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      Primary spindle cell sarcoma of the prostate and 18F-fluorodeoxyglucose-positron-emission tomography/computed tomography findings

      case-report

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          Abstract

          Background:

          Primary sarcoma of the prostate is extremely rare and accounts for 0.1% of all prostate cancers. This type of cancer is associated with poor prognosis due to aggressive biological behavior. The World Health Organization histologically classified prostate sarcomas as stromal tumor of unknown malignant potential (STUMP) and stromal sarcoma.

          Patients and Methods:

          A 39-year-old patient presented with lower urinary tract symptoms over the last few months. On digital rectal examination, the right lobe of the prostate was diffusely hard on palpation. Prostate-specific antigen was 0.5 ng/ml. A biopsy specimen was obtained with the guidance of transrectal ultrasonography. Immunohistochemical examination revealed positive staining for vimentin, actin, and desmin.

          Results:

          18F-fluorodeoxyglucose-positron-emission tomography/computed tomography scans obtained for staging purposes with the diagnosis of primary spindle cell carcinoma of the prostate revealed widespread lung and liver metastases. A doxorubicin-based systemic chemotherapy (CTx) was initiated.

          Conclusion:

          Spindle sarcomas of the prostate have quite aggressive nature and they have high potential to metastase. Average life expectancy is <1 year and the prognosis is poor. CTx and radiation therapy can’t yield curative effects due to poor differentiation.

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          Most cited references20

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          Prognostic factors in adult patients with locally controlled soft tissue sarcoma. A study of 546 patients from the French Federation of Cancer Centers Sarcoma Group.

          To define the prognostic factors in adult patients with locally controlled soft tissue sarcoma (STS) and to determine which patients should be considered for adjuvant treatment. Five hundred forty-six patients with a nonmetastatic and locally controlled STS, collected in a cooperative data base by the French Federation of Cancer Centers (FNCLCC) Sarcoma Group from 1980 and 1989, were studied. Histologic slides of all patients were collegially reviewed. Initial treatment consisted of complete tumor resection with amputation in only 4% of the patients. Adjuvant radiotherapy was administered to 57.9% and adjuvant chemotherapy to 31%. Relationships between tumor characteristics were analyzed, and univariate and multivariate analyses were performed using Cox models for the hazards rate of tumor mortality, development of distant metastasis, and strictly local recurrence. Unfavorable characteristics with an independent prognostic value for tumor mortality were: grade 3 (P = 3 x 10(-10)), male sex (P = 1.5 x 10(-5)), no adjuvant chemotherapy (P = 5.4 x 10(-5)), tumor size > or = 5 cm (P = 3.8 x 10(-3)), and deep location (P = 4.6 x 10(-3)). Unfavorable characteristics for the development of distant metastasis were: grade 3 (P = 4 x 10(-12)), no adjuvant chemotherapy (P = 6.4 x 10(-4)), tumor size > or = 10 cm (P = 9.8 x 10(-4)), and deep location (P = 1.3 x 10(-3)). For the development of local recurrence, the unfavorable characteristics were: no adjuvant radiotherapy (P = 3.6 x 10(-6)), poor surgery (local excision) (P = 2 x 10(-4)), grade 3 (P = 7.6 x 10(-4)), and deep location (P = 10(-2)). Grade, depth, and tumor size were used to define groups of patients according to the metastatic risk. Adjuvant chemotherapy was beneficial in terms of overall survival and metastasis-free survival in grade 3 tumor patients only. Despite worse characteristics concerning tumor depth, tumor-node-metastasis (TNM) and American Joint Committee (AJC)/International Union Against Cancer (UICC) classifications and grade in patients with adjuvant radiotherapy, the latter experienced significantly fewer local recurrences than patients with no radiotherapy. Grade, tumor depth, and tumor size could be used to select patients with a high metastatic risk, for which adjuvant chemotherapy could be beneficial.
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            Histological variants of prostatic carcinoma and their significance.

            The vast majority of prostatic cancers are acinar adenocarcinomas. Histological variants of prostatic carcinoma have been variably defined. One approach is to consider two groups of variants. The first group comprises histological variants of acinar adenocarcinoma and the second group non-acinar carcinoma variants or types. Variants of usual acinar adenocarcinoma defined in 2004 by the World Health Organization (WHO) include atrophic, pseudohyperplastic, foamy, colloid, signet ring, oncocytic and lymphoepithelioma-like carcinomas. The second group of non-acinar carcinoma histological variants or types of prostatic carcinoma accounts for about 5-10% of carcinomas that originate in the prostate. These include sarcomatoid carcinoma, ductal adenocarcinoma, urothelial carcinoma, squamous and adenosquamous carcinoma, basal cell carcinoma, and neuroendocrine tumours, specifically small-cell carcinoma. Recently characterized variants not present in the 2004 WHO classification, including microcystic adenocarcinoma, prostatic intraepithelial neoplasia-like adenocarcinoma, large-cell neuroendocrine carcinoma, and pleomorphic giant cell carcinoma, are also described. The aims of this review are to present the essential histomorphological diagnostic attributes of these variants, and to emphasize the clinical signficance of the variants, when different from usual acinar adenocarcinoma, including clinical presentation and outcome. © 2011 Blackwell Publishing Limited.
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              Specialized stromal tumors of the prostate: a clinicopathologic study of 50 cases.

