Histopathology of prostate cancer and pathologic staging

Prostate Cancer: Principles and Practice

Volumn , Issue , 2005, Pages 105-116

  Epstein, Jonathan I ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

EID: 85056677392     PISSN: None     EISSN: None     Source Type: Book    
DOI: None     Document Type: Chapter

References (128)

1. Gleason DF, Mellinger GT, and the Veterans Administration Cooperative Urological Research Group. Prediction of prognosis for prostatic adenocarcinoma by combined histologic grading and clinical staging. J Urol 1974; 111;58-64.
2. McNeal JE, Villers AA, Redwine EA, et al. Histologic differentiation, cancer volume, and pelvic lymph node metastasis in adenocarcinoma of the prostate. Cancer 1990;66:1225-1233.
3. Epstein JI, Carmichael MJ, Partin AW. Small high grade adenocarcinomas of the prostate in radical prostatectomy specimens performed for non-palpable disease: pathogenic and clinical implications. J Urol 1994;151:1587-1592.
4. Cumming JA, Ritchie AW, Goodman CM, et al. De-differentiation with time in prostate cancer and the influence of treatment on the course of the disease. Br J Urol 1990;65:271-274.
5. Epstein JI, Walsh PC, Carter HB. Dedifferentiation of prostate cancer grade with time in men followed expectantly for stage T1c disease. J Urol 2001;166:1688-1691.
6. Cohen MB, Soloway MS, Murphy WM. Sampling of radical prostatectomy specimens: How much is adequate? Am J Clin Pathol 1994;101:250-252.
7. Hall GS, Kramer CE, Epstein JI. Evaluation of radical prostatectomy specimens: A comparative analysis of sampling methods. Am J Surg Pathol 1994;16:315-324.
8. Smith Sehdev AE, Pan CC, Epstein JI. Comparative analysis of sampling methods in nonpalpable (stage T1C) radical prostatectomy specimen. Hum Pathol 2001;32:494-499.
9. Carter HB, Sauvageot J, Walsh PC, et al. Prospective evaluation of men with stage T1C adenocarcinoma of the prostate. J Urol 1997;157:2206-2209.
10. Epstein JI, Walsh PC, Carmichael M, et al. Pathologic and clinical findings to predict tumor extent of nonpalpable (stage T1c) prostate cancer. JAMA 1994;271:368-374.
11. Bova GS, Fox WM, Epstein JI. Methods of radical prostatectomy specimen processing: A novel technique for harvesting fresh prostate cancer tissue and review of processing techniques. Mod Pathol 1993;6:201-207.
12. Egevad L, Engström K, Busch C. A new method for handling radical prostatectomies enabling fresh tissue harvesting, whole mount sections, and landmarks for alignment of sections. J Urologic Pathol 1998; 9:17-28.
13. Furman J, Murphy WM, Rice L, et al. Prostatectomy tissue for research. Balancing patient care and discovery. Am J Clin Pathol 1998:110:4-9.
14. Hoedemaeker RF, Ruitjer ETG, Ruizeveld-de Winter JA, et al. Processing radical prostatectomy specimens. A comprehensive and standardized protocol. J Urologic Pathol 1998:9:211-222.
15. Wheeler TM, Lebovitz RM. Fresh tissue harvest for research from prostatectomy specimens. The Prostate 1994;25:274-279.
16. Byar DP, Mostofi FK, and the Veterans Administrative Cooperative Urologic Research Groups. Carcinoma of the prostate; prognostic evaluation of certain pathologic features in 208 radical prostatectomies. Cancer 1972;30:5-13.
17. Partin AW, Kattan MW, Subong ENP, et al. Combination of prostatespecific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer: A multi-institutional update. JAMA 1997;277:1445-1451.
18. Epstein JI, Oesterling JE, Eggleston JC, et al. Frozen section detection of lymph node metastases in prostatic carcinoma: Accuracy in grossly uninvolved pelvic lymphadenectomy specimens. J Urol 1986;136:1234-1237.
19. Sgrignoli AR, Walsh PC, Steinberg GD, et al. Prognostic factors in men with stage D1 prostate cancer: Identification of patients less likely to have prolonged survival after radical prostatectomy. J Urol 1994;152:1077-1081.
