Milonas, Daimantas

Background & Objectives: Prostate cancer is the second most diagnosed malignancy among men worldwide and the leading cancer diagnosis in 118 countries, accounting for approximately 1.5 million new cases annually. Despite radical treatment, 20–50% of patients develop biochemical recurrence (BCR). The objective of this study is to evaluate the tendencies of positive lymph nodes and nodal metastasis sizes with BCR status.

Methods: We retrospectively reviewed 26 patients (29 lymph nodes) diagnosed with prostate cancer with regional lymph node metastases following radical prostatectomy and pelvic lymph node dissection between 2012 and 2023 at the Department of Pathology (LUHS). Patients were stratified according to BCR, defined as PSA ≥ 0.2 ng/ml, into two groups: with BCR (n = 13(15)) and without BCR (n = 13(14)). Statistical analysis, including descriptive statistics, t-test, and Mann-Whitney U, was applied (p<0.05).

Results: The mean age of patients was 69.2 (8.8) years. Pathological staging of pT3a was in 46.2%, pT3b – in 42.3% and pT2 – in 11.5% of cases. The mean number of regional lymph nodes removed during radical prostatectomy was 14 (7.2), with a median preoperative PSA of 8.4 ng/ml; neither parameters differed between groups. The median lymph node size was 6.1 (7.15; range: 1.50 – 32.00) mm, while the mean metastasis size was 3.56 (4.9; range: 0.3 – 13.6) mm. Comparison between patients with and without BCR revealed no statistically significant differences in lymph node size (p = 0.057) or metastasis size (p = 0.683), although lymph node size showed a borderline tendency towards larger values in the recurrence group.

Conclusion: This study suggests that size of positive lymph nodes and nodal metastasis alone may not be reliable prognostic factors of BCR following radical prostatectomy, indicating limited utility of these parameters as standalone prognostic indicators.

Introduction & Objectives: Although pelvic lymph node dissection (PLND) is the most accurate method for lymphatic staging in prostate cancer, its therapeutic benefit remains controversial. We investigated oncologic outcomes in high‑risk prostate cancer patients who underwent radical prostatectomy (RP) with or without PLND. Materials & Methods: We retrospectively analyzed patients who underwent RP for localized or locally advanced prostate cancer at a single tertiary center from 01/01/2001 to 12/31/2022. Propensity score analysis was used to create comparable groups. Inclusion criteria for analysis included at least one high-risk prostate cancer feature: preoperative PSA ≥20 ng/mL, postoperative ISUP ≥4, or pathologic stage ≥ pT3a. Patients with incomplete data were excluded. Patients were divided into group 1: omission of PLND, and group 2: performance of PLND. Propensity score matching (1:1) generated two cohorts of 282 patients each. Kaplan–Meier and cumulative incidence functions estimated 15- year clinical progression (CP), cancer-specific mortality (CSM), and overall mortality (OM). Hazard ratios (HR) with 95% confidence intervals (CI) are reported. Analyses were conducted with SAS 9.4. A two-sided p-value < 0.05 was considered statistically significant. Results: Median follow‑up was 119 months (IQR 71–164). Median age was 64 years (60–68) and median PSA - 7.9 ng/mL (5.8–10.3). The study groups were similar regarding preoperative PSA (p =0,8, pathological ISUP (p = 0,6) and pathological stage (p = 0,4). Positive surgical margin (R1) occurred in 230 patients (40.8%). Median number of removed lymph nodes was 8 (IQR 5–14); 35/282 patients had lymph node involvement (12.4%). Overall, the 15‑year cumulative CP rate was 19.4%, CSM 5.6% and OM 26.7%. In multivariable analysis, pathological ISUP and pathological T stage were predictors for CP; age and R1 predicted CSM; and age, pathological ISUP 5 and pT2 predicted OM (p < 0.05). PLND was not found as significant predictor in any analysis. The main goal of the analysis was to compare oncological outcomes between the two groups. 15-year cumulative CP rates were 25.6% (95% CI 18.9–34.6%) in group 1 and 31.3% (95% CI 24.0–40.8%) in group 2 (p = 0.317); CSM was 8.6% (95% CI 4.8–15.1%) versus 8.8% (95% CI 5.2–15.0%) (p = 0.9); OM was 40.2% (95% CI 33.4–48.4%) versus 41.6% (95% CI 34.6–50.0%) (p = 0.77). Conclusions: In this propensity score–matched cohort of patients with high‑risk features, PLND at the time of RP was not associated with improved long-term oncologic outcomes compared with omission of PLND. These findings do not support a therapeutic benefit of PLND in high-risk patients undergoing RP.

