Faruk Ozcan

Discrepancy between Gleason Scores of Biopsy and Radical Prostatectomy Specimens

Objective: The grade of the prostate cancer is an important factor in defining prognosis and deciding on treatment. In this study, we compared the Gleason score determined by 18–gauge core needle biopsies with both the Gleason score and pathological staging of the radical prostatectomy specimens.Patients and Methods: Between July 1992 and September 1998, we performed 144 radical retropubic prostatectomies for clinically localized prostatic carcinoma, after a negative frozen section in bilateral pelvic lymphadenectomy in all cases. Ten patients with pathologic stage T1a and T1b were excluded. The final study group consisted of 134 patients, all of whom had been diagnosed with adenocarcinoma by transrectal needle biopsies with an 18–gauge automated spring–loaded biopsy gun. No patients received neoadjuvant therapy, including androgen deprivation and radiation therapy. All patients had a designated Gleason score on the needle biopsy and prostatectomy specimens.Results: We found that grading error was greatest with well–differentiated (Gleason score 2–4) tumors, The accuracy was 15% for Gleason score 2–4 on needle biopsy. Of the 113 evaluable patients with Gleason score 5–7 on needle biopsy, 110 (97%) were graded correctly. All of the Gleason score 8–10 on needle biopsy was graded correctly. But only 1 patient in our series had Gleason score 8 on needle biopsy. Twenty–seven (25%) of 110 patients with a biopsy grade of Gleason score <7 had the cancer upgraded to 7. Of patients with both Gleason score <7 in the needle biopsy and Gleason score 7 in the prostatectomy specimen, only 3 (11%) had tumor confined to the prostate.Conclusion: The potential for grading error is greatest with well–differentiated tumors and of patients with both Gleason scores <7 in the needle biopsy and Gleason score 7 in the prostatectomy specimen, only 11% had tumor confined to the prostate. This effects treatment policy, especially for watchful waiting criteria.

Correlation of Perineural Invasion on Radical Prostatectomy Specimens with Other Pathologic Prognostic Factors and PSA Failure

OBJECTIVE The aim of this study is to evaluate the relationship between perineural invasion (PNI) and other pathologic prognostic factors in radical retropubic prostatectomy (RRP) specimens and also to assess the role of PNI in prostate-specific antigen (PSA) recurrence after RRP. METHOD 191 consecutive patients had undergone RRP for clinically localized prostate cancer between 1992 and 2000. PNI in RRP specimens and its relation to histopathologic stage and surgical margins is investigated retrospectively. PNI, histopathologic stage, surgical margin status, Gleason score and PSA parameters were used as variables in multivariate analysis for recurrence. RESULTS PNI is correlated statistically significantly with histopathologic stage, positive surgical margins, specimen Gleason score and recurrence. Mean time to failure was earlier in patients with PNI than patients without PNI (56 vs. 73 months, log-rank 15.67, p<0.001). Lymph node involvement, positive surgical margins and PNI remained as independent predictors of recurrence in multivariate analysis. All patients with PNI, positive surgical margins and lymph node metastasis failed in 6 months. CONCLUSION PNI is an important prognostic factor that should be taken into consideration in clinical patient management and follow-up after RRP. The presence of PNI together with positive surgical margins and lymph node metastasis may warrant early adjuvant treatment.

Expression of E-cadherin in prostate cancer in formalin-fixed, paraffin-embedded tissues: correlation with pathological features

Aims: E‐cadherin has been studied recently as a potential marker for tumour progression. The present study aimed to assess the expression of E‐cadherin in formalin‐fixed and paraffin‐embedded radical prostatectomy specimens and to compare its expression with the pathological stage and Gleason score. Methods: This study comprised a total of 58 men who were selected on the basis of the negative surgical margins of surgical specimens from radical retropubic prostatectomies and concomitant pelvic lymph node dissections. Indirect immunoperoxidase staining was performed as described previously using HECD‐1 monoclonal antibody with the retrieval of antigen by treatment of the paraffin‐embedded tissue with microwaves in citrate buffer. Results: Aberrant staining patterns of E‐cadherin were observed in 18 (64%) and in 25 (83%) of cases with pathological stages pT2 and pT3a, respectively ( P > 0.05). Immunohistochemical examination also revealed aberrant staining patterns of E‐cadherin in 16 (89%) of specimens with Gleason score S 7 and in 27 (68%) of specimens with Gleason score < 7 ( P > 0.05). Biochemical recurrence was identified in three (5%) patients and immunohistochemical examination of their specimens revealed aberrant staining patterns of E‐cadherin molecule in all of them. Conclusion: Our preliminary results indicate that, even though we could not demonstrate any significant correlation between E‐cadherin staining pattern and tumour invasion and Gleason scores, aberrant staining patterns of E‐cadherin may be a significant predictor for disease recurrence following radical prostatectomies if supported by large scale studies.

