Blood loss during and after transurethral resection of prostate: a prospective study

OBJECTIVES

Transurethral resection of prostate (TURP) is the gold standard treatment for symptomatic prostatic bladder outlet obstruction. Haemorrhage during and after TURP can lead to significant morbidity and mortality. The purpose of this study was to assess the influence of anaesthesia, operating time, weight of resected prostatic tissue and its histology on blood loss during and after TURP and to revisit the available body of evidence in the literature of urology.

MATERIALS AND METHODS

This is a prospective study of a cohort of 100 consecutive patients who had undergone TURP over a period of one year, where the data was collected on a performa specifically designed for the study, which included the type of anaesthesia administered, resection time, amount of blood lost during and after TURP, weight of the resected prostatic tissue and histology.

RESULTS

Sixty seven patients underwent TURP under spinal anaesthesia (SA) and 33 under general anaesthesia (GA). The median intraoperative (SA: 89.95 (5-936); GA: 105.40 (5-517) mls), postoperative (SA: 72.37 (15-387); GA: 136.43 (11-969) mls) and total (SA: 162.32 (29-1200); GA: 241.83 (21-1251) mls) blood losses were not significantly different between the two groups (95% C.I. -9.90 to 19.22, p= 0.46). The total operating time (SA: 29.70 (10-55); GA: 29.80 (10-65) minutes) and weight of resected prostate (SA: 21.90 (3-45); GA: 18.00 (4-60) gms) were similar between the two groups. There was a trend towards increased blood loss when BPH was associated with prostatitis (N=8). Of these, 3 patients required blood transfusion as compared to 1 patient in rest of the group, although this was not statistically significant (95% C.I - 67.2 to 1120.4, p = 0.87).

CONCLUSIONS

The intraoperative, postoperative and total blood losses related to TURP were not influenced by the type of anaesthesia, resection time, weight of the resected prostate and the histology.

Serum IGF-1 determination in relation to prostate cancer screening: possible differential diagnosis in relation to PSA assays

Prostate Cancer and Prostatic Diseases (2000) 3, 173-175

Prevalence of prostatic intra-epithelial neoplasia (PIN) in biopsies from hospital practice and pilot screening: clinical implications

As high grade PIN is commonly associated with concomitant cancer, current literature recommends re-biopsy of patients with high grade PIN. This paper describes the prevalence of high grade prostatic intra-epithelial neoplasia (PIN) from three independent clinical settings, reported by a single pathologist (MCP). High grade PIN was diagnosed in biopsies from 131 of the 1205 (11%) of patients in whom cancer was suspected in hospital practice, 42 of the 202 (20%) asymptomatic men screened for prostate cancer and 29 of the 118 (25%) patients presenting with prostatism in a case finding study. Re-biopsy on this scale has major clinical and cost implications. However, from a literature review, there is evidence to suggest that the risk of concomitant cancer with high grade PIN may be stratified according to serum PSA. This opinion should be tested prospectively.

How complete is a transurethral resection of the prostate?

OBJECTIVE

To determine the completeness of transurethral resection of the prostate (TURP).

PATIENTS AND METHODS

The prostate volume of 432 patients was measured by transrectal ultrasonography (TRUS) before they underwent a TURP performed by one of three consultant urological surgeons. The prostate tissue collected at resection was weighed, multiplied by 1.2 to compensate for 'shrinkage', and the amount of tissue removed expressed as a percentage of the pre-operative prostate volume determined by TRUS (resection ratio). The patients were categorized into groups based on pre-operative prostate size.

RESULTS

The mean weight of prostate tissue resected was 25.6 g. Resection ratios increased with prostate size, with the largest occurring in prostates of 71-110 g. The surgeon did not resect more than 50% of the gland volume in any group.

CONCLUSION

This study counters the theory that a complete resection of the prostate is routinely achieved. The endoscopic appearances probably imply a complete resection of the adenoma but a considerable volume of the gland remains. This has important implications for the detection of prostate carcinoma at TURP and for the staging of the disease.

