Cancer control following anatomical radical prostatectomy: an interim report

Characterization of single disseminated prostate cancer cells reveals tumor cell heterogeneity and identifies dormancy associated pathways

Cancer dormancy refers to the prolonged clinical disease-free time between removal of the primary tumor and recurrence, which is common in prostate cancer (PCa), breast cancer, esophageal cancer, and other cancers. PCa disseminated tumor cells (DTC) are detected in both patients with no evidence of disease (NED) and advanced disease (ADV). However, the molecular and cellular nature of DTC is unknown. We performed a first-in-field study of single DTC transcriptomic analyses in cancer patients to identify a molecular signature associated with cancer dormancy. We profiled eighty-five individual EpCAM⁺/CD45⁻ cells from the bone marrow of PCa patients with NED or ADV. We analyzed 44 DTC with high prostate-epithelial signatures, and eliminated 41 cells with high erythroid signatures and low prostate epithelial signatures. DTC were clustered into 3 groups: NED, ADV_1, and ADV_2, in which the ADV_1 group presented a distinct gene expression pattern associated with the p38 stress activated kinase pathway. Additionally, DTC from the NED group were enriched for a tumor dormancy signature associated with head and neck squamous carcinoma and breast cancer. This study provides the first clinical evidence of the p38 pathway as a potential biomarker for early recurrence and an attractive target for therapeutic intervention.

Prostatectomie périnéale

There is a lack of prospective randomised trials comparing the efficacy of the different techniques for treating localised prostate cancer. Consequently, selecting one rather than the other appears very difficult. Even radical prostatectomy is controversial regarding its best approach--perineal, retropubic or laparoscopic. The perineal route was the first to be undertaken, and it was dropped out due to the need of performing obturator lymphadenectomy by a separate approach. Widespread use of prostate-specific antigen as a screening method has enabled to diagnose prostate cancer at its early stages, when the potential for lymphatic dissemination is low, which enables to obviate Lymphadenectomy in most patients. This was a promoting circumstance to use the perineal route in radical prostatectomies. In this article we discuss the perineal radical prostatectomy surgical technique, its indications, and its advantages and disadvantages as compared to other approaches.

A preliminary report on a patient-preference study to compare treatment options in early prostate cancer

OBJECTIVE

To prospectively record prognostic factors, quality-of-life and outcome data in a patient-preference controlled study comparing radical prostatectomy with radical radiotherapy for the treatment of early prostate cancer.

PATIENTS AND METHODS

All patients suitable for radical treatment of early prostate cancer were identified and provided with information from a urologist, oncologist and nurse to allow them to choose a treatment option. Prognostic and demographic data were recorded for all patients and patients followed up uniformly, with the additional collection of quality-of-life data.

RESULTS

In a 38-month period, 196 patients were recruited to the trial; of these, 81 chose surgery, 81 radiotherapy, 30 brachytherapy and four 'watchful waiting'. The distribution of acknowledged prognostic factors was similar between the groups.

CONCLUSION

If patient preference continues to divide this population into roughly equal and comparable arms, it should be possible to answer the underlying questions on the treatment of early prostate cancer using this study design.

The role of radical prostatectomy in patients with pretreatment prostate-specific antigen > or = 40 ng/mL

OBJECTIVE

To assess the efficacy of radical prostatectomy (RP) in men presenting with markedly elevated prostate-specific antigen (PSA) levels, the records of 17 patients presenting with serum PSA values > or = 40 ng/mL, who underwent RP at Walter Reed Army Medical Center (WRAMC) between 1990 and 1995, were reviewed.

METHODS

Pathologic and clinical data (staging, Gleason score, recurrences, adjuvant and neo-adjuvant treatment, most recent PSA value, urinary continence, and sexual function) for each patient was examined. The Kaplan-Meier method was used to analyze the disease-free survival (DFS) for PSA and clinical recurrence. Urinary continence and potency were also assessed.

RESULTS

With a mean follow-up of 6.21 years (median 5.28 y), all 17 patients are alive. Five patients have no evidence of disease (NED), and 12 are alive with prostate cancer. Fifteen patients have PSA values between 0.1 and 3.0 ng/mL, and two patients have PSA values that have returned to pretreatment levels. Eleven patients received neo-adjuvant and/or adjuvant therapy. Fourteen men (82.3%) are continent and seven (41.1%) are potent. Survival analysis demonstrates a PSA DFS of 52.9% at five years and 26.5% at nine years; while, clinical DFS was 92.3% at five years and 58.0% at nine years.

CONCLUSIONS

This study suggests a possible surgical role in treating patients presenting with significantly elevated PSA values. While surgery alone is unlikely to cure prostate cancer in these patients, surgery in conjunction with hormonal or radiation therapy may prolong survival with acceptable effects on urinary continence and potency.

Long-term results of treatment for prostate carcinoma by staging pelvic lymph node dissection and definitive irradiation using low-dose rate temporary iridium-192 interstitial implant and external beam radiotherapy

BACKGROUND

The objective of this study was to evaluate long-term treatment outcome of definitive irradiation by using temporary interstitial implant and limited dose of external beam radiotherapy in treatment of localized prostate carcinoma.

METHODS

In total, 536 patients with biopsy-proven adenocarcinoma of the prostate, classification T1-T3, underwent staging pelvic lymph node dissection and brachytherapy delivering an average tumor dose of 30 grays (Gy), supplemented by external beam radiation therapy for an additional dose of 36 Gy delivered over 4 weeks. One hundred of 536 (18%) patients had pathologic D1 disease. A total of 181 patients had undergone transurethral prostatectomy before the treatment. Repeat prostate biopsy was performed on 132 patients 18 or more months after treatment. None of the patients received neoadjuvant or adjuvant hormone therapy.

