses of malignancy.

Is prostate-specific antigen percentage decrease predictive of clinical outcome after permanent iodine-125 interstitial brachytherapy for prostate cancer?

OBJECTIVE

To determine the usefulness of prostate-specific antigen (PSA) percentage (vs. pretreatment value assumed as 100%) in prediction of biochemical relapse, after iodine-125 ((125)I) permanent brachytherapy for prostate cancer, to employ a parameter independent by the initial PSA amount and by the individual prostatic volume.

METHODS AND MATERIALS

Our study included 133 patients, 102 still disease free (Group A) and 31 who experienced proven biochemical recurrence (Group B). PSA levels before and after (125)I brachytherapy were recorded, and PSA percentage vs. pretreatment values were calculated. Cox regression model, receiver operating characteristic curves, and Kaplan-Meier regression model with log-rank test were calculated.

RESULTS

We observed that, in patients submitted to brachytherapy for prostate cancer, a PSA percentage >20% of pretreatment value is highly associated with relapse risk (p<0.0001) and that this association is strongly present since t=6 months of followup (p<0.0001), with a hazard ratio near to five times (4.965), a sensitivity of 72.4%, and specificity of 79.8% related to the chosen cutoff.

DISCUSSION

Despite the amount of PSA is the only parameter that the clinicians can deploy to monitor patient's followup after permanent interstitial brachytherapy for prostate cancer, its evolution in time seems unable to predict early biochemical relapse as it is influenced by prostatic volume and initial PSA amount.

CONCLUSIONS

Our data suggest that a PSA percentage >20% of pretreatment value at 6 months might represent an early, inexpensive, and useful predictive tool of bad outcome in patients after permanent brachytherapy.

Low-dose rate brachytherapy for men with localized prostate cancer

BACKGROUND

Localized prostate cancer is a slow growing tumor for many years for the majority of affected men. Low-dose rate brachytherapy (LDR-BT) is short-distance radiotherapy using low-energy radioactive sources. LDR-BT has been recommended for men with low risk localized prostate cancer.

OBJECTIVES

To assess the benefit and harm of LDR-BT compared to radical prostatectomy (RP), external beam radiotherapy (EBRT), and no primary therapy (NPT) in men with localized prostatic cancer.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1950), and EMBASE (from 1980) were searched in June 2010 as well as online trials registers and reference lists of reviews.

SELECTION CRITERIA

Randomized, controlled trials comparing LDR-BT versus RP, EBRT, and NPT in men with clinically localized prostate cancer.

DATA COLLECTION AND ANALYSIS

Data on study methods, participants, treatment regimens, observation period and outcomes were recorded by two reviewers independently.

MAIN RESULTS

We identified only one RCT (N = 200; mean follow up 68 months). This trial compared LDR-BT and RP. The risk of bias was deemed high. Primary outcomes (overall survival, cause-specific mortality, or metastatic-free survival) were not reported. Biochemical recurrence-free survival at 5 years follow up was not significantly different between LDR-BT (78/85 (91.8%)) and RP (81/89 (91.0%)); P = 0.875; relative risk 0.92 (95% CI: 0.35 to 2.42).For severe adverse events reported at 6 months follow up, results favored LDR-BT for urinary incontinence (LDR-BT 0/85 (0.0%) versus RP 16/89 (18.0%); P < 0.001; relative risk 0) and favored RP for urinary irritation (LDR-BT 68/85 (80.0%) versus RP 4/89 (4.5%); P < 0.001; relative risk 17.80, 95% CI 6.79 to 46.66). The occurrence of urinary stricture did not significantly differ between the treatment groups (LDR-BT 2/85 (2.4%) versus RP 6/89 (6.7%); P = 0.221; relative risk 0.35, 95% CI: 0.07 to 1.68). Long-term information was not available.We did not identify significant differences of mean scores between treatment groups for patient-reported outcomes function and bother as well as generic health-related quality of life.

AUTHORS' CONCLUSIONS

Low-dose rate brachytherapy did not reduce biochemical recurrence-free survival versus radical prostatectomy at 5 years. For short-term severe adverse events, low-dose rate brachytherapy was significantly more favorable for urinary incontinence, but radical prostatectomy was significantly more favorable for urinary irritation. Evidence is based on one RCT with high risk of bias.