              Specialized stromal tumors of the prostate encompass stromal sarcoma and stromal tumors of uncertain malignant potential (STUMP). As a result of their relative rarity and lack of long-term follow-up, the prognosis of STUMP is unclear. We studied 50 cases of STUMP and stromal sarcoma with regard to their clinical presentation and follow-up. Patients ranged in age from 27 to 83 years (mean 58 years). The major presenting signs and symptoms were urinary obstructive symptoms (n=25), abnormal digital rectal exam (n=15), hematuria (n=7), hematospermia (n=1), and rectal dysfunction/fullness (n=3). An elevated prostate-specific antigen was either the sole or a compounding rationale for initial urologic examination and prostate biopsy in a subgroup of patients (n=11). The histology in the 36 cases of STUMP not associated with sarcoma were as follows: 25 composed of stroma with scattered cytologically atypical cells associated with benign glands; 8 resembling glandular-stromal hyperplasia but with hypercellular stroma; 6 with extensive myxoid stroma; and 1 with phyllodes pattern. Four of these cases had mixed patterns. Seven cases of STUMP were associated with sarcoma, either concurrently or subsequently. In another 7 cases, pure sarcomas were encountered: 3 low grade (LG) and 4 high grade (HG). In 19 STUMPs, the location of the lesion was determinable: 10 cases arose in the peripheral zone, 7 cases were located in the transition zone, and 2 cases seemed to involve both zones. In 3 of these cases, tumors were adherent to the rectum at the time of resection. There was no evidence of progression of disease for 14 STUMPs after biopsy, TUR, or enucleation where follow-up ranged from 0.3 to 14 years (mean 4.9 years). Five cases of STUMP showed local tumor growth: 1 case increased in size from 6 to 7.5 cm in 3 years and 4 cases recurred frequently necessitating multiple TURs of the prostate (n=2, n=3, n=3, n=3) over 1.1, 2, 7, and 8 years, respectively. Fourteen patients with STUMP underwent radical prostatectomy (RP) soon after diagnosis; of these, 12 were organ confined where the tumor size ranged from 0.7 to 7.5 cm (mean 2.7 cm); 2 cases with a history of a 28 g TUR and a 275 g enucleation showed no residual tumor in the RP specimen. Three cases were lost to follow-up. The histologic subtypes of STUMP did not correlate with the clinical behavior or likelihood of being associated with sarcoma. Two of the LG sarcomas locally invaded around the seminal vesicle, yet all of the LG sarcomas with follow-up were free of disease at 3, 13, 24, 25, 30, and 36 months. Of the 6 HG sarcomas with follow-up, 3 were free of disease at 3, 17, and 72 months. One man was alive with metastasis to the lung 10 months after RP, 1 man was alive at 280 months with multiple metastases, and another died of disease at 115 months. STUMPs can recur frequently, occur at a young age, often involve the peripheral zone where they can be adherent to the rectum requiring its removal, and can be associated with stromal sarcoma. Although STUMPs can be histologically misdiagnosed as nodular hyperplasia, it is important to recognize that these are neoplasms with unique local morbidity and malignant potential. Whereas LG stromal sarcomas can locally invade, HG sarcomas can metastasize and lead to death.
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                Author and article information

                Journal
                Urol Ann
                Urol Ann
                UA
                Urology Annals
                Medknow Publications & Media Pvt Ltd (India )
                0974-7796
                0974-7834
                Jan-Mar 2015
                : 7
                : 1
                : 115-119
                Affiliations
                [1]Department of Urology, School of Medicine, Sifa University, Izmir, Turkey
                Author notes
                Address for correspondence: Dr. Hakan Ozturk, Basmane Hospital of Sifa University, Fevzipasa Boulevard No. 172/2, 35240, Basmane-Konak, Izmir, Turkey. E-mail: drhakanozturk@ 123456yahoo.com.tr
                Article
                UA-7-115
                10.4103/0974-7796.148657
                4310101
                f35f8529-ee84-4747-a652-7e23b99d20e8
                Copyright: © Urology Annals

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 15 November 2013
                : 24 June 2014
                Categories
                Case Report

                Urology
                diagnosis,positron-emission tomography/computed tomography,prostat cancer,sarcoma,spindle cell prostatic sarcoma,treatment

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