Prognostic parameters in radiotherapeutic management of localized carcinoma of the prostate

Definitive therapy for prostate carcinoma: Mayo Clinic results at 15 years after treatment

Data on long-term follow-up for definitive therapy of prostate cancer are limited, especially for radiation therapy. Either surgery or radiation was used in 322 patients for treatment with curative intent, and follow-up was for a minimum of 15 years. Overall survival was nearly identical to that in age-matched cohort. 5-, 10-, and 15-year recurrence-free survival rates were 77%, 63% and 53%, respectively. Grade and stage were significant prognostic factors for both recurrence and survival. More than 60% of the initial failures were local, and more than 25% of the failures occurred after 10 years. Radiation therapy was used in 137 patients with clinically staged disease. Radical retropubic prostatectomy and perineal prostatectomy were performed in 133 and 44 patients, respectively. In this group, pathological staging was used. Survival rates for surgically treated patients were better than those in the cohort population. In conclusion, overall long-term follow-up demonstrates that definitive treatment does not have an adverse effect on survival from prostate cancer. Local recurrence is a frequent cause of failure. Caution must be used in interpreting any prostate study with less than 10 years of follow-up, because 25% to 50% of the failures occur after that time.

Immunohistochemical prostatic acid phosphatase level as a prognostic factor of prostatic carcinoma

To determine whether prostatic acid phosphatase (PAP) immunoreactivity in prostatic adenocarcinoma is a reliable prognostic factor, the PAP immunohistochemical distribution has been examined in 78 prostatic carcinoma cases. The intensity of PAP immunostaining was graded from 0 to 2, and the scores of the primary and the secondary staining patterns were added to assess the extent of the PAP expression in needle biopsy specimens. As a result, a higher cancer-specific survival rate was observed in patients showing a greater PAP immunostaining (P less than 0.01). Further, a multivariate analysis was made of possible prognostic factors (age, stage, Gleason score, serum PAP, PAP-immunostaining score, and the initial treatment) to estimate the extent of their impact on cancer-specific survival. Results have confirmed that the difference in PAP immunoreactivity is an excellent, independent prognostic factor for prostatic carcinoma.

Adenocarcinoma of the prostate: radioactive gold seed implant plus external irradiation

A total of 119 patients with a diagnosis of adenocarcinoma of the prostate (Stage B and C) were treated at St. Joseph Hospital Houston, Texas from 1971 through 1984 using a combination of radioactive gold seed implant and external irradiation. The prognostic significance of tumor grading and pelvic node involvement was analyzed. Five and 10-year survival for Stage B was 100% and 85% respectively; for Stage C it was 68% and 43% respectively. The cumulative 94% local control rate for Stage B and C cases obtained in this report suggests more effectiveness to control the disease locally with acceptable rate of complications, when radioactive gold seed implant is added.

Prognostic factors in carcinoma of the prostate--analysis of RTOG study 75-06

A total of 566 evaluable patients were accessioned to a phase III RTOG study of extended field irradiation in carcinoma of the prostate from 1976 to 1983. Eligible patients were those with locally advanced disease, either clinical Stage C or clinical Stage A2 or B with pelvic lymph node involvement. The treatment consisted of irradiation of the regional lymphatics followed by a boost to the prostate. The data have been analyzed extensively to identify variables of potential prognostic significance. The assessed factors include tumor size, clinical stage, the degree of histological differentiation, nodal status, serum acid phosphatase status, hormonal management status, age, and race. These factors have been assessed as to their interdependence and correlation with the clinical course (study endpoints) using univariate analyses and Cox's Regression model. Significant interdependence of tumor size and Gleason score and tumor size and acid phosphatase was identified. The population receiving hormonal management either prior to or during radiotherapy had a significantly higher proportion of high grade tumors. Correlation of the assessed variables and the study endpoints (local control, incidence of distant metastases, NED survival, survival) singled out the degree of histological differentiation as the most powerful prognostic factor for all the endpoints. Age proved a useful predictor of local control (younger patients failed at a significantly higher rate), as did tumor size. Elevation of serum acid phosphatase correlated well with the incidence of metastatic disease but was not a useful predictor of survival. Tumor size and hormonal management status correlated well with the incidence of metastatic disease but only when analyzed separately from other factors. Their prognostic value was absent when Cox regression analysis was applied. Nodal status did not correlate well with any of the study endpoints, indicating then that in patients with clinical Stage C disease, treated with definitive radiotherapy to the prostate and regional lymphatics, this parameter may have limited prognostic usefulness. Although patients who received concomitant hormonal management had a significantly higher proportion of high grade lesions, their clinical course fared favorably in comparison with the population not receiving concomitant hormonal management. This may indicate a beneficial effect of adjuvant hormonal treatment which needs to be tested in a prospective study.

First clinical experiences on neodymium-YAG laser irradiation of localized prostatic cancer

This first clinical report on Neodymium-YAG laser irradiation of localized prostatic cancer presents our experiences in 63 patients during 4 years. Transurethral resection extending to the capsule and subsequent laser irradiation according to our standardized treatment procedure give few complications and good functional results. Actuarial disease-free survival is 98% on one year and 80% in the 2-4 year period. The results are promising and comparable to short-term results obtained by radiotherapy and/or interstitial radioactive implants. Further experience is necessary for a definitive comparison to established treatment modalities.

