In November, 2014, 65 prostate cancer pathology experts, along with 17 clinicians including urologists, radiation oncologists, and medical oncologists from 19 different countries gathered in a consensus conference to update the grading of prostate cancer, last revised in 2005. The major conclusions were: (1) Cribriform glands should be assigned a Gleason pattern 4, regardless of morphology; (2) Glomeruloid glands should be assigned a Gleason pattern 4, regardless of morphology; (3) Grading of mucinous carcinoma of the prostate should be based on its underlying growth pattern rather than grading them all as pattern 4; and (4) Intraductal carcinoma of the prostate without invasive carcinoma should not be assigned a Gleason grade and a comment as to its invariable association with aggressive prostate cancer should be made. Regarding morphologies of Gleason patterns, there was clear consensus on: (1) Gleason pattern 4 includes cribriform, fused, and poorly formed glands; (2) The term hypernephromatoid cancer should not be used; (3) For a diagnosis of Gleason pattern 4, it needs to be seen at 10x lens magnification; (4) Occasional/seemingly poorly formed or fused glands between well-formed glands is insufficient for a diagnosis of pattern 4; (5) In cases with borderline morphology between Gleason pattern 3 and pattern 4 and crush artifacts, the lower grade should be favored; (6) Branched glands are allowed in Gleason pattern 3; (7) Small solid cylinders represent Gleason pattern 5; (8) Solid medium to large nests with rosette-like spaces should be considered to represent Gleason pattern 5; and (9) Presence of unequivocal comedonecrosis, even if focal is indicative of Gleason pattern 5. It was recognized by both pathologists and clinicians that despite the above changes, there were deficiencies with the Gleason system. The Gleason grading system ranges from 2 to 10, yet 6 is the lowest score currently assigned. When patients are told that they have a Gleason score 6 out of 10, it implies that their prognosis is intermediate and contributes to their fear of having a more aggressive cancer. Also, in the literature and for therapeutic purposes, various scores have been incorrectly grouped together with the assumption that they have a similar prognosis. For example, many classification systems consider Gleason score 7 as a single score without distinguishing 3+4 versus 4+3, despite studies showing significantly worse prognosis for the latter. The basis for a new grading system was proposed in 2013 by one of the authors (J.I.E.) based on data from Johns Hopkins Hospital resulting in 5 prognostically distinct Grade Groups. This new system was validated in a multi-institutional study of over 20,000 radical prostatectomy specimens, over 16,000 needle biopsy specimens, and over 5,000 biopsies followed by radiation therapy. There was broad (90%) consensus for the adoption of this new prostate cancer Grading system in the 2014 consensus conference based on: (1) the new classification provided more accurate stratification of tumors than the current system; (2) the classification simplified the number of grading categories from Gleason scores 2 to 10, with even more permutations based on different pattern combinations, to Grade Groups 1 to 5; (3) the lowest grade is 1 not 6 as in Gleason, with the potential to reduce overtreatment of indolent cancer; and (4) the current modified Gleason grading, which forms the basis for the new grade groups, bears little resemblance to the original Gleason system. The new grades would, for the foreseeable future, be used in conjunction with the Gleason system [ie. Gleason score 3+3=6 (Grade Group 1)]. The new grading system and the terminology Grade Groups 1-5 have also been accepted by the World Health Organization for the 2016 edition of Pathology and Genetics: Tumours of the Urinary System and Male Genital Organs.

The 2014 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma: Definition of Grading Patterns and Proposal for a New Grading System.

Context— Controversies and uncertainty persist in prostate cancer grading Objective— To update grading recommendations Data Sources— Critical review of the literature along with pathology and 

The 2019 genitourinary pathology society (GUPS) white paper on contemporary grading of prostate cancer

Disease-specific survival of patients with invasive cribriform and intraductal prostate cancer at diagnostic biopsy.

This review focuses on histopathological aspects of carcinoma of the prostate. A tissue diagnosis of adenocarcinoma is often essential for establishing a diagnosis of prostate cancer, and the foundation for a tissue diagnosis is currently light microscopic examination of hematoxylin and eosin (H&E)-stained tissue sections. Markers detected by immunohistochemistry on tissue sections can support a diagnosis of adenocarcinoma that is primary in the prostate gland or metastatic. Histological variants of carcinoma of the prostate are important for diagnostic recognition of cancer or as clinicopathologic entities that have prognostic and/or therapeutic significance. Histological grading of adenocarcinoma of the prostate, including use of the 2014 International Society of Urological Pathology (ISUP) modified Gleason grades and the new grade groups, is one of the most powerful prognostic indicators for clinically localized prostate cancer, and is one of the most critical factors in determination of management of these patients.

