'Vanishing' prostate cancer in radical prostatectomy specimens: incidence and long-term follow-up in 38 cases

Analysis of vanishing endometrial cancer by pathological types

PURPOSE

We asked why endometrial cancer sometimes vanishes.

METHODS

A total of 454 patients diagnosed with endometrioid-type endometrial cancer (EC) (via endometrial sampling) and treated in our clinic over the past 5 years were enrolled. The patients were divided into two groups: vanishing and residual, depending on whether a tumor was detected in the postoperative hysterectomy specimen. Patient age, numbers of pregnancies and deliveries, menopausal status, systemic disease status, hemogram parameters, International Federation of Gynecology and Obstetrics (FIGO) grade, and invasion status (evident on magnetic resonance imaging [MRI]) were compared between the groups.

RESULTS

ECs vanished in 42 (9.25%) patients. The vanishing rates were 19.7% (37/187) in FIGO grade 1 patients, 2.1% (5/238) in grade 2 patients, and 0% (0/29) in grade 3 patients. The average age was lower in the vanishing than the residual group, but the premenopausal status and grade 1 tumor rates were higher (both p < 0.001). An absence of invasion (as revealed by MRI) was more common in the vanishing group (p < 0.001). No recurrence developed in the vanishing group, but recurrences were noted in 3.3% (14/412) of the residual group. There were no significant between-group differences in any of the numbers of pregnancies or births, systemic disease status, or hemogram parameters (all p > 0.05).

CONCLUSION

Vanishing EC is more likely in premenopausal women with endometrioid grade 1 EC (as revealed by endometrial biopsy) who lack myometrial invasion on MRI.

Nondetectable Prostate Carcinoma (pT0) after Radical Prostatectomy: A Narrative Review

(1) Background: Following radical prostatectomy (RP), the absence of a demonstrable tumor on the specimen of a previously histologically proven malignancy is known as the pT0 stage. The aim of our present study is to perform a narrative review of current literature in order to determine the frequency and oncological outcomes in patients with pT0 disease. (2) Methods: A narrative review of all available literature was performed. (3) Results: The incidence of pT0 ranges between 0.07% and 1.3%. Predictors of the pT0 stage are only a single biopsy core with low-grade cancer, a cancer length not exceeding 2 mm and a high prostate volume. Biochemical recurrence ranges between 0 and 11%. (4) Conclusions: The absence of malignancy in the RP specimen despite a previous positive biopsy is a rare and unpredictable finding. Although the prognosis is considered to be excellent in most of the cases, a continued close follow-up is warranted.

Contemporary clinicopathological characteristics of pT0 prostate cancer at radical prostatectomy: A population-based study

BACKGROUND

The incidence of pT0 prostate cancer (CaP) at radical prostatectomy (RP) is extremely rare. We performed the first population-based analysis of pT0 CaP at RP.

METHODS

Within the Surveillance, Epidemiology, and End Results database (2004-2015), we tested for clinical and pathological characteristics according to pT0 vs. non-pT0 CaP and included a multivariable logistic regression model.

RESULTS

pT0 was identified in 358 (0.2%) out of 160,532 clinically localized RP patients. The majority of pT0 patients presented with initial prostate-specific antigen (PSA) <10 ng/ml (82.4%), harboured biopsy Gleason score (GS) 6 (69.8%) and cT1 disease (78.1%). Nonetheless, pT0 was identified in 13 (3.6%) patients with PSA ≥20 ng/ml, in 69 (19.3%) patients with biopsy GS ≥7 and in 78 (21.8%) patients with ≥cT2 disease. In a subset of patients with available number of biopsy cores, pT0 was identified in 34 (33.3%) patients with ≥2 positive biopsy cores. Age, race, marital status, hospital region, population density, PSA, as well as number of biopsy cores did not discriminate between pT0 and non-pT0 cases. Analyses according to annual rates (2004-2015) of pT0 did not vary between the years (0.2%-1.6%, estimated annual percent change: -1.6%, P = 0.3). Neither did the rates vary according to geographic region.

CONCLUSIONS

pT0 at RP is very rare. Even though, most pT0 patients have low PSA, low clinical stage, low biopsy GS, and only one positive biopsy core, those with more aggressive characteristics can still harbour pT0 at RP.

Clinical significance of multiparametric MRI and PSA density as predictors of residual tumor (pT0) following radical prostatectomy for T1a-T1b (incidental) prostate cancer

Purpose

The aim of this study was to evaluate predictors of residual tumor and clinical prognosis in T1a-T1b (incidental) prostate cancer by analysis of specimens from men undergoing surgery for benign prostatic hyperplasia.

Materials and methods

We retrospectively reviewed medical records of incidental prostate cancer patients who had undergone radical prostatectomy. Patients whose tumor statuses were further confirmed by prostate biopsy, or who had used androgen deprivation therapy before radical prostatectomy, were excluded. Clinical and pathological parameters were analyzed to evaluate residual tumor and clinical prognosis. We used univariate and multivariate logistic regression analyses, as well as receiver operator characteristics, to predict residual tumor (pT0).

