Biochemical recurrence rates are similar for pT2-positive surgical margins and pT3a.

OBJECTIVE: Histological details of positive surgical margins in radical prostatectomy specimens have been related to outcome after surgery in rare studies recently published. Our objective is to assess whether the status of surgical margins, the extent and the Gleason score of positive margins, and the extent of the extraprostatic extension are predictive of biochemical recurrence post-radical prostatectomy. MATERIALS AND METHODS: Three hundred sixty-five radical prostatectomy specimens were analyzed. The length of the positive surgical margin and extraprostatic extension and the Gleason score of the margin were recorded. Statistical analyses examined the predictive value of these variables for biochemical recurrence. RESULTS: 236 patients were stage pT2R0, 58 pT2R1, 25 pT3R0 and 46 pT3R1. Biochemical recurrence occurred in 11%, 31%, 20% and 45.7% of pT2R0, pT2R1, pT3R0 and pT3R1, respectively. The extent of the positive surgical margins and the Gleason score of the positive surgical margins were not associated with biochemical recurrence in univariate analysis in a mean follow up period of 35.9 months. In multivariate analyses, only the status of the surgical margins and the global Gleason score were associated with biochemical recurrence, with a risk of recurrence of 3.1 for positive surgical margins and of 3.8 for a Gleason score > 7. CONCLUSION: Positive surgical margin and the global Gleason score are significant risk factors for biochemical recurrence post-radical prostatectomy, regardless of the extent of the surgical margin, the extent of the extraprostatic extension, or the local Gleason score of the positive surgical margin or extraprostatic tissue. pT2R1 disease behaves as pT3R0 and should be treated similarly.

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

INTRODUCTION: The 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. MATERIALS AND METHODS: Of 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. RESULTS: The 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%. CONCLUSION: The 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.

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

INTRODUCTION: The 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. MATERIALS AND METHODS: 100 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. RESULTS: When 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. CONCLUSION: Extended biopsy, with the removal of 14 cores, is more efficient than the sextant procedure in improving the rate of prostate cancer detection.

The York-Mason technique for recto-urethral fistulas.

OBJECTIVE: Recto-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. MATERIAL AND METHODS: We 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. RESULTS: The causes of the fistula were radical retropubic prostatectomy in five patients, perineal debridement of Fournier's 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. CONCLUSION: The 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.

[Well differentiated localized prostate carcinoma: prognostic relevance of tertiary Gleason pattern 4 and tumor volume]. / O padrão 4 de Gleason e o volume tumoral no prognóstico do carcinoma da próstata.

INTRODUCTION: Early introduction of adjuvant radiation or hormone therapy after radical prostatectomy has been advocated in recent literature aiming to improve survival rates in high risk prostate cancer. Traditional prognostic parameters such as serum PSA, Gleason score and clinical stage have been used to identify these cases however accuracy is far from ideal. Recently, tumor volume and presence and percentage of a tertiary less differentiated Gleason pattern have been considered better indicators of prostate cancer behavior. The purpose of this study was to evaluate the importance of presence and percentage of a Gleason pattern 4 and of tumor volume in the outcome of patients treated for well-differentiated prostate adenocarcinoma. METHODS: Seventy seven patients submitted to radical prostatectomy for well-differentiated prostate carcinoma, Gleason score 6 or less, and followed up for at least 5 years were selected. Thirty seven experienced biochemical recurrence while 40 did not. The percentage of Gleason pattern 4, the percentage of the gland involvement (considered as "tumor volume"), capsular invasion and extraprostatic extension were submitted to univariate and multivariate analyses for the evaluation of possible associations with biochemical recurrence. RESULTS: Tumor volume was the most important parameter to predict biochemical recurrence by univariate and multivariate analysis. The median of tumor volume was 25.0% for patients who suffered recurrence, and 11.5% for those with no recurrence (p=0.003). The percentage of Gleason pattern 4 was predictive of recurrence in univariate analysis only. The median percentage of Gleason pattern 4 was 7.5% for patients without recurrence and 19.0% for those who presented recurrence (p=0.046). CONCLUSION: Tumor volume is very objective, easy to evaluate and the most important parameter to predict biochemical recurrence in well-differentiated adenocarcinoma of the prostate. On the other hand, presence and percentage of a tertiary less differentiated Gleason pattern correlated with systemic relapse. Both parameters should be included in future studies to evaluate the role of adjuvant therapy in high risk prostate cancer.

