Carcinoma of the Prostate: Analysis of 200 Cases

Ttt!<; ,IOlTH:-;J"AI~ OF UROLOGY

YoL 81 1 No. 1, January 1959

Printed in V.S.A.

CARCINO::\IA OF THE PROSTATE: ANALYSIS OF 200 CASES WILLIAM J" BAKER

used" If the removed prostate contained adenoor scirrhous cancer, removal of the capsule, wa,; advised, as well as bilateral orchiectomy, and estrogens ordered" In the past few years we have been doing suprapubic enucleations of advanced cancer in large prostates, along 11 itli bilateral orchiectomy am! administration (if" estrogens" 1Y e lmvP had poor luck in convincmg private patients, who have had a transurethrnl resection and the removed tissue shows real cancer, to undergo rndical prnstatovesiculectomy hy any route" J\Iost of these will choose orr,hiectomy, estrogens, deep x-ray and Portisone- W ,' continue to evaluate the use of radioactive for cancer of the prostate glancL -With these lmsil"

The histories and office records of 200 private patients ,vith carcinoma of the prostate gland have been studied in order to bring out facts which might stimulate discussion of this panel TABLE

L Carci"noma of the prostate; 200 Mstories of private patients rev"iewed White patients---182 Colored patients--18

Time interval- 1926 to 1956 59 patients could not be traced 103 patients have died 38 patients are living TABLE

2" Carcinoma of prostate- Prolonged life without estrogens

Occu .. pation

Procedures

X-Ray

Estrogens

findings

Remarks

I

~-1 Busi- , T"-o stage ness n1an

Eugi-

neer

'

''

suprapubic pros ta tee-

No metastases

Not determined

11 yrs" 6

Refused all estro gens" J\!Iyocardial cleallL

tomy T"UJL Vas-

Allergic Lo al I cs

ectomy

t,rogens" JVfyocardial death.

Ph:vsi("Ian

Radical peri-

Reflrned all estrogens" Accident.al death from ('On

neal prost ato-vesiculectomy

CUE,:Sion,

(table 1). These patients were treated during the years J920 to 1956" "-\Jl patients had a positive tissue diagnosis for carcinoma of the prostate gland. 1Ve have used the philosophy of doing radical perinea] prostatovesiculectomies on proven small, well-defined cancers. These patients have been kept on estrogens" The past two years have found us abandoning the perineal route for the retropubic approach for radical prostato" yesiculectomies" If removed prostate contained so-called occult cancer cells, estrogens have been Read at annual meeting of Southeastern Section of American Urologieal Association, Inc", Holly1rnod, FbL, January 12"-16, 1958"

facts in mind, let us look at these 200 with proven prosfatic canceL 11'e know 1Yhat happened to Hl3 nf thPsr patients" They died. Some of them died prcm:1 turely because we failed to notify them to rctuni for estrogens or orchiectomy after 194L Thr, fol. lowing tables contain the factB in regard to tbo~,: dead patients who lived more than five yearn. Table 2 proves that you can have longevity in patients with cancer of the prostate gland withou( the use of estrogens or orchicctomy. One had a suprnpubic prostatectomy, one had a ra.climl perineal prostatovesiculectomy, and one a tram,urethral prostatie resection. T\\-o of these

197

198

WILLIAM J. BAKER

lived 11½ years and one lived 13 years. None of them died a prostatic metastatic death. All of the patients listed in table 3 suffered from cancer of the prostate gland before the use of estrogens or orchiectomy. They lived 15 years, 10 years, five years eight months, five years six months and six years, respectively. All except one died a prostatic metastatic death. TABLE

Race Age

Name

Table 4 depicts the facts of those patients who underwent radical perineal prostatovesiculectomies. They lived eight years three months, 12 years, 11 years six months, 16 years and five years. Only two of these patients died a prostatic metastatic death. It is of scientific interest that in one of these patients a fatal lymphatic leukemia developed. The possible relationship between

