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Unsuspected Prostatic Adenocarcinoma in Patients Who Have Undergone Radical Cystoprostatectomy for Transitional Cell Carcinoma of The Bladder
0022-534 7/88/1396-1214$2.00/0 Vol. 139, June Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1988 by The Williams & Wilkins Co.
UNSUSPECTED PROSTATIC ADENOCARCINOMA IN PATIENTS WHO HAVE UNDERGONE RADICAL CYSTOPROSTATECTOMY FOR TRANSITIONAL CELL CARCINOMA OF THE BLADDER THOMAS RAND PRITCHETT, JOSE MORENO, NANCY E. WARNER, GARY LIESKOVSKY, PETER W. NICHOLS, BRIDGETTE A. COOK AND DONALD G. SKINNER From the Division of Urology and Department of Pathology, University of Southern California School of Medicine, Los Angeles, California
ABSTRACT
In 45 of 165 male cystectomy patients with bladder cancer (27 per cent) incidental adenocarcinoma of the prostate was found during the diagnostic evaluation or histological examination of the cystoprostatectomy specimens. Of the patients 37 had stage Al or A2 and 8 had stage C or Dl prostate cancer. Clinical presentation, stage and grade distributions for each primary and prognostic variable are reviewed. Over-all, 67 per cent of the patients currently are alive with a 3-year actuarial survival rate of 60 per cent. The presence of incidental stage C or Dl prostate cancer in the surgical specimen implies incomplete surgical excision and it may warrant additional postoperative treatment. How€ver, a significantly increased mortality rate among these patients has not been identified during the lirn.ited median followup of 25 months. (J. Ural., 139: 1214-1216, 1988) The unexpected finding of prostatic adenocarcinoma in the excised cystoprostatectomy specimen of a patient with known transitional cell carcinoma of the bladder often can represent a therapeutic dilemma to the urologist. We reviewed our recent cystectomy experience in male patients treated for transitional cell carcinoma of the bladder. The clinical presentation, tumor stage and grade distribution, and survival rates of patients with prostatic adenocarcinoma and transitional cell carcinoma of the bladder at cystectomy are reviewed. A treatment guideline for these patients based on the staging of each primary tumor is proposed. MATERIALS AND METHODS
From April 1983 to June 1986, 165 men underwent radical cystoprostatectomy and urinary diversion for high grade or invasive transitional cell carcinoma of the bladder. Patient age ranged from 34 to 87 years, with a mean age of 65 years. Incidental adenocarcinoma of the prostate was found in 45 men (27 per cent). These patients ranged from 41 to 83 years old, with a mean age of 67 years. All patients presented with symptoms referable to bladder cancer. The most common chief complaint was hematuria. The most frequent symptoms included hematuria in 78 per cent of the patients, dysuria in 42 per cent, nocturia in 33 per cent, frequency in 27 per cent, pain in 13 per cent and weight loss in 11 per cent. While in most patients the diagnosis of bladder cancer was confirmed within 1 month of onset of symptoms, 14 patients had symptoms from 5 to 30 months before the bladder cancer was diagnosed. In only 1 patient was the diagnosis of prostate cancer suspected by rectal examination during evaluation for cystectomy, while in the other 44 it was clinically unsuspected. Preoperatively, all patients had normal alkaline phosphatase levels, while acid phosphatase levels and bone scans were not done routinely. The standard protocol for pathological examination of the cystoprostatectomy specimen involved wide sampling of the prostate, including the apex, posterior lobe (right and left sides, and midline), verumontanum, right and left lateral lobes, and junction of the prostate with the right and left seminal vesicles. Prostatic tissue was fixed in formalin, embedded in paraffin, sectioned and stained with hematoxylin and eosin. Accepted for publication October 7, 1987.
