Primary Renal Angiosarcoma: Rare Tumour with Lethal Outcomes.

Introduction: Renal haemangioma is a benign tumour, and due to its characteristics, it must be distinguished from malignant diseases. We present a clinical case of primary renal angiosarcoma initially mistaken for haemangioma due to their similarity. Case report: A 58-year-old man was admitted to the hospital with suspicion of pulmonary embolism. The patient complained of pain on the left side. An ultrasound and CT scan of the abdomen showed a tumour mass ~20.5 × 17.2 × 15.4 cm in size in the projection of the left kidney. On CT images, there were data for clear cell renal clear cell carcinoma (ccRCC). A left nephrectomy was performed. However, histological examination revealed renal haemangioma. Three months later, the patient presented to the hospital with abdominal and lumbar pain. A CT scan showed multiple small hypoechoic foci up to 2 cm in size in the liver, lungs, and intra-abdominally, with the most data for carcinosis. Histological re-verification of the left kidney showed a renal vascular tumour with pronounced signs of infarction and necrosis with the majority of the evidence supporting angiosarcoma. Despite treatment, the patient's outcome was fatal. Conclusions: Based on the clinical presentation, radiological images and histological examination data, the tumour was initially misdiagnosed as kidney haemangioma. Due to the rarity of this tumour, there are no established treatment protocols or clinical guidelines for managing primary kidney angiosarcoma.

Effect of Clinical Parameters on Risk of Death from Cancer after Radical Prostatectomy in Men with Localized and Locally Advanced Prostate Cancer.

Background: The study aimed to assess predictors and to identify patients at increased risk of prostate-cancer-specific mortality (CSM) after radical prostatectomy (RP). Methods: A total of 2421 men with localized and locally advanced PCa who underwent RP in 2001−2017 were included in the study. CSM predictors were assessed using multivariate competing risk analysis. Death from other causes was considered a competing event. Cumulative CSM and other-cause mortality (OCM) were calculated in various combinations of predictors. Results: During the median 8 years (interquartile range 4.4−11.7) follow-up, 56 (2.3%) of registered deaths were due to PCa. Cumulative 10 years CSM and OCM was 3.6% (95% CI 2.7−4.7) and 15.9% (95% CI 14.2−17.9), respectively. The strongest predictors of CSM were Grade Group 5 (GG5) (hazard ratio (HR) 19.9, p < 0.0001), lymph node invasion (HR 3.4, p = 0.001), stage pT3b-4 (HR 3.1, p = 0.009), and age (HR 1.1, p = 0.0007). In groups created regarding age, stage, and GG, cumulative 10 years CSM ranged from 0.4−84.9%, whereas OCM varied from 0−43.2%. Conclusions: CSM after RP is related to GGs, pathological stage, age, and combinations of these factors, whereas other-cause mortality is only associated with age. Created CSM and OCM plots can help clinicians identify patients with the most aggressive PCa who could benefit from more intensive or novel multimodal treatment strategies.

The Significance of Prostate Specific Antigen Persistence in Prostate Cancer Risk Groups on Long-Term Oncological Outcomes.

OBJECTIVE: To assess the significance of prostate-specific antigen (PSA) persistence at the first measurement after radical prostatectomy (RP) on long-term outcomes in different prostate cancer risk groups. METHODS: Persistent PSA was defined as ≥0.1 ng/mL at 4-8 weeks after RP. Patients were stratified into low-, intermediate- and high-risk groups, according to the preoperative PSA, pathological stage, grade group and lymph nodes status. The ten-year cumulative incidence of biochemical recurrence (BCR), metastases, cancer-specific mortality (CSM) and overall mortality (OM) were calculated in patients with undetectable and persistent PSA in different PCa-risk groups. Multivariate regression analyses depicted the significance of PSA persistence on each study endpoint. RESULTS: Of all 1225 men, in 246 (20.1%), PSA persistence was detected. These men had an increased risk of BCR (hazard ratio (HR) 4.2, p < 0.0001), metastases (HR: 2.7, p = 0.002), CRM (HR: 5.5, p = 0.002) and OM (HR: 1.8, p = 0.01) compared to the men with undetectable PSA. The same significance of PSA persistence on each study endpoint was found in the high-risk group (HR: 2.5 to 6.2, p = 0.02 to p < 0.0001). In the intermediate-risk group, PSA persistence was found as a predictor of BCR (HR: 3.9, p < 0.0001), while, in the low-risk group, PSA persistence was not detected as a significant predictor of outcomes after RP. CONCLUSIONS: Persistent PSA could be used as an independent predictor of worse long-term outcomes in high-risk PCa patients, while, in intermediate-risk patients, this parameter significantly predicts only biochemical recurrence and has no impact on the outcomes in low-risk PCa patients.