Response Rates and Adverse Effects of Continuous Once-daily Sunitinib in Patients with Advanced Renal Cell Carcinoma: A Single-center Study in Turkey

OBJECTIVE Therapy targeted against the vascular endothelial growth factor pathway is a standard of care for patients with metastatic renal cell carcinoma. This study assessed the response rates and toxicity profiles of sunitinib on a continuous once-daily dosing regimen in Turkish patients with metastatic renal cell carcinoma. METHODS Between April 2006 and August 2010, 74 patients with metastatic renal cell carcinoma who received sunitinib on a continuous, once-daily dosing regimen were included. Sunitinib was administered daily at a dose of either 37.5 mg (94% of the patients) or 25 mg (6% of the patients), without interruption, either as a second-line treatment after interferon-α or as a first-line treatment. Response, toxicity, progression-free survival and overall survival were evaluated. RESULTS Of the 74 patients, 65 (88%) were diagnosed with clear cell renal cell carcinoma. The median treatment duration was 10 months (range, 2-42 months). The most common treatment-related adverse events were fatigue (75%), stomatitis (51%) and hypertension (50%). The most common Grade 3 or 4 adverse events were anemia (10%) and hand-foot syndrome (7%). Dose reductions were required in 50% of the patients, and early treatment discontinuation was necessary in 16% of the patients. Cardiovascular events were the most common adverse events that resulted in drug discontinuation. The objective response rate and the disease control rate were 30 and 78%, respectively. The median progression-free survival and overall survival were 13 and 25 months, respectively. CONCLUSIONS Continuous, once-daily administration of sunitinib was generally well tolerated in Turkish patients with advanced renal cell carcinoma in a daily practice setting. This studys response rates were comparable to those in previous randomized trials.

Lymph nodal involvement by renal angiomyolipoma

Angiomyolipoma of the kidney is a clonal neoplasm, apparently part of a family of neoplasms derived from perivascular epithelial cells. A 40‐year‐old woman presented with right flank pain and an otherwise non‐significant medical history. An abdominal computed tomography scan revealed an 18 cm solid mass in the mid‐portion of the right kidney and multiple perihilar lymph nodes. Presumptive diagnosis was renal cell carcinoma. Right radical nephrectomy and a perihilar lymph node dissection was performed through a Chevron incision for the anticipated diagnosis of renal adenocarcinoma. The renal tumor was diagnosed as angiomyolipoma and a component was identified pathologically in a dissected lymph node. There was no evidence of tumor recurrence in the follow‐up period of eight years. The consensus from other studies suggests that this phenomenon is a manifestation of the multicentric nature of angiomyolipoma, rather than due to metastasis. Genetic studies may resolve this question in the future.

Treatment of penile incarceration in an impotent patient

We report a case of penile incarceration in a 53-year-old impotent man. The base of the penis was encircled by a metal ring in order to achieve better erection. There was marked oedema of the entire penis distal to the constricting ring. The metal ring was removed successfully by cutting it with a steel saw.

Tissue Resonance Interaction Method (TRIMprob) has the potential to be used alongside the recognized tests in the screening protocols for prostate cancer.

Abstract:  The objective of this study was to evaluate the accuracy of the magnetic induction technique with a nonlinear tunable oscillator (the Tissue Resonance Interaction Method [TRIMprob]) in the diagnosis of prostate cancer (CaP). Overall, 148 men were split into two groups (patients at risk of CaP [Group 1] and controls [Group 2]) and evaluated with the TRIMprob. Group 1 consisted of 100 patients (mean age: 63.8 ± 7.2 years) with elevated prostate‐specific antigen (>4 ng/mL) levels and/or abnormal digital rectal examination. Eleven patients (Group 2a, mean age: 59.5 ± 7.3) with previously biopsy‐proven CaP served as positive controls. In addition, 37 voluntary men (Group 2b, mean age: 39.8 ± 10.4) with normal prostate‐specific antigen and digital rectal examination without lower urinary tract symptoms served as negative controls. Non‐linear resonance was analyzed at 465 MHz and a cut‐off value of 40 units was detected as the resonance value for the best threshold to distinguish benign conditions from CaP after transrectal ultrasonography‐guided biopsy with a standard 10–12 core technique in Group 1. Mean resonance values (±standard deviation) with the TRIMprob examination for patients in Groups 1 and 2b were 36.72 ± 22.35 and 73.64 ± 10.06, respectively, whereas for patients in Group 2a, it was 13.73 ± 12.12 (P < 0.01). Sensitivity, specificity, positive and negative predictive values of the TRIMprob using the study cohort of Group 1 were found as 76%, 61.3%, 39.6% and 88.5%, respectively. Despite some technical limitations, the non‐invasive TRIMprob examination may have a role in screening protocols for CaP.

