Stage C adenocarcinoma of the prostate. An analysis of 551 patients treated with external beam radiation

Prognostic factors in prostate cancer. Analysis of 874 patients treated with radiation therapy

BACKGROUND

The outcome of radiation therapy for localized prostate cancer depends on many pretreatment variables that are interrelated in complex ways. A multivariate analysis of 874 cases of prostate cancer treated between 1966 and 1988 was conducted. The median length of the follow-up period after radiation therapy was 6.7 years.

METHODS

The disease outcome and rate of survival was analyzed with the proportional hazards model for patients with stage A2 (104), stage B (168), or stage C (602) prostate cancer treated with radiation therapy as the only primary treatment.

RESULTS

Local recurrence rates were 12%, 24%, and 33% at 5, 10, and 15 years, respectively. In multivariate analysis, stage (A2 vs. B+C) and pathologic grade (1 + 2 vs 3 + 4) were independently related to local recurrence. At 10 years local control had been achieved in 79% of favorable cases (stage A2 or stage B/C, grade 1), but in only 62% of unfavorable cases (stage B/C, grade 4). Metastatic relapse rates were 25%, 38%, and 47% at 5, 10, and 15 years, respectively. Factors that independently correlated with metastasis were high pathologic grade, transurethral resection in stage C, elevated acid phosphatase levels, and being 60 years of age or younger. A favorable group of cases (stage A2/B, grade 1 or stage C, grade 1, no transurethral resection, older than 60 years of age) had a metastatic rate of only 10% after 10 years, whereas an unfavorable group (largely stage C, grades 3/4) had a metastatic rate approaching 70%. The overall survival rate was 77%, 49%, and 32% at 5, 10, and 15 years, respectively. Pathologic grade (1 vs 2 + 3 vs 4) and transurethral resection in stage C correlated with survival. A favorable group of patients (stage A2/B or stage C and grade 1) had a normal survival expectation of 15 years. An unfavorable group consisting of grade 4 tumors had a survival rate of less than 20% at 10 years.

CONCLUSIONS

The complexity and long natural history of prostate cancer demand careful stratification and follow-up examination to evaluate treatment results. The study of adjuvants to improve the local effectiveness of radiation and to mitigate the high metastatic rates in unfavorable local disease are urgent priorities.

The fall and rise of prostate-specific antigen. Kinetics of serum prostate-specific antigen levels after radiation therapy for prostate cancer

BACKGROUND

The serum kinetics of prostate-specific antigen (PSA) after radiation therapy for prostate cancer are not well characterized, and the potential prognostic significance of serum half-lives and of serum doubling times is unclear. This study was designed to address those issues.

METHODS

One hundred fifty-four patients with at least four serial PSA determinations who received external-beam radiation therapy alone were analyzed to determine PSA kinetics and to correlate kinetic parameters with outcome. Nonlinear regression techniques were used to estimate PSA half-lives and doubling times.

RESULTS

The PSA data fitted well to exponential models consistent with the hypothesis that PSA kinetics after radiation follow first-order (exponential) kinetics. The mean PSA half-life was 1.9 months (range, 0.5 to 9.2 months). No significant correlation existed between half-life and grade, stage, acid phosphatase level, serum testosterone level, or patient age. A weak correlation between half-life and pretreatment PSA level was observed: patients with low PSA levels tended to have longer half-lives. Half-life did not correlate with disease relapse or with the likelihood of developing a rising PSA profile. PSA doubling time in 37 patients with rising values ranged from 1.6 to 53 months (mean, 12.5 months). Doubling times were significantly longer than half-lives by an average factor of 6.5 and there was no correlation between half-life and subsequent doubling time. Doubling times were longer in low-grade tumors.

CONCLUSIONS

Serum kinetics of PSA in particular its rate of fall after radiation provide little, if any, useful clinical information. It is possible that serum kinetics of PSA are related to tumor cell kinetics but such relationships remain speculative. Correlative cell kinetic--PSA kinetic studies are needed to elucidate the mechanisms underlying the changes in PSA level after radiation therapy.

Prostate-specific antigen. An important marker for prostate cancer treated by external beam radiation therapy

BACKGROUND

Prostate-specific antigen (PSA) is a valuable serum marker for prostate cancer. However, the prognostic importance of baseline PSA values in relation to other prognostic factors has not been elucidated. The incidence of postradiation rising PSA values has not been documented, and the extent to which PSA influences the assessment of radiation therapy is unclear. This study was designed to address these issues.

METHODS

Three hundred and fourteen consecutive patients with baseline PSA values who were treated between 1987 and 1991 with external beam radiation alone were reviewed for disease outcome and posttreatment PSA levels.

