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

Gleason Grade Group 4 prostate biopsy with no cancer seen on final pathology in the magnetic resonance imaging and Prostate Specific Membrane Antigen-Positron Emission Tomography era

Introduction

The absence of prostate cancer on final surgical pathology after biopsy-proven prostate cancer is a rare finding.

Case presentation

Case of pT0 prostate cancer following Gleason Grade Group 4 in 1 out of 12 cores from a transrectal ultrasound-guided biopsy in a man who underwent both magnetic resonance imaging and 18F-PSMA-1007 Positron Emission Tomography prior to radical prostatectomy.

Conclusion

pT0 prostate cancer is rare. The use of novel imaging modalities may help in the workup of prostate cancer.

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.

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.

[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.

Urinary incontinence after radical prostatectomy - experience of the last 100 cases

Radical prostatectomy (RP) is a recognized treatment method of organ-confined prostate cancer. Among post-surgery complications, urinary incontinence is a major one. The aim of this study was to determine the incontinence rate after RP and to analyze factors that might affect it. Between March 2007 and December 2008, 132 RP's were performed at Warsaw Cancer Center. A questionnaire to assess the condition before and after RP was developed by the authors and sent to all treated patients. The questionnaire focused on health status information, function in urinary domain, rate of returning to "normal" activity level as before RP and satisfaction from the treatment. The median age of patients was 62 years. Out of 132 patients 102 subjects (77.2%) responded to the questionnaire. Of all responders, 35 patients (34.3%) reported total urinary continence after RP. After RP 35(34.3%) patients reported total urinary continence and in 55(53.9%) patients urinary incontinence of medium degree was present. In 12 (11.8%) patients significant urinary incontinence developed. The most common cause of urine dripping (82% of patients with any degree of urinary incontinence) was associated with abdominal muscle pressure. No statistically significant association between urinary incontinence and adjuvant radiotherapy after RP or the surgeon performing the RP was found (>0.79, >0.803). Radical prostatectomy carries a certain risk of complications. We observed an 88.2% rate of significant (total and moderate degree) urinary continence. The adjuvant radiotherapy and surgeons, who performed the RP, did not affect the rate of incontinence.

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.

[EAU guidelines on prostate cancer. Part I: screening, diagnosis, and treatment of clinically localised disease]

OBJECTIVE

Our aim was to present a summary of the 2010 version of the European Association of Urology (EAU) guidelines on the screening, diagnosis, and treatment of clinically localised cancer of the prostate (PCa).

METHODS

The working panel performed a literature review of the new data emerging from 2007 to 2010. The guidelines were updated, and level of evidence and grade of recommendation were added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.

RESULTS

A full version is available at the EAU office or Web site (www.uroweb.org). Current evidence is insufficient to warrant widespread population-based screening by prostate-specific antigen (PSA) for PCa. A systematic prostate biopsy under ultrasound guidance and local anaesthesia is the preferred diagnostic method. Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy. PSA doubling time in < 3 yr or a biopsy progression indicates the need for active intervention. In men with locally advanced PCa in whom local therapy is not mandatory, watchful waiting (WW) is a treatment alternative to androgen-deprivation therapy (ADT) with equivalent oncologic efficacy. Active treatment is mostly recommended for patients with localised disease and a long life expectancy with radical prostatectomy (RP) shown to be superior to WW in a prospective randomised trial. Nerve-sparing RP represents the approach of choice in organ-confined disease; neoadjuvant androgen deprivation demonstrates no improvement of outcome variables. Radiation therapy should be performed with at least 74Gy and 78Gy in low-risk and intermediate/high-risk PCa, respectively. For locally advanced disease, adjuvant ADT for 3 yr results in superior disease-specific and overall survival rates and represents the treatment of choice. Follow-up after local therapy is largely based on PSA, and a disease-specific history with imaging is indicated only when symptoms occur.

CONCLUSIONS

The knowledge in the field of PCa is rapidly changing. These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice.

Biopsy misidentification identified by DNA profiling in a large multicenter trial

PURPOSE

The Reduction by Dutasteride of Prostate Cancer Events (REDUCE) prostate cancer risk reduction study randomly assigned 8,231 men to dutasteride or placebo for 4 years. Protocol-mandated biopsies were obtained after 2 and 4 years. After the discovery of three cases of biopsy sample misidentification in the first 2 years, all protocol-mandated biopsy samples were DNA tested to verify biopsy identity.

METHODS

Biopsy and blood DNA profiling was performed retrospectively for the year 2 scheduled biopsies and prospectively for the year 4 scheduled biopsies. Toward the end of year 2, multiple changes were made to improve sample handling and chain of custody.