Background: An inflammatory myofibroblastic tumor (IMT) is a rare mesenchymal tumor, sometimes with urinary bladder involvement (though this is extremely uncommon). Due to its rarity, the exact etiology and optimal treatment strategy remain unclear. Methods: A review of the existing literature on IMT of the urinary bladder was performed. Results: We report a case of a 32-year-old female presenting with frequent urination, hematuria with clots, and lower abdominal pain for one month. Initially misdiagnosed as acute cystitis, the symptoms persisted despite antibiotic therapy. Laboratory findings revealed severe anemia, and imaging studies identified a large bladder mass. Transurethral resection of the bladder tumor (TURB) was performed, and a 96 g mass was removed. Histopathological examination confirmed IMT of the urinary bladder (IMTUB) with positive immunohistochemical staining for ALK, vimentin, and actin. Follow-up at 30 months showed no recurrence, with annual cystoscopy and CT scans confirming remission. Conclusions: IMTUB should be considered in young patients presenting with hematuria and lower urinary tract symptoms. Early diagnosis through cystoscopy, imaging, and histopathological confirmation is essential for appropriate management. TURB remains the gold standard for treatment, with ALK inhibitors providing additional therapeutic options in select cases. Long-term follow-up is necessary due to the unknown malignant potential of IMTUB.

Background/Objectives: The role of extended pelvic lymph node dissection (ePLND) in prostate cancer remains uncertain. Sentinel lymph node (sLN) mapping improves diagnostic precision, yet some patients have no detectable sentinel nodes (“untraceable” sLNs). This study evaluates whether untraceable sLNs predict the absence of lymph node invasion (LNI) and can guide surgical decision-making during radical prostatectomy (RP) with ePLND. Methods: Patients with intermediate- or high-risk prostate cancer and with no radiologically evident LNI were included in the study. A 99mTc-nanocolloid was used as an sLN tracer. RP with sLN dissection and ePLND was performed <20 h after injection. Patients were categorized into two groups: Group 1, traceable sLNs and Group 2, untraceable sLNs (no radiological or intraoperative signal). Results: A total of 53 patients were included. LNI was present in 10 patients (18.9%). Group 1 had 41 patients (77.4%), and Group 2 had 12 patients (22.6%). None of the patients in Group 2 had LNI following ePLND, whereas 10 of 41 patients (24.4%) in Group 1 were node-positive (p = 0.016). Baseline clinical and pathological characteristics were comparable between groups. A total of 17/53 of men (32.1%) experienced biochemical recurrence, overall, with higher observed events in Group 1 (15/41, 36.6%) vs. Group 2 (2/12, 16.7%). However, this difference did not reach statistical significance (p = 0.2). Conclusions: A proportion of PCa patients have no radiologically or intraoperatively detectable sLNs, and none of the patients with untraceable sLNs exhibited LNI following ePLND. These findings suggest that untraceable sLNs may correlate with an extremely low probability of nodal invasion and could serve as a criterion for safely omitting ePLND in selected patients.

