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Lymph Node Metastases in Early Carcinoma of the Prostate
Tim .JouRNAL 01,, CROLOGY Vol. 88, No. I July Ja62 Copyright© 1962 by The Williams & Wilkins Co. Printed in C.S.A.
LYI\IPH KODE METASTASES IK EARLY CARCIKOi\fA OF THE PROSTATE LINO ,J. ARDUIXO
AND
MICHEL A. GLUCKSMAN*
From. the Department of Surgery, Section of Urology, Veterans ,idminislration Center, Des Moines, fmN,
Tlw potential curability of adenocarcinoma of the prostate by radical exc1s10n depends, naturally, on total rP!lloval of the tumor and its regional extensions .. \ serioup deficiency of the radical or total p('rineal prostatectomy !urn been demonstrated b~- Flocb and associatcsH in that the rC'gional lymph nodes can neither be r~xamim)cl nor renwvccl b~, this route. At tirnes 4 -" complete l't'lllm-al of the seminal Yrsicles is difficult or impossible. Flocks, Culp and Porto 3 haYC' graphically shcmn that part of the supC'riority of the retropubic approach for radical prostateetomy is the factor of \Yidr expmmre of the pelvic lymph node;; and ease of doing an extensive JWh'ic lyrnphade1H'Ctom!-· [t follmrn that the prostato,,C'siculcctomy is also accomplislwd in toto ,,,ith mucb less difficnlty. Except for Flock~ and associates, little data 4. 6 bave hren published on the incidence' of regional lymph node metastast's in ('arly, operable aclenocaffinoma of the prostah'. report finding nocle ck.posits in 7 per cPnt of cases ,1,ith im·oh-enwnt of the seminal ,-csides and in 40 per cent of those ,,-ho did have extension of tumor to the seminal \'esicles and periprostatic tissues. Flocks, Culp and Porto 3 rrport a 7 per cent incidence of 1,,-mph node metastases in 2D patients with
carcinoma limited to tlw prostate (opcrablr) and a 38 per cent incidence of l!-mphatic kl)H)ad in 382 patients (locally inoperable) but witliout evidence of (fatant metastases. U Ring their original inYestigation as a gnicl(', we have reYiewecl our experience ffith 71 radical prostatectornics performed O\Tr tbe paRt 5 .1cars (October 1955-August 1960). MATERIALS AND METHODS
The patients ranged from 55 to 72 yearn of age, ,1-ith a mean age of 66.5. Six were 70 yrar~ or older, six were 60 or younger, ancl 59 were from 61 to fi9 years inclusive. ,\.II patiPnts wC'rP P.,amined rectally by thl' st'nior author ,,-ho belirn:d that the tumor had not e:dendC'd to the sC'minal i'C'sicles or the periprostatic tissues. .-\11 bad :-;erurn acid phmphatase lewis JwlmY 1 units (Shinowara-Jones-Rinehart). All were fret) of demonstrable metastase,; on a radiographic surve_1, of the skeleton and r·xcretory urogrnnw. Histologic proof of ad('.nocarcinoma of the pros tate ,ms obtained in each rnse either by ncrdlr, biopsy or, iu those fe\\- glands which 11·pn, not ,'n'u suspil'ious of mali_gnanc_1- clinically, h} transurethral resection. Tn the firnt 10 cases in the series lyn1plmde.nectomy was not performed routinely, hut the obturator, hypogastric, and iliac lymph node chains were palpated at the time of opt,rnbon and an,1• rnlarg;ecl or indurakd nodrs remo,·cd for liistolog;ic examination. Flocks and associates:, han: commented on this error of attemptin?; to assess lymph node i11n11'·emcnt \\ ithout cart'Jnl dissection and histologic rnnfirmation of /fro~,, impr<'ssions, and on the higl1 incidence of invoh-ecl pt'lvic lymph node~ 111 cases of apparent].,- early pro;;tatic caucr-:r. 2 Ln the next cases bilateral iliac lymphatlenectom_\' 11 a., routinely done, wlwthcr or not suspicious nodcc-werr felt, hut in the most recent 44 casr,s extensin· bilateral peh,ic lyrnphaclenectomy, ,1,~ Im.Ye described, has been perfornwd routinrly. The obturator, hypogastric, and iliac cl1ains lmn' lw
Accepted for publicalion December 5, HJGl. !lead a1 annual meeting: of North Central Scetion of American Frnlop;ical Aswciation, Inc., Cincinnati, Ohio, 8eptem her 27--:30, HJGl. * l"rcsent
address: ,.Tetera,ns Administrntion
Hospital, Cinl'innati 20, Ohio. 1 Flocks, H. H.: Trca1nrnnt of c,ueinoma of the prnsl.atc ..J. Urol., 70: '-HJl-498, 1953. 2 Floclrn, R. H. and Culp, D. A.· Radiation Thernpy of Early ProsLatic Cancer. Hpringfield, U1.: Charles C Thomas, 19GO. '1 Floeks, R. H., Culp, D. and Porto, R.' Lymplrntic spread from prostatie cancer. J. C rol., 81: 1D4- HJ6, 19,5!l 'Colby, F. H.: Carcinoma of t,he prostate· results of total prosta1ec1 omy. J. rrol., 69: 7fl780Ci, 1!),5;3. 5 McDonald, H.P., Upchurch, W. Kand S1urdevaut., C. E_: PeriHcn.t biopsy cornbirrnd with
