Satoru Kawakami

To evaluate the long-term oncological outcome of radical prostatectomy for patients with high-risk prostate cancer. Among 378 patients with prostate cancer who underwent radical prostatectomy at our hospital, 189 had high-risk prostate cancer defined as presenting with at least one of the following high-risk factors: prostate-specific antigen >20 ng/ml, clinical T3 and biopsy Gleason score ≥8. The median follow-up was 8.1 years. Of all patients, 106 and 61 had one and two high-risk factors, respectively, and the remaining 22 had all three high-risk factors. Pathological examination of the prostatectomy specimens revealed organ-confined disease, specimen-confined disease and lymph node metastasis in 80 (42%), 102 (54%) and 22 (12%), respectively. The 10-year prostate-specific antigen failure-free and local progression-free survival rates were 48.5 and 87.6%, respectively. The 10-year cancer-specific and overall survival rates were 94.1 and 88.7%, respectively. The 10-year prostate-specific antigen failure-free survivals of patients with one, two and all three high-risk factors were 58.5, 39.9 and 22.7%, respectively (P = 0.0001). Of the 106 patients with one high-risk factor only, the high Gleason score group had the best 10-year prostate-specific antigen failure-free survival (69.1%); in particular, that of patients without Gleason grade 5 was 100% (P= 0.032). Approximately half of patients with high-risk prostate cancer can be cured by radical prostatectomy without any adjuvant treatment. Radical prostatectomy for high-risk prostate cancer provides good long-term local cancer control and cancer-specific survival. In particular, radical prostatectomy for patients with only one high-risk factor can be considered a valuable therapeutic option as the first treatment.

The aim of this study was to assess the surgical outcome of high-grade prostate cancer (PCA) treated with antegrade radical prostatectomy with intended wide resection (aRP) and to establish the risk stratification. A consecutive 77 Japanese patients with Gleason score 8–10 PCA were treated with aRP alone and excluding patients with persistently elevated prostate-specific antigen (PSA), prospectively observed without any treatment until PSA failure was confirmed. PSA failure-free, cancer-specific and overall survival curves were generated with Kaplan–Meier method and the difference between groups was assessed with log-rank test. Cox's proportional hazards model was used to elucidate predictors of PSA failure. During a median follow-up of 6 years, PSA failure was observed in 41 (53%) of the 77 patients. Five- and 10-year PSA failure-free survival rates of the entire cohort were 44.6% and 40.1%, respectively. Both overall and cancer-specific survival rates of the entire cohort at 5 and 10 years were 96.8% and 87.9%, respectively. In a multivariate analysis, PSA (P = 0.008), specimen confinement (SC) (P = 0.006) and persistently elevated PSA after aRP were identified as significant and independent predictors of PSA failure. When stratifying patients into three risk groups according to PSA level and SC status, PSA failure-free survival rate in patients with PSA < 10 ng/ml and specimen-confined disease (SCD) was significantly better than that in those of any other groups. Good prognosis can be expected in patients with high-grade PCA treated with aRP alone when PSA < 10 ng/ml and the tumor was removed as an SCD.

To clarify how popularly the minimally invasive surgeries for urological tumors are currently conducted in Japan and to predict future trends. A nation-wide survey was performed by the Japanese Association for Minimum-Incision Endoscopic Surgery under the support of the Japanese Urological Association (JUA). A questionnaire was sent to 1186 JUA-certified educational institutions asking about surgical practices for representative urological tumors performed in 2005 and those to be performed in the near future. Surgical modalities were categorized into open, laparoscopic and minimized-incision surgeries, defined as that the operator considers the incision to be minimal and including minimum-incision endoscopic surgery but not limited. 506 of the 1186 institutions (43%) responded and 20 193 surgical procedures were reported with radical prostatectomy being most frequently performed. Overall 20% and 6% of the procedures were performed with laparoscopic and minimized-incision surgeries, respectively. More than 20% of the respondents performed open surgery with reduced incision size than before. Surgical procedures without inserting fingers or hand were reported in 5-11% of the open surgeries and 33-45% of the minimized-incision surgeries. Endoscopy was utilized in 4-14% of the open surgeries and 24-59% of the minimized-incision surgeries. There was no difference in the incidence of complications among the surgical modalities. 40% and 27% of the respondents are aiming at laparoscopic surgery and at minimized-incision surgery, respectively. The results of this nation-wide survey indicate that minimally invasive surgeries, currently performed in 26% of urological tumor surgeries, are aimed at by the majority of the survey respondents.

