A major solid undifferentiated carcinoma pattern correlates with tumour progression in locally advanced prostatic carcinoma

Prostate Cancer Metastasis to Thyroid Gland

Metastases to the thyroid gland are rarely encountered in clinical practice. They may originate from various primary sites, mainly kidney, lung, breast, esophagus and uterus. Prostate cancer is one of the most frequent malignancies in men. It generally has a favorable course, and autopsy series have shown occult prostate cancer in many subjects, especially in aged males. However, prostate cancer sometimes exhibits an aggressive behavior and cases with a poor prognosis have been reported. Occasional reports of metastasis from prostate cancer to the thyroid gland have been documented. We describe the case of a 73-year-old patient presenting with thyroid metastasis from long-standing prostate cancer.

Prostatic meningeal carcinomatosis with low serum level of prostate-specific antigen

Less than 1% of patients with metastatic prostate cancer present with abnormally low serum levels of prostate-specific antigen (PSA). Furthermore, cases of prostatic metastases to the meninges with a low serum level of PSA are extremely rare. The present report describes a patient with prostatic meningeal carcinomatosis and low serum PSA levels.

Tumour markers for managing men who present with metastatic prostate cancer and serum prostate-specific antigen levels of <10 ng/mL

OBJECTIVE

To define immunohistochemical features of the primary cancers that might help in the differential diagnosis and monitoring of treatment in men presenting with metastatic prostate cancer and low serum levels of prostate-specific antigen (PSA), who can be difficult to diagnose and manage.

PATIENTS AND METHODS

Paraffin blocks of prostate biopsies were obtained for 33 patients presenting with untreated metastatic prostate cancer and serum PSA levels of <10 ng/mL. Sections were immunostained for PSA, prostatic acid phosphatase (PAP), prostate-specific membrane antigen (PSMA), androgen receptor (AR), chromogranin A and CD 56.

RESULTS

The combined Gleason scores were 8-10 in 25 men (76%) and 6 or 7 in the other eight (24%). Morphologically, there were no neuroendocrine features. PSA immunostaining was equivocal in 12 (36%) cases and in a further 19 (58%) was strong but focal and could be missed on biopsy sampling. PSMA was expressed in 90% of cases, and staining was widely distributed in nine of the 12 in which PSA staining was equivocal. There was strong AR expression in 30 (91%) cases and it was present in areas where PSA was absent.

CONCLUSION

In this patient group, immunohistochemical assessments of PSMA and AR are potentially useful as diagnostic markers.

Clinical features of patients who present with metastatic prostate carcinoma and serum prostate-specific antigen (PSA) levels < 10 ng/mL

BACKGROUND

Although < 1% of men present with prostate-specific antigen (PSA)-negative prostate carcinoma, in that they have serum PSA levels much lower than the tumor burden would suggest, such patients represent a management dilemma. To the authors' knowledge, little information exists in the literature regarding patterns of disease and response to treatment. The authors wished to define the clinical features of this patient group.

METHODS

The British Association of Urological Surgeons Cancer Registry 2000 and 2001 data bases were used to identify the clinical features and outcome of 33 men with metastatic prostate carcinoma who presented with serum PSA levels < 10 ng/mL. Clinical notes and histopathology were reviewed for each patient.

RESULTS

Seventeen patients (51%) presented with urinary symptoms and/or pelvic pain, 6% with cachexia and 21% with bone pain. Characteristic bone metastases were present in 81% of patients, similar to the presentation of men with high serum PSA levels. Hypercalcemia was a feature in 9% of patients. Visceral metastases were present in two patients. The median response duration to first-line hormone manipulation was 7 months. No responses were seen in 11 of 13 patients who received second-line hormones or to any third-line treatment. Three of 5 patients who received chemotherapy responded but developed recurrent disease within 8 weeks of treatment cessation. The median overall survival was 12 months.

CONCLUSIONS

The presentation of patients with treatment-naïve PSA-negative metastatic prostate carcinoma is similar to that of patients with high serum PSA levels, but their median survival and response duration to first-line hormone therapy are of much shorter duration. Second-line hormone therapy is ineffective, but early chemotherapy may be beneficial. Hypercalcemia is a particular feature in this group of patients.

M1 prostate cancer with a serum level of prostate-specific antigen less than 10 ng/mL

BACKGROUND

M1 prostate cancer, which is invasive, is usually associated with a serum level of prostate-specific antigen (PSA) greater than 10 ng/mL, but cases are occurring where the serum PSA level is less than this. The present study investigated the clinical and pathologic characteristics of these cases of M1 prostate cancer.

METHODS

Between April 1989 and March 1998, 167 cases of M1 prostate cancer were diagnosed by transrectal needle biopsy and eight of these with a serum PSA level less than 10 ng/mL were investigated. The patients' ages ranged from 57 to 79 years (median, 73) and the serum PSA levels ranged from less than 4.0 to 9.8 ng/mL. In all cases except one, the distal metastasis was to bones only. All cases had received hormonal therapy as the initial therapy. Immunostaining of PSA, chromogranin A, neuron-specific enolase, carcinoembryonic antigen and vimentin were performed in five of the eight cases.