RESULTS

Clinical stages at diagnosis were: Stage A2, 87 (28%); Stage B, 108 (34%); and Stage C, 119 (38%). At a mean follow-up of 21 months, 25 patients had relapsed, 53 had developed rising PSA profiles, and 58 had either relapsed or had rising PSA profiles. The actuarial relapse rate was 20% at 4 years, the incidence of rising PSA profiles was 38% at 4 years, and the incidence of either relapse or rising PSA was 40% at 4 years. In multivariate analysis, baseline PSA value was the single most important factor predicting for local relapse, metastatic relapse, any disease relapse, and posttreatment rising PSA values. Using relapse or rising PSA as endpoints, the following four prognostic groupings based on baseline PSA and M.D. Anderson (MDA) grade were delineated: I, PSA less than or equal to 4 ng/ml, any grade; II, PSA greater than 4 but less than or equal to 10 ng/ml, Grades 1 and 2; III, PSA greater than 4 but less than or equal to 10 ng/ml, Grades 3 and 4 or PSA greater than 10 but less than or equal to 30 ng/ml, Grades 1 and 2; and IV, PSA greater than 10 but less than or equal to 30 ng/ml, Grades 3 and 4 or PSA greater than 30 ng/ml, any grade. The actuarial incidence of relapse or rising PSA in these groups was: I, less than 10% at 3 years; II, 20% at 3 years; III, 55% at 3 years; and IV, 90% at 30 months. When using traditional endpoints of disease outcome, the patients in this series had an outcome equivalent to that in 799 patients treated in our institution in the pre-PSA era; when using rising PSA profiles as endpoints, treatment was significantly less effective.

CONCLUSIONS

Pretreatment serum PSA level is the single most significant predictor of disease outcome after radiation therapy for local-regional prostate cancer. Moreover, postirradiation PSA values may potentially serve as an early endpoint to evaluate treatment efficacy. Using a rising posttreatment PSA profile as an index of treatment failure reveals that total and permanent eradication of prostate cancer with radiation therapy alone is not achieved as often as previously believed and that multimodal treatment approaches to prognostically unfavorable early stage disease need investigation.

Preliminary results of a hyperfractionated dose escalation study for locally advanced adenocarcinoma of the prostate

The objective of this study was to build on our experience with 3-D conformal radiotherapy (CRT) by using a hyperfractionated dose escalation scheme to maximize the therapeutic ratio between improved local control and reduced morbidity in patients with locally advanced prostate cancer. Twenty patients with locally advanced (T3, T4) adenocarcinoma of the prostate were treated with a hyperfractionated radiotherapy schedule. All fields were designed with a conformal therapy based beam's eye view, 3-D planning system. The pelvic lymph nodes received 1.8 Gy/day to a total dose of 45 Gy in 5 weeks. Using partial transmission blocks, the prostate and periprostatic tissues received 1.3 Gy twice daily (minimum interval of 6 h) to a total dose of 78 Gy in 6 weeks. The dose was chosen by calculating the biologically effective dose (BED) which would produce the same effect in late reacting tissue but an increase for the tumor as our standard dose of 69 Gy delivered in 1.8-2.0 Gy fractions. The alpha/beta chosen for late damage was 3 Gy and 10 Gy was used for the tumor. All 20 patients completed the planned course of treatment. Although an increase in the tumor BED would be expected to result in increased acute effects, no significant worsening of acute side-effects was observed compared with standard treatment. All patients had only mild (Grade 1) rectal or bladder toxicity during treatment. One patient had an exacerbation of diverticulitis during treatment requiring hospitalization for antibiotics but completed treatment on schedule.(ABSTRACT TRUNCATED AT 250 WORDS)

Dedifferentiation of locally recurrent prostate cancer after radiation therapy. Evidence for tumor progression

BACKGROUND

Untreated or unsuccessfully treated prostatic adenocarcinoma may develop more malignant characteristics as time passes--the phenomenon of tumor progression. Whether this occurs after unsuccessful radiation therapy has not been answered. This study was designed to address that issue.

METHODS

The histologic grades at initial diagnosis and at local recurrence were compared in 49 patients who experienced local recurrence after external beam radiation therapy.

RESULTS

Tumor grades were assigned using the M. D. Anderson grading system. At the initial diagnosis, the grades were distributed as follows: Grade 1, 18 (37%), Grade 2, 22 (45%); Grade 3, 8 (16%); and Grade 4, 1 (2%). At recurrence, the grades were: Grade 1, 3 (6%); Grade 2, 14 (29%); Grade 3, 14 (29%); and Grade 4, 18 (37%). The shift to higher grades at recurrence was highly significant (P < 0.001). This dedifferentiation could not be accounted for by possible tissue sampling variability, and stepwise multiple variable logistic regression revealed that the only factor predicting for dedifferentiation was the time since treatment. The tumors that recurred later had a significantly higher likelihood to be dedifferentiated than those that recurred early. Patients whose tumors dedifferentiated had a poorer survival than those whose tumors retained their original grade.