Epidermal growth factor receptor expression by northern analysis and immunohistochemistry in benign and malignant prostatic tumours

Epidermal growth factor receptor (EGFR) expression in 44 benign prostatic hyperplasia (BPH) and 55 prostatic carcinoma specimens has been investigated using Northern blot analysis and immunohistochemistry. The values obtained for the EGFR mRNA in the BPH and carcinoma specimens were not significantly different and in the latter there was no correlation with grade. In the immunohistochemical assays, two antibodies to the external and one to the internal domain of EGFR were used. The former ones stained the basal cell membranes intensely whilst cytoplasmic staining of secretory epithelium was seen in BPH specimens with the latter. In the carcinoma specimens, the intensity of membrane staining correlated with the two external domain antibodies, r = 0.640, P < 0.001, but neither of these correlated with the EGFR mRNA results. All three antibodies demonstrated a trend towards elevated expression of EGFR with dedifferentiation which reached significance only with the internal domain antibody results, P < 0.02. No correlation was observed with tumour EGFR mRNA values and the EGFR immunohistochemical results. The EGFR immunoreaction with the external domain antibody in 14 treated high-grade tumours was comparable to that obtained in 15 untreated anaplastic prostatic tumours. In 5 patients, both pre- and post-treatment samples were available and these exhibited little or no difference in EGFR expression with therapy.

Prostate disease: management options for the primary healthcare team. Report of a working party of the British Prostate Group

The prostate gland has attracted a remarkable increase in interest in the past few years. The two most common diseases of this gland, benign prostatic hyperplasia and carcinoma of the prostate, have been brought into greater prominence by new diagnostic methods, public interest, and a wider choice of surgical and non-surgical treatments. Uncertainty about the significance of these changes has occurred because of the rapidity of change, the profusion of statements, opinions and promotions, and the relatively little guidance available from the profession. Ten urologists and two general practitioners have reviewed the relevant evidence about these two prostate diseases and the newer diagnostic methods; their conclusions are summarised here. Management options and guidance on clinical practice are also discussed. Because of a number of unresolved diagnostic and management issues, detailed requirements for practice guidelines have not been specified.

Prostatic cancer presenting as dysphagia

Neurological dysfunction from base of skull metastasis of prostate cancer is rare. In this case, dysphagia was the presenting symptom and relief occurred after orchidectomy. Improvement of neurological symptoms usually occurs only after local radiotherapy.

Transrectal ultrasound appearances of granulomatous prostatitis

Granulomatous prostatitis is an unusual, but well-recognized entity frequently mistaken for carcinoma on both digital rectal examination and transrectal ultrasound. The ultrasonographic findings of 11 patients with histologically-proven granulomatous prostatitis are reviewed.

Side effects and patient acceptability of transrectal biopsy of the prostate

The side effects and patient acceptability of 230 ultrasound guided prostatic needle biopsies performed by the transrectal route in an out-patient setting were reviewed retrospectively. Most of the side effects were transient and mild; one patient required hospitalization for urinary retention. Patient acceptability was good; over 70% of patients reported no significant pain from the biopsy procedure.

Prostatic 'capsule'--a comparative study of histological and ultrasonic appearances

The histological and transrectal ultrasound (TRUS) appearances at corresponding sites of the periphery of the prostate gland have been compared in 30 benign and 27 malignant glands taken at autopsy. In the benign series, the histological capsule was frequently absent and correlated poorly with the consistent TRUS findings of a regular, well-defined 'ultrasonic capsule'. It is concluded that 'the capsule' should be replaced as a tumour-staging landmark by a more realistic terminology. Carcinoma may be described as intra- or extra-prostatic, or confined or unconfined with respect to the gland. In the malignant glands, there was no correlation between morphologically unconfined cancers and irregular or absent ultrasound 'capsule' when corresponding areas were compared. This disparity must contribute to an underestimation of tumour extent with TRUS.

An immunocytochemical analysis of TGF alpha expression in benign and malignant prostatic tumors