Results

The final analysis included 95 patients. Among these patients, 67 (70.53%) exhibited residual tumor, whereas 28 (29.47%) did not (pT0). Pathology findings showed that 44 (65.67%), 16 (23.88%), and 7 patients (10.45%) exhibited Gleason scores of G6, G7, and ≥G8, respectively. Fifty-seven and 10 patients exhibited pathologic T stages T2 and T3, respectively. Mean follow-up duration was 70.26 (±34.67) months. Biochemical recurrence was observed in 11 patients; none were pT0 patients. Multivariate logistic regression showed that low prostate-specific antigen density after benign prostatic hyperplasia surgery and invisible lesion on multiparametric magnetic resonance imaging were significantly associated with pT0. Additionally, a combination of these factors showed an increase in the diagnostic accuracy of pT0, compared with mpMRI alone (AUC 0.805, 0.767, respectively); this combination showed sensitivity, specificity, and positive predictive values of 71.6%, 89.3%, and 94.1%, respectively.

Conclusion

Our results suggest that patients with incidental prostate cancer who have both prostate-specific antigen density ≤0.08 after benign prostatic hyperplasia surgery as well as invisible cancer lesion on multiparametric magnetic resonance imaging should be considered for active surveillance.

Vanishing endometrial carcinoma in hysterectomy specimens: probable implications for fertility sparing management

Background/aim: The vanishing cancer phenomenon was first reported in radical prostatectomy specimens in the absence of neo-adjuvant treatment. Reported cases are mostly well-differentiated and low-volume tumors. A similar entity was described for hysterectomy specimens of patients with biopsy proven endometrial cancer (EC). In this study, we discuss the probable reasons for vanishing EC and long-term follow-up results of EC patients without residual tumors in hysterectomy specimens. Materials and methods: This study was carried at two institutions in Ankara, Turkey, in a retrospective design. The computerized databases of both institutions were searched for endometrioid type EC patients whose final pathological specimens failed to show any residual tumor. Results: We evaluated 38 endometrial biopsy confirmed EC patients with no residual tumor detected in the hysterectomy specimens among a total of 224 women (17%) with the disease confined to the endometrium. During the follow-up period, no recurrences were noted among the patients. Conclusion: It can be suggested that premenopausal women with FIGO grade 1 endometrioid type EC with MRI proven "absent myometrial invasion" would have a significant probability of having no residual tumor after endometrial biopsy without any further medical treatment.

Prediction of Pathological Complete Response Using Endoscopic Findings and Outcomes of Patients Who Underwent Watchful Waiting After Chemoradiotherapy for Rectal Cancer

BACKGROUND

Nonoperative management for patients with rectal cancer who have achieved a clinical complete response after chemoradiotherapy is becoming increasingly important in recent years. However, the definition of and modality used for patients with clinical complete response differ greatly between institutions, and the role of endoscopic assessment as a nonoperative approach has not been fully investigated.

OBJECTIVE

This study aimed to investigate the ability of endoscopic assessments to predict pathological regression of rectal cancer after chemoradiotherapy and the applicability of these assessments for the watchful waiting approach.

DESIGN

This was a retrospective comparative study.

SETTINGS

This study was conducted at a single referral hospital.

PATIENTS

A total of 198 patients with rectal cancer underwent preoperative endoscopic assessments after chemoradiotherapy. Of them, 186 patients underwent radical surgery with lymph node dissection.

MAIN OUTCOME MEASURES

The histopathological findings of resected tissues were compared with the preoperative endoscopic findings. Twelve patients refused radical surgery and chose watchful waiting; their outcomes were compared with the outcomes of patients who underwent radical surgery.

RESULTS

The endoscopic criteria correlated well with tumor regression grading. The sensitivity and specificity for a pathological complete response were 65.0% to 87.1% and 39.1% to 78.3%. However, endoscopic assessment could not fully discriminate pathological complete responses, and the outcomes of patients who underwent watchful waiting were considerably poorer than the patients who underwent radical surgery. Eventually, 41.7% of the patients who underwent watchful waiting experienced uncontrollable local failure, and many of these occurrences were observed more than 3 years after chemoradiotherapy.

LIMITATIONS

The number of the patients treated with the watchful waiting strategy was limited, and the selection was not randomized.

CONCLUSIONS

Although endoscopic assessment after chemoradiotherapy correlated with pathological response, it is unsuitable for surveillance of patients treated via a nonoperative approach. Incorporation of a "watchful waiting" strategy without establishing proper surveillance protocols and salvage strategies might result in poor local control.

[Analysis and prognostic factors of the specimen of radical prostatectomy in prostate cancer]

OBJECTIVES

Handling and pathologic analysis of radical prostatectomy specimens are crucial to confirm the diagnosis of prostate cancer and evaluate prognostic criteria.