/pdf/histopathology-of-prostate-cancer-6i60zdqzdw.pdf

Histopathology of Prostate Cancer

https://www.europeanurology.com/article/S0302-2838(14)00749-0/pdf/patient-derived-xenografts-reveal-that-intraductal-carcinoma-of-the-prostate-is-a-prominent-pathology-in-brca2-mutation-carriers-with-prostate-cancer-and-correlates-with-poor-prognosis

Patient-derived Xenografts Reveal that Intraductal Carcinoma of the Prostate Is a Prominent Pathology in BRCA2 Mutation Carriers with Prostate Cancer and Correlates with Poor Prognosis

BACKGROUND

Intraductal carcinoma of the prostate (IDC-P) is an adverse prognostic factor for radical prostatectomy (RP). The endpoint in most IDC-P studies is increased prostate-specific antigen (PSA) levels. The aim of this study was to evaluate whether IDC-P in RP specimens is an adverse prognostic factor for progression-free survival (PFS) and cancer-specific survival (CSS).



METHODS

We retrospectively evaluated 206 high-risk prostate cancer patients treated with RP and analyzed data on age, serum PSA level at diagnosis, biopsy Gleason score (bGS), surgical margin (SM), clinical T stage (cT), extraprostatic extension (EPE), seminal vesicle invasion (SVI), lymph node metastasis (LN), and neoadjuvant therapy.



RESULTS

An IDC-P component was found in 104 cases. Forty-four patients experienced clinical failure, and 20 patients died of the disease. Patients with IDC-P showed a higher bGS and stage (including cT, EPE, SVI, and LN) than those without IDC-P. In univariate analysis, IDC-P, PSA level, bGS, SM, cT, SVI, LN, and EPE (P < 0.0001) were significantly associated with PFS. IDC-P (P = 0.0004), PSA level (P < 0.0001), SM (P = 0.0013), cT (P = 0.0019), SVI (P = 0.0012), and LN (P = 0.0002) were significantly associated with CSS. In multivariate analysis, IDC-P (P = 0.0038), and cT (P = 0.0001) were significantly associated with PFS. IDC-P (P = 0.0238) and PSA level (P = 0.0112) were significantly associated with CSS.



CONCLUSIONS

IDC-P in RP specimens was an independent risk factor for PFS and CSS and could predict clinical outcomes. Prostate 74:680–687, 2014. © 2014 Wiley Periodicals, Inc.

Prognostic value of intraductal carcinoma of the prostate in radical prostatectomy specimens.

Objectives To investigate the prevalence of postoperative complications after transvaginal mesh prolapse surgery, and whether modified transvaginal mesh prolapse surgery (without transobturator arms or posterior mesh) has less prevalence of mesh exposure compared with conventional transvaginal mesh prolapse surgery. Methods Medical charts were retrospectively examined for 2648 patients who underwent transvaginal mesh prolapse surgery in a general hospital (2006-2017). Conventional transvaginal mesh prolapse surgery (Prolift-type, n = 2258) was used, with a shift from 2015 to modified transvaginal mesh prolapse surgery (Uphold-type, n = 330). Patients were instructed to have >2 years of follow up and to report if they had problems regarding the operation. Results The prevalence of mesh exposure was 34 out of 2648 (1.28%); 18 vagina (0.68%), 10 bladder (0.38%), two ureter (0.08%) and four rectum (0.15%). The modified transvaginal mesh prolapse surgery group had only one case with vaginal exposure. Vaginal exposure was managed transvaginally or followed by observation. Rectal exposure was managed transvaginally without colostomy. Bladder exposure was managed by transurethral resection with saline. Open ureterocystostomy was carried out to treat ureteral exposure. In the conventional transvaginal mesh prolapse surgery group, three cases of ureteral stenosis and one case with vaginal evisceration of the small intestine were managed transvaginally. The prevalence of postoperative chronic pain was 13 out of 2648 (0.49%; with one patient in the modified transvaginal mesh prolapse surgery group). The patients underwent pharmacotherapy, and one patient underwent additional surgical treatment. Conclusions The reoperation rate as a result of complications after transvaginal mesh prolapse surgery seems to be low. The reoperation rate as a result of prolapse recurrence is also low. A shift from conventional transvaginal mesh prolapse surgery to modified transvaginal mesh prolapse surgery might contribute to a further decrease in the risk of complications.

Mesh exposure after transvaginal mesh prolapse surgery: Out of permissible range?

