Carcinoma of the prostate diagnosed initially as carcinoma of the rectum

Carcinoma of the prostate appearing as a primary rectal tumor is more common than generally realized. Multiple biopsies with special stains and complete urologic investigation may be necessary before its prostatic origin can be established. The importance of making the proper diagnosis is underlined by the differences in treatment for the two lesions.     

Rapid screening for psychologic distress in men with prostate carcinoma: a pilot study

BACKGROUND: As more oncology care is moved to the outpatient setting, the need for a rapid means for oncologists to identify patients with significant distress has increased. Concurrent with this move has been the pressure to reduce time spent with each patient, adding to the likelihood that a distressed patient will not be recognized and will remain untreated in the current health care environment. METHODS: A pilot program was conducted in a prostate carcinoma oncology clinic to test the feasibility of a two-stage approach that identifies patients in significant distress and refers them for treatment. Two pencil and paper self-report measures were used to detect psychologic distress in patients over the previous week: 1) The Hospital Anxiety and Depression Scale (HADS) and 2) "The Distress Thermometer." Patients who scored above an agreed upon cutoff score on either measure (HADS = 15+; Thermometer = 5+) were referred to the psychiatric liaison in the clinic for evaluation. RESULTS: Compliance in filling out the measures was excellent; only 8 of 121 patients (6.6%) refused. Thirty-one percent of evaluable patients were referred based on elevated scores. Seventeen of 29 patients actually were evaluated. Eight of 17 patients met Diagnostic and Statistical Manual (of Mental Disorders)-IV criteria for a psychiatric disorder. CONCLUSIONS: This approach for rapid screening for distress was acceptable in prostate carcinoma patients, although these older men were reluctant to agree to evaluation and treatment. This simple screening method needs further testing and the identification of barriers on the part of the patient and oncologist that impede the identification of the most distressed patients.     

Testicular atrophy in therapeutic orchiectomy specimens from men with prostate carcinoma: association with prior prostate bed radiation and older age

Clinical nutrition training programs for physicians were surveyed to determine their number, demographic characteristics, primary teaching focuses, number of available trainee positions, funding bases, trainee numbers, backgrounds, and career positions taken. Twenty-two active programs were identified, compared with 38 programs in 1993. Thirteen of the programs were primarily focused on adult nutrition and 7 were focused on pediatric nutrition. Twelve programs appeared to have nutrition as their sole subspecialty focus, 8 were housed within gastroenterology fellowships, and 2 were within endocrinology fellowships. Most programs included training in research, which is conducted during a second or third year, or both. The decrease in numbers of programs appears to have resulted not only from relocation, retirement of key faculty members, and loss of training grants, but also because of the clearer definition of clinical nutrition training programs in this survey. The changes also reflect a national trend toward decreasing subspecialization. Within this climate, it is apparent that a new model for the training and career activities of physician nutrition specialists is needed that will attract more physicians into the discipline of nutrition. Intersociety efforts are underway to address this need and to develop a unified voice that can guide clinical nutrition training for physicians into the 21st century.     

A worse prognosis for men with testicular atrophy at therapeutic orchiectomy for prostate carcinoma

BACKGROUND: The significance of testicular atrophy at the time of therapeutic orchiectomy for prostate carcinoma has not been examined even though pretreatment hypogonadism has been associated with poor prognosis during chemical androgen ablation for these tumors. METHODS: Survival after therapeutic orchiectomy was determined for 78 men with prostate carcinoma and related to the histologic severity of testicular atrophy. Included in analysis were the presence or absence of prior radiation therapy, tumor grade and stage at diagnosis, host age, obesity, and smoking habits. RESULTS: Among 35 men who underwent therapeutic orchiectomy for progressive disease after primary radiation therapy to the prostate bed, the 25 men with testicular atrophy had worse 5-year, tumor specific, postorchiectomy survival than the 10 men without testicular atrophy (30% vs. 89%) (P=0.02). These 25 men had tumors of more advanced stage and greater undifferentiation at the time of diagnosis an average of 45 months before orchiectomy, but neither characteristic was related to postorchiectomy survival. Among 25 men with Stage D2 disease (American Urologic Association staging system) with orchiectomy as the primary treatment, the 7 men with testicular atrophy more often had undifferentiated tumors and had lower 2-year tumor specific survival than the 18 men without atrophy (43% vs. 72% ) (P > 0.10). CONCLUSIONS: Testicular atrophy at the time of therapeutic orchiectomy for prostate carcinoma is associated with poor postorchiectomy prognosis in men with prior prostate bed radiation therapy and perhaps in men without prior radiation. The association may reflect a high frequency of inherently more aggressive tumors (often relatively nonandrogen-dependent) among those tumors that are progressing in hypogonadal men.     