RESULTS

Cumulative disease free survival (DFS) including biochemical DFS at 10 and 15 years for classification T1B,C was 78% and 72%; for T2A, 78% and 78%; for T2B,C, 68% and 66%; and for T3A-C, 45% and 45%, respectively. Cause specific survival for the entire group at 10 and 15 years was 89% and 87%, respectively. Severe complications occurred only in the early developmental phase of the study.

CONCLUSIONS

In univariate analysis, the clinical stage, histologic grade, pretreatment PSA level, lymph node status, and results of repeat posttreatment biopsy were all independently significant prognostic factors. However, the authors' study indicates that in multivariate analysis, only two factors emerged with statistical significance-the status of pelvic lymph nodes and the results of posttreatment biopsy. This signifies the importance of local tumor control to achieve ultimate cure and the importance of assessment of pelvic lymph nodes before definitive local therapy other than radical prostatectomy, especially in the high-risk group.

Local recurrence after radical prostatectomy: correlation of US features with prostatic fossa biopsy findings

PURPOSE

To evaluate the diagnostic accuracy of transrectal ultrasonography (US) in the detection of local recurrence following radical prostatectomy.

MATERIALS AND METHODS

Ninety-nine patients with biochemical recurrence after radical prostatectomy were evaluated at transrectal US and prostatic fossa biopsy. Location of suspected recurrence at transrectal US and clinical features, such as prostate-specific antigen levels and digital rectal examination findings, were correlated with biopsy results.

RESULTS

Forty-one (41%) of 99 cases of local recurrence were detected. The percentage of sites of lesions identified at transrectal US and corresponding positive biopsy rates were as follows: the urethrovesical anastomotic area, 56% and 61%; bladder neck, 26% and 54%; retrovesical space, 4% and 100%; and more than one site, 14% and 71%. By comparing transrectal US and digital rectal examination, the sensitivities were 76% and 44% (P =.007), while specificities were 67% and 91% (P =.004), respectively. An increased positive biopsy rate with increasing prostate-specific antigen levels was noted (P =.04).

CONCLUSION

Transrectal US is more sensitive but less specific than digital rectal examination in the detection of local recurrence. Biopsy findings in more than half of the suspected lesions at the urethrovesical anastomotic area and bladder neck were positive. Lesions in the retrovesical space, although less frequently encountered, had a high likelihood of representing cancer recurrence.

Needle biopsy of recurrent adenocarcinoma of the prostate after radical prostatectomy

The objective of this study was to evaluate needle biopsy of recurrent prostate cancer after radical prostatectomy. We evaluated 37 cases of recurrent prostate cancer after radical prostatectomy that were diagnosed by needle biopsy between March 1984 and July 1998. Fifteen were from consultations in which contributors were uncertain of the diagnosis, and 22 were from men who had come to The Johns Hopkins Hospital for treatment. The median interval from radical prostatectomy to biopsy showing recurrent tumor was 40 months. There was no correlation between the interval to recurrence and either pathologic features of the biopsy and radical prostatectomy or various clinical features. The mean extent of adenocarcinoma in the biopsies was 3.2 mm (range, 0.1 to 18 mm; median, 2 mm). The length of recurrent cancer on biopsy correlated with an abnormal rectal examination (P = .001). The mean Gleason score for the recurrent tumors was 6.5, which correlated with the grade of the radical prostatectomy cancer (P = .005). The cancers often lacked overt histologic features of malignancy. Benign prostatic acini were seen in five cases (14%), usually separate from the cancer. In 5 (33%) of the consultation cases, we would not have been able to diagnose cancer if not for the fact that atypical prostate glands should not be present after radical prostatectomy. In well-sampled radical prostatectomies, margins were almost always positive, as was extraprostatic extension. In cases with less sampling, there was a higher incidence of organ-confined disease and margin-negative disease implying suboptimal processing of the radical prostatectomy. After radical prostatectomy, recurrent cancer on needle biopsies may be focal and difficult to diagnose and must be assessed differently than in patients who have not had surgery.

Imaging for recurrent prostate cancer

Multiple imaging modalities are available to evaluate recurrent prostate cancer following primary treatment with RP, RT, or cryo-surgery. These tests must be used in close conjunction with clinical parameters, such as the characteristics of the tumor itself (grade, stage) as well as specific PSA characteristics that can help predict the sites of probable recurrence. Figure 19 represents an algorithm of how patients can be monitored for recurrence according to their mode of primary treatment. As more treatments become available for recurrent prostate cancer, it will be necessary to monitor disease response with many of the imaging modalities discussed in this article.

[Radical prostatectomy in prostate adenocarcinoma. Clinical factors influencing the pathological stage. Diagnostic model]

MATERIAL AND METHODS

Study on the efficacy of stage diagnosis, how to support it based on clinical objective data and description of a prognostic model. Analysis of 160 patients diagnosed with localized prostate adenocarcinoma undergoing radical prostatectomy in the Clínica Universitaria de Navarra between 1988-1997. The statistical study used Fisher's or Pearson's tests for the comparison of qualitative variables. A logistic regression multivariate analysis was run to avoid confounding factors in the pathological stage.

RESULTS

85/160 (53%) were correctly staged. Incorrect staging occurred in patients with higher clinical stage (T1-T2a: 25%; T2bc: 65%). The univariate study shows that the pathological stage is significantly correlated to: a) serum PSA levels (15 ng/mL in P2 vr. 25 ng/mL in P3-4), the most suitable cutoff value being 15 ng/mL. b) digital rectal examination and Gleason. Negatively influencing factors in the multivariate study were: PSA greater than 15 ng/mL, Gleason greater than 5 and a T2bc clinical stage. Risk groups: 4 risk groups are established based on the above factors (inclusion in group 1 involves an 8% risk of having P3, 30% in group 2, 56% in group 3 and 84% in group 4).

CONCLUSIONS

The clinical factors with influence in the pathological stage are PSA, Gleason and clinical stage. The reliability of the risk groups established based on these factors is remarkable.