CONCLUSIONS

The possibilities were considered that the dedifferentiation could arise by tissue sampling error, by persistence and regrowth of high-grade components, by the development of new tumors, or by radiation-induced transformation. None of these mechanisms appeared to explain the data adequately, and it was concluded that the observed dedifferentiation was indeed a manifestation of time-dependent tumor progression. Eradication of the primary tumor is therefore important, not only to allay local symptoms, but also to prevent the emergence of more virulent and potentially lethal tumors.

Effect of split-course radiotherapy on survival and local control in advanced localized prostatic carcinoma

PURPOSE

to analyze the effect of overall treatment time of radiotherapy on survival and local control in locally advanced prostatic cancer in a split-course treatment setting.

METHODS AND MATERIALS

168 patients with Stage C prostatic cancer treated during 1979-1989 by the split-course method where the overall treatment time is protracted. Treatment consisted of whole pelvis irradiation of 40 Gy in 4 weeks, followed by a planned 3-week interruption and an additional 26 Gy by the reduced field technique to a total dose of 66 Gy in 9 weeks and 30-33 fractions. The overall treatment time varied from 55 to 100 days. Thirty-eight percent (63) of the patients were treated primarily with radiotherapy, while the rest (105) had received androgen ablative therapy during 2 to 4.5 years before radiotherapy. To examine the effect of treatment time on local control, the patients were divided into three groups ( < or = 63 days, 64-70 days, and > 70 days) by treatment time.

RESULTS

the 5-year actuarial survival rates, calculated from the date of diagnosis, were 91% for the hormonally manipulated patients and 69% for the patients treated with radiotherapy alone. The 5-year actuarial local control rates, counted from the start of radiotherapy, were 84% for radiotherapy and 80% for the hormonally manipulated group. Overall, no significant effect of treatment time could be seen, either for radiotherapy alone or for the hormonally manipulated group. The results were similar when the material was further divided by T category and histologic grade.

CONCLUSIONS

no significant effect of overall treatment time (55 to 100 days) on survival or local control was found in either group. The survival time from diagnosis was longer in the hormonally pretreated group. Apparently, with adequate doses ( > or = 65 Gy) the overall treatment time becomes less important for local control of advanced prostatic cancer, even in a split-course treatment setting.

Residual disease after radical surgery or radiation therapy for prostate cancer. Clinical significance and therapeutic implications

Radical treatment for prostate cancer aims at complete eradication of tumor. This review of published data makes clear that the goal is less frequently achieved than commonly presumed. Following radical prostatectomy extracapsular disease, carrying a significant risk of local recurrence, is found from 12-68% of the time depending on the clinical tumor stage. Local regrowth is associated with a poorer prognosis. A substantial proportion of patients whose prostate glands are rebiopsied more than 18 months after radiation therapy also have residual tumor. This again predicts for clinical relapse. The likelihood of a positive rebiopsy is dependent on original tumor size and current prostate specific antigen (PSA) levels. Strategies for managing residual disease are critically discussed.

Sexual rehabilitation after treatment for prostate cancer

Although there is little evidence that sexual behavior causes prostate cancer, men with prostate cancer often have sexual dysfunction before the cancer diagnosis is made. Each treatment for prostate cancer increases the prevalence of sexual problems. After nerve-sparing radical prostatectomy, the chance of recovering erections is better for men who are younger and in whom both neurovascular bundles can be spared. Definitions of "potency" after nerve-sparing surgery have not specified the rigidity of the erections achieved. Thus, some men classified as "potent" may wish additional sexual rehabilitation. The chance that definitive radiation therapy will cause erectile dysfunction probably has been overestimated. The prevalence rate may be closer to 25% of men with new problems compared with the 50% often cited in the literature. Men are more at risk to have erection problems after radiation therapy if the quality of erections before treatment was borderline. Hormonal therapy has an impact on the central mechanisms mediating sexual desire and arousability. Therefore, with most treatment methods, only approximately 20% of men remain sexually functional. Newer antiandrogenic drugs interfere less with sexual function, but their long-term ability to control prostate cancer is still under investigation. Sexual rehabilitation should be addressed by the primary care team. Sexual partners should be included in brief sexual counseling, even when a mechanical treatment for erectile dysfunction is prescribed.

