UROLOGICAL SURVEY
Pathology
Bladder neck invasion is an independent predictor of prostate-specific antigen recurrence
Poulos CK, Koch MO, Eble JN, Daggy JK, Cheng L
Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, USA
Cancer. 2004; 101: 1563-8
BACKGROUND: The 1997 TNM staging systi for prostatic carcinoma and the 2002 revision thereof classified prostatic carcinoma with bladder neck involvient classified as pT4 disease. This classification is based on the belief that tumors that invade surrounding structures are more aggressive and warrant higher staging than tumors that do not invade surrounding structures. Recent reports in the literature suggested that microscopic involvient of the bladder neck does not carry independent prognostic significance. Therefore, resection specimens with bladder neck involvient should not be classified as pT4. The current study prospectively examined the prognostic significance of bladder neck involvient by prostatic carcinoma.
METHODS: The authors analyzed the totally ibedded and whole-mounted radical prostatectomy specimens from 364 consecutive patients. The mean patient age was 66 years (range, 41-77 years). The bladder neck, which had been coned from the specimen, was cut in a perpendicular fashion. Involvient of the bladder neck was defined as the presence of neoplastic cells within the smooth muscle bundles of the coned bladder neck. The data were prospectively collected. Bladder neck involvient was analyzed in relation to age, preoperative prostate-specific antigen (PSA) level, prostate weight, Gleason score, final pathologic classification, tumor volume, surgical margin status, the presence of high-grade prostate intraepithelial neoplasm, multifocality, siinal vesicle invasion, extraprostatic extension, perineural invasion, and PSA recurrence.
RESULTS: Bladder neck involvient was found in 22 (6%) of 364 patients. Univariate results indicated that bladder neck involvient versus no bladder neck involvient was significantly associated with preoperative PSA (P < 0.001), higher pathologic classification (P < 0.001), larger tumor volume (P < 0.001), extraprostatic extension (P < 0.001), positive surgical margins (P < 0.001), and PSA recurrence (P = 0.003). In a multivariate logistic regression model controlling for pathologic classification, Gleason score, and surgical margin status, bladder neck involvient was an independent predictor of PSA recurrence (P = 0.04). The adjusted odds ratio for bladder neck involvient was 3.3 (95% confidence interval, 1.04-10.03).
CONCLUSION: In the current study, bladder neck involvient was an independent predictor of early PSA recurrence. The data dionstrated the importance of continued assessment of bladder neck invasion and supported the placient of tumors with bladder neck involvient in a stage that recognizes the prognostic implications of such involvient.
Editorial Comment
Recent studies have questioned the high risk for disease recurrence in cases of bladder neck involvient by the prostate cancer (pT4 disease) (1-4). The risk of recurrence conferred with bladder neck invasion appears not to be different from that with extraprostatic extension (pT3a) or siinal vesical invasion (pT3b).
In a recent study based on patients submitted to radical prostatectomy at our institution (4), we found that bladder neck involvient correlates with pathologic unfavorable findings on radical prostatectomy specimens as well as to preoperative PSA levels. However, the PSA-recurrence risk associated with bladder neck involvient (pT4) was similar to extraprostatic extension (pT3a) and substantially lower than siinal vesicle invasion (pT3b). Our findings favor a need for downstaging of bladder neck involvient in the next version of the TNM staging systi.
The findings of Poulos et al. contradict our study and of other authors (1-4). The subject is controversial and diands further scrutiny. We believe that macroscopic or microscopic involvient of the bladder neck has different biologic implications. The original TNM classification considered as T4 the macroscopic involvient of the bladder neck. Today only microscopic involvient is seen on radical prostatectomies.
REFERENCES
1. Yossepowitch O, Engelstein D, Konichezky M, Sella A, Livne PM, Baniel J: Bladder neck involvient at radical prostatectomy: positive margins or advanced T4 disese? Urology. 2000; 56: 448-52.
2. Dash A, Sanda MG: Prostate cancer involving the bladder neck: recurrence-free survival and implications for AJCC staging modifications. Mod Pathol. 2002; 15: 159A.
3. Yossepowitch O, Sircar K, Scardino PT, Ohori M, Kattan MW, Wheeler TM, et al.: Bladder neck involvient in pathological stage pT4 radical prostatectomy specimens is not an independent prognostic factor. J Urol. 2002; 68: 2011-15.