The role of volume-weighted mean nuclear volume in predicting disease outcome in patients with prostate cancer treated with radical prostatectomy

BACKGROUND

Estimates of volume-weighted mean nuclear volume (MNV) are the only means by which unbiased estimates of three-dimensional parameters can be obtained from single two-dimensional sections without any assumptions. We have reported that for prostate cancer estimates of MNV are prognostically equal or superior to morphological grading of malignancy, such as Gleason score (GS), and in particular, that MNV proved to be a meaningful predictor of prognosis for patients with clinically localized tumors. However, all previous studies were conducted on patients treated conservatively, and no authors have tested whether estimates of MNV can predict the prognosis of patients treated with radical prostatectomy.

MATERIALS AND METHODS

A retrospective prognostic study of 52 patients with clinically localized prostate cancer diagnosed at three Hospitals in Shizuoka Prefecture, Japan (Shizuoka City Hospital, Shizuoka Prefectural Hospital and Shimada Municipal Hospital) and treated by radical prostatectomy was performed. Twenty of these patients were treated with hormone therapy before radical prostatectomy. Unbiased estimates of MNV were compared with clinical stage, histological grading according to GS and neo-adjuvant hormone therapy with regard to the prognostic value.

RESULTS

MNV was significantly correlated with pathological T stage, but was not significantly correlated with the presence or absence of lymph node metastasis. Univariate analysis revealed that MNV correlated significantly with progression-free survival (p = 0.0116). Multivariate analysis revealed that MNV (p = 0.0115) and GS (p = 0.0275) were two significant independent predictors of progression-free survival.

CONCLUSIONS

The results of the present study suggest that MNV and GS are powerful independent predictors of prognosis for prostate cancer treated with radical prostatectomy. We recommend estimates of MNV as a supportive method to the histological grading for patients with prostate cancer.

Have complication rates decreased after treatment for localized prostate cancer?

PURPOSE

The American Urological Association Prostate Cancer Clinical Guidelines Panel reviewed 12,501 publications on prostate cancer from 1955 to 1992 to determine whether the complication rates of external beam radiation therapy, interstitial radiotherapy and radical prostatectomy have decreased.

MATERIALS AND METHODS

Complications reported in at least 6 series, study duration and sample sizes were extracted. Year specific study weighted mean patient ages and complication rates were computed. Regression analysis was performed of the study year on weighted mean patient age and complication rate.

RESULTS

Study year had a significant effect on mean patient age and rate of the majority of complications examined. Data indicated a gradual increase in study patient age and a simultaneous decrease in complications from 1960 to 1990.

CONCLUSIONS

Complication rates in the treatment of localized prostate cancer have decreased during the last 20 to 40 years. This decrease occurred despite evidence that the average age of treated patients had increased during the same period.

The changing role of surgery in the diagnosis and treatment of cancer

Many changes have occurred in the surgical treatment of the cancer patient. For many tumors, surgery has been modified or eliminated. These changes are due to the realization that, for some cancers, more extensive surgical procedures are not more beneficial, to improvements in radiation therapy and chemotherapy, to the availability of better noninvasive or less invasive diagnostic and therapeutic techniques, and to improved surgical equipment (such as videoscopic surgery).

Use of imaging tests for staging newly diagnosed prostate cancer: trends from the CaPSURE database

PURPOSE

We describe secular trends in the use of imaging tests to stage prostate cancer, evaluate the impact of selected clinical factors on test use and compare physician actual use with recommendations in recently published literature.

MATERIALS AND METHODS

This retrospective nonrandomized analysis of a longitudinal disease registry enrolled 3,557 men diagnosed with prostate cancer between 1989 and 1997 at 29 urology practices throughout the United States. Using logistic regression the odds of performing pelvic computerized tomography (CT), pelvic magnetic resonance imaging (MRI), bone scan and excretory urogram were determined annually from 1989 to 1997. The frequency of test use was compared with recommendations from a recent urology literature synopsis.

RESULTS

Use of MRI, CT, bone scan and excretory urogram was unchanged from 1989 to 1997. Compared to recent findings in the clinical literature bone scan, CT and MRI were used too frequently in patients at low risk for metastatic disease.

CONCLUSIONS

Urologists may be overusing bone scan, CT and MRI to stage tumors in patients with a low risk of advanced prostate cancer. Further studies are needed to assess the relationship between individual staging strategies and clinical outcomes.

Phytoestrogens and diseases of the prostate gland

Both benign hyperplasia (BPH) and cancer of the prostate are manifest in men beyond the age of 50. Approximately 50% of men greater than 50 years of age will suffer from the symptoms associated with BPH, especially from bladder outlet obstruction. With the ever-increasing proportion of the population over 65 years of age worldwide, BPH is becoming an important medical problem as the world moves into the next millennium. Cancer of the prostate is the second most commonly diagnosed cancer after skin cancer in the male population of the United States, and the second most common cause of death from cancer after that of the lung. Overall, around the world the incidence of carcinoma of the prostate is increasing annually by 2-3%. Both race and geographical location have a profound influence of the prevalence of prostate cancer worldwide. Black men in the USA have the highest incidence, while the incidence is much lower in Asian men from China, Japan and Thailand. Although the prostate gland is androgen-dependent, it is now recognized that the biological actions of endocrine-related factors, such as androgens, oestrogens, glucocorticoids and certain dietary and environmental factors, are mediated within the gland by various growth regulatory factors. The growth regulatory factors such as epidermal growth factor (EGF), keratinocyte growth factors (KGF), fibroblast growth factors (FGFs) and insulin-like growth factors II and I are mitogenic and directly stimulate cell proliferation under the modulating influence of steroid hormones. Steroids are therefore essential but not directly responsible for cell proliferation. Certain plant compounds such as isoflavonoids, flavonoids and lignans have been proposed as cancer protective compounds in populations with low incidences of prostate diseases. In particular, soya contains the isoflavone genistein, a compound with many properties which could influence both endocrine and growth factor signalling pathways.

