Positive specimen margins and detectable postoperative prostate specific antigen (PSA) levels were analyzed after 200 consecutive radical perineal prostatectomies for clinical stages T1 and T2 adenocarcinoma of the prostate. Clinical parameters that correlated with lymph node metastases in concomitant pelvic lymphadenectomies were also noted. At a mean followup of 35 months 79% of the patients had undetectable PSA levels. Step-section pathological analysis of specimens obtained by either nerve sparing or extended radical modifications revealed that 41% of the tumors were organ confined and 56% had negative margins. Selective sacrifice of the posterolateral periprostatic fascia and the enclosed neurovascular bundle achieved negative margins and undetectable PSA levels despite capsular penetration in 15% of all patients. Of all positive margins with the perineal approach, solitary positive apical and posterolateral margins were infrequent (7% and 16%, respectively) but solitary positive anterior margins were more so (25%). Of those positive anterior margins 41% appeared to be artifactual and 45% might have been eliminated by avoiding avulsion of the puboprostatic ligaments. Pelvic lymphadenectomy could have been eliminated in 58% of the patients (clinical stage T2b or less, biopsy Gleason score 6 or less and PSA level 11 or less, for a node negative predictive value of 99%).

Radical perineal prostatectomy is safe. In our 220 patients there were no deaths and serious morbidity developed in 2%. The continence rate was 95% and 70% of a select group recovered potency.

Early endocrine therapy after radical retropubic prostatectomy was compared to radical prostatectomy alone (nonearly endocrine therapy) for the treatment of carcinoma of the prostate with lymph node metastases. Our retrospective analysis demonstrated that the 2 cohorts were similar with respect to patient age, Gleason sum score, seminal vesicle invasion, lymph node involvement, tumor volume and pathological stage of the primary tumor. The cause-specific survival of the entire group was 84% at 60 months and 78% at 98 months. The cause-specific curves for the early and nonearly endocrine therapy group were not significantly different (p less than 0.194), although the estimated 9-year survival rates were 91 and 71%, respectively. Survival free of disease was significantly prolonged in the early endocrine therapy group (p less than 0.030), with a 9-year estimated rate free of disease of 67% versus 32% in the nonearly endocrine therapy group. Followup prostate specific antigen serum levels were analyzed and the value as a progression marker is discussed. These data suggest that a radical operation plus early endocrine therapy is effective palliation in selected patients with low volume lymph node metastases, producing clinical survival free of disease in most patients.

Aberrant and elevated ganglioside expression has been observed in neoplasms, and has been shown to be an important marker of tumor progression. We therefore studied the gangliosides of renal cell carcinoma (RCC) by analyzing gangliosides from 18 RCC biopsies, 10 RCC lines and 5 normal kidney biopsies. A comparison of tumor with normal tissue revealed a significant difference in individual ganglioside expression in which the former consistently expressed eight major gangliosides, GM3, GM2, GM1, GD3, GD1A, GD2, GD1B and GT1B, according to the nomenclature of Svennerholm. There was a notable significant mean increase in the expression of GM2, GM1 and GD1A and a significant decrease in the expression of GD3 in tumor tissue compared with normal kidney tissue. Compared with tumor biopsy tissue, RCC cell lines showed a significant decrease in the expression of GM3, but a significant increase in GM2, GM1 and GD2. There was a marked increase in a pathway gangliosides (GM2, GM1, and GD1a) in RCC biopsies and cell lines compared with normal kidney. These studies indicating that RCC have markedly aberrant ganglioside expression similar to neural origin tumors may relate to the activation of a ganglioside pathway enzymes. Gangliosides expressed on RCC tumors may be important markers of tumor progression and target antigens for immunotherapy.

In patients with another variable controlling for a high prevalence of significant prostate cancer, the focal nature of a positive biopsy probably reflects only sampling limitations and should not influence treatment. To restrict prostate biopsy to men with a high prevalence of significant cancer, targeted area biopsy alone must replace sextant biopsy in men with a palpable prostatic abnormality but a normal prostate specific antigen level.