Matthew J. Resnick

Longitudinal evaluation of the concordance and prognostic value of lymphovascular invasion in transurethral resection and radical cystectomy specimens.

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Endorectal T2-weighted MRI does not differentiate between favorable and adverse pathologic features in men with prostate cancer who would qualify for active surveillance.

OBJECTIVE With the increased diagnosis of low grade, low volume, potentially non-lethal disease, active surveillance (AS) has become an increasingly popular alternative for select men with low-risk prostate cancer. The absence of precise clinical staging modalities currently makes it difficult to predict which patients are most appropriate for AS. The goal of our study was to evaluate the ability of endorectal MRI (eMRI) to predict adverse pathologic features in patients who would otherwise qualify for an AS program. MATERIALS AND METHODS We retrospectively reviewed our institutions radical prostatectomy (RP) database from 1991 to 2007 and identified 172 patients who would have qualified for AS and underwent preoperative staging eMRI with T2-weighted (T2W) sequences. MRI findings were correlated to final pathology in order to assess the ability of staging eMRI to predict adverse pathologic features in patients suitable for AS. RESULTS The mean age of our cohort was 59.8 ± 6.2 years. The mean PSA at the time of diagnosis was 5.2 ± 2.2 ng/ml. In 51% of patients, no discrete tumor was visualized on eMRI and in 49% of patients a discrete tumor was detected. At the time of RP, Gleason score upgrading, extracapsular extension, and a positive surgical margin occurred in 17%, 6%, and 5% of cases, respectively. Patients with documented tumor on eMRI did not have an increased incidence of adverse pathologic findings with regard to tumor volume (P = 0.31), extra-capsular extension (P = 0.82), Gleason upgrading (P = 0.92), seminal vesicle invasion (P = 0.97), or positive surgical margin rate (P = 0.95) compared with those in whom no tumor was seen. CONCLUSION Discrete tumor identification on eMRI is not predictive of adverse pathologic features in patients who would otherwise qualify for AS. eMRI likely does not provide additional information when prospectively evaluating patients for AS protocols.

Does Race Affect Postoperative Outcomes in Patients With Low-Risk Prostate Cancer Who Undergo Radical Prostatectomy?

OBJECTIVES To assess the magnitude of racial disparities in prostate cancer outcomes following radical prostatectomy for low-risk prostate cancer. METHODS We retrospectively reviewed our database of 2407 patients who under went radical prostatectomy and isolated 2 cohorts of patients with low-risk prostate cancer. Cohort 1 was defined using liberal criteria, and cohort 2 was isolated using more stringent criteria. We then studied pre- and postoperative parameters to discern any racial differences in these 2 groups. Statistical analyses, including log-rank, chi(2), and Fishers exact analyses, were used to ascertain the significance of such differences. RESULTS Preoperatively, no significant differences were found between the white and African-American patients with regard to age at diagnosis, mean prostate-specific antigen, median follow-up, or percentage of involved cores on prostate biopsy. African-American patients in cohort 1 had a greater mean body mass index than did white patients (26.9 vs 27.8, P = .026). The analysis of postoperative data demonstrated no significant difference between white and African-American patients in the risk of biochemical failure, extraprostatic extension, seminal vesicle involvement, positive surgical margins, tumor volume, or risk of disease upgrading. African-American patients in cohort 2 demonstrated greater all-cause mortality compared with their white counterparts (9.4% vs 3.1%, P = .027). CONCLUSIONS In patients with low-risk prostate cancer treated with radical prostatectomy, there exist no significant differences in surrogate measures of disease control, risk of disease upgrading, estimated tumor volume, or recurrence-free survival between whites and African-Americans.

Repeat Prostate Biopsy and the Incremental Risk of Clinically Insignificant Prostate Cancer

OBJECTIVES To determine the incremental risk of diagnosis of clinically insignificant prostate cancer with serial prostate biopsies. METHODS We reviewed our institutional radical prostatectomy (RP) database comprising 2411 consecutive patients undergoing RP. We then stratified patients by the prostate biopsy on which their cancer was diagnosed and correlated biopsy number with the risk of clinically insignificant disease and adverse pathology at radical prostatectomy. RESULTS A total of 1867 (77.4%), 281 (11.9%), and 175 (7.3%) patients underwent 1, 2, and 3 or more prostate biopsies, respectively, before RP. Increasing number of prostate biopsies was associated with increasing prostate volume (P <.01), prostate-specific antigen (P <.01), associated prostate intraepithelial neoplasia (P <.01), and increased likelihood of clinical Gleason 6 or less disease (P <.01). On pathologic analysis, increasing number of prostate biopsies was associated with increased risk of low-volume (P <.01), organ-confined (P <.01) disease. The risk of clinically insignificant disease was found to be 31.1%, 43.8%, and 46.8% in those undergoing 1, 2, and 3+ prostate biopsies, respectively. Conversely, the risk of adverse pathology was found to be 64.6%, 53.0%, and 52.0% in those undergoing 1, 2, and 3+ prostate biopsies, respectively. CONCLUSIONS Patients undergoing multiple prostate biopsies before RP are more likely to harbor clinically insignificant prostate cancer than those who only undergo 1 biopsy before resection. Nonetheless, the risk of adverse pathology in patients undergoing serial biopsies remains significant. The increased risk of prostate cancer overdiagnosis and overtreatment must be balanced with the continued risk of clinically significant disease when counseling patients regarding serial biopsies.