High-dose rate interstitial with external beam irradiation for localized prostate cancer--results of a prospective trial

PURPOSE

A prospective phase II trial was carried out to test the feasibility and effectiveness of a combined interstitial with external beam radiotherapy approach for localized prostate cancer.

MATERIALS AND METHODS

Between October 1992 and December 1994, 82 evaluable patients were treated. T2 and T3 tumours, according to the AJCC classification system of 1992, were found in 21 and 61 cases, respectively. The median follow-up was 24 months; three patients were lost during follow-up. All of the patients were pathologically proven to be node-negative by laparoscopic node dissection of the fossa obturatoria region. A dose of 9 Gy a week was prescribed during the first and second weeks of treatment (10 Gy each week from October 1992 to December 1993) interstitially with high-dose rate Iridium-192 brachytherapy to the prostate and tumour extension beyond the capsule. External beam four-field box irradiation was then given to the prostate to a dose of 45 Gy/25 fractions (40 Gy/20 fractions from October 1992 to December 1993).

RESULTS

Before starting treatment, a PSA value of > or =10 ng/ml was found in 64.6% (53/82) of patients with a median PSA of 14.0 ng/ml. The median PSA 3, 12 and 24 months after completion of therapy was 1.20, 0.78 and 0.70 ng/ml, respectively. The PSA value was < 1.0 ng/ ml in 52.9% of patients at 2 years. Negative punch biopsies 12 and 24 months after therapy were observed in 69.8% (44/63) and 73. 1% (38/ 52) of patients, respectively. A positive biopsy combined with a PSA value of > 1.0 ng/ml was considered as local failure. The local tumour control rate was 79.5% at 2 years. Acute side-effects were not increased relative to external beam irradiation alone. Severe side-effects were observed in three patients (two of the three patients had additional risk factors (colitis ulcerosa and diabetes mellitus)); they developed rectourethral fistulae requiring colostomy after biopsies from the anterior rectal wall.

CONCLUSION

The described method is feasible and well tolerable. The three complications observed were not caused by irradiation alone. Biopsies from the anterior rectal wall after definitive high-dose radiotherapy for prostate cancer have to be seen as obsolete. The rate of negative prostate biopsies of 73.1% after 24 months represents an encouraging result.

Long-term results of radiation therapy for prostate cancer recurrence following radical prostatectomy

PURPOSE

Following radical prostatectomy, radiation therapy may be beneficial in select patients with isolated local recurrence. Pathological stage, Gleason score and the timing of prostate specific antigen (PSA) elevation are useful in distinguishing men with local recurrence from those with distant metastases. We test the ability of these criteria to predict long-term suppression of PSA recurrence following post-prostatectomy radiation therapy.

MATERIALS AND METHODS

Of 1,699 men treated with radical prostatectomy from 1982 to 1995, 82 with an isolated PSA elevation or local recurrence following surgery underwent radiation therapy to the prostatic bed and were followed for at least 2 years. No patient had evidence of metastases at the time of radiation.

RESULTS

Of the men 17 (21%) had an undetectable PSA (less than 0.2 ng./ml.) for 2 or greater years following radiation. The 5-year actuarial PSA recurrence-free rate after radiation was 10%. PSA remained at undetectable levels for 2 or greater years in no patients with Gleason score 8 or greater (12 cases), positive seminal vesicles (12) or positive lymph nodes (3), and in only 1 of 16 men (6%) who had a PSA recurrence within 1 year of prostatectomy. As the interval to PSA recurrence increased, the likelihood of responding to radiotherapy increased to 44% if initial disease detection occurred 5 or more years after prostatectomy. There was no demonstrated advantage to radiating men with an isolated PSA elevation before a documented local recurrence.

CONCLUSIONS

Patients with Gleason score 8 or greater, positive seminal vesicles or lymph nodes, or a PSA recurrence within the first year following surgery rarely benefit from radiation therapy. As the interval to PSA recurrence increases, the likelihood of responding to radiation therapy increases substantially. These parameters are useful in the selection of patients with prostate cancer recurrences who are likely to benefit from radiation to the prostatic bed.

Brachytherapy for clinically localized prostate cancer: results at 7- and 8-year follow-up

In recent years, there has been a resurgence of interest in interstitial radiation as a cost-effective and efficient method of treating organ-confined prostate cancer. We describe our 7- and 8-year results with transperineal Iodine-125 and Palladium-103 implantation. A total of 551 consecutive patients were treated. Of these, 320/551 (58%) received implant alone (Group I), and 231/551 (42%)--considered higher risk patients--were also treated with a modest dose (45 Gy) of external beam irradiation (Group II). The median follow-up for Group I was 55 months, and for Group II, 60 months. At 7 years, the actuarial freedom from biochemical failure (prostate-specific antigen (PSA) < or = 1.0 ng/mL) was 80% in Group I patients, and, at 8 years, 65% in Group II patients. Morbidity was minimal if patients had not undergone prior transurethral prostate resections. The results indicate that interstitial radiation is a valid treatment for clinically localized prostate cancer.

Gold seed implantation in prostate brachytherapy

Interstitial brachytherapy for treatment of prostate cancer with radioactive gold--initially with liquid gold and later with seed technique--is based on an experience of more than four decades. With biopsy results approaching a 80% negative rate, and, at 5 years, a cancer specific survival of 100% for Stages A and B1, 90% for Stage B2, and 76% for Stage C, this form of treatment offers an effective and well-tolerated alternative mode of therapy for patients with localized prostate cancer.

