Prognostic significance of positive surgical margins in radical prostatectomy specimens

PURPOSE

The prognostic significance of positive surgical margins in radical prostatectomy specimens was assessed.

MATERIALS AND METHODS

The interval to progression (increasing prostate specific antigen level) was measured in 478 patients by status of the surgical margins.

RESULTS

At 5 years, the nonprogression rate was 64% for patients with and 83% for those without positive surgical margins. With a high grade cancer, seminal vesicle invasion or lymph node metastases, positive surgical margins had no effect on prognosis; with extracapsular extension and a Gleason score of 6 or less positive surgical margins were associated with a higher progression rate.

CONCLUSIONS

Prognosis was adversely affected by positive surgical margins only in moderately differentiated cancers with extracapsular extension alone. If the cancer is otherwise confined, positive surgical margins are associated with an excellent prognosis unlikely to be improved by adjuvant therapy.

Transforming growth factor-beta 1: comparative immunohistochemical localization in human primary and metastatic prostate cancer

BACKGROUND

We have shown previously that primary prostate cancer demonstrates significant extracellular accumulation of transforming growth factor-beta 1 (TGF-beta 1). To further investigate the potential role of TGF-beta 1 in prostate cancer progression, we evaluated an expanded series of primary prostatic carcinomas and associated lymph node metastases.

EXPERIMENTAL DESIGN

Prostate tissue samples from 37 patients were examined. Three were organ donors, all less than 30 years of age, whose prostates were included as normal controls. Eighteen had undergone radical prostatectomy and pelvic lymph node dissection. Eleven were without evidence of metastasis, whereas seven were found to have prostate cancer within at least one of their pelvic lymph nodes. Sixteen had undergone transurethral resection of the prostate for benign disease, yet all had prostate cancer within the resected specimen (15 were stage T1b; 1 was stage T1a). Twelve of the patients with stage T1b disease underwent pelvic lymph node dissection and implantation of radioactive gold seeds. All 12 had prostate cancer in at least one lymph node. All specimens were examined for the level of expression and localization of TGF-beta 1 by immunohistochemistry using Ab that distinguish intracellular from extracellular TGF-beta 1.

RESULTS

Normal prostate tissue and benign prostatic hyperplasia demonstrated negative or weak intracellular and extracellular staining for TGF-beta 1. By comparison, 29 of 34 primary prostate cancers showed extensive extracellular TGF-beta 1 staining with pronounced intracellular accumulation within epithelial cells in 13 of 34 patients. There was no difference in the staining pattern for extracellular TGF-beta 1 between primary cancers with and without pelvic lymph node metastases. However, in primary cancers without pelvic lymph node metastases, only 1 of 15 patients showed strong intracellular staining for TGF-beta 1 compared with 12 of 19 primary tumors with metastatic disease. In addition, only 2 of 19 lymph node metastases demonstrated weak extracellular TGF-beta 1 staining, but all 19 contained intracellular TGF-beta 1.

CONCLUSIONS

These findings confirm our previous observation that prostate cancer exhibits enhanced intracellular and extracellular accumulation of TGF-beta 1 relative to normal prostate tissue and benign prostatic hyperplasia. In addition, our study documented a significantly more pronounced accumulation of intracellular TGF-beta 1 in primary prostate cancer with metastasis than in primary tumors without metastasis. Moreover, although the pattern of intracellular TGF-beta 1 staining observed in the primary tumor is maintained in the metastasis, a lack of extracellular accumulation of TGF-beta 1 in the metastatic site was noted. This differential pattern may be biologically important and could conceivably reflect a role for TGF-beta 1 in disease progression.

Association of p53 mutations with metastatic prostate cancer

In prostate cancer, mutation of the p53 tumor suppressor gene has been associated with locally advanced disease and hormone-resistant disease that is predominantly localized to bone. However, little is known regarding the status of the p53 gene in metastatic prostate cancer that has not been treated with hormonal manipulation. We evaluated formalin-fixed, paraffin-embedded malignant tissues from 86 patients with various stages of prostate cancer, including pathologically confined, locally advanced, and metastatic disease, to detect abnormal p53 nuclear protein accumulation using immunohistochemistry. No abnormal p53 immunostaining was detected in 18 patients with prostate cancer confined to the gland. Two tumors from 21 patients with locally advanced disease (extracapsular extension and/or seminal vesicle invasion) had abnormal nuclear p53 accumulation, and a mutation in exon 7 of the p53 gene was detected in tumor DNA from one patient using single-strand conformation polymorphism-direct sequencing analysis. Of the remaining 47 patients studied in whom tissues from the prostate gland and a metastatic site (44 lymph node, 2 bone, and 1 lung) were available, only 3 had received hormonal therapy prior to obtaining metastatic tissue. In four patients both primary and metastatic tumors demonstrated accumulation of p53 protein, whereas seven additional patients exhibited p53 accumulation only at the metastatic site. In three patients the metastatic tumors harbored missense single-base substitutions in exon 5, as detected using single-strand conformation polymorphism-direct sequencing. These results indicate that p53 abnormalities are associated with lymph node metastases derived from prostate cancer patients that had not undergone hormonal therapy.

High grade prostatic intraepithelial neoplasia in prostates removed following irradiation failure in the treatment of prostatic adenocarcinoma

Prostatic Intraepithelial Neoplasia (PIN) is widely considered to be a precursor lesion for adenocarcinoma of the prostate. No information is available, however, on the sensitivity of PIN to irradiation or the distribution of residual PIN after radiotherapy. We studied a series of forty-six totally embedded, whole mounted, serially sectioned prostates removed by salvage radical retropubic prostatectomy following irradiation failure in which no hormonal therapy/ablation had been undertaken. The mean age of patients was 65 (56-74) years, the mean dose of radiotherapy was 7,266 (6,000-9,000) cGy (15 external beam, 27 external beam plus iridium or gold seed, 3 iodine, and 1 unknown) and the mean interval for irradiation therapy to prostatectomy was 60 (16-145) months. Thirty-two (70%) of the patients had high grade PIN within the prostatectomy specimen. The pattern of PIN was recorded as described by Bostwick and co workers. The frequency of the different patterns per positive case paralleled in rank those in Bostwick's series of non-irradiated prostates, with the most common to least common per patient being: tufting (78.1%), micropapillary (59.3%), cribriform (34.4%) and flat (15.6%). However, the mean number of foci of PIN per prostate was less than in Bostwick's series (7.1 foci vs. 17 foci). There was no statistically significant difference between groups with or without high grade PIN with regard to various clinical factors (last preoperative serum PSA, age, dose of radiotherapy, interval from irradiation therapy to prostatectomy, Kaplan-Meier survival), or pathologic factors (presence of confined tumor, extracapsular extension, positive surgical margins, seminal vesicle invasion, or positive lymph nodes on permanent sections). We conclude that high grade PIN is common in the prostates of patients who have failed irradiation therapy and that, theoretically, not all recurrent tumors derive from regrowth of the initial, incompletely eradicated tumor. However, because there was no significant difference between the two groups with regard to the clinical and pathologic parameters listed, we consider it likely that most recurrent tumors derive from the initial incompletely eradicated tumor.

Postradical orchiectomy hemorrhage: should an alteration in staging strategy for testicular cancer be considered?

We report 3 cases of postradical orchiectomy hemorrhage from separate institutions. The retroperitoneal and pelvic hematoma formed as a complication of orchiectomy can be misinterpreted to represent metastatic disease on postoperative staging computed tomography scans. As a result of inaccurate information obtained from these evaluations, significant alterations in patient management will result. Prevention and early recognition of this complication are crucial if unnecessary treatment is to be avoided.