3. Carcinoma of the prostate. Five or more years o.f life without estrogens Occu-

pation

Procedures

X-Ray findings

Longevity after Path. Diagnosis

Remarks

---

-- --

w

Estro- Phospha tases gens

No me- None Not de- 15 yrs. Death from myoBanker Suprapubic tercardial failure tasprostatectomy tases mined ------------------------ -------- ---- ---------No me- None Not de- 10 yrs. Prostatic metastatic J.R. w 69 Car- T.U.R. pentasterdeath mined ter tases ---- --- ----- ---- --------------- - - - - - - - Perineal pros- No me- None Not de5 yrs. Prostatic metastatic J.D. w 60 Laborer tatectomy tas ter8 mos. death tases mined ---- -- -- ---- -------- ---- --- ----- ---- ----------Bony 5 yrs. Prostatic metastatic None Not deG.C. w 83 Farmer T.U.R. meter6 mos. death tasmined tases ---- -- -- ---- -------- ---- --- ----- ---- ----------J.N. w 73 Busi- 1, Prostatec- No me- None Not de- 6 yrs. Prostatic metastatic tomy. death ness tastermined man 2,T.U.R. tases C.L.M.

62

I

TABLE

Name

N.M.

Race

w

4. Carcinoma of the prostate. Patients who lived more than five years on estrogens Age

Occupation

Procedures

Athletic

Radical perineal prostatovesiculectomy

-63

X-Ray Findings

Estrogens

Longevity after Path. Diagnosis

Phosphatases

Remarks

--coach

Nome-

tastases

Stilbestrol 1 mg. b.i.d.

Alkaline 5.25 Acid 0.90

8 yrs. 3 mos.

Developed fatal lymphatic leukemia

--

C.H.S.

w

W.T.V.

w

64

Clerk

Radical perinea! pros-1 No metatovesiculectomy tastases

Stilbestrol 1 mg. b.i.d.

Not determined

Physi-

Radical perineal prostatovesiculectomy

None

Not determined

I- 67

cian

No me-

tas-

12 yrs.

I- - - 11 yrs. 6 mos.

tases

A.W.

w

-67

I Business I Radical perinea! pros-1 man

R.F.

w

tatovesiculectomy

I- 60

Lawyer

1) Radical

perineal prostateetomy 2)Bilateral orchiectorny

No me-1 Stilbestrol tas-

1 mg.

tases

b.i.d.

No me-

tastases

Stilbestrol 1 mg. b.i.d.

-

Prosta tic metastatic death

I Not deter-

16 yrs.

mined

Refused all estrogens. Accidental death from concussion

I Death

from coro-

nary occlusion

I Alkaline 23.05 Acid 0.05

5 yrs.

Prostatic

meta-

static death

CARCINOMA OF PROSTATE

cancer and leukemia is further emphasized by two more of our patients with prostatic cancer in whom lymphatic leukemia has developed. Table 5 charts two patients who underwent suprapubic prostatectomies and three patients who underwent transurethral prostatic resections for cancer of the prostate gland. They also were subjected to orchiectomy and/or oral estrogens. One had much deep x-ray therapy. They lived seven years three months, 13 years, eight years, eight years and 10 years. All died a metastatic death. Thus, one can deduce that 86 of the 103 dead

patients lived less than five years. of these 86 occurred in the era before estrogens, orchiectomy, and cortisone. All of the 29 had far advanced cancers of the prostate Therapy consisted of cystotomy, sedatives and slow painful demise, So, 57 of our deceased patients had the advantage of relief from bladder neck obstruction, estrogens, orchiectomy, cortisone, deep x-ray and radiated gold but failed to live five years beyond the time when a positive diagnosis of cancer was made. were, however, quite comfortable and led useful lives until the last few weeks 0£ their

5. Carcinoma of the prostate. Patients who lived more than five years on estrogens

TABLE

- - - - - - - c - ,- - - - - - - - - - - - - ~ - - - - - - - - - - · - - - -

R

Nam-~ --ace -

____ __ R.VV.

A

0 CCU- II pation ___ _:

ge

____ W

60

chant

I-

KW.

W

pros-

W

--~---------!~-

F P

W

P 10sphatases

TACE, cortisone

~;~~-:J mos.

