Prognostic factors in localized prostatic carcinoma

The translational landscape of mTOR signalling steers cancer initiation and metastasis

The mammalian target of rapamycin (mTOR) kinase is a master regulator of protein synthesis that couples nutrient sensing to cell growth and cancer. However, the downstream translationally regulated nodes of gene expression that may direct cancer development are poorly characterized. Using ribosome profiling, we uncover specialized translation of the prostate cancer genome by oncogenic mTOR signalling, revealing a remarkably specific repertoire of genes involved in cell proliferation, metabolism and invasion. We extend these findings by functionally characterizing a class of translationally controlled pro-invasion messenger RNAs that we show direct prostate cancer invasion and metastasis downstream of oncogenic mTOR signalling. Furthermore, we develop a clinically relevant ATP site inhibitor of mTOR, INK128, which reprograms this gene expression signature with therapeutic benefit for prostate cancer metastasis, for which there is presently no cure. Together, these findings extend our understanding of how the 'cancerous' translation machinery steers specific cancer cell behaviours, including metastasis, and may be therapeutically targeted.

Radical prostatectomy: Long-term cancer control and recovery of sexual and urinary function (“trifecta”)

Radical prostatectomy (RP) disrupts the natural history of prostate cancer. However, it could be a significant source of long-term incontinence and potency morbidity. We studied the long-term cancer survival results and the probabilities of achieving ideal "trifecta" outcomes (cancer control, continence, and potency) after this surgical procedure. A total of 1746 intervention-naive patients with clinically localized newly diagnosed prostate cancer underwent RP with curative intent beginning in 1983. The mean follow-up time was 6 years (interquartile range, 3-9). The successive probabilities of achieving ideal trifecta outcomes for up to 24 months following RP versus experiencing biochemical recurrence were estimated using the cumulative incidence method. Additionally, long-term cancer control was assessed by preoperative and postoperative factors. Surgical excision controlled prostate cancer effectively in 1441 (83%) of the 1746 patients studied. At 5, 10, and 15 years, respectively, 82%, 77%, and 75% of patients were free from disease progression. Cancer-specific survival was 99%, 95% and 89%, respectively, at 5, 10, and 15 years. In men with disease progression, the 15-year probabilities of death from prostate cancer versus other causes were similar (32% and 33%, respectively). At 24 months, 60% of patients were potent, continent, and free of cancer, and 12% had experienced recurrence. Use of RP provided excellent long-term cancer control. At 15 years, only 11% of patients had died of prostate cancer. Cancer control was good even for patients with adverse prognostic features. The probability of death from cancer was similar to other causes after disease progression. By 2 years, 60% of men were continent, potent, and cancer free.

Pharmacotherapy for biochemical recurrences after therapy for localised prostate cancer

Prostate-specific antigen (PSA) has revolutionised screening for and monitoring of prostate cancer (CaP). Currently, most men failing potentially curative CaP therapies develop biochemical evidence of recurrent disease (defined by detectable PSA levels) long before the onset of clinical symptoms. Androgen deprivation therapy (ADT) remains the gold standard for the treatment of metastatic CaP. Conventional ADT is orchiectomy or luteinising hormone-releasing hormone agonists. ADT is most commonly associated with side effects such as erectile dysfunction, decreased libido, gynecomastia and osteoporosis. Intermittent ADT or oral anti-androgens may limit the side effects associated with ADT while retaining efficacy. Although widely studied, the optimal timing to begin ADT remains an important and unanswered question. Future advances in gene therapy and immunotherapy hold the greatest promise to provide effective treatments against recurrent CaP while minimising morbidity.

Repetitive and site-specific molecular staging of prostate cancer using nested reverse transcriptase polymerase chain reaction for prostate specific antigen and prostate specific membrane antigen

We performed repetitive molecular staging using, nested rt-PCR for PSA and PSM at the peripheral blood (PB) and bone marrow (BM) of patients with prostate cancer (Pr.Ca) and benign prostate hyperplasia (BPH) after transrectal ultrasonography-guided biopsy (TRUS-B; 6-9 biopsies/patient), Pr.Ca patients after radical prostatectomy (RP), and Pr.Ca patients with diffuse bony metastases. All BPH patients (N = 20) tested negative at BM. Of the 2 who tested positive at PB 2 weeks after TRUS-B tested negative 8 weeks after TRUS-B. Of the 17 Pr.Ca, 7 (41.2%) tested positive at PB for PSA and PSM 2 weeks after TRUS-B while only 4 (23.5%) of them tested positive at repetitive analysis 8 weeks after TRUS-B. Two (11.8%) of the 17 Pr.Ca patients had positive analysis at BM for PSA and PSM 2 and 8 weeks after TRUS-B. Of 12 Pr.Ca patients with negative pre-operative molecular staging, 7 (58.3%) tested positive at PB for PSA and PSM 2 months post-RP but only 3 (25%) of them re-tested positive 12 months post-RP. Of these 12 Pr.Ca, 4 (33.3%) tested positive at BM for PSA and PSM 2 months post-RP while none re-tested positive 12 months post-RP. All Pr.Ca (N = 20) with diffuse bony lesions tested positive at BM. At PB, 6 of them (30%) tested negative for both PSA and PSM. Our data suggest that nested rt-PCR for PSA and PSM at PB is affected by TRUS-B and RP, while such analysis at BM concerted diffuse bony disease.

DNA ploidy and survival of patients with clinically localized prostate cancer treated without intent to cure

BACKGROUND

The optimal approach to diagnosis and treatment of localized prostate cancer remains controversial. Deoxyribonucleic acid (DNA) ploidy has been suggested as an important predictor for outcome in prostate cancer. The purpose of this study was to correlate DNA ploidy with disease-specific survival in patients with clinically localized prostate cancer treated with no intent to cure.

METHODS

DNA ploidy was determined by flow cytometry in archival formalin fixed, paraffin embedded tumor tissue obtained at diagnosis in 120 patients with clinically localized prostate cancer with a nearly complete follow-up.

RESULTS

Ninety (75%) of the tumors were diploid, while only 11 (9%) tumors were categorized as tetraploid. Tumor DNA ploidy (diploid versus nondiploid) significantly associated with histopathological grade (P=0.002) and disease-specific survival (P=0.011), while there was no association with tumor stage (P=0.054). In a multivariate Cox analysis, histopathological grade (P=0.005) was the only significant predictor of disease-specific death, while analyzing the 96 low-grade tumors separately, DNA ploidy became significant (P= 0.024).

CONCLUSIONS

Flow cytometric determined nondiploidy was associated with disease-specific death in patients with clinically localized prostate cancer, but DNA ploidy provided additional prognostic information in patients with low-grade tumors only.

Correlation of prostate needle biopsy and radical prostatectomy Gleason grade in academic and community settings

Prior studies have not analyzed grading patterns and accuracy in nonacademic sites and have not analyzed reasons for discrepant grades. We analyzed 499 radical prostatectomy (RP) specimens at The Johns Hopkins Hospital (JHH) from 1994 and compared them with the corresponding JHH needle biopsy Gleason grade and, when available (n = 390), to the outside institution (non-JHH) Gleason biopsy grade. For JHH, there was exact agreement between biopsy and RP in 58% and agreement to within one digit in 93% of cases, compared with 34% and 67%, respectively, for non-JHH. Combining cases into more meaningful groups (Gleason 2-4, 5-6, 7, and 8-10), there was 66% exact correlation between the biopsy and RP for JHH as compared with 45% for non-JHH. Non-JHH undergraded biopsy results more than JHH, with 22.3% and 1.2% Gleason score 2-4, respectively. None of the cases with a Gleason score of 2-4 on biopsy from JHH or non-JHH were Gleason score 2-4 on RP. Fifty-five percent of the tumors with non-JHH needle biopsy results graded Gleason 2-4 had either capsular penetration, seminal vesicle, or lymph node involvement. All of the tumors with needle Gleason score 2-4 at JHH were organ confined. The JHH needle biopsy grade correlated better with pathologic stage than did non-JHH (R = 0.27 JHH vs. R = 0.12 non-JHH). Extent of cancer in the biopsy sample was not a factor in the accuracy of predicting RP grade or stage. Eighty-two cases evaluated at JHH were signed out by a genitourinary pathologist; the grading of the biopsy samples by other JHH pathologists was just as accurate. Gleason score of > or = 7 on the biopsy sample predicted a Gleason score of > or = 7 in the RP 87.5% of the time. A Gleason score of < 7 predicted a Gleason score of < 7 only 63.9% of the time. Discordant grades in some cases reflected patterns of cancer on needle biopsy that were borderline between two different Gleason scores. Sampling was the major source of discrepancy and was often due to the high-grade component in the RP not being present in the biopsy results or due to a component of cancer on the needle reflecting such a small percentage of the pattern seen on RP that this pattern was not included in the final RP Gleason score.

Proliferative index determination in prostatic carcinoma tissue: is there any additional prognostic value greater than that of Gleason score, ploidy and pathological stage?

PURPOSE

The proliferative index was evaluated as an additional prognostic variable in 244 radical prostatectomy specimens from patients with prostate cancer. This study was done on the grounds that this variable has shown some promise as a prognostic tool in some other carcinomas, for example breast cancer.

MATERIALS AND METHODS

The proliferative index was evaluated in 244 patients undergoing radical prostatectomy for clinically localized disease between January 1988 and August 1994. Proliferative index was determined using the Ki-67 antibody on fresh frozen tissue and MIB-1 on paraffin embedded tissues. Patients were divided into 2 groups based on a proliferative index of less than 1 (185) or 1 or greater (59). Of the patients 49 (20%) had biochemical failure (median 23 months to progressive prostate specific antigen elevation of 0.5 ng./ml. or more). Those whose treatment failed were also divided into 2 groups according to proliferative index: 32 of 185 (18%) with an index of less than 1 and 17 of 59 (27%) with an index of 1 or more. Gleason score and deoxyribonucleic acid ploidy status were also evaluated in all patients and compared in multivariate regression analysis. Operative specimens were categorized as organ confined, specimen confined or margin positive.

RESULTS

The distribution according to margin status in the 2 groups (proliferative index less than 1 and 1 or more) was 40 versus 60% for organ confined, 67 versus 33% for specimen confined and 72 versus 28% for margin positive disease, respectively. The distribution of time to treatment failure in the 2 groups was not markedly different: 7.2 versus 9.4 months for margin positive, 10 versus 14.5 months for specimen confined and 8.5 versus 12 months for organ confined cancer, respectively.

CONCLUSIONS

Multivariate analysis demonstrated that, although deoxyribonucleic acid ploidy seemed to correlate with more advanced disease, only Gleason sum and pathological T stage reached statistical significance when evaluated against time to treatment failure. A high proliferative index added little above the more traditional prognostic indicators of Gleason score, pathological stage and ploidy. Therefore, we question the value of proliferative index as a prognostic indicator using the aforementioned methodology in prostate cancer.

Delayed/salvage radiation therapy in patients with elevated prostate specific antigen levels after radical prostatectomy. A long term follow-up

BACKGROUND

In this article the authors report an analysis and long term results of delayed/salvage radiation therapy administered to asymptomatic patients who had an elevated prostate specific antigen (PSA) level, many months to many years after radical prostatectomy.

METHODS

During 1987 to 1990, 40 asymptomatic patients were found to have an elevated PSA level 9 to 96 months after radical prostatectomy. The patients underwent transrectal needle aspiration biopsy of the urethrovesicle junction anastomosis (uvj); 28 patients had a positive biopsy and 12 patients had a negative biopsy. Delayed/salvage radiation therapy was administered to the pelvis (45 Gray [Gy]) and prostate bed (59.5 Gy), including the uvj.

RESULTS

Twenty-four of 37 patients (65%) were free of clinical disease. In 10 patients (27%), the radiation therapy resulted in a durable decrease in the elevated PSA level below a detectable level for a minimum 5-year follow-up. Five patients were alive with clinical disease. Eight died of disease. Three patients were lost to follow-up.

CONCLUSIONS

This experience shows that delayed/salvage radiation therapy to the pelvis (45 Gy) and prostate bed (59.5 Gy), even many years after radical prostatectomy for pathologic stage pB, pC, and pD1 carcinoma of the prostate, was well tolerated and provided freedom from clinical disease in 24 of 37 patients (65%), and a decrease in elevated PSA level in 10 patients (27%). Delayed/salvage radiation therapy appears to be beneficial for patients who had undergone radical prostatectomy only and then developed rising PSA levels during the follow-up period.

Use of prostate-specific antigen and tumor volume in predicting needle biopsy grading error

OBJECTIVES

To study the discrepancy between histologic grades of needle biopsy and prostatectomy specimens and to define the potential role of prostate-specific antigen (PSA), PSA density, and tumor volume in predicting the tumor grade.

METHODS

Histopathologic grades on needle biopsy and subsequent radical prostatectomy specimens were compared in 135 patients with clinically organ-confined prostate cancer. The frequency of undergrading (difference of one or more grades) by needle biopsy was then compared to PSA, PSA density, and other preoperative parameters.