Long-term evaluation of radical prostatectomy as treatment for clinical stage C (T3) prostate cancer

We reviewed the results of radical prostatectomy in 232 patients with clinical Stage C prostate cancer for comparison with published results of irradiation for clinical Stage C patients. Twenty-two percent were Stage B pathologically (i.e., overstaged clinically); 36 percent were pathologic Stage C and 42 percent were Stage D1. Fifty-four percent had had adjuvant treatment immediately postoperatively. Mean follow-up was 4.9 years, with 86 and 32 patients under observation at five and ten years, respectively. Overall, cause-specific, disease-free, and local recurrence-free survival rates were 84 percent, 89 percent, 69 percent, and 90 percent, respectively, at five years, and 72 percent, 82 percent, 56 percent, and 82 percent, respectively, at ten years. Although adjuvant hormonal treatment affected progression significantly (P = 0.0069), it did not affect survival significantly. When the analysis of survival to a female prostate-specific antigen (PSA) level was combined with clinical disease-free survival to provide a more accurate measure of disease progression, 90 percent, 51 percent, and 38 percent of patients with clinical Stage C prostate cancer were free of disease at one, five, and ten years, respectively. The clinical data suggest that radical surgery often combined with immediate adjuvant therapy may provide better disease control (including PSA values) than primary radiotherapy.

The role of the urethrogram during simulation for localized prostate cancer

Urethrograms on 89 consecutive patients with localized prostate cancer were evaluated retrospectively, and the inferior border of the treatment field based on this study was compared with the inferior border that would have been defined by using the lower border of the ischial tuberosities. An analysis of the relationship between the margin used and the dose at the inferior border of the prostate supported our policy of requiring a 2 cm margin for optimal coverage of the prostate. Inclusion of at least 1 cm of proximal penile urethra was essential to ensure this 2 cm margin. Based on this assumption, twenty-five percent of patients would have had an inadequate margin if the lower border of the ischial tuberosities had been used instead of the urethrogram to define the inferior border of the treatment field. Assuming that a margin of more than 3 cm inferiorly is excessive, 11% of patients would have had excessive urethral irradiation if the bottom of the ischial tuberosities had been used to define the inferior border. Combining these two extremes, more than one in three patients would have had an inappropriate inferior margin if the bottom of the ischial tuberosities had been used to define the inferior border of the treatment field. There was no apparent increase in morbidity as a result of the urethrograms or an increase in treatment related toxicity in association with using the treatment fields defined by urethrography. Computed tomography was complimentary in defining the apex of the prostate. These data support the routine use of the urethrograms during simulation for localized prostate cancer. The use of the lower border of the ischial tuberosities to define the inferior border of the treatment field is associated with an unacceptable risk of either underdosing the apical portion of the prostate or overdosing the urethra.

Management of stage C adenocarcinoma of the prostate

A review of numerous clinical series dealing with the treatment of patients with clinical stage C prostate cancer failed to find the treatment or a combination of treatments that is superior to any other. Accurate staging, which was difficult in older studies, and stage migration, which complicates the comparison of recent to older studies, may contribute to this lack of identification. The majority of patients ultimately experience disease progression and are therefore treated with hormonal therapy, the use of which obscures survival data for initial modes of treatment. These observations point to the need for control of randomised clinical trials to identify effective treatments in the future.

Prostate cancer treated by radiotherapy: a multivariate study

According to respective proportions of evolutive status groups, results of multivariate studies are difficult to interpret. Among the 1099 cases of local form of prostate cancer, treated by radiotherapy from 1975 to 1982 in 16 French Anticancer Institutes, we can observe two homogeneous status groups of patients: disease-free survivors (285 cases) and patients who died of prostate cancer (278 cases). These correspond to 51% of the whole population. Among other things, they are comparable in size, for age at the beginning of radiotherapy and for delay between histologic diagnostic and radiotherapy. We chose to analyse them using multivariate analysis. To take survival into account, we used a Cox model and Kaplan-Meier curves; the group deceased of prostate cancer was further analyzed by a tree-structured regression method. The Cox model and the Kaplan-Meier curves confirmed two main explicative factors: Stage (p < 0.0001) and tumor grade (p < 0.001). Poorer evolution occurs in extracapsular forms and grade I has better survival than others. The tree-structured regression method indicates two other pejorative factors: hormonotherapy prior to radiotherapy and the presence of cardiovascular pathology. Though the pelvic dose does not appear to be a main explicative factor, it seems to improve survival and delay between radiotherapy and recurrence or metastasis in some categories of cases. Other factors such as tumor dose, age and delay between diagnosis and radiotherapy were not found to be significant. These results cannot be extended to the whole population for which they do not constitute a predictive study. We consider them as "baseline data".(ABSTRACT TRUNCATED AT 250 WORDS)

Prostate-specific antigen as a prognostic factor for prostate cancer treated by external beam radiotherapy