Transforming growth factor alpha (TGF alpha) expression was analyzed immunocytochemically on formalin-fixed wax-embedded sections obtained from 24 benign prostatic hyperplasia (BPH) specimens and 76 prostatic carcinoma tissues, 3 human prostatic tumor xenografts, normal kidney, and salivary gland. Low amounts of TGF alpha immunopositivity were encountered in the epithelium of BPH glandular tissues, whereas in the prostatic adenocarcinoma samples, a greater heterogeneity and intensity of TGF alpha immunostaining was observed. The most intense staining was exhibited by the least differentiated tumors, although a few of these were weakly stained. Statistical analysis of the relationship of histopathological grade of tumor with TGF alpha expression in the carcinomas showed a significant correlation of these parameters, 0.01 > P > 0.001. The expression of the proliferation markers Ki-67 and PCNA was also analyzed in the carcinoma specimens, and the relationship of these to TGF alpha expression indicated that there was no significant correlation in this series of tumors between increased growth activity and TGF alpha expression (p approximately 0.25 with both markers). The prostatic carcinoma xenografts TEN12 and TEN15 contained low levels of immunoreactive TGF alpha, which was uniformly distributed, whilst heterogeneous immunostaining was observed in the uroepithelial xenograft TEN16. In the normal human kidney, TGF alpha was concentrated in the epithelium of the distal convoluted tubules (DCT) and the collecting tubules (CT), and lower amounts were identified in the proximal convoluted tubules (PCT). As in the prostatic carcinomas, the immunostaining was eliminated by prior absorption of the antibody with pure TGF alpha and not with human or mouse EGF. No crossreactivity of the TGF alpha antibody with salivary EGF was demonstrated. This study concludes that, in prostate carcinoma, the least differentiated tumors more often expressed greater amounts immunoreactive TGF alpha; however, no relationship between TGF alpha expression and cellular proliferation markers was found.

Can serum prostate-specific antigen replace bone scintigraphy in the follow-up of metastatic prostatic cancer?

Bone scintigraphy is the most sensitive imaging technique for the initial detection of bone metastases and is widely used in the staging of prostatic cancer. This study was performed to assess whether the development of further bone metastases can be detected by serial measurements of the serum glycoprotein prostate-specific antigen (PSA) as an alternative to follow-up scintigraphy. The bone scintigrams and PSA levels of 101 patients with metastatic prostate cancer entered into two therapeutic trials have been reviewed. Serial results of both investigations were available in 59 cases. In three cases new bone deposits were observed without a corresponding rise in PSA. In two other cases the scintigrams were considered to be suspicious of progression with no change in PSA levels; however, further follow-up indicated that these changes were not due to metastases. In 13 cases PSA levels were rising in advance of new deposits on the scintigrams. In the remaining 41 cases the PSA levels and scintigraphic findings paralleled each other. We conclude that serial estimation of PSA levels is a simpler marker for disease progression than bone scintigraphy in metastatic prostatic cancer, but that neither technique in isolation gives complete accuracy.

Inter-relation between measurement of serum prostatic specific antigen and transrectal ultrasound in the diagnosis of benign prostatic hyperplasia and prostatic cancer

Serum prostatic specific antigen (PSA) and ultrasound-determined prostatic volume (UPV) were measured in 50 patients with histologically proven benign prostatic hyperplasia (BPH) and in 40 patients with histologically proven prostatic cancer of whom 17 had evidence of distant metastases (M1) and 23 did not (M0). A good correlation between log PSA and UPV was demonstrated in the BPH group and rearrangement of the linear regression equation allowed calculation of a single variable--the log PSA corrected to a standard prostate volume for any given individual. A volume-corrected PSA correctly identified all patients with M1 disease and greatly improved but did not eliminate overlap of M0 disease with BPH. Reduction of serum PSA to a single volume-corrected variable will allow the introduction of practical and optimum protocols for the management of patients with prostatic enlargement.

Complete resolution of a large seminal vesicle cyst--evidence for an obstructive aetiology

Seminal vesicle cysts may arise from inflammation or obstruction of the seminal vesicle or from embryological remnants such as the müllerian duct. Surgical removal has been proposed as the treatment of choice. A 19-year-old boy presented with abdominal pain and constipation. Investigations revealed a 14-cm multiloculated cyst arising from the right seminal vesicle and a small stone lodged at the orifice of the ipsilateral ejaculatory duct. Following endoscopic removal of the stone the mass decreased in size considerably and 2 months later transrectal ultrasound and magnetic resonance imaging showed normal seminal vesicles and no evidence of the cyst. This case strongly supports an obstructive aetiology for this cyst and we would suggest that, in similar cases, full assessment of the ejaculatory apparatus should be carried out to exclude an obstructive cause before embarking on major surgery.

