Impact of prostate weight on radical prostatectomy outcomes

BACKGROUND

The management of localized prostate cancer in patients with large prostates is controversial.

OBJECTIVES

To investigate the impact of prostate weight on radical prostatectomy outcomes.

METHODS

The files of 244 patients who underwent radical prostatectomy were reviewed. Data were collected on patient and tumor characteristics and on oncological, urinary and erectile function outcomes. Results were compared between patients with prostates weighing < or = 60 g or > 60 g.

RESULTS

A prostate weight of > 60 g was documented in 25% of the patients. There was no difference in clinical stage distribution between patients with smaller and patients with larger prostates. Patients with a larger prostate were characterized preoperatively by higher levels of prostatespecific antigen (9.8 vs. 7.3 ng/ml, P = 0.009), lower tumor grade (biopsy Gleason score < or = 6: 77.6% vs. 90.2% P = 0.04), and a higher incidence of moderate-severe urinary symptoms (69.8 vs. 38.8%, P = 0.0003). Analysis of pathological stage distribution yielded a higher proportion of lower stage disease and a lower incidence of positive margins in the large-prostate group (11.7 vs. 25.8%, P = 0.024). There were no statistically significant between-group differences in the rate of persistent postoperative detectable PSA, biochemical recurrence, urinary incontinence and erectile function.

CONCLUSIONS

The outcomes of radical prostatectomy in patients with large prostate are favorable in terms of cancer characteristics despite their higher preoperative PSA levels, and comparable to that in patients with small prostate in terms of urinary continence and erectile function. Surgery may be particularly beneficial in patients with preoperative urinary symptoms. Hence, radical prostatectomy should not be discouraged as a treatment for localized prostate cancer in patients with sizeable prostates.

Prediction of Extravesical Disease by Preoperative Serum Markers in Patients With Clinically Organ Confined Invasive Bladder Cancer

PURPOSE

We assessed the value of preoperative levels of CEA, CA-125 or CA 19-9 in patients with clinically organ confined bladder cancer to predict pathological extravesical and/or node positive disease.

MATERIALS AND METHODS

Serum levels of CEA, CA-125 and CA 19-9 were measured prospectively in all patients scheduled for cystectomy for clinically organ confined bladder cancer between September 1999 and May 2004. Biomarker expression was compared between patients with pathologically organ confined disease (pT2 or less, pN0) and patients with extravesical disease (greater than pT2, or pN1 or greater), and between patients with pathologically node negative (any pT, pN0) and node positive disease (any pT, pN1 or greater).

RESULTS

Of the 91 patients enrolled, 46 had (51%) pathologically organ confined tumors, 45 (49%) had extravesical disease and 17 (19%) had positive lymph nodes. Preoperative serum levels of all markers were significantly higher in cases of extravesical disease than in organ confined disease. On multivariate analysis CEA with an odds ratio of 8.6 (95% CI 1.51-48.6) and CA-125 with an OR of 29.5 (95% CI 3.6-242.6) proved independent predictors of extravesical disease. CA-125 and CA 19-9 levels were significantly higher in patients with node positive disease than in those with node negative disease. On multivariate analysis CA-125 with an OR of 22.2 (95% CI 3.8-129) and CA 19-9 with an OR of 5.2 (95% CI 1.09-24.76) proved independent predictors of node positive disease.

CONCLUSIONS

Increase in serum tumor markers before cystectomy in patients with clinically organ confined muscle invasive bladder cancer is a strong indicator of the presence of extravesical and node positive disease.

Incidental testicular tumors in infertile men

OBJECTIVE

To characterize the population of infertile men with an incidental finding of testicular tumor diagnosed during infertility work-up and to describe their unique presentation and pathological findings.

DESIGN

Retrospective study of 11 men in whom a testicular tumor was incidentally diagnosed during evaluation for infertility out of 150 patients who underwent orchiectomy over a 10-year period (1992 to 2002).

SETTING

University-affiliated urologic referral center.

PATIENT(S)

Infertile men with an incidental testicular mass who underwent radical orchiectomy.

INTERVENTION(S)

Description of patient characteristics: age at diagnosis, presentation, history of undescended testis, and type of infertility.

MAIN OUTCOME MEASURE(S)

Tumor size and location and pathological diagnosis.

RESULT(S)

Eleven patients met the study's inclusion criteria, 11 tumors were identified and characterized. The tumors were usually small, centrally located and nonpalpable. Histologically, six were malignant germ-cell tumors and three were Leydig-cell tumors; two patients had no histologic evidence of tumor. All patients with a history of undescended testis had malignant germ-cell tumors.

