- Email: [email protected]
Update on urology—prostate cancer
Educational section
679
Update on urology--prostate cancer Series editor: W. B. Feeling
4--Treatment of local disease W. G. Bowsher Consultant Urological Surgeon, Royal Gwent Hospital, Newport, UK
Kej, words: prostate cancer; local disease; treatment.
Why treat local disease?
Prostate cancer is a major cause ofdeath. In 1992 there were 35,000 prostate cancer-related deaths in-the USA. Attempts should be made to decrease the incidence of metastatic disease and there is evidence that radical radiotherapy and radical prostatectomy may prevent this unpleasant mode of death. Whom should be treated?
Whilst the natural history of prostate cancer may be unpredictable in an individual patient, risk factors for progression have been identified. Currently, when deciding on whom to treat, three factors should be considered in particular: I. Age 2. General medical condition 3. Detailed assessment of the patient by history, examination, prostate-specific antigen (PSA), transrectal ultrasound (TRUS), biopsy and more detailed evaluation of the tumour stage.
I. Age Caution is sensible when considering radical therapy in an elderly patient. The natural life expectancy may prove to be much shorter than the anticipated time for disease progression.
2. General medical condition Again, this will affect'a patient's life expectancy. For example, a patient with severe ischaemic heart disease and associated cardiomegaly may be much more at risk of death from myocardial infarction than from cancer progressiqn.
3. Detailed assessnlent of the patient This is achieved by taking a history~, performing a physical examination and by instigating special investigations. Local-
ized disease is usually detected with a combination of rectal examination, serum PSA and if indicated, detailed transrectal ultrasound. Whether these tests occur in the context of a formal screening programme is currently controversial and this issue needs to be further assessed. Histol T. Localized disease should ideally be asymptomatic. Symptoms such as urinary frequency and bladder outflow obstruction may prove to be secondary to a large turnout mass. E.x'amhlation. A rectal examination should be meticulous, otherwise small nodular cancers will be missed. Benign prostatic hyperplasia (BPH) is soft whereas cancer is hard. Asymmetry and induration of the gland may also raise suspicion. PSA. PSA is a sensitive, although not very specific, test for prostate disease. The precise level at which suspicion should be raised is still controversial. The overall size of the gland should be borne in mind (PSA density). PSA may be elevated in prostatitis and urinary tract infection and with massive BPH. PSA is present within the prostatic epithelium and levels are likely to be influenced by the ratio of stroma to epithelium within the gland. The best recognized kit for PSA estimation is 'Hybritech'. When monitoring longitudinal increases in PSA, a standardized laboratory should be used. TRUS. This should be performed by an expert in the technique with additional skills at performing transrectal biopsy. Whilst hypoechoic lesions are most likely to be cancers, both isoechoic and hyperechoic lesions may more rarely be cancers. Biopsy. Tumours with a higher histopathological grade carry a poorer prognosis. The best grading system appears to be that described by Gleason. It should be borne in mind that the tumour is likely to be heterogeneous in grade and that a needle biopsy may not be representative. Also, it may be difficult to provide a Gleason grade from the small amount of tissue present in a needle biopsy. The needle biopsy should therefore be recognized as a way ofconfirming the cancer but it has limited value in determining the prognosis. In such a patient, the stage of the cancer should be regarded as having much more significance.
Educational section
680
More detailed evaluation. These issues, including Computerized Tomography (CT) scanning, Nuclear Magnetic Resonance Scanning (NMR) and pelvic lymph node dissection tire covered in detail in the article in this series on diagnosis and assessment.
How should local disease be treated?
