Radical prostatectomy for locally advanced prostate cancer: Results of a feasibility study (EORTC 30001)

Characteristics of Patients in SPCG-15—A Randomized Trial Comparing Radical Prostatectomy with Primary Radiotherapy plus Androgen Deprivation Therapy in Men with Locally Advanced Prostate Cancer

Background

There is no high-grade evidence for surgery as primary treatment for locally advanced prostate cancer. The SPCG-15 study is the first randomized trial comparing surgical treatment with radiotherapy.

Objective

To describe the baseline characteristics of the first 600 randomized men in the SPCG-15 study. The study will compare mortality and functional outcomes.

Design, setting, and participants

This study is a Scandinavian prospective, open, multicenter phase III randomized clinical trial aiming to randomize 1200 men.

Intervention

Radical prostatectomy with or without consecutive radiotherapy (experimental) and radiotherapy with neoadjuvant androgen deprivation therapy (standard of care).

Outcome measurements and statistical analysis

Cause-specific survival, metastasis-free survival, overall survival, and patient-reported bowel function, sexual health, and lower urinary tract symptoms were measured.

Results and limitations

The distribution of characteristics was similar in the two study arms. The median age was 67 yr (range 45–75 yr). Among the operated men, 36% had pT3a stage of disease and 39% had pT3b stage. International Society of Urological Pathology grades 2, 3, 4, and 5 were prevalent in 21%, 35%, 7%, and 27%, respectively. Half of the men (51%) in the surgery arm had no positive lymph nodes. The main limitation is the pragmatic design comparing the best available practice at each study site leading to heterogeneity of treatment regimens within the study arms.

Conclusions

We have proved that randomization between surgery and radiotherapy for locally advanced prostate cancer is feasible. The characteristics of the study population demonstrate a high prevalence of advanced disease, well-balanced comparison groups, and a demography mirroring the Scandinavian population of men with prostate cancer at large.

Patient summary

This study, which has recruited >600 men, compares radiotherapy with surgery for prostate cancer, and an analysis at the time of randomization indicates that the study will be informative and generalizable to most men with locally advanced but not metastasized prostate cancer.

Tumour irradiation combined with vascular-targeted photodynamic therapy enhances antitumour effects in pre-clinical prostate cancer

BACKGROUND

There is a need to improve the treatment of prostate cancer (PCa) and reduce treatment side effects. Vascular-targeted photodynamic therapy (VTP) is a focal therapy for low-risk low-volume localised PCa, which rapidly disrupts targeted tumour vessels. There is interest in expanding the use of VTP to higher-risk disease. Tumour vasculature is characterised by vessel immaturity, increased permeability, aberrant branching and inefficient flow. FRT alters the tumour microenvironment and promotes transient 'vascular normalisation'. We hypothesised that multimodality therapy combining fractionated radiotherapy (FRT) and VTP could improve PCa tumour control compared against monotherapy with FRT or VTP.

METHODS

We investigated whether sequential delivery of FRT followed by VTP 7 days later improves flank TRAMP-C1 PCa tumour allograft control compared to monotherapy with FRT or VTP.

RESULTS

FRT induced 'vascular normalisation' changes in PCa flank tumour allografts, improving vascular function as demonstrated using dynamic contrast-enhanced magnetic resonance imaging. FRT followed by VTP significantly delayed tumour growth in flank PCa allograft pre-clinical models, compared with monotherapy with FRT or VTP, and improved overall survival.

CONCLUSION

Combining FRT and VTP may be a promising multimodal approach in PCa therapy. This provides proof-of-concept for this multimodality treatment to inform early phase clinical trials.

New Frontiers in Molecular Imaging Using Peptide-Based Radiopharmaceuticals for Prostate Cancer

The high incidence of prostate cancer (PCa) increases the need for progress in its diagnosis, staging, and precise treatment. The overexpression of tumor-specific receptors for peptides in human cancer cells, such as gastrin-releasing peptide receptor, natriuretic peptide receptor, and somatostatin receptor, has indicated the ideal molecular basis for targeted imaging and therapy. Targeting these receptors using radiolabeled peptides and analogs have been an essential topic on the current forefront of PCa studies. Radiolabeled peptides have been used to target receptors for molecular imaging in human PCa with high affinity and specificity. The radiolabeled peptides enable optimal quick elimination from blood and normal tissues, producing high contrast for positron emission computed tomography and single-photon emission computed tomography imaging with high tumor-to-normal tissue uptake ratios. Owing to their successful application in visualization, peptide derivatives with therapeutic radionuclides for peptide receptor radionuclide therapy in PCa have been explored in recent years. These developments offer the promise of personalized, molecular medicine for individual patients. Hence, we review the preclinical and clinical literature in the past 20 years and focus on the newer developments of peptide-based radiopharmaceuticals for the imaging and therapy of PCa.