20. Kothari PS, Scardino PT, Ohori M, et al. Incidence, location, and significance of periprostatic and periseminal vesicle lymph nodes in prostate cancer. Am J Surg Pathol 2001;25:1429-1432.
21. Cheng L, Slezak J, Bergstralh EJ, et al. Dedifferentiation in the metastatic progression of prostate carcinoma. Cancer 1999;86:657-663.
22. Cheng L, Bergstralh EJ, Cheville JC, et al. Cancer volume of lymph node metastasis predicts progression in prostate cancer. Am J Surg Pathol 1998;22:1491-1500.
23. Steinberg GD, Epstein JI, Piantadosi S, et al. Management of stage D1 adenocarcinoma of the prostate: The Johns Hopkins Experience 1974 to 1987. J Urol 1990;144:1425-1432.
24. Debras B, Guillonneau B, Bougaran J. Prognostic significance of seminal vesicle invasion on the radical prostatectomy specimen. Eur Urol 1998;33:271-277.
25. Tefilli MV, Gheiler EL, Tiguert R, et al. Prognostic indications in patients with seminal vesicle involvement following radical prostatectomy for clinically localized prostate cancer. J Urol 1998;160:802-806.
26. Ohori M, Scardino PT, Lapin SL, et al. The mechanisms and prognostic significance of seminal vesicle involvement by prostate cancer. Am J Surg Pathol 1993;17:1252-1261.
27. Epstein JI, Partin AW, Potter SR, et al. Adenocarcinoma of the prostate invading the seminal vesicle: Prognostic stratification based on pathologic parameters. Urology 2000;56:283-288.
28. Catalona WJ, Smith DS. Cancer recurrence and survival rates after anatomic radical retropubic prostatectomy for prostate cancer:Intermediate-terms results. J Urol 1998:160:2428-2434.
29. D’Amico AV, Whittington R, Malkowicz B, et al. A multivariate analysis of clinical and pathological factors that predict for prostate specific antigen failure after radical prostatectomy for prostate cancer. J Urol 1995:154:131-135.
30. Trapasso JG, deKernion JB, Smith RB, et al. The incidence and significance of detectable levels of serum prostate specific antigen after radical prostatectomy. J Urol 1994:152:1821-1825.
31. Salomon L, Anastasiadis AG, Johnson CW, et al. Seminal vesicle involvement after radical prostatectomy: Predicting risk factors for progression. Urology 2003:62:304-309.
32. Sofer M, Savoi M, Kim SS, et al. Biochemical and pathological predictors of the recurrence of prostatic adenocarcinoma with seminal vesicle invasion. J Urol 2003; 169:154-156.
33. Ayala AG, Ro JY, Babaian R, et al. The prostatic capsule: Does it exist:Its importance in the staging and treatment of prostatic carcinoma. Am J Surg Pathol 1989;13:21-27.
34. Jhaveri F, Klein EA, Kupelian PA, et al. Declining rates of extracapsular extension after radical prostatectomy: Evidence of continued stage migration. J Clin Oncol 1999;17:3167-3172.
35. Villers A, McNeal JE, Redwine EA, et al. The role of perineural space invasion in the local spread of prostatic adenocarcinoma. J Urol 1989;142:763-768.
36. McNeal JE, Villers AA, Redwine EA, et al. Capsular penetration in prostate cancer. Am J Surg Pathol 1990;14:240-247.
37. Wheeler TM, Dillioglugil Ö, Kattan MW, et al. Clinical and pathological significance of the level and extent of capsular invasion in clinical stage T1-2 prostate cancer. Hum Pathol 1998;29:856-862.
38. Epstein JI. Evaluation of radical prostatectomy capsular margins of resection: The significance of margins designated as negative, closely approaching, and positive. Am J Surg Pathol 1990;14:626-632.
39. Epstein JI, Sauvageot J. Do close but negative margins in radical prostatectomy specimens increase the risk of postoperative progression? J Urol 1997;157:241-243.
40. Ackerman DA, Barry JM, Wicklund RA, et al. Analysis of risk factors associated with prostate cancer extension to the surgical margin and pelvic node metastasis at radical prostatectomy. J Urol 1993;150:1845-1850.
41. Rosen MA, Goldstone L, Lapin S, et al. Frequency and location of extracapsular extension and positive surgical margins in radical prostatectomy specimens. J Urol 1992;148:331-337.
