Relationship between clinical stage and histological zone of origin in early prostate cancer: morphometric analysis

A detailed morphometric analysis of 96 radical prostatectomy specimens (13 clinical stage A1, 29 A2, 34 B1 and 20 B2) was undertaken to examine the relationship of zone of origin to volume, grade and extraprostatic extension of cancer. In patients with stage A disease, transition zone (TZ) cancer (present in 81%) was significantly larger but of lower grade than peripheral zone (PZ) cancer (present in 90%). The total volume of cancer in stage A1 patients averaged 1.55 ml with 72% of TZ origin. In patients with stage A2 disease, tumour volume averaged 5.83 ml with only 57% of TZ origin. Specimens taken during transurethral resection of the prostate (TURP) revealed TZ cancer in 82% and PZ cancer either alone or with TZ cancer in 22%. The 9 patients with PZ cancer in the TURP specimen included 5 of the 11 with extracapsular extension and all 5 of those with seminal vesicle invasion. Every patient with stage B disease had PZ cancer which, in all except 3 cases, was of significantly larger volume and higher grade than any TZ cancer (present in 43%) in the same gland. In patients with stage B cancer, total tumour volume was 5.13 ml with 91% of PZ origin. TZ cancer tended to be well differentiated in all patients, even at large volumes, whereas PZ cancer was often moderately or poorly differentiated even at low volumes. In patients with stage B disease, TZ cancer appeared to be incidental and of no clinical importance, while in stage A patients PZ cancers were sometimes large, poorly differentiated and extended outside the prostate. Progression of a stage A cancer seems more likely to result from PZ cancer than TZ cancer, and the finding of PZ cancer in a TURP specimen should probably preclude its classification as stage A1.

A comparison of the morphological features of cancer arising in the transition zone and in the peripheral zone of the prostate

To determine the characteristics of transition zone and peripheral zone prostate cancer, we examined a series of 42 stage A and 54 stage B radical prostatectomy specimens with particular attention to the number of separate foci of cancer, zone of origin, volume and grade of each focus, and presence of severe intraductal dysplasia (high grade prostatic intraepithelial neoplasia), extra-capsular extension and seminal vesicle invasion associated with cancer in each zone. We found that there were fundamental differences between transition zone and peripheral zone cancers, and that the features that characterize these tumors were apparent in stages A and B disease. Although the total tumor burden was similar in stages A (3.98 cc) and B (4.56 cc) disease, stage A cancer tended to be multifocal (3.1 tumors per prostate) and more diffuse. While 81% of stage A prostate specimens contained a tumor of transition zone origin and 93% had cancer of peripheral zone origin, transurethral resection of the prostate sampled a transition zone cancer in 77% and a peripheral zone cancer in 31% (8% had both types). Stage B cancer tended to be more focal (2.3 cancers per prostate). All stage B prostate specimens contained a peripheral zone cancer and 43% had a transition zone cancer as well. In only 1 stage B cancer patient was the transition zone tumor the palpable or index cancer. In stages A and B disease, peripheral zone tumors were less well differentiated (median Gleason sum 6 and 7) than transition zone tumors (5 and 5, respectively) and more likely to extend through the capsule (44% versus 11%). Seminal vesicle invasion arose from 19% of the peripheral zone but none of the transition zone cancers. Peripheral zone tumors were almost always (93%) associated with high grade prostatic intraepithelial neoplasia, while none of the transition zone cancers was so associated. For peripheral zone disease there was a moderate correlation between volume and grade (tau = 0.46, p less than 0.001) so that the larger the tumor the higher the Gleason sum but within transition zone disease this correlation was poor (tau = 0.23) and not statistically significant (p greater than 0.05). Extracapsular extension occurred at a smaller volume with peripheral zone cancer (mean 3.86, minimum 0.06 cc) than transition zone cancer (mean 4.98, minimum 0.39 cc). Cancer that arises in the transition zone appears to have a different histogenesis, is associated with more favorable pathological features and may have less malignant potential than tumors that arise in the peripheral zone.

The risk of dying of prostate cancer in patients with clinically localized disease

From 1966 to 1979, 360 patients with clinical stages A2, B and C1 prostate cancer underwent staging pelvic lymphadenectomy, and completed a course of combined interstitial radioactive gold seeds and external beam radiotherapy. All patients had a normal serum prostatic acid phosphatase level and a bone scan negative for metastases. All patients were followed until death or for a mean of 7.3 years (range 1.2 to 18.25 years) for those alive at analysis. To determine the risk of dying of prostate cancer we reviewed the records of the 142 patients (39%) who died. At analysis 21% of the patients had died of prostate cancer and 17% of other known causes. The cause of death could not be determined in 4 patients (1%). Cardiovascular disease accounted for a fifth of all deaths. The actuarial risk of death of prostate cancer for all patients was 8 +/- 3% (+/- 2 standard errors) at 5 years and 30 +/- 7% at 10 years. The risk of death of all causes was 16 +/- 4% at 5 years and 46 +/- 7% at 10 years. An increased risk of cancer death was associated with established risk factors, including advanced local disease, poorly differentiated histology, pelvic nodal metastases and distant recurrence. We also noted a substantial risk of cancer death in patients who had local tumor recurrence. While previous studies have reported a relatively low incidence of cancer deaths (4 to 17%) in patients initially diagnosed with localized disease, our data suggest that prostate cancer is the major cause of mortality in such patients. Aggressive curative therapy, regardless of treatment modality, should be considered for localized prostate cancer in men with a life expectancy of 10 or more years.