The potential prognostic significance of prostate-specific antigen (PSA) serum concentrations was evaluated in 171 patients with stages A2 to C adenocarcinoma of the prostate treated with external beam radiotherapy. After a median follow-up of 17 months, 12 patients sustained relapse of disease and PSA levels were found to be prognostically significant in three ways. (a) Pretreatment PSA level: none of 59 patients with a pretreatment PSA level less than or equal to 4 ng/ml relapsed to date and only one developed a subsequently rising PSA profile; 7 of 102 patients (7%) with a pretreatment PSA level in the range 4-40 ng/ml relapsed and 17 (17%) showed a rising PSA profile; 5 of 10 patients (50%) with a pretreatment PSA level greater than or equal to 40 ng/ml relapsed and six (60%) developed rising PSA values. The differences were significant and were maintained when patients were stratified by stage or grade. (b) PSA level at 6 months: for patients with pretreatment PSA levels in the range 4-40 ng/ml, a 6-month value greater than 2 ng/ml predicted a significantly worse outcome than a 6-month value less than 2 ng/ml. (c) Rising post-treatment PSA values: following a radiation-related nadir in PSA levels, 24 patients experienced rising PSA values and 8 (33%) relapsed at a median time of 5 months after onset of the rising values--a significantly higher relapse rate than observed in patients with non-rising PSA values. Whether the majority, or all, of the patients with rising PSA levels relapse, requires further follow-up. In conclusion, serum PSA levels are strong prognostic determinants of outcome following radiotherapy for prostate cancer and appear to add prognostic information independently of tumor stage and grade.

Phase I/II study of external radio frequency phased array hyperthermia and external beam radiotherapy in the treatment of prostate cancer: technique and results of intraprostatic temperature measurements

As part of an ongoing Phase I/II study at Duke University Medical Center investigating the toxicity and efficacy of external beam radiotherapy plus hyperthermia for deep-seated, locally advanced or recurrent solid tumors, 12 patients with prostate malignancies (adenocarcinoma--11, leiomyosarcoma--1) were treated with radiotherapy plus hyperthermia. Hyperthermia was given after radiotherapy using a Radio Frequency Phase/Amplitude Control Sigma 60 annular phased array device. All patients had simultaneous temperature measurements made in the rectal lumen and within the prostate during at least one hyperthermia session. Intraprostate thermometers were placed via a unique method described herein using both computerized tomography scan and a rigid sigmoidoscope for guidance. We were able to achieve the desired tumor temperature of > or = 42.5 degrees C in only 1/28 (3.5%) of hyperthermia treatments. Subjective symptoms of pain and/or pressure limited power deposition in 79% of hyperthermia treatments. Higher temperatures were achieved in the distal rectum than in the prostate in all treatments, although the differences were not statistically significant. This temperature differential could not be compensated by using phase and amplitude steering. Rectal temperatures adjacent to the prostate were predictive of prostate temperatures. We conclude that using this regional heating technique we were unable to demonstrate an ability to get an advantageous temperature differential between the prostate and normal tissue. This technique is not useful as an adjuvant to radiation therapy for prostate cancer. The usefulness of other regional heating techniques and devices should be explored.

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.

The influence of local control on metastatic dissemination of prostate cancer treated by external beam megavoltage radiation therapy

The influence of local control on metastatic dissemination was analyzed in 601 patients with clinically staged A2 to C prostate cancer treated by high-energy external beam radiation therapy who did not undergo hormonal manipulation before disease progression. Median follow-up for surviving patients was 7.7 years. Ninety-three patients had locally recurrent disease. The actuarial incidence of metastases in these patients (70% at 13 years) was significantly higher than in the 508 patients without local failure (40% at 13 years, P less than 0.001). High stage, high grade, prior transurethral resection, elevated acid phosphatase, disease fixation to the pelvic sidewall, and failure to perform a baseline bone scan correlated positively with the occurrence of metastases. However, except for a slight excess of Stage C, none of the metastatic predictors were more common in patients who failed locally than in those who did not. The Stage C preponderance does not account for the difference in incidence of metastases between the two groups, in as much as metastases were significantly more common in Stage C when disease recurred locally than when it did not. Thus, local control of prostate cancer does decrease the likelihood of metastatic disease. Moreover, patients with local control experienced a significantly better disease-specific survival than patients who failed locally.

Complications following external beam radiation therapy for prostate cancer: an analysis of patients treated with and without staging pelvic lymphadenectomy

We reviewed the treatment morbidity associated with definitive high energy external beam radiotherapy in 289 consecutive patients with clinically localized prostate cancer (stages A2 to C) treated from 1984 to 1988 inclusively. All patients were treated with 18 mv. photon beams via a 4-field box technique. Radiation doses ranged from 5,858 to 6,900 cGy., with a mean dose of 6,456 cGy. and a median dose of 6,400 cGy. A total of 65 patients underwent extraperitoneal pelvic staging lymphadenectomy before radiotherapy. Complications noted in 42 patients were mild (generally trivial) in 23 and moderate in 19 (6.6%). There were no severe complications. The actuarial incidence of moderate complications was 9% at 5 years. Only 6 patients experienced symptoms for longer than 6 months. The risk of complications was not increased in patients who had undergone prior lymph node dissection, and only 2 of 65 had mild lymphedema, which resolved in both cases. We conclude that high energy external beam radiation for prostate cancer can be delivered with a low risk of serious complications, even in patients who have undergone extraperitoneal staging pelvic lymphadenectomy, provided the patients are treated to limited fields with high energy photons and at doses limited to 6,800 cGy. or less.