RESULTS
Pathological staging of the bladder cancer showed 4 patients with carcinoma in situ alone, and 6 with stage Pl, 5 stage P2, 6 stage P3A, 14 stage P3B and 3 stage P4A disease. Seven patients had transitional cell carcinoma metastatic to the lymph nodes (1 with stage Pl, 2 stage P3B and 4 stage P4A disease). Pathological staging of the prostatic cancer showed 37 patients with stage A adenocarcinoma. A total of 25 patients had a microscopic focus in less than 5 per cent of the prostate (stage Al) and 12 had more than 5 per cent of the prostate occupied by adenocarcinoma (stage A2). Six patients had stage C disease and 2 had stage Dl adenocarcinoma. Of the stage C cancer patients 4 had extension through the capsule and 2 had involvement of the seminal vesicles. The 2 patients with adenocarcinoma of the prostate metastatic to the lymph nodes also had extracapsular extension (table 1). The mean ages of the stages Al, A2, C and Dl cancer patients were 66, 66, 74 and 75 years, respectively. Among all 165 male cystectomy patients 9 were 40 to 49, 36 were 50 to 59, 64 were 60 to 69, 4 7 were 70 to 79 and 6 were 80 to 89 years old. Prostate cancer was found incidentally in 11, 14, 36, 28 and 50 per cent of these age groups, respectively. All patients had high grade transitional cell carcinoma or carcinoma in situ of the bladder. The prostatic adenocarcinomas showed a broad range of Gleason combined grading scores, and most patients with higher Gleason scores had higher stage prostatic adenocarcinoma (table 2). Five patients had transitional cell carcinoma confined to the bladder (stage P3A or less) but they had spread of prostatic adenocarcinoma beyond the prostate. Three patients had extension of transitional cell carcinoma into the prostate (stage P4A). A total of 21 patients had extramural extension of transitional cell carcinoma, while 3 had extension of both primaries beyond the confines of the bladder and prostate (table 1). Of the 8 patients with incidental stage C or Dl adenocarcinoma of the prostate 4 were observed with no further cancer therapy. One patient underwent bilateral orchiectomy, while 1 received 4,500 rad to the pelvis. One patient received cisplatin chemotherapy postoperatively, and 1 received radiation and chemotherapy postoperatively.
1214
1215
CONCURRENT BLADDER AND PROSTATE CANCER TABLE
L Comparison of pathological stages of prostate and bladder
TABLE
3. Actuarial survival probability rates
primary tumors
% Alive at
Stage
Bladder Ca Stage
Prostate Ca Stage
1 Yr.
3 Yrs.
Standard Errort
45 (9) 22 (6)
78 95
60 65
± 17 ± 21
23 (3)
61
56
± 28
37 (6)
78
64
± 17
8 (3)
75
50
± 35
16 (4)
94
80
± 18
29 (5)
69
59
± 28
No. Pts.*
Totals PIS
Pl
P2
P3A
P3B
P4A
N+
2
2* 3*
5 0 0
0
5* 0 1*
25 12
0
st 5:j: 0
2 1
1
1* 2 2*
0
1*
0
0
0
0
1*
2
0
0
0
1
1
0
0
2
4
6
5
6
14
3
7
45
Al A.2 Extension through capsule Pos. seminal vesicle
N+ Totals
4
'' One death. Three deaths. :j: Four deaths. TABLE
Gleason's Grade Sum 2-4 5-7 8-10 Totals
All pts. Low stage bladder Ca (Pl, P2, P3A) High stage bladder Ca (P3B, P4, N+) Low stage prostate Ca (Al, A2) High stage prostate Ca (C, Dl) Both primary tumors confined to organ of origin Either Ca spread beyond organ of origin
* Numbers in parentheses are the numbers of patients followed for at least 3 years. t The large standard errors reflect the limited followup currently available.