rndieal ret.ropuhic prostater:tom~, for early carcinoma of the prostate. J. 1~rol., 73: 575-57[), l\l55. 6 Whitmore, W. F., Jr and Mackenzie, A. R. Experiences with various opcrntivc procednres for the total excision of prostatic cancer. Cancer, 12: :3fl6405, 19,59.
DI
92
L. J. ARDUINO AND M. A. GLUCKSMAN
examined histologically, as have been the prostates and seminal vesicles. FINDINGS
Of the 71 patients operated upon, 19 (26.8 per cent) had demonstrable involvement of regional lymph nodes. The seminal vesicles were microscopically invaded in 17 cases (23.9 per cent). In this group of 17 cases, 14 (82.4 per cent) had node metastases. Of the remaining 54 patients whose seminal vesicles were free of tumor, only four (7.3 per cent) had lymph node involvement. Considering only the 44 patients in whom complete pelvic lymphadenectomy was performed, lymph node deposits were demonstrable in 14 (32 per cent). Microscopic invasion of the seminal vesicles was noted in 11 patients (25 per cent). Ten of these 11 (91 per cent) had regional node metastases. Of the remaining 31 patients whose seminal vesicles were free of tumor, four (12.9 per cent) were found to have regional node involvement. In the entire series of 71 patients, five (7 per cent) were found to have microscopic invasion of the true capsule of the prostate but none of these had regional node involvement. Colby 4 has also observed that capsular invasion does not seem to have prognostic importance. In the group of 44 patients who underwent complete pelvic lymphadenectomy, the distribution of the involved nodes in the 14 patients with lymphatic metastases was as follows: Obturator-hypogastric group alone involved ...................................... Obturator-hypogastrics + iliacs involved ....... Obturator-hypogastrics + pre-aortics involved, (iliacs free of neoplasm) . . . . . . . . . . Iliacs alone involved (obturator-hypogastrics "skipped"). . . . . . . . . . . . . . . . . . . . . . . .
2 3 1 8
DISCUSSION
In the group of patients in whom the extensive pelvic lymphadenectomy was performed, a surprising finding was the relationship of clinically latent seminal vesicle involvement to lymph node metastases: 10 of 11 patients with seminal vesicle extension had positive lymph nodes (90 per cent). With clinically evident local extension of prostatic cancer, it is our opinion that the incidence of lymph node metastases would be as great, or perhaps even approach
100 per cent. It would also appear that the reported conversion of locally inoperable to operable glands by the preoperative administration of estrogens1-s can only give a false hope of curability. This practice has been condemned by Barnes9 and Flocks and associates10 have clearly stated that prostatic cancer is incurable when it has locally extended or metastasized. It is not yet possible to draw any conclusions as to whether the removal of involved lymph nodes will increase the longevity or the cure rate achieved by radical prostatectomy, although it is not unreasonable to hope so in view of the experiences of the general surgeons with radical mastectomies, radical neck dissections, etc. Pelvic lymphadenectomy adds only 30 to 45 minutes to the operating time of a radical retropubic prostatectomy and little if anything to operative mortality and morbidity. Whether the finding of involved nodes is of prognostic significance is also unknown, but Colby4 has pointed out that seminal vesicle involvement carries a poor prognosis. Whitmore and Mackenzie 6 have raised these identical questions relative to the therapeutic effect and prognostic significance of lymph node dissection. Of our patients who survived the immediate postoperative period, three have since died of recurrent neoplasm. Two of these did, and one did not, have lymph node involvement at the time of operation. One additional patient who had involvement of the seminal vesicles and regional lymph nodes at the time of operation is presently being treated for osseous metastases. It is interesting that almost one-fourth of the patients in the series had microscopic seminal vesicle invasion which was not detected by preoperative rectal examination or by palpation at operation. In these cases the tumor was still confined by the fascial envelope and local fixation had not yet occurred. 7 Scott, W. W.: An evaluation of endocrine control therapy plus radical perinea! prostatectomy in the treatment of selected cases of advanced carcinoma of the prostate. J. Urol.
