Rev Mex Urol 2015;75(4):202-208

ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA, COLEGIO DE PROFESIONISTAS, A.C.

www.elsevier.es/uromx

Original article

Histopathologic findings in radical prostatectomy specimens at two private hospitals in Mexico City R. Jáuregui-Brechúa,*, R.H. Figueroa-Gómezb, J.A. Pérez-Castroc, H. Brandt-Brandtc and R. Bravo-Leónd a

General Surgery Service, Hospital Ángeles Metropolitano, Universidad La Salle, Mexico City, Mexico

b

Urology Service, Hospital Ángeles Metropolitano, Mexico City, Mexico

c

Pathology Service, Hospital Ángeles Metropolitano, Mexico City, Mexico

d

School of health Sciences, Universidad Panamericana, Mexico City, Mexico

Received 13 March 2015; accepted 11 May 2015 Available online 7 July 2015

KEYWORDS Radical prostatectomy; Prostate cancer; Private hospital

Abstract Aims: To know the number of radical prostatectomies performed at 2 private hospitals in Mexico City and report the histopathologic findings of the surgical specimens. Methods: A review of the radical prostatectomies performed at the Hospital Ángeles Metropolitano and the Hospital Ángeles México in Mexico City within the 6-year period from January 2008 through December 2013 was conducted. Results: Seventy-seven radical prostatectomy specimens were found, with a mean performance of 9.6 prostatectomies per year at the Hospital Ángeles Metropolitano and 3.1 at the Hospital Ángeles México. There were 2.60% cases of acinar adenocarcinoma of the prostate with a Gleason score of 5, 35.06% with a Gleason score of 6, 42.85% with a Gleason score of 7, 12.98% with a Gleason score of 8, no cases with Gleason scores of 9 or 10, and 5 cases (6.49%) in which no cancer was found. There was invasion into the capsule in 27.27% cases, seminal vesicle involvement in 6.5%, regional lymph node invasion in 16.88%, positive bladder margins in 4 cases (5.1%), and no positive urethral margins. Conclusions: In the majority of the prostate cancer cases reviewed, the disease was in the localized stages. Radical prostatectomy is performed more frequently in public hospitals than in the private sector. © 2015 Published by Masson Doyma México S.A. on behalf of Sociedad Mexicana de Urología. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

*Corresponding author at: Paseo del Bosque #125, colonia Paseos de Taxque˜na. Delegación Coyoacán, Ciudad de México. Código postal 04250, Tel: +521 5544476474. Email: [email protected] (R. Jáuregui-Brechú).

2007-4085/© 2015 Sociedad Mexicana de Urología. Publicado por Masson Doyma México S.A. Todos los derechos reservados.

Histopathologic findings in radical prostatectomy specimens at two private hospitals in Mexico City 

PALABRAS CLAVES Prostatectomía radical; Cáncer de próstata; Hospital privado

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Hallazgos histopatológicos en piezas de prostatectomía radical en 2 hospitales privados de la Ciudad de México, D.F Resumen Objetivo: Conocer el número de prostatectomías radicales realizadas en 2 hospitales privados de la Ciudad de México, D.F. y reportar los hallazgos histopatológicos de las piezas quirúrgicas. Materiales y métodos: Se realizó una revisión en el Hospital Ángeles Metropolitano y el Hospital Ángeles México, de la Ciudad de México D.F. durante un periodo de 6 años, entre enero del 2008 y diciembre del 2013. Resultados: Se encontraron 77 piezas de prostatectomía radical, teniendo un promedio de 9.6 prostatectomías/año en el Hospital Ángeles Metropolitano y de 3.1 en el Hospital Ángeles México. Se encontró adenocarcinoma acinar de próstata Gleason 5 en el 2.60%, Gleason 6 en el 35.06%, Gleason 7 en el 42.85%, Gleason 8 en el 12.98%; no se hallaron casos con Gleason 9 ni 10 y no se encontró cáncer en 5 casos (6.49%); se apreció invasión de cápsula en el 27.27%, compromiso de vesículas seminales en el 6.5% e invasión de ganglios regionales en el 16.88%, márgenes quirúrgicos vesicales positivos en 4 casos (5.1%) y no se encontraron bordes quirúrgicos uretrales positivos. Conclusiones: El cáncer de próstata se encontró mayormente en etapas localizadas, la prostatectomía radical se realiza con mayor frecuencia en hospitales públicos. © 2015 Publicado por Masson Doyma México S.A. en nombre de Sociedad Mexicana de Urología. Este es un artículo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Prostate cancer (CaP) is the most frequent noncutaneous cancer and the second most frequent cause of death by cancer in men above the age of 60 years in the United States.1 In 1999, CaP held first place among the cancers affecting men in Mexico.2 Currently it is in second place, only behind lung cancer, which includes both sexes, and represents 3,766 deaths/year with a rate of 11.9 per 100,000 inhabitants.3 Unfortunately, up to 60% of the cases diagnosed for the first time are in clinically advanced stages, eliminating the possibility of curative treatment for those patients.4 With the beginning of the prostate-specific antigen era and opportune CaP detection, this percentage has been decreasing and the rate of localized cancer has increased. Radical prostatectomy (RP) is the treatment of choice, offering better cure rates when the tumor is found in localized stages. However, in Mexico there are few ideal patients for this surgery for 2 important reasons; the first is that it is a country with a low worldwide level of CaP incidence and the second is that in the majority of cases diagnosis is made in advanced disease stages. In contrast, in the United States 85% of the diagnoses are currently made in patients with localized disease and it is one of the countries with the highest worldwide incidence.5 The therapeutic options for CaP include RP with its different approaches (suprapubic, perineal, laparoscopic, robotic-assisted), conventional or conformational radiotherapy, brachytherapy, cryotherapy, hormonal treatment alone or in combination, and chemotherapy, among others. Each of these therapies has different indications, restrictions, and complications, as well as different disease control rates.6-7