DNA ploidy by image analysis of individual foci of prostate cancer: a preliminary report

The malignant potential of an individual focus of prostate cancer is difficult to determine. The established pathological features associated with malignant behavior include tumor volume, grade, and invasiveness (local extension or metastasis). We used nuclear image analysis to determine the DNA ploidy value of each cancer in a series of 30 radical prostatectomy specimens from patients with early stage prostate cancer in order to further explore the malignant potential of each separate focus of cancer. The volume, grade, invasiveness (extracapsular extension or seminal vesicle invasion), and zone of origin of each of the 63 separate cancers were determined. The DNA ploidy histogram of 200 cancer cells was compared with 50 normal epithelial nuclei on the same Feulgen-stained tissue sections. Sixty % of the cancers were diploid, and 40% were nondiploid. Ploidy correlated with volume and grade. All cancers less than 0.02 cm3 were diploid; 26% of foci 0.02 to 2.0 cm3 and 82% of foci greater than 2.0 cm3 were nondiploid. There were 16 cancers of transition zone origin ranging in size from 0.02 to 12.1 cm3 and only one (7.3 cm3) was nondiploid. There were 47 cancers of peripheral zone origin (range, 0.01 to 18.98) and 24 (51%) were nondiploid. Eight of the 24 nondiploid cancers were small (less than 1.0 cm3), and two were only 0.03 cm3. We conclude that some very small prostate cancers are nondiploid and that progression of prostate cancer is not a function of volume alone, whereby tumors only acquire full malignant potential at large volumes. Cancers of peripheral zone origin acquire a nondiploid cell population at a smaller volume than do cancers of transition zone origin, further supporting a fundamental difference between cancers arising in these zones.

The sonographic appearance of irradiated prostate cancer

Transrectal ultrasonography of the prostate was performed before radical prostatectomy in 22 patients with persistent or recurrent cancer after definitive radiotherapy. Serial transverse sonograms were compared with whole-mount step-sections of the prostatectomy specimens to evaluate the sonographic features of irradiated prostate cancer. To define more clearly the effects of radiation on malignant prostatic tissue, we assessed the degree of histological change induced by the irradiation (radiation effects) as none, mild, moderate or severe. A total of 121 areas of cancer greater than 4 mm in maximum diameter were identified on the histological sections. Of these, 105 (87%) showed no radiation effects or mild effects, and 72% (76/105) of these appeared hypoechoic on the corresponding sonogram. There were 16 foci with moderate or severe radiation effects and only 25% (4/16) appeared hypoechoic. The remaining 12 foci were isoechoic. Areas of cancer which show moderate or severe radiation effects tend to become isoechoic while large (greater than 4 mm) foci of cancer in the irradiated prostate usually show little radiation effect, and these foci typically appear hypoechoic.

Elevated plasma chromogranin-A concentrations in prostatic carcinoma

Chromogranin-A is considered a sensitive immunohistochemical tissue marker in neuroendocrine prostatic carcinoma. We report that the plasma chromogranin-A level was elevated in 48% of 25 patients with stage D2 prostate cancer, and suggest that this marker can be used to monitor the clinical course of these patients.

Transrectal ultrasonography in stage A prostate cancer: detection of residual tumor after transurethral resection of prostate

To evaluate the ability of transrectal ultrasonography to detect residual cancer in the prostate gland after transurethral resection in patients with stage A cancer, we studied 38 patients with stage A disease (11 stage A1 and 27 stage A2) in whom transrectal ultrasonography was done at least 3 weeks after resection. Each patient underwent radical prostatectomy, and residual cancer was present in 97% of the specimens (peripheral zone cancer in 95% and transition zone cancer in 61%). At sonography we identified hypoechoic areas suggestive of cancer in 10 patients (26%). In the pathological specimen residual cancer was present at the hypoechoic area in 8 of these cases (positive predictive value 80%). In a retrospective review of the sonograms we identified 25 hypoechoic lesions greater than 5 mm. in diameter, including 15 that corresponded to cancer in the radical prostatectomy specimens (positive predictive value 60%). Granulomas due to the transurethral resection were found in 92% of the radical prostatectomy specimens but none appeared hypoechoic on ultrasound. A total of 103 separate cancers was identified in the whole mount step sections of the radical prostatectomy specimens (2.7 cancers per patient). Of the 103 separate cancers 54 were less than 0.1 cc in volume and none of these could be identified in the retrospective review of the sonograms, 37 were 0.1 to 1.0 cc and 5 of these (14%) appeared hypoechoic, and 12 were greater than 1.0 cc and 10 of these (83%) appeared hypoechoic. Hypoechoic lesions greater than 5 mm. in diameter in the transition zone proved to be cancer in 47% of the cases, while 88% of similar lesions in the peripheral zone proved to be cancer. We conclude that suspicious-appearing hypoechoic lesions suggestive of cancer, whether in the peripheral zone or the transition zone, should be biopsied before expectant management of stage A prostate cancer is considered. Transrectal ultrasonography is useful for restaging after transurethral resection and for evaluating the extent of residual cancer in stages A1 and A2 prostate cancer.

Testicular cancer: the role of the primary care physician in prevention and early detection

Early detection and screening techniques along with the concept of personal responsibility for one's own health are prominent themes in medical education. Testicular cancer, its natural history, and the current approach to prevention, early detection, and diagnosis are discussed with special emphasis on the role of the primary care physician. Current community and school efforts are described along with the availability of patient education resources. Since the incidence of testicular cancer has doubled in the last 20 years, we must give more attention to educating the public by encouraging primary physicians to incorporate instruction on self-examination of the testicles into regular physical exams.

Elevated transforming growth factor-beta 1 and beta 3 mRNA levels are associated with ras + myc-induced carcinomas in reconstituted mouse prostate: evidence for a paracrine role during progression

Mouse prostate reconstitution is a useful model for studying the progression of ras + myc-induced carcinomas. When these oncogenes were introduced into both the epithelial and the mesenchymal compartments, poorly differentiated adenocarcinomas resulted. Restricted introduction of both oncogenes into the epithelium produced epithelial hyperplasia. Malignancies were produced in two out of 17 cases of selectively transformed epithelium, suggesting that the hyperplastic condition represents a premalignant phenotype. Restricted introduction of both oncogenes into the mesenchyme produced only mesenchymal dysplasia. Transforming growth factor-beta 1 (TGF-beta 1) and beta 3 (TGF-beta 3) mRNA levels were elevated in the ras + myc-induced carcinomas when compared to the normal controls or to the epithelial hyperplasias. In contrast, TGF-beta 2 mRNA levels were similar in all control and ras + myc-induced carcinomas. Elevated TGF-beta 1 mRNA levels were also found in mesenchymal dysplasia pointing to a potential paracrine activity by the ras + myc transformed mesenchyme. We conclude that elevated TGF-beta 1 and beta 3 are correlated with progression to malignancy and that mesenchyme derived TGF-beta 1 may play an important role in the promotion of ras + myc-induced carcinomas in this model system.