MATERIAL AND METHODS

A systematic review of the scientific literature was performed in the Medline database (PubMed), using different associations of the following keywords: prostate cancer; prostatectomy; specimen; handling; pathology; tumor staging; Gleason score; surgical margin; prognosis; frozen section; lymph node; biomarkers. A particular search was done on specimen management and characterization of tissue prognostic factors.

RESULTS

Handling of both radical prostatectomy specimen and lymph node dissection is standardized according to international criteria. Although the main histoprognostic factors are still Gleason score, pathologic staging and margin status, these criteria have been refined these last 10 years, allowing to improve the prediction of relapse after surgical treatment.

CONCLUSION

The standardization of handling and pathology reporting of radical prostatectomy specimens will be mandatory for treatment uniformization according to risk stratification in prostate cancer and personalization of therapeutic approaches.

Evaluation of pT0 prostate cancer in patients undergoing radical prostatectomy

OBJECTIVE

To evaluate the incidence, predictors and oncological outcomes of pT0 prostate cancer (PCa).

METHODS

We conducted a retrospective analysis of 20 222 patients undergoing radical prostatectomy (RP) for PCa at the Mayo Clinic between 1987 and 2012. Disease recurrence was defined as follow-up PSA >0.4 ng/mL or biopsy-proven local recurrence. Systemic progression was defined as development of metastatic disease on imaging. Comparisons of baseline characteristics between pT0 and non-pT0 groups were carried out using chi-squared tests. Recurrence-free survival was estimated using the Kaplan-Meier method and compared using the log-rank test.

RESULTS

A total of 62 patients (0.3%) had pT0 disease according to the RP specimen. In univariable analysis, pT0 disease was significantly associated with older age (P = 0.045), lower prostate-specific antigen (PSA; P = 0.002), lower clinical stage (P < 0.001), lower biopsy Gleason score (P = 0.042), and receipt of preoperative transurethral resection, hormonal and radiation therapies (all P < 0.001). In multivariable analysis, lower PSA levels, lower Gleason score, and receipt of preoperative treatment were independently associated with pT0 (all P < 0.05). Seven patients (11%) with pT0 PCa developed disease recurrence over a median follow-up of 10.9 years. All seven patients had preoperative treatment(s) and three had recurrence with a PSA doubling time of <9 months. Compared with non-pT0 disease, pT0 disease was associated with longer recurrence-free survival (P < 0.05). Only one (1.6%) patient with pT0 disease developed systemic progression.

CONCLUSIONS

pT0 stage PCa is a rare phenomenon and is associated with receipt of preoperative treatment and features of low-risk PCa. Although pT0 has a very favourable prognosis, some men, especially those who received preoperative treatment, experience a small but non-negligible risk of disease recurrence and systemic progression.

The prevalence and outcomes of pT0 disease after neoadjuvant hormonal therapy and radical prostatectomy in high-risk prostate cancer

Background

To identify the prevalence and clinical outcomes of pT0 disease following neoadjuvant hormonal therapy (NHT) and radical prostatectomy (RP) in high-risk prostate cancer.

Methods

We retrospectively included 111 patients who had received NHT and RP for the treatment of high-risk prostate cancer. We classified the patients into two groups, the pT0 group and the non-pT0 group, depending on whether a residual tumor was observed.

Results

We identified 6 cases (5.4 %) with pT0 disease after reviewing the slides of all patients. There was no recurrence of disease in the pT0 group during a median follow-up of 59 months. Among the 105 patients in the non-pT0 group, biochemical recurrence (BCR) developed in 60 patients (57.1 %), with the median time to BCR being 14 months.

Conclusions

Among the 111 patients with high-risk prostate cancer, we found 6 cases that showed a complete pathological response after NHT and no recurrence of disease during the follow-up, meaning that the androgen deprivation therapy could potentially eradicate high-risk prostate cancer. This is one of the largest studies demonstrating the prevalence of pT0 disease and its outcomes after NHT among patients with high-risk prostate cancer.

DNA comparison between operative and biopsy specimens to investigate stage pT0 after radical prostatectomy

PURPOSE

The aim was to eliminate, by DNA comparison, any identity mismatch between operative and biopsy specimens and to analyse the determinants of all pT0 prostate cancers occurred in a single institution.

METHODS

All prostate pT0 cases in a single institution over 20 years were investigated. None of the patients had been diagnosed after a transurethral resection of the prostate nor had they received neoadjuvant hormonal treatment. The biopsies performed in other centres had been referred for a centralized pathologic re-analysis. DNA analysis was performed in samples from operative and biopsy specimens, and pairs of tissues were blindly constituted. Correct matching was verified in each pair and compared to the original database in order to comment on the occurrence of identity mismatches in the series.

RESULTS

Nineteen patients (0.77 %) had been diagnosed as having pT0 prostate cancer among the 2,462 RP procedures performed over 19 years. The biopsy re-analysis invalidated the initial diagnosis of prostate cancer in one biopsy set performed elsewhere. Among 12 entirely processed cases, the biochemistry procedure evaluated as "very unlikely" the occurrence of an error in tissue identification in the biopsy setting, during the surgical procedure or the pathological analysis. No identification error of tissue samples was established in this first verified pT0 series.