Papillary Urothelial Carcinoma of the Bladder With Exuberant Pseudosarcomatous Stromal Reaction Following Radiation Therapy

An 82-year-old man, with 6-year history of radical prostatectomy followed by radiotherapy performed for prostatic carcinoma, underwent transurethral resection of a papillary tumor of the bladder lateral walls. Histologically, the lesion displays 2 distinct components: epithelial and stromal. The epithelial component was composed of a noninvasive papillary urothelial carcinoma, predominantly low grade and focally high grade. The stromal component exhibited extensive myxoid changes with increased cellularity but lacking cellular atypia and mitoses. The epithelial component was immunoreactive for pan-cytokeratins and negative for smooth muscle actin (SMA) and vimentin. The stromal component exhibited focal positivity for pan-cytokeratins and SMA, and diffuse immunoreactivity for vimentin. The ki67 reached 70% in the epithelial component and 20% in the stromal component. Papillary intraurothelial carcinoma following radiotherapy may be associated with pseudosarcomatous stromal proliferation. The clinical history and the lack of cellular atypia and mitoses point toward the correct diagnosis.

Pseudoneoplastic mimics of prostate and bladder carcinomas

CONTEXT

The differential diagnoses of prostatic carcinoma and bladder epithelial neoplasms include several histologic mimics that should be known to avoid misdiagnosis.

OBJECTIVE

To discuss pseudoneoplastic lesions of the prostate and bladder that could potentially be confused with prostatic carcinoma and bladder epithelial neoplasms, respectively, with specific focus on their distinguishing histopathologic features.

DATA SOURCES

Relevant published literature and authors' experience.

CONCLUSIONS

Pseudoneoplastic lesions in the prostate include those of prostatic epithelial origin, the most common being atrophy, adenosis (atypical adenomatous hyperplasia), basal cell hyperplasia, and crowded benign glands, as well as those of nonprostatic origin, such as seminal vesicle epithelium. Such lesions often mimic lower-grade prostatic adenocarcinoma, whereas others, such as clear cell cribriform hyperplasia and granulomatous prostatitis, for example, are in the differential diagnosis of Gleason adenocarcinoma, Gleason grade 4 or 5. Pseudoneoplastic lesions of the urinary bladder include lesions that could potentially be confused with urothelial carcinoma in situ, such as reactive urothelial atypia, and others, such as polypoid/papillary cystitis, where papillary urothelial neoplasms are the main differential diagnostic concern. Several lesions can mimic invasive urothelial carcinoma, including pseudocarcinomatous hyperplasia, von Brunn nests, and nephrogenic adenoma. Diagnostic awareness of the salient histomorphologic and relevant immunohistochemical features of these prostatic and urinary bladder pseudoneoplasms is critical to avoid rendering false-positive diagnoses of malignancy.

Benign Mimickers of Prostate Adenocarcinoma on Needle Biopsy and Transurethral Resection

Prostate needle biopsy currently is the gold standard method for the diagnosis, management, and prognosis of prostate cancer. Obtaining an accurate diagnosis is crucial for pursuing proper patient management. This article discusses histologic mimickers of prostate carcinoma highlighting microscopic features that are helpful to reach a correct diagnosis and emphasizing potential diagnostic pitfalls.

Residual prostate cancer after radiotherapy: a study of radical cystoprostatectomy specimens

OBJECTIVES

The incidence of histologic prostate cancer (CaP) after definitive radiation therapy (RT) for localized disease is rarely quantitated. We investigated the relationship between prostate-specific antigen (PSA) and histologically residual CaP after definitive RT in patients undergoing radical cystoprostatectomy (RCP) for unrelated indications.

METHODS

We reviewed our prostate cancer database to identify patients undergoing RCP who previously received definitive RT for localized CaP. Pre-radiation variables examined include PSA, Gleason score, radiation modality, and dose. Post-radiation variables reviewed include PSA, time to RCP, the presence of histologically proven prostate cancer, and Gleason score.

RESULTS

We identified 21 patients who underwent RCP at a median of 60 months after RT for localized CaP. Pre-radiation Gleason scores were low (6 or less) to intermediate risk (3+4) in 82% (14 of 17), intermediate (4+3) to high (8 or greater) in 18% (3 of 17), and unavailable in 4 patients. Median pre-radiation PSA was 9 ng/mL. Median PSA before RCP in all patients was 0.8 ng/mL. A total of 52% (11 of 21) of patients demonstrated active CaP in the RCP specimen. Although 89% (16 of 18) of patients met the Phoenix definition of biochemical freedom from disease, 50% (8 of 16) of these patients had histologically residual CaP at the time of RCP. Median PSA was not significantly different between patients with and without active CaP.

