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Urothelial Cancer of the Prostate
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[[Category:Prostate Cancer]] == Background == * '''90% of cases of urothelial carcinoma of the prostate occur in patients with a history of urothelial cancer of the bladder, primarily bladder carcinoma in situ (CIS)''' ** '''However, only 3% patients with primary urothelial cancer of the bladder develop prostatic urothelial carcinoma''' *** '''In males undergoing radical cystectomy for urothelial cancer, 40% will be found to have urothelial carcinoma of the prostate''' **** '''In patients undergoing cystectomy for bladder cancer, extension of the tumor into the prostatic urethra without stromal invasion does not carry an adverse prognosis''' * '''Primary urothelial carcinoma of the prostate without bladder involvement is''' '''uncommon, accounting for 1-4% of all prostate carcinomas''' == Pathophysiology == * Most patients with urothelial carcinoma of the prostatic ducts and acini will have direct extension of the bladder cancer into the prostatic urethra; however, some patients will have pagetoid spread underneath normal-appearing urothelium at the bladder neck ** Intraductal and infiltrating urothelial carcinoma involving the prostate tends to be seen in higher-stage bladder tumors * '''Risk factors for prostatic urethral involvement include (5):''' *# '''Presence of bladder CIS''' *# '''Previous intravesical chemotherapy''' *# '''Multi-focal disease''' *# '''Tumours at the trigone or bladder neck''' *# '''High-risk NMIBC''' == TNM staging of Urethral Carcinoma (AJCC 8th edition§) == === Prostatic urethra === * '''pTX''': cannot be assessed * '''pT0''': no evidence of primary tumor * '''pTa''': non-invasive papillary carcinoma * '''pTis: carcinoma in situ of the prostatic urethra, periurethra or ducts''' ** '''Tis pu: Carcinoma in situ, involvement of prostatic urethra''' ** '''Tis pd: Carcinoma in situ, involvement of prostatic ducts''' * '''pT1:''' invasion of prostatic urethral '''subepithelial connective tissue''' * '''pT2: invasion of prostatic stroma''' ** '''In the bladder cancer TNM staging system, only patients with prostatic stromal invasion, either direct or indirect, are considered to have T4a-staged bladder cancer disease''' ** '''Extension of the tumor into the prostatic urethra without stromal invasion is currently classified under the prostatic urethral section, not bladder''' * '''pT3''': '''invasion of peri-prostatic fat or bladder neck (extraprostatic extension)''' * '''pT4''': invasion of adjacent organs (example: bladder wall, rectal wall) === Penile urethra === * '''pTX''': cannot be assessed * '''pT0''': no evidence of primary tumor * '''pTa''': noninvasive papillary carcinoma * '''pTis''': carcinoma in situ * '''pT1''': invasion of urethral subepithelial connective tissue * '''pT2''': invasion of corpus spongiosum * '''pT3''': invasion of corpus cavernosum * '''pT4''': invasion of adjacent organs (example: bladder wall) == Diagnosis and Evaluation == * '''Transurethral resection of the prostatic urethra''' ** '''Primary method for detecting prostatic urethral carcinoma''' *** '''For highest yield, prostatic urethral biopsies should include any suspicious area, as well as at 5 and 7 o’clock (precollicular area) especially at the level of the verumontanum''', as this area contains the highest concentration of prostatic ducts ** '''Indications:''' **# '''Positive urine cytology but a negative bladder biopsy''' **# '''Recurrent bladder cancer after multiple courses of intravesical chemotherapy''' **# '''Visible tumour in prostatic urethra''' == Management == * '''Based on the degree or depth of involvement''' ** '''See 2015 CUA NMIBC Guideline Notes''' *** '''pTis pu (CIS of the prostatic urethra) or visible prostatic urethra tumour concomitant with NMIBC of the bladder: TURP then BCG.''' **** BCG is given after TURP for accurate staging and increasing efficacy by increasing surface area *** '''pTis pd (CIS involving the prostatic ducts): treatment controversial, consider TURP + BCG''' **** Despite good response to BCG, prostatic ductal involvement has potential for invasion, and if invasion occurs there is a high risk of metastasis. *** '''Re-biopsy of the prostatic urethra is recommended after BCG to detect recurrences early''' **** '''Recurrence of any HG lesion in prostatic urethra after TURP + BCG: consider radical cystectomy plus urethrectomy''' ***** If patient prefers bladder-sparing approach, consider repeat BCG or intra-vesical gemcitabine *** '''pT2 (prostatic stromal invasion (pT2): radical cystectomy +/- urethrectomy''' **** '''Consideration of urethrectomy should be made, especially if tumor is present near or at the surgical margin''' ** Campbell’s: *** For patients with non-invasive prostatic urethral cancer, TURP with BCG therapy is appropriate. For patients with prostatic ductal disease, complete TURP is warranted, plus BCG therapy *** Prostatic stromal invasion is a poor prognostic factor and is treated with multimodal therapy combining chemotherapy and radical cystectomy == Prognosis == * 5-year survival varies by stage: up to 100% for those with urethral mucosal involvement; 50% with ductal/acinar/glandular involvement; and 40% with stromal invasion == Questions == # What are the risk factors for urothelial carcinoma of the prostate? # What is the pT staging of a patient found to have bladder cancer invading the prostatic stroma? == Answers == # What are the risk factors for urothelial carcinoma of the prostate? ## Presence of bladder CIS ## Previous intravesical chemotherapy ## Multifocal disease ## Tumours at the trigone or bladder neck ## High-risk NMIBC # pT4a == References == * Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 92
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