Relation between aberrant alpha-catenin expression and loss of E-cadherin function in prostate cancer

It is now well documented that E-cadherin expression correlates inversely with tumor grade in various carcinomas including prostate cancer. We also demonstrated a statistically significant correlation between decreased E-cadherin expression and progression-free period in early stage patients treated by radical prostatectomy and decreased survival in patients with advanced stage disease. We now study the relationship between E cadherin and alpha-catenin expression, because in prostate cancer cell lines, mutational inactivation of the alpha-catenin gene can be the cause of the impaired E-cadherin function. Twenty patients treated by radical prostatectomy and 32 advanced stage patients were evaluated immunohistochemically for E-cadherin and alpha-catenin expression. The results were related to tumor grade and disease progression. Four patients in the radical prostatectomy group had aberrant E-cadherin and alpha-catenin expression and showed disease progression. The other 16 patients were free of progression and had normal E-cadherin and alpha-catenin expression. In the advanced stage group, 4 of 13 patients with normal E-cadherin staining showed aberrant alpha-catenin expression and 2 patients (50%) progressed, compared with only 22% progression in patients with both normal E-cadherin and alpha-catenin expression. The other 19 patients with aberrant E-cadherin and alpha-catenin staining had the poorest prognosis. Our results suggest that loss of alpha-catenin expression could be one of the mechanisms responsible for the loss of E-cadherin-mediated cell-cell adhesion in human prostate cancer and might in some cases provide prognostic information.

Comparison of serum prostate specific membrane antigen, prostate specific antigen, and free prostate specific antigen levels in radical prostatectomy patients

BACKGROUND

Higher preoperative prostate specific antigen (PSA) levels are associated with higher pathologic stage and grade in patients undergoing radical prostatectomy (RP). In earlier studies, serum prostate specific membrane antigen (PSMA) elevations were associated with clinical progression and hormone-refractory carcinoma. The goal of this study was to evaluate the serum markers PSMA, free PSA (FPSA), free:total PSA ratio (F:TPSA), and total PSA (PSA) in men undergoing RP.

METHODS

Serum was obtained from 63 patients undergoing RP for clinically localized (T1c, T2) prostate carcinoma. Serum PSA and FPSA were determined by Hybritech Tandem-E(R) and Tandem-R(R), respectively, and PSMA was determined by Western blot analysis. Serum values for these markers were compared with the pathologic stage, surgical margin status, Gleason sum, prostate size (as calculated via reconstruction and transrectal ultrasound), tumor size based on pathologic assessment of the whole mount, and World Health Organization (WHO) grade of the prostatectomy specimen. Markers were also compared against demographic information and the patients' age and race.

RESULTS

There was a weak correlation between serum PSA and positive surgical margins, higher Gleason sum, and WHO grade (P < 0.05). Receiver operating characteristic curve (ROC) analysis comparing sensitivity and specificity of the markers to positive and negative margins as well as seminal vesicle invasion demonstrated PSA and FPSA predictive ability for seminal vesicle invasion. The area under the curve for PSA and FPSA in this case was 0.7318 and 0.7432, respectively. There was also a weak correlation between the FPSA level and margins, with a low ROC area under the curve of 0.6789. The FPSA cannot distinguish the more advanced stage of disease. There was no significant correlation between F:TPSA and PSMA with regard to the study variables in predicting organ confinement. High PSMA levels only correlated with higher stage and were maximal in pT4a classified disease.

CONCLUSIONS

Higher PSA and FPSA levels are likely to be associated with more locally advanced disease. Total PSA was the best marker. However, the cutoff values necessary for significant accuracy between PSA and FPSA are not of clinical usefulness due to the lack of specificity and sensitivity of the markers at those cutoffs. F:TPSA and PSMA levels as currently measured are of limited value in discriminating more aggressive disease in patients with clinically localized CaP.

Microvessel density in core biopsies of prostatic adenocarcinoma: a stage predictor?

Microvessel density was recently reported to be an independent correlate of tumour stage in whole mount prostatectomy specimens. This prompted an investigation of whether the quantitation of tumour microvessels could also be reliably applied to prostatic core biopsies, as a presurgical determinant of local tumour extension. The study was performed on a series of 46 unselected patients with prostatic adenocarcinomas undergoing radical prostatectomy. Intratumoural microvasculature was highlighted immunohistochemically using an antibody against CD31 and subsequently evaluated at x 400 magnification in both biopsies and corresponding prostatectomies. The highest microvessel count was reported for each case. Ten cases (22 per cent) had to be excluded because of insufficient measurable tumour areas in core biopsies. The remaining 36 cases (16 pT2; 20 pT3) showed a high degree of correlation between microvessel density in biopsies and prostatectomies (P < 0.0001). Similarly, pre- and post-operatively determined microvascular counts correlated well with tumour stage (P < 0.0001). Furthermore, the median microvessel density in core biopsies and tumours, i.e., 34, distinguished well between organ-confined and organ-extending tumours (positive predictive value for pT3 tumours 94.4 per cent; sensitivity 85 per cent). These data indicate that the evaluation of microvessels in core biopsies, eventually combined with other parameters, could be a reliable method for the individual prediction of the post-surgical tumour stage of prostatic adenocarcinoma.

The indications, rationale, and results of neoadjuvant androgen deprivation in the treatment of prostatic cancer: Memorial Sloan-Kettering Cancer Center results

OBJECTIVES

The use of neoadjuvant chemotherapy prior to definitive surgery has been firmly established in other areas of oncology, most notably in the treatment to testis and Wilm's tumors. The use of neoadjuvant androgen deprivation therapy (ADT) in conjunction with radical prostatectomy remains a source of controversy. We have conducted phase II and phase III studies to assess the effects of 3 months of preoperative ADT (goserelin and flutamide) on the pathologic staging and postsurgery prostate-specific antigen (PSA) relapse rate. We also reviewed the data confirming the understaging of clinically localized prostatic cancer and the experimental data providing the conceptual support for ADT.