RESULTS

The frequency of undergrading by one level was 45% using the M. D. Anderson Hospital (MDAH) system and 47% using the Gleason system. When the tumor grades were classified into two categories, undergrading rates of 26% (low to high grade by the MDAH system) and 21% (moderately well to poorly differentiated by the Gleason system) were noted. Serum PSA and PSA density correlated with the grading error rate: the higher the PSA and PSA density values, the higher the biopsy undergrading rate. PSA showed a significant correlation with undergrading (P = 0.0019). Undergrading occurred in 32% of patients with a PSA more than 4 and 10 ng/mL or less and in 47% of those with a serum PSA more than 10 ng/mL. In all cases when the PSA was 4 ng/mL or less, the needle biopsy results correctly predicted the final tumor grade category. Tumor volume was not associated with frequency of undergrading.

CONCLUSIONS

The ability to predict tumor grade can be enhanced by considering the serum PSA value.

Observations of pretreatment prostate-specific antigen doubling time in 107 patients referred for definitive radiotherapy

PURPOSE

To determine pretreatment prostate-specific antigen doubling times (PSADT) in patients referred for definitive radiotherapy.

METHODS AND MATERIALS

One hundred and seven patients with histologically proven nonmetastatic prostate cancer and an elevated prostate-specific antigen (PSA) who were referred for radiation therapy had three serum PSA values obtained prior to the start of definitive therapy. Prostate-specific antigen doubling times were calculated by linear regression.

RESULTS

Prostate-specific antigen values increased during the period of observation in 78 patients (73%). Forty-three patients (40%) had calculated PSADT of less than 2 years and of those patients with pretreatment serum PSA values of greater than 10 ng/mL more than 50% has calculated PSADT of less than 2 years.

CONCLUSIONS

A significant minority of patients referred for radiotherapy have calculated PSADT of less than 2 years. The significance of this relatively fast growth rate is as yet undetermined, but suggests that patients referred for radiotherapy may have aggressive disease prior to treatment.

Identification of bone marrow micrometastases in patients with prostate cancer

BACKGROUND

Thirty percent of patients with clinically localized prostate cancer and a negative bone scan will experience relapse with recurrent disease despite treatment of the primary tumor. This may be due to the presence of metastatic prostate cancer cells at the time of treatment undetected by conventional methods, radionucleotide bone scan, and serum prostatic specific antigen blood test.

METHODS

The authors used polymerase chain reaction (PCR) amplification of the prostate-specific antigen (PSA) mRNA sequence reverse-transcriptase PCR (RTPCR) and immunohistochemistry using a PSA antibody to identify metastatic prostate cancer cells in the bone marrow of patients with prostate cancer.

RESULTS

Micrometastases were found in the bone marrow of 29 of the 55 patients (51%) with prostate cancer and in 0 of the 5 patients with benign prostatic hyperplasia. Samples from five of the seven patients with lymph node metastases and from all five patients with bony metastases contained micrometastases. Of the samples taken from 43 patients undergoing radical prostatectomy and with no evidence of metastatic disease, 19 (44%) had micrometastases. Four of the 20 samples (20%) from patients with pathologically localized disease and 15 of the 23 samples (65%) from patients with extraprostatic disease had micrometastases (P = 0.003). Bone marrow slides were available on 24 of the 29 patients who were positive for micrometastases by RTPCR: Immunohistochemistry using the PSA antibody identified metastatic cells in 19 of these 24 patients.

CONCLUSIONS

Reverse-transcriptase polymerase chain reaction of bone marrow samples from patients with clinically localized prostate cancer may improve the accuracy of prostate cancer staging and identify patients at high risk for metastatic disease.

Standardized in vitro mapping with multiple core biopsies of total prostatectomy specimens: localization and prediction of tumour volume and grade

OBJECTIVE

To analyse the ability of systematic core biopsy mapping to provide prognostic information in patients with prostatic cancer.

MATERIALS AND METHODS

The prostates of 60 men with prostatic cancer, stages T0d-T2, who had undergone total retropubic prostatectomy were studied. The average age of the patients was 63 years (range 49-72). Ten core biopsies (1.2 x 35 mm) were taken from the fresh specimens according to a standardized procedure. The total prostatectomy specimens were serially step-sectioned at 5 mm intervals and were assessed regarding tumour volume, grade and pT-stage. The World Health Organization (WHO) grade obtained in the mapping biopsies was compared with that in the operative specimens. Undergrading (WHO) decreased substantially by mapping biopsies, but was still present with the Gleason system.

RESULTS

The volume of extracapsular tumours with extensively positive margins was significantly larger than that of intracapsular tumours (P < 0.01). In addition, the fraction of cancer obtained in the biopsies from tumours with grossly positive margins was significantly smaller than that observed in biopsies from pT2 tumours (P < 0.01). The cancer volume calculated from the result of the mapping correlated positively with the tumour volume determined by planimetry (R = 0.83). A weaker correlation was found when only the six dorsal mapping biopsies were taken into consideration (R = 0.68), but the correlation increased to R = 0.75 when the six most significant biopsies were selected with the help of a correlation matrix. Biopsies from the ventral part of the prostate were also important, to obtain an accurate assessment of the tumour fraction within the whole gland.

CONCLUSION

Mapping of the prostate gland with multiple (six or more) core biopsies is necessary for preoperative assessment of tumour volume, grade and pT stage; these are all of importance when assigning patients with clinically localized prostatic cancer to prognostic classes.

Deferred treatment of clinically localized low grade prostate cancer: the experience from a prospective series at the Karolinska Hospital

From 1978 to 1982, 172 patients with stages T1 to 3NxM0 prostate cancer were included in a surveillance protocol with deferred treatment on symptomatic progression. Median patient age at diagnosis was 68 years (range 38 to 89 years). Mean followup was 80 +/- 32 months. Of the patients 58% had local and 19% had distant progression, and 52% had received treatment at followup. Disease specific survival rate at 10 years was 80% for the total series, 84% for the subgroup with stage T1 or T2 tumor and 92% for those with stage T1 or T2 tumor who were less than 70 years old at diagnosis. For the subgroup with stage T3 tumor the disease specific survival rate at 9 years was 70%. In all subgroups the competing mortality rate was higher than the prostate cancer mortality rate. Deferred treatment appears to be an acceptable option for patients with tumor clinically confined to the prostate and a life expectancy of 10 years or less.