The conventional treatment options are: 1. Surveillance ('watchful waiting') 2. Radiotherapy 3. Total extirpation of the prostate gland and seminal vesicles (radical prostatectomy)
]te SIo'veillance This fiaay be appropriate for elderly or relatively unfit men with a short natural life expectancy. It seems difficult to justify this option for younger men with a long natural life expectancy because in this group there is a significant risk of progressive disease with the passage of time. Tumours with a higher grade or greater stage are more likely to progress. It seems difficult to justify watchful waiting, for example, in a 54-year-old healthy patient with stage T2 disease. Once the cancer becomes nodular (palpable), it is likely to behave in an aggressive fashion with the passage of time. Dilemmas occur when the disease is not palpable and ,has been discovered as an incidental finding: for example. after transurethral resection of the prostate when it is present in less than 5% of the chips (Stage T1A). In such a patient, further imaging may be justified, if the patient is young, to confirm the stage, but surveillance in the older patient is likely to be more appropriate. Dysplasia (Prostatic intraepithelial neoplasia: PIN) may also be discovered on biopsy and be a further reason for surveillance owing to its premalignant potential. From the practical point of view, surveillance consists of enquiry about lower urinary tract symptoms, digital rectal examination and PSA measurement. PSA has added another dimension to surveillance. A rising trend in PSA ('PSA velocity') can give the clue that a cancer is starting to behave more aggressively. If this is suspected, further imaging and, if appropriate, more aggressive treatment may be justified, such as radiotherapy or hormone therapy in the elderly or more unfit group. The frequency with which a patient is assessed under surveillance depends on the amount of clinical suspicion but the majority of patients are seen annually.
Radiotherapy Modern regimes for radiotherapy involve a fractionated course of 1000 cGy delivered weekly in five daily fractions to a total dose of 6000-6500 cGy. In phase I of the regime there is three or four field pelvic irradiation and in phase 2 the prostate is targeted with a 1.5 to 2 cm margin. Complications may include acute or chronic bladder dysfunction, haematuria and radiation proctitis.
er
Fig. I. The catheter is exposed.
Radical proslmectomy The patient has pre-operative bowel preparation. General and epidural anaesthesia is administered and a 20 ch urethral catheter placed. The operation is performed through a lower midline incision with an extraperitoneal dissection. A preliminary lymph node dissection is performed, clearing all the nodes between the medial aspect of the external iliac vein, the pelvic side wall and the obturator nerve on both sides. The nodes are sent for histological examination. The fat is then cleared by blunt dissection from the anterior surface of the distal prostate, suture ligating superficial veins where necessary. This allows bilateral incisions in the endopelvic fascia near the apex of the gland. The puboprostatic ligaments are then divided, allowing the prostate to drop into the pelvis. It is then possible to doubly ligate and divide the block of tissue anterior to the catheter at the apex of the prostate: the dorsal venous complex. If there is persistent bleeding from the dorsal venous complex it is transfixed. The catheter is exposed (Fig. I), clamped and divided allowing division of the posterior urethra and retraction of the gland up towards the bhidder, ligating and dividing the prostatic pedicles. Denonvilliere's fascia is then incised to expose the seminal vesicles and the ampullae of the vas deferens. The ampullae are ligated and divided allowing blunt dissection of the seminal vesicles. The catheter balloon is then pulled against the bladder neck and the anterior bladder neck incised with diathermy. The gland and the seminal vesicles are then removed with haemostasis achieved by tying ligatures and using diathermy. Sutures are used to evert the bladder urothelium (Fig. 2) and a racquet reconstruction (Fig. 3) of the bladder neck is performed. The anastomosis between the bladder and urethra can then be completed under direct vision over a new foley catheter (Figs 4 and 5). All the urinary tract sutures are absorbable. Wound drains
Efhtcational section
681
:
~
-~"
Ii '
Fig. 4. Tile anaslamosis between the bladder and urethra can then be completed under direct vision.
Fig. 2. Sutures are used to evert the bladder 6rothelium.
's~Jv
" ~
,
_/--7
(~:~.,.,.
/6
Fig. 3. Sutures are used to evert the bladder urothelium vision.
are placed and the w o u n d closed. The catheter can be removed between 10 and 14 days post-operatively. Possible complications are listed in Table I. With experience and proper training such problems are kept to a minimum. When the operation is performed by adequately trained surgeons, incontinence is usually m i n o r and transitory. Potency depends upon the preservation of the neurovascular bundles near the apex of the prostate: sometimes these have to be sacrificed to provide a curative cancer operation. '
Radiotherapy or radical prostatectomy? As the natural history of untreated stage T2 cancer is disease progression and decreased life expectancy, 2-~ it seems
:"
"/
Fig. 5. The anastamosis between the bladder and urethra can then be completed under direct vision.
rational to consider active treatment in these patients. The two most o r t h o d o x treatments currently available for disease confined to the prostate are radiotherapy or radical prostatectomy.
