Letter
to
the
Editor
ReplytoAlessiaCimadamore,MarinaScarpelli,Liang
Cheng,etal’sLettertotheEditor,re:MariaChiara
Sighinolfi,BernardoRocco’sWordsofWisdomre:EAU
Guidelines:ProstateCancer2019.MottetN,vanden
BerghRCN,BriersE,etal.https://uroweb.org/guideline/
prostate-Cancer/.EurUrol2019,76:871
Weread withinterest thereportfromCimadamoreet al
[1].Theauthorsdescribea“traumaticneuroma”(TN)asa
novelpathologicalfinding. TNcouldbedetected
inciden-tallyattheprostatesurfaceduringsurgery;histologically,it
is supposed to arise from a truncated nerve at the
periprostatictissue, maybe deriving—asan inflammatory
reaction—fromlocalanesthesiaduringprostatebiopsy(PB)
[1]. The occurrence seems rare but also under-reported,
giventhelackofsymptomsandoncologicaldrawbacks.
However,thefindingofaTNcanposeasurgicalconcern.
TheperceptionofaTNduringthereleaseofbundlescould
resemble tight adhesion of periprostatic tissue to the
capsule.Therefore,itcanbemisinterpretedasextracapsular
extension (ECE)of the tumor and can drive the surgeon
towardanon–nerve-sparingstrategywithawiderplaneof
dissection.
Someconsiderationsmayarise.
First, the possible relationship with PB should be
recognized.
PB is one of the mostfrequent urological procedures,
with1millionPBperformedyearlyintheEuropeanUnion
[2].Theneedforrepeatbiopsyiscommonandmandatorily
scheduledaspartofactivesurveillance(AS).Approximately
one-thirdofmenonASare“reclassified”atfollow-upand
requireadefinitivetreatment[3].TheimpactofmultiplePB
rounds on radical prostatectomy has been evaluated in
termsofcomplications[4];however,theimpactofmultiple
PBs on surgical specimen represents an underaddressed
issue.ThenovelfindingdescribedbyCimadamoreetal[1]
should beknownbysurgeons anddiagnosed
intraopera-tively by pathologists, to avoid unnecessary non
–nerve-sparingprocedures.
How could a finding resembling ECE be clarified
intraoperatively?Assuggestedby2019European
Associa-tionofUrologyguidelines[3],frozensection(FS)analysisis
able to rule out the inadvertentexcision into the tumor.
However,prostateFSislimitedbyanumberoffactors,such
astheabsenceofstandardsampling[5]andtheneedfora
fully equipped setup,consisting ofcryostats, technicians,
andpathologistsonsite,topreparespecimenandinterpret
glassslideswithananalogmicroscope[6].Thus,FSishardly
affordable at all institutions, especially in view of the
contractionofpathologists’workforce.
Intraoperative analysis could be simplified with
fluo-rescence confocal microscopy (FCM) [6]. FCM provides
microscopicanalysisoffreshlyexcisedtissues,withstraight
acquisitionofdigitalimageswithoutconventional
proces-sing, dedicated setup, or an on-site pathologist, since
imagescouldbesharedremotely.
TheabilityofFCMtodiscriminatebetweenprostateand
periprostatic soft tissues hasbeen evaluated on samples
retrieved during radical prostatectomy from suspicious
periprostaticareas[6].FCMagreementwith
hematoxylin-eosinfortheinterpretationofperiprostaticcomponentsis
almost perfect,andnerves couldbedistinguished witha
rateof97.14%ofcorrectdiagnosis(Fig.1).
Whether FCM could depict a TN is still exploratory;
effortsshouldbedonetoextendtherangeoftissues—and
related inflammatory alterations—effectively interpreted
withFCM.
EUROPEAN UROLOGY XXX(2019)XXX–XXX
a v ai l a b l e a t w w w . s c i e n c e d i r e c t . c o m
j o u r n al h o m e p a g e : w w w . e u r o p e an u r o l o g y . c o m
DOI of original article:https://doi.org/10.1016/j.eururo.2020.02.005.