Prognostic value of deoxyribonucleic acid content in prostate cancer: a review of current results

A total of 115 articles on prostate cancer were reviewed for data on the prognostic value of DNA content in the tumor cells. In 44 series, data pertinent to this review were found. There was no consensus in the literature with respect to methods of analysis of DNA content or definitions of subclasses of DNA content such as categories of ploidy. The DNA content of prostate cancer cells was strongly related to tumor grade and stage. When analyzed as a single parameter in univariate analyses, the DNA content had a prognostic value with respect to overall or disease-specific survival. In multivariate analyses the additional prognostic value of the DNA content was less convincing when analysed with tumor grade and stage. The prognostic data from univariate and multivariate analyses available in the literature were mainly derived from patients with advanced disease and data on localized, potentially curable disease were scanty and conflicting.

The role of radical surgery in the treatment of prostatic cancer

At present, prostatic cancer is the most common malignancy in men in many Western countries and its incidence is continuously increasing. Radical prostatectomy has been used for over 80 years, but there is still controversy about its role in the treatment of localized prostatic cancer. Because of insufficient knowledge of the natural history of prostatic cancer and a lack of accurate prognostic factors there are possibilities for both over- and undertreatment. Better staging methods are also required to discriminate between intra- and extracapsular tumours, which is essential for curative treatment. On the basis of the facts mentioned above and because of the poor sensitivity and specificity of transrectal palpation, ultrasound examination and prostate-specific antigen, which are used in screening, diagnosing and staging of prostatic cancer, screening is not yet recommended for the detection of early prostatic cancer.

Pre- and postoperative DNA ploidy patterns correlated to pT-stage, histological grade and tumour volume in total prostatectomy specimens

Fifty-four consecutive patients with a preoperative diagnosis of localized prostatic cancer underwent total retropubic prostatectomy. The specimens were step-sectioned at 5 mm intervals. Volumes of invasive cancer (IC) and prostatic intraepithelial neoplasia (PIN) were calculated by computerized planimetry. From preoperative core and fine needle aspiration biopsies and from each prostatectomy specimen, multiple samples were taken from IC and PIN areas for DNA ploidy analysis. The study aimed to evaluate current biopsy sampling techniques as regards their suitability for DNA analysis and to assess the heterogeneity of DNA-ploidy and correlate the latter to postoperative pT-stage and tumour volume. When compared with the prostatectomy specimens, the preoperative assessment of non-diploid DNA patterns in biopsies had a sensitivity of 62% and a specificity of 86%. Samples from 24 surgical specimens contained non-diploid DNA in the main tumour and in one or several of the satellites. However, all these cases also contained diploid cell lines, both in the main tumour and in one or several of the satellites. Tumours with a volume exceeding 12 cc:s were non-diploid in 87.5% of cases (7/8). Tumours with volumes between 8 and 12 cc:s contained non-diploid foci in 50% of cases (2/4). Tumours smaller than 2 cc:s were non-diploid in 18% of cases (2/11). All non-diploid tumours were moderately or poorly differentiated. Of the non-diploid tumours, 96% (23/24) displayed capsular penetration versus 57% (17/30) of the diploid tumours (p < 0.0001). All PIN samples were made up of diploid cell lines.(ABSTRACT TRUNCATED AT 250 WORDS)

Coumarin (1,2-benzopyrone) for the treatment of prostatic carcinoma

The unavailability of effective treatment for metastatic hormone-refractory and clinically localized but pathologically unfavorable prostatic carcinoma warrants trial of new and promising treatments. Preliminary studies in patients with metastatic disease have shown (a) subjective but no objective responses to 100 mg coumarin and cimetidine daily; (b) objective responses in 3 of 40 patients treated with 3 g coumarin daily, all of whom had normal performance status and 1 of whom remains with three resolved bone metastases and stable prostate-specific antigen levels after 4 years; (c) toxicity only in bedridden patients. We recently initiated two multi-center trials of 1 g coumarin daily. Metastatic prostatic carcinoma patients of normal performance status were treated in a phase II trial. Patients who had been treated by radical prostatectomy, but had surgical margin, seminal vesicle or lymph node involvement or detectable prostate-specific antigen after radical prostatectomy, were randomized to coumarin or placebo.

Flow cytometric DNA analysis of fresh prostatic resections. Correlation with conventional prognostic parameters in patients with prostate cancer

BACKGROUND

DNA ploidy analysis has been investigated as a prognostic indicator in prostate cancer. Most of the data is derived from retrospective studies using paraffin-embedded tissue. This method has drawbacks related to the quality of DNA histograms and uncontrolled data collection.

METHODS

DNA ploidy analysis of freshly resected prostatic tissue was prospectively compared with conventional prognostic variables in 97 men treated with radical prostatectomy for localized prostate cancer.

RESULTS

Regarding the patients, 31.9% were African American and 66% had pathologic Stages C or D1 disease. Only 9.6% of patients with Stages A2 and B had a prostate-specific antigen (PSA) value greater than 10 ng/ml, whereas 97% of patients with PSA values greater than 20 ng/ml had pathologic Stages C and D1. PSA levels correlated with Gleason score (P = < 0.05); 51% and 100% of patients with Gleason score 5-7 and 8-10, respectively, had PSA values greater than 10 ng/ml. Twenty-two patients (23%) had DNA aneuploid tumors. Comparisons of mechanical to enzymatic cell suspensions indicated that DNA aneuploidy was better preserved in mechanical cell preparations. DNA ploidy correlated with pathologic stage (P = < 0.05) and Gleason score (P = < 0.05). Fifteen of 79 patients (18.9%) with Gleason score 5-7 had DNA aneuploid tumors versus 71.4% of patients with Gleason score 8-10. PSA groups correlated with ploidy status (P = 0.01). Although the majority of patients (19 of 22) with DNA aneuploid tumors had elevated preoperative PSA levels, none had a PSA value greater than 50 ng/ml.

CONCLUSIONS

DNA ploidy analysis correlated with established prognostic indicators in prostate cancer; however, its independent correlation with natural history and treatment outcome must be established for it to have an effect on therapeutic decisions.

Radical prostatectomy for pathologic stage C prostate cancer: influence of pathologic variables and adjuvant treatment on disease outcome

A retrospective analysis was performed on 1,035 patients with pathologic Stage C prostate cancer treated with bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. Of these patients, 661 received no immediate adjuvant treatment, 131 adjuvant radiotherapy only, and 103 postoperative adjuvant orchiectomy only. Overall crude survival at five, ten, and fifteen years was 91 percent, 68 percent, and 46 46 percent, respectively. Cause-specific survival was 96 percent, 81 percent, and 66 percent and overall nonprogression survival was 78 percent, 56 percent, and 48 percent at five, ten, and fifteen years, respectively. Patients with margin-positive and residual disease, high-grade tumors, large tumor bulk, and seminal vesicle involvement were more likely to receive adjuvant treatment. However, both univariately and multivariately, only tumor grade and increasing tumor volume correlated significantly with cause-specific survival and local and systemic progression. Adjuvant treatment significantly decreased local, systemic, and overall progression but did not improve cause-specific or crude survival. Orchiectomy and radiation appeared to demonstrate similar efficacy in controlling local recurrences: five-year local recurrence-free survival in this retrospective analysis was > 95 percent for both treatments compared with 84 percent for those without adjuvant treatment.

