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Gleason's histologic grading asclinical prognostic marker in patients with advanced prostatic carcinoma
GLEASON'S HISTOLOGIC GRADING AS CLINICAL PROGNOSTIC MARKER IN PATIENTS WITH ADVANCED PROSTATIC CARCINOMA CURTIS B. SCHWARTZ, M.D. HUSEYIN BEKIROV, M.D. ARNOLD MELMAN, M.D. From the Department of Urology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
ABS TRA C T--We have found that the Gleason's histologic grading system is a good clinical to predict long-term response and prognosis in symptomatic Stage D-2 adenoearcinoma of tt tate. In this retrospective study, 56 cases were reviewed and correlated with bone scan, aci phatase, and symptomatology following bilateral orchiectomy.
Carcinoma of the prostate is the second most common malignancy in men.1 The incidence of prostate cancer increases with age. These tumors may cause progressive disease with extensive metastases to bone, and account for over 22,000 deaths per year in the United States. 2 Approximately 50 percent of patients with metastatic prostate cancer die within thirty months, and 80 percent die within five years. 3 The most common form of hematogenous metastasis from prostate cancer is to the bone, which occurs in almost 85 percent of patients dying of this disease. 4 Bone is the only site of metastasis in 65 percent of patients presenting with metastatic tumor. 5 Although nonspeeifie, the radioisotope bone scan is sensitive in detecting areas of bone metastasis. 6 In 1941 Huggins and Hodges7 first reported that patients with metastatic carcinoma of the prostate showed symptomatic improvement following bilateral orehieetomy. Since then, castration has been widely used in the treatment of symptomatic Stage D-2 prostate cancer. Although this therapy provides relief of bone pain, anorexia, obstructive symptoms, regression of osteoblastie metastases, and reduction in 198
hydronephrosis produced by loca the tumor, improvement in survi been demonstrated conclusively. 8 Studies have shown that testo: growth-promoting effect on tum~ have androgen receptors. ° Treatrn tration causes significant reduetioJ gieal availability of testosterone the loss of testosterone produetk cells in the testis. 1° Despite the i siveness of patients to bilateral many patients relapse within two with hormone-independent tumo tually die of metastatic disease. In havior of prostate cancer is explail herent heterogenieity of the turn respect to the presence and densit~ receptors. 11 The importance of histopatholo malignant disease was recognized 1926.1~ Although several grading been described subsequently, the reproducibility of many of these been inconsistent. 13 Gleason an~ proposed a system of histopatho based on the glandular pattern of I
UROLOGY / MARCH 1991 / VOLUME XXXVII, NUMBE;~ ~
Ii R
TABLEI. Comparisonof grade with acid phosphatase Unchanged Acid Phosphatase Worse Acid Phosphatase proved Acid Phosphatasc No. No. No. Mean Mean No~ Mean Race of Race of Mean Race Mean Dist. FU (Yrs.) Pts. Age Dist. FU (Yrs.) Pts. Age Dist. FU (Yrs.) Pts. Age 13 75 llW/2B 2.5 7 73 6W/1H 2.0 7 76 4W 2.5 4 74 2W/2B 2.5 28 73 20W/7B/2H 3.0 .
.
.
.
.
.
~[-KI~Y'FIT = fo~ow-up, W ---- w--hite; B = i~lack; H = Hispanic.