Acid 0.65

I f:Ldes man

i Suprapubic prostatecI tom?r \Sharp dis-

I Farmer

I T.1.J.R.

No metastases

!:Ut__

W

I 69

I

I ---~----·- - - - - TABLE

No metastases

Stilbestrol 5 mg.

Remark,.,

8 yrs.

13 yrs.

static death

p~;;ta~~~-

Prostatic

Pro.static

mcl,?,-

static deatb --- -- --1-- -~-- ------- - - -· -·

10 yrs.

Not determined

Pros~~-::----~~tn static death

Not determined

---1-~1--------1·-

I

-8 yrn--

min~:___

Stilbestrol 1 mg. a day

I

after Path.

No me- Stilbestiol Not detectas1 mg. mined I sectron) tases t.i.d. 1 I - - - - - ~ - _ _ _ _ _ _ I_ - - - ~ - - - ~ - - - - - - - - - 1 - - - - - - J,C

65

Longevity

l

strogens

Stilbestrol, Alkaline 5.65,

:::~s_

I

Business 1) T,U.R. man 2) Deep x-ray

70

1·

E

No m:-~tilbestrol - Not
2 - - - ~ - - - l _ _ l_l:::r~-1 ) Orcl:~t=-_I G.M.N.

I

No metastases

I tatcctomy : 2) Orchiectomy

I Interior I 1) T.U.R.

68

Xr-Ray Findings

Diagnosis

! 1) Suprapubic

I\:Ier-

I

I'

d

Proce ures

I!

Prostatic st,a tic dea lb

t.i.d.

6. Carcinoma of the prostate, living

Age \Vhen

Name

w

57

- W

I

73

I

Laborer

I

---;;;-1--;;-I

W

68

11) ,

Estrogens

No n1etastases

T. U.R.

Vasectomy T.U.R. Orchiectomy Suprapubic tomy

prostate,·-

Stilbestrol 1 mg. b.i.d.

I Metast<1ses

Stilbestrnl 5 -

to bone

mg q

1

d

[tl().

1

~~rbo;~~---- :a::::c:oe:::eal prostatec- [-;o~neta --;,;:-------

u;;.;-\-z - ;- SmW, G.C.M.

1) 2) 3) 4)

:

I -

Accountant

·1

I

I

I C.H,

X-Ray Findings

Procedures

---·-:-----

-A.A.I-I.

-KP

Occupation

First Seen

!

Clerk

'"=_I

,:::::""" mm<,~Wrne

1·

Penneal b10psy

I None

I

None

] 12

----i--- ------

Stilbestrol l mg. t.1.d.

I

r;,~~c~,-

,, yes

----~ --,~-~ ------~~ ----·---------1·--1---- -----· :

,

1

H.A.S.

I

W

I

62

I

Lawyer

T.U.R.

I

No metas-

_____________l__'_"s_es

_

Stilbestrol l

I

I I

1ng. b.1.d. __ !

----··-----··-···

200

WILLIAM J. BAKER

existence. This is quite a contrast to the 29 patients who did not have the advantage of our modern management of prostatic cancer. It was disconcerting to find that 59 of these 200 private patients could not be traced. It is apparently easy to lose track of people in large cities. Thirty-eight of the 200 patients are living. Tables 6, 7 and 8 list those patients who have lived over five years since a positive tissue diagnosis had been made. All of these 18 patients are comfortable. Only six of these 18 patients have TABLE

Name

Age When First

Race

had bilateral orchiectomy. Two of them underwent perineal biopsy for diagnostic purposes and have lived very well on oral estrogens. In recent months, we have been told by some workers that TACE does not control these cancers as well as other estrogens. Thirteen of these patients have survived on stilbestrol, one on estinyl, two on TACE and two on no estrogens. The two patients who are alive on no estrogenic therapy underwent radical perineal prostatectomy and suprapubic prostatectomy, respectively. Apparently the total cancer was removed in both patients. The two

7. Carcinoma of pi·ostate, living X-Ray Findings

Procedures

Occupation

Estrogens

Phosphatases

F.Mc.

w

Industrial

67

engineer

K.H.