4. Billis A, Freitas LLL, Magna LA: Prostate cancer with bladder neck involvient: pathologic findings with application of a new practical method for tumor extent evaluation and recurrence-free survival after radical prostatectomy. Int Urol Nephrol. (in press).
Dr. Athanase Billis
Full-Professor of Pathology
State University of Campinas, Unicamp
Campinas, São Paulo, Brazil
Prostate needle biopsies: multiple variables are predictive of final tumor volume in radical prostatectomy specimens
Poulos CK, Daggy JK, Cheng L
Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
Cancer. 2004; 101: 527-32
BACKGROUND: Tumor volume is one of the most powerful predictors of patient outcome in prostatic adenocarcinoma. It is uncertain as to which preoperative variables are most predictive of final tumor volume at radical prostatectomy, especially among patients who have had positive biopsies at multiple biopsy sites. The current study attipted to identify the biopsy variables that are most predictive of final tumor volume.
METHODS: The authors examined prostate biopsy specimens from 151 consecutive patients with at least 2 positive biopsy sites. The following data were collected: highest percentage of adenocarcinoma at any biopsy site, percentage of adenocarcinoma at the biopsy site with the highest Gleason score, highest percentage of cores positive for adenocarcinoma at any biopsy site, percentage of positive cores with carcinoma at the site with the highest Gleason score, number of positive sites, tumor bilaterality, and percentage of biopsy sites positive for disease. All patients underwent radical prostatectomy. The prostatectomy specimens were entirely ibedded and whole mounted. Tumor volume was measured using the grid method. Logarithmic transformation was applied to tumor volumes for the purposes of the analysis.
RESULTS: Highest percentage of adenocarcinoma at any biopsy site (P = 0.012), percentage of adenocarcinoma at the biopsy site with the highest Gleason score (P = 0.021), number of positive biopsy sites (P = 0.026), tumor bilaterality (P = 0.008), and percentage of biopsy sites positive for disease (P = 0.0001) all were significant predictors of tumor volume on linear regression analysis. Highest percentage of cores positive for adenocarcinoma (P = 0.081) and percentage of positive cores with carcinoma at the site with the highest Gleason score (P = 0.240) were not significant predictors of tumor volume. Based on the model F statistic, percentage of biopsy sites positive for tumor, tumor bilaterality, and highest percentage of adenocarcinoma at any biopsy site were the variables that were most predictive of tumor volume.
CONCLUSION: Highest percentage of adenocarcinoma at any biopsy site, percentage of adenocarcinoma at the biopsy site with the highest Gleason score, number of positive biopsy sites, tumor bilaterality, and percentage of biopsy sites positive for disease all are useful preoperative predictors of tumor volume in radical prostatectomy specimens. Although these preoperative biopsy parameters were significant in linear regression models, none was sufficient as a single predictor of tumor volume.
Editorial Comment
The study by Poulos et al. showed that multiple pathologic findings seen in needle biopsies are predictive of final volume in radical prostatectomy specimens. The authors used the grid method for measuring tumor volume. Some institutions have calculated the tumor volume accurately, using computer-assisted image analysis systis. Because this method is not feasible for the routine clinical practice, other investigators have proposed alternative simpler means. The grid method is one of these alternative simpler means that measures tumor extent.
A number of studies have documented that the tumor extent, the volume or the percentage of prostatic tissue involved by the tumor within the prostate gland may be important prognostic indicators. However, the subject is controversial. Although most authors agree that tumor extension (percentage of carcinoma or tumor volume) in patients with prostate carcinoma should be reported in radical prostatectomies because of its prognostic importance, in some analyses, tumor size has not been considered to be an independent predictor of tumor recurrence (1,2).
REFERENCES
1. Esptein JI, Carmichael M, Partin AW, Walsh PC: Is tumor volume an independent predictor of progression following radical prostatectomy? A multivariate analysis of 185 clinical stage B adenocarcinoma of the prostate with 5 years of follow-up. J Urol. 1993; 149: 1478-85.
2. Billis A, Magna LA, Ferreira U: Correlation between tumor extent in radical prostatectomies and preoperative PSA, histological grade, surgical margins, and extraprostatic extension: application of a new practical method for tumor extent evaluation. International Int Braz J Urol. 2003; 29: 113-20.
Dr. Athanase Billis
Full-Professor of Pathology
State University of Campinas, Unicamp
Campinas, São Paulo, Brazil
Publication Dates
-
Publication in this collection
24 Nov 2004 -
Date of issue
Oct 2004
