Luciano J. Nesrallah

The role of squamous differentiation in patients with transitional cell carcinoma of the bladder treated with radical cystectomy

OBJECTIVEnWe aim at determining the prognostic value of squamous differentiation in patients with transitional cell carcinoma (TCC) of the bladder that were treated with radical cystectomy.nnnMATERIALS AND METHODSnFrom January 1993 to January 2005, we retrospectively selected 113 patients. Correlations among squamous differentiation with other clinical and pathological features were assessed by both chi-square and Fisher tests. The Kaplan-Meier method was used to evaluate survival curves and statistical significance was determined by the log-rank test. Multivariate analysis was performed through a Cox proportional hazards regression model.nnnRESULTSnSquamous differentiation was observed in 25 (22.1%) of the 113 patients. This finding was significantly related only to the pathological stage. Mean follow-up after cystectomy was 31.7 +/- 28.5 months. Disease recurrence occurred in 16 (64%) and 30 (34%) patients with and without squamous differentiation (log-rank test, p = 0.001), and mortality occurred in 10 (40%) and 14 (16%) of the patients with and without squamous differentiation respectively. Univariate analysis revealed that pathological stage, squamous differentiation, tumor size and lymph node involvement were significant predictors of cancer-specific survival. However, only squamous differentiation and tumor size were independent prognostic variables on multivariate analysis.nnnCONCLUSIONSnSquamous differentiation was an independent prognostic factor for cancer specific survival in patients with bladder cancer treated with radical cystectomy. Further studies with a larger number of patients are necessary to confirm these results.

The York-Mason technique for recto-urethral fistulas

OBJECTIVEnRecto-urethral fistula formation following radical prostatectomy is an uncommon but potentially devastating event. There is no consensus in the literature regarding the treatment of these fistulas. We present here our experiences treating recto-urethral fistulas.nnnMATERIAL AND METHODSnWe analyzed 8 cases of rectourethral fistula treated at our institution in the last seven years. Seven of the patients underwent repair of the fistula using the modified York-Mason procedure.nnnRESULTSnThe causes of the fistula were radical retropubic prostatectomy in five patients, perineal debridement of Fourniers gangrene in one, transvesical prostatectomy in one and transurethral resection of the prostate in the other patient. The most common clinical manifestation was fecaluria, present in 87.5% of the cases. The mean time elapsed between diagnosis and correction of the fistula was 29.6 (7-63) months. One spontaneous closure occurred after five months of delayed catheterization. Urinary and retrograde urethrocystography indicated the site of the fistula in 71.4% of the cases. No patient presented recurrence of the fistula after its correction with the modified York-Mason procedure.nnnCONCLUSIONnThe performance of routine colostomy and cystostomy is unnecessary. The technique described by York-Mason permits easy access, reduces surgical and hospitalization times and presents low complication and morbidity rates when surgically correcting recto-urethral fistulas.

The role of extended prostate biopsy on prostate cancer detection rate: a study performed on the bench

INTRODUCTIONnThe aim of this prospective study was to compare the advantage of performing prostate biopsy with a greater number of cores using the classic sextant procedure, with the aim of reducing false negative results.nnnMATERIALS AND METHODSn100 prostates were acquired from consecutive radical prostatectomies performed by the same surgeon. Fourteen cores were obtained on the bench following surgery using an automatic pistol with an 18-gauge needle. Six of these cores were obtained according to the sextant technique, as described by Hodge et al.; with the addition of a further three lateral cores from each lobe and one from the bilateral transition zone. The whole gland and the fragments were assessed by the same pathologist. An analysis of the frequency of the cancers identified in the cores of the sextant and the extended biopsies was undertaken and the results evaluated comparatively. The chi-square test was used for the comparative analysis of the cancer detection rate, according to the technique used.nnnRESULTSnWhen 6 cores were removed, the positive cancer rate was 75%, which was increased to 88% when 14 cores were (p < 0.001). The withdrawal of 14 cores resulted in a significant 13% (95% CI [5%-21%]) increase in the positive rate of cancer detection.nnnCONCLUSIONnExtended biopsy, with the removal of 14 cores, is more efficient than the sextant procedure in improving the rate of prostate cancer detection.