Prostate specific antigen in the expressed prostatic fluid of men with benign prostatic hyperplasia and prostate carcinoma

PURPOSE: We tested the hypothesis that the histochemically demonstrated prostate specific antigen (PSA) content of prostate carcinoma cells does not necessarily reflect PSA production and secretion by evaluating expressed prostatic fluid. MATERIALS AND METHODS: Expressed prostatic fluid and serum from 152 men with clinical benign prostatic hypertrophy (BPH), 132 with histologically proved BPH and 46 with prostate carcinoma were analyzed with the Hybritech PSA assay. RESULTS: Expressed prostatic fluid PSA levels from carcinoma patients (median 1.70 mg./ml., mean 2.25) were significantly higher than in the histologically proved BPH group (median 1.28 mg./ml., mean 1.42, p < 0.05). CONCLUSIONS: PSA concentration is increased in the expressed prostatic fluid of prostates of men with carcinoma compared to those with histological BPH. This finding may be a functional manifestation of a field change or paracrine effects within the prostate.     

Bacteria in the prostate tissue of men with idiopathic prostatic inflammation

PURPOSE: Although antibiotics represent the first line of treatment for prostatitis syndromes, physicians can document infection in remarkably few cases. We examined the relationship of genitourinary infection to inflammatory prostatitis in 85 subjects without bacteriuria. MATERIALS AND METHODS: Evaluation consisted of cultures of urethra, urine and transperineal prostate biopsies, specifically for commensal and fastidious organisms, and leukocyte counts of expressed prostatic secretions. RESULTS: Men with inflamed expressed prostatic secretions (25) were more likely to have any bacterial isolation (p = 0.01), positive cultures for anaerobic bacteria (p = 0.03), higher total bacterial counts (p = 0.02) and more bacteria, species isolated (p = 0.02) in prostate biopsy cultures than men without expressed prostatic secretion inflammation (60). CONCLUSIONS: Bacterial colonization/invasion of the prostate may be associated with inflammatory prostatitis in some cases.     

Results of radical prostatectomy in men with clinically localized prostate cancer

OBJECTIVE: To assess the results of radical prostatectomy in men with early prostate cancer. DESIGN: Retrospective, nonrandomized, multi-institutional pooled analysis. SETTING: Eight university medical centers in the United States and Europe. PATIENTS: A total of 2758 men with stage Tl and T2 prostatic cancer. MAIN OUTCOME MEASURES: Disease-specific and metastasis-free survival rates. RESULTS: Tumor grade was the most important preoperative factor in determining outcome. Disease-specific survival 10 years following surgery and associated 95% confidence intervals were 94% (range, 87%-98%), 80% (range, 74%-85%), and 77% (range, 65%-86%) for those men with grade 1, 2, and 3 tumors, respectively. Metastasis-free survival at 10 years was 87% (range, 78%-92%), 68% (range, 62%-73%), and 52% (range, 38%-64%) for patients with grade 1, 2, and 3 cancers, respectively. CONCLUSIONS: Radical prostatectomy leads to high 10-year disease-specific survival rates in men with all tumor grades. However, caution is needed in comparing these results with similar studies of alternative treatment strategies, such as watchful waiting, due to the inherent potential biases in uncontrolled trials. Nevertheless, these results offer the best currently available estimates of 10-year outcome of radical prostatectomy in men with clinically localized prostate cancer and may be useful in counseling patients with early malignancy.     

Asymptomatic bacteriospermia. Cause of infertility in men

Two hundred and forty-four surgical patients who received no anticholinergic premedication were compared with 160 patients who had received atropine or scopolamine before the induction of anaesthesia. Infants and patients undergoing heart surgery were excluded. Eleven anaesthetists participated in the study. They were asked to report problems with oropharyngeal and tracheobronchial secretions. Two per cent of unpremedicated patients experienced problems with secretions of a degree sufficient to require treatment. This small percentage appears insufficient to warrant routine preoperative anticholinergic medication.     

