Tuesday, May 27, 2014

Historical Contribution: 1932, Colston & Lewis, Clinical Review of Prostate Cancer


Carcinoma of the Prostate: A Clinical and Pathological Study J. Colston and L. Lewis Southern Medical Journal 1932  25: 696-703

Lloyd G. Lewis, MD
John Archibald Campbell (JAC) Colston was a John Hopkins urologist who worked closely with HH Young during the early 1900's.  Along with Young, he performed perineal prostatectomies and shaped the treatment and understanding of prostate cancer during this time period.  He served with the allied forces during World War I.

LLoyd G. Lewis graduated the Brady Residency in 1933.  He was remembered as a superb surgeon and co-author of The Physiology of Micturation, 1940 after undertaking a number of laboratory experiments involving the innervation of the feline bladder.  During World War II, Lewis served as Chief of Urology at Walter Reed General Hospital in Washington, DC and succeeded in having Walter Reed approved for residency training during his time there.


In the early 1930's, the only means for detection of prostate cancer was a palpable lesion or symptomatic presentation, namely urinary obstruction.  As such, Colston and Lewis review the history of prostate cancer treated at the Brady since its founding in 1915 through 1932 and note that most prostate cancers "will be found to have progressed beyond the limits of the capsule or into the seminal vesicles so that a complete removal is impossible."  In fact, in 1,040 cases of prostate cancer over 17 years, only 36 cases were found to be eligible for radical prostatectomy.  When they reviewed the over 3,700 prostate operations, they found an additional 58 cancers that  were found during operations for presumed benign growth.

Through their thorough review, they were able to make a number of important observations that describe the understanding of prostate cancer at the time, but help shape our modern understanding of the disease today.  Some of the important observations are detailed below.

Colston and Lewis were able to classify prostate cancer patients into one of three categories:

  1. cases suitable for radical prostatectomy
  2. cases too extensive for radical surgery, but asymptomatic
  3. cases too extensive for radical surgery, but with significant symptoms that require palliative treatment; either:
    • radiation treatment
    • intra-urethral treatment (or suprapubic diversion)
    • palliative, perineal prostatectomy
Colston and Lewis were able to describe the anatomic location of prostate cancer within the gland by examining whole prostate glands removed during radical surgery.  They found the "posterior lamella involved in all cases;" and the lateral lobes involved in the majority.  

They described metastatic and local growth patterns.  Thirty percent of men presenting with prostate cancer had metastases at this time.  For the men with local extension, they reviewed infiltration patterns through the seminal vesicles and never into Denonvillier's fascia "explained by the lack of lymphatics in this thick fascial membrane."  In addition, they noted that, "The rapidity of growth depends on the particular type of tumor, and it may be said that the more cellular the tumor, the more rapid the extension," an early description of the grading of prostate cancer.

In addition, they review the available treatments for the symptoms associated with advanced prostate cancer: urinary obstruction, hematuria and pain.  These symptoms could be treated radiation, transurethral and/or perineal procedures.

Finally, they conclude that, "Every effort should be made by earlier diagnosis to increase the percentage of cases suitable for radical operation, which gives normal micturation with perfect control in most cases."

To read the entire manuscript click on the link above or click here.

HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy!