Apical soft tissue biopsies predict biochemical failure in radical perineal prostatectomy patients with apical cancer involvement

The aim of the study was to prospectively assess the role of apical soft tissue biopsies in radical perineal prostatectomy (RPP) patients with documented apical prostate cancer (PCA) involvement. Between June 1998 and May 1999, 77 consecutive men with localized PCA and documented invasion of the prostatic apex underwent RPP by a single surgeon. Soft tissue biopsies were systematically obtained from the prostatic fossa overlying the apex at the time of surgery. Time to biochemical failure was calculated using the Kaplan-Meier method. The rates of positive apical margins and positive apical soft tissue biopsies were 23.4% (18/77) and 15.6% (12/77). The sensitivity, specificity and positive predictive value of positive apical margins for residual apical disease as determined by apical soft tissue biopsy were 41.7, 80, and 28%, respectively. The overall biochemical failure rate was 28.6% (22/77) with a median follow-up of 51 months (range 3-73 months). The 36-month biochemical recurrence-free survival rate was 55.9+/-14.9% for patients with positive apical biopsies and 78.7+/-5.3% for those with negative biopsies (P=0.023). In conclusion, positive apical soft tissue biopsy is an independent predictor of biochemical failure in patients with apical PCA who undergo RPP. Positive apical surgical margins poorly predict residual apical disease that is frequently identifiable by apical soft tissue biopsy. Apical soft tissue biopsies should therefore be obtained in patients with known extensive apical cancer involvement at the time of RPP.

Heat shock protein 70 (HSP70) does not prevent the inhibition of cell growth in DU-145 cells treated with TGF-beta1

BACKGROUND

Mitogen-activated protein kinase (MAPK) is one of the transforming growth factor-beta (TGF-beta signaling pathways while heat shock protein 70 (HSP70) prevents apoptosis by affecting MAPK signaling downstream. However, the interrelationship between TGF-beta and HSP70 signaling is still unknown.

MATERIALS AND METHODS

DU-145 prostate cancer cells were treated with 40 pM and 200 pM TGF-beta1. After 3, 6, 9, 12 and 24 hours, cell proliferation assay and cell cycle analysis were performed. The activities of HSP70 and MAPKs (c-Jun N-terminal kinase 1 (JNK1), extracellular signal-regulated kinase 1 (ERK1), ERK2 and p38) were analyzed by Western blot at each time-point.

RESULTS

TGF-beta1 inhibited the cell growth in a dose-dependent manner at 3 hours. Late G1 accumulation in the cell cycle was observed in a dose-dependent manner after 24 hours. HSP70 and JNK1 increased only at 3 hours and decreased for up to 24 hours thereafter. ERK1, ERK2 and p38 decreased from 3 to 24 hours after TGF-beta1 treatment.

CONCLUSION

These data suggest that HSP70 does not prevent the inhibition of cell growth in DU-145 cells treated with TGF-beta1.

Comparison of ultrasound-guided biopsies and prostatectomy specimens: predictive accuracy of Gleason score and tumor site

OBJECTIVE

To critically evaluate the accuracy of sextant biopsies in predicting Gleason score and the site of tumor location in patients with clinically localized prostate cancer treated by radical perineal prostatectomy.

METHODS

The case records of 289 patients with clinically localized prostate cancer who underwent radical perineal prostatectomy were reviewed, comparing the Gleason score and tumor site location as determined by sextant ultrasound-guided core biopsies with the Gleason score and tumor distribution within the surgical specimens. The prostatectomy specimens were further characterized by extent of disease as organ-confined, specimen-confined or margin-positive.

RESULTS

The Gleason score was identical in 126 (43.5%) patients. An upgrading in the surgical specimen occurred in 118 (40.8%) cases, a downgrading in 43 (14.8%). Overall, 193 (66.7%) patients had a unilateral positive biopsy, while 96 (33.2%) patients had bilateral positive biopsies. Sixty-four (33.1%) patients with a unilateral positive biopsy had cancer confined to one side of the gland, while 127 (65.8%) showed bilateral disease; 142 (73.5%) patients had organ-confined tumors versus 51 (26.4%) patients with capsular penetration. In the 96 patients with bilateral positive biopsies, 64 (66.6%) patients had intracapsular cancer versus 32 (33.3%) patients with either specimen-confined or margin-positive disease. The overall rate of positive margins was 14%. Fifty-one (61.4%) of the 83 patients with non-organ-confined disease had posterolateral capsular penetration in the region of the superior pedicle of the neurovascular bundle, while 28 (33.7%) patients had apical capsular penetration, in the region of the inferior neurovascular pedicle.

CONCLUSIONS

The ability of sextant ultrasound-guided biopsies to estimate the pathological grading is satisfactory: when we consider a difference of +/- 1 in the final Gleason score, the overall correlation is 80%. In 66% of the cases, sextant biopsies predicted unilateral disease when bilateral disease existed. A unilateral positive biopsy does not predict unilateral disease.

Pilot study of dietary fat restriction and flaxseed supplementation in men with prostate cancer before surgery: exploring the effects on hormonal levels, prostate-specific antigen, and histopathologic features

OBJECTIVES

Dietary fat and fiber affect hormonal levels and may influence cancer progression. Flaxseed is a rich source of lignan and omega-3 fatty acids and may thwart prostate cancer. The potential effects of flaxseed may be enhanced with concomitant fat restriction. We undertook a pilot study to explore whether a flaxseed-supplemented, fat-restricted diet could affect the biomarkers of prostatic neoplasia.

METHODS

Twenty-five patients with prostate cancer who were awaiting prostatectomy were instructed on a low-fat (20% of kilocalories or less), flaxseed-supplemented (30 g/day) diet. The baseline and follow-up levels of prostate-specific antigen, testosterone, free androgen index, and total serum cholesterol were determined. The tumors of diet-treated patients were compared with those of historic cases (matched by age, race, prostate-specific antigen level at diagnosis, and biopsy Gleason sum) with respect to apoptosis (terminal deoxynucleotidyl transferase [TdT]-mediated dUTP-biotin nick end-labeling [TUNEL]) and proliferation (MIB-1).

RESULTS

The average duration on the diet was 34 days (range 21 to 77), during which time significant decreases were observed in total serum cholesterol (201 +/- 39 mg/dL to 174 +/- 42 mg/dL), total testosterone (422 +/- 122 ng/dL to 360 +/- 128 ng/dL), and free androgen index (36.3% +/- 18.9% to 29.3% +/- 16.8%) (all P <0.05). The baseline and follow-up levels of prostate-specific antigen were 8.1 +/- 5.2 ng/mL and 8.5 +/- 7.7 ng/mL, respectively, for the entire sample (P = 0.58); however, among men with Gleason sums of 6 or less (n = 19), the PSA values were 7.1 +/- 3.9 ng/mL and 6.4 +/- 4.1 ng/mL (P = 0.10). The mean proliferation index was 7.4 +/- 7.8 for the historic controls versus 5.0 +/- 4.9 for the diet-treated patients (P = 0.05). The distribution of the apoptotic indexes differed significantly (P = 0.01) between groups, with most historic controls exhibiting TUNEL categorical scores of 0; diet-treated patients largely exhibited scores of 1. Both the proliferation rate and apoptosis were significantly associated with the number of days on the diet (P = 0.049 and P = 0.017, respectively).

