Results of local and/or systemic adjuvant therapy in the management of pathological stage C or D1 prostate cancer following radical prostatectomy

Adjuvant Hormone Therapy after Radical Prostatectomy: Indications and Results

Despite recent advances in staging modalities, nearly 30–40% of patients undergoing radical prostatectomy for clinically localized prostate cancer have residual disease. In these cases, one or more of the following conditions may be present: extracapsular disease, positive margins, invasion of the seminal vesicles, lymph node metastases or the postoperative persistence of PSA values above the biological threshold. The optimal management for residual prostate cancer remains controversial and in this setting adjuvant therapy could be appropriate. In the present review we examine the conditions in which hormonal adjuvant therapy can be indicated and the results available from retrospective or non-randomized studies. From the data in the literature and in the absence of randomized prospective studies, prudent conclusions could be drawn on the efficacy of adjuvant hormonal therapy. In cases of small volume, low grade (Gleason score «7) prostate cancer in stage C or D1, radical surgery coupled with adjuvant hormonal therapy leads to survival rates in stage C similar to those in the intraprostatic stage, and in stage D1 with minimal lymph involvement, seems to delay clinical development of metastases. Finally, the quality of life associated with adjuvant therapy and the drug regimens available for this therapy are reviewed.

Current status of lymph node-positive prostate cancer: Incidence and predictors of outcome

In early surgical series, the incidence of positive lymph nodes in patients with prostate cancer was approximately 40%. In the modern era of screening and improved patient selection, the incidence is now <10%, although most series excluded patients with higher risk disease. The risk of having positive lymph nodes is influenced by disease stage, prostate-specific antigen level, and tumor grade and by the aggressiveness of lymph node dissection. Many of the same factors predict the outcome of these patients. Although the percentage of patients with positive lymph nodes has declined, there remain significant numbers of patients with lymph node-positive prostate cancer, and it remains a therapeutic dilemma.

Chemotherapy for prostate cancer: implementing early systemic therapy to improve outcomes

Prostate cancer remains a significant health concern for men in the USA as it is a leading cancer diagnosis and a cause of death. With the use of prostate-specific antigen or screening, a stage migration has occurred with an increase in the number of men diagnosed with early-stage disease. The optimal primary management of these men is evolving, but despite adequate local treatment a significant percentage will develop either biochemical or clinical evidence of recurrent disease. Several criteria for risk stratification have been developed, thus, improving the ability to identify a high-risk population. Small studies have been reported demonstrating the feasibility of neoadjuvant or adjuvant chemotherapy in conjunction with either radiation or radical prostatectomy in this high-risk population, and large phase III studies are ongoing. With the advent of life-prolonging chemotherapy in the hormone-refractory setting, attention must now also be given to early-stage disease so as to develop multi-modality approaches with the hope of increasing survival and ultimately providing a cure.

Treatment options in lymph node-positive prostate cancer

With improved awareness and screening, the incidence of lymph node-positive prostate cancer has declined dramatically over the last 50 years. Stage of cancer, prostate-specific antigen, and grade are risk factors for positive lymph nodes; and those factors, along with the number of involved lymph nodes, are prognostic factors for outcome. Although the numbers have declined, the number of men with lymph node-positive prostate cancer remains significant, and the current challenge is how best to treat these patients. Commonly used treatments include any combination of androgen ablation, surgery, and radiation. There have been a few studies with chemotherapy, and no treatment has been proven superior to the others. Consequently, there remain several reasonable alternatives to treatment, and long-term survival is not unusual.

Role of postoperative radiotherapy after pelvic lymphadenectomy and radical retropubic prostatectomy: a single institute experience of 415 patients

PURPOSE

To evaluate the clinical benefit deriving from early (within 6 months) radiotherapy (ERT) after pelvic lymphadenectomy and radical retropubic prostatectomy for localized/locally advanced adenocarcinoma of the prostate in a single-institution series.

METHODS AND MATERIALS

We retrospectively analyzed 415 patients who underwent pelvic lymphadenectomy and radical retropubic prostatectomy between 1986 and 1998 for pT2b-pT4, pN0-pN1 prostate carcinoma. Of the 415 patients, 237 underwent ERT for adverse pathologic findings and 178 patients did not receive RT or underwent salvage RT < or =6 months (salvage or no RT [SNRT]).

RESULTS

After a median follow-up of 62 months, the 8-year actuarial freedom from biochemical, local and systemic failure, and cause-specific survival rate was 69% vs. 31% (p <0.0001, log-rank), 93% vs. 63% (p <0.0001), 88% vs. 75% (p = 0.04), and 93% vs. 80% (p = 0.02) in the ERT and SNRT group, respectively. A subgroup analysis indicated that an improvement in 8-year actuarial cause-specific survival was associated with ERT in patients with positive resection margins (91% vs. 67%, p = 0.007), extracapsular extension (92% vs. 75%, p = 0.002), Gleason score > or =7 (88% vs. 72%, p = 0.02), and lymph node metastases (88% vs. 68%, p = 0.04). This strong association between ERT and cause-specific survival persisted at multivariate analysis in the whole group of patients examined (hazard ratio, 4.3) and in the subgroups of patients with extracapsular extension (hazard ratio, 4.9), positive resection margins (hazard ratio, 4.7), Gleason score > or =7 (hazard ratio, 4.4), and lymph node metastases (hazard ratio, 7.4).

CONCLUSION

The results of this retrospective analysis indicate that ERT after pelvic lymphadenectomy and radical retropubic prostatectomy improved the 5-year and actuarial 8-year cause-specific survival of patients with adverse pathologic findings such as extracapsular extension, positive resection margins, Gleason score > or =7, and/or positive lymph nodes.

An evidence-based approach to prostate cancer follow-up

The follow-up required for patients with prostate cancer is critically dependent upon the stage of disease and the ultimate goal for treatment. A major difficulty in follow-up in prostate cancer is the lack of data on outcome of various treatment modalities. Additionally, there is a lack of data on the use of treatment modalities early in the course of prostate cancer. Despite these limitations, there is a need to develop an approach to follow these patients pending further study. In this review, we critically assess the natural course of untreated prostate cancer, the complications of local therapy, and the controversy over early versus delayed hormonal therapy. As a result of this discussion, common themes emerge. Most patients diagnosed with prostate cancer die of causes other than prostate cancer such as cardiovascular disease and therefore require additional follow-up. Since patients experience local problems such as urinary obstruction more commonly than symptomatic metastatic disease, instruments to assess urinary symptoms are discussed. Finally, follow-up as a means to determine eligibility for clinical studies is discussed.