Surgical management of high-risk, localized prostate cancer

High-risk prostate cancer is a heterogeneous disease that lacks clear consensus on its ideal management. Historically, non-surgical treatment was the preferred strategy, and several studies demonstrated improved survival among men with high-risk disease managed with the combination of radiotherapy and androgen deprivation therapy (ADT) compared with ADT alone. However, practice trends in the past 10-15 years have shown increased use of radical prostatectomy with pelvic lymph node dissection for primary management of high-risk, localized disease. Radical prostatectomy, as a primary monotherapy, offers the potential benefits of avoiding ADT, reducing rates of symptomatic local recurrence, enabling full pathological tumour staging and potentially reducing late adverse effects such as secondary malignancy compared with radiation therapy. Retrospective studies have reported wide variability in short-term (pathological) and long-term (oncological) outcomes of radical prostatectomy. Surgical monotherapy continues to be appropriate for selected patients, whereas in others the best treatment strategy probably involves a multimodal approach. Appropriate risk stratification utilizing clinical, pathological and potentially also genomic risk data is imperative in the initial management of men with prostate cancer. However, data from ongoing and planned prospective trials are needed to identify the optimal management strategy for men with high-risk, localized prostate cancer.

Localization and restaging of carcinoma prostate by 68Gallium prostate-specific membrane antigen positron emission tomography computed tomography in patients with biochemical recurrence

INTRODUCTION

Radical prostatectomy (RP) and radical radiotherapy (RT) are well established primary curative options for localized prostate cancer. Despite technical improvements, prostate-specific antigen (PSA)-recurrence after RP and RT is a common clinical scenario. We aimed to assess the role of ⁶⁸Gallium (⁶⁸Ga) prostate-specific membrane antigen positron emission tomography computed tomography (PSMA PET/CT) in patients with biochemical recurrence of prostate cancer after RP or RT for the detection and localization recurrent and metastatic disease.

MATERIALS AND METHODS

We ambispectively (70 retrospective and 100 prospective) analyzed the data of men with biochemical recurrence post-RP and post-RT who were evaluated by ⁶⁸Ga PSMA PET/CT at our institute. We aimed to assess the relationship between serum PSA levels and the probability of having a positive scan in patients with recurrent prostate cancer.

RESULTS

The study included 170 men, all had adenocarcinoma of the prostate, 124/170 had previous RP and 46/170 had prior RT. The median serum PSA in the RP group was 1.8 ng/ml and 5.2 ng/ml in the RT group. In the post-RP cohort, the detection rate of ⁶⁸Ga PSMA PET/CT was 39.3% for PSA 0.2 to <0.5 ng/ml, 47.3% for PSA 0.5 to <1 ng/ml, 68.4% for PSA 1 to <2 ng/ml and 93.1% for PSA ≥2 ng/ml. In the post-RT group, the detection rate was 88.8% for PSA 2 to <4 ng/ml and 100% for PSA ≥4 ng/ml.

CONCLUSIONS

⁶⁸Ga PSMA PET/CT provides a novel imaging modality for the detection of prostate cancer recurrence and metastases at low posttreatment PSA levels, which may help in directing appropriate salvage treatments.

Locally advanced prostate cancer imaging findings and implications for treatment from the surgical perspective

The anatomy of the prostate is reviewed in the context of discussing the staging of prostate cancer and patterns of tumor spread. The utility of prostate magnetic resonance imaging along with new advancements in tumor staging are discussed specifically in locally advanced disease. What should be included in the radiology report carries a substantial weight to formulate the urologist's decision in regards to the selection of surgical candidates, preoperative planning and avoiding postoperative complications.

Elderly patients aged ≥ 75 years with locally advanced prostate cancer may benefit from local treatment: a population-based propensity score-adjusted analysis

OBJECTIVE

To evaluate whether elderly patients aged ≥ 75 years with locally advanced prostate cancer (LAPC) may benefit from local treatment (LT).