CONCLUSIONS

Although it must be suspected, specimen identification error was not a cause for pT0 prostate cancer. Only after a full pathological and DNA verification, the pT0 stage remains a sole entity, unexplained in most cases.

pT0 Prostate Cancer: Predictive Clinicopathologic Features in an American Population

INTRODUCTION

The pT0 stage of prostate cancer describes the radical prostatectomy (RP) specimen where no cancer can be identified. Given known racial and geographic differences in prostate cancer incidence and survival, we reviewed our experience with pT0 disease to determine applicability of these predictive features in an American population.

MATERIALS AND METHODS

A retrospective chart review was conducted for all RPs at one state tertiary care institution during a 20-year period (1991-2011). Clinicopathologic features of pT0 patients were collected and their relevant pathologic material re-reviewed.

RESULTS

Of a total of 1,635 RPs performed, 4 (0.2%) not receiving neoadjuvant therapy or other prior prostate surgeries were stage pT0. Biopsies from 3 of 4 patients were re-evaluated and confirmed a small focus, <1% of tissue, of Gleason score 3+3 adenocarcinoma; a fourth was not available for re-review. Our re-review of the RP slides identified small foci of cancer in two of the four, thus yielding a final true pT0 incidence of 0.1%. Preoperative prostate specific antigen ranged from 4.4 to 7.4 ng/ml, clinical stages were all T1c, and there was no evidence of recurrence at 3 months to 10 years of follow-up.

CONCLUSIONS

Stage pT0 prostate cancer is very uncommon, occurring with an incidence of 0.1%, and in our experience occurs only in clinical T1c patients with pre-biopsy prostate specific antigen < 7.5 ng/ml, with Gleason score 3 + 3 adenocarcinoma comprising < 1%, 1 mm of a single core biopsy, a stricter threshold than that seen in non-American populations.

[Status and medicolegal implications in France pT0 stage of prostate cancer: a study by the CC-AFU]

OBJECTIVE

To assess the frequency, circumstances, and possible medico-legal consequences of the pT0 prostate cancer, defined by the absence of tumor in a radical prostatectomy specimen.

METHODS

Six centers retrospectively identified all cases of pT0 and selectionned those that occurred without prior hormone therapy or prostate resection. Preoperative data, histological report and clinical and biological outcome were analyzed. The lawsuits' registry in pathology were consulted at insurance companies.

RESULTS

Thirty cases of pT0 prostate cancer (0.4%) were reported on 7693 patients. The median age was 63years, PSA 7.4ng/mL. The number of positive preoperative biopsies ranged from one to four for a median tumor length of 1mm (0.3 to 18mm). The biopsy Gleason score was 3+3 for 23 patients, less than 5 for six others and included a contingent of grade 4 in two patients. With a median follow-up of 82months, no clinical or biochemical recurrence was observed. One patient complaint for pT0 prostate was found in the insurances registry.

CONCLUSION

The occurrence of a prostate pT0 called into question all the diagnostic procedures and surgical indication. To avoid a forensic procedure, urologists should inform patients of the possibility of this situation before radical prostatectomy.

Trends in prostatic adenocarcinoma tumor volume by visual estimation in prostatectomy specimens

We retrospectively reviewed 1792 consecutive radical prostatectomies (RP) from 2003 to 2006 at a single institution to establish tumor volume reference values, to determine current trends in visually estimated prostate adenocarcinoma tumor volume, and to characterize cases with no residual cancer on RP. Tumor volumes were recorded and subsequently stratified as very low, 0-1%; low, 1.1-10%; intermediate, 10.1-20%; high, 20.1-50%; and very high, >50%, with incidences of 11.7%, 52.1%, 21.5%, 13.2%, and 1.5%, respectively. The incidence of very low volume tumors increased within the time period (p=0.04). Seminal vesicle involvement was detected in 5.0% of cases and lymph node metastasis occurred in 1.4%. Volume categories statistically correlated with seminal vesicle invasion (p=0) and lymph nodes metastases (p=0). Eleven cases of no residual cancer (0.6%) were identified with a non-statically significant increase during the study (p=0.07). The rising incidence of very low volume tumors should be considered by clinicians when discussing treatment options with patients. A discrete tumor volume should be provided for RP specimens as it may be an important prognostic factor.

[Nondetectable prostate cancer in radical prostatectomy specimens]

Since the widespread use of prostate-specific antigen, early diagnosis of prostate cancer at an early stage has been increased. Consequently, a greater frequency of low-volume disease or no tumor has been found in radical prostatectomy specimen.

AIMS

In the present study authors analyzed patients classified as pT0 after radical prostatectomy at their center.

METHODS

1134 radical prostatectomies were evaluated retrospectively at the author's center between 1996 and 2010. If there was no evidence of prostate cancer in the specimen, patient was staged as pT0. Patients were divided into two groups: received neoadjuvant hormonal therapy or not.