Derivation and application of upper limits for prostate specific antigen in men aged 50-74 years with no clinical evidence of prostatic carcinoma

OBJECTIVE

To derive age-specific upper limits for prostate specific antigen (PSA) level in men 50-74 years of age with no clinical evidence of prostatic carcinoma, and to test the sensitivity and specificity for cancer detection of these upper limits.

SUBJECTS AND METHODS

A total of 6166 men were recruited for a multicentre study of prostate cancer detection and underwent a serum PSA determination and digital rectal examination (DRE). Men considered to be clinically free of prostatic carcinoma were those with a normal DRE and a PSA level < or = 4.0 ng/mL, and men with an abnormality in either parameter who underwent ultrasonography-guided prostate biopsy that revealed no evidence of carcinoma. By these criteria, 5469 men had no evidence of prostatic carcinoma. Dividing the population into 5-year age increments, three statistical methods were assessed to derive upper limits for serum PSA level by age; the mean +2 SD, the 99th percentile, and a 97.5% prediction interval based on linear regression.

RESULTS

Newly-derived upper limits calculated by each method in the 50-54 and the 70-74 age group were 3.9 ng/mL and 7.6 ng/mL (mean +2 SD), 5.2 ng/mL and 14.0 ng/mL (99th percentile), and 4.7 ng/mL and 8.2 ng/mL (97.5% prediction interval). The sensitivity of the newly-derived upper limits was tested using receiver operating characteristic curves derived from men with no suspicious findings on DRE and a serum PSA concentration > 4.0 ng/mL. Although the specificity of the test increased with increasing PSA upper limits, no upper limits derived from these three methods yielded adequate sensitivity to detect cancer; sensitivities by age range were from 53 to 94%, using mean +2 SD, from 25 to 50% with the 99th percentile, and from 47 to 64% with the 97.5% prediction interval.

CONCLUSION

We do not recommend age-referenced adjustments in upper limits for serum PSA concentration, but recommend that an upper limit of 4.0 ng/mL be used in all men 50-74 years of age.

A simple ileal substitute bladder after radical cystectomy: experience with a modification of the Studer pouch

Bladder substitution using pouches designed from detubularized bowel is gaining widespread acceptance among urologists and their patients. However, few clinical reports have described the effectiveness of the orthotopic neobladder fashioned from ileum in the manner described by Studer. Since 1988, we have used the Studer technique with minor modifications in 20 men who underwent radical cystoprostatectomy for transitional cell carcinoma of the bladder. Early morbidity from the procedure was minimal, although 2 patients later had anastomotic strictures. Significant late complications included low vitamin B12 levels in 4 patients and persistent hyperchloremia in 1. A total of 18 patients achieved diurnal continence but 9 of these had enuresis. Neobladder compliance and emptying were satisfactory in the 12 patients evaluated urodynamically. Upper tracts remained stable in all patients at a median followup of 24 months (range 9 to 60). Isolated episodes of bacteriuria occurred in 11 patients but followup urine cultures have remained sterile in all continent patients. The Studer ileal neobladder is a simple, effective alternative for urine storage, upper tract preservation and efficient voiding.

Screening for prostate cancer: an analysis of the early experience

Several common misconceptions have fueled the debate over the early detection and treatment of prostate cancer. While prostate cancer is often described as a common cancer that older men die with rather than of, the reality is that the incidence, mortality, and mean age and stage at diagnosis of prostate cancer are very similar to those of breast cancer, which is rarely the subject of similar concerns. Many studies have confirmed that given enough time, all clinically detected prostate cancers will inexorably progress locally and eventually metastasize to regional lymph nodes as well as to distant sites. The relatively slow doubling time compared to that of other cancers and the wide spectrum of biologic activity of prostate cancer have made retrospective studies reporting the long-term survival of conservatively treated patients highly suspect due to selection bias and inadequate follow-up. While it is accepted that a large number of men harbor clinically insignificant cancers in their prostate glands, these estimates have been based on careful pathologic step-sectioning studies of prostates obtained either at autopsy or after cystoprostatectomy for bladder cancer. Several studies have now demonstrated that currently available diagnostic modalities for detecting prostate cancer, DRE, PSA, and TRUS, are not able to detect a significant proportion of small, clinically unimportant cancers. Rather, studies have shown that while the traditional DRE has been largely unsuccessful in detecting prostate cancers at a sufficiently early stage for effective treatment with either radical prostatectomy or radiation therapy, a combination of the DRE and PSA followed by TRUS and ultrasound-guided biopsy in those with abnormal results can detect an increased proportion of clinically significant prostate cancers while they are still confined to the prostate gland and thus more likely to be eradicated by treatment. Several randomized trials are now under way in this country and in Europe that may settle many of these issues over the next decade. However, currently available data suggest that prostate cancer screening holds the promise of decreasing the considerable morbidity and mortality caused by this disease.

DNA ploidy and clonal selection in ras + myc-induced mouse prostate cancer

An important goal in prostate cancer research is to define specific molecular and cellular alterations that are associated with malignant progression. The mouse prostate reconstitution model is a relevant and useful system as it allows the study of early events in cancer progression under conditions where oncogene-initiated cells are surrounded by normal tissue. Using this model, activated ras and myc oncogenes are introduced into urogenital sinus cells via the recombinant retrovirus Zipras/myc 9. After 4 weeks' growth as subcapsular renal grafts, poorly differentiated carcinomas are produced in C57BL/6 mice. In this study we examined the temporal relationships between morphological alterations, growth, DNA ploidy status and clonal selection as determined by Southern blotting in ras + myc-initiated carcinomas. Nuclear image analysis demonstrated that the emergence of a cycling DNA tetraploid cell population strongly correlated with growth and histologic progression. These tightly linked events culminated in the outgrowth of mono- or oligoclonal cancer.

The frequency of apoptosis correlates with the prognosis of Gleason Grade 3 adenocarcinoma of the prostate

BACKGROUND

Although localized carcinomas are predominantly moderately differentiated (Gleason Grade 3), they demonstrate markedly different rates of progression. Previously, the authors reported a correlation between apoptosis and the malignant characteristics of carcinoma in the mouse prostate reconstitution model system and between apoptosis and Gleason grade in the human tumor. This study was undertaken to determine whether the frequency of apoptosis correlates with prognosis and to compare the prognostic significance of the apoptotic index with other prognostic features in Gleason Grade 3 carcinomas.

METHODS

The apoptotic and mitotic indices of malignant and nonmalignant epithelium in 28 consecutive radical prostatectomy specimens were determined for a carcinomas composed entirely of Gleason sum 6 (primary Grade 3, secondary Grade 3) with a clinical stage T2 classification. Each patient was followed for 5-9 years (median 6, years). The indices, defined as the number of apoptotic and mitotic bodies in an H & E-stained section per 100 grids delineated by an ocular measuring field, were determined. The actuarial time to progression, defined as a sustained rise in the serum prostate specific antigen level greater than or equal to 0.4 ng/ml, was correlated with the apoptotic index, the mitotic index, tumor volume, and pathologic stage.

RESULTS

Neither pathologic stage nor tumor volume differed significantly between the group of 19 patients (68%) with no progression and the other 9 whose tumor progressed. The median apoptotic index of the carcinomas was 0.87 (range, 0.12-3.91). For patients with a low apoptotic index (< 0.87), the actuarial progression rate at 5 years was 7% +/- 14% (+/- 2 SE) compared with 50% +/- 26% for those with a high apoptotic index (P < 0.007). Mitotic index had no prognostic significance.

CONCLUSIONS

In carcinoma of the prostate, apoptosis can be recognized in standard H & E sections and quantitated by light microscopy. The apoptotic index may provide additional prognostic information in the predominant grade of early stage carcinoma. Cancer 1995; 75:522-9.

