Carcinoma of the Prostate Updated version

Carcinoma of the Prostate
John R. Caulk and S. B. Boon-Itt
Am J Cancer 1932;16:1024-1052.
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CARCINOMA OF THE PROSTATE
JOHN R. CAULK, M.D., F.A.C.S., St. Louis, Mo.,
S. B. BOON-ITT, M.D., Bangkok, Siam 1
AND
(From the Genilo-Urinary Section of the Department of Surgery, School of Medicine,
Washington University, St. Louis)
One of the most vital problems confronting the urological surgeon today concerns the early recognition and treatment of cancer
of the prostate.
Some authors have likened this lesion to a somewhat analogous
one occurring in the female breast. In many points they are
similar; in many others they are entirely different. Both are
essentially diseases of the latter part of middle life. They are
similar, also, in their tendency to spread very early by the way of
the lymphatic system, in their power to disseminate far and wide,
and in their predilection to skeletal metastasis. In neither of these
two types of carcinoma is the prognosis as to the duration of life
good, and in both the end-results of treatment are still unsatisfactory. Of the two, carcinoma of the prostate appears the more
unfavorable.
Oertel (1) points out the similarity in the reaction of breast
and prostatic tissues and contends that carcinoid hyperplasia in
each of these organs is potentially cancerous, although it does not
always develop into cancer. Cheatle (2) calls attention to a
sequence of events occurring in the prostate similar to that which
is observed in certain diseases of the breast. The cystiphorous
desquamative epithelial hyperplasia is transformed into epithelial
neoplasia, and this latter condition further changes into true
cancerous tissue. In one section of a prostate the author observed
all of these three stages.
According to Mark and McCarthy (3), the first case of carcinoma of the prostate was recognized by Langstaff in 1817.
Billroth in 1867 first attempted to treat this condition by surgery.
The frequency of the neoplasm was not well recognized until 1900,
when Albarran and Halle intimated that it was not uncommon.
Since then a number of studies have been made on the subject,
various facts have been brought to light, and many helpful sug1 The writers acknowledge with thanks the assistance of Dr. John F. Patton in the
preparation of this paper.
1024
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CARCINOMA OF THE PROSTATE
1025
gestions presented by different investigators. In spite of the
numerous studies already made, the management of carcinoma of
the prostate is still far from satisfactory. The following study is
attempted with the hope of furnishing more data on this still
unsolved problem. It comprises 222 cases of prostatic carcinomata
seen in the Genito-Urinary Service of the 'Barnes Hospital and in
private practice. Four cases were apparently metastatic and are
therefore not included in the study. They are discussed under a
separate heading (page 1049).
INCIDENCE
It is well recognized that cancer of the prostate is not uncommon. Hoffman (4) presents data of the New York Pathological
Institute, giving 36 deaths from carcinoma of the prostate in
2,641 deaths from cancer of various organs (908 male deaths and
1,733 female deaths). This makes 1.3 deaths for every 100 deaths
from cancer in both sexes, or 3.96 deaths for every 100 cancer
deaths in males only. According to the mortality statistics (5) of
the U. S. Bureau of the Census, there were in 1927 a total of 1,141.9
deaths from all causes per 100,000 population in the registration
area of the continental United States; 95.6 deaths per 100,000
population were attributed to cancer and malignant tumors of all
kinds, and 3.5 of these were due to carcinoma of the prostate. This
means that in about everyone thousand deaths of persons of both
sexesin 1927 there were 3.5 deaths from carcinoma of the prostate,
or in about every thousand deaths of males, of all ages, 5.6 deaths
were attributable to cancer of the prostate. When this is considered in terms of the total deaths-almost 1,237,000 in the year
1927-the toll is far from insignificant.
These figures, furthermore, represent only the number of cases
definitely known. Without doubt there were many cases not
included in the statistics, either because the diagnosis was not
apparent, or because the secondary symptoms were so preponderant
as to mask the true primary cause.
Young (6) states that 5 per cent of the total number of patients
admitted to his clinic had carcinoma of the prostate. About 2
per cent of all genito-urinary cases seen by one of the writers
(J. R. C.) in private practice were cases of prostatic malignancy.
Of 700 cases of obstructive conditions of the prostate seen by
Barney and Gilbert (7), 23.9 per cent were due to malignancy.
Cunningham (8) found carcinoma of the prostate in 20 per cent
96
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JOHN R. CAULK AND S. B. BOON-ITT
of all cases of prostatic obstruction. Of the 222 cases in the series
under consideration in this paper, only 162 were hospital cases.
This represents about 19 per cent of all the cases of prostatic
obstruction treated in the Barnes Hospital.
Correction of precancerous conditions, early recognition of
cancer, and prompt therapy are fundamental. Since prostatic
inflammation is so ubiquitous and inflammation is in many instances a precursor of cancer, it is quite possible that chronic
prostatitis may be instrumental in the creation of a definite proportion of these cases. With this in view, it would seem necessary
for the medical profession to devote stricter attention to the
inflammatory lesions of the prostate. Our experience seems to
indicate a definite association between the two lesions. It has
been abundantly demonstrated that about one in every five cases
of prostatism is due to cancer, and since approximately 15 per cent
of all men beyond fifty suffer from the results of prostatism, it
would at least appear that neglected inflammatory lesions may
predispose to cancer growth. In hundreds of cases of chronic
prostatitis which have been properly cared for we have seen cancer
develop in but one or two instances.
This view is contrary to the usual conception that prostatic
cancer originates in the posterior lobe, or surgical capsule, well
away from the site of the usual inflammatory or hyperplastic
changes in the gland. Another significant feature which indicates
that many prostate cancers may not originate in the posterior capsule is that tissue removed from the internal orifice of the bladder
by means of the punch clearly exhibits cancer in 80 per cent of the
cases, even though in many instances rectal examination indicated
either an early lesion or questionable malignancy.
DIAGNOSIS
The diagnosis of carcinoma of the prostate in this series was
made largely through the process of exclusion, supported by the
characteristic feel of the carcinomatous gland on palpation per
rectum. The final diagnosis of all cases was made by one of the
senior members of the service. Microscopic examination of tissues
was made in 107 cases. In 64 cases the tissue was obtained by the
punch operation and in 43 by prostatectomy (see Table I). None
was taken by the needle of Barringer. In these 107 cases, the
microscopic report was positive for carcinoma in 94 cases, in 52
of which the tissue was obtained by the cautery punch. It is of
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CARCINOMA OF THE PROSTATE
interest to note that about 80 per cent of tissue removed by the
punch histologically proved to be carcinoma, a finding which is not
in accord with the assumption that carcinoma of the prostate
commonly starts in the posterior capsule. If such were the case,
it would have to be assumed that practically the whole gland would
be involved before the cancerous tissue could be punched out per
urethra.