The role of neoadjuvant hormonal manipulation in localized prostatic cancer

BACKGROUND

Although hormonal manipulation is standard therapy for patients with metastatic prostatic cancer, its use in localized disease in combination with surgical extirpation of the gland has not been investigated thoroughly and systematically.

METHODS

The authors report their initial pilot studies using preoperative neoadjuvant endocrine therapy.

RESULTS

Although marked reduction in serum prostate-specific antigen (PSA) levels occurred in all patients, the PSA level after endocrine manipulation did not predict the pathologic stage. In addition, immunohistochemical staining of the radical prostatectomy specimen for PSA, in several patients with a zero serum PSA level, after endocrine therapy revealed intense PSA staining in the cancer cells but not in benign epithelium. The effects on tumor downstaging were inconclusive. Overall, only 33% of patients had organ-confined disease, but in some patients, complete tumor regression (PO) occurred.

CONCLUSIONS

Neoadjuvant hormonal therapy in prostatic cancer, although definitely not standard therapy, bears investigation. In addition to the effect on the "index" cancer, it also provides an opportunity to evaluate the effect of hormonal agents on microfocal ("early") cancer and known precursors of malignant change. Therefore, it may provide a means of assessing agents of potential use in the development of chemopreventive strategies.

Characterization of localized prostatic cancer: distribution, grading and pT-staging in radical prostatectomy specimens

Ninety-one patients underwent radical retropubic prostatectomy. Forty-three specimens were examined after limited sectioning (series 1) and 48 underwent whole organ serial step-sectioning at 5 mm intervals (series 2) of the removed prostate gland. The latter allowed a more extensive assessment of tumour localization, multicentricity, extension, pT-stage and grade. Eighty-eight percent of specimens in series 1 had free surgical margins compared with only 41% in series 2 (p = 0.00001). Preoperative tumour grading by fine-needle aspiration biopsy, TUR-chips or 1.2 mm core biopsies was in agreement with postoperative grading in the prostatectomy specimens in 48% of the cases in series 1 and 67% in series 2, respectively. In series 2, preoperative localization of the tumours by palpation was accurately assessed in 75% of cases when compared to the findings at step-sectioning. Sixty-eight percent of 40 eligible glands in series 2 contained multiple tumours. 12/13 cases of unifocal tumours (92%) were classified as large single tumours. The sections were divided into four peripheral and four central parts/octants, and the tumour localization was marked within these octants. The apical and middle third of the prostate contained tumour in all cases, whereas the basal (cranial part) was engaged in 35%. Small tumours were localized mainly in the periphery of the gland, with no significant difference between dorsal and ventral octants. However, large tumours were situated mainly in the dorsal peripheral octants, concomitant with an increased involvement of the ventral and central octants.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic lymphadenectomy in genitourinary malignancies

Laparoscopic pelvic lymphadenectomy has been applied to stage prostate cancer since 1989. These same laparoscopic techniques are being used to stage other urological malignancies. This report will detail the role of laparoscopic lymphadenectomy in staging genitourinary malignancies.

Histologic grading of prostate cancer: a perspective

The wide-ranging biologic malignancy of prostate cancer is strongly correlated with its extensive and diverse morphologic appearances. Histologic grading is a valuable research tool that could and should be used more extensively and systematically in patient care. It can improve clinical staging, as outlined by Oesterling et al (J Urol 138: 92-98, 1987), during selection of patients for possible prostatectomy by helping to identify the optimal treatment. Some of the recurrent practical problems with grading (reproducibility, "undergrading" of biopsies, and "lumping" of grades) are discussed and recommendations are made. The newer technologically sophisticated but single-parameter tumor measurements are compared with one important advantage of histologic grading: the ability to encompass the entire low to high range of malignancy. The predictive success of grading suggests that prostate cancers have more or less fixed degrees of malignancy and growth rates (a hypothesis of "biologic determinism") rather than a steady increase in malignancy with time. Most of the observed facts can be interpreted on that basis, including the interrelations of tumor size, grade, and malignancy. The increasing age-adjusted incidence of diagnosed prostate cancer is attributed to new diagnostic tools and increased diagnostic zeal.

Pathologic review of consecutive radical prostatectomy specimens. Nerve sparing versus nonnerve sparing

Retrospective pathologic analysis was conducted of specimens from 88 radical retropubic prostatectomy operations performed between 1982 and 1987 inclusive. The median age of patients was sixty years (range, 46 to 73 years). Of the 88 radical prostatectomies performed, 51 were nerve-sparing (40 bilateral) and 37 were nonnerve-sparing (11 unilateral) procedures. Preoperative clinical staging was similar in both groups. Thirty-five of 37 patients (95%) in nonnerve-staging group and 51 of 51 patients (100%) in nerve-sparing group had clinical Stage B2 disease or less. Pathologic staging in both groups was also similar. In 26 of 37 patients (70%) in nonnerve-sparing group and in 35 of 51 patients (69%) in nerve-sparing group, disease remained localized to the prostate. Both groups were analyzed retrospectively to determine whether or not the incidences of microinvasion of capsule and of extraprostatic disease differed. Review of the apical and lateral margins of the specimens revealed no statistically significant difference in either the degree of microinvasion of capsule or the incidence of extraprostatic disease between the groups.

DNA ploidy and prostate-specific antigen as prognostic factors in clinically resectable prostate cancer

Prostate-specific antigen (PSA) and DNA ploidy as measured by flow cytometry were compared with conventional prognostic indicators in 112 patients who underwent radical prostatectomy for clinically resectable prostate cancer. The variables examined included age, race, prostatic acid phosphatase (PAP), Gleason score of the radical prostatectomy specimen, and pathologic stage. No significant relationships were found between DNA ploidy and age, mean PAP value, and absolute PAP value. Of the 112 patients, 65 (58.0%) had disease limited to the prostate (pathologic Stages A and B); 47 (42.0%) had extraprostatic disease (pathologic Stages C and D1). The stage was related to the Gleason score (P less than 0.0001) where extraprostatic disease was associated with a Gleason score of 6 to 10. Nineteen (17.0%) patients had aneuploid tumors, and 93 (83.0%) had diploid tumors. DNA ploidy significantly correlated with pathologic stage (P = 0.04); aneuploidy was identified more frequently in patients with Stages C and D1 tumors. Aneuploid tumors occurred more frequently than diploid tumors in patients with a Gleason score of 6 to 10 (P = 0.034). Mean PSA values were higher in patients with aneuploid tumors (P = 0.078), extraprostatic neoplasms (P = 0.00001), and cancers with a Gleason score of 6 to 10 (P = 0.0004). Furthermore, PSA values greater than 10.0 ng/ml were associated with extraprostatic disease and a Gleason score of 6 to 10 (P less than 0.05 and P less than 0.001, respectively). Significant racial differences were found with respect to DNA ploidy, mean DNA indices, and mean PSA values. The 18 black patients had more DNA aneuploid tumors (P = 0.043), a higher mean DNA index (P = 0.017), and a higher mean PSA value (P = 0.043) than the 94 white patients. Both PSA and DNA ploidy analysis by flow cytometry appear to be valuable indicators in the evaluation of patients with prostatic carcinoma.