Hydronephrosis Is an Independent Predictor of Poor Clinical Outcome in Patients Treated for Muscle-Invasive Transitional Cell Carcinoma With Radical Cystectomy

OBJECTIVES The purpose of this study was to assess the prognostic significance of hydronephrosis on pathologic and clinical outcomes in muscle-invasive bladder cancer. METHODS We performed a retrospective evaluation of a prospectively maintained cystectomy database and identified patients with hydronephrosis on preoperative imaging. Of a total of 306 patients, 57 (19%) had unilateral hydronephrosis and 17 (6%) had bilateral hydronephrosis. We constructed multivariate Cox regression analysis and Kaplan Meier tables to evaluate the association between preoperative hydronephrosis and clinical outcomes. RESULTS In patients without hydronephrosis, 41.4% had extravesical disease compared with 56.1% and 64.7% in patients with unilateral or bilateral hydronephrosis, respectively. Mean overall survival (OS) among patients without hydronephrosis, with unilateral hydronephrosis, and with bilateral hydronephrosis was 55.5, 42.1, and 22.2 months, respectively. Five-year OS and disease-specific survival (DSS) was 46%, 35%, and 22% (P = .001) and 68%, 54%, and 35% (P = .002), respectively. Multivariate analysis demonstrated that both unilateral and bilateral hydronephrosis are significant independent risk factors for DSS and OS. Bilateral hydronephrosis was found to have a hazard ratio of 3.87 (95% confidence interval [CI] = 1.71-8.78, P = .001) and 2.75 (95% CI = 1.45-5.18, P = .002) for DSS and OS, respectively. The hazard ratios for unilateral hydronephrosis were 1.7 (95% CI = 1.05-2.87, P = .03) and 1.5 (95% CI = 1.03-2.23, P = .04) for DSS and OS, respectively. CONCLUSIONS Preoperative hydronephrosis is associated with a significantly poorer prognosis in patients with muscle-invasive bladder cancer. These patients should be appropriately counseled with regard to overall prognosis and the potential benefit of neoadjuvant chemotherapy.

A Thorough Pelvic Lymph Node Dissection in Presence of Positive Margins Associated With Better Clinical Outcomes in Radical Cystectomy Patients

OBJECTIVES To evaluate the effect of positive surgical margins in patients with muscle-invasive transitional cell carcinoma of the bladder on survival. METHODS A retrospective evaluation of a prospectively maintained radical cystectomy database consisting of the data from 344 patients was performed. Cox regression analysis was done, and Kaplan-Meier tables were developed to evaluate the contribution of this finding to clinical outcomes. RESULTS A total of 304 (88.4%) patients had negative surgical margins in the radical cystectomy specimen, and 40 (11.6%) had positive surgical margins. On univariate analysis, positive surgical margins conferred a significant risk of poorer clinical outcomes. The 5-year overall (OS) and disease-specific survival (DSS) rate was 9% and 18% for patients with positive margins compared with 48% and 65% for patients with negative margins, respectively. The multivariate analysis demonstrated a significant independent risk of decreased recurrence-free survival, DSS, and OS for patients with positive surgical margins. The corresponding hazard ratios were 2.29 (95% confidence interval 1.54-3.41, P < .001), 1.71 (95% confidence interval 1.15-2.56, P < .009), and 1.70 (95% confidence interval 1.23-2.34, P < .001). Despite these findings, patients with positive margins and node-negative disease experienced improved DSS and recurrence-free survival (P = .001 P and = .009, respectively) if >15 lymph nodes were removed during surgery. CONCLUSIONS The presence of positive surgical margins in the pathologic specimen confers a significant independent risk of reduced recurrence-free survival, DSS, and overall survival. Nevertheless, patients with positive surgical margins will still benefit from a meticulous pelvic lymph node dissection.

A case of synchronous bilateral testicular seminoma

Background A previously healthy 51-year-old man with two children sustained a minor testicular trauma and subsequently sought medical care for persistent discomfort.Investigations Physical examination, scrotal ultrasonography, Doppler ultrasound evaluation of testicular blood flow, scrotal MRI, measurement of serum tumor markers and testosterone levels, CT of the chest, abdomen and pelvis, intraoperative frozen section analysis and final pathologic analysis.Diagnosis Bilateral testicular seminoma (clinical stage I).Management The patient initially underwent radical left orchiectomy with intraoperative frozen section analysis, which returned equivocal results. Final pathologic analysis revealed a 2.5 cm left testicular seminoma without vascular invasion. After careful discussion, he ultimately underwent radical right orchiectomy; pathologic analysis revealed a 2.7 cm right seminoma with vascular invasion. Testosterone replacement therapy was initiated. After further discussion, the patient elected to undergo adjuvant abdominal radiotherapy to a total of 25 Gy. The patient showed no evidence of disease over a post-treatment follow-up period of 24 months.