Prostate cancer in men less than 45 years old: influence of stage, grade and therapy

We analyzed patients with histologically proved adenocarcinoma of the prostate to determine the natural history of prostatic cancer in men less than 45 years old. The mean age of the patients was 41 years (range 36 to 44 years). At presentation 5 patients were asymptomatic, 5 had voiding symptoms, 3 had bone pain, 3 had hematuria and 1 had testicular pain. Followup in these patients ranged from 19 to 270 months, with a mean of 111 months. Six patients with clinical stage B disease at diagnosis underwent radical retropubic prostatectomy. These patients enjoy projected 10 and 15-year survival rates of 100 and 82 per cent, respectively. Four patients with stage C disease died of prostatic cancer, although 1 survived for 204 months. Of 4 patients with stage D disease 3 died within 13 months, while 1 still is alive at 48 months. No patient with a Gleason tumor score of 8 to 10 survived more than 13 months. Patient age at presentation appears to be less important than clinical stage, histological grade or treatment modality in the prediction of the course of prostatic cancer. Young men with localized disease at presentation should be treated aggressively and they should have survival rates comparable to actuarial expectancy.     

Disease recurrence in black and white men undergoing radical prostatectomy for clinical stage T1-T2 prostate cancer

PURPOSE: The reported incidence and mortality of prostate cancer are higher among black than white men. Reasons for the disproportionate racial incidence of this disease are not known but most surveys suggest that increased mortality among black men is due to more advanced tumor stage at diagnosis. To determine if racial differences exist in men with similar stage disease we compared disease recurrence in black and white men who underwent radical prostatectomy for clinical stage T1-T2 prostate cancer. MATERIALS AND METHODS: We reviewed the records of all 257 white and 218 black men undergoing radical prostatectomy for clinical stage T1-T2 prostate cancer at the Louisiana State University Medical Center-Shreveport and the Overton-Brooks Veterans Affairs Medical Center between January 1990 and November 1998. Age, race, serum prostate specific antigen (PSA), ultrasound measured prostate volume, PSA density (PSA divided by prostate volume), histological features of the prostate biopsy, clinical stage, pathological stage, histological features of the radical prostatectomy specimen and disease recurrence were reviewed. RESULTS: Black men had significantly higher mean serum PSA and PSA density than white men (2-sided p = 0.005 and 0.03, respectively). There were no statistically significant differences by race in terms of patient age, prostate volume, clinical stage, biopsy Gleason score, pathological stage, positive pelvic lymph nodes, positive surgical margins or PSA recurrence rates. CONCLUSIONS: Black men with clinical stage T1-T2 prostate cancer who underwent radical prostatectomy had significantly higher serum PSA and PSA density than similarly treated white men. However, race appears to have no independent impact on pathological findings or disease recurrence in men with clinically localized prostate cancer treated with radical prostatectomy when the effects of differences in serum PSA are controlled.     

Combined gold seed implantation and external radiotherapy for stage B2 or C prostate cancer

Patients with clinical stage B2 or C prostatic carcinoma represent a group for which there are several treatment options. We followed the course and outcome of 72 patients with clinical stages B and C prostate cancer who were treated with surgical staging, insertion of gold grains and external radiation at our institutions between 1975 and 1984. Of the patients 44 (61 per cent) had clinical stage B disease and the majority (89 per cent) of these were stage B2 lesions. The remaining 28 patients (39 per cent) had clinical stage C tumors. In our series 27 per cent of the clinical stage B and 68 per cent of the clinical stage C cancer patients had positive lymph nodes. The 5-year survival free of disease was 52 per cent for patients with both stages of disease. The 7-year survival free of disease was 47 per cent for patients with clinical stage B and 14 per cent for those with clinical stage C cancer. Lymph node status did not have a statistically significant effect on total survival but survival free of disease correlated significantly with node status. Local treatment failures were defined as patients who required transurethral prostatic resection or orchiectomy for palliation of obstructive symptoms related to local tumor regrowth. By these criteria we prevented local progression in 78 per cent of the patients at 5 years.     