2. Prostate cancer grade and stage Prostate Ca Stage Totals Al
A2
C
D
19 6
8 4 0
2 3
0 2
0
1
0
29 15 1
25
12
6
2
45
With a median followup of 25 months, 67 per cent of these currently are alive. There were no perioperative deaths. the 15 patients who died 8 had no evidence of recurrent carcinoma, 2 died of bladder cancer and 5 died of carcinoma but the primary tumor responsible was not determined. Of the latter 5 patients 3 had stage Al or A2 prostatic cancer with stage P3B bladder cancer, 1 had stage C prostatic cancer with P3A bladder cancer and 1 had stage C prostate cancer stage P4N+ bladder cancer. Ten patients whose transitional cell carcinoma had spread beyond the bladder died and 4 died whose adenocarcinoma had spread beyond the prostate. 3 of the 16 patients with both primary tumors confined o:rgans of origin died. Of the 29 patients with spread of both primaries beyond the organ of origin 11 died. the actuarial survival method of Kaplan and Meier,' and the limited followup currently available, table 3 shows the survival rates for these patients after radical cystoprostatectomy. The 3-year survival rate was 60 per cent with a standard error of 17 per cent. The actuarial 3-year survival .rates for patients with cancer confined to the bladder (stage P3A or less) and those with cancer extending beyond the bladder (stage P3B or greater) were 65 and 56 per cent, respecWhen the patients were grouped according to whether the prnstate cancer was confined to the prostate (stages Al and A2) or had extended beyond the prostate (stages C and Dl), the actuarial 3-year survival rates were 64 and 50 per cent, :respectively. When both primaries were confined to the organ of the actuarial 3-year survival rate was 80 per cent. If either cancer had spread beyond its organ of origin the 3-year actuarial survival rate was 59 per cent. DISCUSSION
Since 18 per cent of all men in the seventh decade of life are to have incidental prostatic carcinoma, it should not he surprising to find occasionally adenocarcinoma of the prostate in an excised cystoprostatectomy specimen. 2 Our reported rates of incidental prostatic cancer of 11, 14, 36, 28 and 50 per cent for patients in the fifth, sixth, seventh, eighth and ninth decades of life, respectively, are within the range of those mcidences reported by Sheldon and associates. 2 Although our over-all incidence of 27 per cent is not unexpected, this finding has been reported infrequently. Selli and associates reviewed a experience and found 33 patients with bladder and prostate cancer, 18 of whom had prostate cancer diagnosed at
radical cystoprostatectomy. 3 Mersheimer and associates in a surgical tumor registry review found that a combination of bladder and prostate cancer was a common observation second in frequency only to the combination of skin and colon cancer.4 While prostate cancer frequently is asymptomatic and its symptoms can be confused with those of bladder cancer, it is surprising that 8 of our patients had pathological stage C or Dl prostatic cancer and only 1 of these was suspected clinically. Our 3-year actuarial survival rate of 64 per cent for patients with stage Al or A2 prostate cancer (table 3) compares favorably to that of 40 to 82 per cent for cystectomy patients with bladder cancer alone as reported by Skinner and Lieskovsky. 5 The 3-year survival rate of 50 per cent (standard error ± 35 per cent) for patients with stages C and Dl prostate cancer is only minimally better than the survival rate of 35 per cent reported by Skinner for bladder cancer patients with positive nodes. 6 An increased risk of death in our 45 patients owing to the presence of prostatic cancer cannot be confirmed. While 7 of the 15 deaths were attributable to the primary cancers, prostatic cancer could not be proved by autopsy or suggested by clinical course to be responsible for any of these deaths. There is no significant difference in the survival rates with the limited followup currently available (table 3). There were no perioperative deaths among the 45 patients. It appears that the presence of incidental adenocarcinoma of the prostate does not add to the surgical mortality of radical cystoprostatectomy and urinary diversion. The presence of pathological stage A prostate cancer should not affect the survival of the cystectomy patient adversely, and we do not alter our postoperative treatment plans if incidental stage A prostatic tumor is found. The finding of pathological stage C or Dl prostate cancer in the surgical specimen implies that the prostate cancer has not been excised totally and, therefore, that the prognosis is worse. While transitional cell carcinoma traditionally has been believed to be more lethal than adenocarcinoma of the prostate, we recommend treating patients with incidental stage C or Dl prostate cancer aggressively with postoperative radiation therapy, chemotherapy and hormonal therapy, just as we do for patients undergoing radical prostatectomy whose disease is upstaged pathologically to stage C or Dl. This is true especially for patients with locally confined bladder cancer. Our policy has been to treat post-prostatectomy pathological stage C prostatic cancer patients with 4,500 rad external beam radiation therapy directed to the prostatic bed through a small portal not including the pelvic sidewalls. 