The rationale for adjuvant chemotherapy for high-risk prostate cancer

PURPOSE OF REVIEW

With the advent of prostate-specific antigen, stage migration has resulted in a shift towards early-stage prostate cancer at diagnosis. Although radical prostatectomy and radical radiotherapy can be curative in organ-confined disease, there remains a significant proportion of early-stage patients who go on to develop progressive, incurable disease. This review will highlight developments in the identification of high-risk patients, and summarize the results of investigations of adjuvant chemotherapy in this setting.

RECENT FINDINGS

The ability to identify patients at high risk of developing progressive disease is improving. Both preoperative and postoperative variables, as well as newer radiographic and molecular tools, can identify at-risk patients who may benefit from adjuvant therapy. Coupled with developments in chemotherapeutic agents for prostate cancer, this provides the rationale for investigating chemotherapy in this setting. Unfortunately, to date, reported trials involving adjuvant chemotherapy in prostate cancer are few, and generally involve small numbers of patients. Some of the studies confirm that certain populations of patients, such as those with node-positive disease, may benefit from systemic therapy. Definitive data, however, will be derived from ongoing randomized trials investigating adjuvant chemotherapy.

SUMMARY

Although definitive data regarding systemic chemotherapy in adjuvant therapy are scarce, the results of the available studies, and the increasing accuracy in delineating the population at risk, have laid the foundation for future and ongoing studies in this area.

Adjuvant and salvage irradiation following radical prostatectomy for prostate cancer

PURPOSE

We performed a retrospective analysis to assess the durability of benefit derived from irradiation after prostatectomy for pT3N0 disease, and the possibility of cure.

METHODS AND MATERIALS

We studied 88 patients who were irradiated after prostatectomy and had available prostate specific antigen (PSA) data, no known nodal or metastatic disease, no hormonal treatment, and follow-up of at least 12 months from surgery. Forty patients received adjuvant therapy for a high risk of local failure with undetectable PSA. Forty-eight patients received salvage therapy for elevated PSA levels. Mean follow up was 44 months from date of surgery and 31 months from irradiation. Biochemical failure was strictly defined as a confirmed rise in PSA of >10%, or as the ability to detect a previously undetectable PSA value.

RESULTS

After salvage irradiation, 69% of patients attained an undetectable PSA. Eighty-eight percent of adjuvant patients were biochemically and clinically free of disease (bNED) at 3 years from prostatectomy. Sixty-eight percent of those receiving salvage irradiation were bNED 3 years after surgery. On univariate analysis, treatment group (adjuvant or salvage), pre-operative PSA, and the status of seminal vesicles were significant prognostic factors. The extent of PSA elevation in the salvage group was also significant. We did not demonstrate a significant difference between those salvage patients referred for persistently elevated PSA as compared to those with a late rise in PSA. On multivariate analysis, the only significant predictor of outcome was treatment group, with adjuvant irradiation having better outcome than salvage.

CONCLUSION

More than two-thirds of this group of patients remain biochemically disease free at 3 years following irradiation, attesting to a number of potential cures. For patients with stage pT3N0 prostate cancer following radical prostatectomy, our data support the use of either routine postoperative adjuvant irradiation or close PSA follow-up with early salvage treatment.

[Radiotherapy after radical prostatectomy: indications, results and side effects]

BACKGROUND

Radiation therapy following radical prostatectomy in locally progressed prostate carcinoma has become increasingly important in the last few years as both adjuvant therapy in patients with pT3-tumors with or without positive margins and treatment for a PSA increase in local recurrence of disease. The background for this is the knowledge gained by using PSA that up to 60% of the patients with histopathologically confirmed pT3/4 tumors or involvement of the lymph nodes are systemically and/or locally progressive after 3 to 5 years if only surgical or radiation therapy was performed.

RESULTS

A number of studies, albeit exclusively retrospective, substantiated a significantly high local tumor control by radiotherapy after radical prostatectomy. This holds true for adjuvant therapy with a PSA in the "zero range" as well as with a PSA increase from the "zero range", whereby it must be taken into consideration that a certain percentage of treated patients with a PSA in the "zero-range" with or without positive margins actually do not need further therapy. Two retrospective studies demonstrated a significant better lengthening of "freedom from treatment failure" that is local and systemic progression of disease. Lengthening the survival time has, however, not yet been proven. With an increase in the PSA from the "zero range" after radical prostatectomy, there are indications that systemic metastatic spread already occurs with values higher than 2.5 to 4 ng/ml and the radiotherapy no longer has any curative intention.

CONCLUSIONS

Adjuvant RT following radical prostatectomy gives better local control rates and probably better rates of "freedom from treatment failure" in patients with locally advanced prostate cancer with positive margins and probably in patients with negative margins. However, in retrospective studies no advantage in overall survival was shown.

Serum prostate-specific antigen elevation in the post-radical prostatectomy patient

The management of postprostatectomy serum prostate-specific antigen elevation is hampered by the inability to determine the location of the recurrence accurately and the lack of data demonstrating a survival advantage from any of the available therapies. Treatment must be individualized for each patient.

Delayed/salvage radiation therapy in patients with elevated prostate specific antigen levels after radical prostatectomy. A long term follow-up

BACKGROUND

In this article the authors report an analysis and long term results of delayed/salvage radiation therapy administered to asymptomatic patients who had an elevated prostate specific antigen (PSA) level, many months to many years after radical prostatectomy.

METHODS

During 1987 to 1990, 40 asymptomatic patients were found to have an elevated PSA level 9 to 96 months after radical prostatectomy. The patients underwent transrectal needle aspiration biopsy of the urethrovesicle junction anastomosis (uvj); 28 patients had a positive biopsy and 12 patients had a negative biopsy. Delayed/salvage radiation therapy was administered to the pelvis (45 Gray [Gy]) and prostate bed (59.5 Gy), including the uvj.

