Prognostic significance of lymphovascular invasion in radical prostatectomy specimens

Study Type – Prognosis (systematic review) Level of Evidence 1a What's known on the subject? and What does the study add? Prognostic factors such as serum PSA, tumor T stage, and Gleason grading are commonly used to predict disease progression and mortality in prostate cancer and to guide treatment decision‐making. These markers are combined to define risk strata that are commonly accepted in practice. Despite the assignment of patients to a specific risk stratum (e.g. intermediate‐risk disease), however, within‐stratum survival duration varies considerably, suggesting that many other factors, including lymphovascular invasion (LVI) may influence prognosis. LVI is currently a recognized prognostic factor in the management of some cancers (e.g. in early‐stage breast cancer) and prostate cancer is known to spread via lymphatic channels. Furthermore, the reporting of microscopic lymphovascular invasion is now considered part of the standard pathologic report of prostatectomy specimens. Nevertheless, scientific studies in this area have produced conflicting conclusions regarding the utility of LVI as a prognostic indicator in prostate cancer. This paper provides a comprehensive review and synthesis of the recent literature. Although a number of studies examining the role of LVI as an independent prognostic factor for biochemical recurrence in prostate cancer have been reported, the characteristics, quality and results of these studies vary considerably. The value of using LVI as a prognostic factor in prostate cancer remains unclear. This study provides a systematically‐performed synthesis of the results of recent research including lymphovascular invasion (LVI) in the multivariate analyses of potential prostate cancer prognostic factors. Not only do we report on the results of these studies, we assess the heterogeneity of the study populations, disease characteristics, and quality of the studies. Ultimately, we determined that meta‐analysis of the existing data is not possible, and thus, there is no ‘best estimate’ of the strength of association between LVI status and disease recurrence after prostatectomy. Most studies, but not all, reveal a weak or statistically insignificant association between LVI status and recurrence. We therefore conclude with a recommendation to clinicians that they should not overweight the importance of LVI status on clinical prognostication. The use of LVI status as a strong predictor of clinical outcomes is not recommended.

OBJECTIVES

• ? To synthesize the results of studies including lymphovascular invasion (LVI) in the multivariate analyses of potential prostate cancer prognostic factors.
• ? To determine the role of LVI as an independent prognostic factor for biochemical recurrence in prostate cancer.

PATIENTS AND METHODS

• ? We performed a comprehensive systematic literature review of studies examining the association between LVI in prostatectomy specimens and prostate cancer recurrence.
• ? Ovid MEDLINE, Embase, Web of Knowledge, Cochrane Database of Systematic Reviews, Database of Abstracts of Review of Effects (DARE) and Google Scholar were searched from January 2000 to February 2009.
• ? The primary outcome of interest was biochemical recurrence measured by serum prostate specific antigen (PSA).

RESULTS

• ? One thousand two hundred and forty‐eight papers met our search criteria. Of these, 19 articles meeting our selection criteria reported results of a multivariate analysis to evaluate LVI as an independent prognostic factor of biochemical recurrence.
• ? Eleven (58%) of these studies concluded that LVI was an independent prognostic factor.
• ? Significant heterogeneity in the study population, disease characteristics and quality of the studies prevented meta‐analysis of the results.
• ? In the nine studies in which the magnitude of independent association of LVI with recurrence was reported, it ranged from an odds ratio or relative risk of 1.37 to 4.39.

CONCLUSIONS

• ? The existing literature is conflicting and of insufficient homogeneity to definitively establish LVI as an important independent prognostic factor of biochemical recurrence in prostate cancer prostatectomy specimens.
• ? Additional adequately powered studies are required to determine the clinical value of reports of LVI involvement.
• ? In the meantime, the use of LVI status as an independent prognostic factor for clinical prognostication and medical decision making is not recommended.