Fatal sepsis following intravesical bacillus Calmette-Guerin administration for bladder cancer

Intravesical administration of bacillus Calmette-Guerin has been shown to be highly effective treatment of superficial bladder cancer. Complications from bacillus Calmette-Guerin therapy are usually minor but serious and even fatal reactions can occur. Five recent cases illustrate the gravity of bacillus Calmette-Guerin sepsis. One man with severe debility and the organic brain syndrome died acutely with a fever of 40 C. Two men had frank sepsis that progressed to multiorgan failure and death. Sepsis progressed despite the use of isoniazid, rifampin and streptomycin. Two men who had equally progressive sepsis with intravesical bacillus Calmette-Guerin survived with the use of cycloserine for the first 72 hours of treatment. Triple antituberculous antibiotics, including cycloserine, may be lifesaving. Sepsis resulted from intravenous absorption through inflamed or disrupted urothelium. Bacillus Calmette-Guerin treatment should not be administered in the presence of severe cystitis or after grossly traumatic catheterization.

Sonographic measurements of transition zone of prostate in men with and without benign prostatic hyperplasia

Modern transrectal ultrasonography is a reliable means of visualizing the transition zone within the prostate gland. We measured the transverse, longitudinal, and anterior diameters and calculated the volume of the prostate and the transition zone in 400 patients. Ninety-seven patients with neither clinical nor sonographic evidence of benign prostatic hyperplasia (BPH) were compared with 108 patients with sonographically apparent BPH. The mean size of the transition zone was 6.14 +/- 3.2 g in the normal group and 24.81 +/- 14.4 g in the BPH group. The size of the transition zone increased significantly in relation to increased age of the patient. Ultrasonography allows accurate measurement of the transition zone and would be useful for documenting changes in the extent of BPH in response to therapy.

Staging of prostate cancer. Value of ultrasonography

Clinical staging is the attempt to determine the pathologic extent of a cancer by clinical tests (Whitmore). Traditionally, staging of prostate cancer has relied on the digital rectal examination, but ultrasonography, which provides an unprecedented picture of the gland, has become a valuable adjunct. The overall sonographic pattern helps to classify a tumor as "localized" or "extensive." A more detailed analysis yields information about the volume and location of the primary tumor; the presence, location, and extent of extracapsular extension; and the presence of seminal vesicle invasion. Comparison of sonograms with corresponding sections of radical prostatectomy specimens demonstrates that ultrasound complements the digital examination in determining by clinical tests the pathologic extent of a cancer.

Ultrasonographic changes in the normal and malignant prostate after definitive radiotherapy

As treatments for early localized prostate cancer come under closer scrutiny, the fundamental problem of documenting the success of radiotherapy becomes more obvious. Currently, no satisfactory method exists to determine tumor viability after radiotherapy. Transrectal ultrasonography is particularly valuable for monitoring the response of prostate cancer to radiotherapy. Persistent cancer retains its hypoechoic appearance after definitive radiotherapy. Hypoechoic lesions greater than 5 mm in diameter found more than 12 months after radiotherapy should be suspected of representing persistent local disease. In our study, albeit in a selected group of patients undergoing salvage radical prostatectomy, 92 per cent of such findings were associated with what we interpreted as viable tumor by light microscopy. Ultrasound-guided biopsy should be considered in such circumstances. The persistence of hypoechoic lesions in more than 65 per cent of patients 12 to 36 months after radiotherapy also suggests that local treatment failure may be underestimated by digital rectal examination and random digitally guided biopsy. Serial measurement of the diameter of hypoechoic lesions may provide a valuable indicator of progress in an individual patient. Patients with enlarging foci of tumor within the prostate after radiotherapy might be selected for biopsy and further treatment. If such a policy is employed, it is likely that a higher incidence of persistent cancer will be found after radiotherapy than has previously been discovered by random digitally guided biopsy.

Pathologic basis of the sonographic appearance of the normal and malignant prostate

The hypoechoic nature of prostatic cancer is now well recognized. In fact, not all cancers are purely hypoechoic; many are isoechoic, and some have a mixed echogenicity. Rarely, we have seen a cancer that was predominantly hyperechoic. Other signs of disturbance of the normal internal anatomy of the prostate may suggest the diagnosis of prostate cancer and are particularly valuable in assessing patients with more advanced disease. Approximately one third of early-stage cancers detected by palpation or transurethral resection are isoechoic. These tumors are anteriorly located, small, and well differentiated and infiltrate among normal glands or are composed of malignant glands similar in size to normal acini. Not all hypoechoic areas within the prostate are cancer; both normal anatomic structures and various benign conditions may appear less echogenic than the normal prostatic parenchyma. A comprehensive understanding of normal prostatic anatomy and the morphology of prostate cancer is essential to the accurate interpretation of the sonogram. Precise interpretation of prostatic sonograms requires detailed correlations of high-quality images with pathologic examinations of the whole prostate. The development of accurate criteria for the sonographic diagnosis of both malignant and benign prostatic diseases can be achieved only by such studies. As the possibilities and limitations of transrectal ultrasonography become apparent from pathologic correlation, the role of ultrasound in the diagnosis of prostate cancer will be placed on a more rational basis.