CONCLUSIONS

These pilot data suggest that a flaxseed-supplemented, fat-restricted diet may affect prostate cancer biology and associated biomarkers. Further study is needed to determine the benefit of this dietary regimen as either a complementary or preventive therapy.

Results of radical prostatectomy in men with locally advanced prostate cancer: multi-institutional pooled analysis

OBJECTIVE

We investigated the disease-specific and metastasis-free survival rates in men with locally advanced (clinical stage T3) prostate cancer who were treated surgically.

METHODS

A retrospective, multi-institutional pooled analysis of the results of surgical treatment in 345 men with clinical stage T3 disease was performed. Survival curves were generated using the Kaplan-Meier method.

RESULTS

Among 298 evaluable patients, pelvic lymphadenectomy alone was performed in 56 men (19%), while 242 men (81%) underwent node dissection and radical prostatectomy. In total, 122 of 298 patients (41%) had nodal metastases and/or seminal vesicle tumor spread. Pathologically organ-confined disease was noted in 27 men (9%). The actuarial 10-year disease-specific and metastasis-free survival rates for all patients managed surgically were 57 and 32%, respectively. For patients with well, moderately and poorly differentiated tumors, cancer-specific survival rates at 10 years were 73, 67 and 29%, respectively.

CONCLUSIONS

A large number of men with clinical stage T3 prostate cancer have advanced disease and are unlikely to achieve improved long-term survival with surgery alone. Although there may be a role for radical prostatectomy in selected patients with low to intermediate grade tumors, such treatment appears unlikely to result in long-term survival in men with high grade disease. A prospective study is necessary to determine the optimal treatment approach in men with locally advanced prostate cancer.

Outcome profiles of locoregional disease after radical prostatectomy and radiotherapy

The purpose of the present study was to examine the outcome profiles of a large number of patients with locally advanced adenocarcinoma of the prostate following radical perineal prostatectomy (RPP) for clinically organ-confined disease. Of 1662 men who underwent RPP performed by a single surgeon between January 1972 and January 1999, 692 patients (41.6%) aged a median of 66.1 years were found to have extracapsular disease on pathological evaluation. The extent of disease was categorized as either specimen-confined (n = 355) or margin-positive (n = 337). The histological grade of the cancer was characterized using the Gleason score. Time to biochemical failure, defined as a prostate-specific antigen (PSA) level of > or = 0.5 ng/ml, and cancer-associated survival were the end points of our outcome analysis using the Kaplan-Meier product-limit method. The median time to cancer-associated death for patients with specimen-confined and margin-positive disease was 18.5 and 13.1 years, respectively. After 5 years, 37% and 54% of the patients with specimen-confined and margin-positive disease, respectively, had PSA failure. Prostate cancer patients with a Gleason score of 5-6, 7, and 8-10 experienced a median time to cancer-associated death of 19.9, 19.2, and 10.5 years, respectively. A subset of patients undergoing adjunctive radiation therapy (XRT) relapsed biochemically after a median period of approximately 18 months. RPP provides a substantial disease-control benefit in patients with specimen-confined cancer. The time to biochemical failure and the time to cancer-associated death are significantly influenced by the biology of the underlying disease, necessitating long-term follow-up in the outcome analysis of any modality of treatment for prostate cancer. A benefit of early adjunctive XRT for local failure remains to be determined.

Early onset baldness and prostate cancer risk

Prostatic carcinoma is the leading cancer among American men, yet few risk factors have been established. Although increased androgen levels have long been associated with both prostatic carcinoma and baldness, to date no studies have shown an association between hair patterning and prostate cancer risk. A lack of standardized instruments to assess baldness or the assessment of hair patterning during uninformative periods of time may have precluded the ability of previous studies to detect an association. We hypothesized that baldness, specifically vertex baldness, should be assessed using standardized instruments and during early adulthood if an association with prostate cancer risk is to be found. To test this hypothesis, we included identical items related to hair patterning in surveys that were administered in two distinct prostate cancer case-control studies (Duke-based study, n = 149; 78 cases; 71 controls and community-based study, n = 130; 56 cases; 74 controls). In each, participants were provided with an illustration of the Hamilton Scale of Baldness and asked to select the diagrams that best represented their hair patterning at age 30 and again at age 40. From these data, the following five categories were created and compared: not bald (referent group); vertex bald early onset (by age 30); vertex bald later onset (by age 40); frontal bald early onset (by age 30); frontal bald later onset (by age 40); and frontal (at age 30) to vertex bald (at age 40). Separate analyses of the two studies are consistent and suggest an association between vertex baldness and prostate cancer [vertex bald early onset odds ratios, 2.44 [confidence interval (CI), 0.57-10.46)] and 2.11 (CI, 0.66-6.73), respectively; vertex bald later onset odds ratios, 2.10 (CI, 0.63-7.00) and 1.37 (CI, 0.47-4.06), respectively]. Although statistical significance was not achieved in either one of these studies, the concordance between the data suggests a need for future studies to determine whether early onset vertex baldness serves as a novel biomarker for prostate cancer and whether androgen production, metabolism, or receptor status differs among these men when compared to those who exhibit other types of hair patterning.

Renal lymphoma in an azotemic patient--usefulness of magnetic resonance imaging

An azotemic patient benefited from diagnostic magnetic resonance imaging (MRI) in the evaluation of his renal mass. This led to suspicion of lymphoma, and provided guidance for percutaneous biopsy. Chemotherapy was then initiated, and an unnecessary nephrectomy was avoided. After a year of follow-up, evolution was stable and renal function significantly improved.

Radical perineal prostatectomy: oncological outcome during a 20-year period

PURPOSE

We examined 4 postulates: 1) radical perineal prostatectomy provides a substantial disease control benefit in men with clinically confined prostate cancer, 2) postoperative prostate specific antigen (PSA) levels are an excellent surrogate end point for defining disease control, 3) the biology of primary malignancy defines the interval to death after recurrence and 4) the interval from intervention to death from recurrence is so long that current series of alternative curative therapies have insufficient duration of observation to permit a comparison with the results of surgery.

MATERIALS AND METHODS

A total of 1,242 men with a median age of 65.2 years who had stage cT1 to 2 N0M0 disease underwent radical perineal prostatectomy. The final pathology specimen was characterized in regard to disease extent, and Gleason grade and score. Patients were followed at 2 weeks, at 2 months and then at 6-month intervals for biochemical, physical and radiographic evidence of disease recurrence. Outcome was evaluated by determining time to biochemical failure (PSA 0.5 ng./ml. or greater) and cancer associated death.

RESULTS

Median time to noncancer death was 19.3 years. Median cancer associated death end point was not reached by patients with organ and specimen confined disease, while it was 12.7 years for margin positive disease. At 5 years 8, 35 and 65% of the patients with organ confined, specimen confined and margin positive disease, respectively, had PSA failure. This served as an excellent surrogate end point, preceding cancer associated death by 5 to 12 years depending on the biological aggressiveness predicted by Gleason grade or score. Biologically aggressive organ confined disease that had been surgically removed was associated with a high percentage of disease-free survival.