     

Lymphovascular invasion is a pathological feature of biologically aggressive disease in patients treated with radical prostatectomy

We examined whether invasion of lymphatic and/or vascular vessels (LVI), or perineural spaces (PNI) is associated with prostate cancer features and outcome. MATERIALS AND METHODS: A total of 630 consecutive men underwent radical retropubic prostatectomy for clinically localized disease. LVI and PNI examination was part of the routine specimen evaluation. RESULTS: Foci of LVI were identified in 32 patients (5%) and 381 (60.5%) had PNI. LVI and PNI were associated with clinical stage T2 disease, higher biopsy and final Gleason sum, extraprostatic extension, seminal vesicle involvement, positive surgical margins and a higher percent of positive biopsy cores (p <0.001). LVI was associated with metastases to regional lymph nodes and higher preoperative serum prostate specific antigen (p <0.001 and 0.004, respectively). PNI and LVI were associated with an increased risk of rapid biochemical progression after radical prostatectomy on univariate (p <0.001 and 0.001, respectively) but not on multivariate analysis. LVI was associated with shorter prostate specific antigen doubling time after biochemical progression (p = 0.012) and higher probabilities of failed local salvage radiation therapy (p = 0.0169), distant metastases (p <0.001) and death (p <0.001). CONCLUSIONS: Only LVI is associated with metastases to regional and distant sites, and most importantly with overall survival. LVI and PNI are associated with established markers of biologically aggressive disease and rapid biochemical progression in patients who underwent radical prostatectomy. Our findings support the routine evaluation of LVI status in radical prostatectomy specimens and its inclusion in predictive models for clinical outcomes, since it appears to be a pathological marker of the lethal phenotype of prostate cancer.     

Prognostic impact of lymphovascular invasion in radical prostatectomy specimens

OBJECTIVE: To estimate the prognostic value of lymphovascular invasion (LVI) in patients with node-negative prostate cancer treated by radical prostatectomy (RP). PATIENTS AND METHODS: In all, 412 patients with prostatic adenocarcinoma who had RP and pN0 status were analysed for all established standard pathological factors and LVI. The influence of these pathological findings on biochemical failure was evaluated by multivariate analysis with the Cox model. The mean (range) follow-up was 52.5 (10-116) months. RESULTS: LVI was identified in 42 patients (10.2%) and significantly associated with a high preoperative prostate-specific antigen (PSA) level, a high PSA density, high percentage of positive biopsy cores, high Gleason score, and seminal vesicle invasion. Of the 42 patients with LVI, 33 (79%) had a Gleason score of > or = 7 and 27 (64%) had pathological stage pT3. The 5-year biochemical-free survival was 87.3% for patients with no LVI and 38.3% with LVI on the RP specimen (P < 0.001). By multivariate analysis, LVI and Gleason score were independent predictors of biochemical failure. CONCLUSION: These results show that in addition to the Gleason score, only LVI is strongly correlated with biochemical failure after RP. These findings support the routine evaluation of LVI status in RP specimens and provide the option for its incorporation into nomograms predictive of oncological outcome.     

Positive surgical margins after radical retropubic prostatectomy: the influence of site and number on progression

PURPOSE: We assessed the effect of location and number of positive margins on biochemical progression in patients after radical retropubic prostatectomy for prostate cancer. MATERIALS AND METHODS: The incidence, location and number of positive surgical margins as well as recurrence and time to recurrence were evaluated in a consecutive series of 734 men who underwent radical retropubic prostatectomy for localized prostate cancer from 1992 through February 1999. RESULTS: Surgical margins were positive in 210 patients (29%), of whom 157 (75%) and 53 (25%) had 1 and more than 1 positive margin, respectively. Of the patients 53 (25%) with tumor at any inked margin had biochemical recurrence. We identified no significant association of a particular location with biochemical recurrence. Bladder neck location did not carry an increased risk of recurrence (hazard ratio 1.23, 95% confidence interval 0.54 to 2.80). However, these findings were made in a limited number of cases with positive bladder neck margins. Patients with more than 1 positive surgical margin were at increased risk for recurrence compared with those with a single positive surgical margin (hazard ratio 2.19, 95% confidence interval 1.11 to 4.32). In addition, prostate specific antigen greater than 20 ng./ml. and seminal vesicle invasion were significant predictors of progression. CONCLUSIONS: In patients with localized prostate cancer and positive surgical margins biochemical progression is not dictated by the specific location of a positive margin. However, multiple positive margins are associated with a significantly increased risk of biochemical recurrence. Longer followup and larger sample size are necessary to confirm these findings.     

