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Five and Seven Year Survival Results of Radical Prostatectomy in Clinically Understaged Stage A and B Prostate Cancer Patients
Accepted 481
482
FIVE AND SEVEN YEAR SURVIVAL RESULTS OF RADICAL PROST ATECTOMY IN CLINICALLY UNDERSTAGED ST AGE A AND B PROSTATE CANCER PATIENTS. Donald R. Miller* and William J. Catalona, St. Louis, MO (presentation to be made by Dr. Miller) To determine the efficacy of radical prostatectomy in the treatment of clinically understaged patients, we reviewed the records of 22 patients with clinical stage A or B prostate cancer treated with radical prostatectomy who had a final pathologic stage C (n = 9) or DI (n = 13) disease, all of whom were at risk for a minimum of 5 years and 12 of whom were at risk for 7 years. Patients were followed with physical examinations, biochemical profiles, bone scans and acid phosphatase measurements. Only 2 stage C patients, both of whom had recurrence, and I stage DI patient received adjuvant hormonal therapy. No patient received postoperative radiation therapy before local recurrence developed. Although the overall survival rate and recurrence-free survival rate were favorable at 5 years (78% alive, 78% recurrence-free for stage C and 77% alive, 69% recurrence-free for stage DI), there was a substantial diminution in both overall survival and recurrencefree survival rates among 12 patients who were at risk for 7 years (50% overall survival, 33% recurrence-free survival - all stage DI). One patient failed with local recurrence only; the remainder failed with local recurrence and/or distant metastases. The results demonstrate that 5 year· followup is inadequate to evaluate the efficacy of radical prostatectomy and that most understaged clinical stage A or B patients will fail after 5 years with distant metastases with or without local
RADICAL PROSTATECTOMY AND STAGE A PROSTATIC ADENOCARCINOMA. David F. Paulson and* Judy E. Robertson, Durham, NC (Presentation to be made by Dr. Paulson) Sixty-eight patients with T 1N0M0 prostatic adenocarcinoma underwent radical perineaI prostatectomy. All 68 had been unsuspected at the time of initial transurethral resection. Patients whose initial resection demonstrated focal malignancy had a repeat staging resection. The identification of any residual malignancy prompted reclassification as Stage A2 . Outcome was assessed as a function of Gleason sum and local anatomic extent of disease. No perioperative deaths occurred 1 no patient suffered rectal injury, no patient was incontinent postoperatively. Seven of 68 patients failed. Two of 31 patients (6%) with organconfined disease failed at 2.6 and 4.3 years. Thirtyfour patients had not organ-confined disease, 10 with specimen-confined disease and 24 with margin positive disease. Zero of 10 with specimen-confined disease failed while 5 of 24 with margin-positive disease failed at 0.9, 1.2, 3.2, 3.2 and 8.0 years. The distribution frequency of the Gleason sum was noted to shift to higher total sum as the extent of local disease increased. Kaplan-Meier analysis of the failure rate of both organ-confined and not confined with a Gleason sum 7 versus 7 demonstrated an advantage to those (P 0.005), However, for organ-confined disease, Gleason sum did not predict failure. The data suggests that occult prostatic malignancy can be treated with safety and efficacy by radical prostatectomy, that failure is dependent on local extent of disease, and local extent of disease is related to increasing Gleason sum of the resected primary.
recurrence.
