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Incidence of prostatic carcinoma in the elderly
INCIDENCE
OF PROSTATIC CARCINOMA
IN THE ELDERLY ILGA RULLIS, 1. ALBERT
M.D.
SHAEFFER,
0. M. LILIEN.
M.D.
M.D.
From the Departments of Pathology and Urology, Syracuse Veterans Administration, and Upstate Medical Center, Syracuse, New York
ABSTRACT - Published reports vary greatly in their estimation of the incidence of prostatic carcinoma. To obtain statistically valid data on the occurrence of this entity in the elderly, serial sections of the entire prostate obtained at 57 consecutive autopsies in males eighty years of age and over were analyzed. The incidence of prostatic carcinoma in this group was 66.7 per cent. The stage and grade of lesions are noted, and a correlation between specimen weight and incidence of malignancy is confirmed. Apparently disparate reports are analyzed.
The incidence of prostatic carcinoma in elderly males has not been clearly defined. Franks’ reported that 66.7 per cent of males in the ninth decade, studied at autopsy, had histologic evidence of prostatic carcinoma, while Gayno? reported an incidence of 38.7 per cent, Moore3 29 per cent, Rich4 20 per cent, and Baron and Angrist5 100 per cent for the same age group. An attempt should be made to bring some order out of the chaos of the actual incidence of prostate cancer in the elderly. In 1966 Halpert and Schmalhorst6 reported their findings on step cross sections of the entire prostate gland in 100 patients aged seventy to seventy-nine years. They were able to arrive at the statistically sound conclusion that prostatic carcinoma was present in 41 per cent of the patients studied. We report our findings in a similar study on 51 patients in the ninth decade, and 6 patients over ninety. Material and Methods Specimens were obtained from 57 consecutive autopsies performed on males eighty years of age and over at the Syracuse Veterans Administration Hospital. Prostates were removed, in toto,
UROLOGY
/ SEPTEMBER1975
/ VOLUMEVI,
NUMBER3
fixed in 10 per cent formalin, and subsequently weighed after removal of surrounding tissues. Specimens were divided in quadrant sections and embedded in 0.4 per cent paraffin blocks. Serial sections of all blocks were prepared and stained with hematoxylin and eosin. All sections were examined. Criteria for diagnosing carcinoma were those routinely employed by us, and previously described in detail.’ Carcinoma staging was made according to the American System classification (modified to permit analysis of in vitro specimens): Stage A (occult cancer), carcinoma not evident on gross examination of the specimen, corresponding to an “incidental” finding of cancer in an operative specimen; Stage B, cancer confined within the prostatic capsule (anterior layer of Denonvilliers’ fascia); Stage C, cancer with invasion of the capsule, extension into seminal vesicles and/or bladder, or extra pelvic involvement. In addition, histologic characteristics were used to grade tumors in increasing order of malignancy: grade I, well-demarcated small gland pattern with minimal invasive features; grades II and III, multiple acinar patterns including small, medium, and cribriform types (acini less regular, flattened, and elongated; cells progressively
295
smaller with darker, more irregular nuclei); and grade IV, complete loss of acinar pattern with diffusely infiltrating solid masses of cells with irregular nuclei and little apparent cytoplasm. Results The prostates varied in weight from 16 to 145 Gm. Of 51 specimens analyzed in the eighty- to eighty-nine-year group, 34 were histologically malignant, revealing an incidence of carcinoma of 66.7 per cent for this category. The average weight for this group was 40 Gm. Distribution according to stage and grade is shown in Table I. Analysis of the weights of specimens which did not reveal carcinoma revealed a weight range from 10 to 44 Gm., with an average weight of 28 Gm. Of the 6 specimens obtained from males over ninety, 5 were found to contain carcinoma.