RP continues to be the gold standard for localized CaP treatment and the retropubic approach is the most widely used in Mexico.8-9 Its main advantage is that it offers the possibility of cure with acceptable collateral damage and it is a well-tolerated procedure with a low morbidity rate and a general mortality rate of 0.2%. Compared with other treatments for localized disease, the potential disadvantages are the need for hospitalization and recovery time, the possibility of incomplete tumor resection, and the risk for erectile dysfunction and urinary incontinence.10 Post-radical retropubic prostatectomy urinary incontinence incidence varies between 2.5 and 87% 11 and severe incontinence between 0.5 and 11%.12 A review was carried out of all RPs performed over a 6-year period at the Hospital Ángeles Metropolitano (HAMe) and the Hospital Ángeles México (HAMx) in Mexico City. The primary aim of the study was to determine the number of RPs performed in 2 private hospitals in Mexico City, the HAMe and the HAMx. The secondary aim was to establish the histopathologic findings of the surgical specimens of those RPs and compare them with the findings published in the national medical literature.

Methods A retrospective and prospective review was carried out of all the RPs performed at 2 private hospitals in Mexico City, the HAMe and the HAMx. The review covered the 6-year period of January 2008 to December 2013 and was based on all the surgical specimens analyzed by the Pathologic Anatomy Department during that time frame. It should be pointed out that the analysis by that department of any surgical specimen obtained from those two hospitals is obligatory.

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The analysis included the number of RPs performed, the Gleason score of the surgical specimen, tumor involvement of the prostatic capsule and seminal vesicles, venous permeation, lymphovascular permeation, and surgical margin involvement, as well as regional lymph node involvement in the cases that underwent lymph node dissection. And finally, a brief comparison with respect to reports in the national medical literature on this same topic was carried out.

35

30

Number of biopsies

25

Results

20

15

10

Within the time frame of January 2008 and December 2013, there were 58 RP specimens from the HAMe and 19 specimens from the HAMx, making a total of 77 RP specimens from both hospitals. Cancer was not identified in 5 specimens, representing 6.49% of the cases. Two patients had a Gleason score of 5 (3+2), representing 2.60%. Twenty-seven patients had a Gleason score of 6 (3+3), corresponding to 35.06% of the cases. Thirty-three patients presented with a Gleason score of 7, representing 42.85%; in 16 (20.79%) of those patients the Gleason sum was (3+4) and in the other 17 (22.08%) the Gleason sum was (4+3). Ten patients, representing 12.98% of the patients, had a Gleason score of 8; 6 of those cases had a Gleason sum of (4+4), in 3 cases the Gleason sum was (5+3), and in one case the Gleason sum was (3+5). None of the cases presented with a Gleason score of 9 or 10 (figs. 1 and 2). Of the 77 surgical specimens, 21 had capsular invasion, corresponding to 27.27% of the cases, whereas 56 of them had no capsular invasion, corresponding to 72.73%. In regard to the seminal vesicles, 5 cases had invasion, corresponding to 6.50% of the cases, whereas 72 of the patients were tumor-free, corresponding to 93.5%. Three cases (3.90%) were positive for venous permeation and 74 cases (96.1%) were negative.