Elderly men with cancer: social work interventions in prostate cancer

Prostate cancer requires the attention of social workers in health care for three reasons: the growing elderly population which will increase the number diagnosed, the recent introduction of new treatments and the lack of social acceptability for this condition. Interventions for prostate cancer are specific to the stage of the disease. These individual, family and group interventions are a model for social work services to elderly men with other forms of cancer. Social workers have opportunity to research quality of life and decision-making issues to enhance medical practise in prostate cancer.     

Clinicopathological characteristics of prostatic adenocarcinoma in men with atypical prostate needle biopsies

PURPOSE: Atypical or nondefinitive diagnoses comprise 1.5 to 10% of all prostate needle biopsies and many men with atypical biopsy have carcinoma on rebiopsy. We characterize the clinical and pathological features of these men and the tumors, and compare them to those of other men who had more than 1 biopsy. MATERIALS AND METHODS: All prostate needle biopsies done at our institution between 1989 and 1996 on men with a followup biopsy were reviewed and the clinicopathological features were correlated. RESULTS: A total of 343 men had more than 1 biopsy during this period. Of the biopsies 64 were atypical and followup (repeat biopsy) was available for 59. Men with an atypical diagnosis were more likely to have carcinoma (34%) and to be diagnosed subsequently earlier (270 days) than those with an initial negative diagnosis (22%, 603 days). No significant differences were noted in patient age, results of digital rectal examination, initial or followup serum prostate specific antigen, subsequently identified tumor size or Gleason score on needle biopsy or at resection. Although on review as many as 38% of the original atypical foci could be reclassified, this reclassification did not significantly change the results of rebiopsy. CONCLUSIONS: Men with an atypical diagnosis on prostate biopsy are significantly more likely to have carcinoma on rebiopsy than men with an initial negative diagnosis, and the second biopsy should be performed at a significantly shorter interval. The tumors that are subsequently identified in these men are similar to those identified in men without an atypical biopsy.     

Primary metastatic carcinoma of the prostate in younger men: a plea to think over usual therapeutic strategies

METHOD: The time from first diagnosis of primary multiple metastatic prostate carcinoma until progression and until death in patients less than 60 years old under two different therapeutic regimens was evaluated. RESULTS: In the group with pure androgen deprivation (n = 21), the mean time until progression was 11.3 (6-55) months, the mean survival time being 21.4 (11-75) months. In the group with androgen deprivation plus cytostatic therapy (n = 10), progression was noted after 26.7 (15-77) months with a medium survival time of 26.2 (16-82) months. CONCLUSION: The data argue in favor of changing the usual treatment strategy to combination therapy in "young' patients with primary metastatic prostatic cancer.     

Isolation and characterization of free form prostate specific antigen (f-PSA) in sera of men with prostate cancer

PURPOSE: The free uncomplexed form of prostate specific antigen (f-PSA) from prostate cancer sera was partially isolated and characterized because the molecular form of f-PSA in the serum is unknown. MATERIALS AND METHODS: 230 ml. of sera from 59 men with bone metastasis and individual PSA values of >2000 ng./mL were combined and centrifuged for 60 minutes at 30,000 RPM (4C). The sera were fractionated by gel filtration column chromatography (Sephacryl S-200, 2.5 cm. x 92 cm.). Free and complexed PSA in the eluted fractions were isolated by measuring immunoreactivity of PSA (Tosoh AIA-600 assay); f-PSA from 23 separate runs were combined, concentrated and re-chromatographed. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) was used to immobilize the isolated proteins onto a nitrocellulose membrane and a polyvinylidene difluoride (PVDF) membrane. Monoclonal antibody (F5) was used to probe PSA on nitrocellulose membrane and the PSA band was detected by Emission Chemoluminescence (ECL) kit. Amino terminal sequence analysis of the isolated f-PSA was performed with a gas-phase sequentor (Applied Biosyntens 4760 A) using the program designed by the manufacturer. RESULTS: 0.5 cc of f-PSA (27,000 ng./mL) was obtained from serums after rechromatography. SDS-PAGE showed one double band around 30 kDa; with ECL technique, one major band at 30-kDa was identified as PSA. The amino terminal sequence analysis of this band showed residue 1 through 9 and 146 through 152. CONCLUSIONS: In our preliminary experiment, the free form of serum PSA is partially isolated directly from human sera. Amino terminal sequence analysis has shown that serum f-PSA is not a pre-mature or zymogen form of PSA because serum f-PSA has a N-terminus identical to that of seminal fluid PSA. A nicked form of f-PSA is also found in these patient sera.     