Table I. Possible specific complications of radical prostatectomy Rectal injury Incontinence Impotence Anastamotic stricture
682
Educational section
Teaching point S u m m a u , o f patient groups suitable f o r surveillance
1. Elderly or relatively unfit men with a short natural life expectancy. 2. Men in whom there is a high index of suspicion of prostatic carcinoma from digital rectal examination and]or PSA estimation but where biopsies have been
negative. 3. When prostatic biopsies have failed to demonstrate carcinoma but have demonstrated dysplasia (prostatic
intraepithelial neoplasia: PIN). S u m m a r y o f patients suitable f o r active treatment by radiotherapy or radical prostatectomy
has focused on the incidence of incontinence and impotence after radical prostatectomy. Nevertheless, when the operation is performed by a properly trained surgeon with an appropriately trained team. the risks of long-tel'm incontinence and impotence may be minimized. In the 1990s there is a greater understanding of the anatomy of Santorini's venous plexus and the neurovascular bundles responsible [br erectile function. A morbidity of 12% is reported after radiotherapy for localized prostate cancer. An impotence rate of between 2284% is also reported after radiotherapy (Lepor, 1989). t4 The biggest argt, ment remains about the long-term cure rate and the long-term results of further randonaized prospective studies would be useful.
The future
Younger fitter patients with T2 N O M O disease. S u m m a o , o f patients where management is very debatable
Patients with low-volume well-differentiated carcinomas.
There have been enthusiastic reports of the results of radiotherapy for Iocalised prostate cancer) Dr Bagshaw and associates have reported that the actuarial 15 year survival rate for irradiation treatment of carcinomas occupying less than half of one lobe is almost as good as that following radical prostatectomy (48%). If the induration or nodule occupies more than half of one lobe or extends bilaterally the 15 year actuarial survival falls to 23%. Currently, there is a lack of data from prospective studies. In a randomized prospective study conducted at Duke University, Carolina. 10 OVo of patients who had undergone radical prostatectomy for stage T I B or T2 disease showed evidence of disease recurrence at 5 years whereas 29% of patients with the same stage of disease progressed after 5 years with radiotherapy/' There have been more retrospective studies: in patients with T2 disease treated by external beam radiation 20-50% developed recurrent disease between 7 and 15 years after treatment. 7''~Other studies following patients with T2 disease after radical prostatectomy suggest that the recurrence rate is between 10-26%. ~ ii These retrospective reports suggest that radical prostatectomy has a higher cure rate than external beam radiotherapy. Further evidence for this comes from PSA studies, observing PSA levels after the treatment of prostate cancer with either radiotherapy or radical prostatectomy. In both of these groups a persistently rising PSA is indicative of recurrent disease. Kabalin et al, (1989) '~ showed that in 5789% of patients who received external beam radiotherapy, a biopsy was positive between 12 and 18 months after radiotherapy treatment. Stamey et al. (1989) ~-" investigated patients 12 months after treatment for localized cancer: 50% had a rising PSA suggestive of active disease. Oesterling (1988) 13 reported patients who had undergone radical prostatectomy for either T I or T2 disease: 91% had PSA levels in the female range. Following radical prostatectomy, clinical disease recurrence appears to occur only in those patients with an elevated (detectable) post operative PSA. Short-term morbidity may be greater after radical prostatectomy than after external beam radiotherapy. Attention
Radiotherapists with new technology are showing interest in the techniques of interstitial brachytherapy for Iocalised prostate cancer. As yet there are no Iong-terrn results of significance. Other clinicians are investigating the role of localized N d : Y A G laser energy, localized cryotherapy and hyperthernfia for the treatment of apparently small localized cancers.
Acknowledgements The figures were provided by Mr J. Peters F R A C S , St Vincent's Hospital. Melbourne.