TABLE
I
Microscopic DiagnoBis of Tissue Removed from Prostate (107 Cases)
Poeitive
Nee.tin
Tissue removed by Caulk's cautery punch (64 cases) ...... 52 cases (81.4 12 cases
per cent)
Tissue removed by prostatectomy (43 eases).............. 42 C&IIeII (97.6 lease
per cent)
TOTAL................................ 94
C&IIeII
13 C&IIeII
It is well recognized that minute growths of the prostate readily
escape detection (Bugbee 11; Hirsch and Schmidt 12). Thus a
negative report on tissue examined does not disprove the presence
of a carcinoma in the gland. In 2 cases in this series, in which
carcinoma was suspected, prostatectomy was done and a microscopic diagnosis of benign hypertrophy was made. A little over a
year later, both patients returned with typical carcinomatous
masses at the site of the prostate, with metastatic lessions in the
bladder. Hunt (28) observed a similar case. It is commonly
understood that simple prostatectomy cannot completely remove
the prostatic tissue, hence a part or perhaps even the whole of the
cancerous growth was left behind in the above cases. This would
seem to support the fact that the lesions were confined to the
posterior capsule.
AGE INCIDENCE
Carcinoma of the prostate is essentially a disease of late middle
age. Table II gives the distribution by decades of 196 cases in this
series. It will be seen that 93.9 per cent of the patients were over
fifty years of age. Approximately 90 per cent were in the sixth,
seventh, and eighth decades. For the entire series the average
age when the patient was first seen was sixty-three years. In
Bumpus' series the average was 64.8 years. Barringer's series of
129 cases (14) showed 122 (94.6 per cent) patients above fifty
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JOHN R. CAULK AND B. B. BOON-ITT
years of age. Only two of his patients were between thirty and
forty. The youngest patient in the writers' series was twenty-five
years old. He was admitted complaining of pain in the rectum of
six months' duration. Examination revealed carcinoma of the
prostate. Death occurred nine days after admission, and postmortem examination revealed carcinoma of the prostate with
metastasis to the liver, peritoneum, retroperitoneal glands, and
mediastinal glands. The youngest patient reported in the literature was a youth of seventeen (Gardner and Cummins, 15).
TABLE
II
Age Incidence in 196 Cases of Carcinoma of the Prostate
2G--29 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3G--39 years....
.. ..
.. .. .. .. ..
4Q-49 years
,
5G--59 years
6lHi9 years
7G--79 years.. . .. . .. .. .. .. .. . .. .. . . .. .. .. ..
8G--89 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
1 ca.se (0.5%)
1 ca.se (0.5%)
10 cases (5.1%)
37 cases (18.9%)
75 cases (38.3%)
60 cases (30.6%)
12 cases (6.1%)
TOTAL ••••••••••••••••••••••••••••.•••.•• 196
Mean average age of 196 cases
Youngest case in the series
Oldest case in the series
cases (100%)
" . . . . . . . . . . . .. 63.4 years
" 25 years
, . " 85 years
SYMPTOMS
Cancer of the prostate in itself produces no symptoms, but on
account of its proximity to the bladder neck, its increase in size
readily gives rise to urinary disturbances. Bumpus (13) reports
that in 79 cases of carcinoma of the prostate with metastasis, pain
occurred as the first symptom in 34.1 per cent, frequent urination
in 27.8 per cent, and difficulty of urination in 16.4 per cent, while
in a group of 283 cases without metastasis, the first symptoms were
frequency in 36.7 per cent, difficulty in 32.5 per cent, and pain in
only 12.01 per cent. Frequency and difficulty in urination were
the two most common symptoms in Bumpus' series. Barringer
(14) reports that 115 of his series of 145 cases presented urinary
disturbances as early symptoms. Barney and Gilbert state that
in over 22 per cent of their cases the chief complaints were not
referable to the genito-urinary system. Bugbee contends that
II the sudden onset of retention in the presence of comparatively
mild urinary symptoms may be suggestive of malignancy."
The chief complaints in 194 cases in the present series are given
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CARCINOMA OF THE PROSTATE
in Table III. It will be observed that 143 of 194 patients, or
about 70 per cent, complained of symptoms referable to the genitourinary system. with a mean average of three years' duration.
Symptoms of obstruction-ranging from some difficulty in voiding
to complete urinary retention-and frequency of urination were the
two most common complaints when the patients were first seen.
In 42 cases, or 21.65 per cent of the total number, the complaints
were not referable to the urinary system but were suggestive of
TABLE III
Chief Complaint8 as Given by Patient8 When Fir8t Seen, with Average Duration
of Complaint
Number
of caeee
COMPLAINTS REFERABLE TO URINABY SYSTEM,
CASES (73.71%)
Averall" duration
of complaint
143
Obstruction to urination (ranging from slight
difficulty to retention)
.
Frequency of urination
.
"Bladder trouble"
.
Painful urination
.
Nocturia
,
, ..
Hematuria
.
Dribbling
.
TOTAL. . . . . . . . . . . . . . . . . . . . . . . . . . . ..
COMPLAINTS SUGGESTIVE OF EXTENSION OR METABTASIS, 42 CASES (21.65%)
Pain in lower back
, ..
Pain in legs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Weakness and loss of weight.... . . . . . . . . . . . . . .
Pain in rectum. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gastro-intestinal symptoms. . . . . . . . . . . . . . . . . .
Edema of lower extremities.... .. . . .. . . . . . . . . .
TOTAL. . . . . • . . . . • . . . . . • • • • • • . • • . . . .
SILENT CASES... . . • . . • . .• . . . . . . • • . . • . . . . • • • • . . .
61 (42.6%)
51 (35.6%)
16 (11.2%)
7 (4.9%)
6 (4.3%)
1
1
143 cases
3 yrs,
2 yrs,
3 yrs.
3 yrs.
1 yr.
2 mos.
11 mos.
8 mos.
1 mo.
10 mos.
3 yrs. (average)
14
10
8
4
4
2
42 cases
9 (4.64%)
extension of the growth or metastatic processes. Among these
complaints, pain in the lower back and in the legs appears to be the
most common. Nine patients were admitted with complaints
other than those recorded above. In these cases the prostatic
growth was found accidentally. One of these nine cases was an
accident case, in which examination revealed carcinoma of the
prostate with extensive skeletal metastasis. Another patient was
admitted to the Medical Service for leukemia i routine physical
examination revealed an independent cancer of the prostate, confirmed by the necropsy report. In one case, carcinoma of the
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JOHN R. CAULK AND S. B. BOON-ITT
prostate was found co-existing with an independent tumor of the
brain. The diagnosis of this last case was confirmed by postmortem examination. These silent cases comprise 4.64 per cent
of the total cases in the series.
TABLE IV
First Symptom as Noted by Patient in 194 Caee«
1. FIRST SYMPTOM REFERABLE TO URINARY SYSTEM
Frequent urination
Difficulty in urination
Painful urination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Nocturia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Hematuria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Retention of urine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Dribbling after micturition. . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Urgency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Wea.k stream. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Desire to urinate all the time. . . . . . . . . . . . . . . . . . . . . . . . . . .