METHODS

Elderly patients aged ≥ 75 years with non-metastatic cT3-4 LAPC who were treated with LT [radical prostatectomy (RP), radiation therapy (RT)] or non-LT (NLT) were identified. After propensity score matching (PSM), cancer-specific mortality (CSM) and other-cause mortality (OCM) rates were assessed. In the assessment of LT vs. NLT and RP vs. RT, multivariable competing risk regression (MVA CRR) analysis was used.

RESULTS

368 and 482 paired patients were matched for LT vs. NLT and RP vs. RT, respectively. 5 and 10 years CSM rates were 9.4 vs. 18.5% in LT and 24.9 vs. 29.3% in NLT-treated patients, respectively (P < 0.0001). 5 and 10 years CSM rates were 3.4% vs. 8.6% in RP and 6.7% vs. 15.1% in RT-treated patients, respectively (P = 0.10). In the MVA CRR model, after PSM, NLT resulted in higher CSM rates in Gleason score 8-10 [subhazard ratio (sHR) = 2.83, P < 0.001], cT3b/4 (sHR = 3.97/2.56, P = 0.003/0.002), cN0 (sHR = 2.52, P < 0.001) or PSA > 10 ng/ml [sHR (PSA = 10.1-20 ng/ml) = 4.59, P = 0.03; sHR (PSA > 20 ng/ml) = 2.77, P = 0.001] patients compared with LT. However, no statistically significant difference in CSM was observed between RP and RT, except for cT3a patients in whom higher CSM rates were noted for RT compared with RP (sHR = 3.91, P = 0.02).

CONCLUSION

LAPC patients may benefit from local treatment despite advanced age. However, this benefit was only seen in patients with cT3b/4, Gleason score 8-10, cN0 or PSA > 10 ng/ml.

Prospective Evaluation of 68Ga-RM2 PET/MRI in Patients with Biochemical Recurrence of Prostate Cancer and Negative Findings on Conventional Imaging

⁶⁸Ga-labeled DOTA-4-amino-1-carboxymethyl-piperidine-d-Phe-Gln-Trp-Ala-Val-Gly-His-Sta-Leu-NH₂ (⁶⁸Ga-RM2) is a synthetic bombesin receptor antagonist that targets gastrin-releasing peptide receptor (GRPr). GRPr proteins are highly overexpressed in several human tumors, including prostate cancer (PCa). We present data from the use of ⁶⁸Ga-RM2 in patients with biochemical recurrence (BCR) of PCa and negative findings on conventional imaging. Methods: We enrolled 32 men with BCR of PCa, who were 59-83 y old (mean ± SD, 68.7 ± 6.4 y). Imaging started at 40-69 min (mean, 50.5 ± 6.8 min) after injection of 133.2-151.7 MBq (mean, 140.6 ± 7.4 MBq) of ⁶⁸Ga-RM2 using a time-of-flight-enabled simultaneous PET/MRI scanner. T1-weighted, T2-weighted, and diffusion-weighted images were acquired. Results: All patients had a rising level of prostate-specific antigen (PSA) (range, 0.3-119.0 ng/mL; mean, 10.1 ± 21.3 ng/mL) and negative findings on conventional imaging (CT or MRI, and a ^99mTc-methylene diphosphonate bone scan) before enrollment. The observed ⁶⁸Ga-RM2 PET detection rate was 71.8%. ⁶⁸Ga-RM2 PET identified recurrent PCa in 23 of the 32 participants, whereas the simultaneous MRI scan identified findings compatible with recurrent PCa in 11 of the 32 patients. PSA velocity was 0.32 ± 0.59 ng/mL/y (range, 0.04-1.9 ng/mL/y) in patients with negative PET findings and 2.51 ± 2.16 ng/mL/y (range, 0.13-8.68 ng/mL/y) in patients with positive PET findings (P = 0.006). Conclusion:⁶⁸Ga-RM2 PET can be used for assessment of GRPr expression in patients with BCR of PCa. High uptake in multiple areas compatible with cancer lesions suggests that ⁶⁸Ga-RM2 is a promising PET radiopharmaceutical for localization of disease in patients with BCR of PCa and negative findings on conventional imaging.