Background: Bladder leiomyosarcoma is an extremely rare non-urothelial malignancy, accounting for less than 0.1% of all bladder tumors. It presents significant diagnostic and therapeutic challenges due to its aggressive nature and the absence of standardized treatment protocols. Case presentation: We report the case of a 61-year-old woman who presented with hematuria, dysuria, and suprapubic pain. Imaging revealed a large, locally invasive bladder mass, and histopathological examination following transurethral resection confirmed leiomyosarcoma. The patient underwent radical cystectomy with resection of adjacent bowel segments and urinary diversion. Histology showed a high-grade leiomyosarcoma (pT3N0) with extensive necrosis and a high mitotic index. Two months postoperatively, peritoneal dissemination was detected. Systemic chemotherapy with dacarbazine and doxorubicin initially led to the regression of metastases, but disease progression occurred within months, including lung, liver, and bone metastases. Palliative radiotherapy and second-line chemotherapy were initiated. As of now, 16 months have elapsed since surgery. Conclusions: This case underscores the aggressive clinical course of bladder leiomyosarcoma despite multimodal therapy and the urgent need for individualized management strategies. Given its rarity, this case contributes to the limited literature and highlights the importance of vigilant follow-ups and further studies to establish evidence-based treatment protocols.

Lymph node-positive (pN1) prostate cancer (PCa) is a heterogeneous disease, and a clear definition of prognostic groups is urgently needed. We aimed to assess cancer-related mortality (CRM) in different prognostic groups of pN1 patients, created based on the pathological PCa characteristics and number of positive lymph nodes (LN+).

Introduction & Objectives: Nephron spearing surgery (NSS) is the primary treatment option for localized renal cell carcinoma, aiming to remove the tumor while preserving kidney function. The goal of surgery is to achieve clean resection margins, as positive margins are believed to increase recurrence risk. However, their impact on overall survival (OS) and cancer-specific survival (CSS) remains debated. Materials & Methods: This study included 964 patients who underwent NSS at a tertiary university center (2012-2023). The primary endpoints were OS and CSS, measured from the date of surgery to the last follow-up or death. Kaplan-Meier curves were used to estimate 10-year OS and CSS rates. Survival differences between patients with positive (R1) and negative (R0) surgical margins were assessed using the log-rank test. Clinical and pathological factors were compared between groups using the Chi-square and Mann-Whitney test. Multivariate Cox regression analysis was performed to identify factors associated with OS and CSS. A p-value < 0.05 was considered statistically significant. Results: Of the 946 patients, 222 (23%) had benign tumors. Among the 742 patients included in the study, 57.28% were male, with a median age of 64 years (IQR 57–71). The median tumor size was 3.1 cm (IQR 2.3– 4.0), and the most common histological subtype was clear cell renal carcinoma (78.97%), followed by papillary renal carcinoma (10.78%) and chromophobe renal carcinoma (8.22%). The majority of tumors were classified as grade G2 (71.1%). R1 resection status was observed in 92 cases (12.2%). During the follow-up period (median: 60.25 months), 111 patients (14.7%) died, with 29 (3.9%) deaths attributed to renal cancer. The 10-year OS rate for the entire cohort was 73.3%, while the CSS rate was 93.2%. No differences in baseline characteristics were found between the R1 and R0 groups. The 10-year OS was 74.4% in the R0 group and 59.1% in the R1 group (p=0.3), while the 10-year CSS was 93.9% and 86.7% (p=0.5), respectively. Multivariate Cox regression analysis did not confirm R1 status as an independent predictor of worse survival (OS: HR=1.4 95% CI:0.77–2.51, p=0.3; CSS: HR=1.7, 95% CI:0.57–5.09, p=0.3). OS was significantly influenced by patient age (HR=1.05, 95% CI: 1.03–1.07, p<0.001) and tumor differentiation grade. A significant difference in OS was observed when comparing G1 and G2 groups (HR=1.9, 95% CI:1.01–3.46, p=0.046), with an even more pronounced effect between G1 and G3 (HR=2.5, 95% CI:1.07–5.74, p=0.03). CSS was also affected by age (HR=1.06, 95% CI:1.02–1.10, p=0.005) and tumor differentiation grade, particularly in the G3 group compared to G1 (HR=8.6, 95% CI:1.75–42.26, p=0.008). Conclusions: R1 status was linked to lower 10-year OS and CSS, but not significantly. Age and tumor differentiation grade were the strongest predictors of survival, while surgical margin status had no significant impact.