Pathological and clinical associations of Ki-67 defined growth fractions in human prostatic carcinoma

Estimation of the growth fraction of 153 prostatic carcinoma specimens employing Ki-67 immunostaining was undertaken and its relationship to various clinical parameters investigated. In prostate specimens, the percentage of tumour nuclei expressing Ki-67 antigen was measured and assigned a Ki-67 score. It was observed that high Ki-67 scores were associated with the poorly differentiated tumours, the correlation of this proliferation marker with histological grade was found to be significant (P less than 0.001). No relationship was observed between the Ki-67 score of the primary tumour with either the patient's age or with the primary tumor stage (T category). The metastatic status of the patient at diagnosis and the Ki-67 score of the tumour were correlated (P less than 0.05), higher Ki-67 scores being associated with M1 disease. Life-table analysis of 86 patients who subsequently received androgen withdrawal therapy, was undertaken with reference to the various Ki-67 scores of their primary tumors. A statistically significant difference in survival times was observed in patients whose Ki-67 values were less than 1% (P less than 0.0001) when compared to those patients whose tumours expressed 1% and over Ki-67 positivity, the former having longer survival times. When patients were subdivided according to their metastatic status and similar life-table analyses were carried out, no statistical difference was found between survival times and Ki-67 scores in M0 staged patients. In the M1 population of patients, however, those patients whose tumours were negative for Ki-67 expression had significantly longer survival times than those patients whose tumours exhibited positive Ki-67 staining (P less than 0.01). Comparing M1 staged patients whose prostate tumor cells exhibited less than 1% Ki-67 positive nuclei with M1 staged patients whose prostate tumour cells contained 1% and higher Ki-67 stained nuclei, a significantly longer survival time was found in the former group of patients (P approximately 0.0001).

Volume of normal prostate, of prostate cancer, and of benign prostatic hyperplasia: are correlations with prostate specific antigen clinically useful?

This retrospective study correlated prostate volume, determined by transrectal ultrasonography, with serum prostate specific antigen (PSA), by Deming regression analysis, in patients with confirmed benign prostatic hyperplasia (BPH) and patients with non-metastatic (M0) or metastatic (M1) prostate cancer. In BPH, a highly significant correlation was found between log10[PSA] and prostate volume. When this PSA/volume regression pattern for BPH was used as a reference standard, all 17 patients with M1 prostate cancer and 83% of the 23 patients with M0 disease were discriminated from BPH.

Relationship of proliferating cell nuclear antigen (PCNA) in prostatic carcinomas to various clinical parameters

Proliferating cell nuclear antigen (PCNA) expression was determined immunohistochemically, using a monoclonal antibody PC10, in 102 prostatic carcinoma samples and in prostate tissue from 21 patients with benign prostatic hyperplasis (BPH). The percentage of cells with stained nuclei ranged from 1% to 58% in the carcinoma specimens and 0% to 10% in the BPH specimens. A semiquantitative scoring system was devised for the degree of PCNA positivity observed in the tumors. Statistical analysis of the PCNA score in relation to the histological grade of the tumors gave a significant positive or negative correlation between these parameters P less than 0.001. No significant correlation between PCNA score was, however, seen with metastatic status, T category (TMN classification) of the primary tumor, or the patient's age at diagnosis. In 65 prostatic cancer patients of known survival, those individuals whose tumors had a PCNA score of +/- (less than 10% of nuclei stained) were compared with those patients whose tumors were either 1+, 2+, or 3+ (greater than 10% of nuclei stained). Life table analysis of the two groups indicated that the patients with the lower PCNA score survived significantly longer than those with the higher PCNA scores, P less than 0.04. Comparison of the Ki-67 expression in frozen sections with the PCNA expression in wax-embedded tissue of 86 prostatic carcinomas was also undertaken. A significant correlation between these two parameters was found, P less than 0.001, although the growth fraction estimated by Ki-67 expression was generally lower than that given by the PCNA scoring system.

Transrectal ultrasound of the ejaculatory apparatus

Most interest in transrectal ultrasound (US) of the prostate has concentrated on its role in the diagnosis and management of prostatic cancer. The increasingly detailed investigation of male patients with infertility has recently led to interest in the use of US in investigating the structure and function of the ejaculatory ducts and seminal vesicles. The anatomy and pathology of the ejaculatory ducts and seminal vesicles as demonstrated by transrectal US are discussed and illustrated.