Current controversies in the management of localized prostate cancer

As longevity has improved and mortality from cardiovascular and other diseases has declined, the risk of death from prostate cancer has increased steadily. Though slow growing, prostate cancer is not a benign disease. Nearly 10% of men in Western countries will be diagnosed with prostate cancer sometime during their life and 3% will die of the disease. The prospects for long-term control of prostate cancer diminish rapidly once the cancer has spread beyond the immediate periprostatic tissue. The 5-year survival rate for men with metastases is less than 30% and almost all will eventually die of their disease. A simple blood test, prostate-specific antigen (PSA), is available. This test, when used in conjunction with ultrasound-guided systematic needle biopsy of the prostate, will detect potentially lethal prostate cancers earlier than digital rectal examination (DRE). Definitive treatment, especially with radical prostatectomy, can eradicate the tumor in 90% of patients if the cancer is still confined to the prostate pathologically, regardless of the tumor grade. Randomized, prospective clinical trials are now underway to demonstrate conclusively whether screening or early definitive therapy will substantially reduce the mortality rate from this disease. Until the results of these trials are available, we recommend that healthy men over age 50, who have a life expectancy of 10 years or longer, have an annual PSA and DRE to detect prostate cancer while it is still curable.

Anatomy of the prostate and distribution of early prostate cancer

Many of the difficulties in understanding diseases of the prostate have arisen through poor understanding of the anatomy of the prostate. The recent description of histologically separate zones in the prostate has been an important advance, allowing evaluation of separate cancers arising in the transition and peripheral zones of the prostate. While the majority of cancers sampled at transurethral resection of the prostate (TURP) are of transition zone origin, most of these prostates contain separate cancers in the peripheral zone. The peripheral zone cancers have a higher grade-to-volume ratio and are more frequently associated with histological features of progression (extracapsular extension, seminal vesicle invasion) than transition zone cancers. Furthermore, peripheral zone cancers are frequently associated with prostatic intraepithelial neoplasia, in contrast to transition zone cancers. These findings suggest a greater biological activity for cancers arising in the peripheral zone. The majority of cancers detected by digital rectal examination are of peripheral zone origin. While associated transition zone cancers are less frequently present than in TURP sampled prostates, a similarly high association of peripheral zone cancers with histological indicators of biological activity is seen. DNA ploidy analysis of separate foci in radical prostatectomy specimens confirms a significantly higher rate of non-diploidy in cancers of peripheral zone origin, some of very small volume, which further suggests a greater biological activity compared to transition zone cancers.

Salvage radical prostatectomy: outcome measured by serum prostate specific antigen levels

We reviewed our experience with salvage radical prostatectomy for locally recurrent cancer in 40 patients to assess the current complication rate and the results using prostate specific antigen (PSA) as an indicator of treatment outcome and to identify better criteria for the selection of appropriate candidates for this operation. Most recurrent cancers were detected by digital rectal examination (26 patients) or increasing serum PSA levels (10). The operation was technically challenging, with 6 rectal injuries (15%), 2 requiring temporary colostomy. Serious technical complications were more common (31%) among the 29 patients who underwent pelvic lymphadenectomy at the time of initial radiotherapy than among the 11 treated with external irradiation alone (9%). Urinary incontinence persisted in 18 of 31 evaluable patients (58%) and was successfully corrected with an artificial urinary sphincter in 9. A total of 21 patients (54%) had pathologically advanced disease (seminal vesicle invasion and/or lymph node metastases). Preoperative PSA levels but not clinical stage or biopsy grade correlated with pathological stage (p < 0.03). If the PSA was less than 10 ng./ml. only 15% of the patients had an advanced pathological stage, compared to 86% if the PSA was 10 or more. After 2 to 97 months (mean 39) 2 patients died of metastatic prostatic cancer, 5 had distant metastases and none had symptomatic local recurrence. At 5 years the actuarial nonprogression rate measured by PSA was 55 +/- 20%. The only pretreatment factor predictive of progression was the serum PSA level. If the PSA was less than 10 ng./ml. the actuarial rate of progression was significantly lower than if the PSA was greater than 10 (p < 0.05). The best results were in the subset of 18 patients with cancer confined to the prostate or immediate periprostatic tissue: 82% had no progression at 5 years. Within each of these pathological stages the results of salvage prostatectomy were similar to those for standard radical prostatectomy in patients with no prior irradiation. Although technically challenging, salvage prostatectomy provides excellent control of radio-recurrent cancer confined to the prostate or immediate periprostatic tissue and is best performed before the preoperative PSA level increases to greater than 10 to 20 ng./ml.

Can radical prostatectomy alter the progression of poorly differentiated prostate cancer?

A favorable outcome after radical prostatectomy for early stage prostate cancer has sometimes been attributed to the relatively benign natural history of the disease rather than the beneficial effects of treatment. Poorly differentiated tumors, however, are recognized as inherently aggressive and progress rapidly when managed conservatively. We determined the actuarial rate of treatment failure after radical prostatectomy for clinically localized (stages T1 to T3) poorly differentiated cancer, using as an end point an increase in the serum level of prostate specific antigen (PSA) to assess whether treatment altered the rapid progression expected of these cancers. Of 500 patients treated with radical prostatectomy, regardless of grade, the actuarial nonprogression rate was 76 +/- 5% at 5 years and 73 +/- 6% at 10 years. Poorly differentiated cancer, defined as Gleason score 7 or greater in the radical prostatectomy specimen, was present in 268 patients (54%) who had a nonprogression rate at 5 years of 55 +/- 12% compared to 92 +/- 4% for the 232 patients with a well or moderately differentiated (Gleason score less than 7) cancer (p < 0.00005). The extent of the cancer (confined or not confined) was strongly associated with progression (p < 0.00005). Only 76 of the 268 poorly differentiated tumors (28%) were confined to the prostate and the prognosis was excellent. At 5 years 85 +/- 18% of the patients had no evidence of progression, compared to 46 +/- 12% with poorly differentiated cancer extending outside the gland (p < 0.0001). In a multivariate analysis neither the grade nor volume of the tumor influenced the rate of progression when the cancer was confined to the prostate. Impalpable tumors detected by an elevated PSA level were as likely to be poorly differentiated as palpable disease (56% versus 63%) but were significantly more likely to be confined to the prostate (44% versus 24%, p < 0.01). Poorly differentiated cancers usually extend outside of the prostate by the time they are detected, and they progress rapidly. PSA increases the detection of impalpable high grade cancer confined to the gland. When these tumors are detected while still confined, most can be controlled by radical prostatectomy.

The pathological features and prognosis of prostate cancer detectable with current diagnostic tests

The discrepancy between the high prevalence of prostate cancer found at autopsy and the low incidence of clinical cancer prompted a study to determine whether the new diagnostic tests, that is ultrasonography and serum prostatic specific antigen (PSA) levels, detect prostate cancer at an earlier stage than the traditional test, digital rectal examination, without detecting a larger proportion of clinically unimportant cancer. Clinically detected cancer treated by radical prostatectomy (306 cases) and incidental cancer found in cystoprostatectomy specimens (90) were categorized into 3 groups by the volume, grade, extent of the cancer and outcome of treatment: clinically unimportant tumor (0.5 cm.3 or less, Gleason grades 1 to 3 and confined to the prostate), clinically important curable cancer (more than 0.5 cm.3 or grade 4 or 5 and confined, or with microscopic extracapsular extension) or advanced disease (extensive extracapsular extension, seminal vesicle invasion or lymph node metastases). Of 306 clinically detected tumors 9% were unimportant and 29% were advanced. In contrast, incidental cystoprostatectomy disease was either unimportant (78%) or curable (22%) and no tumor was advanced (p < 0.0005). Cancer detectable by digital rectal examination, ultrasonography or PSA was distributed similarly among the 3 groups. Impalpable cancer detected by PSA was less likely to be advanced (11%) than cancer detected by digital rectal examination (34%, p = 0.01) but no more likely to be unimportant (13% versus 8%). Of 29 tumors detected only by systematic biopsies because of an elevated PSA level only 4% were advanced, while 17% were unimportant. Cancer detectable with each of the available diagnostic tests was similar and differed distinctly from that found incidentally in cystoprostatectomy specimens. The detection of impalpable cancer by PSA or ultrasound decreased the proportion of advanced tumor detected without increasing significantly the detection of unimportant disease.