Early detection of prostate cancer

Many important features of the biology of prostate cancer have not been discussed in this review, which has emphasized the traditional criteria for characterizing the biologic behavior of the disease: volume, grade, and invasiveness. Studies of the pathology of prostate cancer found at autopsy or in the clinic, the natural history of the disease, and the results of treatment trials leave little room for doubt that large cancers, particularly those that are not well differentiated or that invade outside of the prostate, will prove lethal if not effectively treated. We do not know whether some small prostate cancers are potentially dangerous. Perhaps studies of nuclear features, DNA content, or oncogene expression will be able to distinguish the potentially lethal small cancers from the truly "latent" small cancers. We do, however, have strong evidence that every big cancer is dangerous. Autopsy studies have established that there are not two forms of prostate cancer, but one. Initial malignant transformation in the prostate produces an adenocarcinoma histologically indistinguishable from any other prostate cancer. However, a promoter seems to be necessary to activate the tumor and allow it to express its malignant potential. The strong correlation between the prevalence of large, proliferative cancers found at autopsy and the clinical incidence and mortality rate of prostate cancer in populations around the world strongly supports the concept of a multistep process in the pathogenesis of the disease. If McNeal's detailed volumetric studies are accurate, then we can estimate the proportion of "autopsy" cancers that are large enough to threaten the life and well-being of their host. This proportion appears to be about 20 per cent, and these are the undetected but "clinically important" cancers. The dilemma of prostate cancer becomes less puzzling when viewed in this light. In a daunting display of the power of the paradox of prostate cancer, Chodak estimated that if every cancer present in American men were to be found and treated, 75,000 men would die from the treatment, whereas less than 30,000 are expected to die of the disease this year! But this paradox can be explained by introducing time into the analysis, basing estimates on the lifetime risks rather than the annual incidence. For a 50-year-old man, the lifetime risk of developing cancer in the prostate is about 42 per cent, the risk of developing the disease clinically is 9.5 per cent, and the risk of dying from the disease is 2.9 per cent.(ABSTRACT TRUNCATED AT 400 WORDS)

Prognostic significance of lymph nodal metastases in prostate cancer

Pelvic lymph node metastases indicate a poor prognosis for patients with clinically localized prostate cancer but the significance of minimal nodal metastases still is debated. We determined the progression and cancer specific survival rates based on the extent of nodal metastases in 511 patients followed for a mean of 8.6 years (range 2.5 to 17.5 years) after bilateral pelvic lymph node dissection and irradiation therapy. The patients were divided into 4 groups based on the extent of nodal metastases: NO--negative nodes (359 patients), N1--a single microscopic positive node (37), N2--multiple microscopic positive nodes (86) and N3--grossly positive or juxtaregional nodes (29). The risks of distant metastases and of dying of prostate cancer were much greater in the 152 patients with positive nodes (N+) than in those with negative nodes (p less than 0.00005). The risk of metastatic disease at 10 years was only 31 +/- 7 per cent for the NO patients compared to 83 +/- 7 per cent for the N+ patients, and the risk of dying of prostate cancer was only 17 +/- 6 per cent at 10 years for the NO group and 57 +/- 11 per cent for the N+ patients. Patients with a single microscopic node (N1) had a pattern of progression and cancer specific mortality rate similar to patients with more extensive nodal metastases and markedly worse than patients with negative nodes. The risk of distant metastases was 80 +/- 15 per cent at 10 years for the N1 group, 84 +/- 11 per cent for the N2 group and 88 +/- 13 per cent for the N3 group, while the risk of dying of prostate cancer at 10 years was 40 +/- 19, 66 +/- 15 and 58 +/- 24 per cent, respectively. The finding of a single pelvic lymph node containing microscopic metastatic disease markedly worsened the prognosis of our patients with prostate cancer. Once prostate cancer is found within the pelvic lymph nodes the patient has systemic disease unlikely to be controlled by pelvic lymph node dissection and radiotherapy.

The risk of distant metastases after transurethral resection of the prostate versus needle biopsy in patients with localized prostate cancer

Although transurethral resection of the prostate provides an effective treatment for obstructive voiding symptoms associated with prostate cancer, there is growing concern about the possible role of transurethral resection in the dissemination of this malignancy. To determine the effect of transurethral resection on the rate of development of distant metastasis, we analyzed a large series of patients (379) treated at our institution with definitive radiotherapy for localized prostate cancer that was diagnosed by either needle biopsy or transurethral prostatic resection. In our series the presence of lymph node metastasis was documented by pelvic lymph node dissection in all patients. An initial univariate analysis suggested that patients diagnosed by transurethral resection had distant metastases significantly more rapidly than patients diagnosed by needle biopsy. However, transurethral resection usually was performed because of the presence of obstructive voiding symptoms and such patients were much more likely to have positive lymph node dissections than patients without obstructive voiding symptoms. A proportional hazards regression analysis showed that nodal status and the degree of obstructive voiding symptoms at diagnosis were independent and powerful predictors of the interval to distant metastases, along with stage and grade. The type of initial biopsy (transurethral prostatic resection versus needle biopsy) had no independent prognostic significance in this analysis. Among patients who had substantial obstructive voiding symptoms there was no significant difference in interval to distant metastases between the transurethral prostatic resection and needle biopsy groups. We conclude that the apparent adverse effect of transurethral prostatic resection results from the poor prognosis of tumors causing obstructive voiding symptoms rather than as a direct result of the resection itself.

The appearance of prostate cancer on transrectal ultrasonography: correlation of imaging and pathological examinations

Preoperative transrectal ultrasonograms in 70 patients who underwent radical prostatectomy were compared retrospectively to the histological features of whole mount sections of the surgical specimens. In 42 cases (60 per cent) the tumor could be appreciated as a hypoechoic area on the sonogram. In only 1 case did the tumor appear as a hyperechoic area. In the other 27 cases (39 per cent) the tumor was isoechoic and could not be distinguished clearly from the surrounding tissue. The smallest tumor visualized sonographically measured 4.4 mm. in diameter in the surgical specimen. There was a statistically significant correlation among tumor echogenicity, the actual tumor size and the Gleason grade. Although there was a linear correlation between the size (maximum diameter) of the tumor measured by ultrasound and that determined from the histological sections, ultrasonography generally underestimated the size of the tumor, with the maximum diameter measured sonographically being approximately 4.8 mm. smaller than the diameter measured in the whole mount sections. Of 25 nonpalpable (stage A) tumors 9 (36 per cent) were visualized on ultrasound, while of 45 palpable (stage B) tumors 11 (21 per cent) were not. Although most clinically recognized tumors can be appreciated sonographically, the tumors that are visualized tend to be larger, less well differentiated and palpable. These features favor the use of sonography to stage and monitor established prostate cancers, and suggest that tumors detected by sonography in an early detection program are likely to be clinically important cancers.

Testicular metastasis as the first manifestation of colon carcinoma

Metastatic carcinoma to the testes is uncommon, and it is most often found incidentally at autopsy or after orchiectomy for prostatic carcinoma. One of the rarest causes of testicular tumor is metastasis from another primary site. It is even more unusual when the metastasis to the testicle is the first manifestation of the tumor. We report a case of asymptomatic colon carcinoma presenting as metastases to the testis and epididymis, which was diagnosed after biopsy of testicular nodules. Although nonlymphomatous cancer presenting as an intrascrotal mass is extremely rare, seldom detected clinically and almost never the first sign of disease, it should be considered a possibility, even in the young adult who presents with a mass involving the testicle or epididymis.