42. Stamey TA, Villers AA, McNeal JE, et al. Positive surgical margins at radical prostatectomy: Importance of the apical dissection. J Urol 1990;143:1166-1172.
43. Van Den Ouden D, Bentvelsen FM, Boevé ER, et al. Schröder: Positive margins after radical prostatectomy: Correlation with local recurrence and distant progression. Br J Urol 1993;72:489-494.
44. Watson RB, Civantos F, Soloway MS. Positive surgical margins with radical prostatectomy: Detailed pathological analysis and prognosis. Urology 1996;48:80-90.
45. Weldon VE, Tavel FR, Neuwirth H, et al. Patterns of positive specimen margins and detectable prostate specific antigen after radical perineal prostatectomy. J Urol 1995;153:1565-1569.
46. Barocas DA, Han M, Epstein JI, et al. Does capsular incision at radical retropubic prostatectomy affect disease-free survival in otherwise organ-confined prostate cancer? Urology 2001;58:746-751.
47. Freedland SJ, Aronson WJ, Presti JC, et al. Should a positive surgical margin following radical retropubic prostatectomy be pathological stage T2 or T3? Results from the search database. J Urol 2003;169:2142-2146.
48. Guillonneau B, El-Fettouh H, Baumert H, et al. Laparoscopic radical prostatectomy: Oncological evaluation after 1,000 cases at Montsouris Institute. J Urol 2003;169:1261-1266.
49. Kupelian P, Katcher J, Levin H, et al. Correlation of clinical and pathologic factors with rising prostate-specific antigen profiles after radical prostatectomy alone for clinically localized prostate cancer. Urology 1996;48:249-260.
50. Salomon L, Anastasiadis AG, Antiphon P, et al. Prognostic consequences of the location of positive surgical margins in organconfined prostate cancer. Urol Int 2003;70:291-296.
51. Eggleston JC, Walsh PC. Radical prostatectomy with preservation of sexual function: pathological findings in the first 100 cases. J Urol 1985;134:1146-1148.
52. Epstein JI, Pizov G, Walsh PC. Correlation of pathologic findings with progression following radical retropubic prostatectomy. Cancer 1993;71:3582-3593.
53. Cangiano TG, Litwin MS, Naitoh J, et al. Intraoperative frozen section monitoring of nerve sparing radical retropubic prostatectomy. J Urol 1999;162:655-658.
54. Fromont G, Baumert H, Cathelineau X, et al. Intraoperative frozen section analysis during nerve sparing laparoscopic radical prostatectomy: Feasibility study. J Urol 2003;170:1843-1846.
55. Goharderakhshan RZ, Sudilovsky D, Carrol LA, et al. Utility of intraoperative frozen section analysis of surgical margins in region of neurovascular bundles at radical prostatectomy. Urology 2002;59:709-714.
56. Shah O, Melamed J, Lepor H. Analysis of apical soft tissue margins during radical retropubic prostatectomy. J Urol 2001;165:1943-1949.
57. Epstein JI, Partin AW, Sauvageot J, et al. Prediction of progression following radical prostatectomy: A multivariate analysis of 721 men with long-term follow-up. Am J Surg Pathol 1996;20:286-292.
58. Ohori M, Wheeler TM, Kattan MW, et al. Prognostic significance of positive surgical margins in radical prostatectomy specimens. J Urol 1995:154:1818-1824.
59. D’Amico A, Whittington R, Malkowicz SB, et al. An analysis of the time course of postoperative prostate-specific antigen failure in patients with positive margins: Implications on the use of adjuvant therapy. Urology 1996;47:538-547.
60. Blute ML, Bostwick DG, Bergstralh EJ, et al. Anatomic site-specific positive margins in organ-confined prostate cancer and its impact on outcome after radical prostatectomy. Urology 1997;50:733-739.
61. Fesseha T, Sakr W, Grignon D, et al. Prognostic implications of a positive apical margin in radical prostatectomy specimens. J Urol 1997;158:2176.
62. Ohori M, Abbas F, Wheeler TM, et al. Pathological features and prognostic significance of prostate cancer in the apical section determined by whole mount histology. J Urol 1999;161:500-504.