RESULTS

Overall 32 (2.8%) patients were staged as pT0. The rate of pT0 staging was 9.3% and 1.2% in the hormonally treated group and non-hormonally treated group. False-positive prostate biopsy was found in 2 cases. The rate of pT0 staging was higher in patients with incidental prostate cancer, low Gleason score and enlarged prostate. Biochemical relapse was observed in 3 pT0 patients in the hormonally treated group, among them there was one clinical relapse. In non-hormonally treated group no recurrence was detected.

CONCLUSION

The rate of pT0 staging was higher in the hormonally treated group. Because of biochemical and clinical relapse despite vanishing prostate cancer phenomenon, these cases are considered not to be true pT0. On the basis of present study and other reports the rate of pT0 staging is about one percentage in non-hormonally treated patients. Prognosis of these patients is excellent.

Minimal or No Residual Prostatic Adenocarcinoma on Radical Prostatectomy: A 5-Year Experience With “Vanishing Carcinoma Phenomenon”

Context.—“Vanishing carcinoma phenomenon” (VC) has been defined as the finding of minute or no cancer on radical prostatectomy specimens after a positive biopsy.

Objective.—To discuss our experience with VC and to recommend guidelines for its detection.

Design.—One thousand seven hundred forty-one radical prostatectomy specimens (2004–2009) processed by whole-mount section procedure yielded 21 (1.2%) cases with VC and 6 (0.34%) cases with minimal carcinoma (≤2 mm) in the radical prostatectomy specimen. To find the eluding carcinoma in VC cases or more carcinoma in minimal carcinoma cases, the following was done: 3 levels of all the paraffin blocks were obtained; if negative, the paraffin blocks were melted, the tissue was flipped, and 3 levels were prepared. The tumor bank frozen tissue was also processed for routine examination.

Results.—Three deeper levels in the radical prostatectomy specimen of 21 VC cases failed to show malignancy; however, the flipping and recutting of the tissue yielded a focus of carcinoma (1–5 mm) in 16 of 21 cases and in 3 of 16 cases in the saved frozen tissue. In 1 of the 6 cases with minimal carcinoma, subsequent recuts of the flipped tissue displayed carcinoma (2 foci of tumor, &lt;1 mm each).

Conclusions.—In VC we recommend: embed and process any remaining prostatic tissue including any saved fresh-frozen tissue; obtain 3 levels of each paraffin block; if results are negative, melt and flip the tissue and obtain 3 more levels. Following the above guidelines, a hidden carcinoma may be detected in the majority of the cases of VC.

Preoperative Clinical and Pathological Characteristics of pT0 Prostate Cancer in Radical Prostatectomy

Purpose

To analyze the preoperative clinical and pathological characteristics of patients with pT0 prostate cancer.

Materials and Methods

We retrospectively reviewed the records of 702 patients who underwent radical prostatectomy (RP) at our institution between January 2004 and July 2008 for clinically localized prostate cancer. If there was no evidence of residual tumor in the pathological specimen of the prostate, a patient was staged as pT0. Patients with pT0 disease were compared with a control group of patients who were operated on during the same period.

Results

Overall, 9 (1.3%) patients were staged as pT0 on the pathologic examination. Significant differences were observed between the pT0 group and the control patients in the biopsy Gleason score (p=0.004), the number of positive cores on biopsy (p=0.018), the tumor length of positive cores (p<0.001), and prostate volume (p=0.015). Cutoff values predictive of pT0 tumor status were defined as a biopsy Gleason score sum ≤6, 2 or fewer positive biopsy cores, tumor length on biopsy ≤2 mm, and prostate volume >30 cm³. Whereas 8 of the 9 (88.9%) pT0 patients showed all of these characteristics, only 55 of the 693 (7.9%) control patients fulfilled the criteria. The combination suggested above afforded a sensitivity of 88.8% and a specificity of 92.1% for the prediction of pT0 status.

Conclusions

The frequency of pT0 prostate cancer seen on RP was 1.3%. A combination of clinicopathological features, incorporating a biopsy Gleason score, the number of positive biopsy cores, tumor length on biopsy, and prostate volume, was useful to predict pT0 stage on RP.

Variability in diagnostic opinion among pathologists for single small atypical foci in prostate biopsies