Early detection of prostate cancer: the nature of cancers detected with current diagnostic tests

The goal of an early detection program is not to detect all prostate cancers, but only to detect those that are potentially morbid or lethal (clinically important cancers). The prevalence of such cancers in the population of 50-year-old men can be estimated to be about 6%, using both epidemiologic and pathologic data. Screening trials using PSA and/or TRUS instead of or in addition to DRE have approached this rate of detection. As Fig 1 illustrates, screening appears to detect almost all of the clinically important cancers in the study population. The fear that these tests will detect a high proportion of latent, or clinically unimportant, cancers appears to be unfounded. Our studies and those of others support the concept that 85% to 90% of cancers detectable with current tests are clinically important. The detection of nonpalpable cancers by PSA or TRUS reduces the proportion of cancers detected at an advanced stage without increasing significantly the detection of latent or clinically unimportant cancers. Despite this analysis, we still lack definitive data to show that screening and treating early stage cancers will decrease the mortality rate of this disease. Such a conclusion will require a long-term, randomized screening trial or a comparison of mortality rates among large populations of men differing primarily in the extent of screening for prostate cancer.

Transrectal ultrasound-guided core biopsies of the prostate. A comparison between the standard 1.2-mm needle and three thinner needles

Transrectal ultrasound (TRUS) examination is a well established method for the diagnosis of prostate cancer. The examination technique has, however, certain limitations, and biopsies are needed to differentiate between malignant and benign lesions. In order to determine the influence of the thickness of the needle on the histopathological evaluation of specimens, core biopsies were taken from 36 patients with hypoechoic lesions suggestive of cancer detected by TRUS, using a 1.2-mm cutting needle followed by a thinner needle (0.9-, 0.8- or 0.7-mm). A total of 164 biopsies from 41 hypoechoic lesions were obtained. The specimens were coded and examined by a pathologist. They were judged according to amount of tissue obtained, quality, length, malignancy and grade. The best results were obtained with the 1.2- and 0.9-mm needles. The results were comparable and reliable for both needle types which can be recommended for clinical practice. The 0.8- and 0.7-mm needles were found to give more or less unsatisfactory results.

Frequency of apoptotic bodies positively correlates with Gleason grade in prostate cancer

Tissue samples from patients with carcinoma of the prostate of various Gleason grades were examined for the frequency of apoptotic bodies. Apoptotic bodies were scored by morphometric methods using hematoxylin-eosin (HE)-stained sections from surgical specimens of prostate cancer. Non-neoplastic prostate tissue adjacent to foci of cancer showed a very low frequency of apoptotic bodies. Significantly larger numbers of apoptotic bodies were observed in the areas of carcinoma than in the non-neoplastic control tissues, regardless of Gleason grade. Interestingly, a positive correlation was noted between apoptotic bodies and increasing Gleason grade. The positive correlation suggests that increased programmed cell death is a feature of the increasing malignant potential that is associated with higher Gleason grade in prostate cancer.

The New American Joint Committee on Cancer and International Union Against Cancer TNM classification of prostate cancer. Clinicopathologic correlations

BACKGROUND

The 1992 American Joint Committee on Cancer and International Union Against Cancer TNM classification system for prostate cancer includes categories for the increasingly common nonpalpable cancers detected by serum prostate specific antigen (PSA) levels and transrectal ultrasonography (TRUS), but few details have been published about the pathologic features and prognosis of such cancers.

METHODS

We analyzed the clinical and pathologic features of 400 patients with clinical Stages T1-T3, NO or NX, M0 cancer treated with radical prostatectomy. We compared volume, grade, extension, and prognosis of cancers detected by PSA or TRUS to those detected by the traditional techniques of transurethral resection (TURP) or digital rectal examination.

RESULTS

As clinical stage increased in the TNM classification, the volume, grade, and frequency of extraprostatic spread increased significantly. The 33 nonpalpable, nonvisible tumors detected because of an elevated PSA (T1c) were similar in size and frequency of extension to TURP-detected (T1a-b) cancers, but more often were poorly differentiated (52% vs. 22%) (P < 0.03). No T1c cancer has recurred to date. Nonpalpable T2 cancers detected by TRUS (n = 42) were significantly more likely (47% vs. 18%) to extend outside the prostate than were T1c cancers. Compared to palpable T2 cancers, TRUS-detected T2 cancers were smaller but were similar in grade, extension, and prognosis. T3 cancers were extensive and recurred rapidly; only 6% were confined to the prostate. In contrast, 24% of the T1 and 57% of the T2 cancers were not confined (> or = pT3), but only 6-9% of T1-T2a cancers exhibited advanced pathologic features (seminal vesicle invasion or lymph node metastases), compared with 26% of the T2b-c cancers.

CONCLUSION

The new TNM staging system provides appropriate new categories for inclusion of nonpalpable cancers detected by PSA and ultrasound. This new classification is logical and generally reflects the pathologic extent and prognosis of these tumors, although cancers in the advanced T2 categories are often more extensive.

Detection of microscopic extracapsular extension prior to radical prostatectomy for clinically localized prostate cancer

OBJECTIVE

To assess better techniques of clinical staging to identify the presence and location of extracapsular extension (ECE) and assist the surgeon in the selection of candidates for resection or preservation of neurovascular bundles during radical prostatectomy.

PATIENTS AND METHODS

In a retrospective review of the records of 117 patients with clinically localized (31 T1 and 86 T2) prostate cancer treated with radical prostatectomy the results of digital rectal examination (DRE), real-time transrectal ultrasound (TRUS) and a retrospective review of static films were compared to assess their accuracy in the detection of ECE. The ultrasonic criterion for ECE was bulging or irregularity of the boundary echo adjacent to a hypoechoic lesion. On DRE, the criterion for ECE was palpable bulging of a nodule beyond the normal contour of the prostate. The reference standard was the presence and location of ECE in the whole-mount, serially sectioned radical prostatectomy specimens.

RESULTS

Microscopic ECE was present in 64 of the specimens (55%). There was no significant difference between DRE, prospective TRUS and retrospective TRUS in the overall accuracy of detection of ECE. However, when the results of DRE and TRUS were combined (if either was positive the result was considered positive), the positive predictive value (PPV) was 79% and the sensitivity (91%), with the overall accuracy increased significantly (P < 0.05).

CONCLUSION

The presence and precise location of microscopic ECE can be determined pre-operatively with reasonable accuracy using real-time ultrasound combined with the results of DRE.