7 We have treated those postprostatectomy patients with stage Dl prostatic cancer with adjuvant chemotherapy using 1 gm./M. 2 cyclophosphamide per month for 6 months if less than 6 pelvic nodes contained tumor, or with early hormonal therapy if greater than 6 nodes contained tumor. 8 While the efficacy of these adjuvant therapies
1216
PRITCHETT AND ASSOCIATES
cannot be proved by our current results and the limited followup available, we have been reluctant not to offer additional therapy to cystectomy patients with incidental stage C or D prostate cancer. We recommend these same treatments for patients with incidental stage C or Dl prostate cancer in the cystoprostatectomy specimen. Although 27 per cent of the male cystectomy patients had incidental prostatic adenocarcinoma, 15 per cent (25) had only stage Al focal disease and 12 per cent (20) had higher stage disease (A2, C or D). With 12 per cent of the male cystectomy patients having incidental stage A2, C or Dl prostatic adenocarcinoma and a reported 40 per cent having transitional cell carcinoma in the prostatic urethra, one must be sure to excise the entire prostate during radical cystoprostatectomy.9 One must not sacrifice the completeness of an otherwise successful radical cancer operation by leaving cancer behind in an apical prostatic margin. REFERENCES 1. Kaplan, E. L. and Meier, P.: Nonparametric estimation from
incomplete observations. J. Amer. Stat. Ass., 53: 457, 1958. 2. Sheldon, C. A., Williams, R. D. and Fraley, E. E.: Incidental carcinoma of the prostate: a review of the literature and critical
reappraisal of classification. J. Urol., 124: 626, 1980. 3. Selli, C., Hinshaw, W., Wolfe, J. A. and Paulson, D. F.: Management of patients with concurrent primary tumors of bladder and prostate. Urology, 21: 562, 1983. 4. Mersheimer, W. L., Ringel, A. and Eisenberg, H.: Some characteristics of multiple primary cancers. Ann. N. Y. Acad. Sci., 114: 896, 1964. 5. Skinner, D. G. and Lieskovsky, G.: Contemporary cystectomy with pelvic node dissection compared to preoperative radiation therapy plus cystectomy in management of invasive bladder cancer. J. Urol., 131: 1069, 1984. 6. Skinner, D. G.: Management of invasive bladder cancer: a meticulous pelvic node dissection can make a difference. J. Urol., 128: 34, 1982. 7. Skinner, D. G. and Lieskovsky, G.: Carcinoma of the prostate: an opinion on management of early stage disease with a commentary on the meaning of capsular penetration. J. Urol., 134: 1183, 1985. 8. Skinner, D. G., Lieskovsky, G. and Carter, G. E.: Management of locally extensive cancer of the prostate without evidence of metastatic disease. Probl. Urol., 1: 99, 1987. 9. Montie, J. E., Mirsky, H. and Levin, H. S.: Transitional cell carcinoma of the prostate in a series of cystectomies: incidence and staging problems. J. Urol., part 2, 135: 243A, abstract 557, 1986.
THE JOURNAL OF UROLOGY
Copyright© 1988 by The Williams & Wilkins Co.
UNSUSPECTED PROSTATIC ADENOCARCINOMA IN PATIENTS WHO HAVE UNDERGONE RADICAL CYSTOPROSTATECTOMY FOR TRANSITIONAL CELL CARCINOMA OF THE BLADDER THOMAS RAND PRITCHETT, JOSE MORENO, NANCY E. WARNER, GARY LIESKOVSKY, PETER W. NICHOLS, BRIDGETTE A. COOK AND DONALD G. SKINNER From the Division of Urology and Department of Pathology, University of Southern California School of Medicine, Los Angeles, California
ABSTRACT
In 45 of 165 male cystectomy patients with bladder cancer (27 per cent) incidental adenocarcinoma of the prostate was found during the diagnostic evaluation or histological examination of the cystoprostatectomy specimens. Of the patients 37 had stage Al or A2 and 8 had stage C or Dl prostate cancer. Clinical presentation, stage and grade distributions for each primary and prognostic variable are reviewed. Over-all, 67 per cent of the patients currently are alive with a 3-year actuarial survival rate of 60 per cent. The presence of incidental stage C or Dl prostate cancer in the surgical specimen implies incomplete surgical excision and it may warrant additional postoperative treatment. How€ver, a significantly increased mortality rate among these patients