RESULTS

Four cases were poorly differentiated, two were undifferentiated, one was a mixture of poorly differentiated and undifferentiated and one case was moderately differentiated. Of the five cases in the immunohistochemical study, three cases with an undifferentiated carcinoma component showed negative staining reactions for PSA and all cases were positive for carcinoembryonic antigen. Four of the patients died of prostate cancer. In two of these four cases, hormonal therapy was ineffective, but systemic chemotherapy and irradiation therapy had been moderately effective. The overall 3-year survival rate was 33.3%.

CONCLUSIONS

The cases of M1 prostate cancer with a serum PSA less than 10 ng/mL are almost always poorly differentiated or undifferentiated and have a poor prognosis compared with the usual M1 prostate cancer. Because hormonal therapy is ineffective in these cases, systemic chemotherapy and irradiation therapy should be chosen as the initial therapy.

Nuclear morphometry is of independent prognostic value only in T1 prostatic adenocarcinomas

A series of 325 patients with prostatic adenocarcinoma followed-up for over 13 years was subjected to histomorphometric analysis for the following prognostic factors: the Gleason score and 10 nuclear morphometric factors (mean nuclear area, nuclear perimeter, shortest and longest nuclear axis, form factor and their SDs), using the IBAS 1&2 image analyzer. Nuclear factors, Gleason score (P = 0.0013-0.0148), and T-category (P = 0.004-0.0107) were significantly interrelated, while the M-category was independent of the morphometric parameters. Nuclear factors (P = 0.0003-0.5), Gleason score (P < 0.0001), T-category (P < 0.0001) and M-category (P < 0.0001) predicted the disease outcome. In T1-2M0 tumors, the T-category (P = 0.0001), Gleason score (P < 0.0001), SD of nuclear area (P = 0.057), SD of nuclear perimetry (P = 0.039), mean shortest nuclear axis (P = 0.030), SD of the shortest nuclear axis (P = 0.0045), SD of the longest nuclear axis (P = 0.009), and nuclear form factor (P = 0.0123) were significant prognostic factors. In the multivariate survival analysis, the nuclear area had independent prognostic significance only in T1 tumors, whereas in other subcategories, the clinical stage, Gleason score, and patient age included all the available prognostic information. The results indicate that nuclear morphometric measurements are of borderline significance only in evaluating the intrinsic malignancy of prostatic adenocarcinoma.

The extent of apoptosis in different types of high grade prostatic carcinoma

Apoptosis is the genetically mediated mechanism by which individual cells are deleted from living tissues. The extent of apoptosis in human tumours has not been examined in detail. In this study, apoptotic indices were assessed semiquantitatively by light microscopy in routine haematoxylin and eosin (H & E) stained sections of 15 high-grade carcinomas of the prostate by light microscopy, using the 40 x objective, counting 2000-2500 tumour cells per case. The mean apoptotic index for nine solid undifferentiated carcinomas was 1.7% (range 0.2-2.4%), for three small cell undifferentiated carcinomas 25.2% (range 10-37%), and for three secondary transitional cell carcinomas of the prostate 5.5% (range 2.4-9.1%). In general, apoptosis was easily identified, using the 40 x objective. There were minor variations in apoptosis from field to field in each tumour, and greater variability in the apoptotic index was observed among the small cell undifferentiated carcinomas and transitional cell carcinomas. In conclusion, assessment of apoptosis in routine H & E sections of human tumours is feasible, but it remains to be determined whether the extent of apoptosis correlates with other determinants of biological behaviour.

Estrogen treatment postpones the castration-induced dedifferentiation of Dunning R3327-PAP prostatic adenocarcinoma

Male Copenhagen x Fisher F1 rats, transplanted with the androgen-sensitive Dunning R3327 PAP rat prostatic adenocarcinoma, were castrated when tumor volumes were approximately 1300 mm3. The rats were thereafter followed with measurements of tumor volume. Castration stopped tumor growth, but some of the tumors started to regrow after 7-36 weeks. These tumors relapsing from castration treatment were now considered to be androgen-insensitive. In this study, we defined relapse as the time when the tumor volume had increased to 200% of the volume at the time for castration. At this time, the rats were treated either with estradiol-17 beta (E2, 50 micrograms s.c. daily) or vehicle for 8 weeks. After this period, tumor morphology was examined. The tumors in the vehicle-treated group were heterogeneous, and both highly and more dedifferentiated parts were present. The tumor growth rate was correlated to the epithelial cell nuclear size and its variance, and to the mitotic index. In the E2-treated group, tumor growth rate was retarded throughout the treatment period, and dedifferentiated tumor areas were rare. Estrogen treatment resulted in a reduction of nuclear area and mitotic index, a changed nuclear shape, and an increased apoptotic index compared to that in vehicle-treated tumors. By castration, it is possible to induce an alteration of the androgen-sensitive Dunning R3327 PAP tumor phenotype to an androgen-insensitive tumor with an altered morphology. Estradiol-17 beta apparently inhibits not only the growth, but also postpones the castration-induced dedifferentiation of the tumor.