Prognostic factors of persistently detectable PSA after radical prostatectomy

Objectives:   To determine predictive factors of detectable prostate-specific antigen (PSA) in patients submitted to radical prostatectomy (RP) and to define the prognostic role of this event.
Methods:   A total of 318 patients who underwent RP between 2002 and 2007 were selected from our prospective database. Selection criteria were: no neo-adjuvant therapy; surgical specimens analyzed and reviewed according to a standardized protocol by two pathologists; clinical stage T1,T2 or T3 N0; pathological stage T2–3/N0–1.
Results:   Median age was 65. 22 years. All patients had a PSA greater than 20 ng/mL (6.9%). Fifty-six patients had poorly differentiated prostate cancer at biopsy (17.6%) and 77 after pathological examination. Cancer stage was cT2/3 in 128 (40.2%) patients, pT3 in 79 (24.8%) patients and pN1 in 20 patients (6.2%). Surgical margins were positive in 89 cases (28%). Thirty-three of the 318 patients had detectable PSA (10.3%) after RP. Multivariate analysis confirmed PSA (odds ratio 3.07; P  = 0.0008), pT3a/b stage (odds ratio 2.72; P  = 0.0466) and nodal metastasis (odds ratio 5.68; P  = 0.0060) as independent predictors of detectable PSA after RP. Detectable PSA had a great impact on prognosis. Twenty-four of these 33 patients experienced a PSA progression and needed a second treatment. In a multivariate model, detectable PSA functioned as an independent predictor of PSA progression (hazard ratio 4.54; P  = 0.0000).
Conclusions:   In our experience, a detectable PSA after RP can be predicted by preoperative PSA, pathological stage and nodal status. Moreover, it represents a significant risk factor of PSA progression. The strong imbalance towards risk factors of systemic disease supports the use of hormonal therapy in case of progression.     

Prognostic value of syndecan-1 expression in patients treated with radical prostatectomy

OBJECTIVE

To investigate the association of syndecan‐1 expression with pathological features and disease progression in patients treated with radical prostatectomy (RP) as syndecan‐1 plays a role in the regulation of cell proliferation, migration, and differentiation and its expression is altered in various malignancies.

PATIENTS AND METHODS

Syndecan‐1 immunostaining was performed on a tissue microarray containing cores from 232 consecutive patients treated with RP and bilateral lymphadenectomy for clinically localized prostatic adenocarcinoma. Patients were categorized as having features of aggressive progression if they had evidence of metastases, an after progression prostate‐specific antigen (PSA) doubling time of <10 months, and/or failure to respond to local salvage radiation therapy. Expression was defined as ≥ 10% cells staining for syndecan‐1.

RESULTS

Syndecan‐1 was expressed in 86 patients (37.1%). Expression of syndecan‐1 was associated with higher PSA levels (P = 0.004), higher pathological Gleason sum (P = 0.027) and lymph nodes metastases (P = 0.027). Patients with syndecan‐1 expression were at significantly greater risk of PSA‐progression after surgery (P = 0.034) in univariate but not in multivariate analysis. Patients with features of aggressive progression (n = 22) were more likely to express syndecan‐1 than those with features of nonaggressive progression (63.6% vs 36.4%, P = 0.010). Patients with syndecan‐1 expression were at significantly greater risk of aggressive progression after surgery (P = 0.005) in univariate but not in multivariate analysis.

CONCLUSIONS

Expression of syndecan‐1 was associated with established features of biologically aggressive prostate cancer and PSA‐progression in univariate analysis. These findings suggest a role for syndecan‐1 in prostate carcinogenesis and progression.     

Adverse prognostic significance of capsular incision with radical retropubic prostatectomy