suspected preoperatively, the incidence of carcinoma in this age group exceeded 31.3 per cent. It was initially difficult for us to reconcile this apparently high incidence of unsuspected malignancy with the numerous differing reports available in the literature. These vary from an incidence of 14 per cent4 to 46 per cent. 5 Between these extremes, reports of an incidence of 16.7 per cent,3 21 per cent,’ and 37.6 per cent’ have been reported. While these references are incomplete, they represent many of the studies classically referred to in most textbooks of urology. Such divergence of data could be explained in one or two ways. Either the authors were talking about different diseases or the techniques used for compiling data were sufficiently different to account for the apparent discrepancies. Analyzing these studies confirmed the latter explanation. Rich’s4 report of 14 per cent was based on a single routine section on the prostate taken at the time of autopsy. The author cautioned that, “although the fre-
Comment To arrive at statistically sound conclusions regarding the incidence of prostatic carcinoma, it is obvious that sufficient numbers must be available for review. The report of Halpert and SchmalhorsP is an example of a statistically credible report from which a specific conclusion can be drawn. These workers carried out step sections of the entire prostate gland in 100 specimens from patients aged seventy to seventy-nine. They found 41 carcinomas (41 per cent) of which 17 were diffise and 24 were focal. In an earlier publication’ the same group reported on the frequency of prostatic carcinoma found at autopsy in patients over the age of eighty. In 58 cases one half of the entire prostate was examined in step sections, and 33 carcinomas (56.9 per cent) were found. In those glands containing evidence of malignancy, the carcinoma appeared focal in about one half and was limited to a small area or to several areas of the gland. In 1968 we reported our experience with 200 patients requiring prostatectomy for benign prostatic hyperplasia. 9 One hundred fifty cases (median age 70.5 years) were approached via the perineal route. During the course of the procedure, frozen section of open biopsies of the “posterior lamella” were performed. We observed that in 115 cases in which there was no preoperative suspicion of malignancy (absence of prostatic induration, normal acid phosphatase, and so forth) 24 per cent were found to have an unsuspected malignancy. When we included the remaining 35 cases in which early carcinoma was
296
TABLE I.
Distribution according to grade and stage
Stage Grade
A
B
C
I
6
3
...
II
4
3
3
III
...
IV
...
3 1
7 4
quency with which cancer was found in these sections was surprisingly high, the actual incidence of this condition is, in all probability, still higher.” Moore’s3 report of an over-all incidence of prostatic carcinoma of 16.7 per cent, while based on a step section analysis of prostates obtained at autopsy, reflects the incidence in all subjects studied. Reexamination of the data for subjects between the ages sixty-one and eighty reveals the incidence of carcinoma to be greater than 22 per cent. Thus, from reexamination of studies dealing with the incidence of prostatic malignancy, we may conclude that of all patients undergoing prostatectomy for benign disease, at least 1 of 4 will have an unsuspected carcinoma. We may further conclude that in the eighth decade (seventy to seventy-nine) the incidence of carcinoma will exceed 40 per cent, while in the ninth decade 2 of 3 patients will have histologic evidence of prostatic carcinoma.
UROLOGY
/ SEPTEMBER
1975 / VOLUME
VI, NUMBER3
An apparent correlation between prostate size and carcinoma, previously reported, is again borne out by the observation that the average weight of prostates containing carcinoma was 40 Gm. while those free of cancer was 28 Gm.g Department of Pathology Veterans Administration Hospital Syracuse, New York 13210 (DR. RULLIS) References 1. FRANKS, L. M.: Pathol. Bacterial. 2. GAYNOR, E. P.: 3. MOORE, R. A. : cinoma, J. Urol.
Latent carcinoma of the prostate, J. 68: 603 (1954). Cited in Franks,’ p. 605. The morphology of small prostatic car33: 224 (1935).
UROLOGY / SEF’TEMBER 1975 / VOLUME VI, NUMBER 3
4. RICH, A. R. : On the frequency of occurrence of occult carcinoma of the prostate, ibid. 33: 215 (1935). 5. BARON, E., and ANGRIST, A.: Incidence of occult adenocarcinoma of the prostate, Arch. Pathol. 32: 787 (1941). 6. HALPERT, B., and SCHMALHORST, W. R.: Carcinoma of prostate in patients 70 to 79 years old, Cancer 19: 695 (1966). 7. SCHAEFER, J. A., LILIEN, 0. ;M., and SANDLER, M.: Frozen section diagnosis and mucin production in prostatic carcinoma, Invest. Urol. 6: 493 (1969). 8. SCHMALHORST, R., and HALPERT, B.: Carcinoma of the prostate gland in patients more than 80 years old, Am. J. Clin. Pathol. 42: 170 (1964). 9. LILIEN, 0. M., SCHAEFER, J. A., KILEJIAN, V., and ANDALORO,V. : The case for perineal prostatectomy, J, Urol. 99: 79 (1968).