by
mi ros opy
mos
~aj6r centers employ Gleason s histologic grad~ag System as a means of quantifying the degree i ~ifferentiation of adenocarcinoma of the ~osfate submitted for pathologic diagnosis. There is considerable evidence that histologie ~ading correlates with both local invasiveness ~d metastatic potential; however, there has een a question as to whether grade itself can e used as a predictor of responsiveness or sur'~a!,!5 This retrospective study was done to in~esiigate whether or not Gleason's histologic ~ a d i n g of symptomatic patients with Stage D~ carcinoma of the prostate could be used as a ~linical marker to predict the long-term respon@efiess after bilateral orchiectomy. Material and Methods The clinical records were reviewed from 56 ~ati6~ts aged fifty-six to ninety-three years with ~tage :D-2 adenocarcinoma of the prostate ~ymptomatic from bone metastases having unBd~r~6fie bilateral orchiectomy from 1979 to |i9881 All patients selected had histologically ~ i~6~d prostatic adenocarcinoma diagnosed ~i~h6r:from transurethral resection of the prosI iate:0r core needle biopsy of the prostate. Patients excluded from the study were those wh0 ~ad undergone radical prostatectomy, bilateral adrenalectomy, or hypophysectomy. ~S6 ~xcluded were those patients who were rei ted with estrogen or anti-androgens, or LHlH ~nalogues. Finally, those patients having ergone radiation therapy were also ex~'i~~'~d. -(~f:::the 56 patients, 42 were white, 11 black, N~n~ 8 Hispanic. All patients studied had a base~lin! Neasurement of serum acid phosphatase ~,eVds as well as a pre-orchiectomy bone scan. !'he post-orehiectomy follow-up period ranged , mstx months to over nine years. Assessment ~'f:bOne scan response, acid phosphatase re~ :~!P~n~,and clinical symptomatic response were f~iI~ed over this period. In the later years ~JflOLOOy /
MARCH 1991
prostatic-specific antigen was also included as a preoperative and follow-up marker. However, due to the limited number of patients and the short-term follow-up period, these data were not analyzed in this article. Serial measurements of acid phosphatase levels generally were obtained every three to six months, and repeat bone scans were obtained at approximately sixmonth to one-year intervals. Metastasis to the skeleton was diagnosed when areas of increased uptake of the radiopharmaceutical were noted in sites compatible with the spread of prostate cancer by Correlation with plain bone films. Serial studies were compared and notation was made of any change in the pattern of uptake. Disease advancement or improvement was determined from a scan when there was either an increase or decrease in the intensity and size of uptake in existing lesions, or the development of new metastatic sites versus the resolution of existing lesions. The disease was interpreted as stable if there were no significant changes in the pattern of uptake in consecutive studies. Mixed responses of improvement or deterioration were categorized according to the predominant pattern of change. All pathologic slides of those patients included in the study were reviewed in a blinded fashion by one pathologist. A Gleason's histologic grade sum was assigned to each patient without the pathologist's knowledge of the previously assigned grade nor the patient's history, radiographic findings, or laboratory data. Results This study included patients with Gleason's sum greater than 4. A total of 36 patients had tumors with high Gleason grade (Gleason sum 8 to 10); 20 patients had tumors with intermediate Gleason grade (Gleason sum 5 to 7). Total mean age regardless of race was seventy-three years. Sixty-five percent of patients with tumor of intermediate grade had improvement in their
/ VOLUME XXXVII, NUMBER 3
199
TABLE II.
.... No. (.f P:s. Inter. 10 High 2
Comparison o] grade with bone scan results* --Worse Bone Unchanged Bone Scan IJ~ proved Bone S c a n - No. No. Race of Race Mean of Mean ]Vlz:an Race Mean Dist. FU (Yrs.) Pts. Age kt!e Dist. FU (Yrs.) Pts. Age Dist. 78 2W/1] 7 74 7W 3.0 3 .....:, 9W/1H 2.5 76 21W/9B, 2 76 IW/1B 4.0 32 74: 2W 2.5
*See Key Tabh! [.
TABLEIII. Comparison of grade with symptomatology* S ---Improved Symptoms--Unchanged S y m p t o m s - - - - - W o r s e No. No. No. of Mean of Me.an Race Mean of Race Mean P~:s. Age Dist. FU (Yrs.) Pts. Age Dist. FU (Yrs.) Pts. Age Inter. 16 73 14W/1B/1H 3.0 1 84 lW 4.0 3 78 2 High 1 70 lW 2.0 7 73 3W/3B/1H 3.5 28 76 21~0 *See Keg Table: L Total number of patients = 56. Total number with intermediate Gleason's grade sum = 20. Gleason's :,trade sum = 36.