has not been identified during the lirn.ited median followup of 25 months. (J. Ural., 139: 1214-1216, 1988) The unexpected finding of prostatic adenocarcinoma in the excised cystoprostatectomy specimen of a patient with known transitional cell carcinoma of the bladder often can represent a therapeutic dilemma to the urologist. We reviewed our recent cystectomy experience in male patients treated for transitional cell carcinoma of the bladder. The clinical presentation, tumor stage and grade distribution, and survival rates of patients with prostatic adenocarcinoma and transitional cell carcinoma of the bladder at cystectomy are reviewed. A treatment guideline for these patients based on the staging of each primary tumor is proposed. MATERIALS AND METHODS
From April 1983 to June 1986, 165 men underwent radical cystoprostatectomy and urinary diversion for high grade or invasive transitional cell carcinoma of the bladder. Patient age ranged from 34 to 87 years, with a mean age of 65 years. Incidental adenocarcinoma of the prostate was found in 45 men (27 per cent). These patients ranged from 41 to 83 years old, with a mean age of 67 years. All patients presented with symptoms referable to bladder cancer. The most common chief complaint was hematuria. The most frequent symptoms included hematuria in 78 per cent of the patients, dysuria in 42 per cent, nocturia in 33 per cent, frequency in 27 per cent, pain in 13 per cent and weight loss in 11 per cent. While in most patients the diagnosis of bladder cancer was confirmed within 1 month of onset of symptoms, 14 patients had symptoms from 5 to 30 months before the bladder cancer was diagnosed. In only 1 patient was the diagnosis of prostate cancer suspected by rectal examination during evaluation for cystectomy, while in the other 44 it was clinically unsuspected. Preoperatively, all patients had normal alkaline phosphatase levels, while acid phosphatase levels and bone scans were not done routinely. The standard protocol for pathological examination of the cystoprostatectomy specimen involved wide sampling of the prostate, including the apex, posterior lobe (right and left sides, and midline), verumontanum, right and left lateral lobes, and junction of the prostate with the right and left seminal vesicles. Prostatic tissue was fixed in formalin, embedded in paraffin, sectioned and stained with hematoxylin and eosin. Accepted for publication October 7, 1987.
RESULTS
Pathological staging of the bladder cancer showed 4 patients with carcinoma in situ alone, and 6 with stage Pl, 5 stage P2, 6 stage P3A, 14 stage P3B and 3 stage P4A disease. Seven patients had transitional cell carcinoma metastatic to the lymph nodes (1 with stage Pl, 2 stage P3B and 4 stage P4A disease). Pathological staging of the prostatic cancer showed 37 patients with stage A adenocarcinoma. A total of 25 patients had a microscopic focus in less than 5 per cent of the prostate (stage Al) and 12 had more than 5 per cent of the prostate occupied by adenocarcinoma (stage A2). Six patients had stage C disease and 2 had stage Dl adenocarcinoma. Of the stage C cancer patients 4 had extension through the capsule and 2 had involvement of the seminal vesicles. The 2 patients with adenocarcinoma of the prostate metastatic to the lymph nodes also had extracapsular extension (table 1). The mean ages of the stages Al, A2, C and Dl cancer patients were 66, 66, 74 and 75 years, respectively. Among all 165 male cystectomy patients 9 were 40 to 49, 36 were 50 to 59, 64 were 60 to 69, 4 7 were 70 to 79 and 6 were 80 to 89 years old. Prostate cancer was found incidentally in 11, 14, 36, 28 and 50 per cent of these age groups, respectively. All patients had high grade transitional cell carcinoma or carcinoma in situ of the bladder. The prostatic adenocarcinomas showed a broad range of Gleason combined grading scores, and most patients with higher Gleason scores had higher stage prostatic adenocarcinoma (table 2). Five patients had transitional cell carcinoma confined to the bladder (stage P3A or less) but they had spread of prostatic adenocarcinoma beyond the prostate. Three patients had extension of transitional cell carcinoma into the prostate (stage P4A). A total of 21 patients had extramural extension of transitional cell carcinoma, while 3 had extension of both primaries beyond the confines of the bladder and prostate (table 1). Of the 8 patients with incidental stage C or Dl adenocarcinoma of the prostate 4 were observed with no further cancer therapy. One patient underwent bilateral orchiectomy, while 1 received 4,500 rad to the pelvis. One patient received cisplatin chemotherapy postoperatively, and 1 received radiation and chemotherapy postoperatively.