CONCLUSIONS

Our study confirms our postulates. It also provides guidelines for comparing therapies among institutions and emphasizes that enthusiasm for new treatments may be based on insufficient followup. Patient selection may severely bias outcome independent of treatment when death is used as the end point. Our study establishes the value of PSA as a surrogate end point.

Peptidyl membrane-interactive molecules are cytotoxic to prostatic cancer cells in vitro

Cytotoxic membrane disruption via lytic peptides is a well-recognized mechanism of immune surveillance for antifungal and antibacterial host protection. Naturally occurring lytic peptides were shown to exhibit antitumor activity as well. Peptidyl membrane-interactive molecules (MIMs) are synthetic lytic peptides specifically designed to maximize antitumor activity. We tested nine novel Peptidyl MIMs for activity against four androgen-insensitive prostate-cancer cell lines using a standard microculture tetrazolium (MTT) assay. Five Peptidyl MIMs known to form alpha-helical secondary structures were active against prostate carcinoma and were chosen for further study. Three peptides configured in beta-pleated sheets were noticeably less effective. Concentrations lethal to 50% of the prostate-cancer cell lines treated (D50 values) with the five chosen Peptidyl MIMs ranged from 0.6 to 1.8 microM. For comparison, two alpha-helically structured peptides, D2A21 and DP1E, were tested on several other cancer types: breast (n = 2), colon (n = 2). bladder, cervical and lung carcinomas (n = 1 each). Resulting LD50 values obtained in breast carcinoma cells were significantly higher (P < 0.05) than those observed in prostate cancer cells. LD50 values recorded for D2A21 and DP1E in cervical, colon, bladder, and lung cancer lines were similar to those obtained in prostate cancer cells. As compared with cisplatin, a standard chemotherapeutic drug, the LD50 values recorded for D2A21 were significantly lower (P < 0.04) in prostate-cancer cell lines, suggesting the therapeutic efficacy of Peptidyl MIMs. These data demonstrate for the first time the cytotoxic potential of Peptidyl MIMs against prostate cancer cells and suggest a dependence on a specific secondary alpha-helical structure of the peptide.

Surgical control of clinically localized prostate carcinoma is equivalent in African-American and white males

BACKGROUND

Few studies have compared the outcome of radical prostatectomy between African-American males (AAM) and white males, and the results of the few studies that have are conflicting. Therefore, the authors examined the impact of radical surgery on localized prostate carcinoma in both patient populations, and assessed whether stratification by pathologic extent of local disease would yield an equivalent outcome.

METHODS

Prostate specific antigen (PSA) failure and carcinoma-associated death rates were assessed in 1319 patients (115 AAM and 1204 white males), 872 of whom had a pretreatment serum PSA level taken. The percent of prostate involved by tumor, tumor wet weight, and DNA ploidy status were available in 755, 522, and 638 patients, respectively.

RESULTS

AAM were diagnosed at an earlier age than white males (62.8 years vs. 65.4 years; P = 0.0001). The distribution of pathologic extent of local disease was similar in both races, and AAM had a statistically higher rate of tumors with a Gleason sum of 7-10 at surgery than white males (64% vs. 46%). Race did not play a role in the outcome of patients with organ-confined or specimen-confined tumors. However, in patients with positive surgical margins, the median time to PSA failure and the median carcinoma-associated survival were less in AAM compared with white males. Tumor volume was significantly larger in AAM compared with white males. After multivariate adjustment for the pathologic extent of local disease, tumor grade at surgery, preoperative PSA, tumor volume, and age, African-American race was not a significant prognostic indicator for carcinoma-associated death and PSA failure (P = 0.17 and 0.14, respectively).

CONCLUSIONS

The outcome of radical prostatectomy was similar in both racial groups, although AAM with positive surgical margins tended to fail earlier than white males, suggesting greater biologic aggressiveness of residual disease. Because local extent of disease impacts on PSA failure and survival, and because the disease appears to present earlier in AAM, the AAM population may benefit from early detection programs.

Transient lower extremity neurapraxia associated with radical perineal prostatectomy: a complication of the exaggerated lithotomy position

PURPOSE

We assess the incidence and risk factors associated with lower extremity neurapraxia following radical perineal prostatectomy.

MATERIALS AND METHODS

The medical records of 111 consecutive patients undergoing radical perineal prostatectomy at Duke University Medical Center between June 1994 and June 1995 were retrospectively reviewed. Patients were interviewed by telephone to ascertain whether symptoms had resolved.

RESULTS

Neurapraxia developed in 23 patients (21%). Symptomatology was variable, including sensory and motor deficits of the lower leg and foot. Although lower extremity neurapraxia occurred in a significant number of patients undergoing radical perineal prostatectomy, it appeared to resolve in most.

CONCLUSIONS

Careful attention to detail when positioning the patient and limiting the time in the exaggerated lithotomy position appear to be the most critical aspects to prevent neurapraxia.

Treatment options, selection, and satisfaction among African American and white men with prostate carcinoma in North Carolina

BACKGROUND

In the U.S., prostate carcinoma mortality is greatest among African Americans. In North Carolina, the state with the fourth largest population of African Americans, the prostate carcinoma mortality rate is 2.5 times greater among African Americans than among whites and is the highest reported rate for any state in the nation. To explore potential reasons for the racial differential in mortality, a study was undertaken to determine whether differences related to treatment existed between African American and white men who were diagnosed with prostate carcinoma during the period 1994-1995.

METHODS

Cases were selected from 16 institutions within a region comprising 63 contiguous counties where the overall population was >20% African American. A stratified design was employed to accrue subjects into groups of even size according to race and disease stage (n = 231). A telephone survey was conducted, which assessed treatment options discussed by patients with their physicians, treatment(s) received, factors influencing treatment, satisfaction with treatments discussed and options given, and sociodemographic information.

RESULTS

All measures related to treatment were consistently associated with stage at diagnosis (P < 0.001) rather than other variables measured (i.e., race, age, income, comorbidity, education, and residential status). Furthermore, most subjects reported that their physicians presented several treatment options (65%), that they were satisfied with the options presented (90%), and that the physician was the most important factor influencing their treatment decision (57%).

CONCLUSIONS

These data suggest that African American and white men in North Carolina receive comparable treatment for prostate carcinoma. Therefore, efforts to reduce the racial disparity in mortality should be directed toward lessening the high incidence of later stage disease at diagnosis and exploring potential biologic differences that may increase the risk of more aggressive disease among African Americans.

Radical perineal prostatectomy

Radical perineal prostatectomy is viewed with increasing favor because prostate-specific antigen levels now permit exclusion of node dissection. This review describes the surgical conduct of the procedure, and notes outcome as a function of disease extent.

Does prostate transitional cell carcinoma preclude orthotopic bladder reconstruction after radical cystoprostatectomy for bladder cancer?

PURPOSE

We determined if urethral preservation and orthotopic bladder replacement in patients with transitional cell carcinoma within the prostatic urethra or prostate placed these patients at risk for urethral recurrence or death.