References I. McNeil JE. Bostwick DG. Intraductal dyspl:lsi:l: a pre-malignanl lesion of tile prostate. Hum Pathol 1986: 17: 64. 2. Bumpus HC. Carcinoma of the prostate--a c,linica[ study of one thousand cases. Sm'g G.vnaecol Ohstet 1926: 43: 150-5. 3. Nesbit RM. Plumb RT, Arbor A. Prostatic carcinoma: a followup on 795 patients treated prior to the endocrine era and a comparison of survival rates between these and patients treated by endocrine therapy. Surgery 1946: 20: 263-72. 4. Hanash KA, Urz DC, Cook EN, et al. Carcinoma of the prostate: a fifteen year follow tip. J Urol 1972: 107:450 3. 5. Baghaw MA, Ray RG, et al. External beam radiation therapy of primary carcinoma of the prostate. Cancer 1976: 36: 723-8. 6. Paulson DF, Lin GH, et al. Radical surgery versus radioUlerapy Ibr adenocarcinoma of the prostate. J Urol 1982; 128: 502-4. 7. Hanks GE. External beam radiation therapy for clinically localised prostate cancer: patterns of care studies in the United States. NCI Mmw,qr 1989: 7:75 84. 8. Kabalin JN. Hodge KK. et al. Identification residual cancer in the prostate following radiation therapy: role of transrectal ultrasound guided biopsy and prostate specific antigen. J Urol 1~89: 142:326 31. 9. Culp OS. Radical perinea[ prostatectomy: its past, present and possible future. J Urol 1968: 98:618 26. I 0. Gibbons RP. Correa RJ, et al. Total prostatectomy for clinically localized prostatic cancer: long term results. J Urol 1984; 131: 73-6. 11. Walsh PC, Jewett HJ. Radical surgery for prostatic cancer. Cancer 1980: 45:1906-1 I. 12. Stamey TA, Kabalin JN, et al. Prostate specific antigen in the diagnosis and treatment of adenocarcinoma of the prostate I 1I radiation treated patients. J Urol 1989: 141: 1084-7. 13. Oester[ing JE, Chan DW, et al. Prostate specific antigen in the preoperative and postoperative evaluation o1" Iocalised cancer treated with radical prostatectomy. J Urol 1988: 139: 766-72. 14. Lepor H. The role of radical prostatectomy in the treatment of cancer of the prostate. Cam'er Treat Res 1989: 46: 15-34.
679
Update on urology--prostate cancer Series editor: W. B. Feeling
4--Treatment of local disease W. G. Bowsher Consultant Urological Surgeon, Royal Gwent Hospital, Newport, UK
Kej, words: prostate cancer; local disease; treatment.
Why treat local disease?
Prostate cancer is a major cause ofdeath. In 1992 there were 35,000 prostate cancer-related deaths in-the USA. Attempts should be made to decrease the incidence of metastatic disease and there is evidence that radical radiotherapy and radical prostatectomy may prevent this unpleasant mode of death. Whom should be treated?
Whilst the natural history of prostate cancer may be unpredictable in an individual patient, risk factors for progression have been identified. Currently, when deciding on whom to treat, three factors should be considered in particular: I. Age 2. General medical condition 3. Detailed assessment of the patient by history, examination, prostate-specific antigen (PSA), transrectal ultrasound (TRUS), biopsy and more detailed evaluation of the tumour stage.
I. Age Caution is sensible when considering radical therapy in an elderly patient. The natural life expectancy may prove to be much shorter than the anticipated time for disease progression.
2. General medical condition Again, this will affect'a patient's life expectancy. For example, a patient with severe ischaemic heart disease and associated cardiomegaly may be much more at risk of death from myocardial infarction than from cancer progressiqn.