Incontinence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
54 caBe8
20 C&8eS
20 cases
22 C&8eS
5 cases
4 caSell
3 cases
2 cases
3 cases
1 case
1 case
TOTAL
160 C&ses(82.48%)
II. FIRST SYMPTOM SUGGESTIVE OF SPREAD OF MALIGNANCY
Pain in lower back. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 C&8e8
Gastro-intestinal symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 7 C&8e8
Wea.knllll8 and loss of weight
5 casea
Pain referable to hip joint. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 5 cases
Pain in the legs. • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2 cases
TOTAL
III. FIRST SYMPTOM OTHER THAN THOBE OF GROUPS I AND III
26 C&Be8 (13.4%)
8 cases (4.12%)
The symptoms of onset are listed in Table IV. The earliest
symptoms most commonly observed by the patients in this series
were frequency and difficulty of urination. One of the silent cases
in Table III gave a history of frequent urination several years prior
to the date of admission.
In Table V are tabulated the general symptoms of all cases.
Here it is to be noted that frequent, painful, and difficult urination
are the three most common general symptoms in the series. It is
commonly recognized that low backache and sciatica-like pain are
fairly common in cases with carcinoma of the prostate. In the
present study, pain in the lower back was met with once in every
5 cases, while sciatica-like pain was encountered once in every 6.1
cases.
BLOOD PICTURE
Piney (16) points out that metastatic lesions in the bone marrow frequently give rise to II pernicious anemia JJ -like changes in
the blood. He further summarizes the changes which he believes
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CARCINOMA OF THE PROSTATE
to be sufficiently characteristic for the diagnosis of carcinoma of the
bone marrow as follows: (1) reduction in the number of red corpuscles: (2) high color index, not always above one; (3) slight
leukocytosis; (4) leukocytosis due to increase of polymorphonuclear
TABLE
V
General Symptoms in 194 Cases
Given &8
one of the
symptoms in
Such
symptom
occurs
Frequency of urination ............ " .... " .......... 122 cases lin 1.6 times
Painful urination.................................... 100 cases lin 1.9 times
Difficulty in urination ............................... 94 cases lin 2.1 times
Retention of urine .................................. 70 cases 1 in 2.8 times
Urgency ........................................... 50 cases lin 3.9 times
Hematuria ......................................... 39 cases lin 5.0 times
Dribbling after micturition........................... 41 cases 1 in 4.8 times
Nocturia without increase in frequency during day ...... 41 cases 1 in 4.8 times
Weak stream ....................................... 16 cases 1 in 12.2 times
Difficulty in starting stream .................. ........ 12 cases 1 in 16.2 times
Pain referred to lower back ........................... 39 cases lin 5.0 times
Pain referred to legs................................. 32 cases lin 6.1 times
Pain referred to hip joint............................. 14 cases 1 in 14.0 times
Loss of weight ...................................... 70 cases lin 2.8 times
neutrophils; (5) anisocytosis, ete., well marked; (6) nucleated red
corpuscles present, both normoblasts and megaloblasts: (7) myelocytes and myeloblasts present.
In almost every case of cancer a definite degree of anemia is
present, but this is not of a specific character. Roberts (17) divides carcinoma of the prostate into three groups: (1) cases in
which prostatic symptoms predominate; (2) cases in which pelvic
and sacral pain predominate j (3) cases in which distant dissemination of the growth gives rise to symptoms. In the third
group he recognizes profound anemia, almost of the perniciousanemia type, as one of the clinical features.
In 156 cases of this series blood counts were obtained. The
findings are tabulated in Table VI under two headings: cases with
skeletal metastasis and cases with metastasis elsewhere than in the
osseous system. In the former group the average red cell count
and the mean percentage of hemoglobin of the blood were distinctly lower than in the latter. This reduction in red blood cells
and hemoglobin percentage could not be accounted for by visible
hemorrhage, for, even eliminating the cases with hematuria, the
figures remain low. Eight cases with skeletal metastasis showed
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JOHN R. CAULK AND S. B. BOON-ITT
the most marked anemia, with an average of 2.9 million red blood
cells per cubic millimeter and 50 per cent hemoglobin. It is to be
regretted that the data in these cases are not sufficient to permit a
study of other blood changes also. The figures for the group with
metastasis elsewhere than in the bones are within normal limits.
TABLE VI
Relation of Blood Change8 to Skeletal M etaBtasiB in 156 CaBe8 of Carcinoma of
the Prostaie
With
skeletal
metastasis
TOTAL NUMBER OF CASES . . • • . . . . . . . . . . . . . . . . • . . .
Average hemoglobin .........................
Average red cell count .......................
Average color index ..........................
Average white cell count .....................
NUMBER OF CASES WITHOUT HEMATURIA . . . . . . . . . . .
Average hemoglobin .........................
Average red cell count .......................
Average color index ..........................
Average white cell count .....................
With other
than skeletal
metastasis
32
70 per cent
3,550,000
0.98
8,200
56
95 percent
4j350,OOO
1.10
11,700
23
65 per cent
3,310,000
9.98
8,100
44
lOOper cent
4,360,000
1.15
11,800
Metu-
tati.
leeioDB
not
found
68
BLOOD-PRESSURE READINGS
Blood-pressure readings were recorded in 125 of this series
of cases. The normal blood-pressure variation for the different
ages was computed by Faught's method. On comparison of the
normal computed value for the age with the actual reading of the
case, it is found that 26.4 per cent of the 125 cases showed definitely
high blood-pressure and 20.0 per cent gave readings below the
normal variation. Shaw and Young (19) believe that prostatic
hypertrophy does not cause any marked increase in the bloodpressure and support their contention by figures showing that
blood-pressure bears no relation to the residual urine of the case.
In Table VII cases with urinary disturbances as the chief complaint
and cases with high non-protein nitrogen in the blood are grouped
according to the blood-pressure readings. The percentages in the
high blood-pressure column show a slight rise in cases with urinary
disturbances and also in cases with a high non-protein nitrogen
content of the blood. The increase is not striking, however, as one
would expect if the dysfunction of the genito-urinary apparatus
were responsible for the increase in the blood-pressure. From the
results of this study, therefore, it would seem that, although
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CARCINOMA OF THE PROSTATE
urinary disturbances tend slightly to cause an increase in bloodpressure, one is not justified in concluding that these disturbances
are responsible for the hypertension, for the increase here is within
the limit of error, the total number of cases being comparatively
small.
TABLE
VII
Relation oj Blood-pressure to Urinary Disturbanee« in 1£5 Cose«
TD-
tal
C&ll8II
Blood-preeaure
reading within
normal variation
Blood;1?reeaure
reading higher than
normal variation
Blood-preeaure
reading lower than
normal variation
All cases regardless of
complaints ........... 125 67 cases (53.6%) 33 cases (26.4%) 25 cases (20.0%)
Cases with urinary symptoms as chief complaints............... 90 49 cases (54.4%) 30 cases (33.3%) 11 cases (12.3%)
Cases with non-protein
nitrogen higher than 50
mgm. per 100 c.c. of
7 cases (33.3 %) 2 cases (9.6%)
blood................ 21 12 cases (57.1 %)
SIZE OF THE PROSTATE
The size of the prostate was recorded in 205 cases: 34 per cent
were small, 48 per cent moderate, and only 18 per cent large.
Fifty per cent of the prostates in cases with metastases were small,
25 per cent were of moderate size, and 25 per cent large. Bone
metastases occurred in 19 per cent, and in the majority of instances
were associated with small or moderately enlarged prostates.