Pathologists are increasingly exposed to prostate biopsies with small atypical foci, requiring differentiation between adenocarcinoma, atypical small acinar proliferation suspicious for malignancy, and a benign diagnosis. We studied the level of agreement for such atypical foci among experts in urologic pathology and all-round reference pathologists of the European Randomized Screening study of Prostate Cancer (ERSPC). For this purpose, we retrieved 20 prostate biopsies with small (most <1 mm) atypical foci. Hematoxylin and eosin-stained slides, including 10 immunostained slides were digitalized for virtual microscopy. The lesional area was not marked. Five experts and 7 ERSPC pathologists examined the cases. Multirater kappa statistics was applied to determine agreement and significant differences between experts and ERSPC pathologists. The kappa value of experts (0.39; confidence interval, 0.29-0.49) was significantly higher than that of ERSPC pathologists (0.21; confidence interval, 0.14-0.27). Full (100%) agreement was reached by the 5 experts for 7 of 20 biopsies. Experts and ERSPC pathologists rendered diagnoses ranging from benign to adenocarcinoma on the same biopsy in 5 and 9 biopsies, respectively. Most of these lesions comprised between 2 and 5 atypical glands. The experts diagnosed adenocarcinoma (49%) more often than the ERSPC pathologists (32%) (P<0.001). As agreement was particularly poor for foci comprising <6 glands, we would encourage pathologists to obtain intercollegial consultation of a specialized pathologist for these lesions before a carcinoma diagnosis, whereas clinicians may consider to perform staging biopsies before engaging on deferred or definite therapy.

Degarelix for prostate cancer

The growth of prostate cancer cells is hormone dependent in the majority of patients with the disease. Lowering testosterone either surgically or medically (usually with a gonadotropin releasing hormone (GnRH) agonist) is the standard of care in patients with metastatic prostate cancer. Degarelix is a new GnRH antagonist for the treatment of patients with prostate cancer. In contrast to GnRH agonists, the development of GnRH antagonists was hindered for a long time owing to histamine-releasing activity and lack of potency and water solubility. Recently, however, degarelix has been approved by the FDA for the treatment of advanced prostate cancer. This review summarizes the preclinical and clinical data available for degarelix and describes its potential role in the market of prostate cancer therapeutics.

Screen-detected breast lesions with malignant needle core biopsy diagnoses and no malignancy identified in subsequent surgical excision specimens (potential false-positive diagnosis)

Although breast needle core biopsy (NCB) is now a standard diagnostic procedure in the triple assessment of screen-detected breast lesions, data on the false-positive diagnoses of malignancy (malignant NCB 'B5' with normal/benign surgery) are lacking. In this study, we have studied a large series of NCBs (101,440) to assess the causes and pitfalls resulting in false-positive NCB diagnoses and to evaluate their impact on patients' management in the screening service. Our results showed that of 40,395 malignant NCBs reported during the period of this study, 174 NCBs are considered as false-positives (0.43%; (95% confidence interval [CI]=0.37-0.49%)). However, on review, 165 cases (95%) were found to be the result of true removal of the whole lesion in the core with subsequent negative excision biopsy samples (true-positive NCBs). This may reflect sampling of small screen detected lesions and the use of larger core biopsies at assessment. The remaining 9 cases were considered as true false-positive cores, giving a false-positive rate of 0.02% (95% CI=0.01-0.04%). Analysis of these 9 cases showed that 8 cases, originally diagnosed as DCIS, were classified as borderline lesions or lesions of uncertain malignant potential after surgical excision. The classification and management of such borderline lesions remains controversial and diagnostic surgical excision is usually the optimum management. One case was the result of pathological misinterpretation of fat necrosis as invasive carcinoma. This was the only case that resulted in a significant over-management of the patient. In conclusion, our results showed that the true false-positive rate of NCB is extremely rare. Significant over-management of screen-detected breast lesions as a result of false-positive NCB may be considered almost nil.

[Histological modifications observed in prostate after preserving treatments for prostate cancer and their impact on Gleason score interpretation]

Total prostatectomy remains the main treatment for intermediate risk prostate cancer with a life expectancy greater than 10 years. In other cases non-surgical treatments can be proposed: external radiotherapy (exclusive or combined anti-androgen therapy), brachytherapy with permanent implants, high frequency ultrasounds (HIFU, Ablatherm), cryotherapy or exclusive hormonal treatment. For such patients in case of biological recurrence, prostate biopsies are usually performed in order to affirm the local recurrence. The histological confirmation of persistent tumor is usually required before any treatment: salvage surgery, cryotherapy, and brachytherapy or high intensity focused ultrasound (HIFU). Pathologists must be aware of the histological modifications induced by these different treatments in order to ensure an optimal interpretation of the biopsies. In this review, we describe the modifications observed in the normal prostate and in cancers after these various therapeutic methods, and also after alpha reductase inhibitors proposed as treatment of benign prostate hypertrophy and prostate cancer chemoprevention.

Vanishing Endometrial Carcinoma

Three cases of histologically proven endometrial carcinoma (EmCa) demonstrated no residual carcinoma or biopsy site on the subsequent hysterectomy specimen. The shared identity of both endometrial biopsy and hysterectomy specimen was proven, and specimen misidentification was excluded in all 3 cases through successful DNA profiling. Just as vanishing cancer in prostatic carcinoma has recently been defined and accepted, it is suggested that vanishing EmCa can also be defined using specific pathological and clinical criteria. DNA profiling may serve to confirm the diagnosis. Vanishing EmCa is only a small subset within hysterectomy specimens that show no EmCa after a histological diagnosis of EmCa. The concept of vanishing EmCa may be useful in both clinical and medicolegal practice.

