UROLOGICAL SURVEY   ( Download pdf )

 

PATHOLOGY

Bladder neck invasion is an independent predictor of prostate-specific antigen recurrence
Poulos CK, Koch MO, Eble JN, Daggy JK, Cheng L
Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, USA
Cancer. 2004; 101: 1563-8

  • Background: The 1997 TNM staging system for prostatic carcinoma and the 2002 revision thereof classified prostatic carcinoma with bladder neck involvement classified as pT4 disease. This classification is based on the belief that tumors that invade surrounding structures are more aggressive and warrant higher staging than tumors that do not invade surrounding structures. Recent reports in the literature suggested that microscopic involvement of the bladder neck does not carry independent prognostic significance. Therefore, resection specimens with bladder neck involvement should not be classified as pT4. The current study prospectively examined the prognostic significance of bladder neck involvement by prostatic carcinoma.
  • Methods: The authors analyzed the totally embedded and whole-mounted radical prostatectomy specimens from 364 consecutive patients. The mean patient age was 66 years (range, 41-77 years). The bladder neck, which had been coned from the specimen, was cut in a perpendicular fashion. Involvement of the bladder neck was defined as the presence of neoplastic cells within the smooth muscle bundles of the coned bladder neck. The data were prospectively collected. Bladder neck involvement was analyzed in relation to age, preoperative prostate-specific antigen (PSA) level, prostate weight, Gleason score, final pathologic classification, tumor volume, surgical margin status, the presence of high-grade prostate intraepithelial neoplasm, multifocality, seminal vesicle invasion, extraprostatic extension, perineural invasion, and PSA recurrence.
  • Results: Bladder neck involvement was found in 22 (6%) of 364 patients. Univariate results indicated that bladder neck involvement versus no bladder neck involvement was significantly associated with preoperative PSA (P < 0.001), higher pathologic classification (P < 0.001), larger tumor volume (P < 0.001), extraprostatic extension (P < 0.001), positive surgical margins (P < 0.001), and PSA recurrence (P = 0.003). In a multivariate logistic regression model controlling for pathologic classification, Gleason score, and surgical margin status, bladder neck involvement was an independent predictor of PSA recurrence (P = 0.04). The adjusted odds ratio for bladder neck involvement was 3.3 (95% confidence interval, 1.04-10.03).
  • Conclusions: In the current study, bladder neck involvement was an independent predictor of early PSA recurrence. The data demonstrated the importance of continued assessment of bladder neck invasion and supported the placement of tumors with bladder neck involvement in a stage that recognizes the prognostic implications of such involvement.

  • Editorial Comment
    Recent studies have questioned the high risk for disease recurrence in cases of bladder neck involvement by the prostate cancer (pT4 disease) (1-4). The risk of recurrence conferred with bladder neck invasion appears not to be different from that with extraprostatic extension (pT3a) or seminal vesical invasion (pT3b).
    In a recent study based on patients submitted to radical prostatectomy at our institution (4), we found that bladder neck involvement correlates with pathologic unfavorable findings on radical prostatectomy specimens as well as to preoperative PSA levels. However, the PSA-recurrence risk associated with bladder neck involvement (pT4) was similar to extraprostatic extension (pT3a) and substantially lower than seminal vesicle invasion (pT3b). Our findings favor a need for downstaging of bladder neck involvement in the next version of the TNM staging system.
    The findings of Poulos et al. contradict our study and of other authors (1-4). The subject is controversial and demands further scrutiny. We believe that macroscopic or microscopic involvement of the bladder neck has different biologic implications. The original TNM classification considered as T4 the macroscopic involvement of the bladder neck. Today only microscopic involvement is seen on radical prostatectomies.

References
1. Yossepowitch O, Engelstein D, Konichezky M, Sella A, Livne PM, Baniel J: Bladder neck involvement at radical prostatectomy: positive margins or advanced T4 disese? Urology. 2000; 56: 448-52.
2. Dash A, Sanda MG: Prostate cancer involving the bladder neck: recurrence-free survival and implications for AJCC staging modifications. Mod Pathol. 2002; 15: 159A.
3. Yossepowitch O, Sircar K, Scardino PT, Ohori M, Kattan MW, Wheeler TM, et al.: Bladder neck involvement in pathological stage pT4 radical prostatectomy specimens is not an independent prognostic factor. J Urol. 2002; 68: 2011-15.
4. Billis A, Freitas LLL, Magna LA: Prostate cancer with bladder neck involvement: pathologic findings with application of a new practical method for tumor extent evaluation and recurrence-free survival after radical prostatectomy. Int Urol Nephrol. (in press).

Dr. Athanase Billis
Full-Professor of Pathology
State University of Campinas, Unicamp
Campinas, São Paulo, Brazil