Prostate cancer: transrectal ultrasound and pathology comparison. A preliminary study of outer gland (peripheral and central zones) and inner gland (transition zone) cancer

A study was conducted to compare results of transrectal ultrasound with pathologic findings on 116 patients who underwent radical prostatectomy for treatment of prostate cancer. In 96% (111 of 116), transrectal ultrasound guided biopsies of a hypoechoic lesion proved cancer; seven patients had known Stage A cancer; one patient had cancer detected by palpation and not detected by ultrasound. Cancers in the outer gland (peripheral and central zones) were compared with cancers in the inner gland (transition zone) by both ultrasound and pathology. Forty-eight percent (52 of 108) of cancers originating in the outer gland showed extraprostatic extension (Stage C disease). The primary sites of tumor escape from the outer gland were the prostatic capsule (38%), anterior fibromuscular stroma (5%), seminal vesicle (18%), the base of the gland at the neurovascular bundle (21%), and the apex (31%). Twenty-two percent (17 of 54) of cancers originating in the inner gland (transition zone) showed extraprostatic extension (Stage C disease). The primary sites of tumor escape from the inner gland were the anterior fibromuscular stroma (6%) and apex (11%). Both histologic and biologic differences between outer and inner gland cancers were found when tumor size was controlled. Gleason scores were significantly different for inner and outer gland cancers, with mean scores of 6.2 +/- 1.6 and 7.4 +/- 0.9, respectively. An odds ratio of 8.6 confirmed the increased risk of extraprostatic extension for outer gland cancer. Outer gland cancers showed increased aggressive behavior of both histologic and biologic nature. The difference in biologic aggressiveness of outer and inner gland cancers has definite implications for treatment options. Use of other diagnostic parameters, such as DNA ploidy, may help to determine which cancers to treat and when to treat them; this may have more relevance for cancers originating in the inner gland. Strategic transrectal ultrasound guided biopsy affords accurate tumor mapping and staging when modes of internal spread and escape of cancer from both outer and inner gland are known. Thus, transrectal ultrasound may be our "window of observation" through which additional research may explain the histologic and biologic discrepancies between outer and inner gland cancers.

The prognostic value of modal deoxyribonucleic acid in low grade, low stage untreated prostate cancer

We selected for a prospective surveillance study 167 patients with untreated grades 1 and 2 prostate cancer. The tumors were classified regarding modal deoxyribonucleic acid value (ploidy) by flow cytometry, cytological grade by transrectal fine needle aspiration biopsy and local tumor stage. Of the patients 146 could be evaluated. Mean followup was 50 months. The initial ploidy was statistically correlated to cytological grade but not to initial local tumor stage, prostatic acid phosphatase activity or patient age. Initial ploidy and cytological grade had a prognostic value regarding local tumor progression when considered as single predictors and in combination. Two patients with diploid and 8 with nondiploid tumors initially had metastases during the surveillance. Five patients (1 with diploid and 4 with nondiploid disease) died of prostatic cancer. Modal deoxyribonucleic acid value and cytological grade were of prognostic value in untreated prostate cancer.

The effect of radiation therapy after radical prostatectomy in patients with elevated prostate specific antigen levels

We analyzed the effects of pelvic radiation therapy given to patients who had an elevated prostate specific antigen level after radical prostatectomy. Among men who previously received adjuvant radiation therapy and had appropriately stored serum 15 had elevated prostate specific antigen levels after radical prostatectomy but before radiation therapy. After radiation therapy the prostate specific antigen level decreased by more than 50% in 80% and to female levels in 53% of the patients. We also prospectively treated 29 men who had increasing levels of prostate specific antigen 9 to 95 months after radical prostatectomy but who were otherwise without evidence of disease by the usual criteria. However, 19 of the patients had local disease as evidenced by random needle biopsy of the urethrovesical anastomosis. Complications of radiation therapy were minimal and maximal prostate specific antigen decrease occurred by 6 months after treatment. In 82% of the patients prostate specific antigen levels decreased by more than 50% and in 43% they decreased to female levels. Female levels were achieved after radiation therapy given many years postoperatively even in stage D1 cancer patients but some of the patients subsequently had increasing prostate specific antigen levels. These data suggest that local-regional disease may be the only site of disease persistence after radical prostatectomy in some of the patients who subsequently have distant metastasis. We conclude that radiation therapy after radical prostatectomy can cause elevated prostate specific antigen to decrease to undetectable levels in many patients but the durability and ultimate therapeutic value of this effect are unknown.

Does microinvasion of the capsule and/or micrometastases in regional lymph nodes influence disease-free survival after radical prostatectomy?

Since 1976, 126 patients with clinically localised carcinoma of the prostate have been managed by radical retropubic prostatectomy. All patients with tumour spread beyond the capsule or metastasis in lymph nodes received radiotherapy. Tumour category pT3 was divided into invasion of the capsule or infiltration of the seminal vesicle. The disease-free 10-year survival rate in patients with minimal invasion of the capsule was 72% and in patients with infiltration of the seminal vesicles it was 26%. Unilateral lymph node metastases were classified as microscopic disease or macroscopic infiltration. The disease-free 10-year survival rate in patients with metastasis in 1 lymph node (micro- and macro-metastasis) was 65% in contrast to 0% in patients with bilateral disease.

DNA-ploidy as prognostic factor in prostatic carcinoma

DNA-ploidy in 143 cases of prostatic carcinoma was assessed by flow cytometric analysis of paraffin-embedded biopsy material. The majority of the tumours (64.3%) were diploid, but in advanced stages the DNA-aneuploidy rate increased from 15 to over 60%. No hypoploid tumour was observed and most of the hyperploid tumours were near-tetraploid. DNA-aneuploidy was also strongly related to histological grade. Survival analysis using Cox multivariate regression model revealed that low histological grade (high Gleason score), advanced stage and increased level of prostatic acid phosphatase were the most important prognostic factors. DNA-ploidy per se did not contribute independently as a predictor of survival.