77: 521-527, 1955.
'
Sullivan, J. J. and Hartwig, C. H.: Use of estrogen therapy preliminary to radical perinea! prostatoseminal vesiculectomy in carcinoma of the prostate. J. Urol., 70: 499-502, 1953. 9 Barnes, R. W. and Emery, D. S.: Management of early prostatic carcinoma. Calif. Med., 8
91: 57-61, 1959.
1 ° Flocks, R.H., Harness, W. H., Tudor, J.M. and Pendergast, L.: Treatment of carcinoma of prostate. J. Urol., 66: 393-407, 1951.
LYMPH NODE METASTASES IN EARLY CAUCINOMA OF PROST,\TE
SUMMARY
The incidence and distribution of lymph node metastases in patients ,vith early operable carcinoma of the prostate have been presented. There is a signifieant (2:3.9 per cent) incidence of clinieally undetected nn olvement of the seminal vesicles.
D'..l
·where the seminal vesicle is i1wackd, there is a high incidence (at least 82.4 per cent and probn lily higher) of pelvic lymph node metastases. It is suggested that combining lymphadcnectomy with the retropubic as the l-stagc procedure, or ,,·ith the route as a 2-stage proc<'dure, the long(:\·it_,· or possibly the cur<' rate might be improved.
LYI\IPH KODE METASTASES IK EARLY CARCIKOi\fA OF THE PROSTATE LINO ,J. ARDUIXO
AND
MICHEL A. GLUCKSMAN*
From. the Department of Surgery, Section of Urology, Veterans ,idminislration Center, Des Moines, fmN,
Tlw potential curability of adenocarcinoma of the prostate by radical exc1s10n depends, naturally, on total rP!lloval of the tumor and its regional extensions .. \ serioup deficiency of the radical or total p('rineal prostatectomy !urn been demonstrated b~- Flocb and associatcsH in that the rC'gional lymph nodes can neither be r~xamim)cl nor renwvccl b~, this route. At tirnes 4 -" complete l't'lllm-al of the seminal Yrsicles is difficult or impossible. Flocks, Culp and Porto 3 haYC' graphically shcmn that part of the supC'riority of the retropubic approach for radical prostateetomy is the factor of \Yidr expmmre of the pelvic lymph node;; and ease of doing an extensive JWh'ic lyrnphade1H'Ctom!-· [t follmrn that the prostato,,C'siculcctomy is also accomplislwd in toto ,,,ith mucb less difficnlty. Except for Flock~ and associates, little data 4. 6 bave hren published on the incidence' of regional lymph node metastast's in ('arly, operable aclenocaffinoma of the prostah'. report finding nocle ck.posits in 7 per cPnt of cases ,1,ith im·oh-enwnt of the seminal ,-csides and in 40 per cent of those ,,-ho did have extension of tumor to the seminal \'esicles and periprostatic tissues. Flocks, Culp and Porto 3 rrport a 7 per cent incidence of 1,,-mph node metastases in 2D patients with
carcinoma limited to tlw prostate (opcrablr) and a 38 per cent incidence of l!-mphatic kl)H)ad in 382 patients (locally inoperable) but witliout evidence of (fatant metastases. U Ring their original inYestigation as a gnicl(', we have reYiewecl our experience ffith 71 radical prostatectornics performed O\Tr tbe paRt 5 .1cars (October 1955-August 1960). MATERIALS AND METHODS
