Do robotic prostatectomy positive surgical margins occur in the same location as extraprostatic extension?

PURPOSE: Positive surgical margins (PSMs) may reflect incomplete surgical resection, while extraprostatic extension (EPE) could suggest that complete tumor resection is more difficult. This study evaluated cases with both EPE and PSMs in robotic-assisted radical prostatectomy (RARP) specimens to determine the respective locations of each. METHODS: A single institutional retrospective review of RARP performed between 2007 and 2009 was conducted to identify cases with both EPE and PSM. Prostates were entirely submitted and processed in whole mount format. All locations of EPE and PSM were recorded as was the size of the largest focus of EPE and PSM. RESULTS: About 8.5 % (112/1,315) of RARP had both EPE and PSM. Analysis of cases with concurrent EPE and PSM revealed that EPE occurred most commonly in the mid-gland, particularly in the posterolateral mid-prostate. In contrast, PSM was most frequent at the base (bladder neck), specifically the anterior base. 51.8 % of the cases had EPE and PSM in discordant locations, 19.6 % had EPE and PSM in the same location, and 28.6 % had areas of EPE and PSM both in the same location as well as in different locations. Cases with both concordant and discordant locations of EPE and PSM had significantly more high-risk features including higher tumor volume, more frequent positive nodes, and more frequent Gleason score ≥ 8 compared to concordant or discordant subgroups. CONCLUSION: PSMs frequently did not occur in the same location as EPE. A better understanding of where EPE and PSMs occur may help guide surgical technique to decrease residual tumor.

ER and PR immunohistochemistry and HER2 FISH versus oncotype DX: implications for breast cancer treatment.

Estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor (HER2) concordance between immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH), and Oncotype DX, a commercially available RT-PCR-based assay which recently began reporting biomarker results was assessed. ER concordance was 98.9% (262/265), Pearson correlation coefficient (r) = 0.42, and Spearman's rank correlation (ρ) = 0.25. Positive percent agreement for ER was 98.9% (262/265). One patient with discordant ER results was not offered hormone therapy based on the preferential use of Oncotype DX. PR was concordant in 91.3% (242/265), r = 0.80, ρ = 0.75, and Cohen's kappa (κ) = 0.63. Positive percent agreement for PR was 90.5% (218/241) and negative percent agreement was 100% (24/24). HER2 concordance was 99.2% (245/247), r = 0.35, ρ = 0.28, and κ = 0.12. Positive percent agreement for HER2 was 0% (0/2) and negative percent agreement was 100% (245/245). Of the three FISH HER2-amplified cases, two were negative and one was equivocal, and all FISH HER2-equivocal cases (n = 3) were negative by Oncotype DX. Patients that were FISH HER2-amplified, Oncotype DX HER2-negative did not receive trastuzumab. Although our results demonstrated high concordance between IHC and Oncotype DX for ER and PR, our data showed poor positive percent agreement for HER2. Compared to FISH, Oncotype DX does not identify HER2-positive breast carcinomas. The preferential use of Oncotype DX biomarker results over IHC and FISH is discouraged.

Whole-mount evaluation of penectomies for penile cancer: feasibility, cost and comparison to routine sectioning.

AIMS: Pathological staging in penectomies may be difficult due to the anatomical complexity of penile anatomy, and may be additionally challenging due to the low volume at most institutions. Our study aimed to assess the feasibility of whole-mount processing for penectomy specimens. METHODS AND RESULTS: A 7-year retrospective search for partial or radical penectomies identified 55 specimens, which were processed routinely (n = 31) from 2006 to 2009 and whole-mounted (n = 24) from 2010 to 2012. Routine cases used more slides per case compared to whole mounts (mean 10.4 versus 7.2). Recuts occurred more often in routine cases (12.9% versus 0%). More routine cases had additional blocks grossed (19.4% versus 4.2%). Upon review, five discrepancies that impacted pT staging were identified in the routine group, with none in the whole-mount group. The average estimated additional cost for each whole-mount case compared to routine processing was $40.74, with an increased turnaround time of 1 day. CONCLUSIONS: Whole-mounting is a feasible technique for penectomy that can be utilized with minimal increased cost and turnaround time, and may improve staging. Institutions in which whole-mounting is already established for other organs, such as prostate, may wish to consider utilizing this format for penectomy specimens.