3. Detailed assessnlent of the patient This is achieved by taking a history~, performing a physical examination and by instigating special investigations. Local-
ized disease is usually detected with a combination of rectal examination, serum PSA and if indicated, detailed transrectal ultrasound. Whether these tests occur in the context of a formal screening programme is currently controversial and this issue needs to be further assessed. Histol T. Localized disease should ideally be asymptomatic. Symptoms such as urinary frequency and bladder outflow obstruction may prove to be secondary to a large turnout mass. E.x'amhlation. A rectal examination should be meticulous, otherwise small nodular cancers will be missed. Benign prostatic hyperplasia (BPH) is soft whereas cancer is hard. Asymmetry and induration of the gland may also raise suspicion. PSA. PSA is a sensitive, although not very specific, test for prostate disease. The precise level at which suspicion should be raised is still controversial. The overall size of the gland should be borne in mind (PSA density). PSA may be elevated in prostatitis and urinary tract infection and with massive BPH. PSA is present within the prostatic epithelium and levels are likely to be influenced by the ratio of stroma to epithelium within the gland. The best recognized kit for PSA estimation is 'Hybritech'. When monitoring longitudinal increases in PSA, a standardized laboratory should be used. TRUS. This should be performed by an expert in the technique with additional skills at performing transrectal biopsy. Whilst hypoechoic lesions are most likely to be cancers, both isoechoic and hyperechoic lesions may more rarely be cancers. Biopsy. Tumours with a higher histopathological grade carry a poorer prognosis. The best grading system appears to be that described by Gleason. It should be borne in mind that the tumour is likely to be heterogeneous in grade and that a needle biopsy may not be representative. Also, it may be difficult to provide a Gleason grade from the small amount of tissue present in a needle biopsy. The needle biopsy should therefore be recognized as a way ofconfirming the cancer but it has limited value in determining the prognosis. In such a patient, the stage of the cancer should be regarded as having much more significance.
Educational section
680
More detailed evaluation. These issues, including Computerized Tomography (CT) scanning, Nuclear Magnetic Resonance Scanning (NMR) and pelvic lymph node dissection tire covered in detail in the article in this series on diagnosis and assessment.
How should local disease be treated?
The conventional treatment options are: 1. Surveillance ('watchful waiting') 2. Radiotherapy 3. Total extirpation of the prostate gland and seminal vesicles (radical prostatectomy)
]te SIo'veillance This fiaay be appropriate for elderly or relatively unfit men with a short natural life expectancy. It seems difficult to justify this option for younger men with a long natural life expectancy because in this group there is a significant risk of progressive disease with the passage of time. Tumours with a higher grade or greater stage are more likely to progress. It seems difficult to justify watchful waiting, for example, in a 54-year-old healthy patient with stage T2 disease. Once the cancer becomes nodular (palpable), it is likely to behave in an aggressive fashion with the passage of time. Dilemmas occur when the disease is not palpable and ,has been discovered as an incidental finding: for example. after transurethral resection of the prostate when it is present in less than 5% of the chips (Stage T1A). In such a patient, further imaging may be justified, if the patient is young, to confirm the stage, but surveillance in the older patient is likely to be more appropriate. Dysplasia (Prostatic intraepithelial neoplasia: PIN) may also be discovered on biopsy and be a further reason for surveillance owing to its premalignant potential. From the practical point of view, surveillance consists of enquiry about lower urinary tract symptoms, digital rectal examination and PSA measurement. PSA has added another dimension to surveillance. A rising trend in PSA ('PSA velocity') can give the clue that a cancer is starting to behave more aggressively. If this is suspected, further imaging and, if appropriate, more aggressive treatment may be justified, such as radiotherapy or hormone therapy in the elderly or more unfit group. The frequency with which a patient is assessed under surveillance depends on the amount of clinical suspicion but the majority of patients are seen annually.
Radiotherapy Modern regimes for radiotherapy involve a fractionated course of 1000 cGy delivered weekly in five daily fractions to a total dose of 6000-6500 cGy. In phase I of the regime there is three or four field pelvic irradiation and in phase 2 the prostate is targeted with a 1.5 to 2 cm margin. Complications may include acute or chronic bladder dysfunction, haematuria and radiation proctitis.
er
Fig. I. The catheter is exposed.