Eighty per cent of the bone metastases were located in the pelvis
and lumbar spine, 10 per cent in the femur, 5 per cent in the ribs,
and 5 per cent in the shoulder. There were 7 cases showing direct
extension: 3 to the bladder, 1 to the rectum, 1 to the bladder and
rectum, and 2 to the urethra. It is generally known that carcinoma of the prostate is of two types, one with a strong tendency
to produce early and distant metastasis, the other with a longer
course and commonly associated with marked urinary disturbances.
The prostate gland in this latter type of carcinoma is frequently
found to be enlarged. In the former type the gland is usually of
normal size or smaller than normal.
CYSTOSCOPIC FINDINGS
It is the experience of the Genito-Urinary Service of the Barnes
Hospital that the cystoscopic finding of irregularity at the internal
orifice is of special importance in carcinoma of the prostate. The
intravesical obstruction in cancer of the prostate is usually not as
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JOHN R. CAULK AND S. B. BOON-ITT
pronouncedly lobular as in benign conditions, but tends to assume a
collar arrangement or contracture and is likely to show irregularities, cystic and bullous changes, and occasionally deposits of fibrin
and submucous hemorrhage. An irregular edematous appearance
is suggestive of carcinoma.
Another important feature is puckering of the bladder mucosa
at the sites where the seminal vesicles are in contact with the bladder wall. Submucosal hemorrhages may be observed at the depression, and in later cases small areas of ulceration. This is
designated as II neighborhood carcinoma."
In 105 cases of this series the cystoscopic findings are available.
They are tabulated in Table VIII. About one half of the cases
TABLE
VIII
CY8to8copic Finding8 in 106 Ca8e8
General collar enlargement of the prostate gland with or
without irregularities ............................
Trabeculation of bladder mucosa .....................
Median lobe enlargement ...........................
One or both lateral lobes enlarged ....................
Tumor in bladder ..................................
Diverticulum in bladder ............................
Stone in bladder ...................................
Been in
Docurred
50 cases
46 cases
36 cases
22 cases
17 cases
13 cases
8 cases
once in 2.1 times
once in 2.3 times
once in 2.9 times
once in 4.8 times
once in 6.2 times
onee in 8.1 times
once in 13.0 times
showed some degree of trabeculation or corrugation of the bladder
mucosa. This finding is not of special interest, however, in carcinoma of the prostate, as it is commonly seen in cases of urinary
obstruction. Dossot (20) mentions the fact that in carcinoma of
the prostate the bladder is frequently increased in volume and its
internal surface is trabeculated, with more or less distinct cellules,
an appearance which he believes is definite, especially in adenoid
cancer. Other findings on cystoscopic examination are those of
prostatic hypertrophy, which are not of special interest in this
connection.
METASTASES
Geraghty (21) states that in 21 of 400 cases of carcinoma of the
prostate the process was confined to the gland. Barney and
Gilbert (7) estimate the percentage of cases with metastases in
their series as 58 per cent. In Bumpus' series (22) 28 per cent
of the patients had bony metastases when they were first seen.
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CARCINOMA OF THE PROSTATE
1035
In 98 per cent of Barringer's cases (23) the carcinomatous growth
had already grown beyond the prostate when the patient first was
seen. Of 197 cases in this series, 101, or 51.3 per cent, presented
demonstrable lesions beyond the prostatic gland, and in 80 cases
or 40.6 per cent the process had extended beyond the prostate and
the seminal vesicles.
TABLE
IX
Extension and Distribution of Metastases in 197 Cases
(103 cases, 52.2%. with extension beyond the prostate; 80 cases, 40.6%, with
extension beyond the prostate and seminal vesicles; 36 cases
with metastatic bone lesions)
DIRECT ExT1llNSION
Seminal vesicles. . . . . . . . . . . . . .. .. 39 cases
Bladder
"
21 cases
Rectum. .. .. .. .. . .. .. .. . .. .. .. . 4 cases
Urethra and perineum. . . . . .. .. .. 1 case
Ureter and kidney. . . . . . . . . . . . . . . 1 case
MIIlTASTATIC LESIONS
Lymphatic Sylltem
lnguinallymph nodes. . . . . . . . ..
Retroperitoneal nodes
Mediastinal lymph nodes. . . . . . .
Substernal lymph nodes. . . . . . . . .
Supraclavicular lymph nodes. . . .
Cervical lymph nodes. . . . . . . . . . .
Axillary lymph nodes. . . . . . . . . . .
Lungs .. "
" .. .. .. ..
Liver. . . . . . . . . . . . . . . . . . . . . . . . . .
Peritoneum. . . . . . . . . . . . . . . . . . . ..
Large intestine.. . • . . . . . . .. .. ....
Kidney. . . . . . . . . . . . . . . . . . . . . . . . .
Pleura. .. .. .. .. . .. . .. .. • .. .. .. .
Myocardium. . . . . . . . . . . . . . . . . . . .
Abdominal wall (cystostomy wound)
Brain. . . . . . . . . . . . . . . . . . . . . . . . . .
Bones
Pelvis
Vertebrae
Femur. . . . . . . . . . . . . . . . . . . . . . .
Ribs. .. .. .. .. .. .. .. .. .. .. ....
Shoulder girdle. . . . . . . . . . . . . . ..
Skull. . . . . . . . . . . . . . . . . . . . . . . ..
Humerus, . . . . . . . . . . . . . . . . . . . .
Mandible
" .. .. .. ..
Patella. . . . . . . . . . . . . . . . . . . . . . .
13 cases
10 cases
4 cases
1 case
1 C88t'
1 case
1 case
8 cases
7 cases
4 cases
3 cases
2 cases
2 cases
1 case
1 case
1 case
22 cases (1 in 1.6 caseswith skeletal metastasis)
19 cases (l in 1.9 cases with skeletal metastasis)
6 cases (1 in 6.0 cases with skeletal metastasis)
8 cases (1 in 6.0 caBe8 with skeletal metastasis)
4 cases (1 in 9.0 cases with skeletal metastasis)
3 cases
2 cases
1 case
1 case
The distribution of the metastases in this series is given in
Table IX. Only 15 cases were autopsied and of these only 5 were
found with metastases (Table X). The skeletal metastatic lesions
and the secondary growths in the lung were revealed by the x-ray.
While the extension of the carcinomatous process to seminal vesi-
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American Association for Cancer Research.
1036
JOHN R. CAULK AND S. B. BOON-ITT
eles and to rectum W8B diagnosed by digital palpation, the diagnosis of other metastatic localization W8B reached after the usual
physical examination. In some C8Bes the abdominal metastatie
lesions were visualized through operative wounds.