Prostate specific antigen and gleason grade: an immunohistochemical study of prostate cancer

Prostate cancer is histologically heterogeneous as reflected in the 5 patterns of the Gleason grading system. Gleason grade correlates with volume, extent and prognosis. Serum prostate specific antigen (PSA) levels also correlate with tumor volume but the degree to which grade correlates with PSA has not been precisely defined. To quantify this relationship further, we prepared maps of each grade of cancer in 86 radical prostatectomy specimens from patients with clinical stage T2 cancer. The median per cent of the volume of cancer per prostate composed of grade 1 was 0%, while it was 1% for grade 2, 84% for grade 3, 5% for grade 4 and 0% for grade 5. We stained 95 cancer foci (grades 1 to 5) in 40 of these specimens for PSA. The presence and intensity (0 to 3+) of staining in more than 33,000 acini (or cells) correlated inversely with grade (p < 0.0001). Nearly all acini in grade 1 and most in grade 2 stained positive (2 to 3+) for PSA; 87% were positive but with less intensity in grade 3. While many grade 4 (79%) and grade 5 (49%) cells were positive, the intensity of staining was weak. Serum PSA levels correlated with total tumor volume (r = 0.67) but serum PSA levels per cm.3 of cancer decreased with increasing grade (r = -0.24 and p < 0.02). These studies confirm the strong inverse correlation between Gleason grade and the PSA content of prostate cancer. Since more than 85% of grade 3 acini stained for PSA and grade 3 made up the largest portion (84%) of cancer, the predominant contributor to serum PSA levels from prostate cancer was Gleason grade 3. The other grades contribute relatively little to the serum PSA levels either because of the small volume (grades 1 and 2) or the diminished PSA content (grades 4 and 5).

Some small prostate cancers are nondiploid by nuclear image analysis: correlation of deoxyribonucleic acid ploidy status and pathological features

The biological behavior of a prostate cancer can be predicted to some degree by the volume and extent (stage) of the tumor, and its histological grade. The deoxyribonucleic acid (DNA) ploidy status has been reported by some to be another independent prognostic factor for localized prostate cancer. We determined the DNA ploidy value of each individual focus of cancer in radical prostatectomy specimens using nuclear image analysis (CAS 200 system). Ploidy results were correlated with the volume, Gleason grade and zone of origin (transition zone or peripheral zone) of each tumor, and with the presence of extracapsular extension or seminal vesicle invasion. There were 141 separate cancers in 68 patients (mean 2.1 per prostate): 9 clinical stage A1, 22 stage A2, 23 stage B1 and 14 stage B2. DNA ploidy correlated significantly (p < 0.0001) with volume, grade, extraprostatic spread and zone of origin. Remarkably, some small cancers (1 cc or less) were nondiploid (3 as small as 0.03 cc). Overall, 15% of cancers 0.01 to 0.1 cc and 31% of those 0.11 to 1.0 cc in volume were nondiploid. Of 101 cancers confined to the prostate 76% were diploid, compared to only 13% of those with extraprostatic spread. Most cancers of transition zone origin (86%) were diploid, compared to only 49% of peripheral zone cancers, and ploidy and volume relationships were significantly different for peripheral zone cancers compared to transition zone cancers. All small nondiploid cancers arose in the peripheral zone, while in the transition zone the smallest nondiploid cancer was 1.17 cc. We conclude that prostate cancers that are nondiploid are highly likely to have adverse pathological features. Some small prostate cancers contain a nondiploid cell population and these cancers arise predominantly within the peripheral zone of the prostate. Ploidy and volume relationships provide further support for the hypothesis that there is a difference in malignant potential between cancers of peripheral zone and transition zone origin.

Heterogeneity of prostate cancer in radical prostatectomy specimens

OBJECTIVE

To understand the morphologic and spatial relationships of the various grades of prostate cancer, we investigated whether poorly differentiated cancer usually arises within the center of a large, well-differentiated tumor or more often forms the periphery or leading edge of the tumor.

METHODS

In a series of one hundred and one completely sectioned whole-mount radical prostatectomy specimens removed from patients with clinical Stage T2 prostate cancer, we mapped the distribution of each of the five Gleason grades and assessed their frequency, proportion, and spatial distribution.

RESULTS

The average number of different grades present in our patients was 2.7 (range 1-5). Over 50 percent of the prostates contained at least three different grades of cancer. The number of different Gleason grades present increased significantly with increasing tumor volume (p < 0.0001). Only 10 percent of the index cancers (largest tumor present) were composed of a single grade and these cancers were small (0.02-1.7 cm3). Among cancers with multiple grades, the most common finding (53%) was a high-grade cancer present within the core of a larger, more well-differentiated tumor; however, the opposite pattern, low-grade cancer present within a larger poorly differentiated cancer, was also common (30%) and predominated in very large cancers (> 10 cm3).

CONCLUSION

Small prostate cancers are often composed of a single grade, usually Gleason grade 2 or 3. But most palpable cancers contain multiple grades which are arranged in heterogeneous and unpredictable geographic interrelationships.

The mechanisms and prognostic significance of seminal vesicle involvement by prostate cancer

To assess the mechanisms and prognostic significance of seminal vesicle involvement (SVI) by prostatic adenocarcinoma, we analyzed 312 radical prostatectomy specimens obtained from patients with T1-T3 prostate cancer. Detailed pathological examination demonstrated three patterns of SVI. Type I involvement was direct spread along the ejaculatory duct complex into the seminal vesicles. Type II involvement was spread outside of the prostate, through the capsule, and then into the seminal vesicle. Type III involvement was characterized by the finding of isolated deposits of cancer in the seminal vesicle with no contiguous primary cancer in the prostate. We found SVI in 64 patients (21%), who have been followed for a mean of 31 months (range 1-101). A defining criterion for progression was clinically apparent local or distant recurrence or a postoperative serum prostate specific antigen (PSA) > or = 0.4 ng/ml (Hybritech). Type I SVI was found in 17 (26%), Type II in 21 (33%), and Type III in 8 (13%) cases. In 18 patients (28%), the pattern of SVI appeared to be a combination of types I and II (categorized as Type I+II). Type III (isolated metastasis) SVI was associated with significantly smaller cancers (median, 3.13 vs. 6.7 cc; p < 0.0005) and fewer positive margins (0 vs. 32%; p = 0.05) than in other types. Type II SVI, with direct extension through the capsule, was associated with a significantly higher risk of lymph node metastasis (8 vs. 33%; p < 0.05). When patients with lymph node metastases were excluded, there was a trend toward a more favorable prognosis (p = 0.09) for patients with type III SVI than with other types. Overall, patients with type III SVI had a progression-free survival rate similar to that of 83 patients with extracapsular extension without SVI. We conclude that the prognostic significance of SVI may not be uniformly ominous; instead, it may depend on the specific mechanism of involvement and the pathologic features of the primary tumor.

PSA after definitive radiotherapy for clinically localized prostate cancer

A rising PSA level for clinically localized prostate cancer after definitive radiotherapy is an ominous finding that correlates with positive postirradiation biopsy and traditional clinical progression. The study detailed in this article found that the proportion of patients treated with radiotherapy who achieved stable PSA levels and were clinically free of disease was disappointingly low.