Clinical study on prostatic cancer patients

Clinical observations on prostatic cancer were studied in 27 patients who had been managed in our department between April, 1980 and December, 1986. The mean age at the time of initial clinical visit was 70.6 years old with a range of 55 to 88 years old. Of all 27 patients, 15 men (55.6%) were senior citizens over 70 years old and indeed 23 men (85.2%) were over 60 years old. According to the general rules for clinical and pathological studies on prostatic cancer, there were 10 patients with stage A, 2 patients with stage B, and 15 patients with stage D disease. However, none of our patients had stage C foci of prostatic cancer. Histopathologically, biopsied or surgically resected specimen all showed adenocarcinoma. More frequently the incidence of poorly differentiated adenocarcinoma was found in the specimen from the patients with advanced clinical disease. Anti-androgen therapy with castration or a combined hormonal manipulation initially was done in 25 patients. Simple hormonal treatment using chlormadinone acetate (CMA) was given in 13 patients. Of 25 patients who received hormone treatment, 22 underwent castration whereas, 12 of 13 having undergone single hormonal therapy were castrated. Combined chemohormonal therapy using UFT and CMA or additionally given estramustine phosphate disodium (Estracyt) was subjected only to stage D disease of prostatic cancer. Of 15 patients surgically treated, 11 received transurethral resection of the prostate on the basis of initial diagnosis of benign prostate hypertrophy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Association between American Urologic Association (AUA) urinary symptom score and disease stage in men with localized prostate cancer

We assessed the relationship of American Urological Association (AUA) urinary symptom score and tumor stage in men treated for localized prostate cancer. METHODS: Participants in our study were found through urology and radiation oncology clinics, and all eligible patients were asked to take part. All patients had been initially diagnosed on the basis of rising PSA or abnormal physical examination. Histological confirmation of diagnosis was obtained for all subjects. Tumor stage was determined by digital rectal examination. 265 men with prostate cancer were studied. RESULTS: There was a significant difference in AUA symptom score in the three disease stages (p = 0.035, one way anova). Tukey's multiple range B test showed a significant difference between the AUA symptom scores of patients with t3 disease, when compared to patients with t1 and t2 disease (p = 0.05). The range test showed no significant difference between the AUA symptom scores of patients with t1 and t2 disease (p = 0.897). There was a significant difference in mean age of men with t1, t2, and t3 disease (p < 0.001). Men with t2 disease had a mean age of 69 years, as opposed to men with t1 and t3 disease (mean ages 66 and 64, respectively). Tukey's multiple range B test showed a significant difference (p = 0.05) between the ages of the men with t2 disease and the men with t1 or t3 disease. But there was no significant difference between the ages of the men with t1 and t3 disease. There was no relationship between age and AUA symptom score (r = 0.008, P = 0.89). The AUA symptom score index classifies the symptoms of men with a score of 0 to 7 as mild, 8 to 19 moderate, and 20 and above as severe. According to this classification, 55.6% of the prostate cancer patients we studied had mild symptoms, 37.1% had intermediate symptoms, and 7.3% had severe symptoms. CONCLUSIONS: The majority (approximately 80%) of prostate cancers are found in the peripheral zone. But prostate cancers associated with urinary symptoms might arise in the periurethral transition zone, where almost all symptomatic benign prostatic hypertrophy originates. We hypothesize that symptomatic and non-symptomatic prostate cancer may be two distinct disease entities, each with its own characteristic genetic complement. In addition, urologists are actively seeking additional indicators of prostate cancer aggressiveness. Many prostate cancers are quite indolent and may never cause a problem, but it is impossible to identify such tumors with certainty. Further studies of AUA symptom score and outcome would be worthwhile. If AUA symptom score is a predictor of outcome that is independent of t stage, AUA score might be clinically valuable in disease management.     