Salvage radical prostatectomy for radiorecurrent adenocarcinoma of the prostate

A total of 16 patients with persistent or recurrent prostate cancer 1 to 10 years after definitive treatment with radiotherapy underwent salvage radical prostatectomy. Patients considered to be candidates for the procedure were in excellent health, with a life expectancy of at least 10 years and with no evidence of extension of tumor beyond the prostate. There was no operative mortality but major complications included rectal injury in 3 patients (19 per cent, 1 requiring colostomy), ureteral transection in 1 (6 per cent), anastomotic stricture in 4 (25 per cent), ureterovesical junction stricture in 1 (6 per cent) and persistent urinary incontinence in 4. Whole organ step-section of the surgical specimen revealed positive surgical margins in 6 patients (37.5 per cent). Margins usually were positive at the apex and not at the bladder neck, so that cystoprostatectomy would not have altered the positive margin rate. Although the followup is too short for analysis of tumor recurrence or patient survival rates, the results indicate that salvage radical prostatectomy, although technically demanding, is feasible and that in the majority of properly selected patients the tumor can be removed completely.

Hormone-refractory metastatic prostatic cancer treated with methotrexate, cyclophosphamide plus adriamycin, cis-platinum plus 5-fluorouracil plus cyclophosphamide. National Prostatic Cancer Project randomized trial

From 1982 to 1985, the National Prostatic Cancer Treatment Group conducted a randomized prospective trial of single-agent or combination chemotherapy in 180 patients with metastatic prostatic disease refractory to hormonal therapy. All three of the treatment regimens, methotrexate, Adriamycin plus cyclophosphamide, cis-platinum plus 5-fluorouracil plus cyclophosphamide, showed similar survival and progression-free survival intervals. Future studies utilizing these or other agents, in similar or modified dosage schedules or delivery mechanisms, should note these results. Protocols designed to address subjective quality of life measures and other benefit ratios can be effectively employed considering this report.

Monoclonal antibodies against the androgen receptor: recognition of human and other mammalian androgen receptors

Monoclonal antibodies against the androgen receptor (AR) will provide useful probes for elucidating both the structure and function of this important regulatory protein. Recently, human autoimmune anti-AR sera have been described. The purpose of the current work was to immortalize lymphocytes from the blood of patients with high titer anti-AR antibodies and to produce monoclonal antibodies against the receptor in vitro. Human serum samples (10 microliters) were incubated in high ionic strength buffer (400 mM KCl) for 16 h at 0 C with [3H]Mibolerone-labeled cytosol (100-200 fmol AR) from Dunning tumors. Receptor-antibody complexes were precipitated with goat antihuman immunoglobulin (Ig) antibody. From our 1005 serum samples examined, 5 specimens were detected which precipitated greater than 40% of the AR. These antibodies recognized the AR from human, rat, mouse, dog, steer, chicken, and hamster, but did not recognize estrogen, progesterone, or glucocorticoid receptors. By sucrose gradient analysis in high salt (0.4 M KCl) 1 of the antisera shifted the 4.4S monomeric receptor to 8S, and the others shifted the receptor to 18S. However, all of the antibodies were shown to be IgG class by immunoprecipitation with class-specific second antibodies. Peripheral blood lymphocytes donated by these patients were isolated by histopaque density gradient sedimentation, activated in vitro, transformed with Epstein-Barr virus, and seeded into 96-well plates. From 263 million human lymphocytes plated in 96-well dishes, 1215 wells gave rise to Epstein-Barr virus-transformed lymphoblastoid cells, and 8 of these wells were determined to be anti-AR positive. Cells from 2 of the positive wells were cloned and designated CB54 and UA67, both of which secreted IgG class antibodies against the AR. These 2 monoclonal antibodies have been shown to be highly specific for the AR and to cross-react with the AR from human, rat, and hamster. Studies with the monomeric form of the AR and its proteolytic fragment using sucrose density gradients have suggested that the 2 antibodies recognize different epitopes on the monomeric AR molecule. Furthermore, by Western blot analysis the antibodies have identified the AR as an 118K protein on a sodium dodecyl sulfate gel, which is consistent with our previous findings of the mol wt of the AR.

Identification of "tumor-associated" nucleolar antigens in human urothelial cancer

Nucleoli isolated from HeLa S3 cells were used to produce rabbit antisera capable of binding nucleoli of transitional cell carcinomas (TCCa) of the bladder. Cross-reactivity of the rabbit antiserum with normal nucleoli was reduced by absorption with fetal calf serum, normal human serum, and human placental nucleoli. This antinucleolar antiserum exhibited strong reactivity in immunoperoxidase assays performed on specimens of human bladder cancer. In frozen tissue sections of 24 patients with TCCa and eight individuals without tumor, nucleolar staining was observed in all malignant specimens, but was not observed in seven of the normal specimens. Cytologic examination of bladder washing specimens from 47 normal individuals showed absence of nucleolar staining in 43 (91%) of 47 normal specimens while 12 (86%) of 14 specimens from patients with TCCa were positive. These results suggest that there are antigens associated with the nucleoli of HeLa cells and transitional cell carcinomas which are generally absent (or in low concentration) in normal human urothelial cells, and that antisera to these antigens may be useful in the cytologic diagnosis of human transitional cell carcinoma.

Radical cystectomy with preservation of sexual and urinary function. Use of the ileocolonic pouch ("Le Bag")

Current surgical technique allows radical cystectomy to be performed with preservation of both sexual and urinary function. An ileocolonic pouch (Le Bag), is created to replace the bladder, with anastomosis directly to the urethra. Continence depends on the inherent function of the residual sphincter mechanism. The ileocolonic pouch results in a highly compliant, low-pressure reservoir with a reliable antireflux ureteric implantation.