Comparison of LHRH analogue (Zoladex) with orchiectomy in patients with metastatic prostatic carcinoma

Between November 1983 and February 1986, 358 patients with previously untreated metastatic prostatic carcinoma entered a multicentre, randomised trial in the United Kingdom and the Republic of Ireland, in which the LHRH analogue Zoladex (ICI Pharmaceuticals PLC), administered subcutaneously every 28 days, was compared with orchiectomy. Both treatments were equally effective in lowering serum testosterone concentrations to within the surgically castrate range and this was accompanied by equivalent subjective and objective response rates and times to treatment failure. At a median follow-up of 2 years there was no difference in overall survival, confirming that Zoladex is an effective medical alternative to orchiectomy in patients with metastatic disease.

Origin and structure of benign prostatic hyperplasia

The development of microradiography of the prostate gland has provided a new approach to investigating the origin and structure of benign hyperplasia. It has demonstrated that benign prostatic hyperplasia is usually microadenomatous in structure, although reticular types do occur. It originates at the lateral boundary of the periurethral muscle in the position of the transitional zone. In contrast, stromal nodules are homogeneous and amorphous in structure and develop at the site of the short straight urethral ducts within the periurethral muscle.

Experience with ultrasound guided transperineal prostatic needle biopsy 1985-1988

A consecutive series of 143 ultrasound guided biopsies of the prostate have been analysed. In 84 patients, in whom carcinoma was suspected by both digital examination and ultrasound, 49 cancers were confirmed histologically. In 29 patients in whom digital examination suggested cancer but ultrasound was normal, 2 cancers were confirmed. In 20 patients with a normal digital examination but a suspicious ultrasound appearance, no cancers were proven.

Transrectal ultrasound in the investigation of haemospermia

The transrectal ultrasound findings in 52 patients with haemospermia were reviewed. Scan abnormalities were demonstrated in 43 patients (83%). These included benign prostatic hyperplasia (24 patients), seminal vesicle abnormalities (10 patients), prostatic calcification (32 patients) and two patients with prostatitis. No patient was proven to have prostatic malignancy. Transrectal ultrasonography can suggest a cause of haemospermia in the majority of patients without resort to invasive investigations, and can exclude underlying prostatic malignancy. It is recommended as the first radiological investigation in patients presenting with haemospermia.

Perineal prostatic tumour seedling after 'Tru-Cut' needle biopsy: case report and review of the literature

The prostate gland is being biopsied increasingly frequently, especially as a result of the visualisation of suspect areas on transrectal ultrasonography, using a variety of different needle types. We report only the third case of tumour seedling in the tract following a transperineal biopsy of a prostatic cancer with a 'Tru-Cut' needle. The literature is reviewed with regard to the characteristics and the incidence of seedling and the importance of including the perineum in any treatment option is emphasized.

Structure and per-rectal ultrasonography of prostatic disease using cadaver specimens

One hundred cadaver prostates were examined by per-rectal ultrasound and the findings correlated with the microradiographic and histopathological features of whole sections taken at the levels of scanning. The normal gland consists of both periurethral muscle and glands. The periurethral muscle has little structure on microradiography and is therefore hypoechoic (low amplitude echoes) on ultrasound scanning. The gland itself, both central and peripheral zones, has a lattice appearance on microradiography (reticular structure) and therefore produces mid-range amplitude echoes on ultrasound. Benign hypertrophy develops at the edge of the periurethral muscle and is microadenomatous in structure. This produces mid-range amplitude echoes which are coarser than in the normal gland. Associated calcification has a characteristic distribution around the adenomas. Cancer produces an amorphous structure resulting in loss of ultrasonic echoes (hypoechoic). In a few cancers irregular calcification is present, resulting in high echoes in the ultrasound scan (hyperechoic) which are not in the typical benign distribution. The internal structure of the prostate was therefore demonstrated in its histopathological states by the technique of microradiography and seen to relate to its representation by ultrasound.

The correlation of histopathological, microradiographic and ultrasonographic features in disease of the prostate gland

The histopathological, microradiographic and ultrasonographic features of corresponding areas of 100 cadaveric prostates were examined and correlated statistically to investigate their relationship. Benign glands are seen to be related to reticular structure and mid-range echoes. Benign prostatic hyperplasia is related to microadenomatous structure and mid-range echoes, whilst cancer is related to amorphous structure and low echoes. A small number of cancers have irregular calcification present and these tumours are related to high echoes. The structure of the prostate gland is therefore related to its pathology and explains its ultrasound echogenicity.