63. Yossepowitch O, Sircar K, Scardino PT, et al. Bladder neck involvement in pathological stage pT4 radical prostatectomy specimens is not an independent prognostic factor. J Urol 2002;168:2011-2015.
64. Aydin H, Tsuzuki T, Hernandez D, et al. Positive proximal (bladder neck) margin at radical prostatectomy confers a higher risk of biochemical progression 2004;63:551-555.
65. Obek C, Sadek S, Lai S, et al. Positive surgical margins with radical retropubic prostatectomy: anatomic site-specific pathological analysis and impact on prognosis. Urology 1999;54:682-688.
66. Christensen WN, Partin AW, Walsh PC, et al. Pathologic findings in clinical stage A2 prostate cancer. Relation of tumor volume, grade, and location to pathologic stage. Cancer 1990;65:1021-1027.
67. Chan TY, Partin AW, Walsh PC, et al. The prognostic significance of Gleason score 3+4 versus Gleason score 4+3 tumor at radical prostatectomy. Urology 2000;56:823-827.
68. Han M, Partin AW, Zahurak M, et al. Biochemical (prostate specific antigen) recurrence probability following radical prostatectomy for clinically localized prostate cancer. J Urol 2003;169:517-523.
69. Babaian RJ, Troncoso P, Bhadkamkar VA, et al. Analysis of clinicopathologic factors predicting outcome after radical prostatectomy. Cancer 2001;91:1414-1422.
70. Ohori M, Goad JR, Wheeler RM, et al. Can radical prostatectomy alter the progression of poorly differentiated prostate cancer? J Urol 1994;152:1843-1849.
71. Oefelein MG, Grayhack JT, McVary KT. Survival after radical prostatectomy of men with clinically localized high grade carcinoma of the prostate. Cancer 1995;76:2535-2542.
72. Perrotti M, Rabbani F, Russo P, et al. Early prostate cancer detection and potential for surgical cure in men with poorly differentiated tumors. Urology 1998;52:106-110.
73. Han M, Partin AW, Pound CR, et al. Long term biochemical diseasefree and cancer-specific survival following anatomic radical retropubic prostatectomy: The 15-year Johns Hopkins Experience. Urol Clin N Am 2001;28:555-565.
74. Oefelein MG, Smith ND, Grayhack JT, et al. Long-term results of radical retropubic prostatectomy in men with high grade carcinoma of the prostate. J Urol 1997;158:1460-1465.
75. Mian BM, Troncoso P, Okihara K, et al. Outcome of patients with Gleason score 8 or higher prostate cancer following radical prostatectomy alone. J Urol 2002;167:1675-1680.
76. Rioux-Leclercq N, Chan DY, Epstein JI. Prediction of outcome after radical prostatectomy in men with organ-confined Gleason score 8 to 10 adenocarcinoma. Urology 2002;60:666-669.
77. Teffili MV, Gheiler EL, Tiguert R, et al. Should Gleason score 7 cancer be considered a unique grade category? Urology 1999;53:372-377.
78. Pan C-C, Potter SR, Partin AW, et al. The prognostic significance of tertiary Gleason patterns of higher grade in radical prostatectomy specimens: a proposal to modify the Gleason grading system Am J Surg Pathol 2000;24:563-569.
79. Mosse CA, Magi-Galuzi C, Tsuzuki T, et al. The prognostic significance of tertiary Gleason pattern 5 in radical prostatectomy specimens. Am J Surg Pathol 2004;28:394-398.
80. McNeal JE. Cancer volume and site of origin of adenocarcinoma of the prostate: Relationship to local and distant spread. Hum Pathol 1992;23:258-266.
81. Greene DR, Wheeler TM, Egawa S, et al. A comparison of the morphological features of cancer arising in the transition zone and in the peripheral zone of the prostate. J Urol 1991;146:1069-1076.
82. Humphrey PA, Vollmer RT. Percentage carcinoma as a measure of prostatic tumor size in radical prostatectomy tissues. Mod Pathol 1997;10:326-333.
83. Renshaw AA, Chang H, D’Amico AV. Estimation of tumor volume in radical prostatectomy specimens in routine clinical practice. Am J Clin Pathol 1997;107:704-708.
84. Renshaw AA, Richie JR, Loughlin KR, et al. Maximum diameter of prostatic carcinoma is a simple, inexpensive, and independent predictor of prostate-specific antigen failure in radical prostatectomy specimens. Am J Clin Pathol 1999;111:641-644.