Analysis of prognostic factors in patients with transitional cell carcinoma of the bladder treated with radical cystectomy

OBJECTIVEnTo analyze the results of the treatment of transitional cell carcinoma (TCC) of the bladder with radical cystectomy and determine which prognostic factors can be utilized as disease-free survival and cancer-specific survival independent variables.nnnMATERIALS AND METHODSnMedical records of 113 patients submitted to radical cystectomy and bilateral iliac lymphadenectomy between 1993 and 2005 were reviewed. The risk factors analyzed were age, sex, pathological stage, tumor grade, presence of carcinoma in situ and the presence of lymph nodes involvement.nnnRESULTSnAfter a mean follow-up of 31.7 +/- 28.5 months, 46 patients (40.7%) presented recurrence and 24 patients (21.2%) died due to cancer. Only pathological stage and the lymph nodes involvement became independent variables for recurrence and survival. Patients with T4 stage presented 9.6 times the risk of recurrence of the disease when compared with stage T0 patients (p = 0.010) and the patients with lymph node involvement presented 2.5 times the risk of recurrence (p = 0.047) and 3.1 times the risk of death (p = 0.022) when compared to patients without lymph nodes involvement.nnnCONCLUSIONSnPathological stage and the involvement of lymph nodes represented more important prognostic variables, and in the presence of advanced stage tumors (T3/T4) and involvement of lymph nodes, the institution of adjuvant treatment should be considered.

Age impact in clinicopathologic presentation and the clinical evolution of prostate cancer in patients submitted to radical prostatectomy

OBJECTIVEnTo assess the influence of age in pathological findings and clinical evolution of prostate cancer in patients treated with radical prostatectomy.nnnMATERIALS AND METHODSnFive hundred and fifty-six patients operated on between 1991 and 2000 were selected. Patients were divided into age groups of between 10 and 49 years, 50 to 59 years, 60 to 69 years and 70 to 83 years.nnnRESULTSnPatients having less than 60 years of age presented clinical stage (p = 0.001), PSA (p = 0.013) and biopsy Gleason score (p = 0.013) more favorable than older patients. Age groups did not show any relationship between either postoperative Gleason score or pathological stage or risk of non-confined organ disease and involvement of seminal vesicles. After a mean follow-up of 58.3 months, 149 (27%) patients presented recurrence. Patients aged between 40 and 59 years presented a disease-free survival rate significantly higher when compared to patients aged between 60 and 83 years (p = 0.022). However, when controlled with clinical stage, PSA, Gleason score and percentage of positive fragments, there was no relationship between age and biochemical recurrence risk (p = 0.426).nnnCONCLUSIONSnEven though younger patients presented more favorable preoperative characteristics, postoperative pathological findings and biochemical recurrence rates did not differ between studied age groups.

Salvage Radical Prostatectomy: An Alternative Treatment for Local Recurrence of Radioresistant Cancer

OBJECTIVESnThe treatment of recurrent prostate cancer after radiotherapy or brachytherapy through radical prostatectomy has been little indicated due to the concern over the procedures morbidity. We present the experience of our service with postradiotherapy radical prostatectomy.nnnMATERIALS AND METHODSnBetween 1996 and 2002, 9 patients submitted to radiotherapy due to prostate cancer were treated with salvage surgery for locally recurrent disease. All patients had a biopsy of the prostate confirming the tumor recurrence, increase in the PSA levels and staging without evidence of a systemic disease. We have assessed the morbidity and the recurrence-free survival rate after salvage radical prostatectomy.nnnRESULTSnPreradiotherapy PSA varied from 6.2 to 50 ng/mL (mean 17.3) and clinical staging T1, T2 and T3 in 33.3%, 44.4% and 22.2% of the patients respectively. The interval for the biopsy after conforming external beam radiotherapy or brachytherapy varied from 8 to 108 months (median: 36). Four patients received antiandrogenic therapy neoadjuvant to the surgery with a mean of 7 months (1-48) after radiotherapy. From the six patients potent before the surgery, three have presented erectile dysfunction. Urinary incontinence as well as bladder neck sclerosis occurred in two patients (22.2%). Biochemical recurrence occurred in two individuals (22.2%) 12 months after the surgery. Biochemical recurrence-free survival rate was 77.8% with median follow-up time of 30 months (8-102).nnnCONCLUSIONnSalvage radical prostatectomy is a safe and effective alternative for the treatment of locally recurrent prostate cancer after radiotherapy and brachytherapy.

Preoperative determination of prostate cancer tumor volume: analysis through biopsy fragments

OBJECTIVEnPreoperative determination of prostate cancer (PCa) tumor volume (TV) is still a big challenge. We have assessed variables obtained in prostatic biopsy aiming at determining which is the best method to predict the TV in radical prostatectomy (RP) specimens.nnnMATERIALS AND METHODSnBiopsy findings of 162 men with PCa submitted to radical prostatectomy were revised. Preoperative characteristics, such as PSA, the percentage of positive fragments (PPF), the total percentage of cancer in the biopsy (TPC), the maximum percentage of cancer in a fragment (MPC), the presence of perineural invasion (PNI) and the Gleason score were correlated with postoperative surgical findings through an univariate analysis of a linear regression model.nnnRESULTSnThe TV correlated significantly to the PPF, TPC, MPC, PSA and to the presence of PNI (p < 0.001). However, the Pearson correlation analysis test showed an R2 of only 24%, 12%, 17% and 9% for the PPF, TPC, MPC, and PSA respectively. The combination of the PPF with the PSA and the PNI analysis showed to be a better model to predict the TV (R2 of 32.3%). The TV could be determined through the formula: Volume = 1.108 + 0.203 x PSA + 0.066 x PPF + 2.193 x PNI.nnnCONCLUSIONSnThe PPF seems to be better than the TPC and the MPC to predict the TV in the surgical specimen. Due to the weak correlation between those variables and the TV, the PSA and the presence of PNI should be used together.