Assessment of volume measurement of the prostate using per-rectal ultrasonography

A study was made of 100 cadaveric prostates (71 benign glands and 29 invaded by adenocarcinoma) using a technique that enabled per-rectal ultrasonography to be carried out and their volumes measured by computed planimetry. These volumes were compared directly with the actual volumes of the glands measured after dissection from the cadaver specimens. A high degree of correlation was obtained for the measurement of benign glands (r = 0.982) and glands containing cancers confined within the capsule (r = 0.961). Estimation of the size of cancers unconfined to the gland was poor and measurement was not possible with 3 malignant prostates that had extended beyond the prostatic capsule so that the ultrasonic boundary could not be defined.

Transrectal ultrasound in monitoring response to treatment of prostate disease

Transrectal ultrasound provides a safe method for repeated assessments of the prostate gland in the follow-up of prostatic cancer. Changes in the echo pattern of the gland may be observed following treatment, but these may be difficult to interpret. The capsule may be restored; the tumor may appear smaller, and in some cases, ultrasound identification of the tumor may become impossible. The total gland volume decreases with chemotherapy and hormonal manipulation (subcapsular orchidectomy or drug-induced). The volume generally decreases after radiotherapy but may show a transient increase if there is some associated radiation proctitis. The rate of decrease of total prostatic volume has not been established as a reliable indicator of the subsequent prognosis. Future studies should assess whether sequential measurements of the tumor volume rather than the total prostatic volume may be a more useful guide to prognosis.

Comparative histopathology, microradiography and per-rectal ultrasonography of the prostate using cadaver specimens

A technique for examining cadaver prostates by per-rectal ultrasonography has been developed. The ultrasonic plane was defined and corresponding sections taken for microradiographic and histopathological examination. The technique has enabled a comparison to be made of the structural changes that occur in the prostate in disease states and the corresponding ultrasonic features.

Phase III studies to compare goserelin (Zoladex) with orchiectomy and with diethylstilbestrol in treatment of prostatic carcinoma

Two multicenter, open, randomized phase III clinical trials were conducted in the United Kingdom to compare the effectiveness and safety of the depot formulation of the luteinizing hormone-releasing hormone (LHRH) agonist goserelin (Zoladex, ICI Pharma, Wilmington, Delaware), 3.6 mg sc/28 d, with orchiectomy and with diethylstilbestrol (DES), 1 mg tid, in the treatment of advanced prostatic cancer. In the Zoladex versus orchiectomy trial, there was no significant difference between the treatment groups with regard to subjective and objective responses (British Prostate Group criteria), endocrine responses, clinical effects and side effects, time to treatment failure and death, or survival after similar median follow-up periods. It was concluded that depot Zoladex had behaved as a truly medical alternative to orchiectomy. In the Zoladex versus DES trial, subjective and objective responses (British Prostate Group and National Prostatic Cancer Project criteria), response duration and survival were similar. However, there was a more rapid response to treatment in the depot Zoladex group. Side effects from Zoladex such as flare symptoms during the initial stages of treatment required no discontinuation of therapy; in contrast, 15 percent of patients receiving DES required cessation of therapy during the first three months because of side effects. It was concluded that depot Zoladex was superior to DES in its attainment of an early objective response and in its absence of side effects, and that Zoladex was comparable with DES in terms of response rates and survival.

Diagnostic assessment of benign prostatic hyperplasia

Clinical evaluations of benign prostatic hyperplasia (BPH) are based upon careful history taking, uroflowmetry, palpation of the prostate, and diagnosis of urinary infection or possible damage to the kidneys caused by outflow obstruction. Symptom assessment includes scoring by the patient of the four obstructive and five irritative symptoms of prostatic obstruction: a simple questionnaire is used. The scoring system should be reviewed with the urinary flow measurements as part of the workup. The various forms of ultrasound used for diagnosis, although invaluable, may not be assessed out of context, and the combination of digital palpation and endoscopy generally provide most information leading to a decision for operation. When available, perrectal ultrasound scanning should be used to investigate palpable abnormalities and to identify unexpected prostatic cancer.

Clinical aspects of diagnosis and monitoring of prostatic cancer

This paper discusses the impact of new imaging technologies on our traditional confidence in digital rectal examination for help in diagnosis, biopsy staging and follow-up of patients with prostatic cancer. Ultrasound, particularly per-rectal ultrasound examination, has an important role in the differential diagnosis of smaller palpable abnormalities in the prostate and is especially useful for staging. It is also of value to measure prostatic response to treatment.