Transurethral resection of prostate prior to definitive irradiation for prostate cancer. Lack of correlation with treatment outcome

From 1970 through 1983, 107 patients with newly diagnosed adenocarcinoma of the prostate were treated with radiotherapy with curative intent at Duke University Medical Center. Forty-five patients (42%) underwent transurethral resection of the prostate (TURP) for diagnostic and/or therapeutic purposes prior to beginning radiotherapy. Sixty-one patients (57%) were diagnosed by needle biopsy. TURP and needle biopsy groups were comparable (age, elevated acid phosphatase, early [A2, B] and late [C, D1] disease stages, and follow-up). TURP patients were more likely to have poorly differentiated tumors and were more often given concurrent hormonal therapy. Both univariate and multivariate analyses to study the effect of TURP on patients with prostate cancer treated with radiotherapy were done. We were unable to demonstrate any adverse impact of TURP on the outcome of radiation therapy for prostate cancer. This issue remains controversial and should be addressed in a prospective, randomized trial.

Prostate specific antigen in patients with clinical stage C prostate cancer: relation to lymph node status and grade

The preoperatively drawn sera from 84 previously untreated patients who had clinical stage C prostate cancer and underwent staging pelvic lymph node dissections were sent for monoclonal Hybritech analysis to assess the usefulness of prostate specific antigen (PSA) in predicting lymph node status. Of the 84 patients 47 (56%) had positive lymph nodes at surgery. The median PSA value for all patients with nodal metastases was 11.4 ng/.ml., and for those without it was 11.2 ng./ml. Relative to Gleason score, median PSA values were 11.35 for 2-4, 12.2 for 5-7 and 10.9 ng./ml. for 8-10. Within each M.D. Anderson grade median PSA values were 10.15 for grade I, 13.2 for grade II, 12.7 for grade III and 10.5 ng./ml. for grade IV. Simultaneously drawn preoperative frozen serum samples for 28 of these patients were independently analyzed by the Yang radioimmunoassay. Comparing Hybritech and Yang methods revealed strong statistical co-association (correlation coefficient R2 = 97.36, p less than 0.00001) but neither assay was statistically associated with nodal metastasis. Although no PSA level excluded the presence of nodal disease, we suggest that a Hybritech PSA of greater than 30 ng./ml. and a Yang PSA of greater than 50 ng./ml. may serve as a weak adjunctive marker predicting nodal metastasis.

Results of radiotherapy for localised prostatic carcinoma treated at the Prince of Wales Hospital, Sydney

Between 1980 and 1986 a total of 218 patients with localised prostatic carcinoma received radical pelvic radiotherapy at The Prince of Wales Hospital, Sydney. The mean follow-up time was 4.6 years. The five-year actuarial overall survival rate was 63% (death from all causes) and the five-year cancer-specific survival rate was 73% (death from or with prostate cancer). The overall survival was significantly worse with more advanced clinical stage of the disease (P = 0.003) and with poor histological differentiation of the tumour (P = 0.001). The five-year actuarial rate for local control of tumour in the pelvis was 84%. Late treatment-related complications (occurring or persisting beyond six months) were mild or moderate and the majority settled with conservative management. Only five patients experienced severe complications (necessitating surgical treatment). Of 42 patients with normal potency documented before radiotherapy who were not subsequently hormonally manipulated 23 (55%) retained potency at two years. These results for definitive radiotherapy for localised prostatic carcinoma indicate good local control with minimal morbidity and compare favourably with other published results.

Prostate-specific antigen and external beam radiation therapy in prostate cancer

This study of 133 patients with localized prostate cancer (Stages A2 to C), treated by external beam radiation therapy (XRT), was undertaken for two reasons: (1) to investigate the usefulness of pretreatment serum prostate-specific antigen (PSA) levels in evaluating patients before XRT; and (2) to investigate post-XRT changes in PSA values and their likely clinical significance. It was found that pretreatment PSA values in patients with localized disease exhibit wide patient to patient variability with a greater than 100-fold difference between the lowest and highest values. Although mean PSA values were significantly higher in Stage C disease (51 patients; mean PSA, 17.3 ng/ml) than in Stage A2 disease (31 patients; mean PSA, 9.0 ng/ml), Stage B1 disease (23 patients; mean PSA, 9.1 ng/ml), or Stage B2 disease (28 patients; mean PSA, 10.6 ng/ml), individual values were of virtually no help in assigning individual patients to a clinical stage. PSA levels did not correlate with grade. After XRT, PSA values fell significantly and dramatically in virtually all patients (98%) by 3 months follow-up. Mean PSA fell from 12.5 to 2.6 ng/ml, and median PSA fell from 6.6 to 1.9 ng/ml. In most patients, PSA continued to fall up to 12 months after XRT and then stabilized at 21 months. Although PSA values fell dramatically after XRT, PSA was detectable in the serum of all patients. PSA values tended to transiently and mildly elevate during XRT. In a small proportion of patients, rising PSA values were observed after 6 months. The full significance of this requires further follow-up, of four such patients, one has relapsed. PSA is a more sensitive marker of prostatic radiation than prostatic acid phosphatase.