483
484
WHOLE ORGAN MAPPING OF RADICAL PROSTATECTOMY SPECIMENS. *Thomas M. Wheeler, Peter T. Scardino, *!ladeline Cantini, Houston, Texas (Presentation by Dr. Thomas Wheeler). Detailed mapping of prostatic carcinoma and ductal dysplasia was carried out on 46 radical prostatectomy specimens from whole organ sections. This series of clinically staged patients consisted of 17 A2, 19 81, 7 82, and 3 C1 patients. Thirty-seven patients had more than one focus of carcinoma (80%). Associated ductal dysplasia/carcinoma in situ was present in 41 of 46 patients (89%). Except for one patient who had no residual invasive carcinoma, all had tumor which abutted on the capsule. Stage A2 differed from stage 8 and C in that four or more separate foci of tumor were present in 53% of the former compared to 14% of the latter. Nearly all stage A2 patients had disease anteriorly (94%) and all stage 8 and C had tumor posteriorly. However, 81% of stage A2 patients also had disease posteriorly and 55% of stage 8 and C patients anteriorly. Degrees of extension outside the prostate were defined as level 0, confined to glandular prostate; level I invasion, beyond the extent of normal glands but not into the fascia; level II invasion, into the fascia; level III invasion, through the fascia into the periprostatic soft tissue. All patients with level O or I invasion had negative seminal vesicles and negative nodes while 24% of level II and 35% of level III had positive seminal vesicles and/or positive nodes on permanent sections. Level III invasion occurred in 24% of A2, 42% of 81, and 75% of 82 and C patients. Looking at confinement in the opposite way, 52% of A2, 14% of 81, and 0% of 82 and C1 had either level O or I invasion. These results indicate that the pattern of prostatic cancer is distinctly different in nonpalpable (A2) and palpable (8 and C) tumors and that the tumor always arises adjacent to or invades the capsule.
PROSTATE SHAPE, EXTERNAL STRIATED URETHRAL SPHINCTER, AND RADICAL PROSTATECTOMY: THE APICAL DISSECTION. Robert P. Myers, John R. Goellner*, and (Presentation to be Donald R. Cahill*, Rochester, MN made by Dr. Myers) In an anatomic study of 64 gross specimens, the external striated urethral sphincter was reconfirmed to extend as a single unit from the proximal penile urethra to the bladder base. The configuration of the external striated urethral sphincter was variable and was related to the shape of the apical prostate. Two basic prostatic shapes were recognized, distinguished by the presence or absence of an anterior apical notch. Whether or not a notch existed depended upon the degree of lateral lobe development and the position of its anterior commissure. In radical prostatectomy, knowledge of the variation in the shape of the prostatic apex can help the surgeon achieve optimal urethral transection with maximal preservation of the external striated urethral sphincter and other tissues of the continence mechanism.
224A
482
FIVE AND SEVEN YEAR SURVIVAL RESULTS OF RADICAL PROST ATECTOMY IN CLINICALLY UNDERSTAGED ST AGE A AND B PROSTATE CANCER PATIENTS. Donald R. Miller* and William J. Catalona, St. Louis, MO (presentation to be made by Dr. Miller) To determine the efficacy of radical prostatectomy in the treatment of clinically understaged patients, we reviewed the records of 22 patients with clinical stage A or B prostate cancer treated with radical prostatectomy who had a final pathologic stage C (n = 9) or DI (n = 13) disease, all of whom were at risk for a minimum of 5 years and 12 of whom were at risk for 7 years. Patients were followed with physical examinations, biochemical profiles, bone scans and acid phosphatase measurements. Only 2 stage C patients, both of whom had recurrence, and I stage DI patient received adjuvant hormonal therapy. No patient received postoperative radiation therapy before local recurrence developed. Although the overall survival rate and recurrence-free survival rate were favorable at 5 years (78% alive, 78% recurrence-free for stage C and 77% alive, 69% recurrence-free for stage DI), there was a substantial diminution in both overall survival and recurrencefree survival rates among 12 patients who were at risk for 7 years (50% overall survival, 33% recurrence-free survival - all stage DI). One patient failed with local recurrence only; the remainder failed with local recurrence and/or distant metastases. The results demonstrate that 5 year· followup is inadequate to evaluate the efficacy of radical prostatectomy and that most understaged clinical stage A or B patients will fail after 5 years with distant metastases with or without local
