Review Article | Published:

Concomitant bladder cancer and prostate cancer: challenges and controversies

Nature Reviews Urology volume 14, pages 620629 (2017) | Download Citation

Abstract

Radical cystoprostatectomy (RCP) followed by bilateral pelvic lymphadenectomy and urinary diversion remains the gold-standard therapy for men with localized muscle-invasive bladder cancer (MIBC). Prostate cancer might be incidentally detected at the time of RCP with a reported prevalence of 24–51%. Typically, these patients are considered to have clinically insignificant disease, but data from emerging series challenge this assumption and suggest that some of these tumours might be aggressive, or somehow increase the aggressiveness of the associated MIBC, and can negatively influence the patient's overall survival outcomes. Furthermore, the potential use of prostate-sparing cystectomy in patients with less-aggressive MIBC might lead to newly diagnosed incidental cases of prostate cancer, with characteristics suggestive of clinically significant disease, requiring a specific, separate workup. The development of evidence-based, validated protocols to define the necessary steps for diagnosis of prostate cancer in these patients, including the role of serum PSA testing, digital rectal examination, the role of imaging methods and the indication and type of biopsy protocol, is of major importance to the multidisciplinary management of patients with urological cancer. Finally, the retrospective nature of the available data account for much of the variability in the prevalence of coexisting bladder and prostate cancer and emphasizes the need for randomized trials in this controversial area of urological oncology.

Key points

  • Pathological evaluations of the prostate variably reveal incidental prostate cancer in 24–51% of patients with muscle-invasive bladder cancer (MIBC) undergoing radical cystoprostatectomy (RCP)

  • The reported incidence of prostate cancer in RCP specimens is highly variable, mostly owing to differences in the histopathological analysis techniques used to investigate the samples

  • Most available data suggest that incidentally diagnosed prostate cancer is clinically insignificant; however, emerging data suggest that a subset of these patients could indeed have clinically significant disease

  • A subset of incidentally diagnosed prostate cancers in patients >60 years of age with Gleason ≥7 disease might negatively influence patients' overall survival outcomes, indicating a need for intervention in this subset of patients

  • Preoperative serum PSA levels and digital rectal examination (DRE) results mostly fail to indicate asymptomatic, incidental prostate cancer; however, the introduction of imaging methods such as MRI might assist in detecting such cases

  • The retrospective nature of the available data on prostate cancer aggressiveness in patients undergoing RCP for MIBC, in addition to a lack of prospective data on the risk of clinically significant prostate cancer, all preclude the optimal treatment of such patients

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Author information

Affiliations

  1. Unit of Anatomical Pathology, Department of Surgery and Pathology, Cordoba University Medical School, Cordoba University, E-14004 Cordoba, Spain.

    • Antonio Lopez-Beltran
  2. Champalimaud Clinical Center, Av. de Brasilia, 1400–038 Lisbon, Portugal.

    • Antonio Lopez-Beltran
  3. Departments of Pathology and Urology, Indiana University School of Medicine, 350 West 11th street, Indianapolis, Indiana, USA.

    • Liang Cheng
  4. Department of Urology, IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy.

    • Francesco Montorsi
  5. Institute of Pathological Anatomy and Histopathology, Polytechnic University of the Marche Region (Ancona), School of Medicine, United Hospitals, Via Conca 71, 60126 Torrette, Ancona, Italy.

    • Maria Scarpelli
    •  & Rodolfo Montironi
  6. Histopathology and Molecular Diagnostics Service, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy.

    • Maria R. Raspollini

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Contributions

A. L.–B., M.S., M.R.R. and R.M. researched data for this article, all authors made a substantial contribution to discussions of content, A. L.–B. wrote the manuscript, and all authors reviewed and/or edited the manuscript prior to submission.

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The authors declare no competing financial interests.

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Correspondence to Antonio Lopez-Beltran.

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DOI

https://doi.org/10.1038/nrurol.2017.124

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