CONCLUSION(S)

The use of trans-scrotal sonography enables early diagnosis of small nonpalpable tumors. A history of an undescended testis may necessitate a more aggressive approach, as these patients are at increased risk for testis cancer. Further studies are warranted to establish the yield of routine sonographic screening of infertile men and their specific management.

Neck-dissection surgical specimens treated by lymph node revealing solution

The detection of metastatic lymph nodes in cancer patients is essential for determining the cancer stage, and thus, the therapeutic modalities. However, very small lymph nodes can easily be missed during routine examination. We described a "Lymph Node Revealing Solution" (LNRS) that helps to detect tiny lymph nodes in neck dissection specimens. Twenty-one consecutive specimens of neck-dissection were investigated. The entire surgical specimen, fixed at first in formalin, was searched for lymph nodes by the traditional method. These were excised and sent for processing. The remaining tissue was immersed for 24 hours in LNRS. The lymph nodes stood out as white chalky nodules on the background of the yellow fat. They were then excised, and examined. A total of 227 lymph nodes were detected by the traditional method; 38 (17%) were positive for metastasis. Using the LNRS method, an additional 72 nodes were identified, among them 8 (11%) were positive for metastases and 2 cases were upstaged. LNRS is an inexpensive and easy method of detecting tiny lymph nodes; it enhances significantly the yield of normal and metastatic nodes of neck-dissection specimens and helps to establish a more accurate staging.

Combination chemotherapy following adrenal suppression in androgen- independent prostate cancer

OBJECTIVES

Recent trials with modern chemotherapy have demonstrated activity in androgen-independent prostate cancer, but all focused on patients with progression following androgen suppression or antiandrogen withdrawal. Limited data are available on the activity of chemotherapy in androgen-independent, hormone-refractory (progressing following adrenal suppression) prostate cancer. We evaluated the activity of estramustine combined with vinblastine in this subset of androgen-independent prostate cancer.

METHODS

From January 1995 until April 1999, 19 patients with hormone-refractory prostate cancer received estramustine 140 mg p.o., three times daily along with weekly vinblastine 5 mg/m(2).

RESULTS

A decrease in prostate-specific antigen of 50% or more was noted in 12 patients (63.1%, 95% CI 38.3-83.7%). The median decrease in prostate-specific antigen was 71.2% (range 50.5-85.2%). None of the 7 patients with measurable soft-tissue disease showed an objective response. The median survival from onset of chemotherapy was 6 (range 1.4-27.7) months and from initiation of adrenal suppression 16.9 (range 3.8-40. 5) months.

CONCLUSIONS

The combination of estramustine and vinblastine is capable of inducing activity in androgen-independent prostate cancer progressing after adrenal suppression. In our small sample, the survival rate was low, and we obtained no response in soft-tissue sites. Future prospective trials are needed to determine the benefit of sequential versus simultaneous incorporation of adrenal suppression with chemotherapy in the management of androgen-independent prostate cancer.

Low PSA metastatic androgen- independent prostate cancer

OBJECTIVES

To describe the clinical parameters of low PSA, progressive metastatic androgen-independent prostate cancer.

METHODS

From April 1995 to May 1999, we selected 18 patients with clinically progressive androgen-independent prostate cancer and low PSA (</=10 ng/ml). Patients received cisplatin-based therapy. Specimens from the primary tumor were reviewed and neuroendocrine differentiation was determined with chromogranin-A and neuron-specific enolase immunocytochemical staining.

RESULTS

The median initial PSA level was 1.6 ng/ml (0-9.5). Each patient demonstrated elevation of at least one of the following markers: carcinoembryonic antigen, CA 19-9, CA15-3 and CA 125 CA. Metastases involved bone in 11 patients (61.1%) - 5 (27.7%) blastic, 2 (11.1%) lytic, and 4 (22.2%) combined - liver in 10 patients (55.5%), lymph nodes in 8 (44.4%), and lung in 6 (33.3%); solitary sites as orbit, skin and spleen were noted as well. A prostatic pelvic mass was detected in 13 patients (72.2%). Of the 12 patients who consented to chemotherapy, 8 (66.6%) achieved an objective response (95% CI, 34. 8-90%), including 1 patient with complete response. Hematoxylin and eosin evaluation revealed two major groups: neuroendocrine tumors, either pure small cell cancer in 6 patients (37.5%) or combined small cell cancer and adenocarcinoma in 8 (50%), and predominant poorly differentiated prostate cancer in 2 (12.5%). Neuroendocrine immunoreactivity was detected in all the specimens.