[Prostate cancer dedifferentiation following antiandrogen therapy: a morphological finding or an increased tumor aggressiveness?]. / Desdiferenciação do câncer da próstata após terapia antiandrogênica.

BACKGROUND: Neoadjuvant androgen deprivation in prostate cancer induces tumor volume regression but does not improve outcome of the patient. A possible explanation for this phenomenon could be an increase of the residual tumor aggressiveness brought about by antiandrogen therapy. The purpose of the present study was to evaluate the frequency of tumor dedifferentiation following androgen blockade in prostate cancer and to determine if the remaining tumor shows signs of increased aggressiveness. METHODS: Thirty patients bearing locally advanced prostate cancer (stages T2c - T3) were submitted to neoadjuvant anti-androgenic therapy during four months followed by radical prostatectomy. Gleason scores from biopsy and surgical specimens were compared. Furthermore, the cell proliferation index was evaluated by immunohistochemistry assay for PCNA, tests with strong nuclear staining were considered positive. The percentage of positive nuclei, counted in 500 cells, was determined in several categories of the Gleason score from surgical specimens. RESULTS: In 11(37%) surgical specimens the Gleason score was equal or lower than that found in the biopsy and in 19 (63%) the total score was higher in the surgical specimens (p<0.05). The median of PCNA expression was 4.5%, 10%, 12% and 14% in Gleason scores 2-4, 5-6,7 and 8-10, respectively (p>0.05). The median of cell proliferation indexes was 9% for glandular or specimen confined tumors and was 17% for extraprostatic tumors (p<0.05). CONCLUSION: The lower Gleason score was found in almost 2/3 of patients submitted to antiandrogen therapy. However, the cell proliferation index measured by PCNA was the same for tumors with lower or higher Gleason scores. It seems that cell dedifferentiation seen after neoadjuvant androgen deprivation represents a mere morphologic phenomenon and not a real increase in tumor aggressiveness.

The role of HER2/neu, BCL2, p53 genes and proliferating cell nuclear protein as molecular prognostic parameters in localized prostate carcinoma.

CONTEXT: Prostate cancer is the most frequent solid genitourinary neoplasm in men. Involvement of several genes has been described in the promotion and progression of prostate carcinoma. OBJECTIVE: To study the expression of the oncogenes HER2/neu and BCL2, tumor suppressor gene p53 and the tumor proliferation rate in 150 radical prostatectomy specimens, in order to define their role as prognostic parameters in localized prostate cancer. TYPE OF STUDY: Prospective study. SETTING: Universidade Federal de São Paulo and Hospital Sírio Libanês, Sao Paulo PARTICIPANTS: One hundred and fifty men who were submitted to radical prostatectomy between August 1997 and August 1998, for localized prostate cancer. MAIN MEASUREMENTS: All specimens underwent evaluation in their entirety, to determine tumor volume percentage, tumor extent and Gleason score. Immunohistochemistry was performed to determine gene expression using anti- HER2/neu, BCL2 and p53 antibodies, and proliferating cell nuclear antigen. The chi-squared test was used for correlation between gene expression, proliferative activity and histological variables. RESULTS: Thirty percent of the cases were p53 positive. There was positive correlation between p53 expression and tumor stage. The p53 expression was 22.9% and 42.6% for pT2 and pT3 tumors, respectively (p = 0.01). Expression of HER2/neu, BCL2 and proliferating cell nuclear antigen was identified in 66%, 23% and 43% of patients, respectively. There was no correlation between these three parameters and tumor volume, Gleason score or tumor stage. CONCLUSION: One-third of prostate adenocarcinomas express p53 protein, and this characteristic is related to tumor stage. HER2/neu is frequently expressed in prostate carcinomas, with no correlation with histological parameters. BCL2 is rarely expressed, and together with proliferative activity has no relationship with prognostic pathological variables in these neoplasms.

Incidental and symptomatic renal tumors: impact on patient survival.