Number of biopsies / total percentage

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5

0

5

6

8

7

Gleason score

Twelve cases (15.58%) were positive for lymphovascular permeation and 65 cases (84.42%) were negative. Forty-four cases (57.14%) presented with perineural invasion, whereas it was negative in 33 cases (42.86%) (fig. 3). Four cases (5.1%) had a surgical margin that was positive for neoplasia, all of which involved the bladder margin; no case had a positive surgical margin involving the urethral margin (fig. 4). In relation to the regional lymph nodes, 13 cases (16.88%) had lymph node invasion, 40 cases (51.95%) had negative lymph nodes, and 24 cases (31.17%) did not undergo lymph node dissection (fig. 5). “Acinar adenocarcinoma” was the type of cancer found in all the cancer cases.

25

20

17 (22,08%)

16 (20,79%) 15

10

5

0

Figure 2  Detailed Gleason score

WITHOUT CANCER

6 (4,78%) 2 (2,60%)

3+2

3 (3,87%)

1 (1,3%) 3+3

3+4

10

Figure 1  Gleason score

27 (35,06%)

5 (6,49%)

9

Gleason score

3+5

4+3

4+4

5+3

Histopathologic findings in radical prostatectomy specimens at two private hospitals in Mexico City 

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100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Seminal vesicles

Venous permeation

Negative

Lymphovascular permeation

Perineural invasion

Capsule

Positive

Figure 3  Neoplastic infiltration

80 70 60 50 40

77

73

30 20 10

4

0

Bladder surgical margin

Urethral surgical margin

Positive

Negative

Figure 4  Surgical margins

Discussion Fifty-eight radical prostatectomies were performed at the HAMe within a 6-year time frame, resulting in a mean 9.6 surgeries/year. It should be mentioned that at that hospital,

16,88%

31,17%

51,95%

Positive

Negative

Lymph node dissection was not performed

Figure 5  Lymph node infiltration

more than 50 urologists have performed at least one of some type of urologic surgery within that period of time and only 21 of them have performed at least one RP within that same time frame. In this study, the urologists will be referred to by number, rather than by name. Thus, the urologist that performed the most RPs at the HAMe is referred to as no. “1”, with 16 surgeries, giving him a personal mean of 2.6 surgeries/year. Urologist no. “2” performed 10 surgeries, resulting in a mean of 1.6 surgeries/ year. Urologist no. “3” performed 8 surgeries and had a mean of 1.3 surgeries/year. Urologist no. “4” performed 6 surgeries and had a mean of one surgery/year. Urologist no. “5” performed 2 surgeries, giving him a mean of 0.3 surgeries/year. The remaining 16 urologists performed only one RP during the 6-year time frame, obtaining a mean of 0.16 surgeries/year, each. At the HAMx, urologist no. “1” performed 10 surgeries, giving him a personal mean of 1.6 surgeries/year. Urologist no. “2” performed 3 surgeries and had a mean of 0.5 surgeries/year. Urologists nos. “3” and “4” performed 2 surgeries and had a mean of 0.3 surgeries/year. And urologists nos. “5” and “6” performed one surgery, obtaining a mean of 0.16 surgeries/year. Other references were obtained, such as that of Dr. Elías Zonana-Farca, who reported his personal experience at the Hospital Ángeles Mocel of 105 RPs over a 15-year period, giving him a mean of 7 surgeries/year 13 (fig. 6). Dr. Eduardo Serrano-Brambila reported 38 RPs performed at the Hospital de Especialidades “Centro Médico Nacional Siglo XXI” of the Instituto Mexicano del Seguro Social (IMSS) within a 9-year period resulting in a mean of 4.2 surgeries/ year.14 Dr. Iván Mauricio Schroeder-Ugalde reported 67 RPs performed at the Hospital Central del Sur de Alta Especialidad de Petróleos Mexicanos (PEMEX) within an 8-year period, corresponding to a mean of 8.3 surgeries/ year.15 Dr. Francisco Rodríguez-Covarrubias reported 205 RPs performed at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán over a 20-year period, resulting in a mean of 10.25 surgeries/year.16

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13%

12 10,25% 10,4%

9,6%

10 8,3% 8

8,2%

7,5%

7%

7,3%

5,4%

6 4,2% 4

3,1%

1 Ángeles Mocel 2 CMN Siglo XXI 3 PEMEX 4 INCMyNSZ 5 HGMGG A 6 ISSSTE “C” Hermosillo 7 HGM 8 ISSEMyM 9 HGMGG B 10 Centro Médico ABC 11 Ángeles México 12 Ángeles Metropolitano

2

0

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7

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CMN = Centro Médico Nacional. PEMEX = Petróleos Mexicanos. INCNyNSZ = Instituto Nacional de Ciencias Medicas y Nutrición “Salvador Zubirán” ISSSTE = Instituto de Seguridad y Servicios Sociales de los Trabajadores del

Estado. HGM = Hospital General de México. ISSEMyM = Institudo de Seguridad Social del Estado de México y Municipios. HGMGG = Hospital General Manuel Gea González. ABC = American British Cowdray.