Radiotherapy for localized prostate carcinoma

We reviewed the radiation therapy treatment experience for localized prostate carcinoma at the Joint Center for Radiation Therapy from 1968-1978 (N = 229 patients, median follow-up of 5 years). Actuarial 5 (and 8) year survival rates for clinical Stage A (N = 25), B (N = 85), and C (N = 88) disease were 96% (82), 77% (63), and 61% (38). The corresponding 5 (and 8) year relapse-free survivals were 84% (67), 68% (61), and 53% (36). Actuarial rates of clinical local failure at 5 (and 8) years were 0%, (0), 12% (20), and 15% (30) for Stage A, B, and C respectively. There was a suggestion of a decrease in the force of local and overall recurrence after 8 years, although further follow-up will be necessary for confirmation. Among 42 patients who underwent pelvic lymphadenectomy followed by irradiation, lymph node status appeared to be a strong predictor of distant failure (9% (3/32) failures for node (-) patients compared to 70% (7/10) for node (+) patients). Twenty-nine patients received radiotherapy after radical prostatectomy for clinically palpable (Stage B and C) tumor. Only one of 16 patients treated post-operatively because of microscopic or gross residual disease has developed recurrence. By contrast, only 2 of 13 patients irradiated because of clinical local tumor recurrence remain alive and free of disease. We conclude that radiation therapy can provide effective long-term local control of prostate carcinoma, but that the ultimate radiocurability of the disease is not yet known.

Improved control of bulky prostate carcinoma with sequential estrogen and radiation therapy

Patients with bulky prostate cancer have usually been treated by palliative measures because the likelihood of tumor control with definitive irradiation has been low and the development of distant metastases high. The addition of estrogen to irradiation has not been shown to be of value. However, we believe the method of estrogen administration may have been the cause for the apparent lack of benefit. Estrogen had been started either concurrent with irradiation or had been used for palliation and was given for long and unscheduled time periods prior to irradiation. We have used estrogen for two months prior to and concurrent with irradiation. We postulated that in those patients with estrogen responsive cancer, the reduced tumor burden prior to irradiation could enhance tumor control and survival. Between 1975 and 1980, 25 patients with bulky prostate cancer received sequential estrogen and irradiation, 12 patients irradiation alone and six patients irradiation after having become refractory to long-term estrogen use. One patient was lost to follow-up. Eighteen of 25 (72%) treated by sequential estrogen and irradiation, 14/17 (82%) with estrogen responsive cancer and 4/8 (50%) with estrogen resistant cancer had a complete tumor response. Six of 11 (55%) patients treated by irradiation alone and 2/6 (33%) treated by irradiation for estrogen refractory cancer had a complete tumor response. Disease-free survival was observed in 13/25 (52%) treated by sequential estrogen and irradiation, and 8/17 patients (47%) with irradiation. It is also possible the improved survival in the estrogen responsive group was a direct result of improved local control. Persistent local disease can act as a source for distant metastases. Distant metastases was observed in 15% of patients when the primary tumor was controlled and 30% when there was persistent or recurrent local disease. Also, progressive local disease can be an important cause of death. This was most evident in our patients with estrogen refractory cancer. Almost all patients in this group had progressive local disease that caused serious urinary bleeding and urinary infection that were considered the major cause of death. Our results suggest bulky prostate cancer should be aggressively treated when first diagnosed. The value of adjunct estrogen is unproven. Our results with the use of estrogen prior to and concurrent with irradiation is encouraging. Estrogen may shrink the cancer and allow for a more favorable geometry for external irradiation. Tumor control and survival may be thereby improved.(ABSTRACT TRUNCATED AT 400 WORDS)

Local control and survival after external irradiation for adenocarcinoma of the prostate

From 1966 through 1978, 128 patients with biopsy-proven adenocarcinoma of the prostate underwent external irradiation to the entire pelvis followed by additional irradiation with a field that encompassed the entire prostate with generous margins. Local recurrence was diagnosed when palpable regrowth occurred and was confirmed by biopsy. Eighteen patients (14%) had local recurrence. Actuarial (life table) local recurrence rates, however, were 24% for both for Stage B and C patients. Actuarial five year survival was 100% for the 10 Stage A patients, 91% for the 25 Stage B, and 78% for the 93 Stage C patients. Actuarial five year disease-free survival was 59% for Stage B and 69% for Stage C patients. Local recurrence was affected by the total dose to the whole pelvis and the dose at the center of the prostate. Disease-free survival was influenced by differentiation. High dose external irradiation to the prostate and regional lymph nodes offers the greatest probability of long-term disease-free survival for patients with localized disease. Late bowel complications were seen in 14 patients (11%), two of whom required colostomies. Late urinary tract complications were observed in five patients (4%).

Radiotherapy for prostatic carcinoma: post-irradiation prostatic biopsy and recurrence patterns with long-term followup

From 1968 through 1975, 159 patients with stages A, B and C adenocarcinoma of the prostate were treated with supervoltage radiation therapy. A median dose of 7,200 rad was given. The influence upon survival of grade, stage and a positive biopsy result after irradiation is analyzed. Over-all survival is a patently imprecise test of local treatment because patients die of intercurrent disease and are alive with metastases for significant intervals. The classification of survival with no evidence of recurrent disease excluded those patients dying of intercurrent disease. Therefore, the rate of survival free of disease always will be greater than the over-all survival rate in these patients, and a certain percentage of the patients without evidence of cancer will harbor subclinical disease. The 5 and 10-year survival rates free of disease were 80 and 69 per cent, respectively, in 51 patients with stages A and B cancer, and 66 and 47 per cent, respectively, in 108 with stage C disease. The 5 and 10-year over-all survival rates were 72 and 56 per cent, respectively, in the former and 68 and 39 per cent, respectively, in the latter patients. Survival free of disease and death of prostatic carcinoma were influenced adversely by advancing grade and stage (p less than 0.05), while over-all survival was influenced adversely by grade (p equals 0.02) but not by stage (p greater than 0.05). A positive biopsy result after irradiation did not predict survival free of disease, over-all survival or death of prostatic cancer in patients followed for 10 years (p greater than 0.05).