TABLE
X
Necropsy Findings in 17 Cases (15 Primary; e Metastatic)
PRlMARY CARCINOMA OF PROSTATE
No sign of metastasis in
Metastasis in. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Retroperitoneal nodes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mediastinal nodes
"
Bladder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Peritoneum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pleura
"
Perineum and urethra. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Axillary lymph nodes
"
"
Ureter and kidney. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Kidney. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10 cases
5 cases
3 cases
3 cases
2 cases
2 cases
2 cases
1 case
1 case
1 case
1 case
In~llymphnodes
1 case
Myocardium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 case
Liver. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 case
Pelvis, ribs, and vertebrae
:
" 1 case
METASTATIC CARCINOMA OF THE PROSTATE
Primary carcinoma of the stomach with general metastasis including the
prostatic gland. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 case
Primary carcinoma of bladder with extension to the prostate and metastasis
to adrenal and myocardium. . .. .. .. . . . . . . .. . . . . . .. . . . . . .. .. . . .... 1 case
Extension of the carcinomatous process via seminal vesicles
appears to predominate, with spread to the pelvic bones ranking
next. Barringer (14) and Young believe that the commonest
extension of carcinoma of the prostate is toward the seminal
vesicles, the next most favored line of extension being laterally
from the prostato-vesicular junctions to the rami of the pubic bone.
The findings in this series are entirely in accordance with this view.
One would expect to find the extension of the growth to the seminal
vesicles more frequent than once in about 5 cases, as in this series.
It is to be recalled, however, that early carcinomatous lesions of the
vesicles are very easily missed by the palpating finger.
Dossot (20) also is of the opinion that carcinoma of the prostate frequently extends toward the seminal vesicles, and further
believes that invasion of the bladder is quite frequent. Among his
89.4 per cent of cases with adenopathy, he observed only 3 cases
with involvement of the inguinal lymph nodes. In Bumpus' series
(13),46.1 per cent of the cases had glandular metastases, with the
inguinal lymph nodes heading the list. In this series, also, the
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American Association for Cancer Research.
CARCINOMA OF THE PROSTATE
1037
inguinal nodes head the list of glandular involvement. This is
readily explained by the fact that these nodes are superficially
situated and are therefore easily accessible to the palpating finger,
while early involvement of the iliac and retroperitoneal glands is in
most cases not palpable.
Of Bumpus' cases (13), 51 per cent had secondary growths in
the bones, with the pelvic bones as the most frequent site. Young
(6) states that prostatic carcinoma commonly metastasizes to the
pelvis and vertebrae. Ewing (10) ranks carcinoma of the prostate
as first in metastasis to the osseous system. Kaufmann calculated that about 70 per cent of prostatic carcinomata cause skeletal
metastases, as compared with 37 per cent for thyroid carcinomata
(Limacher) and 14 per cent for mammary carcinomata. In the
present series only 19 per cent of the cases are known to have
skeletal lesions. This relatively small number is due to the fact
that only a few patients, and generally only those in whom bone
metastasis was strongly suspected, were sent for x-ray pictures.
For this reason the percentage in relation to the total number of
cases is too low, while that in relation to the number of cases x-rayed
is too high to be fairly representative. It will be observed in
Table IX that the pelvic bones were the site of metastases once in
every 1.6 cases, and the vertebrae once in every 1.9 cases of carcinoma of the prostate with skeletal metastasis.
The tendency of carcinoma of the prostate to distant dissemination is well recognized. Charteris (24) reports a case with metastasis to the skull and other bones, in which post-mortem examination revealed only slight enlargement of the glands along the iliac
vessels, while the abdominal viscera had completely escaped
invasion. Charteris could not reconcile these findings with metastasis by way of the lymphatic stream. In his opinion, the facts
are more in accordance with blood stream dissemination. Piney
(16) is also of the belief that metastasis to the bones from a primary
growth in the prostate is by way of the blood stream. He further
demonstrates that there is no evidence of lymphatic channels in the
bones. Roberts (17), however, maintains that it is not certain that
the blood stream plays any important role in the spread of cancer
cells from the prostate. He explains metastasis to the lower
extremities by way of the lymphatic plexus surrounding the blood
vessels to the bones. He further suggests a route of spread
through the lymphatic vessels and tissue spaces of the spinal
laminae, with their associated ligaments, by which malignant cells
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American Association for Cancer Research.
1038
JOHN R. CAULK AND S. B. BOON-ITT
may reach the vertebrae, ribs, skull, and other bones. This will
explain the non-involvement of the lymphatic system in the
abdomen in cases with metastasis to the skull and bones of the
upper extremities. Roberts reports three cases with lesions in the
spinal laminae with their ligaments to corroborate his suggestion.
At present the weight of,evidence, such as the finding of iliac lymphatic enlargement in autopsied cases, seems to suggest that the malignant cells commonly pass from the primary site via the lymphatic
system. This fact is of value in early treatment.
One of the cases in this series had metastasis to the myocardium,
which is a comparatively rare site for secondary growth. In
another case brain metastasis was present, with symptoms of
paralysis of the glossopharyngeal and hypoglossal nerves. This
patient also had metastatic lesions in the spine.
'Extensions of carcinoma from the prostate to surrounding
parts-urethra, bladder, and rectum-occur as late manifestations
and are far less frequent than metastatic changes. Only a few
of our cases showed urethral extension. Bladder invasion, except
for the usual obstructive condition at the orifice, occurs usually
from implication through the seminal vesicles. The rectum is
protected by Denonvillier's fascia and is involved as a part of an
invasive process. Like the bladder, it derives its lesions more
commonly from the seminal vesicles. It is usually for the relief
of pain in the back, along the sciatic nerve, or during the act of
urination, that such patients consult a physician. By that time
the disease has extended, in many cases, too far for repair.
Many observers are deceived into thinking that an apparently
cachectic patient is beyond relief, when, as a matter of fact, the
condition is due to uremia and toxemia, the result of obstruction.
In such cases, if the obstruction be removed by proper treatment,
tremendous help may be afforded and the patient, although still
suffering from cancer, may enjoy additional years of comfortable
living. No such case, therefore, should be considered as hopeless.
In every instance the obstruction should be relieved. An opportunity is thus given to determine the comparative effects of the
uremia and toxemia due to the obstruction and the devastation due
to the cancer.
TREATMENT
The results of different methods of treatment reported in the
literature vary considerably. No attempt is made to review them
all. In some hands the radical prostatectomy of Young proves
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American Association for Cancer Research.
CARCINOMA OF THE PROSTATE
1039
successful. Among the 26 cases reported by Smith (27) in which
total prostatectomy was done, there were 3 deaths in the hospital;
8 patients died after leaving the hospital, having lived an average
of twenty-two months after operation, and 15 were still living at
varying periods up to six years after operation. Barney and
Gilbert (7) conclude from their study that surgery alone is better
than radium alone, but the combination of the two is often advantageous. Chute (25) advises simple prostatectomy in all instances
where the malignant process produces obstruction to urination,
but believes that radium should be used in conjunction with
surgery.
Bumpus (22) reports that the results of radium treatment of
cancer of the prostate in his series are inferior to those obtained by
surgery, but he, also, is of the belief that a combination of surgery
and radium offers the best results. Barringer (14), on the other
hand, states that his results show the superiority of radium treatment over operative treatment both in causing regression of the
growth and in coping with the urinary symptoms. Geraghty (21)
stated that in 95 per cent of cases of carcinoma of the prostate
surgery alone is hopeless. He was of the opinion that radium had
a definite field of usefulness. Smith and Peirson (26) advocate
x-ray treatment for cases not suited for surgical removal.