PURPOSE: The prognostic significance of capsular incision (CPI) at radical retropubic prostatectomy remains to be defined. To evaluate this we compared prostate specific antigen recurrence for with CPI to that with established pathological groups. MATERIALS AND METHODS: From January 1998 to December 2000, 409 men underwent radical retropubic prostatectomy at our medical center. CPI was defined as a positive posterior, lateral or posterolateral surgical margin without documented extraprostatic extension (EPE). Excluding patients with preoperative androgen ablation, positive lymph nodes or seminal vesicle involvement there were 129 with organ confined disease and negative surgical margins (pT2/-M), 18 with CPI, 29 with EPE and negative surgical margins (pT3a/-M), and 24 with EPE and positive surgical margins (pT3a/+M). We compared time to biochemical recurrence among these 4 groups using Kaplan-Meier estimates. Cox proportional hazard regression was performed to determine the HR of CPI vs the other groups, while controlling for age, prostate specific antigen, tumor volume and Gleason score. RESULTS: The 3-year likelihood of freedom from biochemical recurrence in the CPI group was 65%, for pT2/-M it was 96%, for pT3a/-M it was 91% and for pT3a/+M it was 58%. The adjusted HR with the 95% CI showed that the risk of biochemical recurrence with CPI was 8.4 times higher than that with pT2/-M (p = 0.002), 5.9 times higher than that with pT3a/-M (p = 0.046) and the same as that with pT3a/+M (p = 0.840). CONCLUSIONS: Isolated posterior, lateral and posterolateral CPI by our definition occurs not uncommonly and it may represent true incision of the capsule and/or difficulty in diagnosing EPE due to a lack of extraprostatic tissue in the surgical specimen. However, the prognostic significance of CPI as defined appears similar to that of pT3a with positive margins.     

Perineural invasion is a prognostic factor for biochemical failure after radical prostatectomy

Objectives:   To identify the prognostic significance of lymphovascular invasion (LVI) and perineural invasion (PNI) in patients undergoing radical prostatectomy for prostate cancer.
Methods:   Overall, 237 patients who had undergone radical prostatectomy for prostate cancer between 1995 and 2004 were analyzed for all clinical and pathological factors. The influence of these two pathological features on biochemical failure-free survival was evaluated by univariate and multivariate analysis.
Results:   Lymphovascular and perineural invasion were identified in 41 (17.2%) and 100 (42.0%) patients, respectively. LVI and PNI were significantly associated with the preoperative prostate-specific antigen (PSA) level, a higher PSA density, a higher pathological stage, a higher Gleason score, a higher frequency of extracapsular extension, a higher frequency of seminal vesicle invasion, and a higher frequency of a positive resection margin. Positive resection margins ( P  = 0.001) and perineural invasion ( P  = 0.011) were identified as independent factors associated with biochemical failure-free survival by the multivariate analysis.
Conclusions:   In this series, PNI was associated with established parameters of biologically aggressive disease, and was an important prognostic factor for biochemical failure-free survival in patients undergoing radical prostatectomy. This finding supports routine evaluation of the PNI status in radical prostatectomy specimens and suggests that patients with PNI should be more closely followed after surgery.     

Malignant cytological washings from prostate specimens: an independent predictor of biochemical progression after radical prostatectomy

PURPOSE: Malignant cells have previously been identified in the cytological washings of prostate specimens obtained at radical prostatectomy for clinically localized prostate cancer. We investigated whether malignant cells in the cytological washings of radical prostatectomy specimens predict biochemical progression. The affect of total androgen blockade on cytological washings was also examined. MATERIALS AND METHODS: Cytological washings were obtained from radical prostatectomy specimens in 147 consecutive patients undergoing the procedure for clinically localized prostate cancer between November 1993 and April 1998. Of the 147 patients 54 were randomly selected to receive 1 month of total androgen blockade immediately before prostatectomy. To obtain the cytological specimen the extirpated prostate was subjected to a normal saline bath, as previously described. The cytology specimen was examined by a single cytopathologist blinded to preoperative and pathological findings. Biochemical progression, defined as prostate specific antigen 0.15 ng./ml. or greater, was determined using the Kaplan-Meier method. We also performed multivariate analysis of factors related to progression, including prostate specific antigen, pathological stage, margin status, Gleason grade and cytology status. Median followup was 37 months (range 13 to 66). RESULTS: Followup was available in 146 of 147 cases. Cytological washings were malignant in 14 of 92 patients (15%) who did not receive total androgen blockade preoperatively. In this group without androgen blockade the biochemical progression rate was significantly higher in those with positive cytology (p < 0.001). Positive cytology was an independent predictor of progression on multivariate analysis and a stronger predictor of progression than Gleason grade. No malignant cells were observed in cases of preoperative total androgen blockade (p < 0.001). However, biochemical progression was similar in the groups with and without androgen blockade (p = 0.355). CONCLUSIONS: Malignant cells may be identified in the cytological washings of radical prostatectomy specimens and they are an independent predictor of biochemical progression. One month of total androgen blockade preoperatively significantly decreases the rate of positive cytology but does not appear to change the rate of early biochemical failure.     