Introduction & Objectives: High-risk prostate cancer (PCa) is an aggressive malignancy with a high risk of progression, metastasis, and poor survival outcomes. The role of pelvic lymph node dissection (PLND) in its management remains unclear. While extended prostate and pelvic lymph node irradiation is commonly used with external beam radiation therapy (EBRT), limited research has evaluated the effectiveness of PLND in this setting. This study compares PLND combined with prostate RT versus extended RT in high-risk PCa patients to assess their impact on disease control. Materials & Methods: This prospective, single-center study included 68 high-risk PCa patients (PSA >20 ng/mL and/or ≥cT2c and/or Gleason score ≥8) who underwent either PLND with prostate RT or extended RT. The PLND+RT group received 80 Gy to the prostate and seminal vesicles, while the extended RT group received an additional 50 Gy to the pelvic lymph nodes. All patients received androgen deprivation therapy (ADT) for three years. The primary outcomes were biochemical recurrence-free (BCR-free) survival and metastasis-free (MTS-free) survival, assessed from treatment initiation. Statistical analyses compared the impact of treatment modality (PLND+RT vs. extended RT) on these outcomes. Results: The median age was 71.5 years (IQR: 67-75.5), and the median PSA was 15.7 ng/mL (IQR: 8-27.7). Both groups were homogeneous in age, clinical stage, biopsy Gleason score, clinical lymph node status and pre-treatment PSA. PNLD+RT was performed in 26 patients (38%), while 42 (62%) received extended RT. The median follow-up was 45.7 months (IQR: 30-58.8). BCR occurred in 23.1% of PLND patients and 11.9% in the extended RT group (p = 0.19). MTS was detected in 23.1% vs. 7.1% of cases, respectively (p = 0.07). Estimated 3 and 5-years BCR-free survival in the entire group was 92 % and 67.9 %, and MTS-free survival was 95.2 % and 58.5 %. 3 and 5- years BCR-free survival was worse in PNLD+RT group than in the extended RT group: 90.1 % vs. 87.1% and 56.7 % vs. 74.1 %, respectively (p = 0.03). 3 and 5-years MTS-free survival was better in the extended RT group: 92.9 % vs. 96.4 % and 57.1 % vs. 82.7 %, respectively (p = 0.048). Conclusions: In high-risk PCa patients treated with external RT, PLND did not provide significant benefits in preventing early disease progression. Extended RT was associated with improved BCR-free and MTS-free survival, but the differences were modest. A longer followup is required to determine the long-term oncological impact of each approach.