CONCLUSIONS

Progressive androgen-independent prostate cancer with low serum PSA is characterized by visceral metastases, high proportion of lytic bone disease, sensitivity to cisplatin-based chemotherapy, and histological features of small cell or poorly differentiated prostate cancer. In this subgroup of patients, selection of the therapeutic approach can be based on clinical parameters. The rise of the serum markers may aid in the diagnosis and follow-up of these patients.

Bladder neck involvement at radical prostatectomy: positive margins or advanced T4 disease?

OBJECTIVES

To assess the prognosis of patients with bladder neck (BN) involvement in radical prostatectomy specimens and compare it with patients with seminal vesicle invasion (SVI) presumed to have an inferior stage according to the TNM classification.

METHODS

Two hundred eighty-six case files of consecutive radical prostatectomies were reviewed. The records of patients with pathologic BN involvement (pT4a) or SVI (pT3c) were thoroughly analyzed and compared. The mean and median follow-up periods were 30.8 and 35.5 months (range 9 to 40), respectively, for the patients with Stage pT4a and 40.8 and 44.1 months (range 8 to 86), respectively, for the patients with Stage pT3c. Particular attention was paid to the preoperative clinical and pathologic evaluation, the pathologic analysis of the prostatectomy specimen, and the postoperative follow-up data. Progression was defined as a prostate-specific antigen level of 0.2 ng/mL and rising. Adjuvant therapy was not initiated unless prostate-specific antigen failure had occurred.

RESULTS

BN involvement was identified in 25 patients (8.7%) and SVI was found in 26 patients (9.1%). In 7 patients (2.4%), the BN was the only site of positive margins. Thirty-six percent of patients with BN involvement and 62% of patients with SVI demonstrated biochemical progression. Disease-free survival and metastasis-free survival rates were significantly better for the patients with Stage pT4a than for the patients with Stage pT3c at 24 and 36 months after surgery. Univariate analysis identified the prostate-specific antigen nadir to be the most significant predictor of prognosis.

CONCLUSIONS

In this study, BN involvement in the surgical specimen carried a lower risk of progression than SVI. On the basis of our preliminary results and those in other studies, a conceivable downstaging of BN involvement in the TNM staging system should be considered. Possibly, additional modification of the TNM staging system should be contemplated on the basis of the results of pathologic analysis and prognosis. The significance of BN involvement and the role of adjuvant therapy in this group of patients need further evaluation.

Involvement of internal genitalia in female patients undergoing radical cystectomy for bladder cancer: a clinicopathologic study of 37 cases

Radical cystectomy for invasive bladder cancer in female patients implies anterior pelvic exenteration. The necessity for routine removal of all internal female genitalia has not, as yet, been investigated. The present study was conducted to investigate the involvement of internal genitalia in these patients. Cystectomy specimens from 37 consecutive female patients with bladder cancer were examined for internal genitalia and urethral involvement. Clinical data were retrospectively collected from hospital charts. Thirty-four patients were available for postoperative follow-up. Of the 37 cases, 30 were transitional cell carcinoma (TCC), 4 squamous cell carcinoma, 1 adenocarcinoma, and 2 undifferentiated carcinoma. Uterine involvement was observed in only 1 case: TCC, stage D1, grade IV. All patients had normal ovaries and a normal vagina regardless of tumor site or stage; however, late ovarian and vaginal recurrences developed in one patient, in whom one ovary had been preserved. Sixteen percent of the patients had urethral involvement. We conclude that synchronous or metachronous involvement of female internal genitalia in bladder cancer is uncommon. Preservation of ovaries and vagina in young patients undergoing radical cystectomy may be considered under strict criteria.

Metachronous renal cell carcinoma metastasis to the contralateral adrenal gland

OBJECTIVES

Metachronous metastasis of renal cell carcinoma to the contralateral adrenal gland is very rare. We review our experience with 5 such patients and compare it with reports in the literature.

METHODS

The records of all 350 patients who underwent nephrectomy for renal cell carcinoma in our center between 1975 and 1992 were reviewed. Five patients were found to have had solitary metachronous metastases to the contralateral adrenal gland on follow-up.