Primary Urethral Plasmacytoma: a Case Report and Literature Review

Plasmacytomas of the urethra are extremely rare neoplasias; they may occur as isolated tumors or concomitantly with generalized multiple myeloma. Herein, we describe the clinical presentation and characteristics of a patient with primary plasmacytoma of the urethra. A 51‐year‐old man presented with terminal hematuria and a palpable penile mass. Magnetic resonance urethrography revealed a 3‐cm long stenotic segment along which the urethral mucosa was found to be irregular. On urethroscopy, papillary mucosal projections extending to the presphincteric area were noted. Lesions were found to be composed primarily of neoplastic plasma cells capable of producing mainly lambda light chain. Upon diagnosis, the patient received external beam radiation therapy targeting the pelvic region. The lesion diminished in size progressively during the treatment course. He was disease‐free after 6 months. Although it is a relatively rare disease, primary urethral plasmacystoma should be considered in the differential diagnosis of urethral tumors and radiation therapy should be an integral part of the treatment strategy.

Should Prostate Cancer Status Be Determined in Patients Undergoing Radical Cystoprostatectomy

Introduction: We estimate the frequency of prostate cancers detected incidentally in radical cystoprostatectomy specimens and discuss whether the prostate cancer status should be determined in patients undergoing radical cystoprostatectomy. Materials and Methods: A total of 97 radical cystoprostatectomies without evidence of prostate cancer on digital rectal examination were performed for transitional cell carcinomas of the bladder between January 2001 and May 2004. The mean patient age at the time of surgery was 66.9 ± 9.52 (range 49–75) years. Results: The overall incidence of prostate cancer detected in radical cystoprostatectomy specimens was 21.6% (21/97 specimens). The mean tumor volume was found to be 0.93 ± 0.81 ml. The tumor volume was >0.5 ml in 12 cases (57.1%). The surgical margin was negative in all cases, and the disease was organ confined in 20 patients (95.2%). Capsular invasion was evident in 2 patients (9.5%), 1 of whom had lymph-node-positive disease. Conclusions: Despite the high prevalence of incidental prostate carcinomas among patients with bladder cancer undergoing cystoprostatectomy, the vast majority of the cancers are organ confined. However, the prostate cancer status should be determined on the basis of digital rectal examination and prostate-specific antigen in patients undergoing radical cystoprostatectomy – especially if prostate-sparing cystectomy is planned.

Sarcomatoid chromophobe renal cell carcinoma with squamous differentiation

Sir, Sarcomatoid change has been found to arise in all subtypes of renal cell carcinoma (RCC). It is well known that those with a sarcomatoid component are most likely to behave in an aggressive fashion. Sarcomatoid change has been reported relatively frequently in chromophobe RCCs. Although squamous differentiation may be seen in many other tumours, it has not been reported in RCCs, especially in chromophobe RCCs. We report here a case of sarcomatoid chromophobe RCC with malignant squamous differentiation. A 60-year-old man complained of lower abdominal and right flank pain. Computed tomography and ultrasonography examinations disclosed a mass in the right kidney, and a radical nephrectomy was undertaken. The surgical specimen revealed a 1161067 cm well-demarcated mass with the central area showing necrosis and cystic degeneration in the cortical part of the kidney. The cut surface of the tumour was beige and whitish in colour and predominantly of solid consistency. Thirty representative samples were sectioned for microscopic examination. The tumour was largely composed of spindle shaped pleomorphic cells, pure-classic chromophobe RCC areas and chromophobe RCC areas with malignant squamous differentiation. Their proportions were 50, 10 and 40%, respectively (Fig. 1). The squamous component of the tumour contained also keratin foci within epithelial cells arranged in whorl-like pattern. Frequent mitosis and frank cytological atypia were present, except in areas of pure chromophobe RCC. The cytoplasm of typical chromophobe RCC areas reacted diffusely with Hales’ colloidal iron stain. Spindle shaped cells were strongly vimentin positive (Fig. 2). However, a faint pancytokeratin and epithelial membrane antigen positivity were observed in some spindle cells. Although we did not observe any other heterologeous component, we investigated immunoreactivity for S-100 protein, smooth muscle actin, desmin and CD56, but none of them were positive. Pure chromophobe RCC areas revealed strong and diffuse