EURURO-8717;No.ofPages2
Pleasecitethisarticleinpressas:Sighinolfi MC,Rocco B.ReplytoAlessiaCimadamore,MarinaScarpelli,LiangCheng,etal’s
Letterto theEditor, re: Maria Chiara Sighinolfi, Bernardo Rocco’s Wordsof Wisdom re:EAU Guidelines: Prostate Cancer
2019.MottetN,....EurUrol(2020),https://doi.org/10.1016/j.eururo.2020.02.006
https://doi.org/10.1016/j.eururo.2020.02.006
Certainly,surgicalstrategyismovingtowardsa
step-by-steptailoredapproach,inwhichthedissectionis
histologi-callydrivenandcouldbemodifiedaccordingly;afull
nerve-sparingstrategytogetherwithsecondaryresectionincase
of tumor persisting at surgical margin could be the
perspective to guarantee complete oncological excision,
whilesparingfunctionaltissueasmuchaspossible.
Conflictsofinterest:The authors have nothing to disclose.
References
[1] CimadamoreA,ScarpelliM,ChengL,etal.Re:MariaChiara
Sigh-inolfi, Bernardo Rocco’s Words ofWisdom re:EAU guidelines:
prostate cancer 2019. Mottet N, van denBergh RCN,Briers E,
et al. https://uroweb.org/guideline/prostate-cancer/. Eur Urol
2019;76:871,Inpress.
[2] CicioneA,DeNunzioC,MannoS,etal.Anupdateonprostatebiopsy
intheeraofmagneticresonanceimaging.MinervaUrolNephrol
2018;70:264–74.
[3] MottetN,BellmuntJ,BollaM,etal.EAU-ESTRO-SIOGguidelineson
prostatecancer.Part1:screening,diagnosis,andlocaltreatment
withcurativeintent.EurUrol2017;71:618–29.
[4] Olvera-PosadaD,WelkB,McClureJA,Winick-NgJ,IzawaJI,Pautler
SE. The impactof multipleprostate biopsies onriskfor major
complicationsfollowingradicalprostatectomy:apopulation-based
cohortstudy.Urology2017;106:125–32.
[5]Sighinolfi MC, EissaA, SpandriV, Puliatti S, MicaliS, Reggiani BonettiL,etal.Positivesurgicalmarginduringradical prostatec-tomy:overviewofsamplingmethodsforfrozensectionsand tech-niquesforthesecondaryresectionofneurovascularbundles.BJUInt 2020.http://dx.doi.org/10.1111/bju.15024,Feb3.
[6]RoccoB,SighinolfiMC,BertoniL,SpandriV,PuliattiS,EissaA,etal. Real-timeassessmentofsurgicalmarginduringradical prostatec-tomy:anovelapproachwithfluorescenceconfocalmicroscopyfor theevaluationofperi-prostaticsofttissues.BJUInt2020.http://dx.
doi.org/10.1111/bju.15000,Jan23.
MariaChiaraSighinolfi* Bernardo Rocco DepartmentofUrology,UniversityofModenaandReggioEmilia,Modena, Italy *Corresponding author: Department of Urology, University of Modena and Reggio Emilia, via del Pozzo 71, Modena 41100, Italy. Tel. +39-059-237-170; Fax: +39-059-422-2368. E-mailaddress:sighinolfic@yahoo.com(M.C.Sighinolfi).
February 5, 2020
Fig.1–DetectionofanervewithFCM.NotetheHEappearance,withrangeofcolors(purpletopink)similartoconventionalpathology.Thelevelof
agreementwithFCMforthedetectionofperiprostaticsofttissuecomponents(connective,muscular,fattytissue,andvessels)hasbeendescribedas
“almostperfect”[6].FCM=fluorescenceconfocalmicroscopy;HE=hematoxylin-eosin.
EUROPEAN UROLOGYXXX(2019)XXX–XXX
2
EURURO-8717;No.ofPages2
Pleasecitethisarticleinpressas:Sighinolfi MC,Rocco B.ReplytoAlessiaCimadamore,MarinaScarpelli,LiangCheng,etal’s
Letterto theEditor, re: Maria Chiara Sighinolfi, BernardoRocco’s Words of Wisdom re: EAUGuidelines: ProstateCancer