How accurate is the index finger? A comparison of digital and ultrasound examination of the prostatic nodule

The per-rectal ultrasound scans and digital assessments of 193 patients with prostatic nodules were analysed retrospectively. There were 88 histologically proven cancers and per-rectal ultrasound demonstrated extracapsular spread of tumour in 36 of these patients. In the diagnosis of prostatic cancer, ultrasound had a sensitivity of 97.6% and a specificity of 93.8% whereas digital examination had a sensitivity of 96.5% and a specificity of 53.3%.

The ultrasound appearances of prostatic cancer with histological correlation

An analysis of the ultrasound appearances of the prostate with its capsule and periprostatic structures was performed in 221 patients with a histologically confirmed diagnosis of prostatic cancer. The cancers were histologically graded into well, moderate and poorly differentiated adenocarcinoma and transitional cell carcinoma. The results of this study indicate that an ill-defined hypoechoic area is the commonest appearance of prostatic cancer; this was seen in 96% of our 221 patients. The cancers were staged by ultrasound into confined (T0, T1, T2) and unconfined (T3) cancers. A breach of the capsule was seen in 55% of cases. In this unconfined group all cancers were hypoechoic in comparison with 92% in the confined group. In the confined cancer group the areas of abnormal echogenicity were present in more than one prostatic quadrant in 76%. Mostly commonly two prostatic quadrants were affected. The abnormal echogenicity was noted in the posterior quadrants of the prostate more commonly (58%) than in the anterior quadrants. The prostate gland appeared round in 67%, semicircular in 25% and crescentic in 8%. The gland was symmetrical in 68%. The prostatic capsule appeared regular in 86% of patients with a confined cancer. In 70% of cases of extensive but confined cancer there was loss of demarcation between the central and peripheral zones of the gland. The unconfined cancer group all had a breach of the capsule and all glands were heterogeneous due to hypoechoic areas. The breach affected more than one quadrant in 81% and most commonly the capsular breach involved two prostatic quadrants. An anterior breach of the capsule was noted much more frequently than a posterior breach. Forty-four per cent of cases had three or four quadrants of the gland involved. In 3% of cases of proven prostatic cancer no definite ultrasound abnormality could be detected. Calcification was seen within the gland in association with the cancer in 63% with approximately equal frequency in confined and unconfined disease. The seminal vesicles showed definite evidence of infiltration in 10%. Both seminal vesicles were seen in 61% and thought to be normal. In 8% only one was seen. Failure to demonstrate either seminal vesicle occurred in 21%. There was no correlation between the ultrasound appearances of prostatic cancer and the histological grading of the tumour.

The treatment of metastatic prostatic cancer with the slow release LH-RH analogue Zoladex ICI 118630

The clinical and endocrine response to a depot preparation of the LH-RH analogue ICI 118630 (Zoladex) was assessed in 55 untreated patients with advanced prostatic cancer. Whereas gonadal androgen suppression was achieved in all patients, subjective and objective clinical response occurred in only 69%, indicated by a relief of bone pain, a decrease in the size of the primary tumour and lymph node metastases and improvement in bone scan appearances. A third of these patients, however, subsequently showed progression of their disease. Serious side effects were not encountered in this study. The depot formulation is a simple, safe and convenient method of administering Zoladex and offers an alternative treatment for metastatic prostatic cancer.

Treatment of patients with advanced cancer of the prostate: phase III trial, zoladex against castration; a study of the British Prostate Group

The interim results of the randomised, Phase III trial of Zoladex against castration in the management of patients with metastatic carcinoma of the prostate is discussed. Trials commenced in October 1984 and incorporated 359 patients when recruitment ceased in January 1986. The preliminary report concerns the first 240 patients who had a minimum of 3 months follow-up. Entry criteria included patients who had no previous treatment with the exception of first-line localised radiotherapy and those who had distant bone or soft tissue metastases. Fourteen patients were excluded on the basis of protocol violations. The objective assessment of response was based on the British Prostate Group Criteria and was performed monthly for the first 3 months and 3-monthly thereafter. Pre-treatment disease characteristics of patients in both groups were similar at entry and there were no significant differences in the subjective response data of patients between the orchidectomy (n = 106) and the Zoladex group (n = 120). Objective response rates at 12 and 24 weeks of treatment were also identical for both treatment groups. Serum testosterone concentrations were below the 'castrate' level (less than 2 nmol/L) for Zoladex group as well as the orchidectomy group up to 48 weeks. The drug was well-tolerated with minimal side effects, those resulting from testosterone withdrawal were similar in both groups. The report therefore indicates clearly that this partical formulation of LH-RH analogue provides a valuable alternative to the surgical procedure in the treatment of carcinoma of the prostate.