Does the gross prosector impact pT3 subclassification or lymph node counts in bladder cancer?

Gross prosector analysis of perivesicular adipose tumor invasion is the sole differentiator between pT3 substages, and gross evaluation is critical to lymph node identification. Gross prosector impact on pT3 subclassification and lymph node counts in cystectomy specimens resected for bladder cancer has not been previously analyzed. Both pT3 subclassification and total number of lymph nodes removed at radical cystectomy for bladder cancer are considered important components of the pathology report; however, both have controversial prognostic significance. Our objective was to assess the impact of the gross prosector on pT3 substaging and lymph node count. Pathology reports from 560 cystectomy cases performed for primary bladder cancer were reviewed. Educational interventions regarding cystectomy gross prosector documentation were conducted. Gross prosectors did not document the presence or absence of macroscopic perivesicular adipose invasion in 17% of cases. There was a decrease in the frequency of cases lacking documentation after educational intervention (33% to 5%, P<.01). Most pT3 cases lacking documentation were classified as pT3a (75%). The percentage of pT3 cases classified as pT3a decreased after intervention (68% to 35%, P<.01). Overcounting of lymph nodes by gross prosectors was more common than undercounting (22% versus 2%). Pathology residents and prosectors with lower caseloads had more uncounted lymph packets (P<.01). In conclusion, we demonstrated an impact of the gross prosector on pT3 substaging and lymph node counts within bladder cancer resection specimens. This novel variable may confound the relationship of these parameters upon oncologic outcomes and should be incorporated into quality assurance programs.

Concordance of lymphovascular invasion diagnosed in penile carcinoma with and without the immunohistochemical markers ERG and CD31.

Lymphovascular invasion (LVI) is an independent predictor of metastatic lymph node disease in penile carcinoma and is one factor used to guide clinical management. The presence of LVI with and without the use of the endothelial immunohistochemical (IHC) markers, ERG and CD31, was retrospectively assessed in 46 penectomy cases containing invasive penile carcinoma (43 squamous cell carcinoma and 3 non-squamous cell carcinoma). Concordance for the detection of LVI between the original report, upon pathology review, and with the use of IHC was determined and histologic pitfalls were identified. For penile squamous cell carcinoma, LVI was diagnosed in 27.9% of tumors in the original reports, 16.3% upon pathology review, and in 16.3% with use of ERG and CD31. Concordance of LVI identification in the original report compared to IHC was 74.4% while concordance of review compared to IHC was 95.3%. Using IHC data as the reference, false positive LVI diagnoses were more common in the original report than false negatives. Histologic mimickers of LVI including involvement of the penile corpora cavernosum or spongiosum vasculature, seromucinous colonization, and a nested pattern of tumor invasion were identified. We demonstrated that it was not uncommon for LVI in penile carcinoma to be overdiagnosed or underdiagnosed. The use of endothelial IHC markers, such as ERG or CD31, or additional pathology consultation is recommended for penectomy cases in which LVI is difficult to histologically discern.

Urologist's Impact on Needle Core Prostate Biopsy Histopathologic Variables Within a Single Institution.

OBJECTIVE: To assess the urologist's impact on prostate needle core biopsy variables including number of containers submitted, total core length, longest core length, and individual core length threshold values, and to elucidate the relationship between these variables and cancer detection rate within a recent cohort. METHODS: A retrospective search was performed to identify patients who had an extended transrectal ultrasound-guided prostate needle core biopsy between 2008 and 2013. RESULTS: One thousand one prostate biopsies were analyzed. Total core length (mean 13.2-22.9 cm, P < .001) significantly varied by submitting urologist but did not impact cancer detection rate per case. Increased core length per container impacted the cancer detection per container (P < .001). The number of cores that met threshold values of 0.5, 1.0, and 1.5 cm as well as longest individual core length (mean 1.7-2.2 cm) significantly varied between urologist (P < .001), although there was no association between these variables and cancer detection. Container number differed significantly between urologists (P < .001) but did not correlate with cancer detection. For the single urologist with a change in his submission protocol during the study period, a nonsignificant change in cancer detection was noted when comparing 12-14 containers vs 6-9 containers. CONCLUSION: Submitting urologist significantly impacts prostate biopsy metrics. An increased amount of tissue per container was associated with higher rates of cancer per container. A nonsignificant change in cancer detection rate was observed when container number was reduced from 12-14 to 6-9.