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979 THE IMPACT OF URETHRAL FROZEN SECTION ATYPIA ON URETHRAL RECURRENCE IN PATIENTS WITH INVASIVE BLADDER CANCER
Vol. 185, No. 4S, Supplement, Monday, May 16, 2011
979 THE IMPACT OF URETHRAL FROZEN SECTION ATYPIA ON URETHRAL RECURRENCE IN PATIENTS WITH INVASIVE BLADDER CANCER Hooman Djaladat*, Eila C. Skinner, Gus Miranda, Jie Cai, Siamak Daneshmand, Los Angeles, CA INTRODUCTION AND OBJECTIVES: Presence of tumor at urethral frozen section is an important predictor of urethral recurrence in patients undergoing radical cystectomy. Urethral atypia is rarely reported by pathologists and has undetermined significance. We evaluated the incidence and outcomes of atypia on urethral frozen section in patients undergoing cystectomy and urinary diversion. METHODS: From 1971 to 2008, 1964 patients with bladder cancer underwent radical cystectomy at the University of Southern California. Urethral frozen sections were performed in 978 patients, and were categorized as no atypia or dysplasia (normal), atypia, and tumor. These three groups had a median follow-up of 12.1 yrs (0.1–36.6 yrs) and were analyzed for urethral recurrence and survival using uni/ multivariate analysis considering other contributing factors such as CIS, tumor multifocality, grade, stage and prostatic involvement. RESULTS: Of the 978 urethral frozen sections, 859 cases (88%) were normal and had a median follow-up of 6.07 yrs (0.1–24.2 yrs). 10 of these patients (1%) recurred in the urethra at a median of 2.5 yrs. A total of 64 patients (6%) had atypia only in urethral frozen section whose permanent pathologic analysis revealed: normal in 22 (34%), atypia in 35 (55%), tumor in 5 (7%), and denuded tissue in 2 (3%). Reviewing this cohort (64 patients) with a median follow up of 13.6 yrs (0.3–22.1 yrs), 3 (4%) had a urethral recurrence at a median of 1 yr; univariate survival analyses could not rule out the possible confounding effect of CIS, multifocality and prostatic involvement on urethral recurrence. 55 of the 978 patients (6%) had tumor at urethral frozen in whom through a median follow-up of 5.9 yrs (0.1–16.7 yrs), three (5%) relapsed in urethra at a median of 0.8 yrs. Compared to normal urethra frozen section, the relative risk of urethral recurrence in atypia and tumor frozen section cases was 3.4 and 5.11 respectively (p⬍0.001). Five-year urethral recurrence free rate was 0.98⫹0.01 in normal group, 0.94⫹0.03 in atypia and 0.93⫹0.04 in tumor group (P⫽0.008). Atypia at urethral frozen had no significant effect on overall survival. CONCLUSIONS: Atypia is reported in about 6% of urethral frozen sections. Urethral recurrence is more common in patients with atypia or tumor in urethral frozen section. Although this may suggest an aggressive initial approach or possible heterotopic diversion to patients with either pathologic finding, neither of them has significant effect on survival rate. Source of Funding: None
980 URETHRAL RECURRENCE AFTER RADICAL CYSTECTOMY AND ILEAL ORTHOTOPIC BLADDER SUBSTITUTION: CAN THE URETHRA BE SPARED? Gianluca Giannarini*, Thomas M. Kessler, Bernhard Kiss, Urs E. Studer, George N. Thalmann, Bern, Switzerland INTRODUCTION AND OBJECTIVES: The optimal management of urethral recurrence after radical cystectomy and orthotopic bladder substitution is still a matter of debate. We assessed the long-term outcome of patients with urethral recurrence after radical cystectomy and ileal orthotopic bladder substitution. METHODS: We retrospectively analyzed 495 consecutive patients with bladder carcinoma and no neoadjuvant therapy who underwent extended pelvic lymph node dissection and radical cystectomy with ileal orthotopic bladder substitution. Preoperative paracollicular (men) or bladder neck (women) biopsies were negative for carcinoma. All patients were prospectively followed with a standardized protocol, including urethral cytology 6-monthly for 2 years, then annually for 3 years. In case of positive cytology, urethroscopy with biopsy and staging for metastases were performed. Based on recurrence stage,
