SIMULTANEOUS PRESENTATION OF ADENOCARCINOMA OF PROSTATE AND TRANSITIONAL CELL CARCINOMA OF BLADDER A. KONSKI, M.D. P. RUBIN, M.D. P. A. DISANTANGNESE, M.D. E. MAYER, M.D. H. KEYS, M.D.

A. COCKETT, M.D. I. FRANK, M.D. R. DAVIS, M.D. C. LUSH, B.A.

From the Departments of Radiation Oncology, University of Rochester Cancer Center, Strong Memorial Hospital, Rochester, and the Albany Medical College, Albany; and the Departments of Pathology and Urology, Strong Memorial Hospital, Rochester, New York

ABS T R A C T-- Simultaneous presentation of transitional cell carcinoma of the bladder carcinoma of the prostate is not uncommon. Twenty-two patients were diagnosed as h taneous or concurrent presentation of prostate and bladder carcinomas between Janua July 1986. The overall five-year survival was 40 percent, with patients presenting u cancer doing better (50%) than those with bladder cancer (32 %). Retrospective rev cases suggests that primary therapy should be directed to the most advanced cance: prostate cancer may be "'cured" with a cystoprostatectomy and, when indicated, radia added postoperatively for the bladder cancer. Eleven patients presented with Stage A cer: 10 of the 11 were treated for their bladder cancer. Treatment was usually radical tectomy with or without postoperative radiation. None died of prostate cancer. Patien: with advanced stage prostate cancer have had recurrence or have died of the prostat

Simultaneous presentation of transitional cell carcinoma of the bladder and adenocareinoma of the prostate could be defined as one cancer being diagnosed at the same time as the other or within the same six-month period, or when one carcinoma is diagnosed during workup for the other. Concurrent presentations of cancers is synonomous with simultaneous presentations and the two terms are used interehangeably in the literature. Concurrent or simultaneous presentations are not uncommon. They present a clinical dilemma for the oncologists who must determine which malignancy should receive the primary treatment. Both primary tumors have Presented at the 6th Annual Meeting of the ESTRO, May 28, 1987, Lisbon, Portugal.

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separate and distinct epidem: natural histories, and patterns There are few reports in the l menting this occurrence with v regimens.l-3 Selli et al. 2 reporte{ with concurrent primary tumo: u n d e r w e n t eystoprostatectom bladder carcinoma and had an ing of the prostate adenoearein ommended aggressive surgical ! gan-confined tumors which sh survival potential equivalent to mor alone. They had a 75 perce: vival rate. 2 Mahadevia, Koss, ar 14 eases of simultaneous bladd cancers in a pathologic study of involving prostatic tissue in cyst

UROLOGY / MARCH 1991 / VOLUME XXXVII, NUMB ~ N

TABLE I.

Li::s,ecimens. Only one of the specimens was exi ~ae~ted ! ~i • ' to eontam adenocarclnoma. i

tJ,

Material and Methods The University of Rochester Cancer Center atified 25 patients with siation of transitional cell carder and adenocareinoma of ~re treated at Strong MemoI between January 1970 and ation oneology records, hosrology office notes were reely. Pathologic material was available, by one of the onfirmation of the diagnosis r tumors. Of the 25 patients only 22 were evaluable: no ble on 1 patient, another pa;ewhere and was transferred ~ment of postoperative comlast patient was found on :ot to have had an adenoear:ate. was used only when it was 'mine the pathologic stage. ations were used for staging ~state cancers. Patients were .'h primary tumor presented :ion of the presenting symp1 examination, radiologie npression of the attending ih this was a retrospective to classify which of the mathe initial treatment from a .operative impressions and res ranged from radical cyscystoscopy, needle biopsy of transurethral resection of ['URBT) and of p r o s t a t e Eight patients were treated while the other 14 patients either preoperatively (6/14) (8/14). The preoperative 20 to 50.40 eGy. Survival I the time of diagnosis using hod. The Gehan test was any difference between the Results ; patients represented 4 perbladder cancers and 2 per[ prostate adenocareinomas

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Patient distribution according to surgical procedure