Transrectal ultrasonography for prostatic cancer. II. The response of the prostate to definitive radiotherapy

Transrectal ultrasonography was used to monitor the response of adenocarcinoma of the prostate to radiotherapy before and 6 to 15 months after treatment combining implantation of radioactive gold seeds with external beam irradiation. Data gathered before and after irradiation therapy suggested that the two most sensitive measures for monitoring the primary tumor are the calculated volume of the prostate and the integrity of the prostatic capsule. The calculated volume of the prostate decreased significantly in all patients by 6 months after radiotherapy. The rate and degree of reduction correlated significantly (P less than 0.05) with the histologic grade of the tumor (poorly differentiated tumors shrinking most rapidly), as well as with the outcome of treatment (P less than 0.05). However, there was no such correlation with stage. After treatment, the average number of sites of capsular disruption decreased steadily, reaching 50% of the pretreatment number by 15 months. Transrectal ultrasonography is a practical, inexpensive, noninvasive tool for monitoring the response of prostatic cancer to definitive radiotherapy, and may provide a means of identifying patients who will respond poorly to treatment.

The prognostic significance of post-irradiation biopsy results in patients with prostatic cancer

To evaluate the prognostic significance of post-irradiation biopsy results in patients with prostatic cancer, we reviewed the records of 803 patients who had been treated with pelvic lymph node dissection, radioactive gold seed implantation and external beam irradiation. Of the patients 124 had 1 or more biopsies within 6 to 36 months after completion of radiotherapy when there was no evidence of local or distant recurrence of tumor. Patients were followed for a mean of 64 months (range 14 to 175 months) and received no other therapy before relapse. Over-all, 43 of these patients (35 per cent) had a positive biopsy result. The incidence of positive biopsy results correlated directly with the initial stage of the tumor, ranging from 22 per cent of stage B1N to 50 per cent of stage C1 lesions. However, biopsy results did not correlate with the grade of the tumor. Local recurrence and distant metastases were much more common among patients with a positive biopsy result (p equals 0.0006). Local recurrence developed in 58 per cent of the patients with a positive biopsy by 5 years and in 82 per cent by 10 years. Of those in whom all biopsies were negative only 18 per cent had local recurrence by 5 years and 32 per cent by 10 years. Biopsy results retained their prognostic significance even among the more favorable subset of patients whose pelvic lymph nodes were negative initially and those with a normal prostatic examination at biopsy. These results indicate that a post-irradiation prostate biopsy 6 to 36 months after completion of treatment can be used to determine the efficacy of a particular radiotherapeutic regimen as well as the success or failure of radiotherapy in an individual patient.

Characterization of steroid receptors in human prostate using mibolerone

Accurate quantitation of androgen receptors requires a radioactive ligand which has affinity and specificity for the receptor and which is stable to metabolic enzymes. In this report, we have characterized the properties of 7 alpha,17 alpha-dimethyl-17 beta-hydroxy-4-estren-3-one (mibolerone) in human benign hyperplastic prostate cytosol and compared them to those of 17 beta-hydroxy-17 alpha-methyl-estra-4,9,11-trien-3-one (R1881). Mibolerone was found to have an affinity (Kd = 1.5 nM) greater than R1881. (Kd = 2.3 nM) for the androgen receptor in human prostate tissue. Surprisingly, mibolerone was found to bind with high affinity to the progesterone receptor in both human prostate (Kd = 5.9 nM) and rabbit uterus (Kd = 1.1 nM). However, binding to this receptor in both species could be blocked with a 500-fold excess of triamcinolone acetonide. [3H]Mibolerone binding to the androgen receptor was competed effectively with unlabeled dihydrotestosterone, R1881, and mibolerone but not by progesterone, diethylstilbestrol or R5020, in the presence of triamcinolone acetonide. Interestingly, mibolerone was more resistant to metabolism than R1881 in prostate cytosol when exposed to elevated temperatures (30 degrees C) for extended periods of time. However, when exposed to high-intensity ultraviolet irradiation, both compounds lost 50% of their binding ability in about 30 minutes. Mibolerone was found to have a very low affinity (Ki = 540 nM) for human sex steroid binding protein. These studies demonstrate that mibolerone is a useful ligand for androgen receptor assays. They also emphasize the need for including competitors of progesterone receptor binding in assays utilizing this steroid for androgen receptor measurements.

Condyloma acuminatum of the bladder and associated urothelial malignancy

The extension of condylomata acuminata into the bladder is rare. Several reports have indicated an association of this disease with carcinoma of the penis and of the female genital tract. We report the first association of condyloma acuminatum with urothelial carcinoma in a man.

Transrectal ultrasonography for prostatic cancer: its value in staging and monitoring the response to radiotherapy and chemotherapy

Current methods to evaluate the size and local extent of prostatic cancer are imprecise. Quantitative assessments of changes after therapy are unreliable. We have used transrectal ultrasonography in 50 patients with clinically localized prostatic cancer to determine the value of this imaging technique in staging the local tumor and in monitoring the response of the tumor to therapy. Transverse images of the prostate were obtained at 5 mm. intervals, and were used to determine the size and shape of the prostate, irregularity or discontinuity of the capsule, extracapsular extension of tumor and invasion into the seminal vesicles. Ultrasonography proved highly accurate in staging. Among 18 previously untreated patients whose tumor appeared to be confined to the prostate by rectal examination 8 (44 per cent) had extension beyond the prostate by ultrasonography, which was confirmed by operative findings. Serial ultrasonograms were performed before and after definitive radiotherapy in 7 patients and chemotherapy in 6 patients. In response to therapy the prostate decreased in size and resumed a more normal, symmetrical shape, the capsule reformed and thickened, the degree of extracapsular extension diminished and the seminal vesicles became normal. Maximal reduction in the size of the prostate usually occurred by 9 months after radiotherapy and by 3 months after chemotherapy. In patients with prostatic cancer transrectal ultrasonography is highly accurate in staging and offers an objective monitor of the response to therapy.