acid phosphatase values while none of the patients had wdues worsened (Table I). This is in contrast: to the 78 percent of patients with highgrade tumors whose acid phosphatase values worsened while 11 percent showed a decrease in their levels'.. Postoperative bone scan showed improvement in 50 percent of patients with intermediate grade versus 11 percent of patients with high-grade tumor. Conversely, 15 percent worsened in the intermediate group versus 89 percent with high-grade tumors (Table II). Analyzing symptomatology, 80 percent of patients with intermediate-grade tumors substantially improved while 15 percent worsened. In patients with high-grade tumors, 78 percent experienced worsening of their symptoms while 1 patient (3 %) improved (Table III). Overall, 50 percent of patients with intermediate-grade tumors improved, 35 percent were unchanged; however, 15 percent experienced worsening of their symptoms and bone scan. In the high-grade group 78 percent of these patients had overall worsening, 19 percent were unchanged, and 3 percent showed improvement. A total of 8 patients died. All of these patients had high-grade tumor. Their mean time to death was four years; their mean age was eighty years. Comment The results of this retrospective study suggest that there is a correlation between Gleason's
200
histologic grading of symptomat: Stage D-2 adenoearcinoma of tt the response of these patients t chiectomy. To correct for subjective fact grading conclusions, this study pathologist designating Gleas sums to each patient. Confidenc, logic appearance of such biops) curately reflects the histologic the entire primary tumor is of tance. Mills et al.l~ found that well and moderately differenti; needle biopsy specimens were poorly differentiated tumors in tomy specimens. Using a gradin: erately, and poorly differentia Stein, and Fair 1~ found that tin primary tumor was underestim cent and overestimated in 8 per die biopsy specimens. Experim son's histologic grading system difference of two digits betweei prostatic biopsy specimen and subsequent radical prostatecton~ curs in 28-48 percent of cases. ~ Pollen et al. ~s found that the persistent bone scan stability ai phosphatase levels in remission prognosis. Those patients with scan stability alone also have time. Similarly, in this study, thos~ improved or unchanged bone
UROLOGY
/
MARCH 1991
/
VOLUME XXXVII,
i m p r o v e d in spite of t h e i r a t a s e levels. I n d e e d , all p a this series h a d w o r s e n i n g responses of b o n e s c a n to ,,ly c o n s i s t e n t w i t h c u r r e n t t h e p o l y e l o n a l n a t u r e of ; whereby, some are androo t h e r s u n r e s p o n s i v e to en-
p r o s t a t e to b i l a t e r a l o r c h i e c t o m y a n d in s t r a t ifying these patients into prognostic groups. 3750 Hudson Manor Terrace 5D East Bronx, New York 10463 (DR. SCHWARTZ)
n.
:hat l o w s o c i o e c o n o m i e stal a p o o r p r o g n o s i s a n d surake e t a l . n ° w e r e t h e first to d mortality rate among of c a n c e r s i n c l u d i n g c a r .te, w i t h a n e s t i m a t e d fivetek p a t i e n t s of 62 p e r c e n t ~ercent for w h i t e p a t i e n t s . that stage-for-stage and r i v a l w a s s i m i l a r in b o t h tients. H o w e v e r , t h e p r e s disease produced earlier e s u l t i n g in a s i g n i f i c a n t l y zal for b l a c k p a t i e n t s . I n md that only black patients m s o n scores. 2~ O u r s t u d y in p r o g n o s i s , p r o g r e s s i o n of rased o n r a c e ; h o w e v e r , o u r tvily s k e w e d to w h i t e p a trend that the more undif9r, t h e w o r s e t h e p r o g n o s i s ; studied did not have well's w i t h t h e l o w e s t G l e a s o n ' s fore, conclusions regarding e m a d e . N e v e r t h e l e s s , this :he g r a d e c a n b e u s e d as a predict the responsiveness 9rehiectomy. Patients with natic Stage D-2 tumors can t the planned therapy has a success, w h i l e t h o s e w i t h t t u m o r c a n b e m o r e realist the surgery may not bene.]able h i s t o p a t h o l o g i c a s s a y :e t e s t o s t e r o n e r e c e p t o r b u r cells, t h e G l e a s o n ' s histois a g o o d clinical m a r k e r to r e s p o n s e in p a t i e n t s w i t h D-2 a d e n o c a r c i n o m a of t h e
~0['OcY
/
MARCH 1991
/