The patients ranged from 55 to 72 yearn of age, ,1-ith a mean age of 66.5. Six were 70 yrar~ or older, six were 60 or younger, ancl 59 were from 61 to fi9 years inclusive. ,\.II patiPnts wC'rP P.,amined rectally by thl' st'nior author ,,-ho belirn:d that the tumor had not e:dendC'd to the sC'minal i'C'sicles or the periprostatic tissues. .-\11 bad :-;erurn acid phmphatase lewis JwlmY 1 units (Shinowara-Jones-Rinehart). All were fret) of demonstrable metastase,; on a radiographic surve_1, of the skeleton and r·xcretory urogrnnw. Histologic proof of ad('.nocarcinoma of the pros tate ,ms obtained in each rnse either by ncrdlr, biopsy or, iu those fe\\- glands which 11·pn, not ,'n'u suspil'ious of mali_gnanc_1- clinically, h} transurethral resection. Tn the firnt 10 cases in the series lyn1plmde.nectomy was not performed routinely, hut the obturator, hypogastric, and iliac lymph node chains were palpated at the time of opt,rnbon and an,1• rnlarg;ecl or indurakd nodrs remo,·cd for liistolog;ic examination. Flocks and associates:, han: commented on this error of attemptin?; to assess lymph node i11n11'·emcnt \\ ithout cart'Jnl dissection and histologic rnnfirmation of /fro~,, impr<'ssions, and on the higl1 incidence of invoh-ecl pt'lvic lymph node~ 111 cases of apparent].,- early pro;;tatic caucr-:r. 2 Ln the next cases bilateral iliac lymphatlenectom_\' 11 a., routinely done, wlwthcr or not suspicious nodcc-werr felt, hut in the most recent 44 casr,s extensin· bilateral peh,ic lyrnphaclenectomy, ,1,~ Im.Ye described, has been perfornwd routinrly. The obturator, hypogastric, and iliac cl1ains lmn' lw
Accepted for publicalion December 5, HJGl. !lead a1 annual meeting: of North Central Scetion of American Frnlop;ical Aswciation, Inc., Cincinnati, Ohio, 8eptem her 27--:30, HJGl. * l"rcsent
address: ,.Tetera,ns Administrntion
Hospital, Cinl'innati 20, Ohio. 1 Flocks, H. H.: Trca1nrnnt of c,ueinoma of the prnsl.atc ..J. Urol., 70: '-HJl-498, 1953. 2 Floclrn, R. H. and Culp, D. A.· Radiation Thernpy of Early ProsLatic Cancer. Hpringfield, U1.: Charles C Thomas, 19GO. '1 Floeks, R. H., Culp, D. and Porto, R.' Lymplrntic spread from prostatie cancer. J. C rol., 81: 1D4- HJ6, 19,5!l 'Colby, F. H.: Carcinoma of t,he prostate· results of total prosta1ec1 omy. J. rrol., 69: 7fl780Ci, 1!),5;3. 5 McDonald, H.P., Upchurch, W. Kand S1urdevaut., C. E_: PeriHcn.t biopsy cornbirrnd with
rndieal ret.ropuhic prostater:tom~, for early carcinoma of the prostate. J. 1~rol., 73: 575-57[), l\l55. 6 Whitmore, W. F., Jr and Mackenzie, A. R. Experiences with various opcrntivc procednres for the total excision of prostatic cancer. Cancer, 12: :3fl6405, 19,59.