CONCLUSIONS

Histologic evidence of CaP was noted in 50% of patients demonstrating biochemical freedom from disease at the time of RCP. Although the biological significance of active CaP in this select population is uncertain, our findings demonstrate the limitations of PSA in monitoring CaP disease activity after definitive RT.

The influence of geometrical changes on the dose distribution after I-125 seed implantation of the prostate

PURPOSE

After prostate implantation, dose calculation is usually based on a single imaging session, assuming no geometrical changes occur during the months of dose accumulation. In this study, the effect of changes in anatomy and implant geometry on the dose distribution was investigated.

MATERIALS AND METHODS

One day, 1 month and 312 months after seed implantation, a combined TRUS-CT scan was made of 13 patients. Based on these scans changes in dose rate distribution were determined in prostate, urethra and bladder and a 'geometry corrected' dose distribution was estimated.

RESULTS

When based on the day-1 scan, parameters representing high dose volumes in prostate and urethra were largely underestimated: V150 of the prostate 18+/-10% and V120 of the urethra 47+/-32%. The dose to a 2cm(3) hotspot in the bladder wall (D2cc), however, was overestimated by 31+/-35%. Parameters based on scans 1 month post-implant or later were all within +/-5% of geometry corrected values.

CONCLUSION

Values meant to indicate the adequacy of dose coverage of the prostate, V100 and D90, were not influenced by geometrical changes and were independent of the post-implant scan date. Other parameters representing high dose volumes changed strongly within the first month after implantation.

The predictive value of 2-year posttreatment biopsy after prostate cancer radiotherapy for eventual biochemical outcome

PURPOSE

To determine the value of a 2-year post-radiotherapy (RT) prostate biopsy for predicting eventual biochemical failure in patients who were treated for localized prostate cancer.

METHODS AND MATERIALS

This study comprised 164 patients who underwent a planned 2-year post-RT prostate biopsy. The independent prognostic value of the biopsy results for forecasting eventual biochemical outcome and overall survival was tested with other factors (the Gleason score, 1992 American Joint Committee on Cancer tumor stage, pretreatment prostate-specific antigen level, risk group, and RT dose) in a multivariate analysis. The current nadir + 2 (CN + 2) definition of biochemical failure was used. Patients with rising prostate-specific antigen (PSA) or suspicious digital rectal examination before the biopsy were excluded.

RESULTS

The biopsy results were normal in 78 patients, scant atypical and malignant cells in 30, carcinoma with treatment effect in 43, and carcinoma without treatment effect in 13. Using the CN + 2 definition, we found a significant association between biopsy results and eventual biochemical failure. We also found that the biopsy status provides predictive information independent of the PSA status at the time of biopsy.

CONCLUSION

A 2-year post-RT prostate biopsy may be useful for forecasting CN + 2 biochemical failure. Posttreatment prostate biopsy may be useful for identifying patients for aggressive salvage therapy.

Cancer therapy-associated CNS neuropathology: an update and review of the literature

Standard therapeutic options for brain tumors include surgery, radiation, and chemotherapy. Unfortunately, these same therapies pose risks of neurotoxicity, the most common long-term complications being radiation necrosis, chemotherapy-associated leukoencephalopathy, and secondary neoplasms. These side effects remain difficult to predict, but are associated with risk factors that include patient age, therapeutic modality and dosage, genetic background, and idiosyncratic predispositions. Experimental treatments designed to enhance efficacy and to minimize neurotoxicity include molecularly targeted, genetic, stem cell, and immune therapies. Newer modifications in radiation and drug delivery include stereotactic radiosurgery, interstitial therapy such as intracavitary brachytherapy and gliadel wafer placement, 3D conformal radiation, boron neutron capture therapy, radiosensitizers, blood-brain barrier disrupting agents, and convection enhanced delivery. Toxicities associated with these newer modalities have yet to be fully investigated and documented. Additionally, a number of recently implemented radiographic techniques such as PET and SPECT imaging have enhanced the ability to distinguish recurrent tumor from radiation necrosis. Nevertheless, post-therapeutic brain biopsies and autopsies remain the gold standard for assessing neurotoxicity, therapeutic efficacy, tumor progression, and the development of secondary neoplasms. At the same time, treatment-associated changes such as tumor necrosis, vasculopathy, inflammation, and cytologic atypia can pose significant diagnostic pitfalls, particularly if the pathologist is not provided a detailed therapeutic history. Therefore, it is critical to recognize the full spectrum of cancer therapy-associated neuropathology, the topic of the current review.