RESULTS

Twenty-four of 37 patients (65%) were free of clinical disease. In 10 patients (27%), the radiation therapy resulted in a durable decrease in the elevated PSA level below a detectable level for a minimum 5-year follow-up. Five patients were alive with clinical disease. Eight died of disease. Three patients were lost to follow-up.

CONCLUSIONS

This experience shows that delayed/salvage radiation therapy to the pelvis (45 Gy) and prostate bed (59.5 Gy), even many years after radical prostatectomy for pathologic stage pB, pC, and pD1 carcinoma of the prostate, was well tolerated and provided freedom from clinical disease in 24 of 37 patients (65%), and a decrease in elevated PSA level in 10 patients (27%). Delayed/salvage radiation therapy appears to be beneficial for patients who had undergone radical prostatectomy only and then developed rising PSA levels during the follow-up period.

Radical prostatectomy for clinically localized prostate cancer: local tumor extension and prognosis

BACKGROUND

This study was performed to evaluate the frequency of local tumor extension and its effect on disease progression after radical prostatectomy.

METHODS

The study consisted of 66 consecutive men who underwent radical prostatectomy for clinically localized prostate cancer without any prior hormonal therapy. Cases were stratified according to pathologic findings. Sites of capsular penetration were also evaluated.

RESULTS

The overall incidences of lymph node metastases, seminal vesicle invasion, capsular penetration, and positive surgical margin were, respectively, 23%, 32%, 55% and 35%. The disease progression rate in patients with positive lymph nodes differed significantly from that in those without nodal metastases (P < 0.0001). Although seminal vesicle invasion, capsular penetration, or positive surgical margin had an adverse effect on prognosis, the difference in progression missed statistical significance, when patients with positive lymph node metastases were excluded. The most common site of capsular penetration was posterolateral, in the area of the neurovascular bundle.

CONCLUSIONS

Extraglandular tumor extension and positive surgical margins are common features of radical prostatectomy specimens. A nerve-sparing operation should be performed selectively and with great caution. The markedly adverse effect of lymph node involvement on progression must be accounted for when evaluating other variables relating to progression.

Suramin as adjuvant therapy with radical prostatectomy

Suramin is a newer agent employed in the management of prostate cancer. One suggested method of action is growth factor inhibition. While suramin has been employed to treat advanced disease its adjuvant role remains unexplored. To address this question we have employed a new model: the orthotopic placement of the Dunning AT-3 tumor. The purpose of this research was to assess the efficacy of adjuvant therapy in controlling residual disease. The method consisted of the injection of 2.4 to 2.6 x 10(6) AT-3 cells (harvested from flank tumors) into the ventral prostates of 29 Copenhagen X Fischer rats. The animals were then divided into four groups: 1) untreated controls (6 rats); 2) ventral prostatectomy only (10 rats); 3) ventral prostatectomy plus suramin (300mg/Kg) on post-op day 3 (5 rats); and 4) ventral prostatectomy plus cytoxan (50 mg/Kg) on post-op day 3 (8 rats). Prostatectomies were performed 10-12 days following AT-3 cell inoculation. Animals were sacrificed 10 days following prostatectomy, autopsied, and residual diseased weighed. All operating procedures: tumor cell inoculations, ventral prostatectomies, and necropsies were performed microsurgically employing a Zeiss operating microscope. The results (in mean tumor weights) were: Group 1, 20 +/- 1.4 gms; Group 2, 6.7 +/- 11.5 gms; Group 3, 2.7 +/- 3.8 gms; and Group 4, 2.2 +/- 2.5 gms. The differences between control and all treatment groups were significant: Group 1 vs. Group 2, P < 0.02; and Group 1 vs. Groups 3 and 4, P < 0.001. We conclude that prostatectomy resulted in a diminished weight of residual disease. Of more importance was the fact that adjuvant therapy further reduced residual disease. The orthotopic placement of the Dunning tumor may serve as a model to evaluate the place of suramin following radical prostatectomy.

An analysis of the time course of postoperative prostate-specific antigen failure in patients with positive surgical margins: implications on the use of adjuvant therapy

OBJECTIVES

The role of adjuvant therapy in the postprostatectomy setting for positive margin patients is an unresolved issue. The purpose of this study is to provide the rationale for patient selection in Phase III trials that test the impact of adjuvant therapy on survival in positive margin prostate cancer patients.

METHODS

Early (12 months or less) and delayed (more than 12 months) postoperative prostate-specific antigen (PSA) failure have been correlated with distant and local failure, respectively, as the site of first failure. In this study, a Cox regression multivariate analysis was used to determine the significant independent clinical and pathologic predictors of early and delayed postoperative PSA failure in 143 margin-positive prostate cancer patients.

RESULTS

Margin-positive patients with positive pelvic lymph nodes, seminal vesicle invasion, or prostatectomy Gleason sum 8 or higher were excluded. For the remaining patients, a prostatectomy Gleason sum of 7, preoperative PSA more than 20 ng/mL, and an endorectal coil magnetic resonance imaging (erMRI) scan showing extensive disease were significant independent predictors of early postoperative PSA failure. Conversely, a prostatectomy Gleason sum of 6 or less, preoperative PSA 20 ng/mL or less, and an erMRI showing limited disease predicted delayed PSA failure.

CONCLUSIONS

Preliminary data suggest that the pattern of first failure can be predicted by the time course of rise in the postoperative PSA. The preliminary results of this study suggest that patient selection for clinical trials examining the efficacy of postoperative adjuvant therapy in the positive margin patient may be determined on the basis of the clinical and pathologic characteristics that predict early versus delayed postoperative PSA failure.

Postoperative prostate-specific antigen as a prognostic indicator in patients with margin-positive prostate cancer, undergoing adjuvant radiotherapy after radical prostatectomy

OBJECTIVES

To identify a population of patients within the group with positive surgical margins after radical prostatectomy who would benefit in terms of improved local control of disease by the administration of adjuvant radiation therapy to the prostate bed.

METHODS

Postoperative prostate-specific antigen (PSA) values were evaluated in 45 patients with margin-positive (MP) disease who underwent adjuvant radiotherapy within 6 months of surgery. All patients were clinically T1-2 MO, and pNO. A cutoff of 0.5 ng/mL or less was used as the level below which PSA was considered undetectable. The mean follow-up time from date of radiation was 33 months.