Search for residual prostate cancer on pT0 radical prostatectomy after positive biopsy

Reported incidence of no residual prostate cancer (i.e. pathological stage pT0) on radical prostatectomy ranges from 0.07 to 4.2%. The incidence is higher after neoadjuvant endocrine treatment. The aim of this study was to search for residual cancer on radical prostatectomy (RP) specimens when an initial sampling failed to find the cancer in patients with positive biopsy. Our database of 1,328 consecutive patients whose biopsies and RP specimen were both examined at the Polytechnic University-United Hospitals of the Marche Region between March 1995 and June 2006 was reviewed. The radical prostatectomies were grossly completely sampled and examined with the whole mount technique. We identified eight patients (i.e. 0.6%; three untreated and five hormonally treated preoperatively, i.e. 0.3 and 0.8%, respectively, of the total number of RPs included in the study) with positive biopsy and with no residual cancer in the initial routine histological examination of the RP. The RP of this group of eight was subjected to additional sectioning and evaluation of the paraffin blocks of the prostatectomy, also after block-flipping, immunostaining with an antibody against CAM 5.2, p63, PSA, and alpha-methylacyl-CoA racemase, and DNA specimen identity analysis. There were no cases with a false positive biopsy diagnosis, and cancer was not overlooked or missed in the initial routine histological examination of any of the 8 pT0 RPs. A minute focus of cancer (the diameter was always below 2.0 mm) was found on the additional sections in five. In particular, cancer was found after block-flipping in one of them. In an additional case, cancer was eventually discovered after immunostaining tissue sections for cytokeratin CAM 5.2, for p63 and PSA. In the remaining two cases (one untreated and the other hormonally treated), cancer was not found (0.15% of the 1,328 RPs included in the study); the review of the description of the macroscopic appearance of the RP and of its slides revealed that part of the peripheral zone corresponding to the site of the positive biopsy was missing, i.e. not removed from the patient at the time of the operation at least in one of the two. DNA specimen analysis confirmed the identity of the biopsy and prostatectomy in both. An extensive search for residual cancer reduces the number of pT0 RPs after a positive biopsy from 0.6 to 0.15%. It is recommended to have the needle biopsy reviewed, carefully look again at the radical prostatectomy, do deeper sections and then flip certain paraffin blocks. In addition, atypical foci should be stained for basal cell markers and often AMACR, especially in hormone-treated cases. If a block is missing part of the peripheral zone (capsular incision), this should be commented on. DNA analysis for tissue identity should be performed when the other steps have been taken without finding cancer.

Photodynamic therapy using meso tetra hydroxy phenyl chlorin (mTHPC) in early prostate cancer

BACKGROUND AND OBJECTIVES

Prostate cancer is increasing in incidence, but current treatments including surgery and radiotherapy have significant side effects. This pilot study was designed to assess the potential of photodynamic therapy (PDT) using meso tetra hydroxy phenyl chlorin (mTHPC) for organ confined prostate cancer.

STUDY DESIGN/PATIENTS AND METHODS

Six men with organ confined prostate cancer were photosensitised with mTHPC (0.15 mg/kg). Between 2 and 5 days later, red light (652 nm) was delivered to areas of biopsy proven cancer via fibres inserted through transperineal needles (50-100 J per site).

RESULTS

After 8 of 10 PDT sessions, the prostate specific antigen (PSA) fell by up to 67%. Early MRI scans showed oedema and patchy necrosis, which resolved over 2 months. Biopsies of treated areas revealed necrosis and fibrosis at 1-2 months.

CONCLUSIONS

PDT for primary prostate cancer appears safe and can reduce PSA levels. As this was a phase I study, no attempt was made to treat the whole prostate; this or targeted tumour ablation could be attempted in a phase II study with an increased number of fibres. This technique merits further investigation in early prostate cancer.

Can pT0 Stage of Prostate Cancer be Predicted before Radical Prostatectomy?

OBJECTIVES

To report our experience with biopsy-proven pT0 prostate cancer over the last 10 yr.

METHODS

We retrospectively analysed a series of 1950 consecutive patients treated with radical prostatectomy (RP) for clinically localized prostate cancer between 1996 and 2005 at our institution. The patients without residual tumour on RP specimen were defined as pT0 patients. The group of pT0 patients was compared with a control group of 295 patients operated consecutively during the same period.

RESULTS

Overall, 11 (0.5%) patients were classified as pT0 on pathologic examination of the RP specimen. There was no pT0 tumour in the control group. Among the pT0 patients, five characteristics were particularly frequent: T1c clinical stage (90.9%), prostate-specific antigen (PSA) <or=15 ng/ml (90.9%), one positive biopsy core only (81.8%), biopsy Gleason score <7 (100%), and prostate weight >or=60 g (100%). All these characteristics were present in 8 of the 11 (72.7%) pT0 patients, while they were present in only 12 of the 295 (4.1%) controls. These parameters, when combined together, had a sensitivity of 72%, a specificity of 96%, and an accuracy of 99% for the prediction of pT0 stage. With a mean follow-up of 30 months after RP, no pT0 patient had clinical or biologic evidence of prostate cancer.