Procedure Radical eystoprostatectomy Cystoseopy, TURB, TURP Cystoscopy, needle Bx. prostate, TURB Cystoscopy, needle Bx. prostate, TURB, TURP Cystoseopy, needle Bx. prostate, lymphadenectomy Partial cystectomy, cystoscopy, TURB, TURP, needle Bx. prostate TOTAL

No. of Pts. 9 5 4 2 1 1 22

presenting to SMH during the study period. Of the 22 patients in this study prostate cancer was diagnosed first in 32 percent (7/22), bladder cancer in 55 percent (12/22), and simultaneously in 13 percent (3/22). Twenty-four percent of the patients presenting with prostate cancer had initial symptoms consisting of frequency, nocturia, and urinary retention; 14 percent of the patients presented with dysuria, hematuria, and incontinence. By contrast 75 percent of the patients presenting with bladder cancer had hematuria as the initial symptom while 33 percent had dysuria and retention, 25 percent nocturia, 17 percent frequency, and 8 percent urgency. When both malignancies were diagnosed simultaneously, there was equal distribution of symptoms of noeturia, hematuria, and retention. The median age of the overall group was seventy-one years (55-89). The median age of patients presenting with bladder cancer was seventy and one-half years (55-84), while the median age was somewhat older, seventy-eight years (65-89), in those patients presenting with prostate cancer. Fifteen patients had pathologic material available for review. Separate primaries were confirmed in every case. Seven patients had their original pathology reviewed at SMH with either subsequent return of their slides to the referring hospital or the slides could not be located. In addition to confirming the presence of two separate primary tumors, the Gleason grade, grade of the bladder cancer, and pathologic stages for both of the tumors were determined when possible. W h e n the slides were not available for review, a grade of "unknown" was entered.

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203

TABLE E.

their bladder cancer even t h o u g h r original treatments in this group we t o w a r d the bladder malignancy. P~ senting with Stage D prostate cance: of their prostate malignancy. Figure 1 shows an overall survi group of 40 percent at five years. separated into groups according to lignancy presented first (Fig. 2), tl cancers seem to do a little better, ] n u m b e r s are too small for any eorrel m a d e . W h e n Stages A and B of tl cancer are c o m b i n e d and survival is function of the stage of the bladder tients with Stage A bladder canoe: (Fig. 3). All patients receiving preo 1 diation h a d residual prostate canoe: logic review, and 5/6 patients h~ bladder cancer.

Patient distribution by stage

Prostate Stages

A

B

C

D

Total

Bladder Stage A Stage B Stage C Stage D TOTALS

2 2 7 0 11

4 2 1 0 7

1 0 0 0 1

2 0 1 0 3

9 4 9 0 22

Most of the patients presented w i t h an early stage of one m a l i g n a n c y and an a d v a n c e d stage of the other ('I;hble II). Table III depicts the distribution of cases according to increasing prostate stage. All patients presenting with early stage prostate cancer are N E D , have bladder cancer recurrence, or have died as a result of

Distribution o] cases by increasing prostate stage Tumor Tumor Bladder Presenting Treated R.T. Stage Grade First First Surgery* (eGy) C III Both B VI 5,000 A III P B I 0 A I P P I 6,600 C III B B II 0 C III B B II 5,580

TABLE III.

Case Stage

Gleason Grade

1

A

?

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

A A A A A A A A A A B B B B B B B

2 6 5 5 5 4 ? 5 ? ? 9 5 8 ? 7 6 6

19 20 21 22

C D D D

7 ? 8 6

B

III

B

B

I

0

C C C

III III III

B B B

B B B

II II II

2,000 Preo 5,000 Preo 4,500 Preo

B B

III III

B B

B B

II I

0 0

A A A B C A B (No residual) A A A C

I I II II III II

Both P P P B B B

P P P P B P B

III IV IV I II III II

6,500 (DES) (DES) 7,000 5,000 Prec 6,600 4,500 Prec

II ? II III

P Both P B

P P P B

III II V II

6,500 (DES) 6,500 2,000 Prec

KEY.. B = bladder; P = prostate; NED = no evidence of disease; LR = local recurrence; D = dead; LtlB = ] bladder; METP = metastatic prostate; DES = diethylstilbestrol. Unless specified R.T. doses signify postoperative t * I: TURF, TURB, and cystoscopy; II: radical cystoprostatectomy; III: cystoscopy, needle biopsy of prostate; TURB; IV: TURF, cystoscopy, needle biopsy of prostate; TURB; V: cystoscopy, needle biopsy of prostate, lymphadenectomy; VI: partial cystectomy, TURF, cystoscopy, needle biopsy of prostate. ~Patient NED after being treated for isolated metastases to his hip. SPatient had local recurrence of persistent prostate cancer but died of AML. §Patient NED after resection of urethral recurrence of bladder cancer.