RESULTS

In 30 of 45 (67%) patients, PSA levels did drop to undetectable levels postoperatively. In 15 of 45 (33%) patients postoperative PSA levels did not drop to undetectable levels. In the group with detectable postoperative PSA, 12 of 15 (80%) failed adjuvant radiotherapy as determined by a progressive increase in PSA levels in a mean time of 0.95 years (range, 4 months to 2.02 years; median, 0.92 years). When postoperative PSA reached undetectable levels, only 10 of 30 (33%) failed treatment, with a mean time to failure of 2.1 years (range, 4 months to 7.8 years; median, 3.31 years).

CONCLUSIONS

The data would suggest that patients who are MP, but attain an undetectable PSA level postoperatively accompanied by a progressive delayed increase in PSA, probably represent a group with local disease recurrence in the prostate fossa, whereas patients whose PSA levels are detectable postoperatively may represent a group with microscopic metastatic disease or a combination of local recurrence and distant disease or large volume local persistent disease. It is in the group of patients in whom the postoperative PSA decreased to undetectable levels that adjuvant radiotherapy may be effective in controlling local progression of prostate cancer through improved local control, as indicated by a durable decrease in PSA values to undetectable levels in roughly two thirds of these patients. Longer follow-up of these patients will be required to determine whether this improved local control will translate into improved survival.

Seminal vesicle biopsy and laparoscopic pelvic lymph node dissection: implications for patient selection in the radiotherapeutic management of prostate cancer

PURPOSE

Seminal vesicle biopsies (SVB) and laparoscopic pelvic lymph node dissection (LPLND) are safe surgical staging procedures for prostate cancer that can yield more accurate information than can be obtained by routine clinical means. This information is critical in patient and treatment selection when planning definitive prostate irradiation. An analysis of the procedural findings was undertaken to better define those patients who might benefit from these procedures.

METHODS AND MATERIALS

From June 1990 to February 1994, 120 patients with clinical Stage T1b to T2c prostate cancer with negative bone scan and pelvic computerized tomography (CT) scans underwent transrectal ultrasound guided SVB (three from each side). Of these patients, 99 also underwent LPLND. Twelve patients were excluded from analysis of LPLND findings because they were treated with 3 months of hormonal therapy prior to LPLND. During LPLND, 0 to 18 nodes were removed (median-five nodes) from the right side and 0 to 20 nodes (median-five nodes) were removed from the left side. Prostate specific antigen (PSA) values ranged from 1.6 to 190 ng/ml, with a median value of 11.5. Combined Gleason grades ranged from 2 to 9, with a median of 6.

RESULTS

A positive SVB was found in 18 patients (15%). A logistic regression analysis was performed to test the effect of grade, PSA, and stage on SVB results. Combined grade and PSA were significant predictors of a positive SVB (p < 0.001 and p = 0.024, respectively). Patients with combined grades of 7 or greater had a higher positive SVB rate of 37.5% (12 out of 32) compared to 7% (6 out of 88) for patients with a lower grade (p < 0.0001). Patients with PSA values greater than 10 had a positive SVB rate of 21% (15 out of 70) compared to 6% (3 out of 50) for patients with values up to 10. There was no morbidity associated with SVB. Laparoscopic pelvic lymph node disection detected positive pelvic nodes in nine patients (10%). The effect of a positive SVB, combined Gleason grade, PSA, and stage on the detection of positive nodes were tested using a stepwise logistic regression analysis. Seminal vesicle biopsy was the most significant predictor of positive nodes (p < 0.0001), while combined grade and PSA were also significant predictors (p = 0.0006 and p = 0.005, respectively). Positive nodes were found in 50% (9 out of 18) of patients with positive SVB compared to 0% (0 out of 69) of patients with a negative SVB (p < 0.0001). Positive nodes were found in 35% (8 out of 23) of patients with a combined grade of 7 or greater compared to 2% (1 out of 64) of patients with a combined grade less than 7 (p < 0.0001). Laparoscopic pelvic lymph node dissection revealed positive nodes in 3% (2 out of 58) of patients with PSA levels < = 20 compared to 24% (7 out of 29) of patients with PSA levels greater than 20 (p = 0.003). Laparoscopic pelvic lymph node dissection was associated with a hospital stay of one night and a minor complication rate of 4%. There were no major complications.

CONCLUSIONS

Seminal vesicle biopsy should be performed before treatment in all patients, except those with low risk factors, undergoing radiation therapy for prostate cancer, due to its ability to upstage patients, select patients for LPLND, and alter radiotherapeutic management. Laparoscopic pelvic lymph node dissection should be considered in patients with high risk features, especially in patients with positive SVB where the likelihood of encountering positive nodes is 50%.

Surgery with adjuvant irradiation in patients with pathologic stage C adenocarcinoma of the prostate

BACKGROUND

In recent years, the routine use of prostate-specific antigen (PSA) to detect cancer of the prostate (CaP) early has renewed the controversy regarding radiotherapy versus radical prostatectomy as the superior definitive treatment. Radiotherapy alone has been reported to result in a high incidence of local recurrence, whereas on the other hand surgical treatment has resulted in a high incidence of microscopic residual tumor. The purpose of this study was to review our treatment results with radical prostatectomy followed by planned courses of postoperative irradiation in patients with pathologic Stage (PS) C disease.

METHODS

From 1972 to 1989, 95 patients with CaP with PS C tumors were treated with radical prostatectomy and bilateral pelvic lymphadenectomy. Pathologic stage distribution was: C1 in 26 (27%), C2 in 37 (39%), and C3 in 32 (34%) patients. The median follow-up was 6 years. All 95 study patients received postoperative pelvic irradiation as the only adjuvant treatment. Radiotherapy treated volume included the prostatic fossa and its immediate vicinity. The RT dose ranged from 33 Gy to 61.8 Gy (median, 45 Gy).

RESULTS

The overall 5- and 10-year actuarial survival rates were 94% and 73%, respectively, with the 5 and 10 year disease specific survival of 98% and 91%, respectively. Clinical and/or prostate specific antigen recurrence was 31% at 5 years and 44% at 10 years. Prostate specific antigen elevation without clinical evidence of recurrent disease was recorded in 26 (27%) patients. Seminal vesicle involvement (C3) and high Gleason's score (8-10) were the most important factors predicting recurrence. Of the 95 patients treated, 2 had pelvic recurrence alone and 1 had local and distant metastatic disease. Radiotherapy was well tolerated with no clinically important morbidity.