DI
92
L. J. ARDUINO AND M. A. GLUCKSMAN
examined histologically, as have been the prostates and seminal vesicles. FINDINGS
Of the 71 patients operated upon, 19 (26.8 per cent) had demonstrable involvement of regional lymph nodes. The seminal vesicles were microscopically invaded in 17 cases (23.9 per cent). In this group of 17 cases, 14 (82.4 per cent) had node metastases. Of the remaining 54 patients whose seminal vesicles were free of tumor, only four (7.3 per cent) had lymph node involvement. Considering only the 44 patients in whom complete pelvic lymphadenectomy was performed, lymph node deposits were demonstrable in 14 (32 per cent). Microscopic invasion of the seminal vesicles was noted in 11 patients (25 per cent). Ten of these 11 (91 per cent) had regional node metastases. Of the remaining 31 patients whose seminal vesicles were free of tumor, four (12.9 per cent) were found to have regional node involvement. In the entire series of 71 patients, five (7 per cent) were found to have microscopic invasion of the true capsule of the prostate but none of these had regional node involvement. Colby 4 has also observed that capsular invasion does not seem to have prognostic importance. In the group of 44 patients who underwent complete pelvic lymphadenectomy, the distribution of the involved nodes in the 14 patients with lymphatic metastases was as follows: Obturator-hypogastric group alone involved ...................................... Obturator-hypogastrics + iliacs involved ....... Obturator-hypogastrics + pre-aortics involved, (iliacs free of neoplasm) . . . . . . . . . . Iliacs alone involved (obturator-hypogastrics "skipped"). . . . . . . . . . . . . . . . . . . . . . . .
2 3 1 8
DISCUSSION
In the group of patients in whom the extensive pelvic lymphadenectomy was performed, a surprising finding was the relationship of clinically latent seminal vesicle involvement to lymph node metastases: 10 of 11 patients with seminal vesicle extension had positive lymph nodes (90 per cent). With clinically evident local extension of prostatic cancer, it is our opinion that the incidence of lymph node metastases would be as great, or perhaps even approach
100 per cent. It would also appear that the reported conversion of locally inoperable to operable glands by the preoperative administration of estrogens1-s can only give a false hope of curability. This practice has been condemned by Barnes9 and Flocks and associates10 have clearly stated that prostatic cancer is incurable when it has locally extended or metastasized. It is not yet possible to draw any conclusions as to whether the removal of involved lymph nodes will increase the longevity or the cure rate achieved by radical prostatectomy, although it is not unreasonable to hope so in view of the experiences of the general surgeons with radical mastectomies, radical neck dissections, etc. Pelvic lymphadenectomy adds only 30 to 45 minutes to the operating time of a radical retropubic prostatectomy and little if anything to operative mortality and morbidity. Whether the finding of involved nodes is of prognostic significance is also unknown, but Colby4 has pointed out that seminal vesicle involvement carries a poor prognosis. Whitmore and Mackenzie 6 have raised these identical questions relative to the therapeutic effect and prognostic significance of lymph node dissection. Of our patients who survived the immediate postoperative period, three have since died of recurrent neoplasm. Two of these did, and one did not, have lymph node involvement at the time of operation. One additional patient who had involvement of the seminal vesicles and regional lymph nodes at the time of operation is presently being treated for osseous metastases. It is interesting that almost one-fourth of the patients in the series had microscopic seminal vesicle invasion which was not detected by preoperative rectal examination or by palpation at operation. In these cases the tumor was still confined by the fascial envelope and local fixation had not yet occurred. 7 Scott, W. W.: An evaluation of endocrine control therapy plus radical perinea! prostatectomy in the treatment of selected cases of advanced carcinoma of the prostate. J. Urol.
77: 521-527, 1955.
'
Sullivan, J. J. and Hartwig, C. H.: Use of estrogen therapy preliminary to radical perinea! prostatoseminal vesiculectomy in carcinoma of the prostate. J. Urol., 70: 499-502, 1953. 9 Barnes, R. W. and Emery, D. S.: Management of early prostatic carcinoma. Calif. Med., 8
91: 57-61, 1959.
1 ° Flocks, R.H., Harness, W. H., Tudor, J.M. and Pendergast, L.: Treatment of carcinoma of prostate. J. Urol., 66: 393-407, 1951.
LYMPH NODE METASTASES IN EARLY CAUCINOMA OF PROST,\TE
SUMMARY
The incidence and distribution of lymph node metastases in patients ,vith early operable carcinoma of the prostate have been presented. There is a signifieant (2:3.9 per cent) incidence of clinieally undetected nn olvement of the seminal vesicles.
D'..l
·where the seminal vesicle is i1wackd, there is a high incidence (at least 82.4 per cent and probn lily higher) of pelvic lymph node metastases. It is suggested that combining lymphadcnectomy with the retropubic as the l-stagc procedure, or ,,·ith the route as a 2-stage proc<'dure, the long(:\·it_,· or possibly the cur<' rate might be improved.