Objective

To confirm the efficacy of using Seprafilm® (Genzyme Corp., Cambridge, MA, USA) for wrapping the ureter to treat the ureteric stenosis caused by retroperitoneal fibrosis (RPF).



Patients and Methods

Between August 2010 and September 2012, 11 ureters in eight patients with RPF (seven males and one female, mean age 65 years) were treated. The mean (range) length of the narrow segment of the ureter was 30 (10–90) mm. During surgery, after having been released from adhesive tissue, the stenotic segment of the ureter was wrapped with Seprafilm to isolate it from the surrounding tissue. A radiographic follow-up was performed every 6 months using computed tomography, i.v. pyelography and/or 99mTc-mercapto-acetylglycyl-glycyl-glycine (99mTc-MAG3) renal scintigraphy.



Results

For the unilateral operations, the mean estimated blood loss was 39 mL, and the mean operating time was 154 min. All ureters were isolated from the fibrotic tissue and wrapped with Seprafilm successfully without major complications. During the mean follow-up period of 17 months, no ureteric restenoses were observed in the affected sides, but new stenosis occurred in the contralateral side of the ureter in one patient.



Conclusions

Although the follow-up period is still limited, we believe that the use of Seprafilm has the potential to become an effective option in the treatment of ureteric stenosis caused by RPF, when the omentum cannot be used. To establish the relative advantages of using Seprafilm over performing a standard omental wrap, further experimentation will be required to compare the two techniques.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/bju.12701

A new treatment for retroperitoneal fibrosis: initial experiences of using Seprafilm® to wrap the ureter

(Objective) A rise of intra-abdominal pressure may exacerbate pelvic organ prolapse (POP) as well as abdominal hernias. This paper aims to assess the possible risk factors of an abdominal mass and ascites as comorbidities of POP. (Methods) We retrospectively reviewed the medical charts of 2,748 POP patients between 2010 and 2016 and extracted eight cases (0.3%) with abdominal mass and ascites as risk factors. (Results) All eight patients were multiparous women aged between 52 and 88 years old. Three patients (cases 1-3) were referred to us for surgery related to POP from gynecologists with previously undetected ovarian tumors. In case 1, we noticed abdominal distension during a transvaginal mesh (TVM) operation. Postoperative CT and MRI scans confirmed the presence of an ovarian tumor 24 cm in diameter (mucinous cystic tumor, borderline malignant). In case 2, transvaginal ultrasound could not detect the ovaries, but a transabdominal ultrasound, which was done to investigate urinary retention, revealed an ovarian tumor 18 cm in diameter (mucinous cystic adenoma). In case 3, a detailed patient history outlined the patient's sense of abdominal fullness and a transvaginal ultrasound found ovarian cancer 10 cm in diameter with ascites (serous adenocarcinoma). Case 4 suffered from autosomal dominant polycystic kidney disease (ADPKD) with large liver cysts. The patient underwent a TVM operation to treat the presenting POP with unusual bleeding (460 g). Case 5 had abdominal distension and cystocele due to huge abdominal mass (recurrence of malignant lymphoma); she desired conservative follow-up to tumor and POP due to old age (88 years old). Two patients suffered from end-stage cancer (case 6: colorectal cancer, case 7: breast cancer) with liver metastasis. In cases 6 and 7, the patients' POP worsened with the increase of ascites, which was managed conservatively. Case 8 presented with liver cirrhosis related ascites and a total uterine prolapse, simultaneously. Colpocleisis was cancelled due to the onset of hepatic coma. (Conclusions) Abdominal mass and ascites are risk factors of POP by increasing abdominal pressure and lesions such as ovarian tumors may present as POP. Even when POP patients are referred from gynecologists, a vaginal examination, carefully recorded patient history, and abdominal palpation should be included as part of a standard treatment regimen to reliably exclude underlying diseases.

Abdominal mass and ascites as risk factors of pelvic organ prolapse

Bofutsushosan (BTS), one of many traditional Japanese medicines (Kampo medicines) is attracting attention for obesity and metabolic syndrome. We report allergic cystitis caused by 8-year BTS usage in a 70-year-old female. The patient presented with micturition pain with sterile pyuria over a 3-month period. Cystoscopy showed diffuse urothelial erythema and edema. Urine cytology specimens showed increased eosinophilic cells. By discontinuing BTS, the cystitis symptoms disappeared after 4 days, and urinalysis normalized. Resuming BTS without physician approval resulted in cystitis symptoms and after cessation the symptoms rapidly subsided. This is the first English case report linking allergic cystitis to herbal medicine.

Drug-induced cystitis caused by herbal medicine (Bofutsushosan).

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