RESULTS

The adrenal metastasis was discovered 18 to 210 months (mean 66.8) after nephrectomy. In 2 patients the lesion was found incidentally on routine computed tomography scan; in the other 3 patients, diagnosis was by ultrasonography, performed because of flank pain and weight loss or routine follow-up. All patients underwent adrenalectomy. Survival ranged from 8 to 64 months (mean 36.4); 3 patients had no evidence of disease at 42, 44, and 64 months postoperatively, and 2 patients died of pulmonary metastasis at 8 and 24 months. Analysis of the clinical data of our 5 patients together with the 9 we found in the published reports revealed that the mean interval between nephrectomy and the appearance of adrenal metastasis was shorter in the patients who died.

CONCLUSIONS

The results of adrenalectomy for metachronous metastasis of renal cell carcinoma to the contralateral adrenal gland are unpredictable. The prognosis is somewhat better when the mean interval between the nephrectomy and the appearance of the adrenal metastasis is longer than 18 months. We recommend adrenalectomy because long-term survival is expected in some of these patients.

Testicular mass as a presenting symptom of isolated polyarteritis nodosa

Isolated polyarteritis nodosa (PAN) of the male testes has rarely been reported. The authors describe two young men with testicular mass as a presenting symptom of isolated PAN, which was diagnosed following orchiectomy. The clinical features of the reported cases are reviewed.

Metachronous bladder tumors in patients with upper urinary tract transitional cell carcinoma

Sixty-nine patients who underwent nephroureterectomy for upper urinary tract transitional cell carcinoma were included in the study. The following data were collected for each patient: grade and stage of renal/ureteral tumor, tumor location, timing of tumor appearance and recurrence in the bladder, grade and stage of each of the recurrent tumors, and number of recurrences. Follow-up ranged between 2 and 15 years. Thirty-three patients (47.8%) developed metachronous bladder tumors. The appearance of the bladder tumors was related to tumor grade and multifocality of the upper urinary tract TCC. Of the 33 patients, 19 had 1 tumor appearance in the bladder, 6 had 2 recurrences, and 8 had 3 recurrences. The 5-year survival rate for patients with no subsequent bladder tumors was 57% compared to 22% for those who had subsequent tumors. It is concluded that the appearance of bladder tumors following nephroureterectomy characterizes a group of patients with biologically more active disease with unfavorable prognosis.

A comparison between digitally-guided fine needle aspiration and ultrasound-guided transperineal core needle biopsy of the prostate for the detection of prostate cancer

OBJECTIVE

To prospectively examine the accuracy of fine needle aspiration (FNA) for the detection of prostate cancer. Ultrasound-guided core needle biopsy of the prostate was used as the standard to which the FNA results were compared.

PATIENTS AND METHODS

One-hundred patients who had been referred for urological evaluation were suspected of having prostate cancer on the basis of digital rectal examination (DRE) and/or transrectal ultrasound (TRUS). All were further evaluated by digitally guided transrectal FNA and by TRUS-guided transperineal core needle biopsy.

RESULTS

Prostate cancer was identified in 54 patients by core needle biopsy and in 45 by FNA. The sensitivity of FNA was 81% and both specificity and positive predictive value were 98%.

CONCLUSION

FNA is easily performed, has negligible morbidity and offers prompt results. These data suggest that FNA is a reasonable initial diagnostic procedure for the detection of prostate cancer. Core needle biopsy may be reserved for patients with negative cytology who are clinically suspected of having prostate cancer. In selected patients, FNA may be used as an alternative to core needle biopsy for diagnosis, treatment planning and follow-up.

Immediate vasoactive effect of citral on the adolescent rat ventral prostate

The vasoactive effect of a fragrance compound, citral, on rat ventral prostate is presented. A combined method of Indian-ink perfusion and postfixation transparency was used. One single dose of citral applied on the back skin of the rat induced an immediate triple response-like effect on the prostatic vascular bed. A slight vasodilatation appeared already after 2 1/2 min, followed by a marked vasoconstriction process after 5-min postcitral administration. Toward the period of 10 min, a second vasodilatation process was noted which persisted for the following 24 hr of observation. This study has demonstrated that changes in the microvascularization of the rat prostate can be estimated by counting the number of carbon-stained blood vessels. The results obtained by this technique are closely related with the findings in the vascular network profile of the macroangiographic observations. The mechanism of action of citral on the microvascularization of the rat ventral prostate is yet unknown. Based on the present findings, we suggest that the neoplastic capacity of citral upon the prostatic epithelia is activated via a nonspecific inflammatory reaction modulated either by local release of neurotransmitters or throughout a direct effect of citral on the endothelial cells.