Prostatic cancer in Aust-Agder County, Norway. Age, stage, grade and mode of presentation

Two hundred and five patients (89 per 100,000 men) with newly diagnosed prostatic cancer comprises all cases in the Aust-Agder County in Norway over a 5-year period. There were 36% stage T0 M0, 19% T1-2 M0, 16% T3-4 M0 and 29% T0-4 M1. In patients with well differentiated disease (G1), 8% had distant metastases on presentation, whereas in the moderately differentiated tumors (G2) and the poorly differentiated tumors (G3) distant metastases occurred in 30% and 62%, respectively. A statistically significantly higher proportion of well differentiated (G1) tumors were observed in the younger age groups (less than 70 years). On presentation diagnosis was suspected on routine digital rectal examination in 9% of the patients, while 12% had symptoms on disseminated disease as mode of presentation. Of patients operated upon for apparently benign hyperplasia 13% had prostatic cancer.     

Prognostic factors in localized prostatic carcinoma

Serial histological sections were performed in 54 radical prostatectomy specimens in an attempt to identify prognostic factors responsible for dissemination of prostatic cancer. Factors considered in the study included clinical versus pathological staging, histological grading of the biopsy specimen compared to the final pathological result, intraprostatic tumor distribution and deoxyribonucleic acid analysis of the tumor by flow cytometry in the last 33 cases. In patients with clinical stages A2 and B1 disease pathological findings were in accord in 78 per cent (11 of 14). However, only 3 of 40 patients with clinical stage B2 tumor had pathological stage B2 disease. Histologically, 72 per cent of the tumors were bilateral. Microscopic involvement of the capsule per se did not appear to influence lymph node invasion, since only 1 of 27 patients with microscopic capsular involvement had pelvic lymph node metastasis. However, 9 of 13 patients with seminal vesicle involvement had pelvic lymph node metastasis. The addition of flow cytometry to the Gleason score improves the predictive value of histological grade in higher stage lesions.     

Operable prostatic carcinoma: correlations among clinical stage, pathological stage, gleason histological score and early disease-free survival

We investigated the relationships among clinical and pathological stages, Gleason histological score and early disease-free survival of 75 patients with localized prostatic carcinoma treated by radical prostatectomy. Carcinoma was confined histologically to the prostate in 81 per cent of the patients with clinical stage A2, 79 per cent with B1N, 38 per cent with B1 and 0 per cent with B2 tumors. The Gleason score correlated directly with clinical and pathological stages, estimated extent of intraprostatic tumor and invasive capacity of the primary tumor. Of the tumors with a Gleason score of 8 or more 81 per cent extended beyond the prostatic capsule. Of 12 patients who suffered distant metastases 9 had tumors that extended beyond the prostatic capsule and 5 had tumors with Gleason scores of 8 or more.     

Prostate specific antigen in the diagnosis and treatment of adenocarcinoma of the prostate. I. Untreated patients

Serum prostate specific antigen levels were determined (Yang polyclonal radioimmunoassay) in 230 men with untreated adenocarcinoma of the prostate after careful clinical staging. Prostate specific antigen was directly proportional to advancing clinical stage, statistically failing to distinguish only between consecutive stages B2 and B3, and between stages C and D1. Serum prostatic acid phosphatase by radioimmunoassay was unable to distinguish men with stages C plus D1 from B2 plus B3 disease but it could distinguish stages C plus D1 from A2 plus B1 (p equals 0.015). Serum prostate specific antigen was directly proportional to increasing Gleason score. In 59 untreated patients multiple prostate specific antigen values were obtained during a mean followup of 10 months. Of the patients 81 per cent showed a steady increase with time, including 91 per cent of men with clinical stage B2 or greater disease. The rate of increase accelerated with time, and correlated with advancing tumor stage and increasing serum concentration of prostate specific antigen. The rate of increase of prostate specific antigen in clinical stages A and B cancer patients suggested a doubling time of at least 2 years. Serum prostate specific antigen was significantly decreased by transurethral resection of prostatic tissue in patients with cancer, as has been shown previously in patients with benign prostatic hyperplasia.     