MATERIALS AND METHODS

The clinical course of all patients undergoing urethral preservation and orthotopic bladder replacement was reviewed. The urethra was sacrificed only if the distal prostatic urethral margin was positive for transitional cell carcinoma. The pathological T stage and the grade of the primary malignancy, local recurrence, site of recurrence (urethral, pelvic, distant) and death were documented.

RESULTS

Of 81 patients 70 were evaluable (June 1996) with a mean followup of 35 months. Of the 70 patients 48 were alive without evidence of disease for a mean of 38 months (range 8 to 107) and 5 died without evidence of disease. Eight of these 53 patients (15%) had prostatic involvement (carcinoma in situ in 6, intraductal carcinoma in 1 and stromal invasive transitional cell carcinoma in 1). Of the 70 patients 17 had disease recurrence (13 died of disease and 4 are alive, 1 of whom had urethral recurrence without initial prostatic transitional cell carcinoma). Of the 17 patients (35%) 6 had transitional cell carcinoma prostatic involvement (carcinoma in situ in 4 and stromal invasion in 2), and 5 of these 6 died, none with or of urethral recurrence but of the primary bladder pathology. Of these 5 patients 1 had stromal invasive transitional cell carcinoma of the prostate and experienced a bulbar urethra recurrence at 1 month and a pelvic recurrence at 3 months, and died at 5 months. Death was not secondary to the urethral recurrence. Thus, of the 14 patients who had prostatic transitional cell carcinoma, only 1 had urethral recurrence (7%), and this recurrence did not present as the cause of death.

CONCLUSIONS

The guidelines for urethral resection can be relaxed, increasing the opportunities for orthotopic reconstruction, without placing the patients at increased risk for death of transitional cell carcinoma.

Anthropometric risk factors for prostate cancer

Cancer of the prostate is the leading cancer among American men, yet few risk factors are known. Anthropometry may help uncover potential risk factors for prostate cancer, since fat distribution, skeletal structure, and musculature may differ between men with this hormonally linked cancer and those without it. A case-control study was undertaken to determine whether anthropometric differences exist between prostate cancer cases and controls and whether such differences are associated with specific hormonal profiles. The study accrued 315 men stratified for race, age, and case/control status. Weight, height (sitting/standing), skinfold thicknesses (triceps, biceps, subscapular, suprailiac, thigh), circumferences (midarm, waist, hip, thigh), breadths (elbow, biacromial, biiliac), hormonal levels (total and free testosterone, dihydrotestosterone, sex hormone-binding globulin), bone density, and body composition were measured. Measures of upper body robustness [i.e., biacromial breadth-to-height ratio (p = 0.02) and biacromial (p = 0.05) and bideltoid (p = 0.04) breadths] were greater among controls. Strong negative associations were found uniformly between sex hormone-binding globulin levels and measures of body adiposity and musculature. Data show that prostate cancer cases exhibit a propensity toward a slight upper body skeleton, which may in itself serve as a risk factor or provide a benchmark of past nutritional and/or hormonal status and help elucidate the etiology of this disease.

Serum androgens: associations with prostate cancer risk and hair patterning

Cancer of the prostate is the leading cancer among American men, yet few risk factors have been established. Hair growth and development are influenced by androgens, and it has long been suspected that prostate cancer also is responsive to these hormones. A blinded, case-control study was undertaken to determine if hair patterning is associated with risk of prostate cancer, as well as specific hormonal profiles. The study accrued 315 male subjects who were stratified with regard to age, race, and case-control status (159 prostate cancer cases/156 controls). Hair-patterning classification and serum levels of total and free testosterone (T), sex hormone binding globulin, and dihydrotestosterone (DHT) were performed. Data indicate that hair patterning did not differ between prostate cancer cases and controls; however, significant hormonal differences were detected between the two groups. Free T was greater among cases than in controls (16.4 +/- 6.1 vs. 14.9 +/- 4.8 pg/ml, P = 0.02). Conversely, DHT-related ratios were greater among controls (P = 0.03 for DHT/T and P = 0.01 for DHT/free T). Several strong associations also were found between hormone levels and hair patterning. Men with vertex and frontal baldness had higher levels of free T (16.5 +/- 5.5 and 16.2 +/- 8.0 pg/ml, respectively) when compared to men with either little or no hair loss (14.8 +/- 4.7 pg/ml) (P = 0.01). Data suggest that increased levels of free T may be a risk factor for prostatic carcinoma. In addition, although no differences in hair patterning were detected between cases and controls within this older population, further research (i.e., prospective trials or case-control studies among younger men) may be necessary to determine if hair patterning serves as a viable biomarker for this disease, especially given the strong association between free T levels and baldness.

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.

Natural history of renal cell carcinoma

The survival of patients with renal cell carcinoma is directly related to the extent of malignancy at the time of treatment. Patients with T1 and T2 disease experience excellent survival independent of the grade of the disease. However, once the disease has extended from the kidney, survival is a function of whether the disease progresses by direct extension or has the ability to move through space and deposit at distant metastatic sites. When this occurs, survival is almost directly a function of the grade and degree of malignancy of the renal tumor.

Results of radical prostatectomy in men with clinically localized prostate cancer

OBJECTIVE

To assess the results of radical prostatectomy in men with early prostate cancer.

DESIGN

Retrospective, nonrandomized, multi-institutional pooled analysis.

SETTING

Eight university medical centers in the United States and Europe.

PATIENTS

A total of 2758 men with stage Tl and T2 prostatic cancer.

MAIN OUTCOME MEASURES

Disease-specific and metastasis-free survival rates.

RESULTS

Tumor grade was the most important preoperative factor in determining outcome. Disease-specific survival 10 years following surgery and associated 95% confidence intervals were 94% (range, 87%-98%), 80% (range, 74%-85%), and 77% (range, 65%-86%) for those men with grade 1, 2, and 3 tumors, respectively. Metastasis-free survival at 10 years was 87% (range, 78%-92%), 68% (range, 62%-73%), and 52% (range, 38%-64%) for patients with grade 1, 2, and 3 cancers, respectively.

CONCLUSIONS

Radical prostatectomy leads to high 10-year disease-specific survival rates in men with all tumor grades. However, caution is needed in comparing these results with similar studies of alternative treatment strategies, such as watchful waiting, due to the inherent potential biases in uncontrolled trials. Nevertheless, these results offer the best currently available estimates of 10-year outcome of radical prostatectomy in men with clinically localized prostate cancer and may be useful in counseling patients with early malignancy.

p53 immunohistochemical and genetic alterations are associated at high incidence with post-irradiated locally persistent prostate carcinoma

PURPOSE

Several reports have shown that cells with p53 mutations display increased resistance to ionizing radiation, a treatment often used clinically for localized prostate carcinoma.

MATERIALS AND METHODS

Totals of 18 post-irradiated locally recurrent prostatic carcinoma specimens and 25 (no radiation) stage D1 node-positive (TxN+MO) primary prostatic carcinoma specimens were tested for p53 immunoreactivity by immunohistochemistry. Of the 18 post-radiation locally recurrent prostatic carcinomas 10 were further analyzed by single strand conformational polymorphism to assess the validity of using this immunohistochemistry approach in irradiated tissue for detecting p53 alterations. Specimens showing p53 alterations by single strand conformational polymorphism were subjected to nucleotide sequence analysis or tested for loss of heterozygosity at a locus within the p53 gene.