CONTEXT: Renal cell carcinoma is the third most frequent genitourinary neoplasia, and there is currently an increase in the incidental diagnosis of tumors confined to the kidneys. OBJECTIVE: To study the survival of patients with incidental and symptomatic renal tumors who have undergone nephrectomy. DESIGN: Retrospective. SETTING: Hospital Sírio Libanês and Hospital Beneficência Portuguesa de São Paulo. PARTICIPANTS: 115 patients with diagnosis of renal cell carcinoma, operated on by the same group of surgeons and evaluated by a single pathologist. MAIN MEASUREMENTS: Sex, age and diagnosis method, analyzed in two groups, according to the tumor diagnosis: Group 1 with incidental diagnosis and Group 2 with symptomatic tumors. The anatomopathological characteristics and patient survival in both groups were evaluated. A statistical analysis was performed using the Student t, chi-squared, log rank and Kaplan-Meyer tests. RESULTS: Among the studied patients, 59(51%) had an incidental diagnosis, with 78% diagnosed by ultrasonography, 20% by computerized tomography scan and 2% during surgeries; 56 patients (49%) were symptomatic. Tumor locations were equally distributed between the two kidneys, and the surgery was conservative for 24% of the incidental and 9% of the symptomatic group. In the incidental group only one patient had tumor progression and there was no death, while in the symptomatic group there were 5 progressions and 10 deaths. The 5-year specific cancer-free survival was 100% in the incidental and 80% in the symptomatic group (p = 0.001) while the disease-free rate was 98% in the incidental and 62% in the symptomatic group (p < 0001). CONCLUSION: Incidental renal tumor diagnosis offers better prognosis, providing longer disease-free survival.

[Extraprostatic disease prediction in patients with carcinoma of the prostate: role of PSA, prostatic biopsy fragments percentage and Gleason score]. / Avaliação da extensão da neoplasia em câncer da próstata: valor do PSA, da percentagem de fragmentos positivos e da escala de Gleason.

OBJECTIVE: To valuate the behavior of the prostatic biopsy fragments percentage, guided by transrectal ultrasonography in extraprostatic disease prediction in patients with localized adenocarcinoma of the prostate gland and, also, to compare the efficiency of this pattern with them got by the valuation of PSA and preoperative Gleason score. METHODS: This retrospective non-controlled study consisted of 522 patients with adenocarcinoma located in the prostate. They were submitted to surgical treatment through retropubic radical prostatectomy. The ages of the patients ranged from 42 to 76 years with a mean of 62.44 years. All of them were submitted to transrectal ultrasonography with prostatic biopsy (direct of the lesion and/or suspected area and sextant) previous to the radical surgical treatment. The 522 patients were divided in groups according to the positive fragments found by the biopsy, what was correlated with the anatomicpathologic findings of intraprostatic disease (limited to the gland) and extraprostatic (invasion periprostatic adiposity and/or the bladder neck and/or the seminal vesicles and/or positive pelvic lymph nodes) of the surgical specimen. RESULTS: Regarding the analysis of the positive fragments percentage, the groups G1 (0-25%), G2 (20-50%) and G3 (51-75%) showed an incidence of the intraprostatic disease two and three times greater than the extraprostatic one. However, when more than 75% of the biopsy fragments were positive (G4, 76-100%), the relation inverted occurring a predominance of the extraprostatic disease over the intraprostatic. In this group 56.98% of the patients showed extraprostatic disease. There was a statistically significant difference of the extraprostatic disease between the groups G3 and G4 (p 0.0068). CONCLUSION: When we compared the three inconstant to evaluate the efficiency order anticipating extraprostatic disease, we verified that the preoperative PSA was the most discriminated (p = 0.000000) followed by the Gleason score of prostatic biopsy (p = 0.000003) and by the positive biopsies percentage (p = 0.000574).

[Incidental and symptomatic kidney cancer: pathological features and survival]. / Carcinoma de células renais incidentais e sintomáticos: fatores patológicos e sobrevida.