References 1. Silverberg E: Cancer statistics, 1985, CA 35:19 (1985). 2. De LaMonte S, et aI: Metastatic behavior of prostate cancer, Cancer 58:985 (1986). 3. Blaekard CE, et al" Orchieetomy for advanced prostatic carcinoma, Urology I: 658 (1973). 4. Jaeobs SC: Spread of prostatic cancer to bone, Urology 21: 337 (1983). 5. McCrea LE, et ah Carcinoma of the prostate: metastases, therapy, and survival. A statistical analysis of 500 eases, Int Coll Surg J 29:723 (1958). 6. Soloway MS, et al: Stratification of patients with metastatic prostate cancer based on extent of disease on initial bone scan, CA 61:195 (1988), 7. Hnggins C, and Hodges CV: The effect of castration, of estrogen, and of androgen iniection on serum phosphatases in metastatic carcinoma of the prostate, Cancer Res 1:292 (1942), 8. Elder JS, et aI: Management of newly diagnosed metastatic carcinoma of the prostate, Urol Clin North Am 11:283 (1984). 9. Coneolina G: Steroid receptors and hormone responsiveness of human prostatic carcinoma, Prostate 3:475 (1982). 10. Isaaes JT: Hormonal responsiveness versus unresponsiveness; progression of prostatic cancer to ant]androgen therapy as studied with the Dunning R-3327-AT and -G rat adenocarcinomas, Cancer Res 42:5010 (1982). 11. Brendler H: Therapy with orchiectomy or estrogens or both, JAMA 210:1074 (1969). 12. Broders AC: Carcinoma, grading and practical application, Arch Pathol 2:376 (1926). 13. Mostofi FK: Problems of grading carcinoma of prostate, Semin Oneol 3:161 (1976). 14. Gleason DF, et al: Prediction of prognosis for prostatic adenocareinoma by combined histological grading and clinical staging, J Urol 111:58 (1974). 15. Mills SE, et ah Gleason histologie grading of prostatic carcinoma: correlations between biopsy and prostateetomy specimens, CA 57:346 (1986). 16. Catalona WJ, Stein A], and Fair Wt~: Grading errors in prostatic needle biopsies: relation to the accuracy of tumor grade in predicting pelvic lymph node metastases, J Urol 127:919 (1982). 17. Lange PH, and Narayan P: Understaging and undergrading of prostate cancer, Urology 21:113 (1983). 18. Pollen JJ, et al: Nuclear bone imaging in metastatic cancer of the prostate, CA 47:2585 (1981). 19. Axtell LM, and Myers MH: Contrast in survival of black and white cancer patients, 1960-1973, J Watt Cancer Inst 60: 1209 (1978). 20. Hesehke MK, et al: Alarming increases of the cancer mortality in the U.S. black population, CA 3l: 673 (1973). 21. Azis H, eta[: Radiation-treated carcinoma of the prostate: comparison of survival of black and white patients by Gleason's grading system, Am J Clin Oneol 11:166 (1988).
VOLUME XXXVII, NUMBER3
201
ABS TRA C T--We have found that the Gleason's histologic grading system is a good clinical to predict long-term response and prognosis in symptomatic Stage D-2 adenoearcinoma of tt tate. In this retrospective study, 56 cases were reviewed and correlated with bone scan, aci phatase, and symptomatology following bilateral orchiectomy.
Carcinoma of the prostate is the second most common malignancy in men.1 The incidence of prostate cancer increases with age. These tumors may cause progressive disease with extensive metastases to bone, and account for over 22,000 deaths per year in the United States. 2 Approximately 50 percent of patients with metastatic prostate cancer die within thirty months, and 80 percent die within five years. 3 The most common form of hematogenous metastasis from prostate cancer is to the bone, which occurs in almost 85 percent of patients dying of this disease. 4 Bone is the only site of metastasis in 65 percent of patients presenting with metastatic tumor. 5 Although nonspeeifie, the radioisotope bone scan is sensitive in detecting areas of bone metastasis. 6 In 1941 Huggins and Hodges7 first reported that patients with metastatic carcinoma of the prostate showed symptomatic improvement following bilateral orehieetomy. Since then, castration has been widely used in the treatment of symptomatic Stage D-2 prostate cancer. Although this therapy provides relief of bone pain, anorexia, obstructive symptoms, regression of osteoblastie metastases, and reduction in 198
hydronephrosis produced by loca the tumor, improvement in survi been demonstrated conclusively. 8 Studies have shown that testo: growth-promoting effect on tum~ have androgen receptors. ° Treatrn tration causes significant reduetioJ gieal availability of testosterone the loss of testosterone produetk cells in the testis. 1° Despite the i siveness of patients to bilateral many patients relapse within two with hormone-independent tumo tually die of metastatic disease. In havior of prostate cancer is explail herent heterogenieity of the turn respect to the presence and densit~ receptors. 11 The importance of histopatholo malignant disease was recognized 1926.1~ Although several grading been described subsequently, the reproducibility of many of these been inconsistent. 13 Gleason an~ proposed a system of histopatho based on the glandular pattern of I
UROLOGY / MARCH 1991 / VOLUME XXXVII, NUMBE;~ ~
Ii R
TABLEI. Comparisonof grade with acid phosphatase Unchanged Acid Phosphatase Worse Acid Phosphatase proved Acid Phosphatasc No. No. No. Mean Mean No~ Mean Race of Race of Mean Race Mean Dist. FU (Yrs.) Pts. Age Dist. FU (Yrs.) Pts. Age Dist. FU (Yrs.) Pts. Age 13 75 llW/2B 2.5 7 73 6W/1H 2.0 7 76 4W 2.5 4 74 2W/2B 2.5 28 73 20W/7B/2H 3.0 .