CONCLUSION

Based on this experience, moderate dose adjuvant radiotherapy after radical prostatectomy in patients with PS C CaP is recommended.

La progressione di malattia dopo prostatectomia radicale: Quale strategia terapeutica?

Cancer progression, following radical prostatectomy, is distinguished by its biological or clinical aspects and is a controversial subject. As adjuvant therapy there is hormonal treatment and radiation therapy or a combination of both. The lack of standardization of the main pathological features of prostate cancer does not allow an accurate valuation of the results from the most important studies. A real efficacy in local or distant control seems to be certain, while the influence on disease-free survival is more uncertain. After a review of the most common options of treatment, the Authors present their results from 107 radical prostatectomies carried out between 1989 and 1994.

Mini-laparotomy staging pelvic lymph node dissection for localized prostate cancer

We report our early experience with mini-laparotomy staging pelvic lymph node dissection (PLND) for clinically localized prostate cancer. We have used virtually the same original technique described by Steiner and Marshall. A 5 cm lower midline abdominal incision provides excellent exposure, allowing complete PLND under direct visualization. If radical retropubic prostatectomy is indicated by the state of the pelvic lymph nodes, this can be performed only by extending the same incision. Nine patients with histologically proven prostate cancer underwent mini-laparotomy staging PLND. The average intraoperative time for mini-laparotomy PLND was 33 minutes (range, 25-50 minutes). The intraoperative blood loss was 44 ml (range, 20-90 ml). The mean number of pelvic lymph nodes removed was 6.9 (range, 5-10 nodes) on the right and 10.8 (range, 8-21 nodes) on the left. Eight patients underwent immediate radical retropubic prostatectomy and one had radiation therapy. There were no complications directly related to the mini-laparotomy staging PLND. Mini-laparotomy staging PLND is an attractive alternative to laparoscopic PLND, especially for patients at low risk of lymph node metastasis.

Adjuvant radiotherapy following radical prostatectomy--results of 56 patients

Patients with adenocarcinoma of the prostate with positive surgical margins and/or seminal vesicle invasion after radical prostatectomy (RP) have a high risk of local recurrence or distant spread of disease. Several investigators reported increased local control rates following adjuvant radiotherapy (RT). However, it is unclear whether this procedure, with or without hormonal therapy (HT), improves the outcome. From 1975 to 1987, 56 patients with adenocarcinoma of the prostate underwent adjuvant RT following RP (pathological stage C1, n = 19; stage C2, n = 17; stage D1, n = 20). In 27 of 56 patients an additional immediate orchiectomy was performed. 48 patients received 4000-5000 cGy to the pelvic lymphatics, including the prostatic fossa, followed by a boost to the prostatic fossa to complete 6400-7000 cGy, whereas 8 patients were treated to the prostatic fossa only. With a median follow-up of 89 months, the overall survival rate of patients with stages C1, C2 and D1 did not differ significantly (10-year overall survival rate 84, 74 and 71, respectively). The local control rate for 5- and 10-years was 96 and 90%, respectively. A significant advantage in overall survival (5- and 10-year rate: 92 versus 93% and 92 versus 63%; P < 0.05, respectively) and clinical disease-free survival (5- and 10-year rate: 92 versus 72% and 92 versus 49%; P < 0.05, respectively) was seen in 27 patients with orchiectomy compared with 29 patients without HT. A total of 15 patients (26%) developed at least one form of late toxicity, in most cases a mild proctitis, cystitis, or penile or leg oedema. However, 6 patients (11%) had severe grade 3 or 4 side-effects that necessitated a cystectomy in 2 cases as well as a colostomy in 2 cases. In all patients with grade 3 or 4 side-effects, 70 Gy as a tumour-encompassing isodose were applied. Adjuvant RT, following RP in stage C and D1 prostate cancer with positive surgical margins and/or seminal vesicle invasion increases local control. Whether immediate HT influences the outcome, as seen in this study, should be proven in prospective clinical trials.

Does radical prostatectomy in the presence of positive pelvic lymph nodes enhance survival?

A retrospective review was performed on all patients with stage D1 prostate cancer treated at Duke University Medical Center between 1975 and 1989. A total of 156 patients underwent staging pelvic lymph-node dissection for clinically organ-confined prostate cancer (stage A or B) but were found to have disease metastatic to the pelvic lymph nodes (stage D1). Of this population, 42 patients also underwent radical prostatectomy (group 1), leaving 114 who did not have their prostate removed (group 2). The median cancer-specific survival was 11.2 years for group 1 versus 5.8 years for group 2 (P = 0.005). In patients with one or two positive lymph nodes the median cancer-specific survival was 10.2 years for group 1 versus 5.9 years for group 2 (P = 0.015). There was no difference in survival if three or more lymph nodes were positive. Adjuvant treatment with immediate androgen deprivation and/or postoperative radiation therapy failed to improve the survival experience. The incidence of local problems, including stricture formation, bleeding, or regrowth of cancer requiring dilation or surgical intervention (transurethral prostatectomy) averaged 9.5% in group 1 and 24.6% in group 2. These data show that patients with limited node-positive disease selected for radical prostatectomy experience a survival advantage over those denied such therapy and that this advantage is independent of adjunctive therapy.

Adjuvant radiation, chemotherapy, and androgen deprivation therapy for pathologic stage D1 adenocarcinoma of the prostate

OBJECTIVES

A retrospective analysis of the results of an aggressive multimodal approach combining radical prostatectomy with adjuvant radiation, chemotherapy, or androgen deprivation therapy for patients with pathologic Stage D1 prostate carcinoma was performed to assess the impact of these therapies on survival, recurrence, local control, and morbidity.

METHODS

Case records of 76 patients with pathologic Stage D1 tumors were reviewed. All had radical retropubic prostatectomy and were recommended adjuvant therapy based on the pathologic extent of the primary tumor and the number of involved lymph nodes.

