Vol. 107. June Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
CARCINOMA OF PROSTATE: TREATMENT AND SURVIVAL WITH
RADICAL PROSTATECTOMY J. A. YOUNG
A. WAITE BOHNE
From the Division of Urology, Henry Ford Hospital, Detroit, Michigan
Cancer statistics indicate that prostatic carcinoma will develop in 35,000 male subjects and that more than 17,000 men will die of the disease in this country in 1971.1 Unfortunately, only 5 per cent of patients with prostatic cancer are candidates for potentially curative measures at the time of diagnosis. 2 • 3 Included in the armamentarinm to provide potentially curative therapy is radical perineal prostatectomy, radical retropubic prostatectomy, interstitial irradiation and endocrine manipulation. 1 Attempts with endocrine treatment to convert advanced lesions to an operable stage have been shown efficacious in selected cases. 5 Recent reported benefits of external irradiation as a potentially curative modality are encouraging.6· 7 However, radical prostatectomy remains the procedure of choice in suitable operative candidates with a clinically localized, cancerous prostatic nodule.8 • 9 Favorable survival results have been reported with the retropubic approach but further time is required for a critical evaluation of this procedure as compared to results obtained with radical perinea! prostatectomy. 3 , 9 Between 1953 and 1968, 52 radical prostatectomies were performed at Henry Ford Hospital for which sufficient information is available for analysis of survival rates. Except for 2 radical retropubic prostatectomies included in the 5-year data and 1 case subsequently followed for 10 years, the statistics reflect results following radical perineal prostatectomy. Young's classic procedure has been used, including total removal of the seminal vesicles in Accepted for publication July 23, 1971. 'Ca-A Cancer Journal for Clinicians, 21: 17, 1971. 2 Rubin, P.: Cancer of the urogenital tract: prostate cancer. J.A.M.A., 210: 322, 1969. 3 Scott, W.W. and Schirmer, H.K. A.: Carcinoma of the prostate. In: Urology. Edited by M. F. Campbell and J. H. Harrison. Philadelphia: W. B. Saunders Co., vol. 2, pp. 1143-1189, 1970. 4 Flocks, R.H.: Carcinoma of the prostate. J. Urol., 101: 741, 1969.
6 Scott, W. W. and Boyd, H. L.: Combined hormone control thrrapy and radical prostatectomy in the treatment of selected cases of advanced carcinoma of the prostate: a retrospective study based on 25 years of experience. J. Urol., 101: 86, 1969. 6 Grout, D. C., Grayhack, J. T., Moss, W. and Holland, J.M.: Radiation therapy in the treatment of carcinoma of the prostate. J. Urol., 106: 411, 1971. 7 Bagshaw, M. A.: Definitive radiotherapy in carcinoma of the prostate. J.A.M.A., 210: 326, 1969. 8 Jewett, H.J.: The case for radical perineal prostatectomy. J. Urol., 103: 195, 1970. 9 Kope_cky, A. A., L_askowski, T. Z. and Scott, R., Jr.: Radwal retropub1c prostatectomy in the treatment of prostatic carcinoma. J. Urol., 103: 641, 1970.
most instances. The operations have been nPrtn,m, by several resident physicians with assistance permanent staff urologists. RESULTS
Twelve of the 52 cases (8 retropubic and 4 prostatectomies) were performed after 1965 therefore, data are not available for 5-year review. All of these 12 patients are alive at present, 11 being followed at least 3 years and one 3 years. However, a third of these patients are going therapy for recurrent disease. The remaining 40 cases have been followed at least 3 years. Of these, 39 patients (97 per cent) were alive and 35 of these (87.5 per cent) were free of tumor, One patient died of metastatic carcinoma of the prostate. Of the 38 cases followed for at least 5 years 35 patients (92 per cent) were alive: 30 per c~nt) without evidence of carcinoma and 5 per requiring further palliative therapy. One patient died of metastatic prostatic carcinoma and 1 patient died of an unrelated neoplasm without evidence of re-current prostatic cancer. One patient was lost to followup at less than 5 years but is considered for this analysis to have died of prostatic carcinoma. Patients who die of unrelated causes have been considered ineligible for survival analysis in other series but such patients are included as mortalities in om review.10 · 11 Of the 18 patients followed for at least 10 13 patients (72 per cent) are alive: 9 (50 per without recurrent disease and 4 (22 per cent) with prostatic cancer. Two patients died as a result metastatic prostatic neoplasms, 2 died of myocardial infarction (1 free of tumor and 1 with neo plasm on estrogen therapy) and 1 died of unrelated cancer without evidence of prostatic carcinoma. Followup of at least 14 years of the 13 alive at 10-year review now reveals 7 survivors. One patient has been lost to followup after 12 years without recurrent disease. Three patients have died of metastatic prostatic cancer and 2 of unrelated causes without prostatic tumor recurrence. Deletion of the 1 case lost at 12 years leaves 7 survivors, in a 41 per cent total survival: 5 (29 per cent) with-out neoplasm and 2 (11 per cent) with cancer. 10 Dees, J.E.: Radical perineal prostatectomy for carcinoma. J. Urol., 104: 160, 1970. 11 Nesbit, R. M. and Baum, W. C.: Endocrine control of prostatic carcinoma; clinical and statistical survey of 1,818 cases. J.A.M.A., 1431: 1317, 1950.