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patients were treated with endourethral bacillus Calmette-Gue´rin (BCG) (6 weekly instillations with 81 mg in 150 ml saline), transurethral resection plus endourethral BCG, urethrectomy or systemic chemotherapy. Urethral recurrence rate, detection rate by cytology, urethrapreservation rate after endourethral BCG and overall survival with preserved urethra were the study outcome measures. RESULTS: After a median follow-up of 45 months (range 3–250) urethral recurrence was diagnosed in 24/495 (4.8%) patients, in 21 (88%) by cytology and in 3 (12%) by hematuria. Carcinoma in situ (Tis), Ta/T1 and T2 recurrences were detected in 13, 7 and 4 patients, respectively. All patients with Tis were treated with endourethral BCG, and 6 of 7 with Ta/T1 recurrence with transurethral resection plus endourethral BCG. Urethrectomy was performed in 1 patient with T2 recurrence, while systemic chemotherapy was given to 4 patients (1 with Ta and 3 with T2 recurrence) due to concomitant metastases. The urethra could be preserved in 11/13 patients with Tis and 3/6 with Ta/T1 recurrence treated with endourethral BCG. Six of 13 patients with Tis, 1/7 with Ta/T1 recurrence and 0/4 with T2 recurrence are still alive with preserved urethra and no evidence of disease. CONCLUSIONS: With routine cytology approximately 90% of urethral recurrences can be detected. In patients with Tis recurrence, the urethra should be primarily spared, since endourethral BCG is successful in most cases. On the contrary, in patients with Ta/T1 recurrence urethrectomy is usually required. Patients with T2 recurrence have a poor prognosis due to frequent concomitant metastases. Source of Funding: None
Prostate Cancer: Detection and Screening Podium 27 Monday, May 16, 2011
10:30 AM-12:30 PM
981 PCA3 AS A PREDICTOR OF UNFAVORABLE CONFIRMATORY BIOPSY PATHOLOGY IN CANDIDATES FOR ACTIVE SURVEILLANCE Sergey Shikanov*, Gautam Jayram, Chicago, IL; Michael S. McGuire, Charles B. Brendler, Evanston, IL INTRODUCTION AND OBJECTIVES: Urinary PCA3 is considered a specific marker of prostate cancer volume. We assessed its ability to predict unfavorable confirmatory biopsy pathology in comparison to both PSA and PSA density (PSAD) in men with prostate cancer being considered for active surveillance. METHODS: The cohort consisted of 71 candidates for active surveillance with clinical stage T1c, Gleason score 6, positive cores ⱕ3 and no involvement of a positive core ⱖ50% on diagnostic biopsy. Confirmatory biopsy revealing Gleason score ⱖ7, ⬎3 positive cores, or ⬎50% involvement of any single core was considered unfavorable. Urinary PCA3, serum PSA and PSAD were compared among men with favorable and unfavorable confirmatory biopsies. Predictive ability of these parameters was determined by ROC analysis. RESULTS: Twenty percent of men (n⫽14) had unfavorable confirmatory biopsies. Median PCA3 was 30 and 54 (p⫽0.1) in men with favorable and unfavorable biopsies, respectively. Forty-four percent and 71% had PCA3 ⬎35 among those with favorable and unfavorable biopsies, respectively (p⫽0.06) (Table 1). On ROC analysis, area under the curve was 0.65 for PCA3 overall, 0.65 for Pca3⬎35, 0.63 for PSA and 0.72 for PSA density. CONCLUSIONS: These preliminary results suggest that PCA3 is no better than either PSA or PSAD in predicting the results of confirmatory biopsies in prostate cancer patients being considered for active surveillance.