204

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MARCH 1991

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Comment '1~ incidence of simultaneous presentations ~|adder and prostate cancer varies in the lit!ure. There are however, few series docuiting this incidence. Androulakakis et al. ~ ad that double primary tumors composed percent of all prostate tumors and 2.6 pert of alI bladder tumors presenting during :study period. This corresponded to our seT h e majority of patients present initially evidence of a bladder malignancy and the itate cancer is discovered incidentally. Selli ll.2 found that 55 percent (18/33) of their ~Sof prostate malignancies were discovered "oiogically after cystoprostatectomy. A1agh the two malignancies can have the same ienting symptoms, it is often easy to deterie which malignancy presented first by his~and physical examination. Radical surgery •~ted toward the bladder primary may be rative" for the prostate malignancy. Ten of l l patients with Stage A bladder cancer had primary treatment directed toward the ~der malignancy, with none of these patients ~gof their prostate malignancy. Radical sure has also been shown to be effective for !y stage prostate cancer. 4-~ Ve obtained a 40 percent five-year survival ! which was lower than that obtained by

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When survival is shown as ]unction of early stage prostate cancer and each individual bladder cancer stage, there appears to be a trend]or better survival with both early stage bladder and prostate cancer. Numbers, however, are too small ]or statistical comparison.

Flcua~. 3.

VOLUME XXXVII, N U M B E R 3

205

Selli e t al. 2 (75 % at 5 years). They, however, did not have as many patients with advanced stage bladder disease which appears to be the most significant prognostic factor. All of the patients with advanced prostate cancer, either Stage C or D, died of the prostate malignancy. Whether the prostate malignancy is incidental to a bladder malignancy or vice versa could not be determined from our study. The charts did not include any of the epidemiologie data necessary to correlate known risk factors with the incidence of the cancers. The clinical dilemma arises with patients having intermediate stages of prostate cancer and varying stages of bladder cancer. Combined modality treatment directed toward the bladder malignancy (preoperative radiation followed by surgery) may not be adequate for the prostate malignancy if it is more advanced than it was thought to be at the diagnosis. Further investigation is necessary to evaluate this issue. It does appear, however, that primary therapy directed toward a bladder malignancy may be adequate for patients who also

206

have a simultaneous or concurrent e prostate primary. Therapy should be individualizec staging procedures are completed an toward the most advanced and aggres malignancies. Toledo Radiologk 4841 Mon: Toledo,

(DR, References 1. Androulakakis PA, Schneider HM, Jaeobi GE feIlner R: Coincident vesical transitional cell earcinq tatic carcinoma, Br J Rad 58:153 (1986). 2. Selli C, Hinshaw W, Wolfe JA, and Paulson ment of patients with concurrent primary tumors c prostate, Urology 21:562 (1983). 3. Mahadevia PS, Koss LG, and Tar IJ: Prostati in bladder cancer, Cancer 58:2096 (1986). 4. Paulson DF, Lin GH, Hinshaw W, Stephani S, Ontology Research Group: Radical surgery versus for adenocareinoma of the prostate, J Urol 128: 5G 5. Walsh PC, and Jewett HJ: Radical surgery for eer. Cancer 45:1906 (1980). 6. Walsh PC, Lepor H, and Eggleston JC: Rad: tomy with preservation of sexual function: anatomi~ logic considerations, Prostate 4:473 (1983).

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Simultaneous presentation of adenocarcinoma of prostate and transitional cell carcinoma of bladder.

Simultaneous presentation of transitional cell carcinoma of the bladder and adenocarcinoma of the prostate is not uncommon. Twenty-two patients were d...
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