Radical proslmectomy The patient has pre-operative bowel preparation. General and epidural anaesthesia is administered and a 20 ch urethral catheter placed. The operation is performed through a lower midline incision with an extraperitoneal dissection. A preliminary lymph node dissection is performed, clearing all the nodes between the medial aspect of the external iliac vein, the pelvic side wall and the obturator nerve on both sides. The nodes are sent for histological examination. The fat is then cleared by blunt dissection from the anterior surface of the distal prostate, suture ligating superficial veins where necessary. This allows bilateral incisions in the endopelvic fascia near the apex of the gland. The puboprostatic ligaments are then divided, allowing the prostate to drop into the pelvis. It is then possible to doubly ligate and divide the block of tissue anterior to the catheter at the apex of the prostate: the dorsal venous complex. If there is persistent bleeding from the dorsal venous complex it is transfixed. The catheter is exposed (Fig. I), clamped and divided allowing division of the posterior urethra and retraction of the gland up towards the bhidder, ligating and dividing the prostatic pedicles. Denonvilliere's fascia is then incised to expose the seminal vesicles and the ampullae of the vas deferens. The ampullae are ligated and divided allowing blunt dissection of the seminal vesicles. The catheter balloon is then pulled against the bladder neck and the anterior bladder neck incised with diathermy. The gland and the seminal vesicles are then removed with haemostasis achieved by tying ligatures and using diathermy. Sutures are used to evert the bladder urothelium (Fig. 2) and a racquet reconstruction (Fig. 3) of the bladder neck is performed. The anastomosis between the bladder and urethra can then be completed under direct vision over a new foley catheter (Figs 4 and 5). All the urinary tract sutures are absorbable. Wound drains
Efhtcational section
681
:
~
-~"
Ii '
Fig. 4. Tile anaslamosis between the bladder and urethra can then be completed under direct vision.
Fig. 2. Sutures are used to evert the bladder 6rothelium.
's~Jv
" ~
,
_/--7
(~:~.,.,.
/6
Fig. 3. Sutures are used to evert the bladder urothelium vision.
are placed and the w o u n d closed. The catheter can be removed between 10 and 14 days post-operatively. Possible complications are listed in Table I. With experience and proper training such problems are kept to a minimum. When the operation is performed by adequately trained surgeons, incontinence is usually m i n o r and transitory. Potency depends upon the preservation of the neurovascular bundles near the apex of the prostate: sometimes these have to be sacrificed to provide a curative cancer operation. '
Radiotherapy or radical prostatectomy? As the natural history of untreated stage T2 cancer is disease progression and decreased life expectancy, 2-~ it seems
:"
"/
Fig. 5. The anastamosis between the bladder and urethra can then be completed under direct vision.
rational to consider active treatment in these patients. The two most o r t h o d o x treatments currently available for disease confined to the prostate are radiotherapy or radical prostatectomy.
Table I. Possible specific complications of radical prostatectomy Rectal injury Incontinence Impotence Anastamotic stricture
682
Educational section
Teaching point S u m m a u , o f patient groups suitable f o r surveillance
1. Elderly or relatively unfit men with a short natural life expectancy. 2. Men in whom there is a high index of suspicion of prostatic carcinoma from digital rectal examination and]or PSA estimation but where biopsies have been
negative. 3. When prostatic biopsies have failed to demonstrate carcinoma but have demonstrated dysplasia (prostatic
intraepithelial neoplasia: PIN). S u m m a r y o f patients suitable f o r active treatment by radiotherapy or radical prostatectomy
has focused on the incidence of incontinence and impotence after radical prostatectomy. Nevertheless, when the operation is performed by a properly trained surgeon with an appropriately trained team. the risks of long-tel'm incontinence and impotence may be minimized. In the 1990s there is a greater understanding of the anatomy of Santorini's venous plexus and the neurovascular bundles responsible [br erectile function. A morbidity of 12% is reported after radiotherapy for localized prostate cancer. An impotence rate of between 2284% is also reported after radiotherapy (Lepor, 1989). t4 The biggest argt, ment remains about the long-term cure rate and the long-term results of further randonaized prospective studies would be useful.
The future
Younger fitter patients with T2 N O M O disease. S u m m a o , o f patients where management is very debatable
Patients with low-volume well-differentiated carcinomas.