Radical Prostatectomy for Locally Advanced Prostate Cancers-Review of Literature

Twenty-five to thirty percent of patients with prostate cancer present with locally advanced disease. While risk stratification remains the same with high incidence of upstaging of disease on imaging and histopathological evaluation; there have been progressive refinements in surgical therapy. With availability of reasonably robust data, radical prostatectomy in men with locally advanced prostate cancers seems to effect improvement in both cancer specific and overall survival rates in comparison to the current standard of care of radiation with androgen deprivation therapy. Studies using radical prostatectomy as a part of multimodality approach have also shown promising results. There is an imminent need for well-designed prospective studies of benefits of radical prostatectomy over radiation and androgen deprivation as well as benefits of multimodality therapy over monotherapy. Surgery for patients with locally advanced prostate cancer is technically challenging. Surgical outcomes are comparable to those of organ-confined disease when performed in high-volume centers. Neoadjuvant therapies prior to radical prostatectomy might improve surgical outcomes, but whether they will translate into a better cancer specific and overall survival are yet to be ascertained.

Role of Surgery in locally advanced prostate cancer

A significant proportion of patients present with locally advanced prostate cancer with inherent higher risk of local recurrence and systemic relapse after initial treatment. Recent literature favors combination of radiation therapy and extended hormonal therapy for this subset of patients. The effectiveness of Radical prostatectomy (RP) alone for locally advanced prostate cancer is controversial and is a focus of debate. However, it can decrease the tumor burden and allows the accurate and precise pathological staging with the need for subsequent treatment. Comparison of RP and other treatment modalities is difficult and incorrect because of inherent selection bias. RP as a part of multi-modality treatment (with neo-adjuvant hormonal therapy (HT) and with adjuvant or salvage radiation therapy (RT)/HT) can provide long term overall and cancer specific survival. Surgical treatment (such as transurethral resection (TUR), JJ stenting and percutaneous nephrostomy (PCN) placement etc.) can also provide symptomatic improvement and palliative care to improve quality of life of patients with advanced prostate cancer.

Treatment of the Primary Tumor in Metastatic Prostate Cancer: Current Concepts and Future Perspectives

CONTEXT

Multimodal treatment for men with locally advanced prostate cancer (PCa) using neoadjuvant/adjuvant systemic therapy, surgery, and radiation therapy is being increasingly explored. There is also interest in the oncologic benefit of treating the primary tumor in the setting of metastatic PCa (mPCa).

OBJECTIVE

To perform a review of the literature regarding the treatment of the primary tumor in the setting of mPCa.

EVIDENCE ACQUISITION

Medline, PubMed, and Scopus electronic databases were queried for English language articles from January 1990 to September 2014. Prospective and retrospective studies were included.

EVIDENCE SYNTHESIS

There is no published randomized controlled trial (RCT) comparing local therapy and systemic therapy to systemic therapy alone in the treatment of mPCa. Prospective studies of men with locally advanced PCa and retrospective studies of occult node-positive PCa have consistently shown the addition of local therapy to a multimodal treatment regimen improves outcomes. Molecular and genomic evidence further suggests the primary tumor may have an active role in mPCa.

CONCLUSIONS

Treatment of the primary tumor in mPCa is being increasingly explored. While preclinical, translational, and retrospective evidence supports local therapy in advanced disease, further prospective studies are under way to evaluate this multimodal approach and identify the patients most likely to benefit from the inclusion of local therapy in the setting of metastatic disease.

PATIENT SUMMARY

In this review we explored preclinical and clinical evidence for treatment of the primary tumor in metastatic prostate cancer (mPCa). We found evidence to support clinical trials investigating mPCa therapy that includes local treatment of the primary tumor. Currently, treating the primary tumor in mPCa is controversial and lacks high-level evidence sufficient for routine recommendation.

Evaluation of Hybrid ⁶⁸Ga-PSMA Ligand PET/CT in 248 Patients with Biochemical Recurrence After Radical Prostatectomy

The expression of prostate-specific membrane antigen (PSMA) is increased in prostate cancer. Recently, (68)Ga-PSMA (Glu-NH-CO-NH-Lys-(Ahx)-[(68)Ga(HBED-CC)]) was developed as a PSMA ligand. The aim of this study was to investigate the detection rate of (68)Ga-PSMA PET/CT in patients with biochemical recurrence after radical prostatectomy.