Prostatic biopsy after irradiation therapy for prostatic cancer

To determine the prognostic significance of a routine needle biopsy of the prostate performed six to thirty-six months after the completion of definitive radiotherapy, biopsy results were analyzed in 146 patients who had no evidence of disease at the time of biopsy and who received no other therapy before proved recurrence of the tumor. Patients were followed up a mean of 3.9 years after radioactive gold seed implantation and external beam irradiation. The total dose was 8,000 rad. Among 146 patients, 56 (38%) had one or more positive biopsy results within this time interval. The positive biopsy rate correlated with the clinical stage ranging from 17 per cent in Stage B1N to 59 per cent in Stage C1. The risk of developing local recurrence or distant metastases at any given time after irradiation therapy was markedly greater in those patients with a positive biopsy result (p less than 0.0005). Prostatic biopsy is an accurate means of measuring the success of radiotherapy. A positive postirradiation biopsy result carries grave prognostic implications for the patient and indicates that the treatment has failed.

Physicochemical characterization of the androgen receptor from hyperplastic human prostate

In this manuscript we have characterized the androgen receptor from human benign prostatic hypertrophied (BPH) tissue. BPH tissue was obtained fresh from surgery, ground, and frozen in liquid nitrogen. Tissue was homogenized in 10 mM Tes buffer (pH 7.4 at 25 degrees C) containing 0.25 M sucrose, 20 mM Na2MoO4, 12 mM monothioglycerol, and 1.5 mM EDTA. Cytosol was labeled with (3H)-R1881 (0.5-10 nM) +/- a 100-fold excess of R1881 and a 500-fold excess of triamcinolone acetonide to identify specific androgen receptor sites. An exchange assay was developed, whereby maximum binding was achieved by raising the temperature to 30 degrees C for 15 min. A high-affinity binding protein was detected (Kd = 1.3 +/- 0.8 nM) which had a binding capacity of 15 +/- 7 fmol/mg protein. Binding was specific for androgens with the following Ki (nM) values: R1881 (0.09), dihydrotestosterone (6), testosterone (50), progesterone (92), estradiol (100), epitestosterone (860), and cortisol (greater than 1,000). Under high ionic conditions the sedimentation coefficient of the receptor was 4.1 S. Higher S values were not observed in the presence of the following protein inhibitors: leupeptin (20 or 150 microM), iodoacetamide (10 mM), DFP (5 mM), PMSF (1 mM), bacitracin (0.1 mM), antipain (0.1 mM), aprotinin (1 TIU/ml). Gel filtration analysis revealed a Stokes radius of 6.5 nm. These data indicate a Mr of 120,000 and a f/fo of 2.01. The receptor eluted from a chromatofocusing column at a pH of 6.8. The receptor bound to phosphocellulose and DNA cellulose after being heat-treated for 15 min at 30 degrees C. These results suggest that BPH tissue contains an androgen receptor which is similar to receptors in other androgen-responsive tissues.

The addition of chemotherapy to hormonal therapy for treatment of patients with metastatic carcinoma of the prostate

Patients with advanced prostate carcinoma that had been stabilized by orchiectomy (ORCH) or hormone therapy for at least 3 months, were randomized to either diethylstilbestrol (DES) alone or DES plus Cytoxan or DES plus Emcyt. A total of 188 patients were randomized between July, 1976 and February, 1982 of which 161 were evaluable for objective response to treatment. Objective response rates, response duration, or survival experiences were not demonstrably different between treatment arms, either for all patients or within good or poor prognosis groups determined by initial pain or acid phosphatase level. Subjective improvements in performance status were small for each treatment. Pain relief was somewhat greater in the chemotherapy-hormone combinations than in the DES/ORCH, but the advantage was not statistically significant. Side effects were primarily nausea and vomiting and leukopenia, mostly in the DES + Cytoxan arm. The duration of stabilization prior to entry did not influence response overall, although there were opposing trends within each of the two chemotherapy arms. The premise for combining antitumor agents with hormones before hormone failure is still felt to be a more logical approach than waiting for the ultimate hormone failure, and a combination of hormones plus two antitumor agents is being evaluated in a subsequent ongoing trial where a more rigid design limits the duration of the preentry period of hormone stabilization.

Thoracoabdominal retroperitoneal lymphadenectomy for nonseminomatous testicular cancer

Retroperitoneal lymphadenectomy remains a mainstay of the management of patients with nonseminomatous testicular cancer. The operation provides accurate information regarding stage and prognosis, which current preoperative staging studies cannot duplicate. The therapeutic value of lymphadenectomy has been demonstrated more clearly for testicular tumors than for any other cancer. Properly performed, the operation results in complete removal of all node-bearing tissue at significant risk of harboring metastases. Yet the morbidity and mortality are low in these young, generally vigorous patients. The only long-term sequela is loss of ejaculation. Efforts are currently underway to determine limits to the operation that will preserve ejaculation while maintaining the efficacy of the procedure.

Comparison of estramustine phosphate, methotrexate and cis-platinum in patients with advanced, hormone refractory prostate cancer

In this clinical trial of men with advanced prostatic cancer no longer responsive to hormone therapy 189 were randomized to receive estramustine phosphate, methotrexate or cis-platinum. Response evaluations were done in 158 cases. Objective response rates (complete, partial or stabilization of disease) were 34 per cent for estramustine phosphate, 36 per cent for cis-platinum and 41 per cent for methotrexate. Subjective parameters indicated a substantial advantage for pain improvement with methotrexate or cis-platinum over estramustine phosphate. Probabilities of continued response indicated some advantage for methotrexate and median response durations at this time were twice as long for methotrexate (32 weeks) as for cis-platinum (16 weeks), with estramustine phosphate intermediate (23 weeks). Survival rates for the original treatment randomization groups were not different at this time. Side effects of estramustine phosphate consisted primarily of nausea and vomiting and/or anorexia but to a lesser extent than with cis-platinum. These effects were somewhat less for methotrexate, for which the major side effects were stomatitis and leukopenia, as well as hepatic toxicity reflected by elevated serum glutamic oxaloacetic transaminase levels. Other side effects of cis-platinum were less than for methotrexate (no stomatitis), except for signs of renal toxicity (elevations in blood urea nitrogen and serum creatinine), which were greater. Methotrexate had a relatively high level of activity against metastatic, progressive, hormone nonresponsive prostatic cancer, with side effects that were substantial but manageable.