METHODS

We report the results of 141 patients, Stage T0-T0, in a Phase II study with concurrent, nonrandomized controls (N = 72) versus a treatment arm (N = 69) of men receiving 3 months of ADT with 3.6 mg goserelin for 28 days and 750 mg flutamide daily. We also report the interim results in 114 men participating in a prospective, randomized study of ADT versus surgery alone.

RESULTS

The 69 patients who received 3 months of goserelin and flutamide followed by radical prostatectomy had a pathologic organ-confined cancer rate of 74%, versus 48% in the control group who received no ADT prior to surgery. The margin-positive rate was 10% in the ADT group versus 33% in the control group. In an interim analysis of 114 patients (59 ADT, 55 control), the organ-confined and margin-positive rates were 73% and 17% in the ADT group versus 56% and 36% in the control arm, respectively. The PSA disease-free rate at a mean follow-up of 28.6 months (range 6.2 to 49.5 months) was 89% in the ADT-treated patients (N = 98) and 84% in the control patients (N = 96). There was no statistical difference demonstrated between the arms with respect to biochemical failure.

CONCLUSIONS

While the pathologic staging of tumors following ADT treatment was improved compared with surgical controls, to date the PSA disease-free survival rates are similar. Patients with residual extracapsular (P3) disease after ADT manifest an increased PSA failure rate compared with those with P3 tumors treated by surgery alone. This suggests that ADT may identify a subset of patients with aggressive tumors that may be candidates for additional therapeutic interventions even before PSA failure occurs.

Neoadjuvant androgen suppression with radiation in the management of locally advanced adenocarcinoma of the prostate: experimental and clinical results

Conventional radiotherapy has been a standard treatment for the management of locally advanced T2c-4 prostatic carcinoma for over 2 decades. The routine use of serum PSA in follow-up makes it clear that > 80% of these patients will show evidence of failure by 10 years. Rebiopsy of those with a rising PSA shows locally persistent disease in the majority of cases. Increasing the radiation dose applied to the prostate increases local control but at the risk of higher morbidity. Experimental data using the Shionogi tumor mouse model suggest a potential gain from neoadjuvant androgen suppression without any increase in normal tissue morbidity. Two randomized trials comparing neoadjuvant androgen suppression prior to radiation therapy with radiation alone in humans show considerable short-term gains in local control and disease-free survival but mature data are still awaited. It is currently unknown whether the positive interaction between radiation and androgen suppression is synergistic or simply additive.

New approaches to adjuvant therapy for patients with adverse histopathologic findings following radical prostatectomy

Some men affected with clinically localized prostate carcinoma suffer life-threatening recurrence, despite previous treatment with surgery or radiation therapy, underscoring the need for new, effective, systemic adjuvant treatment approaches. Recent molecular mechanism-based prostate cancer drug discovery efforts have identified several candidate targets for systemic prostate cancer adjuvant therapy; however, traditional cancer treatment development algorithms may not be appropriate for many of the new treatment strategies. To best exploit the clinical potential of these molecular treatment strategies, novel translational research strategies are required to support hypothesis-driven clinical research and development.

Assessing the variability of outcome for patients treated with localized prostate irradiation using different definitions of biochemical control

PURPOSE

Biochemical control using serial posttreatment serum prostate specific antigen (PSA) levels is being increasingly used to assess treatment efficacy for localized prostate cancer. However, no standardized definition of biochemical control has been established. We reviewed our experience treating patients with localized prostate cancer and applied three different commonly used definitions of biochemical control to determine if differences in therapeutic outcome would be observed.

METHODS AND MATERIALS

Between January 1987 and December 1991, 480 patients with clinically localized prostate cancer received external beam irradiation (RT) using localized prostate fields at William Beaumont Hospital. The median dose to the prostate was 66.6 Gy (range 58-70.4) using a four-field or arc technique. Pretreatment and posttreatment serum PSA levels were recorded. Over 86% (414 of 480) of patients had a pretreatment PSA level available. Three different definitions of biochemical control were used: (a) PSA nadir < 1 ng/ml within 1 year of treatment completion. After achieving nadir, if two consecutive increases of PSA were noted, the patient was scored a failure at the time of the first increase; (b) PSA nadir < 1.5 ng/ml within 1 year of treatment completion. After achieving nadir, if two consecutive increases of PSA were noted, the patient was scored a failure at the time of the first increase; (c) Posttreatment PSA nadir < 4 ng/ml without a time limit. Once the nadir was achieved, if it did not rise above normal the patient was considered to be biochemically controlled. Clinical local control was defined as no palpable prostate nodularity beyond 18 months, no new prostate nodularity, or a negative prostate biopsy.

RESULTS

Median follow-up was 48 months (range 3-112). Pretreatment PSA values were correlated with treatment outcome using the three definitions of biochemical control as well as clinical local control. Pretreatment PSA values were stratified into five groups (Group 1: PSA < 4; Group 2: PSA 4-10; Group 3: PSA 10-15; Group 4: PSA 15-20; and Group 5: PSA > 20), and 5-year actuarial rates of biochemical control were calculated using the three biochemical control and one clinical local control definitions. For Group 1, 5-year actuarial rates of biochemical control were 84%, 90%, 91%, and 96% for Definitions 1-3 and clinical local control, respectively. For Group 2, 5-year actuarial control rates were 45%, 54%, 74%, and 92% for the four definitions, respectively. For Group 3, 5-year actuarial control rates were 26%, 31%, 63%, and 100% for the four definitions, respectively. For Group 4, 5-year actuarial control rates were 24%, 24%, 50%, and 100% for the four definitions, respectively. Finally, for Group 5, 5-year actuarial control rates were 5%, 14%, 15%, and 89% for the four definitions, respectively. Depending on the definition used, statistically significant differences overall in outcome rates were observed. Differences between all four definitions for all pairwise comparisons ranged from 5 to 53% (p < 0.001).