Results of transition zone biopsy in black and white men with suspected prostate cancer

OBJECTIVES: To determine whether biopsy-detectable transition zone tumors are more common in black than in white men with suspected Stage T1c and T2 prostate cancer. METHODS: We performed a prospective study of transition zone prostate biopsy (TZ biopsy) in 1 78 black and 261 white men who had not undergone previous prostate biopsy and in 61 black and 65 white men who had undergone one benign sextant peripheral zone prostate biopsy (PZ biopsy). RESULTS: The mean age of the 239 black and 326 white study patients was 68.6+/-7.4 and 67.2+/-7.2 years, respectively (P = 0.02), the mean prostate-specific antigen (PSA) was 8.4+/-7.4 and 6.4+/-5.4 ng/mL, respectively (P = 0.003), and the mean PSA density was 0.20+/-0.23 and 0.16+/-0.16 ng/mL/mL, respectively (P = 0.006). Overall, cancer was diagnosed by TZ biopsy only in 7 black men (3%) and in no white men (0%) (P = 0.003). However, cancer detection with a TZ biopsy only was not significantly different in the black and white men when controlled for age, PSA, or PSA density (P>0.90). A TZ biopsy only detected cancer in 1% of patients who had not undergone prior PZ biopsy and in 2% of patients who had undergone prior PZ biopsy. Of the seven cancers detected with TZ biopsy, six (86%) had a Gleason score of 2 to 6. CONCLUSIONS: Prostate cancer detection with a TZ biopsy only is not common and when controlled for confounding variables is the same in black and white men. The preferential use of TZ biopsies in black men is not warranted, and the low diagnostic yield argues against routine use of the biopsy technique in men of either race.     

Characteristics of men reporting for prostate cancer screening

A survey to determine demographics, prostate cancer screening practices, and prostate cancer-related knowledge and beliefs was administered to over 1,700 participants at five sites during Prostate Cancer Awareness Week (1991) screening events. Findings are presented by site since significant differences in demographics existed. Results suggest that screenings conducted at the major medical centers attract primarily white males, a number of whom already practice adequate secondary prevention. Thus, if optimal benefit is sought through mass prostate cancer screening, innovative strategies to reach populations that are currently underserved and at risk are necessary.     

Moderators of the benefits of psychoeducational interventions for men with prostate cancer.

The authors examined whether 3 individual difference variables--self-esteem, self-efficacy, and depressive symptoms--interacted with psychoeducational group interventions for men with prostate cancer (n = 250) to predict general and prostate-specific quality of life. Men with nonmetastatic prostate cancer were randomly assigned to an education intervention, an education plus group discussion intervention, or usual care and followed for 12 months. Eight groups of 10 to 12 men were convened in each condition. Men who began the study with lower self-esteem, lower prostate-specific self-efficacy, and higher depressive symptoms benefited the most from the interventions. Of these 3 moderator variables, the most consistent results emerged for self-esteem. That is, the benefits of the intervention were strongest for men with low self-esteem. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prevalence and pathological extent of prostate cancer in men with prostate specific antigen levels of 2.9 to 4.0 ng./ml

Various authors have recommended different values for the upper limit of normal for the monoclonal prostate specific antigen (PSA) assay (for example 4.0 ng./ml. or less by the manufacturer Hybritech or 2.8 ng./ml. or less by others). To our knowledge, no studies have examined the prevalence and pathological extent of prostate cancer detectable by needle biopsy in ambulatory volunteers with PSA levels in the range of 2.9 to 4.0 ng./ml. We evaluated 121 volunteers by rectal examination and transrectal ultrasonography with PSA levels in that range. We performed ultrasound-directed needle biopsy of the prostate if abnormal findings were present on either examination. The prevalence of detectable prostate cancer in this group was 7.2% (8 of 111). All 8 patients had pathologically organ confined cancer, and only 2 had suspicious findings on rectal examination but all had abnormal or suspicious ultrasound findings. We believe that the 7.2% yield from ultrasonography and biopsy in patients with a PSA level of 2.9 to 4.0 ng./ml. is too low to justify further invasive evaluation. Rather, we recommend careful followup and monitoring of these patients with serial PSA measurements and rectal examination, and advise performance of ultrasonography and biopsy if the rectal examination becomes suspicious for cancer or the PSA level increases above 4.0 ng./ml.     