YOUNG AND BOHNE METHODS AND DISCUSSION
Classification of operable lesions corresponded with stage B of Whitmore's classification or stage 2 as described by the Veterans Administration group. 3 • 12 No special patient selection, that is exclusion of those with chronic ills, was used other than selecting patients who were physiologically not more than 70 years old. The average age of patients was 60.6 years, with only 4 patients less than 50 years old and with 13 patients between 65 and 70 years old. Except for 1 patient who 2 months previously had undergone transurethral resection of the prostate for clinically benign disease but with a diagnosis of carcinoma returned after histologic examination, no radical procedures have been performed for latent carcinoma. Several patients with a suspicious prostatic nodule were placed preoperatively on 5 mg. diethylstilbestrol daily for a few weeks to a few months before confirming a clinical diagnosis with biopsy of the prostate. Many of these patients demonstrated regression in the size and/or consistency of the lesion prior to prostatectomy. No stage C (3) lesions were purposely considered for radical prostatectomy. The majority of diagnoses were confirmed by open perineal biopsy, undertaken as the initial step in the operative procedure. Although some surgical specimens were categorized as frankly anaplastic or poorly differentiated, tumor grading generally was not performed and, therefore, no correlation with survival was attempted in this review. No operative mortalities have resulted and immediate complications have not been alarming, except for a ureteroperineal fistula which required operative correction. In addition to the primary, expected late complications of impotence and incontinence, other occasional late complications have included urethral stricture and vesical neck contracture. The incidence of postoperative incontinence of moderate to severe degree has been noted in probably more than 50 per cent of patients. Patients with postoperative recurrence of neoplasm have in most cases been immediately placed on 5 mg. diethylstilbestrol daily or equivalent hormonal therapy. The use of estrogen therapy after postoperative appearance of neoplasm, in many cases local and asymptomatic, is in contradistinction to the usual custom of estrogen use only in non-operable, symptomatic stage 4 (D) patients.13 Our impression as well as that of others is that one is obligated to begin endocrine therapy for patients with recurrent disease postoperatively. 10 The use of stil12 Whitmore, W. F., Jr.: Rationale and results of ablative surgery for prostatic cancer. Cancer, 16:
13 Brendler, H.: Therapy with orchiectomy or estrogens or both. J.A.M.A., 210: 1074, 1969.
bestrol in these patients has not been associated with a clinical impression of an undue incidence of cardiovascular complications and does not appear to adversely influence the 5 and 10-year survival statistics. Estrogens in lower dosage may be as efficacious, as recently emphasized by the latest analyses of the Veterans Cooperative Study. 14-1 6 A few patients, despite postoperative recurrence, are alive a few years after additional therapy with hormonal manipulation and interstitial irradiation. A rare patient, after biopsy verified recurrence and with roentgenographic evidence of neoplasm at that time, remains well following a few years of estrogen therapy but after many subsequent years on no medication with no evidence of carcinoma at the present time. Such a patient corroborates the suspicion that the biologic activity of prostatic cancer is not always predictable on the basis of its histologic appearance.17 SUMMARY AND CONCLUSIONS
Experience is presented with treatment by radical prostatectomy of the localized carcinomatous prostatic nodule in 52 patients seen between 1953 and 1968. Survival rates of 97 per cent at 3 years, 92 per cent at 5 years, 72 per cent at 10 years and 41 per cent at 14 years following radical prostatectomy were noted. A major limitation of this analysis is reflected in the relatively small number of patients included. However, these survival data are similar at 5 and 10-year followup to another recently reported series.18 In addition, the survival rate remains favorable at nearly 15 years followup, when compared to the anticipated survival of a comparable age group of male subjects in the general population without carcinoma of the prostate. Radical prostatectomy remains the treatment of choice for the presumed localized nodule of prostatic cancer. Adjuvant therapy with hormonal manipulation and interstitial or external irradiation appears beneficial in properly selected patients. 14 Bennett, A.H., Dowd, J.B. and Harrison, J. H.: Estrogen and survival data in carcinoma of the prostate. Surg., Gynec. & Obst., 130: 505, 1970. 16 Bailar, J. C., III and Byar, D. P.: Estrogen treatment for cancer of the prostate. Early results with 3 doses of diethylstilbestrol and placebo. Cancer,
26: 257, 1970.
16 Blackard, C. E., Doe, R. P., Mellinger, G. T. and Byar, D. P.: Incidence of cardiovascular disease and death in patients receiving diethylstilbestrol for carcinoma of the prostate. Cancer, 26: 249, 1970. 17 Scott, R., Jr., Mutchnik, D. L., Laskowski, T. z. and Schmalhorst, W.R.: Carcinoma of the prostate in elderly men: incidence, growth, characteristics and clinical significance. J. Urol., 101: 602, 1969. 18 Gilbertsen, V. A.: Cancer of the prostate gland: results of early diagnosis and therapy undertaken for cure of the disease. J.A.M.A., 216: 81, 1971.