Prostate cancer: experience with definitive irradiation in the aged.

When considering therapeutic options for localized prostate cancer, stage and grade of disease have been the most important determinants. In the elderly, the nominal age has assumed increasing importance in the final decision. A balanced judgment must be reached between the patient's normal life expectancy and the rapidity with which the cancer may be expected to express its malignant potential. By careful attention to patient selection and the details of treatment, definitive irradiation can improve quality of life and survival. Of 63 patients aged seventy-three to ninety years referred for irradiation, 56 were found medically suitable for definitive treatment. A review of our experience is presented.

Improved control of bulky prostate carcinoma with sequential estrogen and radiation therapy.

Patients with bulky prostate cancer have usually been treated by palliative measures because the likelihood of tumor control with definitive irradiation has been low and the development of distant metastases high. The addition of estrogen to irradiation has not been shown to be of value. However, we believe the method of estrogen administration may have been the cause for the apparent lack of benefit. Estrogen had been started either concurrent with irradiation or had been used for palliation and was given for long and unscheduled time periods prior to irradiation. We have used estrogen for two months prior to and concurrent with irradiation. We postulated that in those patients with estrogen responsive cancer, the reduced tumor burden prior to irradiation could enhance tumor control and survival. Between 1975 and 1980, 25 patients with bulky prostate cancer received sequential estrogen and irradiation, 12 patients irradiation alone and six patients irradiation after having become refractory to long-term estrogen use. One patient was lost to follow-up. Eighteen of 25 (72%) treated by sequential estrogen and irradiation, 14/17 (82%) with estrogen responsive cancer and 4/8 (50%) with estrogen resistant cancer had a complete tumor response. Six of 11 (55%) patients treated by irradiation alone and 2/6 (33%) treated by irradiation for estrogen refractory cancer had a complete tumor response. Disease-free survival was observed in 13/25 (52%) treated by sequential estrogen and irradiation, and 8/17 patients (47%) with irradiation. It is also possible the improved survival in the estrogen responsive group was a direct result of improved local control. Persistent local disease can act as a source for distant metastases. Distant metastases was observed in 15% of patients when the primary tumor was controlled and 30% when there was persistent or recurrent local disease. Also, progressive local disease can be an important cause of death. This was most evident in our patients with estrogen refractory cancer. Almost all patients in this group had progressive local disease that caused serious urinary bleeding and urinary infection that were considered the major cause of death. Our results suggest bulky prostate cancer should be aggressively treated when first diagnosed. The value of adjunct estrogen is unproven. Our results with the use of estrogen prior to and concurrent with irradiation is encouraging. Estrogen may shrink the cancer and allow for a more favorable geometry for external irradiation. Tumor control and survival may be thereby improved.(ABSTRACT TRUNCATED AT 400 WORDS)

Response of lymph node metastasis to sequential estrogen and radiation therapy in prostate carcinoma.

Increasingly sophisticated diagnostic studies have shown a high incidence of tumor spread to the regional lymph nodes. The status of the lymph nodes has been evaluated by noninvasive diagnostic procedures such as lymphangiography and computerized axial tomography. The applicability of these procedures has been enhanced by the use of stringent criteria. Gross lymph node metastasis can be diagnosed with considerable confidence. Serial observations of lymphangiograms and computerized axial tomograms before and two months after the administration of estrogens provide an added dimension to the interpretation of lymph node metastasis. The nature and range of the response of lymph node metastasis were observed. Survival of patients with gross lymph node metastasis treated by sequential estrogen and radiation therapy was evaluated. A total of 11/18 (61 per cent) of patients remained free of symptoms, 8/11 (74 per cent) with a favorable lymph node metastasis responsive to estrogen therapy, and 3/7 (42 per cent) with lymph node metastasis refractory to estrogen therapy. Follow-up computerized axial tomograms of the lymph nodes done at one and two years after irradiation showed a persistent favorable response. Five patients are alive with disease, and 2 patients died of the disease.

Peyronie's disease revisited.

Various treatment modalities have been suggested for Peyronie's disease. Varying degrees of success have been reported. Certain numbers of cases will have spontaneous remission of the disease process. The treatment, however, should begin as early as possible and recognition should be achieved earlier. The injection technique utilizing a high-pressure metal syringe or syringe jacket with screw-type barrell is still the most successful for the "soft fibrosis" lesions. This was reported about twenty-five years ago. A small number of patients treated by plaque excision and full thickness skin graft replacement have also shown good results. The type of lesion present best dictates the proper treatment.

Using the urinary catheter and other devices.

In diagnosing and managing urinary tract disease, instrumentation should be used only when absolutely necessary. The catheter is probably the urologic instrument most widely used by nonurologists. It can be used to relieve urinary retention, calibrate the urethra, search for obstruction, obtain urine for study, and instill medication into the urethra or bladder. If a catheter cannot be passed because of stricture, passage of a filiform may be attempted. In severe stricture, suprapubic puncture catheterization may be necessary, followed by further instrumentation. Urinary flow rate determinations should be made on all patients given physical examinations. This can be easily done by having the patient void into a plastic cup with a 7/32-inch hole punched in the bottom. If urine does not collect in the cup, the patient has a poor flow rate. A stopwatch may also be used for flow rate determination. Results of cystography, cystometry, and urethral profile studies add to the physician's diagnostic capability in dealing with lower urinary tract disease.