Radiotherapy or surgery for prostate cancer? Ten and fifteen-year results of external beam therapy

Ten and 15-year outcome results are reviewed that demonstrate the role of radiation therapy in the management of prostate cancer. Patients with favorable T2a (B1) cancers of unknown nodal status are shown to have equal 15-year survival whether treated with external beam radiation therapy or radical prostatectomy. Patients of unknown nodal status treated for T2b (stage B2) cancer with external beam radiation therapy show superior survival and disease-free survival when compared to results with radical prostatectomy. The role of radical prostatectomy in these patients is unproven. Patients with lymph node dissection negative clinical stages T1b (A2) and T2 (B) treated with external beam radiation therapy exceed their expected survival at 10 years (65% vs 60%), and 70% are free of any failure at 10 years with the majority of failures due to metastasis, not local disease. Similar results are obtained in selected surgical centers with radical prostatectomy in highly selected patients. Patients with stage T3, 4 (stage C) prostate cancer show 10 and 15-year survivals that offer curative therapy and hope to patients with these locally advanced cancers. No long-term data support a role for radical prostatectomy in these patients.

The effect of overall treatment time on local control in patients with adenocarcinoma of the prostate treated with radiation therapy

Studies of patients treated with radiation therapy for squamous cell carcinoma of the head and neck have demonstrated that when all other variables are constant, protraction of the overall treatment time leads to a decreased probability of local control. Few data exist on the effect of overall treatment time on local control following irradiation of tumors that are generally thought to be slowly proliferating, such as adenocarcinoma of the prostate. This analysis was undertaken to determine the time-dose relationships for local control of prostatic adenocarcinoma at the University of Florida. All patients were treated at least 5 years prior to the date of analysis. For patients with Stage A2 disease, a tumor dose of 6500 cGy in 7 to 7.5 weeks to 7000 cGy in 8 weeks resulted in local control in 17/17 patients (100%). For patients with Stage B1 disease, the local control rate was 14/16 (88%) with an overall treatment time of less than or equal to 8 weeks versus 1/3 in patients who received split-course treatment in greater than 8 weeks (p = .097). For patients with Stage B2, C1, and C2 disease who received greater than or equal to 6500 cGy, the 5-year rate of local control was lower when overall treatment time was protracted beyond 8 weeks. Results were as follows: B2 (62 patients), less than or equal to 8 weeks, 88%, versus greater than 8 weeks, 55%, p = .002; C1 (87 patients), less than or equal to 8 weeks, 88%, versus greater than 8 weeks, 73%, p = .052; Cs (33 patients), less than or equal to 8 weeks, 81%, versus greater than 8 weeks, 65%, p = .056. Stratification by tumor grade of patients with Stage B1, B2, C1, and C2 disease who received greater than or equal to 6500 cGy demonstrated significantly lower local control rates for all grade categories when the overall treatment time was protracted beyond 8 weeks. Five-year local control rates (life-table method) for overall treatment time less than or equal to 8 weeks versus greater than 8 weeks were as follows: well differentiated, 93% versus 73% (p = .003); moderately differentiated, 86% versus 69% (p = .017); and poorly differentiated, 75% versus 59% (p = .046). These data suggest that tumor repopulation during excessively protracted treatment may be a clinically significant factor in patients with adenocarcinoma of the prostate.

Adenocarcinoma of the prostate treated with external-beam radiation therapy: 5-year minimum follow-up