.
.
.
.
.
~[-KI~Y'FIT = fo~ow-up, W ---- w--hite; B = i~lack; H = Hispanic.
by
mi ros opy
mos
~aj6r centers employ Gleason s histologic grad~ag System as a means of quantifying the degree i ~ifferentiation of adenocarcinoma of the ~osfate submitted for pathologic diagnosis. There is considerable evidence that histologie ~ading correlates with both local invasiveness ~d metastatic potential; however, there has een a question as to whether grade itself can e used as a predictor of responsiveness or sur'~a!,!5 This retrospective study was done to in~esiigate whether or not Gleason's histologic ~ a d i n g of symptomatic patients with Stage D~ carcinoma of the prostate could be used as a ~linical marker to predict the long-term respon@efiess after bilateral orchiectomy. Material and Methods The clinical records were reviewed from 56 ~ati6~ts aged fifty-six to ninety-three years with ~tage :D-2 adenocarcinoma of the prostate ~ymptomatic from bone metastases having unBd~r~6fie bilateral orchiectomy from 1979 to |i9881 All patients selected had histologically ~ i~6~d prostatic adenocarcinoma diagnosed ~i~h6r:from transurethral resection of the prosI iate:0r core needle biopsy of the prostate. Patients excluded from the study were those wh0 ~ad undergone radical prostatectomy, bilateral adrenalectomy, or hypophysectomy. ~S6 ~xcluded were those patients who were rei ted with estrogen or anti-androgens, or LHlH ~nalogues. Finally, those patients having ergone radiation therapy were also ex~'i~~'~d. -(~f:::the 56 patients, 42 were white, 11 black, N~n~ 8 Hispanic. All patients studied had a base~lin! Neasurement of serum acid phosphatase ~,eVds as well as a pre-orchiectomy bone scan. !'he post-orehiectomy follow-up period ranged , mstx months to over nine years. Assessment ~'f:bOne scan response, acid phosphatase re~ :~!P~n~,and clinical symptomatic response were f~iI~ed over this period. In the later years ~JflOLOOy /
MARCH 1991
prostatic-specific antigen was also included as a preoperative and follow-up marker. However, due to the limited number of patients and the short-term follow-up period, these data were not analyzed in this article. Serial measurements of acid phosphatase levels generally were obtained every three to six months, and repeat bone scans were obtained at approximately sixmonth to one-year intervals. Metastasis to the skeleton was diagnosed when areas of increased uptake of the radiopharmaceutical were noted in sites compatible with the spread of prostate cancer by Correlation with plain bone films. Serial studies were compared and notation was made of any change in the pattern of uptake. Disease advancement or improvement was determined from a scan when there was either an increase or decrease in the intensity and size of uptake in existing lesions, or the development of new metastatic sites versus the resolution of existing lesions. The disease was interpreted as stable if there were no significant changes in the pattern of uptake in consecutive studies. Mixed responses of improvement or deterioration were categorized according to the predominant pattern of change. All pathologic slides of those patients included in the study were reviewed in a blinded fashion by one pathologist. A Gleason's histologic grade sum was assigned to each patient without the pathologist's knowledge of the previously assigned grade nor the patient's history, radiographic findings, or laboratory data. Results This study included patients with Gleason's sum greater than 4. A total of 36 patients had tumors with high Gleason grade (Gleason sum 8 to 10); 20 patients had tumors with intermediate Gleason grade (Gleason sum 5 to 7). Total mean age regardless of race was seventy-three years. Sixty-five percent of patients with tumor of intermediate grade had improvement in their
/ VOLUME XXXVII, NUMBER 3
199
TABLE II.
