Kelly E. Maloney

Men Older Than 70 Years Have Higher Risk Prostate Cancer and Poorer Survival in the Early and Late Prostate Specific Antigen Eras

PURPOSE We clarified whether men older than 70 years have a higher risk of prostate cancer and poorer survival in the early and late prostate specific antigen eras. MATERIALS AND METHODS A cohort of 4,561 men who underwent radical prostatectomy were stratified into 3 age groups (younger than 60, 60 to 70 and older than 70 years), and early and late prostate specific antigen eras based on the year of surgery (before 2000 and 2000 or later). Race, body mass index, prostate specific antigen, prostate weight, tumor volume, pathological Gleason sum, pathological tumor stage, extracapsular extension, seminal vesicle invasion and surgical margin status were submitted for univariate and multivariable analyses against the previously mentioned groups. Survivals (prostate specific antigen recurrence, distant metastasis and disease specific death) were compared among the 3 age groups using univariate and multivariable methods. RESULTS Compared with younger age groups (younger than 60, 60 to 70 years) men older than 70 years had a higher proportion of pathological tumor stage 3/4 (33.0 vs 44.3 vs 52.1%, p <0.001), pathological Gleason sum greater than 7 (9.5% vs 13.4% vs 17.2%, p <0.001) and larger tumor volume (3.7 vs 4.7 vs 5.2 cc, p <0.001). Pathological Gleason sum in men older than 70 years did not differ between the early and late prostate specific antigen eras (p = 0.071). Men older than 70 years had a higher risk of prostate specific antigen recurrence, distant metastasis and disease specific death on univariate (p <0.05) but not multivariable analysis. CONCLUSIONS Men older than 70 years had higher risk disease and poorer survival in the early and late prostate specific antigen eras. Pathological Gleason sums did not change between the 2 eras. Patient age was an important variable in prostate specific antigen screening, biopsy, treatment and prognosis.

Oncogenic human papillomaviruses are rarely associated with squamous cell carcinoma of the bladder : evaluation by differential polymerase chain reaction

While a strong association between oncogenic human papillomaviruses and squamous cell cancers of the genital tract (penis, urethra and cervix) is known to exist, there is substantial controversy regarding the association of human papillomaviruses and cancers of the bladder. Technical issues regarding assay technique and concern about potential contamination have marred interpretation of previous work. Moreover, because human papillomavirus has been associated predominantly with squamous cell cancers at other sites, any involvement of human papillomavirus and bladder epithelial carcinogenesis must address whether any association between human papillomavirus and squamous cell carcinoma of the bladder exists. Differential polymerase chain reaction and a rigorous protocol to avoid crossover contamination were used to analyze archival bladder carcinoma specimens (22 squamous cell carcinomas and 20 transitional cell carcinomas). Type specific primers for human papillomavirus types 16 and 18 were used as were general primers to detect types 6b, 11, 13, 16, 18, 31, 32, 33, 35, 45 and 51. Only 1 of 22 squamous cell carcinoma specimens (4.4%) was positive (human papillomavirus type 18)--a cadaveric renal transplant patient on chronic immunosuppression. Cervical specimens were human papillomavirus negative in this patient. No human papillomavirus deoxyribonucleic acid was detected in the 20 transitional cell carcinoma cohort. Our results confirm that these human papillomavirus types appear to have little association with invasive transitional cell cancers. Of greater significance, despite this (to our knowledge) first reported case of human papillomavirus type 18 detected in squamous cell carcinoma of the bladder (seen in an immunocompromised patient), we conclude that these oncogenic human papillomavirus types do not have a significant role in squamous cell carcinogenesis of the bladder.

VESICAL ENDOMETRIOSIS: REPORT OF TWO CASES AND REVIEW OF THE LITERATURE

Endometriosis is a common gynecologic disease in which endometrial tissue is deposited outside the normal confines of the uterine cavity. In rare instances, endometriosis involves the urinary tract, with the bladder the most frequent organ affected. Classic presenting symptoms include cyclic irritative voiding symptoms and suprapubic discomfort with or without hematuria. Both medical and surgical management have been advocated, but surgical extirpation is probably more efficacious. Two cases of endometriosis involving the the bladder are presented and contrasted in terms of pathophysiology. Contemporary management of this condition is reviewed, and guidelines for diagnosis and treatment are proposed.