METHODS

Two hundred forty-eight of 393 patients were evaluable for a retrospective analysis. Median prostate-specific antigen (PSA) level was 1.99 ng/mL (range, 0.2-59.4 ng/mL). All patients underwent contrast-enhanced PET/CT after injection of 155 ± 27 MBq of (68)Ga-PSMA ligand. The detection rates were correlated with PSA level and PSA kinetics. The influence of antihormonal treatment, primary Gleason score, and contribution of PET and morphologic imaging to the final diagnosis were assessed.

RESULTS

Two hundred twenty-two (89.5%) patients showed pathologic findings in (68)Ga-PSMA ligand PET/CT. The detection rates were 96.8%, 93.0%, 72.7%, and 57.9% for PSA levels of ≥2, 1 to <2, 0.5 to <1, and 0.2 to <0.5 ng/mL, respectively. Whereas detection rates increased with a higher PSA velocity (81.8%, 82.4%, 92.1%, and 100% in <1, 1 to <2, 2 to <5, and ≥5 ng/mL/y, respectively), no significant association could be found for PSA doubling time (82.7%, 96.2%, and 90.7% in >6, 4-6, and <4 mo, respectively). (68)Ga-PSMA ligand PET (as compared with CT) exclusively provided pathologic findings in 81 (32.7%) patients. In 61 (24.6%) patients, it exclusively identified additional involved regions. In higher Gleason score (≤7 vs. ≥8), detection efficacy was significantly increased (P = 0.0190). No significant difference in detection efficacy was present regarding antiandrogen therapy (P = 0.0783).

CONCLUSION

Hybrid (68)Ga-PSMA ligand PET/CT shows substantially higher detection rates than reported for other imaging modalities. Most importantly, it reveals a high number of positive findings in the clinically important range of low PSA values (<0.5 ng/mL), which in many cases can substantially influence the further clinical management.

Locally advanced and high risk prostate cancer: The best indication for initial radical prostatectomy?

High risk prostate cancer is a deadly disease that needs aggressive treatment. High risk prostate cancer is often treated with androgen deprivation therapy or combined radiohormonotherapy while there is a place for surgery in cases of operable and resectable locally advanced or high risk disease. This review summarises the results of the different treatment strategies for locally advanced and high risk prostate cancer. Radical prostatectomy monotherapy or in combination with radiotherapy and/or hormonal treatment are analysed. They show that radical prostatectomy is an effective treatment modality for these tumours. After surgery, the results of the pathology and the follow-up of serum PSA may indicate the need of additional adjuvant or salvage treatment strategies.

Laparoscopic radical prostatectomy plus extended lymph nodes dissection for cases with non-extra node metastatic prostate cancer: 5-year experience in a single Chinese institution

OBJECTIVE

To investigate the functional and oncologic outcomes of patients with locally advanced or lymph node metastatic prostate cancer (PCa) treated by laparoscopic radical prostatectomy (LRP) in a single Chinese institution.

METHODS

From June 2004 to June 2011, a total of 152 cases including 105 locally advanced PCa and 47 lymph node metastatic PCa who were treated by LRP with extended lymph node dissection (ePLND) were enrolled in this study. Surgical records, urinary continence, complications, and oncologic outcomes were presented.

RESULTS

The mean operation time and bleeding were 240 min and 110 ml, respectively. After 12-87 months (median 48 m) of follow-up, 91.4 and 94.7 % of the patients were urinary continence at 6 and 12 m, respectively. Eighty biochemical recurrent diseases were observed. The 3- and 5-year biochemical progression-free survival rates were 59.2 and 47.3 %, respectively. Multivariate analysis showed that Gleason score (HR: 1.66, 95 % CI: 1.05-2.64, P = 0.031), pathological stage (HR: 1.64, 95 % CI: 1.2-2.23, P = 0.002), and surgical margin status (HR: 1.75, 95 % CI: 1.04-2.95, P = 0.035) were independent predictive factors for subsequent biochemical relapse. The 3- and 5-year overall and cancer-specific survival rates were 90.2, 86.0 and 95.8, 92.3 %, respectively. There were no significant differences in biochemical recurrence-free (42.6 vs. 49.5 %, P = 0.491), overall (83.4 vs. 87.3 % P = 0.503), and cancer-specific survival rates (92.3 vs. 94.9 %, P = 0.801) between lymph node-positive and -negative PCa.