CONCLUSION

When different definitions of biochemical control are used in assessing treatment outcome, significantly different rates of success are noted. Until a standardized definition of biochemical control is adopted, differences in treatment outcome cannot be meaningfully compared.

Prostate cancer. Who is best benefited by external beam radiation therapy?

The major indications for radical radiation therapy of prostate cancer for both early-stage and locally advanced disease are discussed. Important issues in the interpretation of long-term treatment series are reviewed. The outcomes of therapy are analyzed for both early-stage and locally advanced disease, including alternative therapeutic strategies. On the basis of this review of the literature, current treatment recommendations delineate patients most likely to benefit from radiation therapy as opposed to alternative therapeutic modalities.

Local recurrence after radical prostatectomy: characteristics in size, location, and relationship to prostate-specific antigen and surgical margins

OBJECTIVES

To define the sonographic characteristics of local cancer recurrence after radical prostatectomy.

METHODS

in 114 patients with an elevated prostate-specific antigen (PSA) and negative bone scan, 156 ultrasound-guided prostate fossa biopsies were carried out.

RESULTS

in 53.5%, biopsy proved local recurrence. More than one ultrasound-guided biopsy session was required to make the diagnosis in 33% of patients. Local recurrence was seen on ultrasound at the anastomotic site (66%), the bladder neck (16%), and posterior to the trigone (13%). in 5% of patients there was a normal-appearing anastomotic site. Transrectal ultrasound was greater than 90% sensitive in detecting local recurrence, but lacked specificity. Examination of the radical prostatectomy specimens in patients with local recurrence showed positive surgical margins in 66% and organ-confined disease in 20%.

CONCLUSIONS

Transrectal ultrasonography is a useful adjunct to PSA and digital rectal examination in the detection of local recurrences following radical prostatectomy.

Survival after radical retropubic prostatectomy of men with clinically localized high grade carcinoma of the prostate

BACKGROUND

This study was performed to evaluate the efficacy of radical prostatectomy for men with clinically localized, poorly differentiated (Gleason score > or = 7) prostate cancer and to characterize further the prognostic significance of traditional pathologic variables. The effectiveness of adjuvant radiotherapy was assessed in a subpopulation of men for whom the pathologic assessment suggested a high risk of persistent disease.

METHODS

Two hundred thirty-eight consecutive men, 74 of whom had clinically localized, poorly differentiated carcinoma, were followed for a median of 6.2 and 5.1 years, respectively. The disease specific outcomes were derived from a non-prostate specific antigen (PSA) screened population.

RESULTS

The 5-year disease specific survival (DSS) for 52 men with a clinically localized Gleason score of 7 and for 22 men with a Gleason score greater than or equal to 8 carcinoma was 92% and 79%, respectively. The 5-year likelihood of having an undetectable PSA level was 50% for those with a Gleason score of 7 and 38% for those with a Gleason score greater than or equal to 8. Gleason score was the most powerful pathologic predictor of disease progression and survival. Pathologic stage was significantly associated with disease progression for carcinomas with Gleason scores less than 7 but was found to be less predictive of progression for carcinomas with Gleason scores greater than or equal to 7. Adjuvant radiotherapy provided a significantly reduced risk of PSA-detectable progression (P = 0.02, relative risk = 0.56, 95% CI: 0.34, 0.92); however, radiotherapy had no significant impact on DSS.

CONCLUSIONS

Long term DSS is possible in a non-PSA screened series of men with poorly differentiated prostate cancer treated by radical prostatectomy. These results compare favorably with alternative treatment strategies, although they do illustrate a continued need to develop more effective adjuvant therapies for men with poorly differentiated prostate cancer.

Surgery with adjuvant irradiation in patients with pathologic stage C adenocarcinoma of the prostate

BACKGROUND

In recent years, the routine use of prostate-specific antigen (PSA) to detect cancer of the prostate (CaP) early has renewed the controversy regarding radiotherapy versus radical prostatectomy as the superior definitive treatment. Radiotherapy alone has been reported to result in a high incidence of local recurrence, whereas on the other hand surgical treatment has resulted in a high incidence of microscopic residual tumor. The purpose of this study was to review our treatment results with radical prostatectomy followed by planned courses of postoperative irradiation in patients with pathologic Stage (PS) C disease.

METHODS

From 1972 to 1989, 95 patients with CaP with PS C tumors were treated with radical prostatectomy and bilateral pelvic lymphadenectomy. Pathologic stage distribution was: C1 in 26 (27%), C2 in 37 (39%), and C3 in 32 (34%) patients. The median follow-up was 6 years. All 95 study patients received postoperative pelvic irradiation as the only adjuvant treatment. Radiotherapy treated volume included the prostatic fossa and its immediate vicinity. The RT dose ranged from 33 Gy to 61.8 Gy (median, 45 Gy).

RESULTS

The overall 5- and 10-year actuarial survival rates were 94% and 73%, respectively, with the 5 and 10 year disease specific survival of 98% and 91%, respectively. Clinical and/or prostate specific antigen recurrence was 31% at 5 years and 44% at 10 years. Prostate specific antigen elevation without clinical evidence of recurrent disease was recorded in 26 (27%) patients. Seminal vesicle involvement (C3) and high Gleason's score (8-10) were the most important factors predicting recurrence. Of the 95 patients treated, 2 had pelvic recurrence alone and 1 had local and distant metastatic disease. Radiotherapy was well tolerated with no clinically important morbidity.

CONCLUSION

Based on this experience, moderate dose adjuvant radiotherapy after radical prostatectomy in patients with PS C CaP is recommended.

The role of transrectal ultrasound-guided biopsy-based staging, preoperative serum prostate-specific antigen, and biopsy Gleason score in prediction of final pathologic diagnosis in prostate cancer

OBJECTIVES

To evaluate the role of ultra sound-guided systematic and lesion-directed biopsies, biopsy gleason score, preoperative serum prostate-specific antigen (PSA) as three objective and reproducible variables to provide a reliable combination in preoperative identification of risk of extraprostatic extension in patients with clinically localized prostate cancer.