.... No. (.f P:s. Inter. 10 High 2
Comparison o] grade with bone scan results* --Worse Bone Unchanged Bone Scan IJ~ proved Bone S c a n - No. No. Race of Race Mean of Mean ]Vlz:an Race Mean Dist. FU (Yrs.) Pts. Age kt!e Dist. FU (Yrs.) Pts. Age Dist. 78 2W/1] 7 74 7W 3.0 3 .....:, 9W/1H 2.5 76 21W/9B, 2 76 IW/1B 4.0 32 74: 2W 2.5
*See Key Tabh! [.
TABLEIII. Comparison of grade with symptomatology* S ---Improved Symptoms--Unchanged S y m p t o m s - - - - - W o r s e No. No. No. of Mean of Me.an Race Mean of Race Mean P~:s. Age Dist. FU (Yrs.) Pts. Age Dist. FU (Yrs.) Pts. Age Inter. 16 73 14W/1B/1H 3.0 1 84 lW 4.0 3 78 2 High 1 70 lW 2.0 7 73 3W/3B/1H 3.5 28 76 21~0 *See Keg Table: L Total number of patients = 56. Total number with intermediate Gleason's grade sum = 20. Gleason's :,trade sum = 36.
acid phosphatase values while none of the patients had wdues worsened (Table I). This is in contrast: to the 78 percent of patients with highgrade tumors whose acid phosphatase values worsened while 11 percent showed a decrease in their levels'.. Postoperative bone scan showed improvement in 50 percent of patients with intermediate grade versus 11 percent of patients with high-grade tumor. Conversely, 15 percent worsened in the intermediate group versus 89 percent with high-grade tumors (Table II). Analyzing symptomatology, 80 percent of patients with intermediate-grade tumors substantially improved while 15 percent worsened. In patients with high-grade tumors, 78 percent experienced worsening of their symptoms while 1 patient (3 %) improved (Table III). Overall, 50 percent of patients with intermediate-grade tumors improved, 35 percent were unchanged; however, 15 percent experienced worsening of their symptoms and bone scan. In the high-grade group 78 percent of these patients had overall worsening, 19 percent were unchanged, and 3 percent showed improvement. A total of 8 patients died. All of these patients had high-grade tumor. Their mean time to death was four years; their mean age was eighty years. Comment The results of this retrospective study suggest that there is a correlation between Gleason's
200
histologic grading of symptomat: Stage D-2 adenoearcinoma of tt the response of these patients t chiectomy. To correct for subjective fact grading conclusions, this study pathologist designating Gleas sums to each patient. Confidenc, logic appearance of such biops) curately reflects the histologic the entire primary tumor is of tance. Mills et al.l~ found that well and moderately differenti; needle biopsy specimens were poorly differentiated tumors in tomy specimens. Using a gradin: erately, and poorly differentia Stein, and Fair 1~ found that tin primary tumor was underestim cent and overestimated in 8 per die biopsy specimens. Experim son's histologic grading system difference of two digits betweei prostatic biopsy specimen and subsequent radical prostatecton~ curs in 28-48 percent of cases. ~ Pollen et al. ~s found that the persistent bone scan stability ai phosphatase levels in remission prognosis. Those patients with scan stability alone also have time. Similarly, in this study, thos~ improved or unchanged bone
UROLOGY
/
MARCH 1991
/
VOLUME XXXVII,
i m p r o v e d in spite of t h e i r a t a s e levels. I n d e e d , all p a this series h a d w o r s e n i n g responses of b o n e s c a n to ,,ly c o n s i s t e n t w i t h c u r r e n t t h e p o l y e l o n a l n a t u r e of ; whereby, some are androo t h e r s u n r e s p o n s i v e to en-
p r o s t a t e to b i l a t e r a l o r c h i e c t o m y a n d in s t r a t ifying these patients into prognostic groups. 3750 Hudson Manor Terrace 5D East Bronx, New York 10463 (DR. SCHWARTZ)
n.