RESULTS

With a median follow-up of 7 years, overall survival was estimated to be 88% and 66% at 5 and 10 years, respectively, and equaled age- and race-matched controls. Prostate cancer-specific survival at 5 and 10 years was 88% and 74%, respectively. The probability of developing a clinically detectable recurrence (excluding prostate-specific antigen [PSA]) was 29% and 62% at 5 and 10 years, respectively. When PSA was added to the detection data, the probability of developing a recurrence increased to 58% and 78% at 5 and 10 years, respectively. Recurrence and cause-specific survival correlated with Gleason sum. Univariate analysis of the adjuvant therapies demonstrated no effect on survival, but adjuvant radiation alone and in combination with androgen deprivation increased the time to recurrence. Local control was excellent, surgical morbidity was equivalent to that of all patients undergoing prostatectomy during the same time period, and the morbidity of adjuvant therapy was minimal.

CONCLUSIONS

Survival equivalent to age- and race-matched controls, with excellent control of the extensive primary tumor, can be achieved in patients with Stage D1 prostate carcinoma by a combination of radical prostatectomy and radiation therapy without the need for routine androgen deprivation therapy.

A multivariable analysis of clinical factors predicting for pathological features associated with local failure after radical prostatectomy for prostate cancer

PURPOSE

A multivariate analysis is used to determine the predictive value of pretreatment clinical indicators on pathologic features associated with local failure after radical prostatectomy in patients with prostate cancer.

METHODS AND MATERIALS

A retrospective review of the pathologic findings of 235 patients with adenocarcinoma of the prostate treated between 1990 and 1993 with a radical retropubic prostatectomy was performed. The preoperative clinical data including the serum prostate specific antigen, clinical stage, Gleason sum, and endorectal magnetic resonance scan findings are used to identify patients prior to definitive treatment who would be at high risk for having pathologic features associated with local failure at radical prostatectomy. Outcome prediction curves are constructed from a logistic regression multivariate analysis displaying the probability of pathologic involvement of the seminal vesicle, extracapsular disease, or positive surgical margins as a function of the preoperative prostate specific antigen and Gleason sum for the cases when the endorectal magnetic resonance scan is positive, negative, or not included in the multivariate analysis.

RESULTS

Factors identified on multivariate analysis as significant predictors of seminal vesicle invasion include endorectal magnetic resonance scan findings (p < 0.0001), and preoperative prostate specific antigen (p = 0.017). Endorectal magnetic resonance scan findings (p = 0.0016), preoperative prostate specific antigen (p = 0.0002), and Gleason sum (p < 0.0001) were significant predictors of extracapsular extension and preoperative prostate specific antigen (p < 0.0001) and Gleason sum (p = 0.03) were significant predictors of disease extending to the margins of resection. Clinical stage was not a significant predictor (p > 0.05) of pathologic features associated with local failure on multivariate analysis. As a single modality, endorectal surface coil magnetic resonance imaging was accurate 93%, 69%, and 72% of the time for predicting seminal vesicle invasion, transcapsular disease, and final pathologic stage, respectively. Failure to recognize microscopic penetration of the capsule found at the time of pathologic evaluation in a prostate gland with a grossly intact capsule accounts for the majority (70%) of the staging inaccuracies.

CONCLUSIONS

The use of the endorectal surface coil magnetic resonance scan findings in conjunction with both the serum prostate specific antigen and Gleason sum improves the clinical accuracy of predicting those patients at high risk for clinically unsuspected extraprostatic disease. In particular, for the subgroup of patients with moderately elevated prostate specific antigen (> 10-20 ng/mL) and intermediate grade clinically organ confined prostate cancer [Gleason sum: 5-7] where the specificity of these tests to predict for occult extraprostatic disease is suboptimal, the additional information obtained from the endorectal coil magnetic resonance scan allows the physician to definitively subgroup these patients into low and high risk for seminal vesicle invasion or transcapsular disease.

Effect of radiation therapy on detectable serum prostate specific antigen levels following radical prostatectomy: early versus delayed treatment

Radiation therapy may be beneficial after radical prostatectomy in some patients with pathological stage C prostate cancer and in those with detectable postoperative prostate specific antigen (PSA) levels. A total of 64 men underwent postoperative radiation therapy following radical prostatectomy for pathological stage C disease (27), a detectable serum PSA level (11) or both conditions (26). Of the 27 men treated prophylactically for pathological stage C disease 18 (67%) had no evidence of recurrence after radiation within the first 6 months postoperatively (median followup 40 months, range 17 to 97). Of 22 men treated for delayed PSA elevation 15 (68%) currently are disease-free (median followup 27.5 months, range 15 to 47). Of 15 men treated within the first 6 months after radical prostatectomy for persistently detectable PSA levels 8 (53%) had an initial decrease in PSA to undetectable levels but only 5 (33%) had a durable complete response (median followup 36 months, range 8 to 56). We conclude that patients with pathological stage C disease who are most likely to benefit from postoperative radiation therapy are those with initially undetectable postoperative PSA levels. We observed no striking difference in treatment outcome between early and delayed adjuvant radiation therapy.

Early androgen ablation for stage D1 (N1 to N3, M0) prostate cancer: prognostic variables and outcome

To elucidate the outcome for patients with stage D1 (N1 to N3, M0) prostate cancer we reviewed 179 patients with lymphadenectomy proved pelvic nodal metastases who underwent immediate androgen ablation as the only initial treatment. With a median followup of 43 months, the 5 and 8-year actuarial rates of freedom from disease progression were 55% and 25%, respectively, and the median interval to disease progression was 67 months. The 5 and 8-year survival rates were 85% and 57%, respectively. Median survival after disease progression was 36 months. Local and distant disease progression was equally important. At 5 and 8 years the incidence of local progression was 32% and 51%, respectively, while metastatic rates at the same intervals wer 22% and 44%, respectively. Multivariate regression revealed that tumor grade and transurethral resection in preoperative stage C disease correlated with disease progression. Pretreatment prostate specific antigen (PSA) levels were not predictive of outcome. The fact that transurethral resection predicted for local as well as distant failure suggests that the procedure selects for rather than aggravates adverse disease. Posttreatment PSA levels were a sensitive index of response to treatment and of subsequent outcome. All patients who failed to achieve undetectable PSA levels had relapse by 8 years, whereas those whose levels became undetectable experienced only a 5% incidence of disease progression. These data show that androgen ablation alone is not curative for node positive disease but is associated with significant disease control and good short-term (5-year) survival. The primary tumor is an important source of androgen insensitive cells and comprehensive treatment strategies for this stage of disease require attention to the primary tumor as well as microscopic metastases.