RADICAL PROSTATECTOMY AND STAGE A PROSTATIC ADENOCARCINOMA. David F. Paulson and* Judy E. Robertson, Durham, NC (Presentation to be made by Dr. Paulson) Sixty-eight patients with T 1N0M0 prostatic adenocarcinoma underwent radical perineaI prostatectomy. All 68 had been unsuspected at the time of initial transurethral resection. Patients whose initial resection demonstrated focal malignancy had a repeat staging resection. The identification of any residual malignancy prompted reclassification as Stage A2 . Outcome was assessed as a function of Gleason sum and local anatomic extent of disease. No perioperative deaths occurred 1 no patient suffered rectal injury, no patient was incontinent postoperatively. Seven of 68 patients failed. Two of 31 patients (6%) with organconfined disease failed at 2.6 and 4.3 years. Thirtyfour patients had not organ-confined disease, 10 with specimen-confined disease and 24 with margin positive disease. Zero of 10 with specimen-confined disease failed while 5 of 24 with margin-positive disease failed at 0.9, 1.2, 3.2, 3.2 and 8.0 years. The distribution frequency of the Gleason sum was noted to shift to higher total sum as the extent of local disease increased. Kaplan-Meier analysis of the failure rate of both organ-confined and not confined with a Gleason sum 7 versus 7 demonstrated an advantage to those (P 0.005), However, for organ-confined disease, Gleason sum did not predict failure. The data suggests that occult prostatic malignancy can be treated with safety and efficacy by radical prostatectomy, that failure is dependent on local extent of disease, and local extent of disease is related to increasing Gleason sum of the resected primary.
recurrence.
483
484
WHOLE ORGAN MAPPING OF RADICAL PROSTATECTOMY SPECIMENS. *Thomas M. Wheeler, Peter T. Scardino, *!ladeline Cantini, Houston, Texas (Presentation by Dr. Thomas Wheeler). Detailed mapping of prostatic carcinoma and ductal dysplasia was carried out on 46 radical prostatectomy specimens from whole organ sections. This series of clinically staged patients consisted of 17 A2, 19 81, 7 82, and 3 C1 patients. Thirty-seven patients had more than one focus of carcinoma (80%). Associated ductal dysplasia/carcinoma in situ was present in 41 of 46 patients (89%). Except for one patient who had no residual invasive carcinoma, all had tumor which abutted on the capsule. Stage A2 differed from stage 8 and C in that four or more separate foci of tumor were present in 53% of the former compared to 14% of the latter. Nearly all stage A2 patients had disease anteriorly (94%) and all stage 8 and C had tumor posteriorly. However, 81% of stage A2 patients also had disease posteriorly and 55% of stage 8 and C patients anteriorly. Degrees of extension outside the prostate were defined as level 0, confined to glandular prostate; level I invasion, beyond the extent of normal glands but not into the fascia; level II invasion, into the fascia; level III invasion, through the fascia into the periprostatic soft tissue. All patients with level O or I invasion had negative seminal vesicles and negative nodes while 24% of level II and 35% of level III had positive seminal vesicles and/or positive nodes on permanent sections. Level III invasion occurred in 24% of A2, 42% of 81, and 75% of 82 and C patients. Looking at confinement in the opposite way, 52% of A2, 14% of 81, and 0% of 82 and C1 had either level O or I invasion. These results indicate that the pattern of prostatic cancer is distinctly different in nonpalpable (A2) and palpable (8 and C) tumors and that the tumor always arises adjacent to or invades the capsule.
PROSTATE SHAPE, EXTERNAL STRIATED URETHRAL SPHINCTER, AND RADICAL PROSTATECTOMY: THE APICAL DISSECTION. Robert P. Myers, John R. Goellner*, and (Presentation to be Donald R. Cahill*, Rochester, MN made by Dr. Myers) In an anatomic study of 64 gross specimens, the external striated urethral sphincter was reconfirmed to extend as a single unit from the proximal penile urethra to the bladder base. The configuration of the external striated urethral sphincter was variable and was related to the shape of the apical prostate. Two basic prostatic shapes were recognized, distinguished by the presence or absence of an anterior apical notch. Whether or not a notch existed depended upon the degree of lateral lobe development and the position of its anterior commissure. In radical prostatectomy, knowledge of the variation in the shape of the prostatic apex can help the surgeon achieve optimal urethral transection with maximal preservation of the external striated urethral sphincter and other tissues of the continence mechanism.
224A