RESULTS

Of the 6,458 year 2 and 4,777 year 4 biopsies, 26 biopsies reflecting 13 sample handling errors at year 2 (0.4%) and one biopsy reflecting one sample handling error at year 4 (0.02%) were confirmed to be mismatched to the patient for whom they were originally submitted. Of 6,733 reference blood samples profiled, 31 (0.5%) were found to be mismatched to the patient's verified identity profile. Sample identification errors occurred at local research sites and central laboratories.

CONCLUSION

Biopsy misidentification is a potential problem in clinical laboratories and clinical trials. Until now, biopsy misidentification has not been studied in the setting of a large, multinational clinical trial. In the REDUCE study, process improvement initiatives halfway through the trial dramatically reduced biopsy mismatches. The potential for biopsy mismatches in clinical trials and clinical practice is an under-recognized problem that requires rigorous attention to details of chain of custody and consideration of more widespread DNA identity testing.

International Society of Urological Pathology (ISUP) Consensus Conference on Handling and Staging of Radical Prostatectomy Specimens. Working group 1: specimen handling

The 2009 International Society of Urological Pathology Consensus Conference in Boston made recommendations regarding the standardization of pathology reporting of radical prostatectomy specimens. Issues relating to the handling and processing of radical prostatectomy specimens were coordinated by working group 1. Most uropathologists followed similar procedures for fixation of radical prostatectomy specimens, with 51% of respondents transporting tissue in formalin. There was also consensus that the prostate weight without the seminal vesicles should be recorded. There was consensus that the surface of the prostate should be painted. It was agreed that both the prostate apex and base should be examined by the cone method with sagittal sectioning of the tissue sample. There was consensus that the gland should be fully fixed before sectioning. Both partial and complete embedding of prostates was considered to be acceptable as long as the method of partial embedding is stated. No consensus was determined regarding the necessity of weighing and measuring the length of the seminal vesicles, the preparation of whole mounts rather than standardized blocks and the methodology for sampling of fresh tissue for research purposes, and it was agreed that these should be left to the discretion of the working pathologist.

EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease

OBJECTIVE

Our aim was to present a summary of the 2010 version of the European Association of Urology (EAU) guidelines on the screening, diagnosis, and treatment of clinically localised cancer of the prostate (PCa).

METHODS

The working panel performed a literature review of the new data emerging from 2007 to 2010. The guidelines were updated, and level of evidence and grade of recommendation were added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.

RESULTS

A full version is available at the EAU office or Web site (www.uroweb.org). Current evidence is insufficient to warrant widespread population-based screening by prostate-specific antigen (PSA) for PCa. A systematic prostate biopsy under ultrasound guidance and local anaesthesia is the preferred diagnostic method. Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy. PSA doubling time in <3 yr or a biopsy progression indicates the need for active intervention. In men with locally advanced PCa in whom local therapy is not mandatory, watchful waiting (WW) is a treatment alternative to androgen-deprivation therapy (ADT) with equivalent oncologic efficacy. Active treatment is mostly recommended for patients with localised disease and a long life expectancy with radical prostatectomy (RP) shown to be superior to WW in a prospective randomised trial. Nerve-sparing RP represents the approach of choice in organ-confined disease; neoadjuvant androgen deprivation demonstrates no improvement of outcome variables. Radiation therapy should be performed with at least 74 Gy and 78 Gy in low-risk and intermediate/high-risk PCa, respectively. For locally advanced disease, adjuvant ADT for 3 yr results in superior disease-specific and overall survival rates and represents the treatment of choice. Follow-up after local therapy is largely based on PSA, and a disease-specific history with imaging is indicated only when symptoms occur.

CONCLUSIONS

The knowledge in the field of PCa is rapidly changing. These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice.

[Vanishing prostate cancer. Clinical presentation and histological review]

The impossibility to identify cancer in the final surgical specimen has been reported in some patients with prostate cancer undergoing radical prostatectomy. This has been attributed to either a wrong diagnosis or pathological technique, or to spontaneous or biopsy-induced cure of the tumor. This study assessed the incidence of vanishing prostate cancer in our department for 12 years, the clinical characteristics of patients, and their follow-up. The initial puncture biopsies were also re-evaluated using inmunohistochemical stains. Prostate cancer could not be confirmed in the surgical specimen in six out of 346 operated patients (1.73%) receiving no neoadjuvant therapy. When the initial biopsies were reviewed, cancer was only confirmed in three patients. Incidence of vanishing cancer at our department in the 12-year period considered was 0.86% (3/346). No tumor relapse occurred during 4.5 years of follow-up.

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.