979 THE IMPACT OF URETHRAL FROZEN SECTION ATYPIA ON URETHRAL RECURRENCE IN PATIENTS WITH INVASIVE BLADDER CANCER Hooman Djaladat*, Eila C. Skinner, Gus Miranda, Jie Cai, Siamak Daneshmand, Los Angeles, CA INTRODUCTION AND OBJECTIVES: Presence of tumor at urethral frozen section is an important predictor of urethral recurrence in patients undergoing radical cystectomy. Urethral atypia is rarely reported by pathologists and has undetermined significance. We evaluated the incidence and outcomes of atypia on urethral frozen section in patients undergoing cystectomy and urinary diversion. METHODS: From 1971 to 2008, 1964 patients with bladder cancer underwent radical cystectomy at the University of Southern California. Urethral frozen sections were performed in 978 patients, and were categorized as no atypia or dysplasia (normal), atypia, and tumor. These three groups had a median follow-up of 12.1 yrs (0.1–36.6 yrs) and were analyzed for urethral recurrence and survival using uni/ multivariate analysis considering other contributing factors such as CIS, tumor multifocality, grade, stage and prostatic involvement. RESULTS: Of the 978 urethral frozen sections, 859 cases (88%) were normal and had a median follow-up of 6.07 yrs (0.1–24.2 yrs). 10 of these patients (1%) recurred in the urethra at a median of 2.5 yrs. A total of 64 patients (6%) had atypia only in urethral frozen section whose permanent pathologic analysis revealed: normal in 22 (34%), atypia in 35 (55%), tumor in 5 (7%), and denuded tissue in 2 (3%). Reviewing this cohort (64 patients) with a median follow up of 13.6 yrs (0.3–22.1 yrs), 3 (4%) had a urethral recurrence at a median of 1 yr; univariate survival analyses could not rule out the possible confounding effect of CIS, multifocality and prostatic involvement on urethral recurrence. 55 of the 978 patients (6%) had tumor at urethral frozen in whom through a median follow-up of 5.9 yrs (0.1–16.7 yrs), three (5%) relapsed in urethra at a median of 0.8 yrs. Compared to normal urethra frozen section, the relative risk of urethral recurrence in atypia and tumor frozen section cases was 3.4 and 5.11 respectively (p⬍0.001). Five-year urethral recurrence free rate was 0.98⫹0.01 in normal group, 0.94⫹0.03 in atypia and 0.93⫹0.04 in tumor group (P⫽0.008). Atypia at urethral frozen had no significant effect on overall survival. CONCLUSIONS: Atypia is reported in about 6% of urethral frozen sections. Urethral recurrence is more common in patients with atypia or tumor in urethral frozen section. Although this may suggest an aggressive initial approach or possible heterotopic diversion to patients with either pathologic finding, neither of them has significant effect on survival rate. Source of Funding: None
980 URETHRAL RECURRENCE AFTER RADICAL CYSTECTOMY AND ILEAL ORTHOTOPIC BLADDER SUBSTITUTION: CAN THE URETHRA BE SPARED? Gianluca Giannarini*, Thomas M. Kessler, Bernhard Kiss, Urs E. Studer, George N. Thalmann, Bern, Switzerland INTRODUCTION AND OBJECTIVES: The optimal management of urethral recurrence after radical cystectomy and orthotopic bladder substitution is still a matter of debate. We assessed the long-term outcome of patients with urethral recurrence after radical cystectomy and ileal orthotopic bladder substitution. METHODS: We retrospectively analyzed 495 consecutive patients with bladder carcinoma and no neoadjuvant therapy who underwent extended pelvic lymph node dissection and radical cystectomy with ileal orthotopic bladder substitution. Preoperative paracollicular (men) or bladder neck (women) biopsies were negative for carcinoma. All patients were prospectively followed with a standardized protocol, including urethral cytology 6-monthly for 2 years, then annually for 3 years. In case of positive cytology, urethroscopy with biopsy and staging for metastases were performed. Based on recurrence stage,