Factors Predicting Prostatic Biopsy Gleason Sum Under Grading

PURPOSE We determined clinical factors affecting the under grading of biopsy Gleason sum compared with prostatectomy pathology and developed a model predicting the probability of under grading. MATERIALS AND METHODS We analyzed a cohort of 1,701 patients treated for prostate cancer at our institution between 1988 and 2007 with complete biopsy and pathological data available. Patients with a biopsy Gleason sum of 7 or less were included in our analysis. Cases were categorized as under graded or not under graded by comparing biopsy and radical prostatectomy Gleason sums. Logistic regression was used to determine the predictors of under grading based on clinical variables (race, age at diagnosis, body mass index, prostate weight, diagnostic prostate specific antigen, biopsy positive-to-total core ratio, maximal cancer percent in positive cores and time from diagnosis to surgery). A nomogram was developed to calculate the probability of under grading. Results were validated using bootstrapping. RESULTS Under grading occurred in 46.6% of our cohort. Significant variables predicting under grading were age at diagnosis, biopsy Gleason sum, diagnostic prostate specific antigen, prostate weight, biopsy positive-to-total core ratio and maximal percent of cancer in cores (p <0.05). Nomogram predictive accuracy was 72.4%. CONCLUSIONS The risk of Gleason sum under grading can be predicted to a satisfactory level using our nomogram. Predicting under grading would improve patient consulting and identify those who should consider repeat biopsy, ultimately enhancing the accuracy of prostate cancer diagnosis.

Prostatic carcinosarcoma 15 years after combined external beam radiation and brachytherapy for prostatic adenocarcinoma: A case report

A 65-year-old man with a history of combined pelvic external beam radiation therapy (EBRT) and brachytherapy for prostatic adenocarcinoma 15 years prior underwent total pelvic exenteration for presumed rectal sarcoma with prostatic invasion. Pathology revealed carcinosarcoma of prostatic origin. This patient exhibited the longest reported interval between initial presentation with prostatic adenocarcinoma and development of carcinosarcoma. This case is also the first reported case of prostatic carcinosarcoma occurring after combined EBRT and brachytherapy. The increasing use of such combination high-dose radiation therapy may potentially lead to an increased incidence of secondary malignancies such as prostatic carcinosarcoma in the future.

PREDICTING NON-ORGAN CONFINED PROSTATE CANCER AFTER THE YEAR 2000

INTRODUCTION AND OBJECTIVES: To preoperatively predict non-organ confined prostate cancer in patients considering radical prostatectomy. METHODS: A cohort of 1895 patients who underwent radical prostatectomy from 2000 to 2008 was retrieved from the Duke Prostate Center database. Organ confined (pT2) and non-organ confined disease (pT3/4) underwent Kaplan Meier analysis in regards to PSA recurrence (PSAR). Race (African American, non-African American), body mass index (BMI), age at surgery, PSA, clinical Gleason sum ( 7) and clinical tumor stage (cT1, cT2/3) underwent univariate analysis followed by binary logistical regression in regards to non-organ confined disease. A Duke Interactive Clinical Equation (DICE score) was calculated based on significant factors from logistic regression. A patient’s DICE score is a log odds equation that calculates the probability of having non-organ confined disease. RESULTS: There was a difference in PSAR between pT2 and pT3/4 (p 7 were more likely to have non-organ confined disease compared to 7)). Clinical tumor stage, cT2/3, predicted non-organ confined disease (OR=1.58). Older age was associated with non-organ confined disease (OR=1.02).as was greater PSA (OR=1.12). DICE equation x = ln (p/1-p) = -3.627 + 0.019 (Age) + 0.109 (PSA) + 1.087 (cGleason=7) + 1.180 (cGleason >7) + 0.459 (clinical T stage >T1), where p = (e x)/ (1e x) CONCLUSIONS: Using the DICE scoreage, PSA, clinical Gleason sum, and clinical tumor stage preoperatively predicted non-organ confined disease. Non-organ confined disease increases the risk of PSAR.