CONCLUSIONS

In our experience, the rate of pT0 tumours after RP is 0.5%. The combination of clinical stage, preoperative PSA, number of positive biopsy cores, Gleason score, and prostate weight could help to predict pT0 stage after RP.

No residual cancer on radical prostatectomy after positive 10-core biopsy: incidence, biopsy findings, and DNA specimen identity analysis

CONTEXT

It is uncertain whether extensive prostate-specific antigen (PSA) testing and extended biopsies currently performed will increase the incidence of no residual cancer on subsequent prostatectomy.

OBJECTIVE

To identify the incidence of cases with no residual cancer on prostatectomy after a positive 10-core biopsy and to review the clinical, biopsy, and prostatectomy findings and the results of specimen identity analysis.

DESIGN

We identified 9 patients with no residual cancer in 1351 consecutive prostatectomies and we reviewed the clinical, biopsy, and prostatectomy data from our institutional database. In 6 cases encountered after 2003, we also performed a polymerase chain reaction-based microsatellite analysis on formalin-fixed tissue to confirm the identity of the biopsies and prostatectomies.

RESULTS

All patients had positive biopsies in 1 or 2 cores: 1 in 7 and 2 in 2 patients (1 each, unilateral and bilateral). Mean total cancer length on biopsy measured 2.5 mm, which represented 1.7% of the total biopsy tissue. Gleason score 6 was found in 8 of 9 patients and 1 patient had Gleason score 9. Patients' age was 60.3 years, preoperative PSA was 6.0 ng/mL, and PSA density was 0.1 (all means). In 6 cases tested for microsatellite identity, the patient identity was confirmed.

CONCLUSIONS

Incidence of no residual cancer on prostatectomy of 0.67% after 10-core positive biopsy is higher than previously reported. In most cases, finding no residual cancer on prostatectomy after exhaustive work-up may indicate minimal patient disease. Microsatellite analysis provides a useful and cost-effective test in establishing specimen identity.

Comparing methods to measure error in gynecologic cytology and surgical pathology

CONTEXT

Both gynecologic cytology and surgical pathology use similar methods to measure diagnostic error, but differences exist between how these methods have been applied in the 2 fields.

OBJECTIVE

To compare the application of methods of error detection in gynecologic cytology and surgical pathology.

DATA SOURCES

Review of the literature.

CONCLUSIONS

There are several different approaches to measuring error, all of which have limitations. Measuring error using reproducibility as the gold standard is a common method to determine error. While error rates in gynecologic cytology are well characterized and methods for objectively assessing error in the legal setting have been developed, meaningful methods to measure error rates in clinical practice are not commonly used and little is known about the error rates in this setting. In contrast, in surgical pathology the error rates are not as well characterized and methods for assessing error in the legal setting are not as well defined, but methods to measure error in actual clinical practice have been characterized and preliminary data from these methods are now available concerning the error rates in this setting.

Micro-Focal Prostate Cancer: A Comparison of Biopsy and Radical Prostatectomy Specimen Features

OBJECTIVES

To study the pathologic features of radical prostatectomy (RP) specimens of patients operated on the basis of a potentially "Insignificant" prostate cancer (Ca P) characterized by one single focus (less than 3mm) of moderately differentiated adenocarcinoma - Gleason score < or =6, out of 6-10 biopsies and to determine which characteristics, if any, are predictive of the presence of a "non significant" prostate cancer in the specimen characterized by a low volume (<0.5 ml) moderately differentiated organ confined, cancer (Gleason score less than 6).

PATIENTS AND METHODS

PSA, biopsy features, and surgical specimens of a series of 56 patients submitted to RP for "insignificant Ca P" on TRUS prostate biopsies between 1988 and 2004 were compared regarding the number of tumor foci, Gleason grade and score, tumor volume determined by the cylinder method, as well as extraprostatic extension (EPE) and positive surgical margins (P.SM.).

RESULTS

70% of the patients had multifocal microfocal cancer apart from the index tumor. The presence of grade 4 was ignored by the biopsy in 50% of the cases, however the primary grade was correctly evaluated in more than 70% of the biopsy sets. 42% of the patients had a cancer volume less than 0.5 ml and 29% met the definition of insignificant/unimportant cancer characterized by a moderately differentiated (Gleason score < or =6) of low volume (less than 0.5 ml) however no feature accurately predictive of insignificant cancer could be individualized. In this whole series, only 8% of the patients had EPE. When the pre-operative PSA was <10 ng/ml, 98% of the patients had an organ confined tumor.

CONCLUSION

Patients diagnosed with prostate cancer on the basis of one single focus less than 3 mm of moderately differentiated (Gleason < or =6) prostate cancer have 30% of chances of harboring an insignificant tumor in their prostate and are therefore, at risk of being overtreated, however there is at this time no specific feature able to identify these patients pre operatively.