Volume 74, Issue 3, Pages 376-386 (September 2018) Marked Prognostic Impact of Minimal Lymphatic Tumor Spread in Prostate Cancer  Waldemar Wilczak, Corinna Wittmer, Till Clauditz, Sarah Minner, Stefan Steurer, Franziska Büscheck, Till Krech, Maximilian Lennartz, Luisa Harms, Diane Leleu, Marc Ahrens, Sebastian Ingwerth, Christian T. Günther, Christina Koop, Ronald Simon, Frank Jacobsen, Maria C. Tsourlakis, Viktoria Chirico, Doris Höflmayer, Eik Vettorazzi, Alexander Haese, Thomas Steuber, Georg Salomon, Uwe Michl, Lars Budäus, Derya Tilki, Imke Thederan, Christoph Fraune, Cosima Göbel, Marie-Christine Henrich, Manuela Juhnke, Katharina Möller, Ahmed Abdullah Bawahab, Ria Uhlig, Meike Adam, Sören Weidemann, Burkhard Beyer, Hartwig Huland, Markus Graefen, Guido Sauter, Thorsten Schlomm  European Urology  Volume 74, Issue 3, Pages 376-386 (September 2018) DOI: 10.1016/j.eururo.2018.05.034 Copyright © 2018 European Association of Urology Terms and Conditions

Fig. 1 Impact of the methodology for lymph node detection on the fraction of positive lymph nodes (% nodal positive, red bars) and average number of retrieved lymph nodes (av. N LN, blue bars) in the period from 2006 to 2015 in (A and B) all cancers and in subsets of cancers with (C and D) Gleason score 3+4 and (E and F) Gleason score 4+3. Half-years are indicated by –1 and –2 following the year. Green arrows indicate changes in the method of tissue preparation for lymph node detection. a=without fat embedding; b=with fat embedding; c=immunohistochemistry of four lymph nodes; d=acetone pretreatment of fat tissue; e=immunohistochemistry of eight lymph nodes. European Urology 2018 74, 376-386DOI: (10.1016/j.eururo.2018.05.034) Copyright © 2018 European Association of Urology Terms and Conditions

Fig. 2 Prognostic impact of (A) pathological N status; (B) lymph node metastasis size; (C) number of lymph node metastases per patient; (D) pathological L status; and (E) patients grouped according to the L and N stages as well as the lymph node metastases size. PSA=prostate-specific antigen. European Urology 2018 74, 376-386DOI: (10.1016/j.eururo.2018.05.034) Copyright © 2018 European Association of Urology Terms and Conditions

Fig. 3 Examples of lymph vessel invasion, isolated tumor cells (ITC), and small lymph node metastases. (1 and 2) Two cases with lymph vessel invasion: a) hematoxylin and eosin (H&E)-stained tissue section showing tumor cells inside lymph vessels; b) anti-podoplanin immunohistochemical (IHC) staining, specific for endothelium of lymphatic capillaries; c) CD31 (IHC) staining of endothelial cells. (3 and 4) Two cases that were suspicious for lymph vessel invasion according to the H&E-stained section, but turned out to be shrinking artifacts of prostate glands: IHC for podoplanin and CD31 demonstrated lack of lymph vessels. (E) Example of ITC in the lymph node sinus that are: a) not visible in H&E staining; b) but detectable by AE1/3 staining. (F) Example of a micrometastasis (<1mm) that is: a) not visible in H&E staining; b) but detectable by AE1/3 staining. European Urology 2018 74, 376-386DOI: (10.1016/j.eururo.2018.05.034) Copyright © 2018 European Association of Urology Terms and Conditions

Fig. 4 Association between the (A and B) quantitative Gleason grade as well as the (C and D) integrated quantitative (IQ) Gleason score and the frequency of nodal metastases (% N1, p<0.0001 each) and lymph vessel infiltration (% L1, p<0.0001 each). European Urology 2018 74, 376-386DOI: (10.1016/j.eururo.2018.05.034) Copyright © 2018 European Association of Urology Terms and Conditions