1214
1215
CONCURRENT BLADDER AND PROSTATE CANCER TABLE
L Comparison of pathological stages of prostate and bladder
TABLE
3. Actuarial survival probability rates
primary tumors
% Alive at
Stage
Bladder Ca Stage
Prostate Ca Stage
1 Yr.
3 Yrs.
Standard Errort
45 (9) 22 (6)
78 95
60 65
± 17 ± 21
23 (3)
61
56
± 28
37 (6)
78
64
± 17
8 (3)
75
50
± 35
16 (4)
94
80
± 18
29 (5)
69
59
± 28
No. Pts.*
Totals PIS
Pl
P2
P3A
P3B
P4A
N+
2
2* 3*
5 0 0
0
5* 0 1*
25 12
0
st 5:j: 0
2 1
1
1* 2 2*
0
1*
0
0
0
0
1*
2
0
0
0
1
1
0
0
2
4
6
5
6
14
3
7
45
Al A.2 Extension through capsule Pos. seminal vesicle
N+ Totals
4
'' One death. Three deaths. :j: Four deaths. TABLE
Gleason's Grade Sum 2-4 5-7 8-10 Totals
All pts. Low stage bladder Ca (Pl, P2, P3A) High stage bladder Ca (P3B, P4, N+) Low stage prostate Ca (Al, A2) High stage prostate Ca (C, Dl) Both primary tumors confined to organ of origin Either Ca spread beyond organ of origin
* Numbers in parentheses are the numbers of patients followed for at least 3 years. t The large standard errors reflect the limited followup currently available.
2. Prostate cancer grade and stage Prostate Ca Stage Totals Al
A2
C
D
19 6
8 4 0
2 3
0 2
0
1
0
29 15 1
25
12
6
2
45
With a median followup of 25 months, 67 per cent of these currently are alive. There were no perioperative deaths. the 15 patients who died 8 had no evidence of recurrent carcinoma, 2 died of bladder cancer and 5 died of carcinoma but the primary tumor responsible was not determined. Of the latter 5 patients 3 had stage Al or A2 prostatic cancer with stage P3B bladder cancer, 1 had stage C prostatic cancer with P3A bladder cancer and 1 had stage C prostate cancer stage P4N+ bladder cancer. Ten patients whose transitional cell carcinoma had spread beyond the bladder died and 4 died whose adenocarcinoma had spread beyond the prostate. 3 of the 16 patients with both primary tumors confined o:rgans of origin died. Of the 29 patients with spread of both primaries beyond the organ of origin 11 died. the actuarial survival method of Kaplan and Meier,' and the limited followup currently available, table 3 shows the survival rates for these patients after radical cystoprostatectomy. The 3-year survival rate was 60 per cent with a standard error of 17 per cent. The actuarial 3-year survival .rates for patients with cancer confined to the bladder (stage P3A or less) and those with cancer extending beyond the bladder (stage P3B or greater) were 65 and 56 per cent, respecWhen the patients were grouped according to whether the prnstate cancer was confined to the prostate (stages Al and A2) or had extended beyond the prostate (stages C and Dl), the actuarial 3-year survival rates were 64 and 50 per cent, :respectively. When both primaries were confined to the organ of the actuarial 3-year survival rate was 80 per cent. If either cancer had spread beyond its organ of origin the 3-year actuarial survival rate was 59 per cent. DISCUSSION
Since 18 per cent of all men in the seventh decade of life are to have incidental prostatic carcinoma, it should not he surprising to find occasionally adenocarcinoma of the prostate in an excised cystoprostatectomy specimen. 2 Our reported rates of incidental prostatic cancer of 11, 14, 36, 28 and 50 per cent for patients in the fifth, sixth, seventh, eighth and ninth decades of life, respectively, are within the range of those mcidences reported by Sheldon and associates. 2 Although our over-all incidence of 27 per cent is not unexpected, this finding has been reported infrequently. Selli and associates reviewed a experience and found 33 patients with bladder and prostate cancer, 18 of whom had prostate cancer diagnosed at
radical cystoprostatectomy. 3 Mersheimer and associates in a surgical tumor registry review found that a combination of bladder and prostate cancer was a common observation second in frequency only to the combination of skin and colon cancer.4 While prostate cancer frequently is asymptomatic and its symptoms can be confused with those of bladder cancer, it is surprising that 8 of our patients had pathological stage C or Dl prostatic cancer and only 1 of these was suspected clinically. Our 3-year actuarial survival rate of 64 per cent for patients with stage Al or A2 prostate cancer (table 3) compares favorably to that of 40 to 82 per cent for cystectomy patients with bladder cancer alone as reported by Skinner and Lieskovsky. 5 The 3-year survival rate of 50 per cent (standard error ± 35 per cent) for patients with stages C and Dl prostate cancer is only minimally better than the survival rate of 35 per cent reported by Skinner for bladder cancer patients with positive nodes. 