Ultrasonic detection of non-palpable seminal vesicle invasion: a clinicopathological study

In an effort to identify reliable criteria for detecting seminal vesicle invasion (SVI) with transrectal ultrasonography (TRUS) in patients with clinically localised prostate cancer, we reviewed the pre-operative sonograms in 230 patients who underwent radical retropubic prostatectomy; 49 patients (21%) had pathologically confirmed SVI. Conventional sonographic criteria for SVI (asymmetry, distension, atrophy, abnormal echogenicity and irregularity in outline) were present in 58 patients, but only 16 (28%) had pathologically confirmed SVI. On the basis of the results of a preliminary comparison of radical prostatectomy specimens and TRUS, we had revised our criteria for the recognition of SVI: (1) a hypoechoic lesion at the base of the prostate (within 10 mm of the seminal vesicle); (2) an "adhesion sign" resulting from the loss of the echo reflections from the normal fat plane between the prostate and the seminal vesicle; (3) "posterior convexity" of the seminal vesicles. When we reviewed the 230 sonograms retrospectively, we found a hypoechoic tumour at the base in 70 patients, of whom 37 had SVI (positive predictive value (PPV) 53%). An adhesion sign was found in 16 patients, 12 of whom had SVI (PPV 75%). Posterior convexity was present in 4 patients, all of whom had SVI. If any one of our sonographic signs was present, the overall accuracy (83%), sensitivity (90%) and positive predictive value (51%) were significantly better than with any one of the conventional criteria. Patients with SVI were also more likely to have a high serum prostate specific antigen (PSA) level. The PPV for SVI of a PSA level > or = 10 ng/ml was 38%. If the PSA was > 10 ng/ml and TRUS was positive (> or = 1 of our sonographic criteria), 16 (62%) of 26 patients had SVI. If the PSA was < 10 ng/ml and TRUS was negative, only 3 (3%) of 86 patients had SVI. It was concluded that the conventional criteria for detecting SVI on ultrasonography are not accurate in patients with early stage prostate cancer. There are, however, reliable criteria that predict SVI with reasonable accuracy and these criteria, combined with the serum PSA levels, can stratify patients into those with a low risk and those with a high risk of SVI.

Possible mechanism for seeding of tumor during radical prostatectomy

Prostatic adenocarcinoma sometimes recurs locally in the operative bed after radical prostatectomy. Having observed local recurrence in several patients who had a small tumor confined to the prostate on whole mount serial sections, we postulated that some instances of local recurrence could arise from malignant cells shed in prostatic secretions expressed during surgery. To evaluate whether prostatic secretions contain malignant cells and to estimate the frequency of this phenomenon, we collected fresh prostatic secretions from radical prostatectomy specimens immediately after removal. The secretions were analyzed by cytology for the presence of malignant cells. Of 76 samples collected from consecutive patients with clinical stages T1 and T2 prostate cancer at 3 institutions 11 (14%) contained malignant cells. Positive cytology results were most frequent in patients with poorly differentiated tumors. Of 11 cancers with a Gleason sum of 8 to 10 in the prostatectomy specimen 6 (55%) had a positive cytology result. However, of 63 tumors with a Gleason sum of 5 to 7 only 4 (6%) were positive (p < 0.0001). There was no significant correlation with either clinical or pathological stage of the tumor in this small series. Our findings suggest that malignant cells shed during prostatectomy may seed the surgical bed and could be responsible for some instances of local tumor recurrence. The rate of positive cytology results in our study is similar to the local recurrence rates reported in the literature. Surgeons should make prudent attempts to avoid seeding from this source.

Dietary fenretinide, a synthetic retinoid, decreases the tumor incidence and the tumor mass of ras+myc-induced carcinomas in the mouse prostate reconstitution model system

Several epidemiological studies have implicated low dietary and serum levels of retinol with an increased risk for the development of human prostate cancer. In a recent report, dietary fenretinide [N-[(4-hydroxyphenyl)] retinamide], a synthetic retinoid with low toxicity, decreased the incidence of experimentally induced prostate cancer. Fenretinide is currently being evaluated in phase I and phase II clinical trials as an agent for both the treatment and chemoprevention of human prostate cancer. Because of these findings, we investigated whether dietary fenretinide could alter the incidence of phenotype of oncogene-induced prostate cancer in the mouse prostate reconstitution model system. When compared to control-fed animals, dietary fenretinide reduced the tumor incidence by 49% and the tumor mass by 52% of ras+myc-induced cancers in the mouse prostate reconstitution model system, which was modified to prolong the latency period before cancer development. Retinoids have a wide ranging effect on cellular differentiation, growth factor synthesis, and immune function. While its mechanism of action in this system remains unclear, fenretinide is an effective agent for the chemoprevention and growth modulation of oncogene-induced prostate cancer in the mouse prostate reconstitution model system and may be effective for the chemoprevention of human prostate cancer.

Transgenic models for the study of prostate cancer

Transgenic model systems provide tools for obtaining information that clarifies important relationships between genetic alterations and carcinogenesis. One such relationship is the induction of specific growth factor activities by dominantly acting oncogenes. Using a "transgenic organ" model referred to as mouse prostate reconstitution (MPR) under conditions where the ras and myc oncogenes were introduced using a recombinant retrovirus into both the mesenchymal and epithelial compartments of the urogenital sinus, poorly differentiated prostate cancer (PC) was produced with high frequency (> 90%) in inbred C57BL/6 mice. Time-course studies using northern blotting and immunohistochemical analysis showed that the transition from benign to malignant status invariably was associated with the induction of elevated transforming growth factor-beta 1 (TGF-beta 1) expression. Additional immunohistochemical analysis of TGF-beta 1 in human PC and benign prostatic hyperplasia (BPH) showed that positive extracellular staining was significantly more extensive in PC compared with BPH. This differential staining pattern was evident in focal areas of PC adjacent to BPH. These findings in both the MPR model system and human PC suggest that elevated TGF-beta 1 expression is involved in the progression to malignancy and that its pattern of expression may become a useful marker of PC. Additional studies using transgenic animal models will continue to provide important clinically useful information about PC in man.

Association of transforming growth factor-beta 1 with prostate cancer: an immunohistochemical study

Prostate tissue samples from patients with prostatic carcinoma (PC) and/or benign prostatic hyperplasia (BPH) were examined for expression of transforming growth factor-beta 1 (TGF-beta 1) using an immunohistochemical technique. Tissues were stained with CC and LC antisera, which react with extracellular and intracellular TGF-beta 1, respectively. All PC and BPH tissues showed positive extracellular staining; however, CC-immunoreactive material was significantly more extensive in PC compared with BPH, the average positively staining areas being 59% and 26%, respectively. This differential staining pattern was evident in cases in which areas of PC were located adjacent to areas of BPH. LC staining was identified exclusively intracellularly involving both stromal and epithelial cells in cases of PC as well as BPH. However, while stromal cell staining was more pronounced in BPH, epithelial cell staining tended to be more extensive and more intense in PC. The findings suggest that TGF-beta 1 may be biologically important in the development of PC and BPH.

Comparison of the pathologic features and DNA ploidy value of prostate cancers detectable by sonography and by palpation

Ultrasonography of the prostate detects some cancers that are not palpable, but the pathologic features of such cancers have not been well described. Since screening trials consistently find sonography more sensitive (though less specific) than digital rectal examination, nonpalpable cancers that are visible as hypoechoic lesions on ultrasound have been postulated to be early cancers of limited malignant potential and may not require aggressive treatment. To test this hypothesis, we determined the pathologic features and DNA ploidy value of prostate cancers in 63 radical prostatectomy specimens taken from patients with clinical stage T1 (n = 28) and T2 (n = 35) prostate cancer. In 40 patients (63%), the cancer appeared hypoechoic on ultrasound. The median volume of these cancers was 4.19 cm3 (range 0.45-19.22); 80% exhibited extra-capsular extension (ECE); 30% had seminal vesicle invasion (SVI); and 95% were nondiploid by nuclear image analysis (CAS 200 system). In patients with isoechoic cancer, tumor volume was significantly less (median 0.38 cm3) and ECE and SVI occurred less frequently (13% and 0%, respectively). Only seven (30%) had nondiploid tumors. In 35 patients, the tumor was palpable, and the pathologic features and DNA ploidy values (94% nondiploid) of these cancers were similar to those of the tumors that were visible on ultrasound. In seven patients, the cancer was visible by ultrasound but not palpable by digital rectal examination. Median tumor volume was 1.72 cm3 (range 0.45-18.98); four patients (57%) had ECE; one (14%) had SVI, and six (86%) had nondiploid cancers. We conclude that most cancers that appear hypoechoic on ultrasound are clinically important and exhibit aggressive pathologic features. Palpable cancers and sonographically visible cancers are similar and should be staged and treated similarly.