F.G.

w

w

Engineer

50

1) T.U.R. 2) Orchiectomy

No metastases

Stilbestrol 5 mg. q.i.d.

Alkaline 4.2, Acid 1.3

1) 2) 3) 4)

No met.as-

Estinyl 0.01 mg. b.i.d.

Alkaline 9.3, Acid 0.85

T.U.R. Orchiectomy T.U.R. T.U.R.

tases

Longevity after Path. Diagnosis

Seen -- ---

6 yrs. 4 mos. 10 yrs.

---- ----Mechanical

63

engineer

1) Primary suprapubic prostatectomy 2) Vasectomy

No metastases

Stilbestrol 5 mg. t.i.d.

Alkaline 5.2, Acid 0.0

1) T.U.R.(5) 2) Orchiectomy 3) I.V. phosphorated estro-

Metastases to pelvic bones

Stilbestrol 5 mg. q.i.d.

Alkaline 16.4, Acid 12.0

No metastases

Stilbestrol 5 mg. q.i.d.

Alkaline 4.8, Acid 0.0

6 yrs. 2 mos.

--C.D.

54

C

Butcher

6 yrs.

gens

A.C.

w

Machinist

65

Perinea! biopsy

TABLE

6 yrs. 4 mos.

8. Carcinoma of prostate, living X-Ray Findings

Race

Age When First Seen

H.A.S.

w

62

Lawyer

T.U.R.

No metastases

Stilbestrol 1 mg. b.i.d.

5 yrs. 2 mos.

H.B.

W

58

I Farmer

T.U.R.

No metastases

Stilbestrol 1 mg. b.i.d.

9 yrs. 10 mos.

Name

I

Occupation

Procedures

Estrogens

Phos- Longevity After phatases Path. Diagnosis

-----1---------:------1-------1-----1----------:-------C.B.

W

I

64

Painter

l)T.U.R. 2) Deep x-ray

No metastases

TACE 12 rng. b.i.d. Cortisone 25 mg. b.i.d.

8 yrs

----i----·1--1-1---1-----I.B.

H.G.L.

W

I w

65

Laborer

T.U.R.

No metastases

Stilbestrol 1 mg. a day

10 yrs. 3 mos.

-------1------·:-------1-----1----------1 73

Insurance broker

T.U.R.

No metas-

Stilbestrol 1 mg. b.i.d.

tases

14 yrs. 9 mos.

------1--------------·l-------1-----1------------1-----G.G.

I

w

58

Executive

1) T.U.R. 2) Orchiectomy

No metastases

Stilbestrol 1 mg. b.i.d. Cortisone 25 mg. b.i.d.

5 yrs.

-J.W.--1--w--1-----1-------1--T-.u-.-R-.---1----,--------- ----1-----58

Salesman

No metastases

TACE 12 mg. b i.d.

10 yrs. 8 mos.

201

CARCINOMA OF PROSTA'l'E

patil nts who lmYe survived on TACJ,; have lived eight ancl 10 yearn. Their prostatoYC:sicular beds arc flat and firm. They arc comfortable. Sixteen of the 20 patients who have not reached their fifth ~-ear of survival arc using TACE. Their cancers seem well controller! and they am comfortable. Thrse tabulations indicate that phosphatase studic:s, when done, show increases in the scrum alkaline phosphatase ,,,due~ quite regularly. The scrum acid phosphatase values remain relatively normal. Although x-ray studies revealed no bony metastases in most the changes were probably there but not detected by x-ray ;,tudic,s. 0

TABLE 9.

1Ve have a.ll seen carcinoma clevrlop many yenr:, after enucleation of an nclenomatous prosta.tc, gbml. This cancer could dc\TE:lop from an :Fknom atous spheroid or tissue which wa.s not enucle-atccl. It is also tnw that c:auccr ,,-ill develop mam years after transurethral prostati,; resection. Ornnever knows n-hether there wc:re occult canr-('J cells in the first instance. Tables H and IO list tlt,: patients of this study' whose original pathological diagnosis was benign prostatic adenoma and in \Yhom cancer later developed. Eight of tlil'sr patients had transurcthrnl proc:c:durcs and one :, suprapubic prostatectomy. It r;cmld lw that the prostatic res
Pirst tissue e.x:aim·nat·ion, benign; la/er tissue c:r,aminati:on, ,.,m·cinoma --------

I

Name

,--.~--1~, W

C,oLtlreclB.