METHODS

The case records of 813 patients who underwent radical prostatectomy for clinically localized prostate cancer were analyzed. All had multiple systematic biopsies, two to three from each lobe, in addition to lesion-directed biopsies. Additionally, biopsies were done on seminal vesicles (SVs), if abnormal. Based on biopsy results, patients were classified as having stage B1 (T2a-T2b) or B2 (T2c) disease, depending on whether biopsies from one or both lobes were positive and stage C (T3) if there was evidence of SV involvement by biopsy of biopsies from areas of extracapsular extension as seen on transrectal ultrasound (TRUS) were positive. Logistic regression analyses with log likelihood chi-square test was used to define the correlation between individual as well as combination of preoperative variables and pathologic stage.

RESULTS

On final pathologic examination, 473 (58%) patients had organ-confined disease, 188 (23%) had extracapsular extension (ECE), with or without positive surgical margins, and 72 (9%) had SV involvement. Eighty (10%) patients had pelvic lymph node metastases. Biopsy-based staging was superior to clinical staging in predicting final pathologic diagnosis. Logistic regression analyses revealed that the combination of biopsy-based stage, preoperative serum PSA, and biopsy Gleason score provided the best prediction of final pathologic stage. Probability plots constructed with these data can provide significant information on risk of extraprostatic extension in individual patients.

CONCLUSIONS

This study demonstrates that TRUS-guided systematic biopsy in combination with preoperative serum PSA and biopsy Gleason score may provide a cost-effective approach for management decisions and prognostication in patients with prostate cancer.

Transrectal ultrasound-guided transperineal cryoablation in the treatment of prostate carcinoma: preliminary results

PURPOSE

We studied ultrasound-guided percutaneous cryoablation for treatment of prostate carcinoma.

MATERIALS AND METHODS

Our series includes 83 individuals who underwent transrectal ultrasound-guided transperineal percutaneous cryoablation of the prostate. Prostate specific antigen levels, biopsy results and complications were assessed at 3 months.

RESULTS

Of 61 biopsies 8 (13.1%) were positive for carcinoma (half showed stage D disease). Of patients with stages T1 to T3 cancer 92.6% were free of disease at 3 months. Prostate specific antigen levels were significantly decreased by an average of 1.90 ng./ml. (p < 0.05). Major complications were infrequent, including bladder perforation in 1 patient, urethral strictures in 3, bladder outlet obstruction in 2 and partial incontinence in 2. Impotence was frequent but transient.

CONCLUSIONS

Transrectal ultrasound-guided transperineal percutaneous cryoablation of the prostate produces few major complications and appears at 3 months to be effective in eradicating local prostate tumors. Longer followup is required to test the original hypothesis.

Serum prostate-specific antigen and the biologic progression of prostate cancer

OBJECTIVES

We have previously shown that serum prostate-specific antigen (PSA) is proportional to prostate cancer volume and that progression of prostate cancer is proportional to volume, but other investigators have not found serum PSA to be as useful in predicting pathologic stage at the time of radical prostatectomy. Because our series is the only study to examine prospectively all radical specimens at 3-mm intervals, we have examined the relationship between serum PSA and the morphologic indicators of cancer progression in our first 350 radical prostatectomies.

METHODS

Preoperative serum PSA level was tabulated in 350 consecutive patients with prostate adenocarcinoma and compared with morphologic variables in the radical prostatectomy specimen. Morphologic variables included cancer volume, histologic grade, capsular penetration, seminal vesicle invasion, and lymph node metastasis.

RESULTS

Serum PSA showed strong correlation with all morphologic variables, which were highly intercorrelated. Serum PSA level was strongly correlated with cancer volume, histologic grade, and frequency of regional spread to lymph nodes. Close intercorrelations found between all variables were translated into a scale relating each level of serum PSA elevation to stage of disease in morphologic terms. Using this scale, serum PSA level can contribute to patient evaluation and treatment decisions in men with prostate cancer.

CONCLUSIONS

Serum PSA is primarily determined by prostate cancer volume and secondarily by the percentage of high-grade cancer (Gleason grades 4 and 5) in the prostate. Because of this basic relationship, serum levels of PSA provide a clinically useful estimate of morphologic findings in the prostate. Serial PSA determinations should reflect the growth of the cancer as well as the gradual evolution of more malignant cells with the passage of time. The use of a serum PSA-based rating scale can contribute to patient evaluation and treatment decisions in men with prostate cancer.

Morbidity and mortality following radical prostatectomy: a national analysis of Civilian Health and Medical Program of the Uniformed Services beneficiaries

Recent evidence from an analysis of Medicare patients undergoing radical prostatectomy has suggested that perioperative mortality may be substantially greater than that reported in institutional series. To estimate the perioperative mortality and survival of patients of a younger and potentially more representative population of the United States, Civilian Health and Medical Program of the Uniformed Services institutional claims data from October 1, 1987 to January 1, 1993 were analyzed. A total of 1,059 subjects was examined of an average of 60.0 years and all were younger than 65 years. Using Kaplan-Meier estimates, mortality rates following surgery were calculated to be 0.28% at 30 days, 0.28% at 90 days, 1.02% at 1 year, 1.95% at 2 years, 3.14% at 3 years and 4.64% at 4 years. Observed 1 to 5 mortality rates in this series ranged from 0.362 to 0.487 of the expected mortality when compared to the general population and they were statistically significant. At 30 and 90 days postoperatively 3.1% and 4.6% of the patients were rehospitalized. Data demonstrated that mortality and morbidity from radical prostatectomy were low and that conclusions drawn on outcomes of treatment for carcinoma of the prostate should focus on the entire age range of patients who undergo this procedure in the United States.