CONCLUSION

With favorable functional and oncologic outcomes in this cohort of 152 patients, we concluded that LRP plus ePLND is feasible for patients with locally advanced non-extra node metastatic PCa.

Biomarker research in prostate cancer--towards utility, not futility

The identification of an appropriate clinical question is critical for any biomarker project. Despite rapid advances in technology, few biomarkers have been forthcoming for prostate cancer. This could be because the clinical questions under investigation have not actually originated from clinical practice. These clinical questions are difficult to identify in the complex and heterogeneous pathogenesis of prostate cancer. In this Review, we have developed a prostate cancer 'roadmap' to identify the aspects of prostate cancer that may be amenable to biomarker discovery and serve as a guide for future projects in prostate cancer biomarker research.

Oncologic outcomes of asian men with clinically localized prostate cancer after extraperitoneal laparoscopic radical prostatectomy: a single-institution experience

Purpose. To evaluate the midterm oncologic results of extraperitoneal laparoscopic radical prostatectomy (EPLRP) for Asian men with localized prostate cancer. Methods. Between 2004 and 2009, 218 men underwent EPLRP at an Asian tertiary hospital. The mean preoperative prostate-specific antigen (PSA) was 15.5 ng/ml and mean Gleason score was 6.6. Stage distributions were cT1a-b in 21 cases, cT1c in 139, cT2 in 48 and cT3 in 10. Disease recurrence was defined as PSA ≥ 0.2 ng/mL in 2 consecutive measurements or initiation of secondary therapy. Results. Postoperative pathological stage was pT2a-b in 33 patients, pT2cN0 in 10, pT3a in 27, pT3b in 36, pT4 in 9 and pN1 in 10. Positive surgical margins occurred in 14.6% and 48.6% for pT2 and pT3 diseases, respectively (P < .001). The overall PSA recurrence-free survival at 3 and 5 years was 82.1% and 74.5%. By the pathological stages, 3-year recurrence-free survival was 92.4% (pT2), 81.1% (pT3a), 62.6% (pT3b-4) and 55.6% (pN1), respectively (P < .001). Conclusions. EPLRP is curative even for some locally advanced prostate cancers in a midterm follow-up. Even at an Asian center of low volume of radical prostatectomy EPLRP still provides oncologic outcomes similar to that of high volume centers.

[Node-positive prostate cancer. Value of radical prostatectomy]

The current review article critically discusses the potential advantages and disadvantages of radical prostatectomy in patients with locally advanced lymph node-positive prostate cancer. It is the purpose of the manuscript to develop a therapeutic algorithm for management of these patients to achieve optimal oncological and functional results. Based on the data in the literature radical prostatectomy as part of a multimodality approach seems to be indicated in the following clinical scenario: limited intrapelvic lymph node metastasis without bulky disease; complete resectability of the primary cancer and metastases by extended radical prostatectomy and extended pelvic lymphadenectomy; inclusion of the patient in a multimodality approach; life expectancy > 10 years. In patients with extensive locally advanced PCA or large pelvic metastases, radical prostatectomy might be indicated to improve local cancer control and to prevent significant local and supravesical complications. In these cases, the indication for extensive surgery includes radical cystoprostatectomy and should be discussed in an interdisciplinary tumour board.

Prognostic factors for and outcome of locally advanced prostate cancer after radical prostatectomy

OBJECTIVE

To present the outcomes of cT3N0M0 prostate cancer after radical prostatectomy (RP) and determine the prognostic factors in biochemical progression-free survival (BPFS), clinical progression-free survival (CPFS), cancer-specific survival (CSS) and overall survival (OS) after long-term follow-up of 10 years.

PATIENTS AND METHODS

In all, 164 patients who were assessed as clinical T3 prostate cancer by digital rectal examination (DRE), underwent RP and bilateral pelvic lymphadenectomy at Erasmus MC between 1977 and 2004 without neoadjuvant treatment. Preoperative staging computed tomography showed no signs of metastasis. Kaplan-Meier curves were constructed to show BPFS, CPFS, CSS and OS. Cox proportional hazard analysis was used to determine prognostic indicators of disease progression.