Flow cytometric analysis of localized adenocarcinoma of the prostate: the use of archival DNA analysis in conjunction with pathological grading to predict clinical outcome following radical retropubic prostatectomy

Fifty-four specimens from patients undergoing radical prostatectomy for clinically confined prostate cancer between 1983 and 1987 were reviewed to determine the potential for flow cytometric (FCM) analysis of DNA ploidy and replication rate to predict disease recurrence. Each specimen was deparaffinized for FCM analysis and the pathology slides were reviewed by a single pathologist. FCM characteristics were correlated with pathological grade and stage, and both were correlated with disease status. In this series of patients, routine FCM analysis of DNA ploidy and replication rate failed to significantly enhance the ability of standard histopathological grading to predict disease recurrence in patients having clinically localized prostate cancer. Aneuploid tumors pathologically confined to the prostate did not appear to negatively affect prognosis.

Radical prostatectomy as treatment of localized prostatic cancer. Early results, with special focus on transrectal ultrasound for local staging

Radical prostatectomy was performed for localized prostatic cancer on 68 patients (mean age 65 years). Rectal palpation alone was used to determine local operability in the first 38 cases, and its accuracy proved to be 63%. Transrectal ultrasound in conjunction with clinical examination was used instead in the last 30 patients, with 80% accuracy. There was one perioperative death and the total complication rate was 37%. Postoperatively three patients were totally incontinent and five had mild stress incontinence. Of the 29 patients operated on with the nerve-sparing Walsh technique, 11 had penile erections 6 months postoperatively. The mean follow-up time was 34 (4-69) months. Local recurrence or distant metastases were found in 11 cases (16%). In ten of them the primary tumour was locally advanced (pT3 or pT4), and in one it was intracapsular (pT2) but poorly differentiated. Radical prostatectomy is concluded to be safe and its complication rate acceptable. Careful preoperative evaluation of the extent of disease is essential for cure, and transrectal ultrasound increases staging accuracy.

Results of local and/or systemic adjuvant therapy in the management of pathological stage C or D1 prostate cancer following radical prostatectomy

Between 1976 and 1984, 47 of 108 patients (44%) who underwent radical retropubic prostatectomy and pelvic lymphadenectomy for clinical stage A2 or B adenocarcinoma of the prostate were found to have pathological stage C or D1 disease. A total of 31 consecutive patients with pathological stage C disease received 45 to 55 Gy. adjuvant external beam radiation postoperatively. Actuarial 5 and 10-year survival rates free of disease were 92%, with a local recurrence rate of 3% and a distant recurrence rate of 6% at a mean followup of 5 years. Sixteen consecutive pathological stage D1 cancer patients received 45 to 60 Gy. adjuvant external beam radiation alone (4), adjuvant cytotoxic chemotherapy alone with cyclophosphamide (5) or combined adjuvant radiation and chemotherapy (7). Actuarial 5 and 10-year survival rates free of disease were 86% with no local recurrences and a distant recurrence rate of 12% at a mean followup of 5 years. These results provide further evidence to support the use of adjuvant external beam radiation therapy in the management of pathological stage C disease. Our preliminary results suggest that an aggressive, multidisciplinary approach is warranted in pathological stage D1 disease and that adjuvant chemotherapy, with or without adjuvant radiation, may have a role in prolonging survival free of disease in this high risk group.

Flow cytometric measurements of DNA and other cell components in human tumors: a critical appraisal

Fundamental principles of flow cytometry with emphasis on DNA measurements and cell cycle analysis in human cells and tissues are summarized. Some of the pitfalls of cell preparation techniques and histogram interpretation are discussed at length. While consensus has been reached for some organs and tumors that DNA quantitation by flow cytometry (or image cytometry) may be of prognostic value, for most cancers studied to date the information remains incomplete. Thoroughly lacking are well-structured prospective studies because retrospective studies, while suggestive, may not necessarily be of the same value. Potential usefulness of other tumor markers is briefly discussed. Many fundamental questions concerning definitions of "diploid" and "aneuploid" tumors have not been satisfactorily settled. While the goal of "objective measurements" is worthy of further pursuit, the interpretation of results is often highly subjective. The biologic reasons for behavioral differences between diploid and aneuploid tumors are still totally obscure.

Prognostic significance of DNA ploidy in carcinoma of prostate

Flow cytometry was used to measure the DNA content in archived paraffin-embedded human prostatic cancer tissue for 69 patients with known outcomes that presented between 1975 and 1982. Of these, 51 patients had clinically localized lesions and were surgically staged prior to radical prostatectomy, while 18 patients presented with advanced Stage D2 disease. Thirty-six of 37 (97.3%) pathologic Stage B lesions were diploid. In contrast, the majority (72.2%) of patients with metastatic disease had aneuploid tumors. The average Gleason grade for aneuploid tumors was 8.2 +/- 1.98 versus 5.5 +/- 1.89 for diploid tumors (p less than 0.01). For 51 patients with clinically localized tumors, 13.9 percent of diploid tumors with a low Gleason sum (2 to 6) had extracapsular spread of tumor or regional lymph node involvement compared with 83.3 percent of aneuploid tumors with high Gleason scores (7 to 10). The addition of DNA ploidy to degree of glandular differentiation may enhance the prognostic evaluation of prostatic tumors and eventually improve our ability to select patients who are likely to benefit from radical prostatectomy.

Intraprostatic tumor location and pelvic lymph node metastatic pattern in early prostate cancer

Recently we treated 54 patients with clinically localized prostate cancer: 8 had Stage A disease, 13 had Stage B1, 32 Stage B2, and 1 Stage C. Fifty of these patients underwent bilateral pelvic lymphadenectomy and retropubic radical prostatectomy, while the other 4 patients underwent bilateral pelvic lymphadenectomy only. Pathologic staging revealed pelvic lymph node metastases in 12 patients. We reviewed these 12 Stage D1 cases to see whether or not the intraprostatic tumor location influenced the locoregional metastatic nodal pattern. We found that metastases occurred ipsilaterally in 5 cases, while the other 7 patients experienced bilateral pelvic involvement. We failed to find any case in which contralateral nodal involvement occurred without the tumor also involving the pelvic lymph nodes ipsilateral to the intraprostatic tumor. The data suggest that it would be reasonable to perform pelvic lymphadenectomy only on the same side of the prostatic lesion. This modified approach potentially could reduce morbidity and cost to the patient.