RESULTS

Of the 25 stage TxN+MO prostatic carcinomas without radiation 5 (20%) were immunoreactive (consistent with the reported incidence of positive immunoreactivity in clinical/surgical stage TxN+MO primary prostatic carcinomas). In contrast, 13 of 18 post-radiation locally recurrent prostatic carcinoma specimens (72%) were immunoreactive. Multivariate logistic regression analysis showed no dependence of p53 immunoreactivity to grade, stage or androgen status in the post-radiation locally recurrent prostatic carcinoma group, while 8 of 10 hormone naive prostatic carcinoma specimens (80%) were immunoreactive. The temporal relationship between p53 alterations and radiotherapy was assessed. Pre-irradiation prostatic carcinomas available from 5 patients with immunoreactive post-radiation locally recurrent disease were analyzed and all were immunoreactive.

CONCLUSIONS

p53 Alteration in localized prostatic carcinoma is uncommon. Our study confirms others in that even aggressive locally advanced nonirradiated primaries (stage TxN+MO) contain only 20% incidence of p53 alterations. However, our study demonstrates that p53 alterations are found in the preponderant majority of post-radiation locally recurrent prostatic carcinoma specimens. Limited evaluation of pretreatment prostatic carcinoma biopsies uniformly documented the presence of p53 alterations before ionizing radiation, thereby demonstrating that p53 alteration was already present and was not radiation-induced or only correlated with late stage disease. This finding suggests a potential for p53 immunoreactivity to be used as a pretreatment marker that might predict local treatment failure with ionizing radiation. Large scale prospective trials would appear warranted to evaluate conclusively the potential prognostic applicability of p53 pre-screening before enrollment in definitive radiotherapy.

Postoperative prostate-specific antigen as a prognostic indicator in patients with margin-positive prostate cancer, undergoing adjuvant radiotherapy after radical prostatectomy

OBJECTIVES

To identify a population of patients within the group with positive surgical margins after radical prostatectomy who would benefit in terms of improved local control of disease by the administration of adjuvant radiation therapy to the prostate bed.

METHODS

Postoperative prostate-specific antigen (PSA) values were evaluated in 45 patients with margin-positive (MP) disease who underwent adjuvant radiotherapy within 6 months of surgery. All patients were clinically T1-2 MO, and pNO. A cutoff of 0.5 ng/mL or less was used as the level below which PSA was considered undetectable. The mean follow-up time from date of radiation was 33 months.

RESULTS

In 30 of 45 (67%) patients, PSA levels did drop to undetectable levels postoperatively. In 15 of 45 (33%) patients postoperative PSA levels did not drop to undetectable levels. In the group with detectable postoperative PSA, 12 of 15 (80%) failed adjuvant radiotherapy as determined by a progressive increase in PSA levels in a mean time of 0.95 years (range, 4 months to 2.02 years; median, 0.92 years). When postoperative PSA reached undetectable levels, only 10 of 30 (33%) failed treatment, with a mean time to failure of 2.1 years (range, 4 months to 7.8 years; median, 3.31 years).

CONCLUSIONS

The data would suggest that patients who are MP, but attain an undetectable PSA level postoperatively accompanied by a progressive delayed increase in PSA, probably represent a group with local disease recurrence in the prostate fossa, whereas patients whose PSA levels are detectable postoperatively may represent a group with microscopic metastatic disease or a combination of local recurrence and distant disease or large volume local persistent disease. It is in the group of patients in whom the postoperative PSA decreased to undetectable levels that adjuvant radiotherapy may be effective in controlling local progression of prostate cancer through improved local control, as indicated by a durable decrease in PSA values to undetectable levels in roughly two thirds of these patients. Longer follow-up of these patients will be required to determine whether this improved local control will translate into improved survival.

The impact of PSA on prostate cancer management. Can we abandon routine staging pelvic lymphadenectomy?

Despite a negative metastatic evaluation, up to 100% of patients with high-grade tumors are found to harbor metastatic disease within the pelvic lymph nodes at the time of surgery. This article reviews the literature regarding efforts to refine noninvasive preoperative staging through the use of serum tumor markers, improved radiologic imaging, and histologic analysis of the biopsy specimens. A discussion of the renewed controversy regarding the role of pelvic lymphadenectomy in the management of adenocarcinoma of the prostate follows.

Does radical prostatectomy in the presence of positive pelvic lymph nodes enhance survival?

A retrospective review was performed on all patients with stage D1 prostate cancer treated at Duke University Medical Center between 1975 and 1989. A total of 156 patients underwent staging pelvic lymph-node dissection for clinically organ-confined prostate cancer (stage A or B) but were found to have disease metastatic to the pelvic lymph nodes (stage D1). Of this population, 42 patients also underwent radical prostatectomy (group 1), leaving 114 who did not have their prostate removed (group 2). The median cancer-specific survival was 11.2 years for group 1 versus 5.8 years for group 2 (P = 0.005). In patients with one or two positive lymph nodes the median cancer-specific survival was 10.2 years for group 1 versus 5.9 years for group 2 (P = 0.015). There was no difference in survival if three or more lymph nodes were positive. Adjuvant treatment with immediate androgen deprivation and/or postoperative radiation therapy failed to improve the survival experience. The incidence of local problems, including stricture formation, bleeding, or regrowth of cancer requiring dilation or surgical intervention (transurethral prostatectomy) averaged 9.5% in group 1 and 24.6% in group 2. These data show that patients with limited node-positive disease selected for radical prostatectomy experience a survival advantage over those denied such therapy and that this advantage is independent of adjunctive therapy.

Impact of radical prostatectomy in the management of clinically localized disease

The cancer specific death rate following radical prostatectomy in patients with organ confined and specimen confined disease was 10% at 13.5 years, less than the noncancer death rate of 20% for patients in these disease extent categories. The median age of all patients in these categories was 65 years. Cancer remains the dominate cause of death in patients with margin-positive disease, being 40% at 13.5 years. Disease detected by prostate specific antigen (PSA) rather than digital rectal examination appears to be of smaller volume and to have a higher probability of negative margins. Data argue that early detection of PSA will shift patients to a more favorable disease category at surgical intervention. Disease recurrence or persistence by PSA detection seems to precede clinical detection of disease by 3 to 5 years. Disease recurrence by PSA detection does not predict survival outcome, probably does not differentiate between local and distant microscopic recurrence, and is not predictive of biological aggressiveness.

Differential immunoreactivity of transforming growth factor alpha in benign, dysplastic and malignant prostatic tissues

Immunohistochemical examination of radical prostatectomy specimens from 57 patients was performed to determine the differential expression of transforming growth factor alpha in the human prostate. In addition, epidermal growth factor receptor (EGFr) immunoreactivity was assessed in each case. Stromal versus epithelial staining was determined for each histological subtype: benign prostatic hypertrophy (BPH), prostatic intra-epithelial neoplasia (PIN), and prostatic cancer (CaP) by a single pathologist reviewer. TGFa staining was predominant in stroma while EGFr was localized to the epithelial basal cell layer. Immunoreactivity of both TGFa (P = 0.002) and EGFr (P < 0.001) revealed a significant reduction in CaP compared to BPH or PIN. Autocrine stimulation of EGFr by TGFa or other unrecognized factors may be present in CaP. Conversely, altered stromal influence of CaP via TGFa may be present. These observations could form the basis for future cancer therapeutic strategies using antagonist factors.