Adjuvant irradiation after prostatectomy for carcinoma of the prostate with positive surgical margins

BACKGROUND

Patients with adenocarcinoma of the prostate treated with prostatectomy who have tumor at the margins of the surgical specimen or tumor involvement of the seminal vesicles have a high risk of local recurrence and metastatic disease. It is unclear whether postoperative irradiation improves their outcome.

METHODS

This is a retrospective analysis of patients treated with prostatectomy for adenocarcinoma of the prostate who had surgical margins or seminal vesicles involved by tumor. Thirty-four patients received adjuvant postoperative irradiation (Group 1), and 43 patients did not receive irradiation (Group 2).

RESULTS

The tumor control rates in the prostatic bed for patients who had radical prostatectomy were 100% and 84% in Groups 1 and 2, respectively (P = 0.017). Actuarial 10-year disease-free survival from the date of prostatectomy was 46% and 55% for Groups 1 and 2, respectively.

CONCLUSIONS

Adjuvant irradiation after prostatectomy in patients with positive surgical margins or seminal vesical invasion increases prostatic bed local tumor control but does not affect survival. Postoperative irradiation is associated with acceptable morbidity.

Radical retropubic prostatectomy and postoperative adjuvant radiation for pathological stage C (PcN0) prostate cancer from 1976 to 1989: intermediate findings

Between 1976 and 1989, 114 patients undergoing radical retropubic prostatectomy and bilateral pelvic lymph node dissection for prostatic adenocarcinoma were found to have stage PcN0 lesions. Postoperative adjuvant radiation therapy without hormonal treatment was given to 95 of these patients (83%): 26 (27%) with stage C1, 37 (39%) with stage C2 and 32 (34%) with stage C3 disease. The median radiation dose was 45 Gy. given at 180 cGy. daily. Median followup was 4.4 years (range 1.4 to 13.3). The overall 5 and 10-year actuarial rates for the patients were 94% and 70%, respectively. Disease-specific 5 and 10-year actuarial survival rates were 99% and 78%, respectively. At 5 and 10 years the chance of clinical recurrence was estimated as 6% and 13%, respectively, and the chance of recurrence (clinical or indicated by prostate specific antigen levels) was estimated to be 34% and 46%, respectively. Patients with high Gleason scores (8 to 10) and seminal vesicle involvement (stage C3) fared worst. There were 5 patients with clinical distant metastases, 1 with a clinical local recurrence and 1 with both conditions. Detectable elevation of prostate specific antigen without clinically evident recurrence was noted in 25 patients. Radiation therapy was well tolerated with minimal morbidity. Disease-specific survival and survival without clinical recurrence were improved over historical control in patients with stage PcN0 prostate cancer treated by radical prostatectomy alone. These data support a role for adjuvant radiation therapy in stage PcN0 prostate adenocarcinoma following radical prostatectomy.

Counseling the patient with regional metastasis of prostate cancer

BACKGROUND

Treatment options for all stages of prostate cancer are a source of considerable debate; patients with regional nodal metastases have been advised to undergo a wide range of therapies from observation with delayed endocrine treatment to an aggressive combination of radical prostatectomy (RP), radiation therapy (RT), and hormonal treatment.

RESULTS

In the absence of reliable data to confirm the wisest choice, a clinician must counsel the patient based on treatment morbidity, the best estimate of efficacy, and an appreciation of the patient's individual desires regarding treatment. Patients with minimal microscopic nodal metastases treated with RP are destined to have relapses ultimately, but the development of metastases may take 5-10 years even with no additional therapy. Immediate hormonal treatment combined with RP currently is used more commonly, and a subgroup of patients have remained disease-free for more than 10 years. Local morbidity can occur as a consequence of RP or RT or, later in the disease course, secondary to progressive growth of the cancer in the prostate. Finally, the ability to detect nodal metastases with minimal morbidity is available using laparoscopic pelvic lymphadenectomy. Thus, more emphasis may be placed on defining nodal status before definitive therapy.

CONCLUSIONS

Historically, nodal status was used to define whether the patient was eligible for aggressive local therapy; the presence of positive lymph node metastases disqualified a patient to receive RP or RT. In the future, nodal status may not define local therapy but instead may determine whether the patient receives adjuvant hormonal therapy or not. This more aggressive approach has gained acceptance because of the lowered morbidity of both RP or RT and the extended disease-free survival in at least a segment of the patient population. Because patients initially often select the form of local therapy best suited for them, this approach respects this initial decision by offering additional psychologic support in the long term.

Characterization of localized prostatic cancer: distribution, grading and pT-staging in radical prostatectomy specimens

Ninety-one patients underwent radical retropubic prostatectomy. Forty-three specimens were examined after limited sectioning (series 1) and 48 underwent whole organ serial step-sectioning at 5 mm intervals (series 2) of the removed prostate gland. The latter allowed a more extensive assessment of tumour localization, multicentricity, extension, pT-stage and grade. Eighty-eight percent of specimens in series 1 had free surgical margins compared with only 41% in series 2 (p = 0.00001). Preoperative tumour grading by fine-needle aspiration biopsy, TUR-chips or 1.2 mm core biopsies was in agreement with postoperative grading in the prostatectomy specimens in 48% of the cases in series 1 and 67% in series 2, respectively. In series 2, preoperative localization of the tumours by palpation was accurately assessed in 75% of cases when compared to the findings at step-sectioning. Sixty-eight percent of 40 eligible glands in series 2 contained multiple tumours. 12/13 cases of unifocal tumours (92%) were classified as large single tumours. The sections were divided into four peripheral and four central parts/octants, and the tumour localization was marked within these octants. The apical and middle third of the prostate contained tumour in all cases, whereas the basal (cranial part) was engaged in 35%. Small tumours were localized mainly in the periphery of the gland, with no significant difference between dorsal and ventral octants. However, large tumours were situated mainly in the dorsal peripheral octants, concomitant with an increased involvement of the ventral and central octants.(ABSTRACT TRUNCATED AT 250 WORDS)

Postoperative radiation therapy after radical prostatectomy for prostate carcinoma

BACKGROUND

The role and benefit of adjuvant radiation therapy after radical prostatectomy is unclear. This role was evaluated in 58 patients who, after undergoing radical prostatectomy for prostate carcinoma, had local extension of disease beyond the prostate or positive surgical margins. Thirty-nine patients treated surgically alone were compared with 19 patients who received adjuvant postoperative radiation therapy. All patients were followed for at least 5 years, and 50 patients had 10-year follow-ups.