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

THIS IS A COMMENT MODERATED PAPER
available at http://www.bjui.org/commentary Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Lymphovascular invasion (LVI) is a prognostic marker for biologically aggressive disease in numerous tumour types. Indeed, numerous studies have documented the negative prognostic value of LVI in bladder cancer patients who have undergone radical cystectomy, however few studies have evaluated the prognostic value of LVI at TURBT. The current study examines both the concordance between the presence of LVI at TURBT and radical cystectomy specimens and furthermore examines the survival implications of the presence of LVI at both TURBT and radical cystectomy.

OBJECTIVE

To evaluate the concordance transurethral resection of bladder tumour (TURBT) and radical cystectomy (RC) specimens with regard to the presence of lymphovascular invasion (LVI). Additionally, to evaluate the prognostic value of LVI in the prediction of lymph node metastases, overall survival, disease‐specific survival and recurrence‐free survival following RC.

PATIENTS AND METHODS

The records of 487 patients who underwent RC at our institution between 1987 and 2008 were retrospectively reviewed and evaluated for the presence or absence of LVI as determined by pathological evaluation. The presence or absence of LVI was then evaluated on previous transrectal resection specimens of this cohort of patients undergoing RC. Cox regression and Kaplan–Meier analysis were undertaken to evaluate the contribution of LVI to various outcomes.

RESULTS

Of 474 patients with complete LVI data, 60 (12.3%) were found to have LVI at TURBT compared to 161 (33.1%) at RC. Although the presence of LVI at TURBT was more significantly associated with the presence of LVI at RC, only 42.9% of patients in whom LVI was documented at TURBT were found to harbour LVI at RC. The risk of nodal disease was higher in those patients with LVI at TURBT than in those with no evidence of LVI at TURBT (48.3% vs 25.0%, P < 0.001). Additionally, LVI at TURBT was associated with an increasing risk of pathological upstaging and the receipt of adjuvant chemotherapy. Survival analysis showed a significant decrement in overall and recurrence‐free survival among those with LVI at TURBT compared to those with no evidence of LVI.

CONCLUSIONS

Lymphovascular invasion at TURBT provides useful prognostic information that should be incorporated into clinical decision‐making, particularly with regard to cystectomy for nonmuscle‐invasive carcinoma and the administration of neoadjuvant chemotherapy.     

Bladder neck involvement in pathological stage pT4 radical prostatectomy specimens is not an independent prognostic factor

PURPOSE: Bladder neck invasion by prostate cancer in radical prostatectomy specimens is uncommon and, thus, its influence on disease recurrence has not been well defined. Consequently the classification of bladder neck invasion in the TNM staging system is controversial. We studied our cohort of patients with stage pT4 disease and bladder neck invasion to clarify the true clinical behavior and prognostic significance of bladder neck invasion in radical prostatectomy specimens. MATERIALS AND METHODS: The study group consisted of 4,090 consecutive patients treated with radical prostatectomy at one of our institutions between 1983 and 2001. Median followup was 53.1 months (range 1 to 189). After excluding from analysis patients treated with neoadjuvant androgen withdrawal or preoperative irradiation 72 of the remaining 2,571 (2.8%) with bladder neck invasion were classified with stage pT4 disease and their specimens were reviewed. Progression-free probability was determined by Kaplan-Meier analysis. Using the Cox proportional hazards model the independent prognostic significance of bladder neck invasion was assessed after controlling for pretreatment prostate specific antigen, final Gleason sum, extracapsular extension, surgical margins status, seminal vesicle invasion and lymph node involvement. RESULTS: Of the 72 patients categorized with stage pT4 disease 14 (19%) had poorly differentiated Gleason sum 8 to 10 cancer, 38 (53%) had established extracapsular extension, 24 (33%) had seminal vesicle invasion and 8 (11%) had lymph node involvement. However, 26 patients (36%) had cancer confined to the prostate and 28 (39%) had negative surgical margins except for the bladder neck site. The mean 5-year progression-free probability plus or minus SD in all stage pT4 cases was 68% +/- 7%, which was better than in cases of seminal vesicle invasion (52% +/- 5%, log rank test p = 0.0156) but worse than in those of extracapsular extension (84% +/- 4.1%). Univariate analysis of the stage pT4 cohort revealed that higher prostatectomy Gleason sum, more extensive extracapsular extension and seminal vesicle invasion were significantly associated with an adverse prognosis. However, in a multivariate model that included all radical prostatectomy cases the finding of bladder neck invasion or stage pT4 disease did not independently predict prostate specific antigen recurrence. CONCLUSIONS: Stage pT4 disease comprises a heterogeneous group of tumors with various pathological features and inconsistent outcomes. Assigning the pT4 stage to cases of microscopic bladder neck invasion provides no independent ability for predicting disease progression after adjusting for other adverse disease features. Due to this and previously reported data the definition of stage pT4 disease should be modified in the next version of the TNM staging system.     