Small Glandular Proliferations on Needle Biopsies

The current study aimed to determine the incidence of various benign mimickers of prostatic adenocarcinoma most commonly encountered in a busy consultation practice. All prostate needle biopsies from the consult service of one of the authors were prospectively evaluated over a 7-month period. Only cases with foci where the contributor questioned malignancy and which upon expert review the entire case was determined to be benign were included in this study. A total of 567 separate suspected atypical foci from 345 patients of a total of 4,046 patients (8.5%) received in consultation were identified. Of these, 281 foci (49.5%) had immunohistochemical (IHC) studies performed by the outside institution, which included high molecular weight cytokeratin (HMWCK) (n = 280), alpha-methylacyl-CoA racemase (AMACR) (P504s) (n = 45), and p63 (n = 34). The most common mimicker was partial atrophy (203 of 567; 35.8%). Technically adequate IHC for basal cells was performed in 117 cases of partial atrophy with patchy or patchy/negative staining seen in 102 of 117 (87%), with the remaining 13% of cases completely negative. A total of 15 of 19 (79%) cases of partial atrophy were positive with AMACR. Crowded benign glands, insufficiently crowded or numerous to warrant a diagnosis of adenosis, was the second most common mimicker (146 of 567; 25.7%). Crowded benign glands had patchy or patchy/negative IHC for basal cells in 66 of 81 (81%) cases with the remaining 19% of cases completely negative. A total of 7 of 11 (64%) cases of crowded glands were positive for AMACR. In the past, complete atrophy, adenosis, seminal vesicle, and granulomatous prostatitis were considered common mimickers of prostate cancer on prostatic needle biopsies. Our study shows that currently partial atrophy and crowded benign glands are the most common benign changes causing diagnostic difficulty and prompting consultation. Negative or patchy staining for basal cells and positive staining for AMACR may contribute to diagnostic difficulty in these entities.

Learning to Improve Safety: False-Positive Pathology Report Results in Wrongful Surgery

BACKGROUND

A patient experienced a wrongful surgical resection, specifically, a radical retropubic prostatectomy because of a false-positive pathology report.

FINDINGS FROM THE ROOT CAUSE ANALYSIS (RCA)

The RCA team identified three antecedent events that contributed to this medical error: (1) a second (concurring) pathologist did not provide a written opinion, (2) a single pathologist who reviewed and signed the final report, and (3) a pathologist who did not review the case and reconfirm the diagnosis immediately prior to the surgical resection.

RECOMMENDATIONS

The RCA team recommended that the concurring pathologist write his or her diagnostic findings on the referral form, two pathologists review and sign the final typed report, and a pathologist rereview the slides on the business day prior to a surgical resection. Because the prostate specific antigen (PSA) value can be helpful in select cases of prostate cancer, the team recommended the PSA value be referenced when reviewing prostate specimens obtained through fine-needle biopsy.

TRACKING COMPLIANCE

Because a wrongful surgical resection is a rare event, emphasis was placed on measuring compliance with distinct elements that were part of the revised procedure. During a 12-month span, practitioners demonstrated sustained compliance to the enhanced process for analyzing and reporting results.

Radiation-induced Histopathologic Changes of the Breast

The increasingly frequent use of radiation therapy (RT) and systemic chemotherapy (CT) in the treatment of breast carcinoma requires surgical pathologists and cytologists to be familiar with the variable histologic changes initiated by these agents. Both treatment modalities can cause severe epithelial abnormalities, which are difficult to distinguish from carcinoma. The progression or regression of these histologic abnormalities in nonneoplastic breast tissue have not been extensively evaluated. Our study used 120 post-RT biopsy or mastectomy specimens from 117 patients (3 had bilateral carcinoma treated with RT) yielding 120 specimens. The interval from post-RT to biopsy or mastectomy ranged from 1 to 229 months with 25 of the specimens obtained 1 to 12 months after cessation of RT and 95 more than a year post-RT. Twenty-seven specimens were from >6 years after RT. The histologic features of pretreatment and posttreatment specimens were graded (0-3) blindly for each histologic feature to include stromal vascular and fibroblastic changes and epithelial cell changes of the terminal duct lobular unit and extralobular ducts as well as terminal duct lobular unit fibrosis/atrophy. The changes between the pre- and post-RT grades were all statistically significant (P < 0.05) using multiple nonparametric statistical methods and the parametric Student t test. The specimens obtained within the first year post-RT were compared with those from >1 year post-RT, >3 years post-RT, and >6 years post-RT. None of the histologic features evaluated showed significant changes over the various time intervals regardless of the statistical method used. The absence of regression of the radiation-induced histologic changes over time mandates the surgical pathologist be alert to the possibility of RT or CT even without that therapeutic history.