Figure 6  Annual percentage of radical prostatectomies by institution. ABC: American British Cowdray; CMN: Centro Médico Nacional; HGM: Hospital General de México; HGMGG: Hospital General Manuel Gea González; INCNyNSZ: Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán»; ISSEMyM: Instituto de Seguridad Social del Estado de México y Municipios; ISSSTE: Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado; PEMEX: Petróleos Mexicanos.

Seguridad y Servicios Sociales de los Trabajadores del Estado in the city of Hermosillo, Sonora, within a 7-year period, obtaining a mean of 5.4 surgeries/year.18 Dr. Hugo Manzanilla-García reported 53 RPs performed at the Hospital General de México within a 7-year time frame, resulting in a mean of 7.5 surgeries/year.19

Dr. Andrade-Platas reported 156 RPs performed at the Hospital General Dr. Manuel Gea González over a period of 15 years, corresponding to a mean of 10.4 surgeries/ year.17 Dr. Carlos Armando Leos-Gallego reported 38 RPs performed at the Hospital General “C” del Instituto de

250 205 200 156

149

150 105 100

78

66

67

58

53

50

38

38 19

1993-2000

1994-2002

2004-2011

1988-2007

1991-2006

1999-2005

1992-1997

2004-2009

1991-2008

1993-2001

2007-2013

2007-2013

0

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1 Ángeles Mocel 2 CMN Siglo XXI 3 PEMEX 4 INCMyNSZ 5 HGMGG A 6 ISSSTE “C” Hermosillo 7 HGM 8 ISSEMyM 9 HGMGG B 10 Centro Médico ABC 11 Ángeles México 12 Ángeles Metropolitano

Figure 7  Number of radical prostatectomies by institution and period. ABC: American British Cowdray; CMN: Centro Médico Nacional; HGM: Hospital General de México; HGMGG: Hospital General Manuel Gea González; INCNyNSZ: Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán»; ISSEMyM: Instituto de Seguridad Social del Estado de México y Municipios; ISSSTE: Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado; PEMEX: Petróleos Mexicanos.

Histopathologic findings in radical prostatectomy specimens at two private hospitals in Mexico City  Dr. Axel Costilla-Montero reported 78 RPs performed at the Centro Médico del Instituto de Seguridad Social del Estado de México y Municipios (ISSEMyM) within a period of 6 years, corresponding to a mean of 13 surgeries/ year.20 Dr. Zael Santana-Ríos reported 149 RPs performed at the Hospital General Dr. Manuel Gea González over an 18-year period, resulting in a mean of 8.2 surgeries/year.21 Dr. Armando Castro-Gaytán and Dr. Roberto FigueroaGómez reported 66 RPs performed at the Hospital ABC Observatorio within a 9-year time frame, obtaining a mean 7.3 surgeries/year22 (fig. 7). With respect to the histopathologic findings, the 77 surgical specimens analyzed at the HAMe and HAMx had a greater frequency of a Gleason score of 7 (42.85%), followed by a Gleason score of 6 (35.06%). There was a 27.27% frequency of capsular infiltration, concurring with figures reported in the international medical literature. Only 6.5% of the cases presented with seminal vesicle invasion, whereas 16.88% presented with positive regional lymph nodes. Perineural invasion was more frequent than venous invasion and lymphovascular invasion. Pathologic stage was more influenced by the preoperative “selection” of the patients than by the surgical technique itself. No cancer was found in 5 of the 77 reported cases, which could be explained by the following 2 factors: either the tumor was too small and the cancer was not identified in the surgical specimen or there really was no cancer in those specimens. Access to preoperative biopsies was possible in some of those cases and no cancer was identified in any of them; all the biopsy reports were carried out by pathologists outside of the hospital.

Conclusions Despite the fact that RP is the method of choice for treating localized CaP, it is not carried out very often in Mexico. The RP rate is much higher in public hospitals than in private ones. Among the factors responsible for this are: many public hospitals are referral centers, the cost involved in having this procedure in a private hospital, and the success of public health campaigns on the importance of early CaP detection directed at patients attended to at public hospitals. The majority of the surgical specimens have a Gleason score consistent with localized CaP.

Ethical responsibilities Protection of persons and animals. The authors declare that no experiments were performed on humans or animals for this study. Data confidentiality. The authors declare that no patient data appear in this article. Right to privacy and informed consent. The authors declare that no patient data appear in this article.

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Financial disclosure No financial support was received in relation to this article.

Conflict of interest The authors declare that there is no conflict of interest.

Acknowledgements The authors wish to thank the Universidad La Salle and the Pathology and Urology Services of the Hospital Ángeles Metropolitano and Hospital Ángeles México.

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