Head-to-Head Comparison of Two Nomograms Predicting Probability of Lymph Node Invasion in Prostate Cancer and the Therapeutic Impact of Higher Nomogram Threshold.

Introduction: The aim of the study was to compare the performance of the 2012 Briganti and Memorial Sloan Kettering Cancer Center (MSKCC) nomograms as a predictor for pelvic lymph node invasion (LNI) in men who underwent radical prostatectomy (RP) with pelvic lymph node dissection (PLND), to examine their performance and to analyse the therapeutic impact of using 7% nomogram cut-off. Materials and Methods: The study cohort consisted of 807 men with clinically localised prostate cancer (PCa) who underwent open RP with PLND between 2001 and 2019. The area under the curve (AUC) of the receiver operator characteristic analysis was used to quantify the accuracy of the 2012 Briganti and MSKCC nomograms to predict LNI. Calibration plots were used to visualise over or underestimation by the models and a decision curve analysis (DCA) was performed to evaluate the net benefit associated with the used nomograms. Results: A total of 97 of 807 patients had LNI (12%). The AUC of 2012 Briganti and MSKCC nomogram was 80.6 and 79.2, respectively. For the Briganti nomogram using the cut-off value of 7% would lead to reduce PLND in 47% (379/807), while missing 3.96% (15/379) cases with LNI. For the MSKCC nomogram using the cut-off value of 7% a PLND would be omitted in 44.5% (359/807), while missing 3.62% (13/359) of cases with LNI. Conclusions: Both analysed nomograms demonstrated high accuracy for prediction of LNI. Using a 7% nomogram cut-off would allow the avoidance up to 47% of PLNDs, while missing less than 4% of patients with LNI.

Impact of Grade Groups on Prostate Cancer-Specific and Other-Cause Mortality: Competing Risk Analysis from a Large Single Institution Series.

Objective: To assess the risk of cancer-specific mortality (CSM) and other-cause mortality (OCM) using post-operative International Society of Urological Pathology Grade Group (GG) model in patients after radical prostatectomy (RP). Patients and Methods: Overall 1921 consecutive men who underwent RP during 2001 to 2017 in a single tertiary center were included in the study. Multivariate competing risk regression analysis was used to identify significant predictors and quantify cumulative incidence of CSM and OCM. Time-depending area under the curve (AUC) depicted the performance of GG model on prediction of CSM. Results: Over a median follow-up of 7.9-year (IQR 4.4-11.7) after RP, 235 (12.2%) deaths were registered, and 52 (2.7%) of them were related to PCa. GG model showed high and stable performance (time-dependent AUC 0.88) on prediction of CSM. Cumulative 10-year CSM in GGs 1 to 5 was 0.9%, 2.3%, 7.6%, 14.7%, and 48.6%, respectively; 10-year OCM in GGs was 15.5%, 16.1%, 12.6%, 17.7% and 6.5%, respectively. The ratio between 10-year CSM/OCM in GGs 1 to 5 was 1:17, 1:7, 1:2, 1:1, and 7:1, respectively. Conclusions: Cancer-specific and other-cause mortality differed widely between GGs. Presented findings could aid in personalized clinical decision making for active treatment.

Benefits and harms of the new prostate cancer grade grouping on the prediction of long-term oncological outcomes in patients after radical prostatectomy.

OBJECTIVE: To investigate whether the new prostate cancer grade groups model provides significant predictive value and better patient stratification on tumor progression after radical prostatectomy compared with the former Gleason grading models. METHODS: Men treated at a tertiary center by radical prostatectomy between 2005 and 2017 were analyzed. The outcomes of interest were clinical progression-free and cancer-specific survival. Multivariate Cox regression analysis, C-index and decision curve analysis were carried out using three-tier (Gleason score 6, 7 and 8-10), four-tier (Gleason score 6, 7, 8 and 9-10) and new grade groups model. RESULTS: In total, 1759 men were included in the analysis. At a median of 87 months (interquartile range 51-134 months) of follow up, clinical progression was detected in 78 (4.4%) and cancer-related death in 42 (2.4%) patients. The hazard ratio of clinical progression-free was 2.3, 5.7, 5.2 and 29.5; the hazard ratio of cancer-specific survival was 1.7, 3.2, 4.8 and 11.8 in the grade groups 2-5, relative to grade group 1, respectively. The grade groups model had higher C-index in comparison with four- and three-tier grading models for clinical progression-free survival 0.88 versus 0.85 versus 0.83 and for cancer-specific survival 0.82 versus 0.80 versus 0.80, respectively. In the decision curve analysis, the grade groups model shows marginally better net benefit on clinical progression-free and cancer-specific survival. CONCLUSIONS: The new model shows better performance in comparison with former Gleason grading models on the prediction of long-term oncological outcomes.