The treatment of the cases in this series varied at different
times and with different surgeons. Some cases were treated by
simple prostatectomy, either by the perineal route or through a
suprapubic incision, in one or two stages, while others received
radium or x-ray, or both, in addition to surgery. The radical
prostatectomy of Young was not employed in any of the cases.
More recently a more conservative treatment has been adopted.
The cautery punch has been used to relieve obstruction, and
radium, either in combination with x-ray or alone, has been given
to retard the growth. The punch operation was performed in
one or more sittings according to the requirements of the individual
case. Radium was formerly given by inserting needles, containing
12.5 mg. of radium, into the prostate and leaving them in the
glandular tissue for a certain length of time according to the amount
of the treatment required. More recently radon seeds, from one
to two millicuries each, have been used. From 6 to 10 seeds are
implanted into the prostate and vesicles with the aid of two small
trocar needles inserted through the perineum into the prostate
gland. Deep x-ray therapy is usually given a few weeks later,
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American Association for Cancer Research.
1040
JOHN R. CAULK AND S. B. BOON-ITT
although at times it precedes the radium implantation. The
x-ray treatment is generally administered in divided dosage,
regulated by the x-ray department. It is the general practice to
repeat both x-ray and radium treatments at intervals of two to four
months. In some cases where surgery is believed to be contraindicated, only radium and x-ray are given. It is the policy of the
Service to supplement surgical treatment of all cases of carcinoma
of the prostate by radium or x-ray therapy or by combined radium
and x-ray treatment, but this is not always possible.
The experience at Barnes' Hospital with radium therapy coincides very closely with that of other clinics. The enlarged and
stony-hard cancerous prostate is readily reduced in size and becomes softer after radium or radon implantation. It is observed,
however, that radium causes more tissue reaction than radon. In
one of the cases treated with radium needle implantation a prompt
reaction resulted in a dense fibrosis of the orifice, which required
sharp dissection. Histologically the tissue was entirely scar tissue.
A recontracture promptly occurred, which necessitated permanent
suprapubic drainage. In using radon seeds, we have never
observed any such unfortunate complication.
A number of patients came to the clinic with practically hopeless metastases. They had marked urinary disturbances, with
much discomfort and pain on urination. In such cases the punch
operation has proved useful. The removal of a few bites with the
cautery punch generally renders urination free and practically
painless. This permits the patient to enjoy the few remaining
months of his life in comfort. Deep x-ray therapy is found to be
very useful in shrinking and softening the carcinomatous gland,
as well as in the treatment of back pain and the sciatica-like pain
of the lower extremities. In our experience, however, it has no
therapeutic influence on the deep-seated pain of the hip joint.
In only 143 of this series of 218 cases of primary carcinoma of
the prostate are the follow-up records suitable for a study of the
results of treatment. These cases are grouped according to the
type of treatment received. The duration of life after treatment
by the various methods has been averaged. Of these 143 patients,
variously treated, 36 (25.1 per cent) lived three years or more after
treatment, and 25 of these (17.4 per cent of the 143 cases) four
years or more after treatment.
The analysis of the results of treatment in this series of cases
has been supplemented by graphic representations showing the
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American Association for Cancer Research.
1041
CARCINOMA OF THE PROSTATE
duration of life after the different types of therapy. Those patients dying while in the hospital, as the result of operation or
complications thereof, and those in whom the disease had developed beyond therapeutic aid and who were brought to the
hospital to pass their few remaining days in as much comfort as
possible, are not included in the graphic series, since their inclusion
P1'Ol!lt4tectomy "tone
i
__
o
Punch alone
13
10
g
I 1 1
::
Years
X-!'ay alone
13
i
u
;.',
6 9 10
Radium alone
No t!'eatment
16
1~
10
10
11
0-
10
~
1
4 6
GRAPH
1.
DURATION OF LIFE AFTER DIFFERENT TyPES OF THERAPY
would not give a true representation of the benefits derived from
therapy. The graphs are intended to show the relative value of
the different types and combinations of therapy in prolonging life.
The first column to the right of the scale indicates the total
number of cases treated by the particular type of therapy, the
black portion of that column indicates the total number of deaths.
The drop in the black portion of the column from year to year,
therefore, indicates the number of deaths during the preceding
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American Association for Cancer Research.
1042
JOHN R. CAULK AND 8. B. BOON-ITT
year. The drop in the total column is accounted for by deaths,
by patients whose treatment has been too recent to include them,
and by those in whom a follow-up could not be obtained.
Graphs 1, 2 and 3 show the results from different types of
treatment. Graphs 4 and 5 are composites, showing the results
from treatment other than surgery, and from all prostatectomy
Punch and
en
~u
~dium.
Prostatectomy
and l'adium
10
10
0-
~
5
1,. 1, 1 1
'"
".:
Yeat>5 1 2 3 4 S 6 7 6 9 10 11
20
s~u
1)-
18
20
'Punch and
x-ray
16'
US
10
10
'P['ostatectomy
and x-ray
6
~
~
GRAPH
S
2.
DURATION OJ' LIFII
Arrma
DIJ'J'IlRIINT
fins
OJ' THIlRAPY
and cautery punch cases alone and in combination with radium
or x-ray.
A discussion of the graphs will be limited to 4 and 5, the nonsurgical and surgical groups and the cautery punch cases, with
occasional reference to the preceding graphs. Those cases treated
non-surgically, that is, with radium or x-ray, or both, show a sudden
drop in the curve the first two years, leaving only 3 patients, or 12.5
per cent, living over three years and only one patient living more
than five years. Those patients having prostatectomy alone were
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American Association for Cancer Research.
1043
CARCINOMA OF THE PROSTATE
naturally patients who were good surgical risks; 50 per cent of those
who lived after the operation were clinically benign cases, carcinoma having been detected in an otherwise benign hypertrophy
by histologic examination. In such cases the duration of life would
naturally be expected to be longer than in frank cancer cases.
The operative mortality in prostatectomy done for cancer was 17
31
Punch.redium
and x-roay
16
10
Radium and
x-!'ay
9
5
I
1
20
Years
15
1 1
4 .5 6
Proetatectomy;
rediurn and x-f'i!ij
10
10
3
1
Yeers
GRAPH
3.
DUBATION 01'
LIn
1 2 3 4 6
ArrER DIl"JI'ERJIlNT TyplllS 01' TmlRAPY
per cent. In the cases treated by prostatectomy alone, the average
duration of life was forty-four months, while patients having
prostatectomy supplemented by either radium or x-ray therapy or
by both in combination had an average duration of life of only
twenty-five months. Not one patient of this latter group lived five
years.
It is to be observed in Graph 4 for prostatectomy cases that
there is a more gradual decline in the curve. This is due to the
simple prostatectomy cases including clinically benign lesions.
The drop in the curve is more gradual, but in itself is pronounced.
All of these patients died within five years. It seems definitely as
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American Association for Cancer Research.
1044
JOHN R. CAULK AND B. B. BOON-ITT
unsurgieal to attempt to II gouge out" a carcinoma of the prostate
suprapubically as it does to attempt the same type of enucleative
procedure for a cancer of the breast.