BACKGROUND: Patients with early diagnosis of renal cell carcinoma (CCR) have higher chance of cure following surgical treatment. This study was set to compare the pathological characteristics between the surgical specimens and the survival of the patients with incidental and symptomatic CCR. METHODS: One hundred and fifteen patients with sporadic CCR were studied retrospectively following nephrectomy and divided into two groups. Group 1; 59 patients with incidental diagnosis and Group 2; 56 symptomatic patients. The mean age of the patients was 59 years, with 86 men and 29 women. Radical nephrectomy was performed in 96 patients and the conservative surgery was performed in the remaining 19. Comparison parameters included pathological outcome, specifically nuclear grade, pathological stage, size of the tumor and presence of microvascular invasion intratumoral and patients survival. RESULTS: Comparison between the two groups confirmed that the incidental tumors have smaller nuclear grade (p=0.003), smaller size (p=0.001), smaller incidence of microvascular invasion (p<0.001) and lower stage (p<0.001). Disease specific survival and recurrence free survival of the incidental group were statistically higher than the symptomatic group (p<0.001). CONCLUSION: Incidentally discovered CCR have more favorable pathological characteristics, the patients have disease free survival when compared to symptomatic CCR.

[Must the TNM staging of the renal cell carcinoma be modified again?]. / O estadiamento TNM do carcinoma de células renais deve ser modificado novamente ?

OBJECTIVE: The behavior of the renal cells carcinoma stage PT1 is not completely clarified. We studied the presence of factors after prognostics and tumoral size in the recurrence of survival of the sporadic kidney carcinoma after surgical treatment. METHODS: 120 patients followed after nephrectomy had been revised retrospectively 93 PT1, 9 PT2, 11 PT3, 7 PT4, It was analyzed survival and recurrence of the disease inside of three groups of tumors: Group 1: < 4cm, group 2: 4-7cm and group 3: > 7cm, and the prognostics factors above-mentioned evaluated were nuclear degree, microvascular invasion, presence of committed ganglia and sarcomatous degeneration. RESULTS: The frequency of adverse prognostics factors increase as the tumor size increase. In the group 1, we had only four tumors of high degree and only one shown microvascular invasion that does not committed ganglia or sarcomatous degeneration. In group 2 there was 16 tumors of high degree, 4 sarcomatoses, two with positive microvascular invasion and two with positive ganglia. In group 3, was found 18 tumors of high degree, 15 with microvascular invasion and 7 with positive ganglia and 5 sarcomatoses. There was statistical significance in the specific cancer survival (p=0.002) and free of illness (p=0.0002) between the three groups. CONCLUSION: The evolution of tumors PT1 is distinct for lesser tumors of 4 cm and 4-7 cm fitting the subdivision of these two groups in T1a and T1b.

Biochemical recurrence rates are similar for pT2-positive surgical margins and pT3a

Objective Histological details of positive surgical margins in radical prostatectomy specimens have been related to outcome after surgery in rare studies recently published. Our objective is to assess whether the status of surgical margins, the extent and the Gleason score of positive margins, and the extent of the extraprostatic extension are predictive of biochemical recurrence post-radical prostatectomy.Materials and Methods Three hundred sixty-five radical prostatectomy specimens were analyzed. The length of the positive surgical margin and extraprostatic extension and the Gleason score of the margin were recorded. Statistical analyses examined the predictive value of these variables for biochemical recurrence.Results 236 patients were stage pT2R0, 58 pT2R1, 25 pT3R0 and 46 pT3R1. Biochemical recurrence occurred in 11%, 31%, 20% and 45.7% of pT2R0, pT2R1, pT3R0 and pT3R1, respectively. The extent of the positive surgical margins and the Gleason score of the positive surgical margins were not associated with biochemical recurrence in univariate analysis in a mean follow up period of 35.9 months. In multivariate analyses, only the status of the surgical margins and the global Gleason score were associated with biochemical recurrence, with a risk of recurrence of 3.1 for positive surgical margins and of 3.8 for a Gleason score > 7.Conclusion Positive surgical margin and the global Gleason score are significant risk factors for biochemical recurrence post-radical prostatectomy, regardless of the extent of the surgical margin, the extent of the extraprostatic extension, or the local Gleason score of the positive surgical margin or extraprostatic tissue. pT2R1 disease behaves as pT3R0 and should be treated similarly.

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

OBJECTIVE: We 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. MATERIALS AND METHODS: From 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. RESULTS: Squamous 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. CONCLUSIONS: Squamous 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.

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

OBJECTIVE: Determine the prognostic value of perineural invasion (PNI) in patients with transitional cell carcinoma (TCC) of the bladder treated with radical cystectomy. MATERIALS AND METHODS: From 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. RESULTS: The 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. CONCLUSIONS: The 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.