85. Noguchi M, Stamey TA, McNeal JE, et al. Assessment of morphometric measurements of prostate carcinoma volume. Cancer 2000;89:1056-1064.
86. Chen ME, Johnston D, Reyes AO, et al. A streamlined threedimensional volume estimation method accurately classifies prostate tumors by volume. Am J Surg Pathol 2003;27:1291-1301.
87. Carvalhal GF, Humphrey PA, Thorson P, et al. Visual estimate of the percentage of carcinoma is an independent predictor of prostate carcinoma recurrence after radical prostatectomy. Cancer 2000;89:1308-1314.
88. Epstein JI, Carmichael M, Partin AW, et al. Is tumor volume an independent predictor of progression following radical prostatectomy? A multivariate analysis of 185 clinical stage B adenocarcinomas of the prostate with 5 years of followup. J Urol 1993;149:1478-1481.
89. Manoharan M, Civantos F, Kim SS, et al. Visual estimate of percent of carcinoma predicts recurrence after radical prostatectomy. J Urol 2003; 170:1194-1198.
90. Palisaar R, Graefen M, Karakiewicz PI, et al. Assessment of clinical and pathologic characteristics predisposing to disease recurrence following radical prostatectomy in men with pathologically organconfined prostate cancer. Eur Urol 2002;41:155-161.
91. Salomon L, Levrel O, Anastasiasdis AG, et al. Prognostic significance of tumor volume after radical prostatectomy: A multivariate analysis of pathological factors. Eur Urol 2003;43:39-44.
92. Stamey TA, McNeal JE, Yemoto CH, et al. Biological determinants of cancer progression in men with prostate cancer. JAMA 1999;281:1395-1400.
93. DiGiuseppe JA, Sauvageot J, Epstein JI. Increasing incidence of minimal residual cancer radical prostatectomy specimens. Am J Surg Pathol 1997;21:174-178.
94. Van Den Ouden D, Hop WCJ, Kranse R, et al. Tumour control according to pathological variables in patients treated by radical prostatectomy for clinically localized carcinoma of the prostate. Br J Urol 1997;79:203-211.
95. De la Taille A, Rubin MA, Buttyan R, et al. Is microvascular invasion on radical prostatectomy specimens a useful predictor of PSA recurrence for prostate cancer patients? Eur Urol 2000;38:79-84.
96. Ito K, Nakashima J, Mukai M, et al. Prognostic implication of microvascular invasion in biochemical failure in patients treated with radical prostatectomy. Urol Int 2003;70:297-302.
97. Maru N, Ohori M, Kattan MW, et al. Prognostic significance of the diameter of perineural invasion in radical prostatectomy specimens. Hum Pathol 2001;32:828-833.
98. Kao J, Upton M, Zhang P, et al. Individual prostate biopsy core embedding facilitates maximal tissue representation. J Urol 2002;168:496-499.
99. Allen EA, Kahane H, Epstein JI. Repeat biopsy strategies for men with atypical diagnoses on initial prostate needle biopsy. Urology 1998;52:803-807.
100. Srodon M, Epstein JI. Central zone histology of the prostate:A mimicker of high grade prostatic intraepithelial neoplasia. Hum Pathol 2002;33:518-523.
101. McNeal JE. Origin and development of carcinoma in the prostate. Cancer 1969;23:24-34.
102. Spires SE, Cibull ML, Wood DP Jr, et al. Gleason histologic grading in prostatic carcinom. Correlation of 18-guage core biopsy with prostatectomy. Arch Pathol Lab Med 1994;118:705-708.
103. Steinberg DM, Sauvageot J, Piantadosi S, et al. Correlation of prostate needle biopsy and radical prostatectomy Gleason grade in academic and community settings. Am J Surg Pathol 1997;21:566-576.
104. Bostwick DG. Gleason grading of prostatic needle biopsies. Correlation with grade in 316 matched prostatectomies. Am J Surg Pathol 1994;18:796-803.
105. Allsbrook WC, Mangold KA, Yang X, et al. The Gleason grading system: an overview. J Urol Path 1999;10:141-157.
106. Sogani PC, Israel A, Lieberman PH, et al. Gleason grading of prostate cancer: A predictor of survival. Urology 1985;25:223-227.