297
OF PROSTATIC CARCINOMA
IN THE ELDERLY ILGA RULLIS, 1. ALBERT
M.D.
SHAEFFER,
0. M. LILIEN.
M.D.
M.D.
From the Departments of Pathology and Urology, Syracuse Veterans Administration, and Upstate Medical Center, Syracuse, New York
ABSTRACT - Published reports vary greatly in their estimation of the incidence of prostatic carcinoma. To obtain statistically valid data on the occurrence of this entity in the elderly, serial sections of the entire prostate obtained at 57 consecutive autopsies in males eighty years of age and over were analyzed. The incidence of prostatic carcinoma in this group was 66.7 per cent. The stage and grade of lesions are noted, and a correlation between specimen weight and incidence of malignancy is confirmed. Apparently disparate reports are analyzed.
The incidence of prostatic carcinoma in elderly males has not been clearly defined. Franks’ reported that 66.7 per cent of males in the ninth decade, studied at autopsy, had histologic evidence of prostatic carcinoma, while Gayno? reported an incidence of 38.7 per cent, Moore3 29 per cent, Rich4 20 per cent, and Baron and Angrist5 100 per cent for the same age group. An attempt should be made to bring some order out of the chaos of the actual incidence of prostate cancer in the elderly. In 1966 Halpert and Schmalhorst6 reported their findings on step cross sections of the entire prostate gland in 100 patients aged seventy to seventy-nine years. They were able to arrive at the statistically sound conclusion that prostatic carcinoma was present in 41 per cent of the patients studied. We report our findings in a similar study on 51 patients in the ninth decade, and 6 patients over ninety. Material and Methods Specimens were obtained from 57 consecutive autopsies performed on males eighty years of age and over at the Syracuse Veterans Administration Hospital. Prostates were removed, in toto,
UROLOGY
/ SEPTEMBER1975
/ VOLUMEVI,
NUMBER3
fixed in 10 per cent formalin, and subsequently weighed after removal of surrounding tissues. Specimens were divided in quadrant sections and embedded in 0.4 per cent paraffin blocks. Serial sections of all blocks were prepared and stained with hematoxylin and eosin. All sections were examined. Criteria for diagnosing carcinoma were those routinely employed by us, and previously described in detail.’ Carcinoma staging was made according to the American System classification (modified to permit analysis of in vitro specimens): Stage A (occult cancer), carcinoma not evident on gross examination of the specimen, corresponding to an “incidental” finding of cancer in an operative specimen; Stage B, cancer confined within the prostatic capsule (anterior layer of Denonvilliers’ fascia); Stage C, cancer with invasion of the capsule, extension into seminal vesicles and/or bladder, or extra pelvic involvement. In addition, histologic characteristics were used to grade tumors in increasing order of malignancy: grade I, well-demarcated small gland pattern with minimal invasive features; grades II and III, multiple acinar patterns including small, medium, and cribriform types (acini less regular, flattened, and elongated; cells progressively
295
smaller with darker, more irregular nuclei); and grade IV, complete loss of acinar pattern with diffusely infiltrating solid masses of cells with irregular nuclei and little apparent cytoplasm. Results The prostates varied in weight from 16 to 145 Gm. Of 51 specimens analyzed in the eighty- to eighty-nine-year group, 34 were histologically malignant, revealing an incidence of carcinoma of 66.7 per cent for this category. The average weight for this group was 40 Gm. Distribution according to stage and grade is shown in Table I. Analysis of the weights of specimens which did not reveal carcinoma revealed a weight range from 10 to 44 Gm., with an average weight of 28 Gm. Of the 6 specimens obtained from males over ninety, 5 were found to contain carcinoma.