Since the completion of the tabulations for this paper about a
year ago, I have analyzed all the punch cases from many different
angles and standpoints, and will present them to date. It will
be observed on Graph No. 5 that there is a sudden drop in the
curve for the first two years, which results from the fact that the
majority of these patients were very poor risks, many entirely
30
Tr>eatmente othel'
than
2"
30
,AU
~urgef')'
Il4
~l!Itatectomy
cases
23
~
20
.:
':
:\
"
"
20
~
0~
"
"
1~
ItJ
"
~~:
'.
"
;.
"
10
10
.~
~~
-',
::.
"'.;
:;,: ~'f\
:.
.,
\::: ~
.... ::.
"
~I\
.;:
I
,;
'I i~
1 2 3 4
GRAPH
4.
DURATION OJ'
s
6
LInl
ArrmB NON-SUBOICAL TREATMENT AND
PaOBTATIlCTOKY
inoperable. From this time on, unlike the prostatectomy graph,
the curve is more gradual. At the end of three years 29 per cent
of the patients are living and at the end of five years 10.7 per cent
still survive i one patient is living after ten years.
A critical analysis of the punch cases follows:
There were 80 white patients and one colored one. This disproportion is due to the fact that the majority of these patients
were seen in private practice. In this group there were 40 early
cases and 41 advanced cases. I have designated as early those
cases in which there were localized nodular areas in the prostate
without evidences of extension beyond its confines, with seminal
vesicles, membranous urethra, and rectum apparently normal, and
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American Association for Cancer Research.
70
M
AU
punch
caee&
6~
:
"
"
50
"
~~
"
','
"
"
~O
.•." ~ 4
4.5
40
U'l
C\)
U
'5""
~
S:
:.: :-.:
:...
:. ~
,"
"
"
"
"
~:
','
"
.;.
U'l
co
:.:
3.5
1\ :0°
"
"
:::'
30
~:
""
2~
20
1.5
10
GBAPH
5,
DURATION OF
1IFJIl ArrBla
PuNCH OPERATION
1045
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American Association for Cancer Research.
1046
JOHN R. CAULK AND S. B. BOON-ITT
without demonstrable evidence of metastases. This, of course,
is quite indefinite, since it is impossible to determine whether or
not the deep pelvic glands are involved. In a number of instances
in which the prostates showed apparently early lesions, the diagnosis of cancer being difficult, there was pronounced dissemination.
Of the 81 patients, I have been able to follow 69, or 85 per cent.
Of these, 27 are living and 42 have died. Thirty of these died of
cancer, 12 of other causes, including pneumonia, heart conditions,
apoplexy, pyelonephritis, and following a later operation done elsewhere. Two deaths resulted from the punch operation; in both
instances the individuals were extremely depleted.
The time of death was as follows: within six months to a year,
8 cases; within two years, 11 cases; three years, 3 cases; four years,
1 case; five years, 3 cases; six years, 3 cases; over six years, 1 case.
In the total series of cases, the punch operation was done in 83
per cent combined with x-ray or radium or both. Of these patients,
67 per cent had single operations and 33 per cent multiple; 13.5
per cent of the multiple operations were for recurrence of the disease. Seventy-four per cent of the patients were treated with
x-ray, 52 per cent with radium; 17 per cent of the total number
were treated by the punch alone. The majority were cases with
extensive metastases, in which relief of obstruction alone was the
aim. A few refused x-ray and radium.
The results of the combinations of treatment are as follows:
FIRST GROUP
Radium, x-ray and punch: 35 cases (43 per cent)
Those who died lived an average of twenty-seven months.
Those who are living average twenty-five months since the
beginning of treatment. Many of them are in good
condition.
SECOND GROUP
X-ray and punch: 25 cases (30 per cent)
Those who died lived an average of seventeen months.
Those who are living average thirty-eight months since the
beginning of treatment.
THIRD GROUP
Radium and punch: 7 cases (9 per cent)
Those who died lived an average of thirty months. Those
who are living average ninety months since the beginning
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American Association for Cancer Research.
CARCINOMA OF THE PROSTATE
1047
of treatment. This latter figure is striking, but concerns
only two patients, both with low-grade malignancy, who
have remained well one five and one ten years. In both
instances the specimen removed with the punch showed
cancer.
FOURTH GROUP
Punch alone: 14 cases (17 per cent)
Those who died lived an average of twenty-four months.
Those who are living average thirty months since the
beginning of treatment.
Of the 40 early cases, 14 lived three years or more (35 per cent).
Of the 41 advanced cases, 6 lived three years or more (14.6 per
cent). Of the 14 early cases with a survival of over three years,S
had small prostates, 7 had moderate enlargements, 2 extreme
growths. Of the advanced cases, 1 had a small growth and 5 larger
growths. There were, therefore, but 6 patients with small prostates among the 20 who lived over three years, as compared with
14 with larger ones. This demonstrates a decided tendency of the
larger growths to be less malignant, or at least more responsive to
therapy.
To analyze further this group of 20 patients surviving over three
years, there were 14 early cases, treated by: x-ray and punch, 2
cases; radium and punch, 4 cases; x-ray, radium, and punch, 5
cases; punch alone, 3 cases. Of the 3 cases treated by punch alone,
the punch specimen was positive for cancer in one, one died four
years later of cancer, and one is living with definite evidence of
general carcinoma. Sixlate cases were treated by: x-ray and punch,
3 cases; x-ray, radium and punch, 3 cases.
In other words, 29.0 per cent of all the patients lived over three
years. Deducting the 13 cases in which the punch alone was used
because the condition was inoperable and the sole aim was to
relieve urinary obstruction, with no attempt to abate the disease,
there were 16 patients, or 30 per cent, living over three years.
Of the 20 cases, the specimens removed from the orificeby means
of the punch showed definite cancer in IS, or 83.3 per cent, benign
hyperplasia in 3, or 16.6 per cent; in 2 cases there was no examination of the specimen. This definitely indicates the presence of
cancer at the internal orifice of the prostate. In many instances
the disease appeared to be localized and early. Ten of the 12
early cases gave a positive picture of cancer.
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Ten per cent of the total series have lived or are living over five
years. Of these, 6 were early cases, 2 advanced; 5 showed enlargement, in 3 the prostate was small. Of the 2 advanced cases,
the prostate was small in one and large in one; both were controlled by repeated massive doses of x-ray therapy. In 7 of the 8
patients, the tissue removed by the punch showed carcinoma.
The treatment employed in these patients was x-ray and punch in
2 instances; radium and punch in 2; x-ray, radium, and punch in 2;
punch alone in 2. Specimens were removed from 64 patients; in
52, or 81 per cent, positive evidence of cancer was obtained, while
19per cent were benign. In other words, the removal of specimens
from the internal orifice of the bladder in obstructions suggestive
of carcinoma will aid in disclosing the true diagnosis of the disease
in 81 per cent of the cases, thereby stamping it as a valuable aid
in such diagnosis.
Altogether there are 26 patients living who have had the
cautery punch operation. The results are designated below, the
follow-up ranging from six months to ten and a half years.