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

OBJECTIVE: Preoperative 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. MATERIALS AND METHODS: Biopsy 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. RESULTS: The 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. CONCLUSIONS: The 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 tumor invasion, tumor size and Fuhrman grade: a pathological triad for prognostic evaluation of renal cell carcinoma.

PURPOSE: The biological behavior and clinical outcome of renal cell carcinoma are difficult to predict. We investigated the prognostic impact of clinicopathological variables to establish a risk stratification model to predict recurrence and survival rates. MATERIALS AND METHODS: We studied 230 patients with renal cell carcinoma (stages T(1-4) N(x) M(0)) who underwent radical nephrectomy and/or nephron sparing surgery, and were followed for a median of 48 months (range 3 to 140). Univariate and multivariate analyses were performed, and the influence of clinical presentation, histological tumor size, tumor grade, lymph node involvement and microvascular tumor invasion on disease-free and cancer specific survival curves was determined. A composition model based on independent prognostic variables was then created to stratify tumors into low, intermediate and high risk of progression. RESULTS: The tumor recurrence rate was 17% (39 of 230) and the cancer specific mortality rate was 13% (31 of 230). Multivariate analyses determined that microvascular tumor invasion, tumor grade and tumor size were the only independent prognostic factors. Disease-free survival rates for low, intermediate and high risk tumors were 94.7%, 56.8% and 13.1%, respectively. Cancer specific survival rates were 94.7%, 61.7% and 32.0%, respectively. CONCLUSIONS: Tumor size, Fuhrman grade and microvascular tumor invasion are strong and independent predictors of survival of patients with renal cell carcinoma. Risk assessment and stratification based on this triad of pathological features may allow better individualization of followup schedules and trials of adjuvant treatment for patients with renal cell carcinoma.

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

The 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.

Of 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.

The 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%.

The 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. .

Salvage radical prostatectomy: an alternative treatment for local recurrence of radioresistant cancer.

OBJECTIVES: The treatment of recurrent prostate cancer after radiotherapy or brachytherapy through radical prostatectomy has been little indicated due to the concern over the procedure's morbidity. We present the experience of our service with postradiotherapy radical prostatectomy. MATERIALS AND METHODS: Between 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. RESULTS: Preradiotherapy 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). CONCLUSION: Salvage radical prostatectomy is a safe and effective alternative for the treatment of locally recurrent prostate cancer after radiotherapy and brachytherapy.

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

OBJECTIVE: To assess the influence of age in pathological findings and clinical evolution of prostate cancer in patients treated with radical prostatectomy. MATERIALS AND METHODS: Five 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. RESULTS: Patients 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). CONCLUSIONS: Even though younger patients presented more favorable preoperative characteristics, postoperative pathological findings and biochemical recurrence rates did not differ between studied age groups.

A new nomogram to predict pathologic outcome following radical prostatectomy.

OBJECTIVE: To develop a preoperative nomogram to predict pathologic outcome in patients submitted to radical prostatectomy for clinical localized prostate cancer. MATERIALS AND METHODS: Nine hundred and sixty patients with clinical stage T1 and T2 prostate cancer were evaluated following radical prostatectomy, and 898 were included in the study. Following a multivariate analysis, nomograms were developed incorporating serum PSA, biopsy Gleason score, and percentage of positive biopsy cores in order to predict the risks of extraprostatic tumor extension, and seminal vesicle involvement. RESULTS: In univariate analysis there was a significant association between percentage of positive biopsy cores (p < 0.001), serum PSA (p = 0.001) and biopsy Gleason score (p < 0.001) with extraprostatic tumor extension. A similar pathologic outcome was seen among tumors with Gleason score 7, and Gleason score 8 to 10. In multivariate analysis, the 3 preoperative variables showed independent significance to predict tumor extension. This allowed the development of nomogram-1 (using Gleason scores in 3 categories - 2 to 6, 7 and 8 to 10) and nomogram-2 (using Gleason scores in 2 categories - 2 to 6 and 7 to 10) to predict disease extension based on these 3 parameters. In the validation analysis, 87% and 91.1% of the time the nomograms-1 and 2, correctly predicted the probability of a pathological stage to within 10% respectively. CONCLUSION: Incorporating percent of positive biopsy cores to a nomogram that includes preoperative serum PSA and biopsy Gleason score, can accurately predict the presence of extraprostatic disease extension in patients with clinical localized prostate cancer.