Lymphovascular invasion is an independent prognostic factor in prostatic adenocarcinoma

PURPOSE: Gleason grade and tumor stage are well established prognostic factors in prostate cancer. Histological demonstration of tumor in lymphovascular spaces has been associated with poor prognosis in many tumor types but it is not included in current prostate cancer grading and staging schemes. Whether lymphovascular invasion is an independent prognostic factor for disease progression in prostate cancer is uncertain. We retrospectively investigated lymphovascular invasion as a predictive factor for biochemical failure and cancer specific survival following radical prostatectomy. MATERIALS AND METHODS: The records of 504 patients with prostatic adenocarcinoma undergoing radical prostatectomy were reviewed for lymphovascular invasion. Clinical followup data were available on 459 cases. Mean followup was 44 months (range 1.5 to 144). Multivariate analysis was performed using the Cox model. RESULTS: Lymphovascular invasion was identified in 106 cases (21%). Univariate analysis showed a significant association between lymphovascular invasion and higher preoperative serum prostate specific antigen (PSA), advanced pathological stage, higher Gleason score, positive surgical margins, extraprostatic extension, seminal vesicle invasion, lymph node metastasis and perineural invasion (each p <0.001). No association was observed between lymphovascular invasion and patient age at surgery, prostate weight or high grade prostatic intraepithelial neoplasia. Lymphovascular invasion was an independent predictor of PSA recurrence (HR 1.6, 95% CI 1.12 to 2.38, p = 0.01) and cancer specific survival (HR 2.75, 95% CI 1.04 to 2.28, p = 0.041) after controlling for tumor stage, surgical margins and Gleason grade on multivariate analysis. Five-year cancer specific survival was 90% in men with lymphovascular invasion compared to 98% in those without lymphovascular invasion (p <0.001). CONCLUSIONS: Lymphovascular invasion can be identified in approximately 20% of prostate cancer cases. Lymphovascular invasion is an independent risk factor for PSA recurrence and cancer death in patients with prostate cancer.     

Predictors of seminal vesicle invasion before radical prostatectomy

AIM: To predict whether or not seminal vesicle invasion is present before radical prostatectomy, the relationships between clinical parameters and seminal vesicle invasion were analyzed. METHODS: A review was conducted of 187 patients who had been clinically diagnosed with stages A(2), B(0), B(1), B(2) or C prostate cancer and who had undergone radical prostatectomy without neoadjuvant therapy. The parameters analyzed for potential predictors of seminal vesicle invasion before radical prostatectomy included age, clinical stage, serum prostate-specific antigen (PSA) level at biopsy, tumor differentiation of biopsy specimens and percentage of cancer positive cores by biopsy. For percentage of cancer positive cores by biopsy, 143 of 187 patients who underwent transrectal sextant biopsy or more than six transrectal ultrasound guided core biopsies were evaluated. These parameters were subjected to univariate and multivariate logistic regression analyses to identify predictors for seminal vesicle invasion. RESULTS: The median age was 66.8 years (range 51-77 years). Of 187 patients, 27 (14.4%) had seminal vesicle invasion confirmed pathologically. There were significant differences in all parameters except for age between patients with positive and negative seminal vesicle invasion on univariate analysis. Multivariate analysis revealed that serum PSA level, tumor differentiation of biopsy specimens and percentage of cancer positive cores were significant independent predictors of seminal vesicle invasion. CONCLUSIONS: The results showed serum PSA level, tumor differentiation of biopsy specimens and percentage of cancer positive cores by biopsy before radical prostatectomy may be useful predictors for seminal vesicle invasion.     

