Symptomatology of metastatic prostate cancer: prognostic significance

OBJECTIVE

To identify the various presenting symptoms in patients with metastatic prostate cancer, quantify the metastatic load for each symptom group and compare their case-specific survival.

PATIENTS AND METHODS

A prospective and consecutive series of 279 men with metastatic cancer of the prostate was analysed. Based on the symptom at presentation, six different groups were identified: bladder outflow obstruction, bone pain, anaemia, weight loss, paraplegia and alteration of bowel habit.

RESULTS

Significant variations were observed in their metastatic load (Kruskal-Wallis test, P = 0.0035) and in case-specific survival (log-rank test, P = 0.0038).

CONCLUSION

Bladder outflow obstruction, bone pain and anaemia not only dictate treatment selection but we provide evidence that each of these symptoms has considerable prognostic significance in patients with metastatic cancer of the prostate.

Cystometrography provides a previously unrecognized opportunity for successful management of urinary leaks after renal transplantation

We report 3 cases of urinary leakage occurring in male kidney transplant recipients within 6 weeks of renal transplantation. Voiding cystometrography showed that high voiding detrusor pressure was the contributing factor. Endoscopic bladder outlet surgery restored normal detrusor voiding pressure and led to spontaneous resolution of urinary leakage without recurrence in all cases.

Patterns of bone metastasis and their prognostic significance in patients with carcinoma of the prostate

The different patterns of bone metastasis, metastatic load and their prognostic significance were examined in a consecutive series of 169 men with prostatic cancer and bone metastasis at presentation. Patients with an isolated metastasis in the pelvis or dorsal vertebrae had a better prognosis than those whose metastases were either diffuse or involved more distal sites such as the skull or the sternum, although all of these patients were classified as having M1 disease. Bone metastasis involving an area equivalent to 1 vertebral body equalled a metastatic load of 2. Based on their total metastatic load, 3 prognostic groups were identified with significant differences in case-specific survival despite receiving the same hormonal treatment. When comparing the potential efficacy of various treatments one must stratify the metastatic load, which is a powerful prognostic indicator of the outcome in patients with metastatic carcinoma of the prostate.

Audit and its impact in the management of advanced prostatic cancer

From a prospective database of 614 consecutive men with newly diagnosed prostatic cancer an audit of outcome was studied in 169 men who presented with bone metastases and subsequently received hormonal manipulation in the form of monotherapy. The cohort was divided into 2 groups according to serum alkaline and acid phosphatase enzyme levels. Men with normal alkaline phosphatase levels (41.5%) had a better prognosis (median survival 38 months) than those with elevated levels at presentation (58.5%) (median survival 19 months). This difference was highly significant. A similar stratification on prostatic acid phosphatase levels did not yield any prognostic significance. With regard to cause-specific survival, serum alkaline phosphatase was an even more powerful prognosticator, with a median survival of 45 and 21 months for patients with normal and elevated levels respectively. Thus monotherapy is recommended for metastatic prostate cancer patients with normal serum alkaline phosphatase, but for those with elevated alkaline phosphatase the alternative avenues of treatment must be explored.

Evidence that red blood cell protein p55 may participate in the skeleton-membrane linkage that involves protein 4.1 and glycophorin C

Human erythrocyte p55 is a peripheral membrane protein that contains three distinct domains in its primary structure: an N-terminal domain, an SH3 motif, and a C-terminal guanylate kinase domain. We used naturally mutated red blood cells (RBCs) with primary genetic defects resulting in the absence of protein 4.1 (4.1[-] hereditary elliptocytosis) or glycophorin C (Leach elliptocytosis). The absence of either protein was associated with the absence of p55. On a stoichiometric basis, the reduction in glycophorin C (about 80%) was concomitant to the lack of p55 in RBCs devoid of protein 4.1. Similarly, the reduction of protein 4.1 (about 20%) was equivalent to the absence of p55 in RBCs devoid of glycophorin C. These correlations suggest that p55 is associated, in precise proportions, with the protein 4.1-glycophorin-C complex, linking the skeleton and the membrane. The protein 4.1-glycophorin-C cross-bridge is known to be critically important for the stability and mechanical properties of human RBC plasma membrane. Because isoforms of protein 4.1, glycophorin C, and p55 exist in many tissues, these results provide evidence of a linkage between the skeleton and the membrane that may have implications in many nonerythroid cells.

Audit and its impact in the management of early prostatic cancer

An analysis was made of a prospective database of 614 men with newly diagnosed carcinoma of the prostate who presented between January 1978 and December 1990; 3-monthly updates were available on their clinical, haematological and biochemical parameters and 6-monthly updates on chest X-rays, bone scans and skeletal X-rays. It was found that 107 men (mean age 73.5 years) had early disease at presentation. Their management was based on regular surveillance and the treatment deferred until disease progression or development of symptoms. The audit of outcome measured various clinical events. Four patients (3.7%) developed local failure, 11 (10.3%) developed bone metastases, 3 (2.8%) died of cancer with a median survival of 6.3 years, and 34 (31.8%) died of intercurrent disease with a median survival of 2.6 years. The observed survival for 12 years of the whole group was similar to the expected survival for an age-matched population in Scotland. The standardised mortality ratio was 81 (95% confidence limits 57-112).

Portable electrical stimulator for use in small animals

The detailed electronic configuration of a lightweight (7 g) battery-operated portable electrical stimulator unit is described. It has proven useful for the study of the effects of chronic stimulation on skeletal muscle in small animals (i.e., the rat). The unit requires wavelengths in the infrared region for activation. This allows for remote triggering of the stimulator and permits it to function reliably even when animals are housed in rooms illuminated by fluorescent lamps. Unique to the system is the inclusion of a visual indicator of unit function (light-emitting diode), thus providing a convenient means of monitoring unit activation. The stimulator unit described has proven to be highly reliable and very useful for the study of alterations in gene expression in muscle subject to chronic use (M. Takahashi and D. A. Hood, J. Appl. Physiol. 74: 934-941, 1993).

Is the outcome of conservative management for localized prostate cancer acceptable? An overview

The outcome of conservative management in a consecutive series of 107 localized prostate cancers (mean age 73.5 years) has been analyzed. Follow-up ranged from 1 to 12 years. Following regular surveillance and no initial treatment, 3 died from prostate cancer with a median survival of 6.3 years compared to 34 who died from intercurrent disease with a median survival of only 2.6 years. The observed survival for the whole group was similar to the expected survival for an age-matched population in Scotland. This was despite the fact that the nodal status and the capsular invasion were unknown.

Identification of metastatic disease by T category, gleason score and serum PSA level in patients with carcinoma of the prostate

Pre-operative serum prostate specific antigen (Tandem-R assay), T category, Gleason score and the metastatic (M1) status of a consecutive series of 60 patients with newly diagnosed carcinoma of the prostate were studied prospectively. The results revealed that, of these variables, pre-operative serum PSA (greater than 100 ng/ml) was the single most important indicator of metastatic disease, with 100% predictive value. With this alone, 83.3% of M1 disease could be correctly identified. For the remaining 17%, however, we advocate a high index of suspicion if the tumour is T3-T4 category on digital rectal examination (predictive value = 71.4%) and has a high grade with a Gleason score 8-10 (predictive value = 81%).