RESULTS

At 10 years, the actuarial local failure rate was 31% for patients treated with prostatectomy alone versus 6% for the group receiving postoperative radiation therapy (P less than 0.05). The actuarial survival and metastasis-free survival were similar for both groups. When patients with involved lymph nodes were excluded from analysis, the addition of radiation therapy resulted in improved recurrence-free survival (91% versus 46% at 10 years, P = 0.04) and in a trend toward improved metastasis-free survival (91% versus 55%, P = 0.08). Complications occurred in similar frequencies in both groups.

CONCLUSIONS

In patients with local disease extension or positive surgical margins after radical prostatectomy, adjuvant radiation therapy improved local control and was administered with acceptable side effects.

Serum prostate-specific antigen after post-prostatectomy radiotherapy

External beam radiotherapy was administered to 39 patients after radical prostatectomy for adenocarcinoma. Thirty-seven of 39 patients had detectable levels of serum prostate-specific antigen (PSA) prior to irradiation as evidence of residual carcinoma (biochemical evidence of disease). Two patients also had palpable recurrences. Pathologic analysis of the surgical specimens suggested that positive surgical margins, seminal vesicle or lymph node involvement, or high Gleason pattern scores are associated with measurable PSA after surgery. Follow-up ranged from two to seventy-four months (mean 26.8 months). To date, local control has been achieved in all but 1 patient (including 2 patients with palpable tumor prior to radiotherapy). Two distinct risk groups for the development of distant metastases based on the trend of the PSA in relation to the duration of follow-up after radiotherapy are defined. In the high-risk group (those patients with a rising PSA), in 9 of the 18 bone metastases have developed, while none of the 17 low-risk patients have metastatic disease.

Radical retropubic prostatectomy: morbidity and quality of life. Experience with 620 consecutive cases

We describe our experience and complications of radical retropubic prostatectomy. From March 1983 through December 1990, 620 consecutive patients have undergone an anatomical radical retropubic prostatectomy for the treatment of prostatic carcinoma. The surgical technique we used is described. In 167 patients the procedure included preservation of the neurovascular bundles. There were no modifications in the surgical technique during this period. There were no operative deaths. Mean operating time was reduced from 3 hours in the first 100 patients to 1.5 hours in the last 220 patients. The average blood loss was reduced remarkably as well. There were only 3 cases of rectal injury, which were closed primarily and healed completely. One patient died of acute myocardial infarction 12 days after an uneventful operation. This patient accounted for the only perioperative death in our experience. Early complications occurred in 43 patients (6.9%), including only 2 cases (0.3%) of anastomotic urinary leakage. The late complication rate, excluding incontinence and impotence, was 1.3%. No patient was totally incontinent. Among the patients who were followed for 1 year or longer 95% achieved complete urinary control and 5% experienced stress urinary incontinence. Preservation of sexual function in patients who underwent a nerve-sparing operation was achieved in 71%. Our results indicate that radical retropubic prostatectomy can be performed with low morbidity and without affecting the quality of life in the majority of patients.

Radiotherapy following radical prostatectomy in patients with adenocarcinoma of the prostate

From 1973 to 1986, 160 patients with adenocarcinoma localized to the prostate were treated with radical prostatectomy and pelvic lymphadenectomy. In 78 (49%) patients more advanced stage of disease was found at surgery and they received local pelvic irradiation (RT). This consisted of 45 Gy for microscopic and 55 Gy for macroscopic residual disease. RT was given at 1.8 Gy a day, using the four-field "box" technique with the 23 MV X ray beam. Pelvic lymph node metastases were found in 28 (36%) patients who, in addition to RT, received systemic therapy: 20 with cyclophosphamide alone, 4 combined with 5-Fluorouracil, and 4 patients received DES. The 5- and 10-year overall actuarial survival was 95 and 77%, respectively, and the 5- and 10-year disease-free survival was 58 and 43%, respectively. Recurrent tumor was found in 34 (44%) patients. Of these 34 patients, 32 (94%) had distant metastatic tumor and 2 (6%) had local recurrence in the pelvis. The presence of metastatic disease in pelvic lymph nodes had clinical significance since it influenced disease-free survival and the incidence of tumor recurrence. The 10-year disease-free survival for the 50 patients with no lymph node metastases was 51%, as compared to 28% for the 28 patients with such metastases, p = 0.001. Similarly, recurrent tumor was found in 28% of the former and 68% of the latter patients, p = 0.002. Other important parameters predicting recurrence were: clinical stage, p = 0.018, histological grade, p = 0.013, and Gleason's grade, p = 0.002. This treatment program was very well tolerated and of low toxicity. There was no surgical mortality. Surgical complications were seen in 10 (13%) patients including: minor in 5 and major in 5. At 1 year, 77% of the patients remained continent, while 10% had mild stress incontinence. Of the remaining 13% only 3 (4%) patients had severe incontinence (greater than 5 pads daily). RT toxicity was mild with 38% experiencing diarrhea. Severe toxicity was seen in 2 (3%) patients who, early in the study, developed scrotal and lower extremity edema. Severe chemotherapy complications were seen in 1 (4%) patient who had severe neutropenic sepsis. Postoperative radiotherapy is a well tolerated, safe and effective treatment in patients who have microscopic or macroscopic residual tumor following radical prostatectomy.

Adjuvant cytotoxic chemotherapy in association with radical surgery or radical radiation treatment in presumably localized prostatic cancer

The potential benefit of adjuvant cytotoxic chemotherapy after radical surgical or radiation treatment of prostate cancer is discussed in the light of available reported studies. It is concluded that the effect of such treatment must still be regarded as uncertain and that further trials are needed.