RESULTS

The mean (range) follow-up was 100 (1-291) months. At 5, 10 and 15 years, BPFS was 50.4%, 43.0% and 38.3%, respectively, CPFS was 79.7%, 68.7% and 63.5%, CSS was 93.4%, 80.3% and 66.3%, and OS was 87.1%, 67.2% and 37.4%. Multivariate Cox proportional hazard analysis showed that surgical tumour grade, margin and node status were significant factors in CPFS and CSS. Surgical tumour grade, node status and preoperative PSA level were significant factors in BPFS CONCLUSION: RP for clinically locally advanced prostate cancer may produce acceptable long-term BPFS, which is comparable with published results of radiotherapy with adjuvant endocrine therapy. Pathological tumour grade and node status were significant predicting factors in BPFS and CPFS, as well as tumour-specific survival after 100 months follow-up.

Locally advanced prostate cancer: the role of surgical management

Among the heterogeneous population of patients with prostate cancer, a high-risk group with locally advanced prostate cancer (LAPC) present a diagnostic and therapeutic dilemma. Although the incidence of LAPC has decreased with screening since the introduction of prostate-specific antigen (PSA) testing, significantly many patients are still diagnosed with LAPC. These patients are by definition at higher risk of metastatic disease and worse outcomes. The role of radical prostatectomy (RP) in this population has been debated, as the combination of radiotherapy and hormonal therapy is becoming used more frequently for LAPC. Unfortunately, the clinical staging and evaluation of LAPC is a challenge that results in possibly understaging or overstaging these patients. This further complicates therapeutic decision-making, and as a result no established standard treatment has been proposed. Like other patients with prostate cancer, individualized therapeutic choices are essential and depend on a multitude of factors. Herein we examine the role of RP for managing LAPC and attempt to emphasize how the risk of distant disease and difficulty with clinical staging might favour incorporating a surgical approach as part of the therapy for patients with LAPC.

The clinical significance and therapeutic implications of extraprostatic invasion

Invasion of the prostatic margin by cancer establishes a higher risk of disease progression and treatment failure depending upon its extent and other clinical factors. Pathological stage is the most important single prognostic indicator, but determined reliably only in patients having radical prostatectomy. Tumour beyond the prostatic margin or its invasion into the seminal vesicle defines the local stage category as T3, and when confirmed by pathological examination the extent of prostatic margin involvement has prognostic significance. Prediction of extraprostatic invasion may influence therapeutic decisions, but can be difficult to determine for the individual patient prior to treatment. In some individuals having radical prostatectomy, the finding of extraprostatic invasion is unsuspected, and fortunately for the majority of these men the treatment remains curative. On the other hand, when extraprostatic invasion is suspected prior to or at surgery, wide excision may be necessary to achieve negative surgical margins, with other factors contributing independently to the likelihood of subsequent progression. Radiotherapy is an effective alternative treatment for clinical stage T3 and high-risk clinically localized cancer. Recent technological advances and use of combination modality treatment with radiation and hormone manipulation have improved survival outcomes and reduced side-effects. Radiation also has its place as adjuvant treatment following radical prostatectomy in high-risk disease, or as salvage following PSA recurrence, with ongoing trials evaluating potential benefit and toxicity. For clinically localised stage T3 prostate cancer, treatment with surgery or radiotherapy may be highly effective, but multimodality interventions are increasingly being used for primary treatment where clinical assessment indicates that there would otherwise be a high risk for disease progression and therapeutic failure.

[The role of surgery in locally advanced prostate cancer]

Recent retrospective monocentric studies have demonstrated favorable 15-year cancer-specific survival (CSS) rates of up to 86% using radical prostatectomy as part of multimodal treatment in locally advanced prostate cancer (T3-4, N0, M0). Patients most likely to benefit from surgery include those with a biopsy Gleason score < or =8, a prostate-specific antigen level <20 ng/ml, and cT3a cancer. Patients must be informed that additional treatment after prostatectomy might be necessary (30-70%; radiotherapy, hormonal therapy). Urinary incontinence may occur in up to 20%, and severe incontinence (more than two pads per day) is observed in up to 6%.Adjuvant radiotherapy should be considered individually and is not routinely recommended. Extended pelvic lymphadenectomy should be performed, although it has only a minor impact on survival. However, even in patients with lymph node micrometastasis, 10-year CSS can be achieved in 85.6% with the use of additional hormonal therapy. Cancer progression can possibly be delayed by surgical excision of the primary tumor, even in patients with metastasis. The existing data must be checked in prospective randomized trials.

