The Prognostic Significance Of Bladder Neck Invasion In Prostate Cancer: Is Microscopic Involvement Truly A T4 Disease
August 24, 2018
UroToday - Tumor invasion into an adjacent organ has broad reaching implications for local recurrence and potential metastatic spread. In prostate cancer, stage pT4 disease may indicate for example, involvement of the rectum, pelvic sidewall or bladder neck. However, bladder neck invasion (BNI) can be microscopic without other adverse pathologic variables such as high Gleason score or seminal vesical invasion. Due to PSA screening, BNI is an unusual pre-operative diagnosis and is usually microscopic on pathologic assessment. In the online edition of the British Journal of Urology International, Dr. Guillaume Ploussard and colleagues performed a systematic review of this topic and evaluated all articles classifying BNI as pT4 disease by the 2002 TNM staging system.
Ten articles were evaluated, two from large cohorts and the remainder from single center studies. The overall frequency of BNI was 2.8-21%. Overall, 578 cases of BNI were identified with a mean proportion of 5% among the overall cohort of patients. Most studies compare patients with BNI to those without for numerous variables. The following correlations were assessed. Age did not differ among the two groups. Only one study identified a statistically significant difference with regard to an abnormal DRE in patients with BNI in radical prostatectomy (RP) patients. Patients with BNI had a preoperative PSA in the 7.0-11.4ng/ml range, significantly higher than those without. BNI patients more frequently had a RP Gleason score of >7. BNI was associated with extra-prostatic extension in 42-64% of cases, a significantly higher rate than those without BNI. Seminal vesical invasion was noted in the RP specimens in 17-32% of cases, a positive correlation in all but one study. When BNI invasion was present, lymph nodes were also found to be positive in 5-11% of cases, which was statistically significant in two studies that tested for it.
Distinction between a positive surgical margin and BNI was not usually made, and a negative surgical margin was noted in 25-39% of cases with BNI. Tumor volume was assessed in one study and found to be extensive in 48% of cases with BNI vs.19% of cases without BNI.
Overall, BNI was correlated with parameters of more aggressive disease. However, pT4 tumors had better recurrence free survival than pT3b tumors and worse recurrence free survival than pT3a tumors. This is difficult to conceptualize, but one study did find pT3b of worse prognostic significance than BNI. In studies using most clinical and pathological variables in multivariable analysis, it appears that BNI is not of independent predictive value for PSA recurrence.
Ploussard G, Rotondo S, Salomon L
BJU Int. 2009 Oct 26. Epub ahead of print.
UroToday Contributing Editor Christopher P. Evans
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