Does of stage pT0 cystectomy specimen confer a survival advantage in patients with minimally invasive bladder cancer?

Controversy exists regarding the clinical significance of a pathological stage T0 (pT0) specimen found at cystectomy or after repeat transurethral resection for transitional cell carcinoma of the bladder. Many investigators cite this subpopulation of patients as a reason to consider more conservative management, based on the premise that the patient may have benefited from the original transurethral resection. However, we questioned whether outcome would be improved in stage pT0 cancer patients or whether outcome in stage pT0 cases would parallel that noted when the original stage was equivalent to the final pathological stage. To test this hypothesis, we examined the survival advantage occasioned by a stage pT0 finding in 66 of 433 patients who underwent radical cystectomy for transitional cell carcinoma of the bladder. Of the 433 patients studied 54 had clinical stage Tis or Ta, 166 clinical stage T1 and 213 clinical stage T2 disease. Within each of the 3 clinical groups (clinical stage Tis/Ta, clinical stage T1 and clinical stage T2) Kaplan-Meier survival projections were generated comparing patients with stage pT0 disease to those whose pathological stage was identical to the original clinical stage. Among the 54 clinical stage Tis/Ta cancer patients 11 with stage pT0 and 24 with stage pTis/pTa had survival projections of 90% of 5 years. Of 166 patients with clinical stage T1 disease 32 with stage pT0 and 78 with stage pT1 tumor had survival projections of 75% at 5 years. Among 213 patients with clinical stage T2 cancer 23 with stage pT0 and 71 with stage pT2 disease had survival projections of 68% at 5 years. The data suggest that a stage pT0 cystectomy specimen does not confer a survival advantage over that noted from the initiating population in which the final pathological stage and initial clinical stage are equivalent. A patient with a stage pT0 specimen functions, by survival analysis, in a manner similar to one with the stated clinical stage.

Clinical variables which serve as predictors of cancer-specific survival among patients treated with radical cystectomy for transitional cell carcinoma of the bladder and prostate

BACKGROUND

Studies have demonstrated conclusively that the stage and grade of transitional cell tumors at presentation are major determinants of survival for those with the disease in the bladder and prostate. The authors initiated a review of 531 patients with transitional cell carcinoma of the bladder and prostate treated with radical cystectomy between 1969 and 1990 to identify other clinical features predictive of cancer-specific survival.

MATERIALS AND METHODS

Inpatient and clinical medical records were analyzed for age, race, gender, clinical T stage, medical history, and presenting symptoms and signs, and admission laboratory values were correlated with the patient's cancer-specific outcome. Both univariate and multivariate analyses of the various clinical factors were performed to identify variables predictive of cancer-specific survival.

RESULTS

Univariate analysis indicated that clinical T classification, preoperative hemoglobin, tumor grade, irritative voiding symptoms, age, preoperative creatinine, obstructive hydronephrosis on preoperative excretory urography, a history of bladder tumors or nephrouretectomy for transitional cell cancer, prior urinary tract infections, prior pelvic irradiation, and obstructive symptoms were all predictive of poor cancer-specific survival. Multivariate analysis demonstrated that higher clinical T classification (T2, T3a, T3b, T4 versus Ta, Tis, T1) (P < 0.001), increasing age (< 65 years versus > or = 65 years) (P < 0.001), the presence of irritative voiding symptoms (P = 0.01), higher tumor grade, lower preoperative hemoglobin level (< or = 12 gm/dl versus > 12 gm/dl) (P < 0.001), higher preoperative creatinine level (> or = 1.5 mg/dl versus < 1.5 mg/dl) (P = 0.002), a history of nephroureterectomy for transitional cell cancer (P = 0.016), and a history of pelvic irradiation (P = 0.002) were all predictive of poor cancer-specific survival.

CONCLUSIONS

Although clinical T classification and tumor grade remain the best predictors of survival in patients with transitional cell carcinoma of the bladder or prostate, clinical variables such as age, preoperative creatinine and hemoglobin levels, a history of nephroureterectomy or pelvic irradiation, and irritative voiding symptoms at presentation may provide additional prognostic information independent of tumor grade and stage.

Expanding indications for conservative renal surgery in renal cell carcinoma

OBJECTIVE

To more clearly define the selection criteria for conservative renal surgery in renal cell carcinoma.

METHOD

The survival experience of 42 patients who underwent in situ partial nephrectomy (21), enucleation (18), or both (3) over an eighteen-year period was examined. The presence or a history of contralateral cancer, type of surgery, gender, grade, diameter of tumor, age at diagnosis, presenting symptoms, positive surgical margins, smoking history, and stage were examined with regard to prognostic significance.

RESULTS

The five-year cancer-specific survival rates were 100 percent for those patients undergoing partial nephrectomy and 84 percent for those undergoing enucleation. The local recurrence rate was 4.8 percent (2/42) for the group, with both recurrences occurring in patients with von Hippel-Lindau disease. The mean diameter of tumor resected was 4.2 cm. Those patients found to have a positive surgical margin (6) had a significantly shorter disease-specific survival than those who did not (37) (p = 0.004), and those with a smoking history (23) had a significantly shorter survival than non-smokers (19) (p = 0.038).

CONCLUSIONS

We conclude that both partial nephrectomy and enucleation are acceptable approaches to renal cell carcinoma in select cases, with survival rates that closely approximate those found in radical nephrectomy series. Renal carcinomas that are peripherally located and small in diameter (< or = 5 cm) are most appropriate for these procedures, and given the excellent results noted to date, the expanded use of these approaches to include very young patients and those with any disease process that may affect renal function is warranted. A positive surgical margin is an ominous pathologic finding and should be avoided by frozen section biopsy at surgery or possibly intraoperative ultrasonography. Additionally, smokers with renal cell carcinoma have a poorer disease-specific survival than non-smokers, further questioning a carcinogenic etiology in this disease.

Radical cystectomy for stages Ta, Tis and T1 transitional cell carcinoma of the bladder

Between January 1969 and January 1990, 531 patients underwent bilateral pelvic lymph node dissection and radical cystectomy for the management of transitional cell carcinoma of the bladder. Of these procedures 220 were performed for clinical stage Ta (31 patients), Tis (23) or T1 (166) disease, which was either high grade or recalcitrant to transurethral resection and/or intravesical chemotherapy. This subgroup of patients was studied to evaluate the outcome of recurrent or chemotherapy resistant superficial transitional cell carcinoma of the bladder after radical cystectomy. The operative mortality rate for the group was 2.3% and the overall complication rate was 20.4%. The pelvic recurrence rate was 5.9%. The 5-year cancer-specific survival rates for patients with pathological stage Ta (11), Tis (19), T0 (43) and T1 (91) disease were 88%, 100%, 80% and 76%, respectively. The 10-year cancer-specific survival rates were 75%, 92%, 66% and 62%, respectively. A total of 74 patients received preoperative radiation therapy (2,000 rad) but they had no better 5-year cancer-specific survival rates than did nonirradiated patients. Transurethral resection and/or preoperative radiation therapy resulted in a pathological status of T0 in 43 patients but this did not confer a survival advantage. Although bladder preservation is preferable, low operative mortality and pelvic recurrence rates, as well as new methods of continent urinary diversion continue to make radical cystectomy the definitive form of therapy for patients with superficial disease recalcitrant to transurethral therapy.