Preoperative parameters, including percent of positive biopsy cores, in predicting pathological findings after radical prostatectomy

OBJECTIVES: We investigated whether preoperative parameters predict pathological stage at radical prostatectomy for patients with clinically localized prostatic cancer. MATERIALS AND METHODS: We studied a total of 160 men with clinically localized prostatic cancer (less than or equal to clinical T2) who underwent radical rertropubic prostatectomy at Wakayama Medical University. Clinical Ts patients are not included in this study. Preoperative parameters include patient age, Body Mass Index, preoperative serum PSA value, biopsy Gleason score, clinical stage, the percent of positive biopsy cores (%PosBx) and the percent of positive biopsy cores on the dominant side (%DomPosBx). Univariate and multivariate analysis were performed to examine the prognostic significance of these preoperative parameters. Significant independent factors were combined to create a table to predict pathologically organ confined disease. RESULTS: Univariate analysis showed preoperative serum PSA value (p< 0.001), biopsy Gleason score (p =0.001), clinical stage (p = 0.026), %PosBx (p= 0.002) and %DomPosBx (p=0.003) were significantly related to the pathological stage. On multivariate analysis, serum PSA value (p< 0.01), biopsy Gleason score (p<0.05) and %DomPosBx (p<0.05) were significant independent predictors of pathological stage. CONCLUSION: We provide two model combinations using preoperative clinical factors, one is a combination of serum PSA and biopsy Gleason score and the other is a combination of serum PSA and %DomPosBx, which define a new preoperative model for predicting pathological organ confined prostatic cancer. These combinations are useful and provide important information for urologists to determine the appropriate treatment strategy for clinically localized prostatic cancer.     

Outcomes of radical prostatectomy for patients with clinical stage T1a and T1b disease

OBJECTIVE

To compare the outcomes between patients with stage T1a/b with those of patients with T1c cancer of the prostate treated with radical retropubic prostatectomy (RRP), as the appropriate management of clinical stage T1a/b prostate cancer is subject to debate; although many patients are managed expectantly, some have adverse pathological features suggesting that more active treatment might be beneficial.

PATIENTS AND METHODS

From 1983 to 2003, 3478 men had RRP by one surgeon. From this group, we retrospectively identified 29 men with clinical stage T1a and 83 with clinical stage T1b disease. Using statistical analysis we compared the treatment outcomes of these patients with those of 1774 men with clinical stage T1c disease.

RESULTS

Men with T1a/b disease had a significantly lower preoperative prostate‐specific antigen (PSA) level, a greater proportion with organ‐confined disease, and a lower mean/median prostatectomy Gleason score than those with T1c disease. Also, men with T1a/b disease were less likely to be potent before surgery, although the frequency of recovery of potency was similar among all groups. On multivariate analysis with age, year of surgery, PSA level and Gleason score, there was no statistical difference in the rates of biochemical recurrence and the 10‐year overall survival rates. However, patients with T1b disease had a significantly lower cancer‐specific survival.

CONCLUSIONS

T1a and T1b prostate cancer can be associated with aggressive pathological features and have a similar rate of progression as clinical stage T1c disease. That notwithstanding, most patients in the study were cured with RRP and had favourable long‐term functional outcomes.     