:hat l o w s o c i o e c o n o m i e stal a p o o r p r o g n o s i s a n d surake e t a l . n ° w e r e t h e first to d mortality rate among of c a n c e r s i n c l u d i n g c a r .te, w i t h a n e s t i m a t e d fivetek p a t i e n t s of 62 p e r c e n t ~ercent for w h i t e p a t i e n t s . that stage-for-stage and r i v a l w a s s i m i l a r in b o t h tients. H o w e v e r , t h e p r e s disease produced earlier e s u l t i n g in a s i g n i f i c a n t l y zal for b l a c k p a t i e n t s . I n md that only black patients m s o n scores. 2~ O u r s t u d y in p r o g n o s i s , p r o g r e s s i o n of rased o n r a c e ; h o w e v e r , o u r tvily s k e w e d to w h i t e p a trend that the more undif9r, t h e w o r s e t h e p r o g n o s i s ; studied did not have well's w i t h t h e l o w e s t G l e a s o n ' s fore, conclusions regarding e m a d e . N e v e r t h e l e s s , this :he g r a d e c a n b e u s e d as a predict the responsiveness 9rehiectomy. Patients with natic Stage D-2 tumors can t the planned therapy has a success, w h i l e t h o s e w i t h t t u m o r c a n b e m o r e realist the surgery may not bene.]able h i s t o p a t h o l o g i c a s s a y :e t e s t o s t e r o n e r e c e p t o r b u r cells, t h e G l e a s o n ' s histois a g o o d clinical m a r k e r to r e s p o n s e in p a t i e n t s w i t h D-2 a d e n o c a r c i n o m a of t h e
~0['OcY
/
MARCH 1991
/
References 1. Silverberg E: Cancer statistics, 1985, CA 35:19 (1985). 2. De LaMonte S, et aI: Metastatic behavior of prostate cancer, Cancer 58:985 (1986). 3. Blaekard CE, et al" Orchieetomy for advanced prostatic carcinoma, Urology I: 658 (1973). 4. Jaeobs SC: Spread of prostatic cancer to bone, Urology 21: 337 (1983). 5. McCrea LE, et ah Carcinoma of the prostate: metastases, therapy, and survival. A statistical analysis of 500 eases, Int Coll Surg J 29:723 (1958). 6. Soloway MS, et al: Stratification of patients with metastatic prostate cancer based on extent of disease on initial bone scan, CA 61:195 (1988), 7. Hnggins C, and Hodges CV: The effect of castration, of estrogen, and of androgen iniection on serum phosphatases in metastatic carcinoma of the prostate, Cancer Res 1:292 (1942), 8. Elder JS, et aI: Management of newly diagnosed metastatic carcinoma of the prostate, Urol Clin North Am 11:283 (1984). 9. Coneolina G: Steroid receptors and hormone responsiveness of human prostatic carcinoma, Prostate 3:475 (1982). 10. Isaaes JT: Hormonal responsiveness versus unresponsiveness; progression of prostatic cancer to ant]androgen therapy as studied with the Dunning R-3327-AT and -G rat adenocarcinomas, Cancer Res 42:5010 (1982). 11. Brendler H: Therapy with orchiectomy or estrogens or both, JAMA 210:1074 (1969). 12. Broders AC: Carcinoma, grading and practical application, Arch Pathol 2:376 (1926). 13. Mostofi FK: Problems of grading carcinoma of prostate, Semin Oneol 3:161 (1976). 14. Gleason DF, et al: Prediction of prognosis for prostatic adenocareinoma by combined histological grading and clinical staging, J Urol 111:58 (1974). 15. Mills SE, et ah Gleason histologie grading of prostatic carcinoma: correlations between biopsy and prostateetomy specimens, CA 57:346 (1986). 16. Catalona WJ, Stein A], and Fair Wt~: Grading errors in prostatic needle biopsies: relation to the accuracy of tumor grade in predicting pelvic lymph node metastases, J Urol 127:919 (1982). 17. Lange PH, and Narayan P: Understaging and undergrading of prostate cancer, Urology 21:113 (1983). 18. Pollen JJ, et al: Nuclear bone imaging in metastatic cancer of the prostate, CA 47:2585 (1981). 19. Axtell LM, and Myers MH: Contrast in survival of black and white cancer patients, 1960-1973, J Watt Cancer Inst 60: 1209 (1978). 20. Hesehke MK, et al: Alarming increases of the cancer mortality in the U.S. black population, CA 3l: 673 (1973). 21. Azis H, eta[: Radiation-treated carcinoma of the prostate: comparison of survival of black and white patients by Gleason's grading system, Am J Clin Oneol 11:166 (1988).
VOLUME XXXVII, NUMBER3
201