1)

85

2)

w

I Benign I Fe;-21,

T.U.R. T.U.R. T.U.R. T.U.R .

I

w

1)

75

2)

Pnmtatectomy

Benign

T.U.R.

Cancer

- - - - - - --------

I) 2)

57

Stat.us

JD55

Living

I )ea,!

l yr. 2 11)()~'.-

1 yr. 2

lll0S.

------·- - - - - - - -

-------

Sut.ton V.

Diagnosis

Date of Procedure

Benign I 8) Benign I I .J.) Cancer I '\Tov. 15, 195G -·-------i--------- ---- - - - - - - - - - - - · - - - · ]) T.U.R. Benign July 1, Hl51 65 I 2) T.U.R. Cancer July 28, 1[)51

------------ ----

An,tin N .

Path.

Procedures

Race

T.U.R. T.U.R.

-------··-· ~ - ~ ·

I

Benign Cancer

Dead

1936

Oct. --

HJ,

5 rno:--:.

l!NS

-------.------- ------

;\far . .J, 1952 Nov. 14, Hlti2

Livinis

D :ns_ 2 mos.

-----~

TAB!,E 10. First tissue e:ra.m:irwtion, lienign; later tissue examination,

carr-inoma

------

I

Name

Race

i

\Yhen Seen

Procedures I

-----1

I

:\Ticlrnel K.

,v

S3

Date of Procedure

Status

--

T.U.R. 2) T.U.R.

, 1) I j

Path. Diagno:::;is

Benign Cancer

Feb. 26, Hl44 June I, 1952

Living

Benign Cancer

May 12, 1985 Sept. 1, 1938

Dead

-i----~---

A.bralrnm W.

w

67

])

2)

T.U.R. Perinea! prostatectomy

---------

Henry J:\l.

w

67

1)

T.U.R. ! 2) T.U.R. ' i :3) T.U.R.

Benign Benign Cancer

Apr. 9, Hl35 Apr. l, 1940 Apr. 2\), HJ49

Living

8 yrs. 8 mos

76

1) T.U.R. 2) T.U.R.

Benign Cancer

Apr 1, 1939 Jan. 3, 1940

Dead

8 mos

1)

T.U.R. T.U.R.

! Benign

Dec. 3, 1947 Oct. 19, 1954

Living

2)

--··--------

Wm. ~- :.\le.

w

I

----~-

Barne)' R.

w

-----~----

70

Cancer

;) yrs 4 lllOS.

202

WILLIAM J. BAKER

areas of cancer, or that the pathologist did not examine the right prostatic chip, or that cancer developed after the operative procedure. Please note that the time interval is favorable in some instances to an inadequate prostatic resection and in other instances to the development of a cancer between operative procedures. What do all these facts mean? They indicate that our knowledge about the biological behavior of prostatic cancer is not complete. We should demur when we talk about the cure of prostatic cancer by any method. This is so because the cytological characters of malignancy may remain latent for years. There is even evidence to indicate that some prostatic cancers may develop into active cancers and others may regress without

any kind of treatment. These latent or retarded cancers grow very slowly but seldom metastasize to distant sites and these patients die from other causes. Furthermore, the cause of latency of prostatic cancer is unknown. It may be hormonal or it may be associated with the processes of aging. Finally, there is no reliable method of distinguishing latent from active prostatic cancers. Until we know more about biological host resistance, we must be cautious about our claims for any method of treatment of prostatic cancer.

7 W. Madison St., Chicago 2, Ill.

REFERENCE L. M.: Latency and progression in tumors: The natural history of prostatic cancer. Lancet, 2: 1037-1039, 1956.

FRANKS,