The influence of prostate volume on the ratio of free to total prostate specific antigen in serum of patients with prostate carcinoma and benign prostate hyperplasia

BACKGROUND: Determining the ratio of free to total prostate specific antigen (f-PSA to t-PSA, calculated as the percentage of f-PSA [f-PSA%]) in serum allow for a clearer distinction between patients with prostate carcinoma (PCa) and patients with benign prostate hyperplasia (BPH) than determining the level of t-PSA alone. To find influencing factors on f-PSA%, the authors investigated prostate volume, TNM classification, and tumor stage. METHODS: The authors measured f-PSA and t-PSA in 36 men with untreated PCa (tumor classification: T1, 2, 3pNO, MO), 44 patients with BPH, and 54 healthy controls. Prostate volume was determined by transrectal ultrasound. RESULTS: The median values of t-PSA and f-PSA% were 7.8 micrograms/L and 10.5% in PCa patients, 4.3 micrograms/L and 20.8% in patients with BPH, and 1.4 micrograms/L and 23.6% in the control group. Patients with PCa had a significantly lower proportion of f-PSA than BPH patients and healthy men. There was no correlation of f-PSA% to TNM stage or tumor grade. In PCa patients a significant positive correlation (correlation coefficient [r] = 0.51, P < 0.001) was found between f-PSA% and prostate volume, whereas there was no significant correlation in BPH patients (r = -0.27, P > 0.05). There was a significant difference in f-PSA% between PCa and BPH patients with prostate volumes smaller than 40 cm3 (9.0% vs. 21.6%, P < 0.01) but not between patients in these 2 groups with prostate volumes exceeding 40 cm3 (15.1% vs. 18.2%, P = 0.11). CONCLUSIONS: Determining the ratio of f-PSA to t-PSA to discriminate between PCa and BPH patients yields significant results only in men with a prostate volume of less than 40 cm3.     

Embryonal carcinoma of the testis in elderly men

A rare case of pure embryonal carcinoma of the testis in a black man in the tenth decade of life is presented, as well as a review of the literature on germ cell testicular tumors in men 60 years old or more. It is noteworthy that nearly 9 per cent of testicular tumors occur in this age group and a third of these tumors are of germ cell origin.     

The early detection of prostate carcinoma with prostate specific antigen: the Washington University experience

BACKGROUND: It is not yet known whether screening for the detection of early prostate carcinoma will reduce mortality rates. However, data are available to assess intermediate outcomes from screening, including the performance characteristics of the screening tests and shifts in disease stage. METHODS: Approximately 30,000 community volunteers (mean age 60 years; <5% nonwhite) were enrolled in 1 of 3 screening studies. Volunteers were screened with PSA or PSA in combination with digital rectal examination at 6-month intervals, and prostatic biopsy was recommended for those with results suspicious for cancer. Based on a first-time screen, the current study reports screening test results, the proportion of men recommended to undergo biopsy, the proportion who actually underwent biopsy, and the carcinoma detection rates for each study, stratified by initial PSA level. The authors also report the pathologic features of screen-detected carcinomas for a subset of men who underwent radical prostatectomy and for whom complete embedding and microscopic examination of the surgical specimen was performed. RESULTS: Approximately 10% of the volunteers had PSA levels >4.0 ng/mL and 3-10% had digital rectal examination results suspicious for cancer. Overall, 9-20% of volunteers were recommended to undergo biopsy and 8-13% actually underwent the procedure. The positive predictive value for carcinoma detection ranged from 25-33% across studies. In the subset of men for whom surgical specimens were completely embedded, the majority of tumors detected had the clinicopathologic features of significant carcinoma (<10% possibly harmless). CONCLUSIONS: The intermediate outcomes for screening with PSA and/or PSA in combination with digital rectal examination are encouraging. In community volunteers these screening tests demonstrated reasonable positive predictive value and detected carcinomas at an earlier stage. The majority of screen-detected tumors had the pathologic characteristics of medically significant carcinoma.