There have been enthusiastic reports of the results of radiotherapy for Iocalised prostate cancer) Dr Bagshaw and associates have reported that the actuarial 15 year survival rate for irradiation treatment of carcinomas occupying less than half of one lobe is almost as good as that following radical prostatectomy (48%). If the induration or nodule occupies more than half of one lobe or extends bilaterally the 15 year actuarial survival falls to 23%. Currently, there is a lack of data from prospective studies. In a randomized prospective study conducted at Duke University, Carolina. 10 OVo of patients who had undergone radical prostatectomy for stage T I B or T2 disease showed evidence of disease recurrence at 5 years whereas 29% of patients with the same stage of disease progressed after 5 years with radiotherapy/' There have been more retrospective studies: in patients with T2 disease treated by external beam radiation 20-50% developed recurrent disease between 7 and 15 years after treatment. 7''~Other studies following patients with T2 disease after radical prostatectomy suggest that the recurrence rate is between 10-26%. ~ ii These retrospective reports suggest that radical prostatectomy has a higher cure rate than external beam radiotherapy. Further evidence for this comes from PSA studies, observing PSA levels after the treatment of prostate cancer with either radiotherapy or radical prostatectomy. In both of these groups a persistently rising PSA is indicative of recurrent disease. Kabalin et al, (1989) '~ showed that in 5789% of patients who received external beam radiotherapy, a biopsy was positive between 12 and 18 months after radiotherapy treatment. Stamey et al. (1989) ~-" investigated patients 12 months after treatment for localized cancer: 50% had a rising PSA suggestive of active disease. Oesterling (1988) 13 reported patients who had undergone radical prostatectomy for either T I or T2 disease: 91% had PSA levels in the female range. Following radical prostatectomy, clinical disease recurrence appears to occur only in those patients with an elevated (detectable) post operative PSA. Short-term morbidity may be greater after radical prostatectomy than after external beam radiotherapy. Attention
Radiotherapists with new technology are showing interest in the techniques of interstitial brachytherapy for Iocalised prostate cancer. As yet there are no Iong-terrn results of significance. Other clinicians are investigating the role of localized N d : Y A G laser energy, localized cryotherapy and hyperthernfia for the treatment of apparently small localized cancers.
Acknowledgements The figures were provided by Mr J. Peters F R A C S , St Vincent's Hospital. Melbourne.
References I. McNeil JE. Bostwick DG. Intraductal dyspl:lsi:l: a pre-malignanl lesion of tile prostate. Hum Pathol 1986: 17: 64. 2. Bumpus HC. Carcinoma of the prostate--a c,linica[ study of one thousand cases. Sm'g G.vnaecol Ohstet 1926: 43: 150-5. 3. Nesbit RM. Plumb RT, Arbor A. Prostatic carcinoma: a followup on 795 patients treated prior to the endocrine era and a comparison of survival rates between these and patients treated by endocrine therapy. Surgery 1946: 20: 263-72. 4. Hanash KA, Urz DC, Cook EN, et al. Carcinoma of the prostate: a fifteen year follow tip. J Urol 1972: 107:450 3. 5. Baghaw MA, Ray RG, et al. External beam radiation therapy of primary carcinoma of the prostate. Cancer 1976: 36: 723-8. 6. Paulson DF, Lin GH, et al. Radical surgery versus radioUlerapy Ibr adenocarcinoma of the prostate. J Urol 1982; 128: 502-4. 7. Hanks GE. External beam radiation therapy for clinically localised prostate cancer: patterns of care studies in the United States. NCI Mmw,qr 1989: 7:75 84. 8. Kabalin JN. Hodge KK. et al. Identification residual cancer in the prostate following radiation therapy: role of transrectal ultrasound guided biopsy and prostate specific antigen. J Urol 1~89: 142:326 31. 9. Culp OS. Radical perinea[ prostatectomy: its past, present and possible future. J Urol 1968: 98:618 26. I 0. Gibbons RP. Correa RJ, et al. Total prostatectomy for clinically localized prostatic cancer: long term results. J Urol 1984; 131: 73-6. 11. Walsh PC, Jewett HJ. Radical surgery for prostatic cancer. Cancer 1980: 45:1906-1 I. 12. Stamey TA, Kabalin JN, et al. Prostate specific antigen in the diagnosis and treatment of adenocarcinoma of the prostate I 1I radiation treated patients. J Urol 1989: 141: 1084-7. 13. Oester[ing JE, Chan DW, et al. Prostate specific antigen in the preoperative and postoperative evaluation o1" Iocalised cancer treated with radical prostatectomy. J Urol 1988: 139: 766-72. 14. Lepor H. The role of radical prostatectomy in the treatment of cancer of the prostate. Cam'er Treat Res 1989: 46: 15-34.