External validation of Memorial Sloan Kettering Cancer Center nomogram and prediction of optimal candidate for lymph node dissection in clinically localized prostate cancer.

INTRODUCTION: The aim of our study was to evaluate the external validity of the online Memorial Sloan Kettering Cancer Center (MSKCC) nomogram as a predictor for pelvic lymph node invasion (LNI) in men who underwent radical prostatectomy (RP) with pelvic lymph node dissection (PLND). MATERIAL AND METHODS: The study cohort consisted of 679 men with clinically localized prostate cancer (PCa) who underwent RP with PLND between 2005 and 2017. The area under curve (AUC) of the receiver operator characteristic analysis was used to quantify the accuracy of MSKCC nomogram to predict LNI. The specificity, sensitivity and negative predictive value were calculated to assess LNI probability cut-off. RESULTS: A total of 81 of 679 patients had LNI (11.9%). The AUC of MSKCC nomogram was 79%. Using the cut-off value of 7% (sensitivity 88.9%, specificity 45.2% and NPV 96.8%) a PLND could be omitted in 41% (279/679) of men. However, 3.2% (9/279) of men with LNI would be missed. MSKCC nomogram showed good calibration characteristics and high net benefit at decision curve analysis. CONCLUSIONS: MSKCC nomogram in patients with PCa undergoing PLND has 79% discriminated accuracy for prediction of LNI in our cohort. Using a 7% nomogram cut-off, roughly 40% of men would be spared PLND with minimal risk to miss LNI.

Impact of the 2014 International Society of Urological Pathology Grading System on Concept of High-Risk Prostate Cancer: Comparison of Long-Term Oncological Outcomes in Patients Undergoing Radical Prostatectomy.

Objective: To investigate the relationship between the new International Society of Urological Pathology (ISUP) grading system, biochemical recurrence (BCR), clinical progression (CP) and cancer related death (CRD) after open radical prostatectomy (RP) and determine whether the 2014 ISUP grading system influences the concept of high-risk prostate cancer (HRPCa). Patients and Methods: A total of 1,754 men who underwent RP from 2005 to 2017 were identified from a database at a single tertiary institution. Histopathology reports were reassessed according to the 2014 ISUP grading system. All preoperative, pathological, and clinical follow-up data were obtained. Univariable and multivariable Cox regression, Kaplan-Meier and log-rank analyses were performed. Results: At a median (quartiles) follow-up of 83 (48-123) months, 446 men (25.4%) had BCR, 77 (4.4%) had CP and 39 (2.2%) died from cancer. Grade groups 1, 2, 3, 4, and 5 were detected in 404 (23%), 931 (53.1%), 200 (11.4%), 93 (5.3%), and 126 (7.2%), respectively. 10-year biochemical progression free survival difference between Grade group 3 and 4 was minor but significant (log-rank p = 0.045). There was no difference between Grade groups 3 and 4 comparing 10-year clinical progression free and 10-year cancer specific survival: p = 0.82 and p = 0.39, respectively. Group 5 had the worst survival rates in comparison with other groups (from p < 0.005 to p < 0.0001) in all survival analyses. Pathological stage (hazard ratio (HR) 2.6, p < 0.001), positive surgical margins (HR 2.2, p < 0.0001) and Grade group (HR 10.4, p < 0.0001) were independent predictors for BCR. Stage and Grade group were detected as independent predictors for CP-HR 6.0, p < 0.0001 and HR 35.6, p < 0.0001, respectively. Only Grade group 5 (HR 12.9, p = 0.001) and pT3b (HR 5.9, p = 0.001) independently predicted CRD. Conclusions: The new ISUP 2014 grading system is the most significant independent predictor for BCR, CP, and CRD. Grade group 3 and 4 had similar long-term disease progression survival rates and could potentially be stratified in the same risk group. High-risk cancer associated only with group 5.

Significance of Time Until PSA Recurrence After Radical Prostatectomy Without Neo- or Adjuvant Treatment to Clinical Progression and Cancer-Related Death in High-Risk Prostate Cancer Patients.