Androgen sensitivity and gene expression in ras + myc-induced mouse prostate carcinomas

We established an androgen-sensitive cell line (BR31-5) from a ras + myc-induced mouse prostate carcinoma and used this cell line together with a previously reported transplantable androgen-independent mouse prostate carcinoma to investigate patterns of expression for apoptosis-related genes in an androgen-deprived environment. Single cell suspensions derived from the BR31-5 cell line were inoculated into the flank of intact or castrated adult male C57BL/6 mice and tumors were harvested 12 days post-inoculation for Northern blotting. A transplantable androgen-independent prostate cancer was also inoculated into intact or castrated mice and tumors harvested 21 days later. Tumor volume analyses showed that BR31-5 carcinomas were androgen-sensitive. Northern blotting showed that mRNA levels for two apoptosis-related genes, transforming growth factor-beta 1 and c-myc, were significantly elevated to a similar extent in carcinomas grown in castrated hosts compared to intact hosts for both the androgen-sensitive BR31-5 and androgen-independent carcinomas. Levels of mRNA for tissue type plasminogen activator, shown previously to be elevated in androgen-independent carcinomas following growth in castrates, were also increased in BR31-5 carcinomas under similar androgen-deprived conditions but to a lesser extent. Interestingly, testosterone repressed prostate mRNA No. 2 levels shown previously to be similar in both the intact and castrated groups for androgen-independent carcinomas were significantly increased in the castrated group compared to the intact group for BR31-5 carcinomas. Therefore, specific patterns of expression for apoptosis-related genes may be able to discriminate androgen-sensitive and androgen-independent prostate cancer under androgen-deprived conditions.

Sonographic monitoring of prostate cancer after definitive radiotherapy

Thirty patients who had transrectal ultrasonography before and after definitive radiotherapy were studied retrospectively to determine the effects of radiotherapy on the sonographic appearance of prostate cancer. Before therapy one or more discrete hypoechoic areas characteristic of cancer were present in 29 (97%) of the patients. In 10 patients (34%) the hypoechoic areas disappeared six to twenty-seven months (mean 11.4) after radiotherapy, but in 3 of these the hypoechoic lesion subsequently reappeared. Six months after radiotherapy a hypoechoic lesion could still be seen in the original area in 79 percent of 19 patients studied. Sonography showed persistent lesions in 65 percent of 17 patients at twelve months, in 79 percent of 14 patients at twenty-four months, and in 75 percent of 8 patients at thirty-six months. In 9 of the 29 patients (31%), there was a measurable increase in the size of the lesion, but overall, the size (maximum diameter) of the hypoechoic lesion had decreased by a mean of 41 percent when evaluated twelve months after radiotherapy. Previous studies from our laboratory have shown that persistent prostate cancer after definitive radiotherapy retains its hypoechoic appearance, and this study indicates that these characteristic hypoechoic lesions can be monitored by transrectal ultrasound.

Frequency and location of extracapsular extension and positive surgical margins in radical prostatectomy specimens

Positive surgical margins have been reported with disturbing frequency in radical prostatectomy specimens and may portend an increased risk of eventual treatment failure. We determined the location of any cancer, extracapsular extension and positive surgical margins in 144 consecutive step-sectioned radical prostatectomy specimens. Of the 46 stage A cancer patients 98% had residual cancer in the prostate after transurethral resection and in 76% cancer was found posteriorly in the gland. Extracapsular extension was identified in 10 patients (22%): anteriorly in 5, posterolaterally in 5 and on the most apical transverse section in 4. Positive margins were found in 10 patients (22%) and half of these occurred posterolaterally. Of the 98 stage B cancer patients tumor was located posteriorly in 97%. Extracapsular extension was found in 62 patients (63%) and in 87% of these it was located posterolaterally. Positive margins were found in 23%, most commonly in the posterolateral and rectal areas (57% and 26%, respectively), and in more than half of these the positive margin resulted from incision into the capsule. In 18 of the 144 patients (13%) a single positive surgical margin was the only pathological indicator of treatment failure and half of these occurred in the area of the neurovascular bundle. Some of these patients with extraprostatic tumor might have been cured if wide excision of the neurovascular bundle had been performed. Overemphasis on preservation of potency during radical prostatectomy may leave some patients with persistent local disease.

The association of benign prostatic hyperplasia and cancer of the prostate

There are a number of similarities between benign prostatic hyperplasia (BPH) and cancer. Both display a parallel increase in prevalence with patient age according to autopsy studies (86.2% and 43.6%, respectively, by the ninth decade), although cancer lags by 15-20 years. Both require androgens for growth and development, and both respond to antiandrogen treatment regimens. Most cancers arise in prostates with concomitant BPH (83.3%), and cancer is found incidentally in a significant number of transurethral prostatectomy (TURP) specimens (10%). The clinical incidence of cancer arising in patients with surgically treated BPH is approximately 3%. BPH may be related to a subset of prostate cancer which arises in the transition zone, perhaps in association with atypical adenomatous hyperplasia (AAH). It is important to exclude cancer in patients presenting with symptoms of bladder outlet obstruction presumably due to BPH. For such patients, we recommend digital rectal examination (DRE) and, at least in high-risk patients, serum prostate specific antigen (PSA) determination. Transrectal ultrasound (TRUS) should be employed in patients with elevated PSA levels to determine the volume of the prostate, the relative contribution of BPH to volume, and the PSA density (ratio of PSA level to volume). Biopsy should be obtained from any area suspicious for cancer. Early detection and treatment of cancer when it is localized offers the greatest chance for cure.

Detection of residual prostate cancer after radiotherapy by sonographically guided needle biopsy

Detection of persistent or recurrent prostate cancer by digital rectal examination (DRE) after definitive radiotherapy is difficult. With the availability of transrectal ultrasonography (TRUS), the detection of prostate cancer has improved substantially. Since 1987 we have used TRUS to evaluate the prostate after definitive radiotherapy. A hypoechoic lesion suggestive of cancer was identified in 45 of 56 patients (80%) studied. Sonographically directed transrectal needle biopsies were performed in 27 of these (60%), and 16 (59%) were positive for cancer. The presence of a palpable nodule suggestive of cancer (present in 7 patients) was not predictive of a positive biopsy specimen. In 14 patients ultrasound-guided and digitally-guided biopsies were performed at the same time; 8 (57%) of the ultrasound-guided biopsy specimens were positive compared with only 4 (29%) of the digitally-guided biopsy specimens. In all 7 patients with an elevated serum level of prostate-specific antigen (PSA) an ultrasound-guided biopsy result was positive. Random biopsies of sonographically normal (isoechoic) areas of the prostate were performed in 8 patients, but only 2 specimens (25%) were positive for cancer. Ultrasound-guided transrectal biopsy of hypoechoic lesions was a safe and effective technique for identifying residual cancer in the irradiated prostate, regardless of the palpable findings. In the presence of an elevated PSA level, such biopsies invariably identified residual cancer. The use of TRUS, ultrasound-guided biopsy, and the measurement of PSA, in addition to DRE, may aid in the detection of residual cancer after definitive radiotherapy.