A 64-year old female presented with urinary retention. Physical examination revealed a firm mass on the anterior vaginal wall. Magnetic resonance imaging showed a tumor surrounding the urethra, which invaded to the vesical triangle and the anterior vaginal wall. Serum levels of carcinoembryonic antigen and carbohydrate antigen 19-9 were elevated, but squamous cell carcinoma antigen and prostate specific antigen were within normal limits. Pathological examinations of the transurethral and transvaginal needle biopsy specimen suggested mucinous adenocarcinoma. First, the patient received local chemoradiotherapy and systemic chemotherapy using a fluoropyrimidine drug TS-1 and cisplatin. The tumor markers declined to within normal limits after this preoperative therapy. Then she underwent total cysto-urethrectomy with anterior vaginal wall resection, pelvic lymphadenectomy, and urinary diversion with ureterocutaneous fistula. Histopathological examination of the surgical specimen showed mutinous adenocarcinoma invading to the vesical triangle and the anterior vaginal wall. No metastasis was found in the lymph nodes. The final diagnosis was urethral adenocarcinoma, pT4N0, Stage IV. Five months after surgery, local recurrence and distant metastases appeared, and she died 14 months after surgery.

Objectives:  To examine whether history of malignancy adds any significant information to the prediction of positive prostate biopsy in referred men with moderately elevated prostate‐specific antigen (PSA) and to develop a predicting nomogram that does not require extra examinations other than PSA.Methods:  A total of 1767 consecutive Japanese men with PSA less than 10 ng/mL who underwent prostate biopsy were included in the study cohort. Age, digital rectal examination (DRE), PSA, body mass index, family history of prostate cancer and number of previous malignancies other than the prostate were evaluated in regard to their association with prostate cancer. A logistic regression‐based nomogram for predicting prostate cancer was developed and externally validated.Results:  Of the 1767 men, 269 had a history of malignancy with a total of 312 primary sites. Univariate and multivariate analyses revealed that DRE, PSA, age, family history and number of previous malignancies are independent and significant predictors of positive biopsy result. External validation revealed that the predicting accuracy of a nomogram incorporating these five variables is significantly higher than those of PSA or PSA and DRE. Using the nomogram, 8% of unnecessary biopsies would be saved at 95% sensitivity.Conclusions:  We demonstrated for the first time that history of malignancy is a potent predictor of prostate cancer in men with moderately elevated PSA even if the established risk factors are adjusted. The nomogram can be a useful tool in decision‐making of prostate biopsy. In daily practice, history of malignancy should be rigorously taken from these men before a decision is made regarding prostate biopsy.

We report a case of prostatic duct adenocarcinoma treated with radical prostatectomy. Advanced pathological stage (pT3bpN1) was beyond the prediction of the favorable preoperative parameters (cT1cN0, PSA 7.64 ng/ml). The main tumor of ductal adenocarcinoma was occupying the transitional zone and surrounded by scattered micro-foci of acinar adenocarcinoma. We identified coexistence of ductal and acinar adenocarcinoma cells side by side in the same gland. Pure ductal cancer cells were detected in the metastasized lymph node without acinar cancer cells. Strong staining of PSA and loss of p63 expression by both types of adenocarcinoma cells were confirmed immunohistochemically. We discuss the clinical significance of prostatic duct adenocarcinoma in comparision with typical acinar adenocarcinoma.