Clinical and pathological findings in prostates following intravesical bacillus Calmette-Guerin instillations

The prostates of 36 patients who were treated with intravesical bacillus Calmette-Guerin were evaluated by digital rectal examination and transrectal ultrasonography. When abnormal palpatory and/or ultrasonographic findings were detected, core needle biopsies from the suspicious areas were performed. Of the 36 patients 20 underwent biopsies of the prostate. Pathological findings revealed typical granulomas in 8 patients (3 caseating and 5 noncaseating multifocal granulomas). Nonspecific chronic prostatitis was noted in 4 patients and benign prostatic hyperplasia was noted in 8. The number of bacillus Calmette-Guerin instillations ranged from 6 to 19. The interval from initiation of therapy to biopsy ranged from 1.5 to 14.5 months. Caseating granulomas were found during the early course of bacillus Calmette-Guerin instillations (1.5 to 3.0 months), whereas noncaseating granulomas were detected at later stages (4 to 14.5 months). These findings present a high incidence of granuloma formation in patients treated with intravesical bacillus Calmette-Guerin. The duration of therapy is a determinant factor in the induction of granuloma type.

The expression of HLA class I antigens in germ cell testicular cancer

The expression of HLA class I antigens in testicular germ cell tumors (TGCTs) was studied by the immunoperoxidase technique. In the normal testicle, the interstitial cells of Leydig as well as most of the germ cells were significantly stained. In typical seminoma, 75% of the tumor cells in stage I and 30% in stage II were stained. In embryonal cell carcinoma, 25% of the cases in stage I and less than 10% of those in stage II were stained. Mature teratoma was stained in most of the cases, whereas in malignant teratoma only 35% of the cases showed some staining of the tumor cells. In mixed tumors each component displayed its characteristic staining pattern. The expression of class I antigens on tumor cells is required for immune recognition and lysis of the tumor by cytotoxic T-cells. The reduced expression of class I antigens that was related to histologic characteristics and stage suggests that some testicular tumors may escape immune surveillance and become biologically more aggressive.

Incidental small renal tumors accompanying clinically overt renal cell carcinoma

We searched 66 kidneys with renal cell carcinoma for subcapsular or intraparenchymal small nodules in the apparently normal-appearing portion of the kidney. Differentiation between adenoma and carcinoma was done according to histological characteristics. Of the 66 kidneys 20 (30 per cent) contained a total of 58 small nodules ranging from 1 to 15 mm. in diameter. In 9 kidneys the lesions were consistent histologically with carcinoma, in 7 with adenoma and in 4 with carcinoma plus adenoma. Thus, 13 of the 66 kidneys (19.7 per cent) contained small carcinoma. In view of the high incidence of small carcinoma accompanying clinically overt renal cell carcinoma, we suggest that the indications for partial nephrectomy in the management of renal cell carcinoma should be reevaluated.

Osteoclast-type giant cell tumor of the pancreas. Case report

Local resection of a 1200 g, apparently inoperable pancreatic mass was performed on an elderly woman. Because she survived for more than 6 years without recurrence or metastases, the specimens were reviewed. They were compatible with giant cell tumor of osteoclast type. Correct diagnosis of this unusual tumor is important because of its seemingly favorable prognosis.

Pure squamous cell carcinoma and mixed adenosquamous cell carcinoma of the thyroid gland

Four cases of pure squamous cell carcinoma and two cases of mixed squamous cell and glandular carcinoma are reported. Obviously, there is a possibility that squamous cell carcinoma of the thyroid gland develops from the existing squamous cells or as a result of metaplasia of follicular cells. Metastases and direct extension of squamous cell carcinoma in the thyroid gland are much more frequent and must be excluded before the diagnosis can be established. Although the gross and microscopic pathology of these lesions presents no unusual features, follicles lined by metaplastic squamous cells offer strong presumptive evidence of a primary thyroid neoplasm. These tumors are comparatively radioresistant and biologically highly malignant. The treatment of choice is radical surgical resection, and these neoplasms must be treated more aggressively in the initial stage.

Benign angiomyoma of the uterus with unusual macroscopic appearance

Benign mixed uterine tumors are very rare. We present a case of angiomyoma of the uterus with unusual gross appearance and diffuse polypoid growth on the uterine serosal surface. We could not find a macroscopic picture like this described in the literature.