Critical review of radical cystectomy and indicators of prognosis

The data would strongly suggest that, if local control can be established by either radical cystectomy or by transurethral resection, and if no distant disease is existing, that transurethral resection and radical cystectomy provide equivalent survival advantage. Our current dilemma lies in the inability to accurately determine the extent of disease as evidenced by the upstaging error that occurs following radical cystectomy. Thus, the treating physician must decide whether to abandon a therapeutic procedure such as radical cystectomy, which has the potential to cure higher local stage disease than may transurethral resection. It would appear that radical cystectomy as a single therapy remains the treatment of choice.

Possible mechanism for seeding of tumor during radical prostatectomy

Prostatic adenocarcinoma sometimes recurs locally in the operative bed after radical prostatectomy. Having observed local recurrence in several patients who had a small tumor confined to the prostate on whole mount serial sections, we postulated that some instances of local recurrence could arise from malignant cells shed in prostatic secretions expressed during surgery. To evaluate whether prostatic secretions contain malignant cells and to estimate the frequency of this phenomenon, we collected fresh prostatic secretions from radical prostatectomy specimens immediately after removal. The secretions were analyzed by cytology for the presence of malignant cells. Of 76 samples collected from consecutive patients with clinical stages T1 and T2 prostate cancer at 3 institutions 11 (14%) contained malignant cells. Positive cytology results were most frequent in patients with poorly differentiated tumors. Of 11 cancers with a Gleason sum of 8 to 10 in the prostatectomy specimen 6 (55%) had a positive cytology result. However, of 63 tumors with a Gleason sum of 5 to 7 only 4 (6%) were positive (p < 0.0001). There was no significant correlation with either clinical or pathological stage of the tumor in this small series. Our findings suggest that malignant cells shed during prostatectomy may seed the surgical bed and could be responsible for some instances of local tumor recurrence. The rate of positive cytology results in our study is similar to the local recurrence rates reported in the literature. Surgeons should make prudent attempts to avoid seeding from this source.

Genetic risk and carcinogen exposure: a common inherited defect of the carcinogen-metabolism gene glutathione S-transferase M1 (GSTM1) that increases susceptibility to bladder cancer

BACKGROUND

Numerous studies have associated bladder cancer with exposure to carcinogens present in tobacco smoke and other environmental or occupational exposures. Approximately 50% of all humans inherit two deleted copies of the GSTM1 gene which encodes for the carcinogen-detoxification enzyme glutathione S-transferase M1. Recent findings suggest that the GSTM1 gene may modulate the internal dose of environmental carcinogens and thereby affect the risk of developing bladder cancer.

PURPOSE

We investigated whether the absence of the GSTM1 gene affects bladder cancer risk and whether there are racial differences in GSTM1 genotype frequency.

METHODS

Using a polymerase chain reaction (PCR)-based method, we examined the frequency of the homozygous deleted genotype (GSTM1 0/0) in 229 patients with transitional cell carcinoma of the bladder and 211 control subjects who were enrolled from the Urology Clinics at Duke University Medical Center and the University of North Carolina Hospitals. Control subjects were urology clinic patients who primarily presented with benign prostatic hypertrophy or impotence, who had no history of any cancer other than nonmelanoma skin cancer, and who were frequency matched to case patients on race, sex, and age (10-year age intervals). In order to explore racial differences in GSTM1 gene frequency, genotype was also determined in a community-based sample of 466 paid, healthy, unrelated volunteers from Durham and Chapel Hill, N.C. The presence or absence of the GSTM1 gene locus was determined by using a differential PCR, a semiquantitative technique in which multiple genes are coamplified.

RESULTS

Overall, the GSTM1 0/0 genotype conferred a 70% increased risk of bladder cancer (odds ratio [OR] = 1.7; 95% confidence interval [CI] = 1.2-2.5; P = .004). Absence of the GSTM1 gene encoding the glutathione S-transferase M1 enzyme significantly increased risk to persons with exposure to the carcinogens in tobacco smoke (OR = 1.8; 95% CI = 1.2-3.0; P = .01) but poses little increased risk to persons without such exposure. Persons with smoking exposure of more than 50 pack-years who had the GSTM1 0/0 genotype had a sixfold greater risk relative to persons in the lowest risk group (i.e., nonsmokers who were GSTM1 +/+ or +/0). In the pooled clinic control and community sample groups (677 individuals), the GSTM1 0/0 genotype occurred less frequently among Blacks (35%) than among Whites (49%, P < .001).

CONCLUSIONS

These findings support a protective role for the GSTM1 gene in bladder cancer. From these findings, it is estimated that 25% of all bladder cancer may be attributable to the at-risk GSTM1 0/0 genotype.

The value of pathologic factors in predicting cancer-specific survival among patients treated with radical cystectomy for transitional cell carcinoma of the bladder and prostate

BACKGROUND

A recent consensus conference on bladder carcinoma highlighted the need for pathologic predictors of outcome for patients with transitional cell carcinoma of the bladder. This review was undertaken to determine the pathologic features predictive of cancer-specific survival after a radical cystectomy and urinary diversion for transitional cell carcinoma of the bladder and prostate.

METHODS

Between 1969 and 1990, 531 patients with transitional cell carcinoma of the bladder and prostate were treated with radical cystectomy at the Duke University Medical Center. Records and pathologic specimens were analyzed and correlated with outcome. Both univariate and multivariate analyses of the pathologic staging were performed to identify variables predictive of cancer-specific survival.

RESULTS

Univariate analysis indicated that pathologic tumor (pT) stage, positive nodes, positive surgical margins, prostatic stromal involvement, grade, age, ureteral involvement, squamous cell carcinoma, and squamous cell differentiation in the specimen all were predictive of poor cancer-specific survival. Carcinoma in situ (CIS) in the specimen was not an adverse prognostic indicator. Multivariate analysis demonstrated that the pT stage, nodal involvement, positive surgical margins, patient's age at surgery, and loss of histologic differentiation were predictive of poor cancer-specific survival. CIS was found again not to have a negative influence on cancer-specific survival.

CONCLUSIONS

If any of these features are noted in the final pathologic specimen, patients should be considered for some form of additional postoperative treatment such as chemotherapy or radiation therapy in an attempt to improve their chances for cancer-free survival. These factors will become more important in selecting which patients should be placed in developing adjuvant clinical trials.