THE JOURNAL OF UROLOGY姞
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patients were treated with endourethral bacillus Calmette-Gue´rin (BCG) (6 weekly instillations with 81 mg in 150 ml saline), transurethral resection plus endourethral BCG, urethrectomy or systemic chemotherapy. Urethral recurrence rate, detection rate by cytology, urethrapreservation rate after endourethral BCG and overall survival with preserved urethra were the study outcome measures. RESULTS: After a median follow-up of 45 months (range 3–250) urethral recurrence was diagnosed in 24/495 (4.8%) patients, in 21 (88%) by cytology and in 3 (12%) by hematuria. Carcinoma in situ (Tis), Ta/T1 and T2 recurrences were detected in 13, 7 and 4 patients, respectively. All patients with Tis were treated with endourethral BCG, and 6 of 7 with Ta/T1 recurrence with transurethral resection plus endourethral BCG. Urethrectomy was performed in 1 patient with T2 recurrence, while systemic chemotherapy was given to 4 patients (1 with Ta and 3 with T2 recurrence) due to concomitant metastases. The urethra could be preserved in 11/13 patients with Tis and 3/6 with Ta/T1 recurrence treated with endourethral BCG. Six of 13 patients with Tis, 1/7 with Ta/T1 recurrence and 0/4 with T2 recurrence are still alive with preserved urethra and no evidence of disease. CONCLUSIONS: With routine cytology approximately 90% of urethral recurrences can be detected. In patients with Tis recurrence, the urethra should be primarily spared, since endourethral BCG is successful in most cases. On the contrary, in patients with Ta/T1 recurrence urethrectomy is usually required. Patients with T2 recurrence have a poor prognosis due to frequent concomitant metastases. Source of Funding: None
Prostate Cancer: Detection and Screening Podium 27 Monday, May 16, 2011
10:30 AM-12:30 PM
981 PCA3 AS A PREDICTOR OF UNFAVORABLE CONFIRMATORY BIOPSY PATHOLOGY IN CANDIDATES FOR ACTIVE SURVEILLANCE Sergey Shikanov*, Gautam Jayram, Chicago, IL; Michael S. McGuire, Charles B. Brendler, Evanston, IL INTRODUCTION AND OBJECTIVES: Urinary PCA3 is considered a specific marker of prostate cancer volume. We assessed its ability to predict unfavorable confirmatory biopsy pathology in comparison to both PSA and PSA density (PSAD) in men with prostate cancer being considered for active surveillance. METHODS: The cohort consisted of 71 candidates for active surveillance with clinical stage T1c, Gleason score 6, positive cores ⱕ3 and no involvement of a positive core ⱖ50% on diagnostic biopsy. Confirmatory biopsy revealing Gleason score ⱖ7, ⬎3 positive cores, or ⬎50% involvement of any single core was considered unfavorable. Urinary PCA3, serum PSA and PSAD were compared among men with favorable and unfavorable confirmatory biopsies. Predictive ability of these parameters was determined by ROC analysis. RESULTS: Twenty percent of men (n⫽14) had unfavorable confirmatory biopsies. Median PCA3 was 30 and 54 (p⫽0.1) in men with favorable and unfavorable biopsies, respectively. Forty-four percent and 71% had PCA3 ⬎35 among those with favorable and unfavorable biopsies, respectively (p⫽0.06) (Table 1). On ROC analysis, area under the curve was 0.65 for PCA3 overall, 0.65 for Pca3⬎35, 0.63 for PSA and 0.72 for PSA density. CONCLUSIONS: These preliminary results suggest that PCA3 is no better than either PSA or PSAD in predicting the results of confirmatory biopsies in prostate cancer patients being considered for active surveillance.