Clinical study on prostatic cancer detected incidentally by transurethral resection of the prostate

Transurethral resection of the prostate (TUR-P) was performed on 463 consecutive patients with clinically diagnosed benign prostatic hyperplasia (BPH) between April 1994 and June 2000. Pathological examinations of resected prostatic tissues revealed prostatic cancer in 15 (3.2%) of them. Eight (53.3%) of them were in stage A1, and 7 (46.7%) in stage A2. Between 15 cases with prostatic cancer and those with BPH, clinical features including age, serum prostate specific antigen (PSA) levels, prostatic volume, PSA density (PSAD), and resected prostatic tissue weight were compared. As a result, age was the only parameter related with prostatic cancer with a statistically significant difference. The higher the age, prostate cancer was found more frequently. Postoperatively, radical prostatectomy and antiandrogen therapy were performed in 1 and 9 cases, respectively. The remaining 5 cases are being followed with no treatment for prostatic cancer, and have shown no findings suggesting recurrence. These 15 cases are all living disease-free at present. It seems of importance to explain preoperatively the possible detection of prostatic cancer in association with TUR-P, particularly for elderly patients aged 80 years or older.     

Intermediate-term survival results in clinically understaged prostate cancer patients following radical prostatectomy

To determine the natural history of clinically understaged prostatic cancer patients who were followed without adjuvant therapy for at least 6 years after radical prostatectomy we reviewed the clinical courses of 21 patients (1 with clinical stage A and 20 with clinical stage B disease). All patients underwent radical retropubic prostatectomy and 9 had pathological stage C disease (6 with capsular penetration only and 3 with seminal vesicle invasion). A total of 12 patients had pathological stage D1 disease by virtue of positive nodes on permanent sections after frozen sections were read as negative. Among the patients with pathological stage C disease 67 per cent were free of recurrence 6 years after radical prostatectomy. Of the patients with seminal vesicle invasion 33 per cent had recurrence compared to 17 per cent of those with capsular penetration only. Among the 12 stage D1 cancer patients 75 per cent were free of recurrence at 6 years. In both groups patients who were followed beyond 7 years had a diminished survival free of tumor owing to late tumor recurrences. The results indicate that the intermediate survival rates free of tumor in patients with clinically understaged A or B prostatic cancer are remarkably good without adjuvant therapy. However, survival without recurrence appears to decrease after 7 years. All patients who failed treatment did so distantly; no patient failed with local recurrence alone. These results may be important in the evaluation of adjuvant therapy protocols currently under investigation for patients with clinically understaged prostate cancer.     

Predictors of first repeat biopsy cancer detection with suspected local stage prostate cancer

PURPOSE: We determine demographic and tumor related predictors of repeat biopsy cancer detection in men with suspected stage T1c-2 prostate cancer. MATERIALS AND METHODS: The study population included 298 consecutive men with suspected stage T1c-2 prostate cancer who had a benign prostate biopsy at 1 institution between January 1, 1992 and April 1, 1999 and underwent 1 repeat biopsy. Mean age plus or minus standard deviation was 66.8+/-6.7 years for 133 black (55%) and 165 white (45%) patients. Clinical measures included determination of high grade prostatic intraepithelial neoplasia in benign biopsy specimens, Gleason score of malignant biopsy specimens, prostate specific antigen (PSA), PSA density, annualized interbiopsy PSA change, percent free PSA (201 cases) and PSA velocity (171). RESULTS: Cancer was detected on repeat biopsy in 80 cases (27%). Significant differences between patients with benign and malignant repeat biopsies included age (p = 0.001), PSA density (p = 0.0001), percent free PSA (p = 0.0001) and PSA velocity (p = 0.009). High grade prostatic intraepithelial neoplasia in an initial benign biopsy was not predictive of cancer in repeat biopsy (p = 0.12). Multiple logistic regression analysis of all cases showed that age (p = 0.002) and PSA density (p = 0.0002) were independent predictors of cancer. Subset multiple logistic regression analysis modeled with age, PSA density and percent free PSA demonstrated that age (p = 0.002) and percent free PSA (p = 0.0001) were significant independent predictors of malignancy. Subset multiple logistic regression analysis modeled with age, PSA density, percent free PSA and PSA velocity revealed that age (p = 0.02) and percent free PSA (p = 0.0003) were significant independent predictors of cancer. There were no significant differences between the Gleason scores of cancers detected on repeat biopsy compared to 587 stage T1c-2 cancers detected on initial biopsy during the study period (p = 0.09). PSA, PSA density, percent free PSA and PSA velocity were not significantly different among men without a cancer diagnosis who had high grade neoplasia in 1 or 2 benign biopsies. CONCLUSIONS: Greater than 25% of this population of select patients with suspected stage T1c-2 prostate cancer had malignancy detected on repeat biopsy. Percent free PSA was the most powerful predictor of cancer. High grade prostatic intraepithelial neoplasia was not a predictor of repeat biopsy cancer detection and PSA functions were similar among men without cancer who did and did not have high grade neoplasia in 1 or more benign biopsies. This finding suggests that high grade prostatic intraepithelial neoplasia may not be a reliable indicator of clinically significant existing prostate cancer.     