Prognostic factors in renal cancer

In conclusion, the accumulated data indicate that the local extent of a renal carcinoma at the time of surgical intervention is the most important single variable in determining survival. Nuclear grade and cell type of the tumor appear to be of additional prognostic value, especially in patients whose tumor has spread beyond the anatomic confines of the kidney, because these variables may reflect the biologic virulence of the particular tumor in the individual host. Nuclear morphometry and cellular DNA content may play a more important role in the future by identifying that population of patients with clinically localized disease in whom radical nephrectomy will not be not curative, presumably because of concurrent undetectable micrometastases. This distinction will become increasingly important as more effective adjuvant therapies are identified.

Is prostate specific antigen of clinical importance in evaluating outcome after radical prostatectomy

Current bias would conclude that elevation of serum prostate specific antigen (PSA) after radical prostatectomy infers failure of the procedure. Since April 1987 preoperative and postoperative serum PSA levels have been obtained on 226 patients who underwent radical perineal prostatectomy for presumed organ confined prostate cancer (stage T1-2N0M0). Clinical failure as defined by elevation of serum acid phosphatase, biopsy proved local recurrence or evidence of malignant disease on bone scan has occurred in 3.9% of the patients with organ confined, 7.0% with specimen confined and 13.2% with margin positive disease. However, when a PSA elevation of greater than 0.5 ng./ml. was used as an indicator of failure the failure rate became 9.8% for the organ confined group, 39.4% for the specimen confined group and 66.0% for margin positive group. Of the patients who failed clinically the interval from initial elevation of postoperative PSA to clinical detection of failure ranged from 2 to 28 months (median 16). Among the patients with an elevated postoperative PSA level but who have not clinically failed followup ranged from 4 to 46 months (median 23). A total of 11 patients had no evidence of failure at greater than 36 months despite the elevated postoperative serum PSA level. These PSA elevations in patients who undergo supposed curative therapy are distressing. However, at this time the majority of these patients have not failed. In the clinically cured patient biochemical evidence of failure may not be sufficient to change the treatment course.

Stratification of pathologic features in radical prostatectomy specimens that are predictive of elevated initial postoperative serum prostate-specific antigen levels

BACKGROUND

Prostate-specific antigen (PSA) is an important marker for adenocarcinoma of the prostate and is of clinical utility in assessment of residual carcinoma after radical prostatectomy. Although elevated postoperative serum PSA levels have been linked to pathologic stage in radical prostatectomy specimens, limited data are available on the relationship of postoperative PSA levels to margin positivity, intraglandular tumor extent, and histologic grade.

METHODS

Initial postoperative serum PSA levels were related to pathologic features of 90 radical prostatectomy specimens with adenocarcinoma of the prostate. Logistic regression analysis was used to stratify pathologic stage, percentage intraglandular carcinoma, histologic grade, and margin positivity as predictors of elevated initial postoperative PSA levels.

RESULTS

Pathologic stage, percentage carcinoma, and margin positivity were nearly equivalent in strength of prediction, whereas Gleason histologic grade was a significant but less reliable predictor of elevated initial postoperative PSA levels. Thirty-one of 51 (60.8%) patients with extension of carcinoma outside the prostate gland had an elevated initial postoperative PSA level, whereas only 5 of 39 (12.8%) patients with organ-confined carcinoma had an elevated postoperative PSA level. Intraglandular tumor extent greater than 10% was associated with a greater likelihood of an elevated postoperative PSA level. Additional predictive capacity was obtained with concurrent use of pathologic stage and percentage carcinoma or margin positivity in multivariate analysis.

CONCLUSIONS

In radical prostatectomy specimens, pathologic stage, intraglandular carcinoma extent, and margin positivity are particularly important morphologic parameters because they are predictive of residual carcinoma that is detected early, as judged by an elevated initial postoperative serum PSA level.

Squamous cell carcinoma of the prostate: 2 cases of a rare malignancy and review of the literature

Primary squamous cell carcinoma of the prostate is an extremely uncommon malignancy, accounting for less than 1% of all prostatic cancers. We report on 2 patients with primary squamous cell carcinoma of the prostate: 1 with organ-confined disease and 1 with metastatic disease. Both patients presented with urinary obstructive symptoms and carcinoma was not suspected on digital rectal examination. Serum acid phosphatase and prostate specific antigen levels were normal. From a review of the literature and our 2 cases it is apparent that squamous cell carcinoma of the prostate is biologically more aggressive than adenocarcinoma.

Complications of radical cystectomy and urinary diversion: a retrospective review of 675 cases in 2 decades

A retrospective review was performed on all 675 patients who underwent radical cystectomy and urinary diversion during 2 decades. Of the patients 197 were treated from 1969 to 1979 (group 1) and 478 were treated from 1980 until 1990 (group 2). The mean age of patients in group 1 was 56.7 years versus 64.2 years in group 2 (p < 0.001). The overall operative mortality rate in both groups was 2.5%. A total of 215 patients (31.9%) experienced postoperative complications (within 30 days of surgery). The morbidity rate was nearly identical between the 2 groups (32.0% for group 1 versus 31.8% for group 2, p = 0.962). Of note, however, there was a decreased incidence of wound infections and wound dehiscence among the patients in group 2 compared to group 1. Long-term complications occurred in 198 of the 675 patients (29.3%). At followup group 1 had a 35.5% incidence of long-term complications versus 26.8% in group 2 (p = 0.022). Most notably there was significant improvement in the incidence of ureteroenteric anastomotic strictures when comparing groups 1 (11.2%) and 2 (5.2%) (p = 0.006).

Total prostatoseminal vesiculectomy in the treatment of debilitating perineal pain

Persistent perineal pain, unresponsive to antibiotics and analgesia, sufficient to produce an inability to function in any work or social environment is occasionally encountered. A total of 5 such patients underwent total prostatoseminal vesiculectomy: 3 experienced complete relief of the pain and 1 experienced symptomatic relief to the extent that he ranks the residual discomfort as 1 on a scale of 1 to 10. The remaining patient had complete absence of pain for approximately 4 months but thereafter mild, intermittent proximal urethral discomfort developed during voiding. Total prostatoseminal vesiculectomy may be occasionally applicable in the patient disabled by chronic perineal pain. We believe that psychiatric evaluation and concurrence should be a preoperative prerequisite.

Radical prostatectomy: the pros and cons of the perineal versus retropubic approach

Radical prostatectomy is frequently recommended for the treatment of localized adenocarcinoma of the prostate. The use of the perineal versus the retropubic approach is mostly dependent upon the experience of the individual surgeon. This study was performed to evaluate the short-term differences between the 2 operations. Between 1988 and 1989, 173 patients were identified with organ confined prostate cancer (stage A or B) who were treated with radical prostatectomy. Of this total population 122 patients underwent radical perineal prostatectomy (group 1) and 51 patients underwent radical retropubic prostatectomy (group 2). The median estimated blood loss for group 1 was 565 cc and for group 2 it was 2,000 cc (p less than 0.001). Group 1 received a median of 0 units of blood during hospitalization, while group 2 received a median of 3 units of blood (p less than 0.001). The total operative time was slightly shorter for group 1 but the anesthesia time was similar for both patient populations. There was no difference in the incidence of positive surgical margins, and in in-hospital and long-term complication rates between the 2 groups. In light of these significant findings it is our belief that the radical perineal prostatectomy is an excellent approach for the treatment of adenocarcinoma of the prostate.