suspected preoperatively, the incidence of carcinoma in this age group exceeded 31.3 per cent. It was initially difficult for us to reconcile this apparently high incidence of unsuspected malignancy with the numerous differing reports available in the literature. These vary from an incidence of 14 per cent4 to 46 per cent. 5 Between these extremes, reports of an incidence of 16.7 per cent,3 21 per cent,’ and 37.6 per cent’ have been reported. While these references are incomplete, they represent many of the studies classically referred to in most textbooks of urology. Such divergence of data could be explained in one or two ways. Either the authors were talking about different diseases or the techniques used for compiling data were sufficiently different to account for the apparent discrepancies. Analyzing these studies confirmed the latter explanation. Rich’s4 report of 14 per cent was based on a single routine section on the prostate taken at the time of autopsy. The author cautioned that, “although the fre-
Comment To arrive at statistically sound conclusions regarding the incidence of prostatic carcinoma, it is obvious that sufficient numbers must be available for review. The report of Halpert and SchmalhorsP is an example of a statistically credible report from which a specific conclusion can be drawn. These workers carried out step sections of the entire prostate gland in 100 specimens from patients aged seventy to seventy-nine. They found 41 carcinomas (41 per cent) of which 17 were diffise and 24 were focal. In an earlier publication’ the same group reported on the frequency of prostatic carcinoma found at autopsy in patients over the age of eighty. In 58 cases one half of the entire prostate was examined in step sections, and 33 carcinomas (56.9 per cent) were found. In those glands containing evidence of malignancy, the carcinoma appeared focal in about one half and was limited to a small area or to several areas of the gland. In 1968 we reported our experience with 200 patients requiring prostatectomy for benign prostatic hyperplasia. 9 One hundred fifty cases (median age 70.5 years) were approached via the perineal route. During the course of the procedure, frozen section of open biopsies of the “posterior lamella” were performed. We observed that in 115 cases in which there was no preoperative suspicion of malignancy (absence of prostatic induration, normal acid phosphatase, and so forth) 24 per cent were found to have an unsuspected malignancy. When we included the remaining 35 cases in which early carcinoma was
296
TABLE I.
Distribution according to grade and stage
Stage Grade
A
B
C
I
6
3
...
II
4
3
3
III
...
IV
...
3 1
7 4
quency with which cancer was found in these sections was surprisingly high, the actual incidence of this condition is, in all probability, still higher.” Moore’s3 report of an over-all incidence of prostatic carcinoma of 16.7 per cent, while based on a step section analysis of prostates obtained at autopsy, reflects the incidence in all subjects studied. Reexamination of the data for subjects between the ages sixty-one and eighty reveals the incidence of carcinoma to be greater than 22 per cent. Thus, from reexamination of studies dealing with the incidence of prostatic malignancy, we may conclude that of all patients undergoing prostatectomy for benign disease, at least 1 of 4 will have an unsuspected carcinoma. We may further conclude that in the eighth decade (seventy to seventy-nine) the incidence of carcinoma will exceed 40 per cent, while in the ninth decade 2 of 3 patients will have histologic evidence of prostatic carcinoma.
UROLOGY
/ SEPTEMBER
1975 / VOLUME
VI, NUMBER3
An apparent correlation between prostate size and carcinoma, previously reported, is again borne out by the observation that the average weight of prostates containing carcinoma was 40 Gm. while those free of cancer was 28 Gm.g Department of Pathology Veterans Administration Hospital Syracuse, New York 13210 (DR. RULLIS) References 1. FRANKS, L. M.: Pathol. Bacterial. 2. GAYNOR, E. P.: 3. MOORE, R. A. : cinoma, J. Urol.
Latent carcinoma of the prostate, J. 68: 603 (1954). Cited in Franks,’ p. 605. The morphology of small prostatic car33: 224 (1935).
UROLOGY / SEF’TEMBER 1975 / VOLUME VI, NUMBER 3
4. RICH, A. R. : On the frequency of occurrence of occult carcinoma of the prostate, ibid. 33: 215 (1935). 5. BARON, E., and ANGRIST, A.: Incidence of occult adenocarcinoma of the prostate, Arch. Pathol. 32: 787 (1941). 6. HALPERT, B., and SCHMALHORST, W. R.: Carcinoma of prostate in patients 70 to 79 years old, Cancer 19: 695 (1966). 7. SCHAEFER, J. A., LILIEN, 0. ;M., and SANDLER, M.: Frozen section diagnosis and mucin production in prostatic carcinoma, Invest. Urol. 6: 493 (1969). 8. SCHMALHORST, R., and HALPERT, B.: Carcinoma of the prostate gland in patients more than 80 years old, Am. J. Clin. Pathol. 42: 170 (1964). 9. LILIEN, 0. M., SCHAEFER, J. A., KILEJIAN, V., and ANDALORO,V. : The case for perineal prostatectomy, J, Urol. 99: 79 (1968).
297