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.     

A pilot study analyzing PSA,serum testosterone,lipid profile,body mass index and race in a small sample of patients with and without carcinoma of the prostate

Androgens, diet, race and obesity are thought to play some roles in the pathogenesis of prostate cancer. We wanted to evaluate if there were any inter-relationships between prostate specific antigen (PSA), serum testosterone, serum cholesterol, HDL, triglycerides, body mass index (BMI) and race, in older patients with and without prostate cancer (CaP). We evaluated 308 patients referred to urologists in private practice offices and clinics with and without prostate cancer with regard to race, serum PSA, age, serum testosterone, full lipid profile, height and weight, and stage of cancer. We used multivariate analysis, Fisher's exact test and t-tests as well as logistic regression analysis. Data was analyzed using SPSS computer software, and P-values<0.05 were considered statistically significant. Significantly higher levels of serum testosterone were found in black men with CaP than black men without CaP (526+/-28 vs 404+/-19, respectively.) We also found significantly higher levels of serum testosterone in white men with CaP than white men without CaP (409+/-20 vs 302+/-14, respectively, P<0.05). HDL was higher in black men than white men, and triglycerides were higher in white men than black men. Cholesterol was similar across all groups, but BMI was highest in white men with CaP. We also found a significant association between BMI and pathological stage of prostate cancer patients among both black and white men (P<0.05). Our study demonstrated that black men who developed CaP had higher serum testosterone levels, on average, than white men who developed CaP. Furthermore, BMI was highest in white men developing CaP compared to black men, but we found a significant association between pathological stage and BMI in both black and white patients. Although it is controversial whether obesity is considered to be a risk factor for prostate cancer, this small pilot study suggests that BMI may play a role in the progression of the disease once it is established.Prostate Cancer and Prostatic Diseases (2001) 4, 101-105     

Prostate specific antigen in the staging of localized prostate cancer: influence of tumor differentiation, tumor volume and benign hyperplasia.

To evaluate the usefulness of serum prostate specific antigen in the preoperative staging of prostate cancer we examined tumor volume and differentiation, as well as benign prostatic hyperplasia volume to determine their influence on serum antigen levels. Serum prostate specific antigen was measured in 350 men with clinically localized prostate cancer and preoperatively in 72 men with documented benign prostatic hyperplasia. Although the mean antigen levels increased with advancing pathological stage, the usefulness of prostate specific antigen to predict pathological stage for an individual patient was limited: 1 of 102 men (0.9%) with prostate specific antigen levels of less than 2.8 ng./ml. had positive lymph nodes and 5 of 5 men with levels of greater than 100 ng./ml. had either seminal vesicle or lymph node involvement. However, for the majority of men (greater than 70%) with prostate specific antigen values between these 2 extremes the antigen levels did not accurately predict pathological stage. Because serum prostate specific antigen levels correlated with morphometrically determined tumor volume (r equals 0.535, p less than 0.01) they should, in fact, be predictive of pathological stage. However, most men with prostate cancer also have varying degrees of benign prostatic hyperplasia tissue in the gland producing prostate specific antigen. We have found that serum prostate specific antigen does not correlate with the volume of benign hyperplasia within the gland (r equals 0.21, p greater than 0.05). In addition, immunohistochemical studies have suggested that the lack of correlation between pathological stage and serum prostate specific antigen might be explained by a decrease in the production of antigen with increasing histological grade. Our findings of a negative correlation (r equals -0.37, p less than 0.01) between serum prostate specific antigen levels and Gleason score adjusted for tumor volume confirmed this suggestion. Consequently, serum prostate specific antigen levels do not reflect tumor burden and pathological stage accurately in individual patients for 2 reasons: 1) the unpredictable contribution from the benign prostatic hyperplasia component of the gland and 2) the decreasing production of prostate specific antigen by higher grade lesions as tumor volume increases.     