Evaluation of biopsy techniques for androgen receptor assay in human prostatic tissue

Androgen receptors were assayed in nuclei prepared from human benign hypertrophic prostate tissue obtained at retropubic prostatectomy by transurethral resection (TURP) and by cold punch resection. Androgen receptor was not detected in 70% of the transurethrally resected samples, and in those cases where receptors were observed they showed no correlation with enucleated samples. However, androgen receptors were detected in all cold punch resected samples and enucleated tissue with similar concentrations evident in samples from the same gland. These results suggest that prostate specimens collected by TURP are not suitable for androgen receptor analysis, whereas the technique of cold punch resection yields prostate samples that are more reliable for a correct evaluation of androgen receptor content.

A prognostic index for the clinical management of patients with advanced prostatic cancer: a British Prostate Study Group investigation

Patients with histologically proven carcinoma of the prostate (n = 186) were initially assessed and followed up according to the standardized protocol of the British Prostate Study Group, urologists from which contributed patients to this investigation. These patients were given either endocrine therapy or orchidectomy as first line treatment; the ratio of the number of patients receiving these two treatments was similar in each group of subjects compared for survival. Prognostic indices were derived for all patients and for those classified according to the presence (M1) or absence (M0) of metastases. The prognostic indices were derived from clinical and hormone data obtained at initial presentation. Whereas the degree of tumor differentiation and plasma testosterone concentrations were significant prognostic factors in both M0 and M1 disease, growth hormone was only significant in M1 patients, where age was also of borderline significance; elevated growth hormone, higher Gleason grade, younger age, and lower testosterone indicated a poorer prognosis in M1 patients. These findings indicated the feasibility of selecting a poor prognostic group of patients that may derive benefit from a more aggressive therapy.

Growth hormone and prostatic tumours: localization using a monoclonal human growth hormone antibody

The immunocytochemical detection of endogenous human GH and the binding of exogenously applied human GH in tumour tissue from patients with benign prostatic hyperplasia or prostatic carcinoma is reported. Monoclonal human GH antibody binding was exclusively to the connective tissue in both benign and carcinomatous specimens. Specificity control experiments indicated that the antibody could be absorbed with human GH but not with human prolactin. Preincubating the sections with human GH considerably altered the immunocytochemical staining, reducing the reaction product within the connective tissue in a concentration-dependent manner and revealing a binding site for GH within the cytoplasm of epithelial cells.

Treatment of patients with advanced cancer of the prostate using a slow-release (depot) formulation of the LHRH agonist ICI 118630 (Zoladex)

Twenty two patients with advanced carcinoma of the prostate have been treated for up to 3 months with the slow-release (depot) formulation of the luteinizing hormone-releasing hormone (LHRH) agonist ICI 118630. Patients were randomized to receive one of three different doses of ICI 118630 of 0.9, 1.8 or 3.6 mg. The depot preparation was injected subcutaneously every 4 weeks. At the highest dose, the concentration of testosterone in serum was significantly reduced to castrate values after 2-3 weeks of therapy. The smaller doses of ICI 118630 (1.8 or 0.9 mg every 4 weeks) similarly reduced serum testosterone concentrations although, at the lowest dose, testosterone values were not suppressed in all patients during the first month. Hormonal changes were accompanied by subjective clinical improvement in symptomatic patients and there were no significant side effects. The data clearly demonstrate the considerable therapeutic potential of ICI 118630 in the depot formulation for the treatment of advanced carcinoma of the prostate.

Ultrasonic appearances associated with prostatic inflammation: a preliminary study

Per-rectal ultrasonography was performed on 40 patients in whom a diagnosis of prostatitis had been made on the basis of symptoms and signs of prostatic inflammation confirmed by bacteriology, microscopy or pH changes of expressed prostatic secretion. Certain ultrasonic features were present in all patients to a variable degree. A change in volume and weight of the prostate could be an indicator of treatment response.