Six months
Six months to a year .. "
One to two years. . . . . ..
Two to three years
Three to four years .....
Four to five years. . . . . ..
Five to six years
Nine years
"
Ten and a half years ....
1 case. Complete relief of obstruction; patient in good
condition
4 cases. All with relief of obstruction
8 cases. Relief of obstruction in 5. Of the other 3, one
did not return, as he was advised; one has a recurrence
and is about to undergo another operation; the other
received no benefit
3 cases. Complete relief of obstruction in 2; 1 poor result (prostatectomy within the last six months by
another surgeon)
3 cases. Complete relief of obstruction in 2; 1 on
catheter life (tremendous prostate)
3 cases. All with complete relief
2 cases. Both with complete relief
1 case. Symptomatically perfect; carries 2 ounces of
residual urine. Good general condition
1 case. No residual urine. Good general condition
Of the -total number of cases, 77 per cent received complete
relief of obstruction; 23 per cent were either partially benefited or
received no relief.
Forty-two patients have died. Of these, there are records of
the condition of the bladder at the time of death in 40 cases.
Thirty (71 per cent) died from cancer. Of these, there are definite
records as to the bladder condition in 28. Twenty (71 per cent)
had complete relief of obstruction. Six had partial relief. Of
these 6, 3 were in such poor condition as to preclude further surgery
of even this minor type. The other 3 refused further surgery.
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CARCINOMA OF THE PROSTATE
1049
Twelve (29 per cent) died from other causes than cancer. Two
died from hemorrhage following operation. Both these patients
were extremely poor risks with general metastases, and one was a
hemophiliac. Five of the remaining 10 had complete relief of
obstruction; 5 had but partial relief.
Of the q4 cases which have been studied, 46, or 72 per cent,
obtained complete relief of obstruction.
METASTATIC CARCINOMA OF THE PROSTATE
This paper has been concerned chiefly with primary cancer of
the prostate. A note may be added on metastatic cancer of the
prostate. There are four cases in this series of 222 cases in which
the primary site was elsewhere than in the prostate, 3 of these
definite and the fourth questionably so.
Three patients entered the hospital with the chief complaint
referable to the gastro-intestinal tract and with no symptoms
suggestive of a genito-urinary lesion. Physical examlnation resulted in a diagnosis of carcinoma of the stomach with carcinoma
of the prostate. All three patients died in the hospital, but
autopsy was obtained in only one case. In this case necropsy
showed carcinoma of the stomach as the primary lesion, while the
growth in the prostate was proved to be metastatic. In the other
two cases the growths were visualized through the laparotomy
wound. They were definitely carcinoma of the stomach with
extensive metastases to the abdominal viscera. There was probably metastasis to the prostate, also. While it is possible that in
these last two cases the carcinoma of the prostate may have been
an independent growth, co-existing with a similar growth in the
stomach, this would seem less probable than that the lesion was
metastatic. These reports issue from a general pathological
laboratory where there is unquestionably entire familiarity with
the usual tendency of carcinoma of the prostate to be primary and
to metastasize to the abdominal cavity. In the fourth case, the
prostatic lesion of which was not definitely established as being
primary, the clinical diagnosis was carcinoma of the prostate with
extension to badder, chronic cystitis, stricture of the urethra
(metastatic), and myocarditis. The autopsy findings were as
follows:
The bladder is large and contains a large amount of reddish, purulent,
foul-smelling material. The prostate is separated from the symphysis
with difficulty and when removed presents a ragged necrotic mass. This
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JOHN R. CAULK AND S. B. BOON-ITT
whole area, as well as a large portion of the bladder about the neck, is
infiltrated with a firm white mass of tissue. A probe passes through
the posterior urethra and into the bladder with some difficulty. It cannot be determined whether there is any destruction distal to the posterior
urethra. The bladder mucosa. is dirty and covered with a necrotic,
purulent, gray exudate. The rectum is separated with difficulty from
the posterior part of the bladder.
Microscopic section near the dome of the bladder shows islands of
tumor cells still in the mucosa and submucosa. In the section about the
trigone the tumor cells have already extensively infiltrated the muscularis layer. In places the islands of tumor cells have a somewhat papillomatous arrangement, with a basement membrane of connective tissue.
The heart weighs 310 gm. The myocardium of the left ventricle averages
20 mm. in thickness and is infiltrated with a number of nodules of firm
white tissue with a faint yellow tint. Some of these encroach upon the
myocardium of the left ventricle, so that they project as elevated irregular
masses into the ventricular cavity. The valves are all normal. The
coronary vessels appear to be normal.
Microscopic section shows muscle infiltrated with frequent islands of
tumor cells. These cells are large and contain large dark nuclei. Mitotic
figures are frequently observed. The arrangement is that of the squamous epithelium of the bladder mucosa.
The suprarenals are rather small but normal in appearance. The
microscopic section contains a small area of tumor islands, the cells lying
on a basement membrane, as those seen in section of the heart. The
nuclei are hyperchromatic, and the intercellular bridges cannot be made
out, although the cells have the appearance of squamous-cell epithelium.
Anatomical Diagnosis: Primary carcinoma of bladder, with extension
to the prostate; metastases to myocardium and suprarenal.
Ewing (10) classifies carcinoma of the prostate into two groups,
1/ adenocarcinoma"
and " carcinoma." The latter group he
further divides into 1/ scirrhous carcinoma" and "squamous
epithelioma." The microscopic sections of the above case give
the picture of squamous epithelial tumor with a cellular arrangement similar to that of the bladder mucosa. It may be that this
is a carcinoma of the prostate gland of the squamous epithelioma
type as classified by Ewing. It has been shown by Aschoff and
Sehlachta (quoted by Ewing) that in the upper portion of the fetal
prostate, the ducts are lined by squamous epithelium up to the
third month of life or later. Schmidt observed extensive epithelial
metaplasia in chronic suppurative prostatitis. Would it not be
possible, therefore, that the remnant of this squamous epithelial
tissue of the prostate might become the primary seat of the new
growth and that this might later extend directly to the bladder
neck? The metastatic lesions would thus naturally be of squamous-cell type.
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CARCINOMA OF THE PROSTATE
1051
SUMMARY
The frequency of prostatic cancer warrants attention and
demands early recognition.
Chronic inflammation of the prostate may be a predisposing
cause.
The cautery punch operation in conjunction with radium and
x-ray therapy appears to be the method of choice for relieving
obstruction and retarding the progress of the disease.
Seventy-two per cent of the cases thus treated received complete
relief of obstruction.
Twenty-nine per cent of the patients lived or are living over
three years, 10 per cent over five years, a longer duration of life
than that afforded by prostatectomy.
The mortality from the operation, in spite of the fact that it was
done in many instances upon extremely ill patients, upon whom
prostatectomy would not have been considered, is 2.5 per cent.
The mortality rate from prostatectomy in this disease in our clinic
is 17 per cent. Hospitalization has been less than with prostatectomy.
The punch operation affords a definite means of accurately
diagnosing cancer of the prostate in 80 per cent of all cases, early
or late, which indicates that the disease, even in apparently early
cases, is present throughout the substance of the gland.
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