Role of nerve-sparing radical prostatectomy for clinical stage B2 prostate cancer.

To examine the role of nerve-sparing radical prostatectomy in patients with clinical stage B2 prostate cancer we reviewed the first 77 such patients in our series since we adopted the nerve-sparing technique. A total of 47 patients (61%) underwent bilateral and 26 (34%) underwent unilateral nerve-sparing prostatectomy, while in 4 (5%) both neurovascular bundles were resected. Among the patients followed for 12 months 27 of 41 (66%) treated with bilateral and 7 of 19 (37%) treated with unilateral nerve-sparing prostatectomy had potency preserved. With the strict clinicopathological criteria of organ-confined tumor, that is intracapsular tumor with negative surgical margins and undetectable postoperative prostate specific antigen levels, complete tumor excision was achieved in 17 patients (36%) treated with bilateral and 7 of 26 (27%) treated with unilateral nerve-sparing prostatectomy. All patients in whom both neurovascular bundles were resected had pathological stage C or D1 disease. Of the 24 patients who had complete tumor excision by the strict criteria only 15 (19.5% of the 77 preoperatively potent patients) had potency preserved. Of these patients 19 had microscopically positive margins without seminal vesicle invasion (pathological stage C1) with undetectable postoperative prostate specific antigen levels. In addition, 4 patients had seminal vesicle involvement with negative surgical margins and undetectable postoperative prostate specific antigen levels. If these patients also are considered as having complete tumor excision, there was an over-all complete tumor excision rate of 61% (47 of 77), of whom 25 (32% of the 77 patients) had preservation of potency. Ten patients with clinical stage B2 tumor whose potency was preserved had histological and serological evidence of incomplete tumor excision. Of 53 patients with pathological stage C1 disease 9 (17%) had margins positive only in the regions of the neurovascular bundles. Preoperative prostate specific antigen and acid phosphatase levels, and findings on transrectal ultrasonography failed to predict accurately which patients had extracapsular tumor extension. Patients with poorly differentiated tumors and/or bulky disease on rectal examination had a higher incidence of extracapsular extension and positive margins. We conclude that in the majority of potent patients with clinical stage B2 prostate cancer not all of the goals of nerve-sparing radical prostatectomy are realized.(ABSTRACT TRUNCATED AT 400 WORDS)     

Assessment of screening for prostate cancer using the digital rectal examination

An early detection study for prostate cancer was initiated to determine the effect of routine digital rectal examinations on the stage of prostate cancer at diagnosis. A prostate biopsy was recommended if induration, asymmetry or nodules were detected on the digital examination. During a 6-year period 4,160 examinations were performed on 2,131 men more than 45 years old. A prostate biopsy was performed on 144 men and 36 malignant tumors were detected, of which 68 per cent were clinically localized. Pelvic lymph node metastases were found in 6 per cent of the surgically staged cancer patients and in 10 per cent of the patients who had a high grade tumor. Surgical staging revealed that 50 per cent of the patients with clinical stage B disease were upstaged to stage C or D1 disease. These results suggest that mass screening programs using digital examination may not add sufficient benefit over conventional medical care to warrant the expense. Definitive proof that screening can lower the mortality rate from prostate cancer can be obtained only by a prospective randomized clinical trial.