Flow cytometric determination of ploidy in prostatic adenocarcinoma: a comparison with seminal vesicle involvement and histopathological grading as a predictor of clinical recurrence

Flow cytometry was used to evaluate 88 deparaffinized radical prostatectomy specimens to compare deoxyribonucleic acid ploidy in prostatic adenocarcinoma as a predictor of disease progression with other well documented predictors of clinical recurrence. Aneuploidy, Gleason grade and seminal vesicle involvement were nonindependent variables, and all correlated to statistical significance with disease recurrence. The incidence of aneuploidy in the total population was 51 of 88 (58 per cent). Aneuploidy was found in 25 of 28 primary tumors (89 per cent) from patients who subsequently had recurrent disease. Aneuploidy was noted in 40 of 59 specimens (68 per cent) exhibiting seminal vesicle involvement, compared to 11 of 29 (38 per cent) without seminal vesicle involvement (p less than 0.01). The probability of an interval free of disease of 60 months was calculated by Kaplan-Meier analysis to be 85 per cent in diploid specimens compared to 9 per cent in aneuploid specimens (p less than 0.001), and 87 per cent in the absence of seminal vesicle involvement compared to 28 per cent in the presence of seminal vesicle involvement (p less than 0.003). The probability of remaining free of disease in patients exhibiting concomitant diploidy and seminal vesicle involvement (17) was 73 per cent compared to 8 per cent in those with aneuploid specimens and seminal vesicle involvement (p less than 0.004). The incidence of recurrence in patients with Gleason sums of 7 or less was 22 per cent compared to 62 per cent in patients with Gleason sums of greater than 7. There was a 29 per cent incidence of recurrence in intermediate grade tumors (Gleason sum 5 to 7) but only 5 per cent of the patients with intermediate grade diploid tumors had recurrent disease. In conclusion, the recognition of a deoxyribonucleic acid aneuploid stem line in a primary prostatic adenocarcinoma is correlated statistically with a greater likelihood of seminal vesicle invasion and subsequent development of recurrent disease. The markedly increased probability of remaining free of disease in diploid patients, even in the presence of seminal vesicle involvement, suggests that routine flow cytometric analysis in prostatic adenocarcinoma would significantly enhance prognostic stratification.

Relationship of DNA content to conventional prognostic factors in clinically localised carcinoma of the prostate

One hundred and nine patients treated by total prostatectomy for apparently localised carcinoma were analysed to investigate the prognostic significance of capsular invasion and penetration, seminal vesicle invasion, lymph node metastases, grade as assessed by the Gleason and MD Anderson Hospital (MDAH) systems and DNA content measured by flow cytometry of nuclear material extracted from paraffin embedded tumour. Comparison of DNA content was made with 36 benign prostates. Mean follow-up/survival was 60.7 months, at which time 21 patients had evidence of recurrence or had died. Only 5 patients had local recurrence. Tumour grade, as assessed by both the Gleason Sum Score and the MDAH system, correlated with anatomical extent and was the most important determinant of time to recurrence. Fifty-nine tumours were diploid, 44 tetraploid and 6 aneuploid. One of 36 benign prostates showed aneuploidy. Ploidy did not correlate with the anatomical extent of the tumour or with grade. Tetraploid tumours recurred earlier than diploid tumours. None of 6 aneuploid tumours have recurred, although only 3 have been followed beyond 5 years. Multivariate analysis showed that after accounting for grade, none of the other variables, including ploidy, contributed any additional significant prognostic information. Although the results must be regarded as preliminary, in view of the small number of patients with recurrence, they suggest that DNA content offers limited prognostic information in clinically localised prostate cancer.

Radical prostatectomy. Patterns of local failure and survival in 67 patients

Sixty-seven patients with localized carcinoma of the prostate were treated by radical prostatectomy unaided by adjunctive hormonal therapy. Seven patients (10%) have been lost to follow-up, and 13 patients (19%) have died of other causes without evidence of prostate cancer. The crude or direct survival free of disease for traced patients with clinical Stage B1 nodules (11) and clinical B2 lesions (20) followed for at least fifteen years is 36 per cent and 25 per cent, respectively; the crude or direct survival free of disease for pathologic B (29) and C (12) tumors followed for fifteen years is 31 per cent and 8 per cent, respectively. The local failure incidence at fifteen years for pathologic Stage B tumors is 17 per cent and for pathologic C tumors 31 per cent. Capsular invasion alone on histologic examination did not increase the rate of local or distant failure above that noted for tumors that were entirely intracapsular. However, seminal vesicle invasion is associated with a 44 per cent local failure and 66 per cent distant failure rate. The interval between radical prostatectomy and first failure averaged sixty-nine months (median 56 months) and with hormonal therapy the interval between first failure and death averaged seventy months (median 62 months). The patients who underwent radical prostatectomy in this series represent 22 per cent of the 318 patients presenting with localized prostate cancer between 1960 and 1974. A 1.5-cm nodule was found in 5.5 per cent of the presenting population, and all but one of these patients were treated by radical prostatectomy.

The role of radical prostatectomy in the management of prostatic cancer

The indications for radical prostatectomy must reflect the following: an understanding of the natural history of the disease, the projected life span of the patient, the stage of the disease, and the relative morbidity and efficacy of alternative therapeutic regimens. The integration of clinical stage, histologic grade, and pelvic lymph node evaluation has improved the selection of the ideal candidate for radical prostatectomy. In men with localized disease, there is no evidence that any treatment other than radical prostatectomy produces better control of the primary lesion and of distant metastases than does total surgical excision of the prostate. Recently the morbidity of radical prostatectomy has been reduced by improvements in surgical technique. Intraoperative identification and preservation of the branches of the pelvic plexus that innervate the corpora cavernosa has resulted in long-term postoperative potency rates of 70% without compromising complete excision of the tumor. Thus it appears possible today to preserve sexual function in a majority of patients undergoing radical prostatectomy without compromising the cancer operation, an observation that may encourage more physicians to take greater interest in diagnosing prostatic cancer in young men at a stage when it is still curable.

Rectal examination in volume determination of carcinoma of the prostate: clinical and anatomical correlations

A comparison was made between tumor area estimated on rectal palpation and actual tumor size calculated from the radical prostatectomy specimen in 17 patients with prostatic carcinoma. For each patient a diagram of the rectal examination findings was superimposed onto a histological reconstruction map of the surgical specimen, and relative areas were measured with a computer. In only 1 case was there close correlation between palpated and actual tumor area. Seven patients had actual tumor areas that were more than twice the palpated area. In 5 patients the palpated areas corresponded to foci of capsular involvement, while adjacent large areas of cancer abutting the capsule were not recognized. Discrepancies of this magnitude may result not infrequently in assignment of a clinical stage B1 to tumors that are histologically stage B2.