107. Egevad L, Norlen BJ, Norberg M. The value of multiple core biopsies for predicting the Gleason score of prostate cancer. BJU Int 2001;88:716-721.
108. Rubin MA, Dunn R, Kambham N, et al. Should a Gleason score be assigned to a minute focus of carcinoma on prostate biopsy? Am J Surg Pathol 2000;24:1634-1640.
109. Epstein JI, Potter SR. The pathological interpretation and significance of prostate needle biopsy findings: implications and current controversies. J Urol 2001;166:402-410.
110. Murphy WM, Dean PJ, Brasfield JA, et al. Incidental carcinoma of the prostate. How much sampling is adequate? Am J Surg Pathol 1986;10:170-174.
111. Rohr LR. Incidental adenocarcinoma in transurethral resections of the prostate: partial versus complete microscopic examination. Am J Surg Pathol 1987;11:53-58.
112. McDowell PR, Fox WM, Epstein JI. Is submission of remaining tissue necessary when incidental carcinoma of the prostate is found on transurethral resection? Hum Pathol 1994:25:493-497.
113. Greene DR, Wheeler TM, Egawa S, et al. Relationship between clinical stage and histological zone of origin in early prostate cancer:morphometric analysis. Br J Urol 1991;68:499-509.
114. McNeal JE, Price HM, Redwine EA, et al. Stage A versus stage B adenocarcinoma of the prostate: morphological comparison and biological significance. J Urol 1988;139:61-65.
115. Epstein JI, Paull G, Eggleston JC, et al. Prognosis of untreated stage Al prostatic carcinoma: A study of 94 cases with extended follow-up. J Urol 1986;136:837-839.
116. Epstein JI. Prostate Biopsy Interpretation, 3rd ed. New York:Lippincott William and Wilkins, 2002.
117. Kahane H, Sharp JW, Shuman GB, et al. Utilization of high molecular weight cytokeratin on prostate biopsies in an independent laboratory. Urology 1995;45:981-986.
118. Wojno KJ, Epstein JI. The utility of basal cell specific anti-cytokeratin antibody (34 beta E12) in the diagnosis of prostate cancer: a review of 228 cases. Am J Surg Pathol 1995:19:251-260.
119. Rubin MA, Zhou M, Dhanasekaran SM, et al. α- Methylacyl coenzyme A racemase as a tissue biomarker for prostate cancer. JAMA 2002;287:1662-1670.
120. Armas OA, Aprikian AG, Melamed J, et al. Clinical and pathobiological effects of neoadjuvant total androgen ablation therapy on clinically localized prostatic adenocarcinoma. Am J Surg Pathol 1994;18:979-991.
121. Smith DM, Murphy WM. Histologic changes in prostate carcinomas treated with Leuprolide (luteinizing hormone-releasing hormone effect). Distinction from poor tumor differentiation. Cancer 1994;73:1472-1477.
122. Vaillancourt L, Tâtu B, Fradet Y, et al. Effect of neoadjuvant endocrine therapy (combined androgen blockade) on normal prostate and prostatic carcinoma. A randomized study. Am J Surg Pathol 1996;20:86-93.
123. Crook J, Malone S, Perry G, et al. Postradiotherapy prostate biopsies:What do they really mean? Results for 498 patients. Int J Rad Onc Biol Phys 2000;48:355-367.
124. Ro JY, Grignon J, Ayala AG, et al. Mucinous adenocarcinoma of the prostate: Histochemical and immunohistochemical studies. Hum Pathol 1990;21:593-600.
125. Epstein JI, Lieberman P. Mucinous adenocarcinomas of the prostate gland. Am J Surg Pathol 1985;9:299-307.
126. Saito S, Iwaki H. Mucin-producing carcinoma of the prostate: review of 88 cases. Urology 1999;54:141-144.
127. Brinker DA, Potter SR, Epstein JI. Ductal adenocarcinoma of the prostate diagnosed on needle biopsy: correlation with clinical and radical prostatectomy findings and progression. Am J Surg Pathol 1999;23:1471-1479.
128. Christensen WN, Steinberg WN, Walsh PC, et al. Prostatic duct adenocarcinoma: Findings at radical prostatectomy. Cancer 1991;67:2118-2124.