[Oncologic and functional outcomes after radical prostatectomy in T3 prostate cancer]

According to current literature, the gold standard treatment for T3 prostate cancer is the combination of radiotherapy and extended hormonotherapy. Clinical staging based on digital rectal examination seems useless nowadays, since 20% of T3 prostate cancer is overevaluated during physical examination. Prostatic MRI is extensively needed to evaluate extraprostatic extension during preoperative work-up. EAU guidelines recommend radical prostatecomy only in selected patients: less than or equal to cT3a, PSA less than 20 ng/ml and biopsy Gleason score less than or equal to 8. Carcinologic control obtained after radical prostatectomy is variable from one series to another, with biochemical free survival rate at 5, 10 and 15 years that range from 45 to 62%, 43 to 51%, and 38 to 49%. Specific survival rates at 5, 10 and 15 years are, respectively, of 84 to 98%, 85 to 91% and 76 to 84%. Surgical margins rate differ from 22 up to 61% corresponding to several operative techniques and surgeon's own experience. Regarding urinary continence, functional outcomes are in line with those of prostatectomy for localized prostate cancer. Considering erectile dysfunction, rates are linked with the type of surgery, which can be extensive or not. There is no impact on overall or specific survival of neoadjuvant treatments. One current question remains the efficacy of early adjuvant treatment after prostatectomy, especially adjuvant irradiation. Radical prostatectomy can be considered in selected cases as a viable alternative first-line treatment option. However, patients have to be warned that they may undergo complementary treatments during the postoperative course of the disease.

Role of radical prostatectomy in the treatment of high-risk prostate cancer

Controversy remains regarding the preferred therapy for high-risk, clinically localized prostate cancer. High-risk prostate cancer represents a diverse disease entity for which accurate risk assessment is critical to informed counseling and clinical decision making. For men with high-risk features, electing surgery as a local definitive therapy should be based on the best available evidence rather than a surgeon's bias and experience. Patients classified with high-risk prostate cancer by common definitions do not have a uniformly poor prognosis after radical prostatectomy. Many cancers that are clinically categorized as high risk are actually pathologically confined to the prostate, and most of these men do not require additional long-term therapy after surgery. For some high-risk patients, an integrated approach combining local and systemic therapy may be advantageous. Available studies using adjuvant and neoadjuvant strategies have their individual strengths and weaknesses; unfortunately, none has provided persuasive evidence to dictate the standard of care in the high-risk setting. Therefore, results are eagerly anticipated from ongoing randomized trials exploring the merits of perioperative chemohormonal therapy in high-risk patients. This review discusses current limitations and challenges in accurately identifying high-risk patients and focuses on radical prostatectomy alone or as part of multimodal therapy for men with high-risk prostate cancer.

Prediction of Pathological Stage is Inaccurate in Men with PSA Values above 20ng/mL

INTRODUCTION

We hypothesized that either very low (0-2.5 ng/mL) or very high (>20 ng/mL) PSA values may limit the accuracy of pathological stage predictions. To test this hypothesis, we examined 5193 consecutive patients subjected to radical prostatectomy (RP) for localized prostate cancer (PCa).

MATERIAL AND METHODS

Patients were divided into three cohorts according to their pre-treatment PSA value: </=2.5 (n=331), 2.51-20 (n=4545) and >20 ng/mL (n=317). Subsequently in each cohort, the ability of PSA, clinical stage and biopsy Gleason sum was tested in multivariable logistic regression models predicting three separate endpoints: extracapsular extension (ECE), seminal vesicle invasion (SVI) and lymph node invasion (LNI). Predictive accuracy represented the performance benchmark. All models were adjusted for year of surgery and subjected to 200 bootstrap resamples to reduce overfit bias.

RESULTS

For PSA </=2.5 ng/mL, predictive accuracy was 76.7%, 72.3% and 82.8% for respectively ECE, SVI and LNI. For PSA 2.51-20 ng/mL, the predictive accuracy for the same endpoints was 67.8%, 77.4% and 81.6%. Finally, for PSA >20 ng/mL, predictive accuracy was 63.6%, 63.7% and 70.6%.

CONCLUSIONS

The ability to predict pathological stage in patients with PSA values in excess of 20 ng/mL significantly decreased, compared to patients with lower PSA values. Therefore, accurate staging of these patients may require alternative markers or staging schemes.