Objective: The aim of our study was to evaluate the impact of time until biochemical recurrence (BCR) after radical prostatectomy (RP) without neo- or adjuvant treatment on clinical progression (CP) and cancer-related death (CRD) in high-risk prostate cancer (HRPCa) patients. Materials and methods: A total of 433 men with clinically HRPCa treated between 2001 and 2017 were identified. HRPCa was defined as clinical stage ≥T2c and/or biopsy Gleason score (GS) ≥8 and/or preoperative prostate specific antigen (PSA) value ≥20 ng/ml. Exclusion criteria were neo- or adjuvant treatment and incomplete pathological or follow-up data. BCR was defined as two consecutive PSA values ≥0.2 ng/ml after RP. CP was identified as skeletal lesions, local or loco-regional recurrence. CRD was defined as death from PCa. All men were divided into two groups according to BCR. The chi-square and t-tests were used to compare baseline characteristics between groups. Biochemical progression free survival (BPFS), clinical progression free survival (CPFS), and cancer-specific survival (CSS) rates were estimated using Kaplan-Meier analysis. Patients with detected BCR were analyzed for prediction of CP and CRD with respect to time until BCR. The impact of baseline parameters on BCR, CP, and CRD was assessed by Cox regression analysis. Results: BCR, CP, and CRD rates were 47.8% (207/433), 11.3% (49/433), and 5.5% (24/433), respectively. Median (quartiles) time of follow-up after RP was 64 (40-110) months. Ten-year BPFS rate was 34.2%; CPFS, 81%; and CSS, 90.1%. Men with detected BCR were analyzed for prediction of CP and CRD with respect to time until BCR. The most informative cutoff for time from RP until CP and CRD was ≤ 1 year (p < 0.008). According to this cutoff, men were divided into two groups: BCR detected within 1 year and after a 1-year period. Ten-year CPFS was 49.8% in men with early BCR vs. 81.1% in men with late BCR; CSS was 70.9 vs. 92.8% (p = 0.001). Multivariable analysis confirmed that time until BCR within 1 year predicts CP (p = 0.005) and CRD (p = 0.03). Conclusions: Early BCR is associated with poorer oncological outcomes. The presented results may help both to improve follow-up strategy and opt for more aggressive multimodal treatment of HRPCa in men with very early BCR.

Age and aggressiveness of prostate cancer: analysis of clinical and pathological characteristics after radical prostatectomy for men with localized prostate cancer.

INTRODUCTION: The aim of this study was to describe age- related prostate cancer (PCa) characteristics in men after radical prostatectomy (RP). MATERIAL AND METHODS: There were 2,373 men who underwent RP for clinically localized PCa between 2002 and 2017 and had complete data that were included into the study. Among them, 315 (13.3%) men aged ≤55 years (GR-1), 1,098 (46.3%) men aged between 56 to 65 years (GR-2) and 960 (40.4%) men aged older than 65 years (GR-3) were identified. All preoperative and pathological parameters were compared between all three groups and between each group separately. High-risk prostate cancer (HRPCa) cases were analyzed separately. Regression analysis was used to evaluate the impact of age on cancer aggressiveness. RESULT: Clinical stage (cT), biopsy Gleason score and D'Amico risk groups were different comparing age-related study groups (all p <0.01), respectively. Preoperatively cT1 and Gleason 6 were in the highest rate for GR-1 in comparison with GR-3: 35.9 vs. 27.1%, p = 0.003 and 65.1% vs. 56.7%, p = 0.008, respectively. Analyzing pathological parameters, only Gleason 9-10 was different between GR-1 and GR-3-3.8 vs. 7.6%, p = 0.02. There were 921 (38.8%) HRPCa cases identified. Age was a significant predictor for HRPCa (p = 0.019) in the regression analysis. The oldest men (GR-3) had up to 1.5 fold increased risk for HRPCa detection in comparison with the youngest one (p = 0.008, HR1.44. 95% CI 1.098-1.87). CONCLUSIONS: Younger, ≤55-year-old men, are more likely to present with less aggressive clinical and pathological PCa features in comparison with the older ones. Increasing age has a significant influence on HRPCa detection after RP.

Long-Term Oncological Outcomes for Young Men Undergoing Radical Prostatectomy for Localized Prostate Cancer.

Aim. The aim of this study was to describe PCa characteristics and long-term outcomes in young men aged ≤55 years after radical prostatectomy (RP) and to compare them with older men cohort. Methods. Among 2,200 patients who underwent RP for clinically localized PCa at our centre between 2001 and 2015, 277 (10.3%) men aged ≤55 years were identified. All preoperative and pathological parameters were compared between groups. Biochemical progression free survival (BPFS) and disease progression free survival (DPFS) were assessed at 5 and 10 years. Results. Men aged ≤55 years had similar pathological tumor characteristics and biochemical recurrence rate (BCR) compared to their older counterparts. Disease progression rate 2.5% versus 0.4% was higher in older patients (p = 0.026). BPFS rate was not different in both study groups. Estimated 10-year DPFS was 98.8% in younger men compared to 89.2% in their older counterparts (p = 0.031). Multivariate Cox regression showed that Gleason score lymph-nodes and surgical margins status were significant predictors for disease progression. Conclusions. In our cohort, men aged ≤55 years had similar pathological PCa characteristics and BCR rate in comparison with older men. RP can be performed with excellent long-term DPFS results in men with localized PCa at ≤55 years of age.