6 An increased risk of death in our 45 patients owing to the presence of prostatic cancer cannot be confirmed. While 7 of the 15 deaths were attributable to the primary cancers, prostatic cancer could not be proved by autopsy or suggested by clinical course to be responsible for any of these deaths. There is no significant difference in the survival rates with the limited followup currently available (table 3). There were no perioperative deaths among the 45 patients. It appears that the presence of incidental adenocarcinoma of the prostate does not add to the surgical mortality of radical cystoprostatectomy and urinary diversion. The presence of pathological stage A prostate cancer should not affect the survival of the cystectomy patient adversely, and we do not alter our postoperative treatment plans if incidental stage A prostatic tumor is found. The finding of pathological stage C or Dl prostate cancer in the surgical specimen implies that the prostate cancer has not been excised totally and, therefore, that the prognosis is worse. While transitional cell carcinoma traditionally has been believed to be more lethal than adenocarcinoma of the prostate, we recommend treating patients with incidental stage C or Dl prostate cancer aggressively with postoperative radiation therapy, chemotherapy and hormonal therapy, just as we do for patients undergoing radical prostatectomy whose disease is upstaged pathologically to stage C or Dl. This is true especially for patients with locally confined bladder cancer. Our policy has been to treat post-prostatectomy pathological stage C prostatic cancer patients with 4,500 rad external beam radiation therapy directed to the prostatic bed through a small portal not including the pelvic sidewalls. 7 We have treated those postprostatectomy patients with stage Dl prostatic cancer with adjuvant chemotherapy using 1 gm./M. 2 cyclophosphamide per month for 6 months if less than 6 pelvic nodes contained tumor, or with early hormonal therapy if greater than 6 nodes contained tumor. 8 While the efficacy of these adjuvant therapies
1216
PRITCHETT AND ASSOCIATES
cannot be proved by our current results and the limited followup available, we have been reluctant not to offer additional therapy to cystectomy patients with incidental stage C or D prostate cancer. We recommend these same treatments for patients with incidental stage C or Dl prostate cancer in the cystoprostatectomy specimen. Although 27 per cent of the male cystectomy patients had incidental prostatic adenocarcinoma, 15 per cent (25) had only stage Al focal disease and 12 per cent (20) had higher stage disease (A2, C or D). With 12 per cent of the male cystectomy patients having incidental stage A2, C or Dl prostatic adenocarcinoma and a reported 40 per cent having transitional cell carcinoma in the prostatic urethra, one must be sure to excise the entire prostate during radical cystoprostatectomy.9 One must not sacrifice the completeness of an otherwise successful radical cancer operation by leaving cancer behind in an apical prostatic margin. REFERENCES 1. Kaplan, E. L. and Meier, P.: Nonparametric estimation from
incomplete observations. J. Amer. Stat. Ass., 53: 457, 1958. 2. Sheldon, C. A., Williams, R. D. and Fraley, E. E.: Incidental carcinoma of the prostate: a review of the literature and critical
reappraisal of classification. J. Urol., 124: 626, 1980. 3. Selli, C., Hinshaw, W., Wolfe, J. A. and Paulson, D. F.: Management of patients with concurrent primary tumors of bladder and prostate. Urology, 21: 562, 1983. 4. Mersheimer, W. L., Ringel, A. and Eisenberg, H.: Some characteristics of multiple primary cancers. Ann. N. Y. Acad. Sci., 114: 896, 1964. 5. Skinner, D. G. and Lieskovsky, G.: Contemporary cystectomy with pelvic node dissection compared to preoperative radiation therapy plus cystectomy in management of invasive bladder cancer. J. Urol., 131: 1069, 1984. 6. Skinner, D. G.: Management of invasive bladder cancer: a meticulous pelvic node dissection can make a difference. J. Urol., 128: 34, 1982. 7. Skinner, D. G. and Lieskovsky, G.: Carcinoma of the prostate: an opinion on management of early stage disease with a commentary on the meaning of capsular penetration. J. Urol., 134: 1183, 1985. 8. Skinner, D. G., Lieskovsky, G. and Carter, G. E.: Management of locally extensive cancer of the prostate without evidence of metastatic disease. Probl. Urol., 1: 99, 1987. 9. Montie, J. E., Mirsky, H. and Levin, H. S.: Transitional cell carcinoma of the prostate in a series of cystectomies: incidence and staging problems. J. Urol., part 2, 135: 243A, abstract 557, 1986.