Prognostic indicators for upper tract urothelial carcinoma after radical nephroureterectomy: the impact of lymphovascular invasion

Study Type – Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? In an array of urological and non‐urological malignancies, lymphovascular invasion (LVI) is a pathological feature known to be associated with adverse outcomes for recurrence and survival. For some cancers, LVI has therefore been incorporated into American Joint Committee on Cancer TNM staging algorithms. This study presents an analysis of the impact of LVI in upper urinary tract urothelial carcinoma (UTUC) treated at our institution over a 20‐year period. In addition to known associations with features of aggressive disease and overall survival, we were able to show that LVI‐positive status upsets the TNM staging for UTUC. Namely, patients with superficial stage and LVI‐positive disease have overall survival outcomes similar to those of patients with muscle‐invasive LVI‐negative carcinoma. Such evidence may support the addition of LVI to future TNM staging algorithms for UTUC.

OBJECTIVE

• ? To assess the impact of lymphovascular invasion (LVI) on the prognosis of patients with upper urinary tract urothelial cell carcinoma (UTUC) treated with radical nephroureterectomy (RNU).

PATIENTS AND METHODS

• ? The Columbia University Medical Center Urologic Oncology database was queried and 211 patients undergoing RNU for UTUC between 1990 and 2010 were identified.
• ? These cases were retrospectively reviewed, and the prognostic significance of relevant clinical and pathological variables was analysed using log‐rank tests and Cox proportional hazards regression models.
• ? Actuarial survival curves were calculated using the Kaplan–Meier method.

RESULTS

• ? LVI was observed in 68 patients (32.2%).
• ? The proportion of LVI increased with advancing stage, high grade, positive margin status, concomitant carcinoma in situ, and lymph node metastases. The 5‐ and 10‐year overall survival rates were 74.7% and 53.1% in the absence of LVI, and 35.7% and 28.6% in the presence of LVI, respectively.
• ? In multivariate analysis, age, race and LVI were independent predictors of overall survival.

CONCLUSIONS

• ? The presence of LVI on pathological review of RNU specimens was associated with worse overall survival in patients with UTUC.
• ? LVI status should be included in the pathological report for RNU specimens to help guide postoperative therapeutic options.
• ? With confirmation from large international studies, inclusion of LVI in the tumour‐node‐metastasis staging system for UTUC should be considered.

     

Extraperitoneal laparoscopic radical prostatectomy: a prospective evaluation of 600 cases

PURPOSE: We report our experience with the extraperitoneal approach to laparoscopic radical prostatectomy. We describe the technique, clinical and oncological results, and functional outcome. MATERIALS AND METHODS: From February 2002, to March 2004, 600 laparoscopic radical prostatectomies were performed by an extraperitoneal approach and evaluated prospectively. RESULTS: A total of 599 extraperitoneal procedures were performed successfully. Mean operative time was 173 minutes. Mean operative blood loss was 380 cc. The transfusion rate was 1.2%. The major and minor complications rate was 2.3% and 9.2%, respectively. The reoperation rate was 1.7%. Mean hospital stay was 6.3 days. Pathological stage was pT2 and pT3 in 72% and 28% of cases, respectively. Mean Gleason score was 7. The overall positive margin rate was 17.7% (14.6% and 25.6% of pT2 and pT3 tumors, respectively). Median followup was 12 months. Of the patients 95% had prostate specific antigen less than 0.2 ng/ml. Patients were evaluated by a self-questionnaire sent by mail before and after surgery (International Continence Society and International Index of Erectile Function-5). At a median followup of 12 months 84% of the patients were continent (no pad), 7% used 1 precautionary pad and 7% needed 1 pad routinely. At a median followup of 6 months in preoperatively potent patients (International Index of Erectile Function-5 greater than 20) the postoperative erection and intercourse rate was 64% and 43%, respectively, in those with bilateral nerve bundle preservation. CONCLUSIONS: The extraperitoneal technique is a reliable approach to laparoscopic radical prostatectomy.