Human chorionic gonadotropin detected in urinary concentrates from patients with malignant tumors of the testis, prostate, bladder, ureter and kidney

Human chorionic gonadotropin levels in concentrated 24-hour urine and serum were determined by a specific radioimmunoassay of beta-human chorionic gonadotropin in 47 patients with genitourinary carcinoma. Elevated human chorionic gonadotropin levels in urine were observed in 6 of 8 patients with active testicular tumor, 3 of 14 with prostatic cancer, 2 of 10 with bladder cancer, 1 of 2 with ureteral or renal pelvic tumors and 2 of 6 with renal cancer. Of the 14 patients with positive urinary human chorionic gonadotropin 4 had undetectable human chorionic gonadotropin levels in the serum. The tumors of all 8 patients with nontesticular cancer who had increased urinary human chorionic gonadotropin levels were in an advanced clinical stage or of poor histological differentiation. Our results suggest that some nontrophoblastic carcinomas of the genitourinary system are capable of ectopic production of human chorionic gonadotropin, particularly if the malignancy is advanced or poorly differentiated. The radioimmunoassay of beta-human chorionic gonadotropin in concentrated 24-hour urine specimens enhances the sensitivity of detection of ectopic human chorionic gonadotropin production.

A comparison of estramustine phosphate versus cis-platinum alone versus estramustine phosphate plus cis-platinum in patients with advanced hormone refractory prostate cancer who had had extensive irradiation to the pelvis or lumbosacral area

Single and combination chemotherapy was compared in a clinical trial for men with advanced, metastatic prostate cancer who had received prior pelvic irradiation and had had progression of disease despite hormonal therapy. The 149 patients were randomized to receive estramustine phosphate or cis-platinum alone or in combination. Of the 149 patients 25 (17 per cent) were excluded from the study but 124 were evaluated for response and survival. Entry variables were distributed similarly among patients in each treatment arm. There were no complete or partial responders but there were nearly twice as many patients whose disease was stabilized (33 per cent) on the combination regimen compared to estramustine phosphate (18 per cent) and about a third more than for cis-platinum (21 per cent). Analysis of survival revealed some advantage for patients on combination therapy. Major toxicities for all treatments were nausea and vomiting (62 to 88 per cent) and accompanying anorexia (72 to 95 per cent). Azotemia developed in 45 per cent of the patients receiving combination therapy. In addition an elevation in serum creatinine occurred in 22 per cent of the patients receiving combination therapy and in 17 per cent of those receiving cis-platinum alone. Myelosuppression occurred infrequently.

The significance of lymph nodal involvement in renal angiomyolipoma

Renal angiomyolipoma, a benign tumor, can involve regional lymph nodes. Although this phenomenon has been reported previously followup information has been scant. We have treated 3 patients who had renal angiomyolipoma with nodal involvement and all had further evidence of tuberous sclerosis. Each patient had hematuria with flank pain and required nephrectomy. In the ensuing 3 to 11 years none of these patients has had evidence of further disease progression. Nodal involvement may reflect the multicentricity of angiomyolipoma or may represent a form of "benign metastasis" but it does not appear to be a harbinger of disease progression.

Surgical correction of scrotal transposition and perineal hypospadias

A unique surgical technique for simultaneous repair of incomplete scrotal transposition, chordee and perineal hypospadias is presented. A skin bridge left in continuity with pubic skin and penile shaft is deemed essential to ensure adequate vascularity.

Serum alpha-fetoprotein and human chorionic gonadotropin in patients with seminoma

We analyzed the case histories of 31 patients who initially had a diagnosis of seminoma and elevated serum levels of alpha-fetoprotein or human chorionic gonadotropin. We concluded that an elevated alpha-fetoprotein level is firm evidence of the presence of non-seminomatous germ cell tumor and that the patient should be treated accordingly. However, if the level of human chorionic gonadotropin alone is elevated the diagnosis may be either non-seminomatous tumor or seminoma. Patients with seminoma and an elevated level of human chorionic gonadotropin do respond well to radiation therapy if they have low stage disease but if metastatic seminoma is present an elevated human chorionic gonadotropin level appears to be a poor prognostic sign if conventional treatment is given. A plan of treatment is proposed for these patients.

Vesicovaginal and ureterovaginal fistulas: a summary of 25 years of experience

The difficult problem of a vesicovaginal fistula originally was cured surgically by Sims in 1849. During the last 25 years at UCLA and affiliated hospitals 68 patients have been treated by urologic surgeons for fistulas between the vagina and the urinary tract: 21 ureterovaginal and 47 vesicovaginal and urethrovaginal fistulas. The ureterovaginal fistulas often were complex and patients presented the most challenging diagnostic problem. However, they usually were repaired successfully by simple ureteroneocystostomy. Vesicovaginal and urethrovaginal fistulas were repaired transvaginally in 24 cases, with 70 per cent success at the first attempt and 92 per cent success with 2 attempts. Transabdominal or combined approaches were less successful. Only 58 per cent of the cases were closed at first attempt. The transvaginal approach required less operating time, and resulted in less blood loss and shorter hospital stays than the transabdominal approach and will be described in detail.

Relevance of biochemical tumor markers and lymphadenectomy in management of non-seminomatous testis tumors: current perspective

Radioimmunoassay determinations of the biochemical tumor markers, alpha-fetoprotein or human chorionic gonadotropin, revealed elevated serum levels in 94 per cent of the patients with advanced disease. No falsely positive values have been observed. The markers are useful in monitoring the response to therapy and, when persistently elevated after therapy, indicate the presence of residual malignant tumor, usually embryonal carcinoma. However, they have a more limited role in the management and followup of the great majority of new patients with non-seminomatous germ cell tumors of the testis (stages A and B) owing to a falsely negative incidence of 38 per cent in patients found to have retroperitoneal metastases at lymphadenectomy. Furthermore, marker levels obtained during chemotherapy, even in the presence of residual tumor, frequently are normal. Thus, they have a limited role in the early detection of residual disease in patients treated systematically with prophylactic chemotherapy. A meticulous retroperitoneal lymphadenectomy remains the single most important factor in dictating the use of adjuvant chemotherapy, the specific agent and the combination and duration of therapy. The prophylactic use of actinomycin D in stage A and the early aggressive use of vinblastine sulfate and bleomycin in stage B2 have reduced the incidence of recurrence substantially. A prospective plan of management used in 95 consecutive patients since 1974 has resulted in survival free of tumor of 100 per cent for patients with stage A disease, 91 per cent for stage B and 61 per cent for stage C.