Microvascular invasion is an independent prognostic factor in patients with prostate cancer treated with radical prostatectomy

OBJECTIVEnCurrent published data regarding the prognostic value of microvascular invasion (MVI) in patients with prostate cancer (PCa) have yielded mixed results. Furthermore, most important series had surgical procedures performed by multiple surgeons and surgical specimens analyzed by multiple pathologists. We determined the relation of MVI with other pathologic features and whether this finding can be used as an independent prognostic factor in patients with PCa.nnnMATERIALS AND METHODSnWe selected 428 patients with clinically localized PCa treated with radical prostatectomy (RP). MVI was correlated to other pathologic features. The Kaplan-Meier method was used to evaluate survival curves and statistical significance was determined by the log-rank test. Multivariate analysis was performed through a Cox proportional hazards regression model.nnnRESULTSnEleven percent out of the 428 patients presented MVI. Except for the lack of association with biopsy Gleason score, MVI was related to all clinical and pathologic features of RP specimens. Mean follow up after surgery was 53.9 +/- 20.1 months. Patients with MVI presented a recurrence rate of 44.6% compared to only 20.2% for patients without MVI (Log-rank test - p < 0.001). After Cox regression analysis, MVI was an independent prognostic feature related to biochemical recurrence.nnnCONCLUSIONSnMVI is associated to advanced pathologic features of PCa and is an important prognostic factor regarding disease recurrence in patients treated with RP. These findings support the recommendations to the routine evaluation of this variable in pathologic reports of RP specimens.

The accuracy of pathological data for the prediction of insignificant prostate cancer

INTRODUCTIONnThe widespread screening programs prompted a decrease in prostate cancer stage at diagnosis, and active surveillance is an option for patients who may harbor clinically insignificant prostate cancer (IPC). Pathologists include the possibility of an IPC in their reports based on the Gleason score and tumor volume. This study determined the accuracy of pathological data in the identification of IPC in radical prostatectomy (RP) specimens.nnnMATERIALS AND METHODSnOf 592 radical prostatectomy specimens examined in our laboratory from 2001 to 2010, 20 patients harbored IPC and exhibited biopsy findings suggestive of IPC. These biopsy features served as the criteria to define patients with potentially insignificant tumor in this population. The results of the prostate biopsies and surgical specimens of the 592 patients were compared.nnnRESULTSnThe twenty patients who had IPC in both biopsy and RP were considered real positive cases. All patients were divided into groups based on their diagnoses following RP: true positives (n = 20), false positives (n = 149), true negatives (n = 421), false negatives (n = 2). The accuracy of the pathological data alone for the prediction of IPC was 91.4%, the sensitivity was 91% and the specificity was 74%.nnnCONCLUSIONnThe identification of IPC using pathological data exclusively is accurate, and pathologists should suggest this in their reports to aid surgeons, urologists and radiotherapists to decide the best treatment for their patients.

Perineural invasion by transitional cell carcinoma of the bladder in patients submitted to radical cystectomy: what is the prognostic value?

OBJECTIVEnDetermine the prognostic value of perineural invasion (PNI) in patients with transitional cell carcinoma (TCC) of the bladder treated with radical cystectomy.nnnMATERIALS AND METHODSnFrom January 1993 to January 2005, 113 people were selected from 153 patients with TCC of the bladder treated with radical cystectomy. The association between the presence of PNI and other pathologic characteristics were analyzed through Fisher exact test. The Kaplan-Meier method was utilized to assess the survival curve and the statistical significance was determined by the Breslow test. The multivariate analysis was performed through the Cox regression model.nnnRESULTSnThe PNI was identified in 10 (8.8%) of the 113 patients. This variable significantly related to the microvascular invasion and to tumor staging. The mean segment after surgery was 31.7 +/- 28.5 months. Recurrence occurred in 5 (50%) and in 41 (39.8%) patients (p=0.363) and mortality occurred in 2 (20%) and 22 (21.9%) patients (p=0.606) with or without PNI respectively. In Cox regression analysis, patients with PNI presented with 1.53 times (IC 95% 0.60 to 3.91; p=0.371) and 1.60 times (IC 95% 0.37 to 6.95; p=0.532) the risk of recurrence and mortality when compared to patients without PNI.nnnCONCLUSIONSnThe PNI does not constitute an independent variable of disease-free and cancer specific survival in patients with TCC of the bladder treated with radical cystectomy.