This is a retrospective analysis of 225 patients with localized adenocarcinoma of the prostate who were treated with continuous-course external-beam radiation therapy at the University of Florida between October 1964 and August 1982. All patients were treated 5 or more years prior to the date of analysis, and 30% were eligible for 10-year follow-up. Hormonal treatment was used only in the management of recurrent disease. Ten-year results by stage were as follows: local control--A, 96%; B1, 92%; B2, 51%; C1, 57%; C2, 76%. Relapse-free survival--A, 96%; B1, 58%; B2, 38%; C1, 43%; C2, 61%. Absolute survival--A, 69%; B1, 29%; B2, 47%; C1, 35%; C2, 50%. Freedom from distant metastasis--A, 100%; B1, 55%; B2, 71%; C1, 65%; C2, 77%. Tumor grade was an important prognostic variable in most of the subgroups analyzed. The 5-year rate of distant metastasis was significantly greater in patients with stage C disease when the biopsy was made by transurethral resection of the prostate (TURP) rather than by needle biopsy. In stage B patients, the biopsy method was not prognostically important. For the 48 patients who developed recurrent tumor in the prostate gland, with or without concurrent metastasis, the 5-year absolute survival rate calculated from the date of recurrence was 26%, compared with 10% for the 34 patients who developed distant metastasis alone. Severe complications developed in 5 out of 225 patients (2%) and included three severe rectal injuries, one bladder neck contracture, and one femoral head necrosis. Moderate complications developed in 48 out of 225 patients (21%), with rectosigmoiditis (8%) and hematuria (5%) being the most common problems. For both moderate and severe complications, there was a clear trend toward an increasing complication rate with increasing dose. The method of diagnosis appeared to be a factor in the development of urinary incontinence following irradiation: needle biopsy, 0/106 (0%); TURP, 3/112 (3%); subtotal prostatectomy, 1/7 (needle biopsy versus TURP or prostatectomy, p = 0.076). The frequency of peripheral edema following irradiation was influenced by a history of surgical disruption of the pelvic lymphatics: staging lymphadenectomy, 2/16 (13%), versus no lymphadenectomy, 0/209 (p = 0.005). A comparison with other series is presented.

Pelvic lymphadenectomy for staging clinically localized prostate cancer. Indications, complications, and results in 217 cases

We reviewed the findings of 217 consecutive pelvic lymphadenectomies performed in patients with clinically localized prostatic carcinoma focusing particular attention on the importance of completely removing the hypogastric lymph nodes and on the operative complications associated with a more extensive dissection. Metastatic disease was identified in the lymph nodes of 127 patients (58.6%). The hypogastric nodes were involved in two thirds of the patients with lymph node metastases, and in 29 percent the hypogastric nodes were the only site of metastasis. No increased operative morbidity was documented as a result of extending the level of the pelvic lymphadenectomy to include the lower hypogastric nodes. We conclude that although the lower hypogastric lymph nodes have not been routinely included in most pelvic lymphadenectomies, their removal is important in detecting metastases.

Bowel complications after radiotherapy for carcinoma of the prostate: the volume effect

Late radiation-induced bowel complications were studied in 218 patients treated for localized carcinoma of the prostate by radical radiotherapy at the Prince of Wales Hospital between 1980 and 1986. Mild to moderate toxicity was seen in 38 cases, and severe toxicity requiring surgery occurred in 3 patients. The total actuarial complication rate (by 5 years) for all grades was 24% and for severe complications was 1.8%. Significant patient-related risk factors were older age at the time of radiotherapy (p = 0.035) and a previous history of abdominal operations (p = 0.028). Among treatment-related risk factors only inclusion of the whole pelvis in the irradiated volume had a significant association with this complication (p = 0.015). The risk of bowel complications was not related to the total radiation dose or to the use of interstitial implants as employed in this series.

Radical radiotherapy in prostatic carcinoma

During the years 1978-1986 111 fairly elderly patients with prostatic carcinoma in clinical stages B, C, or D, and usually having tumours that were poorly differentiated, received radical radiotherapy to the prostate and bladder and to the adjacent lymph node regions. The side effects were comparable to those reported in the literature. During the follow-up 72% of the patients sooner or later (actuarial analysis) developed local recurrence or distant metastases. The projected survival rate at 8 years was 25%, and should be compared with the 65% expected for an age-matched Swedish male population. After 3 years the two survival curves became rather parallel, indicating a 'cure' rate of the order of 49%. There was a significant difference in survival between patients clinically judged to have only intracapsular carcinoma and those considered to have extracapsular carcinoma. The relatively modest survival figures in the present series reflect the malignant nature of poorly differentiated carcinoma of the prostate.

Adjuvant estrogen following radiation therapy for stage C adenocarcinoma of the prostate: long-term results of a prospective randomized study

Seventy-eight patients with clinical Stage C adenocarcinoma of the prostate were prospectively randomized to receive either radiation alone or radiation and adjuvant estrogen (diethylstilbestrol). No patient had received any prior definitive treatment for cancer. Forty patients were randomized to receive radiotherapy only and 38 patients to receive radiotherapy and estrogen. The median follow-up for all surviving patients was 14.5 years. Whether analyzed according to the original randomization or according to the treatment actually received, disease-free survival in the adjuvant estrogen group was strikingly and significantly higher than in the radiation-only group. At 5, 10, and 15 years patients receiving adjuvant estrogen had respective disease-free survival rates of 71%, 63%, and 63% compared with 49%, 43%, and 35% in patients having radiation only (p = 0.008). However, because of greater intercurrent disease-related mortality in patients receiving estrogen, there was no improvement in survival. This study suggests that a prospective randomized evaluation of early androgen deprivation with orchiectomy or with one of the nonestrogenic agents should be undertaken and that patients receiving early androgen deprivation should not be included in series reporting on the curative potential of radiation as a single modality.