Early detection of prostate cancer

Prostate cancer is unique among the potentially lethal human malignancies in the wide discrepancy between the high prevalence of histologic changes recognizable as cancer and the much lower prevalence of the clinical disease. Despite the availability of effective tests for early detection and of effective treatment for cancers so detected, the diagnosis usually is not established until the tumor is locally advanced or metastatic. Yet, physicians hesitate to use these tests for fear that many cancers found would be latent, of little threat to the life or health of the host, and treatment could introduce inappropriate morbidity. Latent or "clinically unimportant" cancers can be distinguished from those that are clinically important by the larger volume, higher grade, and greater invasiveness of the latter. The available tests can detect only those cancers large enough to be palpable, visible on ultrasound, or capable of elevating the serum level of prostate-specific antigen. Such cancers are clinically important and should be treated for cure if the life expectancy of the patient is sufficiently long and the morbidity rate of therapy is low. Early detection of prostate cancer using the tests that are available today may widen the window of opportunity so that treatment indeed becomes possible in those for whom it is necessary.

Correlation between side of palpable tumor and side of pelvic lymph node metastasis in clinically localized prostate cancer

Of 411 patients with palpable but clinically localized (Stages B or C) adenocarcinoma of the prostate, 100 (24.3%) were found at complete bilateral pelvic lymphadenectomy to have one or more lymph nodes positive for metastasis. These patients were divided into five subgroups on the basis of the location of the palpable tumor at digital rectal examination: left side only, left predominantly, both sides, right side predominantly, or right side only. Among 35 patients with positive nodes and a palpable tumor limited to one side of the prostate (clinically unilobar), metastases were found in the ipsilateral pelvic lymph nodes in 29 (83%). Only 6 (17%) of the patients had contralateral metastasis alone. A unilateral pelvic lymphadenectomy (ipsilateral to the side of the largest palpable tumor, or on either side if the tumor were bilateral) would have detected 80% of the patients with positive lymph nodes, with a positive predictive value of 100% and a negative predictive value of 94%. Lymph node metastases in patients with clinically localized palpable prostate cancer are most likely to be found on the same side as the palpable tumor and are considerably less likely to be found on the contralateral side alone. If frozen section examination of lymph nodes or laparoscopic lymph node dissection is planned before definitive therapy for prostate cancer, the pelvic lymph nodes ipsilateral to the side of the palpable tumor should be removed first.

Unusual hyperechoic appearance of prostate cancer on transrectal ultrasonography

A series of 157 patients with prostate cancer underwent transrectal ultrasonography prior to radical prostatectomy. In 112 patients (71.3%) the tumours appeared hypoechoic relative to the echo pattern of the normal peripheral zone; in 43 (27.4%) they appeared isoechoic, and in only 2 (1.3%) did they appear purely or predominantly hyperechoic. These 2 hyperechoic tumours were unusual ductal adenocarcinomas with central necrosis and dystrophic calcification within solid tumour nests, a pattern similar to that of comedo-carcinoma of the breast. Calcification within prostate cancer was found in 4 of the 157 radical prostatectomy specimens, including 2 other hypoechoic cancers which contained intraluminal or psammomatous calcification. Although the most common sonographic appearance of localised prostate cancer is hypoechoic, a predominantly hyperechoic pattern is seen occasionally and suggests the presence of a high grade ductal adenocarcinoma.

Transforming growth factor beta 1 as a biomarker for prostate cancer

Using the mouse prostate reconstitution (MPR) model system, under conditions where the ras and myc oncogenes are introduced via a recombinant retrovirus into both the mesenchymal and epithelial compartments of the urogenital sinus, poorly differentiated prostate cancer is produced with high frequency (> 90%) using inbred C57BL/6 mice. Northern blotting and immunohistochemical analysis showed that the transition from benign prostatic hyperplasia (BPH) to prostate cancer is invariably associated with the induction of elevated transforming growth factor-beta 1 (TGF-beta 1) expression. Similar analysis of TGF-beta 1 in human BPH and prostate cancer is consistent with our MPR results and indicates that the accumulation of extracellular TGF-beta 1 is significantly more intense in prostate cancer compared to normal or benign prostate tissues. Interestingly, where benign pathologies are observed in the prostatic stroma in the presence of benign prostatic epithelium, extracellular TGF-beta 1 is seen predominantly in the stromal compartment. Experimental studies clearly demonstrate that mRNA levels of TGF-beta 1 and other growth related genes are regulated by androgens in prostate cancer cells. Overall, our results suggest that elevated TGF-beta 1 is involved in the development of prostate cancer. Direct determination of TGF-beta 1 levels and distribution as well as analysis of localized and systemic effects produced by TGF-beta 1 may serve as useful biomarkers for prostate cancer.

Alterations in mRNA levels for growth-related genes after transplantation into castrated hosts in oncogene-induced clonal mouse prostate carcinoma

A clonal mouse prostate carcinoma was established by the introduction of the ras and myc oncogenes via the recombinant retrovirus Zipras/myc 9 using a mouse prostate reconstitution model system. A single-cell suspension derived from an early passage ras+myc-induced carcinoma was inoculated into the flanks of intact or castrated adult male C57BL/6 mice, and tumors were harvested 3 wk postinoculation for northern and Southern blotting. Tumor volume analysis showed that this carcinoma was not dependent on testicular androgens for growth. Southern blot analysis of virus-cell DNA junction fragments revealed that tumor cell populations recovered from both intact and castrated mice were progeny of the same virus-infected cell. Northern blotting showed that mRNA levels for the four growth-related genes transforming growth factor-beta 1 (TGF-beta 1), transforming growth factor-beta 3 (TGF-beta 3), tissue-type plasminogen activator (tPA), and c-myc were significantly elevated in clonal mouse prostate carcinomas grown in castrated hosts. In contrast, androgen receptor mRNA levels were significantly reduced under the same conditions. The response of TGF-beta 1, tPA, and c-myc mRNA levels in the carcinomas grown in castrated hosts was similar to that shown previously in normal rat ventral prostate. However, unlike normal rat ventral prostate after castration, increased numbers of apoptotic cells were not seen in the castrated group relative to the intact group at the time of analysis, indicating that the altered gene expression was not associated with cell death. In addition, testosterone-repressed prostate mRNA number 2 levels, shown previously to be elevated after castration in normal rat ventral prostate, were not increased in the androgen-deprived clonal mouse prostate carcinomas. Therefore, this early passage clonal ras+myc-induced prostate carcinoma demonstrates unique patterns of expression for a set of growth-related genes in an androgen-deprived environment.

The frequency and morbidity of local tumor recurrence after definitive radiotherapy for stage C prostate cancer

Radiotherapy is reported to provide good control of locally advanced prostate cancer. However, few long-term studies have assessed the morbidity related to local tumor recurrence in patients treated with radiotherapy alone (without hormonal manipulation). To determine the frequency and severity of morbidity related to local recurrence we reviewed the course of all patients with clinical stage C prostate cancer treated at our institution between 1966 and 1979 with bilateral pelvic lymph node dissection, radioactive gold seed implantation and external beam irradiation therapy to the prostate. Of the 121 patients 60% died and the 40% still alive at the time of review were followed for a mean of 8.1 years (range 3.3 to 14.8 years). Over-all, 64 patients (53%) had local recurrence, which was defined as a clinical event causing signs or symptoms and was proved by biopsy. On an actuarial basis the risk of local recurrence was 43 +/- 10% (mean +/- 2 standard errors) at 5 years and 74 +/- 11% at 10 years. Any symptomatic episode requiring active intervention or causing morbidity was denoted an adverse event. There were 162 adverse events among the 73 patients (2.2 adverse events per patient): 69% of these were severe (requiring surgical intervention) and 55% were chronic (more than 3 months in duration). The most common cause of an adverse event was bladder outlet obstruction requiring transurethral resection of the prostate (44 patients); 16 patients (13%) became incontinent. Hydronephrosis developed in 24 patients (20%). Local recurrence after definitive radiotherapy for our patients with stage C prostate cancer was common and was associated with serious morbidity, frequently requiring surgical intervention. Radiotherapy alone may not be sufficient to provide long-term local control of stage C prostate cancer.