Introduction & Objectives: Nephron spearing surgery (NSS) is the primary treatment option for localized renal cell carcinoma, aiming to remove the tumor while preserving kidney function. The goal of surgery is to achieve clean resection margins, as positive margins are believed to increase recurrence risk. However, their impact on overall survival (OS) and cancer-specific survival (CSS) remains debated. Materials & Methods: This study included 964 patients who underwent NSS at a tertiary university center (2012-2023). The primary endpoints were OS and CSS, measured from the date of surgery to the last follow-up or death. Kaplan-Meier curves were used to estimate 10-year OS and CSS rates. Survival differences between patients with positive (R1) and negative (R0) surgical margins were assessed using the log-rank test. Clinical and pathological factors were compared between groups using the Chi-square and Mann-Whitney test. Multivariate Cox regression analysis was performed to identify factors associated with OS and CSS. A p-value < 0.05 was considered statistically significant. Results: Of the 946 patients, 222 (23%) had benign tumors. Among the 742 patients included in the study, 57.28% were male, with a median age of 64 years (IQR 57–71). The median tumor size was 3.1 cm (IQR 2.3– 4.0), and the most common histological subtype was clear cell renal carcinoma (78.97%), followed by papillary renal carcinoma (10.78%) and chromophobe renal carcinoma (8.22%). The majority of tumors were classified as grade G2 (71.1%). R1 resection status was observed in 92 cases (12.2%). During the follow-up period (median: 60.25 months), 111 patients (14.7%) died, with 29 (3.9%) deaths attributed to renal cancer. The 10-year OS rate for the entire cohort was 73.3%, while the CSS rate was 93.2%. No differences in baseline characteristics were found between the R1 and R0 groups. The 10-year OS was 74.4% in the R0 group and 59.1% in the R1 group (p=0.3), while the 10-year CSS was 93.9% and 86.7% (p=0.5), respectively. Multivariate Cox regression analysis did not confirm R1 status as an independent predictor of worse survival (OS: HR=1.4 95% CI:0.77–2.51, p=0.3; CSS: HR=1.7, 95% CI:0.57–5.09, p=0.3). OS was significantly influenced by patient age (HR=1.05, 95% CI: 1.03–1.07, p<0.001) and tumor differentiation grade. A significant difference in OS was observed when comparing G1 and G2 groups (HR=1.9, 95% CI:1.01–3.46, p=0.046), with an even more pronounced effect between G1 and G3 (HR=2.5, 95% CI:1.07–5.74, p=0.03). CSS was also affected by age (HR=1.06, 95% CI:1.02–1.10, p=0.005) and tumor differentiation grade, particularly in the G3 group compared to G1 (HR=8.6, 95% CI:1.75–42.26, p=0.008). Conclusions: R1 status was linked to lower 10-year OS and CSS, but not significantly. Age and tumor differentiation grade were the strongest predictors of survival, while surgical margin status had no significant impact.

Introduction & Objectives: High-risk prostate cancer (PCa) is an aggressive malignancy with a high risk of progression, metastasis, and poor survival outcomes. The role of pelvic lymph node dissection (PLND) in its management remains unclear. While extended prostate and pelvic lymph node irradiation is commonly used with external beam radiation therapy (EBRT), limited research has evaluated the effectiveness of PLND in this setting. This study compares PLND combined with prostate RT versus extended RT in high-risk PCa patients to assess their impact on disease control. Materials & Methods: This prospective, single-center study included 68 high-risk PCa patients (PSA >20 ng/mL and/or ≥cT2c and/or Gleason score ≥8) who underwent either PLND with prostate RT or extended RT. The PLND+RT group received 80 Gy to the prostate and seminal vesicles, while the extended RT group received an additional 50 Gy to the pelvic lymph nodes. All patients received androgen deprivation therapy (ADT) for three years. The primary outcomes were biochemical recurrence-free (BCR-free) survival and metastasis-free (MTS-free) survival, assessed from treatment initiation. Statistical analyses compared the impact of treatment modality (PLND+RT vs. extended RT) on these outcomes. Results: The median age was 71.5 years (IQR: 67-75.5), and the median PSA was 15.7 ng/mL (IQR: 8-27.7). Both groups were homogeneous in age, clinical stage, biopsy Gleason score, clinical lymph node status and pre-treatment PSA. PNLD+RT was performed in 26 patients (38%), while 42 (62%) received extended RT. The median follow-up was 45.7 months (IQR: 30-58.8). BCR occurred in 23.1% of PLND patients and 11.9% in the extended RT group (p = 0.19). MTS was detected in 23.1% vs. 7.1% of cases, respectively (p = 0.07). Estimated 3 and 5-years BCR-free survival in the entire group was 92 % and 67.9 %, and MTS-free survival was 95.2 % and 58.5 %. 3 and 5- years BCR-free survival was worse in PNLD+RT group than in the extended RT group: 90.1 % vs. 87.1% and 56.7 % vs. 74.1 %, respectively (p = 0.03). 3 and 5-years MTS-free survival was better in the extended RT group: 92.9 % vs. 96.4 % and 57.1 % vs. 82.7 %, respectively (p = 0.048). Conclusions: In high-risk PCa patients treated with external RT, PLND did not provide significant benefits in preventing early disease progression. Extended RT was associated with improved BCR-free and MTS-free survival, but the differences were modest. A longer followup is required to determine the long-term oncological impact of each approach.